WC Seating Workshop abstract and paper 2016

Schmidt (2016) AATC Workshop 1
AUSTRALIAN ASSISTIVE TECHNOLOGY CONFERENCE 2016
July 27-29th
Surfers Paradise
Collaborate, Empower, Transform - realising opportunities with assistive technology
PAPER TITLE Wheelchair and seating workshop: empowering confident collaborative
approach to appropriate assistive technology selection
Abstract authors: Rachael Schmidt (OT), Yvonne Duncan and Malene Ahern
(Physiotherapists).
ABSTRACT
Procuring specialised wheelchair-seating systems for people with complex mobility needs is
complex. Matching a wheelchair-seating system with the personal needs, goals and aspirations
of the wheelchair consumer takes time and experience. A positive wheelchair outcome requires
access to collaborative services, competent technology prescription and experienced technical
services with access to appropriate technology options. A positive wheelchair-seating outcome
is one that empowers occupational performance, for greater community participation, personal
wellbeing and quality of life of both the person and, their family/caregivers.
The workshop presents the fundamental principles of assessment and prescription – as
informed by the evidence – that encourages person-centred collaboration with all participants
during the procurement process. The workshop content is levelled at early to mid-career
therapists who may prescribe wheelchair and seating systems (occasionally or for the first time)
for children/people with complex mobility impairment.
The workshop aims to cover three discrete themes, as:
1. A theoretical philosophy to underpin evidence based practice of empowering person-
centred wheelchair-seating procurement (including assessment-prescription and
outcome evaluation), participating as a team work to enhance consumer collaboration.
2. Hands on person-centred seating assessment, including a mat evaluation (in sitting and
lying), identifying typical postures to understand the effect non-typical postures have on
seating comfort and function; setting goals and evaluating goals throughout the
procurement process.

3. Initially planned as a three hour workshop, however 90 minutes allocated did not allow
for intended case-based learning activity.
SUMMARY
The workshop content provides fundamental 24hr positioning and wheelchair-seating principles
as a foundation to assistive technology assessment–prescription and providing procurement
services. The strategies provided are for the establishment of your clinical toolbox.
PAPER TITLE Wheelchair and seating workshop: empowering confident collaborative
approach to appropriate assistive technology selection, electronical retrieved from:
https://www.researchgate.net/publication/306108798_Wheelchair_and_seating_worksh
op_empowering_confident_collaborative_approach_to_appropriate_assistive_technolog
y_selection
Paper author: Rachael Schmidt (workshop facilitator)
Overview of workshop content
Australian expert seating clinicians and experienced vendors despair their skill and knowledge
is not being adequately pass to the next generation before retirement or career change
(Schmidt,2015). With this in mind, the workshop aimed to share knowledge with early career
therapists and occasional prescribers of wheelchair-seating procurement (i.e. assessment-
prescription/assistive technology provision-review-training services). These are commonly the
primary therapists - employed by health and disability organizations to provide a range of clinical
and assistive technology services to a diverse caseload (Schmidt, 2015) – who may prescribe
wheelchair and seating technologies occasionally. Designed to build greater prescriber
confidence and skill base, the following presents strategies for building your clinical ‘toolbox’ as
a strategic assistive technology practitioner with a focus on becoming an informed prescriber of
wheelchair-seating technology.
Backgrounding Australian wheelchair-seating service sector
Australia wheelchair-seating (WC-seating) procurement occurs at two levels of service: at a
primary service level (where wheelchair prescription is a small part of general practice and
provided by generic assistive technology suppliers) and at a secondary level i.e. specialized
seating services and expert wheelchair vendors (suppliers and manufacturers) (Schmidt, 2015).

