DME

Blog posts of '2021' 'September'

Funding systems vary around the world, in our corner of the world both Australia and New Zealand have funding systems that are very function based.  Both funding systems require a person to have been diagnosed with a disability to access the system, however what equipment is provided is based on what a person needs to be able to do, it is not related to the person’s underlying diagnosis or medical based needs.  This means that in our funding reports we need to identify activities or tasks that a person wants or needs to be able to do, ideally something that can be measured through an outcome measure, and we link the features of the equipment to the relevant task.

However in the era of evidence based practice, finding evidence to support functional outcomes for equipment provision can be tricky, whereas more evidence is available to support medical benefits associated with equipment. 

What is a medical benefit?  Looking at the ICF, medical benefits are those that occur at a body structure and function level, as opposed to an activity or participation level.  Internationally, there are funding systems that are based on medical necessity, with the equipment that a person receives being linked to their diagnosis and resulting body structure and function limitations.

 

The presence of ‘medical necessity’ based funding systems has influenced the research surrounding wheelchairs and seating, with a number of research articles being available to support the medical benefits surrounding wheelchairs.  This information can be useful for therapeutic purposes but can be tricky to incorporate into a funding report that focuses on function. 

Are the medical benefits offered by a piece of equipment separate to the functional benefits?  Do we only mention the functional benefits in our funding reports?

Looking at the ICF can help answer these questions.  We need to remember that each of the ICF domains does not exist in isolation – each domain is linked or influenced by the other domains.  What we need to understand for a person is how these domains are linked, and how an intervention that may address an issue in one domain may influence factors in another domain. 

The one domain that can be hardest to address in a function based funding system is the body structures and function domain, despite changes in this domain having the potential to influence to both the activity and participation domains.  That said, some body structure and function limitations are easier to work through than others.   Maintaining range of movement or managing spasticity are two body structure and function issues that are regularly raised, with the link to functional tasks being easily established.  For example, regular standing helps a person maintain their range of movement in their lower limbs and this in turn helps maintain their ability to stand transfer in/out of their wheelchair, maintaining a standing transfer means they are able to continue to perform personal care tasks independently.   Or the ability to use tilt, recline and elevating leg supports in their chair helps manage their spasticity and hence maintain a seated position in their wheelchair, maintaining a seated position in their wheelchair means they are able use their eye gaze communication device reliably to successfully communicate with family and friends. 

Meanwhile other body structure and function limitations can be more challenging – for example bladder and bowel health.  Standing has the potential to positively impact on bladder and bowel health, however the research on this is a little more varied as bladder and bowel health is a more challenging area to research.  This doesn’t mean that you can’t incorporate this limitation into your funding reports, but it does mean that your clinical reasoning around this issue needs to be very robust.  For example, you may be working with a person who has frequent urinary tract infections (UTI) and the team are keen to explore power standing as a means of reducing these.  For this person multiple aspects need to be considered, such as

  • How is the frequency of UTIs related to the impairment/disability?
  • What medical options have been trialled and what is the outcome of these?
  • What functional impact do the UTIs cause?  Or how do the UTI’s impact on the person’s roles and responsibilities? 
  • What research is available to suggest that provision of this piece of equipment may be beneficial? 
  • Are there any potential contraindications for this person using this piece of equipment?
  • What are the potential implications if the piece of equipment is not provided?

Is it possible to work through all potential medical benefits to their impact on function?  Potentially not.  One challenging medical benefit to work through is bone mineral density, which is another benefit that is associated with standing.  Again we need to work through the above series of questions, however the answers to these questions may be challenging to incorporate into a funding report, with medical interventions potentially being more effective and low bone mineral density having a more obscure effect on a person’s roles and responsibilities.

Ultimately our funding reports require us to demonstrate good clinical reasoning and the process of justifying how an intervention at a body structure and function level impacts on the other ICF domains is another example of good clinical reasoning.  If you’re not sure how sound your clinical reasoning is in your report, it is good practice to get a peer or colleague to proof read your report before you submit it, ideally the person reviewing your report does not know the person the report relates to.  Having your reports peer reviewed can seem a little scary at first, however this review prior to submitting can save time in the process of getting a piece of equipment funded and help facilitate a good outcome for the person requiring the equipment.

Having trouble working through your clinical reasoning?  The education team is here to help, drop us a line at education.au@permobil.com and we can help point you in the right direction.

Wanting a place to start with research?  The RENSA position papers can help point you in the right direction.See here.  


 

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. 

My most influential mentor once told me that the only pre-requisite for independent mobility is the motivation to move, a statement I have often reflected on and referred to throughout my career. There may be learning or training requirements to reach successful outcomes and specialised set up and inputs may be required but often the only way to determine if someone could use assistive technologies to enable independent mobility is by giving it a go!


