In April 2023, the International Seating Symposium (ISS), hosted by the University of Pittsburgh’s Department of Rehabilitation Science and Technology, welcomed back attendees to the David L. Lawrence Convention Center after postponing and then ultimately hosting the 37th International Seating Symposium in a virtual forum in 2022. We were grateful to have our presenters, exhibitors, and attendees back in person and were enthusiastic for the excitement that awaited many reunions, hands-on pre-conference sessions, and all that comes along with the in-person conferences that we took for granted pre-2020.
For this year’s plenary sessions, we welcomed:
Keynote speaker Chaz Kellem with his session “Beyond Accessibility: Diversity and Inclusion in the Disability Community” to kick off the ISS on Thursday morning
Day 2 included a panel representing industry stakeholders to discuss the topic of ‘Ethics, Education & Outcomes: How Future Credentialing Will Shape Complex Rehab Technology’
Closing keynote speaker Steve Spohn, CEO of Ablegamers, with his session ”The Experience of Helping People Have Player Experiences” to address inclusion of accessible and adaptable options in mainstream technology while creating equal opportunities for individuals with disabilities
Over 80 educational sessions, 15 hands-on pre-conference workshops, 10 paper sessions, and over 20 posters were presented by clinical and industry experts, students, and trainees in the field. Additionally, attendees had the opportunity to visit exhibitors and see, feel, and try devices and new assistive technology in person in the exhibit hall with over 100 exhibitors.
We wanted to extend a sincere thank you to all of the attendees and the many supporters for making the ISS the leading educational conference in the field of wheelchair seating and mobility. We look forward to seeing you again at the next ISS.
Mark R. Schmeler, PhD, OTR/L
Associate Professor
Vice-Chair for Education & Training
University of Pittsburgh
ISS Co-Director
Rachel M. Hibbs, DPT, NCS, ATP/SMS
Assistant Professor
Director of Continuing Education
Unversity of Pittsburgh
ISS Co-Director
“Proceedings from the 38th International Seating Symposium” is presented and supported by the Department of Rehabilitation Science & Technology at the University of Pittsburgh
Thursday, April 13, 2023
DENIALS: Evidence for Practice and Policy Change
Jean Minkel, MPT, ATP
As a professional, receiving that DENIED letter is a real ‘gut punch.’ After all the work that went into the request for approval, how could this request have been denied? That is the question we will explore during this workshop. By reviewing actual denials, participants will have the opportunity to reference a Denial Road Map, to see how careful review of denials and planning for appeals can lead to improved clinical practice, improve documentation and provide an opportunity to challenge and ultimately change public policy. Once over the emotional gut punch, an objective review of a denial can be a very useful tool in quality management and advocacy. In a truly objective review, the first question to ask is, “Is this a legitimate denial?” Legitimate denials may result from a lack of understanding the coverage policy and/or documentation that is vague, confusing and poorly written. Carefully reviewing the reasons for denial and reviewing the policies cited in the denial, the clinical team can gain critical information about the details of the actual coverage policy. If the reasons given in the denial are not consistent with the documentation provided and/or the written coverage policy, then there is an opportunity to Appeal. Appeals are the critical first step, if a policy is ever going to be changed. If there are no appeals, then the insurance can rightly argue, ‘no one has complained about current policy, we have no reason to change it.” This workshop will provide a hands-on opportunity to review Letter of Medical Necessity and the corresponding denial reasons. The Denial Road Map will be used as a resource to access ‘next steps’ and review actual coverage policy. As case study will be presented on how fighting individual denials led to clarification of state policy and written policy update to managed care organizations, in New York State.
Who Knew a Retrospective Cushion Evaluation Chart Review Could be so Much Fun and Clinic-Changing? Learn from our Mistakes … and our Successes
Sharon Sonenblum, PhD; Chris Maurer, MPT, ATP; Mandy McDonald, OT
There are 2.7 million wheelchair users in the United States, with 23 percent of full-time wheelchair users in North America developing a pressure ulcer in their lifetime. As pressure ulcers can contribute to drastic medical costs, decreased independence, and lifestyle changes for proper healing, it is vital to understand what is being done to the seating system in the presence of such ulcers. In late 2021, Dr. Sharon Sonenblum from GA Tech, three DPT students from Emory University, and therapists from the Seating and Mobility Clinic at Shepherd Center teamed up to explore the recommendations for wheelchair users who present with a pressure ulcer. 372 medical records were screened retrospectively, with 133 subjects meeting the inclusion criteria. Data collected from the cushion evaluation visit notes included demographics, PU history, current seating system, adjustments made to the seating system in the session, and interface pressure mapping (IPM) data. Join us for a discussion about what we found out about our interventions, and how this study has improved our standard of practice (and our documentation!) in the clinic!
Seat Yourself with K-12 School Teams: Collaboration is Key!
Daniel Cochrane, MA, MS, ATP; Sheri Lenzo
Wheelchair users who are children ages 12 months to 18 years of age spend a significant portion of those years in schools. Wheelchair use, along with other assistive devices (Henderson et al., 2008), improves participation (Rousseau-Harrison & Rochette, 2013). But seating and mobility assessments often take place outside the school setting. The school environment should be a significant consideration. School professionals are best placed to provide information on this setting. Suppliers and clinicians should proactively collaborate with school professionals in all phases of wheelchair service delivery. School is a complicated environment for wheelchair users. Access to the school environment goes far beyond navigation. In the early grades, learning activities take place on the floor or low table-tops and socialization on the playground is a significant component of the school day. In the intermediate grades, students spend most of their day in a classroom with one teacher, but the room may be arranged with clustered desks. In the older grades, students switch classes each period and access lockers. The RESNA Wheelchair Service Provision Guide (Arledge et al., 2011) refers to the school environment multiple times. The school therapist who may be involved in some aspects of all three stages of the service delivery: Assessment, training, and follow-up. The assessment team should involve at least one school-based professional who can provide a picture of the school environment. AT training is a mandated service in US special education. The school could be an ideal setting for training because of the relative safety of wide hallways or gym and common space areas. For example, the pediatric adaptation of the Wheelchair Skills Training Program (Ouellet et al., 2022). Follow-up services are a crucial aspect of wheelchair services for children. The school-based professional, particularly an occupational therapist or physical therapist who sees the child very regularly in their mobility device is most likely to notice the need for growth adjustments. Collaboration with school-based professionals can be challenging. It can be difficult to know who to contact. “It can be a lot of people to coordinate” (Wright et al., 2010, p. 44). There might also be an issue of intra-disciplinary competition. The child’s school-based physical or occupational therapist is the most obvious contact point, and the parent should be able to provide contact info. Providing wheelchair services at the school might be the best way to reduce the overhead. Another strategy to consider is telehealth. Collaboration and mutual respect are needed between professionals. The school-based therapist should expect to provide perspective but not make final decisions. In a discussion of features, for example, the school-based therapist should assert how participation in the school setting would be enhanced or impeded by the selection of specific wheelchair features.
Segmental Assessment of Trunk Control (SATCo) – Usage in Australia
Amy Bjornson, MPT, ATP/SMS
This seminar is focused on the application of a treatment approach called “Segmental Assessment of Trunk Control,” (SATCo) in the Pediatric Population. Many of our treatment paradigms in therapy and the application of Assistive Technology are based on facilitating proximal stability for distal function. SATCo is an alternative treatment approach that is based on targeted training to gain control of trunk posture. Therapist’s hands or therapy supports are placed on the child’s trunk directly beneath the segment where control is found to be difficult in the child. This support is gradually lowered as control is gained. During the seminar, attendees will learn about SATCo and how SATCo is being used in Australia to inform therapy decisions, educate families and provide an outcome tool for justifying the clinical effectiveness in sitting and standing therapy. Using a case study approach, this will be discussed specific to the selection and set-up in standing frames and a therapy bench.
Use of Research and Interpretation of Outcome Tools for Optimizing Wheelchair Service Delivery
Wendy Koesters, PT, ATP/SMS; Emma Smith, MOT, OTR/L, ATP
Wheelchair service delivery is an evolving process to fine tune client experience and outcomes. From evaluation, trial, implementation to follow up; the purpose of this course is to explore the Quadruple Aim of Health Care. Specifically, this aim is the goal for all clinicians in wheelchair service delivery: to optimize patient experience, improved health of populations, minimizing cost and reducing clinician burnout. Let’s consider how we are telling a client’s story through documentation for optimal reimbursement and time effectiveness for clinician. We’ll explore the role of a clinician scientist with research application: •objective goal setting •using data to rule out less expensive mobility alternatives •comparison of trial set ups for client education and to rule in medically recommended device/components •literature support of these components •use of outcomes to interpret client satisfaction •comparison of patient reported outcome for needs and education post-delivery of equipment Research review, clinical case studies, and sample documentation will be included. Our clinic has been successful with use of the Functional Mobility Assessment with evaluation, education, identifying needed modifications, plus providing value to yearly follow up intervention. This tool has helped to drive quality improvement initiatives. A clinician’s ability to find, interpret and apply applicable research elevates their level of service to achieve the Quadruple Aim of Health Care.
Seating in the In-beTWEEN: Considerations for Adolescent Manual Wheelchair Prescription
Julie Gallagher, PT, DPT; Rebecca Russell, PT, DPT, ATP; Rachel Hibbs, DPT, NCS, ATP
The adolescent manual wheelchair user is a unique client due to the overwhelming amount of body, lifestyle, and social changes that await them in their journey toward adulthood. Their manual wheelchair must meet their evolving needs while still promoting proper seating, positioning, and propulsion mechanics. It is possible to prescribe a manual wheelchair that fits the user currently, while also ensuring its ability to change to meet a user’s developing needs. This session’s discussion will prioritize the selection of components to promote independent mobility and wheelchair skills, as well as provide considerations for the overall set-up of the manual wheelchair to prevent unfortunate musculoskeletal sequelae. We will address ways to identify when a chair’s growth has been maximized, how to justify authorization for new wheelchairs, and how to facilitate the transition from pediatric to adult seating and mobility services. This course will seek to address the question, “How can we prepare for change while meeting an adolescent user’s needs now”? By understanding a diagnosis’ impact on growth patterns, exploring modifications to current chairs to accommodate growth, considering component selection and set-up to maximize independence and efficiency, we can order wheelchairs that successfully bridge a user from youth to adulthood.
A Multisegmented Approach Towards Head Support Interventions
Filipe Correia, MBA; Bart Van der Heyden, PT
When head stability is compromised the correct positioning of the wheelchair user’s head and cervical spine is essential for social interaction, access drive controls, upper extremity function and critical functions like breathing, eating and swallowing (1–4). Head support systems are often needed for clients with progressive neuro muscular disorders such as amyotrophic lateral sclerosis, muscle dystrophy, multiple sclerosis and wheelchair users with cerebral palsy or spinal cord injury. Besides a compromised head control, these users often experience limitations stabilizing the trunk. Therefor head support interventions should be used in conjunction with a seating assessment and seating interventions providing a stable base to support the cervical spine and head (5,6). When assessing for head support interventions, Head Positioning Zones (HPZ) cannot interfere with the user’s hearing, vision or mandibular movement and movements of the Upper Cervical Spine (UCS), consisting of C0-C1, C1-C2, C2-C3 and responsible for approximately 40% of flexion-extension and 60% of axial rotation of the total cervical range of motion (7). When facilitating a functional head control, distal movement of the head and Upper Cervical Spine (UCS) can be enhanced by stabilizing the proximal Lower Cervical Spine (LCS) and thoracic spine.
Turning Clinical Need into Innovative Product: Why is it so Difficult?
Tina Roesler, PT, MS; Bin Ma, MBA
As clinicians evaluate and treat clients in the clinical setting, they are often faced with equipment and technology solutions that do not meet the needs of the client. What do they do? Often, they are left to construct custom fabricated solutions, or reach out to suppliers and manufacturers for help. In other cases, they simply work with what is available and “settle” for “good enough”. But, when you have an idea, why is it so hard to translate that idea for a product or solution into an innovative, viable product? This presentation will discuss the difficulties of new product development in rehabilitation and take attendees through the basic steps of product development. It will discuss the unique roles of clinicians, researchers, and manufacturers in the process and look at the impact it has on evidence based practice. We will try to answer common questions that often plague providers of rehabilitation equipment such as, “I can build that custom in 2 hours, why does it take so long for a company to produce it?” and “Why does it cost so much? Furthermore, we will discuss the importance of clinical feedback and communication during the development process and how each participant can have a positive impact. From concept to clinical reality, we will follow a product’s process through development and discuss the importance of standards, clinical input, and careful review of a product’s safety and viability.
The Effect of Tire Volume on Push-Force Over Surface Obstacles in Manual Wheelchairs
Michael Banks, MA; Marianne Alderson
Optimization of manual wheelchairs to individuals includes a multitude of parameters. This study focuses on the importance of tire width and volume. A preliminary study showed that a 35 mm wide tire required more force to tow an unoccupied wheelchair (loaded with 60 Kg) over a 19 mm obstacle than did a 50 mm tire. This result prompted a more comprehensive examination using a force sensor wheel to measure push force in an occupied wheelchair over a 19 mm (1 × 4) and a 36 mm (2 × 4) obstacle. Casing tension (versus PSI) was calculated to achieve the same tire firmness between the two tire widths. The difference in wheel diameter between the two tire sizes was also taken into account. The 50 mm tire traversed the obstacles with less push force than the 35 mm tire. After the correction for wheel diameter was applied, the 35 mm tire still did not show a statistically significant lower force value. We conclude the 50 mm tire results in less push force and that these results can be extended to a range of surface irregularities encountered in day-to-day wheelchair mobility.
Determining Levels of Enhanced Function Associated with Permobil Smart Drive Manual Wheelchair Power Assist
Samuel Tsang, BS; Martin Ferguson-Pell, PhD, C.Phys., FRSA
Research Objective: To determine if the use of a power-assist device (Permobil SmartDrive) increases average activity level of manual wheelchair users during both summer and winter conditions. Design: A portable wheelchair activity monitor (“Sagitta”) was employed to measure exertion level, speed, time, distance, and temperature conditions. The Sagitta was attached to a sample of manual wheelchair users and recorded the average day-to-day wheelchair usage over a period of time both with and without the SmartDrive installed. To evaluate seasonal differences with wheeled mobility activities, the Sagitta and the SmartDrive were utilized in both summer and winter conditions. This was to determine how the SmartDrive was utilized despite the additional challenges of cold, wind, and snow typically faced by wheelchair users living in colder climates. During the SmartDrive intervention periods, participants were not required to use it full-time. Instead, they were free to use the SmartDrive in whatever situations or capacity worked best for their needs, had they owned a SmartDrive. During the rest of the testing period, the SmartDrive was removed from participant wheelchairs, and they were instructed to continue their daily activities as normal. Participants: A convenience sample of 20 manual wheelchair users were recruited from Edmonton, Alberta, Canada. Interventions: Participants spent two weeks using the SmartDrive and one control week without the SmartDrive in both summer and winter conditions. The order of the intervention was randomized. Main Outcome Measures: Activity level was measured by the effort required to propel the user (duration of pushes, cadence, average force and stroke power), total work (including total pushes, distance traveled, time spent pushing), and number of high-exertion or overexertion events. Results: In summer conditions, the study showed statistically significant increases in activity level when the participant was using the SmartDrive compared to without the SmartDrive. Potential overexertion events were reduced substantially in most participants. In winter conditions, activity data showed no statistically significant increase in activity levels with the SmartDrive installed, and a significant reduction in overall SmartDrive use compared to summer. Conclusions: During summer conditions, the SmartDrive enabled the user to increase their average activity levels in their daily lives compared to wheeled mobility without a SmartDrive. The use of the SmartDrive significantly reduces overexertion events caused by the initial manual push of a pushing sequence which therefore reduces the risk of overuse injuries. The study found the SmartDrive did not increase average wheeled mobility activity levels in winter conditions, which can be attributed to relatively extreme winter conditions as well as the difficulty of using the device in the challenging accessibility environment of Edmonton in the winter.
Clinical Reasoning or Clinically Conceding: A Case Study Example of the Administrative Appeals Tribunal Process within the Australian National Disability Insurance Scheme
Tracee-lee Maginnity, OTR
The National Disability Insurance Scheme (NDIS) is a publicly funded scheme of the Australian Government that fund supports and services associated with disability. It provides people with a “permanent and significant” disability, to full funding for any “reasonable and necessary” support needed to assist in activities of daily living, participation in the community and reach their goals (Australian Government, 2022). Its implementation by the National Disability Insurance Agency (NDIA) in 2013 promoted choice and control for access to CRT supports and has enabled many individuals with disabilities to participate and engage in meaningful occupations. So, what happens if the NDIA deem that an AT application or AT feature does not meet the reasonable and necessary criteria? In these instances, the NDIA can decline an aspect of the AT or decline the AT device as a whole. Approval of an AT application therefore relies heavily on well-articulated clinical reasoning and supporting evidence, provided by the prescribing clinician. In instances where initial applications are declined the Administrative Appeals Tribunal (AAT) provides clinicians and end users an opportunity to appeal the denial (Administrative Appeals Tribunal, 2022). Involvement of the AAT is a multi-step process consisting of both informal and formal conciliation meetings. This can potentially be a lengthy process and cause time delays in end users receiving AT that promotes their independence, safety, and ability to achieve their goals. Although this process offers end users and clinician’s an opportunity to provide additional justification, there are frequent cases highlighted by the media highlighting the financial and emotional burden this process can result in. When faced with an initial decline are therapists conceding to this or backing up their original request? What short- and long-term impact is this having on end users? This session will provide an overview of the appeal process and use real case examples and qualitative data to discuss both the advantages of a functional based funding system and the impact the process can have on participants.
High Tech Adaptive Sports: New & Emerging Options for Clients with Complex Impairments
Madelyn Betz, MS, ATP; Kendra Betz, MSPT, ATP
Recent innovations in assistive technology create an unprecedented opportunity for individuals with the most complex disabilities to participate in a wide realm of adaptive sports. While individuals who use wheelchairs have had many options for sports participation for decades, engagement in most activities has been restricted to those who are highly accomplished manual wheelchair users who are able to use customized court sport chairs, high tech handcycles, and other adaptive technologies that require a significant amount of upper extremity function to use effectively. Historically, adaptive sports and recreation opportunities for people with cervical level SCI, MS, CVA and ALS have been severely limited to non-existent. However, with increased attention on expanding the kinds of sports available along with focused efforts on developing assistive technologies to support individuals with significant impairments, individuals who typically use complex power wheelchairs, and even drive with alternative controls, can now participate as athletes. Examples of sports options for athletes with high level and/or complex disabilities include skiing, water sports like kayaking and sailing, boccia, shooting, curling and soccer. Regardless of the athlete’s personal goals for recreational play or elite level competition, providing the optimal assistive technology, including custom seating interventions and specialized configurations, maximizes enjoyment and success for any chosen sport. This session highlights the significant roles that AT and seating/mobility professionals play in promoting sports and recreation opportunities for clients with the most significant impairments. Attendees will gain new insight into the revolutionary innovations in AT that support sports participation regardless of client limitations. Strategies for client evaluation under the Human Activity Assistive Technology (HAAT) model will be emphasized to guide the match of the complex client to the optimal technology. Options for transferring individuals from power wheelchairs to and from adaptive sport devices will be shared. Case examples with action photos and video will be utilized to demonstrate appropriate processes for adaptive sports interventions. Guidance for accessing technologies and resources will be shared and interactive activities to engage audience participation will be included.
“Client’s Pelvic Obliquity Shifted as They Crossed the Canada/US Border!”
Linda Norton, MSc.CH, PhD, OT Reg (ONT); Weesie Walker, ATP/SMS; Gerry Dickerson, ATP
Although this headline is obviously not true, the road to establishing a common standard for those providing Complex Rehabilitation Technology as not been without its challenges. There were concerns that the practice of delivering complex rehabilitation technology differed significantly by country to draw into question the relevance of a US based designation. Canadians began embracing NRRTS registration in 2018 and since that time, approximately 30% of NRRTS registrants are Canadians. Working together Canadian and American Registered Rehabilitation Technology Suppliers (RRTS®), Manufacturers and clinicians have made the RRTS designation relevant to all. During this session, the presenters will reflect on the benefit of RRTS® designation for suppliers regardless of their geographic location, the intersection where Canadian and US interests and perspectives meet, lessons learned and how we can work together to improve the delivery of Complex Rehabilitation Technology for our clients.
Standards: It’s not About Where we are, it’s About Where we are Going!
Patricia Karg, MSE; Benjamin Gebrosky, BS
We will take a brief look into the national and international standards related to the seating and mobility products. Standards exist to ensure quality and safe products are prescribed to consumers and will be in service for the duration of their life expectancy. Standards help clinicians make informed decisions about the products they are prescribing since all comparable products can be tested against the same set of tests. Manufacturers develop products using existing standards to assess performance and to be compliant, but that does not mean they exceed a given standard. Policy experts may adopt standards and add pass/fail criteria. The standards must have enough rigor and depth to guarantee that the products that adhere to the standards are of sufficient quality and safe for consumers. RESNA has multiple committees and working groups focused on keeping these assistive technology standards relevant and up to date in an ever-evolving field. The volunteer-based Assistive Technology Standards Boards and several standards committees meet regularly to develop and update standards as technological improvements advance the industry. If new products enter the market, standards need to be updated or created to cover the emerging technologies. The newly formed RESNA working group on Warning and Driver Assistance Systems for wheelchairs is researching the need to create a standard related to driver assistance and warnings as a few products on the market incorporate these features. The working group is looking for users, clinicians, service providers, and manufacturers to join the efforts in creating this standard.
Break the Budget, Not the Law
Ginny Paleg, PT, DScPT, MPT; Lisa Kenyon, PT, DPT, PhD, PCS; Andrina Sabet, PT, ATP; Heather Feldner, PhD, PT, MPT, PCS
The current systems for pediatric equipment procurement in the United States (US) and throughout the world are challenging and inconsistent. While laws and rights-based documents already exist to protect a child and family’s access to technologies that support mobility, participation, and health, barriers exist for families in both understanding their rights and advocating for appropriate access. Further, these laws are often misinterpreted, limited, or ignored by policymakers and funders. In this dynamic session, we will present current laws, regulations, and research pertaining to the provision and utilization of assistive technology (standers, supported stepping devices, communication devices, power and manual mobility, etc.) in school systems, clinics, and early intervention programs under IDEA (Parts B and C), and throughout the world. Case studies and court cases will be used to illustrate how we can improve access to appropriate technology using funding, policies, and laws that are already in place. Definitions of the terms ally/allyship, accomplice, and advocate as defined by individuals with lived experience of disability will be shared and discussed as a means to center the voices and experiences of technology users and care partners. The presenters will share their own and other published research supporting the use of assistive technology in classrooms and communities and engage the group in a lively discussion about how therapists and equipment professionals can partner with and empower families to improve access through advocacy. Attendees will leave armed with an action plan to enable access to assistive technology as a critical first step to improve participation and inclusion for all children.
