AT Finals
Top 10 conditions that result in wc use in US
-Neurological: CVA (11.1%)- largest group CP, GB, Huntington's chorea, TBI, MD, Parkinson's, poliomyelitis, SCI, spina bifida, MS -Orthopedic & rheumatological: -Chronic conditions:diabetes, cardiorespiratory, obesity
transitional mobility device
can provide the young child with the means for independent locomotion without the complexity and expense of a power wc
drive wheels (powered wc)
power is delivered to one pair of wheels in mobility technology with the additional sets of wheels providing stability
propelling structure (power wc)
power wc has more variability than manual control interface, electronic controller, powered accessories
standing frames
prone standers, supine, upright and mobile
Access to drive wheels
1-set the drive wheels in flight camber 2- typically for very young children; reverse drive wheels placing the, at the front of the chair with the casters at the back stability rearward must be carefully assessed
tilt and recline
sitting is not a static activity and we need to provide the opportunity to change position for individuals who cannot do so independently tilt=ability to rotating a specific seating position around a fixed axis, changing the orientation in space recline= changing the seat to back angle both provide a change of position and improved circulation, thus bringing pressure relief and greater comfort; potential to improve head and postural control;potential to improve respiratory function, provide a better visual field, regulate blood pressure, ease transfers and allow rest during the day; can be used to achieve a more typical spinal alignment head array controls should be turned off when the user is in the tilt or recline positions so that they can fully rest the head
antitip devices
small wheels attached to a rod and mounted at the back of the chair. prevent the chair from tipping backwards when the drive wheels are located forward on the chair, anti tip devices are recommended can be removed or rotated so they do not interfere with travel when an attendant is pushing the chair
single-switch scanning
time consuming and cognitively demanding and should be considered for power wc control only after other options have been excluded
caster float
when one of the casters does not touch the floor when the wc is on level ground
Stability vs maneuverability
when the axle of the wheel is located either directly under the user's center of gravity or anterior to it, the result is a more maneuverable, responsive chair, one that is desired by the active user more novice wc users or those with less control will feel most comfortable with the axis of the wheel located behind the center of gravity, resulting in a more stable chair
proportional control
with 360 degree directionality means that the chair moves in whichever direction the joystick is displaced, and the greater the displacement, the faster the chair moves
Programs for the Developmentally disabled
within each state provide range of services, including case management, advocacy, community living, and purchase of other services AT may be funded from these services
Factors to consider when selecting a wc
-consumer profile (disability, date of onset, prognosis, size, weight) -consumer needs (activities, contexts, preferences, transportation, reliability, durability, cost) -physical/sensory skills (ROM, motor control, strength, vision, perception) -functional skills (transfers, ability to propel)
Checklist for wc fitting
1-seating position 2-position of control interface 3-transfer method 4-indoors (size, obstacles, doorways, turning circle) 5-outdoors (curbs, soft grass, rough ground, inclines) 6-distance required to travel 7- maneuverability in community 8- lights, horn 9- care provider's training 10- assembly and disassembly 11- charging method 12- battery life and maintenance 13- transport in personal and public vehicles 14-storage 15- maintenance and repair *if there is any question, it is best to delay making an expensive equipment purchase and risking the safety of the user and others. *implementation does not always end with the consumer's acquisition of the device
Medicaid
11 services where AT and services may be funded: -early and periodic screening, diagnostic treatment services -home health, prosthetics, OT -PT -STP -rehabilitative services -preventative services -skilled nursing -services and intermediate care for persons with mental retardation, developmental disabilities and related conditions *device being requested should be identified by its specific name in all documentation and any descriptive terms used should math those in the definition of one of the medicaid services listed -requested equipment or service be considered a medical necessity -prior approval or authorization is required for nearly all services and equipment -ATP needs to request approval from Medicaid for the purchase of such services or devices
casters
2 3/4 to 8 1/4 inches larger casters give a smoother ride but are less responsive and can interfere with foot placement smaller casters are more responsive, contribute to more efficient propulsion, and allow more flexibility in position of the feet, but compromised by rougher ride. if the user is seated too far forward in the chair, excess weight is placed on the casters, making it more difficult to propel because the force required to overcome inertia is greater
Frames that accommodate growth
