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Shoulder Preservation Part 3: The Recommendations for Shoulder Preservation with Manual Wheelchair Propulsion

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Did you know that the average number of pushes per day for a full-time manual wheelchair user is 2,000 to 3,000! Take a second and let this number sink in: 2,000 to 3,000 pushes every day. Now, go ahead and use that great technique we talked about last week and just take your arms and shoulders through 10 pushes. That was 10 pushes and without any bodyweight, weight of the wheelchair, friction of the chair across the ground, etc…. If we are not ourselves a wheelchair user, we cannot fully understand how our shoulders would feel propelling every day, but we can gain an understanding on the amount of work that the shoulders go through on a daily basis and what steps we can take to help in preserving the shoulder long term.

As a therapist, we cannot learn everything in our university, so it is important that we are always continuing the learning process and relying on researchers and experts in our field to guide us in our clinical practice. I often refer to our clinical best practice guidelines and today I want to talk about one of my favourites for shoulder preservation:
 
Preservation of upper limb function following spinal cord injury: A clinical practice guideline for health-care professionals. I highly recommend, if you haven’t already, downloading a copy. In reading the clinical practice guidelines there are 35 recommendations based on evidence-based research to promote preservation of the upper extremity. We will not cover all 35 recommendations, but over the next several blogs we will slowly be covering a few recommendations listed below:
 
1. Provide manual wheelchair users with SCI a high-strength, fully customisable manual wheelchair made of the lightest possible material.

2. Adjust the rear axle as far forward as possible without compromising the stability of the user.

3. Position the rear axle so that when the hand is placed at the top dead-centre position on the pushrim, the angle between the upper arm and forearm is between 100 and 120 degrees.

4. Educate the patient to:
    a. Use long, smooth strokes that limit high impacts on the pushrim.
    b. Allow the hand to drift down naturally, keeping it below the pushrim when not in actual contact with that part of               the wheelchair.

5. Promote an appropriate seated posture and stabilization relative to balance and stability needs.

6. Incorporate flexibility exercises into an overall fitness program sufficient to maintain normal glenohumeral motion and pectoral muscle mobility.

7. Incorporate resistance training as an integral part of an adult fitness program. The training should be individualized and progressive, should be of sufficient intensity to enhance strength and muscular endurance, and should provide stimulus to exercise all the major muscle groups to pain-free fatigue.
 
Hopefully as you read through all of these recommendations at least one or two makes sense already. Today, we are going to end with two videos from the extremely talented Madison de Rozario. Madison is an Australian Paralympic athlete and has helped create a few videos on the importance of shoulder health. In these videos you can see Madison touch on many of the above listed recommendations.
 

 

  

 

Next week, we will continue our discussion on shoulder preservation and deep dive into the recommendations.
Rachel

References:
Preservation of upper limb function following spinal cord injury: A clinical practice guideline for health-care professionals. J Spinal Cord Med. 2005; 28 5: 434–470.

 

Shoulder Prevention Part 2: The Shoulder During Manual Wheelchair Propulsion

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What happens when an individual propels a manual wheelchair?  What muscles are being activated? Does it change across the lifespan?  We will not cover this entire topic today but let’s begin with what is happening with the shoulder during manual wheelchair propulsion.

The first question we have to ask is WHY?  Why are we even talking about the shoulder during manual wheelchair propulsion?

Because the number of individuals who are full-time manual wheelchair users who will develop shoulder dysfunction and/or pain at some point in their life is staggering.  There is up to a 73% reported incidence of repetitive strain injury among full-time manual wheelchair propellers, with the shoulder being the most commonly reported site.  It is important for everyone, no matter if you are the therapist, carer, family, end-user, or supplier, to come together to provide the optimal equipment and outcome for the end-user to decrease their risk of shoulder dysfunction.

Starting at the very beginning, is understanding propulsion. Propulsion can be broken down into two phases: push phase and recovery phase.  In the photo below you can see the two phases highlighted.  The push phase first begins when the hand contacts the push rim and continues until the hand is released from the push rim.  The recovery phase occurs when the hand is first released until the hand makes first contact again with the push rim.

