What is integrated access?
An integrated system provides control of more than one device with the same access method. It allows communication aids and environmental control devices to be integrated to enable users to maximise their functional independence.
My reasons for attending the session were:
- Its applicability to the complex neurological patient group I work with
- I was interested in finding out more about the technology, and how it is used to integrate communication aids and environmental controls in powered wheelchairs
- As a neuro-physiotherapist, I work closely with an occupational therapist and speech and language therapist. Widening my knowledge base will help me understand better how to help patients using communication aids, environmental control systems, and wheelchair driving controls
The presenters, Sarah Ward and Sam Micklewright, are experienced clinicians working at the Chailey Communication Aid Services which is funded by NHS England. Here, children and adults with complex needs in Surrey and Sussex are assessed and provided with high tech communications aids. Specialist clinicians work jointly in the clinic to assist patients in integrating communication aids and environmental control systems, as well as computer/IT and mobile phone access for work and leisure, all from their powered wheelchair.
Topics covered ranged from advantages of integrated systems, considerations as to when to integrate and when not to, wheelchair control systems, and third-party integrators. The speakers shared their experiences of the service through three case studies.
Environmental control systems (ECSs) are instrumental for activities of daily living for people with complex disabilities, and they enable individuals to access their immediate environment by allowing them to have control over a range of appliances installed around their home. Using their most reliable method of access (e.g. direct touch, switches, voice activation, eye gaze), users operate a central controller to access a range of peripheral devices (Lincoln AT services, 2019). Communication aids are mainly used for communication.
So, why integrated access?
- To improve client’s function/ independence
- Client convenience (i.e. switching between driving control and communication aid, mounting different access methods on the wheelchair)
- To promote energy efficiency by reducing effortful functioning
Considerations during assessment:
- Client’s cognition
- Client’s motor control - is the same access method appropriate for one or more systems e.g. joystick control or mouse access?
- Changing client’s condition (i.e. medical stability) as integrated access may not be an appropriate system in some scenarios
- Level of support client has from the family and care team (is the system going to be adaptable?)
Equipment considerations discussed included:
- Commercially available systems that can be integrated (compatibility/reliability)
- Who owns the wheelchair? (if charity owned, permission needs to be sought prior to making adaptations to the wheelchair)
- Who will fund the integrated equipment?
- Who will maintain the access control?
- Who will maintain the integrated equipment?
- Safety considerations and risks involved with the mounting (during transportation, wheelchair stability and who is driving)
Wheelchair control systems discussed:
- Many wheelchair control systems are available
- Patients come with their own powered wheelchair
- Most commonly used systems at Chailey are -
- Dynamics DX2 & LiNX
- Penny & Giles R-Net
The speakers shared information about the pros and cons of key control systems and their clinical relevance. Systems discussed included:
- DX2, a modular power chair control system
- G91S, a scanner module/ display unit that allows user to scan through different modes
- DXACC4B switch box commonly used at Chailey
- LiNX 400/500 series master remote, needed for integrated access. These joysticks are Bluetooth enabled mouse movers for windows/switch control for iOS.
- Other systems discussed were R-Net, Omni, Omni 2 which have Bluetooth modules and are useful for connecting iOS devices and other Bluetooth devices.
Case study 1
The first case study showcased integrating three different systems for an adult with cerebral palsy.
The person previously had:
- A communication aid with two separate trays for communication and mouse mover
- Used four directional switches on powered mobility
- A DX2 wheelchair system which they drove with four directional switches on the other tray
- Cursor on the screen and used switches to move the cursor
The Chailey team added an environmental control unit (ECU)/woodpecker module for the communication aid. Adding the ECU module with the new system meant that there was no need for the tray to be swapped.
The client was re-referred to Chailey two years later. After a period of hospitalisation, they had found that the directional switches for the mouse mover were difficult to use in bed, and they could only access them from their wheelchair. This set-up was not functional.
This was resolved by providing a second access method with single head switch and communication aid with auto-scan option. Directional switches were still used for driving.
