Wheel Chat - Your Go-To Mobility Podcast

Wheel Chat: Episode 16 – Post-Stroke Tone, Splinting & the Truth About Shoulder Slings with Second Skin’s Cathy Harries & Andrea Hinckley

• Wheel Chat • Season 1 • Episode 16

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In this episode of Wheel Chat, Anton and Justin are joined by Cathy Harries and Andrea Hinckley from Second Skin, an Australian-based team of OTs specialising in custom dynamic splints and compression garments. Together, they dig deep into tone management after stroke, the clinical realities of spasticity, and why slings might be doing more harm than good.

With decades of experience and a passion for client-centred innovation, Cathy and Andrea share expert insights on early intervention, splinting strategies, and the critical role of comfort, posture, and pain reduction in long-term outcomes.

What’s in this episode:

  • What tone really is—and why it's more complex than “high” or “low”
  • Rethinking shoulder slings: when they help, when they harm
  • Post-stroke splinting: timing, goals, and who it’s right for
  • Neuroplasticity, function, and why “late” isn’t too late
  • Seating, transfers, and pain management as essential goals
  • Powerful real-world stories that show the impact of the right intervention
  • How to manage expectations without losing hope

This conversation is full of practical takeaways for therapists, rehab teams, and anyone working with post-stroke clients—and we’re hoping to continue it in a future episode.

Connect with Andrea:

👉 LinkedIn: https://www.linkedin.com/in/andrea-hinckley-891677223/

Find out more about Second Skin: https://www.secondskin.com.au/

Email us :
We’d love to hear from you. If you have any questions about this podcast, please email us at wheelchatpod@gmail.com

Follow us : TikTok : https://www.tiktok.com/@wheelchat_podcast

Instagram : https://www.instagram.com/wheelchat_podcast/

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

Anton: Hello and welcome to another podcast episode for Wheel Chat. You're listening to Anton Mitchell and my amazing co-host Justin Boulos. Justin, how are you? 

Justin: Oh, how am I today? Bit of a rough day, but nonetheless good. I won't, I won't keep bra- I won't keep bragging about Australia to you, but the morning was good.

Anton: Yeah. 

Justin: And this evening's even better because I get to talk to you guys so thank you for asking. 

Anton: Yeah. Oh, amazing. I mean, listen, if we ever go for a sponsorship for this I think visiting Australia might be in like seriously, we could be like exporting everyone here from the UK and probably all other areas of the world that are listening and get everyone into Australia for sure. But listen, I'm really, really excited about our two guests that we have on today. I have never met them. We have had some collaborative chats just before coming on the pod but I'm really excited to, to listen to them today and I'm sure everyone will get a huge amount out of it. We have Andrea and Cathy from Second Skin. Now Andrea is the senior OT working with Second Skin and Cathy Harries, I hope I've pronounced that right, and Cathy is the Clinical Services Director at Second Skin. So Second Skin, they're going to tell us all about what is Second Skin. But for any of you guys out there who know you're going to be well excited.

And for the ones that don't well that's even more exciting. So guys, Andrea, Cathy, how are you? 

Andrea and Cathy: Good, thank you. Thank you for inviting us. Yeah, thanks for having us guys. We're super excited to be here. 

Anton: It's a pleasure. It's absolutely brilliant. I guess, just before we continue, Andrea and Cathy, tell us a little bit about yourselves and just tell us a little bit about Second Skin and what Second Skin is, if that's all right.

Andrea and Cathy: Okay. I'm an Occupational Therapist by training of Second Skin Started in 1988 and I started with Second Skin just before 1990. and I'm still there having fun, enjoying myself with something I'm very passionate about. We essentially manufacture dynamic splints for management of a whole range of neurological conditions, for children and adults.

And we also make custom-made, compression garments for a completely different group with burns and trauma and lymphedema, some of that kind of group as well. But one of our biggest passions is splinting for people with any sort of neurological condition, from little people, right up to elderly people is our passion.

We manufacture all of our splints in Perth and that's where all our patent makers and machinists live. And then we have a team of therapists in the capital cities in Australia and also in the UK that travel about seeing clients measuring and prescribing splints all over the place. 

Anton: That's so cool. So we're going to delve in. Andrea, come on. Don't be silent on me! You telling me about yourself as well. 

