Assistive Technology: Seating and Mobility
Stabilize the pelvis
-Immersion (with cushions) -Rigid guides -Strapping
Power Wheelchair Descriptors
*Base -The wheels, motors, suspension, etc of a wheelchair *Seating -The frame and cushions placed on the base to support the body *Seating functions -Tilt -Lateral Tilt -Recline -Elevating Leg rests -Elevating Seat -Stand/Anterior Reach
Find sacrificial zones for increased engagement
*i.e. allow for windswept to allow for more midline trunk *Discuss independence in exchange for energy conservation (dystonia)
Scooter (Group 1) POV
-3 or 4 wheel Power Operated Vehicle (POV) -Group 1 power wheelchairs are intended to be portable as the seat can be removed/separated from the base and loaded into a trunk or van -Steered by a tiller = A Delta tiller is a wrap-around style handle that minimizes strain on the hands and allows the wrists to rest on the handle -Captain's Seat is the only seating Option -Group 1 PWC is also a POV
Pressure Ulcer
-A localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure or pressure in combination with shear
Scoliosis Descriptor
-Abnormal lateral curvature of the spine -Named for the Apex of the curve and the region of the spine where located -Apex of the curve = where the curve is most peaked
Custom Molded Seating Cons
-Adjustments are difficult and often not possible -The mold is only as good as the ATP -Weight gain and growth are not well tolerated -ADL much more difficult to complete in the chair
Trials/Ruling Out
-Ambulation can be ruled out when ROM/MMT/Movement disorder indicate -One may ambulate and get a wheelchair, perform the Timed up and go (TUG) or Berg Balance Test with an adverse result, significant history of falls -A dependent care mobility device is warranted when the individual is unable to complete any of the above and/or is unwilling to self-propel or operate powered mobility -One does not need to self-operate a powered wheelchair to obtain one
Typical Non-Neuro Diagnoses
-Amputees -Cardiac or Respiratory Illnesses -Cancers
Age and the impact on development of pressure ulcers
-As people age, the skin loses some of its elasticity and muscles atrophy, which increases vulnerability to shear -Loss of muscle tissues means less padding between the bone and support surface (i.e. chair)
Cognitive Components of a Seating Evaluation
-Attention -Awareness -Judgement
K0001
-Basic Manual Wheelchair -No axle adjustment fixed depth and few width options
Fixed Tilt Manual Wheelchair
-Basically strollers -Typically, sling back and seat with folding frames (folds up like an umbrella) -Usually at 10º or 30º tilt (drivers set in a car is typically set at 10º-20º posterior tilt)
Protective Factors that reduce likelihood of getting Pressure Ulcers
-Being married -Female -Higher level of education -Employed or going to school -Maintaining effective skin care and inspection regimen -Time since onset (the sooner pressure ulcer is caught, the better)
Comorbidities that could impact Pressure Ulcer Development
-Can impact mobility, result in impaired sensation, result in impaired circulation, and affect proper nutrition -Smoking = leads to poor health consequences and impairs circulation, which then limits the tissue's reperfusion response when pressure is released Ex. Heart diseases, kidney diseases, lung diseases, deep vein thrombosis, pneumonia, leg fractures
Components of a Seating Evaluation: Trials
-Can the individual ambulate in a safe and timely manner for the completion of MRADL in the home? -Can the individual ambulate in a safe and timely manner for the completion of MRADL in the home, using a properly fit cane or walker? -Can the individual self-propel an optimally configured ultra-lightweight manual wheelchair for the safe and timely completion of MRADL in the home? -Can the individual operate and transfer to/from a scooter (POV) for safe and timely completion of MRADL in the home? -Can the individual operate and transfer to/from a power wheelchair for safe and timely completion of MRADL in the home? *Matching User Needs to Seating and Equipment Solutions
Foot box
-Can't wear shoes -Poor motor control -Significant hamstring contracture
Spinal Cord Injury (SCI)
-Cannot actively contract muscles to generate the power necessary for movement -Individuals low or absent tone cannot maintain a sitting position because of loss of strength and endurance -Prone to skin breakdown due to lack of sensation and limited movement below the level of the lesion
Dystrophies
-Cannot actively contract muscles to generate the power necessary for movement -Low or absent tone cannot maintain a sitting position because of loss of strength and endurance -Limited mobility to relieve pressure from weightbearing surfaces can lead to pressure ulcers
Medical History: Component of a Seating Evaluation
-Cardiac (cannot use a manual wheelchair, will become too fatigued with heart issues) -Normo-tension (whether blood pressure is in the normal range) -Skin integrity (history of skin breakdown)
Social Context: Component of a Seating Evaluation
-Caregivers -Vocational Profile -Roles/Responsibilities
Chest Support
-Chest Belt -Chest Harness -Keep anterior boundary to maintain contact with the back of the seat
Pelvic Harness
-Circumferential stabilizer for the pelvis -More effective and appropriate device to manage anterior thrust
Head & Neck Support System
-Clavicular Occipital support -Wraps around head and cushions back of head (Good for head drop)
Drive Wheels
-Component of Manual Wheelchair -For most manual wheelchairs that you self-propel, the rear wheels are the largest -The rear wheels are generally referred to as the "drive wheels" because they have pushrims attached to the rims of the tires that are used to help push the wheelchair forward.
