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The Importance of Self-Initiated Mobility in Early Childhood

 


This is the first blog in our series on early childhood developmental milestones related to mobility. 


Young children are their own change agents. When they want something, they find a way to direct others to provide it for them. They may cry, smile, pout or grimace to cause a reaction to their action. This is a continual, increasingly complex way of making their place on earth their very own. Children learn through exploration. If a child is unable to self-direct their exploration and must rely on others to bring items to them, it is not of their choice.

Children need choice to learn to make decisions, initiate actions and learn reactions.

An infant begins exploring their environment the second they are born. They look around to find the smiling face, put their fingers in their mouth and wiggle any body part they want. If a child is unable to move, they do not find their environment and they may lose their inherent curiosity.

A quick review of development demonstrates how children come to move independently. At around two months of age they lie on their tummy, hold their head up and start to fix their eyes on objects nearby. Once they begin to sit up at 6 months, they stretch out with their hands to find objects within their reach. When successful at finding and manipulating items in reach they begin noticing items beyond their reach and because their arms are not needed to sit up, they reach beyond themselves until they fall on outstretched arms and realise “oh, if I just wiggle the right way I can get that toy.”

This is the beginning of what later becomes crawling which helps to strengthen an infant’s arms and legs to prepare for standing and eventual walking.

But what happens when a young child does not sit unsupported due to a development delay or medical condition that limits their ability?

The typical developmental sequence is altered. Their ability to change their environment, control the objects they want and forage into spaces is halted. What if we could change that? What if we could provide children with a substitute, whether it’s temporary or long term? Wouldn’t it be great if we could provide a device that offers the support a child needs to maintain their change agent status? Permobil recognises the positive impact that creating a mobility solution can have on young children.

The first two years are crucial in development.

The ability to explore the environment ushers in a cascading array of cognitive, social, emotional and spatial skills that concurrently provide tremendous opportunities for growth. Without self-initiated mobility, children are not the agent of change but rather the consequence of someone else’s decision.

Exploration made easy

At only 52lbs, the Explorer Mini is a lightweight, easy-to-transport power mobility device that empowers families and children to explore and learn in home and community environments. 

Learn more

   


  

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS

Associate Professor in the School of Occupational Therapy at Belmont University

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS is an Associate Professor in the School of Occupational Therapy at Belmont University in Nashville, TN. She has over 40 yrs of OT experience and 20 in the area of Assistive Technology.

She is a member of the International Society of Wheelchair Providers, and the Clinicians Task Force. She is a reviewer for American Journal of OT and guest reviewer for many other journals. She has authored journal articles and textbook chapters in the area of OT and pediatric mobility and access.

 

Stacey Mullis, OTR/ATP

Director of Clinical Marketing

Stacey serves as Director of Clinical Marketing for Permobil. A practicing OTR for over 20 years, she has experience in school-based pediatrics, inpatient rehabilitation, long term care, and home health. With her interest in wheelchair seating and positioning, Stacey engaged the challenges of providing appropriate seating in various clinical settings. She now uses this experience to develop programs and resources to educate clinicians on the principles of seating and wheeled mobility.

She is passionate about equipping clinicians and through her previous role as Director of Clinical Education with Comfort Company and now with Permobil she has taught nationally and internationally to increase therapist capacity in this specialty area. 

Why Everyone Should Be Talking About the Shoulder


If you are a physio or occupational therapist working with an individual that utilising a manual or power wheelchair, you should have a better understanding of the shoulder than a sports physio. Yes, that’s right you read that sentence correctly. I want us/our client needs us to better understand the shoulder than a sports physio. Why? While that’s exactly what I will explain in today’s blog. 

Whether you are the end-user, therapist, family, dealer/supplier everyone should be thinking about the client’s shoulders. The statistics are staggering. We know that shoulder pain and dysfunction is a problem for all of us in this world, but this becomes even more significant to consider and address if the end-user relies on their upper extremities for mobility. The percentage of shoulder pain in individuals that utilise a manual wheelchair for their mobility ranges from 32% to 78% (1). It’s not just individuals who propel a manual wheelchair that we should be talking about! Even an individual utilising a power wheelchair? Yes! This is because although we like to blame propulsion for all the shoulder pain, this is just one piece. We also have to think about transfers, overhead reaching, loading/unloading a chair into the car, activities of daily living… just to name a few. This is part of the problem, but there is a whole other side to this story that we need to consider. 

What if the individual already has shoulder pain, limited range of motion, decreased strength, or muscles around the shoulder are not fully innervated? How often as a therapist do you assess your client’s shoulder? Are you assessing for pain? Do you quickly run a gross range of motion assessment and then dive further if you see any limitations? Have you at a minimum grossly tested shoulder strength? 

Yes, understanding how the equipment will affect shoulder health is crucial and this is something that I talk about extensively if you have been in one of my courses, but what about how the shoulder at its current state of health and future health will impact the client in the equipment we are selecting? We cannot determine the most appropriate equipment for a client without understanding their shoulder health and we CANNOT assess the shoulder if we do not ask questions and get hands-on. 

This is why we need to know as much or more than the sports physio. We are assessing a shoulder to perform at a high level with activities that the shoulder was not designed for. Now some of our clients may have a fully intact, strong shoulder with no reports of pain similar to an athlete or they may even be an athlete themselves, but many of our clients will have already existing shoulder impairments and pain. It is our job not only to understand what we need to complete in an assessment to determine their equipment selection such as their environment and goals, but we also need to be able to assess and understand a complex shoulder joint and how this will impact our decision. It is a big responsibility, but also one that can really show our level of education, assessment and critical thinking skills. 