These are the two phases, but how the individual moves through these two phases can vary. Below is a photo showing a few different types of propulsion techniques. These techniques may be confusing to look at in a photo, so you can also click this link to watch a video discussing the optimal push technique.  This optimal technique, called the semi-circular technique, is discussed in the PVA clinical practice guideline for shoulder preservation referenced at the end. We will discuss propulsion technique further in the next blogs, but for today we will go back to the two phases of propulsion.  During each phase, different muscles will be required or activated.

 


 

 https://www.youtube.com/watch?v=BD9kp4u89Gc&feature=youtu.be

There are many studies looking into the activation of muscles during propulsion. This research can be challenging due to the inherent number of variables with testing. For today, we will look at a study by Mulroy and colleagues from 2004.  This study looked at individuals with spinal cord injuries and found the following muscles were activated during each phase:

Push Phase:

Anterior Deltoid, Pectoralis Major, Supraspinatus, Infraspinatus, Serratus Anterior, and Biceps

Recovering Phase:

Middle and Posterior Deltoid, Supraspinatus, Subscapularis, Middle Trapezius, and Triceps

Look at the number of muscles involved in propulsion!  What as a therapist, or end-user, are we doing to protect and strengthen the shoulder? We want to be sure that we are addressing the shoulder from the beginning whether this is through stretching, strengthening, positioning, modifications or education. This will vary for each individual based on their pain level, diagnosis, strength of each muscle, etc… It is best to have an individual program designed by a therapist to ensure that the end-user is safe.

Next week, we will continue to discuss the shoulder and manual wheelchair propulsion, propulsion technique, and look at some of the ways our end-users are taking care of their shoulders!

Rachel

Shoulder Preservation

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Part 1: Starting with a Foundation

As a therapist working with individuals with mobility impairments, did you ever think you would have to know so much about one joint? What joint am I talking about? The SHOULDER! I remember sitting in a classroom many years ago now, telling my classmate that I couldn’t wait to get past the orthopaedic semester and get to the neuro semester. I knew that I wanted to go on after my degree to work with individuals with spinal cord injuries, why did I need to sit through this whole semester on orthopaedics? Of course, after my clinical rotation on my neuro complex, I realised the importance of that semester on orthopaedics and the impact that orthopaedics had in every client that I saw. I often hear therapists tell me that they don’t really remember much from their university about the shoulder or that they “aren’t very good with the shoulder”. As a therapist, it can be challenging the amount of information that we are expected to know to a high degree, but understanding the why gives us the foundation to critically think and be able to examine a situation, client, or piece of equipment and formulate our treatment plan or product selection.

Over the next several weeks we are going to be discussing the shoulder.

 

 

The shoulder is the joint in the body I feel most passionate about, as many of our clients will be relying on their shoulders to now be their main means of mobility. It is crucial that we understand the shoulder from the inside out, building a foundation, as we want to preserve the strength and integrity of the shoulder for our clients for as long as possible. Today, let’s take a couple minutes to understand why the shoulder has such an impact on our clients.
First, we have to go way back to our anatomy class. We are going to mostly focus on the shoulder joint itself today, but we need to remember that the shoulder complex is comprised of 4 different joints that will all play a role into our client who relays on their shoulders for mobility. These 4 joints include: the glenohumeral joint, referred to as the shoulder joint; the acromioclavicular or AC joint; the scapulothoracic joint; and the sternoclavicular or SC joint. These 4 joints work together to provide the great amount of motion that the shoulder complex has.
We learned that the shoulder joint is a ball and socket joint just like the hip, but unlike the hip, the joint capsule is shallow. Look in the photo below. This shows the difference between the two joints. One of the joints is designed for stability, while the other is designed for mobility, mobility in this case meaning a wide range of motion. Do you know which one the shoulder is? That’s right! Hopefully you said the shoulder is designed for its wide range of motion. The problem is that this comes with a cost. The shoulder because it has such great mobility, is very unstable. There are ways that the shoulder joint gains some stability through the rotator cuff muscles, the ligaments, and the labrum. With these additional supports, do we get the stability in the shoulder we need for our full time manual wheelchair user?