Pre-conceived Ideology

We need to consider our own ideology and views and how these impact our decision-making processes around independent mobility. Society can perpetuate stigma and without us having successful experiences to draw on, these ideologies can influence our understanding of capacity. If someone is in an aged care facility, do we still consider independent power wheelchair access? Or is there an assumed capacity that someone will not have the cognitive ability to learn to safely operate a powered mobility option?

I am yet to find a cognitive assessment that definitively correlates to a person’s capacity for independent mobility. Do we consider that the resident may not want to spend the afternoon watching TV, that maybe they want to participate in other activities but require appropriate postural support to functionally engage?

It is not uncommon for an assessment intended to identify areas that require training for independent mobility are used to rule out independent mobility for an individual rather than to then provide areas to focus on for said training. Is this due to safety, to lack of time and resources? What level of clinical reasoning has been used in determining if the individual will be safe? Has the least restrictive option to independent mobility been considered if there are safety concerns?

There are also similar barriers for young children. Whilst we know from human development that children start to ambulate at around the age of 12 months, are we providing similar mobility opportunities to children of this age with mobility impairments? What about our children who are unable to verbalise a goal or desire for independent mobility, or present with challenging reflexes or limited active motor movement, do we consider ways they can be successful, have we provided opportunities to give it a go?


Joystick Access

There are many advantages to a joystick, the proportional function enables acceleration and directional control. A joystick is the standard access input for a powered mobility base and should be our first consideration for enabling independent control. Just because someone experiences some movement impairment in their upper limb doesn’t mean they will not have capacity to access using a joystick, however we may find that we need to modify the position, the location or the joystick knob.

We can also use the electronic programming to modify things such as the sensitivity, the acceleration or how far we need to deflect the joystick to action movement.


Position and Location

The mounting hardware that interfaces the joystick to the chair should have sufficient adjustment to enable it to be positioned further forward or back to enable us to adjust to the users’ individual requirements. You may also need to consider the arm support required in relation to the joystick position. A full-length arm rest may provide additional support but will limit how far back towards the user the controller can be positioned.

The height also needs to be considered, does the hardware enable fine tuning adjustment to raise or lower the control unit for best access to the joystick?

Non-standard mounting may be required to meet a user’s functional requirements. Midline controller mounting often provides better access and outcomes for developing children, the foot or chin may provide best access. Once you have identified how and where a user will access the joystick you can discuss options with your local product specialist.

Consider the user’s upper limb function, both gross motor and fine motor movements need to be considered, as too does strength and grip capacity.


Controller and Joystick

When considering a powered mobility device, we also need to consider the capacity and configuration of the input device, whilst there are many similarities between different manufacturers, there are also differences. What may work for one user may not work for another.

Consider visually – can the user see what they need to see or sometimes it’s around “hiding” or reducing what can be seen to reduce sensory overload.

Can the user access any buttons or switches, can we program in shortcuts or memory functions to make access easier? What hand function does the user have and is the joystick knob matching these individual needs? I was privileged to be invited to an event some years back with Ability Mate coined a toggle-a-thon. Essentially, this was a day where power wheelchair users who were struggling to operate their chair due to controller access came along and met with a designer. Together, they identified what issues they had and came up with a plasticine prototype. This was then assessed in relation to the users’ clinical requirements before a 3D joystick was printed!

This was then trialled and, if required, the design was tweaked and re-printed. It was a great example of a collaborative approach driven by the end user’s needs and the use of 3D printing for users who could utilise a standard controller with modified joystick. I have also used splinting material to mould a hand support and purchased small balls for gross hand grip in those rare cases where an off-the-shelf joystick knob has not quite met the specific required needs.

Switch Control

The advantages of a proportional control input method may be out weighted by fatigue of sustaining the deflection of the joystick or an individual may not have the required strength. It is important to consider both the type of joystick and the potential programming options in the first instance, but for some users switch control may provide the access required.

Proximity switches tend to require less movement to activate and are an important consideration when identifying switch access. The most common proximity switch control is through the use of a head array and this can be an advantageous method to consider for a child starting out with switch-controlled mobility. With the child turning their head towards the direction intended to move, the switch located in the head mounted pads activates.

With switch control, programming is also crucial. Switches can be latched or non-latched – think about a light switch, once you turn the switch on it remains on until you turn the switch off versus the switch only operational whilst you hold the switch down and sustain pressure on it. The switch hardware also differs with the amount of pressure required to activate.

As a therapist it is important to understand the user’s functional capacity to access and draw on your experiences or have an experienced therapist involved. Even working within a specialised seating service there are only a small proportion of wheelchair users that require complex alternative control set up so it is advantageous to work closely with a supplier or manufacturer experienced in setting up and programming the device.

When considering access to independent mobility, it’s often about giving someone an opportunity to trial and working through the process. For further information or to discuss a potential alternative input method for powered mobility, you can always reach out to our team at education.au@permobil.com where we can discuss some of the considerations and assist you with setting up a trial with one of our product specialists.


 
Tracee-lee Maginnity
Clinical Education Specialist
 
Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.