Casters
-Component of Manual Wheelchair -Manual wheelchairs usually have two sets of wheels: A pair in front, called caster or steering wheels; And a pair in the back called drive wheels. -These two small wheels at the front of the wheelchair can swivel in every possible direction, which makes it far easier to manoeuvre the wheelchair when getting out and about
Push-Rim
-Component of Manual Wheelchair -Person grips rim to push wheelchair forward
Dump
-Component of Manual Wheelchair -Seat slope, commonly termed "dump", is defined as the difference between a rear seat to floor height and front seat to floor height of a manual wheelchair
Back Cushions for Positioning, Posterior-Lateral
-Coronal and Sagittal plane support
Back Cushions for Posterior Positioning
-Coronal plane support
Lateral/Protraction Blocks
-Create boundaries around UE for positioning due to motor control issues or hypotonia
Degrees of Freedom for Motor Control
-Decrease degrees of freedom to refine motor control *I2I, SubASIS bar, kneeblock *Upper Extremity Support System SubASIS Rigid bar prevents anterior movement
Pressure
-Defined as force per unit area, which means that a force is applied over a very small area generates more pressure than the same force applied over a larger area
Tilt in Space Manual Wheelchair
-Dependent Care Device (few exceptions) -When the entire chair shifts its position on its frame as one unit, while maintaining the angles of the hips, knees and ankles -Very Heavy -Can be made to be made extremely sturdy
Seat Cushions for Skin Protection
-Designed for active or history of active skin tissue injury -Variety of materials: Air cell, Foam, gel
Seat Cushions for Skin Protection/Positioning
-Designed for high risk for skin injury -Variety of materials, Air cell, Foam, gel or Hybrid
Compact Joystick
-Designed to provide a standard proportional force and throw in the smallest possible package, the Compact Joystick is useful for both hand and chin control -It also includes ports for remote on/off and mode function
Bargain with the hamstrings
-Do you bend knees completely or allow for some slack? -Allow enough slack to reduce spasticity, but do not contribute to further shortening
Power Wheelchair: Elevating Leg-rests
-Edema Management (with tilt) -Repositioning -Spasticity/ROM management -Ground clearance while driving
Power Positioning: Anterior Reach
-Elevated seat that pitches patients slightly forward to encourage anterior pitch (10º to 35º anterior tilt) -Increases Bone Density -Increases bowel and bladder function -Increases access for cooking/cabinets/clothing
Assistive Technology that can lead to Pressure Ulcers
-Equipment that does not fit properly or does not properly support the user
What is the goal of a Seating & Mobility Intervention?
-Evaluate the abilities of the individual with consideration to areas of mobility and functional sitting -Establish and define obstacles to mobility -Define existing boundaries (i.e. funding, caregiver abilities, lifestyle needs, etc.) -Synthesize a mobility solution that is attainable, helpful, adds measurable benefit, and is desired
Cervical Positioning Descriptors
-Flexion/extension, lateral flexion, lateral rotation
Tension
-Forces act in the same line but away from each other (pulling apart) such as the force applied on the antagonist muscle during contraction of the agonist muscle -This force can be applied externally to the body, such as the force exerted on the lateral supports to extend the trunk
Dump & Squeeze
-Form of tension -Applies tension to the hamstrings and back extensors for more aggressive positioning (GOOD) Dump = Rear of wheelchair is lower than the front Squeeze = Brings high back closer to seat of the wheelchair (Allows for more trunk control)
Elevating Leg-rests without recline
-Form of tension -This strains hamstrings and causes sacral shear
Dynamic Friction
-Friction during movement -Impacted by surface conditions such as moisture, heat, texture, and lubricants -Important considerations in the recommendation and design of seating surfaces
Stage 3 Pressure Injury
-Full thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. -Slough and/or eschar may be visible. Undermining and tunneling may occur.