Andrea and Cathy: I've been in OT 20 years this year. I started my career in Brisbane doing the typical rotation stuff and then found my passion in community and OT. So I've been around the tracks doing that for a number of years. Left my good government job about 5 years ago and went into the private sector and then found Second Skin and came to work here 18 months ago. Yeah. 

Justin: Loving it. 

Anton: So cool. 

Andrea and Cathy: Loving it. 

Anton: Thanks guys. 

Andrea and Cathy: Makes my brain tick and think really hard. 

Justin: That's, that's awesome guys. Between two, between the two of you, it sounds like there's, a wealth of knowledge and I really want to get into the topics around this because with me, and Anton's probably the same, we see a lot of clients who have, who have Second Skin, mostly because of they have some sort of, some sort of tone. And I suppose the way I guess I think, think is best to open up this podcast is to understand why does Second Skin even exist. What, what is the product and who is it serving? 

Andrea and Cathy: Oh my goodness. There's a very long answer to that question. 

Justin: We got time. 

Andrea and Cathy: We exist because of the very complex challenge of assisting people in this space, to maximise their achievements and achieve their goals across the, across the age spectrum. There's always been a lot of frustration I think in lots of these clients in terms of being comfortable in something, achieving their goals in something, being able to wear it each and every day with comfort. And so we started in this area because of the challenges of seating and handling children with cerebral palsy, looking for a way to position them effectively so that they could learn sitting skills, standing skills, walking use some of those kind of skills as part of their development. And from there we moved on to how we could make a difference to upper limb positioning and function, lower limb positioning and function, postural management for scoliosis in combination with seating. So we started off with a very simple idea and then over the years moved towards very complex splinting with a very complex group. The occupational therapist who started the company, Jenny Valentine, was very passionate in this area and came up with this idea after being pushed by some of the therapists in the field to do something different in this area that clients could move and grow with as part of their development. And since she passed away, we took up that challenge because we've been working with her for such a long time and continued on this journey.

Justin: I'm sure you'll be doing her very proud at the moment. And yeah, I'd love to know more I guess about who is needing it. So you mentioned people who are needing postural supports and things like that. So I mean we see, Anton and I both see clients who need postural supports all the time. I guess when does someone need to consider coming into something like a Second Skin?

Andrea and Cathy: So, Second Skin has a lot of different types of splints to help benefit clients. There's the body kind of splint, and then there's the upper and lower limb splinting. People might come to us for, you know, when they're little people and they're trying to develop some head control skills for example, or increase their tolerance for sitting you know in the school setting, for example, because they're not able to manage that due to fatigue. So we could get clients that have the CP diagnosis of all different levels, you know genetic kind of conditions, you know childhood stroke, brain injury, that type of thing.

And then we see them obviously through their life and help them to kind of manage the different challenges that come their way through that, through that journey. Then we also get a lot of clients that come to us after things like traumatic brain injury, stroke, new diagnosis of, you know, MS, MND, spinal cord injury, those types of things from some traumatic event or disease progression. And it's about trying to help them to manage that condition that they now have and being able to achieve the things that they want to achieve, in a way that is sensible and comfortable, and is easy for them. Because that's a big thing; this is one part of all the things that they have to manage, and we are really big on making it work for them. And if it takes us one time or ten times to sort that out, we will do that because we want it be right for clients. Yeah. 

Justin: And I suppose you're trying to help people who have these issues with their tones and correct me if I'm wrong, my understanding tone was explained to me as like their resting level of like muscle tension. So like where you are just at a normal base rate. Is that right? 

Andrea and Cathy: This is one of the things Cathy and I was talking about around the terminology of tone, and I think that is really the basis of a lot of confusion and worry from therapists about what is this? Is this ataxia? Is this dystonia? Is this high tone? Is this low? Like what is this? And I think the terminology makes it really tricky. But essentially, very simply, we all have a level of muscle tone present. And you know, those people that don't have injury or illness are able to regulate that tone based on what they're doing, you know, their level of fatigue, their activity that they need to do. When people then have something over the top of that, such as a brain injury or some type of CP diagnosis for example, they're not able to manage that muscle tone as effectively as other people. And I think tone, I describe as a spectrum. It's like similar to the ASD thing, there's such a spectrum of tone. There's a spectrum from no tone at all, to very, very high. And then there's so many things in between. There is people that have dystonia or the people that have the ataxia. So that changing level and intermittent presentations of tone as well between the low tone and the high tone. So yeah, I think the terminology really messes with us.

