Welcome everyone to this course today on Power Wheelchair Driving Methods, my name is Michelle Lange, IM occupational therapist in the Denver Colorado area, one of the areas I have worked frequently, is working with power will chairs, most of the clients I work with personally are unable to emulate or use any type of manual wheelchair, many of the clients that require power will chair , it is important to explore driving methods available to our clients, for a variety of clients despite their must've -- Muscle tone. There are specific driving methods available to provide that independent mobility. We want to begin with disclosures here. I do present educational courses for a variety of companies, including stealth products, I do work with a variety of different driving methods from a variety of companies, I will present this equipment and information objectively as possible. As this course is CEU course we do have specific learning outcomes. Our goal, the participant will be able to list many indicators for various Troy -- Joystick placement locations. >> And compare and contrast newly available ahead arrays. What we will be covering in the course are wheelchair driving methods, these are categorized into main areas, proportional or referred to as analog, or non-proportional, sometimes referred to as digital. Proportional controls are comprised of joysticks. We will have a few other options to explore. Joysticks are most familiar to us, this is a common way to drive a power wheelchair, this is the way we drive a consumer level power chair alternative methods other than a joystick typically require complex electronics, expandable electronics, to use the joystick, it requires the driver to grade the force of their movement. If I cannot grade the force of the movement I might grab that too hard, or might not grab it hard enough and drop it, if I cannot grade the distance I might undershoot or overshoot, the same with jiving with the joystick, for people who have abnormal muscle tone particular , using this joystick is difficult. I have to balance in order to grade my movement, that is referred to as co-contraction, the joystick is used by the hand, I need to balance the extenders in my arm and hand , this is difficult for some of our clients to do, there are clients out there that are able to move a power wheelchair with the joystick, but not necessarily where they want to go we want to make sure they have that efficient control sometimes the client could use a joystick, if it was positioned in the best pot for them. It is important to look -- Best spot for them. It is important to look at the placement, most are mounted on the right side, most are right-handed, this may not match the pattern of movement of the client. I think sometimes we try to force the client to meet the parameters of the equipment. Rather than modifying the equipment to match the client skill set and abilities. Rather than pushing straightahead to the side of their body, parallel to that arm pad rest, that client may instead push it forward and across their body. In that case we can move it to capture that movement. This may require midline mount to support the joystick in that position. We can Ingold the box itself, so that it is matching the angle movement of the client in terms of relationship, moving that arm straight forward rather than across the body. And capturing the movement at the forearm. Many clients tend to primate their forearm -- They tend to extend their forearm a bit. When we accommodate these movements by placing the joystick in a less than typical placement, someone will come along and fix it for us whether we want them to or not. I will literally put a note to say it is crooked on purpose. Here are some of the examples of joystick mounts on the market . These all have some means to swing out of the way, now the joystick is in the front of the body. It does not have to be right midline, anywhere along the continuum to capture best the movement. Most of these are too difficult to get the joystick out-of-the-way independently, the client has to depend on someone else to get the joystick out of their way. There is something available in motion concepts, this particular power slink away joystick, this will allow a client, perhaps to have the ability to independently transfer, and go ahead to move the joystick out-of-the-way independently . Try to bring this back here. I pushing a switch the client can move the joystick out of their way, for transfers. There goes again. >> Now , we have a variety of alternative controls on the market, most of these are alternative joysticks. Let's start with the compact joystick. One of the advantages of some sort of compact joystick. It is smaller . Standard joystick box can be large. It can be difficult for clients who need midline placement. Or of short stature such as children. These particular compacts, it is called single switch, on the top of the joystick itself, is a button. That button if it is pressed by the client acts as a reset. >> Usually when the power wheelchair is turned on, it is in driving mode . If the client moves that joystick, the chair will move in response to that. These complex chairs are capable of far more than mobility, through their driving method, they can control their space for example. The client can change what speed they are driving in. The client can use the driving method to operate interfaced external device, such as a speech generated device, sending infrared such as a television, or a mouse for computer tablet control. There is a large amount they can do, but it requires the change of the motion of the chair, from driving to something else, typically , it requires a reset switch. The client can be in the driving mode, push the button, now they can tilt themselves to shift their weight. Some of the unique features, the top of this is textured. That allows the client to grab it dreadfully . They can not slip off of that surface. The top is nonrenewable -- Removable. If they use a great deal of force, to use that joystick they will not pool -- They will not pull that -- A joystick may not be their best method if they have not a lot of control. -- If they do not have a lot of control. These methods can be used for any feature, there are two switch Jack's on the bottom of the joystick that are at evaded ivies to buttons. Cable is plugged into