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Some products in this article are described in general terms. Please refer to a manufacturer’s website for specific information on these products.

Introduction

Having entered the Complex Rehab Industry in 1995 as an occupational therapist on a spinal cord injury rehabilitation unit, I quickly discovered a passion for the CRT field. To say the landscape of this industry has changed over the years is an understatement. The advancements within the industry have been nothing short of incredible, especially in recent years. Things just seem to be moving in leaps and bounds now.

The last few years involving the introduction of artificial intelligence and smart technology in general have seemed to accelerate the advancements we and our technology users are seeing. Electronics continue to become more advanced, continually offering greater levels of independence and integration with advancing smart technology from the public.

Mainstream demand for emerging technology helps to drive technology applications for those in the community who live everyday with disabilities. Advancements in smart devices (phones and tablets) and smart home technology that is available to the public continue to develop and grow. In addition to smart devices, automotive technology advances for the general population as well. This includes self-driving automobiles, such as Waymo autonomous vehicles, down to a simple backup camera and front and rear sensors to prevent impacts from occurring. These products that benefit the public in turn provide opportunities for technology to be made available for individuals who are living with disabilities and utilizing power mobility in their daily lives. These technological advancements often offer a greater level of independence for individuals who have disabilities and may even offer the potential to, in some cases, reduce caregiver hours and advance the ability of the individual to be able to do more for themselves.

Some of these technologies are smart devices, Bluetooth, video and internet applications to assist with technical support, environmental control and drive control systems (assisted driving and alternative drive controls).

With people who have disabilities living longer and wanting to age in place, some of these technological developments have helped create a safer and more independent environment for these individuals. With that in mind, technology is not for everyone but certainly has its place when it is easy to utilize.

CRT and advancements

Bluetooth technology is advancing environmental controls

Bluetooth technology is available within most Group 3, or complex rehab power wheelchair electronics, today. Whether it be for programming or access to smart devices and computers, Bluetooth technology has advanced the independence levels of individuals who need high end electronics to be able to control a power wheelchair. This technology can allow a CRT Supplier or seating technician to program a wheelchair, the way it drives and how its controlled all using a smart device such as a phone or tablet. The benefit is that changes can often be made via Bluetooth technology, and some power wheelchair brands allow live programming for these changes to take place while the wheelchair user is driving. This provides immediate chair responses for the wheelchair user to feel and experience allowing the user to provide verbal feedback about the change in chair performance. Since most suppliers or technicians have smart phones these days, this programming capability is always with them through an app.

Beyond programming is the smart phone’s capability to control things within the home through a Wi-Fi network. Thirty plus years ago environmental control units used to cost more than $20,000 for a system to control the home environment (lights, TV, temperature control system and possibly a door opener). Today, a do-it-yourself starter kit can range from a few hundred dollars to thousands of dollars. Of course, if professional installation is needed, then cost is reflective.

Smart technology continues to grow in popularity, and its widespread adoption has significantly reduced the cost of converting a home into a smart home environment.

Smart home control systems, such as Home Assistant, Amazon Alexa, Google Home, Apple Home, Vivint Smart Home and Samsung SmartThings (just a few of the available systems), enable individuals across the general population, as well as CRT users, to independently manage their home environments. One of the greatest advantages of these systems is their flexibility: They can be built gradually as a person’s budget allows. Many users begin with simple functions such as controlling light bulbs, wall switches or outlets, and then expand their system over time. As financial resources permit, additional features can be added to increase environmental control, helping ease both the initial cost and the overall impact on the individual.

These technologies can be integrated and controlled with a smart device such as a smart phone or tablet. This is when Bluetooth technology on a power wheelchair can provide significant independence. Bluetooth connectivity allows a wheelchair user who may not have the upper extremity function to hold and access their phone to utilize their driver control (joystick, head array, sip and puff[, etc.) to access their phone or other personal electronic device. All the major power wheelchair manufacturers offer some level of Bluetooth technology. The specific Bluetooth capability and cost (if not included in the driver control) should be investigated if the consumer/user of the wheelchair desires this type of device control. In addition, the Android and Apple iOS operating systems utilize different Bluetooth functionality: mouse mover (Android), switch control (Apple iOS), voice activation with Siri (Apple iOS) or Google voice control (Android), and assistive touch on Apple iOS. This technology can offer a great level of living more independently for people who utilize CRT power.