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It is important that we consider the demands being placed on the shoulder by an individual with a mobility impairment. We have to consider the mobility impairment and the demand that the impairment places on the shoulders. For example, an individual who is a full-time manual wheelchair propeller versus a full-time power wheelchair user. While the individual who is using the manual wheelchair will have to rely on his/her shoulders for their propulsion, both individuals will have to reach overhead throughout their day. This is a key point that we will come back to in later blog sessions as overhead activity can greatly increase the risk of shoulder pain and dysfunction. We can decrease this risk in a power wheelchair with power seat functions when prescribed, but have we educated the client on the use of these power seat functions for shoulder preservation? Does the client understand the importance of limiting the amount of overhead activity throughout their day? How does this differ from an individual who utilises a manual wheelchair for mobility? Next week, we will begin with the demands of the shoulder for a manual wheelchair user.

Throughout the next several blogs, I hope you will continue to learn about the shoulder, its increased importance for clients with a mobility impairment, and the information that we need to continue to or start to consider when prescribing a manual or power wheelchair.

Rachel

 

The Importance of Our Support

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“Every person has the right to have his or her disability compensated as far as possible by aids with the same technical standard as those we all use in our everyday lives.” Dr. Per Uddén
Think about all of the different industries out there. Even if we make this smaller by just considering the industries within healthcare and technology. How many are there? How do they survive, but more importantly how do they thrive? What do I mean by thrive? Today, I am not talking about how much money the industry makes, but rather the advancement of the industry.
Look at some of the industries out there and the constant advancement they are achieving, such as the car industry. This is not just because of the financial backing that they have, but by the involvement from their customers and the industry as a whole. Every day I come to work, I remember the quote at the top. I am here to help in making this statement a reality, just as every one of you reading this blog has a part. Some of us may support this effort through hands-on work with the end-user, some may do this through providing the equipment, or you may be the individual receiving this equipment. No matter what our role is, we all have to work together to continue to push for more research, more innovation, and more advanced products.

One of the most important ways we can support our cause and our industry is through involvement! Involvement allows our voices to be heard, involvement allows for us to further our knowledge, and involvement allows for our industry to continue to grow, develop, and improve. One of the best ways we can get involved is through industry wide conferences, events, and expos. Some of these events allow us the opportunity whether you are an end-user, parent, carer, therapist, supplier, or manufacturer to meet under one roof with the same main objective – for an individual, regardless of a disability, to live their life to the same technical standard.

I am discussing this today as we have a fantastic opportunity to support our industry next week in Sydney with the ATSA Independent Living Expo. This is the perfect example of an expo that provides the platform to move our industry forward. One of my favourite parts of this type of expo are the presentations. This is an opportunity for end-users, family, therapists to all come and learn the most updated research, current affairs within the industry, and the opportunity to ask questions! The more we as a community support, not only the expo, but the presentations through attendance we push the presenters to provide the most up to date, applicable, research driven information.

 


