DME

Blog posts of '2020' 'November'

Clinical Reasoning in Wheelchair and Seating Prescription 


This week we are taking a quick look at clinical reasoning and how it applies to prescription of wheelchair and seating items.  Clinical reasoning is a tricky concept to define, and while universal to all health professions, the exact process appears to vary a little between professions.  There is some research available into clinical reasoning, however most of it involves clinical reasoning for medical professionals or exploring how clinical reasoning is taught to students.

Looking at the research does help give us a definition for clinical reasoning, Gummesson, Sunden and Fex (2018) state clinical reasoning may be explained as being the professional thought process, or the decision-making process, that a clinician undertakes when working with a person.  Delany and Golding (2014) state that clinical reasoning involves gathering and analysing information as well as deciding on therapeutic actions specific to the patients circumstances and wishes, Young and Thomas et al (2020) state clinical reasoning reflects the thinking or reasoning that a health practitioner engages in to solve and manage a clinical problem.   Cited in Edwards and Jones et al (2004), clinical reasoning can be described as a process in which the therapist, interacting with the patient and others (such as family member or others providing care), helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices and professional judgement and knowledge.

Clinical reasoning can differ between therapists of different levels of experience, for example students mainly use a more analytic way of reasoning, where they seek answers from their theoretical knowledge to explain their findings, while more experienced therapists tend to rely on patterns they recognise without full analytical thought process, however experienced therapists will engage in an analytical thought process when presented with something unfamiliar.  (Gummesson, Sunden and Fex 2018)

Edwards and Jones et al (2004) explored clinical reasoning processes in a group of experienced Physiotherapists with different specialities (musculoskeletal, neurology and community) and proposed that physiotherapists use a mixture of hypothetical-deductive reasoning along with narrative reasoning, to acquire an understanding of the person as well as the disease

Hypothetical-deductive reasoning can also be known as diagnostic reasoning, where a therapist attempts to diagnose the underlying concern, and throughout the treatment process will continually evaluate as to whether this reasoning continues to hold true, for example, assessing the impact of an intervention and checking whether the response is in keeping with the initial diagnosis.

Narrative reasoning on the other hand seeks to understand the unique lived experience of person through their stories or narratives, to allow the therapist to gain insight into the person’s experience of pain or disability and their subsequent beliefs, feelings, and health behaviours.   

The combination of these two models of clinical reasoning balance the need to optimally diagnose and manage person’s presentation but also understand and engage with the person’s experience of that disability and pain. 

In our Funding 101 webinar we explored the use of the ICF framework as a means of collecting the wide range of information required to assist in writing a funding report.  A funding report also requires us to demonstrate our clinical reasoning process, so in other words showing our thinking as to how the identified solution will meet the persons identified needs and goals.  This clinical reasoning process needs to incorporate information obtained during our assessment process and may incorporate both a hypothetical-deductive reasoning approach and a narrative approach.  Clinical reasoning to support provision of a wheelchair is often the easy part – a person may have a complete spinal cord injury and is no longer able to walk, hence they require a wheelchair for all functional mobility.  In addition to showing rationale for provision of a wheelchair, we also need to demonstrate clinical reasoning to justify additional features or the additional cost of a higher specification chair  – for example our person with a complete spinal cord injury requires a scripted chair to allow for optimal configuration to maintain shoulder health (as per the RESNA position paper), and they may also require a power assist device to allow them to continue to work in their large workplace or to be independently mobile in their community to allow them to attend activities with their children. 

This clinical reasoning process can help identify what parameters a solution requires, for example the person needs a power assist device that is easily transported in their standard car, or a solution that works well on the varied terrain in their community.  Identifying the parameters of a solution required then matching a particular product to those parameters can assist with documenting our clinical reasoning, as opposed to just stating that a person requires a particular product. 

Another component of clinical reasoning involves considering alternative solutions and balancing up the benefits and challenges of each solution identified.  For example, each power assist device comes with its benefits and challenges, not to mention an actual power wheelchair may be also be a potential option.   This can be where our narrative reasoning can help us – for example incorporating a person’s desire to remain self-propelling or whether or not they are willing to change their vehicle to accommodate a proposed solution.  This narrative reasoning can also expose some challenging issues, such as the person who refuses to consider trialling a power wheelchair despite their lack of functional mobility in a manual wheelchair, or the person who wants to trial of a piece of mobility equipment that is potentially beyond their ability to safely manage due to their progressive condition.