So, where do we learn this information? We learned a foundation in our university, but we cannot stop there. We have to continue to further understand the shoulder and how the individual activities of each client affect their shoulders. I would suggest an orthopaedic course on the shoulder. Yes, I know. This may seem like a strange suggestion, but we and the orthopaedic based therapists have a common goal! You could even try to see if you can attend a course that is not in our specific field of study – an occupational therapy course for a physio and vis versa. Some courses allow OTs, physios, chiropractors, etc… these can be great courses to learn not only from the instructor, but also from each other. Finally -Your Clinical Educators! We are happy to help you further your knowledge and can help you to work on integrating the shoulder with the wheelchair and client to achieve the optimal outcome. Join our free webinar on the shoulder on March 24th at 2pm AEDT. If you haven’t registered yet, use the link below to register and begin your further education of the shoulder.  

Click this link to register for our webinar: 

https://attendee.gotowebinar.com/register/591256185888247052?source=Blog 

Finally, remember the why. We are asking our client’s shoulders to work hard, and we need to make sure they are able to handle the demands that we are placing on them. This might include considering a power assist add on to a manual wheelchair, a power wheelchair with ActiveHeight and ActiveReach, or creating a home exercise program to name a few. The statistics are too high. We need to help to decrease this percentage of individuals experiencing shoulder pain and the only way to do this is through education of ourselves and our clients in order to complete a proper assessment and equipment recommendation.

 

Rachel

 

 

International Wheelchair Day and Accessibility


This week’s blog celebrates International Wheelchair Day and looks into the fundamental concept of accessibility and inclusion.

March 1st 2008 was the first International Wheelchair Day, founded by Steve Wilkinson and has been celebrated on this date every year since. The day has recently gained more traction and provides an opportunity for wheelchair users, their families, friends, support workers and our industry to celebrate the positive impact a wheelchair has in their lives.

The Aims of International Wheelchair Day

To enable wheelchair users to celebrate the positive impact a wheelchair has in their lives.

To celebrate the great work of the many millions of people who provide wheelchairs, who provide      support and care for wheelchair users and who make the World a better and more accessible place    for people with mobility issues.

To acknowledge, and react constructively to, the fact that there are many tens of millions of people    in the world who need a wheelchair, but are unable to acquire one. 

Last Friday, our Permobil Asia Pacific President, Bruce Boulanger, and our Australian Customer Service Manager, Graham van Leeuwen, both experienced some of the barriers wheelchair users face by volunteering to spend the day in a wheelchair. In addition to having a firsthand experience in our TiLite manual wheelchairs, they soon discovered additional planning and task adaptations they had to make to enable them to complete everyday activities of daily living and their normal work tasks.

Luckily, both of our volunteers were very familiar with the workplace environment. They knew where the lift was located and how far the bathrooms are from their desks which makes a difference when you’re mobilising in new ways. But what happens when wheelchair users travel to new communities, new environments, and the information about steps, ramps, parking spots and bathrooms is not available?

We often take for granted our ability to move freely within our environments, yet it is this very environment that creates barriers for those experiencing mobility impairments. So for International Wheelchair Day I volunteered to participate in an Australian initiative, Wheel Easy. Wheel Easy is an online platform designed to be similar to Trip Advisor but with specific accessibility information for each landmark. 

As well as being International Wheelchair Day, yesterday was also the first day of a series of events called Mapping March for Wheel Easy. The events run in various inner-city areas of Sydney throughout the month of March with a purpose to map as many parking spots, restrooms and leisure spots as possible. Crucially, the platform includes descriptions and photos of accessibility.

Yesterday’s event started with a presentation briefing to all the volunteers. The founders, Justine and Max gave a passionate and inspiring presentation on the website and some insight into their life experiences that motivated the development of the platform. Examples of pictures and types of information that would be useful were discussed and an opportunity to ask questions to the team and the Ambassadors about the types of things to look out for.  

We then loaded the site onto our phones and went out and added cafes, parking and local venues to the website. It was really easy to add the information to each location on the site. The crowd sourcing model also enables anyone using the site to review and update information.

It is an eye-opening experience walking around a new community with a focus on accessibility. Often ramps and entrances are tucked away, accessible parking spots don’t meet everyone’s needs and just because a restaurant says it has an accessible bathroom doesn’t mean it is accessible to all types of impairments. The service uses photos which can assist users in planning what establishments they can patron. The process is also an opportunity to engage in discussion about accessibility with local businesses. 

To truly have an inclusive society we need to work towards reducing barriers. Whilst new buildings and communities are more likely to be built to universal standards or building codes that require certain access standards, older infrastructure continues to be more difficult to access and can limit inclusion.

As a wheelchair manufacturer we build and create wheelchairs to enable people with mobility impairments to live full and inclusive lives. However, even when optimal configuration and setup has been achieved the environment can still cause significant barriers. We first aim to ensure that the right fit for the end user and their environment has been met, but we also need to consider that wheelchair users participate in a variety of environments and may require multiple pieces of AT to achieve this.

The first step to breaking down environmental barriers is to create awareness. I challenge readers to create awareness, start a conversation, get involved in an initiative like Mapping March! Let’s keep working towards an inclusive society where barriers are, at the least, minimised. 

