Wheel Chat - Your Go-To Mobility Podcast

Wheel Chat: Episode 8 – Navigating Complex Assessments and Managing Brain Injury Cases

• Wheel Chat • Season 1 • Episode 8

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In this episode of Wheel Chat, Justin and Anthony dive into the complexities of wheelchair assessments for clients with brain injuries. They share real-life experiences working with clients who face cognitive and physical challenges, exploring the importance of proper seating, maintaining client safety, and balancing family expectations with clinical recommendations.

What’s in this episode?

  • Insights into selecting the right power wheelchair for unique needs.
  • Strategies for addressing cognitive barriers and mood fluctuations in assessments.
  • Practical tips for therapists and ATPs on managing challenging cases.
  • The critical role of therapist collaboration and client independence.

Through candid discussions and shared stories, Justin and Anthony highlight the challenges and rewards of providing mobility solutions in complex cases. This episode is packed with valuable advice for professionals in the mobility industry, caregivers, and anyone interested in assistive technology.

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Disclaimer: The views and opinions expressed in this podcast are solely those of Anthony and Justin.

Anthony: Hi and welcome to our next episode of Wheel Chat. I am Anthony Mitchell. 

Justin: I am Justin Boulos and we are so excited to talk about our week. We don't do this week. Do you want to just talk about our, talk about our weeks again? Or should we cover a topic? What do you want to do? 

Anthony: Yeah, well I wanted to bring up because um, yeah, I've just got an interesting one that I wouldn't mind your opinion on and it'd be good to get your feedback. So, I'll chat about my week. But firstly, how are you? How are you feeling?

Justin: Good, mate. Good. Life is good. Still married. So I've also, I've gone well. 

Anthony: Still married. Are we on countdown? Are we thinking, 'oh no, she's going to get rid of me'. 

Justin: I've had some people, a few people run through, I've told you this in person, but I've got like a course coming out and I'm still doing a few initial people first to make sure it's really dialled in some sort of, I've been meeting with people to meet with their objectives of the course, like what do they want to get out of it? What are the actually things they want to learn and make sure it's actually tailored towards them. And yeah, it's been good. Spent a lot of time before, a lot of time working out what people actually want, not just what educators want to talk about. What are therapist's and ATP's actually struggling with and make a course around that. And then now that I've got a few people on the downlow doing, doing it and giving it, like working one on one with them to make sure it's properly dialled in, that's really efficient. So that's been really exciting. I've actually really enjoyed meeting up with people and hearing the feedback. Yeah, so that's all things to come this year, mate.

Anthony: That's really nice. That's really nice. I've had a really busy sort of week since I last spoke to you, just like, you know, in the management side of things, you know, cause obviously, you know, as much as I love going out and doing assessments and, and getting involved in the sort of end user, the reason why we do it, I have a whole sort of management side to my life as well in terms of looking after staff and, um, you know, running a business and all the things that go in between. So, that's been a really busy, busy week for me. Um, really, really fulfilling. We've got a couple of new starters that have just hit their sort of three month period. So it's been really lovely to sort of officially welcome them into the business and, you know, really see them develop over the last three months and they're really sort of able, able to really get into the role now and really develop, which I love.

Anthony: I really get excited by that. So that's been really lovely. And then there's just been like, you know, everyone listening, you know, life, you know, I don't know. I've got kids and life in between and other commitments and then mixing that in with work can sometimes be challenging. So it's been a tiring week, but like a definitely a rewarding week from last week going into this week. So, yeah, it's, it's, it's good to chat, but yeah, it's certainly, I'd be lying to say that it's been all sort of sunshine and rainbows for sure. 

Justin: Yeah, it can't, it can't be all the time. I don't know how you do it, man. Like I don't, I don't have kids yet at the time of filming, hopefully, hopefully get one on the way. Um, but, uh, with my new wife, still exciting to say, um, but I don't have kids yet. Um, and I don't run a business like you do, like you've got staff and all this stuff and I don't know how people do it, man. And on top of the workload that you do, it's, it can be a lot. How do you like, so when you come home, is there like a, an unwind? Like, what do you do to like chill out? 