Stage 4 Pressure Injury
-Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. -Slough and/or eschar may be visible. Rolled edges, undermining and/or tunneling often occur.
Power Wheelchair on Certain Surfaces
-Hard on sand, but some places have carpets so patients can drive up to them
Knee Block
-Hard stop for knees (padded) -Sensory compression at the hip Knee block = prevents kids from spasticity from crossing legs, which can be bad for hips
K0002
-Hemi-Height Manual Wheelchair -Same as K0002 (No axle adjustment fixed depth and few width options) and lowered to allow foot propulsion
K0004
-High Strength Lightweight Manual Wheelchair -Same as K0003 (No axle adjustment fixed depth and few width options) and lowered to allow foot propulsion -Any where from a "stronger" version of the above to seriously built wheelchair with fixed axle
Who do we see as Occupational Therapists ?
-In short, anyone with a mobility limitation -To expand, people with long term mobility limitations -We see people with neuro diagnoses and non-neuro diagnoses
Nutrition and Impact on Pressure Ulcers
-Inadequate nutrition is associated with weight loss and muscular atrophy, which reduce the amount of tissue between the seat surface and bony prominences -Inadequate dietary intake (which results in anemia, decreased protein levels, and vitamin C deficiency) can result in greater susceptibility to pressure ulcer formation and delayed healing of an existing ulcer
Power Wheelchair Positioning: Recline
-Increased surface area for weight distribution with tilt -Spasticity management -Spinal PROM -Self-Catheterization -Repositioning
Stage 1 Pressure Injury
-Intact skin with a localized area of non-blanchable superficial reddening of the skin. -Presence of blanchable redness or changes in sensation, temperature, or firmness may precede visual changes.
Why can't individuals pay out of pocket for wheelchairs?
-It has to go through insurance first; insurance has to deny it before a client can pay out of pocket
Foot Sandles
-Keep Shoes in place on footrest/box
Toe/Heel Straps
-Keep heel and toes in place in wheelchair
Thigh/Knee Lateral Guides
-LE positioning
Spinal Cord Injury impact Pressure Ulcer Development
-Lack of sensation (not repositioning body as much as you should)--reduced movement (like paralysis) can prevent these movements -Issues with temperature regulation (sweating profusely-creates moist environment for infection growth) -Ischial Tuberosity Flattening - caused by loss of muscle fiber and cortical bone overtime coupled with pressure on ischial tuberosities -Urinary and fecal incontinence (moist environment for infection growth) -Changes in skin and muscle tissue overtime -Autonomic dysreflexia - abnormal reactions to autonomic nervous system to stimulation -Degree of severity - individuals with higher level injuries and greater severity have greater sensory and mobility impairments that limit both their ability to detect pain and discomfort and to move to relieve pressure
Pelvic Rotation Descriptors
-Lateralized for the posterior PSIS (Posterior Superior Iliac Spine) -Very often the cause for a pseudo leg length discrepancy *Leg length discrepancy = Not actually a leg length discrepancy (problems with the hip make it appear as if there is a leg length discrepancy)
Windswept Hips Descriptor
-Lateralized to the direction of the knees
Seating the able bodied versus sitting a body looking for help
-Leveling the field to allow individuals to function amongst each other
K0003
-Lightweight Manual Wheelchair -Same as K0002 (No axle adjustment fixed depth and few width options) and lowered to allow foot propulsion -However, this version is lighter
Strength and Motor Quality: Seating Evaluation
-MMT -Observation of dynamic motor dysfunction (dysmetria, dystonia, bradykinesia, ataxia, apraxia, compensation) Dysmetria = inability to regulate speed, distance and range of motion when performing movements Dystonia = involuntary muscle contractions Bradykinesia = slow movements Ataxia = poor muscle control that causes clumsy voluntary movements Apraxia = loss of ability to carry out skills even though there is desire to and person is physically capable
Manual Wheelchair Qualifications
-MRADL ability as mentioned above +Adequate access to rooms +Use of the device will significantly improve ability to participate in MRADL +Has not expressed an unwillingness to use the device +Can self-propel or has someone that can push them
Appendicular Body
-Make sure appendicular body will not rub or bump on frame -Increase chair width vs. padding vs. lateral guides
Psychosocial Components of a Seating Evaluation
-Matching perceived/desired capabilities to actual capabilities (sometimes people want devices that they cannot properly handle) -Depression/Adjustment (!!!)
