Linda Norton

Providers with genuine mobility experts on staff are able to add another level of value for clients and ultimately the entire business. Your experts know that power wheelchairs offer clients with physical disabilities increased independent mobility. But with this increased independence comes responsibility. Is the client a safe and responsible driver? The choice of equipment type, drive control, drive wheel location, and seating all contribute to a client’s functional abilities. Power mobility choices are also influenced by environment, activity level, and transportation options. Determining the best prescription starts with a thorough assessment.

Ideally, the power mobility device is an extension of the person, and this requires a holistic assessment. The client’s physical status, diagnosis, tone, history of pressure ulcers, and range of motion will influence the decision as to what seating is most appropriate, the type of mobility device, and the type of control.

Determine optimum sitting posture before deciding whether power mobility is appropriate for a particular client. Optimum posture can be described as when the client has the most function, is comfortable, and is in a position to prevent future deformities or injuries. After determining optimum posture, identify the seating products/systems that will support that posture. Only when the client is optimally seated should the decision be made as to whether this client can physically operate a power wheelchair, because this optimum position tends to facilitate improved functional movement. Some clients who once were not considered power mobility candidates became excellent power mobility users when their posture was optimized.

When the client is optimally seated, check whether they can reliably access a joystick, and where that joystick needs to be. For complex clients, a joystick not mounted or connected to the chair can be useful because it can be freely moved to find the best location for the client. At this time, consider the support (arm trough) the client needs to access the joystick. If the client can not access the joystick, test alternative controls such as head arrays and single switches. Once the best location has been determined, the challenge becomes mounting the device.

After determining initial access, consider fatigue. Although the client is able to drive using the method determined above, it does not necessarily follow that he will remain consistent throughout the day. Some clients may fatigue and require an alternative control later in the day. The type(s) of controls may have an influence on which power mobility device is most appropriate because not all devices are compatible with alternative controls.

When clients have a diagnosis that is progressive, such as multiple sclerosis, it is important to identify expected changes in functional status and accommodate them within the mobility device. Clients may experience decreased strength and postural control as their disease progresses, so choose a power wheelchair that can be modified with alternative controls, and a dynamic seating system.

Scooters and More
Clients who are ambulatory but experience fatigue during the day, have a history of falls, or have difficulty with outdoor mobility may benefit from a scooter. Clients need to have a good dynamic sitting balance, good range of motion, and strength in at least one arm and hand. Although scooters are primarily for outdoor use, with sufficient space some clients can use them successfully indoors.

Clients who are manual wheelchair users, but are experiencing repetitive strain injuries—or decreased upper extremity strength—may benefit from power assisted wheels. These wheels essentially allow the user to go further with each push of the chair. Although adding a significant amount of weight to the chair, many clients prefer this option to a power chair because the chair continues to have the characteristics of their manual chair (foldable), and they can still put on their old “manual” wheels when needed.

A Symbol of Disability?
After the assessment, it may be apparent that the client would benefit from power mobility; however, the client may be resistive. Clients may view power mobility not as a device that improves independence, but as a symbol of their disability. According to the Canadian Association of Occupational Therapists, approximately 30% of assistive devices are abandoned by users. One of the frequently cited reasons is that clients do not feel as though their opinions were considered. To avoid equipment abandonment, it is important to listen to clients’ concerns, provide education about the advantages of power mobility, and encourage clients to try the device for a period of time.

Cognition and Safety
Cognitive deficits have an impact on the client’s ability to safely operate a power wheelchair. For clients with memory deficits, learning to use an alternative control can be difficult. When a disease is progressive, one approach may be to introduce alternative controls before cognitive abilities deteriorate. Often these learned skills will be preserved and the client will be able to continue to use the alternative controls.

The biggest question often is: Can this client be a responsible, safe power mobility user? For clients with impairments of judgment or lack of impulse control, power mobility may not be the best option.

One way to determine safety is through a power mobility driving assessment. Many clinicians are using informal assessments, and making a clinical judgment as to whether the client is safe. Other tools such as the Power Indoor Driving Assessment (www.fhs.mcmaster.ca/powermobility/pida.htm) and the Power Community Driving Assessment (www.fhs.mcmaster.ca/powermobility/

pcda.htm) are also available. These tools help to ensure a consistent approach but do not recommend a pass/fail score. They are useful though in directing which areas need to be addressed to improve safety.

It is important to distinguish between an “unsafe” power mobility user and one who chooses to engage in unsafe operation. Some clients may do well on a driving assessment, but choose to act in an unsafe way. This creates a stressful situation for providers and leads to questions regarding responsibility and liability. If the client is competent to make decisions, it may not be appropriate to limit their access to power mobility, even if they make poor choices. Documenting that clients are able to drive safely, and that they have been instructed regarding safe driving, is important, particularly where there is concern over the client’s future choices.

Another useful distinction is the client who can do well on a driving assessment, but tends to have safety incidents at other times. These clients may do well in “test” situations when their focus is on the skill of driving, but not during day-to-day activities. One way to assess this is to distract the client during a driving assessment. Carry on a conversation and see if it has an impact on driving ability.

If the client appears to be unsafe, is it a matter of choice, accessibility of the environment, chair speed, or other driving parameters? Before discounting power mobility for a client, check to see if any of these can be modified to improve driving performance.

Linda Norton, OT, is rehabilitation education coordinator for Shoppers Home Health Care, an HME provider in Ontario, Canada. Norton has presented workshops across North America on seating and mobility and pressure ulcer management. She can be reached via e-mail: lnorton@shoppershomehealthcare.ca.