Lecture 5: Assistive Technology: Orthoeses and Wheelchairs Flashcards
Assistive technology professional - a service provider who analyzes the needs of individuals with disabilities, assists in the selection of appropriate equipment, and trains the consumer on how to properly use the equipment. Certification requires passing an examination and paying a fee
quizzes are only on slides speciicied in sylabus
Seating and mobility specialist - advanced certifiction for those who already have assistive technology professional certification
PT/OT/SLP
Documentation - letter of medical necessity, details the clinical justifcation specific to the patient and each component being requested (ex - armrests, leg rests, or wheels) and provides the clinical justifcation for funding by insurance companeies or other payers. Final decisions are the right and responsibility of the pt and/or caregiver
slide 42 wheel chairs (Skipped)
Device applied to the body designed to
* Stabilize or immobilize
* Prevent deformity
* Protect against injury
* Assist w/ function
Orthosis
A wheelchair is an orthosis on a mobility base
wheelchair allows pt to achieve
* Stability
* Controlled mobility
* Skill
For a wheelchair
chairs can look very different depending on the functional of the pt
Goals of proper seating and positioning
* Promote function
* Prevent deformity
* Improve body alignment
* Prevent tissue damage
* Prevent additional complications
* Minimize energy expenditure
* Promote function
* Reduce discomfort
* Maintain trunk stability
Potential secondary complications of wheelchairs - so all this stuff can lead to additional complications
* Decreased sensory awareness - if they arent hving full sensation can develop pressure uclers (these are preventable)
* Limited ability to alter position
* Decreased subQ sotft tissue - especially over bony prominences - can lead to pressure ulcer
* Impaired peripheral circulation
* Abnormal skin integrity
* Exrended periods of sitting
going to actaully need a prescription to get a wheelchair
can do an outcome measure like 6mwt to show they need a wheel chair = additional documentation
types of devices
manual = hands on wheels
power assist drive = goes in back and makes it a power chair
be familiar w/ components
note: not every chair has all these
note: armrests can be different between chairs
Note: the small wheel is called the caster
* large wheeel is the primary means of locomotion
* anti tippers = if someone tried to go into a wheelie in this chair it won’t let them go all the way bakwards (provides some saftey)
heel loops = sits heel nicely
cross bar = normally where were putting the saftey belt
how do you measure for seat height?
* How far should the foot plates be from the floor?
* if too high what happens
* if too low what happens
Measure from the user’s heel to the popliteral folt and add 2 inches to allow clearance of the footrest (if a seat cushion is used, do not add inches)
The foot plates should be at least 2 inches from the floor to allow clerance for wheelchair mobility - don’t want to scrape that pedal
If its too high
* insufficient trunk/arm support because back unholstery too low
* Difficulty positioning knees beneath table or desk
* Difficulty propelling because of difficulty reaching hand rims or floor - difficulty reaching around side
If too low
* Difficulty performing transfers
* Poor posture, excessive trunk/hip/knee flexion
* Risks for pressure ulcer at sacrum or ischial tuberositites
seat width
* how to measure
* if too wide
* if too narrow
Measure the widest aspect of the user’s buttocks, hips, or thighs, and add approximately 1-2 inches; this will provide space for bulky clothing, orthoses, or clearance of the trochanters from the armrest side panel
If too wide
* difficulty propelling with UE’s distance to hand rims increased - hard to reach
* Difficulty performing lateral transfer-need to move body over greater distance - beacuse you have further distance to go
* Difficulty moving through narrow hallways or doorways or using public restroom facilities
* Postural deviations-increased tendency to lean to side for support - lots of gaping and stuff
If too narrow
* Difficulty changing positions - insufficient space needed for adjusting
* Increased contract w/ armrest panel-excessive pressure at greater trochanters
* Difficulty wearing bulky outer garments, orthoeses, or braces
Seat Depth
* measure
* Too short
* Too long
Measure from the user’s posterior buttock, along the lateral thigh, to the popliteral fold; then subtract approximately 2 inches to avoid pressure from the front edge of the seat against the popliteal space
Too short (front to the back)
* Decreased trunk stability-less support under thighs
* Increased wt bearing on ischial tuberosities
* Poor sitting balance based of support has been reduced
Too long (front to back)
* Increased pressure in popliteral area
S/S of decreased circulation in LE
* Ankle edema
* color changes in toes, feet, or legs
* Decreased sensory response to surface stimuli
* Loss of hair follicles
so if someones in a wheelchair and not used to it this can happen
Sling or Hammock seat
* how long do they use this?