 

Tracee-lee Maginnity

Making Professional Development Opportunities Work for You



 

Is it enough to just walk around an expo or attend a clinical presentation, conference or workshop? For me, ongoing development is not so much about meeting the hours required for registration. It is about filling my knowledge gaps and challenging my thinking. If you are just attending to tick off hours you may miss a valuable learning opportunity. Can you relate the new knowledge to a personal development goal? Writing a short reflection will provide evidence of development and assist you to consolidate what you have learned. One of the things I love about seating and mobility is that there are always new challenges and different ways to gain best outcomes. To make the most of any opportunities for ongoing education and development, it is important to be able to identify gaps in your knowledge or skills and seek out appropriate opportunities to meet these goals. Relating any skills or knowledge gained reflectively to enhance your practice will assist with achieving better outcomes for your clients.

 

 

Presenting case studies back to your team is another great way to facilitate open learning and development. For the more experienced clinicians, have you considered submitting at a conference? A case study of an interesting clinical case or a poster presentation is often a great way to start. This is an opportunity to give back to the profession as well as to increase your own skill set. If it’s a bit daunting maybe seek out a colleague to submit together.

Industry Shows

This week our New Zealand team have joined the annual Show Your Ability road show. The Disability Equipment Show travels to 5 cities and provides an opportunity for therapists, end-users and carers to see a range of Assistive Technology from different manufacturers all under one roof. In addition to seeing the newest technology on display, the expo offers an opportunity to see any updates to existing equipment. When I was working as a prescribing therapist I found this expo a chance to ensure I was up to date with what options were available. It’s a great opportunity to get hands on when comparing options. If you are a prescribing therapist, this knowledge can enhance your initial trial process. Attendance can also contribute to your ongoing professional development especially when linked to goals or used to reflectively guide practice. Permobil will be at all venues and we invite you to stop by to say hi and see our mobility and seating options.

 

 

 

Show your Ability Roadshow Expo February/March 2020 (New Zealand)

Monday February 24th - Auckland - ASB Showgrounds

Wednesday February 26th - Hamilton – Claudelands Events Centre

Friday February 28th - Palmerston North – central energy trust Arena

Monday March 2nd - Christchurch - Pioneer recreation and sport centre

Tuesday March 3rd - Dunedin – Edgar Stadium

For more formal CPD opportunities, the ATSA and ATSNZ expos also run simultaneous clinical education streams providing full days of educational sessions and a large industry showcase.

 

 

 ATSA Daily Living Expo (AU) and ATSNZ Expo (NZ)

The Daily Living Expo is sponsored by ATSA (Assistive Technology Suppliers Association). This year the two venues for ATSA are Perth and Melbourne. Swapping locations between Melbourne/Perth and Sydney/Brisbane, ATSA is known for its free Clinical Program which often attracts international presenters. At the time of writing the Perth Program is online and it looks like there are some great presentation on offer! I anticipate the Melbourne program will soon also be available. https://www.atsaindependentlivingexpo.com.au/ 

The New Zealand event equivalent will be held in Auckland on the 8th and 9th of September http://atsnz.org.nz/atsnz-expo/ Rachel and myself will be joining our team at these events to support the education program assist with any clinical questions you may have related to mobility and positioning.

Insert ATSA Banner or photos

International Events

For those wanting to go further afield for some CPD, this year’s International Seating Symposium (ISS) is in Vancouver, but if you’re not booked yet you may want to set this as a goal for next year as it runs March 3 -6. http://www.seatingsymposium.com/

For anyone planning a trip to Europe and wanting to squeeze in some professional development, the European Seating Symposium is held in Dublin, Ireland June 9 – 12. https://europeanseatingsymposium.eu/

Another European conference that focuses on mobility and seated posture is the Postural Management Group, November 2 -4 in Telsford https://www.pmguk.co.uk/conference

If you are new to seating and mobility or you want to further your skills, Permobil currently offers Clinical Education Workshops around New Zealand and Australia. A range of the topics on offer can be found on our website  https://permobil.com.au/permobil-academy/on-site-courses/  We are still finalising the education calendar so the best way to find out about upcoming courses is to subscribe for updates or follow our Facebook pages. If you’re interested in us hosting one of these workshops at your service or in your area reach out to us at Education.au@permobil.com.

Next week we will be introducing the shoulder so don’t miss our Clinical Education Director, Rachel Fabiniak with her blog!

 

Tracee-lee Maginnity

 

 

Using Risk Assessments to Prescribe Cushions?


Can you use a risk assessment score to identify the best cushion for a user?

Risk Assessment Tools are commonly used to assist in the identification of an individual’s risk factors for developing a Pressure Injury (PI). The Waterlow, Braydon and Norton are 3 of the more well-known and commonly used tools. But can these outcome scores be used to prescribe seating?

Since moving to Australia, I have frequently been asked to match seating solutions to a Waterlow score. Waterlow is a commonly used pressure risk assessment. The Waterlow was designed by a Clinical Nurse Educator, Judy Waterlow in 1985. Its purpose was to assist in student education. The last update to the assessment tool was 2005.

 

In a clinical setting the Waterlow scorecard is used to identify risk. The higher the score the more risk factors for potentially sustaining a pressure injury have been identified. However, it is important to understand that these assessments only highlight risk factors and are not a definitive predictor of injury occurrence.

The collection of information is extremely subjective and has shown mixed inter-reliability in scoring. The information focuses on medical and health information, which is of course valid and recommended to be addressed in the health setting.

