Greg: Getting the active support he needs!

Greg is 36-year-old male and has a low thoracic level spinal cord injury (T10 ASIA). He lives a very active life with his wife and is a father to 3-year-old twins. Greg is a long-time wheelchair user as he sustained his spinal cord injury at age 18. He has been using a similar wheelchair setup since that time – a TiLite TR frame with the standard sling back support and ROHO Quadtro Select High Profile cushion. Overall, Greg’s wheelchair worked well for him. It allowed him to do all the activities he wanted and needed to do. The lightweight made for efficient propulsion and eased loading and unloading it into a vehicle. Although his wheelchair did “get the job done” so to speak, Greg felt that he sat slumped in his chair and that he did not have good upright posture and support. He also has a history of shoulder injuries and currently has partial tears of his rotator cuff bilaterally.

Seating & Positioning Concerns:
The ROHO cushion was selected due to Greg’s history of pressure injuries and flap surgery. The ROHO cushion provided excellent pressure reduction properties, although it did not provide optimal positioning components to assist with pelvic positioning and stability. Prior to using the ROHO cushion, Greg used a hybrid style gel cushion (Jay J2) that provided positioning and stability but did not provide sufficient pressure reducing properties.
The sling backrest was selected due to weight and convenience during transport. Prior to using the sling backrest, Greg used a solid backrest (Jay J3), although he reported that he would get “hot spots” of increased pressure when using it. The use of the sling backrest combined with the ROHO Quadtro cushion resulted in Greg sitting with a posterior pelvic tilt. This positioning also promoted a thoracic kyphosis with the shoulders protracted/rounded anteriorly (see photos below). This position places the head of the humerus behind the axle of the wheelchair which is not optimal for efficient push-stroke during propulsion and places Greg’s upper extremities at an increased risk for repetitive stress injuries.

All of Greg’s seated postures (posterior pelvic tilt, kyphosis, shoulders protracted/rounded (anteriorly) were noted to be reducible or partially reducible. Additionally, Greg had a 1” left pelvic obliquity (low on left), also reducible. To correct these postures, we began by trialing a Tarta Original® Custom backrest with Greg. We adjusted the height so that the bottom of the back was right above the PSIS and the top of the back stopped at the lower thoracic area. Since Greg had good trunk control, the placement of the backrest provided posterior pelvic support in combination with the cushion and still allowed full upper extremity and upper thoracic spine mobility. We then selected a combination of staves and padding to fit Greg’s posture.

Next, we took Greg’s measurements to design a Stealth Custom Cushion specific to his needs. We wanted it to measure close to 4” tall to mimic the height of his current cushion. The cushion we ordered measured 16”W x 16”D. On top of a high-density foam base, we placed 3 foam layers for their pressure reducing properties – a bottom layer of 1” soft SunMate FRG, a middle layer of 1” X-Soft SunMate FRG, and a top layer of ½” XX-Soft SunMate FRG. Next, we placed a ½” anti-thrust component to assist in maintaining the position of the ischial tuberosities to prevent a posterior pelvic tilt. Additionally, we added an ultra-lite gel into a well to provide extra pressure reducing properties at the ITs. The gel was placed below 1” of foam to decrease gel migration and help keep the gel in place. Lastly, we included a solid seat insert with the addition of a 1” wedge kit to use on the left side to accommodate his obliquity. The final product was just slightly short of 4” tal (~3.75”), which worked well to meet Greg’s needs in terms of positioning & pressure reduction.

Greg immediately noticed the change in posture with the new backrest and cushion. He stated that he immediately felt supported and that he was sitting more upright. In the photo below you can see this change – the PSIS is now supported with the Tarta Original® Custom backrest along with pelvic support provided by the Stealth Custom Cushion. Supporting the PSIS promotes upright posture of the upper thoracic spine and optimal positioning of the UEs for propulsion – directly over the axle. The flexible feature was an added bonus for Greg because it allowed for natural movement of the spine and did not block movement like a solid backrest. After using the new seating system for over a month, Greg also noted a reduction in shoulder pain. After 5 months of use, Greg has no pressure issues or redness. The new cushion and back are mitigating pressure risk while providing optimal postural support for function.

Heather R. Price, OTR/L, ATP/SMS

What is i-Drive VR?

The i-Drive VR is a power wheelchair driving simulator that uses virtual reality as an assessment and training tool.  VR introduces a more realistic and real time experience than Loonz, while still allowing users to gain practical experience in a safe and fun way.  I-Drive Vr provides a realistic three dimensional immersive and interactive environment to allow users of alternative driver control to learn and practice driving skiills in a safe and fun environment.  It provides a wonderful opportunity to get the drive controls and other products in front of the end user earlier in the process.  This can be used outside of the power wheelchair system in manual chairs or in activity chairs.  It is ideal for customers who need more practice with their driver control.

In keeping with the vision established by i-Drive Loonz, i-Drive VR provides a fun and interactive way to help assess and train power wheelchair driving candidates.  In building upon the ideas behind the Loonz, VR takes driver training and assessments to the next level.  The user’s body will be tricked into feeling the sensation of motion, even while sitting still.