* because of the sling they’re sitting in what happens at the femurs, pelvis, head pos
Short term temp use
internal rotation of femurs
posterior pelvic tilt
Forward head position
tendency for pelvis to slide forward
Transfers may be more difficult
they’re essentially in a bucket
What are our 5 kinds of seat cushions?
* how often do they need pressure relief
* how long should that pressure relief be
* Do you need a cushion if your a long term user?
1) Foam
2) Air (inflatable cushions)
3) Gel
4) Fluid
5) Hybrid
May reduce or eliminate negative outcomes
Elevates person in chair
* Difficult to position chair under a table
* Difficult to use armrests for support
* Alters support from back upholstery
* May require footrests to be adjusted up
Require careful handling to prevent damage
Does not provide adequate pressure relief alone - still need frequent position changes
all long term uses require a cushion
Pressure relief
* every 15-30 minutes (fell)
* For at least 15 seconds
* pressure relieving techniques
whatever works best for pt
would all have covers on them
flat foam = least expensive, easist and simplist
* won’t provide lots of pressure relief
* replaced more frequently
* its just simple
Contoured = shapes thighs and bottom better
* inexpensive, basic
Fluid = less stable for pt
Air filled = light wt, different cells,
gel = could leak and is heavy
* expensive
Hybrid = gel plus foam
everyone needs a cushion for pressure relief
knowledge check: person who is new to using a wheel chair has ankle swelling and difficulty feeling their feet. What do you think is most likely cause
* depth is proably too long
does the cushion itself provide pressure relief?
No, your bottom is still contacting the cushion - you actaully need to be moved
i think it does help to some degree
knowledge check: which wheelchair seat cushion is for short term use?
* sling (so the seet is essentially like cloth across the wheelchair)
brace = orthotic
purpose of a brace
*stabilize/support
* Aid/assist movement
* Restrict movement
can be permanent or temporary
Named for joints they encompass and motion controlled (EX - ankle-foot orthosis or AFO controls the foot and ankle)
Braces
* improves alignment
* Increasing stability at a joint or segment
* Facilitating weak muscles; inhibiting spastic muscles - if someone has foot drop w/ weak ankle DF, it can faiclitate increased DF (like giving DF’s a quick stretch), can inhibit a spastic m (think seating heal in a pos that isnt going to encourage a big increase in tone)
* Limiting or facilitating motion
* Providing proprioceptive feedback - lets them know where limb is in space
* Stimulating an eccentric or concentric muscle contraction
* Preventing contracture or deformity (i.e., anticipating deformity on the basis of condition, maintaining corrected position after surgery or casting, or correcting mild deformitities)
* Positioniong a body part for optimal function
pt pop were using braces in
this orthoeses are applied to the foot amd palced inside or outside a shoe
Foot orthoses
Encompass a shoe and terminate below the knee
Ankle-foot orthoses
This orthesis extends from the shoe to the thigh
Knee-ankle-foot orthoesis
Is a knee ankle foot orthosis with a pelvic band that surrounds the lower torso
Hip-knee-ankle-foot orthosis
this orthoesis covers part of the torso and the lower limbs
Trunk-hip-knee-ankle-foot orthosis
knee orthosis and hip orthosis cover their respective joints
cervical orthoeses encircle entire neck
most trunk orthoses are named by the motions controlled
Orthoses that manage scoliosis are usually named for the city where they were designed
considerations for braces
we would worry about that energy expensditure diagnosis specifically in MS, cardio impairments,
pre fabricated = can just buy off amazon
Foot orthosis
Goal ideas
* anatomical deformity
* Support arches
* Pain relief
* Creating height in shoe - think leg length discrepency
Patient population - EX
* diabetic injury
* Leg length discrepacy
Considerations
* Hygiene (as with all braces)
* Wear and tear (as with all braces)
Ankle foot orthoesis - solid or rigid
* in rigid you can’t bend it at all
