While the wheelchair concept in its simplest form — a sitting platform on top of wheels — is hundreds of years old, power wheelchairs are, of course, much more recent inventions. More recent still are the sophisticated electronics systems that make it possible for wheelchair users to drive independently, to operate power positioning options such as tilt and recline, and even to operate communications devices or environmental controls.
What they lack in lengthy history, power chair electronics make up for in creativity and innovation. Today’s electronics and power chair driving controls offer more choices, flexibility and options than any of their predecessors. But in a world where consumer electronics such as smart phones and portable computers are updated on a seemingly constant basis, power chair electronics users expect their systems to keep pace.
That brings up the crucial question: What will tomorrow’s power chair electronics be like? What functions will be most critical for them to have? And how will complex rehab technology providers and seating& mobility clinicians keep up?
To discuss the current and future states of power chair electronics, we called on industry experts who are among those on the front line of the electronics evolution:
- Mike Babinec, OTR/L, ABDA, ATP, product manager, Invacare Corp.
- Christopher Ligi, national sales manager, Switch-It
- Hymie Pogir, marketing specialist, Permobil
- Lisa Rotelli, director, Adaptive Switch Laboratories (ASL)
- Mike Rozaleski, ATP, product manager/medical mobility, Curtis Instruments
Q: What Will Providers & Clinicians Want Next?
The first question for our expert panel asked — based on current electronics and power chair driving controls — what they anticipated seating & mobility providers and clinicians will want from the “next generation” of systems. What functions would be most important?
The recurring theme here: Simplicity is crucial.
Curtis Instruments’ Mike Rozaleski says, “I believe providers and clinicians would like to see simplified programming and diagnostics. The myriad of programming options are necessary, but with lower reimbursement, providers and clinicians are looking for mechanisms to lower cost while maintaining a high level of care/service. Providing a quicker, easier way to program and diagnose problems with the wheel-chair will help ensure that time can be spent focusing on the client instead of the equipment.”
Christopher Ligi of Switch-It says seating & mobility professionals will want electronics that are “definitely more time efficient and more intuitive.” Electronics with intuitive programming are important, Ligi explains, because “This is something that providers will not be doing every day. They may do power chairs every day, but they may not do a head array every day.”
He says electronics system diagnostics “have certainly come a long way, but there’s still a ways to go. You’ve got an error code that can still mean 10 different things, so I think the next level of diagnostics will have more specific error codes and then along with that, programming. Some systems are more intuitive than others.”
Mike Babinec, Invacare Corp., agrees that an intuitive setup is critical — as is ensuring that electronics systems also continue to pay attention to the basics.
“The current evolution of power wheelchair electronics has made it possible for the driver control to do much more than simply drive the chair or operate powered seating,” he notes. “Programming features to fine-tune driving performance are on the increase as well. In spite of this evolution in process, first and foremost, providers and clinicians — and power wheelchair drivers — will need the next generation of power chair electronics to continue to drive the chair well, smoothly and reliably, in all environments. It almost doesn’t matter what else the chair is capable of or the electronic features it has if it drives poorly, easily veers off course or stalls at everyday obstacles.”
Providers and clinicians alike, Babinec adds, “want the programming and setup of these future systems to be simple and intuitive, with minimal steps required. Systems that are too complex to set up are also susceptible to setup errors, or end up not set up optimally to meet drivers’ needs. Components and features need to be either easily added or already built in as part of the system. Additional driver control options beyond those available today will also be a necessity to better meet users’ needs for independent and safe access to mobility-related activities of daily living.”
Because ASL does so much pediatric business, Lisa Rotelli notes that her perspective on what clinicians and providers want may be a little different.
“But all the time, we get asked for things to be different for kids versus adults,” she explains. “For example: Kids may not read yet, so it would be great to have programmable audio feedback for controls, especially when they’re learning to drive and then once they are also doing other things than driving, like seat functions or Bluetooth output. All displays need to be good color and easily managed.”
Rotelli says, “There still seems to be a debate, for us in this field as well as general society, as to how integrated all our systems should be — like, our phones also being our cameras, our e-mail, etc., yet still have things separate, as some of the Bluetooth even available today is not so seamless or reliable.”
She says truly easy and reliable “mousing” for the computer is needed: “Electronics today provide some of that, but it’s not always able to work. It will be a challenge to keep up, since technology in the big world is changing so rapidly. So I think the industry really needs to look at how we interface with current technology and have included in our electronics easy ways to interface with it.”