the switch Jack's, this can act as a reset. It can act as a male click, or send one or two mouth signals to a speech generated device. SCD. Another compact joystick on the market, is from a relatively newcomer, called Mo-Vis, this compact switch has to Jack's on it -- 2 jacks On it, it holds its own mechanical switch. The toughest joystick is not proportional at all . -- Tough Joystick . -- In the Tough Joystick joystick, the chair will move in forward , left, right, reverse, we also have the diagnosis in between those for discrete directions. Why would we take away the control? In some control joysticks, if the user exerts a significant amount of force they will break the joystick, this is more, heavy-duty, to withstand these forces. Keep in mind, if someone is using so much force to drive their chair using the joystick, they are breaking that mechanism, chances are they are not driving with good control. They are not grading their force of the movement, they are driving with the joystick fully forward. It is difficult to turn and navigate the environment. If you are considering this joystick, make sure that it is the best way to utilize your chair. >> We do have this touchpad. It uses the same technology as the smart phone. It has a touchscreen. It works in 2 different modes. In absolute mode, the client needs to place a finger in the center of the screen, they can move from that Centerpoint. The farther the finger is moved from the center, the faster it will go. If the client can draw a little circle with their finger that is where it can go. This is designed to capture very light small movements. Making it appropriate for someone with weakness. Not all will find that Centerpoint, where center is wherever you start, you can drop your finger down wherever you like on the surface, and move from their. You can see in the picture there is a logo to switch at the bottom of the touchscreen, you can enable this to act as a reset, changing the mode of operation to the chair. If your client will accidentally run into this, it can be disabled so that you do not have to worry about that. This is a mounting option for the touchpad Trico -- For the touchpad -- Touch Pad . The display in the pictures mounted just above, while alternative driving methods, we cannot simply handoff, we want to make sure that they are mounted and that the client has support of whatever portion they are using to activate the driving method. Next we move into many proportional joysticks. >> Many proportionate joysticks, work just as the standard, we have 360 degrees of control in terms of direction. We have speed control built-in, the farther the joystick the faster the chair moves. The difference these do not require the same force and movement as standard joysticks. Standard joysticks require 250 pounds of pressure to activate, to achieve full speed. This particular many joystick, HMC , this is a fraction of what it requires, making this useful for people with muscle weakness. The drawback, of these many proportional joysticks, they tend to be fragile. That can be a drawback for some clients, we do not want these to be broken. Mounting, very important some who are using a many proportionate joystick, chances are, they have muscle weakness , sometimes the forearm and the hands need to be supported, only the the -- Only the discrete movement is required Urkel This pad is made for a variety of joysticks on the market, what is nice about this. Not only does it provide support for the hand, but protects the joystick somewhat . This is fragile, if it gets bumped during a transfer. Depending on the placement. The hand pad takes the hit rather than the joystick. We can change the height of the joystick, depending on how someone is using their finger or thumb, this joystick handle can be recessed with the surface of the hand pad, or protrude above it depending again on the individual and their unique needs. This is a micro extremity control, or MEC, this is made from adaptive switch lapse, ASL. This particular joystick, other than the fact it is wider than the other in the presentation, it acts as a reset , if you push down on the button, the client has to have a lot of ability to do so but not with a lot of force. You can see in the picture on the left, it is sticking up quite a ways. This may work well for someone who might rest , on the pinky side, and using their sound -- Some . -- They are using their thumb. -- >> I like the picture on the left. It shows it mounted on the end of in arm pad. This provides good support . If the client does not have good control, far off the body to the site, you can mount this again, making sure that we provide adequate forearm support as well. Mo-Vis, also offers that many proportional, this is called micro joystick, this particular one requires 10 g of force, one of the unique things of the Mo-Vis line, it has this unique box you see here, this fulfills a couple of options, it has to switch jacks on it one for power, one for mode. It also has a micro USB port, it allows a tablet or a computer to be connected for programming. There are programming options outside of the manufactures electronic system. Each of these power chairs has its own electronic system. For example, into care has Mark six, -- And QLogic -- As long -- Each package offers programming, also programs specifics in terms of the alternative driving method and how it works. This allows additional programming on top of electronics that impact how the joystick works. >> Adaptive switch lapse have the micro extremity control, that we thought a moment ago, this is their extremity control, it requires more pressure than MEC, it is field so that it is moisture resistant. One of the features, you can choose when the client pulls back on this extremity joystick, it would go into reverse -- Instead of going into reverse, it would act to vase -- Activate reset. Pulling back once give a reset command, then when I push forward instead of going forward, I will go reverse, pull back on reset again, and I am forward. Part of the reason this is moisture resistant, this degree of resistance, is often appropriate at the chin. Many fall into the range of 10 or 15 g of force, these work very well at the finger or thumb, we have others that have a slightly higher level of force in the 50 g range, these work well at the chin. Sometimes we have to deal with