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 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.
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 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.