RE H A B CAS E S TUDY
PROBLEM SOLVING WITH ELIO
Written by: LINDSAY ALFORD, BSC.OT
“Mr. X is sliding out of his wheelchair!” “Mrs. X is always leaning to her right!” Undoubtedly, these are examples of referrals that many of you have received. This is a common initial description of the problems that initiate a new referral. Although a clear problem is present and may also pose a safety issue, this is not enough information on which to base equipment recommendations. All too often, equipment changes are made prior to adequately breaking down the problem. We are quick to put on a pelvic belt or a deeper backrest because, of course, we want to help our clients and are eager to fix the issue. But if we do not identify why the current equipment set up is not working and determine the actual source of the problem, we frequently end up chasing the problem, rather than solving it.
FIGURE 1
Elio attempting to propel using both hands and feet in current wheelchair.
The first step to solving a problem is identifying why it is happening. Completing a full seating assessment allows us to identify the physical and functional issues and the product parameters needed to overcome these issues. Most often, when a seating system and/or wheelchair are not working for a user, it is because there is a mismatch between the current parameters of that equipment and the client’s physical or functional issues and needs. To demonstrate this, meet Elio.
FIGURE 2
36
DIRECTIONS 2021.3
Elio demonstrating how he accesses his tablet from the current wheelchair.
Elio is a 48-year-old man with spinocerebellar ataxia (Type 3), a progressive and degenerative genetic disease, who lives in supportive housing. He has
his own suite with daily caregiver support but is alone for periods of time during the day and likes to spend his time watching videos on his tablet. He has bilateral upper extremity spasticity and poor coordination as well as bilateral lower extremity weakness and spasticity. He performs a stand pivot transfer with moderate assistance and propels a non-tilting manual wheelchair with a combination of hands and feet. He used a power wheelchair in the past but recent cognitive deterioration led to safety concerns and so his team and family decided to discontinue use of this base. Elio has impaired speech and is difficult to understand verbally. He can use a letter board and has used an iPad App for communication in the past but was not using this at the time of referral. He is an easygoing guy with a fantastic smile!
PROBLEMS IDENTIFIED IN THE REFERRAL: • Neck pain, especially when accessing laptop or iPad. • Sliding forward in wheelchair, frequently to the point of falling out of the wheelchair. • Leaning to right, causing right upper trunk pressure/pain. • Skin breakdown on coccyx. • Swallowing concerns related to neck position.
TARGETED OUTCOMES IDENTIFIED DURING THE ASSESSMENT: • • • • •
Reduce pain (neck and right trunk). Prevent falls. Heal coccyx wound. Improve safe swallow. Improve independent access to iPad for leisure and communication. • Maintain independent wheelchair propulsion. Elio identified that it was a priority for him to be able to foot propel.
ASSESSMENT IN WHEELCHAIR: The photos illustrate Elio’s equipment and positioning in his manual wheelchair at the time of our initial assessment. In Figure 1, he is shown attempting to propel using both hands and feet. In Figure 2, he is demonstrating how he accesses his tablet, which at home is placed on his small dining table.