But if you think about it in that way, that helps you to really understand what we are working with here. 

Justin: That tone is more on a spectrum that you could be like hypertonic or you could be hypotonic, either way. It's basically saying for, if I'm understanding you correctly, you've got your brain sending electricity, sending messages throughout your whole body and for, for, for regular people, you know, these messages come and go really fine but for some people they're either not sending messages at all, and that would be like a low tone or they might be sending too much and that's would be a high tone or you know, if someone gets excited or something, then they might send too much. So they're basically like difficulty regulating their muscle tone and whether that be from birth or post-injury, like a stroke of what you mentioned.

Andrea and Cathy: Correct, yes. So we work with a rehab physician on the Gold Coast called Dr. John Geow, and he helped us with some education last year and I've stolen his slides.

So I'd like to read you his little definition, if that would be okay? 

Justin: Let's get in. 

Andrea and Cathy: Is that all right? 

Anton: This is, this is next level, Justin. I'm loving it. 

Justin: This is insider information everybody.

Andrea and Cathy: "A motor disorder characterised by velocity dependent increase in tonic stretch reflexes resulting from an upper motor neuron lesion presenting as intermittent or sustained involuntary activation of muscles." So that's the standard definition. He then went on to tell us about his most recent trip to what was called Spasticity X Symposium, which I believe was in America, where all of the gurus of spasticity got together he told me, and they were discussing a new definition of what spasticity was because [00:11:00] they... the consensus is that there's not enough focus on function of people, and the current definition is very medically based. So they came up with a bunch of new definitions, which they're all deciding on at the moment. And they're hoping that instead of it being called 'spasticity', it will be called 'spasticity syndrome'. So there you go! Up to date information from  Spasticity X . 

Anton: Okay, interesting.

Justin: Okay. That'll take a while for people to change that terminology. You get people going to say spasticity for ages. Until, until that changes...

 

Anton: But the, I guess the reason probably just listening to what your explanation is, is that why they're wanting to put it as syndrome is more just so that they can, like you said, put it on a spectrum so that they can gauge the levels right? Because if you have a syndrome then you actually have different levels within that, right?

So they're not just saying one word, like they're, they're actually saying "No, it's a thing. It, there's, there's different levels with it." So I get actually why they probably come to that assumption, although it's probably quite semantic and whatever. Yeah, like it's, yeah, I get it. I get it. So I think that like your explanations have been really detailed there, and I actually got quite a bit from that. But I think in terms of practical, like if we can move into the practical, so if I'm listening to our podcast and I'm sure our listeners are as well, it's like, "Okay, so tell me Andrea, Cathy, like if I've got somebody, a new client or a client I've been working with for a while and I'm maybe not as knowledgeable as you", you know, in that area, you know because every OT... you guys are OT's so you know you, you might not have a specific background in spasticity. You might have come from mental health. You might have, you know, be learning. You might be three years, four years into the job. You might be new, you might be even really experienced in a certain area, but not specifically in spasticity. So I'm looking at my client and I'm going, they're really struggling. I've got amazing seating in place, but it's just not a hundred percent working for me. My night time sleeping, I've tried to put bed positioning in place, but it's not necessarily working the greatest. Like, what, what do I do guys?

Like, you know, help me, help me, Andrea, Cathy, tell me! You know, so where would you first, where would you start? 

Andrea and Cathy: Where would we start? I'd be asking a lot of questions about why what's happened so far hasn't been enough to resolve some of the issues and work out what goals we're all looking towards for that client and what, what the client's goals are, and obviously what their family and carer's goals are, to work out what we need to do.

So sometimes people come with an issue around seating not being comfortable or not being able to be well positioned in a chair for the length of time that they need to stay in that chair. And that can be a tone related issue. If you've got fluctuating tone and certainly the increased tone group in particular, it's very hard to be positioned well across the course of your day because you are changing all of the time. And so for us, it's then about what can we do in terms of reducing the impact of that tone and assisting with the positioning so the combination of the dynamic splint with the chair together is getting a better outcome for that client. Because we see lots of clients where that's the case in that fluctuating tone group, the high tone group, the clients who've got what we call dystonia, which involves often lots of involuntary movements and quite a lot of discomfort over the course of their lifetime. They don't get any easier to position as you get older and things get more difficult. So we are looking for what can we do in combination with what else they're doing to make a difference in that space. It's really important to make a difference to comfort. We see a lot of clients who come with pain and discomfort as they get older.