Innovative Solutions Using Data to Increase Patient Continuum of Care
Ty Bello, BS, RCC
As CRT Providers and Clinical Professionals, we are constantly seeking was of Continuous Improvement that leads to increase patient access, care, and compliance. In recent years we have learned and applied innovative technology to further drive patient satisfaction and outcomes and slowly adopted data as part of the patient continuum of care. This panel discussion will engage providers and clinicians with several data specific conversations that will raise the bar on how we as providers and clinicians can adopt data as an innovative solution. Technology can collect and store data to provide guidance for patient care and understanding the continuum of patient care. Data can help recognize timelines with a change of condition by diagnosis, length of new equipment lifecycle, equipment repair costs and lifecycle and the value variants (cost) of long-term visions vs short-term visions. Data is invaluable with the changes that are coming as the industry moves away from fee for service to a whole life HMO methodology for medical services/equipment. This transition is already in process and accelerating quickly. We will also report on some industry data that will focus on Mobility Diagnosis, Chair Base and Seating Types, Controllers, Battery and Controller Replacements and much more. This has been collected over the past several years and this will be first time this will be reported. How has all of this impacted us up to now and where will this take us?
Rigid Chair Prescription: Creating a Design Template for Optimal Fit
Josh Anderson, BA; Jim Black
Evidence and experience demonstrate the impact of the wheelchair set up on the rider’s propulsion efficiency and the long-term effects of posture and positioning on the body. When scripting an ultra-lightweight wheelchair, there are multiple factors and measurements taken into consideration in order to achieve an optimal fit. This session will provide a hands-on demonstration of the essential measurements that are required to determine the specific front seat height, center of gravity, seat slope, occupied frame length and front frame angle for each rider. A design template provides the clinician and supplier with a flow chart of how to make decisions regarding the wheelchair configuration based on the rider’s body, functional skills, environment of use, transportation, and participatory goals.
Drive Control Selection for Powered Mobility following Acquired Brain Injury
Samantha Williams, OTR/L, CSRS, CBIS, AIT; Wade Lucas, PT, DPT, ATP/SMS
In the field of complex rehabilitation technology there are several conditions that can and do often benefit from power mobility devices. Progressive neurological conditions and spinal cord injuries are frequently considered and recommended power mobility for their primary means of mobility. However, there are a number of conditions that can get overlooked for this technology. One such condition is Acquired Brain Injuries (ABI). This condition has a variety of different and challenging clinical presentations, that mobility device selection can be a daunting task. So much so that powered mobility is often not considered. Some examples of these challenging presentations include: cognitive deficits, poor attention, impaired vision and/or visual neglect, impaired muscle tone, and contractures. Due to the complexity of these challenges, it is important to have a strong working relationship between the clinician and the ATP across the continuum in order to assist with all considerations for setting the patient up for independence. These considerations include options for mounting of the drive control, posture and positioning needs, special programming and environmental access. This case study-based course will look at the principles of drive controls selection, but also take those principles and show how they were implemented in to practice for multiple individuals affected by an acquired brain injury.
Zen and The Art of Wheelchair Service Provision
Lauren Rosen, PT, ATP, SMS, MSMS
Working in a seating clinic has become more and more stressful. From patients and families demanding equipment they saw on the internet to payor sources denying equipment that patients have used for the last twenty years. There are many ways for therapists and suppliers to deal with this added stress. Some healthy, some detrimental to our health. This session will focus on healthy ways to manage stress both during clinic and away from it. Come with an open mind and come away with some helpful stress reduction.
Stakeholder Perceptions of the Complex Rehabilitation Technology Service Delivery Process
Tyler Beauregard, MS, AT, ATC, CSCS; Carmen DiGiovine, PhD, ATP/SMS, RET; Richard Schein, PhD, MPH; Theresa Berner, MOT, OTR/L, ATP; Gina McKernan, PhD
Context: In the United States, 5.5 million adults use a wheelchair or other form of Complex Rehabilitation Technology (CRT) to interact with the world and perform many of their activities of daily living. Receiving CRT that will meet their needs is crucial to maintaining their quality of life. The process of determining what equipment an individual needs, procuring that equipment, and delivering it, known as the CRT Service Delivery Process, is complex, multifaceted, and requires specialized clinical knowledge. This process can take years to complete and requires coordination of several distinct groups of stakeholders with vastly different backgrounds and conflicting goals/incentives. Complex systems, such as this, have many potential points of failure, and determining priorities for system improvement is challenging. A previous scoping review described the CRT delivery process and its barriers and facilitators under current policies. The review revealed several themes seemingly stratified by different stakeholder groups. Those themes may contain opportunities for policy reform to improve the CRT service delivery process. It is important to know in which areas to focus future policy reform efforts. Objective: Elucidate the attitudes of stakeholders regarding the CRT delivery process. Design: Cross-sectional, observational study. Setting: Online survey. Instrument: The questions in the instrument were based on the themes that had emerged from a previously completed scoping review. Questions took the form of positive statements regarding the CRT service delivery process and participants rated their agreement with the statements on a standard six-point likert scale. Participants: We used a snowball sampling strategy to recruit stakeholders in the CRT service delivery process. Snowballs were started by emailing 42 different organizations representing all of the identified stakeholder groups requesting that the email be forwarded to the members of the organization. Ultimately, we received 1069 valid responses. Main Outcome Measures: Percent of respondents that completely or mostly agreeing with the statements, indicating a positive perception of that aspect of the CRT service delivery process. Results: Respondents view the CRT service delivery process, largely, as not performing well with less than 18% of all responses indicating a positive perception. Questions regarding funding and procurement were viewed in the least positive light, with 5% positive responses on average, followed by questions regarding follow-up, maintenance, and repair with less than 10% positive responses. The aspect of the process viewed in the most positive light was fitting, training, and delivery with over 42% positive responses. Conclusions: The CRT service delivery process is not viewed as performing well by its stakeholders. Funding and procurement aspects are viewed particularly negatively which represents an opportunity for focused reform efforts.
Development and Preliminary Reliability and Validity of the Falls Concern Scale for Wheelchair and Scooter Users – FCS-W/C+S
Laura Rice, PhD, MPT, ATP; Sharon Johnson; Catherine Stauffer; Elizabeth Peterson, PhD, OTR/L; Emily Kim, MS
Fear of falling is a common concern for individuals who use wheelchairs and scooters. Of this population, 63% reported a fear of falling and 51% reported that they stopped doing activities they enjoy due to this fear. 1 Participants who report a fear of falling have significantly lower quality of life and community participant scores compared to those who report no fear. 1 Fortunately, targeted interventions can reduce fear of falling. 2 To examine the effectiveness of interventions designed to manage fear of falling, clinicians and researchers must have a way to accurately measure the construct. To date, the Spinal Cord Injury Fall Concerns Scale (SCI-FCS) 3 is the only fear of falling measure applicable to individuals who use a wheelchair or scooter. However, this assessment has only been validated among individuals living with SCI. The purpose of this abstract is to describe the development and preliminary validity and reliability of a fear of falling assessment (Falls Concern Scale for Wheelchair and Scooter Users – FCS-W/C+S) for individuals who use a wheelchair or scooter living with a variety of health conditions. A multistep process was utilized to develop the FCS-W/C+S. Using the SCI-FCS as the foundation, the FCS-W/C+S 1.0 was created. SCI-specific content was removed, and the tool was expanded to include factors associated with falls among individuals who use wheelchairs and scooters. 4,5 The FCS-W/C+S 1.0 was further revised by a group of researchers and individuals who use a wheelchair or scooter to create the FCS-W/C+S 2.0. Next, a focus group comprised of 7 clinicians and researchers involved in fall prevention efforts was held. During the discussion, opinions about specific items, clarity of instruction, and sequence of questions were considered. Findings analyzed using a thematic analysis, 6 revealed the need for clearer instructions, more examples within scale items, and the removal of a section on leisure and exercise. Findings were integrated to create the FCS-W/C+S 3.0. Next, a focus group of 10 individuals who use a wheelchair or scooter living with a variety of health conditions, was convened. Study participants reviewed the FCS-W/C+S 3.0 and provided feedback that included recommendations to clarify instructions and scale items. Changes were integrated to create the FCS-W/C+S 4.0. The reliability and concurrent validity of the FCS-W/C+S 4.0 was assessed by asking individuals in the target population to complete the FCS-W/C+S 4.0 and the current SCI-FCS. Participants were then asked to repeat the FCS-W/C+S 4.0 seven days later. Preliminary results among 61 participants found the FCS-W/C+S to have an acceptable correlation with the SCI-FCS (r = 0.71, p < 0.001). Among 23 participants who completed the FCS-W/C+S an average of 7.7 days later, strong test-retest reliability was found (r = 0.87, p < 0.001). The FCS-W/S+S has potential to be an important tool to assess fear of falling among individuals with a variety of health conditions.
A Decision Aid to Support a Wheelchair Recycling Program
Martin Ferguson-Pell, PhD, C.Phys. FRSA; Steven Siebold; Tessa Harris, OT; Emily Armstrong; Sai Bhargav Chowdary Kancheti; Baljinder Kaur; Utkarsh Pandey
Many wheelchair users in Alberta are supplied by the Alberta Aids to Daily Living (AADL) program. New wheelchairs are provided through a joint assessment process including an occupational therapist (OT) or physiotherapist (PT), the client and their family and a technical representative of the wheelchair supplier (vendor). Recently AADL has introduced a recycling program where, when available, a previously used manual wheelchair is refurbished and provided. One of the challenges with this model is that during the assessment the vendor may not always participate and provide product expertise. In Alberta, when a wheelchair is required, an order is generated by the client’s OT or PT that is then forwarded to AADL where it is assessed for eligibility. For the simpler wheelchair requirements, a Level One Seating authorizer is assigned to complete the assessment and a specification form is completed. The Level 1 credential requires the completion of basic training in wheelchair and seating education or evidence of experience. Usually, the OT or PT has a much wider caseload than just wheelchair assessments. Keeping up to date with product information is therefore challenging and a barrier to implementing the recycling program. To overcome this challenge our team has developed a web application that functions as a decision aid for clinicians to ensure technical compatibility with the clinical requirements of the client. To achieve this the structure of the web application requires an effective clinician-friendly user interface and a back-end that incorporates the necessary algorithm to link clinical requirements (seat height, width and depth, propulsion technique, recline) to the required wheelchair’s technical specifications. The clinical requirements entered into the web apps dashboard are a subset of clinical requirements extracted from the assessment form and validated by the Level 1 OT/PT. A database of wheelchair technical parameters was created from the manufacturers’ data sheets for the web app’s algorithm to refer to. The range of products included in the database was limited in the first instance to those eligible for funding by AADL for clients with basic wheelchair and seating needs. The web app matches the clinical requirements to product technical data in the database using a hierarchical filtering approach resulting in a list of wheelchairs that would be suitable. Based on clinician and client preferences a request from the bank of wheelchairs available from the recycling center is then generated and a wheelchair is provided for fitting at a subsequent clinical session. If a suitable recycled wheelchair is not available, a new one will be provided, with vendor support. The back-end software has been designed to enable expansion of the app to a wider range of wheelchairs, once this proof of concept has been evaluated, Our evaluation will use the two pathways (new w/c with vendor support and used w/c without) to compare outcomes.
Building Consensus in Seating and Wheeled Mobility Evaluations
Michelle Lange, OTR/L, ATP/SMS, ABDA; Filipe Correia, MBA
Seating and wheeled mobility evaluations are ideally team based. Team members include the client, caregivers, clinicians, and the supplier. Sometimes team members may have difficulty achieving consensus, often due to a difference in intervention philosophies. For example, one team member may be reluctant to move forward with power mobility. Without consensus, the client may not receive appropriate equipment and interventions or may receive equipment that is ultimately abandoned due to lack of “buy-in”. This course will address seating and wheeled mobility intervention philosophies and consensus building strategies. Specific case studies will be utilized to illustrate a lack of consensus and strategies to get team members on the same page. Participants will be able to answer questions about each case study using an interactive polling app. Come ready to discuss this important topic!
Power Assist Devices: Show me the Evidence!
Carla Nooijen, PhD; Jennith Bernstein, PT, DPT, ATP/SMS
Power assist devices have primarily been utilized to reduce the risk of repetitive strain injuries and improve propulsion efficiency for individuals who use manual wheelchairs for mobility (Khalili et al. 2021). This is achieved through the benefit of decreased number of propulsion cycles and decreasing the amount of force of effort required to propel (Kloosterman et al. 2013). There is an increasing body of evidence, with multiple recent scientific publications, describing the potential larger impact of power assist devices. Using the framework from the International Classification of Functioning, Disability & Health (ICF, WHO, 2001; McDougall et al., 2010), this course will present up-to-date evidence on power assist devices allowing a holistic approach at how mobility with a power assist device can impact an individual’s life. The primary source of the evidence is a recent systematic literature review, which identified 84 publications of which 35 were included. Other sources are a user survey amongst 125 participants, five interviews with individuals using different types of power assist devices and 32 supporting publications including guidelines and position papers. From the available evidence, it can be concluded that power assist devices play a role that extends beyond the relief of repetitive strain and energy conservation into what activities people can participate in, the environments they can access and navigate in and how independent they are. Another unique aim of this course is to review the evidence-based considerations to be aware of when matching the needs of a person to the type of power assist device. A comparison of the evidence will be made between front, main wheel and rear power assist devices. In addition, clinical applications of a wide variety of power assist devices will be shared to be able to discuss how the literature supports these experiences but also how understanding the lived experience can add knowledge to our clinical decision making that we may not see yet in peer-reviewed literature. This course will provide an overview of the latest evidence regarding all types of power assist devices and will help to guide the equipment evidence-based decision-making process for clinicians, providers, and the individual’s using power assist devices.
RESNA Certification Town Hall
Julie Piriano, PT, ATP/SMS
In the team approach to the provision of Complex Rehab Technology (CRT) RESNA certification of the supplier as an Assistive Technology Professional (ATP) is mandatory for many third-party payors. The Seating and Mobility Specialist (SMS) certification is optional but sends a strong message to consumers that the credentialed individual has advanced knowledge and skills in this area pf practice. This includes the requirement to follow a Code of Ethics (COE) and Standard of Practice (SOP). While the roles and responsibilities of each team member may differ, the mandate to “do no harm” is paramount in the discharge of your professional obligation. This course will provide an overview of the current state of RESNA’s Certification Programs, review the RESNA COE and SOP documents, illustrate what may be considered a violation, and provide participants with tools to protect the integrity of the certification process, resulting credentials and the individuals with disabilities we serve. The session will be informative, interactive and provide time to hear from those who have, or are interested in obtaining one RESNA’s certifications – ATP/SMS/RET.
RESNA Position Paper on the Application of 24-7 Posture Care Management: Feedback Session
Patricia Toole, MSOT, OTR/L, ATP, MAT; Tamara Kittelson, MS, OTR/L, ATP/SMS; Jennifer Hutson, PhD, OTR/L, ATP; Kourtni Bopes, OTD, OTR/L, ATP/SMS; Lee Ann Hoffman, OTD, MSc, ATP/SMS
The RESNA 24-7 Posture Care Management (PCM) SIG and the RESNA board of directors have approved the formation of a work group to publish a position paper on the Application of 24-7 Posture Care Management. 24-7 PCM is a gentle, respectful practice of supporting people with mobility impairments in symmetry to protect their bodies from the distorting effects of gravity. While postural support for clients in sitting (in a wheelchair) and in standing (in a stander) is considered standard care and is well documented in the literature and in RESNA position papers, postural support for those same clients outside of the wheelchair (in lying) is less well documented. The RESNA Position Paper on the Application of 24-7 Posture Care Management focuses on PCM for lying and considers these issues: Who can benefit from 24-7 PCM? What assistive technology exists to support symmetry in lying? What skills does a therapist need to be successful with this intervention? How can the therapist best train the client’s direct support team? What is at risk if this support is not provided? For many of the 131 million people worldwide who use wheelchairs, the hours they spend lying down can contribute to body shape distortions. We know that those unable to change position who spend many hours lying in asymmetrical postures have an increased likelihood of developing body shape distortions (e.g., scoliosis, windswept hips, contractures) and that these postural deviations are associated with pain (Casey et al., 2020, 2021). Because of the link between sitting and lying postures, it’s important that we provide interventions that address the lying orientation. We welcome your critical engagement in the development of this position paper and appreciate your generosity in sharing your experiences with the work group at this interactive session. During this one-hour session the RESNA 24-7 PCM workgroup will share definitions and topical outline for the Application of 24-hour postural care management position paper. We will discuss the purpose of the position paper which specifically relates to postural care for lying, provide an overview of the type of information required for such position papers, and give details about the process we’ve used thus far to inform the position paper. Attendees will be invited to share their ideas about the strengths and areas for improvement as it relates to the position paper content areas.
Development of the Seating and Mobility Index
Rachel Hibbs, DPT, NCS, ATP; Juli Harrison, OTD, OTR/L, ATP; Gianna Rodriquez, MD; Julie Mannlein, PT, ATP
Medical documentation for the process of obtaining Complex Rehabilitation Technology can be just as complex as the technology itself. One of the largest problems the field of CRT faces is funding and reimbursement for the technology. Documentation is not uniform from clinic to clinic, and it can be difficult to numerically measure the client’s need for different devices. CMS coverage policies for CRT devices are also based more on diagnostic criteria and use within the home rather than the functional or participation needs of the person. Although many of the specialty evaluations provide multiple measures of function, there are no currently accepted standardized measures to facilitate objective review, approval, and payer coverage for provision of CRT. This session will provide updates on a project that has as primary objective to systematically develop a unified and validated method for clinicians to assess and quantify a person’s need for different types and levels of CRT based on function, participation, and environmental factors rather than diagnosis. This session will provide background work done and available resources for existing objective measures, resources for current best practice documentation, and updates of the current status of the Seating and Mobility Index.
Mechanical Adjustment and Functional Impact of Lower Rear Seat-to-Floor Height in Manual Wheelchairs
Stephanie Tanguay, OTR/L, ATP; Patrice Kennedy, MPT
Adjustability for manual wheelchairs allows a wide range of fine tuning for rear wheel orientation. Much of the focus on rear wheel orientation and rear seat-to-floor height has been on propulsion and reducing shoulder strain. While lowering rear seat to floor height lowers the consumers’ center of mass, can increase stability, and changes the users’ orientation to the propulsion wheels, this aspect of wheelchair configuration is rarely explored during the evaluation process. In “standard” configuration, the variance from front to rear seat-to-floor height is typically 1.5′′ to 2′′. In many chairs, making these changes can be mechanically cumbersome and time consuming. As a result, many manual chair product trials are completed without adjustment to the chair configuration. Given these factors, it is very possible that clinicians and consumers alike have limited awareness of the postural and functional impact of changing rear seat-to-floor height. This session will examine incremental changes to rear seat-to-floor height and demonstrate the impact of those changes to seat orientation and seated posture. Additional aspects of equipment configuration and back support use and adjustment which can be utilized to maximize functional use of the wheeled mobility device will also be reviewed. The benefits of following consumers from evaluation to delivery and subsequent re-evaluation and adjustment to equipment over time will also be highlighted.
Bariatrics: Pressure Injuries and Wound Care Considerations
Karen Lerner, MS, ABWM, CWS, RN
Human dignity is an essential part of health care for all clients, including those that are obese. Similar to very underweight clients, bariatric patients are at risk for a multitude of difficult and costly to resolve skin conditions. This program will discuss strategies and present evidence to enhance the chance of successful outcomes for clinicians and DME/Rehab Providers who care for bariatric clients and their skin. The scope and problems associated with obesity and bariatrics, the causes and dynamics of bariatrics, solutions for choosing appropriate equipment and caring for the bariatric patient’s skin, and various safety issues associated with the bariatric patient are included
Large Data Analysis of Falls in People with Mobility Limitations
Corey Morrow, PhD, MOT, OTR/L; Mark Schmeler, PhD, OTR/L, ATP; Richard Schein, PhD, MPH; Gede Pramana, PhD
Approximately 13.2% of people in the US live with a disability and 3.6 million adults use a wheeled mobility and seating device. A properly prescribed mobility device may reduce fall and pressure sore risk while improving health-related quality of life. However, there are many barriers to patients accessing prescribed mobility devices such as reimbursement/cost. The Functional Mobility Assessment and uniform dataset (FMA/UDS) is a mobility outcomes registry that provides objective data to increase clinicians’ ability to advocate for life-changing mobility equipment for their patients. This actively growing registry will allow us to analyze how mobility devices impact persons with disabilities. Specifically, analysis on sub-populations by diagnosis, age groups, congenital versus acquired disability, and level of obesity are a few examples. Potential health care quality measures include changes in fall or pressure ulcer frequency, patient satisfaction, and device repair needs. This session will provide our current findings for the demographic information of patients who were prescribed mobility devices, their fall frequency at baseline and follow-up, and patient satisfaction for the overall registry and sub-populations. Lastly, the session will report on preliminary cost-effectiveness modeling for falls and pressure sores as it relates to mobility limitations.