Permobil’s Hymie Pogir suggests a checklist of improvements in several areas: “Overall electronics and electrical systems reliability; trouble-shooting capability; display visibility in bright light conditions.”
Pogir also casts another vote for the importance of overall simplicity. “Reduce the number and size of boxes — modules — and cables,” he says, “and generally simplify setup and programming.”
That setup’s appearance, Babinec adds, will likely evolve as well: “Aesthetics is as important as it ever was, if not more so. Components will need to be smaller, but still accessible. Integrating and hiding the wires on future wheelchair electronic systems will be helpful. Wireless switches and components will help even more, and in some cases offer additional mounting options for easy access by the driver. The need for wireless programming access to the chair for setup and upgrades will grow over time, but we’re not quite ready for that to be the only option for programming.
“Modularity of components will be important to allow providers and clinicians to meet anticipated drivers’ needs, but building features into the electronics to minimize the need for additional boxes and wires will be equally important.”
Q: What Will Consumers Want Next?
In answering what clinicians and providers will want most from tomorrow’s electronics, Ligi pointed out that some existing functions aren’t currently being used “based on a lot of different reasons, from funding to understanding and education, to exposure.” He adds that some providers worry that enabling certain functions of electronics systems, such as the ability to load and display family photos, could backfire if providers receive urgent phone calls for help every time a client wants to download new images from their digital cameras.
Despite that understandable concern, our experts did think those sorts of functions would be high on consumers’ wish lists.
“Increased integration of personal lifestyle needs,” Pogir says, “such as music, phones/communications, control of household electronics.”
Rozaleski says, “Power wheelchair controls have come a long way in the last decade with their ability to not only provide superior power chair performance, but also interface with off-chair devices, such as computers and TVs. I expect that the next generation of wheelchair controls will continue to follow the trend of offering access to affordable consumer electronics, providing the client with additional independence by leveraging these technologies.”
“Consumers/clients need to have choices,” Rotelli says, “But whether all things could be reliably and easily controlled through a chair’s electronics still remains to be seen. And more importantly, how much will it cost?”
Rotelli also questions whether or not all consumers will want the same thing: “Some folks need chairs they can get around in to manage their environmental controls themselves, while others would like to have things ‘built in.’ Most importantly, the TV and phone are biggies. This is still a controversial issue in the real world: How much should we have ‘smart’ appliances, or should we have a ‘central’ brain controller? And what happens if their system crashes? Is everything then not functional?”
In trying to figure out how to make more all-inclusive-control systems more financially viable to providers, Ligi says, “Maybe it needs to be designed in such a way that when something breaks down, it’s specified as medical versus non-medical.” For a house call on a “nonmedical” function such as trouble-shooting or repairing the part of the electronics system that runs the DVD player, Ligi suggests providers in the future might be able to collect a service charge, “just like calling the Geek Squad.” And he admits that even current technology won’t be fully used if doing so is going to cause financial hardship to the provider… not to mention that tasks such as programming electronics systems to turn the air conditioner on takes away from other, clinically based priorities, such as making sure power positioning controls are working properly.
Babinec says improved access to daily technology “will be a given. Future systems will need to be capable of much more than operating the chair. Improved computer access is a good example. Many power wheelchair electronics systems now have and are improving this capability. Future systems, though, will require better access to the more portable PC Tablet devices with WiFi or Bluetooth that can stay mounted on the wheelchair, accessible at all times for the user. Imagine the function many Internet applications can bring to the power wheelchair driver if they have this with them at all times.”
But Babinec also cautions, “First and foremost, future systems will need to be simple to operate, simple to use, easy to understand — for the power wheelchair driver as well as the caregiver. Adding both basic and advanced features and capabilities to power wheelchair electronics has much less value if the power wheelchair driver has difficulty accessing them quickly and consistently.”
And in that same vein of remembering the basics, Pogir adds that consumer wish lists for the future will include “reduced size of standard joysticks and improving visibility of displays.”
“Simpler displays for the driver to read and understand will always be in demand,” Babinec says. “Expect many of the newer displays to be in color.”
Q: Mini Joysticks: When Does Size Matter?
Electronics aren’t the only systems constantly improving, of course; there seems to also be an ever-growing number of choices in driving controls, including alternatives to the standard joystick. Mini joysticks in particular seem to be on the rise, as providers and clinicians realize that size can indeed matter for clients with more complex needs.
So we asked our experts: When and why could a provider or clinician opt to try a mini joystick or some other joystick variation?
