ATP Series: Case Study

No More Compromises

• Jun 01, 2016

Life is a series of compromises, Gandhi said. Of course, there are also times in life to say Enough is enough.

That was the situation when it was time to assess client A.B. for a new power wheelchair. She’d sustained a C5-6 spinal cord injury as a very young adult, and in the following years had built a career with the Kentucky Office of Vocational Rehab and lived independently.

In addition to A.B., the seating & mobility team consisted of Cindy Ramsey, ATP, Numotion; William R. Mattingly, OTR/L, ATP/SMS, Quantum Rehab; Crystal Simpson, MS, ATC/L, ATP, Norton Neurosciences & Spine Rehabilitation Center; and Brittany Rowe, OTAS. A.B.’s power chair — with power tilt and recline, plus manual swing-away footrests — was more than five years old, in poor condition and no longer capable of meeting her physical or functional needs.

During the assessment process, the team determined that A.B.’s chair was missing some important opportunities to maximize its owner’s health and independence. “She used the tilt and recline feature of her chair,” the team notes said. “However, without leg elevation, she was not able to effectively reposition herself, manage her lower-extremity edema, or fully redistribute pressure while using the chair. She had ongoing unstageable pressure ulcers that required flap surgeries for closure. In addition, A.B. had a unique way of using an upward force on her armrests to assist with postural support and upper-body positioning/stability for participation in her activities of daily living (ADLs) that we had to respect and incorporate into the system.”

As the team continued to talk, it became apparent that again and again, the current power chair compromised A.B.’s abilities to function optimally and independently. For instance, A.B. drove to work from her power chair, but had a full-time personal care assistant (PCA) to assist with transfers and ADLs at home, at work and in the community. Both her home and office environments were adapted to enable A.B. to reach what she needed to from her fixed wheelchair height. But these arrangements were far from optimal.

“She is an effective joystick power wheelchair driver, and her home and work environments were accommodated such that everything was placed down low for her in a chair with a static seat-to-floor height,” the team said. “However, she was not fully integrated into the workplace, nor was she able to realize her full potential in performing or participating in her ADLs without access to the vertical environment.”

That made A.B. more dependent on her PCA than she needed or wanted to be. She was stuck at a fixed height in her chair, while the height of the surfaces she needed to reach varied greatly. Bed, toilets at home and at work, dresser, closet, washing machine, kitchen shelves, office desk shelves, refrigerator, microwave…the list went on and on.

“As a result,” the team said, “her PCA performed or assisted with all of A.B.’s tasks, many of which we felt she had the potential of performing independently with the proper technology and training.”

An Uncompromising Solution

To enable A.B. to be more independent, the team considered a power adjustable seat height system, in addition to power tilt/recline and power elevating legrests or a power articulating foot platform.

In addition to A.B.’s desire to reach different heights from her chair, the team had to consider that the chair needed to function in tight quarters at home and at work.

“The overall width of the system posed a challenge,” the team said. “During the evaluation process, we initially chose a cantilevered-style armrest with inset brackets to achieve the narrowest system possible while allowing redundant tissue to be accommodated in the open space underneath. These had to be changed to a set of dual-post flip-back armrests [after] delivery to allow for continued functional use of her power mobility device in the manner she was used to.

“Turning radius and maneuverability of the chair in tight spaces at home, work and in the community were also a concern. As a result, a power articulating, elevating foot platform was chosen over power elevating legrests, as it not only allowed her to move in much tighter spaces, it also provided much better postural support and stability of her legs. In addition, she is able to elevate her legs for effective edema management without a loss of her supported position in the chair.”

The finished system was a Quantum Rehab Q6 Edge 2.0 power chair with dual-post flip-up armrests, TRU-Balance 3 power tilt, power recline, power articulating foot platform, and the iLevel power adjustable seat height system operated through the Q-logic 2 joystick. A custom-configured backrest reduces dependence on the armrests for sitting posture, stability and function.

Ripple Effects

The success of the new system has positively impacted A.B.’s full list of daily activities.

The team noted, “Power tilt, in combination with power recline and a power center-mount articulating, elevating foot platform, has allowed A.B. to independently reposition herself following transfers, manage her clothing post toileting, and effectively reduce pressure over the seated surface, especially at the skin flap site, to reduce her risk for the development of another decubitus ulcer.”

The iLevel power adjustable seat height system enables A.B. to maneuver among the different surface heights — from shelves in the grocery store to the stove in her kitchen — she encounters every day.

“Without iLevel, A.B. was not able to complete daily toileting activities at home or work without assistance due to the uneven surface heights that existed,” the team said. “By adjusting the height of her seat using iLevel, transfer training and modified transfer techniques, she is now able to complete these activities at an independent level.”

Ironically, A.B. works with people who have disabilities and discusses the reasonable accommodations needed in their workplaces. But she was struggling, the team said, in her own work environment. “To accommodate her limited reach, her desk was a ‘mess’ and unprofessional looking, as she could not store anything on the inaccessible shelves or in the inaccessible cabinets above it,” the team said. “Her employer feels that providing iLevel has empowered her to perform eye-to-eye communication as a model for her clients and adds value to her as an employee. Not only can she reach and access the area above her desk and make her own copies at the copy machine, but she is also a much more commanding speaker for the department behind the microphone as well as in person.”

A static seat height meant A.B. could drive to the grocery store, but couldn’t reach shelves independently, and couldn’t cook meals by herself at home. The newly adjustable seat height offered by her iLevel system now means A.B. can prepare meals and eat independently, and can dress herself as well. She can even do her laundry independently.

In the end, A.B. and her rehab team decided the time for continual compromising was over. Rather than A.B. needing to conform to her environment and forgo so much independence due to a static seat height, they chose a system that gave A.B. the flexibility to reach higher.

“After final adjustments, A.B. was able to decrease her need for an assistant at work and at home by being able to complete more ADLs independently,” the team said. “She also achieved a level of social interaction in the community she never thought was possible due to iLevel power seat elevation.

“Access to the vertical environment is vital for a truly successful client outcome. One shouldn’t assume that limitations are fixed limitations. A.B. indicated her new power wheelchair, with all of its improvements, gave her independence that she hasn’t felt in over 14 years.”

This article originally appeared in the June 2016 issue of Mobility Management.