Upper Extremity Positioning, The Missing Seating Intervention
Bart Van der Heyden, PT
Introduction: The incidence of post stroke glenohumeral subluxation is up to 80% and up to 84% with users post TBI develop contractures. Shoulder pain, subluxation and contractures of the UE affect the client’s quality of life, interfere with the rehabilitation process and increase institutionalization rates. Management of hypertonicity, resistance to passive movements, shoulder pain and shoulder subluxation in the upper extremity is challenging for wheelchair users with neurological involvement of the upper extremity because of CVA, brachial plexus injury, or other progressive or traumatic neurological impacts on the upper extremity as may be seen in diagnoses such as spinal cord injury (SCI), Traumatic Brain Injury (TBI), muscular dystrophies, multiple sclerosis and Parkinson’s. Prediction of UE contractures, glenohumeral subluxation and assessment of shoulder pain is an essential task of the therapist, and factors such as innervation pattern, spasticity, pain, oedema and long term position of the body are important to observe and analyze. Prevention is a team approach and may include medication, including pain relief, anti-spasmodics, botulinum toxin, in conjunction to passive movement and positioning of the upper limb throughout the day. Evaluation of clients with upper extremity postural and functional deficits includes examination of joint range of motion, looking for possible contractures, ROM deficits, glenohumeral subluxation and UE pain. Prior to the UE physical exam, it is important to perform a seating evaluation to understand the link between upper extremity posture and seated posture. Once a thorough evaluation has been completed, an UE positioning plan can be individually designed and the most appropriate technique to treat or prevent contractures, ROM deficits, shoulder pain and glenohumeral subluxation can be chosen. Interventions should be specifically adapted to each client and goals for the UE postural interventions may include: 1. Contracture management of the upper extremity and hand 2. Tone management of the upper extremity and hand 3. Reduction of shoulder pain 4. Supports deceased risk of shoulder subluxation 5. Improve/increase proprioceptive input of the affected upper extremity 6. Improve motor control and strength of the upper affected upper extremity 7. Progressive, dynamic positioning of the upper extremity and hand 8. Minimization of injuries from unwanted movements. Conclusion: This session will give an overview of the pathomechnics and risk factors of UE contractures, glenohumeral subluxation and shoulder pain. Best Practice guidelines for Upper Extremity positioning and innovative options for assessment and positioning of the UE will be discussed.
Evaluation of Assistive Technology Service Delivery in Pakistan
Areeba Khan, MS, ATP; Mary Goldberg, PhD; Jon Pearlman, PhD
Purpose: Recently, a Rapid Assistive Technology Assessment was conducted by the World Health Organization in Pakistan where it assessed the need for assistive technology. It discovered that there was a significant room for improvement in many different areas of assistive technology provision, such as funding, availability, or cost. The primary objective of this scholarly paper is to determine if there is a presence of Pakistani providers who provide assistive technology and describe their characteristics. Secondary objectives include determining if the individuals that provide assistive technology adhere to a standard assistive technology service delivery process and whether these providers’ characteristics including geographical region, education, and experience are associated with adherence to the process. Methods: An online Qualtrics survey composed of multiple-choice questions was distributed to physiotherapists, community-based healthcare workers, occupational therapists, and related health professions through a convenience sampling method. There were 71 respondents from 4 provinces of Pakistan who provided demographic information and indicated whether they participate in service delivery and adhere to service delivery steps. SPSS Statistics was used to develop correlation matrices to determine Pearson’s coefficient of number of steps, education level, experience level and continuing education received. Results: 53.5% of respondents stated that they provide assistive technology. In terms of the service delivery process, most individuals participated in the assessment (82.9%) and fewer participated in the follow-up, maintenance, and repair (48.6%). Only 7.8% of individuals participated in all parts of the service delivery process. These respondents were all from one region. The majority of individuals who provide assistive technology received assistive technology education through continuing education, had 11–20 years of experience, and were 35–44 years old. There is weak correlation between number of steps and education level, number of steps and experience level, and number of steps and continuing education received. Conclusions: The majority of respondents provide assistive technology in Pakistan. There was participation in most parts of the service delivery process, except for funding and ordering, with only 15.8% of participants. There is a weak correlation between education level, experience, continuing education received and participation in more parts of the service delivery process. Relevance/Future Prospects: While the majority of respondents do provide assistive technology, a significant proportion (46.5%) do not. This may suggest there is a need for additional advocacy and awareness raising of the benefits of and how to access assistive technology in Pakistan. Educating users on assistive technology and associated resources may empower them to self-advocate for appropriate assistive technology in Pakistan.
Blueprints for Success: Student Perspectives on Enabling Advanced Leadership Roles Within Pressure Injury Management
Richard Kellowan, MSOT, BPHE, OT Reg. (Ont.)
Introduction: Occupational therapy (OT) fieldwork has evolved to include leadership, emerging, advocacy, and program development (LEAP) placements. These placements develop student leadership skills for program and policy development while providing institutions with practical support to pursue quality improvement plans. An academic hospital initiated a twelve – month plan to advance pressure injury (PI) management through LEAP placements. Six students completed five projects: 1) Exploring Best Practices for Wound Prevalence Surveys; 2) OT Practice Profiles for PI Management; 3) Heel Offloading Guide for Clinicians, 4) Exploring the Clinical Utility of Offloading Devices, and 5) Developing Heel Offloading Device Decision Trees. Student outcomes included learning advanced practice knowledge, honing clinical skills, and learning how to implement processes for program and policy development. Outcomes hinged on effective student leadership performance. To - date, there is limited research on how student occupational therapists learn and perform during LEAP placements. This gap may influence LEAP placement outcomes for students, supervisors, and sponsor sites. Objectives: Poster will explore student perspectives on effective supervision for leadership performance during LEAP placements. Approach: Six student occupational therapists that completed LEAP placements in pressure injury management will be purposively selected to complete an online, post – placement survey to describe their experiences. Thematic analysis and member checking will interpret findings. Recommendations for supervising students on LEAP placements will emerge from final results. Results: Recruitment and analysis are ongoing. Deductive themes are: blueprints for success; build my clinical foundation; scaffold my growth; set the roof within reach; and hold an open house. These themes focus on setting specific guidelines for LEAP placements, fostering advanced practice knowledge, mentoring interprofessional growth, structuring realistic goals, and showcasing student outcomes. Conclusion: Student therapists value structured supervision strategies that enable personal and professional growth.
Stand Up for Participation! Strategies to Support Integration of Pediatric Powered Wheelchair Standing Devices into Daily Life Activities
Lisa Kenyon, PhD, PT, DPT, PCS
Powered wheelchair standing devices (PWSDs) allow children who use a powered wheelchair to electronically transition between sitting and standing and drive in either position. Research suggests that the integrated standing feature of the PWSD provides children with the ability to stand when and where they desire, thereby potentially increasing their independence and participation. Yet our recent work strongly suggests that children and families need specific training and support to fully realize the potential benefits of PWSD use. Drawing from a variety of sources, including the facilitating strategies from the Assessment of Learning Powered mobility use, the Pathways and Resources for Engagement and Participation (PREP) model, the Assessment of the Learning Process, and PWSD research studies, this session will introduce specific intervention strategies to support integration of PWSD use into daily life activities. Within this intervention, the clinician, family, and child work collaboratively to identify facilitators and barriers to PWSD use, including environmental, physical, social, institutional, and task demands. Collaborative problem solving and exploration are then used to develop a plan to address identified barriers and while simultaneously maximizing identified facilitators. Case studies and examples from our work will be used to illustrate application of the Stand Up to Participate intervention.
Manual Wheelchair Configuration in Unilateral Upper and Lower Extremity Propulsion: Effects of Rear Wheel Axle Position and Frame Type on Efficiency of Propulsion
Maggie Dahlin, PT, ATP; Janell Jones, PT, DPT; Candy Tefertiller, PT, DPT, PhD, NCS
Individuals with moderate to severe brain injury (BI) may rely on a manual wheelchair for mobility due to impaired standing balance, slower walking speed and limited endurance. The variety of motor, sensory, and cognitive deficits that are associated with BI make successful and efficient manual wheelchair propulsion difficult. Due to these deficits, individuals with BI often use an alternative propulsion strategy requiring the use of one arm and one leg known as hemi-propulsion. The importance of wheelchair axle position and frame type has not previously been evaluated when using a hemi-propulsion technique in individuals with BI. This study investigated the effect of using a lightweight wheelchair (K0004) in comparison to an ultra-lightweight wheelchair (K0005) and evaluated the impact of frame type (folding versus rigid) on wheelchair mobility skills, speed and exertion for individuals with BI using a hemi-propulsion technique. Eighteen participants between 18 and 80 years old, diagnosed with a neurologic injury or disease resulting in hemiplegia or hemiparesis, who use a manual wheelchair for at least four hours per day with a hemi-propulsion technique were recruited. The primary outcome was the modified Wheelchair Skills Test (WST) which includes 9 skills (4 low rolling resistance and 5 high rolling resistance). Secondary outcomes included the Wheelchair Propulsion Test (WPT), 100 m Push Test, Heart Rate (HR) and Rate of Perceived Exertion (RPE). Significant differences were found in the WST, favoring ultra-lightweight wheelchair frames (folding and rigid) in comparison to the lightweight wheelchair. The 100m push test, RPE and the change in HR showed statistical differences favoring both ultra-lightweight frames over the lightweight frame as demonstrated by individuals propelling faster, reporting lower levels of exertion, and exhibiting smaller changes in HR. Significance was not seen with the WPT measures across wheelchair frames. The results suggest that an ultra-lightweight wheelchair with an adjustable axle improved success with wheelchair mobility skills and decreased physical and perceived exertion in comparison to using a lightweight wheelchair with limited adjustability. Results also suggest the use of a rigid (versus folding) frame enabled faster forward mobility. Individuals with BI are often reliant on a hemi-propulsion technique for manual wheelchair mobility which requires foot propulsion in which axle adjustability may be required to achieve optimal biomechanics. Data suggests that using an ultra-light weight wheelchair may lead to improved ability to complete wheelchair skills needed for community mobility and a decrease in the actual and perceived physiological burden associated with propulsion. It also suggests that the use of a rigid frame enables faster forward mobility in comparison to a folding frame among ultra-lightweight wheelchairs.
Wheelchair Failures, Repairs, and Maintenance: What is Best Practice?
Jack Fried, MS; Mark Schmeler, PhD, OTR/L, ATP; Richard Schein, PhD, MPH; Madelyn Betz, MS, ATP; Gede Pramana, PhD; Weesie Walker, ATP/SMS; Mark Sullivan
Complex Rehabilitation Technologies (CRT) are crucial to the everyday lives of people with spinal cord injuries, cerebral palsy, ALS, and other diagnoses. When these custom devices and associated seating and positioning systems are not appropriately provided, these individuals experience reduced independent mobility and access to home and community resources as well as increased pain, pressure sores, and lack of function. Proper provision of CRT goes far beyond the final delivery of the user’s technology. As with all types of equipment, these systems require routine maintenance and repair/replacement of parts. In this case, not having use of the custom fitted system also creates many of the problems stated above. The current process can often take up to 90 days due to the documentation requirements, often in-home service provision, and the complexity of the repair and extensive variety of products needed to customize the system to individual users. Current national policy has identified 5 years as the Reasonable Useful Life (RUL) of any wheelchair. However, it does not cover wheelchair maintenance with the expectation that the user will perform these tasks. Also, replacement of wheelchair components is only covered once the parts have failed. Delays in performing repairs and subsequent adversities is well documented. Studies further show that most users are not aware their device needs maintenance and are often unable to perform these tasks. Right to Repair legislation has been introduced in an attempt to mitigate these issues, but there is no formal standard or guidance on when components should be maintained or replaced or who is qualified to perform this service. An understanding of best practice for repair and maintenance is crucial to decrease the amount of time it takes to intake, diagnose, document and complete a repair to minimize the impact to the consumer, improve the documentation procedures in both content and speed, and establish a preventative maintenance program that catches potential problems before they happen. Over the past 5 years, investigators within the RERC on Wheelchair Standards at the University of Pittsburgh have developed a Wheelchair Repair Registry (WRR) to investigated and report “Real World” repair data to identify the types and frequencies of CRT wheelchair repairs. Other projects have further tested wheelchair components such as cushions and casters to estimate life expectancy. The RERC has collaborated with the National Registry of Rehabilitation Technology Suppliers (NRRTS) to develop a best-practice document related to CRT wheelchair repairs and maintenance that includes recommended timelines for maintenance inspections and expected replacement timelines for common components on CRT wheelchairs. This document can serve as a guide to inform best-practices and advocate for equitable policy/payment models to ensure the safe and functional operation of wheelchairs to reduce adverse events associated with failures.
Early Intervention, Participation and Functional Positioning
Kristine Westby, PT
The human brain needs stimulation from the baby is born and all the way through life. Within the first 2 years of life, it is extremely important that the baby is stimulated, and given the opportunity to develop and grow . Babies that are born with disabilities does not always get this chance. Often, they have long stays in the hospital, their parents are exhausted from worrying, or they are not believed in by their caregivers. Too often we see children that have had to wait for years to receive a technical aid that can help them move around by themselves, and they are delayed more than necessary in their development. This slows down their brain development, their motor development and their ability to develop social skills. All children with disabilities are able to develop, and it is our job as providers and caregivers to give them this experience. They need to learn what happens in their environment when they move around, when they move towards a person, when they knock over an item or when they don’t adjust their speed. All of this is nutrition for the brain to thrive and learn new things. We in Adaptive Imports want to give these children this opportunity, and therefore we have started a cooperation with Krabat in Norway. Krabat has developed several innovative technical aids to give the children a good, active and early start. We want to share our experiences with positioning the children in the four-feet position and giving the opportunity to crawl when they are at the age of crawling. We want to show how research substantiate that four-feet positioning and crawling is important for further development. Furthermore, we want to show you how good positioning can be given in the prone and standing position in aqua therapy, and how this stimulates to mobility and movement. The third aspect of our presentation will be showing how and why we position children with all levels of disability in saddle seats to give them a functional and healthy seated position. We will show you why we regard the pelvis and the hip joints as main aspects of balanced healthy seating, and what happens when this is not taken care of. All of this we will show with our own experience and substantiate it with research. The theme of our presentation will be Functional positioning to secure early mobility.
Documentation LIFE Preserver (Efficiently and Effectively Document a Wheelchair Evaluation)
Daniel Fedor
Do you feel like you are drowning in documentation? Are you spending more time writing and rewriting documentation for health insurers such as Medicare, Medicaid, Medicare Replacement Plans and Private Insurances than actually treating patients? Is this affecting your personal life because there is not enough time during the day to complete the required documentation? Or have you been offered “help” by equipment suppliers in writing the documentation. If so, please be aware this could lead to ethical and legal implications (violate the anti-kickback statute), so just say no to that offer. The amount of documentation required IS overwhelming and there just doesn’t seem to be enough time during the day to give insurances what they expect and to be a productive therapist. There is a COMPLIANT way to give them what they want so qualified patient can receive the mobility equipment in a timely manner. In this interactive workshop participants will gain insight into health insurance plans documentation requirements for mobility products and related accessories. The instructor, a former Director at Medicare, will share the internal thought process of health insurance plans which will enable therapists to provide them what they need in order to approve a claim for qualified patients. This course will teach attendees how to compliantly and efficiently complete an effective evaluation for mobility products in order to reduce the time spent on writing documentation, thus preserving your work and personal LIFE!
What Factors Really Affect the Efficiency of a Manual Wheelchair
Curt Prewitt, PT, ATP, MS
There are many firmly held opinions about what factors most dramatically affect manual wheelchair propulsion efficiency. Which factors have the greatest impact and are most important to consider? Is it the weight of the chair? Is it the component selection? Like an automobile, is it the way it is tuned or set up that optimizes efficiency? Prescribing professionals must understand how people use their manual wheelchairs. They must also understand how wheelchairs actually work as a machine. Armed with this knowledge, the professional can make appropriate decisions to optimize efficiency while meeting the user’s needs for support, stability, and function. This presentation will discuss factors commonly considered to be predictors of manual wheelchair propulsion efficiency. We will compare these factors in light of what current research suggests as being predictive and then provide some applicable conclusions to inform clinical practice.
Please May I Have My Lap Back? Intervention Principles for Management of the Anterior Pelvic Tilt
Daniella Giles, PT, DPT, ATP/SMS
The goal of this presentation is to provide tools for identification and treatment of the anterior pelvic tilt in the wheelchair user. We will discuss common errors in diagnosis and treatment, early and (too) late intervention strategies and diagnosis specific considerations. I will provide the reader with strategies to increase user compliance with use of recommended support systems. Photos and case examples will accompany the written presentation. By far the most common postural alignment in sitting involves a posterior pelvic tilt, with lumbar and thoracic flexion. This can be seen across a variety of diagnosis, functional abilities and age groups. As seating and mobility professionals it is a well-established goal to re-align this posture closer to anatomical neutral, including an increase in anterior pelvic position with lumbar and thoracic extension. Intervention strategies for the anterior pelvic tilt are opposite that of the more prevalent posterior pelvic tilt, and typically are more challenging to resolve. Individuals diagnosed with Muscular Dystrophy (all subtypes), or Spina Bifida have a high propensity towards hyperlordosis. It is not an uncommon presentation in individuals with cerebral palsy, spinal cord injuries and ALS. If an ATP is working with people with any of these diagnoses, there is a high likelihood you will be asked to provide seating interventions for an anterior tilt presentation. For this reason, it is this authors belief there is a substantial need to have the tools and expertise needed to identify and treat this presentation with high accuracy.
Transition Clinicians: Seating Solutions Across the Ages
Elaine Rogers, MPT, ATP; Kathleen Decina, PT
Have you ever had a client tell you “I’m a manual chair user- I’m not going to get a power chair” even though you know it might help decrease their fatigue and shoulder pain? Or what about ambulatory individuals aging with a neurologic injury who can barely make it to the grocery store- what’s the best mobility equipment to transition them to when their focus for years was on being ambulatory? You’ve successfully transitioned a client from a manual chair to a power chair, but their shoulders still hurt- now what? What changes and transitions in seating and mobility equipment are needed as you age with a Spinal Cord Injury or other neurological disorder? And at what age should we expect these transitions? What are the factors driving these transitions? Are they client lead changes, clinician recommendations, forced necessity or preferences and choices? These multiple questions are faced daily when interfacing/serving individuals who are aging with a neurologic disability. What is the timeframe when someone should switch from manual to power- how will that impact their life? As clinicians turning to the literature, we find information related to the aging process and physiological effects [1] such as pain and fatigue [6], leisure participation and isolation [5]. However, limited literature exists to guide the clinician in selection of the best mobility equipment and the best transitions in equipment for individuals aging with a disability. The unique needs of individuals living and aging with a neurological disability related to their mobility equipment are understudied and more complex than the needs of individuals who experience aging into mobility related issues [2] In 2005, life expectancy of individuals even with the most severe impairments had increased to be approximately 80 to 90% of the general population [1] thus changes to equipment are to be expected. A mismatch between the needs of the individual based on functional capacity and their provided wheelchair can lead to decreased mobility, fatigue, poorer posture, pain and pressure ulcers all contributing to poorer quality of life [3]. Requejo et al. [3] stress the importance of best practices, decrease repetitive movements, safe transfer strategies, manual chair performance optimization, promoting optimized posture in manual wheelchair prescription to preserve function as long as possible however literature does not currently guide what changes to make when aging with a disability. This session will focus on what clinicians can and cannot do to assist with transitions necessitated by aging with a neurologic disability. A twenty-five plus years of history with individuals aging with spinal cord injury gives a unique perspective on how to assist individuals through transitions with mobility equipment, thoughts on transition timeframes and acceptance through the use of multiple case examples of success and “failure.”
Reliability and Validity of the Caregiver Assisted Transfer Technique Instrument
Hailee Kulich, BS; Alicia Koontz, PhD, RET, ATP; Ahlad Neti; Chang Dae Lee, PhD, OTR/L; Jordan Hoydick; Ricardo Jimenez, MD
Informal, or unpaid, caregivers provide crucial support to individuals with disabilities. One of the most common activities of daily living that they assist with are transfers, where a caregiver moves a care recipient from one surface to another. However, transfers are physically demanding, putting the caregiver at risk for musculoskeletal pain and injury. While assistive technologies mitigate some injury risks, current transfer technologies are not always immediately available, convenient, or intuitive to use, increasing the risk for injury to both caregivers and care recipients. Additionally, informal caregivers do not always receive adequate training on proper transfer techniques and there is no standard way to evaluate transfer performance. Recently, a new outcome measure, called the Caregiver Assisted Transfer Technique Instrument (CATT) was developed to objectively assess informal caregiver technique during transfers and inform educational and training interventions that will mitigate the risk of developing musculoskeletal pain and injury and promote a safer, less injurious transfer experience for the care recipient. Two versions of the CATT were developed: one to address manual lifting techniques (CATT-M) and another to address transfers using lift-based assistive technologies (CATT-L). The purpose of this study is to assess the reliability and validity of the CATT. Participants were recruited in caregiver and care recipient dyads. Each dyad performed four assisted transfers to two surfaces using their preferred transfer method. Five expert raters evaluated each transfer using the CATT, while a sixth expert rated the quality of the transfer using a global rating scale. Participants were asked to complete a second visit to assess repeated administrations of the CATT. Reliability (intra-rater, interrater, and test-retest) was assessed using interclass correlation coefficients (ICCs), with an ICC of 0.8 or higher defined as good reliability. Spearman rank correlation coefficients were calculated to determine the strength of the relationship between the total score on the CATT and the global scale ratings, with a spearman rank correlation coefficient of greater than or equal to 0.8 considered very strong correlation. At the time of submission, five participant dyads have completed the study protocol. Data analysis is currently ongoing, but preliminary reliability results are promising, showing ICCs ranging from 0.776 to 0.798 for interrater reliability and for 0.805–0.875 intra-rater reliability. Results from this study will be used to refine the CATT so that it is suitable to serve as both an objective indicator of transfer performance and as a guide for training and educational interventions for informal caregivers.
What do Wheelchair Users Want? A Questionnaire About the Most Important Aspects in the Seating System has Been Done Among 150 Wheelchair Users Around the World.