However, a risk assessment should only form one part of the clinical reasoning process when determining the best assistive technology solutions to assist someone in addressing and supporting their pressure management needs.This is reinforced on Judy Waterlow’s website, “It must be remembered that "Waterlow”, like all risk assessment scoring systems is a simplistic tool. Professional judgement must be used in determining the risk status of the patient/client.” (http://www.judy-waterlow.co.uk/waterlow_score.htm) The Braden Risk Assessment Tool could be seen as even more simplistic which again takes a subjective approach with a health/medical focus.

 

This is reinforced on Judy Waterlow’s website, “It must be remembered that "Waterlow”, like all risk assessment scoring systems is a simplistic tool. Professional judgement must be used in determining the risk status of the patient/client.” (http://www.judy-waterlow.co.uk/waterlow_score.htm) The Braden Risk Assessment Tool could be seen as even more simplistic which again takes a subjective approach with a health/medical focus.

But when administered by trained health care providers, a Cochrane search found “The Braden scale is the recommended validated and reliable tool for assessing pressure injury risk in critically ill adults.”https://www.cochrane.org/CD006471/WOUNDS_risk-assessment-tools-used-preventing-pressure-ulcers. Cochrane’s overview of risk assessments key message is;  ‘We cannot be certain whether the use of a risk assessment tool makes any difference to the number of new pressure ulcers that develop among people who are at risk. The certainty of evidence ranged from low to very low”, as such I strongly question the appropriateness of selecting a cushion based on a risk assessment score.

 


This is not to say risk assessments don’t play an important role in the prevention and management of pressure injuries. It’s not to say they can’t provide valuable information and direction to addressing the needs of one’s skin and underlying tissue because they can and do. However, they provide us limited information on the assistive technology needs.

 Jennifer Brit, a Canadian OT, developed the Pressure Management Assessment Tool (PMAT)http://www.hsc.mb.ca/files/SSS-PressureMgmt.pdf  I like its comprehensive approach and how it identifies areas where further education or skill training can be implemented as part of a holistic approach. If you are prescribing equipment for people at risk of pressure injury this is another tool you need to consider.

The pressure redistribution surface that’s chosen needs to be the result of the clinical reasoning process. All seating surfaces provide varying levels of immersion and envelopment. A variety of factors need to be considered when selecting the best option for that individual including, but not limited to:

  1. Postural symmetry: Is the user supported in their most functional position. Is the pelvis neutral with even loading through both Ischial tuberosities (Sitting Bones). How will you address this in the seating?
  2. Pressure History: has the user had a pressure injury before? What was the cause? Is this area at risk of reoccurrence? How will you redirect pressure away from any vulnerable areas? Are you using seating with strong evidence-based research guiding its design and use?
  3. Ability to independently reposition and how: Do you need to consider the contours, the fabric, the surface materials or other accessories that could impede? Or is the functional impairment impacting this capacity and you need to consider multi-positional power functions?
  4. MAT – Did a MAT assessment identify any restrictions to range that will impact on seated posture? How can these be addressed to provide best positioning
  5. Functional independence: Will contours or lateral supports support functional capacity or decrease it? What other ways can support be provided?
  6. Cognition / career support: How will equipment and skin be monitored and maintained? The cushions that provide the highest pressure redistribution or setting up a customised cushion require clinical support. Will the end user be able to manage or have the supports in place to assist if required.
  7. History and experience: What did the user previously use? What did they like and dislike about it?
  8. Comfort and seating tolerance: Has the user recently been on bed rest or recently sustained an injury or illness? Do they need something more complex position-wise or is it purely for occasional use? Will the user tolerate the positioning or will it need to be graded? How can the seating position be graded?

Are you trying to load the GTs and let the ITs immerse into a different density foam or fluid or are you trying to maximise overall immersion or loading? Are you trying to decrease direct pressure or sheer forces? Can the cushion do it all …or do you need to consider secondary supports?

There is much to consider when prescribing seating for full time mobility users. When a user has been diagnosed with a Grade 4 or unstageable injury, usual medical recommendation is to stay off it. It is crucial that a multi-disciplinary approach is taken when looking at pressure management.

Although we need specialised seating to support individuals with pressure injuries, specialised seating alone can’t resolve pressure injuries. It is important to incorporate medical treatment and advice into the management plan. In some cases, multiple seating might be required on different seats or for interim use while an at-risk user is building seating tolerance.

Pressure injuries can result in life threatening situations, long term hospitalisation and have a significant impact on independence and quality of life. Risk assessment tools address the health and wellbeing of tissue but do not correspond to development of injury especially in relation to postural positioning and support.

If you’re new to mobility and seating prescription or want a refresher or upskill we have a range of workshops that we run throughout Australia and New Zealand. https://permobil.com.au/permobil-academy/on-site-courses/ We can facilitate these with your local dealer or you can contact us about running clinical sessions for your team.

For further information contact us education.au@permobil.com

 

Tracee-lee Maginnity

 

Travel – Essential AT for Two Different Locations

 

 


In 2019 I was fortunate enough to travel to two very different destinations, Portugal and Thailand. Despite the differences between the two destinations, there are a few pieces of assistive technology that helped me make the most of these two trips.

To begin with, Portugal. Portugal has been on our list of places to go for many years, and in 2019 my wife and I decided to make it happen. As a wheelchair user who has done considerable travel over the years for both business and leisure my strong preference is to pick a place and spend time there rather than spending a night or two at several locations. This saves me the hassle of searching for accessible rooms, packing and unpacking, and hours in transit.

