INTERMEDIATE LEVEL For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ WHEELCHAIR SERVICE TRAINING PA CKAGE Participant's Workbook ISBN 978 92 4 150576 5 INTERMEDIATE LEVEL WHEELCHAIR SERVICE TRAINING PACK AGE Participant's Workbook Contributors: Editors: Chapal Khasnabis and Kylie Mines Authors: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Peer reviewers: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri, Ritu Ghosh, Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan, and Diane E. Ward. Illustrator: Melissa Puust Photo credits: David Constantine, Jesse Moss, and Chapal Khasnabis Video credits: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Pilot trainers: Andrew Congdon, Mirela Creanga, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Raducan, and Andrew Rose Financial support: US Agency for International Development and Australian Agency for International Development Partner organizations: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania, and Tanzania Training Centre for Orthopaedic Technologists (TATCOT) WHO Library Cataloguing-in-Publication Data Wheelchair service training package: intermediate level / edited by Chapal Khasnabis and Kylie Mines. 1.Wheelchairs – standards. 2.Disabled persons – rehabilitation. 3.Teaching materials. I.Khasnabis, Chapal. II.Mines, Kylie. III.World Health Organization. ISBN 978 92 4 150576 5 (NLM classification: WB 320) © World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Malta Design by Inís Communication – www.iniscommunication.com C O N T EN T S 1 2 3 7 8 11 12 14 16 25 27 30 42 43 44 45 49 50 54 55 Name: Purpose A.1: Wheelchair users who bene t from additional postural support B.1: Assessment overview and assessment interview B.2: Physical assessment – sitting posture without support: foundation of sitting posture B.2: Physical assessment – sitting posture without support: posture drawing B.3: Physical assessment – pelvis and hip posture screen: carrying out the screening B.3: Physical assessment – pelvis and hip posture screen: practising temporary supports B.5: Physical assessment – taking measurements B.6: Selecting wheelchairs and cushions B.8: Prescription (selection) of PSDs – stabilizing the pelvis B.9: Prescription (selection) of PSDs – supporting the hips B.10: Prescription (selection) of PSDs – supporting the trunk B.11: Prescription (selection) of PSDs – supporting the head, thighs and lower legs Practical Two: Product (wheelchair) preparation – task checklist Practical Two: Product (wheelchair) preparation – Intermediate Wheelchair Safe and Ready Checklist B.14: User training B.15: Putting it all together B.16: Maintenance, repairs and follow up Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training – task checklist Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training – intermediate wheelchair safe and ready checklist WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 1 2 Purpose The Intermediate Level training package is designed to support the training of personnel or volunteers to provide an appropriate manual wheelchair and cushion for girls, boys, women and men who need additional postural support to be able to sit upright. The main purpose of this training package is to develop the skills and knowledge of personnel involved in wheelchair service delivery. Delivery of this training package will help to: • increase the number of wheelchair users who receive a wheelchair, which meets their needs; • increase the number of personnel trained in intermediate level wheelchair service delivery; • improve the competencies of wheelchair service delivery personnel; • increase the quality of wheelchair service delivery for people who need comparatively a higher level of intervention than basic level; • include this training package in regular paramedical/rehabilitation training programmes and • achieve greater integration of wheelchair service delivery within rehabilitation services. The purpose of the Participant’s Workbook is to develop the skills and knowledge of personnel involved in wheelchair service delivery. The Participant’s Workbook contains exercises, which will help to test and develop participants’ knowledge and skills. The Participant’s Workbook contains material from lectures, slide presentations and the Reference Manual; it is intended that the participants will keep their copy of the workbook for future reference, if needed. 1 2 A.1: Wheelchair users who bene t from additional postural support 1. Throwing a ball • Choose one person in your group to sit on chair for all three steps of this activity. • The other two people will be helpers. • For each step throw and catch the ball between the person on the seat and helpers ve times. Step 1: While throwing and catching the person seated on the chair sits upright with feet at on the oor. How easy is it to throw and catch the ball? Does it get harder with steps 2 and 3? Why? How does the different position and posture affect how easy it is to catch the ball?Step 2: While throwing and catching one helper tilts the chair onto two side legs and holds it still. Step 3: While throwing and catching, one helper rocks the chair randomly from one leg to another. 2. Drinking • Each person to try drinking water in the different positions and postures described below. • Take just a few sips each time and be careful! • Sitting upright How does the different position and posture affect how easy it is to drink? • Sitting on the chair with your head tipped right back (nose pointing in the air) • Sitting on the chair in a ‘slumped’ posture • Lying down on the assessment bed WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 3 4 B.1: Assessment overview and assessment interview • Work together with your group and complete one set of questions below assigned to you depending on your group number. Group 1 How do the diagnosis/physical issues listed below affect wheelchair provision? For example: • What characteristics of diagnosis/physical issues affect wheelchair provision? • What wheelchair features and training may be helpful? • What is important to know about the wheelchair user in each case? Brain injury Polio Fatigue 3 4 Group 2 How do the diagnosis/physical issues listed below affect wheelchair provision? For example: • What characteristics of diagnosis/physical issues affect wheelchair provision? • What wheelchair features and training may be helpful? • What is important to know about the wheelchair user in each case? Muscular dystrophy Spinal cord injury Spasms/ uncontrolled movements WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 5 6 Group 3 How do the diagnosis/physical issues listed below affect wheelchair provision? For example: • What characteristics of diagnosis/physical issues affect wheelchair provision? • What wheelchair features and training may be helpful? • What is important to know about the wheelchair user in each case? Cerebral palsy Stroke Problems with eating, drinking or swallowing 5 6 Group 4 How do the diagnosis/physical issues listed below affect wheelchair provision? For example: • What characteristics of diagnosis/physical issues affect wheelchair provision? • What wheelchair features and training may be helpful? • What is important to know about the wheelchair user in each case? Spina bi da Progressive conditions (for example, muscular dystrophy, Parkinson disease, multiple sclerosis, motor neurone disease) Hip dislocation WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 7 8 B.2: Physical assessment – sitting posture without support: foundation of sitting posture • Work together to identify what changes happen to upright sitting posture when the pelvis posture changes. • Each person in the group should model one of the pelvis postures described below. The others observe what changes happen to the rest of his/her body. • If there is time, each person in the group should try the different pelvis postures to feel the change in their own body. Pelvis posture Write or draw your observations of the person’s changed posture. Look at the person’s trunk, head and neck, legs. Anterior tilt Posterior tilt Lateral tilt Rotation 7 8 B.2: Physical assessment – sitting posture without support: posture drawing • Draw your own line drawing next to each one below. Posture line drawing from the side Posture line drawing from the front Posture line drawing from the front – pelvis rotation. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 9 10 • Draw in the box below a line drawing to record the posture of the person in the illustration. 1. Sitting posture without support Describe or draw sitting posture without support: 2. Sitting posture without support Describe or draw sitting posture without support: 9 10 3. Sitting posture without support Describe or draw sitting posture without support: 4. Sitting posture without support Describe or draw sitting posture without support: • Draw in the box below a line drawing to record the posture of the person in the illustration. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 11 12 B.3: Physical assessment – pelvis and hip posture screen: carrying out the screening • Carry out the pelvis and hip posture screen on each person taking on the role of wheelchair user in your group. • Record on the ‘pelvis and hip posture screen’ part of the intermediate wheelchair assessment form below the results for each person taking the role of wheelchair user in your group. Wheelchair user one: Pelvis and hip posture screen Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right: Yes No Angle: _______ Left: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Wheelchair user two: Pelvis and hip posture screen Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right: Yes No Angle: _______ Left: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Wheelchair user three: Pelvis and hip posture screen Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right: Yes No Angle: _______ Left: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. 11 12 B.3: Physical assessment – pelvis and hip posture screen: practising temporary supports • Read each wheelchair user’s story. • For each wheelchair user, decide if the wheelchair user’s pelvis can be level and if hips bend to neutral sitting posture (trunk to thigh angle is no more than 90 degrees). • Complete the pelvis and hip posture screen part of the intermediate wheelchair assessment form, decide if the wheelchair user needs temporary support and set up a temporary support for each wheelchair user. • Be sure to check each temporary support and to sit on each temporary support to see what it feels like. Remember ASIS stands for Anterior Superior Iliac Spine. Sam Pelvis and hip posture screen Sam is 4 years old. He has cerebral palsy and cannot sit upright on his own. Through the pelvis and hip posture screen you nd out that: • Sam’s pelvis can be level (both ASIS level); • Sam’s left hip can bend comfortably to neutral sitting posture. Sam has pain in his right hip and it does not bend all the way to neutral sitting posture (trunk to thigh angle is more than 90 degrees). The angle between his trunk and thigh on the right side is approximately 105 degrees. Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right: Yes No Angle: _______ Left: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Does Sam need temporary support? Yes No Martha Pelvis and hip posture screen Martha is 57 years old. She has severe arthritis. She can walk a few steps, however walking is very painful. Through the pelvis and hip posture screen you nd out that: • Martha’s pelvis can be level (both ASIS level); • both of Martha’s hips cannot bend all the way to neutral sitting position (trunk to thigh angle is more than 90 degrees). The angle between her trunk and thigh on both hips is approximately 100 degrees. Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right: Yes No Angle: _______ Left: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Does Martha need temporary support? Yes No WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 13 14 Seren Pelvis and hip posture screen Seren is 16 years old. She had polio as a child and now has severe contractures of both legs. Seren moves around by sitting cross-legged and scooting over the oor. Through the pelvis and hip posture screening you nd out that: • Seren’s pelvis cannot be level. The right side of her pelvis is 20 mm higher than the left; • both of Seren’s hips can bend to neutral sitting posture. Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right: Yes No Angle: _______ Left: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Does Seren need temporary support? Yes No Joe Pelvis and hip posture screen Joe is 25 years old. He had polio as a child and now has severe contractures of both legs. Through the pelvis and hip posture screen you nd out that: • Joe’s pelvis can be level (both ASIS level); • Joe’s right hip can bend to neutral sitting posture comfortably. However his left hip cannot open all the way to neutral (trunk to thigh angle is less than 90 degrees). The angle between his trunk and thigh is 70 degrees. Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right: Yes No Angle: _______ Left: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Does Joe need temporary support? Yes No 13 14 B.5: Physical assessment – taking measurements Madavi is 13 years old and has cerebral palsy. She can sit upright without support, however she nds it very tiring and cannot sit for long. She has a mild xed posterior tilt, and slides forward in her current wheelchair. She has asked for a tray as she would like a table/ surface in front of her so that she can read, write and eat more easily. Below are the results of the hand simulation physical assessment done by wheelchair service personnel. • Read through the completed hand simulation results below: Hand simulation: support needed to sit in neutral posture as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw nal sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Final posture: posterior tilt pelvis; lower trunk slightly curved (side view) but symmetrical (front view) with support on both sides; head slightly forward; legs tend to roll inwards – gentle support brings thighs to neutral. Support needed: • support at front of seat bones; • support at the back of pelvis – does not bring to neutral but prevents from rolling further ; • support back up to shoulders; • side support at trunk – to help keep trunk in middle; • support on both sides of pelvis/hips to keep pelvis in middle; • support on inside of thighs to stop thighs from rolling in – inside thigh wedge; • tray. Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle • Decide what body measurements you will need to take to be able to select a wheelchair for Madavi. • Take these measurements of at least one member of the group and write them in the `taking measurements` part of the intermediate wheelchair assessment form (next page). • How will you ensure that you get the correct seat depth measurement? (Remember that Madavi has a mild xed posterior pelvis tilt) • What measurements will you take to describe the height and size/shape of a tray for her? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 15 16 Taking measurements Body measurements (mm) Wheelchair component measurements (mm) Seat width, depth and footrest height A Hip width = seat width OR 1 = distance between pelvis side pads 2 B Seat depth (back of pelvis to back of the knee) L B less 30–50 mm = seat depth (if length is different, use shorter) 3R C Calf length L = distance between top of the seat to footrest OR = distance between top of the seat to oor for foot propelling 4 R 5 Backrest height D Seat* to bottom of rib cage = distance between top of the seat to top of backrest (measure D, E or F – depending on the wheelchair user’s need) 6 E Seat* to bottom of shoulder blade F Seat* to top of shoulder Modi cations and/or PSDs G Trunk width = distance between trunk side pads/ wedges 7 H Seat* to axilla (armpit) L H less 30 mm = maximum distance between the top of the seat and the top of trunk side pads/wedges (adjust according to hand simulation) 8 R I Seat* to top of the pelvis (PSIS) = distance between the top of the seat and mid-height of rear pelvis pad 9 J Distance between knees = width of knee separator pad 10 K Seat* to base of skull = distance between the top of seat to middle of headrest 11 L Back of pelvis to seat bones L plus 20–40 mm = distance from the backrest support to the beginning of the pre seat bone shelf. 12 O th er *When taking body measurements, the ‘seat’ is the surface on which the seat bones are sitting. 15 16 B.6: Selecting wheelchairs and cushions • Look carefully at each of the locally available wheelchairs. • Work in your group to answer the following questions. • If you are not sure, ask your trainer for clari cation. 1. Lifestyle and environment Questions: Answers: Which wheelchair (or wheelchairs) is best suited to travel over rough/uneven terrain? Why? Which wheelchair (or wheelchairs) would most easily facilitate a standing transfer? Why? Which wheelchair (or wheelchairs) would most easily facilitate a sideways transfer? Why? How does each wheelchair fold or is disassembled for transport? Common methods include: • non-folding; • cross-folding; • backrest folds down; • quick release wheels. Which wheelchair (or wheelchairs) does your group think would be the easiest wheelchair to transport on public transport? Why? Which wheelchairs (if any) have pneumatic tyres? Which wheelchairs (if any) have solid inner tubes? Which wheelchairs (if any) have solid tyres? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 17 18 2. Pressure relief Questions: Answers: What types of cushion can you see in the training room? Which of these would you describe as a pressure relief cushion? Why? Of the pressure relief cushions (if any) – which would be relatively easy to modify to either : • increase pressure relief; • provide additional postural support. What type of cushion covers can you see in the training room? Consider : Water resistance, durability, stretchiness, thickness of fabric. 3. Propelling Questions: Answers: Sit upright in the wheelchair. Is the rear wheel in a good position for you to self-propel? Check: • allow your arm to hang down. Does your hand hang over the axle? • hold the top of the push rim directly below your shoulder. Is your elbow bent between 90–120 degrees? • Is the rear wheel position adjustable? If adjusted – would this improve the propelling position? Do any of the wheelchairs in the training room have an adjustable height seat? When would this be helpful? 17 18 4. Postural support features Questions: Answers: Which wheelchairs (if any) have elevating leg rest? Which wheelchairs (if any) have a solid seat? Which wheelchairs (if any) have a tension adjustable backrest? Which wheelchairs (if any) have additional components designed to provide additional postural support? (You do not need to describe or list the components. Just identify those wheelchairs, which have additional postural supports.) 5. Adjustability Questions: Answers: Which wheelchairs (if any) have the following adjustability? • Footrests height • Footrests angle • Footrests move backwards/forwards • Backrest height up or down • Backrest recline • Tilt in space (seat and backrest tilt) WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 19 20 Intermediate Wheelchair Summary Form • You may complete this form for each of the wheelchairs used in the training programme (ask your trainer for more copies if required). Name of Wheelchair: Manufacturer/supplier: Sizes available: Overall weight: Description: Frame: Fixed/rigid Folding Frame length: Backrest: Slung/canvas Solid Tension Adjustable Seat: Slung/canvas Solid Tension Adjustable Cushion: No cushion Flat foam Foam contoured Fluid Other Footrests: Fixed Removable Other: Castor wheels: Pneumatic Diameter: Solid Width: Rear wheels: Pneumatic Diameter: Push rims Solid Width: Adjustable axle Solid inner tube Removable Brakes: Short lever Long lever Other: Armrest: Curved Square Other: Fixed Removable Other: Push handles: Push handles PSDs: Pelvis strap Calf strap Shoulder harness Foot straps Anti-tip bars Trunk side pads Tray Headrest Pelvis side pads Other: 19 20 Measurements, adjustment options and range of adjustment: Measurements (if the wheelchair is available in different sizes list all sizes) Is this adjustable? Range of adjustment (adjustment range that is possible for this chair)Yes No Seat width Seat depth Seat height Backrest height Backrest recline Footrest height Footrest angle Push handles height Frame length Wheelbase length Backrest to seat angle Tilt in space WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 21 22 Intermediate Wheelchair Summary Form • You may complete this form for each of the wheelchairs used in the training programme (ask your trainer for more copies if required). Name of Wheelchair: Manufacturer/supplier: Sizes available: Overall weight: Description: Frame: Fixed/rigid Folding Frame length: Backrest: Slung/canvas Solid Tension Adjustable Seat: Slung/canvas Solid Tension Adjustable Cushion: No cushion Flat foam Foam contoured Fluid Other Footrests: Fixed Removable Other: Castor wheels: Pneumatic Diameter: Solid Width: Rear wheels: Pneumatic Diameter: Push rims Solid Width: Adjustable axle Solid inner tube Removable Brakes: Short lever Long lever Other: Armrest: Curved Square Other: Fixed Removable Other: Push handles: Push handles PSDs: Pelvis strap Calf strap Shoulder harness Foot straps Anti-tip bars Trunk side pads Tray Headrest Pelvis side pads Other: 21 22 Measurements, adjustment options and range of adjustment: Measurements (if the wheelchair is available in different sizes list all sizes) Is this adjustable? Range of adjustment (adjustment range that is possible for this chair)Yes No Seat width Seat depth Seat height Backrest height Backrest recline Footrest height Footrest angle Push handles height Frame length Wheelbase length Backrest to seat angle Tilt in space WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 23 24 Intermediate Wheelchair Summary Form • You may complete this form for each of the wheelchairs used in the training programme (ask your trainer for more copies if required). Name of Wheelchair: Manufacturer/supplier: Sizes available: Overall weight: Description: Frame: Fixed/rigid Folding Frame length: Backrest: Slung/canvas Solid Tension Adjustable Seat: Slung/canvas Solid Tension Adjustable Cushion: No cushion Flat foam Foam contoured Fluid Other Footrests: Fixed Removable Other: Castor wheels: Pneumatic Diameter: Solid Width: Rear wheels: Pneumatic Diameter: Push rims Solid Width: Adjustable axle Solid inner tube Removable Brakes: Short lever Long lever Other: Armrest: Curved Square Other: Fixed Removable Other: Push handles: Push handles PSDs: Pelvis strap Calf strap Shoulder harness Foot straps Anti-tip bars Trunk side pads Tray Headrest Pelvis side pads Other: 23 24 Measurements, adjustment options and range of adjustment: Measurements (if the wheelchair is available in different sizes list all sizes) Is this adjustable? Range of adjustment (adjustment range that is possible for this chair)Yes No Seat width Seat depth Seat height Backrest height Backrest recline Footrest height Footrest angle Push handles height Frame length Wheelbase length Backrest to seat angle Tilt in space WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 25 26 B.8: Prescription (selection) of PSDs – stabilizing the pelvis Intermediate Wheelchair Summary Form • Read about the wheelchair user, and using the results from the ‘taking measurements’ part of the intermediate wheelchair assessment form add appropriate dimensions to the sketch below. Marian is an 18 year-old female. She has been assessed at your wheelchair service. She and the wheelchair service personnel have decided that she needs the following PSDs to help stabilize her pelvis: • pre seat bone shelf • rear pelvis pad • pelvis strap. Marian’s body measurements are shown in the table below. Taking measurements Body measurements (mm) Wheelchair component measurements (mm) Seat width, depth and footrest height A Hip width 400 = seat width OR 1 = distance between pelvis side pads 2 B Seat depth (back of pelvis to back of the knee) L 420 B less 30–50 mm = seat depth (if length is different, use shorter) 3 380 R 420 380 C Calf length L 420 = distance between top of the seat to footrest OR = distance between top of the seat to oor for foot propelling 4 R 420 5 Backrest height D Seat* to bottom of rib cage = distance between top of the seat to top of backrest (measure D, E or F – depending on the wheelchair user’s need) 6 E Seat* to bottom of shoulder blade 500 F Seat* to top of shoulder Modi cations and/or PSDs G Trunk width 370 = distance between trunk side pads/wedges 7 H Seat* to axilla (armpit) L 480 H less 30 mm = maximum distance between the top of the seat and the top of trunk side pads/wedges (adjust according to hand simulation) 8 450 R 480 450 I Seat* to top of the pelvis (PSIS) 160 = distance between the top of the seat and mid-height of rear pelvis pad 9 25 26 Body measurements (mm) Wheelchair component measurements (mm) J Distance between knees = width of knee separator pad 10 K Seat* to base of skull = distance between the top of seat to middle of headrest 11 L Back of pelvis to seat bones 150 L plus 20–40 mm = distance from the backrest support to the beginning of the pre seat bone shelf. 12 180 O th er *When taking body measurements, the ‘seat’ is the surface on which the seat bones are sitting. • Add the dimensions for Marian to the sketch in the box on the right for a pre seat bone shelf and rear pelvis pad. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 27 28 B.9: Prescription (selection) of PSDs – supporting the hips Sienna’s right hip cannot bend to neutral sitting posture, so her trunk to thigh angle is greater than 90 degrees. During the assessment she used a temporary support (foam build-up under both seat bones and her left thigh) which helped her to sit in a more upright posture. She has been prescribed a cushion that has a pre seat bone shelf and lower seat front (right side) to accommodate her right hip. • Describe Sienna’s PSD on the ‘PSDs or modi cations required’ part of the intermediate wheelchair prescription form below. Use the shadow drawing, and mark where dimensions would be needed. PSD checklist Describe/draw and provide dimensions S ea t / c us hi o n Add solid seat Pre seat bone shelf (= 3 less 12) Lower seat front L R Raised seat front Wedge for anterior tilt Build-up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other 27 28 Robert cannot bend his hips to neutral sitting posture so his trunk to thigh angle is greater than 90 degrees. During assessment he used a temporary support (foam build- up under both seat bones) which allowed him to sit in a more upright posture. He has been prescribed a wheelchair that has a more open seat to backrest angle to accommodate the restriction in his hips. • Describe Robert’s PSD on the ‘PSDs or modi cations required’ part of the intermediate wheelchair prescription form below. Use the shadow drawing, and mark where dimensions would be needed. PSD checklist Describe/draw and provide dimensions S ea t an d ba ck re st Open seat to backrest angle Seat and backrest tilt (tilt in space) B ac kr es t Add solid backrest Rear pelvis pad (= 9) Adjust backrest shape Tension adjustable backrest Backrest recline Trunk side pads (= 7) L R Trunk side wedges(= 7) L R Other T ra y / ar m re st s Tray Modify armrests L R Other H ea d su pp o rt s Flat headrest (= 11) Shaped headrest (= 11) Other WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 29 30 PSD checklist Describe/draw and provide dimensions L ow er le g su pp o rt s Footrest build-ups L R Footrest wedges L R Lower leg supports L R Other S tr ap s Pelvis strap Calf strap Foot straps L R Shoulder harness Other 29 30 B.10: Prescription (selection) of PSDs – supporting the trunk 1. Mark is 16 years old and has a high level spinal cord injury. He has a wheelchair with a slung backrest and seat. His wheelchair is the correct size and he has a soft, at foam cushion. Mark nds it dif cult to sit upright. His back stays rounded and he tends to slide forward in his chair. He is getting red marks on his skin under his seat bones and around his shoulder blades. • Read the results from Mark’s assessment (below). • What PSDs could be provided to help Mark sit upright in his wheelchair? Use the postural PSD Table and PSD Reference Table in your Reference Manual to assist you. • How could you provide or make these supports for Mark, using his current wheelchair? Think about the changes that could be added to the wheelchair seat/ cushion and backrest. • Remember to work in this sequence: Pelvis + HipsTrunk • Use the wheelchair and materials you have been given to show to the rest of the group how you will give Mark the support he needs. Sitting posture without support Pelvis and hip posture screen Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: _______ Left hip: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 31 32 Hand simulation: support needed to sit in neutral posture as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw nal sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle To sit upright, Mark needed: • strong support at the back of his pelvis (both hands on the back of pelvis pushing forward); • light support behind his shoulder blades. 31 32 Intermediate Wheelchair Prescription (Selection) Form 1. Wheelchair user information Wheelchair user’s name: Number: Date of assessment: Date of tting: Assessor’s name: 2. Wheelchair type, size and set-up Type of wheelchair (list available wheelchairs below) Wheelchair dimensions (mm) Seat width Seat depth Backrest height Footrest height Wheelchair set-up Rear wheel position Other: Tilt 3. Cushion type and size Type of cushion Size E.g. pressure relief cushion 4. PSDs or modi cations required PSD checklist Describe/draw and provide dimensions S ea t / c us hi o n Add solid seat Pre seat bone shelf (= 3 less 12) Lower seat front L R Raised seat front Wedge for anterior tilt Build-up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 33 34 PSD checklist Describe/draw and provide dimensions S ea t an d ba ck re st Open seat to backrest angle Seat and backrest tilt (tilt in space) B ac kr es t Add solid backrest Rear pelvis pad (= 9) Adjust backrest shape Tension adjustable backrest Backrest recline Trunk side pads (= 7) L R Trunk side wedges (= 7) L R Other T ra y / ar m re st s Tray Modify armrests L R Other H ea d su pp o rt s Flat headrest (= 11) Shaped headrest (= 11) Other L ow er le g su pp o rt s Footrest build-ups L R Footrest wedges L R Lower leg supports L R Other S tr ap s Pelvis strap Calf strap Foot straps L R Shoulder harness Other 5. Agreement signatures Wheelchair user: Assessor: Wheelchair service manager: 33 34 2. Josephine is 35 years old. She has a spinal cord injury. She lives in a rural village, and is an active member of the local Church. She has previously been provided with a long wheelbase wheelchair, which she likes as it is easy for her family to push over the rough ground in her village. She can push it a little herself when indoors on smooth surfaces. The wheelchair is the correct size for her, and has a solid backrest and seat. She has a thick at foam cushion. Josephine is not comfortable in the wheelchair, and she is nding it harder to push herself. She sits with her pelvis rolled back (posterior pelvis tilt) and her trunk posture is curved forward. • Read the results from Josephine’s assessment (below). • What PSDs could be provided to help Josephine sit as upright as she is able in her wheelchair. • Use the PSD Table and PSD Reference Table in your Reference Manual to assist you. • How could you provide or make these supports for Joseph, using her current wheelchair? Think about the changes that could be added to the wheelchair seat/ cushion and backrest. • Remember to work in this sequence: Pelvis+ HipsTrunk • Use the wheelchair and materials you have been given to show to the rest of the group how you will give Josephine the support she needs. Sitting posture without support Pelvis and hip posture screen Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: 100 degrees Left: hip Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 35 36 Hand simulation: support needed to sit in neutral posture / as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw nal sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle Josephine could not sit upright in neutral sitting posture. Her nal posture is: • trunk rounded forward; • head falling forward; • pelvis in posterior tilt. Her posture is improved with the following support: • temporary support under both seat bones and left thigh; • two hands at the back of her pelvis, full contact support for her lower and upper trunk. 35 36 Intermediate Wheelchair Prescription (Selection) Form 1. Wheelchair user information Wheelchair user’s name: Number: Date of assessment: Date of tting: Assessor’s name: 2. Wheelchair type, size and set-up Type of wheelchair (list available wheelchairs below) Wheelchair dimensions (mm) Seat width Seat depth Backrest height Footrest height Wheelchair set-up Rear wheel position Other: Tilt 3. Cushion type and size Type of cushion Size E.g. pressure relief cushion 4. PSDs or modi cations required PSD checklist Describe/draw and provide dimensions S ea t / c us hi o n Add solid seat Pre seat bone shelf (= 3 less 12) Lower seat front L R Raised seat front Wedge for anterior tilt Build-up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 37 38 PSD checklist Describe/draw and provide dimensions S ea t an d ba ck re st Open seat to backrest angle Seat and backrest tilt (tilt in space) B ac kr es t Add solid backrest Rear pelvis pad (= 9) Adjust backrest shape Tension adjustable backrest Backrest recline Trunk side pads (= 7) L R Trunk side wedges (= 7) L R Other T ra y / ar m re st s Tray Modify armrests L R Other H ea d su pp o rt s Flat headrest (= 11) Shaped headrest (= 11) Other L ow er le g su pp o rt s Footrest build-ups L R Footrest wedges L R Lower leg supports L R Other S tr ap s Pelvis strap Calf strap Foot straps L R Shoulder harness Other 5. Agreement signatures Wheelchair user: Assessor: Wheelchair service manager: 37 38 3. Sian is 3 years old and has cerebral palsy. He has a child-size cross-folding wheelchair with swing-away footrests, a slung seat and backrest. There is no tray and no cushion. His wheelchair is the correct seat depth for him, however it is a little wide. His parents do not own a car and they walk to most places. They can push him around the community in his wheelchair although sometimes they just carry him. Sian can push his wheelchair a little himself when on a smooth surface. Sian can sit upright for very short periods without support. After 10 minutes his trunk starts to collapse and he usually leans forwards and towards the left. This causes his pelvis to lift up on the right side, and more weight goes through his left seat bone. His back has the normal curve for his age. Sian’s mother would like him to be able to play outside with other children and begin to push his wheelchair. • Read the results from Sian’s assessment (below). • What PSDs could be provided to help Sian sit as upright as he is able in his wheelchair? Use the PSD Table and PSD Reference Table in your Reference Manual to assist you. • How could you provide or make these supports for Sian, using his current wheelchair? Think about the changes that could be made to the wheelchair seat/ cushion and backrest. • Remember to work in this sequence: Pelvis+ HipsTrunk. • Use the wheelchair and materials you have been given to show to the rest of the group how you will give Sian the support he needs. Sitting posture without support Pelvis and hip posture screen Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: 80 degrees Left hip: Yes No Angle: 80 degrees If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 39 40 Hand simulation: support needed to sit in neutral posture / as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw nal sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle Sian could sit in neutral siting posture, however with both hips bent (trunk to thigh angle approximately 80 degrees). To sit upright Sian needed: • temporary foam wedge support provided under both thighs; • one hand on each side of his pelvis, holding rmly with gentle support also at the back of his pelvis; • one hand on each side of his trunk, holding rmly. The left side needed support slightly higher than on the right; • light support around his shoulder blades and front of chest. 39 40 Intermediate Wheelchair Prescription (Selection) Form 1. Wheelchair user information Wheelchair user’s name: Number: Date of assessment: Date of tting: Assessor’s name: 2. Wheelchair type, size and set-up Type of wheelchair (list available wheelchairs below) Wheelchair dimensions (mm) Seat width Seat depth Backrest height Footrest height Wheelchair set-up Rear wheel position Other: Tilt 3. Cushion type and size Type of cushion Size E.g. pressure relief cushion 4. PSDs or modi cations required PSD checklist Describe/draw and provide dimensions S ea t / c us hi o n Add solid seat Pre seat bone shelf (= 3 less 12) Lower seat front L R Raised seat front Wedge for anterior tilt Build-up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 41 42 PSD checklist Describe/draw and provide dimensions Se at a nd ba ck re st Open seat to backrest angle Seat and backrest tilt (tilt in space) B ac kr es t Add solid backrest Rear pelvis pad (= 9) Adjust backrest shape Tension adjustable backrest Backrest recline Trunk side pads (= 7) L R Trunk side wedges (= 7) L R Other T ra y / ar m re st s Tray Modify armrests L R Other H ea d su pp o rt s Flat headrest (= 11) Shaped headrest (= 11) Other L ow er le g su pp o rt s Footrest build-ups L R Footrest wedges L R Lower leg supports L R Other S tr ap s Pelvis strap Calf strap Foot straps L R Shoulder harness Other 5. Agreement signatures Wheelchair user: Assessor: Wheelchair service manager: 41 42 B.11: Prescription (selection) of PSDs – supporting the head, thighs and lower legs Read and answer the following questions. Jonah has come for assessment. During hand simulation you nd out that Jonah`s legs tend to fall outwards (abducted) but with gentle support you can bring his legs into a neutral sitting posture (knees closer together). • What changes do you think you can make to his wheelchair and cushion to help him sit with legs in a neutral sitting posture? Sam has been using this wheelchair for two years. He has a head injury, and his legs are quite stiff and tight. In the assessment you nd that Sam`s legs are drawn inwards but you can draw his knees apart into a more neutral sitting posture. However this takes quite a bit of force. With his knees in a more neutral sitting posture Sam feels more balanced. • What changes do you think you can make to his wheelchair and cushion to help him sit with legs in a neutral sitting posture? Elijah is pleased that his wheelchair can fold, and he is able to take it in a car to and from his workplace. However his back is sore and he nds his legs roll into each other. During assessment you nd that Elijah can sit in neutral sitting posture, and with gentle support his legs can sit in neutral sitting posture. • What changes do you think you can make to his wheelchair and cushion to help him sit with legs in a neutral posture? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 43 44 Practical Two: Product (wheelchair) preparation – task checklist • Use the table below to help you plan and prepare the wheelchair and PSDs. – List each task (preferably in the order the tasks should be completed in). – Decide who will be responsible for the task. – Tick off each task as it is completed. List each task Person responsible Tick off when completed 43 44 Practical Two: Product (wheelchair) preparation – Intermediate Wheelchair Safe and Ready Checklist Carry out intermediate wheelchair safe and ready checklist to make sure the wheelchair is safe and ready for the wheelchair user to try. Whole wheelchair including PSDs There are no sharp edges No parts are damaged or scratched The wheelchair travels in a straight line Front castor wheels Spin freely Spin without touching the fork Bolts are tight Front castor barrels Castor fork spins freely Rear wheels Spin freely Axle bolts are tight Tyres in ated correctly (with thumb pressure, wheel can be depressed less than 5 mm) Push rims are secure Brakes Function properly Footrests Footrests are securely attached Frame For a cross-folding wheelchair – the wheelchair folds and unfolds easily For a wheelchair with fold-down backrest – the backrest folds and unfolds easily Cushion The cushion is in the cover correctly The cushion is sitting on the wheelchair correctly The cushion cover fabric is tight but not too tight If the wheelchair has a solid seat: the cushion fully covers the solid seat WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 45 46 B.14: User training • Read ONE of the wheelchair user’s stories below. Your trainer will tell you which one to read. • Decide what skills the wheelchair user needs to learn to be able to use and care for their new wheelchair. Complete the intermediate wheelchair user training checklist on the next page. • Choose the role of wheelchair user, wheelchair service personnel or wheelchair user’s family member/carer. A person assuming the role of the wheelchair service personnel should practise teaching at least three of these skills to other members of the group. Use ‘How to make wheelchair user training successful’ tips outlined in this session of your Reference Manual. Joshua Joshua is 6 years old and has cerebral palsy. He gets sudden uncontrolled movements. He has been prescribed (selected) a child’s wheelchair with PSDs including a lap strap, pelvis side pads and trunk side pads. Joshua has thin, sensitive skin, and the trunk side pads have been provided with extra padding to help ensure he does not develop a pressure sore from the trunk side pads. Joshua’s new wheelchair has a tilt feature, which allows the wheelchair to be tilted back sometimes and then brought more upright. There is also an anti-tip bar, which can be moved out of the way for travelling over rough ground or up and down kerbs. For transport the wheelchair has removable rear wheels and the seat can be taken off the wheelchair frame. Joshua goes to kindergarten every morning. He is picked up by a transport service arranged by the kindergarten. The vehicle is a small motorized three-wheeler. His parents are worried about whether his wheelchair will t inside. Joshua has come for a tting for his new wheelchair. His mother is with him. Sangita Sangita is three years old and has spina bi da. She has movement dif culties; loss of feeling below her waist and has a bulge at the bottom of her spine. Her parents say she has dif culty controlling her bladder and bowels and often has urinary tract infections. Sangita has come to the wheelchair service for a tting of her rst wheelchair, which has quick release wheels, pelvis strap, pelvis side pads, and some shaping of the backrest to avoid pressure around the bulge in her spine. She also has a pressure relief cushion. She has come with both parents. Her parents are worried that if she has a wheelchair she will not want to walk with her calipers. However, she gets frustrated when she cannot play with her brother and sisters outside. 45 46 Kim Som Kim Som is 40 years old and had a head injury 15 years ago. He is very thin as he has dif culty eating. He has a xed forward curve of the spine. Kim Som cannot stand up and is completely dependent upon his mother. He does not speak, however his mother says that he understands simple instructions. In the assessment he was identi ed as a person at risk of developing a pressure sore as he is thin, cannot move independently and has had a pressure sore in the past (from lying in bed). He has just received his rst wheelchair. The wheelchair has a pressure relief cushion and PSD to help Kim Som sit more comfortably. His mother is his carer and has attended the wheelchair tting appointment with him. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 47 48 Intermediate Wheelchair User Training Checklist Skills to Teach Skills Taught Wheelchair handling Folding and lifting the wheelchair Taking off and putting back on any PSDs that need to come off for transport Using quick release wheels Using the brakes Tilting and anti-tip bars (if used) Correct position of PSDs when the wheelchair user is in the wheelchair Using the cushion including positioning correctly Transfers Independent transfer Assisted transfer Other Wheelchair use and mobility Pushing correctly (using the wheelchair user’s preferred method) Up and down a slope Up and down a step On rough ground Partial wheelie How long to sit in the wheelchair (for children and adults with additional postural support needs) Assisted pushing Preventing pressure sores Check areas of high pressure for pressure sores Pressure relief lifts Eat well and drink lots of water What to do if a pressure sore develops 47 48 Skills to Teach Skills Taught How to care for a wheelchair at home Clean the wheelchair ; wash and dry the cushion and cushion cover Oil moving parts Pump the tyres Tighten nuts and bolts Tighten spokes Check upholstery Check for rust Check the cushion What to do if there is a problem Wheelchair needs repairs The wheelchair does not t or is not comfortable WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 49 50 B.15: Putting it all together • Prepare a 10 minute presentation for the whole group about the wheelchair user your group worked with and what your group have learnt. The presentation should include the following points: 1. Information gained from the assessment: • the wheelchair user’s goals (why he/she wants a wheelchair); • their physical needs; • their lifestyle needs; • whether he/she has an existing wheelchair – and whether this wheelchair is meeting their needs; • presence, risk or history of pressure sores; • method of pushing; • sitting posture without support; • results of the pelvis and hip posture screen; • results of the hand simulation. 2. Wheelchair and cushion prescribed (selected): • type of wheelchair; • type of cushion; • any PSDs that were prescribed. 3. Fitting: • any problems that were identi ed at tting and needed to be resolved – and if so, how these were resolved. 4. User training: • what did the wheelchair user and the group decide needed to be covered in user training? 5. Wheelchair user’s feedback • after receiving the wheelchair – did the wheelchair user have any comments/ feedback? 6. Follow up plan: • what arrangements have been made for follow up? 49 50 B.16: Maintenance, repairs and follow up • Read each wheelchair user’s story. • Complete a wheelchair follow up form for each wheelchair user. • Discuss and record any actions to be taken. Thusitha Thusitha is a 7 year-old boy and lives at home with his parents and older sister. He has muscular dystrophy and received a wheelchair through the wheelchair service a year ago. At that time he could walk short distances. He was able to do a standing transfer in and out of the wheelchair on his own. He said he wanted a wheelchair because he is nding it hard to get to school. At the follow up visit, Thusitha said that he is now nding it hard to get in and out of his wheelchair himself. He feels tired and uncomfortable by the afternoon at school. This makes it hard to concentrate. His wheelchair is the correct size and has a medium slung backrest with a simple comfort cushion. When asked to rate how satis ed Thusitha is with his wheelchair he says 4 out of 5. Mirella Mirella is 23 years old and has polio. She makes honey and sells it in the local market. She received a wheelchair with a clip-on tricycle two years ago. She needed some extra PSDs in the wheelchair. She was prescribed a layered foam cushion with modi cations. A rear pelvis pad was added to the backrest of the wheelchair. At the follow up visit Mirella says that she uses her wheelchair and tricycle every day to get to and from the market. She reports that she has had to repair two wheel punctures recently. When checking the wheelchair, the wheelchair service personnel notice that the tyres are very worn out. The rear pelvis pad has slipped down onto the seat and the cushion looks very at. When asked to rate how satis ed she is with her wheelchair, Mirella says 3 out of 5. Ursula Ursula is 6 years old and has cerebral palsy. She likes singing with her sister in the church choir. She received her wheelchair with PSDs eight months ago. She was ill with a chest infection and missed her rst follow up appointment. Her parents say that recently she has not been happy sitting in the wheelchair and asks to get out after an hour. They have noticed a dark mark on her ribs near one of the trunk side pads and wonder whether this could be the problem. The wheelchair service personnel nd a private place and ask Ursula and her parents for permission to check her skin. The wheelchair service personnel con rm that there is a dark mark. They look at the wheelchair and notice that the foam padding on the trunk side pad has compressed. When asked to rate how satis ed they are with Ursula’s wheelchair, her parents say 4 out of 5. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 51 52 Wheelchair Follow Up Form 1. Wheelchair user information Wheelchair user name: _____________________ Number: ___________________________ Date of tting: ____________________________ Date of follow up: ____________________ Name of person carrying out follow up: ___________________________________________ Follow up carried out at: Wheelchair user’s home Wheelchair service centre Other: _____________________________________________________________________ 2. Interview Record action to be taken: Are you using your wheelchair as much as you would like? Yes No If no – why not? Do you have any problems using your wheelchair? Yes No If yes – what are the problems? Do you have any questions about using your wheelchair? Yes No If yes – what questions. Is further training needed? Does the wheelchair user have any pressure sores? Yes No Describe (location and level) How would you rate your satisfaction with your wheelchair from 1–5? (1 is not satis ed and 5 is very satis ed) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes No Is the cushion in good working order and safe to use? Yes No If no for either, what is the problem? 4. Fitting check Does the wheelchair t correctly? Yes No If no – what is the problem? Pressure test level (1=safe, 2=warning, 3=unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes No If no – what is the problem? 51 52 Wheelchair Follow Up Form 1. Wheelchair user information Wheelchair user name: _____________________ Number: ___________________________ Date of tting: ____________________________ Date of follow up: ____________________ Name of person carrying out follow up: ___________________________________________ Follow up carried out at: Wheelchair user’s home Wheelchair service centre Other: _____________________________________________________________________ 2. Interview Record action to be taken: Are you using your wheelchair as much as you would like? Yes No If no – why not? Do you have any problems using your wheelchair? Yes No If yes – what are the problems? Do you have any questions about using your wheelchair? Yes No If yes – what questions. Is further training needed? Does the wheelchair user have any pressure sores? Yes No Describe (location and level) How would you rate your satisfaction with your wheelchair from 1–5? (1 is not satis ed and 5 is very satis ed) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes No Is the cushion in good working order and safe to use? Yes No If no for either, what is the problem? 4. Fitting check Does the wheelchair t correctly? Yes No If no – what is the problem? Pressure test level (1=safe, 2=warning, 3=unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes No If no – what is the problem? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 53 54 Wheelchair Follow Up Form 1. Wheelchair user information Wheelchair user name: _____________________ Number: ___________________________ Date of tting: ____________________________ Date of follow up: ____________________ Name of person carrying out follow up: ___________________________________________ Follow up carried out at: Wheelchair user’s home Wheelchair service centre Other: _____________________________________________________________________ 2. Interview Record action to be taken: Are you using your wheelchair as much as you would like? Yes No If no – why not? Do you have any problems using your wheelchair? Yes No If yes – what are the problems? Do you have any questions about using your wheelchair? Yes No If yes – what questions. Is further training needed? Does the wheelchair user have any pressure sores? Yes No Describe (location and level) How would you rate your satisfaction with your wheelchair from 1–5? (1 is not satis ed and 5 is very satis ed) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes No Is the cushion in good working order and safe to use? Yes No If no for either, what is the problem? 4. Fitting check Does the wheelchair t correctly? Yes No If no – what is the problem? Pressure test level (1=safe, 2=warning, 3=unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes No If no – what is the problem? 53 54 Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training Product (Wheelchair) Preparation – Task Checklist • Use the table below to help you plan and prepare the wheelchair and PSDs for the wheelchair user’s rst tting. – List each task (preferably in the order the tasks should be completed in). – Decide who will be responsible for the task. – Tick off each task as it is completed. List each task Person responsible Tick off when completed WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 55 56 Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training • Carry out intermediate wheelchair safe and ready checklist to make sure the wheelchair is ready for the wheelchair user to try. Intermediate Wheelchair Safe and Ready Checklist Whole wheelchair including PSDs There are no sharp edges No parts are damaged or scratched The wheelchair travels in a straight line Front castor wheels Spin freely Spin without touching the fork Bolts are tight Front castor barrels Castor fork spins freely Rear wheels Spin freely Axle bolts are tight Tyres in ated correctly (with thumb pressure, wheel can be depressed less than 5 mm) Push rims are secure Brakes Function properly Footrests Footrests are securely attached Frame For a cross-folding wheelchair – the wheelchair folds and unfolds easily For a wheelchair with fold-down backrest – the backrest folds and unfolds easily Cushion The cushion is in the cover correctly The cushion is sitting on the wheelchair correctly The cushion cover fabric is tight but not too tight If the wheelchair has a solid seat: the cushion fully covers the solid seat INTERMEDIATE LEVEL For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ WHEELCHAIR SERVICE TRAINING PA CKAGE Participant's Workbook ISBN 978 92 4 150576 5
INTERMEDIATE LEVEL WHEELCHAIR SERVICE TRAINING PA CKAGE Preface The wheelchair is one of the most commonly used assistive devices for enhancing personal mobility which is a precondition for enjoying human rights and living in dignity and assists people with disabilities to become productive members of their communities. For many people with disabilities, an appropriate, well designed and well fitted wheelchair can be the first step towards inclusion and participation in society. The Convention on the Rights of Persons with Disabilities (CRPD) highlights the responsibility of states to ensure personal mobility and to promote the availability and access to such devices at an affordable cost. To ensure that people with disabilities can access an appropriate wheelchair, especially in less resourced parts of the world, WHO developed the Guidelines on the provision of manual wheelchairs in less resourced settings, in partnership with the United States Agency for International Development (USAID) and the International Society for Prosthetics and Orthotics (ISPO). In order to train adequate number of human resources appropriately and facilitate a good wheelchair delivery system based on the Wheelchair guidelines, WHO has taken an initiative to develop a series of Wheelchair Service Training Packages (WSTP) for health and rehabilitation personnel responsible for managing different levels of intervention, as outlined in the Wheelchair guidelines. After a successful launch of the Wheelchair Service Training Package – Basic Level (WSTP-B) in June 2012, we are pleased to release the Wheelchair Service Training Package – Intermediate Level (WSTP-I). In addition to extending the skills and knowledge gained through the Wheelchair Service Training Packages – Basic Level; the Wheelchair Service Training Packages – Intermediate Level has an increased focus on children, as many children due to the nature of common developmental disabilities, require a wheelchair for both mobility and postural support. Alana Of cer Coordinator Disability and Rehabilitation Department of Violence and Injury Prevention and Disability World Health Organization For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ dar@who.int ISBN 978 92 4 150576 5 Rob Horvath Manager Programs for Vulnerable Populations Center of Excellence on Democracy, Human Rights, and Governance US Agency for International Development About the trainin g package Background Following the release of the Wheelchair Service Training Package – Basic level (WSTP-B), the World Health Organisation (WHO) in partnership with United States Agency for International Development (USAID) has developed this Wheelchair Service Training Package – Intermediate Level (WSTP-I). The Wheelchair Service Training Packages – Intermediate Level is the second part of the WHO wheelchair service training package series and focusses more on addressing the needs of people who have severe difficulties in walking and moving around and also having poor trunk control. While developing this training package, special attention was given on provision of appropriate wheelchair for children who have poor trunk control and cannot sit upright on their own. The Wheelchair Service Training Package – Intermediate Level is a step higher in knowledge and skills than the basic level. Like the Wheelchair Service Training Package – Basic Level, the Wheelchair Service Training Package – Intermediate Level also comes with a DVD, which includes all the necessary teaching and reference materials including a set of presentations required to deliver an intermediate level training programme for wheelchair service provision. Purpose The need for wheelchair personnel is universal. The Intermediate Level training package is designed to support the training of personnel or volunteers to provide an appropriate manual wheelchair and cushion for girls and boys, women and men who need additional postural support to sit upright. The main purpose of this training package is to: • increase the number of wheelchair users who receive a wheelchair which meets their needs; • increase the number of personnel trained in Intermediate level wheelchair service delivery; • improve the competencies of wheelchair service delivery personnel; • increase the quality of wheelchair service delivery for people who need comparatively a higher level of intervention than basic level; • include this training package in regular paramedical/rehabilitation training programmes and • achieve greater integration of wheelchair service delivery within rehabilitation services. How to get started 1. Copy the disc (inside the folder) to the hard drive of the computer to be used during training. At least 6 GB of free storage space is needed on the hard drive. 2. Click on the le titled ‘START’. From here, trainers can navigate to the different WSTP Intermediate resources. Trainers may also access the same resources through the folder hierarchy. 3. Open the Trainer’s Manual 3.1 Read the sections About the Wheelchair Service Training Package and Guidance Notes for Trainers and 3.2 Order or print and bind one copy of the Trainer’s Manual for each trainer (where printed copies are not already available). 4. Open the timetable and click the hyperlinks of each session, to access the session presentations and videos. Review each session working through the presentation and session plan (trainer’s manual) to become very familiar with the content, resources and methodology. 5. Follow the guidance notes in the section ‘How to prepare to deliver the training package’ to ensure that all necessary preparations are made well in advance of delivering the training. Prepare all training resources and materials, as suggested in the section How to Prepare to Deliver the Training Package. 6. The best way to deliver the training is to proceed through the lessons in sequential order respecting time allotted for each session as much as possible. Contributors: Editors: Chapal Khasnabis and Kylie Mines Authors: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Peer reviewers: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nelja Essaafi Elkhadiri, Ritu Ghosh, Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan, and Diane E. Ward Illustrator: Melissa Puust Photo credits: David Constantine, Chapal Khasnabis, and Jesse Moss Video credits: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Pilot trainers: Andrew Congdon, Mirela Creanga, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Raducan, and Andrew Rose Financial support: US Agency for International Development and Australian Agency for International Development Partner organizations: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania, and Tanzania Training Centre for Orthopaedic Technologists (TATCOT) The Wheelchair Service Training Package – Intermediate Level Disc contains all of the resources required to deliver the training. Some resources will require adaptation to the local context, and for this reason are provided in both PDF and Word/PowerPoint format. The full list of resources in section 2.8 of the Trainer’s Manual highlights those resources that are most likely to need local adaptation. Below is a list of the contents of the disc. • Wheelchair service forms, checklists and tables: – Postural Support Device Table: » Postural Support Device (PSD) Table – Wheelchair service checklists: » Intermediate wheelchair safe and ready checklist » Intermediate wheelchair fitting checklist » Intermediate wheelchair user training checklist – Wheelchair service forms: » Intermediate wheelchair referral form » Intermediate wheelchair assessment form » Intermediate wheelchair prescription form » Intermediate wheelchair summary form » Wheelchair follow up form • Posters (one PDF file): – Children and wheelchairs – Different positions – Postural Support Device (PSD) table – Intermediate wheelchair user training checklist • Trainer’s observation checklists: – Trainer’s Observation Checklist Practical One – Trainer’s Observation Checklist Practical Two – Trainer’s Observation Checklist Practical Three – Trainer’s Observation Checklist Practical Four • Training programme forms: – Sample invitation letter and consent form for wheelchair users – Sample participants register form – Sample photo consent form – Sample wheelchair user list for practical sessions – Sample participant certificate • Manuals: – Participant’s Workbook – Reference Manual for Participants – Trainer’s Manual • Presentations: – Introduction – A.1 – A.2 Sessions – B.1 – B.17 Sessions (links to the DVDs for each session are embedded in the PowerPoint PDF files). • Video: mp4 and wmv files with and without sub-titles: – Wheelchair service delivery – Wheelchair service steps – The benefits of an appropriate wheelchair – People using postural support devices – Good communication – Physical assessment overview – Pelvis and hip posture screen – Temporary supports – Hand simulation demonstration – Deepak – Hand simulation demonstration – Enith – Hand simulation demonstration – Bahati – Postural support solutions for anterior pelvis tilt – Head support – Product (wheelchair) preparation – Fabricating a footrest modification – Fitting demonstration – Deepak – Fitting demonstration – Careen – Take home message • Training programme evaluation forms: – Training programme evaluation form for participants – Training programme evaluation form for trainers – Training programme session evaluation form for trainers • Timetable with links to the presentations What is on the disc WHO Library Cataloguing-in-Publication Data Wheelchair service training package: intermediate level / edited by Chapal Khasnabis and Kylie Mines. 1.Wheelchairs – standards. 2.Disabled persons – rehabilitation. 3.Teaching materials. I.Khasnabis, Chapal. II.Mines, Kylie. III.World Health Organization. ISBN 978 92 4 150576 5 (package) (NLM classification: WB 320) ISBN 978 92 4 150577 2 (DVD) © World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Malta Design by Inís Communication – www.iniscommunication.com WHEELCHAIR Intermediate Level SERVICE TRAINING P ACKAGE © World Health Organization 2013 To navigate, please clic k START.PDF D esign by Inís Communication • Content packaging by Bizgraphic, Geneva
WHO/NMH/VIP/DAR/13.02 Design by Inís Communication – www.iniscommunication.com WHEELCHAIR SERVICE TRAIN ING PACKAGE INTERMEDIATE LE VEL C H IL D R E N A N D W H E E LC H A IR S Wheelchairs and extra postural support can help children to: Early referral for wheelchairs and extra postural support is important. Move around Communicate Eat by themselves Go to school Play with their friends By the age of one – many children are able to sit by themselves; and are pulling themselves up to stand By the age of two – many children are able to walk on their own Children who are having dif culty doing these things may need a wheelchair and extra postural support. Refer for a wheelchair assessment. WHO/NMH/VIP/DAR/13.02 Design by Inís Communication – www.iniscommunication.com WHEELCHAIR SERVICE TRAIN ING PACKAGE INTERMEDIATE LE VEL D IF FE R E N T P O SI T IO N S Children who use a wheelchair and have limited ability to change their position or posture – need support in different positions during the day and night. SITTING STANDING LYING Standing helps to form the hip joints and the normal curves of the trunk/spine. Standing also stretches out the muscles around the hip, knee and ankle joints and helps to prevent these joints from becoming stiff. Provide support for children when lying to help them to play and sleep comfortably. When a child cannot stand independently, a standing frame can help. Some different ways to support children sitting closer to the oor are: Blankets, foam, towels or pillows can be used to give support. Sitting astride a log, roller or tightly rolled blanket. Sitting with support from a family member/carer. Sitting in a supportive seat which is low to the ground. WHO/NMH/VIP/DAR/13.02 Design by Inís Communication – www.iniscommunication.com WHEELCHAIR SERVICE TRAIN ING PACKAGE INTERMEDIATE LE VEL Discuss with the wheelchair user: what do they know, and what would they like to learn? Use the checklist to remember key things to teach the wheelchair user. W H E E LC H A IR U SE R T R A IN IN G C H EC K LI ST IN T E R M E D IA T E WHEELCHAIR HANDLING Folding and lifting the wheelchair Taking off and putting back on any PSDs that need to come off for transport Using quick-release wheels Using the brakes Tilting and anti-tip bars (if used) Correct position of PSDs when the wheelchair user is in the wheelchair Using the cushion including positioning correctly WHEELCHAIR USE AND MOBILITY Pushing correctly using the wheelchair user’s preferred method Up and down a slope Up and down a step On rough ground Partial wheelie How long to sit in the wheelchair (for children and adults with intermediate postural needs) Assisted pushing PREVENTING PRESSURE SORES Check areas of high pressure for pressure sores Pressure relief lifts Eat well and drink lots of water What to do if a pressure sore develops TRANSFERS Independent transfer or Assisted transfer Teach the most appropriate transfer method for the wheelchair user. WHAT TO DO IF THERE IS A PROBLEM Wheelchair needs repairs Wheelchair does not t or is not comfortable HOW TO CARE FOR A WHEELCHAIR AT HOME Clean the wheelchair; wash and dry the cushion and cushion cover Oil moving parts Pump the tyres Tighten nuts and bolts Tighten spokes Check upholstery Check for rust Check the cushion WHO/NMH/VIP/DAR/13.02 Design by Inís Communication – www.iniscommunication.com WHEELCHAIR SERVICE TRAIN ING PACKAGE INTERMEDIATE LE VEL STRAPS pelvis strap anterior tilt four point strap calf strap foot straps shoulder harness P O ST U R A L SU PP O R T D E V IC E (P SD ) T A B LE SEAT / CUSHION pre seat bone shelf lower seat front (one side) raised seat front wedge for anterior tilt build-up under pelvis pelvis side pads SEAT / CUSHION SEAT & BACKREST outside thigh wedges outside thigh pads inside thigh wedge knee separator pad open seat to backrest angle seat & backrest tilt (tilt in space) BACKREST rear pelvis pad adjust backrest shape tension adjustable backrest backrest recline trunk side pads trunk side wedges TRAY HEAD SUPPORTS LOWER LEG SUPPORTS tray at headrest shaped headrest footrest build-ups footrest wedges lower leg supports 6 7 3 2 1 4 5 11 13 8 12 9 10
INTERMEDIATE LEVEL WHEELCHAIR SERVICE TRAINING PA CKAGE Reference Manual for Partic ipants For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ ISBN 978 92 4 150576 5 W heelchair S ervice Training P ackage R eference M anual for P articipants Interm ediate Level INTERMEDIATE LEVEL Reference Manual for Partic ipants WHEELCHAIR SERVICE TRAINING PA CKAGE Contributors: Editors: Chapal Khasnabis and Kylie Mines Authors: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Peer reviewers: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri, Ritu Ghosh, Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan, and Diane E. Ward. Illustrator: Melissa Puust Photo credits: David Constantine, Jesse Moss, and Chapal Khasnabis Video credits: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Pilot trainers: Andrew Congdon, Mirela Creanga, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Raducan, and Andrew Rose Financial support: US Agency for International Development and Australian Agency for International Development Partner organizations: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania, and Tanzania Training Centre for Orthopaedic Technologists (TATCOT) WHO Library Cataloguing-in-Publication Data Wheelchair service training package: intermediate level / edited by Chapal Khasnabis and Kylie Mines. 1.Wheelchairs – standards. 2.Disabled persons – rehabilitation. 3.Teaching materials. I.Khasnabis, Chapal. II.Mines, Kylie. III.World Health Organization. ISBN 978 92 4 150576 5 (NLM classification: WB 320) © World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Malta Design by Inís Communication – www.iniscommunication.com Terminology The following terms used throughout the training package are de ned below. Appropriate wheelchair A wheelchair that meets the user’s needs and environmental conditions; provides proper t and postural support; is safe and durable; is available in the country; and can be obtained and maintained and services sustained in the country at an affordable price. Manual wheelchair A wheelchair that is propelled by the user or pushed by another person. Postural support device (PSD) A physical device that provides additional postural support – an essential element of intermediate level wheelchair service. Wheelchair A device providing wheeled mobility and seating support for a person with dif culty in walking or moving around. Wheelchair modi cation A change made to a wheelchair. Wheelchair provision An overall term for wheelchair design, production, supply and service delivery. Wheelchair service That part of wheelchair provision concerned with providing wheelchair users with appropriate wheelchairs. Wheelchair service personnel Persons skilled in the provision of an appropriate wheelchair. Wheelchair user A person who has dif culty walking or moving around and uses a wheelchair for mobility. C O N T EN T S VII Preface 1 About the Wheelchair Service Training Package: Intermediate Level 6 A: Core knowledge A.1: Wheelchair users who bene t from additional postural support 13 A.2: Children with disabilities 20 B. Wheelchair service steps 21 Step 1: Referral and appointment 21 Step 2: Assessment 21 Assessment overview and assessment interview 49 Physical assessment – sitting posture without support 54 Physical assessment – pelvis and hip posture screen 59 Physical assessment – hand simulation 63 Physical assessment – taking measurements 71 Step 3: Prescription (selection) 71 Selecting wheelchairs and cushions 80 Prescription (selection) of PSDs – introduction 94 Prescription (selection) of PSDs – stabilizing the pelvis 98 Prescription (selection) of PSDs – supporting the hips 100 Prescription (selection) of PSDs – supporting the trunk 104 Prescription (selection) of PSDs – supporting the head, thighs and lower legs 107 Step 4: Funding and ordering 107 Step 5: Product (wheelchair) preparation 108 Planning and carrying out wheelchair and PSD preparation 109 What to remember when making PSDs 110 Materials and tools needed to make PSDs and modi cations 112 How to make PSDs 128 Carrying out the wheelchair safe and ready checklist 129 Intermediate Wheelchair Safe and Ready Checklist 130 Step 6: Fitting 139 Step 7: User training 139 What are helpful skills for wheelchair users? 144 Step 8: Maintenance, repairs and follow up 144 Managing follow up 145 Common follow up actions Preface The wheelchair is one of the most commonly used assistive devices for enhancing personal mobility, which is a precondition for enjoying human rights and living in dignity and assists people with disabilities to become more productive members of their communities. For many people with disabilities, an appropriate, well designed and well tted wheelchair can be the rst step towards inclusion and participation in society. The United Nations Standard Rules on the Equalization of Opportunities for Persons with Disabilities, the Convention on the Rights of Persons with Disabilities and World Health Assembly Resolution WHA58.23, which deals with disability including prevention, management and rehabilitation, all emphasize the importance of wheelchairs and other assistive devices. To ensure that people with disabilities can access an appropriate wheelchair, especially in less resourced parts of the world, WHO developed the Guidelines on the provision of manual wheelchairs in less resourced settings, in partnership with the United States Agency for International Development (USAID) and the International Society for Prosthetics and Orthotics (ISPO). In order to train adequate number of human resources appropriately and facilitate a good wheelchair delivery system based on the Wheelchair guidelines, WHO has taken an initiative to develop a series of Wheelchair Service Training Package (WSTP) for different levels of health and rehabilitation personnel responsible for managing different levels of intervention, as outlined in the wheelchair guidelines. After a successful launch of the Wheelchair Service Training Package – Basic Level (WSTP-B) in June 2012, we are pleased to release the Wheelchair Service Training Package – Intermediate Level (WSTP-I). In addition to extending the skills and knowledge gained through the Wheelchair Service Training Packages – Basic Level; the Wheelchair Service Training Packages – Intermediate Level has an increased focus on children, as many children, due to the nature of common developmental disabilities, require a wheelchair for both mobility and postural support. Alana Of cer Robert Horvath Coordinator Manager Disability and Rehabilitation Team Programs for Vulnerable Populations Department of Violence and Center of Excellence on Democracy, Injury Prevention and Disability Human Rights, and Governance World Health Organization US Agency for International Development WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 1 2 About the Wheelchair Service Training Package: Intermediate Level Introduction Following the release in 2008 of the Guidelines on the provision of manual wheelchairs in less resourced settings(1) and in 2012 of the Wheelchair Service Training Package – Basic level (WSTP-B); the World Health Organisation (WHO) in partnership with United States Agency for International Development (USAID) has developed this Wheelchair Service Training Package – Intermediate Level (WSTP-I). The WSTP Intermediate Level is the second part of the WHO Wheelchair Service Training Package (WSTP) series focussing more on addressing the needs of people who have severe dif culties in walking and moving around and also poor trunk control. While developing this training package, special attention was given on provision of appropriate wheelchair for children who have poor trunk control and cannot sit upright on their own. The wheelchair is one of the most commonly used assistive devices for enabling personal mobility. For people who have dif culties walking, a wheelchair, which meets their physical, lifestyle and environmental needs is an essential tool, enabling them to enjoy vastly improved health, social and economic well-being. Mobility opens up opportunities for wheelchair users to study, work and engage in cultural activities, as well as to access services such as health care. The importance of mobility is re ected in the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), which advocates for “effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities”. To ensure effective personal mobility, wheelchair users need a wheelchair, which ts them correctly and meets their speci c needs. This requires an approach, which is responsive to individual needs. An effective way of meeting the individual needs of wheelchair users is the provision of wheelchairs through wheelchair services. However, statistics show that less than 5% of those in need actually have access to a properly tted wheelchair. In addition, there are limited training opportunities for personnel to gain the skills needed to prescribe a wheelchair effectively. 1 World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings. Geneva, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, accessed 15 December 2011). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 1 2 The WSTP-I is intended to support the training of personnel ful lling the clinical and technical roles in a wheelchair service (see Guidelines on the provision of manual wheelchairs in less resourced settings, Table 4.2) at intermediate level. The Training Package supports the delivery of the theory and practice needed to begin working with wheelchair users who require additional postural support in order to be able to sit upright. The training package includes how to assess individual needs; assist in selecting and setting up the most appropriate wheelchair with additional postural support; train users and caregivers how to use and maintain their wheelchair and carry out follow up. The training package can be delivered in 35–40 hours, although this period may be extended or reduced according to the speci c needs and resources available in each context. Further practise with a mentor is encouraged to build competencies and enhanced capacity for independent work. Wheelchair Service Training Package is intended to be delivered as a stand-alone short training programme for personnel already working in the eld as well as integrated into the curricula of training programmes for health and rehabilitation personnel. Target audience This training package is for all personnel or volunteers working who are expected to carry out intermediate level wheelchair service delivery in their place of work. This may include health, rehabilitation or technical personnel such as occupational therapists, physiotherapists, prosthetists, orthotists, community health care workers and community-based rehabilitation (CBR) workers. Purpose The Intermediate Level training package is designed to support the training of personnel or volunteers to provide an appropriate manual wheelchair and cushion for girls, boys, women and men who need additional postural support to be able to sit upright. The main purpose of this training package is to develop the skills and knowledge of personnel involved in wheelchair service delivery. Delivery of this training package will help to: • increase the number of wheelchair users who receive a wheelchair, which meets their needs; • increase the number of personnel trained in intermediate level wheelchair service delivery; WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 3 4 • improve the competencies of wheelchair service delivery personnel; • increase the quality of wheelchair service delivery for people who need comparatively a higher level of intervention than basic level; • include this training package in regular paramedical/rehabilitation training programmes and • achieve greater integration of wheelchair service delivery within rehabilitation services. Scope The training package covers: • how to assess mobility and posture support needs of children and adults who need wheelchair with additional postural support • how to work with them to identify the best possible mobility solution; • knowledge and practical tips necessary to provide a manual wheelchair with an appropriate cushion and additional postural support; • training of wheelchair users and where appropriate their family members/ caregivers to make the best use of their wheelchair; • following up wheelchair users to ensure that their wheelchair continues to meet their needs. Required knowledge and skills Previous experience in wheelchair service delivery is essential for participants to gain the most from this intermediate level training. The intermediate level programme has been designed assuming that participants are able to demonstrate the competencies taught in the WHO’s Wheelchair Service Training Package – Basic Level and have practical experience in basic level wheelchair service delivery. Structure The Wheelchair Service Training Package: Intermediate Level is designed to be delivered by trainers who are skilled in intermediate level wheelchair service delivery and can con dently demonstrate the competencies taught in this training programme. There is a range of teaching resources, including: • Trainer’s Manual and trainer’s tools; • Reference Manual for Participants (referred to as Reference Manual); • Participant’s Workbook; • Wheelchair service forms; • Wheelchair service checklists; • Visual aids, including PowerPoint slides, videos and posters. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 3 4 Development process Following the release of the Guidelines on the provision of manual wheelchairs in less resourced settings, WHO formed a working group to develop the Wheelchair Service Training Package. The rst working group meeting was convened by WHO in October 2008 to determine the scope and content of the Training Package. Following circulation and receipt of feedback from over 20 experts in the eld on the proposed Training Package content, a core group of contributors worked to prepare each training package for eld piloting. In 2011, the Intermediate Level training package was piloted in Romania, Kenya and East Timor. Each pilot was observed by members of the WHO Wheelchair Training Package working group. Feedback from trainers, trainee participants and wheelchair users participating in the practical sessions has been incorporated into the nal drafts. In addition to the pilots, the Intermediate Level training package was circulated for peer review. 15 wheelchair experts peer reviewed the document and their valuable feedback and input were considered in nalizing the document. All the authors involved in the development of the training package completed a Declaration of Interest (DOI) and none declared any con ict of interest related to the subject matter. How to use the Reference Manual This Reference Manual gives a summary of the knowledge given in the wheelchair service delivery intermediate level training. Participants may use the Reference Manual after the training programme to remind them of the key points taught in each session. The manual is divided into two sections: A: Core knowledge B: Wheelchair service steps. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 5 6 A: Core knowledge – this section covers information that is relevant to all of the wheelchair service steps. In some contexts, depending on the learning needs of participants, trainers may choose to add more information into this section. B: Wheelchair service steps – this section covers information that will help participants to carry out each of the eight service steps of wheelchair service delivery (see World Health Organisation Guidelines on the provision of manual wheelchairs in less resourced settings (2), page 76) at intermediate level. Basic and intermediate wheelchair service delivery training To help provide the right training for wheelchair service personnel the WHO Training Package provides training at two levels – basic and intermediate. • The basic level teaches participants how to provide a wheelchair for children and adults who have have dif culties in walking and moving around but can sit upright without additional postural support. • The intermediate level teaches participants how to provide a wheelchair for children and adults who need additional support to sit upright. The intermediate level training programme builds on the information and skills participants gained in the basic level. 2 World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings. Geneva, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, accessed 15 December 2011). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 5 6 A: Core knowledge WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 7 8 A.1: Wheelchair users who bene t from additional postural support Wheelchair users are people who already have a wheelchair or who can bene t from using a wheelchair because their ability to walk is limited. Wheelchair users include: • children, adults and the elderly; girls, boys, women and men; • people with different health conditions, lifestyles, life roles and backgrounds; • people living and working in different environments including rural, semi-urban and urban. The needs of each wheelchair user will vary. However, all wheelchair users need an appropriate wheelchair. Every well- tting wheelchair provides the user some postural support. The backrest, cushion, footrests and armrests all provide postural support when adjusted to suit the wheelchair user’s size. However many children and adults need additional postural support in their wheelchair. Additional postural support can be provided by a Postural Support Device (PSD) – a physical device that provides additional postural support. Postural Support Device is an essential element of intermediate level wheelchair service. This includes any addition or modi cation to a wheelchair for providing additional postural support. Throughout this Manual, a Postural Support Device is referred to as a PSD. Wheelchair users who bene t from additional postural support Some people are not able to sit upright without additional support. Some people need a lot of additional support, and some need just a few changes to their wheelchair. Additional postural support can be provided in different ways. Some solutions are very simple, and can be made in a basic workshop. Other solutions may be more complicated. When is additional postural support needed? People need additional postural support for different reasons. Usually it is clear when a wheelchair is not giving enough support to help the wheelchair user sit upright as outlined below. Often wheelchair users, or the family member/caregiver will have good suggestions themselves about what further support they may need. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 7 8 Reasons for needing additional support include: • cannot sit upright; • uncontrolled movements or spasms; • joint stiffness; • tightness; • weakness; • fatigue; • pain or discomfort; • dif culty balancing. De nition: Postural Support Device (PSD) Postural Support Device (PSD) is a physical device that provides additional postural support. PSD is an essential element of intermediate level wheelchair service. How does additional postural support help? There are four very important ways that additional postural support can bene t wheelchair users; 1. Improves balance, posture and stability Improving balance, posture and stability can help a wheelchair user to carry out activities that are not possible or very dif cult for them without additional postural support. 2. Improves comfort Additional postural support can make a wheelchair much more comfortable and can increase the time wheelchair users are able to sit in their wheelchair before becoming tired. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 9 10 3. Helps to prevent the development of pressure sores A pressure sore can develop very quickly. Good postural support helps to prevent pressure sores by making sure that one part of the body is not overloaded. One bene t of sitting upright is that weight is evenly distributed. This helps to reduce the risk of a pressure sore. When a wheelchair user does not sit upright, their weight is unevenly distributed. One part of their body will take more weight than other parts. If that additional weight is on skin, which lies over a bony area, there is a high risk of pressure sores. Examples of bony areas include the seat bones (ischial tuberosity), ribs, hips (trochanters), spine (vertebra) or tail bone (coccyx). When a wheelchair user is not well supported, he/ she tends to slide on the seat. This causes shear, which leads to pressure sores. Sitting well supported prevents sliding and shearing. 4. Helps to slow down or prevent the development of problems with posture in the future Good postural support can prevent problems with posture developing. If a problem with posture has already started, good postural support can slow down or prevent this from getting worse. Good postural support in lying, sitting and standing, started as early as possible is important. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 9 10 Eating and drinking safely Some wheelchair users who have dif culty sitting upright also have problems with swallowing safely. For these people, eating and drinking can be uncomfortable, sometimes frightening, and often dangerous. When people have dif culty swallowing safely, small pieces of food and drink may go into the lungs. This can cause a chest infection, making them very ill or even choking leading to death. Additional postural support in a wheelchair ensures that the wheelchair user can sit upright when eating and drinking. Improving postural support is just one part of the solution for anyone who has problems with swallowing. If at all possible, children or adults with problems swallowing should be referred to someone who has experience in managing this. This could be a paediatrician, speech language therapist, or any allied health or community health worker who has knowledge and training in helping people manage problems with swallowing. What do wheelchair users want? Wheelchair users want to be comfortable and able to get on with their lives. It is important that additional support in the wheelchair does not make day-to-day activities harder. For example, additional postural support should not interfere with transferring in and out of the wheelchair, propelling the wheelchair, accessing desk or workspace and transport. A wheelchair and additional postural support should always: • be practical and easy to use; • be comfortable and not cause additional discomfort; • help wheelchair users to do things and not make them more dif cult; • look good and not be too ‘obvious’. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 11 12 Sometimes wheelchair users nd it hard to get used to a wheelchair with additional postural support. There are different reasons for this including: • the wheelchair user may be used to sitting in a certain way. The additional postural support, which changes their habitual posture, feels uncomfortable or restrictive; • the wheelchair user may not understand why the additional support has been prescribed; • the wheelchair user may feel the additional postural support does not look good and makes his/her disability more obvious. For these reasons, it is very important that wheelchair service personnel work closely with the wheelchair user and their family/caregiver throughout the assessment, prescription, tting, user training and follow up steps. Always discuss solutions with the wheelchair user and always respect their input and nal decisions. The best way to make sure additional postural support will be used by wheelchair user is to: • fully involve the wheelchair user and their family member/caregiver in their assessment, prescription, tting, user training and follow up; • help the wheelchair user and their family member/caregiver to understand why and how additional postural support will help them; • always let the wheelchair user make the nal decision. Good posture can increase self-esteem An important bene t of good additional postural support is that it can help wheelchair users feel good about themselves. Being well supported in a more upright posture can help wheelchair users feel more con dent. With proper support, wheelchair users can be more involved in community life. For example, mobility and additional posture support enables the wheelchair user to go to work or school; visit friends; attend religious services or other community activities. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 11 12 Checklist to help make sure that a wheelchair with additional postural support meets the user’s needs The following checklist can help wheelchair service personnel to ensure that any additional postural support they prescribe is most likely to be successful for the wheelchair user. Checklist: P The wheelchair user and their family member/care giver is fully involved in the prescription decisions The wheelchair user is able to try the wheelchair with the prescribed PSDs before it is nalized (in the centre and at home if possible) and give their feedback The wheelchair and PSDs help the wheelchair user to do the things he/she wants to do: • PSDs improve the wheelchair users’ ability to do things • PSDs do not prevent easy transfers in and out of the wheelchair • PSDs do not make the overall wheelchair too heavy The wheelchair and PSDs are comfortable for the wheelchair user: • PSDs provide support and allow the wheelchair user to sit for longer in their wheelchair than without the PSDs • PSDs provide just enough support and do not support the wheelchair user closer to upright sitting posture than is comfortable for them The wheelchair and PSDs look good (to the wheelchair user) The wheelchair and PSDs are safe: • The nish of any PSD is smooth and there is good padding and pressure relief • Any structural changes to the wheelchair frame have been checked by a quali ed person • The wheelchair does not easily tip forwards, backwards or sideways with the wheelchair user in the chair The wheelchairs and PSDs are practical: • Upholstery can be cleaned or removed for washing • The number of separate parts is as few as possible to prevent them getting lost/ used incorrectly • The wheelchair can be easily loaded into a car/public transport • The wheelchair ts easily within the wheelchair user’s home WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 13 14 A.2: Children with disabilities When providing a child with a wheelchair, it is important to think about how children’s lives are different from adults’. These differences affect the way the wheelchair service personnel work with children and choices about wheelchairs and additional postural support. Some important differences are: • the activities children carry out are different to activities of adults (play, school); • children are often very active and do not stay in one position for very long; • children are in the care of adults; • children cannot always speak for themselves; • children are still developing; • young children have a different sitting posture to adults; • children are still growing. Wheelchairs that meet children’s needs The wheelchairs children use should help them be a part of the activities that children carry out every day. Features in a wheelchair that are important for children include: • If children push themselves, the wheelchair should: – t well to allow them to reach the push rims with comfort; – be light enough for children to control, particularly going up or down hill. • Try always to make sure the child is more visible than his/her wheelchair. • Extended push handles can help family members or caregivers push the wheelchair without having to bend over. • A wheelchair that can ride over uneven and soft surfaces such as grass and sand will make it easier for children to play with their friends. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 13 14 • A child’s wheelchair should make it easier for them to get to school: – if most children in the child’s community walk to school – think about whether a wheelchair can travel on these paths? Does the child need a wheelchair that is good for rough terrain? – if the child will go to school in transport (for example car, bus, rickshaw, taxi), think about how the wheelchair will be transported. • The wheelchair should make it easy for them to be at school. The child should be able to pull up to a desk, or the wheelchair needs a tray as a work surface. Ideally, children’s wheelchairs should: • enable children to push themselves (if they are able); • have push handles to allow adults to assist; • be able to ride over uneven and soft surfaces such as grass and sand; • make it easier for children to get to school; • attractive enough in terms of design, size and colour; • make it easier for children to be at school. Different positions Children do not usually spend much time sitting down. They change the activity they are doing and their position many times during the day. This means that although a wheelchair is important, children should not spend all day in a wheelchair. Wheelchair service personnel need to think about other positions children can use during the day. This is particularly important if the child has very limited movement, tends to sit in the same posture all the time and cannot change position. Some examples of different postures and positions are: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 15 16 Sitting Some different ways to support children sitting independently closer to the oor are: • Sitting astride a roller or tightly rolled blanket. • Sitting with support from a family member/caregiver: – This illustration shows a mother supporting her child with a disability between her legs to help him sit up to eat a biscuit while also supporting her younger child. • Providing a supportive seat, which is low to the ground: – A seat like this is less expensive than a wheelchair with supportive seating and can be a good option for small children. Standing Standing is another important position for children. Standing is an important part of every child’s development. Standing helps to form the hip joints and the normal curves of the trunk. Anyone who spends a lot of time sitting can develop stiff hip, knee and ankle joints. Standing stretches out the muscles around the hip, knee and ankle joints and helps to prevent these joints from becoming stiff. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 15 16 When a child cannot stand independently, a standing frame can help. To prescribe a standing frame, wheelchair service personnel need to fully understand standing posture and the different ways that standing can be supported. If a standing frame is being provided, always check that there is no pressure applied directly onto the child’s knee caps. The best place to support the legs to prevent the knees from bending is just below the knee cap on the shin bone. If a standing frame is used, wheelchair service personnel should advise family members/care givers how long each day a child should use their standing frame. This is a general guide: • when rst starting 5–10 minutes each day; • never leave a child in a standing frame for longer than 1 hour; • provide a tray or table and encourage family members/caregivers to nd a fun activity that the child can do in their standing frame. • when providing children under the age of ve with a standing frame, there are some important things to remember: – the child’s legs should be apart and their feet at least as far apart as the hips are wide; – the child’s feet and knees should point outwards slightly; – the child’s hips and knees should be slightly bent; – never force a young child’s knees and hips completely straight. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 17 18 Lying Lying is another important position. For children, lying on the oor to play is natural. A child may need some support to lie comfortably on the oor. Blankets, foam, towels or pillows can be used to give support. Children under the age of ve who are lying on their stomach should be supported with a roll under their chest to keep their hips in a slightly bent posture. Children spend a lot of time sleeping. If a child sleeps in the same posture every night, they may become xed or stiff in that posture. Wheelchair service personnel can provide advice to family members/caregivers about how to position the child in different ways while they are sleeping. Remember – keep the hips and knees of children under the age of ve slightly bent in all lying and standing positions. Importance of an early referral for children Early referral for children is important, however often parents or referral sources do not refer a child for a wheelchair until the child becomes too heavy to carry. Some of the reasons for this include: • it is sometimes thought that if a child is given a wheelchair, the child will no longer try to walk; • while children are young and light, it is easier to carry them than manage a wheelchair over what may be dif cult terrain and inaccessible environments; • parents may not have funds to pay for a wheelchair and will delay until it becomes too dif cult to carry the child. It is important to reassure parents and referral sources that a wheelchair will not usually prevent a child from walking. It is more likely that early provision of a wheelchair with good postural support will help the child. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 17 18 Here are some reasons why early referral is better than delaying: • Children who have dif culty sitting upright can develop postural problems if not well supported. If a child is referred late some postural problems may have become xed (3). This can make it dif cult for the child to sit comfortably even with support. • Without the experience of sitting and being mobile, a child’s development can be delayed (3, 4). • For children who have some ability to walk – using a wheelchair may make their daily life easier and allow them to do more things in a day (3). For these reasons it is better if children come to a wheelchair service earlier. Educating parents and referral sources Wheelchair service personnel can play a role in educating parents and referral sources about the importance of early referral. The age at which children without a disability learn to sit, stand and walk varies. However, it is generally agreed that a child should be able to: • sit upright on their own without support between 6–8 months; • pull themselves up to stand between 8–10 months; • stand alone without any support and and may also be able to walk while holding hands 10–12 months and • walk alone between 12–18 months. Wheelchair services can encourage referral networks to refer children who: • have dif culty sitting upright or are not pulling up to stand by the age of 1; or • are not walking alone by the age of 2. Where there is a programme of early intervention screening (for example where community health workers are trained to screen children for early intervention), wheelchair services can provide more detailed information to these networks. For example – wheelchair services can suggest that any child identi ed with a signi cant physical problem or delay could be referred to the wheelchair service for an assessment or advice. For very young children, wheelchair services may offer a supportive seat instead of a wheelchair at the initial stage. This can be used inside the home or play school. 3 World Health Organization. (1996). Promoting the development of infants and young children with spina bi da and hydrocephalus. Retrieved from http://whqlibdoc.who.int/hq/1996/WHO_RHB_96.5.pdf 4 Muscular Dystrophy Campaign. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 19 20 Good practice when working with children Whenever working with children it is important to work in a way that both respects and protects children. Key things to remember are: Respect children by: • explaining what you are doing and why in a way that they can understand; • asking permission before beginning physical assessments; • involving children in decision making in a way that suits their age; • if seeing children in a centre, try to make the area as child friendly as possible. Keep children safe by: • always seeing children with their family member/caregiver present; • allowing time for breaks during appointments as children can easily become tired; • seeking permission from the child and family member/caregiver before taking photographs. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 19 20 B. Wheelchair service steps WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 21 22 Step 1: Referral and appointment • See Step 1: Referral and appointment of the Wheelchair Service Training Package – Basic Level Reference Manual for general information about referral and appointment. • See session A.2: Children with disabilities of this Reference Manual on the importance of early referral for children. Step 2: Assessment Assessment overview and assessment interview Assessment Assessment is a second wheelchair service step. Information collected from the assessment will help the wheelchair service personnel and wheelchair user to: • choose the most appropriate wheelchair from those available; • work out what possible additional postural support may be needed; • decide what training or support the wheelchair user family member/caregiver may need to use and maintain their wheelchair. Assessment at both basic and intermediate level is carried out in two parts: • assessment interview; • physical assessment. Assessment interview The rst part of the assessment is the assessment interview. During this part of the assessment the wheelchair service personnel gather information about the wheelchair user, which will help to identify the most appropriate wheelchair for the wheelchair user. The assessment interview components at basic and intermediate level are very similar. These include: • information about the wheelchair user; • physical; • lifestyle and environment; • existing wheelchair. Even though the assessment interview components at basic and intermediate levels are very similar, more information is gathered at intermediate level about the wheelchair user’s diagnosis and any physical issues. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 21 22 Intermediate wheelchair assessment form: 1: Assessment interview Information about the wheelchair user Name: Number: Age: Male Female Phone no.: Address: Goals: The ‘Information about the wheelchair user’ part of the intermediate wheelchair assessment form has an administrative purpose and ensures that the wheelchair service has the wheelchair user’s basic personal and contact information. It also helps the wheelchair service to collect statistical information about wheelchair users seen at the centre. Wheelchair service personnel should also record here what the wheelchair user’s goals are for a new or improved wheelchair. The word ‘goal’ may not be familiar to a wheelchair user. It is up to the wheelchair service personnel to ask questions to nd out what the wheelchair user’s goal or goals are. The following are examples of possible questions wheelchair service personnel may ask to nd out what the wheelchair user’s goal or goals are: • Why did you come to the wheelchair service today? • What should your wheelchair help you do? The following are examples of possible goals: • I need to be able to reach the well to collect water. • I need to be able to get into a lift to reach my apartment. • I need to be able to get my wheelchair into a small car. • I would like to be more comfortable when sitting. • I would like to be able to sit for longer in my wheelchair before I get tired. • I need to be able to get in and out of the wheelchair myself. • I need to be able to sit at a desk to use the computer. • I would like to be able to visit my family and need a wheelchair that I can take on the bus. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 23 24 Physical Diagnosis: Brain Injury Cerebral Palsy Muscular Dystrophy Polio Spina Bi da Spinal Cord Injury Stroke Unknown Other Is the condition likely to become worse? Yes No Physical issues: Frail Spasms/uncontrolled movements Muscle tone (high/low) Lower limb amputation: R above knee R below knee L above knee L below knee Fatigue Hip dislocation Epilepsy Problems with eating, drinking and swallowing Describe: Pain Describe location: Bladder problems Bowel problems If the wheelchair user has bladder or bowel problems, is this managed? Yes No The ‘diagnosis/physical issues’ part of the intermediate wheelchair assessment form is important because some of the features of different diagnosis and physical issues can affect the choice of wheelchair and additional postural supports. The table on the next few pages provides a brief overview of the different diagnosis and physical issues listed on the intermediate wheelchair assessment form. Common characteristics of each diagnosis/physical issue that relate to wheelchair provision are described, and suggestions for wheelchair provision are given. G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Brain Injury Br ai n in ju ry re fe rs t o an y da m ag e to t he br ai n th at o cc ur s af te r bi rt h. D am ag e ca n be ca us ed b y an ac ci de nt o r tr au m a (5 ,6 ) , br ai n in fe ct io n, m en in gi tis (7 ) , ce re br al m al ar ia , al co ho l o r dr ug ab us e (5 ) . T he p ro bl em s ca us ed b y a br ai n in ju ry v ar y de pe nd in g on t he p ar t of t he b ra in t ha t ha s be en d am ag ed an d th e se ve rit y of t he in ju ry (6 ) . Br ai n in ju rie s ca n af fe ct a p er so n’ s w ho le bo dy , o r a pa rt o f t he b od y. Ev en th ou gh b ra in in ju ry is a p er m an en t in ju ry t o th e br ai n, t he e ffe ct s of t he in ju ry o n th e pe rs on ’s ab ilit ie s m ig ht ch an ge o ve r tim e (6 ) . *P le as e no te fo r th e pu rp os es o f th is tr ai ni ng p ro gr am m e th e te rm br ai n in ju ry r ef er s to a cq ui re d an d tr au m at ic b ra in in ju ry o nl y. • di f cu lty w ith m ov in g, p oo r co or di na tio n an d st re ng th (6 ) ; • po or s itt in g an d/ or s ta nd in g ba la nc e (6 ) ; • hi gh m us cl e to ne (s tif fn es s of m us cl es ) (6 ) , w hi ch c an c au se t he w ho le b od y to s tr ai gh te n (fu ll bo dy ex te ns io n) o r cu rl up (f ul l b od y e xi on ); • di f cu lty w ith e at in g, d rin ki ng a nd sw al lo w in g (6 ) ; • di f cu lty w ith t al ki ng , r ea so ni ng a nd un de rs ta nd in g (6 ) ; • ch an ge s in p er so na lit y or b eh av io ur (6 ) ; • se iz ur e (6 ) ; • di f cu lty c on tr ol lin g bo w el a nd bl ad de r, w hi ch in cr ea se s th e ris ks o f de ve lo pm en t of p re ss ur e so re s (6 ) . If th e w he el ch ai r us er d oe s no t ha ve th e ab ilit y to p ro pe l t he ir w he el ch ai r w ith t he ir ar m s, id en tif y w he th er fo ot pr op el lin g w ou ld b e po ss ib le . Fi nd o ut if t he w he el ch ai r us er h as hi gh m us cl e to ne a s th is m ay a ffe ct t he st re ng th r eq ui re d of P SD s. Fr eq ue nt fo llo w u p is im po rt an t as t he w he el ch ai r us er ’s ph ys ic al a bi lit ie s m ay c ha ng e ov er tim e (6 ) . T hi s m ea ns t ha t th e am ou nt o f su pp or t ne ed ed in t he w he el ch ai r m ay ch an ge . Be a w ar e an d se ns iti ve t o po ss ib le ch an ge s in p er so na lit y or b eh av io ur re la te d to in di vi du al ’s he al th c on di tio n (6 ) . Fo r in fo rm at io n on : M us cl e to ne – h ig h an d lo w – s ee pa ge 3 4. Ep ile ps y – se e pa ge 4 0. H ow c an p re ss ur e so re s be p re ve nt ed ? – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 23 24 5 W or ld H ea lth O rg an iz at io n. ( 20 06 ). N eu ro lo gi ca l d is or de rs : P ub lic h ea lth c ha lle ng es . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m en ta l_ he al th /n eu ro lo gy /c ha pt er _3 _b _n eu ro _ di so rd er s_ pu bl ic _h _c ha lle ng es .p df 6 W or ld H ea lth O rg an iz at io n, U ni te d St at es D ep ar tm en t of D ef en se D ru ck er B ra in In ju ry C en te r, M os s R eh ab H os pi ta l. (2 00 4) . R eh ab ili ta tio n fo r pe rs on s w ith t ra um at ic br ai n in ju ry . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ hq /2 00 4/ W H O _D A R _0 1. 9_ en g. pd f 7 W or ld H ea lth O rg an iz at io n. ( 20 11 ). M en in go co cc al m en in gi tis . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m ed ia ce nt re /fa ct sh ee ts /fs 14 1/ en / G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Brain Injury Br ai n in ju ry re fe rs t o an y da m ag e to t he br ai n th at o cc ur s af te r bi rt h. D am ag e ca n be ca us ed b y an ac ci de nt o r tr au m a (5 ,6 ) , br ai n in fe ct io n, m en in gi tis (7 ) , ce re br al m al ar ia , al co ho l o r dr ug ab us e (5 ) . T he p ro bl em s ca us ed b y a br ai n in ju ry v ar y de pe nd in g on t he p ar t of t he b ra in t ha t ha s be en d am ag ed an d th e se ve rit y of t he in ju ry (6 ) . Br ai n in ju rie s ca n af fe ct a p er so n’ s w ho le bo dy , o r a pa rt o f t he b od y. Ev en th ou gh b ra in in ju ry is a p er m an en t in ju ry t o th e br ai n, t he e ffe ct s of t he in ju ry o n th e pe rs on ’s ab ilit ie s m ig ht ch an ge o ve r tim e (6 ) . *P le as e no te fo r th e pu rp os es o f th is tr ai ni ng p ro gr am m e th e te rm br ai n in ju ry r ef er s to a cq ui re d an d tr au m at ic b ra in in ju ry o nl y. • di f cu lty w ith m ov in g, p oo r co or di na tio n an d st re ng th (6 ) ; • po or s itt in g an d/ or s ta nd in g ba la nc e (6 ) ; • hi gh m us cl e to ne (s tif fn es s of m us cl es ) (6 ) , w hi ch c an c au se t he w ho le b od y to s tr ai gh te n (fu ll bo dy ex te ns io n) o r cu rl up (f ul l b od y e xi on ); • di f cu lty w ith e at in g, d rin ki ng a nd sw al lo w in g (6 ) ; • di f cu lty w ith t al ki ng , r ea so ni ng a nd un de rs ta nd in g (6 ) ; • ch an ge s in p er so na lit y or b eh av io ur (6 ) ; • se iz ur e (6 ) ; • di f cu lty c on tr ol lin g bo w el a nd bl ad de r, w hi ch in cr ea se s th e ris ks o f de ve lo pm en t of p re ss ur e so re s (6 ) . If th e w he el ch ai r us er d oe s no t ha ve th e ab ilit y to p ro pe l t he ir w he el ch ai r w ith t he ir ar m s, id en tif y w he th er fo ot pr op el lin g w ou ld b e po ss ib le . Fi nd o ut if t he w he el ch ai r us er h as hi gh m us cl e to ne a s th is m ay a ffe ct t he st re ng th r eq ui re d of P SD s. Fr eq ue nt fo llo w u p is im po rt an t as t he w he el ch ai r us er ’s ph ys ic al a bi lit ie s m ay c ha ng e ov er tim e (6 ) . T hi s m ea ns t ha t th e am ou nt o f su pp or t ne ed ed in t he w he el ch ai r m ay ch an ge . Be a w ar e an d se ns iti ve t o po ss ib le ch an ge s in p er so na lit y or b eh av io ur re la te d to in di vi du al ’s he al th c on di tio n (6 ) . Fo r in fo rm at io n on : M us cl e to ne – h ig h an d lo w – s ee pa ge 3 4. Ep ile ps y – se e pa ge 4 0. H ow c an p re ss ur e so re s be p re ve nt ed ? – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 25 26 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Muscular dystrophy D uc he nn e m us cu la r dy st ro ph y (D M D ) is on e of 2 0 ty pe s of m us cu la r dy st ro ph y. A ll th e m us cu la r dy st ro ph ie s re su lt in m us cl e w ea kn es s (9 ) . D M D is a n in he rit ed co nd iti on t ha t w ea ke ns t he m us cl es gr ad ua lly o ve r tim e (1 0) . T he m us cl es t ha t he lp t he b od y to m ov e ar e af fe ct ed rs t (1 4) . A s th e co nd iti on p ro gr es se s, th e m us cl es o f t he he ar t an d lu ng s ar e al so a ffe ct ed (1 4, 11 ) . It is pr og re ss iv e, w hi ch m ea ns t ha t pe op le w ho h av e m us cu la r dy st ro ph y gr ad ua lly lo se t he a bi lit y to w al k (1 3, 14 ,1 2) , a nd w ill re qu ire a w he el ch ai r (1 3) . A t r st , a p er so n ca n in de pe nd en tly p ro pe l t he w he el ch ai r w ith a g oo d po st ur e (1 3) . H ow ev er , t he ab ilit y to m ai nt ai n go od p os tu re a nd pr op el t he m se lv es d ec re as es a s th e co nd iti on p ro gr es se s (1 3) . N ot e: s om e ot he r pr og re ss iv e ne ur ol og ic al c on di tio ns h av e sim ila r fe at ur es a nd r eq ui re s im ila r ap pr oa ch es w he n pr ov id in g a w he el ch ai r. • pa in a nd d isc om fo rt (1 3) ; • fa tig ue (1 7) ; • pr og re ss iv e m us cl e w ea kn es s; by t he t im e th e pe rs on n ee ds a w he el ch ai r, w ea kn es s ar ou nd t he pe lv is, t ru nk a nd s ho ul de rs a ffe ct s po st ur e (1 7) ; • ch an ge s in p os tu re : – du e to w ea k m us cl es a ro un d th e st om ac h an d th e hi p jo in t a pe rs on w ith m us cu la r dy st ro ph y m ay s it w ith t he ir pe lv is in an te rio r pe lv is til t (t op o f p el vi s fo rw ar d) a nd a n in cr ea se d lu m ba r cu rv e (lo rd os is) (1 7) ; – as m us cl e w ea kn es s pr og re ss es th er e is a hi gh r isk o f t he s pi ne cu rv in g sid ew ay s (s co lio sis ) (1 6) ; • di f cu lti es in b re at hi ng d ue t o ch an ge s in p os tu re a nd m us cl e w ea kn es s (1 7) ; • a ris k of d ev el op in g a pr es su re s or e du e to : – di f cu lty c ha ng in g po sit io n; – be in g un de r- w ei gh t or ov er -w ei gh t. • A s so on a s so m eo ne w ith m us cu la r dy st ro ph y (o r ot he r pr og re ss iv e ne ur ol og ic al c on di tio ns ) be gi ns t o ne ed t he ir w he el ch ai r on a d ai ly ba sis , a t ho ro ug h as se ss m en t of t he ir po st ur al s up po rt is n ee de d. • G oo d po st ur al s up po rt p ro vi de d ea rly c an h el p to p re ve nt fu tu re po st ur al p ro bl em s (1 7) . • A dd iti on al p os tu ra l s up po rt s ho ul d fo cu s on s up po rt in g a ne ut ra l po st ur e an d pr ov id in g in cr ea se d su pp or t as n ee de d (1 7) . • Su pp or tiv e fo ot w ea r an d an gl e ad ju st ab le fo ot re st s ca n he lp m ai nt ai n a ne ut ra l ( or c lo se t o ne ut ra l) fe et po sit io n. W he re a va ila bl e, a n an kl e- fo ot o rt ho sis ( A FO ) m ay a lso b e he lp fu l ( 17 ) . • A rm s up po rt is im po rt an t w he n w ea kn es s af fe ct s th e sh ou ld er s (1 7) . Fo r in fo rm at io n on : • Pa in – s ee p ag e 27 . • Fa tig ue – s ee p ag e 37 . • Pr og re ss iv e co nd iti on s – se e pa ge 3 1. 13 M us cu la r D ys tr op hy C am pa ig n. ( 20 02 ). D uc he nn e m us cu la r dy st ro ph y. R et ri ev ed fr om h tt p: //w w w .m us cu la r- dy st ro ph y.o rg / 14 C en te rs fo r D is ea se C on tr ol a nd P re ve nt io n. ( n. d. ). D uc he nn e m us cu la r dy st ro ph y: Fa ct s he et . R et ri ev ed fr om h tt p: //w w w .c dc .g ov /n cb dd d/ ac te ar ly /p df /p ar en ts _p df s/ D uc he nn e. pd f 15 N ew so m D av is , J . ( 19 80 ). T he r es pi ra to ry s ys te m in m us cu la r dy st ro ph y. Br iti sh M ed ic al B ul le tin , 3 6, 1 35 –1 38 . 16 B ro ok e, M .H ., et a l. (1 98 9) . D uc he nn e m us cu la r dy st ro ph y: Pa tt er ns o f c lin ic al p ro gr es si on a nd e ffe ct s of s up po rt iv e th er ap y. N eu ro lo gy , 3 9, 4 75 –4 81 . 17 M us cu la r D ys tr op hy C am pa ig n. ( 20 11 ). W he el ch ai r pr ov is io n fo r ch ild re n an d ad ul ts w ith m us cu la r dy st ro ph y an d ot he r ne ur om us cu la r co nd iti on s: Be st p ra ct ic e gu id el in es . R et ri ev ed fr om h tt p: //w w w .m us cu la r- dy st ro ph y.o rg / G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Cerebral palsy C er eb ra l p al sy is on e of t he m os t co m m on ch ild ho od ph ys ic al di sa bi lit ie s (8 ,9 ) an d is ca us ed b y an in ju ry t o th e de ve lo pi ng b ra in (1 0) . T he w ay in w hi ch ce re br al p al sy af fe ct s ea ch p er so n is di ffe re nt (1 0) , ho w ev er m os t co m m on ly it a ffe ct s th e w ay t ha t a pe rs on m ov es (8 ,1 0, 11 ) . N ot e ve ry p er so n w ith c er eb ra l p al sy ne ed s to u se a w he el ch ai r (1 0) . H ow ev er , c hi ld re n an d ad ul ts w ith ce re br al p al sy w ho u se a w he el ch ai r fr eq ue nt ly r eq ui re a dd iti on al p os tu ra l su pp or t fo r th em t o be fu nc tio na l an d co m fo rt ab le in t he ir w he el ch ai r. • di f cu lty w ith ly in g, s itt in g or st an di ng u p (1 0) ; • po or b al an ce (1 0) ; • di f cu lty c on tr ol lin g on e pa rt o f t he bo dy w hi lst m ov in g an ot he r – fo r ex am pl e, s itt in g st ill w hi le w rit in g or t ak in g a dr in k fr om a c up a nd sw al lo w in g; • hi gh o r lo w m us cl e to ne (1 0) ; • sp as m s/ un co nt ro lle d m ov em en ts ; • po or c oo rd in at io n (1 0) ; • a te nd en cy t o sit in t he s am e po st ur e al l t he t im e (h ab itu al p os tu re ) (1 0) ; • ot he r ph ys ic al c on ce rn s su ch a s vi su al , h ea rin g, e pi le ps y, sp ee ch o r co m m un ic at io n di f cu lti es (1 0) ; • m ay h av e di f cu lty c on tr ol lin g th ei r bo w el a nd b la dd er , w hi ch m ay in cr ea se t he r isk fo r de ve lo pm en t of pr es su re s or es (1 1, 8) ; • ca n be d if cu lt to b e ab le t o ge t to a to ile t an d sit o n or s qu at o ve r th e to ile t in de pe nd en tly ; • hi p di slo ca tio n (t he h ea d of t he fe m ur co m es o ut o f t he h ip s oc ke t) , w hi ch ca n lim it m ov em en t an d be p ai nf ul . • Fo r m os t w he el ch ai r us er s w ith ce re br al p al sy , g oo d po st ur al s up po rt is im po rt an t to h el p im pr ov e po st ur e, ba la nc e an d ho w e as ily t he y ca n co nt ro l t he ir bo dy t o do t hi ng s. • Be a w ar e th at c ha ng es in p os tu re m ay a t r st fe el s tr an ge fo r a w he el ch ai r us er w ith c er eb ra l p al sy . T he w he el ch ai r us er m ay n ee d tim e to a dj us t. C on sid er c ha ng in g po st ur al su pp or t gr ad ua lly t o al lo w h im /h er t o re ac h a m or e ne ut ra l p os tu re o ve r tim e. • O th er p hy sic al is su es c an h av e an im pa ct u po n th e w he el ch ai r an d po st ur al s up po rt s ol ut io ns . F in d ou t du rin g th e as se ss m en t w ha t ot he r di f cu lti es a w he el ch ai r us er w ith ce re br al p al sy m ay h av e. Fo r in fo rm at io n on : • H ip d isl oc at io n – se e pa ge 3 8. 8 R os en ba um , P . ( 20 03 ). C er eb ra l p al sy . W ha t pa re nt s an d do ct or s w an t to k no w . B ri tis h M ed ic al Jo ur na l, 32 6, 9 70 –9 74 9 C er eb ra l P al sy A us tr al ia . ( n. d. ). C er eb ra l p al sy – t he fa ct s. R et ri ev ed fr om h tt p: //w w w .c er eb ra lp al sy au st ra lia .c om /in de x. ph p/ si te /le ar ni ng ce nt re /t he fa ct s 10 W or ld H ea lth O rg an iz at io n. ( 19 93 ). Pr om ot in g th e de ve lo pm en t of y ou ng c hi ld re n w ith c er eb ra l p al sy : A g ui de fo r m id -le ve l r eh ab ili ta tio n w or ke rs . R et ri ev ed fr om h tt p: // w hq lib do c. w ho .in t/ hq /1 99 3/ W H O _R H B_ 93 .1 .p df 11 K ig ge r, K . ( 20 06 ). C er eb ra l P al sy : A n ov er vi ew . A m er ic an F am ily P hy si ci an , 7 3( 1) , 9 1– 10 0. 12 R oi je n, L ., Po st em a, K ., Li m be ek , v J., & K up pe ve lt, v H . J . M . ( 20 01 ). D ev el op m en t of b la dd er c on tr ol in c hi ld re n an d ad ol es ce nt s w ith c er eb ra l p al sy . D ev el op m en ta l M ed ic in e an d C hi ld N eu ro lo gy , 4 3, 1 03 –1 07 . WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 25 26 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Muscular dystrophy D uc he nn e m us cu la r dy st ro ph y (D M D ) is on e of 2 0 ty pe s of m us cu la r dy st ro ph y. A ll th e m us cu la r dy st ro ph ie s re su lt in m us cl e w ea kn es s (9 ) . D M D is a n in he rit ed co nd iti on t ha t w ea ke ns t he m us cl es gr ad ua lly o ve r tim e (1 0) . T he m us cl es t ha t he lp t he b od y to m ov e ar e af fe ct ed rs t (1 4) . A s th e co nd iti on p ro gr es se s, th e m us cl es o f t he he ar t an d lu ng s ar e al so a ffe ct ed (1 4, 11 ) . It is pr og re ss iv e, w hi ch m ea ns t ha t pe op le w ho h av e m us cu la r dy st ro ph y gr ad ua lly lo se t he a bi lit y to w al k (1 3, 14 ,1 2) , a nd w ill re qu ire a w he el ch ai r (1 3) . A t r st , a p er so n ca n in de pe nd en tly p ro pe l t he w he el ch ai r w ith a g oo d po st ur e (1 3) . H ow ev er , t he ab ilit y to m ai nt ai n go od p os tu re a nd pr op el t he m se lv es d ec re as es a s th e co nd iti on p ro gr es se s (1 3) . N ot e: s om e ot he r pr og re ss iv e ne ur ol og ic al c on di tio ns h av e sim ila r fe at ur es a nd r eq ui re s im ila r ap pr oa ch es w he n pr ov id in g a w he el ch ai r. • pa in a nd d isc om fo rt (1 3) ; • fa tig ue (1 7) ; • pr og re ss iv e m us cl e w ea kn es s; by t he t im e th e pe rs on n ee ds a w he el ch ai r, w ea kn es s ar ou nd t he pe lv is, t ru nk a nd s ho ul de rs a ffe ct s po st ur e (1 7) ; • ch an ge s in p os tu re : – du e to w ea k m us cl es a ro un d th e st om ac h an d th e hi p jo in t a pe rs on w ith m us cu la r dy st ro ph y m ay s it w ith t he ir pe lv is in an te rio r pe lv is til t (t op o f p el vi s fo rw ar d) a nd a n in cr ea se d lu m ba r cu rv e (lo rd os is) (1 7) ; – as m us cl e w ea kn es s pr og re ss es th er e is a hi gh r isk o f t he s pi ne cu rv in g sid ew ay s (s co lio sis ) (1 6) ; • di f cu lti es in b re at hi ng d ue t o ch an ge s in p os tu re a nd m us cl e w ea kn es s (1 7) ; • a ris k of d ev el op in g a pr es su re s or e du e to : – di f cu lty c ha ng in g po sit io n; – be in g un de r- w ei gh t or ov er -w ei gh t. • A s so on a s so m eo ne w ith m us cu la r dy st ro ph y (o r ot he r pr og re ss iv e ne ur ol og ic al c on di tio ns ) be gi ns t o ne ed t he ir w he el ch ai r on a d ai ly ba sis , a t ho ro ug h as se ss m en t of t he ir po st ur al s up po rt is n ee de d. • G oo d po st ur al s up po rt p ro vi de d ea rly c an h el p to p re ve nt fu tu re po st ur al p ro bl em s (1 7) . • A dd iti on al p os tu ra l s up po rt s ho ul d fo cu s on s up po rt in g a ne ut ra l po st ur e an d pr ov id in g in cr ea se d su pp or t as n ee de d (1 7) . • Su pp or tiv e fo ot w ea r an d an gl e ad ju st ab le fo ot re st s ca n he lp m ai nt ai n a ne ut ra l ( or c lo se t o ne ut ra l) fe et po sit io n. W he re a va ila bl e, a n an kl e- fo ot o rt ho sis ( A FO ) m ay a lso b e he lp fu l ( 17 ) . • A rm s up po rt is im po rt an t w he n w ea kn es s af fe ct s th e sh ou ld er s (1 7) . Fo r in fo rm at io n on : • Pa in – s ee p ag e 27 . • Fa tig ue – s ee p ag e 37 . • Pr og re ss iv e co nd iti on s – se e pa ge 3 1. 13 M us cu la r D ys tr op hy C am pa ig n. ( 20 02 ). D uc he nn e m us cu la r dy st ro ph y. R et ri ev ed fr om h tt p: //w w w .m us cu la r- dy st ro ph y.o rg / 14 C en te rs fo r D is ea se C on tr ol a nd P re ve nt io n. ( n. d. ). D uc he nn e m us cu la r dy st ro ph y: Fa ct s he et . R et ri ev ed fr om h tt p: //w w w .c dc .g ov /n cb dd d/ ac te ar ly /p df /p ar en ts _p df s/ D uc he nn e. pd f 15 N ew so m D av is , J . ( 19 80 ). T he r es pi ra to ry s ys te m in m us cu la r dy st ro ph y. Br iti sh M ed ic al B ul le tin , 3 6, 1 35 –1 38 . 16 B ro ok e, M .H ., et a l. (1 98 9) . D uc he nn e m us cu la r dy st ro ph y: Pa tt er ns o f c lin ic al p ro gr es si on a nd e ffe ct s of s up po rt iv e th er ap y. N eu ro lo gy , 3 9, 4 75 –4 81 . 17 M us cu la r D ys tr op hy C am pa ig n. ( 20 11 ). W he el ch ai r pr ov is io n fo r ch ild re n an d ad ul ts w ith m us cu la r dy st ro ph y an d ot he r ne ur om us cu la r co nd iti on s: Be st p ra ct ic e gu id el in es . R et ri ev ed fr om h tt p: //w w w .m us cu la r- dy st ro ph y.o rg / WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 27 28 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Polio Po lio is a n in fe ct io us d ise as e ca us ed b y a vi ru s (1 8) . T he v iru s on ly at ta ck s th e ne rv es t ha t co nt ro l m ov em en t (1 9, 2 0) . O ne in 2 00 p eo pl e w ho h av e po lio de ve lo p so m e fo rm o f p er m an en t m us cl e pa ra ly sis a s a re su lt (1 8) . Po lio u su al ly a ffe ct s ch ild re n un de r th e ag e of ve (1 8) . T he n um be r of co un tr ie s th at a re a ffe ct ed b y po lio ha s dr am at ic al ly d ec re as ed in r ec en t de ca de s (1 8) . • lo ss o f m ov em en t in a ffe ct ed m us cl es (p ar al ys is) – u su al ly o f b ot h le gs (1 9) ; • th in le gs a nd o ft en b ut to ck s du e to m us cl e w as tin g; • x ed n on -n eu tr al p os tu re a ro un d th e an kl es , k ne es a nd h ip s (1 9) ; • w ea kn es s in t he t ru nk m us cl es (1 9) . I n th is ca se , xe d cu rv es o f t he s pi ne m ay d ev el op – in cl ud in g sc ol io sis , in cr ea se d th or ac ic c ur ve ( ky ph os is) , an te rio r pe lv is til t an d in cr ea se d lu m ba r cu rv e (lo rd os is) (1 9) ; • st ro ng a rm s de ve lo pe d to co m pe ns at e fo r th e w ea kn es s in th ei r le gs . • Pe op le w ith p ol io h av e of te n fo un d w ay s to m ov e an d ca rr y ou t di ffe re nt ac tiv iti es d es pi te t he p ar al ys is an d an y po st ur al p ro bl em s th at t he y m ay h av e de ve lo pe d. • A s fo r an y w he el ch ai r us er – t al k w ith t he p er so n ab ou t w ha t po st ur al su pp or t he /s he w an ts . C ar ef ul ly co ns id er t he e ffe ct o f a ny p os tu ra l co rr ec tio n. F or e xa m pl e – so m e pe op le w ith p ol io s it w ith t he ir le gs fu rt he r ap ar t or c ro ss -le gg ed a nd th is he lp s th em t o ba la nc e. T ry in g to co rr ec t th is co ul d m ak e th ei r ba la nc e w or se – a nd t he re fo re m ak e th em le ss in de pe nd en t. • A s m an y pe op le w ith p ol io h av e st ro ng ar m s: – m ak e su re t he w he el ch ai r is se t up to e na bl e an e f ci en t pr op el lin g po sit io n; – co ns id er s ug ge st in g a tr ic yc le ( w he re av ai la bl e) a s th is is a go od m ob ilit y op tio n fo r lo ng er d ist an ce s. • If a w he el ch ai r us er w ith p ol io h as a sh or te ne d tr un k – co ns id er in cr ea sin g th e he ig ht o f t he c us hi on t o pl ac e th em in a m or e ef c ie nt p os iti on fo r pu sh in g. Fo r m or e in fo rm at io n on : • W he el ch ai r se t up fo r ar m p ro pe llin g – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 18 W or ld H ea lth O rg an iz at io n. ( 20 12 ). Po lio m ye lit is . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m ed ia ce nt re /fa ct sh ee ts /fs 11 4/ en / 19 W or ld H ea lth O rg an iz at io n. ( 19 93 ). R eh ab ili ta tio n su rg er y fo r de fo rm iti es d ue t o po lio m ye lit is . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ pu bl ic at io ns /1 99 3/ 92 41 54 45 70 .p df 20 P ol io G lo ba l E ra di ca tio n In iti at iv e. ( n. d. ). Po lio a nd p re ve nt io n. R et ri ev ed fr om h tt p: //w w w .p ol io er ad ic at io n. or g/ Po lio an dp re ve nt io n. as px G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Spina Bi da Sp in a bi d a oc cu rs b ef or e bi rt h (2 1, 2 2) . T he bo ne s of t he sp in e do n ot cl os e fu lly a ro un d th e sp in al n er ve s, le av in g th em un pr ot ec te d (2 1, 22 ) . A s a re su lt, th e pa rt o f t he sp in al c or d, w hi ch lie s un de r th es e bo ne s, m ay n ot d ev el op c or re ct ly o r be d am ag ed (2 1) . D am ag e to t he s pi na l c or d m ig ht af fe ct t he c on tr ol o f t he b la dd er a nd bo w el s (2 1, 1 8, 1 9) . Sp in a bi d a ca n af fe ct p eo pl e di ffe re nt ly, d ep en di ng o n th e siz e of th e ar ea a ffe ct ed a nd t he le ve l o f ne rv e da m ag e (2 1) . • m ov em en t di f cu lti es w ill de pe nd o n w he re t he s pi na b i da is lo ca te d ov er th e sp in e an d ho w m uc h ne rv e an d sp in e co rd d am ag e is pr es en t (2 1) ; • di f cu lty c on tr ol lin g th e bl ad de r an d bo w el (2 1) ; • ab le t o w al k sh or t di st an ce s w ith t he us e of m ob ilit y de vi ce s (2 1) ; • m ay h av e a bu lg e at t he le ve l o f sp in al c or d, w hi ch is d am ag e du e to th e sp in e no t de ve lo pi ng p ro pe rly (p ar tic ul ar ly if t he re h as b ee n no su rg ic al in te rv en tio n) (2 1) ; • re du ce d m us cl e co nt ro l a nd s en sa tio n m ak es s itt in g up rig ht m or e di f cu lt; • m ay h av e a la rg er h ea d (h yd ro ce ph al us ) ca us ed b y a bu ild -u p of ui d (2 1) . T he m ai n tr ea tm en t fo r hy dr oc ep ha lu s is to s ur gi ca lly in se rt a ‘sh un t’, w hi ch a llo w s th e tr ap pe d u id t o dr ai n aw ay – u su al ly in to t he ch ild ’s st om ac h (2 1) . I f t he b ui ld -u p is no t tr ea te d it ca n le ad t o da m ag e of th e br ai n; • at r isk o f d ev el op in g a pr es su re s or e du e to la ck o f s en sa tio n be lo w t he le ve l o f t he in ju ry a nd t he p re se nc e of m oi st ur e if bo w el a nd b la dd er is n ot ef fe ct iv el y m an ag ed (2 1) . • En su re t he w he el ch ai r is se t up t o en ab le e f ci en t pr op el lin g. • T he a m ou nt o f p os tu ra l s up po rt w ill de pe nd o n th e le ve l o f i nj ur y. T he hi gh er t he le ve l, th e m or e su pp or t is lik el y to b e ne ed ed . • If or th ot ic s ar e to b e w or n in t he da y, as k th e w he el ch ai r us er t o w ea r th ei r or th ot ic s du rin g th e w he el ch ai r as se ss m en t. • If a bu lg e is pr es en t, av oi d an y pr es su re on t ha t ar ea . T hi s m ay r eq ui re s ha pi ng th e ba ck re st o r ad ju st in g th e ba ck re st up ho lst er y to a cc om m od at e th e bu lg e. • G oo d po st ur al s up po rt p ro vi de d ea rly ca n he lp t o pr ev en t po st ur al p ro bl em s (2 0) . T hi s is pa rt ic ul ar ly im po rt an t at tim es o f g ro w th . • If a ch ild h as a ‘s hu nt ’, be a w ar e of it s po sit io n if pr ov id in g a he ad re st . • If th e ch ild h as h yd ro ce ph al us , w hi ch is no t be in g tr ea te d, r ef er h im /h er t o a do ct or . Fo r in fo rm at io n on : • W he el ch ai r se t up fo r ar m p ro pe llin g – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. • H ow c an p re ss ur e so re s be p re ve nt ed ? – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 21 W or ld H ea lth O rg an iz at io n. ( 19 96 ). Pr om ot in g th e de ve lo pm en t of in fa nt s an d yo un g ch ild re n w ith s pi na b i da a nd h yd ro ce ph al us . R et ri ev ed fr om h tt p: //w hq lib do c. w ho . in t/ hq /1 99 6/ W H O _R H B_ 96 .5 .p df 22 M al on e, P ., W he el er , R ., & W ill ia m s, J. (1 99 4) . C on tin en ce in p at ie nt s w ith s pi na b i da : L on g te rm s re su lts . A rc hi ve s of D is ea se in C hi ld ho od , 7 0, 1 07 –1 10 . 23 M cD on ne ll, G . V ., M cC an n, J. P . ( 20 00 ). Is su es o f m ed ic al m an ag em en t in a du lts w ith s pi na b i da . C hi ld ’s N er vo us S ys te m , 1 6, 2 22 –2 27 . 24 M us cu la r D ys tr op hy C am pa in . ( 20 11 ). W he el ch ai r pr ov is io n fo r ch ild re n an d ad ul ts w ith m us cu la r dy st ro ph y an d ot he r ne ur om us cu la r co nd iti on s: Be st p ra ct ic e gu id el in es . R et ri ev ed fr om h tt p: //w w w .m us cu la r- dy st ro ph y.o rg / WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 27 28 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Spina Bi da Sp in a bi d a oc cu rs b ef or e bi rt h (2 1, 2 2) . T he bo ne s of t he sp in e do n ot cl os e fu lly a ro un d th e sp in al n er ve s, le av in g th em un pr ot ec te d (2 1, 22 ) . A s a re su lt, th e pa rt o f t he sp in al c or d, w hi ch lie s un de r th es e bo ne s, m ay n ot d ev el op c or re ct ly o r be d am ag ed (2 1) . D am ag e to t he s pi na l c or d m ig ht af fe ct t he c on tr ol o f t he b la dd er a nd bo w el s (2 1, 1 8, 1 9) . Sp in a bi d a ca n af fe ct p eo pl e di ffe re nt ly, d ep en di ng o n th e siz e of th e ar ea a ffe ct ed a nd t he le ve l o f ne rv e da m ag e (2 1) . • m ov em en t di f cu lti es w ill de pe nd o n w he re t he s pi na b i da is lo ca te d ov er th e sp in e an d ho w m uc h ne rv e an d sp in e co rd d am ag e is pr es en t (2 1) ; • di f cu lty c on tr ol lin g th e bl ad de r an d bo w el (2 1) ; • ab le t o w al k sh or t di st an ce s w ith t he us e of m ob ilit y de vi ce s (2 1) ; • m ay h av e a bu lg e at t he le ve l o f sp in al c or d, w hi ch is d am ag e du e to th e sp in e no t de ve lo pi ng p ro pe rly (p ar tic ul ar ly if t he re h as b ee n no su rg ic al in te rv en tio n) (2 1) ; • re du ce d m us cl e co nt ro l a nd s en sa tio n m ak es s itt in g up rig ht m or e di f cu lt; • m ay h av e a la rg er h ea d (h yd ro ce ph al us ) ca us ed b y a bu ild -u p of ui d (2 1) . T he m ai n tr ea tm en t fo r hy dr oc ep ha lu s is to s ur gi ca lly in se rt a ‘sh un t’, w hi ch a llo w s th e tr ap pe d u id t o dr ai n aw ay – u su al ly in to t he ch ild ’s st om ac h (2 1) . I f t he b ui ld -u p is no t tr ea te d it ca n le ad t o da m ag e of th e br ai n; • at r isk o f d ev el op in g a pr es su re s or e du e to la ck o f s en sa tio n be lo w t he le ve l o f t he in ju ry a nd t he p re se nc e of m oi st ur e if bo w el a nd b la dd er is n ot ef fe ct iv el y m an ag ed (2 1) . • En su re t he w he el ch ai r is se t up t o en ab le e f ci en t pr op el lin g. • T he a m ou nt o f p os tu ra l s up po rt w ill de pe nd o n th e le ve l o f i nj ur y. T he hi gh er t he le ve l, th e m or e su pp or t is lik el y to b e ne ed ed . • If or th ot ic s ar e to b e w or n in t he da y, as k th e w he el ch ai r us er t o w ea r th ei r or th ot ic s du rin g th e w he el ch ai r as se ss m en t. • If a bu lg e is pr es en t, av oi d an y pr es su re on t ha t ar ea . T hi s m ay r eq ui re s ha pi ng th e ba ck re st o r ad ju st in g th e ba ck re st up ho lst er y to a cc om m od at e th e bu lg e. • G oo d po st ur al s up po rt p ro vi de d ea rly ca n he lp t o pr ev en t po st ur al p ro bl em s (2 0) . T hi s is pa rt ic ul ar ly im po rt an t at tim es o f g ro w th . • If a ch ild h as a ‘s hu nt ’, be a w ar e of it s po sit io n if pr ov id in g a he ad re st . • If th e ch ild h as h yd ro ce ph al us , w hi ch is no t be in g tr ea te d, r ef er h im /h er t o a do ct or . Fo r in fo rm at io n on : • W he el ch ai r se t up fo r ar m p ro pe llin g – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. • H ow c an p re ss ur e so re s be p re ve nt ed ? – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 21 W or ld H ea lth O rg an iz at io n. ( 19 96 ). Pr om ot in g th e de ve lo pm en t of in fa nt s an d yo un g ch ild re n w ith s pi na b i da a nd h yd ro ce ph al us . R et ri ev ed fr om h tt p: //w hq lib do c. w ho . in t/ hq /1 99 6/ W H O _R H B_ 96 .5 .p df 22 M al on e, P ., W he el er , R ., & W ill ia m s, J. (1 99 4) . C on tin en ce in p at ie nt s w ith s pi na b i da : L on g te rm s re su lts . A rc hi ve s of D is ea se in C hi ld ho od , 7 0, 1 07 –1 10 . 23 M cD on ne ll, G . V ., M cC an n, J. P . ( 20 00 ). Is su es o f m ed ic al m an ag em en t in a du lts w ith s pi na b i da . C hi ld ’s N er vo us S ys te m , 1 6, 2 22 –2 27 . 24 M us cu la r D ys tr op hy C am pa in . ( 20 11 ). W he el ch ai r pr ov is io n fo r ch ild re n an d ad ul ts w ith m us cu la r dy st ro ph y an d ot he r ne ur om us cu la r co nd iti on s: Be st p ra ct ic e gu id el in es . R et ri ev ed fr om h tt p: //w w w .m us cu la r- dy st ro ph y.o rg / WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 29 30 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Spinal Cord Injury A s pi na l c or d in ju ry (S C I) is da m ag e to th e sp in al c or d th at re su lts in r ed uc ed m ov em en t a nd /o r se ns at io n be lo w th e le ve l o f t he in ju ry (2 5) . T he s pi na l c or d al so co nt ro ls th e bl ad de r an d bo w el s so t he se m ay a lso b e af fe ct ed a ft er in ju ry (2 6) . A S C I m ay b e ca us ed b y an a cc id en t, vi ol en ce , d ise as e or in fe ct io n (2 6) . T he ef fe ct s of s pi na l c or d in ju ry d ep en d on th e ty pe a nd le ve l o f t he in ju ry (2 6) . T yp e: A c om pl et e in ju ry is w he n a pe rs on h as n o se ns at io n or v ol un ta ry m ov em en t be lo w t he d am ag ed p ar t of th e sp in al c or d (2 6) . A n in co m pl et e in ju ry is w he n th e pe rs on h as s om e se ns at io n or vo lu nt ar y m ov em en t be lo w t he d am ag ed pa rt o f t he s pi na l c or d (2 6) . L ev el : T he le ve l o f s pi na l c or d in ju ry c an be d es cr ib ed a s te tr ap le gi a/ qu ad rip le gi a, hi gh le ve l p ar ap le gi a or lo w le ve l pa ra pl eg ia (2 6) . A q ua dr ip le gi a/ te tr ap le gi a oc cu rs in t he n ec k, a nd t he a rm s, tr un k, pe lv is an d le gs a re a ffe ct ed (2 6) . A h ig h le ve l p ar ap le gi a oc cu rs in t he u pp er b ac k, an d th e tr un k, p el vi s an d le gs a re a ffe ct ed (2 6, 2 7) . T he a rm s ar e no t af fe ct ed . A lo w le ve l p ar ap le gi a oc cu rs in t he lo w er b ac k an d th e le gs a re a ffe ct ed (2 6) . T he p el vi s m ay a lso b e af fe ct ed (2 2) . • co m pl et e lo ss o f m ov em en t an d se ns at io n if th e in ju ry is c om pl et e or p ar tia l l os s of m ov em en t an d se ns at io n if th e in ju ry is in co m pl et e (2 6) ; • ch ild re n an d ad ul ts w ith q ua dr ip le gi a/ te tr ap le gi a an d hi gh le ve l p ar ap le gi a w ill ha ve p oo r ba la nc e du e to t he lo ss o f m us cl e m ov em en t co nt ro l an d se ns at io n ar ou nd t he t ru nk . T hi s m ak es s itt in g up rig ht m or e di f cu lt an d lo ng -t er m p os tu ra l p ro bl em s ca n de ve lo p qu ic kl y w ith ou t th e co rr ec t su pp or t fr om t he w he el ch ai r; • po ss ib le d if cu lty w ith c on tr ol lin g bo w el o r bl ad de r (2 6) ; • po te nt ia l s pa sm s/ un co nt ro lle d m ov em en ts o f l ow er le gs (2 6) ; • ch ild re n an d ad ul ts w ith a S C I a re at r isk o f d ev el op in g a pr es su re s or e du e to : – la ck o f s en sa tio n be lo w t he le ve l o f th e in ju ry (2 6) ; – pr es en ce o f m oi st ur e if th ei r bo w el an d bl ad de r is no t ef fe ct iv el y m an ag ed . • A lw ay s pr es cr ib e a pr es su re r el ie f cu sh io n to h el p pr ev en t pr es su re so re s. • T he a m ou nt o f p os tu ra l s up po rt re qu ire d fo r a w he el ch ai r us er w ith an S C I w ill de pe nd o n th e le ve l of in ju ry . T he h ig he r th e le ve l, th e m or e po st ur al s up po rt is li ke ly t o be n ee de d (2 7) . • In t he e ar ly s ta ge s af te r in ju ry , ad di tio na l s up po rt fo r th e tr un k an d ar m s m ay b e ne ce ss ar y – pa rt ic ul ar ly fo r hi gh le ve l i nj ur ie s. • M os t pa ra pl eg ic s an d so m e qu ad rip le gi cs /t et ra pl eg ic s ca n se lf- pr op el v er y ef fe ct iv el y (2 6) . E ns ur e th e w he el ch ai r is se t up t o en ab le an e f ci en t pr op el lin g po sit io n. Fo r in fo rm at io n on : • W he el ch ai r se t up fo r ar m pr op el lin g – se e th e W he el ch ai r Se rv ic e Tr ai ni ng P ac ka ge – B as ic Le ve l R ef er en ce M an ua l. • H ow c an p re ss ur e so re s be pr ev en te d? – s ee t he W he el ch ai r Se rv ic e Tr ai ni ng P ac ka ge – B as ic Le ve l R ef er en ce M an ua l. 25 W or ld H ea lth O rg an iz at io n. ( 19 96 ). Pr om ot in g in de pe nd en ce fo llo w in g a sp in al c or d in ju ry : A m an ua l f or m id -le ve l r eh ab ili ta tio n w or ke rs . R et ri ev ed fr om h tt p: // w hq lib do c. w ho .in t/ hq /1 99 6/ W H O _R H B_ 96 .4 .p df 26 B ro m le y, I. (2 00 6) . T et ra pl eg ia a nd p ar ap le gi a: A g ui de fo r ph ys io th er ap is ts . R et ri ev ed fr om h tt p: //x a. yi m g. co m /k q/ gr ou ps /1 67 49 86 7/ 21 44 24 41 49 /n am e/ Te tr ap le gi a+ an d+ Pa ra pl eg ia .p df G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Stroke St ro ke is a t yp e of b ra in in ju ry ca us ed b y a fa ilu re o f t he bl oo d su pp ly t o th e br ai n (2 7, 2 8, 2 9, 30 , 3 1) . D am ag e or di se as e ca n ca us e bl oo d ve ss el s to bl oc k or b ur st , ca us in g da m ag e or d ea th t o th at p ar t of t he b ra in (2 8, 2 9, 3 0, 3 1, 3 2) . H ow a s tr ok e af fe ct s ea ch in di vi du al va rie s, de pe nd in g on t he a re a of t he br ai n, w hi ch h as b ee n af fe ct ed a nd ho w s ev er el y it ha s be en a ffe ct ed (2 9, 31 ) – h ow ev er o ft en ju st o ne s id e of th e bo dy is a ffe ct ed ( he m ip le gi a) (2 8, 31 , 2 8) . • W ea kn es s, le ss m us cl e co nt ro l a nd so m et im es p ai n on t he a ffe ct ed s id e of t he b od y (a ffe ct in g th e ar m , t ru nk an d le g) (2 8) ; • re du ce d or a lte re d se ns at io n on sid e of t he b od y, w hi ch h as b ee n af fe ct ed (2 8) ; • m ay h av e a la ck o f a w ar en es s of s id e of t he b od y, w hi ch h as b ee n af fe ct ed an d th is m ay le ad t o in cr ea se d ris k of fa lls d ur in g tr an sf er s (2 8) ; • m ay h av e di f cu lty s itt in g up rig ht w ith a te nd en cy t o le an o r fa ll to w ar ds t he af fe ct ed s id e of t he b od y (2 8) ; • m ay b e ab le t o st an d up , a nd t ak e a fe w s te ps (m ay be u sin g di ffe re nt ga it) (2 8) ; • m ay h av e di f cu lty s pe ak in g, a s w el l a s sw al lo w in g, w hi ch m ak es e at in g an d dr in ki ng d if cu lt (2 8) ; • m ay h av e di f cu lty c on tr ol lin g bo w el an d bl ad de r (2 8) , a nd it c an a lso b e di f cu lt to b e ab le t o ge t to a t oi le t qu ic kl y en ou gh . • Pr ov id e po st ur al s up po rt t o en co ur ag e a ba la nc ed a nd s ym m et ric al ( bo th s id es th e sa m e) p os tu re . • Fl ip u p or s w in g aw ay fo ot re st s ar e of te n ve ry h el pf ul fo r w he el ch ai r us er s w ith a s tr ok e w ho c an m an ag e a st an di ng t ra ns fe r. • A s on e ar m is li ke ly t o be a ffe ct ed , m an y pe op le w ho h av e ha d a st ro ke ca nn ot p us h th e w he el ch ai r us in g th ei r ar m s. Fi nd o ut if a w he el ch ai r us er c an pr op el w ith t he ir un af fe ct ed a rm a nd st ee r w ith t he ir un af fe ct ed le g. • If th e w he el ch ai r us er h as o th er pr ob le m s, w hi ch a re n ot y et b ei ng ad dr es se d, r ef er t he m fo r fu rt he r he lp if av ai la bl e. Fo r m or e in fo rm at io n on : • W he el ch ai r se t up fo r fo ot p ro pe llin g – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 27 W or ld H ea lth O rg an iz at io n. ( 19 99 ). Pr om ot in g in de pe nd en ce fo llo w in g a st ro ke . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ hq /1 99 9/ W H O _D A R _9 9. 2. pd f 28 W or ld H ea lth O rg an iz at io n. ( 20 12 ). St ro ke , C er eb ro va sc ul ar a cc id en t. R et ri ev ed fr om h tt p: //w w w .w ho .in t/ to pi cs /c er eb ro va sc ul ar _a cc id en t/ en / 29 W or ld H ea lth O rg an iz at io n. ( 20 06 ). N eu ro lo gi ca l d is or de rs : P ub lic h ea lth c ha lle ng es . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m en ta l_ he al th /n eu ro lo gy /c ha pt er _3 _b _n eu ro _ di so rd er s_ pu bl ic _h _c ha lle ng es .p df 30 C ol lin s, C . ( 20 07 ). Pa th op hy si ol og y an d cl as si c at io n of s tr ok e. N ur si ng S ta nd ar d, 2 1( 28 ), 35 –3 9. 31 F ri zz el , J . ( 20 05 ). A cu te s tr ok e: P at ho ph ys io lo gy , d ia gn os is , a nd t re at m en t. A dv an ce d Pr ac tic e in A cu te a nd C ri tic al C ar e, 1 6( 4) , 4 21 –4 40 . 32 H er m an , B ., et a l. (1 98 2) . E pi de m io lo gy o f s tr ok e in T ilb ur g, th e N et he rl an ds . T he p op ul at io n- ba se d st ro ke in ci de nc e re gi st er : 2 . I nc id en ce , i ni tia l c lin ic al p ic tu re a nd m ed ic al c ar e, a nd t hr ee -w ee k ca se fa ta lit y. St ro ke , 1 3( 5) , 6 29 –6 34 . WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 29 30 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Stroke St ro ke is a t yp e of b ra in in ju ry ca us ed b y a fa ilu re o f t he bl oo d su pp ly t o th e br ai n (2 7, 2 8, 2 9, 30 , 3 1) . D am ag e or di se as e ca n ca us e bl oo d ve ss el s to bl oc k or b ur st , ca us in g da m ag e or d ea th t o th at p ar t of t he b ra in (2 8, 2 9, 3 0, 3 1, 3 2) . H ow a s tr ok e af fe ct s ea ch in di vi du al va rie s, de pe nd in g on t he a re a of t he br ai n, w hi ch h as b ee n af fe ct ed a nd ho w s ev er el y it ha s be en a ffe ct ed (2 9, 31 ) – h ow ev er o ft en ju st o ne s id e of th e bo dy is a ffe ct ed ( he m ip le gi a) (2 8, 31 , 2 8) . • W ea kn es s, le ss m us cl e co nt ro l a nd so m et im es p ai n on t he a ffe ct ed s id e of t he b od y (a ffe ct in g th e ar m , t ru nk an d le g) (2 8) ; • re du ce d or a lte re d se ns at io n on sid e of t he b od y, w hi ch h as b ee n af fe ct ed (2 8) ; • m ay h av e a la ck o f a w ar en es s of s id e of t he b od y, w hi ch h as b ee n af fe ct ed an d th is m ay le ad t o in cr ea se d ris k of fa lls d ur in g tr an sf er s (2 8) ; • m ay h av e di f cu lty s itt in g up rig ht w ith a te nd en cy t o le an o r fa ll to w ar ds t he af fe ct ed s id e of t he b od y (2 8) ; • m ay b e ab le t o st an d up , a nd t ak e a fe w s te ps (m ay be u sin g di ffe re nt ga it) (2 8) ; • m ay h av e di f cu lty s pe ak in g, a s w el l a s sw al lo w in g, w hi ch m ak es e at in g an d dr in ki ng d if cu lt (2 8) ; • m ay h av e di f cu lty c on tr ol lin g bo w el an d bl ad de r (2 8) , a nd it c an a lso b e di f cu lt to b e ab le t o ge t to a t oi le t qu ic kl y en ou gh . • Pr ov id e po st ur al s up po rt t o en co ur ag e a ba la nc ed a nd s ym m et ric al ( bo th s id es th e sa m e) p os tu re . • Fl ip u p or s w in g aw ay fo ot re st s ar e of te n ve ry h el pf ul fo r w he el ch ai r us er s w ith a s tr ok e w ho c an m an ag e a st an di ng t ra ns fe r. • A s on e ar m is li ke ly t o be a ffe ct ed , m an y pe op le w ho h av e ha d a st ro ke ca nn ot p us h th e w he el ch ai r us in g th ei r ar m s. Fi nd o ut if a w he el ch ai r us er c an pr op el w ith t he ir un af fe ct ed a rm a nd st ee r w ith t he ir un af fe ct ed le g. • If th e w he el ch ai r us er h as o th er pr ob le m s, w hi ch a re n ot y et b ei ng ad dr es se d, r ef er t he m fo r fu rt he r he lp if av ai la bl e. Fo r m or e in fo rm at io n on : • W he el ch ai r se t up fo r fo ot p ro pe llin g – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 27 W or ld H ea lth O rg an iz at io n. ( 19 99 ). Pr om ot in g in de pe nd en ce fo llo w in g a st ro ke . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ hq /1 99 9/ W H O _D A R _9 9. 2. pd f 28 W or ld H ea lth O rg an iz at io n. ( 20 12 ). St ro ke , C er eb ro va sc ul ar a cc id en t. R et ri ev ed fr om h tt p: //w w w .w ho .in t/ to pi cs /c er eb ro va sc ul ar _a cc id en t/ en / 29 W or ld H ea lth O rg an iz at io n. ( 20 06 ). N eu ro lo gi ca l d is or de rs : P ub lic h ea lth c ha lle ng es . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m en ta l_ he al th /n eu ro lo gy /c ha pt er _3 _b _n eu ro _ di so rd er s_ pu bl ic _h _c ha lle ng es .p df 30 C ol lin s, C . ( 20 07 ). Pa th op hy si ol og y an d cl as si c at io n of s tr ok e. N ur si ng S ta nd ar d, 2 1( 28 ), 35 –3 9. 31 F ri zz el , J . ( 20 05 ). A cu te s tr ok e: P at ho ph ys io lo gy , d ia gn os is , a nd t re at m en t. A dv an ce d Pr ac tic e in A cu te a nd C ri tic al C ar e, 1 6( 4) , 4 21 –4 40 . 32 H er m an , B ., et a l. (1 98 2) . E pi de m io lo gy o f s tr ok e in T ilb ur g, th e N et he rl an ds . T he p op ul at io n- ba se d st ro ke in ci de nc e re gi st er : 2 . I nc id en ce , i ni tia l c lin ic al p ic tu re a nd m ed ic al c ar e, a nd t hr ee -w ee k ca se fa ta lit y. St ro ke , 1 3( 5) , 6 29 –6 34 . WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 31 32 G en er al in fo rm at io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Progressive conditions So m e co nd iti on s ar e kn ow n to g et w or se o ve r tim e. T he se a re k no w n as p ro gr es siv e co nd iti on s. So m e co m m on p ro gr es siv e co nd iti on s ar e: • m us cu la r dy st ro ph y; • Pa rk in so n di se as e; • m ul tip le s cl er os is; a nd • m ot or n eu ro ne d ise as e. Pr ov id in g th e rig ht s up po rt a t th e rig ht t im e ca n he lp p re ve nt p ro bl em s w ith po st ur e. T hi s ca n en su re t he w he el ch ai r us er is a bl e to c on tin ue li vi ng a s fu ll a lif e as po ss ib le fo r as lo ng a s po ss ib le . C er ta in fa ct or s ne ed t o be t ak en in to c on sid er at io n: • de la ys in a ss es sm en t ca n ca us e po st ur e to b ec om e w or se ; • de la ys b et w ee n as se ss m en t an d pr ov isi on m ay m ea n th at a w he el ch ai r an d/ or se at in g m ay n o lo ng er b e su ita bl e by t he t im e it is pr ov id ed ; • fr eq ue nt fo llo w u p is im po rt an t as m ob ilit y an d po st ur e su pp or t ne ed s ca n ch an ge q ui ck ly. If a w he el ch ai r us er h as a d ia gn os is t ha t is n ot li st ed , w ri te d ow n th e na m e of t he d ia gn os is . I f y ou d o no t kn ow a bo ut th is d ia gn os is , i t is a g oo d id ea t o n d ou t m or e ab ou t it . T hi nk a bo ut t he m ai n ch ar ac te ri st ic s of t hi s di ag no si s an d ho w t hi s w ill a ffe ct t he c ho ic e of a w he el ch ai r. W ha t if th e di ag no si s o r co nd it io n is n o t kn ow n? So m et im es t he w he el ch ai r us er m ay n ot k no w t he n am e of t he ir d ia gn os is o r co nd iti on . I t is a ls o po ss ib le t ha t no di ag no si s ha s be en m ad e. In t hi s ca se id en tif y an y sp ec i c ph ys ic al is su es a nd c on tin ue t he a ss es sm en t. So m e ph ys ic al is su es t ha t w he el ch ai r us er s m ay e xp er ie nc e ca n ha ve a d ir ec t im pa ct o n ch oo si ng t he m os t ap pr op ri at e w he el ch ai r. G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Frail Fr ai l p eo pl e ar e lik el y to b ec om e tir ed e as ily , ar e us ua lly le ss ph ys ic al ly a ct iv e an d w ea ke r th an pr ev io us ly a nd m ay w al k ve ry slo w ly (3 3) . O ld er a du lts a re at a h ig he r ris k of b ei ng fr ai l ( 34 , 3 0, 3 1, ) . O ft en e ld er ly pe op le w ho a re fr ai l a re g iv en v er y ba sic w he el ch ai rs w ith ou t go od po st ur al s up po rt t ha t do n ot m ee t th ei r ne ed s (3 2, 3 3) . H ow ev er , p ro vi di ng an a pp ro pr ia te w he el ch ai r w ith g oo d po st ur al s up po rt fo r fr ai l p eo pl e an d el de rly p eo pl e w ho a re fr ai l c an h av e a ve ry p os iti ve im pa ct o n th e pe rs on ’s qu al ity o f l ife (3 7, 3 4, 3 5) . • ge t tir ed q ui ck ly ; • ha ve li m ite d st re ng th t o se lf- pr op el ; • m ay nd it d if cu lt to m ai nt ai n an up rig ht p os tu re d ue t o fa tig ue a nd ge ne ra l w ea kn es s; • m ay b e at r isk o f d ev el op in g a pr es su re s or e du e to : – th in /p ap er y sk in , w hi ch b ru ise s ea sil y; – slo w h ea lin g tim e fo r br ui se s/ so re s; – if ve ry w ea k, m ay b e un ab le t o re po sit io n in de pe nd en tly . • A ss es s th e am ou nt o f p os tu ra l s up po rt ne ed ed c ar ef ul ly – c on sid er in g th at th e lo ng er t he w he el ch ai r us er s its in th e w he el ch ai r th e m or e tir ed h e/ sh e is lik el y to b ec om e, a nd t he m or e th e su pp or t th at m ay b e re qu ire d. • W he el ch ai r fe at ur es t ha t m ay b e us ef ul in cl ud e: – ar m re st s – pr ov id e ad di tio na l po st ur al s up po rt a nd a ss ist w ith pu sh in g up fo r tr an sf er s; – fo ot re st s th at s w in g ou t of t he w ay to fa ci lit at e st an di ng t ra ns fe rs fo r th os e th at a re a bl e to s ta nd ; – pu sh h an dl es t o en ab le o th er p eo pl e to a ss ist w ith p us hi ng ; – a lig ht w ei gh t w he el ch ai r, w hi ch w ill re qu ire le ss e ne rg y fo r th e w he el ch ai r us er t o pu sh h im se lf/ he rs el f. Fo r m or e in fo rm at io n on : • H ow c an p re ss ur e so re s be p re ve nt ed ? – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 33 F ri ed , L ., et a l. (2 00 1) . F ra ilt y in o ld er a du lts : E vi de nc e fo r a ph en ot yp e. Jo ur na l o f G er on to lo gy , 5 6, 1 46 –1 56 34 B or tz , W . ( 20 02 ). A c on ce pt ua l f ra m ew or k of fr ai lty : A r ev ie w . J ou rn al o f G er on to lo gy , 5 7A (5 ), M 28 3– M 28 8. 35 L an g, P., M ic he l, J. P., & Z ek ry , D . ( 20 09 ). Fr ai lty s yn dr om e: A t ra ns iti on al s ta te in d yn am ic p ro ce ss . G er on to lo gy , 5 5, 5 39 –5 49 . 36 R ad er , J ., Jo ne s, D ., & M ill er , L . ( 20 00 ). T he im po rt an ce o f i nd iv id ua liz ed w he el ch ai r se at in g fo r fr ai l o ld er a du lts . J ou rn al o f G er on to lo gi ca l N ur si ng , 2 6, 2 4– 32 . 37 K ra si lo vs ky , G . ( 19 93 ). Se at in g as se ss m en t an d m an ag em en t in a n ur si ng h om e po pu la tio n. P hy si ca l a nd O cc up at io na l T he ra py in G er ia tr ic s, 11 (2 ), 25 –3 8. 38 T re e r, E. , F itz ge ra ld , S ., H ob so n, D ., Bu rs ic k, T ., & Jo se ph , R . ( 20 04 ). O ut co m es o f w he el ch ai r sy st em s in te rv en tio n w ith r es id en ts o f l on g te rm c ar e fa ci lit ie s. A ss is tiv e Te ch no lo gy , 1 6, 1 8– 27 . 39 H un tin gt on ’s D is ea se S oc ie ty o f A m er ic a. (2 01 0) . P hy si ca l a nd O cc up at io na l T he ra py : F am ily g ui de s er ie s. R et ri ev ed fr om h tt p: //w w w .h ds a. or g/ im ag es / co nt en t/ 1/ 1/ 11 69 7. pd f WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 31 32 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Frail Fr ai l p eo pl e ar e lik el y to b ec om e tir ed e as ily , ar e us ua lly le ss ph ys ic al ly a ct iv e an d w ea ke r th an pr ev io us ly a nd m ay w al k ve ry slo w ly (3 3) . O ld er a du lts a re at a h ig he r ris k of b ei ng fr ai l ( 34 , 3 0, 3 1, ) . O ft en e ld er ly pe op le w ho a re fr ai l a re g iv en v er y ba sic w he el ch ai rs w ith ou t go od po st ur al s up po rt t ha t do n ot m ee t th ei r ne ed s (3 2, 3 3) . H ow ev er , p ro vi di ng an a pp ro pr ia te w he el ch ai r w ith g oo d po st ur al s up po rt fo r fr ai l p eo pl e an d el de rly p eo pl e w ho a re fr ai l c an h av e a ve ry p os iti ve im pa ct o n th e pe rs on ’s qu al ity o f l ife (3 7, 3 4, 3 5) . • ge t tir ed q ui ck ly ; • ha ve li m ite d st re ng th t o se lf- pr op el ; • m ay nd it d if cu lt to m ai nt ai n an up rig ht p os tu re d ue t o fa tig ue a nd ge ne ra l w ea kn es s; • m ay b e at r isk o f d ev el op in g a pr es su re s or e du e to : – th in /p ap er y sk in , w hi ch b ru ise s ea sil y; – slo w h ea lin g tim e fo r br ui se s/ so re s; – if ve ry w ea k, m ay b e un ab le t o re po sit io n in de pe nd en tly . • A ss es s th e am ou nt o f p os tu ra l s up po rt ne ed ed c ar ef ul ly – c on sid er in g th at th e lo ng er t he w he el ch ai r us er s its in th e w he el ch ai r th e m or e tir ed h e/ sh e is lik el y to b ec om e, a nd t he m or e th e su pp or t th at m ay b e re qu ire d. • W he el ch ai r fe at ur es t ha t m ay b e us ef ul in cl ud e: – ar m re st s – pr ov id e ad di tio na l po st ur al s up po rt a nd a ss ist w ith pu sh in g up fo r tr an sf er s; – fo ot re st s th at s w in g ou t of t he w ay to fa ci lit at e st an di ng t ra ns fe rs fo r th os e th at a re a bl e to s ta nd ; – pu sh h an dl es t o en ab le o th er p eo pl e to a ss ist w ith p us hi ng ; – a lig ht w ei gh t w he el ch ai r, w hi ch w ill re qu ire le ss e ne rg y fo r th e w he el ch ai r us er t o pu sh h im se lf/ he rs el f. Fo r m or e in fo rm at io n on : • H ow c an p re ss ur e so re s be p re ve nt ed ? – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 33 F ri ed , L ., et a l. (2 00 1) . F ra ilt y in o ld er a du lts : E vi de nc e fo r a ph en ot yp e. Jo ur na l o f G er on to lo gy , 5 6, 1 46 –1 56 34 B or tz , W . ( 20 02 ). A c on ce pt ua l f ra m ew or k of fr ai lty : A r ev ie w . J ou rn al o f G er on to lo gy , 5 7A (5 ), M 28 3– M 28 8. 35 L an g, P., M ic he l, J. P., & Z ek ry , D . ( 20 09 ). Fr ai lty s yn dr om e: A t ra ns iti on al s ta te in d yn am ic p ro ce ss . G er on to lo gy , 5 5, 5 39 –5 49 . 36 R ad er , J ., Jo ne s, D ., & M ill er , L . ( 20 00 ). T he im po rt an ce o f i nd iv id ua liz ed w he el ch ai r se at in g fo r fr ai l o ld er a du lts . J ou rn al o f G er on to lo gi ca l N ur si ng , 2 6, 2 4– 32 . 37 K ra si lo vs ky , G . ( 19 93 ). Se at in g as se ss m en t an d m an ag em en t in a n ur si ng h om e po pu la tio n. P hy si ca l a nd O cc up at io na l T he ra py in G er ia tr ic s, 11 (2 ), 25 –3 8. 38 T re e r, E. , F itz ge ra ld , S ., H ob so n, D ., Bu rs ic k, T ., & Jo se ph , R . ( 20 04 ). O ut co m es o f w he el ch ai r sy st em s in te rv en tio n w ith r es id en ts o f l on g te rm c ar e fa ci lit ie s. A ss is tiv e Te ch no lo gy , 1 6, 1 8– 27 . 39 H un tin gt on ’s D is ea se S oc ie ty o f A m er ic a. (2 01 0) . P hy si ca l a nd O cc up at io na l T he ra py : F am ily g ui de s er ie s. R et ri ev ed fr om h tt p: //w w w .h ds a. or g/ im ag es / co nt en t/ 1/ 1/ 11 69 7. pd f WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 33 34 G en er al in fo rm at io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Spasms/uncontrolled movements So m e pe op le h av e pr ob le m s w ith su dd en u nc on tr ol le d m ov em en ts . T he se c an b e ca lle d sp as m s. Sp as m s ca n be t rig ge re d in d iff er en t w ay s in cl ud in g: • th e po sit io n of t he p er so n’ s hi p, kn ee a nd a nk le ; • to uc h; • m ov em en t of t he w he el ch ai r, pa rt ic ul ar ly o ve r ro ug h/ bu m py gr ou nd . • Fi nd o ut h ow t he u nc on tr ol le d m ov em en ts a ffe ct t he w he el ch ai r us er a nd pr ob le m s ol ve w ith t he m . • So m e su pp or ts o r ad ju st m en ts t o th e w he el ch ai r m ay h el p to r ed uc e sp as m s an d un co nt ro lle d m ov em en ts in cl ud in g: – su pp or tin g to h el p co nt ro l t he p os tu re o f t he p el vi s; – ad ju st in g th e w he el ch ai r se at t o ba ck re st a ng le s o th at t he w he el ch ai r us er s its w ith t he ir hi ps b en t sli gh tly m or e th an n eu tr al ; – po sit io ni ng t he fo ot re st s so t ha t th e kn ee s ar e be nt s lig ht ly m or e th an n eu tr al , ‘tu ck in g’ t he fe et in ; – tr yi ng d iff er en t an gl es o f f oo tr es ts . • St ra ps m ay h el p gi ve a w he el ch ai r us er m or e co nt ro l o ve r th ei r le gs a nd fe et . I f a st ra p is us ed , i t sh ou ld fa st en w ith V el cr o so t ha t it w ill re le as e if th e w he el ch ai r us er fa lls o ut o f t he w he el ch ai r. • If th e m ov em en ts a re v er y st ro ng , c on sid er : – a so lid s ea t an d ba ck re st s up po rt ; – se le ct in g a w he el ch ai r w ith a n ad ju st ab le r ea r w he el s po sit io n. T he r ea r w he el s ca n be p os iti on ed in t he ‘s af e’ p os iti on t o m ak e th e w he el ch ai r m or e st ab le /le ss tip py ; – pr ov id in g an a nt i-t ip b ar t o st op t he w he el ch ai r fr om t ip pi ng o ve r ba ck w ar ds . – T hi s is w hy it is v er y im po rt an t fo r a w he el ch ai r us er t o pr op el t he w he el ch ai r at t he e nd o f a tt in g, t o se e w he th er a ny s pa sm s ar e tr ig ge re d. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 33 34 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Muscle tone – high and low T he t er m m us cl e to ne r ef er s to th e re sis ta nc e/ te ns io n in r es tin g m us cl e w he n it is be in g m ov ed (4 0) . N or m al m us cl e to ne a llo w s th e lim b or jo in t to b e m ov ed fr ee ly a nd ea sil y. H ow ev er s om e pe op le m ay ha ve m us cl e to ne t ha t is to o hi gh o r to o lo w . H ig h m us cl e to ne : T he re is m or e re sis ta nc e/ te ns io n – so it is h ar de r to m ov e a lim b or jo in t (4 1) . A p er so n w ith h ig h m us cl e to ne w ill us ua lly n d it di f cu lt/ aw kw ar d to m ov e th e af fe ct ed li m b or jo in t, an d m ov em en t m ay b e slo w . S om e pe op le w ith hi gh t on e ca n m ov e on ly in a c er ta in ‘ xe d’ p at te rn (4 2) . I f t he m us cl e to ne is ve ry h ig h, a lm os t no m ov em en t is po ss ib le . (c on tin ue d on t he n ex t p ag e) T he d eg re e of d if cu lty c au se d by m us cl e to ne d ep en ds o n ho w s ev er e th e pr ob le m is , a nd w hi ch m us cl es a re af fe ct ed . S om e po ss ib le d if cu lti es fo r w he el ch ai r us er s w ho h av e pr ob le m s w ith m us cl e to ne in cl ud e: • re du ce d ba la nc e (4 2) ; • di f cu lty s itt in g up rig ht a nd co m fo rt ab ly (4 3) ; • re du ce d m us cl e co nt ro l ( 43 ) , w hi ch ca n af fe ct h ow e as ily t he w he el ch ai r us er c an c ar ry o ut d iff er en t ta sk s in cl ud in g pr op el lin g th ei r w he el ch ai r an d tr an sf er rin g; (c on tin ue d on t he n ex t p ag e) W he n to uc hi ng o r he lp in g to m ov e a w he el ch ai r us er w ho h as h ig h or lo w m us cl e to ne , t he se t ip s m ay h el p: • ex pl ai n w ha t yo u ar e go in g to d o be fo re y ou d o it (4 2) ; • m ov e slo w ly a nd a llo w fo r th e tim e it ta ke s fo r a w he el ch ai r us er w ith lo w o r hi gh m us cl e to ne t o re ac t; • pr ov id e r m , c om fo rt ab le s up po rt w ith y ou r ha nd s an d ar m s so t ha t th e w he el ch ai r us er is w el l s up po rt ed ; • w he n st ro ng h ig h to ne c au se s th e w ho le b od y or w ho le li m b to st ra ig ht en , t he t on e ca n so m et im es be c al m ed b y be nd in g on e jo in t. Fo r ex am pl e, if a w ho le le g st ra ig ht en s, be nd in g th e kn ee o r hi p ca n re du ce th e to ne . (c on tin ue d on t he n ex t p ag e) 40 M ar tin , K ., K al te nm ar k, T ., Le w al le n, A ., Sm ith , C ., & Y os hi da , A . ( 20 07 ). C lin ic al c ha ra ct er is tic s of h yp ot on ia : A s ur ve y of p ed ia tr ic p hy si ca l a nd o cc up at io na l t he ra pi st s. Pe di at ri c Ph ys ic al T he ra py , 1 9, 2 17 –2 26 . 41 W or ld H ea lth O rg an iz at io n. ( 19 93 ). Pr om ot in g th e de ve lo pm en t of y ou ng c hi ld re n w ith c er eb ra l p al sy . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ hq /1 99 3/ W H O _ R H B_ 93 .1 .p df 42 W or ld H ea lth O rg an za tio n, U ni te d St at es D ep ar tm en t of D ef en se , D ru ck er B ra in In ju ry C en te r M os sR ha b H os pi ta l. (2 00 4) . R eh ab ili ta tio n fo r pe rs on s w ith t ra um at ic br ai n in ju ry . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ hq /2 00 4/ W H O _D A R _0 1. 9_ en g. pd f WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 35 36 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Lower Limb Amputation Lo w er li m b am pu ta tio n m ay ha pp en a s a re su lt of t ra um a, e. g. r oa d tr af c ac ci de nt , w or k in ju ry o r w ar in ju ry (4 7, 4 8, 4 9) . In o th er sit ua tio ns , l ow er lim b am pu ta tio n m ay b e a pl an ne d su rg ic al p ro ce du re . A n in cr ea sin g nu m be r of p eo pl e ha ve a u ni la te ra l o r bi la te ra l l ow er lim b am pu ta tio n as a s ec on da ry is su e as so ci at ed w ith d ia be te s (5 0, 5 1, 5 2) . M an y pe op le w ho h av e ha d on e or bo th li m bs a m pu ta te d w ill be a bl e to c on tin ue t o w al k w ith t he u se o f pr os th et ic s an d/ or w al ki ng a id s (4 8, 4 9) . H ow ev er , s om e pe op le m ay n ee d a w he el ch ai r fo r so m e tim e or a ll th e tim e (4 8, 4 9, 5 0) . • ca n be v er y ac tiv e in a w he el ch ai r if th ey a re p ro vi de d w ith t he h el p to le ar n go od w he el ch ai r m ob ilit y sk ills ; • th e w he el ch ai r ba la nc e ch an ge s as th er e is le ss w ei gh t at t he fr on t of th e ch ai r; • am pu te es w ho h av e di ab et es m ay be a t a gr ea te r ris k of d ev el op in g pr es su re s or es a s th ei r sk in m ay n ot he al w el l f ro m c ut s or k no ck s (4 9) . • W he n se tt in g up a w he el ch ai r fo r th e r st t im e fo r a pe rs on w ith a n am pu ta tio n, s et t he r ea r w he el s in t he fu rt he st b ac k po sit io n (if a dj us ta bl e) t o re du ce t he c ha nc e of t he w he el ch ai r tip pi ng b ac kw ar ds . A ct iv e us er s m ay qu ic kl y le ar n to b al an ce t he w he el ch ai r, an d th en m ov e th e re ar w he el s fo rw ar d. • W he n te ac hi ng m ob ilit y sk ills : – al w ay s be c ar ef ul w he n an a m pu te e r st t rie s a w he el ch ai r; – te ac h m ob ilit y sk ills c ar ef ul ly a s th er e is a gr ea te r ch an ce t ha t th e w he el ch ai r us er w ill tip b ac kw ar ds . • It is im po rt an t to k no w w he th er t he w he el ch ai r us er w ou ld p re fe r to w ea r th ei r pr os th et ic li m b( s) w he n us in g th e w he el ch ai r, as t hi s m ay c ha ng e th e t o f th e w he el ch ai r. Fo r m or e in fo rm at io n on : • H ow c an p re ss ur e so re s be p re ve nt ed ? – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 47 B ur ge r, H ., M ar in ce k, C ., & Is ak ov , E . ( 19 97 ). M ob ili ty o f p er so ns a ft er t ra um at ic lo w er li m b am pu ta tio n. D is ab ili ty a nd R eh ab ili ta tio n, 1 9( 7) , 2 72 –2 77 . 48 N ar an g, I., M at hu r, P., S in gh , P ., & Ja pe , V . ( 19 84 ). Fu nc tio na l c ap ac iti es o f l ow er li m b am pu te es . P ro st he tic s an d O rt ho tic s In te rn at io na l, 8, 4 3– 51 . 49 W or ld H ea lth O rg an iz at io n, U ni te d St at es D ep ar tm en t of D ef en ce , M os s R eh ab A m pu te e R eh ab ili ta tio n Pr og ra m M os s R eh ab H os pi ta l. (2 00 4) . T he r eh ab ili ta tio n of pe op le w ith a m pu ta tio ns . R et ri ev ed fr om h tt p: //w w w .p os na .o rg /n ew s/ A m pu ta tio ns .p df 50 W or ld H ea lth O rg an iz at io n. ( 20 05 ). W or ld d ia be te s da y: To o m an y pe op le a re lo si ng lo w er li m bs u nn ec es sa ry t o di ab et es . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m ed ia ce nt re /n ew s/ re le as es /2 00 5/ pr 61 /e n/ 51 P ec or ro , R ., R ei be r, G ., & B ur ge rs s, E. ( 19 90 ). Pa th w ay s to d ia be tic li m b am pu ta tio n: B as is fo r pr ev en tio n. D ia be te s C ar e, 1 3( 5) , 5 13 –5 21 . 52 T ra ut ne r, C ., H aa st er t, B. , G ia ni , G ., & B er ge r, M . ( 19 96 ). In ci de nc e of lo w er li m b am pu ta tio ns a nd d ia be te s. D ia be te s C ar e, 1 9( 9) , 1 00 6– 10 09 . 53 W or ld H ea lth O rg an iz at io n. ( 20 10 ). W ou nd a nd ly m ph oe de m a m an ag em en t. R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ pu bl ic at io ns /2 01 0/ 97 89 24 15 99 13 9_ en g. pd f G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Muscle tone – high and low (continued) L ow t o ne : T he re is le ss r es ist an ce – so it is e as y to p as siv el y m ov e th e lim b or jo in t (4 1) . H ow ev er , a pe rs on w ith a lo w m us cl e to ne m ay n d it di f cu lt to b eg in m ov em en t, an d m ay a lso nd c on tr ol lin g th ei r m ov em en t di f cu lt. L ow m us cl e to ne is so m et im es d es cr ib ed a s ‘ op py o r a cc id ’ ( 41 ) . If th e to ne is v er y lo w , i t m ay b e ve ry d if cu lt fo r th e pe rs on to m ov e. W ho h as p ro bl em s w it h m us cl e to ne ? Pr ob le m s w ith m us cl e to ne c an b e a pr ob le m fo r so m e w he el ch ai r us er s. It is a co m m on pr ob le m fo r pe op le w ho h av e ce re br al p al sy ( 42 ) , br ai n in ju ry (4 3) , S C I (3 9) , a nd s tr ok e (4 0) . • W he n th er e is co ns id er ab le h ig h or lo w m us cl e to ne , t he re c an be d if cu lty w ith e at in g, d rin ki ng , sw al lo w in g an d br ea th in g (4 1) . A sp ira tio n (b re at hi ng in p ie ce s of fo od o r liq ui d) is a li fe -t hr ea te ni ng pr ob le m (4 3) ; • In cr ea se d ris k of t he d ev el op m en t of x ed n on -n eu tr al p os tu re s (4 2) . Fo r so m e w he el ch ai r us er s, hi gh m us cl e to ne c an b ec om e gr ea te r w ith e m ot io n, or w he n he /s he is t ry in g ve ry h ar d to do s om et hi ng (4 2, 4 3) H ig h an d lo w m us cl e to ne c an b e a ris k fa ct or fo r hi p di slo ca tio ns (4 2) . T he a m ou nt o f p os tu ra l s up po rt n ee de d w ill de pe nd o n a w he el ch ai r us er ’s as se ss m en t. H ow ev er s om e pa rt ic ul ar co ns id er at io ns fo r w he el ch ai r us er s w ith hi gh t on e in cl ud e: • po st ur al s up po rt s m us t be m ad e st ro ng e no ug h to b e ef fe ct iv e w ith h ig h m us cl e to ne ; • hi gh t on e ca n ca us e po in ts o f h ig h pr es su re b et w ee n th e us er ’s bo dy an d th e w he el ch ai r. Re du ce t hi s by di st rib ut in g fo rc e ov er a la rg er s ur fa ce ar ea . C he ck fo r pr es su re . T ea ch t he w he el ch ai r us er o r hi s/ he r fa m ily m em be r/c ar eg iv er t o ch ec k th e sk in fo r sig ns o f p re ss ur e; • re du ci ng t he t hi gh -t o- tr un k an gl e ca n he lp t o re du ce s tr on g pa tt er ns o f hi gh t on e. 43 W or ld H ea lth O rg an iz at io n. ( 19 96 ). Pr om ot in g in de pe nd en ce fo llo w in g a sp in al c or d in ju ry : A m an ua l f or m id le ve l r eh ab ili ta tio n w or ke rs . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ hq /1 99 6/ W H O _R H B_ 96 .4 .p df 44 A m er ic an H ea rt a nd S tr ok e A ss oc ia tio n. ( n. d. ). Sp as tic ity . h tt p: //w w w .s tr ok ea ss oc ia tio n. or g/ ST RO K EO R G /L ife A ft er St ro ke /R eg ai ni ng In de pe nd en ce /P hy si ca lC ha lle ng es / Sp as tic ity _U C M _3 09 77 0_ A rt ic le .js p 45 R ed st on e, F ., & W es t, J. (2 00 4) . T he im po rt an ce o f p os tu ra l c on tr ol fo r fe ed in g. Pe di at ri c N ur si ng , 3 0, 9 7– 10 0. 46 D ri sc ol l, S. , & S ki nn er , J . ( 20 08 ). M us cu lo sk el et al c om pl ic at io ns o f n eu ro m us cu la r di se as e in c hi ld re n. P hy si ca l M ed ic in e an d R eh ab ili ta tio n C lin ic s of N or th A m er ic a, 19 , 16 3– 19 4. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 35 36 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Lower Limb Amputation Lo w er li m b am pu ta tio n m ay ha pp en a s a re su lt of t ra um a, e. g. r oa d tr af c ac ci de nt , w or k in ju ry o r w ar in ju ry (4 7, 4 8, 4 9) . In o th er sit ua tio ns , l ow er lim b am pu ta tio n m ay b e a pl an ne d su rg ic al p ro ce du re . A n in cr ea sin g nu m be r of p eo pl e ha ve a u ni la te ra l o r bi la te ra l l ow er lim b am pu ta tio n as a s ec on da ry is su e as so ci at ed w ith d ia be te s (5 0, 5 1, 5 2) . M an y pe op le w ho h av e ha d on e or bo th li m bs a m pu ta te d w ill be a bl e to c on tin ue t o w al k w ith t he u se o f pr os th et ic s an d/ or w al ki ng a id s (4 8, 4 9) . H ow ev er , s om e pe op le m ay n ee d a w he el ch ai r fo r so m e tim e or a ll th e tim e (4 8, 4 9, 5 0) . • ca n be v er y ac tiv e in a w he el ch ai r if th ey a re p ro vi de d w ith t he h el p to le ar n go od w he el ch ai r m ob ilit y sk ills ; • th e w he el ch ai r ba la nc e ch an ge s as th er e is le ss w ei gh t at t he fr on t of th e ch ai r; • am pu te es w ho h av e di ab et es m ay be a t a gr ea te r ris k of d ev el op in g pr es su re s or es a s th ei r sk in m ay n ot he al w el l f ro m c ut s or k no ck s (4 9) . • W he n se tt in g up a w he el ch ai r fo r th e r st t im e fo r a pe rs on w ith a n am pu ta tio n, s et t he r ea r w he el s in t he fu rt he st b ac k po sit io n (if a dj us ta bl e) t o re du ce t he c ha nc e of t he w he el ch ai r tip pi ng b ac kw ar ds . A ct iv e us er s m ay qu ic kl y le ar n to b al an ce t he w he el ch ai r, an d th en m ov e th e re ar w he el s fo rw ar d. • W he n te ac hi ng m ob ilit y sk ills : – al w ay s be c ar ef ul w he n an a m pu te e r st t rie s a w he el ch ai r; – te ac h m ob ilit y sk ills c ar ef ul ly a s th er e is a gr ea te r ch an ce t ha t th e w he el ch ai r us er w ill tip b ac kw ar ds . • It is im po rt an t to k no w w he th er t he w he el ch ai r us er w ou ld p re fe r to w ea r th ei r pr os th et ic li m b( s) w he n us in g th e w he el ch ai r, as t hi s m ay c ha ng e th e t o f th e w he el ch ai r. Fo r m or e in fo rm at io n on : • H ow c an p re ss ur e so re s be p re ve nt ed ? – se e th e W he el ch ai r Se rv ic e Tr ai ni ng Pa ck ag e – Ba sic L ev el R ef er en ce M an ua l. 47 B ur ge r, H ., M ar in ce k, C ., & Is ak ov , E . ( 19 97 ). M ob ili ty o f p er so ns a ft er t ra um at ic lo w er li m b am pu ta tio n. D is ab ili ty a nd R eh ab ili ta tio n, 1 9( 7) , 2 72 –2 77 . 48 N ar an g, I., M at hu r, P., S in gh , P ., & Ja pe , V . ( 19 84 ). Fu nc tio na l c ap ac iti es o f l ow er li m b am pu te es . P ro st he tic s an d O rt ho tic s In te rn at io na l, 8, 4 3– 51 . 49 W or ld H ea lth O rg an iz at io n, U ni te d St at es D ep ar tm en t of D ef en ce , M os s R eh ab A m pu te e R eh ab ili ta tio n Pr og ra m M os s R eh ab H os pi ta l. (2 00 4) . T he r eh ab ili ta tio n of pe op le w ith a m pu ta tio ns . R et ri ev ed fr om h tt p: //w w w .p os na .o rg /n ew s/ A m pu ta tio ns .p df 50 W or ld H ea lth O rg an iz at io n. ( 20 05 ). W or ld d ia be te s da y: To o m an y pe op le a re lo si ng lo w er li m bs u nn ec es sa ry t o di ab et es . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m ed ia ce nt re /n ew s/ re le as es /2 00 5/ pr 61 /e n/ 51 P ec or ro , R ., R ei be r, G ., & B ur ge rs s, E. ( 19 90 ). Pa th w ay s to d ia be tic li m b am pu ta tio n: B as is fo r pr ev en tio n. D ia be te s C ar e, 1 3( 5) , 5 13 –5 21 . 52 T ra ut ne r, C ., H aa st er t, B. , G ia ni , G ., & B er ge r, M . ( 19 96 ). In ci de nc e of lo w er li m b am pu ta tio ns a nd d ia be te s. D ia be te s C ar e, 1 9( 9) , 1 00 6– 10 09 . 53 W or ld H ea lth O rg an iz at io n. ( 20 10 ). W ou nd a nd ly m ph oe de m a m an ag em en t. R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ pu bl ic at io ns /2 01 0/ 97 89 24 15 99 13 9_ en g. pd f WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 37 38 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Fatigue So m e w he el ch ai r us er s m ay r eg ul ar ly be co m e tir ed d ur in g th e da y. T hi s m ay b e be ca us e of t he a dd iti on al ef fo rt a nd e ne rg y th ey u se t o sit up rig ht a nd c ar ry o ut a ct iv iti es , o r th e na tu re o f t he ir co nd iti on . Fa tig ue c an b e a pr ob le m fo r so m e el de rly p eo pl e, o r so m e pe op le w ith pr og re ss iv e co nd iti on s (5 0, 5 1) . • m ay b e ab le t o sit u pr ig ht , h ow ev er ca nn ot s ta y up rig ht fo r lo ng d ue t o fa tig ue ; • if w he el ch ai r us er s n d it ha rd t o m ai nt ai n an u pr ig ht p os tu re d ue to fa tig ue , t he y ar e at m or e ris k of de ve lo pi ng p os tu ra l p ro bl em s. • Tr y to nd o ut w ha t it is th at m ak es th e w he el ch ai r us er t ire d. T hi s w ill he lp yo u to nd t he b es t so lu tio n fo r th em . • W he n de ci di ng h ow m uc h po st ur al su pp or t to p ro vi de , c on sid er t he ef fe ct o f f at ig ue . D ur in g th e w he el ch ai r as se ss m en t th e w he el ch ai r us er m ay ha ve m or e en er gy , a nd a pp ea r to n ee d le ss s up po rt . D isc us s ca re fu lly w ith t he w he el ch ai r us er h ow m uc h su pp or t he / sh e ne ed s w he n th ey a re m os t tir ed . • C on sid er a lte rn at iv e re st in g po sit io ns – fo r ex am pl e a tr ay w ith a c us hi on ca n al lo w s om eo ne t o le an fo rw ar d on t he ir ar m s; til t in s pa ce is a no th er re st in g po sit io n. • Pl an ni ng t o ha ve r es ts o ut o f t he w he el ch ai r du rin g th e da y m ay m ak e it po ss ib le t o sit m or e co m fo rt ab ly fo r lo ng er . 54 W or ld H ea lth O rg an iz at io n. ( 20 08 ). A tla s: M ul tip le s cl er os is r es ou rc es in t he w or ld . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m en ta l_ he al th /n eu ro lo gy /A tla s_ M S_ W EB .p df 55 P ar ki ns on ’s D is ea se F ou nd at io n. ( n. d. ). Fa tig ue . R et ri ev ed fr om h tt p: //w w w .p df .o rg /e n/ fa tig ue _p df WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 37 38 G en er al in fo rm at io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Dislocated hips T he re is a h ig he r pr ev al en ce o f th e hi p di slo ca tio n in c hi ld re n w ho ha ve n ev er b ee n ab le t o w al k in de pe nd en tly (5 6, 5 7, 5 8) . T hi s is be ca us e th e so ck et (a ce ta bu lu m ) on t he p el vi s is so ft w he n ch ild re n ar e bo rn , a nd th e ro un d he ad o f t he fe m ur s ha pe s th e so ck et w he n th e le g is m ov in g, or w he n w ei gh t is pu sh in g th ro ug h it w he n st an di ng . I f t he h ip jo in t do es no t fo rm c or re ct ly, t hi s ca n le ad t o di slo ca tio n. It is al so v er y co m m on w ith c hi ld re n w ho h av e tig ht m us cl es a nd h ig h to ne a ro un d th e hi p an d pe lv is an d te nd t o al w ay s sit o r lie w ith t he ir le gs to o ne s id e (5 5) . T hi s ca n be a p ro bl em fo r pe op le w ith c er eb ra l p al sy (5 7, 6 0) or t ra um at ic b ra in in ju ry (6 0) . (c on tin ue d on t he n ex t p ag e) • So m e in di ca tio ns t ha t a pe rs on m ay h av e a di slo ca te d/ su bl ux ed h ip a re : – on e le g ap pe ar s sh or te r th an t he o th er le g (6 0) ; – th ei r le g is al w ay s po sit io ne d cl os er t o th e m id li ne ; – th er e is pa in w he n th e hi p is m ov ed (6 0) ; – w he n ca rr yi ng o ut a r an ge o f m ot io n of t he h ip it m ay n ot b e po ss ib le t o ta ke th e th ig h to t he n eu tr al p os iti on o r to t he o ut sid e of t he b od y; – it is no t po ss ib le t o fu lly s tr ai gh te n th e hi ps . • Re se ar ch s ho w s th at t he fo llo w in g ca n he lp t o re du ce t he t en de nc y fo r hi p di slo ca tio n: – su pp or tin g a ne ut ra l p os tu re in s itt in g an d ly in g fr om a n ea rly a ge . F or y ou ng ch ild re n th is in cl ud es s up po rt in g th e hi ps /t hi gh s in a bd uc tio n (6 1, 6 2) ; – st an di ng in a n eu tr al p os tu re (f or e xa m pl e in a s ta nd in g fr am e) (6 3) . (c on tin ue d on t he n ex t p ag e) 56 S oo , B ., et a l. (2 00 6) . H ip d is pl ac em en t in c er eb ra l p al sy . T he Jo ur na l o f B on e an d Jo in t Su rg er y, 88 , 1 21 –1 29 . 57 S cr ut to n, D ., Ba ir d, G ., & S m ee to n, N . ( 20 01 ). H ip d ys pl as ia in b ila te ra l c er eb ra l p al sy : i nc id en ce a nd n at ur al h is to ry in c hi ld re n ag ed 1 8 m on th s to 5 y ea rs . D ev el op m en ta l M ed ic in e an d C hi ld N eu ro lo gy , 4 3, 4 86 –6 00 58 L on st ei n, J. , & B ec k, K . ( 19 86 ). H ip d is lo ca tio n an d su bl ux at io n in c er eb ra l p al sy . J ou rn al o f P ed ia tr ic O rt ho pa ed ic s, 6, 5 21 –5 26 . 59 C hi ld re n’ s H os pi ta l B os to n. ( n. d. ). A g ui de bo ok fo r hi p su rg er y in c hi ld re n w ith c er eb ra l p al sy . R et ri ev ed fr om h tt p: //c hi ld re ns ho sp ita l.o rg /c lin ic al se rv ic es /S ite 11 66 / D oc um en ts /C P.L E. Bo ok .w eb 2. pd f 60 W or ld H ea lth O rg an za tio n, U ni te d St at es D ep ar tm en t of D ef en se , D ru ck er B ra in In ju ry C en te r M os sR ha b H os pi ta l. (2 00 4) . R eh ab ili ta tio n fo r pe rs on s w ith t ra um at ic br ai n in ju ry . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ hq /2 00 4/ W H O _D A R _0 1. 9_ en g. pd f 61 P ou nt ne y, T. , M an dy , A ., G re en , E ., & G ar d, P . ( 20 09 ). H ip s ub lu xa tio n an d di sl oc at io n in c er eb ra l p al sy – a p ro sp ec tiv e st ud y on t he e ffe ct iv en es s of p os tu ra l m an ag em en t pr og ra m m es . P hy si ot he ra py R es ea rc h In te rn at io na l, 14 (2 ), 11 6– 12 7. 62 H ea lth C en tr e fo r C hi ld re n. ( 20 11 ). Ev id en ce fo r pr ac tic e: S ur ve ill an ce a nd m an ag em en t of h ip d is pl ac em en t an d di sl oc at io n in c hi ld re n w ith n eu ro m ot or d is or de rs in cl ud in g ce re br al p al sy . V an co uv er , B C : T an ja M ay so n. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 39 40 G en er al in fo rm at io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Dislocated hips (continued) Fo r ch ild re n w ho h av en ’t w al ke d an d ha ve a t en de nc y to li e w ith b ot h le gs to o ne s id e (w in ds w ep t) : t he h ip , w hi ch is c lo se st t o th e m id li ne o f th e bo dy (a dd uc te d) a nd t ur ne d in (in te rn al ly r ot at ed ) is th e on e m os t lik el y to d isl oc at e (6 3) . W he n ch ild re n ha ve lo w t on e ar ou nd th e hi p jo in t, th ey c an a lso b e at r isk of h ip d isl oc at io n. T hi s is be ca us e th e m us cl es a nd li ga m en ts a re n ot s tr on g en ou gh t o ho ld t he t w o pa rt s of t he hi p jo in t to ge th er ( th e ac et ab ul um an d th e he ad o f t he fe m ur ). A di slo ca te d hi p is no t al w ay s pa in fu l ( 64 , 65 , 6 6) . • W he n as se ss in g a ch ild o r ad ul t w ho h as a ny o f t he s ig ns o f a p os sib le d isl oc at ed hi p, m ov e th e hi ps g en tly a nd a vo id c au sin g pa in . • If yo u ar e no t su re if a c hi ld o r ad ul t ha s di slo ca te d hi ps r ef er t he c hi ld to a d oc to r/ pa ed ia tr ic ia n or e xp er ie nc ed p hy sio th er ap ist ( if po ss ib le ) fo r fu rt he r ad vi ce . • W he n pr ov id in g a w he el ch ai r an d po st ur al s up po rt fo r an y ch ild o r ad ul t w ith a hi p di slo ca tio n or s us pe ct ed h ip d isl oc at io n: – av oi d po st ur es , w hi ch c au se p ai n; – su pp or t th ei r pe lv is an d tr un k in n eu tr al (a s cl os e to n eu tr al a s po ss ib le ); an d th en s up po rt t he h ip s an d th ig hs a s cl os e to n eu tr al a s po ss ib le . A vo id ‘o ve rc or re ct in g’ t he le g po st ur e as t hi s m ay c au se t he p el vi s to m ov e aw ay fr om ne ut ra l a nd /o r ca us e pa in ; – ch ec k w ha t po sit io n th e pe rs on s le ep s in . A dv ise o n a sle ep in g po sit io n th at av oi ds w in ds w ee pi ng o f t he le gs , a nd t he le gs fr om b ei ng s qu ee ze d tig ht ly ag ai ns t ea ch o th er . 63 P op e, P . ( 20 07 ). S ev er e an d co m pl ex n eu ro lo gi ca l d is ab ili ty : M an ag em en t of t he p hy si ca l c on di tio n. P hi la de lp hi a: El se vi er L im ite d. 64 S he rk , H ., Pa sq ua ri el lo , P ., & D oh er ty , J . ( 20 08 ). H ip d is lo ca tio n in c er eb ra l p al sy : S el ec tio n fo r tr ea tm en t. D ev el op m en ta l M ed ic in e an d C hi ld N eu ro lo gy , 2 5( 6) , 7 38 –7 46 . 65 M or ea u, M . e t al . ( 19 79 ). N at ur al h is to ry o f t he d is lo ca te d hi p in s pa st ic c er eb ra l p al sy . D ev el op m en ta l M ed ic in e an d C hi ld N eu ro lo gy , 2 1( 6) , 7 49 –7 53 . 66 K na pp , R ., & C or te s, H . ( 20 02 ). U nt re at ed h ip d is lo ca tio n in c er eb ra l p al sy . J ou rn al o f P ed ia tr ic O rt ho pa ed ic s, 22 , 6 68 –6 71 . WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 39 40 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Epilepsy Ep ile ps y is a di sr up tio n of t he n or m al ac tiv ity o f t he b ra in t ha t re su lts in se iz ur es (6 7, 6 8, 6 9, 7 0) . U nd er c er ta in ci rc um st an ce s an yo ne c an h av e a se iz ur e (7 0) . T he t er m e pi le ps y is us ed o nl y fo r re cu rr en t, un pr ov ok ed se iz ur es (6 9, 7 0) . (c on tin ue d on t he n ex t p ag e) W ha t to d o if a w he el ch ai r us er h as a se iz ur e du rin g a w he el ch ai r as se ss m en t: W he n a w he el ch ai r us er h as a m in or se iz ur e, w ai t fo r it to b e ov er a nd t he n co nt in ue w ith t he a ss es sm en t. If a w he el ch ai r us er h as a m aj or s ei zu re th e r st p rio rit y is to p ro te ct h im / he r fr om in ju ry (7 1) . I f t he w he el ch ai r us er fa lls fo rw ar d, t ry t o ea se t he fa ll. If th e w he el ch ai r us er is a c hi ld o r a sm al l a du lt, it m ay b e po ss ib le t o sa fe ly lif t th em o nt o th e o or . I f H e/ sh e is a la rg e ad ul t, it w ill be n ec es sa ry fo r th e w he el ch ai r us er t o re m ai n w he re h e/ sh e is (d ue t o po te nt ia l r isk o f i nj ur y to th os e as sis tin g) a nd o nc e th e se iz ur e st op s, gr ad ua lly li ft h im /h er w ith t he he lp o f c o- w or ke rs /fa m ily m em be rs o r ca re gi ve rs . (c on tin ue d on t he n ex t p ag e) W he n pr ov id in g a w he el ch ai r fo r a pe rs on w ho h as e pi le ps y re m em be r: • th e w he el ch ai r us er w ill ne ed s tr ap s th at c an b e un do ne e as ily t o he lp t he m ou t of t he w he el ch ai r; (c on tin ue d on t he n ex t p ag e) 67 M cN am ar a, J. (1 99 4) . C el lu la r an d m ol ec ul ar b as is o f e pi le ps y. T he Jo ur na l o f N eu ro sc ie nc e, 1 4( 6) , 3 41 3– 34 25 . 68 W or ld H ea lth O rg an iz at io n. ( 20 05 ). A tla s: Ep ile ps y ca re in t he w or ld . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m en ta l_ he al th /n eu ro lo gy /E pi le ps y_ at la s_ r1 .p df 69 W or ld H ea lth O rg an iz at io n. ( 20 02 ). Ep ile ps y: A m an ul a fo r m ed ic al a nd c lin ic al o f ce rs in A fr ic a. R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m en ta l_ he al th /m ed ia /e n/ 63 9. pd f 70 W or ld H ea lth O rg an iz at io n. ( 20 06 ). N eu ro lo gi ca l d is or de rs : P ub lic h ea lth c ha lle ng es . R et ri ev ed fr om h tt p: //w w w .w ho .in t/ m en ta l_ he al th /n eu ro lo gy /c ha pt er _3 _a _n eu ro _ di so rd er s_ pu bl ic _h _c ha lle ng es .p df 71 E pi le ps y Fo un da tio n. ( n. d. ). Fi rs t ai d. R et ri ev ed fr om h tt p: //w w w .e pi le ps yf ou nd at io n. or g/ ab ou te pi le ps y/ r st ai d/ in de x. cf m WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 41 42 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Epilepsy (continued) So m e w he el ch ai r us er s m ay h av e ep ile ps y. Se iz ur es m ay b e pa rt ia l or g en er al ize d (7 0) . D ur in g a pa rt ia l se iz ur e a pe rs on m ay o r m ay n ot ha ve im pa ire d co ns ci ou sn es s (7 0) . I f th e co ns ci ou sn es s is no t im pa ire d th e se iz ur e la st s le ss t ha n a m in ut e an d a pe rs on is u su al ly e xp er ie nc in g un co nt ro lle d m ov em en ts (7 2) . I f t he co ns ci ou sn es s be co m es im pa ire d, t he se iz ur e la st s on e or t w o m in ut es a nd th e pe rs on is s lig ht ly a w ar e of w ha t is go in g on b ut c an no t re sp on d or ch an ge h is be ha vi ou r (7 0, 7 3) . D ur in g a ge ne ra liz ed s ei zu re , a p er so n ha s a co m pl et e lo ss o f c on sc io us ne ss (7 0) . A p er so n ex pe rie nc in g a ge ne ra liz ed s ei zu re m ay s ud de nl y fa ll un co ns ci ou sn es s an d in ju re th em se lv es (7 0) . D ur in g th e se iz ur e: • do n ot t ry t o re m ov e th e w he el ch ai r us er fr om t he w he el ch ai r – un le ss th er e is fo od , w at er o r vo m it in t he ir m ou th . I n th is ca se , r em ov e th e w he el ch ai r us er fr om t he ir w he el ch ai r an d lie t he m o n th e sid e, s o th at s al iv a an d m uc us c an r un o ut o f t he m ou th (7 0, 7 3) ; • m ak e sp ac e ar ou nd t he w he el ch ai r us er t o pr ot ec t hi m /h er fr om in ju ry or m ov e th em a w ay fr om a ny th in g th at c an h ar m t he m (7 0) ; • pr ot ec t th e w he el ch ai r us er ’s he ad b y pl ac in g so ft p ad di ng u nd er ne at h it (7 0, 73 ) ; • lo os en t ig ht c lo th in g, r em ov e an y ob je ct s th at c an h ar m t he m a nd m ak e su re t he w he el ch ai r is se cu re (7 0, 7 3) ; • tim e th e du ra tio n of t he s ei zu re an d gi ve t hi s in fo rm at io n to t he w he el ch ai r us er o r hi s/ he r ca re gi ve r af te r th e se iz ur e (7 0) . W ai t ca lm ly w ith t he w he el ch ai r us er un til t he s ei zu re is o ve r. Se ek m ed ic al at te nt io n if: • th e w he el ch ai r us er d oe s no t re ga in co ns ci ou sn es s w he n th e se iz ur e ha s en de d (6 9) ; • th e se iz ur e la st s lo ng er t ha n v e m in ut es (7 0) . • if a w he el ch ai r us er o ft en h as s ei zu re s, w hi ch c au se h im /h er t o fa ll fo rw ar d su dd en ly, p ad h is/ he r tr ay ( if us ed ) so th at h e/ sh e do es n ot h ur t hi s/ he r he ad ; • if a w he el ch ai r us er h as e pi le ps y, w hi ch is no t be in g tr ea te d, r ef er h im /h er t o a do ct or . 72 E pi le ps y A us tr al ia . ( 20 09 ). S ei zu re rs t ai d. R et ri ev ed fr om h tt p: //w w w .e pi le ps ya us tr al ia .n et /u se rD at a/ do cs /F ir st % 20 A id % 20 Br oc hu re % 20 09 .p df 73 E pi le ps y C an ad a. (n .d .). R et ri ev ed fr o ht tp :// ol d. ep ile ps yc an ad a. te st .g la ci er -d ig ita l.c om /s ca ns /b ro ch ur e/ se iz ur es Fi rs tA id .h tm l 74 E pi le ps y C an ad a. (n .d .). R et ri ev ed fr om h tt p: //w w w .e pi le ps y.c a/ en -C A /D ia gn os is -a nd -T re at m en t/ Fi rs t- A id .h tm l WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 41 42 G en er al in fo rm at io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Problems with eating, drinking and swallowing So m e ch ild re n an d ad ul ts m ay h av e di f cu lti es w ith ea tin g, d rin ki ng a nd s w al lo w in g. D if cu lti es w ith e at in g an d dr in ki ng m ay b e ca us ed b y pr ob le m s ta ki ng t he fo od o r dr in k to t he ir m ou th . F or ex am pl e, if w he el ch ai r us er s ha ve d if cu lty c on tr ol lin g th ei r ar m s or h an ds t he y ca nn ot e as ily m an ag e ea tin g or dr in ki ng . A lte rn at iv el y, th e di f cu lty m ay b e ca us ed b y pr ob le m s w ith t he m us cl es a ro un d th e he ad , n ec k, m ou th a s w el l as t ho se , w hi ch c on tr ol s w al lo w in g (7 5) . P oo r ba la nc e, d if cu lty s itt in g up rig ht an d di f cu lty m ai nt ai ni ng a n up rig ht a nd b al an ce d po sit io n of t he h ea d ca n m ak e th is w or se (7 6) . Sw al lo w in g pr ob le m s ca n ca us e fo od o r dr in k to g o in to t he lu ng s. T hi s ca n po te nt ia lly le ad t o ch es t in fe ct io ns (7 7, 7 8, 7 9, 8 0, 8 1) , w hi ch c an m ak e th e pe rs on da ng er ou sly il l ( 82 ) . Si gn s th at a p er so n ha s pr ob le m s w ith s w al lo w in g in cl ud e: • of te n co ug hi ng w he n dr in ki ng (8 3) ; • of te n ch ok in g w he n ea tin g or d rin ki ng (8 4) ; • co ns ta nt d ro ol in g. W he n pr ov id in g a w he el ch ai r fo r a pe rs on w ho h as p ro bl em s w ith e at in g, dr in ki ng a nd s w al lo w in g re m em be r: • go od p os tu ra l s up po rt c an im pr ov e ba la nc e, p os tu re , h ea d an d ha nd co nt ro l a nd r ed uc e pr ob le m s w ith ea tin g, d rin ki ng a nd s w al lo w in g; • a tr ay a nd /o r a he ad re st a re o ft en ne ed ed . If a w he el ch ai r us er h as p ro bl em s w ith s w al lo w in g th at a re n ot b ei ng ad dr es se d, r ef er t he w he el ch ai r us er t o so m eo ne w ho c an h el p. F or e xa m pl e, a pa ed ia tr ic ia n, s pe ec h la ng ua ge t he ra pi st , oc cu pa tio na l t he ra pi st o r ex pe rie nc ed ch ild h ea lth w or ke r. 75 L og em an n, J. , & B yt el l, D . ( 19 79 ). Sw al lo w in g di so rd er s in t hr ee t yp es o f h ea d an d ne ck s ur gi ca l p at ie nt s. C an ce r, 44 , 1 07 5– 11 05 . 76 R ed st on e, F ., & W es t, J. (2 00 4) . T he im po rt an ce o f p os tu ra l c on tr ol fo r fe ed in g. Pe di at ri c N ur si ng , 3 0( 2) , 9 7– 10 0. 77 T ea se ll, R ., M cr ae , M ., M ar ch uk , Y ., & F in es to ne , H . ( 19 96 ). Pn eu m on ia a ss oc ia te d w ith a sp ir at io n fo llo w in g st ro ke . A rc h Ph ys M ed R eh ab , 7 7, 7 7– 70 9. 78 L ou gh lin , G . ( 19 89 ). R es pi ra to ry c on se qu en ce s of d ys fu nc tio na l s w al lo w in g an d as pi ra tio n. D ys ph ag ia , 3 , 1 26 –1 30 . 79 W or ld H ea lth O rg an za tio n, U ni te d St at es D ep ar tm en t of D ef en se , D ru ck er B ra in In ju ry C en te r M os sR ha b H os pi ta l. (2 00 4) . R eh ab ili ta tio n fo r pe rs on s w ith t ra um at ic br ai n in ju ry . R et ri ev ed fr om h tt p: //w hq lib do c. w ho .in t/ hq /2 00 4/ W H O _D A R _0 1. 9_ en g. pd f 80 S ch m id t, J., H ol as , M ., H al vo rs on , K ., & R ed in g, M . ( 19 94 ). V id eo u or os co pi c ev id en ce o f a sp ir at io n pr ed ic ts p ne um on ia a nd d ea th b ut n ot d eh yd ra tio n fo llo w in g st ro ke . D ys ph ag ia , 9 , 7 –1 1. 81 P er ry , L ., & L ov e, C . ( 20 01 ). Sc re en in g fo r dy sp ha gi a an d as pi ra tio n in a cu te s tr ok e: A s ys te m at ic r ev ie w . D ys ph as ia , 1 6, 7 –1 8. 82 h tt p: //w w w .w ho .in t/ m ed ia ce nt re /fa ct sh ee ts /fs 33 1/ en / 83 P ra ss e, J. & K ik an o, G . ( 20 09 ). A n ov er vi ew o f p ed ia tr ic d ys ph ag ia . C lin ic al P ed ia tr ic s, 48 (3 ), 24 7– 25 1. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 43 44 G en er al in fo rm at io n C o m m o n ch ar ac te ri st ic s th at m ay a ff ec t w he el ch ai r pr ov is io n C o ns id er at io ns fo r w he el ch ai r pr ov is io n Pain • It is ve ry im po rt an t to k no w w he th er t he w he el ch ai r us er h as an y pa in , a s th is m ay a ffe ct t he ir ab ilit y to s it co m fo rt ab ly in t he ir w he el ch ai r. • If a w he el ch ai r us er is r eg ul ar ly ex pe rie nc in g pa in , w he el ch ai r se rv ic e pe rs on ne l s ho ul d re fe r th em t o a do ct or /h ea lth c lin ic t o id en tif y th e ca us e of t he p ai n, b ec au se ig no rin g pa in c an b e da ng er ou s. • To a vo id p ai n du rin g th e w he el ch ai r as se ss m en t: – as k w he th er a ny p os iti on s m ak e th e pa in w or se ; s uc h po sit io ns s ho ul d be av oi de d; – as k w he th er a ny m ov em en ts o r po sit io ns m ak e th e pa in le ss ; t he se po sit io ns m us t be c on sid er ed d ur in g th e w he el ch ai r as se ss m en t; – if th e w he el ch ai r us er c an no t co m m un ic at e us in g sp ee ch , nd an ot he r m et ho d to c om m un ic at e be fo re t he w he el ch ai r as se ss m en t be gi ns ; – go od s up po rt a nd c ha ng e of p os iti on ca n pr ev en t or r ed uc e pa in . Bladder and bowel problems • So m e w he el ch ai r us er s ca n ha ve di f cu lty c on tr ol lin g th ei r bl ad de r or b ow el s. T he se p ro bl em s ca n of te n be m an ag ed w ith t he rig ht e qu ip m en t (e .g . c at he te rs ), m ed ic at io n, b la dd er a nd b ow el tr ai ni ng p ro gr am m es . • It is im po rt an t to id en tif y w ho in y ou r ar ea c an o ffe r ad vi ce an d tr ai ni ng t o av oi d th es e co m pl ic at io ns (f or e xa m pl e, sp ec ia lis t do ct or s an d nu rs es ). • So m et im es w he el ch ai r us er s w ho ha ve p oo r bl ad de r or b ow el c on tr ol ha ve d if cu lty c om m un ic at in g w he n th ey n ee d to g o to t he t oi le t. T he y ar e at r isk o f h av in g bl ad de r or b ow el ac ci de nt s. • W he el ch ai r se rv ic e pe rs on ne l n ee d to b e aw ar e th at w he n w or ki ng w ith w he el ch ai r us er s w ho h av e bl ad de r or b ow el p ro bl em s it is po ss ib le t ha t th ey m ay g et s oi le d. G oo d ha nd w as hi ng fa ci lit ie s an d a m ea ns t o cl ea n th e cl in ic a re a ar e im po rt an t. • A d am p or s oi le d cu sh io n ca n ca us e th e sk in t o br ea k do w n. In a dd iti on , ba ct er ia p re se nt in fa ec es r ap id ly le ad to in fe ct ed p re ss ur e so re s. T he w as te pr od uc ts in u rin e an d fa ec es c an a lso in fe ct s or es a nd b ur n th e sk in . • T he c us hi on a nd c ov er s ho ul d be e as ily re m ov ab le t o al lo w t he u se r/c ar eg iv er to c le an t he m . • Pr ov id e a cu sh io n w ith a w at er pr oo f co ve r. If po ss ib le p ro vi de t w o co ve rs t o en ab le t he w he el ch ai r us er t o co nt in ue w ith t he ir da y- to -d ay a ct iv iti es w hi le on e co ve r dr ie s. • If th er e is no w at er pr oo f c ov er , p ro vi de tw o cu sh io ns . • Re fe r th e w he el ch ai r us er t o so m eo ne w ho c an h el p th em t o m an ag e th ei r bo w el a nd b la dd er t o st ay h ea lth y an d av oi d ac ci de nt s. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 43 44 Lifestyle and environment Describe where the wheelchair user will use their wheelchair: Distance travelled per day: Up to 1 km 1–5 km More than 5 km Hours per day using wheelchair: Less than 1 1–3 3–5 5–8 more than 8 When out of the wheelchair, where does the wheelchair user sit or lie down and how (posture and surface)? Transfer: Independent Assisted Standing Non-standing Lifted Other Type of toilet (if transferring to a toilet): Squat Western Adapted Does the wheelchair user often use public/private transport? Yes No If yes, what kind: Car Taxi Bus Other The ‘lifestyle and environment’ part of the intermediate wheelchair assessment form gathers information about where the wheelchair user lives and the things that he/she needs to do in their wheelchair. It is important to consider how the wheelchair and any additional postural support provided will help the wheelchair user to manage to the best of their abilities considering their immediate environment and their lifestyle. Lifestyle and environment questions on the intermediate wheelchair assessment form Discussion Describe where the wheelchair user will use their wheelchair • The wheelchair needs to be practical for the wheelchair user’s home, work or school. For example: – if the wheelchair will be used at home, the wheelchair user needs to be able to move about the home easily to carry out important day-to-day activities; – a wheelchair user who works in an of ce will need a wheelchair, which can t easily into the of ce space; – a wheelchair user who goes to school will need the wheelchair to t comfortably in the classroom and under a desk, or will need a tray built on to the wheelchair; – a wheelchair user who needs to travel to the market or to work on a rough track needs a wheelchair, which works well on rough terrain. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 45 46 Lifestyle and environment questions on the intermediate wheelchair assessment form Discussion Distance travelled per day • Just as someone may walk if going a short distance, but use a bicycle for longer distances, a wheelchair user may use a wheelchair for shorter distances and a tricycle for longer distances. • A tricycle takes less energy to cover the same distance and is faster. Hours per day using the wheelchair • The longer the wheelchair user sits in the wheelchair, the greater the risk of fatigue or a pressure sore. Think about how much support the wheelchair user needs and whether the cushion provides enough pressure relief and comfort. • For any wheelchair user who is ‘active’ in their wheelchair during the day, the wheelchair should be set up to make pushing and other activities as ef cient as possible. The position of the wheels is important. It is also important to check that the backrest supports the wheelchair user, but does not restrict freedom of movement of the shoulder blades. When out of the wheelchair, where does the wheelchair user sit or lie down and how (posture and surface)? • If a wheelchair user stays in the same position for long periods of time, he or she can become stiff and eventually stuck in that position. It may become impossible to sit comfortably in the wheelchair. • It is very important to avoid this situation and provide the wheelchair user with various options of comfortable positions to sit or lie in when not in the wheelchair. • Does the wheelchair user always sit or lie in the same position? – if possible, ask him or her to demonstrate the position; – it is important to know what the preferred position is so that a ‘counter’ (opposite) position can be suggested. It may not always be possible to go straight to the ‘counter’ position. If the wheelchair user has used his or her preferred posture for a long time, going for a completely opposite position straight away may be too uncomfortable, strange and potentially frightening; – work out ways in which to support the trunk and limbs to position them in more neutral and comfortable positions. • Is the wheelchair user able to change his or her position? – if the wheelchair user is not able to change position, he or she is more at risk of developing problems with posture or pressure sores. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 45 46 Lifestyle and environment questions on the intermediate wheelchair assessment form Discussion Transfer • Armrests and footrests can affect how a wheelchair user gets in and out of the wheelchair: – for standing transfers, it is helpful to have footrests, which move out of the way and armrests that the wheelchair user can use to push up; – for non-standing transfers, removable armrests or armrests, which follow the pro le of the wheels can make the transfer easier; – when providing additional postural support, check that the wheelchair user can transfer easily. For example, by adding a seat or a cushion with a wedge, it may be more dif cult for the wheelchair user to transfer. A change in technique may be needed, or a different PSD selected. Type of toilet • The type of toilet and physical access to the toilet will affect how easy it is for the wheelchair user to use it. • It may not be possible to use the toilet because of the design. For example, most wheelchair users nd it very dif cult to use squat toilets. • By asking about the toilet and where the toilet is, the wheelchair service personnel can offer advice on how to transfer to and from the toilet. Wheelchair service personnel may also offer advice on how to adapt the toilet. Does the wheelchair user often use public/private transport? • If a wheelchair user frequently uses transport, he/ she will need to be able to transport the wheelchair easily. Different features of a wheelchair, which make transporting the wheelchair easier include the following: – lighter wheelchairs are easier to lift in and out; – removable wheels and folding frame and/or backrest make a wheelchair easier to transport. • If using public transport, removable parts can be an advantage, as this makes the wheelchair easier to load. However, removable parts can also be a disadvantage, as parts may become separated and lost or stolen. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 47 48 Existing wheelchair (if a person already has a wheelchair) Does the wheelchair meet the user’s needs? Yes No Does the wheelchair meet the user’s environmental conditions? Yes No Does the wheelchair provide proper t and postural support? Yes No Is the wheelchair safe and durable? (Consider whether there is a cushion) Yes No Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes No Comments: If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repairs or modi cations. If a wheelchair user already has a wheelchair, it is important to nd out if it is meeting his or her needs. The ‘existing wheelchair’ part of the intermediate wheelchair assessment form helps to guide the wheelchair service personnel and wheelchair user in assessing whether the existing wheelchair is appropriate for the wheelchair user. When looking at the condition of the wheelchair, look at the surfaces as these can give clues to how a wheelchair user is sitting. For example, a dented cushion on one side can mean there is more pressure going through one seat bone; damaged armrest on one side might mean a wheelchair user is leaning heavily on that side. If you notice anything unusual, ask the wheelchair user about it. If the wheelchair is not meeting the wheelchair user’s needs, the wheelchair service personnel should nd out why. Sometimes the wheelchair is appropriate, but it may not have been correctly adjusted for the wheelchair user. Modi cations, additional postural supports or repairs may help. Good communication skills during an assessment interview Using good communication skills is always important to help to gather the right information in a way, which is respectful and sensitive to the feelings and needs of the wheelchair user. Some ways to help make the assessment interview run smoothly are: • always address the wheelchair users unless they are small children or they are unable to understand or answer your questions; • explain to the wheelchair user that the information he/she provides will help choose the most appropriate wheelchair to meet their needs; WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 47 48 • questions do not need to be asked in the order given on the intermediate wheelchair assessment form. Sometimes wheelchair users will volunteer information before asked, or it may be more natural to ask questions in a different order. Sometimes, communicating through speech may be dif cult. For example, the wheelchair user may not be able to hear or may not be able to speak clearly enough for you to understand. When communication is dif cult, try to nd a way to communicate directly with the wheelchair user. Ask the people who know the wheelchair user well, how you can best communicate. Take the time to understand how the wheelchair user communicates. If you cannot nd a way to communicate directly, make sure that you have someone who knows the wheelchair user well close by at all times. Ask this person to help you communicate with the wheelchair user. Recognizing pain when a wheelchair user cannot speak When wheelchair users are unable to speak, it can be dif cult for them to communicate that they are experiencing pain. However, it is important for the wheelchair service personnel to know if anything they are doing is causing or increasing a wheelchair user’s pain. Non-verbal signs of experiencing pain can include: • crying, shouting, dgeting or sweating; • pushing the assessor’s hand away or trying to move away; • resisting a movement or being unable to maintain a speci c posture; • expression on face – frowning and/or grimacing; • the way someone sits, stands or walks. Ensure that you do not cause or increase existing pain by: • encouraging the wheelchair user to let you know if he/she experiences pain during assessment; • if communication is dif cult – agree a signal for pain before starting the assessment; • avoiding positions that make pain worse; • using positions or movements that make pain less. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 49 50 Physical assessment – sitting posture without support Physical assessment is the second part of the assessment. It includes: • identifying the presence, risk of or history of pressure sores; • identifying the method of pushing; • nding out how the wheelchair user sits and what additional postural support he or she may need through: – observing sitting posture without support; – carrying out a pelvis and hip posture screen. Pelvis and hip posture screening helps to understand how any problems around the pelvis or hips may be affecting the wheelchair user’s sitting posture; – carrying out hand simulation. The wheelchair service personnel uses their hands to ‘simulate’ the support that a wheelchair and additional postural supports may provide; • taking measurements. Information from each of these sections of the intermediate wheelchair assessment form will help wheelchair service personnel to decide how much support the wheelchair user needs. Review of presence, risk of or history of pressure sores and method of pushing Presence, risk of or history of pressure sores /// = does not feel O = previous pressure sore = existing pressure sore Can feel normally? Yes No Previous pressure sore? Yes No Current pressure sore? Yes No If yes, is it an open sore (stage 1–4)? Yes No Duration and cause: Is this person at risk* of a pressure sore? Yes No *A person who cannot feel or has 3 or more risk factors is at risk of pressure sores. Risk factors: cannot move, moisture, poor posture, previous/current pressure sore, poor diet, ageing, under or over weight. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 49 50 Method of pushing How will the wheelchair user push his or her wheelchair? Both arms Left arm Right arm Both legs Left leg Right leg Pushed by a helper Comment: Upright sitting posture Common abbreviations in this section Anatomical structure Abbreviation Anterior Superior Iliac Spine ASIS Posterior Superior Iliac Spine PSIS Ischial Tuberosity IT Can every wheelchair user sit in an upright or neutral posture? Not every wheelchair user can sit in an upright posture, even with support. Wheelchair users who have dif culty sitting upright will demonstrate a range of different sitting postures. The different postures are caused by part (or parts) of the body not being positioned in neutral. During the assessment, the wheelchair service personnel and wheelchair user need to nd the most upright sitting posture the wheelchair user can safely and comfortably achieve and maintain without losing function. The wheelchair and PSDs should support this posture. There are three different nal results that can be found when assessing posture. These are: • Fixed posture - the wheelchair user has a part of the body that is ‘ xed’. With gentle force there is no movement (strong force should never be used). Wheelchair service personnel should provide support to accommodate the non- neutral ( xed) posture. • Flexible to neutral posture – with gentle force the parts of the wheelchair user’s body that are not in neutral can be brought to neutral. In this situation the right support should be given to help the wheelchair user maintain a neutral sitting posture. • Flexible part way to neutral posture – with gentle force the parts of the wheelchair user’s body that are not in neutral can be moved only part way toward neutral. In this situation support is given to help the wheelchair user sit as close to neutral posture as is comfortable and functional for them. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 51 52 Upright sitting posture for young children Children under the age of ve do not have the same upright sitting posture as older children and adults. The sitting posture develops over the rst ve years of the child’s life. The most important differences before the age of ve are: • the child’s back is at and there are no lumbar or thoracic curves; • the child’s ear and hips are in line however their shoulders are slightly further forward; • legs are rolled outwards and apart – not parallel. When working with children under the age of ve, wheelchair service personnel need to remember that children under the age of ve should not be given support that encourages an adult upright sitting posture. This would be uncomfortable and could cause harm to the child. Observing sitting posture A starting point for understanding the wheelchair user’s posture and what support may be needed is to observe his/her sitting posture – without support. For this part of the physical assessment the wheelchair user sits on an assessment bed. Make sure the wheelchair user is safe and that his/her feet are supported. Have an assistant or family member/caregiver sit with him/her if he/she cannot independently, sit safely. Observe whether the wheelchair user can sit in a neutral/upright sitting posture without support. The purpose of observing sitting posture without support is to understand the wheelchair user’s postural tendency/habits. Observing sitting posture is a skill, which takes time and practice to develop. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 51 52 How to tell if a wheelchair user is sitting upright The upright sitting posture described here should be used by wheelchair service personnel as a guide. When working with wheelchair users, the aim is to support each wheelchair user as close to this posture as is comfortable, functional and practical for them. Look from the side and check: P Pelvis upright – ASIS and PSIS level; P Trunk upright; P Back following the three natural curves; P Adult – ear, shoulder and hip in line. Child – ear and hip in line with shoulders slightly forward; P Hips bent to around 90 degrees; P Knees and ankles bent to around 90 degrees; P Heels directly below the knees or slightly forward or back; P Feet at on the oor or footrests. Look from the front and check: P Pelvis level – both ASIS are level; P Shoulders level and relaxed, arms are free to move; P Legs slightly open (abducted); P Head upright and balanced over the body. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 53 54 Recording posture On the intermediate wheelchair assessment form there is space to record the wheelchair user’s sitting posture without support. Sitting posture without support Describe or draw a sitting posture without support: The record will help wheelchair service personnel to remember the wheelchair user’s sitting posture after the assessment. It can also help the wheelchair service personnel to track changes in the wheelchair user’s sitting posture over time. There are a few different ways to record sitting posture including: • describing posture in words; • drawing a picture; • taking photographs (only with permission from the wheelchair user). Below are examples of simple line drawings that can be used to record sitting posture. Sitting posture line drawing from the side. Sitting posture line drawing from the front. Remember! • Not everyone can sit upright. • During assessment, the wheelchair service personnel and wheelchair users work together to nd out how close to upright posture the wheelchair user can sit comfortably. • A wheelchair with additional postural support should help to support a wheelchair user to sit as close to upright as is comfortable for them. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 53 54 Physical assessment – pelvis and hip posture screen Pelvis and hip posture screen Sitting posture is in uenced by what is happening around the pelvis and the hips. In this part of the assessment wheelchair service personnel need to nd out: • if the wheelchair user’s pelvis is level when viewed from the front (this may be with or without support); • if the wheelchair user’s hips are able to bend to a neutral sitting posture (trunk to thigh angle is more than 90 degrees). This may be with or without support. If the pelvis is not level or the hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees), the wheelchair service personnel must nd out more information. It is important to know: • can the wheelchair user sit in neutral posture with the support? • if not – how close to the neutral posture can he/she sit? If the wheelchair user cannot sit in a neutral sitting posture, it is also important to know if the dif culty is due to: • a limit (or restriction) above the pelvis (in the lumbar spine); or • a limit within the pelvis (at the hip joint). In order for the wheelchair service personnel to answer all the questions above it is necessary to carry out a ‘pelvis and hip posture screen’ part of the assessment. This is not a full Range of Motion assessment. The purpose of the pelvis and hip screen taught in this training programme is only to identify the factors noted above. Skilled wheelchair service personnel may choose to carry out a full Range of Motion in order to gather more detailed information. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 55 56 Carrying out a pelvis and hip posture screen Prepare: • explain to the wheelchair user what you are going to do and why it is important; • ask the wheelchair user to lie down on their back on an assessment bed. (Note: in these instructions, the person carrying out a pelvis and hip posture screen is called the ‘assessor’ and the person who assists the assessors is called ‘assistant’, who could be a co-worker, trained assistant, family member or caregiver). Pelvis posture screen: • assessor bends both the wheelchair user’s knees slightly and provides some support, which helps to relieve tension on the hips; • assistant places their hands rmly on the wheelchair user’s trunk, around their lower ribs; • assessor grips the pelvis gently with thumbs on the ASIS; • assessor checks if thumbs/ASIS are level; • if not level, assessor gently but rmly tries to align the pelvis so that both ASIS are level; • assistant reports if he/she feels the trunk move, which means that there is some restriction to the movement; • note how close to neutral/level it is possible to bring the pelvis; • assessor records if the pelvis can be level on the intermediate wheelchair assessment form. Hip posture screen: • assistant gently but rmly holds the wheelchair user’s pelvis; • assessor bends the leg that is not being tested slightly at the knee, resting the foot on the mat. This helps to reduce the tension in the hip being tested. This leg may need to be supported. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 55 56 Hip posture screen: • assessor gently moves the leg being tested into the neutral sitting posture; • assistant reports if he/she feels the pelvis move, which means that there is some limit (restriction) to the movement; • assessor feels how freely the hip joint can move; • assessor repeats on the other side and compares; • assessor records if right and left hip can bend to neutral sitting posture on the intermediate wheelchair assessment form. • assessor records how close to neutral posture each hip can reach with a goniometer with the help of an assistant; • assessor places the pivot point of the goniometer on the hip joint. Assessor positions one arm of the goniometer along the thigh bone and one arm in line with the trunk; • assessor holds the two arms together rmly; • assessor records right and left hip angle degree measurements on the intermediate wheelchair assessment form. Assessor can also draw the angle of the goniometer on a separate piece of paper or on the back of the intermediate wheelchair assessment form. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 57 58 Recording the pelvis and hip posture screen Pelvis and hip posture screen Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: Left hip: Yes No Angle: If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Record the results of the pelvis and hip posture screen on the intermediate wheelchair assessment form. Tick whether the pelvis can be level. Then tick whether each hip can bend to neutral siting posture (90 degree angle). If either the right or left (or both) hip cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees), record the angle. As mentioned above, wheelchair service personnel can also draw the angle of the goniometer on a separate piece of paper or on the back of the intermediate wheelchair assessment form. Temporary supports for xed unlevel pelvis and for the hips that cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) If the pelvis cannot be level or the hip cannot bend to a neutral sitting posture (trunk to thigh angle is more than 90 degrees), it will need to be supported in the non-neutral posture in the nal wheelchair. To continue the assessment, a temporary support should be made for the wheelchair user to sit on. During an assessment, the temporary support will: • help the wheelchair user to sit with more stability and balance; • stop the wheelchair user from compensating for the unlevel pelvis or hips that cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees); • allow the wheelchair service personnel to carry on the assessment and concentrate on the rest of the wheelchair user’s posture including pelvis, trunk, head, neck and legs. A temporary support can be made of rm foam. The table below shows the different postural problems, temporary supports and possible permanent support for these problems. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 57 58 Postural problem Temporary support Permanent support (built into the wheelchair user’s cushion) Fixed unlevel pelvis (lateral tilt) Add a build-up under the higher seat bone and thigh Hip cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) Add a build-up under both seat bones and the thigh of the hip that can bend to neutral sitting posture – sharp edges need to be bevelled before the trial Both hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) Add a build-up to increase the angle between the seat and the backrest. One or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees) Provide a wedge-shaped support in front of the seat bones under the thighs WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 59 60 Physical assessment – hand simulation Hand simulation helps to identify what support the wheelchair user needs. During the hand simulation, the wheelchair service personnel use their hands to nd out: • can the wheelchair user sit in neutral posture with support? • if not – how close to the neutral posture can he/she sit? • what support is needed and where. During a hand simulation, the wheelchair service personnel work with the wheelchair user and an assistant or family member/caregiver to provide support with hands. How to carry out a hand simulation Important aspects to remember when carrying out a hand simulation are: Prepare • Explain to the wheelchair user what you are going to do and why. • Ask the wheelchair user to sit on a rm but padded, at surface. An assessment box is ideal, the wheelchair service personnel and assistant or family member/ caregiver can easily reach the wheelchair user to provide support from the front, back and sides. • If the wheelchair user cannot safely sit without support ask an assistant or family member/caregiver to support them. • Ensure the wheelchair user’s feet are supported at the correct height for them. If the pelvis is unlevel or if one of the hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees), provide a temporary support as described in the previous session. Work as a team • It is often necessary to have more than one pair of hands. • Take help from the assistant, who could be a co-worker, trained assistant, family member or caregiver. • Involving family member/caregiver will help him/her to better understand the nal PSD solution. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 59 60 Use good communication • The wheelchair service personnel should communicate gently (preferably in local language) with the user and the family member/caregiver. • If the wheelchair user cannot talk, nd an appropriate method of communication with them and use it. • Remember to explain to the wheelchair user what you are doing at each step. • Ask the wheelchair user for their feedback after each change. Think carefully about what your hands are doing • Your hands are providing the support that will later be provided by the wheelchair and PSDs. During a hand simulation, pay careful attention to: – where your hands are placed; – the direction of force/support; – how much force/support is being used; – how much surface area your hands are covering (for example, are you using just one nger or a whole hand); – if it is cold, warm up your hands before you begin the hand simulation. • This information will help you to prescribe the nal wheelchair and PSDs. Always provide support at the pelvis rst • The posture of the pelvis will affect the rest of the body. • If the wheelchair user’s pelvis is not in neutral, use your hands to encourage the pelvis towards neutral. • When the pelvis has been supported, focus on other parts of the body in this order: – trunk/arms; – head and neck; – hips and thighs; – lower legs. Make one change at a time • Always make only one change at a time. For example – do not try to change the posture of the trunk at the same time as changing the posture of the pelvis. • Observe how changes in one part of the body affect other parts. • Ask for feedback from the wheelchair user. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 61 62 In order to begin hand simulation part of the physical assessment: • kneel or squat in front of the wheelchair user; • gently place hands on both sides of the wheelchair user’s pelvis; • if the wheelchair user’s pelvis is not in neutral – use hands to bring the pelvis as close to neutral as is comfortable; • do not use very strong force; • nd how close to neutral the pelvis can be supported; • observe how moving the pelvis towards neutral affects the wheelchair user’s trunk, hips, head and neck. • when the pelvis is supported as close to neutral as possible, the wheelchair service personnel can then consider what support is needed at the trunk; • ask the assistant to hold the pelvis in the posture that you have identi ed as ‘as close to neutral as possible’ for this wheelchair user; • explain carefully to the assistant where to hold and how to hold the pelvis. Check that he/she is able to do this before moving on. Provide support at the trunk (if needed): As for the pelvis, if the wheelchair user’s trunk is not in neutral sitting posture, use your hands to provide support. Work in this order: • stabilize the pelvis with your hands; • straighten out the trunk so both shoulders are level (or as close to level as is possible) by providing support with your hands at both sides of the trunk; • bring the trunk upright with head and neck balanced over the pelvis by providing support at the back and sometimes at the front with your hands; • observe the contour of the pelvis and trunk from the side. This is important to plan the shape of the backrest to provide the best support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 61 62 Pay close attention to how trunk support affects the rest of the body. For example, does the trunk support help improve head and neck posture? Even with good pelvis and trunk support, some wheelchair users may nd it hard to hold their head upright. Some suggestions to help improve head and neck posture are: • allow the wheelchair user to recline slightly backwards; • observe whether the wheelchair user is then able to better balance their head over their trunk; • provide additional support for the arms. During the hand simulation, ask the assistant supporting the pelvis if he/she feels any changes as you support the trunk. Remember to always ask the wheelchair user for their feedback. Provide support for other body parts (if needed) • Once the pelvis and trunk are supported in the most neutral sitting posture that is comfortable, check the posture of the head and neck, hips, thighs and lower legs. • Use your hands to nd out how close to neutral each body part can comfortably move. Continue to check how any change affects the rest of the body. Continue to ask the wheelchair user for their feedback. Recording the results from a hand simulation Results of the hand simulation are recorded on the intermediate wheelchair assessment form. There is space to: • record with a tick whether the wheelchair user is able to achieve a neutral sitting posture for each body part with hand support; • describe or line draw the nal sitting posture achieved by the wheelchair user with the hand support; and • describe or line draw the support provided for the wheelchair user to achieve that sitting posture. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 63 64 Hand simulation: support needed to sit in neutral posture / as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw nal sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle Physical assessment – taking measurements Measuring a wheelchair user to select the correct wheelchair size and location of PSDs On the measurements part of the intermediate wheelchair assessment form there are twelve body measurements listed. Five measurements are the same measurements that were previously introduced in the Wheelchair Service Training Package – Basic Level. One additional backrest height body measurement is added to the intermediate wheelchair assessment form. Seat to top of shoulder measurement is used to measure a wheelchair user for a high backrest. There are six more measurements, which will help to decide the size and/or location of PSDs. Sometimes it may be necessary to take more measurements, depending on the PSDs prescribed. There is space on the intermediate wheelchair assessment form to record ‘other’ measurements. How body measuremewnts relate to the size and location of the wheelchair and PSDs Each body measurement that is taken relates to the size of the wheelchair or the location and size of PSDs. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 63 64 On the intermediate wheelchair assessment form the body measurements are listed on the left hand side and the components that each body measurement relates to are listed on the right hand side. For example: • a wheelchair user’s hip width (body measurement A) equals the wheelchair seat width or the distance between the pelvis side pads (component measurements 1 or 2); • a wheelchair user’s seat to axilla (armpit) (measurement H) less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges (wheelchair component measurement 8). The examples above demonstrate that the body measurement does not always equal the wheelchair component measurement and some calculations are needed. In some cases there is a formula to help work out the wheelchair component measurement. Adjustments are often needed at the tting. However accurate body measurements can help to prepare the wheelchair well ahead of the rst tting. The illustrations on the intermediate wheelchair assessment form help to guide wheelchair service personnel as they take the body measurements and relate them to the location and size of PSDs. G H B C D E F I K L J WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 65 66 Taking measurements Body measurements (mm) Wheelchair component measurements (mm) Seat width, depth and footrest height A Hip width = seat width OR 1 = distance between pelvis side pads 2 B Seat depth (back of pelvis to back of the knee) L B less 30–50 mm = seat depth (if L, R lengths are different, use shorter) 3 R C Calf length L = distance between top of the seat to footrest OR = distance between top of the seat to oor for foot propelling 4 R 5 Backrest height D Seat* to bottom of rib cage = distance between top of the seat to top of backrest (measure D, E or F – depending on the wheelchair user’s need) 6 E Seat* to bottom of shoulder blade F Seat* to top of shoulder Modi cations and/or PSDs G Trunk width = distance between trunk side pads/wedges 7 H Seat* to axilla (armpit) L H less 30 mm = maximum distance between the top of the seat and the top of trunk side pads/wedges (adjust according to hand simulation) 8 R I Seat* to top of the pelvis (PSIS) = distance between the top of the seat and mid-height of rear pelvis pad 9 J Distance between knees = width of knee separator pad 10 K Seat* to base of skull = distance between the top of seat to middle of headrest 11 L Back of pelvis to seat bones L plus 20–40 mm = distance from the backrest support to the beginning of the pre seat bone shelf. 12 O th er *When taking body measurements, the ‘seat’ is the surface on which the seat bones are sitting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 65 66 How to take accurate measurements Mistakes in measuring can cause big problems. However taking accurate measurements can sometimes be dif cult. This is particularly a problem when a wheelchair user is very small or nds it hard to sit still or has dif culty sitting upright. Some ways to help take accurate measurements include: • always use a rm tape measure – not a ‘dress makers’ tape measure; the rm tape measure will not bend as much, resulting in an inaccurate measurement; • use of calipers can help to increase the accuracy of measurements; • take measurements of the wheelchair user sitting upright, in the posture that has been identi ed as the most upright, comfortable and functional for them during the hand simulation. If a wheelchair user is measured lying down, the measurements will not be accurate because when lying down the wheelchair user may lengthen or stretch out. It is better to get assistance to support the wheelchair user sitting upright than to lie them down. How to measure: Wheelchair component: Comments: A: Hip width Seat (width) Check there is nothing in the wheelchair user’s pockets before measuring. Measure the wheelchair user’s hips or the widest part of his/ her thighs. Hold two clip boards against each side of the wheelchair user to help to get an accurate measurement. Calipers can also be used. Hip width equals the seat width or the distance between pelvis side pads. If pelvis side pads are provided, the wheelchair seat width may need to be wider. Always try to keep the wheelchair width to a minimum. In countries with cold climates where thick clothes may be worn, some allowance may be needed. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 67 68 How to measure: Wheelchair component: Comments: B: Seat depth Seat (depth) Place a clip board at the back of the wheelchair user to help get an accurate measurement. Measure from the back of the wheelchair user’s pelvis to the back of his/her knee in a straight line. Always measure both legs. If there is a difference between the left and right side, check that the wheelchair user is sitting upright with their pelvis level. If there is still a difference, make the wheelchair prescription for the shorter side. Seat depth less 30–50 mm equals the depth of the seat of the wheelchair. For a wheelchair user whose knees are bent a lot less than 90 degrees, the seat depth may need to be slightly shorter. See the box `For wheelchair users with a xed posterior tilt of the pelvis or xed forward bent trunk .` For wheelchair users with a xed posterior tilt of the pelvis or xed forward bent trunk If a wheelchair user has a xed posterior tilt of the pelvis or xed forward bent trunk, wheelchair service personnel need to think about how this will be accommodated in the wheelchair. This may change the way the seat depth measurement is taken. • If the backrest is reclined (tilted back) to accommodate the pelvis/ trunk, measure from the back of the pelvis to the back of the knee in a straight line as described above. • If the backrest does not recline, supports will be made to accommodate the pelvis/trunk within the seat depth space. Measure from the furthest back point of the body (trunk/pelvis) to ensure that enough seat depth is allowed, as shown in the illustration. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 67 68 How to measure: Wheelchair component: Comments: C: Calf length Footrests (height) Measure from the back of the wheelchair user’s knee to the base of his/her heel. Make sure the wheelchair user’s ankles are bent at 90 degrees (if possible). Always measure both legs. If the wheelchair user wears shoes, measure with the shoes he/she wears most days. If the foot is xed in plantar exion (pointing downwards), measure to the toe. The calf length height equals the top of the cushion to the footrests OR the top of the cushion to the oor if the wheelchair user is foot propelling. The exact footrest location will change slightly depending on how much the cushion compresses when the wheelchair user sits on it. Final adjustment is always needed at tting. D, E and F Backrest (height) D: Seat to bottom of rib cage: Measure from the wheelchair user’s seat to the bottom of the rib cage. To help nd the bottom of the rib cage, place hands on both sides of the pelvis. Gently squeeze hands inwards and slide hands upwards. The bottom of the rib cage is just above the waist. Measurements D, E and F help decide the height of the backrest. The height depends on the needs of the wheelchair user. The information from assessment will guide wheelchair service personnel to decide how high the backrest needs to be to provide the right support for the wheelchair user. If backrest recline or tilt in space is needed, the backrest height must be at least standard (up to the bottom of wheelchair user’s shoulder blades). Remember to consider if the wheelchair users will be propelling the wheelchair themselves, they need freedom to move their shoulder blades. E: Seat to shoulder blade: Measure from the wheelchair user’s seat to the bottom of the shoulder blade in a vertical line. To help nd the bottom of the shoulder blade ask the wheelchair user to shrug their shoulders. F: Seat to top of shoulder: Measure from the wheelchair user’s seat to the top of the shoulder. G: Trunk width Trunk side pads or wedges (distance between) Measure the width of the wheelchair user’s trunk just below the axilla (armpits). Trunk width is the distance between trunk side pads or wedges. The nal position of the trunk side pads or wedges may change during tting, if they are to be placed lower than just below the axilla. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 69 70 How to measure: Wheelchair component: Comments: H: Seat to axilla (armpit) Trunk side pads or wedges (height) Measure from the seat to the axilla (armpit). The seat to axilla measurement less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges. This measurement is a guide. The nal height depends on the assessment and tting. Trunk side pads should never be high enough to put pressure into the axilla (armpit). This can be uncomfortable and cause permanent nerve damage. There should always be at least 30 mm clearance between the top of a trunk side pad and the axilla. See the box `Measuring side trunk supports for a wheelchair user with scoliosis` . Measuring side trunk supports for a wheelchair user with scoliosis (sideways curved trunk) For a wheelchair user with a sideways curved trunk (scoliosis) one trunk side pad may be lower than the other to provide support where needed. As shown in the illustration, the trunk side pad on one side will be positioned at the ‘apex’ of the curve. The trunk side pad on the other side will be positioned just below the axilla. Remember – when providing trunk side pads for a wheelchair user with a scoliosis, also provide pelvis side pads on both sides. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 69 70 How to measure: Wheelchair component: Comments: I: Seat to the top of the pelvis (PSIS) Rear pelvis pad (mid-height) Measure from the seat to the top of the pelvis (PSIS). The seat to the top of the pelvis (PSIS) measurement is used to locate the mid- height of the rear pelvis pad. The depth (thickness) of a rear pelvis pad depends on the results of assessment. J: Distance between knees Knee separator pad Measure the distance between the two knees – with the knees placed as close to neutral as is comfortable for the wheelchair user. The distance between the two knees equals the width of a knee separator pad. The distance will depend on the wheelchair user’s sitting posture. K: Seat to base of skull Headrest (height) Measure from the seat to base of skull. The measurement from the seat to the base of the skull helps to locate the headrest. I: Back of pelvis to seat bones Pre seat bone shelf Measure from the back of the pelvis to the seat bones. From the side of the wheelchair user place your hand (palms up) under the wheelchair user’s bottom to nd the seat bones. Locate the seat bones with one nger – and then withdraw your hand to the side of the wheelchair user. Measure from the back of the wheelchair user’s pelvis to the nger that is located at the seat bones. Wheelchair service personnel may mark on the assessment bed in some way (for example with a piece of chalk) alongside the wheelchair user in line with their seat bones and measure from the mark to the back of the pelvis. The measurement from the back of pelvis to seat bones plus 20–40 mm is the distance from the backrest support to the beginning of the pre seat bone shelf. If a wheelchair user has a xed posterior tilt of the pelvis or xed forward bent trunk the measurement may be different (see the box `For wheelchair users with a xed posterior tilt of the pelvis or xed forward bent trunk`). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 71 72 Remember: • When taking body measurements, the ‘seat’ is the surface on which the seat bones are sitting. • For all vertical measurements (C,D,E,F,H,I,K); the location of the corresponding component will be affected by any changes to the seat and cushion height. • The exact location of all wheelchair components is always checked at the tting. Step 3: Prescription (selection) Selecting wheelchairs and cushions Prescription (selection) is the third step in wheelchair service delivery. Prescription/selection means nding the best match possible between the wheelchairs available and the needs of the wheelchair user. When prescribing a wheelchair for a wheelchair user who needs additional postural support to sit upright, prescription includes: • selecting the type and size of wheelchair most suitable for the wheelchair user; • describing any speci c set-up for that wheelchair; • selecting the type and size of cushion; • selecting what PSDs or modi cations are needed to provide the wheelchair user with additional postural support he/she needs. The prescription is always decided in full partnership with the wheelchair user. On the intermediate wheelchair prescription form used in this training programme, three signatures are needed, which include the wheelchair user, assessor (wheelchair service personnel) and wheelchair service manager. Type of wheelchair and cushion Type of wheelchair To prescribe a wheelchair, wheelchair service personnel need to know these things about the wheelchair: • the type of frame; • the size available and size range; • features available; • adjustments possible and adjustment range. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 71 72 This knowledge will help the wheelchair service personnel to select the most appropriate wheelchair for the wheelchair user and describe how it should be set up. The relevant part of the intermediate wheelchair prescription form is shown below. 2. Wheelchair type, size and set-up Type of wheelchair (list available wheelchairs below) Wheelchair dimensions (mm) Seat width Seat depth Backrest height Footrest height Wheelchair set-up Rear wheel position Other: Tilt The type of frame Wheelchair service personnel need to know the different types of frames that are available locally. For example is the wheelchair a three-wheel or four-wheel wheelchair; a cross-folding or rigid frame; tilting frame; long or short wheelbase. For more information about different types of wheelchair frames, refer to the Wheelchair Service Training Package – Basic Level. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 73 74 Size available and size range Wheelchair size is usually described by the wheelchair seat width and seat depth. The wheelchair seat width is measured from the outside of one seat rail to the outside of the opposite seat rail or between armrests if these sit on top of the seat rail. The wheelchair seat depth is measured from the front of the seat to the backrest. Other important wheelchair dimensions include: • the height of the seat to the oor (this can be important for wheelchair users who propel with their feet); • the height of the backrest. Features available Possible features include the type of seat, backrest, footrests, armrests, castor wheel, rear wheel and PSDs (for example side trunk pads, headrest, straps). Adjustments possible and range of adjustment Wheelchair service personnel should be familiar with the different adjustment range of the locally available wheelchairs. This includes the highest and lowest setting for the footrests, whether the backrest height is adjustable, and whether there are adjustments possible in the rear axle position. To nd the ‘adjustment range’ of any adjustable components it may be necessary to measure the lowest and highest adjustment. Some manual wheelchairs have more features or adjustments than others. Some features or adjustments can be very helpful for wheelchair users who need additional postural support. These features include: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 73 74 Adjustable footrests: Most wheelchairs have footrests that can be adjusted up and down. Some wheelchairs have additional adjustments including: • footrests can move forwards or backwards; • footrest angle can be increased or decreased. These adjustments give more exibility for where the wheelchair user’s feet will be placed. Elevating leg rests: Elevating leg rests can help hold the foot up with the knee extended. This can be helpful for wheelchair users who cannot bend their knee to neutral for sitting. Backrest recline: Backrest recline (tilting the backrest rearwards) can help accommodate: • hips that cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees); • xed posterior pelvis tilt; • xed bent posture of the lower trunk. Tilt in space: Some wheelchairs have what is called ‘tilt in space’. This means that the backrest and the seat tilt back together. The open seat to backrest angle stays the same. Tilted seat position can help: • xed posterior pelvis tilt with hip and knee exion contractures; • low sitting tolerance or discomfort during normal sitting position; • to increase comfort and rest. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 75 76 Rigid seat: Some wheelchairs have a rigid seat base instead of a slung seat. This can provide: • a good base to build additional postural support for the pelvis and hips; • more stability than a slung seat. This can be useful if a wheelchair user has strong uncontrolled movements or is very heavy. Rigid backrest: Some wheelchairs have a rigid backrest. As for a rigid seat, this can provide a good base to build on additional postural support. A rigid backrest can also provide: • more stability than a slung/canvas backrest. This can be useful if a wheelchair user has strong uncontrolled movements; • more support for wheelchair users who are taller and heavier and/or have very oppy trunks. The illustration shows a rigid backrest that has had foam added to provide support for the trunk in just the right place, and side support pads bolted onto the backrest. Some wheelchairs come with a tension adjustable backrest instead of a simple slung backrest. A tension adjustable backrest allows easy adjustment of the support provided by a backrest. The individual straps are pulled tighter or made looser to give more or less support. It is not necessary to have all of these features to provide additional postural support. Many of the features above can be made as modi cations to a basic manual wheelchair. Gathering information about locally available wheelchairs The intermediate wheelchair summary form on the following page can be used to gather and record information about locally available wheelchairs. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 75 76 What to consider before modifying a wheelchair When selecting a wheelchair that will need to be modi ed to provide the support needed by a wheelchair user, wheelchair service personnel should consider: • Is the wheelchair in good working order? • Are the locally available materials and the way that things are made locally, compatible with the wheelchair? • If the wheelchair were to be damaged, can parts be locally repaired or replaced? Type of cushion Wheelchair service personnel should know the types of cushions that are available for them to prescribe. Features to consider include: • the material cushions are made from; • whether the cushion provides pressure relief; • how easy it is to modify the cushion; • whether the cushion cover is water resistant. For more information on cushions including pressure relief cushions, refer to the Wheelchair Service Training Package – Basic Level. The type of cushion and size selected is recorded on the intermediate wheelchair prescription form under ‘Cushion type and size’. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 77 78 3. Cushion type and size Type of cushion Size E.g. Pressure relief cushion If a cushion needs modi cation to make the correct PSD – the details of this are described in a later section on the intermediate wheelchair prescription form. Intermediate Wheelchair Summary Form Name of wheelchair: Insert picture here: Manufacturer / supplier: Sizes available: Overall weight: Description: Frame: Fixed / rigid Folding Frame length Backrest: Slung / canvas Solid Tension Adjustable Seat: Slung / canvas Solid Tension Adjustable Cushion: No cushion Flat foam Foam contoured Fluid Other Footrests: Fixed Removable Other: Castor wheels: Pneumatic Diameter: Solid Width: Rear wheels: Pneumatic Diameter: Push rims Solid Width: Adjustable axle Solid inner tube Removable Brakes: Short lever Long lever Other: Armrest: Curved Square Other: Fixed Removable Other: Push handles: Push handles PSDs: Pelvis strap Calf strap Shoulder harness Foot straps Anti-tip bars Trunk side pads Tray Headrest Pelvis side pads Other: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 77 78 Measurements, adjustment options and range of adjustment: Measurements (if the wheelchair is available in different sizes list all sizes) Is this adjustable? Range of adjustment (adjustment range that is possible for this chair)Yes No Seat width Seat depth Seat height Backrest height Backrest recline Footrest height Footrest angle Push handles height Frame length Wheel base length Backrest to seat angle Tilt in space Intermediate Wheelchair Prescription (Selection) Form This form is for recording the choice of wheelchair, cushion and PSDs for a wheelchair user who cannot sit upright comfortably without support. Keep this form in the wheelchair user’s le. 1. Wheelchair user information Wheelchair user’s name: Number: Date of assessment: Date of tting: Assessor’s name: 2. Wheelchair type, size and set-up Type of wheelchair (list available wheelchairs below) Wheelchair dimensions (mm) Seat width Seat depth Backrest height Footrest height Wheelchair set-up Rear wheel position Other: Tilt 3. Cushion type and size Type of cushion Size E.g. pressure relief cushion WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 79 80 4. PSDs or modi cations required PSD checklist Describe/draw and provide dimensions S ea t / c us hi o n Add solid seat Pre-seat bone shelf (= 3 less 12) Lower seat front L R Raised seat front Wedge for anterior tilt Build-up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other PSD checklist Describe/draw and provide dimensions S ea t an d ba ck re st Open seat to backrest angle Seat and backrest tilt (tilt in space) B ac kr es t Add solid backrest Rear pelvis pad (= 9) Adjust backrest shape Tension adjustable backrest Backrest recline Trunk side pads (= 7) L R Trunk side wedges (= 7) L R Other T ra y / ar m re st s Tray Modify armrests L R Other WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 79 80 H ea d su pp o rt s Flat headrest (= 11) Shaped headrest (= 11) Other L ow er le g su pp o rt s Footrest build-ups L R Footrest wedges L R Lower leg supports L R Other S tr ap s Pelvis strap Calf strap Foot straps L R Shoulder harness Other 5. Agreement signatures Wheelchair user: Assessor: Wheelchair service manager: Prescription (selection) of PSDs – introduction There are many different designs of PSDs and many different ways that a wheelchair can be modi ed to provide a wheelchair user with additional postural support. Several different PSDs are often combined for one wheelchair user to give the overall support he/she needs. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 81 82 What is a PSD? Postural Support Device (PSD) is a physical device that provides additional postural support – an essential element of intermediate level wheelchair service. The Postural Support Device (PSD) Table (afterwards referred to as PSD Table) and Postural Support Device (PSD) Reference Table (afterwards referred to as PSD Reference Table) on the following pages give an overview of the different PSDs introduced throughout this training programme. Some examples of PSDs are shown in the illustration below. Different names for the same thing The same PSDs may have different names, depending on the wheelchair service, location or manufacturer. In this Reference Manual simple descriptive names have been given to each PSD. In each wheelchair service, wheelchair service personnel and wheelchair users can use the terms most familiar and comfortable to them. Pelvis strap Knee separator pad Foot strap Pelvis side pad Trunk side pad High backrest Shoulder harness Headrest WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 81 82 Postural Support Device (PSD) table Seat/cushion pre seat bone shelf lower seat front (one side) raised seat front wedge for anterior tilt build-up under pelvis pelvis side pads Seat/cushion Seat & backrest outside thigh wedges outside thigh pads inside thigh wedge knee separator pad open seat to backrest angle seat & backrest tilt (tilt in space) Backrest rear pelvis pad adjust backrest shape tension adjustable backrest backrest recline trunk side pads trunk side wedges Tray Head supports Lower leg supports tray at headrest shaped headrest footrest build-ups footrest wedges lower leg supports Straps pelvis strap anterior tilt four-point strap calf strap foot straps shoulder harness WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 83 84 Postural Support Devices (PSD) Reference Table PSD Purpose Fit Seat/cushion Pre seat bone shelf A pre seat bone shelf helps to: • keep the pelvis upright; • stop the pelvis from sliding forward; • reduce a tendency to sit with a slumped posture. The beginning of the pre seat bone shelf should sit just in front of the seat bones. Lower seat front (one side) Lowering the seat front on one side as shown can accommodate one hip, which does not bend to neutral posture for sitting (trunk to thigh angle is more than 90 degrees). The amount that the seat is lowered will depend on the angle of the wheelchair user’s hip. There should be even contact under the wheelchair user’s seat bones and both thighs. Raised seat front Raising the seat front can accommodate both hips that cannot to open to neutral sitting posture (trunk to thigh angle less than 90 degrees). Raising the seat front can also help to reduce strong uncontrolled movements or high tone, which causes the body to straighten. The amount that the seat is raised at the front will depend on the wheelchair user’s trunk to thigh angle. There should be even contact under the wheelchair user’s seat bones and both thighs. Wedge for anterior tilt A backwards sloping wedge placed under the seat bones can be helpful for a wheelchair user with a exible anterior tilt pelvis. The wedge encourages the pelvis to roll backwards. The wedge for anterior tilt should stop just in front of the seat bones and level out under the thighs. When providing a wedge for anterior pelvis tilt, ‘mock- up’ the wedge rst during assessment. This will allow the wheelchair user to feel the effect of the wedge, and for the wheelchair service personnel and the wheelchair user to nd the best angle and assess how effective the wedge is. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 83 84 PSD Purpose Fit Build-up under pelvis A build-up can be used to accommodate a wheelchair user who has a xed unlevel pelvis. The build-up helps to: • increase stability for the wheelchair user; • avoid unsafe pressure on the low side of the pelvis. The build-up is under the high seat bone and thigh. There should be even contact under both seat bones and thighs. When prescribing a build- up under the pelvis it may be necessary to adjust the footrests (one may need to be higher than the other). Pelvis side pads will also help to support the pelvis and should be added for anyone with a build-up under the pelvis. Pelvis side pads Pelvis side pads help to: • stop the pelvis from moving sideways where the chair is too wide, or where the hips are narrower than the trunk; • reduce a tendency for the pelvis to tilt sideways. Pelvis side pads should provide rm contact on both sides of the pelvis. Remember that young children should sit with their thighs more apart than adults. For this reason, make sure that pelvis side pads do not come too far forward and push a child’s thighs together. Outside thigh wedges Outside thigh wedges can provide gentle support to: • help maintain neutral alignment of the thigh; • reduce a tendency for a wheelchair user’s legs to draw in or roll outwards. Outside thigh wedges should comfortably support the thighs in neutral alignment when the wheelchair user is stationary and moving. If there continues to be a tendency for the thighs to fall or roll outwards, rmer support may be necessary (see outside thigh pads). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 85 86 PSD Purpose Fit Outside thigh pads Outside thigh pads can provide rm support to help prevent a wheelchair user’s legs from falling or rolling outwards. Outside thigh pads should comfortably support the thighs in neutral alignment when the wheelchair user is stationary and moving. There should be even contact between the pad and the wheelchair user’s leg. Inside thigh wedge An inside thigh wedge provides gentle support to help: • maintain neutral alignment of the thigh; • reduce a tendency for legs to draw together/pull inwards. An inside thigh wedge should comfortably support the thighs in neutral alignment when the wheelchair user is stationary and moving. Check that the thigh wedge does not make it more dif cult for the wheelchair user to transfer in and out of the wheelchair. Knee separator pad A knee separator pad provides rm support to help maintain neutral alignment of the thigh. A knee separator pad can be very useful for people who have a strong tendency to draw both legs in together. A knee separator pad should comfortably support the thighs in neutral alignment when the wheelchair user is stationary and moving. There should be even contact on the wheelchair user’s knee and thighs. A knee separator pad should not contact the groin area at all. Provide a pre seat bone shelf and pelvis strap if there is a risk that the wheelchair user will slide forward into the knee separator pad. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 85 86 PSD Purpose Fit Seat & backrest Open seat to backrest angle Opening (increasing) the seat to backrest angle can be helpful for wheelchair users with a xed posterior pelvis tilt or xed hips. The increased angle accommodates the xed posture and provides rm support to increase comfort and help prevent further postural changes. There should be even contact under the wheelchair user’s seat bones, at the back of their pelvis, lower and upper back. This may require some contouring of the foam, to provide the right support and contact. When opening the seat to backrest angle, care must be taken to ensure that the wheelchair user does not slide forward in the wheelchair. This can cause ‘shearing’, which can develop into a pressure sore. Seat & backrest tilt (tilt in space) Seat and backrest tilt together can help to: • align the upper trunk and head in an upright posture after a xed bent trunk posture has been accommodated if there is still some strain on the head; • align the upper trunk and head in an upright posture for wheelchair users who have very oppy trunks. Tilting the seat and backrest together should only be tried if all other supports for the pelvis and trunk have not worked. Observe closely the effect of tilting, to determine the best angle and how effective it is. In the nal tilt position, the wheelchair user should feel comfortable and their sitting posture should be as close to neutral as possible for them. Backrest Rear pelvis pad Provides support at the top of the pelvis to keep it upright. A rear pelvis pad is usually provided in combination with a pre seat bone shelf, and may also be provided with a pelvis strap. The rear pelvis pad should provide rm contact on the back of the pelvis, at the level of the PSIS, and encourage the pelvis into a neutral, upright sitting posture. Check that there is no strong pressure on the vertebra between the two PSIS. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 87 88 PSD Purpose Fit Adjust backrest shape Adjust the backrest shape to better support the neutral sitting posture of the trunk (normal curves) or accommodate xed non-neutral postures of the trunk. There are different ways to adjust the backrest shape including: • modifying the backrest fabric and adding a rear pelvis pad ( rst illustration); • providing a shaped foam backrest onto a solid backrest; • using a tension adjustable backrest (second illustration). When adjusted, the backrest should provide even contact for the lower, middle and upper back. If a neutral posture is possible, the backrest should support the pelvis in an upright posture, and support the normal curves of the trunk. If a fully neutral posture is not possible, the backrest should support the wheelchair user as close to neutral as possible. Tension adjustable backrest Backrest recline Backrest recline can help to accommodate: • hips that cannot bend to neutral sitting position (trunk to thigh angle is more than 90 degrees); • xed posterior pelvis tilt; • xed exed posture of the lower trunk; • accommodates a xed forward curving trunk; • align the trunk and head. A pre seat bone shelf, a pelvis strap and/or a wedge at the front of the cushion will help to prevent sliding forward. Check that the backrest recline is supporting the wheelchair user in the best alignment possible for them. Ensure there is even contact between the wheelchair user’s back and backrest. Check that the wheelchair user does not slide forward. A pre seat bone shelf, a pelvis strap and/or a wedge at the front of the cushion will help to prevent sliding forward. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 87 88 PSD Purpose Fit Trunk side pads Trunk side pads provide rm support to help keep the trunk in the centre of the back support. If one trunk side pad is provided, another is always provided on the opposite side. Trunk side pads should always be at least 50 mm lower than the wheelchair user’s axilla (armpits) and come only as far forward as needed. There should be even pressure between the wheelchair user and the pad and no points of high pressure. If the support needs to be rm – increase the size of the pad to distribute pressure, and ensure there is enough padding. Trunk side pads should be as thin as possible, to allow the wheelchair user’s arms to swing freely. Trunk side wedges Provide gentle support to help maintain the wheelchair user’s trunk in the centre of the backrest. These are useful when only a small amount of support is needed. Trunk side wedges should help to maintain the wheelchair user in a symmetrical sitting posture (trunk in the centre of the backrest). The wedges should sit below the axilla (armpits), and come only as far forward as needed. Trunk side pads used with pelvis side pads A combination of trunk side pads and pelvis side pads can be used to provide support for a wheelchair user who has a sideways curved trunk (scoliosis). The pads are adjusted to provide support at the top of the curve, at the apex of the curve (opposite side) and at the bottom of the curve. A pelvis side pad is needed on both sides to keep the pelvis in the centre of the seat. Providing support in neutral for someone with a exible scoliosis may also correct a exible, unlevel pelvis. If the sitting posture is exible, the wheelchair user may be able to sit in neutral sitting posture. If the sitting posture is xed, support as close to neutral as is comfortable. Ensure there is even pressure between the wheelchair user and each pad. Check for high pressure points. If rm support is needed – increase the size of the pad to distribute the pressure and ensure there is enough padding. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 89 90 PSD Purpose Fit Moulded back supports A moulded back support can be used to provide support or accommodation for different trunk postures including falling forward and curved trunk. The back support is xed to the wheelchair frame with brackets or straps. This option is not covered in the intermediate level. Tray Tray Trays can be useful in a number of ways including: • providing support for arms, which can help to reduce the tendency of the weight of a wheelchair user’s arms pulling their trunk down and forward; • providing the wheelchair user with a surface close to his/her body to work/play on. Trays are usually positioned just above elbow height. A slightly higher position may be used if the purpose of the tray is to provide additional postural support. Trays should not be used to ‘restrain’ a wheelchair user in their seat. Tray should not add cause any pressure on the user. Headrest Flat headrest A at headrest provides a resting place for the head and stops the head from falling backwards. A headrest should provide good support while the wheelchair user is static and/ or moving. The headrest should contact with the wheelchair user’s head at the base of the skull. Check that the headrest is providing support in the correct alignment – and is not pushing the wheelchair user’s head forwards, or allowing their head to fall backwards. Avoid providing support on the front of a wheelchair user’s head. Shaped headrest A shaped headrest provides more support than a at headrest by contouring around the base of the wheelchair user’s skull. Lower leg supports Footrest build-ups A footrest build-up can be used when one or both feet cannot reach the footrest (and the footrest has been adjusted as high as it will go). Check that there is even contact under both feet. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 89 90 PSD Purpose Fit Footrest wedges A footrest wedge can be used to support xed non-neutral postures of the feet. A footrest wedge can help prevent further changes in the ankle. The aim of footrest wedges is to increase the contact area of the footrest with the wheelchair user’s foot. Most footrest wedges are made individually, depending on the support needed by the wheelchair user’s foot. Check that there is even contact under both feet. Lower leg supports Different lower leg supports can be used to support xed non- neutral postures of the lower legs including knees that cannot bend to 90 degrees (trunk to thigh angle is more than 90 degrees). Different solutions and their t are discussed further in the product (wheelchair) preparation session Straps Pelvis strap The pelvis strap helps to hold the pelvis in place. It is particularly useful for people who have uncontrolled movements and/or a tendency to slide forward. A pelvis strap is often used in combination with a pre seat bone shelf and rear pelvis pad. The pelvis strap should provide rm even contact. There should be no high pressure points. Padding on the strap where it contacts the wheelchair user’s thighs is important. Where the strap is attached to the wheelchair will affect the angle/direction of pull. 45º 90º The angle may be between 45 and 90 degrees. The most effective angle will vary depending on the needs of the wheelchair user. Always assess, discuss and if possible trial the angle of the pelvis strap with the wheelchair user to see which angle is most effective and most comfortable for the wheelchair user. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 91 92 PSD Purpose Fit Anterior tilt four- point strap An anterior tilt four-point strap provides support for a wheelchair user with anterior pelvis tilt. The strap can help to bring the pelvis into a more neutral sitting posture, or provide support to prevent further anterior pelvis tilt. This strap can be provided in combination with an anterior tilt wedge under the wheelchair user’s seat bones. Note that this strap is anchored downwards onto the seat rails; and backwards, onto the backrest uprights. The strap should not be able to slide up onto the stomach. It is important that any strap, which provides support over the two ASIS is well padded, to reduce the risk of pressure sores. Calf strap A calf strap can help to prevent the lower leg from falling backwards. These straps are sometimes provided as standard with a wheelchair. Different types of foot straps provide support to help stabilize the wheelchair user’s feet and help to keep the feet from moving forward/backward. Foot straps – behind the heel A strap behind the heel helps to prevent the foot from sliding backwards. This can be combined with a calf strap to give more support. Foot straps should provide even pressure, and be well padded – particularly if the wheelchair user is not wearing shoes. Foot straps – around the ankle A foot strap around the ankle helps to keep the foot from moving forward and the heel from lifting. Foot straps – over the front of the foot A foot strap over the front of the foot helps to keep the toes from lifting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 91 92 PSD Purpose Fit Shoulder harness A shoulder harness can help to maintain an upright trunk when pelvis support, trunk support and tilting the seat and back have not worked. The shoulder harness shown in this illustration has a chest strap, which provides additional support. The chest strap also helps to keep the shoulder straps in the right position. A shoulder harness should always be used in combination with a pelvis strap. Never prescribe a shoulder harness without a pelvis strap. If used without a pelvis strap, the user can still slide down and the strap can cause strangulation. Check that there is enough padding where the strap crosses the wheelchair user’s shoulder. A chest strap (as shown in the illustration) can help to keep the shoulder strap in place. The shoulder strap should fasten at the same height or higher than the user’s shoulders. This avoids the strap applying a downward force on the wheelchair user’s shoulders when fastened. Recording PSDs on the intermediate wheelchair prescription (selection) form The purpose of the intermediate wheelchair prescription form is to give clear information to the wheelchair service personnel preparing the wheelchair about: • the wheelchair type, size and set-up (covered earlier); • the cushion type and size (also covered earlier); • PSDs or modi cations required. The more detailed information that is provided on the intermediate wheelchair prescription form, the more accurately the wheelchair will be prepared for the rst tting. As there can be a lot of variation in the PSDs that are prescribed, ‘PSDs or modi cations required’ is the most complex part of the intermediate wheelchair prescription form. Wheelchair service personnel can use the ‘PSDs or modi cations required’ part of the intermediate wheelchair prescription form to: • select which PSDs they wish to prescribe/select (using the check boxes) from the list of common PSDs. There is also space to list other types of PSDs under ‘other’; WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 93 94 • draw over the shadow drawings to show the shape and provide dimensions for the PSDs they have prescribed (selected); • write or sketch any additional information. Note: The intermediate wheelchair prescription form does not necessarily say how the PSD should be made. This may be decided in discussion between the wheelchair service personnel preparing the wheelchair and the wheelchair service personnel who have carried out the assessment. Below are two examples of completed ‘PSDs or modi cations required’ part of the intermediate wheelchair prescription form (dimensions not included). PSD checklist Describe/draw and provide dimensions S ea t/ cu sh io n Add solid seat Pre seat bone shelf (=3 less 12) P Lower seat front L R P Raised seat front Wedge for anterior tilt Build-up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other S ea t an d ba ck re st Open seat to backrest angle Seat and backrest tilt (tilt in space) P B ac kr es t Add solid backrest Rear pelvis pad (= 9) Adjust backrest shape Tension adjustable backrest Backrest recline Trunk side pads (= 7) L P R Trunk side wedges(= 7) L R P Other WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 93 94 PSD checklist Describe/draw and provide dimensions T ra y/ ar m re st s Tray Modify armrests L R Other H ea d su pp o rt s Flat headrest (= 11) Shaped headrest (= 11) Other L ow er le g su pp o rt s Footrest build-ups L R Footrest wedges L P R Lower leg supports L R Other S tr ap s Pelvis strap P Calf strap Foot straps L R Shoulder harness Other Prescription (selection) of PSDs – stabilizing the pelvis A number of PSDs are used to provide support to the pelvis. It is important to remember that although PSDs can be used in isolation, many of the PSDs work together. This session looks at different postural problems related to the pelvis and possible PSD solutions. Stabilizing the pelvis rst is the most important thing to do to help a wheelchair user sit upright • When the pelvis is not in an upright posture, there are also changes to the posture of the trunk and hips. • For this reason, supporting or stabilizing the pelvis is the most important thing to do to help a wheelchair user sit upright. • Support provided at the pelvis can reduce the need for support elsewhere. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in posterior tilt and/or slides forward Support needed To bring the pelvis from posterior tilt to more neutral sitting posture, support is usually needed in two areas: • at the back of the pelvis at the level PSIS; • at the front of the pelvis at the seat bones (ischial tuberosities). PSD solutions A pre seat bone shelf provides support in front of the seat bones and helps to: • keep the pelvis upright; • stop the pelvis from sliding forward; • reduce a tendency to sit with a slumped posture. The pre seat bone shelf sits just in front of the seat bones. A rear pelvis pad provides support at the top of the pelvis (at the level of PSIS) and helps to keep the pelvis upright. The combination of a pre seat bone shelf and rear pelvis pad is often used to help wheelchair users to sit with a more upright pelvis and with more stability. A pelvis strap can provide additional support for wheelchair users who have uncontrolled movements and/ or a tendency to slide forwards. The pelvis strap helps to keep the pelvis in place, so that the pre seat bone shelf and the rear pelvis pad continue to provide support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in lateral tilt ( xed unlevel pelvis) Support needed Support is needed under the higher seat bone and thigh to: • increase stability for the wheelchair user; • help to avoid unsafe pressure on the lower side of the pelvis. PSD solutions A build-up under the pelvis helps to: • increase stability for the wheelchair user; • avoid unsafe pressure on the low side of the pelvis. Pelvis side pads provide further support for the pelvis and should be added for anyone with a build-up under the pelvis. Problem: Pelvis moves to one side This problem is often associated with other postural problems. In the two illustrations you can see: • the same man from earlier – who has lateral pelvis tilt ( xed unlevel pelvis) and his pelvis is more towards the left; • a woman with a sideways curve in her spine; her pelvis is also more towards the left. Support needed Support can be provided at the side of both hips. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 97 98 PSD solution Pelvis side pads. Providing pelvis side pads for children Young children should sit with their thighs more apart than adults. This is important for the health and development of their hip joints. This means it is particularly important for children that pelvis side pads do not push children’s thighs together. Problem: Pelvis is in anterior tilt (pelvis tilts forward) WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 97 98 Support needed Support can be provided in two ways: • support at the front of the pelvis (ASIS) pushing backwards; and • encouraging the pelvis to roll backwards by changing the angle of the seat under the seat bones. PSD solutions A wedge for anterior tilt encourages the pelvis to roll backwards towards the backrest. The wedge for anterior tilt should stop just in front of the seat bones and level out under the thighs. An anterior tilt four-point strap provides support at the top and front of the pelvis, encouraging a more neutral sitting posture. Prescription (selection) of PSDs – supporting the hips It is important to remember that any xed/non-neutral postures of the hips will affect pelvis posture if not accommodated. Supporting the hips Problem: One hip cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) The temporary solution for this problem is to place a build-up (foam) under both seat bones and under the thigh of the hip that can bend to neutral sitting posture. PSD solutions Lower seat front on one side – This support can be built into the cushion to accommodate the hip that does not bend to neutral for sitting (trunk to thigh angle is more than 90 degrees). Note: The nal solution is to make an angled cut-out on the side of the hip that cannot bend to neutral for sitting. The angle of the cut-out in the foam will depend on the angle of the wheelchair user’s hip – so this should be checked at the assessment. Note: There is still a pre seat bone shelf in the cushion. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 99 100 Problem: Both hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) The temporary solution for this problem is to place a build-up (foam) under both seat bones. However, this cannot work as a permanent solution as the wheelchair user would tend to slide forward out of their wheelchair. PSD solutions An open seat to backrest angle will allow for the greater trunk to thigh angle. The angle between the seat and backrest will depend on the wheelchair user’s trunk to thigh angle – and this should be decided during the assessment. A possible permanent solution is to have a pre seat bone shelf and pelvis strap, which would stop the wheelchair user to slide forward out of their wheelchair. Problem: One or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees) The temporary solution for this problem is to place a build-up (wedge of rm foam) under the thigh/s that cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees). PSD solution Raise the seat front – A possible permanent solution is to raise the seat front/place a wedge in front of the seat bones/under the thighs. This reduces the angle between the seat and the backrest. The amount that the seat front is raised will depend on the wheelchair user’s trunk to thigh angle – so this should be decided during the assessment. Note: Both seat bones should still sit on a level surface. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 99 100 Helping to reduce uncontrolled movements, high tone or spasms For some wheelchair users, raising the seat front to reduce the trunk to thigh angle at the hip to less than neutral can help to reduce uncontrolled movements, high tone or spasms. Remember – the beginning of the ‘wedge’ should always be in front of the wheelchair user’s seat bones. Their seat bones should sit on a at surface. Prescription (selection) of PSDs – supporting the trunk It is important always to consider rst how to stabilize the pelvis, and then support the trunk. For many people, postural problems related to the trunk can be resolved or improved with good pelvis support. Supporting the trunk Problem: Slumped posture, trunk forward and pelvis is in posterior tilt Support needed • Support to bring the pelvis as close to neutral sitting posture as possible. • Backrest support, which allows the natural curves of the trunk. • Sometimes support at the front of the trunk is also needed. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 101 102 PSD solutions • Pelvis support is provided by: – pre seat bone shelf; – rear pelvis pad; – pelvis strap (not always necessary); – pelvis side pads (not always necessary). • Backrest support is provided by: – adjusting the backrest shape – to provide room for the trunk and allow the back to follow the natural curves. If the backrest continued straight upwards, it would push the wheelchair user forwards. This modi cation to his backrest shape is part of the PSD solution for him. Additional support can be provided by: • tray – a tray can provide additional support to help a wheelchair user maintain an upright trunk posture. • shoulder harness – for a wheelchair user who tires easily, or falls forward – a shoulder harness can help. • seat and backrest tilt – when other PSDs combined have not helped a wheelchair user to sit more upright, tilting the seat and backrest together may help. Backrests need to follow the natural curves of the spine A straight, upright backrest, that has no contouring to support the natural curves of the spine will usually either: • push the top of the trunk forward; • encourage a wheelchair user to move their pelvis forward, so that he/she can lean back into the backrest. Unfortunately, many standard wheelchairs come with a straight up and down backrest. Some modi cation is usually needed to support the wheelchair user so that he/she can sit in the neutral posture comfortably. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 101 102 Problem: Slumped posture, pelvis is in xed posterior tilt and trunk curved forward Support needed • Support to bring the pelvis as close to neutral sitting posture as possible. • Backrest support to support the trunk as close to neutral sitting posture as possible and provide an improved head alignment (more able to look forward). PSD solutions The solutions will vary depending on how much accommodation is required and the type of wheelchairs available. Some suggestions are listed below. • Pelvis support is provided by: – pre seat bone shelf; – rear pelvis pad AND opening up the seat to backrest angle to accommodate and support the xed pelvis posterior tilt; – pelvis strap (not always necessary). • Backrest support is provided by: – backrest recline – to provide room for the xed curve of the trunk. This may help to create a better alignment for the head and neck. This solution would also accommodate the xed pelvis posterior tilt. (Note: upholstered foam needs to be added to any solid backrest). – adjusting the backrest shape – to provide room for the trunk and allow the back to follow the natural curves. Additional support can also be provided by: – tray; – shoulder harness; – seat and backrest tilt. Think about PSD solutions in this order Pelvis and hips Trunk Head and neck Legs WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 103 104 Problem: Trunk leans or falls to one side Support needed • Stabilize pelvis. • Provide support at the side of the trunk. PSD solutions • Trunk side wedges – provide gentle support to help maintain the wheelchair user’s trunk in the centre of the backrest. • Trunk side pads – trunk side supports provide rm support to help keep the trunk in the centre of the backrest support. If one trunk side pad is provided, another one is always provided on the opposite side – may be at a different level. Problem: Fixed or exible sideways curve of the spine. Support needed • Support on the apex of the curve on one side and the top and bottom of the curve on the other side. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 103 104 PSD solutions • Trunk side pads combined with pelvis side pads. If the posture is exible, with this support the wheelchair user may be able to sit in neutral posture. If the posture is xed, support as close to neutral sitting posture as is comfortable. Providing support in neutral sitting posture for a wheelchair user with a exible scoliosis may also correct a exible unlevel pelvis. Prescription (selection) of PSDs – supporting the head, thighs and lower legs Supporting the head Problem: Head tends to fall backwards, forwards or sideways Support needed • Before providing headrest – always rst: – stabilize the wheelchair user’s pelvis; – provide good trunk support ensuring that the trunk is stabilized and balanced over the pelvis. • If a wheelchair user continues to nd it dif cult to hold their head upright, support should be provided: – rst at the base of the skull; – if necessary support can extend around the side of the wheelchair user’s head. PSD solutions There are many different types of headrests. Two commonly used headrests are at and shaped headrests. • Flat headrest – a at headrest is an extension of the backrest, which is contoured to provide support for the head. A at headrest provides a resting place for the head and stops the head from falling backwards. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 105 106 • Shaped headrest – a shaped headrest is shaped to ‘cup’ the base of the head. It may be extended at the sides and come forward to give more support at the side of the head. A shaped headrest provides more support than a at headrest by contouring around the base of the wheelchair user’s skull. When providing a headrest: When providing support for a wheelchair user`s head, always remember that the posture of the head depends also on good pelvis and trunk posture. Avoid providing support at the front of the wheelchair user`s head. Supporting the thighs Problem: Legs drawn outwards (abducted) Support needed • First ensure that the wheelchair user’s pelvis and trunk are stabilized by providing the support required. This may help to bring the legs into a more neutral sitting posture. • Support on the outside of the thighs. PSD solutions • Outside thigh wedges will provide gentle support. Note: In this illustration outside thigh wedges have been added onto a rm foam layer of a cushion. The rm foam has a pre seat bone shelf built in. A soft layer of foam should be added over the top of the whole cushion. • Outside thigh pads will provide rm support. Note: In this illustration the thigh pad is attached to a wooden seat base with a bracket. Room is allowed for a cushion to be placed on top of the wooden seat. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 105 106 Problem: Legs drawn inwards (adducted) Support needed • First ensure that the wheelchair user’s pelvis and trunk are stabilized by providing the support required. This may help to bring the legs into a more neutral sitting posture. • Support on the inside of the thighs and the inside of the knees. PSD solutions • Inside thigh wedges will provide gentle support. Note: In this illustration a thigh wedge has been added onto a rm foam layer of a cushion. The rm foam has a pre seat bone shelf built in. A soft layer of foam should be added over the top of the whole cushion. • A knee separator pad will provide rm support. Note: In this illustration the knee separator pad is attached to a wooden seat base with a bracket. Room is allowed for a cushion to be placed on top of the wooden seat. Supporting the lower legs and feet Problem: One or both knees bend and are xed less than neutral sitting posture (trunk to thigh angle is more than 90 degrees) The solution will depend on the needs of the individual wheelchair user. PSD solutions: • Adjust the footrests backwards if possible. • Adjust the angle of the footrest to match the foot if possible. If this is not possible, use footrest wedges. • Provide a strap to the front of the lower legs for support and protection. • If the front of the seat is pushing on the back of the wheelchair user’s leg/legs it may be necessary to shorten the seat slightly, and bevel the cushion backwards. • For a tall wheelchair user consider raising the seat front or tilting the seat and backrest. By doing this the wheelchair user’s feet will be higher, more forward and possibly in the adjustment range of the standard footrests. Note: • When making any of the above adjustments – check that the castor wheels can still turn fully without bumping into the footrests or wheelchair user’s feet. • If these adjustments are not possible on the available wheelchairs or do not provide enough adjustment, some modi cation may be necessary. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 107 108 Problem: One or both knees cannot bend to neutral sitting posture PSD solutions: • Provide a standard elevating leg rest if available. • Adjust the footrests forward if possible. • Consider providing a 3-wheeled wheelchair if available. Add footrests to the top of the horizontal centre bar. • Extend the footrests forward by adding wood or metal. • Extend the footrest hanger to be more forward – this may require welding and should only be carried out by someone with excellent technical knowledge and skills with metalwork. Note: Whatever solution is decided – it is important to try to ensure that the overall length of the wheelchair is kept to a minimum. Step 4: Funding and ordering • See Step 4: Funding and ordering in the Wheelchair Service Training Package – Basic Level Reference Manual for general information about funding and ordering. Step 5: Product (wheelchair) preparation Product (wheelchair) preparation Product (wheelchair) preparation is the fth step in wheelchair service delivery. Product (wheelchair) preparation means setting up the wheelchair and preparing any PSDs that have been prescribed (selected). At the intermediate level training programme it is usually only possible to prepare the wheelchair to a certain point before a tting is needed. The wheelchair service steps ‘product (wheelchair) preparation’ and ‘ tting’ may be repeated until the wheelchair ts correctly. Often PSDs are not fully xed in place before the rst tting. This is to ensure that adjustments can be made to the wheelchair and PSDs after the tting. Additional postural support can be provided in different ways. Some solutions are very simple, and can be made in a simple workshop. Other solutions may be more complicated and require more technical skill and facilities. Wheelchair service personnel do not have to fabricate PSDs themselves. Wheelchair service personnel can work in partnership with technicians. The WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 107 108 wheelchair service personnel can explain what they need made and how it should work and the technician can work out how this can be made with locally available materials. The wheelchair service personnel can remain involved and guide the fabrication process to ensure that the nal product meets the wheelchair user’s needs as intended. There are often different PSD solutions that will achieve the same support. The solution used will usually depend on the resources available. This includes: • the types of wheelchairs available – and what adjustments are possible; • the materials that are available; • workshop facilities and tools available; • whether there are pre-fabricated supports available – for example pelvis side pads, trunk side pads, straps and headrests. Planning and carrying out wheelchair and PSD preparation Plan and prepare Before beginning to prepare the wheelchair, it is important to plan the work. Careful planning is particularly important if the work of wheelchair preparation is being handed over to someone else (for example a technician working in a workshop); or if more than one person is preparing the wheelchair. Planning and preparing may include the following steps: Review the intermediate wheelchair prescription (selection) form: • ensure that everyone understands all of the information on the form; • ensure there is enough information on the form to be able to prepare the wheelchair. For example – are all the dimensions that are needed there? Are the descriptions of different PSDs detailed enough? Some further discussion or clari cation may be needed. Decide how to achieve the necessary support in the selected wheelchair: • Look at the wheelchair that is going to be used and ask: – What adjustments can be made to the actual wheelchair to provide the necessary support? – What PSDs are already on the wheelchair? • If modi cations or PSDs need to be added, decide: – Are there pre-fabricated supports that can be used? If so – how will these be tted to the wheelchair? – If modi cations or PSDs need to be made from raw materials – what materials will be used, and how will the PSDs be xed to the wheelchair? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 109 110 • Remember to think about how the PSDs and wheelchair will work together. Prepare a task list: • list the tasks that need to be carried out to prepare the wheelchair; • if more than one person is doing the work – decide who is responsible for which tasks. What to remember when making PSDs When preparing a wheelchair with additional postural support, remember the following four tips: 1. PSDs should provide just enough support The amount of support for each wheelchair user will vary. PSDs should provide the support that is needed by the individual wheelchair user, in the right place, and over the right amount of surface area. 2. PSDs and wheelchairs work together as a whole system Adding additional postural support to a wheelchair can change the overall system. For example, adding PSDs may change the inside dimensions of the wheelchair. 3. Avoid creating high pressure areas PSDs can sometimes cause pressure on a particular part of a wheelchair user’s body. For example, if a wheelchair user needs a lot of support to prevent them from leaning to the side, their trunk side pads could be a place of high pressure. In situations like this, consider spreading the force by increasing the surface area. Always ensure there is enough padding on PSDs and under straps. 4. Ensure PSDs are practical and do not reduce function Remember – wheelchair users need wheelchairs and seating that are practical and easy to use, and that help them to be as active as possible. Workshop safety – ve safety rules: • Wear covered shoes in the workshop. • Secure your work piece when cutting or drilling – use a jig or ask for help. • Use safety glasses when using power tools or any other sharp tool. • Keep the work area and walkways organized and clean. • Never cut toward yourself or others. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 109 110 Materials and tools needed to make PSDs and modi cations The table below gives examples of materials that can be used to make PSDs. Materials PSDs or modi cations that the materials may be used for: What to look for when selecting materials for PSDs or modi cations: Metal/ plastic/ wood Metal/plastic/wood form the structure of a PSD e.g. rigid seats and backrests. Wood or metal can be used to make brackets to hold a trunk side pad onto the backrest. 12 mm plywood is very useful for making rigid seats and backrests. It is strong but relatively light in weight. Marine ply is the most durable; however it can be more expensive. 3 mm aluminium sheet and 6 mm acrylic or ABS plastic sheet if available can also be used to make rigid backrests. Adding a fold in the sheet can add rigidity. When using any sheet material, take additional care to remove or pad the sharp edges for the safety of the wheelchair user. Foam/ padding Foam is used over all PSDs in the areas where PSDs are in direct contact with the wheelchair user’s body. Firm foam, which holds its shape, is used to give PSDs the shape they need to provide the right support. Softer foam is used to add comfort and reduce pressure. Examples of the use of foam: • foam should be added to straps to distribute pressure and add comfort; • a rm foam can be used to make a trunk side wedge, added to a cushion to make an outside thigh wedge or inside thigh wedge; • very rm foam (eg. EVA) can be used to make a footrest build-up or footrest wedge and trunk side pads. Look in the local markets and visit foam, shoe, mattress and furniture factories to nd locally available foam. Try to nd local examples of foam in different thicknesses (25 mm and 50 mm) and different rmness. EVA is an example of very rm foam, which is good for providing rm support and structure for a PSD. EVA can sometimes be found where shoes are manufactured. The rm rubber used to make ip- ops can be used in place of EVA. Good quality chip foam is an example of a medium rm foam. Chip foam can be used as the base of a contoured/layered cushion, to make a rear pelvis pad or pre seat bone shelf, or to provide contours on a rigid backrest. Soft ‘mattress foam’ is an example of soft foam used for comfort layers. The most commonly available, cheapest ‘very soft’ foam is not suitable on its own for making pressure relieving cushions without a rmer foam base. Coir (coconut bre) can be used in place of rm foam. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 111 112 Materials PSDs or modi cations that the materials may be used for: What to look for when selecting materials for PSDs or modi cations: Fabric Fabric is used to cover PSDs. Look for a fabric that will be durable and easy to clean (by wiping down or removing for washing). A water-resistant fabric is useful for the seat, cushion and backrest if the wheelchair user is incontinent. A soft, T-shirt type material (cotton or cotton/Lycra) can be used for headrests and trunk side pads and trunk side wedges. A fabric with some stretch will more easily conform to the shape of PSDs. Synthetic fabrics usually make the person hotter than natural fabrics. Try to have at least a few different colours, and offer wheelchair users a choice if this is possible. Nylon webbing/ Velcro / buckles Nylon webbing/Velcro/ buckles are used to make straps including pelvis strap, shoulder harness, calf and foot straps. 25 mm, 35 mm and 50 mm nylon webbing is useful. The wider the strap, the more even the pressure. Melting the cut end of nylon webbing stops them from fraying. Cotton webbing is much less effective. Clip buckles (such as those used on backpacks) can be very easy to use. Use good quality buckles if available as these will last longer. Test them by clipping them together and trying to pull them apart. They should clip together and undo easily, and not pull apart unless released. Velcro is a good fastener, however it needs to be kept clean or it stops working. Soft foam pads should be placed under all webbing straps to protect the wheelchair user’s body. Adhesives Adhesives are used to bond wood and foam. Have a supply of wood glue (commonly known as white glue or PVA) and foam glue (contact adhesive, shoe glue or yellow glue). Ensure that anyone using adhesives knows how to use them correctly. Fasteners Fasteners are used to attach PSDs to the wheelchair. Useful fasteners include: • bolts with nuts (preferably lock-nuts) and washers; • T-nuts ( xed into plywood instead of a nut); • staples (for xing upholstery). Avoid using sharp screws as they may become a hazard if the PSD is damaged. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 111 112 Workshop facilities and tools: A service that is making PSDs on a regular basis will bene t from setting up a workshop space, which has a workbench and vice, storage areas for materials and tools, good lighting and ventilation. The table below gives examples of tools that will help to make PSDs. Useful tools: Used for: Hand saw Cutting wood, plastic or metal with no electricity. Electric saw Cutting wood, plastic or metal (check that the correct blade is used for the materials being cut) where there is electricity. Drill and drill bits Making holes for bolts. Sharp, rigid blade Cutting foam with no electricity. Band saw Cutting wood, plastic and foam where there is electricity. File Smoothing the edges of wood, metal or plastic. Sanding machine Smoothing the edges of wood, metal or plastic where there is electricity. Spanners Tightening nuts and bolts. Industrial sewing machine Sewing fabric upholstery, covers and straps. How to make PSDs The following gives suggestions for how to make the PSDs covered in this training programme. Many of the principles can be applied to other PSDs. Pre seat bone shelf A pre seat bone shelf is made of a piece of rm foam or similar material with a soft foam over the top. The shelf can be placed under the soft foam of a solid seat or between two layers of a layered foam cushion. A pre seat bone shelf may be part of a pressure relief cushion. A pre seat bone shelf sits just in front of the seat bones. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 113 114 Lower seat front (one side) This PSD can be managed by modifying a foam cushion. Cut away the rm foam (not the soft foam) at the front of the seat to the desired angle. The piece of foam removed will be wedge shaped with the thick end at the front of the seat and the thin end just in front of the pelvis or seat bones. If a solid seat is used, and a large angle is needed, part of the seat board can also be cut away to allow hip to open more. Note: By keeping the other hip bent it is easier for the user to keep from sliding forward in the seat. If a large angle is required it may be necessary to build up the entire seat with rm foam at the bottom before modifying but ensure no sharp edge – all the edges need to be bevelled. Check that a higher seat surface will not cause problems with the footrests or backrest height. Raised seat front The seat front may be raised in different ways. Two suggestions are: Place a rm foam wedge under the front of the cushion, ending just in front of the pelvis. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 113 114 Remove the canvas seat and provide a solid seat. Mount the seat with brackets at the angle that is needed. Always provide a cushion with a solid seat. Wedge for anterior tilt A wedge for anterior tilt can be made using the same principle as a pre seat bone shelf. A base layer of rm foam provides the shape for the cushion, and a soft layer of foam is placed over the top. The wedge should be under the seat bones, and stop just in front of the seat bones. The cushion should be level under the thighs. Build-up under pelvis A build-up under the pelvis is made from rm foam or similar material with a soft layer over the top. Build-up under the high side until the pressure under both seat bones feels the same. Pelvis side pads Pelvis side pads can be made in different ways depending on the wheelchair they will be fastened to and how much support is needed. Some suggestions are: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 115 116 • if there are solid armrests that can be used to provide structure/support for the pad, a pelvis side pad can be made from a rm piece of upholstered foam mounted against the armrest. Where the armrest is open (as in this illustration on the left), a solid pelvis side pad may be made from a piece of wood with softer foam glued onto the inside. This should then be upholstered. Mount the pelvis side pad to either the wheelchair frame or a solid seat (as shown) with a bracket. In the illustration on the left, a cushion would then sit on top of the solid seat, protecting the wheelchair user from the bracket and bolts. Outside thigh wedges Cut blocks of rm foam (100 mm x 100 mm x 40 mm) diagonally in half to create two wedges. Keep a stock of these blocks for use during tting wheelchairs. Glue the wedge onto the base foam of a cushion and under the soft foam. Trim corners as needed. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 115 116 If using a moulded foam cushion, slice the cushion horizontally (approximately 20 mm from the top surface) and glue the wedge in place. Trim off any foam that sticks out. Outside thigh pads These pads are made in a similar way to trunk side pads. Usually they are made of a piece of wood, plastic or metal with rm foam on the inside (the side that contacts the users leg) and a soft foam layer. The pad is covered with a durable, comfortable fabric. The pad can be xed to a solid seat with a metal bracket or bracketed onto the wheelchair seat rail. Inside thigh wedge Cut a wedge (50 mm wide x 100 mm long) in half to create two equal pieces. Keep a stock of foam for use during tting wheelchairs. Glue onto the base foam of a cushion and under the soft foam. If using a moulded foam cushion, slice the cushion horizontally (approximately 20 mm from the top surface) and glue in place. Trim off any foam that sticks out. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 117 118 Knee separator pad Knee separator pads are often made of a piece of metal, plastic or wood with rm foam on the top, sides and back (the surfaces that contact the user). Thin, soft foam can also be used over the rm foam for comfort. The pad may be covered with a durable, comfortable fabric. If a wheelchair user needs a knee separator pad, it is best to provide them with a rigid seat. The knee separator pad can be xed to a solid seat with an L-shaped bracket (as illustrated). A simple and easy way to remove or swing away the knee separator pad is needed, so that the wheelchair user can transfer in and out of the wheelchair. Open seat to backrest angle One way to make a more open seat to backrest angle is to add a rm foam wedge onto a solid backrest at the desired angle. This should be covered with a soft foam layer. Seat and backrest tilt (tilt in space) Some wheelchairs include a feature, which allows you to tilt the seat and backrest easily. The following suggestions are for the majority of wheelchairs in use, which do not have this feature. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 117 118 For wheelchairs without a solid seat and backrest place a rm foam wedge under the front of the cushion and adjust or recline the backrest. Replace a canvas/slung seat and backrest with a solid seat and backrest. Attach the brackets to achieve the desired angle for both the seat and the backrest. Always line a solid backrest with rm foam and then a soft foam layer and upholster. Always provide a cushion with a solid seat. This illustration provides an example of a bracket that can be used to attach a solid seat or backrest to a tube. The bracket can be undone by swivelling the locking piece. This allows the seat and backrest to be removed for transport (if the wheelchair is a cross-folding wheelchair). Rear pelvis pad A rear pelvis pad should not be very deep. Depending on the wheelchair user, the pad may be 20–30 mm deep. The pad should always provide support at the level of the PSIS. For wheelchair users with sensitive skin or a particularly bony spine, the foam can be carved away where it passes across the spine to avoid causing a pressure area. Different ways to make a rear pelvis pad are shown below: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 119 120 A rear pelvis pad can be made from a piece of rm upholstered foam strapped in front of a slung backrest fabric. This can be fastened with straps to the backrest uprights. A piece of rm foam forming the rear pelvis pad may be mounted to a solid backrest with a layer of soft foam over the top. The soft foam layer should be suf cient to ensure that the whole of the backrest is comfortable for the wheelchair user. If not, a rm foam layer should be placed on the solid backrest, then the rear pelvis pad, and soft foam over the top. If mounted to a strong strap, a rear pelvis pad can be mounted to provide support from behind a slung backrest fabric. In this case an additional calf strap can be looped around the backrest uprights at the desired height and tightened as needed using the Velcro. Backrest recline and/or adjust backrest shape There are different postural reasons why it can be helpful to be able to recline a backrest. If a wheelchair does not have this as a ready-made adjustable feature or there is no tension adjustable backrest, the support can be made by modifying the wheelchair. Below are two options: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 119 120 With a wheelchair that has a slung backrest, remove the backrest fabric and x a solid backrest at the desired reclined angle. The solid backrest could be made of plywood (at least 12 mm thick). Adjustable brackets can be used to attach the solid back to the backrest uprights. Modify the existing slung backrest fabric: • Make two vertical cuts through the backrest fabric next to the backrest uprights. • Gradually increase the length of the cuts until the wheelchair user’s trunk can relax over the pelvis and not slump forward. • Support the wheelchair user’s trunk with your hand from behind the fabric until you nd the best position. • Thread a strap (50 mm-wide nylon) between the layers of the backrest fabric and loop the ends around the backrest uprights. Stitch the strap and the backrest fabric at the desired position. • An additional calf strap can often be used, which has Velcro at the ends and is the correct length. With Velcro, the strap tension can be adjusted easily. Alternatively, use eyelets and string. • A piece of soft foam can be used to cover the top and front of the strap inside the backrest fabric. This will reduce the risk of developing pressure sores against the top of the backrest support. Trunk side pads Trunk side pads need to provide rm support, and at the same time should be thin enough to not restrict movement of the wheelchair user’s arms. The main structure of the pad may be made from metal, plastic or wood. However trunk side pads always need to be covered in rm foam with a soft foam layer over the top. The foam should be on the inside of the pad (where it contacts the WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 121 122 wheelchair user’s body) and wrap over the top of the pad. The whole pad is then covered with a durable, comfortable fabric. Trunk side pads may be at, or shaped to match the wheelchair user’s body. If they are shaped, the easiest way to create the shape is to carve the shape into rm foam. A shaped pad will need special sewing skills and a cover fabric, which can stretch. Two different ways to fasten trunk side pads to the wheelchair are shown below: A trunk side pad may be fastened to a rigid backrest, which is then covered in rm foam and a soft foam layer. A trunk side pad may be fastened to the backrest uprights of the wheelchair with a metal bracket. Trunk side pads – need to be thin If a trunk side pad is too thick (over 2.5 cm) the pad will restrict arm movement and can also press on the underside of the arm. This can reduce blood ow, damage nerves and interfere with hand function. Use thinner materials that are strong enough to provide the support needed. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 121 122 Trunk side wedges A trunk side wedge can be made from rm foam and incorporated into a rigid backrest support, under the soft foam layer. An external wedge-shaped pad with a separate cover can also be used on the surface of a backrest. This can be fastened with Velcro or straps. Tray A tray is best made of plywood (10 mm to 18 mm depending on the quality/strength of the plywood) and can be attached to the wheelchair armrests with straps or metal or wooden brackets. When deciding how a tray will be attached to the wheelchair, nd a method that is easy for everyone to use. This is so that anyone can remove the tray quickly in an emergency (for example, if the wheelchair user is choking). Headrest Flat headrest A at headrest can either be included in a tall rigid backrest support or attached to the rigid backrest support with a bracket. The headrest is made from rm foam xed onto a piece of wood/plastic, covered with a soft foam layer. This option does not offer easy adjustment for growth or changes in the wheelchair user’s body. A separate headrest attached with a bracket allows for forward, backward and height adjustment. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 123 124 Shaped headrest A shaped headrest can be made with rm foam xed onto a piece of wood/plastic and covered with soft foam or similar material. The shaped headrest can include a shelf to support the base of the skull and wedges to the sides to help hold the head from falling sideways. A comfortable fabric is used to cover the nished headrest. The cover can be made with T-shirt fabric as it is comfortable and stretches to follow the shape of the headrest. The cover can be made close- tting or slightly loose. A “pull string” can secure the cover. An example of how to make a shaped headrest is shown below: 1. 2. 3. Wooden base with holes drilled to be mounted onto headrest bracket. Firm foam rst layer. Firm foam wedges to provide side support for the head. 4. 5. Foam roll for the base of the headrest, to t under the base of the skull. Soft layer of foam added. Headrest shape complete. To complete: • mount the headrest to the wheelchair; • upholster. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 123 124 Footrest build-ups and footrest wedges One of the best materials to use for foot build-ups is very rm foam (EVA or the sole from ip- ops). Wood may also be used, however ensure that the wood is smooth, without splinters, and there is no pressure risk. Footrest build-ups Cut very rm foam (EVA or ip- op sole), wood or other similar material into block shapes (approximately 100 mm x 200 mm x 20 mm). Keep a stock of these blocks for use during wheelchair tting. Glue the blocks to the footrests as needed. Footrest wedges Cut footrest build-up blocks diagonally in half to create two footrest wedges. Cut some blocks along the long side and some along the short side. Keep a stock of these blocks for use during wheelchair tting. Attach a footrest wedge to the footrest as needed to support the sole of the foot. Lower leg supports A solid seat can be made to extend forward from the front of the seat to support a straight leg. This may make turning in small spaces and collapsing the wheelchair for transport dif cult. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 125 126 Pelvis strap A pelvis strap can be made of nylon webbing such as the webbing found in a car seat belt or straps on a backpack. The width of the strap can be about 25 mm wide for children and about 40–50 mm for adults. Clip buckles are the easiest to do up and undo quickly. If these are unavailable, Velcro also works well. Make sure there is at least 100 mm (depending on the size of the wheelchair user) of overlapping Velcro. A covered padding between the strap and the user (particularly where the buckle is), is more comfortable. Where to fasten the ends of the strap? • For most wheelchair users, the ends of the pelvis strap fasten directly below the front of the pelvis, as illustrated. • Changing the location of the attachment will allow the strap to pull on the body from different angles. Placing the attachment directly below the front of the pelvis (ASIS) will pull at 90 degrees to the seat surface (as shown in the illustration). Placing the strap at the back of the seat will pull at 45 degrees to the seat surface. The angle of pull should be between 45–90 degrees unless the strap is designed to provide support for a wheelchair user with an anterior pelvis tilt. If the wheelchair user tends to push the hips up or forward, an anterior tilt four-point strap provides support for a wheelchair user with anterior pelvis tilt. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 125 126 Pelvis strap warning: If a pelvis strap is too loose, a wheelchair user with limited physical control and/ or awareness can slide down. If not attended, strangulation may result. Always teach caregivers how to do up the strap correctly and warn them of the risks of leaving a person unattended. How is the pelvis strap and anterior tilt four-point strap fastened to the wheelchair? • To fasten the strap to a solid seat: – fasten to a solid seat as shown in the illustration to the left. Fold the end of the strap, melt a hole and use a bolt through the wood along with two washers and a nut (preferably a locking nut); – note the washer placed between the folded end. This helps to slow down wear and tear on the webbing, which can eventually make the strap break. • To fasten the strap to a wheelchair frame: – loop around the wheelchair frame and x with a plastic or metal slide buckle (also known as “tri- glide”, “double D-ring” or 3-bar buckle); – the upholstery screw can also be used if it is in the correct position. Calf strap If the wheelchair does not come with a calf strap, one can be made by sewing Velcro onto a piece of 50 mm nylon webbing. The calf strap should be approximately twice as long as the width of the wheelchair. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 127 128 Foot straps Foot straps can be made from 25 mm nylon webbing and Velcro or buckles. One end can be folded and a hole burned through it for a screw, which can x it to the footrest. A covered pad should be used to keep the foot strap from rubbing against the skin and to distribute pressure. Tips for fabricating and using straps: • Fasten straps with Velcro or a buckle. • Add padding onto the strap where it contacts the wheelchair user – this makes it more comfortable by spreading the pressure. • Straps can be bolted to a solid seat or backrest or looped around the wheelchair frame with a slide buckle (also known as tri-glide, double D-ring or 3-bar buckle). • Calf straps, which often come with a wheelchair, can be used in other ways. For example, a calf strap can be used to modify/adjust backrest fabric. Shoulder harness To make a shoulder harness it is best to use a sewing machine and a person with sewing experience. You will need nylon webbing, buckles, and soft foam for padding. Some tips include: • Provide padding over the shoulder, particularly where it is bony. • Ensure that the xing point for the top of the shoulder harness strap is at the same level or slightly higher than the top of the wheelchair user’s shoulder. If it is lower, the strap will pull the wheelchair user down. • Never x the bottom of a shoulder harness strap to a pelvis strap. This will pull the pelvis strap up. • A chest piece, such as the one in this illustration, helps to keep the shoulder harness straps in place and provides support at the front of the trunk. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 127 128 Shoulder harness warning: A close- tting pelvis strap must be used at all times when a shoulder harness or chest strap are in use. Failure to do this can lead to strangulation. Carrying out the wheelchair safe and ready checklist The nal part of product (wheelchair) preparation is to check that the wheelchair is safe and ready to use and all parts are working properly. The wheelchair safe and ready checklist on the next page helps to make sure nothing is forgotten. Wheelchair service personnel can make a copy of this checklist and pin it up at their wheelchair service centre as a reminder each time they prepare a wheelchair. The wheelchair safe and ready checklist should be completed before the wheelchair user arrives for tting. If there is a problem identi ed during the wheelchair safe and ready check, the wheelchair service personnel may do the following: • repair/ x the problem before the tting; • return the wheelchair to the wheelchair workshop to be xed; • contact the supplier of the wheelchair and ask for help with xing the problem. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 129 130 Intermediate Wheelchair Safe and Ready Checklist Checklist: Is the wheelchair safe and ready to use? Whole wheelchair including PSDs PSDs are tightly xed There are no sharp edges No parts are damaged or scratched The wheelchair travels in a straight line Front castor wheels Spin freely Spin without touching the fork Bolts are tight Front castor barrels Castor fork spins freely Rear wheels Spin freely Axle bolts are tight Tyres in ated correctly (with thumb pressure, wheel can be depressed less than 5 mm) Push rims are secure Brakes Function properly Footrests Footrests are securely attached Frame For a cross-folding wheelchair – the wheelchair folds and unfolds easily For a wheelchair with fold-down backrest – the backrest folds and unfolds easily Cushion The cushion is in the cover correctly The cushion is sitting on the wheelchair correctly The cushion cover fabric is tight but not too tight If the wheelchair has a solid seat: the cushion fully covers the solid seat WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 129 130 Step 6: Fitting Fitting is the sixth of the eight steps of wheelchair service delivery. During tting the wheelchair user and wheelchair service personnel make sure the wheelchair and PSDs t well and support the wheelchair user as close to neutral sitting posture with comfort. How to carry out a tting Use the intermediate wheelchair tting checklist on the following pages to guide you during tting. Check in this order: • is the wheelchair ready? • check wheelchair and PSDs t; • check posture; • check pressure; • check t while the wheelchair is moving; • * decide if any further action is required. Remember: A wheelchair tting for a wheelchair user who needs additional postural support takes longer than for a wheelchair user who does not need additional postural support. This is because there are more adjustments that may need to be made. • Wheelchair users need to know that the tting may take more time. They may need to get in and out of the wheelchair while adjustments are made. • They may also need to come back for a second tting if a lot of changes are needed. Is the wheelchair ready? Always ensure that the wheelchair is ready for the wheelchair user to try. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 131 132 Check wheelchair and PSDs t Wheelchair width Correct t: Should t closely. Make sure that: • hips t comfortably between armrests or pelvis side pads; • thighs t comfortably between the armrests, mud/skirt guards or pelvis side pads and are not pushed together; this may happen if pelvis side pads extend too far forward; • trunk ts comfortably between the backrest uprights and/or trunk side wedges or trunk side pads. Seat depth Correct t: There should be at least a 30 mm gap between the back of the knee and the front of seat/cushion. Make sure that: • the wheelchair user is sitting as close to neutral sitting posture as is comfortable for them; How to check: • slide hand between the back of the knee and the cushion. Check there is at least a 30mm gap. Slide down the back of the calf and make sure the calf is not touching the seat/ cushion. • check both sides. If there is a difference between right and left sides, use the shorter leg measurement to make prescription choices. There may be a bigger gap for wheelchair users with long legs; up to 60 mm is acceptable. Correct t gives the thigh good support. This will reduce pressure under the seat bones and helps to stop pressure sores. If the seat length is too long, the wheelchair user will not be able to sit upright. Pelvis Make sure that: • the pre seat bone shelf sits just in front of the seat bones (place your hand under the wheelchair user’s bottom to check); • rear pelvis pad provides support at the PSIS and does not push on the lower trunk; • pelvis side pads t snugly and are not located over the hip joint; • the pelvis strap can be tightened rmly and does not pinch the wheelchair user’s skin (run hands between the strap and the wheelchair user to check). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 131 132 Trunk Make sure that: • trunk side pads do not place any pressure into the armpits. There should be at least 50 mm between the wheelchair user’s armpit and the top of a trunk side pad. • shoulder harness is done up comfortably and it does not pinch skin. • tray supports the length of the forearm and elbows and does not push on stomach. A modi ed tray cut-out may be close to the body, however it should not touch or rub on the wheelchair user’s skin. • check backrest height and tilt. Headrest Correct t: • The headrest should support the wheelchair user’s head at the base of the skull. Make sure that: • the headrest supports the user’s head in a balanced and upright posture. Thighs Make sure that: • there is no high pressure between the wheelchair user’s thighs and thigh supports (including outside thigh pads, inside thigh wedge or knee separator pad). • knee separator pad is not putting any pressure onto the groin area. The knee separator pad should be 40–60 mm away from the groin area for children and 60–100 mm for adults. Footrest height Correct t: The thigh is fully supported on the seat/cushion with no gaps and the feet are fully supported on the footrests with no gaps. How to check: • slide hand between the thigh and the seat/cushion. There should be even pressure along the thigh and no gaps. • look at the foot on the footrest. The foot should be supported at the front and the back with no gaps. If there are gaps under the thigh, the footrest may be too high. If there are gaps under the foot, the footrest may be too low. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 133 134 Backrest height Correct t: The correct t should give the wheelchair user the support he/ she needs and allow an active wheelchair user the freedom to move his/her shoulder blades to push (if self-propelling). How to check: • ask the wheelchair user if the backrest is comfortable; • observe whether the trunk is balanced over the hips; • is the wheelchair user able to push the wheelchair without the backrest interfering? The height of the backrest depends on the needs of the wheelchair user. Wheelchair users who push themselves need a backrest, which allows their shoulder blades to move freely. Wheelchair users who have dif culty sitting upright may need a higher backrest, which gives more support. A backrest, which provides support on a level with the bottom of the wheelchair user’s rib cage is a good height if the wheelchair user: • is t and active; • can sit upright easily with good balance; • will be propelling actively themselves and needs good freedom of movement. Backrest height D (seat to bottom of rib cage). A backrest, which provides support on a level with the bottom of the wheelchair user’s shoulder blades is a good height if the wheelchair user: • is likely to get tired quickly: e.g. elderly or progressive condition; • has some dif culty sitting upright. This backrest height still allows some freedom of movement around the shoulder blades for the wheelchair user to propel the wheelchair with their arms. Backrest height E (seat to bottom of shoulder blade). A higher backrest, which provides support on a level with the top of shoulder is a good height for wheelchair users who need more support; have a backrest recline; have seat and backrest tilt (tilt in space); become tired/fatigued easily. Backrest height F (seat to top of shoulder). Rear wheels position – for hand propelling Correct t: When hands are placed on the push rim, the wheelchair user’s elbow should be at a right angle. How to check: • ask the wheelchair user to grip the push rims at the top of the wheels. Their elbows should be bent at 90 degrees; • also check with the wheelchair user if the rear wheels are positioned correctly for balance (forward for active, back for safe). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 133 134 If the wheelchair user needs the rear wheels to be positioned in the ‘safe’ (further back) position, this may mean that their arms are further back than is ideal for propelling. Explain this compromise to the wheelchair user. If any adjustments are made to the rear wheels position, the brakes will also need to be adjusted and rechecked. Seat height – for foot propelling Correct t: • With the wheelchair user sitting upright, and the back of their pelvis comfortably supported by the backrest, he/she should be able to rest their feet at on the oor. How to check: • ask the wheelchair user to sit upright or as close to upright as is comfortable in the wheelchair, with the back of their pelvis touching the backrest. Check whether their feet can sit at on the oor. If the seat height is too high, wheelchair service personnel can try: • reducing the height of the cushion; • attaching a solid seat lower than the original seat (get technical advice or support to do this). For a wheelchair user who is propelling with only one foot, with the other foot resting on the footrest – check the pressure under the seat bone of the side that is resting on the footrest. Check posture Observe how the wheelchair user is sitting in the wheelchair from the front and from the side. Is he/she sitting in an upright posture? Look to see whether the wheelchair user is sitting in as upright a posture as is comfortable for them. This should be close to the posture identi ed in the hand simulation. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 135 136 Speci cally, check: • is the pelvis upright and level? (if possible) • is the trunk upright and symmetrical? (if possible) • is the head balanced and upright? (if possible) • are legs and feet supported as close to upright sitting posture as possible? • ask the wheelchair user how he/she feels. After looking at the wheelchair user’s overall sitting posture, check that each PSD is providing support as intended. Speci cally, remember to check (if provided): • backrest height, recline and contours; • tilt in space; • pelvis side pads and trunk side pads; • any thigh and lower leg supports. Check pressure For every wheelchair user who is at risk of developing a pressure sore, the tting step includes checking whether the pressure is safe under the seat bones and any other area at risk (e.g. under hip joint or tail bone). For every wheelchair user who is using PSDs that provide rm support – check the pressure between the wheelchair user’s body part and the PSD. Support should feel rm – but not tight. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 135 136 Check t while the wheelchair is moving The nal part of tting is to check how the wheelchair ts when the wheelchair is moving. If a wheelchair user cannot push the wheelchair themselves, ask a family member/caregiver to push them while you observe. What to look for: • does the backrest allow the wheelchair user freedom to move their shoulder blades to push? • does movement of the wheelchair or the action of pushing cause the wheelchair user to change their posture or feel uncomfortable or unstable in any way? • Hand propelling: Is the rear wheels position correct for the wheelchair user to push as well as he/she can? • Foot propelling: Are the seat height and seat depth correct for the wheelchair user to push with their legs? • Do the posture supports allow for unrestricted and safe wheelchair mobility? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 137 138 Intermediate Wheelchair Fitting Checklist 1. Is the wheelchair ready? Has the wheelchair been checked to make sure it is safe and ready to use and all parts are working? 2. Check wheelchair and PSDs t Wheelchair width: • hips t comfortably between armrests or pelvis side pads; • trunk ts comfortably between the wheelchair frame backrest tubes or trunk side pads; • thighs t comfortably between the armrests, mud/skirt guards or pelvis side pads and are not pushed together. Seat depth: • 30 mm gap between the back of each knee and the seat/ cushion. Pelvis: • pre seat bone shelf sits just in front of the seat bones; • rear pelvis pad provides support at the PSIS; • pelvis side pads t snugly and are not located over the hip joint; • pelvis strap can be tightened rmly and does not pinch skin. Trunk: • trunk side pads do not place any pressure into the armpits. There should be at least 30 mm between armpit and top of trunk side pad; • shoulder harness done up comfortably and does not pinch skin; • tray supports the length of the forearms and elbows and does not push on stomach; • check backrest height and tilt. Headrest: • the headrest should usually support the wheelchair user’s head at the base of the skull; • supports the head in a balanced and upright posture. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 137 138 Thighs: • there is no high pressure on thighs caused by the outside thigh pads or knee separator pad; • knee separator pad is 40–60 mm away from the groin area for children and 60–100 mm for adults. Footrest height: • thighs are fully supported on the cushion with no gaps. Feet are fully supported on the footrests with no gaps; • foot straps can be done up rmly without pinching; • calf strap and behind the heel foot straps are supporting calf and feet. 3. Check posture Check from the front and side to see whether the wheelchair user is sitting as close to neutral sitting posture as is comfortable for them: • Is their pelvis upright and level (or as close to this as is comfortable for the user)? • Is the trunk upright and symmetrical (or as close to this as is comfortable for the user)? • Is the head balanced and upright (as much as possible)? • Are legs and feet supported as close to neutral as possible? Check that all PSDs are providing support as intended. In particular check (if provided): • Backrest height, recline and contours • Tilt in space • Pelvis side pads and trunk side pads • Outside and inside thigh wedges, outside thigh pads and lower leg supports Check posture again after 15 minutes to see if there has been any change 4. Check pressure Check pressure under both seat bones. Is the pressure safe on both sides? Level 1 = safe: Fingertips can wriggle up and down 5 mm or more. Level 2 = warning: Fingertips cannot wriggle, but can easily slide out. Level 3 = unsafe: Fingertips are squeezed rmly. It is dif cult to slide ngers out. Place your nger between the wheelchair user’s body and each postural support including pads and straps. Does the postural support make even contact with the body? Is the pressure safe? If the wheelchair user has any particularly bony prominences, bulges or bumps – check there is no pressure on these areas. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 139 140 5. Check t while the wheelchair is moving Does the backrest allow the wheelchair user to move their shoulder blades to push? Does movement of the wheelchair or the action of pushing cause the wheelchair user to change their posture or feel uncomfortable or unstable in any way? Hand propelling: Is the rear wheel position correct for the wheelchair user to push as well as he/she can? Foot propelling: Is the seat height and depth correct for the user to push with their leg/s? Do the posture supports allow for unrestricted and safe wheelchair mobility? 6. Decide if any further action is required Is there any further action necessary? Write any actions in the wheelchair user’s le. Step 7: User training User training Information and training about their wheelchair can help many wheelchair users really bene t from their wheelchair. Without this step, it is possible that the wheelchair will not help the wheelchair user as much as it could. It is important that family members/caregivers also receive the information and training. What are helpful skills for wheelchair users? Wheelchair service personnel can teach wheelchair users skills to help them to stay healthy, use their wheelchair safely and ef ciently, and care for their wheelchair so that it will last longer. The following are good skills to teach all wheelchair users: Wheelchair handling: • How to fold and lift the wheelchair for transport. • How to take off and put back on any PSDs that need to come off for transport. • How to use features on the wheelchair – for example use of brakes, tilting and anti-tip bar, correct position of PSDs and cushion. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 139 140 How long wheelchair users should sit in their wheelchair For some wheelchair users who have not been sitting very much, it may take time for them to become used to sitting in an upright posture. This can be particularly true for children. Wheelchair service personnel need to advise how long the wheelchair user should sit in their wheelchair. Give these guidelines: • If the wheelchair user is used to sitting up, he/she should spend the same amount of time sitting in their new wheelchair. He/she can gradually increase the time, if needed. • If the wheelchair user has not been sitting up, start with no more than 30 minutes followed by a break. • Teach the wheelchair user or family member/caregiver to always check for pressure areas after the wheelchair user has sat in the wheelchair. Transfers (how to get in and out of the wheelchair): • A safe transfer method, which is: – comfortable for the wheelchair user; and – safe for any person assisting or lifting. • How to sit correctly in the wheelchair (for example making sure that the wheelchair user is positioned well back in the wheelchair with seat bones behind any pre seat bone shelf). • How to adjust PSDs correctly – for example how rmly straps need to be done up to work correctly. • Remember that many wheelchair users will be able to transfer in and out of the wheelchair on their own. Independent and assisted transfers are described in the Wheelchair Service Training Package – Basic Level. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 141 142 Wheelchair use and mobility: • The skills that the wheelchair service personnel teach for wheelchair mobility will depend on the abilities of the wheelchair user and their environment. • Always remember to teach the wheelchair user the best way to propel that suits their abilities. • More information on basic wheelchair mobility skills including pushing correctly, going up and down slopes and steps and partial wheelie is available in the Wheelchair Service Training Package – Basic Level Reference Manual. Preventing pressure sores: • Pressure sores are caused by pressure on bony areas, friction and shear. • For wheelchair users who may have dif culty sitting upright, think about: – ensuring they are not sliding – which can cause pressure sores from shear (bony areas sliding over soft tissue); – ensuring that weight distribution is even under both seat bones. • For wheelchair users who use PSDs, ensure they regularly check their skin wherever the wheelchair or PSDs are in contact. • More details on preventing pressure sores is given in the Wheelchair Service Training Package – Basic Level Reference Manual. How to care for a wheelchair at home: • Providing wheelchair users with basic information about how to maintain their wheelchair at home can help to increase the life of the wheelchair. • There are six things that the wheelchair users can do at home to look after their wheelchair and cushion taught in the Wheelchair Service Training Package – Basic Level. This information applies to the intermediate level wheelchair users as well. Some additional care can be taken to check that PSDs are in good working order. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 141 142 What to do if there is a problem: Wheelchair users need to know what to do if there are any problems. Problems may include: • the wheelchair needs repairs; • the wheelchair does not t or is not comfortable. For any of these problems wheelchair users should be able to contact the wheelchair service for help and advice. Make sure that wheelchair users know how to get in contact with the wheelchair service centre. How to make wheelchair user training successful • Find out what the wheelchair user already knows. • Explain, demonstrate and then allow the wheelchair user to practise. • Use language that everyone can understand. • Have wheelchair users teach other wheelchair users. • Use good communication skills. • Be encouraging. Remember – practice is important when learning any new skill. Always try to teach a skill rst by demonstrating, and then giving the wheelchair user an opportunity to practise. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 143 144 Intermediate Wheelchair User Training Checklist Skills to Teach Skills Taught Wheelchair handling Folding and lifting the wheelchair Taking off and putting back on any PSDs that need to come off for transport Using quick release wheels Using the brakes Tilting and anti-tip bars (if used) Correct position of PSDs when the wheelchair user is in the wheelchair Using the cushion including positioning correctly Transfers Independent transfer Assisted transfer Other Wheelchair use and mobility Pushing correctly (using the wheelchair user’s preferred method) Up and down a slope Up and down a step On rough ground Partial wheelie How long to sit in the wheelchair (for children and adults with additional postural support needs) Assisted pushing Preventing pressure sores Check areas of high pressure for pressure sores Pressure relief lifts Eat well and drink lots of water What to do if a pressure sore develops How to care for a wheelchair at home Clean the wheelchair; wash and dry the cushion and cushion cover Oil moving parts Pump the tyres Tighten nuts and bolts Tighten spokes Check upholstery Check for rust Check the cushion What to do if there is a problem Wheelchair needs repairs The wheelchair does not t or is not comfortable WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 143 144 Step 8: Maintenance, repairs and follow up The information about the maintenance, repairs and follow up was covered in the Wheelchair Service Training Package – Basic Level. At the intermediate level the particular importance of follow up for wheelchair users who use wheelchairs with additional postural support is discussed. Follow up Follow up is part of the eighth step in wheelchair service delivery. Overview of follow up All wheelchair users bene t from follow up. However, follow up is most important for: • children; • wheelchair users at risk of developing a pressure sore; • wheelchair users who have a progressive condition; • wheelchair users who need additional postural support in their wheelchair; • wheelchair users who have had dif culty with any of the training or instruction given to them. Most intermediate level wheelchair users need additional postural support – and therefore follow up is particularly important. Managing follow up There is no rule about when follow up should happen, as the best time to follow up will depend on the needs of the wheelchair user. However wherever possible, follow up within six weeks of providing a wheelchair can be very useful to ensure that the wheelchair is working well for the wheelchair user and to reinforce any user training. For children, it is ideal if follow up is every three to six months. This is because the needs of children change quickly as they grow. Follow up can be carried out: • in the wheelchair user’s home; or • at the wheelchair service centre; • at any other location that suits the wheelchair user and the wheelchair service personnel. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 145 146 The location depends on whether the wheelchair user is able to travel to the wheelchair service centre, and whether wheelchair service personnel can travel to the wheelchair user’s home. Follow up can be managed in a number of different ways including: • wheelchair users may be given a follow up appointment when they receive their wheelchair; • follow up may be carried out in the wheelchair user’s home or in the wheelchair service centre; • follow up visits may be part of routine visits to communities by community- based rehabilitation (CBR) personnel who have been trained to carry out follow up; • follow up phone calls may be carried out where transport is dif cult and the wheelchair user has access to a phone. Wheelchair follow up form A wheelchair follow up form (shown below) will help wheelchair service personnel to remember what questions to ask and what to do on a follow up visit. The wheelchair follow up form also has a place to write down any actions that need to be taken. Common follow up actions Common follow up actions include: • Providing more advice or training. For example if a wheelchair user is not using their wheelchair as expected, it may be because they is not con dent about how he/she can get in and out of the wheelchair when he/she is alone. More training in transfers can help to solve this problem. • Re-adjusting the wheelchair. • Carrying out minor repairs. Always encourage wheelchair users and their family members/caregivers to maintain the wheelchair by carrying for a wheelchair at home. Wheelchair service personnel can also help the wheelchair user to arrange for repairs if it is not possible to x any broken parts immediately. • Referring the wheelchair user to another service for support or assistance. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 145 146 Follow up visit to Thusitha Thusitha is seven years old and lives at home with his parents and older sister. He has muscular dystrophy and received a wheelchair through the wheelchair service a year ago. At that time he could walk short distances. He was able to do a standing transfer in and out of the wheelchair on his own. He said he wanted a wheelchair because he is nding it hard to get to school. At the follow up visit, Thusitha said that he is now nding it hard to get in and out of his wheelchair himself. He feels tired and uncomfortable by the afternoon at school. This makes it hard to concentrate. His wheelchair is the correct size and has a medium slung backrest with a simple comfort cushion. During the follow up the wheelchair service personnel: • Found out how Thusitha was getting in and out of his wheelchair. Thusitha was nding it hard to lift himself off the wheelchair. The wheelchair service personnel taught Thusitha how to transfer with a sliding board, which he found much easier. • Reviewed Thusitha’s additional postural support. It was decided that Thusitha would be better supported with a higher backrest and a cushion with posture control and pressure relief. The wheelchair service personnel took the measurements needed to be able to prepare this for tting. An appointment was made for Thusitha to visit the wheelchair service centre for a tting for his new backrest and cushion. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 147 148 Wheelchair Follow Up Form 1. Wheelchair user information Wheelchair user name: Number: Date of tting: Date of follow up: Name of person carrying out follow up: Follow up carried out at: Wheelchair user’s home Wheelchair service centre Other: 2. Interview Record action to be taken: Are you using your wheelchair as much as you would like? Yes No If no – why not? Do you have any problems using your wheelchair? Yes No If yes – what are the problems? Do you have any questions about using your wheelchair? Yes No If yes – what questions. Is further training needed? Do you have any pressure sores? Yes No Describe (location) How would you rate your satisfaction with your wheelchair from 1–5? (5 is very satis ed and 1 is not satis ed) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes No Is the cushion in good working order and safe to use? Yes No If no for either, what is the problem? 4. Fitting check Does the wheelchair t correctly? Yes No If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes No If no – what is the problem? INTERMEDIATE LEVEL WHEELCHAIR SERVICE TRAINING PA CKAGE Reference Manual for Partic ipants For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ ISBN 978 92 4 150576 5 W heelchair S ervice Training P ackage R eference M anual for P articipants Interm ediate Level