It's really important to make handling easier for people because lots of the clients, even the small clients we see with increased tone, are really difficult to get in and out of their equipment handle position effectively over [00:15:00] the day. And if we can make it easier for families to handle you, we'll be looking in that area to see what difference we can make.

And to marry the combination of good seating with good splinting together in a comfortable way that impacts on your goals, which could be accessing technology, it might be driving your wheelchair, it might be using your iPad for your communication. But together we can do better sometimes than some, some device or a splint even on its own.

Lots of times we need the combination of both, particularly in the group , where tone is a real issue for them. 

Anton: That's brilliant. 

Justin: And I'll say probably a lot of our listeners, this is a wheelchair podcast, right? So we often think about the wheelchair, right? And whenever I see someone with tone, I'm looking at it in the lens of how do I configure the wheelchair to accommodate such tone. I think what might be fun is to look at two different types of tone that you might see, or two very common minds, which is cerebral palsy and post-stroke. So if I'm a therapist or a family member or anyone who's working with someone who's had a stroke, what's like step one? Because often you just see people in a sling, so just for anyone who's listening, if you have a stroke then the messages from our brain, the wires, you know, go into one side of the body may be affected. And then particularly with our shoulder, there's a high chance of dislocation and maybe you guys can explain why and what's happening to the shoulder specifically, and a very common treatment after the hospital stay will be like, "All right, let's put you in a sling so your shoulder doesn't sublux. We might put a tray on there to support your arm." At what point are we thinking about using a Second Skin? So specifically talking with stroke, what happens to people post stroke? What is commonly done and what do you guys think should be done? What are people are missing in this therapeutic process?

Andrea and Cathy: So from the perspective of stroke, usually the brain has the bleed on one side and the opposite side is affected. A lot of the times I would firstly say to clinicians, use your eyes and your hands and see what's going on. Because how you see someone sitting statically is not all you need. You need to see what active movement they've got, if any, and what passive range they've got. Because that passive range will give you clues into subluxation, the risk of subluxation and presence of subluxation, but also the... the way someone feels, and if they have any pain. Usually clients with stroke have one side affected, and you will see if you look at them, and Justin and I have talked about this, that you will see it's not just affects the upper limb or the lower limb. Their whole side of their body is affected because the muscle tone, which we talked about earlier, is not what it used to be. So what that means is the spasticity is causing changes to their body and their joints and their positioning and their ability for their body to hold themselves up in a symmetrical way.

So you will usually see with clients with stroke that they, a lower on one side and higher on the other from a trunk perspective. So if you're looking at someone from a wheelchair seating perspective, you'll need to look at that. And we all know that the trunk and the pelvis is the center of the universe when it comes to wheelchair seating.

Same thing with looking at someone post-stroke. What is happening proximally? Because that's where your arms or lower limbs and head is supported. What sometimes happens with clients is that the weight of an arm after a stroke, because they don't have the muscle tone and ability to regulate that tone, then stretches the soft tissue around the shoulder, and I'm quite sure on all of our placements we would've felt some subluxation and had all levels of confusion around that. So essentially that's where the joint, well it's not a joint, it's the contact of three bones that come together: The scapula, the clavicle, and the humeral head; They come apart. And it stretches the surrounding soft tissue around that area. That can cause a lot of pain for people and there is a lot of research and evidence around the presence of that and the pain associations and the pain that comes 5, 10, 15 years later. You will also find that those clients don't have the movement that they used to have.

So they don't, we all move every minute of every day in some way. And if you are sitting in the same position all the time, those muscles are going to go in sympathy and they're going to think, 'oh, this is my new short position. I'll just stay here.' So back at uni we all learn about muscle sarcomeres and all those fancy words. Those things change your joint viscosity, the fluid in your joints, the length of your tendons and your ligaments. They aren't as, you know, stretching, elastic as they used to be. The  sarcomeres and your muscles are reduced. And then that's the secondary complications that we are trying to work on with splinting for, let's say brain injury, stroke, that type of thing, that people aren't moving like they used to. And because of that, then they become, they either get into a stuck kind of position, which is the contracture that you would hear. So what we're trying to do for the long-term chronic population, we are trying to make sure that those secondary complications don't have impacts on their ability to reach their goals and do the things they want to do. Because if you can't get dressed to go out to go shopping, or can't get dressed to go out and get your nails done, or go to the choir that you attend because you've got so much pain, or it takes you twice the amount of time to prepare to get ready, that's not reaching their goals that are important to them. So what can we do to help the chronic population not be affected so much by the secondary implications of spasticity. Because we all, they all live a long life. They're all wonderful people who live these long lives and we need to support them. So that's kind of the stroke population. Cathy, do you want to talk CP stuff? 