2 approaches: 1- design the supporting structure so that it can be adjusted directly. 2-kits provided that allows replacement of various tubes on the frame increasing seat width and length, seat-to-floor height, and other components
propelling structure
2 main parts 1-wheels (including tires and casters) 2-an interface that the consumer uses to move the wc
strollers
2 types 1-umbrella folding with a sling seat 2- full-sized units with solid seats some strollers can now accommodate up to 200 lbs umbrella type generally does not provide good sitting support, but it folds easily for storage in a vehicle ease of transportation, small wheels and short wheelbase of most strollers makes them easily maneuverable by an attendant disadvantage= child is often in a reclined position
computer access vs power wc control
ATP needs to determine that the movement used to control the power wc is safe and reliable
Wheelchair skills Test
Assess the individual's ability to perform basic wc skills such as removal of an armrest and application of the brakes to more complex, advanced skills such as performing a wheelie to negotiate a curb
Customizable Electrically Powered WC
The Attitude: foot platform that lowers to the ground and then raises up to seat height, allowing an individual to transfer independently The latitude: entire seat moves forward and down to the floor
manual wc classifications
Type of frame (rigid vs folding) adjustability of the position of the axle of the rear wheel material used to construct the wc frame
short throw adjustment
ability to alter the degree of ROM required for an individual to operate a control interface useful for consumers who have limited ROM at the control site that is being used
Auxiliary or ECU
ability to operate different functions of the wc or other devices with the same control interface user is able to transfer the output of the controller from the motors to the external device visual display identifies which function is being used
drive wheel location
affects the performance of the chair, making it an important consideration when recommending a chair to a client
Computer-based controllers
allow the storage of a set of value for parameters can store setups and recall them when needed to gradually developing client's driving skills
recline
allows rest without the need to transfer to bed accommodates cases in which more than 90 degrees of hip flexion is required passive ROM of the hips and knees can alleviate orthostatic hypotension, improve bowel and bladder function *may be preferred to tilt in a work or social environment because it is considered to be less obtrusive by the user; does not raise the knees during the position change not good option for some consumers; opening the hip angle will cause excessive extensor tone in some individuals; not useful when the user has limited hip extension ROM; those who use a custom contoured seating system should not use a recline system because of the shear forces that are inevitably present when changing the seat to back angle
ISO versus ANSI/RESNA standards
box 12-3 C&H pg 436
Rigid frame types
box: rectangular shape that provides a strong and durable base cantilever: lighter weight; box replaced with single bar extending between wheels' upright tube; foot rests are extensions of seat rails T or I frame: single bar attached to center of the cantilever that connects to a single front caster; wheels of chairs are removed for transportation which is better: consumer's needs, functional ability, method of transfer, level of activity
marginal ambulator
can walk short distances; may need wheelchair at ties, particularly outside the home
WC for use by older clients
care should be taken to ensure that the center of gravity ratio of the client to the axis of the drive wheel provides an optimal stability and mobility balance
Upright stander
complete weight bearing on the LE
Wheels
composite= tend to be more economical than spoke wheels and require less maintenance; less risk of the user getting a hand caught in the wheel; tend to be more rigid and may give more uncomfortable ride spoke= more maintenance because more difficult to clean; spokes should be readjusted; transmit less vibration from the surface to the user; lighter in weight range in size from 18 to 26 inches in diameter power wc= typically have 18in wheels manual wc= typically have 24in wheels
Shear
concern when changing the seat-to-back angle potential to tear skin, which can lead to a pressure ulcer most recline systems are designed to minimize shear
ultralightweight chairs
consider useful for an individual who uses a manual wc as the primary means of mobility folding frame, available with lower seat-to-floor height axle of rear wheel is adjustable
Center of mass
consideration when elevating a wc that incorporates a tilt-in-space option center of mass moves posteriorly as the seat tilts on some systems; this movement can cause rearward instability is the center of mass of the sear is shifted too far back with respect to the center of mass of the base
Institutional context
criteria for funding client's future needs and implication of current recommendations medical necessity
sensitivity or tremor dampening
damps out the tremor by ignoring small rapid movements and responding to larger, slower ones can become sluggish
Transport wheelchairs
designed for occasional use short-term use upholstery seating and 4 small wheels do not have any adjustability nor is it anticipated that seating systems will be used lightweight, durable, and relatively maintenance free
wheel locks
