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 Duchenne Muscular Dystrophy Awareness Day – 7 September 2020


Monday 7th September marks Duchenne Muscular Dystrophy (DMD) awareness day in both Australia and New Zealand, a global day to raise awareness of those affected by Duchenne and Becker Muscular Dystrophy (BMD).

DMD and BMD are both X-linked recessive disorders, caused by mutations in the dystrophin gene.  This mutation can be caused by a certain part of the DNA being doubled or changed, or be missing altogether, meaning the gene will not work as it is supposed to.  DMD and BMD can be passed down from a mother who is a carrier, or the gene can mutate spontaneously, and occurs in all ethnicities around the world.

The difference between Duchenne and Becker Muscular Dystrophy?  The dystrophin gene encodes the protein dystrophin, which is essential to healthy muscle growth and functioning.  Duchenne patients have a complete lack of the gene that produces dystrophin, while Becker patients have lower levels or a shorter version of the protein.  People diagnosed with Becker Muscular Dystrophy have less severe symptoms that often show later in life. 

Looking specifically at DMD, DMD affects between 1 in 3500 and 1 in 5000 live male births globally.  Affected boys become symptomatic at 3-5 years of age due to proximal muscle weakness, presenting with difficulties with running, more frequent falls and difficulty rising from the floor.  DMD is characterised by a well-known progression, including loss of mobility, reduced range of movement, development of deformities, and reduced independence with activity of daily living tasks. 

Introduction to Duchenne Muscular Dystrophy from World Duchenne Awareness Day on Vimeo.

At this stage there is no cure for DMD, however gene therapy offers potential for future treatment options.  The gene for DMD was one of the first genes discovered, however therapy options are proving challenging due to the range of causes of the mutations that result in DMD.  This range of causes means that one single gene therapy will not work for everyone diagnosed with DMD, however research is ongoing. 

A treatment option that is now well established is the use of corticosteroids.  Corticosteriod use is recommended by the current DMD care standards to start at around 4-6 years of age, and while the exact mechanism as to how they work is currently not well understood, evidence as to their benefit is being demonstrated.  Koeks et al reviewed data collected through the TREAT-NMD global DMD database, identifying that corticosteroid use is common in boys until the age of 14.  For those who had taken steroids, 79% were still ambulant at the age of 10, compared to 52% of those who had not.  The median age when a boy was unable to ambulate in non-steriod treated group was 10 years old, compared to 13 years in the steroid group.  Corticosteroids also significantly reduced the number requiring scoliosis surgery, the need for assisted ventilation and a lower incidence of cardio myopathy in those aged over 20 years of age. 

Another important aspect of therapy is promotion of daily stretching, particularly of the lower limbs, and use of positioning and equipment to prevent development of contractures and deformities.  The DMD Care standards reinforce that stretching needs to begin before loss of range of movement, and to initiate a standing programme using a standing device or wheelchair with upright positioning in the early non-ambulatory stage

This links to a current topic of conversation around the use of power standing wheelchairs for those diagnosed with DMD, with the chair being available for use as walking ability is lost. Research to support use of power standing chairs is currently limited, however evidence is emerging to support their use.  

Bayley et all explored the effect of power standing chairs on range of movement and pain in adolescents with DMD over a 20 week period, and suggested that joint range of movement was preserved during the study period, including a potential increase in hip flexor length, despite a progressive loss of ambulation.

In a qualitative study by Vorster, Evan and Murphy et al,  ‘Capacity to be able’ was the central theme that emerged from the data collected, with provision of a power stand up chair coming at a time when gross motor skills were declining.  A number of benefits were observed with the use of power standing chairs, including participating in school activities that were usually done in standing, such as art or science, to independence with personal care tasks such as toileting and brushing teeth.  More autonomy with participating in activities is considered important for adolescents and appeared to be associated with a strong emotional wellbeing.  An important finding of the study was that individuals who received the power stand up chair after becoming non ambulatory appeared to gain less benefit, highlighting the need for timely provision of power stand up chairs for this group.

Access to power standing chairs for those diagnosed with DMD can be variable depending on the experience of the wheelchair and seating therapist and the funding systems available.  While a power standing chair is not going to be suitable for all adolescents diagnosed with DMD, there is a group that have the potential to maintain a reasonable level of independence and well being if provided with one – at the right time.  The use of corticosteroids now means that boys are now entering adolescence when they lose the ability to walk, and are at an age typically associated with increasing independence.  Provision of a power standing chair will allow these adolescents to gain the therapeutic benefits associated with standing, in particular maintaining range of movement in their lower limbs, as well as maintaining independence in meaningful tasks at home and at school.  While these benefits are in no way a cure for the underlying muscle weakness associated with DMD, it may allow this generation of boys and adolescents with DMD to make the most of the adult life that advances of technology are gradually giving them.

