THE ISSUE WITH powered mobility is a complicated one.
No doubt that the average powered wheelchair or scooter has the ability to transform lives of its users – an elderly man with osteoarthritic knees who has difficulty walking long-distance for medical appointments, the middle-aged housewife with poor endurance from a heart condition needs to go marketing, a teenager with muscular dystrophy has to get to school. Independence in mobility is achieved, and hence one may argue a better quality of life.
In recent years, spotting a powered-user out on the streets is no longer uncommon. You see them on the trains, in shopping malls and out in the neighbourhood hawker centres. Culturally, people no longer relate this with a disability but more so as an alternative mode of transportation. With more of such awareness in public, it is no wonder that referrals to healthcare professionals for prescription of these devices are increasing. The situation is likely also multifactorial – with the introduction of government-funded subsidies like Senior Mobility and Enabling Fund (SMF), an ageing population and the increasing accessibility of public places (or is it?).
And it puts the prescribing therapists in a tight situation.
(1) What do I assess? How do I train?
Seating and postural needs, vision, motor capabilities, cognition, home environment. Does it stop there? Research evidence does not converge onto a single assessment form (they should not) that is considered the gold-standard. And it becomes scarier if therapists are practicing in different ways; some go all out arranging multiple home visits and community outings to train wheelchair skills. On the other spectrum, some may choose to do only a one-trial assessment on hospital grounds and then proceeding to prescribe. Each healthcare institution may also differ from another in terms of assessment and training process. On what basis is our clinical reasoning robust enough to ascertain if a client is deemed fit to be using the powered device?
It also becomes a question of liability – should a client someday be involved in a motor-accident, who is liable? Was our assessment and documentation objective enough at that point in time to justify?
(2) To prescribe or not to prescribe?
Most of the cases that we receive for powered mobility prescription are of clients needing funding, or in the doctors’ opinion may require a therapist’s input in view of an acute medical condition like stroke. I have come across cases where black meets white. I am all for prescribing a powered wheelchair to aid in a client’s community ADLs, but there is something unsafe about the way he manoeuvres his wheelchair in crowded places. Is it a judgement error? Is it failing vision? Is it his risky personality? No matter how many times I step in to correct during trials, it never gets better. At what point do I stop training? Prescribing may put others at risks. But by not prescribing, you have to deal with the ugly situation of an unhappy client.
And it does not stop them from trying to obtain the same device at a different hospital. Our documentation systems are not yet at the stage whereby we have free access across regional health clusters. This puts us in a blind spot – as a prescribing therapist, I may not know that a client has failed an earlier powered mobility trial at a different hospital; unless the client is forthcoming enough.
(3) (Lack of) Regulations
None that I know of thus far. Those who would like a powered mobility device do not necessarily require assessment by a licensed therapist. They are free to purchase from external retailers if they can afford the cost. There are also no regulations by the relevant authorities as to speed limits for powered-users on pedestrian pathways.
(4) Knowing what’s available in the market
With so many devices available from different vendors, it is difficult to keep up-to-date with what is available for our clients. Aside from just knowing, it is just as challenging understanding the different technical specs of the device to match client’s needs. This is when good partnership with vendors matter. I appreciate having consigned devices at our workplace for trials, and having a community of learning amongst my therapist friends on their experiences with new devices.
(5) Maintenance beyond prescription
Many a times, therapists may unknowingly miss out educating a client on the maintenance of their powered mobility device. How often should they do maintenance checks? What to do when they are stuck outside with low-battery? Which vendor should they contact? Are these additional costs self-bourne?
(6) Barriers in the physical environment
As an occupational therapist, we are always looking at the fit between the person-environment-occupations. Sometimes, the person has been fitted to a prescribed powered mobility device but the environment poses challenges for its use. It is not until sitting on a wheelchair and experiencing it as a user did I realise the plethora of barriers in our community. Here are some examples:
The prescribing therapist needs to be able to anticipate these issues when performing a powered mobility assessment and training, to better-tailor interventions targeting essential wheelchair skills and problem-solving.
I am confident that as more and more referrals come in for such devices, our clinical reasoning is further shaped from personal and shared experiences with cases. However, more needs to be done to standardise the process and develop systems in-place to protect both licensed therapists (in objective prescription) and clients (in safety).
Looks like an exciting year ahead for learning!