Justin: Before we talk about CP Andrea?

Andrea and Cathy: Yes. 

Justin: Why don't we just put them, why don't we just put them in a sling? Everything you said makes sense. Their shoulders going weak, they can't support it, the weight of their arm; especially Anton's pythons mate, if Anton had one his arm would be so big and heavy and it would fall down! So why not just put someone in a sling?

Anton: I'm currently taking my top off to show- No, I'm joking! 

Justin: It.seems like the common practice is put them in a, you know, if I'm a hospital OT, discharge him with a folding wheelchair, maybe a lever driver or a foot propeller and put them in a sling. What's the issue with that? 

Andrea and Cathy: The issue with that is if there is some capacity for you to regain some of your function in that limb, even to use it as an assist, prop something with it, keep something steady on your table, none of that's going to happen when you've got a sling on. And so anyone who's got any level of return of movement or the capacity to develop that, is going to be limited by wearing a sling. It definitely, it's deleterious for your balance. It makes it very hard to balance when you're standing and transferring, getting from your wheelchair to your bed and back. If you've got one arm tucked in very closely next to you, and it can actually increase pain rather than decrease pain because you also then limit your ability to have any passive movement happening as well as active movement happening. You can get a very hypersensitive arm as a consequence of keeping your sling on too long, so you won't see slings used long term almost anywhere that we go anymore. Sometimes it's a short term intervention as a first step, if you've got lots of pain and you're just starting to get on your feet. But it's not recommended as a long term intervention to support shoulders after stroke. 

Justin: I saw a client yesterday who had a stroke 20 years ago who was still in a sling. You can roll it around. And this is what I mean because Anton, it might be pretty similar of what you see as well, is what people are doing. And so, that's interesting to note as well. So to know that post-stroke, it's not like a spinal cord injury where, you know, the electrical wires that we're referring to are cut off.

They're more... they're struggling to,to come through. But you're saying there is capacity maybe not to get full range of motion, and it depends on the level of, or the level of injury, but there is capacity to build that strength from that side and they should be doing that. And they can't do that with the sling, so how can they do it with the Second Skin?

Or is there, is there a step before we start to look at Second Skin like trays or Andrea, we spoke about the Bodypoint modular arm support, like what are you, are these steps before or should we going straight to Second Skin or something around this nature? What's the next step from here? 

Andrea and Cathy: So particularly post stroke brain injury people have the capacity to build connections and change, you know, their movement capacity. It's a thing called neuroplasticity and there's a really great book by Dr. Norman Noy, sorry, Norman Doidge, who wrote really two really excellent books actually talking about the capacity that everyone has for neuroplasticity after injury. The big thing for people with stroke is giving, finding the balance between restricting and full movement; Restricting someone, but allowing movement. So you need to figure out how you provide someone with a less restrictive device, but something that supports. So a lot of people have a little bit of movement, so how can we work on that? Well, Second Skin splints I've used clinically for a very long time, and have been a great middle ground between restricting someone and giving them nothing. So it uses multiple layers of fabric, with directional line of pull to support, for example for someone with a shoulder involvement post-stroke, you want to look at getting some external rotation of that humeral head. You don't want them to be internally rotated because then there's no capacity for them to get a shirt on or wash onto their arm or put deodorant on so you want a bit of- 

Justin: Internal rotation meaning a sling. So someone in a sling is not what we want. We want them ... So slings are good for reducing depression in the shoulder, so the shoulder going down. So it helps elevate the shoulder, but it's not helping us with the internal rotation. So now we need to focus on getting some sort of external rotation. And from what you're saying, it needs to be more active rather than just passive. And is that what it does? Like is your splint an active splint or is there a passive splint? Is there differences?

