Best Practice Guidelines for Use of Mobility Equipment within the Educational Environment

1. Best Practice Guidelines for Use of Mobility Equipment within the Educational Environment Department for Education Project 2011 – 2013

2. Outline of Presentation • Introduction • Advantages of independent mobility • Educational outcomes of independent mobility • Posture and seating • Wheelchair skills training • Risk assessments • Transitional stages • Transportation

3. Introduction to Whizz-Kidz • Medium sized national charity • Independence to enjoy an active childhood • Life Journey approach • Highly qualified mobility therapists • Partnership working within the NHS What we do • We give disabled children and young people across the UK customised mobility equipment, training, advice and life skills. • But more than this, we give them the independence to be themselves. We make an immediate and life changing difference to them, their families and their communities.

4. Introduction • Number of disabled children using assistive technology has increased by 60% (Long et al 2003) • Wheelchair as means to independence (Wiart et al 2003) • More prominent existence of wheelchairs in educational milieu • Developments in assistive technology provides increased opportunities for inclusion

5. Advantages of Independent Mobility • Children learn more about their world through movement • Interaction with people, objects and environment • Development of cognitive, emotional and psychological skills • Sense of achievement and autonomy, leading on to further exploration • Lack of independence may mean: • decreased motivation • reduced confidence • feelings of frustration • passive • incurious • learned helplessness • Nisbet 2002

6. Advantages of Independent Mobility • Research shows that children should be provided with access to a wheelchair to enable them to become independent as close as possible to the age when mobility would be occurring naturally within normal childhood development (Butler 1986)

7. Educational Outcomes of Independent Mobility Educational outcomes: Section 351 of Educational Act 1996: Promotes the spiritual, moral, cultural, mental and physical development of pupils at the school and of society. Prepares pupils at the school for the opportunities, responsibilities and experiences of adult life. • Specified National Curriculum standards • Attainment of formal qualifications • Friendships that will be made • Acceptable social behaviours that will be shaped

8. Educational Outcomes of Independent Mobility • Achievement of educational outcomes for disabled children requires: • An inclusive attitude • Adaptation of curriculum • Provision of right equipment at the right time • Including the children, parents, staff in decision making to reduce anxieties, increase confidence, and facilitate inclusion • Facilitate skills in the environment they are used • School staff to be involved in wheelchair skills training to be able to reinforce skills

9. Posture and Seating • What is posture? • The way we hold ourselves. • Three aims of seating intervention: • Maximise function • Minimize secondary complications • Facilitate comfort (Pope 2007)

10. Posture and Seating Good posture: Poor posture can lead to: Contractures and deformities Pressure ulcers Reduced function Respiratory difficulty and infections Urinary tract infections Digestive difficulties Discomfort and pain • Energy efficient • Enables function • Does not cause damage • (Pope 2007)

11. Posture and Seating Key stone pelvis • Posterior pelvic tilt • Anterior pelvic tilt • Pelvic obliquity • Pelvic rotation

12. Wheelchair dimensions - width • Seat width is usually close to the hip width or the widest part of the body. • Seat width too wide: • Pelvic obliquity and scoliosis • Impede access to wheels or joystick • Impact upon accessibility (i.e. doors) • Seat width too narrow: • Create rotational deformities • Cause discomfort • Increased risk of pressure areas

13. Wheelchair dimensions - depth • The seat depth should be slightly shorter than the upper leg length. • Seat depth too long: • Posterior pelvic tilt, slumping in the seat, sliding out of seat, pressure and shear • Increases overall frame length • Impede transfers • Seat depth too short: • Increased pressure on buttocks • Anterior pelvic tilt, drag on legs • Postural adaptation to have more base of support

14. Wheelchair Skills Training • A vital part of providing disabled children with wheelchairs means making sure they know how to use them to their full potential • How to get the most of the wheelchair • Improving confidence and independence • Achieving individual potential

15. Wheelchair Skills Training Whizz-Kidz delivers approximately 72 courses to 750 children and young people 40 schemes will be held within the school environment Involvement of school staff promotes a ‘carry-over’ effect of skills taught Increases teaching staff confidence and gives them the chance to see the equipment in use.

16. Grasp the hand-rims and push evenly with both hands. Position hands at 11 o’clock for starting the stroke. Release hands at 2 o’clock for finishing the stroke. Use smooth strokes matching the speed of the moving wheel. Avoid jerky accelerations that could cause the wheelchair to tip over backwards. Lean forward to avoid lifting the front wheels off the ground. Push with longer, less frequent strokes, allowing coasting where possible. Touch middle fingers onto the axles during recovery phase to reinforce a circular propulsion pattern. Basic Wheelchair Training Tips Manual Wheelchair – Moving forward on a flat surface

17. Wheelchair Training Tips Manual Wheelchair – Stopping • The rate of slowing can be controlled by how hard the hand-rims are gripped. The hand-rims should run through the wheelchair user’s hands. If the wheelchair user stops too quickly, they may tip over forwards. To prevent this, the wheelchair user should lean back whenever they are required to stop quickly. Manual Wheelchair – Turning whilst moving forward The turn should not begin until the axles rear wheels have reached the object (e.g. corner / wall) Slow down the inside wheel. Push harder on the outside wheel.