The most important advice I can give is to remember to ask questions. Whether it is in the presentations or on the floor of the expo, it is important for everyone to ask questions. Questions allow learning and development. Questions are what push us as an industry to advance in our technology, research, and innovation. If we never asked questions, we would just become complacent. It can be intimidating to walk up to a manufacturer, supplier, etc… in the expo, but here are a few ideas to get the conversation started:
Do you have any new products this year? Why were these products designed? What makes them unique? How can they assist in the improvement in the quality of life of the end-user?
It isn’t just about asking questions either. Try it out! Don’t be afraid to get hands on! You can’t always try out every product but ask if you can. One of the best ways we can learn is through trialling. Whether it is sitting on a cushion, driving a power wheelchair, or trying out a robotic arm. Make sure you are keeping safety at the front of this exploration but have fun learning!
Remember that the only way for our industry to continue to develop new products that will better support the end-users, is to create a reason for that continued development, creating the intention for each new design. One of the biggest pushes in this comes from all of you! Asking the questions, providing feedback, and letting the manufacturers know what it is that you need and want. In many industries the customer and the manufacturer are seen as two separate groups, fighting against each other. I want to charge us as an industry to continue to work together to achieve our common goal. One of the greatest ways that we can do this is through events such as the ATSA Independent Living Expo. Whether you are a therapist coming to attend the presentations and learn, an end-user coming to see the products first hand, or a family member just a little over-whelmed and wanting some information – ATSA’s Independent Living Expo is for you!
Here are the dates below for this expo and a few other upcoming expos in Australia and New Zealand. Feel free to email me or post below with other expos going on in your area. I will be at all the events listed below, so be sure to stop by and say hello.

 

ATSA Independent Living Expo

https://www.atsaindependentlivingexpo.com.au

Sydney, May 8-9
Brisbane, May 15-16
Canberra, August 27-28

 

 ATSNZ Expo– Assistive Technology Suppliers New Zealand

 https://www.atsnzexpo.co.nz/

 Auckland, May 23

 

 Source Kids Disability Expo

https://www.sourcekids.com.au/expo/expo-brisbane-2019

Brisbane, July 5-6

 

Oceania Seating Symposium (OSS)

http://www.cmnzl.co.nz/oceania-seating-symposium/

Melbourne, November 12-14

 

 

Understanding the Cushion: How the Cushion Works

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Last week we talked about the importance of increasing surface area contact to redistribute pressure for skin protection. Today, we will talk about two ways in which we can achieve this pressure redistribution: Immersion and offloading.


IMMERSION
Immersion is how much the client sinks into the surface. Immersion works by increasing the surface area contact and therefore redistributing the pressure. Remember from physics in our university that Pressure = Force/Area. The easiest way to describe immersion is to think about how much we sink into a surface, in this case a cushion. When our client sinks into their cushion the amount of surface area contact is increased as opposed to if they are sitting on top of a cushion. A great example of a cushion that works through immersion is a ROHO cushion. ROHO has specific instructions on how to properly adjust the cushion in order to have the full amount of immersion. This is designed to provide the greatest surface area contact and therefore achieve the optimal amount of pressure redistribution. Imagine now if we had a fully inflated ROHO cushion and the client was sitting on top of the cushion… would we still get that immersion into the cushion? No, we would lose the benefits of immersion in this case and decrease the optimal amount of pressure redistribution.
While immersion is a great design not every cushion can work through immersion. Sometimes we don’t want to “sink” down into the cushion, or maybe we can sink down a small amount, but not enough to provide that full amount of pressure redistribution. Let’s take for example a flat foam cushion. Should our client be able to sink down far into a single layer flat piece of foam? If our clients are sinking down far into a single layer flat piece of foam, what is protecting them from bottoming out onto the hard surface under this foam? Foam can often be layered to allow for some immersion on the top while still giving a base for support, but this is why we typically see foam working through the principle of offloading.

 

OFFLOADING
Offloading is just what the name suggests! With offloading the cushion is designed to off-load the pressure under a particular area. In this case, typically we see offloading designed to decrease the pressure under the ITs, ischial tuberosities. The ITs, or your sit bones, are one of the points of highest risk of skin breakdown due to it being the lowest point on the pelvis and therefore having the most amount of pressure placed on this area if sitting on for example a flat piece of foam. The easiest way to think about offloading is to think about a tyre. It you were to sit on a car tyre you would have the open ring of the tyre under your ITs and therefore no pressure would be applied to that area. This is true offloading. What we have to remember though is that although we have offloaded in one area, we have decreased the over all surface area contact. Therefore, we have increased the pressure to the areas that have contact, Pressure= Force/Area. These areas might be able to withstand higher pressures, but it is important to keep in mind. What is more common is to provide partial offloading. This is what we see with pelvic/ischial wells, through contouring and material layering. Partial offloading works by trying to load through the femurs first and thereby allowing for partial offloading of the ITs, sacrum, and coccyx.
It is important that you can look at a cushion and understand how a cushion will work for your client. This is how you are able to narrow down the options for your client and determine which cushions may be appropriate.
If you are interested in furthering your knowledge on the materials and principles behind cushions reach out to Rachel Fabiniak at Rachel.Fabiniak@permobil.com to schedule a clinical education course in your area.