 


Save Our Sons Duchenne Foundation https://www.saveoursons.org.au/ 

Muscular Dystrophy New Zealand https://www.mda.org.nz/ 

Standards of Care for Duchenne Muscular Dystrophy https://vision-dmd.info/revised-standards-of-care-for-duchenne-muscular-dystrophy/  

References 

Koeks Z., Bladen C.L., Salgado D., Clinical Outcomes in Duchenne Muscular Dystrophy: a Study of 5345 Patients from the TREAT-NMD DMD Global Database (2017) Journal of Neuromuscular Diseases 4 293-306 

Vorster N., Evans K., Murphy N., et al (2019) Power standing wheelchairs promote independence, health and community involvement in adolescents with Duchenne muscular dystrophy. Neuromuscular Disorders 29, 221-230 

Bayley K., Parkinson S., Jacoby P etc al (2020) Benefits of power standing wheelchair devices for adolescents with Duchenne muscular dystrophy in the first year of use. Journal of Paediatrics and Child Health 


 

Rachel Maher 

Clinical Education Specialist

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

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

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

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

Preventing Pressure Injuries Outside the Wheelchair

 

Last week Australia was encouraged to create awareness around chronic wounds as part of Wounds Awareness week.

This week it’s New Zealand’s turn to promote awareness with their Wound Awareness week running this month. As such we will continue our theme of Pressure Injury (PI) prevention and redistribution surfaces in this week’s blog.

Good Pressure Injury (PI) risk reduction requires us to consider all the support surfaces being used. We can apply many of the same principles of design, forces, and materials science to multiple surfaces and positions to specifically address potential equipment risks. Today’s blog, whilst still addressing reduction of risk of PI, will look at some of the other positions and surfaces that we need to consider. 


Lying

End users that are dependant on carers for transfer assistance can spend increased time in bed based on the availability of support staff. Whilst this is not ideal it is the reality for many with mobility impairments. This can result in an increased need to complete functional tasks in bed and for the user to use the bed functions such as head raise to enable seated tasks.

Although this bed function can assist someone to complete tasks in bed, we need to acknowledge the shear forces that accompany this bed movement. Using a knee break in conjunction with head raise can reduce the amount of slide but not eliminate the risk of sustaining a shear sacral injury. We also need to consider the mattress surface and how it will interface with the user and the bed profiling.

As with sitting, those that have significant movement limitations will be at a higher risk of sustaining an injury due to lack of movement. For these users the mattress materials and design can be crucial.

A ROHO Mattress Overlay

When we think about the materials that provide the highest levels of redistribution the first thought is air. When air is used in a container that enables it to work as a fluid, we are considering hydrostatic forces rather than peak forces, this enables maximum immersion and envelopment. A benefit of a non-powered air mattress is that there are no power chords as potential trip hazards or risk of power outage impacting the usage.

Other commonly prescribed air mattress options include air alternating systems. These work on the concept of loading and off-loading. These systems usually consist of rows of tubes that inflate and deflate in sequence so that there are times when the depressed cells mean there is no contact on the corresponding area of the body. As such the peak pressure increases when the cells are inflated. This constant changing can make some users feel like they are on gentle waves like water. 

Talley Quattro Acute Mattress Replacement

When considering air alternating systems, you do need to check the minimum user weight requirements as this differs between manufacturer design as does the sequence or ratio of inflated cells. For some users the inflation of cells may not be tolerated. Another point frequently raised by users is the noise of the power unit; whilst most manufacturers have significantly reduced the noise we need to consider the impact even a small noise can make in the quiet silence of the middle of the night….many of us have experienced that dripping tap you may not hear until you lie awake trying to sleep!!

Consider the location of the users home, some areas are known for power cuts and a contingency plan may be required for what to do in the event of a power outage, this may include consideration of a generator in some remote locations.

With both types of air mattresses we do need to consider transfers. Generally the higher the pressure redistribution properties the harder bed mobility is. A foam mattress may not provide the same level of immersion and envelopment or offloading, however because it is a more static, solid option it also has less impact on independent movement. With an alternating mattress there is usually a “hard” or “transfer” mode but pressure risk will be increased if this isn’t returned to normal cycle for lying.

Like wise with the ROHO mattresses, transfers need to be considered. The mattress is available in sections and can be inserted into foam surrounds to assist with bed mobility and transfers.  


Bathroom and Personal Care Tasks

Independent self-care and ADLs can take longer for those with impairments and may be completed from surfaces we don’t consider. When assessing for pressure risk it is important to consider all the support surfaces that are being used.

Commodes come standard with a seat made of similar materials to a toilet seat. Although this is not an issue for someone with full sensation, the ability to move and for short periods of time, it is important to find out more about the tasks and time spent to ensure it is not a concerning risk factor. If risk is identified, consideration of the seat needs to be addressed with padding or a pressure redistribution surface. 

A ROHO Toilet Seat Cushion

Skin tears and injuries do not always come as a direct result of pressure forces, but they can become chronic wounds. Not having the strength to complete a side transfer or mis-judgement may result in the user landing on a surface not intended eg the wheelchair wheel, and sustain a skin injury. Transfer style and other assistive technology such as slide boards may need to be addressed to prevent injury.

Be aware of all surfaces! Be open and have discussions around PI risk, prevention strategies and equipment options. Pressure injuries are for the most part preventable. Chronic wounds can have significant negative impacts both physically and emotionally. Our education team can provide clinical support and education around pressure care and the clinical application to our equipment ranges.