When it comes to how we explain our clinical reasoning in our reports, a study by Delany and Golding (2014) provides a little insight.  Delany and Golding looked at a group of educators working with students – these were educators from a variety of health professions, who explored their own clinical reasoning processes and looked at how to translate this into teaching of their students.  A point that emerged from this study was how the educators had to be more concrete and explicit about their knowledge and reasoning when describing their clinical thinking to a colleague from a different discipline, for example a Physiotherapist needed to explain their clinical reasoning clearly to an educator that had a Social Work background in order for the Social Worker to understand their clinical reasoning process.  This might be something we need to keep in mind when writing our reports – in that the person reading the report and approving the funding may not have the same professional background as the person writing the report.

Where the trial occurs in the report writing process varies across funding options, however the trial does give us a chance to add information to our clinical reasoning process – for example if we are exploring use of a power wheelchair as a means of reducing fatigue, a trial will allow us to establish whether this proves to be true.  In some cases a trial can be a source of new information – for example a persons cognitive abilities may  become clear when trialling a power wheelchair, or new goals may emerge when a person realises what opportunities a change of mobility solution may offer them.

Many of us will have the clinical reasoning abilities discussed here, however how well we are able to articulate them, or document them in a report, will vary.  A useful strategy for improving on your ability to articulate or document your clinical reasoning is to discuss your reasoning with a person who is not familiar with the person you are writing the report about, this can help identify any gaps in your reasoning or challenge any assumptions you have made.  This is likely to result in a report that is easier for the funders to follow and reduce the time taken to get approval for a solution, allowing the person to receive their equipment and fulfill their goals sooner.

For more information on writing successful funding reports, please join us for our next webinar.

Funding 102: How to write successful funding reports in 

Thursday 26 November 2020 starting at 12.00pm 

Register HERE

 


References

Gummesson, C., Sunden, A., & Fex A. (2018). Clincal reasoning as a conceptual framework for interprofessional learning: a literature review and a case study.  Physical Therapy Reviews 23 (1) 29-34

Delany, C., & Golding, C. (2014). Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators.  BMC Medical Education 14 (20) https://doi.org/10.1186/1472-6920-14-20

Young, M.E., & Thomas, A. et al (2020). Mapping clinical reasoning literature across the health professions: a scoping review. BMC Medical Education20(107) https://doi.org/10.1186/s12909-020-02012-9

Edwards, I., & Jones, M. et al (2004). Clinical Reasoning Strategies in Physical Therapy. Physical Therapy 84 (4) 312-330 


Rachel Maher
Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010. 

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.

Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.


 

Worldwide STOP Pressure Injury Day 

Thursday 19th November marks the Worldwide STOP Pressure Injury Day – a day to raise awareness of pressure injuries, and to promote education and collaboration to prevent their occurrence.   Many of us will be familiar with pressure injuries and their implications, both their impact on the person’s quality of life, and the cost to the health sector in treating them.  Worldwide STOP Pressure Injury Day offers us the chance to learn more about pressure injures and how we can assist in their prevention. 

One important source of information on pressure injuries is the ‘Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline’ released last year, which gives an evidenced based overview into the prevention and treatment of pressure injuries.  This guideline is available online for purchase or is accompanied by a quick-reference guide that is free to download.  For therapists, one aspect of pressure care we are frequently involved in is the recommendation of support surfaces – both for lying and sitting, hence it is worth us consulting the guideline and ensuring we are following best practice. 

One challenging aspect of support surfaces in the ongoing need for education on the correct use of any support surface.  For me, November has been a busy month for education about ROHO products, with the most common enquiry being ‘how do I know a ROHO cushion / mattress is inflated correctly’ closely followed by ‘how do I clean the ROHO cushion / mattress and its cover’.  Many of these enquiries have come from nursing staff who are new to working with ROHO, however many caregivers in the community are likely to have the same questions.  Part of our role when working with people who are dependent on a specialised support surfaces to assist in managing their pressure relief, is ensuring the person, and their wider team, understand how these support surfaces work and how to care for them.  We need to ensure they know how to check their support surface is working correctly, how to identify when it is not, and who they need to contact if they need help with repairs or maintenance.  In some instances, this can be a challenge due to high turnover of staff in some areas, meaning trainings may need to be frequently repeated, or written information provided that is easy for new staff members to follow. 

For those who frequently prescribe support surfaces, either mattresses or cushions, this week is a good opportunity to evaluate what tools you use, or resources you have, to assist in preventing pressure injuries.  What tools do you use to help identify who is at risk of developing a pressure injury?  Or what resources do you have to complement use of support surfaces?  Alternatively, this week could be a good opportunity to link in with your community nursing or wound care team - an excuse to meet if your paths don’t often cross despite often working with the same group of people.  This collaboration can be time well spent, as collaboration across teams or different departments often result in a more co-ordinated approach to service delivery, which ultimately benefits the person requiring the service.