Pelvic Obliquity Descriptor
-Misalignment of pelvis that often raises the hip bone -Lateralized for the Inferior Ischial Tuberosity
MRADL
-Mobility-Related Activities of Daily Living (MRADL)" means activities such as toileting, feeding, dressing, grooming, and bathing
Seat Cushions for Positioning
-More aggressive contour -Multi-layered Foam with or without gel
Planar Seat Cushion
-Most basic model -Conforms to body's shape -Appropriate for individuals who require minimal support or who do not use seating systems for long periods of time
Cerebral Palsy
-Neuro Diagnosis -Abnormal muscle tone (usually hypertonic), muscle weakness, primitive reflexes, or uncoordinated movements that impact ability to remain in an upright posture
Is there a 5 year rule for wheelchairs?
-No, five year rule for wheelchairs (it is a guideline, not a rule) -Medicare will provide another wheelchair in less time if there is a problem (ex. mold of wheelchair doesn't fit the person because the mold wasn't made right initially)
Institutional Context: Component of a Seating Evaluation
-Nursing Home -Rehabilitation Facility -Group Home -School
Medial Knee Guide/Pommel
-ONLY to keep Medial Knees from pressure injury -NOT to prevent anterior thrust -Medial knees pressure injury = knee adductors are colliding
Compression
-Occurs when forces move towards each other (pushing together) Ex. The force of the weight of the body of the cushion when the client sits on it
Shear
-Occurs when the superficial layer is stationary relative to the support surface, but deeper structures move Ex. During a low-range movement to shift weight, the client's skin may not move, but the muscles and bones deep in the area do, which results in pressure and deformation of the soft tissue Ex. The force exerted on the deep tissues in the buttocks when a seat back is reclined
Custom Molded Seating Pros
-One size fits you sizing -Full contact support -Maximum pressure distribution -Customizable support (custom guides, mold for positioning, custom residual rest)
Kyphosis Descriptor
-Outward curvature of the spine, will be discussed in terms of the thoracic spine -Can be used to describe a "thoracic kyphosis" or a "kyphotic posture"
Group 2 PWC
-PWC: Power Wheelchair -Can use variety of Seating Options -Can have no more than 2 seating functions -Minimum top speed 3MPH -Minimum Range 7 Miles -Must use joystick -Front, rear or mid wheel drive *Compared to scooters/POVs, Group 2 power wheelchairs have a more durable and robust power base with improved battery life, lasting longer distances for a more active user. Group 2 power wheelchairs can also drive at increased speeds, up to ~4mph, compared to scooters/POVs.
Group 3 PWC
-PWC: Power Wheelchair -Can use variety of Seating Options -Unlimited seating functions -Minimum top speed 4.5MPH -Minimum Range 12 miles -Must have suspension system -Can use any type of controlling device -Front, Mid, Rear Wheel Options -Medicare requires Neurological diagnosis to qualify *Group 3 power wheelchairs are reserved for the severely impaired patient afflicted with diseases such as: Amyotrophic Lateral Sclerosis (ALS), spinal cord injuries resulting in quadriplegia, stroke (CVA) with hemiplegia, late stage Parkinson's, late stage Multiple Sclerosis (MS), cerebral palsy or Muscular Dystrophy
Pelvic Belt
-Padded/Standard -4point vs 2point -Optimally keep the pelvis positioned in the seat cushion -Airplane, standard, safety buckle -Seat belts keep pelvis optimally positioned in the seat
Stage 2 Pressure Injury
-Partial-thickness skin loss or blister. -The wound bed is viable, pink or red, moist. -These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.