You can contact us at education.au@permobil.com or reach out to your local Permobil Territory Sales Manager.  


 

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

This week is Wound Awareness week in Australia. Why is it important to be aware of wounds? Chronic wounds affect half a million Australians with an annual estimated cost of over 3 Billion dollars (Wound Aware website). The definition of a chronic wound encompasses any wound that is resistant to healing.

While Pressure Injuries (PIs) have a direct correlational-causation with peak pressure and shearing forces, the causation of a chronic wound may not be pressure related, however pressure injuries are  the most common causation of a chronic wound.

The impacts on those who experience chronic wounds can extend beyond the physical issues of the wound to affect quality of life and general well-being. It is essential that we consider equipment and best practice guidelines when working with people to assess and trial Assistive Technology options. For more information about wounds and ways to create awareness check out some of the resources at the official website here.

To acknowledge and promote the importance of wound awareness, this week’s blog is a reminder on some of the considerations when prescribing pressure redistribution surfaces for beds and wheelchairs.


Creating Awareness

A historical approach to education around PIs has often included graphic images to shock us into the serious consequences that can result. Although the serious nature of chronic wounds cannot be underestimated, it is important to understand the development of PIs.

Education should be around prevention and monitoring. Yes, an early stage PI usually presents itself as a red mark on the skin surface, but not all red marks on the skin develop into PIs. When prescribing new seating we need to not just tell someone to monitor for red marks, but also advise them on what to do if they get skin markings and what kind of information you may want. As a clinician, the first questions I want to know are the location, if the skin blanches and how long it takes for any red marks to appear and fade.

It is more important that a user is empowered to understand the risks of PI and understand how to decrease those risks. It should become second nature to routinely monitor skin integrity and to know who to contact and when. Open discussions and general awareness can help in breaking the stigma and embarrassment that prevents some people from seeking early intervention.

Post-discharge from your services, who should they contact if they have PI concerns? For those not involved with regular services, you may advise them to re-contact you or their GP.


Who is at risk of a PI?

When prescribing AT, we need to consider the risk factors for the individual. A good risk assessment will not predict who will sustain a pressure injury but can assist in identification of factors that can be addressed to reduce risk. Those at risk include:

  • Individuals who are unable to independently adjust their posture or position
  • Individuals who present with asymmetrical postures and or uneven tonal patterns
  • Individuals who constantly “slide into PPT” (Posterior Pelvic Tilt)
  • Individuals who have history of PIs – old scar tissue
  • Individuals who are sitting or lying for prolonged periods
  • Ageing population

Where do pressure injuries occur?

PIs related to sitting or lying occur around bony prominences, often where the layer of tissue between the bone and skin is minimal such as the sacrum when sitting in posterior pelvic tilt.

Positioning will contribute to the area at higher risk, so the list above indicates the most common areas for sitting and lying supine. When lying on the side however, the greater trochanter and ear are also vulnerable areas.


Seating considerations

During the clinical reasoning process, it is important to consider both the postural positioning and skin protection requirements of each individual. This should guide the identification of the type of seating requirements. The design and materials of the proposed seating options will differ depending on goals and what approach you are taking to pressure redistribution and positioning.

Are you trying to reduce an abnormal postural position or accommodate to increase area of loading? If so, you will need to consider the adjustability and modularity of the seating to achieve the required points of control and contours.

Are you wanting to offload the ITs by increasing the loading of the Greater Trochanters? Consider the types of foam used, the contour and the depth between the areas of the trochanter ledge and the Ischial well.

Are you trying to provide maximum pressure care for someone that doesn’t have complex postural issues but has a history of PI? The Dry Floatation Technology design of a ROHO High profile cushion offers maximum immersion and envelopment and allows individualised set up.

 

Or are you trying to find a cushion for intermittent use such as community outings or the user is at low risk of a pressure injury and has no postural issues? There are a range of basic foam cushions available on the market.

If you would like more information on potential seating solutions or want further clinical support you can contact the clinical education team education.au@permobil.com. If you want to know more about seating and positioning this week’s live webinar on 20 August focuses on Pelvic Obliquity. To Register

 

 

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

 

 

Posterior Pelvic Tilt    


Last weeks live webinar looked at the very common posture that comes from a posteriorly tilted pelvis. Whilst we often discuss the pelvis as the foundation, it is important to appreciate that to support the pelvis back to a neutral position, the primary point of control comes from the backrest. Yes the cushion features will certainly assist as will a pelvic support belt, however we can’t overlook the crucial role the backrest plays. Today’s blog will take a closer look at pelvic blocks as a point of control for reducible posterior pelvic tilt (PPT)  


Pelvic Block

A pelvic block refers to the provision of an insert or contouring in the back support to adjust the force at the pelvis.  Providing an increased force at the posterior aspect of the pelvis can assist in both reducing a PPT and maintaining a neutral pelvis.

There are various ways we can create this force, lets take a closer look at some of the potential options. 