Case study 2
The second case study was about a client in their twenties who:
- Had no cognitive impairments
- Used a communication aid
- Used a single head-switch and auto-scan on a high-tech aid
- Used a powered wheelchair
- Privately purchased a wheelchair with an R-Net control system and Omni scanner controlled with head switch.
The client was referred to assess if integrating a communication aid in the electric wheelchair was achievable using a single head switch.
Initial set-up at assessment included a single head switch going into the Omni. The person was unable to switch from one control to the other using the head switch. The omni-scan freeze-in mode was added by Chailey, where the long press freezes or unfreezes the specified option.
The Chailey team then added an input/output module, power module and Sunrise R-Net programmer (communication mode). A key challenge with this set-up was to use one switch to control both communication and driving. The Sunrise programme enabled the team to achieve this
Case study 3
The third case study was about a 15-year-old client.
Initial setup included a single access method identified by the school – sip only (sip and puff switch to operate with a school communication aid system, and the patient could only use the sip function for the communication aid). Sip to select the auto-scan system.
The young person was simultaneously referred to the communication aid service and specialist communication aid clinic to see if they could also use the system to control the powered wheelchair.
Joint assessment was carried out by the team:
- Person bites on mouthpiece to anchor head position for stability (dystonic movements)
- Consulted specialist dentist regarding mouthpiece material and potential risks with sip and puff switches
- Consulted speech and language therapist (SALT) regarding saliva management and breathing as part of safety assessment
- Assessment of ability to use single sip switch access for communication
- Challenges encountered by the clinicians to source safe and appropriate mouth pieces (SALT provided safe straws)
- Powered wheelchair
- Sip/puff systems were not appropriate as the young person was unable to access as a single system
- LiNX was not suitable due to lack of scanner
- DX G91S scanner was trialled with single sip switch input. Client showed cognitive ability, but scan settings did not allow functional use
- R-Net Omni was trialled, and it allowed safe functional use for driving. Scanner timing was set to allow client to take a breath in between sipping
- Fully integrated access was expected to be too demanding for this young person
Powered mobility with Omni scanner, sip/sniff switch for communication, and communication aid auto-scan was found to be a safer option.
The key challenges with this client were co-ordinating their breathing using a single system for driving and communication.
It is important to note that a significant amount of time and resources are spent on complex systems which are used to provide bespoke solutions to clients. The complex presentation of the clients necessitates integrated working from a variety of specialist professionals. Various technological advances increase the number of options available to improve independence, function and communication for the clients. Occasionally easier options are available off-the-shelf rather than using customised solutions.
The speakers emphasised the importance of managing client expectations as sometimes disadvantages outweighed the benefits, and set-ups may not work for all clients. The speakers also highlighted the importance of identifying who will fund and maintain the equipment.
Other key points in the presentation included:
- With reference to Medical Device Regulations, potential simple solutions must comply
- Available options included mouse mover and woodpecker, but speakers emphasised the importance of considering safety and purpose of use
- In relation to funding of communication aids, it is important to communicate with wheelchair services if long term maintenance is needed
- Chailey can help people with motor neurone disease with ECS and mounting options for communication aids
- Chailey will also do risk assessments for mounting communication aids, and are able to do bespoke mounts as needed
Integrated access can result in increased patient satisfaction, improved independence and cost savings for the NHS. Different options must be trialled and adjusted to meet individual needs.
The challenges I would like to highlight from the presenters’ views and my clinical experience are:
- It is imperative that therapists and other professionals treating people who would benefit from integrated access are aware of the available services and refer appropriately to ensure effective use of professionals’ time
- It is important to manage people’s expectations as there are limits to what technology can assist with
- Sarah Ward and Sam Micklewright (2019) Integrated Access. Posture and Mobility Group. Annual Conference. Telford
- https://www.sussexcommunity.nhs.uk/services/chailey-communication-aidservice.htm (Accessed 18 September 2019)
- http://lincolnatservice.nhs.uk/clinicians/assistive-technology-1 (Accessed 11 October 2019)