In designing a VR system Stealth wanted to ensure that there is clinical evidence that it benefits an end user. Research does indicate that there are benefits to including VR in the assessment and training process.  In one study, it was concluded that power wheelchair performance in the virtual environment was representative of driving ability in the real environment. 

VR has been shown to potentially improve the assessment process in a number of ways. ​Time management is improved by allowing a user to practice skills in a controlled environment, minimizing the need for an assessor to be present 100% of the time. ​ VR can also provide documented results of the assessment, further reducing the need for an assessor to be present 100%of the time. Simply start the VR trial and let the user go through on their own.​ This VR is designed to be experienced in a seated, stationary position making the environment very controlled and safe.​  In theory a user could practice on a VR system as long as needed. They do not have to stop because the therapist is late for the next appointment. The system could be set up in their hospital room! 

How does VR fit into a typical assessment? VR helps to address a couple of major challenges in many assessments. Having equipment that the end user fits into is always a challenge. VR allows the clinical team to try and train on various drive controls in their existing equipment. The VR system is also much more compact and easier to house. It does not require a PWC to be used either, further increasing these factors. And last, in many cases the assessment ends up outdoors and weather can cause a host of problems. VR is stationary, thus eliminating that barrier.

While traditional training methods are still recommended, VR has been shown to improve outcomes when used as a compliment to those. Going back to space and environmental challenges in the training phases, VR requires very little space and the user is stationary eliminating risks. VR does not necessarily require skilled administrators such as a therapist. While a clinician is treating other patients, the user can continue building their skills on their own or with some assistance by virtually anyone.​

This VR system will allow the user to be introduced to various driver controls and virtual environments that increase in complexity over time. To keep the experience as true to reality as possible a true 3d example of a Quantum chair is used. VR does not replace real experience in a real power chair.​ The clients should still demonstrate and practice skills in the PWC. VR can however, allow the user to continue practicing with the driver control to build controlled repeatability and reliability of various access sites and driver controls.​

The i-Drive VR system uses a modified i-Drive interface. Using a standard interface leaves potential for a user to accidentally drive a chair while VR goggles cover their eyes and that cannot be allowed. Stealth can provide a PC that has been optimized for VR as standard computers simply don’t have the graphic horsepower to handle VR. A VR headset will be required as well. 

Moving onto the levels themselves, there are 3 main environments: a gym, an outdoors area and a home environment. The levels have been designed after several power wheelchair skills tests.  Level 1 is a gymnasium.  It offers an open environment with basic obstacles and has five stages.  This first stage is intended to get the driver used to VR and to dial in the driver control method.  Each subsequent stage works on a different basic driving technique. Level 2 is an realistic outdoor forest environment and it offers terrain changes and distractions.  It offers increased difficulty in obstacles over 5 stages.  Level 3 is inside a home.  It has more challenging tasks and distractions in its four stages.  As the stages progress, the driver must use all of their acquired skills to get through the home safely.  The driver must demonstrate the ability to maneuver through obstacles, open and closed doorways, as well as pull up to a table.

 As the experience is updated and continues to grow, more and more of these skills test elements and objectives will be added.  Many of the objectives and elements are written into the plan for the levels and stages but have not been implemented as of yet.​ In the future Stealth would like to introduce more environments such as an urban area with sidewalks and street crossings, maybe a level that involves getting in and out of a lift van, a school bus and various different public transportation modes.​

Much like the Loonz packages, Stealth has developed several VR packages for different needs. VR basic is a PC and Headset that will work for anyone who already may own an assessment interface. The joystick package is everything it takes to use VR with a joystick. The proximity package is everything it takes to use VR with switches and sensors. And the VR complete package is a little of everything; Various driver controls, mounts and inputs for i-Drive as well as a complete system.​

To hear more about what people are saying about the i-Drive VR, check out these videos! ​ ​ ​ ​ ​

Jonathan: Achieving functional mobility with the iDrive Head Array

Jonathan was 11 years old when he was evaluated for his first power wheelchair. Jonathan’s Dad serves in the military and the family had recently moved to our area. He was initially evaluated for positioning and access to a communication device. Soon after, we saw him again to pursue power mobility.

Jonathan has cerebral palsy, autism, impaired hearing, and mild cortical visual impairment (CVI). He wears glasses and hearing aids. He has a Baclofen pump and receives regular Botox injections to his upper extremities. He has also had hip surgery due to bilateral dislocations.


When Jonathan was seen initially, he was seated in a linear seating system on a tilt in space manual wheelchair. He was outgrowing the seating system and was also developing redness over his ischial tuberosities and sacral area with prolonged sitting. He had actually developed a pressure injury over his sacrum when he first received this system. He had a mild scoliosis, however, being on the brink of puberty, we were concerned that this could worsen with a sudden growth spurt. We recommended a molded seating system to address these concerns.


Jonathan using a switch by the left side of his head for communication device access on a Stealth Products Comfort Plus Head Support with swing away assembly.