For more information, contact. For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ ISBN 978 92 4 150576 5 Trainer’s Manual INTERMEDIATE LEVEL WHEELCHAIR SERVICE TRAINING PA CKAGE W heelchair S ervice Training P ackage Trainer’s M anual Interm ediate Level F more informati , contact. For more informati , ontact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/d sabilities/en/ ISBN 978 92 4 150576 5 Trainer’s Manual INTERMEDIAT L VEL HEELCHAIR SERVICE TRAINING PA CKAGE W heelchair S ervice Training P ackage Trainer’s M anual Interm ediate Level INTERMEDIATE LEVEL WHEELCHAIR SERVICE TRAINING PA CKAGE Trainer's Manual Contributors: Editors: Chapal Khasnabis and Kylie Mines Authors: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Peer reviewers: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri, Ritu Ghosh, Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan, and Diane E. Ward. Illustrator: Melissa Puust Photo credits: David Constantine, Jesse Moss, and Chapal Khasnabis Video credits: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Pilot trainers: Andrew Congdon, Mirela Creanga, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Raducan, and Andrew Rose Financial support: US Agency for International Development and Australian Agency for International Development Partner organizations: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania, and Tanzania Training Centre for Orthopaedic Technologists (TATCOT) WHO Library Cataloguing-in-Publication Data Wheelchair service training package: intermediate level / edited by Chapal Khasnabis and Kylie Mines. 1.Wheelchairs – standards. 2.Disabled persons – rehabilitation. 3.Teaching materials. I.Khasnabis, Chapal. II.Mines, Kylie. III.World Health Organization. ISBN 978 92 4 150576 5 (NLM classification: WB 320) © World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Malta Design by Inís Communication – www.iniscommunication.com Terminology The following terms used throughout the training package are de ned below. Appropriate wheelchair A wheelchair that meets the user’s needs and environmental conditions; provides proper t and postural support; is safe and durable; is available in the country; and can be obtained and maintained and services sustained in the country at an affordable price. Manual wheelchair A wheelchair that is propelled by the user or pushed by another person. Postural support device (PSD) A physical device that provides additional postural support – an essential element of intermediate level wheelchair service. Wheelchair A device providing wheeled mobility and seating support for a person with dif culty in walking or moving around. Wheelchair modi cation A change made to a wheelchair. Wheelchair provision An overall term for wheelchair design, production, supply and service delivery. Wheelchair service That part of wheelchair provision concerned with providing wheelchair users with appropriate wheelchairs. Wheelchair service personnel Persons skilled in the provision of an appropriate wheelchair. Wheelchair user A person who has dif culty walking or moving around and uses a wheelchair for mobility. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL C O N T EN T S 1 About the Wheelchair Service Training Package: Intermediate Level 1 Introduction 2 Target audience 2 Purpose 3 Scope 3 Trainers 4 How to get started 5 1. Guidance notes for trainers 5 1.1 Training overview 6 1.2 Training package timetable and duration 6 1.3 Session plans 7 1.4 PowerPoint presentations 7 1.5 Observing/monitoring participants’ progress 8 1.6 Evaluating the training programme after each delivery 8 1.7 Good practice training tips 10 2. How to prepare to deliver the training package 10 2.1 Know the participants’ wheelchair service network 10 2.2 Clarify the participants’ role in wheelchair service delivery 10 2.3 Review each session plan and adjust if necessary 11 2.4 Identify the wheelchairs, cushions and postural support devices that will be used 11 2.5 Invite wheelchair users for practical sessions 13 2.6 Plan groups for practical sessions 14 2.7 Prepare facilities 15 2.8 Prepare the training resources and materials 1 About the Wheelchair Service Training Package: Intermediate Level 1 Introduction 2 Target audience 2 Purpose 3 Scope 3 Trainers 4 How to get started 5 1. Guidance notes for trainers 5 1.1 Training overview 6 1.2 Training package timetable and duration 6 1.3 Session plans 7 1.4 PowerPoint presentations 7 1.5 Observing/monitoring participants’ progress 8 1.6 Evaluating the training programme after each delivery 8 1.7 Good practice training tips 10 2. How to prepare to deliver the training package 10 2.1 Know the participants’ wheelchair service network 10 2.2 Clarify the participants’ role in wheelchair service delivery 10 2.3 Review each session plan and adjust if necessary 11 2.4 Identify the wheelchairs, cushions and postural support devices that will be used 11 2.5 Invite wheelchair users for practical sessions 13 2.6 Plan groups for practical sessions 14 2.7 Prepare facilities 15 2.8 Prepare the training resources and materials 21 3. Detailed session plans 22 Introduction 29 A: Core knowledge 30 A.1: Wheelchair users who bene t from additional postural support 41 A.2: Children with disabilities 51 B: Wheelchair service steps 52 B.1: Assessment overview and assessment interview 60 B.2: Physical assessment – sitting posture without support 77 B.3: Physical assessment – pelvis and hip posture screen 96 B.4: Physical assessment – hand simulation 104 B.5: Physical assessment – taking measurements 114 B.6: Selecting wheelchairs and cushions 126 B.7: Prescription (selection) of Postural Support Devices (PSDs) – introduction 132 B.8: Prescription (selection) of PSDs – stabilizing the pelvis 147 B.9: Prescription (selection) of PSDs – supporting the hips 154 B.10: Prescription (selection) of PSDs – supporting the trunk 164 B.11: Prescription (selection) of PSDs – supporting the head, thighs and lower legs 176 Practical One: Assessment and prescription (selection) 180 B.12: Product (wheelchair) preparation 191 Practical Two: Product (wheelchair) preparation 194 B.13: Fitting 205 B.14: User training 212 Practical Three: Fitting and user training 217 B.15: Putting it all together 219 B.16: Maintenance, repairs and follow up 227 Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training. 232 B.17: Trainer’s feedback, discussion and closing ceremony 1235 Annexes 235 Annex 1: Timetable for intermediate wheelchair service training package 237 Annex 2: Intermediate Wheelchair Referral Form 238 Annex 3: Intermediate Wheelchair Assessment Form 243 Annex 4: Intermediate Wheelchair Prescription (Selection) Form 245 Annex 5: Intermediate Wheelchair Summary Form 246 Annex 6: Intermediate Wheelchair Safe and Ready Checklist 247 Annex 7: Intermediate Wheelchair Fitting Checklist 249 Annex 8: Intermediate Wheelchair User Training Checklist 251 Annex 9: Wheelchair Follow Up Form 252 Annex 10: Postural Support Device (PSD) Table 253 Annex 11: Wedges of rm foam 254 Annex 12: Wheelchair users list for practical sessions 1About the Wheelchair Service Training Package: Intermediate Level Introduction Following the release in 2008 of the Guidelines on the provision of manual wheelchairs in less resourced settings(1) and in 2012 of the Wheelchair Service Training Package–Basic level (WSTP-B); the World Health Organisation (WHO) in partnership with United States Agency for International Development (USAID) has developed this Wheelchair Service Training Package–Intermediate Level (WSTP-I). The WSTP Intermediate Level is the second part of the WHO Wheelchair Service Training Package (WSTP) series focussing more on addressing the needs of people who have severe dif culties in walking and moving around and also poor trunk control. While developing this training package, special attention was given on provision of appropriate wheelchair for children who have poor trunk control and cannot sit upright on their own. The wheelchair is one of the most commonly used assistive devices for enabling personal mobility, but there are often very few training opportunities for service providers to ensure that wheelchair users can attain personal mobility with the greatest possible independence, be productive and enjoy a good quality of life. The need for wheelchair personnel is universal. The Wheelchair Service Training Package–Intermediate Level is intended to support the training of personnel ful lling the clinical and technical roles in a wheelchair service (see Guidelines on the provision of manual wheelchairs in less resourced settings, Table 4.2) at intermediate level. The Training Package supports the delivery of the theory and practice needed to begin working with wheelchair users who require additional postural support in order to be able to sit upright. The training package includes how to assess individual needs; assist in selecting and setting up the most appropriate wheelchair with additional postural support; train users and caregivers how to use and maintain their wheelchair and carry out follow up. The training package can be delivered in 35–40 hours, although this period may be extended or reduced according to the speci c needs and resources available in 1 World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings. Geneva, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, accessed 15 December 2011). 235 Annexes 235 Annex 1: Timetable for intermediate wheelchair service training package 237 Annex 2: Intermediate Wheelchair Referral Form 238 Annex 3: Intermediate Wheelchair Assessment Form 243 Annex 4: Intermediate Wheelchair Prescription (Selection) Form 245 Annex 5: Intermediate Wheelchair Summary Form 246 Annex 6: Intermediate Wheelchair Safe and Ready Checklist 247 Annex 7: Intermediate Wheelchair Fitting Checklist 249 Annex 8: Intermediate Wheelchair User Training Checklist 251 Annex 9: Wheelchair Follow Up Form 252 Annex 10: Postural Support Device (PSD) Table 253 Annex 11: Wedges of rm foam 254 Annex 12: Wheelchair users list for practical sessions WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 32 each context. Further practise with a mentor is encouraged to build competencies and enhanced capacity for independent work. Wheelchair Service Training Package – Intermediate Level is intended to be delivered as a stand-alone short training programme for personnel already working in the eld as well as integrated into the curricula of training programmes for health and rehabilitation personnel. Target audience This training package is for all personnel or volunteers working who are expected to carry out intermediate level wheelchair service delivery in their place of work. This may include health, rehabilitation or technical personnel, community health- care workers, community-based rehabilitation (CBR) workers, occupational therapists, physiotherapists, prosthetists, orthotists, local craftsmen, technicians and wheelchair users. Previous experience in wheelchair service delivery is essential for participants to gain the most from this intermediate level training. The intermediate level training programme has been designed assuming that participants are able to demonstrate the competencies taught in the Wheelchair Service Training Package – Basic Level and have practical experience in basic level wheelchair service delivery. Purpose The Intermediate Level Training Package is designed to support the training of personnel or volunteers to provide an appropriate manual wheelchair and cushion for girls, boys, women and men who need additional postural support to sit upright. The main purpose of this training package is to develop the skills and knowledge of personnel involved in wheelchair service delivery. Delivery of this training package will help to: • increase the number of wheelchair users who receive a wheelchair, which meets their needs; • increase the number of personnel trained in intermediate level wheelchair service delivery; • improve the competencies of wheelchair service delivery personnel; • increase the quality of wheelchair service delivery for people who need comparatively a higher level of intervention than basic level; WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 32 • include this training package in regular paramedical/rehabilitation training programmes and • achieve greater integration of wheelchair service delivery within rehabilitation services. Scope The training package includes: • how to assess mobility and posture support needs of children and adults who need wheelchair with additional postural support • how to work with them to identify the best possible mobility solution; • knowledge and practical tips necessary to provide a manual wheelchair with an appropriate cushion and additional postural support; • training of wheelchair users and where appropriate their family members/ caregivers to make the best use of their wheelchair; • following up wheelchair users to ensure that their wheelchair continues to meet their needs. Trainers Skills: Trainers delivering this training package should be skilled in the assessment and prescription of wheelchairs for people who need additional postural support. Trainers should also be able to carry out or direct the preparation of a manual wheelchair with postural support devices using locally available products, materials and tools. Trainers should have considerable clinical skills in the eld of wheelchair service delivery themselves, enabling them to draw on their own practical experience in the delivery of this training. Previous experience as a trainer will also be bene cial. Wheelchair users: Inclusion of a wheelchair user on the training team is highly recommended. Wheelchair users are able to draw on their own experiences to teach others with similar disabilities. Being trained by a wheelchair user will help the participants to appreciate the central role that wheelchair users play in the selection of their own wheelchair. Number of trainers: It is recommended that there are two trainers for every 8–10 participants. This ratio is particularly important for practical sessions, so that trainers can give participants good support and feedback and ensure that all involved can practise safely. Having an experienced wheelchair user, who knows the subject and training package well, can be an asset during the training programme. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 4 5 Technical support: In order to manage the practical sessions that are an important component of this course, trainers are encouraged to have at least one wheelchair technician experienced at intermediate level available to assist during practical sessions. How to get started 1. Copy the disc (inside the folder) to the hard drive of the computer to be used during training. At least 6GB of free storage space is needed on the hard drive. 2. Click on the le titled ‘START’. From here, trainers can navigate to the different WSTP Intermediate resources. Trainers may also access the same resources through the fold- er hierarchy. 3. Open the Trainer’s Manual 3.1 Read the sections About the Wheelchair Service Training Package and Guidance Notes for Trainers and 3.2 Order or print and bind one copy of the Trainer’s Manual for each trainer (where printed copies are not already available). 4. Open the timetable and click the hyperlinks of each session, to access the session presentations and videos. Review each session working through the presentation and session plan (trainer’s manual) to become very familiar with the content, resources and methodology. 5. Follow the guidance notes in the section ‘How to prepare to deliver the training pack- age’ to ensure that all necessary preparations are made well in advance of delivering the training. Prepare all training resources and materials, as suggested in the section “How to Prepare to Deliver the Training Package”. 6. The best way to deliver the training is to proceed through the lessons in sequential order respecting time allotted for each session as much as possible. 7. At the beginning of the training – give the participants a full set of training materials including: the Reference Manual (1 per participant), Participant’s Workbook (1 per par- ticipant) and a set of posters (1 set per participant). If you do not have these in stock, they can be printed from the disc. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 4 5 1. Guidance notes for trainers 1.1 Training overview Minutes Day Welcome, introduction and overview Introduction 60 O ne A: Core knowledge Sessions , which give participants the background knowledge needed to undertake the wheelchair service step sessions. A.1 Wheelchair users who bene t from additional postural support 60 A.2 Children with disabilities 60 B: Wheelchair service steps Assessment B.1 Assessment overview and assessment interview 90 B.2 Physical assessment – sitting posture without support 90 B.3 Physical assessment – pelvis and hip posture screen 120 B.4 Physical assessment – hand simulation 60 Tw o B.5 Physical Assessment – taking measurements 60 Prescription (selection) B.6 Selecting of wheelchairs and cushions 60 B.7 Prescription (selection) of PSDs – introduction 30 B.8 Prescription (selection) of PSDs – stabilizing the pelvis 90 B.9 Prescription (selection) of PSDs – supporting the hips 45 B.10 Prescription (selection) of PSDs – supporting the trunk 105 Prescription (selection) of PSDs – supporting the trunk 45 T hree B.11 Prescription (selection) of PSDs – supporting the head, thighs and lower legs 120 Practical One: Assessment and prescription (selection) 120 Product (wheelchair) preparation B.12 Product (wheelchair) preparation 60 Practical Two: Product (wheelchair) preparation 150 Fitting B.13 Fitting 60 Fo ur User training B.14 User training 60 Practical Three: Fitting and user training 150 B.15 Putting it all together 120 Maintenance, repairs and follow up B.16 Maintenance, repairs and follow up 60 F ivePractical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training 300 B.17 Trainer’s feedback, discussion and closing ceremony 60 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 6 7 1.2 Training package timetable and duration This training package may be delivered on consecutive days or in blocks over a period of time. The minimum length of time needed to teach the complete intermediate level training package is 35–40 hours. An estimate of the time needed to teach each session is included in the session plan. Note: The actual time taken to teach each session will vary depending on the following factors: • the experience and skills of participants; • the overall number of participants; • the number of locally available wheelchairs; • the amount of time required to adjust and prepare wheelchairs; • whether there is a need for translation during sessions; and • whether additional material is included. Depending on these factors more or less time may be needed to complete the training programme. A sample ve day timetable is provided in Annex 1. This timetable and a blank timetable template are also available on the DVD. Trainers are strongly encouraged to adapt and modify the timetable to suit the local context and the learning needs of participants. For example: • sessions from the training package may be incorporated into existing health or rehabilitation programmes; • wherever rehabilitation personnel already have training in some aspects of the training programme, the corresponding sessions may not be required; • where preparation of wheelchairs requires additional time (for example full assembly is required) it may be necessary to reduce the number of wheelchair users seen in the practical sessions or increase the time allowed. 1.3 Session plans For each session there is a session plan, which guides trainers in delivering the session. At the beginning of each session plan is the following information: • Objectives: what the participant should be able to do at the end of the session; • Resources: what resources are needed for the session; • Context and prior learning: how the session may need to be adapted for different contexts (or situations) and what prior learning or competencies are expected of participants; WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 6 7 • To prepare: how to prepare for the session; • Outline: an outline of the main parts of the session. The rest of the session plan is divided into topics. For each topic, the session plan gives instructions on how to teach the information for that topic. Note: • words in bold are actions for the trainer (for example: ask, demonstrate, explain, show DVD) • shaded boxes give answers to questions asked by the trainer – encourage participants to think of the answers themselves. At the end of every session plan is a summary of the key points. Instead of reading the key points, trainers may ask participants questions to encourage them to identify the key points. By following the session plans carefully, trainers will be able to teach each session well and on time. Session plans provide all of the necessary key points and practical skills that should be covered. Trainers are encouraged to bring their own knowledge, skills and style to the session. 1.4 PowerPoint presentations There are PowerPoint (PPT) slide presentations for almost every session. Trainers should note that only the key points are written on the slides. Trainers should provide the information given next to each slide in the Trainer’s Manual to make sure that every point is covered. Try to avoid reading out the slides. Instead refer to the Trainer’s Manual. 1.5 Observing/monitoring participants’ progress Trainers should monitor closely the progress of each participant. The best opportunity to observe progress is during practical sessions. A trainer’s observation checklist for each practical session can be found on the DVD. Trainers should use this checklist to: • Help them observe the progress of each group of participants during each practical session; • Record examples of good practice and practice needing improvement – to be discussed during each feedback session. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 8 9 The Trainer’s observation checklist may be modi ed and/or further developed by trainers wishing to gather more detailed information about the progress of each participant. 1.6 Evaluating the training programme after each delivery It is a good practice to evaluate the training programme after it has been delivered. Trainers can gather feedback from participants regularly throughout the training programme. Trainers may also record their own thoughts about the training programme as it is delivered. This information can help them to evaluate the training programme at the end, including identifying strengths and weaknesses. This will help trainers to improve both the training package itself and their own skills for delivery in their context for the future. Training programme evaluation forms are available on the DVD. Trainers may wish to adapt or build on these forms in order to meet their needs. 1.7 Good practice training tips Be prepared • read each session plan carefully before training starts; • make sure you are con dent of the material you are delivering; • gather training resources and prepare the training room well. Model good practice for a wheelchair service • respect for participants and wheelchair users; • show care in your work; • be aware at all times of safety in the training room; • be punctual and run sessions according to the timetable. Present information clearly • speak clearly and calmly; • check to make sure everyone in the training room can hear you; • ask questions to check that you have been understood; • make sure your writing on the whiteboard can be read by everyone; • repeat important points to reinforce them. Manage session time • note the time allowed for each session and work to keep to time; • if it is likely that additional time will be needed, plan for this at the beginning; • be sure to complete all the sessions planned for a given day. Give clear and careful demonstrations • make sure everyone can see clearly; • explain what will happen and describe what you are going to do; • demonstrate slowly and repeat if necessary. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 8 9 Build participants` skills • always follow demonstrations with an opportunity for participants to practise; • remember that new learners need time to understand new information. Build success in the small group activities • observe group activities closely and give help if needed; • ensure that you circulate between the small groups and check the progress of each group. Be aware of language differences • if participants are learning in their second language, check they understand – slow down if necessary; • be aware of language differences among wheelchair users and their caregivers; • use interpreters where necessary. Encourage participants to be active and engaged throughout the training • use the different training styles and methods given in the session plans; • avoid talking too much – encourage participants to speak and discuss themselves; • ask questions to encourage participants to think about the answers themselves, rather than always telling them the answer; • encourage everyone to speak, don’t let one participant dominate; • praise good work from participants and give positive feedback; • let participants know they can ask questions at any time; • link learning to real examples that the participants will recognize; • keep the training fun! Use short “warm up” activities/games • Use short warm-up activities (5–10 minutes) to help focus attention. Use activities that are inclusive of participants with disabilities. Consider the needs of people with different abilities • Think about the needs of any participants with visual, hearing or mobility differences. Some activities and teaching approaches may need to be adapted accordingly. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 10 11 2. How to prepare to deliver the training package 2.1 Know the participants’ wheelchair service network Trainers need to be familiar with the wheelchair provision system at their place of work. This includes: • the types of wheelchairs, cushions and postural support devices (PSDs) available locally and who supplies them; • the materials, tools and facilities available for preparing wheelchairs and making PSDs; • the wheelchair services in the area including the level of service they offer; • referral networks in the area; • resource personnel in the area, including wheelchair users who can assist in delivering the training; • other rehabilitation services to which wheelchair service personnel may refer wheelchair users as required. 2.2 Clarify the participants’ role in wheelchair service delivery Find out how wheelchair service delivery ts within the participants’ overall duties at their place of work. For example, will participants be working only in wheelchair service delivery, or do they have other duties as well? De ne the role participants will play in wheelchair service delivery. For example, some personnel may be required to carry out only the clinical or technical aspects covered in the training. Others may ful l both the clinical and technical roles. The expected role should be clear before training begins. Trainers can then relate the training directly to the duties expected of participants. Prior to delivering the training, local trainers may need to adapt the training to t the role participants will carry out within their wheelchair service. 2.3 Review each session plan and adjust if necessary Review each session plan and allocate a lead trainer for each session. A number of the training sessions may need to be adjusted to suit the local context. Suggestions for adjusting sessions to different contexts are provided at the beginning of each session plan under the heading ‘Context’. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 10 11 2.4 Identify the wheelchairs, cushions and postural support devices that will be used Identify which wheelchair types, postural support devices and cushions will be represented in the training. These should be the products available through the participants’ place of work. If there is a large range of wheelchairs, select the best examples of different types of appropriate wheelchairs. Prioritize those that are most commonly available. Make sure you are very familiar with the features of each product. Complete an intermediate wheelchair summary form for each wheelchair and gather product information from the supplier. 2.5 Invite wheelchair users for practical sessions To give participants practice in the skills taught in this training package, it is necessary for them to practise with wheelchair users. Before the training programme, trainers need to identify and invite wheelchair users who are willing and able to attend the practical sessions. Below is a checklist to help identify wheelchair users. Checklist for wheelchair users to participate in practical sessions: Agree willingly to attend the training to assist in practical sessions Need additional postural support to sit upright – however are able to sit upright or close to upright with support Are t and healthy enough to comfortably tolerate attending the training programme Do not have an open pressure sore Live close enough to be able to attend the practical session without having to travel far Have time available to attend the practical session Live close enough for the host organization to follow them up after the training programme Equal number of male and female wheelchair users A range of different physical needs represented Different ages represented WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 12 13 How many wheelchair users are needed? The number of wheelchair users needed for the practical sessions depends on the number of participants. Usually, participants will work in groups of two or three with one wheelchair user. It is better to not have more than four wheelchair users for any one practical session, as this would become dif cult for trainers to manage, monitor and observe. The table below shows how many wheelchair users would be needed for a training programme with 6–8 participants, or 8–12 participants. Participants would be divided into groups of 2–4, working with one wheelchair user. Ideally there should be a ratio of one trainer to two groups of participants working with a wheelchair user. This is to ensure that trainers are able to manage, monitor and observe the practical sessions to ensure safety for the wheelchair users and good learning. Number of participants: 6–8 8–12 Wheelchair users for assessment, prescription, tting and user training Practical One and Three 3 4 Practical Four 3 4 Total number of wheelchair user volunteers needed: 6 8 What do wheelchair users attending practical sessions need to know? Wheelchair users attending the practical sessions need to know: • what will happen when they attend the session; • when they will need to attend and for how long; • that they are welcome to attend with a family member/caregiver; • whether they will receive a wheelchair through their attendance at the training. Trainers and host/training organizations are strongly encouraged to ensure that all wheelchair users attending practical sessions are offered transport or money to cover transport and participation costs. Meals and refreshments should be available while they are on the training programme. Trainers and host/ training organizations may also provide wheelchair users with some payment as honorarium for the time that they spend participating in the training. A sample invitation letter and consent form for wheelchair users is available within the Training Package (see DVD: Forms and checklists). This should be adapted for the speci c context, translated and sent to each wheelchair user (volunteer) to help him/her to make an informed choice about participating in the training. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 12 13 Follow up: • Trainers or host/training organizations need to plan for follow up for any wheelchair user seen during the training, as it is possible that not everything will be complete by the end of the training for each wheelchair user. • Any wheelchair user who receives a wheelchair during the training should be followed up by the host/training organization within 6–8 weeks of receiving their wheelchair. Where to carry out practical sessions: Set up a quiet and private space for each participants’ group to work with their wheelchair user. Portable privacy screens can be used to divide the space and provide some privacy. Trainers may choose to organise at least one practical session to be carried out in the community. This may be in the home of a wheelchair user who has volunteered to have participants visit. Community visits will help to reinforce for participants the practical issues wheelchair users face in their own environment. Trainers need to decide if this is possible, considering: • the availability of transport for participants, • whether there are enough trainers to monitor and observe all participants at different locations, • whether wheelchair users are comfortable having participants visit them in their home, • additional time that may be needed to travel to the community location. 2.6 Plan groups for practical sessions Each group should consist of no more than three participants. It is better to have two groups of two than one group of four. This ensures that participants have a good opportunity to apply their learning and develop their skills. Trainers need to decide who is in which group. Do not leave this to participants to decide. Depending on the skills of participants and the context, trainers may choose their groups as follows. • Team up more con dent participants with less con dent participants. The more con dent participants may help to guide the less con dent participants. Monitor/ observe the groups closely to ensure that everyone is participating. • Team together people who will work together in the future, so that they can develop their skills as a team. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 14 15 For Practical One, Two and Three, keep the same participants in the same groups. For Practical Four, the groups may be changed around, depending on how well they are working together. For each practical session, appoint a “lead” person from the group. Make sure that every participant has an opportunity to be the lead person. Ask the lead person to be responsible for making sure that all steps are carried out. The lead person should be the main person communicating with the wheelchair user and his/her family member/caregiver if needed. 2.7 Prepare facilities To run the training one large training room (or space) may be used. The space needs to be large enough to allow for participants and wheelchair users participating in practical sessions to move around comfortably and to break into small groups. Also required are workbenches; a separate space for lunch and refreshments; and clean toilets. All areas, including toilets, must be wheelchair accessible. The following checklist can be used to assess and prepare training facilities. Facilities checklist: Training room Lecture area Chairs for each participant – with facility for participants to write notes Space for participants to break into small groups of 2–3 Space to display and move around at least three wheelchairs Screens to provide wheelchair users with privacy during practical sessions Adequate lighting and ventilation Lockable/secure Workbenches/workshop facilities One workbench for each small group Lunch/refreshment area Clean area for eating Tables and chairs Nearby space for washing hands – clean towels and soap Toilets Clean toilets supplied with water, toilet paper, hand washing facilities and bins WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 14 15 2.8 Prepare the training resources and materials Printed resources Resource Quantity Comments/instructions Manuals, workbook and posters: Trainer’s Manual 1 per trainer Order from WHO or print and bind. Reference Manual 1 per participant Order from WHO or print and bind. Participant’s Workbook 1 per participant Order from WHO or print and bind. Set of posters 1 per participant Order from WHO or print. Training programme forms: Participants register form 1 per programme Use this form to keep a record of participants attending. Name tags 1 per participant and per trainer Timetable 1 per participant Sample available on DVD; adjust to suit local context. Photo consent form 1 per participant and 1 per wheelchair user (volunteer) Adapt this form for the host/training organization; translate into local language; ensure any person who is photographed signs this form. Invitation letter and consent form for wheelchair users 1 per wheelchair user Adapt the sample letter provided to invite each wheelchair user for the practical sessions. Wheelchair user list for practical sessions 1 per trainer Use this form to plan wheelchair users’ attendance at practical sessions and to keep a record of who is attending and when. Participant certi cate 1 per participant Prepare participant certi cates or adapt the template provided. Training programme evaluation forms: Training programme evaluation form for participants 1 per participant Sample training programme evaluation forms; these may be adapted by trainers as needed. Training programme session evaluation form for trainers 1 per session Training programme evaluation form for trainers 1 per trainer WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 16 17 Trainer’s observation checklists for practical sessions: Practical One 1 per trainer Print. Practical Two Practical Three Practical Four Wheelchair service forms: Provide a complete set of all wheelchair service forms for each participant at the beginning of the training. Additional copies are needed for practical sessions as follows: Intermediate wheelchair referral form — Adapt to suit local context or use local referral form if available. Intermediate wheelchair assessment form 1 per wheelchair user Adapt to suit local context – for example add wheelchair service name or additional information required by local service. Intermediate wheelchair prescription (selection) form 1 per wheelchair user Finalize depending on available wheelchair sizes, types and set-up. Intermediate wheelchair summary form 1 per wheelchair (completed) Complete one for each locally available wheelchair before the training programme begins. Wheelchair follow up form — Adapt to suit local context – for example add wheelchair service name or additional information required by local service. Checklists: Laminated intermediate wheelchair tting checklist 1 per participant Checklists can be found in the printed resources under “Forms, checklists and tables”. Laminated intermediate wheelchair user training checklist Laminated intermediate wheelchair safe and ready checklist Table: Laminated Postural Support Device (PSD) Table 1 per participant Table can be found under “Forms, checklists and tables”. Posters: Children and Wheelchairs 1 1 per participant Different Positions 1 Postural Support Device (PSD) Table 1 Intermediate wheelchair user training checklist 1 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 16 17 Equipment General training equipment: Item Quantity Comments/instructions Large whiteboard 1 Whiteboard marker pens 3–4 Data projector 1 Computer 1 Portable speakers 1 set To assist in hearing the DVDs Stack of paper cups 1 per participant For drinking activity Ball 1 per 2 groups For throwing a ball activity Assessment and prescription equipment: Equipment for demonstrating and practising wheelchair assessment, prescription and tting. Item Quantity Comments/instructions Blocks of rm foam 30 mm x 150 mm x 300 mm 10–15 depending on the number of groups Wedges of rm foam 30 mm X 150 mm X 200 mm (approximately) 10–15 depending on the number of groups See diagram in Annex 11 Cardboard/plastic goniometer/goniometers 1 per group Tape measure 1 per group Firm retractable tape measure (not soft dress maker’s tape measure) in mm. Caliper (if available) 1 per group Assessment beds 1 per group A bench/assessment bed or plinth. The height should be level with average wheelchair seat height. Avoid a hard surface if possible – if using benches provide a thin foam layer and cover or yoga mat. Digital camera 1 If available Privacy screens 1 per group Screens to provide privacy for wheelchair users being seen during practical sessions. Set of foot blocks 1 per group Wooden blocks to provide support for wheelchair users’ feet when sitting on the assessment bed. Several different heights are needed. Disposable gloves (if available) 1 per participant WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 18 19 Wheelchairs: for training and practical sessions with wheelchair users Item Quantity Comments/instructions Wheelchairs for training At least 1 of each locally available wheelchair. Ideally 1 wheelchair per 2 participants. Ensure all wheelchairs are in good working order and have a cushion. Wheelchairs for provision to wheelchair user volunteers 1 per wheelchair user attending the practical sessions There should be enough wheelchairs to be able to prescribe the most appropriate wheelchair for wheelchair users attending the practical sessions. Cushions: for demonstrations Item Quantity Comments/instructions Cushion that has been modi ed to support xed unlevel pelvis 1 Cushion that has been modi ed to support a hip that cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees) 1 Cushion that has been modi ed to support one hip or both hips that cannot open to neutral for sitting posture (trunk to thigh angle less than 90 degrees) 1 Workbench and tool kit: To make PSDs for wheelchair users attending the practical sessions, work benches and basic tools will be required. Trainers should modify this list depending upon the availability of pre-fabricated PSDs and locally available materials. Below is a suggested list: Item Quantity Comments/instructions Workbench 1 per 3 participants This could be a workbench or strong table. A vice on each bench is very helpful. Foam knife/electric knife 1 per 6 participants A ne hacksaw blade can be used as a foam knife. Scissors 1 per 6 participants Large (if possible) Safety glasses 1 per participant Safety glasses should be worn during any activity involving cutting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 18 19 Item Quantity Comments/instructions Hand tools (saw, le, hammer, screwdriver) 1 set per 3 participants Hand tools will be required to make PSDs. The speci c tools needed may vary depending on the materials used. Industrial sewing machine, or needles and thread. 1 An industrial sewing machine is needed to make covers for cushions and/or PSDs. Using a sewing machine is a skill that not everyone has. Possible options: • Find a local sewing shop that can carry out work quickly. • Have a person available with good sewing skills for all product preparation sessions. • Ensure the sewing machine is in good working order before the training begins. First aid kit 1 PSD kit: Locally available examples of the following PSDs will assist in demonstrating the different supports taught in this training programme. Below is a suggested list. Trainers should aim to have a sample of any commonly available pre-fabricated PSDs. Item Quantity Comments/instructions Pelvis side pads 2 Outside thigh pads 2 Knee separator pad 1 Tension adjustable backrest 1 Trunk side pads 2 Headrest 1 Pelvis strap 1 per group Calf strap 1 Foot straps 2 Shoulder harness 1 PSD Materials: The following materials are recommended to make PSDs for wheelchair users attending the practical sessions. This list below is a guide only. The exact list of materials will depend upon: • solutions needed by wheelchair users; • availability of any pre-fabricated PSDs; • materials available locally to make PSDs; and • technical solutions chosen. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 20 21 Item Quantity Comments/ instructions Firm foam (e.g. chip foam) Quantities will vary as noted above. However a suggested amount is: • Firm foam – one sheet each of 1000 mm x 1500 mm x 50 mm and 1000 mm x 1500 mm x 20–30 mm. • Soft foam – half the above quantity. If foam is not available in 50 mm thicknesses – two thinner layers can be glued together. Soft foam should give some resistance when compressed. See reference manual for more information. Soft foam Webbing strap • 20 metres of wide webbing (50 mm width) • 20 metres of narrow webbing (25 mm width) Widths may vary depending on supply. Webbing buckles • 10–12 (to match the webbing strap widths) Wood Quantities will vary as noted above. See Reference Manual for more information. Contact glue for wood and foam. Upholstery fabric EVA or sandal rubber Metal L-brackets if available Variety of screws, nuts, bolts and washers. Velcro or string and eyelets For modi cations to slung backrests. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 20 21 3. Detailed session plans WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 22 23 Introduction O B JE C T IV E S By the end of this session, participants will: know the objectives of the training programme; know the names of trainers and participants; have an overview of the training programme timetable; know any important rules to remember during the training programme. R E S O U R C E S For the session: PPT slides: Introduction; Reference Manual for each participant; Participant’s Workbook for each participant; a complete set of all wheelchair service forms – 1 set for each participant; DVD: Wheelchair service delivery; DVD: Wheelchair service steps; copy of the timetable for each participant; name tags for trainers and each participant. C O N T E X T Adapt this session to suit the local context in which the training is being given. Think about: including an opening ceremony appropriate to the culture/context; changing or adapting the section ‘Introduction of trainers and participants’ to suit the trainers and participants; changing, adapting and/or adding to the list of ‘Housekeeping and expectations’; changing the overview slide if the training programme has been modi ed. T O P R E PA R E Gather resources, review PPT slides, watch DVDs and read through the session plan. O U T L IN E 1. Opening ceremony (if any) 2. Introduction of trainers and participants 3. Training programme overview 4. Training programme timetable, Reference Manual, Participant’s Workbook and wheelchair service forms 5. Housekeeping and expectations 15 15 10 10 10 Total session time 60 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 22 23 VIDEO 1. Opening ceremony (estimated length 15 minutes) The training programme may be opened with an opening ceremony as per local culture and customs. 2. Introduction of trainers and participants (15 minutes) Trainers: Introduce yourself/yourselves. Provide a brief overview of your background and experience of wheelchair delivery. Ask participants in turn to introduce themselves, stating their name, the organization they come from, and what they hope to learn from the training programme. Give out name tags, if these have not already been provided during registration. 3. Training programme overview (10 minutes) INTERMEDIATE LE VEL • This training package includes wheelchair service steps (or parts of steps) for a child or adult who needs additional postural support to sit up and be mobile, including - physical assessment; - prescribing (selecting) wheelchair, cushion and Postural Support Devices (PSD); - preparing the wheelchair with necessary modifications/Postural Support Devices (PSDs); - fitting; - user training; - maintenance, repairs and follow up. 1. Introduction: 2 OVERVIEW Explain: The aim of this training programme is to provide each participant with knowledge and skills that will help them to begin or improve their ability to provide an appropriate manual wheelchair, cushion and postural support for girls, boys, women and men who need additional postural support to sit upright, including: • physical assessment; • prescribing (selecting) wheelchair, cushion and Postural Support Devices (PSD); • preparing the wheelchair with necessary modi cations/Postural Support Devices (PSDs) • tting; • user training; • maintenance, repairs and follow up. Introduce DVD: Wheelchair service delivery. This DVD provides a brief introduction to the WHO Wheelchair Service Training Package. Show DVD. Ask if there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 24 25 INTERMEDIATE LE VEL This training package is divided into two sections: A. Core knowledge; B. Wheelchair service steps. 1. Introduction: 4 WHEELCHAIR S ERVICE TRAININ G PACKAGE - INTERMEDIATE LEVEL Explain: The Wheelchair Service Training Package – Intermediate Level is divided into two sections: A: Core knowledge; B: Wheelchair service steps. INTERMEDIATE LE VEL 1. Wheelchair users who benefit from wheelchair with additional postural support; 2. Children with disabilities. 1. Introduction: 5 A. CORE KNOW LEDGE Explain: Core knowledge section consists of two sessions: A.1: Wheelchair users who bene t from wheelchair with additional postural support, and A.2: Children with disabilities Explain: There are human rights that apply to everybody. The focus of the UNCRPD (United Nations Convention on the Rights of Persons with Disability) is to make sure that everybody recognizes that these rights also apply to people with a disability. INTERMEDIATE LE VEL • The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) says: - All people have a right to personal mobility. • Personal mobility means: - The ability to move in a manner and at the time of one’s own choice. • If you are not aware of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) – understand it and work towards realizing it, especially the article 20 on personal mobility. 1. Introduction: 6 WHAT DOES ‘P ERSONAL MOB ILITY’ MEAN Explain: • There are 50 different articles in the Convention. • Article number 20 is about personal mobility. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 24 25 INTERMEDIATE LE VEL This training package is divided into two sections: A. Core knowledge; B. Wheelchair service steps. 1. Introduction: 4 WHEELCHAIR S ERVICE TRAININ G PACKAGE - INTERMEDIATE LEVEL Explain: The Wheelchair Service Training Package – Intermediate Level is divided into two sections: A: Core knowledge; B: Wheelchair service steps. INTERMEDIATE LE VEL 1. Wheelchair users who benefit from wheelchair with additional postural support; 2. Children with disabilities. 1. Introduction: 5 A. CORE KNOW LEDGE Explain: Core knowledge section consists of two sessions: A.1: Wheelchair users who bene t from wheelchair with additional postural support, and A.2: Children with disabilities Explain: There are human rights that apply to everybody. The focus of the UNCRPD (United Nations Convention on the Rights of Persons with Disability) is to make sure that everybody recognizes that these rights also apply to people with a disability. INTERMEDIATE LE VEL • The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) says: - All people have a right to personal mobility. • Personal mobility means: - The ability to move in a manner and at the time of one’s own choice. • If you are not aware of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) – understand it and work towards realizing it, especially the article 20 on personal mobility. 1. Introduction: 6 WHAT DOES ‘P ERSONAL MOB ILITY’ MEAN Explain: • There are 50 different articles in the Convention. • Article number 20 is about personal mobility. INTERMEDIATE LE VEL • An intermediate level wheelchair service is for girls and boys, women and men who need wheelchairs with modifications or postural support in their wheelchair to sit upright. 1. Introduction: 7 WHAT DOES ‘IN TERMEDIATE L EVEL’ MEAN? Explain: An intermediate level wheelchair service is for girls and boys, women and men who need wheelchairs with modi cations or postural support in their wheelchair to sit upright. INTERMEDIATE LE VEL • A wheelchair service helps ensure each wheelchair user receives an appropriate wheelchair. • Wheelchair service is a key component of the wheelchair provision. 1. Introduction: 8 WHEELCHAIR SERVICE Explain: • As participants know – a wheelchair service works with wheelchair users to ensure that each wheelchair user receives an appropriate wheelchair. • Wheelchair service is a key component of the wheelchair provision. INTERMEDIATE LE VEL • An appropriate wheelchair: - meets the user’s needs and environmental conditions; - provides proper fit and postural support; - is safe and durable; - is available in the country; and - can be obtained and maintained and services sustained in the country at an affordable cost. 1. Introduction: 9 WHAT IS AN AP PROPRIATE WH EELCHAIR? Read the de nition of an appropriate wheelchair. Explain: • The “appropriate wheelchair” for each wheelchair user will always depend on their individual needs and environmental conditions. • The “appropriate wheelchair” for each wheelchair user will also always depend on how well the wheelchair provides proper t and postural support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 26 27 VIDEO INTERMEDIATE LE VEL • Wheelchair service personnel provide people who cannot sit upright without additional postural supports with the most appropriate wheelchair and postural supports available. • Wheelchair service personnel follow eight wheelchair service steps to ensure wheelchair users get appropriate wheelchairs and make optimum use of it. 1. Introduction: 10 THE ROLE OF W HEELCHAIR SER VICE PERSONNE L Explain: • Wheelchair service personnel provide people who cannot sit upright without additional postural supports with the most appropriate wheelchair and postural supports available. • Wheelchair service personnel follow eight wheelchair service steps to ensure wheelchair users get appropriate wheelchairs and make optimum use of it. Ask: What are the eight wheelchair service steps? Acknowledge all correct answers (the terms do not need to be exact). Answers: • referral and appointment; • assessment; • prescription (selection); • funding and ordering; • product (wheelchair) preparation; • tting; • user training; • maintenance, repairs and follow up. Introduce DVD: Wheelchair service steps. This DVD will show the eight steps of wheelchair service delivery that were covered in the Wheelchair Service Training Programme – Basic Level. Ask participants to watch the DVD and note each wheelchair service step. Show DVD. Ask if there are any questions. INTERMEDIATE LE VEL 1. Referral and appointment; 2. Assessment; 3. Prescription (selection); 4. Funding and ordering; 5. Product (wheelchair) preparation; 6. Fitting; 7. User training; 8. Maintenance, repairs and follow up. 1. Introduction: 12 B. WHEELCHAI R SERVICE STEP S Explain: • The role of the wheelchair service personnel is to provide the most appropriate wheelchair, cushion and postural supports for people who need additional postural support to sit upright using the following eight wheelchair steps. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 26 27 Explain: At the intermediate level, some of the wheelchair service steps may take longer or need to be repeated. Ask: When providing a wheelchair user who needs additional postural support with a wheelchair, which wheelchair service steps may take longer, or may need to be carried out more than once? Answers: • assessment may take longer; • product (wheelchair) preparation may take longer; • wheelchair tting may take longer and may need to be repeated; • assessment may continue into the tting if solutions are not clear at the rst appointment; • user training may take longer. Explain: • This intermediate level training will build on knowledge gained in the basic level training. • It will cover: – How to assess a wheelchair user who needs additional postural support to sit upright in order to nd the best possible mobility and seating solution for them. – How to prescribe (select), prepare and t a manual wheelchair with an appropriate cushion and postural support devices, which are any addition or modi cation to a wheelchair, which provide additional postural support. – User training – the intermediate level training programme will cover some additional information or skills wheelchair users who use postural support devices (or their family members/caregivers) need to know to be able to use their wheelchair safely and effectively. Participants will also be provided with an opportunity to practise this step with wheelchair users who need additional postural support. – Follow up – the intermediate level training programme will brie y review the process of follow up and provide participants with an opportunity to practise this step with wheelchair users who need additional postural support. • Step 1 – referral and appointments; step 4 – funding and ordering; and part of step 8 – maintenance and repairs are not covered in this training programme. Ask each participant in turn to give a very brief summary of their role in wheelchair service delivery. Ask participants to include: • whether they are already providing wheelchairs and postural support devices; • whether the children and adults they work with need additional postural support in their wheelchairs. Acknowledge each participant’s summary, and ask questions to clarify their role in wheelchair service delivery. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 28 29 4. Training programme timetable, Reference Manual, Participant` s Workbook and wheelchair service forms (10 minutes) Give a copy of the training programme timetable to each participant. Explain: • The training programme will begin with theory/classroom sessions. • Participants will then practise some of the skills they have been taught in the theory sessions with wheelchair users who have volunteered to assist. Give a copy of the Reference Manual to each participant. Ask participants to write their name on the manual. Explain that they may write any additional notes in this manual. Give a copy of the Participant’s Workbook to each participant. Ask participants to write their name in the workbook. Explain that they will use this Workbook throughout the training and they should bring it to each session. Give a complete set of all wheelchair service forms to each participant. Explain that participants will use these forms throughout the training and they should bring them to each session. 5. Housekeeping and expectations (10 minutes) Explain the following, as required: • location of toilets; • who to talk to about accommodations; • who to talk to about return travel for individual participants (do not go into details); • what to do if there is an emergency. Explain the expectations placed on training programme participants, as required: • each session will begin on time – participants need to make sure that they arrive on time at the beginning of each day and return back to sessions on time after breaks; • participants should always ask questions if they are not sure of something; • treat all wheelchair users equally and respect their dignity; • turn off mobile phones during the sessions; • have fun! WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 28 29 A: Core knowledge WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 30 31 A.1: Wheelchair users who bene t from additional postural support O B JE C T IV E S By the end of this session, participants will be able to: list physical and/or functional reasons why a wheelchair user may need additional postural support; list four bene ts of additional postural support; describe possible reasons why wheelchair users may reject a wheelchair with additional postural support and how to make sure additional postural support will be used by the wheelchair user. R E S O U R C E S For the session: PPT: A.1: Wheelchair users who bene t from additional postural support; Reference Manual; Participant’s Workbook; DVD: The bene ts of an appropriate wheelchair ; DVD: People using postural support devices; stack of paper cups and jug of drinking water, chairs, assessment bed and ball. P R IO R L E A R N IN G Prior learning: understanding that there are differences in wheelchair service delivery for people who can and people who cannot sit upright without additional postural supports. T O P R E PA R E Gather resources, review PPT slides, watch DVDs and read through the session plan. Set-up for small group activity at two or four different locations (depending on number of participants) around or near the training room: • location 1: place a chair and a ball; • location 2: place a chair, assessment bed, jug of drinking water and stack of paper cups. O U T L IN E 1. Introduction 2. Wheelchair users who bene t from additional postural support 3. When is additional postural support needed? 4. What do wheelchair users want? 5. Key point summary 2 6 35 15 2 Total session time 60 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 30 31 VIDEO 1. Introduction (2 minutes) Explain: • Every well- tting wheelchair provides the wheelchair user with some postural support. The backrest, cushion, footrests and armrests provide postural support when adjusted to suit the wheelchair user’s size. • However many children and adults need additional postural support in their wheelchair. Additional postural support can be provided by a postural support device. This is any addition or modi cation to a wheelchair, which is prescribed to provide additional postural support. Throughout this Manual, a postural support device is referred to as a PSD. INTERMEDIATE LE VEL • In this session participants will talk about: - benefits of an appropriate wheelchair; - who benefits from additional postural support; - when additional postural support is needed; - what wheelchair users want. • Wheelchair service personnel need to be able to clearly explain to wheelchair users, their families and carers and others why additional postural support may be beneficial. A.1. Wheelchair users who benefit from additional postural support : 2 INTRODUCTIO N In this session we will talk about: • the bene ts of an appropriate wheelchair; • who bene ts from additional postural support; • when additional postural support is needed; • what wheelchair users want. This information is useful for participants to be able to clearly explain to wheelchair users, their families and caregivers and others why additional postural support may be bene cial. 2. Wheelchair users who bene t from additional postural support (6 minutes) Introduce DVD: The bene ts of an appropriate wheelchair. This DVD will show a range of different wheelchair users carrying out different activities. Most of them have additional postural support built into their wheelchair. This may be easy to see, or hidden in the cushion/backrest. Ask participants to watch closely to see the activities that people are doing; and the different additional postural supports provided in the wheelchair. Notice that the wheelchairs and supports are different for each wheelchair user. Show DVD. Ask if there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 32 33 Ask: What are some of the activities people on the DVD were doing? Answers: • cooking; • dancing; • going to school/doing crafts; • throwing a ball; • weight lifting/training; • walking the dog; • using a computer; • working; • hairdressing. 3. When is additional postural support needed? (35 minutes) Ask: Why do some children or adults need additional postural support? Think about the different physical or functional reasons that children or adults come to a wheelchair service for a wheelchair and additional postural support. Encourage answers. Answers: Physical reasons: • cannot sit upright; • poor balance; • feeling unstable; • uncontrolled movements or spasms; • developing pressure sores; • joint stiffness; • muscle tightness; • weakness; • fatigue; • pain or discomfort. Functional reasons: • nd it hard to do things without additional postural support; • nd it dif cult to eat or drink independently and safely; • get tired easily; • family nds it hard to carry/give additional postural support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 32 33 INTERMEDIATE LE VEL Additional postural support can: 1. improve balance, posture and stability; 2. improve comfort; 3. help to prevent the development of pressure sores; 4. help to slow down or prevent the development of problems with posture in the future. A.1. Wheelchair users who benefit from additional postural support : 4 FOUR BENEFITS OF ADDITIONA L POSTURAL SU PPORT Explain: • People need additional postural support for different reasons. • Four very important ways that additional postural support can bene t wheelchair users are listed here: • Additional postural support can: 1. improve balance, posture and stability; 2. improve comfort so they can sit for longer time periods; 3. help to prevent the development of pressure sores; 4. help to slow down or prevent the development of problems with posture in the future. INTERMEDIATE LE VEL • enhance functioning; • increase a wheelchair user’s self-esteem; • improve a wheelchair user’s quality of life. A.1. Wheelchair users who benefit from additional postural support : 5 GOOD POSTUR AL SUPPORT C AN ALSO: Explain: • Good postural support can also help to enhance functioning and increase a wheelchair user’s self-esteem. • Overall – good postural support can help to improve a wheelchair user’s quality of life. INTERMEDIATE LE VEL Additional postural support can: 1. improve balance, posture and stability; 2. improve comfort; 3. help to prevent the development of pressure sores; 4. help to slow down or prevent the development of problems with posture in the future. A.1. Wheelchair users who benefit from additional postural support : 6 BENEFITS OF AD DITIONAL POST URAL SUPPORT Explain: One of the important bene ts of postural support is improvement of balance, posture and stability. Ask: What are some activities that need good balance, posture and stability? Encourage answers. Answers: • Writing; • propelling a wheelchair; • cooking; • eating and drinking; • communicating. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 34 35 Explain: We are now going to try two activities (throwing a ball and drinking), which will help participants to feel what it might be like to carry out these activities with good balance, posture and stability; and then with poor balance, posture and stability. Small group activity: Groups: Divide participants into groups of 3. Instructions: Ask participants to look at Participant`s Workbook (A.1: Wheelchair users who bene t from additional postural support). Explain: There are two activities – throwing a ball and drinking. Explain that each group should carry out the activity in the locations set-up (point out the locations). Ask participants to write down the answers to the questions in their workbook. Explain that the participants should complete both activities in 10 minutes.. Monitor: Monitor the groups closely. Ensure each group understands the activity. Remind participants to consider the questions in their workbook: • How easy is it to throw and catch the ball? • Does it get harder with steps 2 and 3? • How does the different position and posture affect how easy it is to drink? Once each group has nished an activity, move the groups around. Keep the groups moving quickly so that each group carries out each activity within the time available. Guide participants if necessary. Time: Allow 10 minutes for activity and 10 minutes for feedback WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 34 35 Feedback: 1. Throwing a ball: Ask: Did it become harder to throw and catch the ball as your stability changed (with your chair being tilted, and then rocked)? Encourage responses (throwing the ball should become harder, and require more concentration and effort). Explain: Postural support helps to increase stability, by providing support at the pelvis, and wherever else the person needs support. With increased stability, it is easier to do many things – including propelling a wheelchair, writing, cooking, even speaking. 2. Drinking: Ask: • What did it feel like trying to drink in the different sitting postures? • Did anyone feel like he/she would choke or get water in their airways? Encourage responses (drinking in the different postures would feel uncomfortable and possibly frightening). Explain: • For people who have dif culty sitting upright – eating and drinking can be uncomfortable, sometimes frightening, and often dangerous. • When people have dif culty swallowing safely, small pieces of food and drink may go into the lungs. This can cause a chest infection, making the person very ill. Additional postural support in a wheelchair to ensure that the person can sit upright when eating and drinking can really help. • Providing good postural support should improve head control, which will make it easier and safer to swallow and eat. Note: Improving postural support is just one part of the solution for anyone who has problems with swallowing. Children or adults with problems swallowing should be referred to someone who has experience in managing this. This may include a paediatrician, speech language therapist or community health worker who has knowledge and training in managing swallowing problems. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 36 37 INTERMEDIATE LE VEL Additional postural support can: 1. improve balance, posture and stability; 2. improve comfort; 3. help to prevent the development of pressure sores; 4. help to slow down or prevent the development of problems with posture in the future. A.1. Wheelchair users who benefit from additional postural support : 7 BENEFITS OF AD DITIONAL POST URAL SUPPORT Explain: • Another important bene t of additional postural support is preventing the development of pressure sores. • Pressure sore risk factors are covered in the WSTP Basic Level. Ask: What are the main risk factors for pressure sores (the things that make it more likely a wheelchair user could develop a pressure sore?) Acknowledge correct answers Answers: • Cannot feel (decreased sensation); • cannot move; • moisture from sweat, water or incontinence; • poor diet and not drinking enough water ; • ageing; • weight: underweight or overweight; • poor posture; • previous or current pressure sore; • trauma, bumps or knocks; • heat/fever ; • insect bite. INTERMEDIATE LE VEL • cannot feel (decreased sensation); • cannot move; • moisture from sweat, water or incontinence; • poor posture; • previous or current pressure sore; • poor diet and not drinking enough water; • ageing; • weight: underweight or overweight. A.1. Wheelchair users who benefit from additional postural support : 8 PRESSURE SOR E RISK FACTOR S Explain: • Here is the list of risk factors that are covered in the WSTP Basic Level. • ‘Cannot feel (decreased sensation)’ is in bold – as any wheelchair user who has reduced sensation is automatically at risk of developing a pressure sore. • A wheelchair user with three or more other risk factors may also be at risk of developing a pressure sore. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 36 37 INTERMEDIATE LE VEL • cannot feel (decreased sensation); • cannot move; • moisture from sweat, water or incontinence; • poor posture; • previous or current pressure sore; • poor diet and not drinking enough water; • ageing; • weight: underweight or overweight. A.1. Wheelchair users who benefit from additional postural support : 10 PRESSURE SOR E RISK FACTOR S Explain: • Many wheelchair users who need additional postural support may be unable to move, and are likely to have poor posture. • These are two pressure sore risk factors. • This means that many wheelchair users who use additional postural support could be at risk of developing a pressure sore. • Improving posture will help to reduce this risk. Ask: Why is poor posture a pressure sore risk? (How can poor posture contribute to a pressure sore?) Answers: Poor posture can cause: • Sliding in the wheelchair – which can cause ‘shearing’ forces • Uneven weight distribution causing high pressures under one area (for example more pressure under one seat bone than the other) and can quickly lead to a pressure sore. Explain: Assessing the risk of pressure sores, prescribing solutions that help to prevent pressure sores and providing wheelchair users with good information about how to prevent pressure sores is an important part of wheelchair provision at intermediate level. 4. What do wheelchair users want? (15 minutes) Explain: • We have talked about different ways that additional postural support can help wheelchair users. • However, sometimes wheelchair users nd it hard to get used to a wheelchair that has been prescribed with additional postural support. Sometimes the wheelchair is rejected. Ask: Does anyone have experience of providing a wheelchair with additional postural support and the wheelchair user does not use it? What do they think the reasons for this may be? Encourage answers. As reasons are provided, ask participants if there is anything that could be done to avoid that problem. Supply some examples if necessary. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 38 39 Answers: The reasons why the wheelchair users may reject a wheelchair with additional postural support: What could be done to prevent this: • The wheelchair user nds the wheelchair or additional postural support uncomfortable. • Involve the user as much as possible in the process. • Try to arrange a short trial of equipment before it is nalized. If there are problems these can be xed after the trial. • The wheelchair user’s posture changes; and the wheelchair / additional postural support is no longer comfortable. • Regular follow up can help to ensure that equipment still ts and is comfortable. • The wheelchair user nds that he/she cannot function as well with the additional postural support. • This can be a problem for different reasons. Two common reasons are: - The additional postural support may be impractical and makes functioning harder. For example – the postural support may make it more dif cult to get in and out of the wheelchair. - The wheelchair/additional postural support may be ‘over supporting’ the wheelchair user (bringing them too far from their habitual posture) and the wheelchair user feels uncomfortable/ unbalanced in the new posture; • Check before nalizing equipment that the wheelchair user can carry out the things he/she wants to do (for example transferring). • Avoid making very signi cant changes to the posture of a person who has been sitting in one way for a long time. Consider making changes over time rather than all at once. • The wheelchair user does not like the look of the additional postural support. • Try to make sure that wheelchairs and any additional postural supports are as small and neat as possible. Answers: The reasons why the wheelchair users may reject a wheelchair: What could be done to prevent this: • The wheelchair user (or their family) believes it will make them ‘lazy’ or weaker. • Explain the bene ts of additional postural support. • Reassure wheelchair users (and their family) that when correctly prescribed, additional postural support should not make someone weaker. • Wheelchair service personnel can explain that if a person sits in poor posture, muscles and joints are being pulled out of alignment. This causes the muscles to be stressed and stretched and makes them weaker. Good posture support keeps the body in good alignment. This helps to keep the muscles and joints in the correct position to work well. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 38 39 VIDEO Answers: The reasons why the wheelchair users may reject a wheelchair: What could be done to prevent this: • The environment (home, immediately outside the home or community) is in-accessible. • Wheelchair service personnel can provide some information to the wheelchair user and family about how to make the home and immediate environment more accessible. • Refer the wheelchair user to any organisation that may be able to assist in increasing access – for example community based rehabilitation programme/personnel. INTERMEDIATE LE VEL • Wheelchair and additional postural support that: - is practical and easy to use; - is comfortable; - helps wheelchair users do the things they want and not make things more difficult; - look good and not be too ‘obvious’. A.1. Wheelchair users who benefit from additional postural support : 11 WHAT DO WHE ELCHAIR USER S WANT? Explain: In summary–a wheelchair and additional postural support should always: • be practical and easy to use; • be comfortable and not cause additional discomfort; • help wheelchair users to do the things they want to do and not make them more dif cult; • look good and not be too ‘obvious’. Explain: The best way to make sure additional postural support will be used by wheelchair user is to: • fully involve the wheelchair user in their assessment, prescription and tting; • help the wheelchair user to understand why and how additional postural support will help them; • always let the wheelchair user make the nal decision. Introduce DVD: People using postural support devices. This DVD shows some of the same wheelchair users in the DVD shown earlier. The wheelchair users and some family members talk about why they feel that a wheelchair with the right postural support is helpful to them. Show DVD. Ask if there are any questions. Ask: What were some of the reasons that wheelchair users (or their caregivers) gave for postural support being useful for them? Encourage answers. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 40 41 Answers: • Hussein’s father said that his (Hussein’s) wheelchair tted his body better. He was more comfortable and had no more injury as result of poor support from the wheelchair. • Chaeli said that her trunk supports helped her to become stronger. • Michelle’s (Shelley’s) mother said that Michelle’s wheelchair helped her to have a better quality of life; she can breathe and eat safely; and her posture is well supported. • Ruan’s mother said it has helped her son to eat more easily. • Basila said that her wheelchair helps her to work. Ask participants to look at the checklist on page 12 of the Reference Manual. The checklist can help wheelchair service personnel ensure that any additional postural support they prescribe is most likely to be successful for the wheelchair user. 5. Key point summary (2 minutes) INTERMEDIATE LE VEL • Every well-fitting wheelchair provides the user with some postural support but many children and adults need additional postural support in their wheelchair. • Postural support has many benefits. • Despite these benefits, sometimes wheelchairs with additional postural support are rejected by the users – mostly due to discomfort. • In order to avoid rejection, it is important to: - involve the wheelchair user in their assessment, prescription and fitting; - assist the wheelchair user understand how additional postural support will help them; - always let the wheelchair user make the final decision. A.1. Wheelchair users who benefit from additional postural support : 13 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 40 41 A.2: Children with disabilities O B JE C T IV E S By the end of this session, participants will be able to: describe at least ve features of a wheelchair that are important for children; explain at least two reasons why early referral is important for children; list seven ways to work with children that demonstrate child safety and respect. R E S O U R C E S For the session: PPT Slides: A.2: Children with disabilities; Reference Manual; poster : Children and Wheelchairs; poster : Different Positions; intermediate wheelchair referral form. C O N T E X T Adapt this session to suit the context participants will be working in. Think about: Whether either the host/training organization or participants’ organizations have a child safety policy. In some instances it will be important for all participants to receive and sign a copy of the child safety policy before practical sessions with children begin. T O P R E PA R E Gather training resources, review PPT slides and read through the session plan. Pin up the Children and Wheelchairs poster. Pin up Different Positions poster. O U T L IN E 1. Introduction 2. Wheelchairs that meet children’s needs 3. Different positions 4. Importance of an early referral for children 5. Working with children 6. Key point summary 2 10 15 10 20 3 Total session time 60 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 42 43 1. Introduction (2 minutes) INTERMEDIATE LE VEL • In this session participants will talk about: - how children’s lives and needs are different from adults; - how these differences affect the way wheelchair service personnel work with children with disabilities; - the importance of early referral; - how to work with children with disabilities in a way that respects and protects children’s rights. A.2. Children with disabilities: 2 INTRODUCTIO N Explain: Many children who need a wheelchair also may need additional postural support. For this reason, when talking about intermediate level wheelchair training programme, we need to think about what needs children may have. In this session we will talk about: • how children’s lives and needs are different from adults and how an appropriate wheelchair can meet their unique needs; • how these differences affect the way wheelchair service personnel work with children with disabilities and choices about wheelchairs and additional postural support; • the importance of early referral; • how to work with children in a way that respects and protects children’s rights. 2. Wheelchairs that meet children’s needs (10 minutes) Explain: The lives of young children are different to adults. Children are in the care of adults. They make decisions with the help of those adults, depending on how old they are. Children change activities more frequently, move around a lot and play. Most importantly – children need to go to school. INTERMEDIATE LE VEL The wheelchairs should help children with disabilities to participate like others. A.2. Children with disabilities: 3 WHEELCHAIRS THAT MEET CHI LDREN’S NEEDS The wheelchairs that children use should help children participate in the normal activities that children carry out every day. Ask: What are some features in a wheelchair that would be important for children? Encourage answers. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 42 43 Answers: • If children push themselves, the wheelchair should: - t well to allow them to reach the push rims with comfort; - be light enough for children to control, particularly going up or down hill. • If possible, the wheelchair should emphasize the child – not the wheelchair. • Extended push handles can help family member/caregiver to push the wheelchair without having to bend over. • A wheelchair that can ride over uneven and soft surfaces such as grass and sand will make it easier for children to play with their friends. • A child’s wheelchair should make it easier for them to get to school: - if most children in the child’s community walk to school – think about whether a wheelchair can travel on these paths? Does the child need a wheelchair, which is good for rough terrain? - if the child will go to school in transport (for example car, bus, rickshaw, taxi), think about how the wheelchair will be transported. • The wheelchair should make it easy for them to be at school. Consider whether the wheelchair can go under a desk, or whether the child needs a tray on their wheelchair as a work surface. INTERMEDIATE LE VEL • enable children to push themselves (if they are able); • emphasize the child – not the wheelchair; • have push handles to allow adults to assist; • be able to ride over uneven and soft surfaces such as grass and sand; • make it easier for children to get to school; • make it easier for children to be at school. A.2. Children with disabilities: 4 CHILDREN’S W HEELCHAIRS S HOULD: Summarize: Ideally, children’s wheelchairs should: • enable children to push themselves (if they are able); • emphasize the child – not the wheelchair; • have push handles to allow adults to assist; • be able to ride over uneven and soft surfaces such as grass and sand; • make it easier for children to get to school; • make it easier for children to be at school. 3. Different positions (15 minutes) Explain: • Children do not usually spend much time sitting down. They change the activity they are doing and their position many times during the day. • This means that although a wheelchair is important, children should not spend all day in a wheelchair. • Wheelchair service personnel need to work with children and their family members/caregivers to nd different positions the child can use during the day. • This is particularly important if the child has very limited movement, tends to sit or lie in the same posture all the time. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 44 45 Sitting INTERMEDIATE LE VEL A.2. Children with disabilities: 5 DIFFERENT PO SITIONS – SITT ING Explain: As well as sitting in a wheelchair, children who need additional postural support to sit can be supported in different ways. For example: • Sitting astride a large roll or tightly rolled blanket. • Sitting with support from a family member/ caregiver. The illustration on the slide shows a mother supporting her child with a disability between her legs to help him sit up to eat a biscuit while also supporting her younger child. INTERMEDIATE LE VEL A.2. Children with disabilities: 6 DIFFERENT PO SITIONS – SITT ING • Providing a supportive seat, which is low to the ground: - A seat like this is less expensive than a wheelchair with supportive seating and can be a good option for small children. Standing Explain: Standing is another important position for children. INTERMEDIATE LE VEL A.2. Children with disabilities: 7 DIFFERENT PO SITIONS – STAN DING Explain: • Standing is an important part of every child’s development. • Standing helps to form the hip joints and the normal curves of the trunk. • Anyone who spends a lot of time sitting can develop stiff hip, knee and ankle joints. Standing stretches out the muscles around the hip, knee and ankle joints and helps to prevent these joints from becoming stiff. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 44 45 Explain: • When a child cannot stand independently, a standing frame can help. • To prescribe a standing frame, wheelchair service personnel need to fully understand standing posture and the different ways that standing can be supported. This is not covered in this training programme. • However, if providing a standing frame, always check that there is no pressure applied directly onto the child’s knee caps. The best place to support the legs to prevent the knees from bending is just below the knee cap on the shin bone. INTERMEDIATE LE VEL When providing a standing frame for children under the age of five, remember: • legs should be apart and feet at least as far apart as the hips are wide; • feet and knees should point outwards slightly; • hips and knees should be slightly bent; • never force a young child’s knees and hips completely straight. A.2. Children with disabilities:8 STANDING POS TURE FOR YOU NG CHILDREN Explain: When providing children under the age of ve with a standing frame, there are some important things to remember: • the child’s legs should be apart and their feet at least as far apart as the hips are wide; • the child’s feet and knees should point outwards slightly; • the child’s hips and knees should be slightly bent; • never force a young child’s knees and hips completely straight. Explain: • If a standing frame is used, wheelchair service personnel should advise family members/caregivers how long each day a child should use their standing frame. This is a general guide: – when rst starting 5–10 minutes each day; – never leave a child in a standing frame for longer than 1 hour; – encourage family members/caregivers to nd a fun activity that the child can do in their standing frame, and wherever possible provide a table or tray for activity. Ask: Are standing frames available in the participants’ location? Encourage answers. Lying Explain: Lying is another important position. For children lying on the oor to play is natural. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 46 47 INTERMEDIATE LE VEL A.2. Children with disabilities: 9 DIFFERENT PO SITIONS - LYIN G Explain: • A child with a physical disability may need some support to lie comfortably on the oor: - in this illustration, the child is supported lying on their front. • Children under the age of ve who are lying on their stomach should be supported with a roll under their pelvis to keep their hips in a slightly bent posture. Ask: What materials can family members/caregivers use to help support a child to play on the oor? Answers: • blankets; • foam; • towels; • pillows. INTERMEDIATE LE VEL A.2. Children with disabilities: 10 DIFFERENT PO SITIONS - LYIN G Explain: • In this illustration, the child is supported lying on their side. • Children spend a lot of time sleeping. If a child sleeps in the same posture every night, they may become xed or stiff in that posture. • Wheelchair service personnel can provide advice to family members/caregivers about how to position the child in different ways while he/she is sleeping. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 46 47 4. Importance of an early referral for children (10 minutes) INTERMEDIATE LE VEL A.2. Children with disabilities: 11 IMPORTANCE O F AN EARLY REF ERRAL FOR CHI LDREN Explain: Let’s talk a bit now about how and when children are referred to a wheelchair service. Ask: In the participants’ experience, are children referred for a wheelchair when they are very young, or do parents/referral sources wait until the child becomes too heavy to carry? Encourage answers. Ask: Why are some parents reluctant to bring young children for a wheelchair assessment? Encourage answers. Answers: • parents may be hoping the child will be cured and begin walking; • parents may think that if they give the child a wheelchair, he/she will no longer try to walk; • while children are young and light, it is easier to carry them than manage a wheelchair over dif cult terrain and inaccessible environments; • parents may not have funds to pay for a wheelchair and will delay until it becomes too dif cult to carry the child; • the family may be experiencing guilt or fear that they will be seen in a bad light by others if their child is seen to have a disability. Explain: • Wheelchair service personnel can play a role in educating parents and referral sources about the importance of early referral. • Here are some reasons why early referral is better than delaying: – Children who have dif culty sitting upright can develop postural problems if not well supported. If a child is referred late some postural problems may have become xed (2). This can make it dif cult for the child to sit comfortably even with support. – Without the experience of sitting and being mobile, a child’s development can be delayed (1, 3). – For children who have some ability to walk – using a wheelchair may make their daily life easier and allow them to do more things in a day (1). 2 World Health Organization. (1996). Promoting the development of infants and young children with spina bi da and hydrocephalus. Retrieved from http://whqlibdoc.who.int/hq/1996/WHO_RHB_96.5.pdf 3 Muscular Dystrophy Campain. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 48 49 • It is important to reassure parents and referral sources that a wheelchair is unlikely to prevent a child from walking if this is possible for them. The experience of mobility through a wheelchair while the child is learning to walk will bene t their development in many other ways. Ask: At what age are children without a disability usually able to: • Sit upright independently and without support? Encourage answers. • Pull themselves up to stand? Encourage answers. • Walk alone? Encourage answers. Answers: • Most children: • sit upright on their own without support between 6–8 months; • pull themselves up to stand between 8–10 months; • stand alone without any support and may also be able to walk while holding hands 10–12 months and • walk alone between 12–18 months. INTERMEDIATE LE VEL It is generally agreed that a child should be able to: - sit upright on their own without support between 6–8 months; - pull themselves up to stand between 8–10 months; - stand alone without any support and may also be able to walk while holding hands 10 – 12 months; - walk alone between 12–18 months. A.2. Children with disabilities: 12 KEY MILESTON ES FOR CHILDR EN • Explain: These are key milestones for children that referral sources may identify. INTERMEDIATE LE VEL • have difficulty sitting upright or are not pulling up to stand by the age of 1; or • are not walking alone by the age of 2. • any child who is identified with a significant physical impairments or delayed developmental milestone. A.2. Children with disabilities: 13 REFERRING CH ILDREN TO A W HEELCHAIR SE RVICE Explain: Wheelchair services can encourage referral networks to refer children who: • have dif culty sitting upright or are not pulling up to stand by the age of 1; or • are not walking alone by the age of 2. Where there is a programme of early intervention screening (for example where community health workers are trained to screen children for early intervention), wheelchair services can provide more detailed information to these networks. For example – wheelchair services can suggest that any child identi ed with a signi cant physical problem or delay could be referred to the wheelchair service. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 48 49 Notes for trainers: Participants may ask for more information. Two additional indications that a young child may bene t from early provision of supportive seating are: • Very young children (under the age of one) who tend to be in one type of posture all the time (posture too straight (extended) or too curled up (bent)), who are not able to easily move their limbs, reach or roll, or who have uncontrolled movements. • A child who is able to sit – however sits in the same posture and cannot move easily between postures. Sitting in the same position all the time can lead to problems. Ask participants to look at a copy of the intermediate wheelchair referral form. Explain: • this form can be used by referral organisations to refer wheelchair users to the wheelchair service; • services may adapt this form to suit their service; • the form includes the milestones discussed above. INTERMEDIATE LE VEL A.2. Children with disabilities: 14 SUPPORTIVE S EAT Explain: For very young children who are still light to carry, wheelchair services may offer a supportive seat instead of a wheelchair. This can be used inside the home, and the child can still be carried when outdoors. 5. Working with children (20 minutes) Explain: Whenever working with children it is important to work in a way that both respects and protects children. Ask: What are some of the things that wheelchair service personnel can do to ensure children are respected and protected? Encourage answers. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 50 51 Answers: • always explain to children what you are going to do and why; • involve children in decision making – in an age-appropriate way; • speak with children in a way that they can understand – this means nding a way to explain to children what is happening that they can understand given their age and level of understanding; • allow time for breaks during assessment and tting; • always have a child’s family member/caregiver present when working with a child; • make the space in which you will see children as friendly as possible – for example have some age appropriate toys/activities; posters/images that children enjoy on display; • get permission from children and their family member/caregiver before photographing them. INTERMEDIATE LE VEL • Respect children by: - explaining what you are doing and why – in a way they can understand; - asking permission before beginning the physical assessment; - involving children/their family member/carer in decision making while selecting the appropriate wheelchair; - if children to be assessed in a centre, try to make the area as child friendly as possible. • Keep children safe by: - always asses children with their family member/carer present; - allow time for breaks during appointments as children can easily become tired; - get permission from the child and family member/carer before taking photographs. A.2. Children with disabilities: 15 WORKING WIT H CHILDREN Explain: Key things to remember are: Respect children by: • explaining what you are doing and why in a way that they can understand; • asking permission before beginning physical assessments; • involving children/their family member/ carer in decision making while selecting the appropriate wheelchair • if seeing children in a centre, try to make the area as child friendly as possible. Keep children safe by: • always seeing children with their family member/caregiver present; • allowing time for breaks during appointments as children can easily become tired; • getting permission from the child and family member/caregiver before taking photographs. 6. Key point summary (3 minutes) INTERMEDIATE LE VEL • Children’s lives and needs are different from adults and an appropriate wheelchair can meet their unique needs. • Wheelchair service personnel need to think about other positions children with physical disability can use during the day. • Early referral to the wheelchair service is important for children with disabilities – early mobility, early participation and development. • Respect Rights of the Child. A.2. Children with disabilities: 16 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 50 51 B: Wheelchair service steps WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 52 53 B.1: Assessment overview and assessment interview O B JE C T IV E S By the end of this session, participants will be able to: give an overview of referral and appointment; give a brief summary of the two parts of an intermediate level assessment; list at least eight diagnosis or physical issues that may affect wheelchair users and describe the impact these issues may have on wheelchair provision; list different ways that wheelchair service personnel can improve their communication skills during an assessment. R E S O U R C E S For the session: PPT Slides: B. Referral and Appointment and B.1: Assessment overview and assessment interview; Reference Manual; Participant’s Workbook; DVD: Good communication; intermediate wheelchair assessment form. C O N T E X T A N D P R IO R L E A R N IN G Prior learning: Understanding of the characteristics of different diagnosis/physical issues including: brain injury, cerebral palsy, muscular dystrophy, polio, spina bi da, spinal cord injury, stroke, lower limb amputation. Understanding of the Step 1 of 8 wheelchair service steps – “Referral and appointment” of the Wheelchair Service Training Package–basic level. Basic level assessment including: • understanding the relationship between a wheelchair user’s lifestyle and environment and wheelchair prescription – refer to Wheelchair Service Training Package – Basic Level; • assessing an existing wheelchair to identify whether it meets the wheelchair user’s needs. Adapt this session to suit the context participants will be working in. Think about: Whether a particular type of disability/physical issue is common locally and should be added to the wheelchair assessment form and explained in the session. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 52 53 T O P R E PA R E Gather resources, review PPT slides, watch DVD and read through the session plan. Review the intermediate wheelchair assessment form thoroughly and practise carrying out assessment interview. Review the information on physical conditions on pages 120–125 of the Wheelchair Service Training Package – Basic Level Trainer’s Manual. O U T L IN E 1. Introduction 2. Assessment 3. Assessment interview 4. Good communication skills during an assessment interview 5. Key point summary 10 10 50 15 5 Total session time 90 1. Introduction (10 minutes) INTERMEDIATE LE VEL • It is important to tell referral sources about the service. • A wheelchair referral form can help to give a wheelchair service some initial information about the wheelchair user. • An appointment system can help wheelchair personnel organize their time; and reduces waiting times for wheelchair users. • Referral systems and appointment systems need to be practical for the wheelchair users and wheelchair services. This includes considering how easily people can travel and the different ways that messages can be send. B. Referral and appointment: 5 KEY POINT SUM MARY Explain: Referral and appointment is the rst step in wheelchair service delivery. Show the slides of B.1. Referral and Appointment as outlined in the Wheelchair Service Training Package – Basic Level to refresh and reiterate the importance of step 1. INTERMEDIATE LE VEL • In this session participants will: - explain why assessment is important; - talk about the two parts of assessment; • assessment interview; • physical assessment. - look in detail at the assessment interview; - discuss the importance of good communication skills during assessment; - discuss how to recognise when a wheelchair user who cannot speak or is in pain. Step 2: Assessment Assessment overview and assessment interview B.1. Assessment overview and assessment interview : 2 INTRODUCTIO N Explain: In this session participants we will: • introduce the two parts of assessment – assessment interview and physical assessment; • look in detail at the assessment interview and how discuss how information gathered in the assessment interview will affect wheelchair prescription; • the importance of good communication skills during an assessment; • recognizing when a wheelchair user experiences pain. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 54 55 2. Assessment (10 minutes) INTERMEDIATE LE VEL • The information gained from an assessment helps the wheelchair user and wheelchair service personnel to: - choose the most appropriate wheelchair for the wheelchair user from those available; - choose the most appropriate wheelchair components including postural support devices and accessories from those available; - find out what training the wheelchair user and/or the family need to make the best use of the wheelchair. • Intermediate level needs more careful assessment than basic level. B.1. Assessment overview and assessment interview : 3 WHY DO YOU N EED AN ASSESS MENT? Explain: Assessment is the second of eight wheelchair service steps. Information collected from the assessment is very helpful for the wheelchair service personnel and wheelchair user. • Information gained from an assessment will help the wheelchair service personnel and wheelchair user to: – choose the most appropriate wheelchair from those available; – choose the most appropriate wheelchair components including postural support devices and accessories from those available; – nd out what training the wheelchair user and/or the family need to make the best use of the wheelchair. INTERMEDIATE LE VEL • Assessment is carried out in two parts: - assessment interview; - physical assessment. B.1. Assessment overview and assessment interview : 4 TWO PARTS OF ASSESSMENT Explain: Assessment at both basic and intermediate level is carried out in two parts: • assessment interview; • physical assessment. 3. Assessment interview (50 minutes) Explain: The rst part of the assessment is the assessment interview. During this part of the assessment the wheelchair service personnel gathers information about the wheelchair user. This information will help to identify the most appropriate wheelchair for the wheelchair user. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 54 55 INTERMEDIATE LE VEL The assessment interview components at basic and intermediate level are very similar. These include: • information about the wheelchair user; • physical; • lifestyle and environment; • existing wheelchair. B.1. Assessment overview and assessment interview : 5 ASSESSMENT I NTERVIEW Explain: • The assessment interview components at basic and intermediate level are very similar. These include: - information about the wheelchair user; - physical; - lifestyle and environment; - existing wheelchair. • In this intermediate level programme we will not go over any information that was covered in the Wheelchair Service Training Package – Basic Level. • Participants should be familiar with gathering this information and how it affects wheelchair prescription. • A brief summary is listed in the Reference Manual together with some additional intermediate level information. INTERMEDIATE LE VEL Physical Diagnosis: Brain Injury Cerebral Palsy Muscular Dystrophy Polio Spina Bifida Spinal Cord Injury Stroke Unknown Other ___________________________ Is the condition likely to become worse? Yes No Physical issues: Frail Spasms/uncontrolled movements Muscle tone (high/low) Lower limb amputation: R above knee R below knee L above knee L below knee Fatigue Hip dislocation Epilepsy Problems with eating, drinking and swallowing Describe: ______________________________ Pain Describe location: _________________________________________________________ Bladder problems Bowel problems If the wheelchair user has bladder or bowel problems, is this managed? Yes No B.1. Assessment overview and assessment interview : 6 ASSESSMENT I NTERVIEW – PH YSICAL Explain: Even though the assessment interview components at basic and intermediate levels are very similar, there is more information gathered at intermediate level about the wheelchair user’s diagnosis and any physical issues. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 56 57 Small-group activity Groups: Divide participants into small groups of 2–4. Instructions: Give each group a number (1–5) and assign appropriate assignment in the Participant’s Workbook (B.1: Assessment overview and assessment interview). Ask participants to answer questions assigned to their group in their workbook. Explain: Participants may use the following to help them with the activity: • the Reference Manual; • their own knowledge and experience of working with and learning from people/wheelchair users who have different diagnosis/physical issues described. Explain: Participants have 20 minutes to answer assigned questions. Each group will give feedback to the whole group and provide up to three aspects to be aware of when prescribing a wheelchair for a person with a speci c diagnosis/physical issues. Monitor: Monitor the groups closely. Ensure that each group understands the questions. Encourage groups to use the Reference Manual and their own knowledge. Guide participants if necessary. Time: Allow 20 minutes for the groups to prepare. Allow 10 minutes for feedback and discussion from each group. Please note the time allowed for this activity is based on 4 groups participating, if there are less or more than 4 groups, adjust the time accordingly. Feedback: Ask each group to in turn describe three aspects to be aware of when prescribing a wheelchair for a wheelchair user with a speci c diagnosis/ physical issues. Acknowledge correct answers and correct/clarify any misunderstandings. Allow some discussion – however do not run over time. Note: Trainers should use the notes provided in the Reference Manual to ensure that each group has identi ed appropriate answers. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 56 57 VIDEO 4. Good communication skills during an assessment interview (15 minutes) Explain: Using good communication skills is always important to help to gather the right information in a way, which is respectful and sensitive to the feelings and needs of the wheelchair user. Some ways to help make the assessment interview runs smoothly are: • always address the wheelchair users unless they are small children or they are unable to understand or answer your questions; • explain to the wheelchair user that the information they provide will help choose the most appropriate wheelchair to meet their needs; • questions do not need to be asked in the order given on the intermediate wheelchair assessment form. Sometimes wheelchair users will volunteer information before asked, or it may be more natural to ask questions in a different order. • sometimes, communicating through speech may be dif cult. For example, the wheelchair user may not be able to hear or may not be able to speak clearly enough for you to understand. • when communication is dif cult, try to nd a way to communicate directly with the wheelchair user. Ask the people who know the wheelchair user well, how you can communicate with them. Take the time to understand how the wheelchair user communicates. • if you cannot nd a way to communicate directly, make sure that you have someone who knows the wheelchair user well close by at all times. Ask this person to help you communicate with the wheelchair user. Introduce DVD: Good communication. This video shows a range of different ways that people communicate with each other. Divide the group into two halves based on where people are sitting (participants do not need to move). Explain: Each group should watch the DVD closely and note the different ways that people communicate. Participants should look for: • different ways of communicating (for example sign language); • different examples of good communication technique (for example good eye contact). Show DVD. Ask if there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 58 59 VIDEO Give each group few minutes to write a list of different ways of communicating and different examples of good communication techniques. Ask: What are some of the different ways that people on the DVD communicate? Ask one group to call out their list. Write answers on a whiteboard. For each item – put a tick if the other group also had this answer. Ask the second group if they have any other answers. Answers: • Different verbal communication: - clear speech backed up with demonstrations; - explain and showing; - sounds (vocalisations). • Different non-verbal communication: - gestures; - eye pointing; - nodding; - describing with hands; - connecting; - facial expressions; - sign language; - eye contact; - touch; - asking questions that the wheelchair user can answer with ‘yes’ or ‘no’; using whatever system he/she can to indicate yes or no. • Special communication systems: - communication board; - head pointing; - computer system. • Different ways to make communication better : - good eye contact; - bending down/squatting down to be on the same level as the wheelchair user ; - body language open and relaxed and responsive (facing the wheelchair user, showing interest); - giving people who have dif culty communicating enough time to respond to a question. Introduce the DVD: Good communication. Participants will watch the DVD again and see how many examples they got right. Show the DVD. Acknowledge how many of the points participants identi ed on their rst viewing. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 58 59 Explain: When a wheelchair users are unable to speak, it can be dif cult for them to communicate that they are experiencing pain. Therefore, when working with a wheelchair user – wheelchair service personnel need to know if anything they are doing is causing or increasing wheelchair user’s pain. Ask: How do people usually show that they are in pain? Encourage answers. Answers: • crying; • shouting; • dgeting; • sweating; • pushing the assessor’s hand away or trying to move away; • resisting a movement or being unable to maintain a speci c posture; • expression on face – frowning and/or grimacing; • the way someone sits, stands or walks. Ask: What can you do to make sure you do not cause pain or increase existing pain? Answers: • encourage the wheelchair user to let you know if he/she is experiencing pain during the assessment; • if communication is dif cult – agree on a signal for pain before starting an assessment; • avoid positions that make pain worse; • use positions or movements that make pain less. 5. Key point summary (5 minutes) INTERMEDIATE LE VEL • Assessment is carried out in two parts: - assessment interview; - physical assessment. • All of the interview questions on the wheelchair assessment form are important. The answers can help to build a picture of what will be the most appropriate wheelchair for the user. • Good communication is essential throughout assessment – and all steps of wheelchair provision. • Wheelchair users may communicate in different ways. B.1. Assessment overview and assessment interview : 8 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 60 61 B.2: Physical assessment – sitting posture without support O B JE C T IV E S By the end of this session, participants will be able to: list three differences between child and adult upright sitting posture; observe and record sitting posture using words, drawings or both. R E S O U R C E S For the session: PPT Slides: B.2: Physical assessment – sitting posture without support; Reference Manual; Participant’s Workbook; DVD: Physical assessment overview; intermediate wheelchair assessment form; assessment bed – 1 per group; set of foot blocks. C O N T E X T A N D P R IO R L E A R N IN G Prior learning: Completing the ‘presence, risk of or history of pressure sores’ part of physical assessment and understanding how information gained is likely to affect wheelchair provision. Completing ‘method of pushing’ part of the physical assessment and understanding how information gained is likely to affect wheelchair provision. Basic sitting posture: how to identify and describe an upright sitting posture; understand the bene ts of a sitting upright. How to identify bony landmarks including the Anterior Superior Iliac Spine (ASIS), Posterior Superior Iliac Spine (PSIS) and Ischial Tuberosities (ITs). Adapt this session to suit the context participants will be working in. Think about: When asking participants to nd the ASIS and PSIS on each other and demonstrating this on the volunteer – be aware of any cultural issues related to touching. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 60 61 T O P R E PA R E Gather resources, review PPT slides, watch DVD and read through the session plan. Review the intermediate wheelchair assessment form thoroughly and practise describing or drawing sitting posture without support. Arrange an assessment bed at the front of the training room. Arrange the training room so that participants are seated in a semi-circle facing the front of the room. Place assessment beds around the training room (or outside the room/in adjacent rooms). O U T L IN E 1. Introduction 2. Review of presence, risk or history of pressures sores and method of pushing 3. Overview of the physical assessment 4. Upright sitting posture 5. Upright sitting posture for young children 6. The pelvis is the foundation for sitting posture 7. Observing sitting posture 8. Recording posture 9. Key point summary 5 5 5 20 5 20 8 20 2 Total session time 90 1. Introduction (5 minutes) INTERMEDIATE LE VEL • In this session participants will review: - presence, risk of or history of pressure sores; - method of pushing. • And then focus on ‘sitting posture without support’ including: - review of upright sitting posture for adults and children; - discuss how the pelvis affects sitting posture; - practice observing and recording sitting posture. Step 2: Assessment Physical assessment – sitting posture without support B.2. Physical assessment – sitting posture without support: 2 INTRODUCTIO N Explain: In this session we will introduce physical assessment, which is the second part of the assessment. We will then brie y review two parts of the physical assessment that were introduced during the WSTP Basic Level: • presence, risk of or history of pressure sores; • method of pushing. Explain: We will then focus on the ‘sitting posture without support’ part of physical assessment. We will: • review upright sitting posture for adults and children; • think about how the pelvis affects sitting posture; • practise observing and recording sitting posture. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 62 63 INTERMEDIATE LE VEL • identifying the presence, risk of or history of pressure sores; • identifying the method of pushing; • finding out how the wheelchair user sits and what additional postural support they need through: - observing sitting posture without support; - carrying out a pelvis and hip posture screen; - carrying out a hand simulation; • taking measurements. B.2. Physical assessment – sitting posture without support: 3 PHYSICAL ASSE SSMENT INCLU DES: Explain: Physical assessment includes: • identifying the presence, risk of or history of pressure sores; • identifying the method of pushing; • nding out how the wheelchair user sits and what additional postural support he/ she may need through: - observing sitting posture without support; - carrying out a pelvis and hip posture screen; - carrying out a hand simulation; • taking measurements. Ask: Does anyone know what is meant by the term ‘hand simulation’? Encourage answers. Answer: Hand simulation means using hands to act as the support that a wheelchair and additional postural supports may provide. 2. Review of presence, risk of or history of pressure sores and method of pushing (5 minutes) Explain: The rst two parts of intermediate physical assessment are the same as for the basic level assessment. This includes: • presence, risk of or history of pressure sores; • method of pushing. Explain: In this intermediate level training programme we will not go over any information that was covered in the Wheelchair Service Training Package – Basic Level. Participants should be familiar with gathering this information and how it affects wheelchair prescription. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 62 63 INTERMEDIATE LE VEL 2: Physical Assessment Presence, risk of or history of pressure sores /// = does not feel O = previous pressure sore = existing pressure sore Can feel normally? Yes No Previous pressure sore? Yes No Current pressure sore? Yes No If yes, is it an open sore (stage 1 – 4)? Yes No Duration and cause: _________________________ _________________________________________ Is this person at risk* of a pressure sore? *A person who cannot feel or has 3 or more risk factors is at risk. Risk factors: cannot move, moisture, poor posture, previous / current pressure sore, poor diet, ageing, under or over weight. Yes No B.2. Physical assessment – sitting posture without support: 4 PRESENCE, RISK O F OR HISTORY OF PRESSURE SORE S Explain: It is always important to nd out whether a wheelchair user is at risk of developing a pressure sore. Ask: Does anyone have any questions about this aspect of the assessment? Answer any questions. Remind participants: • If a wheelchair users say that they have had a pressure sore, or if they currently have a pressure sore – ask permission to see it. • It is important to be sure that the wheelchair service personnel assessing, know exactly where the pressure sore is (or was) and whether a referral for a treatment is necessary. INTERMEDIATE LE VEL Method of pushing How will the wheelchair user push their wheelchair? Both arms Left arm Right arm Both legs Left leg Right leg Pushed by a helper Comment: _____________________________________________________________________ B.2. Physical assessment – sitting posture without support: 5 METHOD OF PU SHING Explain: Also just as for basic level wheelchair provision, it is important to identify the best way for the wheelchair user to push their wheelchair. Ask: Does anyone have any questions about this aspect of the assessment? Answer any questions. Remind participants: • To be able to move with as much independence as possible is a basic human right. Even a small amount of independent pushing is worth having. • Providing good postural support can enhance a wheelchair user’s ability to push themselves – and this should be taken into account when assessing how, and how much, a wheelchair user can self-propel. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 64 65 VIDEO 3. Overview of the physical assessment (5 minutes) Introduce the DVD: Physical assessment overview. We will now watch a short DVD, which gives a brief overview of how wheelchair service personnel can work with a wheelchair user to nd out how the wheelchair user sits and what additional support he/she may need. The young girl in the DVD is called Enith. After the interview, the assessor follows this sequence: • observing sitting posture without support; • carrying out a pelvis and hip posture screen; • carrying out a hand simulation. Show the DVD. Explain: • The DVD shows the wheelchair service personnel observing Enith’s posture in her wheelchair. As Enith already has a wheelchair, it is important to know what posture support Enith already has and how well this is supporting her. • We should assume that the wheelchair service personnel also observed Enith’s posture when on the assessment bed, before beginning the pelvis and hip posture screen. Ask if there are any questions. 4. Upright sitting posture (20 minutes) Ask a volunteer to come to the front of the training room and sit on the assessment bed in an upright sitting posture. Ask participants to describe the volunteer’s posture from the side, starting with the pelvis. Participants may have to stand up and move to see. Answers (cover all of these): Side view: • pelvis upright; • trunk upright; • back following its natural curves; • head and neck upright and balanced over the body; • hips bent to around 90 degrees; • knees and ankles bent to around 90 degrees; • feet resting at on the oor (or foot support). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 64 65 Ask participants to describe the volunteer’s posture – this time from the front. Again, ask participants to start with the pelvis. Answers (cover all of these): Front view: • pelvis level; • shoulders level, relaxed and arms free to move; • thighs parallel to each other or angled slightly outward; • head upright and balanced over the body; • trunk in a straight line (not curved or leaning to one side). Thank the volunteer. Explain: The upright posture just described should be used by participants as a guide. When working with wheelchair users, the aim is to support each wheelchair user as close to this posture as is comfortable, practical and functional for the wheelchair user. Explain: • we have talked about why it is important to sit in an upright posture – however not every person is able to sit upright; • wheelchair users that are attending an intermediate level service may demonstrate a range of different sitting postures; • the different sitting postures are caused by part (or parts) of the body not being positioned in neutral; • during the assessment, the wheelchair service personnel and the wheelchair user need to nd the most upright sitting posture that the wheelchair user can safely and comfortably achieve and maintain without losing function; • the wheelchair and PSDs should support this posture; • there are three different nal results that can be found when assessing posture. These are: INTERMEDIATE LE VEL • fixed posture; • flexible to neutral posture; • flexible part way to neutral posture. B.2. Physical assessment – sitting posture without support: 7 WHAT DO THE SE TERMS MEAN ? • xed posture; • exible to neutral posture; • exible part way to neutral posture. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 66 67 Small-group activity Groups: Divide participants into groups of 3. Instructions: Ask participants to discuss amongst themselves what these three terms mean: • xed posture; • exible to neutral posture; • exible part way to neutral posture. Ask them to NOT check their Reference Manual – but to come to their own understanding of these terms. Explain: Participants have 10 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Keep the slide with the three terms up to remind the groups of the question. Monitor each group closely. Ensure that the participants understand the question. Guide participants if necessary. Time: Allow 10 minutes for the activity. Allow 5 minutes for feedback. Feedback: Ask one group to offer their de nition or description of xed posture. • If the de nition/description is clear and correct – acknowledge the answer. If not – ask if any other group can help to clarify. If necessary, the trainer can clarify. Ask a different group to offer their de nition or description of exible to neutral posture. • If the de nition/description is clear and correct – acknowledge the answer. If not – ask if any other group can help to clarify. If necessary, the trainer can clarify. Ask a different group to offer their de nition or description of exible part way to neutral posture. • If the de nition/description is clear and correct – acknowledge the answer. If not – ask if any other group can help to clarify. If necessary, the trainer can clarify. Answers: Fixed posture: • The wheelchair user has a part of the body, which is ‘ xed’. With gentle force there is no movement (strong force should never be used). Flexible to neutral posture: • With gentle force the parts of the wheelchair user’s body that are not in neutral can be brought to neutral. Flexible part way to neutral posture: • With gentle force the parts of the wheelchair user’s body that are not in neutral can be moved only part way toward neutral. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 66 67 Explain: • These terms are described in the Reference Manual. It is important for wheelchair service personnel to consider carefully when supporting a wheelchair user how exible towards neutral posture the wheelchair users are. INTERMEDIATE LE VEL • Fixed posture: - provide support to accommodate the non-neutral (fixed) posture. • Flexible to neutral posture: - provide support to help the wheelchair user maintain a neutral sitting posture. • Flexible part way to neutral posture: - provide support to help the wheelchair user sit as close to neutral posture as is comfortable for them. B.2. Physical assessment – sitting posture without support: 8 HOW CLOSE TO NEUTRAL? • For xed posture – the wheelchair user has a part of the body, which is ‘ xed’. With gentle force there is no movement (strong force should never be used). Wheelchair service personnel should provide support to accommodate the non-neutral ( xed) posture. • For exible to neutral posture – with gentle force the parts of the wheelchair user’s body that are not in neutral can be brought to neutral. In this situation the right support should be given to help the wheelchair user maintain a neutral sitting posture. • For exible part way to neutral posture – with gentle force the parts of the wheelchair user’s body that are not in neutral can be moved only part way toward neutral. In this situation support is given to help the wheelchair user sit as close to neutral posture as is comfortable and functional for them. • Remember that new problems may be created if a wheelchair user is supported in a posture, which is closer to neutral than is comfortable or functional for them. Assessment is therefore very important and needs to consider the wheelchair user’s comfort and function as well as how close to ‘upright sitting posture’ he/she can sit. 5. Upright sitting posture for young children (5 minutes) Explain: Children under the age of ve do not have the same upright sitting posture as older children and adults. The sitting posture develops over the rst ve years of the child’s life. INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 9 CHILD SITTING POSTURE Explain: In this slide, the child is three years old. Both the child and the adult in the slide are in an upright sitting posture. Ask: What differences can participants see between the child and the adult postures? Encourage answers. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 68 69 Answers: Child under ve years old: Adult: • trunk upright, but there are no lumbar or thoracic curves; • the child’s ear and hips are in line however their shoulders are slightly further forward; • legs are rolled outwards and apart – not parallel. • trunk upright, with the back following its natural curves; • the ear, shoulders and hips are in line; • legs parallel to each other or angled slightly outward. INTERMEDIATE LE VEL • Flat back with no lumbar or thoracic curves. • Ears and hips - in line, shoulders – further forward. • Legs – rolled outwards and apart. B.2. Physical assessment – sitting posture without support: 10 CHILD SITTING P OSTURE (UNDER FIVE YEARS OLD ) Explain: The most important differences before the age of ve are: • the child’s back is at and there are no lumbar or thoracic curves; • the child’s ears and hips are in line however their shoulders are slightly further forward; • legs are rolled outwards and apart – not parallel. Explain: When working with children under the age of ve, wheelchair service personnel need to remember that children under the age of ve should not be given support to encourage an adult upright sitting posture. This would be uncomfortable and could cause the child harm. 6. The pelvis is the foundation of sitting posture (20 minutes) Ask: Does a change in the posture of the pelvis affect the rest of the body? Answer: • yes – movement or changes in posture of the pelvis always affect the rest of the body; • the pelvis is the ‘foundation’ of sitting posture. INTERMEDIATE LE VEL Back/posterior Front/anterior Side/ lateral B.2. Physical assessment – sitting posture without support: 11 THE PELVIS IS TH E FOUNDATION OF SITTING PO STURE Explain: We will look at this in more detail now. Understanding how the pelvis affects the rest of the body is a very important part of the intermediate level training programme. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 68 69 INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 13 SIDE VIEW OF P ELVIS Ask: Where is the PSIS and the ASIS on this illustration? Explain: From the side view – the ASIS and PSIS are at the same height. INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 13 FRONT VIEW O F PELVIS Explain: From the front view – the left and right ASIS are level. INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 14 CHECK – IS THE PELVIS LEVEL? Ask a volunteer to come to the front of the training room and sit on the assessment bed in an upright sitting posture. Demonstrate on the volunteer by pointing out the ASIS and PSIS. Place your hands on the volunteer’s pelvis and show how you can gently hold the pelvis with both hands. Thumbs placed on each ASIS and ngers curved towards the back of the pelvis. Ask participants to try this on each other (if not already familiar with this technique), ensuring that each person can nd the ASIS and PSIS on their partner. Thank the volunteer. Ask: Apart from upright or neutral, what other pelvis postures are there? Answers (cover all of these): • anterior/forward tilt (ASIS is lower than PSIS – or top of pelvis moves forward); • posterior/backwards tilt (PSIS is lower than ASIS – or top of pelvis moves backwards); • lateral/sideways tilt (one side of the pelvis is lower than the other); • rotation (one side of the pelvis is rotating forward/backward relative to the opposing side). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 70 71 Common abbreviations in this section Anatomical structure Abbreviation Anterior Superior Iliac Spine ASIS Posterior Superior Iliac Spine PSIS Ischial Tuberosity IT Small-group activity Groups: Divide participants into groups of 4. Instructions: Ask participants to look at Participant’s Workbook (B.2: Physical assessment –sitting posture without support: foundation of sitting posture). Explain: Each group should work together to identify what changes happen to upright sitting posture when pelvis posture changes from upright to anterior tilt, posterior tilt, lateral tilt and rotation. Explain: Participants have 10 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Monitor the groups closely. Ensure that each group understands the questions. Guide participants if necessary. Time: Allow 10 minutes for the groups to prepare. Allow 5 minutes for feedback and discussion. Feedback: Ask: Did each group nd that with the different pelvis postures the rest of the posture changed? Ask Group one: What changes to posture happen with anterior tilt? Ask Group two: What changes to posture happen with posterior tilt? Ask Group three: What changes to posture happen with lateral tilt? Ask Group four: What changes to posture happen with rotation? Answers: Pelvis posture: • anterior tilt • posterior tilt • lateral tilt • rotation Whole body posture (main points around trunk): • trunk extended, increased curve in the lower back (lordosis); • trunk rounds/bends, causes ‘slumped’ posture (kyphosis); • trunk bends sideways (scoliosis); • trunk also rotates. Explain: • The most important point to remember is that the posture of the pelvis will always affect the rest of the body. • When assessing a wheelchair user’s posture, always begin with looking at what the pelvis is doing. When providing postural support, always work to support the pelvis rst. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 70 71 7. Observing sitting posture (8 minutes) Explain: A starting point for understanding the wheelchair user’s sitting posture and what support may be needed is to observe the wheelchair user’s sitting posture – without support. INTERMEDIATE LE VEL • Ensure the wheelchair user’s feet are well supported. • Ensure someone sits with the wheelchair user if they cannot sit safely on their own. • Observe whether the wheelchair user can sit in an upright sitting posture without support. B.2. Physical assessment – sitting posture without support: 15 OBSERVING SIT TING POSTURE WITHOUT SUP PORT Explain: • During assessment, wheelchair service personnel will begin observing the wheelchair user’s posture even during the interview. • At the beginning of the physical assessment, ask the wheelchair user to transfer to an assessment bed. • Make sure the wheelchair user is safe and that their feet are supported. • Provide enough support to ensure the person is sitting safely and cannot fall. An assistant or family member/caregiver may provide this support. • The purpose of observing sitting posture without support is to understand the wheelchair user’s postural tendency/habits. • Observing posture is a skill, which takes time and practice to develop. • We will now look at four different sitting postures – and see how good our skills are at observing different postures. Notes for trainers: • emphasize observing the posture of the pelvis rst – then trunk, head and neck, legs; • if participants nd this activity dif cult, suggest that they mirror the posture themselves so that they can feel it. This may assist with their understanding and observation of each different sitting posture. INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 16 POSTURE 1 Ask: What do participants observe about this person’s posture? Answers: • pelvis tilted forward; • lower back arched; • shoulders back; • neck extended. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 72 73 INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 17 POSTURE 2 Ask: What do participants observe about this person’s posture? Answers: • pelvis rolled back; • hips more open (trunk to thigh angle is more than 90 degrees); • lower back rounded; • neck extends slightly. INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 18 POSTURE 3 Ask: What do participants observe about this person’s posture? Answers: • pelvis lower on right side (always name the lower side); • pelvis appears to be rotated backwards on the right (rotation is often associated with an asymmetrical sitting posture, but not always); • sideways curve in spine with peak of curve on the right; • shoulders not level (lower on the right). INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 19 POSTURE 4 Ask: What do participants observe about this person’s posture? Answers: • pelvis rotated backward on right side (always name the direction and side – e.g. back on the right side); • some trunk rotation (back on the left side); • right leg is falling and rolling outwards and the left leg has rolled inwards. Notes for trainers: For the last posture – if participants do not easily notice the trunk rotation, ask: Does it look as though this boy’s back would be at against the backrest, with even pressure across his whole back? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 72 73 8. Recording posture (20 minutes) INTERMEDIATE LE VEL Sitting posture without support Describe or draw sitting posture without support: B.2. Physical assessment – sitting posture without support: 20 RECORDING SIT TING POSTURE WITHOUT SUP PORT Explain: • On the intermediate wheelchair assessment form there is space to record the wheelchair user`s sitting posture without support. • This record can help the wheelchair service personnel: - to remember the wheelchair user’s sitting posture after the assessment; - to track changes over time. INTERMEDIATE LE VEL • use words; • draw a picture; • take a photograph. B.2. Physical assessment – sitting posture without support: 21 HOW TO RECO RD POSTURE There are a few different ways to record sitting posture including: • describing posture in words – which is what we were just practising; • drawing a picture; • taking photographs (only with permission from the wheelchair user). Explain: • if it is possible to use photographs, wheelchair services need to establish a clear policy about taking and storing photographs; INTERMEDIATE LE VEL • Always get permission from the wheelchair user. • Always ensure that photographs taken for assessment purposes are kept private. • Photograph from: - side; - front; - other. B.2. Physical assessment – sitting posture without support: 22 WHEN TAKING PHOTOGRAPH S • always get permission from the wheelchair users; or the wheelchair user’s family member/caregiver if they are a child; • always ensure that photographs taken for assessment purposes are kept private; • do not use photographs for training purposes (or any other purpose) unless speci c permission has been given by the wheelchair user; • when taking photographs to record posture photograph from the side and front. Other views may also be helpful. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 74 75 Explain: Drawing posture takes some practice. However here is a simple way to record posture using a basic line drawing system. Developing a line drawing method is very helpful for wheelchair service personnel, and can be used easily and effectively. INTERMEDIATE LE VEL Pelvis Leg Trunk Head B.2. Physical assessment – sitting posture without support: 23 SIDE VIEW Explain: This is a simple way to draw upright sitting posture from a side view: • use a triangle to represent the pelvis; • use a wavy line to represent the spine; • use straight lines for legs; • add a circle for the head. INTERMEDIATE LE VEL Cervical curve Lumbar curve Thoracic curve Head B.2. Physical assessment – sitting posture without support: 24 SIDE VIEW SIT TING POSTUR E (UPRIGHT SI TTING) Explain: • The line for the spine shows the normal curves of the spine – (cervical, thoracic and lumbar). • The IT, PSIS and ASIS are represented by the points of the triangle. Ask participants to make the line drawings. INTERMEDIATE LE VEL Pelvis Leg Trunk B.2. Physical assessment – sitting posture without support: 25 FRONT VIEW Explain: This is a simple way to draw an upright sitting posture from a front view. • use a double triangle to represent the pelvis; • use a line to represent the trunk; • use lines to represent the thighs (in this illustration the short line) and calves (see Notes for trainers below); • in this illustration knees are shown with a small circle between the thigh and calf lines and feet are drawn with a small square. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 74 75 INTERMEDIATE LE VEL Shoulders Upright sitting Head B.2. Physical assessment – sitting posture without support: 26 FRONT VIEW • use a straight line across for shoulders; • use a circle for the head. Ask participants to look at Participant’s Workbook (B.2: Physical assessment–sitting posture without support: posture drawing) and draw their own line drawing next to each drawing in their workbook. Explain: Participants can use this simple way of drawing posture to record different postures and we will practise this during the rest of the session. INTERMEDIATE LE VEL B.2. Physical assessment – sitting posture without support: 27 ROTATED PELV IS Explain: If a wheelchair user’s pelvis is rotated, it is possible to draw a curved arrow like this to show, which side of the pelvis is rotated backwards. Ask participants to copy this into their workbook. Notes for trainers: The example line drawings used in this session can be adapted / modi ed to suit individuals. For example, some people may choose to draw leg postures from above. This avoids the effect of ‘foreshortening’ the legs when drawn from the front. In the system described – the thighs look shorter than the calves; and the thighs are slightly abducted. Small-group activity Groups: Divide participants into the groups of 3. Instructions: Ask each group to look at the postures shown in Participant’s Workbook (B.2: Physical assessment–sitting posture without support: posture drawing). Explain that these are illustrations of real people. Ask the group to work together to record the sitting posture shown with a line drawing on the ‘sitting posture without support’ part of the intermediate wheelchair assessment form provided in their workbooks. Explain: Participants have 10 minutes as a group to do this activity and then the groups will come back together for feedback. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 76 77 Monitor: Monitor the groups closely. Ensure that each group understands the activity. Guide participants if necessary. Time: Allow 10 minutes for the activity. Allow 5 minutes for feedback. Feedback: If a whiteboard is available, project each illustration (one at a time) onto the whiteboard. Ask a participant from each group to draw the line drawing over each projected posture. If the whiteboard in not available, ask participants to follow along on their copy while the trainer explains/ draws on the board. Discuss any dif culties participants had with using the line drawing system. Explain that it can be helpful to combine line drawing and words. Example line drawings for trainer: 9. Key point summary (2 minutes) INTERMEDIATE LE VEL • the pelvis is the foundation of sitting posture. Any changes to pelvis posture affect the rest of the body. • the upright sitting posture of a young child and an adult is not the same. • the first part of the hands-on physical assessment is to observe the wheelchair user’s sitting posture without support. • to observe and record posture, wheelchair service personnel may use words, drawings or photographs. B.2. Physical assessment – sitting posture without support: 32 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 76 77 B.3: Physical assessment – pelvis and hip posture screen O B JE C T IV E S By the end of this session, participants will be able to: demonstrate a wheelchair user’s pelvis and hips posture screen to nd out: • if the wheelchair user’s pelvis can be level; • if both hips can bend to neutral sitting posture. demonstrate making a temporary support to accommodate an unlevel pelvis and for when one or both hips cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees). R E S O U R C E S For the session: PPT Slides: B.3 Physical assessment – pelvis and hip posture screen; Reference Manual; Participant’s Workbook; DVD: Pelvis and hip posture screen; DVD: Temporary supports; intermediate wheelchair assessment form; assessment bed – 1 for each group; goniometer/cardboard goniometer – 1 for each group; blocks of rm foam – 1 for each group; wedges of rm foam – 1 for each group; cushion that has been modi ed to support xed unlevel pelvis; cushion that has been modi ed to support a hip that cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees); cushion that has been modi ed to support one hip or both hips that cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees). C O N T E X T A N D P R IO R L E A R N IN G Prior learning: an ability to use a goniometer is helpful, however not essential. Adapt this session to suit the context participants will be working in: consider where assessments will be carried out; when demonstrating temporary supports on the volunteers and asking participants to carry out a pelvis and hip posture screen on each other – be aware of any cultural issues related to touching. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 78 79 T O P R E PA R E Gather resources, review PPT slides, watch DVDs and read through the session plan. Review the intermediate wheelchair assessment form thoroughly and practise carrying out the pelvis and hip posture screen. Practise providing a temporary support. Arrange an assessment bed at the front of the training room. Place the blocks and wedges of rm foam on the assessment bed ready to use as demonstration. Arrange the training room so that participants are seated in a semi-circle facing the front of the room. Place assessment beds around the training room (or outside the room/in adjacent rooms) for participants to carry out small group activity. O U T L IN E 1. Introduction 2. Pelvis and hip posture screen 3. Temporary supports for xed unlevel pelvis or hips that cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees) 4. Demonstration of temporary support for xed unlevel pelvis 5. Demonstration of temporary support for the hips that cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees) 6. Practising temporary supports 7. Key point summary 2 40 5 10 30 30 3 Total session time 120 1. Introduction (2 minutes) Explain: In this session we will continue learning about the physical assessment. INTERMEDIATE LE VEL • In this session participants will talk about: - pelvis and hip posture screen; - temporary supports for pelvis and hip problems. Step 2: Assessment Physical assessment - pelvis and hip posture screen B.3. Physical assessment – pelvis and hip posture screen: 2 INTRODUCTIO N In this session we will talk about: • the pelvis and hip posture screen; • providing temporary supports for pelvis and hip problems. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 78 79 2. Pelvis and hip posture screen (40 minutes) Notes for trainers: The pelvis and hip posture screen that is taught in this training programme is NOT a full Range of Motion assessment. Pelvis: • the screen is only to identify whether the pelvis can be level or not; • this is because it is dif cult to carry out the next stage of physical assessment (hand simulation) without accommodating an unlevel pelvis. Hips: • only hip exion is assessed; • this is because it is dif cult to carry out the next stage of physical assessment (hand simulation) without accommodating any xed restrictions when the hip is bent; • the reference or starting point is the bent hip neutral sitting posture (90 degree angle between the trunk and thighs). Participants are taught to identify: • Can the wheelchair user sit in neutral posture with support? • If not – how close to the neutral posture can he/she is able to sit? • this then relates directly to the wheelchair seat to backrest angle. Ask participants to look at the ‘pelvis and hip posture screen’ part of their copy of the intermediate wheelchair assessment form. INTERMEDIATE LE VEL Pelvis and hip posture screen Check if pelvis is level and hip flexion range in lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: _______ Left hip: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. B.3. Physical assessment – pelvis and hip posture screen: 3 INTERMEDIATE WHEELCHAIR ASSESSMENT F ORM Explain: We know that sitting posture is in uenced by what is happening around the pelvis and the hips. In this part of the assessment wheelchair service personnel need to nd out: • if the wheelchair user’s pelvis is level when viewed from the front. This may be with or without support; • if the wheelchair user’s hips are able to bend to a neutral sitting posture. This may be with or without support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 80 81 INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 4 PELVIS LEVEL, H IPS NEUTRAL S ITTING POSTU RE Explain: • Here you can see that this child’s pelvis is level and his hips are in neutral sitting posture. • Note the wheelchair service provider assessing has her thumbs on the child’s Anterior Superior Iliac Spine (ASIS) so that she can clearly see that the pelvis is level. INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 5 POSTURE OBSE RVATION Ask: Is this man’s pelvis level and his hips in neutral sitting posture? Answer : No If the pelvis is not level or the hips not bent to neutral sitting posture (trunk to thigh angle more than 90 degrees), the wheelchair service personnel must nd out more information. It is important to know: • can the wheelchair user sit in neutral with the support? • if not – how close to the neutral posture can he/she is able to sit? Explain: We know that the pelvis can move in different ways including anterior tilt, posterior tilt, lateral tilt and rotation. Ask participants to move their pelvis in different directions and think about where the movement actually occurs. They may place their hands under their seat bones or look at the person sitting next to them to help work this out. Ask: Where does the pelvis movement happen? Encourage answers. Most important answers: • above the pelvis (in the lumbar spine); • at the bottom of the pelvis (at the hip joint). Explain: If the wheelchair user cannot sit in a neutral sitting posture we need to nd out whether this is due to a limit (or restriction) above the pelvis or at the bottom of the pelvis. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 80 81 INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 6 SIMILAR POSTU RES BUT DIFFE RENT REASON S Explain: Here is an example: • this man is sitting in a slumped posture and his pelvis is in posterior tilt; • from just observing we cannot tell whether this posture is caused by limit (restriction) above the pelvis or below the pelvis (hip joint). This means that a pelvis and hip posture screen is necessary. INTERMEDIATE LE VEL Pelvis and hip posture screen Check if pelvis is level and hip flexion range in lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: _______ Left hip: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. B.3. Physical assessment – pelvis and hip posture screen: 7 QUESTION: CA N THE PELVIS B E LEVEL? Explain: The rst question on this part of the intermediate wheelchair assessment form is: • Can the pelvis be level? Ask: Why is it important to nd this out? Most important answer: • if the person’s pelvis cannot be level, this will affect their sitting posture. INTERMEDIATE LE VEL Pelvis and hip posture screen Check if pelvis is level and hip flexion range in lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: _______ Left hip: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. B.3. Physical assessment – pelvis and hip posture screen: 8 QUESTION: CA N THE HIP BEN D TO NEUTRAL ? Explain: After assessing if the pelvis can be level, wheelchair service personnel identify whether the hips can bend to neutral sitting posture. Emphasize: This assessment is not a full Range of Motion assessment. Only assess hip in bending position to nd out: • Can the wheelchair user sit in neutral posture with the support? • If not – how close to the neutral posture can he/she is able to sit? INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 9 ANGLE BETWE EN THE TRUNK AND THE THIG H Explain: In this slide the line drawing shows one hip that is not in neutral sitting posture (leg shown in red). Ask: Is the angle between the trunk and the thigh (red line) more or less than 90 degrees? Encourage answers. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 82 83 INTERMEDIATE LE VEL • The trunk to thigh angle is LESS than 90 degrees. • The trunk to thigh angle is approximately 70 degrees. B.3. Physical assessment – pelvis and hip posture screen: 10 ANGLE BETWE EN THE TRUNK AND THE THIG H Answer: • LESS than 90 degrees (approximately 70 degrees). INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 11 ANGLE BETWE EN THE TRUNK AND THE THIG H Explain: In this slide the line drawing shows one hip that is not neutral sitting posture (leg shown in red). Ask: Is the angle between the trunk and the thigh (red line) more or less than 90 degrees? Encourage answers. INTERMEDIATE LE VEL • The trunk to thigh angle is MORE than 90 degrees. • The trunk to thigh angle is approximately 100 degrees. B.3. Physical assessment – pelvis and hip posture screen: 12 ANGLE BETWE EN THE TRUNK AND THE THIG H Answer: MORE than 90 degrees (approximately 100 degrees). Ask: Why is it important to nd out if the hip can bend to neutral sitting posture? Encourage answers. Answers: • If one or both hips cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees) – this will affect the wheelchair user’s ability to sit upright. • The hip(s) will need to be accommodated – so that the wheelchair user can sit with their pelvis upright (if this is possible for them). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 82 83 VIDEO INTERMEDIATE LE VEL Pelvis and hip posture screen Check if pelvis is level and hip flexion range in lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: _______ Left hip: Yes No Angle: ______ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. B.3. Physical assessment – pelvis and hip posture screen: 13 IF NEUTRAL IS NOT POSSIBLE ? • If the pelvis cannot be level or if either hip cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees), this will need to be supported in the non-neutral sitting posture in the nal wheelchair. • To continue the assessment, a temporary support should be made for the wheelchair user to sit on. • This will be explained later in this session. Introduce DVD: Pelvis and hip posture screen. This short DVD will show a pelvis and hip posture screen. Ask participants to watch closely because they will practise this on each other afterwards. Show DVD. Ask if there are any questions. Small-group activity Groups: Divide participants into groups of 3. Instructions: Ask participants to look at Participant’s Workbook (B.3: Physical assessment – pelvis and hip posture screen: carrying out the screening). Ask participants to take turns being the wheelchair user, assistant and the wheelchair service personnel. Practise carrying out pelvis and hip posture screen. Ask participants to record the results for each person taking on the role of wheelchair user in the group on the ‘pelvis and hip posture screen’ part of the intermediate wheelchair assessment form in their workbooks. Explain: Participants have 20 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Monitor each group closely and ensure that the person taking on the role of wheelchair service personnel: • positions themselves correctly; • places their hands on the wheelchair user’s pelvis, hips and limbs correctly; • bends the wheelchair user’s legs at the knee (placing a roll/support under the knees); • use hands that are “soft” and does not grip or pinch the wheelchair user. (Use the Notes for trainers under `carrying out a pelvis and hip posture screen` to check that the groups are following the correct steps). Ensure that each group understands the activity. Guide participants if necessary. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 84 85 Time: Allow 20 minutes for the activity. Allow 5 minutes for feedback. Feedback: Ask if anyone has any questions. Ask: For people who had no restrictions, how did the groups complete the `pelvis and hip posture screen` part of the intermediate wheelchair assessment form? (Project a blank intermediate wheelchair assessment form onto the white board). Answer: Tick ‘yes’ for pelvis level; Tick ‘Yes’ for right and left hips. Ask: Did anyone have any restrictions? If yes – ask for more information from the group. Notes for trainers: Trainers may choose whether to teach the hip posture screen part of the assessment using a goniometer, or a cardboard goniometer. If participants are already familiar with using a goniometer, then this is the most sensible choice. If participants have not used a goniometer before, the use of a simple cardboard goniometer with angles marked at 45 degree intervals is suf cient. Notes for trainers: Carrying out a pelvis and hip posture screen: When monitoring the small- group activity above, ensure participants carry out the pelvis and hip posture screen as described below: Prepare: • explain to the wheelchair user what you are going to do and why it is important; • ask the wheelchair user to lie down on their back on an assessment bed. Please note the person carrying out a pelvis and hip posture screen is called the ‘assessor’ and the person who assists the assessors is called ‘assistant’, who could be a co-worker, trained assistant, family member or caregiver). Pelvis posture screen: • assessor bends both the wheelchair user’s knees slightly and provides some support, which helps to relieve tension on the hips; • assistant places their hands rmly on the wheelchair user’s trunk, around their lower ribs; • assessor grips the pelvis gently with thumbs on the ASIS; • assessor checks if thumbs/ASIS are level; • if not level, assessor gently but rmly tries to align the pelvis so that both ASIS are level; • assistant reports if he/she feels the trunk move, which means that there is some restriction to the movement; • note how close to neutral/level it is possible to bring the pelvis; • assessor records if the pelvis can be level on the intermediate wheelchair assessment form. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 84 85 Hip posture screen: • assistant gently but rmly holds the wheelchair user’s pelvis; • assessor bends the leg that is not being tested slightly at the knee, resting the foot on the mat. This helps to reduce the tension in the hip being tested. This leg may need to be supported. • assessor gently moves the leg being tested into the neutral sitting posture; • assistant reports if he/she feels the pelvis move, which means that there is some limit(restriction) to the movement; • assessor feels how freely the hip joint can move; • assessor repeats on the other side and compares; • assessor records if right and left hip can bend to neutral sitting posture on the intermediate wheelchair assessment form. • assessor records how close to neutral posture each hip can reach with a goniometer with the help of an assistant; • assessor places the pivot point of the goniometer on the hip joint. Assessor positions one arm of the goniometer along the thigh bone and one arm in line with the trunk; • assessor holds the two arms together rmly; • assessor records right and left hip angle degree measurements on the intermediate wheelchair assessment form. Assessor can also draw the angle of the goniometer on a separate piece of paper or on the back of the intermediate wheelchair assessment form. 3. Temporary supports for fixed unlevel (lateral tilt) pelvis and hips that cannot bend to neutral sitting posture (5 minutes) Explain: If the pelvis cannot be level or one or both hips cannot bend to a neutral sitting posture (trunk to thigh angle more than 90 degrees), this will need to be supported in the non-neutral posture in the nal wheelchair. To continue the assessment, a temporary support should be made for the wheelchair user to sit on. Ask: Why is it necessary to have the wheelchair user sit on a temporary support to continue with the rest of the assessment? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 86 87 Answers: • During an assessment, the temporary support will: - help the wheelchair user to sit with more stability and balance; - stop the wheelchair user from compensating for the unlevel pelvis or hips that cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees); - allow the wheelchair service personnel to carry on the assessment and concentrate on the rest of the wheelchair user’s posture including pelvis, trunk, head, neck and legs. INTERMEDIATE LE VEL • A temporary support is needed if: - the wheelchair user’s pelvis cannot be level (fixed unlevel pelvis); - one or both of the wheelchair user’s hips have a trunk to thigh angle more or less than 90 degrees. • To continue the assessment, a temporary support should be made for the wheelchair user to sit on. B.3. Physical assessment – pelvis and hip posture screen: 15 TEMPORARY SU PPORTS Explain: Temporary supports are needed for: • xed unlevel pelvis (lateral tilt); • hip that cannot bend all the way to neutral sitting posture (trunk to thigh angle more than 90 degrees); • both hips that cannot bend all the way to neutral sitting posture (trunk to thigh angle less than 90 degrees); • one or both hips that cannot open all the way to neutral sitting posture (trunk to thigh angle less than 90 degrees). After the assessment, this temporary support will be made permanent and will be built into the wheelchair user’s cushion. Explain: • a temporary support can be made from a block of rm foam; • ideally it should be made from the same material as the base of the cushion; • by using the same material, the exact dimension of the material can be decided during the assessment as the compression of the material will be the same; • for this reason it is helpful to have available during assessment blocks and wedges of rm foam; • different height pieces (for example 10 mm, 20 mm, 30 mm) can be combined to make different overall height pieces. Show example blocks and wedges of rm foam. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 86 87 4. Demonstration of temporary support for xed unlevel pelvis (10 minutes) Ask a volunteer to come to the front of the training room and sit on the assessment bed. Demonstrate: Explain: • ask the volunteer to sit with a xed unlevel pelvis (lateral tilt). For a wheelchair user who has a xed unlevel pelvis: • one side of the pelvis and one thigh carry more weight than the other side. This causes a pressure sore risk. The wheelchair user is also not stable as he/she only sits on one side; • the aim is to raise the seat surface to support the higher seat bone. • The temporary support forms a build-up under the high side. • The temporary support should be under the seat bone and thigh. The support will not change the pelvis posture. • However now there is support under the raised seat bone and the wheelchair user will feel more balanced with even pressure under both seat bones. • place the temporary support under the high seat bone of the volunteer. • make sure temporary support extends forward to support the thigh (to just behind the knee). • demonstrate testing the pressure with ngers placed under both seat bones (palm up) and on top of the seat surface. • This can be tested by placing ngers under each seat bone (palm up) simultaneously with the trunk supported and aligned. Thank the volunteer. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 88 89 INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 17 TEMPORARY SU PPORT: FIXED U N-LEVEL PELVIS Explain: • the wheelchair service personnel can now assess the rest of the pelvis and trunk posture; • in the nal wheelchair this support will be built into the cushion. If available – show a cushion that has been modi ed to support a xed unlevel pelvis. Notes for trainers: • When a person has a xed unlevel pelvis, the temporary support is accommodating the posture. It is not correcting the posture. • In the nal product, the wheelchair user will continue to have an asymmetrical posture. The pelvis and thigh on the one side will be higher than the other. The knee and the footrest will also be higher on that side as well. • When providing temporary support for a xed unlevel pelvis: - make sure that the support extends under the length of the thigh. Without extending the support forward, there is a danger that weight bearing will not be equal under both thighs; - make sure that there is still a pre seat bone shelf. This will help to reduce the tendency to slide forward, which can cause shear and lead to pressure sores. 5. Demonstration of temporary support for the hips that cannot bend or open to neutral sitting posture (30 minutes) Explain: Now we will look at temporary support for hip that cannot bend all the way to neutral sitting posture (trunk to thigh angle more than 90 degrees). Ask a volunteer to come to the front of the training room and sit on the assessment bed. Demonstrate: Explain: • Ask volunteer to sit with their RIGHT hip xed with a trunk to thigh angle MORE than 90 degrees. • When sitting with one stiff hip that cannot bend to neutral (trunk to thigh angle more than 90 degrees) – the pelvis will tilt to the side and may also roll back and rotate. • This causes poor posture of the pelvis and trunk and uneven weight bearing under the seat bones. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 88 89 • Place the temporary support under both seat bones and the LEFT thigh (the side where the hip bends to neutral sitting posture) • A build-up is made under both seat bones and the thigh of the hip that can bend to neutral sitting posture. The hip that is xed at an angle more than neutral is then able to rest down. • The height of the build-up should be high enough to support the degree of restriction in the hip. • Show the triangular gap created between the RIGHT thigh and the assessment bed. • There will be a triangular gap between the thigh and the assessment bed. • This should be the same as the angle recorded during the hip posture screen. • The stiff hip is now accommodated and will not cause non-neutral pelvis posture. The wheelchair service personnel can now assess the rest of the pelvis and trunk posture. Thank the volunteer. INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 18 TEMPORARY SU PPORT : HIP THAT CAN NOT BEND TO NEUTRAL Explain: • In the nal wheelchair this temporary support will be built into the cushion to provide permanent support. • A wedge is made in the cushion supporting the thigh at the trunk to thigh angle identi ed in the assessment. The illustration shows one example of how this can be done. Note – a soft foam layer should be placed over the top of this rm foam shape. Make sure no sharp edge in the cushion. If available – show a cushion that has this modi cation. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 90 91 Notes for trainers: • Participants may want to know why a wedge shaped support is not used as the temporary support. Explain that if the wheelchair user sits on a at surface with no accommodation, then it would be necessary to cut a wedged shaped support away from under the thigh, which has a limited hip range. It is not practical of course to cut into the assessment bed. Therefore the wheelchair user is raised off the surface to accommodate the stiff hip. • To save time and material, a gap is left under the thigh and the temporary support will therefore just be under the seat bones and opposite thigh. The thigh drops down at an angle into the gap in the temporary support. In the nal cushion the gap under the thigh will be lled and there will be a wedged shaped support under the thigh. • The permanent support is an asymmetrical cushion. This means the knee and the footrest on one side are lower than the other. This can cause slight instability and shear and other PSDs such as a pelvis strap should be considered. This is discussed later in this training programme. Explain: Now we will think about temporary supports for a wheelchair user who has both hips that cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees). Ask: What temporary supports would be used when both hips cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees)? Encourage one or two volunteers to come forward and demonstrate. The rest of the group can assist by offering suggestions. Ensure that the participants arrive at the correct answer. Answer: Temporary supports when both hips cannot bend to neutral sitting posture (both more than 90 degrees): • a build-up is made under both seat bones to temporarily support the amount of restriction in the hips; • the height of the build-up should be high enough to support the degree of restriction in the hips; • there will be a triangular gap between the thighs and the assessment bed; • this should be the same as the angle recorded with the help of the goniometer; • the assessment can then continue. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 90 91 INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 19 TEMPORARY SU PPORT: BOTH HIPS CA NNOT BEND TO NEUTRAL Explain: • If both hips cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees), then this can be temporarily supported by a build-up under both seat bones. INTERMEDIATE LE VEL • The support is made by increasing the angle between the seat and the backrest. • In the final wheelchair, the temporary support will not be built into the cushion. B.3. Physical assessment – pelvis and hip posture screen: 20 FINAL WHEELC HAIR Explain: In the nal wheelchair, this support will not be built into the cushion. The support is made by increasing the angle between the seat and the backrest. Ask: Why would the permanent support not be built into the cushion, in the same way as the temporary support? Answer: The wheelchair user would tend to slide forward out of their seat. This would make it dif cult for them to stay in their wheelchair and could cause shear – which could lead to the development of a pressure sore. Ask: What temporary supports would be used if one or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees)? Encourage one or two volunteers to come forward and demonstrate. The rest of the group can assist by offering suggestions. Ensure that the participants arrive at the correct answer. Answer: Temporary supports when one or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees): • provide temporary support in front of the seat bones and under the thighs; • a wedge of rm foam would be best; • the assessment can then continue. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 92 93 VIDEO INTERMEDIATE LE VEL B.3. Physical assessment – pelvis and hip posture screen: 21 TEMPORARY SU PPORTS WHEN ONE OR BOTH HIPS CANNOT OPEN TO NEUTRAL S ITTING POSTU RE Explain: • if one or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees), provide temporary support in front of the seat bones and under the thighs; • a wedge of rm foam can be used if available; • if not – for a temporary support – a rectangular block of rm foam is ne. Explain: • The illustration on the slide shows what this would look like built into a cushion on a wheelchair. If available – show a cushion that has this modi cation. Notes for trainers: Participants may want to know why provide support under both thighs if only one hip has a restriction. Answer: • the cushion is usually wedged under both thighs as this helps the wheelchair user to stay symmetrical; • however in some cases it may be best to place the wedge only under the leg with the restriction, for example – if the wedge shape makes it dif cult for the wheelchair user to transfer. Introduce DVD: Temporary supports. This short DVD introduces Richard. Richard has a level pelvis; however both of his hips cannot bend all the way to neutral sitting posture (trunk to thigh angle is more than 90 degrees). In the DVD you will see how the wheelchair service personnel work with Richard to carry out the pelvis and hip screen; and then how temporary supports are provided. Show DVD. Ask if there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 92 93 6. Practising temporary supports (30 minutes) Small-group activity Groups: Divide participants in groups of 2 or 3. Instructions: Ask participants to read each wheelchair user’s story in Participant’s Workbook, (B.3: Physical assessment – pelvis and hip posture screen: practising temporary supports). Explain: For each wheelchair user the participants will need to decide if the wheelchair user’s pelvis can be level and hips bend to neutral sitting posture. Ask participants to complete the `pelvis and hip posture screen` part of the intermediate wheelchair assessment form and decide if the wheelchair user needs temporary support. Ask participants to set-up temporary support to accommodate each wheelchair user. Ask participants to check each temporary support. Each participant should sit on the temporary support to see what it feels like. Explain: Participants have 20 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Monitor each group closely. Ensure that each group understands the activity. Guide participants if necessary. Ensure that participants set up the temporary supports correctly. Time: Allow 20 minutes for activity. Allow 10 minutes for feedback. Feedback: Ask one group to describe the temporary support set-up for Sam; Ask another group to describe the temporary support set-up for Martha; Ask another group to describe the temporary support set-up for Seren; Ask another group to describe the temporary support set-up for Joe; Ask if anyone has any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 94 95 Sam Pelvis and hip posture screen Sam is 4 years old. He has cerebral palsy and cannot sit upright on his own. Through the pelvis and hip posture screen you nd out that: • Sam’s pelvis can be level (both ASIS level); • Sam’s left hip can bend comfortably to the neutral sitting posture. Sam has pain in his right hip and it does not bend all the way to neutral sitting posture (trunk to thigh angle more than 90 degrees). The angle between the trunk and thigh is approximately 105 degrees. Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: 105 degrees Left hip: Yes No Angle: 90 degrees If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Does Sam need temporary support? Yes No The support ts under both seat bones and under the left thigh. There is no support under the right thigh and it rests at an angle. Martha Pelvis and hip posture screen Martha is 57 years old. She has severe arthritis. She can walk a few steps, however walking is very painful. Through the pelvis and hip posture screen you nd out that: • Martha’s pelvis can be level (both ASIS level); • both of Martha’s hips cannot bend all the way to the neutral sitting posture (trunk to thigh angle more than 90 degrees). The angle between the trunk and thigh for both hips is approximately 100 degrees. Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: 100 degrees Left hip: Yes No Angle: 100 degrees If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Does Martha need temporary support? Yes No The support only ts under both seat bones. There is no support under either thigh and both thighs rest at an angle. Seren Pelvis and hip posture screen Seren is 16 years old. She had polio as a child and now has severe contractures of both legs. Seren moves around by sitting cross-legged and scooting over the oor. Through the pelvis and hip posture screen you nd out that: • Seren’s pelvis cannot be level. The right side of her pelvis is 20 mm higher than the left; • both of Seren’s hips can bend to neutral sitting posture. Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: 90 degrees Left hip: Yes No Angle: 90 degrees If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support.. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 94 95 Does Seren need temporary support? Yes No The support ts under the right side of the pelvis and the right thigh. Joe Pelvis and hip posture screen Joe is 25 years old. He had polio as a child and now has severe contractures of both legs. Through the pelvis and hip posture screen you nd out that: • Joe’s pelvis can be level (both ASIS level); • Joe’s right hip can bend to neutral sitting posture comfortably. However his left hip cannot open all the way to neutral (trunk to thigh angle less than 90 degrees). The angle between his trunk and thigh is 70 degrees. Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: 90 degrees Left hip: Yes No Angle: 70 degrees If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. Does Joe need temporary support? Yes No A wedge shaped support ts in front of Joe’s seat bones and under both thighs. The angle of the wedge should be close to 70 degrees (placing the wedge under the left thigh only could also be OK if Joe preferred this, or if a wedge under both thighs affects Joe’s ability to transfer). 7. Key point summary (3 minutes) INTERMEDIATE LE VEL • In the pelvis and hip posture screen wheelchair service personnel find out: - if the wheelchair user’s pelvis can be level; - if the wheelchair user’s hips can bend to a neutral sitting posture. • If not, provide temporary support for the pelvis or hips before continuing assessment: - fixed unlevel pelvis – temporary support under the higher seat bone and thigh; - one fixed hip that cannot bend to neutral – temporary support under both seat bones and the thigh that can reach neutral; - both hips cannot bend to neutral – temporary support under both seat bones; - one or both hips cannot open to neutral – temporary support under both seat bones only. B.3. Physical assessment – pelvis and hip posture screen: 23 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 96 97 B.4: Physical assessment – hand simulation O B JE C T IV E S By the end of this session, participants will be able to: describe how to use their hands (hand simulation) to nd out: • if the wheelchair user can sit in a neutral posture with support; • if not – how close to neutral the wheelchair user can sit comfortably; • what support is needed and where. record ndings from hand simulation on the intermediate wheelchair assessment form. R E S O U R C E S For the session: PPT Slides: B.4: Physical assessment – hand simulation; Reference Manual; DVD: Hand simulation demonstration – Deepak; DVD: Hand simulation demonstration – Enith; DVD: Hand simulation demonstration – Bahati; intermediate wheelchair assessment form. C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: The blocks to be used as temporary support should be made from the same material as the base of the cushion most likely to be used on the wheelchair user’s nal wheelchair. This will give a more realistic effect of the dimensions needed to adapt the base of the cushion. T O P R E PA R E Gather resources, review PPT slides, watch DVDs and read through the session plan. Review the intermediate wheelchair assessment form thoroughly and practise carrying out a hand simulation. O U T L IN E 1. Introduction 2. How to carry out a hand simulation 3. Recording the results of a hand simulation 4. Key point summary 5 15 35 5 Total session time 60 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 96 97 VIDEO 1. Introduction (5 minutes) INTERMEDIATE LE VEL • In this session participants will learn how to complete the final part of the physical assessment – hand simulation. • To carry out a hand simulation, the wheelchair service personnel uses their hands to find out: - can the wheelchair user sit in a neutral sitting posture with support? - if not – how close to neutral can they sit? - what support is needed and where. Step 2: Assessment Physical assessment - hand simulation B.4. Physical assessment – hand simulation: 2 INTRODUCTIO N Explain: • In this session we will talk about how to complete the next part of the physical assessment, which is called ‘hand simulation’. • During the hand simulation, the wheelchair service personnel use their hands to nd out: - can the wheelchair user sit in the neutral posture with support? - if not – how close to the neutral posture can he/she is able to sit comfortably? - what support is needed and where. During a hand simulation, the wheelchair service personnel work with the wheelchair user and an assistant or family member/ caregiver to provide support with hands. INTERMEDIATE LE VEL Hand simulation: support needed to sit in neutral posture / as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw final sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle B.4. Physical assessment – hand simulation: 3 INTERMEDIATE WHEELCHAIR ASSESSMENT F ORM Explain: • This is the section of the intermediate wheelchair assessment form that is used to record the hand simulation results. • We will talk more about recording the results of the hand simulation later in this session. 2. How to carry out a hand simulation (15 minutes) Introduce DVD: Hand simulation demonstration – Deepak. Now we will watch a wheelchair service personnel working with a young man called Deepak to carry out a hand simulation. Deepak does not sit upright. Ask participants to watch closely to see what the assessor and assistant do. Show DVD. Ask if there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 98 99 Explain: • It is important to think carefully about what your hands are doing. Your hands are providing the support that will later be provided by the wheelchair and PSDs. INTERMEDIATE LE VEL • Where are your hands? • The direction of force / support • How much force / support • How much surface area B.4. Physical assessment – hand simulation: 5 WHAT ARE YOU R HANDS DOIN G? • During a hand simulation, pay careful attention to: - where your hands are placed; - the direction of force/support; - how much force/support is being used; - how much surface area your hands are covering (for example, are you using just one nger or a whole hand); • This information will help you to prescribe the nal wheelchair and PSDs. Ask participants: In the DVD just shown – what part of Deepak’s body did the wheelchair service personnel support rst? Encourage answers. Answer: • the pelvis. INTERMEDIATE LE VEL • Provide support at the pelvis first. B.4. Physical assessment – hand simulation: 6 HAND SIMULAT ION ORDER Explain: • Always provide support at the pelvis rst. This is because the posture of the pelvis will affect the rest of the body. • If the wheelchair user’s pelvis is not in neutral, use your hands to encourage the pelvis towards neutral. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 98 99 INTERMEDIATE LE VEL • After pelvis has been supported, provide support in this order: - trunk / arms; - head and neck; - hips and thighs; - lower legs. • Always make only one change at a time. • Observe how changes in one part of the body affect other parts. B.4. Physical assessment – hand simulation: 7 HAND SIMULAT ION ORDER • When the pelvis has been supported, focus on other parts of the body in this order: - trunk/arms; - head and neck; - hips and thighs; - lower legs. • Always make only one change at a time. For example – do not try to change the posture of the trunk at the same time as changing the posture of the pelvis. • Work with an assistant – who could be a family member/caregiver. • Observe how changes in one part of the body affect other parts. • Ask for feedback from the wheelchair user. • Observe the contour of the pelvis and trunk from the side. This is important to help plan the shape the backrest has to be to provide the best support. 3. Recording the results of a hand simulation (35 minutes) INTERMEDIATE LE VEL Hand simulation: support needed to sit in neutral posture / as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw final sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle B.4. Physical assessment – hand simulation: 8 INTERMEDIATE WHEELCHAIR A SSESSMENT FOR M Explain: Results of the hand simulation are recorded on the intermediate wheelchair assessment form. There is space to: • record with a tick whether the wheelchair user is able to achieve a neutral sitting posture for each body part with hand support; • describe or line draw the nal sitting posture achieved by the wheelchair user with the hand support; and • describe or line draw the support provided for the wheelchair user to achieve that sitting posture. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 100 101 VIDEO Introduce DVD: Hand simulation demonstration – Enith. Now we will watch another hand simulation. Explain: • We will see some more now of Enith. In this clip, Enith has attended for assessment with her mother. During the assessment interview, Enith and her mother explained that Enith has a dislocated right hip, which is very painful. Any movement is painful. • Wheelchair service personnel observe that Enith cannot sit upright without support. She sits with her pelvis tiled backwards, trunk curved forwards and her legs are ‘windswept’ to the left. • A pelvis and hip posture screen is carried out. It is found that Enith’s pelvis is level and both her hips can bend to neutral sitting posture. However her right hip is adducted (windswept to the midline) and this posture is xed (cannot be corrected). • Watch closely – afterwards we will discuss what further information the wheelchair service personnel found out through the hand simulation. Show DVD. Ask if there are questions. Ask: What was Enith’s starting posture? Answers: • pelvis in xed posterior tilt; • pelvis unlevel with right side slightly higher; • trunk bent/slumped/collapsed; • shoulders level (Enith’s mother is supporting her by holding her shoulders. Enith’s posture may change if her mother let go); • right hip adducted (windswept towards the left); • right thigh shorter than the left. Ask: Where (what parts of Enith’s body) did the wheelchair service personnel provide support rst, second, third and fourth? Answers: • First: support behind the pelvis; • Second: support behind the trunk; • Third: support on the sides of the trunk; • Fourth: arm support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 100 101 INTERMEDIATE LE VEL Hand simulation: support needed to sit in neutral posture / as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw final sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle B.4. Physical assessment – hand simulation: 10 INTERMEDIATE WHEELCHAIR A SSESSMENT FOR M Project this slide onto a whiteboard (if available). Explain: We will complete the hand simulation part of the intermediate wheelchair assessment form for Enith together. Ask (for each body part) whether with hand support Enith was able to achieve a neutral sitting posture. As each correct answer is given – tick the yes. Ask: How can we describe Enith’s nal posture? Write/draw a description of Enith’s posture onto the whiteboard in the correct space on the intermediate wheelchair assessment form. If the whiteboard in not available, ask participants to follow along on their copy while the trainer explains/draws on the board. Notes for trainers: For this exercise you may also invite participants to come forward and draw Enith’s nal posture onto the whiteboard. Answer: Hand simulation: support needed to sit in neutral posture/as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw the nal sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Posture: • pelvis in posterior tilt; • trunk to thigh angle more than 90 degrees; • lower trunk at (no lumbar curve) and reclined (not upright); • upper trunk upright; • head upright (with arm support); • right leg adducted towards the mid-line (windswept). Note: Enith’s right thigh is shorter than left thigh. Support provided: • rm support at the back of Enith`s pelvis; • support at back of Enith`s trunk; • light support at the sides of trunk; • arm support provided (with Enith`s arms in front of her). Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 102 103 VIDEO Notes for trainers: Participants may ask whether support should be provided for Enith’s right thigh – to bring this into a neutral sitting posture. The information provided in the assessment about the pain in Enith’s hip (with any movement or correction) indicates that only very minimal support (if any) should be provided. Introduce DVD: Hand simulation demonstration – Bahati. Now we will watch another hand simulation. Explain: • Bahati is studying administration at the local college. • Her old wheelchair is worn out and does not give her good postural support. • During the assessment interview, Bahati explained that she gets very tired after a day in her wheelchair. Her goal is to have a wheelchair, which helps her to sit more comfortably for longer – which will help her to be less tired and more able to study. • Watch closely – afterwards we will discuss what the wheelchair service personnel found out through the hand simulation. Show DVD. Ask if there are questions. Ask: What was Bahati’s starting posture? Answer: • slumped sitting posture; • pelvis in posterior tilt; • bent trunk; • right hip bent more than neutral sitting posture with thigh rolling out; • left hip bent less than neutral sitting posture with thigh rolling out. Ask: Where (what parts of Bahati’s body) did the wheelchair service personnel provide support rst, second and third? Answer: • 1: support behind the pelvis; • 2: support behind the lower trunk; • 3: arm support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 102 103 INTERMEDIATE LE VEL Hand simulation: support needed to sit in neutral posture / as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw final sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle B.4. Physical assessment – hand simulation: 12 INTERMEDIATE WHEELCHAIR A SSESSMENT FOR M Project this slide onto a white board (if available) Explain: As for Enith, we will complete the hand simulation part of the intermediate wheelchair assessment form for Bahati together. Ask (for each body part) whether with hand support Bahati was able to achieve a neutral sitting posture. As each correct answer is given – tick the yes. Ask: How can we describe Bahati’s nal posture? Write/draw a description of Bahati’s posture onto the whiteboard in the correct space on the intermediate wheelchair assessment form. Ask: Does anyone have any questions about completing this part of the intermediate wheelchair assessment form? Answer any questions. If the whiteboard in not available, ask participants to follow along on their copy while the trainer explains/draws on the board. Notes for trainers: For this exercise you may also invite participants to come forward and draw Bahati’s nal posture onto the whiteboard. Answer: Hand simulation: support needed to sit in neutral posture/ as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw the nal sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Posture: • pelvis upright and level; • trunk upright. Support provided: • rm support at the back of pelvis; • support for the lower trunk; • arm support to help Bahati maintain a stable upper trunk. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 104 105 Notes for trainers: Bahati requires rm support behind her pelvis and lower trunk to maintain an upright sitting posture. Her upper trunk is not fully stable and tends to move forward. With arm support, her upper trunk is stable. 4. Key point summary (5 minutes) INTERMEDIATE LE VEL • During the hand simulation, the wheelchair service personnel use their hands to find out: - can the wheelchair user sit in neutral posture with support? - if not – how close to the neutral posture can they sit? - what support is needed and where. • Provide support at the pelvis first, and then trunk/arms; head and neck; hips and thighs; lower legs. • Record the results of a hand simulation as accurately as possible. This information will help you to prescribe the final wheelchair and PSDs. B.4. Physical assessment – hand simulation: 13 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. B.5: Physical assessment – taking measurements O B JE C T IV E S By the end of this session, participants will be able to: explain the purpose of taking measurements; demonstrate choosing the measurements needed to select a correct size and location of PSDs; demonstrate taking measurements; use the intermediate wheelchair assessment form to record body measurements. R E S O U R C E S For the session: PPT Slides: B.5: Physical assessment – taking measurements; Reference Manual; Participant`s Workbook; intermediate wheelchair assessment form; tape measure (or caliper if available and commonly used) – 1 for each group; assessment bed – 1 for each group. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 104 105 C O N T E X T A N D P R IO R L E A R N IN G Prior learning: `How to take body measurements` discussed in the Wheelchair Service Training Package – Basic Level (hip width, seat depth, calf length, seat to bottom of rib cage and shoulder blade) Adapt this session to suit the context participants will be working in. Think about: When demonstrating taking measurements on the volunteer and asking participants to practise taking measurements on each other – be aware of any cultural issues related to touching. T O P R E PA R E Gather resources, review PPT slides and read through the session plan. Review the intermediate wheelchair assessment form thoroughly and practise taking measurements. Arrange an assessment bed at the front of the training room. Arrange the training room so that participants are seated in a semi-circle facing the front of the room. Place assessment beds around the training room (or outside the room/in adjacent rooms) ready for participants to use to practise measuring. O U T L IN E 1. Introduction 2. Measuring a wheelchair user to select the correct wheelchair size and location of PSDs 3. Measurement practice 4. Key point summary 2 25 30 3 Total session time 60 1. Introduction (2 minutes) INTERMEDIATE LE VEL • In this session participants will talk about how to take body measurements of a wheelchair user to select the most appropriate wheelchair size and Postural Support Devices (PSDs). Step 2: Assessment Physical assessment – taking measurements B.5. Physical assessment – taking measurements: 2 INTRODUCTIO N • Explain: In this session we will talk about how to take body measurements of a wheelchair user to select the most appropriate wheelchair size and Postural Support Devices (PSDs). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 106 107 2. Measuring a wheelchair user to select the correct wheelchair size and location of PSDs (25 minutes) Notes for trainers: The rst ve measurements taught here are taught in the Wheelchair Service Training Package – Basic Level. Participants should already be able to take these measurements con dently and accurately. If not, trainers should run the Wheelchair Service Training Package – Basic Level `Physical assessment` session with a speci c focus on `How to take body measurements` for any participants who are not con dently and accurately able to take the measurements taught at basic level. Ask participants to look at the ‘Taking measurements’ part of their copy of the intermediate wheelchair assessment form. INTERMEDIATE LE VEL Taking measurements Body measurements (mm) Wheelchair component measurements (mm) Seat width, depth and footrest height A Hip width = seat width OR 1 = distance between pelvis side pads 2 B Seat depth (back of pelvis to back of the knee) L B less 30 – 50 mm = seat depth (if length is different, use shorter) 3 R C Calf length L = distance between top of the seat to footrest OR = distance between top of the seat to floor for foot propelling 4 R 5 Backrest height D Seat* to bottom of rib cage = distance between top of the seat to top of backrest (measure D, E or F – depending on the wheelchair user’s need) 6 E Seat* to bottom of shoulder blade F Seat* to top of shoulder Modifications and / or PSDs G Trunk width = distance between trunk side pads/wedges 7 H Seat* to axilla (armpit) L H less 30 mm = maximum distance between the top of the seat and the top of trunk side pads/wedges (adjust according to hand simulation) 8 R I Seat* to top of the pelvis (PSIS) =distance between the top of the seat and mid-height of rear pelvis pad 9 J Distance between knees = width of knee separator pad 10 K Seat* to base of skull = distance between the top of seat to middle of headrest 11 L Back of pelvis to seat bones L plus 20 – 40 mm = distance from the backrest support to the beginning of the pre seat bone shelf. 12 O th er *When taking body measurements, the ‘seat’ is the surface on which the seat bones are sitting. B.5. Physical assessment – taking measurements: 3 TAKING MEASU REMENTS Explain: • On the intermediate wheelchair assessment form there are twelve body measurements listed. • Five measurements are the same measurements that were previously introduced in the Wheelchair Service Training Package – Basic Level. • One additional backrest height measurement is added to the intermediate wheelchair assessment form. This is the seat to top of shoulder body measurement, which is used to measure a wheelchair user for a high backrest. • There are six more measurements, which will help to decide the size and/or location of PSDs. • It may be necessary to take more measurements, depending on the PSDs prescribed. • There is space on the intermediate wheelchair assessment form to record ‘other’ measurements. INTERMEDIATE LE VEL B.5. Physical assessment – taking measurements: 4 HOW BODY MEA SUREMENTS RE LATE TO WHEEL CHAIR/PSD Explain: This illustration on the intermediate wheelchair assessment form shows how body measurements relate to the wheelchair/PSD. Ask: For example – how does measurement G: Trunk width relate to the wheelchair (what wheelchair component will this help to locate?) Encourage answers. Answer: • The distance between trunk side pads or wedges. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 106 107 INTERMEDIATE LE VEL Taking measurements Body measurements (mm) Wheelchair component measurements (mm) Seat width, depth and footrest height A Hip width = seat width OR 1 = distance between pelvis side pads 2 B Seat depth (back of pelvis to back of the knee) L B less 30 – 50 mm = seat depth (if length is different, use shorter) 3 R C Calf length L = distance between top of the seat to footrest OR = distance between top of the seat to floor for foot propelling 4 R 5 Backrest height D Seat* to bottom of rib cage = distance between top of the seat to top of backrest (measure D, E or F – depending on the wheelchair user’s need) 6 E Seat* to bottom of shoulder blade F Seat* to top of shoulder Modifications and / or PSDs G Trunk width = distance between trunk side pads/wedges 7 H Seat* to axilla (armpit) L H less 30 mm = maximum distance between the top of the seat and the top of trunk side pads/wedges (adjust according to hand simulation) 8 R I Seat* to top of the pelvis (PSIS) =distance between the top of the seat and mid-height of rear pelvis pad 9 J Distance between knees = width of knee separator pad 10 K Seat* to base of skull = distance between the top of seat to middle of headrest 11 L Back of pelvis to seat bones L plus 20 – 40 mm = distance from the backrest support to the beginning of the pre seat bone shelf. 12 O th er *When taking body measurements, the ‘seat’ is the surface on which the seat bones are sitting. B.5. Physical assessment – taking measurements: 5 TAKING MEASU REMENTS Point out on the ‘Taking measurements’ part of the intermediate wheelchair assessment form how: • The body measurements are listed on the left hand side and the wheelchair component measurements that each body measurement relates to are listed on the right hand side. • In some cases there is a formula to help work out the wheelchair component measurement. For example – seat depth (the back of pelvis to back of the knee) LESS 30–50 mm EQUALS the seat depth of the wheelchair. Explain: • For those body measurements for which there is a formula to help work out the wheelchair component measurement – it is helpful to work out the ideal wheelchair component measurement when carrying out the body measurement. • This will help later when preparing the wheelchair user’s prescription. • These body measurements are: – B (seat depth); – H (seat to axilla); and – L (back of pelvis to seat bones). Ask a volunteer to come to the front of the training room and sit on the assessment bed. Demonstrate brie y how to take each measurement, using the Notes for trainers below to guide you. Ensure all participants can see clearly. Notes for trainers: Make sure to emphasize the following key points: • When taking body measurements, the ‘seat’ is the surface on which the seat bones are sitting. • Always measure a wheelchair user sitting up, and in the posture that has been identi ed as the most upright, comfortable and functional for them during the hand simulation. • When measuring a person who has dif culty sitting upright, assistance may be needed. • For all vertical measurements (C,D,E,F,H,I,K) – the location of the corresponding component will be affected by any changes to the seat and cushion height. • The exact location of all wheelchair components is always checked at the tting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 108 109 How to measure: Wheelchair component: Comments: A: Hip width Seat (width) Check there is nothing in the wheelchair user’s pockets before measuring. Measure the wheelchair user’s hips or the widest part of his/her thighs. Hold two clip boards against each side of the wheelchair user to help to get an accurate measurement. Calipers can also be used. Hip width equals the seat width or the distance between pelvis side pads. If pelvis side pads are provided, the wheelchair seat width may need to be wider. Always try to keep the wheelchair width to a minimum. In countries with cold climates where thick clothes may be worn, some allowance may be needed. B: Seat depth Seat (depth) Place a clip board at the back of the wheelchair user to help get an accurate measurement. Measure from the back of the wheelchair user’s pelvis to the back of his/her knee in a straight line. Always measure both legs. If there is a difference between the left and right side, check that the wheelchair user is sitting upright with their pelvis level. If there is still a difference, make the wheelchair prescription for the shorter side. Seat depth less 30–50 mm equals the depth of the seat of the wheelchair. For a wheelchair user whose knees are bent a lot less than 90 degrees, the seat depth may need to be slightly shorter. See the box `For wheelchair users with a xed posterior tilt of the pelvis or xed forward bent trunk` on page 67 of the Reference Manual. C: Calf length Footrests (height) Measure from the back of the wheelchair user’s knee to the base of his/her heel. Make sure the wheelchair user’s ankles are bent at 90 degrees (if possible). Always measure both legs. If the wheelchair user wears shoes, measure with the shoes he/she wears most days. If the foot is xed in plantar exion (pointing downwards), measure to the toe. The calf length height equals the top of the cushion to the footrests OR the top of the cushion to the oor if the wheelchair user is foot propelling. The exact footrest location will change slightly depending on how much the cushion compresses when the wheelchair user sits on it. Final adjustment is always needed at tting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 108 109 How to measure: Wheelchair component: Comments: D, E and F Backrest (height) D: Seat to bottom of rib cage: Measure from the wheelchair user’s seat to the bottom of the rib cage. To help nd the bottom of the rib cage, place hands on both sides of the pelvis. Gently squeeze hands inwards and slide hands upwards. The bottom of the rib cage is just above the waist. Measurements D, E and F help decide the height of the backrest. The height depends on the needs of the wheelchair user. The information from assessment will guide wheelchair service personnel to decide how high the backrest needs to be to provide the right support for the wheelchair user. If backrest recline or tilt in space is needed, the backrest height must be at least standard (up to the bottom of wheelchair user’s shoulder blades); Remember to consider if the wheelchair users will be propelling the wheelchair themselves. If so they need freedom to move their shoulder blades. E: Seat to shoulder blade: Measure from the wheelchair user’s seat to the bottom of the shoulder blade in a vertical line. To help nd the bottom of the shoulder blade ask the wheelchair user to shrug their shoulders. F: Seat to top of shoulder: Measure from the wheelchair user’s seat to the top of the shoulder. G: Trunk width Trunk side pads or wedges (distance between) Measure the width of the wheelchair user’s trunk just below the axilla (armpits). Trunk width is the distance between trunk side pads or wedges. The nal position of the trunk side pads or wedges may change during tting, if they are to be placed lower than just below the axilla. H: Seat to axilla (armpit) Trunk side pads or wedges (height) Measure from the seat to the axilla (armpit). The seat to axilla measurement less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges. This measurement is a guide. The nal height depends on the assessment and tting. Trunk side pads should never be high enough to put pressure into the axilla (armpit). This can be uncomfortable and cause permanent nerve damage. There should always be at least 30 mm clearance between the top of a trunk side pad and the axilla. See the box `Measuring side trunk supports for a wheelchair user with scoliosis` on page 69 of the Reference Manual. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 110 111 How to measure: Wheelchair component: Comments: I: Seat to the top of the pelvis (PSIS) Rear pelvis pad (mid-height) Measure from the seat to the top of the pelvis (PSIS). The seat to the top of the pelvis (PSIS) measurement is used to locate the mid-height of the rear pelvis pad. The depth (thickness) of a rear pelvis pad depends on the results of assessment. J: Distance between knees Knee separator pad Measure the distance between the two knees – with the knees placed as close to neutral as is comfortable for the wheelchair user. The distance between the two knees equals the width of a knee separator pad. The distance will depend on the wheelchair user’s sitting posture. K: Seat to base of skull Headrest (height) Measure from the seat to base of skull. The measurement from the seat to the base of the skull helps to locate the headrest. I: Back of pelvis to seat bones Pre seat bone shelf Measure from the back of the pelvis to the seat bones. From the side of the wheelchair user place your hand (palms up) under the wheelchair user’s bottom to nd the seat bones. Locate the seat bones with one nger – and then withdraw your hand to the side of the wheelchair user. Measure from the back of the wheelchair user’s pelvis to the nger that is located at the seat bones. Wheelchair service personnel may mark on the assessment bed in some way (for example with a piece of chalk) alongside the wheelchair user in line with their seat bones and measure from the mark to the back of the pelvis. The measurement from the back of pelvis to seat bones plus 20–40 mm is the distance from the backrest support to the beginning of the pre seat bone shelf. If a wheelchair user has a xed posterior tilt of the pelvis or xed forward bent trunk the measurement may be different (see the box `For wheelchair users with a xed posterior tilt of the pelvis or xed forward bent trunk` on page 67 of the Reference Manual). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 110 111 Thank the volunteer. Ask: How would participants manage if they are trying to measure a child who is upset or wriggling? Answer: • take time to settle the child if possible; • give the child a break – and try again in a short while when he/she has had a rest/ something to eat or drink; • use family member/caregiver to help support the child – and help them to feel safe; • for a small child it is possible to measure them on their family member/caregiver’s lap. However – wheelchair service personnel must be very careful to have the child in the same ‘ nal’ posture found in the hand simulation. 3. Measurement practice (30 minutes) Small group activity Groups: Divide all the participants into 3 groups. Instructions: Ask participants to read the story of Madavi in the Participant’s Workbook (B.5: Physical assessment – taking measurements). Assign one tape measure (and calliper if available and commonly used) for each group. Explain that participants need to: • Read through the completed hand simulation results for Madavi. • Decide what body measurements they would need to take for Madavi in order to select a wheelchair for her. • Take these measurements of at least one member of the group and write them in the `taking measurements` part of the intermediate wheelchair assessment form provided in their workbook. Explain: • Madavi has a mild xed posterior pelvis tilt. Participants need to think about how they will get the correct seat depth measurement for Madavi. • Madavi has asked for a tray – so participants also need to think about what measurements they need to take to be able to prepare a tray for her. Explain: Participants have 20 minutes to complete the activity and then the groups will come back together for feedback. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 112 113 Monitor: Monitor the groups closely. Ensure that each group understands the activity. Correct measurement techniques as necessary. Guide participants if necessary. Notes for trainers: Focus participants on working out what measurements they think they may need. At this stage they should not go into too much detail thinking about the different postural support solutions, as this will be covered in the next sessions. Time: Allow 20 minutes for the activity. Allow 10 minutes for feedback. Feedback: Ask: What measurements did participants agree would be needed? Answer: Measurements: A, B, C, F, G, H, I, J, L. Ask: How would participants ensure that they take the correct measurement for seat depth? Encourage answers and allow brief discussion. Show slide to clarify the point. INTERMEDIATE LE VEL B.5. Physical assessment – taking measurements: 6 CORRECT MEA SUREMENT FO R SEAT DEPTH Explain: If a wheelchair user has a xed posterior tilt of the pelvis or xed forward curved trunk wheelchair service personnel need to think about how this will be accommodated in the wheelchair. This may change the way the seat depth measurement is taken: • if the backrest is reclined to accommodate the pelvis/trunk, measure from the back of the back of the pelvis to the back of the knee in a straight line; • if the backrest does not recline supports will be made to accommodate the pelvis/trunk within the seat depth space. Measure from the furthest back point of the body (trunk/pelvis) to ensure that enough seat depth is allowed, as shown in the slide. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 112 113 Ask: What measurements would participants take to describe the height and size/shape of a tray for Madavi? Encourage answers and allow brief discussion. Show slide to clarify the point: INTERMEDIATE LE VEL B.5. Physical assessment – taking measurements: 7 HEIGHT AND S IZE/SHAPE OF A TRAY Explain: To decide the ideal height for the tray, measure elbow height: • top of seat to elbow bent at 90 degrees with shoulders relaxed; or • according to the support required that is identi ed during the hand simulation (for example some people may bene t from a slightly higher tray providing more forearm support). To decide how close the tray will come to Madavi’s trunk: • measure the depth of Madavi’s trunk (back to front). If the tray is to wrap around Madavi’s trunk (like the one in the slide illustration): • measure her trunk width (already part of the measurements table of the wheelchair assessment form). 4. Key point summary (3 minutes) INTERMEDIATE LE VEL • On the intermediate wheelchair assessment form there are twelve body measurements listed. • These are the most common measurements to help select the correct size of wheelchair and location of PSDs. • It may be necessary to take more measurements, depending on the PSDs prescribed. • Always measure the wheelchair user in sitting position; as close to neutral sitting posture as they are comfortable (as identified in the hand simulation). • The exact location of all PSDs is always checked at fitting. B.5. Physical assessment – taking measurements: 8 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 114 115 B.6: Selecting wheelchairs and cushions O B JE C T IV E S By the end of this session, participants will be able to: describe the features and adjustability of the locally available wheelchairs and cushions; list useful features of standard wheelchairs that can enable the provision of additional postural support. R E S O U R C E S For the session: PPT Slides: B.6: Selecting wheelchairs and cushions; Reference Manual; Participant’s Workbook; intermediate wheelchair prescription (selection) form; locally available wheelchairs and cushions – 1 of each; written information about the wheelchair provided by the supplier (for example wheelchair brochure/speci cation summary); completed and blank intermediate wheelchair summary form for each locally available wheelchair. C O N T E X T A N D P R IO R L E A R N IN G Prior learning: A sound working knowledge of basic wheelchair prescription (selection) is important for participants undertaking this session. Refer to the Wheelchair Service Training Package – Basic Level Reference Manual ‘Step 3: Prescription (selection)’ as suggested pre-reading for any participants who have not recently undertaken the basic level training programme. Adapt this session to suit the context participants will be working in. Think about: The wheelchairs and cushions available in the participants’ working environment. Preparing sample intermediate wheelchair prescription (selection) form to include the wheelchair and cushion options available for participants in their local service/area. T O P R E PA R E Gather resources, review PPT slides and read through the session plan. Complete intermediate wheelchair summary form for each locally available wheelchair. Trainers should be familiar with each product. They should know the wheelchair sizes, adjustment ranges, features and options or PSDs available. Arrange the locally available wheelchairs and cushions in different locations around the training area. Ensure they are in good working order. Place written information about the wheelchair provided by the supplier on the wheelchair (if available). Label each wheelchair (e.g. wheelchair one, two, three, four). O U T L IN E 1. Introduction 2. Type of wheelchair and cushion 3. Key point summary 8 50 2 Total session time 60 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 114 115 1. Introduction (8 minutes) INTERMEDIATE LE VEL Step 3: Prescription (selection) • Prescription (selection) means: - finding the best match possible between the wheelchairs available and the needs of the wheelchair user. B.6. Selecting wheelchairs and cushions: 2 INTRODUCTIO N Explain: Prescription (selection) is the third step in wheelchair service delivery. Prescription means nding the best match possible between the wheelchairs available and the needs of the wheelchair user. Ask participants to look at their copy of the intermediate wheelchair prescription form INTERMEDIATE LE VEL Step 3: Prescription (selection) • In this session participants will: - talk about selecting wheelchairs and cushions for wheelchair users who need additional postural support to sit upright; - review the locally available wheelchairs to ensure that everyone is familiar with their different features. B.6. Selecting wheelchairs and cushions: 3 INTRODUCTIO N Explain: • In this session we will talk about selecting wheelchairs and cushions for wheelchair users who need additional postural support to sit upright. • We will also review the locally available wheelchairs to ensure that everyone is familiar with their different features. INTERMEDIATE LE VEL 2. Wheelchair type, size and set up Type of wheelchair (list available wheelchairs below) Wheelchair dimensions (mm) Seat width Seat depth Backrest height Footrest height Wheelchair set up Rear wheel position Other: Tilt B.6. Selecting wheelchairs and cushions: 4 SELECTING WH EELCHAIR TYPE , SIZE AND SET U P Explain: Prescription includes: • selecting the type and size of wheelchair most suitable for the wheelchair user; • describing any speci c set-up for that wheelchair. Ask: What are some examples of what should be written in this part of the intermediate wheelchair prescription form? Answers: • rear wheel position (safe/active); • tilt. Explain: This is not the place to write details about PSDs – that comes later on the form. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 116 117 INTERMEDIATE LE VEL B.6. Selecting wheelchairs and cushions: 5 SELECTING CU SHION TYPE AN D SIZE Explain: Prescription also includes: • selecting the type and size of cushion. Explain: If the cushion needs modi cation to make the correct PSD – the details of that are described later on the intermediate wheelchair prescription form. INTERMEDIATE LE VEL PSDs Describe / draw and provide dimensions S ea t / c us hi on Add solid seat Pre-seat bone shelf (=3 less 12) Lower seat front L R Raise seat front Wedge for anterior tilt Build up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other B.6. Selecting wheelchairs and cushions: 6 SELECTING PSD S OR MODIFICAT IONS REQUIRED Explain: Prescription also includes: • selecting what PSDs or modi cations are needed to provide the wheelchair user with additional postural support he/she needs. Explain: • This slide shows just one part of the intermediate wheelchair prescription form. • We will explain in more detail how to complete this section of the form in the following sessions and will practice completing it in the practical sessions. Explain: • The Wheelchair Service Training Package – Basic Level teaches how to select the most appropriate wheelchair and cushion for a wheelchair user who can sit upright without additional postural support. Selection of an appropriate wheelchair is made based on the wheelchair user’s physical, lifestyle and environmental needs. • In the intermediate level training programme, wheelchair service personnel need to take into account the greater postural support needed. • At the same time – the wheelchair user’s lifestyle and environmental needs must still be considered. Ask: What is an example of a ‘lifestyle or environment’ need? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 116 117 Answers: • where the wheelchair user uses their wheelchair (for example – indoors, outdoors, rough terrain); • the distance the wheelchair user travels per day; • how long the wheelchair user spends in their wheelchair ; • how he/she transfers; • the type of toilet the wheelchair user uses; • whether he/she needs to use public transport frequently; • what activities the wheelchair user most wants to carry out in their wheelchair. INTERMEDIATE LE VEL 5. Agreement signatures Wheelchair user: Assessor: Wheelchair service manager: B.6. Selecting wheelchairs and cushions: 7 AGREEMENT SI GNATURES Remember: • the prescription is always decided in full partnership with the wheelchair user; • on the intermediate wheelchair prescription form used in this training programme, three signatures are needed; • this includes the wheelchair user, assessor (wheelchair service personnel) and wheelchair service manager. 2. Type of wheelchair and cushion (50 minutes) Explain: We will now look at the different wheelchairs that are available locally. To prescribe a wheelchair, wheelchair service personnel need to know the following about the wheelchair: INTERMEDIATE LE VEL • type of frame; • sizes available and size range; • features available; • adjustments possible and range of adjustment. B.6. Selecting wheelchairs and cushions: 8 WHEELCHAIR INFORMATION Explain brie y: • Type of frame. For example is it a four- wheel or three-wheel wheelchair; a cross-folding or rigid frame; tilting frame; long or short wheelbase. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 118 119 • Sizes available and size range. Wheelchair size is usually described by the wheelchair seat width and seat depth. The wheelchair seat width is measured from the outside of one seat rail to the outside of the opposite seat rail or between armrests if these sit on top of the seat rail. The wheelchair seat depth is measured from the front of the seat to the backrest. • Features available. For example the type of seat, backrest, footrests, armrests, castor wheel, rear wheel and PSDs (for example trunk side pads, headrest, straps). • Adjustments possible and adjustment range. It is important to know which components are adjustable and the range of adjustment. INTERMEDIATE LE VEL • Some wheelchairs have features and adjustments which can be very useful for wheelchair users who need additional postural support. B.6. Selecting wheelchairs and cushions: 9 USEFUL WHEE LCHAIRS Explain: • Some manual wheelchairs have more adjustments or features than others. • Some adjustments or features can be very helpful for wheelchair users who need additional postural support. • We will look at some particularly helpful features and adjustments now. Explain each point below: INTERMEDIATE LE VEL • Footrest adjustments may include: - height; - forwards and backwards angle; - footrest angle can be increased or decreased. • Footrest adjustments often help to accommodate different postures of feet and legs. B.6. Selecting wheelchairs and cushions: 10 FOOTRESTS Most wheelchairs have footrests that can be adjusted up and down. Some wheelchairs have additional adjustments including: • height; • footrests can move forwards or backwards; • footrest angle can be increased or decreased. These adjustments give more exibility for where the wheelchair user’s feet will be placed. INTERMEDIATE LE VEL • Can help to hold the foot up with knee extended. B.6. Selecting wheelchairs and cushions: 11 ELEVATING LEG REST An elevating leg rest can help hold the foot up with the knee extended. This can be helpful for wheelchair users who cannot bend their knee to neutral for sitting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 118 119 INTERMEDIATE LE VEL • Backrest recline can help accommodate: - hips that do not bend to neutral sitting posture (the trunk to thigh angle is more than 90 degrees); - fixed posterior pelvis tilt; - fixed bent posture of the lower trunk. • An adjustable reclining backrest can provide more options for trunk support. Backrest recline B.6. Selecting wheelchairs and cushions: 12 RECLINING BA CKREST An adjustable reclining backrest can provide more options for trunk support. Backrest recline (tilting the backrest rearwards) can help in accommodating: • hips that cannot not bend to neutral sitting posture (trunk to thigh angle more than 90 degrees); • xed posterior pelvis tilt; • xed bent posture of the lower trunk. INTERMEDIATE LE VEL • The backrest and the seat tilt back together. • The open seat to backrest angle stays the same. B.6. Selecting wheelchairs and cushions: 13 TILT IN SPACE Some wheelchairs have what is called ‘tilt in space’. This means that the backrest and the seat tilt back together. The open seat to backrest angle stays the same. Tilted seat position can help: • xed posterior pelvis tilt with hip and knee exion contractures; • low sitting tolerance or discomfort during normal sitting position; • to increase comfort and rest. INTERMEDIATE LE VEL • Provides a good base to build on additional postural support. • Provides stability which is helpful: - for someone who has strong uncontrolled movements; - for someone who is very heavy. B.6. Selecting wheelchairs and cushions: 14 RIGID SEAT Some wheelchairs have a rigid seat base instead of a slung seat. This can provide: • a good base to build additional postural support for the pelvis and hips; • more stability than a slung seat. This can be useful if a wheelchair user has strong uncontrolled movements or is very heavy. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 120 121 INTERMEDIATE LE VEL • Provides a good base to build on additional postural support. • Provides more stability than a slung / canvas backrest for a wheelchair user with strong uncontrolled movements. • Provides more support for taller and heavier users who have very floppy trunks. B.6. Selecting wheelchairs and cushions: 15 RIGID BACKRES T Some wheelchairs have a rigid backrest. As for a rigid seat, this can provide a good base to build on additional postural support. A rigid backrest can also provide: • more stability than a slung/canvas backrest. This can be useful if a wheelchair user has strong uncontrolled movements; • more support for wheelchair users who are taller and heavier and/or have very oppy trunks. The illustration on the slide shows a rigid backrest that has had foam added to provide support for the trunk in just the right place, and side support pads bolted onto the backrest. INTERMEDIATE LE VEL • Allows easy adjustment of the support provided by a backrest. • The individual straps are pulled tighter or made looser to give more or less support. B.6. Selecting wheelchairs and cushions: 16 TENSION ADJU STABLE BACKR EST Some wheelchairs come with a tension adjustable backrest instead of a simple slung backrest. A tension adjustable backrest allows easy adjustment of the support provided by a backrest. The individual straps are pulled tighter or made looser to give more or less support. INTERMEDIATE LE VEL B.6. Selecting wheelchairs and cushions: 17 RANGE OF ADD ITIONAL WHEE LCHAIR COMPO NENTS Some wheelchairs come with a range of additional components designed to provide additional postural support. We will talk more about different postural supports in the next session. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 120 121 Small-group activity Groups: Divide participants into groups of 3. Instructions: Ask each group to look at Participant’s Workbook (B.6: Selecting wheelchairs and cushions). Ask participants to look carefully at each of the locally available wheelchairs and work together to answer the questions in their workbook. Explain: Participants have 30 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Monitor the groups closely. Ensure that each group understands the questions. Guide participants if necessary. Time: Allow 30 minutes for the activity. Allow 15 minutes for feedback. Notes for trainers: • Allow more time if there are more than four locally available wheelchairs. Feedback: Review each question with the whole group as follows: • ask participants to volunteer answers; • check if everyone agrees; • if there is no disagreement, acknowledge the answer (if it is correct) and move onto the next question; • if not everyone has the same answer – elicit the correct answer and clarify. Allow only brief discussion. Explain: • It is very important that wheelchair service personnel are very aware of the different features of the wheelchairs they have available to them. Only by being very familiar with the wheelchairs can they help wheelchair users nd the best match for their needs. • Point out the intermediate wheelchair summary form in the Participant’s Workbook and/or set of wheelchair service forms. Explain that participants can complete this form for the wheelchairs they have available in their own location after this training. Notes for trainers: • Refer to notes for trainers below for the answers and to ensure that key points are emphasized. • After this session – pin up a copy of a completed intermediate wheelchair summary form for each wheelchair. This can then be referred to during the practical sessions with wheelchair users. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 122 123 Notes for trainers: 1. Lifestyle and environment Questions: Answers/key points for trainers to emphasize: Which wheelchair (or wheelchairs) is best suited to travel over rough/uneven terrain? Why? Features that will increase how easy a wheelchair is to use over rough terrain include: • Three-wheel format; • long wheelbase; • wide front castor/s; • wide rear tyres (‘mountain bike’ style); • solid inner tubes can reduce problems with punctures and are durable; • durability and ability to repair locally should also be considered as wear and tear on wheelchairs used over rough terrain is greater. Which wheelchair (or wheelchairs) would most easily facilitate a standing transfer? Why? Features that make a standing transfer easier include: • swing-away footrests; • armrests to push up on can be helpful. Which wheelchair (or wheelchairs) would most easily facilitate a sideways transfer? Why? Features that make a sideways transfer easier include: • removable armrests; or • armrests that are in line with the rear wheel rim. How does each wheelchair fold or is disassembled for transport? Common methods include: • non-folding; • cross-folding; • backrest folds down; • quick-release wheels. Which wheelchair (or wheelchairs) does your group think would be the easiest wheelchair to transport on public transport? Why? Encourage participants to consider : • how long it takes to fold/disassemble the wheelchair ; • how light the parts are once folded/ disassembled; • whether parts may get lost (for example if a wheelchair disassembles into many different components); • how small the wheelchair is once folded/ disassembled. Which wheelchairs (if any) have pneumatic tyres? Which wheelchairs (if any) have solid inner tubes? Which wheelchairs (if any) have solid tyres? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 122 123 2. Pressure relief Questions: Answers/key points for trainers to emphasize: What types of cushions can you see in the training room? Cushions may be described according to: • The main material: - foam cushions; - cushions made from coconut bre (coir); - cushions lled with air ; - cushions lled with uid or gel. • The shape: - at cushions; - contoured cushions; - moulded cushions; - layered cushions Which of these would you describe as a pressure relief cushion? Why? Pressure relief cushions are likely to include: • foam contoured cushions; • cushions with a uid or gel over a contoured base; • cushions lled with air. Participants should identify what makes the cushion a ‘pressure relief cushion’. Reasons include: • Contours/shaping including: - a ‘well’ under the seat bones (seat bone well); - a shelf before the seat bones; - support under the upper part of the thigh; - grooves, or gutters for the thigh. • Gel/ uid packs, which helps to distribute pressure. (Note – gel/ uid packs should be on a contoured rm foam base with contours as described above). Of the pressure relief cushions (if any) – which would be relatively easy to modify to either : • increase pressure relief; • provide additional postural support. Usually a foam contoured cushion is easier to modify as the foam can be cut or a lift added to reduce pressure. If the air/gel interface layer is a separate unit, it is also easy to make changes to the base, add a lift etc. and then replace the interface layer. (For more information see the Wheelchair Service Training Package – Basic Level part of ‘Cushions’ session. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 124 125 What are the features of the different cushion covers in the training room? Participants may identify these features: • water resistant; • durable; • stretchy (more likely to t to cushion contours); • removable for washing. 3. Propelling Questions: Answers/key points for trainers to emphasize: Sit upright in the wheelchair. Is the rear wheel in a good position for you to self- propel? Check: • allow your arm to hang down. Does your hand hang over the axle? • hold the top of the push rim directly below your shoulder. Is your elbow bent between 90–120 degrees? • Is the rear wheel position adjustable? If adjusted – would this improve the propelling position? Ensure that participants have noted whether the rear wheel position can be improved for self- propelling by adjusting the axle position. Do any of the wheelchairs in the training room have an adjustable height seat? When would this be helpful? The ability to lower the seat height may be helpful to enable correct set-up for a wheelchair user who will propel with their feet. However this feature is not commonly available in many less resourced settings. 4. Postural support features Questions: Answers/key points for trainers to emphasize: Which wheelchairs (if any) have elevating leg rest? Which wheelchairs (if any) have a solid seat? Which wheelchairs (if any) have a tension adjustable backrest? Which wheelchairs (if any) have additional components designed to provide additional postural support? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 124 125 5. Adjustability Questions: Answers/key points for trainers to emphasize: Which wheelchairs (if any) have the following adjustability? • Footrest height • Footrests angle • Footrests move backwards/forwards • Backrest height up or down • Backrest recline • Tilt in space (seat and backrest tilt) More adjustability is helpful when working with wheelchair users who need additional postural support. Note for trainers: Here may be a good point to make the following point about user training: • Always explain to the wheelchair user and their family member/caregiver that the way a wheelchair is set up (or adjusted) will affect the wheelchair user’s postural support. Adjustable parts should not be re-adjusted unless necessary. It is important to maintain the settings set at the nal tting and check/ tighten adjustments to make sure they do not slip. 3. Key point summary (2 minutes) INTERMEDIATE LE VEL • Prescription (selection) includes: - selecting the type and size of wheelchair most suitable for the wheelchair user; - describing any specific set-up for that wheelchair; - selecting the type and size of cushion; - selecting what PSDs or modifications are needed. • Some wheelchair and cushion features make modifications or adding PSDs easier. • Wheelchair service personnel should be very familiar with the wheelchairs and cushions available including all features and adjustments. B.6. Selecting wheelchairs and cushions: 18 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 126 127 B.7: Prescription (selection) of Postural Support Devices (PSDs) – introduction O B JE C T IV E S By the end of this session, participants will be able to: de ne ‘postural support device’; explain the purpose of the intermediate wheelchair prescription (selection) form. R E S O U R C E S For the session: PPT Slides: B.7: Prescription (selection) of PSDs – introduction; Reference Manual; poster : Postural Support Device (PSD) Table; intermediate wheelchair prescription (selection) form; laminated Postural Support Device (PSD) Table – 1 for each participant; PSD kit. C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: PSDs, PSD materials and fabrication methods available in the participants’ working environment. Where participants will carry out wheelchair user tting – for example in the community/users’ homes, in a workshop or in a wheelchair service centre. This may affect the way in which they work and the choices of PSDs. Preparing a sample intermediate wheelchair prescription (selection) form to include PSD options available for participants in their local service/area. T O P R E PA R E Gather resources, review PPT slides and read through the session plan. Pin up the Postural Support Device (PSD) Table poster. Unpack sample PSDs from the PSD kit that have been put together and lay them out on a table at the front of the training room where you can easily reach them. Arrange the training room so that participants are seated in a semi-circle facing the front of the room. O U T L IN E 1. Introduction 2. What is a PSD or PSDs? 3. Recording PSDs on the intermediate wheelchair prescription (selection) form 4. Key point summary 2 10 15 3 Total session time 30 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 126 127 1. Introduction (2 minutes) INTERMEDIATE LE VEL Step 3: Prescription (selection) Postural Support Devices (PSDs) • In this session participants will learn about: - what is meant by the term ‘Postural Support Device / Devices (PSD/PSDs)’; - the final part of the intermediate wheelchair prescription form. B.7. Prescription (selection) of PSDs: 2 INTRODUCTIO N Explain: • For the next 5 sessions, we will continue to learn about the third step of wheelchair service delivery, which is prescription (selection). In the last session we looked at selecting the type of wheelchair and cushion most suitable for the wheelchair user. • In this session we will talk about: - what is meant by the term ‘Postural Support Device / Devices (PSD / PSDs)’; - the nal part of the intermediate wheelchair prescription form. • In each of the following sessions we will look in more detail at these PSDs. • Remember – before nalizing a prescription it is important to make sure that the postural supports required can be provided in the wheelchair selected. 2. What is a PSD? (10 minutes) Give each participant the laminated Postural Support Device (PSD) Table (hence after to be referred to as PSD Table). Ask: What is a ‘postural support device’? Encourage answers. Answers: • A ‘Postural Support Device (PSD – singular and PSDs – plural)’ is: - any physical device, which is added to a wheelchair to provide additional postural support; - examples of PSDs include: headrest, pelvis strap, pelvis side pads; - remember – a wheelchair seat, backrest, footrests, armrests all provide postural support as well. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 128 129 INTERMEDIATE LE VEL B.7. Prescription (selection) of PSDs: 3 EXAMPLES OF PSDS Explain: The illustration on the slide provides some examples of PSDs. Ask: What PSDs can participants see? Answers (participants may use different names/terminology): • trunk side pads; • contoured/shaped backrest and contoured cushion; • pelvis side pads; • pre seat bone shelf. Explain: • There are different designs of PSDs and different ways that a wheelchair can be set up to provide a wheelchair user with additional postural support. • In this training programme some of the most commonly used PSDs are introduced. • The names used in this training programme are simple descriptive terms. Participants may have heard of other terms to describe the same thing. In each wheelchair service, wheelchair service personnel and wheelchair users can use the terms most familiar and comfortable to them. • We will talk more about how these PSDs can be made later in this training programme. • Remember – many wheelchair users may need more than one of the different PSD solutions that we will talk about, combined to provide the right overall solution for them. 3. Recording PSDs on the intermediate wheelchair prescription (selection) form (15 minutes) INTERMEDIATE LE VEL • The prescription form gives information about: - the wheelchair type, size and set-up; - the cushion type and size; - PSDs or modifications required. B.7. Prescription (selection) of PSDs: 4 INTERMEDIATE WHEELCHAIR PRESCRIPTION FORM Explain: • The purpose of the intermediate wheelchair prescription form is to give information to the wheelchair service personnel preparing the wheelchair about: - the wheelchair type, size and set-up (covered earlier); - the cushion type and size (also covered earlier); - PSDs or modi cations required. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 128 129 Explain: • It is on the intermediate wheelchair prescription form that all of the information gained from the assessment is translated into a clear description of the wheelchair that is needed for the wheelchair user. • The more detailed information that is provided on the intermediate wheelchair prescription form, the more accurately the wheelchair will be prepared for the rst tting. • The intermediate wheelchair prescription form does not necessarily say how the PSDs should be made. This may be decided in discussion between the wheelchair service personnel preparing the wheelchair and the wheelchair service personnel who have carried out the assessment. • Different wheelchair services often have different ways to record wheelchair prescription information. Ask participants to look at the examples of completed intermediate wheelchair prescription forms in their Reference Manual at the end of this session. INTERMEDIATE LE VEL PSD checklist Describe / draw and provide dimensions S ea t / c us hi on Add solid seat Pre seat bone shelf (=3 less 12) Lower seat front L R Raise seat front Wedge for anterior tilt Build up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other B.7. Prescription (selection) of PSDs: 5 PSDS OR MODI FICATIONS REQ UIRED Explain: Wheelchair service personnel can use the ‘PSDs or modi cations required’ part of the intermediate wheelchair prescription form to: • select which PSDs they wish to prescribe/ select (using the check boxes) from the list of common PSDs. There is also space to list other types of PSDs under ‘other’; • draw over the shadow drawings to show the shape and provide dimensions for the PSDs they have prescribed (selected); • write or sketch any additional information. INTERMEDIATE LE VEL B.7. Prescription (selection) of PSDs: 6 PSD SIZE AND L OCATION • Alongside the PSD checklist, participants need to provide dimensions so that the PSD can be made to the correct size and located in the correct place on the wheelchair. • The dimension sketch on the PSD Table is a guide to help participants think about the different dimensions needed for each PSD. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 130 131 INTERMEDIATE LE VEL PSDs for seat / cushion. PSDs for seat, backrest, tray, armrests, head supports, lower leg supports and straps. B.7. Prescription (selection) of PSDs: 7 PSD SHADOW DRAWINGS • The two ‘shadow drawings’ on the form can be used as a guide for participants to draw the PSDs prescribed and provide dimensions. INTERMEDIATE LE VEL PSD checklist Describe / draw and provide dimensions S ea t / c us hi on Add solid seat Pre seat bone shelf (=3 less 12) Lower seat front L R Raise seat front Wedge for anterior tilt Build up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other B.7. Prescription (selection) of PSDs: 8 USING PSD CHE CKLIST AND SH ADOW DRAWIN G • For example, this slide shows how the shadow drawing and the PSD checklist on the intermediate wheelchair prescription form have been used to describe a pre seat bone shelf and lower seat front on the right side. • Ask: can anyone think of why a wheelchair user may need the seat to be lowered on one side in this way? Acknowledge correct answers. Answer: • the wheelchair user’s right hip is unable to close fully to 90 degrees. INTERMEDIATE LE VEL B.7. Prescription (selection) of PSDs: 9 USING PSD CHE CKLIST AND SH ADOW DRAWIN G • Explain: This example shows how the shadow drawing and PSD checklist on the second page of the intermediate wheelchair prescription form can be used. • Ask: What PSDs have been recorded on the form? Encourage participants to look at the PSD Table and PSD Reference Table in their Reference Manual if they are not sure. Acknowledge correct answers. Answers: • pre seat bone shelf (this would be selected from the PSD checklist on the rst page of the form); • right and left trunk side pads; • left footrest wedge; • pelvis strap. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 130 131 Explain: On each drawing dimension lines have been added. This shows what dimensions would be needed to make these PSDs. Explain: As we go through the next sessions, we will talk more about what dimensions are needed to help describe the size and location of PSDs. Participants will also practice doing this during the practical sessions. 4. Key point summary (3 minutes) INTERMEDIATE LE VEL • A ‘postural support device’ is any physical device which is added to a wheelchair to provide additional postural support. • The purpose of the intermediate wheelchair prescription form is to give information to the wheelchair service personnel preparing the wheelchair about: - the wheelchair type, size and set-up; - the cushion type and size; - PSDs or modifications required. • The more detailed information that is provided, the more accurately the wheelchair will be prepared for the first fitting. B.7. Prescription (selection) of PSDs: 10 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 132 133 B.8: Prescription (selection) of PSDs – stabilizing the pelvis O B JE C T IV E S By the end of this session, participants will be able to: describe PSDs that help to stabilize and support the pelvis; specify dimensions for a pre seat bone shelf and rear pelvis pad. R E S O U R C E S For the session: PPT Slides: B.8 Prescription (selection) of PSDs – stabilizing the pelvis; Reference Manual; Participant’s Workbook; DVD: Postural support solutions for anterior pelvis tilt; poster : Postural Support Device (PSD) Table; laminated Postural Support Device (PSD) Table – 1 for each participant; PSD kit; pelvis strap – 1 for each group; assessment bed–1 for each group; blocks of rm foam – a few for each group, wedge of rm foam – 1 for each group; wheelchairs – 1 for each group (at least three types represented if possible). C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: PSDs, PSD materials and fabrication methods available in the participants’ working environment. Where participants will carry out wheelchair user tting – for example in the community/users’ homes, in a workshop or in a clinic. This may affect the way in which they work and the choices of PSD. When demonstrating/asking participants to provide support for volunteers – be aware of any cultural issues related to touching. T O P R E PA R E Gather resources, review PPT slides, watch DVD and read through the session plan. Pin up the Postural Support Device (PSD) Table poster. Unpack sample PSDs from the PSD kit that have been put together and lay them out on a table at the front of the training room where you can easily reach them. Arrange an assessment bed at the front of the training room. Arrange the training room so that participants are seated in a semi-circle facing the front of the room. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 132 133 O U T L IN E 1. Introduction 2. Problem: Pelvis is in posterior tilt and/or slides forward 3. Problem: Pelvis is in lateral tilt ( xed unlevel pelvis) 4. Problem: Pelvis is in anterior tilt (pelvis tilts forward) 5. Problem: Pelvis moves to one side 6. Key point summary 2 45 5 25 10 3 Total session time 90 1. Introduction (2 minutes) INTERMEDIATE LE VEL Step 3: Prescription (selection) PSDs – stabilizing the pelvis • During this session participants will learn about some PSDs that are used to provide support to the pelvis. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 2 INTRODUCTIO N Explain: • During this session we will learn about some PSDs that are used to provide support to the pelvis. • Remember – although in this and next sessions we will look at PSDs in isolation – many of the PSDs work together. INTERMEDIATE LE VEL Trunk Pelvis B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 3 SUPPORTING U PRIGHT POSTU RE Explain: To support an adult to sit upright, there are two areas of the body where support is most needed. These are: • pelvis; • trunk. INTERMEDIATE LE VEL • When the pelvis is not in an upright posture, there are also changes to the trunk and hips. • Supporting or stabilizing the pelvis is the most important thing to do to help the wheelchair user to sit upright. • Support provided at the pelvis can reduce the need for support elsewhere. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 4 STABILIZING TH E PELVIS Explain: We are going to look rst at the pelvis: • when the pelvis is not in an upright posture, there are also changes to the trunk and hips; • so supporting or stabilizing the pelvis is the most important thing to do to help the wheelchair user to sit upright; • support provided at the pelvis can reduce the need for support elsewhere. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 134 135 Explain: During this session and through to session ‘B.11: Prescription (selection) of PSDs – supporting the head, thighs and lower legs’ we will follow examples that show a problem, support needed and PSD solutions. In some sessions the format is slightly different. 2. Problem: Pelvis is in posterior tilt and/or slides forward (45 minutes) INTERMEDIATE LE VEL Pelvis tilts backwards (posterior pelvis tilt) B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 5 POSTURAL PRO BLEM Starting posture: • posterior pelvis tilt. Ask a volunteer to come to the front of the training room and demonstrate the problem. INTERMEDIATE LE VEL • What support can be provided to help the volunteer’s pelvis closer to neutral sitting posture? ? B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 6 SUPPORT NEED ED Ask participants – what support (hand support) can be provided to help the volunteer’s pelvis closer to neutral sitting posture? Invite one or two participants to come to the front of the training room and demonstrate with their hands providing support for the volunteer. Encourage the whole group to offer advice if needed. Invited participants should provide support at the back of the pelvis. Acknowledge correct demonstration. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 134 135 INTERMEDIATE LE VEL Support is usually needed in two areas: • at the back of the pelvis; • at the front of the pelvis – more precisely, in front of the seat bones. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 7 SUPPORT FROM POSTERIOR TIL T TO MORE NEU TRAL SITTING POSTU RE Explain: When providing support to bring the pelvis from posterior tilt to more neutral sitting posture – support is usually needed in two areas: • at the back of the pelvis at the level of PSIS – as provided by the invited participants; • at the front of the pelvis – more precisely, in front of the seat bones (ischial tuberosities). Without the support at the front of the seat bones, there is a tendency for the pelvis to shift or slide forward, away from the support provided at the back of the pelvis. Ask: How can support be provided as shown at the front of the seat bones? Invite one or two participants (volunteers) to come to the front of the training room and demonstrate how support could be provided at the front of the seat bones using blocks of rm foam. While doing this, one other invited participant should provide support at the back of the pelvis. Encourage the whole group to offer advice if needed. Acknowledge correct demonstration. Thank the volunteers. Ask participants what PSDs could provide this support? Participants may look at the PSD Table or PSD Reference Table for ideas. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 136 137 INTERMEDIATE LE VEL • helps keep the pelvis upright; • helps to stop the pelvis sliding forward; • helps reduce a tendency to sit with a slumped posture. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 8 PRE SEAT BON E SHELF A pre seat bone shelf provides support in front of the seat bones. It helps to: • keep the pelvis upright; • stop the pelvis from sliding forward; • reduce a tendency to sit with a slumped posture. The pre seat bone shelf sits just in front of the seat bones. Ask: What body measurement do you need to take to be able to decide where a pre seat bone shelf should be on a cushion? Answer: • distance between the back of pelvis to seat bones. INTERMEDIATE LE VEL • Helps to keep the pelvis upright. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 9 REAR PELVIS PA D Explain: A rear pelvis pad provides support at the top of the pelvis (at the level of PSIS). It helps to: • keep the pelvis upright. INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 10 PRE SEAT BONE SHELF AND REA R PELVIS PAD SU PPORT Explain: • Here you can see these two PSDs provided for the same wheelchair user shown in the earlier slide. • With pre seat bone shelf and rear pelvis pad support, this wheelchair user can sit upright. • Notice how the backrest angles backwards to allow for the natural curve of this wheelchair user’s upright trunk. • Good trunk support is an important part of the overall solution. We will talk more about support for the trunk in later sessions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 136 137 Explain: • The combination of a pre seat bone shelf and rear pelvis pad is often used to help wheelchair users to sit with a more upright pelvis (where their starting posture is not xed) and with more stability. • In this next activity, participants will work out how they can describe on the intermediate wheelchair prescription form the dimension and location of these two common PSDs. Small-group activity Groups: Divide participants into groups of 2. Instructions: Ask participants to read the story of Marian in the Participant’s Workbook (B.8: Prescription (selection) of PSDs – stabilizing the pelvis). Ask the participants to work together and use the results from the ‘taking measurements’ part of the intermediate wheelchair assessment form to add appropriate dimensions to the sketch provided. Explain: Participants may use the following to help them with the activity: • PSD Table; • PSD Reference Table. Explain: Participants have 10 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Monitor the groups closely. Ensure that each group understands the activity. Encourage groups to use the Reference Manual and their own knowledge. Guide participants if necessary. Time: Allow 10 minutes for the activity. Allow 5 minutes for feedback. Feedback: INTERMEDIATE LEVEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 11 DIMENSIONS F OR MARIAN’S P SDS Show slide: Ask participants: • What should the distance between the backrest and the beginning of the pre seat bone shelf be for Marian? • What should the distance between the top of the seat to the mid-height of the rear pelvis pad be for Marian? • What other dimensions or information would be helpful? Explain: When completing a whole prescription (selection) form, participants may make a number of dimension sketches with notes such as this one to give the dimensions and location of PSDs. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 138 139 Answers: • The distance between the backrest and the beginning of the pre seat bone shelf should be 170–190mm for Marian (body measurement L plus 20–40mm). • The distance between the top of the seat (where the seat bones sit) to the mid-height of the rear pelvis pad should be 160 mm for Marian. • Other dimensions or information that would be helpful: - specify the type of foam (e.g. rm foam under soft foam to make both the pre seat bone shelf and rear pelvis pad); - specify the height of the pre seat bone shelf. For an adult, this is usually 20–30mm. - specify the depth of the rear pelvis pad. This will depend on the hand simulation/needs of the wheelchair user. Explain: We have looked now at the pre seat bone shelf and rear pelvis pad. Ask: What might happen if a wheelchair user using these supports has uncontrolled movements, or high tone, or spasms that straighten their body (extensor patterns)? Answer: • the wheelchair user could shift away from the pre seat bone shelf and rear pelvis pad. Ask: What direction could support be provided to help prevent this from happening? Ask one or two volunteers to come to the front of the training room and demonstrate where support could be provided. Answers: • support downwards at the top of the thighs. Acknowledge correct demonstration. INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 12 SUPPORT FROM POSTERIOR TIL T TO MORE NEUTRAL SITT ING POSTURE Explain: The top vertical arrow shows the additional support that can be provided to help keep the wheelchair user’s pelvis in place, and against the support provided at the back of the pelvis and the front of the seat bones. Ask: What PSD would provide this support? Answer: • a pelvis strap. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 138 139 INTERMEDIATE LE VEL • Helps hold the pelvis in place. • Helps to stop sliding forward. • Helpful for a wheelchair user with strong uncontrolled movements. 60º B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 13 PELVIS STRAP Explain: • A pelvis strap helps to hold the pelvis in place. • A pelvis strap is very helpful for wheelchair users who have uncontrolled movements and/or a tendency to slide forward. • The pelvis strap helps to keep the pelvis in place, so that the pre seat bone shelf and the rear pelvis pad continue to provide support. • Where the strap is attached to the wheelchair will affect the angle/direction of pull. This will directly affect the way that the pelvis strap works. INTERMEDIATE LE VEL 45º 90º B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 14 WHEELCHAIR S ERVICE TRAININ G PACKAGE - INTERMEDIATE LEVEL • The angle may be between 45–90 degrees. • The most effective angle will vary depending on the needs of the wheelchair user. • Always assess, discuss and if possible trial the angle of the pelvis strap with the wheelchair user to see which angle is most effective and most comfortable for the wheelchair user. Demonstrate with a sample. Thank the volunteers. Small-group activity Groups: Divide participants into groups of 3. Instructions: Provide each group with a wheelchair (preferably different types of wheelchairs) and a pelvis strap. Ask participants to think about where the pelvis strap could be located on their wheelchair to provide an angle of pull of: • 45 degrees; • 60 degrees; • 90 degrees. Explain: Participants have 5 minutes as a group to do this activity and then the groups will come back together for feedback. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 140 141 Monitor: Monitor the groups closely. Ensure that each group understands the activity. Guide participants if necessary. Time: Allow 5 minutes for the activity. Allow 5 minutes for feedback. Feedback: Ask one group for each type of wheelchair to show where the pelvis strap could be located to achieve 45 degrees, 60 degrees and 90 degrees angle of pull. Acknowledge correct demonstrations. Explain: Different solutions are often needed for different types of wheelchairs. However the angle of pull should be decided by the needs of the wheelchair user – not the design of the wheelchair. INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 15 RAISED SEAT F RONT Explain: • Uncontrolled movements, high tone or spasms can sometimes be reduced by increasing the amount of hip exion. • This can be done in the wheelchair by raising the seat front – creating a wedge under the wheelchair user’s thighs. • Note – the wedge should always begin in front of the seat bones as shown in this slide. The seat bones should sit on a flat surface. Ask: How would you provide support if the wheelchair user’s pelvis is xed in posterior tilt and he/she cannot sit with their pelvis upright? Encourage answers. Answer: • For wheelchair users with a xed posterior pelvis tilt further adjustments may be needed to accommodate the posture. • One solution is to increase the angle between the seat and the backrest to accommodate the pelvis posture and provide support to prevent the pelvis from rolling back further. This can be called ‘open the seat to backrest angle’ (see PSD Reference Table). • Care must be taken to ensure that the wheelchair user does not slide forward in the wheelchair. This can cause ‘shearing’, which can develop into a pressure sore. • A pre seat bone shelf, a pelvis strap and raising the seat front will help to prevent sliding forward. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 140 141 INTERMEDIATE LE VEL • Increasing the angle between the seat and the backrest can help accommodate fixed posterior pelvis tilt. • Make sure the wheelchair user will not slide down in the wheelchair. • A pre seat bone shelf, pelvis strap and raising seat front can help prevent sliding forward. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 16 OPEN SEAT TO BACKREST AN GLE Explain: • This illustration shows one way of opening the seat to backrest angle. • Remember – The foam should be shaped to provide support where needed by the wheelchair user. 3. Problem: Pelvis is in lateral tilt ( xed unlevel pelvis) (5 minutes) INTERMEDIATE LE VEL Pelvis is in lateral tilt (fixed unlevel pelvis). B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 17 POSTURAL PRO BLEM Explain: Now we will look at a different postural problem relating to the pelvis. Remember, wheelchair users may have more than one postural problem. We will look at the following postural problem: • pelvis is in lateral tilt/ xed unlevel pelvis (one ASIS higher than the other). Explain: How to support this posture has been discussed in the ‘B.3: Physical assessment – pelvis and hip posture screen’ session. Ask: What is the PSD solution? Acknowledge answers. INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 18 PSD SOLUTION FOR UN-LEVEL PELVIS A build-up under the high side of pelvis will help to: • increase stability for the wheelchair user; • avoid unsafe pressure on the lower side of the pelvis. Explain: There should be even contact under both seat bones and thighs. It may be necessary to adjust the footrests (one may need to be higher than the other). Explain that the image on the slide is from the back of the wheelchair. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 142 143 INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 19 PSD SOLUTION FOR UN-LEVEL PELVIS WITH P ELVIS SIDE PADS Explain: Pelvis side pads will also help to support the pelvis and should be added for anyone with a build-up under the pelvis. 4. Problem: Pelvis moves to one side (10 minutes) Explain: Now we will look at one more postural problem relating to the pelvis. INTERMEDIATE LE VEL • Pelvis moves to one side - lateral pelvis tilt; - pelvis is more towards the left. - sideways curve of the spine; - pelvis is more towards the left. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 20 POSTURAL PRO BLEM Postural problem: • Pelvis moves to one side. Explain: • There are different reasons why this may happen. • This problem is often associated with other postural problems. • In the slide you can see: - the same man from earlier – who has lateral pelvis tilt ( xed unlevel pelvis) and his pelvis is more towards the left; - a woman with a sideways curve in her spine. Her pelvis is also more towards the left. Ask: Where can support be provided to help keep the pelvis in the centre of the wheelchair? Acknowledge correct answers. Answer: • support would be provided at the side of both hips. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 142 143 INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 21 SUPPORT TO H ELP KEEP THE P ELVIS IN THE CENTRE O F THE WHEELC HAIR Ask: What is the PSD solution? Participants may like to refer to PSD Reference Table. Acknowledge correct answers. Answer: • pelvis side pads. INTERMEDIATE LE VEL • Help to stop the pelvis moving sideways. • For young children make sure the pelvis side pads do not push the thighs together. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 22 PELVIS SIDE PA DS Explain: Pelvis side pads help to stop the pelvis from moving sideways. Pelvis side pads should provide rm contact on both sides of the pelvis. Remember: Young children should sit with their thighs more apart than adults. This is important for the health and development of their hip joints. This means it is particularly important for children that pelvis side pads do not push children’s thighs together. 5. Pelvis is in anterior tilt (pelvis tilts forward) (25 minutes) INTERMEDIATE LE VEL Pelvis tilted forward. Lower back arched. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 23 POSTURAL PRO BLEM Explain: Another postural problem is anterior pelvis tilt (pelvis tilts forward). Ask participants – what are some supports that could be provided to help encourage a more neutral sitting posture of the pelvis? Acknowledge answers. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 144 145 VIDEO Answers: • support at the front of the pelvis (ASIS) pushing backwards; • a backwards sloping wedge. Introduce DVD: Postural support solutions for anterior pelvis tilt. In this video we will see Caro, a wheelchair user whose pelvis is in anterior tilt. Watch closely to see the PSD solution that is developed for her. After the video we will discuss. Show DVD. Ask if there are any questions. Ask participants – what support was provided to help Caro sit with her pelvis closer to neutral sitting posture? Answer: • Caro tried a cushion with a wedge for anterior tilt (a backwards sloping wedge) – to see if this helped her pelvis to become more upright. • The wheelchair service personnel then experimented with a pelvis strap, to identify whether the additional support that can be provided by an anterior four-point strap would help Caro further. INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 25 WEDGE FOR AN TERIOR TILT Explain: • A wedge for anterior tilt (a backwards sloping wedge) is placed under the seat bones. This can help a pelvis, which is in anterior tilt to roll backwards, towards the backrest. • The wedge for anterior tilt should stop just in front of the seat bones and level out under the thighs. • When considering using this PSD – try it with the wheelchair user to check: - how it feels; - whether it is effective; - how much angle is comfortable for the wheelchair user. Note – in the DVD, the wheelchair service personnel asked Caro whether the cushion helped her to sit more comfortably. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 144 145 INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 26 WEDGE FOR AN TERIOR TILT Explain: • This illustration shows how this wedge can be made with a combination of rm and soft foam. INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 27 SUPPORT FROM ANTERIOR TILT TO MORE NEU TRAL SITTING POSTU RE Explain: • Support can also be provided at the top at the front of the pelvis to help bring the pelvis into a more neutral sitting posture. Note – in the DVD, the wheelchair service personnel provided support in this way and asked Caro how that felt. Ask participants what PSD could provide this support? Answers: • anterior tilt four-point strap. INTERMEDIATE LE VEL B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 28 ANTERIOR TILT FOUR POINT S TRAP Explain: • This strap is speci cally for anterior tilt. • Note on the illustration that the strap is anchored downwards onto the seat rails; and backwards, onto the backrest uprights. • This is to stop the strap from sliding up onto the wheelchair user’s stomach, which would be very uncomfortable. • It is important that any strap, which provides support over the ASISs is well padded, to reduce the risk of pressure sores. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 146 147 Notes for trainers: The DVD shows a simple strap. This is used just to assess whether a strap is comfortable for Caro and the direction of pull. If asked, explain to participants that a four-point strap would need to be made for the reasons described above. Small-group activity Groups: Divide participants into groups of 3. Instructions: Assign each group some blocks of rm foam; one wedge of rm foam (large enough to sit on); and a pelvis strap. Ask participants to work brie y in groups to: • experiment with the foam to see how they can set up the seat surface to encourage the pelvis to ‘roll’ from anterior tilt to more upright posture (mimic the wedge for anterior tilt); • experiment with the pelvis strap to feel the most effective ‘direction of pull’ to encourage the pelvis from anterior tilt to a more neutral sitting posture. Explain: Participants have 10 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Monitor the groups closely. Ensure that each group understands the activity. Ensure each participant has the opportunity to feel the effect of the wedge on their pelvis posture. Guide participants if necessary. Time: Allow 10 minutes for activity. Allow 5 minutes for feedback. Feedback: Ask the whole group – Did sitting on the wedge for anterior tilt encourage their pelvis to roll backwards? Acknowledge answers. Ask the whole group – What was the most effective angle of pull for the pelvis strap? Acknowledge answers. 6. Key point summary (3 minutes) INTERMEDIATE LE VEL • Supporting or stabilizing the pelvis is the most important thing to do to help the wheelchair user to sit upright. • Support provided at the pelvis can reduce the need for support elsewhere. • Remember – although we are looking one by one at different PSDs – in a final wheelchair, the support provided by the wheelchair and different PSDs or modifications all combine to provide the wheelchair user with an overall system that works for them. B.8. Prescription (selection) of PSDs – stabilizing the pelvis: 29 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 146 147 B.9: Prescription (selection) of PSDs – supporting the hips O B JE C T IV E S By the end of this session, participants will be able to: describe PSDs that provide support for the hips; specify dimensions needed to be able to fabricate at least two PSDs. R E S O U R C E S For the session: PPT Slides: B.9 Prescription (selection) of PSDs – supporting the hips; Reference Manual; Participant’s Workbook; poster : Postural Support Device (PSD) Table; laminated Postural Support Device (PSD) Table–1 for each participant; PSD kit. C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: PSDs, PSD materials and fabrication methods available in the participants’ working environment. Where participants will carry out wheelchair user tting – for example in the community/users’ homes, in a workshop or in a clinic. This may affect the way in which they work and the choices of PSDs. T O P R E PA R E Gather resources, review PPT slides and read through the session plan. Pin up the Postural Support Device (PSD) Table poster. Unpack sample PSDs and lay them out on a table at the front of the training room where you can easily reach them. O U T L IN E 1. Introduction 2. Supporting the hips 3. Completing the ‘PSDs or modi cations required’ section on the intermediate wheelchair prescription form 4. Key point summary 2 25 15 3 Total session time 45 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 148 149 1. Introduction (2 minutes) INTERMEDIATE LE VEL Step 3: Prescription (selection) PSDs – supporting the hips • In this session participants will learn about the different types of PSDs which will help to accommodate fixed non-neutral postures of the hips. • Always remember – PSDs are not usually prescribed in isolation – many of the PSDs work together. B.9. Prescription (selection) of PSDs – supporting the hips: 2 INTRODUCTIO N Explain: • During this session we will look at some PSDs, which will help to accommodate xed non-neutral postures of the hips including: - one hip cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees); - both hips cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees); - one or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees). • Remember – any xed / non-neutral postures of the hip will affect pelvis posture if not accommodated. During the ‘B.3: Physical assessment – pelvis and hip posture screen’ session we looked at how to provide temporary supports to accommodate these postures. • In this session we will look at how these temporary supports become permanent PSDs. • Always remember – PSDs are not usually prescribed (selected) in isolation – many of the PSDs work together. 2. Supporting the hips (25 minutes) Problem: One hip cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees) Explain: We will now look at what can be done if only one hip cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees for one hip only). Ask: As discussed previously, what temporary support was provided for this problem? Encourage answers. Answer: • place a build-up (foam) under both seat bones and under the thigh of the hip that can bend to neutral sitting posture (trunk to thigh angle more than 90 degrees). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 148 149 INTERMEDIATE LE VEL • For wheelchair users who have one hip which cannot bend to neutral for sitting. • Note that there is still a pre seat bone shelf in the cushion. B.9. Prescription (selection) of PSDs – supporting the hips: 3 LOWER SEAT F RONT ON ONE SIDE Explain: • This support can be permanently built into the cushion to accommodate the hip, which cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees) by lowering the seat front on one side. • Lower seat front: The angle of the cut-out in the foam will depend on the wheelchair user’s trunk to thigh angle – so this should be checked at the physical assessment. • Note that there is still a pre seat bone shelf in the cushion. Problem: Both hips cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees) INTERMEDIATE LE VEL Both hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees.) B.9. Prescription (selection) of PSDs – supporting the hips: 4 POSTURAL PRO BLEM Problem: • Both hips cannot bend to neutral sitting posture (trunk to thigh angle more than 90 degrees) Ask: What was the temporary support for this postural problem? Answer: • place a build-up (foam) under both seat bones. Ask: Would this work as a permanent solution and why or why not? Answer: • no, the wheelchair user would tend to slide forward out of their seat. Ask: What can be done instead? Answer: • increase the angle between the seat and the backrest to match the trunk to thigh angle; • provide good back support to help user sit as upright as possible. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 150 151 INTERMEDIATE LE VEL B.9. Prescription (selection) of PSDs – supporting the hips: 5 OPEN THE SEAT TO BACKREST ANGLE A possible solution if both hips cannot bend to neutral sitting posture is to open (increase) the angle between the seat and the backrest: • increasing the seat to backrest angle will accommodate the greater trunk to thigh angle; • the angle will depend on the wheelchair user’s trunk to thigh angle – and this should be decided during the assessment; • prescribe a pre seat bone shelf and a pelvis strap to help prevent sliding forward. Problem: One or both hips cannot open to neutral sitting posture Explain: We will look at one more postural problem to do with hips – which is when one or both hips cannot open to neutral for sitting (trunk to thigh angle less than 90 degrees). Ask all participants to demonstrate this posture where they are sitting. Check that everyone has their hips bent so that their knees are higher than their hips. Ask: Can anyone suggest a solution? Think about the temporary solutions previously discussed. Encourage answers. Answer: • place a build-up (wedge of rm foam) in front of the seat bones and under the thigh/s that cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 150 151 INTERMEDIATE LE VEL • For wheelchair users who have one or both hips which do not bend to neutral for sitting. • Can also help to reduce strong uncontrolled movements. B.9. Prescription (selection) of PSDs – supporting the hips: 6 RAISED SEAT F RONT Explain: • A possible permanent solution is to raise the seat front by placing a wedge in front of the seat bones and under the thighs. • This reduces the angle between the seat and the backrest. The amount that the seat front is raised will depend on the wheelchair user’s trunk to thigh angle. This should be decided during assessment. • Raising the seat front can also help reduce strong uncontrolled movements or high tone where the body straightens. 3. Completing the ‘PSDs or modi cations required’ section on the intermediate wheelchair prescription form (15 minutes) Small-group activity Groups: Divide participants into groups of 2 or 3. Instructions: Ask participants to read wheelchair users’ stories in the Participant’s Workbook (B.9: Prescription (selection) of PSDs – supporting the hips). Ask participants to work together to describe PSDs on the ‘PSDs or modi cations required’ part of the intermediate wheelchair prescription form. Explain: Participants may use the following to help them with the activity: • PSD Table; • PSD Reference Table. Explain: Participants have 10 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Monitor the groups closely. Ensure that each group understands the activity. Encourage groups to use the PSD Table and PSD Reference Table. Guide participants if necessary. Time: Allow 10 minutes for activity. Allow 5 minutes for feedback. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 152 153 Feedback: Ask participants how they felt about drawing the PSDs. Acknowledge that for many people it takes practice to be able to describe PSDs accurately. INTERMEDIATE LE VEL B.9. Prescription (selection) of PSDs – supporting the hips: 7 DIMENSIONS N EEDED TO MAK E THIS PSD Show slide Explain: the important dimensions are: • A: Where the pre seat bone shelf should begin. • B: How high the pre seat bone shelf should be. • C: The difference in the height of the front of the seat between the left and right hip. This creates the angle to accommodate Sienna’s right hip. Ask: How are these dimensions decided? Answers: • A: From Sienna’s body measurement (back of pelvis to seat bones) you can decide where the pre seat bone shelf should start. • B: The height of a pre seat bone shelf is usually between 25–30mm. • C: Measure the height of the temporary support to determine the height of C. INTERMEDIATE LE VEL B.9. Prescription (selection) of PSDs – supporting the hips: 8 DIMENSIONS N EEDED TO MAK E THIS PSD Show slide: Explain: the important dimensions are: • A: Where the pre seat bone shelf should begin. • B: How high the pre seat bone shelf should be. • C and D together provide the dimensions needed to fabricate the wedge, which is added to open the seat to backrest angle. Ask: How are these dimensions decided? WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 152 153 Answers: • A: From Robert’s body measurement (back of pelvis to seat bones) you can decide where the pre seat bone shelf should start. • Note: This measurement must take into account the wedge added to the backrest to open the seat to backrest angle. • B: The height of a pre seat bone shelf is usually between 25–30mm. • C and D: The best way to determine these measurements is to ‘mock-up’ the wedge and test with the wheelchair user. Explain: When making PSDs such as these – it is a good idea to NOT glue the foam in place until after the rst tting. This way the PSD can still be adjusted to make sure it is the right t for the wheelchair user. Notes for trainers: In the example dimension drawing for Robert, the wedge on the backrest has been placed to allow room for a layer of soft foam to be added on top of the cushion, tucking under the wedge. There are different ways to construct this PSD – and individual variations may be explained by trainers, depending on the context, materials and common technical solutions. 4. Key point summary (3 minutes) INTERMEDIATE LE VEL • Any fixed / non-neutral postures of the hip will affect pelvis posture if not accommodated. • When prescribing PSDs with wedges – give dimensions for two sides of the wedge. • When making PSDs similar to the ones described in this session – it is a good idea to NOT glue the foam in place until after the first fitting. B.9. Prescription (selection) of PSDs – supporting the hips: 9 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 154 155 B.10: Prescription (selection) of PSDs – supporting the trunk O B JE C T IV E S By the end of this session, participants will be able to: describe modi cations and PSDs that help to either support the trunk in neutral sitting posture (if possible) or accommodate the trunk in as close to neutral sitting posture as is comfortable for the wheelchair user ; begin problem solving different ways to make modi cations or PSDs that provide support for the pelvis, hips and trunk; complete an intermediate wheelchair prescription (selection) form with assistance. R E S O U R C E S For the session: PPT Slides: B.10: Prescription (selection) of PSDs–supporting the trunk; Reference Manual; Participant’s Workbook; poster : Postural Support Device (PSD) Table; intermediate wheelchair prescription (selection) form; laminated Postural Support Device (PSD) Table – 1 for each participant; PSD kit; PSD materials; Wheelchair – 1 for each group (matching the wheelchair described in each wheelchair user story as closely as possible); blocks of rm foam – a few per whole group; wedges of rm foam – a few per whole group. C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: PSDs, PSD materials and fabrication methods available in the participants’ working environment. Where participants will carry out wheelchair user tting – for example in the community/users’ homes, in a workshop or in a clinic. This may affect the way in which they work and the choices of PSD. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 154 155 T O P R E PA R E Gather resources, review PPT slides and read through the session plan. Pin up the Postural Support Device (PSD) Table poster. Unpack PSD kit, materials, blocks and wedges of rm foam and lay this equipment out on a table at the front of the training room. Line up sample wheelchairs neatly at the front of the training room. O U T L IN E 1. Introduction 2. Supporting the trunk 3. Completing the intermediate wheelchair prescription (selection) form 4. Key point summary 2 115 30 3 Total session time 150 1. Introduction (2 minutes) INTERMEDIATE LE VEL Step 3: Prescription (selection) PSDs – supporting the trunk • In this session participants we will learn about the different types of PSDs that help provide support for the trunk. • Participants will work together in small groups for most of the session, to problem solve the right PSD solution for three different wheelchair users. B.10. Prescription (selection) of PSDs – supporting the trunk: 2 INTRODUCTIO N Explain: We have now looked at different PSDs, which help to stabilize the pelvis and support the hips. In this session we will: • learn about PSDs that provide support for the trunk; • discuss the importance of always considering rst how to stabilize the pelvis and then support the trunk. For many people, postural problems related to the trunk can be resolved or improved with good pelvis support. Participants will work in small groups for most of the session, to problem solve the right PSD solution for three different wheelchair users. Through this session participants should see that PSDs for the trunk do not work in isolation – but are usually combined with PSDs that support the pelvis and sometimes also the hips. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 156 157 2. Supporting the trunk (115 minutes) Whole group activity Groups: This activity is performed with the group as a whole. Instructions: Ask participants to nd a at piece of wall and place a table/bench against the wall. Ask each participant to sit on the table/bench with their pelvis right up against the wall. Explain that participants should sit as upright as they can. Explain: Participants will sit in this posture for about 5 minutes and then the group will provide feedback. Monitor: Monitor participants closely. Ensure that each participant understands the activity. Check that the tables/benches are right up against the wall and that each participant is sitting with their pelvis upright and contacting the wall. Guide participants if necessary. Time: Allow 5 minutes for the activity. Allow 5 minutes for feedback. Feedback: Ask: Is it comfortable to sit like this? Is it possible to sit upright? Answers: • participants should feel as though the wall is pushing their upper trunk forward; or • they feel that they have to move their pelvis forward in order to sit upright. INTERMEDIATE LE VEL B.10. Prescription (selection) of PSDs – supporting the trunk: 3 STRAIGHT BAC KREST = POOR POSTURE Explain: • The reason this is not comfortable, is the wall prevents upright sitting posture. • The wall does not allow for the upper trunk to move backwards, past the line of the pelvis. • This is the same for people sitting in a wheelchair with a straight back. Explain: We have looked at different ways to stabilize the pelvis. However it is very important to then also look at how the trunk can be supported above the pelvis – in either neutral sitting posture (if possible) or supported as close to neutral sitting posture as possible. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 156 157 Small group activity Groups: Divide participants into 3 groups. Instructions: Give each group a number (1–3) and assign an appropriate wheelchair user’s story in the Participant’s Workbook (B.10: Prescription (selection) of PSDs – supporting the trunk). Give each group a wheelchair, which matches (as closely as possible) the wheelchair described in the wheelchair user’s story assigned to them. Assign PSD material, blocks and wedges of rm foam to each group. Explain: • Each group is to read their wheelchair user story very carefully. • Each group has a different wheelchair user with different individual needs. However each of the wheelchair users described needs support for their pelvis and trunk. Two of the wheelchair users have xed hip problems. • Each group should decide how they will provide the support needed by the wheelchair user described in their story. • Each group should try to think of different options and ways to make the PSDs. Explain: • Participants should use the different materials made available to ‘mock up’ at least one solution using the wheelchair they have been given (trainer should point out the materials available). • Encourage participants to ask questions of the trainers at any time. • Participants should be prepared to present their wheelchair user story and solutions to the rest of the group. Explain: • Participants have 60 minutes to complete the assigned wheelchair user story and tasks associated with it. Each group will give feedback to the whole group describing possible solutions to the postural problems. Ask participants to NOT COMPLETE the intermediate wheelchair prescription form at the end of each wheelchair user story yet. This will be done after everyone has given feedback to the whole group and the prescription (selection) solutions are agreed on by the whole group. Monitor: Monitor the groups closely. Ensure that each group understands the activity. Encourage each group to use the wheelchair and materials they have been given to ‘mock up’ the PSDs they would provide for their wheelchair user. Ensure that each group follows the sequence: Pelvis + Hips Trunk. Guide participants if necessary. Time: Allow 60 minutes for activity. Allow 45 minutes for feedback. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 158 159 Feedback: Ask each group to present their wheelchair user story to the rest of the group. Participants should: • give a brief summary of their wheelchair user ; • show the solution they have devised to provide the wheelchair user with the support he/she needs. After each group has presented one solution – ask the whole group: • Do they agree with that solution? Why? • Is there another way that this support could be provided? Encourage participants to consider the different technical solutions that are possible depending on the materials and equipment available. Ensure that the correct answers are provided. If there is any confusion – encourage the whole group to nish solving the problem. Use the Notes for trainers below as a guide. In conclusion – emphasize that the rst priority for each group was (or should be) to stabilize the pelvis. Notes for trainers: Mark is 16 years old and has a high level spinal cord injury. He has a wheelchair with a slung seat and backrest. His wheelchair is the correct size and he has a soft, at foam cushion. Mark nds it dif cult to sit upright. His back stays rounded and he tends to slide forward in his wheelchair. He is getting red marks on his skin under his seat bones and around his shoulder blades. What PSDs could be provided to help Mark sit upright in his wheelchair? Mark’s assessment shows that he is able to sit in neutral posture with support. The PSDs that can be used to support his neutral sitting posture are: Pelvis: • pre seat bone shelf – to support the pelvis in neutral sitting posture and prevent posterior pelvis tilt; • rear pelvis pad – to support the top of the pelvis to stay in neutral sitting posture and prevent posterior pelvis tilt; • pelvis strap (if necessary) – to keep the pelvis in the right sitting posture and stop Mark from sliding away from the rear pelvis pad and up and over the pre seat bone shelf. Trunk: • increase the backrest height – to provide support behind his shoulder blades (note – when Mark is sitting more upright with good pelvis support, he will need the backrest height to be increased). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 158 159 How could these supports be added to Mark’s wheelchair? 1. Seat/cushion: • make Mark a new, contoured cushion with a pre seat bone shelf and a top layer of soft foam. 2. Backrest: A rear pelvis pad could be added in different ways including: • option one: add an adjustable padded strap to the back of the backrest fabric and secure it around the backrest uprights; • option two: secure a block of rm foam to the back of the backrest fabric, secure it using a strap around the backrest canes; • option three: add a tension adjustable backrest and set it up so that there is rm support against the top of Mark’s pelvis; • option four: remove the slung backrest and add a solid backrest. Upholster the backrest with a layer of rm foam covered by a layer of soft foam between the two layers of foam and add a rm foam rear pelvis pad. Cover the backrest with a washable fabric. This option may mean that the wheelchair can no longer fold. The backrest height could be raised in different ways: • option one: t an additional section of fabric onto the backrest uprights if they extend to the height needed; • option two: extend the backrest uprights if they are not high enough. This can be done by cutting the backrest uprights and add in a slightly narrower solid wooden or hollow metal tube. Bolt (if wooden) or weld (depending on the type of metal) the tube in place and add the additional backrest fabric or replace the backrest with one that extends to the height required (for example a tension adjustable backrest); • option three: remove the existing backrest fabric and t a solid backrest of the correct height by bolting it to the backrest uprights, or attaching it with brackets. This option may mean that the wheelchair can no longer fold. 3. Straps: • t a pelvis strap to the seat rails. Josephine is 35 years old. She has a spinal cord injury. She lives in a rural village, and is an active member of the local Church. She has previously been provided with a long wheelbase wheelchair, which she likes as it is easy for her family to push over the rough ground in her village. She can push it a little herself when indoors on smooth surfaces. The wheelchair is the correct size for her, and has a solid backrest and seat. She has a thick at foam cushion. Josephine is not comfortable in the wheelchair, and she is nding it harder to push herself. She sits with her pelvis rolled back (posterior pelvis tilt) and her trunk posture is curved forward. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 160 161 What PSDs could be provided to help Josephine sit as upright as possible in her wheelchair? During Josephine’s assessment, it was found that she could not sit in a fully neutral sitting posture. Her pelvis is xed in a posterior tilt and she could not bend her right hip fully to neutral sitting posture (angle 100 degrees). However, her sitting posture improved (became more upright) with temporary support under her seat bones, rm pelvis support and support behind her trunk. PSDs that may help support Josephine to sit closer to neutral posture, with more stability and to enable her to function better include: Pelvis + Hips: • pre seat bone shelf – to encourage more neutral sitting posture and keep her pelvis from sliding forward ; • lower seat front on right side to accommodate xed right hip; • may also add a pelvis strap – to keep her pelvis back in the seat and stop Josephine from sliding up and over the pre seat bone shelf. Trunk: • open the seat to backrest angle to accommodate her xed posterior pelvis tilt; • adjust backrest shape – to support her rounded trunk; • consider seat and backrest tilt (tilt in space) during tting – if Josephine’s head is not more comfortable once she is sitting more upright with these supports. How could these supports be added to Josephine’s wheelchair? 1. Seat/cushion • modify Josephine’s current cushion or make a new cushion with a pre seat bone shelf and lower seat front on the right side; • the cushion should have a rm foam layer covered by a soft foam layer. 2. Seat and backrest • Open the seat to backrest angle: - option one: if the wheelchair design allows for the angle between the seat and the backrest to be reclined – adjust the wheelchair so that the seat to backrest angle is increased to match the amount of posterior tilt that Josephine has; - option two: make a rm foam wedge to support Josephine’s pelvis in the most upright posture that is comfortable for her and glue this to the solid backrest. Cover the rm foam wedge and shaped foam for Josephine’s trunk with a layer of soft foam. Upholster with a washable fabric. • Adjust backrest shape: - Shape the surface of the backrest to support and accommodate her rounded trunk. Depending on the support needed, build up foam where needed using a rm foam to provide shape. When complete, place a soft foam layer over the whole surface of the backrest. Make sure that any foam added does not push Josephine forward. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 160 161 Note: • The modi cations to the seat and backrest above may reduce the available seat depth. • Participants should consider what could be done if there is not enough seat depth. • Options are: - option one: see if the seat board can move forward (then check propelling position and access to footrests); - option two: move the backrest further back. One way to do this is to attach the backrest to the backrest uprights with brackets. In this case, check that Josephine’s upper arms/trunk are not restricted by the backrest uprights and she is able to move her shoulders freely. 3. Straps: • t a pelvis strap to the seat rails. Sian is three years old and has cerebral palsy. He has a child size cross-folding wheelchair with swing away footrests, a slung seat and backrest. There is no tray and no cushion. His wheelchair is the correct seat depth for him, however it is a little wide. His parents do not own a car and they walk to most places. They can push him around the community in his wheelchair although sometimes they just carry him. Sian can push his wheelchair a little himself when on a smooth surface. Sian can sit upright for very short periods without support. After 10 minutes his trunk starts to collapse and he usually leans forwards and towards the left. This causes his pelvis to lift up on the right side, and more weight goes through his left seat bone. His back has the normal curve for his age. Sian’s mother would like him to be able to play outside with other children and begin to push his wheelchair. What PSDs could be provided to help Sian sit as upright as possible in his wheelchair? Pelvis + Hips: • pre seat bone shelf – to keep Sian’s pelvis in a neutral sitting posture and at the back in the seat; • pelvis side pads – to help support his pelvis to stay in neutral sitting posture, and not lift up on the right side; • pelvis strap – for safety (as he is three) and also may be necessary if he lifts his pelvis up and away from the supports; • raise seat front – to accommodate the 80 degree trunk to thigh angle in Sian’s left and right hips. Trunk: • left and right trunk side pads – to help keep Sian’s trunk in neutral sitting posture and prevent him from falling to the left; • tray – a tray may help Sian to stay upright for longer by giving him support for his arms and help him keep his balance better ; • shoulder harness – may be required at least initially, or when Sian is particularly tired, to help keep his chest and shoulders back against the backrest; • seat and backrest tilt (tilt in space) – this could be added if Sian continues to fall forward and to the left. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 162 163 How could these supports be added to Sian’s wheelchair? 1. Seat / cushion: • Make a cushion for Sian, which has: - a pre seat bone shelf; - raised seat front (made by adding a wedge beginning at the pre seat bone shelf and extending to the front of the cushion – which matches Sian’s trunk to thigh angle). • The cushion could be made on a solid board, which sits over the slung seat. This will provide more support than if the cushion sits on a slung seat. If a solid board is not used, make sure that the base of the cushion has a slight curve to match the shape of the slung seat. • Make pelvis side pads – attach upholstered blocks of rm foam to either : - the armrests/side guards (with glue); - to the seat or to the backrest with a bracket. 2. Backrest: • Add trunk side pads: - option one: replace the slung backrest with a solid backrest and attach trunk side pads to the solid backrest, behind the backrest cushion. The backrest cushion may be cut to allow for the trunk side supports to be positioned correctly (close enough to Sian’s body). Ensure that any brackets are well padded; - option two: attach trunk side pad supports to the backrest uprights with brackets. Make sure that the bracket is shaped to allow the trunk side supports to come in close to Sian’s body. 3. Seat and backrest tilt (tilt in space): • if seat and backrest tilt (tilt in space) is necessary, this could be made by using a solid seat and solid backrest as described above. Attach the seat and backrest with brackets, positioned to place the seat and backrest in tilt. The seat to backrest angle should not change. • Remember if tilt is added Sian should have a headrest. 4. Straps: • t a pelvis strap to the seat rails; • attach the shoulder harness to the solid backrest (top and bottom). 5. Tray: • make a tray for Sian, which wraps around his body – so that he can rest his elbows and forearms on the tray for additional support; • the tray may be tted to the wheelchair armrests – and needs to be able to come on and off easily. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 162 163 3. Completing the intermediate wheelchair prescription (selection) form (30 minutes) Small-group activity Groups: Ask participants to work in the same groups as for the previous activity. Instructions: Ask participants to complete the intermediate wheelchair prescription (selection) form in their workbook for Mark/Josephine/Sian. Explain: Each group is to complete only one form for the wheelchair user whose story they have previously worked with. Explain: Participants do not have the body measurements for each wheelchair user – so they cannot provide dimensions. However – participants should describe/draw where dimensions would be needed. Monitor: Monitor the groups closely. Ensure that each group understands the activity. Before the feedback part of the activity, move between the groups and check each group’s intermediate wheelchair prescription form to see how well each group was able to complete it. Note any dif culties that participants have had. Guide participants if necessary. Time: Allow 20 minutes for activity. Allow 10 minutes for feedback. Feedback: Ask if participants have any questions about completing the intermediate wheelchair prescription form. Clarify any areas of dif culty that you have noted during the activity. 4. Key point summary (3 minutes) INTERMEDIATE LE VEL • You often need more than one PSD. • PSDs work together to provide the right support for each wheelchair user. • Support should always be provided first at the pelvis and hips, and then the trunk. • There are different ways that the same level of support can be provided. The best solution will depend on the wheelchair user’s needs and preferences. It will also depend on the wheelchairs and materials available. • It takes practice for participants to learn how to provide support. It is OK to try different things, and always remember to ask the wheelchair user’s opinion. B.10. Prescription (selection) of PSDs – supporting the trunk: 4 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 164 165 B.11: Prescription (selection) of PSDs – supporting the head, thighs and lower legs O B JE C T IV E S By the end of this session, participants will be able to: describe modi cations and PSDs that provide support for a wheelchair user’s head, thighs and lower legs. R E S O U R C E S For the session: PPT Slides: B.11: Prescription (selection) of PSDs – supporting the head, thighs and lower legs; Reference Manual; Participant’s Workbook; DVD: Head support; poster : Postural Support Device (PSD) Table; laminated Postural Support Device (PSD) Table–1 for each participant; PSD kit; wheelchairs – 1 for each group; foam cushion – 1 for each group. C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: PSD, materials and fabrication methods available in the participants’ working environment. Where participants will carry out wheelchair user tting – for example in the community/users’ homes, in a workshop or in a clinic. This may affect the way in which they work and the choices of PSD. T O P R E PA R E Gather resources, review PPT slides, watch DVD and read through the session plan. Pin up the Postural Support Device (PSD) Table poster. Unpack sample PSDs from the PSD kit that have been put together and lay them out on a table at the front of the training room where you can easily reach them. Line sample wheelchairs neatly at the front of the training room. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 164 165 O U T L IN E 1. Introduction 2. Supporting the head 3. Supporting the thighs 4. Supporting lower legs and feet 5. Key point summary 2 25 60 30 3 Total session time 120 1. Introduction (2 minutes) INTERMEDIATE LE VEL Step 3: Prescription (selection) PSDs – supporting the head, thighs and lower legs • The next series of PSDs that participants will look at focus on providing support for a wheelchair user’s head, thighs and lower legs including feet. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 2 INTRODUCTIO N Explain: • We have now looked at different PSDs, which help to stabilize the pelvis, support problems at the hips and support the trunk. • The next series of PSDs that we will look at focus on providing support for a wheelchair user’s head, thighs and lower legs including feet. 2. Supporting the head (25 minutes) INTERMEDIATE LE VEL Head Support B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 3 Explain: • None of the wheelchair users in the case stories we have just looked at needed a headrest. • However – some children and adults do need a headrest. Ask: Does anyone have any examples of children or adults they have worked with who needed a headrest? Acknowledge answers and allow a brief discussion. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 166 167 INTERMEDIATE LE VEL B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 4 PROBLEM: HEA D FALLS BACKW ARDS, FORWAR DS OR SIDEWAYS Problem: • The head tends to fall backwards, forwards or sideways. Explain: • This slide shows an illustration of a young boy who nds it very dif cult to hold his head up himself. • In the illustration you can see that his mother is supporting his head with her arm. Ask: What would be some possible solutions for this boy? Encourage answers. Answers: • FIRST – provide good pelvis and trunk support – to ensure the boy is as stable as possible. This could include: - pelvis: rear pelvis pad, pre seat bone shelf and pelvis strap; - trunk: adjust backrest shape to provide optimum support for the boy’s trunk, shoulder harness, possibly tilt in space. • These PSDs could improve his head control. • If the boy continues to nd it dif cult to hold his head upright – provide a headrest. Notes for trainers: Emphasize the importance of providing the right pelvis and trunk support; and then considering whether there is still a need for a headrest. Ask: Where on the head can support be provided? Answer: • FIRST – provide support at the base of the skull; • if necessary, support can extend around the sides of the wheelchair user’s head. Notes for trainers: Some participants may suggest a head strap. This should be discouraged as this form of support can be very uncomfortable and potentially dangerous. A head strap should only be used in very speci c circumstances and under close supervision. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 166 167 INTERMEDIATE LE VEL Support should be provided at the base of the wheelchair user’s skull. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 5 SUPPORT NEED ED Explain: • This illustration shows headrest provided at the base of the skull. There are many different types of headrests. In this training programme, we will talk about two types of headrests. INTERMEDIATE LE VEL • Provides a resting place for the head and stops the head from falling backwards. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 6 FLAT HEADRES T Explain: • One is a at headrest: - this is an extension of the backrest; - the backrest is contoured to provide support for the pelvis, lower and upper trunk; and is extended to provide support for the head; - a at headrest provides a resting place for the head and stops the head from falling backwards. INTERMEDIATE LE VEL • provides more support than a flat headrest. • contouring around the base of the wheelchair user’s skull, which helps to prevent the head from falling sideways as well as backwards. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 7 SHAPED HEAD SUPPORT • The other is a shaped headrest. - this is shaped to ‘cup’ the base of the head; - a shaped headrest can be extended at the sides and come forward to give more support on the side of the head; - a shaped headrest provides more support than a at headrest by contouring around the base of the wheelchair user’s skull. Notes for trainers: If there are any other types of headrests locally available (and present at the training programme) show these to participants and explain any speci c features. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 168 169 VIDEO Introduce DVD: Head support. In this video we will see Michael, a young boy whose mother brings him in for assessment because he nds it dif cult to sit upright and hold his head up. During the physical assessment, the wheelchair personnel identify: • Michael’s pelvis is xed in a posterior pelvis tilt; • Michael tends to push his pelvis forward and slide in his wheelchair; • Michael’s upper trunk and head fall forward, and when he brings his head all the way upright he loses head control and his head falls backwards. Watch the process that the wheelchair service personnel go through to identify what postural support Michael needs and how this is provided in his wheelchair. Show DVD. Ask if there are any questions. 3. Supporting the thighs (60 minutes) INTERMEDIATE LE VEL Thigh support B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 9 Explain: We have already looked at stabilizing the pelvis, supporting problems at the hips, providing support to the trunk and providing a headrest. Now we will look speci cally at supporting the thighs. Small-group activity Groups: Divide participants into 3 groups. Instructions: Give each group a wheelchair and a foam cushion. Ask each group to read and answer all three questions in Participant`s Workbook (B.11: Prescription (selection) of PSDs – supporting the head, thighs and lower legs). Explain: • Each group should look at the wheelchair and foam cushion they have been given and think about what they could do with that wheelchair and foam cushion (and other materials or components) to provide the support needed by the wheelchair user. • Think about: - general wheelchair set-up; - the wheelchair user’s whole body; - what PSDs are needed for the thighs. Explain: Participants have 30 minutes as a group to do this activity and then the groups will come back together for feedback. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 168 169 Monitor: Monitor the groups closely. Ensure that each group understands the activity. Guide participants if necessary. Time: Allow 30 minutes for activity. Allow 30 minutes for feedback. Feedback: INTERMEDIATE LEVEL B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 10 JONAH Ask one group to describe their solution for Jonah. Ask if any other groups had other suggestions. Ensure that participants cover all key learning points (please see Notes for trainers below). INTERMEDIATE LE VEL • Help maintain neutral alignment of the thigh. • Reduce a tendency for legs to fall or roll outwards. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 11 OUTSIDE THIG H WEDGES Show slide of outside thigh wedges. INTERMEDIATE LE VEL B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 12 SAM Ask another group to describe their solution for Sam. Ask if any other groups had other suggestions. Ensure that participants cover all key points (please see Notes for trainers below). INTERMEDIATE LE VEL • Provides support on the inside of the thigh; • Provides support for legs that are drawn together / pull inwards; • Provides stronger support than an inside thigh wedge. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 13 KNEE SEPARAT OR PAD Show slide of knee separator pad. INTERMEDIATE LE VEL B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 14 ELIJAH Ask another group to describe their solution for Elijah. Ask if any other groups had other suggestions. Ensure that participants cover all key points (please see Notes for trainers below). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 170 171 INTERMEDIATE LE VEL • Maintains neutral alignment of the thigh; • Reduces a tendency for legs to draw together / pull inwards. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 15 INSIDE THIGH W EDGE Show slide of inside thigh wedge. Notes for trainers: • Jonah has come for assessment. During hand simulation you nd out that Jonah`s legs tend to fall outwards (abducted) but with gentle support you can bring his legs into a neutral sitting posture (knees closer together). • What changes do you think you can make to his wheelchair and cushion to help him sit with legs in a neutral sitting posture? Possible changes to Jonah’s wheelchair : • backrest could be lowered; • seat depth looks too short – and could be lengthened; • footrests look too high – and could be causing the leg posture; • overall – this wheelchair may be too small for him and he might need a larger one. Possible changes to Jonah`s cushion: • pre seat bone shelf may help him to sit more upright (it is dif cult to tell from the front, however he looks slumped); • outside thigh wedges to keep thighs in alignment. How could the outside thigh wedges be made? • glue wedges on top of the cushion and ensure they are secure with a tight tting cover; or • slice into foam at front of the cushion and insert wedges of rm foam and glue. Key points: • Jonah needs support at his thighs – however the whole picture needs to be addressed. • Jonah only needs gentle support at thighs – so wedges are enough (in Jonah`s case there is no need for outside thigh pads). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 170 171 • Sam has been using this wheelchair for two years. He has a head injury, and his legs are quite stiff and tight. In the assessment you nd that Sam`s legs are drawn inwards but you can draw his knees apart into a more neutral sitting posture. However this takes quite a bit of force. With his knees in a more neutral sitting posture Sam feels more balanced. • What changes do you think you can make to his wheelchair and cushion to help him sit with legs in a neutral sitting posture? Possible changes to Sam’s wheelchair : • Sam needs a cushion; • more backrest support including side trunk pads/wedges; • wheelchair is too wide for Sam; • footrests uneven – and may need repair or replacing; • might consider replacing slung seat with solid to help reduce tendency for thighs to roll inwards (encouraged in a slung seat); • overall – this is not an ideal chair for a long-term wheelchair user. Possible changes to Sam`s cushion: • pre-seat bone shelf to help support posture; • a knee separator pad is indicated by the force needed to keep Sam’s thighs apart. How could the knee separator pad be made? • Consider replacing slung seat with solid seat and mounting a knee separator pad onto this (mount to be slid into a bracket under the seat and locked after Sam gets into the chair ; and taken out for him to transfer out). Key learning points: • As for Jonah – the whole picture needs to be addressed. • The strong force needed to hold Sam’s thighs apart indicates that in his case a rm support is needed in a form of a knee separator pad rather than a more gentle support provided by an inside thigh wedge. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 172 173 • Elijah is pleased that his wheelchair can fold, and he is able to take it in a car to and from his workplace. However his back is sore and he nds his legs roll into each other. During assessment you nd that Elijah can sit in neutral sitting posture, and with gentle support his legs can sit in neutral sitting posture. • What changes do you think you can make to his wheelchair and cushion to help him sit with legs in a neutral sitting posture? Possible changes to Elijah’s wheelchair : • tighten slung seat to reduce the sag; • check footrest height. Possible changes to Elijah`s cushion: • pre seat bone shelf to help support posture; • trial an inside thigh wedge added to Elijah’s cushion, to help keep thighs in neutral sitting posture. How could the inside thigh wedge be made? • glue wedge on top of the cushion and ensure they are secure with a tight tting cover; or • slice into foam at front of cushion and insert wedge of rm foam and glue. Key learning points: • As for the others – the whole picture needs to be addressed. • Elijah likes his wheelchair to fold – so adding a solid seat would make this more dif cult. However a thin board slid into his cushion cover, under the cushion, could provide more support and would not make transport more dif cult. 4. Supporting the lower legs and feet (30 minutes) INTERMEDIATE LE VEL Providing support for the lower legs and feet B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 16 Explain: Now we will look at PSDs, which provide support for the lower legs including supporting or accommodating xed non- neutral sitting postures of the feet and knees. Remember – these solutions would be combined with provision of support for the wheelchair user’s pelvis, trunk, head and neck – as required. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 172 173 INTERMEDIATE LE VEL • One or both knees bent and fixed less than neutral. • Possible PSD solutions: - adjust the footrests backwards; - adjust the angle of the footrest or use footrest wedges; - provide a strap to the front of the lower legs; - ensure the front of the seat is not pushing on the back of the legs; - for a tall wheelchair user consider raising the seat front or tilting the seat and backrest. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 17 POSTURAL PRO BLEM Problem: • One or both knees bent and xed less than neutral sitting posture. Possible PSD solutions: • Adjust the footrests backwards if possible. • Adjust the angle of the footrest to match the foot if possible, if not, use footrest wedges. • Provide a strap to the front of the lower legs for support and protection. • Ensure that the front of the seat is not pushing on the back of the wheelchair user’s leg/legs. It may be necessary to shorten the seat slightly and bevel the cushion backwards. • For a tall wheelchair user consider raising the seat front or tilting the seat and backrest. By doing this the wheelchair user`s feet are higher, more forward and possibly in the adjustment range of the standard footrests. When making these adjustments – check that the castor wheels can still turn fully without bumping into the footrests or wheelchair user’s feet. If these adjustments are not possible on the available wheelchairs or do not provide enough adjustment, some modi cation may be necessary. INTERMEDIATE LE VEL • One or both knees cannot bend to neutral. • Possible PSD solutions: - provide a standard elevating leg rest; - adjust the footrests forward; - consider providing a 3-wheeled wheelchair; - extend the footrests forward by adding wood or metal; - extend the footrest hanger to be more forward. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 18 POSTURAL PRO BLEM Problem: • One or both knees cannot bend to neutral sitting posture. Possible PSD solutions: • Provide a standard elevating leg rest if available. • Adjust the footrests forward if possible. • Consider providing a 3-wheeled wheelchair if available. Add footrests on top of the horizontal centre bar. • Extend the footrests forward by adding wood or metal. • Extend the footrest hanger to be more forward – this may require welding and should only be carried out by someone with excellent technical knowledge and skills with metal work. Whatever solution is decided – it is important to try to ensure that the overall length of the wheelchair is kept to a minimum. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 174 175 INTERMEDIATE LE VEL Supports one or both feet when the foot cannot reach the footrest, and the footrest cannot be adjusted high enough. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 19 FOOTREST BUI LD UP Problem: • One or both feet cannot reach the footrest and the footrest cannot be adjusted high enough. Possible PSD solution: • Footrest build-ups – the footrests can be built up for both feet or for only one (as in the slide). Problem: • Fixed non-neutral postures of the ankle. PSD solution: • Footrest wedges – can be used to support the existing posture and help prevent further changes in the ankle. Most footrest wedges are made individually, depending on the support needed by the wheelchair user’s foot. The aim of the footrest wedges is to increase the contact area of the footrest with the wheelchair user’s foot. INTERMEDIATE LE VEL • A calf strap helps prevent the lower leg from falling backwards and feet slipping off the footrests. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 21 CALF STRAP Problem: • The lower leg falls backwards. PSD solution: • Calf strap – a calf strap is often provided with the wheelchair or can be made from strapping and Velcro. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 174 175 INTERMEDIATE LE VEL Behind the heel Around the ankle Over the foot • Foot straps provide support to help stabilize the wheelchair user’s feet and helps to keep the feet from moving forward/backward. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 22 FOOT STRAPS Problem: • Undesired movement or instability of foot on footrest. PSD solution: • Foot straps. INTERMEDIATE LE VEL • Helps to stop feet from sliding backwards. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 23 FOOT STRAP B EHIND THE HEE L A foot strap behind the heel helps to keep the foot from sliding backwards. INTERMEDIATE LE VEL • Helps to stop feet from moving forward and the heel from lifting. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 24 FOOT STRAP A ROUND THE AN KLE A foot strap around the ankle helps to keep the foot from moving forward and the heel from lifting. INTERMEDIATE LE VEL • Helps to keep the toes from lifting. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 25 FOOT STRAP O VER THE FOOT A foot strap over the front of the foot helps to keep the toes from lifting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 176 177 5. Key point summary (3 minutes) INTERMEDIATE LE VEL • PSDs and modifications can provide a wheelchair user with additional postural support. • Wheelchair users need PSDs to be practical, comfortable, to look good, be safe and easy to use. An opportunity to try out PSDs can help wheelchair users to check that it works for them. • There are a wide range of PSDs available. The specific solutions used in each service will vary depending on PSDs, materials and technology available. • The PSD Table gives an overview of different commonly used PSDs. B.11. Prescription (selection)of PSDs – supporting the head, thighs and lower legs: 26 KEY POINT SUM MARY – FOR AL L PSDS Explain: These points are relevant for all of the previous sessions covering PSDs. Read the key points. Ask whether there are any questions. Practical One: Assessment and prescription (selection) O B JE C T IV E S By the end of this session, participants will be able to: Demonstrate an intermediate wheelchair assessment working in a group and with assistance. Demonstrate making an intermediate level wheelchair prescription working in a group and with assistance. R E S O U R C E S Trainer’s observation checklist: Practical One; photo consent forms; intermediate wheelchair assessment and wheelchair prescription (selection) forms; poster : Postural Support Device (PSD) Table; laminated Postural Support Device (PSD) Table – 1 for each participant; clean and private assessment space with assessment bed and privacy screen for each wheelchair user ; blocks of rm foam – a few per whole group; wedges of rm foam – a few per whole group; sample wheelchairs and cushions (unless assessment is carried out in the community); digital camera; tape measure or calliper – 1 for each group, set of foot blocks – 1 for each group. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 176 177 C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: cultural factors – for example whether it is appropriate to have mixed-gender groups doing the assessment; when participants are carrying out a wheelchair assessment on wheelchair users – be aware of any cultural issues related to touching; language factors – for example whether wheelchair users attending speak a common language with all participants; any documentation that the host/training organization may need when assessing or prescribing a wheelchair – for example any additional information that services need to collect about wheelchair users accessing their service (e.g. referral source); how trainers will manage issues that may arise during the assessment/ prescription that cannot be addressed within the session or training programme. For example – additional needs wheelchair users may have that require referral or mobility equipment/PSDs required that cannot be provided or nalized during the session or training programme. T O P R E PA R E Con rm time and travel arrangements with wheelchair user volunteers. Ensure refreshments are available for wheelchair users and their family member/ caregiver. Assign one person to greet wheelchair users as they arrive and show them where they can wait until the session begins. Prepare an assessment bed with a privacy screen for each group. Place all equipment needed for each assessment on the assessment bed. Ensure sample wheelchairs and cushions are in good working order. If there are more than three groups of participants, ask another trainer to assist with monitoring the groups. Decide which participants will work together and with which wheelchair user. Pin up the Postural Support Device (PSD) Table poster. O U T L IN E 1. Assessment and prescription (selection) practice: • Instructions and set-up • Assessment • Prescription (selection) • Feedback 15 45 30 30 Total session time 120 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 178 179 1. Assessment and prescription (selection) practice (120 minutes) Notes for trainers: 1. Photographs: • Ask for signed photo consent form from each wheelchair user to take their photograph. Ensure that wheelchair users understand that their permission is voluntary and that the photographs will be used for further training during this training programme. • Take photographs during the practical of each wheelchair user who has given permission as follows: - in their existing wheelchair (if they have one) (front and the side view); - during physical assessment (sitting posture without support). 2. Observing participants’ practice: • Use the Trainer’s observation checklist for Practical One to ensure that groups perform all the steps in the practical and to note common examples of good practice or practice needing improvement for feedback. Small-group activity Groups: • Divide participants into groups of 3. • Appoint a leader for each group. • Tell each group the name of the wheelchair user they will be working with. • Assign each group a place to work in. • Explain to the participants where they can nd necessary equipment. Instructions: Explain all of the following: Session aim: • The aim of this practical session is to carry out an assessment and prescribe (select) a wheelchair for a wheelchair user. • Participants will work with the same wheelchair user they work with today later on in this training programme, to t the wheelchair selected today and to provide the wheelchair user training. • If it is not possible during this training programme to fully complete the wheelchair user’s wheelchair, arrangements will be made with the wheelchair user to ensure that their wheelchair is completed. Participants should try however to get as much of the work done as possible. Lead person: • The lead person for each group is responsible for making sure that all steps are carried out for assessment and prescription (selection) of the wheelchair. • The lead person should be the main person talking with the wheelchair user and their family member/caregiver. This is to avoid having too many people speaking at once, which can be confusing for everyone. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 178 179 Trainer’s observation and support: • Participants should ask for assistance or clari cation at any time. • Throughout the session trainers will monitor each group and give as much support and advice as needed. • After completing the assessment, participants should ask one trainer to come and check their intermediate wheelchair assessment form. • After completing the prescription, participants should ask one trainer to come and check their intermediate wheelchair prescription form. Time allowed: • Participants should aim to complete the assessment in 45 minutes, and the prescription (selection) in 30 minutes. Ask participants: What are the steps for assessment? Acknowledge correct answers. Ask participants: What are the steps for prescription (selection)? Acknowledge correct answers. Service forms: • Hand out intermediate wheelchair assessment and intermediate wheelchair prescription (selection) forms to each group’s team leader. • At the end of the practical collect the lled out service forms and hand them out in the next practical session. Remind participants that they should actively involve the wheelchair user in every step of the process. Ask: Are there any questions? Answer any questions. Ask each group to prepare the area they are going to work in; then introduce themselves to the wheelchair user they will work with and begin. Monitor and support: Closely monitor the groups, ensure safe practice, observe and evaluate the skills of the participants. Use the Trainer`s observation checklist to record your observations of each group. Throughout the session: • Give time warnings (verbally and/or write on a whiteboard where all participants can see) to help participants manage their time. • Ensure wheelchair users are actively involved. • Ensure every group member is actively involved. At the end of this session, ask participants to thank the wheelchair user for their participation and explain that the wheelchair prescribed (selected) will now be prepared for them and will be ready for them to try when they attend for their next session. Take photographs during the session of wheelchair users who have given signed photo consent forms. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 180 181 Time: Allow 15 minutes for instructions and set-up, 45 minutes to complete the assessment, 30 minutes to complete the prescription (selection), 30 minutes for feedback. Track time using the Trainer’s observation checklist. Feedback: Comment on examples of good practice that you saw during the practical session. Note any particular areas that participants could improve – do not highlight individuals. Ask: Are there any questions? Notes for trainers: It is important to keep a close eye on the clock during practical sessions. The times given above are a guide – however they could vary depending on the experience of participants, the needs of the wheelchair users, the time required to set up. Trainers may need to make necessary adjustments. B.12: Product (wheelchair) preparation O B JE C T IV E S By the end of this session, participants will be able to: describe the process of preparing a wheelchair and PSDs for a wheelchair user who needs additional postural support. R E S O U R C E S For the session: PPT Slides: B.12: Product (wheelchair) preparation; Reference Manual; DVD: Product (wheelchair) preparation; DVD: Fabricating a footrest modi cation; poster : Postural Support Device (PSD) Table; laminated Postural Support Device (PSD) Table – 1 for each participant; laminated intermediate wheelchair safe and ready checklist – 1 for each participant; PSD kit; PSD materials; workbench or a strong table. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 180 181 C O N T E X T A N D P R IO R L E A R N IN G Prior learning: Information about adjusting manual wheelchairs to match a wheelchair user’s size is covered in the Wheelchair Service Training Package – Basic Level. For this session, participants should already be able to: - adjust a wheelchair to physically t a wheelchair user who can sit upright without support; - check that a wheelchair is safe and ready to use using the intermediate wheelchair safe and ready checklist. Adapt this session to suit the context participants will be working in. Think about: The types of locally available wheelchairs. Where, how and with what materials PSDs and modi cations will be made. T O P R E PA R E Gather resources, review PPT slides, watch DVDs and read through the session plan. Pin up the Postural Support Device (PSD) Table poster. Unpack sample PSDs from the PSD kit that have been put together and lay them out on a table (workbench) at the front of the training room where you can easily reach them. Arrange sample PSD materials on a table (workbench) at the front of the training room. Arrange the training room so that participants are seated in a semi-circle facing the front of the room. O U T L IN E 1. Introduction 2. Planning and carrying out wheelchair and PSDs preparation 3. What to remember when making PSDs 4. Materials used to make PSDs and modi cations 5. Key point summary 7 10 10 30 3 Total session time 60 1. Introduction (7 minutes) INTERMEDIATE LE VEL Step 5: Product (wheelchair) preparation • Product (wheelchair) preparation means setting up the wheelchair and preparing any PSDs that have been prescribed (selected). B.12. Product (wheelchair) preparation: 2 PRODUCT (WH EELCHAIR) PRE PARATION Explain: • The fth step in wheelchair service delivery is product (wheelchair) preparation. • Product (wheelchair) preparation means setting up the wheelchair and preparing any PSDs that have been prescribed (selected). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 182 183 INTERMEDIATE LE VEL 1. Referral and appointment 2. Assessment 3. Prescription (selection) 4. Funding and ordering 5. Product (wheelchair) preparation 6. Fitting 7. User training 8. Maintenance, repairs and follow up B.12. Product (wheelchair) preparation: 3 PRODUCT (WH EELCHAIR) PREP ARATION – FITT ING CYCLE • At intermediate level training programme it is usually only possible to prepare the wheelchair to a certain point before a tting is needed. • The wheelchair service steps ‘product preparation’ and ‘ tting’ may be repeated until the wheelchair ts correctly. • Often PSDs are not fully xed in place before the rst tting. This is to ensure that adjustments can be made to the wheelchair and PSDs after the tting. Ask: What are some PSDs that participants think are most likely to need adjustments once the wheelchair user is in the wheelchair? Acknowledge answers. Answers could include the PSDs listed below and others: • Headrest, pre seat bone shelf, trunk side pads, footrest height and any footrest modi cations etc. Explain: This is an important thing to remember when preparing a wheelchair for someone who needs additional postural support. Wherever possible, try to prepare as much of the wheelchair and PSDs as possible before a tting – however do not x down or upholster anything that cannot be easily re-adjusted. INTERMEDIATE LE VEL Step 5: Product (wheelchair) preparation • In this session participants will: - talk about how to plan the work of product preparation; - list some important things to remember when preparing PSDs; - talk about the different materials that can be used to make PSDs. B.12. Product (wheelchair) preparation: 4 INTRODUCTIO N Explain: In this session we will: • talk about how to plan the work of product preparation; • list some important things to remember when preparing PSDs; • talk about the different materials that can be used to make PSDs. Explain: Directly after this session participants will prepare the wheelchairs for the wheelchair users assessed in the Practical One session. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 182 183 VIDEO Introduce DVD: Product (wheelchair) preparation. • In this video we will see an example of a wheelchair being prepared. The child in the DVD is called Ali. He has come back to his wheelchair service for a review of his wheelchair as it is not supporting him as well as he needs. • Ali has a scoliosis (sideways curved spine) and his pelvis is shifted to one side. This is xed. He has very weak trunk muscles. The wheelchair service personnel work to increase the support provided in Ali’s wheelchair. • Note how the two wheelchair personnel work closely together, including Ali and his mother in all discussions. • Also note how the t of PSDs is checked every time that a change/ adjustment is made. Show DVD. Ask if there are any questions. 2. Planning and carrying out wheelchair and PSDs preparation (10 minutes) INTERMEDIATE LE VEL Step 5: PRODUCT (WHEELCHAIR) PREPARATION A: Plan and prepare; B: Adjust the wheelchair and prepare PSDs for fitting; C: Carry out the wheelchair safe and ready check. Step 6: FITTING B.12. Product (wheelchair) preparation: 6 PRODUCT (WH EELCHAIR) PRE PARATION Explain: • In this training programme we will work in the following order: A: Plan and prepare; B: Adjust the wheelchair and prepare the PSDs for tting; C: Carry out the wheelchair safe and ready check. A: Plan and prepare • Before beginning to prepare the wheelchair, it is important to plan the work. • Careful planning is particularly important if the work of wheelchair preparation is being handed over to someone else (for example a technician working in a workshop); or if more than one person is preparing the wheelchair. The planning and preparing may include the following steps: • Review the intermediate wheelchair prescription (selection) form: – ensure that everyone understands all of the information on the form; – ensure there is enough information on the form to be able to prepare the wheelchair. For example – are all the dimensions that are needed there? Are the descriptions of different PSDs detailed enough? Some further discussion or clari cation may be needed. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 184 185 • Decide how to achieve the necessary support in the selected wheelchair: – Look at the wheelchair that is going to be used and ask: – What adjustments can be made to the actual wheelchair to provide the necessary support? – What PSDs are already on the wheelchair? – If modi cations or PSDs need to be added, decide: – Are there pre-fabricated supports that can be used? If so – how will they be tted to the wheelchair? – If modi cations or PSDs need to be made from raw materials – what materials will be used, and how will the PSDs be xed to the wheelchair? – Remember to think about how the PSDs and wheelchair will work together. • Prepare a task list: – list the tasks that need to be carried out to prepare the wheelchair; – if more than one person is doing the work – decide who is responsible for which tasks. B: Adjust the wheelchair and prepare the PSDs for tting • Please refer to ‘How to make PSDs’ section of the Reference Manual on pages 112–127. C: Carry out the wheelchair safe and ready check The wheelchair safe and ready checklist was taught in the WSTP-B. Ask participants to refer to the intermediate wheelchair safe and ready checklist in the WSTP-I Reference Manual. Ask: Is everyone familiar with using this checklist? Does anyone have any questions about completing this checklist? Answer any questions. • This checklist should be completed before the wheelchair user arrives for tting. • After each tting, it may be necessary to carry out further adjustments. • The wheelchair should be checked every time it is adjusted or changed to ensure that it is safe and ready to use – before the wheelchair user tries it. Explain: Remember that the steps ‘product preparation and tting’ may need to be repeated a few times before the wheelchair ts correctly. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 184 185 3. What to remember when making PSDs (10 minutes) INTERMEDIATE LE VEL • Wheelchairs and additional postural supports should always: - be practical and easy to use; - be comfortable and not cause additional discomfort; - help wheelchair users to do the things they want to do and not make things more difficult; - look good and not be too ‘obvious’. B.12. Product (wheelchair) preparation: 7 WHAT DO WHE ELCHAIR USER S WANT? Explain: At the beginning of the training programme, we talked about what wheelchair users want. We talked about the importance of making sure that wheelchair and additional postural support should always: • be practical and easy to use; • be comfortable and not cause additional discomfort; • help wheelchair users to do the things they want to do and not make them more dif cult; • look good and not be too ‘obvious’. Explain: When preparing a wheelchair with additional postural support, the following tips can help: INTERMEDIATE LE VEL 1. PSDs should provide just enough support B.12. Product (wheelchair) preparation: 8 PSDS SHOULD: 1. PSDs should provide just enough support Ask: When you were working with the wheelchair users in the practical session, did you always use your whole hand to provide support? Encourage answers. Answers: • sometimes whole hand; • sometimes just nger tips; • sometimes part of the hand. Explain: The amount of support for each wheelchair user will vary. PSDs should provide the support that is needed by the individual wheelchair user, in the right place, and over the right amount of surface area. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 186 187 INTERMEDIATE LE VEL 2. Work together as a whole system B.12. Product (wheelchair) preparation: 9 PSDS: 2. PSDs and wheelchairs work together as a whole system • Adding additional postural support to a wheelchair can change the overall system. For example: - Adding PSDs may change the inside dimensions of the wheelchair. Ask: Which PSDs are most likely to affect the inside wheelchair component measurements (for example the seat width and seat depth) of a wheelchair? Acknowledge answers. Answers: • adding pelvis side pads can reduce the available seat width; • any PSDs added to the surface of the backrest may ‘reduce’ the available seat depth including: - rear pelvis pad; - adding a wedge to open the seat to backrest angle; • adding a cushion or increasing the height of a cushion will raise the wheelchair user in the wheelchair – and effectively makes the top of cushion to top of backrest distance shorter. Explain: Another example of how the wheelchair and PSDs interact is: • Adding PSDs may change the centre of gravity of the wheelchair–making it harder or easier for it to tip over (for example adding a headrest or heavy components). INTERMEDIATE LE VEL 3. Not create any high pressure areas B.12. Product (wheelchair) preparation: 10 PSDS SHOULD: 3. Avoid creating high pressure areas PSDs can sometimes cause pressure on a particular part of a wheelchair user’s body. For example: • if a wheelchair user needs a lot of support to prevent them from leaning to the side, their trunk side pads could be a place of high pressure. In situations like this, consider spreading the force by increasing the surface area. Always ensure there is enough padding on PSDs and under straps. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 186 187 INTERMEDIATE LE VEL 4. Be practical and functional B.12. Product (wheelchair) preparation: 11 PSDS: 4. Ensure PSDs are practical and do not reduce function Ask: What are some things to consider to ensure that the PSDs are practical and do not reduce function? Answers: • If the wheelchair user currently transports their wheelchair in the boot of a car – make sure that any PSDs added will still t. • If the wheelchair user currently transfers independently – will any PSDs that are added make it harder for him/her to transfer? • Is access to the brakes still easy for the wheelchair user (or his/her caregiver)? • If the wheelchair user was able to propel their wheelchair himself/herself, can he/she still do so? Explain: Remember – wheelchair users need wheelchairs and seating that is practical and easy to use, and that help them to be as active as possible. Explain: • Some PSDs are very simple, and can be made in a simple workshop. Others may be more complicated and require more technical skill and facilities. • Wheelchair service personnel do not have to fabricate modi cations or PSDs themselves. They can work in partnership with technicians. The wheelchair service personnel can explain what they need made and how it should work and the technician can work out how this can be made with locally available materials and tools. 4. Materials used to make PSDs and modi cations (30 minutes) Notes for trainers: • This section will vary depending on the materials available to participants in their local resources, and those materials available for demonstration for this training programme. • Preferably run this session in the same workshop / space where participants will be making PSDs during Practical Two. Arrange the materials on a large workbench, and ask participants to gather around. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 188 189 VIDEO Introduce DVD: Fabricating a footrest modi cation. In this video we will see wheelchair service personnel make a footrest modi cation for Tasi, who has signi cant xed non-neutral ankle posture. Watch closely to see the materials used. Show DVD. Ask if there are any questions. Ask: What were the materials used to make the footrest modi cation? Answers: • rm ‘EVA’ foam; • rubber ip- ops could also be used; • foam glue/adhesive. Show examples of the different materials listed below and different PSDs that have been made using these materials. Explain what the materials may be used for and what to look for when selecting materials. Use the notes below to guide you. Materials PSDs or modi cations that the materials may be used for: What to look for when selecting materials for PSDs or modi cations: Metal/ plastic/ wood Metal/plastic/wood form the structure of a PSD e.g. rigid seats and backrests. Wood or metal can be used to make brackets to hold a trunk side pad onto the backrest. 12 mm plywood is very useful for making rigid seats and backrests. It is strong but relatively light in weight. Marine ply is the most durable, however it can be more expensive. 3 mm aluminium sheet and 6 mm acrylic or ABS plastic sheet if available can also be used to make rigid backrests. Adding a fold in the sheet can add rigidity. When using any sheet material, take additional care to remove or pad the sharp edges for the safety of the wheelchair user. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 188 189 Foam/ padding Foam is used over all PSDs in the areas that PSDs are in direct contact with the wheelchair user’s body. Firm foam, which holds its shape is used to give PSDs the shape they need to provide the right support. Soft foam is used to add comfort and reduce pressure. Examples of the use of foam: • foam should be added to straps to distribute pressure and add comfort; • a rm foam can be used to make a trunk side wedge, added to a cushion to make an outside thigh wedge or inside thigh wedge; • very rm foam (eg. EVA) can be used to make a footrest build-up or footrest wedge and trunk side pads. Look in the local markets and visit foam, shoe, mattress and furniture factories to nd locally available foam. Try to nd local examples of foam in different thicknesses (25 mm and 50 mm) and different rmness. EVA is an example of very rm foam, which is good for providing rm support and structure for a PSD. EVA can sometimes be found where shoes are manufactured. The rm rubber used to make ip- ops can be used in place of EVA. Good quality chip foam is an example of a medium rm foam. Chip foam can be used as the base of a contoured/layered cushion, to make a rear pelvis pad or pre seat bone shelf, or to provide contours on a rigid backrest. Soft ‘mattress foam’ is an example of soft foam used for comfort layers. The most commonly available, cheapest ‘very soft’ foam is not suitable on its own for making pressure relieving cushions without a rmer foam base. Coir (coconut bre) can be used in place of rm foam. Fabric Fabric is used to cover PSDs. Look for a fabric that will be durable and easy to clean (by wiping down or removing for washing). A water resistant fabric is useful for the seat, cushion and backrest if the wheelchair user is incontinent. A soft, T-shirt type material (cotton or cotton/Lycra) can be used for headrests and trunk side pads and trunk side wedges. A fabric with some stretch will more easily conform to the shape of PSDs. Synthetic fabrics usually make the person hotter than natural fabrics. Try to have at least a few different colours, and offer wheelchair users a choice if this is possible. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 190 191 Nylon webbing/ Velcro / buckles Nylon webbing/ Velcro / buckles are used to make straps including pelvis strap, shoulder harness, calf and foot straps. 25 mm, 35 mm and 50 mm nylon webbing is useful. The wider the strap, the more even the pressure. Melting the cut ends of nylon webbing stops them from fraying. Cotton webbing is much less effective. Clip buckles (such as those used on backpacks) can be very easy to use. Use good quality buckles if available as these will last longer. Test them by clipping them together and trying to pull them apart. They should clip together and undo easily, and not pull apart unless released. Velcro is a good fastener, however it needs to be kept clean or it stops working. Soft foam pads should be placed under all webbing straps to protect the wheelchair user’s body. Adhesives Adhesives are used to bond wood and foam. Have a supply of wood glue (commonly known as white glue or PVA) and foam glue (contact adhesive, shoe glue or yellow glue). Ensure that anyone using adhesives knows how to use them correctly. Fasteners Fasteners are used to attach PSDs to the wheelchair. Useful fasteners include: • bolts with nuts (preferably lock-nuts) and washers; • T-nuts ( xed into plywood instead of a nut); • staples (for xing upholstery). Avoid using sharp screws as they may become a hazard if the PSD is damaged. 5. Key point summary (3 minutes) INTERMEDIATE LE VEL • Product preparation includes preparing the wheelchair to match the wheelchair user’s prescription. • Product preparation and fitting may need to be repeated until the wheelchair fits correctly. • A wheelchair safe and ready check should be carried out before the wheelchair user tries the wheelchair. • Wheelchairs and PSDs need to work together as a whole system for the wheelchair user. B.12. Product (wheelchair) preparation: 13 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 190 191 Practical Two: Product (wheelchair) preparation O B JE C T IV E S By the end of this session, participants will be able to: Demonstrate preparing a wheelchair and PSDs for a wheelchair user who needs additional postural support working in a group and with assistance. R E S O U R C E S Participant’s Workbook; Trainer’s observation checklist: Practical Two; blank and completed intermediate wheelchair assessment and intermediate wheelchair prescription (selection) forms from Practical One; poster : Postural Support Device (PSD) Table; laminated Postural Support Device (PSD) Table–1 for each participant; laminated intermediate wheelchair safe and ready checklist – 1 for each participant; PSD kit; wheelchairs and PSD materials; workbenches and tool kits – 1 for each group. C O N T E X T A N D P R IO R L E A R N IN G Prior learning: basic level product (wheelchair) preparation – refer to the Wheelchair Service Training Package – Basic Level; how to carry out wheelchair safe and ready checklist – refer to the Wheelchair Service Training Package – Basic Level. Adapt this session to suit the context participants will be working in. Think about: the wheelchairs, PSD materials and tools that they will have to work with in their own workplace; the amount of wheelchair assembly or fabrication from raw materials required. Trainers will need to adjust the time for this session (which may affect the whole training programme’s timetable) depending on these factors. T O P R E PA R E Arrange to have a technician with expertise in product (wheelchair) preparation to support the trainer and assist participants. Ask participants ahead of time to wear covered shoes for this practical session. Bring the wheelchairs selected to the workspace. Prepare a work space for each group with a workbench and tool kits, lay out the PSD materials for participants to work ef ciently. Unpack sample PSDs from the PSD kit that have been put together and lay them out on a table (workbench) at the front of the training room where you can easily reach them. Pin up the Postural Support Device (PSD) Table poster. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 192 193 O U T L IN E 1. Product (wheelchair) preparation: • Instructions and set-up; • Plan and prepare; • Adjust the wheelchair and prepare PSDs for tting; • Carry out the wheelchair safe and ready check; • Feedback. 10 15 80 15 30 Total session time 150 1. Product (wheelchair) preparation (150 minutes) Notes for trainers: Observing participants’ practice: • Use the Trainer’s observation checklist for Practical Two to ensure that groups perform all the steps in the practical and to note common examples of good practice or practice needing improvement for feedback. Small-group activity Groups: • Divide participants into the same groups as in Practical One. • Appoint a leader for each group (this may be the same leader as for Practical One or a different leader). • Assign each group a place to work in. • Explain to the participants where to nd materials and tools. Instructions: Explain all of the following: Session aim: • The aim of this practical session is to prepare the wheelchair and PSDs for the wheelchair user assessed in Practical One. Workshop safety: Before beginning to work with the tools and materials, participants need to remember the following ve safety rules: • wear covered shoes in the workshop; • secure your work piece when cutting or drilling; • use safety glasses when using power tools or any other sharp tool; • keep the work area and walk ways organized and clean; • never cut toward yourself or others. Lead person: • The lead person for each group is responsible for making sure that all steps are carried out to prepare the wheelchair. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 192 193 Trainer’s observation and support: • Participants should ask for assistance or clari cation at any time. • Throughout the session trainers will monitor each group and give as much support and advice as needed. Service forms: • Hand out the completed intermediate wheelchair assessment and intermediate wheelchair prescription (selection) forms from Practical One to each group’s team leader. • At the end of the practical collect the lled out forms and hand them out in the next practical session. Ask: Are there any questions? Answer any questions. Monitor and support: Closely monitor the groups, ensure safe practice, observe and evaluate the skills of the participants. Use the Trainer’s observation checklist to record your observations of each group. Throughout the session: • Give time warnings (verbally and/or write on a whiteboard where all participants can see) to help participants manage their time. • Ensure every group member is actively involved. Notes for trainers: Some participants may have less technical skills than others. Where possible and appropriate, encourage all participants to practise preparing the wheelchair and PSDs. Give as much technical support as is needed. Time: • Participants should follow the time sequence described below: - A: Plan and prepare (15 minutes). - Ask participants to write the tasks that need to be completed in Participant’s Workbook (Practical Two: Product (wheelchair) preparation – task checklist). - B: Adjust the wheelchair and prepare the PSDs for tting (allow 80 minutes). - C: Carry out the wheelchair safe and ready check (allow 15 minutes). - Ask participants to use the intermediate wheelchair safe and ready checklist in their Participant’s Workbook (Practical Two: Product (wheelchair) preparation – intermediate wheelchair safe and ready checklist). - After completing each step, participants should check with the trainer before moving onto the next step; - 30 minutes for feedback. • More time will be needed if a lot of product (wheelchair) preparation is required. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 194 195 Feedback: Ask each group to brie y present the wheelchair they have prepared to the rest of the group. Each group should explain: • what modi cations or PSDs have been made – and why. • how the modi cations or PSDs were made (materials used and how they have been mounted/attached to the wheelchair). (Allow 5–7 minutes per group). After each presentation, allow a few minutes for the whole group to ask any questions of the presenting group. Brie y comment on examples of good practice that you saw during the practical session. Brie y note any particular areas that participants could improve – do not highlight individuals. Ask: Are there any questions? Notes for trainers: It is important to keep a close eye on the clock during practical sessions. The times given above are a guide – however these could vary depending on the experience of participants, the needs of the wheelchair users, the time required to set up. Trainers may need to make necessary adjustments. B.13: Fitting O B JE C T IV E S By the end of this session, participants will be able to: describe how to check that a wheelchair with PSDs ts a wheelchair user who needs additional postural support. R E S O U R C E S For the session: PPT Slides: B.13: Fitting; Reference Manual; DVD: Fitting demonstration – Deepak; DVD: Fitting demonstration – Careen; poster : Postural Support Device (PSD) Table; laminated Postural Support Device (PSD) Table – 1 for each participant; laminated intermediate wheelchair tting checklist – 1 for each participant. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 194 195 C O N T E X T A N D P R IO R L E A R N IN G Prior learning: The Wheelchair Service Training Package – Basic Level covers a wheelchair tting for a wheelchair user who can sit upright without additional support. The intermediate level steps are similar, however more detail is added in this session. How to carry out a pressure test to check pressures under a wheelchair user’s seat bones. Participants should be familiar with how to carry this out before this session. Adapt this session to suit the context participants will be working in. Think about: The type of wheelchairs and PSDs commonly available. T O P R E PA R E Gather resources, review PPT slides, watch DVDs and read through the session plan. Pin up the Postural Support Device (PSD) Table poster. O U T L IN E 1. Introduction 2. How to carry out a tting 3. Key point summary 2 55 3 Total session time 60 1. Introduction (2 minutes) INTERMEDIATE LE VEL Step 6: Fitting • In this session participants will: - Get introduce the intermediate wheelchair fitting checklist; - Talk about how to carry out a wheelchair fitting at intermediate level. B.13. Fitting: 2 INTRODUCTIO N Explain: • Fitting is the sixth of the eight steps of wheelchair service delivery. • During tting the wheelchair user and the wheelchair service personnel make sure the wheelchair and PSDs t well and support the wheelchair user as close to neutral sitting posture with comfort. • In this session, we will introduce the intermediate wheelchair tting checklist and talk about how to carry out a wheelchair tting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 196 197 2. How to carry out a tting (55 minutes) INTERMEDIATE LE VEL 1. Referral and appointment 2. Assessment 3. Prescription (selection) 4. Funding and ordering 5. Product (wheelchair) preparation 6. Fitting 7. User training 8. Maintenance, repairs and follow up B.13. Fitting: 3 PRODUCT (WH EELCHAIR) PREP ARATION – FITT ING CYCLE Explain: • Participants should all be familiar with the process of carrying out a wheelchair tting. • At the intermediate level, a tting may take longer, and may need to be repeated. Hand out the laminated intermediate wheelchair tting checklist. • This checklist is a guide to help wheelchair service personnel remember the most important things about wheelchair tting. • With practice this process becomes faster and easier. • To begin with – follow the checklist to make sure that nothing is forgotten. INTERMEDIATE LE VEL 1. Is the wheelchair ready? 2. Check the wheelchair and PSDs fit. 3. Check posture. 4. Check pressure. 5. Check fit while the wheelchair is moving. 6. Attend if any further action is required. B.13. Fitting: 4 FITTING INCLU DES: Point out the tting sequence shown on the checklist: 1. Is the wheelchair ready? 2. Check the wheelchair and PSDs t. 3. Check posture. 4. Check pressure. 5. Check t while the wheelchair is moving. 6. Decide if any further action is required. Ask: Are participants likely to be carrying out wheelchair tting at a wheelchair user’s home or at a wheelchair service centre? Encourage answers. Explain: Whether carrying out the tting in a wheelchair user’s home or a wheelchair service centre, make sure you have the following equipment: • wheelchair users’ intermediate wheelchair assessment form and prescription (selection) form; • tape measure or caliper; • any tools needed to make adjustments to the wheelchair or PSDs. It is also helpful to have a few pieces of foam in case you need to try some additional postural supports. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 196 197 VIDEO Introduce DVD: Fitting demonstration – Deepak. We will now watch a short DVD showing Deepak (who we have seen before) being tted for his wheelchair. Ask participants to watch closely. Show DVD. Ask if there are any questions. Ask: Why was it important to add some foam under Deepak’s right foot? Answer: It is more comfortable and easier to balance when both feet are fully supported. Without the foam, Deepak only had contact with one footrest. Ask: The wheelchair service personnel placed some additional foam against the backrest to provide better support for Deepak’s trunk. How will this be added permanently to his backrest? Answer: The foam can be glued to the backrest – under the upholstery. Ask: Why is it important to ask the wheelchair user to propel their wheelchair (or be pushed if he/she cannot propel) during a tting check? Answer: A person’s posture may change once the wheelchair is moving, or from the effort of propelling. Explain: INTERMEDIATE LE VEL 1. Is the wheelchair ready? • Always ensure that the wheelchair is ready for the wheelchair user to try. • This means having completed a ‘wheelchair safe and ready checklist’. B.13. Fitting: 6 FITTING 1. Is the wheelchair ready? Explain: • Always ensure that the wheelchair is ready for the wheelchair user to try. • This means having completed the intermediate wheelchair safe and ready checklist. • This will become a very quick check with practice. INTERMEDIATE LE VEL 2. Check the wheelchair and PSDs fit B.13. Fitting: 7 FITTING 2. Check wheelchair and PSDs t Explain: • During the wheelchair tting, wheelchair service personnel need to physically check that the wheelchair t is correct. • In the next couple of slides we will go over how to check the wheelchair and PSDs t. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 198 199 INTERMEDIATE LE VEL • run fingers down on the outside of the wheelchair user’s thighs; • fingers should just fit comfortably. B.13. Fitting: 8 CHECK WHEEL CHAIR WIDTH When checking the wheelchair width, make sure that: • the wheelchair user’s hips t comfortably between armrests or pelvis side pads; • the wheelchair user’s thighs t comfortably between the armrests, mud/skirt guards or pelvis side pads and are not pushed together. This may happen if pelvis side pads extend too far forward; • the wheelchair user’s trunk ts comfortably between backrest uprights or trunk side pads. To check the wheelchair/hip width: • run ngers down on the outside of the wheelchair user’s thighs; • ngers should just t comfortably. INTERMEDIATE LE VEL • check the wheelchair user is sitting upright, with the back of their pelvis touching the backrest; • there should be a gap between the back of the wheelchair user’s knee and the seat cushion of at least 30mm; • check both sides. B.13. Fitting: 9 CHECK SEAT D EPTH When checking the seat depth, make sure that: • the wheelchair user is sitting as close to neutral sitting posture as is comfortable for them; • there is a gap between the front of the seat/ cushion and the back of the wheelchair user’s knee of at least 30 mm. There may be a bigger gap for wheelchair users with long legs; up to 60 mm is acceptable. To check the seat depth: • slide hand between the cushion and the back of the knee. Count how many ngers. • slide hand down the back of the calf and make sure the calf is not touching the seat/ cushion; • check both sides. • if there is a difference between right and left sides, use the shorter leg measurement to make prescription choices. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 198 199 INTERMEDIATE LE VEL • pre seat bone shelf sits just in front of the seat bones; • rear pelvis pad provides support at the PSIS and does not push on the lower trunk; • pelvis side pads fit snugly; • the pelvis strap does not pinch. B.13. Fitting: 10 CHECK PELVIS When checking the pelvis, make sure that: • the pre seat bone shelf sits just in front of the seat bones (place your hand under the wheelchair user’s bottom to check); • the rear pelvis pad provides support at the PSIS and does not push on the lower trunk; • pelvis side pads t snugly and are not located over the hip joint; • the pelvis strap can be tightened rmly and does not pinch the wheelchair user’s skin (run hands between the strap and the wheelchair user to check). INTERMEDIATE LE VEL • trunk side pads and trunk side wedges do not place any pressure into the armpits; • shoulder harness is done up comfortably and it does not pinch; • tray supports the length of the forearm and elbows and does not push on stomach. B.13. Fitting: 11 CHECK TRUNK When checking the trunk, make sure that: • trunk side pads and trunk side wedges do not place any pressure into the armpits. There should be at least 30 mm between the wheelchair user’s armpit and the top of a trunk side pad; • the shoulder harness is done up comfortably and it does not pinch skin; • the tray supports the length of the forearm and elbows and does not push on the stomach. A modi ed tray cut-out may be close to the body, however it should not touch or rub on the wheelchair user’s skin. Check backrest height and tilt. INTERMEDIATE LE VEL • The headrest should support the wheelchair user’s head at the base of the skull in a balanced and upright posture. B.13. Fitting: 12 CHECK HEADR EST FIT Check the headrest t: • The headrest should support the wheelchair user’s head at the base of the skull. • The headrest should support the user’s head in a balanced and upright posture. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 200 201 INTERMEDIATE LE VEL • no high pressure between the wheelchair user’s thighs and thigh supports; • knee separator pad is not putting any pressure onto the groin area. B.13. Fitting: 13 CHECK THIGHS When checking the wheelchair user’s thighs, make sure that: • there is no high pressure between the wheelchair user’s thighs and thigh supports (including outside thigh pads, inside thigh wedge or knee separator pad); • the knee separator pad is not putting any pressure onto the groin area. INTERMEDIATE LE VEL • even pressure along the thigh and no gaps; • the foot should be supported at the front and the back with no gaps. B.13. Fitting: 14 CHECK THE FO OTREST HEIGH T Finally, check the footrest height. • Check that the wheelchair user’s thigh is fully supported on the seat/cushion with no gaps and their feet are fully supported on the footrest with no gaps. • How to check: - slide hand between the thigh and the seat/ cushion. There should be even pressure along the thigh and no gaps; - look at the foot on the footrest. The foot should be supported at the front and the back with no gaps. INTERMEDIATE LE VEL 3. Check posture B.13. Fitting: 15 FITTING 3. Check posture • After checking that the wheelchair and PSDs t, wheelchair service personnel should then check that the wheelchair user’s posture is as upright as is comfortable for them. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 200 201 INTERMEDIATE LE VEL • Is the wheelchair user sitting in as upright a posture as is comfortable for them? Check from front and side: - Is the pelvis upright and level (if possible)? - Is the trunk upright and symmetrical(if possible)? - Is the head balanced and upright (if possible)? - Are legs and feet supported as close to upright sitting posture as possible? B.13. Fitting: 16 CHECK POSTU RE • Observe the wheelchair user’s posture from the front and the side. • Look to see whether the wheelchair user is sitting in as upright a posture as is comfortable for them. This should be close to the posture identi ed in the hand simulation. • Speci cally, check from front to side: - Is the pelvis upright and level? (if possible) - Is the trunk upright and symmetrical? (if possible) - Is the head balanced and upright? (if possible) - Are legs and feet supported as close to upright sitting posture as possible? • Ask the wheelchair user how he/she feels. INTERMEDIATE LE VEL • Check that each PSD is providing support as intended. Remember to check: - backrest height, backrest recline and adjust backrest shape; - tilt in space; - headrest; - pelvis side pads and trunk side pads; - any thigh and lower leg supports. B.13. Fitting: 17 CHECK POSTU RE • After looking at the wheelchair user’s overall sitting posture, check that each PSD is providing support as intended. • Speci cally, remember to check (if provided): - backrest height, recline and adjust backrest shape; - tilt in space; - headrest; - pelvis side pads and trunk side pads; - any thigh and lower leg supports. INTERMEDIATE LE VEL 4. Check pressure B.13. Fitting: 18 FITTING 4. Check pressure WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 202 203 VIDEO INTERMEDIATE LE VEL • For every wheelchair user who is at risk of developing a pressure sore – check the pressure under the seat bones and any other area at risk. B.13. Fitting: 19 CHECK PRESSU RE • For every wheelchair user who is at risk of developing a pressure sore, the tting step includes checking whether the pressure is safe under the seat bones (using the manual pressure test taught in the WSTP Basic Level) and any other area at risk (e.g. under hip joint or tail bone). INTERMEDIATE LE VEL • For every wheelchair user who is using PSDs that provide firm support – check the pressure between the wheelchair user’s body part and the PSD. B.13. Fitting: 20 CHECK PRESSU RE • For every wheelchair user who is using PSDs that provide rm support – check the pressure between the wheelchair user’s body part and the PSD. Support should feel rm – but not tight. Notes for trainers: How to check pressure under seat bones for all wheelchair users at risk of developing a pressure sore is taught in the Wheelchair Service Training Package –Basic Level. Brie y demonstrate the pressure test/play the basic level DVD “Pressure test demonstration” or ask one of the participants to demonstrate. Introduce DVD: Fitting demonstration – Careen: Watch this short DVD, which shows wheelchair service personnel checking the t of a wheelchair for a young girl called Careen. The wheelchair service personnel check the t of all components and carefully ensure that all straps are tting rmly – but not too tightly. Show DVD. Ask if there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 202 203 INTERMEDIATE LE VEL 5. Check fit while the wheelchair is moving B.13. Fitting: 22 FITTING 5. Check t while the wheelchair is moving • The nal part of wheelchair tting is to check the wheelchair when the wheelchair is moving. INTERMEDIATE LE VEL • Does the backrest allow the wheelchair user freedom to move their shoulder blades to push? • Does movement of the wheelchair or the action of pushing cause the wheelchair user to change their posture or feel uncomfortable or unstable in any way? B.13. Fitting: 23 CHECK FIT WH ILE THE WHEEL CHAIR IS MOVIN G The things to look for: • Does the backrest allow the wheelchair user freedom to move their shoulders to push? • Does movement of the wheelchair or the action of pushing cause the wheelchair user to change their posture or feel uncomfortable or unstable in any way? INTERMEDIATE LE VEL • hand propelling: are the rear wheels position correct for the wheelchair user to push as well as they can? • foot propelling: is the seat height and seat depth correct for the wheelchair user to push with their legs? B.13. Fitting: 24 CHECK FIT WH ILE THE WHEEL CHAIR IS MOVIN G • Hand propelling: Is the rear wheels position correct for the wheelchair user to push as well as he/she can? • Foot propelling: Is the seat height and seat depth correct for the wheelchair user to push with their legs? • Do the posture supports allow for unrestricted and safe wheelchair mobility? Explain: If a wheelchair user cannot push the wheelchair themselves, ask a family member/caregiver to push them while you observe. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 204 205 INTERMEDIATE LE VEL 6. Attend if any further action is required. B.13. Fitting: 25 FITTING 6.Decide if any further action is required Explain: • After making all of these checks, the wheelchair user and wheelchair service personnel need to decide if any action is needed. • It is very common to need to make some adjustments after the rst tting for a wheelchair user who needs additional postural support. • If adjustments are made, the tting step should be repeated from the beginning. • With practice this process becomes quicker, as wheelchair service personnel will become more experienced at noticing what ts and what needs adjusting. Explain: Participants will practise carrying out a tting with wheelchair users twice during this training programme. 3. Key point summary (3 minutes) INTERMEDIATE LE VEL • Fitting includes the following steps: 1. Is the wheelchair ready? 2. Check the wheelchair and PSDs fit. 3. Check posture. 4. Check pressure. 5. Check fit while the wheelchair is moving. 6. Attend if any further action is required. • At the intermediate level, a fitting may take longer, and may need to be repeated. B.13. Fitting: 26 KEY POINT SUM MARY Decide Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 204 205 B.14: User training O B JE C T IV E S By the end of this session, participants will be able to: highlight six skills wheelchair service personnel may teach wheelchair users receiving a wheelchair with modi cations or PSDs; demonstrate teaching a colleague at least three wheelchair skills. R E S O U R C E S For the session: PPT Slides: B.14: User training; Reference Manual; Participant’s Workbook; poster : Intermediate Wheelchair User Training Checklist; laminated intermediate wheelchair user training checklist – 1 for each participant; wheelchairs–1 for each group. C O N T E X T A N D P R IO R L E A R N IN G Prior learning: More information about wheelchair user training is covered in the Wheelchair Service Training Package – Basic Level. Trainers should make sure that participants are already familiar with this step and have skills in teaching basic level wheelchair handling, transfers, wheelchair use and mobility, preventing pressure sores, how to care for a wheelchair at home and what to do if there is a problem. Adapt this session to suit the context participants will be working in. Think about: Whether there are support groups or peer group trainers that can assist in providing wheelchair users and their family members/caregivers with user training. T O P R E PA R E Gather resources, review PPT slides and read through the session plan. Pin up the Intermediate Wheelchair User Training Checklist poster. O U T L IN E 1. Introduction 2. User training – wheelchair user’s stories 3. Key point summary 5 50 5 Total session time 60 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 206 207 1. Introduction (5 minutes) INTERMEDIATE LE VEL • In this session participants will work through three different wheelchair user stories, to highlight some of the particular things that may be important for intermediate level wheelchair users and their family member/carer to learn. Step 7: User training B.14. User training: 2 INTRODUCTIO N Explain: • User training is the seventh step in wheelchair service delivery. • Participants should be familiar with this step from the Wheelchair Service Training Package – Basic Level. • At the intermediate level, the information that wheelchair users need is sometimes different. • In this session we will work through three different wheelchair user stories, which will help to highlight some of the particular things that may be important for intermediate level wheelchair users and their family member/caregiver to learn. Ask: Can anyone suggest what different or additional information/training wheelchair users (and their family members/caregivers) using wheelchairs with additional postural support may need? Encourage answers. Answers: • information about the bene ts of additional postural support; • how to use PSDs correctly (how they should t and what to do if there is a problem); • information about getting used to a wheelchair (particularly for children) and PSDs; • how to take apart and put back together (for example for transport) a wheelchair with PSDs; • different types of transfers – for people who cannot get in and out of the wheelchair themselves. Explain: • The ‘User training’ session in the Reference Manual contains key information regarding this wheelchair service step. • The intermediate wheelchair user training checklist in the Reference Manual can be used as a guide to help wheelchair service personnel identify what the wheelchair user and their family member /caregiver need to know – and teach those things. You do not need to teach everything to every wheelchair user. • In this session we will work through three different wheelchair user stories, which will help to highlight some of the particular things that may be important for intermediate level wheelchair users and their family member/caregiver to learn. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 206 207 2. User training – wheelchair user’s stories (50 minutes) Small-group activity Groups: Divide participants into groups of 3. Instructions: • Assign one wheelchair user’s story from the Participant’s Workbook (B.14: User training) to each group. Ensure participants have their Reference Manual with them. • Ask each group to read the assigned wheelchair user’s story in their workbook. • Based on the information provided in the wheelchair user’s story ask participants to decide what skills the wheelchair user needs to learn to use and care for their new wheelchair and complete the intermediate wheelchair user training checklist in their workbook. • Ask each person in the group to choose a role (wheelchair user, wheelchair service personnel, wheelchair user’s family member/ caregiver). • Ask each person assuming the role of the wheelchair service personnel to teach at least three skills selected from the intermediate wheelchair user training checklist to the wheelchair user and their family member/ caregiver. • Explain to the participants that two of the wheelchair user’s stories are of children, who need a one person lift. It is not possible to actually practise this skill with adults. Participants should describe – without actually lifting. • Remind participants to think about ‘How to make wheelchair user training successful’. Stress the importance of ‘demonstration’ followed by ‘practice’. • Encourage participants to check their Reference Manual for information about each skill they are teaching. • Explain: Participants have 35 minutes to do this activity and then the groups will come back together for feedback. Monitor: • Monitor the groups closely. • Ensure that each group understands the activity. • Encourage groups to use the Reference Manual. • Ensure that each group has selected the appropriate skills to teach the wheelchair user and family member/caregiver (refer to the Notes for trainers below). • Ensure that the group that reads Sangita’s story have also added information for the parents about different positions and explaining the bene ts of a wheelchair and additional postural support for Sangita. • Ensure safe practice. • Correct any techniques if necessary. • Guide participants if necessary. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 208 209 Time: Allow 35 minutes for activity. Allow 15 minutes for feedback. Feedback: Ask one person from each group to: • brie y describe the wheelchair user they provided training for ; • list the most important things the wheelchair user needed to learn. Follow along and add missing information from presentations and correct inaccurate details given. Notes for trainers: Joshua is six years old and has cerebral palsy. He gets sudden uncontrolled movements. He has been prescribed (selected) a child’s wheelchair with PSDs including a pelvis strap, pelvis side pads and trunk side pads. Joshua has thin, sensitive skin, and the trunk side pads have been provided with additional padding to help ensure he does not develop a pressure sore from the trunk side pads. Joshua’s new wheelchair has a tilt feature, which allows the wheelchair to be tilted back sometimes and then brought more upright. There is also an anti-tip bar, which can be moved out of the way for travelling over rough ground or up and down kerbs. For transport the wheelchair has removable rear wheels and the seat can be taken off the wheelchair frame. Joshua goes to kindergarten every morning. He is picked up by a transport service arranged by the kindergarten. The vehicle is a small motorised three wheeler. His parents are worried about whether his wheelchair will t inside. Joshua has come for a tting for his new wheelchair. His mother is with him. Skills participants should teach: Particular points participants should emphasize: Wheelchair handling: • all skills. Transfers: • assisted transfer. Wheelchair use and mobility: • assisted pushing; • how long to sit in the wheelchair. Wheelchair handling: Tilt: • explain reason for using tilt: balance trunk and upright head; • how to ‘lock’ tilt safely in position; • when and why to change the tilt. Anti-tip bar : • reason for anti-tip bar – stops the wheelchair from tipping backwards; • the need to remove anti-tip bar when travelling outside because it can prevent being able to go over rough ground or up and down kerbs. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 208 209 Preventing pressure sores: • checking for pressure sores; • what to do if a pressure sore develops. How to care for a wheelchair at home: • all skills; What to do if there is a problem: • all skills. Taking off and putting back on any PSDs that need to come off for transport: • how to remove the rear wheels; • how to take the seat off the frame; • how to put the wheelchair back together. Transfers: • when transferring keep knees above hips; • keep Joshua’s trunk bent forward whilst fastening the pelvis strap; • show how tight the pelvis strap should be; • emphasize how to check Joshua’s position once in his wheelchair : hips to backrest; seat bones behind the pre seat bone shelf; trunk side pads close to his body but not pinching. Wheelchair use and mobility: • safe pushing by mother and friends indoors and outdoors. Preventing pressure sores: • check skin in all areas where wheelchair or PSDs touch the body; • if no marks, increase time spent in the wheelchair by 10 minutes each day to maximum 2 hours at one time; • check Joshua’s skin every time he gets out of his wheelchair. • If any redness appears and lasts for more than 20 minutes after Joshua is out of the wheelchair, he should not sit in the wheelchair until they have gone. Sangita is three years old and has spina bi da. She has movement dif culties; loss of feeling below her waist and has a bulge at the bottom of her spine. Her parents say she has dif culty controlling her bladder and bowels and often has urinary tract infections. Sangita has come to the wheelchair service for a tting of her rst wheelchair, which has quick release wheels, pelvis strap, pelvis side pads, and some shaping of the backrest to avoid pressure around the bulge in her spine. She also has a pressure relief cushion. She has come with both parents. Her parents are worried that if she has a wheelchair she will not want to walk with her calipers. However, she gets frustrated when she cannot play with her brother and sisters outside. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 210 211 Skills participants should teach: Particular points participants should emphasize: Wheelchair handling: all skills. Transfers: • independent (with and without Calipers) Wheelchair use and mobility: • pushing correctly, slopes, stairs, use of anti-tip bars Preventing pressure sores: • checking for pressure sores • emphasize: checking there are no marks on the skin around the bulge How to care for a wheelchair at home: • all skills. What to do if there is a problem: • all skills. Referral to a urologist: • bladder management and prevention of urine infections Transfers: • discuss with parents that it is good for Sangita to be as independent as possible and transfer by herself. Wheelchair use and mobility: Reassure Sangita’s parents that the wheelchair will not stop Sangita from walking. Explain the bene ts of a wheelchair including: • the wheelchair will help her to to keep up with her siblings outside and also keep her t and active; • the wheelchair will free her hands–instead of holding on to crutches to mobilize, she can sit in wheelchair and use her hands to do things for herself; • the wheelchair helps Sangita to sit in a good posture and prevent problems with posture developing. Length of time sitting in the wheelchair : • Sangita should begin using the wheelchair for short periods (e.g. 30 minutes) a few times during each day; • build up the time as Sangita gets used to the wheelchair ; • Sangita should not stay in the wheelchair for longer than 2 hours without a break. Preventing pressure sores: • Check skin in all areas where wheelchair or PSDs touch the body. • If no marks, increase time spent in the wheelchair by 10 minutes each day to maximum 2 hours at one time. • If any redness appears and lasts for more than 20 minutes after Sangita is out of the wheelchair, she should not sit in her wheelchair until they have gone. Referral: • As Sangita is getting frequent urinary tract infections; wheelchair service personnel could refer Sangita to a doctor for advice on safe bladder management. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 210 211 Kim Som is 40 years old and had a head injury 15 years ago. He is very thin as he has dif culty eating. He has a xed forward curve of the spine. Kim Som cannot stand up and is completely dependent upon his mother. He does not speak, however his mother says that he understands simple instructions. In the assessment he was identi ed as a person at risk of developing a pressure sore as he is thin, cannot move independently and has had a pressure sore in the past (from lying in bed). He has just received his rst wheelchair. The wheelchair has a pressure relief cushion and PSD to help Kim Som sit more comfortably. His mother is his caregiver and has attended the wheelchair tting appointment with him. Skills participants should teach: Particular points participants should emphasize: Wheelchair handling: • all skills (except tilting and anti- tip bars). Transfers: • assisted transfer. Wheelchair use and mobility: • assisted pushing; • how long to sit in the wheelchair. Preventing pressure sores: • checking for pressure sores; • what to do if a pressure sore develops. How to care for a wheelchair at home: • all skills. What to do if there is a problem: • all skills. Transfers: • As a full grown man, it is important that two people lift Kim Som. • Discuss with Kim Som’s mother how she helps Kim Som to get in and out of his wheelchair. Does she have anyone to help her, and does she know how to lift safely? • Check/teach the correct transfer technique. • Emphasize how to check Kim Som’s position once in his wheelchair : hips to backrest; seat bones behind the pre seat bone shelf; trunk side pads close to body but not pinching. Wheelchair use and mobility: • Teach Kim Som’s mother how to safely push him over rough ground, up and down slopes and steps. • Discuss with her how to ask for help if she has to push Kim Som up and down slopes and up and down steps. Preventing pressure sores: • Kim Som should not sit for more than 2 hours at a time. • Build up sitting time gradually, starting with 30 minutes. • Check skin immediately after he gets out of the wheelchair for marks/redness. • If any redness appears and lasts for more than 20 minutes after Kim Som is out of the wheelchair, he should not sit in wheelchair until they have gone. How to care for a wheelchair at home: • Find out from Kim Som’s mother if there is anyone who can help her with this. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 212 213 3. Key point summary (5 minutes) INTERMEDIATE LE VEL • The six most important skills to teach wheelchair users are: - wheelchair handling; - transfers; - wheelchair use and mobility; - preventing pressure sores; - how to care for the wheelchair at home; - what to do if there is a problem. • Remember – practice is important when learning any new skill. Always try to teach a skill first by demonstrating and then giving the wheelchair user an opportunity to practice. B.14. User training: 3 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. Practical Three: Fitting and user training O B JE C T IV E S By the end of this session, participants will be able to: Demonstrate an intermediate level wheelchair tting. Demonstrate intermediate wheelchair user training. R E S O U R C E S Trainer’s observation checklist: Practical Three; photo consent forms; blank and completed intermediate wheelchair assessment form and intermediate wheelchair prescription (selection) forms from Practical One; poster : Postural Support Device (PSD) Table; poster : Intermediate Wheelchair User Training Checklist; laminated Postural Support Device (PSD) Table – 1 for each participant; laminated intermediate wheelchair tting checklist – 1 for each participant; laminated intermediate wheelchair user training checklist –1 for each participant; clean and private space with assessment bed and privacy screen for each group to work with their wheelchair user ; wheelchairs prepared from Practical Two and ready for the rst tting; digital camera; tape measure or caliper – 1 for each group, set of foot blocks – 1 for each group; PSD kit and tool kit to adjust wheelchairs – 1 for each group. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 212 213 C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: cultural factors – for example whether it is appropriate to have mixed-gender groups doing the assessment; when participants are carrying out a tting on wheelchair users – be aware of any cultural issues related to touching; language factors – for example whether wheelchair users attending speak a common language with all participants; any documentation that the host/training organisation may need when assessing or prescribing a wheelchair – for example any additional information that services need to collect about wheelchair users accessing their service (e.g. referral source); how trainers will manage issues that may arise during the tting that cannot be addressed within the session or training programme. For example – wheelchairs prepared do not t and cannot be adjusted to t (a possible solution is to ensure there are additional wheelchairs in a range of sizes that could be used instead); how follow up will be managed for each wheelchair user after the training programme. T O P R E PA R E Con rm time and travel arrangements with wheelchair user volunteers. Ensure refreshments are available for wheelchair users and their family member/caregiver. Assign one person to greet wheelchair users as they arrive and show them where they can wait until the session begins. Prepare a tting area for each group (assessment bed and privacy screen). Ensure that the wheelchairs to be tted are fully prepared (check them against the intermediate wheelchair prescription (selection) forms and con rm that intermediate wheelchair safe and ready checklists have been completed). If there are more than three groups of participants, ask another trainer to assist with monitoring the groups. Pin up the Postural Support Device (PSD) Table poster. Pin up the Intermediate Wheelchair User Training Checklist poster. O U T L IN E 1. Fitting and user training practice: • Instructions and set-up • Fitting • User training 15 90 45 Total session time 150 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 214 215 1. Fitting and user training practice (150 minutes) Notes for trainers: 1. Photographs: • Check that each wheelchair user has been asked for their signed permission to take their photograph. Ensure that wheelchair users understand that their permission is voluntary and that the photographs will be used for further training during this training programme. • Take photographs during the practical of each wheelchair user who has given permission as follows: - in the wheelchair prescribed after tting (front and side view). 2. Meeting the needs of the wheelchair users participating in the practical session: • Not all wheelchairs with PSDs may be completed during the time available in the practical session. • If another appointment is required for any wheelchair users seen during the practical session, the trainer should ensure that an appointment is made by the host/training organization and all assessment, prescription and tting information is handed over to the host/training organization for nalizing the PSD/ nal delivery of the wheelchair. 3. Observing participants’ practice: • Use the Trainer’s observation checklist for Practical Three to ensure that groups perform all the steps in the practical and to note common examples of good practice. Small-group activity Groups: • Divide participants into the same groups as in Practical One and Two. • Appoint a leader for each group (this may be the same leader as for Practical One or Two or a different leader). • Assign each group a place to work in. • Explain where to nd materials and tools. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 214 215 Instructions: Explain all of the following: Session aim: • The aim of this practical session is to carry out steps six and seven of the eight steps of wheelchair service delivery – tting and user training – working with the wheelchair user from the previous practical sessions. • It is possible that participants may not be able to complete the wheelchair for the wheelchair user during the time available. This will depend on the rst tting and what modi cations/adjustments may be necessary. However, participants should use the session time to get as much done as they can. If the wheelchair cannot be completed, arrangements will be made with the wheelchair user to ensure that their wheelchair is completed after the training programme. Lead person: • The lead person for each group is responsible for making sure that all steps are carried out. • The lead person should be the main person talking with the wheelchair user and their family member/caregiver. This is to avoid having too many people speaking at once, which can be confusing for everyone. Trainer’s observation and support: • Participants should ask for assistance or clari cation at any time. • Throughout the session trainers will monitor each group and give as much support and advice as needed. • Explain to the participants that if any problems with the t are identi ed, they should ask the trainer to come and check this, and discuss what modi cations/adjustments may be needed. • After completing the tting, participants should ask one trainer to come and check the tting. Participants DO NOT BEGIN USER TRAINING until the t has been checked by one of the trainers. • After completing the user training, participants should ask one trainer to come and discuss with the group and the wheelchair user what training was provided. Time allowed: • Participants should aim to complete the tting (including making any adjustments) in 90 minutes and user training in 45 minutes. Service forms: • Hand out the wheelchair assessment and wheelchair prescription (selection) forms from previous practicals to each group leader. • Check that each group has at least one copy of the laminated intermediate wheelchair tting and intermediate wheelchair user training checklists. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 216 217 Ask participants: What are the steps for wheelchair tting? Acknowledge correct answers. Remind participants that when it comes to the ‘User training’ step they should only teach the wheelchair user the skills that are relevant to them. For example – it is not necessary to teach pressure relief techniques to a wheelchair user who is not at risk of developing a pressure sore. Remind participants that they should actively involve the wheelchair user in every step of the process. Ask: Are there any questions? Answer any questions. Ask each group to prepare the area they are going to work in; then invite the wheelchair user they are working with to begin. Monitor and support: Closely monitor the groups, ensure safe practice, observe and evaluate the skills of the participants. Use the Trainer’s observation checklist to record your observations of each group. Throughout the session: • Give time warnings (verbally and/or write on a whiteboard where all participants can see) to help participants manage their time. • Ensure wheelchair users are actively involved. • Ensure every group member is actively involved. At the end of this session, ask participants to thank the wheelchair user for their participation. Take photographs during the session of wheelchair users who have signed a photo consent forms. Time: Allow 15 minutes for instructions and set-up, 90 minutes to complete tting and 45 minutes to complete the user training. Feedback: See B.15 Putting it all together Notes for trainers: It is important to keep a close eye on the clock during practical sessions. The times given above are a guide – however they could vary depending on the experience of participants, the needs of the wheelchair users, the time required to set up. Trainers may need to make necessary adjustments. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 216 217 B.15: Putting it all together O B JE C T IV E S By the end of this session, participants will be able to: provide a summary of the wheelchair user they have worked with in the previous practical sessions, including: the wheelchair user’s physical, environmental and lifestyle needs; prescription (selection) solutions and the wheelchair user’s tting and provide appropriate user training. R E S O U R C E S For the session: Participant’s Workbook; photographs of wheelchair users (who have signed the photo consent forms) from the practical sessions. T O P R E PA R E Gather resources and read through the session plan. Ensure that wheelchair users’ photographs have been saved onto the training programme’s computer in a le labelled with their name. O U T L IN E 1. Introduction 2. Participants’ preparation 3. Participants’ presentations and discussion 5 30 85 Total session time 120 1. Introduction (5 minutes) Explain: • In this session participants will have an opportunity to: – share with everyone in the whole group what they have learnt through the last three practical sessions; – ask any questions that they still may have about intermediate level wheelchair service delivery; – explain their clinical logic and be challenged by their colleagues. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 218 219 2. Participants’ preparation (30 minutes) Small-group activity Groups: Ask the groups who worked together for the last three practical sessions to work together. Instructions: Ask each group to prepare a 10 minute presentation about the wheelchair user they worked with and what they learnt. Their presentation should include the points in the Participant’s Workbook (B.15: Putting it all together). Explain that pictures of the wheelchair users are on the training programme computer, which they can use to illustrate their story when they present. Notes for trainers: If participants are not con dent using the computer, explain that the trainers will arrange the pictures for them and show them when needed. Monitor: Monitor the groups closely. Ensure that each group understands the activity. Guide participants if necessary. Time: Allow participants 30 minutes for activity. Feedback: See 3. Participant’s presentations and discussions. 3. Participants’ presentations and discussion (85 minutes) Ask each group to present in turn. Encourage the whole group to ask questions at the end of the presentation: • suggest that during the presentations, participants make notes with questions to ask at the end of each presentation; • encourage participants to challenge the decisions and approach used by the presenting team. Ideally, this will generate discussion, debate and deeper analysis by all participants. Allow 10 minutes for each presentation and 5 minutes for questions (depending on the number of groups). At the end of each presentation: • Make some nal comments that include positive points for the presenters. • Thank each group for their presentation. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 218 219 At the end of all presentations: • Remind participants that there is often not just one correct solution. The best solution may sometimes be a compromise – to best meet the overall needs and wishes of the wheelchair user while making the best use of the resources available. Notes for trainers: • Questions are intended to bring out the con dence of the presenter in their decisions, not to imply that they have done something wrong. • Questions and challenges should be delivered in a friendly manner. B.16: Maintenance, repairs and follow up O B JE C T IV E S By the end of this session, participants will be able to: describe what is included in follow up; complete a wheelchair follow up form for a wheelchair user. R E S O U R C E S For the session: PPT Slides: B.16: Maintenance, repairs and follow up; Reference Manual; Participant’s Workbook; wheelchair follow up form. C O N T E X T A N D P R IO R L E A R N IN G Prior learning: The intermediate level wheelchair follow up form is the same as for basic level. Participants who have completed the Wheelchair Service Training Package – Basic Level should already be familiar with this form. Adapt this session to suit the context participants will be working in. Think about: How follow up will be managed in the participants’ services. For example does the service carry out follow up at the wheelchair user’s home; or invite wheelchair users to the wheelchair service centre for follow up; or coordinate with CBR/community-based staff to carry out follow up. Whether the participants come from a wheelchair service, which has a system for follow up. If so explain the system to participants. Explain what their role is in follow up. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 220 221 T O P R E PA R E Gather resources, review PPT slides and read through the session plan. O U T L IN E 1. Introduction 2. Overview of follow up 3. Wheelchair follow up form 4. Practising follow up 5. Key point summary 2 8 10 35 5 Total session time 60 1. Introduction (2 minutes) INTERMEDIATE LE VEL Step 8: Maintenance, repair and follow up B.16. Maintenance, repairs and follow up: 2 • Information about the maintenance, repairs and follow up was covered in the Wheelchair Service Training Package – Basic Level. • In this session participants will: - refresh the information about follow up; - consider the particular importance of follow up for wheelchair users who need additional postural support INTRODUCTIO N Explain: • Maintenance, repairs and follow up is the eighth step in wheelchair service delivery. • Information about the maintenance, repairs and follow up was covered in the Wheelchair Service Training Package – Basic Level. • In this session we will refresh the information about follow up that was covered at the basic level, and consider the particular importance of follow up for wheelchair users who use wheelchairs with additional postural support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 220 221 2. Overview of follow up (8 minutes) INTERMEDIATE LE VEL • All wheelchair users benefit from follow up. • Follow up is particularly important - children; - wheelchair users at risk of developing a pressure sore; - wheelchair users who have a progressive condition; - wheelchair users who need additional postural support in their wheelchair; - wheelchair users who have had difficulty with any of the training or instruction given to them. B.16. Maintenance, repairs and follow up: 3 WHO NEEDS F OLLOW UP Explain: • All wheelchair users bene t from follow up. Follow up is particularly important for: - children; - wheelchair users at risk of developing a pressure sore; - wheelchair users who have a progressive condition; - wheelchair users who need additional postural support in their wheelchair; - wheelchair users who have had dif culty with any of the training or instruction given to them. Most intermediate level wheelchair users need additional postural support – and therefore follow up is particularly important. INTERMEDIATE LE VEL • There is no rule. • How soon follow up happens depends on the needs of the wheelchair user. • Where possible, follow up within six weeks of providing a wheelchair. • Ideally, follow up children every three to six months. B.16. Maintenance, repairs and follow up: 4 HOW SHOULD FOLLOW UP H APPEN? Explain: • There is no rule about when follow up should happen, as the best time to follow up will depend on the needs of the wheelchair user. • However wherever possible, follow up within six weeks of providing a wheelchair can be very useful to ensure that the wheelchair is working well for the wheelchair user and to reinforce any user training. • For children, it is ideal if follow up is every three to six months. This is because the needs of children change quickly as they grow. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 222 223 INTERMEDIATE LE VEL • In the wheelchair user’s home; • At the wheelchair service centre; • At any other location that suits the wheelchair user and the wheelchair service personnel. B.16. Maintenance, repairs and follow up: 5 WHERE SHOUL D FOLLOW UP HAPPEN? • Follow up can be carried out: - in the wheelchair user’s home; or - at the wheelchair service centre; - at any other location that suits the wheelchair user and the wheelchair service personnel. • The location depends on whether the wheelchair user is able to travel to the wheelchair service centre, and whether wheelchair service personnel can travel to the wheelchair user’s home. Ask: How could follow up be managed (or how is it currently managed) in the participants’ wheelchair service centre? (I.e: where does follow up happen, how often is follow up carried out, who is responsible for follow up, and how are follow up appointments arranged?). Encourage answers. Answers: • some participants may say that follow up is not carried out very often at their wheelchair service centre; • wheelchair users may be given a follow up appointment when they receive their wheelchair ; • follow up may be carried out in the wheelchair user’s home or in the wheelchair service centre; • follow up visits may be a part of routine visits to communities by community-based rehabilitation (CBR) personnel who have been trained to carry out follow up; • follow up phone calls may be carried out (for example where transport is dif cult and the wheelchair user has access to a phone); • follow up durations may vary. Notes for trainers: This may be a good time to discuss with participants ideas for how follow up could be improved in their wheelchair service centres. If some good ideas come from the discussion, trainers may feed these back to wheelchair service managers. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 222 223 3. Wheelchair follow up form (10 minutes) INTERMEDIATE LE VEL • Gather information from the wheelchair user; • Check that the wheelchair is in good working order; • Check the fit of the wheelchair. B.16. Maintenance, repairs and follow up: 6 THE PURPOSE OF FOLLOW U P Explain: • The wheelchair follow up form used in the intermediate level is the same as the follow up form used in the Wheelchair Service Training Package – Basic Level. • This means that a wheelchair service may use the same wheelchair follow up form for any wheelchair user. However, the details and follow up actions may be different. • Follow up appointments are an opportunity to: - gather information from the wheelchair user; - check that the wheelchair is in good working order; - check the tting of the wheelchair. • With this information, wheelchair service personnel need to discuss with the wheelchair user any actions required. Ask participants to look at their copy of the wheelchair follow up form. Explain: The wheelchair follow up form will help wheelchair service personnel remember what questions to ask and what to do on a follow up visit. The wheelchair follow up form also has a place to write down any actions that need to be taken. Common follow up actions include: INTERMEDIATE LE VEL • Providing more advice or training; • Re-adjusting the wheelchair; • Carrying out minor repairs; • Referring the wheelchair user to another service for support or assistance, if needed. B.16. Maintenance, repairs and follow up: 7 COMMON FOLL OW UP ACTION S: Providing more advice or training. • For example if a wheelchair user is not using his/her wheelchair as expected, it may be because he/she is not con dent about how he/she can get in and out of the wheelchair when he/she is alone. More training in transfers can help to solve this problem. Re-adjusting the wheelchair. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 224 225 Carrying out minor repairs. • Always encourage wheelchair users and their family members/caregivers to maintain the wheelchair by caring for a wheelchair at home. Wheelchair service personnel can also help the wheelchair user to arrange for repairs if it is not possible to x any broken parts immediately. Referring the wheelchair user to another service for support or assistance, if needed. Ask: If a wheelchair user reports having a pressure sore, what action should be taken? Answers: • ask to see the pressure sore (make sure this is done in a private place); • record the location and level of pressure sore; • if the pressure sore is on any part of the body, which is touching the wheelchair or PSD, the wheelchair user should stop using the wheelchair ; • if the pressure sore is level 2 or higher, seek specialist’s help for treatment. 4. Practising follow up (35 minutes) Small-group activity Groups: Divide participants into groups of 3. Instructions: Ask participants to read each wheelchair user’s story in Participant’s Workbook (B.16: Follow up). For each wheelchair user the participants will need to complete the wheelchair follow up form, discuss and record any actions to be taken. Explain: Participants have 20 minutes as a group to do this activity and then the groups will come back together for feedback. Monitor: Monitor the groups closely. Ensure that each group understands the activity. Guide participants if necessary. Time: Allow 20 minutes for activity. Allow 15 minutes for feedback. Feedback: For each wheelchair user’s story, ask one group to brie y discuss what follow up actions the group recommended for the wheelchair user. Ask participants: Can anyone from the other groups suggest any further actions? Ensure that participants cover all key learning points (please see Notes for trainers below). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 224 225 Notes for trainers: Wheelchair user’s story: Answers and key learning points: Thusitha is seven years old and lives at home with his parents and older sister. He has muscular dystrophy and received a wheelchair through the wheelchair service a year ago. At that time he could walk short distances. He was able to do a standing transfer in and out of the wheelchair on his own. He said he wanted a wheelchair because he is nding it hard to get to school. At the follow up visit, Thusitha said that he is now nding it hard to get in and out of his wheelchair himself. He feels tired and uncomfortable by the afternoon at school. This makes it hard to concentrate. His wheelchair is the correct size and has a medium slung backrest with a simple comfort cushion. When asked to rate how satis ed Thusita is with his wheelchair he says 4 out of 5. • Find out how Thusitha is getting in and out of his wheelchair. • Consider whether a different type of transfer technique would make the transfer easier e.g. sliding board or assisted standing transfer. • Review his PSDs. Consider higher backrest, tension adjustable backrest, cushion with posture control and pressure relief. • Fatigue is more likely with progressive conditions. Consider whether he needs to have a change of posture during the lunch break so that he is more comfortable and able to concentrate at school in the afternoon. • People with progressive conditions require regular follow up, 3–6 months is ideal. They should come back sooner if necessary. Mirella is 23 years old and has polio. She makes honey and sells it in the local market. She received a wheelchair with a clip-on tricycle two years ago. She needed some additional PSDs in the wheelchair. She was prescribed (selected) a layered foam cushion with modi cations. A rear pelvis pad was added to the backrest of the wheelchair. At the follow up visit Mirella says that she uses her wheelchair and tricycle every day to get to and from the market. She reports that she has had to repair two wheel punctures recently. When checking the wheelchair, the wheelchair service personnel notice that the tyres are very worn. The rear pelvis pad has slipped down onto the seat and the cushion looks very at. When asked to rate how satis ed she is with her wheelchair, Mirella says 3 out of 5. • Arrange to replace the tyres. • Give advice on checking the tyres. • Find out why the rear pelvis pad moved. Reposition and x it in place. Check whether it is supporting Mirella correctly. • Give Mirella advice on where the rear pelvis pad should sit and encourage her to check that it is in the correct position. • Take the cover off the cushion and check that the foam layers are in good condition. Check that the foam layers are not compressed ( at). If the foam is at, replace the top with soft foam layer. • Check Mirella is well supported by the wheelchair, including the rear pelvis pad and cushion. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 226 227 Ursula is six years old has cerebral palsy. She likes singing with her sister in the church choir. She received her wheelchair with PSDs eight months ago. She was ill with a chest infection and missed her rst follow up appointment. Her parents say that recently she has not been happy sitting in the wheelchair and asks to get out after an hour. They have noticed a dark mark on her ribs near one of the trunk side pads and wonder whether this could be the problem. The wheelchair service personnel nd a private place and ask Ursula and her parents for permission to check her skin. The wheelchair service personnel con rm that there is a dark mark. They look at the wheelchair and notice that the foam padding on the trunk side pad has compressed. When asked to rate how satis ed they are with Ursula’s wheelchair, her parents say 4 out of 5. • Advise Ursula and her parents that she must avoid pressure on the sore on her ribs until the mark disappears. • Advise Ursula and her parents to reduce the time in the wheelchair and only increase slowly once the mark has disappeared. • Replace the foam on both trunk side pads. Slide ngers between the trunk side pads and Ursula to check for pressure and adjust if necessary. • Children grow quickly and require regular follow up to prevent problems with posture developing, a regular follow up every 3–6 months is ideal. 5. Key point summary (5 minutes) INTERMEDIATE LE VEL • Follow up appointments are an opportunity to: - gather information from the wheelchair user; - check that the wheelchair is in good working order; - check the fitting of the wheelchair. • Follow up can be carried out: - in the wheelchair user’s home; or - at the wheelchair service centre; or - at any other location that suits the wheelchair user and the wheelchair service personnel. • All wheelchair users benefit from follow up. B.16. Maintenance, repairs and follow up: 8 KEY POINT SUM MARY Read the key points. Ask whether there are any questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 226 227 Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training. O B JE C T IV E S By the end of this session, participants will be able to: Demonstrate working in a group to carry out intermediate wheelchair assessment, prescription (selection), product (wheelchair) preparation, tting and user training. R E S O U R C E S Participant’s Workbook; Trainer’s observation checklist: Practical Four; photo consent forms; intermediate wheelchair assessment and wheelchair prescription (selection) forms; poster : Postural Support Device (PSD) Table; poster : Intermediate Wheelchair User Training Checklist; laminated Postural Support Device (PSD) Table – 1 for each participant; laminated intermediate wheelchair tting checklist – 1 for each participant; laminated intermediate wheelchair user training checklist –1 for each participant; clean and private assessment space with assessment bed and privacy screen for each wheelchair user ; blocks of rm foam – a few per whole group; wedges of rm foam – a few per whole group; PSD materials; PSD kit; workbenches and tool kits – 1 for each group; sample wheelchairs and cushions (unless assessment is carried out in the community); digital camera; tape measure or caliper – 1 for each group, set of foot blocks – 1 for each group. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 228 229 C O N T E X T A N D P R IO R L E A R N IN G Adapt this session to suit the context participants will be working in. Think about: cultural factors – for example whether it is appropriate to have mixed-gender groups doing the assessment; when participants are carrying out a tting on wheelchair users – be aware of any cultural issues related to touching; language factors – for example whether wheelchair users attending speak a common language with all participants; any documentation that the host/training organisation may need when assessing or prescribing a wheelchair – for example any additional information that services need to collect about wheelchair users accessing their service (e.g. referral source); how trainers will manage issues that may arise during the tting that cannot be addressed within the session or training programme; how follow up will be managed for each wheelchair user after the training programme. T O P R E PA R E Con rm time and travel arrangements with wheelchair user volunteers. Ensure refreshments are available for wheelchair users and their family member/ caregiver. Assign one person to greet wheelchair users as they arrive and show them where they can wait until the session begins. Prepare an assessment bed with a privacy screen for each group. Place all equipment needed for each assessment on the assessment bed. Ensure sample wheelchairs and cushions are in good working order. If there are more than three groups of participants, ask another trainer to assist with monitoring the groups. Decide which participants will work together and with which wheelchair user. Ask participants ahead of time to wear covered shoes for this practical session. Prepare a work space for each group with a workbench and tool kits, lay out the PSD materials for participants to work ef ciently. Unpack sample PSDs from the PSD kit that have been put together and lay them out on a table (workbench) at the front of the training room where you can easily reach them. Pin up the Postural Support Device (PSD) Table poster. Pin up the Intermediate Wheelchair User Training Checklist poster. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 228 229 O U T L IN E 1. Assessment, prescription (selection), product (wheelchair) preparation, tting and user training: • Instructions and set-up • Assessment • Prescription (selection) • Product (wheelchair) preparation • Fitting • User training 15 45 30 120 45 45 Total session time 300 1. Assessment, prescription (selection), product (wheelchair) preparation, tting and user training practice (300 minutes) Notes for trainers: 1. Photographs: • Ask for signed photo consent form from each wheelchair user to take their photograph. Ensure that wheelchair users understand that their permission is voluntary and that the photographs will be used for further training during this training programme. • Take photographs during the practical of each wheelchair user who has given permission as follows: - in their existing wheelchair (if they have one) (front and side view); - during physical assessment (sitting posture without support); - in the wheelchair prescribed after tting (front and side view). 2. Meeting the needs of the wheelchair users participating in the practical session: • Not all wheelchairs may be completed during the time available in the practical session. • If another appointment is required for any wheelchair users seen during the practical session, the trainer should ensure that an appointment is made by the host/training organization and all assessment, prescription and tting information is handed over. 3. Observing participants’ practice: • Use the Trainer’s observation checklist for Practical Four to ensure that groups perform all the steps in the practical and to note common examples of good practice or practice needing improvement to highlight during the feedback. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 230 231 Small-group activity Groups: • Divide participants into groups of 2–3. • Appoint a leader for each group. • Tell each group the name of the wheelchair user they will be working with. • Assign each group a place to work in. • Explain where to nd materials and tools. • Explain to the participants where they can nd necessary equipment. Instructions: Explain all of the following: Session aim: • The aim of this practical session is to carry out an assessment, prescription (selection), product (wheelchair) preparation, tting and user training. • If it is not possible during this training programme to fully complete the wheelchair user’s wheelchair, arrangements will be made with the wheelchair user to ensure that their wheelchair is completed. Participants should try however to get as much of the work done as possible. Lead person: • The lead person for each group is responsible for making sure that all steps are carried out. • The lead person should be the main person talking with the wheelchair user and their family member/caregiver. This is to avoid having too many people speaking at once, which can be confusing for everyone. Trainer`s observation and support: • Participants should ask for assistance or clari cation at any time. • Throughout the session trainers will monitor each group and give as much support and advice as needed. • After completing EACH WHEELCHAIR SERVICE STEP participants should ask a trainer to come and check BEFORE beginning the next step. Time allowed: • Participants should aim to complete assessment in 45 minutes, prescription (selection) in 30 minutes, product (wheelchair) preparation 120 minutes, tting in 45 minutes and user training in 45 minutes. Remind participants that the wheelchair users will need a break and refreshments while the wheelchair is being prepared. Morning tea/lunch breaks should be taken – trainers will remind everyone when breaks are scheduled. Service forms: • Hand out intermediate wheelchair assessment and wheelchair prescription (selection) forms to each group’s team leader. • Check that each group has at least one copy of the laminated intermediate tting and user training checklists. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 230 231 Ask participants to use the ‘Product (wheelchair) preparation – task checklist’ in their Participant’s Workbook (Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training) to plan the work to be done. Ask participants to use the Intermediate wheelchair user training checklist in their Participant’s Workbook (Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training) to check if the wheelchair is ready to be used for tting. Remind participants that they should actively involve the wheelchair user in every step of the process. Ask: Are there any questions? Answer any questions. Ask each group to prepare the area they are going to work in; then introduce themselves to the wheelchair user they will work with and begin. Monitor and support: Closely monitor the groups, ensure safe practice, observe and evaluate the skills of the participants. Use the Trainer`s observation checklist to record your observations of each group. Throughout the session: • Give time warnings (verbally and/or write on a whiteboard where all participants can see) to help participants manage their time. • Ensure wheelchair users are actively involved. • Ensure every group member is actively involved. At the end of this session, ask participants to thank the wheelchair user for their participation and explain that the wheelchair prescribed will now be prepared for them and will be ready for them to try shortly. Take photographs during the session of wheelchair users who have signed photo consent forms. Time: Allow 15 minutes for instruction and set-up; 45 minutes to complete the assessment; 30 minutes to complete the prescription (selection), 120 minutes for product (wheelchair) preparation; 45 minutes for tting; 45 minutes for user training. Track time using the Trainer’s observation checklist. Notes for trainers: It is important to keep a close eye on the clock during practical sessions. The times given above are a guide – however they could vary depending on the experience of participants, the needs of the wheelchair users, the time required to set up. Trainers may need to make necessary adjustments. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 232 233 B.17: Trainer’s feedback, discussion and closing ceremony O B JE C T IV E S By the end of this session, participants will be able to: re ect on the nal practical working with wheelchair users to assess, prescribe, prepare and t a wheelchair that meets the wheelchair user’s physical, environmental and lifestyle needs and provide appropriate user training. R E S O U R C E S For the session: PPT Slides: B.17: Trainer’s feedback, discussion and closing ceremony; DVD: Take home message; photographs of wheelchair users (who have signed the photo consent forms) from the practical sessions. T O P R E PA R E Gather resources, review PPT slides, watch DVD and read through the session plan. Ensure certi cates have been printed and signed by trainers. Consider inviting representatives from key stakeholders (for example donors, disabled persons organisations, service providers, relevant ministry) to attend the closing ceremony and to present certi cates. Ensure that wheelchair users’ photographs have been saved onto the training programme’s computer in a le labelled with their name. O U T L IN E 1. Introduction 2. Trainer’s feedback. 3. Discussion of the wheelchair users seen during Practical Four. 4. Closing ceremony and presentation of certi cates. 2 20 30 8 Total session time 60 1. Introduction (2 minutes) Explain: • In this session participants will have an opportunity to: – hear about the wheelchair users that other groups worked with during the last practical session, and the wheelchair solutions prescribed, prepared and tted for them; – hear general feedback about the examples of good practice seen by trainers during the last practical and learn from any mistakes that were made; – ask questions. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 232 233 2. Trainer’s feedback (20 minutes) Using the Trainer`s observation checklist for Practical Four, discuss with the group examples of good practice that you saw during the practical session. Note any particular areas that participants could improve – do not highlight individuals. Ask: Are there any questions? 3. Discussion of the wheelchair users seen during Practical Four (30 minutes) Notes for trainers: • Time available for this will vary depending on how many points need to be covered above in Trainer’s Feedback. Adjust the session accordingly, giving priority to ensuring that important feedback is provided. Ask each group to present in turn to: • brie y summarize the mobility and support needs of the wheelchair user they saw during the practical; • describe the solution that they prescribed (selected); • describe how the product (wheelchair) was prepared; • describe the tting process and any concerns that came up; • comment on how the wheelchair user received the wheelchair and what user training was provided. Encourage the whole group to ask questions at the end of the presentation: • suggest that during the presentations, participants make notes with questions to ask at the end of each presentation; • encourage participants to challenge the decisions and approach used by the presenting team. Ideally, this will generate discussion, debate and deeper analysis by all participants. Allow 5 minutes for each group presentation and 5 minutes for questions (depending on the number of groups). Show photographs of each wheelchair user to help the group illustrate their points (if photographs were taken during the practical). WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 234 235 VIDEO At the end of each presentation: • Emphasize examples of good practice used by the group (use Practical Four: Trainer`s observation checklist). • Thank each group for their presentation. At the end of all presentations: • Remind participants again that there is often not only one correct solution. The best solution may sometimes be a compromise – to best meet the overall needs and wishes of the wheelchair user while making the best use of the resources available. Notes for trainers: • Questions are intended to bring out the con dence of each group in their decisions, not to imply that they have done something wrong. • Questions and challenges should be delivered in a friendly manner. 4. Closing ceremony and presentation of certi cates (8 minutes) Introduce DVD: Take home message. Show DVD. Notes for trainers: • Trainer’s may choose how they wish to present certi cates and close the training programme. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 234 235 Annexes Annex 1: Timetable for intermediate wheelchair service training package Five full days Day 1 Day 2 Day 3 Day 4 Day 5 8:30 Introduction B.4 Physical assessment – hand simulation B.10 Prescription (selection) of PSDs – supporting the trunk B.13 Fitting B.16 Maintenance, repairs and follow up 8:45 9:00 9:15 B.11 Prescription (selection) of PSDs – supporting the head, thighs and lower legs 9:30 A.1 Wheelchair users who bene t from additional postural support B.5 Physical assessment – taking measurements B.14 User training Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training 9:45 10:00 10:15 10:30 A.2 Children with disabilities B.6 Selecting wheelchairs and cushions Time available for trainer and participants to check products before wheelchair users arrive. 10:45 11:00 11:00 – 11:15: Morning tea (adjust time to suit local context and session plan) 11:00 – 11:15: Morning tea (adjust time to suit local context and session plan) 11:15 A.2 Children with disabilities B.6 Selecting wheelchairs and cushions 11:15 – 11:30 Morning tea Practical Three: Fitting and user training Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training 11:30 Practical One: Assessment and prescription (selection) 11:45 B.1 Assessment overview and assessment interview B.7 Prescription (selection) of PSDs -introduction 12:00 12:15 B.8 Prescription (selection) of PSDs – stabilizing the pelvis 12:30 12:45 WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 236 237 1:00 – 2:00 Lunch (adjust time to suit local context and to t with session plan) 2:00 B.1 Assessment overview and assessment interview B.8 Prescription (selection) of PSDs – stabilizing the pelvis Practical One: Assessment and prescription (selection) Practical Three: Fitting and user training Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training 2:15 B.2 Physical assessment – sitting posture without support 2:30 B.12 Product (wheelchair) preparation 2:45 B.9 Prescription (selection) of PSDs – supporting the hips B.15 Putting it all together3:00 3:15 3:15 – 3:30: Afternoon tea (adjust time to suit local context and session plan) 3:15 – 3:30: Afternoon tea (adjust time to suit local context and session plan) 3:30 B.2 Physical assessment – sitting posture without support B.9 Prescription (selection) of PSDs – supporting the hips 3:30 – 3:45 Afternoon tea B.15 Putting it all together Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, tting and user training 3:45 B.10 Prescription (selection) of PSDs – supporting the trunk Practical Two: Product (wheelchair) preparation 4:00 B.3 Physical assessment – pelvis and hip posture screen B.17 Trainer’s feedback, discussion and closing ceremony 4:15 4:30 4:45 5:00 5:15 5:30 5:45 6:00 *Trainers/training institutes could alter the schedule, if needed. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 236 237 Annex 2: Intermediate Wheelchair Referral Form Sample referral form: This form can be adapted by wheelchair services and provided to referral sources to help them refer wheelchair users to the wheelchair service. Please complete referral form and post to: Wheelchair Service Name and Address: Name of referral person: Organization you work for : Referral person contact details (the best way to contact you): Wheelchair user’s name: Date of Birth: Parent/caregiver’s name: Address: How can the wheelchair user be contacted? Post Own Telephone Friend/neighbour’s telephone If by telephone, what is their phone number: Wheelchair user’s disability if known: Reason for referral: • Has no wheelchair • Has a broken wheelchair • Has a wheelchair that does not meet his/her needs • For children: - unable to sit upright or not pulling up to stand by the age of one; - not able to walk by age of two. Please add any other information about the wheelchair user that you think it is important that the wheelchair service knows: Has the wheelchair user agreed to being referred to the wheelchair service? Yes No Signature of referring person: Date: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 238 239 Annex 3: Intermediate Wheelchair Assessment Form This form is for assessment of wheelchair users who cannot sit upright comfortably without support. Wheelchair users who can sit upright easily can be assessed by a person with basic level training. Keep this form in the wheelchair user’s le. Assessor’s name: Date of assessment 1: Assessment Interview Information about the wheelchair user Name: Number: Age: Male Female Phone no.: Address: Goals: Physical Diagnosis: Brain Injury Cerebral Palsy Muscular Dystrophy Polio Spina Bi da Spinal Cord Injury Stroke Unknown Other ______________________________ Is the condition likely to become worse? Yes No Physical issues: Frail Spasms/uncontrolled movements Muscle tone (high/low) Lower limb amputation: R above knee R below knee L above knee L below knee Fatigue Hip dislocation Epilepsy Problems with eating, drinking and swallowing Describe: _______________ Pain Describe location: _________________________________________ Bladder problems Bowel problems If the wheelchair user has bladder or bowel problems, is this managed? Yes No WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 238 239 Lifestyle and environment Describe where the wheelchair user will use their wheelchair: ______________ _____________________________________________________________ Distance travelled per day: Up to 1 km 1–5 km More than 5 km Hours per day using wheelchair: Less than 1 1–3 3–5 5–8 more than 8 When out of the wheelchair, where does the wheelchair user sit or lie down and how (posture and surface)? ________________________________________ Transfer: Independent Assisted Standing Non-standing Lifted Other Type of toilet (if transferring to a toilet): Squat Western Adapted Does the wheelchair user often use public/private transport? Yes No If yes, then what kind: Car Taxi Bus Other _____________________ Existing wheelchair (if a person already has a wheelchair) Does the wheelchair meet the user’s needs? Yes No Does the wheelchair meet the user’s environmental conditions? Yes No Does the wheelchair provide proper t and postural support? Yes No Is the wheelchair safe and durable? (Consider whether there is a cushion) Yes No Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes No Comments: ____________________________________________________ If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repairs or modi cations. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 240 241 2: Physical Assessment Presence, risk of or history of pressure sores /// = does not feel O = previous pressure sore = existing pressure sore Can feel normally? Yes No Previous pressure sore? Yes No Current pressure sore? Yes No If yes, is it an open sore (stage 1–4)? Yes No Duration and cause: _______________________ ________________________________________ ________________________________________ Is this person at risk* of a pressure sore? *A person who cannot feel or has 3 or more risk factors is at risk. Risk factors: cannot move, moisture, poor posture, previous / current pressure sore, poor diet, ageing, under or over weight. Yes No Method of pushing How will the wheelchair user push their wheelchair? Both arms Left arm Right arm Both legs Left leg Right leg Pushed by a helper Comment: _____________________________________________________ Sitting posture without support Pelvis and hip posture screen Describe or draw sitting posture without support: Check if pelvis is level and hip exion range when lying Can pelvis be level? Yes No Can hip bend to neutral sitting posture? Right hip: Yes No Angle: ________ Left hip: Yes No Angle: _________ If pelvis cannot be level or hips cannot bend to neutral sitting posture – accommodate with temporary support. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 240 241 Hand simulation: support needed to sit in neutral posture / as close to neutral posture as is comfortable For each body part: If neutral sitting posture is possible with hand support, tick yes. If not, tick no. Part Yes No Describe or line draw nal sitting posture achieved by the wheelchair user with hand support and describe or line draw the support provided to achieve that sitting posture. Pelvis Trunk Head L Hip R Hip Thighs L Knee R Knee L Ankle R Ankle WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 242 243 Taking measurements Body measurements (mm) Wheelchair component measurements (mm) Seat width, depth and footrest height A Hip width = seat width OR 1 = distance between pelvis side pads 2 B Seat depth (back of pelvis to back of the knee) L B less 30–50 mm = seat depth (if length is different, use shorter) 3R C Calf length L = distance between top of the seat to footrest OR = distance between top of the seat to oor for foot propelling 4 R 5 Backrest height D Seat* to bottom of rib cage = distance between top of the seat to top of backrest (measure D, E or F – depending on the wheelchair user’s need) 6 E Seat* to bottom of shoulder blade F Seat* to top of shoulder Modi cations and/or PSDs G Trunk width = distance between trunk side pads/ wedges 7 H Seat* to axilla (armpit) L H less 30 mm = maximum distance between the top of the seat and the top of trunk side pads/wedges (adjust according to hand simulation) 8 R I Seat* to top of the pelvis (PSIS) = distance between the top of the seat and mid-height of rear pelvis pad 9 J Distance between knees = width of knee separator pad 10 K Seat* to base of skull = distance between the top of seat to middle of headrest 11 L Back of pelvis to seat bones L plus 20–40 mm = distance from the backrest support to the beginning of the pre seat bone shelf. 12 O th er *When taking body measurements, the ‘seat’ is the surface on which the seat bones are sitting. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 242 243 Annex 4: Intermediate Wheelchair Prescription (Selection) Form This form is for recording the choice of wheelchair, cushion and PSDs for a wheelchair user who cannot sit upright comfortably without support. Keep this form in the wheelchair user’s le. 1. Wheelchair user information Wheelchair user’s name: Number: Date of assessment: Date of tting: Assessor’s name: 2. Wheelchair type, size and set-up Type of wheelchair (list available wheelchairs below) Wheelchair dimensions (mm) Seat width Seat depth Backrest height Footrest height Wheelchair set-up Rear wheel position Other: Tilt 3. Cushion type and size Type of cushion Size E.g. pressure relief cushion 4. PSDs or modi cations required PSD checklist Describe / draw and provide dimensions Se at / cu sh io n Add solid seat Pre seat bone shelf (= 3 less 12) Lower seat front L R Raise seat front Wedge for anterior tilt Build-up under pelvis L R Pelvis side pads (= 2) L R Outside thigh wedges L R Outside thigh pads L R Inside thigh wedge (= 10) Knee separator pad (= 10) Other Other WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 244 245 PSD checklist Describe / draw and provide dimensions Se at a nd ba ck re st Open seat to backrest angle Seat and backrest tilt (tilt in space) Ba ck re st Add solid backrest Rear pelvis pad (= 9) Adjust backrest shape Tension adjustable backrest Backrest recline Trunk side pads (= 7) L R Trunk side wedges(= 7) L R Other Tr ay / ar m re st s Tray Modify armrests L R Other H ea d su pp or ts Flat headrest (= 11) Shaped headrest (= 11) Other Lo w er le g su pp or ts Footrest build-ups L R Footrest wedges L R Lower leg supports L R Other St ra ps Pelvis strap Calf strap Foot straps L R Shoulder harness Other 5. Agreement signatures Wheelchair user : Assessor: Wheelchair service manager: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 244 245 Annex 5: Intermediate Wheelchair Summary Form Name of wheelchair : Insert picture here: Manufacturer/ supplier : Sizes available: Overall weight: Description: Frame: Fixed/rigid Folding Frame length: Backrest: Slung/canvas Solid Tension Adjustable Seat: Slung/canvas Solid Tension Adjustable Cushion: No cushion Flat foam Foam contoured Fluid Other Footrests: Fixed Removable/ swing away Other: Castor wheels: Pneumatic Diameter: Solid Width: Rear wheels: Pneumatic Diameter: Push rims Solid Width: Adjustable axle Solid inner tube Removable Brakes: Short lever Long lever Other: Armrest: Curved Square Other: Fixed Removable Other: Push handles: Push handles PSDs: Pelvis strap Calf strap Shoulder harness Foot straps Anti-tip bars Trunk side pads Tray Headrest Pelvis side pads Other: Measurements, adjustment options and range of adjustment: Measurements (if the wheelchair is available in different sizes list all sizes) Is this adjustable? Range of adjustment (adjustment range that is possible for this chair)Yes No Seat width Seat depth Seat height WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 246 247 Backrest height Backrest recline Footrest height Footrest angle Push handles height Frame length Wheel base length Backrest to seat angle Tilt in space Annex 6: Intermediate Wheelchair Safe and Ready Checklist Whole wheelchair including PSDs There are no sharp edges PSDs are well padded and tightly xed No parts are damaged or scratched The wheelchair travels in a straight line Front castor wheels Spin freely Spin without touching the fork Bolts are tight Front castor barrels Castor fork spins freely Rear wheels Spin freely Axle bolts are tight Tyres in ated correctly (with thumb pressure, wheel can be depressed less than 5 mm) Push rims are secure Brakes Function properly WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 246 247 Footrests Footrests are securely attached Frame For a cross-folding wheelchair – the wheelchair folds and unfolds easily For a wheelchair with fold-down backrest – the backrest folds and unfolds easily Cushion The cushion is in the cover correctly The cushion is sitting on the wheelchair correctly The cushion cover fabric is tight but not too tight If the wheelchair has a solid seat: the cushion fully covers the solid seat Annex 7: Intermediate Wheelchair Fitting Checklist 1. Is the wheelchair ready? Has the wheelchair been checked to make sure it is safe and ready to use and all parts are working? 2. Check wheelchair and PSDs t Wheelchair width: • hips t comfortably between armrests or pelvis side pads; • trunk ts comfortably between the wheelchair frame backrest tubes or trunk side pads; • thighs t comfortably between the armrests, mud/skirt guards or pelvis side pads and are not pushed together. Seat depth: • 30 mm gap between the back of each knee and the seat/ cushion. Pelvis: • pre seat bone shelf sits just in front of the seat bones; • rear pelvis pad provides support at the PSIS; • pelvis side pads t snugly and are not located over the hip joint; • pelvis strap can be tightened rmly and does not pinch skin. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 248 249 Trunk: • trunk side pads do not place any pressure into the armpits. There should be at least 30 mm between armpit and top of trunk side pad; • shoulder harness done up comfortably and does not pinch skin; • tray supports the length of the forearms and elbows and does not push on stomach; • check backrest height and tilt. Headrest: • the headrest should usually support the wheelchair user’s head at the base of the skull; • supports the head in a balanced and upright posture. Thighs: • there is no high pressure on caused by the outside thigh pads or knee separator pad; • knee separator pad 40–60 mm away from the groin area for children and 60–100mm for adults. Footrest height: • thighs are fully supported on the cushion with no gaps. Feet are fully supported on the footrests with no gaps; • foot straps can be done up rmly without pinching; • calf strap and behind the heel foot straps supporting calf and feet. 3. Check posture Check from the front and side to see whether the wheelchair user is sitting as close to neutral sitting posture as is comfortable for them: • Is their pelvis upright and level (or as close to this as is comfortable for the user) • Is the trunk upright and symmetrical (or as close to this as is comfortable for the user) • Is the head balanced and upright (as much as possible) • Are legs and feet supported as close to neutral as possible. Check that all PSDs are providing support as intended. In particular check (if provided): • Backrest height, recline and contours • Tilt in space • Pelvis side pads and trunk side pads • Outside and inside thigh wedges, outside thigh pads and lower leg supports Check posture again after 15 minutes to see if there has been any change WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 248 249 4. Check pressure Check pressure under both seat bones. Is the pressure safe on both sides? Level 1 = safe: Fingertips can wriggle up and down 5 mm or more. Level 2 = warning: Fingertips cannot wriggle, but can easily slide out. Level 3 = unsafe: Fingertips are squeezed rmly. It is dif cult to slide ngers out. Place your nger between the wheelchair user’s body and each postural support including pads and straps. Does the postural support make even contact with the body? Is the pressure safe? If the wheelchair user has any particularly bony prominences, bulges or bumps – check there is no pressure on these areas. 5. Check t while the wheelchair is moving Does the backrest allow the wheelchair user freedom to move their shoulders to push? Does movement of the wheelchair or the action of pushing cause the wheelchair user to change their posture or feel uncomfortable or unstable in any way? Hand propelling: Is the rear wheel position correct for the wheelchair user to push as well as he/she can? Foot propelling: Is the seat height and depth correct for the user to push with their leg/s? Do the posture supports allow for unrestricted and safe wheelchair mobility? 6. Decide if any further action is required Is there any further action necessary? Write any actions in the wheelchair user’s le. Annex 8: Intermediate Wheelchair User Training Checklist Skills to Teach Skills Taught Comments Wheelchair handling Folding and lifting the wheelchair Taking off and putting back on any PSDs that need to come off for transport Using quick release wheels WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 250 251 Using the brakes Tilting and anti-tip bars (if used) Correct position of PSDs when the wheelchair user is in the wheelchair Using the cushion including positioning correctly Transfers Independent transfer Assisted transfer Other Wheelchair use and mobility Pushing correctly (using the wheelchair user’s preferred method) Up and down a slope Up and down a step On rough ground Partial wheelie How long to sit in the wheelchair (for children and adults with additional postural support needs) Assisted pushing Preventing pressure sores Check areas of high pressure for pressure sores Pressure relief lifts Eat well and drink lots of water What to do if a pressure sore develops How to care for a wheelchair at home Clean the wheelchair ; wash and dry the cushion and cushion cover Oil moving parts Pump the tyres Tighten nuts and bolts WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 250 251 Tighten spokes Check upholstery Check for rust Check the cushion What to do if there is a problem Wheelchair needs repairs The wheelchair does not t or is not comfortable Annex 9: Wheelchair Follow Up Form This form is for recording information about the wheelchair user from a follow up visit. Keep this form in the wheelchair user’s le. 1. Wheelchair user information Wheelchair user name: Number: Date of tting: Date of follow up: Name of person carrying out follow up: Follow up carried out at: Wheelchair user’s home Wheelchair service centre Other: ___________________________________________ 2. Interview Record action to be taken: Are you using your wheelchair as much as you would like? Yes No If no – why not? Do you have any problems using your wheelchair? Yes No If yes – what are the problems? Do you have any questions about using your wheelchair? Yes No If yes – what questions. Is further training needed? Does the wheelchair user have any pressure sores? Yes No Describe (location and level) How would you rate your satisfaction with your wheelchair from 1–5? (1 is not satis ed and 5 is very satis ed) Rate: Comment: WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 252 253 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes No Is the cushion in good working order and safe to use? Yes No If no for either, what is the problem? 4. Fitting check Does the wheelchair t correctly? Yes No If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes No If no – what is the problem? Annex 10: Postural Support Device (PSD) Table Seat / cushion pre seat bone shelf lower seat front (one side) raised seat front wedge for anterior tilt build-up under pelvis pelvis side pads Seat / cushion Seat & backrest outside thigh wedges outside thigh pads inside thigh wedge knee separator pad open seat to backrest angle seat & backrest tilt (tilt in space) WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL 252 253 Backrest rear pelvis pad adjust backrest shape tension adjustable backrest backrest recline trunk side pads trunk side wedges Tray Head supports Lower leg supports Tray at headrest shaped headrest footrest build-ups footrest wedges lower leg supports Straps pelvis strap anterior tilt four-point strap calf strap foot straps shoulder harness Annex 11: Wedges of rm foam Wedges made from rm foam can be used as temporary supports. The wedges of rm foam may be used alone, or stacked together to make a more acute angle. The dimensions shown below are 30 mm x 150 mm x 200 mm. Slightly smaller and slightly larger wedges would also be useful. WHEELCHAIR SERVICE TRAINING PACKAG E INTERMEDIATE LEVEL A nn ex 1 2: W he el ch ai r us er s lis t fo r pr ac ti ca l s es si on s U se th is ch ec kl ist to o rg an iz e an d sc he du le w he el ch ai r us er v ol un te er s fo r ea ch o f t he p ra ct ica l s es sio ns . R em em be r – w he el ch ai r us er s sh ou ld a lw ay s pa rt ici pa te w illi ng ly. W he re ve r po ss ib le th ei r tim e sh ou ld b e re w ar de d. U se th e ch ec kl ist in th e Tr ai ne r’s M an ua l t o he lp id en tif y w he el ch ai r us er s. P ra ct ic al se ss io n D at e an d ti m e W he el ch ai r us er ’s na m e G en de r A ge D is ab ili ty /m ob ili ty a nd po st ur al s up po rt n ee ds . In vi te d A cc ep te d Tr an sp or t ar ra ng ed M al e Fe m al e Pr ac tic al O ne Pr ac tic al Tw o Pr ac tic al Th re e Pr ac tic al Fo ur W H E E L C H A IR S E R V IC E T R A IN IN G P A C K A G E IN T ER M ED IA T E LE V EL For more information, contact. For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ ISBN 978 92 4 150576 5 Trainer’s Manual INTERMEDIATE LEVEL WHEELCHAIR SERVICE TRAINING PA CKAGE W heelchair S ervice Training P ackage Trainer’s M anual Interm ediate Level F more informati , contact. For more informati , ontact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/d sabilities/en/ ISBN 978 92 4 150576 5 Trainer’s Manual INTERMEDIAT L VEL HEELCHAIR SERVICE TRAINING PA CKAGE W heelchair S ervice Training P ackage Trainer’s M anual Interm ediate Level
SERVICII PENTRU UTILIZATORII DE SCAUN RULANT MANUALUL PARTICIPANTULU I PACHET DE INSTRUIRE - NIVEL INTERMEDIAR
SERVICII PENTRU UTILIZATORII DE SCAUN RULANT MANUALUL PARTICIPANTULU I PACHET DE INSTRUIRE - NIVEL INTERMEDIAR Publicat de Organizația Mondială a Sănătății în 2013, cu titlul Wheelchair Service Training Package: intermediate level. Reference Manual ©World Health Organization 2013 Directorul General al Organizației Mondiale a Sănătății a acordat dreptul de a traduce și de a publica ediția în limba română Fundației Motivation România, care este singura responsabilă pentru ediția în limba română. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului 1. Scaune rulante – standarde. 2. Persoane cu dizabilități – reabilitare. 3. Material pedagogic. I. Khasnabis, Chapal. II. Mines, Kylie. III. Organizația Mondială a Sănătății. Editori: Chapal Khasnabis și Kylie Mines Autori: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler și Rebecca Jackson Stoeckle Revizuit de: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri; Ritu; Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan și Diane E. Ward. Ilustrații: Melissa Puust Foto: David Constantine, Jesse Moss și Chapal Khasnabis Video: Chapal Khasnabis, Amanda McBaine și Jesse Moss Formatori: Andrew Congdon, Mirela Creangă, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Răducan (Niță), Andrew Rose Realizat cu sprijinul financiar al Agenției Statelor Unite pentru Dezvoltare Internațională și al Agenției Australiene pentru Dezvoltare Internațională. Organizații partenere: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania și Tanzania Training Centre for Orthopaedic Technologists (TATCOT) ©Fundația Motivation România, 2014 Această publicație a fost produsă cu sprijinul generos al poporului american, prin Agenția Statelor Unite pentru Dezvoltare Internațională (USAID). Conținutul este responsabilitatea Fundației Motivation România și nu reflectă în mod necesar punctul de vedere al USAID sau al Guvernului Statelor Unite. Descrierea CIP a Bibliotecii Naţionale a României Servicii pentru utilizatorii de scaun rulant : pachet de instruire – nivel intermediar / Sarah Frost, Kylie Mines, Jamie Noon, ... ; ed.: Chapal Khasnabis, Kylie Mines. – Bucureşti : Contaplus, 2014 ISBN 978-606-93630-1-0 I. Frost, Sarah II. Mines, Kylie III. Noon, Jamie IV. Khasnabis, Chapal (ed.) V. Mines, Kylie (ed.) 615.478.3 Terminologie În cadrul acestui document, următorii termeni sunt folosiți conform definițiilor din rândurile de mai jos. Scaun rulant corespunzător Este scaunul rulant care corespunde condițiilor de mediu ale utilizatorului; este potrivit și furnizează suport postural adecvat; este sigur și durabil; este disponibil în țara utilizatorului; poate fi obținut și întreținut, iar serviciile sunt sustenabile în țara respectivă, la cel mai accesibil preț. Scaun rulant cu antrenare manuală Este scaunul rulant antrenat de către utilizator prin propulsie sau de către o altă persoană, prin împingere. Dispozitive de suport postural (DSP); Un dispozitiv fizic care oferă suport postural suplimentar - un element esențial al furnizării de servicii de scaune rulante de nivel intermediar. Scaun rulant Este un dispozitiv cu roți, care oferă mobilitate și suport postural, utilizat de persoane care întâmpină dificultăți în ceea ce privește deplasarea. Modificare scaun rulant O modificare făcută unui scaun rulant. Furnizare de scaune rulante Este termenul generic pentru proiectarea, producția, furnizarea de scaune rulante și servicii de scaune rulante. Servicii de scaune rulante Sunt acea parte a procesului de furnizare a scaunelor rulante care se preocupă de dotarea utilizatorului cu un scaun rulant corespunzător. Personalul furnizor de servicii de scaune rulante Este personalul care are abilitățile necesare furnizării de scaune rulante corespunzătoare. Utilizator de scaun rulant Este persoana care întâmpină dificultăți în ceea ce privește deplasarea și utilizează un scaun rulant pentru mobilitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 4 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Terminologie ....................................................................................................................................................3 Prefață .............................................................................................................................................................5 Despre Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar ..................6 A: Noțiunile fundamentale ...............................................................................................................................10 A.1: Utilizatorii de scaun rulant care au nevoie de suport postural suplimentar .......................................11 A.2: Copiii cu dizabilități ...........................................................................................................................17 B. Etapele furnizării serviciilor de scaune rulante. ...........................................................................................24 Etapa 1: Trimiterea și programarea ..........................................................................................................25 Etapa 2: Evaluarea ...................................................................................................................................25 Rezumatul evaluării și interviul de evaluare .......................................................................................25 Evaluarea fizică – postura în poziția așezat fără suport .....................................................................51 Evaluarea fizică – analiza posturii bazinului și a șoldului ...................................................................57 Evaluarea fizică – procedeul de simulare manuală ............................................................................62 Evaluarea fizică - efectuarea măsurătorilor ........................................................................................68 Măsurarea utilizatorului de scaun rulant în vederea alegerii dimensiunii corecte a scaunului rulant și a poziției dispozitivelor de suport postural. .......................................................68 Etapa 3: Prescrierea (selecția) .................................................................................................................77 Selecția scaunului rulant și a pernei ...................................................................................................77 Prescrierea (selecția) dispozitivelor de suport postural - introducere ................................................88 Prescrierea (selecția) dispozitivelor de suport postural pentru stabilizarea bazinului ........................109 Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea șoldurilor ..........................114 Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea trunchiului .........................117 Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea capului, coapselor și a gambelor .....................................................................................................................121 Etapa 4: Finanțarea și plasarea comenzii ................................................................................................127 Etapa 5: Pregătirea produsului (a scaunului rulant) .................................................................................127 Pregătirea produsului (a scaunului rulant) .........................................................................................127 Planificarea și efectuarea pregătirii scaunului rulant și a dispozitivelor de suport postural ................128 Aspecte de reținut în procesul de confecționare a dispozitivelor de suport postural .........................129 Materialele și instrumentele necesare confecționării dispozitivelor de suport postural și efectuării modificărilor ........................................................................................................................................130 Cum se confecționează dispozitivele de suport postural? .................................................................134 Listă de verificare preliminară utilizării scaunului rulant – nivel intermediar .......................................153 Etapa 6: Probarea produsului (a scaunului rulant) ...................................................................................154 Etapa 7: Instruirea utilizatorului de scaun rulant ......................................................................................166 Care sunt abilitățile de care au nevoie utilizatorii de scaune rulante? ...............................................166 Etapa 8: Întreținerea, reparațiile și monitorizarea .....................................................................................172 Monitorizarea .....................................................................................................................................172 Activități de monitorizare uzuale ........................................................................................................173 Note ..........................................................................................................................................................177 CUPRINS Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 5 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Prefață Scaunul rulant este unul dintre echipamentele asistive cele mai frecvent utilizate pentru îmbunătăţirea mobilităţii personale, aceasta fiind o precondiţie a realizării drepturilor omului şi demnităţii individuale, permiţând persoanelor cu dizabilităţi să devină membri activi ai comunităţii în care trăiesc. În cazul multor persoane, un scaun rulant corespunzător, proiectat şi ajustat pentru a răspunde nevoilor individuale, reprezintă primul pas spre incluziune şi participare socială. Regulile Standard ale Organizaţiei Naţiunilor Unite privind Egalizarea Şanselor pentru Persoanele cu Dizabilități, Convenţia ONU privind Drepturile Persoanelor cu Dizabilităţi şi Rezoluţia Adunării Mondiale a Sănătăţii WHA58.23, care abordează problema dizabilității inclusiv în termeni de prevenție, management și reabilitare, toate subliniază importanţa scaunelor rulante şi a altor echipamente asistive. Pentru a asigura accesul persoanelor cu dizabilități la un scaun rulant corespunzător, în special în zonele lumii unde resursele sunt limitate, OMS a elaborat Ghidul privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, în parteneriat cu Agenția Statelor Unite pentru Dezvoltare Internațională (USAID) și Societatea Internațională pentru Ortezare și Protezare (ISPO). În vederea unei instruiri corespunzătoare a resurselor umane și pentru facilitarea creării unui sistem de furnizare de scaune rulante bazat pe principiile ghidului, OMS a dezvoltat o serie de module de instruire pentru furnizarea serviciilor destinate utilizatorilor de scaun rulant. Acestea se adresează personalului din domeniul sănătății și reabilitării, care lucrează la diverse niveluri și care este responsabil pentru diferitele niveluri de intervenție, așa cum se specifică în ghid. După lansarea cu succes a modulului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază în iunie 2012, suntem bucuroși să putem oferi noul material, numit Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. În plus față de dezvoltarea abilităților și aprofundarea cunoștințelor acumulate prin parcurgerea modulului de bază, Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar pune accent pe cazurile de utilizatori de scaun rulant copii, deoarece există un număr mare de copii care, din cauza specificului celor mai frecvente probleme de dezvoltare, au nevoie de un scaun rulant, atât pentru mobilitate, cât și pentru suport postural. Alana Officer Coordonator Departament Dizabilitate și Reabilitare Departamentul pentru Prevenirea Violenței, Leziunilor și a Dizabilității Organizația Mondială a Sănătății Robert Horvath Manager Programe pentru Grupurile Vulnerabile Centrul de Excelență pentru Democrație, Drepturile Omului și Guvernare Agenția Statelor Unite pentru Dezvoltare Internațională Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 6 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Despre Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar Introducere În urma publicării în anul 2008 a Ghidului privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate(1) și în 2012 a modulului Servicii pentru utilizatorii de scaune rulante. Pachet de instruire - nivel de bază, Organizația Mondială a Sănătății (OMS), în parteneriat cu Agenția Statelor Unite pentru Dezvoltare Internațională (USAID), a dezvoltat un nou modul destinat instruirii, numit Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Nivelul intermediar este cea de-a doua parte a seriei OMS dedicată furnizării de servicii către utilizatorii de scaun rulant și pune accentul pe nevoile persoanelor cu dificultăți severe de deplasare și mobilitate, care au un control redus asupra trunchiului. Pe parcursul procesului de realizare al acestui pachet de instruire, am abordat cu multă atenție aspectele legate de furnizarea unui scaun rulant corespunzător acelor copii care au un grad de control redus al trunchiului și care nu pot menține fără sprijin poziția așezat. Scaunul rulant este unul dintre cele mai frecvent utilizate echipamente asistive pentru îmbunătățirea mobilității personale. Pentru persoanele care întâmpină dificultăți de deplasare, un scaun rulant care corespunde nevoilor lor fizice, stilului de viață și mediului în care trăiesc este un instrument esențial, ajutându-i să se bucure de o ameliorare semnificativă a stării de sănătate, precum și de bunăstare socială și economică. Mobilitatea oferă utilizatorilor de scaun rulant oportunitatea de a studia, de a lucra, de a lua parte la activități culturale și de a accesa servicii, cum ar fi cele de sănătate. Importanța mobilității este reflectată și în Convenția Organizației Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități (CONUDPD), care pledează în favoarea unor „măsuri eficiente pentru asigurarea mobilității persoanelor cu dizabilități, în cel mai înalt grad de independență posibil”. Pentru a asigura o bună mobilitate personală, utilizatorul are nevoie de un scaun rulant care este pe măsura sa și care este în concordanță cu cerințele sale specifice. Acest lucru presupune o abordare care să răspundă nevoilor individuale ale utilizatorilor. O metodă eficientă pentru a răspunde acestor nevoi individuale ale utilizatorilor este furnizarea de scaune rulante prin intermediul serviciilor de scaune rulante. Cu toate acestea, statisticile arată că mai puțin de 5% dintre cei care au într-adevăr nevoie de acest tip de asistență beneficiază de acces la un scaun rulant adecvat. În plus, personalul implicat în furnizarea serviciilor de scaune rulante, are oportunități reduse pentru dobândirea abilităților necesare unei prescrieri corecte a scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar are ca scop sprijinirea instruirii de nivel intermediar a personalului cu atribuții clinice și tehnice în cadrul procesului de furnizare a serviciilor de scaune rulante (vezi Ghidul privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, Figura 4.2). Modulul de instruire susține transmiterea cunoștințelor teoretice și practice necesare pentru începerea lucrului cu acei utilizatori de scaun rulant care au nevoie de suport postural suplimentar pentru a menține poziția așezat. Acesta include: modalitatea de evaluare a nevoilor individuale și de asistare în selecția și pregătirea scaunului rulant adecvat, dotat cu dispozitive de suport postural, componenta de instruire a utilizatorilor și însoțitorilor în ceea ce privește folosirea și întreținerea scaunului rulant, precum și monitorizarea. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 7 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Durata instruirii poate fi de 35-40 de ore, deși aceasta poate fi redusă sau extinsă, în funcție de nevoile specifice și de resursele disponibile în fiecare caz. Se recomandă exercițiul practic cu un îndrumător/ instructor, pentru dezvoltarea competențelor și pentru creșterea capacității de a lucra independent. OMS speră ca acest modul să fie livrat ca un curs de instruire de sine stătător, de scurtă durată, pentru personalul care lucrează deja în domeniu și, în egală măsură, să fie integrat în programa de instruire pentru personalul din domeniul reabilitării. Grupul țintă Acest pachet de instruire este destinat personalului și voluntarilor care au ca atribuții la locul de muncă furnizarea de servicii de scaune rulante la nivel intermediar. Aici poate fi inclus personalul din domeniul sănătății, reabilitării sau personalul tehnic, cum ar fi terapeuții ocupaționali, fizioterapeuții, tehnicienii de protetică și ortetică, personalul medical din comunități sau cel implicat în reabilitarea bazată pe comunitate (RBC). Scopul Modulul intermediar al pachetului de instruire a fost elaborat pentru a sprijini instruirea personalului sau a voluntarilor implicați în furnizarea de scaune rulante cu antrenare manuală corespunzătoare, precum și a pernelor adecvate, acelor copii și adulți care au nevoie de suport postural suplimentar pentru menținerea poziției așezat. Obiectivul principal al acestui pachet de instruire este dezvoltarea abilităților și cunoștințelor personalului furnizor de servicii pentru utilizatorii de scaun rulant. Transmiterea cunoștințelor cuprinse în acest modul de instruire va contribui la: • creșterea numărului de utilizatori care primesc un scaun rulant ce corespunde nevoilor individuale; • creșterea numărului de persoane instruite în ceea ce privește furnizarea de servicii de scaune rulante la nivel intermediar; • îmbunătățirea competențelor personalului furnizor de servicii de scaune rulante; • creșterea calității serviciilor de scaune rulante destinate acelor persoane în cazul cărora este necesară intervenția la un nivel care îl depășește pe cel al serviciilor de scaune rulante de bază; • includerea acestui pachet de instruire în programele de instruire paramedicale/de reabilitare tipice • integrarea într-un grad mai ridicat a furnizării serviciilor pentru utilizatorii de scaun rulant în aria serviciilor de reabilitare. Conținutul Pachetul de instruire include: • modalitatea de evaluare a mobilității și a nevoii de suport postural a copiilor și adulților care necesită un scaun rulant cu suport postural suplimentar; • modalitatea de a lucra cu aceștia în vederea identificării celor mai bune soluții de mobilitate; • cunoștințe și sugestii practice pentru furnizarea unui scaun rulant cu antrenare manuală, dotat cu o pernă corespunzătoare și cu suport postural suplimentar; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 8 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar • instruirea utilizatorilor de scaun rulant și, dacă este cazul, a familiei/însoțitorilor, pentru o cât mai bună utilizare a scaunului rulant; • monitorizarea utilizatorilor pentru a ne asigura că scaunul rulant corespunde în continuare nevoilor acestora. Cunoștințele și abilitățile necesare Pentru ca participanții să poate beneficia într-o cât mai mare măsură de parcurgerea modulului de instruire de nivel intermediar, este esențială experiența anterioară în furnizarea serviciilor pentru utilizatorii de scaune rulante. Programul de nivel intermediar a fost creat pornind de la ideea că participanții sunt capabili să demonstreze că și-au dezvoltat acele competențe care au fost predate în modulul de instruire anterior și că au experiență practică în furnizarea de servicii de scaune rulante la nivel de bază. Structura Servicii pentru utilizatorii de scaun rulant. Pachet de instuire – nivel intermediar este creat cu scopul de a fi predat de către formatori care au abilități în furnizarea de servicii de scaune rulante de nivel intermediar și care pot demonstra competențele predate în acest program de instruire. Există o gamă de resurse de predare, care include: • Manualul formatorului și materialele anexe; • Manualul participantului; • Caietul de exerciții practice; • Formularele pentru furnizarea serviciilor de scaune rulante; • Listele de verificare pentru furnizarea serviciilor de scaune rulante; • Materiale suport vizuale, inclusiv prezentări PowerPoint, materiale video și afișe. Procesul de dezvoltare a cursului După lansarea Ghidului privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, OMS a format un grup de lucru cu scopul dezvoltării pachetului de instruire pentru servicii de scaune rulante. Prima întâlnire a grupului de lucru a fost convocată de către OMS în octombrie 2008, pentru de a stabili temele și conținutul pachetului de instruire. După etapa în care materialul a circulat și a primit, de la mai mult de 20 de experți în domeniu, un feedback în ceea ce privește propunerea de conținut a pachetului de instruire, un grup-nucleu de specialiști a pregătit materialul pentru a fi folosit pe teren, în calitate de proiect pilot. În 2011, pachetul de instruire de nivel intermediar a fost implementat ca proiect pilot în România, Kenya și Timorul de Est. Fiecare proiect a fost monitorizat de membri ai grupului de lucru OMS pentru pachetul de instruire destinat livrării serviciilor de scaune rulante. Răspunsurile primite de la instructori, participanții instruiți și de la utilizatorii de scaun rulant care au luat parte la sesiunile practice au fost încorporate în variantele finale. Pe lângă aceste proiecte pilot, pachetul de instruire nivel intermediar a fost analizat și de către specialiști în domeniu. Un număr de 15 experți în aspecte legate de aceste echipamente de mobilitate au revizuit documentul, iar feedback-ul și sugestiile lor valoroase au fost folosite în etapa de finalizare a documentului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 9 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Toți autorii implicați în elaborarea acestui pachet de instruire au completat o Declarație de Interese. Niciunul dintre autori nu a semnalat că ar exista vreun conflict de interese în ceea ce privește acest subiect. Cum se utilizează Manualul participantului Acest manual creat pentru participanți oferă un rezumat al informațiilor care se regăsesc în modulul de instruire pentru furnizarea serviciilor de scaune rulante de nivel intermediar. Participanții pot folosi Manualul participantului după finalizarea programului de instruire, pentru a-și reaminti punctele cheie predate în fiecare sesiune. Manualul este împărțit în două secțiuni: A: Noțiunile fundamentale B: Etapele furnizării serviciilor de scaune rulante. A: Noțiunile fundamentale – această secțiune include informații care sunt relevante pentru toate etapele furnizării de servicii de scaune rulante. În anumite contexte, în funcție de nevoile de învățare ale participanților, formatorii pot adăuga la această secțiune informații suplimentare. B: Etapele furnizării serviciilor de scaune rulante – această secțiune include informații care vor ajuta participanții în parcurgerea celor opt etape ale furnizării de servicii de scaune rulante de nivel intermediar (vezi Ghidul Organizației Mondiale a Sănătății privind furnizarea scaunelor rulante cu antrenare manuală în zone cu resurse limitate(2), pagina 76). Instruirea pentru furnizarea serviciilor de scaune rulante la nivel de bază și intermediar Pentru a sprijini o instruire corespunzătoare a personalului furnizor de servicii de scaune rulante, Pachetul de instruire OMS este structurat pe instruire la două niveluri - de bază și intermediar. • Nivelul de bază oferă participanților instruire cu privire la furnizarea de scaune rulante acelor copii și adulți care au dificultăți de deplasare și mobilitate, dar care pot menține poziția așezat fără suport postural suplimentar. • Nivelul intermediar oferă participanților instruire cu privire la furnizarea de scaune rulante acelor copii și adulți care necesită suport postural suplimentar pentru menținerea poziției așezat. Programul de instruire de nivel intermediar se bazează pe informațiile și abilitățile acumulate de participanți pe parcursul modulului de instruire la nivel de bază. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 10 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar A: Noțiunile fundamentale Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 11 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.1: Utilizatorii de scaun rulant care au nevoie de suport postural suplimentar Utilizatorii de scaun rulant sunt acele persoane care dețin deja un scaun rulant sau care pot beneficia de pe urma utilizării unui scaun rulant, deoarece capacitatea lor de a se deplasa este limitată. Utilizatorii de scaun rulant includ: • copii, adulți și vârstnici; fete, băieți, femei și bărbați; • persoane cu particularități impuse de starea lor de sănătate, cu stiluri de viață și roluri diferite, având experiențe de viață diverse; • persoane care trăiesc și lucrează în diverse medii, inclusiv în cel rural sau urban ori într-unul care îmbină caracteristicile celor două. Nevoile fiecărui utilizator de scaun rulant sunt diferite. Totuși, toți au nevoie de scaune rulante corespunzătoare. Fiecare scaun rulant adecvat oferă utilizatorului un anumit suport postural. Spătarul, perna, suporturile de picioare și suporturile de brațe oferă suport postural când sunt ajustate, astfel încât să fie pe măsura utilizatorului de scaun rulant. Totuși, mulți copii și adulți necesită suport postural suplimentar în vederea utilizării scaunului rulant. Suportul postural suplimentar se furnizează prin intermediul unui dispozitiv de suport postural (DSP) - un dispozitiv fizic destinat acestui scop. Dispozitivul de suport postural este o parte esențială a serviciului de scaune rulante de nivel intermediar. Aici includem orice element adăugat sau modificare adusă scaunului rulant, pentru a un grad mai ridicat de suport postural. În acest manual, veți întâlni uneori abrevierea „DSP”, care desemnează dispozitivul de suport postural. Utilizatorii de scaune rulante care au nevoie de suport postural suplimentar Există persoane care nu au capacitatea de a menține poziția așezat fără un sprijin suplimentar. Unele dintre acestea au nevoie de un grad ridicat de suport, pe când în cazul altor persoane sunt suficiente câteva ajustări ale scaunului rulant. Există mai multe mijloace de furnizare a suportului postural suplimentar. Unele soluții sunt foarte simple și pot fi confecționate într-un atelier obișnuit. Altele presupun a abordare mai complexă. Când este nevoie de suport postural suplimentar? Există mai multe cauze care fac necesară furnizarea suportului postural suplimentar. De cele mai multe ori, sunt evidente situațiile în care scaunul rulant nu oferă suficient suport pentru menținerea poziției așezat. În mod frecvent, utilizatorii de scaune rulante sau familia/însoțitorii lor vă vor da sugestii foarte bune legate de tipul de suport necesar. Cauzele care determină nevoia de suport postural suplimentar includ: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 12 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar • incapacitatea utilizatorului de scaun rulant de menținere a poziției așezat; • mișcările necontrolate sau spasmele; • articulațiile rigide; • musculatura spastică; • starea de slăbiciune; • oboseala; • durerea sau disconfortul; • dificultățile în menținerea echilibrului; Definiție: Dispozitivele de suport postural (DSP) Dispozitivul de suport postural (DSP) este un dispozitiv fizic care oferă suport postural suplimentar. Dispozitivul de suport postural este un element esențial al furnizării de servicii de scaune rulante de nivel intermediar. Care sunt beneficiile suportului postural suplimentar? Există patru modalități foarte importante prin care suportul postural suplimentar aduce beneficii utilizatorului de scaun rulant: 1. Îmbunătățirea echilibrului, posturii și a stabilității; Îmbunătățirea echilibrului, posturii și a stabilității ajută utilizatorul de scaun rulant în efectuarea unor activități care sunt imposibile sau foarte dificile fără suport postural suplimentar. 2. Creșterea nivelului de confort; Suportul postural suplimentar face scaunul rulant mult mai confortabil și crește durata de timp pe care utilizatorul o poate petrece în scaunul rulant, fără să obosească. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 13 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Prevenirea apariției escarelor Escarele pot evolua cu rapiditate. Suportul postural corespunzător contribuie la evitarea apariției acestora, deoarece ajută la prevenirea exercitării unei greutăți suplimentare la nivelul anumitor părți ale corpului. Un beneficiu al poziției așezat este faptul că greutatea se distribuie în mod egal. Acest aspect ajută la reducerea riscului apariției escarelor. Atunci când un utilizator de scaun rulant nu poate menține poziția așezat, greutatea este distribuită în mod inegal. O parte a corpului va suporta mai multă greutate, comparativ cu altele. Dacă acea greutate suplimentară exercită presiune asupra suprafeței pielii de pe o zonă osoasă, există un risc ridicat de apariție a escarelor. Exemple de zone osoase: oasele bazinului (tuberozitate ischială), coastele, șoldurile (trohanterele), coloana vertebrală (vertebra) sau coccisul. Atunci când un utilizator de scaun rulant nu are suport corespunzător, corpul său va avea tendința de a aluneca pe suprafața de ședere. Se creează astfel frecare, care duce la apariția escarelor. Poziția așezat cu susținere corespunzătoare previne alunecarea și frecarea. 4. Încetinirea sau prevenirea apariției viitoarelor probleme posturale Suportul postural corespunzător poate preveni problemele legate de dezvoltarea unor posturi vicioase. Dacă o problemă posturală a debutat deja, suportul postural corespunzător poate încetini sau preveni înrăutățirea acesteia. Este deosebit de importantă furnizarea de suport postural cât mai timpuriu, atât pentru postura de decubit, cât și pentru pozițiile așezat și stând. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 14 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Consumul în condiții de siguranță al alimentelor și al lichidelor Acei utilizatori de scaun rulant care au dificultăți în ceea ce privește menținerea poziției așezat, vor avea cu siguranță probleme de deglutiție. În cazul acestor persoane, consumul de alimente și de lichide poate fi un proces care produce disconfort, teamă și este deseori chiar periculos. Atunci când există dificultăți în realizarea deglutiției în condiții de siguranță, bucăți mici de alimente sau lichide pot ajunge în plămâni. Acest lucru poate cauza infecție pulmonară, determinând îmbolnăvirea gravă sau chiar sufocarea, cu riscul survenirii decesului. Suportul postural suplimentar în scaun rulant asigură utilizatorului o poziție adecvată atunci când consumă alimente și lichide. Îmbunătățirea suportului postural constituie doar o parte din soluțiile pentru persoanele cu probleme de deglutiție. Dacă este posibil, copiii sau adulții aflați în această situație trebuie să ajungă la personal specializat, cu experiență. În acest sens, poate fi vorba de un pediatru, logoped sau orice altă persoană din domeniul medical sau social care are cunoștințele și pregătirea necesare pentru gestionarea problemelor de deglutiție. Care sunt așteptările utilizatorilor de scaune rulante? Utilizatorii de scaun rulant își doresc un anumit grad de confort și capacitatea de a-și continua existența cotidiană. Este important ca suportul suplimentar oferit de scaunul rulant să nu îngreuneze desfășurarea activităților zilnice. De exemplu, suportul postural suplimentar nu trebuie să interfereze cu efectuarea transferului în și din scaunul rulant, a propulsiei acestuia, cu accesul la birou, la spațiul de lucru ori cu utilizarea mijloacelor de transport. În orice moment, scaunul rulant și suportul postural suplimentar trebuie: • să fie practice și ușor de utilizat; • să fie confortabile și să nu accentueze gradul de disconfort; • să ajute utilizatorul în efectuarea activităților în maniera aleasă de acesta și să nu creeze situații mai dificile; • să aibă un aspect agreabil și să nu „iasă prea mult în evidență”. Uneori, utilizatorii au dificultăți în a se obișnui cu un scaun rulant dotat cu suport postural suplimentar. Cauzele pot fi multiple: • utilizatorul de scaun rulant este obișnuit cu o anumită postură. Suportul postural suplimentar, care modifică postura cu care acesta este familiarizat, pare inconfortabil sau restrictiv; • utilizatorul de scaun nu înțelege motivul pentru care a fost prescris suportul postural suplimentar; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 15 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT • utilizatorul de scaun rulant are impresia că suportul postural are un aspect dezagreabil și că face ca dizabilitatea sa să fie mai evidentă. Acestea sunt motivele pentru care este foarte important ca personalul furnizor de servicii de scaune rulante să lucreze îndeaproape cu utilizatorul și familia/însoțitorul acestuia, pe tot parcursul etapelor de evaluare, prescriere (selecție), probare a produsului (a scaunului rulant), instruire și monitorizare. Întotdeauna discutați împreună cu utilizatorul de scaun rulant despre soluțiile identificate și respectați fără excepție sugestiile și decizia lor finală. Cele mai bune modalități de a ne asigura că suportul postural suplimentar va fi folosit de către utilizatorul de scaun rulant sunt: • să implicăm în întregime utilizatorul de scaun rulant și familia/însoțitorul acestuia în etapele de evaluare, prescriere, probare, instruire și monitorizare; • să ajutăm utilizatorul de scaun rulant și familia/însoțitorul acestuia să înțeleagă cauzele pentru care este nevoie de suport postural suplimentar și modul în care acesta îl va ajuta; • să lăsăm, întotdeauna, utilizatorului de scaun rulant posibilitatea de a fi cel care ia decizia finală. Postura corespunzătoare are un impact pozitiv asupra stimei de sine Un beneficiu al suportului postural suplimentar corespunzător este contribuția sa la o stare de spirit mai bună a utilizatorului de scaun rulant. Sprijinul pentru menținerea unei poziții cât mai apropiate de poziția așezat îi poate determina pe utilizatorii de scaun rulant să aibă mai multă încredere în ei înșiși. Cu ajutorul unui suport postural adecvat, utilizatorii de scaune rulante se pot implica mai mult în viața comunității. De exemplu, mobilitatea și suportul postural suplimentar permit utilizatorului de scaun rulant deplasarea la școală sau locul de muncă; vizitarea prietenilor; prezența la activități religioase sau din comunitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 16 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Listă de verificare pentru scaune rulante cu suport postural suplimentar corespunzător Următoarea listă de verificare ajută personalul furnizor de servicii de scaune rulante să se asigure că suportul postural suplimentar prescris constituie cea mai bună alegere pentru respectivul utilizator de scaun rulant. Listă de verificare: Utilizatorul de scaun rulant și familia/însoțitorul acestuia au fost implicați în întregime în luarea deciziilor din etapa de prescriere (selecție) Utilizatorul are posibilitatea de a încerca scaunul rulant cu dispozitivele posturale prescrise înainte de finalizarea produsului (la sediul furnizorului de servicii de scaune rulante și la domiciliu, dacă este posibil) și să ofere feedback Scaunul rulant și dispozitivele de suport postural (DSP) ajută utilizatorul de scaun rulant în desfășurarea activităților dorite: • DSP-urile îmbunătățesc capacitatea utilizatorului de scaun rulant de a desfășura diverse activități • DSP-urile nu îngreunează efectuarea transferului în și din scaunul rulant • DSP-urile nu cresc prea mult greutatea scaunului rulant Scaunul rulant și dispozitivele de suport postural (DSP) nu provoacă disconfort utilizatorului de scaun rulant: • DSP-urile oferă suport și permit utilizatorului să petreacă în scaunul rulant o durată de timp mai lungă decât ar fi putut în absența acestora. • DSP-urile oferă suficient suport, iar acest sprijin pentru o postură mai apropiată de cea corectă nu are impact asupra gradului de confort al utilizatorului. Scaunul rulant și dispozitivele de suport postural (DSP) au un aspect agreabil (în opinia utilizatorului) Scaunul rulant și dispozitivele de suport postural (DSP) pot fi utilizate în condiții de siguranță: • Finisajul oricărui DSP este neted, DSP-ul este căptușit în mod adecvat și contribuie la reducerea presiunii • Orice modificare structurală a cadrului scaunului rulant a fost verificată de către o persoană calificată • Scaunul rulant nu este instabil (nu se răstoarnă cu ușurință înspre înainte, înapoi sau în lateral) atunci când este folosit de către utilizator • Scaunul rulant și dispozitivele de suport postural (DSP-urile) sunt practice: • Tapițeria poate fi curățată sau îndepărtată în vederea spălării • Numărul de părți componente este cât mai redus posibil, pentru a preveni pierderea/ utilizarea lor incorectă • Scaunul rulant poate fi transportat cu ușurință într-o mașină/în mijloace de transport public • Scaunul rulant poate fi folosit cu ușurință la domiciliul utilizatorului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 17 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.2: Copiii cu dizabilități Atunci când se furnizează un scaun rulant unui utilizator copil, este important să luăm în considerare modul în care stilul de viață al copiilor diferă de cel al adulților. Aceste diferențe influențează felul în care personalul furnizor de servicii de scaune rulante lucrează cu copiii cu dizabilități, precum și alegerea scaunului rulant și a suportului postural suplimentar. Iată câteva dintre cele mai semnificative astfel de diferențe: • activitățile desfășurate de copii sunt diferite de cele ale adulților (joacă, școală); • frecvent, copiii sunt foarte activi și nu păstrează aceeași poziție un timp îndelungat; • copiii se află în grija adulților; • există cazuri în care copiii nu reușesc să își spună părerea; • copiii sunt încă în plin proces de dezvoltare; • copiii mici au o poziție de ședere diferită de cea a adulților; • copiii sunt încă în proces de creștere. Scaune rulante care corespund cerințelor copiilor Scaunele rulante ale utilizatorilor copii trebuie să îi ajute pe aceștia să participe la activitățile cotidiente tipice. Acestea sunt caracteristicile importante ale scaunelor rulante pentru copii: • Dacă propulsia este efectuată de către utilizatorul copil, scaunul rulant trebuie: – să aibă dimensiunea potrivită pentru a permite accesul la inelul de antrenare fără a produce disconfort; – să fie suficient de ușor pentru a putea fi controlat de către utilizatorul copil, în special la urcarea sau coborârea pantelor. • Încercați întotdeauna să vă asigurați ca scaunul rulant este „mai puțin vizibil” decât utilizatorul său. • Mânerele extinse ajută membrii familiei/însoțitorii să efectueze propulsia scaunului rulant, fără a orienta trunchiul înspre înainte. • Un scaun rulant care poate fi folosit pe suprafețe denivelate și moi, cum ar fi iarba sau nisipul, dă posibilitatea utilizatorilor copii să se joace mai ușor cu prietenii lor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 18 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar • Un scaun rulant trebuie să ajute utilizatorul copil să se deplaseze mai ușor la școală: – dacă majoritatea copiilor din comunitate merg pe jos la școală, gândiți-vă dacă scaunul rulant poate fi folosit pe acele trasee. Utilizatorul copil are nevoie de un scaun rulant care este adecvat deplasării pe teren accidentat? – în cazul în care utilizatorul copil se deplasează la școală cu un mijloc de transport (de exemplu: mașină, autobuz, taxi), gândiți-vă la modul în care scaunul rulant va fi transportat. • Scaunul rulant are rolul de a facilita deplasarea la școală. El trebuie să permită utilizatorului copil să se poziționeze la pupitru sau să fie dotat cu o măsuță care să constituie suprafața de lucru. În mod ideal, scaunele rulante ale utilizatorilor copii trebuie: • să le permită acestora să efectueze propulsia în mod independent (dacă au această capacitate); • să aibă mânere pentru a le permite adulților să ofere asistență; • să se poată deplasa pe suprafețe accidentate sau moi, cum ar fi iarba sau nisipul; • să faciliteze deplasarea la școală a acestora; • să aibă un aspect plăcut, din punct de vedere al formei, mărimii și al culorilor; • să faciliteze participarea la cursuri. Diverse posturi De obicei, copiii petrec mult timp în poziția așezat. În cazul lor este firească schimbarea activității și, implicit, a poziției, de multe ori pe parcursul zilei. Acest lucru înseamnă că, deși scaunul rulant este important, utilizatorii copii nu ar trebui să petreacă întreaga zi în scaunul rulant. Personalul furnizor de servicii de scaune rulante trebuie să se gândească și la alte poziții pe care copiii cu dizabilități le pot adopta în timpul zilei. Acest lucru este important în special atunci când mobilitatea este foarte limitată, dacă utilizatorul copil are tendința de a avea permanent aceeași postură și dacă nu își poate schimba poziția. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 19 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Câteva exemple: Poziția așezat Câteva metode de a susține utilizatorii copii în poziția așezat fără sprijin, cât mai aproape de sol: • Așezat, având între genunchi și sub bazin un rulou sau o pătură strâns rulată • Așezat, sprijinit de către un membru al familiei/însoțitor: – În imagine: o mamă își sprijină copilul cu dizabilități cu ajutorul picioarelor, pentru ca acesta să poată menține poziția așezat și să mănânce un biscuit, în timp ce ea ține în brațe copilul ei mai mic. • Cu ajutorul unui scaun de poziționare, cu suprafața de ședere situată aproape de sol: – Un astfel de scaun este mai puțin costisitor decât un sistem de poziționare și poate fi o opțiune în cazul copiilor cu vârste mici. Poziția stând Poziția stând este, în egală măsură, un element esențial în dezvoltarea oricărui copil. Această poziție contribuie la formarea articulațiilor șoldului și a curburilor fiziologice ale trunchiului. În cazul oricărei persoane care stă în poziția așezat perioade îndelungate, există pericolul apariției unei anumite rigidități a șoldurilor și a genunchilor. Poziția stând întinde musculatura la nivelul șoldurilor, genunchilor și a gleznelor și ajută la prevenirea instalării rigidității. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 20 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Atunci când un copil nu poate menține această poziție fără sprijin, poate fi necesară utilizarea unui verticalizator. Pentru a prescrie un astfel de dispozitiv, personalul furnizor de servicii de scaune rulante trebuie să înțeleagă foarte bine ce presupune această poziție și diversele metode prin care putem oferi suport pentru menținerea acesteia. Atunci când se utilizează un verticalizator, verificați întotdeauna că nu se exercită presiune directă asupra rotulei genunchiului. Zona cea mai indicată pentru susținerea membrelor inferioare și prevenirea flexiei genunchilor este situat chiar sub rotulă, pe tibie. Atunci când se folosește un verticalizator, personalul furnizor de servicii de scaune rulante trebuie să informeze membrii familiei/însoțitorii cu privire la durata de timp zilnică de folosire a dispozitivului. Iată câteva sugestii: • în faza inițială, durata zilnică este de 5-10 minute; • durata de folosire a cadrului pentru menținerea poziției stând de către utilizatorul copil nu trebuie să depășească niciodată o oră; • furnizați o măsuță sau o suprafață de lucru și încurajați membrii familiei/însoțitorii să identifice o activitate distractivă, pe care copilul să o desfășoare în timp ce folosește verticalizatorul. • Atunci când furnizați un verticalizator unui copil cu vârstă mai mică de cinci ani, trebuie să aveți în vedere câteva aspecte importante: – membrele inferioare trebuie să fie în abducție, iar între tălpi trebuie să existe o distanță care să fie cel puțin echivalentul lățimii șoldurilor; – picioarele și genunchii cu orientare ușor către exterior; – șoldurile și genunchii ușor flectați; – în cazul copiilor de vârstă mică, nu forțați niciodată niciodată genunchii și articulațiile șoldurilor în extensie completă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 21 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Poziția de decubit Poziția de decubit are și ea un rol semnificativ. Pentru copii, această este o poziție firească în timpul jocului. Uneori, copiii au nevoie de sprijin în poziția de decubit, iar în aceste sens pot fi folosite pături, bucăți de spumă sau de burete, prosoape sau perne. Se recomandă ca în cazul copiilor sub vârsta de cinci ani, atunci când ei se află în poziția de decubit, să plasăm un rulou sub trunchi, astfel încât șoldurile să fie ușor flectate. Copiii petrec mult timp dormind. Dacă postura copilului în timpul somnului este aceeași de fiecare dată, și ea poate deveni fixă sau rigidă. Personalul furnizor de servicii de scaune rulante trebuie să ofere sfaturi membrilor familiei/însoțitorilor cu privire la diferitele posturi pe care copilul le poate adopta în timpul somnului. Rețineți! În toate cazurile, indiferent că este vorba despre poziția așezat, stând sau de decubit, șoldurile și genunchii copiilor cu vârstă de până la cinci ani trebuie să fie ușor flectați. Importanța intervenției timpurii în cazul copiilor Intervenția timpurie în cazul copiilor este esențială. Cu toate acestea, în mod frecvent, părinții sau acele persoane care ar putea direcționa părinții către servicii specializate nu apelează la acestea din urmă decât în momentul în care utilizatorul copil devine prea greu pentru a mai fi transportat în brațe. Mai jos sunt enumerate câteva cauze: • uneori se consideră că în cazul în care utilizatorul copil primește un scaun rulant, acesta nu va mai încerca să meargă; • atât timp cât copiii sunt mici și greutatea lor nu pune probleme, părinții preferă să îi poarte în brațe decât să folosească un scaun rulant pe teren accidentat și în medii inaccesibile; • părinții nu au suficiente fonduri pentru a plăti un scaun rulant și amână până când devine prea dificil să transporte copilul în brațe. Este important să le explicați părinților și acelor persoane care îi pot trimite spre furnizorii de servicii specializate că, în mod obișnuit, un scaun rulant nu va descuraja copilul să meargă. Probabilitate este ca un scaun rulant cu suport postural adecvat, furnizat cât mai devreme, să aibă un efect benefic asupra copilului. Câteva argumente care demonstrează de ce trebuie să recomandăm intervenția timpurie: • În cazul copiilor care prezintă dificultăți în menținerea poziției așezat, în lipsa sprijinului adecvat, pot apărea probleme posturale. Dacă trimiterea se face prea târziu, anumite probleme posturale pot deveni fixe (3). Acest lucru face dificilă adoptarea unei poziții de ședere confortabile, chiar și cu suport. • În absența poziției așezat și a mobilității, dezvoltarea copiilor poate fi întârziată (3,4). • În cazul copiilor care au într-o anumită măsură abilitatea de a merge, folosirea unui scaun rulant le Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 22 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar poate ușura viața și le permite desfășurarea mai multor activități pe parcursul zilei(3). Din aceste motive, în cazul copiilor, este recomandată intervenția timpurie, prin direcționarea părinților/ însoțitorilor către un furnizor de servicii de scaune rulante. Instruirea părinților și a persoanelor implicate în trimiterea utilizatorilor către furnizorii de servicii de scaune rulante Personalul furnizor de servicii de scaune rulante poate contribui la instruirea părinților și a persoanelor implicate în trimiterea utilizatorilor către centrele de acest tip, informându-i cu privire la importanța intervenției timpurii. Vârsta la care copiii fără dizabilități reușesc să adopte poziția așezat, să se ridice în picioare și să meargă variază. Este general acceptat faptul că dezvoltarea unui copil presupune următoarele etape: • să mențină poziția așezat, fără sprijin - între 6 și 8 luni; • să se ridice pentru a sta în picioare - între 8 și 10 luni; • să stea drept, fără sprijin, și să meargă ținut de mâini - între 10 și 12 luni; • să meargă, fără însoțitor - între 12 și 18 luni. Se recomandă să se apeleze la furnizorii de servicii de scaune rulante atunci când: • copiii au dificultăți în a menține poziția așezat sau în a se ridica pentru poziția stând – la vârsta de 1 an sau • atunci când copilul nu poate merge fără asistență - la vârsta de 2 ani. • Acolo unde există un program de screening pentru intervenția timpurie (de exemplu, acolo unde personalul de servicii medicale din comunitate este instruit în ceea ce privește monitorizarea copiilor pentru intervenția timpurie), furnizorii de servicii de scaune rulante pot oferi acestor rețele informații detaliate. De exemplu – personalul furnizor de servicii de scaune rulante poate sugera ca orice copil la care se identifică o problemă fizică semnificativă sau întârziere în procesul de dezvoltare, să fie trimis către evaluare sau consiliere. Pentru copiii de vârstă foarte mică, în etapa inițială, serviciul de scaune rulante poate furniza un scaun de poziționare în locul unui scaun rulant, pentru a fi folosit la domiciliu sau la grădiniță. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 23 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Bune practici în lucrul cu copiii Atunci când lucrați cu copii, este important să îi tratați cu respect și într-o manieră care să îi protejeze. Aspectele cheie: Acordați-le respect și: • explicați-le ce faceți și care sunt motivele, într-un mod care să îi ajute să înțeleagă; • cereți-le permisiunea înainte de a începe evaluarea fizică; • implicați-i pe ei/membrii familiei lor/însoțitorul în luarea deciziei cu privire la alegerea unui scaun rulant corespunzător; • în cazul în care urmează să îi evaluați într-un centru, încercați ca spațiul să fie cât mai potrivit pentru beneficiarii de această vârstă. Aveți în vedere siguranța lor: • evaluându-i în prezența membrilor familiei/ a însoțitorului; • făcând pauze, deoarece copiii pot obosi ușor; • cerându-le permisiunea lor sau membrilor familiei/a însoțitorului înainte de a face fotografii. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 24 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar B. Etapele furnizării serviciilor de scaune rulante. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 25 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Etapa 1: Trimiterea și programarea • Vezi Etapa 1: Pentru informații generale despre trimitere și programare, vezi secțiunea „Trimiterea și programarea” din Manualul participantului din Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază • Vezi secțiunea A.2: „Copiii cu dizabilități” din acest manual, pentru informații referitoare la importanța intervenției timpurii în cazul copiilor. Etapa 2: Evaluarea Rezumatul evaluării și interviul de evaluare Evaluarea Evaluarea este cea de-a doua etapă a procesului de furnizare a serviciilor de scaune rulante. Informațiile dobândite pe parcursul evaluării ajută atât utilizatorul, cât și personalul furnizor de servicii de scaune rulante: • să aleagă scaunul rulant care i se potrivește cel mai bine utilizatorului, din cele disponibile; • să identifice care este suportul postural suplimentar necesar; • să identifice nevoia de instruire și de sprijin a utilizatorului de scaun rulant și a familiei acestuia/a însoțitorului, în ceea ce privește folosirea și întreținerea scaunului rulant. Evaluarea se efectuează în doi pași, atât la nivelul de bază, cât și la cel intermediar: • interviul de evaluare; • evaluarea fizică. Interviul de evaluare Prima parte a evaluării o constituie interviul de evaluare. Pe parcursul acesteia, personalul furnizor de servicii de scaune rulante dobândește informații despre utilizatorul de scaun rulant, informații care vor fi de folos în identificarea celui mai potrivit scaun rulant pentru respectivul utilizator. Există foarte multe asemănări între componentele interviului de evaluare pentru nivelul de bază și cel intermediar. Aici sunt incluse: • informații despre utilizatorul de scaun rulant; • informații despre condiția fizică; • informații despre stilul de viață și mediu în care trăiește; • informații despre scaunul rulant existent. Chiar dacă părțile interviului de evaluare sunt similare pentru nivelul de bază și cel intermediar, în cazul acestuia din urmă sunt solicitate mai multe informații legate de diagnosticul și problemele fizice ale utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 26 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Formular de evaluare – nivel intermediar: 1: Interviul de evaluare Informații despre utilizatorul de scaun rulant; Numele: Numărul: Vârsta: Bărbat Femeie Numărul de telefon: Adresa: Obiective:___________________________________________________________ Rubrica de „Informații despre utilizatorul de scaun rulant” din formularul de evaluare – nivel intermediar are un scop administrativ, asigurând accesul furnizorului de servicii de scaune rulante la datele personale de bază și cele de contact ale utilizatorului. De asemenea, contribuie la colectarea informațiilor statistice despre utilizatorii care apelează la respectivul furnizor de servicii de scaune rulante. Tot la această rubrică, personalul furnizor de servicii de scaune rulante trebuie să noteze care sunt obiectivele utilizatorului, în ceea ce privește scaunul rulant nou sau îmbunătățit. Este posibil ca utilizatorul să nu fie familiarizat cu termenul „obiectiv”. Depinde de personalul furnizor de servicii de scaune rulante ce fel de întrebări pune pentru a identifica aceste obiective. Mai jos găsiți exemple de întrebări prin care personalul furnizor de servicii de scaune rulante poate identifica obiectivele utilizatorului. • De ce ați apelat la furnizorul de servicii de scaune rulante? • Ce activități doriți să desfășurați cu ajutorul scaunului rulant? Câteva exemple de posibile obiective ale utilizatorilor de scaun rulant: • Îmi doresc să ajung la fântână pentru a scoate apă. • Îmi doresc să am acces în ascensor pentru a ajunge la apartamentul meu. • Îmi doresc să pot transporta scaunul meu rulant într-o mașină mică. • Îmi doresc să stau mai confortabil în scaunul rulant. • Îmi doresc să pot petrece mai mult timp în scaunul meu rulant, fără a mă simți obosit. • Îmi doresc să pot realiza singur transferul în și din scaunul meu rulant. • Îmi doresc să pot sta la o masă de birou pentru a folosi calculatorul. • Îmi doresc să îmi pot vizita familia și am nevoie de un scaun rulant cu care să pot călători cu autobuzul. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 27 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Condiția fizică Diagnostic: Traumatism cranio-cerebral Paralizie cerebrală Distrofie musculară Poliomielită Spina bifida Traumatism vertebro-medular Accident vascular-cerebral Necunoscut Altele ___________________________ Există posibilitatea ca situația să se înrăutățească? Da Nu Condiția fizică: Constituție fragilă Spasme sau mișcări necontrolate Tonus muscular (hipertonie/hipotonie) Amputație membru inferior: D de deasupra genunchiului D de sub genunchi S de deasupra genunchiului S de sub genunchi Oboseală Luxație de șold Epilepsie Dificultăți de deglutiție Durere Descrieți: _________________________________________________________ Probleme de management urinar Probleme de management intestinal Dacă există probleme de management urinar sau de tranzit intestinal, acestea sunt gestionate? Da Nu Rubrica „Diagnostic/condiția fizică” din formularul de evaluare - nivel intermediar este importantă deoarece unele caracteristici specifice unui anumit diagnostic și unei anumite condiții fizice pot avea impact asupra alegerii scaunului rulant și a dispozitivelor de suport postural. Tabelul de pe următoarele pagini prezintă un rezumat al diagnosticelor și condițiilor fizice din formularul de evaluare - nivel intermediar. Sunt descrise acele caracteristici de bază care au un impact asupra furnizării scaunului rulant, fiiind oferite și câteva sugestii în acest sens. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 28 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant Tr au m at is m ul c ra ni o- ce re br al Traumatismul cranio- cerebral se referă la orice leziune care se produce la nivelul creierului, după naștere. Aceasta poate fi cauzată de un accident, traumatism(1,2), infecție cerebrală, meningită(3), malarie cerebrală, abuz de alcool sau de droguri(5). Problemele cauzate de traumatismul cranio- cerebral variază în funcție de zona afectată și de severitatea leziunii(6). Traumatismul cranio- cerebral poate afecta corpul total sau parțial. Chiar dacă traumatismul cranio-cerebral reprezintă o leziune permanentă a creierului, efectele acesteia asupra abilităților persoanei se pot schimba în timp. *Rețineți faptul că în cadrul acestui modul de instruire, termenul „Traumatism cranio- cerebral” se referă exclusiv la leziunea cerebrală traumatică dobândită. • dificultăți de mobilitate, coordonare și forță reduse; • echilibru precar în menținerea poziției așezat și/sau poziției stând(6); • hipertonie (rigiditate musculară) (6), care poate cauza extensia sau flexia completă a corpului; • dificultăți de deglutiție(6); • dificultăți de vorbire, gândire sau de înțelegere(6); • schimbare a personalității sau a comportamentului(6); • convulsii(6); • dificultăți de control al vezicii și al sfincterelor, care determină creșterea riscului de apariție a escarelor(6). • Dacă utilizatorul de scaun rulant nu are abilitatea de a realiza propulsia scaunului rulant cu ajutorul brațelor, stabiliți dacă propulsia cu ajutorul membrelor inferioare este o opțiune viabilă. • Aflați dacă este prezentă hipertonia, deoarece acest aspect influențează gradul de rezistență al dispozitivelor de suport postural. Se recomandă monitorizarea frecventă, pentru că abilitățile fizice ale utilizatorului se pot modifica în timp(6). Acest lucru înseamnă și schimbarea gradului de suport necesar în timpul folosirii scaunului rulant. • Trebuie să fiți atenți la potențialele schimbări de personalitate sau de comportament, determinate de starea de sănătate a persoanei. Pentru informații despre: • Tonus muscular – hipertonie și hipotonie - vezi pagina 38. • Epilepsie - vezi pagina 43. • Metode de prevenire a apariției escarelor – vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază, Manualul participantului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 29 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant P ar al iz ia c er eb ra lă Paralizia cerebrală este una dintre cele mai frecvente dizabilități întâlnite la copii(4,5), fiind cauzată de o leziune a creierului aflat în proces de dezvoltare(6). Modalitatea în care paralizia cerebrală afectează fiecare persoană este diferit(10), totuși, de cele mai multe ori, are impact asupra felului în care se mișcă persoana(8,10,7). Nu toate persoanele diagnosticate cu paralizie cerebrală au nevoie să utilizeze un scaun rulant(10). Cu toate acestea, copiii și adulții cu paralizie cerebrală, care sunt utilizatori de scaun rulant, necesită în mod frecvent suport postural suplimentar, pentru creșterea gradului de funcționalitate și confort. • dificultăți în menținerea poziției - de decubit, așezat sau stând(10); • echilibru precar(10); • dificultatea de a controla o parte a corpului în timp ce o altă parte a corpului este în mișcare - de exemplu, menținerea poziției așezat, fără modificarea acesteia, simultan cu activitatea de a scrie, cu consumul de lichide sau deglutiția; • hipertonie sau hipotonie(10); • spasme/mișcări necontrolate; • coordonare defectuoasă(10); • tendință de a avea permanent aceeași postură (poziția obișnuită de ședere)(10); • alte deficiențe, cum ar fi cele vizuale, auditive, epilepsie, dificultăți legate de vorbire sau comunicare(10); • dificultăți de control al vezicii și al sfincterelor, care determină creșterea riscului de apariție a escarelor (11,8); • dificultăți în ceea ce privește deplasarea la toaletă și utilizarea acesteia, fără însoțitor; • luxație de șold (capul femural nu este poziționat în articulația șoldului), fapt care limitează mișcarea și poate provoca dureri. • Pentru majoritatea utilizatorilor de scaun rulant care au diagnosticul de paralizie cerebrală, suportul postural corespunzător este important. Cu ajutorul acestuia se îmbunătățesc postura, echilibrul și gradul de control al corpului în efectuarea diverselor activități. • Rețineți faptul că la început, schimbările de postură pot să li se pară nefirești utilizatorilor de scaun rulant cu paralizie cerebrală. Utilizatorul de scaun rulant poate avea nevoie de timp pentru a se obișnui cu ele. Luați în considerare posibilitatea modificării graduale, pentru ca adoptarea unei posturi cu bazinul aflat cât mai aproape de poziția neutră de ședere să se realizeze în timp. • Există și alte aspecte de ordin fizic care pot influența alegerea scaunului rulant și a dispozitivelor de suport postural. Pe parcursul evaluării, identificați alte tipuri de dificultăți specifice diagnosticului de paralizie cerebrală. Pentru informații despre: Luxația de șold – vezi pagina 42. Poziții de decubit - vezi pagina 21. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 30 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant D is tr ofi a m us cu la ră Distrofia musculară Duchenne (DMD) este una dintre cele 20 de tipuri de distrofie musculară. Toate tipurile de distrofie musculară au ca rezultat slăbirea tonusului muscular(9). Distrofia musculară Duchenne este o afecțiune ereditară care are ca efect atrofia progresivă a musculaturii(10). Primii afectați sunt mușchii scheletici(14). Gradual, musculatura inimii și a plămânilor este și ea afectată.14,11). Este o afecțiune degenerativă, ceea ce înseamnă că persoanele cu distrofie musculară își pierd gradual capacitatea de a se deplasa(13,14,12), ajungând într-un stadiu care impune utilizarea unui scaun rulant(13). La început, persoana poate să efectueze independent propulsia scaunului rulant și are o postură bună(13). Totuși, capacitatea de menținere a unei posturi corecte și de efectuare independentă a propulsiei scade pe măsură ce boala avansează(13). Observație: există anumite afecțiuni neurologice degenerative, cu caracteristici similare, care necesită abordări asemănătoare în procesul de furnizare a unui scaun rulant. • durere și disconfort(13); • oboseală(17); • diminuarea progresivă a forței musculare; în stadiul în care persoana are nevoie de un scaun rulant, forța musculară la nivelul bazinului, trunchiului și al umerilor afectează deja postura(17); • schimbări ale posturii: – din cauza forței musculare scăzute la nivelul abdomenului și articulației șoldului, bazinul se află în înclinare anterioară (partea superioară a bazinului înspre înainte), cu o curbură lombară crescută (lordoză) (17); – pe măsură ce forța musculară se diminuează, crește pericolul apariției curburilor laterale la nivelul coloanei vertebrale (scolioză)(16) • dificultăți respiratorii din cauza modificărilor de postură și a forței musculare reduse(17); • riscul apariției escarelor determinat de: – dificultatea de a schimba poziția; – supraponderabilitate sau subponderabilitate. • De îndată ce persoana cu distrofie musculară (sau care are o altă afecțiune neurologică degenerativă) începe să utilizeze zilnic scaunul rulant, devine necesară evaluarea amănunțită a suportului postural. • Furnizarea în stadiu incipient al unui suport postural corespunzător poate preveni apariția problemelor posturale(17). • Rolul suporturilor posturale este acela de a ajuta la menținerea unei posturi de ședere neutre și de a oferi mai mult sprijin, în funcție de necesități(17). • Încălțămintea ortopedică și suporturile de picioare cu unghi ajustabil contribuie la menținerea picioarelor în poziția neutră (sau apropiată de aceasta). Se recomandă o orteză pentru glezne și picior, acolo unde aceasta este disponibilă(17). • Suportul de brațe este important atunci când forța musculară redusă afectează umerii(17). Pentru informații despre: • Durere - vezi pagina 45. • Oboseală - vezi pagina 41. • Afecțiuni degenerative - vezi pagina 35. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 31 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant P ol io m ie lit a Poliomielita este o boală infecțioasă cauzată de un virus(14). Virusul afectează doar nervii care controlează mobilitatea(15, 16). Una din 200 de persoane afectate de poliomielită dezvoltă un anumit tip de paralizie musculară permanentă(18). De obicei, poliomielita se întâlnește în cazul copiilor sub vârsta de cinci ani(18). Numărul țărilor unde s-au semnalat cazuri de poliomielită a scăzut în mod semnificativ pe parcursul ultimelor decenii(18). • pierderea mobilității în cazul mușchilor afectați (paralizie) - de obicei la nivelul ambelor membre inferioare(19) • membrele inferioare și, în mod frecvent, fesele au musculatura nedezvoltată, rezultat al atrofiei musculare; • postură fixă non-neutră la nivelul gleznelor, genunchilor și al șoldurilor(19); • forță musculară redusă la nivelul mușchilor trunchiului(19). În acest caz, pot să apară curburi fixe ale coloanei vertebrale - inclusiv scolioză, curbură toracică accentuată (cifoză), înclinare anterioară a bazinului și curbură lombară accentuată (lordoză)(19); • membre superioare bine dezvoltate pentru a compensa lipsa de forță a celor inferioare. • În mod frecvent, persoanele afectate de poliomielită identifică modalități care fac posibile mobilitatea și desfășurarea activități diverse, în ciuda paraliziei și a eventualelor probleme posturale. • La fel ca în cazul oricărui utilizator de scaun rulant, discutați cu persoana despre suportul postural pe care aceasta și-l dorește. Luați în considerare efectele pe care le poate avea orice corecție a posturii. De exemplu, unele persoane cu acest diagnostic stau cu picioarele în abducție sau încrucișate, pentru un grad mai ridicat de echilibru. În încercarea de a corecta aceste posturi, riscăm să determinăm pierderea echilibrului, ceea ce îi va face mai puțin independenți. • Având în vedere faptul că multe persoane diagnosticate cu poliomielită au membre superioare puternice: – asigurați-vă că scaunul rulant este configurat în așa fel încât să permită o poziție benefică unei propulsii eficiente; – luați în considerare posibilitatea ca persoana să utilizeze o tricicletă (dacă aceasta este disponibilă), aceasta fiind o bună opțiune pentru deplasarea pe distanțe mai lungi. • Dacă lungimea trunchiului utilizatorului de scaun rulant este mai mică, luați în considerare varianta creșterii înălțimii pernei, pentru o poziție adecvată efectuării propulsiei. Pentru informații despre: Scaunul rulant configurat pentru efectuarea propulsiei manuale - vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - Nivel de bază, Manualul participantului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 32 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant S pi na b ifi da Spina bifida apare înainte de naștere(17, 22). Arcurile vertebrale nu se închid complet în jurul nervilor spinali, lăsându-i neprotejați(21, 22). În consecință, acea parte a măduvei care se află în această zonă nu se dezvoltă corect sau este afectată(21). Deteriorarea măduvei spinării poate influența controlul asupra vezicii și al sfincterelor(21, 18, 19). Spina bifida afectează persoanele în mod diferit, în funcție de dimensiunea zonei afectate și de nivelul de deteriorare a nervilor(21). • dificultățile legate de mobilitate depind de nivelul la care se localizează afecțiunea și de gradul de deterioare a nervilor și a măduvei(21); • probleme de control al vezicii și al sfincterelor(21); • capacitatea de deplasare pe distanțe scurte, cu ajutorul dispozitivelor de mobilitate(21); • eventualele protuberanțe la nivelul măduvei spinării, sunt cauzate de faptul că aceasta nu s-a dezvoltat corespunzător (în special dacă nu a existat nicio intervenție chirugicală)(21). • nivelul de control redus al musculaturii și sensibilitatea diminuată au ca rezultat dificultăți în menținerea poziției așezat; • volum mărit al capului (hidrocefalie) cauzat de acumularea de lichid(21). Tratamentul principal pentru hidrocefalie este introducerea unui „șunt,” prin metode chirurgicale, acesta permițând scurgerea lichidului blocat - de obicei în stomac(21). Dacă acumularea de lichid nu este gestionată, pot apărea leziuni ale creierului; • risc de apariție a escarelor din cauza absenței sensibilității sub nivelul leziunii și a prezenței umezelii, care este o consecință a unui management vezical și intestinal necorespunzător(21). • Asigurați-vă că scaunul rulant este configurat în așa fel încât să permită realizarea unei propulsii eficiente. • Gradul de suport postural va depinde de nivelul la care se situează leziunea. Cu cât leziunea este mai înaltă, cu atât crește gradul de suport postural necesar. • Dacă utilizatorul folosește orteză pe parcursul zilei, cereți acestuia să poarte orteza atunci când se efectuează evaluarea pentru prescrierea scaunului rulant. • Dacă există o protuberanță, trebuie evitată exercitarea unei presiuni pe respectiva zonă. Acest lucru poate însemna necesitatea unui contur al spătarului sau ajustarea tapițeriei acestuia pentru a preîntâmpina această problemă. • Un suport postural corespunzător utilizat cât mai de timpuriu poate preveni apariția problemelor posturale(20). Acest aspect este deosebit de important pe perioada creșterii. • În cazul în care există un „șunt”, atunci când furnizăm o tetieră, trebuie să luăm în considerare poziția acestuia. • În cazul în care identificați un copil cu hidrocefalie netratată, faceți recomandarea ca el să fie consultat de personal medical specializat. Pentru informații despre: • Scaunul rulant configurat pentru realizarea propulsiei cu ajutorul membrelor superioare – vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar, Manualul participantului • Cum pot fi evitate escarele? - vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar, Manualul participantului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 33 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant Tr au m at is m ul v er te br o- m ed ul ar Un traumatism vertebro-medular reprezintă o leziune a măduvei spinării care are ca rezultat diminuarea mobilității și/sau a sensibilității mai jos de nivelul unde se localizează aceasta(21). Măduva spinării controlează vezica și sfincterele, prin urmare acestea pot fi afectate.(26). Un traumatism vertebro-medular poate fi cauzat de un accident, de un act de violență, de boală sau infecție(26). Efectele leziunii măduvei spinării depind de tipul și nivelul acesteia(26). Tipul de leziune: Vorbim despre o leziune completă atunci când sub nivelul acesteia sunt absente sensibilitatea și mobilitatea(26). O leziune incompletă înseamnă că sensibilitatea și mobilitatea sunt prezente sub nivelul acesteia, într-o anumită măsură(26). Nivelul leziunii: Nivelul leziunii coloanei vertebrale poate fi descris ca tetraplegie/cvadriplegie, paraplegie de nivel superior sau paraplegie de nivel inferior(26). Cvadriplegia/tetraplegia se localizează la nivelul părții cervicale, iar membrele superioare, trunchiul, bazinul și membrele inferioare sunt afectate(26). Paraplegia de nivel superior se situează la nivelul superior al coloanei, iar în acest caz, trunchiul, bazinul și membrele inferioare sunt afectate(26). Membrele superioare nu sunt afectate. Paraplegia de nivel inferior se localizează mai jos pe coloana vertebrală, fiind afectate membrele inferioare(26). La rândul său, bazinul poate fi și el afectat.(22) • pierderea completă a mobilității și sensibilității dacă leziunea este completă sau pierderea parțială a mobilității și sensibilității dacă leziunea este incompletă(26). • copiii și adulții cu diagnosticul de cvadriplegie/tetraplegie și paraplegie de nivel superior au un echilibru precar din cauza pierderii sensibilității și a controlului asupra mușchilor în zona trunchiului. Acest lucru face dificilă menținerea poziției așezat, iar pe termen lung, în lipsa unui suport corespunzător oferit de scaunul rulant, pot apărea probleme posturale; • probleme de control al vezicii și al sfincterelor(26); • posibilitatea apariției spasmelor/mișcărilor necontrolate la nivelul gambelor(26); • copiii și adulții cu traumatism vertebro- medular sunt expuși riscului apariției escarelor din cauza: – lipsei de sensibilitate sub nivelul la care se localizează leziunea(26); – prezenței umezelii, ca urmare a unui management vezical și intestinal inadecvat. • Întotdeauna veți prescrie o pernă pentru reducerea presiunii, în vederea prevenirii apariției escarelor. • Gradul de suport postural recomandat în cazul fiecărui utilizator de scaun rulant cu traumatism vertebro-medular va depinde de nivelul la care se situează leziunea. Cu cât aceasta este mai înaltă, cu atât crește mai mult gradul de suport necesar(27). • În stadiile post-traumatice timpurii, poate fi necesar suportul suplimentar la nivelul trunchiului și al membrelor superioare, în special în cazul leziunilor situate la un nivel înalt. • Majoritatea persoanelor cu paraplegie și unele persoane cu cvadriplegie/ tetraplegie au capacitatea de a efectua propulsia în mod foarte eficient(26). Asigurați-vă că scaunul rulant este configurat în așa fel încât să permită o poziție benefică unei propulsii eficiente. Pentru informații despre: • Scaunul rulant configurat pentru efectuarea propulsiei manuale - vezi Servicii pentru utilizatorii de scaun rulant - Nivel de bază, Manualul participantului. • Cum pot fi evitate escarele? – vezi Servicii pentru utilizatorii de scaun rulant - Nivel de bază, Manualul participantului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 34 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant A cc id en tu l v as cu la r c er eb ra l Accidentul vascular cerebral este un tip de traumatism cerebral cauzat de tulburări ale circulației sângelui la nivelul creierului(23, 24, 25, 26, 27). Anumite deteriorări sau boli pot duce la blocarea sau fisurarea vaselor sangvine, cauzând deteriorarea sau necrozarea acelei părți a creierului(28, 29, 30, 31, 32). Impactul pe care îl are un accident vascular cerebral depinde de zona cerebrală afectată și de severitatea leziunii produse(29, 31) – totuși, în mod frecvent, afecțiunea este unilaterală (hemiplegie)(28, 31, 28). • lipsa forței, control redus asupra mușchilor și, uneori, prezența durerii pe partea afectată a corpului (membre superioare, trunchi și membre inferioare)(28); • sensibilitatea redusă sau modificată a părții afectate de accidentul vascular cerebral; • lipsa de conștientizare a hemicorpului afectat, ceea ce determină creșterea riscului de accidente în timpul efectuării transferurilor în și din scaunul rulant(28); • în unele cazuri, persoanele afectate pot avea dificultăți în menținerea poziției așezat, trunchiul având tendința de a se înclina înspre partea afectată de accidentul vascular cerebral(28); • persoanele afectate pot avea capacitatea de a se ridica și de a efectua câțiva pași (mersul ar putea fi modificat)(28); • dificultăți de vorbire și de deglutiție, dificultăți în consumul de alimente și lichide(28); • probleme de control al vezicii și al sfincterelor(28) uneori, aceste persoane nu reușesc să ajungă la toaletă în timp util. • Este nevoie de suport postural pentru o poziție echilibrată și simetrică a corpului. • Suporturile de picioare pliabile pe verticală sau pe orizontală sunt foarte eficiente pentru utilizatorii de scaun rulant care pot efectua stând transferul în și din scaunul rulant. • Având în vedere faptul că în mod obișnuit unul din membrele superioare este afectat, multe dintre persoanele care au avut un accident vascular cerebral nu au capacitatea de a realiza propulsia scaunului rulant cu ajutorul brațelor. Aflați dacă utilizatorul de scaun rulant poate realiza propulsia cu brațul neafectat și dacă poate menține direcția scaunului rulant cu ajutorul membrului inferior neafectat. • Dacă utilizatorul de scaun rulant are și alte probleme, care nu au fost abordate până la momentul respectiv, recomandați-i să se adreseze unor servicii cu competențe în domeniu, dacă acestea sunt disponibile. Pentru informații despre: Scaunul rulant configurat pentru propulsia cu ajutorul membrelor inferioare - vezi Servicii pentru utilizatorii de scaun rulant - Nivel de bază, Manualul participantului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 35 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Aspecte de luat în considerare în procesul de furnizare a scaunului rulant A fe cț iu ni le d eg en er at iv e Se știe că există afecțiuni care au o evoluție negativă. Acestea sunt cunoscute ca fiind afecțiuni degenerative. Câteva exemple cunoscute: • distrofia musculară; • boala Parkinson; • scleroza multiplă; • sindromul de neuron motor. Furnizarea suportului corespunzător la momentul potrivit contribuie la prevenirea problemelor posturale. Astfel, utilizatorul de scaun rulant va avea o cât mai bună calitate a vieții, în condițiile existente, pentru o perioadă cât mai îndelungată. Trebuie să avem în vedere următoarele aspecte: • amânarea evaluării poate duce la înrăutățirea posturii; • trecerea unui interval de timp semnificativ între etapa de evaluare și cea de furnizare poate face ca la momentul primirii de către utilizator a scaunului rulant și a pernei, acestea să nu mai fie corespunzătoare; • monitorizarea frecventă este importantă fiindcă gradul de mobilitate și nevoia de suport postural se pot modifica rapid. Dacă un utilizator de scaun rulant are un diagnostic care nu este menționat în formular, notați-l în formular. Dacă nu cunoașteți aspectele legate de acest diagnostic, este recomandabil să vă informați. Gândiți-vă la principalele caracteristici și la modul în care acestea vor avea impact asupra alegerii scaunului rulant. Ce se întâmplă în cazul în care diagnosticul sau afecțiunea nu sunt cunoscute? Uneori, utilizatorul de scaun rulant nu cunoaște diagnosticul sau afecțiunea. De asemenea, este posibil ca diagnosticul să nu fi fost stabilit. În acest caz, identificați orice problemă fizică specifică și continuați evaluarea. Anumite trăsături ale condiției fizice a utilizatorului de scaun rulant pot influența în mod direct alegerea celui mai potrivit scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 36 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant C on st iu ția fr ag ilă Persoanele cu constituția fragilă sunt predispuse la oboseală și deseori sunt mai puțin active din punct de vedere fizic. Au un tonus mai scăzut, deplasându-se foarte lent(29). Constituția fragilă este prezentă cu precădere în cazul adulților vârstnici.(34, 30, 31,). Frecvent, persoanelor vârstnice li se furnizează scaune rulante simple, fără suport postural corespunzător, care nu răspund cerințelor lor(32, 33). Un scaun rulant corespunzător, cu suport postural adecvat, va avea un efect pozitiv asupra calității vieții persoanelor cu constituție fragilă, indiferent de vârstă(37, 34, 35). • stare de oboseală care se instalează rapid; • forță limitată pentru realizarea propulsiei; • dificultăți în menținerea poziției așezat, din cauza oboselii și lipsei de forță, în general; • riscul apariției escarelor determinată de: – stratul de piele subțiat (asemănătoare hârtiei), care favorizează apariția echimozelor; – intervalul îndelungat necesar vindecării echimozelor/escarelor; – incapacitatea de a se repoziționa independent, din cauza forței reduse. • Evaluați cu atenție gradul de suport postural necesar, luând în considerare faptul că durata de timp de utilizare a scaunului rulant este direct proporțională cu gradul de oboseală și cu cel de suport postural de care are are nevoie utilizatorul. • Caracteristici utile ale scaunului rulant: – suporturi de brațe - reprezintă suport postural suplimentar și punct de sprijin pentru ridicarea corpului în timpul realizării transferului în și din scaunul rulant; – suporturi de picioare care pot fi pliate, în vederea facilitării efectuării transferului în poziția stând, pentru persoanele care pot adopta această poziție; – mânere pentru manevrarea scaunului rulant de către însoțitori; – un scaun rulant cu greutate redusă, pentru efectuarea propulsiei, astfel încât utilizatorul să aibă nevoie de un consum de energie mai redus. Pentru informații despre: • Cum pot fi prevenite escarele? – vezi Servicii pentru utilizatorii de scaun rulant - Nivel de bază, Manualul participantului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 37 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Aspecte de luat în considerare în procesul de furnizare a scaunului rulant S pa sm el e / m iș că ri le n ec on tr ol at e Există persoane care au probleme cauzate de mișcările involuntare, bruște. Acestea se numesc spasme. Spasmele pot fi declanșate de diferiți factori, inclusiv de: • poziția șoldului, genunchiului și a gleznei; • atingere; • deplasarea scaunului rulant, în special pe teren accidentat/ denivelat. • Identificați modul în care mișcările necontrolate afectează utilizatorul de scaun rulant și încercați să găsiți o soluție împreună cu acesta. • Există tipuri de suport sau modificări aduse scaunului rulant care au ca rezultat reducerea spasmelor și mișcărilor necontrolate: – suport pentru controlul posturii bazinului; – ajustarea unghiului dintre suprafața de ședere și spătarul scaunului rulant, în așa fel încât șoldurile utilizatorului să fie flectate într-un grad mai mare decât în poziția neutră de ședere; – poziționarea suporturilor de picioare astfel încât genunchii să fie flectați într-o mai mare măsură decât în poziția neutră, orientând picioarele înspre înapoi; – testarea mai multor unghiuri de poziționare a suporturilor de picioare. • Centurile au ca efect un grad de control mai ridicat asupra membrelor inferioare. Centura trebuie să se închidă cu material de tip Velcro, astfel încât să poată fi desfăcută în cazul în care utilizatorul cade din scaunul rulant. • Dacă mișcările necontrolate sunt foarte puternice, se recomandă: – o suprafață de ședere și un spătar solide; – alegerea unui scaun rulant la care există opțiunea reglării poziției roților din spate. Roțile din spate pot fi plasate în poziția „de siguranță” pentru a face scaunul rulant mai stabil, reducând riscul răsturnării acestuia; – folosirea unei bare anti-răsturnare, astfel încât scaunul rulant să nu se încline înspre înapoi. Este important ca la finalul etapei de probare a produsului (a scaunului rulant), utilizatorul să încerce efectuarea propulsiei, pentru a vedea dacă această activitate cauzează apariția spasmelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 38 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant H ip er to ni a - h ip ot on ia Termenul de „tonus muscular” se referă la gradul de rezistență/ tensiunea din mușchiul aflat în repaus, în momentul mișcării acestuia(36). Tonusul muscular normal permite mișcarea liberă și facilă a membrului sau a articulației. Există persoane cu un tonus muscular accentuat sau redus. Hipertonia: Gradul de rezistență/tensiune este accentuat – așadar, mobilitatea la nivelul unui membru sau a unei articulații este redusă37). În acest caz, mobilitatea unui membru sau a unei articulații creează dificultăți sau pare nefirească, iar mișcarea va fi lentă. Unele persoane aflate în această situație se pot mișca doar într-un anumit mod, într-un tipar „fix”(42). Dacă tonusul muscular este foarte accentuat, aproape nicio mișcare nu este posibilă. (continuarea pe pagina următoare) Dificultatea cauzată de tonusul muscular depinde de gravitatea problemei și de mușchii afectați. Efectele problemelor legate de tonusul muscular sunt: • echilibru precar(38); • dificultăți în menținerea poziției așezat și starea de disconfort(43); • control redus asupra mușchilor(43) care influențează ușurința cu care utilizatorul de scaun rulant desfășoară anumite activități, inclusiv propulsia scaunului rulant și realizarea transferului; (continuarea pe pagina următoare) Atunci când lucrați cu un utilizator de scaun rulant cu hipertonie sau hipotonie/asistați la realizarea transferului se recomandă: • să explicați ce urmează să faceți, înainte de a desfășura acțiunea (42); • să vă mișcați lent și să acordați corpului utilizatorului de scaun rulant timpul necesar să reacționeze; • să oferiți sprijin ferm, fără a produce disconfort, cu ajutorul mâinilor și brațelor, în așa fel încât utilizatorul de scaun rulant să fie bine susținut; • când hipertonia duce la rigidizarea întregului corp sau a unui membru, încercați flexia unei articulații. De exemplu, dacă membrul inferior este în extensie, flexia genunchiului sau a șoldului poate reduce gradul de tensiune musculară. (continuarea pe pagina următoare) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 39 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant H ip er to ni a - h ip ot on ia (c on tin ua re ) Hipotonia: Tensiunea la nivelul musculaturii este mai mică, așadar este mai facilă mișcarea pasivă a membrului sau a articulației(41). Totuși, persoanelor cu hipotonie li se poate părea dificilă inițierea mișcării și controlul acesteia. Tonusul muscular redus este câteodată descris ca „flasc”(41). Dacă hipotonia este foarte accentuată, mobilitatea constituie o problemă severă. Cine are probleme cu tonusul muscular? Problemele legate de hipertonie sau hipotonie au consecințe negative asupra unora dintre utilizatorii de scaun rulant. Acestea sunt destul de frecvente în rândul persoanelor cu paralizie cerebrală(42), traumatism cranio-cerebral(43), traumatism vertebro-medular (39) și accident vascular cerebral (40). • în cazul hipertoniei și a hipotoniei, deglutiția și respirația pot fi îngreunate(41). Inspirarea unor bucăți de alimente sau a lichidelor) este un risc major pentru sănătatea persoanelor afectate de hipertonie sau hipotonie(43); • există, de asemenea, riscul apariției posturilor fixe non- neutre(42). În unele cazuri, hipertonia se poate agrava pe fond emoțional puternic sau atunci când persoana depune eforturi deosebite pentru a desfășura o anumită acțiune(42, 43) Hipertonia și hipotonia constituie un factor de risc care favorizează apariția luxațiilor de șold(42). Gradul de suport postural necesar va fi identificat în urma evaluării utilizatorului de scaun rulant. Mai jos găsiți câteva recomandări pentru utilizatorii de scaun rulant la care este prezentă hipertonia: • dispozitivele de suport postural trebuie să fie suficient de puternice pentru a fi eficiente în hipertonie; • hipertonia poate crea puncte unde se exercită un grad ridicat de presiune, la contactul dintre corpul utilizatorului și scaunul rulant. Reduceți presiunea distribuind forța exercitată pe o suprafață mai mare. Verificați nivelul presiunii. Instruiți utilizatorul de scaun rulant sau membrii familiei/însoțitorii cu privire la verificarea suprafeței pielii, pentru a identifica semnele cauzate de presiune; • micșorați unghiul dintre coapsă și trunchi pentru a reduce manifestările puternice de hipertonie. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 40 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant A m pu ta ția d e m em br u in fe ri or Amputația de membru inferior poate fi rezultatul unei traume, de ex. accident rutier, accident la locul de muncă sau răni din război(43, 44, 45). În alte situații, amputația de membru inferior este o procedură chirurgicală planificată. Un număr tot mai mare de persoane sunt supuse procedurii de amputație unilaterală sau bilaterală a membrului inferior, ca efect secundar asociat diabetului(46, 47, 48). Multe dintre persoanele cu amputație unilaterală sau bilaterală au capacitatea de a se deplasa, acest lucru fiind posibil cu ajutorul protezelor și/sau dispozitivelor asistive pentru deplasare(48, 49). Altele, au nevoie de un scaun rulant pe o anumită perioadă de timp sau permanent(48, 49, 50). • atunci când sunt instruite în ceea ce privește abilitățile de manevrare a scaunului rulant, aceste persoane pot fi foarte active în calitate de utilizatori; • centrul de echilibru al scaunului rulant se schimbă, deoarece în partea frontală a scaunului greutatea este mai mică; • persoanele diagnosticate cu diabet, care au trecut printr-o procedură de amputație, sunt mai expuse riscului de apariție a escarelor, deoarece pielea lor nu se vindecă la fel de bine în urma tăieturilor și a loviturilor(49). • La prima configurare a scaunului rulant pentru o persoană cu amputație, roțile din spate se setează în poziție posterioară extremă (dacă se pot ajusta), pentru a reduce riscul răsturnării înspre înapoi a scaunului rulant. Utilizatorii activi pot învăța rapid modalitatea de a echilibra scaunul, iar apoi roțile din spate pot fi aduse într-o poziție mai avansată. • Atunci când furnizați instruire legată de abilitățile de manevrare: – fiți foarte atenți de fiecare dată când o persoană cu amputație încearcă pentru prima oară un scaun rulant; – predați aceste abilități cu mare grijă, deoarece există un risc mai mare ca utilizatorul de scaun rulant să se răstoarne înspre înapoi. • Este important să știm dacă utilizatorul dorește să poarte proteza în timpul utilizării echipamentului de mobilitate, deoarece acest aspect poate schimba modalitatea de reglare a scaunului rulant. Pentru informații despre: • Cum pot fi prevenite escarele? – vezi Servicii pentru utilizatorii de scaun rulant - Nivel de bază, Manualul participantului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 41 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant O bo se al a Există utilizatori de scaun rulant care, în mod regulat, ating un grad accentuat de oboseală pe parcursul utilizării cotidiene a scaunului rulant. Acest fapt este determinat de efortul depus, de consumul suplimentar de energie pe care le presupune menținerea poziției așezat și efectuarea diferitelor activități. De asemenea, este un efect al tipului de afecțiune. Oboseala se întâlnește în cazul persoanelor vârstnice sau a celor care suferă de afecțiuni degenerative(50, 51). • persoana este capabilă să mențină poziția așezat, dar nu pe o durată îndelungată, din cauza oboselii; • dacă starea de oboseală împiedică utilizatorul să mențină poziția așezat, acesta este mai expus riscului apariției problemelor posturale. • Încercați să aflați care este sursa stării de oboseală a utilizatorului de scaun rulant. Acest lucru vă va ajuta să găsiți cea mai bună soluție pentru el. • Când decideți care este gradul de suport postural de care urmează să beneficieze utilizatorul, luați în calcul efectele oboselii. Pe parcursul evaluării, utilizatorul de scaun rulant poate avea un nivel de energie mai ridicat, dând impresia că are nevoie de un grad de suport mai scăzut. Discutați pentru a vedea care este nevoia reală de suport postural în contextul în care utilizatorul resimte starea de oboseală. • Luați în considerare poziții alternative, pentru odihnă - de exemplu, o măsuță cu pernă poate permite utilizatorului să se aplece înspre înainte, rezemându-se pe brațe; înclinarea în spațiu a spătarului constituie o alternativă. • Planificarea pauzelor destinate odihnei, pe parcursul zilei – în aceste intervale nu se va utiliza scaunul rulant. Rezultatul scontat este prelungirea duratei de timp pe care utilizatorul o poate petrece în scaunul rulant fără a resimți disconfort. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 42 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Aspecte de luat în considerare în procesul de furnizare a scaunului rulant Lu xa ția d e șo ld Luxația de șold apare mai frecvent la copiii care nu au avut niciodată capacitatea de a se deplasa independent(52, 53, 54). Acest lucru este determinat de faptul că articulația (acetabulul) bazinului este moale la naștere, iar capul rotund al femurului modelează cavitatea în timpul mișcării piciorului sau prin greutatea exercitată atunci când persoana se află în poziția stând. Dacă articulația șoldului nu se formează corespunzător, se poate produce luxația. Luxația de șold se întâlnește deseori în cazul copiilor care au musculatura rigidă și hipertonie la nivelul șoldului și bazinului și care au tendința de a ține picioarele orientate într-o parte atunci când sunt în poziția așezat sau de decubit.(55). Poate fi o problemă la persoanelor cu paralizie cerebrală(57, 60) sau traumatism cranio-cerebral(56). • Factorii care indică existența unei luxații/subluxații a șoldului sunt: – unul dintre membrele inferioare pare mai scurt decât celălalt(60); – membrul inferior este tot timpul poziționat mai aproape de linia mediană a corpului; – mișcarea la nivelul șoldului provoacă durere(60); – atunci când se efectuează gama de mișcări pentru șold, coapsa atinge poziția neutră de ședere și nu depășește linia trunchiului; – nu este posibilă extensia completă a șoldurilor. • Cercetările arată că următoarele aspecte pot reduce riscul producerii luxației de șold: – suportul furnizat pentru menținerea poziției așezat și de decubit încă de la o vârstă fragedă. În cazul copiilor mici, acest lucru înseamnă susținerea șoldurilor/coapselor în abducție(57, 58); – poziția stând într-o postură naturală (de exemplu, într-un verticalizator) (63). Lu xa ția d e șo ld În cazul copiilor care nu au mers niciodată și care au tendința de a ține picioarele orientate într-o parte în poziția așezat sau de decubit, șoldul predispus la a fi luxat este cel care se află cel mai aproape de linia mediană a corpului (adductat) și întors către interior (rotație internă)(59). Atunci când copiii prezintă hipotonie la nivelul articulației șoldului, ei sunt expuși riscului de luxație de șold. Acest lucru este cauzat de faptul că mușchii și ligamentele nu sunt suficient de puternice pentru a ține împreună cele două părți ale articulației șoldului (acetabulul și capul femurului). Luxația de șold nu provoacă întotdeauna durere.(60, 61, 62). • Atunci când evaluați un copil sau un adult la care identificați oricare dintre elementele ce pot indica o luxație de șold, mișcarea la nivelul șoldului utilizatorului trebuie să fie ușoară. Evitați să îi produceți durere prin acțiunile desfășurate. • Dacă nu sunteți siguri că adultul sau copilul are o luxație de șold, sfătuiți utilizatorul să apeleze la un medic/ pediatru sau fizioterapeut experimentat (dacă acest lucru este posibil). • Atunci când furnizați un scaun rulant sau dispozitiv de suport postural unui copil sau adult cu luxație de șold sau la care suspectați existența unei luxații de șold: – evitați posturile are pot cauza durere; – sprijiniți bazinul și trunchiul în poziția neutră (sau cât mai aproape de poziția neutră); apoi sprijiniți șoldurile și coapsele cât mai aproape de poziția neutră, în limita posibilităților. Evitați „supracorectarea” posturii membrelor inferioare, deoarece acest lucru poate cauza deplasarea șoldului din poziția neutră și/sau dureri. – verificați care este postura obișnuită în timpul somnului. Recomandați o poziție prin care membrele inferioare să nu aibă tendința de a fi orientate într-o parte sau de a avea un grad accentuat de adducție. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 43 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant Ep ile ps ia Epilepsia este o tulburare a activității cerebrale normale, care determină apariția convulsiilor(63, 64, 65, 66). În anumite circumstanțe, orice persoană poate avea convulsii(70). Termenul epilepsie este folosit doar pentru atacuri care apar în mod repetat, neprovocate(69, 70). Ce putem face în cazul în care apar convulsiile pe parcursul etapei de evaluare pentru prescrierea scaunului rulant: Când un utilizator de scaun rulant are convulsii minore, așteptați încetarea acestora și continuați evaluarea. Dacă utilizatorul de scaun rulant are convulsii majore, prioritatea o constituie siguranța acestuia. Dacă corpul utilizatorului cade înspre înainte, încercați să amortizați căderea. Dacă utilizatorul de scaun rulant este un copil sau un adult de statură mică, puteți să îl ridicați de pe podea în condiții de siguranță. Dacă acesta este un adult cu o înălțime și o greutate mai mari, nu îl mutați (pentru a evita riscul de rănire a celor care efectuează evaluarea) și, după încetarea convulsiilor, îl veți ridica gradual, cu ajutorul colegilor/membrilor familiei sau a însoțitorului. Atunci când furnizați un scaun rulant unei persoane diagnosticate cu epilepsie, nu uitați următoarele: • utilizatorul de scaun rulant va avea nevoie de centuri care pot fi deschise cu ușurință în vederea realizării transferului din scaunul rulant. Ep ile ps ia Unii utilizatori de scaun rulant sunt diagnosticați cu epilepsie. Convulsiile pot fi parțiale sau generalizate(70). Pe parcursul unei convulsii parțiale, persoana poate să își piardă sau nu cunoștiința. În cazul în care starea de cunoștință nu este afectată, convulsiile durează mai puțin de un minut și, de obicei, apar mișcări necontrolate(67). Atunci când starea de cunoștință este afectată, convulsiile durează unul sau două minute și persoană este parțial conștientă de ceea ce se întâmplă, dar nu poate reacționa sau nu își poate schimba comportamentul(70, 73). În cazul unei convulsii generalizate, persoana prezintă o pierdere totală a cunoștinței(70). Aceasta poate surveni bursc și există riscul ca persoana să se rănească. (70). Pe durata convulsiiilor: • nu încercați să transferați utilizatorul din scaunul rulant, excepție situația în care în cavitatea bucală există lichide, alimente sau vomă. În acest caz, transferați utilizatorul din scaunul rulant și poziționați-l în decubit lateral, astfel încât saliva și mucozitățile să poată fi eliminate din cavitatea bucală(70, 73); • creați spațiu în jurul utilizatorului de scaun rulant pentru a-l proteja de rănire sau îndepărtați-l de orice obiect care ar putea provoca rănirea(70); • protejați capul utilizatorului de scaun rulant prin plasarea unui obiect moale sub acesta(70, 73); • lărgiți obiectele de îmbrăcăminte strâmte, îndepărtați orice obiect care îl poate răni și asigurați-vă că scaunul rulant nu reprezintă un pericol(70, 73); • cronometrați perioada convulsiilor și oferiți această informație utilizatorului de scaun rulant sau însoțitorului, după finalizarea convulsiilor (70); Așteptați calm, împreună cu utilizatorul de scaun rulant, încetarea convulsiilor. Apelați la personal medical dacă: • utilizatorul de scaun rulant nu își recapătă cunoștința după oprirea convulsiilor(68); • convulsiile au o durată mai mare de cinci minute(69). • dacă utilizatorul de scaun rulant are în mod frecvent convulsii care cauzează căderea bruscă înspre înainte a corpului, acoperiți măsuța cu un material moale, pentru ca acesta să nu se rănească la cap; • dacă epilepsia nu a fost tratată, recomandați-i să apeleze la un medic. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 44 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Informații generale Aspecte de luat în considerare în procesul de furnizare a scaunului rulant P ro bl em el e de d eg lu tiț ie Există copii sau adulți care au dificultăți în ceea ce privește deglutiția. Dificultățile legate de consumul de alimente și lichide pot fi cauzate de faptul că utilizatorul nu reușește să ducă alimentele și lichidele la gură. De exemplu, dacă utilizatorul de scaun rulant are un control redus al brațelor sau al mâinilor, consumul de alimente sau lichide va fi îngreunat. Alternativ, există probleme ale musculaturii la nivelul capului, gâtului, cavității bucale și, al mușchilor care controlează deglutiția(70). Situația este agravată uneori de echilibrul precar și de dificultățile în menținerea poziției așezat sau a capului într-o poziție echilibrată(71). Problemele de deglutiție determină uneori pătrunderea în plămâni a unor bucăți de alimente sau a lichidelor, ceea ce poate duce la infecții pulmonare(72, 73, 74, 75, 76) și la îmbolnăvirea gravă a utilizatorului(77). Elemente care indică tulburări de deglutiție: • tuse care apare în mod frecvent în timpul consumului de lichide(78); • senzația de lipsă de aer care apare în mod frecvent în timpul consumului de alimente și lichide(84); • salivare constantă. Când furnizați un scaun rulant unei persoane cu probleme de deglutiție, luați în considerare următoarele: • suportul postural corespunzător îmbunătățește echilibrul, postura, controlul asupra capului și membrelor superioare și reduce dificultățile legate de deglutiție; • de multe ori, sunt necesare o măsuța și/sau tetiere. Dacă un utilizator de scaun rulant are tulburări de deglutiție, recomandați-i să apeleze la un specialist, (de exemplu, un pediatru, logoped, terapeut ocupațional sau o persoană cu experiență în domeniul îngrijirii medicale a copiilor). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 45 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Informații generale Caracteristici de bază care au impact asupra procesului de furnizare a scaunului rulant Aspecte de luat în considerare în procesul de furnizare a scaunului rulant D ur er ea • Este foarte important să știm dacă utilizatorul de scaun rulant resimte orice fel de durere, deoarece acest aspect poate afecta capacitatea sa de a sta confortabil în scaunul său rulant. • Dacă utilizatorul de scaun rulant simte frecvent durere, personalul furnizor de servicii de scaune rulante trebuie să îl direcționeze către un medic/clinică pentru a descoperi cauza durerii, deoarece ignorarea ei poate fi periculoasă. • Pentru a evita cauzarea durerii pe parcursul evaluării: – întrebați utilizatorul dacă există o anumită poziție care agravează senzația de durere; astfel de poziții trebuie evitate; – întrebați dacă anumite mișcări sau poziții diminuează senzația de durere; pe parcursul evaluării apelați la acestea; – dacă utilizatorul de scaun rulant nu poate comunica verbal, înainte de începerea evaluării trebuie identificată o altă metodă de comunicare; – suportul corespunzător și schimbarea poziției pot preveni sau reduce senzația de durere. P ro bl em e de m an ag em en t u ri na r și in te st in al • Unii utilizatori de scaun rulant au dificultăți în ceea ce privește controlul la nivelul vezicii sau cel al sfincterelor. Deseori, aceste probleme pot fi administrate cu ajutorul unor dispozitive corespunzătoare (de ex., cateter), al medicamentelor, programelor de instruire pentru management urinar și intestinal. • Este important de știut la cine pot apela utilizatorii de scaun rulant pentru sfaturi și instruire, astfel încât să fie evitate complicațiile (de exemplu, medici sau asistenți medicali de specialitate). • Uneori, utilizatorii de scaun rulant care au un control redus al vezicii sau al sfincterelor au dificultăți și în a comunica faptul că au nevoie să meargă la toaletă. Ei sunt expuși riscurilor ce decurg din această situație. • Personalul furnizor de servicii pentru utilizatorii de scaun rulant trebuie să știe că atunci când lucrează cu utilizatori care au probleme de management urinar și intestinal, există riscuri în ceea ce privește menținerea stării de curățenie. De aceea, sunt importante condițiile adecvate pentru spălarea mâinilor și mijloacele necesare curățării suprafeței unde se lucrează cu utilizatorii. • O pernă umedă sau pătată va cauza iritarea suprafeței pielii. În plus, bacteriile prezente în fecale pot duce rapid la escare infectate. Substanțele eliminate prin urină și fecale vor cauza infectarea rănilor și iritarea suprafeței pielii. • Perna și husa trebuie să fie ușor de îndepărtat pentru a permite utilizatorului/ însoțitorului curățarea acestora. • Furnizați o pernă cu husă impermeabilă. Dacă este posibil, oferiți două huse, pentru a permite utilizatorului de scaun rulant continuarea activităților zilnice în timp ce una dintre huse se usucă. • Dacă nu sunt disponibile huse impermeabile, furnizați două perne. • Recomandați utilizatorului de scaun rulant să apeleze la o persoană care îl poate ajuta în ceea ce privește managementul urinar și intestinal, pentru menținerea stării de sănătate și evitarea incidentelor legate de controlul la nivelul vezicii și al sfincterelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 46 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Stilul de viață și mediul Descrieți mediul în care va fi utilizat scaunul rulant: ____________________________ Distanța zilnică parcursă: Până la 1 km 1–5 km Mai mult de 5 km Durata zilnică de utilizare a scaunului rulant: Mai puțin de 1 oră 1–3 ore 3–5 ore 5–8 ore mai mult de 8 ore Care este poziția utilizatorul atunci când nu folosește scaunul rulant (poziția și tipul de suprafață)? ___ ____________________________________________________________ Transfer: Independent Asistat În picioare Așezat Ridicat Altele Tipul de toaletă (dacă se face transferul la toaletă): La nivelul solului Tipică Adaptată Utilizatorul de scaun rulant folosește în mod frecvent mijloace de transportul în comun/proprii? Da Nu Dacă da, de care: Autoturism Taxi Autobuz Altele __________________ Rubrica referitoare la „stil de viață și mediu” din formularul de evaluare - nivel intermediar se referă la informații legate de locul în care trăiește utilizatorul și la activitățile pe care trebuie să le desfășoare în timpul folosirii scaunului rulant. Este important să luați în considerare modul în care scaunul rulant și orice dispozitiv de suport postural suplimentar furnizat îl vor ajuta pe utilizator să își gestioneze mediul și stilul său de viață, folosindu-se în cel mai înalt grad posibil de abilitățile pe care le are. Întrebări legate de stilul de viață și de mediul utilizatorului de scaun rulant, cuprinse în formularul evaluare - nivel intermediar. Discuție Descrieți mediul în care va fi utilizat scaunul rulant • Utilizarea scaunului rulant trebuie să fie o activitate practică, atât la domiciliu, cât și la locul de muncă sau la școală. De exemplu: – dacă scaunul rulant va fi folosit acasă, utilizatorul trebuie să fie capabil să se deplaseze în interiorul casei, pentru a desfășura cu ușurință activitățile zilnice; – un utilizator care lucrează într-un birou va avea nevoie de un scaun rulant care să încapă cu ușurință în spațiul biroului; – un utilizator care merge la școală va avea nevoie de un scaun rulant care să încapă fără probleme în sala de curs și să poată fi poziționat lângă pupitru, alternativ, să fie dotat cu o măsuță atașată. – un utilizator care trebuie să se deplaseze la piață sau la locul de muncă pe un drum denivelat, va avea nevoie de un scaun rulant care să poată fi manevrat corespunzător pe acest tip de suprafață. Distanța parcursă zilnic • La fel ca în cazul persoanelor care merg pe jos pe distanțe scurte, dar folosesc bicicleta pentru distanțele mai lungi, utilizatorul de scaun rulant are nevoie de un scaun rulant pentru distanțele scurte și de o tricicletă pentru deplasarea pe distanțe mai mari. • O tricicletă presupune un consum de energie mai mic și reduce durata de timp necesară deplasării. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 47 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Întrebări legate de stilul de viață și de mediul utilizatorului de scaun rulant, cuprinse în formularul evaluare - nivel intermediar. Discuție Durata zilnică de utilizare a scaunului rulant • Cu cât durata zilnică de utilizare a scaunului rulant este mai mare, cu atât este mai expus utilizatorul riscului de apariție a escarelor sau instalării senzației de oboseală. Gândiți-vă la gradul de suport de care are nevoie utilizatorul de scaun rulant și dacă perna contribuie în mod corespunzător la reducerea nivelului de presiune și la confortul utilizatorului de scaun rulant. • Pentru orice utilizator care este „activ” pe parcursul folosirii zilnice a scaunului rulant, echipamentul de mobilitate trebuie configurat astfel încât realizarea propulsiei și desfășurarea altor activități să fie cât mai facilă. Poziția roților este importantă. De asemenea, este important să verificați dacă spătarul susține utilizatorul, fără a restricționa libertatea de mișcare la nivelul omoplaților. Care este poziția utilizatorul atunci când nu folosește scaunul rulant (poziția și tipul de suprafață)? • Dacă un utilizator de scaun rulant menține aceeași poziție pe perioade mai îndelungate, postura poate deveni rigidă și, în final, se va permanentiza. În consecință, poate deveni imposibilă găsirea unei posturi confortabile în scaunulul rulant. • Este foarte important să evităm această situație și să-i oferim utilizatorului de scaun rulant diferite opțiuni pentru adoptarea unor poziții confortabile în poziția așezat sau cea de decubit, atunci când nu folosește scaunul rulant. • Utilizatorul de scaun rulant are mereu aceeași postură atunci când se află în poziția așezat sau de decubit? – dacă este posibil, solicitați utilizatorului să vă arate respectiva postură; – este important să cunoaștem postura pe care o preferă utilizatorul, pentru a putea sugera una care să contracareze efectele. Uneori, nu este posibilă trecerea directă la poziția opusă. Dacă utilizatorul a adoptat postura preferată pe o perioadă lungă de timp, trecerea directă la o postură complet opusă poate fi inconfortabilă, neobișnuită sau chiar să producă neliniște; – căutați modalități prin care să fie sprijinite trunchiul și membrele, astfel încât bazinul să se afle cât mai aproape de poziția neutră, iar postura utilizatorului să fie una cât mai confortabilă. • Utilizatorul de scaun rulant poate să își schimbe poziția? – dacă utilizatorul nu își poate schimba poziția, el este expus într-o mai mare măsură riscului apariției problemelor posturale și a escarelor. Transferul • Suporturile de brațe și cele de picioare pot afecta modul în care utilizatorul realizează transferul în și din scaunul rulant: – pentru transferurile efectuate în poziția stând, este recomandabil să existe suporturi de picioare pliabile și suporturi de brațe pe care utilizatorul le poate folosi pentru sprijin; – pentru transferurile în poziția așezat, sunt utile suporturile care pot fi demontate sau cele care urmează profilul roții; – când furnizați suport postural suplimentar, verificați dacă utilizatorul poate efectua transferul cu ușurință. De exemplu, prin adăugarea unei suprafețe de ședere sau a unei perne cu inserție unghiulară, transferul în și din scaunul rulant poate deveni mai dificil. În acest caz, va fi nevoie de schimbarea tehnicii de transfer sau de alegerea unui alt dispozitiv de suport postural. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 48 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Întrebări legate de stilul de viață și de mediul utilizatorului de scaun rulant, cuprinse în formularul evaluare - nivel intermediar. Discuție Tipul de toaletă • Tipul toaletei și accesul la aceasta vor afecta ușurința cu care utilizatorul o va folosi. • Folosirea toaletei poate să fie imposibilă din cauza design-ului acesteia. De exemplu, cei mai mulți utilizatori de scaun rulant au dificultăți mari în utilizarea tipului de toaletă situată la nivelul solului. • Personalul furnizor de servicii de scaune rulante trebuie să ceară informații despre tipul de toaletă și de spațiul unde este situată aceasta, pentru a putea da sfaturi legate de transfer. De asemenea, pot fi formulate recomandări cu privire la adaptarea toaletei. Utilizatorul de scaun rulant folosește în mod frecvent transportul public/privat? • Dacă utilizatorul folosește frecvent mijloace de transport în comun, scaunul rulant trebuie să poată fi transportat cât mai ușor. Există câteva caracteristici care facilitează transportarea sa: – scaunele rulante cu greutate mai mică sunt mai ușor de ridicat; – roțile detașabile și cadrul și/sau spătarul pliant ușurează transportarea scaunului rulant. • Dacă se folosește transportul public, părțile detașabile oferă un avantaj, deoarece astfel scaunul rulant este mai ușor de manipulat. Totuși, părțile detașabile constituie uneori și un dezavantaj, deoarece ele pot fi descompletate, pierdute sau chiar furate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 49 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Scaunul rulant existent (dacă persoana are deja un scaun rulant) Scaunul rulant corespunde cerințelor utilizatorului? Da Nu Scaunul rulant corespunde condițiilor din mediul utilizatorului? Da Nu Este scaunul rulant potrivit și oferă suport postural corespunzător? Da Nu Este scaunul rulant sigur și durabil? (Există sau nu o pernă?) Da Nu Perna oferă o reducere a presiunii adecvată (previne riscul apariției escarelor)? Da Nu Comentarii: _______________________________________________________________ Dacă răspunsul este ”da” la toate întrebările, atunci este posibil ca utilizatorul să nu aibă nevoie de alt scaun rulant. Dacă răspunsul la oricare din aceste întrebări este ”nu”, atunci utilizatorul are nevoie fie de un alt scaun rulant, fie de o altă pernă ori scaunul rulant sau perna au nevoie de reparații, respectiv de modificări. Dacă utilizatorul are deja un scaun rulant, este important să aflăm dacă acesta corespunde cerințelor sale. Secțiunea referitoare la „scaunul rulant existent” din formularul de evaluare - nivel intermediar ajută personalul furnizor de servicii de scaune rulante și utilizatorul să stabilească dacă scaunul rulant existent este unul corespunzător. Atunci când verificați starea scaunului rulant, fiți atenți la suprafețe, deoarece acestea pot oferi indicii cu privire la poziția utilizatorului. De exemplu, o pernă uzată pe o parte poate însemna faptul că există un nivel de presiune mai ridicat pe acea parte a oaselor bazinului; similar, suportul de brațe deteriorat pe una dintre laterale indică faptul că utilizatorul se apleacă puternic în acea parte. Dacă observați ceva neobișnuit, cereți utilizatorului de scaun rulant mai multe informații. Dacă scaunul rulant nu corespunde nevoilor utilizatorului, personalul furnizor de servicii de scaune rulante trebuie să identifice cauzele. Uneori, scaunul rulant este corespunzător, dar nu a fost reglat corect pentru respectivul utilizator. Modificările, suportul postural suplimentar și reparațiilor pot ajuta la remedierea situației. Bune abilități de comunicare în realizarea interviului de evaluare Cu ajutorul unor bune abilități de comunicare, putem dobândi informații corecte într-o manieră care denotă respect și dovedește empatie, luând în considerare sentimentele și nevoile utilizatorului de scaun rulant. Câteva metode pentru desfășurarea în bune condiții a interviului de evaluare: • adresați-vă întotdeauna utilizatorului de scaun rulant, excepție situațiile în care este vorba despre copii de vârstă mică sau de utilizatori care nu au capacitatea de a înțelege și de a răspunde întrebărilor; • explicați întotdeauna utilizatorului de scaun rulant faptul că aceste informații contribuie la alegerea scaunului rulant corespunzător; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 50 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar • întrebările nu trebuie adresate neapărat în ordinea în care ele se regăsesc în formularul de evaluare - nivel intermediar. Se poate întâmpla ca utilizatorii de scaun rulant să ofere informațiile înainte ca personalul furnizor de servicii de scaune rulante să pună întrebarea. De asemenea, uneori este mai firesc ca întrebările să fie adresate într-o altă ordine. Există situații în care comunicarea verbală este dificilă. De exemplu, atunci când utilizatorul de scaun rulant nu este capabil să vă audă sau nu poate vorbi suficient de clar pentru ca răspunsul să fie înțeles. În acest caz, încercați să găsiți o metodă de a comunica direct cu utilizatorul de scaun rulant. Întrebați acele persoane care îl cunosc cel mai bine pe utilizatorul de scaun rulant care este modalitatea optimă de comunicare. Acordați-vă suficient timp pentru a înțelege cum comunică utilizatorul de scaun rulant. Dacă nu găsiți o modalitate de comunicare directă, asigurați- vă că vă asistă o persoană care cunoaște bine utilizatorul. Solicitați acestei persoane să vă ajute în comunicarea cu utilizatorul de scaun rulant. Cum identificăm senzația de durere atunci când utilizatorul de scaun rulant nu poate comunica verbal? Atunci când un utilizator de scaun rulant nu are capacitatea de a comunica verbal, acestuia îi va fi dificil să comunice faptul că simte senzația de durere. Totuși, personalul furnizor de servicii de scaune rulante trebuie să știe dacă vreuna din acțiunile sale cauzează durere sau dacă o accentuează pe cea existentă. Semne non-verbale ale senzației de durere: • persoana plânge, strigă, este agitată sau transpiră; • persoana împinge mâna celui care efectuează evaluarea sau încearcă să se îndepărteze; • persoana se împotrivește unei anumite mișcări sau este incapabilă să mențină o anumită postură; • expresia feței persoanei – privire încruntată și/sau grimasă; • felul în care persoana stă în poziția așezat, stând sau felul în care merge. Asigurați-vă că nu cauzați senzație de durere sau că nu o accentuați pe cea existentă: • încurajați utilizatorul de scaun rulant să vă anunțe dacă simte senzația de durere pe parcursul evaluării; • în cazul în care comunicarea este dificilă – înainte de a începe evaluarea, stabiliți de comun acord un semn prin care persoana evaluată să vă poată arăta că simte durere; • evitați posturile care accentuează senzația de durere; • recurgeți la posturi sau mișcări care ameliorează senzația de durere. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 51 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Evaluarea fizică – postura în poziția așezat fără suport Evaluarea fizică este cea de-a doua componentă a a acestei etape și cuprinde: • identificarea prezenței, riscului apariției escarelor sau a istoricului escarelor; • identificarea metodei de realizare a propulsiei; • identificarea posturii utilizatorului de scaun rulant și a suportului postural suplimentar necesar prin: – observarea posturii în poziția așezat fără suport; – efectuarea analizei posturii bazinului și a șoldului. Această analiză ajută la înțelegerea modului în care problemele de la nivelul bazinului sau al șoldurilor afectează poziția de ședere a utilizatorului; – efectuarea procedurii de simulare manuală. Folosind mâinile, personalul furnizor de servicii de scaune rulante realizează o „simulare”, a suportului pe care îl oferă scaunul rulant sau suporturile posturale suplimentare; • efectuarea măsurătorilor. Informațiile din fiecare secțiune a formularului de evaluare - nivel intermediar vor ajuta personalul furnizor de servicii de scaune rulante să decidă care este gradul de suport de care are nevoie utilizatorul. Informații despre prezența escarelor, riscul de apariție a acestora sau istoricul lor, precum și metoda de realizare a propulsiei Prezența escarelor, riscul de formare a acestora sau istoricul escarelor /// = lipsă sensibilitate = escară anterioară l = escară existentă stânga față spate dreapta D DS S Sensibilitate normală? Da Nu Escară anterioară? Da Nu Escară existentă? Da Nu Dacă da, este o escară deschisă (fază 1 - 4)? Da Nu Durata și cauza: _________________________ _______________________________________ __________________________ ___________________________________ Există riscul* formării de escare? *Se consideră că există riscul apariției escarelor la persoanele la care sensibilitatea este absentă ori la care sunt prezente 3 sau mai mulți factori de risc. Factori de risc: imobilitatea, umezeala, poziția incorectă, escară anterioară/existentă, regim alimentar neadecvat, înaintarea în vârstă, supraponderabilitatea sau subponderabilitatea. Da Nu Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 52 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Metode de propulsie Cum va efectua utilizatorul propulsia scaunului rulant? Cu membrele superioare Cu membrul superior stâng Cu membrul superior drept Cu ambele membre inferioare Cu membrul inferior stâng Cu membrul inferior drept Cu ajutorul unui însoțitor Comentarii: ______________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Postura în poziția așezat Abrevieri utilizate Structura anatomică Abreviere Creasta iliacă antero-superioară CIAS Creasta iliacă postero-superioară CIPS Tuberozitate ischială TI Au toți utilizatorii de scaun rulant capacitatea de a menține poziția așezat sau poziția neutră de ședere? Nu toți utilizatorii de scaun rulant au capacitatea de a menține poziția așezat, nici măcar cu ajutorul suportului postural. Vom identifica o varietate de posturi la acei utilizatori de scaun rulant care au dificultăți în menținerea poziției așezat. Diferitele posturi sunt rezultatul faptului că o anumită parte (sau mai multe părți) a corpului nu se află în poziția neutră de ședere. Pe parcursul evaluării, personalul furnizor de servicii de scaune rulante și utilizatorul de scaun rulant trebuie să identifice acea poziție în care bazinul se află cât mai aproape de poziția neutră, fără a cauza disconfort și păstrând nivelul de funcționalitate. Aceasta este postura pe care trebuie să o susțină scaunul rulant împreună cu dispozitivele de suport postural. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 53 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Există trei rezultate finale ale evaluării posturii. Acestea sunt: • Postura fixă – o parte a corpului utilizatorului de scaun rulant este „fixă”. Lipsește mobilitatea atunci când se exercită o forță de intensitate redusă (nu trebuie niciodată să folosiți o forță de intensitate crescută). Personalul furnizor de servicii de scaune rulante trebuie să ofere suport pentru acomodarea posturii non-neutre (fixe). • Postura flexibilă spre neutră – prin exercitarea unei forțe de intensitate redusă, acele părți ale corpului utilizatorului care nu se află în poziție neutră pot atinge poziția neutră. În această situație, utilizatorul de scaun rulant are nevoie de suport postural corespunzător pentru menținerea poziției neutre de ședere. • Postura parțial flexibilă spre neutră – prin exercitarea unei forțe de intensitate redusă, poziția acelor părți ale corpului utilizatorului care nu sunt situate în poziție neutră poate fi corectată într-o anumită măsură. În această caz, suportul furnizat trebuie să contribuie la menținerea unei posturi cu bazinul cât mai aproape de poziția neutră, în limitele confortului și a păstrării funcționalității. Postura în poziția așezat la copiii până la vârsta de cinci ani Postura copiilor sub vârstă de cinci ani diferă de cea a copiilor mai mari sau a adulților. Aceasta se dezvoltă în primii cinci ani de viață. Particularitățile în cazul copiilor de până la vârsta de cinci ani sunt: • spatele este plan, fără curburi lombare sau toracice; • urechile se află pe aceeași linie cu șoldurile, totuși umerii sunt orientați puțin înspre înainte; • membrele inferioare sunt orientate către exterior și depărtate (în abducție) - nu paralele. În cazul copiilor sub vârsta de cinci ani, personalul furnizor de servicii de scaune rulante trebuie să rețină faptul că suportul postural furnizat nu este același cu cel utilizat pentru poziția așezat la adulți. În ceea ce îi privește pe copii, poziția specifică adulților poate fi inconfortabilă și poate cauza leziuni. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 54 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Analiza posturii în poziția așezat Punctul de plecare în înțelegerea posturii utilizatorului de scaun rulant și a nevoii de suport postural este observarea posturii sale în poziția așezat fără suport. În acest stadiu al evaluării fizice, utilizatorul de scaun rulant este poziționat pe un pat de evaluare. Asigurați-vă că utilizatorul de scaun rulant este în siguranță și că picioarele îi sunt susținute de suprafața pe care se află. Se recomandă ca un asistent sau un membru al familiei/însoțitor să stea așezat lângă utilizatorul de scaun rulant, din motive de siguranță (dacă nu poate menține poziția așezat fără suport). Verificați dacă utilizatorul de scaun rulant poate sta într-o poziție neutră/poziție așezat fără suport. Scopul observării posturii în poziția așezat fără suport este înțelegerea tendințelor/obiceiurilor posturale ale utilizatorului de scaun rulant. Observarea posturii este o abilitate, iar însușirea acestei deprinderi necesită timp și exercițiu. Cum ne dăm seama dacă un utilizator de scaun rulant menține poziția așezat Postura în poziția așezat descrisă mai jos trebuie folosită ca model de către personalul furnizor de servicii de scaune rulant. Atunci când se lucrează cu utilizatorii de scaun rulant, obiectivul este furnizarea de suport, de așa manieră încât postura finală să aibă cât mai multe din caracteristicile posturii prezentare aici. Totodată, ea trebuie să fie confortabilă, practică și funcțională. Priviți din lateral și verificați: Bazinul este drept – creasta iliacă antero-superioară (CIAS) și cea postero-superioară (CIPS) se află la același la nivel; Trunchiul este drept; Spatele urmează cele trei curburi fiziologice; La adulți - urechea, umărul și șoldul se află pe aceeași linie. La copii - urechea și șoldul se află pe aceeași linie, cu umerii orientați puțin înspre înainte; Șoldurile flectate la aproximativ 90 grade; Genunchii și gleznele în flexie de aproximativ 90 grade; Călcâiele sunt fie pe aceeași linie cu genunchii, fie într-o poziție puțin mai avansată sau mai retrasă; Picioarele sprijinite pe sol sau pe suportul de picioare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 55 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Priviți din față și verificați: Bazinul în echilibru – creasta iliacă antero-superioară dreaptă și stângă la același nivel; Umerii sunt la același nivel și sunt relaxați, membrele superioare au libertate de mișcare; Membrele inferioare ușor depărtate (în abducție); Capul drept și în echilibru deasupra corpului; Descrierea posturii Formularul de evaluare – nivel intermediar include o rubrică pentru înregistrarea caracteristicilor posturii corpului în poziția așezat fără suport. Postura corpului în poziția așezat fără suport Datele înregistrate vor ajuta personalul furnizor de servicii de scaune rulante să rețină și după finalizarea evaluării detaliile legate de postura utilizatorului în poziția așezat. De asemenea, va ajuta la monitorizarea în timp a modificărilor de postură. Există mai multe metode de înregistrare a posturii, inclusiv: • descrierea posturii cu ajutorul cuvintelor; • desenarea unei imagini; • efectuarea fotografiilor (doar cu permisiunea utilizatorului de scaun rulant). Descrieți sau desenați postura în poziția așezat fără suport: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 56 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Mai jos sunt exemple de schițe care pot fi folosite pentru înregistrarea poziției de ședere. Schiță a posturii – vedere laterală. Schiță a posturii – vedere din față. Rețineți! • Nu toate persoanele au capacitatea de a menține poziția așezat. • Pe parcursul evaluării, personalul furnizor de servicii de scaune rulante și utilizatorii colaborează pentru a identifica postura în care bazinul se află cât mai aproape de poziția neutră de ședere, fără a produce disconfort utilizatorului de scaun rulant. • Un scaun rulant cu suport postural suplimentar trebuie să susțină utilizatorul într-o poziție așezat cu bazinul cât mai aproape de poziția neutră de ședere, fără să producă disconfort. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 57 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Evaluarea fizică – analiza posturii bazinului și a șoldului Analiza posturii bazinului și a șoldului Postura în poziția așezat este influențată de poziția bazinului și a șoldurilor. În acest stadiu al evaluării, personalul furnizor de servicii de scaune rulante trebuie să afle: • dacă bazinul utilizatorului de scaun rulant se află la același nivel atunci când este privit din față (cu sau fără suport); • dacă șoldurile pot fi flectate în poziția neutră de ședere (unghiul dintre trunchi și coapse este mai mare de 90 de grade), cu sau fără suport. Dacă bazinul nu este drept sau dacă șoldurile nu pot fi flectate în poziția neutră de ședere (unghiul dintre trunchi și șolduri este mai mare de 90 grade), personalul furnizor de servicii de scaune rulante trebuie să afle mai multe informații. Este important să știm: • dacă utilizatorul de scaun rulant poate menține poziția neutră de ședere cu suport • dacă nu – care este postura cea mai apropiată de cea specifică poziției neutre de ședere. Dacă utilizatorul de scaun rulant nu poate menține poziția neutră de ședere, este important să știm dacă dificultatea este cauzată de: • o limitare (restricție) deasupra nivelului bazinului (în zona lombară) sau • o limitare la nivelul bazinului (la articulația șoldului). Pentru ca personalul furnizor de servicii de scaune rulante să poată răspunde tuturor acestor întrebări, este necesară efectuarea analizei posturii bazinului și a șoldurilor, ca parte a etapei de evaluare. Aceasta nu este o evaluare completă a gradului de mișcare. Obiectivul analizei posturii bazinului și a șoldurilor din acest modul de instruire se rezumă la identificarea factorilor notați mai sus. Personalul furnizor de servicii de scaune rulante care deține competențele necesare poate alege efectuarea unei evaluări complete a gradului de mobilitate, în vederea completării informațiilor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 58 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Efectuarea analizei posturii bazinului și a șoldului Pregătire: • explicați utilizatorului de scaun rulant ce urmează să faceți și motivul pentru care această activitate este importantă; • cereți utilizatorului de scaun rulant să adopte poziția de decubit dorsal, pe patul de evaluare. (Notă: persoana care efectuează analiza posturii bazinului și a șoldului este numită „evaluator”, iar persoana care asistă evaluatorul este numită „asistent”, aceasta putând fi un coleg, o persoană care are pregătirea de asistent, un membru al familiei sau un însoțitor). Analiza posturii bazinului: • evaluatorul flectează ușor ambii genunchi ai utilizatorului de scaun rulant, furnizând un anumit grad de suport, ceea ce duce la scăderea tensiunii la nivelul șoldurilor; • asistentul poziționează mâinile pe trunchiul utilizatorului de scaun rulant, la nivelul coastelor inferioare, sprjinind cu fermitate; • evaluatorul plasează mâinile pe bazinul utilizatorului de scaun rulant, având degetele mari poziționate de creasta iliacă antero-superioară (CIAS); • evaluatorul verifică dacă degetele/crestele iliace antero-superioare se situează la același nivel; • dacă nu sunt la același nivel, cu o mișcare lentă, dar fermă, evaluatorul încearcă să îndrepte bazinul, în așa fel încât ambele CIAS să fie la același nivel; • asistentul comunică dacă simte mișcare la nivelul trunchiului, ceea ce ar însemna că există o anumită restricție în mobilitate; • observați cât de aproape de poziția neutră poate fi poziționat bazinul (cât de aproape de poziția de echilibru); • în formularul de evaluare - nivel intermediar, evaluatorul notează dacă bazinul poate fi poziționat în așa fel încât să fie în echilibru. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 59 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Analiza posturii șoldului: • asistentul ține ferm bazinul utilizatorului de scaun rulant, însă fără a-l forța; • evaluatorul flectează puțin genunchiul membrului inferior care nu este testat în acel moment, poziționând piciorul pe saltea. Acest lucru ajută la reducerea tensiunii la nivelul șoldului testat. Este posibil să fie necesară sprijinirea membrului inferior la care se efectuează testul. • evaluatorul mută ușor membrul inferior testat în poziția neutră de ședere; • asistentul comunică dacă simte mișcare la nivelul bazinului, ceea ce ar însemna că există o anumită restricție (limitare) în mobilitate; • evaluatorul constată care este gradul de libertate de mișcare la nivelul articulației șoldului; • evaluatorul repetă acțiunea pe cealaltă parte a corpului și compară rezultatele; • în formularul de evaluare - nivel intermediar, evaluatorul notează dacă șoldul drept și stâng pot fi flectate în poziția neutră de ședere. • cu ajutorul unui asistent și folosind un goniometru, evaluatorul constată cât de aproape de poziția neutră poate ajunge fiecare șold; • evaluatorul poziționează punctul pivot al gonimetrului pe articulația șoldului. Unul din brațele goniometrului va sta de-a lungul femurului, iar celălalt va fi aliniat cu trunchiul; • evaluatorul ține unite cele două brațe ale goniometrului; • în formularul de evaluare - nivel intermediar evaluatorul înregistrează valoarea măsurată (gradul unghiului) la nivelul șoldurilor drept și stâng; • de asemenea, evaluatorul poate desena unghiul goniometrului pe o coală separată sau pe formularul de evaluare – nivel intermediar (pe verso). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 60 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Înregistrarea analizei posturii bazinului și a șoldului Analiza posturii bazinului și a șoldului Notați rezultatele analizei posturii bazinului și a șoldului în formularul de evaluare - nivel intermediar. Bifați dacă bazinul este în echilibru. Bifați apoi dacă fiecare șold poate fi flectat în poziția neutră de ședere (unghi de 90 de grade). Dacă șoldul drept sau cel stâng (sau niciunul) nu poate fi flectat în poziția neutră de ședere (unghiul dintre trunchi și coapse este mai mare de 90 de grade), notați valoarea unghiului. Așa cum se menționează mai sus, personalul furnizor de servicii de scaune rulante poate desena unghiul goniometrului pe o coală separată sau pe formularul de evaluare - nivel intermediar (pe verso). Verificați dacă bazinul este în echilibru, precum și gradul de flexie a șoldului atunci când utilizatorul este în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru realizarea poziției neutre de ședere? Șoldul drept: Da Nu Unghi: _______ Șoldul stâng: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru realizarea poziției neutre de ședere, folosiți un suport provizoriu. Suporturi provizorii pentru bazin fix aflat în poziție vicioasă și șolduri care nu pot fi flectate pentru atingerea poziției neutre de ședere (unghiul dintre trunchi și coapse mai mare de 90 de grade) Dacă bazinul se află în poziție vicioasă sau dacă șoldul nu poate fi flectat în poziția neutră de ședere (unghiul dintre trunchi și coapse este mai mare de 90 grade), aceste părți ale corpului trebuie susținute în postura din scaunul rulant pregătit pentru utilizare. Pentru a continua evaluarea, este nevoie de un suport provizoriu. Pe parcursul unei evaluări, suportul provizoriu: • va ajuta utilizatorul de scaun rulant să mențină o poziție mai stabilă și mai echilibrată; • va împiedica utilizatorul de scaun rulant „să compenseze” bazinul aflat în poziție vicioasă sau șoldurile care nu pot fi flectate în poziția neutră de ședere (unghiul dintre trunchi și coapse mai mare de 90 grade); • va permite personalului furnizor de servicii de scaune rulante să efectueze evaluarea și să se concentreze pe restul posturii utilizatorului de scaun rulant - bazin, trunchi, cap, gât și membre inferioare. Un suport provizoriu poate fi confecționat dintr-o bucată de spumă rigidă/burete rigid. Tabelul de mai jos prezintă diverse probleme posturale, suporturi provizorii și opțiuni de dispozitive de suport permanent pentru aceste persoane. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 61 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Problemă posturală Suport provizoriu Suport permanent (încorporat în perna utilizatorului de scaun rulant) bazin fix inegal (înclinare laterală) Introduceți o inserție sub partea unde oasele bazinului și coapsa sunt poziționate mai sus Șoldul nu poate fi flectat în poziția neutră de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade) Introduceți o inserție sub ambele oase ale bazinului și sub coapsa de pe partea unde șoldul poate fi flectat pentru atingerea poziției neutre de ședere - marginile ascuțite trebuie netezite înainte de prima probare. Niciunul dintre șolduri nu poate fi flectat în poziția neutră de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade) Introduceți o inserție pentru a crește unghiul dintre suprafața de ședere și spătarul. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 62 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Unul sau niciunul dintre șolduri nu poate fi extins pentru a ajunge în poziția neutră de ședere (unghiul dintre trunchi și coapse este mai mic de 90 de grade) Furnizați un suport în formă de inserție unghiulară care să fie poziționat anterior oaselor bazinului și sub coapse Evaluarea fizică – procedeul de simulare manuală Procedeul de simulare manuală ajută la identificarea tipului de suport necesar utilizatorului de scaun rulant. Pe parcursul procedurii de simulare manuală, personalul furnizor de servicii de scaune rulante folosește această metodă pentru a stabili următoarele: • dacă utilizatorul de scaun rulant poate menține fără suport poziția neutră de ședere? • dacă nu - cât de aproape este postura sa de cea corectă? • ce fel de suport este necesar și unde trebuie acesta poziționat. Pe parcursul procedurii de simulare manuală, personalul furnizor de servicii de scaune rulante lucrează împreună cu un asistent sau membru al familiei/însoțitor, astfel încât să poată furniza suportul necesar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 63 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cum se efectuează procedura de simulare manuală Atunci când efectuați procedura de simulare manuală trebuie să aveți în vedere următoarele: Pregătirea procedurii • Explicați utilizatorului de scaun rulant ce urmează să faceți și motivul pentru care efectuați această activitate. • Cereți utilizatorului de scaun rulant să stea pe o suprafață plană, rigidă, dar acoperită cu un material moale. Cutia cu instrumentele necesare evaluării este soluția ideală, deoarece personalul furnizor de servicii de scaune rulante, asistentul sau membrii familiei/însoțitorul pot sprijini cu ușurință utilizatorul din față, spate și lateral. • Dacă utilizatorul de scaun rulant nu poate menține poziția așezat fără suport în condiții de siguranță, cereți unui asistent sau unui membru al familiei/însoțitor să îl susțină. • Asigurați-vă că picioarele utilizatorului de scaun rulant sunt plasate pe o suprafață care le susține la înălțimea adecvată. Dacă bazinul nu este la același nivel sau dacă șoldurile nu pot fi flectate în poziția neutră de ședere (unghiul dintre trunchi și șolduri este mai mare de 90 grade), folosiți un suport provizoriu, urmând indicațiile din sesiunea anterioară. Lucrați în echipă • În mod frecvent, este nevoie de mai multe perechi de mâini pentru a efectua evaluarea fizică. • Cereți ajutorul unei persoane, care poate fi un coleg, asistent instruit, membru al familiei sau un însoțitor. • Implicarea unui membru de familie/al însoțitorului îi va ajuta pe aceștia să înțeleagă mai bine aspectele legate de dispozitivul de suport postural Bune abilități de comunicare • Personalul furnizor de servicii de scaune rulante trebuie să dea dovadă de mult calm în comunicarea cu utilizatorul și cu membrii familiei/însoțitorul acestuia (de preferat în limba vorbită în zonă respectivă). • Dacă utilizatorul de scaun rulant nu poate vorbi, găsiți o metodă de comunicare adecvată. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 64 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar • Nu uitați ca la fiecare pas să îi explicați utilizatorului de scaun rulant ce urmează să faceți. • După fiecare modificare, cereți utilizatorului de scaun rulant un feedback. Gândiți-vă cu atenție la acțiunile desfășurate • În acest stadiu al etapei de evaluare, suportul pe care mai târziu îl vor furniza scaunul rulant și dispozitivele de suport postural este asigurat cu ajutorul mâinilor evaluatorului și al celor care îl asistă. Pe parcursul unei simulări manuale, fiți atenți la următoarele: – poziționarea mâinilor; – direcția forței exercitate/suportului; – nivelul de forță și gradul de suport; – suprafața corpului susținută cu ajutorul mâinilor (de exemplu, folosiți doar un deget sau întreaga palmă); – dacă este frig, încălziți-vă mâinile înainte de începerea procedeului de simulare manuală. • Aceaste informații vă vor ajuta la prescrierea scaunului rulant și a dispozitivelor de suport postural. Stabilizarea bazinului constituie întotdeauna prima etapă • Postura bazinului influențează postura întregului corp. • Dacă bazinul utilizatorului de scaun rulant nu este în poziție neutră, încercați să îl poziționați astfel, cu ajutorul mâinilor. • După stabilizarea bazinului, puteți trece la celelalte părți ale corpului: – trunchi/brațe; – cap și gât; – șolduri și coapse; – gambe; Efectuați câte o singură schimbare, consecutiv. • Efectuați câte o singură schimbare, consecutiv. De exemplu, nu încercați modificarea posturii trunchiului simultan cu schimbarea posturii bazinului. • Observați modul în care o schimbare a unei părți a corpului le afectează pe celelalte. • Rugați utilizatorul de scaun rulant să vă ofere feedback. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 65 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Inițierea procedurii de simulare manuală în etapa de evaluare fizică: • poziționați-vă în fața utilizatorului de scaun rulant, pe genunchi sau ghemuit; • așezați mâinile pe ambele părți ale bazinului utilizatorului de scaun rulant, fără a exercita presiune; • dacă bazinul utilizatorului de scaun rulant nu este în poziție neutră, încercați să îl poziționați astfel, fără a-i provoca disconfort. • nu exercitați prea multă forță • aflați care este poziția bazinului cea mai apropiată de cea neutră, atunci când beneficiază de suport; • observați modul în care mișcarea bazinului pentru atingerea poziției neutre afectează trunchiul, șoldurile, capul și gâtul utilizatorului. • când bazinul se află cât mai aproape posibil de poziția neutră (cu suport), personalul furnizor de servicii de scaune rulante poate trece la identificarea tipului de suport necesar la nivelul trunchiului; • cereți asistentului să mențină bazinul în postura pe care ați identificat-o ca fiind cea mai apropiată de cea neutră, în cazul respectivului utilizator de scaun rulant; • explicați cu atenție asistentului unde și în ce fel să susțină bazinul. Înainte de a continua, verificați dacă asistentul este capabil să facă acest lucru. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 66 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Sprijinirea trunchiului (dacă este necesar): La fel ca în cazul bazinului, dacă trunchiul utilizatorului de scaun rulant nu este în poziția neutră de ședere, sprijiniți-l cu ajutorul mâinilor. Respectați ordinea acțiunilor: • stabilizați bazinul cu mâinile; • îndreptați trunchiul în așa fel încât umerii să fie la același nivel (sau cât mai aproape de același nivel, pe cât este posibil), susținându-l cu mâinile, bilateral; • oferind sprijin atât în partea anterioară, cât și cea posterioară, îndreptați trunchiul, astfel încât capul și gâtul să fie în echilibru în raport cu bazinul: • observați conturul bazinului și al trunchiului din lateral. Acest aspect este important pentru planificarea formei spătarului, astfel încât acesta să furnizeze cel mai bun suport posibil. Fiți atenți la modul în care sprijinul la nivelul trunchiului influențează restul corpului. De exemplu, contribuie acest fapt la îmbunătățirea posturii capului și gâtului? Chiar și atunci când există suport corespunzător pentru bazin și trunchi, unora dintre utilizatorii de scaun rulant le este greu să mențină capul drept. Câteva sugestii pentru îmbunătățirea posturii capului și gâtului: • permiteți corpului utilizatorului de scaun rulant să rămână într-o poziție ușor înclinată înspre înapoi; • observați dacă efectul este îmbunătățirea echilibrului capului în raport cu trunchiul; • furnizați suport suplimentar pentru brațe. Pe parcursul procedurii de simulare manuală, evaluatorul întreabă persoana care ajută la stabilizarea bazinului (asistentul) dacă simte vreo schimbare în momentul în care trunchiul beneficiază de suport. Utilizatorului de scaun rulant trebuie să i se solicite un feedback. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 67 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sprijinirea altor părți ale corpului (dacă este necesar) • Odată ce bazinul și trunchiul sunt susținute în postura cea mai apropiată de cea caracteristică poziției neutre de ședere, fără ca utilizatorul să resimtă disconfort, verificați postura capului, gâtului, șoldurilor, coapselor și gambelor. • Cu ajutorul mâinilor, încercați să identificați care este poziția cât mai apropiată de cea neutră pe care o poate avea fiecare parte a corpului, în limita confortului. Verificați și impactul pe care fiecare modificare îl are asupra restului corpului. Continuați să cereți feedback utilizatorului de scaun rulant. Înregistrarea rezultatelor procedurii de simulare manuală Rezultatele procedurii de simulare manuală se notează în formularul de evaluare - nivel intermediar. Astfel: • bifați dacă părțile corpului utilizatorului de scaun rulant pot atinge poziția neutră, cu suport manual; • descrieți sau schițați postura finală a utilizatorului de scaun rulant la care s-a ajuns cu ajutorul suportului manual; • descrieți sau schițați suportul furnizat. Procedura de simulare manuală: suportul necesar pentru atingerea poziției neutre de ședere / poziții cu bazinul cât mai aproape de poziția neutră de ședere, fără a cauza disconfort Dacă este posibilă atingerea poziției neutre de ședere cu ajutorul suportului manual, bifați „da”. În caz contrar, bifați „nu”. Parte a corpului Da Nu Descrieți sau schițați postura în poziția așezat finală a utilizatorului de scaun rulant, realizată cu suport manual și descrieți sau schițați suportul oferit pentru obținerea respectivei poziții de ședere. Bazin Trunchi Cap Șold S Șold D Coapse Genunchi S Genunchi D Gleznă S Gleznă D Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 68 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Evaluarea fizică - efectuarea măsurătorilor Măsurarea utilizatorului de scaun rulant în vederea alegerii dimensiunii corecte a scaunului rulant și a poziției dispozitivelor de suport postural. În rubrica referitoare la măsurători din formularul de evaluare - nivel intermediar, sunt enumerate douăsprezece tipuri de măsurători. Cinci dintre ele au fost deja prezentate în pachetul de instruire anterior (nivel de bază). În formularul de evaluare – nivel intermediar, capitolul măsurători corp include un element suplimentar, referitor la înălțimea spătarului. Distanța dintre suprafața de ședere și limita superioară a omoplatului este valoarea utilizată în cazul unui spătar înalt. Există alte șase măsurători care contribuie la alegerea dimensiunii și/sau a poziției dispozitivelor de suport postural. Uneori va fi necesar să efectuați mai multe măsurători, în funcție de dispozitivele de suport postural prescrise. Există o rubrică în formularul de evaluare - nivel intermediar pentru înregistrarea acestora. Corespondența măsurători corp - dimensiuni scaun rulant - poziția și mărimea dispozitivelor de suport postural Fiecare măsurătoare corp efectuată are un impact asupra dimensiunii scaunului rulant și asupra poziției și mărimii dispozitivelor de suport postural. În formularul de evaluare - nivel intermediar, măsurătorile corp sunt enumerate pe partea stângă, iar componentele aflate în raport cu fiecare măsurătoare corp sunt enumerate în partea dreaptă. De exemplu: • lățimea șoldurilor utilizatorului de scaun rulant (măsurătoarea corp A) este egală cu lățimea suprafeței de ședere sau distanța dintre inserțiile laterale pentru bazin (măsurători componente 1 sau 2); • distanța dintre șezutul utilizatorului de scaun rulant și axilă (măsurătoarea corp H) minus 30 mm este distanța maximă dintre limita superioară a pernei și limita superioară a inserțiilor laterale/unghiulare pentru trunchi (măsurătoarea componentă 8). Exemplele de mai sus demonstrează că măsurătorile corp nu sunt întotdeauna echivalentul dimensiunilor componentelor scaunului rulant și că sunt necesare anumite calcule. În anumite cazuri, există o formulă pentru a afla valoarea corectă a componentelor scaunului rulant. În mod frecvent, în faza de probare se efectuează diverse ajustări. Cu toate acestea, valorile corecte ale măsurătorilor corp contribuie la pregătirea scaunului rulant înainte de prima probare. Imaginile din formularul de evaluare - nivel intermediar ghidează personalul furnizor de servicii Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 69 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT de scaune rulante în efectuarea măsurătorilor corp și în transpunerea acestora în termeni de poziție și dimensiuni ale dispozitivelor de suport postural. Efectuarea măsurătorilor Măsurători corp (mm) Măsurători componente scaun rulant (mm) Lățimea și adâncimea șezutului, și înălțimea suportului de picioare A Lățime șold = lățime suprafață de ședere SAU 1 = distanță dintre inserțiile laterale pentru bazin 2 B Adâncime șezut (partea posterioară a bazinului până la partea posterioară a genunchiului) S B minus 30-50 mm = adâncimea suprafeței de ședere (dacă lungimea este diferită, folosiți valoarea mai mică) 3D C Lungime gambă S = distanța dintre partea superioară a suprafeței de ședere și suportul de picioare SAU = distanța dintre partea superioară a suprafeței de ședere și sol, în cazul propulsiei cu ajutorul membrelor inferioare 4 D 5 Înălțimea spătarului D Distanța dintre șezut* și limita inferioară a cutiei toracice = distanța dintre partea superioară a suprafeței de ședere și limita superioară a spătarului (măsurați D, E sau F - în funcție de cerințele specifice utilizatorului) 6E Distanța dintre șezut* și limita inferioară a omoplatului F Distanța dintre șezut* și limita superioară a umărului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 70 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Modificările și/sau dispozitivele de sprijin postural G Lățime trunchi = distanța dintre inserțiile laterale/ inserțiile unghiulare laterale pentru trunchi 7 H Distanța dintre șezut* și axilă S H minus 30 mm = distanța maximă dintre partea superioară a suprafeței de ședere și partea superioară a inserțiilor laterale/inserțiilor unghiulare laterale (ajustare în funcție de procedeul de simulare manuală) 8 D I Distanța dintre șezut* și partea superioară a bazinului (creasta iliacă postero-superioară) = distanța dintre partea superioară a suprafeței de ședere și jumătatea înălțimii inserției posterioare pentru bazin 9 J Distanța dintre genunchi = lățimea inserției/dispozitivului pentru separarea genunchilor 10 K Distanța dintre șezut* și baza craniului (occiput) = distanța dintre partea superioară a suprafeței de ședere și linia de mijloc a tetierei 11 L Distanța dintre spatele bazinului și oasele bazinului L plus 20–40 mm = distanța dintre spătar și linia de început a inserției anterioare oaselor bazinului. 12 A lte le *La efectuarea măsurătorilor corpului, „șezutul” reprezintă suprafața ocupată de oasele bazinului. Efectuarea corectă a măsurătorilor Erorile în efectuarea măsurătorilor pot cauza probleme majore. Cu toate acestea, realizarea corectă a acestora poate fi câteodată dificilă, mai ales atunci când utilizatorul de scaun rulant este un copil de vârstă mică, are dificultăți în a sta nemișcat sau nu poate menține poziția așezat. Câteva modalități de efectuare corectă a măsurătorilor: folosiți întotdeauna o ruletă–nu un metru de croitorie; ruleta se va îndoi într-o mai mică măsură, diminuând astfel riscul de a avea măsurători incorecte; folosiți șublere, acestea ajută la creșterea acurateții măsurătorilor; • efectuați întotdeauna măsurătorile cu utilizatorul de scaun rulant în poziția așezat sau Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 71 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT în postura care a fost identificată (în urma procedurii de simulare manuală) ca fiind cea mai apropiată de poziția neutră de ședere și care este confortabilă și funcțională. Dacă utilizatorul de scaun rulant este măsurat în timp ce se află în poziția de decubit, măsurătorile nu vor fi corecte, deoarece, în această poziție pot rezulta valori mai mari decât cele reale. Se recomandă să apelați la un asistent, care să susțină utilizatorul de scaun rulant în poziția așezat, evitând să efectuați măsurătorile cu utilizatorul în poziția de decubit. Modalitatea de efectuare a măsurătorii: Componenta scaunului rulant: Comentarii: A: Lățimea șoldului Suprafața de ședere (lățimea) Înainte de efectuarea măsurătorilor, asigurați-vă că nu există niciun fel de obiecte în buzunarele utilizatorului de scaun rulant. Măsurați șoldurile sau partea cea mai lată a coapselor utilizatorului. Țineți două clipboard-uri de fiecare parte a coapselor utilizatorului de scaun rulant și astfel veți obține măsurători corecte. Puteți folosi și șublere. Lățimea șoldurilor este egală cu lățimea suprafeței de ședere sau cu distanța dintre inserțiile laterale pentru bazin. Dacă se furnizează inserții laterale pentru bazin, lățimea suprafeței de ședere trebuie să fie mai mare. Încercați întotdeauna ca lățimea recomandată să aibă cea mai mică valoare posibilă. În țările cu climat rece, unde se poartă îmbrăcăminte groasă, trebuie să aveți în vedere acest aspect atunci când calculați lățimea recomandată a scaunului rulant. B: Adâncimea șezutului Suprafața de ședere (adâncimea) Pentru a obține măsurători exacte, poziționați un clipboard la spatele bazinului utilizatorului de scaun rulant. Măsurați de la partea posterioară a bazinului până la partea posterioară a genunchiului, în linie dreaptă. Măsurați întotdeauna pe ambele părți. Dacă există vreo diferență între partea dreaptă și stângă, verificați dacă utilizatorul de scaun rulant stă în poziția așezat, cu bazinul în echilibru. Dacă diferența persistă, la prescrierea scaunului rulant luați în considerare valoarea mai mică. Adâncimea suprafeței de ședere minus 30- 50 mm este egală cu adâncimea suprafeței de ședere. În cazul în care un utilizator are genunchii flectați într- un unghi mult sub 90 grade, adâncimea șezutului scaunului rulant va trebui să fie mai redusă. Vezi „Pentru utilizatorii de scaun rulant cu înclinare posterioară fixă a bazinului sau cu înclinare fixă anterioară a trunchiului”. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 72 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Utilizatorii de scaun rulant cu înclinare posterioară fixă a bazinului sau cu înclinare fixă anterioară a trunchiului În cazul în care este prezentă o înclinare posterioară a bazinului sau o înclinare anterioară a trunchiului, personalul furnizor de servicii de scaune rulante trebuie să identifice modalitatea prin care această postură poate fi acomodată în scaunul rulant. Acest lucru are efect asupra metodei de măsurare a adâncimii suprafeței de ședere. • Dacă spătarul este înclinat (înspre înapoi) pentru a susține bazinul/trunchiul, măsurați de la partea posterioară a bazinului până la partea posterioară a genunchiului, în linie dreaptă, conform descrierii de mai sus. • Dacă spătarul nu se înclină, vor fi confecționate suporturi pentru a susține bazinul/ trunchiul. Măsurați de la punctul extrem posterior al corpului utilizatorului de scaun rulant (trunchi/bazin) pentru a vă asigura că valoarea pe care o va avea adâncimea suprafeței de ședere este cea corectă (conform imaginii). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 73 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT C: Lungimea gambei Suporturile de picioare (înălțimea) Măsurați distanța dintre partea posterioară a genunchilor și baza călcâiului. Asigurați-vă că gleznele utilizatorului de scaun rulant sunt flectate la 90 de grade (dacă este posibil). Măsurați întotdeauna ambele membre inferioare. Dacă utilizatorul de scaun rulant poartă încălțăminte, efectuați măsurătoarea cu încălțămintea pe care o poartă în mod frecvent. Dacă piciorul este fixat în flexie plantară (direcție în jos), măsurați până la degetele picioarelor. Înălțimea corespunzătoare lungimii gambei este egală cu distanța dintre limita superioară a pernei și suporturile de picioare SAU cu distanța dintre limita superioară a pernei și podeaua, în cazul propulsiei cu ajutorul membrelor inferioare. Poziția exactă a suporturilor de picioare se va modifica puțin, în funcție de gradul de comprimare a pernei, atunci când utilizatorul de scaun rulant este așezat pe aceasta. Va fi întotdeauna nevoie de ajustare finală în etapa de probare a produsului (a scaunului rulant). D, E și F Spătarul (înălțimea) D: Distanța dintre șezut și limita inferioară a cutiei toracice. Măsurați distanța dintre șezutul utilizatorului de scaun rulant și limita inferioară a cutiei toracice. Pentru a localiza partea inferioară a cutiei toracice, poziționați mâinile pe ambele părți ale bazinului. Apăsați ușor și mișcați- le în sus. Limita inferioară a cutiei toracice este chiar deasupra taliei. Măsurătorile D, E și F ajută la stabilirea înălțimii spătarului. Înălțimea acestuia depinde de nevoile utilizatorului de scaun rulant. Informațiile din formularul de evaluare vor ajuta personalul furnizor de servicii de scaune rulante să decidă care este înălțimea corespunzătoare a spătarului, în așa fel încât acesta să furnizeze suportul de care are nevoie utilizatorul de scaun rulant. Dacă este nevoie de o înclinare în spațiu a spătarului, înălțimea acestuia trebuie să aibă cel puțin valoarea standard (până la limita inferioară a omoplaților utilizatorului de scaun rulant). Rețineți! Dacă utilizatorul de scaun rulant va realiza singur propulsia scaunului rulant, el va avea nevoie de libertate de mișcare la nivelul omoplaților. E: Distanța dintre șezut și omoplat: Măsurați distanța dintre șezutul utilizatoruluide scaun rulant și limita inferioară a omoplatului, în linie verticală. Pentru a găsi limita inferioară a omoplatului, cereți utilizatorului de scaun rulant să își ridice umerii. F: Distanța dintre șezut și limita superioară a omoplatului: Măsurați distanța dintre șezutul utilizatorului de scaun rulant și limita superioară a umărului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 74 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar G: Lățimea trunchiului Inserțiile laterale pentru trunchi sau inserțiile unghiulare laterale pentru trunchi (distanța dintre acestea) Măsurați lățimea trunchiului utilizatorului de scaun rulant în porțiunea situată chiar sub axile. Lățimea trunchiului este distanța dintre inserțiile laterale de trunchi sau inserțiile unghiulare laterale pentru trunchi. Poziția finală a inserțiilor laterale pentru trunchi sau a inserțiilor unghiulare laterale pentru trunchi se poate modifica în etapa de probare,în cazul în care este nevoie să fie plasate mai jos de nivelul axilelor. H: Distanța dintre șezut și axilă Inserțiile laterale pentru trunchi sau inserțiile unghiulare laterale pentru trunchi (înălțimea) Măsurați distanța dintre șezutul utilizatorului de scaun rulant și axilă. Valoarea aferentă distanței dintre șezutul utilizatorului de scaun rulant și axilă minus 30 mm este distanța maximă dintre partea superioară a pernei și partea superioară a inserțiilor laterale pentru trunchi/inserțiilor unghiulare pentru trunchi. Această valoare este orientativă. Înălțimea finală depinde de evaluare și probarea produsului (a scaunului rulant). Inserțiile laterale pentru trunchi nu trebuie niciodată să fie atât de înalte încât să exercite presiune la nivelul axilelor. Acest lucru poate cauza disconfort și deterioarea ireversibilă a nervului. Trebuie să existe întotdeauna o distanță de cel puțin 30 mm între partea superioară a inserțiilor laterale pentru trunchi și axilă. Vezi „Măsurarea inserțiilor laterale pentru trunchi în cazul unui utilizator de scaun rulant cu scolioză”. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 75 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Măsurarea inserțiilor laterale pentru trunchi în cazul unui utilizator de scaun rulant cu scolioză (trunchi curbat lateral) În cazul unui utilizator de scaun rulant cu un trunchi curbat lateral (scolioză) una dintre inserțiile laterale pentru trunchi poate fi situată mai jos în comparație cu cealaltă, pentru a oferi suport acolo unde este necesar. Conform imaginii, una dintre inserțiile laterale pentru trunchi va fi poziționată la apexul curburii. Cealaltă inserție va fi poziționată chiar sub axilă. Rețineți – atunci când furnizați inserții laterale pentru trunchi unui utilizator de scaun rulant cu scolioză, furnizați și inserții laterale pentru bazin, pentru ambele părți. I: Distanța dintre șezut și partea superioară a bazinului (creasta iliacă postero-superioară) Inserția posterioară pentru bazin (înălțime mediană) Măsurați distanța dintre șezutul utilizatorului de scaun rulant și partea superioară a bazinului (CIPS) Măsurătoarea aferentă distanței dintre șezut și partea superioară a bazinului (CIPS) este folosită pentru a localiza mijlocul înălțimii inserției posterioare pentru bazin. Adâncimea (grosimea) inserției posterioare pentru bazin depinde de rezultatele evaluării. J: Distanța dintre genunchi Inserția/dispozitivul pentru separarea genunchilor Măsurați distanța dintre genunchi - cu genunchii situați într-o poziție cât mai apropiată de cea neutră, fără a cauza disconfort. Distanța dintre genunchi este egală cu lățimea inserției/dispozitivului pentru separarea genunchilor. Distanța va depinde de postura în poziția așezat a utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 76 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar K: Distanța dintre șezut și baza craniului (occiput) Tetiera (înălțimea) Măsurați distanța dintre șezutul utilizatorului de scaun rulant și baza craniului (occiput). Măsurătoarea de la șezut până la baza craniului (occiput) ajută la localizarea poziției tetierei. I: Distanța dintre partea posterioară a bazinului și oasele bazinului Inserția anterioară oaselor bazinului Măsurați distanța dintre partea posterioară a bazinului și oasele bazinului. Poziționați-vă pe partea laterală a utilizatorului de scaun rulant și plasați mâna (cu palma orientată în sus) sub șezutul acestuia, pentru a identifica oasele bazinului. Localizați oasele bazinului cu degetul, apoi retrageți mâna pe lateral, fără a modifica poziția degetului. Măsurați distanța dintre partea posterioară a bazinului și degetul care a fost poziționat sub oasele bazinului. Personalul furnizor de servicii de scaune rulante poate marca poziția degetului pe patul de evaluare (de exemplu, cu o bucată de cretă). Semnul se trasează lângă corpul utilizatorului de scaun rulant, pe linia oaselor bazinului. Se va măsura distanța dintre acest semn și partea posterioară a bazinului. Valoarea măsurată de la partea posterioară a bazinului până la oasele bazinului plus 20–40 mm este distanța dintre spătar și linia de început a inserției anterioare oaselor bazinului. Dacă utilizatorul are o înclinare fixă posterioară a bazinului sau trunchi fix înclinat anterior, măsurătorile pot fi diferite (vezi Pentru utilizatorii de scaun rulant cu înclinare posterioară fixă a bazinului sau cu înclinare anterioară fixă a trunchiului) Rețineți: • Atunci când se efectuează măsurătorile corp, „suprafața de ședere” este suprafața pe care o ocupă oasele bazinului. • Pentru toate măsurătorile verticale (C,D,E,F,H,I,K) – poziția componentei aferente va fi influențată de orice modificarea adusă înălțimii la care se situează suprafața de ședere și perna. • Poziția exactă a tuturor componentelor scaunului rulant este verificată întotdeauna în etapa de probare a produsului (a scaunului rulant). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 77 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Etapa 3: Prescrierea (selecția) Selecția scaunului rulant și a pernei Prescrierea (selecția) este cea de-a treia etapă a procesului de furnizare a serviciilor de scaune rulante. Prescrierea/selecția înseamnă găsirea celei mai bune corespondențe dintre tipurile de scaune rulante disponibile și nevoile utilizatorului. Atunci când prescrieți un scaun rulant unui utilizator care are nevoie de suport postural suplimentar pentru a menține poziția așezat, această activitate include: • alegerea tipului de scaun rulant adecvat și a dimensiunii celei mai potrivite, în cazul fiecărui utilizator de scaun rulant; • descrierea oricărei configurări specifice ale respectivului scaun rulant; • alegerea tipului și dimensiunii pernei; • alegerea dispozitivelor de suport postural sau a modificărilor necesare pentru a oferi utilizatorului de scaun rulant suportul postural suplimentar de care acesta are nevoie. Prescrierea (selecția) este întotdeauna rezultatul unui parteneriat complet cu utilizatorul de scaun rulant. În formularul de prescriere (selecție) a scaunului rulant - nivel intermediar, folosit în cadrul acestui program de instruire, se solicită trei semnături: cea a utilizatorului de scaun rulant, cea a persoanei care a realizat evaluarea (reprezentantul furnizorului de servicii de scaune rulante) și managerul respectivului serviciu pentru utilizatorii de scaune rulante. Tipul de scaun rulant și perna 1. Tipul scaunului rulant Pentru a prescrie un scaun rulant, personalul furnizor de servicii de scaune rulante trebui să cunoască următoarele aspecte legate de echipamentul de mobilitate: • tipul cadrului scaunului rulant; • dimensiunea disponibilă și gama de dimensiuni; • caracteristicile disponibile (opțiunile); • tipul și gama de ajustări. Aceste informații vor ajuta personalul furnizor de servicii de scaune rulante să aleagă cel mai potrivit scaun rulant pentru fiecare utilizator și să descrie modul în care acesta va trebui configurat. Partea relevantă a formularului de prescriere (selecție) a scaunului rulant - nivel intermediar este prezentată mai jos. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 78 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 2. Tipul, dimensiunea și configurația scaunului rulant Tipul scaunului rulant (notați mai jos tipurile de scaune rulante disponibile) Dimensiunile scaunului rulant (mm) Lățimea suprafeței de ședere Adâncimea suprafeței de ședere Înălțimea spătarului Înălțimea suportului de picioare Configurația scaunului rulant Poziția roții din spate Altele: Înclinarea Tipul cadrului scaunului rulant Personalul furnizor de sevicii de scaune rulante trebuie să cunoască diferitele tipuri de cadre de scaun rulant disponibile la nivel local. De exemplu, trebuie să știe dacă este un scaun rulant cu patru sau cu trei roți; cu un cadru pliabil sau fix, dacă acesta poate fi înclinat și dacă baza roții este lungă sau scurtă. Pentru mai multe informații despre diferitele tipuri de cadre de scaune rulante, vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 79 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Dimensiunea disponibilă și gama de dimensiuni Dimensiunea scaunului rulant este de obicei dată de lățimea suprafeței de ședere și de adâncimea acestuia. Lățimea suprafeței de ședere este distanța dintre exteriorul barelor laterale ale cadrului șezutului sau dintre suporturile de brațe, dacă acestea sunt plasate pe respectivele bare. Adâncimea suprafeței de ședere a scaunului rulant se măsoară de la partea frontală a suprafeței de ședere până la spătar. Alte dimensiuni importante ale scaunului rulant: • distanța dintre suprafața de ședere și sol (este important în cazul utilizatorilor de scaun rulant care efectuează propulsia cu ajutorul membrelor inferioare); • înălțimea spătarului. Caracteristicile disponibile Următoarele elemente reprezintă caracteristici ale scaunului rulant: tipul suprafeței de ședere, tipul de spătar, de suport de picioare, suport de brațe, tipul de roată frontală, roată din spate și dispozitivele de suport postural (de exemplu inserții laterale pentru trunchi, tetieră, centuri). Tipul și gama de ajustări care pot fi efectuate Personalul furnizor de servicii de scaune rulante trebuie să cunoască tipurile de ajustări ale scaunelor rulante care sunt disponibile la nivel local. Acestea includ intervalul dintre nivelul minim și maxim la care pot fi poziționate suporturile de picioare, posibilitatea de ajustare a înălțimii spătarului sau de a regla poziția axului posterior. Pentru a determina intervalul pe care poate fi poziționată oricare componentă ajustabilă, uneori trebuie stabilite punctul minim și punctul maxim de poziționare a respectivei componentei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 80 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Anumite scaune rulante cu antrenare manuală au un număr mai mare de caracteristici (opțiuni) sau de posibilități de ajustare. Unele dintre acestea pot fi foarte folositoare în cazul utilizatorilor de scaun rulant care au nevoie de suport postural suplimentar. Aici sunt incluse: Suporturile de picioare ajustabile: Majoritatea scaunelor rulante au suporturi de picioare care pot fi poziționate mai sus sau mai jos. Anumite scaune rulante au opțiuni de ajustare suplimentare, cum ar fi: • suporturile de picioare pot fi deplasate înspre înainte sau înspre înapoi; • unghiul suportului de picioare poate fi mărit sau diminuat. Aceste opțiuni oferă mai multă flexibilitate în ceea ce privește poziționarea picioarelor utilizatorului. Suport de picioare cu unghi reglabil: Suportul de picioare cu unghi reglabil face posibilă extensia piciorului, cu genunchiul întins. Această caracteristică este de folos în cazul utilizatorilor de scaun rulant care nu pot flecta genunchii pentru atingerea poziției neutre și, implicit, pentru realizarea poziției așezat. Înclinarea spătarului: Înclinarea spătarului (înclinarea spătarului înspre înapoi) este utilă atunci când: • șoldurile utilizatorului nu pot fi flectate pentru a ajunge în poziția neutră de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade); • este prezentă înclinarea posterioară fixă a bazinului; • este prezentă postura fixă înclinată a părții inferioare a trunchiului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 81 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Înclinarea în spațiu: Anumite scaune rulante au opțiunea „înclinării în spațiu”. Acest lucru înseamnă că spătarul și suprafața de ședere fomează un ansamblu de ședere. Unghiul de deschidere dintre suprafața de ședere și spătar nu se modifică. Poziția înclinată a suprafeței de ședere este utilă în următoarele cazuri: • când este prezentă înclinarea fixă posterioară a bazinului, cu contractura flexorilor de șold și genunchi; • există o toleranță scăzută în ceea ce privește menținerea poziției așezat sau disconfortul posturii corpului în poziția normală de ședere; • când este necesară creșterea nivelului de confort și relaxare. Suprafața de ședere rigidă: Anumite scaune rulante au o suprafață de ședere rigidă, care nu se pliază. Aceasta oferă: o o bază adecvată pentru adăugarea suporturilor posturale suplimentare pentru bazin și șolduri; o un grad de stabilitate mai ridicat decât în cazul suprafeței de ședere pliabile. Acesta este un element important în cazul utilizatorilor de scaun rulant care au mișcări necontrolate sau o greutate corporală foarte mare. Spătarul rigid: Anumite scaune rulante au un spătar rigid. Spătarul rigid reprezintă o bază corespunzătoare pentru adăugarea de suporturi posturale suplimentare. Un suport rigid înseamnă: o un grad de stabilitate crescut în comparație cu cel al spătarului flexibil. Acesta este un aspect important în cazul în care utilizatorul de scaun rulant are mișcări necontrolate; o un grad crecut de suport pentru utilizatorii de scaune rulante cu înălțimea sau greutatea mai mare și/sau cu trunchiul foarte instabil. Imaginea prezintă un spătar rigid căruia i s-a adăugat spumă/burete pentru a furniza suport la nivelul trunchiului, în zona unde acest lucru este necesar, precum și inserții laterale încorporate în spătar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 82 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Unele scaune rulante sunt dotate cu spătar cu tensiune ajustabilă în locul celui simplu, pliabil. Un spătar cu tensiune ajustabilă vă permite să modificați cu ușurință gradul de suport. Benzile individuale se pot regla în funcție de tensiunea necesară pentru furnizarea unui grad mai ridicat sau mai scăzut de suport postural. Nu este nevoie de toate aceste caracteristici pentru a furniza suport postural suplimentar. Multe dintre caracteristicile de mai sus pot fi modificări aduse unui scaun rulant tipic, cu antrenare manuală. Centralizarea informațiilor legate de scaunele rulante disponibile la nivel local Formularul de date tehnice - nivel intermediar pe care îl găsiți mai jos este recomandat pentru strângerea și înregistrarea informațiilor despre scaunele rulante disponibile la nivel local. Care sunt aspectele care trebuie luate în considerare înainte de modificarea unui scaun rulant? Atunci când se alege un scaun rulant care va trebui modificat pentru a oferi suportul postural necesar utilizatorului, personalul furnizor de servicii de scaune rulante trebuie să ia în considerare următoarele aspecte: • Scaunul rulant este în stare bună de funcționare? • Materialele și serviciile disponibile la nivel local sunt compatibile cu scaunul rulant? • În cazul în care scaunul rulant se defectează, componentele pot fi reparate sau înlocuite la nivel local? Tipul de pernă În vederea prescrierii, personalul furnizor de servicii de scaune rulante trebuie să cunoască tipurile de perne disponibile. Caracteristici importante ale pernelor: • materialul din care sunt confecționate pernele; • dacă perna contribuie la reducerea presiunii; • ușurința cu care perna poate fi modificată; • nivelul de impermeabilitate al husei. Pentru mai multe informații despre perne, inclusiv despre pernele pentru reducerea presiunii, vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 83 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Tipul și dimensiunea pernei selectate sunt înregistrate în formularul de prescriere – nivel intermediar, la „Tipul și dimensiunea pernei”. 