Sitting Posture and Impact on Pressure Ulcers
-Pelvic Obliquity *Misalignment of pelvis, usually when one hip is higher than the other -Causes increased pressure and shear under the affected lower Ischial Tuberosity and the posterior aspect of the lower greater trochanter -Posterior Pelvic Tilt *Results in greater pressure on the sacrum and coccyx
Hip/Pelvic Lateral Guides
-Pelvic Positioning
Activity: Impact on Using Wheeled Mobility Devices
-People in wheelchairs may experience greater discomfort remaining in a seated position for a long time, which can impact activity performance by distracting us from other important stimuli (i.e. listening to a lecture in a lecture hall) -People in wheelchairs also may feel uncomfortable reaching for items if they do not get proper support for their wheelchair, impacting performance -People can complete important activities through fine hand use, lifting and carrying objects in hand, using hands and arms (i.e. pulling, pushing, reaching, turning, twisting hand or arms, throwing, catching) -In order to eat a meal, write, use a computer, do schoolwork or work, drive a vehicle, sew, etc. is enabled by a stable, comfortable seating support surface; otherwise, these occupations cannot effectively be engaged in
How do you Charge your Power Wheelchair
-Position your power wheelchair next to a standard electrical outlet -Be certain the controller power is turned off and the motorized wheelchair is in drive mode -Plug the off-board charger into the off-board charger/programming socket on the controller -Plug the off-board charger into the electrical outlet -When the batteries are fully charged, unplug the off-board charger from the electrical outlet and then from the controller
Headrest
-Posterior or lateral support/guidance -Supports back of neck or sides of neck
Human: Impact on Using Wheeled Mobility Devices
-Postural Control *Individuals with CP may have abnormal tone, muscle weakness, primitive reflexes or coordination issues that impair their ability to maintain an upright posture *People with dystrophies cannot actively contract muscles to generate power for movement *Individuals with low or absent tone cannot maintain a sitting position because of loss of strength and endurance *It is harder for people to complete functional tasks with limited postural control (stability) -Comfort *People with sitting discomfort and pain (i..e multiple sclerosis), people with limited mobility (i.e. rheumatoid arthritis, obesity, or cardiac or respiratory conditions) can benefit from comfortable seating *Discomfort may impact ability to complete ADL's -Pressure Ulcer development which can be the result of poor nutrition, weight, spinal cord injury, comorbidities, activity level, etc. (discussed in other sections)
Spinergy ZX-1
-Power Assist Device for Manual Wheelchairs -A revolutionary new power add-on unit that converts a manual wheelchair into the coolest powered chair on the planet
Smoov
-Power Assist Device for Manual Wheelchairs -The SMOOV one is an innovative electric drive that you can easily dock on to and off your wheelchair whenever you need some extra power
Companion
-Power Assist Device for Manual Wheelchairs -This unique mobility solution from Cheelcare is a powered add-on for both rigid and folding manual wheelchairs
Twion/Emotion
-Power Assist Devices for Manual Wheelchairs -Features hub motors that propel the chair in proportion to the user's push -The state-of-the art electric motors are equipped with the most modern software and electronics to provide the extra power needed to travel further and more efficiently
Rear Wheel Drive
-Power Wheelchair Descriptor -2 front casters -2 rear drive wheels
Front Wheel Drive
-Power Wheelchair Descriptor -2 front drive-wheels -2 casters in the rear
Mid-Wheel Drive
-Power Wheelchair Descriptor -2 middle drive-wheels -4 casters; 2 in the front, 2 in the rear
Power Wheelchair Positioning: Elevating Seat
-Raises height of seat (the way you raise seat of desk chair) -The most important feature that Medicare will NOT cover -Easier Transfers -Eye to Eye social contact -Visibility when crossing the street *Calculated 528 wheelchair user fatalities from car accidents between 2006 and 2012 (Kramer, 2015) 36% higher than the general population -Increased access in multi-abled homes (desks, tables, bathroom mirror, etc) -Hold hands on a stroll -Bar Mode (good for sitting at a bar: tall enough)
Power Wheelchair Positioning: Lateral Tilt
-Rarely Used -Enables weight shift
Shortened Wheelchair Back
-Related to tension -Allows for thoracic displacement over the top (avoid the high back on the wheelchair) -GOOD--you want thoracic displacement for normal lumbar kyphosis (superior postural control)