Goal ideas
* Stabilize ankle
* Neutralize foot
* Safety with mobility
* Increased balance
* Increased DF in swing - because pt is sitting in neutral and not moving into PF
pt population - EX
* Foot drop, toe drag, foot slap
* Severe muscle weakness/atrophy
* Hemiparesis/plegia
Considerations
* Limited ROM - near none at ankle allowed
* Limited muscle use - EX = would be push off of plantarflexors (because they’re in neutral)
* There are also semi-rigid AFOs w/ different trimlines
* Can be pre-fabricated (off the shelf)
Ankle-foot Orthoses (AFO) - Articulating or Hinged (means the same thing)
Goal ideas
* Ankle stability
* Allows some ankle mobility (unlike rigid/solid)
* Can be set in certain degree of ROM to assist muscle control (DF/PF assist)
Patient population - EX
* Hemiparesis/plegia
* TBI, stroke, SCI
Considerations
* Wear of hinges
* DF assist - improve foot clearance - helps them into DF
* PF stop: limits knee hyperextension (because PF goes w/ knee extension) - so it stops that knee hypertension which limits genu recurvatum (which is that over hypertension at the knee)
* DF stop: limits knee buckling (remember, DF goes w/ knee flexion)
Ankle-Foot Orthoses (AFO) - Posterior Leaf Spring (PLS)
Goal ideas
* Increased DF in swing
* Increased gait speed
pt population - example
* higher functioning pt
* EX: TBI, stroke
* Unilateral weakness in ability to clear foot
Considderations:
* Can be pre-fabricated (off the shelf)
* Cannot use with high tone - might kick them into higher tone (spasticity - velocity depndent)
theres a small calf peice, and not strap at the malleoli
* this is not meant to be the full length of their foot because we want their toes to do some work
* less resitrictive = more mobility for pt
* also this cannot be for a pt w/ ankle instability because theres nothing on here to stabilize the ankle. more for DF in swing
Ankle foot orthoses - Carbon Fiber
Goal ideas
* increase DF in swing
* Improved push off in gait cycle
* Less restrictive, allows muscle control
* Dynamic brace
Patient population - EX
* higher functioning pt
* DF weakness
Considerations
* May not be appropriate for high tone pts - because might trigger spasticity / no support at ankles
do increases DF swing
where band is depends (can be on front/side)
least resitrictive = most muscles can be active w/ this brace
* need some affinity for dyanmic balance to use this brace
Ankle-Foot Orthoses (AFO) - Ground or Floor Reaction
Good ideas
* Increase DF in swing
* Increased stability in standing
* Increased balance
Patient population - Example
* Looking for stability - MS
* Can often see this brace bilaterally
Considerations
* Anterior shell adds bulk and heat
more for pt that needs stability in standing
* more bulky
* lower functioning pt that needs icnreased stability
* has malleoli support - showing that the whole idea w/ this is increasing support
* often used bilataerally because they’re unstable bilaterally
Ankle-foot orthoses (AFO) - Conventional or Double Metal upright
Good ideas
* Increased DF in swing
* increased balance
Patient population - EX
* pt w/ LE edema or skin concerns - part of what makes it unique
Considerations
* attaches directly to shoe
litteraly fasioned to one pair of shoes, so pt has to use same shoes all the time = bad side
should not provide and AFO if goal is to improve tone/spasticity (and FES)
* we use all those tehcniques we learned prior
AFO’s more for gait pathologies / strength issues / decrease stiffness
FES = often for stength problems
afo = use to improve gait / mobility
AFO used for lower gait speed
FES = for faster walkers where you can rely more on their muscles
estem / bracing often combined
using AFO’s early can enhance progress
AFO = faster gait speed because if they can push off foot they can walker faster
FES = applied to fibular/peroneal nerve (because anterior tib is innervsated by this)
knowledge check: ehst motion would adding a DF stop limit?
* DF goes w/ knee flexion, so knee flexion would be limited (would help decrease knee buckling)
Knowledge check: Which of the following braces is not recommended in a pt w/ high tone?
