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Occupational Therapy (OT) is a vast and varied profession.
One of its many specialisms is wheelchair services; traditionally a National Health Service (NHS) service in the UK, but more increasingly becoming a privately contracted one. Many occupational therapists (OTs) may not know much about the breadth of wheelchair provision or consider it as an area of practice. Wheelchair services have unfortunately received a negative view in the press in recent years, which I believe discredits the amazing work that goes unreported. It is a specialist clinical service, troubled by complicated commissioning, resulting in a postcode lottery of provision.
When you unpick wheelchair services, you see the complex depths of wheelchair prescription is completely individual - and why wouldn’t it be? No two people are the same or have the same requirements from a wheelchair.
The day usually begins with tea, because who can function without a first cup of tea in the morning?! I scan through my emails, then to my running sheet for the day. This lists my appointments and whether they are clinics or home visits. As a service, we try to see as many people as we can in clinic, because we have the facilities required for a thorough assessment. People don’t generally have a plinth in their home, or a variety of transfer equipment; plus the travel time around the county means that not as many people can be seen within the same time frame.
For each of my planned appointments that day, I read through the referral forms, what the appointment is planned for and any recent previous assessments, check what equipment they currently have on issue and make a note of their diagnoses, thinking about how that may impact their function. Then it’s time for our clinical team 'daily huddle'. We sometimes refer to it as our 'daily cuddle', because this is the platform where we support each other as a team, share clinical cases, make joint decisions and discuss any pressing issues.
My first appointment is a gentleman with multiple sclerosis (MS) who uses a powered wheelchair. His hand function has been deteriorating and he is now finding it more difficult to use the joystick to control the wheelchair independently. His fingers are flexed into a fist and despite using night-time splints, he is unable to open his fingers towards the end of the day. His shoulder is getting stiff and he can no longer rest his arm straight on the armrest. So we explore moving his controls, so that they are mounted on a tray across his lap, instead of on the armrest. We try out some different shaped joystick knobs, finding that a chin cup works well and he can still move this around using the outside edge of his fist. With support from our Rehabilitation Engineering Technician, parts are identified to change his controls. We agree to order them and arrange a follow-up appointment for them to be fitted.
After a quick write up, the next appointment is to hand over a self-propelling wheelchair to a 5 year old girl who has always used a buggy until now. She has cerebral palsy, which mainly affects her legs. Her mother lifts her into the wheelchair and, after a few minor adjustments, she is keen to get moving. She doesn’t require much instruction on how to self-propel before she is off and squealing with delight. "Wow, I can move myself!" Her little brother is fixated with the flashing lights that shine brightly from her front castors. Her parents chose them as a 'top up' personal wheelchair budget, so they would match the flashing lights her brother has on his scooter and they can both light up on the way to school. After signing their conditions of loan, they are on their way. I write up their notes and close the referral as completed.
My next appointment is a lady with a spinal cord injury, has developed a pressure ulcer on her sacrum. We discuss:
her daily routine
how she transfers
what clothing she generally wears
how long she spends sitting in her wheelchair
what mattress she has on her bed
whether she sits anywhere else during the day
From this discussion - and by reviewing her position in the wheelchair - it appears that she is sitting with a posteriorly tilted pelvis. This means that a lot of her weight is going down through her sacrum. She is hoisted out to the plinth, to assess her posture outside of the wheelchair. She is able to sit with a neutral pelvis, so it is not a limitation of her body structure that is causing the pressure ulcer. We decide to pressure map to ensure the cushion is providing the correct support. This involves her sitting on a pad across the top of her cushion, which then projects an image of her bottom to the computer screen - a bit like a weather map - showing areas of blue/green for even pressure and orange/red for high peaks. She is hoisted back into the wheelchair. The image shows she has a high peak centrally at the back, where her sacrum is located (and at the exact point of her pressure ulcer). She is then re-hoisted, using the longest loop on the leg strap of her hoist sling. The pressure map is now fully blue/green.
She is amazed that something so simple can create such a difference to her position and reports that she feels as though she is sitting more upright - and will discuss it with her carers when she gets home.
Time for lunch and then I’m on duty for the afternoon. This involves answering queries and taking calls from service users and therapists. First, a gentleman whose cushion is worn out and needs replacing. I source one off the shelf, label it up in the warehouse and request delivery by our repair team. Next is a student at college with a broken harness strap, so I find a replacement in the warehouse and check who is available. One of our Rehabilitation Engineering Technicians has had a cancelled appointment, so is able to fit it for him at college, before he’s due home on transport. I take a couple of queries from OTs in hospitals, who want to discuss cases they are considering referring, to clarify eligibility criteria. Each phone call requires a write-up, so it’s a slow process. However, I feel satisfied that I have made a difference and sorted out some issues for people. I round off my day by checking in with the two therapists that I supervise. I ask how their appointments have gone and if they need any support. One of them is running an approved prescriber training course the next day for community therapists, so I help him set out some wheelchairs and accessories ready for the morning. Then it’s home time.
No two days are the same. It’s such a varied and challenging role, with the added value of working autonomously, but also within a supportive team.
I think a lot of OTs have a perception that working in wheelchair services would 'de-skill' them, but that couldn’t be further from the truth. The core values of our profession are about participation in activity. Providing wheelchairs and postural supports are central to enabling people to be - and remain - active and engaged in daily life. If someone is unable to hold their head up independently, or needs to prop themselves on their arms to maintain an upright sitting position, how are they going to be able to engage in any meaningful activity? Postural management is a prerequisite to occupational performance and mobility is a human right. As wheelchair therapists, we do such an important job of enabling people to both do what they want to do and get to where they want to go. I love it and am a self-confessed 'wheelchair geek'!