Anthony: Yeah, I actually have had to check in on myself the last sort of couple of weeks, really, because I'm working. I'm up really early, again for you, uh, no, no, but I'm up, I'm like in work at like half six most mornings at the moment, which is great.

Anthony: I actually don't mind that I'm good in the morning, that's a good time for me, but it's when I get to like home at eight, half eight, and then I have to sort of get onto the emails, respond to people that obviously you've not been able to do because you've been out all day and meetings and doing other stuff, assessments.

Anthony: So yeah, I've had to check in on myself and just go 'hang on a sec', cause if I'm not doing my exercise like that, I need to do. You know, we spoken about this on the podcast earlier on and stuff, just like from a mental health point of view, if I let that slip after a few weeks, I definitely feel different. I don't feel as, what's the word? Easy? Like, relaxed? Like, you know, I feel less anxious. 

Justin: Stoic is probably the word. 

Anthony: Yeah, I get more anxious. 

Justin: Yeah, yeah, agitated and things bother you more than they should. And it's funny with that, with life and everything, like, you could go through the same experiences of a week or two.

Justin: You could have the same two week experience of, if you're a therapist and you're doing a bunch of reports, or if you're an ATP doing a bunch of trials, like, you could have the same experience, but depending on your mood, it's two different days. And so you might go to your manager and say, 'oh you know, I'm overworked, I'm stressed' and all this stuff, but really it's, it's not, it's not often the context that causes it. It's, it's your, your mindset around it and managing that is a tricky one. Another foreshadow, a great person to have on the pod is the mindful OT, Lisa. She's awesome. She's all about, she's just mastered time. I just love it. It's like she, on her LinkedIn, she's always just like posting like her schedule and how well she like, you know, like how well she's able to, you know, about mindset is everything. And she just, she's had her experience of, you know, having a mental breakdown kind of thing. And you know, her recovery around that. She's very open with all this stuff. So, that's probably another good, another foreshadow episode.

Justin: Let's get Lisa on about how to, well-

Anthony: I'm a massive advocate for mental health. You know, I have ADHD. I'm happy to sort of discuss that. I'm not saying I'm the most knowledgeable on it, but certainly I can tell from my own experiences and what challenges I've had and how I've tried to overcome that and try and continually sort of manage that. But there's so many amazing sides to it, but there's some really down, rubbishy things about it as well. So, yeah, it's about checking in on that and managing that. And, yeah, I'm, you know, in a typical ADH fashion, I hyper focus on certain things and kind of just go full steam and other things maybe don't take priority. And I think sometimes you need to check in and say, 'hang on a sec, I need to, calm down a little bit on that', and invest a little bit better in time and in looking after myself. So, in the main, it's all good. There's no panics, there's no thinking, but I'm just checking in. So I think it's about manifesting it. So if I'm talking to you, I'm mentioning it, I'm telling myself again, that you know, I need to get to the gym and do certain things and get out, just even get out and do a nice walk, and get the dog out and enjoy it. So that's really important, but hey, enough of me, let's move on. So, um, what, what we, what I was saying was at the beginning of the podcast is I had a problem with a client and I'm interested to know how you and the listeners would have approached it.

Anthony: So I went, I was called out to do an assessment, a lovely gentleman, brain injury and he wanted a new electric wheelchair. Well, he wanted his first electric wheelchair. He'd never had a power chair. The physiotherapist who initially made the assessment request had said that the gentleman had been in hospital for several months, whilst he was in hospital, um, recovering, um, they had prescribed him with a Rea Azalea manual wheelchair which, when he was on the ward he wasn't sitting incredibly well.