So for this weeks Worldwide STOP Pressure Injury day, make sure you take some time to learn and some time to reflect.  Take some time to attend an event at your local hospital, or join an online webinar, or browse the Clinical Practice Guidelines or Quick Reference Guide.  Take some time to reflect on your practice and your contribution to preventing pressure injuries – because if each of us takes pressure injuries seriously we can reduce their incidence and prevent the reduction in quality of life that typically accompany them.

Resources

Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline or Quick Practice Guide link  https://pppia.org/guideline/

New Zealand Wound Care Society – Clinical and Public resources https://www.nzwcs.org.nz/resources/stop-pi-day

Wounds Australia – https://www.woundsaustralia.com.au/


Rachel Maher
Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010. 

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.

Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.

What Matters When Scripting a Manual Wheelchair?

Scripting ultra-lightweight manual chairs can be a challenge – what frame material do you choose? What frame design? And then there are all the measurements that you need to get…

When first learning to script manual wheelchairs, it can be hard to know what to focus on, however a recently published article by Lin and Sprigle can help give us some direction.


Lin and Sprigle’s study researched the operator and wheelchair factors on wheelchair propulsion effort, taking a group of 36 people and exploring which factors influenced their propulsion effort over a modified figure eight course.

Lin and Sprigle were keen to explore which factors really matter to everyday wheelchair users. The modified figure eight course was compromised of both tile and carpet surfaces, and thought to be more reflective of the stopping, starting and turning that wheelchair users do in their daily lives. The study group was made up of 23 existing manual wheelchair users who completed the study in their own chairs, and 13 able bodied people who were randomly assigned a pre-configured chair.

Both operator and wheelchair factors were explored. Operator factors included aerobic capacity, muscle strength, maximum propulsion strength and their shoulder position relative to the axle. Wheelchair factors included the mass of the chair, the weight distribution over the chair – given as a percentage weight over the rear wheel, and system friction. 

These factors were assessed over two separate sessions and included five minutes of propelling around the modified figure eight course. The results from these were then statistically analysed, and which factors that influenced propulsion effort identified.   

The results of this study showed that shoulder position of the user relative to the axle, and weight distribution of the chair had the largest influence on propulsion effort, particularly on the tiled surface. So, in other words, where the axle position was placed and where this position was relative to the user’s shoulders mattered.  And in this case, it mattered more than the overall weight of the wheelchair and the fitness of the user.

This result obviously applies to these particular testing conditions. Under different conditions, factors such as the user’s strength and fitness may have more influence.  Of note, the influence of weight distribution and axle position was less pronounced when the person was propelling on carpet, where the carpet itself was a significant factor in the person’s propelling efficiency. The chairs used in the study had a variety of castors and rear wheels with different amounts of friction produced which also produced some impact when propelling on carpet but was not as significant.

The weight distribution on a chair is related to the axle position, with a more forward axle position resulting in more weight over the rear wheels, and vice versa – where the influence of weight distribution on turning resistance is most noticeable when too much weight is towards the front of the chair.

The axle position relative to the shoulder is crucial for maximising the ergonomics of the person self-propelling, with both the axle position relative to the back posts and the height relative to the user being important. Establishing where to set the axle position for new users is often challenging. A more forward axle position results in a chair that is more ‘tippy’ which can be difficult for a new user to manage, while a more rearward axle position can result in a chair that feels ‘heavy’ to push and turn.

This is where adjustable chairs are useful and the axle position can be changed as a user becomes more confident in using their chair, allowing the chair to be configured for optimal efficiency over time.

The seating used on the wheelchair can also contribute to the relative axle position. A change of cushion can change the user’s height relative to the wheel, while a change of back support, or changing between a solid back support and an upholstery back (not to mention an upholstery back that becomes saggy with time) can change how far forward the axle sits.

Another factor that impacts on weight distribution on the chair is the body shape of the user itself – a person who has had both legs amputated above the knees will have no weight towards the front of the chair, while a person with oedematous legs may have more than usual. A bilateral above knee amputee can be challenging to set up as the chair needs to be stable, yet the rear wheel placed in a position to ensure efficient self-propelling. For this group, learning good wheelchair skills is important, while others may need anti-tips to ensure stability of the chair when using on uneven surfaces.