Carlos Kramer
Background: The COVID-19 pandemic forced us all to go digital in a massive way. What started out as a crisis response has now become the next normal, with big implications for how we do education and research. With the impact of the pandemic, we have discovered that wheelchair users have a need to stay in touch with seating specialists. We conducted an online questionnaire through our social media channels where there was a high response from wheelchair users/clinicians (154). Method: In 2020 a questionnaire has been sent out to a group of end-users. The questionnaire contained questions about the most important aspects of their seating system. To give the wheelchair user an idea of what aspects there are in a seating system we summed up the next aspects [1]: – form, fit, and function – pressure management – postural stability – functional mobility – transfers – weight of cushion – microclimate (heat/moisture transfer) – perceived comfort – complexity – maintenance and set-up requirements – hygiene – ability to perform or direct – ability to get client and caregiver education. The questionnaire is based on a seven point Likert-scale with the additional option to indicate that something is ‘not applicable’ and the option to add additional explanation. In the development process of the questionnaire a list of four statements per claim were phrased and presented to a small test group, consisting of five wheelchair users. This test group was conducted to verify that wording used in the statements was clear and readily understandable for (the average) wheelchair user. Discussion with the test group also lead to the need of adding an additional opening question about the wheelchair cushion used at the time of filling in the questionnaire. Results: A total of 154 responses were given to the questionnaire. This total number excludes any faulty, uncomplete or double responses. Eighty percent of respondents were actual wheelchair users themselves. Therapist filling in the questionnaire from their perspective of using the wheelchair cushions made up 20% of the group. Twenty-five percent of respondents to the questionnaire were not Vicair wheelchair cushion users. Conclusion/Discussion: Overall responses are very positive; we can therefor say that amongst the group of respondents the cushions are performing well on the key attributes. Additional explanations given together with the answers lead to giving us valuable insights. It has shown us where uncertainties about how to use the wheelchair cushions still exist, giving us indications that continuing are educational program to ensure both therapist and end users will be valuable. Sharing out knowledge and the information about how to correctly and safely use wheelchair cushions will continue.
Developing a Novel Preference-Based Outcome Measure for Mobility-Related Quality of Life: The MobQoL Study
Nathan Bray, PhD
This paper presentation will describe the development of the MobQoL-7D outcome measure for mobility-related quality of life. Why was the MobQoL-7D developed? At present there is limited robust economic evidence to inform the design of posture and mobility services, or to guide the provision of mobility aids and other mobility-enhancing interventions in a cost-effective manner. The quality-adjusted life year (QALY) outcome framework has become increasingly influential in health policy as a generic approach to measuring outcomes via a single common metric, thus allowing comparisons of cost-effectiveness across disparate interventions. Preference-based outcome measures are systems of health state classification used to calculate QALYs, where each health state (i.e., combination of answers) is assigned a utility weight derived from the societal preference for that state. However, due to the generic nature of commonly used preference-based measures (such as the EQ-5D), they often lack sensitivity in states of disability and chronic illness. The aim of the MobQoL study was therefore to derive a novel outcome measure (known as the MobQoL-7D) for mobility-related quality of life, using a preference-based scoring system suitable for QALY calculations. How was the MobQoL-7D developed? Development of the MobQoL-7D began in 2016 and is due to be completed in October 2022; to date three papers have been published documenting the development of the measure (see reference list). The project combined methods of qualitative outcome measure development, psychometric testing and health state valuation. The dimensions and item-list for the preliminary MobQoL tool were developed through qualitative interviews with 37 people with a wide range of mobility impairments. A psychometric validation study was then undertaken with 342 individuals to assess the measurement properties of each of the fifteen original MobQoL items. The final MobQoL-7D health state classification system was derived from the seven original MobQoL items found to have the best psychometric properties. A final preference elicitation study is now being undertaken to develop utility weights for all health states described by the MobQoL-7D, which in turn will form the basis of the scoring system for MobQoL-7D. As part of this preference elicitation exercise, we intend to recruit 500 participants to complete value set development surveys using the Online Personal Utility Functions (OPUF) system developed by University of Sheffield. Data collection is expected to be completed in September 2022 and the final analysis will be completed by October 2022. Conclusion: The MobQoL-7D is the first outcome measure designed specifically to be sensitive to changes in mobility-related quality of life. It has a wide range of applications across academic and clinical settings and has the potential to improve provision of mobility-enhancing interventions for people with impaired mobility.
Posters
The Saudi Arabia Voice of the Consumer: A Survey of Consumer Priorities to Inform Knowledge Translation Among People with Disabilities Within Saudi Arabia who use Mobility Assistive Technology
Saleh Alqahtani, MS; Brad Dicianno, MD; Mary Goldberg, PhD; Mazen Alqahtani, PhD; Jongbae Kim, PhD; James Joseph, MS; Rory Cooper, PhD
Student Satisfaction with Manual Wheelchair Online Labs Based on 3D Models and Motion Video
Carmen DiGiovine, PhD, ATP/SMS, RET; Amy Sonntag, SLPD, CCC-SLP; Kayden Gill
Development of a Smart Seat Cushion for Use in Individuals with Spinal Cord Injury
Melissa Allman, PT, ATP
Survey Results of Stakeholders Perception of the Complex Rehabilitation Technology Service Delivery Process
Stephanie Chan; Tyler Beauregard, MS, AT, ATC, CSCS; Julia Parachini; Richard Schein, PhD, MPH; Carmen DiGiovine, PhD, ATP/SMS, RET
Satisfaction Survey Analysis of Funding and Procurement of Complex Rehabilitation Technology by State
Julia Parachini; Tyler Beauregard, MS, AT, ATC, CSCS; Stephanie Chan; Richard Schein, PhD, MPH; Carmen DiGiovine, PhD, ATP/SMS, RET
Free Community Seating Clinic for Individuals Living with Paralysis
Stacy McGinnis, MS, OTR/L, ATP
Taking Flight: Enabling Student Occupational Therapists as Leaders for Pressure Injury Management
Richard Kellowan, MSOT, BPHE, OT Reg. (Ont.)
Halloween Wheelchair Costume Clinic – a Need in Disguise for our Young Clients
Matt Lowell, PT; Jen Janowicz, DPT; Claire Behnke, DPT; Scott Jerome, MPT
Rebooting Instrumental Activities of Daily Living Performance During COVID-19 Using Internet-Connected Assistive Devices: Global Online Study
Abbas Quamar, PhD, CRC; Diane Collins, PhD, OT; Harshal Mahajan, PhD
Accuracy Test of a Built-In Body Weight Scale for Power Wheelchairs
Jorge Candiotti, PhD
Postural Care in the age of Covid-19 – A Qualitative Study into the Impact of the Pandemic on the Provision of Postural Care in England
Sarah Clayton, BSc, PGCE; Rachel Wright
“Unique Equipment for Unique Individuals”– Shriners Children’s Journey with Conjoined Twins
Matt Lowell, PT; Scott Jerome, MPT; Claire Behnke, DPT
The Skills on Wheels Training Program; Initial Findings of Five-Week Pediatric Wheelchair Skills Program
Tony Chase, PhD; Kiera Mendoza; Carson Rager; Maria Stiens; Madison Loeser
Participatory Action Design and Engineering of Powered Personal Transfer System for Wheelchair Users
Shantanu Satpute, MS
Mobility … Is it a Human Right? An Appalachian Perspective Amongst Therapy Students and Providers
Alison Kreger, PT, DPT, EdD, PCS, CKTP; Wendy Altizer, PT, ATP; Kyra Kreger
Hammie: Teaching Posture Concepts with a Simplified Anatomical Model
T. Sammie Wakefield, OTR/L; Tamara Kittleson, MS, OTR/L, ATP/SMS; Brian Burkhardt, MS, ATP
Expanding the Horizon of folding K0005 prescription
Derek Logan, PT, ATP; Susan Murphy, ATP
“Turn Right Here”: A Quantitative Approach to Testing the Efficacy of Novel Steering Modifications for Adapted Ride-on Cars
Mia Hoffman, BS; Daniel Campos Zamora; Jon Froehlich, PhD; Heather Feldner, PhD, PT, MPT, PCS; Katherine Steele, PhD
Static or Dynamic? A Presentation of the set-up of a SCED Study, Comparing Postural Balance and Forces Exerted on Seating Systems of Dystonic Wheelchair Users in Static vs. Dynamic Seating Systems
Mike Dongelmans, PT, HP
Family Education Resources for Pediatric Wheelchair Users with Muscular Dystrophy that Address Caregiver Burnout and Stress: A Scoping Review
Kaetlyn Culter, BS; Carmen DiGiovine, PhD, ATP/SMS, RET; Kyle Harris; Shelby Cavazos; Karen Adams, OTR/L, ATP
Friday April 14, 2023
“Disability Language: Think Before You Speak”
Jenny Siegle, BA; Tamara Kittleson, MS, OTR/L, ATP/SMS
Do you think before you speak? Communication can be challenging at the best of times, and especially when interacting with clients/patients/customers. We may cause offense or facilitate engagement, depending upon the words we use. Spend an hour with a wheelchair rider, clinician and mother, discussing how language matters and ways to expand communication skills related to disability. Explore current thoughts on evolution of language about disability. Gain confidence and build relationships in everyday interactions with people who are more than their disability!
Stand up for Participation and Function
Lynore McLean, PT; Ginny Paleg, PT, DScPT, MPT; Roslyn Livingstone, MSc(RS), OT
Postural management programs are recommended to promote function and alignment in lying, sitting and standing for children in GMFCS IV/V. Standers (otherwise referred to as standing-frames) support individuals who cannot stand independently in an aligned and safe standing position and serve as an affordance and environmental enrichment. This one-hour interactive workshop will review the results of our recent scoping review that explored the evidence regarding the use and outcomes of supported-standing programs with children, adolescents and young adults who are diagnosed with CP and classified as GMFCS IV or V. The following key points were identified: •Supported-standing interventions provide an important psycho-social and physical change-of-position •Supported-standing is not passive for those classified as GMFCS IV or V •Supported-standing may enhance participation, functional abilities and fitness •Children and young people need choice in where and when to stand •Individualized assessment and prescription are essential to match personal and environmental needs Although supported-standing intervention research is still limited, few harms have been reported. Lived-experience data and feedback from families, children and therapists suggests that provided supported-standing programs are incorporated effectively into the child’s and family’s lifestyle, they are well-tolerated and can promote participation with siblings, friends and family. The change-of-position from sitting is widely thought to be very important for both physiological and psychological reasons and may enhance functional abilities such as self-feeding, communication access and play. The largest body-of-evidence supports maintenance or improvement in BMD or ROM, although high-quality experimental studies are still required for all outcomes. Most importantly, supported standing may be a means of reducing sedentary behavior and enhancing physical fitness and participation for children and young people classified as GMFCS IV/V. As well as reviewing the results of the scoping review, this workshop will include case studies as well as open discussion. Participants will be able to share their own experiences and identify goals, obstacles and opportunities for integrating supported standing programs in their practice settings.
Designing Wheelchair Provision for People with MS: New Qualitative Research
Faith Brown, MS, OTR; Christel McMullen, PhD
Over 2.2 million people worldwide have Multiple Sclerosis (MS) and approximately 150,000 in the UK. This 2021 qualitative research study explored wheelchair and related assistive technology (AT) provision priorities of people with MS in the United Kingdom. Data was collected via semi-structured interview and vignette methods. Using a critical realist thematic analytical approach, study themes suggested clinical practice considerations and further research needs. The objective of this study was to investigate the wheelchair and ergonomic AT provision priorities of people with Multiple Sclerosis (pwMS). This included identifying service mechanisms to facilitate positive outcomes, those contributing to poor engagement and those which might help navigate tensions of competing individual or service goals. This study is not a specific service evaluation but an exploration of how services might best support pwMS. Four key themes were identified. ‘Clear, accessible information’ reflects participant expressions of a need for understandable, reliable information, emphasizing online resources in a range of formats. ‘Explicit expertise’ captures the value of professional guidance in positive outcomes, as well as difficulties with engagement when specialist input appeared irrelevant or there was a history of negative healthcare experiences. ‘Tailored choice’ highlights participant descriptions of a need for choice adapted to their physical and functional requirements and social perspectives. ‘Minimizing emotional energy’ relates to the emotional energy expenditure of the wheelchair and ergonomic AT provision process as a source of difficulties, sometimes linked to physical fatigue. These themes interacted with participant expressions of the importance of supported autonomy, i.e., a dual need for adequate support and autonomy in decision making for the most effective provision experience. This qualitative study suggests pwMS may have specific needs for wheelchair and ergonomic AT provision related to the physical, social, cognitive and psychological demands of MS. Although all participants identified areas of commendation, some aspects of the private and public processes in the United Kingdom may be out of sync with the requirements of pwMS. Furthermore, the interaction of MS with other social, psychological and environmental factors creates individualized contextual considerations which influence those requirements. The study suggests that provision structures to scaffold cognitive and emotional ease of service engagement by pwMS could help identify problems before they become irremediable. Further research is recommended to expand these findings, such as multidisciplinary investigations to investigate social and information nuances highlighted here or research into specific subgroups.
Considerations when Traveling with a Power Wheelchair
John “Jay” Doherty, OTR, ATP/SMS
Individuals who utilize power mobility everyday have many things to consider when traveling. One of the biggest concerns for people who use a power wheelchair for mobility and their travel partners is; will my wheelchair make it to my destination in one fully functional piece and once I arrive how do I get around. This course will cover the things that can truly impact the success and enjoyment of a travel experience; this includes things to consider when planning your travel, how to tie down a power wheelchair when traveling, how to travel by air with your power wheelchair, What to expect when traveling by air, and what types of services might you need once you have arrived.
AAC for the ATP
Beth Speaker-Christensen, SLP, ATP
Many of us work in a multidisciplinary team. Many clients work with team members with varied skills and tools to share. When considering what is needed to be an effective ATP, we know a generalized knowledge of ALL AT is best. What lies in YOUR scope of practice? What are your special skills? We cannot know it all, but this session will help you to better understand concepts surrounding Augmentative and Alternate Communication (AAC) and effective feature matching. I hope this information will help you ask really good questions for your clients and consider all AT when problem solving and advocating for your clients.
Adverse Events in Wheeled Mobility: Actions to Mitigate Harm & Manage Mistakes
Kendra Betz, MSPT, ATP
Whether resulting from a small mistake or gross negligence, adverse events involving wheeled mobility devices are common and often result in detrimental consequences for the consumer ranging from minor inconvenience to catastrophic injury including death. Examples of well-known adverse events related to wheeled mobility and seating include device malfunction and failure, component design flaws, falls during device use or transfers, skin compromise and both acute and chronic musculoskeletal injury. While safety incidents related to wheeled mobility and seating have been studied and reported in the literature, it is highly likely that the actual number of events is under reported, including those resulting in identifiable harm and others where harm was avoided, also known as a near miss or close call. Evaluating safety events and concerns with an approach aligned with High Reliability Organizations (HRO) including facilitation of a just culture supports awareness of the factors leading to an actual or potential adverse event and identification of the options to prevent or mitigate the same from happening again. The applied HRO principles of 1) sensitivity to operations; 2) reluctance to simplify; 3) preoccupation with failure; 4) commitment to resilience; and 5) deference to expertise provide the foundational structure for understanding and managing inherent safety risks for consumers using wheeled mobility devices. During this session, practical approaches for wheeled mobility interventions will be shared with an emphasis on understanding and mitigating real and potential harm. Targeted topics will include access to and review of relevant data sources, strategies to evaluate adverse events including Root Cause Analysis and Proactive Risk Assessment, human behaviors and communication that impact safety awareness and actions, and human factors engineering applied to system and technology design. Additionally, relevant literature will be emphasized, and education and training recommendations will be included to recognize and manage risk, avoid real and potential harm, report events, mine data sources and implement strategies to mitigate adverse events in wheeled mobility and seating. Case examples will be shared to demonstrate key points and audience interaction will be facilitated to emphasize key points throughout the session.
Cognition: Which Domains are Relevant to Powered Mobility?
Teresa Plummer, PhD, OTR/L, ATP, CAPS, CEAS
The topic of powered mobility frequently includes a preponderance of discussion and attempts to determine what components in the cognitive domain are essential pre-requisites for acquisition or training for infants or adults with neurological deficits. The cognitive domain is quite vast and ambiguous even among scholars in field of cognitive psychology. One expansive definition of cognition is “all processes by which the sensory system input is transformed, reduced, elaborated, stored, recovered, and used”, or simply “information processing” (Healy & Rowe, 2010; Rose et al., 2005). There are many ways that scholars have attempted to categorize the various domains within the construct of cognition. The taxonomy used to describe cognition is important in the wheelchair service sector if we are to use these parameters to determine readiness or pre-requisites for powered mobility success. Some would suggest that the hierarchical order of the specific skills in the cognitive domain include memory, processing speed, and representational competence (Rose et al., 2005). Whereas the Diagnostic Statistical Manual 5 (DSM) organizes the domains as learning and memory, language; perceptual-motor function; executive function; complex attention and social cognition (Sachdev, Blacker, Blazer et al., 2014). Occupational therapist would define the cognitive domains as “information-processing functions carried out by the brain that include attention, memory, executive functions, comprehension and formation of speech, visual perception, calculation ability, praxis skills” (AOTA). The lack of consistency in defining cognition among psychology scholars gives credence to the need for wheelchair service providers to be cautious when stating that cognitive skills are important precursors for powered mobility training and/or prescription. This session will introduce a logical way for us to use appropriate nomenclature (language) for understanding cognition as it relates to powered mobility.
Putting It All Together: Translating Evaluation Findings to Configure the K0005 Manual Wheelchair
Deborah Pucci, PT, MPT
The seating and mobility evaluation has been completed and a K0005 manual wheelchair has been selected as the appropriate piece of equipment. The make and model of the wheelchair has been determined. Now it is time to fill out the order form. How do you compile all of the information from the subjective interview, physical assessment, and equipment trials to determine the final equipment configuration and set up? How do you ensure that the wheelchair will meet the needs of the user now and allow the potential for adjustments over time? This presentation will use clinical examples to demystify the process of translating clinical findings to final equipment prescription, with particular attention to the complexity of rigid K0005 manual wheelchair configuration. Consideration will be given to changes in need as a result of circumstances such as: time post injury or illness, disease progression, and age.
A Clinical Audit to Identify Causes of Review Requests Post Supply of new Custom Moulded Seating Systems at a National Specialised Seating Service
Mary McDonagh, PT; Simon Hall; Ciara Fitzsimons, MS
Aims Custom contoured seating (CCS) is recommended for children and adults presenting with complex seating needs, particularly when standard or ‘off the shelf’ seating systems does not meet their needs (Colbert et al., 1986; Hetzel & Hetzel, 2017; Kim et al., 2013; Trail & Galasko, 1990). The aim of the audit was to examine the causes for clients having to return post supply of their new custom moulded seating systems in advance of the expected review period of 6 months for children and one year for adults as per the service review policy. This audit was conducted with a view to improving efficiencies at service provision level as well as effectiveness at a clinical practice level thereby improving the overall quality of service provision. Method 154 clients in total were identified as being supplied with new custom moulded seating systems between January 2021 and March 2022 across four centers at a national specialized seating service in Ireland. 31 (20%) of these clients contacted the service either directly or through their occupational therapist or physiotherapist requesting a review due to a concern regarding equipment supplied. A senior clinician accessed and reviewed clinical notes to identify the reason the clients had requested a review post supply. Findings Causes of review requests were as follows: problems with seat 51.6%, pressure issues 29%, rapid/unexpected change in weight 25.8%, anticipated review due to level of complexity 19.4%, client not satisfied with seat/not meeting expectations 16.1%, seat too tight 16.1%, seat impacted function 12.9%, pain/discomfort 6.5%, transport issues 6.5%, items missing at supply 3%. Some clients had more than one reason for a review request. A breakdown of ‘issues with seat’ included issues with the shape of seat (50%) such as the client leaning to the one side, wind sweeping not accommodated, support required for pelvic obliquity; issues with head support, issues with foot support, and issues with the set-up of the seat on wheelchair frame. 5 CCS were unsuccessful, 3 of which were moulded seat inserts requiring either a recast or a change to an alternative option. Recommendations post audit Feedback of audit findings shared with clinical team. Education provided including reflection on practice, and recommendations made as follows: more time to be spent conducting and documenting a thorough plinth assessment, including decisions made and photos taken, before, during and after the casting process. Discussion on the selection of appropriate CCS options for clients attending based on clinical need. Clarification of head and foot supports required and adequate planning for set up and supply of same. Scheduling to allow more time for interfacing seats on wheelchairs. Documents used modified and moved online. Purchase of Samsung Galaxy tablets for each clinic to facilitate this. Audit to be completed again after a one-year period of implementing recommendations.
Maximum Tilt and Recline may not Provide Pressure Reduction for Some Wheelchair Users: A Case Series
Cathy Carver, PT, ATP/SMS; Tanya Sinha; Rachel Cowan, PhD
Introduction: People using complex rehab technology power wheelchairs (PWC) who are at risk for pressure injuries need to reposition themselves to “maintain an offloaded position from the seating surface for at least 1–2 minutes every 30 minutes” (Garber, 2014) to allow reperfusion of compressed tissue. Research indicates that the full range of tilt and recline angles should be utilized to allow for an increase in blood flow and pressure relief to ischial tuberosities (Sonenblum & Sprigle, 2011). PWC users are often encouraged to go to their wheelchair’s maximum tilt and recline position to help ensure offloading is achieved (Arledge et al., 2011). However, we have clinically observed that some individuals experience increased pressure at maximum tilt and recline compared to upright. We further have observed that this paradox may be related to body anthropometrics. Therefore, we developed a protocol to document this phenomenon and explore relationships between changes in seat interface pressure and body anthropometrics. Methods: Any PWC user age = 18 years using a PWC with tilt and recline functions who was pressure mapped as a part of their visit to the wheelchair clinic was eligible. We measured peak pressure index (PPI) (Boditrak® lite) in their personal PWC while seated on their cushion at their preferred upright (PU) tilt and recline position and at the maximum tilt and recline (MTMR) position allowed by their wheelchair. We measured shoulder to seat height (cm) as a proxy for trunk length and abdominal girth (cm) and recorded self-reported height (cm) and weight (kg), and pressure injury history, and computed body mass index (kg/m2). Results: Ten individuals with spinal cord injury participated (N = 7 tetraplegia). All had a current or past pressure injury. Six were male. Data are presented as median [interquartile range]; Age: 51 [48–58] years; Injury duration: 17 [4–34.5] years; BMI: 24.3 [19.8–29.4] kg/m2. PPI was greater at MTMR (141 [104–175] mmhg) than PU (72 [64–91] mmhg) p = 0.007 Mann Whitney U). Seat to shoulder height, abdominal girth, height, weight, and BMI were not associated with PPI at MTMR or change in PPI between PU and MTNR (all p = 0.582, spearman rho). Data collection is ongoing. Discussion: The data shows that using maximum tilt and recline in a PWC does not universally result in a decrease in peak pressure from a preferred upright position. We must consider the individual and his/her medical history, current medical condition related to risk factors for developing pressure injuries and/ or recovery from a pressure injury. For some, utilizing MTMR positions may increase peak pressure to a detrimental level. Additional work is needed to determine the cause of increased pressure at MTMR. Limitations: The pressure mapping software did not allow us to measure peak pressure over specific bony prominences and did not indicate the exact location of the peak pressure.