 


Tension Adjustable Backrests

 

 

If clinical reasoning identifies an upholstery back rest, I will always consider a tension adjustable option first. A tension adjustable backrest uses horizontal straps under the front upholstery. By adjusting these straps you can increase or decrease the force as required. Next time you have an opportunity I recommend you try it out. First sit in the wheelchair without adjusting it so you can feel the difference. Next loosen off ALL the straps. Now tighten the lower straps of the backrest from the seat base to the Posterior Superior Iliac Spine (PSIS)as much as you can. Now gently work your way up the straps doing each one above the tightened straps to follow the contours of the trunk position wanted. By having the lower straps tightened you will feel a more upright trunk posture coming from the increased force at the pelvis.

 

 

Another Back rest that uses a similar concept to a tension adjustability, is the Acta Relief. This is a unique backrest. Equipped with an oversized aluminum shell cut-out to allow deeper immersion into the back. It has adjustable Boa system that can be tightened and loosed off at different areas. Whilst a similar concept to tension adjustable straps, the Acta back can provide stronger points of control that maintain and do not slip as webbing straps can, but it has to be removed if chair is regularly folded.


Aftermarket Off The Shelf Back Supports

Most after market or ridged backrests consist of a shell and foam interface. Mounting brackets may provide adjustment for active seat depth and STB angle. You need to understand what you are trying to achieve before identifying appropriate equipment. There may be a standard adjustment such as a dual or hinged shell which enables the shell to be opened at a hinge joint usually just above the PSIS.

Some aftermarket back rests are supplied with dense foam wedges that can be placed between the shell and the foam interface, image 6  shows inserts provided with the  Dreamline contour back rest.

 


Adjustable Backrests

There are several adjustable backrests on the market that allow you to adjust the contouring of the support surface to create individualised support. These tend to work well with significant complex and asymmetrical postures, and for those with ongoing changing postural needs such as those with aggressive progressive conditions. I am frequently surprised when I see clients with these types of backrest with NO adjustment to the contour…it is as flat as the day it was packed at the manufacturers. Whilst we could consider these types of backrests for ongoing needs, they still need to be appropriately selected and individualised to the users current needs. I have had significant success in even minor adjustments through the trunk contour when the point of control has been set up appropriately and is proving the support required. Materials of the backrest are crucial when working with these adjustable backrests. Think critically with the clinical reasoning process, how much force do you want compared to how much immersion. What are you trying to achieve? With  a back support, it is essential to simulate the map findings and identify the impact of gravity and how you can achieve the required support for the end user. An adjustable back is easy to create a pelvic block in as you can adjust the contours to meet the users needs by taking out or adding in foam pieces. When you apply good contouring that provides the appropriate level of support you can create an appropriate solution for the user. 

 

These BAC pads made of a dense closed cell foam and are designed to be moved and overlapped so you can easily build up a pelvic block and other contouring as it is required. Pictured are the standard BAC. 


Making a Pelvic Block  

Not sure if a pelvic block would make a difference with a clients existing seating? Consider doing the towel trial.  Taking a small washcloth or hand towel fold it into several layers and place it at the pelvis area where you want support (seat surface to PSIS height), what I like about this method which I first saw over 15 years ago when Bengt Engstrom facilitated a workshop, was the ease in which to get further information. Most households will have a small towel to fold up and use. I could change the thickness and height to see the impact it could have just as I could place it in front of or behind the foam interface depending on the materials of the backrest.  Bengt is a Swedish Physiotherapist, author and original designer of our Corpus Seating System in the Permobil power bases.  I will use the towel as part of the assessment process, however it can be trialled if wanting to trial different thicknesses etc. I have made multiple pelvic blocks. I find an electric bread knife is a cost effective tool for these kinds of projects so keep one in my tool kit for these purposes.

Step 1 – Take a piece of foam in required density, it should be the thickness you are wanting, I often use a dense 1 or 2 inch.

 

Step 2 - cut a rectangle, approximately as wide as inner back rest (A)and height of seated surface to PSIS (B)

Step 3 - Chamfer off the top corner edge to create transition from pelvis to back support with knife

Step 4 - Attach between the shell and foam interface 

 

A individualised custom pelvic block to provide the force for a reducible posterior tilt…..now don’t forget the cushion and supports to complete the solution! If you have questions about any of the concepts or products featured please contact us at Education.Au@permobil.com

 


 

 

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

 

Reducing Barriers to ROHO Cushion

Set Up    


 

  


ROHO have been manufacturing pressure redistribution surfaces to assist wheelchair users and those at high risk of pressure injury for the past 49 years. This week’s blog looks at how and when the SmartCheck may be used to assist in cushion set up and ongoing use.  


SETTING UP A ROHO CUSHION

Historically, initial set up of a ROHO air cushion involves over-inflating the cushion and then releasing air in relation to the individual user. As air is released, the user is immersed and enveloped leaving a layer of air between the user and the seat interface. Palpation of the lowest bony prominence (in most cases the ITs or Sacrum) is part of the process in guiding both the seated posture and the optimal air levels.

Research and EBP has repeatedly shown that a well-set up air cushion provides a high level of pressure redistribution and many facilities and services will provide an interim ROHO cushion when a pressure injury or high risk of injury has been identified. The main barriers to this type of cushion meeting a user’s needs is in establishing correct air inflation levels.