It has the added advantage of letting me get to know one place well, to find places that are often overlooked by tourist guides, to find the best food and cafes, to meet some local people and shopkeepers and to have a better taste of what life is like. In Portugal we decided we would spend our time in Porto.

 

 

For accommodation I used AirBnB. The accessibility filters now in the AirBnB website have worked well for me. We ended up in one-bedroom apartment right in the heart of Porto, equipped with a kitchen, good living room space and a bathroom set up that worked for me. This option was cheaper than the hotels with good accessibility and allowed us to buy the local cheeses, meats, olives, wines and other produce without having to eat out all the time.

 

 

Porto is an ancient city, built around the Douro River. This means there are a lot of steep hills, cobblestones, steps into shops, and at times narrow crowded sidewalk. Not ideal for wheelchairs! But to compensate for this it is a beautiful city, with magnificent views, architecture, history and very friendly locals. In addition, there is some excellent infrastructure such as the funicular, cable cars, accessible buses and accessible paths along the river and on the famous Dom Luís 1 Bridge. We also did a half day river cruise which was spectacular and then caught the train back to Porto (the train stations had portable ramps to get me into and out of the carriage).

 

  

 

In terms of getting around, we explored a lot of the city by wheeling/walking. We used the buses a few times, but mostly we just wheeled/walked to different areas. I find one of the attractions of old cities like this is to just wheel through the lanes and alleyways, get a feel for the history and be surprised by the small shops and their produce.

 

 

 

I will let the pictures and videos do much of the talking regards the beauty of Porto. In regard to equipment, the two vital pieces of equipment were the SmartDrive and the FreeWheel. These two products work so well together, the FreeWheel for the cobblestones and going down steep hills, the SmartDrive for getting up the steep hills. Having travelled through Europe without the FreeWheel, the difference it makes on cobblestones is truly liberating! Having the SmartDrive allowed my wife and I to explore much more of the city than we could of without it.

 

 

 

Moving onto Thailand, this has been one of my favourite destinations for many years. I have found it challenging (I kind of like to be challenged in my travels) but really rewarding. This trip I focused on two areas, Chiang Rai which is a mountainous province in the North West of Thailand famous for the Golden Triangle, and Prachuap Khiri Khan province in South West Thailand. In Chiang Rai I hired a car from the airport, and for the Prachuap Khiri Khan I hired car and drove from Bangkok (about a 4 hour drive). I travel with portable hand controls which can be fitted to an automatic hire car.

 

 

The Chiang Rai area is incredibly beautiful, and I really enjoyed exploring the mountains and the area known as the Golden Triangle. The history of this area is rich and fascinating, and the food is to die for. The influence of different tribal groups, the surrounding countries and the West all make it an intense cultural experience. While not as filled with tourists as the Thai islands and Chiang Mai, there is still reasonable infrastructure.

 

 

The other area I went to, the Prachuap Khiri Khan province, is a beautiful province that is largely unspoilt. The place I stayed in is very close to the biggest national park in Thailand (more jungle than park). It is only about 50 minutes from Hua Hin, a nice seaside village on the coast which is a popular tourist destination. However, where I stayed is far from the hustle and bustle of tourists. It is a new resort, on a river that had otters in it! All the other guests were Thai, I was the only foreigner staying there. Driving there I passed through areas that warned drivers to beware of wild elephants on the road, the bird life is incredible, and the scenery must be seen to be believed.

 

 

Once again, the SmartDrive and FreeWheel played a critical part in my being able to explore these areas. In the mountains of Chiang Rai, the SmartDrive took me to places I could not have got to without it. The FreeWheel allowed me to explore dirt tracks and off-road areas, as well as cross a suspension bridge that had big gaps in the planks.

If you’re interested in any more details regarding these two trips, please don’t hesitate to contact me. I hope wherever your travels take you in 2020 you have a great time!

 

Malcolm Turnbull

Senior Advisor and Ambassador

Mal - 40 years a para’ 


40 years ago, in the late hours of January 6th, 1980, I was a passenger in a vehicle that went over a 20-metre cliff. After a long wait to be found and rescued, I arrived at Coffs Harbour Hospital with a broken rib, a punctured lung and a deep knowing that something was significantly wrong. Not long after receiving my x-rays the local doctor came with the news that my spine was severed at T5 level, complete, and that I would never walk again. It was a short conversation, in retrospect a blunt statement of fact that I remain grateful for. The full impact of this life changing event would unfold over the years and continues to unfold as I enter into my 60th year. 40 years, two thirds of my life, as a wheelchair user.

There is much I could write about my experiences in Prince Henry Hospital and the following years, enough to fill a book. But today I want to reflect on some of the changes that have happened over the past 40 years. 

There have been obvious changes in the quality and range of Assistive Technology available. My first wheelchair was a chrome plated folding frame wheelchair that weighed around 24kg. It was an “off the shelf” chair, it was so big I “swam” in it. Pioneers in modern wheelchairs, the likes of Michael Callahan, Nick Morozoff, Marty Ball and Mike Dempsey (all wheelchair users) paved the way for the amazing range of manual wheelchairs available today.

The advanced technology built into powered wheelchairs that allow for even the most mobility challenged users to not only get mobile, but to be able to do so in various seating/standing positions and with maximum comfort. Improvements in seating and positioning products, pressure care cushions and support surfaces, motor vehicle modifications and control options, off road devices – power assist was not even a concept in the 1980s. 