secretion. Many electronics, moisture is equipment failure. This helps us deal with secretions and other moisture , such as dirt and grime that can lead to equipment failure. This is the micro pilot, from Switch It, it is an isometric joystick, it relies on force instead of movement, there is extremely little movement in this, if the client pushes against it in a four -- Forward direction, the joystick has an adjustable force depending on your unique client. When this first came out -- These can be very helpful, many joysticks are by the chin, we do have some control of a joystick at this location, clients use circular call movements, or jaw movements to activate the joystick. Repenting -- Preventing the risk. The repetition of movement or the force, by using many proportionate joystick we are using this in reducing force. At the chin however if the level surface the client is not driving on, there is a little bit jarring that occurs, if the client is bounced around a bit, that can result in extraneous movement on the chair as the giant is moving on the joystick, it responds to force, less extraneous movement when used here . Parallel on the floor, you can see in the lower slide, the micro pilot has been mounted parallel to the floor, with most many joysticks this will not work because gravity will pull it downward and the joystick will move the chair on its own. Moving this in the flexed position, now the client can control the joystick in this position. If that is where they had best control, and not worry about the effects of gravity, this is isometric. Petrick -- Pictured here on the upper picture, is a fiber optics which -- This switch, it can be driven by the micro pilot, and cover the switch to act as a reset . High-fiber active switch does not require force. This is a variety of different methods. The lower center picture is a harness, used as a chin joy stick, the micro pilot does not move around, this U-shaped allows you to choose the best position to secure it in the location. Switches also make non-isometric joystick. Micro guide. -- The MicroGuide . Now I-Drive , is a new product from Stealth Products, most will , like Mo-Vis line, it can be programmed on its own directly through I-Drive software package on the computer or in a packet. Available on that individual package, which varies by manufacturer, we have additional programming parameters, that can be done through the software. This is the many proportionate joystick they have various styles and mounting options. >> You can see underneath there is a box. Basically a many CPU. We attach this to make this programming occur , you can see the available handles for this joystick and then on a swing away mound -- Mount. If we were to position a joystick at someone's chin for example. Or if a client is using Sip'n Puff , this is all possible to mount in a variety of ways, however the client might be stuck with this access method, or the hydration by their mouth all the time, there are some powers Swingle a options, by pressing a switch, you can get this out of the way. If I have driven up to my work desk, I can move it out of the way, until I'm ready to drive again. Mo-Vis has a power swing away mound, you can see here. Motion concepts has also a power swing away mound, we will -- Mount . We will watch it , you hear a quick video. The mount will lower , swing to the site, and then when the client pushes the switch again, the amount will rise and return to position, in front of the client. Again that kind being used for a variety of access , the Tough Joystick system has a few more programmable options to allow the client to determine how far they wanted to move to the side. Sometimes quite of a difference can be a challenge, because of obstacles that can be in the way. >> Continuing to work at the variety of many proportionate joysticks we have two us -- To us . Very small, like the micro pilot , an isometric joystick. If you remember computers, eraser top in the middle of the keyboard, controlled the mouse, this uses the same technology. Mounting it in a variety of ways, there is a hand pad, and a ring amount. This can be worn around a ring, and the client can use their them to move the joystick, and the power Wilcher -- Wheelchair. What are the proportions? To a standard joystick, this will require a standard distance, and minimal force to move the joystick. And to sustain the joystick in that forward position to continue moving the chair, a drawback, they can be fragile, and very difficult for anyone else for the client to operate. If funding is available, and there is -- The requirement or the caregiver requires an attendant joystick, MEC requires a reset by pushing downward. We have been mentioning they can be placed by a finger or a thumb, or a chin. If it is placed on the chin, it needs to be mounted on the swing away arm, a be able or a harnessed. We will see examples in the moment, use can lead to repetitive stress of the cervical area, we want to reduce that risk. Because we are reducing the amount of force on travel. Compared to a joy stick that is compact, although they are smaller, they do require the same amount of force as a standard joystick . These many joysticks are sensitive, it can be difficult, but the particularly to drive if the surface is not very smooth. Here are some examples of some of the mounting options we have, to the left we have a caller or a harness, or a bid. The advantage , these stay in relation to the client. If they are moving in relation to the sitting -- Seeding -- Moving from a seeding -- Seating Position. Moving in relation to the joystick, many clients can be referring the swing away bar, now I am not stuck at all times, if it is mealtime, someone will have to remove that harness. Now both adaptive switch labs, and Switch It , has developed a game control, you cannot just power it into the game control, but they have modified it already built into the control, they can be used to drive the chair. These controllers have an array of buttons. Those buttons can be programmed to operate almost anything. One of the buttons could control power, or reset switch, it can be programmed to control and power seat function. The challenge is, you cannot assign them in the field. You need to let the manufacture know I had a time, of what you want them to do. All will control the movement of the chair. Or