* posterior leaf spring (or carbon fiber one)
Knee ankle foot orthosis: so now the knee is encompassed as well as the foot and ankle
Goal ideas
* adds more knee control
pt population ex:
* incomplete SCI w/ some LE function - this is more L2/L3 injury
Considerations
* Bulk
* Donning/Doffing
* Lock versus unlocked
* Hip hiking - because this knee joint is locked out unlocked. If its locked then they have to hike their hip and bring it around to advance it because they’ve lost knee flexion which is needed for foot clearance in swing phase
so brace would be unlocked for things like sitting
Hip-Knee-Ankle-Foot orthosis adds in that hip control
Goal ideas
* adds more hip contorl
Patient population - example
* Requires more stability than KAFO or AFO
* Lower thoracic/lumbar incomplete SCI - because were now stabilizing at the hips
Considerations
* Locked versus unlocked
* Hip hiking
Trunk-Hip-Knee-Ankle-Foot ORthosis
Goal ideas
* Adds lumbar/thoracic support
Patient population - example
* Lower thoracic SCI with trunk/LE involvement, incomplete
Considerations
* Bulk
* Donning/Doffing
* Clothing
Reciprocating gait orthosis
helps w/ movement
helps faciliatte central pattern generator
Other - Knee and Ankle Braces
Goal ideas
* athletes
* support of arthritic change
* Decrease pain during ADLs/leisure activities
* Neuro?
Patient population - example
* Ankle sprain
* Knee surgery
* Neuro?
Considerations
* Off the shelf versus custom-made
* Donning/doffing, abiding by ROM restrictions post OP
note: adding afo changes proprioceptive input
* alters normal movement
Trunk Orthoses - SO/LSO
LSO - Lumbar-sacral orthosis - think belt for SI joint
SO - sacral orthosis
double edged sword because they might become reliant on it and actaully weaken their core - note AFO’s dont do this
Goal ideas
* immobilize or limit movement in spine
PAtient population - example
* Post-op spine surgery (SCI, TBI)
* During certain activities
* Blood pressure regulation
Considerations
* To wear or not to wear
* Associated core weakness
* Reliance
* Donning/doffing
Trunk Orthoses - TLSO
TLSO - thoracic-lumbar-sacral orthosis
Goal ideas
* limit movement after spinal surgery
Patient population - EX
* post op spine surgery
Considerations
* Donning/Doffing - very hard
* can’t be seated to put this on, must be supine
* because they have spine issues and can’t bend
typically post op
cervical orthosis
notice the aspen collar
wont correct but may prevent worsening
typically mostly OT
Bracing:
Pros:
* Increased independence w/ ADLs, Leisure activities
* increased safety w/ walking, transfers, sit to stand, ADLS
* Increased balance
* Pre-fabricated options
* Gain vs loss
Cons:
* weight of brace
* Cost
* Maintenance
* Donning/doffing
* Patient compliance
* Hygiene
* Limiting factors/concerns
* May need to wait for brace to be made
* Gain vs loss
Back height for wheel chair
Measure from the seat of the chair to the bottom of the axilla with the users shoulder flexed to 90 degrees, and then subtract approximatey 4 inches; this will allow the final back height to be below the inferior anglex of the scapula
* NOTE: this measurement will be affected if a seat cushion is to be used; the person should be measured while seated on the cushion, or the thickness of the cushion must be considered by adding the value to the actual measurement
Low back to maximize function
May require/desire traditional higher back for safety, stability, and support
Too high
* difficulty propelling chair
* Excessive irritation to skin over inferior angles of scapulae
* Difficulty with balance-trunk inclined forward
Too low
* decreased trunk stability
* increased postural deviations
Arm rest height:
Measure from the seat of the chair to the olecranon process with the users elbow flexed to 90 degrees, and then add approximately 1 inch
* NOTE: this measurement will be affected if a seat cushion is to be used; the person should be measured while seated on the cushion, or the thickness of the cushion must be considered by adding that value to the actual measurement
If too high
* Propelling-difficult to reach over armrest to grasp hand rims - difficulty propelling
* Difficulty using armrests for transfers - because it might get in the way
* Postural deviations-elevated shouldrs when resting forearms on armrest
* decreased trunk stability and fatigue
If too low
* Poor posture
* back pain
* Decreased balance
* Difficulty w/ transfers - not an adequate push off
Types of arm rests:
Fixed armrests
* permanently attached to chair frame - makes transfers hard because they’ll actually have to stand up and pivot, won’t be able to do sliding board transfer etc…
* Recommended for those performing standing transfers