Environment control systems were starting to appear in the late 1980’s but they cost tens of thousands of dollars and required specialised systems and installs. Now off the shelf devices from mainstream companies are doing more than could ever have been imagined. Add to that the robotics that are in their relative infancy. I find the range of Assistive Technology available today mind boggling, and it is hard to imagine what will be happening in 40 years from now!

Apart from Assistive Technology, facilities for, and attitudes towards, people with disabilities have vastly improved. In 1980 I could access three railway stations in Sydney, there were no building regulations for accessibility, accessible toilets were few and far between and I can’t remember being able to book an accessible hotel room. In my first few years as a wheelchair user, I was referred to doctors in Macquarie Street, Sydney for specialised assessments – and all of their rooms were upstairs! I had to get out of my chair and “bum” it up the stairs, towing my chair behind me.

In 1981 the United Nations General Assembly proclaimed the first International Day of People with Disability which called for a plan of action at the National, Regional and International levels, with an emphasis on equalisation of opportunities, rehabilitation and prevention of disabilities. The theme of IYDP was "Full Participation and Equality", defined as the right of persons with disabilities to take part fully in the life and development of their societies, enjoy living conditions equal to those of other citizens and have an equal share in improved conditions resulting from socio-economic development. This accelerated awareness around disability both here and internationally.

In 2000 the Paralympics were held in Sydney, which really helped push improved accessibility. There is still a lot of work to do, here in Australia and internationally (especially in underdeveloped and developing countries) but it is a huge improvement from the 1980s.  

There have also been improvements in the attitudes towards people with disabilities. I remember when I first left hospital I would go to my local pub for a beer and people would walk past and drop a $2 dollar note on my lap (yes, we had $2 notes!). People asking my companion what I would like to eat instead of asking me, pushing my chair despite my protests, the most inappropriate questions, hushed whispers of pity and amazement that a wheelchair user could drive/work etc. It was not all bleak, of course, there were lots of fantastic people – like the staff at Ultimo UTS who made major adjustments to allow me to study Mechanical Engineering. But there was a general level of ignorance around disability that has improved greatly.

Again, there is a lot more to be done. People living with disabilities in Australia have high levels of unemployment, and there is still a degree of ignorance and fear around how to interact with people who live with disabilities. However, overall the understanding about people with disability has improved hugely. This is also reflected in the language used. Largely gone are terms such as “cripple”, “handicapped”, “retarded”, “disabled”, (although the “Disabled Bathroom” still gets a run – who wants to use a bathroom that is disabled?). In a recent trip my wife and I did a stop-over in Dubai and came across a sign referring to people with disabilities as “People of Determination”. My mum always said I was a determined little so-and-so.

Another thing that has changed dramatically is funding for people with disabilities. In 1980 you were either fortunate enough to be eligible for compensation (eg. from car insurance or worker comp) or you fell into a state-based funding scheme such as Enable. I vividly remember being in Ward 1 at Prince Henry Hospital and hearing compensation lawyers advise other inpatients to avoid work before their compensation case because this would reduce their “loss of income” payout. The compensation cases would often drag out for many years, by which time many people found it extremely difficult to return to the workforce.

The implementation of iCare Lifetime Insurance in NSW, and similar no fault insurance schemes in other states, was a big step forward but it still created a two tiered approach to care – those in the iCare scheme had access to the best equipment and care available while those in the public schemes had access to basic equipment and care. The implementation of the NDIS has been a major reform and is potentially the world leader in provision of services and equipment for people with disabilities. Again, it is not perfect and the lack of uniformity across the nation is frustrating, but it is a huge step forward and at its core embraces principles of empowerment, inclusion and participation for people with disabilities.

There is so much more that can be written, and I am sure others would have lots to say about this. Disability Advocacy groups such as The Quadriplegic and Paraplegic Associations, NSW Physical Disability Council, CPAs – so many great organisations – have made and continue to make a positive impact on the lives of people with disabilities. Medical developments, from the ambulance and first responders to the fundamentals of bowel and bladder care to advanced scanning and medical procedures have made a huge impact. Research into best practise for therapists and clinicians, the expertise and professionalism of Assistive Technology suppliers, access to travel and sports – the ground-breaking Sargood on Collaroy facility – the list goes on. 

Finally, I want to acknowledge the generations of end users that have paved the way for people with disabilities – passionate and forward-thinking wheelchair users like Mark Bagshaw, Chris Sparks, Nick Morozoff, Errol Hyde, Kevin Coombes, Kurt Fearnely and many more.

 

Malcolm Turnbull
Senior Advisor and Ambassador

The Pushtracker E2 - First Impressions

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Last month saw the release of a long-awaited update to the SmartDrive, the all-new Pushtracker E2!

If you’re looking at a power assist option for the first time, or you’re an experienced user of the SmartDrive with the previous Pushtracker, you might ask “why make the switch? What makes the Pushtracker E2 a must-have?” After using the previous Pushtracker for almost 3 years, I took the E2 through its paces and my usual route to university!

The first thing you notice is that the E2 is a smart watch, using the Mobvoi TicWatch E2 as the foundation. This new hardware ups the build quality and gives the user additional functionality such as apps on Google Play Store, phone and social media notifications, weather and all the rest. Like me, if this is your first smart watch you’ll appreciate getting your phone messages straight to your wrist. As a wheelchair user I keep my phone in a bag rather than my pocket – meaning that this is a game changer!

