Power Mobility: Indications and Benefits

• Power mobility is a continuum that starts with assisted ambulation devices like canes, crutches, walkers, and gait trainers, progressing to manual wheelchairs, power-assisted systems, and ultimately, power mobility devices like scooters and power wheelchairs.
• Clients can move along this continuum based on their individual mobility needs, using one or more methods.

Indications for Power Mobility

• Power mobility is suitable for individuals of all ages, including pediatric, adult, and older adult populations.
• Users can range in age from 2 to 95 years old.
• Power mobility can be used by individuals with various disabilities and diagnoses, including cerebral palsy (CP), spinal muscle atrophy, muscular dystrophy, osteogenesis imperfecta, spinal cord injury, COPD, arthritis, ALS, and MS.
• Power mobility is not limited to certain ages or diagnoses.

Benefits of Power Mobility

• Power mobility provides a wide range of access, including elevation and standing functions, and is suitable for different terrains.
• It promotes mobility and independence.
• It can decrease caregiver stress and burden.
• It enables role enablement, participation, and socialization.
• It offers health benefits such as offloading pressure, managing tone, and addressing breathing issues.
• Power mobility conserves energy.
• It enhances self-esteem and confidence.
• It can improve employment rates and decrease the impact on the healthcare system.

Occupational Therapist (OT) Role in Power Mobility

• In Alberta, pediatric cases are often addressed by Physical Therapists (PTs), while older adults are addressed by OTs, though this isn't always the case.
• OTs assess if a client can benefit from a power mobility device and has the skills to use it safely.
• The OT role includes ordering the device, determining its features, providing documentation, following up, and managing incidents.

Power Mobility Device Continuum: Manual Wheelchair Power Assist Systems

• Three types: those that attach to the front to pull, those that attach to the rear to push, and those that attach to the hub of the rear wheels.
• Benefits include increased mechanical efficiency, reduced risk of repetitive strain injury (RSI) by decreasing upper extremity ROM and stroke number.
• Power assist systems decrease metabolic demands associated with manual propulsion, conserving energy.
• They increase average speed traveled and improve the ability to climb inclines and control speed downhill.
• They can increase the overall width and weight of the wheelchair.
• Additional force may require practice to control.

Scooters

• Scooters are driven using handles on a tiller for steering.
• Depression or pulling a lever activates forward and reverse movement.
• Scooters can have 3 or 4 wheels and can be front or rear-wheel drive.
• Speed can be adjusted.
• Seats may swivel to assist with transfers, and some models fold for transport.
• Scooters are often used to increase distance or range and conserve energy.
• They are often used outdoors or in open indoor spaces, though small indoor spaces can be challenging due to a poor turning radius.
• Scooters can be more affordable than power wheelchairs.
• Certain models are easier to transport than power wheelchairs.
• Clients should be able to transfer independently or with limited assistance.
• Clients should have good seating balance to maintain posture while reaching forward and with limited seating support.
• The client should have the physical ability to steer the tiller and depress or pull a lever to activate forward/reverse with hand control.

Power Wheelchair Drive Wheel Configuration

• Drive wheel configuration refers to the placement of the tire that provides drive and power.

Front-Wheel Drive

• The drive wheels are in the front, and casters are behind the client.
• Front-wheel drive can aid in climbing obstacles.
• This configuration supports environmental access, as the client is positioned forward; however, the turning radius is quite large.
• It can be difficult to keep the chair moving in a straight line, especially when going fast on uneven surfaces (prone to fishtailing).
• It may be challenging to learn to use, because the client must become accustomed to the length of the wheelchair behind them.
• Front-wheel drive is suitable for individuals who need to be engaged in an environment in front of them (e.g., students).

Mid-Wheel Drive

• Drive wheels are directly under, and casters are also directly under.
• It is harder to clear obstacles, and the chair can pitch more on uneven terrain.
• Turning radius is smaller, which provides greater maneuverability.
• Use is more intuitive and easier to learn.

Rear-Wheel Drive

• Drive wheels are behind, and casters are in front of the client.
• Rear-wheel drive is able to navigate uneven terrain, but the ride can feel bumpy.
• Large turning radius and length of casters/footrests can make indoor use challenging.
• This configuration provides more directional stability at high speeds because most of the chair's weight is over the drive wheels.
• It can take time to learn, similar to pushing a shopping cart in front.

Power Wheelchair Features to Consider

• Seating and positioning systems
• Access technology
• Interfacing capabilities
• Electronics
• Programming options
• Equipment additions
• Not every chair has every feature.