Power Wheelchair Positioning: Tilt
-Repositioning -Spasticity Management -Weight Shift for pressure relief -Pain management -Self-Catheterization -Fatigue Management -Stargazing (haha)
Ultra-lightweight Manual Wheelchair
-Rigid or Folding *Rigid wheelchairs can technically still fold, but are more rigid than folding wheelchairs -Adjustable axle for: *Shoulder to push-rim distance *Camber = wheels are angled to the side; increases width of wheel-base for somewhere that's bumpy and you don't want to tip, or just for general stability; brings push-rims closer to the side of the body, the less damage you do to rotator cuff *Center of gravity -Very customizable seat depth and width -Adjustable seat to back angle -In most cases must be able to self-propel
Trunk Rotation Descriptor
-Rotation of the spine -Lateralized for the posterior apex -Often where a "rib hump" is described
Pelvic tilt Descriptors
-Rotational position of the pelvis in the coronal plane -Posterior, anterior, neutral
Internal shear
-Sacrum or Its rubbing from the inside (posterior pelvic tilt) -Spine/ribs/scapulae with chair recline (even with shear reduction) -Balancing on elbows/knees = skin breakdown (shear from moving back and forth)
Scapular/Clavicular Positioning Descriptors
-Scapula: Winged, Abducted, Downwardly rotated -Clavicle: Protracted clavicles and elevated clavicles
Ankle Huggers
-Significant ankle support control -Never to be used in isolation (knees) *Ankle Support Control = never use in isolation; should not use this without knee support since ankles develop contractures
Microclimate and the impact on Pressure Ulcers
-Skin moisture results from the microclimate between the body and the seating surface as well as the urinary and fecal continence that are associated with a primary condition -Moist skin is more susceptible to the development of pressure ulcers than dry skin because the moisture increases friction between the skin and support surfaces -A warm, damp environment increases the potential for bacterial growth and infection -Urinary tract infections may be a factor
Correcting Asymmetry
-We aren't here to correct asymmetry, but support and accommodate -Reduce flexible deformity -Support fixed
Power Positioning: Stand
-Some wheelchairs push you up to a standing position; you are still connected and supported to wheelchair (Almost like leaning against a standing-up bed) -Increases Bone density -Increases Bowel and bladder function -Increases Stretch -Increases Eye to Eye social contact -15º posterior tilt -Enables upright toileting (for guys)
Seat Cushions for General Use
-Sometimes a mild contour -Average to poor quality foam
Physical Context: Component of a Seating Evaluation
-Stairs -Doorway widths -Alternate Entrances -Bathroom access -Place of Occupation (School/Work)
Static Friction
-Static friction is a force that keeps an object at rest -Static force must be overcome to initiate movement -Impacted by surface conditions such as moisture, heat, texture, and lubricants -Important considerations in the recommendation and design of seating surfaces
Back Cushions for General Use
-Support only, can be tension adjustable sling (folding)
Physical Context: Impact on Using Wheeled Mobility Devices
-Temperature, sunlight, and moisture have the potential to affect the properties of cushion materials and consequently affect its performance -Gel cushions will become less viscous at higher temperatures, which reduces the amount of cushioning this part of the seat is intended to provide -Gel also freezes if left in an unheated environment (i.e. vehicle or garage) where temperature is below the freezing point -Exposure to light downgrades foam, which is why all cushions have some sort of cover -Foam degrades when it gets wet and bacteria can also grow in a wet foam cushion
Clinical Descriptors Forces
-Tension *Along the same line away from each other -Compression *Along the same line towards each other -Shear *Along parallel lines across each other (IRL: the most destructive and problematic force)
Head Array
-The Head Array is a power wheelchair alternative driving method that works well for clients who have fair to good head control
Matching the Equipment to the Needs
-The Medicare Algorithm -Does this fit the environment? Caregiver abilities? Funding options? -Will the intervention hurt the patient? -Choosing the seating intervention *Not all manufacturers make the same size *Will the individual have more difficulty if positioning is the sole priority *If there is a conflict between what is wanted and what is safe can we mitigate the risk? -Increased breaks, caregiver assistance, increased skin assessment etc.