Andrea and Cathy: So can our sleeves try to elevate that humeral head back to where it should live and do some external rotation of the humeral head and instead of the curved kind of posture we need to work on getting some scapula involvement to open up the chest. Because you will see a lot of clients, you know, that hunchback of Notre Dame curved, an arm sitting really close to their midline. We want to open up that chest. I can think of a client that we saw at the sunny coast last year, a lovely elderly gentleman and delightful wife, and he was in that exact position and had pain, so much pain. And he was very early on in his stroke journey and we said to him, "We can do better here!" And we got a shoulder and elbow splint for him, so we opened up his chest. We did some external rotation, got some scapular involvement and we helped support his elbow, so that he could do some standing with his excellent EP to support him to reach his goals.

Justin: Can I ask is that, how soon after the stroke is that intervention expected to be done? 

Andrea and Cathy: Look, he, he came to us I think he was about 18 months post-stroke. Some people come to us very early on and some people come to us, you know, 10, 15 years post and think and say to us, "Why haven't I heard of you before?!"

Justin: And in an ideal world, maybe this is tooting your, tooting your own products horn, but in an ideal world should everyone be in a splint? Is it your contention that we should be splinting everyone really early on to prevent because prevention's better, or is it more let's see what happens after 12 months, then we start looking at splints.

Andrea and Cathy: I think there's two ways to think of that Justin, is that you need to think about what people's goals are and the capacity for neuroplasticity and what... what avenues they want to take to manage that. Because there's that population who are really engaged in that rehab and, and really want to give that a really great crack. And that's really important early on from a whole task specific repetitive practice mantra that's tutored in the OT physio world. Then I think that there is another population, particularly a pain population, because pain has such an impact on people from the perspective of social withdrawal and isolation that they don't want to do and participate because of the pain. If you've got people like that very early on in their stroke, you've got to try something to help them, don't you? You know that's important, because we can do better for them and they need to be given the opportunity to try different things to help them. But I think like any other device, there's got to be very sound clinical reason why you would prescribe it. So we are looking for those issues of pain, someone where we could facilitate a change in function, someone where we could facilitate some of that return of movement if possible. Or someone where we need to protect that limb for the future because we know we've got a lot of pain early on that's not resolving. Or we've got swelling in their hand, we've got spasticity in their limb that everyone can see early on needs to be managed well. And there's many other techniques out there obviously to manage spasticity. We're not the only thing that people would use as an intervention. But we're certainly looking to be part of that picture for clinical goals that we can achieve for each client.

So everyone would have to be assessed individually to see what it is we can achieve with what we can do, and we'd be the first to say it's not the right thing to do. If it's not the right thing to do us, it'll be the right thing to do some other things as well. So part of our job is to say whether what we do is going to achieve those goals, or whether we think, no, it's not, it's not indicated for you, it's not going to achieve what you are looking for. We would then refer you to other practitioners for other interventions. 

Justin: Okay. Who's not... who's not right for this sort of intervention post-stroke? 

Andrea and Cathy: Well, let me think about that. Someone who doesn't have any pain, who's actually getting some nice return of function very successfully and doesn't need an intervention to facilitate that; they're doing really well with their active therapy program. That would be the first group that I would think about. Someone where we need something else to happen as well as what we could offer in order to get the best outcome. So if someone really has a very high level of spasticity and needs some botulinum toxin injections to relax some of that spasticity and allow us to do what we do. There are some people we would say it's not possible to do what we do successfully without those two interventions together. And there's others, from even from a postural point of view that would, would arrive in seating that's not suitable, where we would say we would need the seat first so that you are well positioned to then see what's the other component of your posture that we could address as well. So there's always something else that goes with what we do in the vast majority of clients that we would see. 

Anton: That's, I'm just, I honestly, I'm sucking it in guys. I'm, I'm taking it all in and there's just so much benefit to listening. No honestly, I'm really glad, like I, I actually am at the point where I don't really care if this is a podcast or not. I'm just really selfishly enjoying taking this information in. But I've got, I've got a few questions like that are relevant to, to everyone I guess. So like as a, as somebody who supplies seating myself, wheelchair or static seating in the home et cetera, for both children and adults there's a few things that I have to ask you, and I just want your opinion, like your advice. So I think this is relative to whatever we're supplying; How do you manage people's expectations? Because expectation is a huge thing, right? So you're coming in, you know, therapists has said, "Oh guys, you know, I've got Andrea, I've got Cathy coming in the Second Skin! It's really worked for my clients.