3.Tipul și dimensiunea pernei Tipul de pernă Dimensiunea De exemplu, pernă pentru reducerea presiunii Pentru cazul în care o pernă are nevoie de modificări cu scopul de a se crea un dispozitiv de suport postural corect, detaliile sunt descrise într-una din secțiunile următoare ale formularului de prescriere - nivel intermediar. Formular de date tehnice ale scaunului rulant – nivel intermediar Denumire scaun rulant: Inserați imagine aici: Producător / Furnizor: Dimensiuni disponibile: Greutate totală: Descriere: Cadru: Fix/rigid Pliabil Lungime cadru Spătar Pliabil/material textil Rigid Tensiune ajustabilă Șezut: Pliabil/material texti Rigid Tensiune ajustabilă Pernă: Fără pernă Plată, din spumă/ burete Cu contur, din spumă/burete Fluid Altele Suporturi de picioare: Fixe Detașabile / pliabile pe lateral Altele: Roți frontale: Pneumatice Diametru: Solide Lățime: Roți din spate Pneumatice Diametru: Inele antrenare Solide Lățime: Ax reglabil Tub interior solid Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 84 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Suporturi pentru brațe: Curbate Pătrate Altele: Fixe Detașabile Altele: Mânere: Mânere: Dispozitive de suport postural: Centură pentru bazin Centură pentru gambe Ham pentru umeri Centură pentru picioare Bară anti- răsturnare Inserții laterale pentru trunchi Măsuță Tetieră Inserții laterale pentru bazin Altele: Măsurători, opțiuni de modificări și gama de ajustări: Măsurători (dacă scaunul rulant este disponibil în mai multe mărimi, specificați toate mărimile) Este ajustabil? Gamă de ajustări (gama de ajustări ce pot fi făcute pentru acest scaun) Da Nu Lățime suprafață de ședere Adâncime suprafață de ședere Înălțime suprafață de ședere Înălțime spătar Unghi înclinare spătar Înălțime suport de picioare Unghi înclinare suport de picioare Înălțime mânere Lungime cadru Lungime bază roți Unghi spătar și șezut Unghi înclinare în spațiu Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 85 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Formular de prescriere (selecție) a scaunului rulant – nivel intermediar Acest formular se utilizează pentru înregistrarea informațiilor referitoare la tipul de scaun rulant, pernă și dispozitivele de sprijin postural pentru utilizatorii de scaun rulant care nu pot menține fără sprijin poziția așezat confortabilă. Păstrați acest formular în dosarul utilizatorului de scaun rulant. 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data evaluării: Data probării produsului (a scaunului rulant): Numele persoanei care efectuează evaluarea: 2. Tipul, dimensiunea și configurația scaunului rulant Tipul scaunului rulant (notați mai jos tipurile de scaune rulante disponibile) Dimensiunile scaunului rulant (mm) Lățimea suprafeței de ședere Adâncimea suprafeței de ședere Înălțimea spătarului Înălțimea suportului de picioare Configurația scaunului rulant Poziția roții din spate Altele: Unghiul de înclinare Tipul și mărimea pernei Tipul de pernă Dimensiunea Ex: pernă pentru reducerea presiunii Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 86 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 4. Dispozitivele de suport postural sau modificările necesare Listă de verificare a dispozitivelor de suport postural Descrieți/desenați și notați dimensiunile S up ra fa ța d e șe de re / pe rn a Adăugare suprafață de ședere rigidă Inserție anterioară oaselor bazinului (3 - 12) Inserție pentru reglarea unghiului de înclinare a bazinului S D Înălțarea suprafeței de ședere inserție prin anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Inserții pentru stabilizarea bazinului S D Inserții laterale pentru bazin (=2) S D Inserții unghiulare exterioare pentru coapse S D Inserții exterioare pentru coapse S D Inserție interioară pentru coapse (= 10) Inserție pentru separarea genunchilor (= 10) Altele Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 87 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Listă de verificare a dispozitivelor de suport postural Descrieți/desenați și notați dimensiunile S up ra fa ța de ș ed er e și sp ăt ar ul Deschidere unghi suprafață de ședere - spătar Unghi de înclinare suprafață de ședere - spătar (înclinarea în spațiu) S pă ta ru l Adăugare unui spătar solid Inserție posterioară pentru bazin Spătar cu formă ajustabilă Spătar cu tensiune ajustabilă Spătar cu unghi de înclinare ajustabil Inserții laterale pentru trunchi (= 7) S D Inserții unghiulare laterale pentru trunchi (= 7) S D Altele M ăs uț a / su po rtu ril e de b ra țe Măsuță Modificarea suporturilor de brațe S D Altele Te tie re le Tetieră plată (= 11) Tetieră conturată (= 11) Altele S up or tu ril e pe nt ru pi ci oa re Inserții plane pentru suportul de picioare S D Inserții unghiulare pentru suportul de picioare S D Dispozitive de sprijin pentru gambă S D Altele C en tu ril e Centură pentru bazin Centură pentru gambe Centură pentru picior S D Ham pentru umeri Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 88 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 5. Acordul Semnătură utilizator de scaun rulant: Semnătură evaluator: Semnătură manager furnizor servicii de scaune rulante Prescrierea (selecția) dispozitivelor de suport postural - introducere Există multe modele diferite de dispozitive de suport postural, precum și diverse modalități prin care scaunul rulant poate fi modificat astfel încât să ofere utilizatorului suport postural suplimentar. Frecvent, pentru un singur utilizator de scaun rulant vom recurge la o combinație de dispozitive de suport postural, cu scopul de a furniza suportul general de care acesta are nevoie. Ce este un dispozitiv de suport postural? Dispozitivul de suport postural (DSP) este un dispozitiv fizic care oferă suport postural suplimentar - un element esențial al serviciului de scaune rulante de nivel intermediar. Tabelul de dispozitive de suport postural (DSP) (numit în continuare Tabel DSP) și tabelul de referințe pentru dispozitivele de suport postural (DSP) (numit în continuare Tabel de referințe DSP) de pe următoarele pagini oferă un rezumat al diferitelor dispozitive de suport postural incluse în acest program de instruire. În imaginea de mai jos găsiți câteva exemple de dispozitive de suport postural . Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 89 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Inserție/dispozitiv pentru separarea genunchilor Spătar înalt Inserție laterală pentru trunchi Inserție laterală pentru bazin Ham pentru umeri Centură pentru picior Centură pentru bazin Tetieră Termeni diferiți Aceleași dispozitive de suport postural pot avea denumiri diferite, în funcție de furnizorul de servicii de scaune rulante, de zonă sau producător. În acest Manual al participantului, fiecare dispozitiv de suport postural este denumit cu termeni simpli, descriptivi. În cadrul fiecărui serviciu de scaune rulante, personalul și utilizatorii pot folosi termenii cu care sunt familiarizați. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 90 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Tabel dispozitive de suport postural (DSP) Suprafața de ședere / perna Inserție anterioară oaselor bazinului Inserție pentru reglarea unghiului de înclinare a bazinului (unilateral) Înălțarea suprafeței de ședere prin inserție anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Inserții pentru stabilizarea bazinului Inserții laterale pentru bazin Suprafața de ședere / perna Suprafața de ședere și spătarul Inserții unghiulare exterioare pentru coapse Inserții exterioare pentru coapse Inserție unghiulară interioară pentru coapse Inserție/ dispozitiv pentru separarea genunchilor Deschiderea unghiului dintre suprafața de ședere și spătar Unghiul de înclinare dintre suprafața de ședere și spătar (înclinarea în spațiu) Spătarul Inserție posterioară pentru bazin Spătar cu formă ajustabilă Spătar cu tensiune ajustabilă Spătar cu unghi de înclinare ajustabil Inserții laterale pentru trunchi Inserții unghiulare laterale pentru trunchi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 91 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Măsuța Tetierele Suporturile pentru picioare Măsuță Tetieră plată Tetieră conturată Inserții plane pentru suportul de picioare Inserții unghiulare pentru suportul de picioare Dispozitiv de sprijin pentru gambă Centurile Centură pentru bazin Centură în patru puncte pentru prevenirea înclinării anterioare Centură pentru gambe Centură pentru picioare Ham pentru umeri Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 92 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Tabel de referințe pentru dispozitivele de suport al posturii (DSP) Dispozitiv de suport postural Obiectiv Probarea produsului Suprafața de ședere / perna Inserția anterioară oaselor bazinului O inserție anterioară oaselor bazinului ajută la: • menținerea bazinului în poziția așezat; • prevenirea alunecării bazinului înspre înainte; • reducerea tendinței de adoptare a unei poziții „prăbușite”. Linia de început a inserției anterioare oaselor bazinului trebuie să fie poziționată chiar în fața oaselor bazinului. Inserția pentru reglarea unghiului de înclinare a bazinului (unilateral) Reglarea unghiului de înclinare a bazinului unilateral, ca în imagine, acomodează un șold care nu poate fi flectat până la atingerea poziției neutre de ședere (unghiul dintre trunchi și coapse este mai mare de 90 de grade). Gradul de reglare a unghiului de înclinare va depinde de unghiul șoldului utilizatorului de scaun rulant. Presiunea în zona de contact dintre suprafața de ședere și oaselor bazinului (inclusiv coapse) trebuie să fie distribuită egal pe toată suprafața zonei. Înălțarea suprafeței de ședere prin inserție anterioară Înălțarea suprafeței de ședere poate acomoda șoldurile care nu pot fi extinse până la atingerea poziției neutre de ședere (unghiul dintre trunchi și coapse este mai mic de 90 de grade). Înălțarea suprafeței de ședere poate avea ca rezultat inclusiv reducerea mișcărilor necontrolate puternice sau a hipertoniei, care cauzează rigiditate la nivelul corpului. Gradul de înălțare a suprafeței de ședere va depinde de unghiul dintre trunchiul și coapsele utilizatorului de scaun rulant. Presiunea în zona de contact dintre suprafața de ședere și oaselor bazinului (inclusiv coapse) trebuie să fie distribuită egal pe toată suprafața zonei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 93 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Dispozitivul unghiular pentru înclinarea anterioară a bazinului O inserție unghiulară cu înclinare posterioară, plasată sub oasele bazinului,este utilăîn cazul utilizatorilor de scaun rulant cu înclinare anterioară flexibilă a bazinului. Inserția unghiulară determină poziționarea înspre înapoi a bazinului. Suprafața dispozitivului unghiular pentru înclinarea anterioară a bazinului nu trece de linia oaselor bazinului și se nivelează sub coapse. În vederea furnizării unui dispozitiv unghiular pentru înclinarea anterioară a bazinului, în etapa de evaluare confecționați o „machetă” a inserției. Acest lucru va permite utilizatorului de scaun rulant să simtă efectele pe care le poate avea un astfel de dispozitiv. Totodată, personalul furnizor de servicii de scaune rulante și utilizatorul au posibilitatea de a găsi unghiul optim de înclinare și să stabilească gradul de eficiență al dispozitivului. Inserțiile pentru stabilizarea bazinului Inserția pentru stabilizarea bazinului este recomandată în cazul utilizatorilor de scaun rulant care au bazinul într-o postură vicioasă fixă. Inserția ajută la: • creșterea gradului de stabilitate a utilizatorului de scaun rulant; • evitarea exercitării unui nivel de presiune mai ridicat în partea inferioară a bazinului. Inserția se află sub oasele superioare ale bazinului și coapse. Presiunea în zona de contact dintre suprafața de ședere și oaselor bazinului (inclusiv coapse) trebuie să fie distribuită egal pe toată suprafața zonei. Prescrierea unei inserții pentru stabilizarea bazinului va implica uneori ajustarea suporturilor de picioare (unul dintre acestea va trebui poziționat mai sus, comparativ cu celălalt). Inserțiile laterale pentru bazin vor contribui și la susținerea bazinului și ar trebui folosite în cazul oricărei persoane care are o inserție pentru stabilizarea bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 94 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Inserțiile laterale pentru bazin Inserțiile laterale pentru bazin au ca efect: • oprirea deplasării înspre lateral a bazinului atunci când scaunul rulant este prea lat sau când șoldurile sunt mai înguste decât trunchiul; • reducerea tendinței bazinului de a se înclina înspre lateral. Inserțiile laterale pentru bazin trebuie să susțină bine ambele părți ale bazinului. Rețineți faptul că în cazul copiilor de vârstă mică, poziția de ședere corectă presupune ca abducția la nivelul coapselor să fie mai accentuată decât la adulți. Din acest motiv, asigurați-vă că inserțiile laterale pentru bazin nu au o poziție prea avansată și nu forțează coapsele utilizatorului de scaun rulant copil (în adducție). Inserțiile unghiulare exterioare pentru coapse Inserțiile unghiulare exterioare pentru coapse ajută la: • menținerea alinierii neutre a coapselor; • reducerea tendinței membrelor inferioare de a aluneca înspre interior sau înspre exterior. Atunci când utilizatorul de scaun rulant este în repaus sau în mișcare, inserțiile unghiulare exterioare pentru coapse le susțin pe acestea într-o aliniere neutră, fără a produce disconfort. Dacă în continuare coapsele au tendința de a aluneca înspre interior sau exterior, atunci este nevoie de un grad accentuat de suport (vezi inserțiile exterioare pentru coapse). Inserțiile exterioare pentru coapse oferă un grad ridicat de suport, pentru a preveni căderea sau rotirea înspre exterior a membrelor inferioare (abducție). Atunci când utilizatorul de scaun rulant este în repaus sau în mișcare, inserțiile exterioare pentru coapse le susțin pe acestea într-o aliniere neutră, fără a produce disconfort. Presiunea în zona de contact dintre inserție și membrele inferioare trebuie să fie distribuită egal pe toată suprafața zonei. Inserția unghiulară interioară pentru coapse O inserție unghiulară interioară pentru coapse contribuie la: • menținerea alinierii naturale a coapselor; • reducerea tendinței de alunecare înspre interior a membrelor inferioare (adducție). Atunci când utilizatorul de scaun rulant este în repaus sau în mișcare, inserțiile unghiulare interioare pentru coapse le susțin pe acestea într-o aliniere neutră, fără a produce disconfort. Verificați ca inserția unghiulară interioară pentru coapse să nu îngreuneze transferul în și din scaunul rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 95 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Inserție/dispozitiv pentru separarea genunchilor Inserția/dispozitivul pentru separarea genunchilor înseamnă un grad ridicat de suport pentru menținerea alinierii neutre a coapselor. Inserția/dispozitivul pentru separarea genunchilor se recomandă în cazul în care coapsele utilizatorului de scaun rulant sunt în adducție (au tendința de a aluneca înspre interior). Atunci când utilizatorul de scaun rulant este în repaus sau mișcare, inserția pentru separarea genunchilor susține coapsele într-o aliniere neutră, fără a produce disconfort. Presiunea în zona de contact dintre genunchii, respectiv coapsele utilizatorului și inserție trebuie să fie distribuită egal pe toată suprafața zonei. Inserția/dispozitivul pentru separarea genunchilor nu trebuie să intre în contact cu zona inghinală. Dacă există riscul ca bazinul utilizatorului să alunece către inserția pentru separarea genunchilor, furnizați o inserție anterioară oaselor bazinului și o centură pentru bazin. Suprafața de ședere și spătarul Deschiderea unghiului dintre suprafața de ședere și spătar Deschiderea (creșterea) unghiului dintre suprafața de ședere și spătar este recomandată atunci când este vorba despre utilizatori de scaun rulant cu înclinare posterioară fixă a bazinului sau cu șolduri fixe. Unghiul crescut acomodează postura fixă și oferă un grad ridicat de suport, pentru mai mult confort și pentru prevenirea schimbărilor posturale ulterioare. Contactul cu oasele bazinului, cu partea posterioară a bazinului, respectiv cu partea inferioară și superioară a spatelui trebuie să fie egal. Acest lucru poate însemna o conturare a spumei/ buretelui, pentru a oferi suportul corect și contactul corespunzător. Atunci când crește unghiul dintre suprafața de ședere și spătar, este important să prevenim alunecarea înspre înainte a utilizatorului de scaun. Această alunecare determină riscul apariției escarelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 96 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Înclinarea suprafeței de ședere și a spătarului (înclinare în spațiu) Înclinarea unitară a suprafeței de ședere și a spătarului contribuie la: • alinierea capului și a părții superioare a trunchiului, după acomodarea unei posturi vicioase fixe a trunchiului,atunci când, în continuare, se exercită presiune asupra capului; • alinierea capului și a părții superioare a trunchiului în cazul utilizatorilor de scaun rulant cu trunchiul foarte instabil. Înclinarea unitară a suprafeței de ședere și a spătarului se recomandă doar atunci când alte suporturi pentru bazin și trunchi s-au dovedit ineficiente. Observați cu atenție efectele înclinării pentru a determina cel mai bun unghi și gradul de eficiență al acestuia. În poziția finală de înclinare, utilizatorul de scaun rulant trebuie să stea confortabil, iar bazinul trebuie să se afle cât mai aproape de poziția neutră de ședere, pe cât posibil. Spătarul Inserția posterioară pentru bazin Sprijină partea superioară a bazinului, pentru a-l menține drept. Inserția posterioară pentru bazin se furnizează de regulă împreună cu o inserție anterioară oaselor bazinului, eventual cu o centură pentru bazin. Inserția posterioară pentru bazin trebuie să ofere un grad ridicat de suport în zona posterioară a bazinului, la nivelul crestei iliace postero-superioare și să mențină bazinul în poziția neutră de ședere. Verificați nivelul de presiune exercitat asupra vertebrei dintre cele două creste iliace postero- superioare. Nivelul de presiune nu trebuie să fie ridicat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 97 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Spătarul cu formă ajutabilă Forma spătarului se ajustează pentru o mai bună susținere a trunchiului în poziția neutră de ședere (curburi fiziologice ) sau pentru a acomoda posturile non-neutre ale trunchiului. Există mai multe modalități de ajustare a formei spătarului, inclusiv: • modificarea materialului textil al spătarului și adăugarea unei inserții posterioare pentru bazin (prima imagine); • prin adăugarea la partea solidă a spătarului a unui element (spătar suplimentar) din spumă/ burete cu contur; • utilizarea unui spătar cu tensiune ajustabilă (a doua imagine). După ajustare, presiunea în zona de contact dintre spătar și partea inferioară, mediană, respectiv superioară a trunchiului trebuie să fie distribuită egal pe toată suprafața zonei. Dacă este posibilă atingerea posturii neutre, spătarul trebuie să susțină bazinul în poziția așezat, precum și curburile fiziologice ale trunchiului. Dacă nu este posibilă atingerea unei posturi complet neutre, spătarul trebuie să susțină utilizatorul într-o poziție în care bazinul se află cât mai aproape de poziția neutră, în limita posibilităților. Spătarul cu reglare a tensiunii Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 98 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Înclinarea spătarului Înclinarea spătarului este utilă în cazul: • șoldurilor ce nu pot fi flectate pentru atingerea poziției neutre de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade); • prezenței înclinării posterioare fixe a bazinului; • posturii fixe a părții inferioare a trunchiului. • trunchiului fix cu orientare înspre înainte (cifoză); • în care este necesară alinierea trunchiului și a capului. Inserția anterioară oaselor bazinului, centura pentru bazin și/sau inserția unghiulară în partea frontală a pernei previn alunecarea înspre înainte. Verificați dacă înclinarea spătarului susține corpul de așa manieră încât părțile acestuia sunt aliniate cât mai mult posibil. Asigurați-vă că presiunea din zona de contact dintre trunchi și spătar este distribuită egal pe toată suprafața zonei. Verificați ca utilizatorul de scaun rulant să nu alunece înspre înainte. Inserția anterioară oaselor bazinului, centura pentru bazin și/sau inserția unghiulară în partea frontală a pernei previn alunecarea înspre înainte. Inserțiile laterale pentru trunchi Inserțiile laterale pentru trunchi oferă un grad ridicat de suport pentru a menține trunchiul pe linia mediană a spătarului. În cazul în care se utilizează o inserție laterală pentru trunchi, aceasta va fi obligatoriu însoțită de o inserție pentru partea opusă a trunchiului. Inserțiile laterale pentru trunchi trebuie să fie situate întotdeauna cu cel puțin 50 mm mai jos de axila utilizatorului și să nu fie mai late decât este necesar. Presiunea din zona de contact dintre trunchi și inserție trebuie să fie distribuită egal pe toata suprafața zonei. Dacă este nevoie de un grad ridicat de suport, măriți dimensiunea inserției, pentru o distribuire corectă a presiunii și asigurați- vă că inserția este acoperită în întregime, astfel încât trunchiul să fie protejat. Inserțiile laterale pentru trunchi trebuie să fie cât mai subțiri, pentru a nu reduce libertatea de mișcare la nivelul brațelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 99 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Inserțiile unghiulare laterale pentru trunchi Furnizează un grad de suport mai redus, menținând trunchiul utilizatorului pe linia mediană a spătarului. Acestea sunt utile atunci când gradul de suport necesar nu este unul accentuat. Inserțiile unghiulare laterale pentru trunchi contribuie la menținerea utilizatorului de scaun rulant într-o postură simetrică (trunchiul pe linia mediană a spătarului). Inserțiile unghiulare trebuie să fie situate sub axilă și să nu fie mai late decât este necesar. Inserții laterale pentru trunchi folosite cu inserții laterale pentru bazin Inserțiile laterale pentru trunchi și inserțiile laterale pentru bazin pot fi folosite împreună cu scopul de a furniza suport acelor utilizatori care au trunchiul curbat înspre lateral (scolioză). Inserțiile sunt ajustate pentru a oferi suport în partea superioară a curburii, la apexul curburii (în partea opusă) și în partea inferioară a curburii. Sunt necesare inserții laterale de ambele părți ale bazinului, pentru a-l menține în centrul suprafeței de ședere. Furnizarea de suport pentru atingerea poziției neutre de ședere în cazul unei persoane cu scolioză flexibilă poate contribui la corectarea unui aflat în poziție vicioasă. Dacă postura de ședere este flexibilă, este posibil ca utilizatorul de scaun rulant să poată menține poziția neutră de ședere. Dacă postura de ședere este fixă, furnizați suport pentru atingerea unei poziții cu bazinul cât mai aproape de poziția neutră de ședere, fără a crea disconfort. Asigurați-vă că presiunea în zona de contact dintre spatele utilizatorului și fiecare inserție este distribuită egal. Verificați dacă există puncte în care se exercită o presiune ridicată. Dacă este nevoie de un grad ridicat de suport, măriți dimensiunea inserției pentru a distribui presiunea exercitată și asigurați-vă că inserția este acoperită în întregime, pentru protejarea trunchiului. Suportul posterior conturat Suportul posterior conturat pentru spate poate fi folosit ca dispozitiv de suport postural sau pentru acomodarea diferitelor posturi ale trunchiului, inclusiv orientarea înspre înainte a trunchiului sau trunchiul curbat. Suportul pentru spate este atașat de cadrul scaunului rulant prin dispozitive de fixare sau curele. Această opțiune nu este prezentată în cadrul pachetului de instruire de nivel intermediar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 100 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Măsuța Măsuța Măsuțele sunt utile în diverse moduri: • oferă suport pentru brațe, ceea ce reduce tendința trunchiului de a fi tras în jos și înspre înainte, sub acțiunea greutății brațelor; • oferă utilizatorului de scaun rulant o suprafață pentru lucru/joacă, situată în proximitatea sa. De obicei, măsuțele sunt poziționate chiar deasupra nivelului coatelor. Ele pot fi poziționate la un nivel puțin mai înalt dacă obiectivul este ca furnizarea de suport postural suplimentar. Măsuțele nu trebuie folosite pentru „fixarea” corpului utilizatorului în scaunul său rulant. Măsuța nu trebuie să exercite niciun fel de presiune asupra utilizatorului. Tetiera Tetiera plată Tetiera plată este utilă pentru poziționarea capului și oprește căderea înspre înapoi a acestuia. Tetiera trebuie să ofere suport corespunzător în timp ce utilizatorul de scaun rulant este în repaus și/sau mișcare. Tetiera trebuie să intre în contact cu capul utilizatorului de scaun rulant la baza craniului (occiput). Verificați dacă tetiera oferă suport respectând alinierea corectă. Asigurați-vă că nu impune capului o orientare înspre înainte și că nu permită alunecarea acestuia înspre înapoi. Evitați poziționarea oricărui tip de suport în partea frontală a capului utilizatorului. Tetieră conturată Gradul de suport oferit de tetiera conturată este mai ridicat comparativ cu tetiera plată, deoarece urmează linia de la baza craniului utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 101 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Dispozitivele de sprijin pentru picioare Inserțiile plane pentru suportul de picioare Inserția plană pentru suportul de picioare poate fi folosită atunci când unul sau niciunul dintre picioare nu poate ajunge la suportul de picioare (iar suporturile de picioare au fost plasate în cea mai înaltă poziție posibilă). Verificați dacă presiunea în zona de contact dintre picioare și suportul de picioare este distribuită egal. Inserțiile unghiulare pentru suportul de picioare Inserția unghiulară pentru suportul de picioare poate fi folosită pentru susținerea posturilor fixe non-neutre a picioarelor. Inserția unghiulară pentru suportul de picioare poate preveni apariția modificărilor de postură la nivelul gleznelor. Scopul inserțiilor unghiulare pentru suportul de picioare este extinderea zonei de contact dintre suportul de picioare și picioarele utilizatorului de scaun rulant. Majoritatea inserțiilor unghiulare pentru suportul de picioare sunt create individual, în funcție de gradul de suport necesar la nivelul picioarelor utilizatorului. Dispozitivele de sprijin pentru gambe Pentru susținerea posturilor non-neutre ale gambelor putem folosi diverse dispozitive de sprijin pentru gambe. Acestea sunt utile și în cazul în care genunchii utilizatorului nu pot fi flectați la 90 de grade (unghiul dintre trunchi și coapse este mai mare de 90 de grade). Diverse soluții și modalitatea de probare a acestora vor fi abordate în sesiunea de pregătire a produsului (a scaunului rulant) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 102 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Centurile Centura pentru bazin Contribuie la menținerea bazinului în poziția corespunzătoare. Este recomandat în special în cazul persoanelor care au mișcări necontrolate și/sau al căror corp are tendința de a aluneca înspre înainte în timpul utilizării scaunului rulant. Centura pentru bazin este folosită frecvent împreună cu inserția anterioară oaselor bazinului și cu inserția posterioară pentru bazin. Presiunea în zona de contact dintre centura pentru bazin și bazinul utilizatorului de scaun trebuie să fie distribuită egal. Nu trebuie să existe puncte în care presiune exercitată să fie mai ridicată. Este importantă stratul de protecție în zonele unde centura intră în contact cu coapsele utilizatorului. Poziția unde se atașează centura de corpul utilizatorului de scaun rulant va afecta unghiul format și orientarea centurii. Unghiul poate fi între 45 și 90 de grade. Valoarea ideală a acestuia va depinde de nevoile utilizatorului de scaun rulant. La evaluare, discutați întotdeauna cu utilizatorul și, dacă este posibil, testați unghiul centurii pentru bazin împreună cu acesta, pentru a stabili poziția cea mai eficientă și mai confortabilă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 103 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Centura în patru puncte pentru prevenirea înclinației anterioare a bazinului Centura în patru puncte oferă suport utilizatorilor cu înclinație anterioară a bazinului. Centura contribuie la situarea bazinului într-o poziție de ședere mai apropiată de cea neutră sau la prevenirea accentuării înclinației anterioare a bazinului. Această centură poate fi folosită împreună cu inserția unghiulară pentru prevenirea înclinației anterioare, plasată sub oasele bazinului utilizatorului. Rețineți că centura este atașată de cadrul suprafeței de ședere, iar în partea posterioară de cadrul spătarului. Centura nu trebuie să alunece în sus pe abdomenul utilizatorului de scaun rulant. Este important ca orice centură care oferă suport la nivelul ambelor creste iliace antero- superioare să fie acoperită cu strat de protecție, pentru a reduce riscul apariției escarelor. Centura pentru gambe Centura pentru gambe contribuie la prevenirea alunecării înspre înapoi a gambelor utilizatorului de scaun rulant. Uneori, aceste centuri sunt incluse în opțiunile standard ale scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 104 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Diferitele tipuri de centuri pentru picioare ajută la stabilizarea picioarelor utilizatorului de scaun rulant și previn alunecarea înspre înainte sau înspre înapoi a acestora. Centurile pentru picior –în spatele călcâiului Centura situată în spatele călcâiului contribuie la prevenirea alunecării înspre înapoi a piciorului. Aceasta poate fi folosită împreună cu o centură pentru gambe, pentru un grad de suport mai ridicat. Centurile pentru picioare trebuie să exercite un nivel de presiune egal și să fie acoperite cu un strat care să protejeze picioarele, în special în cazul în care utilizatorul de scaun rulant nu poartă încălțăminte. Centurile pentru picior –la nivelul gleznei Centura pentru picior la nivelul gleznei previne alunecarea înspre înainte a piciorului și împiedică ridicarea călcâiului. Centurile pentru picior - peste picior Centura pentru picior situată peste acesta previne ridicarea degetelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 105 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Hamul pentru umeri Hamul pentru umeri contribuie la menținerea trunchiului în poziție corectă în cazurile în care suportul pentru bazin, suportul pentru trunchi, precum și înclinarea suprafeței de ședere și a spătarului nu au avut rezultate. Hamul pentru umeri din imagine are o centură pentru piept, care oferă suport suplimentar. Centura pentru piept ajută la menținerea în poziția corectă a hamurilor pentru umeri. Hamul pentru umeri trebuie folosit întotdeauna împreună cu o centură pentru bazin. Nu veți prescrie niciodată un ham pentru umeri fără a prescrie și o centură pentru bazin. În cazul în care hamul pentru umeri se folosește fără o centură pentru bazin, trunchiul utilizatorului de scaun rulant poate aluneca, iar centura poate cauza strangularea. Verificați dacă există un strat de protecție în locul în care hamul trece peste umărul utilizatorului de scaun rulant. Centura pentru piept (ca în imagine) ajută la menținerea în poziție corectă a hamului pentru umeri. Hamul pentru umeri trebuie fixat la nivelul umerilor sau mai sus. Astfel se evită exercitarea unei forțe descendente asupra umerilor utilizatorului. Înregistrarea în formularul de prescriere (selecție) – nivel intermediar a informațiilor referitoare la dispozitivele de suport postural Obiectivul formularului de prescriere (selecție) - nivel intermediar este să ofere personalului furnizor de servicii de scaune rulante care pregătește produsul informații cu privire la: • tipul, dimensiunea și configurația scaunului rulant (abordate în secțiunile anterioare); • tipul și dimensiunea pernei (abordate în secțiunile anterioare); • dispozitivele de suport postural sau modificările necesare. Cu cât informațiile din formularul de prescriere (selecție) a scaunului rulant – nivel intermediar sunt mai detaliate, cu atât mai eficientă va fi pregătirea scaunului rulant pentru prima probare. Din cauză că pot exista multe aspecte referitoare la dispozitivele de suport postural prescrise, secțiunea „Dispozitivele de suport postural și modificările necesare” este partea cea mai complexă din formularul de prescriere (selecție) - nivel intermediar. Personalul furnizor de servicii de scaune rulante poate folosi această secțiune a formularului de prescriere – nivel intermediar pentru următoarele aspecte: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 106 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar • pentru a alege dispozitivele de suport postural pe care intenționează să le prescrie/aleagă, folosind lista de dispozitive. De asemenea, există un spațiu unde pot fi notate și alte tipuri de dispozitive de suport postural („Altele”); • pentru a face schițe peste imaginile din formular, astfel încât să fie înregistrate forma și dimensiunile dispozitivelor de suport postural prescrise (selectate); • pentru a nota orice informație sau schiță suplimentară. Observație: Formularul de prescriere (selecție) - nivel intermediar nu prezintă neapărat modul în care dispozitivele de suport postural trebuie confecționate. Acest aspect poate fi decis în urma discuțiilor dintre personalul furnizor de servicii de scaune rulante care pregătește scaunul rulant și cel care a efectuat evaluarea. Următoarele două exemple arată modul de completare al secțiunii „Dispozitivele de suport postural și modificările necesare” din formularul de prescriere (selecție) a scaunului rulant -nivel intermediar (dimensiunile nu sunt incluse) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 107 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Listă de verificare a dispozitivelor de suport postural Descrieți/desenați și notați dimensiunile S up ra fa ța d e șe de re / pe rn a Adăugare suprafață de ședere rigidă Inserție anterioară oaselor bazinului (3 - 12) Inserție pentru reglarea unghiului de înclinare a bazinului S D Înălțare suprafață de ședere prin inserție anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Inserții pentru stabilizarea bazinului S D Inserții laterale pentru bazin (=2) S D Inserții unghiulare exterioare pentru coapse S D Inserții exterioare pentru coapse S D Inserție unghiulară interioară pentru coapse (= 10) Inserție/dispozitiv pentru separarea genunchilor (= 10) Altele Altele S up ra fa ța d e șe de re ș i sp ăt ar ul Deschidere unghi suprafață de ședere - spătar Înclinare suprafață de ședere și spătar (înclinare în spațiu) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 108 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar S pă ta ru l Adăugare suprafață de ședere rigidă Inserție posterioară pentru bazin (=9) Spătar cu formă ajustabilă Spătar cu tensiune ajustabilă Înclinare spătar Inserții laterale pentru trunchi (=7) S D Inserții unghiulare laterale pentru trunchi (=7) L D Altele M ăs uț ă / co tie re Măsuță Modificarea suporturilor de brațe S D Altele Te tie re le Tetieră plată (= 11) Tetieră conturată (= 11) Altele S up or tu ril e m em br el or in fe rio ar e Inserții plane pentru suportul de picioare S D Inserții unghiulare pentru suportul de picioare S D Dispozitive de sprijin pentru gambă S D Altele C en tu ril e Centură pentru bazin Centură pentru gambe Centuri pentru picior S D Ham pentru umeri Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 109 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Prescrierea (selecția) dispozitivelor de suport postural pentru stabilizarea bazinului Mai multe tipuri de dispozitive de suport postural sunt folosite pentru a furniza suport bazinului. Este important de reținut faptul că, deși dispozitivele de suport postural pot fi folosite individual, de cele mai multe ori se apelează la mai multe tipuri de astfel de dispozitive. Această secțiune prezintă câteva probleme posturale ale bazinului, precum și soluțiile identificate, cu ajutorul dispozitivelor de suport postural. Stabilizarea bazinului este primul și cel mai important pas în a ajuta utilizatorul de scaun rulant să mențină poziția așezat o Atunci când bazinul nu este în poziția corectă, survin schimbări de postură la nivelul trunchiului și al șoldurilor. o Din acest motiv, susținerea sau stabilizarea bazinului este cel mai important pas în a ajuta utilizatorul scaunului rulant să mențină poziția așezat. o Suportul oferit la nivelul bazinului poate reduce nevoia de suport postural suplimentar la nivelul unei alte părți a corpului. Problemă: Înclinarea posterioară a bazinului și/sau tendința bazinului de a aluneca înspre înainte Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 110 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Suport necesar Pentru a contracara înclinarea posterioară și pentru a situa bazinul într-o poziție mai apropiată de cea neutră de ședere, de obicei este nevoie de furnizarea de suport la nivelul a două zone: o partea posterioară a bazinului, la nivelul crestei iliace postero-superioare; o partea frontală a bazinului, la nivelul oaselor bazinului (tuberozităților ischiale). Soluțiile oferite de dispozitivele de suport postural Inserția anterioară oaselor bazinului oferă suport în partea anterioară a oaselor bazinului și contribuie la: • menținerea în echilibru a bazinului; • prevenirea alunecării înspre înainte a bazinului; • reducerea tendinței de a avea o postură „prăbușită”. Inserția anterioară oaselor bazinului este plasată exact înaintea oaselor bazinului. Inserția posterioară pentru bazin furnizează suport în partea superioară a bazinului (la nivelul crestei iliace postero-superioare) și ajută la menținerea în echilibru a bazinului. Inserția anterioară oaselor bazinului și inserția posterioară pentru bazin sunt folosite împreună în mod frecvent, pentru ca utilizatorii de scaun rulant să poată menține bazinul în echilibru și pentru un grad mai ridicat de stabilitate. Centura pentru bazin reprezintă un suport suplimentar în cazul utilizatorilor de scaune rulante care au mișcări necontrolate și/sau la care există tendința de alunecare înspre înainte. Centura pentru bazin menține bazinul în poziție, astfel încât inserția anterioară oaselor bazinului și inserția posterioară pentru bazin să furnizeze suportul necesar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 111 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Problemă: Înclinarea laterală a bazinului (bazin fix inegal) Suport necesar Este necesară furnizarea de suport sub oasele superioare ale bazinului și sub coapse pentru: • creșterea stabilității utilizatorului de scaun rulant; • evitarea exercitării unui nivel de presiune ridicat la nivelul părții inferioare a bazinului. Soluțiile oferite de dispozitivele de suport postural Inserția pentru stabilizarea bazinului are ca rezultat: • creșterea stabilității utilizatorului de scaun rulant; • evitarea exercitării unui nivel de presiune prea mare la nivelul părții inferioare a bazinului. Inserțiile laterale pentru bazin sprijină bazinul și sunt necesare ori de câte ori se recomandă o inserție pentru stabilizarea bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 112 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Problemă: Bazinul este orientat înspre lateral În mod frecvent, această situație este asociată altor probleme posturale. În cele două imagini puteți observa: • utilizatorul de scaun rulant din exemplul precendent, cu bazinul situat în înclinare laterală (bazin fix inegal), orientat înspre stânga; • o persoană cu o curbură laterală a coloanei vertebrale, având, de asemenea, bazinul orientat înspre stânga. Suport necesar Suportul necesar poate fi oferit din lateral, la nivelul ambelor șolduri. Soluțiile oferite de dispozitivele de suport postural Inserțiile laterale pentru bazin. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 113 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Furnizarea de inserții laterale pentru bazin în cazul utilizatorilor de scaun rulant copii Atunci când se află în poziția așezat, gradul de abducție al coapselor copiilor de vârstă mică trebuie să fie mai accentuat decât în cazul adulților. Acest lucru este important pentru sănătatea și dezvoltarea articulațiilor șoldului. În consecință, este esențial ca inserțiile laterale pentru bazin să nu forțeze apropierea (adducția) la nivelul coapselor copiilor. Problemă: Înclinarea anterioară a bazinului (bazinul orientat înspre înainte) Suport necesar Există două modalități de a oferi suport: o prin suport poziționat în fața bazinului (creasta iliacă antero-superioară), forța exercitată fiind orientată înspre partea posterioară; o prin imprimarea unei mișcări înspre înapoi a bazinului, schimbând unghiul suprafeței de ședere, sub oasele bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 114 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Soluțiile oferite de dispozitivele de suport postural Dispozitivul unghiular pentru înclinarea anterioară a bazinului determină bazinul să fie orientat mai mult către partea posterioară a scaunului rulant, spre spătar. Suprafața acestui tip de inserție trebuie să ajungă până la linia din fața oaselor bazinului și să fie la același nivel sub coapsele utilizatorului. Centura în patru puncte pentru prevenirea înclinației anterioare a bazinului oferă suport în partea superioară și anterioară a bazinului, încurajând atingerea unei poziții de ședere mai apropiate de cea neutră. Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea șoldurilor Este important de reținut faptul că orice postură fixă/non-neutră a șoldurilor, dacă nu este acomodată, va afecta postura bazinului. Sprijinirea șoldurilor Problemă: Unul dintre șolduri nu poate fi flectat până la atingerea poziției neutre de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade) Soluția temporară pentru această problemă este plasarea unei inserții (spumă/burete) sub ambele oase ale bazinului și sub coapsa care nu atinge poziția neutră. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 115 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Soluțiile oferite de dispozitivele de suport postural Inserția pentru reglarea unghiului de înclinare a bazinului (unilateral) - Acest suport poate fi încorporat pernei pentru acomodarea un șold care nu poate fi flectat pentru atingerea poziției neutre de ședere (unghiul dintre trunchi și coapse este mai mare de 90 de grade). Observație: Soluția permanentă este o tăietură unghiulară pe partea unde se află șoldul care nu poate fi flectat până în poziția neutră. Unghiul tăieturii din spumă/burete va depinde de unghiul șoldului utilizatorului de scaun rulant - deci, acest aspect trebuie verificat la evaluare. Observație: Perna include o inserție anterioară oaselor bazinului. Problemă: Niciunul dintre șolduri nu poate fi flectat până la atingerea poziției neutre de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade) Soluția temporară pentru această problemă este plasarea unei inserții (burete/spumă) sub ambele oase ale bazinului. Totuși, aceasta nu poate fi o soluție permanentă, deoarece utilizatorul de scaun rulant va avea tendința de a aluneca înspre înainte în scaunul rulant. Soluțiile oferite de dispozitivele de suport postural Deschiderea unghiului dintre suprafața de ședere și spătar va crește unghiul dintre trunchi și coapse. Unghiul dintre suprafața de ședere și spătar va depinde de unghiul format de trunchiul și coapsele utilizatorului de scaun rulant - acest aspect trebuie determinat pe parcursul evaluării. O posibilă soluție permanentă este inserția anterioară oaselor bazinului și centura pentru bazin, care ar opri alunecarea înspre înainte a utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 116 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Problemă: Unul sau niciunul dintre șolduri nu poate fi extins până atingerea poziției neutre de ședere (unghiul dintre trunchi și coapse este mai mic de 90 de grade) Soluția temporară pentru această problemă este plasarea unei inserții (unghiulare, din spumă rigidă/burete rigid) sub șoldul care nu poate fi extins până la atingerea poziției neutre de ședere (unghiul dintre trunchi și coapse este mai mic de 90 de grade). Soluțiile oferite de dispozitivele de suport postural Înălțarea suprafeței de ședere prin inserție anterioară – o potențială soluție permanentă este ridicarea suprafeței de ședere prin inserție anterioară/plasarea unei inserții unghiulare în partea anterioară oaselor bazinului/sub coapse. Astfel se reduce unghiul dintre suprafața de ședere și spătar. Gradul de ridicare a suprafeței anterioare de ședere va depinde de unghiul dintre trunchiul și coapsele utilizatorului - acest lucru trebuie determinat pe parcursul evaluării. Observație: Ambele oase ale bazinului trebuie să fie poziționate pe o suprafață plană. Reducerea mișcărilor necontrolate, a hipertoniei și a spasticității În cazul unor utilizatori de scaune rulante, înălțarea părții anterioare a suprafeței de ședere pentru reducerea unghiului format de trunchi și coapse la nivelul șoldurilor, cu alterarea poziției neutre de ședere, contribuie la reducerea mișcărilor necontrolate, a hipertoniei și a spasticității. Rețineți! Marginea inserției unghiulare trebuie să fie tot timpul în partea anterioară a oaselor bazinului. Oasele bazinului trebuie să fie poziționate pe o suprafață plană. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 117 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea trunchiului Este esențial să începem întodeauna prin identificarea metodei de stabilizare a bazinului, apoi a trunchiului. În multe cazuri, problemele posturale ale trunchiului pot fi soluționate sau ameliorate dacă bazinul beneficiază de un sprijin adecvat. Stabilizarea trunchiului Problemă: Postură „prăbușită”, trunchi orientat înspre înainte și bazin în înclinare posterioară Suportul necesar • Suport pentru situarea bazinului într-o poziție cât mai apropiată de cea neutră de ședere, în măsura în care acest lucru este posibil. • Suport furnizat de spătar, care acomodează curburile fiziologice ale coloanei vertebrale. • Uneori este necesară furnizarea de suport în partea anterioară a trunchiului. Soluțiile oferite de dispozitivele de suport postural • Suportul pentru bazin este furnizat utilizând: – inserția anterioară oaselor bazinului; – inserția posterioară pentru bazin; – centura pentru bazin (nu este tot timpul necesară); – inserțiile laterale pentru bazin (nu sunt întotdeauna necesare); • Suportul oferit de spătar înseamnă: – ajustarea formei spătarului - pentru a oferi spațiu trunchiului și pentru a permite coloanei vertebrale să urmeze curburile fiziologice. Un spătar mai înalt ar împinge înspre înainte utilizatorul de scaun rulant. Această modificare a formei spătarului este parte a soluției identificate în acest caz. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 118 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Gradul de suport postural suplimentar poate fi crescut folosind: • măsuța - o măsuță înseamnă suport suplimentar pentru ca utilizatorul să poată menține o postură corectă a trunchiului. • hamul pentru umeri–pentru utilizatorii care au tendința de a obosi repede sau al căror trunchi cade înspre înainte. • înclinarea suprafeței de ședere și a spătarului–atunci când folosirea altor dispozitive de suport postural nu ajută la menținerea poziției așezat de către utilizatorul de scaun rulant, înclinarea suprafeței de ședere și a spătarului poate fi o potențială soluție. Spătarul trebuie să urmeze curburile fiziologice ale coloanei vertebrale Un spătar drept, neînclinat,fără contururile necesare acomodării curburilor fiziologice ale coloanei vertebrale, va determina, de obicei, următoarele: • orientarea înspre înainte a părții superioare a trunchiului; • mișcarea înspre înainte a bazinului utilizatorului, astfel încât utilizatorul să se poată sprijini de spătar. Din păcate, multe scaune rulante standard sunt echipate cu un spătar drept. În consecință, sunt necesare anumite modificări în vederea susținerii utilizatorului de scaun rulant într-o poziție neutră confortabilă pentru acesta. Problemă: Postură „prăbușită”, bazin aflat în înclinare posterioară fixă și trunchi orientat înspre înainte Suport necesar • Suport pentru situarea bazinului într-o poziție cât mai apropiată de cea neutră de ședere, în măsura în care acest lucru este posibil. • Suport furnizat de spătar pentru a susține trunchiul cât mai aproape de poziția neutră de ședere și pentru alinierea capului (creșterea capacității utilizatorului de a privi drept înainte) Soluțiile oferite de dispozitivele de suport postural Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 119 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Soluțiile depind de gradul de acomodare necesar și de tipurile de scaune rulante disponibil. Mai jos sunt prezentate câteva sugestii: • Suportul pentru bazin este furnizat utilizând: • inserția anterioară oaselor bazinului; • inserția posterioară pentru bazin ȘI deschiderea unghiului dintre suprafața de ședere și spătar pentru a acomoda și susține înclinarea posterioară fixă a bazinului; • centură pentru bazin (nu este întotdeauna necesară); • Suportul oferit de spătar înseamnă: – spătar cu unghi de înclinare ajustabil - pentru a oferi spațiu curburii fixe a trunchiului. Acest lucru poate duce la o mai bună alinierea a capului și gâtului. Această soluție este adecvată și pentru înclinarea fixă posterioară a bazinului. (Observație: fiecărui spătar rigid i se va adăuga burete/spumă cu căptușeală). – ajustarea formei spătarului - pentru a oferi suficient spațiu trunchiului și pentru a permite coloanei vertebrale să urmeze curburile fiziologice. Gradul de suport postural suplimentar poate fi crescut folosind: – măsuța; – hamul pentru umeri; – înclinarea suprafeței de ședere și a spătarului. Ordinea de abordare a soluțiilor de suport postural este următoarea Bazin și șolduri Trunchi Cap și gât Membre inferioare Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 120 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Problemă: Trunchiul se înclină sau are tendința de a cădea înspre lateral Suport necesar • Stabilizarea bazinului. • Suport poziționat în părțile laterale ale trunchiului. Soluțiile oferite de dispozitivele de suport postural • Inserțiile unghiulare laterale pentru trunchi - oferă un grad de suport redus, în vederea menținerii trunchiului utilizatorului pe linia mediană a spătarului. • Inserțiile laterale pentru trunchi - oferă un grad ridicat de suport pentru a menține trunchiul pe linia mediană a spătarului. O inserție laterală pentru trunchi va fi furnizată întotdeauna cu o inserție pentru partea opusă a trunchiului, aceasta din urmă putând fi situată la un nivel diferit. Problemă: Curbură laterală fixă sau flexibilă a coloanei vertebrale Suport necesar • Suport la nivelul apexului curburii pe o parte și la nivelul superior și inferior al curburii pe partea opusă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 121 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Soluțiile oferite de dispozitivele de suport postural • Inserțiile laterale pentru trunchi folosite împreună cu inserțiile laterale pentru bazin. Dacă postura este flexibilă, cu ajutorul acestui suport, utilizatorul de scaun rulant poate fi capabil să mențină poziția neutră de ședere. Dacă postura este fixă, oferiți suport pentru atingerea unei poziții de ședere cât mai apropiate de cea neutră, în limita confortului. Furnizând suport în poziția neutră de ședere unui utilizator de scaun rulant cu scolioză flexibilă, putem corecta și bazinul aflat în poziție vicioasă. Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea capului, coapselor și a gambelor Sprijinirea capului Problemă: Capul are tendință de a aluneca înspre înapoi, înspre înainte sau înspre lateral Suport necesar • Pași obligatorii înainte de furnizarea unei tetiere: – stabilizarea bazinului utilizatorului de scaun rulant; – oferirea unui suport corespunzător la nivelul trunchiului, asigurându-ne că acesta este stabil și în echilibru în raport cu bazinul. • Dacă utilizatorul de scaun rulant continuă să aibă dificultăți în ceea ce privește menținerea capului într-o poziție echilibrată, este nevoie de suport postural suplimentar: – în prima etapă, la baza craniului (occiput); – dacă este necesar, suportul se poate extinde pentru a sprijini părțile laterale ale capului; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 122 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Soluțiile oferite de dispozitivele de suport postural Există multe tipuri de tetiere. Două dintre cele mai frecvent utilizate tipuri de tetiere sunt cele plate și cele conturate. • Tetiera plată - tetiera plată este o extensie a spătarului, având o formă conturată, astfel încât să ofere suport la nivelul capului. Tetiera plată previne alunecarea înspre înapoi a acestuia. • Tetiera conturată–forma tetierei conturate are rolul de a cuprinde baza capului utilizatorului de scaun rulant. Poate fi extinsă la margini, iar această prelungire înspre înainte a tetierei crește gradul de suport pe părțile laterale ale capului. Gradul de suport oferit de tetiera conturată este mai mare decât în cazul tetierei plate, datorită susținerii de la nivelul bazei craniului (occiput) utilizatorului de scaun rulant. Furnizarea tetierei: Atunci când furnizați suport suplimentar la nivelul capului utilizatorului de scaun rulant, nu uitați că postura capului depinde și de postura corespunzătoare a bazinului și trunchiului. Evitați soluțiile de suport postural poziționate în partea frontală a capului utilizatorului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 123 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sprijinirea coapselor Problemă: Membre inferioare orientate spre exterior (în abducție) Suport necesar • În primul rând, asigurați-vă că bazinul și trunchiul utilizatorului de scaun rulant sunt stabilizate prin intermediul suportului postural necesar. Acest lucru poate ajuta la poziționarea membrelor inferioare într-o poziție de ședere mai apropiată de cea neutră. • Suport în partea exterioară a coapselor. Soluțiile oferite de dispozitivele de suport postural • Inserțiile unghiulare exterioare pentru coapse vor furniza un grad de suport mai redus. Observație: În imaginea alăturată, inserțiile unghiulare exterioare pentru coapse au fost plasate peste stratul solid de burete/spumă al unei perne. Perna încorporează o inserție anterioară oaselor bazinului. Se recomandă utilizarea unui strat de burele/spumă moale, care să acopere întreaga suprafață a pernei. • Inserțiile unghiulare exterioare pentru coapse vor furniza un grad ridicat de suport. Observație: În imaginea alăturată, inserția pentru coapse este atașată unei suprafețe de ședere din lemn, cu ajutorul unui dispozitiv de fixare. Există suficient spațiu pentru a permite plasarea unei perne deasupra suprafeței de ședere din lemn. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 124 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Problemă: Membre inferioare orientate spre interior (în adducție) Suport necesar • În primul rând, asigurați-vă că bazinul și trunchiul utilizatorului de scaun rulant sunt stabilizate prin intermediul suportului postural necesar. Acest lucru poate ajuta la poziționarea membrelor inferioare într-o poziție de ședere mai apropiată de cea neutră. • Furnizați suport la nivelul părții interioare a coapselor și a genunchilor. Soluțiile oferite de dispozitivele de suport postural • Inserțiile unghiulare interioare pentru coapse vor furniza un grad de suport mai redus. Observație: În imaginea alăturată, a fost adăugată o inserție unghiulară pentru coapse peste stratul solid de burete/spumă al unei perne. Perna încorporează o inserție anterioară oaselor bazinului. Se recomandă utilizarea unui strat de burele/spumă moale, care să acopere întreaga suprafață a pernei. • Inserția pentru separarea genunchilor oferă un grad ridicat de suport. Observație: În imaginea alăturată, dispozitivul pentru separarea genunchilor este atașat unei suprafețe de ședere din lemn, cu ajutorul unui dispozitiv de fixare. Există suficient spațiu pentru a permite plasarea unei perne deasupra suprafeței de ședere din lemn. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 125 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sprijinirea gambelor și a picioarelor Problemă: Unul sau ambii genunchi sunt flectați și fixați într-un unghi mai mic decât cel caracteristic poziției neutre de ședere (unghiul dintre trunchi și coapse este mai mare de 90 de grade) Soluția va depinde de nevoile utilizatorului de scaun rulant. Soluțiile oferite de dispozitivele de suport postural Ajustați suporturile de picioare în așa fel încât acestea să fie orientate înspre înapoi, dacă acest lucru este posibil. • Ajustați unghiul suportului pentru picioare pentru a se potrivi cu poziția piciorului. Dacă nu este posibil, utilizați inserții unghiulare pentru suportul de picioare. • Folosiți o centură în partea anterioară a gambelor, pentru sprijin și protecție. • Dacă partea frontală a suprafeței de ședere exercită presiune asupra părții posterioare a membrului inferior/membrelor inferioare ale utilizatorului de scaun rulant, poate fi necesară scurtarea suprafeței de ședere și tăierea oblică a marginii pernei. • În cazul unui utilizator înalt, luați în considerare înălțarea părții frontale a suprafeței de ședere sau înclinarea suprafeței de ședere și a spătarului. Astfel, picioarele utilizatorului vor fi poziționate mai sus, mai mult înspre înainte și, probabil, la un nivel care să se situeze în intervalul oferit de posibilitățile de ajustare a suporturilor de picioare standard. Observație: • Atunci când efectuați oricare dintre ajustările de mai sus, verificați dacă roțile frontale se pot învârti complet, fără a întâmpina vreun obstacol, cum ar suporturile de picioare sau picioarele utilizatorului de scaun rulant. • Dacă aceste ajustări nu sunt posibile în cazul scaunelor rulante disponibile sau dacă nu au rezultatul dorit, va fi necesară efectuarea unor modificări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 126 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Problemă: Unul sau niciunul dintre genunchi nu poate fi flectat pentru atingerea poziției neutre de ședere Soluțiile oferite de dispozitivele de suport postural: • Furnizarea unui suport de picioare standard, cu unghi reglabil, dacă este disponibil. • Ajustați suporturile pentru picioare înspre înainte, dacă această opțiune este disponibilă. • Luați în considerare furnizarea unui scaun rulant cu trei roți, dacă acest lucru este posibil. Adăugați suporturile de picioare în partea superioară a barei centrale orizontale. • Extindeți înspre înainte suporturile de picioare, prin adăugare unor elemente din lemn sau metal. • Extindeți bara suportului pentru picioare pentru a fi într-o poziție mai avansată. Acest operațiune poate implica sudarea materialului și trebuie efectuată de către o persoană cu foarte bune cunoștințe tehnice și cu abilități în ceea ce privește lucrul cu metalele. Observație: Oricare ar fi soluția adoptată, este important să încercați să vă asigurați că lungimea totală a scaunului rulant va avea cea mai mică valoare posibilă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 127 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Etapa 4: Finanțarea și plasarea comenzii • Vezi Etapa 4: Pentru informații generale despre aceste aspecte, vezi secțiunea „Finanțarea și plasarea comenzii” din Servicii pentru utilizatorii de scaune rulante. Pachet de instruire – nivel de bază. Etapa 5: Pregătirea produsului (a scaunului rulant) Pregătirea produsului (a scaunului rulant) Pregătirea produsului (a scaunului rulant) este cea de-a cincea etapă a procesului de furnizarea de serviciilor de scaune rulante. Pregătirea produsului (a scaunului rulant) înseamnă configurarea scaunului rulant și pregătirea dispozitivelor de suport postural prescrise (selectate). În modulul de instruire de nivel intermediar, pregătirea scaunului rulant poate fi efectuată doar până la un anumit punct fără ca probarea echipamentului de mobilitate să devină necesară. În procesul de furnizare a serviciilor pentru utilizatorii de scaun rulant, etapele care corespund pregătirii produsului (a scaunului rulant) și probării acestuia trebuie repetați până când scaunul rulant corespunde în totalitate. De multe ori, dispozitivele de suport postural nu sunt fixate în întregime înainte de prima probare. Acest lucru este necesar pentru a ne asigura că scaunul rulant și dispozitivele de suport postural pot fi ajustate și după probarea lor. Există mai multe modalități de furnizare a suportului postural suplimentar. Anumite soluții sunt foarte simple și pot fi confecționate într-un atelier tipic. Altele sunt mai complexe și necesită mai multe abilități tehnice sau diverse facilități. Personalul furnizor de servicii de scaune rulante nu trebuie să confecționeze el însuși dispozitivele de suport postural, ci are posibilitatea de a colabora cu tehnicieni. Reprezentanții furnizorului de servicii de scaune rulante trebuie să dea indicații cu privire la elementul de care este nevoie și la modul său de funcționare, iar tehnicienii găsesc soluții pentru confecționarea acestuia din materialele disponibile la nivel local. Se recomandă ca personalul care oferă servicii utilizatorilor de scaun rulant să fie implicat în procesul de confecționare a dispozitivelor de suport postural, pentru a se asigura că produsul final va răspunde nevoilor utilizatorului de scaun rulant. În mod frecvent, veți identifica soluții diverse la aceeași problemă. Acestea depind de cele mai multe ori de resursele disponibile: • tipurile de scaune rulante disponibile și ajustările care pot fi efectuate; • materialele disponibile; • facilitățile de care dispun atelierele și instrumentele disponibile; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 128 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar • existența suporturilor prefabricate - de exemplu, inserții laterale pentru bazin, inserții laterale pentru trunchi, centuri și tetiere. Planificarea și efectuarea pregătirii scaunului rulant și a dispozitivelor de suport postural Planificarea și pregătirea Înainte de a începe etapa de pregătire a scaunului rulant, este importantă planificarea activității. Planificarea atentă este cu atât mai importantă cu cât activitatea de pregătire a scaunului rulant este transferată unei alte persoane (de exemplu, unui tehnician care lucrează într-un atelier) sau dacă este efectuată de mai multe persoane. Planificarea și pregătirea implică următorii pași: Revedeți formularul de prescriere (selecție) a scaunului rulant - nivel intermediar: • asigurați-vă că toate persoanele implicate înțeleg toate informațiile din formular; • asigurați-vă că în formular sunt înregistrate suficiente informații pentru pregătirea scaunului rulant. De exemplu - sunt notate în formular toate dimensiunile necesare? Sunt suficient de detaliate descrierile diferitelor dispozitive de suport postural? Este posibil să fie necesare discuții sau clarificări suplimentare. Decideți modalitatea prin care scaunul rulant selectat va oferi gradul de suport postural suplimentar necesar: • Priviți scaunul rulant care urmează să fie folosit și puneți următoarele întrebări: – Ce ajustări pot fi făcute acestui scaun rulant pentru a oferi suportul necesar? – Ce dispozitive de suport postural sunt deja montate pe scaunul rulant? • În cazul în care este nevoie de modificări sau dacă trebuie adăugate dispozitive de suport postural, decideți: – Există suporturi prefabricate care pot fi folosite? Dacă da - cum vor fi acestea montate pe scaunul rulant? – Dacă modificările sau dispozitivele de suport postural trebuie confecționate din materii prime - ce materiale vor fi folosite și cum vor fi fixate pe scaunul rulant dispozitivele de suport postural? • Nu uitați să luați în considerare modul în care scaunul rulant și dispozitivele de suport postural vor funcționa împreună. Pregătiți o listă de sarcini: • enumerați sarcinile care trebuie efectuate pentru a pregăti scaunul rulant; • dacă sunt implicate mai multe persoane, decideți care sunt sarcinile fiecăreia. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 129 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Aspecte de reținut în procesul de confecționare a dispozitivelor de suport postural Atunci când pregătiți un scaun rulant cu suport postural suplimentar, nu uitați următoarele patru sugestii: 1. Dispozitivele de suport postural trebuie să ofere suficient suport Gradul de suport necesar fiecărui utilizator de scaun rulant va varia. Dispozitivele de suport postural trebuie să furnizeze suportul de care are nevoie fiecare utilizator de scaun rulant, acolo unde acest lucru este necesar și pe suprafața corespunzătoare. 2. Dispozitivele de suport postural și scaunele rulante funcționează unitar, ca un sistem complet Adăugarea elementelor de suport postural suplimentar poate schimba întregul sistem al scaunului rulant. De exemplu, adăugarea dispozitivelor de suport postural poate modifica dimensiunile interioare ale scaunului rulant. 3. Evitarea creării zonelor unde se exercită un nivel ridicat de presiune Dispozitivele de suport postural pot exercita uneori presiune asupra anumitor zone ale corpului utilizatorului de scaun rulant. De exemplu, dacă utilizatorul are nevoie de un grad ridicat de suport pentru a preveni înclinarea trunchiului înspre lateral, inserțiile laterale pentru trunchi ar putea constitui o zonă unde presiunea exercitată să fie prea mare. În astfel de situații, luați în considerare distribuirea forței exercitate prin creșterea suprafeței de contact. Asigurați-vă întotdeauna că există suficient material pentru a acoperi întreaga suprafață a dispozitivelor de suport postural și partea interioară a centurilor. 4. Asigurați-vă că dispozitivele de suport postural sunt practice și nu reduc capacitatea utilizatorilor de scaun rulant de a desfășura diverse activități Rețineți - utilizatorii au nevoie de scaune rulante și de suprafețe de ședere care sunt practice și ușor de folosit și care îi ajută să fie cât mai activi posibil. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 130 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Siguranța în atelier - cinci reguli de siguranță: • În atelier purtați încălțăminte care acoperă piciorul. • Atunci când tăiați sau găuriți un element, asigurați-vă că el este fixat - utilizați un șablon sau cereți asistență. • Utilizați ochelari de protecție atunci când folosiți scule electrice sau instrumente ascuțite. • Asigurați-vă că spațiul de lucru și căile de acces sunt bine organizate și curate. • Nu îndreptați niciodată lama instrumentului de tăiat în direcția în care vă aflați sau în care se află alte persoane. Materialele și instrumentele necesare confecționării dispozitivelor de suport postural și efectuării modificărilor Tabelul de mai jos conține exemple de materiale care pot fi folosite pentru confecționarea dispozitivelor de suport postural: Materiale Dispozitive de suport postural (DSP) sau modificări pentru care pot fi folosite materialele: Aspecte importante în alegerea materialelor pentru confecționarea dispozitivelor de suport postural sau efectuării modificărilor: Metal/ plastic/ lemn Metalul/plasticul/lemnul formează structura unui DSP -de exemplu, suprafețe de ședere și spătare rigide. Lemnul sau metalul poate fi folosit pentru confecționarea dispozitivelor de fixare a inserției laterale pentru trunchi de spătarul scaunului rulant. Placajul de 12 mm este foarte util în confecționarea spătarelor și suprafețelor de ședere rigide. Este rezistent, dar are o greutate relativ mică. Placajul stratificat este cel mai rezistent; totuși, poate fi mai scump. Pentru confecționarea spătarelor rigide se pot folosi plăci de aluminiu de 3 mm și plăci acrilice de 6 mm sau plăci de plastic ABS, dacă sunt disponibile. Plierea plăcii poate crește gradul de rigiditate. Atunci când utilizați orice tip de plăci, asigurați-vă că ați eliminat sau ați acoperit cu material marginile ascuțite, pentru a proteja siguranța utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 131 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Burete/ căptușeală Buretele/spuma se utilizează în cazul tuturor DSP-urilor, în zonele în care acestea intră în contact direct cu corpul utilizatorului de scaun rulant. Buretele rigid/spuma rigidă, care își menține forma, se utilizează pentru ca DSP- urile să aibă forma adecvată, necesară furnizării de suport postural. Buretele/spuma cu o rigiditate mai mică au rolul de a crește gradul de confort și de a reduce nivelul de presiune exercitată. Exemple de utilizare ale buretelui/spumei: • se adaugă burete/spumă la centuri, cu scopul de a distribui egal presiunea exercitată și de a crește nivelul de confort; • buretele rigid/ spuma rigidă se utilizează pentru confecționarea inserției unghiulare laterale pentru trunchi, se adaugă pernei pentru a crea o inserție unghiulară exterioară pentru coapse sau o inserție unghiulară interioară pentru coapse; • buretele foarte rigid (de ex., poliuretan) sau spuma cu un grad ridicat de rigiditate sunt necesare pentru confecționarea inserțiilor plane sau unghiulare pentru suportul de picioare ori pentru inserțiile laterale pentru trunchi. Căutați materialele în magazinele locale și contactați fabricile care produc spumă/ burete, încălțăminte, saltele sau mobilă pentru a identifica la nivel local sursele de spumă/burete. Încercați să găsiți la nivel local spumă/ burete de grosime variată (25 mm și 50 mm) și cu grade de rigiditate diferite. Poliuretanul este un exemplu de spumă foarte rigidă, care oferă rezistență și structură solidă în vederea confecționării de DSP-uri. Uneori, acest material poate fi găsit în fabricile de încălțăminte. Cauciucul rigid, folosit pentru încălțămintea purtată de regulă la ștrand, poate înlocui poliuretanul. Buretele din fulgi încleiați, de foarte bună calitate este un exemplu de burete cu rigiditate medie. Acesta poate fi folosit ca bază pentru o pernă cu contur/cu straturi, pentru confecționarea inserțiilor posterioare pentru bazin sau a celor anterioare oaselor bazinului, precum și pentru adăugarea la spătarul rigid a stratului conturat. Spuma/buretele cu grad scăzut de rigiditate, folosite la fabricarea saltelelor, se recomandă pentru confecționarea straturilor de confort. Buretele cu un grad de rigiditate scăzut sau spuma „moale”, disponibile la scară largă, la un preț scăzut, nu sunt recomandate în confecționarea pernelor pentru reducerea presiunii decât cu o bază din burete/spumă mai rigide. Fibra de nucă de cocos poate fi folosită în locul spumei rigide/buretelui rigid. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 132 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Material textil Materialul textil este folosit pentru acoperirea suprafeței DSP-urilor. Căutați un material textil care este rezistent și ușor de curățat (prin ștergere sau prin îndepărtarea în vederea spălării). Materialul textil impermeabil se folosește pentru suprafața de ședere, perna sau spătarul scaunului rulant în cazul în care utilizatorul are probleme de management vezical și intestinal. Un material textil moale, folosit pentru fabricarea tricourilor (bumbac sau bumbac/lycra), poate fi folosit pentru tetiere, inserții laterale pentru trunchi sau inserții unghiulare laterale pentru trunchi. Un material textil cu un anumit grad de elasticitate se va adapta cu mai multă ușurință formei DSP-ului. În general, materialele textile sintetice vor crește temperatura la nivelul suprafaței pielii utilizatorului de scaun rulant mai mult decât cele naturale. În măsura în care este posibil, încercați să dispuneți de mai multe culori și oferiți utilizatorului opțiunea de a alege. Chingi din nailon/ Velcro/ catarame Chingile din nailon/Velcro/ cataramele sunt folosite pentru centuri, incluzând centurile pentru bazin, hamul pentru umeri și centurile pentru picioare și gambe. Chingile din nailon de 25 mm, 35 mm și 50 mm sunt foarte folositoare. Cu cât centura este mai lată, cu atât presiunea exercitată se distribuie mai uniform. Topirea capătului chingilor de nailon previne desfacerea acestora. Chinga din bumbac este mult mai ineficientă. Cataramele de tipul celor folosite la rucsacuri sunt foarte ușor de utilizat. Încercați să folosiți catarame de o bună calitate, deoarece acestea au o durată mai mare de utilizare. Conectați elementele cataramelor și trageți de ele, pentru a testa funcționarea lor. Ar trebui să se închidă și să se deschidă ușor și să nu se desfacă atunci când nu sunt deblocate. Materialul de tip Velcro constituie un sistem bun de prindere. El trebuie menținut curat, în caz contrar există riscul ca el să nu mai funcționeze. Trebuie introduse inserții din burete/spumă moale sub toate centurile, pentru a proteja corpul utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 133 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Adezivi Adezivii sunt folosiți pentru lipirea lemnului și buretelui/ a spumei. Se recomandă să aveți un stoc de adeziv pentru lemn (cunoscut sub numele de adeziv de tip aracet) și adeziv pentru burete (adeziv de contact, pentru încălțăminte). Asigurați-vă că persoanele care utilizează adezivul știu cum să îl folosească în mod corespunzător. Sisteme de fixare Sistemele de fixare sunt folosite pentru atașarea DSP- urilor la scaunul rulant. Sistemele de fixare utilizate includ: o șuruburi cu piulițe (preferabil contrapiulițe) și șaibe; o piulițe pentru lemn (prinse în placaj în locul unei piulițe); o capse (pentru fixarea tapițeriei). Evitați utilizarea șuruburilor ascuțite, deoarece pot deveni periculoase în cazul în care DSP-ul se deteriorează. Facilități și instrumente în cadrul atelierului: Un centru furnizor de servicii pentru utilizatorii de scaun rulant, care confecționează DSP-uri în mod frecvent, are nevoie de un atelier amenajat, care să aibă o masă de lucru dotată cu menghină, zone de depozitare pentru materiale și instrumente, iluminare și ventilație corespunzătoare. Tabelul de mai jos oferă exemple de instrumente care ajută la confecționarea DSP-urilor. Instrumente folositoare: Utilizate la: Ferăstrău manual Tăierea lemnului, plasticului sau a metalului, fără conectare la o sursă de curent electric. Ferăstrău electric Tăierea lemnului, plasticului sau a metalului (asigurați-vă că se utilizează lama corespunzătoare materialului tăiat), acolo unde există sursă de curent electric. Burghie și vârfuri de burghie Crearea găurilor pentru șuruburi. Lamă ascuțită, rigidă Tăierea buretelui, fără conectare la sursă de electricitate. Ferăstrău cu bandă Tăierea lemnului, plasticului și buretelui, acolo unde există sursă de curent electric. Pilă Netezirea marginilor lemnului, metalului sau a plasticului. Mașină de șlefuit Netezirea marginilor lemnului, metalului sau a plasticului, acolo unde există sursă de curent electric. Chei Strângerea șuruburilor și piulițelor. Mașină de cusut industrială Coaserea tapițeriei din material textil, a huselor și a centurilor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 134 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Cum se confecționează dispozitivele de suport postural? În continuare, vom vedea mai multe sugestii pentru crearea dispozitivelor de suport postural prezentate în acest modul de instruire. Multe dintre principiile prezentate pot fi aplicate și în cazul altor dispozitive de suport postural. Inserția anterioară oaselor bazinului Inserția anterioară oaselor bazinului este confecționată dintr-o bucată de spumă rigidă/burete rigid sau dintr-un material similar, având un strat superior din burete moale/ spumă moale. Inserția poate fi plasată sub buretele moale al unei suprafețe de ședere solide sau între două straturi ale unei perne multistrat confecționată din burete. Inserția anterioară oaselor bazinului poate fi încorporată într-o pernă pentru reducerea presiunii. Inserția anterioară oaselor bazinului este plasată exact înaintea oaselor bazinului. Inserția pentru reglarea unghiului de înclinare a bazinului (unilateral) Acest dispozitiv de suport postural poate fi confecționat prin modificarea unei perne din spumă/burete. Tăiați spuma rigidă/buretele rigid (nu materialul moale) din partea anterioară a suprafeței de ședere pentru a obține unghiul dorit. Bucata de spumă/burete îndepărtată va avea forma unei inserții unghiulare, cu porțiunea groasă în partea anterioară a suprafeței de ședere și partea subțire poziționată chiar în fața bazinului sau a oaselor bazinului. Dacă se utilizează o suprafață de ședere solidă și este nevoie de un unghi larg, este posibilă îndepărtarea (tăierea) unei părți din suprafața de ședere, pentru a permite șoldului un grad de flexie mai mare. Observație: Menținând în flexie celălalt șold al utilizatorului de scaun rulant, putem preveni mai ușor alunecarea înspre înainte a utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 135 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT În cazul în care este nevoie de un unghi mai mare, este posibil să fie necesară ridicarea întregii suprafețe de ședere, în partea inferioară a acestuia,cu un strat de spumă rigidă. Asigurați-vă că nu există margini ascuțite, că acestea au fost nivelate. Verificați dacă suprafața de ședere mai înaltă nu are u efect negativ asupra înălțimii suporturilor de picioare sau a spătarului. Înălțarea suprafeței de ședere prin inserție anterioară Partea anterioară a suprafeței de ședere poate fi înălțată prin diverse metode. Mai jos sunt prezentate două dintre acestea: Introduceți o inserție unghiulară confecționată din spumă rigidă/burete rigid sub partea frontală a pernei. Această inserție trebuie să ajungă până la linia unde începe bazinul utilizatorului de scaun rulant. Eliminați suprafața de ședere confecționată din material textil și furnizați o suprafață de ședere rigidă. Cu ajutorul dispozitivelor de fixare, montați suprafața de ședere, poziționând-o în unghiul necesar. În cazul suprafeței de ședere rigide, furnizați întotdeauna o pernă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 136 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Dispozitivul unghiular pentru înclinarea anterioară a bazinului Dispozitivul unghiular pentru înclinarea anterioară a bazinului poate fi confecționat folosind același principiu ca și în cazul inserției anterioare oaselor bazinului. Stratul de bază din spumă rigidă/burete rigid este cel care imprimă forma pernei, iar stratul de spumă/burete moale este plasat în partea superioară. Dispozitivul unghiular trebuie să se situeze sub oasele bazinului și să se oprească la linia de început a acestora. Sub coapse, perna trebuie să fie la același nivel. Inserțiile pentru stabilizarea bazinului Inserția pentru stabilizarea bazinului este confecționată din spumă rigidă/burete rigid sau dintr-un material similar, având un strat de spumă/burete moale în partea superioară. Introduceți materialul pentru inserție sub partea mai înaltă până când presiunea exercitată sub ambele oase ale bazinului este egală. Inserțiile laterale pentru bazin Inserțiile laterale pentru bazin pot fi confecționate în mai multe feluri, în funcție de scaunul rulant pe care vor fi montate și de gradul de suport necesar. Câteva sugestii: • Dacă apărătorile laterale sunt solide și pot fi folosite ca structură/suport, inserția laterală pentru bazin poate fi confecționată dintr-o bucată de spumă rigidă/burete rigid, montată pe suportul de brațe. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 137 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT În cazul în care suportul de brațe este decupat (ca în imaginea din stânga), inserția laterală pentru bazin poate fi confecționată dintr-o bucată de lemn având lipit pe partea interioară un strat de spumă/burete moale. Apoi, aceasta trebuie acoperită cu material textil. Montați inserția laterală pentru bazin fie pe cadrul scaunului rulant, fie pe o suprafață de ședere solidă, cu ajutorul unui dispozitiv de fixare metalic. În cazul prezentat în imaginea din stânga, trebuie plasată o pernă în partea superioară a suprafeței solide de ședere, protejând utilizatorul de scaun rulant de suporturile metalice și șuruburi. Inserțiile unghiulare exterioare pentru coapse Tăiați în două, pe diagonală, plăci din spumă rigidă/ burete rigid (100 mm x 100 mm x 40 mm), pentru a crea două inserții unghiulare. Păstrați aceste plăci pentru a le folosi pe parcursul probării scaunului rulant. Lipiți inserția unghiulară pe spuma/buretele care formează stratul de bază al pernei și sub stratul de spumă/burete moale. Îndreptați colțurile, în funcție de necesitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 138 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Dacă folosiți o pernă conturată, din spumă/burete, tăiați perna pe orizontală (aproximativ 20 mm de la partea superioară) și lipiți inserția unghiulară. Tăiați surplusul de material. Inserțiile unghiulare exterioare pentru coapse Aceste inserții sunt confecționate în mod similar inserțiilor laterale pentru trunchi. De regulă, sunt confecționate dintr-o bucată de lemn, plastic sau metal, cu un burete solid situat pe partea interioară (partea care intră în contact cu membrul inferior al utilizatorului) și un strat de spumă/burete moale. Inserția este acoperită cu un material textil rezistent și confortabil. Inserția este fixată pe o suprafață solidă de ședere cu ajutorul unui dispozitiv de fixare sau poate fi atașată de bara suprafeței de ședere a scaunului rulant. Inserția interioară unghiulară pentru coapse Tăiați în două o inserție unghiulară (lățime de 50 mm x lungime de 100 mm) pentru a avea două părți egale. Păstrați câteva plăci pentru a le folosi pe parcursul probării scaunelor rulante. Folosiți adeziv pentru a atașa inserția pe stratul de bază al pernei, sub cel superior, din spumă/ burete moale. Eliminați surplusul de material. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 139 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Dacă folosiți o pernă conturată confecționată din spumă/ burete, tăiați perna pe orizontală (aproximatv 20 mm de la partea superioară) și lipiți la loc. Tăiați surplusul de spumă/ burete. Inserția/dispozitivul pentru separarea genunchilor Inserțiile/dispozitivele pentru separarea genunchilor se confecționează de cele mai multe ori din metal, plastic sau lemn, având spumă rigidă/burete rigid pe partea superioară, laterală și posterioară (suprafețele care intră în contact cu corpul utilizatorului de scaun rulant). Pentru creșterea gradului de confort se poate folosi un strat subțire de spumă/burete moale deasupra stratului din material rigid. Inserția/dispozitivul se acoperă cu un material textil rezistent și confortabil. Dacă utilizatorul are nevoie de inserție/dispozitiv pentru separarea genunchilor, se recomandă furnizarea unei suprafețe rigide de ședere. Inserția/dispozitivul pentru separarea genunchilor se atașează de suprafața ședere rigidă cu ajutorul unui suport metalic în formă de L (așa cum puteți vedea în imagine). Este necesară o metodă simplă și ușoară de îndepărtare sau pliere a inserției/dispozitivului pentru separarea genunchilor, pentru ca utilizatorul să poată efectua transferul în și din scaunul rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 140 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Deschiderea unghiului dintre suprafața de ședere și spătar Modalitatea de a mări unghiul dintre suprafața de ședere și spătar este adăugarea unei inserții unghiulare din spumă rigidă/burete rigid peste un spătar solid, la unghiul de care este nevoie. Această inserție trebuie acoperită cu un strat de spumă/burete moale. Înclinarea suprafeței de ședere și a spătarului (înclinarea în spațiu) Anumite tipuri de scaune rulante au o caracteristică ce permite înclinarea ușoară a suprafeței de ședere și a spătarului. Majoritatea tipurilor de scaune rulante care se folosesc în mod uzual nu au această caracteristică, iar în acest caz putem recurge la următoarele variante. Dacă suprafața de ședere și spătarul nu sunt rigide, plasați sub partea frontală a pernei o inserție unghiulară din spumă rigidă/burete rigid și ajustați sau înclinați spătarul. Înlocuiți suprafețele de ședere și spătarele pliabile cu suprafețe de ședere și spătare solide. Poziționați dispozitivele de fixare în așa fel încât unghiul spătarului și al suprafeței de ședere să fie cel corespunzător. Spătarul trebuie acoperit cu un strat din spumă rigidă/burete rigid, apoi un strat din spumă/burete moale, apoi se adaugă tapițeria.Suprafața de ședere rigidă trebuie să fie acoperită întotdeauna cu o pernă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 141 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Această imagine prezintă un exemplu de dispozitiv de fixare pentru atașarea unei suprafețe solide de ședere sau a unui spătar. Brațul poate fi desfăcut prin pivotarea sistemului de închidere. Acest lucru permite demontarea suprafeței de ședere și spătarului în vederea transportului (în cazul unui scaun rulant pliabil). Inserția posterioară pentru bazin Inserția posterioară pentru bazin nu trebuie să aibă o adâncime prea mare. În funcție de utilizatorul de scaun rulant, inserția poate avea 20-30 mm adâncime. Inserția trebuie să ofere întotdeauna suport la nivelul crestelor iliace postero-superioare. În cazul utilizatorilor care au suprafața pielii sensibilă sau la care protuberanțele osoase ale coloanei vertebrale sunt accentuate, spuma/buretele trebuie decupate pe linia coloanei vertebrale pentru a evita exercitarea unui nivel ridicat de presiune. Mai jos sunt prezentate câteva modalități de confecționare a inserțiilor posterioare pentru bazin: Inserția posterioară pentru bazin poate fi confecționată dintr-o bucată de spumă rigidă/burete rigid care se acoperă cu material textil și care se poziționează pe partea anterioară a materialului textil al spătarului pliabil. Aceasta poate fi atașată de barele verticale ale spătarului cu ajutorul unor chingi. Bucata de spumă rigidă/burete rigid care formează inserția posterioară pentru bazin poate fi montată pe un spătar rigid, având un strat de spumă/burete moale aplicat pe partea superioară. Stratul de spumă/burete moale ar trebui să fie suficient pentru a asigura confortul utilizatorului de scaun rulant. În caz contrar, pe spătarul rigid trebuie adăugat un strat de spumă rigidă/burete rigid, după care se poziționează inserția posterioară pentru bazin, urmând un strat de spumă/burete moale, pe partea superioară. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 142 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Cu ajutorul unei chingi rezistente, inserția posterioară pentru bazin poate fi atașată unui spătar pliabil. În acest caz, putem utiliza o centură suplimentară, cum este cea pentru gambe, pe care să o poziționăm în jurul spătarului, la înălțimea și tensiunea adecvate (cu ajutorului unui material de tip Velcro). Înclinarea spătarului și/sau ajustarea formei spătarului Există diverse probleme posturale pentru care înclinarea spătarului poate fi o soluție utilă. În cazul în care scaunul rulant nu are această caracteristică sau dacă nu există un spătar cu tensiune ajustabilă, suportul va fi furnizat prin modificarea scaunului rulant. Mai jos sunt prezentate două opțiuni: În cazul unui scaun rulant cu spătar pliabil, îndepărtați materialul spătarului și montați un spătar rigid, care să fie situat la unghiul de înclinare corespunzător. Spătarul solid poate fi făcut din placaj (cu o grosime de cel puțin 12 mm). Dispozitivele de fixare ajustabile se recomandă pentru atașarea spătarului rigid de barele verticale ale cadrului acestuia. Modificarea materialului existent al spătarului pliabil: o Efectuați două tăieturi verticale în materialul spătarului, în proximitatea barelor verticale. o Măriți gradual lungimea tăieturilor până când trunchiul utilizatorului de scaun rulant are o poziție relaxată în raport cu bazinul și nu alunecă înspre înainte. o Poziționați mâinile în partea posterioară a materialului și susțineți trunchiul utilizatorului cu mâinile, până la găsirea poziției optime. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 143 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT o Introduceți o centură (nailon cu lățimea de 50 mm) între straturile materialului spătarului pliabil și înfășurați capetele în jurul spătarului. Cu ajutorul unor capse, fixați centura și materialul spătarului în poziția corespunzătoare. o Putem folosi o centură suplimentară, cum este cea pentru gambe, care are lungimea corectă și material de tip Velcro la capete. Cu acest tip de material, tensiunea centurii poate fi ușor ajustată. Alternativ, folosiți capse și benzi. o Folosiți o bucată de burete moale pentru a acoperi partea superioară și frontală a centurii, aflate în interiorul materialului spătarului. Acest lucru va scădea riscul apariției escarelor în zonele trunchiului care se află în contact cu partea superioară a spătarului. Inserțiile laterale pentru trunchi Inserțiile laterale pentru trunchi trebuie să ofere un grad ridicat de sprijin și, în același timp, să fie suficient de subțiri pentru a nu restricționa libertatea de mișcare a brațelor utilizatorului de scaun rulant. Structura principală a inserției poate fi confecționată din metal, plastic sau lemn. Cu toate acestea, inserțiile laterale pentru trunchi trebuie întotdeauna acoperite cu spumă rigidă/burete rigid, având deasupra un strat de spumă/burete moale. Spuma/buretele trebuie să se situeze în partea interioară a inserției (acolo unde intră în contact cu corpul utilizatorului) și să acopere partea superioară a inserției. Întreaga inserție este apoi acoperită cu un material textil rezistent și confortabil. Inserțiile laterale pentru trunchi pot fi plate sau conturate, pentru a se potrivi formei corpului utilizatorului de scaun rulant. Dacă sunt conturate, cea mai ușoară metodă de a crea forma este prin decuparea conturului în materialul spumei rigide/buretelui rigid. Inserția conturată presupune abilități de coasere speciale și un material elastic pentru husă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 144 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Mai jos sunt prezentare două metode pentru atașarea inserțiilor laterale pentru trunchi: Inserția laterală pentru trunchi poate fi prinsă de un spătar rigid, care apoi se acoperă cu spumă rigidă/burete rigid și un strat de spumă/burete moale. Inserția laterală pentru trunchi poate fi atașată de spătar cu ajutorul unui dispozitiv de fixare metalic. Inserțiile laterale pentru trunchi trebuie să fie subțiri Dacă inserția laterală pentru trunchi este prea groasă (peste 2,5 cm), inserția va restricționa libertatea de mișcare a brațelor și poate exercita presiune asupra părții inferioare a acestora. Este posibil ca acest lucru să reducă fluxul sangvin, să provoace deteriorarea nervilor și să interfereze cu funcțiile membrelor superioare. Folosiți materiale mai subțiri, care sunt suficient de rezistente pentru a oferi suportul necesar. Inserțiile unghiulare laterale pentru trunchi Inserția unghiulară laterală pentru trunchi poate fi confecționată din spumă rigidă/burete rigid și încorporată în suportul spătarului rigid, sub stratul de spumă/burete moale. De asemenea, pe suprafața spătarului putem folosi o inserție în unghiulară, cu o căptușeală separată. Aceasta se atașează cu material de tip Velcro sau centuri. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 145 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Măsuța Cel mai indicat material pentru confecționarea măsuței este placajul (de la 10 mm la 18 mm, în funcție de calitatea/ gradul de rezistență al placajului). Măsuța poate fi atașată de suportul de brațe al scaunului rulant, cu ajutorul centurilor sau al dispozitivelor de fixare metalice sau din lemn. Atunci când luați decizia cu privire la metoda de prindere a măsuței, gândiți-vă la o metodă facilă pentru toți cei implicați. Acest lucru este important pentru ca oricine să poată decupla măsuța rapid, în caz de urgență (de exemplu, dacă utilizatorul de scaun rulant se îneacă). Tetiera Tetiera plată Tetiera plată poate fi încorporată într-un spătar rigid înalt sau atașată spătarului rigid cu ajutorul unui dispozitiv de fixare. Tetiera este confecționată din spumă rigidă/burete rigid care se fixează pe o bucată de lemn/plastic, fiind acoperit cu un strat moale de spumă/burete. Această opțiune nu permite ajustări simple pentru a ține pasul cu dezvoltarea sau schimbările la nivelul corpului utilizatorului de scaun rulant. O tetieră separată atașată cu ajutorul unui dispozitiv de fixare permite ajustarea înspre înainte, înspre înapoi și pe înălțime. Tetiera conturată Tetiera conturată poate fi confecționată din spumă rigidă/burete rigid care se atașează pe o suprafață din lemn/plastic și se acoperă cu spumă/burete moale ori un alt material similar. Tetiera conturată poate include o inserție pentru susținerea bazei craniului (occiput) și inserții unghiulare laterale pentru a opri alunecarea înspre lateral a capului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 146 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Pentru acoperirea tetierei, se utilizează un material textil care asigură confortul utilizatorului de scaun rulant. Acesta poate fi un material folosit pentru fabricarea tricourilor, care este confortabil și suficient de elastic pentru a se mula pe forma tetierei. Husa poate fi strânsă sau mai laxă. Tetiera poate fi fixată cu ajutorul unui șnur . Mai jos este prezentat un exemplu de confecționare a unei tetiere conturate: 1. 2. 3. Bază de lemn cu orificii, în vederea montării pe suportul tetierei. Primul strat din spumă rigidă/ burete rigid. Inserții unghiulare spumă rigidă/burete rigid pentru sprijinirea din lateral a capului. 4. 5. Pentru a finaliza: o fixați tetiera pe scaunul rulant; o acoperiți cu material textil. Rolă din spumă/burete la baza tetierei, pentru baza craniului (occiput). Strat moale din spumă/ burete, adăugat tetierei. Conturul finalizat al tetierei. Inserțiile plane pentru suportul de picioare și inserțiile unghiulare pentru suportul de picioare Unul dintre cele mai adecvate materiale folosite pentru confecționarea inserțiilor plane pentru picioare este spuma rigidă/buretele rigid (poliuretan sau materialul utilizat pentru talpa încălțămintei de ștrand). Puteți folosi și lemn, însă asigurați-vă că acesta este neted, fără așchii și că nu există riscul exercitării de presiune. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 147 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Inserțiile plane pentru suportul de picioare Tăiați spuma rigidă/buretele rigid (poliuretan sau materialul utilizat pentru talpa încălțămintei de ștrand), lemnul sau un alt material similar pentru a forma plăci (de aproximativ 100 mm x 200 mm x 20 mm). Păstrați aceste plăci pentru a le folosi pe parcursul probării scaunului rulant. Atașați plăcile la suporturile de picioare, în funcție de necesități. Inserțiile unghiulare pentru suportul de picioare Tăiați pe diagonală plăcile de inserții plane în vederea confecționării a două inserții unghiulare pentru suportul de picioare. Tăiați câteva plăci pe lungime și câteva pe lățime. Păstrați-le pentru a le folosi pe parcursul probării scaunului rulant. Atașați inserția unghiulară pe suportul de picioare, pentru a susține piciorul. Dispozitivele de sprijin pentru gambe Putem crea o suprafață de ședere rigidă, care să fie în prelungirea părții frontale a suprafeței de ședere, pentru a susține membrul inferior în extensie. Acest lucru va îngreuna manevrele de întoarcere în spații restrânse sau plierea scaunului rulant în vederea transportării acestuia. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 148 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Centura pentru bazin Centura pentru bazin poate fi creată din benzi de nailon, cum sunt cele folosite pentru centurile de siguranță ale vehiculelor sau pentru curerele rucsacurilor. Lățimea centurii trebuie să fie de aproximativ 25 mm în cazul utilizatorilor copii și aproximativ 40-50 mm pentru utilizatorii adulți. Centurile cu cleme sunt cel mai ușor de manevrat. Dacă acestea sunt indisponibile, puteți folosi material de tip Velcro. Asigurați-vă că suprafața de suprapunere a materialului de tip Velcro este de cel puțin 100 mm (în funcție de dimensiunile corpului utilizatorului de scaun rulant). Căptușeala plasată în zonele de contact dintre centură și corpul utilizatorului de scaun rulant (în special în zona clemelor) crește gradul de confort. Cum se fixează capetele centurii? o În cazul majorității utilizatorilor de scaune rulante, capetele centurii pentru bazin se închid direct în fața bazinului, conform imaginii. o Schimbarea poziției zonei de conectare a elementelor centurii va permite acționarea din diferite unghiuri. Plasarea zonei de conectare direct sub partea anterioară a bazinului (creasta iliacă antero-superioară) va crea un unghi de tragere de 90 de grade în raport cu suprafața de ședere (vedeți imaginea). Poziționare centurii în spatele suprafeței de ședere va determina un unghi de tragere de 45 de grade în raport cu suprafața de ședere. Unghiul de tragere trebuie să fie între 45-90 de grade, excepție situația în care centura este făcută pentru a oferi suport unui utilizator de scaun rulant cu o înclinare anterioară a bazinului. Dacă șoldurile utilizatorului de scaun rulant au tendința de a se ridica sau de a aluneca înspre înainte, se recomandă o centură în patru puncte pentru prevenirea înclinației anterioare a bazinului pentru acomodarea înclinării anterioare a bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 149 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Avertizare în ceea ce privește utilizarea centurii pentru bazin: În cazul în care centura este prea laxă, există pericolul ca utilizatorii de scaun rulant cu un control limitat asupra corpului și/sau care nu conștientizează în totalitate poziția corpului, să alunece în scaunul rulant. Dacă aceștia nu sunt supravegheați, centura poate provoca strangularea. Este obligatorie instruirea însoțitorilor cu privire la prinderea corectă a centurii Cum se atașează de scaunul rulant centura pentru bazin și centura în patru puncte pentru prevenirea înclinației anterioare a bazinului? o Atașarea centurii de o suprafață rigidă de ședere: o atașați centura de o suprafață de ședere rigidă,după cum se vede în imaginea din stânga. Îndoiți capătul centurii, creați un orificiu prin topirea materialului și folosiți un șurub care să treacă prin lemn, împreună cu două șaibe și o piuliță (preferabil o contrapiuliță); o observați șaiba plasată la capătul îndoit. Acest lucru ajută la încetinirea procesului de uzură și de deteriorare a benzii, care, în cele din urmă, poate duce la ruperea centurii. o Atașarea centurii de cadrul scaunului rulant: o înfășurați în jurul cadrului scaunului rulant și fixați cu o cataramă metalică sau din plastic, care glisează (cunoscut și sub denumirea de cataramă cu reglaj); o se poate folosi și șurubul care fixează tapițeria, dacă acesta este în poziție corectă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 150 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Centura pentru gambe În cazul în care dotările standard ale scaunului rulant nu includ o centură pentru gambe, o astfel de centură poate fi confecționată prin coaserea unei bucăți de material de tip Velcro pe o bucată de bandă de nailon de 50 mm. Centura pentru gambe trebuie să fie de aproximativ două ori mai lungă decât lățimea scaunului rulant. Centura pentru picior Centura pentru picior poate fi confecționată din bandă de nailon de 25 mm și utilizând material de tip Velcro sau catarame. Unul dintre capete poate fi îndoit, fiind necesar și un orificiu pentru șurub, care va atașa centura de suportul pentru picioare. Centura trebuie acoperită pe interior cu un strat de protecție, astfel încât frecarea exercitată asupra suprafeței pielii să fie redusă, iar presiunea să fie distribuită în mod egal. Sugestii în ceea ce privește confecționarea și utilizarea centurilor: • Fixați centurile utilizând material de tip Velcro sau catarame. • Adăugați o căptușeală pe partea interioară a centurii, în zona în care aceasta intră în contact cu corpul utilizatorului de scaun rulant – va crește nivelul de confort prin distribuirea presiunii. • Centurile pot fi atașate pe o suprafață de ședere rigidă sau pot fi înfășurate în jurul cadrului scaunului rulant cu o cataramă ce glisează (cataramă cu reglaj). • Centurile pentru gambe, care de multe ori fac parte din dotarea standard a scaunului rulant, pot fi folosite și prin alte metode. De exemplu, centura pentru gambe poate fi folosită pentru modificarea/ajustarea materialului textil al spătarului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 151 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Hamul pentru umeri Pentru a confecționa un ham pentru umeri, este indicat să folosiți o mașină de cusut și să apelați la o persoană care are experiență în ceea ce privește cusutul. Veți avea nevoie de bandă de nailon, catarame și spumă/burete moale pentru căptușeală. Câteva sugestii: o Folosiți căptușeală în zona umerilor, în special în zona osoasă. o Asigurați-vă că punctul de fixare pentru partea superioară a hamului pentru umeri este pe aceeași linie cu partea superioară a umărului utilizatorului de scaun rulant sau la un nivel ușor mai ridicat. Dacă este situat mai jos, hamul va trage utilizatorul de scaun rulant în jos. o Nu atașați niciodată partea inferioară a hamului pentru umeri de centura pentru bazin. Acest lucru va determina deplasarea în sus a centurii pentru bazin. o Centura pentru piept, precum este cea din imagine, ajută la menținerea poziției elementelor hamului pentru umeri și oferă suport în partea frontală a trunchiului. Avertizare în ceea ce privește hamul pentru umeri: Atunci când se folosește un ham pentru umeri sau o centură pentru trunchi, întotdeauna trebuie utilizată și o centură pentru bazin care să fie tensionată cât mai mult posibil. Nerespectarea acestei reguli determină apariția pericolului de strangulare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 152 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Efectuarea pașilor preliminari utilizării scaunului rulant în condiții de siguranță Partea finală a pregătirii produsului (a scaunului rulant) este verificarea, pentru a ne asigura că scaunul rulant este pregătit pentru a fi utilizat în condiții de siguranță și că părțile acestuia funcționează corespunzător. Lista de verificare preliminară utilizării scaunului rulant de mai jos vă ajută să parcurgeți toți pașii necesari. Este indicat ca personalul furnizor de servicii de scaune rulante să afișeze un exemplar din această listă de verificare în spațiul unde își desfășoară activitatea, pentru a-l folosi de fiecare dată când se efectuează pregătirea unui scaun rulant. Lista de verificare preliminară utilizării scaunului rulant trebuie completată înainte ca utilizatorul de scaun rulant să sosească pentru etapa de probare a produsului (a scaunului rulant). Dacă pe parcursul verificării preliminare a scaunului rulant se identifică o problemă, personalul furnizor de servicii de scaune rulante are următoarele opțiuni: • să repare/rezolve problema înainte de probare; • să returneze scaunul rulant la atelier, pentru efectuarea reparațiilor; • să contacteze furnizorul scaunului rulant pentru a cere sfaturi în ceea ce privește modalitățile de rezolvarea problemei, Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 153 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Listă de verificare preliminară utilizării scaunului rulant – nivel intermediar Scaunul rulant în ansamblu, incluzând dispozitivele de suport postural Nu există margini ascuțite Dispozitivele de suport postural sunt bine căptușite și fixate corespunzător Nu există părți defecte sau zgâriate Traiectoria scaunului rulant este dreaptă Roțile frontale Se învârt fără a întâmpina vreo rezitență Se învârt fără a atinge furca roții Șuruburile sunt strânse Furcile roților frontale Furca roții frontale se învârte fără a întâmpina vreo rezistență. Roțile din spate Se învârt fără a întâmpina vreo rezitență Șuruburile axului sunt strânse Anvelopele sunt umflate în mod corect (la presiunea aplicată cu un deget, anvelopele se deformează mai puțin de 5 mm) Inelele de antrenare nu prezintă niciun pericol Frânele Funcționează corespunzător Suporturi pentru picioare Suporturile pentru picioare sunt montate corespunzător Cadrul Scaunul rulant pliabil se închide și se deschide cu ușurință În cazul unui scaun rulant cu spătar pliabil - spătarul se pliază și revine în poziția inițială cu ușurință Perna Perna este introdusă corect în husă Perna este poziționată corect în scaunul rulant Materialul textil al pernei este întins, dar nu mai mult decât este necesar. Dacă scaunul rulant are o suprafață de ședere rigidă: perna acoperă în întregime șezutul solid. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 154 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Etapa 6: Probarea produsului (a scaunului rulant) Probarea produsului (a scaunului rulant) este cea de-a șasea etapă din procesul de furnizare a serviciilor de scaune rulante. Pe parcursul probării produsului (a scaunului rulant), utilizatorul și personalul furnizor de servicii de scaune rulante se asigură că scaunul rulant și dispozitivele de suport postural sunt corespunzătoare și că sprijină corpul utilizatorului de așa manieră încât postura acestuia este cât mai apropiată de cea corectă, fără ca utilizatorul de scaun rulant să resimtă vreun disconfort. Cum se efectuează probarea produsului (a scaunului rulant) Folosiți lista de verificare preliminară utilizării scaunului rulant - nivel intermediar ca pe un instrument care să vă ghideze în parcurgerea etapei de reglare a produsului (a scaunului rulant). Ordinea pașilor este următoarea: o verificați dacă scaunul rulant este pregătit; o verificați dacă scaunul rulant are dimensiunea adecvată și dacă dispozitivele de suport postural sunt pe măsură; o verificați postura; o verificați nivelul de presiune; o verificați scaunul rulant în timp ce acesta se află în mișcare; o verificați dacă este necesară efectuarea altor operațiuni. Rețineți: Probarea produsului (a scaunului rulant) în cazul unui utilizator care are nevoie de suport postural suplimentar durează mai mult decât în cazul unui utilizator care nu necesită un astfel de suport. Cauza acestui fapt este numărul mai mare de ajustări care trebuie efectuate. • Utilizatorii de scaune rulante trebuie să știe că probarea poate dura mai mult. De asemenea, este posibil ca pe parcursul ajustărilor, utilizatorul să fie nevoit să realizeze de mai multe ori transferul în și din scaunul rulant. • Totodată, efectuarea unui număr mare de modificări poate impune o nouă programare pentru probarea produsului (a scaunului rulant). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 155 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Este scaunul rulant pregătit? Asigurați-vă întotdeauna că scaunul rulant este pregătit pentru a fi probat de către utilizator. Verificați dacă scaunul rulant și dispozitivele de suport postural sunt corespunzătoare. Lățimea scaunului rulant Modalitatea corectă de probare: Trebuie să se potrivească într-o cât mai mare măsură. Asigurați-vă că: • șoldurile se poziționează în mod confortabil între suporturile de brațe și inserțiile laterale pentru bazin; • coapsele se poziționează în mod confortabil între suporturile de brațe, apărătorile laterale sau inserțiile laterale pentru bazin și nu se exercită presiune asupra lor; acest lucru se poate întâmpla dacă inserțiile laterale pentru bazin se extind prea mult înspre înainte; • trunchiul se poziționează în mod confortabil între barele verticale ale spătarului și/sau între inserțiile unghiulare laterale pentru trunchi sau inserțiile laterale pentru trunchi. Adâncimea suprafaței de ședere Modalitatea corectă de probare: Trebuie să existe o distanță de cel puțin 30 mm între partea posterioară a genunchiului (zona poplitee) și partea frontală a suprafeței de ședere/a pernei. Asigurați-vă că: • utilizatorul de scaun rulant are o postură cât mai apropiată de poziția neutră de ședere, fără a resimți disconfort; Modalitatea de verificare: • introduceți mâna în spațiul dintre partea posterioară a genunchiului (zona poplitee) și pernă. Verificați dacă există o distanță de cel puțin 30 mm. Glisați mâna în jos pe partea posterioară a gambei și asigurați-vă că aceasta nu atinge suprafața de ședere/perna. • verificați ambele părți. Dacă există diferențe între partea dreaptă și stângă, folosiți valoarea mai mică pentru a efectua prescrierea. În cazul utilizatorilor de scaun rulant care au membre inferioare mai lungi; se acceptă o distanță de până la 60 de mm. Dacă aceste elemente sunt pe măsură, ele oferă coapselor un suport corespunzător. Se reduce astfel nivelul de presiune de sub oasele bazinului și se previne apariția escarelor. Dacă lungimea suprafeței de ședere este prea mare, utilizatorul de scaun rulant nu va putea menține poziția așezat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 156 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Bazinul Asigurați-vă că: • inserția anterioară oaselor bazinului este situată chiar în fața oaselor bazinului (introduceți mâna sub șezutul utilizatorului pentru a verifica); • inserția posterioară pentru bazin furnizează suport la nivelul crestei iliace postero-superioare și nu exercită presiune asupra părții inferioare a trunchiului; • inserțiile laterale pentru bazin sunt pe măsură și nu sunt poziționate deasupra articulației șoldurilor; • centura pentru bazin poate fi strânsă corespunzător și nu provoacă leziuni în contact cu suprafața pielii utilizatorului de scaun rulant (introduceți mâna între centură și utilizator pentru a verifica). Trunchiul Asigurați-vă că: • inserțiile laterale pentru trunchi nu exercită presiune asupra axilelor.Trebuie să existe o distanță de cel puțin 50 mm între axile și partea superioară a inserției laterale pentru trunchi. • hamul pentru umeri poate fi închis fără a provoca disconfort și fără a provoca leziuni în contact cu suprafața pielii. • măsuța susține lungimea antebrațului, precum și coatelor și nu exercită presiune asupra abdomenului. Măsuța poate fi situată aproape de trunchiul utilizatorului, totuși, aceasta nu trebuie să atingă suprafeța pielii sau să provoace fricțiune la nivelul acesteia. • verificați înălțimea și înclinarea spătarului. Tetiera Modalitatea corectă de probare: • Tetiera trebuie să susțină capul utilizatorului de scaun rulant la baza craniului (occiput). Asigurați-vă că: • tetiera sprijină capul utilizatorului de scaun rulant, astfel încât acesta este în echilibru. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 157 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Coapsele Asigurați-vă că: • nu există un nivel de presiune ridicat în zona de contact dintre coapsele utilizatorului de scaun rulant și suporturile pentru coapse (incluzând inserțiile exterioare pentru coapse, inserțiile unghiulare interioare pentru coapse sau inserția/dispozitivul pentru separarea genunchilor). • Inserția/dispozitivul pentru separarea genunchilor nu exercită presiune asupra zonei inghinale. Distanța dintre inserția/dispozitivul pentru separarea genunchilor și zona inghinală trebuie să fie de 40-60 mm în cazul copiilor și 60-100 mm în cazul adulților. Înălțimea suportului de picioare Modalitatea corectă de probare: Coapsele sunt sprijinite în totalitate pe suprafața de ședere/ pernă fără a se distanța de aceasta, iar picioarele sunt susținute în întregime de suporturile de picioare. Modalitatea de verificare: • poziționați mâna între coapsa utilizatorului de scaun rulant și suprafața de ședere/pernă. Presiunea exercitată trebuie să fie egală de-a lungul coapselor, iar contactul trebuie să fie uniform. • observați modalitatea în care piciorul este poziționat pe suportul de picioare. Acesta trebuie să fie susținut atât în partea anterioară, cât și în cea posterioară, iar contactul trebuie să fie uniform. Dacă contactul coapselor cu suprafața de ședere nu este uniform, acest lucru înseamnă că suportul de picioare este poziționat prea sus. Contactul neuniform la nivelul picioarelor indică faptul că suportul de picioare este poziționat prea jos. Înălțimea spătarului Modalitatea corectă de probare: Ajustarea corectă oferă utilizatorului de scaun rulant suportul de care acesta are nevoie și libertatea de mișcare necesară la nivelul omoplaților pentru a realizarea propulsiei (în caz de auto-propulsie). Modalitatea de verificare: • întrebați utilizatorul de scaun rulant dacă spătarul este confortabil; • observați dacă trunchiul are o poziție echilibrată în raport cu șoldurile; • este capabil utilizatorul să efectueze propulsia scaunului rulant fără ca spătarul să îl împiedice în a face acest lucru? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 158 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Înălțimea spătarului depinde de nevoile utilizatorului de scaun rulant. Utilizatorii de scaune rulante care realizează propulsia în mod independent au nevoie de un spătar care să nu limiteze libertatea de mișcare la nivelul omoplaților. Utilizatorii de scaune rulante care au dificultăți în ceea ce privește menținerea poziției așezat au avea nevoie de un spătar mai înalt, care să le ofere mai mult suport. Un spătar care furnizează sprijin la nivelul limitei inferioare a cutiei toracice a utilizatorului are o înălțime corespunzătoare dacă utilizatorul: • are o stare de sănătate bună și este activ; • poate menține cu ușurință poziția așezat, având un echilibru corespunzător; • realizează propulsia scaunului rulant în mod activ și are nevoie de libertate de mișcare. Înălțime spătar D (distanța dintre suprafața de ședere și limita inferioară a cutiei toracice) Un spătar care furnizează sprijin la nivelul limitei inferioare a omoplaților utilizatorului are o înălțime corespunzătoare dacă utilizatorul: • obosește repede: de ex., în cazul persoanelor vârstnice sau diagnosticate cu afecțiuni degenerative; • prezintă anumite dificultăți în menținerea poziției așezat. La acest nivel înălțimea spătarului încă permite suficientă libertate de mișcare la nivelul omoplaților pentru ca utilizatorul să reușească să efectueze propulsia în mod independent, cu ajutorul brațelor. Înălțime spătar E (distanța dintre suprafața de ședere și limita inferioară a omoplatului). Un spătar mai înalt, care oferă suport la nivelul limitei superioare a umerilor, este soluția adecvată pentru utilizatorii de scaun rulant care au nevoie de un grad ridicat de suport; cei care beneficiază de pe urma înclinării spătarului sau a înclinării suprafeței de ședere și a spătarului (înclinare în spațiu), precum și în cazul acelor utilizatori care obosesc repede. Înălțime spătar F (distanța dintre suprafața de ședere și limita superioară a umărului) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 159 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Poziția roților din spate - pentru realizarea propulsiei cu ajutorul brațelor Modalitatea corectă de probare: Atunci când mâinile sunt plasate pe inelul de antrenare, coatele utilizatorului sunt situate într-un unghi drept. Modalitatea de verificare: • rugați utilizatorul de scaun rulant să își poziționeze mâinile pe partea superioară a inelelor de antrenare. Coatele trebuie să formeze un unghi de 90 de grade; • de asemenea, verificați împreună cu utilizatorul de scaun rulant dacă roțile din spate sunt corect poziționate pentru un nivel ridicat de echilibru (înspre înainte pentru activ, înspre înapoi pentru siguranță). Dacă utilizatorul de scaun rulant are nevoie ca roțile din spate să fie poziționate în așa fel încât scaunul rulant să ofere mai multă stabilitate (mai înspre spate), mâinile sale nu vor mai fi poziționate în poziția ideală decât poziția ideală pentru realizarea propulsiei. Explicați utilizatorului de scaun rulant necesitatea acestui compromis. În cazul în care se efectuează ajustări ale poziției roților din spate, frânele trebuie și ele ajustate și verificate. Înălțimea spătarului - pentru realizarea propulsiei cu ajutorul picioarelor Modalitatea corectă de probare: • În poziția așezat, cu partea posterioară a bazinului susținută în mod confortabil de către spătar, picioarele sunt poziționate pe sol. Modalitatea de verificare: • solicitați utilizatorului să adopte poziția așezat sau o postură cât mai apropiată de aceasta, în limita confortului, astfel încât partea posterioară a bazinului să atingă spătarul. Verificați dacă suprafața tălpilor atinge în întregime solul. Dacă înălțimea suprafeței de ședere este prea mare, personalul furnizor de servicii de scaune rulante poate recurge la următoarele soluții: • să reducă înălțimea pernei; • să furnizeze o suprafață de ședere rigidă care să fie poziționată la o înălțime mai mică decât suprafața de ședere existentă (solicitați sfaturi sau suport tehnic pentru efectuarea acestei activități). În cazul utilizatorilor de scaun rulant care efectuează propulsia cu ajutorul membrelor inferioare, având un picior poziționat pe suport, verificați nivelul de presiune sub osul bazinului de pe partea pe care se află piciorul în repaus. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 160 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Verificați postura Observați poziția în scaunul rulant a utilizatorului, privind din față și din lateral. Utilizatorul de scaun rulant se află în poziția așezat? Verificați dacă bazinul utilizatorului de scaun rulant se află într-o poziție cât mai apropiată de cea neutră de ședere, fără a resimți vreun disconfort. Aceasta ar trebui să fie apropiată de postura identificată în urma procedeului de simulare manuală. Verificați în mod atent următoarele aspecte: • dacă bazinul se află în echilibru, la același nivel (dacă acest lucru este posibil) • dacă trunchiul este poziționat drept și simetric (dacă acest lucru este posibil) • dacă există echilibru la nivelul capului (dacă acest lucru este posibil) • dacă membrele inferioare și picioarele sunt situate într-o poziție cât mai apropiată de cea caracteristică poziției așezat? • cum se simte utilizatorul de scaun rulant. După analiza posturii generale a utilizatorului de scaun rulant, verificați dacă fiecare dispozitiv de suport postural își îndeplinește rolul. În special, nu uitați să verificați următoarele aspecte (dacă se furnizează aceste elemente): • înălțimea, înclinarea și contururile spătarului; • înclinarea în spațiu; • inserțiile laterale pentru bazin și pentru trunchi; • orice suport la nivelul șoldurilor și al gambelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 161 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Verificați presiunea În cazul utilizatorilor de scaune rulante la care există riscul apariției escarelor, pașii etapei de probare a produsului (a scaunului rulant) includ verificarea nivelului de presiune sub oasele bazinului și în orice altă zonă de risc (de ex., sub articulația șoldului sau coccis). În cazul utilizatorilor de scaun rulant cărora li s-au furnizat dispozitive de suport postural cu un grad de suport ridicat - verificați presiunea în zona de contact dintre corpul utilizatorului de scaun rulant și respectivul dispozitiv de suport postural. Sprijinul trebuie să fie ferm, dar nu în mod exagerat. Verificați scaunul rulant în timp ce acesta se află în mișcare Partea finală a etapei de probare a produsului (a scaunului rulant) este verificarea scaunului rulant în timp ce acesta se află în mișcare. Dacă utilizatorul nu poate efectua în mod independent propulsia scaunului rulant, rugați un membru de familie/însoțitor să facă acest lucru, pentru a putea observa modul de funcționare. Aspecte ce trebuie urmărite: • permite spătarul suficientă libertate de mișcare la nivelul omoplaților pentru ca utilizatorulde scaun rulant să efectueze propulsia? • mișcarea scaunului rulant sau efectuarea propulsiei duce la schimbarea posturii utilizatorului, provoacă disconfort sau senzația de instabilitate? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 162 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar • Propulsia efectuată cu ajutorul brațelor: roțile din spate sunt poziționate corect pentru ca utilizatorul de scaun rulant să poată realiza propulsia cât mai bine? • Propulsia efectuată cu ajutorul picioarelor: înălțimea și adâncimea suprafeței de ședere sunt adecvate pentru ca utilizatorul de scaun rulant să poată efectua propulsia cu ajutorul picioarelor? • Dispozitivele de suport postural permit mobilitatea nerestricționată și în condiții de siguranță a scaunului rulant? Listă de verificare a pașilor pentru probarea produsului (a scaunului rulant) – nivel intermediar 1. Este scaunul rulant pregătit? Scaunul rulant a fost verificat în ceea ce privește siguranța utilizării sale și funcționarea tuturor componentelor? 2. Verificați dimensiunea scaunului rulant și a dispozitivelor de suport postural. Lățimea scaunului rulant: o coapsele sunt poziționate confortabil între suporturile de brațe sau între inserțiile laterale pentru bazin; o trunchiul este poziționat confortabil între părțile laterale ale cadrului spătarului sau între inserțiile laterale pentru trunchi; • coapsele sunt poziționate confortabil între suporturile de brațe, apărătoarele laterale sau inserțiile laterale pentru bazin, iar asupra lor nu se exercită presiune. Adâncimea șezutului scaunului rulant: • distanță de 30 mm între partea posterioară a genunchilor (zona poplitee) și suprafața de ședere/pernă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 163 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Bazinul: • inserția anterioară oaselor bazinului este poziționată chiar în fața acestora; • inserția posterioară pentru bazin oferă suport la nivelul crestei iliace postero-superioare; • inserțiile laterale pentru bazin se potrivesc în mod confortabil și sunt localizate deasupra articulației șoldurilor; • centura pentru bazin poate fi strânsă și nu afectează suprafața pielii. Trunchiul: • inserțiile laterale pentru trunchi nu presează axilele; există o distanță de cel puțin 30 mm între axile și partea superioară a inserției laterale pentru trunchi; • hamul de umeri se potrivește confortabil și nu afectează pielea; • măsuța susține lungimea antebrațelor și coatelor și nu exercită presiune asupra cavității abdominale. • verificați înălțimea și înclinarea spătarului. Tetiera: • tetiera trebuie să susțină capul utilizatorului de scaun rulant la baza craniului (occiput). • menține capul drept, într-o poziție echilibrată. Coapsele: • inserțiile exterioare pentru coapse sau inserția/dispozitivul pentru separarea genunchilor nu exercită presiune asupra coapselor; • distanța dintre inserția/dispozitivul pentru separarea genunchilor și zona inghinală trebuie să fie de 40-60 mm la copii și 60-100 mm la adulți. Înălțimea suportului de picioare: • coapsele sunt sprijinite în totalitate pe pernă, fără a se ridica. Piciorul este sprijinit în totalitate pe suportul de picioare, fără a se ridica; • centura pentru picior poate fi legată adecvat, fără a afecta suprafața pielii; • centura pentru gambe și centura pentru călcâie susțin gamba și picioarele. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 164 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 3.Verificați postura Verificați din față și din lateral pentru a vedea dacă utilizatorul de scaun rulant are o postură cât mai apropiată de poziția neutră de ședere, în limita confortului. • Bazinul este drept și se află în echilibru (sau cât mai aproape posibil de postura corectă, în limita confortului individual). • Trunchiul este drept și simetric (sau cât mai aproape posibil de postura corectă, în limita confortului individual). • Capul este drept și într-o poziție echilibrată (atât cât este posibil). • Picioarele și tălpile sunt așezate cât mai aproape de poziția neutră. Verificați dacă toate dispozitivele de suport postural oferă sprijinul necesar. Verificați în mod special (dacă este posibil): • Înălțimea, unghiul de înclinare și contururile spătarului • Înclinarea în spațiu • Inserțiile laterale pentru bazin și inserțiile laterale pentru trunchi • Inserțiile unghiulare interioare și exterioare pentru coapse, inserțiile exterioare pentru coapse și dispozitivele de sprijin pentru gambă Verificați postura încă o dată, după 15 minute, pentru a vedea dacă au intervenit schimbări. 4. Verificați presiunea Verificați presiunea sub ambele părți ale oaselor bazinului utilizatorului de scaun rulant. Nivelul de presiune este sigur pe ambele părți? Nivel 1 = sigur: Vârfurile degetelor se pot mișca în sus și în jos 5 mm sau chiar mai mult. Nivel 2 = avertizare: Vârfurile degetelor nu se pot mișca, dar pot fi retrase cu ușurință. Nivel 3 = pericol: Degetele sunt strânse cu putere. Este dificilă retragerea degetelor. Poziționați degetele între corpul utilizatorului de scaun rulat și fiecare dispozitiv de suport postural, incluzând pernele și centurile. Contactul dintre dispozitivul de suport postural și corp este egal? Presiunea se menține la un nivel sigur? Dacă utilizatorul de scaun rulant are proeminențe osoase, umflături sau lovituri, verificați dacă se exercită presiune asupra acestor zone. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 165 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 5. Verificați scaunul rulant în timp ce acesta se află în mișcare Spătarul oferă suficientă libertate de mișcare la nivelul umerilor pentru ca utilizatorul să poată realiza propulsia? Mișcarea scaunului rulant sau activitatea de propulsie a acestuia cauzează schimbarea posturii utilizatorului, creează stare de disconfort sau lipsă de stabilitate? Propulsia cu ajutorul brațelor: Roțile din spate sunt poziționate corect pentru ca utilizatorul de scaun rulant să poată realiza cât mai bine propulsia? Propulsia cu ajutorul picioarelor: Înălțimea și adâncimea șezutului scaunului rulant sunt corespunzătoare, pentru ca utilizatorul de scaun rulant să poată realiza propulsia cu piciorul/picioarele? Dispozitivele de suport postural permit manevrarea scaunului rulant fără restricții și în condiții de siguranță? 6. Decideți dacă sunt necesare intervenții suplimentare Sunt necesare intervenții suplimentare? Notați orice intervenție în dosarul utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 166 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Etapa 7: Instruirea utilizatorului de scaun rulant Instruirea utilizatorului de scaun rulant Informațiile și instruirea cu privire la folosirea scaunului rulant îi ajută pe cei mai mulți dintre utilizatori să beneficieze la maximum de avantajele pe care le oferă un scaun rulant. Fără parcurgerea acestei etape, este posibil ca utilizator să nu folosească scaunul rulant la întregul său potențial. Este important ca membrii familiei/însoțitorii să aibă și ei acces la aceste informații și instruire. Care sunt abilitățile de care au nevoie utilizatorii de scaune rulante? Utilizatorii de scaun rulant au nevoie de informații și de abilități care să îi ajute la menținerea stării de sănătate, utilizarea eficientă și în siguranță a scaunului rulant, îngrijirea scaunului rulant pentru o perioadă de funcționare cât mai îndelungată. Abilitățile pe care ar trebui să și le însușească fiecare utilizator de scaun rulant: Manevrarea scaunului rulant: • Modalitatea de pliere și manevrare a scaunului rulant în vederea transportării acestuia • Demontarea și montarea oricărui dispozitiv de suport postural în vederea transportării scaunului rulant. • Modul de utilizare a caracteristicilor scaunului rulant - de exemplu: utilizarea frânelor, unghiul de înclinare și bara anti-răsturnare, poziționarea corectă a pernei și a dispozitivelor de suport postural. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 167 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cât timp poate petrece utilizatorul în scaunul rulant? În cazul acelor utilizatori de scaun rulant care nu au petrecut mult timp în poziția așezat, procesul de acomodare la poziția în scaunul rulant poate dura. Acest lucru este valabil în special atunci când este vorba despre utilizatori de scaun rulant copii. Personalul furnizor de servicii de scaune rulante trebuie să ofere instruire cu privire la durata de timp recomandată în cazul fiecărui utilizator. Transmiteți următoarele informații: • Dacă utilizatorul este familiarizat cu menținerea poziției așezat, se recomandă ca el să petreacă în noul său scaun rulant durata de timp pe care o petrece în mod obișnuit în poziția așezat. Dacă este necesar, acest interval de timp poate crește, gradual. • Dacă utilizatorul nu a mai petrecut timp în poziția așezat, începeți cu perioade de maximum 30 de minute, urmate de o pauză. • Instruiți utilizatorul de scaun rulant sau membrii familiei/însoțitorii cu privire la necesitatea verificării zonele asupra cărora se exercită presiune, după fiecare utilizare a scaunului rulant. Transferurile (în și din scaunul rulant): • Metodă sigură de transfer: – nu produce disconfort utilizatorului de scaun rulant; – nu are efecte negative asupra persoanei care oferă asistență în realizarea transferului. • Poziția corectă în scaunul rulant (de exemplu, ne asigurăm că utilizatorul este poziționat corect în scaunul rulant, cu oasele bazinului situate în partea posterioară a oricărui tip de inserție anterioară oaselor bazinului). • Modul de ajustare corectă a dispozitivelor de suport postural - de exemplu, cât de strânse trebuie să fie centurile pentru ca ele să aibă efectul scontat. • Rețineți că mulți dintre utilizatorii de scaun rulant sunt capabili să efectueze în mod independent transferul în și din scaunul rulant. Transferurile independente și asistate sunt prezentate în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - Nivel de bază. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 168 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Utilizarea scaunului rulant și mobilitatea: • Deprinderile pe care personalul furnizor de servicii rulante le transmite în ceea ce privește mobilitatea în scaunul rulant vor depinde de abilitățile utilizatorului și de mediul său. • Întotdeauna veți instrui utilizatorul de scaun rulant cu privire la metoda de efectuare a propulsiei care se potrivește cel mai bine abilităților sale. • Mai multe informații despre mobilitatea în scaunul rulant (nivel de bază), inclusiv cu privire la propulsia corectă, urcarea și coborârea pantelor și a treptelor și ridicarea în echilibru pe două roți sunt disponibile în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - Nivel de bază, Manualul participantului. Prevenirea apariției escarelor: • Escarele sunt cauzate de presiunea exercitată pe zonele osoase, de frecare sau alunecare. • În cazul utilizatorilor de scaune rulante care au dificultăți în menținerea poziției așezat, trebuie să aveți în vedere următoarele: – să vă asigurați de faptul că nu alunecă în scaunul rulant – alunecarea poate duce la apariția escarelor (zonele osoase care intră în fricțiune cu țesutul moale); – să vă asigurați că distribuția greutății este uniformă sub ambele părți ale oaselor bazinului. • În cazul utilizatorilor de scaune rulante cărora li se furnizează dispozitive de suport postural, asigurați-vă că aceștia sunt instruiți cu privire la necesitatea verificării în mod regulat a suprafeței pielii în zonele în care corpul intră în contact cu dispozitivele de suport postural. • Mai multe detalii despre prevenirea apariției escarelor sunt prezentate în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - Nivel de bază, Manualul participantului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 169 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Întreținerea la domiciliu a scaunului rulant: • Furnizarea unor informații de bază legate de întreținerea scaunului rulant la domiciliu contribuie la prelungirea duratei de utilizare a scaunului rulant. • Există șase aspecte pe care utilizatorii le pot pune în practică la domiciliu în vederea întreținerii pernei și scaunului lor rulant. Acestea sunt prezentate în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - Nivel de bază. Informații sunt valabile și în cazul utilizatorilor de scaun rulant care au nevoie de servicii de scaune rulante de nivel intermediar. Există câteva operațiuni suplimentare pentru verificarea stării de funcționare a dispozitivelor de suport postural. Cum se procedează în cazul apariției unei probleme: Utilizatorii de scaune rulante trebuie să știe cum să procedeze în cazul în care apare o problemă. Acestea pot însemna fie că: • scaunul rulant necesită reparații; • scaunul rulant nu este corespunzător sau nu oferă gradul se confort necesar. În oricare din cazurile de mai sus, utilizatorii trebuie să aibă posibiltatea de a contacta serviciul de scaune rulante pentru a cere asistență și sfaturi. Asigurați-vă că utilizatorii cunosc datele de contact ale centrului unde se furnizează servicii de scaune rulante. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 170 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Cum ne putem asigura de eficiența procesului de instruire al utilizatorului de scaun rulant • Aflați care sunt aspectele pe care utilizatorul de scaun rulant le cunoaște deja. • Explicați, demonstrați și apoi dați utilizatorului de scaun rulant posibilitatea să exerseze. • Folosiți un limbaj accesibil. • Oferiți utilizatorului de scaun rulant oportunitatea de a instrui, la rândul său, alți utilizatori de scaune rulante. • Nu uitați că este nevoie de abilități bune de comunicare. • Încurajați utilizatorul de scaun rulant. Rețineți– exersarea oricărei abilități nou învățate este esențială. Atunci când instruiți utilizatorul de scaun rulant, începeți cu partea de demonstrație și oferiți utilizatorului de scaun rulant oportunitatea de a exersa fiecare abilitate. Listă de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar Abilități de învățat Abilități învățate Manevrarea scaunului rulant Plierea și ridicarea scaunului rulant Demontarea și montarea oricărui dispozitiv de suport postural care trebuie îndepărtat în vederea efectuării transportului Utilizarea roților cu sistem de decuplare rapidă Utilizarea frânelor Unghiul de înclinare și bara anti-răsturnare (dacă se folosește) Poziția corectă a dispozitivelor de suport postural atunci când utilizatorul folosește scaunul rulant Utilizarea pernei, inclusiv poziționarea corectă Transferuri Transfer independent Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 171 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Transfer asistat Altele Utilizarea scaunului rulant și mobilitatea în scaun rulant Propulsia corectă (utilizarea metodei preferate de propulsie a utilizatorului de scaun rulant) Urcarea și coborârea unei pante Urcarea și coborârea unei trepte Deplasarea pe teren accidentat Ridicarea în echilibru pe două roți Durata de timp petrecută în scaunul rulant (pentru copii și adulți care au nevoie de suport postural suplimentar) Propulsia asistată Prevenirea apariției escarelor Verificarea zonelor asupra cărora se exercită o presiune crescută Tehnici pentru reducerea presiunii Alimentație și hidratare corespunzătoare Ce trebuie făcut în cazul apariției unei escare Întreținerea la domiciliu a scaunului rulant Curățarea scaunului rulant; spălarea și uscarea pernei și a husei Lubrifierea părților mobile Umflarea anvelopelor Strângerea șuruburilor și a piulițelor Strângerea spițelor Verificarea părților textile Verificarea existenței petelor de rugină Verificarea pernei Cum se procedează în cazul apariției unei probleme Scaunul rulant necesită reparații Scaunul rulant nu este corespunzător sau nu este confortabil Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 172 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Etapa 8: Întreținerea, reparațiile și monitorizarea Informațiile despre întreținere, reparații și monitorizare au fost abordate în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - Nivel de bază. În modulul intermediar se discută despre importanța monitorizării utilizatorilor care folosesc scaune rulante cu suport postural suplimentar. Monitorizarea Monitorizarea este cea de-a opta etapă în procesul de furnizare a serviciilor de scaune rulante. Prezentarea activității de monitorizare Toți utilizatorii de scaun rulant beneficiază de pe urma monitorizării.Totuși, monitorizarea este esențială în cazul: • utilizatorilor de scaun rulant copii; • utilizatorilor de scaun rulant la care este prezent riscul apariției escarelor; • utilizatorilor de scaun rulant diagnosticați cu afecțiuni degenerative; • utilizatorilor de scaun rulant care necesită suport postural suplimentar în scaunul rulant; • utilizatorilor de scaun rulant care, pe parcursul instruirii, au avut dificultăți în deprinderea unor abilități. Majoritatea utilizatorilor de scaune rulante care fac obiectul acestui modul au nevoie de suport postural suplimentar, în consecință, monitorizarea este foarte importantă. Gestionarea activității de monitorizare Nu există o regulă legată de intervalul la care trebuie efectuată monitorizarea utilizatorului de scaun rulant, deoarece acesta va depinde de nevoile utilizatorului de scaun rulant. Totuși, în măsura în care acest lucru este posibil, vizita de monitorizare la un interval de șase săptămâni de la furnizarea scaunului rulant poate fi foarte folositoare, pentru a vă asigura că scaunul rulant funcționează corespunzător și pentru a consolida instruirea utilizatorului. În cazul utilizatorilor de scaun rulant copii, se recomandă ca monitorizarea să aibă loc la intervale de trei până la șase luni. Acest lucru se datorează faptului că nevoile copiilor se schimbă repede, odată cu creșterea lor. Monitorizarea poate fi efectuată: • la domiciliul utilizatorului de scaun rulant; • la centrul unde se furnizează servicii de scaune rulante; • în orice altă locație convenabilă utilizatorului de scaun rulant și personalului care furnizează servicii de scaune rulante. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 173 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Locația va fi decisă în funcție de posibilitatea utilizatorului de a se deplasa la centrul unde se furnizează servicii de scaune rulante sau de cea a personalului serviciilor de scaune rulante de a se deplasa la domiciliul utilizatorului. Activitatea de monitorizare poate fi gestionată prin diverse căi: • la momentul furnizării scaunului rulant, utilizatorii pot fi programați pentru efectuarea activității de monitorizare; • monitorizarea poate fi efectuată la domiciliul utilizatorului sau la centrul unde se furnizează servicii de scaune rulante; • vizitele de monitorizare pot fi parte a unor vizite de rutină efectuate de către personalul de servicii de reabilitare bazată pe comunitate (RBC), care a fost instruit pentru efectuarea activității de monitorizare; • monitorizarea poate avea loc telefonic în cazul în care transportul este dificil, iar utilizatorul de scaun rulant are acces la un telefon. Formularul de monitorizare a utilizării scaunului rulant Formularul de monitorizare a utilizării scaunului rulant (prezentat mai jos) va ajuta personalul furnizor de servicii de scaune rulante să își reamintească întrebările care trebuie adresate pe parcursul monitorizării și pașii unei vizite de monitorizare. Formularul de monitorizare a scaunului rulant are și o rubrică în care pot fi înregistrate activitățile care trebuie efectuate. Activități de monitorizare uzuale Activitățiile de monitorizare uzuale includ: o Sfaturi și instruire suplimentare De exemplu, dacă un utilizator nu folosește scaunul rulant conform așteptărilor noastre, acest lucru se poate datora faptului că persoana nu are suficientă încredere în sine pentru efectuarea transferului independent în și din scaunul rulant. Instruirea suplimentară cu privire la transferuri poate soluționa această problemă. o Reajustarea scaunului rulant. o Efectuarea unor reparații minore. Încurajați întotdeauna utilizatorii de scaune rulante și membrii familiei/însoțitorii să dedice timp întreținerii scaunului rulant prin efectuarea unor reparații minore la domiciliu. Personalul furnizor de servicii de scaune rulante poate asista utilizatorii în ceea ce privește programarea unor reparații dacă acestea nu pot fi rezolvate imediat. o Direcționarea utilizatorului de scaun rulant către un alt serviciu, pentru suport sau asistență. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 174 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Thusitha - vizită de monitorizare Thusitha are 7 ani și trăiește acasă cu părinții și sora mai mare. Este diagnosticat cu distrofie musculară și, în urmă cu un an, a primit un scaun rulant prin intermediul unui centru furnizor de servicii de scaune rulante. La acea dată,el putea parcurge distanțe scurte. Era capabil să efectueze independent transferul în poziția stând. Își dorea un scaun rulant deoarece îi este dificil să se deplaseze la școală. La monitorizare, Thusitha a spus că întâmpină greutăți în realizarea transferului independent în și din scaunul rulant. După amiaza, la școală, se simte obosit și crește nivelul său de disconfort. Acest lucru îl împiedică să se concentreze. Scaunul său rulant are dimensiunea potrivită și are un spătar mediu pliabil, cu o pernă standard, pentru confort. Pe parcursul monitorizării, personalul furnizor de servicii de scaune rulante: • A identificat care este modalitatea prin care Thusitha efectuează independent transferul în și din scaunul rulant. Lui Thusitha îi este dificil să își ridice corpul de pe scaunul rulant. Personalul furnizor de servicii de scaune rulante l-a învățat pe Thusitha cum să efectueze transferul cu ajutorul unei plăci de transfer, soluție pe care el a considerat-o ca fiind potrivită.. • A verificat suportul postural suplimentar al lui Thusitha. S-a decis că pentru Thusitha ar fi mai util un spătar mai înalt și o pernă care să furnizeze un control al posturii și care să reducă presiunea. Personalul furnizor de servicii de scaune rulante a efectuat măsurătorile necesare pentru a pregăti aceste elemente în vederea probării. Thusitha a fost programat la centrul unde se oferă servicii de scaune rulante, pentru probarea noului spătar și a pernei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 175 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Formular de monitorizare a utilizării scaunului rulant 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data probării produsului (a scaunului rulant): Data efectuării monitorizării: Numele persoanei care efectuează monitorizarea: Monitorizarea a avut loc la: Domiciliul utilizatorului Centrul de reparații scaune rulante Altă locație: _____________ ____________________________ 2. Interviu Notați activitatea recomandată: Utilizați scaunul rulant atât de frecvent precum vă doriți? Da Nu Dacă nu - de ce nu? Întâmpinați vreo dificultate în utilizarea scaunului dvs. rulant? Da Nu Dacă da - care sunt aceste dificultăți? Aveți întrebări în ceea ce privește utilizarea scaunului rulant? Da Nu Dacă da - care sunt acestea? Este nevoie de instruire suplimentară? Utilizatorul de scaun rulant prezintă escare? Da Nu Descrieți (localizarea și gravitatea) Cum ați nota, pe o scală de la 1 la 5, gradul de satisfacție oferit de scaunul dvs. rulant? (1 - deloc satisfăcut și 5 foarte satisfăcut) Notă: Comentarii: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 176 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în siguranță? Da Nu Perna este în stare bună și poate fi utilizată în siguranță? Da Nu Dacă răspunsul la oricare dintre întrebările de mai sus este „nu”, vă rugăm să precizați problema. 4. Verificare ajustări Scaunul rulant se potrivește? Da Nu Dacă nu - care sunt problemele? Test nivel presiune(1 = sigur, 2 = avertizare, 3 = nesigur) (dacă există riscul apariției escare ) Stânga: Dreapta: Utilizatorul are o poziție confortabilă în scaunul rulant atunci când stă pe loc, când se deplasează și pe întreg parcursul zilei? Da Nu Dacă nu - care sunt problemele? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 177 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Note 1 Organizația Mondială a Sănătății. (2006). Tulburări neurologice: Provocări ale sistemului medical public. Preluat de la http://www.who.int/mental_health/neurology/chapter_3_b_neuro_disorders_ public_h_challenges.pdf 2 Organizația Mondială a Sănătății, Departamentul de Apărare al Statelor Unite ale Americii, Centrul Drucker pentru Traumatisme cranio-cerebrale, Spitalul de Reabilitare Moss (2004). Reabilitarea persoanelor cu traumatism cranio-cerebral. Preluat de la http://whqlibdoc.who.int/hq/2004/WHO_ DAR_01.9_eng.pdf 3 Organizația Mondială a Sănătății. (2011). Meningită meningococică. Preluat de la http://www.who. int/mediacentre/factsheets/fs141/en/ 4 Rosenbaum, P. (2003). Paralizie cerebrală. Ce vor să să știe părinții și medicii. British Medical Journal (Jurnalul Medical Britanic), 326, 970–974 5 Paralizie cerebrală Australia. (n.d.). Paralizia cerebrală – realitatea. Preluat de la http://www. cerebralpalsyaustralia.com/index.php/site/learningcentre/thefacts 6 Organizația Mondială a Sănătății. (1993). Susținerea dezvoltării copiilor mici diagnosticați cu paralizie cerebrală: Ghid pentru persoanele din domeniul reabilitării - nivel mediu. Preluat de la http://whqlibdoc.who.int/hq/1993/WHO_RHB_93.1.pdf 7 Kigger, K. (2006). Paralizie cerebrală: Un rezumat. American Family Physician (Medicul de familie american), 73(1), 91–100. 8 Roijen, L., Postema, K., Limbeek, vJ., & Kuppevelt, vH. J. M. (2001). Dezvoltarea controlului vezicii urinare la copii și adolescenți diagnosticați cu paralizie cerebrală. Developmental Medicine and Child Neurology (Medicina dezvoltării și neurologie infantilă), 43, 103–107. 9 Campania pentru distrofie musculară. (2002). Distrofia musculară Duchenne. Preluat de la http:// www.muscular-dystrophy.org/ 10 Centrul pentru controlul bolilor și prevenire. (n.d.). Distrofia musculară Duchenne: Caracteristici. Preluat de la http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/Duchenne.pdf 11 Newsom Davis, J. (1980). Sistemul respirator în distrofia musculară. British Medical Bulletin (Buletin Medical Britanic), 36, 135-138 12 Brooke, M.H., et al. (1989). Distrofia musculară Duchenne: Tiparele evoluției clinice și efectele terapiei de susținere. Neurology (Neurologie), 39, 475–481. 13 Campania pentru distrofie musculară. (2011). Furnizarea de scaune rulante pentru copiii și adulții diagnosticați cu distrofie musculară și alte afecțiuni neuromusculare: Ghid de bune practici. Preluat de la http://www.muscular-dystrophy.org/ 14 Organizația Mondială a Sănătății. (2012). Poliomielită. Preluat de la http://www.who.int/ mediacentre/factsheets/fs114/en/ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 178 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 15 Organizația Mondială a Sănătății. (1993). Chirurgia reparatorie a deformărilor cauzate de poliomielită. Preluat de la http://whqlibdoc.who.int/publications/1993/9241544570.pdf 16 Inițiativa globală de eradicare a poliomielitei. (n.d.). Poliomielita și prevenirea acesteia. Preluat de la http://www.polioeradication.org/Polioandprevention.aspx 17 Organizația Mondială a Sănătății. (1996). Susținerea dezvoltării sugarilor și copiilor mici diagnosticați cu cu spina bifida și hidrocefalie. Preluat de la http://whqlibdoc.who.int/hq/1996/ WHO_RHB_96.5.pdf 18 Malone, P., Wheeler, R., & Williams, J. (1994). Continența la pacienții diagnosticați cu spina bifida: Rezultate pe termen lung. Archives of Disease in Childhood (Arhiva bolilor în copilărie), 70, 107–110. 19 McDonnell, G. V., McCann, J. P. (2000). Aspecte ale gestionării din punct de vedere medical a situației adulților diagnosticați cu spina bifida. Child’s Nervous System (Sistemul nervos al copilului), 16, 222–227. 20 Campania pentru distrofie musculară. (2011). Furnizarea de scaune rulante pentru copiii și adulții diagnosticați cu distrofie musculară și alte afecțiuni neuromusculare: Ghid de bune practici. Preluat de la http://www.muscular-dystrophy.org/ 21 Organizația Mondială a Sănătății. (1996). Promovarea independenței după traumatismul vertebro- medular: Manual pentru persoanele din domeniul reabilitării - nivel mediu. Preluat de la http:// whqlibdoc.who.int/hq/1996/WHO_RHB_96.4.pdf 22 Bromley, I. (2006). Tetraplegia și paraplegia: Ghid pentru fizioterapeuți. Preluat de la http:// xa.yimg.com/kq/groups/16749867/2144244149/name/Tetraplegia+and+Paraplegia.pdf 23 Organizația Mondială a Sănătății. (1999). Promovarea unui stil de viață independent după accidentul vascular-cerebral. Preluat de la http://whqlibdoc.who.int/hq/1999/WHO_DAR_99.2.pdf 24 Organizația Mondială a Sănătății. (2012). Accidentul vascular-cerebral. Preluat de la http://www. who.int/topics/cerebrovascular_accident/en/ 25 Organizația Mondială a Sănătății. (2006). Tulburările neurologice: Provocări ale sistemului medical public. Preluat de la http://www.who.int/mental_health/neurology/chapter_3_b_neuro_disorders_ public_h_challenges.pdf 26 Collins, C. (2007). Fiziopatologia și clasificarea accidentului vascular-cerebral. Standarde de îngrijire, 21(28), 35–39. 27 Frizzel, J. (2005). Accidentul vascular-cerebral: fiziopatologie, diagnostic și tratament. Practici la nivel avansat în îngrijirea acută și critică, 16(4), 421–440. 28 Herman, B., et al. (1982). Epidemiologia accidentului vascular cerebral în Tilburg, Olanda. Registrul incidenței accidentului vascular cerebral: 2. Incidența, tabloul clinic preliminar și îngrijirea medicală inițială. Survenirea decesului după trei săptămâni. Accidentul vascular- cerebral, 13(5), 629–634. 29 Fried, L., et al. (2001). Constituția fragilă la adulții vârstnici: Dovezi pentru un fenotip. Jurnal de gerontologie, 56, 146–156 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 179 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 30 Bortz, W. (2002). Cadrul conceptual al constituției fragile: Rezumat. Jurnal de gerontologie, 57A(5), M283–M288. 31 Lang, P., Michel, J. P., & Zekry, D. (2009). Sindromul constituției fragile: Un stadiu tranzițional în procesul dinamic. Gerontologie, 55, 539–549. 32 Rader, J., Jones, D., & Miller, L. (2000). Importanța suprafeței de ședere personalizate a scaunului rulant în cazul adulților vârstnici cu constituție fragilă. Jurnal de îngrijire gerontologică, 26, 24–32. 33 Krasilovsky, G. (1993). Evaluarea și managementul suprafeței de ședere la rezindeții unui centru de îngrijire. Terapia fizică și ocupațională în geriatrie, 11(2), 25–38. 34 Trefler, E., Fitzgerald, S., Hobson, D., Bursick, T., & Joseph, R. (2004). Rezultatele utilizării scaunelor rulante la rezidenții unor centre de îngrijire pe termen lung. Tehnologie asistivă, 16, 18–27. 35 Societatea pentru Boala Huntington din Statele Unite ale Americii. (2010). Terapie fizică și ocupațională: Seria de ghid familial. Preluat de la http://www.hdsa.org/images/content/1/1/11697. pdf 36 Martin, K., Kaltenmark, T., Lewallen, A., Smith, C., & Yoshida, A. (2007). Caracteristici clinice ale hipotoniei: Studiu realizat de fizioterapeuți și terapeuți ocupaționali din pediatrie. Terapie fizică pediatrică, 19, 217–226. 37 Organizația Mondială a Sănătății. (1993). Susținerea dezvoltării copiilor mici diagnosticați cu paralizie cerebrală. Preluat de la http://whqlibdoc.who.int/hq/1993/WHO_RHB_93.1.pdf 38 Organizația Mondială a Sănătății, Departamentul de Apărare al Statelor Unite ale Americii, Centrul Drucker pentru Traumatisme cranio-cerebrale, Spitalul de Reabilitare Moss (2004). Reabilitarea persoanelor cu traumatism cranio-cerebral. Preluat de la http://whqlibdoc.who.int/hq/2004/WHO_ DAR_01.9_eng.pdf 39 Organizația Mondială a Sănătății. (1996). Promovarea unui stil de viață independent după traumatismul vertebro-medular: Manual pentru persoanele din domeniul reabilitării - nivel mediu. Preluat de la http://whqlibdoc.who.int/hq/1996/WHO_RHB_96.4.pdf 40 Asociația Americană pentru Inimă și Accident vascular-cerebral. (n.d.). Spascititatea. http://www. strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/PhysicalChallenges/ Spasticity_UCM_309770_Article.jsp3 41 Redstone, F., & West, J. (2004). Importanța controlului postural în consumul de alimente. Îngrijire pediatrică, 30, 97–100. 42 Driscoll, S., & Skinner, J. (2008). Complicații musculoscheletale ale bolilor neuromusculare la copii. Medicină fizică și clinici de reabilitare din America de nord, 19, 163–194. 43 Burger, H., Marincek, C., & Isakov, E. (1997). Mobilitatea persoanelor după amputația traumatică a membrului inferior.Disabilitate și Reabilitare, 19(7), 272–277. 44 Narang, I., Mathur, P., Singh, P., & Jape, V. (1984). Capacitățile funcționale ale persoanelor cu amputație de membru inferior. Proteze și Orteze International, 8, 43–51. 45 Organizația Mondială a Sănătății, Departamentul de Apărare al Statelor Unite ale Americii, Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 180 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Programul Moss de reabilitare a persoanelor cu amputație, Spitalul de reabilitare Moss. (2004). Reabilitarea persoanelor cu amputație. Preluat de la http://www.posna.org/news/Amputations.pdf 46 Organizația Mondială a Sănătății. (2005). Ziua mondială a diabetului: Prea multe persoane își pierd inutil membrele inferioare din cauza diabetului. Preluat de la http://www.who.int/mediacentre/ news/releases/2005/pr61/en/ 47 Pecorro, R., Reiber, G., & Burgerss, E. (1990). Modalități de realizare a amputației diabetice ale membrelor: Bazele profilaxiei. Îngrijirea diabetului, 13(5), 513–521. 48 Trautner, C., Haastert, B., Giani, G., & Berger, M. (1996). Incidența amputației membrului inferior și a diabetului. Îngrijirea diabetului, 19(9), 1006-1009. 49 Organizația Mondială a Sănătății. (2010). Administrarea rănilor și limfedemului. Preluat de la http:// whqlibdoc.who.int/publications/2010/9789241599139_eng.pdf 50 Organizația Mondială a Sănătății. (2008). Atlas: Resurse privind scleroza multiplă în lume. Preluat de la http://www.who.int/mental_health/neurology/Atlas_MS_WEB.pdf 51 Fundația pentru Boala Parkinson. (n.d.). Starea de oboseală. Preluat de la http://www.pdf.org/en/ fatigue_pdf 52 Soo, B., et al. (2006). Luxația de șold în paralizia cerebrală. Jurnalul chirurgiei osoase și a articulațiilor, 88, 121–129. 53 Scrutton, D., Baird, G., & Smeeton, N. (2001). Displazia de șold în paralizia cerebrală bilaterală: incidență și istoric natural la copiii cu vârste între 18 luni și 5 ani. Medicina dezvoltării și neurologie infantilă, 43, 486-600. 54 Lonstein, J., & Beck, K. (1986). Luxația și subluxația de șold în cazurile de paralizie cerebrale. Journal of Pediatric Orthopaedics (Jurnalul ortopediei pediatrice), 6, 521–526. 55 Spitalul de copii din Boston. (n.d.). Ghid pentru intervenția chirurgicală la șold în cazul copiilor diagnosticați cu paralizie cerebrală. Preluat de la http://childrenshospital.org/clinicalservices/ Site1166/Documents/CP.LE.Book.web2.pdf 56 Organizația Mondială a Sănătății, Departamentul de Apărare al Statelor Unite ale Americii, Centrul Drucker pentru Traumatism cranio-cerebral, Spitalul de Reabilitare Moss (2004). Reabilitarea persoanelor diagnosticate cu traumatism vertebro-medular. Preluat de la http://whqlibdoc.who.int/ hq/2004/WHO_DAR_01.9_eng.pdf 57 Pountney, T., Mandy, A., Green, E., & Gard, P. (2009). Subluxația și luxația de șold în cazurile de paralizie cerebrală - un studiu despre eficacitatea programelor de management postural. Physiotherapy Research International (Cercetare internațională) în domeniul fizioterapiei, 14(2), 116–127. 58 Centru de îngrijire pentru copii. (2011). Dovadă pentru practică: Supravegherea și managementul luxației de șold la copiii cu tulburări neuromotorii, incluzând paralizia cerebrală. Vancouver, BC: Tanja Mayson. 59 Pope, P. (2007). Tulburarea neurologică severă și complexă: Managementul condiției fizice. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 181 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Philadelphia: Elsevier Limited. 60 Sherk, H., Pasquariello, P., & Doherty, J. (2008). Luxația de șold în paralizia cerebrală. Alegerea tratamentului. Medicină de dezvoltare și neurologie infantilă, 25, 738-746. 61 Moreau, M. et al. (1979). Istoricul natural al luxației de șold în paralizia cerebrală spastică. Medicină de dezvoltare și neurologie infantilă, 21, 749-753. 62 Knapp, R., & Cortes, H. (2002). Luxația de șold netratată în paralizia cerebrală. Jurnal de ortopedie pediatrică, 22, 668-671. 63 McNamara, J. (1994). Baza celulată și moleculară a epilepsiei. Jurnal de neurologie, 14(6), 3413–3425. 64 Organizația Mondială a Sănătății. (2005). Atlas: Îngrijirea epilepsiei pe glob. Preluat de la http:// www.who.int/mental_health/neurology/Epilepsy_atlas_r1.pdf 65 Organizația Mondială a Sănătății. (2002). Epilepsie: Manual pentru persoanele din domeniul medical și clinic din Africa. Preluat de la http://www.who.int/mental_health/media/en/639.pdf 66 Organizația Mondială a Sănătății. (2006). Tulburări neurologice: Provocări ale sistemului medical public. Preluat de la http://www.who.int/mental_health/neurology/chapter_3_a_neuro_disorders_ public_h_challenges.pdf 67 Epilepsy Australia. (2009). Acordarea primului ajutor în cazul convulsiilor. Preluat de la http://www. epilepsyaustralia.net/userData/docs/First%20Aid%20Brochure%2009.pdf 68 Epilepsy Canada. (n.d.). Preluat de la http://old.epilepsycanada.test.glacier-digital.com/scans/ brochure/seizuresFirstAid.html 69 Epilepsy Canada. (n.d.). Preluat de la http://www.epilepsy.ca/en-CA/Diagnosis-and-Treatment/ First-Aid.html 70 Logemann, J., & Bytell, D. (1979). Tulburări de deglutiție la pacienții a trei tipuri de operații chirurgicale la nivelul capului și gâtului. Cancer, 44, 1075–1105. 71 Redstone, F., & West, J. (2004). Importanța controlului postural în consumul de alimente. Pediatric Nursing (Îngrijire pediatrică), 30 (2), 97–100. 72 Teasell, R., Mcrae, M., Marchuk, Y., & Finestone, H. (1996). Pneumonia asociată cu aspirarea în urma accidentului vascular-cerebral. Arch Phys Med Rehab, 77, 77–709. 73 Loughlin, G. (1989). Consecințe respiratorii ale deglutiției disfuncționale și a aspirației. Disfagia, 3, 126–130. 74 Organizația Mondială a Sănătății, Departamentul de Apărare al Statelor Unite ale Americii, Centrul Drucker pentru Trauatism cranio-cerebral, Spitalul de Reabilitare Moss (2004). Reabilitarea persoane cu traumatism cranio-cerebral. Preluat de la http://whqlibdoc.who.int/hq/2004/WHO_ DAR_01.9_eng.pdf 75 Schmidt, J., Holas, M., Halvorson, K., & Reding, M. (1994). Videofluoroscopia aspirației care Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 182 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar prezice pneumonia și decesul, dar nu deshidratarea în urma accidentului vascular-cerebral. Disfagia, 9, 7-11. 76 Perry, L., & Love, C. (2001). Monitorizarea disfagiei și aspirației în atacul cerebral acut: O revizuire sistematică. Dysphasia (Disfasia), 16, 7–18. 77 http://www.who.int/mediacentre/factsheets/fs331/en/ 78 Prasse, J. & Kikano, G. (2009). Prezentare a disfagiei pediatrice. Pediatrie clinică, 48(3), 247– 251. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul participantului Pagina 183 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT
Materialul nu poate fi reprodus integral sau parțial fără menționarea sursei și fără acordul scris al Fundației Motivation România. Fundația Motivation România Str. Podișor nr 1, Sat Buda, Comuna Cornetu, Ilfov, România Tel: 021 448 02 42 Fax: 021 448 11 07 Email: info@motivation.ro www.motivation.ro Telefonul utilizatorului de scaun rulant: 0800 030 668
Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 1. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 2. Publicat de Organizația Mondială a Sănătății în 2013, cu titlul Wheelchair Service Training Package: intermediate level. Trainer’s Manual ©World Health Organization 2013 Directorul General al Organizației Mondiale a Sănătății a acordat dreptul de a traduce și de a publica ediția în limba română Fundației Motivation România, care este singura responsabilă pentru ediția în limba română. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Manualul formatorului 1. Scaune rulante – standarde. 2. Persoane cu dizabilități – reabilitare. 3. Material pedagogic. I. Khasnabis, Chapal. II. Mines, Kylie. III. Organizația Mondială a Sănătății. Editori: Chapal Khasnabis și Kylie Mines Autori: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler și Rebecca Jackson Stoeckle Revizuit de: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri; Ritu; Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan și Diane E. Ward. Ilustrații: Melissa Puust Foto: David Constantine, Jesse Moss și Chapal Khasnabis Video: Chapal Khasnabis, Amanda McBaine și Jesse Moss Formatori: Andrew Congdon, Mirela Creangă, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Răducan (Niță), Andrew Rose Realizat cu sprijinul financiar al Agenției Statelor Unite pentru Dezvoltare Internațională și al Agenției Australiene pentru Dezvoltare Internațională. Organizații partenere: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania și Tanzania Training Centre for Orthopaedic Technologists (TATCOT) ©Fundația Motivation România, 2014 Această publicație a fost produsă cu sprijinul generos al poporului american, prin Agenția Statelor Unite pentru Dezvoltare Internațională (USAID). Conținutul este responsabilitatea Fundației Motivation România și nu reflectă în mod necesar punctul de vedere al USAID sau al Guvernului Statelor Unite. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 3. Servicii pentru utilizatorii de scaun rulant Pachet de instruire: nivel intermediar Manualul formatorului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 4. Terminologie În cadrul acestui document, următorii termeni sunt folosiţi conform definiţiilor din rândurile de mai jos. Scaun rulant corespunzător Este scaunul rulant care corespunde condiţiilor de mediu ale utilizatorului; este potrivit şi furnizează suport postural adecvat; este sigur şi durabil; este disponibil în ţara utilizatorului; poate fi obţinut şi întreţinut, iar serviciile sunt sustenabile în ţara respectivă, la cel mai accesibil preţ. Scaun rulant cu antrenare manuală Este scaunul rulant antrenat de către utilizator prin propulsie sau de către o altă persoană, prin împingere. Dispozitive de suport postural (DSP) Un dispozitiv fizic care oferă suport postural suplimentar - un element esenţial al furnizării de servicii de scaune rulante de nivel intermediar. Scaun rulant Este un dispozitiv cu roţi, care oferă mobilitate şi suport postural, utilizat de persoane care întâmpină dificultăţi în ceea ce priveşte deplasarea. Modificare de scaun rulant O modificare făcută unui scaun rulant. Furnizare de scaune rulante Este termenul generic pentru proiectarea, producţia, furnizarea de scaune rulante şi servicii de scaune rulante. Servicii de scaune rulante Sunt acea parte a procesului de furnizare a scaunelor rulante care se preocupă de dotarea utilizatorului cu un scaun rulant corespunzător. Personalul furnizor de servicii de scaune rulante Este personalul care are abilităţile necesare furnizării de scaune rulante corespunzătoare. Utilizator de scaun rulant O persoană care întâmpină dificultăţi în ceea ce priveşte deplasarea şi utilizează un scaun rulant pentru mobilitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 5. Cuprins Despre Servicii pentru utilizatorii de scaun rulant. Pachet de instruire pentru serviciile de scaune rulante - nivel intermediar Introducere Grupul ţintă Scopul Conţinutul Formatorii Pregătirea activităţii 1. Recomandări pentru formatori 1.1 Prezentarea programului de instruire 1.2 Orarul şi durata modulului de instruire 1.3 Planificarea sesiunilor 1.4 Prezentările PowerPoint 1.5 Observarea/monitorizarea progresului participanţilor 1.6 Evaluarea sesiunii de instruire după fiecare prezentare 1.7 Modele de bună practică 2. Pregătirea livrării programului de instruire 2.1 Cunoaşterea reţelelor de furnizare de servicii de scaune rulante ale participanţilor la curs 2.2 Clarificarea rolului participanţilor în procesul de furnizare de servicii de scaune rulante 2.3 Parcugerea fiecărui plan de sesiune şi adaptarea sesiunilor, în cazul în care este necesar 2.4 Identificarea scaunelor rulante, pernelor şi dispozitivelor de suport postural care vor fi utilizate în cadrul sesiunilor 2.5 Invitarea utilizatorilor de scaune rulante la sesiunile practice 2.6 Planificarea grupelor pentru sesiunile practice 2.7 Pregătirea locului de desfăşurare a cursului 2.8 Pregătirea resurselor şi materialelor necesare procesului de instruire 3. Planuri de sesiune detaliate Introducere A: Noţiuni fundamentale A.1: Utilizatorii de scaun rulant care au nevoie de suport postural suplimentar A.2: Copiii cu dizabilităţi B: Etapele furnizării serviciilor de scaune rulante B.1: Rezumatul evaluării şi interviul de evaluare B.2: Evaluarea fizică – postura în poziţia aşezat fără suport B.3: Evaluarea fizică – analiza posturii bazinului şi a şoldului B.4: Evaluarea fizică – procedeul de simulare manuală B.5: Evaluarea fizică - efectuarea măsurătorilor Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 6. B.6: Alegerea scaunelor rulante şi a pernelor B.7: Prescrierea (selecţia) dispozitivelor de suport postural - introducere B.8: Prescrierea (selecţia) dispozitivelor de suport postural - stabilizarea bazinului B.9: Prescrierea (selecţia) dispozitivelor de suport postural - sprijinirea şoldurilor B.10: Prescrierea (selecţia) dispozitivelor de suport postural - sprijinirea trunchiului B.11: Prescrierea (selecţia) dispozitivelor de suport postural - sprijinirea capului, coapselor şi a gambelor Sesiunea practică 1: Evaluarea şi prescrierea (selecţia) B.12: Pregătirea produsului (a scaunului rulant) Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) B.13: Probarea produsului (a scaunului rulant) B.14: Instruirea utilizatorului de scaun rulant Sesiunea practică 3: Probarea produsului (a scaunului rulant) şi instruirea utilizatorului B.15: Recapitulare B.16: Întreţinerea, reparaţiile şi monitorizarea Sesiunea practică 4: Evaluarea, prescrierea (selecţia), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) şi instruirea utilizatorului B.17: Feedback-ul formatorului, discuţii, ceremonia de încheiere Anexe Anexa 1: Orarul modulului de instruire pentru furnizarea serviciile de scaune rulante – nivel intermediar Anexa 2: Formular de trimitere - nivel intermediar Anexa 3: Formular de evaluare - nivel intermediar Anexa 4: Formular de prescriere (selecţie) a scaunului rulant - nivel intermediar Anexa 5: Formular date tehnice - nivel intermediar Anexa 6: Listă de verificare scaunului rulant de nivel intermediar Anexa 7: Listă de verificare preliminară utilizării scaunului rulant - nivel intermediar Anexa 8: Listă de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar Anexa 9: Formular de monitorizare a utilizării scaunului rulant - nivel intermediar Anexa 10: Tabel dispozitive de suport postural (DSP); Anexa 11: Inserţii unghiulare din burete rigid/spumă rigidă Anexa 12: Lista utilizatorilor de scaun rulant care participă la sesiunile practice Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 7. Despre Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar Introducere În urma publicării în anul 2008 a Ghidului privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate1) şi în 2012 a modulului Servicii pentru utilizatorii de scaune rulante. Pachet de instruire - nivel de bază, Organizaţia Mondială a Sănătăţii (OMS), în parteneriat cu Agenţia Statelor Unite pentru Dezvoltare Internaţională (USAID), a dezvoltat un nou modul destinat instruirii, numit Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Nivelul intermediar este cea de-a doua parte a seriei OMS dedicată furnizării de servicii către utilizatorii de scaun rulant şi pune accentul pe nevoile persoanelor cu dificultăţi severe de deplasare şi mobilitate, care au un control redus asupra trunchiului. Pe parcursul procesului de realizare al acestui pachet de instruire, am abordat cu multă atenţie aspectele legate de furnizarea unui scaun rulant corespunzător acelor copii care au un grad de control redus al trunchiului şi care nu pot menţine fără sprijin poziţia aşezat. Scaunul rulant este unul dintre cele mai frecvent utilizate echipamente asistive pentru îmbunătăţirea mobilităţii personale. Pentru persoanele care întâmpină dificultăţi de deplasare, un scaun rulant care corespunde nevoilor lor fizice, stilului de viaţă şi mediului în care trăiesc este un instrument esenţial, ajutându-i să se bucure de o ameliorare semnificativă a stării de sănătate, precum şi de bunăstare socială şi economică. Mobilitatea oferă utilizatorilor de scaun rulant oportunitatea de a studia, de a lucra, de a lua parte la activităţi culturale şi de a accesa servicii, cum ar fi cele de sănătate. Importanţa mobilităţii este reflectată şi în Convenţia Organizaţiei Naţiunilor Unite privind Drepturile Persoanelor cu Dizabilităţi (CONUDPD), care pledează în favoarea unor „măsuri eficiente pentru asigurarea mobilităţii persoanelor cu dizabilităţi, în cel mai înalt grad de independenţă posibil”. Pentru a asigura o bună mobilitate personală, utilizatorul are nevoie de un scaun rulant care este pe măsura sa şi care este în concordanţă cu cerinţele sale specifice. Acest lucru presupune o abordare care să răspundă nevoilor individuale ale utilizatorilor. O metodă eficientă pentru a răspunde acestor nevoi individuale ale utilizatorilor este furnizarea de scaune rulante prin intermediul serviciilor de scaune rulante. Cu toate acestea, statisticile arată că mai puţin de 5% dintre cei care au într-adevăr nevoie de acest tip de asistenţă beneficiază de acces la un scaun rulant adecvat. În plus, personalul implicat în furnizarea serviciilor de scaune rulante, are oportunităţi reduse de a dobândi abilităţile necesare pentru o prescriere corectă a scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar are ca scop sprijinirea instruirii de nivel intermediar a personalului cu atribuţii clinice şi tehnice în cadrul procesului de furnizare a serviciilor de scaune rulante (vezi Ghidul privind 1 Organizația Mondială a Sănătății. Ghid privind furnizarea scaunelor rulante cu antrenare manuală în zone cu resurse limitate. Geneva, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, accesat la 15 decembrie 2011). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 8. furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, Figura 4.2). Modulul de instruire susţine transmiterea cunoştinţelor teoretice şi practice necesare pentru începerea lucrului cu utilizatorii de scaun rulant care au nevoie de suport postural suplimentar pentru a menţine poziţia aşezat. Acesta include: modalitatea de evaluare a nevoilor individuale şi de asistare în selecţia şi pregătirea scaunului rulant adecvat, dotat cu dispozitive de suport postural, componenta de instruire a utilizatorilor şi însoţitorilor în ceea ce priveşte folosirea şi întreţinerea scaunului rulant, precum şi monitorizarea. Durata instruirii poate fi de 35-40 de ore, deşi aceasta poate fi redusă sau extinsă, în funcţie de nevoile specifice şi de resursele disponibile în fiecare caz. Se recomandă exerciţiul practic cu un îndrumător, pentru dezvoltarea competenţelor şi pentru creşterea capacităţii de a lucra independent. OMS speră ca acest modul să fie livrat ca un curs de instruire de sine stătător, de scurtă durată, pentru personalul care lucrează deja în domeniu şi, în egală măsură, să fie integrat în curricula programelor de instruire pentru personalul din domeniul reabilitării. Grupul ţintă Acest pachet de instruire este destinat personalului şi voluntarilor care au ca atribuţii la locul de muncă furnizarea de servicii de scaune rulante la nivel intermediar. Aici poate fi inclus personalul din domeniul sănătăţii, reabilitării sau personalul tehnic, cum ar fi terapeuţii ocupaţionali, fizioterapeuţii, tehnicienii de protetică şi ortetică, personalul medical din comunităţi sau cel implicat în reabilitarea bazată pe comunitate (RBC). Scopul Modulul intermediar al pachetului de instruire a fost elaborat pentru a sprijini instruirea personalului sau a voluntarilor în furnizarea unui scaun rulant cu antrenare manuală corespunzător şi a unei perne adecvate acelor copii şi adulţi care au nevoie de suport postural suplimentar pentru menţinerea poziţiei aşezat. Principalul scop al instruirii este dezvoltarea abilităţilor şi cunoştinţelor personalului implicat în procesul de livrare a serviciilor de scaune rulante. Cursul va contribui la: creşterea numărului de utilizatori de scaune rulante care primesc un scaun rulant care răspunde nevoilor lor; creşterea numărului de persoane instruite în ceea ce priveşte furnizarea de servicii de scaune rulante la nivel intermediar; îmbunătăţirea competenţelor personalului furnizor de servicii de scaune rulante; creşterea calităţii serviciilor de scaune rulante furnizate acelor persoane care au nevoie de un nivel de intervenţie care depăşeşte sfera celui de bază; includerea acestui pachet de instruire în programele de instruire tipice, destinate personalului paramedical/de reabilitare; integrarea într-o mai mare măsură a furnizării serviciilor de scaune rulante în cadrul serviciilor de reabilitare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 9. Conţinutul Pachetul de instruire include: modalitatea de evaluare a mobilităţii şi nevoii de suport postural a copiilor şi adulţilor care necesită un scaun rulant cu suport postural suplimentar; modalitatea de a lucra cu aceştia în vederea identificării celor mai bune soluţii de mobilitate; cunoştinţe şi sugestii practice pentru furnizarea unui scaun rulant manual cu o pernă corespunzătoare şi cu suport postural suplimentar; instruirea utilizatorilor de scaun rulant şi, dacă este cazul, a familiei/însoţitorilor, pentru a asigura o cât mai bună utilizare a scaunului rulant; monitorizarea utilizatorilor pentru a ne asigura că scaunul rulant răspunde în continuare nevoilor acestora. Formatorii Abilităţi: Formatorii care susţin modulul de nivel intermediar trebuie să fie instruiţi în evaluarea şi prescrierea scaunelor rulante pentru persoane care necesită suport postural suplimentar. De asemenea, aceştia trebuie să aibă capacitatea de a efectua sau de a coordona pregătirea în vederea utilizării a unui scaun rulant cu antrenare manuală dotat cu dispozitive de suport postural, folosind produse, materiale şi instrumente disponibile la nivel local. Formatorii ar trebui să deţină abilităţi din domeniul clinic, aplicate în sfera serviciilor furnizării de scaune rulante, care să le permită să se bazeze pe propriile experienţe practice în prezentarea acestui curs. Totodată, experienţa anterioară de formator constituie un avantaj. Utilizatorii de scaun rulant: Se recomandă includerea unui utilizator de scaun rulant în echipa care livrează cursul. Utilizatorii de scaune rulante pot să apeleze la propriile experienţe pentru a-i ajuta să înveţe pe cei cu dizabilităţi similare. Faptul că sunt instruiţi de către un utilizator de scaun rulant, îi va ajuta pe participanţi să aprecieze rolul central pe care utilizatorii îl au în alegerea scaunelor rulante pe care urmează să le utilizeze. Numărul formatorilor: Se recomandă doi formatori pentru fiecare grupă de 8 - 10 participanţi. Acest lucru este important în special în ceea ce priveşte sesiunile practice, pentru ca formatorii să poată acorda participanţilor asistenţă şi un feedback adecvat, precum şi pentru a asigura că exerciţiile practice se desfăşoară în condiţii de siguranţă. Prezenţa unui utilizator de scaun rulant cu experienţă, care cunoaşte bine subiectul şi conţinutul pachetului de instruire, va aduce un element de valoare programului de instruire. Suportul tehnic: Pentru desfăşurarea sesiunilor practice, care reprezintă componente importante ale acestui curs, se recomandă formatorilor să lucreze cu cel puţin un tehnician de scaune rulante care are experienţă în furnizarea serviciilor de scaune rulante la nivel intermediar şi care îi poate astfel asista pe parcursul sesiunilor practice. Cum începem 1. Copiaţi discul (din pachetul de resurse pentru instruire) pe hard drive-ul calculatorului care va fi folosit pe parcursul cursului. Este nevoie de cel puţin 6GB de spaţiu liber pe hard drive. 2. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 10. Faceţi clic pe fişierul denumit „Start”. De aici, formatorii pot naviga spre diversele resurse ale pachetului de instruire de nivel intermediar. De asemenea, formatorii pot accesa aceleaşi resurse şi din fişiere. 3. Deschideţi Manualul formatorului. 3.1. Citiţi secţiunea Despre Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar şi Recomandările pentru formatori. 3.2. Comandaţi sau listaţi câte un exemplar din Manualul formatorului pentru fiecare formator implicat în livrarea modulului de instruire (în cazul în care nu sunt deja disponibile exemplare pe suport de hârtie). 4. Accesaţi documentul cu orarul şi faceţi clic pe hyperlink-urile fiecărei sesiuni pentru a accesa prezentările şi filmele sesiunilor. Parcurgeţi fiecare prezentare şi fiecare planificare de sesiune (Manualul formatorului) pentru a vă familiariza cu conţinutul, resursele şi metodologia. 5. Urmaţi recomandările din capitolul „Pregătirea livrării programului de instruire” pentru a vă asigura că au fost făcute toate demersurile cu suficient timp înainte de începerea cursului. Pregătiţi toate resursele şi materialele necesare instruirii, conform descrierii din secţiunea „Pregătirea livrării programului de instruire”. 6. Cea mai bună modalitate de livrare a cursului este prin parcurgerea lecţiilor în ordine secvenţială, respectând cât mai mult posibil durata de timp alocată fiecărei sesiuni. 7. La începulul cursului, furnizaţi participanţilor un set complet de materiale, incluzând: Manualul participantului (1 pentru fiecare participant), Caietul de exerciţii practice (1 pentru fiecare participant) şi un set de afişe (1 set pentru fiecare participant) Dacă aceste materiale nu sunt disponibile, acestea pot fi listate de pe disc. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 11. 1. Recomandări pentru formatori 1.1 Prezentarea programului de instruire Minute Ziua Primire, introducere şi rezumat Introducere 60 U nu A: Noţiuni fundamentale Sesiunile care oferă participanţilor noţiunile fundamentale necesare parcurgerii etapelor procesului de furnizare a serviciilor de scaune rulante. A.1 Utilizatorii de scaune rulante care au nevoie de suport postural suplimentar 60 A.2 Copiii cu dizabilităţi 60 B: Etapele furnizării serviciilor de scaune rulante Evaluarea B. B.1 Trimiterea şi programarea Rezumatul evaluării şi interviul de evaluare 90 B.2 Evaluarea fizică - poziţia aşezat fără suport 90 B.3 Evaluarea fizică – analiza posturii bazinului şi a şoldului 120 B.4 Evaluarea fizică - simulare manuală 60 D oi B.5 Evaluarea fizică - efectuarea măsurătorilor 60 Prescriere (selecţie) B.6 Selecţia scaunelor rulante şi a pernelor 60 B.7 Prescrierea (selecţia) DSP-urilor - introducere 30 B.8 Prescrierea (selecţia) DSP-urilor - stabilizarea bazinului 90 B.9 Prescrierea (selecţia) DSP-urilor - sprijinirea şoldurilor 45 B.10 Prescrierea (selecţia) DSP-urilor - sprijinirea trunchiului 105 B.10 Prescrierea (selecţia) DSP-urilor - sprijinirea trunchiului 45 Trei B.11 Prescrierea (selecţia) DSP-urilor - sprijinirea capului, coapselor şi a gambelor: 120 Sesiunea practică 1: Evaluarea şi prescrierea (selecţia) 120 Pregătirea produsului (a scaunului rulant) B.12 Pregătirea produsului (a scaunului rulant) 60 Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) 150 Probarea produsului (a scaunului rulant) B.13 Probarea produsului (a scaunului rulant) 60 P atru Instruirea utilizatorului de scaun rulant B.14 Instruirea utilizatorului de scaun rulant 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 12. Sesiunea practică 3: Probarea produsului (a scaunului rulant) şi instruirea utilizatorului de scaun rulant 150 B.15 Recapitulare 120 Întreţinerea, reparaţiile şi monitorizarea B.16 Întreţinerea, reparaţiile şi monitorizarea 60 C inci Sesiunea practică 4: Evaluarea, prescrierea (selecţia), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) şi instruirea utilizatorului utilizatorului de scaun rulant 300 B.17 Feedback-ul formatorului, discuţii, ceremonia de încheiere 60 1.2 Orarul şi durata programului de instruire Acest program de instruire poate fi livrat în zile consecutive sau în grupe de zile pe parcursul unei anumite perioade de timp. Perioada minimă necesară pentru predarea întregului modul de instruire de nivel intermediar este de 35-40 de ore. O estimare a duratei de timp necesară fiecărei sesiuni este inclusă în planificarea sesiunilor. Notă: Durata de timp necesară pentru parcurgerea fiecărei sesiuni poate varia în funcţie de următorii factori: experienţa şi abilităţile participanţilor; numărul total al participanţilor; numărul scaunelor rulante disponibile la nivel local; perioada necesară pentru ajustarea şi pregătirea scaunelor rulante; nevoia de a asigura traducere simultană pe parcursul sesiunilor; necesitatea de a include materiale suplimentare. În funcţie de aceşti factori, durata necesară finalizării programului de instruire variază. În anexa I este prezentat un model de orar pentru cinci zile de curs. Acesta, precum şi un model necompletat, sunt disponibile şi pe DVD. Formatorii sunt încurajaţi să adapteze şi să modifice orarul, în aşa fel încât acesta să fie în concordanţă cu contextul local şi cu nevoile de instruire ale participanţilor. De exemplu: sesiunile din pachetul de instruire pot fi incluse în programe de sănătate sau reabilitare existente; dacă personalul de reabilitare are deja experienţă în ceea ce priveşte anumite aspecte ale programului de instruire, parcurgerea respectivei sesiuni nu este necesară; dacă pregătirea scaunelor rulante necesită mai mult timp (de exemplu, este necesară asamblarea completă a acestora) poate deveni necesară reducerea numărului de utilizatori de scaun rulant care participă la sesiunile practice sau, alternativ, creşterea duratei de timp alocate sesiunii. 1.3 Planificarea sesiunilor Pentru fiecare sesiune există un plan al acesteia, care îi ajută pe formatori în ceea ce priveşte prezentarea sesiunii. La începutul fiecărui plan de sesiune, veţi găsi următoarele informaţii: Obiective: care sunt acele abilităţi pe care participanţii trebuie să le dobândească până la finalul sesiunii; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 13. Resurse: care sunt resursele necesare desfăşurării sesiunii; Context şi cunoştinţe dobândite anterior: modul în care sesiunea trebuie adaptată la diverse contexte (sau situaţii) şi care sunt informaţiile dobândite anterior sau competenţele necesare; De pregătit: modul de pregătire pentru sesiune; Prezentare: un rezumat al principalelor părţi ale sesiunii. Restul planului este împărţit în funcţie de subiecte. Pentru fiecare subiect, planificarea sesiunii oferă instrucţiuni despre modul de predare a informaţiilor referitoare la respectivul subiect. Notă: cuvintele cu caractere aldine reprezintă activităţile formatorului (de exemplu: întrebaţi, demonstraţi, explicaţi, prezentaţi materialul video) căsuţele haşurate oferă răspunsuri la întrebările adresate participanţilor de către formator - încurajaţi participanţii să formuleze răspunsuri. La finalul fiecărui plan de sesiune există o recapitulare a punctelor cheie. În loc să citească punctele cheie, formatorii pot adresa întrebări participanţilor, astfel încât să îi încurajeze să identifice punctele cheie. Respectând planificarea sesiunii, formatorii vor reuşi să parcurgă fiecare sesiune, respectând durata de timp alocată. Planificările sesiunilor oferă toate punctele cheie şi abilităţile practice necesare care trebuie predate. Formatorii sunt încurajaţi să contribuie cu propriile cunoştinţe, abilităţi şi să abordeze transferul de cunoştinţe într-un stil propriu. 1.4 Prezentări PowerPoint Există prezentări PowerPoint (PPT) pentru aproape fiecare sesiune. Formatorii trebuie să ştie că doar punctele cheie sunt scrise în slide-uri. Formatorii trebuie să ofere informaţiile cuprinse în fiecare slide din Manualul formatorului, pentru a se asigura că toate temele au fost parcurse. Încercaţi să evitaţi să citiţi slide-urile. În schimb, faceţi referire la Manualul formatorului. 1.5 Observarea/monitorizarea progresului participanţilor Formatorii trebuie să monitorizeze cu atenţie progresul fiecărui participant. Cea mai bună oportunitate pentru acest lucru este pa parcursul sesiunilor practice. Pe DVD există câte o listă de verificare şi observaţii pentru formator, pentru fiecare sesiune practică. Formatorii trebuie să folosească lista de verificare pentru a: a monitoriza progresul fiecărui grup de participanţi pe durata sesiunilor practice; a nota exemple de bună practică, precum şi aspecte care necesită îmbunătăţiri – acestea vor fi discutate în fiecare sesiune de feedback. Lista de verificare şi observaţii a formatorului poate fi modificată şi/sau dezvoltată de către formatorii care doresc să înregistreze informaţii mai detaliate despre fiecare participant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 14. 1.6 Evaluarea programului de instruire după fiecare prezentare Se consideră un exemplu de bună practică evaluarea programului de instruire după livrarea acestuia. Formatorii pot primi feedback de la participanţi pe întreaga perioadă a programului de instruire. De asemenea, formatorii îşi pot nota propriile păreri despre procesul de predare, pe parcursul acestuia. Aceste informaţii îi pot ajuta la final, în vederea evaluării programului de instruire, pentru identificarea punctelor forte şi a aspectelor mai puţin bune. Astfel, în viitor, formatorii vor putea îmbunătăţi atât conţinutul pachetului de instruire, cât şi propriile lor abilităţi de prezentare. Formularele de evaluare a programului de instruire sunt disponibile pe DVD. Acestea pot fi adaptate sau dezvoltate de către formatori, pentru a se potrivi cerinţelor lor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 15. 1.7 Modele de bună practică Fiţi pregătiţi o parcurgeţi cu atenţie fiecare plan de sesiune înainte de începerea cursului; o asiguraţi-vă că sunteţi familiarizat cu conţinutul materialului, înainte de prezentarea acestuia; o pregătiţi resursele pentru instruire şi sala de curs. Oferiţi un model de buna practică în livrarea serviciilor de scaune rulante o respectaţi participanţii şi utilizatorii de scaun rulant; o prezentaţi interes pentru ceea ce aveţi de făcut; o fiţi atenţi în permanenţă la respectarea regulilor de siguranţă din sala de curs; o fiţi punctuali şi respectaţi orarul. Prezentaţi informaţiile cu claritate o vorbiţi clar şi calm; o asiguraţi-vă că toată lumea din sală vă poate auzi; o puneţi întrebări pentru a verifica dacă aţi fost înţeleşi; o asiguraţi-vă că scrisul de pe tablă este citeţ; o repetaţi informaţiile importante pentru a le consolida. Gestionaţi cu atenţie durata de timp alocată sesiunii o fiţi atenţi la durata fiecărei sesiuni şi respectaţi timpul aclocat; o dacă intuiţi că veţi avea nevoie de mai mult timp, planificaţi acest lucru de la început; o asiguraţi-vă că parcurgeţi toate sesiunile planificate pentru respectiva zi. Oferiţi demonstraţii clare şi exacte o asiguraţi-vă că toată lumea vă vede cât se poate de bine; o explicaţi ce urmează să se întâmple şi descrieţi ceea ce urmează să faceţi; o nu vă grăbiţi cu desfăşurarea demonstraţiilor şi repetaţi dacă este cazul. Dezvoltaţi abilităţile participanţilor o după fiecare demonstraţie, ofeiţi participanţilor oportunitatea de a exersa; o nu uitaţi că participanţii au nevoie de timp pentru a înţelege informaţiile. Încurajaţi reuşitele în activităţile de grup o monitorizaţi cu atenţie activităţile grupului şi oferiţi asistenţă, atunci când este necesar; o treceţi pe la fiecare grupă, pentru a verifica progresul făcut. Fiţi atenţi la diferenţele de limbă o dacă participanţii învaţă într-o altă limbă decât cea maternă, asiguraţi- vă că au înţeles ce spuneţi - vorbiţi mai lent dacă este nevoie; o fiţi atenţi la diferenţele dintre dintre limba vorbită de către utilzatorii de scaun rulant şi însoţitorii lor; o apelaţi la interpreţi dacă este necesar. Încurajaţi participanţii să fie activi şi să se implice pe toată durata instruirii o folosiţi diversele stiluri şi metode de instruire prezentate în planificările sesiunilor; o evitaţi să vorbiţi prea mult - încurajaţi participanţii să vorbească şi să discute între ei; o evitaţi să oferiţi toate răspunsurile, puneţi întrebări pentru a încuraja participanţii să se gândească la răspunsuri; o încurajaţi fiecare participant să vorbească, nu lăsaţi ca oricare dintre Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 16. participanţi să domine; o oferiţi apreciere pentru sarcinile efectuate corect, precum şi feedback pozitiv; o participanţii trebuie să ştie că pot pune întrebări oricând; o corelaţi învăţarea cu exemple reale, pe care participanţii le recunosc; o faceţi în aşa fel încât instruirea să fie distractivă! Utilizaţi activităţi/jocuri „de încălzire” o Folosiţi scurte activităţi „de încălzire” (5-10 minute) pentru a ajuta la focalizarea atenţiei. Folosiţi activităţi care includ participanţii cu dizabilităţi. Luaţi în considerare nevoile persoanelor cu diferite abilităţi o Gândiţi-vă la nevoile oricărui participant cu dizabilităţi vizuale, auditive sau legate de mobilitate. Anumite activităţi şi metode de predare trebuie adaptate corespunzător. 2. Pregătirea livrării programului de instruire 2.1 Cunoaşterea reţelelor de furnizare de servicii de scaune rulante ale participanţilor la curs Formatorii trebuie să cunoască sistemul de furnizare a scaunelor rulante la locul unde ăşi desfăşoară activitatea. Acesta include: tipurile de scaune rulante, perne şi dispozitive de suport postural (DSP) disponibile la nivel local şi furnizorii acestora; materialele, instrumentele şi facilităţile disponibile pentru pregătirea scaunelor rulante şi confecţionarea dispozitivelor de suport postural; serviciile de scaune rulante existente în zonă, incluzând nivelul serviciilor pe care le oferă; reţelele existente în zonă, care pot direcţiona utilizatorii către furnizorii de servicii de scaune rulante; personalul-resursă din zonă, inclusiv utilizatorii de scaune rulante care pot asista în procesul de livrare al cursului; alte servicii de reabilitare spre care personalul furnizor de servicii de scaune rulante poate direcţiona utilizatorii de scaune rulante, în funcţie de nevoile acestora. 2.2 Clarificarea rolului participanţilor în procesul de furnizare de servicii de scaune rulante Aflaţi modul în care furnizarea de servicii de scaune rulante se încadrează în sarcinile generale ale participanţilor în activitatea lor la locul de muncă. De exemplu, participanţii vor lucra doar în domeniul furnizării de servicii de scaune rulante sau vor avea şi alte sarcini? Definiţi rolul participanţilor în procesul de furnizare a serviciilor de scaune rulante. De exemplu, atribuţiile unora se pot rezuma doar la aspectele clinice sau cele tehnice incluse în modulul de instruire. Este posibil ca alţii să deţină ambele tipuri de responsabilităţi. Rolul pe care fiecare participant îl va deţine trebuie să fie clar înainte de începerea instruirii. Astfel, formatorii pot corela procesul de instruire cu viitoarele sarcini ale participanţilor. Înainte de livrarea cursului, formatorii locali trebuie să adapteze cursul la Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 17. responsabilităţile pe care le vor avea participanţii în cadrul centrului de furnizare a serviciilor de scaune rulante. 2.3 Parcugerea fiecărui plan de sesiune şi adaptarea sesiunilor, în cazul în care este necesar Revedeţi fiecare planificare şi decideţi care dintre formatori va răspunde de fiecare sesiune. Unele sesiuni de instruire pot impune adaptarea la contextul local. Sugestiile legate de corelarea cu diverse contexte sunt menţionate la începutul fiecărei planificări, la capitolul „Context”. 2.4 Identificarea scaunelor rulante, pernelor şi a dispozitivelor de suport postural care vor fi folosite Identificaţi tipurile de scaune rulante, de dispozitive de suport postural şi de perne care vor fi prezentate în curs. Acestea trebuie să fie produse disponibile la locul de muncă al participanţilor. Dacă există o gamă largă de scaune rulante, alegeţi cele mai reprezentative exemple dintre diferitele tipuri de scaune rulante corespunzătoare. Prioritare trebuie să fie cele mai frecvent utilizate. Asiguraţi-vă că sunteţi familiarizaţi cu caracteristicile fiecărui produs. Completaţi un formular de date tehnice – nivel intermediar şi solicitaţi furnizorului informaţii despre produs. 2.5 Invitarea utilizatorilor de scaune rulante la sesiunile practice Pentru ca participanţii să poată exersa abilităţile prezentate în cadrul programului de instruire, este necesară participarea unor utilizatori de scaune rulante. Înainte de programul de instruire, formatorii trebuie să identifice şi să invite la sesiunile practice câţiva utilizatori de scaune rulante care sunt dispuşi să participe. Mai jos aveţi o listă de verificare pentru identificarea utilizatorilor de scaune rulante. Listă de verificare pentru participarea utilizatorilor de scaune rulante la sesiunile practice: Sunt de acord cu participarea la curs pentru a oferi asistenţă în cadrul sesiunilor practice Au nevoie de suport postural suplimentar pentru menţinerea poziţiei aşezat, cu suport, pot menţine această poziţie sau una apropiată Au o stare fizică adecvată, care le permite participarea la programul de instruire, fără consecinţe negative Nu au escare Locuiesc suficient de aproape pentru a putea participa la sesiunile practice, fără a fi nevoie de o călătorie lungă Au timp disponibil pentru a participa la sesiunea practică Locuiesc suficient de aproape încât organizatorii să poată desfăşura monitorizarea după încheierea programului de instruire Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 18. Număr egal de utilizatori de scaun rulant bărbaţi şi femei Prezintă o gamă cu diferite cerinţe fizice Vârste diferite De câţi utilizatori de scaune rulante este nevoie? Numărul necesar de utilizatori de scaun rulant pentru desfăşurarea sesiunilor practice depinde de numărul participanţilor la curs. În mod normal, participanţii lucrează în grupe de câte două sau trei persoane, împreună cu un utilizator de scaun rulant. Serecomandă să nu fie mai mult de patru utilizatori de scaune rulante în sesiunile practice, deoarece formatorilor le va fi dificil să gestioneze, monitorizeze şi să observe activitatea. Tabelul de mai jos prezintă numărul necesar de utilizatori de scaune rulante pentru un program cu 6-8 participanţi sau 8-12 participanţi. Participanţii vor fi împărţiţi în grupe de câte 2-4 persoane şi vor lucra cu câte un utilizator de scaun rulant. În mod ideal, ar trebui să existe un formator la fiecare două grupe de participanţi care lucrează cu utilizatori de scaun rulant. Acest lucru este necesar pentru a ne asigura că formatorii pot gestiona, monitoriza şi observa sesiunile practice, pentru siguranţa utilizatorilor de scaune rulante şi pentru un proces de învăţare corect. Numărul participaţilor: 6-8 8-12 Utilizatori de scaune rulante pentru evaluare, prescriere, probarea produsului (a scaunului rulant) şi instruirea utilizatorului de scaun rulant Sesiunile practice 1 şi 3 3 4 Sesiunea practică 4 3 4 Numărul total de utilizatori de scaun rulant voluntari recomandat pentru desfăşurarea sesiunilor practice: 6 8 Ce trebuie să ştie utilizatorii de scaun rulant care participă la sesiunile practice? Utilizatorii de scaun rulant care participă la sesiunile practice trebuie să ştie următoarele: activităţile la care vor lua parte; când vor participa şi durata; faptul că pot participa însoţiţi de un membru al familiei/însoţitor; dacă vor primi un scaun rulant în urma participării la curs. Se recomandă formatorilor şi organizaţiilor gazdă/care oferă programul de instruire să le explice tuturor utilizatorilor de scaun rulant care participă la sesiunile practice că transportul le va fi asigurat sau că vor fi decontate cheltuielile legate de transport şi participare. De asemenea, vor fi asigurate mesele şi pauzele de cafea pe toată perioada programului de instruire. Formatorii şi organizaţiile gazdă/cele care oferă programul de instruire pot oferi utilizatorilor de scaun rulant o plată sub formă de onorariu pentru participarea la instruire. Modelul de scrisoare de invitaţie şi formularul de acord pentru utilizatorii de scaun rulant se găsesc în Pachetul de instruire (vezi DVD: Formulare şi liste de verificări). Acestea trebuie adaptate la contextul specific, traduse şi trimise fiecărui utilizator de scaun rulant Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 19. (voluntar), în aşa fel încât aceştia să poată lua o decizie informată cu privire la participarea la cursul de instruire. Monitorizarea: Formatorii sau organizaţiile gazdă/care oferă programul de instruire trebuie să planifice monitorizarea oricărui utilizator de scaun rulant prezent la curs, deoarece este posibil ca procesul de livrare să nu fie finalizat înainte de finalul instruirii. Toţi utilizator de scaun rulant care primesc un scaun rulant pe perioada cursului trebuie să beneficieze de a activitate de monitorizare efectuată de către organizaţia gazdă/care oferă programul de instruire într-un interval de 6-8 săptămâni de la primirea scaunului rulant. Locul de desfăşurare a sesiunile practice: Asiguraţi-vă că există un spaţiu liniştit şi privat în care fiecare grupă pe participanţi poate lucra cu utilizatorul de scaun rulant. Paravanele portabile pot fi folosite pentru a delimita spaţiul şi pentru a oferi un anumit grad de confort. Formatorii pot opta să organizeze cel puţin o sesiune practică în cadrul comunităţii. Acest lucru poate avea loc la domiciliul unui utilizator de scaun rulant care se oferă voluntar pentru a primi în vizită participanţii. Vizitele în comunitate îi vor ajuta pe participanţi să înţeleagă aspectele practice cu care se confruntă utilizatorii de scaun rulant în mediul lor de viaţă. Formatorii trebuie să decidă dacă acest lucru constituie o opţiune, luând în considerare următoarele: existenţa mijloacelor pentru asigurarea transportului participanţilor, dacă există suficienţi formatori pentru a putea monitoriza şi observa activitatea tuturor participanţilor în diversele locuri de desfăşurare a sesiunilor practice, dacă utilizatorii de scaune rulante sunt de acord cu primirea participanţilor în casele lor, durata de timp suplimentară necesară deplasării în comunitate. 2.6 Planificarea grupelor pentru sesiunile practice Fiecare grupă trebuie să fie formată din maximum trei participanţi. Se recomandă să aveţi două grupe de câte două persoane decât un grup de patru persoane. Aceasta este modalitatea prin care vă asiguraţi că participanţii au oportunitatea de a pune în aplicare ceea ce au învăţat şi de a-şi dezvolta abilităţile. Formatorii trebuie să decidă care va fi componenţa grupelor. Nu lăsaţi acest lucru la latitudinea participanţilor. În funcţie de abilităţile participanţilor şi de context, formatorii au următoarele variante: să formeze echipe în care să existe participanţi cu niveluri diferite de încredere în propriile abilităţi. Cei care au mai multă siguranţă de sine îi pot ajuta pe colegii lor. Monitorizaţi/observaţi activitatea grupelor, pentru a vă asigura că toţi membrii echipei sunt implicaţi. În cazul în care există participanţi care vor lucra împreună în viitor, grupaţi-i, astfel îmcât să aibă posibilitatea de a-şi dezvolta abilităţile ca echipă. Pentru sesiunile practice 1, 2 şi 3, păstraţi componenţa grupelor. Pentru sesiunea practică 4, aceasta poate fi modificată, în funcţie de cât de bine lucrează împreună membrii acestora. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 20. Pentru fiecare sesiune practică, desemnaţi câte un responsabil de echipă. Asiguraţi-vă că, alternativ. fiecare participant are ocazia de a fi responsabil. Cereţi acestuia să se asigure că sunt parcurşi toţi paşii necesari. Responsabilul este cel care comunică cu utilizatorul de scaun rulant şi, acolo unde este necesar, cu membrii familiei/însoţitorii. 2.7 Pregătirea spaţiului de desfăşurare a cursului Pentru a derula programul de instruire, este nevoie de o încăpere (sau un spaţiu) mare. Spaţiul trebuie să fie suficient de mare pentru ca participanţii şi utilizatorii de scaun rulant să poată desfăşura sesiunile practice, fiind împărţiţi pe echipe. Este nevoie şi de un spaţiu exterior pentru a putea exersa abilităţile de manevrare a scaunului rulant, de un spaţiu rezervat pentru a lua masa, precum şi de grupuri sanitare curate. Toate spaţiile, inclusiv toaletele, trebuie să fie accesibile utilizatorilor de scaun rulant. Următoarea listă de verificare poate fi folosită pentru a evalua şi a pregăti spaţiul alocat derulării cursului de instruire: Listă de verificare pentru spaţiul desemnat desfăşurării cursului : Sala de curs Zona pentru predarea părţii teoretice Câte un scaun pentru fiecare participant – dotat cu măsuţă pentru scris Suficient spaţiu pentru ca să poată fi alcătuite grupe de câte 2–3 participanţi Suficient spaţiu pentru a poziţiona şi pentru a manevra cel puţin trei scaune rulante Paravane pentru a oferi utilizatorilor de scaun rulant un spaţiu delimitat Lumina şi ventilaţie adecvate Posibilitatea de a încuia uşa de acces a sălii Mese de lucru/facilităţi specifice atelierului de lucru Masă de lucru pentru fiecare grupă Zona pentru pauza de prânz/cafea Spaţiu curat unde se poate lua masa Mese şi scaune Spaţiu unde există facilităţi pentru spălarea mâinilor – prosoape curate şi săpun Toalete Toalete curate, cu apă, hârtie igienică, facilităţi pentru spălarea mâinilor şi coşuri pentru deşeuri Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 21. 2.8 Pregătirea resurselor şi materialelor pentru instruire Materiale imprimate Resursă Cantitate Comentarii/Instrucţiuni Manuale, caiete de exerciţii practice şi afişe: Manualul formatorului 1 per formator Se comandă de la OMS sau se imprimă şi se leagă. Manualul participantului 1 per participant Se comandă de la OMS sau se imprimă şi se leagă. Caietul de exerciţii practice 1 per participant Se comandă de la OMS sau se imprimă şi se leagă. Set de afişe 1 per participant Se comandă de la OMS sau se imprimă şi se leagă. Formulare pentru programul de instruire: Formular pentru înregistrarea participanţilor 1 per curs de instruire Acest formular este necesar pentru a înregistra participanţii la curs. Ecusoane 1 per participant şi 1 per formator Desfăşurător 1 per participant Modelele sunt disponibile pe DVD; adaptaţi pentru conformitate cu contextul local. Formular de acord foto 1 per participant şi 1 per utilizator de scaun rulant (voluntar) Adaptaţi acest formular pentru formator/organizaţia unde are loc cursul de instruire, traduceţi- l în limba în care va fi desfăşurat cursul, asiguraţi-vă că toate persoanele care vor fi fotografiate semnează acest formular. Scrisoare de invitaţie şi acord de participare pentru utilizatorii de scaun rulant 1 per utilizator de scaun rulant Adaptaţi modelul de scrisoare din pachet, pentru a invita la sesiunile practice fiecare utilizator de scaun rulant. Lista de utilizatori de scaun rulant pentru sesiunile practice 1 per formator Folosiţi acest formular pentru a planifica participarea utilizatorilor de scaun rulant la sesiunile practice şi pentru a avea o evidenţă a participării. Certificate pentru participanţi 1 per participant Prepare participant certificates or adapt the template provided. Formulare de evaluare ale cursului de instruire Formular de evaluare al 1 per participant Modele de formulare de Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 22. programului de instruire - pentru participanţi evaluare a cursului de instruire; acestea pot fi adaptate de către formatori, în funcţie de necesităţi. Formular de evaluare a sesiunii de instruire -pentru formator 1 per sesiune Formular de evaluare al programului de instruire – pentru formatori 1 per formator Lista de verificare şi observaţii pentru formator - pentru sesiunile practice Sesiunea practică 1 1 per formator Tipăriţi Sesiunea practică 2 Sesiunea practică 3 Sesiunea practică 4 Formulare pentru furnizarea serviciilor de scaune rulante: La începutul programului de instruire, fiecare participant va primi un set complet de formulare utilizate în furnizarea serviciilor de scaune rulante. Pentru sesiunile practice, vor fi necesare exemplare suplimentare. Formular de trimitere a utilizatorului de scaun rulant – nivel intermediat — Adaptaţi pentru a fi în concordanţă cu contextul local sau folosiţi formularul de trimitere disponibil pe plan local, dacă acesta există. Formular de evaluare – nivel intermediar 1 per utilizator de scaun rulant Adaptaţi pentru a fi în concordanţă cu contextul local – de exemplu, adăugaţi numele furnizorului de servicii de scaune rulante sau informaţii suplimentare solicitate de furnizorii locali. Formular de prescriere (selecţie) a scaunului rulant – nivel intermediar 1 per utilizator de scaun rulant Finalizaţi în funcţie de mărimile de scaune rulante disponibile şi de opţiuni. Formular de date tehnice scaun rulant 1 per scaun rulant Completaţi unul pentru fiecare tip de scaun rulant disponibil, înainte de începerea programului de instruire. Formular de monitorizare a utilizării scaunului rulant Adaptaţi la contextul local – de exemplu, adăugaţi numele furnizorului de servicii de scaune rulante sau informaţii suplimentare solicitate de furnizorii locali. Liste de verificare: Lista de verificare a paşilor pentru probarea produsului 1 per participant Listele de verificare sunt disponibile la resurse Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 23. (a scaunului rulant) – nivel intermediar (laminat) imprimate, la „Formulare , liste de verificare şi tabele”. Lista de verificare pentru instruirea utilizatorului de scaun rulant – nivel intermediar (laminat) Listă de verificare preliminară utilizării scaunului rulant – nivel intermediar (laminat) Tabel: Tabel dispozitive de suport postural (DSP) - laminat 1 per participant Tabelul poate fi găsit la „Formulare, liste de verificare şi tabele”. Afişe: Copiii şi Scaunele rulante 1 1 per participant Diferite posturi 1 Tabel dispozitive de suport postural (DSP) 1 Liste de verificare – nivel intermediar 1 Echipament Echipament general pentru desfăşurarea programului de instruire: Item Cantitate Comentarii/instrucţiuni Tablă de scris de dimensiuni mari 1 Markere pentru tabla de scris 3–4 Videoproiector 1 Computer 1 Boxe audio portabile 1 set Pentru materialele audio aflate pe DVD Pahare de unică folosinţă 1 per participant Pentru consumul de răcoritoare Minge 1 la 2 grupe Pentru activitatea cu mingea Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 24. Echipament pentru etapele de evaluare şi prescriere (selecţie): Echipament pentru demonstraţii şi exersarea etapelor de evaluare, prescriere (selecţie) şi probare a produslui (scaunului rulant). Item Cantitate Comentarii/instrucţiuni Spumă/burete cu dimensiunile de 30 mm x 150 mm x 300 mm 10–15, în funcţie de numărul grupelor Spumă/burete de formă unghiulară cu dimensiunile de 30 mm X 150 mm X 200 mm (aproximativ) 10–15, în funcţie de numărul grupelor Vezi diagrama din Anexa 11 Goniometru/goniometre din carton/plastic 1 per grupă Ruletă 1 per grupă Ruletă rigidă, retractabilă (nu metru de croitorie), care indică mm. Etrier (dacă este disponibil) 1 per grupă Paturi pentru evaluare 1 per grupă Bancă/pat pentru evaluare/suport. Înălţimea trebuie să fie aproximativ la acelaşi nivel cu înălţimea medie a şezutului scaunului rulant. În măsura în care este posibil, evitaţi suprafeţele tari – dacă utilizaţi bănci, acoperiţi suprafaţa acestora cu un strat subţire de spumă/burete şi cu o pătură sau un burete pentru exerciţiile de yoga. Cameră foto digitală 1 Dacă este disponibilă Paravane 1 per grupă Paravane pentru delimitarea spaţiilor în care se va lucra cu utilizatorii de scaun rulant pe parcursul sesiunilor practice. Set plăci pentru picioare 1 set per grupă Bucăţi confecţionate din lemn, pentru a oferi utilizatorilor de scaun rulant suport la nivelul picioarelor, atunci când se află pe patul de evaluare. Acestea trebuie să fie de înălţimi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 25. diferite. Mănuşi de unică folosinţă (dacă sunt disponibile) 1 per participant Scaune rulante: pentru instruire şi pentru sesiunile practice cu utilizatorii de scaun rulant Item Cantitate Comentarii/instrucţiuni Scaune rulante pentru instruire Cel puţin câte unul pentru fiecare tip de scaun rulant disponibil pe plan local. Ideal este să avem disponibil câte un scaun rulant pentru fiecare pereche de participanţi. Asiguraţi-vă că toate scaunele rulante sunt în bună stare de funcţionare şi că sunt dotate cu o pernă. Scaune rulante care să le fie furnizate utilizatorilor care participă la sesiunile practice 1 pentru fiecare utilizatorul de scaun rulant care participă la sesiunile practice Ar trebui să fie disponibile suficiente scaune rulante pentru a putea prescrie câte un scaun rulant care să corespundă într-o cât mai mare măsură nevoilor individuale ale fiecărui utilizator care participă la sesiunile practice. Perne: pentru demonstraţii Item Cantitate Comentarii /instrucţiuni Pernă modificată pentru a oferi suport în cazul unui bazin fix inegal 1 Pernă modificată pentru a oferi suport în cazul unui şold care nu poate fi flexat în poziţia neutră de şedere (unghiul dintre trunchi şi coapsă este mai mare de 90 de grade) 1 Pernă modificată pentru a oferi suport în cazul în care unul sau niciunul din şolduri nu poate sta în poziţia corectă pentru poziţia aşezat (unghiul dintre trunchi şi coapsă este mai mic de 90 de 1 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 26. grade) Bancul de lucru şi trusa de scule: Pentru a confecţiona dispozitive de suport postural pentru utilizatorii de scaun rulant care participă la sesiunile practice, sunt necesare mese de lucru şi câteva scule de bază. Formatorii pot modifica această listă în funcţie de dispozitivele de suport postural pre-fabricate şi de materialele disponibile pe plan local. Găsiţi mai jos o listă de sugestii: Item Cantitate Comentarii/instrucţiuni Banc de lucru 1 la 3 participanţi Aceasta poate fi un banc de lucru sau o masă solidă. O menghină pe fiecare banc de lucru poate fi foarte utilă. Cuţit pentru spumă/cuţit electric 1 la 6 participanţi O lamă fină de fierăstrău poate fi utilizată ca un cuţit pentru spumă. Foarfece 1 la 6 participanţi De dimensiuni mari (dacă este posibil) Ochelari de protecţie 1 per participant Ochelarii de protecţie trebuie purtaţi în timpul oricărei activităţi care implică tăiere. Scule (fierăstrău, pilă, ciocan, şurubelniţă) 1 set la 3 participanţi Aceste scule sunt necesare pentru a cofecţiona dispozitive de suport postural. Necesarul de instrumente de lucru variază în funcţie de materialele folosite. Maşină de cusut industrială sau ace şi fir pentru cusut. 1 Maşina de cusut industrială este necesară pentru confecţionarea huselor de pernă şi/sau a dispozitivelor de suport postural. Nu toată lumea are abilităţile necesare pentru a utiliza o maşină de cusut industrială. Posibile opţiuni: o Identificaţi un atelier de croitorie care poate onora comenzi într-o perioadă de timp scurtă. o Identificaţi o persoană care are bune abilităţi de cusut şi care să fie disponibilă să participe la toate sesiunile în care se confecţionează diverse elemente. o Înainte de începerea cursului, asiguraţi-vă că maşina de cusut este în stare bună de funcţionare. Trusă de prim ajutor. 1 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 27. Trusa de dispozitive de suport postural: Următoarele mostre de dispozitive de suport postural disponibile pe plan local vor susţine procesul de învăţare. Găsiţi mai jos o listă orientativă. Se recomandă formatorilor să aibă câte o mostră din fiecare tip de dispozitiv de suport postural prefabricat care poate fi găsit local. Item Cantitate Comentarii/instrucţiuni Inserţii laterale pentru bazin 2 Inserţii exterioare pentru coapse 2 Inserţie pentru separarea genunchilor 1 Spătar cu tensiune ajustabilă 1 Inserţii laterale pentru trunchi 2 Tetieră 1 Centură pentru bazin 1 per grupă Centură pentru gambe 1 Centură pentru picior 2 Ham pentru umeri 1 Materiale dispozitive de suport postural: Următoarele materiale sunt recomandate pentru confecţionarea de dispozitive de suport postural destinate utilizatorilor de scaun rulant care participă la sesiunile practice. Lista de mai jos este orientativă. Lista exactă a materialelor va depinde ce: soluţiile de care au nevoie utilizatorii de scaun rulant; disponibilitatea oricăror dispozitive de suport postural prefabricate; materiale pentru confecţionarea dispozitivelor de suport postural disponibile local; soluţiile tehnice alese. Item Cantitate Comentarii/instrucţiuni Spumă solidă/burete solid (e.g. din fulgi încleiaţi) Cantităţile vor varia aşa cum este menţionat mai sus. Totuşi, cantităţile sugerate sunt: o Spumă solidă/burete solid – o bucată cu dimensiunile de 1000 mm x 1500 mm x 50 mm and 1000 mm x 1500 mm x 20–30 mm. o Spumă moale/burete moale – jumătate din cantitatea de mai sus. Dacă nu este disponibilă spumă/burete cu grosimea de 50 de mm – lipiţi cu adeziv două straturi mai subţiri. Spuma moale opune o oarecare rezistenţă la comprimare. Pentru mai multe informaţii, vezi Manualul participantului. Soft foam Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Manualul formatorului Pagina 28. Material pentru chingi 20 de m de material lat (lăţime 50 mm) 20 de m de material îngust (lăţime 25 mm) Lăţimea acestora depinde de stoc. Catarame pentru chingi 10–12 (cu aceeaşi lăţime ca materialul pentru chingi) Lemn Cantităţile variază în funcţie de cele menţionate mai sus. Pentru mai multe informaţii, vezi Manualul participantului. Adeziv pentru lemn şi spumă/burete Material textil pentru husă EVA (etilen vinil acetat) sau aracet Colţare metalice, dacă există Diverse şuruburi, piuliţe, bolţuri şi şaibe. Material de tip Velcro sau şnur şi capse Pentru modificările la spătarele pliabile. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 29. 3. Planuri de sesiune detaliate Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 30. Introducere O B IE C TI V E La finalul acestei sesiuni, participanţii: vor cunoaşte obiectivele programului de instruire; vor cunoaşte numele formatorilor şi al participanţilor; vor cunoaşte orarul de desfăşurare al programului de instruire; vor cunoaşte care sunt regulile ce trebuie respectate pe întreaga durată a programului de instruire. R E S U R S E Pentru sesiune: slide-uri PPT: Introducere; Manualul participantului; Manualul de exerciţii practice; un set complet de formulare - 1 set pentru fiecare participant; DVD: Furnizarea serviciilor de scaune rulante; DVD: Etapele furnizării serviciilor de scaune rulante; pentru fiecare participant - un exemplar din orarul de desfăşurare al programului de instruire; ecusoane pentru formatori şi pentru fiecare participant. C O N TE X T Adaptaţi conţinutul acestei sesiuni în aşa fel încât informaţiile să fie în concordanţă cu contextul în care vor lucra participanţii. Luaţi în considerare următoarele aspecte: includerea unei ceremonii de deschidere corespunzătoare contextului cultural; modificarea sau adaptarea capitolului „Prezentarea formatorilor şi a participanţilor” pentru a se potrivi cu cei prezenţi la curs; modificarea, adaptarea şi/sau completarea listei „Regulile programului de instruire şi aşteptări”; modificarea slide-ului cu rezumatul programului de instruire, dacă au intervenit schimbări. D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. P R E ZE N TA R E 1. Ceremonie de deschidere (dacă există) 2. Prezentarea formatorilor şi a participanţilor 3. Prezentarea programului de instruire 4. Orarul programului de instruire, Manualul participantului, Caietul de exerciţii practice şi formularele 5. Regulile programului de instruire şi aşteptările 15 15 10 10 10 Durata totală a sesiunii 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 31. 1. Ceremonia de deschidere (durată estimativă de 15 minute) Programul de instruire poate include o ceremonie de deschidere, în funcţie de contextul cultural şi de obiceiurile locale. 2. Prezentarea formatorilor şi a participanţilor (15 minute) Formatori: Vă rugăm să vă prezentaţi. Oferiţi câteva detalii despre activitatea şi experienţa pe care o aveţi în furnizarea de servicii de scaune rulante. Cereţi participanţilor să se prezinte, să îşi spună numele, organizaţia la care lucrează şi aşteptările pe care le au de la acest program de instruire. Oferiţi ecusoane, dacă participanţii nu le-au primit deja la înregistrare. 3. Prezentarea programului de instruire (10 minute) Explicaţi: Scopul acestui program de instruire este de a oferi fiecărui participant cunoştinţele şi abilităţile care îi vor ajuta să dobândească sau să îşi îmbunătăţească abilităţile de furnizare a unui scaun rulant manual corespunzător, a unei perne şi a suporturilor posturale pentru copii şi adulţi care necesită suport postural suplimentar în vederea menţinerii poziţiei aşezat: – evaluarea fizică; – prescrierea (selecţia) scaunului rulant, a pernei şi a dispozitivelor de suport postural (DSP-urilor); – pregătirea scaunului rulant cu modificările necesare/ cu dispozitivele de suport postural (DSP-uri); – probarea produsului (a scaunului rulant); – instruirea utilizatorului de scaun rulant; – întreţinerea, reparaţiile şi monitorizarea. Pregătiţi vizionarea materialului video: Furnizarea serviciilor de scaune rulante. Acest material video oferă o scurtă introducerea a programului de instruire pentru furnizarea serviciilor de scaune rulante în viziunea OMS. Prezentaţi materialul video. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 32. Explicaţi: Pachetul de instruire pentru furnizarea serviciilor de scaune rulante de nivel intermediar este împărţit în două secţiuni: A: Noţiuni fundamentale; B: Etapele furnizării serviciilor de scaune rulante. Explicaţi: Secţiunea dedicată noţiunilor fundamentale constă din două părţi: A.1: Utilizatorii de scaun rulant care au nevoie de suport postural suplimentar A.2: Copiii cu dizabilităţi Explicaţi: Drepturile omului se aplică tuturor persoanelor. Scopul CONUDPD (Convenţia Naţiunilor Unite privind Drepturile Persoanelor cu Dizabilităţi) este de a asigura recunoaşterea generală a faptului că aceste drepturi se aplică şi în cazul persoanelor cu dizabilităţi. Explicaţi: o Există 50 de articole diferite în cadrul CONUDPD. o Articolul 20 se referă la mobilitatea personală. Explicaţi: Furnizarea de servicii de scaune rulante de nivel intermediar este destinat adulţilor şi copiilor (fete, băieţi, femei şi bărbaţi) care, în vederea menţinerii poziţie aşezat) au nevoie de scaune rulante cu modificări sau de suport postural. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 33. Explicaţi: o După cum bine ştiu participanţii, furnizorul de servicii de scaune rulante lucrează împreună cu utilizatorii pentru a se asigura că fiecare primeşte un scaun rulant corespunzător. o Serviciile de scaune rulante sunt o componentă cheie în furnizarea scaunelor rulante. Citiţi definiţia scaunului rulant corespunzător. Explicaţi: o „Scaunul rulant corespunzător” fiecărui utilizator va fi mereu în concordaţă cu cerinţele sale individuale şi cu condiţiile specifice mediului în care trăieşte. o De asemenea, „scaunul rulant corespunzător” fiecărui utilizator va depinde întotdeauna de modul în care scaunul rulant este pe măsura utilizatorului şi de suportul postural oferit. Explicaţi: o Personalul furnizor de servicii de scaune rulante oferă acelor persoane care, în absenţa suportului postural suplimentar, nu pot menţine poziţia aşezat fără suport, cele mai adecvate scaune rulante disponibile, precum şi suportul postural corespunzător. o Personalul urmează cele opt etape ale furnizării de servicii de scaune rulante pentru a se asigura că utilizatorii de scaun rulant primesc un echipament de mobilitate corespunzător şi că beneficiază în cel mai înalt grad posibil de utilizarea acestuia. Întrebaţi: Care sunt cele opt etape ale furnizării serviciilor de scaune rulante? Confirmaţi toate răspunsurile corecte (nu este nevoie ca terminologia să fie exactă). Răspunsuri: o trimiterea şi programarea; o evaluarea; o prescrierea (selecţia); o finanţarea şi plasarea comenzii; o pregătirea produsului (a scaunului rulant); o probarea produsului (a scaunului rulant); o instruirea utilizatorului de scaun rulant; o întreţinerea, reparaţiile şi monitorizarea. Pregătiţi vizionarea materialului video: Etapele furnizării serviciilor de scaune rulante. Acest material video va prezenta cele opt etape ale furnizării de servicii de scaune rulante care au fost parcurse în programul de instruire anterior (nivel de bază). Cereţi participanţilor să vizioneze materialul video şi să noteze fiecare etapă a procesului de furnizare a serviciilor de scaune rulante. Prezentaţi materialul video. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 34. Explicaţi: o Rolul personalului furnizor de servicii de scaune rulante este acela de a oferi scaunele rulante, pernele şi suporturile posturale corespunzătoare persoanelor care necesită suport postural suplimentar pentru menţinerea poziţiei aşezat, parcurgând următoarele opt etape. Explicaţi: În cazul furnizării serviciilor de scaune rulante de nivel intermediar, anumite etape ale procesului de furnizare pot avea o durată mai mare sau trebuie efectuate de mai multe ori. Întrebaţi: Atunci când furnizaţi un scaun rulant unui utilizator care necesită suport postural suplimentar, care sunt acele etape care pot avea o durată mai mare sau pe care este posibil să fiţi nevoiţi să le repetaţi? Răspunsuri: o evaluarea poate dura mai mult; o pregătirea produsului (a scaunului rulant) poate dura mai mult; o probarea scaunului rulant poate dura mai mult şi poate fi necesară repetarea ei; o evaluarea poate continua în etapa de probare a scaunului rulant dacă soluţiile nu sunt clare încă de la prima programare; o instruirea utilizatorului de scaun rulant poate dura mai mult. Explicaţi: o Instruirea de nivel intermediar va completa cunoştinţele acumulate în modulul de instruire anterior. o Vor fi abordate: o Modalitatea de evaluare a unui utilizator de scaun rulant care necesită suport postural suplimentar pentru menţinerea poziţiei aşezat, în vederea identificării celei mai bune soluţii de poziţionare şi de mobilitatea. o Modalitatea de prescriere (selecţie), de pregătire şi probare a unui scaun rulant cu antrenare manuală , dotat cu o pernă şi dispozitive de suport postural corespunzătoare, tipurile de modificări sau elementele care pot fi adăugate şi care oferă suport postural suplimentar. o Instruirea utilizatorului de scau rulant- programul de instruire de nivel intermediar va introduce informaţii suplimentare sau abilităţi pe care utilizatorii de scaun rulant care au nevoie de dispozitive de suport postural (sau membrii familiei/însoţitorii acestora) trebuie să le cunoască pentru a putea folosi scaunul rulant în mod eficient şi în condiţii de siguranţă. De asemenea, participanţilor li se oferă oportunitatea de a exersa această etapă cu utilizatori de scaune rulante care au nevoie de suport postural suplimentar. o Monitorizarea - programul de instruire de nivel intermediar oferă o scurtă recapitulare a etapei de monitorizare şi va da participanţilor ocazia de a Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 35. exersa acest pas cu utilizatori de scaune rulante care necesită suport postural suplimentar. o În cadrul acestui program de instruire nu sunt abordate următoarele: etapa 1 – trimiterea şi programarea; etapa 4 – finanţarea şi plasarea comenzii; etapa 8, parţial – întreţinerea şi reparaţiile. Solicitaţi fiecărui participant să prezinte pe scurt care este rolul său în furnizarea serviciilor de scaune rulante. Rugaţi participanţii să menţioneze: o dacă au avut deja ocazia să furnizeze scaune rulante şi dispozitive de suport postural; o dacă adulţii şi copiii cu care lucrează necesită suport postural suplimentar pentru utilizarea scaunului rulant. Fiţi atenţi la prezentarea fiecărui participant şi adresaţi întrebări pentru clarificarea rolului lor în procesul de furnizare a serviciilor de scaune rulante. 4. Orarul de desfăşurare a programului de instruire, Manualul participantului, Caietul de exerciţii practice şi formularele (10 minute) Oferiţi fiecărui participant un exemplar din orarul de desfăşurare al programului de instruire. Explicaţi: o Programul de instruire va începe cu sesiuni teoretice/în sala de curs. o Urmează ca participanţii să exerseze anumite abilităţi care le-au fost predate în sesiunile teoretice cu utilizatori de scaune rulante care s-au oferit să asiste în mod voluntar. Oferiţi fiecărui participant un exemplar din Manualul participantului. Cereţi participanţilor să îşi scrie numele pe manual. Explicaţi faptul că pot nota orice informaţii suplimentare în acest manual. Oferiţi fiecărui participant un exemplar din Caietul de exerciţii practice. Cereţi participanţilor să îşi scrie numele pe caiet. Explicaţi faptul că vor folosi acest Caiet de exerciţii practice pe parcursul instruirii şi că trebui să-l aducă cu ei la fiecare sesiune. Oferiţi fiecărui participant un set complet de formulare. Explicaţi faptul că vor folosi aceste formulare pe parcursul instruirii şi că trebui să le aducă cu ei la fiecare sesiune. 5. Regulile programului de instruile şi aşteptările (10 minute) Explicaţi următoarele, în funcţie de context: o locul unde sunt situate toaletele; o cine este persoana responsabilă cu aspectele legate de cazare; o cine este persoana responsabilă de aspectele legate de transportul participanţilor (fără a intra în detalii); o care sunt paşii în cazul în care apare o urgenţă. Explicaţi care sunt aşteptările cărora trebuie să le răspundă participanţii la programul de instruire, în funcţie de context: o fiecare sesiune va începe la ora stabilită – participanţii trebuie să se asigure că sunt punctuali atât la începutul fiecărei zile de instruire, cât şi după fiecare pauză; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 36. o în cazul în care nu sunt siguri de anumite aspecte, participanţii trebuie să pună întrebări; o fiecare utilizator de scaun rulant va fi tratat în mod egal şi cu acelaşi respect; o telefoanele mobile vor fi setate pe modulul silenţios sau vor fi închise; o toată lumea ar trebui să se simtă bine pe întreaga durată a cursului de instruire! Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 37. A: Noţiunile fundamentale Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 38. A.1: Utilizatorii de scaune rulante care au nevoie de suport postural suplimentar D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. Pregătiţi două sau patru spaţii pentru activităţile de grup (în funcţie de numărul de participanţi), în sala de curs sau în apropierea acesteia: o spaţiul 1: poziţionaţi un scaun şi o minge; o spaţiul 2: poziţionaţi un scaun, un pat de evaluare, recipient cu apă potabilă şi pahare de unică folosinţă. P R E ZE N TA R E 1. Introducere 2. Utilizatori de scaune rulante care necesită suport postural suplimentar 3. Când este necesar suportul postural suplimentar? 4. Ce aşteptări au utilizatorii de scaun rulant? 5. Recapitulare puncte cheie. 2 6 35 15 2 Durata totală a sesiunii 60 O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să enumere cauzele fizice şi/sau funcţionale care au ca rezultat necesitatea utilizării de suport postural suplimentar; să enumere patru beneficii ale suportului postural suplimentar; să descrie potenţiale cauze ale refuzului de a folosi scaunul rulant cu suport postural suplimentar şi modalităţi prin care ne putem asigura de faptul că utilizatorul îl va folosi. R E S U R S E Pentru sesiune: : A.1: Utilizatorii de scaune rulante care au nevoie de suport postural suplimentar; Manualul participantului; Caietul de exerciţii practice; DVD: Beneficiile utilizării unui scaun rulant corespunzător; DVD: Persoane care utilizează dispozitive de suport postural; pahare de unică folosinţă şi un recipient cu apă potabilă, scaune, pat de evaluare şi minge. C U N O Ş TI N ŢE D O B Â N D IT E A N TE R IO R Cunoştinţe dobândite anterior: înţelegerea faptului că există diferenţe în modalitatea de furnizare a serviciilor de scaune rulante pentru persoanele care pot menţine poziţia aşezat fără suport postural şi cele care nu pot menţine poziţia aşezat în absenţa suportului postural suplimentar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 39. 1. Introducere (2 minute) Explicaţi: o Fiecare scaun rulant care se i potriveşte în mod corespunzător utilizatorului oferă un anumit grad de suport postural. Spătarul, perna, suporturile de picioare şi suporturile de braţe furnizează suport postural atunci când sunt ajustate în aşa fel încât să fie pe măsura utilizatorului de scaun rulant. o Cu toate acestea, există un număr mare de copiii şi adulţi care au nevoie de suport postural suplimentar. Acesta poate fi oferit cu ajutorul unui dispozitiv de suport postural, care reprezintă o completare sau o modificare o scaunului rulant, prescris pentru a rezolva problema suportului postural suplimentar. În acest manual, abrevierea pentru dispozitivul de suport postural este „DSP”. În această sesiune vom discuta despre: o beneficiile utilizării unui scaun rulant corespunzător; o cine sunt utilizatorii care au nevoie de suport postural suplimentar; o când este nevoie de suport postural suplimentar; o ce fel de scaune rulante îşi doresc utilizatorii. Aceste informaţii sunt importante, deoarece astfel participanţii vor avea abilitatea de a explica în mod clar utilizatorilor de scaun rulant, familiilor şi însoţitorilor lor, precum şi altor persoane, beneficiile suportului postural suplimentar. 2. Utilizatorii de scaune rulante care au nevoie de suport postural suplimentar (6 minute) Pregătiţi vizionarea materialului video: Beneficiile utilizării unui scaun rulant corespunzător; Acest material video prezintă mai mulţi utilizatori de scaun rulant care desfăşoară diverse activităţi. Majoritatea au un suport postural suplimentar adăugat scaunului lor rulant. Acesta poate fi observat cu uşurinţă sau poate fi încorporat pernei/spătarului. Cereţi participanţilor să observe cu atenţie activităţile desfăşurate; precum şi diferitele suporturi posturale suplimentare. Luaţi în considerare faptul că scaunele rulante şi suporturile sunt diferite în cazul fiecărui utilizator de scaun rulant. Prezentaţi materialul video. Verificaţi dacă există întrebări. Întrebaţi: Care sunt activităţile desfăşurate de utilizatorii de scaun rulant prezentaţi în materialul video? Răspunsuri: o gătitul; o dansul; o mersul la şcoală/activităţi de meşteşugărie; o aruncarea unei mingi; o ridicarea de greutăţi/antrenament; o plimbatul câinelui; o utilizarea unui calculator; o activităţi la locul de muncă; o coafura. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 40. 3. Când este nevoie de suport postural suplimentar? (35 de minute) Întrebaţi: De ce există utilizatori de scaun rulant copii sau adulţi care ai nevoie de suport postural suplimentar? Gândiţi-vă la diferitele cauze de ordin fizic sau funcţional care determină copiii sau adulţii utilizatori de scaun rulant să apeleze la furnizorii de servicii de scaune rulante pentru un echipament de mobilitate şi suport postural suplimentar. Încurajaţi participanţii să răspundă. Răspunsuri: Cauze de ordin fizic: o incapacitatea menţinerii poziţiei aşezat; o echilibrul precar; o instabilitatea; o mişcările necontrolate sau spasmele; o apariţia escarelor; o articulaţiile rigide; o rigiditatea musculară; o tonusul scăzut; o oboseala; o durerea sau disconfortul. Cauze de ordin funcţional: o dificultatea de a desfăşura anumite activităţi în absenţa suportului postural suplimentar; o dificultăţi în ceea ce priveşte consumul de alimente sau lichide, în mod independent şi în condiţii de siguranţă; o senzaţia de oboseală care se instalează rapid ; o familia are dificultăţi în ceea ce priveşte transportarea/furnizarea de sport postural suplimentar. Explicaţi: o Utilizatorii au nevoie de suport postural suplimentar din mai multe motive. o Mai jos sunt prezentate patru modalităţi foarte importante prin care suportul postural suplimentar aduce beneficii utilizatorului de scaun rulant: o Suportul postural suplimentar: 1) îmbunătăţeşte echilibrul, postura şi stabilitatea; 2) îmbunătăţeşte nivelul de confort pentru creşterea duratei de timp petrecute în scaunul rulant; 3) ajuta la prevenirea apariţiei escarelor; 4) ajuta la încetinirea sau prevenirea apariţiei problemelor posturale. Explicaţi: o Suportul postural corespunzător poate ajuta şi la creşterea nivelului de funcţionalitate şi la îmbunătăţirea stimei de sine a utilizatorului de scaun rulant. o În general, suportul postural corespunzător are ca rezultat îmbunătăţirea calităţii vieţii utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 41. Explicaţi: Unul dintre cele mai importante beneficii ale suportului postural este îmbunătăţirea echilibrului, posturii şi a nivelului de stabilitate. Întrebaţi: Care sunt acele activităţi pentru care este nevoie de un echilibru bun, o postură corectă şi stabilitate? Încurajaţi participanţii să răspundă. Răspunsuri: o scrisul; o efectuarea propulsiei scaunului rulant; o gătitul; o consumul de lichide şi alimente; o comunicarea. Explicaţi: Vom încerca acum să desfăşurăm două activităţi (aruncarea unei mingi şi consumul de lichide), care îi vor ajuta pe participanţi să simtă ce presupune efectuarea acestor activităţi în condiţii de echilibru, postură şi stabilitate bune; respectiv precare sau incorecte. Activitate cu grupe mici: Grupe: Împărţiţi participanţii în grupe de câte 3 participanţi. Instrucţiuni: Cereţi participanţilor să lucreze cu Caietul de exerciţii practice (A.1: Utilizatorii de scaune rulante care au nevoie de suport postural suplimentar). Explicaţi: Există două activităţi - aruncarea unei mingi şi consumul de lichide. Explicaţi faptul că fiecare grup ar trebui să desfăşoară această activitate în spaţiile amenajate în acest scop (indicaţi unde se află acestea). Cereţi participanţilor să noteze răspunsurile la întrebările din caietul de exerciţii practice. Explicaţi faptul că participanţii trebuie să finalizeze activităţile în 10 minute. Monitorizare: Monitorizaţi cu atenţie activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Reamintiţi participanţilor să ia în considerare întrebările din caietul de exerciţii: o Cât de uşoare de realizat sunt activităţile de aruncare şi prindere a mingii? o Creşte nivelul de dificultate la etapele 2 şi 3? o În ce mod influenţează poziţiile şi posturile diferite uşurinţa cu care se consumă lichide? După ce fiecare grup a terminat una dinte activităţi, schimbaţi activitatea desfăşurată. Ritmul trebuie să fie unul mai alert, astfel încât fiecare grupă să desfăşoare fiecare dintre activităţile programate în durata de timp alocată acestui exerciţiu. Oferiţi asistenţă participanţilor, dacă acest lucru este necesar. Timp: Durata exerciţiului este de 10 minute pentru activitate şi 10 minute pentru feedback. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 42. Feedback: 1. Aruncarea unei mingi Întrebaţi: A devenit mai dificilă aruncarea şi prinderea mingii odată cu schimbarea nivelului de stabilitate (cu scaunul înclinat şi apoi mişcat)? Încurajaţi participanţii să răspundă (aruncarea mingii ar trebui să fie mai dificilă şi să necesite mai multă concentrare şi efort). Explicaţi: Sprijinul postural ajută la creşterea stabilităţii prin suportul oferit la nivelul bazinului şi în orice altă zonă în care acesta este necesar. Datorită creşterii nivelului de stabilitate, va fi mai uşoară efectuarea multor activităţi – inclusiv efectuarea propulsiei scaunului rulant, scrisul, gătitul, chiar şi comunicarea verbală. 2. Consumul de lichide: Întrebaţi: o Cum v-aţi simţit încercând să consumaţi lichide cu corpul aflat în diferite poziţii de şedere? o Aţi avut senzaţia că vă veţi îneca sau că apa pătrunde pe căile aeriene? Încurajaţi participanţii să răspundă (consumul de lichide cu corpul aflat în diferite posturi poate crea disconfort şi chiar teamă). Explicaţi: o În cazul persoanelor care prezintă dificultăţi în menţinerea poziţiwi aşezat – consumul de alimente şi lichide poate provoca disconfort, uneori chiar teamă şi, frecvent, poate fi periculos. o Atunci când persoanele au dificultăţi de deglutiţie, există riscul ca bucăţi mici de alimente sau lichide să ajungă în plămâni. Acest lucru poate cauza infecţii pulmonare,fiidn un real pericol pentru starea de sănătate. Suportul postural suplimentar într-un scaun rulant contribuie mult le menţinerea poziţiei aşezat în timpul consumului de alimente şi lichide. o Suportul postural corespunzător trebuie să îmbunătăţească controlul poziţiei capului, ceea ce va facilita un proces de deglutiţie în condiţii de siguranţă. Notă: Îmbunătăţirea suportului postural este doar una din soluţiile în cazul persoanelor cu probleme de deglutiţie. Se recomandă ca acestea să apeleze la persoane specializate, (pediatru, logoped sau asistent social) care au cunoştinţele şi pregătirea necesară pentru gestionarea problemelor de deglutiţie. Explicaţi: o un alt avantaj al suportului postural suplimentar este prevenirea apariţiei escarelor. o factorii de risc ce duc la apariţia escarelor au fost sunt prezentaţi în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Întrebaţi: Care sunt principalii factori de risc care pot duce la apariţia escarelor (factorii care cresc probabilitatea apariţiei escarelor în cazul unui utilizator de scaun rulant?) Notaţi răspunsurile corecte Răspunsuri: o lipsa de sensibilitate (sensibilitate o postura necorespunzătoare; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 43. diminuată); o imobilitatea; o umezeală cauzată de transpiraţie, lichide sau incontinenţă; o nutriţie necorespunzătoare sau consum insuficient de apă; o înaintarea în vârstă; o greutatea: subponderabilitatea sau supraponderabilitatea; o traumatismele, loviturile; o căldura/febra; o înţepăturile provocate de insecte. Explicaţi: o Iată lista de factori de risc prezentaţi în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. o lipsa de sensibilitate (sensibilitatea diminuată)’ este cu litere aldine – deoarece orice utilizator de scaun rulant care prezintă sensibilitate redusă este expus în mod automat riscului apariţiei escarelor. o Un utilizator de scaun rulant la care sunt prezenţi trei sau mai mulţi factori de risc este, de asemenea, expus riscului apariţiei escarelor. Explicaţi: o Un număr mare de utilizatori de scaun rulant care necesită suport postural suplimentar sunt imobili şi au probabil au o postură necorespunzătoare. o Imbilitatea şi postura necorespunzătoare reprezintă doi factori de risc care pot duce la apariţia escarelor. o Acest lucru înseamnă că mulţi utilzatori de scaun rulant care necesită suport postural suplimentar sunt expuşi la riscului apariţiei escarelor. o Îmbunătăţirea posturii va contribui la reducerea acestui risc. Întrebaţi: De ce postura necorespunzătoare reprezintă un factorb de risc care poate duce la apariţia escarelor? (cum poate postura necorespunzătoare contribui la apariţia unei escare?) Răspunsuri: Postura necorespunzătoare poate cauza: o Alunecarea în scaunul rulant - care poate cauza forţe de „forfecare” o Distribuţia inegală a greutăţii, care cauzează creşterea nivelului de presiune într-o anumită zonă (de exemplu, nivel de presiune mai mare sub una din părţile oaselor şezutului), ceea ce poate determina rapid apariţia escarelor. Explicaţi: Evaluarea riscului apariţiei escarelor, prescrierea soluţiilor care ajută la prevenirea apariţiei escarelor şi instruirea utilizatorilor de scaune rulante a unor informaţii cu privire la modul de prevenire a apariţiei escarelor sunt o componentă importantă o furnizării de scaune rulante la nivel intermediar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 44. 4. Care sunt aşteptările utilizatorilor scaunelor rulante? (15 minute) Explicaţi: o Am discutat despre diversele modalităţi prin care suportul postural suplimentar este benefic utilizatorilor de scaune rulante. o Totuşi, uneori, utilizatorii de scaun rulant se obişnuiesc greu cu un scaun rulant dotat cu suport postural suplimentar. Câteodată, aceştia resping scaunul rulant. Întrebaţi: Aţi avut vreodată oportunitatea să furnizaţi un scaun rulant cu suport postural suplimentar, iar utilizatorul să nu îl folosească? Care credeţi că au fost cauzele? Încurajaţi participanţii să răspundă. În timp ce vă sunt prezentate argumente, întrebaţi participanţii care sunt modalităţile de a evita această problemă. Prezentaţi câteva exemple, dacă este necesar. Răspunsuri: Cauzele care determină un utilizator să refuze utilizarea unui scaun rulant cu suport postural suplimentar: Cum poate fi prevenită această situaţie: o Scaunul rulant sau suportul postural suplimentar provoacă disconfort. o Implicaţi cât mai mult posibil utilizatorul în procesul de selecţie. o Încercaţi să programaţi o testare a echipamentului înainte de finalizarea pregătirii sale. Dacă există probleme, acestea pot fi rezolvate ulterior acestei probări. o Postura utilizatorului se modifică; scaunul rulant / suportul postural suplimentar nu mai sunt confortabile. o Printr-o monitorizare desfăşurată la intervale regulate ne putem asigura că echipamentul de mobilitate este în continuare pe măsură şi că este confortabil. o Utilizatorul de scaun rulant consideră că nu poate suportul postural suplimentar îl împiedică în desfășurarea activităților. o Acest lucru poate constitui o problemă. Două dintre cele mai des întâlnite cauze sunt: o Suportul postural suplimentar poate să nu fie practic şi să îngreuneze desfășurarea activităților. De exemplu, suportul postural poate face mai dificilă realizarea transferului în și din scaunul rulant. o Scaunul rulant/suportul postural suplimentar furnizează un grad de suport mult prea ridicat (îndepărtând prea mult utilizatorul de postura obişnuită), astfel utilizatorul resimte disconfort / are un echilibru precar în noua o Înainte de finalizarea echipamentului, verificaţi dacă utilizatorul de scaun rulant poate desfășura activitățile pe care le dorește pe care le doreşte (de exemplu, efectuarea transferului). o Evitaţi schimbarea semnificativă a posturii unei persoane care a menținut o anumită poziţie o perioadă mult prea îndelungată. Încercaţi să efectuați schimbările treptat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 45. postură; o Utilizatorului de scaun rulant nu îi place aspectul suportului postural suplimentar. o Încercaţi să vă asiguraţi că scaunele rulante şi suporturile posturale suplimentare au dimensiuni cât mai mici posibil şi că au un aspect agreabil. Răspunsuri: Cauzele care determină un utilizator să refuze utilizarea unui scaun rulant cu suport postural suplimentar: Cum poate fi prevenită această situaţie: o Utilizatorul de scaun rulant (sau familia sa) consideră că echipamentul de mobilitate îl va determina să fie mai „leneş” sau îi va scădea nivelul de forță. o Explicaţi care sunt beneficiile suportului postural suplimentar. o Reasiguraţi utilizatorii de scaun rulant (şi famiiliile lor) de faptul că, atunci când sunt prescrise în mod corect, suporturile posturale suplimentare nu scad nivelul de forță. o Personalul furnizor de servicii de scaune rulante poate explica faptul că, prin menținerea unei poziţii necorespunzătoare, musculatura şi articulaţiile nu respectă alinierea corectă. Acest lucru cauzează tensiune la nivelul musculaturii, întinderea acesteia și scade nivelul de forță. Postura corectă menţine alinierea adecvată a părților corpului. Acest lucru are ca efect menţinerea în poziţie corectă a muşchilor şi a articulaţiilor, pentru un nivel de funcționalitate corespunzător. o Mediul în care trăiește (domiciliul, zona din proximitate sau comunitatea) este inaccesibil. o Personalul furnizor de servicii de scaune rulante oferă informaţii utilizatorului şi familiei sale despre modul în care domiciliul și mediul în care trăiește utilizatorul pot deveni mai accesibile. o Utilizatorul de scaun rulant trebuie îndrumat către orice organizaţie care îi poate furniza asistență în ceea ce privește creșterea gradului de acces - de exemplu, către programe/personal de reabilitare bazată pe comunitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 46. Explicaţi: În concluzie - scaunul rulant şi suporturile posturale suplimentare trebuie să îndeplinească următoarele condiții: o să fie practice şi uşor de utilizat; o să nu cauzeze disconfort; o să nu îngreuneze desfășurarea activităților; o să aibă un aspect agreabil și „să nu iasă prea mult în evidență”. Explicaţi: Cele mai bune metode de a ne asigura că suportul postural suplimentar va fi folosit de către utilizator: o implicarea, din toate punctele de vedere, a utilizatorului de scaun rulant în etapele de evaluare, prescriere şi probare a produsului (a scaunului rulant); o informarea utilizatorului de scaun rulant, astfel încât acesta să înţeleagă motivele pentru care suportul postural suplimentar constituie un beneficiu o respectarea faptului că utilizatorul de scaun rulant este întotdeauna cel care ia decizia finală. Pregătiţi vizionarea materialului video: Persoane care utilizează dispozitive de suport postural. Acest material video prezintă câţiva dintre utilizatorii de scaunei rulantei din materialul video anterior. Utilizatorii de scaun rulant şi membrii ai familiilor lor discută despre motivele pentru care scaunul rulant cu suport postural suplimentar corespunzător este folositor în cazul lor. Prezentaţi materialul video. Verificaţi dacă există întrebări. Întrebaţi: Care sunt cauzele menționate de utilizatorii de scaun rulant (sau de către însoțitori) cu privire la beneficiile utilizării de suport postural? Încurajaţi participanţii să răspundă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 47. Răspunsuri: o Tatăl lui Hussein spune că datorită suportului postural, scaunul rulant se potrivește într- o mai mare măsură corpului lui Hussein. Nivelul de confort este mai ridicat şi nu mai are leziuni cauzate de gradul scăzut de suport furnizat de scaunu rulant. o Chaeli spune că suportul pentru trunchi a ajutat-o să aibă un trunchi mai puternic. o Michelle (mama lui Shelley) consideră că scaunul rulant al lui Michelle îi oferă lui Shelly o mai bună calitate a vieţii; deoarece ea poate respira şi consuma alimente în condiții de siguranţă, iar postura ei este bine susţinută. o Mama lui Ruan spune că scaunul rulant îl ajută pe fiul ei să consume mai ușor alimente. o Basila consideră că scaunul rulant o ajută să lucreze. Cereţi participanţilor să consulte lista de verificare din Manualul participantului. Lista de verificare ajută personalul furnizor de servicii de scaune rulante să se asigure că suportul postural suplimentar prescris se va dovedi alegerea corectă pentru fiecare utilizator de scaun rulant. 5. Recapitulare puncte cheie (2 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 48. A.2: Copiii cu dizabilităţi O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să descrie cel puţin cinci caracteristici ale unui scaun rulant care sunt importante în cazul utilizatorilor copii; să prezinte cel puţin două motive care fac ca intervenția timpurie să fie importantă în cazul utilizatorilor copii; să prezinte şapte metode de lucru cu utilizatorii copii, care să se desfășoare în condiții de siguranţa şi care dau doavdă de respect faţă de aceștia. R E S U R S E Pentru sesiune: prezentări PPT: A.2: Copiii cu dizabilităţi; Manualul participantului; afiş: „Copiii şi scaunele rulante”; afiş: „Diferitele poziţii”; Formular de trimitere – nivel intermediar. C O N TE X T Adaptaţi conținutul acestei sesiuni în așa fel încât informațiile să se potrivească cu contextul în care vor lucra participanţii. Luați în considerare următoarele aspecte: Dacă organizaţia gazdă/care organizează instruirea sau organizaţiile unde lucrează participanţii au o politică în ceea ce privește lucru în condiții de siguranță cu utilizatorii copii. În anumite cazuri este important ca fiecare participant să primească şi să semneze un exemplar din politica privind lucrul cu utilizatorii copii, înainte de începerea sesiunilor practice care îi implică pe aceștia. D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. Utilizați afișul „Copiii şi scaunele rulante”. Utilizați afişul „Diferitele poziţii”. P R E ZE N TA R E 1. Introducere 2. Scaune rulante care răspund cernțelor utilizatorilor copii 3. Diferitele poziţii 4. Importanţa intervenției timpurii în cazul utilizatorilor copii 5. Lucrul cu utilizatorii copii 6. Recapitulare puncte cheie 2 10 15 10 20 3 Durata totală a sesiunii 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 49. 1. Introducere (2 minute) Explicaţi: Un număr mare de copii care au nevoie de scaun rulant au nevoie, totodată, de suport postural suplimentar. Din acest motiv, când ne referim la programul de instruire de nivel intermediar, trebuie să ne gândim la nevoile copiilor. În această sesiune vom discuta despre: o modul în care vieţile şi cerințele specifice utilizatorilor copii sunt diferite de cele ale adulţilor şi felul în care un scaun rulant corespunzător răspunde nevoile lor specifice; o modul în careaceste diferenţe afectează metodele de lucru ale personalului furnizor de servicii de scaune rulante cu copiii cu dizabilităţi, precum şi alegerea scaunului rulant şi a suportului postural suplimentar; o importanţa intervenției timpurii; o metode de lucru cu utilizatorii copiii, astfel încât dreptuile lor să fie protejate și respectate. 2. Scaune rulante care răspund cerințelor utilizatorilor copii (10 minute) Explicaţi: Stilul de viață al copiilor de vârstă mică diferă de cel al adulţilor. Copiii se află în grija adulţilor și iau decizii cu ajutorul acelor adulţi, în funcție de vârsta lor. Activitățile desfășurate de copii se schimbă mai frecvent, se află adeseori în mișcare şi se joacă o mare parte din timp. Un aspect și mai important îl constituie faptul că aceștia trebuie să meargă la şcoală. Scaunele rulante folosite de utilizatorii copii trebuie să îi ajute pe aceștia să participe la activităţile cotidiene tipice ale copiilor. Întrebaţi: Care sunt acele caracteristici ale scaunului rulant care sunt importante pentru copii? Încurajaţi participanţii să răspundă. Răspunsuri: o Dacă propulsia este efectuată de către copii, scaunul rulant trebuie: o să fie pe măsura utilizatorului copil, în așa fel încât acesta să aibă acces la inelele de antrenare; o să fie suficient de uşor pentru a putea fi controlat, în special la urcarea sau coborârea pantelor. o Pe cât posibil, scaunul rulant nu ar trebui să „iasă în evidență” mai mult decât utilizatorul copil. o Mânerele extinse ajută membrii familiei/însoțitorii să efectueze propulsia scaunului rulant fără a se apleca. o Se recomandă un scaun rulant care poate trece fără dificultăți peste suprafeţe denivelate şi moi, cum ar fi iarba sau nisipul, astfel încât utilizatorii copiii și prietenii lor să se poată juca împreună. o Un scaun rulant trebuie să ajute utilizatorul copil să se deplaseze mai ușor la școală: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 50. o dacă majoritatea copiilor din comunitate merg pe jos la școală, gândiți-vă dacă scaunul rulant poate fi folosit pe acele trasee. Utilizatorul copil are nevoie de un scaun rulant care este adecvat deplasării pe teren accidentat? o în cazul în care utilizatorul copil se deplasează la școală cu un mijloc de transport (de exemplu, mașină, autobuz, taxi), gândiți-vă la modul în care scaunul rulant va fi transportat. o Scaunul rulant are rolul de a facilita deplasarea la școală. El trebuie să permită utilizatorului copil să se poziționeze la pupitru sau să fie dotat cu o măsuță care să constituie suprafața de lucru. Rezumat: o În mod ideal, scaunele rulante ale utilizatorilor copii trebuie: o să le permită acestora să efectueze propulsia în mod independent (dacă au această capacitate); o să aibă mânere pentru a permite adulților să ofere asistență; o să se poată deplasa pe suprafețe accidentate sau moi, cum ar fi iarba sau nisipul; o să faciliteze deplasarea la școală a acestora; o să aibă un aspect plăcut, din punct de vedere al formei, mărimii și al culorilor; o să faciliteze participarea la cursuri. 3. Diverse posturi (15 minute) Explicaţi: o De obicei, copiii petrec mult timp în poziția așezat. În cazul lor este firească schimbarea activității și, implicit, a poziției, de multe ori pe parcursul zilei. o Acest lucru înseamnă că, deși scaunul rulant este important, utilizatorii copii nu ar trebui să petreacă întreaga zi în scaunul rulant. o Personalul furnizor de servicii de scaune rulante trebuie să se gândească și la alte poziții pe care copiii cu dizabilități le pot adopta în timpul zilei. o Acest lucru este important în special în cazul în care mobilitatea este foarte limitată, dacă utilizatorul copil are tendința de a avea permanent aceeași postură și dacă nu își poate schimba poziția. Poziția așezat Explicaţi: La fel ca în timpul utilizării scaunului rulant, copiii care au nevoie de suport postural suplimentar pentru menținerea poziţiei așezat, pot beneficia de acesta în diverse moduri. De exemplu: o Așezat, având între genunchi și sub bazin un rulou sau o pătură strâns rulată o Așezat, sprijinit de un membru al familiei/însoțitor. În imagine vedem o mamă care își sprijină copilul cu dizabilități cu ajutorul picioarelor, pentru ca acesta să Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 51. poată menține poziția așezat și să mănânce un biscuit, în timp ce ea ține în brațe copilul ei mai mic. o Cu ajutorul unui scaun de poziționare, cu suprafața de ședere situată aproape de sol: o Un astfel de scaun este mai puțin costisitor decât un sistem de poziționare și poate fi o bună opțiune în cazul copiilor cu vârste mici. Poziția stând Explicaţi: Poziția stând este o altă poziţie importantă pentru copii. Explicaţi: o Poziția stând este, în egală măsură, un element esențial în dezvoltarea oricărui copil. o Această poziție contribuie la formarea articulațiilor șoldului și a curburilor fiziologice ale trunchiului. o În cazul oricărei persoane care stă în poziția așezat perioade îndelungate, există pericolul apariției unei anumit rigidități a șoldurilor și a genunchilor. Poziția stând întinde musculatura la nivelul șoldurilor, genunchilor și gleznelor și ajută la prevenirea instalării rigidității. Explicaţi: Atunci când un copil nu poate menține această poziție fără sprijin, poate fi necesară utilizarea unui verticalizator. Pentru a prescrie un astfel de dispozitiv, personalul furnizor de servicii de scaune rulante trebuie să înțeleagă foarte bine ce presupune această poziție și diversele metode prin care putem oferi suport pentru menținerea acesteia. Cu toate acestea, atunci când trebuie să furnizați un verticalizator, verificați întotdeauna că nu se exercită presiune directă asupra rotulei genunchiului. Cel mai bun loc pentru susținerea piciorului și prevenirea flexiei genunchilor este situat chiar sub rotulă, pe tibie. Explicaţi: o Atunci când se furnizează un verticalizator unui copil sub vârsta de cinci ani, trebuie vute în vedere câteva aspecte esențiale: – membrele inferioare trebuie să fie depărtate, iar între tălpi trebuie să existe o distanță care să fie cel puțin echivalentul lățimii șoldurilor; – picioarele și genunchii trebuie să fie orientați ușor către exterior; – șoldurile și genunchii ușor flectați; – în cazul copil de vârstă mică, nu forțați niciodată extensia completă la nivelul genunchilor și a articulației șoldurilor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 52. Explicaţi: Atunci când se folosește un verticalizator, personalul furnizor de servicii de scaune rulante trebuie să informeze membrii familiei/însoțitorii cu privire la durata de timp zilnică de folosire a dispozitivului. Iată câteva sugestii: – în faza inițială, durata zilnică este de 5-10 minute; – durata de folosire a cadrului pentru menținerea poziției stând de către utilizatorul copil nu trebuie să depășească niciodată o oră; – furnizați o măsuță sau o suprafață de lucru și încurajați membrii familiei/însoțitoriisă identifice o activitate distractivă, pe care copilul să o desfășoare în timp ce folosește verticalizatorul. Întrebaţi: Sunt disponibile verticalizatoarele în zonele unde îți desfășoară activitatea participanții?. Încurajaţi participanţii să răspundă. Poziția de decubit Explicaţi: Poziția de decubit are și ea un rol semnificativ. Pentru copii, această poziție este firească atunci când se joacă. Explicaţi: o Un copil cu o dizabilitate fizică poate avea nevoie de un anumit suport pentru o poziție de decubit confortabilă, pe podea: o în această imagine, copilul este susţinut în partea anterioară a trunchiului, pentru a putea menține poziția decubit. o Se recomandă ca în cazul copiilor sub vârsta de cinci ani, atunci când ei se află în poziția de decubit, să plasăm un rulou sub trunchi, astfel încât șoldurile să fie ușor flectate. Întrebaţi: Care sunt materialele care pot folosite de către membrii familiei/însoțitori pentru a susţine un copil care se joacă pe podea? Răspunsuri: o pături; o burete/spumă; o prosoape; o perne. Explicaţi: o În această imagine, copilul se află în poziția de decubit lateral, cu suport. o Copiii petrec mult timp dormind. Dacă postura copilului în timpul somnului este aceeași de fiecare dată, aceasta poate deveni fixă sau rigidă. o Personalul furnizor de servicii de scaune rulante trebuie să ofere sfaturi membrilor familiei/însoțitorilor cu privire la diferitele posturi pe care copilul le poate adopta în timpul somnului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 53. 4. Importanța intervenției timpurii în cazul copiilor (10 minute) Explicaţi: Să discutăm acum despre cum şi când trebuie să facem recomandarea ca un copil să fie direcționat către un furnizor de servicii de scaune rulante. Întrebaţi: Din experienţa participanţilor, copii ajung la un furnizor de servicii de scaune rulante la o vârstă foarte mică ori părinţii/persoanele care pot face această trimitere așteaptă până când copilul devine prea greu pentru a fi transportat în brațe? Încurajaţi participanţii să răspundă. Întrebaţi: De ce unii părinţi sunt refractari la ideea de a duce copiii de vârstă mică la furnizorul de servicii de scaune rulante pentru o evaluare? Încurajaţi participanţii să răspundă. Răspunsuri: părinţii speră că afecțiunea poate fi vindecată și copilul va începe să meargă; părinţii consideră că dacă vor oferi copilului un scaun rulant, acesta nu va mai încerca să meargă; cât timp copiii sunt tineri şi au o greutate mică, le este mai uşor părinților să îi transporte în braţe decât să folosească un scaun rulant pe teren accidentat şi în medii inaccesibile; părinţii nu au suficiente fonduri pentru a plăti un scaun rulant şi amână până când devine prea dificil să mai transporte copilul în brațe. familia are un sentiment de vinovăţie sau de teamă cu privire la modul în care cei din jur se vor raporta la dizabilitatea copilului. Explicaţi: Personalul furnizor de servicii de scaune rulante poate contribui la instruirea părinților și a persoanelor implicate în trimiterea utilizatorilor către centrele de acest tip, informându-i cu privire la importanța intervenției timpurii. Mai jos sunt câteva motive pentru care se recomandă intervenția timpurie, în detrimentul amânării: – În cazul copiilor care prezintă dificultăți în menținerea poziției așezat, în lipsa sprijinului adecvat, pot apărea probleme posturale. Dacă trimiterea se face prea târziu, anumite probleme posturale pot deveni fixe(2). Acest lucru poate face dificilă adoptarea unei poziții de ședere confortabile, chiar și cu suport. – În absența poziției așezat și a mobilității, dezvoltarea copiilor poate fi întârziată(3,3). – În cazul copiilor care au într-o anumită măsură abilitatea de a merge, folosirea unui scaun rulant le poate ușura viața și le permite desfășurarea mai multor activități pe parcursul zilei( Este important să le explicați părinților și surselor care îi pot trimite spre furnizorii de servicii specializate că, în mod obișnuit, un scaun rulant nu va descuraja copilul să meargă. Există o probabilitate mai mare ca un scaun rulant cu suport postural adecvat, furnizat cât mai devreme, va avea un efect benefic asupra copilului. 2 Organizația Mondială a Sănătății. (1996). Promovarea dezvoltării sugarilor și a copiilor mici diagnosticați cu spina bifida și hidrocefalie. Preluat de la http://whqlibdoc.who.int/hq/1996/WHO_RHB_96.5.pdf 3 Campania privind distrofia musculară. (2011). Furnizarea de scaune rulante copiilor și adulților cu distrofie musculară și alte afecțuni neuromusculare: Ghid de bune practici. Preluat de la http://www.muscular-dystrophy.org/ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 54. Întrebaţi: Care este vârstă la care, în mod tipic, copiii fără dizabilităţi reușesc: o să mențină poziţia aşezat, independent, fără suport? Încurajaţi participanţii să răspundă. o să se ridice pentru a sta în picioare? Încurajaţi participanţii să răspundă. o să meargă, fără asistență? Încurajaţi participanţii să răspundă. Răspunsuri: o Majoritatea copiilor: reușesc să mențină poziţia aşezat, fără asistență - perioada 6 - 8 luni; reușesc să se ridice pentru poziția stând – perioada 8 - 10 luni; reușesc să mențină poziția stând fără sprijin şi pot merge, cu asistență – perioada 10 - 12 luni; să meargă, fără asistență – perioada 12 - 18 luni. Explicaţi: Acestea sunt etape cheie în dezvoltarea copiilor, pe care „sursele” de trimitere le pot identifica. Explicaţi: Furnizorii de servicii de scaune rulante trebuie să încurajeze acele reţele de persoane care pot face acest tip de trimiteri să acționeze în cazurile în care copiii: o copiii au dificultăți în a menține poziția așezat sau în a se ridica pentru poziția stând – înainte de vârsta de 1 an sau o atunci când copilul nu poate merge fără asistență - înainte de vârsta de 2 ani. Acolo unde există un program de screening pentru intervenția timpurie (de exemplu, acolo unde personalul de servicii medicale din comunitate este instruit în ceea ce privește monitorizarea copiilor în vederea identificării nevoii de intervenție timpurie), furnizorii de servicii de scaune rulante pot oferi acestor rețele informații detaliate. De exemplu – personalul furnizor de servicii de scaune rulante poate sugera că orice copil identificat cu o problemă fizică semnificativă sau întârziere în procesul de dezvoltare să fie trimis către o evaluare sau consiliere. Note pentru formatori: Este posibil ca participanţii să solicite mai multe informaţii. Două indicii suplimentare care arată că un copil de vârstă mică ar putea beneficia de furnizarea timpurie a unui scaun de poziționare sunt: o Copiii de vârstă foarte mică (sub vârsta de un an) care au tendinţa de a avea întotdeauna aceeași postură, fie că este vorba despre o postură cu corpul aflat în extensie sau în flexie, cei care nu reuşesc să îşi mişte cu ușurință membrele, să se întindă pentru a apuca un obiect, să se rostogolească sau cei care au mișcări necontrolate. o Copiii care pot menține poziția așezat, dar care au mereu aceeași postură și au dificultăți în schimbarea acesteia. Menținerea permanentă a unei poziții poate determina diverse probleme. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 55. Cereţi participanţilor să analizeze formularul de trimitere - nivel intermediar Explicaţi: o acest formular poate fi folosit de organizaţiile care direcționează utilizatorii către furnizorii de servicii de scaune rulante; o furnizorii de servicii de scaune rulante pot adapta acest formular, dacă este necesar; o formularul include etapele de dezvoltare menționate mai sus. Explicaţi: În cazul copiilor de vârstă mică, pe care părinții/însoțitorii pot încă să îi transporte în braţe cu ușurință, furnizorii de servicii de scaune rulante pot furniza un scaun de poziționare în locul unui scaun rulant. Acesta poate fi folosit în interior, iar copilul poate fi transportat în braţe în exterior. 5. Bune practici în lucrul cu copiii (20 de minute) Explicaţi: Atunci când lucrați cu copii, este important să îi tratați cu respect și într-o manieră care să îi protejeze. Întrebaţi: Care sunt elementele prin care personalul furnizor de servicii de scaune rulante asigură respectarea şi protejarea copiilor? Încurajaţi participanţii să răspundă. Răspunsuri: o explicați copiilor ce urmează să faceți și care sunt motivele, într-un mod care să îi ajute să înțeleagă; o implicați copiii în luarea deciziilor – într-un mod adecvat vârstei lor; o comunicați cu copiii folosind un limbaj pe care ei îl pot înțelege – acest lucru înseamnă să găsiți o modalitate de a le explica ce se întâmplă, având în vedere vârsta și nivelul lor de înțelegere; o faceți pauze pe parcursul etapelor de evaluare și probare a produsului (a scaunului rulant); o atunci când lucrați cu copiii, asigurați-vă că este prezent un membru al familiei/însoțitor; o asigurați-vă că spațiul în care vă veți întâlni cu copiii este cât mai preitenos și adecvat vârstei lor – de exemplu, jucării/activități potrivite vârstei lor, postere/imagini; o înainte de a realiza fotografi, cereți permisiunea copiiilor și a membrilor de familie/însoțitorilor. Explicaţi: Aspectele cheie pe care trebuie să le rețineți sunt: Este necesară o abordare care dă dovadă de respect: o explicați-le ce faceți și care sunt motivele, într-un mod care să îi ajute să înțeleagă; o cereți-le permisiunea înainte de a începe evaluarea fizică; o implicați-i pe ei/membrii familiei lor/însoțitorul în luarea deciziei cu privire la alegerea unui scaun rulant corespunzător; o în cazul în care urmează să îi evaluați într-un centru, încercați ca spațiul să fie cât mai potrivit pentru beneficiarii Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 56. de această vârstă. Aveți în vedere siguranța lor: o evaluându-i în prezența membrilor familiei/ a însoțitorului; o făcând pauze, deoarece copiii pot obosi ușor; o cerându-le permisiunea lor sau membrilor familiei/a însoțitorului înainte de a face fotografii. 6. Recapitulare puncte cheie (3 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 57. B: Etapele furnizării serviciilor de scaune rulante Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 58. B.1: Rezumatul evaluării şi interviul de evaluare O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să prezinte un rezumat al activităților specifice etapei de trimitere și programare; să prezinte un rezumat al celor două părţi ale evaluării - nivel intermediar; să enumere cel puţin opt diagnosticuri sau afecțiuni fizice specifice utilizatorilor de scaun rulant şi să descrie modul în care acestea influențează procesul de furnizare al unui scaun rulant; să prezinte diferite modalităţi prin care personalul furnizor de servicii de scaune rulante îşi poate îmbunătăţi abilităţile de comunicare, pe parcursul unei evaluări. R E S U R S E Pentru sesiune: prezentări PPT: B. Trimiterea şi programarea şi B.1: Rezumatul evaluării şi interviul de evaluare: Manualul participantului; Caietul de exerciţii practice; DVD: Bune abilități de comunicare; Formular de evaluare - nivel intermediar. C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoştinţe dobândite anterior: Înţelegerea caracteristicilor specifice unor diagnosticuri/afecțiuni fizice diferite, inclusiv: traumatism cranio-cerebral, paralizie cerebrală, distrofie musculară, polimielită, spina bifida, traumatism vertebro-medular, accident vascular cerebral, amputație de membru inferior. Însușirea cunoștințelor cu privire la etapa 1 din cele opt ale furnizării serviciilor de scaune rulante - „Trimitere şi programare”, din Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Evaluarea - nivel de bază, inclusiv: înţelegerea raportului dintre stilul de viaţă al utilizatorului de scaun rulant şi mediul mediul în care trăiește şi prescrierea scaunului - vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază; o evaluarea unui scaun rulant existent pentru a identifica dacă scaunul rulant este potrivit nevoilor utilizatorului. Adaptaţi conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanţii. Luați în considerare următoarele aspecte: Dacă un anumit tip de dizabilitate/afecțiune fizică se întâlnește în mod frecvent în zonă şi dacă ar trebui adăugat/ă în formularul de evaluare, cu explicarea specificului său în cadrul sesiunii. D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. Recitiți cu atenție formularul de evaluare şi exersaţi efectuarea interviului de evaluare. Revedeți informaţiile despre afecțiunile fizice din Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază, Manualul participantului. - Manualul formatorului. P R E ZE N TA R E 1. Introducere 2. Evaluare 3. Interviul de evaluare 4. Bune abilităţi de comunicare pe parcursul interviului de evaluare 5. Recapitulare puncte cheie 10 10 50 15 5 Durata totală a sesiunii 90 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 59. 1. Introducere (10 minute) Explicaţi: Trimiterea şi programarea reprezintă prima etapă a procesului de furnizare a serviciilor de scaune rulante. Prezentaţi slide-urile din B.1. Trimiterea şi programarea, conform Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază pentru a reaminti participanților importanţa acestei etape. Explicaţi: În această sesiune vom discuta despre: cele două părți componente ale evaluării - interviul de evaluare şi evaluarea fizică. detalii specifice interviului de evaluare şi despre modul în care informaţiile dobândite pe parcursul acestuia vor influența prescrierea scaunului rulant; importanţa utilizării unor bune abilităţi de comunicare în timpul evaluării; modalitatea prin care putem identifica faptul că utilizatorul de scaun rulant resimte durere. 2. Evaluarea (10 minute) Explicaţi: Evaluarea este cea de-a doua etapă din cele opt specifice procesului de furnizare a serviciilor de scaune rulante. Informaţiile obținute pe parcursul evaluării sunt foarte importante, atât pentru personalul furnizor de servicii de scaune rulante, cât şi pentru utilizator. o Informaţiile obținute în timpul acestei etape vor ajuta personalul furnizor de servicii de scaune rulante şi utilizatorul la: o alegerea celui mai adecvat scaun rulant din cele disponibile; o alegerea celor mai potrivite componente pentru scaunul rulant, din cele disponibile, incluzând aici dispozitivele de suport şi accesoriile; o identificarea nevoii de instruire a utilizatorului de scaun rulant şi/sau a familiei pentru ca utilizatorul să poată beneficia în cel mai înalt grad posibil de folosirea scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 60. Explicaţi: Evaluarea este efectuată în două părţi, atât la nivel de bază, cât şi la nivel intermediar: interviul de evaluare; evaluarea fizică; 3. Interviul de evaluare (50 de minute) Explicaţi: Prima parte a evaluării o constituie interviul de evaluare. Pe parcursul acesteia, personalul furnizor de servicii de scaune rulante adună informaţii despre utilizatorul de scaun rulant. Aceste informaţii vor ajuta la identificarea celui mai potrivit scaun rulant pentru respectivul utilizator. Explicaţi: Componentele interviului de evaluare în livrarea serviciilor de scaune rulante la nivel de bază şi la nivel intermediar sunt foarte similare. Acestea includ: – informaţii despre utilizatorul de scaun rulant; – informații despre starea fizică; – informații despre stilul de viaţă şi mediul în care trăiește; – informații despre scaun rulant existent. În cadrul modului de nivel intermediar nu vom aborda elementele curpinse în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Participanţii ar trebui să fie familiarizați cu modalitatea de obținere a acestui tip de informaţii şi cu felul în care acestea influențează prescrierea scaunului rulant. în Manualul participantului se găsește un rezumat al acestei părți, împreună cu informaţii suplimentare, specifice nivelului intermediar. Explicaţi: Chiar dacă părţile interviului de evaluare sunt foarte similare la nivel de bază şi intermediar, în cazul celui din urmă se solicită și se obțin mai multe informaţii legate de diagnosticul şi afecțiunile fizice ale utilizatorului. Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 2-4 participanți. Instrucţiuni: Desemnați care va fi numărul fiecărei grupe (de la1 la 5) şi indicați care dintre sarcinile menționate în Caietul de exerciții practice îi revine fiecărei grupe (B.1. Rezumatul evaluării şi interviul evaluării). Cereţi grupelor să răspundă la setul de întrebări indicat din Caietul de exerciţii practice. Explicaţi: Pe parcursul acestei activități, participanţii pot folosi următoarele resurse: o Manualul participantului; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 61. o propriile cunoştinţe şi experienţa acumulate din lucrul cu persoane/utilizatori de scaun rulant cu diverse diagnostice/afecțiuni fizice. Explicaţi: Participanţii au la dispoziţie 20 de minute pentru a răspunde la întrebările date. Fiecare grupă va prezenta întregului grup până la trei aspecte care trebuie luate în considerare atunci când se prescrie un scaun rulant pentru o persoană cu un anumit diagnostic/afecțiune fizică. Monitorizare : Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grupă înţelege întrebările. Încurajaţi grupele să folosească Manualul participantului şi cunoştinţele proprii. Oferiți asistență participanţilor, dacă acest lucru este necesar. Durata: Acordaţi 20 minute pentru pregătirea grupelor. Acordaţi 10 minute pentru feedback şi discuţii. Nu uitaţi că durata alocată acestei activități este calculat pentru patru grupe de participanți. Dacă numărul grupelor este mai mare sau mai mic, adaptați durata exercițiului. Feedback: Cereţi fiecărei grupe să descrie trei aspecte pe care trebuie să le avem în vedere atunci când prescriem un scaun rulant pentru un utilizator cu un anumit diagnostic/afecțiune fizică. Confirmaţi răspunsurile corecte şi corectaţi/clarificaţi orice neînţelegere. Permiteţi participanților să discute - totuşi, nu depăşiţi timpul alocat exercițiului. Notă: Formatorii ar trebui să folosească notele din Manualul participantului, pentru a se asigura că fiecare grupă a identificat răspunsurile corecte. 4. Bune abilităţi de comunicare pe parcursul interviului de evaluare (15 minute) Explicaţi: Bunele abilități de comunicare sunt esențiale pentru obținerea informaţiilor corecte într-o manieră care se bazează pe respect şi care ia în considerare sentimentele şi nevoile utilizatorului de scaun rulant. Mai jos sunt enumerate câteva metode care ajută la buna desfășurare a interviului de evaluare: adresaţi-vă întotdeauna utilizatorului de scaun rulant, excepţie situaţiile în care utilizatorii sunt copii mici sau sunt persoane care nu înţeleg ori nu pot răspunde întrebărilor voastre; explicaţi utilizatorului de scaun rulant faptul că informaţiile oferite de el ajută la alegerea celui mai potrivit scaun rulant, în conformitate cu nevoile sale; întrebările nu trebuie adresate obligatoriu ordinea din formularul de evaluare - nivel intermediar. Câteodată, utilizatorii de scaune rulante oferă unele informaţii înainte de a fi întrebaţi sau veți constata că este mai firesc să abordați întrebările într-o altă ordine. Câteodată, comunicarea verbală poate fi dificilă. De exemplu, atunci când utilizatorul de scaun rulant nu este capabil să vă audă sau nu poate vorbi suficient de clar pentru ca voi să înţelegeţi răspunsul. Atunci când comunicarea este dificilă, încercaţi să găsiţi o cale de comunicare directă cu utilizatorul de scaun rulant. Întrebaţi persoanele care îl cunosc cel mai bine pe respectivul utilizator care este cea mai bună modalitate de comunicare cu acesta. Acordaţi-vă suficient timp pentru a înţelege modulîn care comunică utilizatorul de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 62. dacă nu găsiţi o modalitate de a comunica direct, asiguraţi-vă că aveți alături, pe tot parcursul întâlnirii, o persoană pe care utilizatorul o cunoaște. Cereţi acestei persoane să vă ajute în comunicarea cu utilizatorul de scaun rulant. Pregătiţi vizionarea materialului video: Bune abilități de comunicare Acest material video ne arată diverse modalităţi de comunicare. Împărţiţi participanții în două grupe, în funcţie de locul unde sunt așezați (ei nu trebuie să îşi schimbe locul în sala de curs). Explicaţi: Fiecare grupă urmărește cu atenţie materialul video şi notează modalităţi de comunicare identificate. Participanţii trebuie să fie atenţi la: diversele modalităţi de comunicare (de exemplu, limbaj mimico-gestual); diferitele exemple de tehnici de bună comunicare (de exemplu, contact vizual bun). Prezentaţi materialul video. Verificaţi dacă există întrebări. Acordaţi fiecărei grupe câteva minute pentru a crea o listă cu modalităţile de comunicare identificate şi cu exemple de tehnici de comunicare eficiente. Întrebaţi: Care sunt modalităţile prin care comunică persoanele prezentate în materialul video? Cereţi uneia dintre grupe să prezinte lista. Scrieţi răspunsurile pe tablă. Bifați elementele care se regăsesc și pe lista celeilate grupe/ Întrebaţi participanții din cea de-a doua grupă dacă mai au şi alte răspunsuri. Răspunsuri: Modalităţi de comunicare verbală: – vorbire clară, completată cu demonstraţii; – explicaţie şi prezentare; – sunete (vocalizare). Modalităţi de comunicare non-verbală: – gesturi; – fixarea unui punct cu privirea; – semne cu ajutorul capului; – descrierea cu ajutorul mâinilor; – relaționare; – expresii faciale; – limbaj mimico-gestual; – contact vizual; – atingere; – întrebări la care utilizatorul de scaun rulant poate răspunde cu „da” sau „nu”; folosirea oricărui sistem pentru a indica „da” sau „nu”. Sisteme speciale de comunicare: – tablă de comunicare; – indicarea cu ajutorul mișcării capului; – sisteme de calculator. Modalităţi de îmbunătăţire a comunicării: – contact vizual bun; – aducerea corpului la acelaşi nivel cu utilizatorul de scaun rulant (aplecare/ghemuire); – limbaj corporal relaxat şi care facilitează comunicarea (contact vizual cu utilizatorul de scaun rulant, demonstrarea existenței interesului); – acordarea de timp suficient pentru formularea unui răspuns în cazul persoanelor care au dificultăţi în comunicare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 63. Prezentare material video: Bune abilități de comunicare; Participanţii vor viziona din nou materialul video şi vor vedea câte exemple au reuși să identifice în mod corect. Prezentați materialul video. Confirmaţi numărul de puncte identificate corect de către participanţi, după prima vizualizare. Explicaţi: În cazul în care un utilizator de scaun rulant nu are capacitatea de a comunica verbal, poate fi dificil ca acesta să comunice faptul că resimte durere. De aceea, atunci când se lucrează cu un utilizator de scaun rulant, personalul furnizor de servicii de scaune rulante trebuie să ştie dacă acțiunile desfășurate cauzează durere sau sporesc nivelul de durere resimțit de către utilizatorului. Întrebaţi: Cum comunică persoanele, în mod obișnuit, faptul că resimt durere? Încurajaţi participanţii să răspundă. Răspunsuri: plâns; ţipăt; agitație; transpiraţie; împingerea mâinii evaluatorului sau încercarea de a se îndepărta; rezistenţa la o anumită mişcare sau incapacitea de menţinere a unei anumite poziţii; expresia feţei – privire încruntată şi/sau grimasă; felul în care o persoană menține poziția aşezat, stând sau felul în care merge. Întrebaţi: Ce puteţi face pentru a vă asigura că nu cauzaţi durere sau nu sporiţi nivelul de durere resimțit? Răspunsuri: o încurajaţi utilizatorul de scaun rulant să vă anunţe dacă resimte durere pe parcursul evaluării; o dacă există dificultăți de comunicare – înainte de începerea evaluării, stabiliți un semn prin care utilizatorul vă poate comunica faptul că resimte durere; o evitaţi poziţiile care cresc nivelul de durere; o folosiţi poziţii sau mişcări care ameliorează durerea. 5. Recapitulare puncte cheie (5 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 64. B.2: Evaluarea fizică – postura în poziţia de şedere fără suport O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să prezinte trei diferenţe între specificul poziţiei așezat în cazul copiilor şi al adulţilor; să analizeze și să înregistreze poziţia așezat folosind cuvinte, schițe sau ambele. R E S U R S E Pentru sesiune: slide-uri PPT: B.2: Evaluarea fizică - poziţia așezat fără suport; Manualul participantului; Caietul de exerciţii practice; DVD: Rezumatul evaluării fizice; Formular de evaluare - nivel intermediar. pat de evaluare – 1 pentru fiecare grupă; set de suporturi din lemn pentru picioare. C O N TE X T Ș I C U N O Ș TI N Ș E D O B Â N D IT E A N TE R IO R Cunoştinţe dobândite anterior: Completarea secțiunii „prezența escarelor, riscul apariției escarelor sau escare anterioare” din partea de evaluare fizică şi înţelegerea modului în care informaţiile obținute influenţează procesul de furnizare a scaunului rulant. Completarea secțiunii „metoda de efectuare a propulsiei” din partea de evaluare fizică şi înţelegerea modului în care informaţiile obținute influenţează procesul de furnizare a scaunului rulant. Postura în poziția așezat tipică: cum putem identifica şi descrie poziția așezat; înţelegerea beneficiilor poziției așezat. Cum pot fi identificate zonele osoase cu importanță crescută, inclusiv creasta iliacă antero-superioară (CIAS), creasta iliacă postero-superioară (CIPS) şi tuberozităţile ischiale (TI). Adaptaţi conținutul acestei sesiuni astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanți. Luați în considerare următoarele aspecte: Atunci când cereți participanţilor să identifice CIAS şi CIPS și să demonstreze procedeul lucrând cu un voluntar, luaţi în considerare aspectele culturale legate de atingerea corpului altor persoane. D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. Recitiți cu atenţie formularul de evaluare – nivel intermediar şi exersaţi modalitatea de a descrie sau de a desena poziţia așezat fără suport. Plasaţi un pat de evaluare în sala de curs, astfel încât acesta să poată fi văzut de către toți participanții. Aranjaţi sala de curs de așa manieră încât participanţii să stea într-un semicerc, cu faţa către locul unde este amenajat patul de evaluare. Poziționați paturi de evaluare în sala de curs (sau în afara sălii/în săli conexe). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 65. R E ZU M A T 1. Introducere 2. Analiza prezenţei escarelor, riscului apariției acestora sau a escarelor anterioare, precum şi a metodei de efectuare a propulsiei 3. Rezumatul evaluării fizice 4. Poziţia așezat 5. Poziţia așezat la copiii de vârstă mică 6. Bazinul este fundația poziţiei așezat 7. Observarea posturii în poziția așezat 8. Înregistrarea posturii 9. Recapitulare puncte cheie 5 5 5 20 5 20 8 20 2 Durata totală a sesiunii 90 1. Introducere (5 minute) Explicaţi: În această sesiune vom aborda aspectele legate de evaluarea fizică, aceasta fiind cea de-a doua parte a etapei de evaluare. Apoi vom recapitula pe scurt cele două părţi ale evaluării fizice care au fost prezentate în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază: o prezenţa escarelor, riscul apariției acestora sau escare anterioare; o metoda de efectuare a propulsiei. Explicaţi: Ne vom concentra apoi pe ceea ce înseamnă „postura în poziţia așezat fără suport” a evaluării fizice. Vom discuta despre: o specificul poziţiei așezat în cazul adulţilor şi al copiilor; o modul în care bazinul influențează poziția așezat; o exersarea modalității de analiză şi înregistrare a posturii în poziția așezat. Explicaţi: Evaluarea fizică include: o identificarea prezenţei escarelor, a riscului apariției acestora sau a istoricului escarelor; o identificarea metodei de efectuare a propulsiei; o identificarea poziției utilizatorul de scaun rulant şi a nevoii de suport postural suplimentar prin: o observarea poziţiei așezat fără suport; o efectuarea unei analize a posturii bazinului şi a şoldurilor; o efectuarea unei proceduri de simulare manuală; o efectuarea măsurătorilor. Întrebaţi: Știe cineva ce înseamnă termenul de „procedură de simulare manuală”? Încurajaţi participanţii să răspundă. Răspuns: Procedeul de simulare manuală înseamnă simularea, cu ajutorul mâinilor, a modului în care acționează scaunul rulant şi suportul postural suplimentar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 66. 2. Analiza prezenţei escarelor, a riscului apariției acestora sau a escarelor anterioare, precum și a metodei de efectuare a propulsiei (5 minute) Explicaţi: Primele două părţi ale evaluării fizice de nivel intermediar sunt identice cu cele ale evaluării din modulul de bază. Acestea includ: prezenţa escarelor, riscul apariției acestora sau escarele anterioare; metoda de efectuare a propulsiei. Explicaţi: În modulul de nivel intermediar nu vom aborda informaţiile discutate în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Participanţii trebuie să cunoască deja modalitatea de obținere a informaţiilor şi modul în care acestea au impact asupra prescrierii scaunului rulant. Explicaţi: Este întotdeauna important să aflăm dacă la utilizatorul de scaun rulant este prezent riscul apariției escarelor. Întrebaţi: Aveți întrebări legate de acest aspect al evaluării? Răspundeţi la orice întrebare. Reamintiţi-le participanţilor: o În cazul în care un utilizator de scaun rulant spune că a avut escare sau dacă are escare în momentul evaluării - cereţi permisiunea de a vedea escara. o Este important ca personalul furnizor de servicii de scaune rulante care face evaluarea să ştie exact unde este localizată escara (sau unde a fost localizată) şi să stabilească dacă este necesar ca utilizatorul să fie trimis la tratament. Explicaţi: În mod similar activităților specifice acestei etape la nivel de bază, este important să identificăm cea mai bună metodă de realizarea a propulsiei în cazul respectivului utilizator de scaun rulant. Întrebaţi: Aveți întrebări legate de acest aspect al evaluării? Răspundeţi la orice întrebare. Reamintiţi-le participanţilor: o Capacitatea de mobilitate în cel mai înalt grad de independenţă posibil este unul din drepturile fundamentale ale omului. Obținerea chiar şi a unui grad scăzut de independență în ceea ce privește realizarea propulsiei este un obiectiv care merită urmărit. o Furnizarea unui suport postural adecvat poate îmbunătăţi capacitatea utilizatorului de scaun rulant de realizare a propulsiei, iar acest aspect trebuie luat în considerare atunci când se evaluează cum şi cât de mult poate realiza propulsia respectivul utilizator de scaun rulant. 3. Rezumatul evaluării fizice (5 minute) Prezentare material video: Rezumatul evaluării fizice. Acum vom viziona un material video scurt care oferă un rezumat al modului în care personalul furnizor de servicii de scaune rulante poate lucra cu utilizator pentru a identifica poziția acestuia și tipul de suport postura suplimentar necesar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 67. Tânăra din material se numește Enith. După interviu, evaluatorul desfășoară activitățile în următoarea secvenţă: o observarea poziţiei așezat fără suport; o efectuarea unei analize a posturii bazinului şi a şoldurilor; o efectuarea unei proceduri de simulare manuală; Prezentați materialul video. Explicaţi: o Materialul video prezintă modul în care personalul furnizor de servicii de scaune rulante analizează postura lui Enith în timpul utilizării scaunului rulant. Datorită faptului că Enith are deja un scaun rulant, este important de ştiut ce fel de suport postural are deja şi care este gradul de suport oferit de acesta. o Presupunem că personalul furnizor de servicii de scaune rulante a observat deja postura lui Enith pe patul de evaluare, înainte de începerea analizei posturii bazinului şi a şoldurilor. Verificaţi dacă există întrebări. 4. Poziţia aşezat (20 de minute) Rugați un voluntar (participant) să vină în partea din față a sălii de curs şi să se aşeze pe patul de evaluare, în pozitia aşezat. Cereţi participanţilor să descrie postura în poziția așezat a voluntarului, privită din lateral, începând cu bazinul. Este posibil ca participanții să fie nevoiți să se ridice pentru a putea vedea mai bine. Răspunsuri (abordați toate aceste aspecte): Vedere laterală: o bazinul în echilibru; o trunchiul drept; o spatele urmând curburile fiziologice; o capul şi gâtul drepte şi aflate în echilibru în raport cu corpul; o șoldurile flectate la aproximativ 90 de grade; o genunchii şi gleznele flectați la aproximativ 90 de grade; o picioarele poziţionate pe sol (sau pe suportul de picioare). Solicitați participanţilor să descrie postura voluntarului - de această dată privită din faţă. Din nou, cereți-le să înceapă cu bazinul. Mulţumiţi voluntarului. Explicaţi: Postura în poziția așezat descrisă trebuie folosită ca punct de reper. Atunci când lucraţi cu utilizatorii de scaun rulant, obiectivul este de a susţine fiecare utilizator într- o poziție cât mai apropiată de aceasta, într-un mod care să fie cât mai confortabil, practic şi funcţional pentru utilizatorul de scaun rulant. Răspunsuri (Abordați toate aceste aspecte): Vedere din față: o bazinul la același nivel; o umerii la același nivel, relaxaţi, braţele au libertate de mişcare; o coapsele paralele sau în orientate puţin spre exterior; o capul drept şi în echilibru în raport cu corpul; o trunchiul urmează o linie dreaptă (nu este curbat sau orientat către lateral). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 68. Explicaţi: o am discutat despre motivele pentru care poziţia aşezat este importantă; totuşi, nu toate persoanele au capacitatea de a menține poziţia aşezat; o vom întâlni la utilizatorii de scaune rulante care au nevoie de servicii de scaune rulante de nivel intermediar o diversitate de posturi în poziția așezat; o diferitele posturi sunt rezultatul faptului că o parte (sau părţi) a corpului nu se află în poziția neutră; o pe parcursul evaluării, personalul furnizor de servicii de scaune rulante şi utilizatorul de scaun rulant trebuie să găsească poziția așezat cea mai apropiată de oziția neutră de ședere pe care o poate atinge utilizatorul, în condiții de siguranţă şi în mod confortabil, şi pe care o poate menţine fără diminuarea funcţionalității; o scaunul rulant şi dispozitivele de suport postural trebuie să susţină această postură. o există trei rezultate finale ale evaluării posturii. Acestea sunt: o postura fixă; o postura flexibilă spre neutră; o postura flexibilă parţial spre neutră; Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 3 participanți. Instrucţiuni: Cereţi participanţilor să discute între ei despre înţelesul acestor trei termeni: o postură fixă; o postură flexibilă spre neutră; o postură flexibilă parţial spre neutră; Solicitați-le să NU caute în Manualul participantului, ci să identifice propria or versiune a semnificației acestor termeni. Explicaţi: Participanţii au la dispoziţie 10 minute pentru a efectua această activitate de grup, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Afişaţi slide-ul cu cei trei termeni pentru a le reaminti grupelor întrebările. Monitorizaţi cu atenție activitatea fiecărei grupe. Asiguraţi-vă că participanţii înţeleg întrebarea. Oferiți asistență participanţilor, dacă acest lucru este necesar. Durata: Acordaţi 10 minute pentru activitate. Acordaţi 5 minute pentru feedback. Feedback: Cereţi unei grupe să prezinte definiţia sau descrierea posturii fixe. o Dacă definiţia/descrierea este clară şi corectă - confirmaţi răspunsul. Dacă nu - întrebaţi dacă participanții oricărei alte grupe pot ajuta în clarificarea răspunsului. Dacă este cazul, formatorul poate clarifica răspunsul Cereţi unei alte grupe să prezinte definiţia sau descrierea posturii flexibile spre neutru. o Dacă definiţia/descrierea este clară şi corectă - confirmaţi răspunsul. Dacă nu - întrebaţi dacă participanții oricărei alte grupe pot ajuta în clarificarea răspunsului. Dacă este cazul, formatorul poate clarifica răspunsul Cereţi unei alte grupe să prezinte definiţia sau descrierea posturii flexibile parţiale spre neutru. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 69. o Dacă definiţia/descrierea este clară şi corectă - confirmaţi răspunsul. Dacă nu - întrebaţi dacă participanții oricărei alte grupe pot ajuta în clarificarea răspunsului. Dacă este cazul, formatorul poate clarifica răspunsul. Răspunsuri: Postură fixă: o Utilizatorul de scaun rulant are o parte a corpului care este „fixă”. Aceasta nu devine mobilă prin exercitarea unui grad redus de forță (nu vom folosi niciodată un grad ridicat de forţă). Postură flexibilă spre neutră: o Prin exercitarea unui grad redus de forță, acele părţi ale corpului utilizatorului de scaun rulant care nu sunt în poziţie neutră, pot atinge această poziție. Postură flexibilă parţial spre neutră: o Prin exercitarea unui grad redus de forță, acele părţi ale corpului utilizatorului de scaun rulant care nu sunt în poziţie neutră, pot atinge parţial această poziție. Explicaţi: o Aceşti termeni sunt prezentaţi în Manualul participantului. Este important ca atunci când personalul furnizor de servicii de scaune rulante susține utilizatorul de scaun rulant să ia în considerare gradul de flexibilitate pentru atingerea poziției neutre prezent la respectivul utilizator. o Pentru postura fixă – o parte a corpului utilizatorului de scaun rulant este „fixă”. Atunci când exercităm un grad de forţă redus, nu există mobilitate (nu vom folosi niciodată un grad crescut de forță). Personalul furnizor de servicii de scaune rulante trebuie să ofere suport pentru acomodarea posturii non-neutre (fixe). o Pentru postura flexibilă spre neutră – atunci când exercităm un grad de forță redus, acele părți ale corpului utilizatorului de scaun rulant care nu sunt în poziţie neutră, pot atinge această poziție. În această situaţie, este necesar un suport corespunzător pentru a ajuta utilizatorul de scaun rulant să menţină poziţia neutră de şedere. o Pentru postura flexibilă parţial spre neutră - atunci când exercităm un grad de forță redus, acele părți ale corpului utilizatorului de scaun rulant care nu sunt în poziţie neutră pot fi aduse parţial spre această poziție. În această situaţie, este necesar un suport corespunzător pentru a ajuta utilizatorul de scaun rulant în menținerea unei poziții cât mai apropiate de cea neutră, care să fie confortabilă și să nu influențeze negativ nivelul de fuuncționalitate. o Nu uitaţi că pot apărea probleme noi atunci când utilizatorul de scaun rulant este susţinut într-o postură care este mai aproape de poziția neutră de ședere, dar care nu este confortabilă sau funcţională. De aceea, evaluarea este foarte importantă şi trebuie să luăm în considerare atât nivelul de confort şi de funcţionalitate în desfășurarea activităților, cât şi menținerea utilizatorului într-o poziție cât mai apropiată de poziţia neutră de ședere. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 70. 5. Poziţia aşezat la copiii de vârstă mică (5 minute) Explicaţi: Poziția așezat ce caracterizează copiii sub vârsta de cinci ani nu este similară cu poziția așezat specifică copiilor mai mari sau adulţilor. Postura în poziţia aşezat se dezvoltă în primii cinci ani ai vieţii copilului. Explicaţi: Acest slide prezintă un copil cu vârsta de trei ani. Atât copilul, cât şi adultul din imagine sunt în poziţia aşezat. Întrebaţi: Ce diferenţe puteți observa între postura copilului şi cea a adultului? Încurajaţi participanţii să răspundă. Răspunsuri: Copil cu vârsta sub cinci ani: Adult: o trunchiul drept, fără curburi lombare sau toracice; o urechile şi şoldurile copilului sunt situate pe aceeași linie, totuşi umerii sunt orientaţi puţin înspre înainte; o membrele inferioare sunt orientate înspre exterior şi sunt în adducție - nu paralele. o trunchiul drept, spatele prezintă curburile fiziologice; o urechile, umerii şi şoldurile se află pe aceeași linie; o membrele inferioare paralele sau orientate puţin înspre exterior. Explicaţi: Cele mai importante diferenţe specifice înainte de vârsta de cinci ani sunt: o spatele copilului este plan şi nu există curburi lombare sau toracice; o urechile şi şoldurile copilului sunt situate pe aceeași linie, totuşi umerii sunt orientaţi puţin înspre înainte; o picioarele sunt orientate către exterior şi sunt în adducție - nu paralele. Explicaţi: Atunci când se lucrează cu copii sub vârsta de cinci ani, personalul furnizor de servicii de scaune rulante trebuie să reţină faptul că suportul furnizat diferă de cel care este destinat poziţiei aşezat în cazul adulţilor. În cazul copiilor sub vârsta de cinci ani, acest tip de suport poate provoca disconfort şi poate cauza leziuni. 6. Bazinul constituie baza poziţiei așezat (20 de minute) Întrebaţi: Schimbarea poziției bazinului influențează restul corpului? Răspuns: o da – mişcările sau schimbările poziţiei bazinului influențează întotdeauna restul corpului; o bazinul constituie baza poziţiei așezat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 71. Explicaţi: Vom aborda în detaliu acest aspect. Înţelegerea modului în care poziția bazinului influențează restul corpului reprezintă o componentă esențială a programului de instruire de nivel intermediar. Întrebaţi: Identificați în această imagine creasta iliacă postero-superioară şi creasta iliacă antero-superioară? Explicaţi: Din perspectivă laterală - CIPS şi CIAS sunt situate la același nivel. Explicaţi: Din perspectivă frontală - CIAS stângă şi dreaptă sunt situate la același nivel. Cereţi unui voluntar (participant) să vină în faţa celorlalți participanți şi să se aşeze pe patul de evaluare, în pozitie aşezat. Demonstraţi, cu ajutorul voluntarului, unde sunt localizate CIAS şi CIPS. Poziționați mâna pe bazinul voluntarului şi arătaţi modul în care puteţi susţine bazinul cu ambele mâini. Degetele mari sunt plasate pe cele două CIAS, iar restul degetelor, curbate, sunt orientate către partea posterioară a bazinului. Cereţi participanţilor să exerseze cu colegii lor (dacă încă nu sunt familiarizați cu această tehnică), asigurându-vă de faptul că fiecare persoană reuşeşte identifice CIAS şi CIPS în cazul colegului cu care lucrează. Mulţumiţi voluntarului. Întrebaţi: Ce alte posuri ale bazinului există în afară de poziţie așezat sau neutră? Răspunsuri (discutaţi toate aceste aspecte): o înclinare anterioară/înspre înainte (CIAS este situată la un nivel inferior comparativ cu CIPS - sau partea superioară a bazinului este orientată înspre înainte); o înclinare posterioară/înspre înapoi (CIPS este situată la un nivel inferior comparativ cu CIAS - sau partea superioară a bazinului este orientată înspre înapoi); o înclinare laterală/într-o parte (una din părțile laterale ale bazinului este situată mai jos); o rotaţie (o parte a bazinului se roteşte înspre înainte/înapoi în raport cu partea opusă). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 72. Abrevieri utilizate în această parte Structura anatomică Abreviere Creasta iliacă antero-superioară CIAS Creasta iliacă postero-superioară CIPS Tuberozitate ischială TI Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 4 participanți. Instrucţiuni: Cereţi participanţilor să consulte Caietul de exerciții practice (B.2: Evaluarea fizică - poziţia așezat fără suport: baza poziţiei așezat). Explicaţi: Participanții din fiecare grupă trebuie să lucreze împreună pentru a identifica modificările poziţiei așezat atunci când postura bazinului se modifică, având ca rezultat înclinarea anterioară, înclinarea posterioară, înclinarea laterală sau rotaţia. Explicaţi: Participanţii au la dispoziţie 10 minute pentru a efectua această activitate, iar apoi grupurile se vor reuni pentru partea de feedback. Monitorizare : Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare dintre grupe înţelege ce are de făcut. Acordați asistență participanţilor, dacă acest lucru este necesar. Durata: Acordaţi 10 minute pentru pregătirea grupelor. Acordaţi 5 minute pentru feedback şi discuţii. Feedback: Întrebaţi: Fiecare grupă a observat că poziția bazinului influențează întreaga postură? Întrebaţi grupa 1: Care sunt modificările de postură care rezultă din înclinarea anterioară a bazinului? Întrebaţi grupa 2: Care sunt modificările de postură care rezultă din înclinarea posterioară a bazinului? Întrebaţi grupa 3: Care sunt modificările de postură care rezultă din înclinarea laterală a bazinului? Întrebaţi grupa 4: Care sunt modificările de postură care rezultă din rotația bazinului? Răspunsuri: Postura bazinului: Postura întregului corp (cu accent pe trunchi): o Înclinare anterioară o trunchi în extensie, curbură crescută în zona lombară (lordoză); o Înclinare posterioară o trunchiul se curbează/arcuieşte, cauzând o postură „prăbușită” (cifoză); o Înclinare laterală o trunchiul se curbează înspre lateral (scolioză); o Rotaţie o trunchiul se roteşte și el. Explicaţi: o Cel mai important aspect pe care trebuie să îl rețină participanții este faptul că poziţia bazinului va influența întotdeauna restul corpului. o Atunci când evaluaţi postura unui utilizator de scaun rulant, începeţi întotdeauna prin a observa bazinul. Atunci când oferiţi suport postural, începeţi întotdeauna prin a susţine bazinul. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 73. 7. Observarea poziţiei aşezat (8 minute) Explicaţi: Un punct de plecare în ceea ce privește înţelegerea poziţiei aşezat a utilizatorului de scaun rulant şi a tipului de suport necesar este observarea poziţiei așezat a utilizatorului de scaun rulant – în absența suportului. Explicaţi: o Pe parcursul evaluării, personalul furnizor de servicii de scaune rulante va începe prin observarea poziției utilizatorului de scaun rulant încă de la efectuarea interviului de evaluare. o La începutul evaluării fizice, cereţi utilizatorului de scaun rulant să efectueze transferul pe un pat de evaluare. o Asiguraţi-vă că utilizatorul de scaun rulant este în siguranţă şi că picioarele sunt susţinute de suprafața pe care se află. o Oferiţi un grad de suport suficient pentru ca persoana evaluată să fie în siguranță și pentru a evita căderile. Un asistent sau un membru de familie/însoțitor poate furniza acest suport. o Motivul observării poziţiei așezat fără suport este nevoia de a înţelege tendinţele/obişnuinţele posturale ale utilizatorului de scaun rulant. o Analiza posturii este o abilitate, care se dezvoltă în timp şi cu exerciţiu. o Vom observa în cele ce urmează patru poziţii așezat diferite - şi vom stabili cât de eficiente sunt abilităţile noastre de observare a diferitelor posturi.. Note pentru formatori: o puneți accent pe faptul că poziția bazinului trebuie să fie primul element observat – apoi cea a trunchiului, capului şi gâtului, membrelor inferioare; o dacă participanţii consideră că această activitate este dificilă, sugeraţi-le să încerce să adopte respectiva postura, pentru a înțelege mai bine ce presupune ea. Acest lucru poate ajuta în înţelegerea şi observarea fiecărei poziţii de şedere. Întrebaţi: Ce observați în ceea ce privește poziția acestei persoane? Răspunsuri: o bazinul înclinat înspre înainte; o arcuirea zonei lombare; o umerii orientaţi înspre înapoi; o gâtul în extensie. Întrebaţi: Ce observați în ceea ce privește poziția acestei persoane? Răspunsuri: o bazinul înclinat înspre înapoi; o unghiul de la nivelul șoldurilor mai mare (unghiul dintre trunchi şi coapse mai mare de 90 grade); o arcuirea zonei lombare; o gât ușor în extensie. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 74. Întrebaţi: Ce observați în ceea ce privește poziția acestei persoane? Răspunsuri: o bazinul nu se află în echilibru, partea din dreapta fiind mai jos (notaţi întotdeauna care este partea situată mai jos); o bazinul pare să fie în rotație posterioară pe partea dreaptă (rotația este deseori asociată cu o poziţie asimetrică, dat nu întotdeauna); o curbare laterală a coloanei vertebrale, cu apexul curburii în partea dreaptă; o umerii nu se află la același nivel (mai jos în partea dreaptă). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 75. Întrebaţi: Ce observați în ceea ce privește poziția acestei persoane? Răspunsuri: o bazin în rotație posterioară pe partea dreaptă (notaţi întotdeaunadirecţia şi partea corpului - de exemplu, posterior, pe partea dreaptă); o un anumit grad de rotație la nivelul trunchiului (posterior, pe partea stângă); o membrul inferior drept este căzut şi orientat către exterior, iar piciorul drept este orientat către interior. Note pentru formatori: În cazul ultimului exemplu prezentat - dacă participanţii au dificultăți în a observa rotaţia bazinului, întrebaţi: Credeţi că spatele persoanei din imagine se sprijină pe spătar, cu presiune distribuită egal pe toată suprafaţa spatelui? 8. Observarea poziţiei aşezat (20 de minute) Explicaţi: o În formularul de evaluare - nivel intermediar există o rubrică pe care o vom folosi pentru a descrie poziția așezat fără suport a utilizatorului de scaun rulant. o Această informaţie poate ajuta personalul furnizor de servicii de scaune rulante: o să rețină aspectele legate de poziţia așezat a utilizatorului de scaun rulant, după terminarea evaluării; o să monitorizeze schimbările care se produc de-a lungul timpului. Există câteva metode de înregistrare a poziţiei așezat, inclusiv: o descrierea poziției cu ajutorul cuvintelor - ceea ce am exersat anterior; o desenarea unei imagini; o realizarea de fotografii (doar cu permisiunea utilizatorului de scaun rulant). Explicaţi: o atunci când se folosesc fotografii, personalul furnizor de servicii de scaune rulante trebuie să stabilească o politică clară în ceea ce privește realizarea şi stocarea fotografiilor; o cereţi întotdeauna permisiunea utilizatorului de scaun rulant sau a membrilor familiei/însoțitorului, în cazul utilizatorilor de scaun rulant copii; o asiguraţi-vă întotdeauna că fotografiile realizate în scopul evaluării sunt gestionate în condiții de confidenţialitate; o nu folosiţi fotografiile cu scopul de a instrui (sau cu alte scopuri), doar în cazul în care care aveţi permisiunea utilizatorului de scaun rulant în acest sens; o fotografiile pentru înregistrarea poziției trebuie făcute din Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 76. perspectivă frontală şi laterală. Alte unghiuri pot fi de asemenea folositoare. Explicaţi: Desenarea poziției utilizatorului de scaun rulant necesită exercițiu. Cu toate acestea, există o metodă simplă de desenare a poziției, folosind un sistem simplu, de tip schiță. Dezvoltarea unei metode facile și eficiente, bazată pe realizarea de schițe este foarte utilă pentru activitatea personalului furnizor de servicii de scaune rulante. Explicaţi: Aceasta este o metodă simplă de schițare a poziţiei așezat, vedere laterală: o folosiţi un triunghi pentru a reprezenta bazinul; o folosiţi o linie ondulată pentru a reprezenta coloana vertebrală; o folosiţi linii drepte pentru membrele inferioare; o folosiţi un cerc pentru a reprezenta capul. Explicaţi: o Linia pentru coloana vertebrală reprezintă curburile fiziologice ale coloanei - (cervicală, toracică şi lombară). o TI, SIPS şi CIAS sunt reprezentate de punctele triunghiului. Cereţi participanţilor să realizeze schițele. Explicaţi: Aceasta este o metodă simplă de schițare a poziţiei așezat, vedere frontală: o folosiţi un triunghi dublu pentru a reprezenta bazinul; o folosiţi o linie pentru a reprezenta trunchiul; o folosiţi linii pentru a schița coapsele (linia scurtă din această imagine) şi gambele (vezi mai jos Note pentru formatori); o În această imagine, genunchiul reprezintă micul cerc situat între liniile şoldului şi gambelor,iar picioarele sunt simbolizate printr-un pătrat mic. o folosiţi o linie dreaptă orizontală pentru umeri; o folosiţi un cerc pentru a reprezenta capul. Cereţi participanţilor să consulte Caietul de exerciții practice (B.2: Evaluarea fizică - poziţia așezat fără suport: schița poziției) şi să realizeze propriul desen lângă desenul din caietul de exerciţii. Explicaţi: Participanţii pot folosi această metodă simplă de desenare pentru a înregistra diferitele posturi ale utilizatorilor de scaune rulante, aspect pe care îl vom exersa în timpul rămas în cadrul acestei sesiuni. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 77. Explicaţi: Dacă bazinul unui utilizator de scaun rulant este în rotație, vom desena o săgeată curbată pentru a arăta care parte a bazinului este în rotație posterioară. Cereţi participanţilor să copieze acest desen în caietul de exerciții practice. Note pentru formatori: Exemplele de desene tip schiță folosite în această sesiune pot fi adaptate/modificate. De exemplu, anumite persoane pot alege să deseneze poziția membrelor inferioare așa cum sunt văzute de sus. Acest lucru elimină efectul de „scurtare” a aspectului acestora, care apare atunci în momentul în care ele sunt observate din față. În acest mod, şoldurile par să aibă o lungime mai mică decât gambele și par a fi în abducție. Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 3 persoane. Instrucţiuni: Cereţi fiecărei grupe să observe pozițiile prezentate în Caietul de exerciții practice (B.2: Evaluarea fizică - poziţia așezat fără suport: schița poziției). Explicaţi faptul că aceste imagini reprezintă persoane reale. Cereţi grupului să lucreze împreună pentru a realiza schița poziției așezat în rubrica „poziţia așezat fără suport” a formularului de evaluare - nivel intermediar, din caietul de exerciţii practice. Explicaţi: Participanţii au la dispoziţie 10 minute pentru ca fiecare grupă să finalizeze această activitate, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grupă înţelege în ce constă activitatea. Oferiți asistență participanţilor, dacă acest lucru este necesar. Durata: Acordaţi 10 minute pentru activitate. Acordaţi 5 minute pentru feedback. Feedback: În cazul în care este posibil, proiectaţi fiecare imagine (consecutiv) pe o coală de pe suportul de flichart. Cereţi unui participant din fiecare grupă să realizeze schița pe imaginea proiectată. Dacă nu este disponibil un astfel de suport cereţi participanţilor să lucreze pe caietul de exerciții practice, în timp ce formatorul explică/desenează pe tablă. Discutaţi dificultăţile întâmpinate de participanţi în ceea ce privește realizarea schițelor. Explicaţi că poate fi utilă varianta în care schițele sunt completate de explicații în cuvinte. Exemple de schițe pentru formator: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 78. 9. Recapitulare puncte cheie (2 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 79. B.3: Evaluarea fizică – analiza posturii bazinului şi a şoldului O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să demonstreze modalitatea de efectuare a unei analize a posturii bazinului şi a şoldurilor, pentru a stabili dacă: o dacă bazinul utilizatorului de scaun rulant poate fi în echilibru; o dacă şoldurile pot fi flectate pentru atingerea poziției neutre de şedere. să demonstreze că au capacitatea de a furniza suport provizoriu pentru acomodarea unui bazin care nu se află în echilibru şi pentru situaţiile în care unul sau niciunul dintre şolduri nu pot fi flectate pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi şolduri este mai mare de 90 de grade). R E S U R S E Pentru sesiune: slide-uri PPT: B.3 Evaluarea fizică - analiza posturii bazinului şi a şoldului; Manualul participantului; Caietul de exerciţii practice; DVD: Analiza posturii bazinului şi a şoldului DVD: Suporturile provizorii; Formular de evaluare - nivel intermediar. pat de evaluare – 1 pentru fiecare grupă; goniometru – 1 pentru fiecare grupă; bucăţi de burete solid/spumă solidă – 1 pentru fiecare grup; inserții unghiulare din burete solid/spumă solidă – 1 pentru fiecare grupă; pernă care a fost modificată pentru a susţine un bazin fix care nu se află în echilibru; pernă care a fost modificată pentru a susţine un şold care nu poate fi flectat pentru atingerea poziției neutre de şedere (unghiul dintre trunchi şi coapse mai mare de 90 de grade) pernă care a fost modificată pentru a susţine un şold sau ambele şolduri care nu pot poate ajunge în poziţia neutră de şedere (unghiul dintre trunchi şi coapse mai mică de 90 de grade); C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoştinţe dobândite anterior: abilitatea de utilizare a unui goniometru este utilă, dar nu esenţială. Adaptaţi această sesiune pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanţii: luaţi în considerare locul unde se va realiza evaluarea; atunci când demonstraţi utilizarea suporturile provizorii cu ajutorul voluntarilor şi solicitații participanţilor să efectueze o analiză a posturii bazinului şi a şoldului - luaţi în considerare aspectele culturale legate de atingerea corpului altor persoane. D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. Recitiți întregul formular de evaluare – nivel intermediar şi exersaţi efectuarea analizei posturii bazinului şi a șoldului. Exersaţi furnizarea de suport provizoriu. Poziționați un pat de evaluare în așa fel încât să fie văzut de către toți participanții din sala de curs. Plasaţi bucăţile şi inserțiile unghiulare din burete solid/spumă solidă pe patul de evaluare, pentru a fi gata de utilizare în timpul demonstraţiei. Aranjaţi sala de curs de așa manieră încât participanţii să stea într-un semicerc, cu faţa către locul unde este amenajat patul de evaluare. Poziționați paturi de evaluare în sala de curs (sau în afara sălii/în săli conexe) pentru ca participanţii să efectueze activităţile în grupe mici.. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 80. R E ZU M A T 1. Introducere 2. Analiza posturii bazinului şi a şoldului. 3. Suporturi provizorii pentru bazin fix care nu se află în echilibru sau pentru şolduri care nu pot fi flectate pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 de grade) 4. Demonstrarea furnizării suporturilor provizorii pentru bazinul fix care nu se află în echilibru 5. Demonstrarea suporturilor provizorii pentru şolduri care nu pot fi flectate pentru atingerea poziției neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 de grade) 6. Exersarea furnizării suporturilor provizorii 7. Recapitulare puncte cheie 2 40 5 10 30 30 3 Durata totală a sesiunii 120 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 81. 1. Introducere (2 minute) Explicaţi: În această sesiune vom afla mai multe despre evaluarea fizică. În această sesiune vom discuta despre: o analiza posturii bazinului şi a şoldului; o furnizarea de suporturi provizorii pentru problemele la nivelul bazinului şi l şoldurilor. 2. Analiza posturii bazinului şi a şoldului (40 de minute) Note pentru formatori: Analiza posturii bazinului şi a şoldului prezentată în acest program de instruire NU reprezintă o evaluare completă a gradului mobilitate. Bazinul: o analiza stabilește doar dacă bazinul este în echilibru sau nu; o acest lucru este necesar pentru că fără corectarea poziției bazinului, este dificilă efectuarea următorului stadiu al evaluării fizice (procedeul de simulare manuală) o Șoldurile: o se evaluează doar gradul de flexie al şoldului; o acest lucru este necesar pentru că fără acomodarea posturilor fixe ale flexiei șoldului, este dificilă efectuarea următorului stadiu al evaluării fizice (procedeul de simulare manuală); o punctul de referinţă îl constituie poziția neutră de ședere, cu şoldul flectat pentru atingerea unghiului corect (90 grade între trunchi şi şolduri). Participanţii învață să identifice: o dacă utilizatorul de scaunul rulant poate menține poziția așezat fără suport o dacă nu - cât de aproape de poziţia neutră este poziția utilizatorului de scaun rulant? o acest aspect este legat direct de unghiul dintre suprafața de ședere şi spătarul scaunului rulant. Cereţi participanţilor să citească secțiunea referitoare la analiza posturii bazinului şi a şoldului din formularul de evaluare – nivel intermediar, din exemplarul primit. Explicaţi: Știm că poziţia așezat este influenţată de postura la nivelul bazinului şi a şoldurilor. În cadrul aceastei părți a evaluării, personalul furnizor de servicii de scaune rulante trebuie să stabilească: o dacă bazinul utilizatorului de scaun rulant este în echilibru, atunci când este privit din faţă (cu suport sau în absența acestuia); o dacă şoldurile utilizatorului de scaun rulant pot fi flectate pentru atingerea poziției neutre de ședere (cu suport sau în absența acestuia). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 82. Explicaţi: o În imagine, bazinul utilizatorului de scaun copilului este în echilibru,iar şoldurile în postura specifică poziţiei neutre de şedere. o observaţi faptul că reprezentantul furnizorului de servicii de scaune rulante are degetul mare plasat pe creasta iliacă antero-superioară (CIAS), putând astfel stabili cu exactitate dacă bazinul este la același nivel. Întrebaţi: În cazul utilizatorului de scaun rulant din imagine, stabiliți dacă bazinul este în echilibru, iar șoldurile sunt în postura specifică poziției neutre de ședere. Răspuns: Nu Dacă bazinul nu este în echilibru sau dacă şoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere (unghiul dintre trunchi şi şolduri este mai mare de 90 grade), personalul furnizor de servicii de scaune rulante trebuie să afle mai multe informaţii. Este important de ştiut: o dacă utilizatorul de scaun rulant poate menține poziţia neutră de ședere cu suport? o dacă nu - cât de aproape de poziţia neutră de ședere este postura sa? Explicaţi: Știm că bazinul se poate mişca în diverse moduri, incluzând aici înclinarea anterioară, înclinarea posterioară, înclinarea laterală sau rotația. Cereţi participanţilor să își poziționeze bazinul în diverse moduri și să se gândească unde anume se localizează mişcarea. Pentru a înțelege mai bine, ei pot să își plaseze mâinile sub oasele bazinului sau să urmărească mișcarea efectuată de un alt participant. Întrebaţi: Unde începe mişcarea de la nivelul bazinului ? Încurajaţi participanţii să răspundă. Cele mai importante răspunsuri: o deasupra bazinului (în zona lombară a coloanei vertebrale); o în partea inferioară a bazinului (la articulația şoldului). Explicaţi: o Dacă utilizatorul de scaun rulant nu poate menține poziţia neutră de şedere, trebuie să aflăm dacă acest lucru se datorează unei limitări (sau restricţii) localizate deasupra sau dedesubtul nivelului bazinului (articulaţiei şoldului), deoarece soluţia de suport postural necesară va fi diferită în funcție de acest aspect. Explicaţi: Iată un exemplu: o această persoană are o postură „prăbușită”, iar bazinul se află în înclinare posterioară; o doar observând, nu putem să ne dăm seama dacă această postură este cauzată de o limitare (restricţie) localizată deasupra sau dedesubtul nivelului bazinului (articulaţiei şoldului). Acest lucru înseamnă că este necesară o analiză a posturii bazinului şi a şoldului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 83. Explicaţi: Prima întrebare din această secțiune a formularului de evaluare - nivel intermediar este: o Bazinul este în echilibru? Întrebaţi: De ce este important să stabilim acest lucru? Cel mai important răspuns: o dacă bazinul persoanei nu este în echilibru, acest lucru va afecta poziția așezat. Explicaţi: După evaluarea poziției bazinului, personalul furnizor de servicii de scaune rulante stabilește dacă şoldurile pot fi flectate până la atingerea poziției neutre de şedere. Accentuaţi: Această evaluare nu este o evaluare completă a gradului de mobilitate. Analizați doar flexia şoldului pentru a stabili: o dacă utilizatorul de scaun rulant poate menține poziţia neutră de ședere cu suport? o dacă nu – care este postura cea mai apropiată de poziția neutră de ședere pe care o poate atinge utilizatorul de scaun rulant? Explicaţi: În această imagine, schița reprezintă un caz în care şoldul nu este flectat pentru atingerea poziţiei neutre de şedere (membrul inferior desenat cu linie roşie). Întrebaţi: Unghiul dintre trunchi şi coapse (linia roşie) este mai mare sau mai mic de 90 de grade? Încurajaţi participanţii să răspundă. Răspuns: o MAI PUȚIN de 90 de grade (aproximativ 70 de grade). Explicaţi: În această imagine, schița reprezintă un caz în care şoldul nu este flectat pentru atingerea poziţiei neutre de şedere (membrul inferior desenat cu linie roşie). Întrebaţi: Unghiul dintre trunchi şi coapse (linia roşie) este mai mare sau mai mic de 90 de grade? Încurajaţi participanţii să răspundă. Răspuns: MAI MARE de 90 de grade (aproximativ 100 de grade). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 84. Întrebaţi: De ce este important să aflăm dacă şoldul poate fi flectat pentru atingerea poziției neutre de şedere? Încurajaţi participanţii să răspundă. Răspunsuri: o Dacă niciunul dintre şolduri nu poate fi flectat pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 grade), acest lucru va afecta capacitatea utilizatorului de scaun rulant de a menține poziţia aşezat. o Va fi necesară acomodarea șoldului (şoldurilor), astfel încât bazinul utilizatorului de scaun rulant să fie drept (dacă acest lucru este posibil). o Dacă bazinul nu este în echilibru sau dacă şoldurile nu pot fi flectate până la atingerea poziţiei neutră de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 grade), acestea vor trebui susţinute în postura non-neutră, în scaunul rulant care va fi livrat utilizatorului. o Pentru a continua evaluarea, este necesară folosirea unui suport provizoriu. o Acest aspect va fi abordat pe parcursul acestei sesiuni. Pregătiţi vizionarea materialului video: Analiza posturii bazinului şi a şoldului Acest material video scurt va prezenta procedeul de analiză a posturii bazinului şi a şoldului. Cereţi participanţilor să urmărească materialul cu multă atenție, deoarece mai târziu vor exersa ei înșili această procedură. Prezentaţi materialul video. Verificaţi dacă există întrebări. Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 3 persoane. Instrucţiuni: Cereţi participanţilor să consulte Caietul de exerciţii practice (B.3: Evaluarea fizică - analiza posturii bazinului şi a şoldului: efectuarea analizei). Cereţi participanţilor să joace pe rând rolul utilizatorului de scaun rulant, al asistentului şi al personalului furnizor de servicii de scaune rulante. Exersaţi efectuarea analizei posturii bazinului şi a şoldului. Cereţi participanţilor să înregistreze rezultatele fiecărei persoane care are rolul utilizatorului de scaun rulant în cadrul grupei, trecându-le la secțiunea „analiza posturii bazinului şi a şoldurilor” Explicaţi: Participanţii au la dispoziţie 20 minute pentru a efectua această activitate, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea fiecărei grupe şi asiguraţi-vă că persoana care are rolul personalului furnizor de servicii de scaune rulante: o are o poziție corectă; o îşi poziţionează corect mâinile pe bazinul, şoldurile şi membrele utilizatorului de scaun rulant; o flectează membrele inferioare ale utilizatorului de scaun rulant la nivelul genunchilor (punând sub genunchi o rolă/suport); o atingerea mâinilor este „uşoară” şi nu strânge sau răneşte utilizatorul de scaun rulant. (Folosiţi Notele pentru formatori din „efectuarea analizei posturii bazinului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 85. şi a şoldului” pentru a vă asigura că grupele desfășoară activitatea în mod corect). Asiguraţi-vă că fiecare grupă înţelege în ce constă activitatea. Acordați asistență participanţilor, dacă acest lucru este necesar. Durata: Acordaţi 20 minute pentru finalizarea activității. Acordaţi 5 minute pentru feedback. Feedback: Verificaţi dacă există întrebări. Întrebaţi: În cazul persoanelor la acre nu există limitări în ceea ce privește mobilitatea, cum au completat grupele secțiunea „analiza posturii bazinului şi a şoldului” din formularul de evaluare – nivel intermediar? (Proiectaţi un model de formular de evaluare – nivel intermediar). Răspuns: Bifaţi ‘da’ pentru bazin în echilibru; Bifaţi ‘Da’ pentru şoldul drept şi cel stâng. Întrebaţi: Au fost cazuri în care existau limitări de mobilitate? Dacă da - cereţi grupelor să ofere mai multe informaţii. Note pentru formatori: Formatorii pot alege să predea partea de analiză a posturii şoldurilor din cadrul evaluării cu ajutorul unui goniometru sau al unui goniometru din carton. Dacă participanţii cunosc deja modul de utilizare a unui goniometru, atunci aceasta este varianta cea mai potrivită. Dacă participanţii nu au mai folosit un astfel un instrument, utilizarea unui goniometru din carton cu unghiuri marcate la intervale de 45 de grade este suficientă. Note pentru formatori: Efectuarea analizei posturii bazinului şi a şoldului: Atunci când monitorizaţi activitatea grupelor, asiguraţi-vă că participanţii efectuează această procedură urmând pașii de mai jos: Pregătire: o explicați utilizatorului de scaun rulant ce urmează să faceți și motivul pentru care această activitate este importantă; o utilizatorul trebuie să se afle pe patul de evaluare, în poziția de decubit dorsal. Rețineți faptul că persoana care efectuează analiza posturii bazinului și a șoldului este numită „evaluator”, iar persoana care asistă evaluatorul este numită „asistent”, aceasta putând fi un coleg, o persoană care are pregătirea de asistent, un membru al familiei sau un însoțitor. Analiza posturii bazinului: o evaluatorul flectează ușor ambii genunchi ai utilizatorului de scaun rulant, furnizând un anumit grad de suport, ceea ce duce la scăderea tensiunii la nivelul șoldurilor; o asistentul poziționează mâinile pe trunchiul utilizatorului de scaun rulant, la nivelul coastelor inferioare, sprjinind cu fermitate; o evaluatorul plasează mâinile pe bazinul Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 86. utilizatorului de scaun rulant, având degetele mari poziționate de creasta iliacă antero-superioară (CIAS); o evaluatorul verifică dacă degetele/crestele iliace antero- superioare se situează la același nivel; o dacă nu sunt la același nivel, cu o mișcare lentă, dar fermă, evaluatorul încearcă să îndrepte bazinul, în așa fel încât ambele CIAS să fie la același nivel; o asistentul comunică dacă simte mișcare la nivelul trunchiului, ceea ce ar însemna că există o anumită restricție în mobilitate; o observați cât de aproape de poziția neutră poate fi poziționat bazinul (cât de aproape de poziția de echilibru); o în formularul de evaluare - nivel intermediar, evaluatorul notează dacă bazinul poate fi poziționat în așa fel încât să se afle în echilibru. Analiza posturii şoldului: asistentul ține ferm bazinul utilizatorului de scaun rulant, însă fără a-l forța; evaluatorul flectează puțin genunchiul membrului inferior care nu este testat în acel moment, poziționând piciorul pe saltea. Acest lucru ajută la reducerea tensiunii la nivelul șoldului testat. Este posibil să fie necesară sprijinirea membrului inferior la care se efectuează testul. evaluatorul mută ușor membrul inferior testat în poziția neutră de ședere; asistentul comunică dacă simte mișcare la nivelul bazinului, ceea ce ar însemna că există o anumită restricție (limitare) în mobilitate; evaluatorul constată care este gradul de libertate de mișcare la nivelul articulației șoldului; evaluatorul repetă acțiunea pe cealaltă parte a corpului și compară rezultatele; în formularul de evaluare - nivel intermediar, evaluatorul notează dacă șoldul drept și stâng pot fi flectate în poziția neutră de ședere. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 87. cu ajutorul unui asistent și folosind un goniometru, evaluatorul constată cât de aproape de poziția neutră poate ajunge fiecare șold; evaluatorul poziționează punctul pivot al gonimetrului pe articulația șoldului. Unul din brațele goniometrului va sta de-a lungul femurului, iar celălalt va fi aliniat cu trunchiul; evaluatorul ține unite cele două brațe ale goniometrului; în formularul de evaluare - nivel intermediar evaluatorul înregistrează valoarea măsurată (gradul unghiului) la nivelul șoldurilor drept și stâng; de asemenea, evaluatorul poate desena unghiul goniometrului pe o coală separată sau pe formularul de evaluare – nivel intermediar (verso). 3. Suporturi provizorii pentru bazin fix aflat în poziție vicioasă (înclinare laterală) şi şolduri care nu pot fi flectate pentru atingerea poziției neutre de şedere (5 minute) Explicaţi: Dacă bazinul se află în poziție vicioasă sau dacă șoldul nu poate fi flectat în poziția neutră de ședere (unghiul dintre trunchi și coapse este mai mare de 90 grade), aceste părți ale corpului trebuie susținute în postura non-neutră din scaunul rulant pregătit pentru utilizare. Pentru a continua evaluarea, este nevoie de un suport provizoriu. Întrebaţi: De ce este important să folosim un suport provizoriu pentru continuarea etapei de evaluare? Răspunsuri: Pe parcursul unei evaluări, suportul provizoriu: o va ajuta utilizatorul de scaun rulant să mențină o poziție mai stabilă și mai echilibrată; o va împiedica utilizatorul de scaun rulant „să compenseze” bazinul aflat în poziție vicioasă sau șoldurile care nu pot fi flectate în poziția neutră de ședere (unghiul dintre trunchi și coapse mai mare de 90 grade); o va permite personalului furnizor de servicii de scaune rulante să efectueze evaluarea și să se concentreze pe restul posturii utilizatorului de scaun rulant - bazin, trunchi, cap, gât și membre inferioare. Explicaţi: Suporturile provizorii sunt necesare atunci când: o bazinul utilizatorului este fix și inegal (în înclinare laterală) o şoldul nu poate fi flectat pentru atingerea poziției neutre de ședere (unghiul dintre coapse şi trunchi este mai mare de 90 de grade); o niciunul dintre şolduri nu pot fi flectate în întregime pentru atingerea poziției neutre de ședere (unghiul dintre coapse şi trunchi este mai mic de 90 de grade); Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 88. o unul sau niciunul dintre şolduri nu pot fi extinse în întregime pentru atingerea poziţiei neutre de ședere (unghiul dintre coapse şi trunchi este mai mic de 90 de grade); După evaluare, acest suport provizoriu va deveni o componentă permanentă încorporată în perna scaunului rulant. Explicaţi: o un suport provizoriu poate fi confecţionat dintr-o bucată de spumă solidă/burete solid; o în mod ideal, suportul trebuie să fie din acelaşi material din care este confecționat stratul de bază al pernei; o prin folosirea aceluiaşi tip de material, dimensiunea exactă a materialului poate fi stabilită pe parcursul evaluării, deoarece compresia materialului va fi identică; o din acest motiv, se recomandă ca pe parcursul evaluării să avem la dispoziţie bucăți dreptunghiulare sau unghiulare confecționate din spumă solidă/burete solid; o pot fi combinate bucăţi cu înălţimi diferite (de exemplu, 10 mm, 20 mm, 30 mm) pentru a crea componente cu înălţimi diferite. Arătaţi bucăți dreptunghiulare sau unghiulare confecționate din spumă solidă/burete solid. 4. Demonstrație privind utilizarea suporturilor provizorii în cazul utilizatorilor cu bazinul fix, în poziție vicioasă (10 minute) Rugați un voluntar să vină în faţa participanților şi să se aşeze pe patul de evaluare. Demonstraţi: Explicaţi: o cereţi voluntarului să adopte o poziție cu bazinul fix, aflat în poziție vicioasă (înclinare laterală). În cazul utilizatorilor de scaun rulant care au bazinul fix, în poziție vicioasă: o o parte a bazinului şi una dintre coapse susţin o greutate mai mare, comparativ cu partea opusă. Acest lucru are ca rezultat riscul apariției escarelor. De asemenea, utilizatorul de scaun rulant nu are o poziție stabilă, deoarece greutatea sa este mai mult pe o parte ; o soluția o reprezintă înălțarea suprafeţei de ședere pentru a susţine oasele bazinului situate mai sus. o Suportul provizoriu formează o inserție pe partea situată mai sus. o Suportul provizoriu trebuie să fie situat sub oasele bazinului de pe respectiva parte şi sub coapsă. Suportul nu va Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 89. o poziționați suportul provizoriu sub partea laterală situată mai sus. o asiguraţi-vă că suportul provizoriu este suficient de lung pentru a susţine coapsa (se extinde până în zona situată chiar în spatele genunchiului). modifica postura bazinului. o Cu ajutorul acestui suport provizoriu, se îmbunătățește echilibrul utilizatorului de scaun rulant, iar presiunea va fi distribuită egal pe întreaga suprafață de sub oasele bazinului. o demonstraţi modalitatea de testare a nivelului de presiune prin plasarea degetelor în spațiul dintre ambele părți ale oaselor bazinului (cu palma în sus) şi suprafața de şedere. o Nivelul de presiune poate fi testat prin plasarea degetelor sub oasele bazinului (cu palma în sus), în timp ce trunchiul este susţinut şi drept. Mulţumiţi voluntarului. Explicaţi: o personalul furnizor de servicii de scaune rulante poate evalua în continuare postura bazinului şi a trunchiului; o suportul va fi încorporat în perna scaunului rulant care va fi livrat utilizatorului. În cazul în care este disponibilă, prezentaţi o pernă care a fost modificată pentru a susţine un bazin fix aflat în poziție vicioasă. Note pentru formatori: o Atunci când bazinul utilizatorului este fix și se află în poziție vicioasă, suportul provizoriu contribuie la susţinerea posturii. Suportul provizoriu nu corectează postura. o În timpul folosirii scaunului rulant, postura utilizatorul va fi în continuare asimetrică. Bazinul şi una dintre coapse vor fi situate mai sus comparativ cu cealaltă coapsă. De asemenea, pe aceeași parte, genunchiul şi suportul pentru picioare se vor situa mai sus. o Atunci când se furnizează suport provizoriu pentru un bazin fix aflat în poziție vicioasă: o asiguraţi-vă că suportul se poziționează sub întreaga lungime a coapselor. Dacă suportul nu se extinde înspre înainte, există pericolul ca greutatea să nu fie distribuită în mod egal sub ambele coapse; o asiguraţi-vă că există o inserţie anterioară oaselor bazinului. Aceasta va reduce tendința corpului de a aluneca înspre înainte, fapt care poate cauza iritarea suprafeței pielii şi crește riscul apariției escarelor. 6. Demonstrație privind utilizarea suportului provizoriu în cazul utilizatorilor cu şolduri care nu pot fi flectate sau extinse până la atingerea poziţiei neutre de şedere (30 de minute) Explicaţi: În cele ce urmează ne vom ocupa de suportul provizoriu necesar în cazul în care şoldurile nu pot fi flectate pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 grade). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 90. Rugați un voluntar (participant) să vină în faţa grupului de participanți la curs şi să se aşeze pe patul de evaluare. Demonstraţi: Explicaţi: o Cereţi voluntarului să stea cu şoldul DREPT fix, având unghiul dintre trunchi şi coapse MAI MARE de 90 de grade. o În cazul unui şold fix, care nu poate fi flectat până la atingerea poziției neutre de ședere (unghiul dintre trunchi şi coapsă este mai mare de 90 de grade), bazinul se va înclina înspre lateral şi există posibilitatea apariției rotației bazinului. o Acest lucru are ca rezultat o poziție necorespunzătoare a bazinului şi a trunchiului şi distribuția inegală a greutății sub oasele bazinului. o Plasaţi suportul provizoriu sub ambele părți ale oaselor bazinului şi sub coapsa STÂNGĂ (partea pe care coapsa poate fi flectată până la atingerea poziţiei neutre de şedere) o Se introduce o inserţie sub ambele părți ale oaselor bazinului şi sub coapsa de pe partea unde şoldul poate fi flectat pentru atingerea poziției neutre de şedere. Șoldul care se află într-o poziție fixă, având un unghi mai mare decât cel specific poziției de ședere neutre, va reuşi astfel să se relaxeze. o Înălţimea inserţiei trebuie să fie calculată corect, astfel încât inserția să acomodeze gradul de limitare a mobilității la nivelul şoldului. o Arătați spațiul triunghiular format între coapsa DREAPTĂ şi suprafața de ședere a patului de evaluare. o Există un spațiu triunghiular format între coapsă şi suprafața de ședere a patului de evaluare. o Acesta trebuie să fie identic cu unghiul stabilit prin analiza posturii şoldului. o Șoldul fix este susținut şi nu va cauza o poziţie vicioasă a bazinului. Personalul furnizor de servicii de scaune rulante poate efectua în continuarea evaluarea posturii bazinului şi a trunchiului. Mulţumiţi voluntarului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 91. Explicaţi: o Acest suport provizoriu va fi încorporat în perna scaunului rulant care va fi livrat, pentru a oferi suport permanent. o O inserție unghiulară este introdusă în perna scaunului rulant, pentru a sprijini coapsa la unghiul dintre trunchi şi coapsă stabilit în cadrul etapei de evaluare. Imaginea prezintă o modalitate prin care poate fi realizat acest lucru. Notă – se recomandă poziționarea unui strat din spumă/burete moale deasupra inserției din spumă solidă/burete solid. Asiguraţi-vă că nu există margini ascuţite în interiorul pernei. Dacă este disponibilă, prezentaţi o pernă care a fost modificată în acest mod. Note pentru formatori: o Există posibilitatea ca participanţii să vă întrebe de ce un suport cu formă unghiulară nu poate fi folosit ca suport provizoriu. Explicaţi faptul că dacă un utilizator de scaun rulant ar sta pe o suprafaţă plană, fără a beneficia de sprijin, ar fi necesară îndepărtarea unui suport cu formă unghiulară de sub coapsa de pe partea unde șoldul are un grad de mobilitate limitat. Evident, tăierea suprafeței patului de evaluare nu reprezintă nicidecum o soluție. În consecință, utilizatorul de scaun rulant este ridicat de pe suprafaţa de ședere pentru a acomoda şoldul aflat în poziție fixă. o Pentru a economisi timp şi materiale, se lasă un spațiu sub coapsă, astfel suportul provizoriu va fi poziționat doar sub oasele bazinului şi cealaltă coapsă. Coapsa se va situa la unghiul corespunzător în spațiul suportului provizoriu. La produsul final (perna), spațiul de sub coapsă va fi umplut, iar sub coapsă va exista un suport de formă unghiulară. o Suportul provizoriu este o pernă asimetrică. Acest lucru înseamnă că genunchiul şi suportul pentru picioare de pe o parte sunt situate mai jos decât pe partea opusă. Pot rezulta instabilitate şi alunecare şi se recomandă luarea în considerare a altor DSP-uri, cum ar fi centura pentru bazin. Acest aspect nu este discutat în acest program de instruire. Explicaţi: Vom discuta în cele ce urmează despre suporturi provizorii pentru cazurile în care niciunul dintre şolduri nu poate fi flectat pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 de grade). Întrebaţi: Ce fel de suporturi provizorii pot fi folosite atunci când niciunul dintre şolduri nu poate fi flectat pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 de grade)? Încurajaţi unul sau doi voluntari (voluntari) să vină în faţa grupului, pentru a face o demonstraţie. Ceilalți participanți pot oferi sugestii. Asiguraţi-vă că participanţii vor identifica răspunsul corect. Răspuns: Suporturi provizorii pentru cazul în care unul sau niciunul dintre şolduri nu pot fi flectate pentru atingerea poziţiei neutre de şedere (ambele unghiuri sunt mai mari de 90 de grade): Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 92. o se folosește o inserţie sub ambele părți ale oaselor bazinului, pentru a acomoda mobilitatea limitată la nivelul şoldurilor; o înălţimea inserţiei trebuie să fie calculată corect, astfel încât inserția să acomodeze gradul de limitare a mobilității la nivelul şoldurilor. o există un spațiu triunghiular între coapsă şi suprafața de ședere a patului de evaluare. o acesta trebuie să fie identic cu unghiul măsurat cu ajutorul goniometrului. o evaluarea poate fi efectuată în continuare. Explicaţi: o În cazul în care niciunul dintre şoduri nu poate fi flectat pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 grade), atunci acestea pot fi sprijinite tenporar cu ajutorul unei inserţii poziținate sub ambele părți ale oaselor bazinului. Explicaţi: La livrarea scaunului rulant, acest suport provizoriu nu va fi încorporat în pernă. Suportul este creat prin creşterea unghiului dintre suprafața de edere şi spătar. Întrebaţi: De ce suportul permanent nu este încorporat în pernă, la fel ca şi în cazul suportului provizoriu? Răspuns: Utilizatorul de scaun rulant ar avea tendinţa de a aluneca înspre înainte în scaunul rulant. Acest lucru îngreunează utilizarea scaunului rulant şi crește riscul apariției escarelor. Întrebaţi: Ce fel de suporturi provizorii pot fi folosite atunci când unul sau niciunul dintre şolduri nu poate fi extins pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mic de 90 de grade)? Încurajaţi unul sau doi voluntari (voluntari) să vină în faţa grupului, pentru a face o demonstraţie. Ceilalți participanți pot oferi sugestii. Asiguraţi-vă că participanţii vor identifica răspunsul corect. Răspuns: Suporturi provizorii pentru cazul în care unul sau niciunul dintre șolduri nu poate fi extins pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mic de 90 de grade): o furnizarea unui suport provizoriu anterior oaselor bazinului şi sub coapse; o cea mai bună soluție o reprezintă folosirea unei inserţii unghiulare din spumă solidă/burete solid; o evaluarea poate fi efectuată în continuare. Explicaţi: o în cazul în care unul sau niciunul dintre șolduri nu poate fi extins pentru atingerea poziţiei neutre de şedere (unghiul dintre trunchi şi coapse este mai mic de 90 de grade), furnizați suport provizoriu în zona anterioară oaselor bazinului şi sub coapse; o puteți folosi o inserţie unghiulară din spumă solidă/burete solid, dacă este disponibilă; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 93. o în caz contrar, folosiți o bucată de spumă solidă/burete solid de formă dreptunghiulară, pentru a confecționa un suport provizoriu. Explicaţi: o imaginea alăturată ne arată modul în care ar arăta acest suport încorporat în perna unui scaun rulant. Dacă este disponibilă, prezentaţi o pernă care a fost modificată în acest mod. Note pentru formatori: Este posibil ca participanţii să întrebe motivul pentru care se furnizează suport sub ambele coapse, chiar dacă limitările de mobilitate sunt prezente doar la unul dintre șolduri. Răspuns: o de regulă, perna are o formă unghiulară sub ambele coapse, deoarece acest lucru ajută la menţinerea simetriei: o totuşi, în anumite cazuri, se recomandă ca inserția unghiulară să fie plasată doar sub membrul inferior pe partea căruia există limitarea de mobilitate; de exemplu, dacă forma inserției îngreunează realizarea transferului în și din scaunul rulant. Pregătiţi vizionarea materialului video: Suporturi provizorii. Acest material video scurt îl prezintă pe Richard. Bazinul lui Richard este drept, cu toate acestea niciunul dintre șolduri nu poate fi flectat până la atingerea poziţiei neutră de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 de grade). Veţi vedea modul în care personalul furnizor de servicii de scaune rulante lucrează cu Richard pentru efectuarea analizei bazinului şi z şoldului și cum se furnizează suporturile provizorii. Prezentaţi materialul video. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 94. 6. Exersarea suporturilor provizorii (30 de minute) Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 2 sau 3 persoane. Instrucţiuni: Cereţi participanţilor să citească cazul fiecărui utilizator de scaun rulant din Caietul de exerciții practice (B.3: Evaluarea fizică - analiza posturii bazinului şi a şoldului: exersarea suporturilor provizorii). Explicaţi: În cazul fiecărui utilizator de scaun rulant, participanţii vor trebui să decidă dacă bazinul utilizatorului este drept şi dacă șoldurile pot fi flecate pentru atingerea poziţiei neutre de şedere. Cereţi participanţilor să completeze secțiunea referitoare la analiza posturii bazinului şi a şoldului din formularul de evaluare – nivel intermediar și să decidă dacă utilizatorul are nevoie de suport provizoriu. Solicitaţi participanţilor să pregătească un suport provizoriu pentru fiecare dintre utilizatorii de scaun rulant din exercițiu. Cereţi participanţilor să verifice fiecare suport provizoriu. Se recomandă ca fiecare participant să testeze suportul provizoriu, pentru a înțelege modul în care acesta funcționează. Explicaţi: Participanţii au la dispoziţie 20 de minute pentru a efectua această activitate, apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea fiecărei grupe. Asiguraţi-vă că fiecare grup înţelege ce presupune activitatea. Oferiți asistență grupelor, dacă acest lucru este necesar. Asiguraţi-vă că participanţii pregătesc corect suporturile provizorii. Durata: Acordaţi 20 minute pentru finalizarea activității. Acordaţi 10 minute pentru feedback. Feedback: Cereţi unei grupe să descrie suportul provizoriu confecționat pentru Sam; Cereţi unei grupe să descrie suportul provizoriu confecționat pentru Martha; Cereţi unei grupe să descrie suportul provizoriu confecționat pentru Seren; Cereţi unei grupe să descrie suportul provizoriu confecționat pentru Joe; Verificaţi dacă există întrebări. Sam Analiza posturii bazinului şi a şoldului Sam are 4 ani. El este diagnosticat cu paralizie cerebrală și nu poate menține singur poziția așezat. Făcând analiza posturii bazinului și a șoldului vom constata că: o Bazinul lui Sam este în echilibru (crestele iliace antero-superioare se află la același nivel); o Șoldul stâng al lui Sam poate fi flectat până la atingerea poziției neutre de ședere, fără a-i produce vreun disconfort. Sam acuză dureri la nivelul șoldului drept, iar acesta nu poate fi flectat în întregime pentru poziția neutră de ședere (unghiul dintre trunchi și coapse este mai mare de 90 de grade). Unghiul dintre trunchi și coapsă, pe partea dreaptă, este de Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Unghi: 105 de grade Stânga: Da 90 de grade Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 95. aproximativ 105 grade. Necesită Sam suport provizoriu? Da Nu Suportul provizoriu este poziționat sub ambele părți ale oaselor bazinului şi sub coapsa stângă. Nu există suport sub coapsa dreaptă, iar aceasta formează un unghi. Martha Analiza posturii bazinului şi a şoldului Martha are 57 de ani. Este diagnosticată cu artrită severă. Se poate deplasa pe o distanță de câțiva pași, dar acest lucru îi provoacă un grad ridicat de durere. Făcând analiza posturii bazinului și a șoldului vom constata că: o Bazinul Marthei este în echilibru (crestele iliace antero-superioare se află la același nivel); o Niciunul dintre șolduri nu poate fi flectat în întregime până la atingerea poziției neutre de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade). Unghiul dintre trunchi și coapse la ambele șolduri este de aproximativ 100 de grade. o Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Unghi: 100 de grade Stânga: Da Nu Unghi: 100 de grade Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Necesită Martha suport provizoriu? Da Nu Suportul este situat doar sub oasele bazinului. Nu există suport sub coapse, iar acestea formează un unghi. Seren Analiza posturii bazinului şi a şoldului Seren are 16 ani. În copilărie a avut poliomielită și a rămas cu contracții severe la membrele inferioare.pilărie şi prezintă contracţii severe la ambele picioare. Seren se deplasează cu rapiditate pe podea, ținând membrele inferioare încrucișate. Făcând analiza posturii bazinului și a șoldului vom constata că: o Bazinul lui Seren nu este în echilibru. Partea dreaptă a bazinului ei este situată cu cu 20 mm mai sus decât cea stângă; Ambele şolduri pot fi flectate până la atingerea poziției neutre de şedere. Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: 90 de grade Stânga: Da Nu Unghi: 90 de grade Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. o Necesită Seren suport provizoriu? Da Nu Suportul este poziționat sub partea dreaptă a bazinului şi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 96. Joe Analiza posturii bazinului şi a şoldului Joe are 25 de ani. În copilărie a avut poliomielită și a rămas cu contracții severe la ambele membre inferioare. Făcând analiza posturii bazinului și a șoldului vom constata că: o Bazinul lui Joe este fi echilibru (crestele iliace antero-superioare se află la același nivel); o Șoldul drept al lui Joe poate fi flectat până la atingerea poziției neutre de ședere, fără a-i produce disconfort. Totuși, șoldul stâng nu poate fi extins în întregime (unghiul dintre coapse și trunchi este mai mic de 90 de grade). Unghiul dintre trunchi și coapsă este de 70 de grade. Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: 90 de grade Stânga: Da Nu Unghi: 70 de grade Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Necesită Joe suport provizoriu? Da Nu Un suport în formă de inserţie unghiulară este poziționat în faţa oaselor bazinului şi sub ambele coapse. Unghiul suportului unghiular trebuie să fie de aproximativ 70 de grade (suportul unghiular poate fi poziționat exclusiv sub coapsa stângă, în cazul în care Joe preferă această variată sau dacă suportul plasat sub ambele coapse împiedică utilizatorul în realizarea transferului în și din scaunul rulant). 7. Recapitulare puncte cheie (3 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. sub coapsa dreaptă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 97. B.4: Evaluarea fizică – procedeul de simulare manuală O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să descrie modul în care, cu ajutorul procedeului de simulare manuală, putem afla: o dacă utilizatorul de scaun rulant poate menține poziția așezat cu suport; o dacă nu - cât de aproape de poziţia neutră de ședere este postura utilizatorului de scaun rulant; o tipul de suport necesar şi poziționarea acestuia. notaţi informaţiile obținute în urma exersării procedeului de simulare manuală în formularul de evaluare – nivel intermediar. R E S U R S E Pentru sesiune: slide-uri PPT: B.4: Evaluarea fizică – procedeul de simulare manuală; Manualul participantului; DVD: Demonstraţie procedeul de simulare manuală - Deepak; DVD: Demonstraţie procedeul de simulare manuală - Enith; DVD: Demonstraţie procedeul de simulare manuală - Bahati; Formular de evaluare - nivel intermediar. C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptaţi conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanţii. Luați în considerare următoarele aspecte: Se recomandă ca materialul care urmează să fie folosit pentru confecționarea suporturilor provizorii să fie cel din care este confecționat stratul de bază al pernei care va fi livrată utilizatorului de scaun rulan. Astfel vom putea evalua cât mai corect care sunt dimensiunilor necesare pentru adaptarea stratului de bază a pernei. D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. Recitiți în întregime formularul de evaluare – nivel intermediar şi exersaţi procedeul de simulare manuală. P R E ZE N TA R E 1. Introducere 2. Cu se realizează procedeul de simulare manuală 3. Înregistrarea rezultatelor procedeului de simulare manuală 4. Recapitulare puncte cheie 5 15 35 5 Durata totală a sesiunii 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 98. 1. Introducere (5 minute) Explicaţi: o Pe parcursul acestei sesiuni vom discuta despre următorul pas al etapei de evaluare fizică, numit „procedeul de simulare manuală”. o Procedeul de simulare manuală înseamnă că personalul furnizor de servicii de scaune rulante stabilește următoarele, cu ajutorul mâinilor: o dacă utilizatorul de scaun rulant poate menține poziția așezat cu suport? o dacă nu – care este postura cea mai apropiată de cea neutră pe care utilizatorul o poate menține, fără a resimți disconfort? o ce tip de suport este necesar şi unde este acesta poziționat. Pe parcursul procedeului de simulare manuală, personalul furnizor de servicii de scaune rulante oferă utilizatorului suportul necesar, lucrând împreună cu un asistent sau membru al familiei/însoțitor. Explicaţi: o Aceasta este secțiunea din formularul de evaluare - nivel intermediar folosită pentru înregistrarea rezultatelor procedeului de simulare manuală. o Vom aborda partea referitoare la înregistrarea rezultatelor procedeului de simulare manuală pe parcursul acestei sesiuni. 2. Cum se realizează procedeul de simulare manuală (15 minute) Pregătiţi vizionarea materialului video: Demonstraţie procedeul de simulare manuală – Deepak. Vom vedea personalul furnizor de servicii de scaune rulante lucrând cu un tânăr pe nume Deepak, pentru realizarea procedeului de simulare manuală. Deepak nu poate menține poziţia aşezat. Cereţi participanţilor să urmărească materialul video cu multă atenție. Prezentaţi materialul video. Verificaţi dacă există întrebări. Explicaţi: o Este important să fiți foarte atenți la acțiunile necesare. Cu ajutoul mâinilor, furnizați suportul pe care mai târziu îl vor oferi scaunul rulant şi DSP-urile. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 99. o Pe parcursul procedeului de simulare manuală, fiţi atenţi la următoarele: o locul unde vă sunt poziționate mânile; o direcţia forţei/suportului; o nivelul de forţă şi gradul de suport; o suprafaţa pe care acționează mâinile (de exemplu, dacă se folosește doar un deget sau întreaga palmă); o Aceaste informaţii vor contribui la prescrierea scaunului rulant şi a DSP-urilor corespunzătoare pentru respectivul utilizator de scaun rulant. Întrebaţi participanţii: În materialul video prezentat, care parte a corpului a fost sprijinită prima de către personalul furnizor de servicii de scaune rulante? Încurajaţi participanţii să răspundă. Răspuns: o bazinul Explicaţi: o Bazinul va fi întotdeauna prima parte a corpului pe care o vom sprijini. Acest lucru este rezultatul faptului că poziția bazinului influențează poziția celorlate părți ale corpului. o Dacă bazinul utilizatorului de scaun rulant nu este în poziţie neutră, încercați să corectați poziția cu ajutorul mâinilor. o După ce bazinul a fost stabilizat, ne vom concentra pe celelalte părți ale corpului, conform următoarei secvențe: o trunchi/membre superioare; o cap şi gât; o şolduri şi coapse; o gambe. o Efectuaţi câte o singură schimbare, consecutiv. De exemplu, nu încercaţi să schimbați postura trunchiului simultan cu schimbarea posturii bazinului. o Lucraţi cu un asistent - acesta poate fi un membru al familiei/însoțitor. o Observaţi modul în care modificarea posturii unei părţi a corpului influențează celelalte părţi ale corpului utilizatorului. o Solicitați un feedback utilizatorului de scaun rulant. o Observaţi conturul bazinului şi al trunchiului din lateral. Acest aspect este important pentru a decide care va fi forma spătarului, astfel încât acesta să furnizeze suportul optim. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 100. 3. Înregistrearea rezultatelor unei simulări manuale (35 de minute) Explicaţi: Rezultatele procedeului de simulare manuală sunt înregistrate în formularul de evaluare - nivel intermediar. Există secțiuni pentru: o a bifa dacă părțile corpului utilizatorul de scaun rulant pot atinge poziția neutră de ședere, cu ajutorul suportului manual; o a descrie sau schița postura finală a utilizatorului de scaun rulant, rezultată în urma furnizării suportului manual; o a descrie sau a schița tipul de suport oferit, astfel încât utilizatorul să poată atinge respectiva postură de şedere. Pregătiţi vizionarea materialului video: Demonstraţie procedeul de simulare manuală – Enith. Vom viziona un alt exemplu de realizare a procedeului de simulare manuală. Explicaţi: o Vom afla acum mai multe despre Enith. În acest material video, este prezentată Enith, care a venit la evaluare împreună cu mama ei. Pe parcursul interviului de evaluare, Enith şi mama ei au explicat că Enith are luxație de şold drept, care face ca orice mișcare să îi provoace durere. o Personalul furnizor de servicii de scaune rulante observă că Enith nu poate menține poziţia aşezat fără suport. Bazinul se află în înclinare posterioară, trunchiul este curbat înspre înainte, iar membrele inferioare sunt „înclinate” spre stânga. o Se efectuează analiza posturii bazinului şi a şoldului. Se stabilește că bazinul ei se află în echilibru şi că ambele şolduri pot fi flectate pentru atingerea poziţiei neutre de şedere. Cu toate acestea, şoldul ei drept este orientat spre interior (spre linia mediană), iar această postură este fixă (nu poate fi corectată). o Priviţi cu atenţie – vom discuta apoi care sunt celelalte informaţii pe care personalul furnizor de servicii de scaune rulante le-a obținut cu ajutorul procedeului de simulare manuală. Prezentaţi materialul video. Verificaţi dacă există întrebări. Întrebaţi: Care a fost postura inițială a lui Enith? Răspunsuri: o bazin în înclinare posterioară fixă; o bazin care nu se află în echilibru, având partea dreaptă situată puţin mai sus; o trunchi curbat/„prăbușit”/în colaps; o umerii la același nivel (mama ei o sprijină la nivelul umerilor ei. În absența acestui suport, postura lui Enith se modifică); o şold drept orîn adducție (orientat spre stânga); o lungimea coapsei drepte este mai scurtă decât cea stângă. Întrebaţi: Care parte a corpului beneficiază prima de sprijin? Care sunt următoarele și în ce ordine? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 101. Răspunsuri: o pasul 1: suport furnizat în partea posterioară a bazinului; o pasul 2: suport în partea posterioară a trunchiului; o pasul 3: suport în părţile laterale ale trunchiului; o pasul 4: suport la nivelul membrelor superioare. Proiectaţi acest slide (dacă acest lucru este posibil). Explicaţi: Vom completa împreună partea referitoare la procedeul de simulare manuală din formularul de evaluare - nivel intermediar – cazul Enith. Întrebaţi (pentru fiecare parte a corpului) dacă suportul manual a contribuit la atingerea poziției neutre de ședere. Bifaţi „da” de fiecare dată când se oferă un răspuns corect. Întrebaţi: Cum putem descrie postura finală a lui Enith? Scrieţi/desenaţi pe tablă o descriere a posturii lui Enith, precum şi în spaţiul corespunzător din formularul de evaluare – nivel intermediar. Dacă nu este disponibilă o tablă, cereţi participanţilor să folosească exemplarul pe care îl au, în timp ce formatorul explică/desenează pe o coală de flipchart. Note pentru formatori: Pentru acest exerciţiu, puteţi ruga participanţii să vină în faţă pentru a desena postura finală a lui Enith. Răspuns: Procedeul de simulare manuală: suportul necesar pentru atingerea poziției neutre de ședere / poziții cu bazinul cu bazinul cât mai aproape de poziția neutră de ședere, fără a cauza disconfort. Pentru fiecare parte a corpului: Dacă este posibilă atingerea poziţiei neutre de şedere cu ajutorul suportului manual, bifaţi „da”. În caz contrar, bifaţi „nu”. Parte a corpului Da Nu Descrieţi sau schițați poziția așezat finală a utilizatorului de scaun rulant, realizată cu suport manual şi descrieţi sau desenaţi sau schițați suportul oferit pentru obţinerea respectivei poziții de ședere. Postură: bazin aflat în înclinare posterioară. unghiul dintre trunchi şi coapsă este mai mare de 90 de grade; partea inferioară a trunchiului este plană (absența curburii lombare) şi înclinată (nu dreaptă); partea superioară a trunchiului este dreaptă; capul în poziție dreaptă (cu ajutorul suportului manual); picior drept orientat spre interior spre linia mediană (în adducție). Notă: Lungimea coapsei drepte a lui Enith este mai scurtă decât cea stângă. Suport oferit: grad ridicat de suport în partea posterioară a bazinului lui Enith; Bazin ✓ Trunchi ✓ Cap ✓ Șold S ✓ Șold D ✓ Coapse ✓ Genunchi S ✓ Genunchi D ✓ Gleznă S ✓ Gleznă D ✓ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 102. suport în partea posterioară a trunchiului lui Enith; grad scăzut de suport în părţile laterale ale trunchiului; suport pentru membrele superioare (cu brațul poziționat în față). Note pentru formatori: Participanţii ar putea să vă întrebe dacă se poate oferi suport la nivelul coapsei drepte, în vederea atingerii poziţiei neutre de şedere. Informaţiile din evaluare legate de durerea resimțită la nivelul şoldurilor (cauzată de orice mişcare sau încercare de corectare a posturii) indică faptul că se recomandă doar un grad minim de suport (sau absența suportului). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 103. Pregătiţi vizionarea materialului video: Demonstraţie procedeul de simulare manuală – Bahati. Vom vedea în cele ce urmează un alt exemplu de procedură de simulare manuală. Explicaţi: o Bahati este student la științe administrative la facultatea locală. o Scaunul ei rulant este uzat şi nu îi oferă suport postural corespunzător. o Pe parcursul interviului de evaluare, Bahati a spus că oboseşte o zi în scaunul rulant o obosește mult. Ea își dorește să aibă un scaun rulant pe care să îl poată folosi pe durate mai lungi, fără a resimți disconfort, reducând astfel oboseala şi având condiții mai bune pentru studiu. o Priviţi cu atenţie – vom discuta mai târziu despre ce alte informaţii a aflat personalul furnizor de servicii de scaune rulante cu ajutorul procedeului de simulare manuală. Prezentaţi materialul video. Verificaţi dacă există întrebări. Întrebaţi: Care a fost postura inițială a lui Bahati? Răspuns: o poziţie așezat „prăbușită”; o bazin aflat în înclinare posterioară. o trunchi curbat; o şold drept flectat mai mult decât este necesar pentru atingerea poziţiei neutre de şedere, cu coapsa dreaptă în abducție; o şold stâng flectat mai mult decât este necesar pentru atingerea poziţiei neutre de şedere, cu coapsa stângă în abducție; Întrebaţi: Care parte a corpului beneficiază prima de sprijin? Care sunt următoarele și în ce ordine? Răspuns: o pasul1: suport furnizat în partea posterioară a bazinului; o pasul 2: suport furnizat în partea posterioară, la nivelul inferior al trunchiului; o pasul 3: suport la nivelul membrelor superioare. Proiectaţi acest slide (dacă acest lucru este posibil). Explicaţi: Ca şi în cazul lui Enith, vom completa împreună partea referitoare la procedeul de simulare manuală din formularul de evaluare - nivel intermediar (pentru Bahati). Întrebaţi (pentru fiecare parte a corpului) dacă suportul manual a contribuit la atingerea poziției neutre de ședere. Bifaţi „da” de fiecare dată când se oferă un răspuns corect. Întrebaţi: Cum putem descrie postura finală a lui Bahati? Scrieţi/desenaţi pe tablă o descriere a posturii lui Bahati, precum şi în spaţiul corespunzător din formularul de evaluare – nivel intermediar. Întrebaţi: Aveți întrebări legate de completarea acestei secțiuni din formularul de evaluare – nivel intermediar? Răspundeţi la orice întrebare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 104. Dacă nu este disponibilă o tablă, cereţi participanţilor să folosească exemplarul pe care îl au, în timp ce formatorul explică/desenează pe o coală de flipchart. Note pentru formatori: Pentru acest exerciţiu, puteţi ruga participanţii să vină în faţă pentru a desena postura finală a lui Bahati. Răspuns: Procedeul de simulare manuală: suportul necesar pentru atingerea poziției neutre de ședere / poziții cu bazinul cu bazinul cât mai aproape de poziția neutră de ședere, fără a cauza disconfort. Pentru fiecare parte a corpului: Dacă este posibilă atingerea poziţiei neutre de şedere cu ajutorul suportului manual, bifaţi „da”. În a corpului caz contrar, bifaţi „nu”. Parte Da Nu Descrieţi sau schițați poziția așezat finală a utilizatorului de scaun rulant, realizată cu suport manual şi descrieţi sau desenaţi sau schițați suportul oferit pentru obţinerea respectivei poziții de ședere. Postură: bazin drept şi aflat în echilibru; trunchi drept; Suport oferit: grad ridicat de suport în partea posterioară a bazinului; suport în partea posterioară, la nivelul inferior al trunchiului; suport la nivelul membrelor superioare, pentru stabilitatea părții superioare a trunchiului. Bazin ✓ Trunchi ✓ Cap ✓ Șold S ✓ Șold D ✓ Coapse ✓ Genunchi S ✓ Genunchi D ✓ Gleznă S ✓ Gleznă D ✓ Note pentru formatori: Bahati are nevoie de un grad ridicat de suport în partea posterioară a bazinului şi la nivelul inferior al trunchiului, astfel încât ea să poată menține poziția așezat. Partea superioară a trunchiului nu este în întregime stabilă și are tendința de a se orienta înspre înainte. Prin suportul furnizat la nivelul membrelor superioare, partea superioară a trunchiul devine stabilă. 4. Recapitulare puncte cheie (5 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 105. B.5: Evaluarea fizică - efectuarea măsurătorilor O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să explice care este scopul efectuării măsurătorilor; să aleagă măsurătorile necesare pentru a selecta dimensiunea şi poziția corectă a DSP-urilor; să demonstreze modalitatea de efectuare a măsurătorilor; să folosească formularul de evaluare – nivel intermediar pentru a înregistra valorile măsurătorilor. R E S U R S E Pentru sesiune: slide-uri PPT: B.5: Evaluarea fizică - efectuarea măsurătorilor: Manualul participantului; Caietul de exerciţii practice; Formular de evaluare - nivel intermediar. ruletă metalică (sau şubler, dacă este disponibil şi poate fi folosit în mod confortabil) - 1 pentru fiecare grup; pat de evaluare – 1 pentru fiecare grup; C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoştinţe dobânsite anterior: „Efectuarea măsurătorilor” din Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază (lăţime şold, adâncime şezut, lungime gambă, limita inferioară a cutiei toracice şi limita inferioară a omoplaţilor) Adaptați conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte: Atunci când demonstraţi efectuarea măsurătorilor cu ajutorul voluntarilor şi când solicitați participanţilor să efectueze aceste măsurători - luaţi în considerare aspectele culturale legate de atingerea corpului altor persoane. D E P R E G Ă TI T Pregătiți toate materialele, revedeți slide-urile PPT şi parcurgeți planul de sesiune. Recitiți formularul de evaluare – nivel intermediar şi exersaţi efectuarea măsurătorilor. Plasaţi un pat de evaluare în sala de curs, pentru a putea fi văzut de către toți participanții. Aranjaţi sala de curs de așa manieră încât participanţii să stea într-un semicerc, cu faţa către locul unde este amenajat patul de evaluare. Plasaţi paturi de evaluare în sala de curs (sau în exteriorul sălii/în săli adiacente), pentru ca participanţii să exerseze efectuarea măsurătorilor. P R E ZE N TA R E 1. Introducere 2. Efectuarea măsurătorilor pentru alegerea dimensiunii corespunzătoare și a poziției adecvate a DSP-urilor 3. Exersarea efectuării măsurărilor 4. Recapitulare puncte cheie 2 25 30 3 Durata totală a sesiunii 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 106. 1. Introducere (2 minute) Explicaţi: Pe parcursul acestei sesiuni, participanţii vor discuta modalitatea de efectuare a măsurătorilor, astfel încât să putem alege dimensiunea optimă a scaunului rulant şi a DSP-urilor. 2. Efectuarea măsurătorilor pentru alegerea dimensiunii optime a scaunului rulant și a DSP-urilor. Note pentru formatori: Cele cinci măsurători prezetate aiciau fost abordate și în modulul de instruire anterior. Participanţii trebuie să fie deja familiarizați cu modalitatea de efectuare corectă a acestor măsurători. În caz contrar, formatorii trebuie să reia capitolul referitor la evaluarea fizică din „Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază”, punând accentul pe efectuarea măsurătorilor, astfel încât toți participnații să poată realiza aceste măsurători corect și cu un nivel ridicat de încredere în cunoștințele pe care le au. Cereţi participanţilor să citească secțiunea „Efectuarea măsurătorilor” din formularul de evaluare – nivel intermediar. Explicaţi: o În rubrica referitoare la măsurători din formularul de evaluare - nivel intermediar, sunt enumerate douăsprezece tipuri de măsurători. o Cinci dintre ele au fost deja prezentate în pachetul de instruire anterior (nivel de bază). o În formularul de evaluare – nivel intermediar, capitolul măsurători corp include un element suplimentar, referitor la înălțimea spătarului. Distanța dintre suprafața de ședere și limita superioară a omoplatului este valoarea utilizată în cazul unui spătar înalt. o Există alte șase măsurători care contribuie la alegerea dimensiunii și/sau a poziției DSP- urilor. o Uneori va fi necesar să efectuați mai multe măsurători, în funcție de dispozitivele de suport postural prescrise. o Există o rubrică în formularul de evaluare - nivel intermediar pentru înregistrarea acestora. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 107. Explicaţi: Această imagine inclusă în formularul de evaluare – nivel intermediar prezintă corespondențele dintre măsurătorile corp și dimensiunile scaunului rulant/DSP-urilor. Întrebaţi: De exemplu – care este corespondența dintre măsurătoarea G: Lăţimea trunchiului și scaunul rulant (la localizarea cărei componente a scaunului rulant va contribui această măsurătoare?) Încurajaţi participanţii să răspundă. Răspuns: o Distanţa dintre inserţiile laterale sau inserţiile unghiulare laterale pentru trunchi. Evidenţiaţi în secțiunea„Efectuarea măsurătorilor” din formularul de evaluare – nivel intermediar faptul că: o măsurătorile corp sunt enumerate pe partea stângă, iar componentele legate de fiecare măsurătoare corp sunt enumerate în partea dreaptă. o în anumite cazuri, există o formulă care ajută la stabilirea dimensiunilor componentelor scaunului rulant. De exemplu, adâncimea suprafeţei de şedere (de la partea posterioară a bazinului până la partea posterioară a genunchilor/zona poplitee) MINUS 30-50 mm EGAL cu adâncimea suprafeţei de şedere a scaunului rulant. Explicaţi: o Pentru acele măsurători corp pentru care există o formulă în vederea stabilirii dimensiunii componentei scaunului - este bine să identificați valoarea ideală a componentei scaunului rulant atunci când efectuaţi măsurătorile părților corpului. o Acest lucru vă va ajuta mai târziu, în etapa de prescriere a scaunului rulant. o Măsurătorile corp sunt: o B (adâncimea suprafeței de şedere); o H (distanţa dintre suprafaţa de şedere şi axilă); o L (distanţa dintre partea posterioară a bazinului şi oasele bazinului). Cereţi unui voluntar (participant) să vină în faţa celorlați participanți şi să se aşeze pe patul de evaluare. Demonstraţi pe scurt modalitatea de efectuare a fiecărei măsurători, folosind notele pentru formatori. Asiguraţi-vă că fiecare participant vede clar cum sunt realizate măsurătorile. Note pentru formatori: Puneţi accent pe următoarele puncte cheie: o Atunci când efetuați măsurătorile corp, „șezutul” reprezintă suprafaţa ocupată de oasele bazinului. o Efectuați întotdeauna măsurătorile cu utilizatorul de scaun rulant în poziţia așezat sau în postura care a fost identificată ca fiind cea mai apropiată de aceasta, în limitele păstrării nivelului de confort și funcționalitate, așa cum rezultă în urma procedeului de simulare manuală. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 108. o Atunci când realizați măsurătorile în cazul unei persoane care are dificultăţi în ceea ce privește menținerea poziției așezat, este posibil să aveți nevoie de asistență. o Pentru toate măsurătorile verticale (C,D,E,F,H,I,K) – localizarea respectivei componente va fi influențată de orice schimbare în ceea ce privește înălţimea suprafeţei de şedere şi a pernei. o Poziția exactă a tuturor componentelor scaunului rulant este întotdeauna verificată în etapa de probare a produsului (a scaunulu rulant). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 109. Modalitatea de efectuare a măsurătorii: Componenta scaunului rulant: Comentarii: A: Lățimea șoldului Suprafața de ședere (lățimea) Înainte de efectuarea măsurătorilor, asigurați-vă că nu există niciun fel de obiecte în buzunarele utilizatorului de scaun rulant. Măsurați șoldurile sau partea cea mai lată a coapselor utilizatorului. Țineți două clipboard-uri de fiecare parte a coapselor utilizatorului de scaun rulant și astfel veți obține măsurători corecte. Puteți folosi și șublere. Lățimea șoldurilor este egală cu lățimea suprafeței de ședere sau cu distanța dintre inserțiile laterale pentru bazin. Dacă se furnizează inserții laterale pentru bazin, lățimea suprafeței de ședere trebuie să fie mai mare. Încercați întotdeauna ca lățimea recomandată să aibă cea mai mică valoare posibilă. În țările cu climat rece, unde se poartă îmbrăcăminte groasă, trebuie să aveți în vedere acest aspect atunci când calculați lățimea recomandată a scaunului rulant. B: Adâncimea șezutului Suprafața de ședere (adâncimea) Pentru a obține măsurători exacte, poziționați un clipboard la spatele bazinului utilizatorului de scaun rulant. Măsurați de la partea posterioară a bazinului până la partea posterioară a genunchiului, în linie dreaptă. Măsurați întotdeauna pe ambele părți. Dacă există vreo diferență între partea dreaptă și stângă, verificați dacă utilizatorul de scaun rulant stă în poziția așezat, cu bazinul în echilibru. Dacă diferența persistă, la prescrierea scaunului rulant luați în considerare valoarea mai mică. Adâncimea suprafeței de ședere minus 30-50 mm este egală cu adâncimea suprafeței de ședere. În cazul în care un utilizator are genunchii flectați într-un unghi mult sub 90 grade, adâncimea șezutului scaunului rulant va trebui să fie mai redusă. Vezi „Pentru utilizatorii de scaun rulant cu înclinare posterioară fixă a bazinului sau cu înclinare fixă anterioară a trunchiului”. C: Lungimea gambei Suporturile de picioare (înălțimea) Măsurați distanța dintre partea posterioară a genunchilor și baza călcâiului. Asigurați-vă că Înălțimea corespunzătoare lungimii gambei este egală cu Poziția exactă a suporturilor de picioare se va modifica puțin, în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 110. gleznele utilizatorului de scaun rulant sunt flectate la 90 de grade (dacă este posibil). Măsurați întotdeauna ambele membre inferioare. Dacă utilizatorul de scaun rulant poartă încălțăminte, efectuați măsurătoarea cu încălțămintea pe care o poartă în mod frecvent. Dacă piciorul este fixat în flexie plantară (direcție în jos), măsurați până la degetele picioarelor. distanța dintre limita superioară a pernei și suporturile de picioare SAU cu distanța dintre limita superioară a pernei și podeaua, în cazul propulsiei cu ajutorul membrelor inferioare. funcție de gradul de comprimare a pernei, atunci când utilizatorul de scaun rulant este așezat pe aceasta. Va fi întotdeauna nevoie de ajustare finală în etapa de probare a produsului (a scaunului rulant). D, E și F Spătarul (înălțimea) D: Distanța dintre șezut și limita inferioară a cutiei toracice. Măsurați distanța dintre șezutul utilizatorului de scaun rulant și limita inferioară a cutiei toracice. Pentru a localiza partea inferioară a cutiei toracice, poziționați mâinile pe ambele părți ale bazinului. Apăsați ușor și mișcați-le în sus. Limita inferioară a cutiei toracice este chiar deasupra taliei. Măsurătorile D, E și F ajută la stabilirea înălțimii spătarului. Înălțimea acestuia depinde de nevoile utilizatorului de scaun rulant. Informațiile din formularul de evaluare vor ajuta personalul furnizor de servicii de scaune rulante să decidă care este înălțimea corespunzătoare a spătarului, în așa fel încât acesta să furnizeze suportul de care are nevoie utilizatorul de scaun rulant. Dacă este nevoie de o înclinare în spațiu a spătarului, înălțimea acestuia trebuie să aibă cel puțin valoarea standard (până la limita inferioară a omoplaților utilizatorului de scaun rulant). Rețineți! Dacă utilizatorul de scaun rulant va realiza singur propulsia scaunului rulant, el va avea nevoie de libertate de mișcare la nivelul omoplaților. E: Distanța dintre șezut și omoplat: Măsurați distanța dintre șezutul utilizatoruluide scaun rulant și limita inferioară a omoplatului, în linie verticală. Pentru a găsi limita inferioară a omoplatului, cereți utilizatorului de scaun rulant să își ridice umerii. F: Distanța dintre șezut și limita superioară a omoplatului: Măsurați distanța dintre șezutul utilizatorului de scaun rulant și limita superioară a umărului. G: Lățimea trunchiului Inserțiile laterale pentru trunchi sau inserțiile unghiulare laterale pentru trunchi (distanța dintre acestea) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 111. Măsurați lățimea trunchiului utilizatorului de scaun rulant în porțiunea situată chiar sub axile. Lățimea trunchiului este distanța dintre inserțiile laterale de trunchi sau inserțiile unghiulare laterale pentru trunchi. Poziția finală a inserțiilor laterale pentru trunchi sau a inserțiilor unghiulare laterale pentru trunchi se poate modifica în etapa de probare,în cazul în care este nevoie să fie plasate mai jos de nivelul axilelor. H: Distanța dintre șezut și axilă Inserțiile laterale pentru trunchi sau inserțiile unghiulare laterale pentru trunchi (înălțimea) Măsurați distanța dintre șezutul utilizatorului de scaun rulant și axilă. Valoarea aferentă distanței dintre șezutul utilizatorului de scaun rulant și axilă minus 30 mm este distanța maximă dintre partea superioară a pernei și partea superioară a inserțiilor laterale pentru trunchi/inserțiilor unghiulare pentru trunchi. Această valoare este orientativă. Înălțimea finală depinde de evaluare și probarea produsului (a scaunului rulant). Inserțiile laterale pentru trunchi nu trebuie niciodată să fie atât de înalte încât să exercite presiune la nivelul axilelor. Acest lucru poate cauza disconfort și deterioarea ireversibilă a nervului. Trebuie să existe întotdeauna o distanță de cel puțin 30 mm între partea superioară a inserțiilor laterale pentru trunchi și axilă. Vezi „Măsurarea inserțiilor laterale pentru trunchi în cazul unui utilizator de scaun rulant cu scolioză”. I: Distanța dintre șezut și partea superioară a Inserția posterioară pentru Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 112. bazinului (creasta iliacă postero-superioară) bazin (înălțime mediană) Măsurați distanța dintre șezutul utilizatorului de scaun rulant și partea superioară a bazinului (CIPS) Măsurătoarea aferentă distanței dintre șezut și partea superioară a bazinului (CIPS) este folosită pentru a localiza mijlocul înălțimii inserției posterioare pentru bazin. Adâncimea (grosimea) inserției posterioare pentru bazin depinde de rezultatele evaluării. J: Distanța dintre genunchi Inserția/dispozitivul pentru separarea genunchilor Măsurați distanța dintre genunchi - cu genunchii situați într-o poziție cât mai apropiată de cea neutră, fără a cauza disconfort. Distanța dintre genunchi este egală cu lățimea inserției/dispozitivului pentru separarea genunchilor. Distanța va depinde de postura în poziția așezat a utilizatorului de scaun rulant. K: Distanța dintre șezut și baza craniului (occiput) Tetiera (înălțimea) Măsurați distanța dintre șezutul utilizatorului de scaun rulant și baza craniului (occiput). Măsurătoarea de la șezut până la baza craniului (occiput) ajută la localizarea poziției tetierei. I: Distanța dintre partea posterioară a bazinului și oasele bazinului Inserția anterioară oaselor bazinului Măsurați distanța dintre partea posterioară a bazinului și oasele bazinului. Poziționați-vă pe partea laterală a utilizatorului de scaun rulant și plasați mâna (cu palma orientată în sus) sub șezutul acestuia, pentru a identifica oasele bazinului. Localizați oasele bazinului cu degetul, apoi retrageți mâna pe lateral, fără a modifica poziția degetului. Măsurați distanța dintre partea posterioară a bazinului și degetul care a fost poziționat sub Valoarea măsurată de la partea posterioară a bazinului până la oasele bazinului plus 20–40 mm este distanța dintre spătar și linia de început a inserției anterioare oaselor bazinului. Dacă utilizatorul are o înclinare fixă posterioară a bazinului sau trunchi fix înclinat anterior, măsurătorile pot fi diferite (vezi Pentru utilizatorii de scaun rulant cu înclinare posterioară fixă a bazinului sau cu înclinare anterioară fixă a trunchiului) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 113. oasele bazinului. Personalul furnizor de servicii de scaune rulante poate marca poziția degetului pe patul de evaluare (de exemplu, cu o bucată de cretă). Semnul se trasează lângă corpul utilizatorului de scaun rulant, pe linia oaselor bazinului. Se va măsura distanța dintre acest semn și partea posterioară a bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 114. Mulţumiţi voluntarului. Întrebaţi: Care este modalitatea de efectuare a măsurătorilor în cazul unui utilizator copil care este agitat sau care își schimbă frecvent poziția? Răspuns: o dacă este posibil, aşteptaţi până când utilizatorul copil se linişteşte; o faceți o pauză şi încercaţi efectuarea măsurătorilor puţin mai târziu, după ce acesta s-a odihnit/a consumat alimente sau lichide; o cereţi unui membru al familiei/însoțitor să vă ajute și să îl facă pe utilizatorul copil să se simtă în siguranţă; o în cazul unui copil mic, putem efectua măsurătorile în timp ce acesta se află în braţele unui membru al familiei/însoțitorului. Totuşi, personalul furnizor de servicii de scaune rulante trebuie să fie atent ca postura „finală” a copilului mic să fie aceeaşi cu cea identificată cu ajutorul procedeului de simularea manuală. 3. Exersarea efectuării măsurătorilor (30 de minute) Activitate cu grupe mici Grupe: Împărţiţi toţi participanţii în 3 grupe. Instrucţiuni: Cereţi participanţilor să citească cazul lui Madavi din Caietul de exerciții practice (B.5: Evaluarea fizică - efectuarea măsurătorilor). Oferiţi fiecărei grupe o ruletă (şi o riglă, dacă este disponibilă şi folosită în mod frecvent). Explicaţi faptul că participanţii trebuie: o să citească rezultatele procedeului de simulare manuală pentru Madavi, o să decidă care sunt măsurătorile corp care trebuie efectuate pentru a prescrie un scaun rulant pentru Madavi; o să efectueze aceste măsurători pe cel puţin unul din membrii grupei şi să le înregistreze în secțiunea „Efectuarea măsurătorilor” din formularul de evaluare – nivel intermediar, din caietul de exerciții practice. Explicaţi: o Bazinul lui Madavi se află într-o uşoară înclinare fixă posterioară. Participanţii trebuie să se gândească la modul în care vor stabili valoarea corectă pentru adâncimea suprafeței de ședere. o Madavi a solicitat o măsuţă - așadar, participanţii trebuie să se gândească la tipul de măsurători necesare pentru a pregăti o măsuţă pentru acest scaun rulant. Explicaţi: Participanţii au la dispoziţie 20 minute pentru a efectua această activitate, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Dacă este cazul, corectaţi tehnicile de efectuare a măsurătorilor. Oferiți asistență grupelor, dacă acest lucru este necesar. Note pentru formatori: Încurajați participanţii să identifice măsurătorile pe care ei le consideră necesare. În această etapă, participanții nu trebuie să abordeze în detaliu diferitele soluţii de suport postural, deoarece acest aspect se va discuta în următoarea sesiune. Durata: Acordaţi 20 minute pentru desfășurarea activității. Acordaţi 10 minute pentru feedback. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 115. Feedback: Întrebaţi: Care sunt măsurătorile pe care pearticipanţii le consideră necesare? Răspuns: Măsurătorile: A, B, C, F, G, H, I, J, L. Întrebaţi: Care este modalitatea prin care participanţii vă puteți asigura de faptul că ați efectuat în mod corect măsurătorilor corecte pentru adâncimea suprafaţei de şedere? Încurajaţi răspunsurile şi permiteţi participanților să poarte scurte discuţii. Prezentaţi slide-ul pentru clarificarea acestui aspect. Explicaţi: În cazul în care bazinul unui utilizator de scaun rulant se află în înclinare posterioară sau dacă trunchiul este într-o postură fixă, orientată înspre înainte, personalul furnizor de servicii de scaune rulante trebuie să identifice modul în care aceste posturi vor fi acomodate în scaunul rulant. Acest lucru poate schimba modul în care se efectuează măsurarea adâncimii suprafeţei de şedere. o dacă spătarul este înclinat pentru a sprijini bazinul/trunchiul, măsuraţi distanța dintre partea posterioară a bazinului și partea posterioară a genunchiului (zona poplitee), în linie dreaptă; o dacă spătarul nu se înclină, se vor crea suporturi pentru a sprijini bazinul/trunchiul în spaţiul creat de adâncimea suprafeţei de şedere. Măsuraţi distanța dintre limita posterioară a corpului (trunchi/bazin) pentru a vă asigura că există suficient spațiu, după cum este prezentat în slide. Întrebaţi: Care sunt măsurătorile necesare pentru a stabili înălţimea şi mărimea/forma măsuţei pentru Madavi? Încurajaţi răspunsurile şi permiteţi participanților să poarte scurte discuţii. Prezentaţi slide-ul pentru clarificarea acestui aspect. Explicaţi: Pentru a decide valoarea ideală a înălțimii măsuţei, stabiliți la ce înălţimea sunt situate coatele: o distanța dintre limita superioară a suprafeţei de şedere coatele flectate la 90 de grade, având cu umerii relaxaţi sau o în funcţie de nevoia de suport identificată pe parcursul procedeului de simulare manuală (de exemplu, pentru unele persoane ar constitui un avantaj măsuţa situată puţin mai sus, care oferă mai mult suport la nivelul antebraţelor). Pentru a decide distanța dintre măsuţă și trunchiul lui Madavi: o măsuraţi adâncimea trunchiului lui Madavi (dinspre partea anterioară spre cea posterioară). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 116. Dacă forma măsuţei va urma linia trunchiului lui Madavi (ca în imaginea din slide): o măsuraţi lăţimea trunchiului ei (valoare inclusă în tabelul de măsurători din formularul de evaluare – nivel intermediar). 4. Recapitulare puncte cheie (3 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 117. B.6: Selecția scaunului rulant şi a pernei O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să descrie caracteristicile şi posibilitățile de ajustare a scaunelor rulante şi ale pernelor disponibile la nivel local; să prezinte caracteristicile scaunelor rulante standard, care permit furnizarea de suport postural suplimentar. R E S U R S E Pentru sesiune: slide-uri PPT: B.6: Alegerea scaunelor rulante şi pernelor: Manualul participantului; Caietul de exerciţii practice; Formular de prescriere (selecţie) – nivel intermediar; Scaune rulante şi perne disponibile la nivel local – 1 din fiecare tip; Informaţii scrise despre scaunul rulant oferit de furnizor (de exemplu, broşura/fișa specificaţiilor tehnice ale scaunului rulant); formulare de date tehnice ale scaunului rulant, completate şi necompletate, pentru fiecare tip de scaun rulant disponibil la nivel local. C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoştinţe dobândite anterior: Este important ca participanții la această sesiune de instuire să cunoască principiile necesare pentru prescrierea (selecția) scaunului rulant care au fost predate în cadrul modulului de bază. Faceţi referire la Manualul participantului din Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază, Etapa 3: Prescrierea (selecţia)”. Participanții care nu au parcurs recent modulul de bază trebuie să recitească acest capitol. Adaptați conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte: Tipurile de scaun rulant şi de perne disponibile în zona în care lucrează participanţii. Pregătirea unor modele de formulare de prescriere (selecţie) – nivel intermediar, care să includă tipurile de scaune rulante şi perne disponibile în zona în care lucrează participanții. D E P R E G Ă TI T Pregătiți toate resursele, revedeți slide-urile PPT şi parcurgeți planul de sesiune. Completaţi fișa de date tehnice - nivel intermediar pentru fiecare tip de scaun rulant disponibil la nivel local. Formatorii trebuie să cunoască fiecare produs, precum și dimensiunile, posibilitățile de ajustare, caracteristicile şi opţiunile sau DSP-urile disponibile. Aranjaţi scaunele rulante şi pernele disponibile la nivel local în sala de curs. Asiguraţi-vă că sunt într-o stare bună de funcţionare. Asigurați-vă că sunt disponibile informaţiile scrise oferite de furnizorul pe scaunul rulant. Marcaţi fiecare scaun rulant (de exemplu, scaunul rulant unu, doi, trei, patru). R E ZU M A T 1. Introducere 2. Tipul de scaun rulant şi tipul pernă 3. Recapitulare puncte cheie 8 50 2 Durata totală a sesiunii 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 118. 1. Introducere (8 minute) Explicaţi: Prescrierea (selecția) este cea de-a treia etapă a procesului de furnizare a serviciilor de scaune rulante. Prescrierea/selecția înseamnă găsirea celei mai bune corespondențe dintre tipurile de scaune rulante disponibile și nevoile utilizatorului. Cereţi participanţilor să se analizeze formularul de prescriere (selecție) - nivel intermediar. Explicaţi: o În această sesiune vom discuta despre selecția scaunelor rulante şi a pernelor pentru acei utilizatori de scaun rulant care au nevoie de suport postural suplimentar pentru menținerea poziţiei aşezat. o De asemenea, vom analiza scaunele rulante disponibile pe plan local, pentru a ne asigura că suntem familiarizați cu diversele lor caracteristici. Explicaţi: Prescrierea înseamnă: alegerea tipului de scaun rulant adecvat și a dimensiunii celei mai potrivite, în cazul fiecărui utilizator de scaun rulant; descrierea oricărei configurări specifice ale respectivului scaun rulant. Întrebaţi: Ce fel de informații ar trebui notate în această secțiune a formularului de prescriere (selecție) a scaunului rulant – nivel intermediar? Răspunsuri: o poziţia roţii din spate (pentru creșterea nivelului de siguranță/activă); o înclinarea. Explicaţi: Aceasta nu reprezintă secțiunea unde se înregistrează detaliile despre DSP-uri – aceasta este inclusă în continuarea formularului. Explicaţi: Prescrierea înseamnă, de asemenea: alegerea tipului și dimensiunii pernei. Explicaţi: Dacă perna are nevoie de modificări pentru confecționarea corectă a unui DSP - detaliile acestui aspect sunt descrise într-un capitol ulterior al formularului de prescriere (selecție) - nivel intermediar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 119. Explicaţi: Prescrierea include : o selecţia DSP-urilor sau a modificărilor necesare pentru a furniza utilizatorului de scaun rulant suportul postural suplimentar de care acesta are nevoie. Explicaţi: o Acest slide prezintă doar o parte a formularului de prescriere (selecție) a scaunului rulant – nivel intermediar. o Vom explica mai detaliat modul de completare al acestei secţiuni a formularului pe parcursul următoarele sesiuni şi vom exersa această activitate în sesiunile practice. Explicaţi: o Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază ne învaţă modalitatea de a alege varianta optimă de scaun rulant și pernă pentru utilizatorii de scaun rulant care nu pot menține poziţia aşezat fără suport postural suplimentar. Selecţia unui scaun rulant corespunzător se face pornind de la nevoile fizice și cerințele legate de de stilul de viaţă, precum şi de mediul în care trăiește utilizatorul de scaun rulant. o În programul de instruire modul intermediar, personalul furnizor de servicii de scaune rulante trebuie să ia în considerare faptul că este necesar un grad mai ridicat de suport postural. o În acelaşi timp, trebuie să avem în vedere specificul legat de stilul de viaţă şi mediul în care trăiește utilizatorul de scaun rulant. Întrebaţi: Dați exemple de cerințe legate de stilul de viaţă sau de mediul în care trăiește utilizatorul de scaun rulant? Răspunsuri: o locul unde utilizatorul îşi foloseşte scaunul rulant (de exemplu, în interior, în exterior, pe teren accidentat); o distanţa zilnică parcursă de utilizatorul de scaun rulant; o durata de timp petrecută în scaunul rulant; o modalitatea de realizare a transferului; o tipul de toaletă pe care îl folosește utilizatorul de scaun rulant; o necesitatea utilizării frecvente a transportului public; o care sunt activităţile pe care utilizatorul doreşte să le desfășoare în scaunul rulant. Reţineţi: o prescrierea (selecția) este întotdeauna rezultatul unui parteneriat complet cu utilizatorul de scaun rulant; o pe formularul de prescriere (selecție) a scaunului rulant – nivel intermediar, folosit în acest program de instruire, este nevoie de trei semnături; o acestea reprezintă acordul utilizatorului de scaun rulant, al persoanei care efectuează evaluarea (personalul furnizor de servicii de scaune rulante) şi al managerului serviciului de scaune rulante. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 120. 2. Tipul de scaun rulant şi de pernă (50 de minute) Explicaţi: Vom discuta în cele ce urmează despre diferitele tipuri de scaune rulante disponibile la nivel local. Pentru a prescrie un scaun rulant, personalul furnizor de servicii de scaune rulante trebuie să dețină următoarele informații despre utilizator: Explicaţi pe scurt: o Tipul cadrului: de exemplu, trebuie să știm dacă este un scaun rulant cu patru sau cu trei roți; cu un cadru pliabil sau fix, dacă acesta poate fi înclinat și dacă baza roții este lungă sau scurtă. o Dimensiunea disponibilă şi gamă de dimensiuni: dimensiunea scaunului rulant este de obicei dată de lăţimea suprafeţei de şedere şi adâncimea suprafeţei de şedere. Lățimea suprafeței de ședere este distanța dintre exteriorul barelor laterale ale cadrului șezutului sau dintre suporturile de brațe, dacă acestea sunt plasate pe respectivele bare. Adâncimea suprafeței de ședere a scaunului rulant se măsoară de la partea frontală a suprafeței de ședere până la spătar. Caracteristicile disponibile: de exemplu: tipul suprafeței de ședere, tipul de spătar, de suport de picioare, suport de brațe, tipul de roată frontală, roată din spate și DSP-urile (de exemplu inserții laterale pentru trunchi, tetieră, centuri). o Tipul și gama de ajustări posibile: este esențiat să știm care sunt acele componente care pot fi ajustate şi în ce mod. Explicaţi: o Anumite tipuri de scaune rulante cu antrenare manuală au mai multe opțiuni pentru ajustări, comparativ cu altele. o Există ajustări sau caracteristici de care beneficiază utilizatorii de scaune rulante care necesită suport postural suplimentar. o Vom vedea în continuare câteva astfel de caracteristici şi ajustări folositoare. Explicaţi fiecare punct de mai jos: Majoritatea tipurilor de scaune rulante au suporturi pentru picioare care pot fi ajustate pe înălțime. Anumite scaune rulante au și alte opțiuni de ajustare suplimentare, cum ar fi: o suporturile de picioare pot fi deplasate înspre înainte sau înspre înapoi; o unghiul suportului de picioare poate fi crescut sau diminuat. Aceste ajustări oferă mai multă flexibilitate în ceea ce privește poziția picioarelor utilizatorului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 121. Un suport de picioare ajustabil pe verticală creează posibilitatea extensiei piciorului, cu genunchiul întins. Această caracteristică este de folos în cazul utilizatorilor de scaun rulant care nu pot flecta genunchii pentru atingerea poziției neutre și, implicit, pentru realizarea poziției așezat. Un spătar cu poziție ajustabilă (înclinare în spațiu) oferă mai multe opţiuni pentru sprijinirea trunchiului. Înclinarea spătarului (înclinarea spătarului înspre înapoi) este utilă atunci când: o șoldurile utilizatorului nu pot fi flectate pentru a ajunge în poziția neutră de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade); o este prezentă înclinarea posterioară fixă a bazinului; o este prezentă postura fixă înclinată a părții inferioare a trunchiului. Unele tipuri de scaune rulante au disponibilă opțiunea de „înclinare în spaţiu”. Acest lucru înseamnă că spătarul și suprafața de ședere fomează un ansamblu de ședere. Unghiul de deschidere dintre suprafața de ședere și spătar nu se modifică. Poziția înclinată a suprafeței de ședere este utilă în următoarele cazuri: când este prezentă înclinarea fixă posterioară a bazinului, cu contractura flexorilor de șold și genunchi; există o toleranță scăzută în ceea ce privește menținerea poziției așezat sau disconfortul posturii corpului în poziția normală de ședere; când este necesară creșterea nivelului de confort și relaxare. Anumite tipuri de scaune rulante au o suprafață de ședere rigidă, care nu se pliază. Aceasta oferă: o o bază adecvată pentru adăugarea suporturilor posturale suplimentare pentru bazin și șolduri; o un grad de stabilitate mai ridicat decât în cazul suprafeței de ședere pliabile. Acesta este un element important în cazul utilizatorilor de scaun rulant care au mișcări necontrolate sau o greutate corporală foarte mare. Anumite scaune rulante au un spătar rigid. Spătarul rigid reprezintă o bază corespunzătoare pentru adăugarea de suporturi posturale suplimentare. Un suport rigid înseamnă: o un grad de stabilitate crescut în comparație cu cel al spătarului flexibil. Acesta este un aspect important în cazul în care utilizatorul de scaun rulant are mișcări Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 122. necontrolate; o un grad crecut de suport pentru utilizatorii de scaune rulante cu înălțimea sau greutatea mai mare și/sau cu trunchiul foarte instabil. Imaginea prezintă un spătar rigid căruia i s-a adăugat spumă/burete pentru a furniza suport la nivelul trunchiului, în zona unde acest lucru este necesar, precum și inserții laterale încorporate în spătar. Unele scaune rulante sunt dotate cu spătar cu tensiune ajustabilă în locul celui simplu, pliabil. Un spătar cu tensiune ajustabilă vă permite să modificați cu ușurință gradul de suport. Benzile individuale se pot regla în funcție de tensiunea necesară pentru furnizarea unui grad mai ridicat sau mai scăzut de suport postural. Există tipuri de scaune rulante cu diverse componente suplimentare care au ca scop furnizarea de suport postural suplimentar. Vom discuta despre diferitele suporturi posturale în următoarea sesiune. Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 3 participanți. Instrucţiuni: Cereţi fiecărei grupe să lucreze cu Caietul de exerciţii practice (B.6: Selecţia scaunului rulant şi a pernei). Cereţi participanţilor să observe cu atenţie fiecare tip de scaun rulant disponibil la nivel local şi să răspundă la întrebările din caietul de exerciții pratice. Explicaţi: Participanţii au la dispoziţie 30 minute pentru a parcuge această activitate, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege ce presupune activitatea. Oferiți asistență grupelor, dacă acest lucru este necesar. Durata: Acordaţi 30 minute pentru finalizarea activității. Acordaţi 15 minute pentru feedback. Note pentru formatori: o În cazul în care sunt disponibile mai mult de patru tipuri de scaune rulante, adaptați durata de timp destinată acestui exercițiu. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 123. Feedback: Reluați fiecare întrebare, împreună cu întregul grup, după cum urmează: o cereţi participanţilor să dea răspunsuri; o verificaţi dacă toată lumea este de acord; o dacă nu există neînţelegeri, confirmaţi răspunsurile (dacă sunt corecte) şi treceţi la următoarea întrebare; o dacă nu toți participanții au acelaşi răspuns, alegeți răspunsul corect şi clarificaţi. Permiteţi discuţii scurte. Explicaţi: o Este foarte important ca personalul furnizor de servicii de scaune rulante să cunoască foarte bine diferitele caracteristici ale scaunelor rulante disponibile. Utilizatorul va primi cel mai potrivit scaun rulant doar dacă personalul cunoaşte foarte bine caracteristicile scaunelor rulante. o Reamintiți-le participanților că în Caietul de exerciții practice există fișa de date tehnice a scaunului rulant - nivel intermediar şi/sau că au la dispoziție setul de formulare de servicii de scaune rulante. Explicaţi faptul că participanţii pot completa acest formular pentru tipurile de scaune rulante pe care le au disponibile în locurile unde lucrează, după finalizarea acestui curs. Note pentru formatori: o Consultaţi notele pentru formatori de mai jos pentru răspunsuri şi pentru a vă asigura că punctele cheie sunt evidenţiate. o După această sesiune, atașați fiecărui scaun rulant fișa de date tehnice – nivel intermediar completată. Aceasta va fi folosită pe parcursul sesiunii practice cu utilizatorii de scaune rulante. Note pentru formatori: 1. Stilul de viaţă şi mediul în care trăiește Întrebări: Răspunsuri/puncte cheie de evidenţiat de către formatori: Care este tipul de scaun rulant (sau tipurile de scaune rulante) cel mai potrivit pentru utilizarea pe teren accidentat/denivelat? De ce? Caracteristicile care cresc uşurinţa cu care se utilizează scaunul rulant pe teren accidentat includ: o formatul cu trei roţi; o bază a roții lungă; o roată frontală lată/roţi frontale late; o anvelope late pe roțile din spate (stil ‘mountain bike’); o camerele solide sunt mai durabile și reduc probabilitatea fisurării acestora; o de asemenea, durabilitatea şi posibilitatea de a repara la nivel local eventualele probleme trebuie luate în considerare, deoarece uzura scaunelor rulante folosite pe teren accidentat este mai mare. Care este tipul de scaun rulant (sau tipurile de scaune rulante) care facilitează efectuarea transferului în poziția stând? De ce? Caracteristicile care uşurează efectuarea transferului în poziția stând includ: o suporturi de picioare pliabile; o suporturi de brațe care furnizează sprijin. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 124. Care este tipul de scaun rulant (sau tipurile de scaune rulante) care facilitează efectuarea transferului pe lateral? De ce? Caracteristicile care uşurează efectuarea transferului pe lateral includ: o suporturi braţe detaşabile; o suporturi de braţe care sunt situate pe aceeași în linie cu inelul de antrenare al roții din spate. Care este modalitatea de pliere sau de demontare a scaunului rulant, în vederea transportării? Metode frecvente: o scaunul rulant nu se pliază, o plierea pe verticală o plierea spătarului o roţi cu sistem rapid de detaşare. Care este tipul de scaun rulant (sau tipurile de scaune rulante) pe care fiecare grupă de participanți îl consideră ca fiind cel mai uşor de transportat cu mijloace de transport public? De ce? Încurajaţi participanţii să ia în considerare următoarele: o durata necesară pentru plierea/ demontarea scaunului rulant; o greutatea părţilor componente după pliere/demontare o posibilitatea pierderii părţilor componente (de exemplu, dacă un scaun rulant este demontat în multe componente diferite); o dimensiunea scaunului rulant după pliere/demontare Care sunt tipurile de scaune rulante (dacă există) care au roţi pneumatice? Care sunt tipurile de scaune rulante (dacă există) care au camere interioare solide? Care sunt tipurile de scaune rulante (dacă există) care au roţi solide? 2. Reducerea nivelului de presiune Întrebări: Răspunsuri/puncte cheie de evidenţiat de către formatori: Ce tipuri de perne sunt prezente în sala de curs? Pernele pot fi descrise în funcţie de: o Materialul din care sunt confecționate: o perne din spumă/burete; o perne confecționate din fibre de nucă cocos; o perne cu aer. o perne cu lichid sau gel. o Formă: o perne plate; o perne cu contur; o perne modelate; o perne multistrat Care dintre aceste tipuri de perne consideraţi că sunt perne pentru reducerea presiunii? De ce? Pernele pentru reducerea presiunii includ: o perne cu contur din spumă/burete; o perne cu lichid sau gel pe un strat de bază cu contur; o perne cu aer. Participanţii trebuie să identifice elementele care fac ca o pernă să fie o „pernă pentru Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 125. reducerea presiunii”. Acestea se referă la: o Contur/formă, inclusiv: o zona de sub oasele bazinului (zona de reducere a presiunii); o o inserţie anterioară oaselor bazinului; o suport sub partea superioară a coapselor; o caneluri sau crestături pentru poziționarea coapselor. o Pachete cu gel/lichid, care ajută la distribuirea presiunii. (Notă - pachetele cu gel/lichid trebuie să fie poziționate pe o bază conturată, confecționată din spumă solidă/burete solid, așa cum se arată mai sus). Care dintre tipurile de perne pentru reducerea presiunii ar fi cel mai uşor de modificat pentru: o creșterea nivelului de reducere a presiunii; o furnizarea de suport postural suplimentar. De obicei, o pernă cu contur din spumă/burete este mai uşor de modificat, deoarece materialul poate fi tăiat sau i se poate adăuga un alt strat, pentru reducerea presiunii. Dacă stratul de contact cu aer/gel este un element separat, atunci modificarea bazei, adăugarea unui strat suplimentar etc., cu schimbarea ulterioară a stratului de contact nu constituie o operațiune dificilă. (Pentru mai multe informaţii, vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază, sesiunea „Perne”). Care sunt caracteristicile huselor pernelor care se află în sala de curs? Participanţii pot identifica aceste caracteristici: o impermeabilitatea; o durabilitatea; o elasticitatea (materialul se potrivește mai bine cu conturul pernei); o poate fi îndepărtată pentru a fi spălată. 3. Efectuarea propulsiei Întrebări: Răspunsuri/puncte cheie de evidenţiat de către formatori: Aşezaţi-vă în scaunul rulant. Roata din spate are o poziţie corespunzătoare pentru efectuarea propulsiei? Verificaţi: o extindeți braţul în jos. Mâna este pe linia axului? o poziționați mâna pe partea superioară a inelului de antrenare, pe aceeași linie cu umărul. Cotul este flectat într-un unghi de 90-120 de grade? o dacă poziţia roţii din spate este ajustabilă? În cazul ajustării – se ameliorează poziţia pentru efectuarea propulsiei? Asiguraţi-vă că participanţii au observat dacă poziţia roţii din spate poate fi modificată pentru îmbunătățirea realizării propulsiei, prin ajustarea poziţiei axului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 126. Există vreun scaun rulant în sala de curs care are suprafaţa de şedere ajustabilă pe înălţime? În ce situații poate fi util acest aspect? Opțiunea de coborâre a suprafeței de ședere poate contribui la configurarea corectă a scaunului pentru un utilizator care realizează propulsia cu ajutorul membrelor inferioare. Totuşi, această nu este o caracteristică frecvent disponibilă. 4. Caracteristicile suportului postural Întrebări: Răspunsuri/puncte cheie de evidenţiat de către formatori: Care tipuri de scaune rulante (dacă există) au suporturi de picioare ajustabile pe verticală? Care tipuri de scaune rulante (dacă există) au suprafaţă de şedere solidă? Care tipuri de scaune rulante (dacă există) au spătar cu tensiune ajustabilă? Care tipuri de scaune rulante (dacă există) au componente suplimentare care au ca scop furnizarea de suport postural suplimentar? 5. Ajustabilitatea Întrebări: Răspunsuri/puncte cheie de evidenţiat de către formatori: Care tipuri de scaune rulante (dacă există) au următoarele opțiuni de ajustări? o Înălţimea suportului de picioare Mai multe opțiuni de ajustare sunt de folos atunci când lucrăm cu utilizatori de scaune rulante care au nevoie de suport postural suplimentar. Note pentru formatori: În acest stadiu puteţi prezenta următorul punct legat de instruirea utilizatorului: o Explicaţi întotdeauna utilizatorului de scaun rulant şi membrilor familiei/însoțitorului modul în care configurația (sau ajustarea) scaunului rulant influențează suportul postural al utilizatorului de scaun rulant. Componentele se reajustează doar dacă este necesar. Este importantă să păstrăm configurația stabilită pentru etapa finașă de probare a produsului (a scaunului rulant) şi să verificăm/fixăm componentele ajustate. o Unghiul suportului de picioare o Deplasarea înspre înainte/înapoi a suporturilor de picioare o Modificarea înălțimii spătarului o Înclinarea spătar o Înclinarea în spaţiu (înclinarea suprafeţei de şedere şi a spătarului) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 127. 3. Recapitulare puncte cheie (2 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 128. B.7: Prescrierea (selecţia) dispozitivelor de suport postural (DSP) - Introducere O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să definească „dispozitivul de suport postural’; să explice scopul formularului de prescriere (selecţie) a scaunului rulant – nivel intermediar. R E S U R S E Pentru sesiune: slide-uri PPT: B.7: Prescrierea (selecţia) DSP-urilor - introducere; Manualul participantului; afiş: Tabel dispozitive de suport postural (DSP); Formular de prescriere (selecţie) a scaunului rulant – nivel intermediar; Tabel cu dispozitive de suport postural (DSP), laminat – 1 pentru fiecare participant; Set DSP C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptați conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte: DSP-urile, materialele şi metodele de confecționare a DSP-urilor disponibile în zona în care lucrează participanţii. Locul unde participanţii vor efectua probarea scaunului rulant - de exemplu, în comunitate/domiciliul utilizatorilor, într-un atelier sau la centrul de servicii de scaune rulante. Acest aspect poate influența modul în care se lucrează şi selectează DSP-urile. Pregătirea unui model de formular de prescriere (selecţie) a scaunului rulant – nivel intermediar, care să includă opţiunile de DSP-uri disponibile în zona particpanţilor. D E P R E G Ă TI T Pregătiți toate resursele, revedeți slide-urile PPT şi parcurgeți planul de sesiune. Folosiți afişul „Tabelul de dispozitive de suport postural (DSP)”. Luați mostrele de DSP-uri din setul DSP şi plasaţi-le pe o masă în faţa sălii de curs, unde să aveţi acces uşor la ele. Aranjaţi sala de curs de așa manieră încât participanţii să stea într-un semicerc, cu faţa către locul unde este amenajat patul de evaluare. R E ZU M A T 1. Introducere 2. Ce este dispozitivul de suport postural? 3. Înregistrarea DSP-urilor în formularul de prescriere (selecţie) a scaunului rulant - nivel intermediar 4. Recapitulare puncte cheie 2 10 15 3 Durata totală a sesiunii 30 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 129. 1. Introducere (2 minute) Explicaţi: o Pe parcursul următoarelor cinci sesiuni vom continua să învăţăm mai multe despre cea de-a treia etapă a procesului de furnizare a serviciilor de scaune rulante, adică despre prescriere (selecţie). În ultima sesiune am discutat despre alegerea celui mai potrivit tip de scaun rulant şi de pernă. o În această sesiune vom discuta despre: o Ce înseamnă „dispozitivul/dispozitivele de suport postural (DSP/DSP-uri); o partea finală a formularului de prescriere (selecție) a scaunului rulant – nivel intermediar. o În fiecare dintre sesiunile următoare vom aborda în detaliu aceste DSP-uri. o Rețineți – înainte de finalizarea unei prescrieri, este important să vă asiguraţi că suporturile posturale necesare pot fi furnizate împreună cu scaunul rulant selectat. 2. Ce este un dispozitiv de suport postural (DSP)? (10 minute) Oferiţi fiecărui participant Tabelul cu dispozitivele de suport postural (DSP), laminat (denumit în continuare Tabel DSP). Întrebaţi: Ce este un „dispozitiv de suport postural”? Încurajaţi participanţii să răspundă. Răspunsuri: o • Un dispozitiv de suport postural (DSP – singular şi DSP-uri – plural) este: o este orice dispozitiv fizic adăugat scaunului rulant pentru a furniza suport postural suplimentar; o tipurile de DSP includ: tetieră, centură pentru bazin, inserţii laterale pentru bazin; o rețineți – suprafaţa de şedere, spătarul, suporturile de picioare şi suporturile de braţe oferă, de asemenea, suport postural. Explicaţi: Imaginea oferă câteva exemple de DSP. Întrebaţi: Ce DSP-uri identifică participanţii? Răspunsuri (participanţii pot folosi o terminologie diferită): o inserţii laterale de trunchi o spătar cu contur/cu formă şi pernă cu contur; o inserţii laterale pentru bazin o inserţie anterioară oaselor bazinului Explicaţi: o Există diferite forme de DSP şi diferite moduri prin care scaunul rulant poate fi configurat pentru a oferi utilizatorului suport postural suplimentar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 130. o În acest program de instruire vom discuta despre câteva tipuri de DSP, care sunt frecvent utilizate. o Denumirile folosite în acest program de instruire sunt termeni simpli, descriptivi. Este posibil ca participanţii să cunoască alţi termeni, care sunt folosiţi pentru descrierea aceluiaşi tip de dispozitiv. În cadrul fiecărui serviciu de scaune rulante, personalul și utilizatorii pot folosi termenii cu care sunt familiarizați. o Ulterior, vom aborda și modalitatea de confecționare al acestor DSP-uri. o Nu uitaţi – un număr mare de utilizatori de scaun rulant poate avea nevoie de mai multe soluţii diferite oferite de DSP, care, combinate,oferă soluţia generală corectă. 3. Înregistrarea DSP-urilor în formularul de prescriere (selecţie) a scaunului rulant - nivel intermediar (15 minute) Explicaţi: o Obiectivul formularului de prescriere (selecție) a scaunului rulant - nivel intermediar este ca personalul furnizor de servicii de scaune rulante care pregătește scaunul rulant, să dețină cât mai multe informații cu privire la: o tipul, dimensiunea şi configuraţia scaunului rulant (subiect abordat anterior); o tipul şi dimensiunea pernei (subiect abordat anterior); o DSP-uri sau la modificările necesare. Explicaţi: o În formularul de prescriere (selecție) a scaunului rulant - nivel intermediar se găsesc toate informaţiile dobândite pe parcursul evaluării, „traduse” într-o descriere clară a scaunului rulant de care are nevoie utilizatorul de scaun rulant. o Cu cât formularul conține informaţii mai detaliate, cu atât mai bine vom reuși să pregătim scaunul rulant, chiar pentru prima probare. o Formularul de prescriere (selecție) a scaunului rulant - nivel intermediar nu prezintă neapărat modul în care trebuie confecționate DSP-urile. Acest aspect se decide în urma discuţiilor dintre personalul furnizor de servicii de scaune rulante care pregăteşte scaunul rulant şi personalul furnizor de servicii de scaune rulante care a efectuat evaluarea. o Serviciile de scaune rulante au deseori metode diferite de înregistrare a informaţiilor necesare prescrierii. Cereţi participanţilor să analizeze exemplele de formulare de prescriere (selecție) - nivel intermediar care sunt deja completate în Manualul participantului (la finalul capitolului) . Explicaţi: Personalul furnizor de servicii de scaune rulante poate folosi secțiunea „DSP-urile sau modificările necesare” din formularul de prescriere (selecție) a scaunului rulant - nivel intermediar pentru: o a alege, din lista DSP-urilor uzuale, acele dispozitive pe care trebuie să le prescrie/selecteze (folosind căsuţele). De asemenea, există un spaţiu pentru notarea altor tipuri de DSP-uri, denumit „Altele”; o a trasa peste desenele existente forma şi dimensiunile DSP-urile prescrise (selectate); Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 131. o a nota sau schiţa orice informaţie suplimentară. o Alături de lista de verificare a DSP-urilor, participanţii trebuie să ofere informații referitoare la dimensiunile acestora, pentru ca DSP-urile confecționate să aibă mărimea corectă şi să fie poziţionate corect. o Schiţa de dimensiuni din tabelul DSP este un ghid pentru a ajuta participanţii în alegerea mărimii fiecărui DSP. o Cele două „schiţe” din formular pot fi folosite de către participanţi pentru a desena DSP-urile prescrise şi pentru a preciza dimensiunile. o De exemplu, acest slide prezintă modul în care schiţele şi lista de verificare a DSP-urilor din formularul de prescriere (selecție) a scaunului rulant - nivel intermediar au fost folosite pentru descrierea unui inserţii anterioare oaselor bazinului şi a unei inserţii pentru reglarea unghiului de înclinare a bazinului pe partea dreaptă. o Întrebaţi: Puteți numi cauzele pentru care un utilizator de scaun rulant poate avea nevoie de o astfel de reglare a unghiului de înclinare, într-o parte? Aprobaţi răspunsurile corecte. Răspuns: o şoldul drept al utilizatorului de scaun rulant nu poate fi flectat pentru atingerea unghiului de 90 de grade. o Explicaţi: Acesta este un exemplu care arată modul în care pot fi folosite schiţele şi lista de verificare a DSP- urilor de pe a doua pagină a formularului de prescriere (selecție) a scaunului rulant - nivel intermediar. o Întrebaţi: Care au fost DSP-urile înregistrate în formular? Încurajaţi participanţii să consulte Tabelul DSP şi Tabelul de referinţe DSP din Manualul participantului, în cazul în care nu sunt siguri. Aprobaţi răspunsurile corecte Răspunsuri: o inserţie anterioară oaselor bazinului (aceasta este selectată din lista de verificare a DSP-urilor de pe prima pagină a formularului); o inserţii laterale pentru trunchi – dreapta și stânga; o inserţii unghiulare pentru suportul de picioare - stânga; o centură pentru bazin Explicaţi: Fiecărui desen i s-au adăugat linii pentru dimensiuni. Acestea indică dimensiunile necesare pentru confecționarea acestor DSP-uri. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 132. Explicaţi: Pe parcursul următoarelor sesiuni vom discuta mai mult despre informațiile necesare pentru descrierea dimensiunilor şi poziției DSP-urilor. Participanţii vor exersa acest aspect în sesiunile practice. 4. Recapitulare puncte cheie (3 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 133. B.8: Prescrierea (selecţia) DSP-urilor - stabilizarea bazinului O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să descrie DSP-urile care contribuie la stabilizarea şi susţinerea bazinului; să specifice dimensiunile inserţiei anterioare oaselor bazinului şi ale inserţiei posterioare pentru bazin. R E S U R S E Pentru sesiune: slide-uri PPT: B.8 Prescrierea (selecţia) DSP-urilor - stabilizarea bazinului; Manualul participantului; Caietul de exerciţii practice; DVD: Soluţii de suport postural pentru înclinarea anterioară a bazinului; afiş: „Tabel dispozitive de suport postural (DSP)”; Tabel dispozitive de suport postural (DSP), laminat – 1 pentru fiecare participant; Set DSP: centură pentru bazin – 1 pentru fiecare grup; pat de evaluare – 1 pentru fiecare grup; plăci de burete solid/spumă solidă – câteva pentru fiecare grup, inserţie unghiulară din spumă solidă/burete solid – 1 pentru fiecare grup; scaune rulante – 1 pentru fiecare grup (cel puţin trei tipuri, dacă este posibil). C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptați conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții.Luați în considerare următoarele aspecte: DSP-urile, materialele şi metodele de confecționare a DSP-urilor disponibile în zona unde lucrează participanţii. Locul unde participanţii vor efectua probarea scaunului rulant - de exemplu, în comunitate/domiciliul utilizatorilor, într-un atelier sau clinică. Acest aspect poate afecta modul în care se lucrează şi se selectează DSP-urile. Atunci când faceți demonstraţia/cereţi participanţilor să lucreze cu voluntarii, luaţi în considerare aspectele culturale legate de atingerea corpului altor persoane. D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. Plasaţi afişul „Tabelul de dispozitive de suport postural (DSP)”. Luați mostrele de DSP din setul DSP şi plasaţi-le pe o masă în faţa sălii de curs, unde să aveţi acces uşor la ele. Plasaţi un pat de evaluare în partea din faţă a sălii de curs. Aranjaţi sala de curs de așa manieră încât participanţii să stea într-un semicerc, cu faţa către locul unde este amenajat patul de evaluare. P R E ZE N TA R E 1. Introducere 2. Problemă: Bazinul se află în înclinare posterioară şi/sau alunecă înspre înainte 3. Problemă: Bazinul se află în înclinare laterală (bazin fix inegal) 4. Problemă: Bazinul se află în înclinare anterioară (bazinul este orientat înspre înainte) 5. Problemă: Bazinul se deplasează spre o parte 6. Recapitulare puncte cheie 2 45 5 25 10 3 Durata totală a sesiunii 90 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 134. 1. Introducere (2 minute) Explicaţi: o În această sesiune, vom învăţa despre DSP-urile folosite pentru stabilizarea bazinului. o rețineți – chiar dacă în această sesiune şi în următoarele sesiuni vom aborda separat diferitele tipuri de DSP, acestea, de cele mai multe ori, se folosesc împreună. Explicaţi: Pentru ca utilizatorul de scaun rulant adult să poată menține poziţia așezat, este nevoie de suport la nivelul a două părți ale corpului. Acestea sunt: o bazinul; o trunchiul. Explicaţi: Întâi vom observa bazinul: o Atunci când bazinul nu se află în echilibru, se produc modificări la nivelul trunchiului şi al şoldurilor. o așadar, sprijinirea şi stabilizarea bazinului sunt cei mai importanți pași pentru menținerea poziției așezat. o suportul oferit la nivelul bazinului poate reduce gradul de suport necesar la nivelul unei alte părți a corpului. Explicaţi: Pe parcursul acestei sesiuni şi a sesiunii „B.11: Prescrierea (selecţia) DSP- urilor - sprijinirea capului, coapselor şi a gambelor”, vom vedea exemple care prezintă probleme posturale, suportul necesar şi soluţiile DSP. În anumite sesiuni, formatul este puţin diferit. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 135. 2. Problemă: Bazinul se află în înclinare posterioară şi/sau alunecă înspre înainte (45 de minute) Poziţie inițială: o înclinare posterioară a bazinului. Cereţi unui voluntar (participant) să vină în faţa sălii de curs şi să prezinte problema. Întrebaţi participanţii – ce tip de suport (suport manual) putem furniza, astfel încât bazinul voluntarului să atingă o poziţie cât mai apropiată de cea neutră de şedere? Rugați unul sau doi participanţi să vină în faţa sălii de curs şi să demonstreze modalitatea de furnizare de suport manual. Încurajaţi întregul grup să ofere sfaturi, dacă este nevoie. Participanţii trebuie să ofere suport în partea posterioară a bazinului. Aprobaţi răspunsurile corecte. Explicaţi: Atunci când se furnizează suport pentru a aduce bazinul dintr-o înclinare posterioară către o poziţie mai apropiată de poziția neutră de şedere, este nevoie, de obicei, de suport în două zone: o în partea posterioară a bazinului, la nivelul CIPS - după cum au procedat participanții; o în partea anterioară a bazinului, mai precis în faţa oaselor bazinului (tuberozităţi ischiale). În absența suportului în partea anterioară oaselor bazinului, bazinul va avea tendința să alunece înspre înainte, îndepărtându-se de suportul oferit în partea posterioară a bazinului. Întrebaţi: Cum poate fi oferit suportul în partea anterioară a oaselor bazinului? Rugați unul sau doi voluntari (participanți) să vină în faţa sălii de curs pentru a demonstra modul de furnizare a suportului în partea anterioară oaselor bazinului, folosind plăci de spumă solidă/burete solid. În timpul acestei activităţi, un alt participant trebuie să ofere suport în partea posterioară a bazinului. Încurajaţi întregul grup să ofere sfaturi, dacă este nevoie. Aprobaţi răspunsurile corecte. Mulţumiţi voluntarilor. Întrebaţi participanţii ce tip de DSP poate oferi acest fel suport? Participanţii pot consulta Tabelul DSP sau Tabelul de referinţe DSP, pentru identificarea răspunsului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 136. Inserţia anterioară oaselor bazinului oferă susţinere în partea frontală a oaselor bazinului. Contribuie la: menținerea în echilibru a bazinului; prevenirea alunecării bazinului înspre înainte; reducerea tendinței de adoptare a unei poziții „prăbușite”. Inserţia anterioară oaselor bazinului este plasată exact în faţa oaselor bazinului. Întrebaţi: Care sunt măsurătorile corp pe care trebuie să efectuaţi pentru a putea decide unde pe o pernă se va localiza inserţia anterioară oaselor bazinlui? Răspuns: o distanţa dintre partea posterioară a bazinului şi oasele bazinului. Explicaţi: Inserţia posterioară pentru bazin oferă suport la nivelul părții superioare a bazinului (la nivelul CIPS) Contribuie la: o menţinerea în echilibru a bazinului; Explicaţi: o Aici puteţi vedea două DSP-uri furnizate utilizatorului de scaun rulant prezentat în slide-ul anterior. o Cu ajutorul inserţiei anterioare oaselor bazinului şi a inserţiei posterioare pentru bazin, acest utilizator de scaun rulant poate menține poziţia aşezat. o Observaţi modul în care spătarul se înclină înspre înapoi, pentru a acomoda curbura fiziologică a trunchiului acestui utilizator de scaun rulant. o Suportul corespunzător la nivelul trunchiului este o parte importantă a soluţiei generale. Vom discuta mai multe despre sprijinirea trunchiului în sesiunile următoare. Explicaţi: o Utilizarea simultană a inserţiei anterioare oaselor bazinului şi a inserţiei posterioare pentru bazin este o soluție folosită frecvent pentru ca utilizatorii de scaun rulant să poate menține bazinul în echilibru (în cazul în care postura inițial nu este fixă) şi pentru mai multă stabilitate. o Pe parcursul acestei activități, participanţii vor lucra la modalitatea de înregistrare a dimensiunilor și a poziției acestor două DSP-uri frecvent utilizate, în formularul de prescriere (selecție) a scaunului rulant - nivel intermediar. Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 2 participanți. Instrucţiuni: Cereţi participanţilor să citească cazul lui Madavi din Caietul de exerciții practice (B.8: Prescrierea (selecţia) DSP-urilor - stabilizarea bazinului). Cereţi participanţilor să lucreze împreună şi să folosească valorile din secțiunea referitoare la efectuarea măsurătorilor din formularul de evaluare - nivel intermediar, pentru a putea nota dimensiunile Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 137. corespunzătoare în schiţa de mai jos. Explicaţi: Participanţii pot folosi următoarele: o Tabelul DSP; o Tabelul de referinţe DSP; Explicaţi: Participanţii au la dispoziţie 10 minute ca pentru a efectua această activitate, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Încurajaţi grupele să folosească Manualul participantului şi cunoştinţele proprii. Oferiți asistență grupelor, dacă acest lucru este necesar. Durata: Acordaţi 10 minute pentru desfășurarea activității. Acordaţi 5 minute pentru feedback. Feedback: Prezentaţi slide-ul: Întrebaţi participanţii: o Care trebuie să fie distanţa dintre spătarul şi limita inserţiei anterioare oaselor bazinului în cazul Marianei? o Care trebuie să fie distanţa dintre partea superioară a suprafeţei de şedere şi linia de mijloc a inserţiei posterioare pentru bazin în cazul Marianei? o Ce alte dimensiuni sau informaţii pot fi de folos? Explicaţi: Atunci când se completează un formular de prescriere (selecţie), participanţii pot face mai multe schiţe, cu dimensiuni și cu notiţe, similare cu aceasta, pentru a oferi informații cu privire la dimensiunile şi poziția DSP-urilor. Răspunsuri: o Distanţa dintre spătar şi limita inserţiei anterioare oaselor bazinului trebuie să fie de 170 -190 mm în cazul Marianei (măsurătoarea S plus 20-40 mm). o Distanţa dintre partea superioară a suprafeţei de şedere (zona în care sunt poziționate oasele bazinului) şi linia de mijloc a inserţiei posterioare pentru bazin trebuie să fie de 160 mm în cazul Marianei. o Alte dimensiuni sau informaţii care pot fi de folos: o specificarea tipului de spumă/burete (de ex., spumă solidă/burete solid sub spumă moale/burete moale, atât pentru confecționarea inserţiei anterioare oaselor bazinului, cât şi a inserţiei posterioare pentru bazin); o specificarea înălţimii inserţiei anterioare oaselor bazinului. În cazul unui adult, aceasta este de obicei de 20-30 mm; o specificarea adâncimii inserţiei posterioare pentru bazin. Va depinde de procedeul de simulare manuală/nevoile utilizatorului de scaun rulant. Explicaţi: Am discutat despre inserţia anterioară oaselor bazinului, precum şi despre inserţia posterioară pentru bazin. Întrebaţi: Ce se poate întâmpla dacă utilizatorul de scaun rulant care foloseşte aceste suporturi are mişcări necontrolate, hipertonie sau spasme care cauzează extensia corpului (tipare de extensie)? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 138. Răspuns: o utilizatorul de scaun rulant își poate modifica poziția în raport cu inserţia anterioară oaselor bazinului şi cu inserţia posterioară pentru bazin. Întrebaţi: Care ar trebui să fie direcția suportului exercitat pentru a ajuta la prevenirea acestei situaţii? Rugați unul sau doi participanţi să vină în faţa sălii de curs şi să prezinte zonele în care s-ar putea oferi acest suport. Răspunsuri: o suport descendent, în partea superioară a coapselor. Aprobaţi răspunsurile corecte. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 139. Explicaţi: Săgeata verticală reprezintă suportul suplimentar care poate fi oferit pentru a menţine în poziție bazinul utilizatorului de scaun rulant, în opoziție cu suportul din partea posterioară a bazinului şi din partea anterioară oaselor bazinului. Întrebaţi: Care sunt DSP-urile care furnizează acest tip de suport? Răspuns: o o centură pentru bazin. Explicaţi: o O centură pentru bazin ajută la menţinerea bazinului în poziția corectă. o Centura pentru bazin este recomandată în cazul utilizatorilor de scaune rulante care au mişcări necontrolate şi/sau tendinţa de a aluneca înspre înainte în scaunul rulant. o Centura pentru bazin ajută la menţinerea în poziție a bazinului, astfel încât inserţia anterioară oaselor bazinului şi inserţia posterioară pentru bazin să furnizeze suportul corespunzător. o Locul în care centura este ataşată de scaunul rulant va afecta unghiul/direcţia de întindere. Acest aspect afectează direct modul de funcţionare a centurii pentru bazin. o Unghiul poate fi între 45 şi 90 de grade. o Valoarea ideală a acestuia va depinde de nevoile utilizatorului de scaun rulant. o La evaluare, discutați întotdeauna cu utilizatorul și, dacă este posibil, testați unghiul centurii pentru bazin împreună cu acesta, pentru a stabili poziția cea mai eficientă și mai confortabilă. o Demonstraţi cu un exemplu. Mulţumiţi voluntarilor. Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 3 participanți. Instrucţiuni: Fiecare grupă va lucra cu câte un scaun rulant (cu tipuri diferite de scaune rulante, dacă acest lucru este posibil) şi o centură pentru bazin. Cereţi participanţilor să se gândească unde va fi localizată centura pentru bazin, în așa fel încât să rezulte un unghi de: o 45 de grade o 60 de grade o 90 de grade Explicaţi: Participanţii au la dispoziţie 5 minute pentru a efectua această activitate, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Oferiți asistență grupelor, dacă acest lucru este necesar. Durata: Acordaţi 5 minute pentru desfășurarea activitoții. Acordaţi 5 minute pentru feedback. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 140. Feedback: Cereţi grupelor să prezinte pentru fiecare tip de scaun rulant locul unde trebuie poziționată centura pentru bazin pentru ca rezultatul să fie un unghi de 45 de grade, 60 de grade şi 90 de grade. Confirmați răspunsurile corecte. Explicaţi: Deseori este nevoie de soluţii diverse pentru diferite tipuri de scaune rulante. Totuşi, unghiul trebuie decis în funcţie de cerințele utilizatorului de scaun rulant, nu de tipul scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 141. Explicaţi: o Uneori, mişcările necontrolate, hipertonia sau spasmele pot fi diminuate prin creşterea flexiunii şoldului. o Acest lucru se poate obține prin înălțarea părții anterioare a suprafeţei de şedere, cu o inserţie unghiulară poziționată sub coapsele utilizatorului de scaun rulant. o Notă – marginea inserţiei unghiulare trebuie să fie întotdeauna situată la limita anterioară a oaselor bazinului, conform slide-ului. Oasele bazinului trebuie să se afle pe o suprafaţă plană. Întrebaţi: Care este tipul de suport necesar în cazul în care bazinul utilizatorului de scaun rulant este se află în înclinare posterioară fixă, în poziție vicioasă? Încurajaţi participanţii să răspundă. Răspuns: o Este posibil ca utilizatorii de scaun rulant cu o înclinare posterioară fixă a bazinului să aibă nevoie de mai multe ajustări pentru acomodarea posturii. o O soluţie o reprezintă creşterea unghiului dintre suprafaţa de şedere şi spătar pentru acomodarea poziţiei bazinului şi furnizarea de suport, astfel încât să prevenim orientarea înspre înapoi a bazinului. Aceasta va fi denumită „deschiderea unghiului dintre suprafaţa de şedere şi bazin” (vezi Tabelul de referinţe DSP). o Trebuie să ne asigurăm că utilizatorul de scaun rulant nu va aluneca înspre înainte. Acest lucru poate irita suprafața pielii, ceea ce duce la riscul apariției escarelor. o Inserţia anterioară oaselor bazinului, centura pentru bazin şi înălţarea suprafeţei de şedere prin inserţie anterioară pot preveni alunecarea înspre înainte. Explicaţi: o Această imagine prezintă o modalitate de deschidere a unghiului dintre suprafaţa de şedere şi spătar. o Rețineți – Buretele trebuie să fie conturat pentru a oferi suport acolo unde este necesar. 3. Problemă: Bazinul se află în înclinare laterală (bazin fix inegal) (5 minute) Explicaţi: Vom aborda încă o problemă posturală legată de bazin. Rețineți, utilizatorii de scaune rulante pot avea mai multe probleme posturale. Vom discuta despre următorul caz: o bazinul se află în înclinare laterală/bazin fix inegal (una dintre CIAS este situată mai sus comparativ cu cealaltă). Explicaţi: Modalitatea de furnizare de suport în cazul acestei posturi a fost abordată în sesiunea „B.3: Evaluarea fizică - analiza posturii bazinului şi a şoldului: Întrebaţi: Care este soluția DSP recomandată? Confirmați răspunsurile. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 142. O inserţie sub partea ridicată a bazinului va avea ca rezultat: o creşterea nivelului de stabilitate a utilizatorului de scaun rulant; o evitarea exercitării unui nivel de presiune riscant în partea inferioară a bazinului. Explicaţi: Presiunea trebuie să fie distribuită egal pe toată suprafața zonei de contact dintre ambele părți ale oaselor bazinului şi coapse. Poate fi necesară ajustarea suporturilor pentru picioare (unul va fi situat mai sus decât celălalt). Eplicaţi faptul că imaginea din slide reprezintă partea posterioară a scaunului rulant. Explicaţi: Inserţiile laterale pentru bazin vor contribui și ele la susţinerea bazinului şi ar trebui folosite în cazul utilizatorilor care au o inserţie pentru stabilizarea bazinului. 4. Problemă: Bazinul se deplasează înspre lateral (10 minute) Explicaţi: Vom aborda încă o problemă posturală legată de bazin. Problemă posturală: o Bazinul se deplasează înspre lateral. Explicaţi: o Există mai multe cauze care au ca rezultat această problemă posturală. o În mod frecvent, această problemă este asociată cu alte probleme posturale. o În acest slide puteţi vedea: o Același utilizator ca mai înainte, cu bazinul aflat în înclinare laterală (bazin fix inegal) şi bazinul orientat înspre stânga; o un utilizator cu o curbură laterală a coloanei vertebrale. Bazinul este orientat mai mult înspre stânga. Întrebaţi: Ce tip de suport putem furniza pentru ca bazinul să rămână situat pe linia mediană a scaunului rulant? Confirmați răspunsurile corecte Răspuns: o este necesar suport în partea laterală a ambelor şolduri. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 143. Întrebaţi: Care este soluţia DSP recomandată? Participanţii pot consulta Tabelul de referinţe DSP. Confirmați răspunsurile corecte Răspuns: o inserţii laterale pentru bazin Explicaţi: o Inserţiile laterale pentru bazin previn deplasarea înspre lateral a bazinului. o Inserţiile laterale pentru bazin trebuie să ofere un grad ridicat de suport de ambele părţi ale bazinului. Reţineţi: o În cazul copiilor mici, gradul de abducție al coapselor trebuie să fie mai mare comparativ cu adulţii. Acest lucru este important pentru sănătatea şi dezvoltarea articulaţiilor şoldului. Este esențial ca inserţiile laterale pentru bazin să nu exercite presiune asupra coapselor copiilor, apropiindu-le. 5. Bazinul se află în înclinare anterioară (bazin înclinat anterior) (25 de minute) Explicaţi: O altă problemă posturală o reprezintă înclinarea anterioară a bazinului (bazinul înclinat anterior) Întrebaţi participanţii – ce fel de suport putem oferi pentru menținerea bazinului într-o poziție mai apropiată de cea neutră? Confirmați răspunsurile. Răspunsuri: o suport în partea anterioară a bazinului (CIAS), direcționat înspre înapoi; o inserţie unghiulară înclinată, cu partea înclinată orientată posterior. Pregătiţi vizionarea materialului video: Soluţii de suport postural pentru înclinare anterioară a bazinului. În acest material video îl vom vedea pe Caro, un utilizator de scaun rulant al cărui bazin se află în înclinare anterioară. Priviţi cu atenţie pentru a vedea soluţia DSP recomandată. După vizionarea acestui materia video, vom discuta despre soluția identificată. Prezentaţi materialul video. Verificaţi dacă există întrebări. Întrebaţi participanţii – ce tip de suport a fost furnizat pentru ca bazinul utilizatorului de scaun rulant să fie într-o poziție cât mai apropiată de cea neutră de şedere? Răspuns: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 144. o Caro a încercat o pernă cu inserţie unghiulară pentru înclinare anterioară (o inserţie unghiulară cu partea înclinată orientată posterior) pentru a stabili dacă aceasta ajută la îndreptarea bazinului ei. o Apoi, personalul furnizor de servicii de scaun rulante a testat o centură pentru bazin, cu scopul de a vedea dacă suportul suplimentar furnizat de o centură în patru puncte pentru prevenirea înclinaţiei anterioare a bazinului poate fi o soluție eficientă. Explicaţi: o Inserţia unghiulară pentru înclinarea anterioară a bazinului (o inserţie unghiulară cu partea înclinată orientată posterior) este poziţionată sub oasele bazinului. Acest lucru poate determina bazinul aflat în înclinare anterioară, să se orienteze înspre înapoi, spre spătar. o Suprafața inserţiei unghiulare pentru înclinarea anterioară a bazinului trebuie să se oprească la limita anterioară a oaselor bazinului şi să se situeze la același nivel sub coapse. o Atunci când luaţi în considerare utilizarea acestui tip de DSP, testați-l împreună cu utilizatorul de scaun rulant, pentru a stabili: o modul în care este perceput de către utilizatorul de scaun rulan; o dacă este eficient; o care este unghiul care oferă senzația de confort. Notă – în acest material video, personalul furnizor de servicii de scaune rulante a întrebat-o pe Caro dacă perna a ajutat-o să stea mai confortabil. Explicaţi: o Această imagine prezintă cum modalitatea de confecționare a acestui tip de inserţie unghiulară, prin combinarea spumei solide/buretelui solid cu spumă moale/burete moale. Explicaţi: o Putem furniza suport şi în partea anterioară a bazinului pentru a-l determina să se mențină într-o poziţie mai apropiată de cea neutră de şedere. Notă - în acest material video, personalul furnizor de servicii de scaune rulante a oferit un astfel de tip de suport și a întrebat-o pe Caro cum se simte. Întrebaţi participanţii care sunt acele DSP-uri care furnizează acest tip de suport? Răspunsuri: o centura în patru puncte pentru prevenirea înclinării anterioare a bazinului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 145. Explicaţi: o Această centură este folosită special pentru înclinarea anterioară a bazinului. o Observaţi în imagine faptul că centura este atașată de cadrul suprafeței de ședere, iar în partea posterioară de cadrul spătarului. o Astfel este oprită alunecarea centurii în sus pe abdomenul utilizatorului de scaun rulant, fapt care ar produce disconfort. o Este important ca orice centură care oferă suport la nivelul ambelor CIAS să fie acoperită cu un strat de protecție, astfel încât să fie redus riscul apariţiei escarelor. Note pentru formatori: Materialul video prezintă o centură simplă. Aceasta este folosită doar pentru a vedea dacă centura reprezintă o soluție confortabilă în cazul lui Caro şi pentru a stabili unghiul de exercitare a forței. Dacă participanţii întreabă, precizați că centura în patru puncte trebuie folosită din motivele menționate mai sus. Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 3 participanți. Instrucţiuni: Oferiţi fiecărei grupe câteva bucăţi de spumă solidă/burete solid; o inserţie unghiulară din spumă solidă/burete solid (suficient de mare pentru a se putea sta pe ea); o centură pentru bazin. Cereţi participanţilor să lucreze pe echipe pentru: o a experimenta modul prin care suprafaţa de şedere poate contribui la schimbarea posturii bazinului din înclinare anterioară spre o poziţie mai apropiată de cea corectă (să simuleze utilizarea unei inserţii unghiulare pentru înclinarea anterioară a bazinului); o a testa centura pentru bazin, în vederea identificării celei mai eficiente direcţii de exercitare a suportului, astfel încât postura bazinului să se schimbe de la o înclinare anterioară la o poziţie mai apropiată de cea neutră de şedere. Explicaţi: Participanţii au la dispoziţie 10 minute pentru a efectua această activitate, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Asiguraţi-vă că fiecare participant are oportunitatea de a testa efectele inserţiei unghiulare asupra poziţiei bazinului. Oferiți asistență grupelor, dacă acest lucru este necesar. Durata: Acordaţi 10 minute pentru desfășurarea activității. Acordaţi 5 minute pentru feedback. Feedback: Întrebaţi întregul grup – A contribuit inserţia unghiulară pentru înclinarea anterioară a bazinului la orientarea înspre spate a bazinului? Confirmați răspunsurile. Întrebaţi întregul grup - Care a fost cel mai eficient unghi stabilit pentru centura pentru bazin? Încurajaţi participanţii să răspundă. Aprobaţi răspunsurile. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 146. 6. Recapitulare puncte cheie (3 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 147. B.9: Prescrierea (selecţia) DSP-urilor - sprijinirea şoldurilor O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să descrie tipurile de DSP care oferă suport la nivelul şoldurilor; să specifice dimensiunile necesare pentru confecționarea a cel puţin două DSP- uri. R E S U R S E Pentru sesiune: slide-uri PPT: B.9 Prescrierea (selecţia) DSP-urilor - sprijinirea şoldurilor; Manualul participantului; Caietul de exerciţii practice; afiş: „Tabel dispozitive de suport postural (DSP)”; Tabel de dispozitive de suport postural (DSP), laminat – 1 pentru fiecare participant; Set DSP: C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptați conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte: DSP-urile, materialele şi metodele de confecționare a DSP-urilor disponibile în zona în care lucrează participanţii. Locul unde participanţii vor efectua probarea scaunului rulant - de exemplu, în comunitate/domiciliul utilizatorilor, într-un atelier sau clinică. Acest aspect poate afecta modul în care se lucrează şi se selectează DSP-urile. D E P R E G Ă TI T Pregătiți toate resursele, revedeți slide-urile PPT şi parcurgeți planul de sesiune. Folosiți afişul „Tabelul de dispozitive de suport postural (DSP)”. Luați mostrele de DSP-uri din setul DSP şi plasaţi-le pe o masă în faţa sălii de curs, unde să aveţi acces uşor la ele. P R E ZE N TA R E 1. Introducere 2. Sprijinirea şoldurilor 3. Completarea secţiunii „DSP-uri sau modificări necesare” din formularul de prescriere (selecție) a scaunului rulant - nivel intermediar 4. Recapitulare puncte cheie 2 25 15 3 Durata totală a sesiunii 45 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 148. 1. Introducere (2 minute) Explicaţi: o În această sesiune vom discuta despre diferite tipuri de DSP care au ca scop acomodarea posturilor fixe non- neutre ale şoldurilor, în cazurile în care: o unul din șolduri nu poate fi flectat pentru atingerea poziţiei neutră de şedere (unghiul dintre coapse şi trunchi este mai mare de 90 de grade) o niciunul dintre şolduri nu poate fi flectat pentru atingerea poziţiei neutră de şedere (unghiul dintre coapse şi trunchi este mai mare de 90 de grade) o unul sau niciunul dintre şolduri nu poate fi extins pentru atingerea poziției neutre de ședere (unghiul dintre trunchi şi coapse este mai mic de 90 de grade) o În absența acomodării, orice postură fixă/non-neutră a şoldurilor va afecta postura bazinului. Pe parcursul secțiunii „B3: Evaluarea fizică - analiza posturii bazinului şi a şoldurilor” am discutat despre modalitatea de acomodare a acestor posturi, cu ajutorul suportului postural suplimentar. o În această sesiune vom vedea modul prin care aceste suporturi provizorii devin DSP-uri cu utilizare permanentă. o Reţineţi – de regulă, DSP-urile nu sunt prescrise separat - multe dintre acestea se folosesc împreună. 2. Sprijinirea şoldurilor (25 de minute) Problemă: Unul dintre şolduri nu poate fi flectat până la atingerea poziţiei neutre de şedere (unghiul dintre coapse şi trunchi este mai mare de 90 de grade) Explicaţi: În cele ce urmează, vom identifica soluții pentru cazul în care doar unul dintre şolduri nu poate fi flectat până la atingerea poziției neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 de grade doar în cazul uneia dintre coapse). Întrebaţi: Conform celor discutate anterior, ce suport provizoriu este recomandat pentru rezolvarea acestei probleme? Încurajaţi participanţii să răspundă. Răspuns: o introduceţi o inserţie (spumă/burete) sub ambele părți ale oaselor bazinului şi sub coapsa şoldului care nu poate fi flectat până la atingerea poziției neutre de ședere (unghiul dintre trunchi şi coapse este mai mare de 90 de grade). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 149. Explicaţi: o Acest suport poate fi încorporat definitiv în perna scaunului rulant, pentru acomodarea şoldului care nu poate fi flectat până la atingerea poziției neutre de şedere (unghiul dintre trunchi şi coapse este mai mare de 90 de grade) prin reglarea unghiului de înclinare a bazinului (unilateral). o Inserţia pentru reglarea unghiului de înclinare a bazinului Unghiul secțiunii tăiate va depinde de unghiul dintre trunchiul şi coapsele utilizatorului de scaun rulant - deci, acest aspect trebuie verificat la evaluare. o Luați în considerare faptul că perna are încorporată o inserție anterioară oaselor bazinului. Problemă: Niciunul dintre şolduri nu poate fi flectat până la atingerea poziţiei neutre de şedere (unghiul dintre coapse şi trunchi este mai mare de 90 de grade) Problemă: o Niciunul dintre şolduri nu poate fi flectat până la atingerea poziției neutre de şedere (unghiul dintre coapse şi trunchi este mai mare de 90 de grade) Întrebaţi: Ce fel de suport provizoriu se recomandă pentru această problemă posturală? Răspuns: o introduceţi o inserţie (spumă/burete) sub ambele părți ale oaselor bazinului. Întrebaţi: Ar putea fi aceasta o soluţie permanentă? De ce? De ce nu? Răspuns: o nu, corpul utilizatorului de scaun rulant ar avea tendinţa de a aluneca înspre înainte în scaunul rulaant. Întrebaţi: Ce se poate face în schimb? Răspuns: o creşterea unghiului dintre suprafaţa de şedere şi spătar pentru a se potrivi cu unghiul dintre trunchi şi coapse; o furnizarea unui suport corespunzător în partea posterioară a corpului, pentru a ajuta utilizatorul de scaun rulant să mențină o poziție cât mai apropiată de cea așezat. În cazul în care niciunul dintre şolduri nu poate fi flectat pentru atingerea poziţiei neutre de şedere, o soluţie o poate constitui deschiderea (creşterea) unghiului dintre suprafaţa de şedere şi spătar: o creşterea unghiului dintre suprafaţa de şedere şi spătar va acomoda unghiul mai mare dintre trunchi şi coapse; o unghiul va depinde de unghiul dintre trunchiul şi coapsele utilizatorului de scaun rulant - acest aspect trebuie decis pe parcursul evaluării; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 150. o prescrierea unei inserţii anterioare oaselor bazinului şi a unei centuri pentru bazin, pentru prevenirea alunecării înspre înainte a bazinului utilizatorului de scaun rulant. Problemă: Unul sau niciunul dintre şolduri nu poate fi extins pentru atingerea poziţiei neutre de şedere Explicaţi: Vom discuta despre o altă problemă posturală la nivelul şoldurilor - când unul sau niciunul dintre șolduri nu poate fi extins pentru atingerea poziției neutre de şedere (unghiul dintre trunchi şi coapse este mai mic de 90 de grade). Cereţi tuturor participanţilor să demonstreze această postură, fără a-și părăsi locurile. Verificaţi ca toți participanții să aibă șoldurile flectate de așa manieră încât genunchii să se situeze mai sus decât nivelul şoldurilor. Întrebaţi: Puteți sugera o soluţie? Gândiţi-vă la soluţiile provizorii discutate anterior. Încurajaţi participanţii să răspundă. Răspuns: o introducerea unei inserţii (inserţie unghiulară din spumă solidă/burete solid) înaintea oaselor bazinului şi sub coapsa/coapsele care nu pot fi extinse pentru atingerea poziției corecte (unghiul dintre trunchi şi coapse este mai mic de 90 de grade). Explicaţi: o O potențială soluţie permanentă o reprezintă ridicarea suprafeţei de şedere prin inserţie unghiulară în faţa oaselor bazinului şi sub coapse. o Acesta reduce unghiul dintre suprafaţa de şedere şi spătar. Gradul de înălţare a suprafeţei de şedere va depinde de unghiul dintre trunchiul şi coapsele utilizatorului de scaun rulant. Acest lucru ar trebui decis pe parcursul evaluării. o Înălţarea suprafeţei de şedere contribuie și la reducerea mişcărilor necontrolate puternice sau a hipertoniei, care provoacă extensia corpului. 3. Completarea secţiunii „DSP-uri sau modificări necesare” din formularul de prescriere (selecție) a scaunului rulant - nivel intermediar (15 minute) Activitate pentru grupe mici Grupe: Împărţiţi participanţii în grupe de câte 2 sau 3 persoane. Instrucţiuni: Cereţi participanţilor să citească descrierile utilizatorilor de scaun rulant din Caietul de exerciţii practice (B.9: Prescrierea (selecţia) DSP-urilor - sprijinirea şoldurilor). Cereţi participanţilor să lucreze împreună pentru a descrie DSP-urile de la secțiunea „DSP-uri sau modificări necesare” din formularul de prescriere (selecție) a scaunului rulant - nivel intermediar. Explicaţi: Participanţii pot folosi următoarele: o Tabelul DSP; o Tabelul de referinţe DSP; Explicaţi: Participanţii au la dispoziţie 10 minute pentru a efectua această activitate, iar apoi gurpele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 151. Încurajaţi grupele să folosească Manualul participantului şi Tabelul de referinţe DSP. Oferiți asistență grupelor, dacă acest lucru este necesar. Durata: Acordaţi 10 minute pentru desfășurarea activității. Acordaţi 5 minute pentru feedback. Feedback: Cereţi părerea participanţilor cu privire la schițarea DSP-urilor. Rețineți faptul că, în cazul multor persoane, este nevoie de exerciţiu pentru a putea descrie corect DSP-urile. Prezentaţi slide-ul. Explicaţi: dimensiunile importante sunt: o A: Locul de unde începe inserţia anterioară oaselor bazinului. o B: Înălţimea inserţiei anterioare oaselor bazinului. o C: Diferenţa de înălţime a părţii frontale a suprafeţei de şedere dintre şoldul stâng şi cel drept. Aceasta creează unghiul pentru acomodarea şoldului drept al Siennei. Întrebaţi: Cum se decide valoarea corectă a acestor dimensiuni? Răspunsuri: o A: Cu ajutorul măsurătorilor corp ale Siennei (partea posterioară a bazinului până la oasele bazinului) puteţi decide locul de unde trebuie să înceapă inserţia anterioară oaselor bazinului. o B: Înălţimea unei inserţii anterioare oaselor bazinului este, de obicei, între 25–30 mm. o C: Măsuraţi înălţimea suportului provizoriu pentru a determina înălţimea C. Prezentaţi slide-ul. Explicaţi: dimensiunile importante sunt: o A: Locul de unde începe inserţia anterioară oaselor bazinului. o B: Înălţimea inserţiei anterioare oaselor bazinului. o C şi D oferă împreună dimensiunile necesare confecționării inserţiei unghiulare, pentru deschiderea unghiului dintre suprafaţa de şedere şi spătar. Întrebaţi: Cum se decide valoarea corectă a acestor dimensiuni? Răspunsuri: o A: Cu ajutorul măsurătorilor corp ale lui Robert (partea posterioară a bazinului până la oasele bazinului) puteţi decide locul de unde trebuie să înceapă inserţia anterioară oaselor bazinului. o Notă: Această măsurătoare trebuie să ia în considerare inserţia unghiulară adăugată spătarului pentru a deschide unghiul dintre suprafaţa de şedere şi spătar. o B: Înălţimea unei inserţii anterioare oaselor bazinului este, de obicei, Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 152. între 25–30 mm. o C şi D: Cea mai bună metodă de efectuare a acestor măsurători este folosirea unei inserţii unghiulare de probă, pe care o puteți testa împreună cu utilizatorul de scaun rulant. Explicaţi: Atunci când se confecționează DSP-uri similare cu cele descrise în această sesiune, se recomandă să NU atașați cu adeziv spuma/buretele înainte de prima probare. Astfel, DSP-ul va putea fi ajustat pentru a ne asigura că se potriveşte în mod corect. Note pentru formatori: În cazul lui Robert, în desenul cu dimensiuni, inserţia unghiulară de pe spătar a fost astfel plasată încât să lase loc unui strat de spumă/burete moale, care se adaugă părții superioară a pernei, introducându-se sub inserţie. Există diferite metode de confecționare a acestui DSP, iar variantele individuale pot fi explicate de către formatori, în funcţie de context, materiale şi soluţii tehnice uzuale. 4. Recapitulare puncte cheie (3 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 153. B.10: Prescrierea (selecţia) DSP-urilor - sprijinirea trunchiului O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să descrie modificările şi DSP-urile care contribuie fie la sprijinirea trunchiului în poziţie neutră de şedere (dacă acest lucru este posibil), fie la acomodarea trunchiului într-o poziţie cât mai apropiată de cea neutră de şedere, în limita menținerii confortului utilizatorului de scaun rulant; să înceapă rezolvarea problemelor legate de modificări sau DSP-uri care oferă suport la nivelul bazinului, şoldurilor şi a trunchiului; să completeze un formular de prescriere (selecţie) a scaunului rulant - nivel intermediar, cu asistenţă. R E S U R S E Pentru sesiune: slide-uri PPT: B.10: Prescrierea (selecţia) DSP-urilor - sprijinirea trunchiului; Manualul participantului; Caietul de exerciţii practice; afiş: „Tabel dispozitive de suport postural (DSP)”; Formular de prescriere (selecţie) a scaunului rulant – nivel intermediar; Tabel de dispozitive de suport postural (DSP), laminat – 1 pentru fiecare participant; Set DSP: Materiale DSP; Scaun rulant – 1 pentru fiecare grupă (un model care să fie cât mai apropiat de cel descris în fiecare caz); bucăţi de spumă solidă/burete solid – câteva pentru întregul grup; inserţii unghiulare din spumă solidă/burete solid – câteva pentru întregul grup; C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptați conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte: DSP-urile, materialele şi metodele de fabricare a DSP-urilor disponibile în zona în care lucrează participanții. Locul unde participanţii vor efectua probarea scaunului rulant - de exemplu, în comunitate/domiciliul utilizatorilor, într-un atelier sau clinică. Acest aspect poate afecta modul în care se lucrează şi se selectează DSP-urile. D E P R E G Ă TI T Pregătiți toate resursele, revedeți slide-urile PPT şi parcurgeți planul de sesiune. Folosiți afişul „Tabelul de dispozitive de suport postural (DSP)”. pregătiți setul DSP, materialele, plăcile şi inserţiile unghiulare din spumă solidă/ burete solid şi plasaţi aceste echipamente pe o masă, în partea din faţă a sălii de curs. Aranjaţi scaunele rulante în partea din faţă a sălii de curs. R E ZU M A T 1. Introducere 2. Sprijinirea trunchiului 3. Completarea formularului de prescriere (selecţie) a scaunului rulant - nivel intermediar 4. Recapitulare puncte cheie 2 115 30 3 Durata totală a sesiunii 150 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 154. 1. Introducere (2 minute) Explicaţi: Am discutat despre diferitele DSP-uri care au ca rezultat stabilizarea bazinului, sprijinirea șoldurilor şi a trunchiului. În această sesiune: o vom învăţa despre acele DSP-uri care oferă suport la nivelul trunchiului; o vom discuta de ce este important să stabilizăm întâi bazinul, urmând să ne ocupăm de sprijinirea trunchiului. În cazul multor persoane, problemele posturale legate de trunchi pot fi rezolvate sau îmbunătăţite prin suport postural corespunzător. În cea mai mare parte a sesiunii, participanţii vor lucra împreună în grupe mici, pentru a găsi soluţia DSP potrivită pentru trei utilizatori de scaune rulante diferiți. Pe parcursul acestei sesiuni, participanţii trebuie să observe că DSP-urile pentru trunchi nu lucrează în mod independent, ci, de regulă, se folosesc împreună cu DSP-uri care furnizează suport la nivelul bazinului şi, câteodată, al şoldurilor. 2. Sprijinirea trunchiului (115 de minute) Activitate pentru întregul grup Grupe: Această activitate este efectuată cu întregul grup. Instrucţiuni: Cereţi participanţilor să găsească un perete plan şi să poziționeze o masă/bancă lângă acesta. Cereţi participanţilor să stea pe masă/bancă cu bazinul lipit de perete. Explicaţi faptul că poziția lor trebuie să fie cât mai aproape de poziţia aşezat. Explicaţi: Participanţii vor sta în această poziţie aproximativ 5 minute, iar apoi grupul va oferi feedback. Monitorizare: Monitorizaţi fiecare participant. Asiguraţi-vă că fiecare participant înţelege în ce constă activitatea. Verificaţi ca mesele/băncile să fie drepte lângă perete şi ca fiecare participant să stea cu bazinul drept, atingând peretele. Oferiți asistență grupelor, dacă acest lucru este necesar. Durata: Acordaţi 5 minute pentru desfășurarea activității. Acordaţi 5 minute pentru feedback. Feedback: Întrebaţi: Este această poziţie una confortabilă? Este posibilă menținerea poziţiei aşezat? Răspunsuri: o participanţii ar trebui să aibă senzația că peretele le împinge înspre înainte partea superioară a trunchiului; sau o să aibă senzația că trebuie să îşi orienteze bazinul înspre înainte pentru a putea menține poziţia aşezat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 155. Explicaţi: o Motivul disconfortului este că peretele împiedică menținerea poziţiei aşezat. o Peretele nu permite părții superioare a trunchiului să depășească linia bazinului. o Aceasta situaţie este similară cu cea a utilizatorilor care stau într-un scaun rulant cu un spătar drept. Explicaţi: Am discutat despre diferite căi de stabilizare a bazinului. Totuşi, este important să privim şi modul în care trunchiul poate fi susţinut deasupra bazinului - ori în poziţia neutră de şedere (dacă se poate) sau susţinut cât mai aproape de poziţia neutră de şedere. Activitate cu grupe mici Grupe: Împărţiţi participanţii în 3 grupe. Instrucţiuni: Desemnați fiecărei grupe un număr (de la 1 la 3) şi câte un scaun rulant care să corespundă celui descris în fiecare caz din Caietul de exerciții practice (B.10: Prescrierea (selecţia) DSP-urilor - sprijinirea trunchiului). Oferiţi fiecărei grupe un scaun rulant care se potriveşte (într-o cât mai mare măsură) cu scaunul rulant descris în cazul de care se va ocupa echipa. Oferiţi fiecărei echipe materiale DSP, plăci şi inserţii unghiulare din spumă solidă/burete solid. Explicaţi: o Fiecare grupă trebuie să citească cu atenţie cazul care îi revine. o Fiecare grupă se ocupă de un utilizator de scaun rulant diferit, cu nevoi individuale diferite. Totuşi, fiecare utilizator de scaun rulant descris are nevoie de sprijin la nivelul bazinului şi al trunchiului. În două dintre cazuri este vorba despre şold aflat într-o postură fixă. o Fiecare grupă ar trebuie să decidă modalitatea prin care va oferi suportul necesar utilizatorului de scaun rulant din cazul respectiv. o Fiecare grupă trebuie să se gâdească la diferite opţiuni şi metode de confecționare a DSP-urilor. Explicaţi: o Participanţii trebuie să folosească materialele disponibile pentru a „simula” cel puţin o soluţie pentru scaunul rulant care le-a fost desemnat (formatorul trebuie să indice materialele disponibile). o Încurajaţi participanţii să pună întrebări în orice moment al desfășurării activității. o Participanţii trebuie să fie pregătiţi să prezinte cazul utilizatorului de scaun rulant şi soluţiile identificate. Explicaţi: o Participanţii au la dispoziţie 60 de minute pentru a rezolva cazul și sarcinile asociate cu acesta. Fiecare echipă va oferi feedback întregului grup de participanți, prezentând posibilele soluţii la respectivele probleme posturale. Cereţi participanţilor să NU COMPLETEZE formularul de prescriere (selecție) a scaunului rulant - nivel intermediar de la finalul fiecărui caz. Acest lucru se va face după sesiunea de feedback şi după ce soluţiile de prescriere (selecţie) au fost aprobate de întregul grup. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 156. Încurajaţi fiecare grupă să folosească scaunul rulant şi materialele oferite pentru a confecționa DSP-ul pe care l-ar oferi utilizatorului de scaun rulant. Asiguraţi-vă că fiecare grupă urmează secvența corectă a paşilor: Bazin + Șolduri Trunchi Oferiți asistență grupelor, dacă acest lucru este necesar. Timp: Acordaţi 60 minute pentru desfășurarea activității. Acordaţi 45 minute pentru feedback. Feedback: Cereţi fiecărei grupe să prezinte cazul utilizatorului de scaun rulant. Participanţii trebuie: o să ofere o scurtă descriere a utilizatorului de scaun rulant; o să prezinte soluţia de suport postural suplimentar identificată pentru respectivul utilizator de scaun rulant. După ce fiecare echipă propune soluţia, întrebaţi întregul grup: o Sunteţi de acord cu această soluţie? De ce? o Mai există o altă modalitate prin care putem oferi același tip de suport? Încurajaţi participanţii să ia în considerare diferitele soluţii tehnice posibile, în funcţie de materialele şi echipamentele disponibile. Asiguraţi-vă că răspunsurile sunt corecte. Dacă există confuzii, încurajaţi întregul grup să rezolve problema. Folosiţi Notele pentru formatori de mai jos. În concluzie – accentuaţi faptul că prioritatea fiecărei grupe a fost (sau trebui să fie) stabilizarea bazinului. Note pentru formatori: Mark, în vârstă de 16 ani, are un traumatism vertebro-medular cu o leziune la nivel înalt. El are un scaun rulant cu spătar și suprafață de ședere pliabile. Scaunul său rulant are dimensiunea corectă și are o pernă moale și plată, confecționată din spumă/burete. Mark are dificultăți în a menține poziția așezat. Spatele său urmează o linie curbată și are tendința de a aluneca înspre înainte în scaunul rulant. Pielea de sub oasele bazinului și în zona omoplaților se înroșește. Care sunt tipurile de DSP cu ajutorul cărora Mark poate menține poziţia aşezat în scaunul rulant? În urma evaluării lui Mark, constatăm că el poate menține poziţia aşezat cu suport. DSP- urile pentru susţinerea poziţiei neutre de şedere sunt: La nivelul bazinului: o inserţie anterioară oaselor bazinului - pentru sprijinirea bazinului în poziţia neutră de şedere şi pentru prevenirea înclinării posterioare a bazinului; o inserţie posterioară pentru bazin - pentru susţinerea părţii superioare a bazinului, astfel încât să fie menținută poziţia neutră de şedere şi pentru prevenirea înclinării posterioare a bazinului; o centură pentru bazin (dacă este necesară) – pentru a menţine bazinul în postura corectă de şedere şi pentru a opri distanțarea de inserţia posterioară pentru bazin şi alunecarea corpului peste inserţia anterioară oaselor bazinului. La nivelul trunchiului: o creşterea înălţimii spătarului - pentru a oferi suport la nivelul omoplaţilor (notă – atunci când Mark menține poziția așezat, cu ajutorul suportului la nivelul bazinului, înălţimea spătarului trebuie să fie mai mare). Cum pot fi montate aceste suporturi pe scaunul rulant al lui Mark? 1. Suprafaţă de şedere / pernă: o confecționarea unei perne conturate noi, cu o inserţie anterioară oaselor bazinului şi un Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 157. strat superior din spumă moale/burete moale. 2. Spătar: Inserţia anterioară pentru bazin poate fi adăugată prin mai multe modalităţi: o opțiunea 1: adăugarea unei centuri ajustabile căptuşite în spatele materialului textil al spătarului şi atașarea acesteia de barele verticale ale spătarului; o opțiunea 2: plasarea unei bucăți de spumă solidă/burete solid în spatele materialului textil al spătarului şi atașarea ei de barele verticale ale spătarului; o opțiunea 3: adăugarea unui spătar cu tensiune ajustabilă şi reglarea acestuia, astfel încât gradul de suport la nivelul părții superioare a bazinului lui Mark să fie unul ridicat ; o opțiunea 4: îndepărtarea spătarului pliabil cu unul solid. Capitonaţi spătarul cu un strat de spumă solidă/burete solid acoperit cu un strat de spumă moale/burete moale, între cele două straturi, şi adăugaţi o inserţie posterioară pentru bazin confecționată din spumă solidă/burete solid. Acoperiţi spătarul cu un material textil ce poate fi spălat. Această opţiune poate avea ca rezultat imposibilitatea de a plia scaunul rulant. Înălţimea spătarului poate fi modificată prin mai multe căi: o opțiunea 1: fixați o bucată suplimentară de material textil între barele verticale ale spatarului, dacă înălţimea acestora o permite; o opțiunea 2: extindeţi barele verticale ale spătarului, dacă nu este suficient de înalte. Acest lucru se poate face prin tăierea barelor verticale ale spătarului şi introducerea unor tuburi cu un diametru mai mic, confecționate din lemn sau metal (care nu este umplut). Fixațiţi cu şuruburi (lemn) sau sudaţi (în funcţie de tipul metalului) tuburile şi adăugaţi material textil suplimentar pentru spătar sau înlocuiţi-l cu unul care are dimensiunea adecvată (de exemplu, spătar cu tensiune ajustabilă); o opțiunea 3: eliminaţi materialul textil al spătarului şi montaţi un spătar solid, de înălţime corespunzătoare, fixat de barele verticale ale spătarului cu ajutorul şuruburilor. Puteți utiliza alte dispozitive de fixare Această opţiune poate avea ca rezultat imposibilitatea de a plia scaunul rulant. 3. Centuri: o montaţi o centură pentru bazin pe barele suprafeţei de şedere; Josephine, 35 de ani, are un traumatism vertebro-medular. Locuiește în mediul rural și este membru activ al bisericii locale. Josephine a primit un scaun rulant cu o bază a roții lungă, de care este mulțumită, deoarece familia ei o poate împinge cu ușurință pe terenul accidentat din satul ei. Josephine poate efectua și ea propulsia scaunului rulant, pe distanțe scurte, pe teren fără denivelări, în interior. Scaunul rulant are dimensiunea potrivită pentru ea și are spătarul și suprafața de ședere rigide. Are o pernă groasă și plană, confecționată din spumă. Poziția de ședere în scaunul rulant nu este una confortabilă și îi este dificil să realizeze propulsia. Bazinul este înclinat spre partea posterioară (înclinare posterioară a bazinului), postura trunchiului este înclinată înainte. Care sunt tipurile de DSP cu ajutorul cărora Josephine poate menține poziţia aşezat în scaunul rulant? Pe parcursul evaluării Josephinei, s-a stabilit că ea nu poate menține o poziţie așezat corectă. Bazinul ei fix se află în înclinare posterioară şi nu îşi poate flecta șoldul drept pentru atingerea poziţiei neutre de şedere (unghi de 100 grade). Totuşi, postura ei de şedere s-a îmbunătăţit cu ajutorul suportului provizoriu poziționat sub oasele bazinului și al gradului ridicat de suport la nivelul bazinului şi al trunchiului. DSP-urile pentru susţinerea poziţiei neutre de şedere sunt: La nivelul bazinului și al șoldurilor: o inserţie anterioară oaselor bazinului - pentru menținerea unei poziţii mai corecte şi pentru prevenirea alunecării înspre înainte a bazinului; o inserţie pentru reglarea unghiului de înclinare a bazinului pe partea dreaptă, pentru Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 158. acomodarea şoldului drept aflat în postură fixă; o centură pentru bazin– pentru a menţine bazinul în postura corectă de şedere şi pentru a opri distanțarea de inserţia posterioară pentru bazin şi alunecarea corpului peste inserţia anterioară oaselor bazinului. La nivelul trunchiului: o deschiderea unghiului dintre suprafaţa de şedere şi spătar pentru acomodarea înclinării posterioare fixe; o ajustarea formei spătarului - pentru susţinerea curburii trunchiului; o pe parcursul etapei de probare a produsului (a scanului rulant), luaţi în considerare înclinarea suprafeţei de şedere şi a spătarului (înclinare în spaţiu) – stabiliți dacă poziția capului este mai confortabilă atunci când poziția ei este susținută de aceste suporturi. Cum pot fi montate aceste suporturi pe scaunul rulant al lui Josephine? 1. Suprafaţă de şedere / pernă o modificaţi perna curentă sau confecționați o pernă nouă, care să includă o inserţie anterioară oaselor bazinului şi o inserţie pentru reglarea unghiului de înclinare a bazinului, în partea dreaptă; o perna trebuie să conţină un strat de spumă solidă/burete solid, acoperit cu un strat de spumă moale/burete moale. 2. Suprafaţă de şedere şi spătar o Deschiderea unghiului dintre suprafaţa de şedere şi spătar o opțiunea 1: dacă scaunul rulant permite înclinarea unghiului dintre suprafaţa de şedere şi spătar, ajustaţi scaunul rulant astfel încât unghiul dintre suprafaţa de şedere şi spătar să fie mai mare, pentru a acomoda înclinarea posterioară a bazinului; o opțiunea 2: confecționați o inserţie unghiulară din spumă solidă/ burete solid, pentru a susţine bazinul într-o poziție cât mai apropiată de cea corectă, în limitele confortului și atașați-o de spătarul solid, cu adeziv. Acoperiţi inserţia unghiulară şi suportul conturat pentru trunchiul Josephinei cu un strat de spumă moale/burete moale. Acoperiți cu un material textil care poate fi spălat. o Ajustarea formei spătarului o Conturaţi suprafaţa spătarului pentru a susţine şi a acomoda trunchiul utilizatorului. În funcţie de suportul necesar, introduceţi o inserţie din spumă/burete acolo unde este nevoie, folosind un material solid. După finalizare, introduceţi un strat de spumă moale/burete moale pe întreaga suprafaţă a spătarului. Asiguraţi-vă că inserția nu împinge înspre înainte trunchiul utilizatorului de scaun rulant. Notă: o Modificările de mai sus ale suprafeţei de şedere şi ale spătarului pot reduce adâncimea suprafeţei de şedere. o Participanţii trebuie să se gândească la soluții pentru cazurile în care adâncimea suprafeţei de şedere devine insuficientă. o Opțiuni: o opțiunea 1: verificați dacă placa suprafeţei de şedere poate fi deplasată înspre înainte (apoi verificaţi poziţia pentru realizarea propulsiei şi accesul la suporturile de picioare); o opțiunea 2: mutaţi spătarul înspre înapoi. O metodă o reprezintă ataşarea spătarului de barele verticale ale acestuia, cu ajutorul unor dispozitive de fixare. În acest caz, verificaţi dacă libertarea de mișcare la nivelul membrelor superioare/trunchiului utilizatorului este limitată de barele verticale ale spătarului și dacă umerii se pot mișca fără restricții. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 159. 3. Centuri: o montaţi o centură pentru bazin pe barele suprafeţei de şedere; Sian are 3 ani și este diagnosticat cu paralizie cerebrală. El are un scaun rulant pliabil, pentru copii. Suporturile de picioare, suprafața de ședere și spătarul se pliază și ele. Nu există măsuță și nici pernă. Adâncimea suprafeței de ședere este corectă, totuși, lățimea este puțin prea mare. Părinții săi nu au mașină și merg pe jos în majoritatea locurilor. În comunitate, ei manevrează scaunul rulant, însă, uneori, îl poartă în brațe. Sian poate să realizeze propulsia scaunului rulant pe distanțe scurte, atunci când suprafața pe care se deplasează este dreaptă. Sian poate menține poziția așezat fără suport pe perioade foarte scurte. După 10 minute, trunchiul său cedează și, de obicei, se apleacă înspre față și stânga. Acest lucru cauzează ridicarea părții drepte a bazinului său și o greutate mai mare pe partea stângă a bazinului. Coloana vertebrală prezintă curbura fiziologică tipică pentru vârsta sa. Mama lui Sian își dorește ca el să se poată juca afară cu alți copii și să înceapă să realizeze singur propulsia scaunului său rulant. Care sunt tipurile de DSP cu ajutorul cărora Sian poate menține poziţia aşezat în scaunul rulant? La nivelul bazinului și al șoldurilor: o inserţie anterioară oaselor bazinului – pentru a menţine bazinului lui Sian în poziţia neutră de şedere şi în partea posterioară a suprafeţei de şedere; o inserţii laterale pentru trunchi – pentru sprijinirea bazinului în poziţia neutră de şedere şi prevenirea ridicării acestuia în partea dreaptă; o centură pentru bazin – pentru siguranţă (deoarece are vârsta de trei ani) şi pentru prevenirea deplasării bazinului în raport cu suporturile; o înălţarea suprafeţei de şedere prin inserţie anterioară – pentru acomodarea unghiului de 80 de grade dintre trunchi şi coapsela nivelul șoldurilor. La nivelul trunchiului: o inserţii laterale pentru trunchi pentru partea dreaptă şi stângă - pentru menţinerea trunchiului lui Sian în poziţie neutră de şedere şi pentru prevenirea orientării acestuia către partea stângă; o măsuţă – o măsuţă poate contribui la menținerea poziţiei aşezat pe durate de timp mai lungi, furnizând suport la nivelul braţelor şi îmbunătățind echilibrul; o ham pentru umeri – poate fi necesar la început sau atunci când Sian este foarte obosit, astfel încât trunchiul şi umerii să se sprijine pe spătar; o înclinarea suprafeţei de şedere şi a spătarului (înclinarea în spaţiu) – în cazul în care trunchiul lui Sian continuă să cadă înspre înainte și spre stânga. Cum pot fi montate aceste suporturi pe scaunul rulant al lui Sian? 1. Suprafaţă de şedere / pernă: o Confecționați o pernă care să aibă următoarele caracteristici: o inserţie anterioară oaselor bazinului; o înălţarea suprafeţei de şedere prin inserţie anterioară (creată prin adăugarea unei inserţii unghiulare - de la limita inserţiei anterioare oaselor bazinului până la partea frontală a pernei, care să se potrivească cu unghiul dintre trunchi şi coapse. o Perna poate fi făcută dintr-o placă solidă, poziționată peste suprafața de ședere pliabilă. Gradul de suport va fi mai mare în acest caz. Dacă nu folosiți placa din material solid, asiguraţi-vă că baza pernei are o uşoară curbură, astfel încât să se așeze în mod corect pe suprafața de şedere pliabilă. o Confecționați inserţii laterale pentru bazin – ataşaţi bucăţi din spumă solidă/burete solid, acoperite cu un strat de material de protecție: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 160. o suporturilor de braţe/apărătoarelor laterale (cu adeziv); o suprafeței de şedere sau spătarului, cu ajutorul unor dispozitive de fixare. 2. Spătar: o Adăugaţi inserţii laterale pentru trunchi; o opţiunea 1: înlocuiţi spătarul pliabil cu un spătar solid şi plasaţi inserţiile laterale pentru bazin pe spătarul solid, în spatele pernei spătarului. Perna spătarului poate fi tăiată pentru a permite poziţionarea corectă a inserţiilor laterale pentru trunchi (suficient de aproape de corpul utilizatorului). Asiguraţi-vă că spătarul este acoperit cu un material de protecție; o opțiunea 2: ataşaţi inserţiile laterale pentru trunchi de barele verticale ale spătarului, utilizând dispozitive de fixare. Asiguraţi-vă că aceste dispozitive au formă corespunzătoare pentru a permite inserţiilor laterale pentru trunchi să se situeze chiar în apropierea corpului utilizatorului de scaun rulant. 3. Înclinarea suprafeţei de şedere şi a spătarului (înclinarea în spaţiu): o pentru înclinarea (în spaţiu) spătarului, este nevoie de o suprafață de şedere solidă şi de un spătar solid, conform descrierii de mai sus. Ataşaţi suprafaţa de şedere şi spătarul cu dispozitive de fixare, astfel încât să se creeze efectul de înclinare. Unghiul dintre suprafaţa de şedere şi spătar nu trebuie să se schimbe. o În cazul în care se recurge la această metodă, Sian va avea nevoie şi de o tetieră. 4. Centuri: o montaţi o centură pentru bazin pe barele suprafeţei de şedere; o ataşaţi hamul pentru umeri la spătarul solid (în partea superioară și inferioară). 5. Măsuţă o confecționați o măsuţă pentru Sian care să urmeze linia trunchiului său, în așa fel încât el să îşi poată rezema coatele şi antebraţele pe aceasta; o măsuţa trebuie atașată de suporturile de braţe ale scaunului rulant şi trebuie să poată fi montată/demontată fără dificultate. 3. Completarea formularului de prescriere (selecţie) a scaunului rulant - nivel intermediar (30 de minute) Activitate pentru grupe mici Grupe: Cereţi participanţilor să păstreze componența echipelor de la activitatea anterioară. Instrucţiuni: Solicitați participanţilor să completeze formularul de prescriere (selecţie) a scaunului rulant - nivel intermediar din Caietul de exerciţii practice, pentru cazurile Mark/Josephine/Sian. Explicaţi: Fiecare grupă trebuie să completeze un singur formular, pentru utilizatorul de scaun rulant al cărui caz l-au soluționat. Explicaţi: Participanţii nu au măsurătorile corp pentru fiecare utilizator de scaun rulant, deci nu pot oferi dimensiunile. Totuşi, participanţii trebuie să descrie/schițeze unde vor fi poziționate DSP-urile. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Înainte de sesiunea de feedback a activităţii, verificaţi formularul de prescriere (selecție) a scaunului rulant - nivel intermediar completat de fiecare grupă, pentru stabili cum au rezolvat participanții exercițiul. Notaţi orice dificultăţi întâmpinate de participanţi. Oferiți asistență grupelor, dacă acest lucru este necesar. Durata: Acordaţi 20 minute pentru desfășurarea activității. Acordaţi 10 minute pentru feedback. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 161. Feedback: Verificaţi dacă participanţii au întrebări legate de completarea formularului de prescriere (selecție) a scaunului rulant - nivel intermediar. Clarificaţi orice aspecte dificile pe care le-aţi notat pe parcursul activităţii. 4. Recapitulare puncte cheie (3 minute) Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 162. B.11: Prescrierea (selecţia) DSP-urilor - sprijinirea capului, coapselor şi a gambelor O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să descrie modificările şi DSP-urile care furnizează suport la nivelul capului, coapselor şi a gambelor utilizatorului de scaun rulant. R E S U R S E Pentru sesiune: slide-uri PPT: B.11: Prescrierea (selecţia) DSP-urilor - sprijinirea capului, coapselor şi a gambelor; Manualul participantului; Caietul de exerciţii practice; DVD: Sprijinirea capului; afiş: „Tabel dispozitive de suport postural (DSP)”; Tabel de dispozitive de suport postural (DSP), laminat – 1 pentru fiecare participant; Set DSP: scaune rulante – 1 pentru fiecare grupă; pernă din spumă/burete – 1 pentru fiecare grupă; C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptați conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte: DSP-urile, materialele şi metodele de fabricare disponibile în zona în care lucrează participanții. Locul unde participanţii vor efectua probarea scaunului rulant - de exemplu, în comunitate/domiciliul utilizatorilor, într-un atelier sau clinică. Acest aspect poate afecta modul în care se lucrează şi se selectează DSP-urile. D E P R E G Ă TI T Pregătiţi toate resursele, revedeţi prezentările PPT, parcurgeţi materialul video şi citiţi planificarea sesiunii. Plasaţi afişul „Tabelul de dispozitive de suport postural (DSP)”. Luați mostrele de DSP-uri din setul DSP şi plasaţi-le pe o masă în faţa sălii de curs, unde să aveţi acces uşor la ele. Aranjaţi modelele de scaune rulante în partea din faţă a sălii de curs. P R E ZE N TA R E 1. Introducere 2. Sprijinirea capului 3. Sprijinirea coapselor 4. Sprijinirea gambelor şi a picioarelor 5. Recapitulare puncte cheie 2 25 60 30 3 Durata totală a sesiunii 120 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 163. 1. Introducere (2 minute) Explicaţi: o Am discutat despre diferitele tipuri de DSP necesare pentru stabilizarea bazinului și pentru sprijinirea șoldurilor şi a trunchiului. o Următoarea serie de DSP-uri are ca rol suportul oferit la nivelul capului, coapselor şi al gambelor utilizatorului de scaun rulant. 2. Sprijinirea capului (25 de minute) Explicaţi: o Niciunul dintre utilizatorii de scaune rulante despre care am discutat nu avea nevoie de o tetieră. o Totuşi, există utilizatori copii şi adulţi cărora le este recomandată tetiera. Întrebaţi: Ați avut oportunitatea să lucrați cu utilizatori copii sau adulți care aveau nevoie de o tetieră? Ascultați răspunsurile şi permiteţi o scurtă discuţie. Problemă: o Capul are tendinţă de a aluneca înspre înapoi, înspre înainte sau înspre lateral. Explicaţi: o În această imagine vedem un băiat căruia îi este dificil să își mențină capul în echilibru. o Puteţi observa faptul că mama sa îi susţine capul cu mâinile. Întrebaţi: Care ar fi câteva soluţii recomandate în acest caz? Încurajaţi participanţii să răspundă. Răspunsuri: o PRIMUL PAS: oferiţi suport corespunzător la nivelul bazinului şi al trunchiului pentru a avea un nivel de stabilitate. Furnizarea suportului: o bazin: inserţie posterioară pentru bazin, inserţie anterioară oaselor bazinului şi centură pentru bazin; o trunchi: ajustarea conturului spătarului pentru a oferi suport optim la nivelul trunchiului, ham pentru umeri sau înclinarea în spaţiu a spătarului. o Aceste DSP-uri ar putea îmbunătăţi controlul la nivelul capului. o Dacă există în continuare dificultăți în ceea ce privește menţinerea în echilibru a capului, furnizați o tetieră. Note pentru formatori: Accentuaţi importanţa furnizării suportului corespunzător la nivelul bazinului şi al trunchiului; decizia cu privire la necesitatea tetierei se va lua după acest pas. Întrebaţi: Care este zona de la nivelul capului unde se furnizează suport? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 164. Răspuns: o PRIMUL PAS: furnizați suport la baza craniului (occiput); o dacă este necesar, suportul se poate extinde în părţile laterale ale capului utilizatorului; Note pentru formatori: Unii participanţi ar putea sugera o centură pentru cap. Această abordare trebuie descurajată, deoarece acest tip de suport poate fi foarte incomod şi chiar periculos. Centura pentru cap trebuie folosită doar în circumstanţe specifice şi doar sub supraveghere. Explicaţi: o Această magine prezintă o tetieră la baza craniului (occiput). Există mai multe tipuri de tetiere. În acest program de intruire vom discuta despre două dintre acestea. Explicaţi: o Prima este o tetieră plată: o aceasta este o extensie a spătarului; o spătarul este conturat pentru a oferi suport la nivelul bazinului și al părții superioare și inferioare a trunchiului, fiind extins pentru a furniza suport la nivelul capului; o tetiera plată reprezintă un loc de repaus pentru cap şi previne alunecarea înspre înapoi a capului. o A doua este o tetieră conturată. o are un contur care „susţine” capul la baza craniului; o tetiera conturată poate fi extinsă la margini şi înspre înainte pentru un grad ridicat de suport în partea laterală a capului; o tetiera conturată oferă un grad de suport mai mare decât tetiera plată, deoarece urmează linia bazei craniului utilizatorului de scaun rulant. Note pentru formatori: Dacă există alte tipuri de tetiere disponibile pe plan local (şi la programul de intruire), prezentaţi-le participanţilor şi explicaţi care sunt caracteristicile acestora. Pregătiţi vizionarea materialului video: Sprijinirea capului: În acest material video îl vom vedea pe Michael, pe care mama sa îl aduce la evaluare, deoarece are dificultăţi în ceea ce privește menținerea poziţiei aşezat şi nu reușește să mențină capul în poziție de echilibru. Pe parcursul evaluării, personalul furnizor de servicii de scaune rulante stabilește Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 165. următoarele: o bazinul lui Michael este fix și se află în înclinare posterioară; o Michael are tendinţa de a-şi împinge bazinul înspre înainte şi de a aluneca în scaunul rulant; o partea superioară a trunchiului şi capul lui Michael au tendința de a aluneca înspre înainte, iar atunci când capul este în poziţie complet dreaptă, poziția nu poate fi menținută, deoarece acesta aluenca înspre înapoi. Observați procesul prin care trece personalul furnizor de servicii de scaune rulante pentru a identifica tipul de suport postural de care Michael are nevoie şi modalitatea de furnizare a acestuia. Prezentaţi materialul video. Verificaţi dacă există întrebări. 3. Sprijinirea coapselor (60 de minute) Explicaţi: Am discutat deja despre stabilizarea bazinului, sprijinirea şoldurilor și furnizarea de suport la nivelul trunchiului, precum şi despre tetiere. Acum vom discuta despre sprijinirea coapselor. Activitate pentru grupe mici Grupe: Împărţiţi participanţii în 3 grupe. Instrucţiuni: Oferiţi fiecărei grupe un scaun rulant şi o pernă din spumă/burete. Cereţi fiecărei grup să citească şi să răspundă la toate cele trei întrebări din Caietul de exerciţii practice (B.11: Prescrierea (selecţia) DSP-urilor - sprijinirea capului, coapselor şi a gambelor). Explicaţi: o Fiecare grupă trebuie să observe scaunul rulant şi perna din spumă/burete care le-au fost desemnate şi să se gândească la ceea ce ar putea face cu acel scaun rulant şi pernă (şi cu alte materiale sau componente) pentru a furniza suportul necesar utilizatorului de scaun rulant. o Luați în considerare următoarele aspecte: o configuraţia generală a scaunului rulant; o corpul utilizatorului de scaun rulant; o ce DSP-uri sunt necesare la nivelul coapselor. Explicaţi: Participanţii au la dispoziţie 30 minute pentru a efectua această activitate, iar apoi grupele se vor reuni pentru feedback. Monitorizare: Monitorizaţi cu atenție activitatea grupelor. Asiguraţi-vă că fiecare grup înţelege în ce constă activitatea. Oferiți asistență grupelor, dacă acest lucru este necesar. Durata: Acordaţi 30 minute pentru desfășurarea activității. Acordaţi 30 minute pentru feedback. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 166. Feedback: Cereţi uneia dintre grupe să descrie soluţia identificată în cazul lui Jonah. Întrebaţi dacă celelalte grupe au alte sugestii. Asiguraţi-vă că participanţii parcurg toate punctele cheie de învăţare (vezi mai jos Note pentru formatori). Prezentaţi slide-ul despre inserţiile unghiulare exterioare pentru coapse. Cereţi uneia dintre grupe să descrie soluţia propusă pentru Sam. Întrebaţi dacă celelalte grupe au alte sugestii. Asiguraţi-vă că participanţii parcurg toate punctele cheie (vezi mai jos Note pentru formator). Prezentaţi slide-ul despre inserţia/dispozitivul de separare a genunchilor. Cereţi uneia dintre grupe să descrie soluţia recomandată în cazul lui Elijah. Întrebaţi dacă celelalte grupe au alte sugestii. Asiguraţi-vă că participanţii parcurg toate punctele cheie (vezi mai jos Note pentru formator). Prezentaţi slide-ul despre inserţiile unghiulare interioare pentru coapse. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 167. Note pentru formatori: Jonah are o programare pentru o evaluare. Pe parcursul procedurii de simulare manuală, constatați că membrele inferioare au tendința să alunece spre exterior (abducție), dar cu un grad redus de sprijin puteți să repoziționați coapsele în poziția neutră de ședere (genunchii mai apropiați). o Care sunt modificările pe care le puteți aduce scaunului rulant și pernei, în așa fel încât utilizatorul să poată avea coapsele în poziția neutră de ședere? o Potențiale modificări ale scaunului rulant al lui Jonah: o reducerea înălțimii spătarului; o adâncimea suprafeţei de şedere pare a fi prea mică – se recomandă creșterea ei; o suporturile de picioare sunt poziționate prea sus şi pot cauza postura incorectă a membrelor inferioare; o acest scaun rulant pare a fi prea mic pentru el şi poate avea nevoie de unul mai mare. Posibile modificări ale pernei lui Jonah: o inserţia anterioară oaselor bazinului va determina o poziție așezat mai corectă (este dificil să observăm din perspectivă frontală, dar postura pare să fie „prăbușită”); o inserţie unghiulară exterioară pentru coapse pentru a menţine alinierea acestora. Cum putem confecționa inserţiile unghiulare exterioare pentru coapse? o lipiţi inserţiile unghiulare pe partea superioară a pernei şi acoperiţi cu husa; sau o tăiaţi partea frontală a pernei şi introduceţi inserţia unghiulară din spumă solidă/burete solid, apoi fixați-o cu adeziv. Puncte cheie: o Jonah are nevoie de suport la nivelul coapselor - totuşi, trebuie să privim imaginea în ansamblu. o Jonah are nevoie doar de un grad redus de suport la nivelul coapselor - deci inserţiile unghiulare sunt suficiente (în cazul lui Jonah nu este nevoie de inserţii exterioare pentru coapse). Sam folosește acest scaun rulant de doi ani. A avut o leziune la nivelul capului și membrele sale inferioare sunt destul de rigide și fixe. Pe parcursul evaluării, constatați că acestea sunt orientate spre interior, dar genunchii pot fi poziționați pentru Potențiale modificări ale scaunului rulant al lui Sam: o Sam are nevoie de o pernă; o grad mai ridicat de suport la nivelul spătarului, inclusiv inserţii/inserţii unghiulare laterale pentru trunchi; o scaunul rulant este prea lat pentru Sam; o suporturile de picioare sunt inegale necesită reparaţii sau să fie înlocuite; o se poate lua în considerare înlocuirea suprafeţei de şedere pliabile cu una solidă, pentru a reduce tendinţa de alunecare înspre interior a coapselor (cauzată de suprafaţa de şedere pliabilă); Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 168. atingerea unei posturi mai apropiate de cea corectă. Totuși, pentru a face acest lucru, este nevoie de destul de multă forță. Având genunchii într-o poziție mai apropiată de cea neutră de ședere, Sam se simte mai echilibrat. o Care sunt modificările pe care le puteți aduce scaunului rulant și pernei, în așa fel încât utilizatorul să poată avea membrele inferioare în poziția neutră de ședere? o în general, acesta nu este un scaun rulant ideal pentru utilizarea pe termen lung. Posibile modificări ale pernei lui Sam: o inserţie anterioară oaselor bazinului pentru susţinerea posturii; o se recomandă o inserţie/dispozitiv pentru separarea genunchilor. Cum putem confecționa inserţia/dispozitivul pentru separarea genunchilor? o Luați în considerare înlocuirea suprafeţei de şedere pliabile şi montarea unei inserţii/unui dispozitiv pentru separarea genunchilor (montat pentru a culisa pe un dispozitiv de fixare sub suprafaţa de şedere şi blocat după ce Sam se aşează în scaun; îndepărtat pentru efectuarea transferului). Puncte cheie de învăţare: o În cazul lui Jonah, este importantă imaginea de ansamblu. o Nivelul de forță necesară prevenirii adducției coapselor lui Sam indică faptul că, în cazul său, este nevoie de un grad de suport ridicat, sub forma unei inserţii/unui dispozitiv pentru separarea genunchilor. Aceasta soluție este mai indicată folosirea inserţiilor unghiulare interioare pentru coapse, care furnizează un grad de suport mai redus. Elijah este mulțumit de faptul că scaunul său rulant este pliabil și că îl poate lua în mașină atunci când se deplasează la locul de muncă și înapoi. Cu toate acestea, Elijah are dureri de spate și coapsele sale tind să se atingă (abducție). Pe parcursul evaluării, constatați că Elijah poate menține poziția așezat și, cu un grad redus de suport, membrele inferioare ating poziția neutră de ședere. o Care sunt Potențiale modificări ale scaunului rulant al lui Elijah: o reducerea greadului de deformare a suprafeței de şedere pliabile; o verificarea înălţimii suportului de picioare. Posibile modificări ale pernei lui Elijah: o inserţie anterioară oaselor bazinului pentru susţinerea posturii; o testaţi o inserţie unghiulară interioară pentru coapse, care se adăugă pernei pentru menţinerea coapselor în poziţie neutră de şedere. Cum putem confecționa această inserţie unghiulară interioară pentru coapse? o fixați cu adeziv inserţiile unghiulare pe partea superioară a pernei şi acoperiţi cu husă; sau o tăiaţi partea frontară a pernei şi introduceţi inserţia unghiulară din spumă solidă/burete solid şi fixați-o cu adeziv. Puncte cheie de învăţare: o la fel ca în cazurile anterioare, trebuie să Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 169. modificările pe care le puteți aduce scaunului rulant și pernei, în așa fel încât membrele inferioare ale utilizatorul să fie în poziția neutră de ședere? o avem în vedere imaginea de ansamblu. o Elijah doreşte ca scaunul său rulant să se plieze, așadar, adăugarea unei suprafeţe solide de şedere ar crea dificultăţi. Totuşi, o placă subţire, introdusă în căptuşeala pernei sale, sub pernă, poate oferi mai mult suport şi nu ar îngreuna transportul. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 170. 4. Sprijinirea gambelor şi a picioarelor (30 de minute) Explicaţi: Vom discuta despre DSP-urile care oferă suport la nivelul gambelor, inclusiv despre acomodarea posturilor fixe non-neutre ale picioarelor şi genunchilor. Rețineți: Aceste soluţii sunt completate de suportul furnizat la nivelul bazinului, trunchiului, capului şi al gâtului, conform nevoilor utilizatorului de scaun rulant. Problemă: o Unul sau ambii genunchi sunt flectați într-o postură fixă care nu atinge poziţia neutră de şedere. Posibile soluţii DSP: o Deplasați suportul de picioare înspre înapoi, dacă acest lucru este posibilpentru picioare. o Ajustaţi unghiul suportului de picioare sau folosiţi inserţii unghiulare pentru suporturile de picioare. o Oferiţi o centură pentru gambe, pentru sprijin şi protecţie. o Asiguraţi-vă că partea frontală a suprafeţei de şedere nu exercită presiune asupra părții posterioare a membrelor inferioare. În caz contrar, este necesară scurtarea suprafeţei de şedere şi înclinarea înspre înapoi a pernei. o În cazul unui utilizator de scaun rulant înalt, luaţi în considerare ridicarea părţii frontale a suprafeţei de şedere sau înclinarea suprefeţei de şedere şi spătarului. Astfel, membrele inferioare ale utilizatorului vor fi situate mai sus, mai mult înspre înainte şi, probabil, în intervalul de opțiuni de ajustare a suporturilor de picioare standard. Atunci când efectuaţi oricare dintre aceste ajustări, verificaţi daca roţile frontale pot să se învârtească fără a se lovi de suporturile de picioare sau de picioarele utilizatorului de scaun rulant. Dacă aceste ajustări nu pot fi efectuate pe scaunul rulant disponibil sau dacă nu putem face suficiente ajustări, vor fi necesare modificări. Problemă: o Unul sau niciunul dintre genunchi nu poate fi flectat pentru atingerea poziţiei neutre de şedere Posibilă soluţie DSP: o Furnizarea unui suport de picioare pliabil pe verticală, dacă este disponibil. o Deplasați suportul de picioare înspre înainte, dacă acest lucru este posibil. o Dacă este posibil, luaţi în considerare furnizarea unui scaun rulant cu trei roţi. Adăugați suportul de picioare la bara orizontală centrală. o Extindeţi suportul de picioare, adăugând lemn sau metal. o Extindeţi bara suportului pentru picioare pentru o poziție înspre îaninte. Acest lucru poate implica sudare şi trebuie Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 171. efectuată de către o persoană cu foarte bune cunoştinţe tehnice şi abilităţi de lucru cu metalele. Indiferent de soluţie, este important să vă asiguraţi că lungimea totală a scaunului rulant va avea cea mai mică valoare posibil. Problemă: o Unul sau niciunul dintre picioare nu ajunge la suportul de picioare, iar poziția acestuia nu poate fi ajustată suficient. Posibilă soluţie DSP: o Inserţii plane pentru suportul de picioare – se pot plasa inserţii plane pentru ambele picioare sau doar pentru unul dintre ele (la fel ca în imagine). Problemă: o Postură fixă non-neutră a gleznei. Soluţii DSP: o Inserţii unghiulare pentru suportul de picioare - pot fi folosite pentru susţinerea posturii existente şi pentru prevenirea modificărilor posturale ulterioare. Majoritatea inserţiilor unghiulare pentru suportul de picioare sunt confecționate individual, în funcţie de nevoile utilizatorului de scaun rulant. Scopul inserţiilor unghiulare pentru suportul de picioare este creșterea zonei de contact dintre suportul pentru picioare și picioarele utilizatorului de scaun rulant. Problemă: o Gamba alunecă înspre spate. Soluţie DSP: o Centura pentru gambe – frecvent, aceasta este furnizată împreună cu scaunul rulant sau poate fi confecționată din material de tip Velcro. Problemă: o Mişcare necontrolată sau instabilitate a piciorului pe suportul pentru picioare. Soluţie DSP: o Centuri pentru picior. Centura pentru picior din spatele călcâiului previne alunecarea înspre înapoi a piciorului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 172. Centura pentru picior la nivelul gleznei oprește alunecarea înspre înainte a piciorului şi ridicarea călcâiului. Centura pentru picior peste partea frontală a piciorului previne ridicarea degetelor de la picioare. 5. Recapitulare puncte cheie (3 minute) Explicaţi: Aceste puncte sunt importante pentru toate sesiunile anterioare în care s-a discutat despre DSP-uri. Citiţi punctele cheie. Verificaţi dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 173. Sesiunea practică 1: Evaluarea şi prescrierea (selecţia) O B IE C TI V E La finalul acestei sesiuni, participanţii vor putea: să demonstreze modalitatea de realizare a evaluării - nivel intermediar, lucrând în grup și cu asistenţă. să demonstreze modalitatea de prescriere (selecție) a scaunul rulant - nivel intermediar, lucrând în grup și cu asistenţă. R E S U R S E Listă de verificare și observaţii pentru formator: Sesiunea practică; Formular de consimţământ pentru poză; formulare de evaluare şi de prescriere (selecţie) a scaunului rulant – nivel intermediar; afiş: „Tabel dispozitive de suport postural (DSP)”; Tabel de dispozitive de suport postural (DSP), laminat – 1 pentru fiecare participant; spaţiu de evaluare curat şi delimitat, cu pat de evaluare şi paravan, pentru fiecare utilizator de scaun rulant; bucăţi de spumă solidă/burete solid – câteva pentru întregul grup; inserţii unghiulare din spumă solidă/burete solid – câteva pentru întregul grup; modele de scaune rulante şi perne (excepţie situaţia în care evaluarea se realizează în comunitate); Aparat foto digital; metru sau şubler - 1 pentru fiecare grup, set de plăci pentru picioare - 1 pentru fiecare grup. C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptați conținutul acestei sesiuni, astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte: factorii culturali – de exemplu, dacă este adecvată crearea grupelor mixte în vederea realizării evaluării; atunci când participanţii realizează o evaluare, luaţi în considerare aspectele culturale legate de atingerea corpului altor persoane; factorii lingvistici – de exemplu, dacă utilizatorii de scaune rulante care participă vorbesc o limbă cunoscută de toţi participanţii; orice document pentru evaluarea sau prescrierea (selecția) unui scaun rulant de care are nevoie organizaţia unde are loc cursul - de exemplu, orice informaţii suplimentare despre utilizatorul de scaun rulant care apelează la serviciile lor (de ex., surse de trimitere); modul în care formatorii vor gestiona problemele care pot apărea pe parcursul evaluării/prescierii (selecției) și care nu pot fi soluționate pe parcursul sesiunii sau al programului de instruire. De exemplu, nevoi suplimentare ale utilizatorilor de scaun rulant care necesită recomandări sau echipamente de mobilitate/DSP- uri ce nu pot fi furnizate sau finalizate pe durata programului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 174. D E P R E G Ă TI T Confirmaţi ora şi detaliile legate de deplasarea utilizatorilor de scaune rulante voluntari. Asiguraţi-vă că există băuturi răcoritoare pentru utilizatorii de scaune rulante şi membrii familiei/însoțitori. Desemnați o persoană care să întâmpine utilizatorii de scaun rulant şi să le prezinte locul unde pot aştepta până la începerea sesiunii. Pregătiţi un pat de evaluare cu paravan pentru fiecare grupă de lucru. Plasați toate echipamentele necesare evaluării pe patul de evaluare. Asiguraţi-vă că scaunele rulante şi pernele sunt în stare bună de funcţionare. Dacă sunt mai mult de trei grupe de participanţi, cereţi ajutorul unui alt formator, pentru o cât mai bună monitorizare a activității grupelor. Decideţi componența grupelor de participanţi și care sunt utilizatorii de scaun rulant cu care va lucra fiecare echipă. Afişul „Tabelul de dispozitive de suport postural (DSP)”. R E ZU M A T 1. Exersarea evaluării şi prescrierii (selecției): o Instrucţiuni şi organizare o Evaluare o Prescriere (selecţi) o Feedback 15 45 30 30 Durata totală a sesiunii 120 1. Exersarea evaluării şi prescrierii (selecției) (120 de minute) Note pentru formatori: 1. Fotografii: o Cereţi fiecărui participant să semneze un formular de consimţământ pentru fotografii. Asiguraţi-vă că utilizatorii de scaune rulante înţeleg faptul că își acordă permisiunea în mod voluntar şi că fotografiile vor fi folosite în procesul de instruire, pe parcursul acestui modul de pregătire. o Pe parcursul sesiunilor practice, realizați fotografii ale utilizatorilor de scaune rulante care şi-au dat acordul, după cum urmează: o în scaunul rulant existent (dacă au unul), perspectivă frontală şi laterală; o pe parcursul evaluării fizice (poziţia așezat fără suport). 2. Monitorizarea activității participanţilor: o Utilizaţi lista de verificare și observaţii pentru formator - Sesiunea practică 1, pentru a vă asigura că grupele parcurg toţi paşii sesiunii şi pentru a nota exemple de bună practică sau aspectele care necesită îmbunătăţire, în vederea oferirii de feedback. Activitate pentru grupe mici Grupe: o Împărţiţi participanţii în grupe de câte 3 persoane. o Desemnați un responsabil pentru fiecare grup. o Comunicații fiecărei grupe numele utilizatorului de scaun rulant cu care va lucra. o Alocaţi fiecărui grup un loc pentru activitate. o Pezentaţi participanţilor locul unde pot găsi echipamentele necesare. Instrucţiuni: Explicaţi următoarele: Scopul sesiunii: o Scopul acestei sesiuni practice este efectuarea unei evaluări şi a unei prescrieri (selecţii). o Participanţii vor lucra cu acelaşi utilizator de scaun rulant pe tot parcursul zilei, trecând și prin etapa de reglare a produsului (a scaunului rulant) și de instruire a utilizatorului de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 175. o Dacă pe parcursul acestui program de instruire nu este posibilă pregătirea în totalitate a scaunului rulant, se vor face programări în vederea finalizării scaunului rulant. Totuşi, participanţii trebuie să încerce să parcurgă cât mai mult posibil din procesul de pregătire a scaunului rulant. Responsabilul: o Responsabilul fiecărei grupe se asigură că membrii echipei parcurg toţi paşii pentru evaluarea şi prescrierea (selecţia) scaunului rulant. o Responsabilul este principala persoană care comunică cu utilizatorul de scaun rulant şi, dacă este necesar, cu membrii familiei/însoțitorii. Astfel se evită crerea de confuzie. Observațiile și sprijinul oferit de formator: o Participanții pot cere asistență sau clarificări în orice moment al sesiunii practice. o Pe parcursul sesiunii, formatorii vor monitoriza fiecare grupă și vor oferi asistența necesară bunei desfășurări a activității. o După încheierea activității, participanții trebuie să solicite prezența unui formator pentru a discuta despre modul în care au completat formularul de evaluare. o După încheierea activității, participanții trebuie să solicite prezența unui formator pentru a discuta despre modul în care au completat formularul de prescriere (selecție). Durata de timp: o Participanţii trebuie să finalizeze evaluarea în 45 de minute şi prescrierea (selecţia) în 30 de minute. Întrebaţi participanţii: Care sunt paşii specifici etapei de evaluare? Aprobați răspunsurile corecte Întrebaţi participanţii: Care sunt paşii specifici etapei de prescriere (selecție)? Aprobați răspunsurile corecte Formulare de servicii: o Oferiţi fiecărui responsabil de grupă formulare de evaluare şi de prescriere (selecţie) a scaunului rulant - nivel intermediar. o La finalul sesiunii practice, strângeți formularele completate şi înmânaţi-le la următoarea sesiune practică. Reamintiți-le participanților că trebuie să implice în mod activ utilizatorul de scaun rulant, de-a lungul întregului proces. Întrebaţi: Există întrebări? Răspundeţi oricăror întrebări. Cereți fiecărei grupe să pregătească zona în care va lucra; și să invite apoi utilizatorul de scaun rulant cu care va lucra. Monitorizare şi suport: Monitorizați activitatea grupelor, asigurați-vă că activitatea se desfășoară în condiții de siguranță, observați și evaluați abilitățile participanților. Folosiți lista de verificare și observații pentru formator și notați observațiile legate de fiecare echipă. Pe parcursul sesiunii: o Informați participanții cu privire la durata de timp rămasă (verbal și/sau în scris pe tablă, pentru ca toți participanții să fie informați) pentru o mai bună administrare a timpului alocat exercițiului. o Asigurați-vă că utilizatorii de scaun rulant sunt implicați în mod activ. o Asigurați-vă că fiecare membru al echipei este implicat în mod activ. La finalul acestei sesiuni, cereți participanților să le mulțumească utilizatorilor de scaun rulant pentru participare şi explicaţi faptul că scaunul Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 176. rulant prescris (selectat) va fi pregătit pentru probare în cadrul următoarei sesiuni practice. Faceți fotografii utilizatorilor de scaun rulante care au semnat formularul de acord pentru fotografiere. Durata: Acordaţi 15 minute pentru instrucțiuni şi pregătire, 45 de minute pentru finalizarea evaluării, 30 de minute pentru completarea prescrierii și 30 de minute pentru feedback. Monitorizați timpul cu ajutorul listei de verificare și observaţii pentru formator. Feedback: Discutați despre exemplele de bună practică pe care le-ați observat pe parcursul sesiunii practice. Menționați aspectele unde participanții au nevoie de îmbunătățiri – fără a numi persoanele. Întrebaţi: Există întrebări? Note pentru formatori: Pe parcursul sesiunilor practice, este important să monitorizați durata de timp. Intervalele menționate mai sus sunt orientative, ele vor varia în funcție de experiența participanților, nevoile utilizatorului de scaun rulant și perioada necesară pregătirilor. Durata de timp necesară parcurgerii acestei va fi adaptată contextului. B.12: Pregătirea produsului (a scaunului rulant) O B IE C TI V E La finalul acestei sesiuni, participanții vor știi: să descrie procesul de pregătire al unui scaun rulant și a dispozitivelor de suport postural pentru un utilizator de scaun rulant care are nevoie de suport postural suplimentar. R E S U R S E Pentru sesiune: slide-uri PPT: B.12: Pregătirea produsului (scaunului rulant); Manualul participantului; DVD: Pregătirea produsului (a scaunului rulant); DVD: Efectuarea unei modificări a suportului pentru picioare; Afiș: Tabel dispozitive de sprijin postural (DSP); Tabel dispozitive de sprijin postural (DSP), laminat – 1 pentru fiecare participant; Listă preliminară utilizării scaunului rulant - nivel intermediar, laminat - 1 pentru fiecare participant; Set DSP-uri: Materiale DSP; Masă de lucru sau o masă solidă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 177. C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoștințe dobândite anterior: Informațiile legate de ajustarea unui scaun rulant cu antrenare manuală, pentru ca acesta să se potrivească utilizatorului de scaun rulant sunt prezentate în Servicii pentru scaune rulante. Pachet de instruire - nivel de bază. Se presupune că participanții dețin deja următoarele abilități: o de ajustare a scaunului rulant, în așa fel încât acesta să fie pe măsura utilizatorului de scaun rulant, care să poată menține poziția așezat fără suport; o de verificare a modului în care scaunul rulant este pregătit pentru a fi utilizat în condiții de siguranță, cu ajutorul listei de verificare preliminare utilizării scaunului rulant. Adaptați conținutul acestei sesiuni în așa fel încât informațiile să fie în concordanță cu contextul în care participanții vor lucra. Luați în considerare următoarele aspecte: Tipurile de scaune rulante disponibile la nivel local. Unde, cum și din ce materiale vor fi confecționate dispozitivele de suport postural și cum vor fi efectuate modificările. D E P R E G Ă TI T Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii. Afișați „Tabelul de dispozitive de sprijin postural (DSP)”. Luați mostrele de DSP din setul DSP și plasați-le pe o masă a sălii de curs, unde să aveți acces ușor la ele. Aranjați mostrele de materiale pentru DSP pe o masă (masă de lucru), în fața sălii de curs. Aranjați sala de curs astfel încât participanții să stea într-un semicerc, orientați către partea din față a sălii. P R E ZE N TA R E 1. Introducere 2. Planificarea și efectuarea pregătirii scaunului rulant și DSP-urilor 3. Aspecte de reținut în procesul de confecționare a DSP-urilor 4. Materiale pentru DSP-uri și modificări 5. Recapitulare puncte cheie 7 10 10 30 3 Durata totală a sesiunii 60 1. Introducere (7 minute) Explicați: o A cincea etapă în procesul de furnizare a serviciilor de scaune rulante este pregătirea produsului (a scaunului rulant). o Pregătirea produsului (a scaunului rulant) înseamnă configurarea scaunului rulant și pregătirea DSP-urilor prescrise (selectate). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 178. o La nivel intermediar, pregătirea preliminară a scaunului rulant este posibilă doar până într-un anumit punct, înainte ca probarea sa de către utilizatorul să devină necesară. o În modulul de instruire de nivel intermediar, pregătirea scaunului rulant poate fi efectuată doar până la un anumit punct fără ca probarea echipamentului de mobilitate să devină necesară. o Etapele care corespund pregătirii produsului (a scaunului rulant) și probării acestuia trebuie repetate până când scaunul rulant corespunde în totalitate. o În mod frecvent, DSP-urile nu vor fi fixate definitiv înainte de prima probare. Astfel, vom putea face ajustări și după etapa de probare. Întrebați: Care credeți că sunt acele DSP care, în mod obișnuit, vor avea nevoie de ajustări odată ce utilizatorul folosește în scaunul rulant? Notați răspunsurile. Răspunsurile pot include DSP-urile enumerate mai jos, precum și altele: o Tetiera, inserția anterioară oaselor bazinului, inserțiile laterale pentru trunchi, înălțimea suportului de picioare și orice modificare a suporturilor de picioare etc. Explicați: Este important să reținem acest aspect atunci când pregătim un scaun rulant pentru un utilizator care are nevoie de suport postural suplimentar. Încercați ca înainte de probarea de către utilizator, pregătirea scaunului rulant și a DSP-urilor să fie cât mai avansată - totuși, nu fixați sau nu acoperiți cu tapițerie elemente ce nu pot fi ajustate cu ușurință. Explicați: În această sesiune: o vom discuta despre modul în care se face planificarea pregătirii produsului; o vom enumera aspecte importante care trebuie luate în considerare pe parcursul pregătirii DSP-urilor; o vom discuta despre diferitele materiale care pot fi folosite pentru confecționarea DSP-urilor. Explicați: După această sesiune, participanții vor pregăti scaunele rulante pentru utilizatorii evaluați în sesiunea practică 1. Pregătiți vizionarea materialului video: Pregătirea produsului (a scaunului rulant). o În acest material video este prezentat un exemplu de pregătire a unui scaun rulant. Utilizatorul copil din materialul video se numește Ali. A revenit la furnizorul de servicii de scaune rulante pentru noi ajustări, deoarece scaunul său rulant nu îl susține atât de bine precum ar avea nevoie. o Ali este diagnosticat cu scolioză (coloana vertebrală curbată înspre lateral), iar bazinul său este orientat înspre lateral. Bazinul lui Ali este într- o postură vicioasă fixă. Musculatura trunchiului este foarte slabă. Personalul furnizor de servicii de scaune trebuie să crească gradul de suport oferit de scaunul rulant al lui Ali. o Observați modul în care personalul furnizor de servicii de scaune rulante Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 179. lucrează, incluzându-i pe Ali și pe mama sa în toate discuțiile. o De asemenea, observați modul în care DSP-urile sunt verificate de fiecare dacă când se efectuează o modificare/ajustare. Prezentați materialul video. Verificați dacă există întrebări. 2. Planificarea și efectuarea pregătirii scaunului rulant și DSP-urilor (10 minute) Explicați: o Acest program de instruire prevede următoarea ordine a operațiunilor: A: Planificarea și pregătirea; B: Ajustarea scaunului rulant și pregătirea DSP-urilor pentru probare; C: Parcurgerea pașilor preliminari utilizării scaunului rulant, pentru a ne asigura că acesta poate fi folosit în condiții de siguranță. A: Planificare și pregătire o Înainte de a demara pregătirea scaunului rulant, este importantă planificarea activității. o Planificarea atentă este cu atât mai importantă cu cât activitatea de pregătire a scaunului rulant este transferată unei alte persoane (de exemplu, unui tehnician care lucrează într-un atelier) sau dacă este efectuată de mai multe persoane. o Planificarea și pregătirea implică următorii pași: o Revedeți formularul de prescriere (selecție) a scaunului rulant de nivel intermediar: o asigurați-vă că toată persoanele implicate înțeleg informațiile cuprinse în formular; o asigurați-vă că în formular sunt înregistrate suficiente informații pentru pregătirea scaunului rulant. De exemplu - sunt notate în formular toate dimensiunile necesare? Sunt suficient de detaliate descrierile diferitelor dispozitive de suport postural? Este posibil să fie necesare discuții sau clarificări suplimentare. o Decideți modalitatea prin care scaunul rulant selectat va oferi gradul de suport postural suplimentar necesar: o Priviți scaunul rulant care urmează să fie folosit și puneți următoarele întrebări: o Ce ajustări pot fi făcute acestui scaun rulant pentru a oferi suportul necesar? o Ce DSP-uri sunt deja montate pe scaunul rulant? o În cazul în care este nevoie de modificări sau dacă trebuie adăugate dispozitive de suport postural, decideți: o Există suporturi prefabricate care pot fi folosite? Dacă da - cum vor fi acestea montate pe scaunul rulant? o Dacă modificările sau dispozitivele de suport postural trebuie confecționate din materii prime - ce materiale vor fi folosite și cum vor fi fixate pe scaunul rulant dispozitivele de suport postural? o Nu uitați să luați în considerare modul în care scaunul rulant și dispozitivele de suport postural vor funcționa împreună. o Pregătiți o listă de sarcini: o enumerați sarcinile care trebuie efectuate pentru a pregăti scaunul rulant; o dacă sunt implicate mai multe persoane, decideți care sunt sarcinile fiecăreia. B: Ajustarea scaunului rulant și pregătirea DSP-urilor pentru montare Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 180. Consultați secțiunea „ Cum se confecționează dispozitivele de suport postural?” din Manualul participantului. C: Efectuarea verificărilor pentru utilizarea în condiții de siguranță a scaunului rulant Lista de verificare preliminară utilizării scaunului rulant a fost prezentată în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire-nivel de bază. Cereți participanților să consulte lista preliminară utilizării scaunului rulant - nivel intermediar din Manualul participantului. Întrebați: Sunt toți participanții familiarizați cu modul de utilizare al acestei liste de verificare? Există întrebări legate de completarea acestei liste de verificare? Răspundeți la orice întrebare. o Lista de verificare trebuie parcursă înainte de sosirea utilizatorului în vederea probării produsului (a scaunului rulant). o După fiecare probare, pot fi identificate noi elemente ce necesită ajustări. o După fiecare ajustare sau modificare și înainte ca utilizatorul să îl probeze, scaunul rulant trebuie verificat, pentru a ne asigura că este pregătit pentru folosirea în condiții de siguranță. Explicați: Rețineți că etapele de pregătire și probare a produsului pot fi repetate de mai multe ori înainte ca echipamentul de mobilitate să se potrivească în totalitate utilizatorului de scaun rulant. 3. Aspecte de reținut în procesul de confecționare a DSP-urilor (10 minute) Explicați: La începutul programului de instruire am discutat despre așteptările utilizatorilor de scaun rulant. Am discutat despre cât de important este faptului ca scaunul rulant și suportul postural suplimentar să fie: o să fie practice și ușor de utilizat; o să fie confortabile și să nu crească nivelul de disconfort; o să asiste utilizatorii de scaun rulant în desfășurarea activităților în maniera dorită de ei și să nu creeze obstacole în acest sens; o să fie agreabile din punct de vedere estetic și să „nu iasă prea mult în evidență”. Explicați: Atunci când pregătiți un scaun rulant cu suport postural suplimentar, aveți în vedere următoarele aspecte: 1. DSP-urile trebuie să ofere suficient suport Întrebați: Pe parcursul sesiunii practice, în lucrul cu utilizatorul de scaun rulant, ați folosit întreaga suprafață a mâinii pentru a furniza suport? Încurajați participanții să răspundă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 181. Răspunsuri: o uneori întreaga suprafață a mâinii; o uneori doar vârful degetelor; o uneori doar o parte a mâinii. Explicați: Gradul de suport necesar fiecărui utilizator de scaun rulant va varia. Dispozitivele de suport postural trebuie să furnizeze suportul de care are nevoie fiecare utilizator de scaun rulant, acolo unde acest lucru este necesar și pe suprafața corespunzătoare. 2. Dispozitivele de suport postural și scaunele rulante funcționează unitar, ca un sistem complet. o Adăugarea elementelor de suport postural suplimentar poate schimba întregul sistem al scaunului rulant. De exemplu: o Adăugarea DSP-urilor poate modifica dimensiunile interioare ale scaunului rulant. a Întrebați: Care sunt acele DSP-uri care au impact asupra măsurătorilor componentelor interioare ale scaunului rulant (de exemplu, lățimea suprafeței de ședere și adâncimea suprafeței de ședere)? Notați răspunsurile. Explicați: Un alt exemplu al impactului DSP-urilor asupra scaunului rulant: o Adăugarea DSP-urilor poate influența centrul de greutate al scaunului rulant – crescând sau diminuând riscul de răsturnarea al acestuia (de exemplu, adăugarea unei tetiere sau unei componente cu greutate crescută). 3. Evitarea creării zonelor unde se exercită un nivel ridicat de presiune Dispozitivele de suport postural pot exercita uneori presiune asupra anumitor zone ale corpului utilizatorului de scaun rulant. De exemplu: dacă utilizatorul are nevoie de un grad ridicat de suport pentru a preveni înclinarea trunchiului înspre lateral, inserțiile laterale pentru trunchi ar putea constitui o zonă unde presiunea exercitată să fie prea mare. În astfel de situații, luați în considerare distribuirea forței exercitate prin creșterea suprafeței Răspunsuri: o adăugarea inserțiilor laterale pentru bazin poate reduce lățimea disponibilă a suprafeței de ședere; o orice DSP adăugat la suprafața spătarului poate „reduce” adâncimea disponibilă a suprafeței de ședere, iar aici includem: o inserția posterioară pentru bazin; o adăugarea unei inserții unghiulare pentru deschiderea unghiului dintre suprafața de ședere și spătar; o adăugarea unei perne sau creșterea înălțimii unei perne va ridica utilizatorui în scaunul rulant și va scurta distanța dintre partea superioară a pernei și limita superioară a spătarului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 182. de contact. Asigurați-vă întotdeauna că există suficient material pentru a acoperi întreaga suprafață a dispozitivelor de suport postural și partea interioară a centurilor. 4. Asigurați-vă că dispozitivele de suport postural sunt practice și nu reduc capacitatea utilizatorilor de scaun rulant de a desfășura diverse activități Întrebați: Care sunt aspecte care trebuie luate în considerare pentru a vă asigura că DSP-urile sunt practice și nu reduc capacitatea de desfășurare a activităților? Răspunsuri: o Dacă utilizatorul de scaun rulant transportă scaunul într- un autoturism, asigurați-vă că după montarea DSP-urilor, echipamentul de mobilitate încape în portbagajul vehiculului. o Dacă utilizatorul de scaun rulant efectuează transferul în și din scaunul rulant în mod independent, DSP-urile montate ar putea face mai dificil acest lucru? o Utilizatorul (însoțitorul) întâmpină vreun obstacol în acționarea frânelor? o Utilizatorul de scaun rulant are în continuare posibilitatea de a efectua propulsia în mod independent? Explicați: Rețineți - utilizatorii au nevoie de scaune rulante și sisteme de poziționare care sunt practice și ușor de utilizat și care îi ajută să fie cât mai activi posibil. Explicați: o Anumite DSP-uri sunt foarte simple și pot fi confecționate într-un atelier tipic. Altele sunt mai compleze și necesită mai multe abilități tehnice sau diverse facilități. o Personalul furnizor de servicii de scaune rulante nu trebuie să confecționeze el însuși dispozitivele de suport postural, ci are posibilitatea de a colabora cu tehnicieni. Reprezentanții furnizorului de servicii de scaune rulante trebuie să dea indicații cu privire la elementul de care este nevoie și la modul său de funcționare, iar tehnicienii găsesc soluții pentru confecționarea acestuia din materialele disponibile la nivel local. 4. Materialele și instrumentele necesare confecționării dispozitivelor de suport postural și efectuării modificărilor (30 minute) Note pentru formatori: o Această secțiune va fi adaptată în funcție de materialele disponibile la nivel local și de materialele disponibile pentru această sesiune de instruire. o În cazul în care acest lucru este posibil, se recomandă ca această sesiune să se desfășoare în același atelier/spațiu în care participanții vor confecționa DSP-urile pe parcursul Sesiunii practice 2. Aranjați materialele pe o masă de lucru de dimensiuni mari și cereți participanților să se poziționeze în jurul acesteia. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 183. Pregătiți vizionarea materialului video: Modificarea suportului de picioare. În acest material video vom vedea modul în care personalul furnizor de servicii de scaune rulante efectuează modificări ale suportului de picioare pentru Tasi, un utilizator cu glezna într-o poziție vicioasă accentuată (postură fixă non-neutră). Priviți cu atenție pentru a identifica materialele folosite. Prezentați materialul video. Verificați dacă există întrebări. Întrebați: Care au fost materialele folosite pentru modificarea suportului de picioare? Răspunsuri: o poliuretan rigid; o cauciuc pentru confecționarea tălpilor de încălțăminte; o lipici/adeziv pentru spumă/burete. Prezentați mostre ale materialelor enumerate mai jos și ale DSP-urilor care au fost confecționate din acestea. Explicați la ce pot fi folosite materialele și care sunt aspectele pe care trebuie să le aibă în vedere participanții atunci când aleg materialele. Folosiți informațiile de mai jos pentru a vă ghida. Materiale Dispozitive de suport postural (DSP) sau modificări pentru care pot fi folosite materialele: Aspecte importante în alegerea materialelor pentru confecționarea dispozitivelor de suport postural sau efectuării modificărilor: Metal/plastic/lemn Metalul/plasticul/lemnul formează structura unui DSP -de exemplu, suprafețe de ședere și spătare rigide. Lemnul sau metalul poate fi folosit pentru confecționarea dispozitivelor de fixare a inserției laterale pentru trunchi de spătarul scaunului rulant. Placajul de 12 mm este foarte util în confecționarea spătarelor și suprafețelor de ședere rigide. Este rezistent, dar are o greutate relativ mică. Placajul stratificat este cel mai rezistent; totuși, poate fi mai scump. Pentru confecționarea spătarelor rigide se pot folosi plăci de aluminiu de 3 mm și plăci acrilice de 6 mm sau plăci de plastic ABS, dacă sunt disponibile. Plierea plăcii poate crește gradul de rigiditate. Atunci când utilizați orice tip de plăci, asigurați-vă că ați eliminat sau ați acoperit cu material marginile ascuțite, pentru a proteja siguranța utilizatorului de scaun rulant. Burete/căptușeală Buretele/spuma se utilizează în cazul tuturor DSP-urilor, în zonele în care acestea intră în contact direct cu corpul Căutați materialele în magazinele locale și contactați fabricile care produc spumă/burete, încălțăminte, saltele sau mobilă pentru a identifica la nivel local sursele de Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 184. utilizatorului de scaun rulant. Buretele rigid/spuma rigidă, care își menține forma, se utilizează pentru ca DSP-urile să aibă forma adecvată, necesară furnizării de suport postural. Buretele/spuma cu o rigiditate mai mică au rolul de a crește gradul de confort și de a reduce nivelul de presiune exercitată. Exemple de utilizare ale buretelui/spumei: se adaugă burete/spumă la centuri, cu scopul de a distribui egal presiunea exercitată și de a crește nivelul de confort; buretele rigid/ spuma rigidă se utilizează pentru confecționarea inserției unghiulare laterale pentru trunchi, se adaugă pernei pentru a crea o inserție unghiulară exterioară pentru coapse sau o inserție unghiulară interioară pentru coapse; buretele foarte rigid (de ex., poliuretan) sau spuma cu un grad ridicat de rigiditate sunt necesare pentru confecționarea inserțiilor plane sau unghiulare pentru suportul de picioare ori pentru inserțiile laterale pentru trunchi. spumă/burete. Încercați să găsiți la nivel local spumă/burete de grosime variată (25 mm și 50 mm) și cu grade de rigiditate diferite. Poliuretanul este un exemplu de spumă foarte rigidă, care oferă rezistență și structură solidă în vederea confecționării de DSP-uri. Uneori, acest material poate fi găsit în fabricile de încălțăminte. Cauciucul rigid, folosit pentru încălțămintea purtată de regulă la ștrand, poate înlocui poliuretanul. Buretele din fulgi încleiați, de foarte bună calitate este un exemplu de burete cu rigiditate medie. Acesta poate fi folosit ca bază pentru o pernă cu contur/cu straturi, pentru confecționarea inserțiilor posterioare pentru bazin sau a celor anterioare oaselor bazinului, precum și pentru adăugarea la spătarul rigid a stratului conturat. Spuma/buretele cu grad scăzut de rigiditate, folosite la fabricarea saltelelor, se recomandă pentru confecționarea straturilor de confort. Buretele cu un grad de rigiditate scăzut sau spuma „moale”, disponibile la scară largă, la un preț scăzut, nu sunt recomandate în confecționarea pernelor pentru reducerea presiunii decât cu o bază din burete/spumă mai rigide. Fibra de nucă de cocos poate fi folosită în locul spumei rigide/buretelui rigid. Material textil Materialul textil este folosit pentru acoperirea suprafeței DSP-urilor. Căutați un material textil care este rezistent și ușor de curățat (prin ștergere sau prin îndepărtarea în vederea spălării). Materialul textil Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 185. impermeabil se folosește pentru suprafața de ședere, perna sau spătarul scaunului rulant în cazul în care utilizatorul are probleme de management vezical și intestinal. Un material textil moale, folosit pentru fabricarea tricourilor (bumbac sau bumbac/lycra), poate fi folosit pentru tetiere, inserții laterale pentru trunchi sau inserții unghiulare laterale pentru trunchi. Un material textil cu un anumit grad de elasticitate se va adapta cu mai multă ușurință formei DSP-ului. În general, materialele textile sintetice vor crește temperatura la nivelul suprafaței pielii utilizatorului de scaun rulant mai mult decât cele naturale. În măsura în care este posibil, încercați să dispuneți de mai multe culori și oferiți utilizatorului opțiunea de a alege. Chingi din nailon/Velcro/catarame Chingile din nailon/Velcro/cataramele sunt folosite pentru centuri, incluzând centurile pentru bazin, hamul pentru umeri și centurile pentru picioare și gambe. Chingile din nailon de 25 mm, 35 mm și 50 mm sunt foarte folositoare. Cu cât centura este mai lată, cu atât presiunea exercitată se distribuie mai uniform. Topirea capătului chingilor de nailon previne desfacerea acestora. Chinga din bumbac este mult mai ineficientă. Cataramele de tipul celor folosite la rucsacuri sunt foarte ușor de utilizat. Încercați să folosiți catarame de o bună calitate, deoarece acestea au o durată mai mare de utilizare. Conectați elementele cataramelor și trageți de ele, pentru a testa funcționarea lor. Ar trebui să se închidă și să se deschidă ușor și să nu se desfacă atunci când nu sunt deblocate. Materialul de tip Velcro constituie un sistem bun de prindere. El trebuie menținut curat, în caz contrar există riscul ca el să nu mai funcționeze. Trebuie introduse inserții din burete/spumă moale sub toate centurile, pentru a proteja corpul Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 186. utilizatorului de scaun rulant. Adezivi Adezivii sunt folosiți pentru lipirea lemnului și buretelui/ a spumei. Se recomandă să aveți un stoc de adeziv pentru lemn (cunoscut sub numele de adeziv de tip aracet) și adeziv pentru burete (adeziv de contact, pentru încălțăminte). Asigurați-vă că persoanele care utilizează adezivul știu cum să îl folosească în mod corespunzător. Sisteme de fixare Sistemele de fixare sunt folosite pentru atașarea DSP-urilor la scaunul rulant. Sistemele de fixare utilizate includ: o șuruburi cu piulițe (preferabil contrapiulițe) și șaibe; o piulițe pentru lemn (prinse în placaj în locul unei piulițe); o capse (pentru fixarea tapițeriei). Evitați utilizarea șuruburilor ascuțite, deoarece pot deveni periculoase în cazul în care DSP-ul se deteriorează. 5. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 187. Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) O B IE C TI V E La finalul acestei sesiuni, participanții vor putea: să demonstreze, lucrând în echipă sau cu asistență, modalitatea de pregătire a unui scaun rulant și a DSP-urilor pentru un utilizator de scaun rulant care necesită suport postural suplimentar . R E S U R S E Caiet de exerciții practice; Listă de verificare și observații pentru formator: Sesiunea practică 2; Formulare de evaluare, prescriere (selecție) a scaunului rulant - nivel intermediar din Sesiunea practică 1 (completate și necompletate); Afiș: „Tabel dispozitive de sprijin postural (DSP)”; Tabel dispozitive de sprijin postural (DSP), laminat – 1 pentru fiecare participant; Listă de verificare preliminară utilizării scaunului rulant - nivel intermediar - 1 pentru fiecare participant; Set DSP-uri: Scaune rulante și materiale DSP; Masă de lucru și seturi de instrumente – 1 pentru fiecare grup; C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoștințe dobândite anterior: pregătirea produsului (a scaunului rulant) - nivel de bază; vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază; modalitatea de parcurgere a listei de verificare preliminare utilizării scaunului rulant - vezi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Adaptați conținutul acestei sesiuni în așa fel încât informațiile să fie în concordanță cu contextul în care participanții vor lucra. Luați în considerare următoarele aspecte: scaunele rulante, materialele pentru confecționarea DSP-urilor și instrumentele pe care le vor avea la dispoziție la locul lor de muncă; numărul de dispozitive ce trebuie confecționate din materii prime sau volumul de asamblări ale scaunelor rulante. Formatorii trebuie să adapteze durata sesiunii în funcție de acești factori (acest lucru poate afecta întregul orar al programului de instruire). D E P R E G Ă TI T Asigurați prezența unui tehnician cu experiență în ceea ce privește pregătirea produsului (a scaunului rulant), pentru a susține formatorul și pentru a oferi asistență participanților. Înainte de începerea sesiunii practice, cereți participanților să poarte încălțăminte care acoperă piciorul. Poziționați scaunele rulante selectate în zona desemnată ca fiind spațiul de lucru. Pregătiți un spațiu de lucru pentru fiecare grupă, dotat cu masă de lucru și set de instrumente. Plasați materialele pentru DSP-uri în așa fel încât participanții să poată lucra cât mai eficient. Aranjați mostrele de DSP din setul și poziționați-le pe o masă în fața sălii de curs, unde să aveți acces ușor la ele. Folosiți afișul „Tabelul de dispozitive de sprijin postural (DSP)”. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 188. P R E ZE N TA R E 1. Pregătirea produsului (a scaunului rulant): o Intrucțiuni și organizare; o Planificare și pregătire; o Ajustarea scaunului rulant și pregătirea DSP-urilor pentru probare; o Efectuarea verificărilor preliminare utilizării în condiții de siguranță a scaunului rulant. o Feedback: 10 15 80 15 30 Durata totală a sesiunii 150 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 189. 1. Pregătirea produsului (a scaunului rulant) (150 de minute) Note pentru formatori: Observarea activității participanților: o Utilizați lista de verificare și observații pentru formatori utilizată în Sesiunea practică 1, pentru a vă asigura că grupele parcurg toți pașii sesiunii și pentru a nota exemple de bună practică sau aspecte ce trebuie îmbunătățite, care vă vor ajuta să oferiți feedback. Activitate pentru grupe mici Grupe: o Împărțiți participanții în grupe; componența acestora este aceeași ca în Sesiunea practică 1. o Desemnați un responsabil pentru fiecare grupă (poate fi același ca în Sesiunea practică 1 sau un alt responsabil). o Alocați fiecărei grupe un spațiu pentru desfășurarea activității. o Explicați participanților unde pot găsi materialele și instrumentele. Instrucțiuni : Explicați următoarele aspecte: Scopul sesiunii: o Obiectivul acestei sesiuni practice este pregătirea scaunului rulant și a DSP-urilor pentru utilizatorul de scaun rulant evaluat în Sesiunea practică 1. Siguranța în spațiul de lucru: Înainte de a începe să lucreze cu instrumente și materiale, participanții trebuie să cunoască următoarele cinci reguli de siguranță: o În atelier se va purta încălțăminte care acoperă piciorul. o Elementele care trebuie tăiate sau perforate vor fi fixate în prealabil. o Se vor utiliza ochelari de protecție în timpul folosirii mașinilor-unelte sau a instrumentelor ascuțite. o Spațiul de lucru și căile de acces trebuie să fie amenejate corect și să fie curate; o Lama instrumentului de tăiat nu va fi îndreptată niciodată către cel care efectuează operațiunea de tăiere sau către alte persoane. Responsabilul: o Responsabilul fiecărei grupe se asigură că sunt parcurși toți pașii necesari pregătirii scaunului rulant. Observațiile și sprijinul oferit de formator: o Participanții pot cere asistență sau clarificări în orice moment al sesiunii practice. o Pe parcursul sesiunii, formatorii vor monitoriza fiecare grupă și vor oferi asistența necesară bunei desfășurări a activității. Formulare: o Înmânați fiecărui responsabil de grup formularele de evaluare și cele de prescriere (selecie) – nivel intermediar completate în Sesiunea practică 1. o La finalul sesiunii practice adunați formularele completate și înmânați- Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 190. le la următoarea sesiune practică. Întrebați: Există întrebări? Răspundeți la orice întrebare. Monitorizar e și suport: Monitorizați activitatea grupelor, asigurați-vă că sunt respectate regulile de siguranță, observați și evaluați abilitățile participanților. Folosiți lista de verificare și observații pentru formator pentru a nota observațiile legate de fiecare grup. Pe parcursul sesiunii: o Informați participanții cu privire la durata de timp rămasă (verbal și/sau în scris pe tablă, pentru ca toți participanții să fie informați) pentru o mai bună administrare a timpului alocat exercițiului. o Asigurați-vă că fiecare membru echipei este implicat în mod activ în desfășurarea activității. Note pentru formatori: Veți constata că există diferențe între abilitățile tehnice ale participanților. Dacă este posibil, încurajați toți participanții să exerseze pregătirea scaunului rulant și a DSP-urilor. Oferiți suportul tehnic de care au nevoie participanții. Durata: o Se recomandă ca participanții să respecte secvențele prezentate mai jos: o A: Planificare și pregătire (15 minute). Cereți participanților să noteze în Caietul de exerciții practice sarcinile ce trebuie efectuate (Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) - listă de verificare a sarcinilor). o B: Ajustarea scaunului rulant și pregătirea DSP-urilor pentru probare (80 de minute). o C: Verificarea preliminară utilizării în condiții de siguranță a scaunului rulant (15 minute). Cereți participanților să folosească lista de verificare preliminară utilizării scaunului rulant - nivel intermediar din Caietul de exerciții practice (Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) - Listă de verificare preliminară utilizării scaunului rulant - nivel - intermediar). o Înainte de a trece la următorul pas, participanții și formatorul verifică împreună modul în care au fost îndeplinite cerințele exercițiului.; o acordați 30 de minute pentru feedback. o În cazul în care trebuie pregătit un lot de scaune rulante, durata de timp alocată va crește. Feedback: Cereți fiecărei grupe să prezinte pe scurt cazul utilizatorului de scaun căruia i-a fost pregătit scaunul rulant. Fiecare grupă trebuie să explice: o ce modificări au fost efectuate sau ce DSP-uri au fost montate și de ce. o modul în care au fost efectuate modificările sau modalitatea de confecționare a DSP-urilor (materiale utilizate și modul in instalare/montare a acestora pe scaunul rulant). (Alocați 5-7 minute fiecărei grupe). După fiecare prezentare, acordați întregului grup de participanți oportunitatea de a întrebări referitor la cazul prezentat. Discutați pe scurt despre exemplele de bună practică pe care le-ați observat pe parcursul sesiunii practice. Menționați, fără a intra în detalii, aspectele unde participanții au nevoie de Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 191. îmbunătățiri – fără a numi persoanele. Întrebați: Mai există întrebări? Note pentru formatori: Pe parcursul sesiunilor practice, este important să monitorizați durata de timp. Intervalele menționate mai sus sunt orientative, ele vor varia în funcție de experiența participanților, nevoile utilizatorului de scaun rulant și perioada necesară pregătirilor. Durata de timp necesară parcurgerii acestei va fi adaptată contextului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 192. B.13: Probarea produsului (a scaunului rulant) O B IE C TI V E La finalul acestei sesiuni, participanții vor putea: să descrie modalitatea de a verifica dacă scaunul rulant și DSP-urile corespund cerințelor utilizatorului de scaun rulant care necesită suport postural suplimentar. R E S U R S E Pentru sesiune: slide-uri PPT: B.13: Probarea produsului (a scaunului rulant); Manualul participantului; DVD: Demonstrație probarea produsului (a scaunului rulant) - Deepak; DVD: Demonstrație probarea produsului (a scaunului rulant) - Careen; afiș: „Tabel dispozitive de sprijin postural (DSP)”; Tabel dispozitive de sprijin postural (DSP), laminat – 1 pentru fiecare participant; Listă preliminară utilizării scaunului rulant - nivel intermediar, laminat - 1 pentru fiecare participant. C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoștințe dobândite anterior: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază prezintă modalitatea de probare a scaunului rulant pentru utilizatorii care pot menține poziția așezat fără suport suplimentar. La nivel intermediar, pașii sunt similari, dar există mai multe aspecte care trebuie luate în considerare. Modalitatea de identificare a nivelului de presiune exercitat sub oasele bazinului utilizatorului de scaun rulant. Înainte de această sesiune, participanții trebuie să cunoască modul de efectuare al acestui test. Adaptați conținutul acestei sesiuni în așa fel încât informațiile să fie în conconrdanță cu contextul în care participanții vor lucra. Luați în considerare următoarele aspecte: Tipurile de scaune rulante și DSP-urile disponibile în mod obișnuit. D E P R E G Ă TI T Pregătiți toate resursele, revedeți prezentările, parcurgeți materialul video și citiți planificarea sesiunii. Folosiți afișul „Tabelul de dispozitive de sprijin postural (DSP)”. P R E ZE N TA R E 1. Introducere 2. Cum se realizează probarea produsului (a scaunului rulant) 3. Recapitulare puncte cheie 2 55 3 Durata totală a sesiunii 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 193. 1. Introducere (2 minute) Explicați: o Probarea produsului (a scaunului rulant) este cea de-a șasea etapă a procesului de furnizare de servicii de scaune rulante. o Pe parcursul probării, utilizatorul și personalul furnizor de servicii de scaune rulante se asigură că scaunul rulant și DSP-urile sunt corespunzătoare și că sprijină utilizatorul în așa fel încât bazinul acestuia se află într-o poziție cât mai apropiată de cea neutră, fără a produce disconfort. o Pe parcursul acestei sesiuni, vom prezenta lista de verificare a pașilor pentru probarea produsului (a scaunului rulant) - nivel intermediar și vom discuta despre modalitatea de efectuare a probării scaunului rulant. 2. Cum se realizează probarea produsului (55 de minute) Explicați: o Toți participanții trebuie să cunoască modalitatea prin care se efectuează probarea produsului (a scaunului rulant). o La nivel intermediar, această etapă poate dura mai mult și poate fi necesară repetarea ei. Ditribuiți lista de verificare a pașilor pentru probarea produsului (a scaunului rulant) - nivel intermediar (exemplare laminate). o Această listă de verificare este un instrument care ajută personalul furnizor de servicii de scaune rulante să rețină principale aspecte legate de probarea produsului (a scaunului rulant). o În urma exersării procesului, acesta devine mai rapid și mai ușor. o Pentru început, urmăriți lista de verificare pentru a vă asigura că toți pașii au fost parcurși. Prezentați secvența activităților specifice probării scanului rulant, cuprinse în lista de verificare: 1. Este scaunul rulant pregătit? 2. Verificați dacă scaunul rulant are dimensiunea adecvată și dacă dispozitivele de suport postural sunt pe măsură. 3. Verificați postura. 4. Verificați presiunea. 5. Verificați scaunul rulant în timp ce acesta este în mișcare. 6. Decideți dacă sunt necesare alte intervenții. Întrebați: Probarea produsului (a scaunului rulant) se va efectua la domiciliul utilizatorului sau într-un centru de servicii de scaune rulante? Încurajați participanții să răspundă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 194. Explicați: Indiferent de locul unde se realizează probarea produsului (a scaunului urulant), fie că ne referim la domiciliul utilizatorului sau la un centru de servicii de scaune rulante, asigurați-vă că aveți toate instrumentele necesare: o formularele de evaluare pentru scaunul rulant și prescriere (selecție) – nivel intermediar; o metru sau șubler; o orice instrumente necesare pentru ajustarea scaunului rulant sau DSP-urilor. De asemenea, este bine să aveți câteva bucăți de burete/spumă, pentru cazurile în care trebuie să încercați câteva suporturi posturale suplimentare. Pregătiți vizionarea materialului video: Demonstrație probarea produsului (a scaunului rulant) - Deepak. În continuare, vom vedea un scurt material video despre Deepak (pe care l-am mai văzut înainte, într-un alt material), în timpul etapei de probare a scaunului său rulant. Cereți participanților să privească cu atenție. Prezentați materialul video. Verificați dacă există întrebări. Întrebați: De ce a fost necesară adăugarea unui element din burete/spumă sub piciorul drept al lui Deepak? Răspuns: Utilizatorul își poate menține echilibrul mai ușor și fără a resimți confort atunci când ambele picioare sunt susținute în mod corespunzător. Fără suportul din burete/spumă, doar unul dintre picioarele lui Deepak era sprijinit de suportul de picioare. Întrebați: Personalul furnizor de servicii de scaune rulante a adăugat spătarului un strat suplimentar din burete/spumă, pentru a oferi un grad de suport mai accentuat la nivelul trunchiului lui Deepak. Cum va deveni acest strat un element permanent al spătarului? Răspuns: Buretele/spuma pot fi lipite de spătar, sub tapițerie. Întrebați: De ce este important să cerem utilizatorului să efectueze propulsia (sau însoțitorului, în cazul în care utilizatorul nu poate face acest lucru) pe parcursul verificărilor din etapa de probare? Răspuns: Postura persoanei se poate modifica atunci când scaunul rulant este în mișcare sau din cauza efortului depus pentru propulsie. Explicați: 1. Este scaunul rulant pregătit? Explicați: o Asigurați-vă întotdeauna că scaunul rulant este pregătit pentru a fi probat de către utilizator. o Acest lucru înseamnă parcurgera tuturor pașilor prevăzuți în lista de verificare. o În urma exersării pașilor din etapa de probare, această operațiune va deveni mult mai rapidă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 195. 2. Verificați dacă scaunul rulant are dimensiunea adecvată și dacă DSP-urile sunt pe măsură. Explicați: o Pe parcursul etapei de probare a produsului (a scaunului rulant), personalul furnizor de servicii de scaune rulante trebuie să verifice fizic dacă scaunul rulant este corespunzător. o În următoarele slide-uri, vom vedea modul în care se realizează probarea scaunului rulant și a DSP-urilor. Atunci când verificați lățimea scaunului rulant, asigurați-vă că: o șoldurile utilizatorului de scaun rulant sunt poziționate confortabil între suporturile de brațe sau inserțiile laterale pentru bazin; o coapsele sunt poziționate confortabil între suporturile de brațe, apărătoarele laterale sau inserțiile laterale pentru bazin și nu se exercită presiune asupra lor. Acest lucru se poate întâmpla dacă inserțiile laterale pentru bazin se extind prea mult înspre înainte; o trunchiul utilizatorului de scaun rulant încape confortabil între spătarul drept sau inserțiile laterale pentru trunchi. Pentru verificarea lățimii scaunului rulant/șoldurilor: o glisați degetele în spațiul dintre partea exterioară a coapselor utilizatorului și interiorul părților laterale ale scaunului rulant; o degetele trebuie să aibă suficient spațiu . Atunci când verificați adâncimea suprafeței de ședere a scaunului rulant, asigurați-vă că: o utilizatorul de scaun rulant are bazinul într-o poziție cât mai apropiată de poziția neutră de ședere, fără a resimți disconfort; o există o distanță de cel puțin 30 mm între partea frontală a suprafeței de ședere/pernă și partea posterioară a genunchilor utilizatorului (zona poplitee). Această distanță poate crește în cazul utilizatorilor cu o lungime mai mare a membrelor inferioare; se acceptă valori de până la 60 de mm. Pentru verificarea adâncimii suprafeței de ședere: o introduceți mâna între partea frontală a pernei și partea posterioară a genunchiului (zona poplitee). Numărați câte degete încap în respectivul spațiu. o glisați mâna în spațiul din partea posterioară a gambei și asigurați-vă că aceasta nu atinge suprafața de ședere/perna; o verificați ambele părți. o În cazul în care există diferențe între partea dreaptă și stângă, pentru prescriere folosiți valoarea mai mică. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 196. Atunci când verificați bazinul, asigurați-vă că: o inserția anterioară oaselor bazinului este plasată chiar în partea anterioară a acestora (plasați mâna sub șezutul utilizatorului pentru a verifica); o inserția posterioară pentru bazin oferă suport la nivelul crestelor iliace postero-superioare și nu exercită presiune la nivelul trunchiului inferior; o inserțiile laterale pentru bazin au dimensiunea potrivită și sunt localizate deasupra nivelului articulației șoldurilor; o centura pentru bazin poate fi strânsă adecvat și nu rănește suprafața pielii utilizatorului de scaun rulant (pentru verificare, introduceți mâna între centură și corpul utilizatorului). Când verificați trunchiul, asigurați-vă că: o inserțiile laterale pentru trunchi și inserțiile unghiulare laterale pentru trunchi nu exercită presiune la nivelul axilelor; trebuie să existe să fie o distanță de cel puțin 30 de mm între axile și limita superioară a inserției laterale pentru trunchi; o hamul pentru umeri nu produce disconfort și nu rănește suprafața pielii; o măsuța susține lungimea antebrațului, precum și coatelor și nu exercită presiune asupra abdomenului. Măsuța poate fi situată aproape de trunchiul utilizatorului, totuși, aceasta nu trebuie să atingă suprafeța pielii sau să provoace fricțiune la nivelul acesteia. Verificați înălțimea și înclinarea spătarului. Verificarea tetierei: o Tetiera trebuie să susțină capul utilizatorului de scaun rulant la baza craniului (occiput). o Tetiera sprijină capul utilizatorului de scaun rulant, astfel încât acesta este în echilibru. Atunci când verificați coapsele utilizatorului de scaun rulant, asigurați-vă că: o nu se exercită presiune în zona dintre coapsele utilizatorului și suporturile pentru coapse (incluzând inserțiile exterioare pentru coapse, inserțiile unghiulare interioare pentru coapse sau inserția/dispozitivul pentru separarea genunchillor). o Inserția/dispozitivul pentru separarea genunchilor nu exercită presiune asupra zonei inghinale. Verificarea înălțimii suportului de picioare (ultima operațiune). Verificați dacă coapsele sunt sprijinite în totalitate pe suprafața de ședere/pernă fără a se distanța de aceasta, iar picioarele sunt susținute în întregime de suporturile de picioare. Modalitatea de verificare: poziționați mâna între coapsa utilizatorului de scaun rulant și suprafața de ședere/pernă. Presiunea exercitată trebuie Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 197. să fie egală de-a lungul coapselor, iar contactul trebuie să fie uniform; o observați modalitatea în care piciorul este poziționat pe suportul de picioare. Acesta trebuie să fie susținut atât în partea anterioară, cât și în cea posterioară, iar contactul trebuie să fie uniform. 3. Verificați postura o După verificarea dimensiunii scaunului rulant și a DSP- urilor, personalul furnizor de servicii de scaune rulante trebuie să stabilească dacă postura utilizatorului de scaun rulant este cea corectă, în limita confortului acestuia. o Observați postura utilizatorului de scaun rulant din față și lateral. o Verificați dacă bazinul utilizatorului de scaun rulant se află într-o poziție cât mai apropiată de cea neutră de ședere, fără a resimți vreun disconfort. Aceasta ar trebui să fie apropiată de postura identificată în urma procedeului de simulare manuală. o Verificați în mod atent următoarele aspecte: o Este bazinul drept și la nivel? (dacă se poate) o Este trunchiul drept și simetric? (dacă se poate) o Este capul echilibrat și drept? (dacă se poate) o Sunt picioarele și tălpile susținute cât mai aproape posibil de postura de șezut dreaptă? o Întrebați utilizatorul de scaun rulant cum se simte. o După observarea posturii generale a utilizatorului de scaun rulant, verificați ca fiecare DSP să ofere suportul intenționat. Verificați în mod atent următoarele aspecte (acolo unde este cazul): o Înălțimea spătarului, înclinarea spătarului și ajustarea formei spătarului; o înclinarea în spațiu; o tetiera; o inserțiile laterale pentru bazin și pentru trunchi; o orice suport la nivelul șoldurilor și al gambelor. 4. Verificați nivelul de presiune Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 198. o În cazul utilizatorilor de scaune rulante la care există riscul apariției escarelor, pașii etapei de probare includ verificarea nivelului de presiune sub oasele bazinului (folosind testul manual pentru verificarea nivelului de presiune din Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază) și în orice altă zonă de risc (de ex., sub articulația șoldului sau coccis). o Pentru fiecare utilizator de scaun rulat care folosește DSP- uri ce oferă un grad ridicat de suport - verificați nivelul de presiune în zona de contact dintre DSP și respectiva parte a corpului. Sprijinul trebuie să fie ferm, dar nu în mod exagerat. Note pentru formatori: Modul de verificare a nivelului presiunii sub oasele bazinului în cazul utilizatorilor de scaun rulant la care este prezent riscul apariției escarelor este prezentat în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Prezentați pe scurt testul de stabilire a nivelului de presiune/rulați materialul video din pachetul de instruire – nivel de bază („Demonstrație testului de presiune”) sau cereți unui participant să facă demonstrația. Pregătiți vizionarea materialului video: Demonstrație probarea produsului (a scaunului rulant) - Careen; Vizionați acest scurt material video care prezintă personalul furnizor de servicii de scaune rulante în timp ce verifică un scaun rulant ce va fi furnizat unei fetițe pe nume Careen. Personalul furnizor de servicii de scaune rulante verifică toate componentel și se asigură că toate centurile se potrivesc în mod corespunzător – fără a exercita un nivel de presiune mai mare decât cel recomandat. Prezentați materialul video. Verificați dacă există întrebări. 5. Verificați scaunul rulant în timp ce acesta este în mișcare o Partea finală a etapei de probare a produsului (a scaunului rulant) este verificarea scaunului rulant în timp ce acesta se află în mișcare. Aspecte de luat în considerare: o permite spătarul suficientă libertate de mișcare la nivelul omoplaților pentru ca utilizatorul de scaun rulant să efectueze propulsia? o mișcarea scaunului rulant sau efectuarea propulsiei duce la schimbarea posturii utilizatorului, provoacă disconfort sau senzația de instabilitate? o Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 199. o Propulsia efectuată cu ajutorul brațelor: roțile din spate sunt poziționate corect pentru ca utilizatorul de scaun rulant să poată realiza propulsia cât mai bine? o Propulsia efectuată cu ajutorul picioarelor: înălțimea și adâncimea suprafeței de ședere sunt adecvate pentru ca utilizatorul de scaun rulant să poată efectua propulsia cu ajutorul picioarelor? o Dispozitivele de suport postural permit mobilitatea nerestricționată și în condiții de siguranță a scaunului rulant? o Explicați: Dacă utilizatorul nu poate efectua singur propulsia scaunului rulant, cereți unui membru al familiei/însoțitorului să facă acest lucru, pentru a puteea observa modul de funcționare. 6. Decideți dacă sunt necesare intervenții suplimentare Explicați: o După efectuarea tuturor acestor verificări, utilizatorul de scaun rulant și personalul de servicii de scaune rulante trebuie să decidă dacă sunt necesare și alte intervenții. o În mod frecvent, după prima probare a produsului (a scaunului rulant) de către utilizatorul de scaun rulant care necesită suport postural suplimentar, va fi necesară efectuarea unor ajustări. o În cazul în care se fac ajustări, pașii etapei de probare trebuie reluați. o Odată ce personalul furnizor de servicii de scaune rulante devine mai experimentat în identificarea elementelor care corespund cerințelor și a celor care necesită ajustări, acest proces devine mai rapid Explicați: Pe parcursul acestui program de instruire, participanții vor exersa de două ori modalitatea de efectuare a pașilor din etapa de probare a produsului (a scaunului rulant). 3. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 200. B.14: Instruirea utilizatorilor de scaun rulant O B IE C TI V E La finalul acestei sesiuni, participanții vor putea: să evidențieze șase abilități pe care utilizatorii de scaune rulante cu modificări sau DSP-uri le pot învăța cu ajutorul personalului furnizor de servicii de scaune rulante. să demonstreze modalitatea prin care unul din colegi își însușește cel puțin trei abilități legate de manevrarea scaunul rulant. R E S U R S E Pentru sesiune: slide-uri PPT: B.14: Instruirea utilizatorului; Manualul participantului; Caietul de exerciții practice; afiș: „Listă de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar” Lista de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar, laminat - 1 pentru fiecare participant; scaune rulante – 1 pentru fiecare grup; C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoștințe dobândite anterior: Mai multe informații despre instruirea utilizatorului scaunului rulant sunt incluse în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Formatorii trebuie să se asigure că participanții sunt deja familiarizați cu această etapă și că și-au însușit modalitatea de predare (la nivel de bază) a abilităților referitoare la manevrarea scaunului rulant, efectuarea transferului, utilizarea și mobilitatea scaunului rulant, prevenirea apariției escarelor, întreținerea la domiciliu a scaunului rulant și de gestionare a potențialelor probleme. Adaptați conținutul acestei sesiuni în așa fel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte: Dacă există grupuri de susținere sau colegi formatori care pot oferi asistență în procesul de instruire a utilizatorilor de scaun rulant/însoțitorilor. D E P R E G Ă TI T Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii. Afișați „Lista de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar”. P R E ZE N TA R E 1. Introducere 2. Instruirea utilizatorului – cazuri de utilizatori de scaune rulante 3. Recapitulare puncte cheie 5 50 5 Durata totală a sesiunii 60 1. Introducere (5 minute) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 201. Explicați: o Instruirea utilizatorului de scaun rulat este cea de-a șaptea etapă a procesului de furnizare a serviciilor de scaune rulante. o Participanții trebuie să cunoască aspectele specifice acestei etape din Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. o La nivelul de lucru intermediar, informațiile de care au nevoie utilizatorii de scaune rulante sunt uneori diferite. o În cadrul acestei sesiuni, vom lucra cu trei cazuri diferite, pentru a evidenția anumite aspecte specifice care pot fi utile utilizatorilor de scaun rulant cu cerințe de nivel intermediar și pentru membrii familiilor acestora/ însoțitori. Întrebați: Puteți enumera care sunt acele informații/abilități suplimentare de care pot avea nevoie utilizatorii (și membrii familiei/însoțitorii) care folosesc scaune rulante cu suport postural suplimentar? Încurajați participanții să răspundă. Răspunsuri: o Informații despre beneficiile suportului postural suplimentar; o Modalitatea de utilizare adecvată a DSP-urilor (ce înseamnă ca acestea să fie pe măsură și modul de a gestiona eventualele probleme); o Informații legate de acomodarea utilizatorului la scaunul rulant (în special în cazul utilizatorilor copii) și la DSP-uri; o Metodele de dezasamblare și asamblare a unui scaun rulant dotat cu DSP-uri (de exemplu, în vederea transportării); o diferite tehnici de realizare a transferului - în cazul persoanelor care nu pot realiza independent transferul în și din scaunul rulant. Explicați: o Sesiunea „Instruirea utilizatorului de scaun rulant” din Manualul participantului conține informații cheie despre această etapă a procesului de furnizare a serviciilor de scaune rulante. o Lista de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar din Manualul participantului poate fi folosită ca un ghid pentru identificarea nevoii de instruire a utilizatorului de scaun rulant și a membrilor de familie/a însoțitorului și pentru transmiterea acestor cunoștințe. Nu toți utilizatorii de scaun rulant au nevoie de toate abilitățile specifice folosirii acestui tip de echipament de mobilitate. o Pe parcursul acestei sesiuni, vom lucra cu trei cazuti diferite de utilizatori de scaun rulant, pentru a accentua anumite aspecte specifice, care sunt importante pentru utilizatorii de scaun rulant cu cerințe de nivel intermediar și pentru membrii familiei/însoțitorii lor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 202. 2. Instruirea utilizatorului - cazurile utilizatorilor de scaun rulant (50 de minute) Activitate pentru grupe mici Grupe: Împărțiți participanții în grupe de câte 3 participanți. Instrucțiuni: o Indicați fiecărei grupe care este cazul de care va trebui să se ocupe, din cele incluse în Caietul de exerciții practice (B.14: Instruirea utilizatorului de scaun rulant). Asigurați-vă că participanții au la îndemână Manualul participantului. o Cereți fiecărei grupe să citească descrierea utilizatorului de scaun rulant din cazul care îi revine. o Pe baza informațiilor oferite în, întrebați participanții care sunt acele abilități de care are nevoie respectivul utilizator în vederea folosirii și întreținerii noului scaun rulant. Cereți utilizatorilor să completeze lista de verificare pentru instruirea utilizatorului de scaun rulant - nivel intermediar, din caietul de exerciții practice. o Cereți fiecărei persoane din grupă să aleagă un rol (utilizator de scaun rulant, personal furnizor de servicii de scaune rulante, membru defamilie/însoțitor). o Cereți fiecărui participant care a ales rolul personalului furnizor de servicii de scaune rulante să selecteze și să predea cel puțin trei abilități cuprinse în lista de verificare pentru instruirea utilizatorului de scaun rulant - nivel intermediar. Aceste abilități trebuie însușite de către utilizatoru și de către membrii familiei/însoțitor. o Explicați participanților faptul că două dintre cazurile prezentate se referă la utilizatori copii care au nevoie de asistență (pentru a fi ridicați). Nu este posibilă exersarea acestei abilități atunci când se lucrează cu utilizatori adulți. Participanții trebuie să prezinte procedura, fără a efectua ridicarea în sine. Reamintiți-le participanților să se gândească la secțiunea „Cum ne putem asigura de eficiența procesului de instruire al utilizatorului de scaun rulant?” o Evidențiați importanța „demonstrării” abilității, urmată de „exersare”. o Încurajați participanții să consulte Manualul participantului pentru informații despre fiecare abilitate pe care o predau. o Explicați: Participanții au la dispoziție 35 de minute pentru a efectua această activitate, iar apoi grupele vor reveni pentru feedback. Monitorizare: o Monitorizați cu atenție activitatea grupelor. o Asigurați-vă că fiecare grupă înțelege în ce constă activitatea. o Încurajați grupele să utilizeze Manualul participantului. o Asigurați-vă că fiecare grup a ales abilitățile corespunzătoare pe care le va preda utilizatorului de scaun rulant și membrilor familiei/însoțitorului (Vezi mai jos „Notele pentru formatori”. o Asigurați-vă că grupa care se ocupă de cazul Sangitei a oferit părinților informații cu privire la diferite poziții, explicând beneficiile unui scaun rulant și al sprijinului postural suplimentar. o Asigurați-vă ă exercițiul se desfășoară în condiții de siguranță. o Dacă este cazul, corectați tehnicile. o Oferiți asistență participanților, dacă acest lucru este necesar. Durata: Alocați 35 de minute pentru activitate. Alocați 15 minute pentru feedback. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 203. Feedback: Cereți câte unui reprezentant din fiecare grupă: o să prezinte pe scurt cazul utilizatorului de scaun rulant căruia i-a oferit instruire; o să prezinte cele mai importante aspecte pe care utilizatorul trebuie să le învețe. Urmăriți și adăugați informațiile omise și corectați erorile. Note pentru formatori: Joshua are 6 ani și este diagnosticat cu paralizie cerebrală, având mișcări nevoluntare bruște. I s-a prescris (selectat) un scaun rulant pentru copii, prevăzut cu DSP-uri, inclusiv o centură pentru bazin, inserții laterale pentru bazin și inserții laterale pentru trunchi. Pielea lui Joshua este subțire, sensibilă, iar inserțiile laterale pentru trunchi au un strat de protecție în plus, pentru a ajuta la prevenirea apariției escarelor. Noul scaun rulant al lui Joshua permite înclinarea înspre înapoi a scaunului rulant și revenirea la poziția inițială. De asemenea, există o bară anti-înclinare, care poate fi demontată pentru deplasările pe drum accidentat sau la urcarea și coborârea bordurilor. În vederea transportării, roțile din spate sunt detașabile, iar suprafața de ședere poate fi îndepărtată de pe cadru. Joshua merge la grădiniță în fiecare dimineață, cu serviciul de transport al grădiniței. Vehiculul este o mașină mică cu trei roți. Părinții săi sunt îngrijorați că scaunul rulant nu va avea loc în acest vehicul. Joshua are o programare pentru probarea scaunului rulant. Mama sa îl însoțește. Abilități de predat: Puncte cheie care trebuie scoase în evidență: Manevrarea scaunului rulant: o toate abilitățile. Transferuri: o transfer asistat. Utilizarea și mobilitatea în scaunul rulant: o propulsia asistată o durata zilnică de utilizare a scaunului rulant. Prevenirea apariției escarelor: o verificarea existenței escarelor; o acțiuni recomandate în cazul apariției unei escare. Întreținerea la domiciliu a scaunului rulant: o toate abilitățile. Gestionarea problemelor: o toate abilitățile. Manevrarea scaunului rulant: Unghiul de înlinare: o explicați efectele schimbării unghiului de înclinare scaunului rulant: echilibrarea trunchiului și îndreptarea capului; o modalitatea de „fixare” a unghiului de înclinare în poziția necesară; o când și de ce este necesară schimbarea unghiului de înclinare. Bara anti-răsturnare: o motivele utilizării barei anti-răsturnare – previne răsturnarea înspre înapoi a scaunului rulant; o motivul demontării barei anti-răsturnare pentreu deplasarea în exterior este faptul că aceasta poate interfera cu capacitatea de rulare pe teren accidentat sau cu urcarea și coborârea bordurilor. Demontarea și montarea oricărui DSP care trebuie îndepărtat în vederea transportării: o modalitatea de demontare a roților din spate; o modalitatea de demontare a suprafeței de ședere; o modalitatea de reasamblare a scaunului rulant. Transferurile: o atunci când se efectuează transferul, mențineți genunchii deasupra nivelului șoldurilor; o mențineți trunchiul lui Joshua aplecat înspre înainte în timp ce cuplați centura pentru bazin; o demonstrați cât de strânsă trebuie să fie centura pentru bazin; o accentuați modul de verificare a poziției lui Joshua Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 204. atunci când el se află în scaunul rulant: șoldurile ating spătarul; oasele bazinului în spatele inserției anterioare oaselor bazinului; inserțiile laterale pentru trunchi aproape de corpul său, fără a irita suprafața pielii. Utilizarea și mobilitatea în scaunul rulant: o efectuarea propulsiei asistate, de către mamă și prieteni, atât în exterior, cât și în interior, în condiții de siguranță. Prevenirea apariției escarelor: o verificarea suprafeței pielii în toate zonele de contact dintre scaunul rulant sau DSP și corpul utilizatorului de scaun rulant; o dacă nu apar semne pe suprafața pielii, se recomandă creșterea duratei de timp de utilizare a scaunului rulant cu câte 10 minute pe zi, fără a depăși intervalul de două ore de utilizare neîntreruptă; o verificarea suprafeței pielii după fiecare utilizare a scaunului rulant. o în cazul apariției oricărei urme de iritație (înroșirea pielii) care persistă mai mult de 20 de minute după îndepărtarea sursei de presiune (după utilizarea scaunului rulant), scaunul rulant nu va fi utilizat până la dispariția totală a urmei de iritație. Sangita are trei ani și este diagnosticată cu spina bifida. Are dificultăți de mobilitate; lipsa sensibilității sub nivelul taliei și o protuberanță în partea inferioară a coloanei vertebrale. Părinții ei spun că are dificultăți în controlul vezicii și al sfincterelor și că are în mod frecvent infecții ale tractului urinar. Sangita a venit la furnizorul de servicii de scaune rulante pentru a proba primul ei scaun rulant, care are roți cu detașare rapidă, centură pentru bazin, inserții laterale pentru bazin și o anumită conturare a spătarului pentru a evita formarea presiunii la nivelul protuberanței de pe coloana vertebrală. De asemenea, are și o pernă pentru reducerea presiunii. A venit cu ambii părinți. Aceștia sunt îngrijorați de faptul că, dacă va avea un scaun rulant, ea nu va mai dori să se deplaseze cu ajutorul cârjelor. Totuși, Sangita este nemulțumită atunci când nu se poate juca în exterior cu frații și surorile sale. Abilități de predat: Puncte cheie care trebuie scoase în evidență: Manevrarea scaunului rulant: toate abilitățile. Transferuri: o independent (cu sau fără cârje) Utilizarea și mobilitatea în scaunul rulant: o realizarea corectă a propulsiei, pante, trepte, utilizarea barei anti- răsturnare Prevenirea apariției escarelor: o verificarea existenței escarelor; o accentuați: verificarea Transferurile: o discuții cu părinții și recomandarea ca Sangita să fie cât se poate de independentă și să efectueze independent transferul în și din scaunul rulant. Utilizarea și mobilitatea în scaunul rulant: Discuții cu părinții pentru a înlătura teama că utilizarea scaunului rulant va reduce motivația Sangitei de a se deplasa fără ajutorul echipamentului de mobilitate. Explicarea beneficiilor unui scaun rulant, printre care: o scaunul rulant o va ajuta să țină pasul cu frații ei, atunci când se află în exterior, să fie în formă și o persoană activă; o libertatea de a utiliza membrele superioare – acestea nu vor trebui să manevreze cârjele în vederea deplasării, având posibilitatea de a desfășura diverse activități; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 205. existenței semnelor de iritație pe suprafața pielii în zona protuberanței. Întreținerea la domiciliu a scaunului rulant: o toate abilitățile. Gestionarea problemelor: o toate abilitățile. Recomandarea consultului urologic: o management urinar și prevenirea infecțiilor urinare o scaunul rulant o ajută pe Sangita să mențină o poziție corespunzătoare și previne problemele posturale. Durata de timp zilnică de utilizare a scaunului rulant: o pentru început, Sangita trebuie să folosească scaunul rulant pe perioade scurte (de ex., 30 de minute) de câteva ori pe parcursul fiecărei zile; o după adaptarea utilizatorului la scaunul rulant, durata de timp poate crește treptat; o Sangita nu trebuie să utilizeze scaunul rulant mai mult de două fără întrerupere. Prevenirea apariției escarelor: o verificarea suprafeței pielii în toate zonele de contact dintre scaunul rulant sau DSP și corpul utilizatorului de scaun rulant; o dacă nu apar semne pe suprafața pielii, se recomandă creșterea duratei de timp de utilizare a scaunului rulant cu câte 10 minute pe zi, fără a depăși intervalul de două ore de utilizare neîntreruptă; o în cazul apariției oricărei urme de iritație (înroșirea pielii) care persistă mai mult de 20 de minute după îndepărtarea sursei de presiune (după utilizarea scaunului rulant), scaunul rulant nu va fi utilizat până la dispariția totală a urmei de iritație. Recomandarea consultului urologic: o Din cauză că Sangita are în mod frecvent infecții ale tractului urinar, personalul furnizor de servicii de scaune rulante trebuie să recomande consultul urologic, pentru management urinar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 206. Kim Som are 40 de ani și a avut un traumatism cranio-cerebral în urmă cu 15 ani. El este subponderal și are dificultăți în ceea ce privește consumul alimentelor. Coloana vertebrală prezintă o curbură fixă înspre înainte. Kim Som nu poate adopta poziția stând și depinde în totalitate de mama lui. Nu vorbește, dar mama sa spune că înțelege indicațiile simple. În urma evaluării s-a constatat că există riscul apariției escarelor, deoarece este subponderal, este incapabil de a se mișca independent și a avut o escară în trecut (din cauza poziției în pat). Kim Som tocmai primit primul său scaun rulant. Scaunul rulant este dotat cu o pernă pentru reducerea presiunii și cu DSP-uri al căror rol este creșterea nivelului de confort. Mama sa îi este și însoțitor și au venit împreună la programarea pentru probarea scaunului rulant. Abilități de predat: Puncte cheie care trebuie scoase în evidență: Manevrarea scaunului rulant: o toate abilitățile (exceptând înclinarea și barele anti- răsturnare). Transferuri: o transferul asistat. Utilizarea și mobilitatea scaunului rulant: o propulsia asistată; o durata zilnică de utilizare a scaunului rulant. Prevenirea apariției escarelor: o verificarea existenței escarelor; o acțiuni recomandate în cazul apariției unei escare. Întreținerea la domiciliu a scaunului rulant: o toate abilitățile. Gestionarea problemelor: o toate abilitățile. Transferurile: o Fiind vorba de un adult, este important să existe două persoane care să îl ridice pe Kim Som. o Discuții cu mama utilizatorului cu privire tehnica transferului asistat. Există o persoană care să o asiste? Cunoaște tehnica ridicării utilizatorului în condiții de siguranță? o Verificați/predați tehnica de transfer corectă. Scoateți în evidență metoda de verificare a poziției lui Kim Som în timpul utilizării scaunului rulant: șoldurile ating spătarul; oasele bazinului în spatele inserției anterioare oaselor bazinului; inserțiile laterale pentru trunchi aproape de corpul său, fără a irita suprafața pielii. Utilizarea și mobilitatea în scaunul rulant: o Însușirea de către mama utilizatorului a tehnicii de realizare a propulsiei asistate pe teren accidentat, pe teen în pantă și pe trepte. o Modalitatea prin care însoțitorul trebuie să solicite asistență la realizarea propulsiei scaunului rulant pe teren în pantă sau la urcarea și coborârea treptelor. Prevenirea apariției escarelor: o Kim Som nu trebuie să utilizeze scaunul rulant mai mult de două ore fără întrerupere. o Perioada de utilizare crește treptat, începând cu 30 de minute. o Verificarea suprafeței pielii imediat după utilizarea scaunului rulant, pentru a identifica semne/urme de înroșire pe suprafața pielii. o În cazul apariției oricărei urme de iritație (înroșirea pielii) care persistă mai mult de 20 de minute după îndepărtarea sursei de presiune (după utilizarea scaunului rulant), scaunul rulant nu va fi utilizat până la dispariția totală a urmei de iritație. Întreținerea la domiciliu a scaunului rulant: o Identificarea persoanelor care pot oferi asistență mamei utilizatorului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 207. 3. Recapitulare puncte cheie (5 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 208. Sesiunea practică 3: Probarea produsului (a scaunului rulant) și instruirea utilizatorului de scaun rulant O B IE C TI V E La finalul acestei sesiuni, participanții vor putea: să demonstreze modalitatea de efectuare a probării produsului (a scaunului rulant) - nivel intermediar. să demonstreze modalitatea de instruire a utilizatorului - nivel intermediar. R E S U R S E Listă de verificare și observații pentru formator: Sesiunea practică 3: Formular de consimțământ pentru realizarea pozelor; formulare de evaluare și prescriere (selecție) – nivel intermediar, completate și necompletate, de la Sesiunea practică 1; afiș: „Tabel dispozitive de sprijin postural (DSP)”; afiș: „Listă de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar” Tabel dispozitive de sprijin postural (DSP), laminat – 1 pentru fiecare participant; listă de verificare a pașilor pentru probarea produsului (a scaunului rulant) - nivel intermediar, laminat - 1 pentru fiecare participant. listă de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar, laminat - 1 pentru fiecare participant; spațiu curat și delimitat, pentru desfășurarea evaluării, dotat cu pat de evaluare și paravan pentru fiecare grup, în vederea lucrului cu utilizatorul de scaun rulant; scaune rulante pregătite în Sesiunea practică 2 și pregătite pentru prima probare; aparat foto digital; metru sau șubler - 1 pentru fiecare grupă, set de plăci pentru picioare - 1 pentru fiecare grupă. Set DSP-uri și set de instrumente pentru ajustarea scaunului rulant - 1 pentru fiecare grupă. C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptați conținutul acestei sesiuni astfel încât informațiile să fie în concordanță cu contextul în care participanții vor lucra. Luați în considerare următoarele aspecte: factori culturali – de exemplu, dacă pentru etapa evaluării, pot fi create grupe mixte, cu persoane de ambele sexe; atunci când participanții parcurg pașii etapei de probare a scaunului rulant, fiți atenți la aspectele culturale legate de contactul fizic; factori lingvistici – de exemplu, dacă utilizatorii de scaune rulante care participă și participanții vorbesc aceeași limbă; orice documentație de care are nevoie organizația-gazdă a cursului în vederea evaluării sau prescrierii unui scaun rulant - de exemplu, orice informații suplimentare necesare despre utilizatorul de scaun rulant care apelează la serviciile lor (de ex., surse de trimitere); modul în care formatorii vor administra problemele care pot apărea pe parcursul probării și care nu pot fi soluțonate în cadrul sesiunii sau al programului de instruire. De exemplu, scaunele rulante pregătite nu sunt pe măsură și nu pot fi ajustate (o posibilă soluție ar fi asigurarea existenței unor scaune rulante suplimentare de diferite dimensiuni mărimi, pentru a le înlocui); modalitatea de realizare a monitorizării pentru fiecare utilizator de scaun rulant, după finalizarea programului de instruire. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 209. D E P R E G Ă TI T Confirmați ora și detaliile legate de deplasarea utilizatorilor de scaune rulante voluntari. Asigurați-vă că există băuturi răcoritoare pentru utilizatorii de scaune rulante și membrii familiei/însoțitori. Desemnați o persoană care să întâmpine utilizatorii de scaune rulante și să le prezinte locul unde pot aștepta până la începerea sesiunii. Pregătiți o zonă pentru desfășurarea etapei de probare, pentru fiecare grupă (pat de evaluare și paravane). Asigurați-vă că scaunele rulante care urmează a fi probate sunt pregătite în totalitate (verificați-le cu ajutorul formularelor de prescriere (selecție) a scaunului rulant - nivel intermediar și confirmați completarea listei de verificare preliminare utilizării scaunului rulant - nivel intermediar). Dacă sunt mai mult de trei grupe de participanți, solicitați asistență unui alt formator, pentru monitorizarea grupelor. Pregătiți afișul „Tabelul de dispozitive de sprijin postural (DSP)”. Pregătiți afișul „Lista de verificare a instruirii utilizatorului de scaun rulant - nivel de bază”. P R E ZE N TA R E 1. Exersarea pașilor din etapa de probare a produsului (a scaunului rulant) și din cea a instruirii utilzatorului: o Instrucțiuni și organizare o Probarea produsului (a scaunului rulant) o Instruirea utilizatorilor 15 90 45 Durata totală a sesiunii 150 1. Exersarea pașilor din etapa de probare a produsului (a scaunului rulant) și a etapei de instruire a utilzatorului (150 de minute) Note pentru formatori: 1. Fotografii: o Verificați dacă fiecărui utilizator de scaun rulant i-a fost solicitat acordul scris pentru în vederea realizării de fotografii. Asigurați-vă că utilizatorii de scaune rulante înțeleg faptul că permisiunea se acordă în mod voluntar și că fotografiile vor fi folosite pentru instruire, în cadrul acestui program. o Pe parcursul sesiunilor practice, faceți fotografii ale utilizatorilor de scaune rulante care și-au dat acordul, după cum urmează: o în scaunul rulant prescris după probare (perspectivă frontală și laterală). 2. Satisfacerea cerințelor utilizatorilor de scaun rulant care participă la sesiunea practică o Nu toate scaunele rulante dotate cu DSP-uri pot fi finalizate în perioada de timp disponibilă în sesiunea practică. o Dacă este nevoie de o altă programare pentru oricare utilizator de scaun rulant care a participat la sesiunea practică, formatorul trebuie să se asigure că această programare este stabilită de organizația gazdă și că toate informațiile legate de evaluare, prescriere și probare a produsului (a scaunului rulant) ajung în posesia organizației gazdă, pentru finalizarea DSP-urilor/livrarea finală a scaunului rulant. 3. Observarea metodei de lucru a participanților: o Utilizați lista de verificare și observații pentru formatori din Sesiunea practică 3, pentru a vă asigura că grupele parcurg toți pașii sesiunii practice și pentru a nota exemple de bună practică. Activitate pentru grupe mici Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 210. Grupe: o Împărțiți participanții în grupe care să aibă aceeași componență ca în Sesiunea practică 1 și 2. o Desemnați un responsabil pentru fiecare grupă (poate fi același ca în Sesiunea practică 1 sau 2 sau un alt responsabil). o Alocați fiecărei grupe un spațiu pentru desfășurarea activității. o Explicați unde pot fi găsite materialele și instrumentele. Instrucțiuni: Explicați următoarele: Scopul sesiunii: o Obiectivul acestei sesiuni practice este parcurgerea etapelor șase și șapte a procesului de furnizare a serviciilor de scaune rulante – probarea produsului (a scaunului rulant) și instruirea utilizatorului - lucrând cu utilizatorul de scaun rulant din sesiunea practică anterioară. o Este posibil ca nu toți participanții să reușească finalizarea scaunului rulant pentru utilizator în perioada de timp disponibilă. Acest lucru va depinde de prima probare și de modificările/ajustările necesare. Totuși, participanții trebuie să folosească durata de timp alocată pentru a pregăti într-o cât mai mare măsură scaunul rulant. Dacă procesul nu poate fi definitivat, se vor planifica activitățile necesare finalizării pregătirii scaunului rulant, după încheierea programului de instruire. Responsabilul: o Responsabilul fiecărei grupe se va asigura de faptul că se parcurg toți pașii etapei. o Responsabilul va fi cel care comunică preponderent cu utilizatorul de scaun rulant și, în caz de necesitate, cu membrii familiei/însoțitorii, pentru a evita crearea de confuzii. Observațiile formatorului și asistența oferită de acesta: o Participanții pot cere asistență sau clarificări în orice moment, pe întreg parcursul exercițiului. o Pe durata sesiunii, formatorii vor monitoriza activitatea fiecărei grupe și vor oferi asistență, atât cât este necesar. o Explicați participanților faptul că, în cazul în care sunt identificate probleme legate de probarea scaunului rulant, ei trebuie să solicite prezența formatorului, care va verifica aspectele constate și u care se vor discuta modificările/ajustările necesare. o După finalizarea exercițiului, participanții vor solicita prezența unui formator, care va verifica rezultatul. Participanții nu trebuie să înceapă instruirea utilizatorului de scaun rulant până când rezultatul etapei de probare a produsului (a scaunului rulant) nu a fost verificată de către un formator. o După încheierea instruirii utilizatorului de scaun rulant, participanții trebuie să solicite prezența unui formator pentru a discuta cu membrii echipei și cu utilizatorul de scaun rulant despre instruirea acestuia. Durata de timp: o Participanții trebuie să încerce să parcurgă etapa de probare (inclusiv efectuarea ajustărilor) în 90 de minute și cea a instruirii utilizatorului de scaun rulant în 45 de minute. Formulare: o Înmânați fiecărui responsabil de grup formularele de evaluare a și de prescriere (selecție) - nivel intermediar completate în sesiunile practice anterioare. o Verificați dacă fiecare grupă are cel puțin un exemplar laminat din lista de verificare a pașilor pentru probarea scaunului rulant și din lista de Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 211. verificare a instruirii utilizatorului de scaun rulant - nivel intermediar. Întrebați participanții: Care sunt pașii etapei de probare a produsului (a scaunului rulant)? Aprobați răspunsurile corecte Reamintiți-le participanților faptul că, în etapa „Instruirea utilizatorului de scaun rulant”, ei trebuie să predea doar abilitățile care sunt relevante în cazul respectivului utilizator de scaun rulant. De exemplu, nu este necesară predarea tehnicilor de reducere a presiunii în cazul unui utilizator de scaun rulant la care nu este prezent riscul apariției a escarelor. Reamintiți-le participanților că trebuie să implice în mod activ utilizatorul de scaun rulant, de-a lungul întregului proces. Întrebați: Există întrebări? Răspundeți oricăror întrebări. Cereți fiecărei grupe să pregătească zona în care va lucra; și să invite apoi utilizatorul de scaun rulant cu care va lucra. Monitorizare și suport: Monitorizați activitatea grupelor, asigurați-vă că activitatea se desfășoară în condiții de siguranță, observați și evaluați abilitățile participanților. Folosiți lista de verificare și observații pentru formator și notați observațiile legate de fiecare echipă. Pe parcursul sesiunii: o Informați participanții cu privire la durata de timp rămasă (verbal și/sau în scris pe tablă, pentru ca toți participanții să fie informați) pentru o mai bună administrare a timpului alocat exercițiului. o Asigurați-vă că utilizatorii de scaun rulant sunt implicați în mod activ. o Asigurați-vă că fiecare membru al echipei este implicat în mod activ. La finalul acestei sesiuni, cereți participanților să le mulțumească utilizatorilor de scaun rulant pentru participare. Faceți fotografii utilizatorilor de scaun rulante care au semnat formularul de acord pentru fotografiere. Durata: Acordați 15 minute pentru instrucțiuni și pregătire, 90 de minute pentru etapa de probare, 45 de minute pentru instruirea utilizatorului de scaun rulant. Feedback: Vezi B.15 „Recapitulare” Note pentru formatori: Este important să monitorizați timpul pe durata sesiunilor practice. Timpii menționați mai sus sunt cu titlu orientativ, ei putând varia în funcție de experiența participanților, nevoile utilizatorului de scaun rulant, perioada necesară pregătirilor. Formatorii pot adapta durata de timp în funcție de aceți factori. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 212. B.15: Recapitulare O B IE C TI V E La finalul acestei sesiuni, participanții vor putea: să prezinte un rezumat al cazului utilizatorului de scaun rulant cu care au lucrat în sesiunea practică anterioară, inclusiv: cerințe de ordin fizic, condiții de mediu, stil de viață; soluțiile pentru prescrierea (selecția) scaunului rulant, probarea produsului și instruirea corespunzătoare a utilizatorului de scaun rulant. R E S U R S E Pentru sesiune: Caiet de exerciții practice; Fotografii ale utilizatorilor de scaun rulant (în cazul celor care au semnat formularul de consimțământ pentru fotografiere) D E P R E G Ă TI T Pregătiți toate resursele și parcurgeți planul sesiunii. Asigurați-vă că fotografiile utilizatorilor de scaune rulante au fost salvate în calculatorul utilizat pe durata programului de instruire, într-un fișier denumit cu numele lor. P R E ZE N TA R E 1. Introducere 2. Pregătirea participanților 3. Prezentările și discuțiile participanților 5 30 85 Durata totală a sesiunii 120 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 213. 1. Introducere (5 minute) Explicați: o În această sesiune, participanții vor avea oportunitatea: o să împărtășească tuturor participanților care au fost aspectele învățate în ultimele trei sesiuni practice; o să adreseze eventualele întrebări pe care încă le mai au legat de furnizarea de servicii de scaune rulante de nivel intermediar; o să explice raționamentul lor și să fie provocați la discuții de către colegii lor. 2. Pregătirea participanților (30 de minute) Activitate pentru grupe mici Grupe: Cereți grupelor care au lucrat împreună în ultimele trei sesiuni practice să păstreze aceeați componență. Instrucțiuni: Cereți fiecărei echipe să pregătească o prezentare de 10 minute despre utilizatorul de scaun rulant cu care au lucrat și despre ceea ce au învățat. Prezentarea lor ar trebui să includă punctele din Caietul de exerciții practice (B.15: Recapitulare). Explicați faptul că fotografiile utilizatorilor de scaune rulante sunt disponibile în calculatorul utilizat pe durata programului de instruire și că le pot folosi pentru a ilustra prezentarea lor. Note pentru formatori: Dacă participanții nu au abilități de utilizare a calculatorul, explicați faptul că formatorii vor pregări fotografiile pentru ei și le vor afișa când va fi nevoie. Monitorizare: Monitorizați cu atenție activitatea grupelor. Asigurați-vă că fiecare grupă înțelege indicațiile de lucru. Oferiți asistență participanților, dacă acest lucru este necesar. Durata: Acordați participanților 30 minute pentru finalizatrea acestei activități. Feedback: Vezi 3: „Prezentările participanților. Feedback”. 3. Prezentările participanților. Feedback (85 de minute) Cereți grupelor să prezinte pe rând. Încurajați întregul grup ca la finalul prezentării, să pună întrebări. o sugerați ca pe parcurs, participanții să noteze întrebările pe care doresc să le adreseze la finalul fiecărei prezentări; o încurajați participanții să analizeze deciziile și abordările folosite de echipa care face prezentarea. În mod ideal, acest lucru va genera discuții, dezbateri și o analiză mai detaliată. Acordați 10 minute pentru fiecare prezentare și 5 minute pentru întrebări (în funcție de numărul de grupe). La finalul fiecărei prezentări: o Faceți câteva comentarii finale, care includ puncte pozitive la adresa prezentatorilor. o Mulțumiți fiecărei grupe pentru prezentare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 214. La finalul tuturor prezentărilor: o Reamintiți-le participanților că, de multe ori, există mai multe soluții corecte. Câteodată, cea mai bună soluție poate fi un compromis - pentru a satisface cât mai bine nevoile și dorințele generale ale utilizatorului de scaun rulant, utilizând cât mai bine resursele disponibile. Note pentru formatori: o Întrebările sunt pentru a ridica nivelul de încredere în deciziile luate, nu pentru a sugera că s-a greșit. o Întrebările și provocările trebuie adresate într-o manieră pozitivă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 215. B.16: Întreținerea, reparațiile și monitorizarea O B IE C TI V E La finalul acestei sesiuni, participanții vor putea: să descrie ce presupune etapa de monitorizare; să completeze un formular de monitorizare pentru un utilizator de scaun rulant. R E S U R S E Pentru sesiune: slide-uri PPT: B.16: Întreținerea, reparațiile și monitorizarea; Manualul participantului; Caietul de exerciții practice; Formular de monitorizare. C O N TE X Ș C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Cunoștințe dobândite anterior: Formularul de monitorizare - nivel intermediar este la fel cu cel utilizat la nivel de bază. Participanții care au participat la modulul de instruire anterior cunosc deja acest formular. Adaptați conținutul acestei sesiuni, în așa fel încât informațiile să fie în concordanță cu contextul în care participanții vor lucra. Luați în considerare următoarele aspecte: Cum se va efectua monitorizarea la centrele de furnizare de servicii de scaune rulante unde vor lucra participanții. De exemplu, centrul efectuează monitorizarea la domiciliul utilizatorului de scaun rulant, îl invită pe acesta la sediu sau colaborează cu echipele implicate în reabilitarea bazată pe comunitate?. Verificați dacă participanții reprezintă furnizori de scaune rulante care au un sistem de monitorizare. Dacă da, explicați sistemul participanților. Explicați care este rolul lor în monitorizare. D E P R E G Ă TI T Pregătiți toate resursele, revedeți slide-urile PPT și parcurgeți planul sesiunii. P R E ZE N TA R E 1. Introducere 2. Rezumatul monitorizării 3. Formular de monitorizare a utilizării scaunului rulant 4. Exersarea efectuării monitorizării 5. Recapitulare punctel cheie 2 8 10 35 5 Durata totală a sesiunii 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 216. 1. Introducere (2 minute) Explicați: o Întreținerea, reparațiile și monitorizarea sunt cea de-a opta etapă a procesului de furnizare a serviciilor de scaune rulante. o Informațiile despre întreținere, reparații și monitorizare au fost abordate în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire -nivel de bază. o În această sesiune vom reîmprospăta cunoștințele despre monitorizare, care au fost prezentate în modulul aferent nivelului de bază și vom lua în considerare importanța specifică a monitorizării utilizatorilor de scaune rulante care au nevoie de sprijin postural suplimentar. 2. Rezumatul monitorizării (8 minute) Explicați: o Toți utilizatorii de scaun rulant beneficiază de pe urma monitorizării. Monitorizarea este importantă cu precădere în următoarele cazuri: o utilizatori de scaun rulant copii; o utilizatori de scaun rulant la care este prezent riscul apariției escarelor; o utilizatori de scaun rulant diagnosticați cu o afecțiune degenerativă; o utilizatori de scaun rulant care necesită suport postural suplimentar; o utilizatori de scaun rulant care au avut dificultăți în însușirea abilităților în etapa de instruire sau în asimilarea instrucțiunile oferite. Majoritatea utilizatorilor de scaune rulante care au nevoie de servicii de nivel intermediar au nevoie de suport postural suplimentar, în consecință, monitorizarea este foarte importantă. Explicați: o Nu există o regulă cu privire la intervalele de timp la care trebuie să se desfășoare monitorizarea, deoarece aceasta va depinde de nevoile utilizatorului de scaun rulant. o Totuși, acolo unde este posibil, se recomandă edfectuarea monitorizării la șase săptămâni de la furnizarea scaunului rulant, pentru a ne asigura că scaunul rulant funcționează corespunzător și pentru a consolida instruirea utilizatorului. o În cazul copiilor, monitorizarea ideală se realizează la intervale cuprinse între trei și șase luni. Acest lucru se datorează faptului că nevoile copiilor se schimbă repede, odată cu creșterea lor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 217. o Monitorizarea poate fi realizată: o la domiciliul utilizatorului de scaun rulant; o la centrul de servicii de scaune rulante; o în orice altă locație convenabilă utilizatorului de scaun rulant și personalului furnizor de servicii de scaune rulante. o Locația depinde de posibilitatea utilizatorului de a se deplasa la centrul de servicii de scaune rulante și de posibilitatea personalului furnizor de servicii de scaune rulante de a se deplasa la domiciliul utilizatorului. Întrebați: Cum poate fi gestionată monitorizarea (sau cum este gestionată în mod curent) în cadrul centrul de servicii de scaune rulante de unde provin participanții? (de ex., unde are loc monitorizarea, frecvența acesteia, cine răspunde de monitorizare și cum sunt stabilite programările pentru monitorizare?). Încurajați participanții să răspundă. Răspunsuri: o unii participanți vor spune că monitorizarea nu este efectuată în mod frecvent în cadrul centrului de servicii de scaune rulante de unde provin; o utilizatorii sunt programași pentru monitorizare în momentul primirii scaunului rulant; o monitorizarea poate fi efectuată la domiciliul utilizatorului sau la centrul de servicii de scaune rulante; o vizitele de monitorizare pot fi parte a unor vizite de rutină efectuate de personalul de servicii de reabilitare bazată pe comunitate (RBC), care a fost instruit în acest sens; o pot fi efectuate convorbiri telefonice de monitorizare (de exemplu, în cazul în care transportul este dificil și utilizatorul de scaun rulant are acces la un telefon); o intervalele de timp pentru monitorizare pot varia. Note pentru formatori: Aceasta poate fi o bună ocazie de a discuta cu participanții despre modul în care poate fi îmbunătățită modalitatea de realizate a monitorizării în centrele de servicii de scaune rulante de unde provin. Dacă,în urma discuțiilor, sunt identificate idei valoaroase, formatorii le pot prezenta managerilor din centrele de servicii de scaune rulante. 3. Formular de monitorizare a utilizării scaunului rulant (10 minute) Explicați: o Formularul de monitorizare a utilizării scaunului rulant - nivel intermediar este similar celui folosit în pachetul de instruire pentru serviciile de scaune rulante - nivel de bază. o Acest lucru înseamnă că serviciul de scaune rulante poate folosi același formular de monitorizare a utilizării scaunului rulant pentru orice utilizator. Totuși, detaliile, precum și activitățile de monitorizare pot fi diferite. o Activitatea de monitorizare înseamnă o oportunitate pentru: o dobândirea de informații de la utilizatorul de scaun rulant; o verificarea funcționării corespunzătoare a scaunului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 218. rulant; o verificarea modului în care scaunul rulant este corespunzător respectivului utilizator. o Având aceste informații, personalul furnizor de servicii de scaune rulante trebuie să discute cu utilizatorul care sunt acțiunile necesare. Cereți participanților să analizeze formularul de monitorizare a utilizării scaunului rulant. Explicați: Formularul de monitorizare a utilizării scaunului rulant va ajuta personalul furnizor de servicii de scaune rulante să adreseze toate întrebările necesare și să parcurgă toți pașii specifici vizitei de monitorizare. Formularul de monitorizare a utilizării scaunului rulant are și o rubrică în care pot fi notate acțiunile recomandate. Activitățile de monitorizare specifice includ: Întrebați: Care sunt acțiunile recomandate în cazul în care un utilizator de scaun rulant menționează existența unei escare? Răspunsuri: o cereți permisiunea de a vedea escara (asigurați-vă că acest lucru se întâmplă într-un spațiu retras); o notați locația și stadiul escarei; o dacă escara este localizată într-o zonă de risc, unde corpul utilizatorului intră în contact cu scaunul rulant sau cu DSP-ul, utilizatorul trebuie să întrerupă utilizarea scaunului rulant; o dacă escara este în stadiul 2 sau mai avansată, discutați cu un specialist pentru a stabili tratamentul. 4. Exersarea efectuării monitorizării (35 de minute) Activitate pentru grupe mici Grupe: Împărțiți participanții în grupe de câte trei persoane. Instrucțiuni: Cereți participanților să citească cazul fiecărui utilizator de scaun rulant din Caietul de exerciții practice, (B.16: Monitorizarea). Pentru fiecare Oferirea de informații sau instruire suplimentare. o De exemplu, dacă un utilizator nu folosește scaunul rulant conform așteptărilor, acest lucru se poate datora faptului că are încredere în propria sa abilitate de a efectua independent transferul în și din scaunul rulant. Instruirea suplimentară în ceea ce privește tehnicile de transfer poate soluționa această problemă. Reajustarea scaunului rulant. Efectuarea unor reparații minore. Încurajați întotdeauna utilizatorii de scaune rulante și membrii familiei/însoțitorii să întrețină scaunul rulant prin efectuarea unor reparații minore la domiciuliu. Personalul furnizor de servicii de scaune rulante poate oferi asistență utilizatorilor pentru programarea reparațiilor, dacă acestea nu pot fi rezolvate imediat. Recomandarea către un alt serviciu pentru sprijin sau asistență. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 219. utilizator, participanții trebuie să completeze formularul de monitorizare a scaunului rulant, să discute și să înregistreze orice acțiune. Explicați: Fiecare grupă are la dispoziție 20 minute pentru a finaliza această activitate, iar apoi echipele se vor reuni pentru sesiunea de feedback. Monitorizare: Monitorizați cu atenție activitatea grupelor. Asigurați-vă că fiecare grupă înțelege indicațiile de lucru. Oferiți asistență participanților, dacă acest lucru este necesar. Timp: Acordați 20 minute pentru finalizarea acestei activități. Acordați 15 minute pentru feedback. Feedback: Pentru fiecare caz, cereți uneia dintre grupe să prezinte pe scurt care sunt activitățile de monitorizare recomandate în cazul respectivului utilizator. Întrebați participanții: Participanții din alte grupe au alte sugestii în ceea ce privește activitățile recomandate? Asigurați-vă că participanții parcurg toate punctele cheie (vezi mai jos Note pentru formatori). Note pentru formatori: Caz utilizator de scaun rulant: Răspunsuri și puncte cheie: Thusitha are 7 ani și locuiește cu părinții și sora mai mare. Este diagnosticat cu distrofie musculară și, în urmă cu un an, i-a fost furnizat un scaun rulant, prin intermediul serviciului de scaune rulante. La acea dată, el putea încă să se deplaseze pe distanțe scurte și avea capacitatea de a efectua independent transferul în poziția stând. Își dorește un scaun rulant deoarece are dificultăți în ceea ce privește deplasarea la școală. La monitorizare, Thusitha a spus că întâmpină greutăți în realizarea transferului independent în și din scaunul rulant. După amiaza, la școală, se simte obosit și crește nivelul său de disconfort. Acest lucru îl împiedică să se concentreze. Scaunul său rulant are dimensiunea potrivită și are un spătar mediu pliabil, cu o pernă standard, pentru confort. În ceea ce privește gradul de satisfacție legat de scaunul rulant, utilizatorul a acordat nota 4 din 5. o Identificarea metodei de transfer. o Identificarea unei alte tehnici de transfer, pentru facilitarea transferului, de ex. o placă de transfer sau transferul asistant în poziția stând. o Analiza DSP-urilor. Nu pierdeți din vedere următoarele opțiuni: un spătar mai înalt, spătar cu ajustare a tensiunii, pernă de reducere a presiunii și cu control al posturii. o Oboseala apare mai frecvent în cazul afecțiunilor degenerative. Luați în considerare nevoia de schimbare a posturii pe parcursul pauzei de masă, pentru creșterea nivelului de confort și pentru mărirea capacități de concentrare pe durata după amiezei. o Persoanele cu afecțiuni degenerative necesită monitorizare regulată, la intervale de 3-6 luni fiind varianta ideală. Monitorizarea poate fi efectuată mai frecvent, dacă acest lucru este necesar. Mirella are 23 de ani și a avut poliomielită. Ea deține stupi, iar mierea o vinde în piața din localitate. Acum doi ani, ea a primit un scaun rulant cu tricicletă atașabilă. Mirela avea nevoie de dispozitive de suport postural și i-a fost prescrisă o pernă cu modificări, confecționată din mai multe straturi de spumă. Spătarului scaunului rulant i-a fost adăugată o inserție o Acțiunile necesare pentru schimbarea anvelopelor. o Furnizarea de informații legate de verificarea anvelopelor. o Stabilirea cauzei deplasării inserției posterioare pentru bazin. Repoziționarea și fixarea inserției. Verificarea modului în care aceasta oferă suport corespunzător. o Furnizarea de informații cu privire la Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 220. posterioară pentru bazin. La vizita de monitorizare, Mirella a spus că folosește scaunul rulant și tricicleta în fiecare zi pentru a se deplasa la piață și înapoi. Ea a menționat că recent a fost nevoită să repare două pene de roată. La verificarea scaunului rulant, personalul furnizorului de servicii de scaune rulante a observat că anvelopele erau foarte uzate. Inserția posterioară pentru bazin alunecase pe șezutul scaunului rulant și perna părea foarte plată. Când a fost întrebată despre gradul de satisfacție legat de scaunul rulant, Mirella a acordat nota 3 din 5. poziția corectă a inserției posterioare pentru bazin. Încurajați utilizatorul să verifice dacă aceasta este în poziția corectă. o Îndepărtarea husei pernei și verificarea stării straturilor de burete/spumă. Verificați dacă straturile de burete/spumă sunt compresate (plate). Dacă buretele/spuma s-au aplatizat, înlocuiți partea superioară cu un strat moale de burete/spumă. o Verificați dacă Mirella este susținută adecvat în scaunul rulant, inclusiv de către inserția posterioară pentru bazin și pernă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 221. Ursula are 6 ani și este diagnosticată cu paralizie cerebrală. Îi place să cânte în corul bisericii împreună cu sora ei. A primit scaunul rulant și dispozitivele de suport postural cu opt luni în urmă. A fost bolnavă din cauza unei infecții la nivelul toracelui și a lipsit de la prima programare de monitorizare. Părinții ei au spus că în ultimul timp Ursulei nu îi mai place să stea în scaunul rulant și cere să fie ridicată din el după o oră. Au observat o pată întunecată pe coaste, în zona de lângă una dintre inserțiile laterale pentru trunchi și se întrebau dacă aceasta ar putea fi cauza problemei. Personalul de servicii de scaune rulante a găsit un spațiu retras și i-au cerut Ursulei și părinților ei permisiunea de a-i verifica aspectul pielii. Astfel, s-a confirmat existența unei pete întunecate pe suprafața pielii. Au analizat scaunul rulant și au observat că stratul de spumă al inserției laterale pentru trunchi era comprimat. Când au fost întrebați despre gradul de satisfacție legat de scaunul rulant al Ursulei, părinții ei au acordat nota 4 din 5. o Recomandați evitarea exercitării de presiune pe rana de la nivelul coastelor până când dispare orice urmă de iritație. o Recomandați reducerea duratei de timp petrecută în scaunul rulant și mărirea acesteia doar după ce semnul a dispărut. o Înlocuirea buretelui/spumei din ambele inserții laterale pentru trunchi. Introduceți degetele în spațiul dintre inserțiile laterale pentru trunchi și corpul utilizatorului pentru a verifica nivelul de presiune și pentru a efectua ajustări, dacă este necesar. o Copiii au un ritm de creștere rapid și este necesară o monitorizare la intervale regulate, astfel încât să fie prevenită apariția problemelor posturale. Intervalul recomandat pentru efectuarea monitorizării este de 3-6 luni. 5. Recapitulare puncte cheie (5 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 222. Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea și probarea produsului (a scaunului rulant) și instruirea utilizatorului de scaun rulant. O B IE C TI V E La finalul acestei sesiuni, participanții vor putea: să demonstreze, lucrând în echipă, modalitatea de a efectua evaluarea, prescrierea (selecția), pregătirea și probarea produsului (a scaunului rulant) și instruirea utilizatorului de scaun rulant - nivel intermediar.. R E S U R S E Caietul de exerciții practice; Listă de verificare și observații pentru formator: Sesiunea practică 4; Formular de acord pentru fotografiere; Formulare de evaluare și de prescriere (selectare) – nivel intermediar Afiș: „Tabel dispozitive de sprijin postural (DSP)”; Afiș: „Listă de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar” Tabel dispozitive de sprijin postural (DSP), laminat – 1 pentru fiecare participant; Listă de verificare a pașilor pentru probarea produsului (a scaunului rulant) - nivel intermediar, laminat - 1 pentru fiecare participant. Listă de verificare a instruirii utilizatorului de scaun rulant - nivel intermediar, laminat - 1 pentru fiecare participant; spațiu pentru realizarea evaluării curat și retras, cu pat de evaluare și paravan, pentru fiecare utilizator de scaun rulant; bucăți de burete rigid/spumă rigidă – mostre pentru întregul grup; inserții unghiulare din burete rigid/spumă rigidă – mostre pentru întregul grup; Materiale DSP; Set DSP-uri: masă de lucru și seturi de instrumente – 1 pentru fiecare grup; modele de scaune rulante și perne (excepție fiind situația în care evaluarea are loc în comunitate); Aparat foto digital; metru sau șubler - 1 pentru fiecare grup, set de plăci pentru picioare - 1 pentru fiecare grup. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 223. C O N TE X T Ș I C U N O Ș TI N ȚE D O B Â N D IT E A N TE R IO R Adaptați conținutul acestei sesiuni astfel încât informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele: factori culturali – de exemplu, dacă pentru etapa evaluării, pot fi create grupe mixte, cu persoane de ambele sexe; atunci când participanții parcurg pașii etapei de probare a scaunului rulant, fiți atenți la aspectele culturale legate de contactul fizic; factori lingvistici – de exemplu, dacă utilizatorii de scaune rulante care participă și participanții vorbesc aceeași limbă; orice documentație de care are nevoie organizația-gazdă a cursului în vederea evaluării sau prescrierii unui scaun rulant - de exemplu, orice informații suplimentare necesare despre utilizatorul de scaun rulant care apelează la serviciile lor (de ex., surse de trimitere); modul în care formatorii vor administra problemele care pot apărea pe parcursul probării și care nu pot fi soluțonate în cadrul sesiunii sau al programului de instruire. De exemplu, scaunele rulante pregătite nu sunt pe măsură și nu pot fi ajustate (o posibilă soluție ar fi asigurarea existenței unor scaune rulante suplimentare de diferite dimensiuni mărimi, pentru a le înlocui); modalitatea de realizare a monitorizării pentru fiecare utilizator de scaun rulant, după finalizarea programului de instruire. D E P R E G Ă TI T Confirmați ora și detaliile legate de deplasarea utilizatorilor de scaune rulante voluntari. Asigurați-vă că există băuturi răcoritoare pentru utilizatorii de scaune rulante și membrii familiei/însoțitori. Desemnați o persoană care să întâmpine utilizatorii de scaune rulante și să le prezinte locul unde pot aștepta până la începerea sesiunii. Pregătiți un pat de evaluare cu paravan pentru fiecare grupă. Puneți toate echipamentele necesare evaluării pe patul de evaluare. Asigurați-vă că scaunele rulante și pernele sunt în stare bună de funcționare. Dacă sunt mai mult de trei grupe de participanți, solicitați asistență unui alt formator, pentru monitorizarea grupelor. Decideți care va fi componența echipelor și cu care dintre utilizatorii de scaun rulant va lucra fiecare dintre acestea. Înainte de începerea sesiunii practice, solicitați participanților să poarte încălțăminte care acoperă piciorul. Pregătiți un spațiu de lucru pentru fiecare grupă, dotat cu masă de lucru și set de instrumente și plasați materialele DSP pentru ca participanții să poată lucra cât mai eficient. Luați mostrele de DSP din setul DSP și poziționați-le pe o masă în fața sălii de curs, unde să aveți acces la ele să fie cât mi ușor. Plasați afișul „Tabelul de dispozitive de sprijin postural (DSP)”. Plasați afișul „Lista de verificare a instruirii utilizatorului de scaun rulant - nivel de bază”. P R E ZE N TA R E 1. Evaluarea, prescrierea (selecșia), pregătirea și probarea produsului (a scaunului rulant) și instruirea utilizatorului de scaun rulant o Instrucțiuni și organizare o Evaluarea o Prescrierea (selecția) o Pregătirea produsului (a scaunului rulant) o Probarea produsului (a scaunului rulant) o Instruirea utilizatorilor de scaun rulant 15 45 30 120 45 45 Durata totală a sesiunii 300 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 224. 1. Exersarea evaluării, prescrierii (selecției), pregătirii și probării produsului (a scaunului rulant) și a instruirii utilizatorului de scaun rulant (300 de minute) Note pentru formatori: 1. Fotografii: o Verificați dacă fiecărui utilizator de scaun rulant i-a fost solicitat acordul scris pentru în vederea realizării de fotografii. Asigurați-vă că utilizatorii de scaune rulante înțeleg faptul că permisiunea se acordă în mod voluntar și că fotografiile vor fi folosite pentru instruire, în cadrul acestui program. o Pe parcursul sesiunilor practice, faceți fotografii ale utilizatorilor de scaune rulante care și-au dat acordul, după cum urmează: o în scaunul rulant, dacă dețin unul (imagine frontală și laterală); o pe parcursul efectuării evaluării fizice (poziție de ședere fără suport). o în scaunul rulant prescris după probarea produsului (perspectivă frontală și laterală). 2. Satisfacerea cerințelor utilizatorilor de scaun rulant care participă la sesiunea practică o Nu toate scaunele rulante dotate cu DSP-uri pot fi finalizate în perioada de timp disponibilă în sesiunea practică. o Dacă este nevoie de o altă programare pentru oricare utilizator de scaun rulant care a participat la sesiunea practică, formatorul trebuie să se asigure că această programare este stabilită de organizația gazdă și că toate informațiile legate de evaluare, prescriere și probare a produsului (a scaunului rulant) ajung în posesia organizației gazdă, pentru finalizarea DSP-urilor/livrarea finală a scaunului rulant. 3. Observarea metodei de lucru a participanților: o Utilizați lista de verificare și observații pentru formatori din Sesiunea practică 3, pentru a vă asigura că grupele parcurg toți pașii sesiunii practice și pentru a nota exemple de bună practică. Activitate pentru grupe mici Grupe: o Împărțiți participanții în grupe de câte 2-3 participanți. o Desemnați câte un responsabil pentru fiecare grupă. o Comunicați fiecărei grupe numele utilizatorului de scaun rulant cu care vor lucra. o Alocați fiecărei grupe un loc pentru desfășurarea activității. o Explicați unde pot fi găsite materialele și instrumentele. o Indicați participanților unde pot găsi echipamentele necesare. Instrucțiuni: Explicați următoarele: Scopul sesiunii: o Scopul acestei sesiuni practice este efectuarea unei evaluări, prescrieri (selecții), parcurgerea pașilor specifici pregătirii produsului (a scaunului rulant), exersarea etapei de probare a produsului (a scaunului rulant) și de instruire a utilizatorului de scaun rulant. o Dacă pe parcursul acestui program de instruire nu este posibilă pregătirea în totalitate a scaunului rulant în vederea folosirii acestuia de către utilizator, se vor planifica acțiunile necesare pentru finalizarea acestuia. Totuși, participanții trebuie să încerce ca la finalul exercițiului scaunul rulant să fie pregătit într-o cât mai mare măsură. Responsabilul: o Responsabilul fiecărei grupe trebuie să se asigure că au fost parcurși toți pașii exercițiului. o Responsabilul va fi cel care comunică preponderent cu utilizatorul de scaun rulant și, în caz de necesitate, cu membrii familiei/însoțitorii, Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 225. pentru a evita crearea de confuzii. Observațiile și suportul oferit de formator: o Participanții pot cere asistență sau clarificări în orice moment, pe întreg parcursul exercițiului. o Pe durata sesiunii, formatorii vor monitoriza activitatea fiecărei grupe și vor oferi asistență, atât cât este necesar. o După parcurgerea FIECĂREI ETAPE A PROCESULUI DE FURNIZARE DE SERVICII de scaune rulante, participanții vor solicita prezența unui formator pentru a verifica rezultatele ÎNAINTE de a trece la următorul pas. Durata: o Participanții trebuie să parcurgă etapa de evaluare în 45 de minute, cea de prescriere (selecție) în 30 de minute, să parcurgă pașii pentru pregătirea produsului (a scaunului rulant) în 120 de minute, să realizeze probarea în 45 de minute, iar instruirea utilizatorului în 45 de minute) Reamintiți-le participanților faptul că utilizatorul de scaun rulant va avea nevoie de o pauză și de apă/răcoritoare în timp ce scaunul rulant este pregătit. Trebuie prevăzute pauzele de cafea/de prânz - formatorii vor relua informația cu privire la planificarea intervalelor de pauză. Formulare: o Înmânați fiecărui responsabil formularele de evaluare și de prescriere (selecție) a scaunului rulant - nivel intermediar. o Verificați ca fiecare grupă să dețină cel puțin un exemplar din lista de verificare a pașilor pentru probarea scaunului rulant și lista de verficare a instruirii utilizatorului de scaun rulant nivel intermediar (exemplare laminate). Cereți participanților să folosească lista de verificare preliminară utilizării produsului (a scaunului rulant) - nivel intermediar din Caietul de exerciții practice (Sesiunea practică 4: Evaluarea, prescrierea, pregătirea și probarea produsului) și instruirea utilizatorului de scaun rulant) pentru planificarea activităților ce trebuie efectuate. Cereți participanților să folosească lista de verificare a instruirii utilizatorului - nivel intermediar din Caietul de exerciții practice (Sesiunea practică 4: Evaluarea, prescrierea, pregătirea și probarea produsului) și instruirea utilizatorului de scaun rulant) pentru a verifica dacă scaunul rulant este pregătit pentru probare. Reamintiți-le participanților faptul că trebuie să implice în mod activ utilizatorul de scaun rulant, pe durata întregului procesului. Întrebați: Există întrebări? Răspundeți la orice întrebare. Cereți fiecărei grupe să pregătească zona în care va lucra; apoi să se prezinte utilizatorului de scaun rulant cu care vor lucra și să înceapă exercițiul. Monitorizare și suport: Monitorizați activitatea grupelor, asigurați-vă că sunt respectate regulile de siguranță, observați și evaluați abilitățile participanților. Folosiți lista de verificare și observații pentru formator pentru a nota observațiile legate de fiecare grupă de participanți. Pe parcursul sesiunii: o Informați participanții cu privire la durata de timp rămasă (verbal și/sau în scris pe tablă, pentru ca toți participanții să fie informați) pentru o mai Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 226. bună administrare a timpului alocat exercițiului. o Asigurați-vă că utilizatorii de scaune rulante sunt implicați în mod activ. o Asigurați-vă că fiecare membru al grupului este implicat în mod activ. La finalul acestei sesiuni, cereți participanților să mulțumească utilizatorului de scaun rulant pentru participarea sa și explicați că scaunul rulant prescris va fi pregătit acum și va fi disponibil pentru probă în cel mai scurt timp. Faceți fotografii utilizatorilor de scaun rulante care au semnat formularul de acord pentru fotografiere. Durata: Acordați 15 minute pentru instrucțiuni și pregătire, 45 de minute pentru finalizarea evaluării, 30 de minute pentru completarea prescrierii, 120 de minute pentru pregătirea produsului (a scaunului rulant), 45 de minute pentru probarea scaunului rulant și 45 de minute pentru instruirea utilizatorului. Monitorizați timpul cu ajutorul listei de verificare și observații pentru formator. Note pentru formatori: Pe parcursul sesiunilor practice, este important să monitorizați durata de timp. Intervalele menționate mai sus sunt orientative, ele vor varia în funcție de experiența participanților, nevoile utilizatorului de scaun rulant și perioada necesară pregătirilor. Durata de timp necesară parcurgerii acestei va fi adaptată contextului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 227. B.17: Feedback-ul instructorului, discuții, ceremonia de încheiere O B IE C TI V E La finalul acestei sesiuni, participanții vor putea: să tragă concluzii în ceea ce privește lucrul cu utilizatorul de scaun rulant pentru evaluarea, prescrierea, pregătirea și probarea unui scaun rulant care corespunde cerințelor fizice, de mediu și de stil de viață ale utilizatorului și pentru a-i oferi instruire corespunzătoare. R E S U R S E Pentru sesiune: slide-uri PPT: B.17: Feedback-ul formatorului, discuții, ceremonia de încheiere DVD: Mesaj pentru acasă; Fotografii ale utilizatorilor de scaun rulante (care au semnat formularul de acord pentru fotografiere) D E P R E G Ă TI T Pregătiți toate resursele, revedeți prezentarea PPT, vizionați materialul video și parcurgeți planul sesiunii. Asigurați-vă că certificatele sunt listate și semnate de formatori. Luați în considerare invitarea unor persoane interesate de subiect (de exemplu, donatori, organizații pentru persoane cu dizabilități, furnizori de servicii, miniștri) pentru a participa la ceremonia de încheiere și pentru prezentarea certificatelor. Asigurați-vă că fotografiile utilizatorilor de scaune rulante au fost salvate în calculatorul programului de instruire, într-un fișier denumit cu numele lor. P R E ZE N TA R E 1. Introducere 2. Feedback-ul instructorului. 3. Discuții despre utilizatorii de scaune rulante din Sesiunea practică 4. 4. Ceremonia de încheiere și prezentarea certificatelor. 2 20 30 8 Durata totală a sesiunii 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 228. 1. Introducere (2 minute) Explicați: o În această sesiune, participanții vor avea ocazia: o să afle mai multe detalii despre utilizatorii de scaune rulante cu care au lucrat celelalte grupe în ultima sesiune practică și despre soluțiile de scaune rulante prescrise, pregătite și probate de către aceștia; o să primească feedback-ul general despre exemplele de bună practică observate de formatori în ultima sesiune practică și să învețe din eventualele greșeli; o să adreseze întrebări. 2. Feedback-ul formatorului (20 de minute) Folosiți lista de verificare și observații pentru formatori din Sesiunea practică 4, discutați cu participanții exemplele de bună practică pe care le-ați observat pe parcursul acesteia. Menționați aspectele care au nevoie de îmbunătățiri, fără a numi persoane. Întrebați: Există întrebări? 3. Discuții despre utilizatorii de scaune rulante din Sesiunea practică 4 (30 de minute) Note pentru formatori: o Durata alocată va depinde de numărul punctelor de discuție. Adaptați intervalul de timp, prioritară fiind furnizarea unui feedback corespunzător. Cereți fiecărei grupe să prezinte, pe rând: o rezumatul cerințelor legate de abilitățile mobilitate și de suport pe care le-au identificat pe parcursul sesiunii practice; o soluțiile identificate și prescrise (selectate); o modul de pregătire a produsului (a scaunului rulant); o procesul de probare a produsului (a scaunului rulant) și problemele apărute; o comentarii despre modul în care utilizatorul a primit scaunul rulant și despre instruirea oferită acestuia. Încurajați întregul grup să pună întrebări, la finalul prezentării: o sugerați ca pe parcursul prezentării, participanții să noteze întrebările pe care doresc să le adreseze la finalul fiecărei prezentări; o încurajați participanții să analizeze deciziile și abordările echipei care face prezentarea. În mod ideal, acest lucru va genera discuții, dezbateri și o analiză mai atentă. Alocați 5 minute pentru fiecare prezentare și 5 minute pentru întrebări (în funcție de numărul de grupe). Prezentați fotografii ale fiecărui utilizator de scaun rulant, pentru a ajuta grupul în ilustrarea punctelor discutate (în cazul în care s-au realizat fotografii pe parcursul sesiunii practice). La finalul fiecărei prezentări: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 229. o Subliniați exemplele de bună practică utilizate de grup (vezi Sesiunea practică 4: Lista de verificare și observații pentru formatori). o Mulțumiți fiecărui grup pentru prezentare. La finalul tuturor prezentărilor: Reamintiți-le participanților că, de multe ori, există mai multe soluții corecte. Uneori, cea mai bună soluție poate fi un compromis - pentru a răspunde cât mai bine cerințelor și așteptărilor utilizatorului de scaun rulant, folosind cât mai eficient resursele disponibile. Note pentru formatori: o Întrebările sunt pentru a ridica nivelul de încredere în deciziile luate, nu pentru a sugera că s-a greșit. o Întrebările și provocările trebuie adresate într-o manieră pozitivă. 4. Ceremonia de încheiere și înmânarea certificatelor (8 minute) Pregătiți vizionarea materialului video: Mesaj pentru participanți; Prezentați materialul video. Note pentru formatori: o Formatorii pot alege modalitatea în care vor fi prezentate certificatele și în care se va încheia programul de instruire. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 230. Anexe Anexa 1 : Orar de desfășurare a cursurilor Ziua 1 Ziua 2 Ziua 3 Ziua 4 Ziua 5 8:30 Introducere B.4 Evaluarea fizică – procedeul de simulare manuală B.10 Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea trunchiului B.13 Probarea produsului (a scaunului rulant) B.16 Întreținerea, reparațiile și monitorizarea 08:45 09:00 09:15 B.11 Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea capului, coapselor și a gambelor 09:30 A.1 Utilizatorii de scaun rulant care necesită suport postural suplimentar B.5 Evaluarea fizică – efectuarea măsurătorilor B.14 Instruirea utilizatorului Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului 09:45 10:00 10:15 10:30 A.2 Copiii cu dizabilități B.6 Selecția scaunului rulant și a pernei Perioadă alocată verificării de către formator si de către participanți a materialelor, înainte de sosirea utilizatorilor de scaun rulant. 10:45 11:00 11:00 – 11:15: Pauză de cafea (adaptați ora pentru a se potrivi cu contextul local și cu planul sesiunii) 11:00 – 11:15: Pauză de cafea (adaptați ora pentru a se potrivi cu contextul local și cu planul sesiunii) 11:15 A.2 Copiii cu dizabilități B.6 Selecția scaunului rulant și a pernei 11:15 – 11:30 Pauză de cafea Sesiunea practică 3: Probarea produsului (a scaunului rulant) și instruirea utilizatorului Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului 11:30 Sesiunea practică 1: Evaluarea și prescrierea (selecția) 11:45 B. Trimiterea și programarea B.1 Prezentarea etapei de evaluare și interviul de evaluare B.7 Prescrierea (selecția) dispozitivelor de suport postural - introducere 12:00 12:15 B.8 Prescrierea (selecția) dispozitivelor de suport postural petru stabilizarea bazinului 12:30 12:45 1:00 – 2:00 Prânz (adaptați ora pentru a se potrivi cu contextul local și cu planul sesiunii) 02:00 B. Trimiterea și programarea B.1 Prezentarea etapei de evaluare și interviul de evaluare B.8 Prescrierea (selecția) dispozitivelor de suport postural - stabilizarea bazinului Sesiunea practică 1: Evaluarea și prescrierea (selecția) Sesiunea practică 3: Probarea produsului (a scaunului rulant) și instruirea utilizatorului Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului 02:15 B.2 Evaluarea fizică - poziția de ședere fără suport 02:30 B.12 Pregătirea produsului (a scaunului rulant) 02:45 B.9 Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea șoldurilor B.15 Sumarizare 03:00 03:15 03:15 – 03:30: Pauză de cafea (adaptați ora pentru a se potrivi cu contextul local și cu planul sesiunii) 03:15 – 03:30: Pauză de cafea (adaptați ora pentru a se potrivi cu contextul local și cu planul sesiunii) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 231. 03:30 B.2 Evaluarea fizică - poziția de ședere fără suport B.9 Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea șoldurilor 3:30 – 3:45 Pauză de cafea B.15 Recapitulare Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului 03:45 B.10 Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea trunchiului Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) 04:00 B.3 Evaluare fizică - analiza poziției bazinului și a șoldurilor B.17 Feedback oferit de formatori, discuții, ceremonia de încheiere 04:15 04:30 04:45 05:00 05:15 05:30 05:45 06:00 Formatorii/organizațiile care susțin cursul pot modifica programul după cum este necesar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 232. Anexa 2 : Formular de trimitere către furnizorul de servicii de scaune rulante – nivel intermediar Model formular de trimitere: Acest formular poate fi adaptat de către furnizorul de servicii de scaune rulante și transmis celor care pot direcționa utilizatorii de scaun rulant către furnizorul de servicii de scaune rulante. Vă rugăm completați formularul de trimitere și expediați-l către: Numele și adresa serviciului de scaune rulante: Numele persoanei care face trimiterea: Organizația pentru care lucrați: Datele de contact ale persoanei care face referirea (unde puteți fi contactat cel mai ușor): Numele utilizatorului de scaun rulant: Data nașterii: Numele părintelui / însoțitorului: Adresa: Cum poate fi contactat utilizatorul de scaun rulant? Poștă Telefon propriu Telefon prieten / vecin Dacă telefonic, care este numărul de telefon: Dizabilitatea utilizatorului de scaun rulant, dacă este cunoscută: Motivele trimiterii: Nu deține scaun rulant Deține un scaun rulant defect Deține un scaun rulant necorespunzător În cazul copiilor: o incapacitatea de a menține poziția așezat sau de a sta în picioare înainte vârsta de un an; o incapacitatea de a merge înainte de vârsta de doi ani. Vă rugăm precizați orice altă informație despre utilizator, pe care o considerați relevantă pentru furnizorul de servicii de scaune rulante: Utilizatorul este de acord să fie direcționat către furnizorul de servicii de scaune rulante? Da Nu Semnătura persoanei care face trimiterea: Data: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 233. Anexa 3 : Formular de evaluare a utilizatorului de scaun rulant – nivel intermediar Formular pentru evaluarea utilizatorilor de scaun rulant care nu pot menține cu ușurință poziția așezat fără suport.Utilizatorii de scaun rulant care pot menține poziția așezat pot fi evaluați de către o persoană care a parcurs modulul de instruire pentru nivelul de bază.Păstrați acest formular în dosarul utilizatorului de scaun rulant. Numele persoanei care efectuează evaluarea: Data efectuării evaluării 1 Interviul de evaluare Informații despre utilizatorul de scaun rulant; Numele: Numărul: Vârsta: Bărbat Femeie Numărul de telefon: Adresa: Obiective:______________________________________________________________________ Condiția fizică; Diagnostic: Traumatism cranio-cerebral Paralizie cerebrală Distrofie musculară Poliomielită Spina bifida Traumatism vertebro-medular Accident vascular cerebral Necunoscut Altele ___________________________ Există posibilitatea ca situația să se înrăutățească? Da Nu Condiția fizică: Constituție fragilă Spasme sau mișcări necontrolate Tonus muscular (hipertonie/hipotonie) Amputație membru inferior: D de deasupra genunchiului D de sub genunchi S de deasupra genunchiului S de sub genunchi Oboseală Luxație de șold Epilepsie Probleme de deglutiție Descrieți: _____________________ Durere Descrieți: _________________________________________________________ Probleme de management urinar Probleme de management intestinal Dacă există probleme de management urinar sau de tranzit intestinal, acestea sunt gestionate? Da Nu Stilul de viață și mediul Descrieți mediul în care va fi utilizat scaunul rulant: ____________________________ Distanța zilnică parcursă: Până la 1 km 1–5 km Mai mult de 5 km Durata zilnică de utilizare a scaunului rulant: Mai puțin de 1 oră 1–3 ore .3–5 ore 5–8 ore mai mult de 8 ore Care este poziția utilizatorul atunci când nu folosește scaunul rulant (poziția și tipul de suprafață)? ______________________________________________________________________ Transfer: Independent Asistat În picioare Așezat Ridicat Altele Tipul de toaletă (dacă se face transferul la toaletă): La nivelul solului Tipică Adaptată Utilizatorul de scaun rulant folosește în mod frecvent mijloace de transportul în comun/proprii? Da Nu Dacă da, de care: Autoturism Taxi Autobuz Altele __________________ Scaun rulant existent (dacă persoana are deja un scaun rulant) Scaunul rulant corespunde cerințelor utilizatorului? Da Nu Scaunul rulant corespunde condițiilor din mediul utilizatorului? Da Nu Este scaunul rulant potrivit și oferă suport postural corespunzător? Da Nu Este scaunul rulant sigur și durabil? (Există sau nu o pernă?) Da Nu Perna oferă o reducere a presiunii adecvată (previne riscul apariției escarelor)? Da Nu Comentarii: _____________________________________________________________________ Dacă răspunsul este ”da” la toate întrebările, atunci este posibil ca utilizatorul să nu aibă nevoie de alt scaun rulant. Dacă răspunsul la oricare din aceste întrebări este ”nu”, atunci utilizatorul are nevoie fie de un alt scaun rulant, fie de o altă pernă ori scaunul rulant sau perna au nevoie de reparații, respectiv de modificări. 2 Evaluarea fizică Prezența escarelor, riscul de formare a acestora sau istoricul escarelor /// = lipsă sensibilitate O = escară anterioară = escară existentă Sensibilitate normală? Da Nu Escară anterioară? Da Nu Escară existentă? Da Nu Dacă da, este o escară deschisă (fază 1 - 4)? Da Nu Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 234. Durata și cauza: _________________________ _________________________________________ Există riscul* formării de escare? *Se consideră că există riscul apariției escarelor la persoanele la care sensibilitatea este absentă ori la care sunt prezente 3 sau mai mulți factori de risc. Factori de risc: imobilitatea, umezeala, poziția incorectă, escară anterioară/existentă, regim alimentar neadecvat, înaintarea în vârstă, supraponderabilitatea sau subponderabilitatea. Da Nu Metode de realizare a propulsiei Cum va efectua utilizatorul propulsia scaunului rulant? Cu ambele membre superioate Cu membrul superior stâng Cu membrul superior drept Cu ambele membre inferioare Cu membrul inferior stâng Cu membrul inferior drept Cu ajutorul unui însoțitor Comentarii: _____________________________________________________________________ Postura corpului în poziția așezat fără suport Analiza poziției bazinului și a șoldurilor Descrieți sau desenați postura corpului în poziția așezat fără suport. Verificați dacă bazinul este în echilibru, precum și gradul de flexie al șoldului atunci când utilizatorul este în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Șoldul drept: Da Nu Unghi: _______ Șoldul stâng: Da Nu Unghi: ______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Pentru fiecare parte a corpului: Dacă este posibilă atingerea poziției neutre de ședere cu ajutorul suportului manual, bifați „da”. În caz contrar, bifați „nu”. Partea corpului Da Nu Descrieți sau schițați postura în poziția așezat finală a utilizatorului de scaun rulant, realizată cu suport manual și descrieți sau schițați suportul oferit pentru obținerea respectivei poziții de ședere. Bazin Trunchi Cap Șold S Șold D Coapse Genunchi S Genunchi D Gleznă S Gleznă D Efectuarea măsurătorilor Măsurători corp (mm) Măsurători componente scaun rulant (mm) Lățimea și adâncimea suprafeței de ședere, înălțimea suportului de picioare A Lățime șold = lățime suprafață de ședere SAU 1 = distanța dintre inserțiile laterale pentru bazin 2 B Adâncime șezut (partea S B minus 30-50 mm = adâncimea șezutului scaunului 3 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 235. posterioară a bazinului până la partea posterioară a genunchiului) D rulant (dacă lungimea este diferită, folosiți valoarea mai mică) C Lungime gambă S = distanța dintre partea superioară a suprafeței de ședere și suportul de picioare SAU = distanța dintre partea superioară a șezutului scaunului rulant și sol, în cazul propulsiei cu ajutorul membrelor inferioare 4 D 5 Înălțimea spătarului D Distanța dintre șezut* și limita inferioară a cutiei toracice = distanța dintre partea superioară a suprafeței de ședere și limita superioară a spătarului (măsurați D, E sau F - în funcție de cerințele specifice utilizatorului) 6 E Distanța dintre șezut* și limita inferioară a omoplatului F Distanța dintre șezut* și limita superioară a umărului Modificările și/sau dispozitivele de sprijin postural G Lățime trunchi = distanța dintre inserțiile laterale/inserțiile unghiulare laterale pentru trunchi 7 H Distanța dintre șezut* și axilă S H minus 30 mm = distanța maximă dintre partea superioară a suprafeței de ședere și partea superioară a inserțiilor laterale/inserțiilor unghiulare laterale (ajustare în funcție de procedeul de simulare manuală) 8 D I Distanța dintre șezut* și partea superioară a bazinului (creasta iliacă postero- superioară) = distanța dintre partea superioară a suprafeței de ședere și jumătatea înălțimii inserției posterioare pentru bazin 9 J Distanța dintre genunchi = lățimea inserției/dispozitivului pentru separarea genunchilor 10 K Distanța dintre șezut* și baza craniului (occiput) = distanța dintre partea superioară a suprafeței de ședere și linia de mijloc a tetierei 11 S Distanța dintre partea posterioară a bazinului și oasele bazinului L plus 20–40 mm = distanța dintre spătar și linia de început a inserției anterioare oaselor bazinului. 12 A lte le *La efectuarea măsurătorilor corpului, „șezutul” reprezintă suprafața ocupată de oasele bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 236. Anexa 4 : Formular de prescriere (selecție) a scaunului rulant – nivel intermediar Acest formular se utilizează pentru înregistrarea informațiilor referitoare la tipul de scaun rulant, pernă și dispozitiv de sprijin postural pentru utilizatorii de scaun rulant care nu pot menține fără sprijin poziția așezat. Păstrați acest formular în dosarul utilizatorului de scaun rulant. 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data evaluării: Data probării produsului (a scaunului rulant): Numele persoanei care efectuează evaluarea: 2. Tipul, dimensiunea și configurația scaunului rulant Tipul scaunului rulant (notați mai jos tipurile de scaune rulante disponibile) Dimensiunile scaunului rulant (mm) Lățimea suprafeței de ședere Adâncimea suprafeței de ședere Înălțimea spătarului Înălțimea suportului de picioare Configurația scaunului rulant Poziția roții din spate Altele: Unghiul de înclinare Tipul și mărimea pernei Tipul de pernă Dimensiunea E.g. pernă pentru reducerea presiunii 4. Dispozitivele de suport postural sau modificările necesare Listă de verificare a dispozitivelor de suport postural Descrieți / desenați și notați dimensiunile S up ra fa ța d e șe de re / pe rn a Adăugare suprafață de ședere solidă Inserție anterioară oaselor bazinului (3 - 12) Inserție pentru reglarea unghiului de înclinare a bazinului S D Înălțarea suprafeței de ședere inserție prin anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 237. Inserții pentru stabilizarea bazinului S D Inserții laterale pentru bazin (=2) S D Inserții unghiulare exterioare pentru coapse S D Inserții exterioare pentru coapse S D Inserție interioară pentru coapse (= 10) Inserție pentru separarea genunchilor (= 10) Altele Altele Listă de verificare a dispozitivelor de suport postural Descrieți / desenați și notați dimensiunile S up ra fa ța d e șe de re ș i sp ăt ar ul Deschidere unghi suprafață de ședere - spătar Unghi de înclinare suprafață de ședere - spătar (înclinarea în spațiu) S pă ta ru l Adăugare spătar solid Inserție posterioară pentru bazin Spătar cu formă ajustabilă Spătar cu tensiunie ajustabilă Spătar cu unghi de înclinare ajustabil Inserții laterale pentru trunchi (= 7) S D Inserții unghiulare laterale pentru trunchi (= 7) S D Altele M ăs uț a / su po rtu ril e de b ra țe Măsuță Modificarea suporturilor de brațe S D Altele Te tie re le Tetieră plată (= 11) Tetieră conturată (= 11) Altele S up or tu ril e de pi ci oa re Inserții plane pentru suportul de picioare S D Inserții unghiulare pentru suportul de picioare S D Dispozitive de sprijin pentru gambă S D Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 238. Altele C en tu ril e Centură pentru bazin Centură pentru gambe Centuri pentru picior S D Ham pentru umeri Altele 5. Acordul Semnătură utilizator de scaun rulant: Semnătură evaluator: Semnătură manager furnizor servicii de scaune rulante Anexa 5 : Formular de date tehnice ale scaunului rulant – nivel intermediar Denumire scaun rulant: Inserați imagine aici: Producător / Furnizor: Dimensiuni disponibile: Greutate totală: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 239. Descriere: Cadru: Fix/rigid Pliabil Lungime cadru Spătar Pliabil/material textil Rigid Tensiune ajustabilă Suprafață de ședere Pliabil/ material textil Rigid Tensiune ajustabilă Pernă: Fără pernă Plată, din spumă/burete Cu contur, din spumă/burete, Fluid Altele Suporturi de picioare: Fixe Detașabile / pliabile pe lateral Altele: Roți frontale: Pneumatice Diametru: Solide Lățime: Roți din spate Pneumatice Diametru: Inele antrenare Solide Lățime: Ax reglabil Tub interior solid Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Suporturi pentru brațe: Curbate Pătrate Altele: Fixe Detașabile Altele: Mânere: Mânere: Dispozitive de suport postural: Centură pentru bazin Centură pentru gambe Ham pentru umeri Centuri pentru picioare Bară anti-răsturnare Inserții laterale pentru trunchi Măsuță Tetieră Inserții laterale pentru bazin Altele: Măsurători, opțiuni de modificări și gama de ajustări: Măsurători (dacă scaunul rulant este disponibil în mai multe mărimi, specificați toate mărimile) Este ajustabil? Gamă de ajustări (gama de ajustări ce pot fi făcute pentru acest scaun) Da Nu Lățime suprafață de ședere Adâncime suprafață de ședere Înălțime suprafață de ședere Înălțime spătar Unghi înclinare spătar Înălțime suport de picioare Unghi înclinare suport de picioare Înălțime mânere Lungime cadru Lungime bază roți Unghi spătar – suprafață de ședere Unghi înclinare în spațiu Anexa 6: Listă de verificare preliminară utilizării scaunului rulant – nivel intermediar Scaunul rulant în ansamblu, incluzând dispozitivele de suport postural Nu există margini ascuțite Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 240. Dispozitivele de suport postural sunt bine căptușite și fixate corespunzător Nu există părți defecte sau zgâriate Traiectoria scaunului rulant este dreaptă Roțile frontale Se învârt fără a întâmpina vreo rezistență Se învârt fără a atinge furca roții Șuruburile sunt strânse Furcile roților frontale Furca roții frontale se învârte fără a întâmpina vreo rezistență. Roțile din spate Se învârt fără a întâmpina vreo rezistență Șuruburile axului sunt strânse Anvelopele sunt umflate în mod corect (la presiunea aplicată cu un deget, anvelopele se deformează mai puțin de 5 mm) Inelele de antrenare nu prezintă niciun pericol Frânele Funcționează corespunzător Suporturile de picioare Suporturile de picioare sunt montate corespunzător Cadrul Scaunul rulant se pliază și de depliază cu ușurință În cazul unui scaun rulant cu spătar pliabil - spătarul se pliază și revine în poziția inițială cu ușurință Perna Perna este introdusă corect în husă Perna este poziționată corect în scaunul rulant Materialul textil al pernei este întins, dar nu mai mult decât este necesar. Dacă scaunul rulant are o suprafață de ședere rigidă: perna acoperă în întregime suprafața de ședere Anexa 7: Listă de verificare a pașilor pentru probarea produsului (a scaunului rulant) – nivel intermediar 1. Este scaunul rulant pregătit? Scaunul rulant a fost verificat în ceea ce privește siguranța utilizării sale și funcționarea tuturor componentelor? 2. Verificați dimensiunea scaunului rulant și a dispozitivelor de suport postural. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 241. Lățimea scaunului rulant: o coapsele sunt poziționate confortabil între suporturile de brațe sau între inserțiile laterale pentru bazin; o trunchiul este poziționat confortabil între barele verticale ale cadrului spătarului sau între inserțiile laterale pentru trunchi; o coapsele sunt poziționate confortabil între suporturile de brațe, apărătoarele laterale sau inserțiile laterale pentru bazin, iar asupra lor nu se exercită presiune. Adâncimea suprafeței de ședere: o distanță de 30 mm între partea posterioară a genunchilor (zona poplitee) și suprafața de ședere/pernă. Bazinul: o inserția anterioară oaselor bazinului este poziționată chiar în fața acestora; o inserția posterioară pentru bazin oferă suport la nivelul crestei iliace postero- superioare; o inserțiile laterale pentru bazin au dimensiunea potrivită și sunt localizate deasupra articulației șoldurilor; o centura pentru bazin poate fi închisă și nu afectează suprafața pielii. Trunchiul: o inserțiile laterale pentru trunchi nu exercită presiune la nivelul axilelor. Există o distanță de cel puțin 30 mm între axile și limita superioară a inserției laterale pentru trunchi; o hamul pentru umeri poate fi închis fără a produce disconfort și nu afectează suprafața pielii; o măsuța susține lungimea antebrațelor și coatele și nu exercită presiune asupra abdomenului; o verificați înălțimea și unghiul de înclinare al spătarului. Tetiera: o tetiera susține capul utilizatorului de scaun rulant la baza craniului (occiput). o menține capul drept, într-o poziție echilibrată. Coapsele: o inserțiile exterioare pentru coapse sau inserția/dispozitivul pentru separarea genunchilor nu exercită presiune asupra coapselor; o distanța dintre inserția/dispozitivul pentru separarea genunchilor și zona inghinală trebuie să fie de 40-60 mm la copii și 60-100 mm la adulți. Înălțimea suportului de picioare: o coapsele sunt sprijinite în totalitate pe pernă, fără a se ridica. Piciorul este sprijinit în totalitate pe suportul de picioare, fără a se ridica; o centura pentru picior poate fi legată adecvat, fără a afecta suprafața pielii; o centura pentru gambe și centura pentru călcâie susțin gamba și picioarele. 3. Verificați postura Verificați din față și din lateral dacă bazinul utilizatorului de scaun rulant este situat cât mai aproape de poziția neutră de ședere, fără a produce disconfort. o Bazinul este drept și se află în echilibru (sau cât mai aproape posibil de postura corectă, în limita confortului utilizatorului). o Trunchiul este drept și simetric (sau cât mai aproape posibil de postura corectă, în limita confortului utilizatorului). o Capul este drept și într-o poziție de echilibru (în limita posibilităților). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 242. o Membrele inferioare și tălpile se află cât mai aproape de postura specifică poziției neutre. Verificați dacă toate dispozitivele de suport postural oferă sprijinul necesar. Verificați în mod special (dacă este posibil): o Înălțimea, unghiul de înclinare și contururile spătarului o Înclinarea în spațiu o Inserțiile laterale pentru bazin și inserțiile laterale pentru trunchi o Inserțiile unghiulare interioare și exterioare pentru coapse, inserțiile exterioare pentru coapse și dispozitivele de sprijin pentru gambă Verificați postura încă o dată, după 15 minute, pentru a vedea dacă au intervenit schimbări. 4. Verificați presiunea Verificați presiunea sub ambele părți ale oaselor bazinului utilizatorului de scaun rulant. Nivelul de presiune este sigur pe ambele părți? Nivel 1 = sigur: Vârfurile degetelor se pot mișca în sus și în jos 5 mm sau chiar mai mult. Nivel 2 = avertizare: Vârfurile degetelor nu se pot mișca, dar pot fi retrase cu ușurință. Nivel 3 = pericol: Degetele sunt strânse cu putere. Este dificilă retragerea degetelor. Poziționați degetele între corpul utilizatorului de scaun rulant și fiecare dispozitiv de suport postural, incluzând pernele și centurile. Presiunea în zona de contact dintre dispozitivul de suport postural și corpul utilizatorului este distribuită egal? Nivelul de presiune constituie un risc? Dacă utilizatorul de scaun rulant are proeminențe osoase, umflături sau lovituri, verificați dacă se exercită presiune asupra acestor zone. 5. Verificați scaunul rulant în timp ce acesta se află în mișcare Spătarul oferă suficientă libertate de mișcare la nivelul umerilor pentru ca utilizatorul să poată realiza propulsia? Mișcarea scaunului rulant sau activitatea de propulsie a acestuia cauzează schimbarea posturii utilizatorului, creează stare de disconfort sau lipsă de stabilitate? Propulsia cu ajutorul membrelor superioare: Roțile din spate sunt poziționate corect pentru ca utilizatorul de scaun rulant să poată realiza cât poate bine propulsia? Propulsia cu ajutorul membrelor inferioare: Înălțimea și adâncimea șezutului scaunului rulant sunt corespunzătoare, pentru ca utilizatorul de scaun rulant să poată realiza propulsia cu membrul inferior/membrele inferioare? Dispozitivele de suport postural permit manevrarea scaunului rulant fără restricții și în condiții de siguranță? 6. Decideți dacă sunt necesare intervenții suplimentare Sunt necesare intervenții suplimentare? Notați orice intervenție în dosarul utilizatorului de scaun rulant. Anexa 8: Listă de verificare a instruirii utilizatorului de scaun rulant – nivel intermediar Abilități de învățat Abilități învățate Comentarii Manevrarea scaunului rulant Plierea și ridicarea scaunului rulant Demontarea și montarea oricărui dispozitiv de suport postural care trebuie îndepărtat în vederea efectuării transportului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 243. Utilizarea roților cu sistem de decuplare rapidă Utilizarea frânelor Unghiul de înclinare și bara anti-răsturnare (dacă se folosește) Poziția corectă a dispozitivelor de suport postural atunci când utilizatorul folosește scaunul rulant Utilizarea pernei, inclusiv poziționarea corectă Transferuri Transfer independent Transfer asistat Altele Utilizarea și manevrarea scaunului rulant Propulsia corectă (utilizarea metodei de propulsie preferate a utilizatorului de scaun rulant) Urcarea și coborârea unei pante Urcarea și coborârea unei trepte Deplasarea pe teren accidentat Ridicarea în echilibru pe două roți Durata petrecută în scaunul rulant (pentru copii și adulți care au nevoie de suport postural suplimentar) Propulsia asistată Prevenirea apariției escarelor Verificarea zonelor asupra cărora se exercită o presiune crescută Tehnici pentru reducerea presiunii Alimentație și hidratare corespunzătoare Ce trebuie făcut în cazul apariției unei escare Întreținerea la domiciliu a scaunului rulant Curățarea scaunului rulant; spălarea și uscarea pernei și a husei Lubrifierea părților mobile Umflarea anvelopelor Strângerea șuruburilor și a piulițelor Strângerea spițelor Verificarea părților textile Verificarea existenței petelor de rugină Verificarea pernei Cum se procedează în cazul apariției unei probleme Scaunul rulant necesită reparații Scaunul rulant nu este corespunzător sau nu este confortabil Anexa 9: Formular de monitorizare a utilizării scaunului rulant 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data probării produsului (a scaunului rulant): Data efectuării monitorizării: Numele persoanei care efectuează monitorizarea: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 244. Monitorizarea a avut loc la: Domiciliul utilizatorului Centrul de reparații scaune rulante Altă locație: _________________________________________ 2. Interviu Notați activitatea recomandată: Utilizați scaunul rulant atât de frecvent precum vă doriți? Da Nu Dacă nu - de ce nu? Întâmpinați vreo dificultate în utilizarea scaunului dvs. rulant? Da Nu Dacă da - care sunt aceste dificultăți? Aveți întrebări în ceea ce privește utilizarea scaunului rulant? Da Nu Dacă da - care sunt acestea? Este nevoie de instruire suplimentară? Utilizatorul de scaun rulant prezintă escare? Da Nu Descrieți (localizarea și gravitatea) Cum ați nota, pe o scală de la 1 la 5, gradul de satisfacție oferit de scaunul dvs. rulant? (1 - deloc satisfăcut și 5 foarte satisfăcut) Notă: Comentarii: 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în siguranță? Da Nu Perna este în stare bună și poate fi utilizată în siguranță? Da Nu Dacă răspunsul la oricare dintre întrebările de mai sus este „nu”, vă rugăm să precizați problema. 4. Verificare ajustări Scaunul rulant se potrivește? Da Nu Dacă nu - care sunt problemele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = nesigur) (dacă există riscul apariției escare ) Stânga: Dreapta: Utilizatorul are o poziție confortabilă în scaunul rulant atunci când stă pe loc, când se deplasează și pe întreg parcursul zilei? Da Nu Dacă nu - care sunt problemele? Anexa 10: Tabel dispozitive de suport postural (DSP) Suprafața de ședere/ pernă Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 245. Inserție anterioară oaselor bazinului Inserție pentru reglarea unghiului de înclinare a bazinului (unilateral) Înălțarea suprafeței de ședere prin inserție anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Inserții pentru stabilizarea bazinului Inserții laterale pentru bazin Suprafața de ședere / pern Suprafața de ședere și spătarul Inserții unghiulare exterioare pentru coapse Inserții exterioare pentru coapse Inserție unghiulară interioară pentru coapse Inserție pentru separarea genunchilor Deschiderea unghiului dintre șezut și spătar Unghiul de înclinare dintre șezutul scaunului rulant și spătar (înclinarea în spațiu) Spătarul Inserție posterioară pentru bazin Spătar cu formă ajustabilă Spătar cu tensiune ajustabilă Spătar cu unghi de înclinare ajustabil Inserții laterale pentru trunchi Inserții unghiulare laterale pentru trunchi Măsuța Tetierele Suporturile pentru gambe Măsuță Tetieră plată Tetieră conturată Inserții plane pentru suportul de picioare Inserții unghiulare pentru suportul de picioare Dispozitiv de sprijin pentru gambă Centurile Centură pentru bazin Centură în patru puncte pentru prevenirea înclinării anterioare Centură pentru gambe Centură pentru picioare Ham pentru umeri Anexa 11: Inserții unghiulare din burete solid/spumă solidă Inserțiile temporare din burete solid/spumă solidă pot fi folosite ca suporturi provizorii, fie individual, fie combinate, pentru a forma un unghi mai ascuțit. Dimensiunile din imaginea de mai jos sunt 30 mm x 150 mm x 200 mm. Inserțiile unghiulare cu dimensiuni mai mari sau mai mici decât cele menționate se pot dovedi și ele utile. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 246. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 247. Anexa 12: Lista utilizatorilor de scaun rulant pentru desfășurarea sesiunilor practice Utilizați această listă de verificare pentru organizarea și planificarea părții practice desfășurate cu ajutorul voluntarilor utilizatori de scaun rulant. Rețineți că utilizatorii de scaun rulant trebuie să participe întotdeauna în mod voluntar. În măsura în care este posibil, voluntarii pot fi răsplătiți pentru timpul investit de ei. Utilizați lista de verificare din manualul formatorului pentru a identifica utilizatorii de scaun rulant. Sesiune practică Data și ora Numele utilizatorului de scaun rulant Sex Vârsta Dizabilitate/cerințe de mobilitate și sprijin postural. Invitat Confirmat Transport asigurat M F Sesiune practică 1 Sesiune practică 2 Sesiune practică 3 Sesiune practică 4 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire: nivel intermediar: Pagina 248.
