Page 23 - Mobility Management, May 2017

is giving an opinion. It’s my job to take those parts and try to figure out what’s optimal for this person. Another thing I like to do — and this is why I think multiple \[assessment\] visits are really important — is maybe in the first one, everyone is there. And then in the second one, it’s just me and the person that’s getting the chair. Then he can say, ‘My mom says this, but I really want to do this.’”
The Mat Evaluation
After one or more conversations about goals and priorities, it’s time for clinical observations. “I like to look at what they’re sitting on now, and see how they propel,” Merring said. “I need to see: What does their pelvis do, what does their spine do, how strong are their arms, can they propel or not, how strong are their legs? And then I seat them on the mat: What is the shape their pelvis takes, the spine takes, the rib cage takes, when gravity starts to take effect? If you have a very tall \[client\] and a very short one, gravity may affect their thoracic spines differently.”
Merring also uses that time to discuss aches and pains potentially related to self propelling.
“As I’m doing my mat assessment, if I’ve gotten a good history, I can say, ‘I see you’ve had some minor shoulder issues or moderate shoulder issues in the right shoulder. I’m going to move your arm: Does this hurt?’”
Having a family member present can be helpful to this part of the process, Merring noted, because “A lot of times, people
in chairs have accommodated for so long that they think \[discomfort\] is normal. Maybe \[a family member\] says, ‘I see you grimace’ or ‘Three or four times a week, you do complain
of shoulder pain when you’re going to bed.’ That extra set of eyes can give you the data you need to help determine what this person could use.”
Pressure Injury Considerations
Pressure injury risk is always a concern for wheelchair users, and therefore is a critical consideration when choosing between power and manual mobility.
“If a person wants manual mobility and they have a history of pressure injuries,” Merring said, “I have to make sure I’m helping them optimize their seating system so that they can have the best cushion and the best postural support. People sometimes forget that an open back angle can increase pres- sure over the sacrum. A scoliotic curve that’s not corrected can increase pressure over an IT \[ischial tuberosity\]. So the cushion is important, the backrest is important, how they sit in their current seat is important.
“After all that, can the person do the pressure reliefs that they’re supposed to be doing frequently and adequately? If they can’t, I may start leaning toward power tilt, or if they’re really pushing for \[manual\], I start talking about a training program or a maintenance program so they get some feedback. We’ll
do our evaluations with pressure mapping, and it’s incredible that when you put a pressure map under
someone and have them lean to the right, lean to the left and lean forward, you can see that even
without completely pushing up, you can clear all pressure from underneath each IT just from leaning
left and right. We’ll use that for training also. If the person really wants manual, has used manual and has
an issue with pressure relief — then after we’ve made sure the seating system we’re going to order is optimal, we’ll use
pressure mapping for some additional training.” Merring also observes the client’s shear risk during
the assessment.
“When I do my mat assessment, I get my initial picture of
what it’s like for this person to do a transfer,” he said. “I get a baseline, because they’re usually transferring from one surface to another level surface. If I see a little bit of struggle or a little
If you collapse that space, you are inhibiting the ability of the scapula to do upward rotation
bit of drag, I may have them repeat it. And if time allows, I like to see how they get in and out of a car, as well. Are they drag- ging, are they lifting? Do we have to think about floor-to-seat height because the car transfer is a major transfer or the toilet transfer is a major transfer?”
SCI & MRADLs
So when the conversations have taken place, the mat eval is finished, the pressure injury history has been considered — what ultimately determines whether power or manual mobility is better for a given client?
“The mobility need for people with incomplete cervical SCI will depend upon the completeness of injury and subsequent strength,” Merring said. “Lower cervical spine injuries will depend upon their upper body and postural strength post injury.”
And while the power vs. manual question commonly comes up for lower-cervical SCI, Merring said that isn’t the only scenario.
“Something I’ve been considering more lately are people with higher thoracic injuries secondary to the extent of compromised postural strength and the effect that has on the shoulders during propulsion and other issues,” Merring said. “Postural strength
is an important aspect of wheelchair propulsion that can be overlooked. Impaired postural strength can be improved by providing optimal positioning with ergonomic seating through the frame, cushion and backrest. Improved postural position improves a person’s ability to propel, allowing for someone with compromised muscle strength to possibly propel a wheelchair if it is optimally configured.”
Continued on page 30
MobilityMgmt.com
MOBILITY MANAGEMENT | MAY 2017 23