perhaps it just moves forward and reverse, or left and right , what you want the buttons to do, when the client presses them. This works very well with [Indiscernible] , this joystick is too far away and requires force, the game control however can be held close to the body, midline, this is where they have better control, the joysticks do not require force, only about 40 or 50 g. This is the mushroom joystick. It is designed for clients, who cannot grasp a joystick handle. There are a lot of sticks out there, a variety. This is so the Palm can rest on the dome. The challenge as this is a standard joystick, it is stiff and requires 250 g to move it, the dome is very smooth and the clients slide off. Here is another one here, by [Indiscernible], unlike this smooth surface from stealth, this has a textures so that clients are less likely to slip off. Again for standard joystick. This would not work on a miniature joystick. >> Earlier we discussed the small joystick, this compact joystick is made by the power wheelchair manufacturers, and can be used to interface with other controls. This is an example. This is a foot control. Available from three manufacturers. HMC is now owned and distributed by [Indiscernible], available to be used on other tears as well. In this case, it is attached to a platform, up placed by the foot. You will strap the foot down , for it to work, you can see it is attached to a shoe holder with straps, when the client pushes it towards the chair it was forward, when the foot is pivoted to the line left or right, it moves in that corresponding direction. As much as the client can move their foot within 360 degree circle, that is where the chair will move. Which is forward, right, left, -- This works for a client who does not have good control perhaps of the upper extremities, but isolated control the foot. I have worked with a few clients who used a very well, maybe this wasn't the particular pattern of movement they used. In that case, you can still mount a joystick near the foot, the client can use whatever pattern works best for them. That same compact joystick can be attached to the proportionate arm control, available from switch it . >> Letting the hand drop down towards the floor, this moves the chair forward by lifting it towards the ceiling, it moves the chair in reverse, it turns the chair left and right. This works similarly to a mobile arm support. If you are working with the client, who would benefit from mobile arm support, doesn't have shoulder strength, they may be able to use this particular method. >> Another proportionate control is the head control. It also uses a compact joystick. Several companies make these. When the client pushes the head rear word, -- When they turn their head side to side, the chair is turned in that direction, there are different strategies for accessing reverse, usually a reset switches activated, you can see a switch pictured, it is designed for this feature. When the client activates the switch, Ford and reverse are toggled -- Forward and reverse are toggled. The proportionate head control, on the market when it was out was quite popular, for clients with fair head control. There was a problem, the client who had abnormal muscle tone, this sustained pressure against the rear pad required to move the forward action in the chair. Difficult each hot -- They had difficulty stopping. Overtime with driving long distance, they would have difficulty with relief and crashing into things, they moved over to technology called head array. We will discuss this in a bit. >> Another proportionate control, called Magitek it requires not just fair to good harkened -- Head control. >> It is an option for higher level spinal cord injury as opposed to using sip and puff -- Sip'n Puff . At the client moves the forward enough, the chair will move in the direction of the head, the farther they had moves the faster the chair goes. If this neutral drone --'s own is small, they really need to know the upright position. If the neutral zone is large they need to drive with exaggerated head movement. There are a couple new features available on Magitek in the last few years. First emergency stop switch port , if the client was in trouble driving, either the caregiver or the client can push the stop switch. It will shut down the system. The other feature, overrate. At the sudden amount of movement occurring to the sensor, example, if the sensor were to fall off someone's head, we do not want the chair to keep driving. The client would not have the ability to stop at that point, they could not return to neutral. Overrate shuts the system down. And the amount of movement is programmable . Over range, the client moves too far from center, then the client has a seizure, balls to their side, they do not return to neutral, the chair will stop so that the client knows they are safe. And mentioned earlier, and variety of joystick handles, some prefer a larger handle, a ball to break up tone for clients. I find personally if we are looking at lots of different handles, however the joystick may be difficult for the client use. One alternative, I usually use, goalpost style, primarily designed for people who do have control of the drive of the stick, but do not have good grasp. Maybe somebody who has see five or 66 -- If they have C5 or C6 . You can see here extension fifth switch, this switch sends a signal out to the reset, whatever the client desires . So that was a look at the various proportional driving message -- Methods. And other alternative proportionate controls, the advantage is that we have depending on the client and their skill set, full directional control, as well as speed control. Not everyone can use proportionate driving method, even alternative one, we can explore non-proportional, or digital driving methods. These non-proportional, all in essence use a switch . We can use a mechanical switch, electrical switches, or a combination of those. Let's dive in to see what these options are. Here are a whole horse -- Host of driving methods. We will discuss why we would use these with individual clients. What are the indicators. It is possible to drive a power wheelchair, with a calm nation of 1 to 5 switches. Ideally when I am working with the client I'm trying to find at least switch sites, if I cannot , they will be used for forward, left, and right. For a