Page 30 - Mobility Management, March 2019

ATP Series
Fighting Fatigue
Fatigue in Power Wheelchair Users
Complex rehab power chair users have additional tools that can help mitigate fatigue.
“For clients in a power chair, it’s critically important that they’re using their power features because sometimes they’re not,” Wenzel said. “If they were to use the tilt and the recline power features to their advantage, they could conserve energy. That’s a big thing, energy conservation. If I’m in a chair, what can I do to conserve energy so I can do my ADLs [activities of daily living] and the job duties I need to do?”
Wenzel believes in helping clients to conserve energy as much as possible as early as possible — though he acknowledged that fatigue can be a tough concept to pin down
Repositioning via tilt and recline can provide temporary relief for power chair users who find sitting upright to be hard work. “With tilt, you’re changing where the pressure is on your body, changing it to your back and posterior side of your body rather than on your bottom,” he explained. “Then recline can help open up the angle, and it does make you feel better. When you sit all day, you’re fighting gravity. When you’re sitting up all day, if you don’t have the musculature to maintain an erect sitting posture all day, you’re going to get tired. If you have the ability to tilt and recline, you can use gravity to your advantage and conserve your energy for the activities you want to do.”
“We still provide static positioning when we should be looking at more dynamic positioning,” Sayre said. “I’m a firm believer in using tilt and recline in conjunction with one another. I know some therapists use only tilt. But I believe the more positioning we can offer with recline and tilt, the more we can accommo- date. We need to do a better job of teaching that, [so] a person can accommodate that fatiguing and then go back to being functional.”
Anyone who’s ever been stuck in an overly long business meeting already knows the value of being able to change posi- tions occasionally.
“What we change instinctively when we’re sitting in a meeting — we’re changing positions, we’re leaning on our elbows on the table — we don’t allow [consumers] to do that in their chairs,” Sayre said. “But we can allow them to do that if we give them the appropriate armrests, or tilt and recline — opening up the recline and tilting back a little bit and just giving them elevating legrests. Different positioning to allow the body to rest in certain areas for less fatigue.”
It’s also important to make sure power chair users can continue to access their power seating options even if they do
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fatigue. “To do that and be functional,” Sayre said, “requires different accessories, like switch access and controls. I would always try to do an assessment in the morning, and then try to bring them back and do the fitting in the afternoon, because I would see such a difference in the person. In the morning, if they had a good night’s sleep, they were well rested and they had a lot of control. But in the afternoon, as time went on, they tired out. Their whole posture became so different, and this was not the same person I had seen.”
Sayre has accommodated those postural differences by offering multiple controls: a joystick to use most of the time, but a secondary control such as a head array that would still be acces- sible to the user once fatigue set in.
Or the intervention “can be something little, like an elbow block, a secondary positioner,” Sayre said. “You put the elbow block there on the armrest, and she knows her arm is never going to fall backward.” Even when the client is fatigued, the elbow block keeps her arm in place so she’s able to reach the positioning controls, thus eliminating the very real fear of getting “stuck” in tilt or recline and being unable to come out of it.
Sure, there’s also the option of recommending that clients prone to fatigue only use their powered seating when someone else is nearby to assist. “But that’s not autonomous,” Sayre said. “We’re trying to keep this person as independent as possible. Everyone wants to be as independent as possible.”
Funding to Fight Fatigue
Of course, seating and mobility teams seeking to help clients overcome fatigue must also fight the funding battle.
“We don’t get paid for comfort, and we don’t really get paid for fatigue,” Sayre said. “So how do you prove [the need for the equipment] and make that evidence based?”
Wenzel agreed that justification can be challenging. His suggestions included wording justifications in the present
tense, rather than describing the desired equipment as a form
of prevention. For instance, it’s true that an optimally fit and configured ultralightweight manual wheelchair could prevent future fatigue and all the potential problems that come with it. But the more effective justification route would be to explain how that optimally configured and fit chair will lead to better client outcomes today, rather than focusing on fatigue that might set in years from now.
So documentation might explain how achieving the optimal center of gravity, front and rear seat-to-floor heights, seat width and depth, etc., via an ultralightweight chair is better than a stan- dard manual wheelchair today.
In that case, “You would incorporate [fatigue] and the impact of fatigue as part of the justification,” Wenzel said. “But it’s really the inability to propel a standard wheelchair efficiently: The wheel is too far back, we can’t get enough width or depth or seat inclination. That would be more of the justification for the K0005.”
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