* only if no need to remove arm rests
Removable Armrests: - much easier for transfers
* Recommended for users who perform lateral scoot, squat pivot, or sliding board transfers
* Some pivot up when unlocked
Desk or cutout armrests
* Want to position wheelchair close to a permanent surface such as desk, table, sink, or countertop
* Usually can be reversed to improve support when for standing transfer
Adjustable armrests
* Need to adjust armrest height for different activities
* Cushions with different thickness or bulky outer garments
Leg Length
Footplates too low
* increased pressure on distal posterior aspect of thigh
* Lack of footplate clearance-unsafe
Footplates too high
* Increased pressure to ischial tuberositites
* Difficulty positioning chair beneath table or desk
TEST S/s of decreased circulation in LE’s
* Ankle edema
* Cholor changes in toes, feet, or legs
* Decreased sensory response to surface stimuli
* Loss of hair follicles
Measurements: - wheelchair - normally taking measurements on plinth/matt - not actaully going to be in WC
pt seated on hard surface for measurement
* seated in wheelchair on level surface for confirmation of fit
Wear usualy clothing - including shoes
Cushions or other components need to be in place - because it changes measurements
Patient sits erect with pelvis in contract with back upholstery - need to be in normal seated posture
LEs on footplates/leg rests
Bottom of footplate at least 2 inches from the floor
Measure:
1) Seat height
2) Leg length
3) Seat depth
4) Seat width
5) Back height
6) Armrest height
7) Footplate length
Confirmation of Fit
* Chair on level, smooth surface
* Patient sits erect with pelvis in contact w/ back upholstery
* LEs on legrest
* Bottom of footrest at least 2 inches from the floor
* Let the patient try it - let them actaully move around in chair
What is a standard wheel chair seat width
16-20 inches
What is a normal standard wheelchair depth
16 to 17 inches
What is a normal standard wheelchair back height
16 to 19 inches
What is a normal standard wheel chair seat height?
17-19.5 inches
What is a normal standard wheelchair armrest?
9 to 11 inches
HOw much weight can a standard wheelchair support?
250-350 pounds
biartric wheel chair = for bigger pts
Inward angle of the drive wheel relative to the vertical position?
Camber
basically the top of the wheels are angled in, increasing the BOS
If the WC has high camber what happens to the wheels at the bottom?
Wider at bottom more narrow ontop (increase BOS which is why they use these w/ sports)
* increased camber improves a wheelchairs stability and agility and reduces shoulder strain during propulsion
What kind of lock is this?
Toggle lock (push or pull locks) (pull up to unlock, push down to lock)
* Pushing forward or backward
* Extension can be attached-poor trunk control or limited function of an UE - makes it longer and easier to reach from the contralateral UE (extension not shown)
What kind of lock is this?
Z or Scissor Lock
* Beneath chair seat
* Must be able to reach under seat
* Propulsion w/o interference from lock
have to be able to bend and get underneath - needs trunk stbility / ROM
* so used when you dont want to worry about that lock on the side of the chair getting in the way
What kind of lock is this?
Auxiliary lock for a reclining back chair
* Release back
* Attendant needed - so need someone else unless custom electric WC
this is in the back of the chair and releases it back
* this is for someone who has someone push them
* someone must help them w/ this unless electric
What kind of lock is this?
Hill climber
* Prevent WC from rolling down a hill/incline while propelling up (stops from rolling backwards)
In the past, manual wheelchair locks have been referred to as” brackes”. However, some wheelchair users assumed that wheelchair brakes were to be used to slow the chair, similar to the use of brakes in a car. The use of the term “locks” better conveys the intended purpose of securing the chair
* So you can get sued for saying breaks
Lock extensions - just goes right ontop
Push Rims:
* also called hand rims
Most commonly used means of manually advancing a wheelchair
* Other = power, lever/gears - can be powered or not powered
want the pt to use the rim not the tire
* hygene (not touching ground)
* More smooth and better for the hands
so, they’re the part you’re actually supposed to push
What kind of leg rests is this?
Fixed w/ solid footplate
* cannot be moved
What kind of leg rests is this?
Swing away
What kind of leg rests is this? (taking them off)
Removable (can be swing away as well, but also can just remove them)
What kind of leg rests is this?