Remote technical access to chair electronics

Advancements in technology have made it possible to remotely access and troubleshoot the electronics of power wheelchairs. Faster internet speeds, widespread home Wi‑Fi and the near‑universal availability of cellular service have helped bring these remote capabilities into the CRT industry. One example is Quantum Rehab’s Interactive Assist, which allows Quantum’s technical and sales support teams to view a chair’s electronics in real time to help an onsite technician or wheelchair user with troubleshooting or programming needs. In addition, some suppliers and manufacturers offer secure apps that use video — operated by the wheelchair user or a caregiver — to show technicians what may be wrong with the equipment. This approach speeds up parts ordering, reduces unnecessary service visits and ensures that when a technician arrives, they have the correct components on hand, minimizing delays and multiple appointments.

These types of remote services are a time saver and benefit for the supplier and the consumer.

Artificial intelligence and internet search options

With today’s internet resources — whether through traditional web searches or the use of artificial intelligence — wheelchair users can access more information than ever before. While these tools won’t account for an individual’s personal preferences unless specifically prompted, they do provide valuable general insights into available products. For someone beginning the search for equipment that supports mobility and independence, these online resources can serve as an excellent starting point.

Just like the general population, a person who needs a mobility device for independent mobility can do a search for options and benefits offered before meeting with their evaluating team. The evaluating team can then provide the individual with further information regarding what products are available and what may match their individual needs. The team approach is still an important part of the product selection process to provide the most clinically appropriate product features for the individual to ensure optimal outcomes.

Assisted driving options

Some advancements in technology are collision alerting/avoidance systems for individuals who may experience challenges with power wheelchair driving due to visual, perceptual, behavioral or cognitive issues that impact their ability to safely operate and maintain control of a power wheelchair. These technologies provide options for the evaluating team to consider for individuals who may be considered borderline for safe power mobility driving and give them opportunities to have greater independence.

These collision avoidance systems are similar to those in automobiles that we have all become accustomed to. Devices such as backup cameras that show an individual their surroundings, the LUCI system that utilizes sensors and avoids impacts and accidents, and the Braze Mobility system that offers a blind spot sensor system are options currently available.

Backup cameras — The most basic of these safety enhancement systems is a backup camera. Quantum Rehab offers a backup camera that utilizes a separate screen. This camera is plugged into the power wheelchair’s electronics system. The system offers two options: Option 1 is when a reverse command is given, the camera (which has night vision capability) turns on allowing the wheelchair user to see behind the wheelchair on the screen mounted in front of them. Option 2 is to have the camera on with a switch hit and a second switch hit turns the camera off.

Braze Mobility also has a backup camera system in which a switch turns the camera on and when the switch is clicked again it turns the backup camera off.

These backup camera systems are very cost effective for an individual to purchase for use with their wheelchair and offer additional safety to the wheelchair user of knowing they can see behind the wheelchair before backing up, which for many wheelchair users is a challenge due to physical limitations.

The Braze Mobility System – as stated above, has a back camera system but in addition it  has sensor systems that notify the wheelchair user of potential impact danger. The system does not prevent impacts from occurring, and it identifies objects that are 2 feet from the system with a warning light/beep or vibration sensor on the chair. At 1 foot it provides a danger light/auditory beep or vibration to the user to notify of the danger. This system will not control the power wheelchairs movement; it is only a warning system to help individuals maneuver in spaces where the user may have blind spots and not be able to adequately see the space.

As stated earlier the Braze Mobility system does not take control or stop the chair so that still requires the wheelchair user to possess that skill set for reaction time. The Braze system also does not detect drop-offs so the wheelchair user must be able to utilize their depth perception and vision to identify these community dangers.

The LUCI system — This system is one of the more sophisticated assisted driving systems in the CRT industry today. The LUCI system utilizes a sensor to help an individual avoid impacts with objects, people or even avoid drop-offs, according to the LUCI website.

LUCI’s website states “their system offers Mobility Level 2 (partial automation),” which allows the user to have control and receive technical assistance. The LUCI system will slow a wheelchair down or even stop the wheelchair to avoid a collision or prevent the wheelchair from going off a drop-off. The website informs that “the system works in the home, indoors and outdoors day or night.” The website also reports that “Seeing drop-offs in the built environment is easier for LUCI than when you are “off-roading.” So, driving on natural surfaces, like a grassy field or gravel path, may lead LUCI to slow you down.”

LUCI has a “crowded driving environment” benefit as well. When in a crowd of people, the LUCI system will slow the chair down to avoid striking another person who may not be paying attention to the individual in the wheelchair. This may prevent a power wheelchair user from unintended contact with a person or object leading to potential injury when negotiating through congestion. Knowing that the chair can adapt to this type of environment can assist in reducing stress and anxiety and reduce potential embarrassment for the wheelchair user.

This type of driving assistance system should be evaluated by a clinician and supplier to see if the technology may be able to assist individuals with depth perception and visual and perceptual issues be able to independently drive a power wheelchair.

Autonomous automobiles have started to advance this technology further. It appears that this type of technology may one day make power mobility more accessible for individuals who are currently unable to operate a power wheelchair. Such advancements have the potential to significantly influence the future of mobility devices.

Robotic devices

The Jaco robotic arm is a device that can be mounted to a power wheelchair to support individuals with limited upper‑extremity function who are unable to independently take a drink, feed themselves, participate in leisure activities or perform work‑related tasks (see the picture below of a young woman using a robotic arm with Vigo control). Once installed, the arm can be operated through the wheelchair’s electronics or through an alternative control interface such as a joystick or computer. These systems can significantly enhance independence, autonomy and self‑esteem while also reducing the need for caregiver assistance.

Drive controls

The complexity of power wheelchairs continues to evolve over time. The advancements described above represent only a portion of the technological progress that has expanded opportunities for independence. Modern programming features now allow the clinical team to finely tailor a wheelchair’s performance to the specific needs of each individual. These adjustable parameters influence how the chair drives, how the power positioning system moves and how the user manages their health, comfort and functional needs throughout the day. Thoughtful programming can significantly enhance how a person utilizes their wheelchair, supporting optimal function and greater independence.

One area where power mobility is rapidly developing is drive controls. Drive controls or alternative driving devices have many advanced features that can significantly optimize the individual’s abilities to independently control their power wheelchair.

There are two distinct types of driver controls: proportional and non-proportional, often referred to as switched or digital controls. Proportional controls allow the user to incrementally control the chair speed and direction of movement typically using extremitymovements to influence the force and direction applied to the drive control. Proportional controls tend to be very efficient from a usage and driving perspective.

Switched drive controls do not regulate speed and direction as efficiently as proportional controls as contacting the switch can only turn a function on or off. A switched controlled system can be successful for individuals with limited movement and range of motion, muscle control/tone issues or for those who have challenges with motor planning.

Proportional drive controls

Development of proportional controls has evolved and there are now a variety of options designed to meet different force and throw requirements suitable for access with different body parts including hand/finger, head, chin, lip and foot.

Most applications for proportional control tend to be at the head and upper and lower extremities. Proportional controls may be available from the power wheelchair manufacturer or from a specialty drive control manufacturer. Suppliers and evaluating teams can be very creative with how these devices are positioned and utilized with the individual. The drive control on a power wheelchair can be just as unique as the individual driving the power wheelchair.

For purposes of discussion, the proportional controls will be divided into sections: large throw, short throw, head controlled and foot controlled. For reference, the term “large throw joysticks” has to do with the distance the joystick moves from providing a minimal speed command to a full speed command to move the power wheelchair in the desired direction. These require greater active movement to achieve maximum driving speeds and often require more force to move the joystick itself.

Large throw proportional joystick controls — includes what most people would commonly refer to as standard joysticks. These are typically similar in size, and the joystick knob on many of these devices can be substituted with different shapes for a more optimal hand grip when the standard option is not appropriate. Beyond the standard offering of joysticks by each of the power wheelchair manufacturers, a variety of specialty control manufacturers have developed controls to provide individuals with drive control challenges with proportional electronic assistance to manage both uncontrolled movement (tone, tremor) or weakness. The three main companies of alternative drive controls are Mo-Vis (Stealth Products), Adaptive Switch Labs (ASL/Invacare) and Switch-It (Sunrise).

The larger throw joysticks also can vary in the amount of force needed to deflect the joystick in the direction desired. For individuals who have larger or strong (high tone) movements, there are heavier force options. The heavy-duty joystick from Mo-Vis requires 650 grams of force to deflect, allowing these individuals who apply a great deal of force into a joystick to be able to have the possibility of driving with a proportional drive control. These larger throw joysticks have lighter force joystick options as well. Some such options include the ASL Compact joysticks, Switch-It VersaGuide and the Mo-Vis All Around light, which only requires 120 grams of force and 7 mm of throw to drive full speed.

There are so many options today that allow evaluating teams of therapists and suppliers to truly match the unique characteristics needed by the individual to the right device.

Short throw proportional controls — These proportional drive controls have a much smaller, or shorter throw, and lighter force required to deflect the joystick and are very small and compact in overall size. They are often used by individuals who have very limited movement and strength and often are only able to move their finger(s). These small throw proportional controls require minimal strength to deflect the joystick — from 50 grams to as little as 8 grams of force. Since these are very small and compact, they can be recessed into a palm support (arm pad or tray) and utilized with the fingertip.

There is often a little more training required with use of short throw proportional controls since they are more fragile. Unfortunately, because the individual driving the wheelchair does not have a lot of strength, these are not often broken due to the wheelchair user but typically broken by the caregivers. This fragile nature of the alternative drive control needs to be addressed with the home team at initial delivery.

Head-controlled proportional drive controls — The RIM proportional drive control was one of the first in the industry. There are still power wheelchair drivers who drive with this system today. Proportional head-controlled drive controls have evolved significantly over the years, and there are now several ways to drive with head movements. The first and most important factor is the individual’s preference: at the lips/mouth, the chin and head are all available in proportional controls.

The control at the chin has been utilized for many years. The benefit of driving this way today is that the drive controls are much smaller and require smaller movements to drive independently. When looking at chin controls the size of the joystick may be important to the individual. The all-around joysticks from Mo-Vis, compact Joysticks from ASL and the VersaGuide from Switch-It are all options but tend to be on the larger size and require more force to deflect. The Mo-Vis Multi and the ASL Orbit only require approximately 50 grams of force to deflect and are relatively small in size, so other people see more of the person instead of the drive control. These devices are mentioned over some of the lighter force proportional controls because when driving with the head these are a good match for the forces applied to the drive control.

The lips/mouth is another location at the head that a proportional control can be placed, and the very light force proportional controls like the ASL Molecule, Mo-Vis Micro and Switch-It Micro Guide tend to be good choices since they require much smaller forces and are very small in size. The industry has seen advancement in mounting these devices. There are manual swing away booms, power swing away booms and harnesses that the individual wears. It truly is up to the individual to decide what option is preferred for their situation.

A control for the head, from a proportional perspective, that has seen the most change and advancement over the years is the proportional head array. This started many years ago with RIM control and has since advanced significantly. There are several proportional head control systems that use pressure sensors inside the head pads to allow proportional driving to take place. The three main proportional pad head controls available today are the Switch-It Dual Pro, ASL Fusion and the Mo-Vis Proportional head control (below). They allow the driver to drive proportionally in all directions by allowing the user applying a certain amount of force on the pad in the direction they want to drive causing the wheelchair to speed up to the speed desired. on a pad in the direction they want to drive causing the wheelchair to speed up. These types of drive controls continue to advance with time.

The last proportional control for the head is a sensor that the wheelchair user wears and then controls the proportional movements of the wheelchair with forward flexion, lateral right and left flexion and capital extension of the neck. The newest additions to these head controls are Sunrise Medical’s Vigo, munevo DRIVE and the Magitek system. Each of these is worn in a different manner. The Vigo is an earpiece the user wears, and it senses its position in space from the starting neutral position. The munevo system relies on the individual to wear a pair of google glasses and senses the position in space. Magitek is typically worn on a head band or hat, and just like the other systems adjust speed according to head position in space. These systems all can reset neutral which is an advantage to people whose posture may change some during the daytime.

The variety of proportional head controls available today truly allows evaluating teams to match the right device to the individual and their specific physical, functional and aesthetic requirements. Experience has proven that while individuals with similar conditions and functional abilities may require similar technology, what works for one person doesn’t always work for another.

Foot-controlled proportional drive controls — The final location that teams may see sufficient movement for proportional controls is at the foot. These devices can be categorized into two types: gross movement and finer movement proportional controls.

Gross movement proportional foot controls – These types of controls are when the larger movements of the legs are utilized. The movements associated are typically knee extension, knee flexion, and external and internal rotation of the hip or in some individuals it may include abduction and adduction of the hip. The mushroom joystick is often utilized as this type of proportional foot control.These proportional controls are ideal for individuals who may have tone or some muscle control issues in their body, and these drive controls are often dropped into a custom location in the footplate of the power wheelchair. These foot controls allow the individual to move the joystick and drive very functionally, adjusting their speed and direction smoothly. Although the mushroom joystick has been around, it is mentioned because it has led to advancements in the finer movement proportional foot controls discussed next.

Fine movement proportional foot controls — These foot proportional controls require finer movements located down at the ankle. The body movements these devices require are plantar flexion, dorsiflexion and ankle rotation to the right and left. These movements tend to allow a finer level of proportional driving than the more gross motor controlled proportional controls. The two proportional foot drives on the market are the ASL foot control mounting adaptor, which requires a proportional compact joystick to be added to the mount and the Mo-Vis proportional foot drive control, the newest advancement with proportional foot driving, which has been well-received in the industry.

These proportional foot-drive controls can allow a person with a progressive neurological condition such as ALS or an individual diagnosed with a central spinal cord injury be able to drive proportionally with their foot, which as discussed is more intuitive and efficient for independent mobility.

Switch drive controls

If an individual cannot consistently access and maintain control of  a proportional drive control and yet has movement in at least one body part, then advancements in switch technology allow individuals to be able to achieve independent power mobility.

Switches have developed into mechanical options, requiring force to activate and electronic options, responding to body contact or light sensitive (where the body movement breaks the beam of light to activate). The manner in which they can be integrated into a drive control continues to evolve.

Head arrays using three switches embedded in the rear, right and left head pads with optional mode switches as well four- and five-switch array systems (often mounted on trays) have not changed significantly over the years. However, two switches, one switch and eye gaze driving systems have made advancements.

Two switch driving systems — Stealth Products has a device called the iDrive that offers a driving option for two switches. The power wheelchair electronics programmed as a three-switch drive control. The iDrive is programmed as a linked drive control, and the two mechanical or electronic switches are plugged into the iDrive unit; the left switch drives left, and the right switch drives right. When both switches are pressed, they drive forward. If both switches are clicked together and released quickly, the directional arrow on the display toggles to the reverse direction, and when both switches are engaged again the chair drives reverse. This form of driving can maintain not only independent driving but also access to powered seat functions and electronic device access (using Bluetooth) through the power wheelchair for a longer time.

One switch driving system — One switch driving utilizes a scanner, which may be built into the electronics or may require a separate unit plugged into the power wheelchair to allow for single switch scanning driving to take place; it depends on the manufacturer as to which scanning system is available.

Single switch scanning is often looked upon as tedious and a last resort for driving. This may be true for some individuals but for others it is a way of maintaining independent mobility. The single switch scanning systems available have continued to evolve in different ways.  All scanning systems offer a visual scanner that lights up in some way (some have an arrow that turns yellow, and others utilize LED lights to signify a driving direction when the switch is activated.) Some manufacturers have developed scanning sequences to enhance driving efficiency (but may require a greater understanding of the sequence to get to the direction they want). Other manufacturers offer the ability to program a custom scanning pattern (ask your manufacturers reps for further information on what their electronics offer). Some scanning systems offer auditory beeps (auditory beeps can be activated or shut off).

Although this form of driving may initially take longer than traditional driving, with practice clients learn the sequencing and chair response to become efficient independent drivers. If some individuals find it too difficult or tedious to drive this way, it can also offer them independent power positioning control so they can continue to access their power positioning system to assist in managing their health independently (skin integrity, change of position, respiratory positioning, etc.).

Eyegaze drivecontrol systems — Eye gaze is a technology that has been utilized for quite a long time for communication and computer control. Only in more recent years has it been applied toward independent control of a power wheelchair. This is technology that I would still consider somewhat in its infancy. An eye gaze system allows individuals to drive by looking at a tablet or computer mounted on their wheelchair (these devices show what is on the other side of the device for safe driving). The device has a camera system on it that focuses on the eyes of the individual. When they move their eyes while looking at the screen the directional arrow lights up representing the direction they want to drive. As their gaze remains on that arrow, the power wheelchair drives in that direction.

This technology can provide independence to continue to drive and control a power wheelchair for individuals who have progressive neurological conditions although continuing to lose functional movement. Like other switch drive systems, eye gaze technology allows individuals independent access to driving and control of other chair functions and technologies (power positioning, communication devices, computers and personal electronics).

This technology continues to advance and offers more options for individuals who do not have consistent movement of any other body part. There are, however, some drawbacks such as outdoor driving, which can be impacted by the sunlight. The companies selling this technology (Tolt Technologies, Ability Drive and the Home Brace System) continue to make advancements in the usability of this technology in all environments (one such advancement is the Home Brace system offers a system that utilizes a pair of glasses with a camera that helps with sunlight interference, this will be a very personal choice for the individual). While this technology is expensive, consider the value of independence that can be achieved or maintained when the technology is utilized. Those of us in the CRT industry know you cannot put a price on independence and a maintained sense of productivity.

Conclusion

 Technology has advanced in leaps and bounds and in more recent years has accelerated significantly. The technologies utilized in the CRT industry continue to evolve, expanding opportunities for independence. The challenge now lies in getting these devices funded so they can be provided. As an industry and as users of the equipment, our job is to create awareness so that the functional and health benefits of  these technologies can be understood by government officials and funding sources develop funding for the implementation of these devices. This is not an easy task and requires time and significant effort.

Another ongoing challenge for manufacturers and suppliers is keeping pace with rapid technological change while continuing to refine existing equipment and develop new solutions. Ultimately, every advancement circles back to a single goal: supporting greater independence for the individuals served by the CRT industry.

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Jay may be reached at jdoherty@quantumrehab.com

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