Power Wheelchair Types

• Travel or compact power wheelchairs
• Basic power wheelchairs
• Complex power wheelchairs
• Unique PMDs
• Self-driving PMDs with detection systems and brain-computer interfaces

Seating and Positioning Systems

• Seating and positioning are critical for ensuring the function, comfort, health, and safety of the PMD user.
• Seating systems can be off-the-shelf or custom.
• Clinicians must ensure that seating products fit with the power wheelchair frame being recommended or ordered.
• If a client requires an assessment for a new seating system through a seating clinic, the clinician should ensure the frame is coordinated with the seating assessment to ensure an appropriate match between the frame and seating system.

Considerations for Power Wheelchair Seating

• Does the client feel secure when using a PMD?
• Is the client's visual field maximized for PMD use?
• Are the client's hands free for accessing the joystick?
• Is the client's tone controlled, or does tone activate with the exertion of PMD use, negatively impacting access to the joystick?
• The client's tone: Is it controlled, or does it activate with the exertion of PMD use?

Power Positioning (Actuators)

• Power tilt
• Power recline
• Power elevating leg rests
• Power seat elevation
• Power standing

Power Seat Elevation and Standing

• Power seat elevation and standing can increase independence and function through greater access to the environment.
• They can potentially reduce caregiver hours and the level of assistance needed.
• They can improve social interactions, allowing the client to engage with the world at eye level.
• These features can improve safety and visibility within the community.
• Standing can reduce pain, protect the skin, and decrease the risk of joint deformity.

Power Positioning Drawbacks

• Power positioning options have potential drawbacks.
• Power recline can cause increased shearing if not used at the proper angles with the right type of seating components.
• Power elevating leg rests can increase the overall seat to floor height of the chair and prevent environmental access.
• Power elevating leg rests can be heavy and hard for caregivers to remove.
• Power positioning options increase the overall cost of a PMD significantly and can be costly to repair.

Access Technologies

• A standard joystick is the most common way to operate a PMD, but successful use may be impacted by multiple factors.
• Alternative options include finger control, chin control, head array, switch array, sip and puff, and brain control interface.
• Access technologies include tracking technology.

Gyroscopes and Voltage Meters

• Gyroscopes or voltage meters can assist in correcting the client's direction of travel without requiring them to make compensatory adjustments.
• They may help over difficult terrain or on different inclines where the chair would normally stray from its path.
• These features are useful for clients with declining or limited use of a standard joystick, especially those using alternative access tech.
• They can reduce the number of movements and overall time for the client to get from point A to point B, which may benefit motor effort, fatigue, and client frustration.
• These features are not standard on all power wheelchairs and clinical justification is required for funding through AADL.

Interfacing

• Some power wheelchairs do more than just move; they can also activate information communication technology, environmental control units, and augmentative communication devices.
• These power wheelchairs have an environmental control module integrated into the joystick of the LCD screen, allowing the client to interact with specific menus with a variety of devices.
• IR tech or Bluetooth are used.

Electronics of Power Wheelchairs

• Hardware and software of the chair impact what the wheelchair is able to do and how information is displayed.
• Non-expandable electronics allow for the operation of the power wheelchair through a joystick, but limit the ability to add power positioning features.
• Fewer drive profiles are available and there is no capacity to integrate with assistive technology (AT).
• Expandable electronics allow operation through a joystick or specialty controls.
• Multiple actuators can be controlled through driver input.
• More parameters are available for programming, and the system can be interfaced with AT.

Programming of Power Wheelchairs

• Programming involves adjusting parameters in power wheelchair electronics to improve how the client drives and responds to input commands.
• Power wheelchairs come from the factory with pre-set programming, or trial chairs are programmed for other clients.
• Reviewing the programming for the current client is important at the outset.
• Programming requires access to manufacturer-specific handheld programmers or computer programs.
• Some sites purchase their own programmers, which takes knowledge and practice; contacting a vendor for support is recommended.
• It is recommended that the client try the chair with clinician supervision after the programming changes have been made to ensure safety.

Equipment Additions

• Consider what also needs to be added to the wheelchair: ventilator, O2 tank, IV poles, tube feeds, or communication devices.
• Remember the overall weight capacity of the chair, which must account for the weight of these additions along with the client's weight.
• Consider the chair's center of gravity to ensure these additions do not cause the chair to tip.