SERVICII PENTRU UTILIZATORII DE SCAUN RULANT CAIET DE EXERCIȚII PRAC TICE PACHET DE INSTRUIRE - NIVEL INTERMEDIAR
SERVICII PENTRU UTILIZATORII DE SCAUN RULANT CAIET DE EXERCIȚII PRAC TICE PACHET DE INSTRUIRE - NIVEL INTERMEDIAR Publicat de Organizația Mondială a Sănătății în 2013, cu titlul Wheelchair Service Training Package: intermediate level. Participant’s Workbook ©World Health Organization 2013 Directorul General al Organizației Mondiale a Sănătății a acordat dreptul de a traduce și de a publica ediția în limba română Fundației Motivation România, care este singura responsabilă pentru ediția în limba română. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice 1. Scaune rulante – standarde. 2. Persoane cu dizabilități – reabilitare. 3. Material pedagogic. I. Khasnabis, Chapal. II. Mines, Kylie. III. Organizația Mondială a Sănătății. Editori: Chapal Khasnabis și Kylie Mines Autori: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler și Rebecca Jackson Stoeckle Revizuit de: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri; Ritu; Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan și Diane E. Ward. Ilustrații: Melissa Puust Foto: David Constantine, Jesse Moss și Chapal Khasnabis Video: Chapal Khasnabis, Amanda McBaine și Jesse Moss Formatori: Andrew Congdon, Mirela Creangă, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Răducan (Niță), Andrew Rose Realizat cu sprijinul financiar al Agenției Statelor Unite pentru Dezvoltare Internațională și al Agenției Australiene pentru Dezvoltare Internațională. Organizații partenere: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania și Tanzania Training Centre for Orthopaedic Technologists (TATCOT) ©Fundația Motivation România, 2014 Această publicație a fost produsă cu sprijinul generos al poporului american, prin Agenția Statelor Unite pentru Dezvoltare Internațională (USAID). Conținutul este responsabilitatea Fundației Motivation România și nu reflectă în mod necesar punctul de vedere al USAID sau al Guvernului Statelor Unite. Descrierea CIP a Bibliotecii Naţionale a României Servicii pentru utilizatorii de scaun rulant : pachet de instruire – nivel intermediar / Sarah Frost, Kylie Mines, Jamie Noon, ... ; ed.: Chapal Khasnabis, Kylie Mines. – Bucureşti : Contaplus, 2014 ISBN 978-606-93630-1-0 I. Frost, Sarah II. Mines, Kylie III. Noon, Jamie IV. Khasnabis, Chapal (ed.) V. Mines, Kylie (ed.) 615.478.3 Nume: __________________ CUPRINS Scop ........................................................................................................................ 4 A.1: Utilizatorii de scaun rulant care necesită suport postural suplimentar ............. 5 B.1: Rezumatul evaluării și interviul de evaluare ..................................................... 6 B.2: Evaluarea fizică – postura corpului în poziția așezat fără suport: baza posturii corpului în poziția așezat ......................................................................................... 10 B.2: Evaluarea fizică – postura corpului în poziția așezat fără suport: desenarea posturii ..................................................................................................................... 11 B.3: Evaluarea fizică - analiza posturii bazinului și a șoldului ................................ 15 B.3: Evaluarea fizică - analiza posturii bazinului și a șoldului: verificarea suporturilor provizorii .................................................................................................................. 16 B.5: Evaluarea fizică - efectuarea măsurătorilor...................................................... 19 B.6: Alegerea scaunelor rulante și a pernelor......................................................... 22 B.8: Prescrierea (selecția) dispozitivelor de suport postural pentru stabilizarea bazinului .................................................................................................................. 30 B.9: Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea șoldurilor .................................................................................................................. 32 B.10: Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea trunchiului: ............................................................................................................... 35 B.11: Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea capului, coapselor și a gambelor ............................................................................. 50 Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) – listă de verificare a pașilor ............................................................................................. 52 Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) – Listă de verificare preliminară utilizării scaunului rulant – nivel intermediar .................... 53 B.14: Instruirea utilizatorului de scaun rulant........................................................... 54 B.15: Recapitulare ................................................................................................... 58 B.16: Întreținerea, reparațiile și monitorizarea ......................................................... 59 Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului ........................................................................................................ 66 Sesiunea practică 4: Evaluarea, prescrierea (selectarea), pregătirea produsului (scaunului rulant), reglarea și instruirea utilizatorului ........................................ 67 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 4 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Scop Modulul de instruire pentru nivelul intermediar a fost creat cu scopul de a sprijini procesul de instruire a personalului sau a voluntarilor implicați în furnizarea de scaune rulante cu antrenare manuală corespunzătoare, precum și a pernelor destinate adulților și copiilor care necesită sprijin postural suplimentar pentru menținerea poziției așezat. Obiectivul principal al acestui pachet de instruire este dezvoltarea abilităților și cunoștințelor personalului furnizor de servicii pentru utilizatorii de scaun rulant. Transmiterea cunoștințelor cuprinse în acest modul de instruire va contribui la: • creșterea numărului de utilizatori care primesc un scaun rulant corespunzător nevoilor individuale; • creșterea numărului de persoane instruite în ceea ce privește furnizarea de servicii de scaune rulante la nivel intermediar; • îmbunătățirea competențelor personalului furnizor de servicii de scaune rulante; • creșterea calității serviciilor de scaune rulante destinate acelor persoane în cazul cărora este necesară intervenția la un nivel care îl depășește pe cel al serviciilor de scaune rulante de bază; • includerea acestui pachet de instruire în programele de instruire paramedicale/de reabilitare tipice • integrarea într-un grad mai ridicat a furnizării serviciilor pentru utilizatorii de scaun rulant în aria serviciilor de reabilitare. Scopul Caietului de exerciții practice este dezvoltarea cunoștințelor și abilităților personalului implicat în livrarea de servicii destinate utilizatorilor de scaun rulant. Acesta conține exerciții care vor contribui la testarea și îmbunătățirea cunoștințelor și abilităților participanților. Caietul de exerciții practice include materiale din cadrul cursurilor, din prezentările PPT, precum și din Manualul participantului. Este indicat ca participanții să păstreze acest caiet, pentru a-l putea consulta ulterior, dacă acest lucru este necesar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 5 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.1: Utilizatorii de scaun rulant care necesită suport postural suplimentar 1. Aruncarea unei mingi Alegeți o persoană din grupă. Pe parcursul celor trei etape ale acestei activități, aceasta va fi așezată pe un scaun. Celelalte două persoane din grupă o vor ajuta. La fiecare etapă, mingea va fi aruncată de câte cinci ori între persoana așezată pe scaun și celelalte două persoane din echipă. Etapa 1: În timpul aruncării și prinderii mingii, persoana de pe scaun va menține poziția așezat, cu tălpile poziționate în întregime pe sol. Cât de ușoare sunt activitățile de aruncare și prindere a mingii? Etapele 2 și 3 sunt mai dificile? De ce? Cum afectează diferitele poziții și posturi ușurința cu care mingea este aruncată și prinsă?Etapa 2: Pe parcursul aruncării și prinderii, un membru al echipei înclină scaunul în lateral, pe două picioare și îl menține în această poziție. Etapa 3: În timpul aruncării și prinderii, un membru al echipei înclină scaunul de pe un picior pe altul, în mod aleatoriu. 2. Paharul cu apă Fiecare persoană va încerca să bea apă adoptând pozițiile și posturile prezentate mai jos. Sorbiți din pahar de fiecare dată și fiți atenți! o Poziția așezat Cum influențează diferitele poziții și posturi ușurința cu care se bea apă? o Așezat pe scaun, cu capul înclinat înspre înapoi (nasul orientat în sus) o Așezat pe scaun, într-o postură „prăbușită” o Întins pe patul de evaluare Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 6 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar B.1: Rezumatul evaluării și interviul de evaluare Lucrați împreună cu membrii echipei din care faceți parte și răspundeți la unul din seturile de întrebări de mai jos, în funcție de numărul grupei din care faceți parte. Grupa 1 Cum influențează diagnosticul/aspectele fizice de mai jos procesul de furnizare a scaunului rulant? De exemplu: • Care sunt acele caracteristici ale diagnosticului/aspectelor fizice care au un impact asupra procesului de furnizare a scaunului rulant? • Care sunt acele caracteristici ale scaunului rulant care ar fi utile și ce fel de instruire se recomandă? • Care sunt aspectele pe care este important să le știm despre fiecare utilizator de scaun rulant? Traumatism cranio-cerebral Poliomielită Oboseală Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 7 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Grupa 2 Cum influențează diagnosticul/aspectele fizice prezentate mai jos procesul de furnizare a scaunului rulant? De exemplu: • Care sunt acele caracteristici ale diagnosticului/aspectelor fizice care au un impact asupra procesului de furnizare a scaunului rulant? • Care sunt acele caracteristici ale scaunului rulant care ar fi utile și ce fel de instruire se recomandă? • Care sunt aspectele pe care este important să le știm despre fiecare utilizator de scaun rulant? Distrofie musculară Traumatism vertebro-medular Spasme/mișcări necontrolate Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 8 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Grupa 3 Cum influențează diagnosticul/aspectele fizice de mai jos procesul de furnizare a scaunului rulant? De exemplu: • Care sunt acele caracteristici ale diagnosticului/aspectelor fizice care au un impact asupra procesului de furnizare a scaunului rulant? • Care sunt acele caracteristici ale scaunului rulant care ar fi utile și ce fel de instruire se recomandă? • Care sunt aspectele pe care este important să le știm despre fiecare utilizator de scaun rulant? Paralizie cerebrală Accident vascular cerebral Probleme de deglutiție Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 9 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Grupa 4 Cum influențează diagnosticul/aspectele fizice de mai jos procesul de furnizare a scaunului rulant? De exemplu: • Care sunt acele caracteristici ale diagnosticului/aspectelor fizice care au un impact asupra procesului de furnizare a scaunului rulant? • Care sunt acele caracteristici ale scaunului rulant care ar fi utile și ce fel de instruire se recomandă? • Care sunt aspectele pe care este important să le știm despre fiecare utilizator de scaun rulant? Spina bifida Afecțiuni degenerative (de exemplu, distrofie musculară, boala Parkinson, scleroză multiplă, sindrom de neuron motor) Luxație de șold Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 10 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar B.2: Evaluarea fizică – postura corpului în poziția așezat fără suport: baza posturii corpului în poziția așezat Lucrați împreună pentru a identifica schimbările apărute la nivelul poziției așezat în momentul în care postura bazinului se modifică. Fiecare persoană din grupă trebuie să adopte câte o poziție cu bazinul într-una din posturile descrise mai jos. Restul grupei observă schimbările care au loc la nivelul întregului corp. Dacă timpul alocat exercițiului permite acest lucru, fiecare membru al grupei ar trebui să încerce diferitele posturi ale bazinului, pentru a simți el însuși schimbările la nivelul corpului. Poziția bazinului Notați sau desenați aspectele pe care le observați legat de modificarea posturii persoanei. Observați trunchiul, capul, gâtul și membrele inferioare. Înclinare anterioară Înclinare posterioară Înclinare laterală Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 11 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Rotație B.2: Evaluarea fizică – postura corpului în poziția așezat fără suport: desenarea posturii Trasați schițele lângă cele din tabelul de mai jos. Schița posturii văzută din lateral Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 12 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Schița posturii văzută din față Schița posturii văzută din față – cu rotația bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 13 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Trasați schița posturii persoanei din imagine. 1. Postura corpului în poziția așezat fără suport Descrieți sau desenați postura corpului în poziția așezat fără suport: 2. Postura corpului în poziția așezat fără suport Descrieți sau desenați postura corpului în poziția așezat fără suport: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 14 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Trasați schița posturii persoanei din imagine. 3. Postura corpului în poziția așezat fără suport Descrieți sau desenați postura corpului în poziția așezat fără suport: 4. Postura corpului în poziția așezat fără suport Descrieți sau desenați postura corpului în poziția așezat fără suport: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 15 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT B.3: Evaluarea fizică - analiza posturii bazinului și a șoldului Efectuați analiza posturii bazinului și șoldului pentru persoana care are rolul utilizatorului de scaun rulant în grupa din care faceți parte. Notați cele observate în rubrica corespunzătoare acestei părți, inclusă în formularul de evaluare – nivel intermediar. Utilizatorul de scaun rulant 1: Analiza posturii bazinului și a șoldului Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: _______ Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Utilizatorul de scaun rulant 2: Analiza posturii bazinului și a șoldului Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: _______ Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 16 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Utilizatorul de scaun rulant 3: Analiza posturii bazinului și a șoldului Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: _______ Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. B.3: Evaluarea fizică - analiza posturii bazinului și a șoldului: verificarea suporturilor provizorii Citiți cazul fiecărui utilizator de scaun rulant de mai jos. În cazul fiecărui utilizator de scaun rulant, decideți dacă bazinul acestuia este în echilibru și dacă șoldurile pot fi flectate pentru atingerea poziției neutre de ședere (unghiul dintre trunchi și coapse nu este mai mare de 90 de grade). Completați partea de analiză a posturii bazinului și a șoldului în rubrica corespunzătoare acestei părți, inclusă în formularul de evaluare – nivel intermediar. Decideți dacă utilizatorul are nevoie de suport provizoriu și pregătiți un astfel de suport pentru fiecare utilizator de scaun rulant. Asigurați-vă că ați verificat fiecare suport provizoriu și că le-ați încercat voi înșivă, pentru a înțelege ce presupun ele. Nu uitați! CIAS înseamnă creasta iliacă antero-superioară. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 17 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sam Analiza posturii bazinului și a șoldului Sam are 4 ani. El este diagnosticat cu paralizie cerebrală și nu poate menține singur poziția așezat. Făcând analiza posturii bazinului și a șoldului vom constata că: o Bazinul lui Sam este în echilibru (crestele iliace antero-superioare se află la același nivel); o Șoldul stâng al lui Sam poate fi flectat până la atingerea poziției neutre de ședere, fără a-i produce vreun disconfort. Sam acuză dureri la nivelul șoldului drept, iar acesta nu poate fi flectat în întregime pentru poziția neutră de ședere (unghiul dintre trunchi și coapse este mai mare de 90 de grade). Unghiul dintre trunchi și coapsă, pe partea dreaptă, este de aproximativ 105 grade. Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: _______ Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Necesită Sam suport provizoriu? Da o Nu Martha Analiza posturii bazinului și a șoldului Martha are 57 de ani. Este diagnosticată cu artrită severă. Se poate deplasa pe o distanță de câțiva pași, dar acest lucru îi provoacă un grad ridicat de durere. Făcând analiza posturii bazinului și a șoldului vom constata că: o Bazinul Marthei este în echilibru (crestele iliace antero-superioare se află la același nivel); o Niciunul dintre șolduri nu poate fi flectat în întregime până la atingerea poziției neutre de ședere (unghiul dintre coapse și trunchi este mai mare de 90 de grade). Unghiul dintre trunchi și coapse la ambele șolduri este de aproximativ 100 de grade. Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: _______ Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Necesită Martha suport provizoriu? Da Nu Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 18 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Seren Analiza posturii bazinului și a șoldului Seren are 16 ani. În copilărie a avut poliomielită și a rămas cu contracții severe la membrele inferioare. Seren se deplasează cu rapiditate pe podea, ținând membrele inferioare încrucișate. Făcând analiza posturii bazinului și a șoldului vom constata că: o Bazinul lui Seren nu este în echilibru. Partea dreaptă a bazinului ei este situată cu 20 mm mai sus decât cea stângă; o Ambele șolduri pot fi flectate până la atingerea poziției neutre de ședere. Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: _______ Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Necesită Seren suport provizoriu? Da Nu Joe Analiza posturii bazinului și a șoldului Joe are 25 de ani. În copilărie a avut poliomielită și a rămas cu contracții severe la ambele membre inferioare. Făcând analiza posturii bazinului și a șoldului vom constata că: o Bazinul lui Joe este fi echilibru (crestele iliace antero-superioare se află la același nivel); o Șoldul drept al lui Joe poate fi flectat până la atingerea poziției neutre de ședere, fără a-i produce disconfort. Totuși, șoldul stâng nu poate fi extins în întregime (unghiul dintre coapse și trunchi este mai mic de 90 de grade). Unghiul dintre trunchi și coapsă este de 70 de grade. Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: _______ Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Necesită Joe suport provizoriu? Da Nu Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 19 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT B.5: Evaluarea fizică - efectuarea măsurătorilor Madavi are 13 ani și este diagnosticată cu paralizie cerebrală. Poate menține poziția așezat fără suport, dar cu toate acestea, obosește repede și nu poate menține această poziție o perioadă îndelungată. Are o ușoară înclinare posterioară fixă a bazinului, iar corpul ei are tendința să alunece înspre partea din față a scaunului rulant pe care îl folosește acum. A cerut o măsuță deoarece dorește să aibă o masă/suprafață care să o ajute să citească, să scrie și să mănânce. Mai jos sunt rezultatele evaluării fizice prin procedeul de simulare manuală efectuată de către personalul furnizor de servicii de scaune rulante. Parcurgeți rezultatele finale ale procedeului de simulare manuală: Procedeul de simulare manuală: suportul necesar pentru atingerea poziției neutre de ședere sau a unei poziții cu bazinul cât mai aproape de poziția neutră de ședere, fără a cauza disconfort. Dacă este posibilă atingerea poziției neutre de ședere cu ajutorul suportului manual, bifați „da”. În caz contrar, bifați „nu”. Parte a corpului Da Nu Descrieți sau schițați postura în poziția așezat finală a utilizatorului de scaun rulant, realizată cu suport manual și descrieți sau schițați suportul oferit pentru obținerea respectivei poziții de ședere. Bazin Trunchi Postură finală: bazin cu înclinare posterioară; partea inferioară a trunchiului ușor curbată, (vedere laterală), dar simetrică (vedere frontală), cu suport de ambele părți; capul ușor proiectat înspre înainte; tendința membrelor inferioare de a se orienta spre interior – un grad de suport redus sprijină coapsele în poziție neutră. Suport necesar: o suport în partea anterioară a oaselor bazinului; o suport la nivelul părții posterioare a bazinului - nu se atinge poziția neutră, dar previne înclinarea suplimentară; o suport la nivelul spatelui, până la umeri; o suport lateral al trunchiului - pentru a ajuta la menținerea trunchiului pe linia mediană; o suport de ambele laturi ale bazinului/șoldurilor, pentru a menține bazinul pe linia mediană ; o suport în partea interioară a coapselor pentru a opri adducția - inserție unghiulară interioară pentru coapse; o măsuță. Cap Șold S Șold D Coapse Genunchi S Genunchi D Gleznă S Gleznă D Decideți care sunt măsurătorile necesare pentru a putea alege un scaun rulant pentru Madavi. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 20 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Efectuați aceste măsurători pe cel puțin unul din membrii grupei și notați valorile obținute în rubrica corespunzătoare din formularul de evaluare – nivel intermediar. Cum vă veți asigura că ați obținut valoarea corectă pentru adâncimea suprafeței de ședere? (Nu uitați că Madavi are o ușoară înclinare fixă posterioară a bazinului) Ce măsurători veți efectua pentru a descrie înălțimea și mărimea/forma măsuței pentru acest utilizator? Efectuarea măsurătorilor Măsurători corp (mm) Măsurători componente scaun rulant (mm) Lățimea și adâncimea suprafeței de ședere și înălțimea suportului de picioare A Lățime șold = lățime suprafață de ședere SAU 1 = distanță dintre inserțiile laterale pentru bazin 2 B Adâncime șezut (partea posterioară a bazinului până la partea posterioară a genunchiului) S B minus 30-50 mm = adâncimea suprafeței de ședere (dacă lungimea este diferită, folosiți valoarea mai mică) 3 D C Lungime gambă S = distanța dintre limita superioară a suprafeței de ședere și suportul de picioare SAU = distanța dintre limita superioară a suprafeței de ședere și sol, în cazul propulsiei cu ajutorul membrelor inferioare 4 D 5 Înălțimea spătarului D Distanța dintre șezut* și limita inferioară a cutiei toracice = distanța dintre limita superioară a suprafeței de ședere și limita superioară a spătarului (măsurați D, E sau F - în funcție de cerințele specifice ale utilizatorului) 6 E Distanța dintre șezut* și limita inferioară a omoplatului F Distanța dintre șezut* și limita superioară a umărului Modificările și/sau dispozitivele de suport postural G Lățime trunchi = distanța dintre inserțiile laterale/ inserțiile unghiulare laterale pentru trunchi 7 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 21 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT H Distanța dintre șezut* și axilă S H minus 30 mm = distanța maximă dintre partea superioară a suprafeței de ședere și partea superioară a inserțiilor laterale/inserțiilor unghiulare laterale (ajustare în funcție de procedeul de simulare manuală) 8 D I Distanța dintre șezut* și partea superioară a bazinului (creasta iliacă postero-superioară) = distanța dintre partea superioară a suprafeței de ședere și jumătatea înălțimii inserției posterioare pentru bazin 9 J Distanța dintre genunchi = lățimea inserției/dispozitivului pentru separarea genunchilor 10 K Distanța dintre șezut* și baza craniului (occiput) = distanța dintre partea superioară a suprafeței de ședere și linia de mijloc tetierei 11 L Distanța dintre partea posterioară a bazinului și oasele bazinului L plus 20–40 mm = distanța dintre spătar și linia de început a inserției anterioare oaselor bazinului. 12 A lte le *La efectuarea măsurătorilor corpului, „șezutul” reprezintă suprafața ocupată de oasele bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel intermediar. Caiet de exerciții practice Pagina 2 K Distanța dintre șezut* și baza craniului = distanța dintre partea superioară a suprafeței de ședere și mijlocul tetierei 11 L Distanța dintre partea posterioară a bazinului și oasele bazinului L plus 20–40 mm = distanța dintre cadrul spătarului și partea de început a inserției anterioare oaselor bazinului. 12 Al te le *La efectuarea măsurătorilor corpului, „șezutul” reprezintă suprafața pe care sunt așezate oasele bazinului. B.6: Alegerea scaunelor rulante și a pernelor Observați cu atenție fiecare scaun rulant disponibil pe plan local. Lucrați împreună în grupe pentru a răspunde la următoarele întrebări. Dacă nu sunteți sigur/ă, cereți clarificări formatorilor . 1. Stilul de viață și mediul Întrebări: Răspunsuri: Care este tipul de scaun rulant (sau tipurile de scaune rulante) cel mai potrivit pentru deplasarea pe teren accidentat/denivelat? De ce? Care este tipul de scaun rulant (sau tipurile de scaune rulante) cel mai potrivit pentru efectuarea transferului în picioare? De ce? B C D E F K I S A G H Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 22 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar B.6: Alegerea scaunelor rulante și a pernelor Observați cu atenție fiecare scaun rulant disponibil pe plan local. Lucrați împreună în grupe pentru a răspunde la următoarele întrebări. Dacă nu sunteți sigur/ă, cereți clarificări formatorilor . 1. Stilul de viață și mediul Întrebări: Răspunsuri: Care este tipul de scaun rulant (sau tipurile de scaune rulante) cel mai potrivit pentru deplasarea pe teren accidentat/denivelat? De ce? Care este tipul de scaun rulant (sau tipurile de scaune rulante) cel mai potrivit pentru efectuarea transferului în picioare? De ce? Care este tipul de scaun rulant (sau tipurile de scaune rulante) cel mai potrivit pentru efectuarea transferului lateral? De ce? Cum se pliază sau demontează în vederea transportului fiecare tip de scaun rulant? Variante: o scanul rulant nu poate fi pliat; o plierea pe verticală; o plierea înspre înainte a spătarului; o roți cu sistem de decuplare rapidă. Care este tipul de scaun rulant (sau tipurile de scaune rulante) pe care membrii grupei îl consideră ca fiind cel mai ușor de manevrat în mijloacele de transport public? De ce? Care sunt tipurile de scaune rulante (dacă există) dotate cu anvelope pneumatice? Care sunt tipurile de scaune rulante (dacă există) cu camere interioare solide? Care sunt tipurile de scaune rulante (dacă există) cu anvelope solide? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 23 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 2. Reducerea presiunii Întrebări: Răspunsuri: Care sunt tipurile de pernă pe care le puteți vedea în sala de curs? Care dintre acestea considerați că sunt perne pentru reducerea presiunii? De ce? Dintre pernele pentru reducerea presiunii (dacă există) - care ar putea fi modificată cel mai ușor pentru: o a crește nivelul de reducere a presiunii; o a oferi suport postural suplimentar. Ce tip de huse pentru perne puteți identifica în sala de curs? Luați în considerare: impermeabilitatea, durabilitatea, elasticitatea, grosimea materialului. 3. Propulsia: Întrebări: Răspunsuri: Așezați-vă în scaunul rulant, în poziția neutră de ședere. Roata din spate are poziția corespunzătoare pentru efectuarea propulsiei? Verificați următoarele: o lăsați-vă brațul în jos. Mâna depășește nivelul axului? o poziționați mâna pe partea superioară a inelului de antrenare, astfel încât să se situeze pe aceeași linie cu umărul. Cotul este îndoit într-un unghi cuprins între 90 și 120 de grade? Poziția roții din spate este ajustabilă? În caz de ajustare, se îmbunătățește poziția pentru efectuarea propulsiei? Există în sala de curs vreun scaun rulant al cărui suprafață de ședere poate fi reglată pe înălțime? În ce situații se poate dovedi util acest aspect? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 24 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 4. Caracteristicile suportului postural: Întrebări: Răspunsuri: Care sunt tipurile de scaune rulante (dacă există) care au suporturi de picioare ajustabile pe înălțime? Care sunt tipurile de scaune rulante (dacă există) care au suprafața de ședere solidă? Care sunt tipurile de scaune rulante (dacă există) care au spătar cu tensiune ajustabilă? Care sunt tipurile de scaune rulante (dacă există) care au componente adăugate pentru a oferi suport postural suplimentar? (Nu trebuie să descrieți sau să enumerați componentele. Trebuie doar să identificați acele scaune rulante care au suporturi posturale suplimentare.) 5. Ajustabilitatea Întrebări: Răspunsuri: Care sunt tipurile de scaune rulante (dacă există) care au următoarele opțiuni de ajustare: o Înălțimea suportului de picioare o Unghiul suportului de picioare o Poziționarea înspre înainte/înapoi a suporturilor de picioare o Înălțimea spătarului o Înclinarea spătarului o Înclinarea în spațiu (înclinarea șezutului și a spătarului) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 25 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Formular de date tehnice ale scaunului rulant – nivel intermediar Puteți completa acest formular pentru fiecare scaun rulant utilizat în programul de instruire (în cazul în care aveți nevoie de mai multe exemplare, solicitați-le formatorului). Denumire scaun rulant: Inserați imagine aici: Producător / Furnizor: Dimensiuni disponibile: Greutate totală: Descriere: Cadru: Fix/rigid Pliabil Lungime cadru Spătar Pliabil/material textil Rigid Tensiune ajustabilă Suprafață de ședere: Pliabilă/material textil Rigidă Tensiune ajustabilă Pernă: Fără pernă Plată, din spumă/ burete Cu contur, din spumă/burete Fluid Altele Suporturi de picioare: Fixe Detașabile / pliabile pe lateral Altele: Roți frontale: Pneumatice Diametru: Solide Lățime: Roți din spate Pneumatice Diametru: Inele antrenare Solide Lățime: Ax reglabil Tub interior solid Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Suporturi pentru brațe: Curbate Pătrate Altele: Fixe Detașabile Altele: Mânere: Mânere: Dispozitive de suport postural: Centură pentru bazin Centură pentru gambe Ham pentru umeri Centură pentru picioare Bară anti- răsturnare Inserții laterale pentru trunchi Măsuță Tetieră Inserții laterale pentru bazin Altele: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 26 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Măsurători, opțiuni de modificări și gama de ajustări: Măsurători (dacă scaunul rulant este disponibil în mai multe mărimi, specificați toate mărimile) Este ajustabil? Gamă de ajustări (gama de ajustări ce pot fi făcute pentru acest scaun)Da Nu Lățime suprafață de ședere Adâncime suprafață de ședere Înălțime suprafață de ședere Înălțime spătar Unghi înclinare spătar Înălțime suport de picioare Unghi înclinare suport de picioare Înălțime mânere Lungime cadru Lungime bază roți Unghi spătar și suprafață de ședere Unghi înclinare în spațiu Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 27 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Formular de date tehnice ale scaunului rulant – nivel intermediar Puteți completa acest formular pentru fiecare scaun rulant utilizat în programul de instruire (în cazul în care aveți nevoie de mai multe exemplare, solicitați-le formatorului). Denumire scaun rulant: Inserați imagine aici: Producător / Furnizor: Dimensiuni disponibile: Greutate totală: Descriere: Cadru: Fix/rigid Pliabil Lungime cadru Spătar Pliabil/material textil Rigid Tensiune ajustabilă Suprafață de ședere: Pliabilă/material textil Rigidă Tensiune ajustabilă Pernă: Fără pernă Plată, din spumă/ burete Cu contur, din spumă/burete Fluid Altele Suporturi de picioare: Fixe Detașabile / pliabile pe lateral Altele: Roți frontale: Pneumatice Diametru: Solide Lățime: Roți din spate Pneumatice Diametru: Inele antrenare Solide Lățime: Ax reglabil Tub interior solid Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Suporturi de brațe: Curbate Pătrate Altele: Fixe Detașabile Altele: Mânere: Mânere: Dispozitive de suport postural: Centură pentru bazin Centură pentru gambe Ham pentru umeri Centură pentru picioare Bară anti- răsturnare Inserții laterale pentru trunchi Măsuță Tetieră Inserții laterale pentru bazin Altele: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 28 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Măsurători, opțiuni de modificări și gama de ajustări: Măsurători (dacă scaunul rulant este disponibil în mai multe mărimi, specificați toate mărimile) Este ajustabil? Gamă de ajustări (gama de ajustări ce pot fi făcute pentru acest scaun)Da Nu Lățime suprafață de ședere Adâncime suprafață de ședere Înălțime suprafață de ședere Înălțime spătar Unghi înclinare spătar Înălțime suport de picioare Unghi înclinare suport de picioare Înălțime mânere Lungime cadru Lungime bază roți Unghi spătar și suprafață de ședere Unghi înclinare în spațiu Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 29 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Formular de date tehnice ale scaunului rulant – nivel intermediar Puteți completa acest formular pentru fiecare scaun rulant utilizat în programul de instruire (în cazul în care aveți nevoie de mai multe exemplare, solicitați-le formatorului). Denumire scaun rulant: Inserați imagine aici: Producător / Furnizor: Dimensiuni disponibile: Greutate totală: Descriere: Cadru: Fix/rigid Pliabil Lungime cadru Spătar Pliabil/material textil Rigid Tensiune ajustabilă Suprafață de ședere: Pliabilă/material textil Rigidă Tensiune ajustabilă Pernă: Fără pernă Plată, din spumă/ burete Cu contur, din spumă/burete Fluid Altele Suporturi de picioare: Fixe Detașabile / pliabile pe lateral Altele: Roți frontale: Pneumatice Diametru: Solide Lățime: Roți din spate Pneumatice Diametru: Inele antrenare Solide Lățime: Ax reglabil Tub interior solid Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Suporturi de brațe: Curbate Pătrate Altele: Fixe Detașabile Altele: Mânere: Mânere: Dispozitive de suport postural: Centură pentru bazin Centură pentru gambe Ham pentru umeri Centură pentru picioare Bară anti- răsturnare Inserții laterale pentru trunchi Măsuță Tetieră Inserții laterale pentru bazin Altele: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 30 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Măsurători, opțiuni de modificări și gama de ajustări: Măsurători (dacă scaunul rulant este disponibil în mai multe mărimi, specificați toate mărimile) Este ajustabil? Gamă de ajustări (gama de ajustări ce pot fi făcute pentru acest scaun)Da Nu Lățime suprafață de ședere Adâncime suprafață de ședere Înălțime suprafață de ședere Înălțime spătar Unghi înclinare spătar Înălțime suport de picioare Unghi înclinare suport de picioare Înălțime mânere Lungime cadru Lungime bază roți Unghi spătar și suprafață de ședere Unghi înclinare în spațiu B.8: Prescrierea (selecția) dispozitivelor de suport postural pentru stabilizarea bazinului Citiți cazul utilizatorului de scaun rulant prezentat mai jos și, folosind valorile obținute la secțiunea „efectuarea măsurătorilor” din formularul de evaluare – nivel intermediar, notați dimensiunile corespunzătoare în schița de mai jos. Mariana este o tânără de 18 ani. A fost evaluată de către personalul centrului de servicii pentru utilizatorii de scaun rulant unde lucrați. Împreună, au decis că are nevoie de următoarele dispozitive de suport postural în vederea stabilizării bazinului: o inserție anterioară oaselor bazinului o inserție posterioară pentru bazin o centură pentru bazin Valorile măsurătorilor sunt prezentate în tabelul de mai jos. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 31 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Efectuarea măsurătorilor Măsurători ale corpului (mm) Măsurători ale componentelor scaunului rulant (mm) Lățimea și adâncimea suprafeței de ședere și înălțimea suportului de picioare A Lățime șold 400 = lățime suprafață de ședere SAU 1 = distanța dintre cele două inserții laterale pentru bazin 2 B Adâncime șezut (partea posterioară a bazinului până la partea posterioară a genunchiului) S 420 B minus 30-50 mm = adâncimea suprafeței de ședere (dacă distanța este diferită, folosiți valoarea mai mică) 3 380 D 420 380 C Lungime gambei S 420 = distanța dintre partea superioară a suprafeței de ședere și suportul de picioare SAU = distanța dintre partea de sus a suprafeței de ședere și sol în cazul propulsiei cu ajutorul membrelor inferioare 4 D 420 5 Înălțimea spătarului D Distanța dintre șezut* și limita inferioară a cutiei toracice = distanța dintre limita superioară a suprafeței de ședere și limita superioară a spătarului (măsurați D, E sau F - în funcție de nevoile utilizatorului) 6 E Distanța dintre șezut* și limita inferioară a omoplatului 500 F Distanța dintre șezut* și limita superioară a omoplatului Modificările și / sau dispozitivele de suport postural G Lățime trunchi 370 = distanța dintre inserțiile laterale/ inserțiile unghiulare laterale pentru trunchi 7 H Distanța dintre șezut* și axilă S 480 H minus 30 mm = distanța maximă dintre partea superioară a suprafeței de ședere și partea superioară a inserțiilor laterale/inserțiilor unghiulare laterale pentru trunchi (se reglează în funcție de procedeul de simularea manuală) 8 450 D 480 450 I Distanța dintre șezut* și partea superioară a bazinului (creasta iliacă postero-superioară) 160 = distanța dintre partea superioară a suprafeței de ședere și jumătatea înălțimii inserției posterioare pentru bazin 9 J Distanța dintre genunchi = lățimea inserției/dispozitivului pentru separarea genunchilor 10 K Distanța dintre șezut* și baza craniului (occiput) = distanța dintre limita superioară a suprafeței de ședere și linia de mijloc a tetierei 11 L Distanța dintre partea posterioară a bazinului și oasele bazinului 150 L plus 20–40 mm = distanța dintre spătar și linia de început inserției anterioare oaselor bazinului. 12 180 A lte le *La efectuarea măsurătorilor corpului, „șezutul” reprezintă suprafața ocupată de oasele bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 32 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Introduceți dimensiunile pentru inserția anterioară oaselor bazinului și inserția posterioară pentru bazin. B.9: Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea șoldurilor Șoldul drept al Siennei nu poate fi flectat până la atingerea poziției neutre de ședere, deci unghiul dintre trunchi și coapsă este mai mare de 90 de grade. Pe parcursul evaluării, în cazul ei a fost utilizat un suport provizoriu (strat de spumă/burete sub ambele oase ale bazinului și coapsa dreaptă), care a ajutat-o să mențină poziția așezat. I s-a prescris o pernă cu o inserție anterioară oaselor bazinului și inserție pentru reglarea unghiului de înclinare a bazinului (partea dreaptă). Această pernă are rolul de a stabiliza șoldul drept. Descrieți dispozitivul de suport postural al Siennei în rubrica pentru dispozitive de suport postural și modificări necesare din formularul de prescriere (selecție) a scaunului rulant – nivel intermediar. Utilizați schița și marcați punctele în care este necesară modificarea dimensiunilor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 33 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Listă de verificare a dispozitivelor de suport postural (DSP) Descrieți/desenați și specificați dimensiunile S up ra fa ța d e șe de re / pe rn a Adăugarea unei suprafețe de ședere rigide Inserție anterioară oaselor bazinului (= 3 - 12) Inserție pentru reglarea unghiului de înclinare a bazinului S D Înălțarea suprafeței de ședere prin inserție anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Inserții pentru stabilizarea bazinului S D Inserții laterale pentru bazin (= 2) S D Inserții unghiulare exterioare pentru coapse S D Inserții exterioare pentru coapse S D Inserție unghiulară interioară pentru coapse (= 10) Inserție/dispozitiv pentru separarea genunchilor(= 10) Altele Altele Șoldurile lui Robert nu pot fi flectate până la atingerea poziției neutre de ședere, deci unghiul dintre trunchi și coapse este mai mare de 90 de grade. Pe parcursul evaluării, în cazul lui a fost utilizat un suport provizoriu (inserții din spumă/burete sub oaselor bazinului) care l-a ajutat să mențină poziția așezat. I s-a prescris un scaun rulant al cărui unghi format de suprafața de ședere a scaunului rulant și spătar este mai mare, pentru a acomoda astfel restricțiile impuse de gradul de flexie a șoldurilor sale. Descrieți dispozitivul de suport postural al lui Robert în rubrica pentru dispozitive de suport postural și modificări necesare din formularul de prescriere (selecție) a scaunului rulant – nivel intermediar. Utilizați schița și marcați punctele în care modificarea dimensiunilor este necesară. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 34 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Listă de verificare a dispozitivelor de suport postural (DSP) Descrieți/desenați și specificați dimensiunile S up ra fa ța de ș ed er e și sp ăt ar ul Deschidere unghi suprafață de ședere - spătar Înclinare suprafața de ședere și spătar (înclinare în spațiu, fără modificarea unghiului) S pă ta ru l Adăugare spătar solid Inserție posterioară pentru bazin (= 9) Spătar cu formă ajustabilă Spătar cu tensiune ajustabilă Înclinare spătar Inserții laterale pentru trunchi (= 7) S D Inserții unghiulare laterale pentru trunchi(= 7) S D Altele M ăs uț a / su po rtu ril e de b ra țe Măsuță Modificare suporturi de brațe S D Altele Te tie re Tetieră plată (= 11) Tetieră conturată (= 11) Altele S up or t d e p ic io ar e Inserții plane pentru suportul de picioare S D Inserții unghiulare pentru suportul de picioare S D Dispozitiv de sprijin pentru gambă S D Altele C en tu ri Centură pentru bazin Centură pentru gambe Centuri pentru picior S D Ham pentru umeri Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 35 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT B.10: Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea trunchiului: 1. Mark, în vârstă de 16 ani, are un traumatism vertebro-medular cu o leziune la nivel înalt. El are un scaun rulant cu spătar și suprafață de ședere pliabile. Scaunul său rulant are dimensiunea corectă și are o pernă moale și plată, confecționată din spumă/burete. Mark are dificultăți în a menține poziția așezat. Spatele său urmează o linie curbată și are tendința de a aluneca înspre înainte în scaunul rulant. Pielea de sub oasele bazinului și în zona omoplaților se înroșește. Citiți rezultatele evaluării lui Mark (mai jos). Care sunt dispozitivele de suport postural care ar putea să îl ajute pe Mark să mențină poziția așezat în scaunul său rulant? Pentru ajutor, folosiți tabelul cu dispozitivele de suport postural și tabelul de referință din Manualul participantului. Cum ați putea să furnizați aceste dispozitive sau să le confecționați, pornind de la scaunul rulant actual? Gândiți-vă la modificările care pot fi efectuate la suprafața de ședere a scaunului rulant, la pernă și la spătarul acestuia. Rețineți ordinea corectă: Bazin + Șolduri Trunchi Utilizați scaunul rulant și materialele pe care le-ați primit pentru a arăta celorlalți participanți modul în care îi veți oferi lui Mark suportul de care are nevoie. Postura în poziția așezat fără suport Analiza posturii bazinului și a șoldurilor Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: _______ Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 36 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Procedeul de simulare manuală: este suportul necesar pentru atingerea poziției neutre de ședere sau a unei poziții cu bazinul cât mai aproape de poziția neutră de ședere, fără a cauza disconfort. Dacă este posibilă atingerea poziției neutre de ședere cu ajutorul suportului manual, bifați „da”. În caz contrar, bifați „nu”. Parte a corpului Da Nu Descrieți sau schițați postura în poziția așezat finală a utilizatorului de scaun rulant, realizată cu suport manual și descrieți sau schițați suportul oferit pentru obținerea respectivei poziții de ședere. Bazin Trunchi Pentru a menține poziția așezat, Mark are nevoie de: o suport puternic în partea posterioară a bazinului (ambele mâini pe partea posterioară a bazinului, apăsând înspre înainte); o grad redus de suport la nivelul omoplaților. Cap Șold S Șold D Coapse Genunchi S Genunchi D Gleznă S Gleznă D Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 37 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Formular de prescriere (selecție) a scaunului rulant – nivel intermediar 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data evaluării: Data probării produsului (a scaunului rulant): Numele persoanei care efectuează evaluarea: 2. Tipul, dimensiunea și configurația scaunului rulant Tipul scaunului rulant (notați mai jos scaunele rulante disponibile) Dimensiunile scaunului rulant (mm) Lățimea suprafeței de ședere Adâncimea suprafeței de ședere Înălțimea spătarului Înălțimea suportului de picioare Configurația scaunului rulant Poziția roții din spate Altele: Unghiul de înclinare 3. Tipul și mărimea pernei Tipul de pernă Dimensiunea De exemplu, pernă pentru reducerea presiunii Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 38 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 4. Dispozitivele de suport postural sau modificările necesare Listă de verificare a dispozitivelor de suport postural (DSP) Descrieți/desenați și notați dimensiunile S up ra fa ța d e șe de re / pe rn a Adăugare suprafață de ședere rigidă Inserție anterioară oaselor bazinului (3 -12) Inserție pentru reglarea unghiului de înclinare a bazinului S D Înălțarea suprafeței de ședere prin inserție anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Inserții pentru stabilizarea bazinului S D Inserții laterale pentru bazin (=2) S D Inserții unghiulare exterioare pentru coapse S D Inserții exterioare pentru coapse S D Inserție interioară pentru coapse (= 10) Inserție dispozitiv pentru separarea genunchilor (= 10) Altele Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 39 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Listă de verificare a dispozitivelor de suport postural (DSP) Descrieți/desenați și notați dimensiunile S up ra fa șa de ș ed er e și sp ăt ar ul Deschidere unghi suprafața de ședere - spătar Unghi de înclinare suprafața de ședere - spătar (înclinarea în spațiu) S pă ta ru l Adăugare spătar rigid Inserție posterioară pentru bazin Spătar cu formă ajustabilă Spătar cu tensiune ajustabilă Spătar cu unghi de înclinare ajustabil Inserții laterale pentru trunchi (= 7) S D Inserții unghiulare laterale pentru trunchi (= 7) S D Altele M ăs uț a/ su po rtu ril ed e de b ra țe Măsuță Modificare suporturi de brațe S D Altele Te tie re le Tetieră plată (= 11) Tetieră conturată (= 11) Altele S up or tu ril e de p ic io ar e Inserții plane pentru suportul de picioare S D Inserții unghiulare pentru suportul de picioare S D Dispozitive de sprijin pentru gambă S D Altele C en tu ril e Centură pentru bazin Centură pentru gambe Centuri pentru picior S D Ham pentru umeri Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 40 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 5. Acordul Semnătură utilizator de scaun rulant: Semnătură evaluator: Semnătură manager furnizor servicii de scaune rulante 2. Josephine, 35 de ani, are un traumatism vertebro-medular. Locuiește în mediul rural și este membru activ al bisericii locale. Josephine a primit un scaun rulant cu o bază a roții lungă, de care este mulțumită, deoarece familia ei o poate împinge cu ușurință pe terenul accidentat din satul ei. Josephine poate efectua și ea propulsia scaunului rulant, pe distanțe scurte, pe teren fără denivelări, în interior. Scaunul rulant are dimensiunea potrivită pentru ea și are spătarul și suprafața de ședere rigide. Are o pernă groasă și plană, confecționată din spumă. Poziția de ședere în scaunul rulant nu este una confortabilă și îi este dificil să realizeze propulsia. Bazinul este înclinat spre partea posterioară (înclinare posterioară a bazinului), postura trunchiului este înclinată înainte. Citiți rezultatele evaluării lui Josephine (mai jos). Care sunt dispozitivele de suport postural care ar putea să o ajute pe Josephine să mențină poziția așezat în scaunul ei rulant? Pentru ajutor, folosiți tabelul cu dispozitivele de suport postural și tabelul de referință din Manualul participantului. Cum ați putea să furnizați aceste dispozitive sau să le confecționați, pornind de la scaunul rulant actual? Gândiți-vă la modificările care pot fi efectuate la suprafața de ședere, la perna și spătarul acestuia. Rețineți ordinea corectă: Bazin + Șolduri Trunchi Utilizați scaunul rulant și materialele pe care le-ați primit pentru a arăta celorlalți participanți modul în care îi veți oferi lui Josephine suportul de care are nevoie. Postura în poziția așezat fără suport Analiza posturii bazinului și a șoldurilor Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: 100 grade Stânga: Da Nu Unghi: _______ Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 41 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Procedeul de simulare manuală: este suportul necesar pentru atingerea poziției neutre de ședere sau a unei poziții cu bazinul cât mai aproape de poziția neutră de ședere, fără a cauza disconfort. Dacă este posibilă atingerea poziției neutre de ședere cu ajutorul suportului manual, bifați „da”. În caz contrar, bifați „nu”. Parte a corpului Da Nu Descrieți sau schițați postura în poziția așezat finală a utilizatorului de scaun rulant, realizată cu suport manual și descrieți sau schițați suportul oferit pentru obținerea respectivei poziții de ședere. Bazin Trunchi Cap Șold S Șold D Coapse Genunchi S Genunchi D Gleznă S Gleznă D Josephine nu poate menține poziția neutră de ședere. Postura ei finală este: o trunchi înclinat înspre înainte; o capul orientat înspre înainte; o bazin în înclinare posterioară. Postura ei este îmbunătățită cu ajutorul următorului suport: o suport provizoriu sub ambele oase ale bazinului și sub coapsa stângă; o mâinile poziționate pe partea posterioară a bazinului, suport care sprijină în întregime partea superioară și cea inferioară a trunchiului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 42 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Formular de prescriere (selecție) a scaunului rulant – nivel intermediar 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data evaluării: Data probării produsului (a scaunului rulant): Numele persoanei care efectuează evaluarea: 2. Tipul, dimensiunea și configurația scaunului rulant Tipul scaunului rulant (notați mai jos scaunele rulante disponibile) Dimensiunile scaunului rulant (mm) Lățimea suprafeței de ședere Adâncimea suprafeței de ședere Înălțimea spătarului Înălțimea suportului de picioare Configurația scaunului rulant Poziția roții din spate Altele: Unghiul de înclinare 3. Tipul și mărimea pernei Tipul de pernă Dimensiunea De exemplu, pernă pentru reducerea presiunii Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 43 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 4. Dispozitivele de suport postural sau modificările necesare Listă de verificare a dispozitivelor de suport postural (DSP) Descrieți/desenați și notați dimensiunile S up ra fa ța d e șe de re / pe rn a Adăugare suprafață de ședere solidă Inserție anterioară oaselor bazinului (3 - 12) Inserție pentru reglarea unghiului de înclinare a bazinului S D Înălțarea suprafeței de ședere prin inserție anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Inserții pentru stabilizarea bazinului S D Inserții laterale pentru bazin (=2) S D Inserții unghiulare exterioare pentru coapse S D Inserții exterioare pentru coapse S D Inserție interioară pentru coapse (= 10) Inserție/dispozitiv pentru separarea genunchilor (= 10) Altele Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 44 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Listă de verificare a dispozitivelor de suport postural (DSP) Descrieți/desenați și notați dimensiunile S up ra fa ța de ș ed er e și s pă ta ru l Deschidere unghi suprafața de ședere - spătar Unghi de înclinare suprafața de ședere - spătar (înclinarea în spațiu) S pă ta ru l Adăugare spătar rigid Inserție posterioară pentru bazin Spătar cu formă ajustabilă Spătar cu tensiune ajustabilă Spătar cu unghi de înclinare ajustabil Inserții laterale pentru trunchi (= 7) S D Inserții unghiulare laterale pentru trunchi (= 7) S D Altele M ăs uț a / S up or tu ril e de br aț e Măsuță Modificare suporturi de brațe S D Altele Te tie re le Tetieră plată (= 11) Tetieră conturată (= 11) Altele S up or tu ril e pe nt ru pi ci oa re Inserții plane pentru suportul de picioare S D Inserții unghiulare pentru suportul de picioare S D Dispozitive de sprijin pentru gambă S D Altele C en tu ril e Centură pentru bazin Centură pentru gambe Centuri pentru picior S D Ham pentru umeri Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 45 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 5. Acordul Semnătura utilizator de scaun rulant: Semnătură evaluator: Semnătură manager furnizor servicii de scaune rulante 3. Sian are 3 ani și este diagnosticat cu paralizie cerebrală. El are un scaun rulant pliabil, pentru copii. Suporturile de picioare, suprafața de ședere și spătarul se pliază și ele. Nu există măsuță și nici pernă. Adâncimea suprafeței de ședere este corectă, totuși, lățimea este puțin prea mare. Părinții săi nu au mașină și merg pe jos în majoritatea locurilor. În comunitate, ei manevrează scaunul rulant, însă, uneori, îl poartă în brațe. Sian poate să realizeze propulsia scaunului rulant pe distanțe scurte, atunci când suprafața pe care se deplasează este dreaptă. Sian poate menține poziția așezat fără suport pe perioade foarte scurte. După 10 minute, trunchiul său cedează și, de obicei, se apleacă înspre față și stânga. Acest lucru cauzează ridicarea părții drepte a bazinului său și o greutate mai mare pe partea stângă a bazinului. Coloana vertebrală prezintă curbura fiziologică tipică pentru vârsta sa. Mama lui Sian își dorește ca el să se poată juca afară cu alți copii și să înceapă să realizeze singur propulsia scaunului său rulant. Citiți rezultatele evaluării lui Sian (mai jos). Care sunt dispozitivele de suport postural care ar putea să îl ajute pe Sian să mențină poziția așezat în scaunul lui rulant? Pentru ajutor, folosiți tabelul cu dispozitivele de suport postural și tabelul de referință din Manualul participantului. Cum ați putea să furnizați aceste dispozitive sau să le confecționați, pornind de la scaunul rulant actual? Gândiți-vă la modificările care pot fi efectuate la suprafața de șederer a scaunului rulant, la pernă și la spătarul acestuia. Rețineți ordinea corectă: Bazin + Șolduri Trunchi Utilizați scaunul rulant și materialele pe care le-ați primit pentru a arăta celorlalți participanți modul în care îi veți oferi lui Sian suportul de care are nevoie. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 46 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Postura în poziția așezat fără suport Analiza poziției bazinului și a șoldurilor Verificați dacă oasele bazinului se află la același nivel, precum și gradul de flexie al șoldului atunci când utilizatorul se află în poziția de decubit. Bazinul este în echilibru? Da Nu Șoldul poate fi flectat pentru atingerea poziției neutre de ședere? Dreapta: Da Nu Unghi: 80 grade Stânga: Da Nu Unghi: 80 Dacă bazinul nu este în echilibru sau dacă șoldurile nu pot fi flectate pentru atingerea poziției neutre de ședere, folosiți un suport provizoriu. Procedeul de simulare manuală: este suportul necesar pentru atingerea poziției neutre de ședere sau a unei poziții cu bazinul cât mai aproape de poziția neutră de ședere, fără a cauza disconfort. Dacă este posibilă atingerea poziției neutre de ședere cu ajutorul suportului manual, bifați „da”. În caz contrar, bifați „nu”. Parte a corpului Da Nu Descrieți sau schițați postura în poziția așezat finală a utilizatorului de scaun rulant, realizată cu suport manual și descrieți sau schițați suportul oferit pentru obținerea respectivei poziții de ședere. Bazin Trunchi Cap Șold S Șold D Coapse Genunchi S Genunchi D Gleznă S Gleznă D Sian poate menține poziția neutră de ședere, dar cu ambele șolduri flexate (unghiul dintre trunchi și coapse este de aproximativ 80 de grade). Pentru a sta în poziția așezat, Sian are nevoie de: o inserție unghiulară provizorie, confecționată din spumă/burete, sub ambele coapse; o mâinile poziționate de ambele părți ale bazinului, susținând ferm, sprijinind ușor și partea posterioară a bazinului; o mâinile poziționate de fiecare parte a trunchiului, susținând ferm. Suportul pe partea stângă trebuie să se situeze puțin mai sus decât cel de pe partea dreaptă; o sprijin redus la nivelul omoplaților și în partea frontală a pieptului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 47 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Formular de prescriere (selecție a scaunului rulant –nivel intermediar 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data evaluării: Data probării produsului (a scaunului rulant): Numele persoanei care efectuează evaluarea: 2. Tipul, dimensiunea și configurația scaunului rulant Tipul scaunului rulant (notați mai jos scaunele rulante disponibile) Dimensiunile scaunului rulant (mm) Lățimea suprafeței de ședere Adâncimea suprafeței de ședere Înălțimea spătarului Înălțimea suportului de picioare Configurația scaunului rulant Poziția roții din spate Altele: Unghiul de înclinare 3. Tipul și mărimea pernei Tipul de pernă Dimensiunea De exemplu, pernă pentru reducerea presiunii Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 48 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 4. Dispozitivele de suport postural sau modificările necesare Listă de verificare a dispozitivelor de suport postural (DSP) Descrieți/desenați și notați dimensiunile S up ra fa ța d e șe de re / pe rn a Adăugare suprafață de ședere solidă Inserție anterioară oaselor bazinului (3 -12) Inserție pentru reglarea unghiului de înclinare a bazinului S D Înălțarea suprafeței de ședere prin inserție anterioară Dispozitiv unghiular pentru înclinarea anterioară a bazinului Inserții pentru stabilizarea bazinului S D Inserții laterale pentru bazin (=2) S D Inserții unghiulare exterioare pentru coapse S D Inserții exterioare pentru coapse S D Inserție interioară pentru coapse (= 10) Inserție/dispozitiv pentru separarea genunchilor (= 10) Altele Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 49 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Listă de verificare a dispozitivelor de suport postural (DSP) Descrieți/desenați și notați dimensiunile S up ra fa ța de ș ed er e și s pă ta ru l Deschidere unghi suprafața de ședere - spătar Unghi de înclinare suprafața de ședere - spătar (înclinarea în spațiu) S pă ta ru l Adăugare spătar solid Inserție posterioară pentru bazin Spătar cu formă ajustabilă Spătar cu tensiune ajustabilă Spătar cu unghi de înclinare ajustabil Inserții laterale pentru trunchi (= 7) S D Inserții unghiulare laterale pentru trunchi (= 7) S D Altele M ăs uț a / S up or tu ril e de br aț e Măsuță Modificare suporturi de brațe S D Altele Te tie re le Tetieră plată (= 11) Tetieră conturată (= 11) Altele S up or tu ril e pe nt ru pi ci oa re Inserții plane pentru suportul de picioare S D Inserții unghiulare pentru suportul de picioare S D Dispozitive de sprijin pentru gambă S D Altele C en tu ril e Centură pentru bazin Centură pentru gambe Centuri pentru picior S D Ham pentru umeri Altele Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 50 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar 5. Acordul Semnătura utilizator de scaun rulant: Semnătura evaluator: Semnătură manager furnizor servicii de scaune rulante B.11: Prescrierea (selecția) dispozitivelor de suport postural pentru sprijinirea capului, coapselor și a gambelor Citiți și răspundeți la următoarele întrebări: Jonah are o programare pentru o evaluare. Pe parcursul procedurii de simulare manuală, constatați că membrele inferioare au tendința să alunece spre exterior (abducție), dar cu un grad redus de sprijin puteți să repoziționați coapsele în poziția neutră de ședere (genunchii mai apropiați). o Care sunt modificările pe care le puteți aduce scaunului rulant și pernei, în așa fel încât utilizatorul să poată avea coapsele în poziția neutră de ședere? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 51 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sam folosește acest scaun rulant de doi ani. A avut o leziune la nivelul capului și membrele sale inferioare sunt destul de rigide și fixe. Pe parcursul evaluării, constatați că acestea sunt orientate spre interior, dar genunchii pot fi poziționați pentru atingerea unei posturi mai apropiate de cea corectă. Totuși, pentru a face acest lucru, este nevoie de destul de multă forță. Având genunchii într-o poziție mai apropiată de cea neutră de ședere, Sam se simte mai echilibrat. o Care sunt modificările pe care le puteți aduce scaunului rulant și pernei, în așa fel încât utilizatorul să poată avea membrele inferioare în poziția neutră de ședere? Elijah este mulțumit de faptul că scaunul său rulant este pliabil și că îl poate lua în mașină atunci când se deplasează la locul de muncă și înapoi. Cu toate acestea, Elijah are dureri de spate și coapsele sale tind să se atingă (adducție). Pe parcursul evaluării, constatați că Elijah poate menține poziția așezat și, cu un grad redus de suport, membrele inferioare ating poziția neutră de ședere. o Care sunt modificările pe care le puteți aduce scaunului rulant și pernei, în așa fel încât membrele inferioare ale utilizatorul să fie în poziția neutră de ședere? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 52 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) – listă de verificare a pașilor Utilizați tabelul de mai jos ca instrument în planificarea și pregătirea scaunului rulant și a dispozitivelor de suport postural. Enumerați sarcinile (preferabil în ordinea în care acestea trebuie efectuate). Decideți cine va fi responsabil pentru fiecare sarcină. Bifați fiecare sarcină după ce a fost finalizată. Enumerați sarcinile Persoană responsabilă Bifați când se finalizează Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 53 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sesiunea practică 2: Pregătirea produsului (a scaunului rulant) – Listă de verificare preliminară utilizării scaunului rulant – nivel intermediar Utilizați lista de verificare preliminară utilizării scaunului rulant pentru a vă asigura că acesta este pregătit pentru a fi probat de utilizator în condiții de siguranță. Scaunul rulant în ansamblu, incluzând dispozitivele de suport postural Nu există margini ascuțite Nu există părți defecte sau zgâriate Traiectoria scaunului rulant este dreaptă Roțile frontale Se învârt fără a întâmpina vreo rezistență Se învârt fără a atinge furca roții Șuruburile sunt strânse Furcile roților frontale Furca roții frontale se învârte fără a întâmpina vreo rezistență. Roțile din spate Se învârt fără a întâmpina vreo rezistență Șuruburile axului sunt strânse Anvelopele sunt umflate în mod corect (la presiunea aplicată cu un deget, anvelopele se deformează mai puțin de 5 mm) Inelele de antrenare nu prezintă niciun pericol Frânele Funcționează corespunzător Suporturile de picioare Suporturile de picioare sunt montate corespunzător Cadrul Scaunul rulant se pliază și se depliază cu ușurință În cazul unui scaun rulant cu spătar pliabil - spătarul se pliază și revine în poziția inițială cu ușurință Perna Perna este introdusă corect în husă Perna este poziționată corect în scaunul rulant Materialul textil al pernei este întins, dar nu mai mult decât este necesar Dacă scaunul rulant are o suprafață de ședere rigidă: perna acoperă în întregime suprafața de ședere Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 54 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar B.14: Instruirea utilizatorului de scaun rulant Parcurgeți UNA dintre poveștile utilizatorilor de scaune rulante de mai jos. Formatorul vă va indica pe care dintre ele să o citiți. Decideți care sunt abilitățile pe care trebuie să le dobândească utilizatorul pentru a putea folosi și întreține noul său scaun rulant. Completați lista de verificare pentru instruirea utilizatorului de scaun rulant – nivel intermediar, aflată pe pagina următoare. Decideți care este rolul fiecărei persoane din grupă: utilizator scaun rulant, personal al furnizorului de servicii de scaune rulante sau membru de familiei/însoțitor. Persoana care alege să reprezinte furnizorul de servicii de scaune rulante trebuie să exerseze modalitatea de predare a cel puțin trei dintre aceste abilități, care să fie însușite de către ceilalți membrii ai echipei. Folosiți sugestiile din capitolul „Cum să avem o sesiune de instruire a utilizatorului de scaun rulant eficientă” prezentat în Manualul participantului. Joshua Joshua, în vârstă de 6 ani, are diagnosticul de paralizie cerebrală, având mișcări necontrolate bruște. I s-a prescris (selectat) un scaun rulant pentru copii dotat cu dispozitive de suport postural, incluzând o centură pentru bazin, inserții laterale pentru bazin și inserții laterale pentru trunchi. Pielea lui Joshua este subțire, sensibilă, acesta fiind motivul pentru care inserțiile laterale pentru trunchi au o căptușeală suplimentară, pentru a preveni apariția escarelor. Noul scaun rulant al lui Joshua are o caracteristică referitoare la unghiul de înclinare, care permite înclinarea înspre înapoi a scaunului rulant și revenirea la poziția inițială. De asemenea, există o bară anti-înclinare, care poate fi demontată înainte de călătoriile pe drum accidentat sau de urcarea și coborârea bordurilor. În vederea transportului, roțile din spate pot fi detașate, iar suprafața de ședere poate fi îndepărtată de pe cadru. Joshua merge la grădiniță în fiecare dimineață. Transportul este asigurat de către un serviciu oferit de grădiniță. Vehiculul este o mașină mică ce are trei roți. Părinții săi sunt îngrijorați de faptul că există posibilitatea ca scaunul rulant să nu încapă în vehicul. Joshua a venit pentru a proba noul său scaun rulant. Mama sa îl însoțește. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 55 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sangita Sangita are trei ani și este diagnosticată cu spina bifida. În cazul ei sunt prezente dificultăți de mobilitate; lipsește sensibilitatea sub nivelul taliei și există o protuberanță în partea inferioară a coloanei vertebrale. Părinții ei spun că are dificultăți în ceea ce privește controlul asupra vezicii și al sfincterelor și că apar în mod frecvent infecții ale tractului urinar. Sangita a venit la centrul de servicii de scaune rulante pentru probarea primului ei scaun rulant, care are un sistem de roți cu detașare rapidă, centură pentru bazin, inserții laterale pentru bazin și spătar cu contur pentru a evita formarea presiunii la nivelul părții unde se este localizată protuberanța, pe partea inferioară a coloanei vertebrale. De asemenea, Sangita are și o pernă pentru reducerea presiunii. A venit însoțită de ambii părinți. Aceștia sunt îngrijorați că având scaunul rulant, Sangita nu va mai dori să se deplaseze cu ajutorul cârjelor. Totuși, Sangita este frustrată de faptul că nu se poate juca afară cu fratele și surorile sale. Kim Som Kim Som are 40 de ani și a avut un traumatism cranio-cerebral în urmă cu 15 ani. El este subponderal și are dificultăți în ceea ce privește consumul alimentelor. Are o curbură a coloanei vertebrale care este fixă și orientată înspre înainte. Kim Som nu se poate ridica și depinde în totalitate de mama lui. Nu vorbește, dar mama sa spune că el înțelege instrucțiunile simple. Pe parcursul evaluării a fost identificată prezența riscului de apariție a escarelor, din cauza greutății scăzute, a imposibilității de a efectua mișcări în mod voluntar și a unei escare pe care a avut-o în trecut (cauzată de poziția în pat). Kim Som tocmai a primit primul său scaun rulant. Scaunul rulant are o pernă pentru reducerea presiunii și dispozitiv de suport postural pentru o poziție mai confortabilă. Mama sa îi este și însoțitor și a venit cu el la întâlnirea programată pentru probarea scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 56 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Listă de verificare a instruirii utilizatorului de scaun rulant – nivel intermediar Abilități de învățat Abilități învățate Manevrarea scaunului rulant Plierea și ridicarea scaunului rulant Demontarea și montarea oricărui dispozitiv de suport postural care trebuie îndepărtat în vederea efectuării transportului Utilizarea roților cu sistem de decuplare rapidă Utilizarea frânelor Unghiul de înclinare și bara anti-răsturnare (dacă se folosește) Poziția corectă a dispozitivelor de suport postural atunci când utilizatorul folosește scaunul rulant Utilizarea pernei, inclusiv poziționarea corectă Transferuri Transfer independent Transfer asistat Altele Utilizarea și manevrarea scaunului rulant Propulsia corectă (utilizarea metodei de propulsie preferate a utilizatorului de scaun rulant) Urcarea și coborârea unei pante Urcarea și coborârea unei trepte Deplasarea pe teren accidentat Menținerea în echilibru pe două roți Durata petrecută în scaunul rulant (pentru copii și adulți cu nevoi suplimentare de suport postural) Propulsia asistată Prevenirea apariției escarelor Verificarea zonelor asupra cărora se exercită o presiune crescută Tehnici pentru reducerea presiunii Alimentație și hidratare corespunzătoare Ce trebuie făcut în cazul apariției unei escare Întreținerea la domiciliu a scaunului rulant Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 57 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Curățarea scaunului rulant; spălarea și uscarea pernei și a husei Lubrifierea părților mobile Umflarea anvelopelor Strângerea șuruburilor și a piulițelor Strângerea spițelor Verificarea părților textile Verificarea existenței petelor de rugină Verificarea pernei Cum se procedează în cazul apariției unei probleme Scaunul rulant necesită reparații Scaunul rulant nu este corespunzător sau nu este confortabil Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 58 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar B.15: Recapitulare Pregătiți o prezentare cu durata de 10 minute pentru întregul grup, în care să vorbiți despre utilizatorul de scaun rulant cu care a lucrat grupa din care faceți parte și despre aspectele învățate. Prezentarea trebuie să includă următoarele puncte: 1. Informațiile dobândite în cadrul evaluării: o obiectivele utilizatorului de scaun rulant (motivul pentru care dorește să aibă un scaun rulant); o cerințe fizice; o cerințe legate de stilul de viață; o dacă utilizatorul are deja un scaun rulant și dacă acest scaun rulant satisface nevoile sale; o prezența escarelor, riscul apariției sau istoricul acestora; o metoda de propulsie; o poziția de ședere fără suport; o rezultatele analizei posturii bazinului și a șoldului; o rezultatele procedeului de simulare manuală. 2. Scaunul rulant și perna prescrise (selectate): o tipul de scaun rulant; o tipul de pernă; o orice dispozitive de suport postural prescrise. 3. Probarea: o orice probleme identificate în etapa de probare a produsului (a scaunului rulant) care trebuie rezolvate – care au fost soluțiile găsite. 4. Instruirea utilizatorului: o care este nevoia de instruire identificată de către membrii grupei, împreună cu utilizatorul de scaun rulant? 5. Feedback-ul utilizatorului de scaun rulant o utilizatorul a oferit feedback după primirea scaunului rulant? 6. Plan de monitorizare: o care sunt activitățile planificate în ceea ce privește monitorizarea? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 59 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT B.16: Întreținerea, reparațiile și monitorizarea Citiți povestea fiecărui utilizator de scaun rulant. Completați un formular de monitorizare a utilizării scaunului rulant pentru fiecare utilizator. Discutați și notați activitățile recomandate. Thusitha Thusitha este un băiat de 7 ani, care locuiește cu părinții și sora mai mare. Thusitha are distrofie musculară și în urmă cu un an a primit un scaun rulant prin intermediul serviciului de scaune rulante. În acea perioadă, el putea să se deplaseze pe distanțe scurte, fără a utiliza un echipament de mobilitate. Era capabil să efectueze singur transferul în și din scaunul rulant, în picioare. A spus că dorește să aibă un scaun rulant pentru că are dificultăți în a se deplasa la școală. La monitorizare, Thusitha a menționat că întâmpină dificultăți în a se așeza sau a se ridica fără ajutor din scaunul rulant. După amiezile, la școală, el se simte obosit, iar nivelul de confort scade. Acest aspect îl împiedică să se concentreze. Scaunul său rulant are dimensiunea corectă și are un spătar pliabil de înălțime medie, dotat cu o pernă simplă, pentru confort. Când a fost întrebat despre gradul de satisfacție legat de scaunul rulant, Thusitha a acordat nota 4 din 5. Mirella Mirella are 23 de ani și a avut poliomielită. Ea deține stupi, iar mierea o vinde în piața din localitate. Acum doi ani, a primit un scaun rulant cu tricicletă atașabilă. Mirela avea nevoie de dispozitive de suport postural și i-a fost prescrisă o pernă cu modificări, confecționată din mai multe straturi de spumă/burete. Spătarul scaunului rulant are la nivelul baziniului o inserție posterioară pentru bazin. La vizita de monitorizare, Mirella a spus că folosește scaunul rulant și tricicleta în fiecare zi pentru a se deplasa la piață și înapoi. Ea a menționat că recent a fost nevoită să repare două pene de roată. La verificarea scaunului rulant, personalul furnizorului de servicii de scaune rulante a observat că anvelopele erau foarte uzate. Inserția posterioară pentru bazin alunecase pe suprafața de ședere a scaunului rulant și perna părea foarte plată. Când a fost întrebată despre gradul de satisfacție legat de scaunul rulant, Mirella a acordat nota 3 din 5. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 60 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Ursula Ursula are 6 ani și este diagnosticată cu paralizie cerebrală. Îi place să cânte în corul bisericii împreună cu sora ei. A primit scaunul rulant și dispozitivele de suport postural cu opt luni în urmă. Ursula fost bolnavă și a lipsit de la prima programare de monitorizare. Părinții ei au spus că în ultimul timp Ursulei nu îi mai place să stea în scaunul rulant și cere să fie ridicată din el după o oră. Au observat o pată întunecată pe coaste, în zona de lângă una dintre inserțiile laterale pentru trunchi și se întrebau dacă aceasta ar putea fi cauza problemei. Personalul furnizor de servicii de scaune rulante a găsit un spațiu retras și i-a cerut Ursulei și părinților ei permisiunea de a-i verifica aspectul suprafeței pielii. Astfel, s-a confirmat existența unei pete întunecate. Au analizat scaunul rulant și au observat că stratul de spumă al inserției laterale pentru trunchi era comprimat. Când au fost întrebați despre gradul de satisfacție legat de scaunul rulant al Ursulei, părinții ei au acordat nota 4 din 5. Formular de monitorizare a utilizării scaunului rulant 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data probării produsului (a scaunului rulant): Data efectuării monitorizării: Numele persoanei care efectuează monitorizarea: Monitorizarea a avut loc la: Domiciliul utilizatorului Centrul de reparații scaune rulante Altă locație: ______ __________________________ _________ 2. Interviu Notați activitatea recomandată: Utilizați scaunul rulant atât de frecvent precum vă doriți? Da Nu Dacă nu - de ce nu? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 61 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Întâmpinați vreo dificultate în utilizarea scaunului dvs. rulant? Da o Nu Dacă da - care sunt aceste dificultăți? Aveți întrebări în ceea ce privește utilizarea scaunului rulant? Da o Nu Dacă da - care sunt acestea? Este nevoie de instruire suplimentară? Utilizatorul de scaun rulant are escare? Da o Nu Descrieți (localizarea și gravitatea) Cum ați nota, pe o scală de la 1 la 5, gradul de satisfacție oferit de scaunul dvs. rulant? (1 - deloc satisfăcut și 5 foarte satisfăcut) Notă: Comentarii: 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în siguranță? Da Nu Perna este în stare bună și poate fi utilizată în siguranță? Da Nu Dacă răspunsul la oricare dintre întrebările de mai sus este „nu”, vă rugăm să precizați problema. 4. Verificare ajustări Scaunul rulant se potrivește? Da Nu Dacă nu - care sunt problemele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = nesigur) (dacă există riscul apariției escarei) Stânga: Dreapta: Utilizatorul are o poziție confortabilă în scaunul rulant atunci când scanul rulant nu se mișcă, este manevrat de către acesta, sau pe întreg parcursul zilei? Da Nu Dacă nu - care sunt problemele? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 62 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Formular de monitorizare a utilizării scaunului rulant 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data probării produsului (a scaunului rulant): Data efectuării monitorizării: Numele persoanei care efectuează monitorizarea: Monitorizarea a avut loc la: Domiciliul utilizatorului Centrul de reparații scaune rulante Altă locație: ______ __________________________ _________ 2. Interviu Notați activitatea recomandată: Utilizați scaunul rulant atât de frecvent precum vă doriți? Da Nu Dacă nu - de ce nu? Întâmpinați vreo dificultate în utilizarea scaunului dvs. rulant? Da o Nu Dacă da - care sunt aceste dificultăți? Aveți întrebări în ceea ce privește utilizarea scaunului rulant? Da o Nu Dacă da - care sunt acestea? Este nevoie de instruire suplimentară? Utilizatorul de scaun rulant are escare? Da o Nu Descrieți (localizarea și gravitatea) Cum ați nota, pe o scală de la 1 la 5, gradul de satisfacție oferit de scaunul dvs. rulant? (1 - deloc satisfăcut și 5 foarte satisfăcut) Notă: Comentarii: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 63 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în siguranță? Da Nu Perna este în stare bună și poate fi utilizată în siguranță? Da Nu Dacă răspunsul la oricare dintre întrebările de mai sus este „nu”, vă rugăm să precizați problema. 4. Verificare ajustări Scaunul rulant se potrivește? Da Nu Dacă nu - care sunt problemele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = nesigur) (dacă există riscul apariției escarei) Stânga: Dreapta: Utilizatorul are o poziție confortabilă în scaunul rulant atunci când scanul rulant nu se mișcă, este manevrat de către acesta, sau pe întreg parcursul zilei? Da Nu Dacă nu - care sunt problemele? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 64 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Formular de monitorizare a utilizării scaunului rulant 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data probării produsului (a scaunului rulant): Data efectuării monitorizării: Numele persoanei care efectuează monitorizarea: Monitorizarea a avut loc la: Domiciliul utilizatorului Centrul de reparații scaune rulante Altă locație: ______ __________________________ _________ 2. Interviu Notați activitatea recomandată: Utilizați scaunul rulant atât de frecvent precum vă doriți? Da Nu Dacă nu - de ce nu? Întâmpinați vreo dificultate în utilizarea scaunului dvs. rulant? Da o Nu Dacă da - care sunt aceste dificultăți? Aveți întrebări în ceea ce privește utilizarea scaunului rulant? Da o Nu Dacă da - care sunt acestea? Este nevoie de instruire suplimentară? Utilizatorul de scaun rulant are escare? Da o Nu Descrieți (localizarea și gravitatea) Cum ați nota, pe o scală de la 1 la 5, gradul de satisfacție oferit de scaunul dvs. rulant? (1 - deloc satisfăcut și 5 foarte satisfăcut) Notă: Comentarii: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 65 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în siguranță? Da Nu Perna este în stare bună și poate fi utilizată în siguranță? Da Nu Dacă răspunsul la oricare dintre întrebările de mai sus este „nu”, vă rugăm să precizați problema. 4. Verificare ajustări Scaunul rulant se potrivește? Da Nu Dacă nu - care sunt problemele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = nesigur) (dacă există riscul apariției escarei) Stânga: Dreapta: Utilizatorul are o poziție confortabilă în scaunul rulant atunci când scanul rulant nu se mișcă, este manevrat de către acesta, sau pe întreg parcursul zilei? Da Nu Dacă nu - care sunt problemele? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 66 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului Pregătirea produsului (scaunului rulant) – listă de verificare a sarcinilor Utilizați tabelul de mai jos ca instrument în planificarea și pregătirea scaunului rulant și a dispozitivelor de suport postural. Enumerați sarcinile (preferabil în ordinea în care acestea trebuie efectuate). Decideți cine va fi responsabil pentru fiecare sarcină. Bifați fiecare sarcină după ce a fost finalizată. Enumerați sarcinile Persoană responsabilă Bifați când se finalizează Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 67 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sesiunea practică 4: Evaluarea, prescrierea (selectarea), pregătirea produsului (scaunului rulant), reglarea și instruirea utilizatorului Folosiți lista de verificare preliminară utilizării scaunului rulant pentru a vă asigura că scaunul rulant este pregătit pentru a fi probat de către utilizator, în condiții de siguranță. Listă de verificare preliminară utilizării scaunului rulant – nivel intermediar Scaunul rulant în ansamblu, incluzând dispozitivele de suport postural Nu există margini ascuțite Nu există părți defecte sau zgâriate Traiectoria scaunului rulant este dreaptă Roțile frontale Se învârt fără a întâmpina vreo rezistență Se învârt fără a atinge furca roții Șuruburile sunt strânse Furcile roților frontale Furca roții frontale se învârte fără a întâmpina vreo rezistență. Roțile din spate Se învârt fără a întâmpina vreo rezistență Șuruburile axului sunt strânse Anvelopele sunt umflate în mod corect (la presiunea aplicată cu un deget, anvelopele se deformează mai puțin de 5 mm) Inelele de antrenare nu prezintă niciun pericol Frânele Funcționează corespunzător Suporturile de picioare Suporturile de picioare sunt montate corespunzător Cadrul Scaunul rulant se pliază și se depliază cu ușurință În cazul unui scaun rulant cu spătar pliabil - spătarul se pliază și revine în poziția inițială cu ușurință Perna Perna este introdusă corect în husă Perna este poziționată corect în scaunul rulant Materialul textil al pernei este întins, dar nu mai mult decât este necesar. Dacă scaunul rulant are o suprafață de ședere rigidă: perna acoperă în întregime suprafața de ședere Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 68 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 69 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel intermediar. Caiet de exerciții practice Pagina 70 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel inte rmediar ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
Materialul nu poate fi reprodus integral sau parțial fără menționarea sursei și fără acordul scris al Fundației Motivation România. Fundația Motivation România Str. Podișor nr 1, Sat Buda, Comuna Cornetu, Ilfov, România Tel: 021 448 02 42 Fax: 021 448 11 07 Email: info@motivation.ro www.motivation.ro Telefonul utilizatorului de scaun rulant: 0800 030 668
嗀㒻嗂ᑄ㒄➦ぶ㦄 䧌ⷷ 䊘⥠䃾 世界卫生组织 学员手册 轮椅服务中级教程 求真出版社 图书在版编目 (CIP)数据 轮椅服务中级教程/ (美)弗罗斯特等著;钟磊等译.-北京:求真出版社,2016.1 ISBN978 7 80258 230 9 Ⅰ.①轮… Ⅱ.①弗…②钟… Ⅲ.①四肢-残疾人-社会服务-技术培训-教材 Ⅳ.①C913.69 中国版本图书馆CIP数据核字 (2016)第030732号 世界卫生组织于2013出版,原标题为 (WheelchairServiceTrainingPackage:Inter- mediateLevel)ⓒ世界卫生组织2013 世界卫生组织授予深圳市残疾人辅助器具资源中心翻译中文版的权利,并委托求真出 版社出版。中文版的翻译质量和准确性由深圳市残疾人辅助器具资源中心负责。若英 文版与中文版有任何出入,应以英文原版为准。 轮椅服务中级教程:学员手册ⓒ世界卫生组织2016 轮椅服务中级教程 著 者:[美]弗罗斯特 等 译 者:钟 磊 赫 琳 责任编辑:计 悦 出版发行:求真出版社 社 址:北京市西城区太平街甲6号 邮政编码:100050 印 刷:北京华联印刷有限公司 经 销:新华书店 开 本:787×1092 1/16 字 数:611千字 印 张:29.25 版 次:2016年5月第1版 2016年5月第1次印刷 书 号:ISBN978 7 80258 230 9/C·6 定 价:98.00 编辑热线:(010)83190270 销售服务热线:(010)83190297 83190289 83190292 版权所有 侵权必究 印装错误可随时退换 术 语 本教程中的术语定义如下: 适用的轮椅 能够满足使用者需求以及环境状况的轮椅;提供适配和体位支撑并且安全耐 用;国内可得到且在国内能够以最经济和实惠的价格购买和维修并接受持续 的服务。 手动轮椅 由使用者本人驱动或由其他人推行的轮椅。 体位支撑装置 (PSD) 用于提供附加体位支撑的装置,是中级轮椅服务的主要内容。 轮椅 为行走或移动困难者提供轮式移动和坐位支撑的器具。 轮椅改制 对轮椅进行改造。 轮椅供应体系 轮椅设计、生产、供应和提供服务的总术语。 轮椅服务 轮椅供应体系的一部分,以确保每位使用者都能获得一辆适用的轮椅。 轮椅服务人员 提供适用轮椅服务中具有专业技能的人员。 轮椅使用者 有行走或移动困难而需要使用轮椅代步的人士。
, 1 序言 2 《轮椅服务中级教程》概述 6 A:核心知识 7 A.1:受益于附加体位支撑的轮椅使用者 12 A.2:残障儿童 19 B:轮椅服务步骤 20 步骤1:转介和预约 20 步骤2:评定 20 评定概述和面谈评估 48 身体检查——— 无支撑坐姿 52 身体检查——— 骨盆和髋关节姿势检查 57 身体检查——— 用手模拟 61 身体检查——— 进行测量 69 步骤3:处方 (选择) 69 选择轮椅和坐垫 79 体位支撑装置 (PSDs)的处方 (选择)——— 介绍 94 体位支撑装置 (PSDs)的处方 (选择)——— 稳定骨盆 98 体位支撑装置 (PSDs)的处方 (选择)——— 支撑髋关节 100 体位支撑装置 (PSDs)的处方 (选择)——— 支撑躯干 104 体位支撑装置 (PSDs)的处方 (选择)——— 支撑头部、大腿 和小腿 107 步骤4:经费与订购 107 步骤5:产品 (轮椅)准备 108 计划和实施轮椅及体位支撑装置 (PSD)准备 109 当制作体位支撑装置 (PSDs)时应记住什么 110 制作体位支撑装置 (PSDs)和改制需要的材料和工具 112 如何制作PSDs 128 进行轮椅安全和准备检查 128 中级轮椅安全和准备检查表 129 步骤6:适配 139 步骤7:使用者培训 139 对轮椅使用者有帮助的技能是什么? 143 步骤8:保养、维修和随访 143 随访管理 144 常见的随访措施 1 序 言 轮椅是提高个人移动能力最常用的辅助器具之一,是享有人权和尊严生活的前提。有了轮椅,可 以帮助残疾人成为所在社区里更有效的成员。对许多残疾人而言,拥有一辆适用的、设计优良并且适 配的轮椅是他们融入和参与社会的第一步。 联合国 《残疾人机会均等标准规则》、《残疾人权利公约》和 “世界卫生大会 WHA58.23号决议” 中规定残疾包括预防、管理和康复的内容,都强调轮椅和其他辅助器具的重要性。为确保残疾人特别 是那些资源有限地区的残疾人能够容易地获得一辆适用的轮椅,世界卫生组织与美国国际开发署 (USAID)和国际假肢与矫形器学会 (ISPO)合作,编写了 《资源有限地区手动轮椅服务指南》。 为了在轮椅服务指南的基础上恰如其分地培训人力资源并提供良好的轮椅服务体系,世界卫生组 织为不同层次的负责管理不同水平干预的卫生和康复人员按照轮椅服务指南大纲主动编写了 《轮椅服 务教程》系列。在2012年6月成功出版 《轮椅服务初级教程》之后,我们非常高兴地出版 《轮椅服务 中级教程》。 为了拓展 《轮椅服务初级教程》中获得的知识和技能,《轮椅服务中级教程》主要关注儿童,因为 很多儿童由于常见发育障碍的特性,需要轮椅用于移动和体位支撑。 AlanaOfficer RobertG.Horvath 协调员 经理 残疾与康复组 弱势群体项目 暴力和伤害预防及残疾司 民主、人权和良治卓越发展中心 世界卫生组织 美国国际开发署 ,%3" 2 《轮椅服务中级教程》概述 简介 世界卫生组织 (WHO)于2008年和2012年分别发布了 《资源有限地区手动轮椅服务指南①》和 《轮椅服务初级教程》(WSTP B),WHO与美国国际开发署 (USAID)共同开发了这套 《轮椅服务 中级教程》(WSTP I)。《轮椅服务中级教程》是 WHO 轮椅服务系列教程的第二部分,它更注重于 解决那些行走和移动严重困难以及躯干控制较差者的需求。当编写本教程时,特别注意到要为那些躯 干控制较差和不能独立坐直的儿童提供适用的轮椅。 轮椅是能使个人移动的最常用辅助器具之一。对于行走困难的人士,满足他们身体、生活方式和 环境需求的一辆轮椅是一个重要的工具,促使他们极大地改善健康、社会和生活水平。行动能力为轮 椅使用者获得学习、工作和参与文化活动以及卫生保健服务的机会。 移动的重要性反映在联合国 《残疾人权利公约》(UNCRPD)中,提倡 “采取有效措施确保残疾 人尽可能独立地享有个人移动能力”。为确保有效的个人移动,轮椅使用者需要正确适配和满足他们特 殊需求的轮椅。这需要对个人需求做出反应的一种方法。 满足轮椅使用者个人需求的一种有效方法是通过轮椅服务提供轮椅。然而,数据显示真正需要轮 椅的人士中只有不到5% 获得了正确适配的轮椅。另外,轮椅服务人员接受有效地开具轮椅处方的培 训机会很少。 《轮椅服务中级教程》用于支持服务人员的培训,帮助他们完成中级轮椅服务中临床和技术角色 (见 《资源有限地区手动轮椅服务指南》表4.2),本教程是为那些给需要附加体位支撑才能坐直的轮 椅使用者开始工作的服务人员提供所需的理论和实践支持。本教程包括如何评估个人需求,协助选择 和安装带附加体位支撑的最适用轮椅,培训使用者和护理者如何使用和保养他们的轮椅并开展随访。 ① 世界卫生组织,《资源有限地区手动轮椅服务指南》,日内瓦,2008(http://www.who.int/ disabilities/publications/technology/wheelchairguidelines/en/index.html,取得日期2011年12月15 日) 3 本教程可以在35~40小时内完成,根据不同情况的具体需求和可用资源,培训时间可能会延长或 缩短。鼓励学员与教师共同实践,提高职业素质并增强独立工作能力。 《轮椅服务中级教程》既可以提供给已经在这个领域工作的人员作为独立的短期培训项目,又可以 把该教程纳入到卫生保健和康复人员培训项目的课程里。 目标人群 本教程是为所有期望在工作场所提供中级轮椅服务的人员和志愿者准备的,这其中包括卫生保健、 康复或技术人员,例如:作业治疗师、物理治疗师、假肢制作师、矫形器制作师、社区医护人员和社 区康复工作者。 目的 本中级教程是为支持服务人员或志愿者的培训而设计的,使他们能为那些需要附加体位支撑才能 坐直的儿童和成人提供适合的手动轮椅和坐垫。 本教程的主要目的是提高轮椅服务人员的知识和技能,本教程的实施将有助于: 增加能满足个人需求的轮椅使用者数量; 增加接受轮椅服务中级培训的人员数量; 提高轮椅服务人员的职业素质; 针对需要比初级轮椅服务更高层级干预的轮椅使用者,提高为他们轮椅服务的质量; 将本教程加入到常规辅助医疗/康复培训项目中; 将提供轮椅服务更大程度地整合到康复服务里。 范围 本教程包括: 如何评定需要附加体位支撑轮椅的儿童和成人的移动和体位支撑需求; 如何与他们一起确定最可能的移动解决方案; 提供带合适坐垫和附加体位支撑的手动轮椅所必需的知识和实践技巧; 培训轮椅使用者以及在适当的时候培训他们的家人/护理者,帮助他们充分利用自己的轮椅; 随访轮椅使用者以确保他们的轮椅持续地满足需求。 ,%3" 4 需要的知识和技能 以往轮椅服务的经验对于学员最大限度地从中级教程中获得知识是必要的。中级教程的设计是基 于假定学员能够展示 WHO《轮椅服务初级教程》中学到的技能,并且具有初级轮椅服务的经验。 结构 《轮椅服务中级教程》是专门提供给熟悉中级轮椅服务并能够自信地演示本教程技能的教师。这里 有一系列的教学资源,包括: 《教师手册》和培训工具; 《学员手册》; 《实训手册》; 轮椅服务表; 轮椅服务检查表; 视觉教具,包括幻灯片、视频和海报。 发展进程 《资源有限地区手动轮椅服务指南》发布后,WHO 接着成立了工作组编写轮椅服务教程。2008 年10月由 WHO召集工作组第一次会议确定教程的范围和内容。在与教程内容所涉及领域超过20位 专家的广泛交流并收集反馈意见后,编著核心小组为本教程在不同地点进行实地试点准备。 2011年,本教程在罗马尼亚、肯尼亚和东帝汶进行试点。WHO 轮椅教程工作组成员观察每一个 试点。参加试点实操单元的教师、学员和轮椅使用者的反馈意见已被纳入最后的定稿。除了试点之外, 对中级教程也进行了广泛的同行评审。15位轮椅专家同行评审文件,他们有价值的反馈已经体现在最 终的文稿中。 所有参与编写教程的作者都完成一项利益声明 (DOI),无人宣称与相关的主题有任何利益冲突。 如何使用学员手册 本学员手册概括了轮椅服务中级培训的知识。学员可以在培训结束后利用学员手册提醒自己每单 元讲授的要点。本手册分为两部分: A:核心知识 5 B:轮椅服务步骤 A:核心知识——— 本部分包括与所有轮椅服务步骤有关的信息。在某些情况下,根据学员的学习 需求,教师可以选择增加一些知识到本部分中。 B:轮椅服务步骤——— 本部分包括有助于学员开展轮椅中级服务八个步骤中每个步骤的信息 (见 世界卫生组织 《资源有限地区手动轮椅服务指南》,第76页)。 初级和中级轮椅服务培训 为了给轮椅服务人员提供正确的培训,WHO培训教程在两个层次提供培训———初级和中级。 初级教学员如何为行走和移动困难,但是不需要附加体位支撑而能够坐直的儿童和成人提供 轮椅。 中级教学员如何为需要附加体位支撑才能坐直的儿童和成人提供轮椅。 中级培训以学员从初级培训中获得的知识和技能为基础。 ,%3" 6 A:核心知识 7 A.1:受益于附加体位支撑的轮椅使用者 轮椅使用者是指已经有一辆轮椅的人或者步行能力受限但能从轮椅使用中受益的人。轮椅使用者 包括: 儿童、成年人和老人; 有不同健康状况、生活方式、生活角色和背景的人; 在不同环境,包括农村、城乡结合部及城市生活和工作的人。 每位轮椅使用者的需求不同。然而,他们都需要一辆适用的轮椅。 每辆适配良好的轮椅都为轮椅使用者提供一定的体位支撑。靠背、坐垫、脚踏板和扶手都能根据 轮椅使用者的尺寸进行调整以提供体位支撑。然而许多儿童和成人在他们使用的轮椅上需要附加体位 支撑。 体位支撑装置 (PSD)能够提供附加体位支撑———是提供附加体位支撑的物理装置,体位支撑装 置是 《轮椅服务中级教程》的重要内容,包括为在轮椅上提供体位支撑进行的任何增加或修改。在本 教程中,体位支撑装置简称PSD。 受益于附加体位支撑的轮椅使用者 有些人没有附加支撑就无法坐直,有些人需要许多附加支撑,并且有些人只需对轮椅稍加改制。 附加体位支撑可以通过不同方式提供,有些解决方案很简单,并且在一个简单的小车间就可以完成, 有些解决方案则比较复杂。 何时需要附加体位支撑? 人们需要附加体位支撑的原因各不相同,通常当轮椅不能提供足够的支撑来帮助使用者坐直如下 述情形是需要的。有时轮椅使用者或家人/护理者也会对他们所需进一步支撑提出好的建议。 需要附加支撑的原因包括: 不能坐直 不受控制的运动或痉挛 关节强直 肌肉僵硬 虚弱无力 ,%3" 8 疲劳 疼痛或不舒适 平衡障碍 定义:体位支撑装置 (PSD) 体位支撑装置 (PSD)是提供附加体位支撑的物理装置。 PSD是中级轮椅服务的重要内容。 附加体位支撑有何帮助? 附加体位支撑在以下4个方面对轮椅使用者有帮助: 1.改善平衡、姿势和稳定性 改善平衡、姿势和稳定性能帮助轮椅使用者完成没 有体位支撑时不可能完成或很难完成的活动。 2.提高舒适性 附加体位支撑可以使轮椅使用者更舒适并且能够在 他们疲劳前增加坐轮椅的时间。 3.有助于预防压疮的发生 压疮发展相当迅速,良好的体位支撑有助于预防压 疮,确保身体的一部分没有超负荷。 坐直的好处就是体重被均匀分布,这有助于降低压 疮的风险。 当轮椅使用者不能坐直时,他们的体重就不能均匀 分布,他们身体的一侧比另一侧承担更多的重量, 如果附加体重作用于骨突部位皮肤上,就存在压疮 的高风险。 9 骨突部位包括坐骨 (结节)、肋骨、髋骨 (转子)、脊骨 (脊椎)或尾骨 (尾椎)。 当轮椅使用者没有得到良好的支撑,他/她就会在椅座上滑动,产生导致压疮的剪切力,良好的坐 位支撑可以避免滑动和剪切力。 4.有助于减缓或预防未来姿势问题的发展 良好的体位支撑可以预防姿势引发的问题,如果姿势引发的问题已经出现,良好的体位支撑则可 以减缓或预防这个问题加重。在卧位、坐位、立位良好的体位支撑,尽早开始是重要的。 安全地进食和饮水 有些坐直困难的轮椅使用者还伴有安全吞咽问题,对于那些进食和饮 水引起不适的人,有时是令人恐惧的,并且通常是危险的。当人们有 吞咽困难时,少许食物和水就可能进入气管,可以导致肺部感染,使 病情加重,甚至窒息导致死亡。 轮椅上附加体位支撑可以确保轮椅使用者在进食和饮水时坐直。 改进体位支撑恰好也是吞咽问题人士解决办法的一部分。如果可能的 话,将有吞咽问题的儿童和成人转介给处理这方面有经验的人,这些 人可能是儿科医生、言语治疗师或任何与健康相关或社区健康工作者, 他们具有帮助人们处理吞咽问题的知识和技能。 轮椅使用者需要什么? 轮椅使用者想要舒适并能享受生活,重要的是在轮椅上附加支撑不会使日常活动变得更难。 例如,附加体位支撑不会妨碍上下轮椅、推动轮椅、靠近桌子或工作场所以及转移。 ,%3" 10 一辆轮椅和附加体位支撑应该总是: 实用且容易使用; 舒适且不会导致其他不适; 有助于轮椅使用者做事而不是更困难; 外观好看且不要太 “显眼”。 有时轮椅使用者发现很难习惯于有附加体位支撑的轮椅,这有不同的原因,包括: 轮椅使用者可能习惯一种姿势坐着,附加体位支撑改变了他们习惯的姿势,感觉不舒适或受 限制。 轮椅使用者可能不理解为什么要开具附加支撑的处方; 轮椅使用者可能感觉附加体位支撑看起来不好看,使他们的残疾更明显。 由于这些原因,轮椅服务人员与轮椅使用者和他们的家人/护理者在整个评定、处方、适配、使用 者培训及随访等步骤的密切沟通是非常重要的。总是与轮椅使用者讨论解决办法并且始终尊重他们的 意见并最终决定。 确保轮椅使用者使用附加体位支撑最好的方法就是: 轮椅使用者和他们的家人/护理者在评定、处方、适配、使用者培训和随访过程中全程参与; 帮助轮椅使用者和他们的家人/护理者理解附加体位支撑为什么会为他们带来帮助以及如何对 他们有益; 应该让轮椅使用者做最后的决定。 良好的姿势能够增强自尊 良好的附加体位支撑的一个重要好处就是能有助于轮椅使用者自我感 觉良好。提供良好的支撑处于一个更直立的姿势能帮助轮椅使用者感 觉更自信。 由于合适的支撑,轮椅使用者能够更多地参与社区生活。例如,移动 和附加体位支撑能使轮椅使用者去工作和上学;拜访朋友;出席宗教 仪式或其他社区活动。 11 检查表有助于确保有附加体位支撑的轮椅满足轮椅使用者的需求 下面的检查表能够帮助轮椅服务人员确保他们选择的任何一个附加体位支撑对轮椅使用者都是最 有效的。 检查表 √ 轮椅使用者和他们的家人/护理者全都参与到轮椅处方的决定中 □ 在最后确定前,轮椅使用者能够试用已经开具处方的有PSDs的轮椅 (如果可能,在 中心和家里)并给出反馈意见 □ 轮椅和PSDs能够帮助轮椅使用者做他/她想做的事情: PSDs提高了轮椅使用者做事的能力 □ PSDs不会妨碍轮椅使用者轻易上下轮椅 □ PSDs不会使整辆轮椅太重 □ 轮椅和PSDs对于轮椅使用者是舒适的: PSDs提供支撑并且让轮椅使用者坐轮椅的时间比没用体位支撑前长 □ PSDs提供足够的支撑和支撑轮椅使用者接近直立的坐姿且更舒适 □ 轮椅和PSDs外观好看 (对轮椅使用者) □ 轮椅和PSDs是安全的: 任何一个PSD成品是光滑的并且用软垫包好和减压 □ 对轮椅框架任何结构上的改变必须由有资质的人员进行检查 □ 轮椅使用者坐在轮椅上时,轮椅不会轻易地向前、向后或侧方翻倒 □ 轮椅和PSDs是实用的: 装饰面料能被清洁或拆下洗涤 □ 可拆数量尽可能少以避免丢失/错误使用 □ 轮椅能够容易放进小汽车/公共运输工具里 □ 轮椅可以容易地放在使用者家中 □ ,%3" 12 A.2:残障儿童 当为一位儿童提供轮椅时,重要的是要考虑儿童的生活与成人如何不同,这些不同影响轮椅服务 人员为儿童服务的工作方式以及选择轮椅和附加体位支撑,这些重要的不同是: 儿童进行的活动与成人的活动不同 (玩耍、上学); 儿童通常比较活跃,不会停留在一个位置很长时间; 儿童由成人照看; 通常儿童不能自己表达; 儿童仍在发育; 幼儿与成人坐姿不同; 儿童仍在成长。 满足儿童需求的轮椅 儿童使用的轮椅应该有助于他们参与每天的正常活动,轮椅对儿童的重要作用包括: 如果儿童自己推轮椅,轮椅应该: - 非常合适允许他们能够舒适地接触手推圈; - 对儿童足够轻便易于控制,尤其是上下 坡道。 应该设法确保关注儿童比他/她的轮椅更多。 拉高把手能帮助家人或护理者推轮椅时不用过于弯腰。 轮椅可以穿过不平坦和柔软的地面例如草地和沙地,使儿童更容易和他们的朋友们玩耍。 13 儿童的轮椅应该使他们上学更容易: - 如果儿童所在社区中大多数儿童走路去上学 ——— 思考轮椅是否能通过这些道路? 儿童需 要一辆适合粗糙路面的轮椅吗? - 如果儿童使用交通工具去上学 (例如小汽车、 公交车、人力车、出租车),思考轮椅如何 运输。 轮椅应该使他们在学校方便。儿童应该能够靠近 课桌,或轮椅需要一个桌面板作为工作台。 理想情况下,儿童轮椅应该: 使儿童能自己推轮椅 (如果他们能); 有把手让成人给予协助; 能通过不平坦和柔软的地面如草地和沙地; 使儿童上学更容易; 设计的款式、大小和颜色要有足够的吸引力; 使儿童在学校更方便。 不同的姿势 儿童通常并不总是坐着,一天里他们会不断地改变活动和体位,这意味着尽管轮椅很重要,儿童 也不应该整天都坐在轮椅上。 轮椅服务人员需要考虑儿童白天能够采取的其他体位,特别重要的是如果儿童只有非常有限的运 动,始终以同一个姿势坐着并且无法改变体位。 不同姿势和体位的例子包括: ,%3" 14 坐位 支撑儿童独立坐在地板上的一些不同方法是: 跨坐在一个滚筒或卷紧的毯子上。 坐时要借助家庭成员/护理者的支撑: - 插图显示一位妈妈,用双腿支撑她的残疾孩 子帮助他坐起来吃饼干,同时还抱着更小的 孩子。 提供一个低至地面的支撑椅座: - 像这样的椅座比带支撑椅座的轮椅便宜,对 于幼儿是一个不错的选择。 站立位 站立是儿童另一个重要体位,站立是每位儿童发展的重要部分,站立有助于形成髋关节和躯干的 正常曲度。 任何人长时间坐着会发生髋、膝、踝关节强直,站立时拉伸髋、膝、踝关节周围肌肉有助于预防 这些关节变得僵硬。 15 当儿童不能独立站立时,站立架可以给予帮助。为了 处方站立架,轮椅服务人员需要全面熟悉站立姿势和 站立支撑的不同方法。 如果提供一个站立架给儿童,应该检查是否有压力直 接作用在儿童的膝盖上,支撑腿部防止膝盖弯曲的最 佳位置就是在膝盖下方的胫骨上给予支撑。 如果使用站立架,轮椅服务人员应该告知家人/护理者 儿童每天应该使用站立架多长时间。这是通常的指导: 当首次使用时每天站5~10分钟; 决不能让儿童站在站立架上超过1小时; 提供一个桌面板或桌子并鼓励家人/护理者找到适 合儿童在站立架上进行的有趣的活动。 当为5岁以下儿童提供站立架时,应该记住以下 事项: - 儿童的双腿应该分开并且双脚分开至少与髋部 同宽; - 儿童的双脚和双膝应该稍向外; - 儿童的髋关节和膝关节应该稍屈曲; - 不要强迫幼儿的膝关节和髋关节完全伸直。 ,%3" 16 卧位 卧位是另一个重要的体位,儿童趴在地板上玩耍是 很正常的。 儿童可能需要一些支撑才能舒服地躺在地板上,毯 子、泡沫塑料、毛巾或枕头都常用于支撑。 5岁以下的儿童俯卧位时应该在胸部下方用滚筒支 撑以保持他们的髋关节处于稍微屈曲的姿势。 儿童花很多时间睡觉,如果儿童每晚以同一个姿势睡 觉,他们可能固定或强直在那个体位。 当儿童睡觉时如何以不同方式摆放他们,轮椅服务人 员可以向家人/护理者提出建议。 记住——— 对于5岁以下儿童,在所有卧位和站立位时 要保持髋膝部稍屈曲。 儿童早期转介的重要性 儿童早期转介是重要的,然而通常父母或转介来源都不会为了轮椅转介儿童,直到他们太重而无 法抱动。一些原因包括: 有时人们认为如果儿童使用了轮椅,他将不再试着走路; 当儿童较小且体重轻时,在道路崎岖和环境复杂的地方抱着儿童比掌控轮椅要容易。 父母可能没钱支付轮椅的费用并且拖着直到无法抱动儿童。 重要的是消除父母和转介来源的顾虑,通常轮椅不会降低儿童的行走能力。而更为可能的是早提 供具有良好体位支撑的轮椅将有助于儿童。 17 以下是早转介比晚转介好的原因: 坐直困难的儿童如果没有得到良好的支撑,就会有姿势问题。如果儿童转介晚了,有些姿势问 题就会变成不可逆转②,即使给予支撑,儿童也很难舒适地坐着。 如果缺少坐着和移动的经历,儿童的发育将会迟缓②③。 对于那些有行走能力的儿童——— 使用轮椅会让他们的日常生活更容易,并且允许白天做更多的 事情②。 如果儿童早些接触轮椅服务,这些原因就会改善。 教育父母和转介来源 轮椅服务人员可以在早期转介的重要性方面,发挥教育父母和转介来源的作用。 健康的儿童在学习坐、站和走的年龄会有差异。然而,通常认为一个儿童应该能够: 6~8个月没有支撑可以自己坐直; 8~10个月可以自己拉起站立; 10~12个月没有任何支撑可以独自站并且还可以牵着手走; 12~18个月可以独自行走。 轮椅服务单位会鼓励转诊网络转介这些儿童: 坐直困难或1岁还不能拉起站立; 2岁仍不能独自行走。 如果有早期干预筛查的项目 (例如培训社区卫生工作者筛查需要早期干预的儿童),轮椅服务单位 可以提供更加详细的信息给这些网络。例如——— 轮椅服务单位可以建议所有发现有明显肢体问题或发 育迟缓的儿童,都应该转介给轮椅服务机构进行评定或建议。 对于非常小的婴儿,轮椅服务单位在最初阶段可以提供支持性椅座代替轮椅。这个椅座可以放在 家里或幼儿园使用。 ,%3" ② ③ 世界卫生组织 (1996),促进脊柱裂和脑积水婴儿和幼儿的发展,检索自http://whqlibdoc. who.int/hq/1996/WHO_RHB_96.5.pdf 肌营养不良运动 (2011),肌营养不良和其他神经肌肉疾病的儿童和成人的轮椅供应体系:最佳实 践指南,检索自http://www.muscular dystrophy.org/ 18 为儿童服务时的良好做法 不论何时为儿童服务,重要的是采取尊重和保护的方式。要记住的关键事情是: 通过以下方式尊重儿童: 以他们能够理解的方式说明你正在做什么以及为什么这样做; 开始身体检查之前,应征得同意; 以适合儿童年龄的方式,让儿童参与决定; 如果在中心接待儿童,尽可能地将该区域布置得对儿童亲切。 通过以下方式确保儿童安全: 应该和儿童的家人/护理者一起接待儿童; 由于儿童容易疲劳,在预约时预留休息的时间; 在拍照前应征得儿童和家人/护理者的同意。 19 B:轮椅服务步骤 ,%3" 20 步骤1:转介和预约 见 《轮椅服务初级教程》中步骤1:关于转介和预约的基本资料。 见本书A.2单元:关于残疾儿童早期转介的重要性。 步骤2:评定 评定概述和面谈评估 评定 评定是轮椅服务的第2步。从评定获得的信息将有助于轮椅服务人员和轮椅使用者: 从可得到的轮椅中选择最适用的轮椅; 拟定可能需要的合适的附加体位支撑; 确定轮椅使用者家人/护理者在轮椅使用和保养方面需要的培训和支持。 初级和中级教程中评定都是分为两部分: 面谈评估; 身体检查。 面谈评估 评定的第一部分是面谈评估。在这项评估过程中,轮椅服务人员收集轮椅使用者的信息,这些信 息有助于为轮椅使用者找到最适用的轮椅。 在初级和中级教程中面谈评估的内容非常相似,它们包括: 轮椅使用者的相关信息 身体状况 生活方式和环境 现有的轮椅 尽管初级和中级面谈评估的内容非常相似,但是中级服务需要收集更多关于轮椅使用者诊断和所 有身体问题的信息。 21 中级轮椅评定表 1:面谈评估 轮椅使用者相关信息 姓名: 编号: 年龄: 男□ 女□ 电话号码: 住址: 目的: 中级轮椅评定表中 “轮椅使用者相关信息”部分有管理的目的,并且确保轮椅服务单位有轮椅使 用者个人基本信息和联系资料,它还有助于轮椅服务单位收集统计在中心接待的轮椅使用者资料。 轮椅服务人员还应该在使用者目的栏中记录轮椅使用者是要一个新的还是改制轮椅。“目的”这个 词可能使用者并不熟悉,这取决于轮椅服务人员提出问题了解使用者的目的或目标是什么。 下面是可能问题的例句,轮椅服务人员提出问题并找到使用者的目的或目标是什么: 今天你为什么来到轮椅服务单位? 你的轮椅应该帮你做什么? 下面是可能目的的例子: 我需要能去水井取水。 我需要能进电梯到我的房间。 我需要能让轮椅进入小汽车。 我想要坐轮椅时更舒适些。 我想在疲劳前能够坐轮椅的时间长些。 我需要自己能上下轮椅。 我需要能坐在桌边用计算机。 我想要能够拜访我的家人,并且需要一辆我能推上公交车的轮椅。 ,%3" 22 身体状况 诊断:脑损伤□ 脑性瘫痪□ 肌营养不良症□ 小儿麻痹症□ 脊柱裂□ 脊髓损伤□ 中风□ 原因不明□ 其他□ 病情可能加重吗? 是□ 否□ 身体状况:虚弱□ 痉挛/不随意运动□ 肌张力 (高/低)□ 下肢截肢:右膝上□ 右膝下□ 左膝上□ 左膝下□ 疲劳□ 髋关节脱位□ 癫痫□ 与进食、饮水和吞咽有关的问题□ 描述: 疼痛□ 描述部位: 小便问题□ 大便问题□ 如果轮椅使用者有小便或大便问题,能处理好吗? 是□ 否□ 中级轮椅评定表中 “诊断/身体状况”部分是重要的,因为不同的诊断和身体状况的一些特征会影 响轮椅和附加体位支撑的选择。 接下来的几页提供了在中级轮椅评定表中列出的不同诊断和身体状况的概述,描述了与轮椅提供 相关的每个诊断/身体状况的常见特征,并且给出轮椅准备的建议。 23 ,%3" 24 25 ,%3" 26 27 ,%3" 28 29 ,%3" 30 31 ,%3" 32 33 ,%3" 34 35 ,%3" 36 37 ,%3" 38 39 ,%3" 40 41 ,%3" 42 43 生活方式和环境 描述轮椅使用者将在哪里使用自己的轮椅: 每天移动的距离:1公里以内□ 1~5公里□ 5公里以上□ 每天使用轮椅的小时数:少于1小时□ 1~3小时□ 3~5小时□ 5~8小时□ 超过8小时□ 当不在轮椅上时,使用者坐或躺在哪里以及怎样? (姿势和接触面) 转移:独立□ 辅助□ 站立式□ 非站立式□ 移位机□ 其他□ 厕所类型 (如果转移到厕所):蹲厕□ 坐厕□ 定制的□ 轮椅使用者经常乘坐公共/私人交通工具? 是□ 否□ 如果是,哪种交通工具? 小汽车□ 出租车□ 公交车□ 其他□ 中级轮椅评定表中 “生活方式和环境”部分,收集轮椅使用者生活在哪里以及他/她每天需要在轮 椅上做的事情的信息,重要的是要考虑提供的轮椅和任何附加体位支撑,将会如何帮助轮椅使用者在 他们现有的环境和生活方式下达到最佳能力。 在中级轮椅评定表中生活方式和环境问题 讨论 描述轮椅使用者的轮椅将在哪里使用 轮椅对于使用者的家庭、工作场所或学校都应该实 用,例如: - 如果轮椅在家里使用,轮椅使用者需要能够容 易地在家到处移动并完成重要的日常活动; - 在办公室工作的轮椅使用者需要可以适合办公 空间的轮椅; - 上学的轮椅使用者需要轮椅适应教室并低于课 桌,或需要在轮椅上装一个桌面板; - 经过粗糙路面去市场或工作的轮椅使用者,需 要在粗糙地面运行良好的轮椅。 每天出行的距离 如同人们近距离可能步行,但远距离则骑自行车一 样,轮椅使用者可能用轮椅近距离出行,而三轮车 用作远距离出行。 同样的距离三轮车更省力且更快。 ,%3" 44 续表 在中级轮椅评定表中生活方式和环境问题 讨论 每天使用轮椅多长时间 轮椅使用者坐在轮椅上的时间越长,疲劳或压疮发 生的风险就会越大。思考轮椅使用者需要多大的支 撑以及坐垫是否提供足够的减压与舒适。 对于整天在轮椅上活动的使用者,轮椅的设置应该 有利于他们推行及让他们尽可能高效地参与其他活 动。轮子位置很重要。同时重要的是确保靠背支撑 轮椅使用者,但是不应限制手臂的自由活动。 不在轮椅上时,使用者坐或躺在哪里以及如 何? (姿势和接触面) 如果轮椅使用者长时间保持同一体位,他/她会变 僵硬并且最终会陷于那个体位,不可能舒适地坐在 轮椅上。 为了避免这种情况,非常重要的是给轮椅使用者提 供用于坐或躺的各种不同舒适体位,让其不坐轮椅 时进行选择。 轮椅使用者总是以同一个姿势坐或躺着吗? - 如果可能,让他/她演示这个体位; - 重要的是知道什么是首选体位,以便建议一个 “相反的”(对抗的)体位,不可能总是直接采 用 “相反的”体位。如果轮椅使用者已经采用 他/她的首选体位很长时间,马上选择一个完全 相反的体位,或许会不太舒服、奇怪以及可能 害怕; - 找出方法,在哪里支撑躯干和四肢使他们在更 接近中立位和舒适的姿势。 轮椅使用者能够变换他/她的体位吗? - 如果轮椅使用者不能变换体位,他或她有更多 发生姿势或压疮问题的风险。 45 续表 在中级轮椅评定表中生活方式和环境问题 讨论 转移方式 扶手和脚踏板可能影响轮椅使用者如何上下轮椅: - 对于站立式转移者,可移开的脚踏板和扶手有 助于撑起; - 对于非站立式转移者,可拆的扶手或轮式扶手 可以让转移更容易; - 当提供附加体位支撑时,检查轮椅使用者是否 能够轻易地转移。例如,由于增加了一个椅座 或楔形垫,可能使轮椅使用者转移更困难。可 能需要更改转移技术,或者选择其他的PSDs。 卫生间类型 卫生间类型及进出卫生间的方式将影响轮椅使用者 使用的难易程度。 由于设计问题,使用者可能无法使用卫生间。例 如,大多数轮椅使用者使用蹲式厕所有困难。 通过询问卫生间及所在位置,轮椅服务人员可以就 如何进出卫生间提出建议,轮椅服务人员也可以为 如何改造卫生间提出建议。 轮椅使用者经常使用公共/私人交通工具? 如果轮椅使用者经常使用交通工具,他/她需要能 够容易地运输轮椅,轮椅的不同特点使得轮椅运输 更容易,包括以下: - 轻便轮椅更容易进出; - 可拆卸的轮子和折叠框架和/或靠背让轮椅更容 易运输; 如果使用公共交通工具,可拆卸的部件可能是一个 优点,因为这使轮椅更容易装载。然而,可拆卸部 件也可能是一个缺点,因为部件可能分离和丢失或 被盗。 ,%3" 46 现有的轮椅 (如果已经有一辆轮椅) 轮椅能满足使用者的需求吗? 是□ 否□ 轮椅能适合使用者的环境状况吗? 是□ 否□ 轮椅能提供适配和体位支撑吗? 是□ 否□ 轮椅安全耐用吗? (考虑是否有坐垫) 是□ 否□ 坐垫减压效果理想吗? (如果使用者有压疮的风险) 是□ 否□ 备注: 如果所有问题的答案都是 “是”,使用者可能并不需要一辆新的轮椅。如果这些问题中的任何一个 答案是 “否”,使用者需要一辆不同的轮椅或坐垫;或者现有的轮椅或坐垫需要进行维修或改制。 如果轮椅使用者已经有一辆轮椅,重要的是确定是否符合他或她的需求。中级轮椅评定表中 “现 有的轮椅”部分,有助于在评定现有的轮椅是否适合使用者方面,指导轮椅服务人员和使用者。 当观察轮椅的状况时,观察其外观,因为这些会暗示轮椅使用者是如何坐轮椅的。例如,坐垫一 侧凹陷可能意味着一侧坐骨承受更多压力;一侧扶手破损可能意味着轮椅使用者严重偏向那一侧。如 果你察觉到任何异常,向轮椅使用者询问。 如果轮椅不符合使用者的需求,轮椅服务人员应该找出原因。有时轮椅是合适的,但可能没有为 轮椅使用者进行正确调试。改制、附加体位支撑或维修可能会有所帮助。 在面谈评定中良好的沟通技巧 拥有良好的沟通技巧是非常重要的,它有助于以一种对轮椅使用者感受和需求保持尊重和敏感性 的方式收集正确的信息。 有助于面谈评估顺利进行的一些方法是: 应该向轮椅使用者提问,除非他们是婴幼儿或他们无法理解或回答你的问题; 向轮椅使用者说明他/她提供的信息将有助于选择最适用的轮椅来满足他们的需求; 不必按照中级轮椅评定表中的顺序进行提问,有时轮椅使用者在你提问之前会主动提供信息, 或许以不同的顺序提问更自然。 47 有时通过语言沟通可能困难,例如:轮椅使用者可 能无法听到或者无法说得清晰而让你明白。 当沟通困难时,试图找到一种直接与轮椅使用者沟 通的方式,询问非常了解轮椅使用者的人,问他如 何与他们进行沟通。花点时间来了解轮椅使用者如 何沟通。 如果你不能找到一种直接沟通的方式,确保有非常 了解轮椅使用者的人一直在旁边。请这个人来帮助 你与轮椅使用者沟通。 当轮椅使用者不能说话时识别疼痛 当轮椅使用者不能说话时,他们可能难以表达自己经受的疼痛。因此,当为轮椅使用者服务时, 轮椅服务人员需要知道他们正在做的事情是否导致或增加轮椅使用者的疼痛。 感觉疼痛的非语言信号包括: 哭泣、喊叫、烦躁和大汗; 推开评定人员的手或者试图离开; 抗拒一个动作或者不能保持一种特定的姿势; 面部表情———皱眉和/或痛苦的表情; 坐位、站立或行走的方式。 通过以下方式确保你没有导致或增加现有的疼痛: 如果轮椅使用者在评定过程中疼痛,鼓励他/她让你知道; 如果沟通困难———在开始评定之前就疼痛的信号达成一致; 避免使疼痛加重的体位; 采用使疼痛减轻的体位或活动。 ,%3" 48 身体检查———无支撑坐姿 身体检查是评定的第二部分,包括: 记录压疮的出现、风险或病史; 确认推轮椅的方法; 找出轮椅使用者如何坐着以及他或她可能需要什么附加体位支撑,通过: - 观察无支撑坐姿; - 进行骨盆和髋关节姿势检查。骨盆和髋关节姿势检查有助于理解骨盆或髋关节周围的问题 会如何影响轮椅使用者的坐姿; - 用手模拟。轮椅服务人员用他们的手来 “模拟”轮椅及附加体位支撑提供的支撑; - 进行测量。 中级轮椅评定表中的每部分信息将会帮助轮椅服务人员决定轮椅使用者需要多少支撑。 复习压疮的出现、风险或病史和推轮椅的方法 压疮的出现、风险或病史 ///=没有感觉 ○=以前的压疮 ●=现有的压疮 感觉正常吗? 是□ 否□ 以前有压疮吗? 是□ 否□ 现在有压疮吗: 是□ 否□ 如果有,是否破溃 是□ 否□ (1~4阶段)? 持续时间和原因: 这个人有患压疮的风险※吗? 是□ 否□ ※一个人感觉丧失或有3个或以上风险因素,就有患压疮的风险。风险因素:不能移动、潮湿、不良姿势、以前/ 现在有压疮、营养不良、衰老、体重过轻或超重。 49 推轮椅的方法 轮椅使用者如何推他/她的轮椅? 双臂□ 左臂□ 右臂□ 双腿□ 左腿□ 右腿□ 由一位助手推行□ 备注: 直立坐姿 本单元中常用的缩写 解剖结构 缩写词 髂前上棘 ASIS 髂后上棘 PSIS 坐骨结节 IT 每位轮椅使用者都可以坐在直立或中立的姿势吗? 即使有支撑也不是每位轮椅使用者都能坐在直立的姿势。坐直困难的轮椅使用者将演示一系列不 同的坐姿。不同的姿势是由于身体部位没摆放在中立位所致。 在评定过程中,轮椅服务人员和轮椅使用者需要找出最直立的坐姿,轮椅使用者能够安全且舒适 地达到和保持这个体位而不丧失功能,轮椅和PSDs应该支持这个体位。 当评定体位时,可以发现有3种不同的最终结果,它们是: 僵硬的姿势———轮椅使用者身体某个部位是 “僵硬的”,用轻柔的力量无法推动 (不要用大 力)。轮椅服务人员应该提供支撑以适应其非中立位 (僵硬的)姿势。 可整体推到中立位的姿势———用轻柔的力量,不在中立位的轮椅使用者身体部位能推到中立 位。在这种情况下,应该提供正确的支撑来帮助轮椅使用者维持中立位坐姿。 可部分推到中立位的姿势———用轻柔的力量,不在中立位的轮椅使用者的身体部位仅能部分推 到接近中立位。在这种情况下,提供支撑有助于轮椅使用者尽可能地接近中立位坐姿,这样他 们更舒适和更易发挥功能。 ,%3" 50 幼儿的坐直位 5岁以下的儿童与年龄较大的儿童和成人的坐直姿势不一样,坐姿在儿童5岁后形成。 5岁前最重要的差异是: 儿童的背部是平的,没有腰椎或胸椎曲线; 儿童的耳朵和臀部成一直线,而他们的肩部略 向前; 双腿外展并分开———不平行。 当为5岁以下的儿童服务时,轮椅服务人员需要记 住5岁以下的儿童不应该支撑得像成人那样坐直。 这是不舒服的并且可能对儿童造成伤害。 观察坐姿 为了解轮椅使用者的姿势以及需要什么支撑,首先 要观察无支撑时他/她的坐姿。 为了进行身体检查,轮椅使用者坐在检查床上。 确保轮椅使用者是安全的,并且支撑他/她的双脚。 如果他/她不能独立、安全地坐着,有一个助手或家 人/护理者与他/她坐在一起。观察轮椅使用者无支 撑下能否以中立/直立的坐姿坐着。 观察无支撑下坐姿的目的是了解轮椅使用者的姿势 偏好/习惯,观察坐姿是一项技能,需要时间和实践 来掌握。 51 如何判断轮椅使用者是否坐直 这里描述的坐直姿势应该被轮椅服务人员作为指南使用。当为轮椅使用者服务时,目的是支撑 每位轮椅使用者接近这个姿势是舒适、有效和实用的。 从侧面看并检查: √骨盆直立———髂前上棘和髂后上棘水平; √躯干直立; √背部呈3个生理弯曲; √成人———耳朵、肩膀和臀部成一直线。 儿童———耳朵、臀部成一直线,肩膀略向前; √髋关节屈曲接近90度; √膝关节和踝关节屈曲接近90度; √足跟在膝关节的正下方或稍前或稍后; √双脚平放在地面或脚踏板上。 从前面看并检查: √骨盆水平———两侧髂前上棘是水平的; √肩膀水平并放松,手臂自由活动; √双腿稍稍分开 (外展); √头部中立且在身体上方保持平衡。 记录姿势 中级轮椅评定表上有一个空白处用来记录轮椅使用者的无支撑坐姿。 无支撑坐姿 描述或绘画无支撑坐姿 记录将帮助轮椅服务人员记住轮椅使用者评定 后的坐姿,也能帮助轮椅服务人员跟踪轮椅使 用者随着时间推移坐姿的变化。 还有几种不同的方法记录坐姿,包括: 用文字描述坐姿; 画图; 拍照 (仅在得到轮椅使用者的许可)。 ,%3" 52 下面是常用来记录坐姿的简易线条绘画的例子。 侧面坐姿线条绘画 正面坐姿线条绘画 记住! 不是每个人都能坐直。 在评定过程中,轮椅服务人员和轮椅使用者共同参与,找出轮椅使用者如何能够接近直立姿势舒 适地坐着。 具有附加体位支撑的轮椅将有助于支撑轮椅使用者接近直立且舒适地坐着。 身体检查———骨盆和髋关节姿势检查 骨盆和髋关节姿势检查 坐姿是受骨盆和髋关节周围病变的影响,在这部分评定中,轮椅服务人员需要了解: 当从正面观察时,轮椅使用者的骨盆是否水平 (可以有或没有支撑); 在有或没有支撑的情况下,轮椅使用者的髋关节能否屈曲到中立位坐姿 (躯干和大腿的角度是 否为90度)。 53 如果骨盆不水平或髋关节不能屈曲到中立位坐姿 (躯干和大腿的角度大于90度),轮椅服务人员必须 了解更多的信息,重要的是知道: 轮椅使用者能在支撑下坐在中立位的姿势吗? 如果不能———他/她能够多大程度地接近中立位 坐姿? 如果轮椅使用者不能以中立位姿势坐,同样重要的 是要知道这个困难是否由于: 骨盆以上 (在腰椎)受限 (或限制);或 骨盆内的受限 (在髋关节)。 为了使轮椅服务人员回答以上所有问题,必须进行 评定部分的 “骨盆和髋关节姿势检查”。 这不是一个完整的运动评定。在本教程中讲授骨盆 和髋关节姿势检查的目的仅是确定上文提到的因素。 为了获得更详细的资料,有经验的轮椅服务人员可 以选择进行完整的运动评定。 进行骨盆和髋关节姿势检查 准备: 向轮椅使用者说明你将要做什么,以及这样做的重要性; 让轮椅使用者躺在检查床上。 (注意:在此说明,进行骨盆和髋关节姿势检查的人叫 “评定者”,辅助评定者的那个人叫 “助手”, 助手可能是同事、受过培训的助手、家人或护理者)。 ,%3" 54 骨盆姿势检查 评定者稍微屈曲轮椅使用者的双膝并提供支撑, 这有助于减轻对髋关节的拉伸; 助手将手紧紧放在轮椅使用者的躯干上,大约肋 骨下部; 评定者轻轻地抓住骨盆,拇指放在髂前上棘上; 评定者检查拇指/髂前上棘是否水平; 如果不是水平的,评定者设法轻柔而稳定地调整 骨盆使两侧髂前上棘水平; 助手报告他/她是否感觉到躯干移动,这意味着 这个动作有些受限; 标记可能使骨盆接近中立位/水平位的程度; 评定者在中级轮椅评定表上记录骨盆能否水平。 髋关节姿势检查 助手轻柔而紧紧地按住轮椅使用者的骨盆; 评定者稍屈曲未检测腿的膝关节,把脚放在垫子 上,这有助于降低受检测髋关节的张力,这条腿 可能需要支撑。 评定者轻柔地活动被检测腿至中立位坐姿; 助手报告他/她是否感觉到骨盆活动,这意味着 这个动作有些受限; 评定者感觉髋关节能够活动的自由程度; 评定者重复另一侧并比较; 评定者在中级轮椅评定表上记录左右髋关节是否 都可以屈曲至中立位坐姿。 55 续表 髋关节姿势检查 评定者在助手帮助下,用量角器记录每侧髋关节 能达到中立位姿势的程度; 评定者将量角器的轴心放在大转子处,并把量角 器的一边靠在大腿上,而另一边与躯干平行; 评定者用力地握住量角器的两条边; 评定者在中级轮椅评定表上记录左右髋关节的角 度测量值,也可以把量角器的角度画在另外一张 纸上或在中级轮椅评定表的背面。 记录骨盆和髋关节姿势检查 骨盆和髋关节姿势检查 检查卧位时骨盆是否水平以及髋关节屈曲的 范围 骨盆可以水平吗? 是□ 否□ 髋关节能屈曲到中立位坐姿吗? 右髋: 是□ 否□ 角度: 左髋: 是□ 否□ 角度: 如果骨盆不能处于水平或髋不能屈曲到中立 位坐姿———提供临时支撑。 在中级轮椅评定表上记录骨盆和髋关节姿势检 查结果。 勾选骨盆能否水平。 勾选每侧髋关节能否屈曲到中立位坐姿 (90 度)。 如果右或左 (或双侧)任何一个髋关节不能屈 曲到中立位坐姿 (躯干到大腿的角度大于90 度),记录这个角度。 如上所述,轮椅服务人员也可以在另外一张纸上 或在中级轮椅评定表的背面画出量角器的角度。 为僵硬的不水平骨盆以及不能屈曲到中立位坐姿的髋关节 (躯干到大腿 的角度大于90度)提供临时支撑 如果骨盆不能水平或单侧或双侧髋关节不能屈曲到中立位坐姿 (躯干到大腿的角度大于90度), 它将在最终的轮椅上被支撑于非中立位姿势。为了继续评定,应该为轮椅使用者做一个临时支撑使其 坐在上面。 ,%3" 56 在评定过程中,临时支撑将: 帮助轮椅使用者坐得更稳定以及更平衡; 阻止轮椅使用者补偿不水平的骨盆或不能屈曲到中立位坐姿的髋关节 (躯干与大腿之间的角度 大于90度); 让轮椅服务人员继续评定,并且专注于轮椅使用者姿势的其他部分,包括骨盆、躯干、头、颈 和腿; 临时支撑可以用硬泡沫塑料制作,下表展示不同的姿势问题、针对这些问题临时和可能永久的支撑。 姿势问题 临时支撑 永久支撑 (固定在轮椅使用者的坐垫里) 僵硬的不水平骨盆 (侧向倾斜) 在较高侧坐骨和大腿下方加一 个补高 髋关节不能屈曲到中立位坐姿 (躯干与大腿之间的角度大于90 度) 在两侧坐骨和髋关节能屈曲到 中立位坐姿一侧的大腿下加一 个补高———在试用前锐利边缘 需要倒角 两侧髋关节都不能屈曲达中立 位坐姿 (躯干与大腿之间的角 度大于90度) 加一个补高来增加椅座和靠背 之间的角度 57 续表 姿势问题 临时支撑 永久支撑 (固定在轮椅使用者的坐垫里) 一侧或两侧髋关节不能伸展到 中立位坐姿 (躯干与大腿之间 的角度小于90度) 在坐骨前大腿下提供一个楔形 支撑 身体检查———用手模拟 用手模拟有助于确定轮椅使用者需要什么支撑。在用手模拟过程中,轮椅服务人员用他们的双手 来了解: 轮椅使用者在支撑下能坐在中立位姿势吗? 如果不能,他/她能在多大程度接近中立位姿势坐? 需要什么支撑以及在哪里支撑? 在用手模拟过程中,轮椅服务人员与轮椅使用者和助手或家人/护理者共同用双手提供支撑。 如何开展用手模拟? 当开展用手模拟时要记住的重要方面是: 准备 向轮椅使用者说明你将要做什么以及为什么这 样做。 让轮椅使用者坐在硬但有衬垫的平面上,比较理 想是有一个评定箱,轮椅服务人员和助手或家 人/护理者能够轻易地伸手够到轮椅使用者,从 前面、后面和侧面来提供支撑。 ,%3" 58 如果没有支撑轮椅使用者不能安全地坐着,让一 个助手或家人/护理者支撑他们。 确保轮椅使用者的双脚支撑在正确的高度。如果 骨盆不是水平的或者如果一侧髋关节不能屈曲到 中立位坐姿 (躯干到大腿的角度大于90度),如 同前面描述提供一个临时支撑。 以团队的形式工作 常常需要不只一双手。 要接受助手的帮助,助手可能是同事、受过训练 的助理、家人/护理者。 家人/护理者的参与将帮助他/她更好地理解最终 的PSD解决方案。 使用良好的沟通技巧 轮椅服务人员应该轻柔地 (最好使用当地语言)与使用者和家人/护理者沟通。 如果轮椅使用者无法说话,找出一种与他们沟通的恰当方式并使用它。 记住向轮椅使用者说明你每一步将要做什么。 每次改变后询问轮椅使用者的反馈意见。 仔细思考你的手要做什么 你的手正在提供以后由轮椅和PSDs提供的支撑,在用手模拟时,特别注意: - 你的双手放在哪里; - 力量/支撑的方向; - 用多大的力量/支撑; - 你的双手覆盖的面积多大 (例如,你只是用一根手指或整只手); - 开始用手模拟前,如果手是冷的,温暖你的手。 这个信息有助于你处方最终的轮椅及PSDs。 59 应该先在骨盆提供支撑 骨盆的姿势将影响身体的其他部位。 如果轮椅使用者的骨盆不在中立位,用你的双手使骨盆接近中立位。 当骨盆得到支撑后,关注身体的其他部位的顺序是: - 躯干/手臂; - 头和颈; - 髋关节和大腿; - 小腿。 每次做一项调整 应该每次只做一项调整。例如———不要尝试在调整骨盆的同时调整躯干。 观察身体某一部位的调整如何影响其他部位; 询问轮椅使用者的反馈。 开始身体检查的用手模拟: 跪或蹲在轮椅使用者前面; 轻柔地将手放在轮椅使用者骨盆两侧; 如果轮椅使用者的骨盆不在中立位———用双手把 骨盆舒适地摆至接近中立位; 不要用大力; 找出骨盆被支撑到接近中立位的程度; 观察向中立位移动骨盆时,如何影响轮椅使用者 的躯干、髋、头和颈部; 当骨盆尽可能被支撑到接近中立位时,轮椅服务 人员此时考虑躯干需要什么支撑; 让助手支撑保持轮椅使用者的骨盆在你已经确认 为 “尽可能接近中立位”的姿势; 仔细地向助手说明支撑哪里以及如何支撑骨盆, 继续评定前确保他/她能做到这一点。 ,%3" 60 在躯干提供支撑 (如需要): 关于骨盆,如果轮椅使用者的躯干不在中立位坐姿, 用你的双手提供支撑,按照以下顺序: 用你的双手稳定骨盆; 用你的双手在躯干两侧提供支撑,使躯干挺直以 便双肩是水平的 (或者尽可能接近水平); 用你的双手在骨盆后面有时在前面提供支撑,支 撑躯干直立以及头和颈部平衡; 从侧面观察骨盆和躯干的外形,重要的是设计靠 背的形状以提供最佳支撑。 密切关注躯干支撑如何影响身体的其他部位。例如,躯干支撑有助于改善头和颈部姿势吗? 即使 有良好的骨盆和躯干支撑,有些轮椅使用者可能发现很难保持头部直立。有助于改善头和颈部姿势的 一些建议是: 允许轮椅使用者略向后倚靠; 观察轮椅使用者是否能够更好地平衡他们躯干以上的头部; 为手臂提供附加支撑。 在用手模拟时,当你支撑躯干时让助手支撑骨盆,他/她是否感觉到任何变化,记住总是询问轮椅 使用者的反馈。 为身体其他部位提供支撑 (如需要) 一旦骨盆和躯干被支撑在最中立的坐姿是舒适 的,检查头和颈部、髋、大腿和小腿的姿势; 用你的双手找到每个身体部位如何能够舒适地接 近中立位,继续检查某个变化如何影响身体的其 他部位,继续询问轮椅使用者的反馈。 61 记录用手模拟的结果 用手模拟的结果记录在中级轮椅评定表中,有空格: 勾选记录在 “用手支撑”下,轮椅使用者的每个身体部位是否能够达到中立位坐姿; 描述或线条绘画轮椅使用者在用手支撑下实现的最终坐姿; 描述或线条绘画轮椅使用者实现这种坐姿提供的支撑。 用手模拟:用手支撑坐在中立位/尽可能舒适地接近中立位 对于每个身体部位:如果用手支撑中立位坐姿是可能的,勾选 “是”,如果不能,勾选 “否”。 部位 是 否 骨盆 □ □ 躯干 □ □ 头 □ □ 左髋 □ □ 右髋 □ □ 大腿 □ □ 左膝 □ □ 右膝 □ □ 左踝 □ □ 右踝 □ □ 描述或线条绘画用手支撑轮椅使用者能达到最终的坐姿,并且描述或线 条绘画达到那个坐姿提供的支撑。 身体检查———进行测量 测量轮椅使用者以选择正确的轮椅尺寸和PSDs位置 在中级轮椅评定表的测量部分,列出12个身体测量,5个测量是和之前在 《轮椅服务初级教程》 中介绍的一样。中级轮椅评定表中增加了靠背高度的身体测量,座面到肩峰的尺寸常用来测量需要高 靠背的轮椅使用者。还有其余6个测量将有助于确定尺寸和/或PSDs位置。 有时可能必须进行更多的测量,这取决于PSDs处方。中级轮椅评定表上有空白用于记录 “其他 的”测量。 ,%3" 62 身体测量如何与轮椅和PSDs的尺寸及位置相关 每个身体测量都与轮椅的尺寸或PSDs位置及尺寸相关。 在中级轮椅评定表中,身体测量列在左侧,与每个身体测量相关的部件列在右侧。 例如: 轮椅使用者的臀宽 (身体测量A)等于轮椅椅座宽度或骨盆侧垫间的距离 (部件尺寸1或2); 轮椅使用者的座面到腋下 (腋窝)(测量H)减去30mm即为座面顶端到躯干侧垫/楔形垫的最 大距离 (轮椅部件尺寸8)。 以上例子表明,身体测量不总是等于轮椅部件尺寸并且需要某些计算。有时候有公式来帮助算出 轮椅部件的尺寸。 适配时常常需要调整,然而第一次适配前,精确的身体测量可有助于准备好轮椅。 中级轮椅评定表中的插图有助于指导轮椅服务人员完成身体测量以及与其相关的PSDs的位置和 尺寸。 进行测量 身体测量 (mm) 轮椅部件测量 (mm) 座宽、座深和脚踏板高度 A 臀宽 =椅座宽度或 1 =骨盆侧垫间距离 2 63 续表 身体测量 (mm) 轮椅部件测量 (mm) B 臀后到腘窝 左 右 减去30mm~50mm=椅座深度 (如果左右长度不等,取短侧) 3 C 腘窝到足底 左 右 =座面顶端到脚踏板的距离或 =座面顶端到地面的距离,脚推 轮椅 4 5 靠背高度 D 座面※到胸腔下缘 E 座面※到肩胛下角 F 座面※到肩峰 =座面顶端到靠背顶部距离 (测 量D、E或F,取决于轮椅使用 者的需要) 6 改制和/或PSDs G 躯干宽 =躯干侧垫/楔形垫之间的距离 7 H 座 面※ 到 腋 窝 (腋下) 左 右 H减30mm=座面顶端和躯干侧 垫/楔形垫间的最大距离 (根据 用手模拟调整) 8 I 座面※到骨盆上缘 (PSIS) =座面顶端与骨盆后垫中部之间 的距离 9 J 两膝间距离 =膝分隔垫之间的宽度 10 K 座面※到颅底 =座面顶端到头靠中间的距离 11 L 骨盆后部到坐骨 L加20mm~40mm=从靠背支撑 到坐骨前垫高开始点之间的距离 12 其他 ※当进行身体测量时,“座面”是坐骨坐着的平面。 如何进行精确测量 测量中的错误会导致大问题。然而进行精确测量有时可能是困难的,当轮椅使用者个子很小或者 ,%3" 64 发现其很难坐着不动或坐直有困难时,这尤其是个问题。 以下方法有助于进行精确测量,包括: 应该用硬卷尺测量———不是用 “裁缝”卷尺测量;硬卷尺 测量将不会弯曲太多,导致一个不精确的测量值; 使用卡尺能有助于测量得精确; 轮椅使用者坐直进行测量,在用手模拟中被认定为最直 立、舒适和功能性的体位。如果轮椅使用者躺着测量,测 量值将不精确,因为躺着时轮椅使用者可能变长或伸展。 最好让助手支撑轮椅使用者坐直,比让他们躺着好。 如何测量 轮椅部件 备注 A:臀宽 椅座 (宽度) 测量前检查轮椅使用者的口袋, 里面不要放东西。测量轮椅使用 者臀部或大腿最宽的部位。拿两 个硬板紧贴轮椅使用者身体两侧 有助于获得准确的测量值。也可 以使用卡尺。 臀宽等于椅座宽度或骨盆侧垫之 间的距离。 如果有骨盆侧垫,椅座宽度可 能需要加宽。应该设法保持椅 座宽度在最小。 在气候寒冷穿厚衣服的国家, 可能需要一些预留量。 B:臀后到腘窝 椅座 (宽度) 放一块硬板在轮椅使用者后背有 助于获得精确的测量值,测量从 轮椅使用者的骨盆后部到他/她 的腘窝的直线距离。 应该测量双腿。 如果左侧和右侧不同,检查轮椅 使用者是否骨盆水平坐直。如果 仍然不同,按照短边开具轮椅 处方。 臀后到腘窝的距离减去30mm~ 50mm等于椅座深度。 对于膝关节屈曲远远小于90度 的轮椅使用者,椅座深度可能 需要稍短些。参见下图 “僵硬 骨盆后倾或僵硬躯干前屈的轮 椅使用者”。 65 僵硬骨盆后倾或僵硬躯干前屈的轮椅使用者 如果一位轮椅使用者具有僵硬的骨盆后倾或躯干前屈, 轮椅服务人员需要考虑将如何使其与轮椅适应,这可能 要改变座深测量方法。 如果靠背向后倾斜 (后倾)来适应骨盆/躯干,综上 所述,测量从骨盆后部到腘窝的直线距离。 如果靠背没有倾斜,要在座深空间内做支撑来适应 骨盆/躯干。从身体背部最远点 (躯干/骨盆)测量 以确保允许足够的椅座深度,如图所示。 如何测量 轮椅部件 备注 C:腘窝到足底 脚踏板 (高度) 测量轮椅使用者腘窝到他/她脚 后跟底部的距离。确保轮椅使用 者的脚踝屈曲90度 (如果可能) 应该测量两条腿,如果轮椅使用 者穿鞋,穿他/她平时经常穿的 鞋子测量。如果脚固定在跖屈 (向下),测量到脚尖的距离。 该长度等于座面顶端到脚踏板的 高度或者座面顶端到地板的高 度,如 果 轮 椅 使 用 者 用 脚 推 轮椅。 脚踏板的确切位置将取决于当 轮椅使用者坐在轮椅上时坐垫 被压缩多少而稍稍变化。 在适配时应该需要进行最终的 调整。 ,%3" 66 续表 如何测量 轮椅部件 备注 D、E和F 靠背 (高度) D:座面到胸腔下缘:测量轮椅 使用者座面到胸腔下缘的距离。 为了帮助找到胸腔下缘,把双手 放在骨盆两侧,双手向内轻轻挤 压并向上滑动,胸腔下缘恰好就 在腰部的正上方。 E:座面到肩胛下角:测量轮椅 使用者的座面到肩胛下角的垂直 距离。 为了帮助找到肩胛下角,可以让 轮椅使用者耸耸肩膀。 F:座面到肩峰:测量轮椅使用 者的座面到肩峰的距离。 测量D、E和F有助于确定靠背 的高度。高度取决于轮椅使用者 的需求。从评定获得的信息将有 助于轮椅服务人员决定,需要多 高的靠背才能为轮椅使用者提供 正确的支撑。 如果需要靠背后倾或整体后倾, 靠背高度必须至少是标准的 (到轮椅使用者的肩胛下角)。 记得考虑如果轮椅使用者自己 推轮椅,他们需要自由地活动 肩胛骨。 G:躯干宽度 躯干侧垫/楔形垫 (间距) 测量轮椅使用者腋下 (腋窝)的 躯干宽度。 躯干宽度是躯干侧垫或楔形垫之 间的距离。 如果躯干侧垫或楔形垫放置的 位置比腋下低,它们的最终位 置在适配时可能需要调整。 67 续表 如何测量 轮椅部件 备注 H:座面到腋下 (腋窝) 躯干侧垫/楔形垫 测量 座 面 到 腋 下 (腋 窝)的 距离。 座面到腋下 (腋窝)的测量值减 去30mm 就是座面顶端和躯干 侧垫/楔形垫顶端之间的最大 距离。 这个测量值是个指导,最终的 高度取决于评定和适配。 躯干侧垫不应该太高对腋下 (腋窝)施加压力,这可能会不 舒适并导致永久神经损害。躯 干侧垫顶端和腋下之间应该有 至少30mm的间隙。 参阅下图 “为脊柱侧弯的轮椅 使用者测量躯干侧支撑”。 为脊柱侧弯 (躯干向侧面弯曲)的轮椅使用者测量躯干侧支撑 对于一位躯干向侧面弯曲 (脊柱侧弯)的轮椅使 用者,一侧躯干侧垫可能低于另一侧来提供所需 部位的支撑。 如图所示,一侧躯干侧垫将定位在曲线的 “顶 点”,另一侧躯干侧垫将定位于腋下。 记住———当为脊柱侧弯的轮椅使用者提供躯干侧 垫时,还应该在两侧提供骨盆侧垫。 ,%3" 68 如何测量 轮椅部件 备注 I:座面到髂嵴 (PSIS) 骨盆后垫 (中间高度) 测量 座 面 到 髂 嵴 (PSIS)的 距离。 坐垫到髂嵴 (PSIS)的测量值 用来定位骨盆后垫中间的高度。 骨盆后垫的深度 (厚度)取决 于评定结果。 J:两膝间距离 膝分隔垫 在两膝放置于接近中立位且对轮 椅使用者来说是舒适的情况下, 测量两膝间距离。 两膝间的距离等于膝分隔垫的 宽度。 距离将取决于轮椅使用者的 坐姿。 K:座面到颅底 头靠 (高度) 测量座面到颅底的距离。 测量座面到颅底的距离有助于定 位头靠的位置。 L:骨盆后到坐骨 坐骨前垫高 测量骨盆后到坐骨的距离。 从轮椅使用者侧面将你的手 (手 掌向上)放在轮椅使用者臀部下 面寻找坐骨,用一个手指定位坐 骨———然后收回你的手到轮椅使 用者的侧面,测量从轮椅使用者 的骨盆后部到定位在坐骨的手指 之间的距离。 轮椅服务人员可以用某种方式 (例如用一支粉笔)在与轮椅使 用者坐骨旁边平行的位置在检查 床上做记号,然后测量从标记点 到骨盆后的距离。 骨盆后到坐骨的距离加20mm~ 40mm是靠背支撑到坐骨前垫高 起点的距离。 如果轮椅使用者的骨盆僵硬后 倾或躯干僵硬前屈,测量值可 能会不同 (参见框图 “僵硬骨 盆后倾或僵硬躯干前屈的轮椅 使用者”)。 69 记住: 当进行身体测量时,“座面”是坐骨正在坐着的平面。 所有的垂直测量 (C、D、E、F、H、I、K),与之相应的部件定位将会受座面和坐垫高度变化的 影响。 所有轮椅部件的精确定位应该在适配时进行检查。 步骤3:处方 (选择) 选择轮椅和坐垫 处方 (选择)是轮椅服务中的第3步。 处方/选择是指在可得到的轮椅和使用者需求之间尽可能选出最佳匹配。 当为需要附加体位支撑坐直的轮椅使用者处方轮椅时,处方包括: 选择最适合轮椅使用者的轮椅类型和尺寸; 描述这辆轮椅的特殊设置; 选择最适合的坐垫类型和尺寸; 选择需要的PSDs或改制,为轮椅使用者提供他/她所需要的附加体位支撑。 处方通常是在与轮椅使用者充分合作的情况下来决定的,在本教程使用的中级轮椅处方表中,需 要3个签名,包括轮椅使用者、评定人 (轮椅服务人员)和评定组长。 轮椅和坐垫的类型 轮椅的类型 为了处方一辆轮椅,轮椅服务人员需要知道轮椅的以下情况: 轮椅架的类型; 可得到的尺寸和尺寸范围; 可利用的功能部件; 可能的调整和调整范围。 这些知识将有助于轮椅服务人员为轮椅使用者选择最合适的轮椅并且描述应该如何设置。中级轮 椅处方表的相关部分如下所示。 ,%3" 70 2.轮椅的类型、尺寸和设置 轮椅类型 (可得到的轮椅列表) 轮椅尺寸 (mm) □ 座宽 □ 座深 □ 靠背高度 □ 脚踏板高度 轮椅设置 后轮位置 后倾 其他 轮椅架类型 轮椅服务人员需要知道当地可得到轮椅架的不同类 型,例如是三轮轮椅或四轮轮椅;交叉折叠式或固 定式轮椅架;长轴距或短轴距。 关于不同轮椅架的更多信息,参阅 《轮椅服务初级 教程》。 71 可得到的轮椅尺寸和范围 轮椅的尺寸通常由轮椅椅座宽度和深度来描述。 轮椅椅座宽度是测量一侧椅座固定杆外缘到对侧椅 座固定杆外缘或两侧扶手间的距离 (如果扶手在椅 座固定杆的上面)。轮椅椅座深度是测量从椅座前面 到靠背的距离。 其他重要的轮椅尺寸包括: 椅座到地面的高度 (这个对于用脚推轮椅的使用 者是重要的); 靠背的高度。 可利用的功能部件 可能的功能包括椅座的类型、靠背、脚踏板、扶手、小脚轮、后轮和PSDs(例如躯干侧垫、头 枕、绑带)。 可调性及可调范围 轮椅服务人员应该熟悉当地可得到轮椅的不同调节范围,包括脚踏板的最高和最低位置、靠背的 高度是否可调、后轮轴位置是否可调。 为了找到所有可调部件的 “调节范围”,必须测量最低和最高的调节值。 有些手动轮椅较其他轮椅具有更多的功能部件或可调部件,有些功能部件或可调部件对需要附加 体位支撑的轮椅使用者非常有帮助。这些产品特点包括: 可调脚踏板 大多数轮椅都有上下可调的脚踏板。 有些轮椅具有额外的调节。包括: 脚踏板能够向前或向后调; 脚踏板角度能够增加或减少。 这些调节让轮椅使用者双脚的放置位置有更大的灵 活性。 ,%3" 72 可抬起腿托 可抬起腿托能有助于保持脚抬起并伸膝,这对于坐 着时膝关节不能屈曲到中立位的轮椅使用者是有帮 助的。 靠背后倾 靠背后倾 (靠背向后倾斜)有助于适应: 髋关节不能屈曲到中立位坐姿 (躯干与大腿之间 的角度大于90度); 僵硬的骨盆后倾; 僵硬的腰部后凸姿势。 整体后倾 一些轮椅有所谓的 “整体后倾”功能,这意味着靠 背和椅座整体后倾,椅座和靠背之间的角度保持不 变,后倾型椅座有助于: 僵硬的骨盆后倾伴有髋和膝屈曲挛缩; 正常坐姿的低耐受性或不舒适; 增加舒适性和休息。 硬椅座 一些轮椅是硬椅座而不是悬吊式椅座,它能提供: 一个良好的底座,用于为骨盆和髋关节提供附加 体位支撑; 比悬吊式椅座更稳定,如果轮椅使用者有强烈的 不受控制的运动或体重较重,这可能非常有用。 73 硬靠背 一些轮椅是硬靠背。对于硬椅座,它可以提供一个 良好的基础用于建立附加体位支撑。硬靠背也能 提供: 比悬吊式/帆布靠背更稳定,如果轮椅使用者有 强烈的不受控制的运动,这可能有用; 为身材较高和体重较重和/或躯干非常无力的轮 椅使用者提供更多的支撑。 如图所示一个已经添加泡沫塑料的硬靠背,刚好在 正确的位置为躯干提供支撑,侧支撑垫用螺栓固定 在靠背上。 一些轮椅有张力可调靠背而不是简单的悬吊式靠背, 张力可调靠背可以让我们轻易地调节靠背提供的支 撑,独立的绑带被拉紧或放松来增加或减少支撑。 没有必要具有所有上述功能来提供附加体位支撑,上面的许多功能可由普通手动轮椅改制完成。 收集当地可得到轮椅的信息 下文的中级轮椅参数表常用来收集和记录当地可得到轮椅的信息。 轮椅改制前要考虑什么 当选择一辆轮椅,需要改制来提供轮椅使用者所需的支撑时,轮椅服务人员应该考虑: 轮椅处于良好的运行状态吗? 当地可得到这些材料及制作方法可行吗? 与轮椅匹配吗? 如果轮椅破损,部件能在当地维修或更换吗? ,%3" 74 坐垫类型 轮椅服务人员应该知道可得到的供他们处方的坐垫 类型,要考虑的产品特点包括: 坐垫的制作材料; 坐垫是否减压; 修改坐垫是否容易; 坐垫套是否防水。 关于坐垫包括减压坐垫的更多信息,请参阅 《轮椅 服务初级教程》。 选择的坐垫类型和尺寸记录在中级轮椅处方表 “坐垫类型和尺寸”里。 3.坐垫类型和尺寸 坐垫类型 尺寸 例如:减压坐垫 □ □ 如果坐垫需要改制来制作正确的PSD———这方面的细节将在后面的中级轮椅处方表章节中叙述。 中级轮椅参数表 轮椅名称: 制造商/供货商: 可得到的类型: 总重量: 此处插入图片 描述: 轮椅架: 固定式/刚性 □ 可折叠 □ 轮椅架长度 靠背: 悬吊式/帆布 □ 硬的 □ 张力可调 □ 75 续表 椅座: 悬吊式/帆布 □ 硬的 □ 张力可调 □ 坐垫: 没有坐垫 □ 平面泡沫塑料 □ 泡沫塑料波形 □ 流体 □ 其他: □ 脚踏板: 固定的 □ 可拆 □ 其他: 小脚轮: 气胎 □ 直径: 实心胎 □ 宽度: 后轮: 气胎 □ 直径: 手推圈 □ 实心胎 □ 宽度: 轴距可调 □ PU胎 □ 可拆卸 □ 刹车: 短杆 □ 长杆 □ 其他 扶手: 弧形 □ 方形 □ 其他 固定式 □ 可拆卸 □ 其他 把手: 把手 □ PSDs: 骨盆带 □ 小腿带 □ 肩带 □ 足带 □ 防翻杆 □ 躯干侧垫 □ 桌面板 □ 头靠 □ 骨盆侧垫 □ 其他: □ 测量尺寸、调整选项及范围: 测量尺寸 (如果轮椅有不同的尺 寸,列出所有的尺寸) 是否可调 是 否 调整范围 (该轮椅可能的 调整范围) 椅座宽度 □ □ 椅座深度 □ □ 椅座高度 □ □ 靠背高度 □ □ 靠背后倾 □ □ ,%3" 76 续表 测量尺寸 (如果轮椅有不同的尺 寸,列出所有的尺寸) 是否可调 是 否 调整范围 (该轮椅可能的 调整范围) 脚踏板高度 □ □ 脚踏板角度 □ □ 把手高度 □ □ 轮椅架长度 □ □ 轮椅轴距长度 □ □ 靠背与椅座角度 □ □ 整体后倾 □ □ 中级轮椅处方 (选择)表 对于没有支撑就无法舒适地坐直的轮椅使用者,此表是用于记录他们的轮椅、坐垫及PSDs的选 择,将这张表保留在轮椅使用者的档案中。 1.轮椅使用者信息 轮椅使用者姓名: 编号: 评定日期: 适配日期: 评定人姓名: 2.轮椅的类型、尺寸和设置 轮椅类型 (可得到轮椅列表) 轮椅尺寸 (mm) □ 椅座宽度 □ 椅座深度 □ 靠背高度 □ 脚踏板高度 轮椅设置 后轮位置 后倾 其他 77 3.坐垫的类型和尺寸 坐垫类型 尺寸 例如:减压坐垫 □ □ 4.PSDs或需要的改制 PSD清单 描述/绘画并提供尺寸 椅 座/ 坐垫 加入硬椅座 □ 坐骨前垫高 (=3-12) □ 降低坐垫前部 左□ 右□ 升高坐垫前部 □ 前倾楔形垫 □ 骨盆下补高 左□ 右□ 骨盆侧垫 (=2) 左□ 右□ 大腿外侧楔形垫 左□ 右□ 大腿外侧垫 左□ 右□ 大腿内侧楔形垫 (=10) □ 膝分隔垫 (=10) □ 其他 □ 其他 □ ,%3" 78 续表 PSD清单 描述/绘画并提供尺寸 椅 座 和 靠 背 增加椅座与靠背角度 □ 椅座与靠背后倾 (整体后倾) □ 靠 背 加入硬靠背 □ 骨盆后垫 (=9) □ 可调形状靠背 □ 可调张力靠背 □ 靠背后倾 □ 躯干侧垫 (=7) 左□ 右□ 躯干侧楔形垫 (=7) 左□ 右□ 其他 □ 桌面 板/ 扶手 桌面板 □ 改制扶手 左□ 右□ 其他 □ 头部 支撑 扁平头靠 (=11) □ 有形头靠 (=11) □ 其他 □ 小腿 支撑 脚踏板补高 左□ 右□ 脚踏板楔形垫 左□ 右□ 小腿支撑板 左□ 右□ 其他 □ 绑带 骨盆带 □ 小腿带 □ 足带 左□ 右□ 肩带 □ 其他 □ 79 5.同意签名: 轮椅使用者: 评定人: 评定组长: 体位支撑装置 (PSDs)的处方 (选择)———介绍 有很多PSDs的不同设计以及许多不同的轮椅改制方法,为轮椅使用者提供附加体位支撑。通常 结合几种不同的PSDs为一位轮椅使用者提供他/她所需要的全部体位支撑。 什么是PSD? 体位支撑装置 (PSD)是提供附加体位支撑的一种物理器具———中级轮椅服务的重要内容。下页 的体位支撑装置 (PSD)表 (后面简称PSD表)和体位支撑装置 (PSD)参考表 (后面简称PSD参考 表)给出了不同PSDs的概述,这个内容在整个教程中介绍。PSDs一些示例如下面插图所示。 ,%3" 80 相同部件的不同名称 相同的PSDs可以有不同的名称,取决于轮椅服务机构、地点或制造商,在本 《学员手册》中,给 出了每个PSD的简单描述性名称,在每个轮椅服务机构、轮椅服务人员和轮椅使用者可以用他们最 熟悉和舒服的术语。 体位支撑装置 (PSD)表 椅座/坐垫 坐骨前垫高 降低椅座 前部 (一侧) 升高椅座前部 骨盆前倾楔形垫 骨盆下补高 骨盆侧垫 椅座/坐垫 椅座和靠背 大腿外侧 楔形垫 大腿外侧垫 大腿内侧楔形垫 膝分隔垫 增加椅座和 靠背角度 椅座和靠背后 倾 (整体后倾) 靠背 骨盆后垫 可调形状靠背 可调张力靠背 靠背后倾 躯干侧垫 躯干侧楔形垫 81 桌面板 头靠 小腿支撑 桌面板 扁平头靠 有形头靠 脚踏板补高 脚踏板楔形垫 小腿支撑板 绑带 骨盆带 骨盆前倾四点带 小腿带 足带 肩带 体位支撑装置 (PSD)参考表 PSD 目的 适配 椅座/坐垫 坐骨前垫高 坐骨前垫高有助于: 保持骨盆直立; 阻止骨盆向前滑; 降低下滑坐姿的趋势。 坐骨前垫高的起点刚好位于坐 骨的前面。 降低椅座前部 (一侧) 如图所示降低一侧坐垫前部适用 于一侧髋关节不能屈曲到中立位 坐姿 (躯干与大腿的角度大于 90度)。 坐垫降低多少将取决于轮椅使 用者髋关节屈曲的角度。 轮椅使用者的坐骨和两侧大腿 下应该与坐垫均匀接触。 ,%3" 82 续表 PSD 目的 适配 升高椅座前部 升高坐垫前部适用于两侧髋关节 均不能伸展到中立位坐姿 (躯干 与大腿的角度小于90度)。 升高坐垫前部也有助于减少由于 强烈的不受控制的运动或高张力 导致的身体挺直。 坐垫前面升高多少将取决于轮 椅使用者躯干与大腿的角度。 轮椅使用者的坐骨和两侧大腿 下应该与坐垫均匀接触。 骨盆前倾楔形垫 放在坐骨下面的向后倾斜的楔形 垫有助于伴有灵活的骨盆前倾的 轮椅使用者。 楔形垫促使骨盆向后滚动。 骨盆前倾的楔形面应该终止在 坐骨的前面及在大腿下水平。 当要提供一个骨盆前倾楔形垫 时,评定时先用一个楔形垫 “实物模型”,它将会使轮椅使 用者感觉楔形垫的效果,并且 为轮椅服务人员和轮椅使用者 找到最佳角度,并且评定楔形 垫的效果如何。 骨盆下补高 补高常适用于伴有僵硬的不水平 骨盆的轮椅使用者。 补高有助于: 增加轮椅使用者的稳定性; 避免较低侧骨盆下的不安全 压力。 补高是在高的坐骨和大腿下面。 轮椅使用者的两侧坐骨和大腿 下应该是均匀的压力。 当处方一个骨盆下补高时,可 能需要调整脚踏板 (一侧可能 需要高于另一侧)。 骨盆侧垫也将有助于支撑骨盆, 所以应该适配给骨盆下补高的 人士。 83 续表 PSD 目的 适配 骨盆侧垫 骨盆侧垫有助于: 当轮椅太宽或臀部比躯干窄 时,阻止骨盆向侧方移动; 降低骨盆侧倾趋势。 骨盆侧垫应该在骨盆两侧紧密 地接触。 记住幼儿坐着时他们的大腿比 成人分得开些,由于这个原因, 确保骨盆侧垫不要向前伸的太 远并把儿童的双腿挤在一起。 大腿外侧楔形垫 大腿外侧楔形垫能够提供柔和的 支撑: 帮助保持大腿的中立位; 减少轮椅使用者的大腿内收 或外展趋势。 当轮椅使用者静止不动或活动 时,大腿外侧楔形垫应该舒适 地支撑大腿在中立位。 如果大腿有继续滑落或外展的 趋势,必须要更牢固的支撑 (参阅 “大腿外侧垫”)。 大腿外侧垫 大腿外侧垫能够提供稳固的支 撑,有助于防止轮椅使用者的大 腿滑落或外展。 当轮椅使用者静止不动或活动 时,大腿外侧垫应该舒适地支 撑大腿在中立位。 垫子与轮椅使用者的大腿应该 均匀接触。 大腿内侧楔形垫 大腿内侧楔形垫能提供柔和的支 撑以帮助: 保持大腿中立位摆放; 减少两腿靠近/内收的趋势。 当轮椅使用者静止不动或活动 时,大腿内侧楔形垫应该舒适 地支撑大腿在中立位摆放。检 查大腿楔形垫不要使轮椅使用 者上下轮椅更困难。 ,%3" 84 续表 PSD 目的 适配 膝分隔垫 膝分隔垫提供稳固的支撑帮助大 腿保持在中立位摆放。 膝分隔垫对两侧大腿有强烈内收 趋势的轮椅使用者可能是非常有 用的。 当轮椅使用者静止不动或活动 时,膝分隔垫应该舒适地支撑 大腿在中立位摆放。 轮椅使用者的膝部和大腿应该 与分隔垫有均匀的接触。 膝分隔垫不应该接触到腹股沟 区域,如果轮椅使用者有向前 滑动到膝分隔垫的风险,就应 该提供坐骨前垫高和骨盆带。 椅座/靠背 增加椅座和靠背角度 增加 (加大)椅座与靠背的角度 对僵硬的骨盆后倾或僵硬髋关节 的轮椅使用者有用。 增加的角度适应僵硬的体位,并 提供稳定的支撑以增加舒适性以 及帮助预防进一步的姿势变化。 轮椅使用者的坐骨下、骨盆后 部、腰背和胸背部应该与垫子 均匀接触,这可能需要一些塑 形的泡沫塑料来提供正确的支 撑和接触。 当增加椅座与靠背的角度时, 必须确保轮椅使用者在轮椅上 没有向前滑动,这会产生 “剪 切力”,并会导致压疮。 85 续表 PSD 目的 适配 椅座和靠背后倾 (整体后倾) 椅座和靠背整体后倾有助于: 在已经适应僵硬的躯干屈曲 姿势后如果头部仍有压力时, 调整躯干上部和头呈直立 姿势。 对于躯干非常无力的轮椅使 用者,调整躯干上部和头呈 直立姿势。 如果骨盆和躯干的所有其他支 撑都没有效果时,应该只能尝 试椅座和靠背整体后倾。 仔细观察后倾效果,确定最佳 的角度以及效果如何。 在最终的后倾位置,轮椅使用 者应该感觉舒适,并且他们的 姿势应尽可能接近中立位。 靠背 骨盆后垫 在髂嵴部位提供支撑以保持骨盆 直立。 骨盆后垫通常与坐骨前垫高一同 提供,也 可 以 与 骨 盆 带 一 同 提供。 骨盆后垫应该与骨盆后部在髂后 上棘水平处紧密接触,并且促使 骨盆达到中立、直立的坐姿。 确保左右髂后上棘之间的脊椎 上没有大的压力。 可调形状靠背 可调张力靠背 调节靠背形状以更好支撑躯干的 中立位坐姿 (正常弯曲)或适应 躯干僵硬的非中立位姿势。 有不同的方法来调节靠背形状, 包括: 调整靠背面料并增加骨盆后 垫 (左图1); 在硬靠背上增加一个有形泡 沫塑料靠背; 使用可调张力靠背 (左图2)。 当调节形状时,靠背应该与背的 下部、中间和上部均匀的接触。 如果中立位的姿势是可能的, 靠背应该支撑骨盆在直立的姿 势,并且支撑躯干呈正常的 曲度。 如果不可能完全实现中立位姿 势,靠背应该支撑轮椅使用者 尽可能接近中立位。 ,%3" 86 续表 PSD 目的 适配 后倾靠背 后倾靠背有助于适应: 不能屈曲至中立位坐姿 (躯 干和大腿的角度大于90度) 的髋关节; 僵硬的骨盆后倾; 腰部僵硬的屈曲姿势; 僵硬的躯干前屈; 调整躯干和头成一直线。 坐骨前垫高、骨盆带和/或坐垫前 部楔形垫有助于防止向前滑动。 确保后倾靠背支撑轮椅使用者 使他们尽可能达到最佳姿势。 确保轮椅使用者的背部与靠背 之间均匀的接触。 检查轮椅使用者没有向前滑动。 坐骨前垫高、骨盆带和/或坐垫 前部楔形垫有助于防止向前 滑动。 躯干侧垫 躯干侧垫提供稳固的支撑有助于 保持躯干在背部支撑的中心。 如果提供了一个躯干侧垫, 通常对侧也应该提供。 躯干侧垫通常应该至少低于轮椅 使用者腋下 (腋窝)50mm,并 且根据需要尽可能向前伸。 轮椅使用者与侧垫之间应该压 力均匀,且没有高压力点。如 果支撑需要稳固———加大侧垫 的尺寸以分布压力,并且确保 有足够厚的软垫。 躯干侧垫应该尽可能薄以允许 轮椅使用者的手臂自由摆动。 87 续表 PSD 目的 适配 躯干侧楔形垫 提供柔和的支撑有助于保持躯干 在靠背的中心。当只需要少量的 支撑时,它是有帮助的。 躯干侧楔形垫有助于维持轮椅 使用者的背部对称的坐姿 (躯 干在靠背的中心)。 楔形垫应该放在腋下 (腋窝), 并且根据需要尽可能向前。 躯干侧垫与骨盆 侧垫一起使用 躯干侧垫与骨盆侧垫一起使用, 为躯干侧弯 (脊柱侧弯)的轮椅 使用者提供支撑。 在曲线的顶端,曲线的最高点 (对侧)和曲线的底部,调整侧 垫提供支撑。 两侧都需要骨盆侧垫以保持骨盆 在椅座中央。 为有弹性的脊柱侧弯提供支撑于 中立位,也可以矫正有弹性的不 水平骨盆。 如果坐姿是灵活的,轮椅使用 者就能坐在中立位坐姿。如果 坐姿是僵硬的,支撑其舒适地 接近中立位。 确保轮椅使用者与每块垫子之 间均匀的接触,检查高压力点。 如果需要稳固的支撑———加大 侧垫的尺寸以分布压力,并且 确保有足够厚的软垫。 塑形背部支撑 塑形背部支撑可用于提供支撑或适应不同的躯干姿势,包括向前 跌落和弯曲的躯干。 背部支撑是用支架或绑带固定在轮椅架上。 此部件在中级教程中不涉及。 ,%3" 88 续表 PSD 目的 适配 桌面板 桌面板 桌面板在许多方面是有帮助的, 包括: 为手臂提供支撑,它可以有 助于减少轮椅使用者手臂向 下或向前拉躯干的力量; 为轮椅使用者提供一个靠近 他/她身体的平面,以便于工 作和/或娱乐。 桌面板通常定位在比手肘稍高 的高度,如果桌面板的目的是 为了附加体位支撑,位置可以 稍高。 桌面板不应被用于 “限制”轮 椅使用者在他们的椅座上。桌 面板不应该增加作用于使用者 的任何压力。 头靠 扁平头靠 扁平头靠为头部提供休息并阻止 头部后仰。 有形头靠 有形头靠通过包住轮椅使用者的 颅底,比扁平头靠提供更多的 支撑。 当轮椅使用者静止和/或活动 时,头靠应该提供良好的支撑。 头靠应该与轮椅使用者的头颅 底部均匀接触。 确保头靠以正确的方式提供支 撑———而不是向前推轮椅使用 者的头部,或者让他们的头向 后倒。 不要在轮椅使用者的头前面提 供支撑。 89 续表 PSD 目的 适配 小腿支撑 脚踏板补高 当单脚或双脚都不能达到脚踏板 时,可选用脚踏板补高 (脚踏板 已经调整到它的最高点)。 确保足部下方有均匀接触。 脚踏板楔形垫 脚踏板楔形垫常用于支撑僵硬的 非中立位姿势的足部。 脚踏板楔形垫有助于防止踝关节 进一步变化。 脚踏板楔形垫的目的就是增加脚踏 板与轮椅使用者足部的接触面积。 根据轮椅使用者足部所需的支 撑,大多数脚踏板楔形垫都是个 性化制作的。 确保双足底均匀接触。 小腿支撑板 不同的小腿支撑板可用于支撑僵 硬的非中立位姿势的小腿,包括 不能屈曲到90度的膝关节 (躯 干与大腿的角度大于90度)。 不同的解决方案及其适配将在 产品 (轮椅)准备单元进一步 讨论。 ,%3" 90 续表 PSD 目的 适配 绑带 骨盆带 骨盆带有助于保持骨盆在适当的 地方,它对有不受控制的运动和 /或向前滑动的人是特别有帮 助的。 骨盆带通常与坐骨前垫高和骨盆 后垫一起使用。 骨盆带应该稳固均匀的接触, 应该没有高压力点。骨盆带上 与轮椅使用者大腿接触部位的 软垫非常重要。 骨盆带在轮椅上的位置将影响 拉力的角度/方向。 角度可以在45度和90度之间, 最有效的角度将取决于轮椅使 用者的需要。 应该评定、讨论,并且如果可 能与轮椅使用者试用骨盆带的 角度,看哪个角度对轮椅使用 者最有效和最舒适。 骨盆前倾四点带 骨盆前倾四点带为骨盆前倾的轮 椅使用者提供支撑。 它能帮助骨盆摆在更加中立的坐 姿,或提供支撑以防止骨盆进一 步前倾。 它也可以和轮椅使用者坐骨下的 骨盆前倾楔形垫一起使用。 记住骨盆带向下固定在椅座固 定杆上,向后固定在靠背杆上。 带子不能滑到腹部上。 重要的是在髂前上棘上提供支 撑的所有带子都应该用软垫包 好,以降低压疮的风险。 91 续表 PSD 目的 适配 小腿带 小腿带可有助于防止小腿向后滑落。 这些带子有时作为轮椅标准配置。 不同的足带提供支撑,以帮助稳定使用者的足部,有助于防止轮椅使用者的脚向前/向后滑动。 足带———足跟后面 足带在足跟后面有助于预防足向 后滑落。它与小腿带一起使用可 提供更多支撑。 足带———围绕踝部 绕踝足带有助于防止足部向前滑 动并阻止足跟抬起来。 足带———在足前面 足带在足前部有助于防止脚趾 抬起。 足带应该提供均匀的压力,以 及用软垫包好———尤其是当使 用者不穿鞋子时。 肩带 当骨盆支撑、躯干支撑以及椅座 与靠背后倾无效时,肩带有助于 维持躯干直立。 如图所示的肩带包含提供附加支 撑的胸带。胸带也有助于保持肩 带在正确的位置。 肩带通常与骨盆带一起使用。 永远不要处方一个没有骨盆带 的肩带。如果使用没有骨盆带 的肩带,使用者仍能滑下来, 并且肩带能够导致窒息。 确保经过轮椅使用者肩部的带 子有足够的衬垫。 胸带 (如图所示)能够帮助保 ,%3" 92 续表 PSD 目的 适配 持肩带在适当的位置。肩带应 该系在与轮椅使用者肩部一样 的高度或高于其肩部。当肩带 系紧时,这样可以避免产生向 下的压力作用于轮椅使用者的 肩部。 在中级轮椅处方 (选择)表上记录PSDs 中级轮椅处方表的目的是为轮椅服务人员准备轮椅提供明确的信息: 轮椅的类型、尺寸和设置 (前面介绍过); 坐垫的类型和尺寸 (前面也介绍过); PSDs或需要的改制。 中级轮椅处方表中提供的信息越详细,初次适配准备的轮椅就越精准。 由于处方的PSDs有很多变化,因此 “PSDs或需要的改制”是中级轮椅处方表中最复杂的部分。 轮椅服务人员可使用中级轮椅处方表中 “PSDs或需要的改制”部分来: 从常见的PSDs清单中选择他们想要处方/选择哪个PSDs。还可以在下面 “其他”空格里列出 其他PSDs; 画出透视图以显示其形状,并写出他们处方 (选择)的PSDs的尺寸; 写出或概述任何附加信息。 注意:中级轮椅处方表不必列出应该如何制作PSDs。它应该由准备轮椅的轮椅服务人员与进行评定的轮椅服务人 员共同讨论决定。 93 下表是完成了中级轮椅处方表 “PSDs或需要的改制”部分的两个示例 (不包括尺寸) PSD清单 描述/绘画并提供尺寸 椅 座/ 坐垫 增加硬椅座 □ 坐骨前垫高 (=3-12) √ 降低坐垫前部 左□ 右√ 升高坐垫前部 □ 前倾楔形垫 □ 骨盆下补高 左□ 右□ 骨盆侧垫 (=2) 左□ 右□ 大腿外侧楔形垫 左□ 右□ 大腿外侧垫 左□ 右□ 大腿内侧楔形垫 (=10) □ 膝分隔垫 (=10) □ 其他 □ 其他 □ 椅 座 和 靠 背 增加椅座和靠背角度 □ 椅座与靠背后倾 (整体后倾) √ 靠 背 增加硬靠背 □ 骨盆后垫 (=9) □ 可调形状靠背 □ 可调张力靠背 □ 靠背后倾 □ 躯干侧垫 (=7) 左√ 右□ 躯干侧楔形垫 (=7) 左□ 右√ 其他 □ ,%3" 94 续表 PSD清单 描述/绘画并提供尺寸 桌面板 /扶手 桌面板 □ 改制扶手 左□ 右□ 其他 □ 头 部 支 撑 扁平头靠 (=11) □ 有形头靠 (=11) □ 其他 □ 小腿 支撑 脚踏板补高 左□ 右□ 脚踏板楔形垫 左√ 右□ 小腿支撑板 左□ 右□ 其他 □ 带子 骨盆带 √ 小腿带 □ 足带 左□ 右□ 肩带 □ 其他 □ 体位支撑装置 (PSDs)的处方 (选择)———稳定骨盆 许多PSDs常用来为骨盆提供支撑,重要的是要记住尽管PSDs可以单独使用,但许多PSDs共同 发挥作用。本单元着眼于与骨盆相关的不同姿势问题以及可能的PSDs解决方案。 为了帮助轮椅使用者坐直,稳定骨盆是首先要做的最重要的事情 当骨盆不在直立姿势时,躯干和髋关节的姿势也会发生变化; 因此,支撑或稳定骨盆是帮助轮椅使用者坐直最重要的事情; 对骨盆提供支撑可以减少对于其他部位支撑的需求。 95 问题:骨盆后倾和/或向前滑动 需要的支撑 为了把骨盆从后倾位摆至更中立位坐姿,通常需要在以下两个部位 支撑: 在骨盆后部髂后上棘水平处; 在骨盆前部坐骨处 (坐骨结节)。 PSD解决方案 坐骨前垫高在坐骨前提供支撑有助于: 保持骨盆直立; 阻止骨盆前滑; 降低下滑坐姿的趋势。 坐骨前垫高刚好位于坐骨前面。 骨盆后垫在骨盆的上部 (髂后上棘水平处)提供支撑,有助于保 持骨盆直立。 坐骨前垫高与骨盆后垫常一起使用帮助轮椅使用者坐着时骨盆更直立和更稳定。 骨盆带能够为有不受控制的活动和/或骨盆向前滑动趋势的轮椅使用者提供附加支撑。骨盆带有助 于保持骨盆在适当的位置,这样坐骨前垫高和骨盆后垫可以持续提供支撑。 ,%3" 96 问题:骨盆侧倾 (僵硬的不水平骨盆) 需要的支撑 在较高的坐骨和大腿下需要支撑以: 增加轮椅使用者的稳定性; 有助于避免较低侧骨盆下的不安全压力。 PSD解决方案 骨盆下补高有助于: 增加轮椅使用者的稳定性; 避免较低侧骨盆下的不安全压力。 骨盆侧垫为骨盆提供进一步的支撑并应适配给骨盆 下补高的使用者。 问题:骨盆移向一侧 这个问题通常与其他姿势问题有关,右边两个插图 你可以看到: 来自较早前的同一位男士———伴有骨盆侧倾 (僵硬的不水平骨盆),并且他的骨盆更转向 左侧; 伴有脊柱侧弯的女士;她的骨盆也更转向左侧。 需要的支撑: 在髋关节的两侧提供支撑。 97 PSD解决方案 骨盆侧垫。 为儿童提供骨盆侧垫 幼儿坐位时他们的双腿应该比成年人分得开些。 这对他们髋关节的健康和发育是重要的。 这意味着骨盆侧垫不要把儿童的大腿挤压在一起,这点对儿童特别 重要。 问题:骨盆前倾 (骨盆向前倾斜) ,%3" 98 需要的支撑 可以两种方式提供支撑: 在骨盆 (ASIS)前面提供支撑向后推; 通过改变坐骨下椅座的角度,促使骨盆向后滚。 PSD解决方案 骨盆前倾楔形垫促使骨盆朝靠背的方向向后滚,骨盆前倾楔形 垫应该刚好终止于坐骨前面并且在大腿下水平。 骨盆前倾四点带在骨盆上面和前面提供支撑,促使更接近中立 位坐姿。 体位支撑装置 (PSDs)的处方 (选择)———支撑髋关节 重要的是要记住如果任何僵硬的/非中立位姿势的髋关节不进行调适,它将影响骨盆的姿势。 支撑髋关节 问题:一侧髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度) 这个问题的临时解决方案是在两侧坐骨下和髋关节能屈曲至中立位坐 姿的大腿下放置一个补高 (泡沫塑料)。 PSD解决方案 降低一侧的椅座前部———这个支撑可以成为坐垫的一部分以适应不能 屈曲至中立位坐姿的髋关节 (躯干与大腿的角度大于90度)。 注意:最终解决方案是在不能屈曲至中立位坐姿的髋关节一侧的坐垫做一个角度 切割,泡沫塑料切割的角度取决于轮椅使用者髋关节的角度———这应该在评定时确定。 注意:这个坐垫仍然有一个坐骨前垫高。 问题:两侧髋关节都不能屈曲至中立位坐姿 (躯干与大腿之间的角 度大于90度) 这个问题的临时解决方案是在两侧坐骨下放置一个补高 (泡沫塑 料),然而当轮椅使用者有向前滑下轮椅的趋势时,这不能作为一个永久 性的解决方案。 99 PSD解决方案 增加椅座与靠背的角度将让躯干与大腿的角度更大,椅座 与靠背之间的角度将取决于轮椅使用者的躯干与大腿的角度 ———并且这应该在评定过程中决定。 一个可能的永久性解决方案是提供一个坐骨前垫高和骨盆 带,它可以阻止轮椅使用者向前滑下轮椅。 问题:一侧或两侧髋关节不能伸展至中立位坐姿 (躯干与大腿的角度小于90度) 这个问题的临时解决方案是在不能伸展至中立位坐姿 (躯干与大腿的角度小于90度)的大腿下面 放一个补高 (硬泡沫塑料楔形垫) PSD解决方案 升高坐垫前面———一个可能永久性的解决方案是升高坐垫前面 /在坐骨前面/大腿下面放一个楔形垫,这样会减少椅座与靠背之间 的角度。椅座前面升高多少将取决于轮椅使用者的躯干与大腿的角 度———因此这应该在评定过程中决定。 注意:两侧坐骨应该仍然坐在一个水平面上。 帮助减轻不受控制的活动、高张力或痉挛 对于有些轮椅使用者,升高椅座前部来减小躯干与大腿的 角度,髋关节小于中立位有助于减轻不受控制的活动、高 张力或痉挛。 记住:楔形垫通常应该从轮椅使用者的坐骨前开始,他们 的坐骨应该坐在一个平面上。 ,%3" 100 体位支撑装置 (PSDs)的处方 (选择)———支撑躯干 通常重要的是首先考虑稳定骨盆,然后是支撑躯干。对于许多人来说,与躯干相关的姿势问题, 能够通过良好的骨盆支撑来解决或改善。 支撑躯干 姿势问题:不良姿势,躯干向前及骨盆后倾 需要的支撑 支撑可促使骨盆尽可能接近中立位坐姿; 靠背支撑,可让躯干呈正常弯曲; 有时在躯干前面的支撑也是需要的 。 PSD解决方案 提供体位支撑,通过: - 坐骨前垫高; - 骨盆后垫; - 骨盆带 (不总是必须); - 骨盆侧垫 (不总是必须)。 提供靠背支撑,通过: - 调整靠背形状—为躯干留足空间,并且让背部呈现正常 弯曲。如果靠背继续笔直向上,它将会向前推轮椅使用 者。对靠背形状的改制是PSD解决方案的一部分。 提供附加体位支撑,通过: 桌面板———桌面板可以提供附加体位支撑以帮助轮椅使用者 维持躯干直立的姿势。 肩带———对于容易疲劳或向前跌落的轮椅使用者有帮助。 椅座与靠背后倾———当其他PSDs组合仍不能帮助轮椅使用 者坐得更直时,椅座和靠背整体后倾可能会有帮助。 101 靠背需要遵循脊柱的正常弯曲 一个笔直的、直立的没有轮廓支撑脊柱正常弯曲的靠背, 通常为以下两种情况之一: 推躯干上部向前; 促使轮椅使用者的骨盆向前移动以便他能往后靠在靠 背上。 不幸的是,很多标准轮椅都有上下笔直的靠背,通常需要 改制来支撑轮椅使用者,使他能够舒适地坐在中立位坐姿。 问题:下滑姿势、骨盆僵硬后倾和躯干后凸 需要的支撑 支撑使骨盆尽可能接近中立位坐姿; 靠背支撑支持躯干尽可能接近中立位坐姿并提供 一个改善的头部位置 (能够向前看)。 PSD解决方案 解决方案将视需要调整多少以及可得到的轮椅类型 的不同而变化,下面列出一些建议: 提供骨盆支撑,通过: - 坐骨前垫高; - 骨盆后垫和增加椅座与靠背的角度来适应和支 撑僵硬的骨盆后倾; - 骨盆带 (不总是必须)。 ,%3" 102 提供靠背支撑,通过: - 靠背后倾———为僵硬的躯干畸形提供空间,这可 能有助于创造一个更好的头部和颈部摆位,这个 解决方案也适合僵硬的骨盆后倾 (注意:任何硬 靠背上都需要加上软垫的泡沫塑料); - 调整靠背形状———为躯干留足空间,并且让 背部呈现正常弯曲。 通过以下提供附加体位支撑: - 桌面板; - 肩带; - 椅座与靠背后倾。 以下面的顺序思考PSD解决方案 骨盆和髋关节 躯干 头和颈部 双腿 问题:躯干倾斜或倒向一侧 需要的支撑 稳定骨盆 在躯干侧面提供支撑 103 PSD解决方案 躯干侧楔形垫———提供柔和的支撑以帮助保持轮 椅使用者的躯干在靠背的中央。 躯干侧垫———躯干侧支撑提供稳定的支撑以帮 助保持躯干在靠背的中央。 如果一侧提供了躯干侧垫,通常情况下对侧也应提 供另一个侧垫———可能在不同的高度。 问题:僵硬的或有弹性的脊柱侧弯 需要的支撑 在弯曲侧的顶点和另一侧弯曲的顶端和底部 支撑。 PSD解决方案 躯干侧垫与骨盆侧垫组合 如果姿势是灵活的,用这个支撑轮椅使用者或许能 够坐在中立位坐姿。如果姿势是僵硬的,支撑其舒适地 接近中立位坐姿。为灵活的脊柱侧弯的轮椅使用者提供 支撑使其处于中立位坐姿,也可以矫正灵活的不水平 骨盆。 ,%3" 104 体位支撑装置 (PSDs)的处方 (选择)———支撑头部、大腿和小腿 支撑头部 问题:头部后仰、下垂或侧偏 需要的支撑 提供头靠前———通常首先: - 稳定轮椅使用者的骨盆; - 提供良好的骨盆支撑,确保骨盆以上的躯干 稳定和平衡。 如果轮椅使用者仍然觉得很难保持头部直立, 应该提供支撑: - 首先在颅底部; - 如果必要,支撑可延伸围绕轮椅使用者的头 部侧面。 PSD解决方案 有很多不同类型的头靠,两种常用的头靠是扁平头 靠和有形头靠。 扁平头靠———扁平头靠是靠背的延伸,通过塑 型为头部提供支撑。扁平头靠为头部提供休息 位置,并阻止头部后仰。 有形头靠———有形头靠是头底部呈 “杯”状, 它可以延伸到两侧,在头部侧面提供更多的支 撑。通过包住轮椅使用者颅底,有形头靠比扁 平头靠提供更多的支撑。 105 当提供头靠时: 当为轮椅使用者的头部提供支撑时,应该记住头部姿势也取决于良好的骨盆和躯干姿势。 避免在轮椅使用者的头前面提供支撑。 支撑大腿 问题:大腿向外展 (外展) 需要的支撑 首先通过提供需要的支撑确保轮椅使用者的骨 盆和躯干是稳定的,这可能有助于使大腿处于 更加中立的坐姿。 在大腿外侧支撑。 PSD解决方案 大腿外侧楔形垫将提供柔和的支撑。 注意:插图中大腿外侧楔形垫已经加到坐垫的硬泡沫塑料 层上,硬泡沫塑料上有了坐骨前垫高,软层泡沫塑料应该加在 整个坐垫的顶层。 大腿外侧垫将提供稳定的支撑 注意:插图中的大腿外侧垫是用一个支架连接在木制椅座 基底上,并预留空间让坐垫放在木制椅座上。 问题:大腿向内收 (内收) 需要的支撑 首先通过提供需要的支撑确保轮椅使用者的骨 盆和躯干是稳定的,这可能有助于使大腿处于 更加中立的坐姿。 在大腿内侧和膝关节内侧支撑。 ,%3" 106 PSD解决方案 大腿内侧楔形垫将提供柔和的支撑。 注意:插图中的大腿内侧楔形垫已经加到坐垫的硬泡沫塑 料层上,硬泡沫塑料上加了坐骨前垫高,软层泡沫塑料应该加 在整个坐垫的顶层。 膝分隔垫将提供稳定的支撑 注意:插图中的膝分隔垫是用一个支架连接在木制椅座基 底上,并预留空间让坐垫放在木制椅座上。 支撑小腿和双脚 问题:一侧或双侧膝屈曲并且是僵硬的,小于中立 位坐姿 (躯干与大腿角度小于90度) 解决方案将取决于轮椅使用者的个人需要。 PSD解决方案 如果可能,向后调整脚踏板。 如果可能,调整脚踏板的角度以适应脚的位置。 如果不行,则用脚踏板楔形垫。 加一条绑带在小腿前面用于支撑和保护。 如果椅座的前端压迫轮椅使用者的腿部/双腿后 面,可能需要把椅座稍微缩短并且向后斜切坐垫。 对于高个子的轮椅使用者,考虑升高坐垫前部 或倾斜椅座和靠背。通过这样做,轮椅使用者 的双脚抬高了、更往前了并且可能在标准脚踏 板的可调范围内。 注意: 在做上述任一项调整时———确保小脚轮仍能自由转动没有碰到脚踏板或轮椅使用者的双脚。 如果可得到的轮椅不可能这样调整或者不能给予足够的调整,可能需要部分改制。 107 问题:一侧或双侧的膝关节不能屈曲至中立位坐姿 PSD解决方案 如果有,提供一个标准的可升高腿托。 如果可能,向前调整脚踏板。 如果有,考虑提供一辆三轮轮椅。把脚踏板加 在中间横杆的上面 通过加入木材或金属板来向前延伸脚踏板。 向前延伸脚踏板固定杆———这可能需要焊接, 并且应该由具有丰富技术知识和技能的金属加 工工人来实施。 注意:无论决定用何种解决方法,重要的是设法确保轮椅 的总长度维持在最小。 步骤4:经费与订购 参阅步骤4:经费与订购——— 《轮椅服务初级教程》中有关经费与订购的基本信息。 步骤5:产品 (轮椅)准备 产品 (轮椅)准备 产品 (轮椅)准备是轮椅服务第5步。产品 (轮椅)准备是指安装轮椅以及准备已经处方 (选择) 的所有PSDs。 在中级轮椅教程中,通常在需要进行适配之前只可能准备轮椅到一定程度,轮椅服务步骤 “产品 (轮椅)准备”和 “适配”可能需要多次重复直到轮椅正确适配。通常第一次适配之前,PSDs不完全 固定到位,这是为了确保适配后可以对轮椅和PSDs进行调整。 附加体位支撑可以不同的方式提供,有些解决方案非常简单并且在简单的车间就可以完成。其他 解决方案可能比较复杂,并且需要更高的技术和设备。 轮椅服务人员不必亲自制作PSDs。 轮椅服务人员可以与技术人员合作。轮椅服务人员可以说明他们需要做什么以及如何发挥作用, 而技术人员应该想出办法用当地可得到的材料制作完成。 ,%3" 108 通常有不同的PSD解决方案达到同样的支撑效果。采用的解决方案通常取决于可利用的资源。 包括: 可得到的轮椅类型———哪些部件可以进行调整; 可用的材料; 可用的车间设施和工具; 是否有可用的预制支撑部件———例如骨盆侧垫、躯干侧垫、带子和头靠。 计划和实施轮椅及体位支撑装置 (PSD)准备 计划及准备 开始准备轮椅前,重要的是计划工作。如果轮椅的准备工作交给其他人做 (例如车间的技术员), 或者如果不止一个人在准备轮椅,详细计划尤为重要;计划及准备工作可能包括以下的步骤: 检查中级轮椅处方 (选择)表 确保每个人都理解表上的所有信息; 确保表上有足够的信息来准备轮椅,例如———所有需要的尺寸都有吗? 不同PSDs的描述够详 细吗? 可能需要进一步的讨论和厘清。 决定在选择的轮椅上如何实现必要的支撑 观察将要使用的轮椅并提问: - 对实际的轮椅可以做哪些调整以提供必要的支撑? - 轮椅上已经有了哪些PSDs? 如果改制或需要增加PSDs,决定: - 有预制的支撑可以使用吗? 如果有———如何安装到轮椅上? - 如果改制或PSDs需要由原材料制作———将使用什么材料,以及PSDs如何固定在轮椅上? 记住思考PSDs和轮椅将如何一起发挥作用。 准备任务列表 列出准备轮椅需要完成的工作任务; 如果不止一个人做这项工作———决定谁负责哪项工作。 109 当制作体位支撑装置 (PSDs)时应记住什么 当准备具有PSDs的轮椅时,请记住以下4点建议: 1.PSDs应提供足够的支撑 每位轮椅使用者的支撑程度会有所不同,PSDs应该在正确的地方以及正确的接触表面区域为每位 轮椅使用者提供需要的支撑。 2.PSDs和轮椅作为一个整体系统共同发挥作用 轮椅加入附加体位支撑会改变整体系统。例如,加入PSDs可能改变轮椅的内部尺寸。 3.避免产生高压区域 PSDs有时会在轮椅使用者身体的特定部位产生压力,如果一位轮椅使用者需要很多支撑以防止其 偏向一侧,他的躯干侧垫可能是高压力区域。 在这种情况下,考虑通过增加表面积来分散压力。应该确保PSDs表面和绑带下有足够的衬垫。 4.确保PSDs实用而不降低功能 记住———轮椅使用者需要实用的和易于使用的轮椅和椅座,并帮助他们尽可能活跃。 车间安全———5条安全规则: 在车间穿全包鞋; 当切割或钻孔时固定好你的加工件———用夹具或寻求帮助; 当使用电动工具或其他任何锋利的工具时,戴上防护眼镜; 保持工作区域和走道整齐、干净; 不要对着自己或他人切割。 ,%3" 110 制作体位支撑装置 (PSDs)和改制需要的材料和工具 下表列出常用来制作PSDs材料的例子。 材料 用于制作PSDs和改制的材料 当制作PSDs和改制选择材料时的关注要点 金属/ 塑料/ 木材 金属/塑料/木材构成 PSD 的结构, 如硬椅座和靠背。 木材或金属可以用来制作支架,固定 躯干侧垫在靠背上。 12mm的胶合板用来制作硬椅座和靠背非常有用。 它很坚固但重量相对较轻。船用胶合板最耐用, 但是比较贵。 如果有,3mm的铝板和6mm的亚克力或ABS塑 料板也能用来制作硬靠背。板折叠一层使用可以 增加刚度。 当使用任何板材时,为了轮椅使用者的安全,特 别注意去除或包裹锐利边缘。 泡沫 塑料/ 衬垫 泡沫塑料用于包覆所有PSDs与轮椅 使用者身体直接接触的区域。 硬泡沫塑料能保持其形状,用于实现 PSDs需 要 的 形 状 来 提 供 正 确 的 支撑。 较软的泡沫塑料用于增加舒适性并降 低压力。 使用泡沫塑料的例子: 泡沫塑料应该加到带子上以分散 压力并增加舒适性; 硬泡沫塑料可以用于制作躯干侧 楔形垫,加入到坐垫上做成大腿 外侧楔形垫或大腿内侧楔形垫; 非常硬的泡沫塑料 (例如EVA) 可以用来制作脚踏板补高或脚踏 板楔形垫和躯干侧垫。 在当地市场寻找并参观泡沫塑料、鞋、床垫、家 具厂发现当地可得到的泡沫塑料。 设法找到当地不同厚度 (25mm 和50mm)和硬 度的泡沫塑料样品。 EVA是非常硬的泡沫塑料样品,它对于提供稳定 的支撑和PSD的结构有用。EVA有时可以在生 产鞋的工厂找到。 用于制作人字拖鞋的硬橡胶可用来代替EVA。 质量好的聚合泡沫塑料是中等硬度泡沫塑料的实 例,聚合泡沫塑料可以用作波形/多层坐垫的底 座,制作骨盆后垫或坐骨前垫高,或在硬靠背上 塑造轮廓。 软 “床垫泡沫塑料”是软泡沫塑料用作舒适层的 实例。 如果没有较硬的泡沫塑料作为底座,最常用、最 便宜的 “非常软”的泡沫塑料不太适合单独用来 制作减压坐垫。 椰壳纤维 (椰子纤维)可以用来代替硬泡沫塑料。 111 续表 材料 用于制作PSDs和改制的材料 当制作PSDs和改制选择材料时的关注要点 面料 面料用于包覆PSDs。 寻找一种耐用和便于清洁的面料 (便于擦洗或取 下清洗),如果轮椅使用者大小便失禁,防水面料 对于椅座、坐垫和靠背都有用。柔软的、T恤类 材料 (棉或棉/莱卡)可用作头靠、躯干侧垫和躯 干侧楔形垫,有弹性的面料更容易适应PSDs的 形状。 合成面料通常比天然面料让人感觉更热。 如果可能,尝试提供至少几种不同颜色的面料让 轮椅使用者选择。 尼龙带 /尼龙 搭扣/ 带扣 尼龙带/尼龙搭扣/带扣用来制作绑 带,包括骨盆带、肩带、小腿带和 足带。 25mm、35mm和50mm 的尼龙带是有用的,带 子越宽压力越均匀。熔化尼龙带的切割端以防磨 损,棉织带效果差些。 插扣 (例如双肩包上使用的)非常容易使用,如 果有,使用质量好的插扣将会更耐用。通过把它 们合在一起和分开来测试。它们应该容易地分和 合,除非松开否则不被拉开。 尼龙搭扣是一个好的紧固件,然而它需要保持清 洁,否则会失效。 软泡沫塑料垫应该放在所有的织带下面以保护轮 椅使用者的身体。 黏合剂 黏合剂用于黏合木材和泡沫塑料。 有木材胶 (通常称为白胶水或PVA)和泡沫塑料 胶 (接触黏合剂、鞋胶水或黄胶水)。 确保使用黏合剂的所有人都知道如何正确使用。 紧固件 紧固件用于安装PSDs在轮椅上。 有用的紧固件包括: 螺栓及螺母 (最好锁紧螺母)和垫圈; T形螺母 (取代螺母钉进胶合板); 订书针 (用于固定装饰面料)。 避免使用尖的螺钉,因为如果PSD损坏时,它们 会导致危险。 ,%3" 112 车间设施和工具:建立一个工作车间,包括一个工作台和台钳、材料和工具存储区,良好的照明 和通风,对于定期制作PSDs的服务单位将是非常有益的。下表列出了有助于制作PSDs的工具清单。 有用的工具 用于 手动锯 手工切割木头、塑料或金属 电动锯 在有电的地方切割木头、塑料或金属 (确保选择正确的刀片用于切割不同的材料) 钻和钻头 为螺钉钻孔 美工刀 手工切割泡沫塑料 带锯 在有电的地方切割木头、塑料和泡沫塑料 锉刀 打磨木头、金属或塑料的边缘 砂带磨光机 在有电的地方打磨木头、金属或塑料的边缘 扳手 紧固螺母和螺栓 工业缝纫机 缝纫装饰面料、套子和绑带 如何制作PSDs 下面给出如何制作本教程中涉及PSDs的建议,许多原则可应用到其他PSDs。 坐骨前垫高 坐骨前垫高是由一块硬泡沫塑料或类似材料及其 上面的软泡沫塑料组成。 垫高层可以放在硬椅座的软泡沫塑料下面,或多 层泡沫塑料坐垫的两层之间。 坐骨前垫高可以作为减压坐垫的一部分。 坐骨前垫高恰好位于坐骨前面。 113 降低坐垫前部 (一侧) 这个PSD可以通过修改一块泡沫塑料坐垫完成。 切除坐垫前部的硬泡沫塑料 (而不是软泡沫塑料) 到需要的角度。 切掉的那块泡沫塑料是楔形,厚端在坐垫前部,薄 端就在骨盆或坐骨前部。 如果使用硬坐垫就需要一个较大角度,且部分椅座 板也要切掉,使髋部能够更加伸展。 注意:通过保持另一侧髋关节屈曲,可以更容易阻止使用者 在椅座上前滑。 如果需要较大角度,改制前可能必须做一个具有硬 泡沫塑料底座的完整坐垫,但要确保没有锐利的边 缘———所有的边缘需要倒角。 检查较高的椅座面不会导致脚踏板或靠背高度的 问题。 升高椅座前部 椅座前部可以不同的方式升高,两个建议是: 在坐垫的前部下面放一个硬泡沫塑料楔形垫,恰好 终止于骨盆前部。 ,%3" 114 去掉帆布椅座更换为一个硬椅座。 根据需要的角度用支架安装椅座。 应该为硬椅座配一个坐垫。 骨盆前倾楔形垫 用与坐骨前垫高同样原理制作一个骨盆前倾楔形垫, 硬泡沫塑料基底层构建坐垫的形状,软泡沫塑料层 放在顶层上。 楔形垫应该在坐骨下面,并止于坐骨前,坐垫应该 在大腿下水平。 骨盆下补高 骨盆下补高应该由硬泡沫塑料或类似材料和其上面 的软泡沫塑料层组成。 高的一侧下补高,直到两侧坐骨下压力相同。 骨盆侧垫 根据骨盆侧垫所安装轮椅的不同以及需要多大的支撑,可以有不同的制作方法,建议是: 115 如果有固定的扶手用于为垫子提供结构/支撑, 骨盆侧垫可由一块装饰性硬泡沫塑料制作并紧靠 扶手安装。 在扶手是移开的情况下 (如左插图),硬骨盆侧垫可 以用一块木头和内侧粘上较软的泡沫塑料做成,并 且应该进行表面装饰。 要么安装骨盆侧垫在轮椅架上,要么用支架固定在 硬椅座上。 在左侧插图中,将坐垫放在硬椅座上,保护轮椅使 用者不受支架和螺钉伤害。 大腿外侧楔形垫 对角切一块硬泡沫塑料 (100mm×100mm×40mm) 为两块,做成两个楔形块,保留一块在适配轮椅时 使用。 粘贴楔形块在坐垫的基底泡沫塑料上和软泡沫塑料 下,根据需要修剪边角。 ,%3" 116 如果使用塑形泡沫塑料坐垫,水平剪切坐垫 (距坐 垫顶部约20mm)并在合适位置粘贴楔形块,修剪 伸出来的泡沫塑料。 大腿外侧垫 这些垫子和躯干侧垫用同样方法做成。 通常它们由一块木头、塑料或金属以及内层 (接触 轮椅使用者大腿的一侧)的硬泡沫塑料和软泡沫塑 料外层组成。 垫子包上耐用、舒适的面料。 垫子用金属支架固定到硬椅座上或用支架固定到轮 椅椅座固定杆上。 大腿内侧楔形垫 切割一块楔形块为相同的两块 (宽 50mm× 长 100mm),保留一块泡沫塑料在适配时使用,将其 粘贴在坐垫的基底泡沫塑料上和软泡沫塑料下。 如果使用塑形泡沫塑料坐垫,水平切开坐垫 (距坐 垫顶部约20mm)并粘贴在合适的位置,修剪所有 伸出来的泡沫塑料。 117 膝分隔垫 膝分隔垫通常是由一块金属、塑料或木头及其上面、 侧面和后面 (接触使用者的表面)的硬泡沫塑料组 成。为了增加舒适性,薄的、软泡沫塑料通常放在 硬泡沫塑料上面。垫子可用耐用、舒适的面料包上。 如果轮椅使用者需要膝分隔垫,最好提供给他们一 个硬椅座。 膝分隔垫可以用一个L形支架固定在硬椅座上 (如 图)。 需要一种简易的拆卸或转开膝分隔垫的方法,以便 轮椅使用者能够上下轮椅。 增加椅座与靠背的角度 制作椅座与靠背更大角度的方法是根据需要的角度, 在硬靠背上加入一个硬泡沫塑料楔形垫,并且应该 再加上一层软泡沫塑料。 椅座与靠背后倾 (整体后倾) 有些轮椅具有容易地后倾椅座与靠背的功能,以下建议是针对正在使用的、不具有此功能的大部 分轮椅。 ,%3" 118 对于没有硬椅座和靠背的轮椅,在坐垫的前部下方 放置一个硬泡沫塑料楔形垫,并且调整或向后倾斜 靠背。 用硬椅座和靠背替换帆布/悬吊式椅座和靠背。 根据所需的角度,把椅座和靠背固定到支架上。 应该用硬泡沫塑料做硬靠背衬里,然后是一层软泡 沫塑料并装饰,通常为硬椅座配一个坐垫。 此图提供支架的例子,用于固定硬椅座或靠背到管 子上。 支架可以通过旋转锁块松开。 便于运输时拆下椅座和靠背 (如果是交叉折叠式轮 椅)。 骨盆后垫 骨盆后垫不应该很厚。它取决于轮椅使用者的状况,后垫可以20mm~30mm厚。 骨盆后垫通常应该在PSIS水平处提供支撑。 对于皮肤敏感或瘦骨嶙峋的轮椅使用者,泡沫塑料要在脊骨经过的区域切割,以免产生压力区域。 下面展示制作骨盆后垫的不同方法: 119 骨盆后垫是由一块装有软垫的硬泡沫塑料组成,绑 在悬吊式靠背面料的前面,可以用绑带固定在靠背 立杆上。 一块硬泡沫塑料加工成型的骨盆后垫可以安装到硬 靠背上,其表面用一层软泡沫塑料覆盖。 软泡沫塑料层应足够厚以确保整个靠背对轮椅使用 者是舒适的。 如果不够舒适,应该在硬靠背上放一层硬泡沫塑料, 然后放置骨盆后垫,软泡沫塑料放在最上面。 如果骨盆后垫安装在结实的带子上,应该安装在悬 吊式靠背面料的后面以提供支撑。 在这种情况下,用附加一条皮带围绕靠背立杆周围 固定在期望的高度,并且根据需要用魔术贴固定。 靠背后倾和/或调整靠背形状 靠背后倾有不同的体位原因,如果一辆轮椅没有现成可调的功能或者没有张力可调的靠背,应该 通过改制这部轮椅来实现这个支撑。下面是两个选项: ,%3" 120 具有悬吊式靠背的轮椅,去掉靠背面料并根据需要 的角度安装一个硬靠背。 硬靠背应该用胶合板制作 (至少12mm厚)。 可调支架常用于固定硬靠背到靠背立杆上。 改制现有的悬吊式靠背面料: 在靠背立杆旁对靠背面料做两个垂直切口。 逐渐增加切口长度直到轮椅使用者骨盆以上的躯 干能放松而不是向前低垂。 用你的手从面料后面支撑轮椅使用者的躯干,直 到你找到最佳位置。 在靠背面料层之间穿过一条带子 (50mm宽尼龙 布)并于尾部绕过靠背立杆。在所需位置缝合带 子和靠背面料。 通常可以使用一个附加皮带,尾部有尼龙搭扣并 且长度合适,带子的张力可轻易调节或使用洞眼 或绳子。 在靠背面料内常用一块软泡沫塑料包住皮带的上 面和前面。这会降低接触靠背支撑表面发生压疮 的风险。 躯干侧垫 躯干侧垫需要提供稳定的支撑,同时应该足够薄而不限制轮椅使用者双臂的活动。 侧垫的主要结构可以是由金属、塑料或木头构成,然而躯干侧垫通常需要用硬泡沫塑料覆盖,表 层为一层软泡沫塑料。泡沫塑料应该在侧垫内侧 (接触轮椅使用者身体部位)并包裹侧垫顶部,然后 整个侧垫用耐用、舒适的面料包裹。 121 躯干侧垫可以是扁平的,或有形的适合轮椅使用者的身体。如果是有形的,做成有形的最简单方 法是把硬泡沫塑料切割成形状。制作有形侧垫需要特殊缝纫技能和有弹性的表层面料。 固定躯干侧垫到轮椅上的两种不同方法如下所示: 躯干侧垫可以固定在硬靠背上,然后用硬泡沫塑料 和软泡沫塑料层覆盖。 躯干侧垫可以用金属支架固定在轮椅靠背立杆上。 躯干侧垫———必须是薄的 如果躯干侧垫太厚 (超过2.5cm),侧垫将限制手 臂的活动,也会压迫手臂内侧。 这会降低血流量,损害神经并影响手功能。 使用较薄的材料但是足够结实以提供必要的支撑。 ,%3" 122 躯干侧楔形垫 躯干侧楔形垫可由硬靠背支撑、硬泡沫塑料和软泡 沫塑料层共同组成。 带有独立套子的外部楔形垫也能用在靠背的表面, 它可用魔术贴或绑带固定。 桌面板 桌面板最好用胶合板做成 (厚度10mm至18mm取 决于胶合板的质量/强度),并且用绑带或金属或木 支架安装在轮椅扶手上。 当决定桌面板如何安装在轮椅上时,找到一种每个 人都容易使用的方法。以便在紧急状态下 (例如当 轮椅使用者哽塞时)任何人都能卸下桌面板。 头靠 扁平头靠 扁平头靠可以是高的硬靠背支撑的一部分,或者用 一个支架安装到硬靠背支撑上。 头靠是由固定在一块木头/塑料上的硬泡沫塑料及表 面的软泡沫塑料层组成。 轮椅使用者的身体处于发育或有变化时,这种类型 的头靠不容易进行调整。 独立的头靠用支架安装并允许向前、向后和高度的 调整。 123 有形头靠 有形头靠是由固定在一块木头/塑料上的硬泡沫塑料和软泡沫塑料或类似材料包覆而成。有形头靠 可由一个架子支撑颅底,并且两侧的楔形有助于保持头部不侧歪。 舒适的面料用于包覆做好的头靠。套子可用T恤面料制作,因为它舒适并有弹性服帖于头靠的形 状。套子可以做成紧密贴合或稍微宽松,“背后的拉线”能拉紧头靠套。 下面的例子展示如何制作有形头靠: 木制底座钻孔安装在头 第一层硬泡沫塑料。 硬泡沫塑料楔形垫为 靠支架上。 头部提供侧支撑。 泡沫塑料卷成头靠的基底, 加上软泡沫塑料层 需要完成: 安装在颅底下方。 完成头靠形状。 把头靠安装在轮椅上; 装饰。 ,%3" 124 脚踏板补高和脚踏板楔形垫 制作脚踏板补高最好的材料之一是非常硬的泡沫塑料 (EVA或人字拖鞋底),也可以用木头,但 要确保木头是光滑的、没有开裂,没有压力风险。 脚踏板补高 将非常硬的泡沫塑料 (EVA或人字拖鞋底)、木头 或其他类似材料切成块 (约100mm×200mm× 20mm),预留其中一些轮椅适配时使用。根据需要 粘贴此块到脚踏板上。 脚踏板楔形垫 斜切脚踏板补高块成两半,做成两块脚踏板楔形垫。 沿着长边切几块以及沿着短边切几块,预留其中一 些轮椅适配时使用。 根据需要安装脚踏板楔形垫到脚踏板上以支撑足底。 小腿支撑板 硬椅座可以从座位前面向前延伸以支撑僵直的腿。 这可能使轮椅难以在狭小的空间转向及折叠运输。 125 骨盆带 骨盆带可用尼龙带制作,就像看到的汽车座椅安全 带或双肩包的背带。 带的宽度儿童大约25mm,成人约40mm~50mm。 回形扣是最容易扣上并迅速打开的。如果无法得到, 尼龙搭扣效果也不错。要确保尼龙搭扣至少有 100mm (取决于轮椅使用者的体型)的重叠。 骨盆带和轮椅使用者 (尤其是带扣处)之间加衬垫 使其更加舒适。 骨盆带的两端固定在哪里? 对于大多数轮椅使用者,骨盆带的两端固定在骨 盆前部的正下方,如图。 更改固定的位置将使骨盆带从不同角度拉动身 体,骨盆带固定在骨盆前面正下方 (ASIS)将以 90度角拉向椅座表面 (如图所示)。固定骨盆带 在椅座后面将以45度角拉向椅座表面。拉动的 角度应该在45度~90度之间,除非骨盆带是设 计为骨盆前倾的轮椅使用者提供支撑。 如果轮椅使用者经常向上向前抬起自己的臀部,应 使用骨盆前倾四点带为骨盆前倾的轮椅使用者提供 支撑。 ,%3" 126 骨盆带警告: 如果骨盆带过于宽松,身体控制能力有限和/或感觉受限的轮椅使用者可能滑下来,如果没有留意, 可能导致窒息。应该教护理者如何正确系上骨盆带并告诫他们让轮椅使用者无人看管的风险。 骨盆带和骨盆前倾四点带如何固定在轮椅上? 固定骨盆带到硬椅座上: - 如左图所示固定到硬椅座上,折叠骨盆带一 端,打一个孔并用螺栓穿过木板与两个垫圈 和一个螺母 (最好用锁紧螺母); - 注意垫圈应该放在折叠端之间。这有助于减 缓骨盆带的磨损及撕扯,这会最终使骨盆带 断裂。 固定骨盆带到轮椅架上: - 环绕轮椅架并用塑料或金属滑扣 (也叫 “拉 心扣”、“双D扣”或 “3巴扣”)固定 - 如果它在合适的位置,也可以用家具螺丝。 小腿带 如果轮椅没有配小腿带,可以在一条50mm宽的尼 龙带上缝制一个尼龙搭扣做成小腿带。 小腿带长度应该约为轮椅座宽的两倍。 127 足带 足带可由25mm尼龙带和尼龙搭扣或扣环组成。 一端可折叠并烧一个洞供螺钉穿过,用螺钉将足带 固定在脚踏板上。 应使用衬垫使足带不摩擦皮肤并分散压力。 制作及使用足带的提示: 用尼龙搭扣或扣环固定足带。 在接触轮椅使用者的足带部位加上衬垫———通过分布压力使其更舒适。 足带可以用螺栓固定在硬椅座上或靠背或用滑扣 (也叫 “拉心扣”、“双D扣”或 “3巴扣”)环 绕轮椅架。 小腿带通常与轮椅一起提供,可用于其他方面,例如小腿带可用于改制/调整靠背结构。 肩带 要制作肩带最好有一台缝纫机和一位有缝纫技能的人。你将需要尼龙带、扣环和做衬垫的软泡沫 塑料,一些提示包括: 在肩部用衬垫包覆,尤其是骨突出部位。 确保肩带上部固定点与轮椅使用者的肩峰在同一 水平或稍高,如果固定点较低,肩带将下拉轮椅 使用者。 千万不要把肩带底部固定到骨盆带上,这将会向 上拉骨盆带。 如图所示的胸片,有助于保持肩带在合适的位置 并在躯干前部提供支撑。 ,%3" 128 肩带提示: 当使用肩带或胸带时,必须同时使用合身的骨盆带,如果不这样做会导致窒息。 进行轮椅安全和准备检查 产品 (轮椅)准备的最后部分是检查轮椅是安全的并准备好使用,并且所有的部件都正常工作。 下文的轮椅安全和准备检查表有助于确保没有遗忘任何事情。轮椅服务人员应该复印一份检查表 并钉在他们的轮椅服务中心作为每次准备轮椅的一个提示。 轮椅安全和准备检查表应该在轮椅使用者来适配前完成。 如果在轮椅安全和准备检查时发现有问题,轮椅服务人员可以按照以下方式处理: 适配前修理/解决这个问题; 将轮椅返回轮椅车间修理; 联系轮椅供应商并请他们帮助解决这个问题。 中级轮椅安全和准备检查表 检查表:轮椅是安全的并准备好使用了吗? 整辆轮椅包括PSDs PSDs安装牢固 □ 没有尖锐边角 □ 无部件损坏或刮伤 □ 轮椅能够沿直线行进 □ 前小脚轮 自由地转动 □ 转动而不触及前叉 □ 螺栓是拧紧的 □ 前小脚轮套 小脚轮叉自由地转动 □ 后轮 自由地转动 □ 轴螺栓是拧紧的 □ 129 续表 轮胎充气正常 (用拇指按压,轮胎下陷不超过5mm) □ 手推圈是稳固的 □ 刹车 正常工作 □ 脚踏板 脚踏板连接稳固 □ 轮椅架 交叉折叠式轮椅———轮椅能够轻易地折叠和展开 □ 靠背折叠式轮椅———靠背能够轻易地折叠和展开 □ 坐垫 坐垫刚好放在坐垫套内 □ 坐垫正好放在轮椅上 □ 坐垫套面料是紧贴的,但不是太紧 □ 如果轮椅是硬椅座:坐垫完全覆盖硬椅座 □ 步骤6:适配 适配是提供轮椅服务八个步骤的第六步,适配过程中轮椅使用者和轮椅服务人员要确保轮椅和 PSDs完全适配,并支撑轮椅使用者舒适地接近中立位坐姿。 如何进行适配 适配过程中用下文的中级轮椅适配检查表来指导你,按此顺序检查: 轮椅准备好了吗? 检查轮椅和PSDs适配; 检查姿势; 检查压力; 在轮椅移动过程中检查适配; ※决定是否需要进一步的行动。 ,%3" 130 记住: 为需要附加体位支撑的轮椅使用者进行轮椅适配比不需要附加体位支撑的适配花费的时间更长, 这是因为可能需要做出更多的调整。 轮椅使用者应该知道适配可能花更多的时间,当做调整时他们可能需要上下轮椅。 如果需要许多调整,他们也可能需要回来进行二次适配。 轮椅准备好了吗? 应该确保为轮椅使用者试用准备好轮椅。 检查轮椅和PSDs适配 椅座宽度 适配: 基本没有间隙。 确保: 臀部舒适地坐在扶手之间或骨盆侧垫之间; 大腿舒适地放在扶手、挡泥板/护裙板或骨盆侧垫之间并且不会挤 在一起,如果骨盆侧垫向前伸得太长,两腿就会挤在一起。 躯干舒适地靠在靠背立杆和/或躯干侧楔形垫或躯干侧垫之间。 椅座深度 适配: 腘窝和椅座/坐垫前部之间至少有30mm的间隙。 确保: 轮椅使用者舒适地坐在接近中立位坐姿。 如何检查? 手在腘窝和坐垫之间滑动,应该至少有30mm的间隙。手在小 腿后部向下滑并确保小腿不碰到椅座/坐垫。 检查两侧,如果左右两侧不同,根据较短腿的测量值开具处方。 长腿的轮椅使用者可能有较大的间隙,60mm以内是可以接受的。 适配使大腿得到良好的支撑,这将降低坐骨下的压力并有助于预 防压疮。如果椅座太深,轮椅使用者将无法坐直。 〛 131 骨盆 确保: 坐骨前垫高正好位于坐骨的前面 (把你的手放在轮椅使用者臀 部下面来检查); 骨盆后垫在PSIS处提供支撑而不是推腰部; 骨盆侧垫紧密贴合并且不高于髋关节; 骨盆带可以绑紧并且不会挤压轮椅使用者的皮肤 (在骨盆带和 轮椅使用者之间用手来进行检查)。 躯干 确保: 躯干侧垫不要对腋窝施加压力,轮椅使用者腋窝与躯干侧垫顶 端之间应该至少有30mm的距离。 肩带舒适地穿上并且不会挤压皮肤。 桌面板支撑整个前臂和肘关节并且不会挤压腹部,经过切割改 制的桌面板可以靠近身体,然而它不应该碰到或摩擦轮椅使用 者的皮肤。 检查靠背的高度和后倾。 头靠 适配: 头靠应该在颅底支撑轮椅使用者的头。 确保: 头靠应该支撑轮椅使用者的头使其处于平衡和直立的姿势。 大腿 确保: 轮椅使用者大腿和大腿支撑之间没有大的压力 (包括大腿外侧 垫、大腿内侧楔形垫或膝分隔垫)。 膝分隔垫不会施加任何压力在腹股沟部位,膝分隔垫应该远离 腹股沟部位,儿童至少40mm~60mm,成人60mm~100mm。 ,%3" 132 脚踏板高度 适配: 大腿完全支撑在椅座/坐垫上没有间隙,并且足部完全支撑在脚踏 板上没有间隙。 如何检查: 手在大腿和椅座/坐垫之间滑动,整个大腿的压力应该均等并 且没有间隙。 查看脚踏板上的每只脚,脚的前部和后部应平放在脚踏板上并 且没有间隙。 如果大腿下面有间隙,则脚踏板可能太高。如果脚下面有间隙, 则脚踏板可能太低。 靠背高度 适配: 靠背高度应该使轮椅使用者得到他/她所需要的支撑,并且活动量 大的轮椅使用者可以自由地活动他/她的双臂推轮椅 (如果是自行 推轮椅)。 如何检查: 询问轮椅使用者靠背是否舒适; 观察臀部上方的躯干是否平衡; 靠背妨碍轮椅使用者推轮椅吗? 靠背的高度取决于轮椅使用者的需求,自己推轮椅的使用者要求靠背不要妨碍他们的肩膀自由地活 动,坐直有困难的轮椅使用者需要更高的靠背以提供更多的支撑。 如果轮椅使用者: 健康并且活动量大; 具有良好的平衡能力,并且能够轻松地坐直; 自己主动地推轮椅并且需要好的活动自由度。 可选用支撑轮椅使用者胸腔下缘高度的靠背。 靠背高度D (座面到胸腔下缘)。 133 如果轮椅使用者: 可能很快感觉疲劳,例如老年人或进行性疾病患者; 坐直有一定难度。 可选用支撑轮椅使用者肩胛下角高度的靠背。 这个靠背高度仍然让轮椅使用者的肩膀活动有一定的自由度并且 可以用双臂推轮椅。 靠背高度E (座面到肩胛下角)。 对需要更多支撑、靠背后倾、椅座和靠背后倾 (整体后倾)容易疲劳/疲倦的轮椅使用者,可选择与 肩部等高的高靠背。 靠背高度F (椅座到肩峰)。 后轮位置 适配: 当轮椅使用者的双手放在手推圈上时,其肘部应该呈直角。 如何检查: 让轮椅使用者紧握手推圈顶部的位置,肘部应该屈曲呈90度; 还要从平衡性的角度,与轮椅使用者共同检查后轮位置是否合 适 (后轮向前调适用于活跃的使用者,向后调比较安全)。 如果轮椅使用者需要后轮定位于 “安全” (进一步向后)的位置, 这可能意味着双臂要进一步向后才是推轮椅的理想位置。要向轮 椅使用者说明这种利弊。 如果后轮的位置有任何调整,刹车也需要进行调整并且重新检查。 椅座高度———对于脚驱动的轮椅 适配: 在轮椅使用者坐直的情况下,骨盆后部可以舒适地倚着靠背, 他/她应该能够把双脚平放在地面上。 ,%3" 134 如何检查: 让轮椅使用者在轮椅上舒适地坐直或者接近坐直,骨盆后部倚 着靠背,检查双脚是否可以平放在地面上。 如果椅座太高,轮椅服务人员可以尝试: 降低坐垫的高度; 更换一个比原椅座低的硬椅座 (听取技术意见是否支持这样 做)。 对于只用单脚推轮椅,而另一只脚搁在脚踏板上的轮椅使用者 ———检查放在脚踏板上那只脚的坐骨下的压力。 检查姿势 从侧面和前面观察轮椅使用者是如何坐在轮椅上的, 他/她是坐直的姿势吗? 观察轮椅使用者是否舒适地坐在直立的姿势,这应 该接近于用手模拟确定的姿势。 135 具体检查: 骨盆直立和水平吗? (如果可能) 躯干直立和对称吗? (如果可能) 头部平衡和直立吗? (如果可能) 双腿和双脚尽可能地接近直立坐姿吗? 询问轮椅使用者感觉如何。 观察轮椅使用者整个坐姿后,检查每个PSD是否按照计划提供支撑,具体来说,记住检查 (如果 已经提供): 靠背高度、后倾和轮廓; 整体后倾; 骨盆侧垫和躯干侧垫; 所有的大腿和小腿支撑。 检查压力 对于有发生压疮风险的每位轮椅使用者,适配步骤 包括检查坐骨下的压力是否安全和其他所有的风险 部位 (例如髋关节或骶尾部下)。 对于用 PSDs来提供稳固支撑的每位轮椅使用者 ———检查轮椅使用者身体部位与PSD之间的压力。 应该感觉支撑稳定———但不紧。 ,%3" 136 在轮椅使用者移动过程中检查适配 适配过程的最后部分是在轮椅使用者移动过程中检查轮椅适配情况。如果轮椅使用者不能独立推 轮椅,让一位家人/护理者推轮椅。 观察什么: 靠背允许轮椅使用者自由地活动双肩推轮椅吗? 轮椅的移动或推行动作会导致轮椅使用者改变他 们的姿势或感觉不舒适或不稳定吗? 手推轮椅:后轮的位置对于轮椅使用者推轮椅是 否正确以及他/她能推动吗? 脚推轮椅:对于用脚推行的轮椅使用者,椅座的 高度和椅座深度正确吗? 体位支撑允许轮椅移动不受限制和安全吗? 中级轮椅适配检查表 1.轮椅准备好了吗? 轮椅已经检查且能确保安全使用以及所有的部件都正常工作吗? □ 2.检查轮椅和PSDs适配 椅座宽度: 臀部舒适地坐在扶手或骨盆侧垫之间; 躯干舒适地靠在轮椅架靠背管或躯干侧垫之间; 大腿舒适地放在扶手、挡泥板/护裙板或骨盆侧垫之 间并且不会挤压在一起。 □ 137 椅座深度: 腘窝与椅座/坐垫之间有30mm间隙。 □ 骨盆: 坐骨前垫高刚好在坐骨前面; 骨盆后垫在PSIS处提供支撑; 骨盆侧垫紧密贴合并且不高于髋关节; 骨盆带能绑紧但是不挤压皮肤。 □ 躯干: 躯干侧垫不要在腋窝处施压,腋窝与躯干侧垫顶端 之间应该至少有30mm的间隙; 肩带舒适地穿上并且不会挤压皮肤; 桌面板支撑整个前臂和肘关节并且不会挤压腹部; 检查靠背高度和后倾。 □ 头靠: 头靠通常应该在颅底支撑轮椅使用者的头部; 支撑头部保持平衡和直立的姿势。 □ 大腿: 大腿外侧垫或膝分隔垫不会导致大腿上大的压力; 膝分隔垫距儿童腹股沟区40mm~60mm,成人腹股 沟区60mm~100mm。 □ 脚踏板高度: 大腿完全支撑在坐垫上没有间隙,双脚完全支撑在 脚踏板上没有间隙; 足带可以牢固地系紧而不会挤压足; 小腿带和足跟带支撑小腿和双脚。 □ ,%3" 138 3.检查姿势 从前面和侧面观察,轮椅使用者是否舒适地坐在接近中立位的坐姿: 骨盆直立和水平吗 (或舒适地接近这个体位)? □ 躯干直立和对称吗 (或舒适地接近这个体位)? □ 头部平衡和直立吗 (尽可能地)? □ 支撑腿和脚尽可能地接近中立位吗? □ 检查所有的PSDs是否都按照计划提供支撑。特别检查 (如果已经提供): 靠背高度、后倾和轮廓 □ 整体后倾 □ 骨盆侧垫和躯干侧垫 □ 大腿内侧和外侧楔形垫、大腿外侧垫和小腿支撑板 □ 15分钟后再检查姿势,看看是否有什么变化 □ 4.检查压力 检查两侧坐骨下的压力,两侧压力安全吗? 1级=安全:指尖能够上下摆动5mm或更多。 2级=警告:指尖不能摆动,但能轻易地抽出。 3级=不安全:指尖被压得很紧,手指很难抽出。 □ 把你的手指放在轮椅使用者身体和每个体位支撑之间,包括衬垫和绑带。 体位支撑与身体均匀接触吗? 压力安全吗? □ 如果轮椅使用者有任何特别骨突、膨出或肿块———确保这些部位没有压力。 □ 5.在轮椅使用者移动过程中检查适配 靠背允许轮椅使用者移动双肩来推轮椅吗? □ 轮椅的移动或推轮椅的动作会导致使用者改变他们的姿势或感觉不舒适或不稳定吗? □ 手推轮椅:后轮的位置对于轮椅使用者推轮椅是否正确以及他/她能推吗? □ 脚推轮椅:椅座高度和深度对于用脚推轮椅的使用者正确吗? □ 体位支撑允许不受限制和安全的轮椅移动吗? □ 139 6.决定是否需要进一步的行动 有必要采取进一步的行动吗? 在轮椅使用者档案上写下采取的任何行动。 □ 步骤7:使用者培训 使用者培训 轮椅的信息资讯和培训能帮助很多轮椅使用者真正受益于自己的轮椅。没有这一步,轮椅使用者 将无法发挥轮椅的最大功效。重要的是家人/护理者也获得这些信息资讯和培训。 对轮椅使用者有帮助的技能是什么? 轮椅服务人员应该教给轮椅使用者技能以助于维持健康、安全有效地使用轮椅、保养轮椅以便其 延长寿命。下面是教给所有轮椅使用者的有用技能: 操作轮椅: 运输时如何折叠和抬起轮椅。 运输时如何拆下和装回PSDs。 如何使用轮椅———例如刹车、后倾和防翻杆的使 用、PSDs和坐垫的正确位置。 轮椅使用者应该坐在轮椅上多长时间 对于那些不经常坐轮椅的使用者,可能要花时间习惯于直立姿势坐着,儿童尤其如此。轮椅服务人 员需要告知轮椅使用者应该坐在轮椅上多长时间。提供以下指导: 如果轮椅使用者习惯于坐着,他/她应该花同样多的时间坐在他们的新轮椅上。如果需要,他/她 应逐渐增加时间。 如果轮椅使用者还不能坐起来,刚开始时不超过30分钟然后休息。 教会轮椅使用者或家人/护理者在使用者坐轮椅后经常检查其受压部位。 ,%3" 140 转移 (如何上下轮椅): 安全的转移方法是: - 轮椅使用者舒适; - 安全地任何辅助或抬起。 如何正确地坐在轮椅上 (例如确保轮椅使用者被放回轮 椅上时坐骨位于坐骨前垫高的后面)。 如何正确调整PSDs———例如绑带需要系多紧才能发挥 作用。 记住许多轮椅使用者能独立地上下轮椅,独立和辅助转 移在 《轮椅服务初级教程》中有介绍。 轮椅的使用和移动: 轮椅服务人员教给关于轮椅移动的技能取决于轮椅使用 者的能力和他们的环境。 应该记住教给轮椅使用者适合他们能力的推轮椅最好 方法。 更多关于轮椅基本移动技能的信息包括正确推动、上下斜坡 和台阶以及翘前轮基本技巧可查阅 《轮椅服务初级教程》。 预防压疮: 压疮是由骨突部位的压力、摩擦力和剪切力导致。 对于坐直困难的轮椅使用者,思考: - 确保他们不滑动———由于剪切力能导致压疮 (骨突 部位在软组织上滑动)。 - 确保两侧坐骨下重量均匀分布。 对于使用PSDs的轮椅使用者,确保他们定期检查与轮 椅或PSDs接触的皮肤。 关于预防压疮的更详细资料可查阅 《轮椅服务初级教程》。 141 如何在家保养轮椅: 为轮椅使用者提供关于如何在家保养轮椅的基本信息有 助于延长轮椅的寿命。 《轮椅服务初级教程》中介绍了轮椅使用者在家能够做 到保养轮椅和坐垫的6件事情,这些资料同样适用于中 级轮椅使用者。增加额外保养以确保PSDs处于正常工 作状态。 如果有问题,怎么办: 轮椅使用者需要知道如果出现问题怎么办,问题包括: 轮椅需要维修; 轮椅不适配或不舒适。 对于这些问题,轮椅使用者应该能够联系轮椅服务中心寻求帮助和建议。确保轮椅使用者知道如 何与轮椅服务中心取得联系。 如何成功地对轮椅使用者进行培训 了解轮椅使用者已经掌握的技能。 讲解、演示,然后让轮椅使用者实操练习。 使用通俗易懂的语言。 让轮椅使用者互教互学。 运用良好的沟通技巧。 要善于鼓励轮椅使用者。 记住———当学习任何新技能时,实操很重要。第一次应该通过示范来教技能,并且随后给轮椅使用 者机会练习。 ,%3" 142 中级轮椅使用者培训检查表 需要教的技能 已经教的技能 操作轮椅 折叠和抬起轮椅 □ □ 拆下和装回所有的PSDs以便运输的需要 □ □ 使用快拆轮 □ □ 使用刹车 □ □ 后倾和防翻杆 (如果使用) □ □ 当使用者坐在轮椅上时,在正确的位置安装PSDs □ □ 使用坐垫,包括正确摆放 □ □ 转移 独立转移 □ □ 在协助下转移 □ □ 其他 □ □ 轮椅的使用和移动 正确地推轮椅 (用轮椅使用者喜欢的方式) □ □ 上下斜坡 □ □ 上下台阶 □ □ 粗糙地面 □ □ 翘前轮基本技巧 □ □ 在轮椅上坐多长时间 (对于需要附加体位支撑的儿童和成人) □ □ 辅助下推轮椅 □ □ 预防压疮 检查易发压疮的高压部位 □ □ 减压技巧 □ □ 营养膳食并充足饮水 □ □ 如果发生压疮,该怎么办 □ □ 如何在家保养轮椅 清洁轮椅,清洗并晾干坐垫和坐垫套 □ □ 143 为活动部件上油 □ □ 给轮胎打气 □ □ 拧紧螺母和螺栓 □ □ 拧紧辐条 □ □ 检查装饰面料 □ □ 检查是否生锈 □ □ 检查坐垫 □ □ 如果出现问题,怎么办 轮椅需要维修 □ □ 轮椅不适配或不舒适 □ □ 步骤8:保养、维修和随访 关于保养、维修和随访的信息已经在 《轮椅服务初级教程》中介绍了,在中级教程中,将讨论随 访对于使用附加体位支撑的轮椅使用者的特殊重要性。 随访 随访是轮椅服务第8步的一部分。 随访概述 所有的轮椅使用者都从随访中受益,然而随访对以下人员最为重要: 儿童; 有发生压疮风险的轮椅使用者; 有进行性疾病的轮椅使用者; 在轮椅上需要附加体位支撑的轮椅使用者; 接受任何培训或指导有困难的轮椅使用者。 大多数中级轮椅使用者需要附加体位支撑,因此随访特别重要。 随访管理 何时应该进行随访没有明确的规定,随访的最佳时机取决于轮椅使用者的需要。但是只要有可能, ,%3" 144 在轮椅交付后的6周之内进行随访都是非常有用的,确保轮椅使用良好并且加强使用者培训。对于儿 童来说,如果每3~6个月进行一次随访是理想的。这是因为随着儿童的成长,他们的需求变化很快。 随访可以在以下地点进行: 在轮椅使用者家里; 在轮椅服务中心; 在其他适合轮椅使用者和轮椅服务人员的任何地方。 地点取决于轮椅使用者是否能够前往轮椅服务中心,以及轮椅服务人员是否能前往轮椅使用者 家中。 随访可以用许多不同的方式进行管理,包括: 当轮椅使用者收到轮椅的时候,就和他们预约随访时间; 随访可以在轮椅使用者家里或轮椅服务中心进行; 把随访作为日常社区家访的一部分,由已经接受过培训的社区康复人员 (CBR)对轮椅使用者 进行随访。 如果交通困难并且轮椅使用者能够使用电话,可以安排电话随访。 轮椅随访表 轮椅随访表 (见下页)将帮助轮椅服务人员记住随访时问什么问题以及做什么,轮椅随访表也 有空白处写下需要采取的任何措施。 常见的随访措施 常见的随访措施包括: 提供更多的建议或训练。 例如,如果轮椅使用者没有按照预期使用轮椅,可能是因为他/她对于如何独自上下轮椅没有信 心,转移方面更多的训练可能有所帮助。 重新调整轮椅。 进行小型维修。 应该鼓励轮椅使用者和他们的家人/看护者通过在家保养轮椅来维护轮椅。如果不能立即修理任何 损坏的部件,轮椅服务人员也可以帮助轮椅使用者安排维修轮椅。 145 转介轮椅使用者至其他服务单位寻求支持或援助。 对希塔的随访 希塔7岁和他父母及姐姐生活在一起。他患有肌肉萎缩症,一年前通过轮椅服务获得了一辆轮椅。 那时他能走很短的距离,能做站立式转移并独立上下轮椅,他说自己想要一辆轮椅,因为他发现上 学困难。 在随访过程中,希塔说他现在发现很难独自上下轮椅,在学校下午时他感到疲劳和不舒适。这使他 难以集中精力,他的轮椅大小合适,并且有一个中型的悬吊式靠背及简单的舒适坐垫。 随访过程中轮椅服务人员: 发现希塔是如何上下轮椅的,希塔发觉自己很难离开轮椅,轮椅服务人员教希塔如何用一块转移 板转移,他感觉容易多了。 重新检查希塔的附加体位支撑,决定使用较高的靠背和具有姿势控制及减压的坐垫,希塔将得到 更好的支撑。轮椅服务人员采取必要的措施为适配做准备。 为希塔预约来轮椅服务中心适配他的新靠背和坐垫。 轮椅随访表 1.轮椅使用者信息 轮椅使用者姓名: 编号: 适配日期: 随访日期: 随访人员姓名: 随访地点:轮椅使用者家里□ 轮椅服务中心□ 其他: 2.面谈内容 记录应采取的措施: 您能如您所愿地使用轮椅吗? 是□否□ 如果不能———为什么? 您在使用轮椅的过程中,遇到什么困难吗? 是□否□ 如果有,是什么困难? 您在使用轮椅的过程中,有什么不懂的问题吗? 是□否□ 如果有,问题是什么? 需要进一步的培训吗? ,%3" 146 您有压疮吗? 是□否□ 如果有,请描述 (位置)。 您对自己轮椅的满意度用1~5如何评价? (1是不满意,5是 非常满意) 评价: 建议: 3.轮椅和坐垫的检查 轮椅是处于良好的工作状态并且可以安全地使用吗? 是□否□ 坐垫是处于良好的工作状态并且可以安全地使用吗? 是□否□ 如果以上两项有任何一项答案是否,请问是什么问题? 4.适配检查 轮椅适配正确吗? 是□否□ 如果不适配,是什么问题? 压力测试等级 (1级=安全级,2级=警告级,3级=不安全 级)(轮椅使用者是否有发生压疮的风险) 左: 右: 轮椅使用者在静止、移动的情况下,能舒适地坐直吗? 能一整 天都这样坐着吗? 是□否□ 如果不能,请问是什么问题?