 

 

Understanding the Cushion: Why it matters what we are sitting on?

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Have you ever been to an event where you had to sit on hard metal benches for hours? They are so uncomfortable that many people bring thin foam cushions to help alleviate pain and discomfort. OR have you had to drive during a long road trip and can barely feel your bottom at the rest stop because it has gone numb? That is why truck drivers often purchase cushions to sit on in their trucks.

What is happening?

The pain that we feel when we sit on a firm, flat surface for long periods of time is due to a buildup of pressure right under our bony prominences. The most common bones are our “sitting bones,” the ischial tuberosities (ITs). As well, we often slouch and can sit right on our sacrum and/or coccygeal bone.

If we do nothing to protect those bony areas pressure builds up, cutting off blood supply, oxygen, and nutrient delivery to that area, leaving the skin and tissue between the seat surface and the bony prominence susceptible to ischemia. As we start to feel our bottom go numb, we begin to move and fidget, trying to relieve the discomfort or numbness.

What about our clients? Can they all move around to relieve this discomfort?  Or, do they even have the sensation to know that they need to move around?

We prescribe our clients a cushion to help assist with pressure relief, but do we understand what that cushion is doing?  It is important to understand the design and theory of how a cushion works to ensure it is the right type of cushion for your client.  If we are looking at a cushion for skin protection, we are looking at cushions to increase surface contact area.

Increasing Surface Contact Area:

We have to step back into our physics course to first understand.  Pressure is equal to Force over Area: P=F/A. Pressure can never truly be eliminated, but it can be redistributed to greater surface areas to produce less pressure. So, our goal should be pressure redistribution over the greatest surface area rather than only through small surface areas that would increase pressure.

 

 

How do we redistribute pressure in a skin protection wheelchair cushion?

We know now that we want to increase the surface area that the client contacts when sitting on a cushion. Pressure distribution can be accomplished in one of two cushion designs:

  •          Immersion
  •          Offloading

Next week we will begin our discussion on what these two design principles are and how they work.

Ana Endsjo, MOTR/L, Clinical Education Manager LTC Division Business Region Americas and Rachel Fabiniak, Clinical Education Australia/New Zealand

 

 

Mobility is a Human Right?

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Mobility is a Human Right. Take a second to think about that statement. How do we define mobility? Is it simply the act of moving from one place to another? The Oxford English Dictionary defines mobility as the ability to move or to be moved freely and easily. I want us to focus on the beginning part of this definition – the ABILITY to move. Then, every individual, whether they are a child, adult, or elderly, that has the ability to move, should be provided the opportunity for mobility.

 

I had the privilege of attending the Source Kids Expo in Melbourne, Australia this past Friday and Saturday. Source Kids was started by Emma Price, a mom whose eldest child has a disability. Emma created Source Kids as a resource for other parents raising children with a disability. This past weekend I was able to meet families from all around Victoria (and Australia). While some families approached with questions in hand and ideas about what they were looking for, many families came with a blank slate hoping to learn a little more about what resources were available. It was incredible to witness the number of families and therapists that attended this expo.