TOO MUCH AIR

When an air cushion is over-inflated we are not able to immerse in it effectively. Many users that find an air cushion unstable are actually sitting on an over-inflated cushion, rather than immersing into it as designed. When over-inflated, there is also increased peak pressure at the lowest bony points. Let’s think about a tyre, a tyre is filled with air. They are usually highly inflated and the more air that goes in the ‘harder’ they become.

The material of the cushion that contains the air will also impact the immersion and envelopment capacity of the cushion. Which is why ROHO is very particular about what their cushions are made of, hence why they make all their neoprene on-site.

NOT ENOUGH AIR

When a cushion is under-inflated and there is no layer of air between the user and the seat base, there is a risk of bottoming out and increased pressure. The cushion is designed to have a layer of air under the user, however we find that air cushions incorrectly set up are more likely to have too much air rather than too little.


WHEN THE SET UP GOES WRONG

I like to set up an air cushion with a user consciously. What I mean by that is I tend to talk through the process before and during the set up. I want them to be aware of the changes in how they are sitting as the air is released. If there is a wall mirror in the room we will often do the set up in front of it and talk about how they are immersing (or sinking) into it as the air is adjusted.

Many long term ROHO users know straight away if their cushion is correctly inflated by how they sit and feel. Others may need more consistent monitoring of the inflation level and assistance in checking and setting up. The set up and maintenance of inflation has been a barrier in some settings. Initial set up is often completed by a therapist but the user may need to adjust the inflation levels over time. I had one client who reported that her carer always added more air to the cushion even though she knew it required less.

Sometimes therapists arrange hire of an air cushion and it is sent directly to the end user. I once went to visit a client who was hospitalised for a pressure injury. The custom cushion had been removed and she was sitting on a ROHO. It was so over-inflated it was difficult to press down on the fully expanded cells, when I queried who had set it up for her she advised it was a maintenance worker.

So how do we overcome or reduce some of these barriers? For some, it is about education and training but others may need a more concrete cue. How can someone who has experienced a pressure injury and is anxious about their cushion set up feel more confident that it’s configured to meet their needs? For those that don’t know about the SmartCheck, it is a tool that can assist in checking the inflation level of a ROHO Single Compartment Cushion.

ROHO SMARTCHECK 

At a simplistic level, the Smart Check uses sensors to guide the appropriate level of inflation for the user. The SmartCheck is separate to the cushion and attaches as required to any Sensor-ready cushion. All single valve, single compartment ROHO cushions sold in New Zealand and Australia are Sensor Ready. This enables a SmartCheck device to be added at any stage even if not identified as a need until after someone has purchased the cushion. 

Once attached to the cushion, the SmartCheck uses illumination and arrows to enable you to set up and check the inflation level. 

SmartCheck is easy to use and can provide peace of mind to those at risk of pressure injuries and to those supporting them. It is a good idea to learn how to set up, override and reset to factory default settings. We have a great set up guide which is available HERE that walks you through the steps. 

If you want more information on the set up and use of SmartCheck, you can reach out to your local Territory Sales Mannager or contact us at education.au@permobil.com

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

Smart Actuators – What are they and what do they do?   


Actuators are used on power wheelchairs to make the seat move – so it is an actuator that makes a seat move back into tilt, or the back support recline, or the leg supports elevate.  A smart actuator is an actuator that has a sensor attached to it, allowing it to sense its position in space.  A smart actuator is able to sense its position at any point between being fully retracted or fully extended, or for example whether the seat is in no tilt, or in 15 degrees of tilt, or 45 degrees, as opposed to being in no tilt, or full tilt.  These sensors are also linked to the specific actuator, so use of another actuator will not interfere with the information it provides, for example the use of power recline will not interfere with the tilt actuator knowing how much tilt it is in.

Why are smart actuators useful?  Smart actuators allow for very specific programming of power seat functions, taking the guess work out of using these functions and making them easier for the end user to manage.   For some users, smart actuators can be the difference between successfully managing the power functions on their chair (and hence maximising their independence) and the chair being too complex, and an alternative solution being required.

Smart actuators allow for limits to be placed on how a power seat function moves, so a tilt or recline actuator can be limited on how far it will allow the seat to move back, or the leg supports limited as to how high they can elevate.  Restricting how a power seat function moves can be helpful when a person requires a power seat function for a particular purpose, however there are risks associated with this function if they use it outside a particular range.  For example a person may require the use of power recline to assist with pressure relief, however too much recline can create issues with reflux after meals. 

The Corpus VS power articulating leg supports are another example of when restricting actuator movement is useful.  These leg supports offer 8” of vertical travel, meaning they can be programmed to lower the footplate to the floor for ease of transfers.  Without the smart actuator, a person needs to be able to judge when the footplate has reached the floor, if they don’t lower the footplate far enough, their safety may be compromised with having a small lip to manage, or if they lower the footplate too low, trying to push it through the floor, there is risk to damage to the actuator with potential risk of early failure.  The smart actuator allows the leg support actuator to be programmed to stop when the footplate reaches the floor, promoting a safe transfer and preventing damage to the actuator.

