by Michelle L. Lange, OTR/L, ABDA, ATP/SMS, and Eric Grieb, ATP, CRTS, OTR/L
Driving a power wheelchair may appear to be a simple task. In reality, independent driving requires specific motor, visual, and cognitive skills. These skills are assessed during the power mobility evaluation. However, even if a power wheelchair is recommended, the client will generally benefit from mobility training to optimize driving efficiency. Providing a power wheelchair without mobility training is like putting a teenager behind the wheel without driver’s training.
The average teen has spent years in a motor vehicle as a passenger, observing how a car is operated. The average teen also has typical motor, visual, and cognitive skills. In contrast, new power wheelchair users may have never observed another person driving a wheelchair and may have motor, visual, and/or cognitive limitations. The average teen must complete 50 hours of supervised driving before receiving a license. In contrast, many new power wheelchair users have no training at all. Providing power wheelchair training increases the likelihood of successful outcomes by optimizing mobility skills and efficiency.
Before starting driving lessons, basic power wheelchair training is imperative. This includes care and maintenance of the wheelchair, as well as basic operating instructions. A power wheelchair may be quite intimidating to the client and/or caregivers. Providing basic instructions decreases this anxiety. Providing written instructions for future reference is very helpful as well.
The authors of this article recommend that any training be documented and any written instructions be copied and filed. If written instructions are lost, these can be retrieved and provided again. Documenting training can also limit liability.
Some clients will hop into a power wheelchair and take off, requiring no training at all. Other clients may require extensive and long-term training, particularly if the client has a slow learning curve. Children, in general, respond better to minimal instructions using simple and consistent vocabulary. Learning through trial and error while driving in quiet, large spaces is often most effective. Just as a teen doesn’t begin by driving on the freeway, a new power wheelchair driver needs to begin in large, quiet environments, and gradually move to areas that require more accuracy and contain more distractions.
Using a power wheelchair requires mobility concepts such as cause/effect, stop/go, directional, problem solving, and judgment. Before a power wheelchair is recommended, the client will typically demonstrate at a minimum cause/effect and stop/go concepts.
Cause and effect, in power mobility, is recognizing that an action (such as pressing a switch) leads to a result (movement of the wheelchair). This concept is typically obvious as a facial response to movement. Before equipment recommendation (pre-mobility training), cause and effect can be developed using switch toys and other activities such as single-switch software and tablet apps.
Stop and go concepts are one step above cause and effect. The driver recognizes that one action (such as pressing a switch) results in moving and another action (such as switch release) results in stopping. At this point, the client may not stop accurately, but does understand the concept. To develop accuracy in stopping, the trainer may ask the client to drive to a specific destination (drive to the table) and stop before collision. When training children, games such as Red Light, Green Light can be employed and are especially effective when involving peers.
Directional concepts are the understanding that moving the joystick in a certain direction will move the wheelchair in the corresponding direction, or that pressing one switch will move the wheelchair in one direction while pressing another switch moves the wheelchair in a different direction. Conceptually, this does not mean that the client can drive accurately yet. To develop the client’s ability to apply these concepts to driving, the trainer may ask the client to drive to a specific location (drive to the table), which requires the client to choose the correct joystick movement or directional switch. Placing motivating objects at the destination may help. A game that reinforces this skill in children is Follow the Leader.
Problem solving requires the client to combine and time joystick movements or switch activations to get from one location to
another. Many clients require practice to develop accurate and efficient driving. The client may initially take “the long way” from point A to point B, but with continued practice, accuracy improves and time required to move between locations decreases. The trainer may choose a location that requires a combination of joystick movements or switch activations and encourage the client to drive there. For children, playing Hide and Seek is a great way to train this skill.
Judgment is difficult to measure and to train. Many of the clients we work with have impaired judgment due to lack of experience. We learn the consequences of our actions through experience and then develop judgement as a result. For example—taking the perspective of a child—if I run into my friend on the playground it hurts us both, and I remember that in the future. If my wheelchair runs into another child, however, this may not hurt me and therefore I may have difficulty understanding why it hurts the child.
In general, it is helpful for the trainer to remain positive, calm, and patient. If the trainer is anxious, the client may become anxious. Many clients need time to process commands, and so the trainer should use simple instructions and then wait—giving the client time to process and act on the command rather than having to process a string of commands given by multiple people.
Extensive motor repetitions are required to develop a motor pattern to the point of automaticity. When a movement becomes automatic, one reacts without thinking. For example, a ball bounces across the street in front of your car, and your foot is on the brake. You didn’t think about where the brake is, where your foot was, and what you needed to do—you only thought, “stop!” We ultimately want a client to think of where they want to drive the power wheelchair, not how to drive. The clients we work with may require extensive driving practice to develop this automaticity.