 

 

 

Throughout these two days, we were able to help several children experience independent mobility with a manual or power wheelchair for the first time. The age of the children that trialed manual or powered wheelchairs ranged from 2.5 years old and up. Some of the parents had wanted to try out a wheelchair while others had never thought it possible for their child to learn and use a wheelchair. I cannot accurately describe the feeling that comes over you when you see a child move around efficiently and independently with a wheelchair for the first time, but their face says it all. It is true happiness. While these amazing moments continued throughout the expo, I couldn’t help but consider all the individuals that have potential for safe, independent mobility but may never have access to this type expo. That is why this week the blog was shifted from a discussion on cushions and is now dedicated to Mobility! We know that not every individual will have the capacity to perform independent mobility even given the best mobility devices on the market, this is why there are so many great options out there for wheelchairs and mobility devices that can be controlled by carers and family. For those individuals that do have the capacity, we have to remember that mobility is a human right. It can be challenging whether you are a carer, parent, family member, friend, or therapist to know if someone is appropriate or the “right age” to trial a mobility device. I want to challenge everyone to stop thinking about if and when someone is appropriate, instead believe that everyone should be given the opportunity for mobility until they prove that they are unable to or would be unsafe.

 

 

While we have children on one end, we also have to remember the aged population. These individuals may have had independent mobility their entire lives. Is there an age where we can say it is okay that they no longer should have safe independent mobility? What age is that: 90, 85, 78? Once you hit that age then we should just give you a wheelchair that you can sit in, but are not able to move? Is that independent mobility? Or, have we taken away this human right? There is no age where safe independent mobility should be denied. The key is of course that this mobility is safe. Let us as therapists, families, and as an industry to make sure that we are not denying this potential safe and independent mobility to anyone regardless of their age.

 

It can be scary to determine if someone is ready for safe, independent mobility, but remember you have resources to help! Never be afraid to ask questions to safely determine if someone has the capacity to trial a mobility device. Giving someone independent mobility who has the ability to move is their human right.

Rachel

 

There Are So Many Cushion Options: Where do I start?

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Over the next several weeks, we will be discussing cushions and how to choose the right cushion for your client. It can be challenging to pick a cushion for a client when there are so many options out there today. Some of the questions I commonly get are: Where should I start? How do I narrow down the options? What will work best for my client? Can I just keep them on the same cushion they already have?

 

Let’s start by first considering the client goals and your goals as the therapist. These might include goals such as: positioning goals, skin protection goals, or function-based goals. Often, we might have multiple goals for seating that we are trying to meet. Take a look at the chart below. Here are a few examples of goals that we might be trying to meet with the cushion. We have to remember that one cushion may not be able to achieve all of our goals, but what is most important? Where can we have overlap? How can we achieve the best outcome for our client?

 

 

 

Once you decide what goals you are trying to accomplish then you can begin to look at what design of cushions you should be considering. Let’s consider two examples.
Client 1: The therapist’s goal and the client’s goal are both to maintain the client’s posture thereby allowing the client to have increased function. The current cushion does not maintain the client’s position, allowing the client to collapse into a posterior pelvic tilt and therefore decreasing their range of motion with shoulder flexion for overhead activities.
Client 2: The therapist’s goal is skin protection. The client has a history of multiple pressure injuries on his ischial tuberosities bilaterally. The client has been limited in their sitting tolerance due to pressure and therefore the therapist is looking for the best possible skin protection cushion for their client.

For these examples above would the Client 1 and Client 2 benefit from the same cushion? Perhaps, but not likely. Look at the example of two cushions below. Which cushion would you trial with each client?

 

You could trial both cushions for each client, but in this case if we had to choose, we would choose the air-cell based cushion for client 2 and the contoured foam cushion for client 1. How did I come to this conclusion?

 

The next step is to understand the design and materials of cushions to determine when or why you might choose one cushion over another. Next week we will begin with discussing the design behind cushions and how they work.
For this week it is important to remember that there is not one cushion that works for every client! In fact, every client even with the same cushion will have a unique interaction. We can even go as far to say that the same client on the same cushion will likely have a different interaction with that cushion each time they sit on it as they sit slightly different each time and many clients move around throughout their day.

Rachel

What Causes Pressure Injuries? 

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We just finished discussing backrests over the past several blogs.  We will now move onto another support surface: Cushions.  But first, I want to take one step back and discuss pressure. Pressure is one of the reasons that we all spend so much time considering the support surfaces for our clients.  Today we will have a little review on pressure from Ana Endsjo, US Clinical Education Manager LTC Division.
 