On the Permobil chairs, the smart actuators allow for programming of both memory seat functions and Independent Positioning Mode through the Intelligent Control System (ICS).  Both programming functions allow for a user to access a particular seated position through the use of one switch or button, even though the position may require use of multiple power functions to achieve.

Independent Repositioning Mode, or IRM, is use of specific power seat functions programmed to move in a sequential order, with each seat function moving to the desired angle before the next function starts to move.  IRM utilises power tilt, power elevating leg supports and power recline sequentially, with varying angles able to be programmed depending on the users needs.  This feature is typically used for those who have high pressure relief needs where it is vital that power tilt is used before power recline to maintain the persons posture in the seat.  Use of IRM means that a user does not need to remember which sequence to use the power functions in, where they are taken through the required sequence with use of a single switch or button. 

Memory seating is similar in that multiple power seat functions are involved, however slightly different in that the actuators move simultaneously, the idea being to move a person into their desired position as quickly as possible.  Memory seating has more varied uses, from setting of a ‘home’ position which can be the users preferred sitting position, to positioning for transfers and function.  For some users they have a particular position that allows them to transfer in/out of their chair independently, or a position that allows them maximum function at a work station, these are positions that can be programmed into the chair, allowing the user to move in and out of these multiple times per day with ease. 

For more information on Independent Repositioning Mode or Memory Seating, on our Permobil chairs, please contact sales.nz@permobil.com  


Rachel Maher

Clinical Education Specialist

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

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

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

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

 

 

Funding Considerations for Power Standing  


Power wheelchairs that offer the option of power standing have several physiological and functional benefits, however accessing funding for these chairs can be challenging.  Funders are keen to fund the most cost-effective option, in many instances this is provision of a separate power wheelchair and standing frame.

Having two separate solutions may work well for some, particularly for those who are unable to manage the complexities of a power stand up chair or those who have a well-established routine in place with a standing frame.  However, for others having a two separate solutions may not be ideal, in this blog I am going to focus on two common examples.

For many teenagers or young adults, regular use of a standing frame can become challenging due to a variety of reasons – it may no longer fit well into the school routine, transfers in/out of the standing frame may be challenging, or the limited mobility while in the standing frame, and often time away from their peers, creates issues with compliance.  This can result in limited opportunities for standing and weight bearing at a time when they are moving through puberty and a rapid period of growth.  

For some of these young adults, there is potential to demonstrate how provision of a power stand up chair can be cost effective, often through demonstrating the potential to reduce carer support hours and with functional gains leading to increased independence.  If a young adult has, or may soon need, carer support hours to assist with transferring in/out of their standing frame, these are hours that are no longer needed with a power stand up chair.  A young adult also has the potential to increase their independence with access to power standing, particularly if they have reasonable hand function.  Provision of a power stand up chair may mean that a teenager or young adult can come home from school independently, being able to access their home and food from the pantry or fridge and have independence at home without needing their parents or a carer.  Some teenagers or young adults, particularly males, may also be able to use the toilet independently with use of power standing, further increasing their ability to be at home or school without support.  A power wheelchair with power standing often results in increased function, or reduced need for support, at school, typically in science and technology subjects.  Science and technology are subjects that are typically undertaken at raised tables or in an environment where a person is standing, making access to these subjects from a wheelchair more challenging.  Use of power standing can reduce the need for environmental modifications and a person may be able to participate in these subjects alongside their peers.

Another group of wheelchair users where access to power standing can often be easily justified are those with conditions that create increased tone in their lower limbs, limiting their ability to stand and walk.  For this group, regular standing or weight bearing often assists with managing their increased tone, prolonging their ability to stand transfer.  For many their ability to stand independently declines over time, and a standing frame may be considered, however independent transfers in/out of the standing frame may also be an issue.  For these people access to power standing can result in a reduction in the number of carer support hours required – in the short term as assistance is not required to manage a standing frame, and potentially in the medium term as independent transfers are maintained for longer.  Further cost benefits may occur if use of power standing maintains a person’s independence with activities of daily living at home and/or reduces the need for modifications to their environment. 

When completing funding requests for a power wheelchair with power standing, a person’s goals is often the best place to start – particularly those that are likely to maintain or increase their independence.  These goals can be complemented with information on their carer support package – and how this may change if the goals are achieved.  For those who were previously had some mobility on their feet, provision of power standing may allow a person to remain living at home independently or with minimal support, while for some teenagers and young adults, there can be a significant reduction in carer support hours, or reduced reliance on family, with provision of power standing due to an increase in functional abilities and the resulting independence it gives them.  This ability to maintain a current support package, or potentially reduce the number of carer support hours required, can be an objective way of demonstrating to the funders that a power wheelchair with power standing is a cost-effective option.

For more information on power standing on our Permobil chairs, please contact Sales.NZ@permobil.com

If you are wanting to know more about prescribing power standing, please join us on Thursday 23rd July at 1.30pm for our free webinar.  