The Importance of Headrests for Function and Transportation: A Retrospective and Prospective Study
Naomi Gefen, PhD, MSc, OT, MPA; Zohar Filber
Background: Independent sitting is a major milestone in a child’s development. Sitting is a complex skill that includes core and dynamic stability. If achieved, children can then free the use of their hands for daily functioning. Some children can sit independently but do not have the ability to transfer balance from side to side, forward to backward and have to rely on external supports. Children with complex physical disabilities often need to use special external supports- headrests, side supports, chest harnesses, belts, knee abductors, thigh supports, back and sitting cushions, arm and leg supports. The headrest is essential when used on a wheelchair for transportation in protecting neck excursion. Headrests are also used for support when in tilt and recline and for some children in an upright position, to allow feeding, breathing, swallowing, communication, rest, eye-gaze systems and more. Cushions have been studied extensively, due to their importance in preventing pressure sores. Few studies have looked at headrests and their importance in function and participation. The goal of this study was to assess the use of headrests and their impact on function. Methods: This study has two stages; 1) A retrospective study of 40 children (ages 2–18 years) with physical disabilities that participated in a lending program for headrests; 2) A prospective study of up to 30 children with physical disabilities (2–18 years) that borrowed a headrest from the program for two weeks according to a specific protocol. Outcome measures included user experience, user satisfaction, mealtime duration and sitting endurance. Results: This study is ongoing but initial results of the retrospective study indicate the importance of the headrest for function and transportation. (By April 2023- data collection and analysis will be finished). Conclusion: A headrest is an essential support, and it is important to examine its contribution to function and transportation in a reliable and valid study.
ALS: Anticipating Change to Maintain Independence in Mobility
Pamela Glazener, OTR, ATP; Stuart Strack, ATP
Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease that causes muscle weakness, muscle atrophy, respiratory compromise, speech and swallowing difficulties. The disease progression can be rapid, average or slow. Life expectancy from the onset of symptoms typically is 3–5 years, however patients have been known to live longer. There is no known cure for ALS at this time. When considering power mobility for this patient population, it is important to understand the potential progression of symptoms and understand how to accommodate for that progression. When initiating the wheelchair assessment, it is also important to approach the patient in a holistic manner and consider the entire picture: breathing, nutrition, financial burden, transportation, home environment, being overwhelmed by new diagnosis and decline in functional status. Explaining the functional benefit of a power mobility device in terms that the patient understands is vital to the acceptance of the device in early stages of this disease. Professionals working with this population need to have a thorough understanding of the disease symptoms, progression and how trauma/fall impact the progression of this disease. Early access to power mobility in the ALS population is beneficial and necessary. Case studies of ALS patients will be presented in this course. Each case study will demonstrate different stages of progression and important steps in determining current and future drive controls based on that progression. The case studies will range from standard joystick to 4 switch system to eye gaze controls.
Wheeled Mobility Telehealth Protocol
Brian Hinaman, MHS, OTR/L, ATP/SMS; John Moossa, MSOT, OTR/L, ATP; Brian Niedermayer, MS, OTR/L; Jenna Neubauer, MS, OTR/L, ATP
The COVID-19 pandemic has facilitated numerous changes in our daily lives since March 2020. Health care has experienced profound changes during this pandemic with respect to the way it is delivered in order to reduce patient/staff exposure to the coronavirus, preserve personal protective equipment (PPE), and reduce the risk of surges on facilities. The Health Resources Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Telehealth services help provide routine and specialty care to patients while minimizing the transmission risk of SARS-CoV-2, the virus that causes COVID-19, to healthcare personnel and patients. While telehealth technology is not new, the COVID-19 pandemic has restructured telehealth access and promoted the use of telehealth as a way to deliver routine, primary, and specialty care. Many VA hospitals canceled elective procedures and outpatient clinics in March 2020 when the pandemic engulfed our society. Wheelchair users in need of a new or replacement wheelchair were faced with closed clinics and limited or no access to the knowledgeable and experienced occupational therapists, many of which are RESNA-certified ATPs and SMSs. The Department of Veteran Affairs led a focused effort on the promotion of telehealth across all healthcare disciplines. In January 2020, the department facilitated about 41,000 telehealth appointments. In January 2021, veterans used telehealth for 798,000 appointments. Researchers have concluded that telehealth wheelchair and seating assessment may be as effective as in-person assessment and telehealth assessment was viewed favorably by wheelchair users. The Wheeled Mobility Telehealth Protocol was created with the goal “To create a research and clinical based practice guideline when completing wheeled mobility consults over telehealth.” This will help facilitate best practices for the novice and the experienced therapist in this area. Telehealth has proven to improve access to rehabilitation services and specialists; prevent unnecessary delays in receiving care; help reduce unnecessary face-to-face visits; and as mentioned before, put less demand on the veterans, caregivers, the VA, and the financial and community resources. Telehealth also increases efficiency of care and enables more effective assessments because we are now able to go to the veteran’s home, workplace, vehicle, and recreational environments. This will reduce guess work and mistakes and decrease the time that the veteran has to wait for their mobility device. Telehealth Wheeled Mobility Protocol is a guideline for completing wheeled mobility consults over telehealth and is structured around five components: screening, evaluation, device trial, delivery, and follow up.
Adaptive Car Seats: The Missing Piece of the 24-Hour Positioning Puzzle
Connie Nieberding, PT, MPT, ATP, CKTP, CPST; William Danner, MOT, OT/L
For patients with complex medical needs, transportation and 24-hour positioning within a vehicle has always been challenging due to the inability to maintain an upright position, poor posture, and behaviors. The complicated medical, social, and emotional needs of our patients often create a barrier to safe transportation. Commercial car seats do not provide proper upright positioning that is required for vehicle restraint systems to be able to work effectively. Currently, most children and adults with complex special needs are transported using pillows, blankets, and other items to prop them up and make their transport comfortable. However, these methods are not safe and put the patient and families at severe risk of injury and death in the event of a crash or impact. Most families are not aware of the available options to keep their loved ones safe and properly upright positioned in a vehicle. Many families need an adaptive car seat to keep their family member safe. When creating a complex rehabilitation technology equipment plan, a comprehensive adaptive car seat evaluation should be considered if the patient is improperly positioned in a vehicle or unable to maintain an upright position. This type of evaluation includes a combination of a Child Passenger Safety Technician (CPST) and an Assistive Technology (AT) trained physical or occupational therapist (PT/OT) to find the best transportation solution for the patient. This is completed using trials of various adaptive car seats available as well as discussions about the types of vehicles the car seat will be installed in. Adaptive car seats provide positioning and support to meet the patient’s complex medical needs as well as provide the upright positioning required for the vehicle restraints to be used efficiently and effectively. They often have a combination of harnesses, pelvic supports, trunk supports, hip supports, and hip abductors that can provide optimal upright positioning when used in conjunction with the vehicle restraint system to establish a safe environment for transportation. A complex rehabilitation equipment evaluation with an AT trained OT/PT is then completed with trials of the adaptive car seats that meet both the patient’s needs, and the transportation needs of the family. Due to the increasing awareness of the need for adaptive car seats for our clients and their continued need for 24-hour positioning, a triage model was established. The triage model includes assessing the family’s needs, a comprehensive evaluation, fitting, education, and delivery. Due to this triage process, we have seen over 200+ families for the full selection/ordering process with an in-person fit and delivery of the adaptive car seats. This has increased the proper fit and use of these adaptive car seats to over 90% at day of delivery. In summary, adaptive car seats when properly evaluated, fit, delivered, and installed are a crucial piece to the 24-hour positioning puzzle.
The Importance of Technological Education Combined with Clinical Practice
Adner Silva, ATP
This presentation aims to illustrate the use of various technologies, such as general electronics, special controls, games and simulators, in users with severe physical limitations, as well as the importance of knowing how to use them in different clinical cases in order to maximize the potential of use of available devices. Aims and Objectives Demonstrate the use of technologies in specific clinical cases to enable better learning, integration and user independence. Demonstrate the importance of teaching technology to professionals to maximize applicability in emerging clinical cases. Background The presentation shows various possibilities of the use of technologies in users with different pathologies through their functional capacity, fruit of the author’s experience in the clinical cases presented. It is well known that technology is increasingly used to help learning, communication, integration and independence of users with disabilities, and it is becoming increasingly important to monitor electronic developments as well as to properly teach their use and integration in clinical cases. Currently, various types of technology can be used, depending on clinical objectives, with some examples: • Games, Virtual Reality and special commands for learning. • General electronics and special commands for driving, device integration (Bluetooth, IR, etc …), postural change (tilt, recline etc …). • Virtual Reality Simulator for evaluation without mobility base. There are many professionals with great technology knowledge and others with great clinical knowledge, however, the singular knowledge in both parts, compromises the effectiveness of the technological use in the clinical cases, often losing opportunities of assessment or even costs in unnecessary products, if knowledge of the technology were adequate. It is in this sense that quality training is crucial for health professionals to have a good outcome in each assessment, ensuring an appropriate product for each clinical case. Discussion The integration of technology into clinical cases by a knowledgeable practitioner is of great importance to develop case-specific skills, contributing to an effective assessment of assistive products as well as minimizing waste of time or unnecessary costs, in other products. The various professionals (Technology Providers and Clinicians) should have constant contact and communication in order to share knowledge from both parties for a better result, both in technologies and products as well as clinical case evaluations, with the end user highly benefiting, in its evolutionary process.
Datasets & Registries Related to Complex Rehabilitation Technology
Mark Schmeler, PhD, OTR/L, ATP; Brad Dicianno, MD; Richard Schein, PhD, MPH; Gede Pramana, PhD
Large datasets and registries are essential elements for the consideration of accountable and value-based healthcare and associated policy. The field of Complex Rehabilitation Technology (CRT) is relatively new to using large datasets and registries, and therefore policies surrounding CRT have not necessarily been based on research with standardized outcome measures, uniform datasets, or other similar strategies. However, some preliminary work and data sources do exist, that may have potential to align CRT with the Quadruple-Aim approach to contemporary healthcare. This session will provide updates on a project that has as its primary objective to use the information obtained from existing datasets and registries to draft a new policy for insurance coverage of devices including wheelchairs, along with answering important questions about the devices that people with disabilities utilize. This session will provide background on the work done and updates of the current status of datasets and registries.
Robotic Wheelchairs – How do we Define Them and Where are we at?
Sivashankar Sivakanthan, MS
Current Electric Powered Wheelchairs that people are using still have increased accident risk due to the insufficient stability to navigate through sidewalks and curb cuts. Unfortunately, we live in environments across the US, where sidewalks are damaged and absent of curb cuts. As it is difficult, to change every sidewalk around us we need to look toward technology that can keep our veterans safe. Robotic Wheelchairs are becoming a global topic, but current research has not been guided by frameworks or guidelines. These guidelines or frameworks do not exist yet, which is the purpose of this current research. Changing the lives of people with disabilities, to provide the best possible solutions to everyday environmental barriers where current electric-powered wheelchairs may not be suitable. Robotic wheelchair research and development is a growing sector. This presentation introduces a robotic wheelchair taxonomy, and a readiness model supported by a mini review of existing research. The taxonomy is constructed by power wheelchair and, mobile robot standards, the ICF and, PHAATE models. The mini-review of 2797 articles spanning 7 databases produced 205 articles and 4 review articles that matched inclusion/exclusion criteria. The review and analysis illuminate how innovations in robotic wheelchair research progressed and have been slow to translate into the marketplace. This taxonomy and readiness model was constructed in hopes to guide future developers and providing an insight into the future.
Position for Function in Long-Term Care
Anna Sokol, RN, MN, BScK
When someone talks about the long-term care population, a certain image or set of expectations get formulated. We typically imagine a senior resident in a wheelchair, dependent on caregivers for assistance with mobility, self-care, feeding, etc. While functioning levels among people receiving long-term care may be similar, their seating and positioning needs are very unique. How do you select the back, cushion, and headrest to facilitate function? What should you consider when person’s functional levels change from day to day? What if one of the medical conditions prohibits certain position? We will talk about the complex interplay of comorbidities, individual factors, environmental constraints, goals of care, and how they may affect selection of seating. During this session, we will review several case studies. The studies will include solutions for asymmetrical postures, complex orthopedic presentations, unpredictable functional trajectories, and approaches to maximize wound healing potential. This session is aimed to provide an attendee with a better understanding of an assessment components that inform wheelchair seating prescription in the context of a long-term care. We will talk about the latest trends in the long-term care world and will discuss how functional goals formulated in a collaborative setting affect the ways wheelchair seating is selected.
The Skills on Wheels Research Program; Initial Findings from Pediatric Wheelchair Skills Training
Tony Chase, PhD; Joseph O’Neil; Tiffany Stead, OTR; Kiera Mendoza; Carson Rager, CTRS; Whitney Kozlowski; Maria Stiens; Madison Loeser; Daniel Sego; Anna Serino; Mary Carter
Many times, when children are prescribed wheelchairs, they are measured, fitted, and given some targeted therapy for navigating specific life situations. Occupational participatory goals are at the forefront of much of this work. Oftentimes, however, no regular training is provided to address everyday function and use of the adaptive equipment. The Skills on Wheels Training Program builds upon the work of the larger Wheelchair Skills Training Program (WSTP) by focusing the training on pediatric wheelchair users. These children attend a five-week program that incorporates wheelchair skills training from the lower-level skills (e.g., rolling forward) to the higher-level skills (e.g., navigating curbs, ramps, and stairs). Skills on Wheels also incorporates occupational therapy and physical therapy doctoral students in the training. Students participate as trainers and spotters for training. Caregivers for the children attend programming that involves support groups as well as information sessions about wheelchair care and maintenance. This presentation is focused on the development and assessment of the program. Outcome measures focused on pre/post changes of the children’s participation, confidence, and wheelchair skills. Findings from the first two years of the program showed that the participants (N = 21) increased in all wheelchair skills measured by the Wheelchair Skills Test (WST) with many significant gains. Participating children also showed significant gains in self-advocacy, community participation, and decreased fear of falling. Caregivers demonstrated a significantly increased desire to see their children grow in community participation after seeing the skills gained from the program. The program has demonstrated success in the first two years and has also expanded to 4 cities in three countries leaving much room for continued exploration of findings.
Pediatric Powered Wheelchair Standing Devices: An Exploratory Study
Lisa Kenyon, PhD, PT, DPT, PCS; Naomi Aldrich, PhD; William Miller, PhD, MScOT
BACKGROUND/PURPOSE: A powered wheelchair standing device (PWSD) is a type of powered wheelchair that allows an individual to electronically move between sitting and standing and drive in either position. Published clinical studies involving PWSD use in pediatrics are limited to boys with Duchenne muscular dystrophy (DMD) and provide only very low levels of evidence (Levels IV and V) to support PWSD use. These studies do not reflect PWSD use in children with other conditions. The purpose of this exploratory study was to explore PWSD use in children with neurodevelopmental conditions other than DMD. Methods: A single-subject research design (SSRD) A-B-A withdrawal design wherein A1 (baseline) equaled 4 weeks; B (the intervention, i.e., use of the PWSD) equaled 12 weeks; and A2 (withdrawal) equaled 4 weeks was used in this study. The target behavior was activities and participation as measured via the Canadian Occupational Performance Measure (COPM) administered twice weekly throughout all phases of the study. Secondary outcome measures were administered at the start and end of the A1 (baseline) phase and at the end of both the B (intervention) and A2 (withdrawal phases) and included the Strengths and Difficulties Questionnaire (SDQ), the EQ-5D-Y, and qualitative interviews. A three-measure perceptual implementation outcome survey (the Acceptability of Intervention Measure, the Intervention Appropriateness Measure, and the Feasibility of Intervention Measure was administered at the end of the B (intervention) phase. Each participant’s COPM scores were analyzed using split-middle celeration lines calculated for each phase of the study. To determine statistical significance, the proportion of B (intervention) phase data points falling above or below the A1 (baseline) and A2 (withdrawal) celeration lines was compared with the minimum proportion required for a significant effect at p < 0.05 using the probability table provide by Ottenbacher. Following the COPM manual, the clinical significance of the COPM outcomes was set as an increase of 2 or more points in performance. RESULTS: All participants achieved both statistically and clinically significant changes in identified occupational performance problems during the intervention phase as compared to both the baseline and withdrawal phases. Parents and children reported overall satisfaction with the PWSD device and identified both benefits and challenges to PWSD use. DISCUSSION: Despite the emphasis in the literature on PWSD use in boys with DMD, our findings suggest a possible transdiagnostic application of PWSDs.
Development of a new Tool: Progression of Pediatric Powered Mobility
Lori Rosenberg, PhD, OTR; Naomi Gefen, PhD, MSc, OT, MPA
Aim: Children with cerebral palsy (CP) with mobility limitations often have less opportunities for development; powered mobility (PM), which enables independent mobility, is therefore important for development (Rosen et al., 2018). Field and Livingstone (2018) describe children’s driving ability in three stages: exploratory, operational and functional (Field & Livingstone, 2018). An assessment according to these stages facilitates individual tailored interventions (Kenyon et al., 2021). The aim of this research was to develop a tool to assess progression of powered mobility skills for children within the framework of the three driving stages and to determine the tool’s psychometric properties. Experimental design: A three-phase, mixed-method design. Methodology: Phase I) conceptualization based on international specialists’ input through a focus group or interview to generate initial items; Phase II) tool development using a two-round Delphi survey and Phase III) evaluation of psychometric properties from eight video recordings of children with CP (Gross Motor Function Classification Scale III-V). Internal consistency of the Pediatric Powered Mobility (3PM) was assessed as were its interrater reliability and convergent validity in comparison to the Powered Mobility Program, Assessment of Learning Powered Mobility tool, Powered Mobility Proficiency test. Data collection: Qualitative data was collected in Phase I from the 24 specialists that participated in the focus group or interviews. Quantitative and qualitative data was collected in phase II through 21 responses to the first Delphi round and 13 responses the second Delphi round. The quantitative data for reliability and validity of the new assessment was obtained through the ratings of 10 experienced therapists who viewed video recordings of 8 children. Results: Content from experts led to the development of the first 3PM version (19 demographic and 61 driving skill items). This version was distilled to 14 demographic and 41 driving skill items through the Delphi rounds. The final version of the 3PM, following Field and Livingstone’s three driving stages, includes 14 demographic items, 10 exploratory items, 17 operational items and 14 functional items. Internal consistency was excellent (Cronbach alpha = 0.96) as was the interrater reliability (ICC = 0.96, 95% confidence interval = 0.95–0.96). Pearson correlation coefficients between the 3PM and other assessments demonstrated good convergent validity. Conclusions: The 3PM, created through international collaboration, has excellent psychometric values as a valid measure that can be used reliably to assess children’s powered mobility skills.
Importance of Standing on Early Development
Maryann Girardi, PT, DPT, ATP
Learning is “a change in the capability of a person to perform a skill that must be inferred from a relatively permanent improvement in performance as a result of practice or experience” (Magill, 2007, p. 247). Children learn and develop skills through experiences with their environment. Children with neuromotor delays require assistance to enable them to have these varied experiences that foster growth and development. Children who are unable assume antigravity postures such as sitting or standing due to decreased strength or control are routinely provided custom seating systems to provide the external support needed to be upright. But these children also need to be provided standing experiences. Having the experience of standing provides them with increased visual fields, sensory input through their whole body, opportunities to develop anti-gravity musculature, and experiment with their interactions with their environment. The introduction of a supported standing program as early as 9 months of age (the age when their typically developing peers start to stand) provides the child with the weight bearing and antigravity postures same as their typically developing peers are experiencing. Weight bearing provides the input that the skeletal system needs to develop and grow. This is especially true for the hip joint, early standing in abduction has been shown to stabilize the migration percentage (measure of hip displacement) promotes symmetrical development of both hips and may improve the shape of the acetabulum (Macias-Merlo, Bagur-Calafat, Girabent-Farrés, & Stuberg, 2016) and maintained the flexibility of the muscles decreasing the risk of hip dislocation and improving future gait with a wider base of support and increased walking speed (Macias-Merlo, Bagur-Calafat, Girabent-Farrés, & Stuberg, 2015). Children with CP become quickly fatigued when maintaining a vertical posture due to the increased torque they use for standing and they use a more a passive and reflexive control system with limited sensory information (Goodworth & Saavedra, 2021). It is unclear if these deficits are caused directly by neural damage or if they are a secondary result from the lack of upright positioning that provides them with experience and the ability to practice learning the control in the vertical posture (Goodworth, 2021). The use of external supports to facilitate the development of postural control has been effective for learning trunk control in stages from the head down. This support reduces the overload of information by learning to control one or two joints at a time (Butler & Major, 1992). Audu and Daly (2017) found improvements in head control, upper extremity function and sitting by an 18-month-old child with CP with 8 weeks use of a standing frame. This course will discuss the theories of motor learning and development of motor skills and how the early introduction of a supported standing program can facilitate these.
Vibration, Impact and Energy Dissipation of Manual Wheelchairs
Jacob Misch, PhD; Stephen Sprigle, PhD, MSPT, ME
Manual wheelchair users, especially those who travel outdoors, will maneuver over a variety of terrain. Uneven terrain can expose users to whole-body vibrations and impacts that can lead to fatigue, back and neck pain as well as increased spasticity. In the context of wheelchair use, both vibration and impact reflect types of energy that can be transferred through the frame to the user. This instructional course will review the differences between whole-body vibrations and impacts with respect to wheelchair operation and surfaces. This information will then be compared with what we know about how wheelchair users move throughout the day. A simple vibration exposure calculator will also be reviewed as a means to quickly and efficiently assess the health risk levels based on measurements of seated vibration exposure, according to the guidelines established by the ISO. To address the growing concern of health risks and discomfort associated with vibration exposure during wheelchair use, many technologies have been designed specifically to dissipate energy during overground propulsion, including casters and drive wheels. In addition, claims have been made about the influence of wheelchair frame design on energy dissipation. The course will present data using a robotic wheelchair propulsion device to objectively measure propulsion costs and vibration exposure levels of wheelchairs traveling over real-world environments with highly repeatable propulsion characteristics. Measuring energy dissipation and cost during propulsion allows us to make objective performance comparisons between wheelchair components and configurations, which can be weighed against the user’s functional requirements and personal preferences. By making this knowledge publicly available, clinicians and wheelchair users will be empowered to make more meaningful, informed decisions when choosing between the options of available manual wheelchair configurations.