 

 

It also looks like a device that anyone would wear, which is important for many of us. I also can’t wait to change the wristband to something more stylish. The Pushtracker E2 is compatible with most standard 22mm bands. While on the topic of aesthetics, you can choose from dozens of watch faces and customise it to show both Pushtracker and SmartDrive Battery.

The instructions were simple enough – download WearOS on your phone, turn on the Pushtracker E2, and pair the two. Sign into your Google account on the E2 and go through the prompts. It takes a short while to update all the software, during which the watch may feel slow. Once set up, head into the Play Store to find your Permobil apps.

Permobil developed two apps for users to download onto the watch – Pushtracker to keep track of your wheeling activity, and SmartDrive MX2+ - your main control to activate your SmartDrive. The apps look sleek and are much more intuitive to use on the AMOLED touch screen compared with the old Pushtracker. You’ll want to Favourite the SmartDrive app so you can quickly press the menu button and launch the app before you tap.

https://www.youtube.com/watch?v=jLEK1C_6UiA

 

How does it feel initially? If you used the old Pushtracker it’s both familiar and different. In my case it was too sensitive by default, so I fiddled with the Tap Sensitivity setting until I found the sweet spot. For me that’s 70%. Be sure to go through Tap Training in the app settings menu to become familiar with the responsiveness. In any case, the first trip out with the Pushtracker E2 was like a mini retrial. I recommend everyone to carefully get the hang of it before using it in tight places. Pretty soon I was using it just as intuitively as before.

The trek to my university is almost one, giant hill, so I can't imagine tackling it without a power chair or power assist. It's a 5 minute ride from the station and just accessing the library at the top means there's a hill from every direction.

 

 

From my experience so far, I didn’t experience any disconnection with the Bluetooth while in-use, unlike the frustrating black spots I encountered with the old Pushtracker. The new hardware sports an antenna that’s 8 times stronger than before and it definitely feels like it.

The only trouble I had was in the initial tap to go during the first day or so, getting used to the new feel of the watch. The different sensitivity also meant the speed unintentionally set too early making have to stop and start again.

Finally, and crucially, is battery life. I noticed when not in-use the battery is far more capable than the old Pushtracker. How fast the E2 drains depends on how you use its smartwatch functions. Like a phone, I noticed it can get dangerously low towards the end of the day if the display is always in use. I recommend turning off the always-on display, reducing the brightness a bit and always turning off the SmartDrive app, away from its ready-to-tap screen whenever you stop using your power assist.

 

But with so many devices I now carry with me, a powerbank is an essential item in my backpack. It will also win you some friends! Charging is very fast and the E2 comes with a USB charger to plug into a computer or power adapter. If you charge with a computer, a blue USB 3.0 port will give maximum charging rate.

If I was to find a complaint, it would be that the watch is a bit large for my skinny wrist. But I can understand the designers opted for a size that can be easier used by those with limited hand function. For a touch screen, bigger is easier.

As an active user who needs to get around town every day, the E2 feels like a natural transition. Whereas before I would wear the Pushtracker only because I had to use the SmartDrive, I now wear it because it’s just useful for everything else. Have you got your hands on the Pushtracker E2 yet? Sound off on your thoughts below!

 

Sergei

 

Continuing Professional Development (CPD) requirements for Occupational Therapy registration

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New Zealand and Australia both require Occupational therapists to complete ongoing training as part of maintaining competency as a registered therapist. Both Systems require OTs to be nationally registered and to prove ongoing competence to the board on request. This competence is measured by the training and education opportunities that the therapist has undertaken throughout the year.  Both systems have an expectation that therapists will maintain standards and stay up to date with latest technology and practice by attending ongoing education. 

 

With a wide choice of ongoing education opportunities available in relation to AT, the education team at Permobil are confident that our clinical education courses meet the updated registration standard. For Australians the CPD hours have been reduced to 20 hours as of Dec 1st, 2019. It is important for therapists registered in both countries to keep up to date with the requirements their board imposes.  Audits for previous years will still require you to meet that year`s requirements.

I recently had a conversation with a senior OT / Team leader who was asking about our education opportunities for her staff. She articulated she had previously attended “CPD trainings” that did not offer her any professional development as were not pitched at a level she felt met the course description. She reported that she was happy to send her staff to workshops with our team as she felt they provided good skills and learning opportunities for her staff. She expressed her frustration at releasing staff to find that the course she sent them on did not actually benefit their roles.

An increasing number of services are working in a billable hour’s models, with national insurance schemes in place in both NZ and AU. This can put increased pressure on income generation and taking time out for education is not always seen as a priority. However, CPD needs to be given value, partly due to it being a board requirement but mostly because it helps us grow and become better therapists by setting goals and pushing ourselves to constantly grow.

How do we make CPD work for us? Set yourself clear goals and look for training opportunities that will address your goals. Read course and workshop descriptions to see if they include skills or information that will assist your practice. Talk to educators about your goals and needs if you`re not sure that it’s the right workshop for you. Talk to colleagues that have attended the training already if it`s been previously run and how they found it, time is precious, and you want to be getting the training you expect!  Just attending a workshop or webinar whilst a great way of meeting your CPD hours is not the sole intention of CPD. How will you implement what you have learned into practice? How has the training enhanced your knowledge and work role? What do you need to do next? More important than the certificate you may receive is holding onto any notes you have written at the training, better still a small reflection on what you have learned, how you will use it to improve practice and where to next.

