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Case of Excellence: John

“It's always been important to be as free as I still can be.” 

When we meet John, he shares with us that he has been experiencing limitations in his health and function related to his seating and wheeled mobility solutions. Through a collaborative approach between John, his clinical team and Permobil, adjustments were completed to his existing set-up and new equipment was installed. We followed John along this journey and here are the results of what he shared with us.  

John is a 43 year old artist, welder, athlete, and world traveler who resides in Belgium. He is extremely independent and has always placed high value on being self-sufficient since his accident in 2005 which resulted in paraplegia of the trunk and lower extremities. He does have a medical history of recurring pressure injuries on his sacrum and spine as well as fluctuating levels of pain in the upper extremities.  

Just as many individuals experienced, the global pandemic resulted in a reduction in activity level and travel for John. As a result, he experienced a variety of physiological and psychological changes. 

It was hoped that new seating and wheeled mobility would aid in his healing and function, however, he still had the following limitations in body functions and structures, activities and participation.

”I was out all the time before. I was doing miles everyday and now I feel like I can’t do it anymore because if I would go out today and just ride with my wheelchair, tomorrow my shoulders would be completely wrecked.. I would wake up at night having to move my arms for two minutes for the pain to go away.”  

Comparison table of John's pre and post intervention

Pre-intervention limitations

  • Body functions and structures

    • Loss of muscle mass impairing his sitting posture and comfort 
    • Pain in both the right and left shoulder 
    • Decreased upper extremity range of motion  
    • Sleep-related issues due to pain 
    • Category II [Stage 2] pressure injury on the left ischial tuberosity (IT)
    • Reducible postural asymmetry: Left pelvic obliquity, right pelvic rotation, posterior pelvic tilt, left trunk deviation (lean), thoracic kyphosis and cervical hyperextension 

  • Activities 

    • Unable to complete typical activities of daily living due to limited overhead reaching
    • Challenges with using his wheelchair for grocery shopping as he is unable to propel the distance required
    • Limitations in his physical exercise activities, as every day propulsion results in pain and fatigue
    • Stability in his chair was limited as his pelvis tended to slide forward with activity throughout  the day.  

    “Before I would easily do 10 km per day. I would get the groceries, then at noon I went to the forest where my friends were. I would then go back to eat and take a long walk with my dog and then back to my friends to go to the beach to sit there for the sunset.”   

  • Participation  

    • Limitations on how long he can work on his art and welding due to challenges handling the tools required
    • Decreased involvement in social activities as he is not able to propel the distance required
    • Limited travel opportunities 
”My hope is that there are no more external factors that keep me from having a normal physical life in the way that I can, but I need to work on my physical condition, and I feel as if right now I can't. I can’t do it because of my chair it is not well configured.”  
”My hope is that there are no more external factors that keep me from having a normal physical life in the way that I can, but I need to work on my physical condition, and I feel as if right now I can't. I can’t do it because of my chair it is not well configured.”  
”My hope is that there are no more external factors that keep me from having a normal physical life in the way that I can, but I need to work on my physical condition, and I feel as if right now I can't. I can’t do it because of my chair it is not well configured.”  
”My hope is that there are no more external factors that keep me from having a normal physical life in the way that I can, but I need to work on my physical condition, and I feel as if right now I can't. I can’t do it because of my chair it is not well configured.”  

John's goals

John's goals

After discussion with John and his clinical team, it was determined that he had the following seating and mobility goals:
•    Better positioning 
•    Pain reduction
•    Heal pressure injury
•    Reclaim previous active physical life outdoors
•    Increased possibility for social interaction.

To achieve these goals, it was determined that the configuration of his manual wheelchair should be adjusted as well as to recommend as a more supportive back support and a seat cushion that could provide more off-loading of his ischial tuberosity as well as improved stability throughout the day.

Outcomes 1: Body functions & structures

When we meet with John again, it is two months after his manual wheelchair was adjusted and he received his new back support and seat cushion. Looking at his outcomes from an ICF standpoint he following changes were observed: 

  • Overall improved physiological and psychological well-bein
  • Reduced shoulder pain
  • Healed category II (stage 2) pressure injury on left IT
  • Improved digestion and bowel control
  • Reduced postural impairments

Pressure injury status was scored with the Bates-Jensen Wound Assessment Tool (BWAT). The BWAT is an international tool to monitor and measure the healing process. There are a variety of wound characteristics that are evaluated over time including the size and depth of the pressure injury, if there is any type of exudate (drainage), the skin color, if there is edema or softening of the skin areas, and if there is presence of new blood cells. Out of the total items that are scored, the goal is to obtain a low score, where the numbers can range from 9-65.   

Pre-intervention his BWAT score was 29. Post-intervention his BWAT score was reduced to 13. This is representative of a healed Stage 2 pressure injury.

As John was using the ROHO Hybrid Select with the optional air insert, once his pressure injured was closed and healed, his clinical team determined to then use the optional insert to improve overall seating surface pressure redistribution.*

Outcomes 2: Activities

  • Ability to propel the distance needed to go to the grocery store
  • No limitations in overhead reaching
  • Regular workouts for strength and endurance
  • Improved stability as pelvis does not slide out as much during activities
  • Improved propulsion stroke.

"The most important [thing] to me is to move because I feel that if I am not moving, I am suffering more from my shoulder."

Front view comparison

  • Pre-intervention

    Note left trunk lean, pelvic rotation and pelvic obliquity

  • Post-intervention

    Reduced trunk lean, pelvic rotation and thoracic kyphosis
Lateral view comparison

  • Pre-intervention

    Note thoracic kyphosis, posterior pelvic tilt and cervical hyper extension.

  • Post-intervention

    Post-intervention: reduced thoracic kyphosis, posterior pelvic tilt and cervical hyper extension

     

Research shows

  • Mobility base:

    • When individually configured allows individuals to perform wheelchair skills.
    • Reduces shoulder pain when individually configured.
    • By reducing the onset of repetitive strain injury, a individually configured chair can reduce shoulder pain and dysfunction.

  • Seating system:

    • Reduces shoulder pain by providing postural support and control 
    • Promotes skin and soft tissue protection and provides an environment for wound healting when a cushion provides optional off-loading of the ITs 

Outcomes 3: Participation

  • Increased frequency and opportunity to socialize with others, especially outside of the home
  • Sitting tolerance improved to where he felt comfortable and stable to support returning to his artwork
  • Gained employment working with heavy machinery polishing materials.

All seating and mobility goals reached. 

References
Full list of references used to develop this Case Report
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