devices that prevent the wheels from moving, during transfers and other stationary activities consider how the user transfers, ability to access wheel locks, what lock options would be most reliable
front-wheel drive chair
drive wheels are located ahead of the user's confer of gravity, with the high-ratio front-wheel drive wheels being closer to the center of gravity than with the low ratio
mid-wheel drive chair
drive wheels are located directly under the user's center of gravity castors are located both in front of and behind the drive wheels (intended to be in contact with the surface when the chair is in motion)
smart WC
either a standard power wc to which a computer and a collection of sensors have been added or a mobile robot base to which a seat have been attached useful for wc users who have low vision or a severely restricted visual field, motor impairments such as excessive tone or tremor, or cognitive impairments that limit their ability to navigate a wc safely 3 functions: collision avoidance, navigation along walls or through doorways, and navigation from one place to another user must have some control of the chair because collision avoidance is not a feature with this navigation function 4 main types of sensors: infrared, sonar, laser range finders, and computer vision
IBOT mobility
electronic balance system which allows the mobility system to be customized for a user's size, weight, and center of gravity *INDEPENDENCE 4000 5 functions: standard, four-wheel, stair, balance, and remote can navigate uneven surfaces, travel through sand and gravel, and climb over street curbs user is kept in horizontal position and is balanced and stable; significantly expands the recreational options for users because they can visit the beach, go over hiking trails, and cross grass fields able to go up or down flights of stairs, although users must have sufficient upper extremity strength to stabilize themselves with handrails has the ability to balance on 2 wheels requirements for safe operation: weight range 75-250, and ability to operate a push button telephone and control a joystick
Push handles (peds frame)
extended handles are available so that the caregiver does not need to lean or bend forward to grasp the push handles
Social context
family, peers, social environment supports peers with experience with various mobility devices can be a great source of information and can share their knowledge peers and families may exert pressure in the choice of a manual vs power wc
Ventilator orientation
fixed mount= orientation of the ventilator is congruent with that of the wc seat articulating mount= required with tilt or recline features of the seating system
Bariatric chairs
for those whose mobility is impaired by obesity and related chronic diseases "baros"=weight "iatrics"=medical treatment Typical wc= up to 300 lbs support up to 600lbs (some 1000lbs) allows the use of a larger seat while still maintaining as narrow a width as possible if there is significant soft tissue accumulation around the buttocks, the configuration of the seat back must be considered because the buttocks may protrude further than the shoulders, requiring the individual to lean back if the upper back is to be in contact with the seat back.
Supporting structure
frame and attachments to it specialized seating and positioning accessories to the frame
Medicare
funds DME some AT such as speech-generating devices, mobility aids/accessories, hospital beds, and lifts are covered under Part B
Standard wc
generally useful for very short-term use such as rentals at an airport or shopping mall folding chairs with minimal adjustments limited choice of seat width and depth heaviest, not useful for long-term because they requires great deal of energy
manual wheelchair users
has some method of propelling a manual wheelchair, whether it is with both UE, both LE, or one UE and one LE
independent manual mobility system
have the ability to propel a wc manually 2 large wheels in the back and 2 smaller wheels in front
Physical contexts
indoors vs outdoors accessibility door width floor surfaces layout access (ramp, stairs) transportation climate/weather
nonproportional control
joystick controls fewer degrees of movement and, regardless of displacement, the chair travels at a preselected speed if user wishes to change direction, they must release the joystick in one direction and activate it in the direction of the change
Measurement
leg length thigh length back height to base of scapula back height to top of shoulder hip breadth taken will in a seated position *adipose tissue spreads when lying down
front rigging
leg rests and footplates support the legs and feet angle options: increase the comfort of the user by accommodating the preferred knee flexion angle, but they can also add to the turning radius, which may be a factor for mobility in some environments styles the swing away make it easier to transfer in and out of the wc height of footplate should support the desired position of the lower extremities
supine standers
less common fewer options support for the posterior surfaces of the body leaned back so hand use is less functional useful for people who do not have good head control because supports the head and neck
leading casters
located ahead of the front vertical tube increase forward stability and are less sensitive to front loading contribute to a longer wheelbase and are less responsive
trailing casters
located with the caster behind the front vertical tube of the chair in this position, casters reduce the overall length of the chair and improve the chair's responsiveness but result in less forward stability of the chair