Says Pogir: “Utilization of joysticks other than the ‘standard’ remote joystick is typically based on access and location needs. If the driver needs the joystick mounted in a location closer or higher or more midline as examples, the standard joystick probably is not physically suited for such relocation, and other options have to be utilized.”
“The mini joystick,” Rotelli says, “was originally for chin control… then it was — and primarily works best — for clients who have degenerative weakness and limited range of motion. It has really made the difference in keeping these clients driving proportionally.
“The size is appealing for pediatrics, and some clinicians choose it without realizing the fine motor control needed for its use. And the finite programming the chair needs to make them drive smoothly can make the chair feel non proportional. Its mounting position has to be flexible to place it where it’s needed for a client who has very limited range. Standard joysticks in general are not very flexible for mounting or even for resting; this makes the use of alternative joysticks more important.”
Rotelli and Ligi — whose companies manufacture alternative drive controls of various types — both emphasized the need for providers and clinicians to be familiar with the differences among such controls. And sometimes, those differences can be relatively subtle.
“Our ‘mushroom’ joystick is not so sensitive and can be managed by a child,” Rotelli says. “However, I would not necessarily call it a mini; I would call it an alternative joystick. Joystick variations are generally used for clients who have only hand control left, but the control they have is good — like clients with muscular dystrophy and ALS. So flexibility in mounting is truly an accommodation to the range of motion available to the client.”
Ligi says, “Other mini joysticks out there (require) much less throw than a standard joystick, but the (Switch-It) MicroPilot takes it even further, where it’s virtually no throw. So that increases its applicability to SMA, etc. It’s just based on minute pressure, so it’s applicable for strength or fatigue issues.”
He says strength and range-of-motion difficulties would be the two main reasons mini joysticks could be considered. “Then a secondary one, besides mounting flexibility, is access point — where you put it. It’s just really easy to get a mini joystick into tinier places than you could even with a compact joystick.”
While mini joysticks are most often associated with chin or hand use, Babinec points out, “Some… can be used for lip and tongue control as well. Not all mini and short-throw joysticks are the same. Some take less force than others to operate, but these also offer more challenges when driving outdoors or in rougher terrain. Some may require slightly more force to operate than others, but may have other features, such as a built-in mode switch. It is important to look at a big picture, and match the features of the joystick — with the needs and abilities of the driver — to the environments to be traversed. When evaluating for mounting locations, positioning for release off the inductive is just as important as positioning for control and operation of the inductive.”
Q: Switches: For Some Users, the Best Choice
In the imagined or real hierarchy of drive control choices, switches sometimes are seen as less desirable than proportional controls of various types. But our experts pointed out that’s not a fair assessment.
“Any driver control an individual is able to successfully use to operate their mobility device automatically becomes elevated from second or third choice to the best choice,” Babinec says. “For many individuals, using proportional driver controls with non-discrete speed and direction control offers more maneuverability over that of digital or switch driver controls. Key here is the word ‘many.’ It is not ‘all’ individuals.
“Some drivers using switch systems such as proximity head arrays, fiber optic switch systems, and even sip and puff systems operate their mobility device with much more accurate and safer maneuverability skills than those of some joystick drivers. Switches, when chosen appropriately and positioned correctly, are easily accessed, easily activated, easily released and easily distinguished from each other regarding directional control. These are important considerations when evaluating for powered mobility. Switch drivers generally drive at slower speeds, but different driving speeds are attainable in digital systems through use of latched driving or changing drive profiles. Correcting veer for a switch driver when driving forward is a challenge for some, but often made easier through proper programming of the system.”
Pogir says, “Selection of a non-proportional driver input is based on matching the driver’s functional and cognitive skills to the most appropriate technology. Often a non-proportional input will provide the technology that maximizes driver capability, so it is not a choice between best or second best, but rather a choice of ‘best for the purpose.’
“In addition, the adjustability of driving parameters and the driving algorithms behind non-proportional inputs have become so effective that a non-proportional input can provide a performance similar to a proportional input.”
Asked when a switch system may be more beneficial or preferred to a proportional system, Rotelli says, “Kids, kids, kids! Instead of 360 degrees of control and the further you displace it from neutral the faster it will go, switches control one direction only. This makes it very predictable and consequently easier cognitively to learn to manage mobility.
“Mobility can then more transparently become driving with experience, which may or may not lead to joystick use. The real question is not proportional vs. non proportional, but must be what kind of control — of fine motor and hands — the client has, and how much experience in mobility the client has. Managing 360 degrees of movement is not easy for the inexperienced.”