Elevating with calf rests and movable footplates
* Push-button adjustments for legrest length are visible along the shaft of the legrest
Elevating LEgrests:
* Entire front rigging can be elevated and maintained at different heights
* Unable to fully flex knees - duh
* Knee flexion must be avoided
* Calf panel attached to legrest - need this to support leg
* Lowering level that releases the adjustment lock
* May need to take pressure off to lower
* Protect LE when legrest is lowered
* LE/LEs elevated - greater tendency to tip backwards
This elevation is not a long term position - think edema where you need legs above heart
What are casters?
Smaler wheels designed to provide stability and to allow directional changes
Location compared to drive wheel will affect BoS
* so can be further back I guess
Vary in size from approximately 2 to 8 inches (5 to 20 cm) in diameter
Large casters create more stability (rough terrain) but are slower and require more room to turn
so casters turn in a full circle and allow directional changes
Different kinds of tires:
Pneumatic (air-filled) - better for outdoor activity
* Light
* Good shock absorption, traction and durability (outdoors)
* Need proper inflation/risk going flat
* Power chairs - sometimes
Foam-Filled
* Less maintenance
* Increased weight
* May be used in power chairs
Solid Rubber - less energy - better indoors - more typical tire
* Requires less energy to propel
* Better indoors
* Typical of standard chairs
types of wheelchairs
What kind of wheel chair is this?
Transport, Depot or Companion Chair (going to call it transport)
* 3 different names
* Designed to be inexpensive, accommodate a large variety of body sizes, and be attendant-propelled (so you can’t push them yourself)
* Not suited to long-term or independent use - these are the ones you’ll often find in hospitals to transport pts
NOTE: theres no big wheel - not long term chair (duh cant push yourself)
What kind of chair is this?
know all areas of chair
Standard WC
* Frames are now lighter in wt and constructed from aluminum, titanium, airplane steel, or carbon fiber reinforced materials
* The standard manual WC box frame is fixed, depending on the model, supports 250-300 lbs
* Bariatric WC frames are typically wider and support 350-850 lbs, although some manufacutres make chairs for up to 1k
This is showing a rigid frame - fully configurable vs non adjustable basic frame
Knowledge check: Which wheel chair tire best for an active pt navigating outdoors
pneumatic
Notice how different the seat is. frame is similar
customized = to adapt to the pt. on the left you can see the one made for an amputee
reclining = axillary lock. Someone would have to push it back for them
* I think reclining is just the seat
lightweight = super light. For higher functioning pts who want more movement. Must have good trunk contorl (small backrest)
* think lower thoracic SC injury (good trunk control)
Notice the camber on the sports chairs
* Small casters = move better
One arm drive chairs - has a power rim (for when someone only has 1 functional UE and limited use of LE) - outer rim = for far drive, inner for near drive
* One functional UE, limited functional use of LEs
* Two hand rims attached to same wheel
* outer, larger rim propels far-drive wheel
* Inner, smaller rim propels near-drive wheel
* Both hand rims simultaneously-chair propelled straight
* Use of one hand rim independently causes chair to turn
* Heavier and more difficult to hold than standard chair
Hemi wheellchair similar to one arm drive. One side is for propulsion. The wheels look different - less on less involved side where they’re dpendent
Semi and fully reclining chairs
* Vertically to fully horizontal
* Adjustment knobs or levers side of back frame
* Headrest and elevating leg rests required
* Rear wheels more posterior - to prevent LOB
Only the back rest goes back
Tilt-in-space WC
Adjustment at various angles and can be wheeled with the user positioned at any angle
Entire chair able to tilt
opposed to reclining chair this one has tilt on the entire chair
great for MS pts for pressure relief - if they could adjust on their own they could use the other one. This is for when you really need pressure relief
* the reclining WC should be used for more longer term users (who can adjust on their own) - however, if they’re a long term user you dont want to have to sit up all day - so use that chair just to lay back for comfort
Externally powered WC - not always w/ joystick - need hand contorl for that
Insufficient strength or motor control of extremitites to propel standard chair
Front, mid or rear wheel drive
Various controls
* Head
* Finger
* Chin
* Head
* Tongue
* Mouth
* Eye gaze
wheel position can change per chair
Scooter
W/ falls you should do what first? (from WC’s)
* what else do you do?
Tuck the head first to protect it
then cross the arms, with the hands placed on knees pushing them away (to prevent knees from coming into face) - they may not have contorl of legs if they’re in a WC