Quick Measures to Track Fit and Function of Manual Wheelchairs Over Time
Jessica Tsotsoros, PhD, OTR/L; Lynn Jeffries, PT, DPT, PhD, PCS
Wheelchair professionals champion the idea of appropriate provision of wheelchairs to provide greater participation and inclusion in family, school, work, and community. With limited time and resources, tracking this effort may be challenging. This course will provide an overview of two freely available validated measures assessing the maintenance condition of the wheelchair and how well the wheelchair supports the person within their environment and daily activities. Participants in this course will have an opportunity for hands-on practice with both measures. Once familiar with the tools, the information can be completed in less than fifteen minutes by the wheelchair professional. The information gathered can be used clinically or to provide information to insurance companies or other stakeholders.
Wheelchair Management When Wounds are Present
Darcy Erickson, OTR/L, ATP
Addressing seating, positioning and mobility needs in persons using manual or power mobility when wounds are present requires in-depth knowledge of multiple aspects of care provision. Therapists need to possess strong knowledge of primary and co-morbid medical conditions and their effect on seating and mobility, equipment options and configurations, and match the right products with the right person at the right times. They also need to understand insurance benefits and limitations as well as work collaboratively with other disciplines to address underlying conditions contributing to the wounds. This course will provide foundational and new learning opportunities to consider when helping wheelchair users maximize health and function, even when wounds are present.
Improving the Control Interface for Assistive Robotic Manipulators: Manual to Autonomous
Cheng-Shiu Chung, PhD; Ding Dan, PhD; Breelyn Styler, PhD
Powered wheelchair technologies have evolved to assist independence for people with severe physical limitations due to injury and neuromuscular diseases, not only in mobility but also in comfort, stability, and medical benefits of advanced seating systems. However, despite improved mobility independence, they still face reaching and object handling/manipulation challenges which require assistance from a personal caregiver for essential activities of daily living (ADLs) such as dressing, food preparation, eating, and drinking. The 2005 U.S. Census reported that over 11 million people had a problem reaching overhead, and an equal number needed assistance with ADLs or instrumental activities of daily living (IADLs). Almost 16 million people had difficulty lifting grocery bags, and 7 million had problems grasping a drinking glass. The inability to independently perform ADLs triggers the need for personal assistance and could lead to residential care relocation which significantly impacts the quality of life. In addition to service animals and low-tech assistive devices, such as simple pick-up tools and robotic feeders, assistive robotic manipulators (ARMs) have emerged as a potential solution to assist with a wide range of everyday manipulation tasks. Recent studies show that up to 150,000 people with disabilities in the United States (0.06% of the population) could benefit from an ARM. The integration of ARMs with personal tasks could positively impact activity, participation, and quality of life reducing reliance on caregivers. The challenges of the ARM control interfaces include controlling 6 degree-of-freedom (DoF) through low DoF input and assistance from intent detection and reliability of autonomous control. This instructional course includes an introduction and demonstration of the research and development of improved manual and autonomous ARM control interfaces. Control interfaces shipped with ARMs can be unintuitive to control, this course introduces the possibility of alternative control interfaces which include a thumb joystick, touchscreen, voice, and vision-guided control. Existing control interfaces include a keypad and joysticks. The thumb joystick allows a user with a limited range of motion to access full ARM functions. The touchscreen interface provides a wireless smartphone interface allowing ARM control for both the local user and remote caregiver. The voice control allows natural language ARM control. The vision-guided control interface provides autonomous assistance through computer vision recognition and path planning. The demonstration of control interfaces includes a thumb joystick customizable for individuals with cerebral palsy, an intuitive smartphone touchscreen interface, and a vision-guided control that autonomously assists with fine manipulation.
Improve Outcomes of Patients Receiving Accurate CRT Through the Continuum from Inpatient Rehabilitation to Outpatient Care
Theresa Berner, MOT, OTR/L, ATP; Cathy Carver, PT, ATP/SMS; Vince Schiappa, MS, ATP; Rachel Hibbs, DPT, NCS, ATP
Complex rehabilitation technology (CRT) requires a comprehensive approach with specific roles from members of the healthcare team. These roles can be challenging to coordinate within one level of care and exceedingly difficult among multiple levels of care. The full continuum of care represents when a patient begins care during inpatient rehabilitation through when they receive the equipment in outpatient and/or home health. The need to have continuity through each phase is necessary and important to the success of the equipment. This session will review a framework and decision process that considers each area of the continuum and will offer methods to bridge the gaps in care. Cuppett, Schein, et al found that it took the average person to receive their CRT 102 days after the assessment. New injury or identification of a disease create several factors that risk medical changes or unanticipated progression during the equipment acquisition process. The inpatient rehabilitation team is charged to predict and anticipate the needs of the individual as they heal and recover which can be quite challenging since each individual situation is different. It takes skill and careful planning to assure that the equipment is not over or under prescribed. When changes are identified, strong communication and teamwork is necessary to assure the patient gets the correct equipment at the right time. It is common for the CRT wheelchair supplier to put it in the middle as the patient moves through different care teams. When processes for follow-up care are in place, the rate of errors and miscommunication can be reduced. When there are no processes for follow-up the CRT supplier is left on their own with little support. When gaps in care or lack of follow-up processes are in place there is risk for the wrong equipment being provided at the wrong time which can result in pressure injuries, complications in positioning and inability to use insurance for equipment needed. This interactive session will review examples of workflows for the audience to consider for their clinic to reduce poor outcomes. Suggestions on how to communicate within one system, across several systems or even across multiple states will be reviewed. A review of all team members roles and how the CRT supplier can be a key player in the process will be discussed. Complex Rehabilitation Technology is expensive and challenging to get. Consumers have one chance to get it right and the health care team owes it to the consumer to have safety nets in place to assure the best equipment is provided
Advancing Assistive Technologies to the Community through a Multi-Level Technology Transfer Training Program
Michelle Zorrilla, PhD, MPH; Mary Goldberg, PhD; Jon Pearlman, PhD; Julie Faieta, PhD, OTR; Nancy Augustine, MSEd
Assistive Technologies (ATs) are needed by an estimated 1 billion individuals worldwide to live active, independent lives (Tebbutt, 2016). As the global population increases and ages, the number of individuals who need ATs is expected to double, from 1 to 2 billion people, by 2050 (WHO, 2018). The amount spent on ATs is estimated to grow in parallel with this need from $15 Billion in 2015 to over $26 Billion by 2024 (McCue, 2017; Coherent Market, 2018). This potential impact and market size opportunity underlie the urgency to perform effective Assistive Technology Technology Transfer (ATTT). Poorly defined and fragmented markets, a high rate of abandonment of devices by end-users and a lack of clear regulations are cited as barriers to successful ATTT. Successful ATTT is possible despite these hurdles. There is a need to streamline and improve the efficiency of ATTT that requires interdisciplinary collaboration of the healthcare landscape, researchers, industry and the community. To address this need, the IMPACT Center has developed a multifaceted approach to assist innovators in getting their ATs to market. Join us as we look at trends of technology transfer (TT) success, perceived barriers and facilitators, and the fundamentals of TT through training initiatives and strategies. Hear from some of the companies and innovators that have gone through the IMPACT Center’s training program. What did they learn? Where are they now? Find out how to get your great idea to the intended audience and discover some cool new assistive technologies being developed in the mobility space.
Following up the Wheelchair Provision Assessment with Evaluating the Actual use of the Power Wheelchair
Leonie Snijders, OTR/L, Msc; Carla Nooijen, PhD
Users with complex mobility needs depend on a suitable power wheelchair to keep and/or sustain as much autonomy and participation in their community as possible (Samuelsson & Wressle, 2013). The degree of “fit” between the client, wheelchair, and the environment is essential to gain positive effects on mobility and quality of life (Hammel et al., 2013). The group of people with severe coordination impairments (such as cerebral palsy), is one of the population groups with the largest complex mobility needs for power wheelchairs (Frank & De Souza, 2016). However, very little is known about how they use their wheelchair in daily life, which makes it hard to ensure a right fit of wheelchair. The aim of this study is to investigate the fit of the recommended power wheelchair, by assessing the relation between the wheelchair provision assessment and the mobility and power function use of people with complex mobility needs due to coordination impairments. A total of seven persons were included in this study from a Long-Term Care facility in The Netherlands. All these persons are using a power wheelchair as their primary mobility device and need alternative drive controls and/or additional seating and positioning support. The participant’s medical records were reviewed, in particular the wheelchair assessment and requirements which provide information on why a certain wheelchair was selected, mapped within the ICF-model (International Classification of Functioning, Disability and Health) Wheelchair use was studied by analyzing device-measured Connected wheelchair data in the period July 2021 to February 2022. Outcome measures included distance travelled and power function usage. The main results include an evaluation of the reasons why a wheelchair with certain functionalities was selected and to what extend the persons use these functionalities in their daily life. The insights from this evaluation on the wheelchair provision along with the device-measured use of the wheelchair can support the healthcare professional to provide evidence-based wheelchair provision for persons with coordination impairments. Furthermore, it provides valuable knowledge to improve wheelchair service, product delivery and policy.
The Impact of a Powered Standing Wheelchair for a Person with Okinawan Neurogenic Muscular Atrophy
Rachel Fabiniak, PT, DPT; Carla Nooijen, PhD
Background: Okinawan neurogenic muscular atrophy, hereditary motor and sensory neuropathy with proximal dominant involvement: HMSN-P, is a chronic, progressive disease characterized by adult-onset spinal muscular atrophy combined with sensory neuropathy. Studies suggest that the disease process is similar to ALS-like severe motor paralysis. HMSN-P shows autosomal dominant inheritance and progresses slowly over >30 years (Taniguchi, 2022). There is little evidence behind treatment options currently. A potential intervention that has showed a wide range of positive effects in other population groups, e.g., those with Duchenne muscular dystrophy, is standing in a powered wheelchair (Paleg & Livingstone, 2015; Bayley et al., 2020). Over a period of 5 months, this exploratory study followed one client with HMSN-P to examine the physical, functional and psychosocial effects of use of a standing powered wheelchair. Method: The client utilized the standing powered wheelchair for 8 hours per day across 5 months. Measurements were performed at baseline, after 2, and 4 months. The evaluation of the physical assessment included lower extremity edema, fasting blood glucose, bone mineral density, pressure injury status, and pain (NPRS); the functional impact was assessed with the Functional Mobility Assessment; and the psychological impact included quality of life (WHOQOL-BREF). Results: The results showed a positive impact of the power standing wheelchair in the physical domain, with improvements in bone mineral density and blood glucose levels, in the functional domain with improvements in indoor mobility, and in the psychosocial domain with improvements in quality of life. Conclusion: After starting to use a standing powered wheelchair, a person with HMSN-P showed a broad range of improvements in all the assessed domains; medical, functional and psychosocial. These promising results can serve as a basis for the development of a larger cohort study.
Quantifying Joystick Activation and Path Navigation During Powered Mobility use in Toddlers
Nicole Zaino, MS; Kimberly Ingraham, PhD; Heather Feldner, PhD, PT, MPT, PCS; Katherine Steele, PhD
For many infants and toddlers with mobility disabilities, access to developmentally appropriate mobility technology is crucial to facilitate self-initiated movement, exploration, and social engagement. Delayed early mobility (i.e., 2–4 years later than nondisabled peers) can initiate a cascade of effects such that toddlers with disabilities fall behind their peers across multiple developmental domains [1]. New technology, such as the Permobil Explorer Mini, is expanding powered mobility access and options for very young children with disabilities [2,3]. The Explorer Mini has the unique advantage of allowing seated and standing driving positions, allowing the child to simultaneously work on mobility and functional skills. Previous work has qualitatively described the initial driving and emotional experience of toddlers using the Explorer Mini. The goal of this study is to quantify how toddlers with disabilities (ages 12–36 months) use powered mobility by investigating how they learn to activate the joystick and navigate through space. Children and their parent(s) participated in multiple play sessions driving the Explorer Mini in an enriched play environment in seated and standing positions. Each visit consisted of two 20-minute play sessions. We developed and deployed a custom sensor-suite that integrates with the Explorer Mini that includes joystick tracking, encoders on the wheels to accurately calculate the distance traveled, and four compact compression load cells to measure loading through the child’s legs versus the seat. Additionally, a Qualisys 12-camera motion capture system was used to track Explorer Mini movement. Preliminary results for two participants (P1: M, 14 mo, 8 play sessions; P2: M, 16 mo, 2 play sessions) demonstrate that children quickly engage with the joystick in their first play session and learn to move along a forward path. Participants traveled between 7 and 180 meters during a 20-minute play session. Participants activated the joystick an average of 683 times (range: 276–1326) during a 20-minute play session. The average time of each joystick activation was 0.83 seconds. Of these activations, 89.7% were short bursts of less than 1 second. The longest joystick activations were between 18.5 and 89.6 seconds, which often corresponded to periods where they were spinning in circles or continuously driving. Joystick activation was primarily forward (50.9%), with significantly less left/right (27.4%) and backwards (4.8%). Tracking joystick activation and navigation while children learn to use the Explorer Mini can provide insight into learning patterns and inform future development and training. These results are among the first to quantify child and device-related driving metrics in a new pediatric mobility device. Understanding how children with disabilities learn and move using such technology is key to improving access to on-time mobility experiences.
Young Children & Adolescents with Dystonic, Dyskinetic CP & Their Seating and Mobility Challenges
Karen Kangas, OTR/L, ATP
Creating seating systems which support true function and postural control for children with cerebral palsy is challenging. Understanding how having dystonia and/or dyskinesia cerebral palsy creates more of a challenge. These children’s complex bodies demonstrate dramatic surges of tone, which occur randomly, but which sometimes are activate environmentally. Rather than thinking a child is exhibiting strong extensor tone, it is critical to recognize dystonic cerebral palsy as its own unique characteristics. Dystonia does co-exist with spasticity, but also exists in isolation. Its surges of power, its underlying postural reactions are not simple and not simply the hypertonicity associated with spasticity or athetosis. With Dystonic cerebral palsy and its inherent non-progressive lesions in the basal ganglia, sensory processing may appear initially as “different,” as the child’s resting and active postures may present themselves as dramatically different. This session will share these unique characteristics as well as sharing successful strategies for creating seating for functional independence for task participation and postural control and growth over time.
The Procurement Process for Wheelchairs: Where do we Begin? From the National Level to the Global Level: Understanding the Current Process Regionally to Create a Global Consistency
Stefan Morin, MSOT; Rachel Fabiniak, PT, DPT
A recent position paper discussed the global challenges to accessing appropriate wheelchairs. The position paper describes the need to develop appropriate and sustainable wheelchair service provision systems globally (Gowran, 2021). In this presentation we will utilize the information in this position paper as the basis for our globally conducted survey on the procurement and clinical decision-making process. Understanding the current trends in the prescription process based on funding systems and available wheelchair options will help provide a foundation of the regional, cultural and access barriers in the current procurement process of wheelchairs. From the survey results, we will look at the common trends across countries in the procurement process. As clinicians, are we performing a seating assessment? Are we all following a client-centered approach? How many people are involved in the procurement process? Based on the survey results, regarding presented case examples, we will examine regional differences with clinical reasoning and outcomes on AT choices. Are these differences based on access to equipment and funding? Environmental and cultural differences? Based on guess work or reliance on “what has worked in the past”? If we are to create a global wheelchair service provision guide, we will need to understand potential barriers that exist in our communities. From our survey results, we will investigate what considerations should be utilized when creating a global service provision guide and offer reflection as to the potential future steps on this much needed work. While our literature review showed a number of researchers and clinicians in the field working towards the same goal, we will end with the importance we each have in bringing our knowledge and experience forward to create a truly global wheelchair service provision guide. Along with the guide, we need to consider how clinicians in less resourced settings can have the same access to information as those in more resourced settings or countries. As a clinician, what process are you following to organize and streamline the referral, assessment, and provision of equipment? What challenges do you experience and how do you work around them? How do you complete an assessment without a mat, with limited assistance and in a less than ‘ideally set-up’ environment? We will present the concept of an assessment toolkit. The toolkit will be a starting point for maximizing the clinician’s success in providing a client-centered, optimized outcome.
Status of Smart Home Technology for People with Disabilities in Korea
Yun-hwan Lee, BS; Jongbae Kim, PhD; Dong-wan Kim; Seong-woo Jeong; Kwangtae Moon
As technologies advance, smart home technology is attracting attention in the study of home environment modification for people with disabilities. In Korea, smart home research is being actively conducted to improve ADL performance for people with disabilities at home. However, various living environments and cultures exist and the physical functions of people with disabilities also differ depending on the medical diagnosis. so various technologies are required for home modification. In this session, we will introduce various smart home technologies applied in Korea. Along with this, we will introduce smart home application cases according to residential environment and application cases for people with spinal cord injuries. Through this session, we intend to discuss the future direction of smart home technology for people with disabilities.
International Society of Wheelchair Professionals’ (ISWP) Online Learning Modules for Wheelchair Service Providers
Amira Tawashy, MS; Krithika Kandavel, MS; Sara Munera, PT, MS, ATP; R. Lee Kirby, MD
The World Health Organization (WHO) estimates that less than 20% of the 100 million people in the world who need a wheelchair have access to an appropriate one. Inappropriate wheelchair service provision has adverse effects on basic human rights. Limited training allocated to wheelchair service provision contributes to inappropriate wheelchair service delivery. The International Society of Wheelchair Professionals (ISWP) has a mission to serve as a global resource for wheelchair service provision through education and information exchange. In its aim to professionalize wheelchair services, ISWP promotes the 2012 World Health Organization (WHO) Wheelchair Service Training Package - Basic. Expert opinion provided the original basis for this package. This basic package, in turn, has been the primary source of content of the ISWP’s learning modules. Given the time elapsed since publication of the original WHO training package and the subsequent ISWP training modules, a review and update of this information was considered prudent. This was completed in 2021/2022 and necessary revisions, which reflected current literature and practice, were integrated into the ISWP materials to create an up-to-date, online, and interactive learning experience. This 1 hour ISS instructional course will provide information to participants on the development and content of the updated ISWP learning resources for wheelchair provision, including the evidence-based additions to the module. These updates and additions were completed iteratively, through consensus of an international group of content experts. ISWP’s online modules can be used either through instructor facilitation or asynchronous self-study. They are an evidence-based resource for wheelchair provision. The ultimate goal of providing these evidence-based resources for wheelchair provision education is to improve wheelchair service delivery and, facilitate the achievement of basic human rights on a global scale.
“I Just Want to Move!” … Keeping Children with Autism Spectrum Disorder Safe
Erin Baker, PT, DPT, ATP; Amber Yampolsky, PT
Estimated prevalence of ASD as reported by the CDC is 1 in 44 children with the disorder being 4 times more prevalent in boys than girls and occurs in all racial, ethnic, and socioeconomic groups. A majority of the time, children with ASD have fairly typical mobility levels but without the cognitive capacity for safety. As a result, ASD impacts not only the life of the individual with ASD but also the lives of their families and caregivers Families of children with ASD report challenges with elopement, sleep difficulties, and self-harm or aggressive behaviors that impact day to day life. Approximately 1 in 4 children with ASD elope or wander away from supervision each year. Children with ASD typically wander from crowded, noisy, and stressful locations which can make community outings or trips to medical appointments very difficult. Elopement does not only occur in community spaces but also from the home and even the car. The risk is constant which requires caregivers to be always on high alert to maintain the safety of the child with ASD. Sleep disturbances are another presenting problem and are often poorly managed by medication. Families report the most prevalent sleep problems being bedtime resistance, sleep onset difficulties, night awakenings and poor sleep duration. If a child with ASD has sleep disturbances, elopement, unsafe behaviors, or self-harm, these concerns leave families and caregivers having to be awake and alert any time the child is. Poor sleep quality of the child with ASD then impacts caregiver sleep quality and increases overall caregiver strain. How is a caregiver to be alert to care for and maintain safety of a child with ASD if they are unable to sleep themselves? The combination of sleep disturbances and elopement creates significant stress and increased burden on families of children with ASD. They often are trying to find ways to keep them safe but are not aware of resources available to assist. Therefore, families often turn to their own creative devices to try to solve these problems. This commonly looks like tents attached to beds, locks and alarms on all doors and windows, attaching harnesses and various straps to car seats, using child locks on car doors and windows, and in the community the use of leashes or ill-fitting wagons and strollers. We as therapists and assistive technology professionals can help to bridge the gap and assist families and others who provide care for those with autism to know and understand what options are available and help to improve overall quality of life for both the child with autism and their family. This presentation will provide education on available mobility devices and securements to prevent community elopement, beds to assist in safe sleep and prevent elopement from the home, and car seats or harnesses for safe vehicular transportation.
A Policy Analysis on Power Standing Systems
Cara Masselink, PhD, OTR/L, ATP; Ashley Detterbeck, DPT, ATP/SMS; Nicole LaBerge, PT, ATP
Power wheelchairs are designed to allow individuals with disabilities independence with their mobility and repositioning needs. However, the sitting position restricts these individuals to only accessing the horizontal plane, which limits their functional activities above seated height. A power seat function that has changed how individuals not only reposition themselves in space but also increase access to their vertical home environment, is a power standing system. Power standing systems have a long list of medical and functional benefits, however due to the current payor guidelines, they have not been easily obtainable to those that could benefit from them. In this course we will discuss and evaluate the options for national coverage criteria of power standing systems. Current and emerging evidence will be reviewed and the most recent update on the request of a National Coverage Determination policy change, will be addressed.
Air Cushions: Fact, Fiction, and the Future
Joseph Ott, PhD, ATP, RET
Pressure injury prevention is one of the most challenging goals of the seating and mobility industry with 1 out of every 5 SCI users developing a pressure injury at some point. Unfortunately, prevention is hard without any actionable data or feedback to work with. A common answer is to put someone on an air cushion, but that is not a golden ticket to ensuring prevention. Air cushions are an effective option only when they are used correctly. The industry has many rules of thumb on proper pressure relieving requirements, but it all is rooted back to one single study that was conducted in 1976. While the Reswick and Rogers Pressure-time Curve is valid as a general rule, it becomes less accurate as it approaches an axis. Since that study, every follow-up has expanded upon it with some improvements, but we still fall short of a true preventative measure. Currently, the ideal pressure for a user is simply defined by a “calibrated” hand performing a palpitation on the ITs to determine the level of immersion. Normally, this is set in a clinic when the user is fitted to the cushion but then they are expected to maintain this ideal pressure throughout the daily routines without any more guidance and an uncalibrated hand. What if there was a more accurate way? A preliminary study has researched the acceptable pressure levels for an air cushion, the factors that contribute to changing that pressure, and a device for continuous monitoring of an air cushion. Furthermore, the differences between skin pressure and air cushion pressure were investigated. Lastly, a novel technique to monitor offloading through the air cushion that can be used to inform users if they have completed a targeted offload.