Rotelli adds that the beneficial nature of switches isn’t relegated just to the very young: “Even ALS clients love using switches when they know they have predictable control, but this is usually by using proximity sensors at the head, which means they still can drive. You can’t just discuss proportional versus non proportional. You have to consider how the non-proportional system is set up and the chair programmed and how the client is taught. This discussion of proportional vs. non proportional is usually only made by folks with little clinical experience with kids and adults who have very complex needs. After all, no one had this discussion for sip and puff users, who by the way are nonproportional users, but who can use a latched mode.”
“Essentially,” Rotelli adds, “if the client has excellent hand control and can rest her arm on an armrest, she is a candidate for a joystick. Switches have typically been used for those who can’t use a joystick. Here at ASL, obviously we deal with alternative access, and I would have to say that if you know how to program a chair adequately, you can drive really well with switches. With kids, it’s really wonderful to see them learn to drive, especially those kids who have ‘failed’ opportunities to drive with a joystick. Or to see kids or adults with a brain injury who were thought not smart enough to drive, be able to drive. It would really be great if therapists and suppliers (who are new were) to present clients with options instead of presuming that a joystick is always the best and that switches are not.”
Q: How will tomorrow’s electronics improvements make life easier for tomorrow’s providers and clinicians?
Finally, we asked how the ongoing electronics evolution can benefit providers and clinicians, who are certainly under pressure from multiple sources to accomplish more each day, perhaps with fewer resources.
Says Rozaleski: “Flexibility and customization. Today’s electronics can be tailored to the needs of a specific individual on site. PC-based programming tools simplify setup and allow providers and clinicians to store commonly used configurations, providing them with the opportunity to quickly change wheelchair performance characteristics and add specialty input devices. Additionally, expandable electronics allow the chair to be reconfigured to meet clients’ changing needs.”
Pogir notes, “Electronics — driving, seat function control, communication and control of devices on chair and off chair — are smarter and more capable than ever. They are easier to access and adjust.” He adds that evolving electronics “provide better tools that enable practitioners — ATPs, clinicians, etc. — to deliver better outcomes.”
Rotelli says of this question, “Manufacturers have been trying to figure this out for years. Some think that therapists, suppliers and clients should be able to manage their own electronics, and we here at ASL really believe that. But industry wide, many suppliers believe they should have control of programming, and this has been a real problem, as then therapists think they aren’t supposed to know how to program. We really need to change this.”
She adds, “Many of the manufacturers have come up with memory cards, etc., hoping that this might help the client to manage her chair. But in reality, remote programmers should be an automatic part of the package when powered chairs are purchased. The programming needs to be friendlier, less ‘engineer-like’ language. I’m not sure we have enough ‘evolution,’ but we need ‘revolution’ here.”
Ligi relates the question in part to the earlier discussion about providers who are hesitant to enable power chair electronics to control personal communications or environmental systems, because they fear their time will be monopolized by “Come sync my iPod to my power chair” demands. In addition to providers potentially charging for those sorts of service calls — “a cash opportunity,” Ligi says — he adds, “What I think manufacturers need to move to: Letting some things be done by the user or family, as opposed to everything having to be done by the RTS.”
While greater functionality can spawn new questions — such as who exactly is responsible for a house call if a power chair user can’t figure out how to use his joystick to open his living room drapes — Babinec says ultimately, more functions are a good thing.
“The number one benefit of the evolution of power wheelchair electronics to providers and clinicians is the increase in the number of options available to meet the needs of their customers — their patients,” he says. “This is true both from a product standpoint and a feature standpoint, as well. There are technologies and controls today that did not exist even five years ago. The function, safety and independence this brings to the everyday lives of those dependent on this technology is truly priceless.
“This increase in options is for both modular components easily added to the system, as well as built-in features. This increase in options has given the provider and clinician the flexibility to build a system and customize it to match the needs of their user. While increased options can sometimes mean increased complexity, the evolution has brought even easier trouble-shooting to the picture, as some systems will provide text explaining not only what fault or error has occurred, but what to do to correct it on the spot. Although these are helpful for the provider and clinician, it is the power wheelchair user who ultimately benefits.”
And as the final word on electronics, Babinec says, “It is important not to forget the first commandment about power wheelchair electronics: Thou shalt not evaluate for, nor talk of power chair electronics, without addressing seating first. The best programming, best driver control selection and mounting, and latest software upgrades cannot substitute for incorrect seating and positioning.”