new driver, I'm not concerned right off the bat, these are very movable, and many clients cannot see behind them to back up, I may not offer reverse immediately, but to rely on left and right, and then as we added income the client will only use this to get them out of a tight spot, and rely on the other switches. If I can find that switch, we can make it reverse or reset, using this to allow the driver to access reverse. As well as a host of other features. If I can find five switches, I may choose to give them as separate version, usually for clients that have other needs, I am looking for four switch sites, to choose reset for those , can the client still drive? It is possible with only one switch. We will look at this in a moment. There are a couple of strategies out there as well, for clients that can only use two switches, to access full directional control. As well as reset. >> Single Switch scanning. Let's say in your assessment, you can only find one switch this client can use. Or perhaps two switches, can be sometimes that second switch is used as a reset. The client needs to be able to see and monitor the display. Either on the display of the power will chair itself, or -- Wheelchair itself, or the adaptive one shown here. In this external display there is a component, if it fits behind the chair, this is the red button, this allows the caregiver to use the switch as well, the piece he looks at, is pictured just below, there are some small white arrows, and then some lights come the client would push the switch, and a scan would begin, forward, right , reverse, left . What's the -- Once the derive desired direction -- What they want to move in that direction, down a hallway, they would push it once and release the scan will start. Hit and hold my switch. As long as I want to continue forward motion along the highway, if I have veered off course, I would release my switch, let the scan resume, choose the direction, and attempt my course. This could be a tedious way of driving from point a to point B. It does provide independent driving for clients who only have one or two switch sites. You can turn on auditory feedback to help the client, it is a sick it -- Second beep . Some other modifications will help, when someone is controlling interfaced communication device, or may need a larger display. >> Programming is very important with many access methods. You can program a scanner in turn certain directions. If eight directions are scanned, you can use the date nulls in between -- Diagonals in between our primary directions. We can change the direction of the scan , for example forward, left, right, can be scanned frequently as reverse, they tend to reverse less often. Allowing someone to at debate the switch and change the option on this chair. >> There are a lot of programming options for each of these access methods to better customize use to an individual client. ASLT has recently -- ASLT -- >> ASL Has come up with a two switch control. We can have the first switch move through the direction, and the second switch select the required or the desired direction. Why would we do this? For some clients, the automatic scan, where he hit a switch, this can cause anticipation and anxiety in the client. By using two switches, the first switch is activated repeatedly until the highlighted , and then the second switch is moved in that direction. The drawback, the client has to hit a switch frequently. This may be difficult for some of our clients as well. QLogic which is available on quantum rehab power channels, has this option for the two switch control. Imagine these two switches right here, could be any to the client -- Any two switches the client can use. If the first switch is pressed again, and held down, the chair will move in a forward direction. Of that switch is only activated one time , the chair will move to the left. If the switch is pressed quickly and then released, it will access a mode or an action. At the second switch, this little blue switch is pressed once, twice, held down, the chair will move into reverse. If the switch is activated once, only, the chair will turn to the right. It is a little confusing. So we only have two switches required, and for directional control. As well as access to reset. That is great. The drawback, the client has to use these switches in a way that they hit the switch momentarily, in a sustained fashion. And where even a double-click is required for reset. This is a very specific requirements that in terms of motor skills the client may or may not have. These access methods, we really want to try them out, and see if it meets their needs. Another option, that provides 2 switch control, is from I Drive , this will allow them to act as three, you can combine mechanical and electrical switches, most of these options we look at only allow us to use mechanical switches, or electrical switches, not to combine them simultaneously. This will allow us to combine them, to the left we have a jellybean switch, to the right there is a proximity switch. And electrical switch. We will talk about these in a bit. This is how Link works. >> If the client only activates the right switch, the chair goes to the right if you release the switches, you can activate reverse reset can be activated with a double-click if the client is able to use it , or a third switch, this can be used as reset. This is intuitive, then the QLogic system. For access. Now as I mentioned before, we are looking for three switch sites it is possible to drive with only one or two switches, it can be challenging, I want to have three or four if possible, as I am hunting from these sites, I am looking for a location on the body where they have good control, where we have a smaller movement as possible, not large movement . That takes a lot of time and effort . I do not want it to be driven by a pattern of movement we might see with increased muscle tone, or reflexive activity such as a neck reflex , we want this to be an isolated movement. From which the client has good control. As I am hunting down these sites, I want the strongest to be forward. Clients have to activate more directions most of the time, if I can find for Mac -- If I can find 4 switch sites, then [Indiscernible-speaker away from microphone], if I am going to combine mechanical switches. I need an interface box to plug them