mobility skills
manual mobility: maneuvering wc indoors on a level surface, in and around tight spaces, and over surfaces such as carpet, tile or linoleum active user in manual wc: preparation in advanced mobility is suggested; negotiating rough/uneven terrain, propel up and down ramps and curbs independently; wheelies
Lifting mechanisms
manual= hydraulic system that uses wither a pump or a lever to raise the person to the standing position powered= person activates a button to move into the upright position
Scooters
marginal ambulators and need mobility to conserve energy most often use the scooter front-wheel drive does better on level terrain and are more maneuverable real-wheel drive: rider's weight is positioned over the motor, so there is better traction and more power tiller-type control: acceleration accomplished by either grasping a level on the tiller with the fingers or pressing with the thumb can have proportional (variable) speed or switched (constant) speed control seat is typically a bucket seat with few options on seat width, depth, or back height; padded or unpadded versions; several types of armrests (fixed, flip-up, none) some have swivel seat; some seats can accommodate specialized seating equipment advantages: lighter in weight, can be disassembled for transportation in a car, are easy to maneuver, are less costly than other power wc, and are more acceptable than other types of power wc disadvantage: do not provide flexibility in control interfaces; very little flexibility; seat typically doesn't provide adequate postural support need to have a fair amount of trunk and UE control
marginal manual wheelchair user
may have UE injury caused by overuse or manual wheelchair mobility may not be the most efficient means of mobility for the person; manual wheelchair used part of the time and power wc part of the time
hand rims
may have vinyl coating titanium, aluminum, and stainless steel knobs or extensions can be added if an individual has the use of only one arm and hand, 2 hand rims are put on the intact side and a linkage is attached between the inner hand rim and the opposite wheel
Standing wc
may make it possible to avoid having to make modifications to a home or work setting functional and social benefits report positive psychological benefits when they are at the same level as others 3 basic configurations: manual driven with a manual lifting mechanism; manual driven with a power lift; and power driven with a power lift cost and size often limit usefulness stability in the upright position is a concern; not all standing wc are mobile while in the upright position
Switches
mechanical= must be physically activated t initiate a control command electronic= do not require physical contact proximity= activate when the use is close to the switch but not necessarily touching it fiberoptic= emit an invisible beam that initiates an nation when interrupted
rear-wheel drive
more common drive wheels are located behind the center of gravity of the user well behind the center of gravity in a low-ratio real-wheel drive front wheels are castors and anti tipping wheels may or may not be present drive wheels of a high-ratio rear-wheel drive are closer to the user's center of gravity
Lightweight chairs
more flexibility in choice of seat width and adjustment of back height
full-length armrest
more support, extend to the front of the seat rails
growth
most common approach is to use a frame large enough to accommodate a few years' growth and then add components that keep the child in a stable and functional position
prone standers
most common type provide support not he anterior side of the body weight bearing on the long bones and LE joints is major benefit generally tilted forward to use gravity for keeping the body upright in the stander *does not give the individual the option of moving into a seated position
Common controls of power wc
most common= direct selection through 4-direction joystick (most joysticks have a ball on top) sip and puff are a common control interface for high SCI (hard puff moves forward, hard sip moves in revers, soft puff turns right, soft sip turns left); good oral motor control is required
Power-assist mechanism
motor is located in the hub of the rear wheels that is linked to the hand rims (push-rim activated power-assist wheels); when user applies force above a preset level to the hand rims, such as when going up an incline, the motors engage and help to propel the wc can also be turned off, which allows the manual wc to function in the usual manner
momentary control
motors are activated only while the switch is pressed, which provides the greatest control for the user
full ambulator
no mobility impairment
Direct drive systems
often provide dynamic or active braking of the wc by providing a voltage that stops the motor offers more control
Push handles
option on a manual chair used by an attendant or caregiver to maneuver the chair different shapes and are different materials to assist with grip and handling in difficult situations
center of gravity
position of the axle of the drive wheel relative to the user's center of gravity affects the stability and maneuverability of the wc when user is seated in wc, the center of mass moves above the seat and forward and backward, depending on the seated position of the individual and drive wheels as the center of mass moves backwards, closer tot he axis of the drive wheel or even slightly behind it, stability decreases and maneuverability increases