Measurement for Seating – More Than Just Numbers
Stefanie Laurence, BS, OT Reg. (Ont.), RRTS
In the world of durable medical equipment, measurements are more than just numbers. They are an important step in ensuring a successful prescription. This session will cover what to measure, how to measure, why to measure, and how to relate the numbers to the device being prescribed.
Wheelchair Backs that Support the Spinal Curves: Assessing Backrest Type and Placement with Postural and Functional Outcomes
Maggie Dahlin, PT, ATP; Janell Jones, PT
A properly fit wheelchair and seating system can have a profound impact on the daily life of people with spinal cord injury (SCI). A backrest that supports the natural spinal curves is thought to enhance posture, functional mobility, and comfort for manual wheelchair (MWC) users. However, there is little research comparing the efficacy of a solid posture-back to the standard upholstery back. Results of a previous pilot study demonstrated clinical relevance and statistical trends for improvements in postural alignment and functional outcomes when using a solid back, although there was not enough power to establish statistical significance. The objective of our current in-progress study is to provide a fully powered clinical trial which investigates if using a solid backrest for MWC propulsion improves postural alignment, function and wheelchair mobility, as compared with an upholstery backrest; and to explore the impact of overall back height, seat gap, and contour when using a solid backrest. In this presentation we will define wheelchair backrest and positioning terminology, describe how we are evaluating backrest placement, and discuss postural, functional, physiological and subjective outcomes. We will review the aim of the study including assessment of the efficacy of an upholstered versus solid backrest and evaluation of the contour and placement of solid backrests in order to better inform clinical practice and to provide evidence based advocacy.
Aging with a Disability: A Case Study Outlining Orthotic and Prosthetic Seating Interventions for the Treatment of Sagittal Plane Spinopelvic Deviations in a Pediatric SCI
Daniella Giles, PT, DPT, ATP, SMS
The life expectancy for persons living with an SCI is now nearly equal to those aging without a significant disability. Quality of life outcome measures have shown it is not only possible for individuals with mobility related disabilities to live into the 6th and 7th decade, but many are also living a happy, fulfilled life. These are two encouraging factors for the professionals who are working hard to ensure this is possible for as many people as possible. Despite these positive advances, there are known risk factors associated with aging with a SCI that must be carefully considered when evaluating assistive technology devices. Individuals who are acquire a SCI early in life will have the greatest risk for acquiring co-morbidities associated with long-term aging including spinal deviations, pressure injuries and declining functional mobility. Specifically of focus of this paper are seating and mobility provisions. This presentation will highlight significant factors of the evaluation, treatment and monitoring of custom seating interventions provided to an individual with a C5 ASIA A SCI sustained at age 3. This individual case study is unique in that she presents with a severe anterior lateral tendency, but due to flaccid muscle tone and dynamic functional mobility, she has maintained near normal PROM. In the absence of significant contractures, we were able to meet her goals of full reduction of the hyperlordosis and a sagittal pelvic alignment of near neutral. I will discuss the triumphs and challenges over 13 years of interventions provided from age 15–28 years old.
An Exploration of the Perspectives of Paediatric Physiotherapists and Occupational Therapists who Refer to Specialised Seating Services, on the use of and Provision of Custom Contoured Seating Systems
Mary McDonagh, PT; May Stinson; Joanne Marley
Aim To explore the thoughts, opinions, and perspectives of referring therapists on the use of custom contoured seating (CCS) for children, as well as the processes and services involved in their provision. Explore the thoughts, opinions, and perspectives of referring therapist on when and why CCS should be considered and recommended for children with complex seating needs. Research Methodology This study will use qualitative research methodology, using a grounded theory (GT) approach, involving focus group interviews of a combination of occupational therapists and physiotherapists who refer children with complex seating needs to the Assistive Technology and Specialist Seating Service (ATSS) in the Central Remedial Clinic (CRC). This service is based in Dublin and provides regional and outreach services throughout Ireland. Grounded theory is best suited for studying a phenomenon with little known information, to generate a substantive theory that will explain social processes or actions about the focus of the study (Urcia, 2021). There is a paucity of research exploring the perspectives of referring therapists on the use of custom contoured seating for children with complex seating needs. Since this is a novel piece of research, GT is a sound methodology for the purpose of this study. Participant recruitment Sampling in GT is purposive, in that participants are chosen so that additional information can be obtained to assist in generating conceptual categories. Focus group questions The research framework will be a co-production framework, involving an advisory group consisting of a panel of expert clinicians with experience in assessing for and supplying CCS. The group will include a senior physiotherapist, a senior occupational therapist and senior clinical engineer with at least three years of experience in assessing for and providing custom contoured seating for children. The clinical advisory group will be involved in the development of the topics for discussion for the focus groups. Data analysis According to Robson (2002) the purpose of analysis is to generate a theory to explain what is central within the data. This is achieved by carrying out three types of coding; open coding to find the categories, axial coding to interconnect them, and selective coding to establish the core category or categories. A member of the research team will check the data analysis process and a consensus meeting with the primary investigator will take place to agree and confirm theme validity. Focus group interviews will take place until saturation point of key themes is reached. Themes emerging from the coded data are used to build a theoretical model. At this stage, the researcher will select clear and compelling extract examples, conduct a final analysis of the selected abstracts, relating back to overall data analysis, the research question itself and existing literature.
A Multi-Disciplinary Approach to On Time Mobility and the Impact on Development
Teresa Plummer, PhD, OTR/L, ATP, CAPS, CEAS; Ana Allegretti, PhD, OTR, ATP; Scott Burns
In 2022, Feldner, Plummer and Hendry published a guideline for introducing powered mobility to infants and toddlers. This work was the result of Delphi consensus study that garnered input from more than 40 international experts and evidence from 150 peer reviewed sources. The guideline was created, in part, to help ensure that best practice and evidence is used to support inter-disciplinary intervention strategies that are reproducible, repetitive, and reliable. This instructional course will focus on how the guideline is used to create developmentally appropriate goals for infants. Illustrations of how the guideline is used in various therapeutic contexts (OT/PT/SLP) will be presented. Additionally, the presenters will illustrate the inter-relatedness of developmental milestones and the use and benefits of powered mobility. Motor skill acquisition provides a measurable connection to developmental processes. What has not been clearly documented as yet, is the role that powered mobility can play in motor skill acquisition, or for that matter any specific developmental milestone. In addition, little has been presented/published on the specific developmental milestone of language, vision, posture, social skills or hand skills related to powered mobility interventions. There is a direct link between motor skills and language skills. It is imperative that access to and consistent intervention approaches are developed, tested and presented to gather data on the effectiveness and efficacy of powered mobility for infants.
Saturday, April 15, 2023
Are We Really Doing Client-Centered Practice?
Susan Taylor, OTR/L; Emma Smith, PhD, OT, ATP/SMS; Karen Roy, LCSW; Anne Kieschnik, BSW, ATP, CRTS; Weesie Walker, ATP/SMS
We are at a place during which the time for a wheelchair and seating evaluation and fitting/ training is limited. The temptation can be to “lead” the conversation or rush through a fitting/training to come to a conclusion by the end of the evaluation or training. In some cases, the ATP and therapist do not even work together at the same time with the client. These factors do not exactly promote good communication between the client, the therapist and the supplier. It is not unusual to see clients who are so beaten down by the system that they agree with whatever is said. The results can be equipment abandonment and dissatisfaction. We dutifully throw around the term “client-centered,” but what does that really mean in practice? In this one-hour instructional session, we will discuss the importance of listening to and setting goals with your client to achieve client-centered practice in the limited time available to suppliers and clinicians. Finally, we will share stories and experiences to highlight the potential benefits of using this client-centered approach. This session will be conducted in a moderated talk-show style with experienced clinicians and suppliers in the field, who will draw from their wealth of experience providing seating and wheeled mobility to clients. Audience participation will be encouraged.
What can we Learn from Finite Element Analysis (FEA) Outcomes of Wheelchair Back Supports Interventions in our Clinic?
Alexander Siefert, PhD; Bart Van der Heyden, PT
Introduction: Back support interventions are frequently prescribed for maintaining the wheelchair user’s sagittal plane alignment and to increase postural support, wheelchair mobility and comfort. Providing the user with lumbar support and supporting the Posterior Superior Iliac Spine (PSIS) is frequently used strategy to maintain sagittal alignment of the spine. Back support systems replacing the standard sling upholstery exist in many shapes, hardware adjustment features and user interface materials. Unfortunately, only few manufactures of back support replacement systems have published outcome studies on the effect of shape and design on postural alignment, tissue integrity and intervertebral disk loading. In the presented study the influences of the following parameters are examined: -Location of the lumbar support -Different shapes of PSIS and lumbar support -Amount of force provided by the lumbar support The study is carried out using the numerical Finite Element Analysis (FEA) approach, using the Virtual Human Model (VHM) Jo. The following parameters will be evaluated for each parameter: -Pressure Imaging -Friction at the cushion – client interface -Internal tissue strains: Volumetric Strain Distribution (VSD) -Intervertebral disc loading Conclusion: Based on these FEA findings, we can improve our understanding of the mechanical interaction between the human body and lumbar and PSIS set ups. This session will provide an overview of biomechanical strategies and clinical indications of different back supports systems currently available on the market and will share the findings form the FEA study.
The Safespace Home Adaptation: UK Based Research & Best Practice on Supporting Challenging Behaviours, Sensory Processing and Sleep
Sue King, MSW
INTRO: This seminar explores the most recent research, data and best practice in the UK relating to the ‘Safespaces’ home adaptation with particular focus on its success in supporting sensory processing disorders, challenging behaviour and sleep. Home modification as a way of supporting children with complex needs to live safely in the family home is an innovative approach which has been gaining ground in the UK since 2001. This approach is now being transferred to a range of other environments e.g., schools, respite etc thanks to a growing body of supportive research. BODY: The seminar explores how creating a safe, modified environment can support children with complex needs and severe learning disabilities and their families. The session explores home adaptations in the UK and offers a number of case studies demonstrating how a Safespace home adaptation (a customized safe or sensory room), supports children with challenging behaviors, sensory processing disorders or sleep issues. We explore the positive outcomes which include increased safety, improved sleep and reduction in medication and explore the most recent data that supports these outcomes. The session will explore the UK Governments 2019 recommendation strategy for reducing restrictive practices and the UK National body for Home Improvement agencies’ recommendations for designing home adaptations. We will also look at how funding can be acquired in the UK for home modifications and discuss the potential for the American market. Case studies are supported with relevant and recent research that looks at the wider benefits to society including how investing in a customized home modification can yield a 5 fold ROI through the saving of public funds. CONCLUSION: Providing children and young people with complex needs with a custom made modification to the home can have a significant impact on families, society and the economy as a whole. The benefits are significant and include increased safety, improved sleep and a reduction in medication. Research has also shown that customized home modifications which benefit the whole family and enable a child or young person to remain at home, can yield a 5 fold return of investment
Elopement: To Equip or Not to Equip?
Missy Bryan, OTD, OTR/L, ATP, CPST; Stephanie Frazer, OT; Kristen Kalemeris Madison, PT; Sarah Moran, PT, DPT; Maredith Russo, PT; Kenneth Swantek, PT, DPT; Alacia Stainbrook, PhD, BCBA-D
Elopement is a common reason for referral to a pediatric outpatient seating and mobility clinic. Elopement is defined as “a dependent person exposing him or herself to potential danger by leaving a supervised, safe space or the car of a responsible person (Anderson et al., 2021, p. 2). Elopement often limits participation of child and caregiver in meaningful life activities, as families may be fearful of taking their child into novel or unprotected spaces (Celia et al., 2020). Commercial and non-commercial assistive technologies may be used to prevent elopement, including visual prompts, door locks, gates, monitoring and tracking devices, wrist or backpack leashes, and adaptive car seats, strollers, and safety beds. Non-technology related elopement reduction interventions include behavioral intervention strategies, awareness of elopement by neighbors, and addressing elopement in the Individualized Education Plan (Pereira-Smith et al., 2020). Use of adaptive equipment, such as car seats and strollers with anti-elopement harnesses and mesh enclosure beds, can reduce elopement; however, it comes at a price of potentially restricting autonomy and physical movement of the child. Decision making regarding elopement prevention intervention recommendations is multi-faceted and complex. Seating and mobility teams (of which the child and family are the most important members) must weigh and balance factors of safety, participation, autonomy, environment, sensory modulation, and rest of the child and caregiver. Adaptive equipment should be used judiciously and safely, and caregivers should receive education on appropriate use of the devices. Less-invasive interventions should be considered prior to provision of adaptive equipment and possibly provided alongside the adaptive equipment. This session will present a method for considering the broad range of interventions available to decrease elopement while valuing the autonomy of the child and perspectives of the caregivers, with a long-term goal for fading the necessity of adaptive equipment as appropriate.
Resources from the International Society of Wheelchair Professionals to Improve your Wheelchair Service Provision Practice
Krithika Kandavel, MS; Mary Goldberg, PhD; Jon Pearlman, PhD; Alex Kamadu; Sara Munera, PT, MS, ATP
The WHO suggests that 70 million people need wheelchairs. The problem is multi-faceted, but a core barrier is lack of access to appropriate training, resulting in limited capacity to provide wheelchairs worldwide. An appropriate wheelchair can prevent secondary health complications, enhance quality of life, and facilitate access to human rights such as education, healthcare, and employment (WHO, 2008). USAID has funded projects at the system and local level to support implementation and the creation of Guidelines for appropriate manual wheelchair provision in less-resourced settings and Training packages. The International Society of Wheelchair Professionals (ISWP) was established in 2015 as a development project funded by USAID. ISWP’s ambitious goal has been to become a global coordinating body of the wheelchair sector to leverage and scale previous achievements of the global wheelchair sector. ISWP’s vision is that “all people who need wheelchairs receive appropriate products and services with dignity, enabling them to access education, employment and health care and to participate in their communities.” During its 6 years of incubation at the University of Pittsburgh, ISWP became a global, collaborative, and multi-disciplinary platform of end-users, clinicians, designers, researchers, and activists. It grows daily with 6,200+ members from 120 countries and a social media reach of 112,000+ followers in 113 countries. It has recently spun out of the university to serve as an independent non-profit and appointed its first Executive Director. Additionally, ISWP has leveraged digital platforms to develop scalable, and mostly open access, tools and resources to its community such as: Wheelchair Educators’ Package to guide integration of wheelchair content into curriculum across 3 states of integration: advocating, planning & teaching, and evaluating. Wheelchair specific content in courses supports the development of a competent workforce of Occupational Therapists, Physical Therapists, and Prosthetics and Orthotics wheelchair service providers. ISWP Wheelchair Service Training Series support the training of wheelchair providers in basic and intermediate level, trainers of both levels, and managers of wheelchair services and other stakeholders. ISWP Wheelchair Certifications at the basic, intermediate and trainer level provide recognition of wheelchair providers’ and trainers’ appropriate knowledge and skills. Several lessons learned from various case studies from low- and middle-income countries pertaining to each resource will be presented. These lessons are critical to identify gaps for improvement and future work. The future of ISWP as a separate entity involves opportunities for sustainability and to support its members through its tools, resources, and community to advocate and advance their local/national wheelchair sector with a systemic view. Challenges ahead include reaching critical mass at the local levels.
Equality for the Aging: Ensuring Access to Assistive Technology for the Aged Care Population
Catherine Sweeney, PT, ATP/SMS; Heather Cianciolo, OTR/L, ATP/SMS; Rika Millen, MOT
Global census and survey data tells us that the world population is not only growing, but also living longer due to improved access to health services and medical and technological advances (Australian Bureau of Statistics, 2021). While longevity is widely considered a success conceptually, challenges arise for the aging population. This demographic typically requires increased functional assistance and healthcare costs that are related to significant comorbidities. Research also confirms that the use of assistive technology is highly effective at improving functional abilities, reducing the risk for costly medical complications, and reducing caregiver burden. However, despite these known benefits, a gap remains between access to assistive technology for younger people as compared to access given for the ageing population (World Health Organization, 2021). Often, mobility devices that are less adjustable or have fewer features to assist with medical self-management or functional tasks are prescribed to older clients, despite presenting with the same deficits as younger people. Attitudinal biases exist among certain medical teams and funding agencies regarding the needs of the older adult regarding assistive technology (Royal Commission into Aged Care Quality and Safety, 2021). This 1-hr presentation will examine the current approach to AT procurement for older adults with functional impairments related to the ageing process in the US and Australia; take a focused look at wheeled mobility and seating and positioning for the aging person with disability and will present research-based best practice recommendations for clinical application.
Flying with Wheels: The Latest on Advocacy, Inside Cabin Development, Research, and Policy
Jessica Pedersen, OTD, MBA, OTR/L, ATP/SMS; Faith Brown, MS, OTR
Stories have been shared internationally outlining how individuals have had their wheelchairs damaged or lost during flight. Some of the stories highlight how this affects a person’s travel or worse their health because they were not sitting in an appropriate wheelchair and seating system for a long period of time waiting for repairs or replacements. Much has happened these last few years in the efforts to advocate for staying in a wheelchair during a flight. This session will discuss the research and advocacy led by All Wheels Up, the findings of the US Transportation Board concerning wheelchair securement systems, the latest in interior designs to accommodate a wheelchair spot, and how wheelchair manufacturers, wheelchair riders, and their families are involved. Participants will be able to learn what has developed in the world of traveling with a wheelchair since 2019. Open discussion will take place promoting dialogue pertaining this topic as well as how professionals specializing in the area of wheelchairs and seating might be involved in this effort.
Research-Based Implementation of a Patient Reported Outcome (Functional Mobility Assessment) Into a Busy Seating Clinic
Matthew Yankie, PT, DPT, ATP; Heather Schriver, PT, DPT
Patient reported outcome measures are questionnaires that measure patients’ perceptions of the impact of a condition and its treatment on their health (Dawson, 2010). The intention of PROMs feedback is to enhance communication between patients and clinicians, improve the detection of patient problems, support clinical decision-making about treatment through ongoing monitoring and to empower patients to become more involved in their care (Greenhalgh, 2014). It is often seen as daunting task to collect these outcomes and integrate them into clinical practice. This presentation focuses on the implementation of the Functional Mobility Assessment over a decade of process refinement into a busy seating clinic, and how clinicians are able to take this data and make quality improvements within their program to improve seated and wheeled mobility service delivery and patient satisfaction.
Developing a Segmental Trunk Support Seating System for Children with CP Undergoing Segmental Intensive Trunk Training (SITT)
Bhavini Surana, PT, MPT, EDD; Victor Santamaria, PT, PhD; Tatiana Dinora Luna; Sunil Agrawal, PhD; Andrew Gordon, PhD, MS
Purpose: Describing the development process of a segmental trunk support seating system for children with cerebral palsy (CP) undergoing Segmental Intensive Trunk Training (SITT) Background: Children with CP GMFCS IV-V often exhibit difficulty in maintaining independent upright sitting balance. SITT is based on two concepts: 1) provision of external support at specific trunk segments outlined in segmental assessment of trunk control (SATCO), instead of entire trunk, to create opportunities for practicing functional activities that challenge the static, proactive and reactive control, and 2) structured manipulation of motor learning framework components like practice, feedback, attention, and skill progression. SITT sessions span 2 hours and involve practicing motor skills for a large number of repetitions. The purpose of the seating system was to create a closed chain by 1) stabilizing the pelvis in sitting and 2) provide sustained static support to specific trunk segments. Methods: The prototype consisted of a Kaye® bench with adjustable height fitted with SATCO straps for pelvic stabilization in sitting. The adjustable height was chosen to accommodate children of different age groups. A vertical device for providing segmental trunk support was built using the 80/20 Inc.® aluminum T-slot building system. Positioned behind the bench, the vertical device had a broad base for stability and an upright rigid column for hosting the trunk segment enclosure. The T-slot system is modular and easy to use. The vertical column had channels that allowed us to slide the trunk enclosure up and down effortlessly for supporting desired trunk segment. The trunk enclosure was square in shape and consisted of 2 inch T-slot pieces lined with heavy duty foam, posteriorly and laterally, with a Rifton® large strap anteriorly. The whole device was mounted on locking caster wheels to make the setup portable. 5 children with CP GMFCS IV-V (6–12 years) participated in testing the prototype. Testing outcomes included stability, alignment, comfort, and number of adjustments, while performing SATCO, Box and blocks test, and bimanual activities. The initial setup could not withstand the strong extensor moment exhibited by the children and required multiple adjustments as they moved in different directions while performing activities like ball throwing. To improve stability, the caster wheels were removed, and the device was bolted on a wooden base. The bench was separately stabilized using ratchet straps. The Rifton® strap was replaced by a 2 inch T slot piece lined with heavy duty foam. Post iterations, the overall setup was stable and met the protocol requirements. Conclusion: A stable seating system capable of providing sustained segmental support to children with CP was developed by a systematic iterative process. Future iterations will focus on using separate trunk enclosures for different age groups to make the setup more customizable.
Effectiveness of In-Wheel Suspension in Reducing Vibration and Shock in Manual Wheelchair Users
Allison Brunswick; Ahlad Neti; Alicia Koontz, PhD, RET, ATP
Daily exposure to whole body vibrations (WBV) can result in fatigue, neck pain, and back pain for manual wheelchair users (MWUs) with spinal cord injuries (SCIs). Uneven ground, curb drops, and random bumps can also exacerbate the WBV felt by MWUs. Suspension frames have been created to reduce the intensity of vibrations or shock; however, they tend to be bulkier and heavier than non-suspension frames and the suspension components are not effective in attenuating multi-directional shocks. Commercial suspension wheels have recently been created to handle these multi-directional vibrations and shocks and can retrofit onto an existing wheelchair frame, allowing the user to keep their preferred wheelchair with minimal modification. The purpose of this study is to compare the effects of a novel in wheel suspension wheel (LoopWheel) to a lightweight carbon fiber based wheel (Spinergy CLX) and standard spoke wheel on attenuating the shocks and vibrations experienced during wheelchair propulsion. We hypothesize that the LoopWheel and Spinergy wheels will have lower root mean squared (RMS) and vibrational dose value (VDV) values than the standard spoke wheel. MWUs were asked to propel over a mobility course with different textured surfaces, gravel, and curb drops three times at a consistent self-chosen speed with each wheel. The wheels were tested in a random order and had covers that blinded the MWUs to the wheel type being tested. Shimmer 3 inertial measurement units (IMUs) were used to collect acceleration data from the backrest, seat plate, and footrest on the wheelchair frame. RMS and VDV of the magnitude of accelerations were calculated from the Shimmer 3 IMU data. These values are representative of the vibrations and shock, respectively, experienced through the wheelchair frame during propulsion. Participants were given a survey after each trial on the mobility course to gather their level of comfort and opinions of the wheels they had used. Data collection is currently ongoing. A repeated measures ANOVA will be used to assess the differences in the shock and vibration metrics between the three wheels. The in-lab user survey will be used to assess if the suspension wheels are able to improve comfort and quality of life. If the in-wheel suspension is found to be effective, the next steps would be to see if using suspension wheels for a longer period of time could help those with neck or back pain reduce their symptoms and/or increase their community participation.
Home is Where the Erg is: Development of a Home Rower for People with Spinal Cord Injuries
Johanne Mattie, MASc; Mine Celebi; Anika Cheng; Ben Mortenson, PhD, MSc, BScOT, OT; Bonita Sawatzky; James Laskin; Carolyn Sparrey; Jaimie Borisoff
Physical exercise plays a critical role in the management of chronic diseases and spinal cord injury (SCI) (Pattyn et al., 2013; Jacobs et al., 2004), however many barriers to exercise participation exist-most notably lack of time and lack of transportation to accessible facilities (de Groot et al., 2020). To address these barriers, we have recently developed the Home_aROW, a low cost adapted rowing machine that allows wheelchair users to exercise from the convenience of their own home. The Home_aROW was developed using a user-centered design process and is based on the aROW rowing machine that was created by our team in earlier work (Wong et al., 2021; Sawatsky et al., 2022). The aROW consists of an adapter that mounts to a Concept 2 rower. It includes an adjustable lap pad that secures the user’s proximal thighs and stabilizes their wheelchair during exercise. For users with limited trunk stability, an adjustable chest pad can be positioned to support the user’s torso. The Home_aROW utilizes a similar system of adjustable supports but uses the flywheel section of a lower cost rowing machine (the SunnyErg) as a base. The adapter mounts to a wooden frame around the rower, and an adjustable ceiling pole stabilizes the machine during exercise. As with the aROW, users row from their wheelchair, thus obviating the need for transfers and allowing them to take full advantage of their own wheelchair seating. An initial concept prototype for the Home_aROW was developed and feedback from users was used to refine the design through iterative design-build-test cycles. Feedback was obtained through a mixed-methods study that compared use of the Home_aROW in participants’ homes with use of the aROW in community gyms. Participant’s perceptions of the machines were explored through semi-structured interviews that probed barriers and facilitators, desired modifications, exercise effectiveness, and issues related to home vs gym work outs. Participants were also asked to complete the System Usability Scale (Klug et al., 2017) to rate their perceptions of usability. Findings from this research will be used to guide future design revisions of the Home_aROW, inform the development of training materials, and guide deployment activities. It is anticipated that the Home_aROW will provide a practical home exercise option for people with SCI, and support ergometer rowing as an accessible, effective, and enjoyable exercise.
Disability Justice in Seating and Mobility: Recognizing and countering mobility-related ‘inspiration’ and ‘overcoming’ narratives and their impact on technology users and professionals
Heather Feldner, PhD, PT, MPT, PCS; Andrina Sabet, PT, ATP; Kayla Brown; Jean Minkel, MPT, ATP
It is common on social media, in television and film, and in every-day life to see examples of inspiration narrative; known in the disability community as “inspirational porn.” These are images, stories, and language that objectify people with disabilities, typically for the benefit of nondisabled people to make them feel better about their own circumstances. These images and words often depict someone with a disability being portrayed as the sentimental hero, persisting ‘despite’ their disability, or ‘overcoming’ disability to perform every-day tasks, such as going to school, playing a sport, and of course, walking. Many of these narratives involve mobility technology users in reductive, inaccurate, or inappropriate ways. What are the origins of these inspiration narratives? How do people with disabilities respond to these tropes? How might these common images impact the lives of mobility technology users and our own industry? This session will address these and other critical questions as we examine common inspiration narratives surrounding disability and mobility technology use. We will unpack the idea of ‘inspiration porn’ as defined by the disability community. Disability history, ableism, advocacy, and the disability community’s response to these narratives will be discussed, including excerpts from a TED talk about inspiration narratives and their hurtful effects by Stella Young, a late disability rights activist, comedian, and powered wheelchair user who first coined the term. Participants will discuss alternative narratives and opportunities to develop more meaningful diversity partnerships with and for the disability community. Through amplifying Stella Young’s voice and the voices of other disability community members, we will explore these issues to better align CRT professionals to be effective allies with the disability community, and to call attention to the perpetuation of these narratives. Are we, the CRT community, unknowingly (until now), participants in the promotion of inspiration narratives? Are we embracing and acting in ways to promote disability in diversity discussions? The ultimate goal for this session is to introduce new ways of thinking about mobility, disability, and the messages and value propositions imposed on wheeled mobility provision and use within our society.
Rehabilitation Engineers: Who we are and what we do!
Kaila Ott, MS, ATP, RET; John Miller, MS; Stephanie Vasquez-Gabela, MRT
Rehabilitation engineering is often a field that is overlooked or misunderstood on a rehabilitation team, but clinical rehabilitation engineers have valuable skill sets for the application of complex rehabilitation technology on a multidisciplinary rehabilitation team. They use engineering principles to prescribe, design, develop, implement, and modify wheelchair and assistive technology solutions for individuals with disabilities. With different perspectives and engineering backgrounds, each rehabilitation engineer can operate and specialize in different capacities. Rehabilitation engineers can operate in various roles, including direct service delivery, industry design and development, or research, but rehabilitation engineers on a clinical team typically can function in all these capacities. Clinical rehabilitation engineers frequently collaborate with occupational therapists, physical therapists, and speech and language pathologists on assistive technologies such as environmental control units, power wheelchair alternative drive systems, and augmentative and alternative communication devices; services can also extend to physicians, recreation therapists, nursing staff, and other disciplines. Clinical rehabilitation engineers are employed in multiple healthcare settings, including the public and private sector. The Veterans Health Administration (VHA) employs clinical rehabilitation engineers at multiple VA medical centers to serve as subject matter experts and to support clinical staff in evaluating clients, identifying appropriate equipment, and installation and training. Clinical rehabilitation engineers within the VHA also use rapid prototyping and manufacturing tools such as 3D printers, laser cutters, scanners, computer-aided design software, and more to create new and custom technologies when off-the-shelf products are not sufficient for a client. Clinical rehabilitation engineers operate differently in the private sector, collaborating with an assistive technology supplier, but they provide similar expertise to maximize a client’s independence. They also help identify and eliminate cost inefficiencies such as overlapping assistive technologies or contracting custom products. At the University of Pittsburgh Medical Center-Center for Assistive Technology, clinical rehabilitation engineers play a key role in the assistive technology service delivery process and the integration of assistive technologies for inpatient and outpatient clients, school districts, and external clinics. Clinical rehabilitation engineers specialize in both consumer and custom products, a unique skill set that enhances the client outcome. Employing a clinical rehabilitation engineer as a member of a multidisciplinary team provides an integral role in understanding the human condition, diagnosis, and function while serving as a subject matter expert in identifying, integrating, and customizing a myriad of wheelchair and assistive technology devices for clients.
Product Quality Improvement: Using Performance Standards to Ensure that a Product is Safe and Effective
Patricia Karg, MSE; David Brienza, PhD; Jack Fried, MS; Jon Pearlman, PhD
This session will focus on answering the question “How do you know that a product is safe and effective?” The “you” in that statement could be a clinician, manufacturer, supplier or wheelchair user. But no matter the audience, we will discuss how to interpret and apply wheelchair cushion and caster performance standards to promote improved product quality. We aim to translate standardized test metrics to clinically important information that our audiences will be able to immediately apply to their daily practices. We will also explore real world performance evidence to demonstrate product failures that occur commonly in the community. Industry attendees will gain understanding of the test metrics and how they can use the tests to their advantage as they develop and market their products.
Inpatient, Outpatient and Home Early Postural Management Intervention for Infants: BIBI and WHIPPY two Innovative Devices
Rosaria E. Caforio
Preterm and sick newborns need more care and attention than healthy and term infants. Age at birth, illness, hospital stay time, traumas and medical treatments, as well as the non-continuous closeness to the mother affect their sensory and psycho-motor development. An estimated 15 million babies are born too early every year. That is more than 1 in 10 babies. Approximately 1 million children die each year due to complications of preterm birth. Many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems. Best practices and standards for improving the quality of care, prevention of disability, treatments of illnesses and pain as well as rehabilitation for small and sick newborns include lying down and gradually sitting postural management intervention both for inpatient and outpatient as well during their stay at home. For example, postural management intervention is required for these infants during their stay in NICUs, SUB NICUs, during and after surgery, during speech and psychomotor interventions, and so on. Also, at home postural management intervention is required during their stay in the baby carrycot, cot, stroller, highchair and so on. Avoid any kind of sensory trauma and maintain these infants always as if they were in the arms of their mother whatever the situation, they live is fundamental to promote their sensory, perceptual, psycho-motor, physiological recovery and to prevent/contain motor damage and deformities. At the state of the art few devices are available to deal with the innumerable problems and needs of these fragile infants and their families as well as of the staff and clinicians who have to care and treat them. This work will introduce participants to two innovative devices both for postural management inpatient, outpatient and home, flexible in use and adaptable to a variety of situations developed with the intention of giving a continuity of sensory approach to the preterm and sick newborns and at the same time accompanying them during the various steps of their treatments, their daily life and their growth. Also developed at the same time to give to clinicians, staff and families simple and intuitive instruments for manage posture of infants in every situation and for most of the treatments both lying down and sitting.
What are my Options - Clinical Reasoning: Power add on and Power Assist Products
Amy Bjornson, MPT, ATP/SMS
Power assist and power add on systems have rapidly evolved in recent years. They are commonly considered as an alternative to a power wheelchair or as a method of making a manual wheelchair a more functional option. This workshop will focus on the functionality and the clinical implications and decision process for each category. We’ll look the clinical indicators for this technology, objective measures useful to qualify the technology with your client and provide tips for successful funding approval. This workshop will focus on the technology of Power Assist and Power Add On systems for manual wheelchairs. We’ll look at the design and clinical application of both technologies and their ability to promote sustainable, functional outcomes
Co-creation Challenge Workshops; How to Co-Create Where Everyone has a Voice
Rachael McDonald, PhD; Paraskevi Triantis; Claudia Bridge; Alyse Brown; Anna Lane; Ronald Bartels
Traditional development of assistive devices and products has been in answer to a specific problem, and often retrofitted to an individual. Yet, rates of abandonment of technology are high–up to 78% in some technologies (Petrie et al., 2018). “Design for Disability” has been a concept for a number of years (de Couvreur & Goossens, 2011), with emerging technologies and manufacturing processes there is more potential than ever to ensure that technologies enabling participation in life can be achieved. Furthermore, the sustainability of assistive technologies requires successful implementation and translation into practice; and participatory co-design with end users is an important and emerging concept (Carroll et al., 2021). Finally, with the increasing demands on health systems internationally, innovative solutions to accessing products, supports, and services are required. The MedTechVic hub is an innovative multidisciplinary team based in Melbourne, Australia, where all partners interested in the development of enabling and assistive technologies come together to address the issues of the end users. The hub consists of physical spaces (the enabling AT lab and the Volumetric Capture Studio), manufacturing readiness workshops, a clinical fellows program, Impact Ph.D./masters programs, work integrated learning placements, and Challenge workshops that underpin all other activities. We have developed a number of models for the co-design Challenge workshops, based upon the needs and abilities of end-users. These include supported face to face experiences, hybrid or fully online models with support. This workshop will share our experiences of a collaborative model for co-creation with everyone involved, including people with lived experience, care and support persons, clinicians as well as researchers, designers, engineers, manufacturers, retailers, and lawyers. Participants will come up with an idea for a wheelchair or assistive technology, and work in small groups to develop a plan for a co-designed solution. The workshop will commence briefly with theory and a structure for participants to work with. Examples will be given that demonstrate solutions in both physical and digital products as well as educational offerings. Participants will engage with material specifically around how to develop and run challenge workshops and how to progress from this to engagement, co-design, and co-evaluate enabling products and services. At the end of the workshop, participants will have developed knowledge and skills to engage further with the concept and process of co-design for enabling technologies within their own area of interest.
Are you in control? Formalising the Drive control Selection Process for Powered Mobility Users
Rebecca Van Craeymeersch, MA, MS
Proportional hand joysticks are still the most common type of drive controls for PWCs. There is actually very little quantitative data on the use and function outcomes of the different types of control devices nor on the actual prevalence of control devices for a representative group of clients, but research indicates that more than 90% of PWCs are controlled by joysticks. Proportional hand joysticks are intuitive to use, provide more precise control than non-proportional devices by allowing the user to increase and decrease speed in all directions, which provides the user with increased control when navigating through different environments and are cost effective. But what if the client cannot access the standard location of the drive control, or lacks motor skills to operate the control? First of all, the body part or area that is able to provide sustainable, repeatable and consistent movement for independent control needs to be identified during the assessment. Although proportional controls seem fairly intuitive and easy to use, they do require fine motor skills. The hand and fingers are the default option, as they are typically used for manipulative tasks. But even then, the positioning is crucial: do you mount the drive control at the end of the arm support or towards midline position? When the hands and fingers are not an option, the use of other anatomical sites should be considered, such as the head, the chin or the foot. Secondly, the required force is also crucial. For example, for some types of Muscular Dystrophy, small distal movements remain possible for a long time. In that case, very sensitive joystick controls may be required. On the other side of the spectrum, users with severe dystonic movements might require very durable joysticks. This session will focus on the assessment, the location, the type and the settings of controls for every individual. Gaining a better understanding of the control options and its indications for use will help reaching the client’s full functional potential of today’s joystick technology and will allow users who might otherwise not be able to drive a PWC safe and controlled mobility.
Supporting Complex Body Shapes with Custom Contouring Seating
Sofia Bello, PT
People with limited/restricted mobility are at significant risk of developing body deformities due to their habitual posture, gravity, and time. Understanding the “why” is essential to address “how” to correct and manage their posture. Biological or musculoskeletal changes may develop which, if not addressed in time, can be progressive and tend to reinforce body distortion and asymmetrical postures generating a negative impact for the person. We must be able to distinguish which are the disruptive postures and seek for the appropriate supports that allow us to achieve function with the best care of the body shape. Failure to protect symmetrical body alignment can result in complications (e.g., scoliosis, respiratory and digestion difficulties). Providing solutions capable of meeting patients’ postural changes over time is vital, not only to ensure the goals of the seating intervention, but also to meet funding sources that require seating systems to last for several years. Innovations in custom contouring seating technologies provide a range of opportunities for users with complex postural distortions, offering technologies match body shape and positioning needs throughout the lifecycle of the device in changing shape and contour. We will identify and provide options for appropriate Assistive Technology Solutions to support therapists’ clinical reasoning in selecting seating systems capable of meeting patients’ needs throughout the process, increasing functional seating outcomes, reducing overall costs, and avoiding the destructive impact of postural changes. WHO demonstrates that there are high records of wheelchair abandonment due to poor performance of the device by not providing the correct support and not meeting the user’s needs. Continued care and support for the complex and asymmetric body shape that develops more deformities over time, now clinicians and therapists can re-think, re-evaluate and re-use the existing solution without discontinuing the device and ensuring that the user can have an appropriate postural support that matches body shape and enhances their participation. The ability to provide person-centered products that are adjustable and customized to the user, capable of meeting specific positioning needs and considering the context of their use, has been very well received around the world. Therapists, users, caregivers, and funding boards want to be able to change the configuration of a product at any time, and multiple times as needed; not only to adjust to clinical changes, but also to increase the product’s lifespan. Complex seating is indeed complex, and adjustability is one key point in every intervention, for everyone involved in the wheeled mobility and seated process. Being up to date and understanding what is on the market is therefore paramount, to support our clinical reasoning process and to enable people to choose what better meets their goals, today and in the future. Shaping better lives!
A Review on the Update of the RESNA Position Paper for the Application of Tilt, Recline, and Elevating Legrests
Jillian Stamatelos, OTR/L, ATP/SMS; Grace Denfeld, OTR; Vincent Campbell, OT; Tabatha James, OT; Heather Cianciolo, OTR/L, ATP/SMS; Jennith Bernstein, PT, DPT, ATP/SMS; Rebecca Russell, PT, DPT, ATP
A RESNA Position Paper on Clinical Practice is an official statement by the organization that, based on the consensus of experts and evidence summarizes current research and best-practice trends in relevant areas of Assistive Technology. These Position Papers on Clinical Practice, issued by the international professional organization, declare the necessity (medical and/or functional) of specific assistive technology devices and services under appropriate circumstances, and guide practitioners in decision making. These papers require periodic updates to ensure the most current research is reviewed and that the papers are up to date to assist clinicians with problem solving, as well as to assist with obtaining approval for such devices through various payors. The current paper has not been updated since 2015. This presentation will summarize the current findings and serve as a platform for the authors to receive feedback from their peers to ensure quality content.
Development and Validation of an Overuse Risk Monitor for Manual Wheelchairs Users Through Wearable Sensors
Ahlad Neti, BS; Allison Brunswick; Alicia Koontz, PhD, RET, ATP
Manual wheelchair users (MWUs) experience a high prevalence of upper extremity joint discomfort and pain associated with repetitive motions involved in their activities of daily living (ADLs). Many daily tasks such as propelling, overhead reaching, pressure relief lifts, and transfers impose high forces and moments on the shoulders, elbows, and wrists. The quantity and loading demands of these tasks as they are performed in real-world environments is largely unknown. Prior work has been focused on identifying gross wheelchair motions (e.g., distance and speed) and the biomechanics of these activities through the use of complex motion capture setups. Limited work has been focused on monitoring the amount of high risk activities being performed in a free-living environment through easier to setup wearable sensors. This study aims to develop and validate a wearable sensor suite and machine learning based classification models to classify the risk associated with performing real-world activities. Eight wireless electromyography (EMG) sensors and five inertial measurement units (IMUs) were placed on the upper extremities of MWUs to acquire quantitative data on muscle activity and body movement while performing ADLs. Participants performed six activities: propulsion at a self-chosen pace on a mobility course (nine trials), independent transfers (six to nine), overhead reach (2 min), pressure relief lifts (2 min), folding laundry (2 min), and paperwork (approx. 2 min). EMG data is used to identify level of muscle activation and IMU data will be processed to obtain joint angles and other kinematics. Data collection and analysis is currently ongoing. Activities will be categorized into low (paperwork, laundry), moderate (mobility course, pressure relief), and high (transfers and overhead reach with a weighted object) risk. The EMG/IMU data will be windowed and labeled into epochs and then processed through feature generation and selection. Classification models will be generated using a 70/30 training/testing split among 75% of the subjects; the remaining 25% will be used as a separate holdout validation set. Supervised classification techniques such as SVM, KNN, and Decision Trees will be used to generate activity intensity level classifiers from the collected data via a Python and SciKitLearn library. A cutoff of 70% accuracy will be used determine successful classification of activity risk; however, other outcomes will also be investigated such as F1 score and area under the ROC curve. The models that perform the best will be validated on the holdout validation set to confirm robustness of models. Further analysis will be conducted to determine most optimal number of sensors required for accurate activity risk recognition through feature importance calculations. The results of this study will be insightful for developing more robust activity trackers for MWUs and to identify when injury risk due to the performance of routine ADLs is high.
Why Can’t I go to the Park? A Geospatial Analysis of How the Built Environment Impacts Adapted Ride-On Car Use
Mia Hoffman, BS; Jon Froehlich, PhD; Katherine Steele, PhD; Kyle Winfree, PhD; Heather Feldner, PhD, PT, MPT, PCS
Children’s socio-emotional development occurs through play and engaging with the environment around them. Young children with disabilities can explore their environment using early powered mobility devices, such as an adapted ride-on car (ROC). Families use ROCs in their homes, but also outside and in their local community. As such, this study investigated how the built environment impacts ROC use in the community environment using geospatial data. Using a custom data logger, we tracked ROC usage of fourteen children with cerebral palsy or developmental delay (8M: 6F; age: 1–5, 2.5 ± 1.45; GMFCS: II-IV) in Western Washington over the course of a year. An Arduino Pro Mini was programmed to track switch activation, wheel rotations, and geospatial position (GPS). In combination with GPS data analysis, we evaluated the accessibility and walkability/wheelability of the immediate area surrounding each participant’s home, and the proximity of community spaces that would be utilized by a family with young children. Children actively drove for longer durations and higher percentages of the play session outside their home compared to inside (outside: M = 8.1 min, inside: M = 2.9 min, p ≪ 0.01). However, children mainly drove inside and close to their homes (M = 0.10-mile radius). We found that as the walkability/wheelability increased, the ROC use outside also increased, most notably in the distance that the families traveled during a play session. For three participants who lived in Seattle, we also assessed neighborhood accessibility via Project Sidewalk, a crowd-sourced mapping initiative that measures sidewalk accessibility by identifying barriers, such as missing curb cuts. Two of these participants lived extremely close to a park, but never drove there because there was no accessible route. The third participant drove to the nearby park over 50 times because they had an accessible route. This study shows that location and built environment accessibility are crucial factors in assessing deployment and use patterns of early powered mobility technology. Play session duration and drive distances both increased significantly with outside driving, but accessible outside paths varied and were influenced by environmental factors. We found that families who established a routine driving route or a safe place to drive (e.g., empty parking lot, courtyard) utilized their ROC more. Most importantly, we found that relative inaccessibility of the built environment was detrimental to ROC use, restricting the areas in which their child could explore. As such, future work needs to be conducted with open-source mapping initiatives, like Project Sidewalk, to investigate the impact of the built environment and support families in identifying accessible areas for deployment and use of early powered mobility in home and community environments.