Generic (non-specialist) services tend to use commercially available modular wheelchair-
seating products while specialize services mix modular products with custom-made solutions for
complex postures.
Fact: Wheelchair-seating procurement and servicing are:
 recognized as complex, interactive multi-modal approach consisting of the stakeholders
from both sides of the service equation (consumers, their care providers,
clinicians/therapists, vendors/suppliers/technician and manufacturers) and;
 best practiced within a collaborative person-centred team approach (Di Marco et al.,
2003; Gowran et al., 2012; Kittel et al.,2002; Mortenson & Miller, 2008; Plummer, 2010;
Routhier et al.,2003; Schmidt, 2015; White & Lemmer, 2001);
and as such a comprehensive wheelchair-seating service should be considered as;
 a component of 24 hour positioning management (in seating, standing and lying) as part
of a daily rehabilitation and/or lifestyle routine (Hall & Marshall, (nd); NHS Purchasing
and Supply Agency, 2008).
Aim: The following provides essentials for building your wheelchair-seating toolbox, as a start –
and therefore is not exclusive - based on available evidence as at 2016. The first essential
toolbox item is to learn is thinking as a strategic practitioner.
No 1 essential toolbox item: Become a strategic practitioner.
Definition: Strategic assistive technology practitioners are person-centred, sensitive, curious and
proactive team collaborators. As prescribers, strategic practitioners can confidently advocate
clear need for necessary resources (on behalf of their stakeholders/consumers) and in doing so
can challenge - as creative risk takers – and aspire for the most person-centred capacity
empowering outcome as informed by proactive evidence-based knowledge.
Evidence-based practice: A number of theoretical models/frameworks used within the
assistive technology (AT) are informed by the International Classification of Functioning,
Disability and Health (ICF) based on AT enablement: as in the Matching Person and
Technology (MPT) by Scherer (2008). MPT provides a useful model to guide AT enablement
with its ‘milieu’. The milieu concepts considers the environment in which the AT is applied
including: personal capacity, their bio-psycho-social and occupational lifestyle, the built and
natural physical, cultural, eco-political environments that impact upon enabling function and
performance (Scherer, Craddock & Mackeogh, 2010). For example, a comprehensive

wheelchair ‘milieu’ describes the context in which a person and their wheelchair are used,
by/with whom and for what purposes (essential/necessary, desired and aspirational).
An extension on the ICF framework is evident in an emerging number of wheelchair-seating
service models/frameworks that pin successful wheelchair outcome to personal empowerment:
i.e. to what extent does the wheelchair-seating solution empower personal capability for
meaningful occupational engagement and societal participation (Eggers et al., 2009; Gowran,
2012; Gowran et al., 2012; Mortenson & Miller, 2008; Routhier et al., 2003).
Strategy: as a strategic prescriber apply the following broad ICF enabling principles to
empowering personal capacity as a measure wheelchair-seating success. A wheelchair-seating
prescription should aim for:
 empowering personal capability: optimal comfort, stable support is essential for
functional wheelchair mobility. Seating comfort, postural support and efficient wheeled
mobility are integral to enabling functional capacity, empowering productive participation
and enhancing lifestyle quality (Mortenson & Miller, 2008).
 enhancing personal health & lifestyle wellbeing outcomes: ensure optimal seating and
positioning solutions support for optimal health and systems function across their day
and night activity (Lukersmith, 2012; NSW FAC, 2016);
 enabling and accommodating for growth/change: prescribe a wheelchair system with
some adjustability for postural change during acceptable funding cycle (Arledge et al.,
2011; Batavia, 2010; Schmidt, 2015)
 resisting deformity/pathology and enhance safety: educate stakeholders in 24hr
positioning and pressure care management; ensure carer providers are trained in safe
OHS management and wheelchair is maintained for safe use (Lukersmith, 2012; Neville,
2005; Spinal Outreach Team, 2013).
No 2 essential toolbox item: a strategic prescriber is a reflexive clinical reasoner.
A reflexive clinical reasoner applies theoretical philosophy to support your clinical reasoning and
practice. They engage in proactive and interactive self-directed learning activities that provide
informed information and engage in knowledge exchange. Case-by-case discussion is an
effective way of reviewing your decision making pathways (i.e. clinical reasoning), especially if
backed with relevant theoretic foundation.

 Consider presenting a challenging case study as a conference paper: underpin your
presentation with a searching question to generate audience response/feedback.
Consider a co-joint presentation first time to build confidence: the personal rewards are
worth the effort.
Take time to review your wheelchair interventions, as review feedback assist develop your
clinical reasoning skill. The following evidence-based tools are in current clinical use:
 GAS (Goals Attainment Scale edited by Kiresuk et al., 2014) were variously used to
collaborately plan and evaluate each person-centred session as well as for wheelchair
satisfaction and service effectiveness;
 COPM (Candian Occupational Performance Measure by Law et al,. 1990) was used to
evaluate wheelchair satisfaction;
 QUEST (Quebec User Evaluiation of Satisfaction with Assistive Technology by Demers
et al., 2002) was applied to evaluating both wheelchair and service satifaction.
While the above measures were evident within an Australian context, they are other measures
to be considered:
 WhOM (Wheelchair Occupational Measure by Mortenson et al., 2007) a wheelchair-
specific outcome measure.
 WhOM and GAS were identified by Kenny and Gowran (2014) as a quick, effective
person-centred measure.
 Additional outcome measures are addressed by Kenny and Gowran (2014) and Harris,
Pinnington & Ward (2005) papers.
Strategy: A strategic prescriber develops their evidence-based practice through proactive
collaborations. They:
 work to a collaborative team mentality that shares and exchanges evidence-based
knowledge (e.g. journal clubbing, conference presentation/poster production);
 engage a compatible, experienced clinical peer, advisor or mentor (either 1:1 or
electronically);
 share clinical experiences using case study methodology to demonstrate effective (or
not so) successful interventions.
Presenting your own case studies requires confidence but the rewards are in developing skill
and articulating essential clinical reasoning.
No 3: essential toolbox item: A strategic prescriber thinks holistically.