into. Adaptive and stealth both have these. We then grab individual switches or array , and connect them to the chair, the switch of Ray, -- Switch array , Looking at this case study, that will hopefully clarify this. This is Landon he is using three switches on his tray Landon had a joystick on his wheelchair , we were trying to determine difficulty because of motor limitations, or understanding. We took the joystick off, and we placed three switches, now the task was concrete for a young boy . >> The right switch turned the chair towards the right , this was more concrete, this allowed us to analyze tasks better, we did determine that Landon did understand the task, and he needed to use switches . Even though he can move the wheelchair, he could not get it in the exact direction he wanted it. This is faith. Who has cerebral palsy, Faith had the will chair already, this came with a joystick, she can move the chair but nowhere near she wanted to go, we wanted her to have control. Someone else saw Faith, and tried head array. Faith had difficulty as well because she needed to stabilize against the headrest, to provide isolated control , elsewhere in her body. Besides having triple possibly -- Cerebral palsy , she also has acidosis, and she is needing therapy, if this allows them to free up control somewhere else, they needed to stabilize with her head. This did free up other locations, she was able to pull back with her left arm and activate a switch. You can see a jellybean switch in the circle . In the lower right picture , to turn left, faith was able to squeeze her hand, we put a switch on the strap base in her hand. The arm was not always in the same position, she knew that the switch to stay in relation with her hand, she would squeeze it to make a left turn . At the time of the evaluation, she was able to adapt her left hit. And you can see she has more control over the left side of her body. By the time the chair arrived, faith decided she would like to use a switch in the right hand, that she squeeze. We put another one, and she did very well. This picture , this is faith in her chair, she has taken it to school, this is the first time she drove with remarkable control. I would love to share the video, but unfortunately we do not have adequate photo releases to do so. She drove quite well. There is hardware placed in front of her knees, a power communication device mounted on Hersh -- On her chair. It is possible to combine a variety of switches to me an individual client and their needs. There are a number of Switch array's on the market as well. We will look at some of these starting with Sip'n Puff , this has been around for a long time, that is old school now, and we do not use that, it is still efficient access method for many clients. This works well for clients that do not have good control of their extremities, but to have good oral motor control, good lip closure, and a soft palate. This is required for maintaining pressure within the mouth, this is not activated right breath control, many people who use this are on a ventilator. Controlled by managing the air pressure within the mouth, if the client can puff out there P -- teeth -- Puff out their cheeks. You should be able to use sip and puff. Hickey -- Here you can see different ways for mounting. This is a very important part of providing these alternative driving methods. >> Sip'n Puff is controlled by using for discrete pressures, these are translated and specific movement of the chair, a hard puff , increasing pressure within the mouth, results in forward movement. To the right. Reducing pressure, in the mouth, moving the chair, a soft sit turns it to the left. >> It is too hard to sustain, so we typically use latch. By providing one hard puff, it is placed and usually a hard sip will stop the chair , speed can be controlled in a number of different ways, varying by the manufacturers package, a common strategy, once the chair is in latch, the client will continue to execute hard pubs, the speed will ramp up, -- Hard Puffs . >> This will increase the speed of the client. I-Drive uses these simple controls as well. The pressures are on the I-Drive software. Traditionally when we program these for discrete commands , it is not always easy to see. These pressures when they are being programmed, they can be programmed on a tablet or a computer that can provide better feedback. A more motivating way to do this. A child may try to blow out a certain amount of candles, this can be an effective way of programming and teaching Sip'n Puff. The ability to access proportionate speed. The Sip'n Puff control on I-Drive, consists of two different stages available to the client . In Stage I as the client slowly executes a path -- a puff , Usually it would turn it to the right, this allows speed and to creep up to a table, the client would move into Step 2, where we would have additional pressure control QLogic, available on the quantum chairs, has in other which is to pressure, -- 2 pressure. Any 2 sips moves it into reverse and one sip into -- Onto the left. Instead the client simply has to remember how many puffs or sips to execute. Similar to the switch control . There is also a programming available called command time, or sampling delay. This allows for a delay before the command is accepted. Blatz -- Let's say it requires a hard puff , the chair may read a soft puff, and go right before going forward. I have had this happen to some clients we have worked with. Instead this provides a slight delay, given the time to build up pressure, and when the chair responds, it only goes forward rather than turning to the right. The new command allowed time to build pressure . People who use Sip'n Puff, have little or no movement of their head, if that Strauch turns, this can be an unsafe situation, both ASL and Switch It , offers -- Where the client cannot keep it in their mouth, the chair has a kill switch or stop switch. Or intentionally as a reset switch, they can open their mouth wide, triggering the switch, when they put that straw back, it can be used as a reset , the client can be driving, stop, close their mouth on the straw, and control something else. This can be very important for safety reasons. We use this with two clients in the Denver area, Travis and Jessica, when Travis was in latch, he hit a bump in the carpet, his chair went through