Before a power wheelchair recommendation, a variety of motor activities, such as playing with switch toys, can be used to develop the ability to press and hold a switch. Driving a power wheelchair requires sustained contact with the joystick or a switch, as opposed to other assistive technologies that may only require a momentary switch contact. After power wheelchair delivery, training is most effective in the wheelchair.
Programming a power wheelchair customizes driving parameters to the client’s needs and abilities. During training, further programming may be required to optimize driving. As the client improves, overall speed and responsiveness may be increased to match the client’s increased competence.
Recently introduced to the mobility market are alternative drive control systems that combine advanced programming and hardware to optimize operation. Among these devices are systems designed for convenient “plug and play” installation, and built to be compatible with wheelchairs offered by a variety of manufacturers. These include systems built around a central processing unit and designed for use with a head array, sip and puff, joysticks, tray arrays—or combinations such as joystick and head array, or sip and puff/tray array. A tablet device can be used to program commands for these alternative drive control systems to make a range of detailed adjustments with the aim of creating smooth and responsive operation.
Tracking technologies are optional on complex rehab power wheelchairs and increase efficiency in driving by reducing the amount of joystick movements and switch activations required to drive from one location to another. Tracking keeps the chair “on track,” reducing compensatory movements required to remain on course. For example, if a client is driving down the sidewalk and crosses a driveway, many wheelchairs will drift downward on this slope. Now, the client has to compensate for this course deviation with additional joystick movements or switch activations to correct their course. With tracking, the chair will maintain a straight course despite changes in slope. Competent joystick drivers will make these compensatory movements while driving and may not require tracking technologies, but this feature can be especially valuable for switch drivers. An informal study demonstrated a significant reduction in the amount of required switch activations and time to complete a course when tracking was enabled.1
Just as power mobility training optimizes power wheelchair driving, programming and tracking technologies do as well. When recommending a power wheelchair, tracking technologies should be considered, particularly for switch drivers.
Drive Wheel Configuration
Power wheelchairs are available in three drive wheel configurations: front, center, and rear. Each configuration drives differently, and specific training can optimize navigation. An example is turning a corner. When driving a rear-wheel-drive power wheelchair, the driver will need to make a wide turn to clear the front end of the wheelchair. Therefore, if the client is driving down a hallway and turning into a doorway on the right side, a rear-wheel-drive chair may need to be on the left side of the hall to complete the turn. When driving a front-wheel-drive configuration, the driver would stay on the right side of the hallway to make a 90-degree turn into that doorway to clear the rear end of the wheelchair. A center or mid-wheel power wheelchair clears the doorway best when turning from the middle of the hallway. The client may benefit from specific training to navigate the environment in a particular drive wheel configuration in addition to standard mobility training.
Training resources are available that provide more detailed suggestions, including guides for pre-mobility and mobility training, and powered wheelchair training guides. Some resources are available for purchase, and others are offered at no charge.
A favorite training tool among some therapists is the Remote Stop Switch. This allows the trainer to stop the power wheelchair from a distance by pressing a button, freeing the trainer to stand away from the client, encouraging him to drive while observing how he is doing. A Remote Stop App is pending from one wheelchair accessory manufacturer for use on a smartphone. Funding is challenging for Remote Stop Switches, but this App reportedly will be priced affordably.
A coordinated, team approach to mobility training is essential in facilitating optimal functional outcomes for the prospective driver with significant cognitive or motor impairment; and is key in avoiding the potential for equipment abandonment. This requires a common understanding and collaborative planning among team members. Issues that should be discussed include:
1) Duration, frequency, and limitations of skilled mobility training anticipated for the client.
2) Functionally relevant training environments and any potential restrictions surrounding service provision. For example, under some health plans, the clinician cannot bill for services outside of the clinic. The health plan may also limit the number of visits.
3) Client and caregiver responsibilities in the mobility training process (ie, home program).
4) The delineation of roles and responsibilities in the training process between clinician, supplier, caregiver, and client.
While mobility training is a shared responsibility, the clinician assumes primary responsibility for leading the process. Utilizing a combination of standardized assessments and clinical judgment, the clinician formulates and implements a graded plan for mobility training tailored to the client’s unique set of needs.
Assessment and treatment surrounding mobility needs are considered to be a billable service for both occupational and physical therapists under most health plan rules. These interventions are billed under a unique set of CPT codes, and the clinician must further understand the specifics of the individual health plan’s rules and limitations surrounding Mobility Assessment and Training in the context of formulating an optimal treatment plan.
The treatment plan will typically include instruction in, and monitoring of, a supervised home mobility training program to be implemented by the client and caregiver. This component is essential for success given the restrictions imposed on therapy services by many of today’s health plans. Due to restrictions in the number of skilled visits allowed, the caregiver and client frequently carry a significant amount of responsibility for the ultimate mobility outcome.