［美］弗罗斯特 等著 钟 磊 赫 琳 译 世界卫生组织 教师手册 轮椅服务中级教程 求真出版社 图书在版编目 (CIP)数据 轮椅服务中级教程/ (美)弗罗斯特等著;钟磊等译.-北京:求真出版社,2016.1 ISBN978 7 80258 230 9 Ⅰ.①轮… Ⅱ.①弗…②钟… Ⅲ.①四肢-残疾人-社会服务-技术培训-教材 Ⅳ.①C913.69 中国版本图书馆CIP数据核字 (2016)第030732号 世界卫生组织于2013出版,原标题为 (WheelchairServiceTrainingPackage:Inter- mediateLevel)ⓒ世界卫生组织2013 世界卫生组织授予深圳市残疾人辅助器具资源中心翻译中文版的权利,并委托求真出 版社出版。中文版的翻译质量和准确性由深圳市残疾人辅助器具资源中心负责。若英 文版与中文版有任何出入,应以英文原版为准。 轮椅服务中级教程:教师手册ⓒ世界卫生组织2016 轮椅服务中级教程 著 者:[美]弗罗斯特 等 译 者:钟 磊 赫 琳 责任编辑:计 悦 出版发行:求真出版社 社 址:北京市西城区太平街甲6号 邮政编码:100050 印 刷:北京华联印刷有限公司 经 销:新华书店 开 本:787×1092 1/16 字 数:611千字 印 张:29.25 版 次:2016年5月第1版 2016年5月第1次印刷 书 号:ISBN978 7 80258 230 9/C·6 定 价:98.00 编辑热线:(010)83190270 销售服务热线:(010)83190297 83190289 83190292 版权所有 侵权必究 印装错误可随时退换 术 语 本教程中的术语定义如下: 适用的轮椅 能够满足使用者需求以及环境状况的轮椅;提供适配和体位支撑并且安全耐 用;国内可得到且在国内能够以最经济和实惠的价格购买和维修并接受持续 的服务。 手动轮椅 由使用者本人驱动或由其他人推行的轮椅。 体位支撑装置 (PSD) 用于提供附加体位支撑的装置,是中级轮椅服务的主要内容。 轮椅 为行走或移动困难者提供轮式移动和坐位支撑的器具。 轮椅改制 对轮椅进行改造。 轮椅供应体系 轮椅设计、生产、供应和提供服务的总术语。 轮椅服务 轮椅供应体系的一部分,以确保每位使用者都能获得一辆适用的轮椅。 轮椅服务人员 提供适用轮椅服务中具有专业技能的人员。 轮椅使用者 有行走或移动困难而需要使用轮椅代步的人士。 , 1 《轮椅服务中级教程》概述 1 简介 2 目标人群 2 目的 2 范围 3 教师 3 如何开始 4 1.教师指引 4 1.1培训概述 5 1.2课程表与课时 5 1.3单元计划 6 1.4幻灯片演示 6 1.5观察/监督学员进度 6 1.6每期培训结束后评估培训项目 7 1.7有效的实操培训提示 9 2.如何准备实施教程 9 2.1了解学员的轮椅服务网络 9 2.2明确学员在提供轮椅服务中的角色 9 2.3检查每期单元计划以及必要时进行调整 10 2.4明确将要使用的轮椅、坐垫和体位支撑装置 10 2.5邀请轮椅使用者参与实操单元 12 2.6实操单元分组 13 2.7设施准备 14 2.8培训资源和材料准备 20 3.详细的单元计划 21 前 言 28 A:核心知识 29 A.1:受益于附加体位支撑的轮椅使用者 39 A.2:残障儿童 50 B:轮椅服务步骤 51 B.1:评定概述和面谈评估 58 B.2:身体检查———无支撑坐姿 75 B.3:身体检查———骨盆和髋关节姿势检查 95 B.4:身体检查———用手模拟 103 B.5:身体检查———进行测量 113 B.6:选择轮椅和坐垫 124 B.7:体位支撑装置 (PSDs)的处方 (选择)———介绍 130 B.8:体位支撑装置 (PSDs)的处方 (选择)———稳定骨盆 145 B.9:体位支撑装置 (PSDs)的处方 (选择)———支撑髋关节 151 B.10:体位支撑装置 (PSDs)的处方 (选择)———支撑躯干 161 B.11:体位支撑装置 (PSDs)的处方 (选择)———支撑 头部、大腿和小腿 173 实操一:评定和处方 (选择) 177 B.12:产品 (轮椅)准备 188 实操二:产品 (轮椅)准备 191 B.13:适配 202 B.14:使用者培训 209 实操三:适配和使用者培训 213 B.15:整合所有知识 215 B.16:保养、维修和随访 222 实操四:评定、处方 (选择)、产品 (轮椅)准备、适配和使用者培训 227 B.17:教师反馈、讨论和结业典礼 230 附 录 230 附录1:轮椅服务中级教程课程表 232 附录2:中级轮椅转介表 233 附录3:中级轮椅评定表 238 附录4:中级轮椅处方 (选择)表 241 附录5:中级轮椅参数表 242 附录6:中级轮椅安全和准备检查表 243 附录7:中极轮椅适配检查表 247 附录8:中极轮椅使用者培训检查表 248 附录9:轮椅随访表 250 附录10:体位支撑装置 (PSD)表 251 附录11:硬泡沫塑料楔形垫 252 附录12:参与实操单元的轮椅使用者列表 1 《轮椅服务中级教程》概述 简介 世界卫生组织 (WHO)于2008年和2012年分别发布了 《资源有限地区手动轮椅服务指南①》和 《轮椅服务初级教程》(WSTP B),WHO与美国国际开发署 (USAID)共同开发了这套 《轮椅服务 中级教程》(WSTP I)。《轮椅服务中级教程》是 WHO轮椅服务系列教程的第二部分,它更注重于 解决那些行走和移动严重困难以及躯干控制较差者的需求。当编写本教程时,特别注意到要为那些躯 干控制较差和不能独立坐直的儿童提供适用的轮椅。 轮椅是能使个人移动的最常用辅助器具之一,但是由于服务提供者所接受培训的机会很少,难以 确保轮椅使用者获得最大限度的个人独立移动,享受富有成效和高质量的生活。 世界各地都需要轮椅服务人员,《轮椅服务中级教程》用于支持服务人员的培训,帮助他们完成中 级轮椅服务中临床和技术角色 (见 《资源有限地区手动轮椅服务指南》表4.2),本教程是为那些对需 要附加体位支撑才能坐直的轮椅使用者开始工作的服务人员提供所需的理论和实践支持。本教程包括 如何评估个人需求,协助选择和安装带附加体位支撑的最适用轮椅,培训使用者和护理者如何使用和 保养他们的轮椅并开展随访。 本教程可以在35~40小时内完成,根据不同情况的具体需求和可用资源,时间可能会延长或缩 短。鼓励学员与教师共同实践,提高职业素质并增强独立工作能力。 《轮椅服务中级教程》既可以提供给已经在这个领域工作的人员作为独立的短期培训项目,又可以 把该教程纳入到卫生保健和康复人员培训项目的课程里。 6/3" ① 世界卫生组织, 《资源有限地区手动轮椅服务指南》,日内瓦,2008(http://www.who. int/disabilities/publications/technology/wheelchairguidelines/en/index.html,取得日期2011年12月 15日) 2 目标人群 本教程是为所有期望在工作场所提供中级轮椅服务的人员和志愿者准备的,这其中包括卫生保健、 康复或技术人员、社区医护人员、社区康复工作者、作业治疗师、物理治疗师、假肢制作师、矫形器 制作师、当地技工、技术员和轮椅使用者。 为了让学员从中级教程中最大程度地获取知识,以往轮椅服务的经验是必不可少的。中级教程假 定学员能够展示在轮椅服务初级教程中学习到的能力并且具备初级轮椅服务的实践经验。 目的 本中级教程是为支持服务人员或志愿者的培训而设计的,使他们能为那些需要附加体位支撑才能 坐直的儿童和成人提供适合的手动轮椅和坐垫。 本教程的主要目的是提高轮椅服务人员的知识和技能,本教程的实施将有助于: 增加能满足个人需求的轮椅使用者数量; 增加接受中级轮椅服务培训的人员数量; 提高轮椅服务人员的职业素质; 针对需要比初级轮椅服务更高层级干预的轮椅使用者,提高为他们轮椅服务的质量; 将本教程加入到常规辅助医疗/康复培训项目中; 将提供轮椅服务更大程度地整合到康复服务里。 范围 本教程包括: 如何评定需要附加体位支撑轮椅的儿童和成人的移动和体位支撑需求; 如何与他们一起确定最可能的移动解决方案; 提供带合适坐垫和附加体位支撑的手动轮椅所必需的知识和实践技巧; 培训轮椅使用者以及在适当的时候培训他们的家人/护理者,帮助他们充分利用自己的轮椅; 随访轮椅使用者以确保他们的轮椅持续地满足需求。 3 教师 技能:实施本教程的教师应该对需要附加体位支撑的人进行评定和开具轮椅处方非常熟练。教师 也应该能够实施或指导使用当地可得到的产品、资源和工具,来准备具有附加体位支撑装置的手动轮 椅。教师应该在提供轮椅服务领域具有相当多的临床技巧,使他们能够依靠自身的实践经验来实施培 训。教师以往的培训经验也是有益的。 轮椅使用者:强烈建议将一位轮椅使用者加入培训团队。轮椅使用者能够利用自身经验来教其他 相同残疾的人。轮椅使用者参与培训将有助于学员意识到轮椅使用者在选择自己轮椅中的重要作用。 教师数量:建议每8~10名学员配两位教师。该配比对于实操单元尤其重要,以便于教师能够为 学员提供良好的支持和反馈,并确保所有学员安全地实操。培训中有一名有经验的轮椅使用者,并且 能熟练掌握培训主题与内容,可能是一笔培训财富。 技术支持:为了管理实操单元,教师中至少有一位对中级轮椅服务有经验的轮椅技术员,鼓励他 们在实操单元提供协助。 如何开始 1.拷贝光盘 (文件中)至电脑硬盘以供培训中使用。硬盘中至少需要6GB的储存空间。 2.点击 “开始”文件。从这里,教师可以浏览轮椅服务教程里不同的中级资源。教师也可以通过 文件夹到达相同的资源位置。 3.打开 《教师手册》。 3.1阅读 “轮椅服务教程”和 “教师指引”部分。 3.2为每位教师订购或打印和装订 《教师手册》(如果没有印刷稿)。 4.打开课程表并点击每单元的超级链接,进入单元的幻灯片和录像。通过幻灯片和单元计划 (《教师手册》)浏览每单元以熟悉内容、资源和方法。 5.按照 “如何准备实施教程”部分的指引,确保所有必需的准备都在实施培训前完成。按照 “如 何准备实施教程”部分的建议准备所有的培训资源和材料。 6.实施培训的最好方式是尽可能按照每单元分配的时间及顺序执行。 7.培训开始之前,为每位学员发放1套完整的培训资料,包括: 《学员手册》 (每位学员1本)、 《实训手册》(每位学员1本)和1套海报 (每位学员1套)。如果库存没有,可以从光盘中打印出来。 6/3" 4 1.教师指引 1.1培训概述 分钟 日期 欢迎、前言及概述 前言 60 A.核心知识 本单元,为学员提供在 开展轮椅服务步骤中需 要的背景知识。 A.1 受益于附加体位支撑的轮椅使用者 60 A.2 残障儿童 60 B.轮椅服务步骤 评定 B.1 评定概述和面谈评估 90 B.2 身体检查———无支撑坐姿 90 B.3 身体检查———骨盆和髋关节姿势检查 120 B.4 身体检查———用手模拟 60 B.5 身体检查———进行测量 60 处方 (选择) B.6 选择轮椅和坐垫 60 B.7 体位支撑装置 (PSDs)的处方 (选择)———介绍 30 B.8 体位支撑装置 (PSDs)的处方 (选择)———稳定骨盆 90 B.9 体位支撑装置 (PSDs)的处方 (选择)———支撑髋关节 45 B.10 体位支撑装置 (PSDs)的处方 (选择)———支撑躯干 105 体位支撑装置 (PSDs)的处方 (选择)———支撑躯干 45 B.11 体位支撑装置 (PSDs)的处方 (选择)———支撑头 部、大腿和小腿 120 实操一:评定和处方 (选择) 120 产品 (轮椅)准备 B.12 产品 (轮椅)准备 60 实操二:产品 (轮椅)准备 150 适配 B.13 适配 60 使用者培训 B.14 使用者培训 60 实操三:适配和使用者培训 150 B.15 整合所有知识 120 保养、维修和随访 B.16 保养、维修和随访 60 实操四:评定、处方 (选择),产品 (轮椅)准备,适配和使用者培训 300 B.17 教师反馈、讨论和结业典礼 60 第 一 天 第 二 天 第 三 天 第 四 天 第 五 天 5 1.2课程表与课时 本教程应在连续时间或在一定时间分段实施。完成中级教程至少需要35-40小时。每单元需要的 预估时间已经包括在该单元计划中。 注意:每单元的实际时间将根据以下因素而改变: 学员的经验和技能; 全体学员的数量; 当地可得到的轮椅数量; 培训中是否需要翻译; 是否需要增加其他内容。 取决于以上因素,完成教程的时间可能或多或少。 5天课程表的范例见附录1。该课程表及其空白课程表格式也可在DVD中获得。 强烈建议教师根据当地的情况及学员的培训需求调整和修改课程表。例如: 培训项目中的单元内容应与现有的卫生或康复培训项目结合; 如果康复人员已经在其他地方接受过培训项目中某些内容的培训,对应的单元可以删减; 如果轮椅需要额外的准备时间 (例如需要完全组装),可以在实操单元中减少轮椅使用者的数量 或增加分配的时间。 1.3单元计划 每单元都有单元计划用于指导教师如何实施。在每单元计划的开始都有如下信息: 目标:本单元结束后学员将能够做什么; 资源:本单元需要什么资源; 情境和以前学过的知识:本单元如何根据不同的情境 (或情况)进行调整,期望学员具备哪些 已有的知识或能力; 准备:如何为本单元作准备; 大纲:本单元主要内容大纲。 单元计划的其余部分被分为多个主题。对于每个主题,单元计划就如何传递主题信息给予指导。 备注: 黑体字是指教师的行动 (例如:提问,演示,说明,播放DVD) 6/3" 6 阴影框给出教师提问的答案———但是鼓励学员自我思考答案。 每单元计划的最后是要点概括。教师应向学员提问而不是讲出要点,启发他们自己找到要点。 周密地遵循单元计划,教师将能够按时教好每单元。单元计划提供了所有必要的要点和应涵盖的 实操技能。鼓励教师在授课中加入自己的知识、技能和风格。 1.4幻灯片演示 几乎所有的单元都准备了幻灯片演示。教师应该明白只有关键点出现在幻灯片中。教师应当讲授 《教师手册》中与每张幻灯片相关的信息以确保所有知识点都涵盖到。应多查阅 《教师手册》,而避免 按照幻灯片照本宣科。 1.5观察/监督学员进度 教师应该密切关注每位学员的进度。观察进度的最佳机会是实操单元。 每次实操单元的教师观察表可在DVD中获得。 教师们应该将该检查表用于: 帮助他们观察每组学员在每次实操单元中的进度。 记录实操中良好和需要改进的案例,用于反馈单元的讨论。 教师收集到每位学员进度的更详细信息后,教师观察表可以修改和/或进一步完善。 1.6每期培训结束后评估培训项目 在每期培训结束后,对培训项目进行评估是好的做法。教师可以在实施培训项目过程中定期向学 员收集反馈信息。教师也可以在培训过程中记录他们自己关于培训项目的想法。这些信息都有助于在 最后评估培训项目,包括找出优缺点。这将有助于教师在日后改进培训教材以及根据所处的情境提高 他们自身的教学技能。 培训项目评估表格可在DVD中获得。为满足教师的需求,他们可以修改或重做这个表格。 7 1.7有效的实操培训提示 准备 培训开始前仔细阅读每单元培训计划; 确保对讲授的内容胸有成竹; 收集培训资源并准备好培训教室。 为轮椅服务建立 良好的实操典范 尊重学员及轮椅使用者; 培训过程中展现关爱; 培训教室中随时注意安全; 按照课程表准时授课。 清晰地传递信息 清晰并从容地讲述; 确保教室内的每位学员都能听到; 通过提问来检查学员对授课内容的理解; 确保每位学员都看到白板上的书写内容; 重复重要观点以示强调。 管理单元时间 注意每单元允许的时间及按时间执行; 如果需要增加时间,应在开始时就计划; 确保在计划的日期完成所有的单元内容。 清晰细致的演示 确保每位学员能看清楚; 解释将发生什么,并描述你将做什么; 如有必要,慢慢地演示并重复。 增强学员技能 演示后总是预留学员实操的机会; 切记初学者需要时间理解新知识。 在小组活动中促进 成功 近距离观察小组活动并在需要时提供帮助; 确保教师在小组之间巡视并检查他们的进展。 6/3" 8 注意语言差异 如果学员正在学习第二语言,随时检查他们是否理解,如有必要,放慢 速度; 注意轮椅使用者与护理者之间的语言差异; 如有必要,使用翻译。 鼓励学员积极参与 整个培训 在不同的单元可以运用不同的培训风格和方法; 避免讲得太多,鼓励学员表达和他们互相讨论; 通过提问来鼓励学员自己思考答案,而不总是告诉他们答案; 鼓励每位学员发言,而不是让某位学员主导; 表扬学员的优秀表现并给予积极反馈; 让学员知道他们可以随时提问; 学习的知识要与学员了解的真实案例联系起来; 让培训变得快乐! 运用简短的热身 活动/游戏 运用简短的热身活动 (5~10分钟)来帮助集中注意力。使用包括残疾学 员能参与的活动。热身游戏的选择包含在培训项目工具包中。 考虑不同能力学员的 需求 考虑到某些视力、听力或移动困难学员的需求。一些活动和教学方法可能 需要相应地进行调整。 9 2.如何准备实施教程 2.1了解学员的轮椅服务网络 教师需要熟悉学员工作所在区域的轮椅供应体系,包括: 所在区域可得到的轮椅、坐垫和体位支撑装置 (PSDs)款式及其供应者; 用于准备轮椅和制作PSDs的材料、工具和设施; 所在区域的轮椅服务,包括他们提供服务的水平; 所在区域的转介网络; 所在区域的资源伙伴,包括哪些轮椅使用者可以为实施培训提供帮助; 其他的康复服务机构,当有需要时,其中的轮椅服务人员可以为本教程提供轮椅使用者。 2.2明确学员在提供轮椅服务中的角色 了解提供轮椅服务是否与学员所在的工作区域的所有职责相适应。例如,学员将要做的仅仅是提 供轮椅服务,或者他们同时还有其他的职责吗? 界定学员在提供轮椅服务中扮演的角色。例如,某些服务人员只需要承担临床或技术方面的工作。 而其他人则可能担任临床和技术的双重职责。 在开始培训前应该要明确学员期望扮演的角色。然后教师才能将培训与学员期望的职责直接联系 起来。在实施培训之前,当地的教师可能需要对培训进行调整,以适应学员将来在轮椅服务中承担的 角色。 2.3检查每期单元计划以及必要时进行调整 检查每个单元计划并为每个单元分配一位主导教师。 许多培训单元需要根据当地的情境来调整,调整建议列在每单元计划开始的 “情境”标题下。 6/3" 10 2.4明确将要使用的轮椅、坐垫和体位支撑装置 确定将在培训中使用哪些款式的轮椅、体位支撑装置和坐垫。这些应该是在学员工作地点可以得 到的产品。如果有很多不同款式的轮椅,要选择不同类型最具代表性的轮椅,优先考虑哪些最容易得 到的。 确保你非常熟悉每个产品的特征。为每辆轮椅填写一张中级轮椅参数表并从供应商处取得产品 信息。 2.5邀请轮椅使用者参与实操单元 为了让学员在本教程中练习讲授的技能,有必要让他们与轮椅使用者一起进行实操。在培训项目 开始之前,教师需要发现并邀请愿意且有能力参与实操单元的轮椅使用者。 以下清单用于帮助发现轮椅使用者。 参与实操单元的轮椅使用者清单: 自愿同意参与培训以协助实操单元 □ 需要附加体位支撑才能坐直,要能够坐直或在支撑下近似于坐直 □ 身体健康足以全程参与培训项目 □ 无压疮 □ 住在附近而不用远距离跋涉参加实操单元 □ 有空闲时间参与实操单元 □ 住在附近便于主办机构在培训后随访 □ 男女轮椅使用者数量相当 □ 不同身体需求的代表 □ 不同年龄代表 □ 11 需要多少轮椅使用者? 参与实操单元的轮椅使用者数量取决于学员数量。通常,学员以2人或3 人一组与一位轮椅使用者一起工作。任何一个实操单元最好不要超过四位轮椅使用者,因为这会为教 师管理、监督和观察培训带来困难。 下面的表格显示一个6~8位学员或8~12位学员的培训项目需要多少轮椅使用者。学员将被分为 2~4人一组,与一位轮椅使用者一起工作。 理想的情况是,一位教师配比两组学员以及一位轮椅使用者。这有利于确保教师能够管理、监督 和观察实操单元,保证轮椅使用者的安全和良好的学习效果。 学员数量: 6~8 8~12 轮椅使用者参与评定、处方、适配和使 用者培训 实操一和三 3 4 实操四 3 4 轮椅使用的志愿者需求总数: 6 8 参与实操单元的轮椅使用者需要知道什么? 轮椅使用者参与实操单元需要知道: 当他们参加实操单元时将会发生什么; 他们什么时候参加并需要多长时间; 欢迎他们带家属/护理人员参加; 参加培训他们是否会获得一辆轮椅。 鼓励教师和主办机构向所有参与实操单元的轮椅使用者提供交通或包括交通及参与成本的经费。 当他们参与培训项目时,应提供就餐及茶点。教师和主办机构应向轮椅使用者提供他们参与培训的每 日津贴。 轮椅使用者的邀请信范本及同意书可在教程中获得 (见DVD:表格和检查表)。该文本应按照当 地的情况进行修改,翻译并寄给每位轮椅使用者 (志愿者)以帮助他/她作出参与培训的知情选择。 6/3" 12 随访 教师或主办方需要为在培训过程中见过的所有轮椅使用者制订即刻随访计划,因为在培训结束 时,对于每位轮椅使用者而言,不是所有事情都能完成。 在培训过程中,任何轮椅使用者在取得轮椅6~8周内都应由主办机构/教师进行随访。 在哪里进行实操单元:布置一个安静和私密的场所用于每组学员与他们的轮椅使用者一起工作。 便携式私密屏风可以用于分隔场所和保护隐私。 教师可以选择至少一个实操单元在社区实施。这可能是在愿意参与的轮椅使用者家中。 社区拜访有助于增强学员了解轮椅使用者在他们环境中面临的实际问题。教师需要决定这是否可 行,考虑: 学员交通工具的便利性; 是否有足够的教师在不同地点来监督和观察所有的学员; 学员到轮椅使用者家进行拜访,轮椅使用者是否感到愉快放松; 到社区地点拜访需要额外的时间。 2.6实操单元分组 每组应不超过三位学员。四人两组比四人一组要好。这将保证学员都有机会应用所学知识并提升 他们的技能。 教师需要决定谁在哪组。不要让学员自行决定。根据学员的技能和情境,教师可以按照以下方法 来选择他们的分组。 将自信心强的与自信心差的学员同组。自信心强的学员可以帮助指导自信心差的学员。近距离 监督/观察各组以确保每位学员都参与。 将未来会在一起工作的学员分在一组,以便他们可以发挥团队技能。 实操一、二和三,不要打乱学员的分组。实操四,根据学员如何有效地合作,分组可以改变。 每次实操单元,每组指定一名 “组长”。应确保每位学员都有机会成为组长。要求组长负责确保所 有的步骤都实施。如果需要,组长应该成为与轮椅使用者和他/她家属/护理人员之间沟通的主要人员。 13 2.7设施准备 为开展培训,需要使用一间大的培训教室 (或空间)。空间应足够的大允许学员和轮椅使用者参与 实操单元,自由地到处移动并分成小组。同时需要户外区域用于轮椅移动技能实操,就餐和茶点的独 立空间,以及干净的卫生间。所有的区域,包括卫生间,必须是轮椅无障碍的。 以下检查表用于检查和准备培训设施。 设施检查表: 培训教室 授课区域 □ 每位学员的椅子———方便学员记笔记 □ 学员分成2~3人一组的空间 □ 至少有容纳三辆轮椅展示和移动的空间 □ 实操单元中为轮椅使用者提供隐私保护的屏风 □ 充足的光线及通风 □ 可锁/安全的 □ 工作台/车间设施 每个小组一个工作台 □ 午餐/茶点区域 洁净的就餐区域 □ 桌与椅 □ 附近的洗手场所———干净的毛巾和肥皂 □ 卫生间 洁净的卫生间并提供水、卫生纸、洗手设施和垃圾箱 □ 6/3" 14 2.8培训资源和材料准备 印刷的资源 资源 数量 √ 备注/说明 手册、实训手册及海报: 《教师手册》 每位教师1份 □ 从 WHO订购或印刷并装订。 《学员手册》 每位学员1份 □ 从 WHO订购或印刷并装订。 《实训手册》 每位学员1份 □ 从 WHO订购或印刷并装订。 海报 每位学员1份 □ 从 WHO订购或印刷并装订。 培训项目表: 学员考勤表 每期1张 □ 该表用于记录学员出勤。 胸牌 每位学员及教师1个 □ 课程表 每位学员1份 □ DVD中有样表,可根据当地情况修改。 肖像同意表 每位学员1份及每位轮椅 使用者 (志愿者)1份 □ 培训/主办机构需要肖像同意表;翻译 为当地语言;确保拍照的所有人签署 本表。 轮椅使用者邀请函及同 意书 每位轮椅使用者1份 □ 轮椅使用者邀请函及同意书范本可以 修改 参与实操单元的轮椅使用 者名单 每位教师1份 □ 该名单用于计划参加实操单元的轮椅 使用者并记录参加人及时间。 学员证书 每位学员1份 □ 准备学员证书或修改提供的范本 培训项目评估表: 学员的培训项目评估表 每位学员1份 □ 教师的培训项目单元评估表 每单元1份 □ 教师的培训项目评估表 每位教师1份 □ 培训项目评估表格范本;教师可以根 据需要对它们进行修改。 实操单元的教师观察表 实操一 实操二 实操三 实操四 每位教师1份 □ □ □ □ 印刷 15 轮椅服务表: 在培训开始时为每位学员提供一套完整的轮椅服务表。实操课需要的其他复印资料如下: 中级轮椅转介表 — □ 如果可能,根据当地情况修改或使用当地的转介表。 中级轮椅评定表 每位轮椅使用者 1份 □ 根据当地的情景修改,例如,增加轮椅服务单位名称 或当地服务需要附加的信息。 中级轮 椅 处 方 (选择)表 每位轮椅使用者 1份 □ 根据可得到轮椅的类型、尺寸和设置最后确定。 中级轮椅参数表 每辆轮椅 1 份 (已完成的) □ 培训项目开始之前为每种当地可得到轮椅填写一份。 轮椅随访表 — □ 根据当地的情景修改,例如,增加轮椅服务单位名称 或当地服务需要附加的信息。 检查表: 塑封的中级轮椅 适配检查表 塑封的中级轮椅 使用者 培 训 检 查表 塑封的中级轮椅 安全和 准 备 检 查表 每位学员1份 □ □ □ 检查表可以在打印资源 “表格、检查表和数据表”中 找到。 表: 塑封的体位支撑 装置 (PSD)表 每位学员1份 □ 可以在打印资源 “表格、检查表和表”中找到。 海报: 儿童与轮椅 1 □ 不同的姿势 1 □ 体位支撑装置 (PSD)表 1 □ 中级轮椅使用者培训检查表 1 □ 每位学员1份 6/3" 16 设备 通常的培训设备 数量 备注/指导 大白板 1 □ 白板笔 3~4 □ 投影机 1 □ 电脑 1 □ 便携式音箱 1套 □ 用于播放DVD声音 一摞纸杯 每位学员一摞 □ 用于喝水 球 每2组一个 □ 用于掷球活动 评定和处方设备:用于演示和练习轮椅评定、处方和适配的设备。 项目 数量 备注/指导 许多硬泡沫塑料块 30mm×150mm×300mm 根据小组的数量, 10~15块 □ 许多硬泡沫塑料楔形块 30mm×150mm×200mm 根据小组的数量, 10~15块 □ 见附录11中的示意图 纸板/塑料量角器/量角器 每组1个 □ 卷尺 每位学员1个 □ 最小刻度为毫米的可缩回硬卷尺 (不是做衣服的软卷尺) 卡尺 (如果有) 每组1把 □ 检查床 每组1张 □ 长凳/检查床或平台。 高度应与普通轮椅椅座高度一致。 如果可能,避免使用硬面,如果使 用长凳则配薄泡沫塑料层和套,或 瑜伽垫。 数码相机 1 □ 如果有 屏风 每组1个 □ 屏风用于在实操单元为轮椅使用者 保护隐私。 一套足垫块 每组1套 □ 当轮椅使用者坐在检查床上时,木 块用于支撑他们的双脚,需要有不 同高度。 一次性手套 (如果有) 每位学员1双 □ 17 轮椅:用于轮椅使用者培训和实操单元。 项目 数量 备注/指导 用于培训的轮椅 当地现有轮椅至少1 辆。理想的是每2位 学员1辆 □ 确保所有的轮椅都处于良好状态并有 坐垫。 用于提供给轮椅使用志愿 者的轮椅 参加实操单元的每位 轮椅使用者1辆 □ 应该有足够多的轮椅用于为参加实操单 元的轮椅使用者开具最适用的轮椅处方。 坐垫:用于演示。 项目 数量 备注/指导 用于支撑僵硬的不水平骨盆的改制坐垫 1 □ 用于支撑不能屈曲到中立位坐姿的髋关节 (躯干与大腿的角度大于90度)的改制坐垫 1 □ 用于支撑不能伸展至中立位坐姿的单侧或双 侧的髋关节 (躯干与大腿的角度小于90度) 的改制坐垫 1 □ 工作台和工具包:为了给参加实操单元的轮椅使用者制作PSDs,需要工作台和基本的工具。教师 应该根据可得到的PSDs预制品和当地可得到的材料来修改本列表。以下是建议列表: 项目 数量 备注/指导 工作台 每3位学员1张 □ 可以是工作台或坚固的桌子。最好在每张工 作台上有一个台钳。 泡沫塑料刀/电工刀 每6位学员1把 □ 细的钢锯条可以用作泡沫塑料刀。 剪刀 每6位学员1把 □ 大的 (如果可能) 防护眼镜 每位学员1副 □ 在所有切割活动中必须戴防护眼镜。 6/3" 18 续表 项目 数量 备注/指导 手工工具 (锯子、锉 刀、锤子、螺丝刀) 每3位学员1套 □ 手工工具用于制作PSDs。根据使用的材料需 要不同的工具。 工业缝纫机,或针 和线 1 □ 工业缝纫机用于制作坐垫套和/或PSDs。 使用缝纫机是一项技术并非每个人都会。可 能的选择是: 找到一家当地的缝纫店可以尽快地开展工作。 找到一位具备熟练缝纫技术的人参加所有 的产品准备单元。 在培训开始之前确保缝纫机处于良好状态。 急救包 1 □ PSD套件:当地可得到的以下PSDs样品将有助于本教程中讲授不同支撑的演示。以下是一个建 议列表。教师应该有意识地获得所有常见的预制PSDs样品。 项目 数量 备注/指导 骨盆侧垫 2 □ 大腿外侧垫 2 □ 膝分隔垫 1 □ 可调张力靠背 1 □ 躯干侧垫 2 □ 头靠 1 □ 骨盆带 每组1个 □ 小腿带 1 □ 足带 2 □ 肩带 1 □ PSD材料:建议用以下的材料为参加实操单元的轮椅使用者制作PSDs。以下列表只是一个指引。 材料的准确列表将取决于: 轮椅使用者需要的解决方案; 所有可得到的PSDs预制品; 当地可得到用于制作PSDs的材料; 选择的技术方案。 19 项目 数量 备注/指导 硬泡沫塑料 (例如,聚合泡沫塑 料) 软泡沫塑料 数量将根据上面而变化。但是建 议的数量是: 硬泡沫塑料———一整块,每 块1000mm×1500mm× 50mm和1000mm× 1500mm×20mm~30mm 软泡沫塑料———以上数量的 一半 □ □ 如果没有50mm 厚的 泡沫塑料,可以用两 块薄的泡沫塑料粘在 一起。 当软泡沫塑料被压缩 时,它应该有一定的 阻力。 获取更多信息,参见 《学员手册》。 织物带 织物搭扣 20米的宽织物 (50mm宽) 20米的窄织物 (25mm宽) 10~12 (与织物带的宽度匹 配) □ □ 根据供应情况,宽度 可以调整。 木头 用于粘木料和泡沫塑料的胶水 装饰面料 EVA或橡胶 如果有,金属L形支架 不同型号的螺钉、螺帽、螺栓和 垫圈 尼龙搭扣或线和圆孔眼 数量根据以上而调整 用于悬吊式靠背的改制 □ □ □ □ □ □ □ 获取更多信息,参见 《学员手册》。 6/3" 20 3.详细的单元计划 21 前言 目标 本单元结束后,学员将: □了解教程的目标; □熟悉教师和学员的姓名; □概括了解培训课程表; □熟悉许多需要记住的重要规则。 资源 本单元 □幻灯片:导论; □每位学员1本 《学员手册》; □每位学员1本 《实训手册》; □完整的轮椅服务表,每位学员1套; □DVD:提供轮椅服务; □DVD:轮椅服务步骤; □每位学员1份课程表; □教师和每位学员的胸牌。 情境 根据培训当地的情境修改本单元。思考: □适合当地文化/情境的开幕式; □根据教师和学员的情况,修改和调整 “介绍教师和学员”单元; □修改、调整或增加 “后勤和期望”列表; □如果培训教程修改了,调整概述的幻灯片。 准备 □收集资源,检查幻灯片,观看DVD并浏览单元计划。 大纲 1.开幕式 (如果有) 2.介绍教师和学员 3.教程概述 4.培训课程表,《学员手册》,《实训手册》和轮椅服务表 5.后勤和期望 15 15 10 10 10 总单元时间 60 6/3" 22 1.开幕式 (估计15分钟) 可以根据当地的文化和风俗以开幕式的方式开始培训。 2.介绍教师和学员 (15分钟) 教师:自我介绍。简要介绍背景及轮椅服务工作经验。 让学员轮流介绍自己:姓名、工作单位,以及他们期望从培训中学到什么。 如果胸牌没有在报名时提供,可以这时分发。 3.教程概述 (10分钟) • 0 M?L7 -, 1,E !PG!P - D - FE >5 (PSD) - E ?,/>5(PSDs) - FG - +6A - 5 LA 1. A: 2 说明:教程的目的是为每位学员培训知识和技能, 帮助他们具备或提高为那些需要附加体位支撑才能 坐直的儿童和成人提供适用的手动轮椅、坐垫和体 位支撑的能力,包括: 身体检查; 处 方 (选 择)轮 椅,坐 垫 和 体 位 支 撑 装 置 (PSD); 准备轮椅以及必要的改制/体位支撑装置 (PS- Ds); 适配; 使用者培训; 保养、维修和随访。 VIDEO 介绍DVD:提供轮椅服务。本DVD简要介绍 WHO轮椅服务教程。 播放DVD。 询问是否有任何问题。 23 0G A. .A B. E !P 1. A: 4 说明:轮椅服务中级教程分为两部分: A:核心知识; B:轮椅服务步骤。 1. ,L,E +6 2. !L1 1. A: 5 说明:核心知识由两个单元组成: A.1:受益于附加体位支撑的轮椅使用者 A.2:残障儿童 说明:人权适用于所有人。UNCRPD (《联合国残疾人权利公约》)的重点在于确保每个人都认 识到这些权利也适用于残疾人。 • 6 !+ 4(UNCRPD) : - G 0, • 0 - 8F, L0,7 • .F6 !+ 4 (UNCRPD) @) 120 0 1. A: 6 .0 说明: 公约有50条。 第20条是关于个人移动。 6/3" 24 • 4E FM?E M? E 7 -,1 1. A: 7 说明:中级轮椅服务是为那些需要改制轮椅或需要 在轮椅上有体位支撑才能坐直的儿童和成人提供 服务。 • E .!E +69 F+,E • E E 3,G?4 G 1. A: 8 说明: 正如学员知道的,轮椅服务人员与轮椅使用者一 起合作才能确保每位轮椅使用者得到适用的轮椅。 提供轮椅服务是轮椅供应体系的重要组成部分。 • EF+,E - %C+6M" )( - FG - 6+ - - 74# , C 5 5, 1. A: 9 阅读适用轮椅的定义。 说明: 对于每位轮椅使用者 “适用的轮椅”将取决于他 们的个人需求和环境状况。 对于每位轮椅使用者 “适用的轮椅”也取决于轮 椅如何提供正确适配和体位支撑。 25 • E FM?L 7 -, F+,E
, • E 'E !P. E +69F+,E , + 1. A: 10 说明: 轮椅服务人员为那些需要附加体位支撑才能坐直 的人士提供最适用的轮椅和可得到的体位支撑。 轮椅服务人员按照8个轮椅服务步骤以确保轮椅 使用者获得适用的轮椅以及最佳的使用。 提问:轮椅服务的8个步骤是什么? 感谢所有正确的答案 (用词不需要非常准确)。 答案: 转介和预约; 评定; 处方 (选择); 经费与订购; 产品 (轮椅)准备; 适配; 使用者培训; 保养、维修和随访。 VIDEO 介绍DVD:轮椅服务步骤。本DVD将演示轮椅服务初级教程中轮椅服务的8个 步骤。让学员观看DVD并注意每个轮椅服务步骤。 播放DVD。询问是否有任何问题。 1. E N4 2. A 3. F 4. 4CAC 5. E 6. FG 7. +6A 8. 5 LA A 说明: 轮椅服务人员的职责是按照8个轮椅服务步骤为 需要附加体位支撑才能坐直的人提供最适用的轮 椅、坐垫和体位支撑。 6/3" 26 说明:在中级教程,一些轮椅服务步骤可能需要较长的时间或需要重复。提问:当为一位需要附 加体位支撑才能坐直的轮椅使用者提供轮椅时,轮椅服务的哪些步骤需要较长的时间,或可能需要重 复多次? 回答: 评定可能需要较长时间; 产品 (轮椅)准备可能需要较长时间; 轮椅适配可能需要较长时间和重复多次; 如果在第一次预约时解决方案不明确,评定可能需要持续至适配; 使用者培训可能需要较长时间。 说明: 本中级教程建立在初级教程获得的知识上。 它涵盖: - 如何对一位需要附加体位支撑才能坐直的轮椅使用者进行评定,并为他们找到最佳移动和 座位的解决方案。 - 如何开处方 (选择),并准备和适配一辆具有合适的坐垫和体位支撑装置的手动轮椅,它 有许多用于提供附加体位支撑的附加物或改制部件。 - 使用者培训———中级教程包括使用体位支撑装置的轮椅使用者 (或他们家人/护理者)需 要知道的其他信息或技能,以使他们能够安全和有效地使用轮椅。也将给予学员与需要附 加体位支撑的轮椅使用者一起练习本步骤的机会。 - 随访———中级教程将简要地回顾随访的流程,以及为学员提供与需要附加体位支撑的轮椅 使用者一起练习本步骤的机会。 步骤1———转介和预约;步骤4———经费与订购;步骤8的部分内容———保养和维修在本教程 中没有涉及。 让每位学员轮流简要介绍他们在轮椅服务中的职责,包括: 他们是否已经提供过轮椅和体位支撑装置; 他们服务的儿童和成人在轮椅上是否需要附加体位支撑。 感谢每位学员的总结,并通过提问厘清他们在轮椅服务中的职责。 27 4.培训课程表,学员手册,实训手册和轮椅服务表 (10分钟) 给每位学员一张培训课程表。 说明: 培训将以理论/课堂单元开始。 学员将在志愿参与的轮椅使用者帮助下实操在理论课学到的一些技能。 给每位学员一本 《学员手册》。让学员将名字写在上面。告知他们可以在该手册上做笔记。 给每位学员一本 《实训手册》。让学员将名字写在上面。告知他们将在培训过程中使用该手册以及 每次课应将它带来。 给每位学员一套完整的轮椅服务表。说明学员将在培训过程中使用这些表格以及他们应该把这些 表格带来。 5.后勤管理与期望 (10分钟) 根据需要,说明如下: 卫生间的地点; 谁负责住宿; 谁负责个别学员的返程安排 (不需要详细); 如果遇到紧急情况怎么办。 根据需要,说明培训对学员的要求: 每堂课将准时开始,学员需要确保他们每天按时到达,并在课间休息后按时返回; 如果学员有疑问,他们应该及时提问; 平等对待所有轮椅使用者并尊重他们; 上课期间关闭手机; 学得开心! 6/3" 28 A:核心知识 29 A.1:受益于附加体位支撑的轮椅使用者 目标 本单元结束后,学员将能够: □列出轮椅使用者需要附加体位支撑的身体和/或功能原因; □列出附加体位支撑的四种好处; □描述轮椅使用者弃用附加体位支撑轮椅的可能原因以及如何确保轮椅使用者使用附加体 位支撑。 资源 本单元: □幻灯片:A.1:受益于附加体位支撑的轮椅使用者; □ 《学员手册》; □ 《实训手册》; □DVD:适用轮椅的好处; □DVD:使用体位支撑装置的人士; □一摞纸杯和一壶水,椅子,检查床和球。 以前学 过的内 容 以前学过的内容: □了解能够坐直人士的轮椅服务和需要附加体位支撑才能坐直人士的轮椅服务的区别。 准备 □收集资源,检查幻灯片,观看DVD并浏览单元计划。 □在培训教室周围或附近布置2个或4个不同的地点用于小组活动 (根据学员的数量) 地点1:放一个椅子和一个球; 地点2:放一把椅子,检查床,一壶水和一摞纸杯。 大纲 1.前言 2.受益于附加体位支撑的轮椅使用者 3.何时需要附加体位支撑? 4.轮椅使用者需要什么? 5.要点概括。 2 6 35 15 2 总单元时间 60 6/3" 30 1.前言 (2分钟) 说明: 每辆适配良好的轮椅都为轮椅使用者提供一定的体位支撑。靠背、坐垫、脚踏板和扶手都能根 据轮椅使用者的尺寸进行调整以提供体位支撑。 然而很多儿童和成人在他们的轮椅上需要附加体位支撑。附加体位支撑可以由体位支撑装置提 供。它是对轮椅增加任何部件或改制,用于提供附加体位支撑。在本手册中,体位支撑装置称 为PSD。 • - F+E , - B ,L - M?L - E +6M? • E M?7 E +6, *6 $ @GL + A.1. ,L,E +6 本单元,我们将学习: 适用轮椅的好处; 谁受益于附加体位支撑; 何时需要附加体位支撑; 轮椅使用者需要什么。 这些信息有助于学员向轮椅使用者、他们的家人、 护理者和其他人清楚地解释附加体位支撑为什么 有用。 2.受益于附加体位支撑的轮椅使用者 (6分钟) VIDEO 介绍DVD:适用轮椅的好处。本DVD将展示不同的轮椅使用者从事不同的活动。 他们中大部分人的轮椅上都有附加体位支撑。有些容易看见,或隐藏在坐垫/靠 背里。 让学员仔细地观看人们从事的活动,以及他们轮椅上不同的附加体位支撑。注意 每位轮椅使用者的轮椅和支撑都不相同。 播放DVD。 询问是否有任何问题。 31 提问:DVD中的人们从事什么活动? 回答: 做饭; 跳舞; 上学/做工艺; 扔球; 举重/训练; 遛狗; 使用电脑; 工作; 美发。 3.何时需要附加体位支撑? (35分钟) 提问:为什么一些儿童或成人需要附加体位支撑? 儿童或成人来到轮椅服务单位,思考他们需要 轮椅和附加体位支撑的不同身体或功能性原因。鼓励回答。 回答: 身体原因: 不能坐直; 关节强直; 平衡障碍; 肌肉僵硬; 感觉不稳; 虚弱无力; 不受控制的运动或痉挛; 疲劳; 压疮; 疼痛或不舒适。 功能性原因: 没有附加体位支撑很难做事; 容易疲劳; 难以独立和安全地吃饭或喝水; 家人发现很难给予附加体位支撑。 6/3" 32 L : 1. > 0 2. Q8F 3. NL +, + 4. 5NL LN,
A.1. ,L,E +6: 4 说明: 需要附加体位支撑的人士有不同的原因。 附加体位支撑可以为轮椅使用者带来的四个非常 重要的好处在于: 附加体位支撑可以: 1.改善平衡、姿势和稳定性; 2.提高舒适性,因此他们可以坐得更久些; 3.有助于预防压疮的发生; 4.有助于减缓或预防未来姿势问题的发展。 • 7 • E +6,8 • QE +6,+#CG A.1. ,L,E +6: 5 说明: 良好的体位支撑有助于增强功能和提升轮椅使用 者的自尊。 一般来说,良好的体位支撑可以有助于提高轮椅 使用者的生活质量。 L : 1. > 0 2. Q8F 3. NL +, + 4. 5NL LN, A.1. ,L,E +6: 6 说明:体位支撑的一个重要好处是改善平衡性、姿 势和稳定性。 提问:哪些活动需要良好的平衡性、姿势和稳定性? 鼓励回答。 回答: 书写; 推动轮椅; 做饭; 吃饭和喝水; 沟通。 33 说明:我们将尝试两项活动 (扔球和喝水),它将帮助学员感受在良好平衡性、姿势和稳定性以及 在较差平衡性、姿势和稳定性下开展这些活动有何不同。 小组活动: 分组 学员分为3人一组。 指导 让学员翻阅 《实训手册》(A.1:受益于附加体位支撑的轮椅使用者)。 说明:有两项活动,扔球和喝水。 说明每组应该在布置的场地开展活动 (指出位置)。 让学员在他们的 《实训手册》上写下问题的答案。 说明学员应该在10分钟之内完成两项活动。 监督 密切地监督各组。 确保每组清楚该活动。 提醒学员思考他们 《实训手册》上的问题: 如何才能容易地扔球和接球? 第2和3步变得更难了吗? 不同的位置和姿势如何影响喝水的容易程度? 一旦每组完成一项活动,让各组换位置。让各组很快地换位置因此每组在有限的时间完成 每项活动。 如果必要,给予学员指导。 时间 允许活动10分钟和反馈10分钟。 6/3" 34 续表 反馈 1.扔球: 提问:当你的稳定性改变时 (当你的椅子倾斜并摇动时),扔球和接球变得困难了吗? 鼓励回答 (扔球变得更难,需要更专心和耗费更多的气力)。 说明:通过在骨盆以及其他需要支撑的地方提供体位支撑有助于增加稳定性。随着稳定性 的增加,做事情更容易,包括:推动轮椅、书写、做饭,甚至讲话。 2.喝水: 提问: 尝试在不同坐姿喝水时的感觉如何? 是否有人感觉他/她将哽噎或水进入气道? 鼓励回答 (不同的坐姿喝水可能感觉不舒适和可能使人惊恐)。 说明: 对于坐直有困难的人士,吃饭和喝水可能不舒适,有时惊恐,通常比较危险。 当人们难以安全地吞咽时,一小块食物和水可能进入肺。这可能导致胸部感染,使人患 重病。轮椅上的附加体位支撑确保该人士可以坐直,当吃饭和喝水时可以真正给予帮助。 提供良好的体位支撑应该改善头部控制,它使吞咽和吃东西更容易和安全。 注意:改善体位支撑只是吞咽有困难人士的解决方法之一。具有吞咽困难的儿童或成人应 该转介至具有这方面经验的专业人士。包括儿科医生、言语治疗师或在处理吞咽困难方面 具有知识和接受过培训的社区卫生工作者。 L : 1. > 0 2. Q8F 3. NL +, + 4. 5NL LN, A.1. ,L,E +6: 7 说明: 附加体位支撑的另一个重要的好处是预防压疮的 发生。 压疮的风险因素在 《轮椅服务初级教程》涉及了。 提问:压疮的主要风险因素是什么 (使轮椅使用者 更容易发生压疮的事件)? 感谢正确的回答。 35 回答: 感觉丧失 (感觉减退); 不良姿势; 不能移动; 以前或现在患有压疮; 汗水、水或大小便失禁导致的潮湿; 外伤、碰撞、撞击; 不良饮食和不充足饮水; 热/发热; 衰老; 昆虫叮咬。 体重:过轻或超重; • ?(?F) • 70 • """/8,%$ • 8 • ) + • 8OO CO" • >6 • GEECG A.1. ,L,E +6: 8 说明: 这是 《轮椅服务初级教程》中讲过的风险因素。 “感觉丧失 (感觉减退)”是黑体字,因为所有 感觉减退的轮椅使用者不自觉地具有发生压疮的 风险。 具有三种或更多其他风险因素的轮椅使用者也可 能有发生压疮的风险。 • ?(?F); • 70 • """/8,%$ • 8 • ) + • 8OO CO" • >6 • GEECG A.1. ,L,E +6 9 说明: 需要附加体位支撑的很多轮椅使用者可能不能移 动,并且容易有不良姿势。 这里有两种压疮风险因素。 这意味着使用附加体位支撑的很多轮椅使用者有 发生压疮的风险。 改善姿势将有助于降低这种风险。 6/3" 36 提问:不良姿势为什么是一个风险因素? (不良姿势如何导致压疮?) 回答: 不良姿势可以导致: 在轮椅上滑动,这样会形成剪切力。 不均衡的体重分布会导致某一区域下高压力 (例如,一侧坐骨下压力大于另一侧),并且可以很 快导致压疮。 说明:评估压疮的风险,找到有助于预防压疮的方法和为轮椅使用者提供如何预防压疮的信息是 中级轮椅供应体系的重要内容。 4.轮椅使用者需要什么? (15分钟) 说明: 我们将讨论附加体位支撑可以为轮椅使用者提供帮助的不同方式。 然而,有时轮椅使用者发现自己很难习惯有附加体位支撑的轮椅。有时轮椅被弃用。 提问:有人曾经有过提供附加体位支撑的轮椅,但是被轮椅使用者弃用的经验吗? 他们认为可能 的原因是什么? 鼓励回答。由于原因已经讲出来了,向学员提问,如何才能避免这种问题的发生。如果可能,提 供一些案例。 回答: 轮椅使用者弃用附加体位支撑轮椅的原因: 如何才能避免: 轮椅使用者发现轮椅或附加体位支撑不 舒适。 让使用者尽可能地参与。 在轮椅完成之前尝试安排一次短期的装置试用。如 果有问题可以在试用后进行解决。 轮椅使用者的姿势发生了改变;以及轮 椅/附加体位支撑不再舒适。 定期随访可以有助于确保装置仍然适配和舒适。 37 续表 回答: 轮椅使用者发现附加体位支撑不再发挥 作用。 该问题可能有不同的原因。 两个常见的原因是: - 附加体位支撑可能不切实际并使完成功 能困难。例如,体位支撑可能使得上下 轮椅困难。 - 轮椅/附加体位支撑可能 “过度支撑”轮椅 使用者 (使他们远离习惯的姿势)和轮椅使 用者在新的姿势位置感觉不舒适/不平衡。 在装置最后完成之前检查轮椅使用者是否可以完成 他/她想做的事情 (例如转移)。 避免对一个人已经较长时间习惯的姿势做非常大的 调整。 思考在较长时间渐进地调整而不是一次调整到位。 轮椅使用者不喜欢附加体位支撑的外观。 让轮椅和所有的附加体位支撑尽可能地小和整洁。 轮椅使用者弃用轮椅的原因: 如何才能避免: 轮椅使用者 (或他们的家人)认为轮椅 使他们变得 “懒散”或虚弱。 说明附加体位支撑的好处。 打消轮椅使用者 (和他们的家人)的疑虑,正确处 方时,附加体位支撑不会使他们变得虚弱。 轮椅服务人员可以说明,如果一个人不良的坐姿, 肌肉和关节不在正常的位置,这导致肌肉紧张并被 拉伸,使他们更弱。良好的体位支撑让身体处于良 好的对线。这有助于保持肌肉和关节处于正确的良 好工作位置。 环境 (家、家附近或社区)有障碍 轮椅服务人员可以向轮椅使用者和家人提供一些如 何使家和附近环境无障碍的信息。 转介轮椅使用者至任何可以协助促进无障碍的机构, 例如,社区康复项目/人员。 6/3" 38 • E LB - + + - 8F - E +6, L - ?- ? - A.1. ,L,E +6 说明:总之,轮椅和附加体位支撑应该: 实用和容易使用; 舒适和不会导致其他不适; 有助于轮椅使用者做他们想做的事情并且不困难; 外观好看又不要太 “显眼”。 说明: 确保轮椅使用者使用附加体位支撑的最好办法是: 让轮椅使用者完全参与他们的评定、处方和适配过程; 协助轮椅使用者理解附加体位支撑为什么会为他们带来帮助,以及如何对他们有益; 应该让轮椅使用者做最后的决定。 VIDEO 介绍DVD:使用体位支撑装置的人士。本DVD介绍一些在之前DVD中出现过的 轮椅使用者。轮椅使用者和家人谈论他们为什么觉得具有正确体位支撑的轮椅对 自己有帮助。 播放DVD。 询问是否有任何问题。 提问:轮椅使用者 (或他们的护理者)认为体位支撑对他们有用的原因是什么? 鼓励回答。 回答: 侯赛因的父亲说他 (侯赛因)的轮椅很适配。他感觉很舒适并且没有再受到由于轮椅支撑不足造 成的伤害了。 查理说她的躯干支撑帮助她变得更强壮。 米歇尔 (雪莱)的妈妈说米歇尔的轮椅有助于她得到好的生活质量;她可以安全地呼吸和吃东西; 她的体位得到良好的支撑。 茹安的妈妈说轮椅有助于她儿子吃东西更容易。 巴斯拉说她的轮椅有助于她工作。 39 让学员看 《学员手册》上第11页的检查表。检查表可以有助于轮椅服务人员,确保他们选择的所 有附加体位支撑对于轮椅使用者都是最有效的。 5.要点概括 (2分钟) • !EFG8,E G, '6A1 ,E M?L • L A • LF L,E > +6+? 8F • F+G?, - AE +6 A FG - E +6 ,L - BAE +6 , A.1. ,L,E +6: 13 讲出关键点。 询问是否有任何问题。 A.2:残障儿童 目标 本单元结束后,学员将能够: □描述轮椅对于儿童重要的至少5种特征; □说明为什么早期转介对于儿童重要的至少两个原因; □列出为儿童服务中展示儿童安全和尊重的7种方法。 资源 本单元: □幻灯片:A.2:残障儿童; □ 《学员手册》; □海报:儿童与轮椅; □海报:不同的姿势; □中级轮椅转介表。 情境 根据学员将工作的情境修改本单元。思考: □主办/培训机构或学员的机构是否有儿童的安全策略。例如,在儿童的实操单元开始之 前,重要的是所有的学员都收到和签署儿童安全策略书。 6/3" 40 续表 准备 □收集培训资源,检查幻灯片并浏览单元计划。 □把儿童与轮椅的海报挂起来。 □把不同姿势的海报挂起来。 大纲 1.前言 2.满足儿童需求的轮椅 3.不同的姿势 4.儿童早期转介的重要性 5.为儿童服务 6.要点概括 2 10 15 10 20 3 总单元时间 60 1.前言 (2分钟) • : - 1,+# M" - F E !L1 , - E,G? - G 1 ,1- A.2. !L1: 2 说明:许多需要轮椅的儿童也需要附加体位支撑。 因为这个原因,当讨论轮椅服务中级教程时,我们 需要思考儿童可能有什么需求。 本单元,我们将学习: 儿童的生活和需求与成人有何不同,以及一辆适 用的轮椅如何能够满足他们的个性化需求; 这些不同如何影响轮椅服务人员为残障儿童服务 的方式,以及影响轮椅和附加体位支撑的选择; 早期转介的重要性; 如何以尊重和保护儿童权利的方式与儿童相处。 41 2.满足儿童需求的轮椅 (10分钟) 说明:幼儿的生活与成人不同。儿童受到成人的照顾。根据年龄,他们在成人的帮助下做决定。 儿童频繁地变换活动,到处移动和玩耍。最重要的是,儿童需要去上学。 1+,E B !,! # A.2. !L1: 3 儿童使用的轮椅应该有助于他们参与每天的正常 活动。 提问:轮椅上的什么特点对儿童重要? 鼓励回答。 回答: 如果儿童自己推轮椅,轮椅应该: - 非常合适让他们舒适地伸到手推圈; - 对儿童足够轻便易于控制,尤其是上下斜坡。 如果可能,轮椅服务应该强调儿童,而不是轮椅本身。 拉高把手可以有助于家人/护理者推轮椅时不用过于弯腰。 轮椅可以通过不平坦和柔软地面 (例如草地和沙地),使儿童更容易和他们的朋友们玩耍。 儿童的轮椅应该使他们上学更容易: - 如果儿童所在社区的大多数儿童走路去上学,思考轮椅是否可以通过这些道路? 儿童需要一辆 适合粗糙地面的轮椅吗? - 如果儿童使用交通工具 (例如,汽车、公交车、人力车、出租车)上学,思考轮椅如何运输。 轮椅应该使他们在学校更方便。思考轮椅是否可以靠近课桌,或儿童的轮椅上是否需要一个桌面 板作为工作台。 6/3" 42 • 7A18E 7 • B16 E • A5 • 7FE E M9
" • 1 • 1 A.2. !L1 : 4 概括: 理想的,儿童轮椅应该: 能够让儿童自己推轮椅 (如果他们能); 强调儿童,而不是轮椅; 有把手让成人给予协助; 能够通过不平坦和柔软地面,例如草地和沙地; 使儿童上学更容易; 使儿童在学校更方便。 3.不同的姿势 (15分钟) 说明: 儿童通常并不总是坐着。一天里他们会不断地改变活动和体位。 这意味着尽管轮椅很重要,儿童也不应该整天都坐在轮椅上。 轮椅服务人员应该与儿童也和他们的家人/护理者一起找到儿童白天能够采取的不同姿势。 特别重要的是如果儿童只有非常有限的运动,始终以同一个姿势坐着并且无法改变体位。 坐位 A.2.!L1: 5 说明: 与坐在轮椅上一样,需要附加体位支撑的儿童可以 以不同的方式得到支撑。 例如: 跨坐在一个滚筒或卷紧的毯子上。 坐时要借助家人/护理者的支撑。幻灯片中的图示 显示一位妈妈,用她的双腿支撑她的残疾小孩,帮 助她坐起来吃饼干,同时还抱着更小的孩子。 43 A.2.!L1: 6 提供一个低至地面的支撑椅座,它: - 像这样的椅座比带支撑椅座的轮椅便宜,对 于幼儿是一个不错的选择。 站立位 说明:站立是儿童另一个重要体位。 A.2.!L1: 7 说明: 站立是每位儿童发展的重要部分。 站立有助于形成髋关节和躯干的正常曲度。 任何人长时间坐着会发生髋、膝和踝关节强直。 站立时拉伸髋、膝和踝关节周围的肌肉并有助于 预防这些关节变得僵硬。 说明: 当儿童不能独自站立时,站立架可以给予帮助。 为了开具站立架处方,轮椅服务人员需要全面熟悉站立姿势和站立支撑的不同方法。这并不在 本教程中介绍。 然而,如果提供一个站立架,应该检查是否有压力直接作用在儿童的膝盖上。支撑腿部预防膝 盖弯曲的最佳位置是在膝盖下方的胫骨上给予支撑。 6/3" 44 ,110 A • 7B 78PG
• 7 7B0 •P8 78B0 •?F,78 P8 - A.2.!L1:8 说明: 当为5岁以下儿童提供站立架时,应该记住以下 事项: 儿童的双腿应该分开并且双脚应该至少与髋部 同宽; 儿童的双脚和双膝应该稍向外; 儿童的髋关节和膝关节应该稍屈曲; 不要强迫幼儿的膝关节和髋关节完全伸直。 说明: 如果使用站立架,轮椅服务人员应该告知其家人/护理者,儿童应该每天使用站立架多长时间。 这是通常的指引: - 当首次使用时每天5~10分钟; - 决不能让儿童站在站立架上超过一个小时; - 鼓励家人/护理者找到一项儿童可以在站立架上玩的有趣活动,以及在可能情况下提供一个桌 子或桌面板用于儿童活动。 提问:学员当地有站立架吗? 鼓励回答。 卧位 说明:卧位是另一个重要的体位。儿童趴在地上玩耍是很正常的。 A.2.!L1: 9 说明: 肢体残障的儿童可能需要一些支撑才能舒适地趴 在地上; - 图中所示,该儿童趴着时前面给予了支撑。 5岁以下儿童俯卧位时,应该在胸部下方用滚筒 支撑以保持他们的髋关节处于稍微屈曲的姿势。 45 提问:家人/护理者可以使用什么东西以帮助儿童在地上玩耍? 回答: 毯子; 泡沫塑料; 毛巾; 枕头。 A.2. !L1: 10 说明: 图示中,支撑儿童侧躺着。 儿童花很多时间睡觉。如果儿童每晚以同一个姿 势睡觉,他们可能固定或强直在那个体位。 当儿童睡觉时如何以不同方式摆放他们,轮椅服 务人员可以向家人/护理者提出建议。 4.儿童早期转介的重要性 (10分钟) A.2.!L1: 11 说明:让我们现在来讨论如何以及什么时候儿童转 介接受轮椅服务。 提问:根据学员的经验,儿童应当年幼时转介至轮 椅服务,还是等到儿童变得太重而无法搬动时才转 介至轮椅服务? 鼓励回答。 提问:为什么一些家长不愿意带幼儿接受轮椅评定? 鼓励回答。 6/3" 46 回答: 家长可能希望孩子能治愈并能开始走路; 家长可能认为如果他们给孩子一辆轮椅,他/她将不再尝试行走; 当儿童年幼和体重轻的时候,比较容易搬动他们而不是用轮椅来通过难走的地面和有障碍的环境; 家长可能没有钱买一辆轮椅而一直耽搁,直到变得越来越困难而无法搬动孩子; 家长可能觉得愧疚或担忧,如果他们的孩子被人看到有残疾,他们将被别人看到负面的形象。 说明: 在儿童早期转介的重要性方面,轮椅服务人员在教育家长和转介资源中可以扮演重要的角色。 以下是早转介比晚转介好的几个原因: - 坐直困难的儿童如果没有得到良好的支撑,就会有姿势问题。如果儿童转介晚了,有些姿 势问题就会变成不可逆转②。即使给予支撑,儿童也很难舒适地坐着。 - 如果缺少坐和移动的经历,儿童的发育将会迟缓③。 - 对于那些有行走能力的儿童,使用轮椅可以让他们的日常生活更容易,并且允许白天做更多的 事情。 重要的是消除家长和转介来源的顾虑,轮椅不会降低儿童的行走能力。当儿童学习行走的时 候,通过轮椅来移动的经验将在其他很多方面有助于他们的发展。 提问:健康的儿童通常在几岁时能够: 没有支撑自己坐直? 鼓励回答。 自己站起来? 鼓励回答。 独自行走? 鼓励回答。 回答: 大部分儿童: 6~8个月没有支撑可以自己坐直; 8~10个月可以自己拉起站立; 10~12个月没有任何支撑可以独自站,并且可以牵着手走; 12~18个月可以独自行走。 ② ③ 世界卫生组织 (1996)。促进脊柱裂和脑积水婴儿和幼儿的发展,检索来自于http://whqlib- doc.who.int/hq/1996/WHO_RHB_96.5.pdf。 肌肉萎缩运动 (2011)。为肌肉萎缩和其他神经肌肉状况的儿童和成人提供轮椅:最佳实践准 则。检索来自于http://www.muscular-dystrophy.org/ 47 FA1B7 - 68 " 8 - - 810 8C10 - 1012 " )81
(-C - 1218 )8>C A.2.!L1: 12 说明:这些都是对转介来源的孩子进行识别的关键 里程碑。 • - L1F7C10 • 2F7)8>C • H 6LN 6F5, 1 A.2.!L1: 13 说明:轮椅服务单位可以鼓励转介网络转介有以下 情况的儿童: 坐直困难或到1岁还不能拉起站立; 2岁仍不能独自行走。 如果有早期干预筛查的项目 (例如,培训社区卫生 工作者筛查需要早期干预的儿童),轮椅服务单位可 以提供更加详细的信息给这些网络。例如,轮椅服 务单位可以建议所有发现有明显肢体问题或发育迟 缓的儿童,都应该转介至轮椅服务单位进行评定或 建议。 教师提示: 学员可能要求得到更多的信息。幼儿可能受益于早期提供支撑性椅座的两个附加标志是: 婴儿 (1岁以内)始终以一种姿势 (姿势过于伸直 (伸展)或过于屈曲 (弯曲)),他们不能容易 地活动自己的四肢,伸展或屈曲,或有无法控制的运动。 能坐的儿童,然而以一种姿势坐和无法轻松地改变姿势。始终以一种姿势坐会导致问题。 让学员看中级轮椅转介表。 说明: 本表是用于转介机构来转介轮椅使用者至轮椅服务单位; 服务单位可以根据他们的服务修改本表; 这个表包含上面提到的关键阶段。 6/3" 48 A.2. !L1: 14 说明:对于非常轻,能抱的小婴儿,轮椅服务单位 可以提供支持性椅座代替轮椅。它可以在家里使用, 并且在户外时儿童仍然可以被抱着。 5.为儿童服务 (20分钟) 说明:无论何时,重要的是以尊重和保护儿童的方式为儿童服务。 提问:轮椅服务人员可以做些什么以确保儿童得到尊重和保护? 鼓励回答。 回答: 应该向儿童说明你将做什么以及为什么要这样做; 以适合儿童年龄的方式让儿童参与决定; 以儿童能够明白的方式进行交谈,这意味着根据他们的年龄和理解水平,找到一种方式向儿童说 明正在发生什么; 在评定和适配过程中预留时间休息; 当为儿童服务时应该让儿童的家人/护理者在场; 把你接待儿童的空间营造得尽可能的友善,例如,有一些与儿童年龄相适应的玩具/活动;以儿 童喜欢的方式展示海报/图片; 在为他们拍照之前,征得儿童和家长/护理者的同意。 • G1 - 1 ,,B ! F - D - FF+,E A1/,/*6 - 1 7 B 51 • FE.1 - B1,K/*6C1 - +1 + N4 N+, L - '1 /*6, A.2. !L1: 15 说明:应记住的主要事情: 通过以下方式尊重儿童: 以儿童可以理解的方式说明你正在做什么以及为 什么这么做; 在开始身体检查之前,应征得同意; 当选择适用的轮椅时,让儿童/他们的家人/护理 者参与决定; 如果在中心接待儿童,尽可能地将该区域布置得 对儿童亲切。 49 通过以下方式确保儿童安全: 应该与儿童的家长/护理者一起接待儿童; 由于儿童容易疲劳,在预约时预留休息的时间; 在拍照前应征得儿童和家长/护理者的同意。 6.要点概括 (3分钟) • 1,+# M" F+,E % C, M" • E M?66!L1,+, • E E !L1—— ,F ,
G? • G1, A.2.!L1 16 讲出要点。 询问是否有任何问题。 6/3" 50 B:轮椅服务步骤 51 B.1:评定概述和面谈评估 目标 本单元结束后,学员将能够: □ 概述转介和预约; □ 简要地概括中级评定的两部分; □ 列出可能影响轮椅使用者的8项诊断或身体问题,以及描述这些问题对轮椅供应体系造 成的影响; □ 列出轮椅服务人员可以在评定过程中提高他们沟通技巧的不同方法。 资源 本单元: □ 幻灯片:B.转介和预约以及B.1:评定概述和面谈评估; □ 《学员手册》; □ 《实训手册》; □ DVD:良好的沟通; □ 中级轮椅评定表。 情境 和以 前学 过的 内容 以前学过的内容: □ 熟悉不同诊断/身体问题的特征,包括:脑损伤、脑性瘫痪、肌肉萎缩症、小儿麻痹症、 脊柱裂、脊髓损伤、中风、下肢截肢。 □ 熟悉轮椅服务8个步骤的第1步,《轮椅服务初级教程》“转介和预约”部分。 □ 初级评定,包括: 熟悉轮椅使用者生活方式和环境与轮椅处方之间的关系,参考 《轮椅服务初级教 程》; 评估现有的轮椅以确定它是否满足轮椅使用者的需求。 根据学员将工作的情境修改本单元。思考: □ 如果一种特定类型的残疾/肢体问题在当地非常普遍,应该增加到轮椅评定表中并在单 元中说明。 6/3" 52 续表 准备 □ 收集资源,检查幻灯片,观看DVD并浏览单元计划。 □ 仔细地检查中级轮椅评定表并练习开展面谈评估。 □ 检查 《轮椅服务初级教程》之 《教师手册》第99~102页上的身体状况信息。 大纲 1.前言 2.评定 3.面谈评估 4.面谈评估中良好的沟通技巧 5.要点概括 10 10 50 15 5 总单元时间 90 1.前言 (10分钟) • G?, .E $E , • E E> AE 9E +6, • N4 E , L1 E +6, L • E N4BE +6 E + 6< E F,
F4 B.E N4: 5 说明:转介和预约是提供轮椅服务的第一步。 播放 《轮椅服务初级教程》中的幻灯片B.1转介和 预约,以提示和重复步骤1的重要性。 • - B AG? - 4A,GMBA D - B4 @MBA - AAA8"F,G? - AA7BB,E +6,9 A !P A A F MBA B.1.A F MBA: 2 说明:本单元,学员将: 介绍评定的两部分:面谈评估和身体检查; 详细查看面谈评估,并讨论面谈评估中收集的信 息如何影响轮椅处方; 评定过程中良好沟通技巧的重要性; 当轮椅使用者疼痛时,能识别。 53 2.评定 (10分钟) • A9, E +6 E - E +6 ,E F F+,E - ,GF F+,E G >5
L - )E +6/ +E M? A • 4"4M? 4 A B.1.A F MBA: 3 说明:评定是8个轮椅服务步骤的第2步。评定中 收集的信息对轮椅服务人员和轮椅使用者都非常 有用。 从评定获得的信息有助于轮椅服务人员和轮椅使用者: - 从可得到的轮椅中选择最适用的轮椅; - 从可得到的轮椅部件中选择最合适的轮椅部件,包括体位支撑装置和附件; - 发现轮椅使用者/家人最佳使用轮椅需要哪些培训。 • AG - MBA - D B.1.A F MBA 4 说明:初级和中级评定都是分两部分实施: 面谈评估; 身体检查。 3.面谈评估 (50分钟) 说明:评定的第一部分是面谈评估。在这项评估过程中,轮椅服务人员收集轮椅使用者的信息。 该信息有助于为轮椅使用者找到最适用的轮椅。 6/3" 54 4 4E MBA, M- •E +6,- •D( •+# ) •) ,E B.1. A F MBA: 5 说明: 初级和中级面谈评估的内容非常相似。包括: - 轮椅使用者的相关信息; - 身体状况; - 生活方式和环境; - 现有的轮椅。 在中级教程中,我们将不再重复 《轮椅服务初级 教程》中已经讲过的所有信息。 学员应该熟悉如何收集这些信息以及它如何影响 轮椅的处方。 简要概述与增加的一些中级信息都已列在 《学员手 册》中。 说明: 尽管初级和中级面谈评估的内容非常相似,但是中 级需要收集更多关于轮椅使用者诊断和所有身体问 题的信息。 小组活动 分组 学员分成2~4人一组。 指导 为每组编号 (1~5)并分配 《实训手册》上适当的任务 (B.1:评定概述和面谈评估)。 让学员回答 《实训手册》上分配给他们组的问题。 说明:学员可以用以下资源来帮助他们完成: 《学员手册》; 他们自己的知识和工作经验,以及向具有不同诊断/身体问题的轮椅使用者/人士学习。 说明:学员有20分钟来回答布置的问题。每组将向所有小组反馈以及当为有特殊诊断/身 体问题的人士开具轮椅处方时,提供最多3个需要关注的方面。 55 续表 监督 密切地监督各组。 确保每组明白问题。 鼓励各组使用 《学员手册》和他们自己的知识。 如果需要,指导学员。 时间 允许20分钟让各组准备。 允许10分钟让每组反馈和讨论。 请注意本活动允许的时间是以4组学员参与为基础计算的,如果少于或超出4组,相应地 调整时间。 反馈 当为特定诊断/身体问题的轮椅使用者开具轮椅处方时,让每组轮流描述应该关注的3个方面。 感谢正确的回答并纠正/说明一些错误的理解。 允许一些讨论,但是不要超出时间。 注意:教师应该使用 《学员手册》中提供的备注以确保每组都找到了合适的答案。 4.面谈评估中良好的沟通技巧 (15分钟) 说明: 拥有良好的沟通技巧是非常重要的,它有助于以一种对轮椅使用者的感受和需求保持尊重和敏感 性的方式收集正确的信息。有助于面谈评估顺利进行的一些方法是: 应该向轮椅使用者提问,除非他们是婴幼儿或他们无法理解或回答你的问题; 向轮椅使用者说明,他们提供的信息将有助于选择最适用的轮椅来满足他们的需求; 不必按照中级轮椅评定表中的顺序提问。有时候轮椅使用者在你提问之前会主动提供信息,或 许以不同的顺序提问更自然。 有时,语言沟通可能困难。例如,轮椅使用者可能无法听到或无法说得清楚而让你明白。 当沟通困难时,尝试找到一种直接与轮椅使用者沟通的方式。询问非常了解轮椅使用者的人, 问他如何与他们进行沟通。花点时间来了解轮椅使用者如何沟通。 如果你无法找到一种直接沟通的方式,确保有非常了解轮椅使用者的人一直在旁边。请这个人 帮助你与轮椅使用者沟通。 6/3" 56 VIDEO 介绍DVD:良好的沟通。本录像介绍人们彼此沟通的许多不同方法。 根据学员坐的位置 (学员不需要移动),把所有人员分成两组。 说明:每组应该仔细地观看DVD并注意人们沟通的不同方式。学员应该寻找: 沟通的不同方法 (例如,手语); 良好沟通技巧的不同案例 (例如,恰当的眼神接触)。 播放DVD。 询问是否有任何问题。 给每组几分钟时间用于写下沟通的不同方法和良好沟通技巧的不同案例。 提问:DVD中人们不同的沟通方式有哪些? 让一组说出他们的答案。把答案写在白板上。如果其 他组也有相同的答案,在这个答案旁边画勾。如果他们有其他答案,向第二组提问。 回答: 不同的语言沟通: - 清晰地表达辅以示范; - 说明和演示; - 声音 (发声)。 不同的非语言沟通: - 手势; - 用眼指示; - 点头; - 用手描述; - 接触; - 面部表情; - 手语; - 眼神接触; - 触摸; - 提问时,轮椅使用者可以用 “是”或 “否”来回 答问题;他/她也可以用任何系统来表达是或否 特殊的沟通系统: - 沟通板; - 头部控制杆; - 电脑系统。 以下方式使沟通更好: - 恰当的眼神接触; - 弯腰或蹲下来与轮椅使用者处于同 一水平面上; - 开放和放松以及积极反应的肢体语 言 (面向轮椅使用者,表示关注); - 给沟通困难的人士充足的时间来回 答问题。 57 VIDEO 介绍DVD:良好的沟通。学员将再次观看DVD并发现自己答对了多少。 播放DVD。 确认学员在他们第一次观看时发现了多少种沟通方式。 说明:当轮椅使用者不能说话时,他们可能难以表达自己经受的痛苦。因此,当为轮椅使用者服 务时,轮椅服务人员需要知道他们正在做的事情是否导致或增加轮椅使用者的疼痛。提问:当人们疼 痛时他们通常的表现是什么? 鼓励回答。 回答: 哭; 喊叫; 坐立不安; 出汗; 推开评估者的手或试图离开; 抗拒一个动作或不能保持一种特定的姿势; 面部表情,皱眉/或痛苦的表情; 坐位、站立或行走的方式。 提问:为了确保你没有导致疼痛或增加现有的疼痛,你可以怎样做? 回答: 如果轮椅使用者在评定过程中疼痛,鼓励他/她让你知道; 如果沟通困难,在开始评定之前就疼痛的信号达成一致; 避免使疼痛加重的体位; 采用使疼痛减轻的体位或活动。 6/3" 58 5.要点概括 (5分钟) • AG - MBA - D • E A>, MBLNG G?,LN , 1 0+6 F+E ,+M • AE0 E , !P8, "FG G?, • E +6 + ,"F B.1.A F MBA: 8 讲出要点。 询问是否有任何问题。 B.2:身体检查———无支撑坐姿 目标 本单元结束后,学员将能够: □ 列出儿童与成人坐直姿势的3个区别; □ 用文字、绘画或图文并茂来观察和记录坐姿。 资源 本单元: □ 幻灯片:B.2:身体检查———无支撑坐姿; □ 《学员手册》; □ 《实训手册》; □ DVD:身体检查概述; □ 中级轮椅评定表; □ 检查床,每组一张; □ 一套足垫块。 59 续表 情境 和以 前学 过的 内容 以前学过的内容: □ 完成身体检查的 “压疮的出现、风险或病史”部分,以及了解获得的信息会如何影响轮 椅供应体系。 □ 完成身体检查的 “推轮椅的方法”部分,以及了解获得的信息会如何影响轮椅供应 体系。 □ 基本的坐姿: □ 如何识别和描述坐直的姿势; □ 了解坐直的好处。 □ 如何识别骨性标记,包括髂前上棘 (ASIS)、髂后上棘 (PSIS)和坐骨结节 (ITs)。 根据学员将工作的情境修改本单元。思考: □ 当让学员相互之间找髂前上棘 (ASIS)、髂后上棘 (PSIS)和在志愿者身上演示这项活 动时,注意身体接触引起的文化问题。 准备 □ 收集资源,检查幻灯片,观看DVD并浏览单元计划。 □ 仔细地检查中级轮椅评定表并练习描述或绘画无支撑坐姿。 □ 把检查床摆放在培训教室的前面。 □ 布置培训教室,让学员面向教室前面坐成半圆形。 □ 把检查床放在培训教室周围 (或教室外面/邻近的房间里)。 大纲 1.前言 2.复习压疮的出现、历史或病史和推轮椅的方法 3.身体检查概述 4.坐直的姿势 5.幼儿的坐直位 6.骨盆是坐姿的基础 7.观察坐姿 8.记录姿势 9.要点概括 5 5 5 20 5 20 8 20 2 总单元时间 90 6/3" 60 1.前言 (5分钟) • N - +,)NL+ - E ,# • ' # - 1 -, - 6P, - 4? A !P A D B.2. D —— : 2 本单元,我们将介绍身体检查,它是评定的第二 部分。 我们将简要地回顾在 《轮椅服务初级教程》中介绍 的身体检查的两部分: 压疮的出现、风险或病史; 推轮椅的方法。 说明:我们将关注身体检查的 “无支撑坐姿”部分。我们将: 检查成人和儿童坐直的姿势; 思考骨盆如何影响坐姿; 练习观察和记录坐姿。 • A +,)NL+ • AE ,# • FE )E +6 M? /L - ? - F>P, P8 - + • F>#G B.2.D : 3—— 说明:身体检查包括: 识别压疮的出现、风险或病史; 识别推轮椅的方法; 发现轮椅使用者如何坐以及他/她可能需要哪种 附加体位支撑: - 观察无支撑坐姿; - 进行骨盆和髋关节姿势检查; - 用手摸拟; 进行测量。 提问:有人知道 “用手模拟”一词是什么意思吗? 鼓励回答。 回答: 用手模拟是指用双手来作为轮椅和附加体位支撑 可能提供的支撑。 61 2.复习压疮的出现、风险或病史和推轮椅的方法 (5分钟) 说明:中级身体检查的前两部分与初级检查是一样的。它包括: 压疮的出现、风险或病史; 推轮椅的方法。 说明:在中级教程中我们将不再复习 《轮椅服务初级教程》中已经讲过的知识。学员应该熟悉收 集这些信息以及它们如何影响轮椅的处方。 B.2.D : 4 D —— 说明:重要的是发现轮椅使用者是否有发生压疮的 风险。 提问:有人对检查压疮的内容有问题吗? 回答所有 问题。 提醒学员: 如果轮椅使用者说他曾经有过压疮,或他现在有 压疮,请求允许看一下压疮。 重要的是确保轮椅服务人员确切地知道压疮在哪 里以及是否有必要转介治疗。 ——B.2.D : 5 E ,# E +6E 77 7 77 7+> # 说明:与初级轮椅供应体系一样,重要的是识别轮 椅使用者推轮椅的最好方法。 提问:有人对这方面检查有问题吗? 回答所有问题。 提醒学员: 能够尽可能独立地移动是基本的人权。即使是少 量独立地推行也值得拥有。 良好的支撑可以提升轮椅使用者自己推行的能 力,当评估轮椅使用者自己如何推动,以多大的 力量推动时,这应该要考虑到。 6/3" 62 3.身体检查概述 (5分钟) VIDEO 介绍DVD:身体检查概述。我们现在将观看DVD短片,它简要地概括了轮椅服 务人员如何与轮椅使用者一起发现轮椅使用者如何坐,以及他/她可能需要哪种附 加支撑。DVD中的小女孩名叫恩尼斯。面谈后,评估者按照以下步骤: 观察无支撑坐姿; 进行骨盆和髋关节姿势检查; 用手模拟。 播放DVD。 说明: DVD展示了轮椅服务人员观察恩尼斯在她轮椅上的姿势。由于恩尼斯已经有 了一辆轮椅,重要的是知道恩尼斯已经有哪些体位支撑以及支撑的程度如何。 我们应该假设当恩尼斯在检查床上时,在开始骨盆和髋关节姿势检查之前,轮 椅服务人员已经观察了他的姿势。 询问是否有任何问题。 4.坐直的姿势 (20分钟) 让一位志愿者到培训教室前面来,并以坐直的姿势坐在检查床上。 让学员在侧面从骨盆开始描述志愿者的姿势。学员可能需要站起来并走动来观察。 回答 (涵盖所有这些内容): 侧视图: 骨盆直立; 躯干直立; 背部呈自然弯曲; 头和颈直立且在身体上方保持平衡; 髋关节屈曲接近90度; 膝关节和踝关节屈曲接近90度; 双脚平放于地面 (或脚有支撑)。 63 让学员从前面描述志愿者的姿势。再一次,让学员从骨盆开始。 回答 (涵盖所有这些内容): 正视图: 骨盆水平; 肩膀水平,放松及手臂自由活动; 双腿平行或稍微外展; 头部中立且在身体上方保持平衡。 躯干呈一条直线 (不弯曲或倾向一侧)。 感谢志愿者。 说明:学员应该将刚刚描述的直立姿势用作指导。当为轮椅使用者服务时,目标是支撑每位轮椅 使用者尽可能安全、舒适和功能性地接近这个姿势。 说明: 我们已经讲过坐直为什么重要,然而并不是每个人都可以坐直; 接受中级轮椅服务的轮椅使用者可能呈现一系列的不同坐姿; 不同的坐姿是由一个 (或部分)身体部位没有处于中立位引起的; 在评定过程中,轮椅服务人员和轮椅使用者需要找到最佳的坐直姿势,使得轮椅使用者可以安 全和舒适地达到和维持功能,而不是失去功能; 轮椅和PSDs应该支撑这个姿势; 当评估姿势时,可以发现有3个不同的最终结果。 它们是: • ., • 0, • G0, B.2.D —— : 7 僵硬的姿势; 可整体推到中立位的姿势; 可部分推到中立位的姿势。 6/3" 64 小组活动 分组 学员分成3人一组。 指导 让学员在他们中间讨论这3个词的意思: 僵硬的姿势; 可整体推到中立位的姿势; 可部分推到中立位的姿势。 让他们不要查阅 《学员手册》,而是找到自己对这些词汇的理解。 说明:每组的学员有10分钟时间讨论,然后各组再回来反馈。 监督 停留在3个词汇的幻灯片处以提醒各组的问题。 密切地监督各组。 确保学员明白问题。 如果必要,指导学员。 时间 允许10分钟活动。 允许5分钟反馈。 反馈 让一组提供他们关于僵硬姿势的定义或描述。 如果定义/描述是清晰和正确的,感谢回答。如果不是,询问其他小组是否可以帮助厘 清。如果必要,教师可以阐明。 让另外的小组提供他们对于可整体推到中立位姿势的定义或描述。 如果定义/描述是清晰和正确的,感谢回答。如果不是,询问其他小组是否可以帮助厘 清。如果必要,教师可以厘清。 让另外的小组提供他们对于可部分推到中立位姿势的定义或描述。 如果定义/描述是清晰和正确的,感谢回答。如果不是,询问其他小组是否可以帮助厘 清。如果必要,教师可以厘清。 回答: 僵硬的姿势 轮椅使用者身体某个部位是 “僵硬的”。用轻柔的力量无法推动 (不 要用大力)。 可整体推到中立 位的姿势 用轻柔的力量,不在中立位的轮椅使用者身体部位能推到中立位。 可部分推到中立 位的姿势 用轻柔的力量,不在中立位的轮椅使用者的身体部位仅能部分推到接 近中立位。 65 说明: 这些词在 《学员手册》中有描述。对轮椅服务人员来说,重要的是在支撑轮椅使用者时要仔细 考虑,如何柔性地把轮椅使用者推向中立位。 —— • ., - FM0., • 1, - E +650 • G1, - E +6 78F F0 B.2.D : 8 对于僵硬的姿势,轮椅使用者某部分身体是僵硬 的。用轻柔的力量无法推动 (不要用大力)。轮 椅服务人员应该提供支撑以适应这种非中立位 (僵硬的)姿势。 对于可整体推到中立位的姿势,用轻柔的力量,不在中立位的轮椅使用者身体部位能推到中立 位。这种情况下,应该提供正确的支撑帮助轮椅使用者维持中立位坐姿。 对于可部分推到中立位的姿势,用轻柔的力量,不在中立位的轮椅使用者的身体部位仅能部分 推到接近中立位。这种情况下,提供支撑有助于轮椅使用者尽可能接近中立位坐姿,这样他们 更舒适和更易发挥功能。 记住,如果轮椅使用者被支撑处于接近中立位的姿势,而不是让他们更舒适和更易发挥功能, 可能会产生新的问题。因此,评定非常重要,需要考虑轮椅使用者的舒适和功能性以及他/她 如何能够接近 “直立的坐姿”。 5.幼儿的坐直位 (5分钟) 说明:5岁以下的儿童与大龄儿童和成人的坐直姿势不一样。坐姿在儿童5岁后形成。 ——B.2.D : 9 说明:本幻灯片中,该儿童3岁。幻灯片中的儿童 和成人都是坐直的。 提问:学员可以看到儿童和成人坐姿有何差异? 鼓励回答。 6/3" 66 回答: 5岁以下儿童 成人 躯干直立,但是没有腰椎或胸椎曲线; 儿童的耳朵和臀部成一直线,然而他们的肩 部略向前; 双腿外展并分开,不平行。 躯干直立,背部呈自然弯曲; 耳朵,双肩和臀部成一直线; 双腿相互平行或稍微外展。 —— • 6G ," 7 7 4 • 6 7G-4 • 60 • 7 B.2.D : 10 说明: 在5岁之前最大的不同是: 儿童的背部是平的以及没有腰椎或胸椎曲线; 儿童的耳朵和臀部成一条直线,然而他们的肩部 稍微向前; 双腿外展并分开,不平行。 说明:当为5岁以下的儿童检查时,轮椅服务人员需要记住,5岁以下的儿童不应该被支撑得像 成人那样坐直。这可能会不舒适并给儿童带来伤害。 6.骨盆是坐姿的基础 (20分钟) 提问:骨盆姿势的变化会影响身体的其他部分吗? 回答: 是,骨盆姿势的移动或改变总是影响身体的其他部分; 骨盆是坐姿的基础。 6M !M M B.2.D : 11—— 说明: 我们现在来仔细地看骨盆。 了解骨盆如何影响身体其他部分是中级教程的重要 内容。 67 B.2.D – : 13—— 提问:插图中髂前上棘和髂后上棘在哪里? 说明:从侧面看,髂前上棘和髂后上棘在同一高度。 B.2.D – : 13—— 说明:从正面看,左右髂前上棘是水平的。 ——B.2.D : 14 让一位志愿者到教室前面来,并以坐直的姿势坐在 检查床上。在志愿者身上演示并指出髂前上棘和髂 后上棘。把你的手放在志愿者的骨盆上并演示你如 何能够轻轻地用双手控制骨盆。拇指放在髂前上棘 上并且手指弯曲在骨盆后面。 让学员相互练习 (如果对这项技术不熟悉),确保每 位学员可以在他们的同伴身上找到髂前上棘和髂后 上棘。 感谢志愿者。 6/3" 68 提问:除了直立或中立,还有其他哪些骨盆姿势? 回答 (涵盖所有的内容): 骨盆前倾 (髂前上棘比髂后上棘低,或骨盆上端向前运动); 骨盆后倾 (髂后上棘比髂前上棘低,或骨盆上端向后运动); 侧向倾斜 (骨盆一侧比另一侧低); 旋转 (相对于一侧,骨盆另一侧向前旋转/向后旋转)。 本单元中常用的缩写 解剖结构 缩写 髂前上棘 ASIS 髂后上棘 PSIS 坐骨结节 IT 小组活动 分组 把学员分成4人一组。 指导 让学员看 《实训手册》(B.2:身体检查,无支撑坐姿:坐姿的基础)。 说明:当骨盆姿势从直立变化到前倾、后倾、侧倾和旋转时,每组应该共同来找出直立的 坐姿有什么变化。 说明:每组学员有10分钟来做这项活动,然后各组将一起回来反馈。 监督 密切地监督各组。 确保每组理解问题。 如果必要,引导学员。 时间 允许10分钟让各组准备。 允许5分钟反馈和讨论。 反馈 提问:每组是否发现随着不同的骨盆姿势,身体其他部分发生的变化? 向第一组提问:向前倾斜时姿势会发生什么变化? 向第二组提问:向后倾斜时姿势会发生什么变化? 向第三组提问:侧面倾斜时姿势会发生什么变化? 向第四组提问:旋转时姿势会发生什么变化? 69 续表 回答: 骨盆姿势: 前倾 后倾 侧倾 旋转 整个身体姿势 (重点关注躯干周围) 躯干拉伸,腰部的弯曲度增加 (脊柱前凸); 躯干弯曲,导致 “下滑”姿势 (脊柱后凸); 躯干向一侧弯曲 (脊柱侧弯); 躯干也旋转。 说明: 最重要是记住骨盆的姿势将影响身体的其他部分。 当评估轮椅使用者姿势时,应该从检查骨盆的姿势开始。当提供姿势支撑时,应该首先 支撑骨盆。 7.观察坐姿 (8分钟) 说明:观察轮椅使用者的无支撑坐姿是了解轮椅使用者坐姿和需要什么支撑的起点。 —— • .E +6, 7C, • E +67 )0 . C • ?E +6
-0, B.2.D : 15 说明: 在评定甚至面谈过程中,轮椅服务人员将开始观 察轮椅使用者的姿势。 身体检查之前,让轮椅使用者转移至检查床上。 确保轮椅使用者是安全的并且他们的双脚得到 支撑。 提供足够的支撑以确保轮椅使用者安全地坐并且不会跌倒。协助者或家庭成员/护理者可以提 供这种支撑。 观察无支撑坐姿的目的是了解轮椅使用者的姿势偏好/习惯。 观察姿势是一项技术,需要时间和实践来掌握。 我们将看到4种不同的坐姿,并且知道我们观察不同姿势的技术如何。 6/3" 70 教师提示: 强调首先观察骨盆的姿势,然后躯干、头、颈和腿; 如果学员发现进行这项活动困难,建议他们对着镜子观察自己的姿势,这样他们可以进行感受。 这也可以用于他们理解和观察不同的坐姿。 ——B.2.D : 16 提问:学员观察这个人是什么姿势? 回答: 骨盆前倾; 腰前凸; 双肩内收; 颈部前伸。 B.2.D : 17—— 提问:学员观察这个人是什么姿势? 回答: 骨盆后倾; 髋关节超过中立位 (躯干与大腿之间的角度超 过90度); 腰部后凸; 颈部稍前伸。 ——B.2.D : 18 提问:学员观察这个人是什么姿势? 答案: 骨盆右倾 (通常说低的一侧); 骨盆右侧向后旋转 (旋转通常与对称坐姿联系 起来,但是也不总是这样); 脊柱侧弯,向右凸; 双肩不水平 (右侧低)。 71 ——B.2.D : 19 提问:学员观察这个人是什么姿势? 回答: 骨盆右侧向后旋转 (应该说出方向和哪侧,例 如,右侧向后); 部分躯干旋转 (左侧向后); 右腿快要掉下来了并且外旋,左腿内旋。 教师提示: 对于最后一种姿势,如果学员无法轻易地注意到躯干的旋转,提问: 看起来就好像该男孩的后背平靠在靠背上,他的整个后背是相同的压力。 8.记录姿势 (20分钟) ——B.2.D : 20 F5+ 说明: 中级轮椅评定表上有一个空白处用于记录轮椅使 用者的无支撑坐姿。 该记录可以有助于轮椅服务人员: - 记住评定后轮椅使用者的坐姿; - 追踪随时间推移而坐姿的变化。 —— • + • + • ' B.2.D : 21 这里有几种不同记录坐姿的方式,包括: 用文字描述坐姿,这是我们已经练习过的方式; 画图; 拍照 (只有轮椅使用者同意时)。 6/3" 72 —— • BE +6, • B.+A-,,'( • ' - M - !M - B.2.D : 22 说明: 如果可以用拍照的方式,轮椅服务单位需要建立 拍照和保存照片的一项明确制度; 应该取得轮椅使用者的允许;或如果他们是儿 童,应取得轮椅使用者家人/护理者的同意; 应该确保用于评定目的的照片保密; 如果没有取得轮椅使用者的特定允许,不得将照 片用于培训目的 (或其他目的); 拍照时要记录侧面和正面姿势的照片。其他位置 的拍照可能也有用。 说明:绘画姿势需要一些练习。然而这里有一种简易的线条绘画方式来记录姿势。学会线条绘画 方法对轮椅服务人员非常有用,并且可以容易和有效地使用。 —— P, 7D B.2.D : 23 说明:这是一种简易的方式来画坐直姿势的侧视图。 用一个三角形来代表骨盆; 用一条波浪线来代表脊柱; 用直线来代表双腿; 用一个圈代表头。 —— N 7 7 Head B.2.D : 24 说明: 代表脊柱的波浪线显示脊柱的正常曲线 (颈椎、 胸椎和腰椎)。 坐骨结节、髂前上棘和髂后上棘由三角形上的点 来代表。 73 让学员画线条图。 P, 7D B.2.D ─ : 25—— 说明:这是一种简易的方式来画坐直姿势的正视图。 用两个三角形来代表骨盆; 用一条线来代表躯干; 用线条来代表大腿 (图中的短线条)和小腿 (见 下面的教师提示); 图中膝关节用大腿和小腿线连接点的小圈来代 表,双脚用小方格来代表。 —— 6 -0 B.2.D 26 用一边到另一边的直线代表肩膀; 用一个圈代表头。 让学员看 《实训手册》(B.2:身体检查———无支撑 坐姿:姿势绘画)并且在他们的练习本上每幅图旁 边画他们自己的线条图。 说明:学员可以用这种绘画姿势的简易方式来记录 不同的姿势,并且我们将在后面的单元进行练习。 B.2.D : 27—— 说明:如果轮椅使用者的骨盆是旋转的,可能要画 一个像图中显示的弯曲箭头,一侧的骨盆向后旋转。 让学员把这个图模仿画在他们的练习本上。 6/3" 74 教师提示: 本单元中讲的线条图例子可以修改/调整用于不同的人。例如,一些人可能喜欢从上面开 始画大腿姿势。这避免了当从正面画时对大腿造成 “投影缩短”的影响。在描述的系统中,大腿看 起来比小腿短,并且大腿稍微外展。 小组活动 分组 把学员分成3人一组。 指导 让每组看 《实训手册》上的姿势 (B.2:身体检查———无支撑坐姿:姿势绘画)。 说明这些都是真实的人物插图。让各组一起工作,在他们的 《实训手册》的中级轮椅评定 表上 “无支撑坐姿”部分用线图记录坐姿。 说明:每组学员有10分钟时间开展这项活动,然后各组将返回进行反馈。 监督 密切地监督各组。 确保每组明白这项活动。 如果必要,引导学员。 时间 允许10分钟活动。 允许5分钟反馈。 反馈 如果有白板,把每个插图 (每次一张)投影到白板上。让每组一位学员在每幅投影的姿势 上画线条图。如果没有白板,当教师在板上说明/画的时候,让学员在他们的练习本上画。 讨论学员在画线条图中遇到的困难。 说明把线条图和语言结合起来可能是有用的。 教师线条绘画范例: 75 9.要点概括 (2分钟) —— • P, ,.P,, G
D,G • -, , • DD ,1G ?E +6, • ? AE
7?+ + ' B.2.D : 32 讲出要点。 询问是否有任何问题。 B.3:身体检查———骨盆和髋关节姿势检查 目标 本单元结束后,学员将能够: □ 演示轮椅使用者骨盆和髋关节姿势检查来发现: 轮椅使用者的骨盆是否可以水平; 两侧的髋关节是否可以屈曲至中立位坐姿。 □ 当一侧或两侧髋关节不能屈曲至中立坐姿时 (躯干与大腿之间的角度大于90度),演示 做临时支撑以适应不水平的骨盆。 资源 本单元: □ 幻灯片:B.3身体检查———骨盆和髋关节姿势检查; □ 《学员手册》; □ 《实训手册》; □ DVD:骨盆和髋关节姿势检查; □ DVD:临时支撑; □ 中级轮椅评定表; □ 检查床———每组1个; □ 量角器/纸板量角器———每组1个; □ 多块硬泡沫塑料———每组1块; □ 楔形硬泡沫塑料块———每组1块; □ 用于支撑僵硬的不水平骨盆的改制坐垫; □ 用于支撑髋关节不能屈曲至中立位姿势的改制坐垫 (躯干与大腿之间角度大于90度); □ 用于支撑单侧或两侧髋关节不能伸展至中立位坐姿的改制坐垫 (躯干与大腿之间角度小于90度)。 6/3" 76 续表 情境 和以 前学 过的 内容 以前学过的内容: □ 能够使用量角器是有用的,但不是必需的。 根据学员将工作的情境修改本单元: □ 考虑在哪里开展检查; □ 当在志愿者身上演示临时支撑时,让学员相互开展骨盆和髋关节姿势检查,注意由于身 体接触引起的文化问题。 准备 □ 收集资源,检查幻灯片,观看DVD并浏览单元计划。 □ 仔细地检查中级轮椅评定表并练习开展骨盆和髋关节姿势检查。练习提供临时支撑。 □ 布置一个检查床在教室前面。 □ 把硬泡沫塑料块和楔形块放在检查床上,准备用于演示。 □ 布置教室让学员坐成半圆形面向教室前面。 □ 把检查床放在教室四周 (或教室外面/临近的房间),用于学员开展小组活动。 大纲 1.前言 2.骨盆和髋关节姿势检查 3.为僵硬的不水平骨盆或不能屈曲至中立位坐姿的髋关节 (躯干与大腿之间角度大 于90度)提供临时支撑 4.僵硬的不水平骨盆临时支撑的演示 5.不能屈曲至中立位姿势髋关节 (躯干与大腿之间角度大于90度)临时支撑的演示 6.练习临时支撑 7.要点概括 2 40 5 10 30 30 3 总单元时间 120 77 1.前言 (2分钟) 说明:本单元我们将继续学习身体检查的内容。 —— • - P, P8 - LN,P, P8 !P A D P, Q8 B.3. D P, P8 : 2 本单元,学员将学习: 骨盆和髋关节姿势检查; 为有问题的骨盆和髋关节提供临时支撑。 2.骨盆和髋关节姿势检查 (40分钟) 教师提示: 本教程中讲的骨盆和髋关节姿势检查不是完整的运动评定。 骨盆: 检查是用于识别骨盆是否可以水平; 这是因为如果没有调节好不水平的骨盆,很难开展下一步的身体检查 (用手模拟)。 髋关节: 只检查髋关节的屈曲; 这是因为当髋关节屈曲的时候,如果没有调节好任何僵硬的限制,很难开展下一步的身体检查 (用手模拟); 参考点或起点是髋关节屈曲至中立位坐姿 (躯干与大腿之间为90度)。教会学员识别: — 轮椅使用者是否可以在支撑下坐在中立位? — 如果不能,他/她能够接近中立位坐姿的程度如何? 它直接和轮椅椅座与靠背之间的角度有关。 6/3" 78 让学员看一下他们中级轮椅评定表上的 “骨盆和髋关节姿势检查”部分。 ——B.3.D P, P8 : 3 说明:我们知道坐姿受骨盆和髋关节周围病变的影 响。在本部分检查中,轮椅服务人员需要了解: 在有或无支撑的情况下从正面看,轮椅使用者的 骨盆是否水平; 在有或无支撑的情况下,轮椅使用者的髋关节是 否能够屈曲至中立位坐姿。 B.3.D – P, P8 : 4—— 说明: 你可以看到这位儿童的骨盆是水平的,他的髋关 节处于中立位坐姿。 注意轮椅服务人员把她的拇指放在该儿童的髂前 上棘 (ASIS)上,这样她可以清楚地看到骨盆是 否水平。 ——B.3.D P, P8 : 5 提问:该男子的骨盆水平吗? 并且他的髋关节处于 中立位坐姿吗? 回答: 不是。 79 如果骨盆不水平或髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度),轮椅服务 人员必须了解更多的信息。重要的是知道: 轮椅使用者能在支撑下坐在中立位的姿势吗? 如果不能,他/她能够多大程度地接近中立位坐姿? 说明:我们知道骨盆可以以不同的方式运动,包括前倾、后倾、侧倾和旋转。 让学员向不同的方向移动他们的骨盆并思考运动真正从哪里产生。他们可以把手放在自己的坐骨 下或观察坐在自己旁边的人来帮助获得答案。 提问:骨盆运动发生在哪里? 鼓励回答。 最重要的回答: 骨盆上方 (腰椎); 骨盆底部 (髋关节)。 说明: 如果轮椅使用者无法以中立位姿势坐,我们需要发现这是否是由于骨盆上方或骨盆底部受限引起的。 B.3.D ——P, P8 : 6 说明:这是一个案例: 该男子是下滑的坐姿并且他的骨盆后倾; 仅从观察我们不能判断该姿势是否是由于骨盆上 方或骨盆下面 (髋关节)受限引起的。这意味着 骨盆和髋关节姿势检查是必要的。 ——P, P8 : 7B.3.D 说明:中级轮椅评定表上这部分的第一个问题是: 骨盆能水平吗? 提问:发现该问题为什么重要? 最重要的回答: 如果某人的骨盆不能水平,这将影响他的 坐姿。 6/3" 80 ——B.3.D P, P8 : 8 说明:检查完骨盆是否可以水平后,轮椅服务人员 需要确认髋关节是否可以屈曲至中立位坐姿。 强调:这项检查不是完整的运动评定。只检查在屈 曲位置的髋关节以发现: 轮椅使用者是否可以在支撑下以中立位姿势坐? 如果不能,他/她能够在多大程度上接近中立位 姿势? ——B.3.D P, P8 : 9 说明:这张幻灯片中线条图显示一侧的髋关节没有 处于中立位坐姿 (显示浅灰色的腿)。 提问:躯干与大腿 (浅灰线)之间的角度大于或小 于90度? 鼓励回答。 • D7L,@90 • D7L,@4 70 B.3.D – P, P8 : 10—— 回答: 小于90度 (大约70度)。 81 ——B.3.D P, P8 : 11 说明:这张幻灯片中线条图显示一侧的髋关节没有 处于中立位坐姿 (显示浅灰色的腿)。 提问:躯干与大腿 (浅灰线)之间的角度大于或小 于90度? 鼓励回答。 • D7L,@90 • D7L,@4 100 . –B.3D ——P, P8 : 12 回答: 大于90度 (大约100度)。 提问:发现髋关节是否可以屈曲至中立位坐姿为什么重要? 鼓励回答。 回答: 如果一侧或两侧髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度),这将影响轮 椅使用者坐直的能力。 髋关节将需要进行调节,以便轮椅使用者可以以骨盆直立的方式坐 (如果这对于他们可能)。 6/3" 82 B.3.D ─ P, P8 : 13—— 如果骨盆不能水平或如果一侧的髋关节不能屈曲 至中立位坐姿 (躯干与大腿之间的角度大于90 度),它将需要在最后的轮椅中支撑于非中立位 坐姿。 为了继续这项检查,需要提供临时支撑用于轮椅 使用者坐在上面。 这将在本单元稍后说明。 VIDEO 介绍DVD:骨盆和髋关节姿势检查。本DVD短片将演示骨盆和髋关节姿势检查。 让学员仔细观看因为他们将在之后相互练习。 播放DVD。 询问是否有任何问题。 小组活动 分组 把学员分成3人一组。 指导 让学员看 《实训手册》(B.3:身体检查———骨盆和髋关节姿势检查:进行检查)。 让学员轮流扮演轮椅使用者、协助人员和轮椅服务人员。练习开展骨盆和髋关节姿势检查。 让学员在 《实训手册》上的中级轮椅评定表 “骨盆和髋关节姿势检查”部分记录对轮椅使 用者的检查结果。 说明:每组学员有20分钟开展这项活动,然后各组将返回进行反馈。 监督 密切地监督各组并确保扮演轮椅服务人员的学员: 正确地站位; 把他们的手正确地放在轮椅使用者的骨盆、髋和四肢上; 在膝关节处弯曲轮椅使用者的大腿 (在膝关节下放一个卷/支撑); 手要 “轻柔”且不要抓或捏轮椅使用者; (用 “开展骨盆和髋关节姿势检查”中的教师提示来确保各组遵循正确的步骤)。 确保各组清楚该活动。 如果必要,引导学员。 83 续表 时间 允许20分钟活动。 允许5分钟反馈。 反馈 询问是否有任何问题。 提问:对于关节没有受限的轮椅使用者,各组如何完成中级轮椅评定表上的 “骨盆和髋关 节姿势检查”部分? (把空白的中级轮椅评定表投影在白板上)。 回答:骨盆水平在 “是”下画勾,左右髋关节可以屈曲至中立位坐姿在 “是”下画勾。 提问:有人还有其他部位受限吗? 如果有,从小组中寻求更多的信息。 教师提示: 教师可以选择是否用量角器或纸板量角器来教评定中的髋关节姿势检查部分。如果学员已经熟悉 量角器的使用,这是最合理的选择。如果学员没有用过量角器,使用有45度间隔角度的纸板量角器就足 够了。 教师提示: 开展骨盆和髋关节姿势检查;当监督以上的小组活动时,确保学员按照以下描述的内容 开展骨盆和髋关节姿势检查。 准备: 向轮椅使用者说明你将要做什么,以及这样做的重要性; 让轮椅使用者躺在检查床上。 请注意开展骨盆和髋关节姿势检查的人称为 “评定者”,协助评定者的人称为 “助手”,他们可以是 同事、经过培训的助手、家人或护理者。 骨盆姿势检查: 评定者稍微屈曲轮椅使用者的双膝并提供支撑, 这有助于减轻对髋关节的拉伸; 助手把双手紧紧地放在轮椅使用者的躯干上,大 约肋骨下部; 评定者轻轻地抓住骨盆,拇指放在髂前上棘上; 评定者检查拇指/髂前上棘是否水平; 如果不是水平的,评定者设法轻柔而稳定的调节 骨盆使两侧髂前上棘水平; 助手报告他/她是否感觉到躯干移动,这意味着 这个动作有些受限; 标记可能使骨盆接近中立位/水平位的程度; 评定者在中级轮椅评定表上记录骨盆能否水平。 6/3" 84 续表 髋关节姿势检查: 助手轻柔而紧紧地按住轮椅使用者的骨盆; 评定者稍微屈曲未检查腿的膝关节,把脚放在垫 子上。这有助于降低受检查髋关节的张力。这条 腿可能需要支撑。 评定者轻柔地活动检查腿至中立位坐姿; 助手报告他/她是否感觉到骨盆活动,如果骨盆 活动,这意味着这个动作有些受限; 评定者感觉髋关节能够活动的自由程度; 评定者重复另一侧并比较; 评定者在中级轮椅评定表上记录左右髋关节是否 都可以屈曲至中立位坐姿。 评定者在助手的帮助下用量角器记录每侧髋关节 能达到中立位姿势的程度; 评定者把量角器的轴心放在大转子处。评定者把 量角器的一边靠在大腿上,另一边与躯干平行; 评定者用力地握住量角器的两条边; 评定者在中级轮椅评定表上记录左右髋关节的角 度测量值。评定者也可以把量角器的角度画在另 外一张纸上或在中级轮椅评定表的背面。 3.为僵硬的不水平 (侧倾)骨盆或不能屈曲至中立位坐姿的髋关节提供 临时支撑 (5分钟) 说明:如果骨盆不能水平或单侧或双侧髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大 于90度),它将在最终的轮椅上被支撑于非中立姿势。为了继续评定,应该为轮椅使用者做一个临时 85 支撑使其坐在上面。 提问:为什么要让轮椅使用者坐在临时支撑上继续进行评定呢? 回答: 在评定过程中,临时支撑将: - 帮助轮椅使用者坐得更稳定和更平衡; - 阻止轮椅使用者补偿不水平的骨盆或补偿不能屈曲至中立位坐姿的髋关节 (躯干与大腿之间 的角度大于90度); - 让轮椅服务人员进行评定并且专注于轮椅使用者姿势的其他部分,包括:骨盆、躯干、头、 颈和腿。 —— • M? - E +6,P,7" (.,"P ,); - E +6 D7L,@ 90 • 55F>ABE +6 A M B.3.D P, P8 : 15 说明:临时支撑用于: 僵硬的不水平骨盆 (侧倾); 不能屈曲至中立位坐姿 (躯干与大腿之间的角度 大于90度)的单侧或双侧髋关节; 不能伸展至中立位坐姿 (躯干与大腿之间的角度 小于90度)的单侧或双侧髋关节。 评定后,这种临时支撑将固定下来并将被加入到轮 椅使用者的坐垫中。 说明: 临时支撑可以由一块硬泡沫塑料制成; 它最好由与坐垫底座相同的材料制成; 通过使用相同的材料,由于材料的压缩比是相同的,材料的确切尺寸可以在评定中确定下来; 因为这个原因,在评定过程中获得一些硬泡沫塑料块和楔形块是有用的; 各种不同厚度的泡沫塑料块 (例如:10mm、20mm、30mm)可以组合成不同整体厚度的块。 展示不同的硬泡沫塑料块和楔形块。 6/3" 86 4.僵硬的不水平骨盆临时支撑的演示 (10分钟) 让一位志愿者到教室前面并坐在检查床上。 演示 说明 让志愿者以僵硬的不 水平骨盆 (侧倾)方 式坐。 对于僵硬的不水平骨盆的轮椅使用者: 一侧的骨盆和大腿比另一侧承担更多的重 量。这会导致压疮风险。轮椅使用者也不 稳定,因为他/她只坐在一侧上。 目标是提升座面以支撑较高的坐骨。 把临时支撑放在志愿 者较高一侧的坐骨下。 确保临时支撑向前伸 以支撑大腿 (正好放 在膝关节后面)。 临时支撑在较高大腿一侧下形成了一个 补高。 临时支撑应该在坐骨和大腿下。支撑并不 改变骨盆的姿势。 现在在升高的坐骨下有支撑并且由于两侧 坐骨下的压力均等,轮椅使用者将感到更 平衡。 把手指放在两侧的坐 骨下 (手掌向上)与 座面 之 间 演 示 测 试 压力。 在支撑好躯干并坐直的前提下,通过把手 指放在每侧的坐骨下 (手掌向上)进行 测试。 感谢志愿者。 87 B.3.D ─ P, P8 : 17 • .,"P, —— 说明: 轮椅服务人员可以评估骨盆和躯干的其余部分; 在最后的轮椅上,这种支撑将被固定在坐垫上。 如果可能,展示一个已经经过改制,支撑僵硬不水 平骨盆的坐垫。 教师提示: 当一个人是僵硬的不水平骨盆,临时支撑是适应这种姿势而不是纠正这种姿势。 在最后的轮椅上,轮椅使用者将仍然是非对称姿势。一侧的骨盆和大腿比另一侧高。这一侧的膝 关节和脚踏板也将比另一侧高。 当为僵硬的不水平骨盆提供临时支撑时: - 确保支撑延伸至整个大腿下部。如果支撑没有延伸至前端,两侧大腿下的压力将不相同,这 会有危险; - 确保有一个坐骨前垫高。这将有助于减少向前滑的趋势,前滑会产生剪切力并导致压疮。 5.不能屈曲或伸展至中立位坐姿的髋关节临时支撑的演示 (30分钟) 说明:现在我们将看到为不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度)的髋关节做 临时支撑。让一位志愿者到教室前面并坐在检查床上。 演示 说明 让志愿者以右髋关节屈曲时, 躯干与大腿之间的角度大于 90度坐。 当坐着时,一侧僵硬的髋关节不能屈 曲至中立位 (躯干与大腿之间的角度 大于90度),骨盆将向一侧倾斜并且 可能向后滚并旋转。 这会导致骨盆和躯干的不良姿势并且 坐骨下不均匀的承重。 6/3" 88 续表 演示 说明 把临时支撑放 在两侧的坐骨 和 左 大 腿 下 (该侧髋关节能 屈曲至中立位 坐姿) 补高放在两侧的坐骨和髋关节能屈曲 至中立位姿势一侧的大腿下。僵硬地 处于超过中立角度的髋关节可以放下 来了。 补高的高度应该足够高以支撑髋关节 受限的角度。 展示右大腿和检查床之间的 三角形间隙。 大腿与检查床之间有一个三角形 间隙。 这应该与髋关节姿势检查记录的角度 一样。 僵硬的髋关节现在适应了并且不会导 致非中立的骨盆姿势。轮椅服务人员 可以评估骨盆和躯干的其余部分。 感谢志愿者。 3 • P87 80 B. .D P, P8 : 18—— 说明: 在最终的轮椅上,该临时支撑将固定在坐垫上提 供永久的支撑。 在坐垫上做一个楔形垫,以支撑在评定过程中发 现的躯干与大腿之间角度大于90度一侧的大腿。 插图展示了如何做楔形垫的一个案例。注意,软 泡沫塑料层应该放在硬泡沫塑料的上面。确保坐 垫没有尖锐边角。 如果可能,展示一个已经改制好的坐垫。 89 教师提示: 学员可能想知道为什么楔形支撑没有作为临时支撑。说明如果轮椅使用者坐在没有经过调整的平 面上,有必要在大腿下切割一个楔形支撑,这侧大腿髋关节的活动范围是有限的。在检查床上切 割当然是不太现实的。因此升高轮椅使用者坐的表面来适应强直的髋关节。 为了节省时间和资源,大腿下有一个间隙,临时支撑将放在坐骨和另一侧大腿下。大腿掉下来在 临时支撑上形成一个角度。在最终的坐垫上大腿下的间隙将被填满并且大腿下将有一个楔形 支撑。 永久性支撑是一个非对称坐垫。这意味着一侧的膝关节和脚踏板比另一侧低。这可能会导致稍微 不稳和剪切力,可以考虑其他体位支撑装置例如骨盆带。这将在本教程的稍后部分介绍。 说明:我们现在思考为双侧髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度)的 轮椅使用者做临时支撑。 提问:当双侧髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度)时,可以使用哪 种临时支撑? 鼓励1~2位志愿者上前来演示。其余的小组成员可以通过提供建议来协助。 确保学员找到正确的答案。 回答: 当双侧髋关节不能屈曲至中立位坐姿 (两侧躯干与大腿之间的角度大于90度)时的临时支撑: 在双侧坐骨下用一个补高以临时支撑髋关节的受限量; 补高的高度应足够高以支撑髋关节受限的角度; 在大腿和检查床之间将有一个三角间隙; 它应该与量角器记录的角度相同; 检查可以继续。 6/3" 90 ——B.3.D P, P8 : 19 • P87 80 说明: 如果双侧髋关节不能屈曲至中立位坐姿 (躯干与 大腿之间的角度大于90度),那么可以由坐骨下 的补高进行临时支撑。 • FE M6L ,@ • 4,E ? B.3.D ─P, P8 : 20 说明:在最终的轮椅上,该支撑将不固定在坐垫上。 通过增加椅座与靠背之间的角度来提供支撑。 提问:永久性支撑为什么不像临时支撑那样固定在 坐垫上? 回答: 轮椅使用者可能向前滑出他们的椅座。这可能使 他们坐在轮椅上困难并产生剪切力,并可能导致 压疮的产生。 提问:如果一侧或双侧的髋关节不能伸展至中立位坐姿 (躯干与大腿之间的角度小于90度),应 该使用哪种临时支撑? 鼓励1~2位志愿者上前来演示。其余的小组成员可以通过提供建议来协助。 确保学员找到正确的答案。 回答: 当单侧或双侧髋关节不能伸展至中立位坐姿 (躯干与大腿之间的角度小于90度)时的临时支撑: 在坐骨前和大腿下提供临时支撑; 一块硬泡沫塑料楔形垫最好; 评定可以继续。 91 B.3.D ─P, P8 : 21 • P8 780 说明: 如果单侧或双侧的髋关节不能伸展至中立位坐姿 (躯干与大腿之间的角度小于90度),在坐骨前 和大腿下提供临时支撑; 如果可能,可以用一块硬泡沫塑料楔形垫; 如果不行,最好用一块长方形的硬泡沫塑料作为 临时支撑。 说明: 幻灯片中的插图展示楔形垫固定在轮椅上的坐垫 是怎么样的。 如果有的话,展示一个已经改制好的坐垫。 教师提示: 学员可能想知道,如果只有一侧髋关节受限,为什么在两侧大腿下提供支撑。 答案: 坐垫在双侧大腿下通常呈楔形,因为这有助于轮椅使用者保持平衡。 然而,在有些情况下,最好只在受限的大腿下放楔形垫,例如,如果楔形垫让轮椅使用者转移 困难。 VIDEO 介绍DVD:临时支撑。本短片介绍理查德。理查德的骨盆是水平的;然而他双侧 的髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度)。在DVD中 你将看到轮椅服务人员如何与理查德一起开展骨盆和髋关节姿势检查;然后如何 提供临时支撑。 播放DVD。 询问是否有任何问题。 6/3" 92 6.练习临时支撑 (30分钟) 小组活动 分组 把学员分成2~3人一组。 指导 让学员阅读 《实训手册》上的每个轮椅使用者故事。(B.3:身体检查———骨盆和髋关节姿 势检查:练习临时支撑)。 说明:对于每位轮椅使用者,学员将需要决定轮椅使用者的骨盆是否可以水平以及髋关节 是否可以屈曲至中立位坐姿。 让学员完成中级轮椅评定表上的 “骨盆和髋关节姿势检查”部分并决定轮椅使用者是否需 要临时支撑。 让学员安装临时支撑以适应每位轮椅使用者。 让学员检查每个临时支撑。 每位学员应该坐在临时支撑上体会是什么感觉。 说明:每组学员有20分钟开展这项活动,然后各组将返回原位进行反馈。 监督 密切地监督各组。 确保每组明白活动。 如果必要,指导学员。 确保学员正确地安装临时支撑。 时间 允许20分钟开展活动。 允许10分钟反馈。 反馈 让一组描述为萨姆安装的临时支撑; 让另一组描述为玛莎安装的临时支撑; 让另一组描述为赛恩安装的临时支撑; 让另一组描述为乔安装的临时支撑; 询问是否有任何问题。 93 萨姆 骨盆和髋关节姿势检查 萨姆4岁,他患有脑瘫并且无法独立地坐直。通过 骨盆和髋关节姿势检查你会发现: 萨姆的骨盆可以水平 (两侧ASIS水平); 萨姆的左髋关节可以舒适地屈曲至中立位坐姿。 萨姆的右髋关节疼痛,不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度)。躯干与大 腿之间的角度大约是105度。 当卧位时检查骨盆是否水平和髋关节屈曲范围: 骨盆是否可以水平? 是√ 否□ 髋关节是否可以屈曲至中立位坐姿? 左髋关节:是√否□ 角度:90度 右髋关节:是□ 否√ 角度:105度 如果骨盆不能水平或髋关节不能屈曲至中立位 坐姿,用临时支撑来适应。 萨姆是否需要临时支撑? 是√ 否 □ 支撑正好放在双侧的坐骨和左大腿下。右大腿下没有支撑,它放下来时有一个角度。 玛莎 骨盆和髋关节姿势检查 玛萨57岁,她有严重的关节炎。她能走几步,然而 走起来很疼。通过骨盆和髋关节姿势检查你会发现: 玛萨的骨盆可以水平 (两侧ASIS水平); 玛萨两侧的髋关节不能屈曲至中立位坐姿 (躯 干与大腿之间的角度大于90度)。两侧躯干与 大腿之间的角度大约是100度。 当卧位时检查骨盆是否水平和髋关节屈曲范围: 骨盆是否可以水平? 是√ 否□ 髋关节是否可以屈曲至中立位坐姿? 左髋关节:是□ 否√ 角度:100度 右髋关节:是□ 否√ 角度:100度 如果骨盆不能水平或髋关节不能屈曲至中立位 坐姿,用临时支撑来适应。 玛萨是否需要临时支撑? 是√ 否 □ 支撑正好放在双侧的坐骨下。双侧大腿下没有支撑,双侧大腿放下来时有一个角度。 赛恩 骨盆和髋关节姿势检查 赛恩16岁。她小时候得了小儿麻痹症,现在双腿 严重挛缩。赛恩通过盘腿坐的方式四处移动并且在 地面挪动。通过骨盆和髋关节姿势检查你会发现: 赛恩的骨盆不能水平。右侧骨盆比左侧骨盆 高20mm; 赛恩的两侧髋关节可以屈曲至中立位坐姿。 当卧位时检查骨盆是否水平和髋关节屈曲范围: 骨盆是否可以水平? 是□ 否√ 髋关节是否可以屈曲至中立位坐姿? 左髋关节:是√ 否□ 角度:90度 右髋关节:是√ 否□ 角度:90度 如果骨盆不能水平或髋关节不能屈曲至中立位 坐姿,用临时支撑来适应。 6/3" 94 续表 赛恩是否需要临时支撑? 是√ 否 □ 支撑正好放在右侧骨盆和大腿下。 乔 骨盆和髋关节姿势检查 乔25岁。他小时候得了小儿麻痹症,现在双腿有严重 的挛缩。通过骨盆和髋关节姿势检查,你会发现: 乔的骨盆可以水平 (两侧ASIS水平); 乔右侧的髋关节可以舒适地屈曲至中立位坐姿。然 而他的左髋关节不能伸展至中立位 (躯干与大腿之 间的角度小于90度)。躯干与大腿之间的角度是 70度。 检查当卧位时骨盆是否水平和髋关节屈曲 范围: 骨盆是否可以水平? 是√ 否□ 髋关节是否可以屈曲至中立位坐姿? 左髋关节:是□ 否√ 角度:70度 右髋关节:是√ 否□ 角度:90度 如果骨盆不能水平或髋关节不能屈曲至中 立位坐姿,用临时支撑来适应。 乔是否需要临时支撑? 是√ 否 □ 楔形支撑放在乔的坐骨前面和双侧大腿下面。楔形垫的角度应该接近70度 (如果乔愿意,或者如果 两侧大腿下的楔形垫影响乔的转移,楔形垫放在左大腿下面也是可以的)。 7.要点概括 (3分钟) • P, P8 E0E
) - E +6,P,
" - E +6,P8
80 • 7 55AP,P8 - .,"P,——EQ, P 7 - ., # 80,P8—— P #)0,7 - P8 # 80—— P - P8 #80—— P B.3.D ——P, P8 : 23 讲出要点。 询问是否有任何问题。 95 B.4:身体检查———用手模拟 目标 本单元结束后,学员将能够: □ 描述如何用他们的双手 (用手模拟)来发现: 轮椅使用者是否可以在支撑下以中立位坐姿坐; 如果不能,轮椅使用者如何尽可能舒适地接近中立位坐; 需要哪种支撑以及在哪里。 □ 在中级轮椅评定表上记录用手模拟的结果。 资源 本单元: □ 幻灯片:B.4:身体检查———用手模拟; □ 《学员手册》; □ DVD:用手模拟演示———迪帕克; □ DVD:用手模拟演示———恩尼斯; □ DVD:用手模拟演示———巴哈迪; □ 中级轮椅评定表。 情境 和以 前学 过的 内容 根据学员将工作的情景修改本单元。思考: □ 用做临时支撑垫的材料应该与轮椅使用者最终轮椅上的坐垫底座的材料相同。这将带来 更加真实的效果。 准备 □ 收集资源,检查幻灯片,观看DVD和浏览单元计划。 □ 仔细地检查中级轮椅评定表并练习开展用手模拟。 大纲 1.前言 2.如何开展用手模拟 3.记录用手模拟的结果 4.要点概括 5 15 35 5 总单元时间 60 6/3" 96 1.前言 (5分钟) • D , G –+ • + E0E +,
) - E +6 0 - 7/78F F0 - M? / !P A D + B.4. D ——+ : 2 说明: 本单元,我们将学习如何完成身体检查的另一个 内容,称为 “用手模拟”。 在用手模拟过程中,轮椅服务人员用他们的双手 来了解: - 轮椅使用者可以在支撑下以中立位姿势坐吗? - 如果不能,他/她如何能够舒适地接近中立位 姿势坐? - 需要什么支撑以及在哪里支撑。 在用手模拟的过程中,轮椅服务人员与轮椅使用者 以及协助者或家人/护理者共同用双手提供支撑。 B.4.D ——+ : 3 + + 0/ 78F F0 !DG + )0 + + DG F4 ++E +6, F4 +) ,P, D P8
P8 7 78
78 D8
D8 说明: 这是中级轮椅评定表的部分内容,用于记录用手 模拟的结果。 我们将在本单元的稍后部分更多地学习记录用手 模拟的结果。 2.如何开展用手模拟 (15分钟) VIDEO 介绍DVD:用手模拟演示———迪帕克。现在我们将观看轮椅服务人员为一位叫迪 帕克的年轻男子开展用手模拟。迪帕克没有坐直。让学员仔细地观看评估者和协 助者如何做。 播放DVD。 询问是否有任何问题。 97 说明: 重要的是仔细地思考你的双手在做什么。你双手提供的支撑稍后将由轮椅和PSDs来提供。 • , • G/,
• ,G/ • , ?-,M0 B.4.D ——+ : 5 在用手模拟过程中,特别注意: - 你双手放的地方; - 力量/支撑的方向; - 用多大的力量/支撑; - 你的双手覆盖的面积多大 (例如,你只用一 根手指或一整只手); 这些信息有助于你开具最终的轮椅和PSDs处方。 向学员提问:刚刚播放的DVD中,轮椅服务人员首先支撑迪帕克的哪部分身体? 鼓励回答。 回答: 骨盆。 • OP, B.4.D ─+ : 6 说明: 应该首先支撑骨盆。这是因为骨盆的姿势将影响 身体的其他部位。 如果轮椅使用者的骨盆不在中立位,用你的双手 使骨盆接近中立位。 6/3" 98 • P,> 'N - D/7 - N - P8 7 - 7 • B!! NB • ?D G,B G B.4.D ——+ : 7 当骨盆得到支撑后,关注身体其他部位的顺 序是: - 躯干/手臂; - 头和颈; - 髋关节和大腿; - 小腿。 应该每次只做一项调整。例如,不要尝试在调整骨盆的同时调整躯干。 由协助者参与,他可以是家人/护理者。 观察身体某个部位的调整如何影响其他部位。 询问轮椅使用者的反馈。 从侧面观察骨盆和躯干的轮廓。重要的是设计靠背的形状以提供最佳支撑。 3.记录用手模拟的结果 (35分钟) —— + + 0/ 78F F0 !DG + )0 + + DG F4 ++E +6, F4 +) ,P, D P8
P8 7 78
78 D8
D8 + 说明:用手模拟的结果记录在中级轮椅评定表上。 表上的空白: 勾选记录在用手支撑下,轮椅使用者的每个身体 部位是否能够达到中立位坐姿; 描述或线条画出轮椅使用者在用手支撑下实现的 最后坐姿; 描述或线条画出轮椅使用者实现这种坐姿提供的 支撑。 99 VIDEO 介绍DVD:用手模拟演示———恩尼斯。现在我们将观看另一个用手模拟。 说明: 现在我们将看到恩尼斯的更多情况。在录像剪辑中,恩尼斯与她妈妈一起来接 受评定。在面谈评估过程中,恩尼斯和她妈妈告知恩尼斯的右髋关节脱臼,并 且很疼。任何运动都疼。 轮椅服务人员观察恩尼斯没有支撑无法坐直。她坐着的时候骨盆后倾,躯干向 前弯,她的双腿 “风吹样”偏向左。 进行骨盆和髋关节姿势检查。发现恩尼斯的骨盆是水平的并且她双侧的髋关节 可以屈曲至中立位坐姿。然而,她的右髋关节内收 (风吹样到中线)并且这种 姿势是僵硬的 (不能被纠正)。 仔细地观察,随后我们将讨论轮椅服务人员通过用手模拟发现的更多信息。 播放DVD。 询问是否有任何问题。 提问:恩尼斯的起始姿势是怎样的? 回答: 僵硬的骨盆后倾; 骨盆不水平,右侧稍高; 躯干前屈/下滑/倾倒; 双肩水平 (恩尼斯的妈妈握住恩尼斯的肩膀来支撑她。如果她妈妈放手,恩尼斯的姿势可能改 变); 右髋关节内收 (风吹样偏向左); 右大腿比左大腿短。 提问:轮椅服务人员首先、其次、第三和第四支撑哪里 (恩尼斯身体的哪部分)? 回答: 首先:支撑骨盆后面; 其次:支撑躯干后面; 第三:支撑躯干的两侧; 第四:支撑手臂。 6/3" 100 B.4.D ——+ : 10 + + 0/ 78F F0 !DG + )0 + + DG F4 ++E +6, F4 +) ,P, D P8
P8 7 78
78 D8
D8 投影这张幻灯片到白板上 (如果有)。 说明:我们将为恩尼斯完成中级轮椅评定表上的用 手模拟部分内容。 提问:在手支撑下恩尼斯 (身体的每个部位)是否 能够达到中立位坐姿。 由于已经给出了正确答案,在 “是”下画勾。 提问:我们如何描述恩尼斯的最后姿势? 在白板上中级轮椅评定表的空白处写下/描述恩尼斯的姿势。 如果没有白板,当教师在板上说明/画的时候,让学员在他们的练习本上画。 教师提示: 对于这个练习,你也可以邀请学员上前来并把恩尼斯的最终姿势画在白板上。 回答: 用手模拟:用手支撑坐在中立位/尽可能舒适地接近中立位。 对于每个身体部位:借助手支撑,如果能实现中立位坐姿,勾 “是”,如果不能,勾 “否”。 部位 是 否 骨盆 □ √ 躯干 □ √ 头 √ □ 左髋 √ □ 右髋 √ □ 大腿 □ √ 左膝 √ □ 右膝 √ □ 左踝 √ □ 右踝 √ □ 描述或线条绘画由手支撑实现的轮椅使用者的最终坐姿以及 描述或线条绘画实现坐姿所提供的支撑。 姿势: 骨盆后倾; 躯干与大腿之间的角度大于90度; 躯干下部平直 (无腰椎曲线)和倾斜 (不直立); 躯干上部直立; 头直立 (用手支撑); 右腿向中线内收 (风吹); 注意:恩尼斯的右大腿比左大腿短。 提供的支撑: 稳固地支撑在恩尼斯骨盆的后部; 支撑在恩尼斯躯干后部; 在躯干侧面轻度支撑; 提供手臂支撑 (恩尼斯的手臂在她的前面)。 101 教师提示: 学员可能会问是否应该为恩尼斯的右大腿提供支撑,以便把它放在中立位姿势。评定过程中恩尼斯 髋关节疼痛的信息 (任何运动或矫正)表明只需要提供很轻微的支撑 (如果有)。 VIDEO 介绍DVD:用手模拟演示———巴哈迪。现在我们将观看另一个用手模拟的案例。 说明: 巴哈迪在当地一所大学学习管理。 她的旧轮椅已经用坏了,不能给她提供良好的体位支撑。 在面谈评估过程中,巴哈迪告知她在自己的轮椅上坐一天后感到非常疲惫。她 想要一辆能够帮助她长时间坐得更加舒适的轮椅,这将有助于让她不那么累,更 能够学习。 仔细观看,随后我们将讨论轮椅服务人员通过用手模拟发现了什么。 播放DVD。 询问是否有任何问题。 提问:巴哈迪的起始姿势是怎样的? 回答: 下滑的坐姿; 骨盆后倾; 躯干弯曲; 随着双腿转向左侧,右髋关节屈曲大于中立位坐姿; 随着双腿转向左侧,左髋关节屈曲小于中立位坐姿。 提问:轮椅服务人员首先、其次和第三在哪里提供支撑 (巴哈迪身体的哪部分)? 回答: 1:支撑骨盆后面; 2:支撑腰部后面; 3:支撑手臂。 6/3" 102 B.4.D ——+ : 12 + + 0/ 78F F0 !DG + )0 + + DG F4 ++E +6, F4 +) ,P, D P8
P8 7 78
78 D8
D8 投影这张幻灯片在白板上 (如果有)。 说明:与恩尼斯一样,我们将为巴哈迪一起完成中 级轮椅评定表上的用手模拟部分。 提问:在手支撑下巴哈迪 (每个身体部位)是否能 够实现中立位坐姿。 由于已经给出了正确答案,在 “是”下画勾。 提问:我们如何描述巴哈迪的最后姿势? 在白板上中级轮椅评定表的正确空白处写/画描述巴哈迪的姿势。 提问:有人对于完成中级轮椅评定表的这部分有任何问题吗? 回答任何问题。 如果没有白板,当教师在板上说明/画的时候,让学员在他们的练习本上画。 教师提示: 对于这个练习,你也可以邀请学员上前来并把巴哈迪的最终姿势画在白板上。 回答: 用手模拟:用手支撑坐在中立位/尽可能舒适地接近中立位。 对于每个身体部位:借助手支撑,如果能实现中立位坐姿,勾 “是”,如果不能,勾 “否”。 部位 是 否 骨盆 √ □ 躯干 √ □ 头 √ □ 左髋 √ □ 右髋 √ □ 大腿 √ □ 左膝 √ □ 右膝 √ □ 左踝 √ □ 右踝 √ □ 描述或线条绘画由手支撑实现的轮椅使用者的最终坐姿以及描 述或线条绘画实现坐姿所提供的支撑。 姿势: 骨盆直立并水平; 躯干直立; 提供的支撑: 在骨盆后部稳定的支撑; 支撑腰部; 支撑手臂有助于巴哈迪维持稳定的上部躯干。 103 教师提示: 巴哈迪的骨盆后部和腰部需要稳定的支撑以维持直立的坐姿。她的上部躯干不完全稳定, 向前。在手臂的支撑下,她的腰部稳定。 4.要点概括 (5分钟) • + ,E0E +, ) - E +6 0 - 7/78F F0 - M? / • OP,' D/7 N P8 77 • 7. A+ ,5 B 4,E PSDs B.4.D ——+ : 13 讲出要点。 询问是否有任何问题。 B.5:身体检查———进行测量 目标 本单元结束后,学员将能够: □ 说明进行测量的目的; □ 演示所选择的测量方法,用于选择PSDs的正确尺寸和位置; □ 演示进行测量; □ 用中级轮椅评定表记录身体测量值。 资源 本单元: □ 幻灯片:B.5:身体检查———进行测量; □ 《学员手册》; □ 《实训手册》; □ 中级轮椅评定表; □ 卷尺 (或如果有,常用的游标卡尺),每组1把; □ 检查床,每组1张。 6/3" 104 续表 情境 和以 前学 过的 内容 以前学过的内容: □ “如何进行身体测量”已经在轮椅服务初级教程中学习了 (臀宽、臀后到腘窝、腘窝到 足底、座面到胸腔下缘和肩胛下角) 根据学员将工作的情境修改本单元。思考: □ 当在志愿者身上演示测量和让学员相互练习测量时,注意由于身体接触引起的文化 问题。 准备 □ 收集资源,检查幻灯片并浏览单元计划。 □ 仔细地检查中级轮椅评定表并练习进行测量。 □ 在教室前面布置好检查床。 □ 布置好教室让学员面向教室前面坐成半圆形。 □ 把检查床放在教室四周 (或教室外面/临近的房间),准备让学员用于练习测量。 大纲 1.前言 2.测量轮椅使用者以选择正确的轮椅尺寸和PSDs的位置 3.练习测量 4.要点概括 2 25 30 3 总单元时间 60 1.前言 (2分钟) • E +6F >D#GF F,E >5 (PSDs) !P A D F>#H B.5. D ——F>#G: 2 说明:本单元,我们将学习如何对轮椅使用者进行 身体测量以选择最合适的轮椅尺寸和体位支撑装置 (PSDs)。 105 2.测量轮椅使用者以选择正确的轮椅尺寸和PSDs的位置 (25分钟) 教师提示: 这里介绍的前5种测量方法已经在 《轮椅服务初级教程》中讲过了。学员应该能够自信 和准确地进行这些测量。如果不能,教师应该为那些不能自信和准确地进行测量的学员讲授 《轮椅 服务初级教程》“身体检查”单元,并重点强调 “如何进行身体测量”部分。 让学员看他们中级轮椅评定表上的 “进行测量”部分。 B.5.D ─F>#G: 3 UNNUF"F DFUNNU"C P, L,D/ E., Q7>6 M6Q ' M775 N1M6N1,D/ E +,M"#G'() ( M67@ ) M65 36'V * D D L,D/ + M770 + PP N1D L, D/ + F>B
, MP,N1P N1P, L,D/ - 78L,D/ 7L L, . MN,D/ N1ML,D/ / P, G P /PP M6 P Q& L,D/ F>#G M P,M F>#G $ 7D Q 说明: 在中级轮椅评定表上列出了12个身体部位的 测量。 5个测量与之前在 《轮椅服务初级教程》中介绍 的是一样的。 靠背高度测量增加到中级轮椅评定表中。是指座面到肩峰的身体测量,它用于测量需要高靠背 的轮椅使用者。 还有其余6个测量,它们将有助于决定PSDs的尺寸和位置。 可能还需要进行更多的测量,这取决于PSDs处方。 中级轮椅评定表上空白处用于记录其他部位的测量。 B.5.D ——F>#G: 4 • D#GE PSDs- 说明:中极轮椅评定表中的插图显示了身体测量如 何与轮椅/PSDs相关。 提问:例如,如何测量G:与轮椅相关的躯干宽度 (这将有助于找到哪个轮椅部件?)鼓励回答。 回答: 躯干侧垫或楔形垫之间的距离。 6/3" 106 —— UNNUF"F DFUNNU"C P, L,D/ E., Q7>6 M6Q ' M775 N1M6N1,D/ E +,M"#G'() ( M67@ ) M65 36'V * D D L,D/ + M770 + PP N1D L, D/ + F>B
, MP,N1P N1P, L,D/ - 78L,D/ 7L L, . MN,D/ N1ML,D/ / P, G P /PP M6 P Q& L,D/ F>#G M P,M F>#G $ 7D Q 指出中级轮椅评定表上的 “进行测量”部分: 身体测量列在左侧,以及与身体测量相关的轮椅 部件测量列在右侧。 一些案例中有公式用于计算轮椅部件的尺寸。例如,坐深 (臀后到腘窝)减去30mm~50mm 等于轮椅的座深。 说明: 对于一些用公式来帮助计算轮椅部件尺寸的身体测量,当进行身体测量时,计算出理想的轮椅 部件尺寸是有用的。 这将有助于后面准备轮椅使用者的处方。 这些身体测量是: - B (臀后到腘窝); - H (座面到腋下); - L (骨盆后面到坐骨)。 让一位志愿者到教室前面来并坐在检查床上。 简要地演示如何进行每项测量,用下面的教师提示来做指导。确保所有的学员都可以看清楚。 教师提示: 确保强调以下要点: 当进行身体测量时,座面是坐骨坐的表面。 测量时轮椅使用者应该坐直,以及在用手模拟过程中他们处于最直立、舒适和功能性的体位。 当测量坐直困难的人士时,可能需要一位协助者。 对于所有的纵向测量 (C、D、E、F、H、I、K),对应部件的位置将受椅座和坐垫高度调整的影响。 所有轮椅部件的确切位置应该在适配过程中检查。 107 如何测量 轮椅部件 备注 A:臀宽 椅座 (宽度) 测量前检查轮椅使用者的口袋,里面不 要放东西。测量轮椅使用者的臀部或大 腿最宽的部位。 拿两块硬板紧贴轮椅使用者两侧有助于 获得准确的测量值。也可以使用卡尺。 臀宽等于座宽或骨盆侧垫 之间的距离。 如果有骨盆侧垫,轮椅座宽可 能需要加宽。 应该设法保持轮椅座宽在最小。 在气候寒冷穿厚衣服的国家, 可能需要一些预留量。 B:臀后到腘窝 椅座 (深度) 放一块硬板在轮椅使用者的后背有助于 获得准确的测量值。测量从轮椅使用者 骨盆后部到他/她腘窝的直线距离。 应该测量双腿。 如果两侧的测量值不同,检查轮椅使用 者是否骨盆水平坐直。如果仍然不同, 按照短边开具轮椅处方。 臀后到腘窝的距离减去 30mm~50mm 等于轮椅 椅座的深度。 对于膝关节屈曲远远小于90度 的轮椅使用者,座深可能需要 稍短些。 参见 《学员手册》第65页 “僵 硬骨盆后倾或僵硬躯干前屈的 轮椅使用者”框图。 C:腘窝到足底 脚踏板 (高度) 测量轮椅使用者腘窝到他/她脚后跟底 部的距离。确保轮椅使用者的脚踝屈曲 90度 (如果可能)。 应该测量两条腿。如果轮椅使用者穿 鞋,穿他/她平时经常穿的鞋子测量。 如果脚固定在跖屈 (向下),测量到脚 尖的距离。 该长度等于座面顶端到脚 踏板的高度或座面顶端到 地面的高度 (如果轮椅使 用者用脚推轮椅)。 脚踏板的确切位置将取决于当 轮椅使用者坐在轮椅上时坐垫 被压缩多少而稍稍变化。 在适配时应该需要进行最终的 调整。 6/3" 108 续表 如何测量 轮椅部件 备注 D、E和F 靠背 (高度) D:座面到胸腔下缘: 测量轮椅使用者座面到胸腔下缘的 距离。 为了帮助找到胸腔下缘,把双手放在骨 盆两侧。双手轻轻地向内挤压并向上滑 动。胸腔下缘恰好在腰部的正上方。 E:座面到肩胛下角: 测量轮椅使用者座面到肩胛下角的垂直 距离。 为了帮助找到肩胛下角,让轮椅使用者 耸耸肩。 F:座面到肩峰 测量轮椅使用者座面到肩峰的距离。 测量D、E和F有助于确 定靠背的高度。 高度取决于轮椅使用者的 需求。 从评定获得的信息将有助 于轮椅服务人员决定,需 要多高的靠背才能为轮椅 使用者提供正确的支撑。 如果需要靠背后倾或整体后倾, 靠背高度必须至少是标准的 (至轮椅使用者的肩胛下角); 如果轮椅使用者自己推轮椅, 记得考虑。如果是这样,他们 需要自由地活动肩胛骨。 G:躯干宽度 躯干侧垫或楔形垫 (间距) 测量轮椅使用者腋下 (腋窝)的躯干 宽度。 躯干宽度是躯干侧垫或楔 形垫之间的距离。 如果躯干侧垫或楔形垫放置的 位置比腋下低,它们的最终位 置在适配时可能需要调整。 H:座面到腋下 (腋窝) 躯干侧垫或楔形块 (高度) 测量座面到腋下 (腋窝)的距离。 座面到腋下的测量值减去 30mm是座面顶端和躯干 侧垫/楔形垫顶端之间的 最大距离。 该测量值是一个指导。最终的 高度取决于评定和适配。 躯干侧垫不应该太高而对腋下 (腋窝)施加压力。这可能会不 舒适并导致永久神经损害。躯 干侧垫顶端与腋窝之间应该有 至少30mm的间隙。 参见 《学员手册》第67页 “为 脊柱侧弯的轮椅使用者测量躯 干侧支撑”框图。 109 续表 如何测量 轮椅部件 备注 I:座面到髂嵴 (PSIS)。 骨盆后垫 (中间高度) 测量座面到髂嵴 (PSIS)的距离。 座面到髂嵴 (PSIS)的 测量用于找到骨盆后垫中 间高度的位置。 骨盆后垫的厚度取决于评定的 结果。 J:两膝间距离 膝分隔垫 在两膝放置于接近中立位且对轮椅使用 者来说是舒适的情况下,测量两膝间 距离。 两膝间的距离等于膝分隔 垫的宽度。 距离将取决于轮椅使用者 的坐姿。 K:座面到颅底 头靠 (高度) 测量座面到颅底的距离。 测量座面到颅底的距离有 助于定位头靠的位置。 I:骨盆后到坐骨 坐骨前垫高 测量从骨盆后到坐骨的距离。 从轮椅使用者侧面将你的手 (手掌向 上)放在轮椅使用者的臀下面寻找坐 骨。用一根手指定位坐骨,然后收回你 的手到轮椅使用者的侧面。测量轮椅使 用者骨盆后部到定位在坐骨的手指之间 的距离。 轮椅服务人员可以用某种方式 (例如用 一支粉笔)在与轮椅使用者坐骨旁边平 行的位置在检查床上做记号,然后测量 从标记点到骨盆后的距离。 骨盆后到坐骨的距离加 20mm~40mm 是靠背支 撑到坐骨前垫高起点的 距离。 如果轮椅使用者的骨盆僵硬后 倾或躯干僵硬前屈,测量值可 能会不同 (见 《学员手册》第 65页上的 “僵硬骨盆后倾或僵 硬躯 干 前 屈 的 轮 椅 使 用 者” 框图。) 感谢志愿者。 6/3" 110 提问:如果学员试图测量一位沮丧或扭来扭去的儿童,他们应该怎么办? 回答: 如果可能,花些时间来解决好儿童; 让儿童休息一下,他/她休息了一会儿/吃或喝点儿东西再开始; 让家人/护理者来帮助支撑儿童,让他们感觉安全; 对于一些幼儿,可以让他们家人/护理者抱着进行测量。然而,轮椅服务人员必须非常小心,让 儿童处于与用手模拟中找到的同样的最终姿势。 3.练习测量 (30分钟) 小组活动 分组 所有学员分成3组。 指导 让学员阅读 《实训手册》上马达维的故事 (B.5:身体检查———进行测量)。每组分配一个 卷尺 (如果有且常用,则用游标卡尺)。 说明学员需要: 读一遍为马达维完成的用手模拟结果。 为了帮马达维选择一辆轮椅,决定他们需要进行哪些身体测量。 为本组的至少一位学员进行所有的测量并把结果记录在 《实训手册》上中级评定表 “进 行测量”部分。 说明: 马达维的骨盆轻度僵硬后倾。学员需要思考他们如何为马达维进行正确的座深测量。 马达维要求一个桌面板,因此为她准备桌面板,学员也需要思考他们需要进行哪些 测量。 说明:学员有20分钟来完成这个活动,然后各组将返回进行反馈。 111 续表 监督 密切地监督各组。 确保每组了解活动。 在必要时纠正测量技术。 如果必要,指导学员。 教师提示:学员应专注于想出他们认为需要哪些测量。本阶段,他们不需要对不同的体位 支撑方法想得太深入,因为这将在下一单元学习。 时间 允许活动20分钟。 允许反馈10分钟。 反馈 提问:学员认为需要进行哪些测量? 回答:测量A、B、C、F、G、H、I、J、L 提问:学员如何确保他们进行正确的座深测量? 鼓励回答并允许简短地讨论。播放幻灯片 以厘清要点。 B.5.D ——F>#G: 6 说明:如果轮椅使用者的骨盆僵硬后倾或躯干僵 硬前屈,轮椅服务人员需要思考如何在轮椅中调 适。这可能要改变座深测量的方法: 如果靠背倾斜来适应骨盆/躯干,测量从骨盆 后到腘窝的直线距离。 如果靠背不能后倾,座深空间内将提供支撑以 适应骨盆/躯干。正如幻灯片中显示的,从身 体 (躯干/骨盆)最远端测量以确保允许足够 的座深。 6/3" 112 续表 反馈 提问:学员需要进行哪些测量以描述马达维桌板的高度和尺寸/形状? 鼓励回答,并允许简 短地讨论。播放幻片灯以厘清要点。 B.5.D ——F>#G: 7 说明: 为了决定桌面板的理想高度,测量肘的高度: 当肘屈曲90度以及肩放松时,椅座顶部到肘 的高度; 根据用手模拟中找到的需要支撑 (例如一些人 可能从稍微高些的桌面板获益,以提供更多的 前臂支撑)。 为了决定桌面板离马达维的躯干多近: 测量马达维躯干的深度 (从后到前)。 如果桌面板围绕马达维的躯干 (如幻灯片中图 示): 测量她躯干的宽度 (已经是轮椅评定表的一部 分)。 4.要点概括 (3分钟) • 4E A>12ND#G • +,#G F!.,E PSDs,5 • ,PSDs 7 ?F>#G • B #GE +6 78F F0 !+ ., • PSDs ,.5B FGF> B.5.D ——F>#G: 8 讲出要点。 询问是否有任何问题。 113 B.6:选择轮椅和坐垫 目标 本单元结束后,学员将能够: □ 描述当地可得到的轮椅和坐垫的特点和可调节性; □ 列出可以提供附加体位支撑的标准轮椅的有用特点。 资源 本单元: □ 幻灯片:B.6:选择轮椅和坐垫; □ 《学员手册》; □ 《实训手册》; □ 中级轮椅处方 (选择)表; □ 当地可得到的轮椅和坐垫,每种一个; □ 由供应商提供轮椅的文字资料 (例如轮椅小册子/产品说明书); □ 当地可得到每辆轮椅已填好和空白的 《中级轮椅参数表》。 情境 和以 前学 过的 内容 以前学过的内容: □ 初级轮椅处方 (选择)的相关工作知识对于学员开展本单元非常重要。参考 《轮椅服务 初级教程》之 《学员手册》“步骤3:处方 (选择)”,建议没有参加过轮椅服务初级教 程培训的学员提前阅读。 根据学员将工作的情境修改本单元。思考: □ 学员工作环境可得到的轮椅和坐垫。 □ 为学员准备中级轮椅处方 (选择)的样表,该样表包含他们当地服务机构/地区可得到 的轮椅和坐垫选项。 准备 □ 收集资源,检查幻灯片并浏览单元计划。 □ 为当地可得到的每辆轮椅完成中级轮椅参数表。教师应当熟悉每个产品。他们应该知道 轮椅的尺寸、可调范围、特点和选项或可获得的PSDs。 □ 当地可得到的轮椅和坐垫布置在教室的不同地方。确保它们处于良好的工作状态。把供 应商提供的轮椅资料放在轮椅上 (如果有)。为每辆轮椅做标记 (例如,轮椅1、2、3、 4)。 大纲 1.前言 2.轮椅和坐垫的类型 3.要点概括 8 50 2 总单元时间 60 6/3" 114 1.前言 (8分钟) !P F • (F) : - ,E E +6M"L 7, G B.6. FE : 2 说明: 处方 (选择)是提供轮椅服务的第3步。 处方是指在可得到的轮椅和轮椅使用者需求之间尽 可能选出最佳匹配。 让学员看他们的中级轮椅处方表。 !P 3: (F) • - M?L7 -,E +6FE - N ,E .!G' , (& B.6.FE : 3 说明: 本单元我们将学习为需要附加体位支撑才能坐直 的轮椅使用者选择轮椅和坐垫。 我们也将回顾当地可得到的轮椅,确保每个人都 熟悉它们的不同特点。 @4 @4 说明: 处方包括: 选择最适合轮椅使用者的轮椅类型和尺寸; 描述该轮椅的所有特殊设置。 提问:在中级轮椅处方表上的这部分应该记录些 什么? 回答: 后轮位置 (安全/灵活); 后倾。 说明:这里没有位置用于记录PSDs的细节,它会 放在后面的表格中。 115 B.6.FE : 5 3. ,2 ,2 说明: 处方也包括: 选择坐垫的类型和尺寸。 说明:如果坐垫需要修改以制作正确的 PSDs, PSDs的细节描述在后面的 《中级轮椅处方表》上。 B.6.FE : 6 说明: 处方也包括: 选择需要哪些PSDs或改制以提供轮椅使用者需 要的附加体位支撑。 说明: 这个幻灯片只显示了中级轮椅处方表的一部分。 我们将在下一单元详细地介绍如何完成表格的这 部分以及将在实操单元练习完成它。 说明: 《轮椅服务初级教程》教轮椅服务人员如何为不需要附加体位支撑能够坐直的轮椅使用者选择 最适合的轮椅和坐垫。选择适合的轮椅是基于轮椅使用者的身体、生活方式和环境需求。 在中级教程中,轮椅服务人员需要考虑更大的体位支撑需求。 同时,轮椅使用者的生活方式和环境需求也必须要考虑。 提问:“生活方式和环境”需求的例子是什么? 6/3" 116 回答: 轮椅使用者在哪里使用他们的轮椅 (例如,家里、户外、粗糙地面); 轮椅使用者每天出行的距离; 轮椅使用者在轮椅上多长时间; 他/她如何转移; 轮椅使用者使用的厕所类型; 他/她是否需要经常使用公共交通工具; 轮椅使用者最想在他们的轮椅上开展哪些活动。 +61 _____________ A1 _____________ A4K1 _____________ 记住: 处方通常是在与轮椅使用者充分沟通的情况下决 定的; 本教程中使用的中级轮椅处方表上,需要签3 个名; 包括轮椅使用者、评定人 (轮椅服务人员)和评 定组长。 2.轮椅和坐垫的类型 (50分钟) 说明:我们将看到当地可得到的不同轮椅。为了开具轮椅处方,轮椅服务人员需要知道轮椅的以 下信息: E ,2
, 9
+,7G
7,B B9 B.6.FE : 8 简要说明: 轮椅架的类型。例如,四轮或三轮轮椅;交叉折 叠或固定式框架;后倾式框架;长或短轴距。 117 可得到的尺寸和尺寸范围。轮椅尺寸通常由轮椅座宽和座深所描述。轮椅座宽是测量一侧椅座 固定杆外缘到对侧椅座固定杆外缘或两侧扶手之间的距离 (如果扶手在椅座固定杆的上面)。 轮椅椅座深度是测量椅座前面到靠背的距离。 可利用的功能部件。例如,椅座类型、靠背、脚踏板、扶手、前小脚轮、后轮和PSDs(例如, 躯干侧垫、头靠、带子)的类型。 可能的调整和调整范围。重要的是知道哪些部件可以调整以及调整的范围。 • E ,7G BM ?L,E +6 + B.6.FE : 9 说明: 一些手动轮椅比其他轮椅有更多的可调部件或功 能部件。 一些可调部件或功能部件对于需要附加体位支撑 的轮椅使用者非常有用。 我们现在将看到一些特殊有用的功能部件和可调 部件。 说明以下的每个要点: • 7D B 7 - Q -
- @ • B7D F F7
7, B.6.FE : 10 大多数轮椅都有上下可调的脚踏板。 一些轮椅有附加的调节包括: 高度; 脚踏板可以向前或向后调; 脚踏板的角度可以增加或减少。 这些调节让轮椅使用者双脚的放置位置有更大的灵 活性。 • 7C 7 B.6.FE : 11 可抬起腿托可以有助于保持脚抬起来并伸膝。这对 于坐着时膝关节无法屈曲至中立位的轮椅使用者非 常有用。 6/3" 118 • M6 F - P87 80 D7L,@90 - .,P, - .,7G • B M6 D ,F M6 B.6.FE : 12 可调后倾靠背可以为躯干支撑提供更多的选择。 靠背后倾可以有助于适应: 髋关节不能屈曲至中立位坐姿 (躯干与大腿之间 的角度大于90度); 僵硬的骨盆后倾; 僵硬的腰部后凸姿势。 • M6 • M6L,@ B.6.FE : 13 一些轮椅具有所谓的 “整体后倾”功能。 这意味着靠背和椅座可以整体向后倾。椅座与靠背 之间的角度保持不变。后倾型椅座有助于: 僵硬的骨盆后倾伴有髋关节和膝关节屈曲挛缩; 正常坐姿的低耐受性或不舒适; 增加舒适性和休息。 • , L ,. • +60 M +,: - & F,+6 - MG,+6 B.6.FE : 14 一些轮椅是硬椅座而不是悬吊式椅座。它能提供: 一个良好的底座,用于为骨盆和髋关节提供附加 体位支撑; 比悬吊式椅座更稳定。如果轮椅使用者有强烈地 不受控制的运动或体重较重时,这可能非常 有用。 119 • , L ,. • & F, E +6" /M 6 0 • DQEQ GEGD M ,E +6 , B.6.FE : 15 一些轮椅是硬靠背。硬靠背是一个不错的底座,用 于提供附加体位支撑。 硬靠背也可以提供: 比悬吊式/帆布靠背更稳定。如果轮椅使用者有 强烈地不受控制的运动,这可能有用; 为身高较高和体重较重和/或躯干非常无力的轮 椅使用者提供更多的支撑。 幻灯片中的插图展示了硬靠背上增加了泡沫塑料到 正确的位置为躯干提供支撑,以及用螺栓把侧支撑 垫固定在靠背上。 • AM6, B • )0, 3 , B.6.FE : 16 一些轮椅有张力可调的靠背而不是简单的悬吊式 靠背。 张力可调的靠背允许靠背的张力可以轻松地调整。 独立的绑带被拉紧或放松来增加或减少支撑。 B.6.FE : 17 一些轮椅有各种附加部件用于提供附加体位支撑。 我们将在下一单元介绍不同的体位支撑。 6/3" 120 小组活动 分组 学员分成3人一组。 指导 让每组看 《实训手册》(B.6:选择轮椅和坐垫)。 让学员仔细地看当地可得到的每种轮椅,并共同回答 《实训手册》上的问题。 说明:每组学员有30分钟来开展这项活动,然后各组将返回进行反馈。 监督 密切地监督各组。 确保每组理解问题。 如果必要,引导学员。 时间 允许30分钟活动。 允许15分钟反馈。 教师提示: 如果当地超过4种轮椅,允许更多的时间。 反馈 按照以下内容,与所有学员一起检查每个问题: 让学员主动回答; 检查是否每个学员都同意; 是否有不同意见,感谢回答 (如果是正确的)并进入下一个问题。 如果不是每个人都有相同的答案,引导正确的答案并厘清。 允许简短地讨论。 说明: 重要的是轮椅服务人员充分认识到可得到轮椅的不同特点。只有非常熟悉这些轮椅,他 们才可以帮助轮椅使用者找到最适合于他们需求的轮椅。 指出 《实训手册》上的中级轮椅参数表或一套轮椅服务表。说明学员可以在培训结束后 为他们当地可得到的轮椅完成这个表格。 教师提示: 参考以下的教师答案提示并确保强调要点。 本单元结束后,把完成的每辆轮椅的中级轮椅参数表钉起来。这可以用于在实操单元让 轮椅使用者查阅。 121 教师提示: 1.生活方式和环境 问题: 教师强调的答案/要点: 哪种轮椅 (或哪些轮椅)最适合 在粗糙/不平坦地面使用? 为什么? 有助于轮椅在粗糙地面使用的特点包括: 三轮框架; 长轴距; 宽的前小脚轮; 宽的后轮 (“山地自行车”类型); PU胎可以减少扎破的问题并且耐用; 耐用并且能够在当地维修,应该也要考虑到由于在粗糙地面使 用,轮椅的磨损和撕裂会增加。 哪种轮椅 (或哪些轮椅)最有利 于站立式转移? 为什么? 有利于站立式转移的特点包括: 可外转的脚踏板; 可升高的扶手可能有用。 哪种轮椅 (或哪些轮椅)最有利 于侧向转移? 为什么? 有利于侧向转移的特点包括: 可拆卸或可上翻的扶手; 轮形扶手。 每种轮椅如何折叠或为了运输如 何拆卸? 通常的方法包括: 不能折叠; 交叉折叠; 靠背向下折叠; 快拆轮。 你们小组认为哪种轮椅 (或哪些 轮椅)在公共交通工具上最好 运输? 为什么? 鼓励学员思考: 折叠/拆卸轮椅需要的时间; 折叠/拆卸后部件有多轻; 部件是否会丢失 (例如轮椅拆散成许多不同的部件)。 折叠/拆卸后,轮椅有多小。 哪种轮椅 (如果有)是气胎? 哪种轮椅 (如果有)是PU胎? 哪种轮椅 (如果有)是实心胎? 6/3" 122 续表 2.减压 问题: 教师强调的答案/要点: 你在教室中看到了哪种类型的 坐垫? 坐垫可以按照以下描述: 主要的材料: - 泡沫塑料坐垫; - 椰子纤维 (椰壳纤维)制成的坐垫; - 空气填充的坐垫; - 流体或凝胶填充的坐垫。 形状: - 平面坐垫; - 波形坐垫; - 模塑坐垫; - 多层坐垫。 其中的哪些可以称为减压坐垫? 为什么? 减压坐垫可能包括: 泡沫塑料波形坐垫; 波形底座加流体或凝胶的坐垫; 空气填充的坐垫。 学员应该知道坐垫减压的原因。原因包括: 波形/有形包括: - 坐骨下的 “槽”(坐骨槽); - 坐骨前垫高; - 大腿根部下的支撑; - 放置大腿的凹槽或沟槽。 凝胶/流体块有助于分散压力。 (注意———凝胶/流体块应该放 在上面所描述的波形硬泡沫塑料底座的上面)。 减压坐垫中 (如果有),哪个相 对容易调整实现以下功能: 增加减压; 提供附加体位支撑。 通常泡沫塑料波形坐垫容易调整,因为泡沫塑料可以切割或增加 一个垫高块用于减压。 如果空气/凝胶连接层是独立的单元,也容易调整底座,增加一个 垫高层等。并更换连接层。 (更多的信息参见 《轮椅服务初级教程》“坐垫”单元部分)。 123 续表 2.减压 教室中不同坐垫套的特点是什么? 学员可以找到这些特点: 防水; 耐用; 有弹性 (容易适应坐垫的波形); 可拆洗。 3.推动 问题: 教师强调的答案/要点: 在轮椅上坐直。后轮处于良好的位置便于 你自己推动吗? 检查: 让你的手臂放下来。你的手处于轮轴 线上吗? 握住手推圈最高点的手在你肩膀的正 下方。你的肘关节屈曲在90~120度 之间吗? 后轮的位置可调吗? 如果可调,这能 改善推动位置吗? 为了自己推动轮椅,确保学员注意到是否可以通过调整 轮轴的位置而改善后轮的位置。 教室中的哪些轮椅椅座高度可调? 这在什么时候有用? 椅座高度可调可能有助于为用脚推动的轮椅使用者获得 正确的设置。 然而这种轮椅在许多资源有限地区并不容易获得。 4.体位支撑特点 问题: 教师强调的答案/要点: 哪种轮椅 (如果有)具有可升降的腿托? 哪种轮椅 (如果有)有硬椅座? 哪种轮椅 (如果有)有张力可调的靠背? 为了实现提供附加体位支撑的功能,哪种 轮椅 (如果有)有附加的部件设计? 6/3" 124 续表 5.可调性 问题: 教师强调的答案/要点: 哪种轮椅 (如果有)具有以下的可调性? 脚踏板高度 脚踏板角度 脚踏板向前/向后移动 靠背高度升或降 靠背后倾 整体后倾 (椅座和靠背倾斜) 当为需要附加体位支撑的轮椅使用者服务时,轮椅部件更多的可 调性是有用的。 教师提示:现在可能是很好的时机来整理使用者培训的以下要点: 应该向轮椅使用者和他们的家人/护理者说明,轮椅安装 (或 调整)的方式将影响轮椅使用者的体位支撑。除非必要,可调 部件不应该重调。重要的是让装置保持最后适配的状态,并检 查/加固可调部件以确保它们不滑脱。 3.要点概括 (2分钟) • F - F F E +6,E 2 - FE , (!A5 - F ,2 - FM? PSDs • E ,(&PSDs • E B ,E M' ,7G B B.6.FE : 18 讲出要点。 询问是否有任何问题。 B.7:体位支撑装置 (PSDs)的处方 (选择)———介绍 目标 本单元结束后,学员将能够: □ 定义 “体位支撑装置”; □ 说明中级轮椅处方 (选择)表的目的。 125 续表 资源 本单元: □ 幻灯片:B.7:PSDs的处方 (选择)———介绍; □ 《学员手册》; □ 海报:体位支撑装置 (PSD)表; □ 中级轮椅处方 (选择)表; □ 塑封的体位支撑装置 (PSD)表———每位学员1张; □ PSD套件。 情景 和以 前学 过的 内容 本单元可根据学员将工作的情境进行修改。思考: □ PSDs,学员工作当地可得到的PSDs材料和制作方法。 □ 学员将在哪里进行轮椅使用者适配———例如,在社区/使用者家中,在工场或轮椅服务 中心。这可能会影响他们工作的方式和PSDs的选择。 □ 准备一张包含学员当地可得到PSD选项的中级轮椅处方 (选择)样表。 准备 □ 收集资源,检查幻灯片和浏览单元计划。 □ 把体位支撑装置 (PSD)表海报钉起来。 □ 把PSDs样品从放在一起的PSD套件中取出来,并把它们放在教室前面的桌子上,以便 你可以容易拿到。 □ 布置教室让学员坐成半圆面向教室前面。 大纲 1.前言 2.什么是PSD或PSDs? 3.在中级轮椅处方 (选择)表上记录PSDs 4.要点概括。 2 10 15 3 总单元时间 30 6/3" 126 1.前言 (2分钟) !P >5 36'36'V , F • - >5(PSD/PSDs)A - 4E >, G B.7. PSDs,(F): 2 说明: 下面的5个单元,我们将继续学习提供轮椅服务 的第3步———处方 (选择)。上一单元我们看到 了为轮椅使用者选择最适合于他们的轮椅和坐垫 的类型。 本单元,我们将学习: - “体位支撑装置 (PSD/PSDs)”一词是什么 意思; - 中级轮椅处方表的最后部分。 下面的每个单元,我们将仔细地介绍这些PSDs。 记住,在开具最后的处方之前,重要的是确保在 已经选定的轮椅上可以提供需要的体位支撑。 2.什么是PSD (10分钟) 给每位学员塑封的体位支撑装置 (PSD)表 (以下称为PSD表)。 提问:什么是 “体位支撑装置”? 鼓励回答。 回答: 体位支撑装置 (PSD———单数和PSDs———复数)是: - 任何物理器具,它增加到轮椅上以提供附加体位支撑; - PSDs的例子包括:头靠、骨盆带、骨盆侧垫; - 记住,轮椅椅座、靠背、脚踏板、扶手也同样提供体位支撑。 127 B.7. PSDs,(F): 3 说明:幻灯片中插图展示了PSDs的一些例子。 提问:学员可以看到哪些PSDs? 回答 (学员可能用不同的名称/术语): 躯干侧垫; 波形/塑型的靠背和波形坐垫; 骨盆侧垫; 坐骨前垫高。 说明: PSDs的不同设计和轮椅安装的不同方法为轮椅使用者提供附加体位支撑。 本教程介绍一些经常使用的PSDs。 本教程中使用的词语是简单描述性用语。学员可能听说过其他词语来描述同样的事物。在每个 轮椅服务单位,轮椅服务人员和轮椅使用者可以使用自己最熟悉和最舒适的词汇。 我们将在本教程的后面部分介绍这些PSDs如何制作。 记住,许多轮椅使用者可能需要不止一种我们将介绍的PSD解决方法,多种PSD组合为他们 提供正确而全面的解决方案。 3.在中级轮椅处方 (选择)表上记录PSDs(15分钟) • > - E 2 A5 - 2 - PSDsM?, B.7. PSDs,(F): 4 说明: 中级轮椅处方表的目的是为轮椅服务人员准备轮 椅提供以下信息: - 轮椅类型、尺寸和设置 (前面介绍过); - 坐垫的类型和尺寸 (前面也介绍过); - PSDs或需要的改制。 6/3" 128 说明: 在中级轮椅处方表上所有从评定中收集的信息都要转换为轮椅使用者所需要轮椅的清晰描述。 中级轮椅处方表上提供的信息越详细,初次适配准备的轮椅就越精准。 中级轮椅处方表并不需要列出PSDs应该如何制作。它可以在准备轮椅的服务人员和进行评定 的轮椅服务人员之间讨论来决定。 不同的轮椅服务单位通常用不同的方式来记录轮椅处方信息。 让学员查看他们 《学员手册》本单元最后部分已完成的中级轮椅处方表中的案例。 B.7. PSDs,(F): 5 说明: 轮椅服务人员可以用中级轮椅处方表上的 “PSDs或 需要的改制”部分来: 选择他们希望从常见的PSDs列表中处方/选择 (使用勾选框)哪种PSDs。在 “其他”下面也有 空白处用于列出其他类型的PSDs; 在阴影图上绘画以显示已经处方 (选择)PSDs 的形状和提供的尺寸; 写下或素描所有的附加信息。 在 PSD 清单旁边,学员需要提供尺寸,以使 PSD可以制成正确的尺寸并安装在轮椅上的正确 位置。 PSD表上尺寸素描是一个引导,来帮助学员思考 每个PSD需要的不同尺寸。 B.7. PSDs,(F): 6 129 / "PSDs A5(A5AA5A( 5"PSDsA (B.7. PSDs, F): 7 表上的两个 “透视图”可以用作引导,让学员绘 画处方的PSDs并提供尺寸。 B.7. PSDs,(F): 8 例如,这张幻灯片显示中级轮椅处方表上的透视 图和PSD清单如何用于描述坐骨前垫高和右侧的 降低椅座前部。 提问:有人能够想起为什么轮椅使用者需要用这 种方式降低一侧椅座? 感谢正确的回答。 回答: 轮椅使用者的右髋关节不能完全接近90度。 B.7. PSDs,(F): 9 说明:这个案例显示如何使用 《中级轮椅处方表》 第2页的透视图和PSD清单。 提问:表上记录了哪些PSDs? 如果学员不清楚,鼓 励他们查看 《学员手册》的PSD表和PSD参考表。 感谢正确的回答。 回答: 坐骨前垫高 (这可以从表上第1页的PSD清单 中选择); 左右躯干侧垫; 左脚踏板楔形垫; 骨盆带。 6/3" 130 说明:图上画出的每一条尺寸线都显示出制作这些PSDs时需要的具体尺寸。 说明:在我们仔细检查下一单元的时候,我们将更多地介绍需要哪些尺寸有助于描述PSDs的尺 寸和位置。学员也将在实操单元进行练习。 4.要点概括 (3分钟) • L (*>5E L • 4E >,-, E E - E 2 A5 - 2 - PSDsM?, • ,CB4O!FG,E C. B.7. PSDs,(F): 10 讲出要点。 询问是否有任何问题。 B.8:体位支撑装置 (PSDs)的处方 (选择)———稳定骨盆 目标 本单元结束后,学员将能够: □ 描述有助于稳定和支撑骨盆的PSDs; □ 具体说明坐骨前垫高和骨盆后垫的尺寸。 资源 本单元: □ 幻灯片:B.8PSDs的处方 (选择)———稳定骨盆; □ 《学员手册》; □ 《实训手册》; □ DVD:骨盆前倾的体位支撑解决方法; □ 海报:体位支撑装置 (PSD)表; □ 塑封的体位支撑装置 (PSD)表———每位学员1张; □ PSD套件; □ 骨盆带———每组1个; □ 检查床———每组1张; □ 硬泡沫塑料块———每组一些,硬泡沫塑料楔形块———每组1块; □ 轮椅———每组1辆 (如果可能,至少3种类型的代表)。 131 续表 情境 和以 前学 过的 内容 根据学员将工作的情境修改本单元。思考: □ 学员工作环境可得到的PSDs、PSD材料和制作方法。 □ 学员将在哪里开展轮椅使用者适配———例如在社区/使用者家中、工场或诊所。这将影 响他们工作的方式和PSD的选择。 □ 当演示/让学员为志愿者提供支撑时,注意由于身体接触引起的任何文化问题。 准备 □ 收集资源,检查幻灯片,观看DVD并浏览单元计划。 □ 把体位支撑装置 (PSD)表海报钉起来。 □ 把PSDs样品从放在一起的PSD套件中取出来,并把它们放在教室前面的桌子上,以便 你可以容易拿到。 □ 布置教室让学员坐成半圆面向教室前面。 大纲 1.前言 2.问题:骨盆后倾或向前滑动 3.问题:骨盆侧倾 (僵硬的不水平骨盆) 4.问题:骨盆向一侧移动 5.问题:骨盆前倾 (骨盆向前倾) 6.要点概括 2 45 5 10 25 3 总单元时间 90 1.前言 (2分钟) !P F 36'V0P, • P,, PSDs B.8. PSDs,(F) ——0P,: 2 说明: 本单元我们将学习用于提供骨盆支撑的一些PS- Ds。 记住,尽管本单元和下一单元我们将单独介绍 PSDs,但是许多PSDs是在一起使用。 6/3" 132 D P, B.8. PSDs,(F) ─0P,: 3 说明: 为了支撑成年人坐直,有两个身体部位最需要支撑。 它们是: 骨盆; 躯干。 • P," -0 D P8 + • 0P, E +6 - G ?, • P, G ,M" B.8. PSDs,(F) ─ 0P,: 4 说明: 我们将首先看骨盆: 当骨盆不在直立姿势时,躯干和髋关节的姿势也 会发生变化; 因此支撑或稳定骨盆是帮助轮椅使用者坐直最重 要的事情; 对骨盆提供支撑可以减少对于其他部位支撑的需求。 说明:从本单元一直到单元 “B.11:PSDs的处方 (选择)———支撑头部、大腿和小腿”,我们将 按照提出问题、支撑需求和PSD解决方案的顺序进行介绍。有一些单元形式会稍微不同。 2.问题:骨盆后倾或向前滑动 (45分钟) P, P,
B.8. PSDs,(F) ─0P,: 5 起始体位: 骨盆后倾。 让一位志愿者到教室前面并演示问题。 133
/6,P,F 0 ? ? B.8. PSDs,(F) ─0P,: 6 向学员提问,可以提供哪些支撑 (用手支撑)帮助 志愿者的骨盆更接近中立位坐姿? 邀请1或2位学员到教室前面并用手演示为志愿者 提供支撑。 如果需要,鼓励所有学员提供建议。 受邀的学员应该在骨盆后部提供支撑。 感谢正确的演示。 P, 0 FM? G •P, G • P,M 2. B PM B.8. PSDs,(F) ─0P,: 7 说明: 当提供支撑把骨盆从后倾位摆到更中立位坐姿时, 通常需要在两个部位提供支撑: 在与PSIS水平的骨盆后部,正如受邀学员做的 那样; 在骨盆前部,更精确地说,在坐骨前面 (坐骨结 节)。 如果缺少坐骨前面的支撑,骨盆可能移动或向前滑 动,远离骨盆后面提供的支撑。 提问:如图所示,如何在坐骨前面提供支撑? 邀请1或2位学员 (志愿者)到教室前面并用硬泡 沫塑料块演示如何在坐骨前提供支撑。同时,另一 位受邀的学员应该在骨盆后部提供支撑。如果需要, 鼓励所有学员提出建议。 感谢正确的演示。 感谢志愿者。 向学员提问哪些PSDs可以提供这种支撑? 学员可以查看PSD表或PSD参考表找到答案。 6/3" 134 • P,-0 • L!P, % • L% ,C B.8. PSDs,(F) ─0P,: 8 坐骨前垫高在坐骨前提供支撑。 它有助于: 保持骨盆直立; 阻止骨盆前滑; 降低下滑坐姿的趋势。 坐骨前垫高刚好位于坐骨前面。 提问:为了决定坐骨前垫高应该在坐垫的哪个位置, 你需要测量身体的哪部分尺寸? 回答: 骨盆后部与坐骨之间的距离。 P,-0 B.8. PSDs,(F) ─0P,: 9 说明: 骨盆后垫在髂嵴 (与PSIS水平处)提供支撑。 它有助于: 保持骨盆直立。 B.8. PSDs,(F) ─0P,: 10 说明: 这里你可以看到为之前幻灯片中的同一位轮椅使 用者提供两个PSDs。 有了坐骨前垫高和骨盆后垫的支撑,轮椅使用者 可以坐直。 注意到靠背的角度如何向后调,以允许轮椅使用 者直立躯干的自然弯曲。 良好的躯干支撑是整体解决方案的重要部分。我 们将在后面的单元介绍更多的躯干支撑。 135 说明: 坐骨前垫高和骨盆后垫常一起使用帮助轮椅使用者坐时骨盆更直立 (他们的起始姿势不是僵硬 的)和更稳定。 下一次活动,学员将制定出他们如何在中级轮椅处方表上描述这两个常用PSDs的尺寸和位置。 小组活动 分组 学员分成2人一组 指导 让学员阅读实训手册上的马丽安故事 (B.8:PSDs的处方 (选择)———稳定骨盆)。 让学员在一起工作并使用中级轮椅评定表上 “进行测量”部分的结果,将合适的尺寸增加 到提供的草图上。 说明:学员可以使用以下来帮助他们开展这项活动: PSD表; PSD参考表。 说明:每组的学员有10分钟来开展这项活动,然后各组将返回原位进行反馈。 监督 密切地监督各组。 确保每组明白该活动。 鼓励各组使用 《学员手册》和他们自己的知识。 如果必要,引导学员。 时间 允许10分钟活动。 允许5分钟反馈。 反馈 B.8. PSDs,(F) —— 0P,: 11 播放幻灯片: 向学员提问: 对于马丽安,靠背和坐骨前垫高开始位置之间的 距离是多少? 对于马丽安,座面顶端与骨盆后垫之间的距离是 多少? 其他哪些尺寸或信息也有用? 说明:当完成整个处方 (选择)表后,学员可能完成了许多尺寸草图和注释,例如这张图 用于给出PSDs的尺寸和位置。 6/3" 136 回答 对于马丽安,靠背和坐骨前垫高开始位置之间的距离应该是170mm~190mm (身体测量L加 20mm~40mm)。 对于马丽安,座面顶端 (坐骨坐的地方)与骨盆后垫之间的距离应该是160mm。 其他有用的尺寸或信息: - 具体说明泡沫塑料的类型 (例如,软泡沫塑料下的硬泡沫塑料用于制作坐骨前垫高和骨盆后垫); - 具体说明骨盆前垫高的高度。对于成年人,通常是20mm~30mm。 - 具体说明骨盆后垫的深度。它将取决于用手模拟/轮椅使用者的需求。 说明:我们现在将看到坐骨前垫高和骨盆后垫。 提问:如果使用这些支撑的轮椅使用者有不受控制的运动,或高肌张力,或让他们身体变直 (伸 肌模式)的痉挛,会发生什么? 回答: 轮椅使用者可能移动远离坐骨前垫高和骨盆后垫。 提问:在哪个方向提供支撑有助于阻止这种情况的发生? 让1或2位志愿者到教室前面来并演示在哪里提供支撑。 回答: 在大腿顶部向下支撑。 感谢正确的演示。 B.8. PSDs,(F) ——0P,: 12 说明:上面的垂直箭头显示可以提供附加支撑以帮 助保持轮椅使用者的骨盆在原位,并且在骨盆后部 和坐骨前部提供反向支撑。 提问:哪种PSD提供这种支撑? 回答: 骨盆带。 137 • P, • L!% • &, F ,E +6 +60º B.8. PSDs,(F) ——0P,: 13 e 说明: 骨盆带有助于保持骨盆在适当的位置。 骨盆带对于那些有不受控制运动或可能向前滑的 轮椅使用者非常有用。 骨盆带有助于保持骨盆在适当的位置,这样坐骨 前垫高和骨盆后垫持续提供支撑。 带子固定在轮椅上的位置将影响拉力的角度/方 向。这会直接影响骨盆带工作的方式。 45º 90º B.8. PSDs,(F) ——0P,: 14 角度可能在45~90度之间。 根据轮椅使用者需求的不同,最有效的角度将 不同。 应该评估、讨论,并且如果可能与轮椅使用者一 起试用骨盆带的角度,哪个角度对于轮椅使用者 最有效和最舒适。 用一个案例来演示。 小组活动 分组 学员分成3人一组 指导 提供每组一辆轮椅 (最好是不同类型的轮椅)和骨盆带。为了实现以下角度的拉力,让学 员思考骨盆带应该放在他们轮椅的什么位置: 45度; 60度; 90度。 说明:每组学员有5分钟开展这项活动,然后返回原地进行反馈。 监督 密切地监督各组。 确保每组理解该活动。 如果必要,引导学员。 6/3" 138 续表 时间 允许5分钟活动。 允许5分钟反馈。 反馈 让一组用每种类型的轮椅来展示,骨盆带放在什么位置可以实现45度、60度和90度的拉 力角度。 感谢正确的演示。 说明:不同类型的轮椅需要不同的解决方法。然而,拉力的角度应该由轮椅使用者的需求 决定,而不是由轮椅的设计决定。 B.8. PSDs,(F) —— 0P,: 15 说明: 髋关节屈曲角度的增加有时可以降低不受控制的 运动、高肌张力或痉挛。 它可以通过升高椅座前部来实现———在轮椅使用 者的大腿下放一个楔形垫。 注意,正如幻灯片中的图所示,楔形垫应该起始 于坐骨前面。坐骨应该坐在平面上。 提问:如果轮椅使用者的骨盆僵硬的后倾并且他/她坐着时骨盆无法直立,你应该如何提供支撑? 鼓励回答。 回答: 对于僵硬的骨盆后倾的轮椅使用者,可能需要进一步的调整以适应这种姿势。 一种解决方法是增加椅座与靠背之间的角度来适应骨盆的姿势,并提供支撑以阻止其进一步向后 滚。这可以被称为 “增加椅座与靠背的角度”(见PSD参考表)。 必须小心以确保轮椅使用者不会在轮椅上向前滑。这会导致 “剪切力”,并会产生压疮。 坐骨前垫高、骨盆带和升高椅座前部都将有助于阻止其向前滑。 139 • M6L,@
F., P, • .E +6 E
% • P QP, Q GG L! % B.8. PSDs,(F) ——0P,: 16 说明: 这个插图显示了增加椅座与靠背之间角度的一种 方法。 记住,泡沫塑料应该塑形以在轮椅使用者需要的 位置提供支撑。 3.问题:骨盆侧倾 (僵硬的不水平骨盆)(5分钟) P,.," P, B.8. PSDs,(F) 0P, 说明:我们现在看到与骨盆相关的另一种姿势问题。 记住,轮椅使用者可能有不止一种姿势问题。 我们看下面的姿势问题: 骨盆侧倾/僵硬的不水平骨盆 (一侧的ASIS比另一 侧高)。 说明:如何支撑这种姿势已经在单元 “B.3:身体 检查———骨盆和髋关节姿势检查”中介绍过了。 提问:PSD的解决办法是什么? 感谢回答。 B.8. PSDs,(F) ——0P,: 18 较高骨盆一侧下的补高将有助于: 增加轮椅使用者的稳定性; 避免较低侧骨盆下的不安全压力。 说明:两侧坐骨和大腿下应该是均匀的压力。可能 需要调整脚踏板 (一侧脚踏板可能需要比另一侧 高)。 说明幻灯片中的照片是从轮椅的后面拍摄。 6/3" 140 B.8. PSDs,(F) ——0P,: 19 P, 说明: 骨盆侧垫也将有助于支撑骨盆,所以应该适配给骨 盆下补高的人士。 4.问题:骨盆向一侧移动 (10分钟) 说明:我们现在看与骨盆有关的另一个姿势问题。 • P, 0 - P, - P, - 7 - P, B.8. PSDs,(F) —— 0P,: 20 姿势问题: 骨盆向一侧移动。 说明: 这个问题产生有许多不同的原因。 这个问题通常与其他姿势问题相关联。 幻灯片中,你可以看到: - 与之前是同一个人,他的骨盆侧倾 (僵硬的 不水平骨盆)并且他的骨盆更转向左侧; - 这位女士她的脊柱侧弯。她的骨盆也更转向 左侧。 提问:可以在哪里提供支撑帮助保持骨盆在轮椅中 间? 感谢正确的回答。 回答: 应该在髋关节的两侧提供支撑。 141 B.8. PSDs,(F) ——0P,: 21 P, E 提问: PSD的解决办法是什么? 学员可以查阅 PSD 参 考表。 感谢正确的回答。 回答: 骨盆侧垫。 • L!P,0 • .P, ? 7 C B.8. PSDs,(F) ——0P,: 22 说明: 骨盆侧垫有助于阻止骨盆向两侧移动。 骨盆侧垫应该在骨盆两侧紧密地接触。 记住: 幼儿坐着时他们的大腿分得比成人开些。这对于他 们髋关节的健康和发育很重要。对于儿童尤其重要 的是,骨盆侧垫不要把儿童的大腿挤在一起。 5.骨盆前倾 (骨盆向前倾)(25分钟) P, 7 B.8. PSDs,(F) ——0P,: 23 说明: 另一个姿势问题是骨盆前倾 (骨盆向前倾)。 向学员提问,提供哪些支撑可以有助于促使骨盆处于更加中立的坐姿? 感谢回答。 6/3" 142 回答: 在骨盆 (ASIS)前面提供支撑向后推; 向后倾斜的楔形垫。 VIDEO 介绍DVD:骨盆前倾的体位支撑解决方法。本录像中,我们将看到一位叫卡罗的 轮椅使用者,她的骨盆前倾。仔细地观看为她提供的PSD解决方法。观看录像 后,我们将进行讨论。 播放DVD。 询问是否有任何问题。 向学员提问,提供哪种支撑可以帮助卡罗坐着时骨盆更接近中立位坐姿? 回答: 卡罗尝试了带骨盆前倾楔形垫的坐垫 (向后倾斜的楔形垫),来看这是否有助于让她的骨盆更 直立。 然后,轮椅服务人员尝试使用骨盆带,确认在前面的四点带提供的附加支撑是否可以进一步地帮 助卡罗。 B.8. PSDs,(F) ——0P,: 25 说明: 把骨盆前倾楔形垫 (向后倾斜的楔型垫)放在坐 骨下。它可以有助于前倾的骨盆朝靠背的方向向 后滚。 骨盆前倾楔形垫应该刚好终止于坐骨的前面并且 在大腿下水平。 当考虑使用PSD时,与轮椅使用者一起来检查: - 感觉怎么样; - 是否有效; - 轮椅使用者感觉舒适的角度是多少。 注意,在DVD中,轮椅服务人员询问卡罗坐垫是否 让她坐得更舒适。 143 B.8. PSDs,(F) ——0P, : 26 说明: 这个插图显示如何用硬泡沫塑料和软泡沫塑料来 制作楔形垫。 B.8. PSDs,(F) ——0P, : 27 P,8 0, 说明: 也可以在骨盆前面的上部提供支撑以帮助将骨盆摆 在一个更加中立位坐姿。 注意,在DVD中,轮椅服务人员用这种方式提供支 撑并询问卡罗感觉如何。 向学员提问,哪种PSD可以提供这种支撑? 回答: 骨盆前倾四点带。 B.8. PSDs,(F) ——0P, : 28 说明: 这种绑带特别适合于骨盆前倾。 注意插图中,带子向下固定在椅座固定杆上,向 后固定在靠背杆上。 这样防止绑带向上滑到轮椅使用者的腹部,否则 会很不舒服。 重要的是,在髂前上棘上提供支撑的任何绑带都 应该用软垫包好,以降低压疮的风险。 6/3" 144 教师提示:DVD中演示了一个简易的绑带。它只用于评估绑带对于卡罗是否舒适以及拉力的方向。 如果有问题,向学员说明,需要为了上面所述的原因而制作四点绑带。 小组活动 分组 学员分成3人一组 指导 每组发一些硬泡沫塑料块;一个硬泡沫塑料楔形垫 (足够大可以坐在上面);以及一条骨盆带。 让每组学员短暂地在一起工作: 为了促使骨盆从前倾 “滚”到更直立的姿势 (模拟前倾的楔形垫),让他们用泡沫塑料 来试验应如何布置座面; 用骨盆带试验来感受最有效的拉力方向,以促使骨盆从前倾到更加中立的坐姿。 说明:每组学员有10分钟来开展活动,然后返回原地进行反馈。 监督 密切地监督各组。 确保每组理解活动。 确保每位学员有机会感受楔形垫对于维持他们骨盆姿势的效果。 如果必要,引导学员。 时间 允许10分钟活动。 允许5分钟反馈。 反馈 向所有学员提问,坐在骨盆前倾楔形垫上会促使他们的骨盆向后滚吗? 感谢回答。 向所有学员提问,骨盆带最有效的拉力角度是多少? 感谢回答。 6.要点概括 (3分钟) • 0P, E +6 - G?, • P, G,M" • A1 4E ,PSDs E ,PSDs 4 ,35
+E +6 B.8. PSDs,(F) ——0P,: 29 讲出要点。 询问是否有任何问题。 145 B.9:体位支撑装置 (PSDs)的处方 (选择)———支撑髋关节 目标 本单元结束后,学员将能够: □ 描述为髋关节提供支撑的PSDs; □ 具体说明制作至少两个PSDs需要的尺寸。 资源 本单元: □ 幻灯片:B.9PSDs的处方 (选择)———支撑髋关节; □ 《学员手册》; □ 《实训手册》; □ 海报:体位支撑装置 (PSD)表; □ 塑封的体位支撑装置 (PSD)表,每位学员1张; □ PSD套件。 情境 和以 前学 过的 内容 根据学员将工作的情境修改本单元。思考: □ PSDs,学员工作环境可得到的PSD材料和制作方法。 □ 学员将在哪里开展轮椅使用者适配,例如在社区/使用者的家中,在工场或诊所。这可 能会影响他们工作的方法和PSDs的选择。 准备 □ 收集资源,检查幻灯片和浏览单元计划。 □ 把体位支撑装置 (PSD)表的海报钉起来。 □ 把PSDs从PSD套件中取出来,并把它们放在教室前面的桌子上,以便你可以容易 拿到。 大纲 1.前言 2.支撑髋关节 3.完成中级轮椅处方表上的 “PSDs或需要的改制”部分 4.要点概括 2 25 15 3 总单元时间 45 6/3" 146 1.前言 (2分钟) !P F 36'V —— —— Q8 • 2 ,PSDs F.,M0,P8 • BAF ,PSDs6 A PSDs4 C + B.9. PSDs,F P8: 2 说明: 本单元中,我们将看到一些PSDs,它们将有助 于适应僵硬的非中立位髋关节,包括: - 一侧髋关节不能屈曲至中立位坐姿 (躯干与 大腿之间的角度大于90度); - 两侧髋关节不能屈曲至中立位坐姿 (躯干与 大腿之间的角度大于90度); - 一侧或双侧髋关节不能伸展至中立位坐姿 (躯干与大腿之间的角度小于90度)。 记住,如果不进行调节,任何僵硬/非中立姿势的髋关节将影响骨盆的姿势。在B.3单元 “身 体检查———骨盆和髋关节姿势检查”,我们将看如何提供临时支撑以适应这种姿势。 在本单元,我们将看到这些临时支撑如何变成永久的PSDs。 应该记住,通常不是处方 (选择)单个的PSDs———而是许多PSDs组合一起发挥作用。 2.支撑髋关节 (25分钟) 问题:一侧髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度) 说明:如果一侧的髋关节不能屈曲至中立位坐姿 (仅有一侧髋关节的躯干与大腿之间的角度大于 90度),我们现在将看到可以怎么办。 提问:正如之前讨论的,为这种姿势问题提供什么临时支撑? 鼓励回答。 回答: 放置一个补高 (泡沫塑料)在两侧坐骨下和能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90 度)一侧髋关节的大腿下。 147 + - P8 # 80,E +6 • P Q B.9. PSDs,F • # ' ——P8: 3 说明: 通过降低一侧的椅座前部,以适应不能屈曲至中 立位坐姿 (躯干与大腿之间的角度大于90度) 的髋关节,且这种支撑可以成为坐垫的一部分。 降低椅座前部:泡沫塑料切掉的角度将取决于轮 椅使用者躯干与大腿之间的角度,因此应该在身 体检查的时候确定。 注意这个坐垫上仍然有一个坐骨前垫高。 问题:两侧髋关节不能屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度) P87 8 0 D 7L,@90 B.9. PSDs,F——P8: 4 问题: 两侧的髋关节不能屈曲至中立位坐姿 (躯干与大 腿之间的角度大于90度) 提问:为这种姿势问题提供什么临时支撑? 回答: 放一个补高垫 (泡沫塑料)在两侧的坐骨下。 提问:这可以作为长期的解决方案吗? 以及为什么或为什么不? 回答: 不,轮椅使用者可能会向前滑出他们的椅座。 提问:怎么能够代替? 回答: 增加椅座和靠背之间的角度以适应躯干与大腿之间的角度; 提供良好的背部支撑以帮助使用者尽可能地坐直。 6/3" 148 B.9. PSDs,F——P8: 5 如果两侧的髋关节不能屈曲至中立位坐姿,可能的 解决办法是打开 (增加)椅座与靠背之间的角度: 增加椅座与靠背之间的角度将适应躯干与大腿之 间更大的角度; 角度将取决于轮椅使用者躯干与大腿之间的角 度,这应该在评定过程中决定; 处方坐骨前垫高和骨盆带将有助于阻止向前滑。 问题:一侧或双侧的髋关节不能伸展到中立位坐姿 说明:当一侧或双侧的髋关节不能伸展到中立位坐姿 (躯干与大腿之间的角度小于90度)时,我 们将看到与髋关节有关的更多问题。 当他们坐着的时候,让所有学员演示这种姿势。检查每位学员让他们的髋关节屈曲,以使他们的 膝关节比髋关节高。 提问:有人可以提出一个解决方案吗? 思考之前讨论过的暂时性解决方法。鼓励回答。 回答: 放一个补高垫 (硬泡沫塑料楔型垫)在坐骨前面和在不能伸展到中立位坐姿 (躯干与大腿之间的 角度小于90度)一侧/双侧的大腿下。 • + - P 8 # 80, E +6 • L&,
,F B.9. PSDs,F——P8: 6 说明: 可能长期的解决方案是放一个楔形垫在坐骨前面 和大腿下面以升高椅座前部。 这减少了椅座和靠背之间的角度。椅座前部的升 高量将取决于轮椅使用者躯干与大腿之间的角 度。这应该在评定过程中决定。 升高椅座前部也可以有助于降低强烈的不受控制 的运动或身体拉直部位的高肌张力。 149 3.完成中级轮椅处方表上的 “PSDs或需要的改制”部分 (15分钟) 小组活动 分组 把学员分成2或3人一组。 指导 让学员阅读 《实训手册》上的轮椅使用者故事 (B.9:PSDs的处方 (选择)———支撑髋关 节)。 让学员一起描述中级轮椅处方表上的 “PSDs或需要的改制部分。 说明:学员可以使用以下资料帮助他们开展活动: PSD表; PSD参考表。 说明:每组学员有10分钟开展活动,然后各组将返回原地进行反馈。 监督 密切地监督各组。 确保每组明白活动。 鼓励各组使用PSD表和PSD参考表。 如果必要,引导学员。 时间 允许10分钟活动。 允许5分钟反馈。 反馈 问学员他们感觉PSDs画的怎么样。 对于很多人来说,需要长期的练习才能够精准地描绘PSDs。 B.9. PSDs,F—— P8: 7 播放幻灯片。 说明:重要的尺寸是: A:坐骨前垫高应该从哪里开始。 B:坐骨前垫高应该多高。 C:左右髋关节椅座前部高度的差异。该角度 用于适应西耶娜的右髋关节。 提问:这些尺寸如何决定? 6/3" 150 续表 反馈 回答: A:根据西耶娜的身体测量 (骨盆后部到坐骨),你可以决定坐骨前垫高应该从哪里 开始。 B:坐骨前垫高的高度通常是25mm~30mm。 C:测量临时支撑的高度以决定C的高度。 B.9. PSDs,F——P8: 8 播放幻灯片 说明:重要的尺寸是: A:坐骨前垫高应该从哪里开始。 B:坐骨前垫高应该多高。 C和D共同决定制作楔形垫需要的尺寸,这将增 加椅座与靠背之间的角度。 提问:这些尺寸如何决定? 回答: A:根据罗伯特的身体尺寸 (骨盆后部到坐骨),你可以决定坐骨前垫高应该从哪里 开始。 注意:该尺寸必须考虑加入到靠背的楔形垫会增加椅座与靠背之间的角度。 B:坐骨前垫高的高度通常是25mm~30mm。 C和D:决定这些尺寸的最好方法是模拟楔形垫并让轮椅使用者试用。 说明:当制作像这样的PSDs时,在完成第一次适配之前,不要在原位粘贴泡沫塑料。这 是因为PSD可能仍然需要调整,以确保它对于轮椅使用者是适配的。 教师提示: 在为罗伯特尺寸绘画的案例中,靠背上的楔形垫允许放置一层软泡沫塑料在靠垫的顶部, 并塞进楔形垫下面。有不同的方法构建这个PSD,教师可能需要说明由于情境、材料和常用的技术 方法会导致个体的差异。 151 4.要点概括 (3分钟) • F>B8./M0,P8 P,, • ,PSDs 5 , • F,2PSDs O!F G ?#"2C B.9. PSDs,F——P8: 9 讲出要点。 询问是否有任何问题。 B.10:体位支撑装置 (PSDs)的处方 (选择)———支撑躯干 目标 本单元结束后,学员将能够: □ 描述有助于轮椅使用者支撑躯干在中立位坐姿 (如果可能)或适应躯干尽可能舒适地接 近中立位坐姿来改制和制作PSDs。 □ 开始要解决的问题是以不同方式来改制或制作PSDs,让它们为骨盆、髋关节和躯干提 供支撑; □ 在帮助下完成中级轮椅处方 (选择)表。 资源 本单元: □ 幻灯片:B.10:PSDs的处方 (选择)———支撑躯干; □ 《学员手册》; □ 《实训手册》; □ 海报:体位支撑装置 (PSD)表; □ 中级轮椅处方 (选择)表; □ 塑封的体位支撑装置 (PSD)表,每位学员1张; □ PSD套件; □ PSD材料; □ 轮椅———每组1辆 (尽可能地接近每个轮椅使用者故事中描述的轮椅); □ 硬泡沫塑料垫———几个 □ 硬泡沫塑料楔形垫———几个 6/3" 152 续表 情境 和以 前学 过的 内容 根据学员将工作的情境修改本单元。思考: □ PSDs,学员工作环境可得到的PSD材料和制作方法。 □ 学员将在哪里开展轮椅使用者适配,例如在社区/使用者的家中,在工场或诊所。这可 能会影响他们工作的方法和PSDs的选择。 准备 □ 收集资源,检查幻灯片和浏览单元计划。 □ 把体位支撑装置 (PSD)表的海报钉起来。 □ 打开PSDs套件,把材料、硬泡沫塑料块和楔形垫放在教室前面的桌子上。 □ 把轮椅整齐地排在教室前面。 大纲 1.前言 2.支撑躯干 3.完成中级轮椅处方 (选择)表 4.要点概括 2 115 30 3 总单元时间 150 1.前言 (2分钟) !P 3: (F) PSDs ——0 • 2 ,PSDs D • ,G L 4F> ,E +6@LN !., PSD@ B.10. PSDs,(F) —— D: 2 说明: 我们已经看过了不同的PSDs,它们有助于稳定骨盆 和支撑髋关节。 本单元,我们将: 学习为躯干提供支撑的PSDs。 讨论为什么总是先考虑如何稳定骨盆,然后支撑 躯干,该顺序的重要性。对于很多人,与躯干相 关的姿势问题可以通过良好的骨盆支撑得到解决 或改善。 153 大多数单元,学员将以小组进行工作,为3个不同的轮椅使用者解决问题,找到正确的PSD解决 方案。 通过本单元,学员应该看到躯干的PSDs并不单独起作用,但是通常是组合式PSDs,它们支撑骨 盆,有时也支撑髋关节。 2.支撑躯干 (115分钟) 全体学员活动 分组 本活动由全体学员一起完成。 指导 让学员找到一块平的墙并把一张桌子/工作台靠墙放。让每位学员坐在桌子/工作台上并且 他们的骨盆直立靠在墙上。说明学员应该尽可能地坐直。 说明:学员将以这种姿势坐大约5分钟,然后进行反馈。 监督 密切地监督各组。 确保每位学员了解活动。 确保桌子/工作台靠墙并且每位学员坐着时骨盆直立并接触墙面。 如果必要,引导学员。 时间 允许5分钟活动。 允许5分钟反馈。 反馈 提问:像这样坐舒适吗? 可能坐直吗? 回答: 学员应该感觉到好像墙在向前推他们的上半身; 他们感觉到,为了坐直他们不得不向前移动骨盆。 B.10. PSDs,(F) ——D: 3 说明: 不舒适的原因是平的墙面阻碍了直立的坐姿。 墙面不允许背部向后移动,超过骨盆线。 这与人们坐在直背的轮椅上是同样的道理。 6/3" 154 说明:我们已经看到稳定骨盆的不同方法。然而非常重要的是看到躯干如何支撑在骨盆上方,如 处于中立位坐姿 (如果可能)或支撑下尽可能接近中立位坐姿。 小组活动 分组 把学员分成3组。 指导 给每组编一个号码 (1~3)并且分配 《实训手册》(B.10:PSDs的处方 (选择)———支撑 躯干)中一个适合的轮椅使用者故事。 给每组一辆轮椅,满足 (尽可能接近)分配给他们的轮椅使用者故事中描述的轮椅。为每 组分配PSD材料、硬泡沫塑料块和楔形块。 说明: 每组仔细地阅读他们的轮椅使用者故事。 每组有个性化需求的不同轮椅使用者。故事中描述的每位轮椅使用者需要支撑他们的骨 盆和躯干。其中的两位轮椅使用者有僵硬髋关节的问题。 根据故事中描述的轮椅使用者需要,每组应决定如何才能提供对应的支撑。 每组应该尝试思考不同的选择和方法来制作PSDs。 说明: 学员应该使用可得到的不同材料在提供给他们的轮椅上 “模拟”至少1种解决方案 (教 师应该指出可得到的材料)。 鼓励学员在任何时候向教师提问。 学员应该准备向其余的组员展示他们的轮椅使用者故事和解决办法。 说明: 学员有60分钟来完成分配的轮椅使用者故事和有关的任务。每组将向全体学员反馈针 对姿势问题可能的解决方案。让学员先不要完成每个轮椅使用者故事后面的中级轮椅处 方表。在每位学员向全体学员反馈并且处方 (选择)解决方案得到全体学员的同意后, 方可完成该表。 监督 密切地监督各组。 确保每组明白活动。 鼓励每组使用他们得到的轮椅和材料来 “模拟”PSDs,为他们的轮椅使用者提供支撑。 确保每组按照顺序:骨盆+髋关节→躯干。 如果必要,引导学员。 时间 允许60分钟活动。 允许45分钟反馈。 155 续表 反馈 让每组向其余的小组展示他们的轮椅使用者故事。 学员应该: 简要概括他们的轮椅使用者情况; 展示他们想出的解决办法来为轮椅使用者提供他/她需要的支撑。 每组提出一个解决办法后,向全体学员提问: 他们同意这种解决办法吗? 为什么? 还有其他办法可以提供这种支撑吗? 鼓励学员考虑不同的技术方案,这可能取决于可得到的材料和设备。 确保提供正确的答案。如果有困惑,鼓励全体学员一起解决问题。下面的教师提示作为 引导。 总之,强调每组的第一优先是 (或应该是)稳定骨盆。 教师提示: 马克16岁,是一位高位脊髓损伤者。他有一辆悬吊式椅座和靠背的轮椅。他的轮椅尺寸是正确的并 且有一个软的、平面的泡沫塑料坐垫。 马克发现自己很难坐直。他的腰弯着,他在轮椅上会向前滑。他坐骨下和肩胛骨旁的皮肤上有红斑。 提供哪种PSDs有助于马克在他的轮椅上坐直? 马克的评定显示他能够在支撑下以中立位姿势坐。用于支撑他中立位坐姿的PSDs是: 骨盆: 坐骨前垫高,支撑骨盆在中立位坐姿并阻止骨盆前倾; 骨盆后垫,支撑骨盆上部保持在中立位坐姿并且阻止骨盆前倾; 骨盆带 (如果必要),保持骨盆在正确的坐姿并且阻止马克滑出骨盆后垫和坐骨前垫高。 躯干: 增加靠背高度,在他的肩胛骨后面提供支撑 (注意,马克在良好的骨盆支撑下时坐得更直,他将 需要增加靠背高度)。 6/3" 156 续表 这些支撑如何加入到马克的轮椅中? 1.椅座/坐垫: 为马克制作一个新的,带坐骨前垫高和软泡沫塑料顶层的波形坐垫。 2.靠背: 骨盆后垫可以用不同的方式加入,包括: 选项1:把一个可调垫块带加入到靠背面料的后面并且围绕靠背杆固定它; 选项2:固定一块硬泡沫塑料在靠背面料的后面,用一根带子围绕靠背杆固定它; 选项3:增加一个可调张力的靠背,并且调整它使其为马克的骨盆上端提供稳定的支撑; 选项4:用一个硬靠背替换悬吊式靠背。该靠背是由一层硬泡沫塑料和一层软泡沫塑料组成,并且在它们 之间加入一层硬泡沫塑料骨盆后垫。用可清洗面料来做靠背套。这个选项意味着轮椅不能再折叠了。 靠背高度可能用不同方式升高: 选项1:如果靠背杆延伸到需要的高度,则增加一段面料并固定在靠背杆上; 选项2:如果靠背杆不够高,则要延长靠背杆。这可能通过切断靠背杆并且插入一个稍微细的硬 木棒或中间空的金属管。在适当的位置用螺钉固定 (如果是木棒)或焊接 (取决于金属的类型) 放入的管子,并且增加附加的靠背面料,或用一个延长到需要高度的靠背来更换原有的靠背 (例 如,张力可调靠背); 选项3:取下现有的靠背面料,然后配一个正确高度的硬靠背并用螺栓固定在靠背杆上,或用托 架固定。这个选择意味着轮椅不能再折叠。 3.带子: 在椅座固定杆上安装骨盆带。 约瑟芬35岁,是一位脊髓损伤者。她生活在农村,是当地教堂的一位活跃成员。她以前得到了一辆 长轴距的轮椅,由于她家人可以容易地推着这辆轮椅经过粗糙的乡村地面,所以她很喜欢。当在家 中的平坦地面时,她可以自己推一会儿。轮椅的尺寸对她合适,有一个硬靠背和椅座。她有一个厚 的平面泡沫塑料坐垫。 约瑟芬在轮椅上不舒适,并且她发现很难推动自己。她坐着时骨盆向后滚 (骨盆后倾)并且她的躯 干向前弯。 157 续表 为了帮助约瑟芬尽可能地在她的轮椅上坐直,应该提供哪种PSDs? 在约瑟芬的评定过程中,发现她无法以完全中立位坐姿坐。她的骨盆是僵硬的后倾并且她无法使右 髋关节完全屈曲至中立位坐姿 (角度100度)。然而,她的坐姿可以通过在坐骨下给予临时支撑、稳 固的骨盆支撑和躯干后部支撑得到改善 (变得更直立)。 PSDs可以帮助支撑约瑟芬更接近中立姿势坐,并且更加稳定和使她具有更好的功能性,包括: 骨盆+髋关节: 坐骨前垫高,促进更中立的坐姿和阻止她的骨盆向前滑; 降低右侧椅座前部的高度以适应僵硬的右髋关节; 也可以加入一条骨盆带,让她的骨盆向后坐在椅座上并且阻止约瑟芬从坐骨前垫高上滑开。 躯干: 增加椅座与靠背的角度以适应她僵硬的骨盆后倾; 调整靠背形状,支撑她的圆形躯干; 如果约瑟芬在这些支撑下坐得更直,但是她的头并不舒适,在适配过程中还要考虑椅座和靠背后 倾 (整体后倾)。 这些支撑如何加入到约瑟芬的轮椅中? 1.椅座/坐垫 修改约瑟芬现在的坐垫或制作一个带有坐骨前垫高和降低右侧椅座前部的新坐垫; 该坐垫应该有一个硬泡沫塑料层并覆盖一层软泡沫塑料层。 2.椅座和靠背 增加椅座与靠背之间的角度: - 选项1:如果轮椅的设计允许椅座与靠背之间的角度可调,调整轮椅使椅座与靠背之间的角 度增加以适应约瑟芬需要后倾的角度; - 选项2:制作一个硬泡沫塑料楔形垫,以支撑约瑟芬的骨盆到她舒适的最直立的姿势并粘贴 在硬靠背上。用一层软泡沫塑料覆盖硬泡沫塑料楔形垫和适合约瑟芬躯干形状的泡沫塑料。 再用可清洗的面料装饰。 调整靠背形状: - 塑造靠背表面的形状以支撑和适应她的圆形躯干。根据需要支撑的力度,在需要的地方用硬 泡沫塑料垫高以塑造形状。当完成时,放一个软泡沫塑料层在靠背的整个表面。确保加入的 任何泡沫塑料不会把约瑟芬向前推。 6/3" 158 续表 注意: 以上对椅座和靠背的修改可能减少椅座的深度。 如果椅座深度不够,学员应该考虑怎么办。 选项有: - 选项1:检查椅座板是否可以向前移 (然后检查推动的位置和双脚是否可以到达脚踏板); - 选项2:把靠背向后移。一种方法是用托架把靠背固定在靠背杆上。这种情况下,检查约瑟 芬的上臂/躯干是否受到靠背杆的限制,她是否能够自由地移动双肩。 3.带子: 在椅座固定杆上安装一条骨盆带。 希恩是一位3岁的脑瘫儿童。他有一辆儿童尺寸、可外翻脚踏板、悬吊式椅座和靠背的交叉折叠轮椅。没 有桌面板和坐垫。轮椅座深对他合适,但是有点儿宽。他父母没有小汽车,他们走路去大部分地方。他们 可以在社区推他,尽管有时他们只是抱他。当在平坦地面时,希恩可以自己推一会儿轮椅。 希恩在没有支撑下可以坐直一会儿。10分钟后他的躯干开始塌陷,他通常向前和向左倾斜。这导致 他的骨盆右侧抬起,他左侧坐骨承受更多的体重。他的后背有与他年龄相符的正常弯曲。希恩的妈 妈希望他能够与其他孩子一起户外玩耍并且推他的轮椅。 为了帮助希恩在轮椅上尽可能地坐直,应提供哪种PSDs? 骨盆+髋关节: 坐骨前垫高———保持希恩的骨盆在中立位坐姿和在椅座的后部; 骨盆侧垫———帮助支撑他的骨盆保持在中立位坐姿,右侧不抬起; 骨盆带———为了安全 (因为他才3岁)并且如果他抬起骨盆远离支撑,骨盆带也是必要的。 升高椅座前部———适应希恩左右髋关节躯干与大腿之间80度的角度; 躯干: 左右躯干侧垫———帮助保持希恩的躯干在中立位坐姿和阻止他倒向左侧; 桌面板———桌面板有助于为希恩的手臂提供支撑和让他保持良好的平衡来帮助他保持直立时间 更久。 肩带———可能至少刚开始时需要,或当希恩特别累时,帮助保持他的胸部和肩靠在靠背上; 椅座与靠背后倾 (整体后倾)———如果希恩继续向前和向左倒,可以加上整体后倾。 159 续表 这些支撑如何加到希恩的轮椅上? 1.椅座/坐垫: 为希恩做一个坐垫,它有: - 坐骨前垫高; - 升高椅座前部 (通过在坐骨前垫高开始的地方加入一个楔形垫并延伸到坐垫的前部,它适合 希恩躯干与大腿之间的角度)。 坐垫应该放在硬板上,硬板放在悬吊式椅座上。这将比坐垫放在悬吊式椅座上提供更多的支撑。 如果没有使用硬板,确保坐垫的底座有稍微的弧度以贴合悬吊式椅座的形状。 制作骨盆侧垫———把装饰过的硬泡沫塑料块固定在以下任何地方: - 扶手/侧边挡板 (用胶水); - 用支架固定在椅座或靠背上。 2.靠背: 增加躯干侧垫: - 选项1:用硬靠背替换悬吊式靠背并且固定躯干侧垫到硬靠背上,可能要切割靠背垫以允许 躯干侧垫放在正确的位置 (尽可能靠近希恩的身体)。确保所有的支架都用软垫包好; - 选项2:用支架把躯干侧垫固定在靠背杆上。确保支架形状有助于躯干侧垫靠近希恩的身体。 3.椅座与靠背后倾 (整体后倾): 如果椅座与靠背后倾 (整体后倾)是必须的,这可以通过上面描述的用一个硬椅座和硬靠背来实 现。用支架来固定椅座和靠背,定好位置放好倾斜的椅座和靠背。椅座与靠背之间的角度不能 调整。 记住,如果倾斜角度增加了,希恩应该有一个头靠。 4.带子: 安装一条骨盆带到椅座固定杆上; 把肩带固定在硬靠背上 (顶部和底部)。 5.桌面板: 为希恩装一个桌面板,环绕他的身体,因此他可以把肘和前臂放在上面作为附加的支撑; 桌面板应该安装到轮椅扶手上,且要能够容易地装上和取下。 6/3" 160 3.完成中级轮椅处方 (选择)表 (30分钟) 小组活动 分组 让学员按照上次活动同样的分组。 指导 让学员为马克/约瑟芬/希恩完成 《实训手册》上的中级轮椅处方 (选择)表。 说明:每组只为他们之前服务过的故事中的轮椅使用者完成一张轮椅处方 (选择)表。 说明:学员没有对每位轮椅使用者进行身体测量,因此他们不能提供尺寸。然而,学员应 该描述/画出需要哪些尺寸。 监督 密切地监督各组。 确保每组理解活动。 活动的反馈环节之前,在各组之间巡视并检查每组的中级轮椅处方表,以检查各组如何能 够顺利地完成。注意学员面临的所有困难。 如果必要,引导学员。 时间 允许20分钟活动。 允许10分钟反馈。 反馈 对于完成中级轮椅处方表,询问学员是否有任何问题。厘清你在活动过程中注意到的所有 困难的地方。 4.要点概括 (3分钟) • +6FM?!/PSD • 4 PSDs!E +6!., • BO P, P8' D • ,# , ,@ E +6,M" ,E • M?D B ,# BABLE +6,? B.10. PSDs,(F) ——D: 4 讲出要点。 询问是否有任何问题。 161 B.11:体位支撑装置 (PSDs)的处方 (选择)———支撑头部、大腿 和小腿 目标 本单元结束后,学员将能够: □ 描述为轮椅使用者头部、大腿和小腿提供支撑的PSDs和改制。 资源 本单元: □ 幻灯片:B.11:PSDs的处方 (选择)———支撑头部、大腿和小腿; □ 《学员手册》; □ 《实训手册》; □ DVD:头部支撑; □ 海报:体位支撑装置 (PSD)表; □ 塑封的体位支撑装置 (PSD)表,每位学员1张; □ PSD套件; □ 轮椅———每组1辆; □ 泡沫塑料坐垫———每组1个。 情境 和以 前学 过的 内容 根据学员将工作的情境修改本单元。思考: □ PSDs,学员工作环境可得到的PSD材料和制作方法。 □ 学员将在哪里开展轮椅使用者适配,例如在社区/使用者的家中,在工场或诊所。这可 能会影响他们工作的方法和PSDs的选择。 准备 □ 收集资源,检查幻灯片和浏览单元计划。 □ 把体位支撑装置 (PSD)表的海报钉起来。 □ 把PSDs样品从PSD套件中取出来,并把它们放在教室前面的桌子上,以便你可以容易 拿到。 □ 把轮椅样品整齐地摆放在教室前面。 6/3" 162 续表 大纲 1.前言 2.支撑头部 3.支撑大腿 4.支撑小腿和双脚 5.要点概括 2 25 60 30 3 总单元时间 120 1.前言 (2分钟) !P 3:(F) PSDs ——G7 7 • ,PSDs?E +6,G7 7 7 B.11. PSDs,F—— G7 7: 2 说明: 我们已经学习过不同的PSDs,它们有助于稳定 骨盆、支撑有问题的髋关节和支撑躯干。 我们将学习其他的PSDs,主要为轮椅使用者的 头部、大腿和小腿包括双脚提供支撑。 2.支撑头部 (25分钟) G B.11. PSDs,F——G7 7: 3 说明: 我们在案例故事中看到的轮椅使用者没有一位需 要头靠。 然而,一些儿童和成人需要头靠。 提问:有学员曾经服务过的儿童或成年人需要头靠 的吗? 感谢回答并允许简短地讨论。 163 B.11. PSDs,F—— 7 7: 4
M 问题: 头会向后、向前或向侧面倒。 说明: 幻灯片显示了一个幼儿的插图,他很难保持自己 的头直立。 插图中,你可以看到他妈妈用手臂支撑他的头。 提问:这位儿童,可能的解决方案是什么? 鼓励回答。 回答: 首先,提供良好的骨盆和躯干支撑,确保儿童尽可能地稳定。这可能包括: - 骨盆:骨盆后垫、坐骨前垫高和骨盆带; - 躯干:调整靠背形状为儿童的躯干提供最优支撑,肩带,可能整体后倾。 这些PSDs可能改善他的头部控制。 如果发现儿童保持自己头部直立仍然有困难,提供一个头靠。 教师提示: 强调提供正确的骨盆和躯干支撑的重要性,然后考虑是否仍然有头靠的需求。 提问:头部的哪个地方可以提供支撑? 回答: 首先———在颅底提供支撑; 如果必要,支撑可以延伸围绕轮椅使用者的头部侧面。 教师提示: 一些学员可能建议使用头带。这应该进行阻止,因为这种形式的支撑可能会不舒适并且 有潜在的危险。头带只可以在非常特定的环境并且在密切的监督下使用。 6/3" 164 • B E +6, N B.11. PSDs,F——7 7: 5 说明: 本插图显示了头靠支撑在颅底。 有许多不同类型的头靠。本教程中,我们将介绍两种类型的头靠。 • G, L!G B.11. PSDs,F——7 7: 6 说明: 一种是扁平头靠: - 它是靠背的延伸; - 靠背塑形为骨盆、躯干上下部提供支撑,并且 延伸为头部提供支撑; - 扁平头靠为头部提供休息的地方并且阻止头部 后仰。 • "M , • FE E +6, N L!G
M
M B.11. PSDs,F——7 7: 7 另外一种是有形头靠。 - 它形状像 “杯”状用于托住头的底部; - 有形头靠可以延伸到两侧,在头部侧面提供更 多的支撑; - 有形头靠通过包住轮椅使用者的颅底,比扁平 头靠提供更多的支撑。 教师提示: 如果当地有其他类型的头靠 (并且出现在培训过程中),把它们展示给学员并说明其所有 特性。 165 VIDEO 介绍DVD:头部支撑。录像中,我们将看到一位幼儿名叫迈克尔,他的妈妈带他 来参加评定,因为他很难坐直并且抬起头困难。在身体检查的过程中,轮椅服务 人员发现: 迈克尔的骨盆僵硬后倾; 迈克尔的骨盆有向前的趋势并且在轮椅上滑动; 迈克尔的上躯干和头向前倒,当他试图把自己的头直立时,他失去对头的控 制,他的头向后倒。 观看轮椅服务人员仔细检查的过程,以发现迈克尔需要哪种支撑以及如何在他的 轮椅上提供这些支撑。 播放DVD。 询问是否有任何问题。 3.支撑大腿 (60分钟) 7 B.11. PSDs,F—— 7 7 说明: 我们已经学习过稳定骨盆,支撑髋关节、支撑躯干 和提供头靠。 现在我们将特别介绍支撑大腿。 小组活动 分组 学员分成3组。 指导 给每组一辆轮椅和一个泡沫塑料坐垫。让每组看并回答 《实训手册》上的3个问题 (B. 11:PSDs的处方 (选择)———支撑头部、大腿和小腿)。 说明: 每组应该看他们得到的轮椅和泡沫塑料坐垫,并思考为了给轮椅使用者提供需要的支 撑,他们可以对轮椅和泡沫塑料坐垫 (以及其他材料或部件)做些什么。 思考: - 常规轮椅安装; - 轮椅使用者的整个身体; - 大腿需要哪种PSDs。 说明:每组学员有30分钟的时间开展这个活动,然后各组返回原地进行反馈。 6/3" 166 续表 监督 密切地监督各组。 确保每组理解活动。 如果必要,引导学员。 时间 允许30分钟活动。 允许30分钟反馈。 反馈 B.11. PSDs,F—— 7 7: 10 让一组描述他们为乔纳准备的解决方案。询问其 他组是否有其他建议。确保学员涵盖所有的关键 学习要点 (请见下面的教师提示)。 • 7,0 0 • L 7:,C B.11. PSDs,F——7 7 11 播放大腿外侧楔形垫的幻灯片。 B.11. PSDs,F——7 7: 12 让另一组描述他们为萨姆准备的解决方案。询问 其他组是否有其他建议。 确保学员涵盖所有的要点 (请见下面的教师提 示)。 • 7 • , 7 • ,"7 B.11. PSDs,F—— 7 7: 13 播放膝分隔垫的幻灯片。 B.11. PSDs,F——7 7: 14 让另外一组描述他们为伊利亚准备的解决方案。 询问其他组是否有其他建议。 确保学员涵盖所有的要点 (请见下面的教师提示)。 167 续表 反馈 • 700 • L7,C B.11. PSDs,F——7 7: 15 播放大腿内侧楔形垫的幻灯片。 教师提示: 乔纳来参加评定。在用 手模拟的过程中,你发 现乔纳的双腿向外倒 (外展),但是轻轻地支 撑你可以把他的双腿放 到中立位坐姿 (膝关节 靠在一起)。 你认为可以对他的轮 椅和坐垫做哪些调整 以帮助他坐着时双腿 放在中立位? 对乔纳轮椅可能的调整: 靠背降低些; 椅座深度看起来太短,应该加长些; 脚踏板看起来太高,这会导致腿的不良姿势; 整体———这辆轮椅对他太小了,他可能需要一辆大 些的轮椅。 对乔纳坐垫可能的调整: 坐骨前垫高可以帮助他坐得更直立 (仅从前面难以 判断,然而他看起来有下滑趋势); 大腿外侧楔形垫保持大腿在正确的位置。 大腿外侧楔形垫如何制作? 把楔形垫粘在坐垫顶层并确保它们是牢固的并有一 个紧密合适的套; 在坐垫前部切一个口子后插入硬泡沫塑料楔形垫并 进行粘贴。 要点: 乔纳需要在他的大腿上有支撑,然而整个画面需要 处理。 乔纳大腿上只需要柔和的支撑,因此楔形垫就足够 了 (乔纳的案例中,不需要用大腿外侧垫)。 6/3" 168 续表 萨姆使用这辆轮椅已 经两年了。他是脑损 伤,他的双腿很僵硬 和强直。在评定中你 发现萨姆的双腿内收 但是你可以把他的双 膝分开处于更中立的 坐姿。然而,这需要 相当大的力量。当他 的膝关节处于更加中 立的坐姿时,萨姆感 觉更平衡了。 你认为你可以对他的 轮椅和坐垫做哪些调 整,以帮助他坐的时 候双 腿 处 于 中 立 位 坐姿? 萨姆轮椅可能的调整: 萨姆需要一个坐垫; 更多的靠背支撑包括躯干侧垫/楔形垫; 萨姆的轮椅太宽; 脚踏板不在同一水平,可能需要维修或更换; 可以考虑更换悬吊式椅座为硬椅座来帮助减少大腿 内收 (在悬吊式椅座中会促进这种姿势); 整体———对于长期的轮椅使用者这不是一辆理想的 轮椅。 萨姆坐垫可能的调整: 坐骨前垫高有助于支撑姿势; 膝分隔垫可以保持萨姆的大腿分开,只是大腿持续 受力。 膝分离垫如何制作? 考虑把悬吊式椅座更换为硬椅座并且安装一个膝分 隔垫在上面 (安装到椅座下面的托架上,萨姆坐上 去后就锁好,他转移时拿掉)。 学习要点: 对于乔纳———整体形象需要处理。 把萨姆大腿分开需要的强大力量显示,在他的案例 中,需要用膝分隔垫的方式提供有力的支撑而不是 由大腿内侧垫提供的柔和支撑。 169 续表 伊利亚很满意,他的 轮椅可以折叠,并且 他能够把它放进汽车 往返工场。然而他的 后背疼痛并且发现他 的双腿相互交叉在一 起。在评定过程中, 你发现伊利亚能以中 立位坐姿坐,在柔和 的支撑下他的双腿能 坐到中立位坐姿。 你认为你可以对他的 轮椅和坐垫做哪些调 整以帮助他坐的时候 双腿处于中立位坐姿? 伊利亚轮椅可能的调整: 拉紧悬吊式椅座以减少下垂; 检查脚踏板高度。 对伊利亚坐垫可能的调整: 坐骨前垫高有助于支撑姿势; 尝试在坐垫中加入大腿内侧楔形垫,有助于保持大 腿在中立位坐姿。 大腿内侧楔形垫如何制作? 把楔形垫粘在坐垫顶层并确保它们牢固并有一个紧 密合适的套; 在坐垫前部切一个口子后插入硬泡沫塑料楔形块并 进行粘贴。 学习要点: 对于其他———整体形象需要处理。 伊利亚喜欢他的轮椅可以折叠———因此加入一个硬 椅座可能使折叠变得困难。然而,一块薄板放进坐 垫套内,在坐垫下面,可以提供更多的支撑并且不 会造成转移困难。 4.支撑小腿和双脚 (30分钟) 7
7 B.11. PSDs,F——7 7: 16 说明: 我们现在将介绍PSDs,它为小腿提供支撑,包括支 撑或适应僵硬的非中立位坐姿的双脚和膝关节。 记住———这些解决方法应该根据需要,与轮椅使用 者骨盆、躯干、头和颈的支撑一起提供。 6/3" 170 ,78 ., 0
7,36' @ -
B7D - B87D ,@+7D - 7M5 - . ,1NE +67,
G - Q,E +66< Q G M6 B.11. PSDs——a: 17 • • 问题: 一侧或双侧的膝关节屈曲和僵硬的小于中立位 坐姿。 可能的PSD解决方案: 如果可能,向后调整脚踏板。 如果可能,调整脚踏板的角度以适应脚的位置, 如果不行,则用脚踏板楔形垫。 加一条绑带在小腿前面用于支撑和保护。 如果椅座的前端压迫轮椅使用者腿/双腿后面。可能需要把椅座稍微缩短并向后斜切坐垫。 对于高个子的轮椅使用者,考虑升高椅座前部或倾斜椅座和靠背。通过这样做,轮椅使用者的 双脚抬高了、更向前了并且可能在标准脚踏板的调整范围内。 当进行这些调整时,确保小脚轮仍然可以自由转动而不碰到脚踏板或轮椅使用者的双脚。 如果这些调整在现有的轮椅上不可能或不能提供足够的调整,可能需要一些改制。 • ,787 80 • 7,PSD@# - , L7 - B7D - 6<E3EE - FE H 7D - 7D B.11. PSDs,F—— 7 7: 18 问题: 一侧或双侧的膝关节不能屈曲至中立位坐姿。 可能的PSD解决办法: 如果有,提供一个标准的可升高腿托。 如果可能,向前调整脚踏板。 如果有,考虑提供一辆3轮轮椅。把脚踏板加在 中间横杆的上面。 通过加入木板或金属板来向前延伸脚踏板。 向前延伸脚踏板固定杆,这可能需要焊接并且应该由具有丰富技术知识和技能的金属加工工人 来实施。 无论决定用何种解决方法,重要的是设法确保轮椅的总长度维持在最小。 171 • 7 #7D 7D #BCQ 7 7 B.11. PSDs,F—— 7 7: 19 问题: 一侧或双侧的脚不能伸到脚踏板和脚踏板无法调 整到足够高。 可能的PSD解决办法: 脚踏板补高———脚踏板可以双脚或单脚补高 (如 幻灯片所示)。 • FD8.,M0 • 7 • NLD8,F!
B.11. PSDs,F——7 7: 20 问题: 踝关节僵硬的非中立位姿势。 PSD解决办法: 脚踏板楔形垫———可以用于支撑现在的姿势和帮 助预防踝关节的进一步变化。 根据轮椅使用者脚需要的支撑,大部分脚踏板楔形 垫需要个性化制作。 脚踏板楔型垫的目的是增加轮椅使用者脚在脚踏板 上的接触面积。 • 7 NL7
7%7D B.11. PSDs,F—— 7 7: 21 问题: 脚向后掉。 PSD解决办法: 小腿带———小腿带通常与轮椅配套提供或可以用 皮带材料和魔术贴做成。 6/3" 172 问题: 脚在脚踏板上有不随意的运动或不稳定。 PSD解决办法: 足带。 • L! 7
% B.11. PSDs,F——7 7: 23 足带在足跟后面有助于预防足向后滑落。 • L!7 0
L!CDC B.11. PSDs,F——7 7: 24 绕踝足带有助于防止足部向前滑动并阻止足跟抬 起来。 • L!7CC B.11. PSDs,F——7 7: 25 足带在足前部有助于阻止脚趾抬起。 173 5.要点概括 (3分钟) • PSDs E +6L • E +6M?,PSDsB+8F-
+AE +6B+PSDs PSDs • ,PSDs/2M! +,( ,@# ,PSDs • PSD>+, PSDs B.11. PSDs,F —— 7 7: 26 说明: 这些要点与之前介绍PSDs的所有单元密切相关。 讲出要点。 询问是否有任何问题。 实操一:评定和处方 (选择) 目标 本单元结束后,学员将能够: □ 在小组中和协助下演示中级轮椅评定。 □ 在小组中和协助下演示制定中级轮椅处方。 资源 □ 教师观察表:实操一; □ 肖像同意表; □ 中级轮椅评定表和中级轮椅处方 (选择)表; □ 海报:体位支撑装置 (PSD)表; □ 塑封的体位支撑装置 (PSD)表———每位学员1张; □ 清洁和私密的检查空间和检查床以及每位轮椅使用者的私密屏风; □ 一些硬泡沫塑料块———整组几块; □ 一些硬泡沫塑料楔形块———整组几块; □ 轮椅和坐垫样品 (如果评定不是在社区进行); □ 数码相机; □ 卷尺或游标卡尺———每组1个,足垫块———每组1套。 6/3" 174 续表 情境 和以 前学 过的 内容 根据学员将工作的情境修改本单元。思考: □ 文化因素———例如,不同性别的学员同组开展评定是否合适; □ 当学员为轮椅使用者开展轮椅评定时,注意由身体接触引起的任何文化问题; □ 语言因素———例如,参与的轮椅使用者是否与所有学员讲相同的语言; □ 当评定或处方轮椅时,主办/培训机构可能需要的所有文件,例如服务机构需要收集轮 椅使用者取得服务的任何附加信息 (例如,转介来源); □ 教师将如何处理在评定/处方中出现的问题,这些问题无法在单元或培训项目中得到解 决。例如,轮椅使用者可能有其他需求,在单位或培训项目中无法提供或完成需要的转 介或移动设备/PSDs。 准备 □ 与轮椅使用志愿者确定时间和行程安排。确保为轮椅使用者和他们的家人/护理者提供 茶点。 □ 当轮椅使用者到达的时候指定专人去迎接他们,并引导他们在单元开始之前可以待在某 个地方。 □ 为每组准备一张检查床以及保护隐私的屏风。把所有需要的检查设备放在检查床上。 □ 确保轮椅和坐垫样品都安全可靠。 □ 如果有超过3组学员,让其他教师来协助管理。 □ 决定哪些学员与轮椅使用者在一起工作。 □ 把体位支撑装置 (PSD)表海报钉起来。 大纲 1.评定和处方 (选择)实操: 指导和安装 评定 处方 (选择) 反馈 15 45 30 30 总单元时间 120 175 1.评定和处方 (选择)实操 (120分钟) 教师提示: 1.拍照: 要求每位轮椅使用者签署肖像同意表才进行拍照。确保轮椅使用者明白他们的同意是自愿的并且 照片将用于本教程的进一步培训。 对已经签署同意的每位轮椅使用者,实操过程中按照以下流程进行拍照: - 在他们现在的轮椅上 (如果他们有)(正面和侧面); - 在身体检查的过程中 (无支撑坐姿)。 2.观察学员的实操: 使用实操一的 《教师观察表》来确保各组在实操中执行所有的步骤,并且注意常见的良好实操或 需要改进的实操用于反馈。 小组活动 分组 把学员分成3人一组。 每组指定一位组长。 告诉每组他们将服务的轮椅使用者姓名。 分配每组一个工作的场地。 向学员说明他们可以在哪里找到必要的器材。 指导 说明以下的所有内容: 单元目标: 本实操单元的目标是为一位轮椅使用者进行评定和处方 (选择)一辆轮椅。 本训练项目之后,学员将与今天一起工作的同一位轮椅使用者继续工作,适配今天选择 的轮椅和提供轮椅使用者培训。 不太可能在本教程中完全完成轮椅使用者的轮椅,应与轮椅使用者进行安排确保完成他 们的轮椅。学员应该尽可能多做工作。 组长: 每组的组长负责确保评定和轮椅处方 (选择)的所有步骤都完成。 组长应该是与轮椅使用者和他们家人/护理者之间的主要沟通者。这将避免太多人同时 讲话,这可能会造成混乱。 6/3" 176 续表 教师观察和支持: 学员可以在任何时候请求协助或解释。 在整个单元,教师将监督每组并根据需要尽可能地提供支持和建议。 完成评定后,学员应该请一位教师来检查他们的中级轮椅评定表。 完成处方后,学员应该请一位教师来检查他们的中级轮椅处方表。 允许的时间: 学员应该在45分钟内完成评定,30分钟内完成处方 (选择)。 向学员提问:评定的步骤是什么? 感谢正确的回答。 向学员提问:处方 (选择)的步骤是什么? 感谢正确的回答。 服务表格: 向每组的组长分发中级轮椅评定表和中级轮椅处方 (选择)表。 实操结束后,收集填写的服务表并在下一实操单元分发。 提醒学员他们应该让轮椅使用者积极地参与到每个步骤中。 提问:有问题吗? 回答问题。 让每组准备他们将工作的场地,然后把他们介绍给轮椅使用者并开始工作。 监督与 支持 密切地监督各组,确保安全地实操,观察和评估学员的技能。 用教师观察表记录你对每组的观察。 整个单元: 给予时间提示 (口头或写在学员可以看到的白板上)以帮助学员管理他们的时间。 确保轮椅使用者积极地参与。 确保每组成员都积极地参与。 本单元结束后,让学员感谢轮椅使用者的参与,并说明现在将为他们准备轮椅处方 (选 择),当他们参与下一单元时让他们试用。 在本单元中,为已经签署了肖像同意表的轮椅使用者拍照。 177 续表 时间 允许15分钟指导和安装,45分钟完成评定,30分钟完成处方 (选择),30分钟反馈。 用教师观察表追踪时间。 反馈 评价你在实操单元看到的良好实操案例。 注意学员可以改进的任何特别地方———不要强调个人。 提问:有问题吗? 教师提示: 在实操单元重要的是密切地关注时间。上面给出的时间是一个指导———然而,根据学员 的经验,轮椅使用者的需求,安装需要的时间,所需要的时间会变化。教师可以根据需要进行调整。 B.12:产品 (轮椅)准备 目标 本单元结束后,学员将能够: □ 描述为需要附加体位支撑的轮椅使用者准备轮椅和PSDs的过程。 资源 本单元: □ 幻灯片:B.12:产品 (轮椅)准备; □ 《学员手册》; □ DVD:产品 (轮椅)准备; □ DVD:脚踏板修改的制作; □ 海报:体位支撑装置 (PSD)表; □ 塑封的体位支撑装置 (PSD)表———每位学员1张; □ 塑封的中级轮椅安全和准备检查表———每位学员1张; □ PSD套件; □ PSD材料; □ 工作台或结实的桌子。 6/3" 178 续表 情境 和以 前学 过的 内容 以前学过的内容: □ 有关调整手动轮椅来满足轮椅使用者尺寸的知识已经在 《轮椅服务初级教程》中讲过。 本单元,学员应该已经能够: - 调整一辆轮椅以适配不需要支撑能够坐直的轮椅使用者; - 用中级轮椅安全和准备检查表来确保轮椅安全和准备使用。 根据学员将工作的情境修改本单元。思考: □ 当地可得到的轮椅类型。 □ PSDs和改制在哪里进行,如何开展以及用哪些材料制作。 准备 □ 收集资源,查看幻灯片,观看DVD并浏览单元计划。 □ 把体位支撑装置 (PSD)表的海报钉起来。 □ 把PSDs样品从PSD套件中取出来,并把它们放在教室前面的桌子 (工作台)上,以便 你可以容易拿到。 大纲 1.前言 2.计划和进行轮椅及PSDs准备 3.当制作PSDs时应记住什么 4.用于制作PSDs和改制的材料 5.要点概括 7 10 10 30 3 总单元时间 60 1.前言 (7分钟) !P E • E >E F, PSDs B.12. E : 2 说明: 轮椅服务的第五步是产品 (轮椅)准备。 产品 (轮椅)准备是指安装轮椅并准备已经处方 (选择)的所有PSDs。 179 1. E N4 2. A 3. F 4. 4CAC E FG 7. +6A 8. 5 LA .B.12 E :3 在中级教程中,在需要进行适配之前通常只可能 准备轮椅到一定程度。 轮椅服务步骤中的 “产品准备”和 “适配”可能 需要多次重复直到轮椅正确适配。 通常第一次适配之前,PSDs不完全固定到位。 这是为了确保适配后可以对轮椅和 PSDs进行 调整。 提问:当轮椅使用者坐在轮椅上时,学员认为哪些PSDs最可能需要进行调整? 感谢回答。 答案可能包括以下列出的PSDs和其他: 头靠、坐骨前垫高、躯干侧垫、脚踏板高度和任何脚踏板的改制等等。 说明:当为需要附加体位支撑的人士准备一辆轮椅时,这是需要记住的重要事情。如果可能,在 适配之前尝试准备尽可能多的轮椅和PSDs,然而不要固定或装饰任何东西,否则再调整是不容易的。 !P E • - A - PSDs A,G? - +PSDs, B.12. E : 4 说明: 本单元我们将: 学习如何计划产品准备的工作; 当准备PSDs时,列出需要记住的重要事情; 介绍可以用于制作PSDs的不同材料。 说明: 本单元结束后,学员将为实操一单元中评定的轮椅 使用者准备轮椅。 6/3" 180 VIDEO 介绍DVD:产品 (轮椅)准备。 本录像中我们将看到准备一辆轮椅的案例。DVD中的儿童叫阿里。他返回轮 椅服务单位检查轮椅的原因是,这辆轮椅不能像他需要的那样提供支撑。 阿里脊柱侧弯 (脊柱向一侧弯曲)并且他的骨盆移向一侧且僵硬。他的躯干肌 肉力量很差。轮椅服务人员为他增加轮椅上的支撑。 注意两位轮椅服务人员如何密切地合作,包括阿里和他母亲参与所有的讨论。 同时注意PSDs的适配如何在每次改变/调整的时候进行检查。 播放DVD。 询问是否有任何问题。 2.计划和进行轮椅及PSDs准备 (10分钟) !P E A: A ; B: FGBE PSDs C: F>E !P 6: FG B.12. E : 6 说明: 本教程中我们将按照以下顺序工作: A:计划和准备; B:为适配调整轮椅和准备PSDs。 C:进行轮椅安全和准备检查。 A:计划和准备 开始准备轮椅前,重要的是计划工作。 如果轮椅准备工作交给其他人做 (例如车间的技术员),或如果不止一个人在准备轮椅,详细 计划尤为重要。 计划和准备可能包括以下的步骤: 检查中级轮椅处方 (选择)表: - 确保每个人都理解表上的所有信息; - 确保表上有足够的信息来准备轮椅。例如,所有需要的尺寸都有吗? 不同PSDs的描述够 181 详细吗? 可能需要进一步的讨论或厘清。 决定在选择的轮椅上如何实现必要的支撑: - 观察将要使用的轮椅并提问: - 对实际的轮椅可以做哪些调整以提供必要的支撑? - 轮椅上已经有了哪些PSDs? - 如果改制或需要增加PSDs,决定: - 有预制的支撑可以使用吗? 如果有,如何安装到轮椅上? - 如果改制或PSDs需要由原材料制作,将使用什么材料,并且PSDs如何固定到轮椅上? - 记住思考PSDs和轮椅将如何一起发挥作用。 准备任务列表: - 列出准备轮椅需要完成的任务; - 如果不止一人做这项工作,决定谁负责哪项任务。 B:为适配调整轮椅和准备PSDs 请参考 《学员手册》第112-127页上 “如何制作PSDs”部分。 C:进行轮椅安全和准备检查 轮椅安全和准备检查表已经在轮椅服务初级教程中讲过了。让学员参考 《轮椅服务中级教程》之 《学员手册》上的中级轮椅安全和准备检查表。 提问:有人对使用这个检查表熟悉吗? 有人对于完成这个检查表有问题吗? 回答任何问题。 这个检查表应该在轮椅使用者来适配之前完成。 每次适配之后,可能需要进一步的调整。 在轮椅使用者试用轮椅之前,每次轮椅调整或修改后,都应该进行检查确保安全和准备使用。 说明:记住,在轮椅正确地适配之前,“产品准备和适配”步骤可能需要重复好几次。 6/3" 182 3.当制作PSDs时应记住什么 (10分钟) • E LB - + + - 8F 8,8F - E +6, L - - ? - B.12. E : 7 说明:教程开始的时候,我们已经讨论了轮椅使用 者的需求。我们讨论过重要的是确保轮椅和附加体 位支撑应该: 实用和方便使用; 舒适和不会导致其他的不舒适; 有助于轮椅使用者做想做的事情并且不困难; 好看又不要太 “显眼”。 说明:当准备一辆具有附加体位支撑的轮椅时,以下技巧有用: (1)C, B.12. E : 8 (1)PSDs应该提供足够的支撑 提问:当你在实操单元为轮椅使用者服务时,你总 是用整只手来提供支撑吗? 鼓励回答。 回答: 有时候整只手; 有时候只是手指尖; 有时候部分手。 说明:每位轮椅使用者的支撑程度会有所不同。PSDs应该在正确的地方以及正确的接触表面区域 为每位轮椅使用者提供需要的支撑。 183 (2). + B.12. E : 9 (2)PSDs和轮椅作为一个整体系统发挥作用 轮椅加入附加体位支撑会改变整体系统。例如: - 加入PSDs可能改变轮椅的内部尺寸。 提问:哪些PSDs最可能影响一辆轮椅的内部部件尺寸 (例如座宽和座深)? 感谢回答。 回答: 加入骨盆侧垫会减少座宽; 在靠背表面加入任何PSDs可能减少座深,包括: - 骨盆后垫; - 加入一个楔形垫以增加椅座与靠背的角度; 加入一个坐垫或增加坐垫的高度将升高轮椅中的轮椅使用者,实际上缩短了坐垫顶端到靠背顶端 的距离。 说明:轮椅和PSDs相互影响的其他例子是: 加入PSDs会改变轮椅的重心,使其容易或难以翻倒 (例如加入头靠或重的部件)。 (3). F+Q B.12. E : 10 (3)避免产生高压区域 PSDs有时会在轮椅使用者身体的特定部位产生压 力。例如: 如果轮椅使用者需要很多支撑以防止其偏向一 侧,他的躯干侧垫可能处于高压力区域。在这种 情况下,考虑通过增加表面积来分散压力。应该 确保在PSDs表面和绑带下有足够的衬垫。 6/3" 184 (4). + L7 B.12. E 11 (4)确保PSDs实用和不会降低功能 提问:确保PSDs实用和不会降低功能,需要考虑 哪些事情? 回答: 如果轮椅使用者现在用汽车行李箱运输他们的轮椅,确保加入的所有PSDs同样能放进去。 如果轮椅使用者现在独立地转移,加入的所有PSDs让他/她转移变得困难吗? 轮椅使用者 (或他/她的护理者)仍然容易地够到刹车吗? 如果轮椅使用者能够自己推动轮椅,他/她仍然能够这样做吗? 说明: 记住,轮椅使用者需要轮椅和椅座实用并且容易使用,并且有助于他们尽可能地活跃。 说明: 一些PSDs非常简单,可以在简易的工场制作。其他可能比较复杂需要更多的技能和设施。 轮椅服务人员不必亲自改制或制作PSDs。他们可以与技术人员合作。轮椅服务人员可以说明 他们需要什么以及如何发挥作用,技术员应该想出办法如何用当地可得到的材料和工具制作 出来。 4.用于制作PSDs和改制的材料 (30分钟) 教师提示: 本部分将根据学员当地可得到的材料而调整,并且这些材料可以用于本教程的演示。 本单元最好在实操二中制作PSDs的同一工场进行。把材料放置在一张大工作台上,并让学员聚 在一起。 185 VIDEO 介绍DVD:脚踏板修改的制作。本录像中我们将看到轮椅服务人员为塔西进行脚 踏板改制,他的踝关节有明显的僵硬且不处于中立位。仔细地观看使用的材料。 播放DVD。 提问:使用了什么材料来进行脚踏板改制? 回答: 硬 “EVA”泡沫塑料; 也可以用橡胶人字拖鞋; 泡沫塑料胶水/黏合剂。 展示下面列出的不同材料的例子和使用这些材料来制作的不同PSDs。 说明选择材料可以用于制作什么以及选择材料时要关注哪些内容。 使用下面的注释来指导你。 材料 用于制作PSDs或改制的材料 当制作PSDs或改制选择材料时的关注要点 金属/ 塑料/ 木材 金属/塑料/木材形成PSD的结 构,例如硬椅座和靠背。 木材或金属可以用来制作支架, 固定躯干侧垫到靠背上。 12mm的胶合板用来制作硬椅座和靠背非常有用。它很 坚固但是重量相对较轻。船用胶合板最耐用,但是比 较贵。 如果有,3mm的铝板和6mm的亚克力板或ABS塑料板 也能用于制作硬靠背。在板中加入一层可以增加刚度。 6/3" 186 续表 泡沫 塑料/ 衬垫 泡沫塑料用于包覆PSDs与轮椅 使用者身体直接接触的区域。 硬泡沫塑料能保持其形状,用于 实现PSDs需要的形状来提供正 确的支撑。 较软的泡沫塑料用于增加舒适性 并降低压力。 使用泡沫塑料的例子: 软泡沫塑料应该加到带子上 以分散压力和增加舒适性; 硬泡沫塑料可以用于制作躯 干侧楔形垫,加入到坐垫上 做成大腿外侧楔形垫或大腿 内侧楔形垫; 非常硬的泡沫塑料 (例如, EVA)可以用于制作脚踏板 补高或脚踏板楔形垫和躯干 侧垫。 在当地市场寻找并参观泡沫塑料、鞋、床垫和家具厂发 现当地可得到的泡沫塑料。 尝试找到当地不同厚度 (25mm 和50mm)和不同硬度 的泡沫塑料样品。EVA是非常硬泡沫塑料的样品,它对 提供坚固的支撑和PSD 的结构有用。EVA 有时可以在 生产鞋的工厂找到。用于制作人字拖的硬橡胶可以用来 代替EVA。 质量好的聚合泡沫塑料是中等硬度泡沫塑料的实例。聚 合泡沫塑料可以用作波形/多层坐垫的底座,制作骨盆后 垫或坐骨前垫高,或在硬靠背上塑造轮廓。 软 “床垫泡沫塑料”是软泡沫塑料用于舒适层的实例。 如果没有硬泡沫塑料底座,最常用、便宜的 “非常软” 的泡沫塑料不太适合单独用于制作减压坐垫。 椰壳纤维 (椰子纤维)可以用来代替硬泡沫塑料。 面料 面料用于包覆PSDs。 寻找一种耐用和便于清洁的面料 (通过擦拭或取下清 洗)。如果轮椅使用者大小便失禁,防水面料对于椅座、 坐垫和靠背都有用。柔软的、T 恤类材料 (棉或棉/莱 卡)可以用作头靠和躯干侧垫和躯干侧楔形垫。有弹性 的面料更容易适应PSDs的形状。 合成面料通常比天然面料让人感觉更热。 如果可能,尝试提供至少几种不同的颜色让轮椅使用者 选择。 187 续表 尼龙带/ 尼龙搭 扣/带扣 尼龙带/尼龙搭扣/带扣用于制 作绑带,包括骨盆带、肩带、小 腿带和足带。 25mm、35mm 和50mm 的尼龙带是有用的。带子越宽 压力越均匀。熔化尼龙带的切割端以防磨损。棉织带效 果差些。 插扣 (例如背包上使用的)非常容易使用。如果有,使用质 量好的插扣将会更耐用。通过把它们合在一起和分开来测试。 它们应该容易地分和合,除非松开否则不被拉开。 尼龙搭扣是一个好的紧固件,然而,它需要保持清洁, 否则会失效。 软泡沫塑料垫应该放在所有的织带下面以保护轮椅使用 者的身体。 黏合剂 黏合剂用于粘合木材和泡沫 塑料。 有木材胶 (通常称为白胶水或PVA)和泡沫塑料胶 (接 触黏合剂、鞋胶水或黄胶水)。 确保使用黏合剂的所有人都知道如何正确地使用。 紧固件 紧固 件 用 于 安 装 PSDs 在 轮 椅上。 有用的紧固件包括: 螺栓及螺母 (最好是锁紧螺母)和垫圈。 T形螺母 (取代螺母钉进胶合板); 订书针 (用于固定装饰面料)。 避免使用尖的螺钉,因为如果PSD损坏了,它们会导致 危险。 5.要点概括 (3分钟) • E %CE +6, • FG 7M?GF>-E !.FG • E +6B+E BF>E
• E PSDsB + B.12. E : 13 讲出要点。 询问是否有任何问题。 6/3" 188 实操二:产品 (轮椅)准备 目标 本单元结束后,学员将能够: □ 在小组中和协助下演示为需要附加体位支撑的轮椅使用者准备轮椅和PSDs。 资源 □ 《实训手册》; □ 《教师观察表》:实操二; □ 实操一的空白和完成的中级轮椅评定表和中级轮椅处方 (选择)表; □ 海报:体位支撑装置 (PSD)表; □ 塑封的体位支撑装置 (PSD)表,每位学员1张; □ 塑封的中级轮椅安全和准备检查表,每位学员1张; □ PSD套件; □ 轮椅和PSD材料; □ 工作台和工具箱,每组1个。 情境 和以 前学 过的 内容 以前学过的内容: □ 初级产品 (轮椅)准备,参考 《轮椅服务初级教程》; □ 如何实施轮椅安全和准备检查表,参考 《轮椅服务初级教程》。 根据学员将工作的情境修改本单元。思考: □ 在他们工场将使用的轮椅、PSD材料和工具; □ 轮椅组装的数量或生产需要原材料的数量。教师需要根据这些因素调整本单元的时间 (它可能影响整个培训的课程表)。 准备 □ 安排一位在产品 (轮椅)准备方面具有专长的技术员支持教师和协助学员。 □ 在本实操单元之前让学员穿上全包鞋。 □ 把选择好的轮椅带到工场。 □ 为每组准备一个工作场地以及工作台和工具箱,为学员把PSD材料摆放好以有效率地 工作。 □ 把PSDs样品从PSD套件中取出来,并把它们放在教室前面的桌子 (工作台)上,以 便你可以容易拿到。 □ 把体位支撑装置 (PSD)表海报钉起来。 189 续表 大纲 1.产品 (轮椅)准备: □ 指导和安装; □ 计划和准备; □ 为适配调整轮椅和准备PSD; □ 开展轮椅安全和准备检查; □ 反馈。 10 15 80 15 30 总单元时间 150 1.产品 (轮椅)准备 (150分钟) 教师提示: 观察学员的实操: 用实操二的教师观察表来确保各组执行实操中的所有步骤,并注意良好实操或需要改进实操的例 子用于反馈。 小组活动 分组 把学员按照实操一进行同样的分组。 每组指定一位组长 (可以与实操一的组长相同或不同)。 分配每组一个场地进行工作。 向学员说明哪里可以找到材料和工具。 指导 说明以下的内容: 单元目标: 本实操单元的目标是为实操一中评定的轮椅使用者准备轮椅和PSDs。 工场安全: 在开始用工具和材料工作之前,学员需要记住以下5个安全规则: 在车间穿全包鞋; 当切割或钻孔时,确保你的加工件安全; 当使用电动工具或其他任何锋利的工具时,戴上防护眼镜; 保持工作区域和走道整齐和干净; 不要对着自己或他人切割。 组长: 每组的组长负责确保所有的步骤都实施来准备轮椅。 6/3" 190 续表 教师观察和支撑: 学员可以在任何时候请求协助或厘清。 本单元中教师将监督每组并给予需要的支持和意见。 服务表: 向每组组长分发实操一中已完成的中级轮椅评定表和中级轮椅处方 (选择)表; 实操结束之前收集填写的表格并在下一次实操单元分发。 提问:有问题吗? 回答问题。 监督和 支持 密切地监督各组,确保安全实操,观察和评价学员的技能。 用教师观察表记录你对每组的观察。 整个单元: 给予时间提示 (口头或写在所有学员可以看到的白板上)以帮助学员管理他们的时间。 确保每组学员都积极地参与。 教师提示:一些学员的技术水平可能比其他学员差。在可能和适当的时候,鼓励所有学员 练习准备轮椅和PSDs。尽可能多地给予需要的技术支持。 时间 学员应该按照以下描述的时间顺序: - A:计划和准备 (15分钟)。 - 让学员在 《实训手册》上写下需要完成的任务 (实操二:产品 (轮椅)准备 ——— 任务清单)。 - B:为适配调整轮椅和准备PSDs(允许80分钟)。 - C:进行轮椅安全和准备检查 (允许15分钟)。 - 让学员使用他们 《实训手册》上的中级轮椅安全和准备检查表 (实操二:产品 (轮椅)准备——— 中级轮椅安全和准备检查表)。 - 完成每步之后在实施下一步之前,学员应该与教师确认。 - 30分钟反馈。 如果许多产品 (轮椅)需要准备,将需要更多的时间。 191 续表 反馈 让每组向其他组简要地展示他们准备的轮椅。每组应该说明: 做了哪些改制或PSDs,以及为什么。 改制或PSDs如何制作 (使用的材料和他们如何被安装/固定到轮椅上)。 (每组允许5~7分钟)。 每次展示后,允许几分钟让全体学员向展示组提问。 简要地点评你在实操单元中看到的良好实操的案例。 简要地提出学员可以改进的任何特别的地方———不要针对个人。 提问:有没有任何问题? 教师提示: 实操过程中重要的是密切地注意时间。上面给出的时间只是一个指导———然而,根据学 员的经验、轮椅使用者的需求、安装需要的时间,所需要的时间会变化。教师可以根据需要进行必 要的调整。 B.13:适配 目标 本单元结束后,学员将能够: □ 描述如何检查一辆带PSDs的轮椅,并如何适配给一位需要附加体位支撑的轮椅使 用者。 资源 本单元: □ 幻灯片:B.13:适配; □ 《学员手册》; □ DVD:适配演示———迪帕克; □ DVD:适配演示———卡琳; □ 海报:体位支撑装置 (PSD)表; □ 塑封的体位支撑装置 (PSD)表———每位学员1张; □ 塑封的中级轮椅适配检查表———每位学员1张。 6/3" 192 续表 情境 和以 前学 过的 内容 以前学过的内容: □ 《轮椅服务初级教程》主要为能够坐直且不需要附加支撑的轮椅使用者进行轮椅适配。 中级服务步骤是一样的,然而,本单元增加一些更详细的内容。 □ 如何实施压力测试以检查轮椅使用者坐骨下的压力。学员应该在本单元之前熟悉如何 实施。 根据学员将工作的情境修改本单元。思考: □ 通常可得到的轮椅和PSDs的类型。 准备 □ 收集资源,检查幻灯片,观看DVDs并浏览单元计划。 □ 把体位支撑装置 (PSD)表的海报钉起来。 大纲 1.前言 2.如何开展适配 3.要点概括 2 55 3 总单元时间 60 1.前言 (2分钟) !P 4: 2 FG • - 4E FG > - F>4E FG B.13. FG—— 说明: 适配是轮椅服务8个步骤中的第6步。 在适配过程中,轮椅使用者和轮椅服务人员确保 轮椅和PSDs良好地适配,并且支撑轮椅使用者 尽可能舒适地接近中立位坐姿。 本单元,我们将介绍中级轮椅适配检查表和讨论 如何开展轮椅适配。 193 2.如何开展适配 (55分钟) 1. E N4 2. A 3. F 4. 4CAC E FG 7. +6A 8. 5 LA . B.13 FG——4: 3 说明: 学员应该熟悉开展轮椅适配的过程。 在中级服务中,适配可能时间长些,并且可能需 要进行多次。 分发塑封的中级轮椅适配检查表。 该检查表是一个指导,它有助于轮椅服务人员记住轮椅适配中最重要的事情。 通过实践,这个过程会变得更快更容易。 一开始,按照检查表确保不遗漏任何事情。 E E PSDs FG E +60E0 FG M?F!,> B.13.FG——4: 4 指出检查表中显示的适配步骤: (1)轮椅准备好了吗? (2)检查轮椅和PSDs适配。 (3)检查姿势。 (4)检查压力。 (5)在轮椅使用者移动过程中检查适配。 (6)决定是否需要进一步的行动。 提问:学员可能在轮椅使用者家中或在轮椅服务中心开展轮椅适配吗? 鼓励回答。 说明:无论在轮椅使用者家中或在轮椅服务中心开展轮椅适配,确保你有以下的工具: 轮椅使用者中级轮椅评定表和中级轮椅处方 (选择)表; 卷尺或游标卡尺; 用于调整轮椅或PSDs的任何工具。 准备几块泡沫塑料也有用,以防你需要尝试其他的附加体位支撑。 6/3" 194 VIDEO 介绍DVD:适配演示———迪帕克。我们现在将观看一个短片,该短片演示为迪帕 克 (我们之前见过)适配轮椅。 让学员仔细观看。 播放DVD。 询问是否有任何问题。 提问:在迪帕克的右脚下面加入一些泡沫塑料垫为什么是重要的? 回答:当双脚完全支撑的时候,更舒适和容易平衡。如果没有泡沫塑料垫,迪帕 克只能一只脚接触脚踏板。 提问:轮椅服务人员把一些附加的泡沫塑料垫放在靠背上为迪帕克的躯干提供更 好的支撑。它如何长期地固定到靠背上? 回答:泡沫塑料可以粘在靠背上,在装饰面料里面。 提问:在适配检查过程中,让轮椅使用者推动他们的轮椅 (或如果他/她不能自己 推动,由他人推行)为什么重要? 回答:一旦轮椅移动或产生推动效果的时候,个人的姿势会发生改变。 说明: E " • B.E 4E +6B+ • F -4E > B.13.FG—— 4: 6 (1)轮椅准备好了吗? 说明: 应该确保轮椅为轮椅使用者试用准备好了。 这意味着已经完成了中级轮椅安全和准备检 查表。 通过不断实践,这步检查将变得更快。 2 E PSDsFG B.13.FG—— 4: 7 (2)检查轮椅和PSDs适配 说明: 在轮椅适配过程中,轮椅服务人员需要仔细地检 查轮椅适配是否正确。 下面几张幻灯片,我们将复习如何检查轮椅和 PSD适配。 195 • E +67 % • B?8F B.13.FG——4: 8 当检查轮椅座宽时,确保: 轮椅使用者的臀部舒适地坐在扶手之间或骨盆侧 垫之间; 轮椅使用者的大腿舒适地放在扶手、挡泥板/护 裙板之间或骨盆侧垫之间,不会挤在一起。如果 骨盆侧垫向前伸得太长,两腿就会挤在一起。 轮椅使用者的躯干舒适地靠在靠背立杆之间或躯 干侧垫之间。 为了检查轮椅/臀的宽度: 手指在轮椅使用者大腿外侧滑动; 手指应该感觉到舒适。 • .E +6 - P, G3CM6 • E +670 L8B 30mm,L L • B.13.FG——4: 9 当检查座深时,确保: 轮椅使用者舒适地坐在接近中立位坐姿; 椅座/坐垫前部与轮椅使用者腘窝之间至少有 30mm 的间隙。长腿的轮椅使用者可能需要较大 的间隙,60mm 以下都可以接受。 为了检查椅座深度: 手在坐垫与腘窝之间滑动。数一下有几根手指。 手在小腿后部向下滑动并确保小腿不碰到椅座/ 坐垫; 检查两侧。 如果左右两腿长度不同,根据较短腿的测量值开 具处方。 6/3" 196 • P Q! P ,M • P, PSIS 7G • P, 3 FG • P, E + 6,,6 B.13.FG——4: 10 当检查骨盆时,确保: 坐骨前垫高正好位于坐骨的前面 (把你的手放在 轮椅使用者的臀部下面来检查); 骨盆后垫在PSIS处提供支撑,并且不会挤压腰部; 骨盆侧垫紧密贴合并且不高于髋关节; 骨盆带可以牢固地拉紧并且不会挤压轮椅使用者的 皮肤 (在带子和轮椅使用者之间用手进行检查)。 • D D 70 • 638F ,6 • M 7 6 7G B.13.FG——4: 11 当检查躯干时,确保: 躯干侧垫和躯干侧楔形垫不要对腋窝施加压力。 轮椅使用者腋窝和躯干侧垫顶端应该至少30mm 的间隙; 肩带舒适的穿上并且不会挤压皮肤; 桌面板支撑整个前臂和肘关节,并且不会挤压腹 部。经过切割改制的桌面板可以靠近身体,然而 它不应该碰到或摩擦轮椅使用者的皮肤。 检查靠背高度和后倾角度。 • MB NE +6, > -0, B.13.FG——4: 12 检查头靠适配: 头靠应该在颅底支撑轮椅使用者的头。 头靠应该支撑轮椅使用者的头使其处于平衡和直 立的姿势。 197 • E +6,7 7 L" , • 7L 76" B.13.FG——4: 13 当检查轮椅使用者大腿时,确保: 轮椅使用者大腿和大腿支撑之间没有大的压力 (包括大腿外侧垫、大腿内侧楔形垫或膝分隔 垫); 膝分隔垫不会施加任何压力在腹股沟区域。 • 7 , " LL • 7,G
GB 7D " LL B.13.FG—— 4: 14 最后,检查脚踏板高度: 检查轮椅使用者的大腿完全支撑在椅座/坐垫上 没有间隙,并且他们的双脚完全支撑在脚踏板上 没有间隙。 如何检查: - 手在大腿和椅座/坐垫之间滑动。整个大腿的 压力应该均等并且没有间隙; - 查看脚踏板上的每只脚。脚的前部和后部应平 放在脚踏板上并且没有间隙。 B.13.FG —— 4: 15 (3)检查姿势 检查完轮椅和PSDs的适配后,轮椅服务人员应 该检查轮椅使用者的姿势是否舒适地坐直。 6/3" 198 • E +6 8F - M M? - P,-0 " 7 - D-0 0 7 - G> -0 7 - 7 7 7 F-0 B.13.FG——4: 16 从前面和侧面观察轮椅使用者的姿势。 要检查轮使用者是否舒适地坐直。这应该接近于 用手模拟确定的姿势。 具体来说,从前面到侧面进行检查: - 骨盆直立和水平吗 (如果可能)? - 躯干直立和对称吗 (如果可能)? - 头部平衡和直立吗 (如果可能)? 双腿和双脚尽可能地接近直立坐姿吗? 询问轮椅使用者感觉如何。 • .!PSD'A A - M6QM6 BM6 ( - - M - P, D - 7 7 .B.13FG—— 4: 17 观察轮椅使用者的整个坐姿后,检查每个PSD 是否按照计划提供支撑。 具体来说,记住检查 (如果已经提供): - 靠背高度、后倾和调整靠背形状; - 整体后倾; - 头靠; - 骨盆侧垫和躯干侧垫; - 所有的大腿和小腿支撑。 B.13.FG ——4 : 18 (4)检查压力 199 • ! + +NL,E +6 P NLG, B.13.FG——4 : 19 对于有发生压疮风险的每位轮椅使用者,适配步 骤包括检查坐骨下的压力是否安全 (用 《轮椅服 务初级教程》中讲过的徒手压力测试方法)和其 他所有的风险部位 (例如髋关节或尾骨下)。 • +PSDs ,!E +6 E +6DG PSD L, B.13.FG——4 20 对于用PSDs来提供稳固支撑的每位轮椅使用者, 检查轮椅使用者身体部位与PSD之间的压力。应 该感觉支撑稳定,但不紧。 教师提示: 如何检查所有具有压疮风险的轮椅使用者坐骨下的压力已经在 《轮椅服务初级教程》中 讲过了。简要地展示压力测试方法/播放初级DVD “压力测试演示”或让一位学员来演示。 VIDEO 介绍DVD:适配演示———卡琳:观看本短片,它演示了轮椅服务人员为一位叫卡 琳的女孩进行轮椅适配。轮椅服务人员检查所有部件的适配并仔细地确保所有的 带子安装牢固———但不是太紧。 播放DVD。 询问是否有任何问题。 6/3" 200 E +60E0 FG B.13.FG ——4: 22 (5)在轮椅使用者移动过程中检查适配 轮椅适配的最后部分是在轮椅使用者移动过程中 检查轮椅适配情况。 • M6AE +68+ 0 6 E • E ,0>8E +6 ,? 8F0 B.13.FG—— 4: 23 检查的内容包括: 靠背允许轮椅使用者自由地移动双肩来推轮 椅吗? 轮椅的移动或推行动作会导致轮椅使用者改变他 们的姿势或感觉不舒适或不稳定吗? • + E,5E +6E !.