Jonathan had been using a Head Mouse to control his communication device, though he lacked the precision required to accurately make vocabulary selections. Instead, after evaluation, we recommended single switch scanning using a switch by the left side of his head. Due to his impaired vision, we also recommended auditory scanning to provide an auditory ‘cue’ during the scan. He required a private speaker to listen to these cues so that his communication partners only heard what he selected, rather than all of his choices.

A Stealth Products Comfort Plus head support with bilateral swing away assembly was recommended. His AbleNet Specs switch was mounted by the left side of his head and a facial pad with embedded speaker was mounted on the right side. The hardware allowed for precise positioning of the switch. The switch could also be swung away, as needed, and then returned to a consistent and locked position by the left side of his head for optimal access to the communication device.


Jonathan had been evaluated for power mobility at age 3 and 5 years, though a power wheelchair was not recommended at that time. It was unclear whether alternative driving methods had been explored. We saw Jonathan at the Supplier’s office and placed him in an evaluation power wheelchair, providing as much postural support as possible. He had been using a Head Mouse to use his communication device in the past and, although he lacked the precision required to move a cursor between dozens of vocabulary choices, he did demonstrate adequate head control to use a Head Array.

Jonathan using the iDrive Pro Series Head Array during evaluation.

A Stealth Products iDrive Head Array was placed on the evaluation power wheelchair and Jonathan quickly demonstrated cause and effect, stop and go concepts, directional concepts, and fair problem solving and judgment. At one point, he indicated that he wished to go outside (we began driving in the lobby). It was cold and he was told that we could not do so. He drove with good accuracy directly to the door leading outside multiple times. We were so pleased with his driving abilities that we put on our coats and all went out with him for a while as he drove in the parking lot. Of course, he then avoided the ramp leading back inside! His Mom recorded Jonathan driving to send to his Dad who was deployed at the time – a very emotional time for all!

Jonathan driving in the evaluation power wheelchair on a sunny, but very cold, Colorado day!

Jonathan demonstrated strong readiness for a power wheelchair, and we anticipated that he would be a proficient driver with some mobility training. He was very motivated and careful. Although he has some visual limitations, he was able to see adequately to drive inside as well as outdoors. We recommended a midwheel drive power wheelchair with power tilt, power seat elevate, and tracking (did you know that tracking technologies have been demonstrated to increase efficiency in Head Array drivers by up to 69%?). We recommended a Stealth Products iDrive Head Array Pro Series which includes an occipital pad as well as a bilateral swing away assembly with lateral pads. Each pad has an embedded proximity switch for driving control. This hardware provided more precise placement of the lateral pads. We also were able to add a suboccipital pad. This additional support was added for three reasons: 1) Jonathan tends to hyperextend his neck at times and this pad, in conjunction with the occipital pad, reduced this tendency, 2) the suboccipital pad provided more stability to optimize function, and 3) this pad provided a ‘starting point’, allowing Jonathan to pivot off of the pad to activate the proximity switch in the occipital pad for Forward directional control.  

Jonathan needed a way to change modes so that he could Drive, access Reverse, and control his power seating. In the future, he would also be able to change his speed (by choosing which Driving Profile he was in). A Mode switch was provided. He was able to access this with his left hand. His control in this location was not adequate for driving, however a Mode switch only requires a momentary, rather than sustained, switch activation and does not require precise timing and accuracy.

Finally, Jonathan needed to communicate while using his power wheelchair. We recommended several months of practice with the new power wheelchair before Jonathan used his communication device on this base. He continued to use the communication device while in his manual wheelchair – this gave him many months of practice using the new switch site by the left side of his head before having to use this same switch site for driving. Using a switch for scanning requires the user to wait and then quickly activate (momentary activation) when the desired vocabulary choice is scanned. Using a switch for driving a power wheelchair requires sustained activation with accurate release for stopping. We wanted Jonathan to firmly establish these motor patterns before we combined the tasks of driving and communicating.

To drive and talk, we ordered an interfacing component (in this case, an R-Net Input Output Module, or IOM) and interfacing cable (ASL 8021L). Jonathan could use his Mode switch to choose an Auxiliary mode. When he then activated his left head switch, instead of turning to the Left, a switch signal was sent to the communication device. The Mode switch was then used to return the power wheelchair to driving mode.

This sure sounds complicated, but these solutions are the result of teamwork. As an occupational therapist, I evaluated Jonathan’s positioning as well as access to a communication device and power wheelchair. I worked closely with the speech language pathologist, supplier, and manufacturer representative in the evaluation and equipment recommendation process, as well as the delivery and training. And, most importantly, Jonathan and his Mom were so motivated and willing to put in the hard work to get him Moving!

Michelle is an occupational therapist in private practice, Access to Independence. She is a well-respected lecturer and author. She is the co-editor of Seating and Wheeled Mobility: a clinical resource guide, editor of Fundamentals in Assistive Technology, 4th ed., NRRTS Continuing Education Curriculum Coordinator and Clinical Editor of Directions magazine. Michelle is a member of the Clinician Task Force. Michelle is a RESNA Fellow, certified ATP, certified SMS and is a Senior Disability Analyst of the ABDA.