To Register   


 

Rachel Maher

Clinical Education Specialist

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

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

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

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

 

ActiveReach – Increasing Vertical AND Horizontal Reach 


Last week we discussed the potential benefits of ActiveHeight, a feature that can increase functional independence for many, however for some, horizontal reach continues to be an issue.  Horizontal reach can be challenging for those with limited trunk control, it may be a person has difficulty reaching forward from their wheelchair seat, or they have limited rotation for when they need to access a surface side on.  Some of these users continue to have reasonable hand function and could increase their functional independence if they have a means of reaching forward to allow functional use of their hands – which brings us to ActiveReach.

ActiveReach incorporates the use of anterior tilt to bring a person up and forward, this can be further complemented by additional power functions to optimise positioning, depending on the amount of ActiveReach required.  ActiveReach allows a person to increase their functional reach by 3” for every 10 degrees of ActiveReach used, with a maximum of 45 degrees of ActiveReach available on the F5. 

The use of the modified Functional Reach Test can be a means of assessing whether a person may benefit from, or the functional reach gained from, using ActiveReach.  Use of the modified Functional Reach Test can complement functional goals identified by the person, for example a person may identify that they are having difficulty preparing a meal on the stove top as they have difficulty reaching forward to safely stir the food in the pot, or to use utensils to serve the food they have prepared.  The modified Functional Reach Test can be used to confirm that the person has limited functional reach, and to show that their functional reach has increased during a trial.

ActiveReach and Active Height can also be used together to allow a person to reach into overhead cupboards, with ActiveReach further increasing a person’s vertical height, as the anterior tilt component of ActiveReach will lift the rear of the seat providing additional height.  This combination of functions can be useful for those who have limited shoulder range of movement and are needing additional height to access unmodified environments, for example reaching items on a shelf at the supermarket.

ActiveReach can also be used to assist with standing transfers.  Some users have difficulty initiating a sit to stand, particularly if they are unable to move forward on their seat to allow their feet to be placed slightly behind their knees.  Use of ActiveReach can place a person in a position that allows for ease of moving from sitting to standing, potentially maintaining an independent or assisted stand transfer.  Maintaining this transfer can be important for those who are active in the community or wish to minimise their carer support requirements.

Maintaining independent transfers is further promoted by use of the powered foot support, this foot support is the same one used on the F5VS (Power standing) that allows for a change in vertical height in the footplate, potentially allowing a footplate to be lowered to the floor to allow for ease of standing transfers.

The combination of power seat functions used in ActiveReach is complex, however use of ActiveReach can be made easy for the end user by using smart actuators.  The smart actuators on the Permobil chairs allows for the desired ActiveReach position to be programmed into the chair, allowing a person to move to this position by use of a button or switch.  This means that the user does not need to remember what sequence to use the power functions in, or where each function needs to be positioned to, for successful use of ActiveReach.

For more information on ActiveReach on our Permobil chairs, please contact sales.nz@permobil.com  Our Customer Service team will direct your enquiry to the relevant Territory Sales Manager for your region.

If you are wanting to know more about prescribing ActiveReach, please join us on Thursday 23rd July at 1.30pm for our free webinar.  

To Register 


 

 

Rachel Maher
Clinical Education Specialist

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

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

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

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

 

 

 

 

Power Seat Elevation - Desirable or Essential?


This week the spotlight is on power seat elevation, also known as power elevating seat or hi-low.  Power seat elevation is a powered seat function that raises and lowers the seat, to provide a varying amount of vertical seat to floor height. It does not change the seated angles of the seat relative to the ground.

 

Power seat elevate is a power wheelchair seat function that can increase the quality of life for an end user, however it is often a seating function that funders consider ‘desirable’ as opposed to ‘essential’.

For many of our users, we can justify to the funder how power seat elevation is essential to maximise an end user’s independence, often to facilitate independent transfers or increase a person’s vertical reach.  Power seat elevation allows the user to adjust the height of their seat to optimise transfers, either by raising the seat to floor height to allow for ease of standing transfer, or to allow the seat to floor height of the power wheelchair to be set just higher than the surface they are transferring to, for ease of use of a transfer board.

Power seat elevation also allows a person to increase their seat to floor height to increase their vertical reach, allowing them to reach items such as a light switch or items in a cupboard that may otherwise be beyond their reach.

RESNA (Rehabilitation Engineering and Assistive Technology Society of North America) have recently updated their Position Paper on the Application of Seat Elevation Devices for Wheelchair Users.  For those new to the RESNA Position Papers, these papers summarise current research and best practice trends for a variety of topics.  The 2019 update on the use of power seat elevate provides additional insight on where power seat elevate may be beneficial, or perhaps even essential, for end users.

A person is typically prescribed a power wheelchair as they do not have sufficient upper limb function or endurance to achieve all day independent mobility in a manual wheelchair, hence are more likely to have issues with upper limb function and/or fatigue. 

A person seated in a power wheelchair is typically positioned at a lower level than their standing peers, which forces a wheelchair user to maintain an upward gaze to achieve eye contact.  This can result in a person sitting in increased cervical extension for prolonged periods of time, this posture can be uncomfortable for any person, and can ultimately lead to pain.  For those who have an increased thoracic kyphosis, their posture may result in them sitting in a degree of cervical extensional already, hence they may not have sufficient range of movement to allow them to make eye contact with a person in standing.