a sliding glass door, before the mom can stop the chair. He was okay. This is a time where we would need a stop switch. >> This moves us into the head array. This is a tri-pad headrest pictured 3 to 5 proximity switches in it, these are capacitive switches, they need to move within proximity of the switch to activate, not activated by the upholstery or other materials, this works well with clients with little extremity control, but very good head control. Really it would be only one head array on the market, available for [Indiscernible], recently we have a variety of head raise available to us. You bring your head contacting , either the side pads can be turning to the side, they can get a diagonal movement. This is the new ATOM, this allows additional features, the client can turn it on or off by pressing external switch, the client can turn the entire chair on and off, but the client approaches a work surface, and doesn't care to turn off the entire chair, they have the option to turn the head array, to rest their head. This other option allows the Adam -- ATOM , Into a speech therapy advice, if additional electronics may be required, they are experienced -- Expensive. By using the ATOM , it bypasses some of these programming requirements. -- Usually the left switch will require the double tap to activate a reset. Some of that is on QLogic itself as well. And auditory feedback , when it is activated there is a beep. >> A mechanical switch you might hear a discrete click, this provides a beep to let the client know they have activated the switch, the feedback can be turned off. It will probably turn them nuts in a small amount of time. >> Permobil, This unique head array, you can combine switches of that best meets the clients need, this is something that we can do on the Permobil head array. You can place to switches, if they are maintaining consciousness with the rear pad, to get this diagnosed -- Diagnosed movement. -- >> -- [Indiscernible-speaker away from microphone] -- Many Had raised on the market consist of this tripod head rest, where we have a hinge, in the style we have much more adjustability, the side pad has a ball and socket joint , I can move them in a precise location to capture the requirements. Also this particular headrest , has a horseshoe shaped piece the base of the school, providing more stability . Instead of a client hovering between these switches they can pivot on each of the primary pads, it can enable the client to use the head array successfully. The stealth I-Drive line, like the Permobil head array, this allows both switches to be used. There are some additional programming available as well, such as programming how the client activates the reset or the mode switch. This can be used with a wry -- While -- A wide variety. This very unique support can be used in combination of the head array, this is showing on the right, I-Drive software, this just shows how it works. Separate programming on top of the power wheelchair electronics, they have an app pending as a remote stop, that can be used in any I Drive products, they can stop the chair remotely if the client gets into a potentially dangerous situation, say they are not paying attention, this is important even though remote stops are available as a separate hardware id., they are often difficult to get funded Turco They also have a control app pending as well. Switch It has a dual Pro . Another head array that allows us to choose either a proportional method of activation, or a switch control method above , or combine the two, how do they work on the head array, if the client exerts force, it will speed up. It is important to keep in mind, Limited speed control for the client, however if they use excessive amount of force, they may move faster than they want to. >> By using both, the client may use speed traditionally and may be used as a traditional head array. This is one of the clients they work with, Taylor using his head array during an evaluation. These same proximity switches can be used outside of the head array. Typically on a tray. These are activated by our body and the capacity to conduct electricity. These can be placed underneath a tray. Why would we do this as opposed to putting switches on top? If we were to put mechanical switches the client would have to lift up and over the switches, the vertical movement can be difficult for folks in specially increased tone. They have to slide their hand over the location, often times I will put a tactile cue to let them know where the switch might be. >> I am not using stickers because I want them to see where they are driving using the tactile view, the client can maintain visual regard of the environment Turco [Captioners Transitioning] By placing them in the trade, we are eliminating a plane of movement. Now, I like placing these in a clear try if I can that helps the client to have a better visual feel as they are driving, some people like to put these in a solvents trying a couple these trays pictured here are hollow inside. And it -- and it -- they had a cover to protect the cable, these trays are available from a assail -- ASL. The soul the system earlier for the fire would where sensor on top of the head, have a proximity array that places proximity switches to the medial and lateral needs, there are some clients with ALS who have some decent control at their legs, oftentimes a bulbar form of ALS we can see some control at the legs for a period of time . That moves us into fiber optic switches, fiber optic switches like proximity are electronic switch, they do not require any force, the client just needs to approach the switch, how these work is there are two cables that attach to each terminal of the switch, a fiber optic beam of light is emitted on one of those cables, and when it see something like a finger or a thumb, it is reflected back on the second table and that activates the switch. These are designed to capture a smaller movement in a proximity switch. And work really well for people with muscle weakness. The cables are very fragile, and these like other access methods need to be well mounted. In this picture on the left these are mounted underneath a tray, and you can see some of the movement does the finger over each location for forward left right and even reverse or reset, these coming -- mounted on the surface of the tray or on