When we talk about wounds caused by pressure, we often only consider the pressure on our bottom. However, pressure can be created by any support surface that comes in contact with the body such as the: the backrest, cushion, arm rests, and head support.
 
So, let’s clarify the definition of pressure when considering it from the seated posture.
 
Pressure is a continuous force applied on or against an object through direct contact. In seating, equipment such as the seat and/or back support surface is in constant contact with the body, creating peak pressures.
 
Peak pressure is a constant pressure directly under or against the bony prominences that will cause a pressure injury without proper pressure redistribution through appropriate cushion and back support choices. Peak pressures are commonly found at the ITs, sacrum, coccyx, and on the spinous process, injuring the skin and underlying tissue, muscle, and, in extreme cases, bone.
 
 Pressure from a seated posture comes from:
  • downward pressure from gravity
  • upward pressure from the seat surface
  • horizontal pressure along the spine from the back support
  
When these peak pressures are not addressed through proper pressure redistribution techniques with the appropriate cushion and back support, the skin, tissue, and bone is compromised. Sustained loading against the back support and/or seat surface causes constant compression of that skin and tissue under a bony prominence, leading to a pressure injury. The degree of injury depends on the layers of skin impacted.
 
It is important that we as therapists begin to understand the critical role that the seated posture plays in the prevention and treatment of pressure injuries.
 
Thank you Ana.
 
The next several blogs we will be discussing cushions. From materials of cushions to what type of cushion will be best for your client, cushions can vary greatly, and it can be challenging to look at a room full of cushions and know which ones to pick for your client.
 
Rachel
 
 

 

How do I choose a backrest for my client?
 
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We have talked for a couple weeks now about backrests and the importance of choosing the right backrest for our client, but how do we make that final decision? There are so many backrest options out there and typically a client can benefit from more than just one option. Often, I am asked the question, “As a therapist should I know all the backrest options on the market?”  The answer is simple – NO. Your role as the therapist is to know what your client would benefit from for positioning, function, comfort, etc… Then, to communicate those needs to your supplier who can offer specific options. Remember that the client should have options, and your supplier will offer these.
 
This is not to say that every client should trial 5 different backrest options at the seating appointment, but instead to keep in mind that there are options.  We want to consider what the goals of the seating system are, and then determine when discussing or trialling a backrest option if that option is meeting those goals. Those goals being both your goals as the therapist and the goals of your client.
 
 
 
So now you have looked at a few backrest options and you think you found one that the client is happy with, what’s next?  We want to be able to show that our goals have been achieved. The best way we can do this is by completing outcome measures.  Outcome measures will give us objective feedback to truly show if the goals we were looking to accomplish have been met. Outcome measures are an important tool that we should be utilising during our wheelchair evaluation process, especially when it comes to funding.  Reviewers like to see outcome measures as these are not subjective to your opinion, but instead objectively give insight into the outcomes of the equipment you are trialling.
 
There are many options for outcome measures and we will have an upcoming blog dedicated to these, but for today let’s think about a few options. For example, we have a client and the goal for this client and his seating system was that he would have less pain in his back.  We could simply have the client complete the numeric pain rating scale in his current seating system and then with this new backrest option depending on how quickly the pain typically starts. This outcome seems simple but showing the difference in the numbers could be powerful or could give you the feedback that perhaps another backrest option is required.
 
Another example is the client that needs to be positioned well for stability but has to be able to reach within their environment in order to be independent.  Here we can think about a functional outcome measure like the modified functional reach test. This test will allow us to see how far our client can reach forward and can be compared to their previous seating system. It is important to remember that the set-up of the chair and cushion will largely impact this score, so be sure to have considered the whole seating system.  If you have not heard of the modified functional reach test, it is one of my favourites. I included the link to the exam below.
 
Remember that there are always numerous backrest options out there and likely more than one option will work for your client.
 
Rachel
 
Modified Functional Reach Test: