Introduction to Module 4

Welcome back! I hope that everyone is doing well. Let’s get started with the 4th module. Using the GET WISE framework, the following items will be covered in the 4th module:

During this module, we will: (project GET WISE)

G – Goals toward engaging in desired activities will be set.
E – Discussion on how exercise can be used to manage MS related symptoms.
T – Check in on the performance of complex transfer skills (toilet, vehicle, and bed).

W – Final session of new wheelchair/scooter skills in challenging environments (curbs, ramps, and wheelie).
I – Discussion on engagement in desired activities will be held.
S – The influence of MS Symptoms on falls will be discussed.
E –Discussion on the influence of the environment on engagement in desired activities will be held.

I hope that you enjoy the material for this week.

Influence of MS Symptoms on Falls

GET WISE Section: Symptom Management

In this segment, we will talk about how some of the symptoms associated with MS increase the potential for falls. Because there are so many symptoms associated with MS, we will not be able to cover everything. Some symptoms that you experience may not be discussed today. However, just because we don’t talk about them, it doesn’t mean that they are not important! If you have questions about how additional symptoms can influence a fall, please speak with your trainer.

Many of the symptoms associated with MS can influence the occurrence of a fall.

While many symptoms contribute to a fall, some of the most common are:

• Fatigue
• Spasticity
• Muscle weakness

The most important thing to remember is that you should LISTEN TO YOUR BODY!

You are an expert on how your body reacts to various medications, experiences, etc. Only you know how you feel at any given time of the day. Be aware of how your body feels, especially when you plan on participating in activities that are not a part of your daily routine. You may want to consider reorganizing your activities or ask for additional assistance during times you do not feel your best.

In your manual you will find a listing of of how common MS symptoms can contribute to a fall. To read more about the influence of other symptoms, please look at the National Multiple Sclerosis Society’s website on MS related symptoms. There is a link to the website in your manual.

In this session we are going to discuss the most common symptoms, fatigue, spasticity and muscle weakness.

Fatigue is a very common MS related symptom. About 80% of individuals with MS experience fatigue. MS fatigue is commonly described as a feeling of exhaustion that is unrelated to an individual’s level of exertion. This is different from muscle fatigue that results from physical activity.

Fatigue has been found to be a common factor associated with falls among wheelchair/scooter users. Wheelchair/scooter users with MS often reported that while performing a transfer or attempting to walk short distances they felt very tired and simply did not have the energy to complete the activity.

Therefore, if you are feeling fatigued, take a brief “time out” before engaging in an activity that you know you will need a lot of energy to perform. Think about if you have enough energy to do that activity and if there is another way that it could get done. For example: if you were planning on transferring to a tub bench to take a shower, consider taking a sponge bath in the short term and getting into the shower later when you have more energy. Alternatively, you may want to ask a care partner for additional assistance when doing energy-demanding activities.

The National Multiple Sclerosis Society has developed an extensive guide related to management of fatigue. The link to this guide is provided for you in your manual.

Next up is spasticity. Spasticity is one of the most common symptoms associated with MS and is a major contributor to falls. The term spasticity refers to feelings of stiffness and a reduced ability to maintain smooth, controlled movements of a limb. It may be as mild as a feeling of tight muscles, or may be so severe as to produce painful, uncontrollable spasms.

In falls related to spasticity, wheelchair/scooter users have often reported that they were unable to control the movement in the affected extremity which resulted in a loss of balance. If you frequently experience spasticity, be aware that this increases your risk of falling. If you need to carry out a strenuous task, such as performing a transfer or doing a complex wheelchair skill, try to think about other ways that you might want to do your desired activity.

Finally, muscle weakness is common in people with MS. Weakness in muscles can cause shoulder, elbow, knee, hip, or ankle instability, which in turn can cause a fall while trying to stand, sit, or transfer. It is reported that wheelchair users with MS fell during daily activities, such as transfers, because their arms were weak. More importantly, in previous studies, it was found that many wheelchair/scooter users with MS could not get up from a fall or move themselves to a communication device in order to seek help (e.g. pulling a cord, pushing an alarm button, or using a phone) due to muscle weakness.

The good news is that exercise can help you improve and maintain muscle strength. Further, research has found that exercise can help manage falls by improving muscle strength.

If any of these symptoms are causing significant problems for you, such as increasing the frequency of your falls, making it difficult for you to perform your activities of daily living, or limiting your engagement in desired activities, you might want to consider seeking help from a physical or occupational therapist. To do so, call your doctor and make an appointment. Tell him/her that you have had a “decline in function” and what specific activities you can no longer perform. Your doctor will help you to decide if it would be best for you to see a physical or occupational therapist.

Please see your manual for additional information on other symptoms that commonly affect individuals living with MS.

Module 4 Journal

Welcome back. In this segment we will discuss the journal entry for module 4. Please turn to page 110 of your manual. As a reminder, the journal entries will help you to think about the information that was presented during the education session and to help you integrate what you have learned into your everyday life.

For this week, ,please think about one or two transfers that you performed last week. What type of transfer did you perform? Did you use any of the new techniques you learned? If so, did you feel any differences? If not, what prevented you for using the new techniques you learned?

The module this week will not contain any new information regarding transfers. However, please remember to keep practicing your transfers at home with a care partner.

Advanced Wheelchair Skills Introduction

Today is our final segment of wheelchair/scooter skill instruction. We will discuss how to navigate curbs, ramps, and cross-slopes. We will follow the same procedure we have done for the past 2 modules. Separate videos have been created for manual wheelchair users and power wheelchair and scooter users. If you primarily use a manual wheelchair, please watch the video ‘Manual Wheelchair Skills (Advanced)’. If you primarily use a power wheelchair or a scooter, please watch the video ‘Power Wheelchair/Scooter Skills (Advanced).

The skills that we will be discussing today are much more complex – As always, please make sure that you have someone spotting you when you practice these skills.

Manual Wheelchair Skills (Advanced)

Today, during the final wheelchair education session, we will learn and review some advanced wheelchair skills to allow you to safely and successfully navigate a variety of environments in your home and community. Please turn to page 111 of your manual.

First up is Going up/down a curb

Level changes (e.g. curbs, steps, home entries, uneven sidewalk sections) are common obstacles found in everyday life and can be challenging to navigate. Knowing and applying the appropriate techniques to manage level changes is important to prevent falls from occurring.

We will now be watching videos showing how to go up and down a curb. These videos are also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual correspond to the key information presented in the videos. If you have any questions about how to modify these techniques to your specific needs, you can discuss it with the trainer during the online discussion session.

General tips to reduce the frequency of falls and injury:

When going up a curb

• Reposition or remove the rear anti-tippers, if necessary.
• Approach the curb at a slow but consistent speed. It is easier to pop the front wheels (casters) when moving.
• Don’t lean forward when you approach the curb, it can increase the weight on the front wheels (casters) and make popping them up more difficult.
• Approach the curb with your front wheels (casters) pointing straight forward. Approaching the curb at an angle can make the skill more difficult.
• Pop the front wheels (casters) up from the ground, just high enough to clear the curb. It may take a few tries to get your timing down. Please see the instructions on how to “pop-up” the front wheels (casters) in Session #3 (page 99).
• Lean forward slightly once your rear wheels have made contact with the curb. This will bring your front wheels (casters) back down.
• Continue to push and apply forces of moderate intensity to help your wheelchair climb up the curb.

When going down a curb

• Approach the curb while facing forward, as this allows you to watch for traffic while you complete the movement.
• When descending a curb, ideally you should perform the skill in a wheelie position to keep your body level and avoid falling forward. To perform the skill, put your chair in a wheelie position and slowly roll forward, down the curb. You should ONLY attempt this skill if you feel confident in your ability to perform a wheelie on a level surface. Instructions on how to perform a wheelie will be performed later in this module.
• If you are not comfortable performing a wheelie, push your wheelchair forward over the curb, shifting your weight slightly backwards to avoid falling forward.

Going up/down a slope

Pushing a wheelchair up ramps or hills are common obstacles found in everyday life. Although common, they can be difficult to navigate. Appropriate techniques are needed to avoid a fall.

We will now be watching videos showing how to go up and down a slope. These videos are also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual correspond to the key information presented in the videos. If you have any questions about how to modify these techniques to your specific needs, you can discuss it with the trainer during the online discussion session.

When going up a slope (ramp)

• If you have a backpack or other gear on the back of your wheelchair, give it to a friend to carry (preferred), or if you are alone, put it on your lap. This will help prevent tipping backwards.
• Push forward onto the slope.
• Lean forward while going up the slope and use shorter, more frequent strokes. This will help keep your forward momentum going as you move up the incline.
• Place your feet on the footrest to avoid catching your foot on the ground when navigating the ground-slope transition at the start of the incline. Catching your foot on the ground could lead to a lower limb injury or a fall.
• If you get tired on the way up the incline, hold onto a handrail (if applicable) or ask for assistance.
• Consider using a “hill holders” device. This device allows the rear wheels to roll forwards, but not backwards.
• When you find a steep ramp that you can’t go up independently, ask for assistance.
  • Have your care partner walk behind you and ask him/her to push your wheelchair using the push handles or the back of your wheelchair.
  • Push forward on your hand rims at the same time.

When going down a slope

• Always check the slope for obstacles, such as cracks, before going down.
• Push your wheelchair forward onto the slope, shifting your weight slightly backwards to avoid falling forward.
• Proceed slowly to maintain control. Be prepared to stop at any time.
• Apply light but consistent pressure on the hand rims to control your speed. Gloves are helpful to avoid injuries.
• Place your feet on the footrest to avoid catching your foot on the ground when navigating the slope-ground transition at the bottom of the ramp.
• Use handrails if available.
• When you find a steep ramp that you can’t go down independently, ask for assistance.
  • Have your care partner step behind you and hold onto the push handles.
  • Have your care partner roll the wheelchair down backward.
  • Apply pressure on the hand rims to help reduce your speed.
  • If possible, lean forward.

Traversing a side-slope

Side-slopes or cross–slopes are common obstacles found in everyday life and can be challenging to navigate. For example, many sidewalks are sloped toward the street to allow water to run off. Side-slopes are also often found where sidewalks cross driveways. Appropriate technique to manage side-slope is important to prevent a fall from occurring.

We will now be watching videos showing how to traverse a slide slope. These videos are also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual correspond to the key information presented in the videos. If you have any questions about how to modify these techniques to your specific needs, you can discuss it with the trainer during the online discussion session.

General tips to reduce the frequency of falls and injury:

• Push your wheelchair forward across the slope.
• Shift your weight slightly uphill-side to avoid falling sideways on steep cross-slopes.
• To avoid your wheelchair turning down hill, push harder on the downhill wheel.
• Different push frequencies may be required for each hand to keep the wheelchair moving straight. For example, when moving across a side-slope with the right side downhill, the right hand may push 2-3 times for every 1 push on the left.

Performing a wheelie

A wheelie is a method of lifting your front wheels (casters) off the ground. It is an essential skill for being able to independently navigate a variety of surfaces and challenging environments in a manual wheelchair. Performing a wheelie requires a lot of practice. This module will give you some initial information regarding how to perform a wheelie, however to master this skill, please consider asking your physician to order occupational or physical therapy services.

We will now be watching videos showing how to perform a wheelie. These videos are also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual correspond to the key information presented in the videos. If you have any questions about how to modify these techniques to your specific needs, you can discuss it with the trainer during the online discussion session.

Please remember, you must have a friend or care partner spot you during the practice of a wheelie.

The first thing to do is work on finding your balance point.

• To find your balance point, please follow these steps:
  • Lock your brakes and have a spotter tilt you and your wheelchair back to the point where you feel balanced between tipping forward and tipping backward. This may be farther back than you expect.
  • Look at how high your front wheels are off the ground to get a sense of your balance point.
  • Repeat this exercise with your brakes unlocked.
  • Once a spotter tilts back to the balance point with your brakes unlocked, gently rock forward and back around your balance point by pushing and pulling on your hand rims.
  • Try to relax your neck and shoulders and avoid controlling your balance by leaning with your head and shoulders.

After you’ve experienced your balance point

• Apply the wheelchair pop–up techniques discussed previously to tilt your wheelchair back into a wheelie position (page 99).
• If you are having difficulty getting tipped far enough backwards to reach the balance point, push forward more forcefully.
• Try to maintain your balance in the wheelie position.
• To land, pull back on the wheels to gently bring the front wheels (casters) to the ground.

Care partner(s) spotting during wheelie practice

• Your care partner’s (spotter) role is to prevent you from falling while performing this skill. Care partners and wheelchair users must communicate clearly before and during the practice.
• Make sure both you and your care partner are ready before starting a wheelie and talk through each step as you go.
• Have your care partner place a sturdy strap on the bar behind your wheelchair backrest and grasp firmly with one hand.
• If your wheelchair has anti-tippers that prevent wheelies, your care partner will need to remove them during wheelie practice.
• Your care partner should stand close in a slight lunge position behind the wheelchair, so that they can block the wheelchair from tipping back with their body as well as the strap.
• Your care partner should keep a hand free to grasp your shoulder if it looks like you might fall forward.

Please now take some time now or later this week to practice these skills. Please remember to have a care partner with you when you are practicing these skills.

Power Wheelchair and Scooter Skills (Advanced)

This module is the final power wheelchair/scooter skill education session. We will discuss and review some advanced wheelchair/scooter skills to allow you to safely and successfully navigate a variety of environments in your home and community. Please now turn to page 116 of your manual.

Going up/down a curb

Level changes (e.g. curbs, steps, home entries, uneven sidewalk sections) are common obstacles found in everyday life and can be challenging to navigate. Appropriate technique to manage level changes is important to prevent a fall from occurring.

We will now be watching videos showing how to go up and down a curb. These videos are also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual correspond to the key information presented in the videos. If you have any questions about how to modify these techniques to your specific needs, you can discuss it with the trainer during the online discussion session.

General tips to reduce the frequency of falls and injury:

When going up a curb

• Search for an alternate route or a curb cut when you approach curbs.
• Elevate your footrest (if necessary) to increase ground clearance.
• Approach the curb at a slow speed and drive forward. Smooth, continuous forward movement is the most successful method of traversing an obstacle (As you see in the video, when the participant goes too slow, he cannot get up the curb.).

When going down a curb

• Approach the curb while facing forward, as this allows you to watch for traffic while you complete the movement.
• Drive your wheelchair forward over the curb, shifting your weight slightly backwards to avoid falling forward.

Scooter considerations

• Use the same techniques as described above.
• Scooters have smaller wheels compared to power wheelchairs and are not able to traverse high curbs. Very carefully consider the height of the curb before attempting to go/down. Have a care partner stand close to you when attempting a new curb.

Going up/down a slope (ramp)

Ramps or hills are common obstacles found in everyday life. Although common, they can be difficult to navigate. Appropriate techniques are needed to avoid a fall.

We will now be watching videos showing how to go up and down a ramp. These videos are also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual correspond to the key information presented in the videos. If you have any questions about how to modify these techniques to your specific needs, you can discuss it with the trainer during the online discussion session.

Going up a slope (ramp)

• Use the tilt and/or leg-elevation functions to avoid scraping the footrests at the bottom of the ramp.
• Drive fast enough to maintain forward movement but not too fast that you lose control.
• Place your feet on the footrest to avoid catching your foot on the ground when navigating the ground-slope transition at the start of the ramp. Catching your foot on the ground could lead to a lower limb injury or a fall.

Going down a slope (ramp)

• Always check the slope for obstacles, such as cracks, before going down.
• Drive your wheelchair forward onto the slope, shifting your weight slightly backwards to avoid falling forward. If you have power tilt in space on your chair, put yourself in a little bit of tilt. This will help keep your body level when going down the ramp.
• Control your speed. Be prepared to stop at any time.
• Place your feet on the footrest to avoid catching your foot on the ground when navigating the slope-ground transition at the bottom of the ramp.

Scooter considerations

• Scooters can tip over very easily, especially on ramps.
• You should only attempt minimal ramps in a scooter and have a care partner with you when attempting a new ramp.
• Do not make a sharp turn while going up/down a ramp.

Traversing a side-slope

Side-slopes or cross–slopes are common obstacles found in everyday life and can be challenging to navigate. For example, many sidewalks are usually sloped toward the street to allow water to run off. Side-slopes are also often found where sidewalks cross driveways. Appropriate technique to manage side-slope is important to prevent a fall from occurring.

We will now be watching videos showing how to go up and down a ramp. These videos are also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual correspond to the key information presented in the videos. If you have any questions about how to modify these techniques to your specific needs, you can discuss it with the trainer during the online discussion session.

General tips to reduce the frequency of falls and injury:

• Before traversing a slide-slope, check for wet or slippery surfaces (such as wet leaves) that will decrease traction. If these items are noted, take extreme caution and avoid the area if possible.
• Drive your chair at a moderate speed. You should use enough speed to keep you moving but not so much that you lose control.
• Drive slightly up-hill, if space allows.
• Shift your weight slightly uphill-side to avoid falling sideways on steep cross-slopes.

Scooter considerations

• Use the same techniques as described above.
• Do your best to avoid steeper side-slopes. Scooters can tip over sideways very easily, especially on steeper side-slopes due to the relatively narrow width and high center of gravity.

Please now take some time now or later this week to practice these skills. Please remember to have a care partner with you when you are practicing these skills.

Home and Community Participation

Active participation in your home and community is important to the health and well-being of wheelchair and scooter users. This section with focus on helping you to think about activities you enjoy doing and how to develop the skills to do those activities. Please now turn to page 119 of your program manual.

Engaging in activities is important to your identity, to fulfilling roles and responsibilities, and to satisfaction with life. Research confirms that being actively involved in family and the community is vital to health and wellbeing1 and has an important link to quality of life2. Being an active member of society is a key factor in sustaining health.3 Considering your activity goals is the first step to ensuring ongoing participation in what matters to you. We will be discussing this concept further during the goal writing session for this module and during the online discussion.

Module 4 Goal

During this module, a discussion was held on safe participation in desired activities in your home and community. Please write a goal related to how you will get started or make progress in participating in an activity that is meaningful to you in your home or community. There is space for you to work on your goal on page. 120 of your manual.

While you are writing this goal, think about some potential barriers to achieving your goal and how you might overcome then.

In Session 2, we introduced a strategy called action planning. As a refresher, an action plan is a way to break down a large goal into smaller, manageable steps. This is a strategy or a tool that can support you in achieving your goals. When making a large goal, such as this one, using action planning is a good strategy to make a this large goal seem more manageable.

Please take some time this week to complete your action plan with the goal you have identified for participation.

Module 4 Closing Remarks

We are now going to wrap up the material for this module. Before we go, I would like to remind you of a few things to do prior to the online discussion:

• Continue doing the home exercise program 3x/week. (page 16).
• Use your exercise log to track your exercises. (folder).
• Goal: Development of a plan for participation in desired activities. (page 120).
• Journal: Complete your journal entry reflecting on transfer skills (page 110).

During the next session we will:

G – Goals will be set for maintenance of wheelchair/scooter and transfer skills after the program ends.
E – Exercise program will be reviewed during the online discussion
T

W – The influence of wheelchair/scooter set up and maintenance will be discussed
I – Continued discussion will be held during the online discussion session on the goals that were set about engagement in desired activities. S
E