The power wheelchair supplier also has an integral role in the mobility training process. While not a billable service for the supplier, the responsibility for helping the client to achieve their mobility goals is equally shared. RM
Michelle L. Lange, OTR/L, ABDA, ATP/SMS, has more than 25 years of experience and is former clinical director of The Assistive Technology Clinics of The Children’s Hospital of Denver. She lectures globally, and has authored six book chapters and nearly 200 articles. She is editor of Fundamentals in Assistive Technology, 4th ed, and clinical editor of NRRTS Directions.
Eric Grieb, ATP, CRTS, OTR/L, earned a BS in occupational therapy from Colorado State University in 1992. He has worked in the clinical subspecialty of Seating and Wheeled Mobility for the last 20 years as a clinician and supplier of complex rehabilitation technology. For more information, contact RehabEditor@allied360.com.
1. Brown L, Lange M. (June 2013) Tracking Technologies: a Phase 1 Study to Validate Efficiency. In Mobility Management. 2013;(June): 24-25. A summary of these results can also be found at www.atilange.com under Resources.
Innovation in Manual Wheelchair Design
by Kirsten Davin, OTDR/L, ATP, SMS
Through the last several decades, manual wheelchair design has evolved from the once heavy, cumbersome steel frame that was difficult to self-propel and transport, to today’s variety of lightweight aluminum and titanium alloys. As improved materials came to the forefront, wheelchair users were offered greater variety, including the introduction of ultralight options, folding and rigid frame options, sport chairs, and more.
Within recent years, wheelchair users have had the luxury of selecting either rigid frame wheelchairs, often used for sports, and designed for increased energy transfer efficiency, shock absorption, and durability for high-intensity activities, or ultralight folding frame chairs, which provide ease in transport, load/unloading, and self-propulsion for everyday users. Choosing between a rigid and a folding frame design was often difficult, since both offered significant benefits and each design provided its own specific advantages. However, thanks in part to engineering innovation, today’s wheelchair users can enjoy rewards that represent the best of both structural types.
Only recently, as manufacturers continued to push the envelope on design, has the seating and positioning world been introduced to an ultralight-weight manual wheelchair concept that combines the benefits of rigid frame styling with the convenience of folding frame design. Formed from titanium, these ultralight wheelchairs employ one-piece side frames in contrast to the typical two- or three-piece side frames that generally are bolted together. These innovative one-piece side frames serve to reduce flex and energy loss at the junction sites while amplifying energy transfer with each push and providing maximal durability, all while often ringing in at a frame weight of less than 13 pounds. This durability and strength, coupled with a user-friendly folding mechanism, provides the user with a powerful new combination of stability, performance, and versatility.
Another positioning option that is quickly growing in popularity is the utilization of a horizontal tilt system. Standard tilt systems may be used to tilt the wheelchair user posteriorly to aid in repositioning or pressure relief, yet the concept of horizontally tilting seating systems have come to the forefront in recent years and continue to grow in popularity. More specifically in the pediatric arena, horizontal tilt systems can benefit the user by accommodating for significant spinal asymmetries or scoliotic presentation, as well as allow the user to adjust the lateral position of the seating system to offset visual field deficits and, as a result, improve functional capabilities and the performance of activities of daily living.
In addition to wheelchair design enhancement, the technology associated with the perfect wheelchair fit has also evolved. For decades, wheelchair users, therapists, and equipment providers all have been aware of the benefits pressure mapping can provide in assuring proper fit. Not all facilities were able to implement this valuable tool, however, since the costs associated with purchasing a pressure mapping system could be a barrier for organizations with limited budgets. Recently, however, clinically based pressure mapping systems have been developed by startup companies that aim to provide pertinent data for seating and positioning at less expense than some of the market’s more established technologies. The emerging technologies are being positioned to expand accessibility to pressure mapping systems beyond seating clinics and large healthcare affiliates. They are built to provide utility that includes enabling individual mobility users to ensure proper seating position within their personal mobility devices, as well as monitor air cushions. These systems also aim to offer inpatient hospitals and skilled nursing facilities economical tools to improve balance and posture, perform self-righting activities following stroke, or as a biofeedback tool on the orthopedic floor that ensures compliance with postoperative weight-bearing restrictions.
As technology continues to progress, and yesterday’s concept becomes today’s reality, wheelchair users find themselves with more user-friendly and performance-enhancing features than ever. Additional exploration of these simple design adjustments and an implementation of the newest, most innovative design can reap prodigious benefits in efficiency, wellness, and personal independence, offering the wheelchair user unparalleled luxury and safety.
Kirsten N. Davin, OTDR/L, ATP, SMS, owns Escape Mobility Solutions LLC, Pleasant Plains, Ill, and specializes in wheelchair seating, positioning, and assistive technology provision. She conducts continuing education seminars and lectures nationwide. Davin also is a staff occupational therapist at Memorial Medical Center, Springfield, Ill, and on faculty at Rocky Mountain University of Health Professions, Provo, Utah. For more information, contact email@example.com.