Anthony: He was slipping to the forward, uh, slipping to the forward, slipping to the front of the seat cushion. Almost looking a little bit iron board like, if that was a good description of it. You know, very stiff, exactly. And just very windswept as well and just all over not sitting very well. So I, this was the description that I was given and she was great enough to give me a little bit more background, which I won't give as such, but, yeah, he needed help. But he was really, really independent in terms of, although he's hoisted and non weight bearing, he independently wanted to be able to access other areas of the nursing home that he's currently living in, and was that an option? Um, so very successful gentleman in his career. Very headstrong. Uh, these was the, this was the brief. So I've gone out, met the gentleman, really kind of, really lovely guy. Don't know how much experience you have with brain injury, but, you know-

Justin: It's actually funny you say, I've had a similar, like, hearing you talk, I'm like, wow, this is getting closer and closer to my guy. I've got a similar guy who I met on the brain injury unit. Who was on a Rea Azalea, so for those who don't know, it's a tilt and space manual wheelchair. And pretty big guy, and with the brain injury, he is now very dependent on other people, but they, uh. So I was talking to his wife and his wife, like, I saw the photos of you know, his whole room was covered in photos of him, you know, it's like two different people, but she was like, oh, he would, this is, this couldn't have happened to a worse guy. This is the most autonomous guy, doesn't like anyone doing anything for himself. You know, the head of the house kind of very much like the guy, like, yeah, he just doesn't like to be helped and here he is now needing all this help, and not being able to mobilise himself. And we did a trial for a power wheelchair. So it sounds similar to yours. 

Anthony: Yeah. 

Justin: I'm curious to see how yours, yours turned out. 

Anthony: Yeah. So, um, so he, you know, one of the things that, Beth the physio had sort of briefed me on was basically saying, you know, he can go in and out of mood, he can be quite stubborn in presentation, you know, one minute you could meet him and he could be great.

Anthony: And, next week, next day, next hour, he could just, shut down and, say, 'no, I'm not doing that' or 'I'm not interested, leave' sort of situation. 

Justin: I find that, just to sort of be a little listening ear as well, is that I found that is, that is very common with people with brain injuries. And that was the same thing that we got to and he was like, absolutely refused to get into the chair even though he'd been complaining about his current chair for ages. And he, because he had that language barrier as well, he couldn't articulate it so he had to get the set, you know his speech board, and again the nurse would go like 'alright this row, this row, this row, okay'? So like, for those who don't know, I'm going to like, imagine a bunch of letters on a, on a grid and I would just say, is it this row? This row? Okay. Yes. This row. Which column? This one? This one? Like, alright, you know, 'B', let's go next letter. And then so doing that, you can imagine that adds to the frustration of it all. And the mood swings that I get at times. And so, you know, you can imagine with that brain injury as well. Um, it's tricky and it's tricky as reps. You've got to be in and out. You can't, you know, you're not, you can't, you don't have the opportunity to spend four hours, you know, waiting for them to, you know, we'll go grab a coffee and come back. 

Anthony: Yeah. 

Justin: So yeah, it is tricky. 

Anthony: Yeah. No, it is it. Um, anyway, the guy was so lovely and was really accommodating on the day, which was amazing because he wasn't just interested

Anthony: when I got there in the wheelchair, he wanted to look at an electric wheelchair and he wanted a new chair for in the home whilst he was there. So we're looking at two different products really. But his driver was the electric wheelchair. So I wanted to keep his attention levels high and keep him interested.

Anthony: So I did my initial assessment on the bed, and looked at him in supine and looked at his range of movements. Gave me an understanding. He had slight hip rotation, slight obliquity, nothing really that was of too much concern in terms of uh, that we weren't able to correct it. So, um, yeah, he, he couldn't passively on his left side get to 90. He could only get to around about 75 degrees on left side hip range. 

Justin: So, so for those listening as well, 90 would be a 90 degree angle. And then 70 would be like, if you drive your knee to the ground while your sitting, that's more of an open, it depends on how you do it. I never know the actual-

Anthony: No, that's right. 

Justin: Which way is it? Is it, is it, isn't, is you go higher, not is higher than 90 more open or is less than 90? 

Anthony: No, you know, yeah, so more open would be going down the scale from 90 to zero. Closing the hip angle. I would be going up to you like you're 120. So like, you know, if you can get past 90. You know, bringing knee to chest. 

Justin: You're good. 

Anthony: Is that, you're going to go past 90, right? So you can go into anterior tilt or posterior, whichever, right? So, so in terms of that, he had a slight hip rotation and slight obliquity. As I say, I was able to correct it. Sat him on the end of the edge of the bed after looking in supine.