18. Wheelchair Training Tips Power Wheelchair – Moving and stopping • One person only taking charge and giving instructions. • The first instruction that a first time power chair user should understand is ‘stop’. • Driving the wheelchair in circles is an acceptable first time movement. • It is acceptable for the child to bump into things initially. • Consider greater rewards for following instructions. • Power wheelchairs may be rear-, front- or mid-wheel- drive. This affects the drive path and ease of moving wheelchair forward. • If the user is over-correcting when driving, changing the contact point with the joystick may improve the fluidity of the driving. • If the user’s hand control is limited, then alternative access can be considered.

19. Risk Assessment • School environment • Size and type of wheelchair prescribed is based on user’s needs, therefore the environment needs to be adapted: • Access to buildings and play areas • Steps • Steepness of ramps • Doorways and corridors • Turning space • Toileting and changing facilities • Storage and charging

20. Risk Assessment • Use of harnesses and belts • “…should never be provided for the purpose of preventing problem behaviour, although, in extreme circumstances, they might be used to manage risks.” DOH2002 • Multidisciplinary risk assessment • Documentation in care plan • Wheelchair providers policy will probably state for ‘postural use only’ but will not be in a position to monitor

21. Risk Assessment • Manual Handling • Legislation indicates best practice for pushing / pulling of wheelchairs (HSE, revised 2004) • Risk assessment for moving and handling • Slings left in situ might impact on postural and pressure management

22. Wheelchair provision during transitional stages Whizz-Kidz endeavours to pre-empt key transitional stages within a child and young person’s life, so that the right mobility equipment is provided at the right time. Primary School- to move from a buggy to a wheelchair • Independence • Interaction with peers • Element of growth in equipment • Low seat to ground height

23. Wheelchair provision during transitional stages Secondary School – to move towards powered mobility • Should be planned in proceeding 12 months • Powered mobility for less efficient self-propellers • Increase independence • Conserve energy • Risers for accessing alternative school environment

24. Wheelchair provision during transitional stages Adulthood – further education, employment, socialising • Additional features onto powered wheelchairs i.e. lights, indicators, increased speeds • Promote independence • Improve social, educational and employment interactions

25. Support during transitional stages • Ambassador Clubs • Kidz Unlimited • Skillz for Life • Camp Whizz-Kidz • Work Experience Placements

26. Guidance on the use of transport services • Minimum standards which are advocated for a user who travels in their wheelchair in a vehicle: • Users should transfer into vehicle seats if possible • Users should not travel with the wheelchair at an angle or facing sideways • Wheelchair brakes should be on and power switched off • Headrest should be provided • Wheelchair needs to be tied down and user is appropriately restrained • (Guidance on the Safe Transportation of Wheelchairs MDA 2001)

27. Guidance on the use of transport services • According to the MDA 2001: • “… in the small number of injuries and fatalities recorded, investigations reveal that the cause is rarely attributed to a piece of faulty equipment. The majority are the result of inappropriate, inadequate or incorrectly used equipment.” • Main problems include: • Lack of consistent communication • Lack of product information • Inadequate training • Inappropriate use of Wheelchair Tiedown and Occupant Restraint Systems • Not securing unoccupied wheelchairs • Incorrect use of tail lifts / ramps

28. Further Information • Whizz–Kidzwebpage • News and Resources • Guidance for Schools and Families • http://www.whizz-kidz.org.uk/newsandresources/guidance-for-schools-and-families/

29. References • Butler C (1986) Effects of Powered Mobility on Self-Initiated Behaviours of Very Young Children with Locomotor Disability Developmental Medicine & Child NeurologyVol 28: 325-332 • Department for Education and Skills (2004) Five Year Strategy for Children andLearners: putting people at the heart of public services London: HM Government • Department of Health (2002) Guidance for restrictive physical interventions: How to provide safe services for people with learning disabilities and autistic spectrum disorder London: Department of Health • Education Act (1996) (c.56) London: HMSO • Health and Safety Executive (2004) Manual Handling Operations Regulations 1992 (revised) • Health and Safety Executive (2011) Five Steps to Risk Assessment London: Health and Safety Executive

30. References continued • Long T, Huang L, Woodbridge M, Woolverton M, Minkel J (2003) Integrating Assistive Technology Into an Outcome-Driven Model of Service Delivery Infants and Young ChildrenVol 16(4): 272-283 • Medical Devices Agency (2001) Guidance on the Safe Transportation of Wheelchairs Belfast: Northern Ireland Adverse Incident Centre • NisbetPD (2002) Assessment and Training of Children for Powered Mobility in the UK Technology and DisabilityVol 14: 173-182 • Pauline Pope (2007) Severe and Complex Neurological Disability: Management of the Physical Condition Amsterdam: Elsevier • Wiart L, Darrah J, Cook A, Hollis V, May L (2003) Evaluation of Powered Mobility Use in Home and Community Environments Physical and Occupational Therapy in PaediatricsVol 23(2): 59-76