The World Health Organization (WHO, 2001) states personal mobility is a basic human right.
Strategy: Become a social justice advocate by empowering personal wheeled mobility as a
basic human right for people with complex postural-mobility disorder (WHO).
 Enabling WC-seating capacity generates better quality of health, wellbeing and lifestyle
outcomes and empowers occupational capability for enhancing MEANINGFUL
participation, as desired.
No 4 essential toolbox item: A strategic practitioner is an effective person-centred
communicator.
Practice person-centred active listening during interviewing to encourage information sharing
and exchanges. Active information exchange builds a full understanding of the consumer and
their care providers’ wheeled-mobility needs, wants and aspirations.
Strategy: Being person-centred - may initially - feel like it requires more of your intervention
time but evidence shows:
 being person-service ensures the right wheelchair is provided based on setting realistic
goals.
 successful person-centred outcomes are aligned to service effectiveness (Dolan, 2013).
Articulate person-centred wheelchair-seating goals confidently: Set goals that demonstrate
improved bio-function and empowered psycho-social outcomes. For example, show how the
prescribed WC-seating solutions:
a) improve health systems (pulmonary-digestion/cardio-vascular function);
b) enhance capacity to engage (communication, sensory and cognitive capacities);
c) empower capabilities to participate (functional mobility across all domains of life: i.e.
meaningful wheeled activity and in comfortable relaxation) and
d) reduce dependence (reliance on support services/carers where practicable)
(Mortenson & Miller, 2008; NHS Purchasing and Supply Agency; Rigby, Ryan, &
Campbell, 2009; Wynn & Wickham, 2009).
No 5: essential toolbox item: a strategic prescriber is a structured thinker.
Underpin the fundamental principles of 24 hour positioning to WC-seating prescription for
optimal support and comfort by addressing:
 postural symmetry: promote sustainable skeletal alignment with comfortable neutral
pelvis for sitting balance where possible;

 muscle equilibrium & control: normalise tone for comfort and support (for lying &
sitting);
 stable base: enhance proximal stability through a stable base of support (rather than
focussing on achieving a tiring upright 90-90-90 sitting position);
 maximise head control: align vestibular system and support head for an even eye level
to promote physical, cognitive and sensory function (vision, communication & oral motor
function);
 pressure redistribution and dispersal: promote 24hr pressure care management and
educate to prevent skin breakdown where possible;
 promote wellness and safety: facilitate health (i.e. cardiac, respiratory, digestion) and
nervous system function to minimise pathology;
 enhance optimal comfort (for lying & sitting);
 enable functional activity (NSW FACS, 2016; Schmidt, 2015).
Strategy: A strategic prescriber thinks comprehensively.
Use these fundamental principle of 24hr positioning management to:
 demonstrate your clinical reasoning during WC-seating assessment-prescription;
 evaluate WC prototype home-based trials;
 demonstrate funding rationale/report;
 evaluate wheelchair provision-fitting satisfaction (post-provision).
No 6 essential toolbox item: a strategic practitioner is an open and transparent
communicator.
Six Seating Service Steps evident in Australian WC-seating procurement describes a non-
linear, interactive seating service pathway (refer Figure 2). The service pathway consists of:
Step 1: Intake: analyze referral for appropriate service selection
Step 2: Assessment-prescription: seating assessment, seating interview &
environmental evaluation to set realistic person-centred goals
Step 3:Technology selection: home-based prototype trial and trial evaluation;
Step 4:Technology evaluation: reporting funding rational/clinical reasoning;
Step 5: Provision-fitting: Matching the person and the wheelchair-seating solutions
(including follow-up trials and fittings);
Step 6: Post-provision review: review best reviewed within 6 weeks discharge and
seating service efficiency (Schmidt, 2015).
A seventh step should be considered in WC-seating procurement as:

Step 7: Scheduled maintenance/repair (understand wheelchair lifestyle cycle and
anticipate when to start the upgrade process)
Figure 1: The Australian Six Seating Service Steps (Schmidt, 2015, pp 430)
A strategic prescriber facilitates an informed person-driven wheelchair procurement. Consumers
operating within a National Disability Insurance Scheme (NDIS) environment need to know all
costs of associated services and wheelchair technology (including ongoing maintenance and
repairs) to be funded. Ongoing maintenance and repairs are essential costs for a viable and
safe wheelchair working-life.
Strategy: A strategic prescriber is an open and transparent practitioner:
 keep everyone on the same page: communicate a clear service pathway with all relevant
stakeholders, be it the consumer-carer unit, team members and/or funding
agents/funding applications;
 an itemised service pathway enables informed decision making: i.e. for selecting the
best service/team members, appropriate assistive technology resources and sustainable
funds to procure the right wheelchair solution.
No 7 essential toolbox item: A strategic practitioner prioritizes and plans in advance.

Strategic use of intake times assists sorting referrals/requests early by case complexity and
before service intervention starts. Strategic intake assists select the appropriate service,
intervention approach and resources required based on the case complexity.
Strategy: A strategic prescriber is strategic from the ‘get-go’!
 Identify the complexity of each referral by applying the Four Domains of Postural
Function (refer Figure 2) components: i.e. according to flexible or fixed posture, pressure
care status and functional activity (e.g. transfer capacity or dependence).
Figure 2 Four domains of bio-functional complexity (Schmidt, 2105, pp 295)
No 8: essential toolbox item: A strategic practitioner forms respectful partnerships.
A comprehensive prescriber plans for current goals & future aspirations and assesses
comprehensively via:
1. a mat evaluation (plinth assessment within a collaborative team), evaluation of person’s
physical-cognitive status and their existing wheelchair-seating technologies;
2. collaborative seating interview (active listening and information exchange) and
3. environmental evaluation (routine consumer and carer activities/roles/occupations at home
and in community).
Strategy: A strategic prescriber is a sensitive observer, active listener and creative collaborator.
A strategic prescriber owns their own seating assessment data and WC-seating measurements!

 careful observation: a seating assessment is essential for accurate WC-seating
prescription. The mat evaluation (plinth assessment) provides functional data on postural
function, range of movement, muscle tone, skin integrity and balance in lying and sitting;
 active listening: evaluate consumer’s physical function: observe their current sitting and
mobility function, their current wheelchair system (application and signs of fatigue, ‘wear
and tear’) and listen to consumer-carer stories about wheelchair usage, expectations
and disappointments;
 take photos before, during and after each assessment, fitting and trial. Use photography
to make informed choices, to educate and communicate with all team/stakeholders (with
signed consent). A photo speaks volumes.
 compare your measurements with vendor measurements, for accuracy and work as a
team.
 collaborative information exchange: Where possible, undertake mat evaluations
within a nurturing seating team to build skill and confidence; or if solo consider using
webcam links (during assessment) to engage with off-site seating peers or clinical
supervisors to augment your seating assessment skill development;
 Educate consumers and care providers from the start to enhanced the collaborative
decision making process. Informed ‘person-directed’ decision-making is aligned to
setting realist goals and successful/satisfactory outcomes.
More resources:
Mat evaluation designed for beginners: the follow two YouTube videos demonstrate basic mat
evaluation technique in supine and in supported/unsupported siting:
 Minkel (2008) Wheelchair seating mat evaluation part 1:
https://www.youtube.com/watch?v=Is8WAT4i9ZU
 Minkel (2008) Wheelchair seating mat evaluation part 2:
https://www.youtube.com/watch?v=Phy9p9J3SsY
More advanced mat evaluation material:
Novak, I., & Watson, E. (Producer). (2005). Seating and Positioning: The practical guide to assessment and
prescription. [video]
State Spinal Cord Injury Service. (2009a). Spinal Seating Professional Development Program. Retrieved from:
http://www.health.nsw.gov.au/gmct/spinal/education.asp
No 9 essential toolbox item: A strategic practitioner is creative, trustworthy collaborator.
As previously noted, WC-seating procurement is an acknowledged complex, interactive multi-
modal approach consisting of the stakeholders from both sides of the service equation