Justin: He had a person behind him supporting just so he didn't fall back and he was able to maintain a pretty good sitting position with somebody helping from behind and supporting and I was able to just have a little feel of his 'e skills', put my hand under his bottom and sort of just de-rotate, help with that rotation. So all that was capable and therefore then I applied it. So I put them in a Manta back from Spex and Dreamline STX seat cushion, put onto an Ottobock B4 wheelchair. He was quite, he's very tall, but very slim. Just to clarify, the Ottobock B4, that's a rear wheel drive power chair isn't it?

Anthony: Rear wheel drive, yeah. Um, and I wouldn't traditionally- 

Justin: What made you go that one? 

Anthony: Yeah, well, I wasn't sure. I had a few in the, in, in the van with me, and what I was concerned about was how much he was actually capable of, of, of, of using it. But in the background, his family were saying if he's not able to use it, could we take it out, you know, could we control it from the back and like take it outdoors. And the terrain that the home is in, uh, it's in a really lovely area but it's kind of, um, it's got like fields and quite outdoorsy. So I thought the rear wheel drive would be more suitable for that user group, in terms of, sorry, that, that terrain and having that. So, we had some options of attendant control on the back as well. 

Justin: I'll just say for the listeners as well, in terms of the differences between rear and mid wheel and front wheel, just looking at it, there's, there's a lot of different factors.

Justin: One factor being how easy is it to drive from the back? I would say rear wheel drive is the easiest because your joystick is right on top of the drive wheel. So it's a lot more intuitive to drive. Like when you turn left, your hand actually moves left. But when you go into mid wheel drives, now when you turn left, your hand actually goes to the right and even worse for front wheel drive. So in terms of ease of driving, uh, rear wheel drive power chairs, uh, the easiest. 

Anthony: Yeah. So that was, that was my thought process, exactly right. So, we got him in, we got him sat really well actually. He sat really, really well. So he was like, 15 inches wide, but his seat depth was something like 20, 20 inch, I think in the end, 20. So, you know, he was really slim and long. Yeah, exactly. But really strong, actually really, really strong, strong gentlemen. But you know what? If I showed you a before and after, which I really should have done; I should do that more, actually. I'm going to remember to do that-

Justin: With consent from the client, which we will get.

Anthony: Thank you. Yeah, absolutely. He, cause in his Azalea like, as I said before, he was very wind swept. He goes into posterior pelvic tilt. Essentially his position was very much how I thought it was, that it was because of the chair that he was in. It was the wrong seat depth. It wasn't a great seat width. It was far too wide. So he had so much space just to sort of rotate. And you know, a lot of our users, if you give them space, they're going to take it. But we do that anyway to fixate, to give ourselves support, to feel stable in the chair. But if we, by narrowing the width, gave him the armrest width, had a more contoured seat cushion, like I described and gave him the lateral support and the hug that he needed, rather than just too small focally positioned laterals that didn't really meet him that well because the, the base of the Azalea was, was wider than him essentially. So the laterals weren't really making a huge amount of contact on his area. So by me giving him that feedback, um, it, it just all worked much better and he was able to sit. Exactly. And I put a, uh, I had a two point, pelvic strap on there. And again, just along with that positioned in the right way, he didn't move, like he didn't, he didn't show me any reasons that he was going into posterior. So we had him sat out for a good 30-40 minutes, while we tried the wheelchair. He had no pressure issues, so it was no issues with that. 

Justin: So what was the issue? You had a good solution with the seat in, that he was swimming in the Azalea, too much room, no, not enough support, so you gave him the contoured seat, better lateral support. Was he able to drive himself? 

Anthony: No. So this is the problem. Um, sorry, I've done a long way around to tell it, but I just wanted to sort of tell you that it was all going well until this point. Um, he, he couldn't drive the chair. He could drive it for very, very short periods. So i.e 10 seconds. Like if I said, 'right, I want you to drive to, you know, like 10 metres down the corridor', within three metres he was like steering off to the left, steering off to the right. His distraction was, was brought, you know, he'd look at something and forget maybe the job, the task in hand.

Anthony: So that was very much linked with his injury, with his brain injury, I think. And that was a concern to me, initially. Family I could see were very eager, like it was a really difficult situation. I don't know how you would deal with that normally, but they were kind of like wanting it to be okay. And very quickly I was like, this isn't going to be right. Do you pick up pretty quick? 