the side of the tray, you can also mount them with in an arm trough. Here they are pictured on the side of the tray is some clients have better control with their fingers flexed over the edge of that trait and can flex the finger towards the fiber optic switch. ASL has a version of this as well as using the link function on the stealth I-Drive system where the client can cover two of these beings together, it will move the chair forward, cover only a low switch and it will move the chair to the left side, cover the rights, the right directional control, the client can reach a third switch this can be used as a reset. This allows a tremendous amount of control of the chair for a very very small amount of movement. To either side of the switches. Here are some other mounting options. Obviously mounting is a big deal with something like fiber optic switches, this hand pad has little mini goose necks in it and these hold the fiber optic switches so they can be moved directly for a client needs that control, the I drive system has a really nice feature called, tuning where you can choose the activation distance, how close the client needs to be to the switch to activate it by Sibley pushing a button when the client is in a desired location. And this is much easier than a more tedious way of adjusting other systems. Let's look at a quick case study here this is for read and he is eight years old and has spinal muscular atrophy type 1, as such he has profound muscle weakness, he was able to drive with a combination of fiber optic and proximity switches to capture is very small movements and very limited amount of force physiological switches do not require that force. He was able to drive with a fiber optic switch under his right index finger for forward, if I've optic switch under his left index finger far left, and proximity switches placed by his medial knees for rights and reset. You can see these pictured here. We made a custom arm trough for him to hold this fiber optic switch, he has better control with his fingers in this flexed position over the edge of the arm trough and he pulls that finger back ever so slightly, to activate the switch under each index finger and then he can ask the date switches those of the yellow switches, belted by his medial knees. There's a few common -- combination systems that are available, the analog digital drive system combines the joystick and a cadre so far the rivers are controlled on the joystick and left and right controlled on the Head array this was a custom set up that works for a specific client who had these movements many of these companies will work with you to best match your individual clients needs. More commonly combined are Head array and Sip 'n Puff sip is reversed and left and right are controlled on the head array obviously the client needs to have some movement of their head but perhaps does not have control to use that rear pad in the same client may have difficulty discriminating those hard and soft puffs in this way can combine the two for pest control. This is a custom set up that allowed us to combine mechanical and electronic switches for Julian who has spinal atrophy at the time is required some custom electronics from adaptive switch last, because combining mechanical and electronic switches was not something we could readily do. Today we could do this using the I drive system, but here we have combined a fiber optic switch by his left thumb for forward, a Microlite by his right medial knee, for returns and proximity switches at either side of his head for left and for reset and is allowed Julian independent control of his driving, a reverse, of this power tilt and even his speed. There is one system available that utilizes eye gaze and it is called will talk, it is made in Sweden, and it also in addition to providing driving is also a communication device, and can control devices in the environment so is a package system that is fairly expensive, it's primarily designed for clients who have ALS, it's distributed by adaptive switch labs but the best my knowledge is not yet available for distribution in the US, that could happen here in the future. As you can see there's quite a variety of alternative driving methods that are available. This allows our clients who are ready to use the power chair but have significant motor limitations, to have a variety of options to meet your specific needs. I encourage you to try each of these methods out for yourself, to arrange for demonstrations, where you can hop in a chair, and try driving with these methods. It would be very difficult for you to teach someone else how to drive a car if you are not a driver yourself. By trying each of these driving methods out, you can have a better sense of how to evaluate a client for this access method and train them how to use it. I want to thank you for your attention to this course today. I hope it was helpful. Here's my contact information. If you have any other further questions you can contact me by email and look at the resources that are available on my website including one of the handouts that you have for this session today. Thank you everyone. >> That was excellent. Thank you. How can we do for time? Touch over 90 minutes which is fine. I got a little off track I tried -- usually I start at the top of the hour and we started afterwards and I was thinking, what time did we start exactly. I knew I was running late. I'm glad it was not too bad. No problem. Were good. Yes Michelle, in the meantime, if you could send me the PowerPoint that you use, so if you can send us the other document that you have, which would be the decision-making -- They are in the dropbox folder right now. Okay. I have those as PDFs so we're good to go. I think all of your videos are there also. That should be in good shape. Great. As your putting this together if you need anything else let me know. Great. I will be in touch with you as we get closer to the recitation that you are helping out with. Thank you for agreeing to do that. In the meantime we will get them set up. Thank you. Thank you appreciate it. We will see you at ISS. I will be there. I was working on my presenter form yesterday so I have to finish some stuff today. Good deal. Thank you. Goodbye. Captioner we have completed. So you're free to leave. Okay thank you. You have a great they also. >> [ Event concluded ]