Power Mobility Device Assessment and Provision Process

• Clients may have impairments with the potential to impact PMD skills, such as vision deficits, spatial impairments, uncontrolled reflexes or tone, and cognitive impairment.
• Incidents may lead to client or public injury, WCB claims, property damage, and automobile accidents.
• Falls, collisions with objects, collisions with cars, and rolls/tip-overs are common.
• Ask yourself: is power mobility the most appropriate option for your client at this time?
• Analyze risks and barriers to effective use.

Assessment: Part 1 (Client Evaluation)

• No gold standard exists to determine whether a client is a safe PMD user.
• Assessment can include the impact of medical diagnoses and medications, as well as basic physical, visual, perceptual, cognitive, and behavioral abilities.
• Assessment is based on function and measuring actual performance, not just capability.
• Assessment reflects the diversity of individual driving requirements.
• Assessment and processes should be standardized and applied consistently.

Client Assessment: Possible Components

• Interview
• Review of medical/behavioral stability
• Physical screen
• Vision screen
• Perceptual screen
• Cognitive screen
• Behavioral screen
• Summary/recommendations

Assessment Process

• Provides a consistent process, but is not a recipe.
• It is meant to guide clinical reasoning to select components that adequately assess individual client needs.
• Each section may be completed in varying degrees of detail depending on the client’s individual areas of impairment.
• Hearing, vision, perception, and cognition may be assessed for their impact on skills

Summary and Recommendations

• No single assessment or screening tool can be used in isolation to determine fitness to use a PMD.
• Tailored to the client
• Scores are integrated to get a complete picture of the client and guide next steps

Recommendations Based on Assessment Findings

• Proceed to PMD trial.
• Have follow-ups or interventions prior to proceeding to PMD trial.
• Proceed to PMD trial with parameters to support successful intervention.
• Use a mobility device as an alternative to a PMD at present.
• If PMD use is not recommended, alternative solutions for mobility and occupational participation can be explored with the client, family, and healthcare team.

Other Considerations

• Clinician Education: The clinician should have adequate education and experience to complete the PMD and provision.
• Guidelines and policies: The clinician's place of work should have PMD guidelines and policies.

Driving Skills Assessment in PMD Provision (Part 2)

• Clinicians explore PMD selection and features that meet specific needs and goals in collaboration with the client.
• A PMD trial and driving skills assessment gives the clinician the opportunity to see the client in action in various functional environments; it is an opportunity for exploration, problem-solving, and information on the PMD.
• Wheelchair sizing and dimensions use the same guidelines as with manual wheelchairs.
• Prior to the trial, know the client's budget, educate yourself on funding agencies.
• Present financially-realistic options based on coverage.

Driving Skills Assessment: Outcomes

• An assessment can determine if a PMD is the "best mobility fit" for the client’s current level of function.
• The need for further training or environmental modifications to support successful intervention can be identified.
• The assessment can determine whether the PMD selection needs to be "tweaked" or modified to better match the client’s needs.

Training

• A facet of PMD use often becomes highly underutilized.
• Training users are important to enhance safety, driving performance, and satisfaction.

Possible Training Topics

• Getting on and off the PMD safely.
• Orientation to the PMD itself (on/off, speeds, horn, manual/drive).
• Directional concepts (stop/go, right/left turns).
• Functional concepts (approaching tables, bed, toilet).
• Indoor spaces (hallways, doorways, elevators).
• Outdoor spaces (sidewalks, curbs, weather).
• Public spaces (driving in crowds, adhering to signals and signs, adjusting to traffic).
• "Safety plan" for emergency situations.
• Where to go for repairs or if equipment malfunctions
• Sometimes family, caregivers, or staff require training as well

Training Objectives

• The goal of training is to optimize performance and support safety.
• Requires considering personal, environmental, and occupational factors and implementing a targeted approach.
• Techniques can include trial and error, hand over hand, verbal and visual cues, chaining, games, grading, and demonstration modeling.
• Completion of training sessions is based on skill level and confidence.

Incident Management and Research Themes

• Solutions focus on reasonable risk-taking instead of eliminating risk altogether.
• A power mobility user’s need for mobility is balanced with the rights of others for safety.
• Incident management can include systematic methods for documenting unsafe use of a PMD or responding to specific concerns.
• Emphasize problem-solving to allow users to maintain their mobility.

Incident Management Process

• The severity and cause of the incident determine what actions are needed.
• Not all incidents are serious enough to assess the client's PMD use or require a PMD's removal.
• Immediate attention is necessary for physical injury to a PMD user or others; significant property damage; the weaponization of a PMD; use while impaired by drugs or alcohol; or a pattern of repeated incidents.