So, what is the one thing we need to get right when scripting a manual chair? The position of the axle – this can make a world of difference to the end user and how easy their chair is to manage. Not sure how to get this right? Consider starting with an adjustable chair and ask your local supplier or dealer with help to set it up. Then trial the chair in the places the person needs to use the chair to ensure that the set-up is just right.

Still wondering about the weight of the wheelchair? We’ll come back to this in a later blog!

Reference

Jui-Te Lin & Stephen Sprigle (2020) The influence of operator and wheelchair factors on wheelchair propulsion effort, Disability and Rehabilitation: Assistive Technology, 15:3


Rachel Maher
Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010. 

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.

Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.

The WhOM and Funding Reports  

Our last three webinars for 2020 are looking at funding and how to write successful funding reports.  Writing reports is a skill that some of us struggle more with than others, where understanding what information is vital to the funding report can be a challenge. In today’s blog we are taking a look at the WhOM and how it can assist with writing funding reports. 

Writing funding reports for wheelchairs can seem simple on the surface – a person is unable to walk, or does not have functional mobility, hence requires a wheelchair.  However the world of wheelchairs is not so simple, with wheelchairs being available in all sorts of sizes, configurations and with different features, and hence we need to be able to communicate to the funders why a particular chair at a particular cost is essential to meet a person’s needs.

In a previous role I worked as a Paediatric Physiotherapist, and worked closely with the local Orthotist, a very experienced person who was often very direct with his thoughts, and often in our joint appointments he would ask me outright – Rachel, what are we wanting to achieve here?  Which brings me back to the WhOM.

For those who are new to the WhOM – the WhOM is an outcome measures that focuses on participation – often the ICF domain that is most meaningful to end users.  The WhOM can be a means of establishing ‘what are we trying to achieve’ with a wheelchair, where mobility is expanded from moving from point A to point B, to ‘I want to be able to go into town without my parents’ or ‘I want to be able to cook my own meals’.  For our younger wheelchair users and their families, there is a modified version – the WhOM-YP.

The goals identified through the WhOM will be as diverse as the range of people we work with, and some of these goals will relate to funding guidelines, while others won’t – but each goal deserves to be acknowledged.  

The WhOM asks a person to score each goal on how important it is to them, and how satisfied they are with how they complete each goal.  Asking a person to rate how important a goal is to them can help differentiate between a goal that has been identified by another person (eg a caregiver or support worker) and what is meaningful to them, as well as prioritise intervention if different goals contradict each other – for example indoor and outdoor goals that are not able to be achieved in one mobility solution.  Asking a person to rate how satisfied they are with how they perform each goal will hopefully give you the opportunity to demonstrate that your intervention was effective – as their satisfaction score will hopefully improve post intervention. 

How well the WhOM influences the outcome can depend on what we do next.  The WhOM has helped us identify what we want to achieve, the next step is to work through is how we will achieve it.  Once we have established our goals we then need to work through each goal and analyse what is required to achieve it.  For our young person who is wanting to go to town on his own, it may be that we are looking at power assist for their manual chair, or time spent on improving wheelchair skills to manage on/off busses or crossing the road safely and independently. For our person who is wanting to cook meals independently we may be looking at ActiveReach or power standing, or adaptive equipment and strategies to compensate for reduced hand function. In other words, while the WhOM is an outcome measure that is designed for wheelchair users, the intervention that results from completing it may or may not be related to the wheelchair. 

This analysis often provides information to support a funding request – for example our person who is wanting to cook, as part of analysing this goal we have looked whether the person can access their kitchen in their wheelchair, confirmed that they have the hand function to complete the required tasks safely (with or without assistive equipment), they have the range of movement in their legs for ActiveReach, and alternative options have been considered, such as whether a caregiver is required to assist.  Failing to complete this analysis typically results  in funding reports that are lacking in information – and remember, the person who is reviewing the funding report has not met the person who requires the wheelchair – hence if the report does not contain the required information the funding body will not be able to support funding for what can be a high cost solution.   

Ultimately everyone involved in the wheelchair prescription and funding process is wanting to facilitate good outcomes for end users, our role as therapists is to be able to identify what these good outcomes might look like and communicate how a piece of equipment is going to achieve them in our funding reports.

The WhOM manual and assessment form is freely available online, for more information please see https://millerresearch.osot.ubc.ca/tools/mobility-outcome-tools-2/the-wheelchair-outcome-measure-whom/

For more information on our upcoming webinars



 

Rachel Maher
Clinical Education Specialist 

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and later gained her Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service, working with children aged 0 to 16 years.  

Rachel later moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.  

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.