(consumers, their care providers, clinicians/therapists, vendors/suppliers/technician and
manufacturers).
Strategy: A strategic prescriber is a person-centred advocate that:
 forms collaborative partnerships based on mutual respect that informs consumer
decision making;
 proactively listens to experienced wheelchair consumers with lived experience and
knowledge that - if used wisely – can expedite selection of appropriate service and
technology based on past knowledge;
 develop trusted working relationship/s with your local service providers for efficient
service delivery. Knowledgeable service providers are often well informed to consumer’s
wheelchair and environmental context and their ready access enables multiple sessions
for effective technology and consumer fit;
 seek a seating team, seating peer or mentor (either 1:1 or electronically) with whom you
can openly share case-by-case difficulties/successes and learn through reflection;
A network of trusted seating peers bodes bode well for maintaining a healthy working life and for
your long term wellbeing.
No 10 essential toolbox item: A strategic practitioner creates mutual opportunities.
A modified form of the Australian Seating Service Benchmark (refer Figure 3) qualifies a clear
service pathway (as outlined in Figure 1) and quantifies each step by estimated service time
(primary and secondary service levels) and by seating approach (modular or custom-made).
Note: the Six Seating Service Steps (see Figure 1) has been augmented by Schmidt to include
a seventh step: i.e. ‘outline scheduled maintenance plan’. This is a reminder to the prescribing
therapist to include a simple consumer-driven plan for ongoing maintenance through an
estimated lifespan (i.e. 5-7 years is common) of wheelchair-seating system. It provides a
timeframe as to strategically commence a wheelchair and/or seating upgrade action for
proactive funding accumulation/application planning.
Application of the Australian Seating Service Benchmarking (benchmarking data) can inform
practice to anticipate resource needs in the following ways:
 Primary therapy service: A prescribing therapists who collaborates with an expert
wheelchair technician to assess, prescribe, provide-fit and evaluate the successful
application of commercially available modular products will need to allocate between 20-
30 therapy hours.

 Secondary service support: A prescribing therapist who supports their consumer through
a custom-made wheelchair-seating system may need to allocate more therapy hours (an
additional 7-20 hours) to collaborate with a specialist seating service.
 Home-based seating assessment: Although a home-based assessment consumes more
therapy hours (1-4hours) than a clinic-based seating assessment (.5-2 hours), the
additional data gathered provides environmental context and seating interview in lifestyle
context.
 Post-provision review: The data collected via a post-provision review provides invaluable
clinical reasoning confirmation. It may require 1-4 therapy hours, depending on
wheelchair-seating complexity and travel.
 Preparing consumer-carer: the combined consumer-carer contribution can be estimated
at between 40-60 combined hours for modular and 60-80 combined hours when fitting
custom-made solutions.
Figure 3: Australian Seating Service Benchmark (modified) (Schmidt, 2016; pp 443)

Strategy: A strategic prescriber advocates for essential resources for mutual benefit.
Strategic practitioner anticipates consumer and service requirement early, to reduce
procurement delays (e.g. coordinating stakeholder services, delays in technology supply,
additional funding, etc.). Planning ahead and keeping stakeholders’ informed helps reduce
frustration.
Apply the benchmarking data (Figure 3) to
 estimate your service time early i.e. identify necessary resources/supports/time/costs,
prior to service intervention;
 compare and validate a range of WC-seating technology & service estimates;
 alert your consumers and their care providers of the potential contribution they may have
to accommodate during the process of acquiring a new wheelchair-seating system;
 advocate on behalf of your consumer for sustainable funding for services and
technology;
 advocate on behalf of yourself for greater support and again for advocating on behalf of
your team or service for appropriate resources to ensure an appropriate level of service
for the wheelchair referral.
Conclusion:
The workshop provides ten strategies for building confidence as a strategic prescriber of
wheelchair-seating systems. Combining the Four Domains of Bio-functional Complexity with a
clear service pathway (modified seven service steps) and the Australian Seating Service
Benchmarking data provide valuable information for making decisions early. These strategies
guide reflexive practice aligned with service transparently. As strategic practitioners, early
career and occasional prescribers are advised to practice as person-centred listeners,
observers and collaborators. Working within a transparent, collaborative team environment is
the ultimate learning experience for early career prescribers, but distance can be addressed
through creative electronic solutions. This paper provides some basic strategies to begin your
journey; ongoing clinical practice, experience with peers and life-long learning will continue to
strengthen your confidence and competency.
Corresponding author: R. Schmidt, Schmidt Consultancy: rachel@olexports.com.au

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