Justin: Yeah, well, I went, I went through the exact same thing. So, the guy I was working with, was saying exactly what you said. Very distractible, very this, very that.

Justin: So I think for us, what we did to resolve it was keep his eyes focused. So I kept saying to him, like the best cue you can give someone when they're learning to drive is having the eyes where they're going. People always tend to look at the joystick or they look at, it's like what you said, they get distracted, but even if you have to say, look, I'll stand like 15 metres ahead and say, 'stare at my shoes, drive towards my shoes, shoes, shoes'. And I'll be like, I'll just say his name's Bob. I'll say, Bob. I sort of reduce the cues. So you start with, 'okay, make sure that you're looking at my shoes'. 

Anthony: Yeah. 

Justin: That, that translates to 'remember my shoes, shoes, Bob and you're trying to like grade those cues as much as possible. But uh, and he did well eventually. We actually had to do a second trial because, again with all the cognition, all the difficulties of he didn't want to get in the chair and all that, we kind of ran out of time. So we went out and did it again. For extent, like by the time we scripted the chair OT uh, agreeably went, said we need to do another trial just to make sure it's suitable. But we actually ended up, we did go with it. So he showed promise, he showed- for, for me it was, he showed the ability to learn and he was getting better. What I said on another earlier podcast a few weeks ago was, writing people off early is something that can happen, but I do know you have to make a clinical decision each time. I'm not saying that everyone, you know- 

Anthony: Yeah. 

Justin: I'm not saying that everyone gets, you know, if they don't do it, then don't just give him some time, but you do have to make a decision. And I think that the decision is based on, are they showing improvements? Do they understand cause and effect? And what does the family think about the situation? And you might get a family that is a bit too eager and say, yeah, like, absolutely, let's do it. Um, and maybe that's not safe, but ultimately, I say this all the time, it's... Well, I don't know how it works in England, but Australia there's a lot of good choice. And I don't think it's necessarily up to the, the therapist to make the decision or me to make a decision. I think it's up to the therapist and I to both be advocates for the pros and cons of the situation. 

Anthony: Yeah. 

Justin: And then ultimately make the family decide. So saying, look, personally, I'm not sure if he's going to be able to learn this. If he does make a mistake, then it could cause this issue. Here are ways we can mitigate this. He only gets access to driving with supervision. You guys agree he's only going to drive in open areas. So all that kind of stuff, and you try to work out a plan to make what's, what's most safe, but yeah, the power is definitely up in the into the user over here in Australia. But yeah, but yeah, you still got to be safe.

Justin: You don't want someone causing an accident and saying, you know, making a recommendation of what you said so- 

Anthony: So no, I think that's great advice. And actually, so, what happened was through sort of him trying late and he was really keen bless him, you know, like, there wasn't like a point like he was like, giving up or was getting frustrated, but he wasn't recognising that he was... it felt like he wasn't recognising that he wasn't getting it. Um, he must have been, but he was really trying, and I didn't want to stop that. 

Justin: Would you have the opportunity for an extended trial, or even a rental for a few weeks? Is that an option for you guys over there? 

Anthony: Well, no, we definitely offer that, but my concern was that he definitely wasn't safe in that environment and if the, unless because he was in a care home environment and the family weren't around him the whole time, one of the issues that I was sort of aware of and was highlighting it to the family was if they're not there and let's just say there's a chance where a carer didn't realise that he wasn't able to use it and they transferred him in and felt it was, he was okay, would that be a risk? Right? So one of the ways of overcoming that would have been to maybe have the controller mounted on the back, but you could just then put it on as and when he wanted to. But I just felt that there was too many potential risks with that for myself to make a call on that. Um, I was, it wasn't my call to make whether he could have this or not. I just have to make it as I see it at that moment. So I was trying to recognise that. Um, so that was one of the things. So essentially family could have controlled it from the back and had an attendant control, that was an option. What happened was, basically, we came away and I just basically said to the family, I'm not sitting 100% comfortable with this. I don't think it'd be safe, however, it's not my job to tell you whether or not he can have it. I'm just giving you my opinion. I would really like to come back with the therapist, to make a more sort of guided plan if that was something or not something, to give some more sort of feedback. So they were like, yeah, that sounds great. But what happened was the next day I got an email from the, or sorry, two days later I got an email from the therapist saying there's concerns around from the nursing home and from family now that he had a bit of an episode the following day, nothing linked with the wheelchair, something to do with behavior and, uh, they're concerned that he would use the chair potentially as a weapon. Um, like if he gets angry, he could, you know, or-

Justin: That happens a lot, yeah. 