Sip N Puff
-The Sip & Puff System, available with a fiber optic switch, is designed for individuals with no upper extremity function -The system translates breath pressures into non-proportional driving controls and commands for all wheelchair and seating functions
Mobility.Activity Level and Impact on Pressure Ulcers
-The ability to move in order to relieve or redistribute pressure and the amount of physical activity in which the individual engages -Moving to relieve pressure over an area is how the body typically responds to prevent tissue damage -Normally when there is a lack of oxygen and chemical irritation, pain signals from the nerve endinggs trigger postural changes, and there is little tissue damage -However, when a person does not sense pain or discomfort or has limited/no mobility, she is unable to respond to these signals,which can result in remaining in the same position for a long time leading to a pressure ulcer -Individuals with movement limitations due to pain, muscle denervation, or neurologic impairment affecting coordination are at risk -Mobility can also be impacted by wish to remain in wheelchair and refusal to be transferred to another surface
Center of Gravity
-The center of gravity changes as posture changes from standing to sitting and in different sitting positions -The force of the earth's gravitational field tends to pull the body towards the center of the earth and must be accounted for in designing a seating system
Social Context: Impact on Using Wheeled Mobility Devices
-The clinician should determine who is in the environments in which the wheelchair is being used and their influence on use; where appropriate, the clinician should identify who the caregiver is and the issues that may affect their ability to support wheelchair use -Educating the caregiver is key -Important to know who will assist client with using wheelchair -It is important that caregivers and other members of social support system (i.e. teachers, staff, etc.) know how to use the wheelchair -The social context influences the instructions given to the users of the system and considerations with respect to the weight, complexity and maintenance of the system (e.g. cleaning or ensuring proper inflation of air-filled cushions) -Misuse or inadequate maintenance of the system will reduce its effectiveness in meeting the client's needs -The user and the caregivers need to be familiar with proper use and care of the seating system -Individuals who routinely lift and carry a seating system must be able to do so with good body mechanics to decrease the risk of injury -An individual maintaining a system should also take care not to use harsh or abrasive chemicals when cleaning the device because they can also cause damage -In some situations, the system that is most ideal for the client cannot be recommended because of the inability of the caregiver to use and care for it
Back Cushions for Planar With Lateral Supports (Seating System)
-When growth is expected -Cannot use with high risk for skin injury
Institutional Context: Impact on Using Wheeled Mobility Devices
-The clinician usually has the responsibility to provide the necessary documentation to justify and secure funding for seating devices -Consequently, it is important to remain current on funding requirements when recommending seating products -The process of obtaining funding, including who bears the responsibility for each aspect of the process and eligibility requirements of the user and device, are the main aspects of funding that require the clinician's attention -The CDC defines a restraint as "any manual method or physical or mechanical device, material or equipment attached or adjacent that the individual cannot remove easily which restricts freedom of movement or normal access to one's body" -Certain legal jurisdictions have legislation that regulates the use of restraints with individuals residing in institutional settings to limit the inappropriate use of restraints (this legislation has implications for the use of straps, pelvic belts, and sub-Anterior Superior Iliac Spine Bars
Equilibrium
-The force generated by the body is equal in magnitude and opposite in direction to the force generated by the seating system -When a body is at rest and internal and external forces are balanced, the body is in a state of static equilibrium -When forces are balanced around a body during movement, resulting in a constant velocity, it is described as dynamic equilibrium -Both are important in seating and positioning systems
Postural Control: Component of Seating Evaluation
-The individual's ability to control the posture in a sitting position (i.e. how much support is required to maintain a comfortable sitting position with a reasonable amount of effort) and the response to various positioning changes (this is assessed by putting the client on a mat to evaluate whether they can sit and maintain a seated position without assistance
Picking out Adaptive Devices is important for:
-The individuals needs and the caregivers needs -Balancing clinical science and everyday life -Fashion (choosing color of aesthetic devices) *Chair color *JACKETS!!!!! *Shoes *Bags -Target -Billy's Shoes (shoes with zippers to insert orthotics) -Zappos -"Coolture" Jackets are issue with wheelchairs (i.e. do you put jacket over the chair?) -get a bigger jacket and put it on backwards (some people use ponchos)
Compression