It's really great." Or "Justin's coming, he's got an amazing wheelchair" and this, that and the other and it's like the person's now built up and it's like, 'okay, this is going to change my life. This is going to do it.' I think that's a real, I think we want to highlight that because it's not a magic suit. It's not a magic splint. It's not a magic wheelchair. Right? Oh, here we go. Yeah and I want to know, I want to know how you manage that, first question, so I'll let you answer that first. 

Andrea and Cathy: Yeah. Wow. Very differently with each client, depending on who we are talking to, as to how we would tackle that. First, first we have to ask a lot of questions about what's going on. So I think we ask lots of questions about everything from your lifestyle, to your social situation, to issues around pain and function, what kind of history you've had before with other devices; That often gives us a really good clue of where to go. And lots of questions about what's top of your list. What's the biggest goal that you are looking to achieve? And that tells you a lot of things about that situation because some people present with a goal that you think yeah, straight on the bat, that's exactly where we are going. They might say, "I'd like to be able to drive my electric wheelchair more easily." That's a goal that often we can achieve and look at that and think, how do we do that? If you've got someone who comes in and isn't walking and says, "I'd really like to walk" and has no ability at this point to sit independently or stand independently, then that's not something that any device is going to achieve. And so it's how do we build that gap and how, how do we bridge across that gap? First I've got to find out if that's where you are thinking you want to get to, and then work out what we could offer. And so our conversation is often a long one down that direction to work out what we can do. And then I think you've got to be really honest and say "I don't think we can achieve this, but I do think, what I do think is this, and this is why I think this would be an achievable goal for you," because people will get onto the, onto that achievable goal, I think if they've got the opportunity to think about 'what is it I really want?' So if you can't transfer from your wheelchair to the toilet, I'm not talking about walking at this point. I might be having a conversation about walker use, and have you got one coming and are you thinking about trialing a walker? But I wouldn't be saying, "Let's get a splint because we are going to make a difference to your walking." I'd be looking at how do we get, how do we help you achieve more independence in your transfers as the first step. So we've got to be really honest with people I think about what you can achieve and what you can't. Because if you build up that expectation, you're going to have very disappointed people with any device saying that just doesn't do what you said it was going to do. 

Yeah. Don't ever say you can do something and don't deliver it is my mantra. Yeah. Don't ever promise something you can't deliver.

Anton: I think my wife kind of regretting that now guys. 

Andrea and Cathy: It's true though, it isn't shopping, it's not Father Christmas, it's not any of those things. It's about sound clinical reasoning behind what we can all achieve for people.

Anton: Yeah, that's good advice. 

Andrea and Cathy: That gives them a sense, well it gives them a sense of winning in terms of the success that they're able to, and we often say to each other, "We have to get a win! We have to get a win!" And that's what we're looking for. But what, what's the win for you is very different to a win for the next person. So I think you've got to be honest in a very professional way and reason you way through to a more successful goal. 

Justin: Oh, absolutely. I thought that was extremely sound advice guys. [00:35:00] Guys, I would actually love to dive even more into CP and things like that, but we might be running out of time for today's episode. So I think maybe what will be a fun thing to do is let's keep this episode as post-stroke, which I think was very informative, I think we covered quite a bit in terms of what to do post-stroke and the kind of interventions we should be thinking about. Before we wrap up today's session, do you guys have any good, I guess, win stories of stroke clients that you've worked with that have really stuck out for you, that you might want to share for us so we can end today on a, on a beautiful note.

Andrea and Cathy: So many! So many, so many!

Justin: I always find this question so hard when people ask me about wheelchairs. I'm like, 'oh, I don't know. Do you want me to tell you this week?!' Like-