Use of power tilt can assist with improving eye contact for some users, however this may not be ideal for others who have good upper limb function and need to be positioned upright to maximise their independence.

Many wheelchair users are also living and working in environments that are designed for a person who is standing and walking, for example kitchen bench and cupboard heights are typically set for a person in standing, as are light switches and elevator buttons.

A wheelchair user may have sufficient range of movement to access these environments, however this often results in them reaching above their head, hence using their shoulders towards their end range of movement frequently throughout a day, which can also result in pain and fatigue.

When considering whether to request power seat elevation on a chair, we perhaps need to consider the frequency and duration that a person needs to undertake overhead activities and the potential impact of this over a length of time.  It may be that transitioning a person to power mobility may resolve any shoulder pain that was caused by self-propelling, however a person may still experience pain if they are needing to reach overhead a number of times each day as part of maintaining their independence at home or work.

So how much seat elevation can we get on a chair?  The amount of seat elevation available varies between 8 and 14 inches, and how this is achieved varies from chair to chair.  Power seat elevation on the Permobil chairs is referred to as ActiveHeight, this allows 12” of seat elevate on the Permobil F3 and M3 and 14” on the F5 and M5.

In addition to elevate, the seat also moves back over the base by 3.5” to allow maximum stability while driving the chair in an elevated position. This stability is important for users who may be using ActiveHeight outdoors or for extended periods during the day.

For more information on ActiveHeight on our Permobil chairs, please contact us at sales.nz@permobil.com or call 0800 115 222.

If you are new to prescribing power seat functions or want to know more, please join us on our webinar this Thursday 9th July at 1.30pm.

For further information on the RESNA position papers, follow the link here 


  

 

Rachel Maher
Clinical Education Specialist

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

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

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

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

 

 

 

Where is the Drive Wheel and Why Does it Matter? 


The drive wheel on a power wheelchair is the larger wheel if you are looking at your wheelchair or client’s wheelchair. The location of this drive wheel can have a large impact on how the power wheelchair drives and manoeuvres in different environments.

There are three main types of drive wheel configurations on power wheelchairs: front-wheel drive, mid-wheel drive, and rear-wheel drive. In this blog, we will focus on front-wheel drive.

Front-Wheel Drive

The front-wheel drive power wheelchair is typically going to be good for manoeuvrability indoors and optimal for outdoor use. This is because of the larger drive wheel being the first wheel to overcome the uneven terrain versus the smaller casters. Because the front wheels are connected to the drive motors, these pull the casters over obstacles and through various terrains versus if the casters were the front wheel. In the case of the casters being in front, the casters are being pushed, the force generated is forward and downward. This would be similar to a ploughing effect and can increase the likelihood of becoming stuck in certain situations. For individuals looking to go over all terrains, the front-wheel drive wheelchair may offer the best solution.
Another benefit of front-wheel drive is the smoothness of the ride. Look at how many wheels are on the ground. In the case of front-wheel drive there are four wheels versus the six wheels with a mid-wheel drive chair. This means that as the end-user goes over a bump in a front-wheel drive chair, they would feel the force of that bump two times versus three in a mid-wheel drive. This can also be important for individuals that may easily lose their positioning when going over any uneven terrain.
We could talk about front-wheel for hours, but the final benefit to mention is the front-wheel drive chair’s smallest front turning aspect. In all the configuration options, the chair will turn on its drive wheel.

The photo below shows an example of a bathroom. In this bathroom the sink is positioned against the wall. Because the wheelchair turns on its drive wheel and the end-user can only pull themselves so close to the wall before turning, we can see the only chair to gain full access to the sink is the front-wheel drive. Does this mean that everyone should have a front-wheel drive wheelchair? No, but it does mean that it is important for clinicians, suppliers, and clients (end-users) to consider the environment that the client lives in. 


Often, I hear that people stay clear of front-wheel drive because it doesn’t have as small of a turning radius as mid-wheel drive and it is harder to learn to drive. Both of those statements are true. The front-wheel drive will have a slightly larger 360 degree turning radius, but as you saw above it has the smaller front turning aspect which may be utilised more than someone turning in a full circle. Front-wheel drive may be less intuitive to learn how to drive versus mid-wheel drive, but with a little practice and a few key tips, many users find front-wheel drive to be just as easy to learn as mid-wheel.

The two key points I like to teach someone when learning to drive a front-wheel drive wheelchair is:

  • Hug the corner. When going through a doorway the end-user will want to “hug” the corner or keep a tight turn.
  • Turn towards the problem. For example, when positioned adjacent to a wall/barrier, turn toward the wall/barrier, then slightly reverse to allow the rear casters clearance for turning in the desired direction. This might sound complicated, but if you remember to turn into the problem you will easily manoeuvre away from the problem.

Keep in mind that not everyone will benefit from the same drive wheel configuration and it is important to ask the questions and complete an evaluation to determine which drive wheel would be best for you or your client.

Interested in learning more about drive wheel configuration? Join our Clinical Education Specialist, Rachel Maher this Thursday June 25th at 2.00pm for our free webinar.

 To Register

Rachel Fabiniak

Director of Clinical Education