Anthony: Yeah. 

Justin: But there's still so many ways, there's still so many ways around it. Like you could do, you could have I mean, there's remote stop switches. You can have an emergency button on the back, which is just a mechanical switch that you have a big one on the back that people can just slap. Um, only gets access with supervision, so, you know, he only gets access to drive when someone's got the remote stop to do that stuff, or even just bring him down even more, like alright, can we just get him to have two switches we can turn left and right, or can he just be able to tilt himself, like, can we program it that way? So I think somethings always better than nothing, but it is a tricky one to go with. Where you're, you want to make sure the person's safe, but you also want to afford them as much opportunity as they can. 

Anthony: Exactly. So, um, so yeah, so it's kind of work in progress in terms of right now. The rental solution that you kind of mentioned was something that we discussed just like doing a temporary, but what I've also suggested is that if they're willing to, um, we have some excellent people in our company, that, although we couldn't do it in a long term sort of free-bay, we wouldn't do that, but we could maybe organise two or three sessions, maybe hour at a time where along with the therapist we could just bring the wheelchair out and let that gentleman have like an hour session where we do some training, if you want to call it that. 

Justin: Go to an empty car park or somewhere in a nice wide open area. 

Anthony: Yeah and just try it because ultimately, we want this gentleman to have what he wants, like he's got that entitlement. He's more than capable in terms of knowing what he wants at times. You know, he might not have his own safety at heart, but he's definitely, you know, he should have the right to try and work towards what he wants to get. So we want to try and assist him with that. So that's something that we have put to the therapist and the family. So, you know, let's see how it goes. It's, uh, it's that, but it's really just interesting to see how you would have done it, dealt with it, thought about it, processed it. I think ultimately one of the things that I've taken from your chat and how I felt was we really need, this is where it's key to have the therapist involvement. You know, and have that professional opinion. We always strive to have that person on the assessment. Sometimes it's not available. Sometimes funding doesn't allow that therapist to be present at the assessment sometimes. 

Justin: Yeah, I think it sounds like it's, it sounds like it's quite different between Australia and in England sometimes. Cause with ours like there's always, well there has to be a therapist present for like, for the report to get run. But I think either way, the for me, my thought process with these situations is, and when you're trying to work out if somethings appropriate, and this could be when you work with kids, post stroke, post brain injury, whoever it is, always have the goal of how can I have some level of independence?

Justin: And you could, you just keep stripping it back, go from independent driving, okay, assigned driving, assigned driving only in open areas. You know, um, switch driving can only go left and right, can only go left, whatever, just something, can only tilt, can only hit the button for a memory position. Something is better than nothing, is my final opinion on that one.

Anthony: Nice one. Cheers, Justin. Uh, good work. Anything from your side? Anything you want to raise? No, no. 

Justin: You've had a pretty easy week. 

Anthony: That's it for me for the week, yeah. Listen, guys, that's probably a perfect time to wrap up. Justin, cheers for your help with that one. Great to get feedback. If anyone wants to comment, like, subscribe, please feel free to click on the link and, let us know your feedback. It's always beneficial. If you've got any problems or anything that you're struggling with yourselves as therapists or end users or family, family members, whoever's listening to us this week, uh, please feel free to get in touch, reach out and we will happily chat about it and try and raise it on our next episodes. Um, for that, for now, Justin, cheers pal. Have a great rest of the week. I will chat to you next week. 

Justin: You too, mate. 

Anthony: Thanks guys for listening to Wheel Chat. 'Wheel Chat' to you next week alright! 

Justin: See you, mate. 

Anthony: All the best. Bye.