latched control
press and release quickly but unable to maintain switch activation when the switched is pressed once, the motors turn on and remain on. When the switch is pressed again, the motors turn off
dependent mobility system
propelled by an attendant chosen when: individual is not at all capable of independently propelling a wc or a secondary system is needed that is lightweight and easily transported
shimmy
rapid vibration that is often felt when pushing a shopping cart smaller casters tend to have less shimmy than larger ones, but larger casters offer a smoother ride and are less likely to be caught on uneven surfaces major factors resulting in shimmy= position of the caster fork and stem, the shape of the wheel, and the tension in the caster axle and swivel mechanism where they attach to the frame
batteries
rechargeable mounted under the chair require smaller amounts of current for a longer time wet-cell= less expensive and last longer; more hazardous and require more maintenance than gel batteries so are less commonly used for powered wc gel (sealed) batteries= will not spill, which makes them more desirable for transportation; do not require any maintenance other than keeping charged at room temp, wc batteries commonly have 30 to 90amp-hr capacity at 12 volts
low-shear systems
recline systems designed to minimize shear
tilt
recommended when it is desirable to maintain the seating position for the function or for control of other devices mounted on wc because the whole seat pivots around an axis, shear is not a concern Disadvantages: as the seat tilts and the knees are raised, the LE may be impinged between a desk and the system; bladder constriction may occur; extreme degrees of tilt may cause the user to feel postural insecure; may interfere with the use of a tray increases the seat to floor height, which may precent the user from transferring into an adopted van
alignment
refers to the degree to which the two wheels are parallel to each other
camber
refers to the degree to which the wheel is mounted off vertical, usually 1 to 4 degrees wheel camber affects the responsiveness of the chair wc becomes more stable and propulsion is more efficient; greater access to wheels increases the overall width of the chair and lowers the rear seat to floor height
rigid ultralight wc
rigid frame quick release rear wheels back of most folds down to facilitate transfer and storage of the chair in a vehicle axle of the rear wheel of these chairs can be adjusted
desk-length armrest
shorter in the front to allow the consumer to move closer to a desk or table
Stationary vs mobile
stationary= people who have good upper body strength mobile= often sit-to-stand wc that allow changes in position from sitting to standing and vice versa; can be powered of manual; when the user is in a vertical position, these units generally function like a prone stander
goal of wheeled mobility intervention
support the user's ability to move in the environment
head array
typically, the user has access to 3 switches: moving the head backward causes the chair to move forward, tilting it to the right moves the chair right, and the opposite initiates travel to the left; tilting the head forward stops the chair individuals who tend to move into extension when their neck is extended may not be good candidates for this type of system because they may not be able to reliably stop or reverse the chair if extensor tone inhibits forward flexion of the neck
totally/severely mobility-impaired user
unable to propel self independently in a manual wc; dependent mobility base or powered mobility base the only option for independent mobility
Children's Medical services
under the age of 21 who have chronic disabling conditions and who meet income limitations funded by federal govt under title V of the social security act
independent powered mobility
user has difficulty propelling a manual wc electrically powered wc (driven by user)
Tricare (CHAMPUS)
CHAMPUS= civilian health and medical program of the uniformed services federally funded that provides medical benefits to active duty military members and their dependents, and military retirees and dependents contracts with various health insurance companies provides medically necessary equipment and AT
Tires
Solid= require less maintenance of all types but are the least versatile; best on smooth indoor surfaces; less efficient when used on carpeted surfaces or other rough/uneven terrain; typically have a smooth surface pneumatic= inner tube or a flat free insert; useful over more varied terrain; require maintenance, can be punctured; (research=rolling resistance and energy expenditure were significantly decreased when tires were inflated to 50% of recommended pressure)
Stages of mobility skills in children
Stage 1: exploratory, child is encouraged to explore mobility in an environment that is safe and motivating. GOAL= child to explore and learn how to control the mobility device; gives verbal feedback as it relates to what the child is doing at the movement and only to reinforce simple mobility concepts. purpose= minimize the amount of verbal direction given to the child and maximize the child's interest in interacting with the environment Stage 2: directive, GOAL= child to use the mobility device to move in the general area of a target Stage 3: purposeful, skills learned by child are applied to home and school contexts in which more constraints are placed on the situation