Andrea and Cathy: We had a lovely lady, let's call her Betty, who had a wonderful mom who pushed everything and pushed boundaries as a child. And then she got to angsty teenage years and kind of disengaged. And then she got on with life. Very intelligent lady, got married, had some kids, and you know, we all get old things start to happen. So she was really starting to get some pain in her shoulder. She reported to us that she was going for weekly physio, weekly massage, you know, working, raising three kids. She came to us because she'd been brought to us back in the day as a kid by her mum and she talked about how she wanted to get her pain under control in her shoulder because she spent a good 40 years with, you know, an upper limb that's quite severely affected by spasticity, and tried to just manage it and muddle her way through. She got an arm and hand splint from us, but we talked to her about reconsidering Botox as well as splinting. She went and got some Botox, and came back to us with a lovely compliment of the combination of her botulinum toxin and her splint changing her life. Even her husband said to her, you are a different woman. She essentially said to us, "Is this what people feel pain-free? Is this what life can be like pain-free? This is incredible. I never thought this was normal to be pain free." She was able to go over to, was it the USA and do some presentations and study work with her work over at one of the universities over there. She was able to get on a plane, and do those things pain free, and she never thought she would be able to do that. And I think that's one of the big things that, one of the big compliments that made us smile,

because this intelligent lady... yeah, contributes amazing things to the world. We're still able to achieve something, you know, 40 years down the track after her original injury. We've currently got a lovely gentleman who plays competitive lawn boules. He's just delightful. He's probably six foot tall. Yes, he's very tall. And he has a non-functional limb after his stroke. He's had some pain in his shoulder and a limb that flails around; it's very hard to control. So we've made him an arm splint that's got some additional stability in it to keep that limb stable when he is balancing to play playing boules! Because it's very difficult to play lawn boules when you've got one arm swinging across in front of you when you're trying to maintain your balance. He's seriously competitive. Like he, he would beat the pants off all of us with his lawn boules skills ten times over, and so our goal for him was to do with positioning of that limb shoulder pain, but most importantly lawn boules. 

Anton: Amazing, amazing stories guys. Thank you so much. Thank you so much. I would love you guys to be on another episode, if that was cool with you, because I think we really want to get drilled into the CP side of things as well; So cerebral palsy. 

Andrea and Cathy: We would love to.

Anton: And understand the suit as well in terms of how that actually does help because I know there's going to be people listening going, 'tell me more. I want to know how this is going to actually, I'd like, tell me more about it.' So I think there's definitely another session in there. Justin, how you feeling about that? 

Justin: Yeah, ab-absolutely. I think there's more sessions in terms about, from my understanding, like there's sensory, like you know, having the compression garments, there's some sensory component to it that's more than just, you know, maybe a lateral support, you know, there's a bit more to it and like about the compression garment, so I'm excited for that. But just to summarise today in terms of takeaway points that I took on, tone is on a spectrum. Well, tone is basically your resting, your resting state of muscles. Sometimes your resting state is disrupted by an injury or something that you're born with and the signals aren't getting passed down to your body; whether it's not enough, whether it's too much, whether it's up and down, fluctuating. And that's why hopefully maybe in the future it'll be called a spasticity 'syndrome.' Syndrome! And in terms of like some, like early interventions key. No matter what you're doing, whether it be a Second Skin, whether it be a tray or sling or anything early interventions key, particularly for post-stroke. And the reason why you might consider something like a Second Skin is because you want to reduce the- you need to have goals, so whether it be a functional goal or even just a pain, pain reduction goal, which is quite good. And the ideal position that we want to encourage is contrary to what people might believe, which is external rotation but not too much external rotation where you tear something and we want to have the shoulder and not an elevated, but in a neutral height position from there... yeah! Is that a fair summary of today's chat? 

Anton: Amazing. Listen, Justin- 

Andrea and Cathy: One thing Justin; spasticity is over people's lifetime and it's important that we ensure we don't just look at it once and then look at a look at things again. You know, people change and move over time and we need to make sure that we keep on top of these things, yeah. 

Justin: And that, that would be a big talking point I think in our next episode where we talk about tone management over a lifetime, specifically for people with cerebral palsy. 

Andrea and Cathy: Sounds fabulous. Thank you for having us. 

Justin: Fabulous guys. 

Anton: No, listen for everyone listening, please don't forget to click like, and subscribe and also send in all your questions. We're receiving lots and we will always strive to answer those or get back, but we'll also try and raise them in, in the, of the episodes or podcasts that are future and upcoming. So if you have enjoyed listening to Andrea and Cathy, which I have hugely enjoyed, I know Justin will have as well, please do get in touch and we will look forward to seeing everyone and hearing and listening and talking to everyone soon.

Thanks everyone. Take care. You'll be listening to Wheel Chat. 

Justin: Thanks guys. Thanks Andrea and Cathy.

Andrea and Cathy: Thank you.