2020 Permobil education will continue to provide educational opportunities around Australia and New Zealand. We have a range of new and existing workshops that will be run face to face around Australasia. Watch out online as we will be releasing these new additions very soon.

We will also continue to develop our webinar platform for more product specific training and of course our weekly blog! Over the next few weeks Sergei and Mal will be sharing some exciting and informative real-life experiences through our blogs and Rachel and I will return next year with the clinical blogs.

On behalf of the clinical education team and Permobil we would like to thank you for your continued support of our Blog this year and wish you and your families safe and happy holidays!

 

Rachel and Tracee-lee

To pommel or not to pommel, a look at adduction points of control

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Historically known as a Pommel or an Abductor, the new ISO terminology to describe this product parameter is a medial thigh support. This support can be independent of the seating (attached to the seat pan of the mobility base) or built into the cushion through the contours of the cushion itself.

Abduction and adduction of the hip joint are a continuum; neutral positioning is when the knee joint and hip bones are in line and symmetrical. If the knee is medial (Knees together touching) the hip joint is adducted. If the knee joint is lateral to the hip joint (Knees apart), the hip is abducted.

 

 

We frequently refer to the sitting position being as neutral as possible and we know if the wheelchair is too wide this has a negative impact on the shoulder joint for self-propulsion. So why do we use medial thigh supports in seating? When do we consider its use? What are the disadvantages of this type of support? We also know that the larger the base of support the more stability gained, abduction increases our seated base of support thus can be a preferred position. Body dimensions may also require a more abducted seated position, so why not sit everyone abducted?

In addition to forcing self-propulsion from a vulnerable position (in shoulder abduction), the increase in the width of the seating may also decrease accessibility in some environments. The clinical reasoning process needs to consider the hip ranges of motion established in a MAT assessment, tone patterns, proximal stability of the pelvis, and users’ functional goals to determine the seating parameters. What kind of supports are required based on the capacity of someone to gain functional support and stability?

 

                                  Abduction                                                             Adduction

                                                                                     

  

 

 

 

 

 

 

 

 

 

 

 

 

If a femur is positioned in more abduction than there is passive range, the impact on the pelvis will be seen with the pelvis rotating in the same direction to enable the femoral position.  This is commonly seen when a non-reducible wind sweeping position is not accommodated. Wind sweeping is the tendency for both limbs to sweep to one side – one hip will be abducted and the other adducted.

Longitudinal hip surveillance studies have provided us invaluable information on hip migration, causations, high risk group identification and resulted in guidelines such as https://www.ausacpdm.org.au/wp-content/uploads/2017/05/2014-Aus-Hip-Surv-Guidelines_booklet_WEB.pdf - which is an excellent resource.

 

 

 

The resource explains “Progressive displacement can result in asymmetric pressure that may deform the femoral head and or acetabulum (also termed acetabular dysplasia). Hip dysplasia may lead to degeneration of articular cartilage and pain25. Problems with limited range of movement and pain can interfere with function, ability to be positioned, hygiene and personal care. In a large subset of children the progressive displacement can develop into dislocation of one or both hips (Cooke et al, 1989).”

For anyone working or caring for young children with Cerebral Palsy and mobility impairment, potential risk groups have been identified and are encouraged to be referred to a hip surveillance program. Seating positioning recommendations for these children is likely to include some abduction for either chair or bed positioning.

One thing a pommel is not is a load bearing surface or a safety stop! When someone does not have the hip flexion ranges to sit with the hips bent at 90 degrees they are likely to “slide” out of the seating as they try to open their hip angle to meet the seat-to-back angle of the seating. I have been involved in cases like this where the support people then ask us to make the seat more ramped – based on the anti-thrust seat concept they may have had as a child or seen others utilising. If they do not have the range to sit in a 90 degree seat-to-back angle, raising the front of the cushion will only make it more difficult to maintain a flexed hip. They will continue to attempt to open this angle by sliding into posterior pelvic tilt (PPT) – see my previous blog for more on that.

If there is a pommel fitted this is often all that is holding the individual in the seating if they don’t have the capacity to bend their hips enough. When doing custom seating I would often have support workers or carers asking for this pommel to be larger as it stopped the user from sliding out. If we are prescribing AT, It is part of our job as a therapist to be able to articulate and educate what the points of control are and how they can benefit someone’s positioning and ultimately their function.

 

             A Dreamline Swing-Down Abductor Pommel

So, what is a pommel? What point of control is it addressing? The purpose of a pommel or leg troughs in a cushion are solely intended to reduce the level of adduction. The ongoing implication for adduction includes instability, increased difficulties with personal care and hygiene tasks, increased pressure risk at the knees and of significant concern, increased risk of posterior hip dislocation especially for those individuals who have never had opportunity of the hip fossa fully developing through walking and weight bearing.

When considering a pommel or a support to decrease adduction, there are several factors to consider. Should it be integrated into the cushion? This is likely to be determined by factors such as transfer style. Should it be removable? What environments is the user in requiring support? Can the support workers easily fit and remove it as required? How high is it? Generally, it does not need to protrude above the user’s thighs. What angulation can be achieved? Can it be adjusted for ongoing needs?

Do you want to know more about product parameters, MAT or functional seated positioning? Permobil offer a range of workshops including practical hands-on learning opportunities, blogs, workshops and webinars. Don’t hesitate to reach out to us for further information! Follow our blog to be the first to find out more details on our 2020 training opportunities which will be released very shortly!

 

Tracee-lee Maginnity