-Tissue Ischemia under the occiput or ischial tuberosities -Immersion in a positioning cushion -Knee Block -Boundary based positioning (lateral guides, seating, straps) -Weight bearing Lateral guide = corset that keeps body in midline so trunk doesn't have to work as hard Knee Block = put compression between knees and Acetabular fossa which is helpful for people with spasticity and dysregulation
Sensory Components of a Seating Evaluation
-Touch -Pressure -Proprioception -Vision/Hearing
External Shear
-Transfer board -Repositioning -Toileting -Dressing, (Epidermolysis Bullosa-condition where mild shear of skin causes sloughing of skin)
Thoracic Lateral Guides
-Trunk Positioning
CMS
-Type of funding descriptor -Centers for Medicare & Medicaid Services -Medicare: Federal level, pays at 80% (will not pay for seat elevation) -Medicaid: State level resource, pays 20%
HCPCS Codes
-Type of funding descriptor -Healthcare Common Procedure Coding System *Level I, CPT Common Procedural Codes, Identify the medical services and procedures performed *Level II Products supplies, services not covered by Level I
ICD 10 Diagnosis
-Type of funding descriptor -International Classification of Diseases, The catalogued codes that allow us to narrow in on funding for evaluation, treatment, and application for funding
Private Insurance
-Type of funding descriptor -United Healthcare, Aetna, Cigna, Fidelis, Healthfirst, etc. -Private Insurance = The private insurance companies listed will administer Medicaid or Medicare program
Trough
-Unable to keep UE on traditional arm rest
Group 4 Power Wheelchair
-Upgraded Suspension -Not recognized as medically necessary by Medicare *Group 4 bases are designed for stability to accommodate greater amounts of anterior tilt, seat elevation, and standing. Group 4 suspension is designed for multiple terrains and can decrease the transmission of bumps and vibration to the person in the wheelchair
Use of Postural Descriptors
-Use postural descriptors when providing info to insurance since they never meet patients
Upper Extremity Support System (Tray)
-Used for individuals to rest their UE when they are unable to use the arm rests Ex. With spasticity, you may not be able to use arm rests
Calf Pad
-Usually for LE support in tilt
Proportional Switches
-Variable amplitude of power, based on proximity or pressure placed on input device
Weight Status and Impact on Pressure Ulcers
-While an overweight person has more adipose tissue over bony prominences than a thinner person, such tissue has less effect to redistribute pressure in these areas than muscle -The added weight may compress structures and impair blood flow -It may be difficult for overweight persons to perform pressure relief exercises -Caregivers may have more difficulty moving an overweight individual, which may make shear forces a greater possibility
Self-Catheterization
-With self-catheterization (also called clean intermittent catheterization), you use a catheter (tube) to drain urine from your bladder
Respiratory and Circulatory Factors: Component of a Seating Evaluation
-With skeletal deformities, pulmonary and cardiac functions can be compromised -It is important to know whether certain positions enhance or limit respiration
Can someone get a powered wheelchair if they cant operate it?
-Yes, because someone else can operate the powered wheelchair for them with a joystick
Is goniometry useful
-Yes, goniometry and using numbers is immensely helpful
Manual Wheelchair Descriptors
1.Dump 2.Center of Gravity 3.Shoulder to Push-rim Distance 4.Casters 5.Drive Wheels 6. Tilt In Space 7. Seat to Back Angle 8. Back Canes 9. Hangers 10. Wheel locks
Seating the Body in a Wheelchair
90-90-90 rule is a myth People would not comfortably sit at 90 degree angles all day—90 degree knee angle
ATP
Assistive Technology Professional
Alternate Controls
Chair controls outside of a basic joystick: -Compact Joystick -Head Array -Sip N Puff -Switches -Eye Gaze
Insurance Important Points
Insurance does not always cover follow-up visit after assistive device delivery, so devices may not fit right because the OT could not evaluate the person (since insurance would not pay for that session) The same chair can be coded (by insurance) differently if it is for a child vs. an adult, or has more buttons, etc.
Why are postural asymmetries so much more important for individuals that use wheelchairs?
It's because whether you can move your body or not, in most cases, people are unable to move their body in a way that is going to relieve their skin
Physical Components of a Seating Evaluation
Limitations with PROM and AROM Tone: Spasticity, Rigidity, Tremor
Why would anyone want to use a manual chair over a powered one?
Many people choose manual wheelchairs because they meet their mobility requirements, are easier to transport, and are less expensive than electric wheelchairs
Why does it take so long to get a wheelchair?
OT evaluation + approval for wheelchair by insurance, especially for specifications
Shear
Occurs when forces are parallel (sliding across surfaces) such as the movement that occurs between the head of the femur across the acetabulum When shear force is present, deep structures move in the direction of the applied force while superficial structures remain immobile
PWC
Power Wheelchair
Why doesn't everyone at risk for skin breakdown use a ROHO®?
ROHO cushion doesn't offer great stability
Savant
Severe head support for hypotonia or atonia Atonia = lack of muscle tone Hypotonia = reduced muscle tone Good for ALS, and Spinal Muscular Atrophy (SMA)
Use the Least Restrictive Intervention Possible. True or False?
True
Typical Neuro Diagnoses
•Hemiparesis •SCI •Cerebral Palsy •Muscular Dystrophy •ALS •Spina Bifida