• +7+7E , +6 Q $! . B.13.FG—— 4: 24 手推轮椅:后轮的位置对于轮椅使用者推轮椅是 否正确以及他/她能推动吗? 脚推轮椅:对于用脚推行的轮椅使用者,椅座的 高度和椅座深度正确吗? 体位支撑允许不受限和安全的轮椅移动吗? 说明:如果轮椅使用者不能自己推轮椅,当你观察的时候,让一位家人/护理者来推他们。 201 M?F!,> B.13.FG ——4: 25 (6)决定是否需要进一步的行动 说明: 所有的检查进行完后,轮椅使用者和轮椅服务人 员需要决定是否需要进一步的行动。 对于需要附加体位支撑的轮椅使用者,首次适配 后,通常需要进行一些调整。 如果进行了调整,适配步骤应该从头开始再次 重复。 通过练习,这个过程会变得更快,因为轮椅服务人员 将变得更熟练,关注到哪些适配和哪些需要调整。 说明:在本教程中,学员将与轮椅使用者一起练习开展两次适配。 3.要点概括 (3分钟) • FG !P E E PSDsFG E +60E0 FG M?F!,> • 4E FG 7M? LK 7M ?GF> B.13.FG—— 4: 26 讲出要点。 询问是否有任何问题。 6/3" 202 B.14:使用者培训 目标 本单元结束后,学员将能够: □ 对于那些接受轮椅改制或PSDs的轮椅使用者,强调轮椅服务人员可以教给他们的6项 技能; □ 演示教一位同事至少3项轮椅技能。 资源 本单元: □ 幻灯片:B.14:使用者培训; □ 《学员手册》; □ 《实训手册》; □ 海报:中级轮椅使用者培训检查表; □ 塑封的中级轮椅使用者培训检查表——— 每位学员1张; □ 轮椅——— 每组1辆。 情境 和以 前学 过的 内容 以前学过的内容: □ 轮椅使用者培训的更多信息包含在 《轮椅服务初级教程》中。 □ 教师应该确保学员已经熟悉本步骤,并且具备教初级轮椅操作、转移、轮椅使用和移 动、预防压疮、如何在家保养轮椅和如果有问题应怎么办的技能。 根据学员将工作的情境修改本单元。思考: □ 是否有支援小组或同侪小组的教师,他们可以在为轮椅使用者和他们的家人/护理者进 行使用者培训方面提供协助。 准备 □ 收集资源,检查幻灯片并浏览单元计划。 □ 把中级轮椅使用者培训检查表海报钉起来。 大纲 1.前言 2.使用者培训——— 轮椅使用者故事 3.要点概括 5 50 5 总单元时间 60 203 1.前言 (5分钟) • ,E +6 B4 E +6 / *6M?,(G?, !P +6A B.14. +6A: 2 说明: 使用者培训是提供轮椅服务的第7步。 通过 《轮椅服务初级教程》,学员应该熟悉本 步骤。 在中级服务中,轮椅使用者需要的信息有时会 不同。 本单元我们将完成3个不同的轮椅使用者案例,它将有助于强调中级服务中轮椅使用者和他们 家人/护理者需要学习的一些特别重要的内容。 提问:培训轮椅使用者 (和他们的家人/护理者)使用具有附加体位支撑的轮椅时,有人可以想到 需要哪些不同或附加的信息吗? 鼓励回答。 回答: 关于附加体位支撑好处的信息; 如何正确使用PSDs(它们应该如何适配和如果有问题该怎么办); 有关逐渐习惯轮椅 (尤其是儿童)和PSDs的信息; 如何拆卸和安装 (例如为了运输)带PSDs的轮椅; 不同类型的转移——— 对于无法自己上下轮椅的人士。 说明: 在 《学员手册》上的 “使用者培训”单元包含本轮椅服务步骤的关键信息。 《学员手册》上的中级轮椅使用者培训检查表可以用作一个指导,用于帮助轮椅服务人员发现 轮椅使用者和他们的家人/护理者需要知道些什么,并教这些内容。你不需要给每位轮椅使用 者教所有的内容。 本单元,我们将介绍3个不同的轮椅使用者故事,它将有助于强调中级轮椅服务中使用者和他 们家人/护理者需要学习的一些特别重要的内容。 6/3" 204 2.使用者培训———轮椅使用者故事 (50分钟) 小组活动 分组 把学员分成3人一组 指导 每组分配一个 《实训手册》(B.14:使用者培训)上的轮椅使用者故事。确保每位学员 都有 《学员手册》。 让每组阅读分配给他们的实训手册上的轮椅使用者故事。 根据轮椅使用者故事中提供的信息,让学员决定轮椅使用者需要学习哪种技能来使用和 保养他们的新轮椅,并完成他们 《实训手册》上的中级轮椅使用者培训检查表。 让组内的每个人选择一个角色 (轮椅使用者、轮椅服务人员、轮椅使用者家人/护理 者)。 让每个人承担轮椅服务人员的角色,并从中级轮椅使用者培训检查表中选择至少3项技 能来教轮椅服务者和他们家人/护理者。 向学员说明,其中的两个轮椅使用者故事中是儿童,他需要一个人抱起。因此不可能真 正地与成人一起练习该技能。学员应该描述,而不是真正地抱起。 提醒学员思考 “如何让轮椅使用者培训成功”。强调演示后实操的重要性。 鼓励学员检查 《学员手册》上他们教的每项技能的信息。 说明:学员有35分钟时间进行这项活动,然后各组将返回原地进行反馈。 监督 密切地监督各组。 确保每组明白该活动。 鼓励每组使用 《学员手册》。 确保每组选择适用的技能教给轮椅使用者和家人/护理者 (参考以下的教师提示)。 确保阅读珊吉塔故事的小组为她的家长增加一些不同姿势的信息,并说明轮椅和附加体 位支撑对于珊吉塔的好处。 确保安全地实操。 如果必要,纠正任何技巧。 如果必要,指导学员。 205 续表 时间 允许35分钟活动。 允许15分钟反馈。 反馈 让每组选一人出来: 简要地描述他们培训的轮椅使用者; 列出轮椅使用者需要学习的最重要内容。 跟随并增加报告中忽略的信息并纠正给出的不准确细节。 教师提示: 约书亚是一位6岁的脑瘫儿童。他有突然不受控制的运动。为他处方 (选择)了一辆带有PSDs的 儿童轮椅,包括骨盆带、骨盆侧垫和躯干侧垫。约书亚的皮肤较薄且敏感,并且躯干侧垫配了附加 的衬垫有助于确保躯干侧垫不会导致压疮。 约书亚的新轮椅具有后倾功能,这让轮椅有时可以后倾并且让他头部更直立。这辆轮椅也有一个防 翻杆,在经过粗糙地面或上下路缘时,这个防翻杆也可以移开。为了运输,该轮椅后轮可拆卸以及椅 座可以从轮椅架上拿开。 约书亚每天早上去幼儿园。他由幼儿园安排的运输服务单位进行接送。交通工具是一个小的摩托三 轮车。他父母担心这辆轮椅是否可以放在里面。 约书亚前来对他的新轮椅进行适配。他妈妈和他一起过来。 学员应该教的技能 学员应该强调的特殊点: 轮椅操作: 所有技能。 转移: 协助下转移。 轮椅的使用和移动: 协助推行; 在轮椅上可以坐多长时间。 轮椅操作: 后倾: 说明使用后倾的原因:平衡躯干和头部直立; 如何在适当的位置安全地 “锁定”后倾; 何时和为什么要调整后倾。 防翻杆: 使用防翻杆的原因,阻止轮椅后翻; 当外出时需要拆卸防翻杆,因为经过粗糙地面或上下路缘时它 会形成障碍。 6/3" 206 续表 预防压疮: 检查压疮; 如果发生了压疮,怎么办。 如何在家保养轮椅: 所有的技能; 如果有问题,怎么办: 所有的技能。 为了运输把需要拆卸的所有PSDs取下来和放回去: 如何拆卸后轮; 如何把椅座从轮椅架上拿下来; 如何把轮椅恢复原位。 转移: 当转移时,让膝关节高于髋关节; 当紧固骨盆带的时候,让约书亚躯干向前弯; 演示骨盆带应该多紧; 强调如何检查约书亚在轮椅上的位置:臀部贴着靠背;坐骨在 坐骨前垫高的后部;躯干侧垫靠近他身体,但是不要挤压。 轮椅的使用和移动: 室内和户外由妈妈和朋友安全地推行。 预防压疮: 检查轮椅或PSDs接触身体所有区域的皮肤; 如果没有压痕,在轮椅上的时间每天增加10分钟,一直到每 次最长2小时; 每次约书亚离开轮椅的时候,检查他的皮肤。 如果出现红斑并在约书亚离开轮椅后持续超过20分钟,在红 斑消失之前他不应该继续坐在轮椅上。 珊吉塔是一位脊柱裂的3岁儿童。她运动困难,她腰部以下感觉丧失并且她的脊柱底部膨出。她父 母说她难以控制自己的大小便,经常泌尿系统感染。 珊吉塔来到轮椅服务单位对她的第一辆轮椅进行适配,这辆轮椅有快拆轮、骨盆带、骨盆侧垫,异 形的靠背避开压迫她的脊柱膨出。她也有一个减压坐垫。她和她父母一起过来。父母担心如果有了 一辆轮椅她将不再想用她的膝踝足矫形器走路。然而,当她无法与兄弟姐妹一起在外玩耍的时候, 她感到沮丧。 207 续表 学员应该教的技能: 学员应该强调的特殊点: 轮椅操作: 所有的技能。 转移: 独立 (有或者没有膝踝足矫 形器) 轮椅的使用和移动: 正确地推、斜坡、台阶、使 用防翻杆 预防压疮: 检查压疮 强调:检查膨出周围的皮肤 上是否有压痕 如何在家保养轮椅: 所有的技能。 如果有问题,怎么办: 所有的技能。 转介至泌尿科医生: 膀胱管理和预防尿路感染 转移: 与她的父母讨论,珊吉塔尽可能地独立地自己转移,这对她 有益。 轮椅的使用和移动: 让珊吉塔的父母放心,使用轮椅不会阻碍她行走。说明轮椅的好 处包括: 轮椅将有助于她在户外紧跟她的兄弟姐妹,也有助于她保持健 康和活跃; 轮椅将解放她的双手而不是握住拐杖来移动,她可以坐在轮椅 上并用双手做其他事情; 轮椅有助于珊吉塔以良好的姿势坐并预防姿势问题的发展。 坐在轮椅上的持续时间: 刚开始时珊吉塔应该每天使用轮椅较短时间 (例如30分钟) 几次; 当珊吉塔适应轮椅后,逐渐增加使用时间; 珊吉塔不应该坐在轮椅上超过2小时而没有休息。 预防压疮: 检查身体上所有与轮椅或PSDs接触部位的皮肤。 如果没有压痕,在轮椅上的时间每天增加10分钟,一直到每 次最长2小时; 如果出现红斑并在珊吉塔离开轮椅后持续超过20分钟,在红 斑消失之前她不应该继续坐在轮椅上。 转介: 由于珊吉塔经常泌尿系统感染,轮椅服务人员可以转介珊吉塔 给医生以提供安全管理膀胱的建议。 6/3" 208 金颂40岁,他15年前脑损伤。因为他吃东西困难,所以非常瘦。他的脊柱僵硬向前弯曲。金颂不 能站立并且完全依赖他母亲。他不能说话,但是他母亲说他明白简单的指令。 在评定过程中,他被确认为有发生压疮的风险。因为他瘦,不能独立地移动并且过去曾经有过压疮 (躺在床上的时候)。 他刚刚获得第一辆轮椅。轮椅有一个减压坐垫和PSD帮助他坐得更舒适。他妈妈是他的护理者并且 和他一起参加轮椅适配。 学员应该教的技能: 学员应该强调的特殊点: 轮椅操作: 所有的技能 (除了后倾和防 翻杆)。 转移: 协助下转移。 轮椅的使用和移动: 协助下推行; 坐在轮椅上多长时间。 预防压疮: 检查压疮; 如果发生压疮,怎么办。 如何在家保养轮椅: 所有的技能。 如果有问题,怎么办: 所有的技能。 转移: 对于一位成年男子,重要的是需要两个人把金颂抬起。 与金颂的母亲一起讨论,她如何帮助金颂上下轮椅。有人帮助 她吗,她知道如何安全地抱吗? 检查/教正确的转移技巧。 强调如何检查金颂在轮椅中的位置:臀部贴着靠背;坐骨在坐 骨前垫高的后面;躯干侧垫靠近身体但是不要挤压身体。 轮椅的使用和移动: 教金颂的母亲如何安全地在粗糙地面、上下斜坡和台阶推 轮椅。 如果她不得不推金颂上下斜坡和上下台阶,教她如何寻求 帮助。 预防压疮: 金颂不应该一次坐超过2小时。 从30分钟开始,逐渐增加坐的时间。 他离开轮椅后,立即检查他的皮肤是否有压痕/红斑。 金颂离开轮椅之后,如果有任何红斑出现并且持续超过20分 钟,他不应该继续坐在轮椅上直到红斑消失。 如何在家保养轮椅: 从金颂的母亲那里了解是否有人可以帮助她保养轮椅。 209 3.要点概括 (5分钟) • 5E +6,N G?,7 - E - E0 - E + 0 - NL + - E - LN • A7 G?, D1 !BFE/9 7L 5 4 B.14.+6A: 3 讲出要点。 询问是否有任何问题。 实操三:适配和使用者培训 目标 本单元结束后,学员将能够: □ 演示中级轮椅适配。 □ 演示中级轮椅使用者培训。 资源 □ 教师观察表:实操三; □ 肖像同意表; □ 来自于实操一的空白和已完成的中级轮椅评定表和中级轮椅处方 (选择)表; □ 海报:体位支撑装置 (PSD)表; □ 海报:中级轮椅使用者培训检查表; □ 塑封的体位支撑装置 (PSD)表——— 每位学员1张; □ 塑封的中级轮椅适配检查表——— 每位学员1张; □ 塑封的中级轮椅使用者培训检查表——— 每位学员1张; □ 具有检查床和屏风的洁净和私密空间,用于让每组为轮椅使用者服务; □ 实操二中准备的轮椅并用于进行首次适配; □ 数码相机; □ 卷尺和卡尺——— 每组1个,足垫块——— 每组1套; □ 用于调整轮椅的PSD套件和工具套件——— 每组1套。 6/3" 210 续表 情境 和以 前学 过的 内容 根据学员将工作的情境修改本单元。思考: □ 文化因素——— 例如让不同性别的组员在一起进行评定是否合适; □ 当学员对轮椅使用者进行适配时,注意由身体接触引起的任何文化问题; □ 语言因素——— 例如参与的轮椅使用者是否与所有学员讲同一种语言; □ 当评定或处方轮椅时,主办/培训机构可能需要的任何资料——— 例如服务单位需要收 集轮椅使用者获得服务的任何附加信息 (例如转介来源); □ 教师将如何处理在适配中出现的问题,这些问题无法在单元或教程中得到解决。例如 ——— 准备的轮椅不适配和无法调整来适配 (可能的解决办法是确保有一定尺寸范围另 外的轮椅可以使用); □ 培训结束后,每位轮椅使用者的随访如何处理。 准备 □ 与轮椅使用者的志愿者确认时间和行程安排。确保为轮椅使用者和他们家人/护理者 准备饮食。 □ 当他们到达的时候安排一人去迎接他们,并引导他们在单元开始之前待在哪里。 □ 为每组准备适配场地 (检查床和隐私屏风)。 □ 确保将适配的轮椅完全准备好 (对照中级轮椅处方 (选择)表进行检查,并确认中级 轮椅安全和准备检查表已经完成)。 □ 如果超过3组学员,再请一位教师来协助管理。 □ 把体位支撑装置 (PSD)表海报钉起来。 □ 把中级轮椅使用者培训检查表海报钉起来。 大纲 1.适配和使用者培训实操: 指导和安装 适配 使用者培训 15 90 45 总单元时间 150 211 1.适配和使用者培训实操 (150分钟) 教师提示: 1.照片: 确保每位轮椅使用者已被要求签署肖像同意表。确保轮椅使用者明白他们的同意是自愿的,并且 照片将被用作本教程的进一步培训。 对每位已经同意的轮椅使用者在实操中按照以下进行拍照: - 在适配后的轮椅上 (前面和侧面)。 2.满足参与实操单元的轮椅使用者的需求: 不是所有带PSDs的轮椅都可能在实操单元的时间内完成。 如果实操单元中看到的轮椅使用者需要其他预约,教师应该确保预约是由主办/培训机构做出, 并且所有的评定、处方和适配信息将移交给主办/培训机构,用于完成PSD/轮椅的最后交付。 3.观察学员的实操: 用实操三的教师观察表,确保各组执行实操中的所有步骤并且注意良好实操的常见例子。 小组活动 分组 把学员按照实操一和实操二相同的分组。 每组指定一位组长 (组长可以与实操一或实操二相同或不同)。 分配每组工作的场地。 说明在哪里可以找到材料和工具。 指导 说明所有以下内容: 单元目标: 本实操单元的目标是实施轮椅服务8个步骤中的第6部和第7步———适配和使用者培训 ———为之前实操单元的轮椅使用者服务。 学员可能无法在有限的时间为轮椅使用者完成轮椅适配。这将取决于首次适配和可能需 要哪些改制/调整。然而,学员应该尽可能地在单元时间多完成工作。如果轮椅无法完 成,将与轮椅使用者一起安排确保他们的轮椅在培训后完成。 6/3" 212 续表 指导 组长: 每组的组长负责确保所有的步骤都完成。 组长应该是与轮椅使用者和他们家人/护理者沟通的主要人员。否则太多人同时讲话会 造成混乱。教师观察和支持: 学员可以在任何时候请求协助或解释。 在实操过程中,教师将监督每组及根据需要提供更多的支持和建议。 向学员说明,如果发现轮椅适配有任何问题,他们应该请教师来检查,并讨论可能需要 什么改制/调试。 完成适配后,学员应该请一位教师来检查适配情况。只有经过教师检查轮椅适配后才可 以开始使用者培训。 完成使用者培训后,学员应该请一位教师来,与本组学员及轮椅使用者一起讨论为轮椅 使用者提供了什么培训。 允许的时间: 学员应该在90分钟内完成适配 (包括进行任何调整),以及用45分钟进行使用者培训。 服务表: 向每组组长分发以前实操的轮椅评定表和轮椅处方 (选择)表。 确保每组至少有一份塑封的中级轮椅适配检查表和中级轮椅使用者培训检查表。 提问学员:轮椅适配的步骤是什么? 感谢正确回答。 提醒学员,他们应该只教与轮椅使用者有关的技能。例如,对于没有发生压疮风险的轮椅 使用者,没有必要教减压技巧。 提醒学员他们应该让轮椅使用者积极地参与过程中的每步。 提问:是否有任何问题? 回答任何问题。 要求每组准备他们将工作的场地,然后再邀请轮椅使用者开始工作。 213 续表 监督和 支持 密切地监督各组,确保安全地实操,观察和评价学员的技能。 用教师观察表记录你对每组的观察。 整个单元: 使用时间提示 (口头和/或写在学员可以看到的白板上)以帮助学员管理时间。 确保轮椅使用者积极参与。 确保每组学员积极参与。 本单元结束后,要求学员感谢轮椅使用者的参与。 在实操单元中,对签署肖像同意表的轮椅使用者进行拍照。 时间 允许15分钟指导和安装,90分钟完成适配和45分钟完成使用者培训。 反馈 见B.15整合所有知识。 教师提示: 在实操单元中,重要的是密切关注时间。上面给出的时间只是一个指导———然而,根据 学员的经验,轮椅使用者的需求或调试轮椅需要的时间,以上的时间可以调整。教师可以根据需要 进行调整。 B.15:整合所有知识 目标 本单元结束后,学员将能够: □ 对他们在实操单元服务过的轮椅使用者进行总结,包括:轮椅使用者的身体、环境和生 活方式需求、处方 (选择)方案和轮椅使用者适配以及提供适合的使用者培训。 资源 本单元: □ 《实训手册》; □ 实操单元中拍摄的轮椅使用者 (已经签署了肖像同意表的)照片。 准备 □ 收集资源并浏览单元计划。 □ 确保轮椅使用者的照片以他们的名字命名,并保存在培训电脑上。 6/3" 214 续表 大纲 1.前言 2.学员准备 3.学员报告和讨论 5 30 85 总单元时间 120 1.前言 (5分钟) 说明: 本单元,学员将有机会: - 与其他人分享他们在最后3个实操单元学到的知识; - 提出他们对于中级轮椅服务仍然存在的问题; - 说明他们的临床逻辑和其他学员提出的质疑。 2.学员准备 (30分钟) 小组活动 分组 让最后3次实操单元在一起工作的学员再在一起工作。 指导 要求每组准备10分钟关于他们服务的轮椅使用者以及他们所学到知识的报告。他们的报告 应该包含 《实训手册》上的要点 (B.15:整合所有知识)。 说明轮椅使用者的照片在培训电脑中,当他们报告的时候,他们可以用来说明他们的故事。 教师提示:如果学员不方便使用电脑,向他们说明教师将为他们整理照片并在需要时播放。 监督 密切地监督各组。 确保每组明白活动。 如果必要,引导学员。 时间 允许30分钟活动 反馈 见3.学员报告和讨论 215 3.学员报告和讨论 (85分钟) 要求每组轮流地报告。 鼓励所有小组在报告结束后提问: 在报告过程中,建议学员做好问题的笔记以便在每个报告结束后提问; 鼓励学员质疑报告小组提出的决定和方法。最好是,这将激发所有学员的讨论、争论和深入 分析。 允许每个报告10分钟,提问5分钟 (取决于小组的数量)。 每个报告结束后: 作出最后的评论,包括对报告者积极的观点。 感谢每组的报告。 所有报告结束后: 提醒学员通常不是只有一个正确的解决办法。最好的解决办法有时可能是一个折中——— 既要最 有效地利用现有资源,又要最好地满足轮椅使用者的所有需求和期望。 教师提示: 问题的目的在于表明报告者决定的自信心,而不是暗示他们做错了一些事情。 应该以一种友好的方式提出问题和质疑。 B.16:保养、维修和随访 目标 本单元结束后,学员将能够: □ 描述随访中包含什么内容; □ 为轮椅使用者完成轮椅随访表。 资源 本单元: □ 幻灯片:B.16:保养、维修和随访; □ 《学员手册》; □ 《实训手册》; □ 轮椅随访表。 6/3" 216 续表 情境 和以 前学 过的 内容 以前学过的内容: □ 中级轮椅随访表与初级轮椅随访表相同。参加过轮椅服务初级教程培训的学员应该对这 个表很熟悉。 根据学员将工作的情境修改本单元。思考: □ 随访在学员的单位如何进行。例如,服务单位在轮椅使用者家中进行随访;或邀请轮椅 使用者到服务单位进行随访;或与社区康复员合作进行随访。 □ 学员是否来自于一个轮椅服务单位,该单位有一个随访制度。如果有,向学员说明该制 度。说明他们在随访中的职责。 准备 □ 收集资源,查看幻灯片和浏览单元计划。 大纲 1.前言 2.随访概述 3.轮椅随访表 4.练习随访 5.要点概括 2 8 10 35 5 总单元时间 60 1.前言 (2分钟) !P 5 LA B.16. 5 LA: 2 • 5 LA,4 E 4 0 • - LA, - 6LAM?L,E +6,(!G ? 说明: 保养、维修和随访是轮椅服务的第8步。 保养、维修和随访的信息已经在 《轮椅服务初级 教程》中介绍了。 本单元,我们将更新已经在初级服务中介绍过的 随访信息,并思考随访对于使用附加体位支撑的 轮椅使用者的特殊重要性。 217 2.随访概述 (8分钟) • ,E +6GLA , • LA5(G? - 1 - + +NL,E +6 - F>++,E +6 - E M?L,E +6 - A L,E +6 B.16.5 LA: 3 说明: 所有的轮椅使用者都将从随访中受益。随访对于 以下人员最为重要: - 儿童; - 有发生压疮风险的轮椅使用者; - 有进行性疾病的轮椅使用者; - 在轮椅上需要附加体位支撑的轮椅使用者; - 接受任何培训或指导有困难的轮椅使用者。 大多数中级轮椅使用者需要附加体位支撑,因此随 访特别重要。 • " .,? • LAK LF> E +6, M" • 7 E , F >LA • *1!3j6 F>LA B.16.5 LA: 4 说明: 何时应该进行随访没有明确的规定,因为进行随 访的最佳时机取决于轮椅使用者的需要。 然而只要有可能,在轮椅交付后的6周之内进行 随访都是非常有用的,确保轮椅使用良好并且加 强使用者培训。 对于儿童来说,如果每3~6个月进行一次随访 是比较理想的。这是因为随着儿童的成长,他们 的需求变化很快。 • E +6, • E • F E +6 E , B.16. 5 LA: 5 随访可以在以下地点进行: - 在轮椅使用者家中; - 在轮椅服务中心; - 在其他适合轮椅使用者和轮椅服务人员的任 何地方。 地点取决于轮椅使用者是否能够前往轮椅服务中心, 以及轮椅服务人员是否能够前往轮椅服务者家中。 6/3" 218 提问:在学员的轮椅服务中心,随访如何管理 (或现在如何管理)? (例如,随访在哪里进行,随 访多久一次,谁负责随访,以及随访预约如何安排?) 鼓励回答。 回答: 一些学员可能会说,随访不会经常在他们的轮椅服务中心进行; 当轮椅使用者收到轮椅的时候,就和他们预约随访时间; 随访可以在轮椅使用者家中或轮椅服务中心进行; 把随访作为日常社区家访的一部分,由已经接受过培训的社区康复人员 (CBR)对轮椅使用者进 行随访; 可以安排电话随访 (例如,在交通困难的地区和轮椅使用者能够使用电话的情况下); 随访所需要的时间可能会不同。 教师提示: 这是一个与学员讨论 “轮椅服务中心的随访如何改进”的好时机。如果通过讨论获得一 些好的观点,教师可以将这些信息反馈给轮椅服务管理者。 3.轮椅随访表 (10分钟) • E +6L • E 8,( • E ,FG B.16.5 LA: 6 说明: 中级服务中使用的轮椅随访表与 《轮椅服务初级 教程》中使用的一样。 这意味着轮椅服务单位可以对任何轮椅使用者用 相同的轮椅随访表。然而,细节和随访措施可能 会不同。 随访预约是一个机会: - 从轮椅使用者处收集信息; - 检查轮椅处于良好的状态; - 检查轮椅的适配。 有了这些信息,轮椅服务人员需要与轮椅使用者 讨论需要采取的任何措施。 219 让学员看他们的轮椅随访表。 说明:轮椅随访表将有助于轮椅服务人员记住要问哪些问题,以及随访中要做哪些事情。轮椅随 访表也有一个空白处用于记录需要采取的任何措施。常见的措施包括以下内容: • ,AA • GBE • F> 5 • M?EE +68 " B.16.5 LA: 7 (1)提供更多的建议或培训。 例如,如果轮椅使用者没有按照预期使用轮椅, 可能是因为他/她对于独自上下轮椅没有信心。 转移方面更多的训练可能有所帮助。 (2)重新调整轮椅。 (3)进行小型维修。 应该鼓励轮椅使用者和他们的家人/护理者通过在家保养轮椅来维护轮椅。如果不能立即修理 任何损坏的部件,轮椅服务人员也可以帮助轮椅使用者安排维修。 (4)如果需要,转介轮椅使用者至其他服务单位寻求支持或帮助。 提问:如果轮椅使用者告知自己有压疮,应采取什么措施? 回答: 要求看一下压疮 (确保这是在私密的场所进行); 记录压疮的位置和等级; 如果压疮出现在与轮椅或PSD接触的身体任何部位上,轮椅使用者应该停止使用轮椅; 如果压疮等级在2级或更高,寻求专科医生帮助治疗。 4.练习随访 (35分钟) 小组活动 分组 把学员分成3人一组。 6/3" 220 续表 指导 让学员阅读 《实训手册》(B.16:随访)上的每个轮椅使用者故事。对于每位轮椅使用者, 学员将需要完成轮椅随访表,讨论并记录采取的任何措施。 说明:学员有20分钟时间来做这项活动,然后各组将返回原地进行反馈。 监督 密切地监督各组。 确保每组明白该活动。 如果必要,引导学员。 时间 允许20分钟活动。 允许15分钟反馈。 反馈 对于每个轮椅使用者故事,让一组简要地讨论为轮椅使用者推荐什么随访措施。向学员提 问:其他组的学员可以提出其他进一步的措施吗? 确保学员涵盖所有的关键学习要点 (请 见下面的教师提示)。 教师提示: 轮椅使用者故事: 回答和关键学习要点: 希塔7岁和他父母及姐姐生活在一起。他患有 肌肉萎缩症,一年前通过轮椅服务获得了一辆 轮椅。那时他能走很短的距离。他能够站立式 转移并独立上下轮椅。他说自己想要一辆轮 椅,因为他发现上学困难。在随访过程中,希 塔说他现在发现很难独自上下轮椅。在学校下 午时他感到疲劳和不舒适。这使他难以集中精 力。他的轮椅大小合适,并且有一个中型的悬 吊式靠背及简单的舒适坐垫。 当要求希塔对自己轮椅的满意度按照总分5分 进行评分时,他打4分。 发现希塔如何上下轮椅。 考虑是否不同的转移技巧可以使转移更容易,例 如,转移板或协助站立转移。 讨论他的PSDs,考虑高靠背、可调张力靠背、带 姿势控制和减压的坐垫。 随着进行性状况的发展,他可能更疲劳。考虑他 是否需要在午餐休息时变换体位,这样他会更舒 适并且能够集中精力进行下午的学习。 具有进行性疾病的人需要经常随访,3~6个月是 比较理想的。如果必要,他们应该很快回来。 221 续表 米莱拉23岁,是一名小儿麻痹症患者。她酿 造蜂蜜并在当地市场销售。两年前她获得了一 辆轮椅带前挂装置的三轮车。她需要在轮椅上 有一些附加的PSDs。为她处方 (选择)了一 个改制的多层泡沫塑料坐垫。骨盆后垫加在轮 椅的靠背上。 在随访中,米莱拉说她每天用这辆三轮车往返市场。 她说自己最近补过被扎破的两个轮胎。当检查 轮椅时,轮椅服务人员注意到轮胎磨损严重。 骨盆后垫滑到了椅座上并且坐垫看起来很平。 当要求米莱拉对自己轮椅的满意度按照总分5 分进行评分时,她打3分。 安排更换轮胎。 对检查轮胎提出建议。 找到骨盆后垫移动的原因。重新定位并固定。检 查它是否正确地支撑米莱拉。 给米莱拉建议骨盆后垫的位置,并且提醒她检查 它是否处于正确的位置。 把坐垫套拿开并检查泡沫塑料层是否完好。检查 泡沫塑料层是否被压缩 (变平)。如果泡沫塑料 层变平,用软泡沫塑料层更换。 确保米莱拉被轮椅良好地支撑,包括骨盆后垫和 坐垫。 乌苏拉是一位6岁的脑瘫儿童。她喜欢与她姐 姐在教堂唱诗班唱歌。她在8个月之前获得一 辆带PSDs的轮椅。 由于呼吸系统感染生病,她错过了第一次随访 预约。她父母说她最近在轮椅上不开心并要求 坐轮椅一小时后离开。他们注意到在她肋骨上 靠近躯干侧垫一侧有一块暗斑,并想知道这是 否是一个问题。 轮椅服务人员找到一个私密的场所,并取得乌 苏拉和她父母的同意检查她的皮肤。轮椅服务 人员证实这是一块暗斑。他们检查了轮椅并注 意到躯干侧垫上的泡沫塑料垫受到挤压。 当被要求对满意度按照总分5分进行评分时, 她父母的评分是4分。 建议乌苏拉和她父母,她必须避免肋骨受压直到 暗斑消失。 建议乌苏拉和她父母减少坐轮椅的时间,只有暗 斑消失后,坐轮椅时间才可以逐渐增加。 更换两侧躯干侧垫上的泡沫塑料。如有必要,用 手指在躯干侧垫与乌苏拉身体之间滑动,以检查 压力并调整。 儿童生长很快需要经常地随访以阻止异常姿势的 发展,最好是每3~6个月进行一次随访。 6/3" 222 5.要点概括 (5分钟) • LAN4 - E +6L - E 8,( - E ,FG • LA &F> - E +6 - E - F E +6 E , • ,E +6GLA , B.16.5 LA: 8 讲出要点。 询问是否有任何问题。 实操四:评定、处方 (选择)、产品 (轮椅)准备、适配和使用者 培训 目标 本单元结束后,学员将能够: □ 演示在小组中开展中级轮椅评定、处方 (选择)、产品 (轮椅)准备、适配和使用者 培训。 资源 □ 《实训手册》; □ 教师观察表:实操四; □ 肖像同意表; □ 中级轮椅评定表和中级轮椅处方 (选择)表; □ 海报:体位支撑装置 (PSD)表; □ 海报:中级轮椅使用者培训检查表; □ 塑封的体位支撑装置 (PSD)表———每位学员1张; □ 塑封的中级轮椅适配检查表———每位学员1张; □ 为每位轮椅使用者准备的有检查床和隐私屏风的洁净和私密检查空间; □ 硬泡沫塑料块———所有学员几块; □ 硬泡沫塑料楔形块———所有学员几块; □ PSD材料; □ PSD套件; 223 续表 资源 □ 工作台和工具套件———每组1个; □ 轮椅和坐垫样品 (如果检查不是在社区进行); □ 数码相机; □ 卷尺或卡尺———每组1个,足垫块———每组1套。 情境 和已 经学 过的 内容 根据学员将工作的情境修改本单元。思考: □ 文化因素——— 例如让不同性别的组员在一起进行评定是否合适; □ 当学员对轮椅使用者进行适配时,注意由身体接触引起的任何文化问题; □ 语言因素——— 例如参与的轮椅使用者是否与所有学员讲同一种语言; □ 当评定或处方轮椅时,主办/培训机构可能需要的任何资料——— 例如服务单位需要收 集轮椅使用者获得服务的任何附加信息 (例如转介来源); □ 教师将如何处理在适配中出现的问题,这些问题无法在单元或教程中得到解决。 □ 培训结束后,每位轮椅使用者的随访如何处理。 准备 □ 与轮椅使用的志愿者确认时间和行程安排。确保为轮椅使用者和他们家人/护理者准备 饮食。 □ 当他们到达的时候安排一人去迎接他们,并引导他们在单元开始之前待在哪里。 □ 为每组准备检查床和隐私屏风。把每次检查需要的所有设备放在检查床上。 □ 确保轮椅和坐垫样品处于良好的工作状态。 □ 如果超过3组学员,再请一位教师来协助管理。 □ 决定哪些学员与哪位轮椅使用者一起工作。 □ 在本实操单元之前让学员穿上全包鞋。 □ 为每组准备有工作台和工具套件的工作场地,为学员把PSD 材料摆放好以便高效地 工作。 □ 把PSDs样品从PSD套件中取出来,并放在培训教室前面的桌子 (工作台)上,以便 你可以容易拿到。 □ 把体位支撑装置 (PSD)表海报钉起来。 □ 把中级轮椅使用者培训检查表海报钉起来。 6/3" 224 续表 大纲 1.评定、处方 (选择)、产品 (轮椅)准备、适配和使用者培训 指导和安装 评定 处方 (选择) 产品 (轮椅)准备 适配 使用者培训 15 45 30 120 45 45 总单元时间 300 1.评定、处方 (选择)、产品 (轮椅)准备、适配和使用者培训实操 (300 分钟) 教师提示 1.照相: 要求每位轮椅使用者签署肖像同意表。确保轮椅使用者明白他们的同意是自愿的,照片将用于本 教程的进一步培训。 对同意拍照的每位轮椅使用者在参与实操单元按照以下方式拍照: - 在他们现有的轮椅上 (如果他们有)(前方和侧方); - 在身体检查过程中 (无支撑坐姿); - 在适配后处方的轮椅上 (前方和侧方)。 2.满足参加实操单元的轮椅使用者需求: 不是所有的轮椅都能在实操单元的时间内完成。 如果在实操单元看到任何轮椅使用者需要其他预约,教师应该确保预约由主办/培训机构作出并 且所有的评定、处方和适配信息都进行移交。 3.观察学员实操: 用实操四的教师观察表来确保各组执行实操中的所有步骤,并在反馈过程中注意良好实操的常见 案例或强调需要改进的实操。 225 小组活动 分组 把学员分成2~3人一组。 每组指定一位组长。 告诉每组他们将服务的轮椅使用者姓名。 分配每组工作的场地。 说明在哪里找材料和工具。 向学员说明他们在哪里可以找到必要的设备。 指导 说明以下内容: 单元目标: 本实操单元的目标是进行评定、处方 (选择)、产品 (轮椅)准备、适配和使用者 培训。 如果不能在培训过程中完全完成轮椅使用者的轮椅,将与轮椅使用者一起安排以确保完 成他们的轮椅。然而学员应该尽可能多地完成一些工作。 组长: 每组的组长负责确保所有的步骤都完成。 组长应该是与轮椅使用者和他们家人/护理者之间的主要交流者。这将避免太多人同时 讲话,可能会造成混乱。 教师观察和支持: 学员可以在任何时候请求协助或解释。 在整个单元,教师将监督每组并根据需要尽可能地提供支持和建议。 完成每个服务步骤后及开始下一步之前,学员应该请一位教师来检查。 允许的时间: 学员应该在45分钟内完成评定、30分钟内完成处方 (选择)、12分钟完成产品 (轮 椅)准备、45分钟内完成适配和45分钟内完成使用者培训。 提醒学员轮椅使用者需要休息和茶点。 应该有早茶/午餐休息——— 当休息时间到的时候,教师应提醒每位学员。 服务表: 给每组组长分发中级轮椅评定表和中级轮椅处方 (选择)表。 确保每组至少有一份塑封的中级轮椅适配检查表和轮椅使用者培训检查表。 6/3" 226 续表 指导 让学员用 《实训手册》上的 “产品 (轮椅)准备——— 任务清单”(实操四:评定、处方 (选 择)、产品 (轮椅)准备、适配和使用者培训)来计划将要做的工作。 让学员用 《实训手册》上的中级轮椅使用者培训检查表 (实操四:评定、处方 (选择)、 产品 (轮椅)准备、适配和使用者培训)来检查轮椅是否已经为适配准备好了。 提醒学员他们应该积极地让轮椅使用者参与过程中的每一步。 提问:有任何问题吗? 回答任何问题。 让每组准备他们将工作的场地;并把他们自己介绍给将服务的轮椅使用者,然后开始工作。 监督和 支持 密切地监督各组,确保安全地实操,观察和评价学员的技能。 用教师观察表来记录你对每组的观察。 本单元: 用时间提醒 (口头和/或写在所有学员都可以看到的白板上)以帮助学员管理时间。 确保轮椅使用者积极地参与。 确保每组学员积极地参与。 本单元结束后,让学员感谢轮椅使用者的参与,并说明处方的轮椅将会为他们准备好,将 会很快让他们试用。 对签署了肖像同意表的轮椅使用者在实操单元拍照。 时间 允许15分钟指导和安装;45分钟完成评定;30分钟完成处方 (选择),120分钟完成产品 (轮椅)准备;45分钟完成适配;45分钟完成使用者培训。 用教师观察表追踪时间。 教师提示: 在实操单元中,重要的是密切关注时间。上面给出的时间只是一个指导——— 然而,根据 学员的经验、轮椅使用者的需求或调试轮椅需要的时间,以上的时间可以调整。教师可以根据需要 进行调整。 227 B.17:教师反馈、讨论和结业典礼 目标 本单元结束后,学员将能够: □ 思考与轮椅使用者一起进行的最后实操工作,包括评定、处方、准备和适配一辆轮椅满 足轮椅使用者的身体、环境和生活方式需求并提供适合的使用者培训。 资源 本单元: □ 幻灯片:B.17:教师反馈、讨论和结业典礼; □ DVD:临别赠言; □ 实操单元中轮椅使用者 (签署了肖像同意表)的照片。 准备 □ 收集资源、检查幻灯片、观看DVD并浏览单元计划。 □ 确保印刷证书并由教师签名。 □ 考虑邀请主要参与方的代表 (例如捐资者、残疾人组织、服务提供者、相关部门)参 加结业典礼并发证。 □ 确保轮椅使用者的照片已经保存到培训电脑上,并以他们的名字命名。 大纲 1.前言 2.教师反馈 3.对实操四中服务的轮椅使用者进行讨论 4.结业典礼和发证 2 20 30 8 总单元时间 60 1.前言 (2分钟) 说明: 本单元,学员将有机会: - 了解其他小组在最后实操单元服务的轮椅使用者、处方的轮椅解决办法、准备和适配有关 的情况; - 了解教师在最后实操单元看到的良好实操案例的反馈,并从所有的错误中学习; - 提问题。 6/3" 228 2.教师反馈 (20分钟) 用实操四的教师观察表,与学员讨论你在实操单元看到的良好实操案例。 注意学员可以改进的任何特别地方———不要强调个人。 提问:有任何问题吗? 3.对实操四中服务的轮椅使用者进行讨论 (30分钟) 教师提示: 本部分需要的时间将取决于教师反馈中需要涵盖多少要点。相应地调整单元,优先确保提供重要 的反馈。 让每组轮流报告: 简要地概括在实操单元中他们服务的轮椅使用者的移动和支撑需求; 描述他们处方 (选择)的解决方案; 描述产品 (轮椅)是如何准备的; 描述适配过程和出现的任何问题; 评价轮椅使用者如何获得轮椅以及已经提供哪些使用者培训。 鼓励所有学员在报告结束后提问题: 建议在报告过程中,学员记下在每次报告后需要提的问题; 鼓励学员质疑报告小组的决定和解决方法。理想的是,这将激发所有学员的讨论、争论和深入 分析。 每组报告允许5分钟,提问5分钟 (根据小组的数量)。 播放每位轮椅使用者的照片以帮助各组阐明他们的观点 (如果在实操过程中拍照了)。 每次报告结束后: 强调每组所用的良好实操的案例 (用实操四:教师观察表)。 感谢每组的报告。 所有报告结束后: 再次提醒学员通常不只有一个正确的解决办法。最好的解决办法有时是一个折中———既要最充 分地利用现有资源,又要最好地满足轮椅使用者的整体需求和期望。 229 教师提示: 问题的目的在于证明报告者决定的自信心,而不是暗示他们做错了一些事情。 应该以一种友好的方式提出问题和质疑。 4.结业典礼和发证 (8分钟) VIDEO 介绍DVD:临别赠言。 播放DVD。 教师提示: 教师可以选择他们如何发证以及结束培训。 6/3" 230 附录 附录1:轮椅服务中级教程课程表 5整天 1 1 1 1 1 4 % D ——+ % 36'V , F—— P % FG % 5
LA % 36'V , F—— G7
7 $ , L ,E +6 % D ——F>#G % +6A A F
E F G +6A $ !L 1 % FE
L+
E + 6E E 9 , AB L 9 ,
AB L $ ! L 1 % FE
9 FG +6A A F
E F G +6A A
F % A F M BA % 36'V , F——4 % 36'V , F——0 P, 231 续表 NU + @AKU % A F
MBA V ,F 0 P , A F FG + 6A AF E F G +6 A % D %
E % V ,F P8 %
.A 9 AB L 9 AB L % D % V ,F P8 9 %
.A AF E F G +6 A %V ,F D E % D P, P 8 % OAA 5 / —— —— —— —— —— —— —— ※ 如果需要,教师/培训机构可以调整日程安排。 6/3" 232 附录2:中级轮椅转介表 转介样表:本表可以由轮椅服务单位进行修改,并提供给转介来源,有助于他们转介轮椅使用者至 轮椅服务单位。 请完成转介表并邮寄至: 轮椅服务单位名称和地址: 转介人姓名: 工作单位: 转介人联系方式 (与您联系的最佳方式): 轮椅使用者姓名: 出生日期: 父母/护理者姓名: 如何与轮椅使用者联系? 邮寄□ 自己的电话□ 朋友/邻居的电话 □ 如果电话联系,电话号码: 如果知道,轮椅使用者的残疾类型: 转介原因: 无轮椅 有一辆坏的轮椅 有一辆轮椅,但不满足他/她的需求 儿童: - 到1岁时不能坐直或无法拉起站立 - 到2岁时仍不能行走 □ □ □ □ □ □ 请补充轮椅服务单位需要了解的关于轮椅使用者的其他任何重要信息: 轮椅使用者同意被转介到轮椅服务单位吗? 是□ 否 □ 转介人签名: 日期: 233 附录3:中级轮椅评定表 本表适用于在无支撑下不能舒适坐直的轮椅使用者的评定。能够容易地坐直的轮椅使用者可以由接 受过初级服务培训的人员进行评定。此表放在轮椅使用者的档案中。 评定人姓名: 评定日期: 1.面谈评估 轮椅使用者信息 姓名: 编号: 年龄: 男 □ 女 □ 电话号码: 地址: 目的: 身体状况 诊断:脑损伤 □ 脑性瘫痪 □ 肌肉萎缩症 □ 小儿麻痹症 □ 脊柱裂 □ 脊髓损伤 □ 中风 □ 未知 □ 其他 □ 身体状况可能会变得更差吗? 是 □ 否 □ 身体问题:虚弱 □ 痉挛或不受控制的运动 □ 肌张力 (高/低)□ 下肢截肢:右大腿 □ 右小腿 □ 左大腿 □ 左小腿 □ 疲劳 □ 髋关节脱位 □ 癫痫 □ 进食和吞咽困难 □ 描述: 疼痛 □ 描述位置: 小便问题 □ 大便问题 □ 如果轮椅使用者有小便或大便问题,能处理好吗? 是 □ 否 □ 6/3" 234 生活方式和环境 请描述轮椅使用者将在哪里使用他们的轮椅: 每天移动的距离:1公里以内 □ 1~5公里 □ 5公里以上 □ 每天使用轮椅的小时数:少于1小时 □ 1~3小时 □ 3~5小时 □ 5~8小时□ 多于8小时 □ 不在轮椅上的时候,轮椅使用者坐或卧在哪里 (姿势以及接触面如何)? 转移:独立完成□ 协助完成□ 站立式□ 非站立式□ 移位机完成□ 其他□ 厕所类型 (如果转移到厕所):蹲厕 □ 坐厕 □ 定制的 □ 轮椅使用者是否经常使用公共/私人交通工具? 是□ 否□ 如果是,哪种交通工具:小汽车□ 出租车 □ 公交车 □ 其他 现有的轮椅 (如果已经有了一辆轮椅) 轮椅能满足使用者的需求吗? 是 □ 否 □ 轮椅能适合使用者的环境状况吗? 是 □ 否 □ 轮椅能提供适配和体位支撑吗? 是 □ 否 □ 轮椅安全耐用吗? (考虑是否有坐垫) 是 □ 否 □ 坐垫的减压效果理想吗? (如果使用者有压疮风险) 是 □ 否 □ 备注: 如果所有问题的回答都是 “是”,使用者可能不需要一辆新轮椅。如果这些问题中的任何一个回答 是 “否”,则使用者需要更换轮椅或坐垫;或现有的轮椅或坐垫需要进行维修或改制。 235 2.身体检查 压疮的出现、风险或病史 ///= 没有感觉 感觉正常吗? 是 □ 否 □ O= 以前的压疮 以前有压疮吗? 是 □ 否 □ ● =现有的压疮 现在患有压疮吗? 是 □ 否 □ 如果有,是否破溃 (1-4级) 是 □ 否 □ 持续时间和原因: 此人有患压疮的风险※吗?※如有一个人有感觉丧失 或者 有3个或更多的风险因素,就有患压疮的风险。风险因素: 不能移动、潮湿、不良姿势、以前/现有的压疮、营养不良、 衰老、体重过轻或超重。 是 □ 否 □ 推轮椅的方法 轮椅使用者如何推轮椅? 双臂 □ 左臂 □ 右臂 □ 双腿 □ 左腿 □ 右腿 □ 由一位助手推行 □ 备注: 无支撑坐姿 骨盆和髋关节姿势检查 描述或绘画无支撑坐姿: 当卧位时,检查骨盆是否水平以及髋关节屈曲范围 骨盆可以水平吗? 是□ 否□ 髋关节可以屈曲至中立位坐姿吗? 右髋关节:是□ 否□ 角度: 左髋关节:是□ 否□ 角度: 如果骨盆无法水平或髋关节无法屈曲至中立位———用临时 支撑适应。 6/3" 236 用手模拟:用手支撑坐在中立位/尽可能舒适地接近中立位 对于每个身体部位:如果用手支撑可以实现中立位坐姿,在 “是”下画勾,如果不是,在 “否”下 画勾。 身体部位 是 否 骨盆 □ □ 描述或线条绘画用手支撑轮椅使用者的最后坐姿,并描述或 线条画出实现该坐姿提供的支撑。 躯干 □ □ 头 □ □ 左髋关节 □ □ 右髋关节 □ □ 大腿 □ □ 左膝关节 □ □ 右膝关节 □ □ 左踝关节 □ □ 右踝关节 □ □ 进行测量 C"FUNNU D F"FUNNU $ 7D Q $ 7 P, L,D/ % $P, G7 0 % PPPP $ EK E .,
& 70C MN17D Q MN1 MQ7 >6
237 续表 C"FUNNU D F"FUNNU M7Q ' M775 MN1M6N1,D / E +6,M" #G '( ) ( M67@ ) M6 36'V * D D L,D / + M770 + PP N1D L, D / +F>B
, MP,N1P MN1P, L ,D/ - 78L,D/ 7L L, . MN,D/ MN1ML,D / / P, G P /PPPP M6 P QC&L,D/ ※当进行测量时,“座面”是指坐骨坐的平面。 6/3"
图书在版编目 (CIP)数据 轮椅服务中级教程/ (美)弗罗斯特等著;钟磊等译.-北京:求真出版社,2016.1 ISBN978 7 80258 230 9 Ⅰ.①轮… Ⅱ.①弗…②钟… Ⅲ.①四肢-残疾人-社会服务-技术培训-教材 Ⅳ.①C913.69 中国版本图书馆CIP数据核字 (2016)第030732号 世界卫生组织于2013出版,原标题为 (WheelchairServiceTrainingPackage:Inter- mediateLevel)ⓒ世界卫生组织2013 世界卫生组织授予深圳市残疾人辅助器具资源中心翻译中文版的权利,并委托求真出 版社出版。中文版的翻译质量和准确性由深圳市残疾人辅助器具资源中心负责。若英 文版与中文版有任何出入,应以英文原版为准。 轮椅服务中级教程:实训手册ⓒ世界卫生组织2016 轮椅服务中级教程 著 者:[美]弗罗斯特 等 译 者:钟 磊 赫 琳 责任编辑:计 悦 出版发行:求真出版社 社 址:北京市西城区太平街甲6号 邮政编码:100050 印 刷:北京华联印刷有限公司 经 销:新华书店 开 本:787×1092 1/16 字 数:611千字 印 张:29.25 版 次:2016年5月第1版 2016年5月第1次印刷 书 号:ISBN978 7 80258 230 9/C·6 定 价:98.00 编辑热线:(010)83190270 销售服务热线:(010)83190297 83190289 83190292 版权所有 侵权必究 印装错误可随时退换 , 1 目的 2 A.1:受益于附加体位支撑的轮椅使用者 3 B.1:评定概述和面谈评估 7 B.2:身体检查———无支撑坐姿:坐姿的基础 8 B.2:身体检查———无支撑坐姿:姿势绘画 11 B.3:身体检查———骨盆和髋关节姿势检查:进行检查 12 B.3:身体检查———骨盆和髋关节姿势检查:练习临时支撑 14 B.5:身体检查———进行测量 16 B.6:选择轮椅和坐垫 25 B.8:体位支撑装置 (PSDs)的处方 (选择)———稳定骨盆 27 B.9:体位支撑装置 (PSDs)的处方 (选择)———支撑髋关节 29 B.10:体位支撑装置 (PSDs)的处方 (选择)———支撑躯干 41 B.11:体位支撑装置 (PSDs)的处方 (选择)———支撑头部、 大腿和小腿 42 实操二:产品 (轮椅)准备———任务清单 43 实操二:产品 (轮椅)准备———中级轮椅安全和准备检查表 44 B.14:使用者培训 48 B.15:整合所有知识 49 B.16:保养、维修和随访 51 实操四:评定、处方 (选择)、产品 (轮椅)准备、适配和使用者 培训———任务清单 52 实操四:评定、处方 (选择)、产品 (轮椅)准备、适配和使用者 培训———中级轮椅安全和准备检查表
1 目的 本中级教程是为支持服务人员或志愿者的培训而设计的,使他们能为那些需要附加体位支撑才能 坐直的儿童和成年人提供适合的轮椅和坐垫。 本教程的主要目的是提高轮椅服务人员的知识和技能,本教程的实施将有助于: 增加能满足个人需求的轮椅使用者数量; 增加接受中级轮椅服务培训的人员数量; 提高轮椅服务人员的职业素质; 针对需要比初级轮椅服务更高层级干预的轮椅使用者,提高为他们轮椅服务的质量; 将本教程加入到常规辅助医疗/康复培训项目中; 将提供轮椅服务更大程度地整合到康复服务里。 《实训手册》的目的是培训轮椅服务人员的技能和知识。《实训手册》包括有助于测试和发展学员 知识与技能的练习,包括来自于课堂、幻灯片和 《学员手册》的资料。目的在于让学员保留他们的 《实训手册》,以便将来在需要时可以作为参考。 ,\3" 2 A.1:受益于附加体位支撑的轮椅使用者 1.扔球 从你所在的小组选一人出来坐在椅子上,参与这项活动的3个步骤。 另外两人是助手。 每个步骤,坐在椅子上的人和助手之间扔球和接球5次。 第1步:当扔球和接球时,在椅子上的人坐直并且双脚 平放在地面。 第2步:当扔球和接球时,一位助手倾斜椅子使一侧的 椅腿离地并保持其稳定。 第3步:当扔球和接球时,一位助手随机地从一条腿到 另外一条腿摇椅子。 扔接球有多容易呢? 第2步和第3步变得 更难了吗? 为什么? 不同的位置和姿势如 何影响接球的容易程度? 2.喝水 每个人按照以下描述的不同位置和姿势喝水。 每次只喝几小口并小心! 坐直 头向正后仰坐在椅子上 (鼻子朝空中) 以 “下滑”姿势坐在椅子上 躺在检查床上 不同的位置和姿势如何影响喝水的容易程 度? 3 B.1:评定概述和面谈评估 与组员合作,并按照小组编号完成下面分配给你小组的问题。 第1组 以下列出的诊断/身体问题如何影响轮椅的选择? 例如: 诊断/身体问题的哪些特征影响轮椅的选择? 哪些轮椅特征和培训可能有帮助? 重要的是在每个案例中了解轮椅使用者的哪些信息? 脑损伤 小儿麻痹症 疲劳 ,\3" 4 第2组 以下列出的诊断/身体问题如何影响轮椅的选择? 例如: 诊断/身体问题的哪些特征影响轮椅的选择? 哪些轮椅特征和培训可能有帮助? 重要的是在每个案例中了解轮椅使用者的哪些信息? 肌肉萎缩症 脊髓损伤 痉挛/不受 控制的运动 5 第3组 以下列出的诊断/身体问题如何影响轮椅的选择? 例如: 诊断/身体问题的哪些特征影响轮椅的选择? 哪些轮椅特征和培训可能有帮助? 重要的是在每个案例中了解轮椅使用者的哪些信息? 脑性瘫痪 中风 饮食或吞咽 困难 ,\3" 6 第4组 以下列出的诊断/身体问题如何影响轮椅的选择? 例如: 诊断/身体问题的哪些特征影响轮椅的选择? 哪些轮椅特征和培训可能有帮助? 重要的是在每个案例中了解轮椅使用者的哪些信息? 脊柱裂 进行性疾病 (例 如:肌 肉萎缩症、 帕金森、多 发 性 硬 化 症、运动神 经元病) 髋关节脱位 7 B.2:身体检查———无支撑坐姿:坐姿的基础 当骨盆姿势变化时,学员一起来发现直立的坐姿有什么变化。 小组的每个人都应该模拟以下描述的一种骨盆姿势。其他人观察他/她身体的其他部分发生了哪 些变化。 如果时间允许,小组的每个人都应该尝试不同的骨盆姿势来感受他们自己身体的变化。 骨盆姿势 写下或绘画你对姿势变化的观察。观察他的躯干、头和颈、腿。 前倾 后倾 侧倾 旋转 ,\3" 8 B.2:身体检查———无支撑坐姿:姿势绘画 在下面的每个图后面画出你自己的线条绘画。 侧面的姿势线条绘画 正面的姿势线条绘画 正面的姿势线条绘画———骨盆旋转 9 用线条绘画记录插图中人的姿势,并把它画在下面的框内。 无支撑坐姿 描述或绘画无支撑坐姿: 无支撑坐姿 描述或绘画无支撑坐姿: ,\3" 10 用线条绘画记录插图中人的姿势,并把它画在下面的框内。 无支撑坐姿 描述或绘画无支撑坐姿: 无支撑坐姿 描述或绘画无支撑坐姿: 11 B.3:身体检查———骨盆和髋关节姿势检查:进行检查 小组的每个人轮流扮演轮椅使用者,对他们进行骨盆和髋关节姿势检查。 记录每个人扮演轮椅使用者检查的结果,并写在下面中级轮椅评定表上的 “骨盆和髋关节姿势 检查”部分中。 轮椅使用者一: 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位坐姿———用临时支撑来适应。 轮椅使用者二: 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位坐姿———用临时支撑来适应。 轮椅使用者三: 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位坐姿———用临时支撑来适应。 ,\3" 12 B.3:身体检查———骨盆和髋关节姿势检查:练习临 时支撑 阅读每个轮椅使用者的故事。 对于每位轮椅使用者,决定轮椅使用者的骨盆是否可以水平以及髋关节是否可以屈曲至中立位 坐姿 (躯干与大腿之间的角度是否为90度)。 完成中级轮椅评定表上的骨盆和髋关节姿势检查部分,决定轮椅使用者是否需要临时支撑并为 每位轮椅使用者安装一个临时支撑。 确保检查每个临时支撑并坐在每个临时支撑上来看感受如何。记住ASIS代表髂前上棘。 萨姆 萨姆4岁,他患有脑瘫并且无法独立地坐直。 通过骨盆和髋关节姿势检查你会发现: 萨姆的骨盆可以水平 (两侧ASIS水平); 萨姆的左髋关节可以舒适地屈曲至中立位 坐姿。萨姆的右髋关节疼痛,始终无法屈 曲至中立位坐姿 (躯干与大腿之间的角度 大于90度)。躯干与大腿之间的角度大约 是105度。 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲 角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位 坐姿———用临时支撑来适应。 萨姆需要临时支撑吗? 是 □ 否 □ 玛莎 玛莎57岁,她有严重的关节炎。她能走几步, 然而走起来很疼。通过骨盆和髋关节姿势检查 你会发现: 玛莎的骨盆可以水平 (两侧ASIS水平); 玛莎两侧的髋关节始终无法屈曲至中立位坐姿 (躯干与大腿之间的角度大于90度)。两侧躯干 与大腿之间的角度大约是100度。 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲 角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位 坐姿———用临时支撑来适应。 玛莎需要临时支撑吗? 是 □ 否 □ 13 赛恩 赛恩16岁。她小时候得了小儿麻痹症,现在 双腿严重挛缩。赛恩通过盘腿坐的方式四处移 动并且在地面挪动。通过骨盆和髋关节姿势检 查你会发现: 赛恩的骨盆不能水平。右侧骨盆比左侧骨 盆高20mm; 赛恩的两侧髋关节可以屈曲至中立位坐姿。 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲 角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位 坐姿———用临时支撑来适应。 赛恩需要临时支撑吗? 是 □ 否 □ 乔 乔25岁。他小时候得了小儿麻痹症,现在双 腿有严重的挛缩。通过骨盆和髋关节姿势检 查,你会发现: 乔的骨盆可以水平 (两侧ASIS水平); 乔右侧的髋关节可以舒适地屈曲至中立位 坐姿。然而他的左髋关节始终无法伸展至 中立位 (躯干与大腿之间的角度小于90 度)。躯干与大腿之间的角度是70度。 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲 角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位 坐姿———用临时支撑来适应。 乔需要临时支撑吗? 是 □ 否 □ ,\3" 14 B.5:身体检查———进行测量 马达维是一名13岁的脑瘫儿童。她可以无支撑坐直,但是她感到非常疲劳并且不能久坐。她的骨盆 轻度僵硬后倾,并且在她现在的轮椅上向前滑。她提出要一个桌面板,因为她想在自己面前有一个 桌/表面,这样她可以容易地看书、写字和吃东西。以下是轮椅服务人员用手模拟进行身体检查的 结果。 阅读下面已经完成的用手模拟结果: 用手模拟:用手支撑坐在中立位/尽可能舒适地接近中立位 对于每个身体部位:通过用手支撑,如果中立位坐姿可以实现,勾 “是”,如果不能,勾 “否”。 部位 是 否 骨盆 □ □ 描述或画出用手支撑实现的轮椅使用者的最终坐姿以及实现坐姿所提供 的支撑。 躯干 □ □ 头 □ □ 左髋 □ □ 右髋 □ □ 大腿 □ □ 左膝 □ □ 右膝 □ □ 左踝 □ □ 右踝 □ □ 最后的姿势:骨盆后倾;当在两侧支撑时,腰部稍微弯曲 (侧视图)但 是对称 (正视图);头稍微向前,双腿向内收———轻轻地支撑让大腿处于 中立位。 需要的支撑: 支撑在坐骨前面; 支撑在骨盆后部———不会推向中立位但是阻止进一步前滚; 后部支撑到双肩; 躯干侧支撑———帮助保持躯干在中间; 支撑在骨盆/髋关节两侧以保持骨盆在中间; 支撑在大腿内侧以阻止大腿内收———大腿内侧楔形垫; 桌面板。 为了给马达维选择轮椅,你需要知道测量身体的哪部分的尺寸。 对组内至少一位成员进行这些尺寸的测量,并把他们记录在中级轮椅评定表 (下一页)上的 “进 行测量”部分。 你如何确保自己获得正确的椅座深度尺 寸? (记住马达维的骨盆轻度僵硬后倾) 哪些尺寸将用来描述她的桌面板高度、 尺寸/形状? 15 进行测量 身体测量 (mm) 轮椅部件测量 (mm) 座宽、座深和脚踏板高度 A 臀宽 =座宽或 1 =骨盆侧垫之间的距离 2 B 大腿长 (骨盆后 部到腘窝) 左 右 B减去30~60mm=椅座深度 (如果左右两边长度不同,取较 短的一个数值) 3 C 腘窝到足底 左 右 =座面顶端到脚踏板高度或 =座面顶端到地面高度 (脚推行者) 4 5 靠背高度 D 座面※到胸腔下缘 E 座面※到肩胛下角 F 座面※到肩峰 =座面顶端到靠背顶端的距离 (根据轮椅使用者的需求,测量 D、E或F) 6 改制和/或PSDs G 躯干宽度 =躯干侧垫/楔形垫之间的距离 7 H 座 面※ 到 腋 下 (腋窝) 左 右 H减去30mm=椅座顶端到躯干 侧垫/楔形垫之间的最大距离 (根据用手模拟进行调整) 8 I 座面到骨盆顶端 (髂后上 棘) =椅座顶端与骨盆后垫之间的 距离 9 J 膝关节之间的距离 =膝分隔垫之间的宽度 10 K 座面到颅底的距离 =座面顶端与头靠中间的距离 11 L 骨盆后部到坐骨 L加20~40mm=靠背支撑到坐 骨前垫高开始点之间的距离 12 其他 ※当进行测量时,“座面”是指坐骨坐的平面。 ,\3" 16 B.6:选择轮椅和坐垫 仔细地看当地可得到的每款轮椅。 小组讨论回答下面的问题。 如果你没有把握,请教师来说明。 1.生活方式和环境 问题: 回答: 哪种轮椅 (或哪些轮椅)最适合在粗糙/不平坦 地面使用? 为什么? 哪种轮椅 (或哪些轮椅)最有利于站立式转移? 为什么? 哪种轮椅 (或哪些轮椅)最有利于侧向转移? 为什么? 每种轮椅如何折叠或为了运输如何拆卸? 通常的 方法包括: 固定式; 交叉折叠; 靠背向下折叠; 快拆轮。 你们小组认为哪种轮椅 (或哪些轮椅)在公共交 通工具上最好运输? 为什么? 17 续表 哪种轮椅 (如果有)是气胎? 哪种轮椅 (如果有)是PU胎? 哪种轮椅 (如果有)是实心胎? 2.减压 问题: 回答: 你在教室中看到了哪种类型的坐垫? 其中的哪些可以称为减压坐垫? 为什么? 减压坐垫中 (如果有),哪个相对容易调整实现 以下功能: 增加减压; 提供附加体位支撑。 你可以在培训教室中看到哪种类型的坐垫套? 考虑:防水、耐用、有弹性、薄面料。 3.推行 问题: 回答: 在轮椅上坐直。后轮处于良好的位置便于自己推 行吗? 检查: 让你的手臂放下来。你的手处于轮轴线上吗? 当手握住手推圈的最高点时,手在你肩膀的 正下方。你的肘关节屈曲在90~120度之 间吗? 后轮的位置可调吗? 如果可调,这能改善推 动位置吗? ,\3" 18 续表 教室中的哪些轮椅椅座高度可调? 这在什么时候有用? 4.体位支撑特点 问题: 回答: 哪种轮椅 (如果有)具有可升降的腿托? 哪种轮椅 (如果有)有硬椅座? 哪种轮椅 (如果有)有张力可调的靠背? 为了实现提供附加体位支撑的功能,哪种轮椅 (如果有)具有附加的部件设计? 5.可调性 问题: 回答: 哪种轮椅 (如果有)具有以下的可调性? 脚踏板高度 脚踏板角度 脚踏板向前/向后移动 靠背高度升或降 靠背后倾 整体后倾 (椅座与靠背后倾) 19 中级轮椅参数表 你可以为本教程中使用的每辆轮椅完成本表 (如果需要,向教师要更多的空表)。 轮椅名称: 制造商/供应商: 可提供的尺寸: 整体重量: 描述: 轮椅架: 固定式/刚性 □ 可折叠 □ 轮椅架长度: 靠背: 悬吊式/帆布 □ 硬 □ 张力可调 □ 椅座: 悬吊式/帆布 □ 硬 □ 张力可调 □ 坐垫: 无坐垫 □ 平面泡沫塑料 □ 波形的泡沫塑料 □ 流体 □ 其他 □ 脚踏板: 固定式 □ 可拆/外转 □ 其他: 小脚轮: 气胎 □ 直径: 实心胎 □ 宽度: 后轮: 气胎 □ 直径: 手推圈 □ 实心胎 □ 宽度: 可调轴 □ PU胎 □ 可拆卸 □ 刹车: 短杆 □ 长杆 □ 其他: 扶手: 弧形的 □ 方形 □ 其他: 固定式 □ 可拆 □ 其他: 把手: 把手 □ PSDs: 骨盆带 □ 小腿带 □ 肩带 □ 足带 □ 防翻杆 □ 躯干侧垫 □ 桌面板 □ 头靠 □ 骨盆侧垫 □ 其他: ,\3" 20 测量尺寸、调整选项及范围: 测量尺寸 (如果轮椅有不同的尺 寸,列出所有的尺寸) 是否可调 是 否 调整范围 (该轮椅可 能的调整范围) 椅座宽度 □ □ 椅座深度 □ □ 椅座高度 □ □ 靠背高度 □ □ 靠背后倾 □ □ 脚踏板高度 □ □ 脚踏板角度 □ □ 把手高度 □ □ 轮椅架长度 □ □ 轴距长度 □ □ 靠背与椅座之间的角度 □ □ 整体后倾 □ □ 21 中级轮椅参数表 你可以为本教程中使用的每辆轮椅完成本表 (如果需要,向教师要更多的空表)。 轮椅名称: 制造商/供应商: 可提供的尺寸: 整体重量: 描述: 轮椅架: 固定式/刚性 □ 可折叠 □ 轮椅架长度 靠背: 悬吊式/帆布 □ 硬 □ 张力可调 □ 椅座: 悬吊式/帆布 □ 硬 □ 张力可调 □ 坐垫: 无坐垫 □ 平面泡沫塑料 □ 波形的泡沫塑料 □ 流体 □ 其他 □ 脚踏板: 固定式 □ 可拆/外转 □ 其他: 小脚轮: 气胎 □ 直径: 实心胎 □ 宽度: 后轮: 气胎 □ 直径: 手推圈 □ 实心胎 □ 宽度: 可调轴 □ PU胎 □ 可拆卸 □ 刹车: 短杆 □ 长杆 □ 其他: 扶手: 弧形的 □ 方形 □ 其他: 固定式 □ 可拆 □ 其他: 把手: 把手 □ PSDs: 骨盆带 □ 小腿带 □ 肩带 □ 足带 □ 防翻杆 □ 躯干侧垫 □ 桌面板 □ 头靠 □ 骨盆侧垫 □ 其他: ,\3" 22 测量尺寸、调整选项及范围: 测量尺寸 (如果轮椅有不同的尺 寸,列出所有的尺寸) 是否可调 是 否 调整范围 (该轮椅可 能的调整范围) 椅座宽度 □ □ 椅座深度 □ □ 椅座高度 □ □ 靠背高度 □ □ 靠背后倾 □ □ 脚踏板高度 □ □ 脚踏板角度 □ □ 把手高度 □ □ 轮椅架长度 □ □ 轴距长度 □ □ 靠背与椅座之间的角度 □ □ 整体后倾 □ □ 23 中级轮椅参数表 你可以为本教程中使用的每辆轮椅完成本表 (如果需要,向教师要更多的空表)。 轮椅名称: 制造商/供应商: 可提供的尺寸: 整体重量: 描述: 轮椅架: 固定式/刚性 □ 可折叠 □ 轮椅架长度 靠背: 悬吊式/帆布 □ 硬 □ 张力可调 □ 椅座: 悬吊式/帆布 □ 硬 □ 张力可调 □ 坐垫: 无坐垫 □ 平面泡沫塑料 □ 波形的泡沫塑料 □ 流体 □ 其他 □ 脚踏板: 固定式 □ 可拆/外转 □ 其他: 小脚轮: 气胎 □ 直径: 实心胎 □ 宽度: 后轮: 气胎 □ 直径: 手推圈 □ 实心胎 □ 宽度: 可调轴 □ PU胎 □ 可拆卸 □ 刹车: 短杆 □ 长杆 □ 其他: 扶手: 弧形的 □ 方形 □ 其他: 固定式 □ 可拆 □ 其他: 把手: 把手 □ PSDs: 骨盆带 □ 小腿带 □ 肩带 □ 足带 □ 防翻杆 □ 躯干侧垫 □ 桌面板 □ 头靠 □ 骨盆侧垫 □ 其他: ,\3" 24 测量尺寸、调整选项及范围: 测量尺寸 (如果轮椅有不同的尺 寸,列出所有的尺寸) 是否可调 是 否 调整范围 (该轮椅可 能的调整范围) 椅座宽度 □ □ 椅座深度 □ □ 椅座高度 □ □ 靠背高度 □ □ 靠背后倾 □ □ 脚踏板高度 □ □ 脚踏板角度 □ □ 把手高度 □ □ 轮椅架长度 □ □ 轴距长度 □ □ 靠背与椅座之间的角度 □ □ 整体后倾 □ □ 25 B.8:体位支撑装置 (PSDs)的处方 (选择)———稳 定骨盆 中级轮椅参数表 阅读轮椅使用者故事,并用中级轮椅评定表上 “进行测量”单元的结果,把合适的尺寸加入到 下面的素描图中。 马丽安是一位18岁的少女。她在你的轮椅服务单位接受评定。她和轮椅服务人员共同决定,她需要 以下PSDs来帮助稳定她的骨盆: 骨盆前垫高 骨盆后垫 骨盆带 马丽安的身体测量尺寸在下面的表格中。 进行测量 身体测量 (mm) 轮椅部件测量 (mm) 座宽、座深和脚踏板高度 A 臀宽 400 =座宽或 1 =骨盆侧垫之间的距离 2 B 大腿长 (骨盆后 部到腘窝) 左 420 右 420 B减去30~60mm=椅座深度 (如果左右两边长度不同,取较 短的一个数值) 3 380 380 C 腘窝到足底 左 420 右 420 =座面顶端到脚踏板高度或 =座面顶端到地面高度 (脚推行 者) 4 5 靠背高度 D 座面※到胸腔下缘 E 座面※到肩胛下角 500 F 座面※到肩峰 =座面顶端到靠背顶端的距离 (根据轮椅使用者的需求,测量 D、E或F) 6 ,\3" 26 续表 身体测量 (mm) 轮椅部件测量 (mm) 改制和/或PSDs G 躯干宽度 370 =躯干侧垫/楔形垫之间的距离 7 H 座 面※ 到 腋 下 (腋窝) 左 480 右 480 H减去30mm=椅座顶端到躯干 侧垫/楔形垫之间的最大距离 (根据用手模拟进行调整) 8 450 450 I 座面到骨盆顶端 (髂后上 棘) 160 =座面顶端与骨盆后垫之间的 距离 9 J 膝关节之间的距离 =膝分隔垫之间的宽度 10 K 座面到颅底的距离 =座面顶端与头靠中间的距离 11 L 骨盆后部到坐骨 150 L加20~40mm=靠背支撑到坐 骨前垫高开始点之间的距离 12 180 其他 ※当进行测量时,“座面”是指坐骨坐的平面。 把马丽安坐骨前垫高和骨盆后垫的尺寸加入到 右边的素描框图中。 27 B.9:体位支撑装置 (PSDs)的处方 (选择)———支撑 髋关节 西耶娜的右髋关节无法屈曲至中立位坐姿,因为她 的躯干与大腿之间的角度大于90度。 在评定过程中,她用了一个临时支撑 (在两侧坐骨 和她左大腿下用泡沫塑料补高),帮助她以更直立 的姿势坐。 为她选择了一个带坐骨前垫高和降低坐垫前部 (右 侧)的坐垫,以适应她的右髋关节。 在下面中级轮椅处方表 “PSDs或需要的改制”部分描述西耶娜的PSD。运用透视图,并标出 需要的尺寸。 PSD清单 描述/绘画和提供尺寸 椅 座/ 坐垫 加入硬椅座 □ 坐骨前垫高 (=3-12) □ 降低坐垫前部 左□ 右□ 升高坐垫前部 □ 骨盆前倾楔形垫 □ 骨盆下补高 左□ 右□ 骨盆侧垫 (=2) 左□ 右□ 大腿外侧楔形垫 左□ 右□ 大腿外侧垫 左□ 右□ 大腿内侧楔形垫 (=10) □ 膝分隔垫 (=10) □ 其他 □ 其他 □ ,\3" 28 罗伯特无法屈曲他的髋关节至中立位坐姿,因为他 的躯干与大腿之间的角度大于90度。 在评定过程中,他用了临时支撑 (两侧坐骨下用泡 沫塑料补高),这让他以更直立的姿势坐。 为了适应他髋关节受限的情况,为他选择了一辆椅 座与靠背之间角度更大的轮椅。 在下面中级轮椅处方表 “PSDs或需要的改制”部分描述罗伯特的PSD。运用透视图,并标出 需要的尺寸。 PSD清单 描述/绘画和提供尺寸 椅座和 靠背 增加椅座与靠背的角度 □ 椅座与靠背后倾 (整体后倾) □ 靠背 加入硬靠背 □ 骨盆后垫 (=9) □ 靠背形状可调 □ 张力可调靠背 □ 靠背后倾 □ 躯干侧垫 (=7) 左□ 右□ 躯干侧楔形垫 (=7) 左□ 右□ 其他 □ 桌面板 /扶手 桌面板 □ 改制扶手 左□ 右□ 其他 □ 29 续表 头支撑 扁平头靠 (=11) □ 有形头靠 (=11) □ 其他 □ 小腿 支撑 脚踏板补高 左□ 右□ 脚踏板楔形垫 左□ 右□ 小腿支撑板 左□ 右□ 其他 □ 带子 骨盆带 □ 小腿带 □ 足带 左□ 右□ 肩带 □ 其他 □ B.10:体位支撑装置 (PSDs)的处方 (选择)———支撑 躯干 1.马克16岁,是一位高位脊髓损伤者。他有一辆悬吊式椅座和靠背的轮椅。他的轮椅尺寸是正确 的,并且有一个软的、平面的泡沫塑料坐垫。 马克发现自己很难坐直。他的腰弯着,他在轮椅上会向前滑。他坐骨下和肩胛骨旁的皮肤上有红斑。 阅读马克的评定结果 (下面)。 提供哪种PSDs有助于马克在他的轮椅上坐直? 用 《学员手册》上的PSD表和PSD参考表来帮 助你。 你如何为马克在他现有的轮椅上提供或制作这些支撑? 思考给轮椅椅座/坐垫/靠背带来的变化。 记住工作的顺序:骨盆+髋关节→躯干 用得到的轮椅和材料向其他组员展示,你如何为马克提供他需要的支撑。 ,\3" 30 无支撑坐姿 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲 角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位坐 姿———用临时支撑来适应。 用手模拟:用手支撑坐在中立位/尽可能舒适地接近中立位 对于每个身体部位:通过用手支撑,如果中立位坐姿可以实现,勾 “是”,如果不能,勾 “否”。 部位 是 否 骨盆 √ □ 描述或线条绘画用手支撑实现的轮椅使用者的最终坐姿,以及描述或线 条绘画实现坐姿所提供的支撑。 躯干 √ □ 头 √ □ 左髋 √ □ 右髋 √ □ 大腿 √ □ 左膝 √ □ 右膝 √ □ 左踝 √ □ 右踝 √ □ 为了坐直,马克需要: 在他骨盆后部大力的支撑 (两 只手在骨盆后部向前推); 在他肩胛骨后面轻轻地支撑。 31 中级轮椅处方 (选择)表 1.轮椅使用者信息 轮椅使用者姓名: 编号: 评定日期: 适配日期: 评定人姓名: 2.轮椅的类型、尺寸和设置 轮椅类型 (以下列出可得到的轮椅) 轮椅尺寸 (mm) □ 座宽 □ 座深 □ 靠背高度 □ 脚踏板高度 轮椅设置 后轮位置 后倾 其他: 3.坐垫类型和尺寸 坐垫类型 尺寸 例如:减压坐垫 □ □ 4.PSDs或需要的改制 PSD清单 描述/绘画并提供尺寸 椅座/ 坐垫 加入硬椅座 □ 坐骨前垫高 (=3-12) □ 降低坐垫前部 左□ 右□ 升高坐垫前部 □ 骨盆前倾楔形垫 □ 骨盆下补高 左□ 右□ 骨盆侧垫 (=2) 左□ 右□ 大腿外侧楔形垫 左□ 右□ 大腿外侧垫 左□ 右□ 大腿内侧楔形垫 (=10) □ 膝分隔垫 (=10) □ 其他 □ 其他 □ ,\3" 32 PSD清单 描述/绘画并提供尺寸 椅座和 靠背 增加椅座与靠背的角度 □ 椅座与靠背后倾 (整体后倾) □ 靠背 加入硬靠背 □ 骨盆后垫 (=9) □ 可调形状靠背 □ 张力可调靠背 □ 靠背后倾 □ 躯干侧垫 (=7) 左□ 右□ 躯干侧楔形垫 (=7) 左□ 右□ 其他 □ 桌面板 /扶手 桌面板 □ 改制扶手 左□ 右□ 其他 □ 头支撑 扁平头靠 (=11) □ 有形头靠 (=11) □ 其他 □ 小腿 支撑 脚踏板补高 左□ 右□ 脚踏板楔形垫 左□ 右□ 小腿支撑板 左□ 右□ 其他 □ 带子 骨盆带 □ 小腿带 □ 足带 左□ 右□ 肩带 □ 其他 □ 5.同意 轮椅使用者签名: 评定人签名: 评定组长签名: 33 2.约瑟芬35岁,是一位脊髓损伤者。她生活在农村,是当地教堂的一位活跃成员。她以前得到了一 辆长轴距的轮椅,由于她家人能较容易地推着这辆轮椅经过粗糙的乡村地面,所以她很喜欢。当在 家中的平坦地面时,她可以自己推一会儿。轮椅的尺寸对她合适,有一个硬靠背和椅座。她有一个 厚的平面泡沫塑料坐垫。 约瑟芬在轮椅上不舒适,并且她发现很难推动自己。她坐着时骨盆向后滚 (骨盆后倾)并且她的躯 干向前弯。 阅读约瑟芬的评定结果 (下面)。 提供哪种PSDs有助于约瑟芬在她的轮椅上尽可能地坐直? 用 《学员手册》上的PSD表和PSD参考表来帮助你。 你如何为约瑟芬在她现有的轮椅上提供或制作这些支撑? 思考给轮椅椅座/坐垫/靠背带来的 变化。 记住工作的顺序:骨盆+髋关节→躯干 用你得到的轮椅和材料向其他组员展示,你如何为约瑟芬提供她需要的支撑。 无支撑坐姿 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位坐姿 ———用临时支撑来适应。 ,\3" 34 用手模拟:用手支撑坐在中立位/尽可能舒适地接近中立位 对于每个身体部位:通过用手支撑,如果中立位坐姿可以实现,勾 “是”,如果不能,勾 “否”。 部位 是 否 骨盆 □ √ 描述或线条绘画用手支撑实现的轮椅使用者的最终坐姿,以及描述或线 条绘画实现坐姿所提供的支撑。 躯干 □ √ 头 □ √ 左髋 √ □ 右髋 □ √ 大腿 √ □ 左膝 √ □ 右膝 √ □ 左踝 √ □ 右踝 √ □ 约瑟芬不能以中立位坐姿坐直。她的最后姿 势是: ● 躯干后凸; ● 头向前倒; ● 骨盆后倾。 在以下支撑下,她的姿势有改善: ● 两侧坐骨和左大腿下临时支撑; ● 两只手在她骨盆后面,完全接触支撑她的 躯干上部和下部。 35 中级轮椅处方 (选择)表 1.轮椅使用者信息 轮椅使用者姓名: 编号: 评定日期: 适配日期: 评定人姓名: 2.轮椅的类型、尺寸和设置 轮椅类型 (以下列出可得到的轮椅) 轮椅尺寸 (mm) □ 座宽 □ 座深 □ 靠背高度 □ 脚踏板高度 轮椅设置 后轮位置 后倾 其他: 3.坐垫类型和尺寸 坐垫类型 尺寸 例如:减压坐垫 □ □ 4.PSDs或需要的改制 PSD清单 描述/绘画并提供尺寸 椅座/ 坐垫 加入硬椅座 □ 坐骨前垫高 (=3-12) □ 降低坐垫前部 左□ 右□ 升高坐垫前部 □ 骨盆前倾楔形垫 □ 骨盆下补高 左□ 右□ 骨盆侧垫 (=2) 左□ 右□ 大腿外侧楔形垫 左□ 右□ 大腿外侧垫 左□ 右□ 大腿内侧楔形垫 (=10) □ 膝分隔垫 (=10) □ 其他 □ 其他 □ ,\3" 36 PSD清单 描述/绘画并提供尺寸 椅座和 靠背 增加椅座与靠背的角度 □ 椅座与靠背后倾 (整体后倾) □ 靠背 加入硬靠背 □ 骨盆后垫 (=9) □ 可调形状靠背 □ 张力可调靠背 □ 靠背后倾 □ 躯干侧垫 (=7) 左□ 右□ 躯干侧楔形垫 (=7) 左□ 右□ 其他 □ 桌面板 /扶手 桌面板 □ 改制扶手 左□ 右□ 其他 □ 头支撑 扁平头靠 (=11) □ 有形头靠 (=11) □ 其他 □ 小腿 支撑 脚踏板补高 左□ 右□ 脚踏板楔形垫 左□ 右□ 小腿支撑板 左□ 右□ 其他 □ 带子 骨盆带 □ 小腿带 □ 足带 左□ 右□ 肩带 □ 其他 □ 5.同意 轮椅使用者签名: 评定人签名: 评定组长签名: 37 3.希恩是一位3岁的脑瘫患者。他有一辆儿童尺寸、可外翻脚踏板、悬吊式椅座和靠背的交叉折叠 轮椅。没有桌面板和坐垫。轮椅椅座深度对他合适,但是有点宽。他父母没有小汽车,他们走路去 大部分地方。他们可以在社区推他,尽管有时他们只是抱他。当在平坦地面时,希恩可以自己推一 会儿轮椅。 希恩在没有支撑下可以坐直一会儿。10分钟后他的躯干开始塌陷,他通常向前和向左倾斜。这导致 他的骨盆右侧抬起,他左侧坐骨承受更多的体重。他的后背有与他年龄相符的正常弯曲。希恩的妈 妈希望他能够与其他孩子一起玩耍并且推他的轮椅。 阅读希恩的评定结果 (下面)。 提供哪种PSDs有助于希恩尽可能在他的轮椅上坐直? 用 《学员手册》上的PSD表和PSD参考 表来帮助你。 你如何为希恩在他现有的轮椅上提供或制作这些支撑? 思考给轮椅椅座/坐垫/靠背带来的变化。 记住工作的顺序:骨盆+髋关节→躯干 用你得到的轮椅和材料向其他组员展示,你如何为希恩提供他需要的支撑。 无支撑坐姿 骨盆和髋关节姿势检查 当卧位时检查骨盆是否水平以及髋关节的屈曲角度 骨盆是否水平? 是 □ 否□ 髋关节是否可以屈曲至中立位坐姿? 右:是□ 否□ 角度: 左:是□ 否□ 角度: 如果骨盆不能水平或髋关节无法屈曲至中立位坐姿——— 用临时支撑来适应。 ,\3" 38 用手模拟:用手支撑坐在中立位/尽可能舒适地接近中立位 对于每个身体部位:通过用手支撑,如果中立位坐姿可以实现,勾 “是”,如果不能,勾 “否”。 部位 是 否 骨盆 □ □ 描述或线条绘画用手支撑实现的轮椅使用者的最终坐姿,以及描述或线 条绘画实现坐姿所提供的支撑。 躯干 □ □ 头 □ □ 左髋 □ □ 右髋 □ □ 大腿 □ □ 左膝 □ □ 右膝 □ □ 左踝 □ □ 右踝 □ □ 希恩不能以中立位姿势坐,然而两侧髋关节可以屈曲 (躯干与大腿之 间的角度大约是80度)。 为了坐直,希恩需要: 临时泡沫塑料楔形垫在两侧大腿下提供支撑; 双手分别放在他骨盆的两侧,紧紧地抓住并且在他骨盆后部轻轻地 支撑; 双手分别放在他躯干的两侧,紧紧地抓住。左侧需要的支撑位置稍 微比右侧高; 环绕在他双肩胛骨和胸部前面轻轻地支撑。 39 中级轮椅处方 (选择)表 1.轮椅使用者信息 轮椅使用者姓名: 编号: 评定日期: 适配日期: 评定人姓名: 2.轮椅的类型、尺寸和设置 轮椅类型 (以下列出可得到的轮椅) 轮椅尺寸 (mm) □ 座宽 □ 座深 □ 靠背高度 □ 脚踏板高度 轮椅设置 后轮位置 后倾 其他: 3.坐垫类型和尺寸 坐垫类型 尺寸 例如:减压坐垫 □ □ 4.PSDs或需要的改制 PSD清单 描述/绘画并提供尺寸 椅座/ 坐垫 加入硬椅座 □ 坐骨前垫高 (=3-12) □ 降低坐垫前部 左□ 右□ 升高坐垫前部 □ 骨盆前倾楔形垫 □ 骨盆下补高 左□ 右□ 骨盆侧垫 (=2) 左□ 右□ 大腿外侧楔形垫 左□ 右□ 大腿外侧垫 左□ 右□ 大腿内侧楔形垫 (=10) □ 膝分隔垫 (=10) □ 其他 □ 其他 □ ,\3" 40 PSD清单 描述/绘画并提供尺寸 椅座和 靠背 增加椅座与靠背的角度 □ 椅座与靠背后倾 (整体后倾) □ 靠背 加入硬靠背 □ 骨盆后垫 (=9) □ 可调形状靠背 □ 张力可调靠背 □ 靠背后倾 □ 躯干侧垫 (=7) 左□ 右□ 躯干侧楔形垫 (=7) 左□ 右□ 其他 □ 桌面板 /扶手 桌面板 □ 改制扶手 左□ 右□ 其他 □ 头支撑 扁平头靠 (=11) □ 有形头靠 (=11) □ 其他 □ 小腿 支撑 脚踏板补高 左□ 右□ 脚踏板楔形垫 左□ 右□ 小腿支撑板 左□ 右□ 其他 □ 带子 骨盆带 □ 小腿带 □ 足带 左□ 右□ 肩带 □ 其他 □ 5.同意 轮椅使用者签名: 评定人签名: 评定组长签名: 41 B.11:体位支撑装置 (PSDs)的处方 (选择)———支撑 头部、大腿和小腿 阅读和回答下面的问题 乔纳来参加评定。在用手模拟的过程中,你发现乔纳的腿向外倒 (外展),但 是轻轻地支撑你可以把他的腿放到中立位坐姿 (膝关节靠在一起)。 你认为可以对他的轮椅和坐垫做哪些调整,以帮助他坐着时腿放在中立位。 萨姆使用这辆轮椅已经两年了。他是脑损伤,他的双腿很僵硬和强直。在评 定中你发现萨姆的大腿内收但是你可以把他的双膝分开处于更中立的坐姿。 然而,这需要相当大的力量。当他的膝关节处于更加中立的坐姿时,萨姆感 觉更平衡了。 你认为可以对他的轮椅和坐垫做哪些调整,以帮助他坐的时候大腿处于中 立位坐姿? 伊利亚很满意,他的轮椅可以折叠,并且他能够把它放进汽车往返工场。然 而他的后背疼痛并且发现他的双腿相互交叉在一起。在评定过程中,你发现 伊利亚能以中立位坐姿坐,在柔和的支撑下他的双腿能坐到中立位坐姿。 你认为可以对他的轮椅和坐垫做哪些调整,以帮助他坐的时候双腿处于中 立位坐姿? ,\3" 42 实操二:产品 (轮椅)准备———任务清单 用下面的表格来帮你计划以及准备轮椅和PSDs。 - 列出每项任务 (最好按照任务应该完成的顺序)。 - 决定谁负责该项任务。 - 当每项任务完成后,在后面方框内画勾。 列出每项任务 负责人 完成后画勾 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 43 实操二:产品 (轮椅)准备———中级轮椅安全和准备检查表 用中级轮椅安全和准备检查表来确保轮椅是安全的以及准备让轮椅使用者试用。 整辆轮椅包括PSDs 没有尖锐边角 □ 无部件损坏或刮伤 □ 轮椅能够沿直线行进 □ 前小脚轮 自由地转动 □ 转动而不触及轮叉 □ 螺栓是拧紧的 □ 前小脚轮套 小脚轮叉自由地转动 □ 后轮 自由地转动 □ 轴螺栓是拧紧的 □ 轮胎充气正常 (用拇指横压轮胎,轮胎稍微下陷不超过5mm) □ 手推圈是稳固的 □ 刹车 正常工作 □ 脚踏板 脚踏板连接牢固 □ 轮椅架 对于交叉折叠式轮椅,轮椅轻易地折叠和展开 □ 对于靠背折叠式轮椅,靠背可以轻易地折叠和展开 □ 坐垫 坐垫刚好放在坐垫套内 □ 坐垫正好放在轮椅上 □ 坐垫套面料是紧贴的,但不是太紧 □ 如果轮椅是硬椅座:坐垫完全覆盖椅座 □ ,\3" 44 B.14:使用者培训 阅读下面的一个轮椅使用者故事。你的教师将告诉你阅读哪个使用者故事。 决定轮椅使用者需要学习哪些技能来使用和保养他们的新轮椅。完成下一页的轮椅使用者培训 检查表。 选择轮椅使用者、轮椅服务人员或轮椅使用者家人/护理者的角色。扮演轮椅服务人员角色的人 应该练习教至少三项技能给组内的其他人员。用 《学员手册》上列出的 “如何让轮椅使用者培 训成功”技巧。 约书亚 约书亚是一位6岁的脑瘫儿童。他有突然不受控制的运动。为他选择了一辆带有PSDs的儿童 轮椅,包括骨盆带、骨盆侧垫和躯干侧垫。约书亚的皮肤较薄且敏感,并且躯干侧垫配了附加的衬 垫有助于确保躯干侧垫不会导致压疮。 约书亚的新轮椅具有后倾功能,这让轮椅有时可以后倾并且让他头部更直立。这辆轮椅也有一 个防翻杆,在经过粗糙地面或上下路缘时,这个防翻杆也可以移开。为了运输,该轮椅后轮可拆卸 以及椅座可以从轮椅框架上拿开。 约书亚每天早上去幼儿园。他由幼儿园安排的运输服务单位进行接送。交通工具是一个小摩托 三轮车。他父母担心这辆轮椅是否可以放在里面。 约书亚来对他的新轮椅进行适配。他妈妈和他一起过来。 珊吉塔 珊吉塔是一位脊柱裂的3岁儿童。她运动困难,腰部以下感觉丧失并且在她的脊柱底部膨出。 她父母说她难以控制自己的大小便,经常泌尿系统感染。 珊吉塔来到轮椅服务单位对她的第一辆轮椅进行适配,这辆轮椅有快拆轮、骨盆带、骨盆侧垫, 异形的靠背避开压迫她的脊柱膨出。她也有一个减压坐垫。她和她父母一起过来。父母担心如果她 有了一辆轮椅她将不再想用她的膝踝足矫形器走路。然而,当她无法与她的兄弟和姐妹一起在外玩 耍的时候,她感到沮丧。 45 金颂 金颂40岁,他15年前颅脑损伤。因为吃东西困难,所以他非常瘦。他的脊柱僵硬向前弯曲。 金颂不能站立并且完全依靠他母亲。他不能说话,但是他母亲说他明白简单的指令。 在评定过程中,他被确认为有发生压疮的风险。因为他瘦,不能独立地移动并且过去曾经有过 压疮 (躺在床上的时候)。 他刚刚获得第一辆轮椅。轮椅有一个减压坐垫和PSD帮助他坐得更舒适。他妈妈是他的护理者 并且和他一起参加轮椅适配。 ,\3" 46 中级轮椅使用者培训检查表 需要教的技能 已经教的技能 轮椅操作 折叠和搬运轮椅 □ □ 拆下和装回所有的PSDs以便运输的需要 □ □ 使用快拆轮 □ □ 使用刹车 □ □ 后倾和防翻杆 (如果使用) □ □ 当轮椅使用者坐在轮椅上时,在正确的位置安装PSDs □ □ 使用坐垫,包括正确摆放 □ □ 转移 独立转移 □ □ 在协助下转移 □ □ 其他 □ □ 轮椅使用和移动 正确地推轮椅 (用轮椅使用者喜欢的方法) □ □ 上下斜坡 □ □ 上下台阶 □ □ 粗糙地面 □ □ 翘前轮基本技巧 □ □ 在轮椅上坐多长时间 (对于需要附加体位支撑的儿童和成人) □ □ 协助推行 □ □ 47 续表 需要教的技能 已经教的技能 预防压疮 检查易发压疮的高压部位 □ □ 减压技巧 □ □ 营养膳食并充足饮水 □ □ 如果发生压疮,该怎么办 □ □ 如何在家保养轮椅 清洁轮椅,清洗并晾干坐垫和坐垫套 □ □ 为活动部件上油 □ □ 给轮胎打气 □ □ 拧紧螺母和螺栓 □ □ 拧紧辐条 □ □ 检查装饰面料 □ □ 检查是否生锈 □ □ 检查坐垫 □ □ 如果出现问题,该怎么办 轮椅需要维修 □ □ 轮椅不适配或不舒适 □ □ ,\3" 48 B.15:整合所有知识 向所有学员做10分钟的报告,关于你所在小组服务的轮椅使用者情况以及你们小组学习到的 知识。 报告应该包括以下要点: 1.从评定中获得的信息 轮椅使用者的目的 (为什么他/她想要一辆轮椅); 他们身体的需求; 他们生活方式的需求; 他/她是否已有一辆轮椅,这辆轮椅是否满足他们的需求; 压疮的出现、风险或病史; 推轮椅的方法; 无支撑坐姿; 骨盆和髋关节姿势检查的结果; 用手模拟的结果。 2.处方 (选择)的轮椅和坐垫 轮椅的类型; 坐垫的类型; 处方的所有PSDs。 3.适配 适配中发现及需要解决的所有问题,如果有问题,如何解决。 4.使用者培训 轮椅使用者和组员决定的哪些内容应该包括在使用者培训中? 5.轮椅使用者反馈 获得轮椅后,轮椅使用者有任何意见或反馈吗? 6.随访计划 已经为随访做出了哪些安排? 49 B.16:保养、维修和随访 阅读每个轮椅使用者故事。 为每位轮椅使用者完成轮椅随访表。 讨论和记录采取的任何行动。 希塔 希塔7岁和他父母及姐姐生活在一起。他患了肌萎缩症并且在一年前通过轮椅服务获得了一辆 轮椅。那时候他可以短距离行走。他能够独立地站立式上下轮椅。他说自己想要一辆轮椅,因为他 发现上学困难。 在随访过程中,希塔说他现在自己很难独立地上下轮椅。在学校到了下午他感到疲劳和不舒适。 这使他难以集中精力。他的轮椅尺寸正确并且有一个中号的悬吊式靠背及简单的舒适坐垫。 当要求希塔对自己轮椅的满意度按照总分5分进行评分时,他打4分。 米莱拉 米莱拉23岁,是一名小儿麻痹症患者。她酿造蜂蜜并在当地市场销售。两年前她获得了一辆轮 椅带前挂装置的三轮车。她需要在轮椅上安装一些附加的PSDs。为她处方 (选择)了一个改制的多 层泡沫塑料坐垫。骨盆后垫加在轮椅的靠背上。 在随访中,米莱拉说她每天用这辆三轮车往返市场。 她说自己最近补过被扎破的两个轮胎。当检查轮椅时,轮椅服务人员注意到轮胎磨损严重。骨 盆后垫滑到椅座上并且坐垫看起来很平。 当要求米莱拉对自己轮椅的满意度按照总分5分进行评分时,她打3分。 乌苏拉 乌苏拉是一位6岁的脑瘫儿童。她喜欢与她姐姐在教堂唱诗班唱歌。她在八个月之前获得一辆 带PSDs的轮椅。 由于呼吸系统感染生病,她错过了第一次随访预约。她父母说她最近在轮椅上不开心并要求坐 轮椅一小时后离开。他们注意到在她肋骨上靠近躯干侧垫一侧有一块暗斑,并想知道这是否是一个 问题。 轮椅服务人员找到一个私密的场所,并取得乌苏拉和她父母的同意检查她的皮肤。轮椅服务人 员证实这是一块暗斑。他们检查了轮椅并注意到躯干侧垫上的泡沫塑料垫受到挤压。 当被要求对满意度按照总分5分进行评分时,她父母的评分是4分。 ,\3" 50 轮椅随访表 1.轮椅使用者信息 轮椅使用者姓名: 编号: 适配日期: 随访日期: 随访人员姓名: 随访地点:轮椅使用者家 □ 轮椅服务中心 □ 其他 □ 2.面谈内容 记录应采取的措施: 您能如您所愿地使用轮椅吗? 是 □ 否 □ 如果不能,为什么? 您在使用轮椅的过程中,遇到什么问题吗? 是 □ 否 □ 如果有,是什么问题? 您在使用轮椅的过程中,有什么不懂的问题吗? 是 □ 否 □ 如果有,问题是什么? 需要进一步的培训吗? 您有压疮吗? 是 □ 否 □ 如果有,请描述 (位置和等级) 您对自己轮椅的满意度用1~5如何评价? (1是不满意,5是非常满意) 评价: 备注: 3.轮椅和坐垫的检查 轮椅是处于良好的工作状态并且可以安全地使用吗? 是 □ 否 □ 坐垫是处于良好的工作状态并且可以安全地使用吗? 是 □ 否 □ 如果以上两项有任何一项答案是否,请问是什么问题? 4.适配检查 轮椅适配正确吗? 是 □ 否 □ 如果不适配,是什么问题? 压力测试等级 (1级=安全级,2级=警告级,3级=不安全级) (使用者是否有发生压疮的风险) 左: 右: 轮椅使用者在静止、移动时,能舒适地坐直吗? 能一整天都这样坐吗? 是 □ 否 □ 如果不能,请问是什么问题? 51 实操四:评定、处方 (选择)、产品 (轮椅)准备、适 配和使用者培训———任务清单 产品 (轮椅)准备———任务清单 用以下的表格来帮助你计划和准备轮椅使用者首次适配的轮椅和PSDs。 - 列出每项任务 (最好按照任务应该完成的顺序)。 - 决定谁负责该项任务。 - 当每项任务完成后,在后面的方框内画勾。 列出每项任务 负责人 完成后画勾 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ ,\3" 52 实操四:评定、处方 (选择)、产品 (轮椅)准备、 适配和使用者培训———中级轮椅安全和准备检查表 用中级轮椅安全和准备检查表来确保轮椅是安全的以及准备让轮椅使用者试用。 中级轮椅安全和准备检查表 整辆轮椅包括PSDs 没有尖锐边角 □ 无部件损坏或刮伤 □ 轮椅能够沿直线行进 □ 前小脚轮 自由地转动 □ 转动而不触及轮叉 □ 螺栓是拧紧的 □ 前小脚轮套 小脚轮叉自由地转动 □ 后轮 自由地转动 □ 轴螺栓是拧紧的 □ 轮胎充气正常 (用拇指横压轮胎,轮胎稍微下陷不超过5mm) □ 手推圈是稳固的 □ 刹车 正常工作 □ 脚踏板 脚踏板连接牢固 □ 轮椅架 对于交叉折叠式轮椅,轮椅轻易地折叠和展开 □ 对于靠背折叠式轮椅,靠背可以轻易地折叠和展开 □ 坐垫 坐垫刚好放在坐垫套内 □ 坐垫正好放在轮椅上。 □ 坐垫套面料是紧贴的,但不是太紧。 □ 如果轮椅是硬椅座:坐垫完全覆盖椅座 □
Published by the World Health Organization in 2013 Wheelchair service training package: intermediate level © World Health Organization (2013) 세계보건기구는 국립재활원에 한국어판에 대한 번역과 출판의 권리를 승인하였으며, 국립재활원은 한국어판의 질과 신뢰성에 대해 온전히 책임이 있음. 영문판과 한국어판 사이에 불일치가 있을 때에는 원문인 영문판이 정확성을 가짐. The World Health Organization has granted translation and publication rights for an edition in Korean to National Rehabilitation Center, which is solely responsible for the quality and faithfulness of the Korean version. In the event of any inconsistency between the English and the Korean versions, the original English version shall be the binding and authentic version. 휠체어 서비스 교육 교재 – 중급단계 © 국립재활원 (2017) Authors/Editors of the original version Editors: Chapal Khasnabis and Kylie Mines Authors: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle 번역서의 저자/편집인 저자: 김남희, 김진주, 김호진, 손소희, 임명준, 이보람, 정승민 (가나다순) 감수: 이보람, 한지아 편집: 김남희, 김진주, 이보람 ISBN : 978-89-6810-197-7(93330) 용어사전 다음과 같이 교육 교재에서 사용되는 용어들을 정리합니다. 적절한 휠체어 적절한 휠체어란 사용자의 요구와 환경에 잘 맞는 휠체어를 뜻합니다. 즉 사용자의 몸에 꼭 맞고 자세를 지지해주어야 하며, 안전하고 내구성이 좋아야 합니다. 또한 사용자가 살고 있는 나라에서 쉽게 구할 수 있고 적당한 가격에 수리와 유지 보수를 할 수 있어야 합니다. 수동 휠체어 수동 휠체어는 사용자에 의해 직접 조작되거나 다른 사람이 뒤에서 밀어주면서 조작되는 장치를 말합니다. 자세보조용구(Postural Support Device, PSD) 자세보조용구(PSD)는 사용자의 자세에 대해 추가적인 자세지지를 제공하는 장치를 의미합니다. 이 장치는 중급 휠체어 서비스의 중요한 요소입니다. 휠체어 걷거나 움직이기 어려운 사람이 앉은 채로 이동할 수 있도록 바퀴를 단 의자를 의미합니다. 휠체어 변형 휠체어의 변형을 의미합니다. 휠체어 보급 휠체어의 디자인, 생산, 보급, 서비스 배달을 포괄적으로 의미합니다. 휠체어 서비스 휠체어 보급 중에서 사용자에게 적절한 휠체어를 제공해주는 것을 의미합니다. 휠체어 서비스 인력 적절한 휠체어를 제공해주는 숙련된 인력을 의미합니다. 휠체어 사용자 걷거나 움직이기 어려워서 휠체어를 사용하여 이동하는 사람을 의미합니다. 서문 휠체어 서비스 교육자료: 중급에 대하여 A: 핵심 내용 A.1: 추가적인 자세 지지로 효과를 얻는 휠체어 사용자 A.2: 장애 아동 B. 휠체어 서비스 단계 1 단계: 의뢰서와 진료 2 단계: 평가 평가 개요와 인터뷰 신체 측정 – 자제지지 없이 앉는 자세 신체 측정 – 골반과 고관절 자세 평가 신체 측정 – 손을 이용한 시뮬레이션 신체 측정 – 치수 측정 3 단계: 주문 (선택) 휠체어와 쿠션 선택 PSD 의 주문 – 개요 PSD 의 주문 – 골반의 안정화 PSD 의 주문 – 고관절 지지 PSD 의 주문 – 체간 지지 PSD 의 주문 – 머리와 허벅지, 하지 지지 4 단계: 자금과 주문 5 단계: 제품의 준비 휠체어와 PSD 의 준비 과정 PSD 제작 시 기억해야 할 것 PSD 를 제작 시 필요한 재료들 PSD 제작 방법 휠체어 안전 점검 중급 휠체어 안전 및 준비 체크리스트 6 단계: 피팅 7 단계: 사용자 훈련 사용자에게 유용한 기술은? 8 단계 유지와 보수 추후 관리 주요 추후관리 C O N T E N T S VII 1 6 13 20 21 21 21 49 54 59 63 71 71 80 94 98 100 104 107 107 108 109 110 112 128 129 130 139 139 144 144 145 서문 휠체어는 사용자의 이동성을 향상시키기 위해 가장 널리 사용되는 보조기기 중 하나입니다. 이동하는 것은 인권을 누리고 품위를 지키는데 필요한 전제조건이며, 장애가 있는 사람들이 지역사회에서 더욱 생산적인 구성원이 될 수 있도록 도와줍니다. 제대로 설계되고 몸에 잘 맞는 적절한 휠체어는 장애를 가진 많은 사람들에게 사회에 통합되고 참여할 수 있게 하는 첫 걸음이 될 것입니다. 장애인의 기회 평등에 관한 국제연합(UN) 표준규칙, 장애인권리협약, 그리고 장애 예방, 관리 그리고 재활을 다룬 세계보건총회 (World Health Assembly) 결의안 WHA58.23 에서 모두 휠체어와 기타 보조기구의 중요성을 강조하였습니다. 세계보건기구(WHO)는 특히 저개발국가에 있는 장애인들이 적절한 휠체어를 구할 수 있도록 저개발국가의 수동 휠체어 보급을 위한 지침서를 미국 국제 개발처 (USAID)와 국제 의지보조기 협회 (ISPO) 와 협력하여 개발하였습니다. 적정한 수의 인력을 적절하게 교육시키고 휠체어 지침서에 근거한 효과적인 휠체어 전달 체계를 실현시키기 위해 세계보건기구(WHO)는 지침서에 서술된 다양한 단계에서의 개입과 관련한 다양한 단계의 보건/재활 인력을 위한 휠체어 서비스 교육자료를 개발하기 위한 계획을 가졌습니다. 그리하여 2012 년 6 월 휠체어 서비스 교육교재 – 초급 (WSTP-B)의 성공적인 발표 후, 휠체어 서비스 교육자료 – 중급 (WSTP-I)을 기쁜 마음으로 발표하게 되었습니다. 휠체어 서비스 교육자료 – 초급 편에서 습득한 기술과 지식을 더욱 발전시키는 것뿐만 아니라 휠체어 서비스 교육자료 – 중급 편에서는 보다 소아에 더 집중하여 다루게 됩니다. 발달 장애의 특징으로 인하여 많은 아동들이 이동과 자세 지지 모두를 위해 휠체어가 필요하기 때문입니다. Alana Officer Robert Horvath 코디네이터 운영자 장애와 재활 팀 취약한 인구를 위한 프로그램 폭력과 손상 예방과 장애 부서 민주주의, 인권과 거버넌스 전문 센터 세계보건기구 WHO 미국 국제 개발처 (USAID) 휠체어 서비스 교육자료: 중급에 대하여 서론 2008 년 발표한 저개발국가의 수동휠체어 보급 지침서(1) 와 2012 년에 발표한 휠체어 서비스 교육자료 – 초급 (WSTP-B)에 이어 세계보건기구 (WHO)는 미국 국제 개발처 (USAID)와 합작으로 휠체어 서비스 교육자료 – 중급 (WSTP-I)을 발표하였습니다. 휠체어 서비스 교육자료 – 중급은 세계보건기구(WHO)의 휠체어 서비스 교육자료 시리즈의 두 번째 자료이며 걷기와 이동 그리고 체간 조절에 극심한 어려움이 있는 사용자들의 요구를 다루는 것에 더욱 초점을 맞췄습니다. 이번 교육자료를 집필하는 과정에서 체간 조절이 저하되어 있고 스스로 바르게 앉기 힘든 아동들에게 적절한 휠체어 제공하기 위해 특별히 주의를 기울였습니다. 휠체어는 사용자의 이동을 위해 가장 널리 사용되는 보조기기 중 하나입니다. 걷는데 어려움이 있는 사람들에게 자신의 몸과 생활방식 그리고 환경적 요구에 맞는 휠체어는 필수적인 도구로서 매우 향상된 건강, 사회적 그리고 경제적 안녕을 즐길 수 있게 해주는 수단이 될 수 있습니다. 사용자들은 휠체어를 통해 이동하면서 공부하고 일하며, 문화생활을 즐기고 의료서비스를 받으러 갈 수 있습니다. “가능한 최대의 독립성을 가지면서 개인의 이동성을 장애인들에게 보장하기 위한 효과적 방안”을 지지하는 UN 장애인권리협약 (UNCRPD)에 이동성의 중요성은 반영되어 있습니다. 사용자의 효과적 이동성이 보장되기 위해서는, 휠체어 사용자들은 자신의 몸에 딱 맞고 그들의 특이적 요구를 충족하는 휠체어가 필요합니다. 이를 위해서는 개개인의 요구에 부합하는 접근이 필요합니다. 휠체어 사용자들의 각각의 요구를 충족시키는 효과적 방법은 휠체어 서비스를 통해 휠체어를 제공하는 것입니다. 그러나 통계에 따르면, 휠체어를 필요로 하는 자 중의 5% 미만 만이 자신에게 적절한 휠체어를 제공받고 있습니다. 게다가 휠체어 인력이 효과적 휠체어를 선택하는데 필요한 기술을 습득하기 위한 교육 기회도 제한적인 상황입니다. WSTP-I 는 휠체어 서비스 중 임상적, 기술적 역할을 담당하는 인력의 중급 수준의 교육을 지원하기 위해 제작되었습니다 (저개발국가의 수동휠체어 보급 지침서, 표 4.2 참고). 본 교육 교재는 바르게 앉기 위하여 추가적인 자세지지가 요구되는 휠체어 사용자들을 돕기 위해 필요한 이론과 실습에 대한 제공을 지원합니다. 또한 본 교육교재는 개개인의 요구를 평가하는 방법; 추가적인 자세지지가 있는 가장 적절한 휠체어를 선택하고 세팅 하는 방법; 사용자와 보호자들이 어떻게 휠체어를 사용하고 관리하며 사후관리를 하는지에 대해 교육하는 것을 포함합니다. 본 교육교재를 이용한 교육은 35~40 시간 정도가 소요되나, 각 상황마다의 특별한 요구와 이용 가능한 자원에 따라 소요 시간이 늘어나거나 줄어들 수 있습니다. 능력 향상과 독립적 작업을 위한 역량 강화를 위해서 멘토와 함께 추가적인 연습을 하는 것을 권장합니다. 휠체어 서비스 교육교재는 이미 현직에서 활동하고 있는 인력을 위한 독립형 단기 교육 프로그램뿐만 아니라 보건과 재활 인력을 위한 교육 프로그램의 교육과정에도 통합되어 사용될 수 있습니다. 대상자 본 교육자료는 자신이 일하는 곳에서 중급단계의 휠체어 서비스를 시행해야 하는 모든 인력과 봉사자들을 위해 제작되었습니다. 이는 작업치료사, 물리치료사, 의지보조기기사, 지역사회 보건 종사자, 지역사회중심 재활사업 (Community-based Rehabilitation, CBR) 종사자와 같은 보건, 재활 및 기술직 인력을 포함합니다. 목적 중급 교육교재는 바르게 앉기 위해 추가적인 자세지지가 필요한 남녀노소에게 적절한 수동 휠체어와 방석을 제공할 수 있도록 현직의 인력과 봉사자의 교육을 지원하고자 만들어졌습니다. 본 교육교재의 주된 목적은 휠체어 서비스 전달에 관계된 인력들의 기술과 지식을 발전시키는데 있습니다. 본 교육교재는 다음과 같은 점에서 유용합니다: 자신의 요구에 맞는 적절한 휠체어를 제공받는 휠체어 사용자들이 많아지도록 도울 것입니다; 휠체어 서비스 전달의 중급단계를 훈련 받은 인력이 많아지도록 도울 것입니다; 휠체어 서비스 전달을 담당하는 인력의 업무 역량 강화를 도울 것입니다 초급 수준보다 높은 수준의 휠체어 서비스 개입을 필요로 하는 사람들을 위한 휠체어 서비스 질의 향상을 도울 것입니다 준의료 활동/재활 교육 프로그램에서 휠체어 서비스 교육 과정이 포함되도록 도울 것입니다. 재활서비스 내에 휠체어 서비스 제공 서비스가 더욱 잘 통합되도록 도울 것입니다. 범위 본 교육자료는 다음의 사항들을 포함합니다. 추가적인 자세지지가 장착된 휠체어가 필요한 성인과 아동의 이동성과 자세지지의 요구를 평가하는 방법 사용자의 이동문제를 해결하기 위해 그들과 함께 가능한 방법 중 최선의 이동의 해결책을 찾는 방법 적절한 방석과 추가적인 자세지지를 가지고 있는 수동 휠체어를 제공하는데 필요한 지식과 실용적 정보 휠체어 사용자와 그들의 가족들/보호자들이 그들의 휠체어를 자장 잘 사용할 수 있게끔 교육하는 방법 휠체어가 지속적으로 사용자의 요구를 충족하도록 하는 후속 조치 요구되는 선행 지식과 기술 본 중급 단계 교육으로부터 최대한 많은 것을 얻어가기 위해서는 휠체어 서비스 제공에서의 기존의 경험이 필수적입니다. 중급 프로그램은 참가자들이 WHO 의 휠체어 서비스 교육자료 – 초급에서 배운 능력을 수행 가능하고 초급단계의 휠체어 서비스 전달의 실전 경험을 가지고 있다는 전제로 작성되었습니다. 구성 휠체어 서비스 교육교재: 중급은 중급 단계의 휠체어 서비스 제공에 숙달된, 그리고 본 교육 프로그램에서 다루게 되는 능력들을 자신 있게 수행할 수 있는 교육자들에 의해 교육될 수 있도록 디자인 되었습니다. 본 교재에는 다음과 같은 교육 자료가 제공됩니다: 교육자 매뉴얼과 교육자 도구들; 교육 참가자를 위한 참조 자료 (참조 매뉴얼로 명명); 교육 참가자 학습지; 휠체어 서비스 서식; 휠체어 서비스 체크리스트; 파워포인트 슬라이드, 비디오, 포스터를 포함한 시각 자료. 개발 과정 저개발국가의 수동휠체어 보급 지침서를 발표한 이후 세계보건기구(WHO)는 휠체어 서비스 교육자료를 제작하기 위한 팀을 구성하였습니다. 첫 번째 그룹 미팅이 2008 년 10 월에 세계보건기구(WHO)에 의해 소집되어 교육자료의 범위와 내용을 결정하였습니다. 이 제안된 교육 교재 내용에 대해 20 명 이상의 해당분야 전문가들로부터 피드백이 순환되고 수집되었으며, 이어서 저자들 중 핵심 그룹은 현장 모의 시험을 위한 각 교육 자료를 준비하였습니다. 2011 년에는 중급 단계 교육교재가 루마니아, 케냐, 동티모르에서 시범적으로 사용되었습니다. 각 시범사업은 세계보건기구(WHO) 휠체어 교육교재 실무단 그룹원들에 의해 조사되었습니다. 시범사업에 참여한 교육자, 교육 참가자들과 휠체어 사용자들의 의견은 최종안에 함께 포함되었습니다. 시범사업뿐만 아니라 중급 교육자료는 전문가 심사를 받았습니다. 15 명의 휠체어 전문가가 문서를 심사하였고 그들의 소중한 피드백과 조언들이 교육자료의 최종작업에 유용하게 사용되었습니다. 교육교재 개발에 참여한 모든 저자들은 이해관계에 대한 선언 (DOI)을 마쳤고 모두 해당 주제에 대한 이해상충이 없었습니다. 참조 매뉴얼 사용방법 본 참조 매뉴얼은 휠체어 서비스 전달 중급 교육과정에서 다루는 지식들에 대한 요약을 제공하고 있습니다. 참가자들은 교육 프로그램을 이수한 이후에도 참조 매뉴얼을 사용하여 각 세션에서 배운 주요 내용들을 환기시킬 수 있습니다. 본 매뉴얼은 다음과 같이 두 부분으로 나뉩니다: A: 핵심 지식 B: 휠체어 서비스 단계 A: 핵심 지식 – 이 부분은 휠체어 서비스 모든 단계와 관련된 정보를 포함하고 있습니다. 몇몇 상황에서는, 교육 참가자의 학습 필요에 따라 교육자들은 이 부분에 부가적 정보를 추가하여 교육을 진행할 수도 있습니다. B: 휠체어 서비스 단계 – 이 부분은 교육 참가자들이 중급 수준의 휠체어 서비스 제공의 8 가지 단계를 습득할 수 있는 정보를 포함하고 있습니다 (WHO 저개발국가의 수동휠체어 보급 지침서(2), 76 페이지 참고). 초급 & 중급 휠체어 서비스 제공 교육 휠체어 서비스 인력에게 적절한 교육을 제공하기 위해 WHO 교육 교재는 초급과 중급, 두 가지 레벨의 교육을 제공합니다. 초급 교육은 교육 참가자들에게 걷거나 이동하는데 어려움이 있지만 추가적인 자세지지 없이도 바르게 앉을 수 있는 아동들과 성인들에게 휠체어를 제공하는 방법을 가르치고 있습니다. 중급 교육은 교육 참가자들에게 바르게 앉기 위해서 추가적인 자세지지가 필요한 아동들과 성인들에게 휠체어를 제공하는 방법을 가르치고 있습니다. 중급 교육 프로그램은 교육 참가자들이 초급에서 습득한 정보와 기술을 기반으로 하고 있습니다. A: 핵심 지식 A.1: 추가적인 자세지지로 효과를 얻는 휠체어 사용자 휠체어 사용자들은 휠체어를 이미 가지고 있거나 보행능력의 제한으로 휠체어를 사용함으로써 효과를 얻을 수 있는 사람들을 말합니다. 휠체어 사용자들은 다음과 같은 사람들을 포함합니다: 아동, 성인, 노년층; 서로 다른 건강상태, 생활방식 그리고 삶의 역할과 배경을 가진 사람들 지방이나 준 도시, 도시들을 포함하는 다양한 환경에서 생활하고 일하는 사람들 각각의 휠체어 사용자들의 요구는 다양할 수 있습니다. 그러나 모든 휠체어 사용자들은 적절한 휠체어가 필요합니다. 몸에 잘 맞는 휠체어는 사용자에게 어느 정도의 자세지지를 제공합니다. 등받이, 방석, 발 받침대와 팔걸이는 사용자의 몸에 잘 맞게 맞춰질 경우 모두 자세지지를 제공하게 됩니다. 그러나 많은 아동과 성인들은 휠체어에 추가적인 자세지지가 필요하게 됩니다 추가적인 자세지지는 추가적인 자세지지를 제공하는 물리적 장치인 자세보조용구(PSD) 통해 제공됩니다. 자세보조용구(PSD)는 중급 휠체어 서비스에서 필수적인 요소입니다. 자세보조용구(PSD)는 추가적인 자세지지를 위해 휠체어에 추가된 부가물이나 변형을 포함합니다. 본 매뉴얼에서는 자세보조용구를 PSD 로 표기하였습니다. 추가적인 자세지지로 효과를 얻는 휠체어 사용자 몇몇 사람들은 추가적인 지지 없이는 바르게 앉을 수 없습니다. 어떤 이들은 많은 양의 추가적 지지가 필요한 반면, 어떤 이들은 휠체어에 약간의 변경만이 필요합니다. 추가적인 자세지지는 여러 방법으로 제공될 수 있습니다. 몇몇 해결방법은 매우 단순하며 기본 작업장에서 완성될 수 있습니다. 다른 해결방법들은 조금 더 복잡할 수도 있습니다. 언제 추가적인 자세지지가 필요한가요? 사용자들은 제각기 다른 이유들로 추가적인 자세지지가 필요합니다. 아래 묘사된 것과 같이 똑바로 앉는데 적절한 지지가 제공되지 않는 휠체어를 사용하는 대개의 경우는 그 문제점이 명확합니다. 종종 휠체어 사용자나 가족/보호자는 그들의 휠체어에 추가로 필요한 지지에 대한 좋은 의견을 가지고 있을 수도 있습니다. 추가적 지지가 필요한 이유로는 다음과 같은 경우가 있습니다. 바른 자세로 앉을 수 없는 경우; 조절되지 않는 움직임 또는 경련; 관절 강직; 근육의 긴장; 위약; 피로; 통증 또는 불편감; 균형 장애 정의: 자세보조용구(PSD) 자세보조용구(PSD)는 추가적인 자세지지를 제공하는 물리적 장치를 의미합니다. PSD 는 중급 휠체어 서비스에서 필수적 요소입니다. 추가적인 자세지지가 어떻게 도움이 되나요? 휠체어 사용자에게 추가적인 자세지지가 도움이 될 수 있는 매우 중요한 방법에는 다음 네 가지가 있습니다; 1. 균형과 자세 및 안정성 향상 균형과 자세 및 안정성을 향상시켜 사용자가 이전에 추가적인 자세지지 없이는 힘들거나 불가능했던 활동들을 수행할 수 있도록 도울 수 있습니다. 2. 편안함 향상 추가적인 자세지지는 휠체어를 더욱 편안하게 만들어 주어 사용자가 피로해지기 전까지 앉아 있을 수 있는 시간을 늘려주게 됩니다. 3. 욕창이 발생하는 것을 방지 욕창은 매우 갑작스럽게 발생할 수 있습니다. 적절한 자세지지는 몸의 한쪽 부위로 체중이 쏠리는 것을 방지하면서 욕창이 생기는 것을 막을 수 있습니다. 바르게 앉아서 얻게 되는 효과 중 하나는 체중이 균등하게 분포된다는 점입니다. 이것은 욕창 발생의 위험을 줄일 수 있습니다. 휠체어 사용자가 바르게 앉아있지 않으면, 사용자의 체중은 불균등하게 분포하게 됩니다. 몸의 한쪽 부위가 다른 부위들에 비해 더 많은 체중을 지탱하게 됩니다. 그 추가적 체중이 뼈 돌출 부위 바로 위에 있는 피부에 가해지게 된다면 욕창이 생길 위험이 높게 됩니다. 뼈 돌출 부위의 예로는 좌골(Ischial tuberosity), 갈비뼈, 고관절 주변 부위 (trochanters), 척추(Vertebra) 그리고 꼬리뼈(coccyx)가 있습니다. 휠체어가 사용자를 제대로 지지를 하지 못한다면, 사용자는 좌석에서 아래로 미끄러질 수 있습니다. 이것은 전단력을 발생시켜 욕창을 일으킬 수 있습니다. 적절한 지지를 받아 바르게 앉는다면 미끄러짐과 전단을 방지할 수 있습니다. 4. 미래에 자세 문제가 발생하는 것을 늦추거나 방지 효과적인 자세지지는 사용자의 자세에 문제가 발생하는 것을 방지할 수 있습니다. 이미 사용자의 자세에 문제가 발생했다면 효과적인 자세지지는 문제가 악화되는 것을 늦추거나 방지할 수 있습니다. 누운 자세, 앉은 자세 그리고 서있는 자세에서의 적절한 자세지지는 가능한 빨리 이루어지는 것이 중요합니다. 안전하게 먹고 마시기 바르게 앉는데 어려움을 겪는 사용자들 중 일부는 음식을 안전하게 삼키는데도 문제가 있을 수 있습니다. 그런 이들에게 먹고 마시는 것은 불편하거나 무서운 일이 될 수 있으며 종종 위험하기까지 합니다. 만약 안전하게 음식물을 삼키는데 어려움이 있다면, 작은 음식물 조각이나 음료가 폐 안으로 들어갈 수 있습니다. 이것은 폐에 감염을 유발시켜 사용자들이 심하게 앓게 되거나 사망에 이를 수 있는 질식을 발생 시킬 수도 있습니다. 휠체어의 추가적인 자세지지는 사용자가 먹고 마실 때 바르게 앉을 수 있도록 도와줍니다 삼키는데 어려움이 있는 사람에게 자세지지를 향상시켜주는 것은 해결책의 일부분에 불과합니다. 가능하다면 음식물을 삼키는데 어려움을 겪고 있는 아동이나 성인들이 이런 문제를 다루는데 경험이 있는 전문가에게 도움을 받도록 해야 합니다. 이러한 전문가로는 삼킴 장애를 다루는데 전문지식이 있고 훈련을 받은 재활의학과 의사, 소아과 의사, 언어치료사, 보건직이나 보건소 종사자가 있을 수 있습니다. 휠체어 사용자들은 무엇을 원하나요? 휠체어 사용자들은 편안하길 바라고 자신들의 생활을 원할히 이어나가고 싶어합니다. 따라서 휠체어의 추가적인 자세지지가 일상생활을 더욱 어렵게 만들지 않도록 하는 것은 중요합니다. 예를 들어, 추가적인 자세지지가 사용자가 휠체어에 올라가고 내려오는 데, 휠체어를 앞으로 몰고 가는데, 책상이나 작업장 또는 교통수단에 다가가는데 방해를 하면 안됩니다. 휠체어와 추가적인 자세지지는 항상 다음의 사항들이 지켜져야 합니다: 실용적이고 사용하기 쉬워야 합니다; 편안하고 추가적인 불편감을 발생시키지 않습니다; 휠체어 사용자가 활동하는데 도움이 되고 활동을 더 어렵게 만들지 않습니다; 휠체어가 보기에 좋으며 장애를 가지고 있는 것이 너무 ‘두드러져 보이지’ 않도록 합니다. 종종 휠체어 사용자들은 휠체어에 있는 추가적인 지지에 적응하는데 어려움을 겪습니다. 여기에는 다음과 같은 여러 가지 이유가 있습니다. 휠체어 사용자들은 특정한 자세로 앉는 것에 익숙해져 있습니다. 따라서 사용자의 습관적 자세를 교정해주는 추가적인 자세지지가 불편하거나 답답하게 느껴질 수 있습니다. 휠체어 사용자들은 왜 추가적인 자세지지가 자신들에게 필요한지 이해하지 못할 수 있습니다. 휠체어 사용자들은 추가적인 자세지지가 보기에 좋지 않으며 이로 인해 자신들이 장애가 두드려져 보일까 걱정합니다. 이러한 이유들로, 휠체어 서비스 인력이 평가, 주문, 피팅, 사용자 교육 및 후속조치 등 모든 과정에서 사용자와 그들의 가족/보호자와 긴밀하게 협의하는 것은 매우 중요합니다. 항상 휠체어 사용자와 같이 해결책을 의논하며 사용자의 의견과 최종 결정을 존중하여야 합니다. 휠체어 사용자가 추가적인 자세지지를 잘 사용하도록 하게 하는 가장 좋은 방법은 다음과 같습니다: 평가, 주문, 피팅, 사용자 교육 및 후속조치 등 모든 과정에서 사용자와 그들의 가족/보호자가 충분하게 참여하도록 합니다. 휠체어 사용자와 그들의 가족/보호자가 추가적인 자세지지가 왜 필요하고 어떻게 효과적인지 이해할 수 있도록 합니다. 항상 휠체어 사용자가 최종 결정을 할 수 있도록 합니다. 좋은 자세는 사용자의 자존감을 높여줄 수 있습니다. 효과적인 자세지지의 주요한 장점 중 하나는 휠체어 사용자들이 자기 자신에게 만족감을 느낄 수 있다는 점입니다. 더욱 바른 자세로 적절한 자세지지를 받아 앉게 됨으로써 사용자들은 더욱 자신감을 가질 수 있습니다. 적절한 지지로 인해 휠체어 사용자들은 지역사회 활동에 더욱 활발히 참여할 수 있습니다. 예를 들어, 이동성 확보와 추가적인 자세지지로 인하여 사용자들은 직장이나 학교에 다닐 수 있고, 친구들을 만나며 종교활동이나 기타 다른 지역사회 활동에도 참여할 수 있게 됩니다. 추가적인 자세지지가 있는 휠체어가 사용자의 요구를 충족시키는지를 확인하기 위한 체크리스트 다음의 체크리스트는 휠체어 서비스 인력이 주문한 추가적인 자세지지가 휠체어 사용자에게 가장 성공적으로 사용될 수 있도록 도와줍니다. 체크리스트: 휠체어 사용자와 그들의 가족/보호자가 휠체어 주문에 함께 충분하게 참여합니다. □ 최종 구매여부가 결정되기 이전에 휠체어 사용자가 자세보조용구(PSD)가 장착된 휠체어를 (센터에서 그리고 가능하다면 집에서) 시범적으로 적용해보고 피드백을 줄 수 있습니다. □ 휠체어와 장착된 자세보조용구(PSD)가 휠체어 사용자가 하고 싶은 것들을 하는데 도움이 됩니다: 자세보조용구(PSD)가 휠체어 사용자의 활동 능력을 향상시켜줍니다. □ 자세보조용구(PSD)가 휠체어에 쉽게 올라타고 내리는데 방해하지 않습니다. □ 자세보조용구(PSD)로 인해 휠체어 전체가 너무 무거워지지 않습니다. □ 휠체어와 장착된 자세보조용구(PSD)가 휠체어 사용자에게 편안함을 제공합니다: 자세보조용구(PSD)가 사용자를 지지를 제공하고 자세보조용구(PSD)가 장착되지 않았을 때보다 더 오래 휠체어 앉을 수 있도록 도와줍니다. □ 자세보조용구(PSD)가 적당한 정도의 지지를 제공하고 편안한 자세 그 이상으로 바르게 앉게 하기 위해 사용자를 지나치게 지지하지 않습니다. □ 휠체어와 장착된 자세보조용구(PSD)가 (휠체어 사용자에게) 보기에 좋습니다. □ 휠체어와 장착된 자세보조용구(PSD)가 안전합니다: □ 자세보조용구(PSD)의 마감이 매끄럽고 안감이 충분하며 압력 완화가 잘 이루어집니다. □ 휠체어 프레임의 구조적 변형이 있다면 자격을 갖춘 사람으로부터 점검 받아야 합니다. □ 사용자가 앉아 있을 때 휠체어가 쉽게 앞으로, 뒤로, 또는 옆으로 기울어지지 않습니다. □ 휠체어와 장착된 자세보조용구(PSD)가 실용적입니다: 휠체어의 덮개를 닦을 수 있거나 세척을 할 수 있도록 벗겨집니다. □ 휠체어가 올바르지 않게 조립되거나 부품을 잃어버리지 않을 수 있도록 분리되었을 때 부품의 수가 가능한 적게끔 합니다. □ 자동차나 대중 교통수단에 휠체어를 쉽게 실을 수 있습니다. □ 휠체어가 사용자의 집에 잘 들어가고 보관하기에 용이합니다. □ A.2: 장애 아동 아동들에게 휠체어를 제공할 때, 아동들의 생활이 성인들과 어떻게 다른지 고려하는 것이 중요합니다. 이러한 차이점들은 휠체어 서비스 인력이 아동과 협의하는 방식과 휠체어와 추가적인 자세지지의 선택에 영향을 줍니다. 아동들의 주요 차이점들은 다음과 같습니다: 아동들의 활동은 성인들의 그것과 차이가 있습니다 (놀이나 학교생활); 아동들은 종종 매우 활동적이며 한 곳에 그리 오래 머물지 않습니다; 아동들은 성인들의 보호를 받습니다; 아동들이 자신의 생각을 늘 말할 수 있는 것은 아닙니다; 아동들은 아직 발달하고 있는 중입니다; 어린 아동들은 성인과 앉는 자세에 차이가 있습니다; 아동들은 아직 자라고 있는 중입니다. 아동의 요구를 충족하는 휠체어 아동들이 사용하는 휠체어는 아동들이 매일 수행하는 활동들에 잘 참여할 수 있도록 도움이 되어야 합니다. 아동들에게 중요한 휠체어의 요소들은 다음과 같습니다: 만약 아동 사용자가 본인 스스로 휠체어를 밀게 된다면, 다음의 사항들이 지켜져야 합니다. — 아동 사용자의 손이 바퀴 손잡이에 편안하게 닿아야 합니다. — 특히 언덕을 올라가고 내려갈 때, 아동 사용자가 쉽게 조종할 수 있을 만큼 가벼워야 합니다. 항상 아동의 휠체어보다 아동이 더 잘 보이도록 합니다. 의자 뒷손잡이를 높게 하여 가족들이나 보호자가 휠체어를 밀 때 허리를 굽히지 않아도 되도록 합니다. 휠체어가 풀 밭이나 모래 위 같이 울퉁불퉁하고 푹신한 표면 위를 잘 지나갈 수 있어야 아동들이 친구들과 놀기에 용이합니다. 아동의 휠체어는 아동이 학교에 등교하기 용이하게 해줘야 합니다: — 만약 아동이 속한 지역사회의 대부분의 아동들이 학교에 걸어서 등교한다면 –휠체어가 이 등굣길에서 잘 이동할 수 있을지 생각해봐야 합니다. 아동이 거친 지면을 지나가기 충분한 휠체어가 필요한 것은 아닌가요? — 만약 아동이 학교에 가기 위해 (자동차, 버스, 인력거나 택시와 같은) 교통수단을 이용한다면, 휠체어를 교통수단에 어떻게 실을 수 있을지 고려해 봐야 합니다. 휠체어는 아동이 학교에서 생활하는 것을 용이하게 해줘야 합니다. 아동이 휠체어를 책상 가까이로 쉽게 이동시킬 수 있거나 아니면 휠체어가 공부를 할 수 있는 트레이를 장착하고 있어야 합니다. 이상적으로 말했을 때 아동들의 휠체어는 다음과 같은 사항들이 지켜져야 합니다. 아동이 (가능하다면) 스스로 휠체어를 밀 수 있도록 되어 있어야 합니다; 성인들이 뒤에서 도와줄 수 있도록 뒷손잡이가 있어야 합니다; 휠체어가 풀 밭이나 모래 위 같이 울퉁불퉁하고 푹신한 표면 위를 잘 지나갈 수 있어야 합니다; 아동이 학교에 등교하기 더 용이하게 해야 합니다; 디자인, 크기, 그리고 색감이 충분히 호감적이어야 합니다; 휠체어가 아동들이 학교에서 지내는 것을 더 용이하게 해줘야 합니다. 아동들의 다른 자세들 보통 아동들은 많은 시간을 앉아서 보내지는 않습니다. 하루 종일 아이들은 다양한 활동을 하며 자세를 수없이 바꿉니다. 이것은 비록 휠체어가 아동들에게 중요하긴 하나 아이들이 하루 종일 휠체어에 앉아있지 않아야 함을 의미합니다. 휠체어 서비스 인력은 하루 동안 아동들이 취할 수 있는 다른 자세들을 고려해봐야 합니다. 이것은 만약 아동이 매우 제한된 움직임을 가지고 있고, 늘 같은 제세로 앉아있으며 자세를 바꿀 수 없을 때 더욱 중요합니다. 다음은 아동이 취할 수 있는 다양한 자세의 몇 가지 예입니다. 앉아 있기 아동들을 바닥 가까이에서 독립적으로 앉게끔 지지해주는 방법으로는 다음과 같이 여러 가지가 있습니다. 굴림대(롤러)나 돌돌 말아진 이불 위에 걸터앉기. 가족이나 보호자로부터 도움을 받아 앉기: — 왼쪽 그림은 장애가 있는 자녀가 일어나 앉아 과자를 먹을 수 있게 다리 사이에 받쳐서 지지하는 동시에, 어린 아이까지 돌보는 엄마를 보여주는 그림입니다. 바닥 가까이에서 몸을 지지해주는 의자 위에 앉기: — 이와 같은 의자는 자세를 지지해주는 휠체어보다 저렴하며 나이가 어린 아동들에게 좋은 선택이 될 수 있습니다. 서있기 서있는 것은 아동들에게 또 하나의 중요한 자세입니다. 서있는 것은 모든 아이들의 발달에 중요한 부분입니다. 서 있는 자세는 고관절의 형성과 체간의 정상적인 굴곡 형성을 도와줍니다. 오랜 시간 앉아만 있는 경우 뻣뻣한 고관절, 무릎관절 그리고 발목관절이 발생 할 수 있습니다. 서 있는 자세는 고관절, 무릎관절 및 발목관절 주위의 근육들을 스트레칭 시켜주며 관절들이 뻣뻣해지는 것을 예방해 줄 수 있습니다. 만약 아동이 독립적으로 설 수 없다면, 기립훈련기가 도움이 될 수 있습니다. 기립훈련기를 주문하기 위해서 휠체어 서비스 인력은 아동의 서 있는 자세에서 지지를 받을 수 있는 다양한 방법을 충분히 이해해야 합니다. 기립훈련기가 제공되었다면, 아동의 무릎뼈에 직접적인 압력이 가해지지는 않는지 확인해야 합니다. 무릎이 굽혀지지 않도록 다리를 지지하는 가장 좋은 위치는 무릎뼈 바로 아래의 정강이뼈 부위 입니다. 기립훈련기를 사용 중이라면, 휠체어 서비스 인력은 사용자의 가족과 보호자에게 하루에 얼마 동안 기립훈련기를 사용하는 것이 좋은지 안내해야 합니다. 일반적인 지침은 다음과 같습니다: 처음 시작할 때는 하루에 5-10 분정도 사용합니다; 1 시간 이상 아동을 기립훈련기에 세우지 말아야 합니다; 책상이나 트레이를 설치하고 아이들이 기립받침대에서 할 수 있는 재미있는 활동을 가족/보호자들이 찾아봐 줄 수 있도록 독려합니다. 5 세 미만 아동에게 기립훈련기를 적용하는 경우, 다음 사항들을 기억하는 것이 중요합니다: — 아동의 다리가 벌어져 있고 최소 골반 너비만큼 발이 벌어져 있도록 합니다; — 아동의 발과 무릎이 살짝 바깥 방향을 향하게 합니다; — 아동의 고관절과 무릎이 살짝 굽혀지도록 합니다; — 힘을 주어 억지로 어린 아이의 무릎과 고관절이 완전히 펴지도록 하는 일이 없도록 합니다. 누워 있기 누워있는 것은 또 하나의 중요한 자세입니다. 놀이를 하기 위해 바닥에 눕는 것은 아동들에게는 자연스러운 일입니다. 아동이 바닥에 편하게 누워있기 위해 약간의 지지가 필요할 수 있습니다. 이불, 폼, 수건 또는 베개 등을 사용하여 지지를 제공할 수 있습니다. 5 세 미만 아동이 배를 깔고 누워있다면 가슴 아래에 둥글게 만 이불과 같은 받침대를 두어서 고관절이 살짝 구부러져 있는 자세가 되도록 해야 합니다. 아이들은 오랜 시간 잠을 잡니다. 만약 같은 자세로만 매일 밤 자게 되면 그 자세로 몸이 고정되거나 뻣뻣해질 수 있습니다. 휠체어 서비스 인력은 가족이나 보호자에게 아동이 자고 있을 때 어떻게 다양한 방식으로 아동의 자세를 취해 주어야 하는지에 대한 조언을 제공할 수 있습니다. 기억하십시오 –5 세 미만 아동의 경우 누워있거나 서있는 모든 자세에서 고관절과 무릎이 살짝 구부러진 상태로 유지해야 합니다. 아이들을 위한 조기 의뢰의 중요성 아이들을 위한 조기 의뢰는 중요하지만 종종 부모들이나 의뢰자들은 아이들을 안고 다니기 무거워지기 전까지는 휠체어 의뢰를 하지 않습니다. 이에 대한 몇 가지 이유는 다음과 같습니다: 아동에게 휠체어가 주어지면 더 이상 걸으려고 노력하지 않을 것이라고 생각합니다; 아동이 어리고 가벼울 때는 아이를 안고 다니는 것이 복잡한 지형이나 접근이 불가한 환경에서 휠체어를 관리하는 것보다 더 쉽기 때문입니다; 부모들이 휠체어를 구입할 비용이 없어 아이를 안고 다니기 힘들 때까지 구입을 미루기 때문입니다. 아이들 부모와 의뢰자들에게 휠체어 사용이 아이들이 걷는 것을 대개는 방해하지 않음을 안심시키는 것은 중요합니다. 오히려 적절한 자세 지지를 가진 휠체어를 조기에 제공하는 것이 아이에게 더욱 이롭기 마련입니다. 조기에 의뢰하는 것이 미루는 것보다 나은 이유는 다음과 같습니다: 바르게 앉는데 어려움이 있는 아동은 적절한 지지를 제공 받지 못하면 자세 문제가 발생할 수 있습니다. 만약 의뢰가 너무 늦어버린다면 몇 가지 자세 문제는 고정되어 버릴 수도 있습니다. (3) 이런 경우에는 지지가 제공되어도 아동이 편안하게 앉기 어렵게 됩니다. 앉아있는 경험과 움직임에 대한 경험이 없다면 아동의 발달이 지연될 수 있습니다 (3, 4). 어느 정도 걸을 수 있는 능력을 가진 아동의 경우, 휠체어를 이용한다면 일상생활이 더욱 쉬워지며 하루 동안 더 많은 활동을 할 수 있게 됩니다. (3). 이러한 이유들로 인하여, 아동들이 휠체어 서비스를 조기에 받는 것이 더 좋다고 할 수 있습니다. 아이들의 부모와 의뢰자들에 대한 교육 휠체어 서비스 인력은 조기 의뢰의 중요성에 대해 부모들과 의뢰자들을 교육하는 일에 일정 역할을 수행할 수 있습니다. 장애가 없는 아이들이 앉고, 서고 걷는 것을 배우는 나이에는 개개인에 따라 차이가 있습니다. 그렇지만 대체적으로 아이가 다음과 같이 수행하게 된다고 보고 있습니다: 6-8 개월 사이에 지지 없이 홀로 앉을 수 있습니다; 8-10 개월 사이에 자신의 몸을 당겨 일어날 수 있습니다; 10-12 개월 사이에 지지 없이 홀로 서 있을 수 있으며 손을 잡고 걸울 수도 있습니다; 12-18 개월 사이, 홀로 걸어 다닐 수 있습니다. 휠체어 서비스는 의뢰 네트워크에 다음과 같은 아동을 의뢰하도록 독려합니다: 1 세가 될 때까지 똑바로 앉기 어려워하며 몸을 당겨 일어나지 못하는 아동; 또는 2 세가 될 때까지 홀로 걷지 못하는 아동. 조기 개입 스크리닝 프로그램이 있는 지역에서는 (예를 들어, 지역사회의 보건소 직원들이 조기개입을 위해 아동들을 스크리닝을 하도록 교육되어 있는 경우) 휠체어 서비스 인력은 의뢰 네트워크에 더욱 자세한 정보를 제공할 수 있습니다. 예를 들면, 심각한 신체 문제나 발달 지연이 발견된 아동의 경우 휠체어 서비스에 평가나 조언을 위해 의뢰되도록 제안할 수 있습니다. 매우 어린 아동의 경우, 휠체어 서비스는 초기 단계에서는 휠체어 사용 보단 아동을 지지해주는 좌석을 제공할 수 있습니다. 이것은 집 안이나 놀이학교에서도 사용될 수 있습니다. 아동들을 대하며 작업할 때의 적정 수칙 아동을 대하는 경우에는 항상 아동을 존중하며 보호하는 방식으로 작업을 하는 것이 매우 중요합니다. 다음은 기억해야 할 주요 사항들입니다: 아동을 존중하기: 아동이 이해할 수 있는 방식으로 지금 당신이 무엇을 하고 있는지 그리고 왜 하고 있는지를 설명해줍니다; 신체 평가 이전에 허락을 먼저 구합니다; 어린 연령의 아동이 이해할 수 있는 방식으로 아동이 의사 결정에 참여 할 수 있도록 합니다; 센터에서 아동을 만나는 경우, 가능한 최대로 아동에게 친근한 환경이 되도록 노력합니다 아동을 안전하게 보호하기: 항상 아동의 부모나 보호자와 함께 아동을 대합니다; 아이들이 쉽게 지칠 수 있는 점을 고려하여 약속 시간 내에 쉬는 시간을 마련합니다; 사진을 찍기 전에는 아동과 가족/보호자의 동의를 구합니다. B: 휠체어 서비스 단계 1 단계: 휠체어 의뢰와 예약 휠체어 의뢰와 예약에 대한 전반적인 정보를 위해 ‘휠체어 서비스 교육교재 – 초급 참조 매뉴얼의 1 단계: 의뢰와 예약’에서 참고하세요. 아동들의 조기 의뢰의 중요성에 대해 본 참조 매뉴얼의 ‘세션 A.2: 장애를 가진 아동’에서 참고하세요. 2 단계: 평가 평가 개요와 평가 인터뷰 평가 평가는 휠체어 서비스의 두 번째 단계입니다. 평가를 통해 얻은 정보는 휠체어 서비스 인력과 사용자에게 다음과 같이 도움이 될 것입니다: 선택 가능한 휠체어 중에서 가장 적절한 휠체어를 선택할 수 있게 됩니다; 어떠한 추가적인 자세지지가 더 필요할지에 대해 알아볼 수 있게 됩니다; 휠체어를 사용하고 유지하는데 사용자 가족/보호자에게 어떤 훈련이나 도움이 필요한지 파악할 수 있게 됩니다. 초급 및 중급에서의 평가는 다음과 같이 두 파트로 진행됩니다: 평가 인터뷰; 신체 평가 평가 인터뷰 평가의 첫 번째 파트는 평가 인터뷰입니다. 평가 부분에서는 휠체어 서비스 인력이 사용자에 대한 정보를 파악하게 되고, 이것은 사용자에게 어떤 휠체어가 가장 적절할지를 결정하는데 도움이 될 것입니다. 초급과 중급에서의 평가 인터뷰 요소들은 매우 유사하며 다음의 사항들을 포함합니다: 휠체어 사용자에 대한 정보; 신체 정보; 생활방식 및 환경; 기존의 휠체어 초급과 중급에서의 평가 인터뷰 요소들은 매우 유사하지만, 중급에서 휠체어 사용자의 진단과 신체적 문제에 대한 더 많은 정보를 다루게 됩니다.. 중급 휠체어 평가 양식: 1: 평가 인터뷰 휠체어 사용자에 대한 정보 이름: 번호: 나이: 남자 □ 여자 □ 전화번호: 주소: 목 표: 중급 휠체어 평가 양식의 ‘휠체어 사용자에 대한 정보’ 부분은 관리적 목적으로 사용되고 휠체어 서비스를 위해 사용자의 연락처와 기본 정보를 가지고 있게 됩니다. 이는 또한 센터를 내방한 사용자들에 대한 통계적 정보를 수집하는데도 도움이 됩니다. 휠체어 서비스 인력은 새로 구입한 또는 더 향상된 휠체어를 통해 휠체어 사용자가 어떤 목표를 이루고자 하는지 본 양식에 기입해야 합니다. ‘목표’라는 단어가 휠체어 사용자에게 생소한 표현일 수 있습니다. 따라서 질문을 하여 사용자의 목표나 목표들에 대해 알아내는 것은 순전히 휠체어 서비스 인력에게 달려있습니다. 다음은 휠체어 서비스 인력이 사용자의 목표를 알아내기 위해 사용할 수 있는 질문들의 예입니다: 오늘 휠체어 서비스 센터에 방문한 이유는 무엇인가요? 당신의 휠체어가 어떤 것들을 하는데 도움이 되었으면 하세요? 다음은 사용자가 목표로 기입할 수 있는 예입니다: 물을 얻기 위해 우물로 갈 수 있으면 좋겠습니다. 제가 사는 아파트에 가기 위해 엘리베이터에 탈 수 있었으면 좋겠습니다. 작은 차에 제 휠체어를 넣고 다닐 수 있으면 좋겠습니다. 앉았을 때 더 편안했으면 합니다. 피로해지기 전까지 오랜 시간 휠체어에 앉아 있을 수 있으면 좋겠습니다. 혼자 스스로 휠체어에 올라타고 내릴 수 있어야 합니다. 컴퓨터를 사용하기 위해 책상 앞에 앉을 수 있어야 합니다. 가족을 만나러 갈 수 있었으면 좋겠고 버스에 함께 탈 수 있는 휠체어가 필요합니다. 신체 정보 진단: 뇌 손상□ 뇌성마비□ 근위축증□ 소아마비□ 이분척추□ 척수 손상 □ 뇌졸중□ 알려지지 않은 질환□ 기타□ 상태가 더 악화되기 쉽습니까? 예□ 아니요□ 신체 문제들: 노쇠□ 경련/조절되지 않는 움직임□ 근긴장도(증가/저하)□ 하지 절단: 오른쪽 무릎 위□ 오른쪽 무릎 아래□ 왼쪽 무릎 위□ 왼쪽 무릎 아래□ 피로□ 고관절 탈구□ 간질□ 음식물을 먹고 마시고 삼키는 데에 문제가 있음□ 설명: 방광 문제□ 장 문제□ 만약 휠체어 사용자가 방광이나 장 문제가 있다면, 이에 대한 치료를 받고 있는 있습니까? 예□ 아니요□ 다양한 진단과 신체 문제들에서 나타나는 몇 가지 임상양상들이 휠체어와 추가적인 자세지지의 선택에 영향을 줄 수 있기 때문에 이 진단/신체 문제들 부분은 은 중급 휠체어 평가 양식에서 중요한 부분을 차지합니다. 다음 몇 장에 걸쳐 나오는 표 안에는 중급 휠체어 평가 양식에 언급된 여러 진단들과 신체 문제들에 대한 간략한 개요가 제공되어 있습니다. 휠체어 제공과 관련된 각각의 진단/신체 문제들의 흔한 특징들과 휠체어 제공에 대한 제안이 기술되어 있습니다. 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급에 대한 고려사항 뇌 손 상 뇌 손상은 출생 이후 뇌에 발생한 모든 손상을 의미합니다. 뇌 손상은 사고나 외상(5,6), 뇌염이나 수막염(7), 뇌성 말라리아나 알코올 및 약물 남용(5)에 의해 발생할 수 있습니다. 뇌 손상으로 인한 문제들은 손상이 생긴 부위와 손상의 정도에 따라 달라지게 됩니다(6). 뇌 손상은 환자의 몸 전체 또는 일부분에 영향을 미칠 수 있습니다. 뇌에 생긴 손상은 영구적이지만 뇌 손상으로 악화되었던 환자의 상태는 시간이 흐르면서 달라질 수 있습니다(6). *본 훈련 프로그램의 목적 상 뇌 손상의 의미는 후천적이고 외상성인 경우만을 의미합니다. 거동의 어려움, 신체 동작의 조정능력과 근력 저하(6); 앉거나 서있을 때의 균형 감각 저하(6); 몸이 꼿꼿이 세워지거나 (온 몸 신전) 웅크려지는 (온 몸 만곡) 근긴장도 증가 (근육이 딱딱해 지는 현상) (6); 먹고 마시는 것이 어렵거나 삼킴 곤란 (6); 말을 하고 논리적인 사고를 하고 이해하는데 어려움 (6); 성격이나 행동 변화 (6); 발작 (6); 욕창 발생의 위험을 증가시키는 장과 방광 조절의 어려움(6). 만약 휠체어 사용자가 양팔로 휠체어를 앞으로 밀 수 없다면, 발을 이용해 앞으로 나아가는 것은 가능한지 확인합니다. 자세보조용구에 필요한 강도에 영향을 줄 수 있는 휠체어 사용자의 근긴장도가 증가해 있는지 확인합니다. 시간이 흐르면서 환자의 신체 상태에 변화가 일어날 수 있기 때문에 경과관찰이 자주 이루어져야 합니다(6). 이는 휠체어에 필요한 지지 정도를 변경해야 할 수 있음을 의미합니다. 사용자의 건강 상태에 따라 성격이나 행동에 변화가 생길 수 있음을 인지하고 있어야 합니다 6). 더 많은 정보를 위해서는: 근긴장도 증가와 감소 - 34 페이지 참고 발작 - 40 페이지 참고 욕창은 어떻게 방지하나요? – 휠체어 서비스 교육자료 –초급 과정 참조 매뉴얼 참고 5 World Health Organization.(2006).Neurological disorders: Public health challenges. Retrieved from http://www.who.int/ mental_health/neurology/chapter_3_b_neuro _disorders_public_h_challanges.pdf 6 World Health Oganization, United States Department of Defense Drucker Brain Injury Center, Moss Rehab Hospital.(2004). Rehabilitation for persons with traumatic brain injury. Retrived from http://whqlibdoc.who.int/hq/2004/WHO_DAR_01.9_eng.pdf 7 World Health Organization.(2011). Meningococcal meningitis. Retrieved from http://www.who.int/mediacentre/factsheets/fs141/en/ 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시 고려사항 뇌 성 마 비 뇌성마비는 가장 흔한 아동 청소년기 신체 장애 중 하나이며(8,9) 발달중인 뇌에 생긴 손상에 의해 발생합니다(10). 뇌성마비로 인해 생기는 증상들은 다양하지만(10), 사람의 움직이는 방식에 영향을 주는 것이 가장 흔합니다(8,10,11). 뇌성마비를 가진 모든 사람이 휠체어가 필요한 것은 아닙니다(10). 그러나 휠체어를 사용하는 뇌성마비 아동과 성인은 휠체어에서의 기능적 활동과 편안함을 위해 흔히 추가적인 자세지지가 필요합니다. 눕기, 앉기, 또는 서있기 어려움(10); 균형의 저하(10); 몸의 한 부위를 움직일 때 몸의 다른 부위의 움직임을 조절하기 어려움 – 예를 들면, 글씨를 쓸 때 가만히 앉아있는 것이나 음료를 컵에 들고 마시며 삼키는 것; 근긴장도 증가 또는 감소(10); 경련/조절되지 않는 움직임; 신체 동작의 조정능력 저하(10); 항상 같은 자세로 앉아있으려는 경향 (습관적 자세) (10); 그 외 신체 이상: 시각 이상, 청각 이상, 간질, 말하는 능력 및 의사소통의 어려움(10); 욕창의 발생 위험을 증가시키는 방광과 장 조절의 어려움(11,8); 화장실에 가기 어렵거나 변기 위에 혼자 힘으로 앉아있기 어려움; 통증 및 운동 범위 제한을 일으킬 수 있는 고관절 탈구 (비구 밖으로 대퇴 골두가빠겨나오는 것) 뇌성마비를 가지고 있는 휠체어 사용자의 대부분은 자세와 균형을 향상시키고 활동시더 쉽게 몸의 움직임을 조절하기 위해 효과적인 자세지지가 중요합니다. 뇌성마비를 가진 휠체어 사용자가 자세 변화 후 처음에는 어색하게 느낄 수 있다는 것을 인지하고 있어야 합니다. 휠체어 사용자는 자세의 변화에 적응하는데 시간이 필요할 수 있습니다. 시간이 지남에 따라 더욱 중립적인 자세에 가까워지도록 점진적으로 사용자의 자세지지 장치를 교정하는 것을 고려합니다. 기타 다른 신체적 문제가 휠체어와 자세지지 방식에 영향을 줄 수 있습니다. 평가를 진행하는 동안 뇌성마비를 가지고 있는 사용자가 다른 어려움은 없는지 확인합니다. 더 많은 정보를 위해서는: 고관절 탈구 - 38 페이지 참고 8 Rosenbaum, P. (2003). Cerebral palsy. What parents and doctors want to know. British Medical Journal, 326, 970–974 9 Cerebral Palsy Australia. (n.d.). Cerebral palsy – the facts. Retrieved from http://www.cerebralpalsyaustralia.com/index.php/site/learningcentre/thefacts 10 World Health Organization. (1993). Promoting the development of young children with cerebral palsy: A guide for mid-level rehabilitation workers. Retrieved from http://whqlibdoc.who. int/hq/1993/WHO_RHB_93.1.pdf 11 Kigger, K. (2006). Cerebral Palsy: An overview. American Family Physician, 73(1), 91–100. 12 Roijen, L., Postema, K., Limbeek, vJ., & Kuppevelt, vH. J. M. (2001). Development of bladder control in children and adolescents with cerebral palsy. DevelopmentalMedicine and Child Neurology, 43, 103–107. 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 근 위 축 증 뒤시엔느근위축증 (DMD)는 20 가지의 근위축증 중 하나입니다. 모든 종류의 근위축증은 근력 약화를 야기합니다(9). DMD 는 시간이 흐르면서 점차적으로 근력이 약화되는 유전 질환입니다(10). 몸을 움직이는 근육부터 영향을 받게 되고(14)병이 진행되면서 심장과 폐부위의 근육도 영향을 받습니다(14,11). 근위축증은 진행성 경과를 보입니다. 이는 환자가 점차 걷는 능력을 잃게 되고(13,14,12) 휠체어가 필요하게 됨을 의미합니다(13). 초기에는 사용자가 좋은 자세로 독립적으로 휠체어를 몰 수 있습니다(13). 그러나 질환이 진행되면서 좋은 자세를 유지하는 능력과 혼자서 휠체어를 몰 수 있는 능력이 점차 감소하게 됩니다.(13). 주의: 다른 진행성 신경질환도 유사한 양상을 보이기 때문에 휠체어를 제공할 때 비슷한 접근이 필요합니다. 통증과 불편감(13); 피로(17); 진행성 근 위약; 휠체어가 필요한 시기 즈음에는 골반,체간 그리고 어깨 주변 근육의 위약이 발생하여 자세에 지장이 있게 됨(17); 자세의 변화; - 근위축증에걸린 사람은 복부와 고관절 주변 근력이 약해져 골반이 전방으로 기울어지거나(골반의 상부가 앞으로 향함) 요추의 만곡이증가(척추 전만)될 수 있다(17); - 근위축이 심해짐에 따라 척추가 좌우로 휘어질 위험이 증가합니다(척추 측만) (16); 자세변화나 근 위약으로 인한 호흡 곤란(17); 다음과 같은 이유로 욕창 위험의 증가: - 자세를 바꾸는데 어려움; - 체중감소 또는 체중증가. 근위축증 (또는 다른 진행성 신경 질환)에 걸린 사람이 일상생활을 위해 휠체어가 필요하게 되면, 그들의자세지지에 대한완전한 평가가 필요합니다. 조기에 제공된 효과적인 자세지지는 향후에 발생할 수 있는 자세 문제를 방지할 수 있습니다(17). 추가적인 자세지지는 중립적인 자세를 지지하는데 초점을 두며, 필요에 따라 지지를 증가시켜 제공합니다(17). 보조적 신발과 각도를 조절할 수 있는 발받침대는 발의 위치를 중립적으로(또는 중립에 가깝게) 유지하는데 도움이 될 수 있습니다. 만약 구할 수 있다면,단하지 보조기 (AFO)를 사용하는 것이 도움이 될 수 있습니다(17). 어깨를 침범하는 위약이 발생되면 팔 지지대가 필요합니다(17). 더 많은 정보를 위해서는: 통증 - 27 페이지 참고 피로 - 37 페이지 참고 진행성 질환- 31 페이지 참고 13 M uscular Dystrophy Campaign. (2002). Duchenne muscular dystrophy. Retrieved from http://www.muscular-dystrophy.org/ 14 Centers for Disease Control and Prevention. (n.d.). Duchenne muscular dystrophy: Fact sheet. Retrieved from http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/Duchenne.pdf 15 N ewsom Davis, J. (1980). The respiratory system in muscular dystrophy. British Medical Bulletin, 36, 135–138. 16 Brooke, M.H., et al. (1989). Duchenne muscular dystrophy: Patterns of clinical progression and effects of supportive therapy. Neurology, 39, 475–481. 17 M uscular Dystrophy Campaign. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practiceguidelines. Retrieved from http://www.muscular-dystrophy.org/ 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 소 아 마 비 소아마비는 바이러스에 의한 감염성 질환입니다(18). 소아마비 바이러스는 운동을 조절하는 신경에만 침범합니다(19,20). 소아마비에 걸린 200 명 중 한 명은 영구적인 근육 마비가 발생합니다(18). 소아마비는 대개 5 세 미만의 아동에게 발생합니다(18). 최근 수 십 년 동안 소아마비가 발생하는 국가의 수는 극적으로 감소하였습니다(18). 증상이 생긴 근육의 운동능력 상실 (마비) – 대부분의 경우 양쪽 다리(19); 근육 위축으로 인해 얇아진 다리와 엉덩이; 중립이 아닌 자세로 굳어진 발목과 무릎, 고관절의 자세(19); 체간을 지지하는 근육의 위축(19). 이런 경우 구축된 척추 만곡이 발생할 수 있습니다 – 척추 측만증, 흉추만곡심화 (척추 후만증), 전방으로 골반이 기울어지고 요추의 만곡심화 (척추 전만증) (19); 환자의 다리 근력 약화를 보상하기 위해 강화된 양 팔. 소아마비를 가진 사람들은 마비와 자세의 문제가 발생하여도 움직이거나 다양한 활동들을 수행하기 위한 방법을 보통 찾아냅니다. 휠체어 사용자에게 어떠한 자세보조 장치를 원하는지 물어봅니다. 자세 교정으로 인한 결과를 주의 깊게 고려해봅니다. 예를 들어 – 소아마비를 가진 사람들은 양 다리를 벌리거나 다리를 꼬아 앉음으로써 균형유지에 도움을 받습니다. 이를 교정하려고 하면 사용자의 균형을 악화시킬 수 있으며독립성을 저하시킬 수 있습니다. 소아마비를 가지고 있는 사람들은 강한 팔을 가지고 있기 때문에 다음의 사항들을 유념해야 합니다: - 효과적인 휠체어 추진을 위한 자세가 가능하게끔 휠체어가 맞추어져 있는지 확인합니다; - 먼 거리를 이동할 때 더 좋은 이동성을 제공할 수 있는 (구할 수 있다면) 세 바퀴 휠체어제안을 고려해봅니다. 소아마비를 가지고 있는사용자가 단축된체간을 가지고 있다면 휠체어를 더 효율적으로 밀기 쉬운 자세가 되도록 쿠션의 높이를 높이는 것을 고려합니다. 더 많은 정보를 위해서는: 팔을 이용한 휠체어 추진을 위한 휠체어 설정 – 휠체어 서비스 교육자료 – 초급 참조 매뉴얼 참고. 18 World Health Organization. (2012). Poliomyelitis. Retrieved from http://www.who.int/mediacentre/factsheets/fs114/en/ 19 World Health Organization. (1993). Rehabilitation surgery for deformities due to poliomyelitis. Retrieved from http://whqlibdoc.who.int/publications/1993/9241544570.pdf 20 Polio Global Eradication Initiative. (n.d.). Polio and prevention. Retrieved from http://www.polioeradication.org/Polioandprevention.aspx 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 이 분 척 추 이분척추는 출생 전에 발생합니다(21,22). 척추 뼈가 척수신경을 완전히 감싸지 못하여 보호되지 않은 상태로 남아 문제가 됩니다(21,22). 그로 인해 척추 뼈 밑에 존재하는 척수의 일부가 알맞게 발달하지 않거나 손상 받게 됩니다(21). 척수의 손상은 방광과 장의 조절에 영향을 줄 수 있습니다.(21,18,19). 이분척추에 의한 임상양상은 손상된 부위의 크기와 손상된 신경의 위치에 따라 다르게 나타날 수 있습니다.(21). 운동 장애의 정도는 이분척추가 발생한 척추 위치와 척수와 신경근의 손상 정도에 따라 달라집니다(21); 방광과 장의 조절 이상(21); 이동 보조 기구를 이용하여 짧은 거리를 걷는 것이 가능합니다(21); (특히 수술적 치료를 한 적이 없을 때)척수부위에서 혹이 발생할 수 있는데, 이것은 척추가 제대로 발달하지 못해 생긴 손상이라 할 수 있습니다. (21); 근육 운동 조절과 감가기능 저하로 인해 똑바로 앉는 것이 어려워질 수 있습니다; 체액의 저류로 인해 머리의 크기가 클 수 있습니다 (수두증) (21). 수두증의주요 치료로는 정체된 체액을 보통 아동의 위장으로 배액 시키는 ‘션트’ 삽입술이 있습니다 (21). 체액의 저류를 치료하지 않으면 뇌에 손상이 발생할 수 있습니다; 손상된 척추 아래의 감각 이상이 있고 방광과 장이 제대로 관리되지 않는 경우, 습기로 인해 욕창의 위험이 증가합니다(21). 효율적 추진이 가능하도록 휠체어가 맞춰졌는지 확인합니다. 손상된 척추의 위치에 따라 제공되는 자세지지의 정도를 결정합니다. 높은 부위에 생긴 손상일수록 더 많은 자세지지가 필요합니다. 보조기를 낮 동안 착용하는 경우라면 사용자에게 평가가 진행되는 동안 착용을 부탁합니다. 혹이 있다면, 그 부위에 압력이 가해지지 않도록 주의합니다. 등받이의 변형이 필요하거나 혹이 들어갈 수 있도록 등받이 덮개를 조절 해야 할 수 있습니다. 조기에 적절한 자세지지를 제공받으면자세의 문제들을 방지할 수 있습니다(20). 이는 성장기에 특히 중요합니다. 아동이‘션트’를 가지고 있다면, 머리받침대를 설치할 때 션트의위치에 주의합니다. 만약 아동이 수두증이 있지만 치료를 받고 있지 않다면 의사에게 진료를 의뢰합니다. 더 많은 정보를 위해서는: 팔을 이용한 휠체어 추진을 위한 휠체어 설정 – 휠체어 서비스 교육자료 – 초급 참조 매뉴얼 참고 어떻게 욕창을 방지할 수 있나요? – 휠체어 서비스 교육자료- 초급 참조 매뉴얼 참고. 21 World Health Organization. (1996). Promoting the development of infants and young children with spina bifida and hydrocephalus. Retrieved from http://whqlibdoc.who.int/hq/1996/WHO_RHB_96.5.pdf 22 M alone, P., Wheeler, R., & Williams, J. (1994). Continence in patients with spina bifida: Long terms results. Archives of Disease in Childhood, 70, 107–110. 23 M cDonnell, G. V., McCann, J. P. (2000). Issues of medical management in adults with spina bifida. Child’s Nervous System, 16, 222–227. 24 M uscular Dystrophy Campain. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 척 수 손 상 척수손상 (SCI)은 척수에 손상이 생겨 손상된 부위 아래의 운동 능력이 감소하거나 감각신경에 이상이 발생하는 질환입니다(25). 척수는 방광과 장 또한 조절하기 때문에 손상 이후에 이곳에 문제가 발생할 수도 있습니다(26). SCI 는 사고나 폭력, 질병 또는 감염에 의해 발생할 수 있습니다(26). 척수손상은 손상 정도와 손상된 부위에 따라 다른 결과를 야기합니다(26). 손상의 정도: 완전 손상은 환자가 다친 척수 아래로 감각이 없거나 수의적 운동이 불가능할 때를 말합니다(26). 불완전 손상은 환자가 다친 척수 아래로 감각이 다소 남아있거나 수의적 운동이 어느 정도 가능할 때 입니다(26). 손상된 척수 부위: 척수손상 부위는 사지 마비, 높은 부위 하지 마비 또는 낮은 부위 하지 마비로 분류할 수 있습니다(26). 사지마비는 목 부위에서 발생하고 팔, 체간, 골반, 그리고 다리에 영향을 줍니다(26). 높은 부위 하지 마비는 등 부위에 발생하고 체간, 골반 및 다리에 영향을 줍니다(26,27). 낮은 부위 하지 마비는 허리에 발생하고 다리에 영향을 줍니다(26). 또한 골반에도 영향을 줄 수 있습니다(22). 완전 손상의 경우, 운동 능력과 감각의 완전 소실이 발생하고 불완전 손상의 경우, 운동 능력과 감각의 부분 소실이 발생합니다(26); 사지마비와 높은 척수 부위 하지 마비를 가지고 있는 아동과 성인은 체간 주변의 근육 운동 조절과 감각의 상실로 균형 저하가 발생합니다. 이로 인해 똑바로 앉는 것이 더 어려워지며 휠체어로부터 적절한 지지가 제공되지 않으면 장기적인자세의 문제가 빠르게 발생할 수 있습니다; 장과 방광 조절에 문제가 발생할 수 있습니다(26); 하지에 경련/조절되지 않는 움직임이 발생할 수 있습니다(26); 척수손상을 가지고 있는 아동과 성인은 다음의 이유들로 인해 욕창 발생의 위험이 있습니다: - 손상된 부위 이하 감각 소실(26); - 장과 방광의 문제가 효과적으로 관리되지 않을 때 발생할 수 있는 습기 욕창을 방지하기 위해서 항상 압력완화 쿠션을 처방합니다. 척수손상이 있는 휠체어 사용자에게 필요한 자세지지의 정도는 손상된 부위에 따라 달라집니다. 더 높은 부위에 손상이 생길수록 더 많은 자세지지가 필요합니다(27). 수상 후 초기에는 체간과 팔에 추가적인 자세지지가 필요할 수 있습니다 – 특히 높은 부위의 손상의 경우에 더 그렇습니다. 대부분의 하지 마비와 일부 사지마지 사용자는 스스로 매우 효과적으로 휠체어를 추진할 수 있습니다(26). 효율적 추진이 가능하도록 휠체어 설정이 되었는지를 확인합니다. 더 많은 정보를 위해서는: 팔을 이용한 휠체어 추진을 위한 휠체어 설정 – 휠체어 서비스 교육자료 – 초급 참조 매뉴얼 참고 어떻게 욕창을 방지할 수 있나요? – 휠체어 서비스 교육자료 - 초급 참조 매뉴얼 참고. 25 World Health Organization. (1996). Promoting independence following a spinal cord injury: A manual for mid-level rehabilitation workers. Retrieved from http:/whqlibdoc.who.int/hq/1996/WHO_RHB_96.4.pdf 26 Bromley, I. (2006). Tetraplegia and paraplegia: A guide for physiotherapists. Retrieved from http://xa.yimg.com/kq/groups/16749867/2144244149/name/Tetraplegia+and+Paraplegia.pdf 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어지급시 고려사항 뇌 졸 중 뇌졸중은 뇌로 가는 혈액 공급의 장애로 인한 뇌손상의 일종입니다. (27,28,29,30,31). 손상이나 질병은혈관의 폐쇄나 파열을 유발할 수 있으며 이로 인해 뇌의 일부분이 손상되거나 괴사할 수 있습니다. (28,29,30,31,32). 뇌졸중이 발생한 뇌의 부위와 손상된 정도에 따라 뇌졸중의 결과는 달라질 수 있습니다(29,31)– 그러나 대부분의 경우 몸의 한쪽에 문제가 발생합니다 (편마비)(28,31,28). 근위약, 근육운동 조절 능력 저하 그리고 발병한 쪽 몸(팔, 체간, 다리)의 통증(28); 편측감각 저하 및 변화(28); 발병한쪽 몸에 대한 인식의 부족으로 인해 이동 도중 낙상의 위험 증가(28); 문제가 생긴 쪽으로 기대거나 넘어지려는 경향이 있으면서 똑바로 앉기에 어려움이 발생할 수 있습니다(28); 자리에서 일어나서 (다른 보행을 할 수 있으나) 몇 발자국 걷는 것이 가능할 수 있습니다(28); 먹고 마시는 것을 어렵게 만드는 삼킨 곤란 뿐 아니라 말하기에도 어려움을 보일 수 있습니다(28); 장과 방광을 조절하는데 어려움이 생길 수 있으며(28), 또한 화장실로 충분히 빠른 시간 안에 가는 것이 어려울 수 있습니다. 자세지지를 제공하여 (양 쪽이 동등하게) 균형적 그리고 대칭적으로 앉는 것을 독려할 수 있습니다. 위로 접히거나 바깥쪽으로 젖혀지는 발받침대는서서 이동이 가능한 뇌졸중 휠체어 사용자에게 흔히 매우 도움이 됩니다. 한 쪽 팔 위약이 있는 경우가 많아 뇌졸중을 경험한 사용자는 많은 경우 팔을 이용하여 휠체어를 운전하지 못합니다. 사용자가 정상측 팔 한쪽으로 운전하고, 정상측 다리로 조종할 수 있는지 확인해봅니다. 휠체어 사용자가 아직 해결하지 못한 다른 문제가 있다면, 가능한 경우 추가적 도움을 받을 수 있도록 의뢰합니다. 더 많은 정보를 위해서는: 발을 이용한 추진을 위한 휠체어설정– 휠체어 서비스 교육자료 – 초급 참조 매뉴얼 참고. 27 World Health Organization. (1999). Promoting independence following a stroke. Retrieved from http://whqlibdoc.who.int/hq/1999/WHO_DAR _99.2.pdf 28 World Health Organization. (2012). Stroke, Cerebrovascular accident. Retrieved from http://www.who.int/topics/cerebrovascular_accident/en/ 29 World Health Organization. (2006). Neurological disorders: Public health challenges. Retrieved from http://www.who.int/mental_health/neurology/chapter_3_b_neuro_disorders_public_h_challenges.pdf 30 Collins, C. (2007). Pathophysiology and classification of stroke. Nursing Standard, 21(28), 35–39. 31 Frizzel, J. (2005). Acute stroke: Pathophysiology, diagnosis, and treatment. Advanced Practice in Acute and Critical Care, 16(4), 421–440. 32 Herman, B., et al. (1982). Epidemiology of stroke in Tilburg, the Netherlands. The population-based stroke incidence register: 2. Incidence, initial clinical picture and medical care, and three- week case fatality. Stroke, 13(5), 629–634. 일반 정보 휠체어 지급시고려사항 진 행 성 질 환 몇몇 질환들은 시간이 지날수록 더 악화된다고알려져 있습니다. 이런 경우들을 진행성 질환이라고 하게 됩니다. 다음의 질환들은 주요 진행성 질환입니다: 근위축증; 파킨슨병; 다발성 경화증; 운동 신경원 질환. 적절한 시기에 적절한 자세지지를 제공하는 것은 자세 문제를 예방하는데 도움이 될 수 있습니다. 이로 인해 휠체어 사용자는 최대한으로 충족된 삶을 최대한 오래 살 수 있게 됩니다. 이때 다음의 사항들을 고려해야 합니다. 평가를 지연시키게 되면 자세를 더 악화시킬 수 있습니다; 평가 후와 휠체어 제공 사이에 지연이 발생하게 되면, 휠체어가 막상 제공되었을 때는 휠체어와 앉는 장치가 더 이상 사용자에게 적절하지 않을 수도 있습니다; 이동성과 자세의 지지에 대한 요구가 빠르게 변할 수 있기 때문에 경과관찰을 자주 하는 것은 중요합니다. 휠체어 사용자가 여기에 명시되지 않은 진단을 가지고 있다면, 진단명을 적어봅니다. 이 진단명에 대해 잘 알지 못한다면, 이에 대해 더 알아보는 것이 좋습니다. 진단의 주요 특징과 이것이 휠체어 선택에 어떻게 영향을 줄지 고려해 보도록 합니다. 진단 또는 질환에 대해 잘 모른다면 어떻게 해야 하나요? 가끔 휠체어 사용자는 본인의 진단명과 질환에 대해 모르고 있을 수 있습니다. 또한 아무런 진단을 받지 못한 경우도 생길 수 있습니다. 이런 경우에는 특정 신체적 문제를 파악하고 평가를 계속 진행합니다. 휠체어 사용자가 가지고 있는 몇몇 신체적 문제는 가장 적절한 휠체어를 선택하는데 직접적인 영향을 줄 수 있습니다. 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 노 쇠 노쇠한 사람들은 쉽게 피로해지며 이전보다 신체적으로 덜 활동적이고 약해지며 보행 시 매우 천천히 걸을 수 있습니다(33). 노인들은 노쇠의 위험이 더 높습니다(34,30,31). 종종 노쇠한 노인들에게 그들의 요구를 충족시키지 못하는, 적절한 자세지지가 장착되지 않은 기본적인 휠체어가 주어지는 경우가 많습니다(32,33). 그러나 이들에게 좋은 자세지지를 갖춘 적절한 휠체어를 제공하는 것은 그들의 삶의 질에 매우 긍정적 영향을 줄 수 있습니다(37,34,35). 쉽게 피곤해 집니다; 스스로 휠체어를 추진하기에 힘이제한적입니다; 피로와 전반적 위약으로 인해 똑바로 앉은 자세를 유지하는 것이 힘들 수 있습니다; 다음의 이유로 인해 욕창 발생의위험 있습니다: - 쉽게 멍이 드는 얇고 종잇장 같은 피부; - 멍/상처 발생시 더딘 회복시간; - 매우 쇠약한 경우에는, 홀로 자세를 고치는 것이 불가능할 수 있습니다. 자세지지가 어느 정도 필요한지 신중히 평가해야 합니다 – 휠체어에 오래 앉을수록 사용자가 더 많이 피로해질 수 있고 더 많은 자세지지가 필요하다는 것을 고려해야 합니다. 유용한 휠체어 특징들은 다음이 있습니다: - 팔걸이 – 추가적인 자세지지를 제공하고 이동 시에 밀어서 일어나는 움직임을 보조합니다; - 서는 것이 가능한 사용자들의 경우에 밖으로 젖혀져서 이동을 용이하게 해주는 발받침대; - 보호자용 손잡이는 타인이 휠체어를 밀어주는 것을 용이하게 합니다; - 가벼운 휠체어는 사용자가 스스로 휠체어를 운전할 때 용이합니다. 더 많은 정보를 위해서는: 어떻게 욕창을 방지할 수 있나요? – 휠체어 서비스 교육자료 – 초급 참조 매뉴얼 참고. 33 Fried, L., et al. (2001). Frailty in older adults: Evidence for a phenotype. Journal of Gerontology, 56, 146–156 34 Bortz, W. (2002). A conceptual framework of frailty: A review. Journal of Gerontology, 57A(5), M283–M288. 35 Lang, P., Michel, J. P., & Zekry, D. (2009). Frailty syndrome: A transitional state in dynamic process. Gerontology, 55, 539–549. 36 R ader, J., Jones, D., & Miller, L. (2000). The importance of individualized wheelchair seating for frail older adults. Journal of Gerontological Nursing, 26, 24–32. 37 Krasilovsky, G. (1993). Seating assessment and management in a nursing home population. Physical and Occupational Therapy in Geriatrics, 11(2), 25–38. 38 T refler, E., Fitzgerald, S., Hobson, D., Bursick, T., & Joseph, R. (2004). Outcomes of wheelchair systems intervention with residents of long term care facilities. AssistiveTechnology, 16, 18–27. 39 Huntington’s Disease Society of America. (2010). Physical and Occupational Therapy: Family guide series. Retrieved from http://www.hdsa.org/images/content/1/1/11697.pdf 일반 정보 휠체어지급시 고려사항 경 련 /조 절 되 지 않 는 움 직 임 어떤 이들은 갑작스런 조절되지 않는 움직임의 문제들을 가지고 있습니다. 이를 경련이라고 합니다. 다음과 같은 다양한 경우에 경련이 유발될 수 있습니다: 고관절과 무릎 및 발목의 위치; 접촉; 휠체어의 움직임, 특히 거칠고 울퉁불퉁한 지면 위를 지나갈 때. 조절되지 않는 움직임이 휠체어 사용자에게 어떤 영향을 끼치는 지를 알아보고 그들과 해결방안을 찾아야 합니다. 다음과 같은 몇몇 휠체어의 지지장치들이나 조절장치들은 경련과 그 밖의 조절되지 않는 움직임을 줄이는데 도움을 줄 수 있습니다: - 골반자세를 조절하는 것을 도와주도록 지지를 제공하는 것; - 휠체어 사용자의 고관절이 중립적인 자세보다 살짝 더 굽혀진 상태로 앉을 수 있게 좌석과 등받이 사이의 각도를조절하는 것; - 무릎이 중립적인 자세보다 조금 더 굽혀질 수 있도록, 이를테면 발을 안쪽으로 좀더 들어갈 수 있게발받침대의 위치를 설정 하는 것; - 발받침대의 각도를 다양하게 시도해보는 것. 설치된 스트랩은 휠체어 사용자가 다리와 발을 조절하는데 더욱 도움이 되도록 할 수 있습니다. 스트랩이 사용되었다면 벨크로로 고정이 되어야 사용자가 휠체어 밖으로 넘어졌을 때 풀려질 수 있습니다. 움직임의 힘이 매우 강하다면 다음의 사항들을 고려해야 합니다: - 단단한 좌석과 좌석 등받이; - 위치 조절 가능한 뒷바퀴가 있는 휠체어를 선택할 수 있습니다. 뒷바퀴는 ‘안전한’위치에 위치하게 하여 휠체어가 더 안정적이고 덜 기울어지게 합니다; - 기울어짐-방지 바를 설치하여 휠체어가 뒤쪽으로 기울어지는 것을 방지하도록 합니다; - 휠체어 핏팅의 마지막 단계에서 사용자에게 휠체어를 추진하게끔 하는 중요한 이유기 여기에 있는데, 그것은 경련이 유발되는지를 확인하기 위함입니다. 일반 정보 휠체어지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 근 긴 장 도 증 가 및 저 하 근긴장도는쉬고 있는 근육을 수동적으로 움직일 때 나타나게 되는 저항/긴장을 말합니다(40). 정상적인 근긴장도는 사지와 관절이 자유롭고 쉽게 움직일 수 있도록허용합니다. 그러나 어떤 사람들의 경우에는근긴장도가너무 높거나 너무 낮을 수 있습니다. 근긴장도 증가: 저항/긴장이 더 높아져 사지나 관절을 움직이기 더 어렵게 됩니다(41). 높은 근긴장도를 가진 사람은 사지와 관절을 움직이는 것이 어렵고 어색할 수 있으며, 그 움직임이 느려질 수 있습니다. 높은 근긴장도를 가지고 있는 몇몇의 경우에서는 특정 ‘고정된’양상으로만 움직일 수 있습니다(42). 근긴장도가 매우 증가되어 있다면 움직임이 거의 불가능할 수 있습니다. (다음 페이지에 계속) 근긴장도 이상에 의해 유발되는 어려움의 정도는 근긴장도의 심한 정도와 관련된 근육들의 종류 에 달려 있습니다. 근긴장도에 문제가 있는 휠체어사용자들에게 발생 가능한 몇 가지 어려움은 다음과 같습니다: 균형감각 저하(42); 똑바로 그리고 편하게 앉는 것의 어려움(43); 사용자가 휠체어를 운전하거나 이동하는 것과 같은 활동을 수월하게 수행하는데 영향을 줄 수 있는 운동 조절능력의 감소; (다음 페이지에 계속) 근긴장도 증가 및 저하가 있는 휠체어 사용자를 만지거나 움직이는 것을 도울 때 도움이 되는 정보는 다음과 같습니다: 행동에 옮기기 전에 어떤 행동을 할 것인지 미리 설명합니다(42); 천천히 움직여야 하며 근긴장도 증가 또는저하되어 있는 사용자가 반응할 수 있는 시간을 주도록 합니다; 당신의 손과 팔을 사용하여 견고하고 편안한 지지를 제공하여 휠체어 사용자가 적절한 지지를 받을 수 있도록 합니다; 근긴장도의 증가가 심하여 온 몸 또는 사지가 모두 꼿꼿이 펴질 경우, 관절 하나를 굽혀서 긴장도를 풀어줄 수 있습니다. 예를 들어 한 쪽 다리가 전체가 쭉 펴질 경우 무릎이나 고관절을굽힘으로써 긴장도를 낮출 수 있습니다. (다음 페이지에 계속) 40 M artin, K., Kaltenmark, T., Lewallen, A., Smith, C., & Yoshida, A. (2007). Clinical characteristics of hypotonia: A survey of pediatric physical and occupational therapists. Pediatric Physical Therapy, 19, 217–226. 41 World Health Organization. (1993). Promoting the development of young children with cerebral palsy. Retrieved from http://whqlibdoc.who.int/hq/1993/WHO_RHB_93.1.pdf 42 World Health Organzation, United States Department of Defense, Drucker Brain Injury Center MossRhab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. Retrieved from http://whqlibdoc.who.int/hq/2004/WHO_DAR _01.9_eng.pdf 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 근 긴 장 도 증 가 및 저 하 ( 계 속 ) 근긴장도 저하: 저항이 적어 관절과 사지를 수동적으로 움직이기 쉬워집니다(41). 그러나 근긴장도가 저하된 사람은 움직이기 시작할 때 어려움을 느낄 수 있으며, 자신의 움직임을 조절하는 것을 어려워할 수 있습니다. 낮은 근긴장도는 종종 ‘늘어져’ 있거나 ‘축 쳐져’ 있다고 묘사됩니다(41). 근긴장도가 매우 낮아지면 움직이는 것이 매우 어려울 수 있습니다. 어떤 경우에근긴장도에 문제가 생기나요? 근긴장도의이상은 일부 휠체어 사용자에게 발생할 수 있습니다. 뇌성마비(42)와 뇌 손상(43), 척수 손상(39)그리고 뇌졸중(40)이 있는 사람들에게 흔하게 발생합니다. 심한 근긴장도의 증가 및 저하가 있으면 먹고 마시고 삼키고 숨쉬는데 어려움이 생길 수 있습니다(41). 흡인 (음식물이나 액체 일부를 들여 마시는 행위)은 생명을 위협할 수 있는 문제입니다(43); 중립적이지 않은 고정된자세 발생의 위험이 증가합니다(42). 몇몇 휠체어 사용자에서는 감정이 격해지거나 무언가 매우 열심히 하려고 하였을 때 근긴장도 증가가 더욱 심해질 수 있습니다(42,43). 근긴장도의 증가 및 저하는 고관절 탈구의 위험인자가 될 수 있습니다(42). 휠체어 사용자에 대한 평가에 따라 필요한 자세지지의 정도가 달라집니다. 그러나 높은근긴장도를 보이는 휠체어 사용자들을 위한 몇몇 특별 고려사항들은 다음과 같습니다.: 근긴장도증가에도 효과적일 만큼 자세지지가 충분히 견고해야 합니다; 높은 근긴장도는 사용자의 몸과 휠체어 사이에 압력이 높은 지점을 야기할 수 있습니다. 더 넓은 표면 위로 힘을 분산하여 이러한 압력을 줄여줘야 합니다. 압력을 측정하여 확인합니다. 사용자와 가족/보호자에게 피부에 강한 압력이 가해진 징후를 확인하는 것을 가르칩니다; 허벅지와 체간이 이루는 각도를 줄여줌으로써 높은 근긴장도의 강한 패턴을 줄일 수 있습니다. 43 World Health Organization. (1996). Promoting independence following a spinal cord injury: A manual for midlevel rehabilitation workers. Retrieved from http://whqlibdoc.who.int/hq/1996/WHO_RHB_96.4.pdf 44 A merican Heart and Stroke Association. (n.d.). Spasticity. http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/PhysicalChallenges/Spasticity_UCM_309770_Article.jsp 45 R edstone, F., & West, J. (2004). The importance of postural control for feeding. Pediatric Nursing, 30, 97–100. 46 D riscoll, S., & Skinner, J. (2008). Musculoskeletal complications of neuromuscular disease in children. Physical Medicine and Rehabilitation Clinics of North America, 19,163–194. 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 하 지 절 단 하지 절단은 외상(예: 교통사고), 근무 중 사고, 전쟁 중 부상에 의해 발생할 수 있습니다(47,48,49). 다른 경우에서는, 하지 절단은 계획된 수술의 결과 일수도 있습니다. 점차 많은 수의 사람들에게서 당뇨로 인한 이차적 문제로 한쪽 또는 양쪽 하지 절단을 받게 됩니다(50,51,52). 양쪽 또는 한쪽 다리가 절단된 많은 사람들은 의지와 보행보조기를 사용하여 계속 걸을 수 있습니다(48,49). 하지만 어떤 이들은 휠체어를 잠시 동안 또는 모든 시간 사용해야 합니다(48,49,50). 적절한 휠체어 이동 기술을 배울 수 있게 도와준다면, 휠체어를 타면서 매우 활동적으로 지낼 수 있습니다; 의자의 앞부분에 무게가 덜 실리기 때문에 휠체어 밸런스가 변할 수 있습니다; 당뇨가 있는 경우는, 상처 난 피부의 회복이 잘 이루어지지 않아서 더 높은 욕창 발생의 위험이 있습니다(49). 다리를 절단한 사용자에게 처음으로 휠체어를 설정할 때, (조절 가능하다면) 뒷바퀴를 최대한 뒤쪽에 설치하여 휠체어가 뒤로 넘어지는 것을 방지해야 합니다. 활동적 사용자들은 휠체어의 균형을 맞추는 것을 빠르게 배울 수 있는데, 이럴 경우 뒤에 설치한 바퀴를 앞으로 이동시킵니다. 이동 기술을 가르칠 때 다음의 사항들을 지켜야 합니다: - 다리를 절단한 사용자가 처음 휠체어를 사용할 때는 늘 조심해야 합니다; - 사용자가 뒤로 넘어갈 위험이 있기 때문에 조심해서 교육해야 합니다. 휠체어의 핏팅이 달라질 수 있기 때문에 사용자가 휠체어를 탈 때 의지를 착용하는 것을 선호하는지를 알아봐야 합니다. 더 많은 정보를 위해서는: 어떻게 욕창을 방지할 수 있나요? – 휠체어 서비스 교육자료 – 초급 참조 매뉴얼 참고. 47 Burger, H., Marincek, C., & Isakov, E. (1997). Mobility of persons after traumatic lower limb amputation. Disability and Rehabilitation, 19(7), 272–277. 48 N arang, I., Mathur, P., Singh, P., & Jape, V. (1984). Functional capacities of lower limb amputees. Prosthetics and Orthotics International, 8, 43–51. 49 World Health Organization, United States Department of Defence, Moss Rehab Amputee Rehabilitation Program Moss Rehab Hospital. (2004). The rehabilitation of people with amputations. Retrieved from http://www.posna.org/news/Amputations.pdf 50 World Health Organization. (2005). World diabetes day: Too many people are losing lower limbs unnecessary to diabetes. Retrieved from http://www.who.int/mediacentre/news/releases/2005/pr61/en/ 51 Pecorro, R., Reiber, G., & Burgerss, E. (1990). Pathways to diabetic limb amputation: Basis for prevention. Diabetes Care, 13(5), 513–521. 52 T rautner, C., Haastert, B., Giani, G., & Berger, M. (1996). Incidence of lower limb amputations and diabetes. Diabetes Care, 19(9), 1006–1009. 53 World Health Organization. (2010). Wound and lymphoedema management. Retrieved from http://whqlibdoc.who.int/publications/2010/9789241599139_eng.pdf 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 피 로 몇몇 휠체어 사용자는 주기적으로 주간에 피로가 올 수 있습니다. 이는 똑바로 앉거나 추가적 활동을 하는데 노력과 에너지를 사용하기 때문이거나 그들의 질환이나 상태 때문일 수 있습니다. 피로는 일부 노인이나 진행성 질환이 있는 사람들에게 문제가 될 수 있습니다(50,51). 똑바로 앉을 수 있을지 모르나, 피로로 인해 오랜 시간 똑바로 앉지 못할 수 있습니다; 휠체어 사용자가 피로로 인해 똑바로 앉은 자세 유지를 힘들어 할 경우, 자세에 문제가 생길 위험이 증가됩니다. 그들은 자세문제 발생의 위험이 더 높습니다. 무엇이 사용자를 지치게 만드는지를찾도록 노력합니다. 사용자를 위한 최고의 해결책을 찾는데 도움이 될 것입니다. 필요한 자세지지의 정도를 판단할 때, 피로에 대해 고려해야 합니다. 평가가 진행되는 동안 사용자는 평소보다 에너지가 더 있어 자세지지가 덜 필요한 것처럼 보일 수 있습니다. 사용자가 최대로 피곤할 때 필요한 자세지지의 정도를 사용자와 주의 깊게 상의하여야 합니다. 대안적인 휴식자세를 고려합니다 – 예를 들어 쿠션이 있는 트레이의 경우 사용자로 하여금 팔을 이용하여 앞으로 기댈 수 있게끔 해줄 수 있습니다; 좌석과 등받이를 젖히는 것 또한 또 다른 대안적 휴식 자세가 될 수 있습니다. 낮 동안에 휠체어 밖에서의 휴식을 계획하여 더 긴 시간 동안 편안하게 앉을 수 있도록 합니다. 54 World Health Organization. (2008). Atlas: Multiple sclerosis resources in the world. Retrieved from http://www.who.int/mental_health/neurology/Atlas_MS_WEB.pdf 55 Parkinson’s Disease Foundation. (n.d.). Fatigue. Retrieved from http://www.pdf.org/en/fatigue_pdf 일반 정보 휠체어 지급시고려사항 고 관 절 탈 구 독립적으로 한번도 걷지 못했던 아동들에게서 고관절 탈구의 발병률이 더 높습니다. (56,57,58). 이는 태어났을 때 골반의 비구가 부드러워 둥근대퇴골두 면이 다리가 움직일 때나 서 있을 때 몸무게가 비구를 누르면서 비구의 모양을 형성하기 때문입니다. 고관절이 알맞게 형성되지 못하면, 고관절탈구로 이어질 수 있습니다. 또한 고관절 탈구는 고관절과골반 주변의 근육들이 단축되고 높은 근긴장도를 보이며 늘 한쪽 다리 위로 앉거나 눕는 경향이 있는 환아들에서 흔히 발생합니다(55). 이는 뇌성마비(57,60)나 외상성 뇌 손상(60)이 있는 사람들에게서 문제가 될 수 있습니다. (다음 페이지에 계속) 고관절 아탈구/탈구가 있는 것을 시사할 수 있는 소견은 다음과 같습니다: - 한쪽 다리가 다른 쪽 보다 더 짧아 보이는 경우(60); - 다리가 늘 중앙선에 근접하게 위치하는 경우; - 고관절을 움직일 때 통증을 느끼는 경우(60); - 고관절의 관절가동범위 운동을 할 때 허벅지를 중립 자세나 몸 바깥쪽으로 위치시킬 수 없는 경우; - 고관절을 완전하게 펼 수 없는 경우. 연구에 의하면 다음의 방법들이 고관절 탈구 경향을 줄이는데 도움이 될 수 있다고 합니다. - 이른 나이 때부터 앉고 누워있을 때의 중립적 자세를 지지합니다. 어린 아이들에게 이는 고관절/허벅지를 외전한 자세로 지지하는 것을 포함합니다(61,62); - (예를 들어 기립 훈련기에서) 중립적 자세로 서 있는 것(63). (다음 페이지에 계속) 56 Soo, B., et al. (2006). Hip displacement in cerebral palsy. The Journal of Bone and Joint Surgery, 88, 121–129. 57 Scrutton, D., Baird, G., & Smeeton, N. (2001). Hip dysplasia in bilateral cerebral palsy: incidence and natural history in children aged 18 months to 5 years. Developmental Medicine and Child Neurology, 43, 486–600 58 Lonstein, J., & Beck, K. (1986). Hip dislocation and subluxation in cerebral palsy. Journal of Pediatric Orthopaedics, 6, 521–526. 59 Children’s Hospital Boston. (n.d.). A guidebook for hip surgery in children with cerebral palsy. Retrieved from http://childrenshospital.org/clinicalservices/Site1166/Documents/CP.LE.Book.web2.pdf 60 World Health Organzation, United States Department of Defense, Drucker Brain Injury Center MossRhab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. Retrieved from http://whqlibdoc.who.int/hq/2004/WHO_DAR _01.9_eng.pdf 61 Pountney, T., Mandy, A., Green, E., & Gard, P. (2009). Hip subluxation and dislocation in cerebral palsy – a prospective study on the effectiveness of postural management programmes. Physiotherapy Research International, 14(2), 116–127. 62 Health Centre for Children. (2011). Evidence for practice: Surveillance and management of hip displacement and dislocation in children with neuromotor disorders including cerebral palsy. Vancouver, BC: Tanja Mayson. 일반 정보 휠체어 지급시고려사항 고 관 절 탈 구 ( 계 속 ) 이제껏 걷지 못하고 두다리를 한쪽으로 하고 누우려는 경향이 있는 아이들에서 고관절이 내전되어 몸의 중앙선에 가장 가깝게 위치하고, 내전되어 안쪽으로 돌아있을 때 가장 탈구 되기 쉽습니다 (63). 아이들의 고관절 부위에 근긴장도가 낮을 때에도 탈구의 위험이 있습니다. 이는 고관절의 두 부분 (비구와 대퇴골두)을 연결하며 잡고 있는 근육과 인대의 힘이 약하기 때문입니다. 고관절 탈구가 항상 통증을 일으키지는 않습니다(64,65,66). 고관절 탈구 가능성의 징후를 보이는 아동이나 성인을 평가할 때 골반을 조심스럽게 움직이도록 하고 통증을 유발하지 않도록 합니다. 아동이나 성인 사용자가 고관절이 탈구되었는지 확실하지 않을 때는 (가능하다면) 의사/소아과 의사 또는 경험이 많은 물리치료사에게 자문을 구해야 합니다. 고관절 탈구가 있거나 의심되는 아동이나 성인에게 휠체어와 자세지지를 제공할 때는 다음을 유념해야 합니다: - 통증을 유발하는 자세를 피합니다; - 사용자의 골반과 체간을 중립적인 자세 (최대한 중립적인 자세)로 지지합니다; 그런 다음 둔부와 허벅지를 가장 중립적인 자세가 되도록 지지합니다. 골반을 중립적인 자세에서 벗어나게 하여 통증을 유발할 수 있는 다리 자세의 과한 교정을 피해야 합니다; - 사용자가 어떤 자세로 자는지 확인합니다. 잘 때 양 다리를 한쪽으로 움직이거나 양 다리가 서로 맞대어져 꽉 눌려지지 않게 주의하도록 합니다. 63 Pope, P. (2007). Severe and complex neurological disability: Management of the physical condition. Philadelphia: Elsevier Limited. 64 Sherk, H., Pasquariello, P., & Doherty, J. (2008). Hip dislocation in cerebral palsy: Selection for treatment. Developmental Medicine and Child Neurology, 25(6), 738–746. 65 M oreau, M. et al. (1979). Natural history of the dislocated hip in spastic cerebral palsy. Developmental Medicine and Child Neurology, 21(6), 749–753. 66 Knapp, R., & Cortes, H. (2002). Untreated hip dislocation in cerebral palsy. Journal of Pediatric Orthopaedics, 22, 668–671. 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 간 질 간질은 뇌의 정상적인 활동의 이상으로 인해발작들이 일어나는 것입니다(67,68,69,70). 특정한 상황에 놓이게 되면 누구나 발작을 할 수 있습니다(70). 간질이라는 용어는 유발 요인 없이 재발하는 발작을 의미합니다(69,70). (다음 페이지에 계속) 휠체어 평가가 진행되는 동안 사용자가 발작을 일으킨다면 다음을시행합니다: 사용자가 가벼운 발작을 일으킨다면 발작이 멈출 때까지 기다린 후 평가를 이어갑니다. 휠체어 사용자가 강한 발작을 일으킨다면 사용자를외상으로부터 보호하는 것이 가장 우선 순위입니다(71). 사용자가 앞으로 넘어진다면 가볍게 넘어지도록 해야 합니다. 사용자가 아동이거나 청소년이라면 사용자를 안전하게 들어서 바닥에 눕히는 것이 가능할 수 있습니다. 사용자가 다 큰 성인이라면 발작을 일으킬 때 (도움을 주다가 도움을 주는 이가 다칠 수 있으므로) 사용자가 그 자리에 머무르도록 하고, 발작이 멈춘 후 가족의 일원이나 보호자의 도움을 얻어 사용자를 이동시켜야 합니다. (다음 페이지에 계속) 간질을 앓고 있는 사람에게 휠체어를 제공할 때는 다음의 사항들을 기억해야 합니다: 휠체어 사용자가 휠체어에서 나오기 쉽도록 손 쉽게 풀 수 있는 스트랩이 필요합니다; (다음 페이지에 계속) 67 M cNamara, J. (1994). Cellular and molecular basis of epilepsy. The Journal of Neuroscience, 14(6), 3413–3425. 68 World Health Organization. (2005). Atlas: Epilepsy care in the world. Retrieved from http://www.who.int/mental_health/neurology/Epilepsy_atlas_r1.pdf 69 World Health Organization. (2002). Epilepsy: A manula for medical and clinical officers in Africa. Retrieved from http://www.who.int/mental_health/media/en/639.pdf 70 World Health Organization. (2006). Neurological disorders: Public health challenges. Retrieved from http://www.who.int/mental_health/neurology/chapter_3_a_neuro_disorders_public_h_challenges.pdf 71 E pilepsy Foundation. (n.d.). First aid. Retrieved from http://www.epilepsyfoundation.org/aboutepilepsy/firstaid/index.cfm 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 간 질 ( 계 속 ) 휠체어 사용자의 일부는 간질을 앓고 있을 수 있습니다. 발작은 부분발작 또는 전신발작일 수 있습니다(70). 부분발작이 일어나는 동안 환자는 의식이 저하될 수도 있고 그렇지 않을 수도 있습니다(70). 의식이 저하되지 않는다면 발작은 1 분 이내에 멈추며 환자는 보통 조절되지 않는 움직임을 보입니다(72). 의식이 저하되는 경우에는 발작은 1 분에서 2 분동안 지속되며 환자는 어떤 일이 일어나고 있는지 조금은 인지하고 있으나 반응하거나 행동에 변화를 줄 수는 없습니다(72,73). 전신발작이 일어나는 동안에는 완전하게 의식소실이 발생합니다(70). 전신발작을 일으킨 사람은 갑자기 의식을 잃고 넘어져 다칠 수 있습니다(70). 발작이 일어나는 동안 다음의 사항들을 준수해야 합니다: 사용자의 입에 음식물, 물 또는 구토가 있지 않는 한 사용자를 휠체어에서 내리려고 하지 말아야 합니다. 만약 있다면 이런 경우에는 사용자를 옆으로 눕혀 침과 점액이 입 밖으로 흘러 나오도록 해야 합니다(70,73); 휠체어 사용자 주변에 공간을 만들어 사용자를 외상으로부터 보호하거나 그들을 해칠 수 있는 것들로부터 이동시킵니다(70); 부드러운 받침대를 두어서 사용자의 머리를 보호합니다(70,73); 꽉 조이는 옷은 느슨히 하고, 사용자를 다치게 할 수 있는 물건들을 제거하고휠체어가 고정되어 안정적인지 확인합니다(70,73); 발작이 지속되는 시간을 잰 뒤 사용자나 보호자에게 이를 알립니다(70). 휠체어 사용자와 발작이 멈출 때까지 침착하게 기다립니다. 다음의 경우에는 의료진의 도움을 구합니다: 발작이 멈췄는데도 사용자의 의식이 돌아오지 않을 때(69); 발작이 5 분 이상 지속될 때(70). 사용자가 자주 발작을 일으켜서 갑자기 앞으로 넘어지는 경우가 많다면,트레이에(만약 사용한다면) 패드를 장착하여 사용자의 머리가 다치지 않게 합니다; 휠체어 사용자가 간질을 앓고 있지만 치료를 받고 있지 않다면 의사의 진료를 의뢰해야 합니다. 72 E pilepsy Australia. (2009). Seizure first aid. Retrieved from http://www.epilepsyaustralia.net/userData/docs/First%20Aid%20Brochure%2009.pdf 73 E pilepsy Canada. (n.d.). Retrieved fro http://old.epilepsycanada.test.glacier-digital.com/scans/brochure/seizuresFirstAid.html 74 E pilepsy Canada. (n.d.). Retrieved from http://www.epilepsy.ca/en-CA/Diagnosis-and-Treatment/First-Aid.html 일반 정보 휠체어 지급시고려사항 먹 고 마 시 고 삼 키 는 데 문 제 가 있 는 경 우 일부 아동과 성인은 먹고 마시고 삼키는데 문제를 가지고 있습니다. 먹고 마시는데 어려움 있는 경우에 입으로 음식물을 가져오는 과정의 문제가 발생할 수도 있습니다. 예를 들어 휠체어 사용자가 손이나 팔을 사용하는데 문제가 있다면 사용자는 먹고 마시는 것을 쉽게 수행하기 힘듭니다. 그밖에 먹고 마시는 것의 어려움은 삼킴을 조절하는 근육뿐 아니라 머리와 목, 입 주변의 근육의 문제에 의해서도 발생할 수 있습니다(75). 균형 저하와 똑바로 앉아 있기 어려움, 그리고 머리의 똑바르고 균형 잡힌 자세를 유지하는 것의 어려움은 이를 더욱 악화시킵니다. (76). 삼킴 장애는 음식물이나 음료를 폐로 가게 할 수 있습니다. 이는 폐에 염증을 일으켜 환자를 매우 위험하게 할 가능성이 있습니다(77,78,79,80,81). 환자가 삼키는데 어려움이 있다는 것을 나타내는 징후는 다음과 같습니다: 무언가를 마실 때 자주 기침을 합니다(83); 먹거나 마실 때 목에 자주 걸립니다(84); 침을 지속적으로 흘립니다. 먹고 마시고 삼키는데 문제가 있는 환자에게 휠체어를 제공할 때는 다음의 사항들을 기억해야 합니다: 효과적인 자세지지는 균형, 자세, 그리고 손과 머리의 조절 능력을 향상시켜 주며, 먹고 마시고 삼키는데 생긴 문제를 줄여줄 수 있습니다; 트레이나 머리받침대가 종종 필요합니다. 휠체어 사용자가 삼키는데 문제가 있지만 치료받고 있지 않다면 소아과 의사, 언어치료사, 작업 치료사나 경험이 많은 소아보건 종사자 등 도움을 줄 수 있는 사람에게 의뢰해야 합니다. 75 Logemann, J., & Bytell, D. (1979). Swallowing disorders in three types of head and neck surgical patients. Cancer, 44, 1075–1105. 76 R edstone, F., & West, J. (2004). The importance of postural control for feeding. Pediatric Nursing, 30(2), 97–100. 77 T easell, R., Mcrae, M., Marchuk, Y., & Finestone, H. (1996). Pneumonia associated with aspiration following stroke. Arch Phys Med Rehab, 77, 77–709. 78 Loughlin, G. (1989). Respiratory consequences of dysfunctional swallowing and aspiration. Dysphagia, 3, 126–130. 79 World Health Organzation, United States Department of Defense, Drucker Brain Injury Center MossRhab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. Retrieved from http://whqlibdoc.who.int/hq/2004/WHO_DAR _01.9_eng.pdf 80 Schmidt, J., Holas, M., Halvorson, K., & Reding, M. (1994). Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia, 9, 7–11. 81 Perry, L., & Love, C. (2001). Screening for dysphagia and aspiration in acute stroke: A systematic review. Dysphasia, 16, 7–18. 82 http://www.who.int/mediacentre/factsheets/fs331/en/ 83 Prasse, J. & Kikano, G. (2009). An overview of pediatric dysphagia. Clinical Pediatrics, 48(3), 247–251. 일반 정보 휠체어 지급에 영향을 주는 주요 특징 휠체어 지급시고려사항 통 증 사용자가 휠체어에 편안하게 앉는데 영향을 줄 수 있는 통증이 있는지 아는 것은 매우 중요합니다. 통증이 있는데도 이를 무시하는 것은 위험하기 때문에 사용자가 규칙적으로 통증을 느끼고 있다면 휠체어 서비스 인력은 사용자의 통증에 대해 의사에게 알려야 합니다. 휠체어 평가 시 통증을 피하기 위해서는: - 어떤 특정 자세를 취할 때 통증이 심해지지 않는지 물어보고 그러한 자세를 피해야 합니다; - 어떤 특정 자세나 움직임이 통증이 감소하도록 하는지 물어보고 평가를 진행할 때 그러한 자세를 고려해야 합니다; - 사용자가 말로 대화할 수 없다면 의사소통 할 수 있는 다른 방법을 평가가 시작되기 전에 찾아야 합니다; - 효과적인 지지와 자세의 변화로 통증을 줄이거나 없앨 수 있습니다. 방 광 과 장 의 문 제 사용자의 일부는 자신의 방광이나 장을 조절하는데 어려움이 있을 수 있습니다. 이러한 문제는 올바른 기구 (카테터)나 약 처방, 방광과 장 훈련 프로그램을 통해 관리할 수 있습니다. 우리 주변 지역에서 이러한 합병증을 피하기 위해 누가 조언과 교육 (예를 들어 전문의나 간호사)을 제공할 수 있는지 파악하는 것은 중요합니다. 때로는 방광이나 장 조절에 어려움을 겪고 있는 사용자들이 언제 화장실을 가고 싶은지 표현하는데 어려움이 있습니다. 그들은 방광이나 창자 조절 사고의 위험을 지니고 있습니다. 방광이나 장 조절에 어려움을 겪고 있는 휠체어 사용자와 있을 때 휠체어 서비스 인력은 자신들에게 변이 묻거나 더러워질 수 있다는 것을 인지하고 있어야 합니다. 준수한 손 씻는 시설과 클리닉 공간을 청소할 수 있는 수단을 확보하는 것은 중요합니다. 습하거나 변이 묻은 쿠션은 사용자의 피부를 손상시킬 수 있습니다. 또한 배설물에 존재하는 박테리아는 욕창 감염을 빠르게 유발할 수 있습니다. 소변과 대변의 노폐물 또한 욕창 부위를 감염시킬 수 있고 피부에 화학적 화상을 일으킬 수도 있습니다. 쿠션과 덮개는 사용자/보호자가 손쉽게 세척할 수 있도록 쉽게 벗겨져야 합니다. 방수커버가 있는 쿠션을 제공해야 합니다. 가능하다면 두 개의 덮개를 제공하여 하나의 덮개가 마르는 동안 사용자가 일상생활을 이어갈 수 있도록 합니다. 방수커버가 없다면 두 개의 쿠션을 제공 합니다. 사용자의 방광과 장을 건강하게 유지하고 배설로 인한 사고를 예방할 수 있도록 도움을 줄 수 있는 전문가에게 사용자를 의뢰하여야 합니다. 생활방식과 환경 사용자가 어느 장소에서 휠체어를 사용할 것인지 기입하세요: 하루 동안 이동하는 거리: 최대 1km□ 1-5km□ 5km 이상□ 하루 동안 휠체어를 사용하는 시간: 1 시간 미만□ 1-3 시간□ 3-5 시간□ 5-8 시간□ 8 시간 이상□ 휠체어 밖으로 나왔을 때, 휠체어 사용자가 어디에 어떻게 앉거나 누워있나요 (어떤 표면에서 어떠한 자세로)? 트랜스퍼: 혼자서□ 도움을 받고□ 서서□ 서지 않고□누군가 들어줘서□ 기타□ 변기의 종류 (화장실을 이용할 때): 재래식□ 양식 변기□ 장애인 전용 화장실□ 휠체어 사용자가 자주 대중교통/자가용을 이용하나요? 예□ 아니요□ 만약 예라고 대답했다면 어떤 종류의 교통수단을 이용하나요? 자가용□ 택시□ 버스□ 기타 중급 휠체어 평가 양식의 ‘생활방식과 환경’은 휠체어 사용자가 어디에 살며 휠체어를 탄 채로 어떤 활동을 해야 하는지에 대한 정보를 수집합니다. 제공된 휠체어와 추가적인 자세 지지가 사용자의 생활방식과 환경에서 당장 어떻게 도움이 될 것인지 고려하는 것은 중요합니다. 중급 휠체어 평가 양식의 ‘생활방식과 환경‘ 질문들 논의 사용자가 어느 장소에서 휠체어를 사용할 것인지 기입하세요 제공된 휠체어가 사용자의 집이나 직장, 학교에서 실용적이어야 합니다. 예를 들어: - 집에서 휠체어를 사용한다면, 사용자는 중요한 일상 활동을 하기 위해 편리하게 돌아다닐 수 있어야 합니다; - 사무실에서 일하는 사용자는 사무실 환경에 잘 맞는 휠체어를 사용해야 합니다; - 휠체어를 타고 학교에 등교하는 사용자는 교실 환경에 잘 맞으며 책상 앞에서 편안하게 사용할 수 있거나 트레이가 장착된 휠체어를 사용해야 합니다; - 휠체어를 타고 시장에 가거나 거친 길을 지나가야 하는 사용자는 거친 표면에서 이상 없이 잘 움직이는 휠체어를 사용해야 합니다. 중급 휠체어 평가 양식의 ‘생활방식과 환경‘ 질문들 논의 하루 동안 이동하는 거리 짧은 거리는 걷지만 먼 거리는 자전거를 이용하듯이, 휠체어 사용자는 짧은 거리에는 휠체어를 사용하지만 먼 거리는 세 바퀴 휠체어를 사용할 수 있습니다. 세 바퀴 휠체어는 같은 거리에 적은 힘이 들며 더 빨리 이동할 수 있습니다. 하루 동안 휠체어를 사용하는 시간 사용자가 휠체어에 오래 앉아있을수록 피로도가 높아지며, 욕창의 위험이 올라갑니다. 사용자에게 얼마나 많은 지지가 필요하며 휠체어의 쿠션이 압력완화와 편안함을 제대로 제공하는지를 고려해야 합니다. ‘활동적인’ 사용자가 하루 동안 휠체어를 사용한다면 사용자의 휠체어는 더 효율적으로 이동하면서 다른 활동을 하기에도 용이해야 합니다. 바퀴의 위치가 중요합니다. 등받이가 사용자를 충분히 지지하면서 어깨뼈의 움직임을 방해하지는 않는지 확인하는 것도 중요합니다. 휠체어 밖으로 나왔을 때, 휠체어 사용자가 어디에 어떻게 앉거나 누워있나요 (어떤 표면에서 어떠한 자세로)? 휠체어 사용자가 같은 자세로 오래 있으면 사용자의 몸이 뻣뻣해지면서 결국 그 자세로 굳어져버릴 수 있습니다. 이로 인해 휠체어에 편안하게 앉는 것이 불가능해질 수 있습니다. 이런 상황을 방지하는 것은 매우 중요하며 사용자가 휠체어에 앉아있지 않을 때에도 앉거나 누울 수 있는 편안한 자세를 다양하게 제공해야 합니다. 휠체어 사용자가 항상 같은 자세로 앉거나 누워 있나요? - 가능하다면 사용자에게 선호하는 자세를 직접 보여달라고 하십시오; - 사용자가 선호하는 자세를 알아야 그 ‘반대’ 자세를 제안해줄 수 있습니다. 바로 그 ‘반대’자세를 취하는 것이 늘 가능하지 않을 수도 있습니다. 만약 사용자가 선호하는 자세로만 오랜 시간 지내왔다면 완전히 반대 자세를 바로 취하는 것이 불편하고 이상하거나 또는 두렵게 느껴질 수 있습니다. - 사용자의 몸통과 사지가 더욱 중립적이고 편안한 자세를 취할 수 있도록 몸통과 사지를 지지할 수 있는 방법을 강구해 봅니다. 휠체어 사용자가 본인의 자세를 스스로 바꿀 수 있나요? - 휠체어 사용자가 스스로 자세를 바꿀 수 없다면, 사용자는 자세 문제나 욕창 발생의 위험이 증가합니다. 중급 휠체어 평가 양식의 ‘생활방식과 환경‘ 질문들 논의 트랜스퍼 팔걸이와 발받침대는 사용자가 휠체어에 오르고 내리는 방식에 영향을 줄 수 있습니다: - 선 자세로 트랜스퍼를 하는 경우에는 발 받침대가 접이식인 것이 좋습니다. 또한 팔걸이가 있는 휠체어의 경우 사용자가 몸을 밀어 올릴 때 유용합니다. - 서지 않고 트랜스퍼를 하는 경우, 분리 가능한 팔걸이나 바퀴의 윤곽과 비슷한 팔걸이를 사용하는 것이 트랜스퍼를 더 쉽게 합니다. - 추가적인 자세 지지를 제공하는 경우 사용자가 쉽게 트랜스퍼를 할 수 있는지 확인해야 합니다. 예를 들어 웨지가 있는 쿠션이나 좌석을 추가하는 경우 휠체어 사용자가 트랜스퍼를 하는데 더 어려움을 겪을 수 있습니다. 트랜스퍼 기술의 변화나 다른 종류의 자세보조용구를 사용해야 할 수 있습니다. 변기의 종류 변기의 종류와 화장실로의 물리적 접근성은 휠체어 사용자가 얼마나 쉽게 화장실을 사용할 수 있는지 영향을 줍니다. 변기의 디자인으로 인해 화장실을 사용하는 것이 불가능할 수 있습니다. 예를 들어, 대부분의 휠체어 사용자는 재래식 화장실을 사용하는 것을 매우 어려워합니다. 휠체어 서비스 인력은 화장실의 위치나 화장실에 대해 물어보면서 변기로 그리고 변기로부터의 트랜스퍼에 대해 조언할 수 있습니다. 또한 휠체어 서비스 인력은 장애인이 사용하는데 편리하도록 화장실을 변형하는 방법에 대해서도 조언할 수 있습니다. 휠체어 사용자가 자주 대중교통/자가용을 이용하나요? 휠체어 사용자가 교통수단을 자주 사용한다면, 사용자는 휠체어를 손쉽게 운반할 수 있어야 합니다. 휠체어의 운반을 용이하게 할 수 있는 휠체어의 특징들은 다음을 포함합니다: - 더 가벼운 휠체어는 휠체어를 싣고 내리는데 더 쉽습니다; - 분리 가능한 바퀴나 접히는 프레임과 등받이를 사용하면 휠체어 운반이 용이해질 수 있습니다. 대중교통을 이용한다면, 분리 가능한 부품들은 싣고 내리는데 용이하여 이점으로 작용할 수 있습니다. 그러나 한편으로는 이 분리된 부품들을 분실하거나 도난 당할 수도 있어 단점으로 작용할 수도 있습니다. 기존 휠체어 (사용자가 이미 휠체어를 가지고 있다면) 휠체어가 사용자의 요구를 충족하고 있나요? 예□ 아니요□ 휠체어가 사용자의 환경적 상황에 알맞은가요? 예□ 아니요□ 휠체어가 사용자의 몸에 잘 맞고 자세를 올바르게 지지하나요? 예□ 아니요□ 휠체어가 안전하고 내구성이 좋은가요? (쿠션의 유무를 고려하세요) 예□ 아니요□ (사용자가 욕창 위험이 있다면) 휠체어의 쿠션이 압력을 적절히 완화시켜주나요? 예□ 아니요□ 코멘트: 만약 모든 질문에 ‘예’를 선택하였다면, 해당 사용자는 새로운 휠체어가 필요하지 않습니다. 만약 하나의 질문에라도 ‘아니요’를 선택하였다면, 해당 사용자는 새로운 휠체어나 쿠션이 필요합니다; 또는 기존 휠체어나 쿠션을 수리하거나 수정해야 합니다. 만약 사용자가 이미 휠체어를 소지하고 있다면, 휠체어가 사용자의 필요를 충족하는지 확인하는 것이 중요합니다. 중급 휠체어 평가 양식의 ‘기존 휠체어’ 부분은 휠체어 서비스 인력과 사용자가 기존 휠체어가 사용자에게 적절한지 알아보는데 도움이 됩니다. 휠체어의 상태를 확인할 때 휠체어의 표면을 보면 어떻게 사용자가 휠체어에 앉는지 알아볼 수 있습니다. 예를 들어, 휠체어 쿠션의 한쪽 면이 움푹 들어가 있다면 한쪽 궁둥뼈에 더 많은 압력이 가해지고 있는 것일 수 있습니다. 휠체어의 한쪽 팔걸이가 파손되어 있다면 사용자가 그쪽으로 많이 기대고 있는 것일 수 있습니다. 휠체어에 어떤 이상이 보인다면, 사용자에게 어떻게 된 일인지 물어봐야 합니다. 휠체어가 사용자의 요구를 충족시키지 않는다면 휠체어 서비스 인력은 어떠한 이유 때문인지 파악해야 합니다. 종종 휠체어는 사용자에게 적절하지만 휠체어 사용자에게 잘 맞춰져 있지 않은 경우가 있습니다. 수선, 수리 또는 추가적인 자세지지가 도움이 될 수 있습니다. 평가 인터뷰에 효과적인 커뮤니케이션 방법 좋은 커뮤니케이션 기술을 사용하는 것은, 휠체어 사용자의 요구와 사용 감성에 민감하게 반응하고 존중하는 방식으로 올바른 정보를 얻는 데에 항상 중요합니다. 평가 인터뷰를 매끄럽게 진행하도록 돕는 방법은 다음과 같습니다: 휠체어 사용자가 아주 어리거나 당신의 말을 잘 이해하지 못하고 질문에 대답을 하지 못하지 않는 경우를 제외하고 항상 휠체어 사용자에게 먼저 말을 걸어야 합니다; 휠체어 사용자에게 사용자가 제공하는 정보가 휠체어 사용자의 요구를 충족하는 가장 적절한 휠체어를 고르는데 도움이 될 것이라고 설명합니다; 중급 휠체어 평가 양식의 순서대로 질문을 할 필요는 없습니다. 종종 휠체어 사용자는 자진해서 본인들의 정보에 대해 말하는 경우가 있고, 질문을 양식의 순서와 다른 순서로 할 때 더 자연스러운 경우도 있습니다. 종종 말로 하는 커뮤니케이션에 어려움이 있을 수 있습니다. 예를 들어, 휠체어 사용자가 듣는 것에 어려움이 있거나 당신이 알아듣기 어렵게 말 하는 경우도 있습니다. 커뮤니케이션에 어려움이 있을 경우 휠체어 사용자와 직접적으로 의사 소통할 수 있는 방법을 찾아야 합니다. 휠체어 사용자를 잘 아는 지인에게 어떻게 하면 사용자랑 가장 잘 소통할 수 있는지 물어봐야 합니다. 시간을 갖고 휠체어 사용자가 어떻게 사람들과 의사 소통하는지 이해해야 합니다. 사용자와 직접적으로 의사 소통하는 방법을 찾지 못한 경우, 사용자와 많은 시간을 함께하는 사람을 찾아야 합니다. 그 지인의 도움을 받아 휠체어 사용자와 대화하는 것이 좋은 방법입니다. 휠체어 사용자가 말을 할 수 없을 때 사용자가 느끼는 통증 파악하기 휠체어 사용자가 말을 할 수 없을 경우, 사용자가 통증을 표현하는데 어려움이 있을 수 있습니다. 그러나 휠체어 서비스 인력은 그들이 하는 일이 사용자의 통증을 발생시키거나 증가시키는지를 아는 것이 중요합니다. 말이 아닌 다른 방법으로 통증을 느끼고 있는 것을 표현하는 방법은 다음과 같습니다: 우는 것, 소리지르는 것, 땀을 흘리거나 안절부절 못할 수 있습니다; 평가자의 손을 밀치거나 손길을 피하려 할 수 있습니다; 움직임에 저항하거나 특정 자세를 유지하는 것을 못할 수 있습니다; 얼굴을 찌푸리거나 찡그리는 표정을 지을 수 있습니다; 앉고 서있거나 걷는 방식. 다음의 방법들을 사용하여 당신에 의해 통증이 생기거나 통증이 심해지지 않도록 유의합니다: 평가를 진행하는 동안 통증이 느껴지면 바로 알려달라고 해야 합니다; 대화를 하는데 어려움이 있다면, 통증이 느껴질 때 보내는 신호를 평가 시작 전에 정해둡니다; 통증을 악화시키는 자세를 취하지 않도록 해야 합니다; 통증을 줄여주는 자세나 동작을 사용합니다. 신체 측정 – 지지 없이 앉아 있는 자세 신체 측정은 평가의 두 번째 항목입니다. 신체 측정은 다음의 사항들을 포함합니다: 욕창의 존재나 위험 또는 과거력을 확인합니다; 휠체어를 미는 방법을 확인합니다; 다음의 방법을 통해 어떻게 휠체어 사용자가 앉으며 어떤 자세지지가 필요할지 찾아냅니다: - 지지 없이 앉는 자세를 관찰합니다; - 골반과 고관절 자세를 관찰합니다. 골반과 고관절 자세를 관찰하는 것은 골반이나 고관절의 문제가 사용자의 앉는 자세에 어떻게 영향을 미치는지를 이해할 수 있습니다; - 손을 이용하여 설명합니다. 휠체어 서비스 인력은 손을 이용하여 휠체어와 추가적인 자세 지지가 어떻게 사용자를 지지할 것인지 묘사할 수 있습니다; 치수를 잽니다. 중급 휠체어 평가 양식의 이러한 각 항목으로부터 얻게 된 정보는 얼마 정도의 지지가 사용자에게 필요할지 휠체어 서비스 인력이 결정하는데 도움을 줍니다. 욕창의 존재나 위험 또는 과거력 확인하기 욕창의 존재나 위험 또는 과거력 /// = 감각이 없다. 정상적인 감각이 있나요? 예□ 아니요□ ○ = 과거 욕창이 있었던 부위 과거에 욕창이 있었던 적이 있나요? 예□ 아니요□ ● = 현재 욕창이 있는 부위 현재 욕창이 있나요? 예□ 아니요□ 만약 그렇다면, 아물지 않은 상처 예□ 아니요□ (1-4 기) 인가요? 발병기간 및 원인: 욕창의 위험*이 있나요? 예□ 아니요□ *감각이 없거나 3 개 이상의 위험인자를 가지고 있는 사람은 욕창의 위험이 있다고 할 수 있습니다. 위험인자: 움직일 수 없음, 습한 환경, 나쁜 자세, 욕창의 과거력/현병력, 식사량 저하, 저체중 또는 과체중. 휠체어를 미는 방법 휠체어 사용자가 어떻게 휠체어를 미나요? 양 팔을 사용하여□ 왼쪽 팔을 사용하여□ 오른팔을 사용하여□ 양 다리를 사용하여□ 왼쪽 다리를 사용하여□ 오른쪽 다리를 사용하여□ 다른 이가 앞으로 밀어줍니다□ 코멘트: __________________________________________________________________________________________________________________ 똑바로 앉는 자세 자주 사용되는 약자 표기 해부학적 구조 약자 상전장골극 ASIS 상후장골극 PSIS 좌골결절 IT 모든 휠체어 사용자가 똑바로 앉거나 중립적인 자세를 취할 수 있나요? 심지어 자세지지를 받는다고 해도, 모든 휠체어 사용자가 똑바로 앉을 수는 없습니다. 똑바로 앉는데 어려움이 있는 사용자는 앉을 때 타인과는 다른 여러 자세를 취하게 됩니다. 중립적으로 위치하지 않는 몸의 부위 (또는 부위들)에 의하여 이러한 자세들이 나타납니다. 평가를 진행하는 동안, 안전하고 편안하게 취할 수 있으면서 기능의 상실 없이 그 자세를 유지할 수 있는 최대한 똑바른 자세를 찾을 수 있도록 노력해야 합니다. 이때 휠체어와 자세보조용구는 사용자의 자세를 지지해야 합니다. 자세를 평가할 때 다음과 같은 세 가지의 다른 최종 결과가 발견될 수 있습니다: 구축된 자세– 휠체어 사용자 몸의 한 부위가 ‘구축된’ 경우입니다. 약하게 힘을 가했을 경우에는 움직임이 없습니다. (이때 절대로 강한 힘을 가하지 말아야 합니다.) 이런 경우, 휠체어 서비스 인력은 중립적이지 않은 사용자의 자세 (구축된 자세)에 적절한 지지를 제공해야 합니다. 중립적인 자세가 가능한 유연한 자세 - 사용자에게 약하게 힘을 가했을 경우 몸의 한 부위가 중립적이지 않은 자세로부터 중립적인 자세로 바뀌는 것이 가능한 경우입니다. 이런 경우, 사용자의 중립적인 자세 유지를 위해 올바른 자세지지가 제공되어야 합니다. 일정 부분 중립적인 자세가 가능한 유연한 자세 - 사용자에게 약하게 힘을 가했을 경우에 중립방향으로 일부분만 움직이는 경우입니다. 이런 경우, 사용자가 편안하고 기능적이면서 중립 자세에 가장 가까운 자세로 앉을 수 있도록 자세지지가 제공되어야 합니다. 아동의 똑바로 앉은 자세 5 세 미만 아동의 똑바로 앉은 자세는 5 세 이상의 아동 또는 성인과는 다른 형태를 갖습니다. 앉은 자세는 아동의 인생의 첫 5 년에 걸쳐 발달하게 되기 때문입니다 5 세 미만 아동의 가장 중요한 차이점들은 다음과 같습니다: 아동의 등은 쭉 펴져있으며 흉추와 요추에 굴곡이 없습니다; 옆에서 보았을 때 아동의 귀와 고관절이 일직선 상에 있지만 어깨는 보다 약간 전방에 위치합니다. 양 다리는 바깥쪽으로 돌아가 있고 벌어져 있어서 평행하지 않습니다. 5 세 미만 아동의 휠체어 주문 작업을 할 때, 휠체어 서비스 인력은 5 세 미만 아동에게 성인의 똑바로 앉는 자세를 지지하는 방법과 다른 방법을 고려해야 합니다. 아동은 성인의 방법이 불편할 수 있으며 아동에게 해가 될 수도 있습니다. 앉은 자세 관찰하기 휠체어 사용자의 자세를 이해하고 어떠한 지지가 필요할지 파악하는 것은 자세지지를 받지 않은 상태에서 사용자의 자세를 관찰하는 것부터 시작합니다. 신체 측정의 과정 중 앉는 자세를 관찰할 때 휠체어 사용자는 평가를 위한 침대 위에 앉아 있어야 합니다. 먼저 휠체어 사용자의 양 발이 지지되어 있으며 안전하게 앉아 있는지 확인합니다. 휠체어 사용자가 혼자서 앉는 것이 불가능한 경우 누군가 보조를 하거나 가족/보호자가 사용자와 함께 앉도록 해야 합니다. 그런 다음 휠체어 사용자가 자세지지 없이 똑바로 앉거나 중립적으로 앉을 수 있는지 관찰합니다. 자세지지 없이 앉는 자세를 관찰하는 목적은 휠체어 사용자가 자세를 취할 때의 버릇이나 특징을 보기 위해서 입니다. 앉는 자세를 관찰하는 것은 시간과 연습이 필요한 기술입니다. 휠체어 사용자가 똑바로 앉았는지 판단하는 방법 여기서 묘사되는 똑바로 앉는 자세는 휠체어 서비스 인력에게 지침서로 쓰일 수 있습니다. 휠체어 사용자와 주문 작업을 할 때, 편안하면서 활동의 제약이 없지만 최대한 똑바로 앉는 자세를 취할 수 있도록 지지해야 합니다. 옆에서 사용자의 자세를 관찰하면서 다음의 사항들을 확인합니다: 골반이 똑바른지 확인합니다 – ASIS 와 PSIS 레벨; 몸통이 똑바른지 확인합니다; 등에 정상적인 3 가지 굴곡이 보이는지 확인합니다; 성인 – 귀, 어깨, 골반이 일직선 상에 위치하는지 확인합니다. 아동 – 귀와 골반은 일직선 상에 있지만 어깨는 다소 전방에 위치하는지 확인합니다. 앉았을 때 엉덩이가 90 도에 근접한 각을 이루는지 확인합니다; 무릎과 발목이 90 도에 근접한 각을 이루는지 확인합니다; 발꿈치가 무릎 아래에 위치하거나 약간 전방이나 후방에 위치 하는지 확인합니다; 발바닥이 바닥이나 발판에 평평하게 붙어있는지 확인합니다. 정면에서 사용자의 자세를 관찰하면서 다음의 사항들을 확인합니다: 골반 레벨 – 양쪽 ASIS 가 평평한지 확인합니다; 양 어깨가 평평하고 힘이 들어가있지 않으며, 양 팔이 자유롭게 움직일 수 있는지 확인합니다; 양 다리가 약간 벌어져 있는지 확인합니다; 고개가 똑바르게 위치하며 한쪽에 치우치지 않는지 확인합니다; 사용자의 자세 기록하기 중급 휠체어 양식에는 지지를 받지 않은 채 앉아있는 사용자의 자세를 기입할 수 있는 공간이 있습니다. 자세를 기록하는 것은 평가가 끝난 뒤 휠체어 서비스 인력이 사용자의 앉는 자세를 기억하는데 도움이 됩니다. 또한 시간이 경과함에 따라 변화하게 되는 사용자의 앉는 자세를 비교 관찰하기에도 용이합니다. 앉는 자세를 기입하는 여러 방법은 다음과 같습니다: 앉는 자세를 글로 표현합니다; 그림을 그립니다; (사용자에게 먼저 양해를 구한 이후) 사진을 촬영합니다. 아래는 앉는 자세를 기록할 때 사용할 수 있는 선으로 그려진 그림들의 예입니다. 앉는 자세를 옆에서 보았을 때의 선 그림 앉는 자세를 정면에서 보았을 때의 선 그림 기억하세요! 모든 사람들이 똑바로 앉을 수 있는 것은 아닙니다. 평가를 진행하는 동안 휠체어 서비스 인력과 사용자는 편안하게 최대한 똑바로 앉는 자세를 찾도록 함께 노력해야 합니다. 추가적인 자세지지가 있는 휠체어는 사용자가 편안하게 최대한 똑바로 앉는 자세를 취할 수 있도록 도움이 되어야 합니다. 지지를 받지 않은 채 앉아있는 자세 지지를 받지 않은 채 앉아있는 사용자의 자세를 그리거나 묘사하세요: 신체 측정–골반과 둔부 자세 관찰 골반과 둔부 자세 관찰 앉는 자세는 골반과 둔부에 따라 달라질 수 있습니다. 신체 측정 – 골반과 둔부 자세 관찰에서는 휠체어 서비스 인력은 다음의 사항을 발견해야 합니다: 정면에서 바라보았을 때 (자세지지가 있거나 없는 경우) 양 골반이 평평한지 확인합니다; 사용자의 골반이 중립적인 자세를 취하기 위해 90 도로 굽혀지는지 (몸통과 허벅지가 이루는 각도가 90 도 이상을 이루는지) 확인합니다. 이때 자세지지가 있거나 없을 수 있습니다. 만약 골반이 평평하지 않거나 둔부가 중립적인 자세로 굽혀지지 않는 경우 (몸통과 허벅지가 이루는 각도가 90 도 이상), 휠체어 서비스 인력은 더 많은 정보를 얻어야 합니다. 다음의 사항들을 알아내는 것이 중요합니다: 자세를 지지했을 때 휠체어 사용자가 중립적인 자세를 취할 수 있나요? 그렇지 않다면, 사용자가 얼마나 중립적인 자세에 근접하게 앉을 수 있나요? 만약 사용자가 중립적인 자세로 앉을 수 없다면, 다음의 이유로 인해 어려움을 겪는 것인지 확인하는 것이 중요합니다: 골반 위 (요추 부위)에서 제약이 있는 것인지 확인합니다; 골반 부위 (고관절)에서 제약이 있는 것인지 확인합니다. 휠체어 서비스 인력이 앞서 언급한 상황들을 파악하기 위해서 평가의 ‘골반과 둔부 자세 관찰’을 진행하는 것이 필요합니다. 이것은 관절가동범위 평가가 아닙니다. 본 프로그램에서 말하는 골반과 둔부 자세 관찰의 목적은 앞서 언급한 사항들을 확인하는데 있습니다. 그렇지만 더 많은 정보를 습득하기 위해서 숙련된 휠체어 서비스 인력은 관절가동범위 평가를 진행할 수 있습니다. 골반과 고관절 자세를 관찰하는 방법 준비과정: 휠체어 사용자에게 앞으로 어떤 과정이 있을지 이유와 함께 설명합니다; 평가를 위한 침대 위에 휠체어 사용자가 눕도록 합니다. (주의: 본 설명에서 골반과 고관절 자세를 관찰하는 사람을 ‘평가자’라고 표현합니다. 또한 직장 동료, 숙련된 보조, 가족, 또는 보호자와 같이 평가자를 보조하는 사람을 ‘보조’라고 표현합니다.) 골반 자세 관찰 사용자의 양 무릎을 약간 구부리고 받침대를 놓아서 골반에 힘이 들어가는 것을 방지합니다; 보조는 사용자의 아래쪽 갈비뼈 쪽 몸통을 꽉 잡아줍니다; 평가자는 엄지가 ASIS 에 오도록 골반을 조심히 잡습니다; 평가자는 양쪽 ASIS 에 위치한 양손의 엄지가 일직선 상에 위치하는지 확인합니다; 양손의 엄지가 일직선 상에 위치하지 않다면 평가자는 조심스럽게 힘을 주어 양쪽 ASIS 가 일직선 상에 위치하도록 합니다; 몸통이 움직이는 것이 느껴질 경우 보조는 이 사실을 평가자에게알립니다. 이는 ASIS 의 이동을 저항하는 힘이 들어갔음을 의미합니다; 힘을 주었을 때 골반이 얼마나 중립적인 자세에 근접했는지 확인합니다; 평가자는 중급 휠체어 평가 양식에 결과를 기록합니다. 고관절 자세 관찰 보조는 조심스럽게 사용자의 골반을 잡습니다; 평가자는 관찰하려는 반대쪽 무릎을 약간 구부려서 발바닥이 매트에 닿게 합니다. 이는 관찰하려는 쪽 둔부에 힘이 가해지는 것을 방지합니다. 반대쪽 다리는 지지를 받을 수 있습니다. 고관절 자세 관찰 평가자는 관찰하는 쪽 다리를 중립적으로 앉는 자세와 같이 구부립니다; 골반의 움직임이 감지된다면 보조는 이 사실을 평가자에게 알립니다. 이는 다리의 이동을 저항하는 힘이 들어갔음을 의미합니다; 평가자는 고관절이 얼마나 자유롭게 움직일 수 있는지 확인합니다; 평가자는 반대쪽도 동일하게 관찰하고 양쪽을 비교합니다; 평가자는 오른쪽과 왼쪽 둔부가 중립적인 자세로 구부려지는지 중급 휠체어 평가 양식에 기입합니다. 보조의 도움과 함께 평가자는 각도기를 사용하여 둔부가 얼마나 중립적인 자세에 근접했는지 기록합니다; 평가자는 고관절에 위치한 각도기의 중심점을 표시합니다. 평가자는 그림과 같이 각도기의 한쪽이 허벅지를 향하고 다른 쪽이 몸통을 향하게 합니다; 평가자는 각도기의 양쪽을 꽉 움켜쥡니다; 평가자는 오른쪽과 왼쪽 고관절 각도를 중급 휠체어 평가 양식에 기입합니다. 평가자는 또한 각도기로 잰 각도를 다른 종이에 그리거나 양식의 뒷면에 그립니다. 골반과 고관절 자세 관찰의 기록 골반과 둔부 자세 관찰의 결과를 중급 휠체어 평가 양식에 기입하세요. 양 골반이 일직선을 이루는지 체크 표시 하세요. 그런 다음 각각의 둔부가 중립적인 앉는 자세로 구부려지는지 (90 도) 체크 표시 하세요. 만약 오른쪽이나 왼쪽 (또는 양쪽) 둔부가 중립적인 앉는 자세로 구부려지지 않는다면 (몸통과 허벅지가 이루는 각도가 90 도 이상이라면), 각도를 기록하세요. 앞서 언급했듯이, 휠체어 서비스 인력은 각도기의 각도를 다른 종이에 그리거나 중급 휠체어 평가 양식 뒷면에 그릴 수도 있습니다. 중립적인 앉는 자세(몸통과 허벅지가 이루는 각이 90 도 이상인)로 굽혀지지 않고 평평하지 않은 골반과 고관절을 위한 일시적인 자세지지 양 골반이 일직선 상에 있지 않거나 고관절이 중립적인 앉는 자세(몸통과 허벅지가 이루는 각이 90 도 이상)로 굽혀지지 않으면, 휠체어를 사용할 때 중립적이지 않은 앉는 자세로 지지 받아야 합니다. 평가를 계속 진행하기 위해서 사용자가 앉아 있는 휠체어에 일시적으로 지지를 제공해야 합니다. 평가가 진행되는 동안 일시적인 자세지지는 다음과 같은 역할을 합니다: 사용자가 휠체어 위에서 더 안정적이고 균형이 유지된 체 앉을 수 있게 됩니다; 양 골반이 일직선 상에 있지 않거나 고관절이 중립적인 앉는 자세(몸통과 허벅지가 이루는 각이 90 도 이상)로 굽혀지지 않기 때문에 휠체어 사용자가 취하는 안 좋은 습관을 방지하게 됩니다; 휠체어 서비스 인력이 평가를 계속 진행할 수 있게 하며, 골반과 몸통 및 머리, 목, 다리를 포함한 사용자의 자세에 집중할 수 있게 도와줍니다. 단단한 폼 재질로 일시적인 자세지지가 만들어질 수 있습니다. 아래의 표에 각각 다른 종류의 자세 문제들에 필요한 일시적인 자세지지와 영구적인 자세지지를 설명하고 있습니다. 골반과 고관절 자세 관찰 누웠을 때 양 골반이 일직선을 이루는지 골반의 구부림은 어떤지 기입하세요. 양 골반이 일직선을 이루나요? 예□ 아니요□ 둔부가 중립적인 앉는 자세로 구부려지나요? 오른쪽 둔부: 예□ 아니요□각도: 왼쪽 둔부: 예□ 아니요□각도: 만약 양 골반이 일직선을 이루지 않거나 골반이 중립적인 앉는 자세로 구부려지지 않는다면 일시적인 자세지지를 제공하세요. 자세의 문제 일시적인 자세지지 (휠체어 사용자의 쿠션에 설치된) 영구적인 자세지지 양쪽이 일직선 상에 있지 않은 상태로 굳어진 골반 (외측으로 기울어진 상태) 높은 쪽 궁둥뼈와 허벅지 아래에 받침대를 설치합니다. 한쪽 둔부가 중립적인 앉는 자세 (몸통과 허벅지가 이루는 각이 90 도 이상)로 굽혀지지 않는 경우 중립적인 앉는 자세로 굽혀지는 쪽 허벅지와 양 궁둥뼈 아래에 받침대를 설치합니다 – 설치하기 전에 날카로운 가장자리는 사면이 되어야 합니다. 양쪽 고관절이 중립적인 앉는 자세 (몸통과 허벅지가 이루는 각이 90 도 이상)로 굽혀지지 않는 경우 좌석과 등받이 사이 각이 늘어날 수 있도록 받침대를 설치해야 합니다. 한쪽 또는 양쪽 고관절이 중립적인 앉는 자세 (몸통과 허벅지가 이루는 각이 90 도 미만)로 만들어지지 않는 상태 웨지 모양의 지지대를 궁둥뼈 앞, 양쪽 허벅지 아래에 설치합니다. 신체 측정 – 손을 이용한 시뮬레이션 손을 이용한 시뮬레이션은 휠체어 사용자에게 어떤 자세지지가 필요한지 파악하는데 도움이 됩니다. 손으로 시뮬레이션을 할 때, 휠체어 서비스 인력은 손을 이용하여 다음 사항들을 알아낼 수 있습니다: 휠체어 사용자가 자세지지를 받으면 중립적인 자세로 앉을 수 있나요? 그렇지 않다면 – 사용자가 얼마나 근접하게 중립적인 자세를 취할 수 있나요? 어떠한 지지가 어디에 필요한지 알 수 있습니다. 손을 이용하여 시뮬레이션을 하는 동안, 휠체어 서비스 인력은 사용자와 보조 또는 가족/보호자에게 손으로 자세를 지지해줄 수 있습니다. 손을 이용한 시뮬레이션 방법 손을 이용한 시뮬레이션을 할 때 다음의 사항들을 잘 기억해야 합니다: 준비 휠체어 사용자에게 앞으로 어떤 행동을 왜 할 것인지 설명합니다. 휠체어 사용자에게 단단하지만 쿠션이 있는 평평한 곳에 앉도록 합니다. 휠체어 서비스 인력과 보조 또는 가족/보호자가 사면에서 도움을 줄 수 있는 평가를 위한 상자모양 침대가 최적의 장소입니다. 자세지지 없이 사용자가 안전하게 앉을 수 없다면 보조나 가족/보호자에게 도움을 요청합니다. 사용자의 양 발이 적정 높이에서 지지 받고 있는지 확인해야 합니다. 골반이 평평하지 않거나 한쪽 골반이 중립적인 앉는 자세로 굽혀지지 않는다면 (몸통과 허벅지가 이루는 각이 90 도 이상), 이전에 언급한 임시적인 자세지지를 제공합니다. 팀워크 종종 손이 모자라는 경우가 있습니다. 동료나 숙련된 보조, 가족 또는 보호자에게 도움을 얻습니다. 가족/보호자의 도움을 받는 것이 사용자가 최종 PSD 해결책을 이해하는데 도움이 됩니다. 효과적인 대화하기 휠체어 서비스 인력은 사용자, 가족/보호자와 (가능하다면 현지 언어를 사용하여) 상냥하게 대화하여야 합니다. 휠체어 사용자가 말을 할 수 없으면 사용자와 대화하는 적절한 방법을 찾아 사용해야 합니다. 각각의 단계에서 무엇을 할 것인지 설명하는 것을 잊어서는 안됩니다. 각각의 변화를 줄 때 사용자의 피드백을 받아야 합니다. 손이 무엇을 하고 있는지 생각해야 합니다 당신의 손은 휠체어와 PSD 가 제공하게 될 자세지지를 보여주고 있는 것입니다. 손을 이용한 시뮬레이션 동안 다음의 사항들을 신경 써야 합니다: - 당신의 손이 어디에 위치하고 있는지 알고 있어야 합니다; - 자세지지의 힘이 어느 방향인지 알고 있어야 합니다; - 어느 정도의 자세지지가 사용될 것인지 알고 있어야 합니다; - 두 손이 얼마만큼의 표면적을 가지고 있는지 (예를 들어, 한 손가락을 사용하고 있는지 손바닥을 다 사용하고 있는지) 파악하고 있어야 합니다; - 손이 차갑다면 손을 이용한 시뮬레이션을 하기 이전에 따뜻하게 만들어야 합니다. 언급된 정보들은 최종 휠체어와 PSD 가 주문될 때 도움이 될 것입니다. 골반의 지지를 가장 먼저 합니다 골반의 위치는 나머지 몸의 자세에 큰 영향을 줍니다. 사용자의 골반이 평평하지 않다면 손을 이용하여 골반이 평평해질 수 있도록 합니다. 골반이 평평해졌다면 다른 부위를 다음의 순서대로 확인합니다: - 몸통/양 팔; - 머리와 목; - 둔부와 허벅지; - 양 다리. 한번에 하나의 변화만을 줍니다 늘 한번에 하나의 변화만을 줘야 합니다. 예를 들어 – 골반의 자세를 바꾸려고 할 때 동시에 몸통의 자세를 바꾸려고 하면 안됩니다. 한 부위의 자세 변화가 다른 부위에 영향을 미치는지 관찰합니다. 휠체어 사용자에게서 피드백을 얻습니다. 신체 평가 - 손을 이용한 시뮬레이션을 시작하기 휠체어 사용자 앞에 무릎을 꿇고 앉거나 쪼그려 앉습니다; 휠체어 사용자의 양 골반에 부드럽게 손을 위치시킵니다; 사용자의 골반이 평평하지 않다면 – 손을 이용하여 양 골반이 최대한 평평해지도록 합니다; 매우 강한 힘을 쓰지 않습니다; 골반이 얼마나 중립적인 자세에 가까워지는지 파악합니다; 휠체어 사용자의 골반이 중립적인 자세에 가까워짐에 따라 몸통과 둔부, 머리와 목에 어떤 변화가 생기는지 관찰합니다; 골반이 최대한 중립적인 자세에 가까워졌을 때 휠체어 서비스 인력은 몸통에는 어떤 자세지지가 필요할지 고려할 수 있습니다; 보조에게 골반을 잡아서 ‘가장 중립적인 자세’를 유지할 수 있도록 합니다; 보조에게 골반의 어느 부위를 어떻게 잡아야 하는지 상세히 설명합니다. 보조가 잘 잡고 있는지 확인한 후 다음 단계로 넘어갑니다. 몸통 자세지지 (필요한 경우): 골반의 경우와 마찬가지로 사용자의 몸통이 중립적인 앉는 자세가 아니라면, 손을 사용하여 자세지지를 제공해야 합니다. 다음의 순서로 진행합니다: 손을 사용하여 골반을 안정화시킵니다; 양 손을 사용하여 자세를 지지하여 몸통을 쫙 피고 양 어깨가 (가능한 최대한) 평평하도록 합니다; 머리와 목이 균형을 잡은 상태로 골반 위에 몸통이 똑바로 위치할 수 있도록 앞쪽과 뒤쪽에 손을 이용하여 자세를 지지합니다; 골반과 몸통의 윤곽을 좌우에서 살펴봅니다. 최적의 자세지지를 위한 등받이 설치 계획에 중요한 부분입니다. 몸통을 지지함으로써 다른 부위에 어떤 변화가 생겼는지 자세히 관찰합니다. 예를 들어 몸통의 자세지지가 머리와 목의 자세를 향상시켰습니까? 올바르게 골반과 몸통을 지지한다고 하여도 몇몇 사용자들은 고개를 가누는데 어려움을 겪습니다. 머리와 목의 자세를 바로잡기 위한 방법은 다음과 같습니다: 휠체어 사용자가 뒤로 살짝 기댈 수 있게 합니다; 그런 다음 사용자가 몸통 위에서 머리의 균형을 잘 잡는지 확인합니다; 양 팔을 위한 추가적인 자세지지를 제공합니다. 손을 이용한 시뮬레이션 동안, 몸통을 지지하는 동안 골반에는 어떠한 힘의 변화가 없었는지 보조에게 물어봅니다. 휠체어 사용자에게 피드백을 얻는 것을 잊지 말아야 합니다. 몸의 다른 부위의 자세지지 (필요한 경우) 골반과 몸통이 가장 중립적인 앉는 자세로 편안하게 지지되었다면 머리와 목, 둔부와 허벅지 및 다리의 자세들을 확인합니다. 손을 이용하여 몸의 각각의 부위가 중립적인 자세로 편하게 움직일 수 있는지 알아봅니다. 자세의 변화로 인하여 다른 부위에 영향을 끼쳤는지 확인하는 것을 계속해야 합니다. 계속해서 휠체어 사용자에게 피드백을 얻어야 합니다. 손을 이용한 시뮬레이션 결과 기록하기 손을 이용한 시뮬레이션의 결과는 중급 휠체어 평가 양식에 기록하여야 합니다. 다음의 사항들을 할 수 있는 공간이 마련되어 있습니다: 손을 이용한 자세지지로 휠체어 사용자의 각각의 부위가 중립적인 앉는 자세를 취할 수 있는지 체크표시 합니다; 손을 이용한 자세지지로 얻게 된 최종 앉는 자세를 묘사하거나 선을 이용하여 그림을 그립니다; 안정적으로 앉는 자세를 취하기 위해서 필요한 자세지지를 묘사하거나 선을 이용하여 그림을 그립니다. 손을 이용한 시뮬레이션: 편안하게 중립적인 자세 또는 최대한 중립적인 자세로 앉기 위해 필요한 자세지지 각각의 부위: 손을 이용한 자세지지로 중립적인 자세가 가능하다면 ‘예’에 체크표시를 그렇지 않다면 ‘아니요’에 체크표시 하세요. 부위 예 아니요 손을 이용한 자세지지로 얻게 된 최종 앉는 자세를 묘사하거나 선을 이용하여 그림을 그리세요. 또한 안정적으로 앉는 자세를 취하기 위해서 필요한 자세지지를 묘사하거나 선을 이용하여 그림을 그리세요. 골반 □ □ 몸통 □ □ 머리 □ □ 왼쪽 고관절 □ □ 오른쪽 고관절 □ □ 허벅지 □ □ 왼쪽 무릎 □ □ 오른쪽 무릎 □ □ 왼쪽 발목 □ □ 오른쪽 발목 □ □ 신체 측정 – 치수 측정 알맞은 휠체어 크기와 PSD 의 위치를 위해 휠체어 사용자의 치수 측정 중급 휠체어 평가 양식의 치수 측정 부분에는 12 가지의 신체 측정 목록이 있습니다. 그 중 5 가지의 신체 치수 측정은 휠체어 서비스 교육자료 – 초급에서 언급된 내용입니다. 추가적인 등받이 높이를 위한 치수 측정이 중급 휠체어 평가 양식에 추가되었습니다. 좌석에서부터 어깨까지의 치수는 휠체어 사용자의 등받이 높이를 위해 사용됩니다. 자세보조용구의 크기와 위치를 결정하는데 도움이 되는 6 가지 치수 측정이 더 있습니다. 주문된 자세보조용구에 따라서 더 많은 치수 측정이 필요할 수 있습니다. 중급 휠체어 평가 양식에는 이러한 경우를 위해 ‘기타’ 치수 측정을 위한 공간이 있습니다. 어떻게 자세보조용구와 휠체어의 크기 및 위치가 몸의 치수와 연관되어 있는지 알아봅시다 자세보조용구와 휠체어의 크기 및 위치는 측정된 부위의 치수와 연관되어 있습니다. 중급 휠체어 평가 양식에는 치수 측정이 왼쪽에 나열되어있고 측정된 각 부위와 연관된 부품이 오른쪽에 나열되어 있습니다. 예를 들어: 휠체어 사용자의 둔부 너비 (치수 측정 A)는 휠체어 좌석과 골반 측면 패드의 너비 (부품 측정 1 과 2)와 똑같습니다; 휠체어 사용자의 좌석에서 겨드랑이까지의 거리 (치수 측정 H)에서 30mm 를 뺀 거리는 쿠션에서 몸통 측면 패드/웨지까지의 최대 거리 (휠체어 부품 측정 8)와 같습니다. 위에 언급한 예들은 몸의 치수가 항상 휠체어 부품의 치수와 동일하지 않고 약간의 계산이 필요하다는 것을 보여줍니다. 몇몇 경우에는 휠체어 부품의 치수 측정을 위한 공식도 있습니다. 피팅을 하는 동안 약간의 변형이 필요할 수 있습니다. 그러나 정확한 신체 측정을 통해 첫 번째 피팅에 충분한 휠체어를 준비할 수 있습니다. 휠체어 서비스 인력이 사용자 신체의 치수를 재고 그것들을 자세보조용구의 위치와 크기에 연관시키는데 도움이 되고자 중급 휠체어 평가 양식은 다음과 같은 그림 설명을 포함하고 있습니다. 치수 측정하기 신체 치수 측정 (mm) 휠체어 부품 치수 측정 (mm) 좌석의 너비, 깊이와 발판의 높이 A 둔부의 너비 = 좌석의 너비 1 = 골반 측면 패드 사이의 거리 2 B 좌석의 깊이 (골반의 뒤에서부터 무릎의 뒤까지) L B 에서 30-50mm 를 뺀 값 = 좌석 깊이 (만약 L, R 의 길이가 다르다면 짧은 것 사용) 3 R C 종아리 길이 L = 좌석 위부터 발판까지의 거리 = 발로 운전하는 휠체어의 좌석 위부터 바닥까지의 거리 4 R 5 등받이 높이 D 좌석*에서 갈비뼈 아래까지 = 좌석 위부터 등받이 위까지의 거리 (사용자의 필요에 따라 D, E, F 의 치수를 재세요) 6 E 좌석*에서 어깨뼈 아래까지 F 좌석*에서 어깨 위까지 자세보조용구의 변형 G 몸통의 너비 = 몸통 측면 패드/웨지 사이의 거리 7 H 좌석*에서 겨드랑이까지의 L H 에서 30mm 를 뺀 값 = 좌석 위에서 몸통 측면 패드/웨지 위까지의 최대 거리 (손을 이용한 시뮬레이션으로 맞춰진 상태) 8 R I 좌석*에서 골반 위 (PSIS)까지 = 좌석 위에서 발판 증강의 중간까지의 거리 9 J 무릎 사이의 거리 = 무릎 분리 패드의 너비 10 K 좌석*에서 머리뼈의 아래까지 = 좌석 위에서 머리받이의 중간까지의 거리 11 L 골반뒤에서 궁둥뼈까지 L 에서 20-40mm 를 더한 값 = 등받이에서 궁둥뼈 앞 받침대가 시작하는 곳까지의 거리 12 기타 *신체 치수를 측정할 때, ‘좌석’은 궁둥뼈가 앉아있던 표면을 의미합니다. 어떻게 정확하게 측정할 수 있을까 치수를 측정할 때 실수를 하게 되면 큰 문제가 발생할 수 있습니다. 그러나 정확하게 치수를 측정하는 것은 어려운 일입니다. 휠체어 사용자가 매우 작거나 가만히 앉아 있지 못하거나 똑바로 앉는데 어려움이 있으면 특히 문제가 됩니다. 정확한 치수 측정을 위한 방법은 다음과 같습니다: 항상 단단한 재질로 된 테이프 자를 사용합니다 – 옷을 만들 때 쓰는 테이프 자가 아닙니다; 단단한 재질로 된 테이프 자는 잘 휘어지지 않기 때문에 정확한 치수를 잴 수 있습니다; 캘리퍼스를 사용하는 것은 치수 측정의 정확도를 높여줍니다; 손을 이용한 시뮬레이션이 진행되었을 때 취하였던 휠체어 사용자의 똑바로 (또는 최대한 똑바로) 앉은 자세에서 치수를 잽니다. 사용자가 누운 상태에서 치수를 잰다면 누워 있는 상태에서는 사용자의 치수가 늘어나기 때문에 부정확합니다. 보조의 도움으로 사용자가 똑바로 앉을 수 있도록 한 뒤 치수를 재는 것이 좋은 방법입니다. 측정 방법 휠체어 부품: 코멘트: A: 둔부 너비 좌석 (너비) 휠체어 사용자의 주머니에 아무것도 없는지 확인하세요. 사용자의 둔부나 허벅지 중 가장 두꺼운 부분의 측정하세요. 휠체어 사용자의 양 쪽에 두개의 클립보드를 대어서 정확한 측정을 할 수 있습니다. 캘리퍼스 또한 사용될 수 있습니다. 둔부 너비는 좌석의 너비 또는 골반 측면 패드 사이의 거리와 동일합니다. 골반 측면 패드가 장착된다면 휠체어 좌석은 조금 더 넓어야 합니다. 휠체어 너비를 최소로 하려고 노력해야 합니다. 추운날씨가 지속되는 나라의 경우 사용자가 두꺼운 옷을 입을 수 있으니 공간에 여유를 두어야 합니다. 측정 방법 휠체어 부품: 코멘트: B: 좌석 깊이 좌석 (깊이) 휠체어 사용자의 등에 클립보드를 대어서 정확한 측정을 할 수 있습니다. 사용자의 골반 뒤에서 사용자의 무릎 뒤까지 가상의 일직선을 재도롣 합니다. 늘 양쪽 다리를 재어야합니다. 왼쪽과 오른쪽에 차이가 있다면 휠체어 사용자가 골반이 평평한 채로 똑바로 앉아있는지 확인하세요. 그래도 차이가 있다면 더 짧은 쪽을 사용하여 휠체어를 주문하세요. 좌석의 깊이는 휠체어 좌석의 깊이보다 30-50mm 더 짧습니다. 90 도 보다 훨씬 이하로 밖에 안 구부려지는 무릎을 가진 사용자의 경우, 좌석의 깊이는 살짝 짧아져야 합니다. 아래의 텍스트 상자를 참고하세요. 골반이 뒤로 기울어져 있거나 몸통이 앞으로 굽혀져 있는 사용자 사용자의 골반이 뒤로 기울어져 있거나 몸통이 앞으로 굽혀져 있다면, 휠체어 서비스 인력은 이를 어떻게 조정할지 고민해야 합니다. 이때는 좌석의 깊이를 재는 방법을 바꿔야 합니다. 골반/몸통을 조절하기 위하여 등받이가 기울어져 있다면, 위에서 언급하였듯이 골반의 뒤에서부터 무릎의 뒤까지의 가상의 선을 측정합니다. 등받이가 기울어져 있지 않다면, 좌석 깊이 공간 내에서 자세를 지지하여 골반/몸통을 조절할 수 있습니다. 몸의 가장 뒷부분에서부터 (몸통/골반) 측정하여 그림에서처럼 충분한 좌석 깊이가 주어져야 합니다. 측정 방법 휠체어 부품: 코멘트: C: 종아리 길이 발판 (높이) 휠체어 사용자의 무릎 뒤에서 사용자의 힐 바닥까지의 거리를 재세요. (가능하다면) 사용자의 발목이 90 도 굽혀져 있는지 확인하세요. 양쪽 다리 모두 측정하세요. 사용자가 신발을 신고 있다면 가장 자주 신는 신발을 신은채로 측정하세요. 발바닥쪽 굽힘 상태로 발이 굳어져 있다면 발가락까지 재세요. 종아리 높이는 쿠션 위부터 발판까지 또는 쿠션 위에서부터 앞으로 운전을 위한 발판까지의 거리와 같습니다. 사용자가 쿠션에 앉았을 때 쿠션이 다소 내려가기 때문에 정확한 발판의 위치는 다소 변동될 수 있습니다. 피팅 과정에서 최종 변형이 생길 수 있습니다. D, E, F 등받이 (높이) D: 좌석에서부터 갈비뼈 아래까지: 사용자의 좌석에서 갈비뼈 가장 아래까지의 거리를 재세요. 갈비뼈의 아래를 찾으려면 먼저 양손을 골반 위에 위치하세요. 그런 다음 양손을 모으면서 손 측면이 위로 올라오게 하세요. 갈비뼈의 아래는 허리 바로 위에 있습니다. D, E, F 를 측정하여 등받이의 높이를 알 수 있습니다. 사용자의 필요에 따라 등받이의 높이에는 변화가 생길 수 있습니다. 평가에서 얻은 정보를 토대로 휠체어 서비스 인력은 올바른 자세를 위하여 등받이가 어느정도 높아야하는지 결정할 수 있습니다. 등받이가 기울어져 있어야 한다면, 등받이 높이는 적어도 표준이어야 합니다 (사용자의 어깨뼈 아래까지 정확한 수치). 사용자가 스스로 휠체어를 몰 경우, 어깨뼈의 운동에 제약이 없어야 한다는 것을 기억해야 합니다. E: 좌석에서 어깨뼈 아래까지: 사용자의 좌석에서 어깨뼈의 아래까지 세로로 된 가상의 선의 길이를 재세요. 어깨뼈의 아래를 찾으려면 사용자에게 어깨를 위로 으쓱 올려보라고 부탁합니다. F: 좌석에서 어깨 위까지: 사용자의 좌석에서 어깨 위까지의 거리를 측정하세요. G: 몸통 너비 몸통 측면 패드/ 웨지 (사이의 거리) 겨드랑이 바로 아래에서 몸통의 너비를 측정하세요. 몸통 너비는 몸통 측면 패트/웨지 사이의 거리와 같습니다. 몸통 측면 패드/웨지의 최종 위치는 겨드랑이 바로 아래보다 더 낮게 설치된다면 피팅 과정에서 변경될 수 있습니다. 측정 방법 휠체어 부품 코멘트 H: 좌석에서 겨드랑이 체간 측면 패드 또는 웨지 (높이) 좌석에서 겨드랑이까지 길이를 측정합니다. 좌석에서 겨드랑이까지 거리에서 30 mm 를 뺀 것이 쿠션의 윗부분과 체간 측면 패드/웨지 사이의 최대거리입니다. 이 거리는 가이드일 뿐입니다. 최종 높이는 평가와 피팅에 달려있습니다. 체간 측면 패드는 겨드랑이에 압력을 가할 정도로 높으면 절대 안됩니다. 이는 사용자를 불편하게 하며 영구적인 신경손상을 초래할 수 있습니다. 최소 30 mm 여유 공간이 항상 체간 측면 패드의 가장 윗 부분과 겨드랑이 사이에 있어야 합니다. (‘척추 측만증을 가진 휠체어 사용자를 위한 측면 체간 지지장치 측정’ 박스를 보세요) 척추 측만증(옆으로 굽은 체간)이 있는 휠체어 사용자를 위한 측면 체간 지지 측정 체간이 옆으로 굽은(척추 측만증) 휠체어 사용자는 체간 측면 패드 중 하나가 지지가 필요한 다른 쪽 측면패드 보다 낮은 위치에 있습니다. 그림에서 보이듯 한쪽 체간 측면 패드는 휘어진 부분의 가장 돌출된 지점에 위치할 것입니다. 다른 쪽 체간 측면 패드는 겨드랑이 바로 밑에 위치할 것입니다. 기억하세요. 척추 측만증을 가진 휠체어 사용자에게 체간 측면 패드를 제공할 때에는 골반 측면 패드도 양쪽에 제공해야 합니다. 측정 방법 휠체어 부품: 코멘트: I: 좌석에서 골반 위까지 (후상장골극) 골반 뒤 패드 좌석에서 골반 위까지를 측정하세요. 좌석에서 골반 위(후상장골극)까지 길이는 중간높이의 골반 뒤 패드를 놓을 때 도움이 됩니다. 골반 뒤 패드의 깊이는 평가결과에 달려있습니다. J: 무릎 사이 거리 무릎 분리 패드 휠체어 사용자가 편안한 자세에서 가장 중립적으로 무릎을 놓은 후 무릎 사이 거리를 측정하세요. 양 무릎사이의 거리는 무릎 분리 패드의 너비와 동일합니다. 거리는 휠체어 사용자의 앉는 자세에 달려있습니다. K: 좌석에서 머리 기저부까지 머리받침대 (높이) 좌석에서 머리 기저부까지를 측정하세요 좌석에서 머리 기저부까지의 길이는 머리받이를 놓을 때 도움이 됩니다. I: 골반 뒤에서 좌골까지 좌골 앞 받침대 골반 뒤에서 좌골까지를 측정하세요. 휠체어 사용자 옆에서 휠체어 사용자의 엉덩이 아래에 손(손바닥을 위로)을 넣어 좌골을 찾습니다. 한 손가락을 좌골에 놓고, 휠체어 사용자 측면으로 손을 뺍니다. 휠체어 사용자 골반 뒤에서 좌골에 위치한 손가락까지의 거리를 측정합니다. 휠체어 서비스 인력은 휠체어 사용자의 좌골 위치를 초크 등을 사용하여 평가용 침대에 표시하고, 표시 지점에서 골반 뒤까지를 측정합니다. 골반 뒤에서 좌골까지의 길이에 20 – 40 mm 를 더하면 등받이에서 전좌골 턱(pre seat bone shelf) 시작부분까지의 거리입니다. 만약 휠체어 사용자가 구축된 골반후방경사가 있거나 체간이 앞으로 굽어진 채 구축되어 있다면, 측정이 달라질 수 있습니다. (‘구축된 골반후방경사 또는 앞으로 굽은 구축된 체간을 가진 휠체어 사용’ 박스를 보세요) 3 단계: 선택 및 주문 휠체어와 방석 선택 휠체어 및 관련 보조기기의 선택은 휠체어 서비스 전달에서 세 번째 단계입니다. 이 단계에서는 휠체어 사용자가 필요한 부분과 구할 수 있는 휠체어 사이에서 가능한 최적의 조합을 찾게된다. 체간을 세우기 위해 추가적인 자세지지가 필요한 경우 다음 사항을 휠체어 주문 시에 포함시켜야 한다. 휠체어 사용자에게 가장 잘 맞는 휠체어 종류와 크기를 선택 해당 휠체어의 특이 구조를 확인 방석의 종류와 크기 선택 휠체어 사용자가 필요한 추가적인 자세보조용구(PSD) 또는 추가될 사항 선택 휄체어의 주문은 항상 사용자와 함께 결정합니다. 이 교육 프로그램에서 사용된 중급 휠체어 처방 양식에는 휠체어 사용자, 평가자(휠체어 서비스 인력), 휠체어 서비스 관리자를 포함한 세 개의 서명이 필요합니다. 휠체어와 방석 종류 휠체어 종류 휠체어를 주문할 때 휠체어 서비스 인력은 휠체어에 관한 다음과 같은 사항을 알아야 합니다. 프레임 종류 유통되고 있는 해당 휠체어의 제공 가능한 크기 및 범위 유통되고 있는 해당 휠체어의 제공 가능한 추가 선택사항 및 특징 유통되고 있는 해당 휠체어 부품의 변형 및 조절 가능한 범위 기억하세요: 신체 측정을 할 때는 ‘좌석’은 좌골이 놓이는 면입니다. 모든 수직 측정(C,D,E,F,H,I,K)에서 좌석과 쿠션 높이 변화는 해당 부품의 위치에 영향 을 줄 것입니다. 모든 휠체어 부품의 정확한 위치는 피팅때 항상 확인합니다. 이러한 지식은 휠체어 서비스 인력이 사용자에게 어떻게 가장 적절한 휠체어를 제공하고 구성할 수 있는지에 대해 도움을 줄 것입니다. 중급 휠체어 처방 양식 관련 내용을 아래에 첨부합니다. 2. 휠체어 종류, 크기, 구조 휠체어 종류 (제공 가능한 휠체어를 아래 열거합니다) 휠체어 치수 (mm) □ 좌석 너비 □ 좌석 깊이 □ 등받이 높이 □ 발판 높이 휠체어 구조 뒷바퀴 위치 기타: 기울기 프레임 종류 휠체어 서비스 인력은 지역 내에서 구할 수 있는 여러 종류의 프레임을 알아야 합니다. 예를 들어 휠체어가 세바퀴 또는 네바퀴 휠체어인지, 접이식 또는 고정형 프레임인지, 바퀴간 거리가 긴지 짧은지 알아야 합니다. 휠체어 프레임의 여러 종류에 대한 더 많은 정보는 휠체어 서비스 교육 교재 – 초급을 참고하세요. 제공 가능한 휠체어 크기와 범위 휠체어 크기는 대부분 휠체어 좌석 너비와 깊이로 설명됩니다. 휠체어 좌석 너비는 한쪽 좌석 태두리(seat rail)의 외측에서 반대쪽 좌석 태두리 (seat rail)의 외측까지를 측정합니다. 팔걸이가 좌석 태두리 (seat rail)위에 있는 경우 팔걸이 사이의 거리로 측정됩니다. 휠체어 좌석 깊이는 좌석 앞 부분에서 등받이까지의 거리로 측정됩니다. 추가로 중요한 휠체어 치수는 다음과 같습니다. 바닥에서 좌석까지의 높이 (이것은 다리로 휠체어를 미는 사 용자에게 중요한 계측 수치입니다.) 등받이 높이 제공 가능한 추가 선택사항 및 특징 추가적로 선택 가능한 특징에는 좌석, 등받이, 발판, 팔걸이, 캐스터 휠, 뒷바퀴, 자세보조용구(PSD)(예를 들어 측면 체간 패드, 머리받침대, 스트랩)가 있습니다. 부품의 변형 및 조절 가능한 범위 휠체어 서비스 인력은 지역 내에서 구할 수 있는 휠체어의 다양한 변형 및 조절 범위에 대해 알고 있어야 합니다. 이는 가장 높고 낮은 발판 설정 범위, 등받이 높이가 조절가능한지, 뒤 바퀴축 위치가 조절이 가능한지를 말합니다. 모든 조절 가능한 부품의 ‘조절 범위’를 알아보기 위해서는 가장 낮은 조절값과 가장 높은 조절값을 측정해봐야 합니다. 몇몇 수동 휠체어는 다른 휠체어보다 더 큰 조절 범위가 있을 수 있습니다. 특정 부품의 특징과 조절범위는 추가적인 지지가 필요한 휠체어 사용자에게 매우 중요 할 수 있습니다. 특히 다음과 같은 부품들은 이러한 조절 범위가 특히 중요합니다. 조절가능 발판: 대부분의 휠체어는 위아래로 조절가능한 발판이 있습니다. 몇몇 휠체어는 다음과 같은 추가적인 조절을 할 수 있습니다. 발판이 앞뒤로 움직일 수 있다. 발판 각을 크거나 작게 조절 할 수 있다. 이와 같은 조절 기능은 발이 놓여질 위치를 휠체어 사용자에 맞추어 조절 할 수 있게 해줍니다. 발받침대 올림: 발받침대를 올리면 무릎이 펴진 상태로 다리를 드는 것을 도와줄 수 있습니다. 이는 앉아 있을 때 무릎을 중립자세로 굽힐 수 없는 사용자에게 유용할 수 있습니다. 뒤로 젖혀지는 등받이(Backrest recline): 뒤로 젖혀지는 등받이는 다음과 같은 지지를 할 수 있습니다. 중립 자세로 굽힐 수 없는 고관절 (체간에서 허벅지 각이 90도 이상) 구축된 후방골반경사(fixed posterior pelvis tilt) 하부 체간이 굽은 채로 구축된 자세. 틸트기능(Tilt in space): 몇몇 휠체어는 ‘틸트’기능이 있습니다. 이 뜻은 등받이와 좌석이 함께 뒤로 젖혀진다는 것입니다. 좌석에서 등받이까지의 각은 동일하게 유지됩니다. 틸트기능은 다음과 같을 때 도움을 줄 수 있습니다. 구축된 후방골반경사에 고관절과 무릎관절이 굽어진 상태에서 구축된 경우 정상적인 앉는 자세로 앉는게 불편하고 오래앉지 못하는 경우 편안함과 안정감 증가시키기고자 할 때 단단한 좌석(Rigid seat): 몇몇 휠체어는 느슨한 좌석받침(seat base) 대신 단단한 좌석받침으로 구성되어 있습니다. 이는 다음을 제공합니다 골반과 고관절을 위한 추가적인 자세보조용구(PSD)를 설치할 좋은 기 반 느슨한 좌석받침 보다 더 나은 안정성. 이는 강한 불수의적 움직임이 있거나 무거운 휠체어 사용자에게 유용할 수 있습니다. 단단한 등받이(Rigid backrest): 몇몇 휠체어는 단단한 등받이로 구성되어 있습니다. . 단단한 좌석받침과 마찬가지로 이것은 추가적인 자세보조용구(PSD)를 세울 골격을 제공합니다. 단단한 등받이는. 느슨한/캔버스 등받이보다 더 나은 안정성을 주며 강한 불수의적 움 직임이 있는 휠체어 사용자에게 유용할 수 있습니다. 키가 크고 무거우며 늘어진 체간을 가진 휠체어 사용자를 위해 더 많 은 지지를 제공합니다.. 위 그림은 체간을 제자리에 있게 지지하는 폼이 추가된 단단한 등받이와 등받이에 볼트로 부착된 측면 지지 패드를 보여줍니다. 몇몇 휠체어는 느슨한 등받이 대신 장력 조절가능 등받이(tension adjust backrest)가 내장되어 나옵니다. 장력 조절가능 등받이는 등받이가 제공하는 지지를 쉽게 조절할 수 있게 해줍니다. 각각의 스트랩을 더 조이거나 풀어 더 많거나 적은 지지를 줄 수 있습니다. 추가적인 자세지지를 제공하기 위해 위와 같은 특징들이 다 있을 필요는 없습니다. 위에 나온 많은 특징들은 기본 수동휠체어를 변형하면 만들 수 있습니다. 지역 내에서 구할 수 있는 휠체어에 대한 정보 수집 다음 장에 있는 중급 휠체어 요약 양식은 지역 내에서 구할 수 있는 휠체어에 대한 정보 수집과 기록을 위해 쓰일 수 있습니다. 방석 종류 휠체어 서비스 인력은 주문 할 수 있는 다양한 방석 종류들을 알아야 합니다. 고려해야 할 특징은 다음과 같습니다. 방석을 구성하는 재료 방석이 압력을 완화를 시키는지 방석을 수정하기가 얼마나 간편한 지 방석 커버가 방수인지 방석에 대한 자세한 사항은 휠체어 훈련 패키지 – 초급을 참고하세요 선택된 방석 종류와 크기에 대해서는 아래에 있는 중급 휠체어 처방 양식 중 ‘방석 종류와 크기’부분을 참고하시면 됩니다. 휠체어를 수정하기 전 고려해야 할 사항 휠체어 사용자에게 필요한 지지를 제공하기 위해 휠체어를 수정해야 할 경우 휠체어 선택 시 휠체어 서비스 인력은 다음을 고려해야 합니다 - 휠체어가 잘 작동하는가? - 부품이 현지에서 조달 가능한가? 그리고 그것들이 휠체어와 호환되는가? - 만약 휠체어가 고장 나면 현지에서 수리되고 대체할 수 있는가? 3. 방석 종류와 크기 방석 종류 크기 예) 압력완화 방석 □ □ 만약 방석이 올바른 자세보조용구(PSD)를 만들기 위해 수정되어야 하면, 관련된 세부사항은 이후에 있는 중급 처방 양식에 기술하게 됩니다. 중급 휠체어 요약 양식 휠체어 이름: (사진) 제조자 / 공급자: 가능한 사이즈: 전체 무게: 묘사: 프레임 고정형/ 견고형 □ 접이식 □ 프레임 길이 등받이 느슨한/캔버스 □ 단단함 □ 장력 조정 가능 □ 좌석 느슨한/캔버스 □ 단단함 □ 장력 조정 가능 □ 방석 방석 없음 □ 평편한 폼 □ 윤곽진 폼 □ 액체형 □ 기타 □ 발판 고정형 □ 분리 가능 □ 기타: 캐스터 휠 공압 □ 지름: 단단한 □ 너비: 뒷바퀴 공압 □ 지름: 푸시림 □ 단단한 □ 너비: 조정 가능 차축 □ 단단한 내관 □ 분리 가능 □ 브레이크 짧은 레버 □ 긴 레버 □ 기타: 팔걸이 휘어있는 □ 네모난 □ 기타: 고정형 □ 분리 가능형 □ 기타: 푸시 핸들 푸시 핸들 □ 자세보조용구(PSD) 골반 스트랩 □ 종아리 스트랩 □ 어깨 벨트 □ 발 스트랩 □ 넘어짐 방지 바 □ 체간 측면 패드 □ 트레이 □ 머리받침대 □ 골반 측면 패드 □ 기타 치수, 조절 옵션과 조절 범위: 치수 (만약 휠체어가 다른 크기가 가능하면 모든 크기를 열거하세요) 조절 가능여부 조절 범위 (휠체어가 가능한 조절 범위) 가능 불가능 좌석 너비 □ □ 좌석 깊이 □ □ 좌석 높이 □ □ 등받이 높이 □ □ 등받이 기울기 □ □ 발판 높이 □ □ 발판 각도 □ □ 푸시 핸들 높이 □ □ 프레임 길이 □ □ 바퀴간 거리(wheel base length) □ □ 젖힘(recline) □ □ 틸트(tilt in space) □ □ 중급 휠체어 처방(선택) 양식 이 양식은 지지 없이 편안하게 꼿꼿이 앉을 수 없는 휠체어 사용자를 위한 휠체어, 방석, 자세보조용구(PSD)의 선택을 열거합니다. 이 양식은 휠체어 사용자 파일에 보관합니다. 1. 휠체어 사용자 정보 휠체어 사용자 이름: ______________________ 번호: _________________________ 평가 날짜: _________________________________ 피팅 날짜: _________________________ 평가자 이름: __________________________________ 2. 휠체어 종류, 크기, 구조 휠체어 종류 (구입/제공 가능한 휠체어를 아래 열거합니다) 휠체어 치수 (mm) □ 좌석 너비 □ 좌석 깊이 □ 등받이 높이 □ 발판 높이 휠체어 구조 뒷바퀴 위치 기타: 기울기 3. 방석 종류와 크기 방석 종류 크기 예) 압력완화 방석 □ 4. 자세보조용구(PSD) 및 필요한 수정사항들 자세보조용구(PSD) 체크리스트 치수를 묘사/그림으로 제공 좌 석 / 방 석 단단한 좌석 받침 추가 □ 전 좌골 턱(pre-seat bone shelf)(=3 번, 12 번) □ 전방 좌석 내림 좌□ 우□ 전방 좌석 올림 □ 골반전방경사를 위한 웨지(wedge) □ 골반 하부 높임 좌□ 우□ 골반 측면 패드(pad) (2 번) 좌□ 우□ 외측 허벅지 웨지 좌□ 우□ 외측 허벅지 패드 좌□ 우□ 내측 허벅지 웨지 (10 번) □ 무릎 분리 패드(10 번) □ 기타 □ 기타 □ 자세보조용구(PSD) 체크리스트 치수를 묘사/그림으로 제공 좌 석 /등 받 이 좌석에서 등받이 각도 □ 틸트(tilt in space) □ 등 받 이 단단한 등받이 추가 □ 골반 뒤 패드(9 번) □ 등받이 모양 조정 □ 장력 조정가능 등받이 □ 뒤로젖혀진(recline)등받이 □ 체간 측면 패드(7 번) 좌□ 우□ 체간 측면 웨지(7 번) 좌□ 우□ 기타 □ 트 레 이 / 팔 걸 이 트레이 □ 팔걸이 수정 좌□ 우□ 기타 □ 머 리 지 지 대 평편한 머리받침대(11 번) □ 곡선형 머리받침대(11 번) □ 기타 □ 하 부 다 리 지 지 발판 증강 좌□ 우□ 발판 웨지 좌□ 우□ 하부 다리 지지 좌□ 우□ 기타 □ 스 트 랩 골반 스트랩(strap) □ 종아리 스트랩 □ 발 스트랩 좌□ 우□ 어깨 벨트(belt) □ 기타 □ 5. 서명 휠체어 사용자: ____________ 평가자: ___________ 휠체어 서비스 관리자: __________________ 자세보조용구(PSD)의 선택 – 소개 자세보조용구(PSD)는 여러 디자인이 있고 휠체어 사용자에게 추가적 자세지지를 제공하기 위해 다양한 방법으로 사용될 수 있습니다. 휠체어 사용자에게 필요한 자세지지를 제공하기 위해 한번에 여러 가지 자세보조용구(PSD)를 복합적으로 사용 할 수 있다. 자세보조용구(PSD)는 무엇인가? 자세보조용구(PSD)는 추가적 자세지지를 제공하는 물리적 장치로 중급 휠체어 서비스 단계에서 핵심적입니다. 다음 제시되는 자세보조용구(PSD) 표와 자세보조용구(PSD) 참고 표는 이 교육 프로그램에 소개되는 여러 자세보조용구(PSD)를 보여줍니다. 아래 그림은 몇 가지 자세보조용구(PSD) 예시를 소개하고 있습니다. 같은 것에 대한 다른 이름들 같은 자세보조용구(PSD)라 해도 휠체어 서비스, 장소, 제조자에 따라 다른 이름을 가질 수 있습니다. 이 참고 매뉴얼에서 각 자세보조용구(PSD)에 간단한 서술적 이름을 붙였습니다. 각 휠체어 서비스 휠체어 서비스 인력, 그리고 휠체어 사용자는 그들에게 편하고 익숙한 용어를 사용할 수 있습니다. 머리받침대 어깨벨트 높은 등받이 등받이 체간 측면 패드 골반 측면 패드 골반 스트랩 무릎 분리패드 발 스트랩 스트랩 자세보조용구(PSD) 표 좌석/방석 앞 좌석 받침대 전방 좌석 내림 (한쪽) 전방 좌석 올림 전방 기울임을 위한 웨지 골반 하부 높임 골반 측면 패드 좌석/방석 좌석&등받이 외측 허벅지 웨지 외측 허벅지 패드 내측 허벅지 웨지 무릎 분리 패드 젖힘 기능(open seat to backrest angle) 틸트(tilt in space) 등받이 골반 뒤 패드 등받이 모양 조정 장력 조정가능 등받이 뒤로 젖혀진 등받이(recline) 체간 측면 패드 체간 측면 웨지 트레이 머리받침대 하부 다리 지지 트레이 평편한 머리받침대 곡선형 머리받침대 발판 높임 발판 웨지 하부다리 지지대 스트랩 골반 스트랩 전방경사 4- 포인트 스트랩 종아리 스트랩 발 스트랩 어깨 벨트 자세보조용구(PSD) 목적 규격 좌석/방석 전 좌골 턱 (pre seat bone self) 전 좌골 턱은 - 골반을 꼿꼿하게 유지되게 도와줍니다 - 골반이 앞으로 미끄러지지 않게 도와줍니다. - 앞으로 숙여진 자세로 앉아있는 경향을 감소시키도록 도와줍니다. 전 좌골 턱은 좌골 바로 앞에 위치합니다. 전방 좌석 내림 (한쪽) (lower seat front (one side)) 그림과 같이 한쪽을 전방 좌석 내림을 하면 중립 앉은 자세로 구부려지지 않는 한쪽 고관절을 안정시킬 수 있다. (체간과 허벅지 각이 90 도 이상인 경우) 좌석 내림 정도는 휠체어 사용자의 고관절 각도에 따라 정해집니다. 휠체어 사용자의 좌골 아래와 양쪽 허벅지에 균일하게 접촉(even contact)하도록 제작되어야 합니다. 전방 좌석 올림 (raised seat front) 전방 좌석 올림은 중립 앉은 자세로 벌어지지 않는 양쪽 고관절에 적용 할 수 있습니다 . (체간과 허벅지 각이 90 도 미만인 경우) 전방 좌석 올림은 몸을 뻗치게 하는 강한 불수의적 움직임이나 높은 긴장도를 줄여주는데 도움을 줍니다. 전방 좌석 올림 정도는 휠체어 사용자의 체간에서 허벅지 각에 따라 정해집니다. 휠체어 사용자의 좌골 아래와 양쪽 허벅지에 균일하게 접촉하도록 제작되어야 합니다. 전방 경사를 위한 웨지 (wedge for anterior tilt) 좌골 아래가 뒤로 기울어진 웨지는 유연(flexible)하여 교정이 가능한 전방경사 골반인 경우에 도움을 줄 수 있습니다. 웨지는 골반이 뒤로 돌아가게 (roll backwards) 해줍니다. 전방 경사를 위한 웨지는 좌골 바로 앞에까지 노여야 하고 허벅지아래 부분과 평행해야 합니다. 전방 경사를 위한 웨지를 제공 할 때는 모형 웨지를 첫 평가 때 사용합니다. 이는 휠체어 사용자가 웨지의 효과를 느낄 수 있게 해주고 휠체어 서비스 인력과 사용자가 가장 좋은 각을 찾고 웨지의 효용성을 평가할 수 있게 해줍니다. 자세보조용구(PSD) 목적 규격 골반 하부 높임 (build-up under pelvis) 골반 하부 높임은 비대칭 골반을 가진 휠체어 사용자를 도와줍니다. 올림은 - 휠체어 사용자의 안정성을 증가시킵니다. - 낮은쪽 골반의 압력완화에 도움이 됩니다. 골반 하부 높임은 높은쪽 좌골과 허벅지 아래에 위치합니다. 양쪽 좌골과 양쪽 허벅지 아래에 균일한 접촉이 있어야 합니다. 골반 하부 높임을 주문할 때는 발판의 조절이 필요할 수 있습니다. (한쪽 발판이 다른 쪽보다 높아야 할 수 있습니다.) 골반 측면 패드는 골반을 지지하는데 도움을 주고, 골반 하부 높임을 한 모든 사람에게 추가되어야 합니다. 골반 측면 패드 (pelvis side pads) 골반 측면 패드는 - 의자가 너무 넓거나,체간보다 엉덩이가 작아 골반이 측면으로 움직이는 것을 막아 줍니다. - 골반이 옆으로 기울어지는 경향을 줄여줍니다. 골반 측면 패드는 양쪽 골반에 딱 맞아야 합니다. 어른에 비해 어린이는 허벅지 사이를 더 떨어뜨린 채 앉아야 하는걸 기억하세요. 이와 같은 이유로 골반 측면 패드가 너무 앞으로 나와 어린이의 허벅지를 밀지 않게 합니다. 외측 허벅지 웨지 (outside thigh wedges) 외측 허벅지 웨지는 다음과 같은 가벼운 지지를 제공합니다 - 허벅지가 중립자세로 있을 수 있게 도와줍니다. - 휠체어 사용자의 다리가 밖으로 돌아가거나 안으로 모아지는 경향을 줄여줍니다. 외측 허벅지 웨지는 휠체어 사용자가 정지하고 있을 때와 움직일 때 허벅지가 중립자세로 있도록 지지해야 합니다. 만약 허벅지가 지속적으로 바깥쪽으로 돌아가거나 벌어진다면 더 단단한 지지가 필요할 것입니다. (외측 허벅지 패드를 보세요) 자세보조용구(PSD) 목적 규격 외측 허벅지 패드 (outside thigh pads) 외측 허벅지 패드는 단단한 지지를 제공해 휠체어 사용자의 다리가 바깥쪽으로 돌아가거나 떨어지는 것을 방지하는데 도움을 줍니다. 외측 허벅지 패드는 휠체어 사용자가 정지하고 있을 때와 움직일 때 허벅지를 중립자세로 편안하게 지지해야 합니다. 패드와 휠체어 사용자의 다리 사이에 균일한 접촉이 있어야 합니다. 내측 허벅지 웨지 (inside thigh wedge) 내측 허벅지 웨지는 다음과 같은 가벼운 지지를 제공합니다. - 허벅지가 중립자세로 있도록 도와줍니다. - 다리가 안으로 움직이거나 모아지는 경향을 줄여줍니다. 내측 허벅지 웨지는 휠체어 사용자가 정지하고 있을 때와 움직일 때 허벅지를 중립자세로 편안하게 지지해야 합니다. 허벅지 웨지가 휠체어에서 나오고 들어가는 이동동작을 방해하지 않는지 확인해야 합니다. 무릎 분리 패드 (knee separator pad) 무릎 분리 패드는 허벅지가 중립자세로 있을 수 있게 단단한 지지를 제공합니다. 무릎 분리 패드는 양쪽 다리가 안으로 모아지는 강한 경향이 있는 사람에게 매우 유용합니다. 무릎 분리 패드는 휠체어 사용자가 정지하고 있을 때와 움직일 때 허벅지를 중립자세로 편안하게 지지해야 합니다. 휠체어 사용자의 무릎과 허벅지 사이에 균일한 접촉이 있어야 합니다. 무릎 분리 패드는 사타구니에 닿지 않아야 합니다. 만약 휠체어 사용자가 무릎 분리 패드 앞으로 미끄러질 위험이 있다면 전좌골 턱과 골반 스트랩을 제공하세요. 자세보조용구(PSD) 목적 규격 좌석&등받이 등받이 젖힘 기능 (Open seat to backrest angle) 등받이 젖힘 기능은 구축된 엉덩이이나 구축된 후방경사가 있는 휠체어 사용자에게 유용합니다. 증가된 각은 구축된 자세에 알맞고, 편안함을 증가시키며 추가적으로 발생할 수 있는 자세 변화를 방지하기 위한 단단한 지지를 제공합니다. 휠체어 사용자의 양쪽 좌골, 골반 뒤, 위쪽 등과 아래쪽 등에 균일한 접촉이 있어야 합니다. 정확한 지지와 접촉을 제공하기 위해서는 외형형성이(contouring of the foam) 필요할 수 있습니다. 좌석에서 등받이 각이 벌어지면, 휠체어 사용자가 휠체어 앞으로 미끄러지지 않게 조심해야 합니다. 이것은 욕창으로 발달할 수 있는 ‘전단 (shearing)’을 유래할 수 있습니다. 틸트기능 (Seat & backrest tilt (tilt in space)) 틸트는 - 구축된 구부러진 체간을 지지한 뒤에도 머리에 부담이 가해질 경우 상체와 머리를 꼿꼿한 자세로 있도록 돕습니다. - 축 쳐진 자세로 있는 휠체어 사용자가 꼿꼿하게 체간과 머리를 둘 수 있도록 돕습니다.. 좌석과 등받이 틸트는 골반과 체간을 위한 다른 모든 지지가 효과적이지 않을 때만 시도 되어야 합니다. 최선의 틸트각을 정하기 위해 틸트의 영향과 효과를 가까이에서 관찰해야 합니다. 최종 틸트 자세에서 휠체어 사용자가 편안함을 느껴야 하고 앉은 자세는 가능한 중립자세와 가까워야 합니다. 등받이 골반 뒤 패드 (Rear pelvis pad) 자세를 꼿꼿하게 하기 위해 골반의 위에서 지지를 제공합니다.. 골반 뒤 패드는 대부분 좌골 앞 받침대와의 조합이나 골반 스트랩과 함께 제공됩니다. 골반 뒤 패드는 후상장골극(PSIS) 높이에서 골반 뒤에 단단하게 접촉되어야 하며, 꼿꼿이 앉은 자세에서 골반을 중립에 있게 합니다. 후상장골극 사이 척추뼈에 강한 압력이 없는지 확인해야 합니다. 자세보조용구(PSD) 목적 규격 등받이 모양 조절 (adjust backrest shape) 체간의 중립자세(정상곡선) 또는 체간의 구축된 비중립자세에 맞게 등받이를 조정합니다. 등받이 모양을 조절하는 다양한 방법이 있습니다. - 등받이 천을 변경하고 골반 뒤 패드를 추가하는 법 (첫 번째 그림) - 딱딱한 등받이에 모양진 폼 등받이를 제공하는 법 - 장력 조절가능 등받이를 사용하는 법 (두 번째 그림) 조절되었을 때 등받이는 하부, 중부, 상부 등과 균일한 접촉을 제공해야 합니다. 만약 중립 자세가 가능하면 등받이는 꼿꼿한 자세에서 골반을 지지해야 하고 체간의 정상 곡선을 지지해야 합니다. 만약 완벽한 중립적 자세가 불가능하다면 등받이는 가능한 가장 중립에 가깝게 휠체어 사용자를 지지해야 합니다. 장력 조절가능 등받이 (tension adjustable backrest) 뒤로 젖혀진 등받이 (backrest recline) 뒤로 젖혀진 등받이는 다음과 같이 맞추는데 도움이 될 수 있습니다. - 중립 자세로 굽어지지 않는 고관절(체간에서 허벅지 각이 90 도 이상). - 구축된 후방골반경사 - 하부 체간이 구부러진 채 구축된 자세 - 구축된 척추 전반증. - 머리를 체간 위에 배열시킬 때 . 좌골 앞 받침대, 골반 스트랩, 전좌골 턱(pre seat bone shelf)는 앞으로 미끄러지는 것을 방지하는데 도움을 줄 것입니다. 뒤로 젖혀진 등받이가 휠체어 사용자를 가능한 가장 정렬된 형태로 지지를 하는지 체크하세요. 휠체어 사용자의 등과 등받이가 동일한 접촉을 하고 있는지 확인하세요. 휠체어 사용자가 앞으로 미끄러지지 않게 체크하세요. 전좌골 턱(pre seat bone shelf), 골반 스트랩, 방석 앞 웨지는 앞으로 미끄러지는 것을 방지하는데 도움을 줄 것입니다. 자세보조용구(PSD) 목적 규격 체간 측면패드 (Trunk side pads) 체간 측면패드는 사용자의 몸이 등받이의 정중앙에 오도록 단단한 지지를 제공합니다. 만약 측면 패드를 한쪽에 했다면, 반대쪽에도 항상 측면패드를 해야 합니다. 체간 측면패드는 휠체어 사용자의 겨드랑이보다 50mm 아래에 위치해야 합니다. 또한 필요한 정도만 앞쪽으로 나와있어야 합니다. 양쪽 패드로 사용자에게 균일한 압력이 주어져야 하며, 강한 압력이 주어지는 것을 방지해야 합니다. 만약 강한 고정 압력이 필요하면 패드의 크기를 늘려서 힘을 분산시켜야 하며, 안감이 충분히 채워져 있어야 합니다.. 체간 측면패드는 가능한 얇아야 하며, 사용자의 양 팔이 자유롭게 움직일 수 있도록 설치되어야 합니다. 체간 측면웨지 (Trunk side wedges) 체간 측면웨지는 사용자의 몸이 의자 등받이의 중앙에 위치하도록 부드럽게 감싸줍니다. 적은 힘의 지지가 필요한 사용자에게 적합합니다. 체간 측면웨지는 휠체어의 사용자가 균형적으로 앉는 자세 (몸이 등받이의 정중앙에 위치하는 자세)를 취할 수 있도록 도와줍니다. 양쪽 웨지는 겨드랑이 아래에 위치해야 하며, 필요한 정도만 정면으로 나와있어야 합니다. 체간 측면패드와 골반 측면패드 (Trunk side pads used with pelvis side pads) 체간 측면패드와 골반 측면패드의 혼합은 몸이 한쪽으로 굽은(측만증이 있는) 휠체어 사용자에게 지지를 제공할 수 있습니다. 양쪽에 위치한 패드들은 환자의 등이 굽은 모양에 맞게 위치하여 양 옆에서 환자를 지지합니다. 환자의 골반이 의자의 정중앙에 위치하도록 해야하며 골반 측면패드는 양쪽에 위치하여 합니다. 유연성 있는 척추 측만증이 있는 사용자를 중립자세로 지지해 줌으로써 비대칭 골반을 교정할 수 있습니다. 앉은 자세가 유연성 있게 움직인다면 휠체어 휠체어 사용자는 중립자세로 앉을 수 있습니다. 앉은 자세가 고정되어 있다면 최대한 똑바로 앉을 수 있도록 패드를 설치해야 합니다. 양쪽 패드와 사용자 사이에 균일한 압력이 주어져야 합니다. 혹시라도 강한 압력이 주어지지 않는지 확인해야 합니다. 만약 단단한 지지가 필요하면 패드의 크기를 늘려서 힘을 분산시켜야 하며, 안감이 충분히 채워져 있는지 확인해야 합니다. 자세보조용구(PSD) 목적 규격 몰딩형 등 지지대 (moulded back supports) 몰딩형 등 지지대는 앞으로 넘어가거나 만곡 형태의 체간을 포함한 다른 체간 자세를 지지하는데 쓰일 수 있습니다. 등 지지대는 브라켓이(brackets) 또는 스트랩으로 휠체어 프레임에 고정됩니다. 이 옵션은 중급에서는 다루지 않습니다. 트레이 트레이 (tray) 트레이는 여러 방면에서 유용합니다. - 팔의 지지를 제공하여 체간이 아래쪽이나 앞쪽으로 숙여지는 것을 감소 시킬 수 있습니다. - 휠체어 사용자 몸에 가깝고 작업하거나 놀 수 있는 공간을 제공합니다. 트레이는 대부분 팔꿈치 높이에 위치합니다. 추가적인 지지를 위해 이 보다 약간 높이 위치시킬 수 있습니다. 트레이는 휠체어 사용자가 좌석에 앉았을 때 자유로운 행동을 방해하면 안됩니다. 트레이로 인하여 사용자에게 압력이 가해져서는 안됩니다. 머리받침대 평편한 머리받침대 (flat headrest) 평편한 머리 받침대는 머리가 쉴 공간을 제공하고 머리가 뒤로 넘어가지 않게 합니다. 머리 받침대는 휠체어 사용자가 움직이지 않을 때나 움직일 때 지지를 제공해야 합니다. 머리 받침대는 휠체어 사용자의 머리 기저부와 접촉해야 합니다. 머리 받침대가 올바른 맞춤을 제공하는지 체크하세요. 휠체어 사용자의 머리를 앞으로 밀지 않는지, 뒤로 넘어가게 하는 것이 아닌지 확인하세요. 휠체어 사용자의 머리 앞을 지지하는 것은 피하세요. 곡선형 머리받침대 (shaped headrest) 곡선형 머리받침대는 평편한 머리받침대보다 휠체어 사용자의 머리의 윤곽에 맞춰져 더 나은 지지를 제공합니다. 하퇴 지지대 발 받침대 올림 (footrest build-ups) 발 받침대 올림은 한쪽이나 양 쪽 발이 발 받침대에 닿지 않을 때 사용할 수 있습니다. (발 받침대가 가장 높게 조절되었을 때) 양 발 아래에 동일한 접촉이 있는지 체크하세요. 자세보조용구(PSD) 목적 규격 발 받침대 웨지 (footrest wedges) 발 받침대 웨지는 구축된 발의 비중립적인 자세를 지지하는데 두 발에 동일한 접촉이 있는지 체크하세요. 사용될 수 있습니다. 발 받침대 웨지는 발목의 추가적인 변화를 예방하는데 도움을 줄 수 있습니다 발 받침대 웨지의 목적은 휠체어 사용자의 발과 발 받침대의 접촉면을 증가시키기 위함입니다. 대부분의 발 받침대 웨지는 휠체어 사용자의 발에 지지가 필요한 정도에 따라 개별적으로 제작됩니다. 하퇴 지지대 (lower leg supports) 90 도로 구부릴 수 없는 무릎(체간과 허벅지 사이 각이 90 도 이상)을 포함하여, 하퇴의 구축된 비중립적인 자세를 지지하는데 다른 하퇴 지지대가 쓰일 수 있습니다. 다른 해결책과 피팅(fitting)은 제품(휠체어) 준비 세션에서 더 자세히 논의됩니다. 스트랩 골반 스트랩 (pelvis strap) 골반 스트랩은 골반이 제 위치에 있도록 도와줍니다. 골반 스트랩은 불수의적인 움직임을 보이거나 앞으로 미끄러지는 경향을 보이는 사람에게 유용합니다. 골반 스트랩은 전 좌골턱과 골반 뒤 패드와 결합하여 자주 쓰입니다. 골반 스트랩은 단단하고 동일한 접촉을 제공해야 합니다. 강하게 압박되지 않도록 해야 합니다. 휠체어 사용자의 허벅지와 접촉하는 부위에 패드를 붙이는 것이 중요합니다. 스트랩은 휠체어 부착지점에 따라 당겨지는 각과 방향이 영향 받을 것입니다. 45 도에서 90 도 사이에 각이 형성 될 것입니다. 가장 효과적인 각은 휠체어 사용자의 필요 정도에 따라 달라질 것입니다. 휠체어 사용자에게 가장 편안하고 효율적인 스트랩의 각도를 알아보기 위해 가능하면 시연을 해보고 평가 및 논의를 해야 합니다. 자세보조용구(PSD) 목적 규격 전방 경사 4-점 스트랩 (anterior tilt four-point strap) 전방 경사 4-점 스트랩은 전방 골반 경사가 있는 휠체어 사용자에게 지지를 제공합니다. 스트랩은 골반을 더 중립적인 앉은 자세로 유지하도록 도와줍니다. 또한 추가적인 전방 골반 경사를 예방하기 위해 지지를 제공합니다. 이 스트랩은 휠체어 사용자의 좌골 아래 전방 경사 웨지와 함께 제공될 수 있습니다. 스트랩이 좌석 프레임(레일) 아래로, 그리고 등받이 뒤로 묶여있음을 알아 두세요.. 스트랩은 배 위로 미끄러져 올라가지 않게 되어야 합니다. 욕창이 생길 위험을 줄이기 위해 두 전상장골극(ASIS)에 걸쳐 지지를 제공하는 모든 스트랩은 패드가 잘 붙어있어야 합니다. 종아리 스트랩 (calf strap) 종아리 스트랩은 하퇴가 뒤로 넘어가는 것을 방지합니다. 이 스트랩은 종종 기본적으로 휠체어에 제공됩니다. 여러 종류의 발 스트랩은 휠체어 사용자의 발을 안정 및 지지해주고 발이 앞/뒤로 움직이지 않게 도와줍니다. 발꿈치 뒤로 감싸는 발 스트랩 (foot straps-behind the heel) 발꿈치 뒤로 감싸는 발 스트랩은 발이 뒤로 미끄러지지 않게 해줍니다. 종아리 스트랩과 함께 사용하면 더 나은 지지를 제공합니다. 특히 휠체어 사용자가 신발을 신지 않는다면 발 스트랩은 균일한 압력을 주고 패드가 잘 부착되어야 합니다. 발목을 감싸는 발 스트랩 (foot straps-around the ankle) 발목을 감싸는 발 스트랩은 발이 앞으로 움직이지 않게 해주고 발꿈치가 들리지 않게 도와줍니다. 발등 위로 감싸는 발 스트랩 (foot straps-over the front of the foot) 발등 위로 감싸는 발 스트랩은 발가락이 들리지 않게 도와줍니다. 자세보조용구(PSD) 목적 규격 어깨 벨트 (shoulder harness) 어깨 벨트는 골반 지지, 몸통 지지, 좌석과 등의 경사가 효과적이지 않을 때 올바르고 꼿꼿한 체간을 유지하는데 도움을 줄 수 있습니다. 그림에서는 보여주는 어깨 벨트는 추가적인 지지를 제공하는 가슴 스트랩을 포함하고 있습니다. 가슴 스트랩은 어깨 벨트가 제자리에 있게 도움을 줍니다. 어깨 벨트는 항상 골반 스트랩과 함께 사용되어야 합니다. 골반 스트랩 없이 절대 어깨 벨트를 주문하지 않습니다. 만약 골반 스트랩 없이 사용된다면 사용자가 앞으로 미끄러질 수 있으며 이는 질식을 야기할 수 있습니다. 휠체어 사용자의 어깨를 가로지르는 끈에 적당한 패드가 있는지 체크해야 합니다. 가슴 스트랩 (그림에서 보이는)은 어깨 스트랩 이 제자리에 있게 도와줍니다. 어깨 스트랩은 사용자의 어깨보다 높거나 같은 높이에서 조여져야 합니다. 이는 벨트가 조여질 때 휠체어 사용자의 어깨 아래로 향하는 힘을 피하게 해줍니다. 중급 휠체어 처방(선택) 양식에 기록하는 자세유지장치(PSD) 중급 휠체어 처방 양식의 목적은 휠체어를 준비하는데 있어 다음과 같은 명확한 정보를 휠체어 서비스 인력에게 제공하고자 하는 것입니다. 휠체어 종류, 크기, 구조 (앞서 다룬 내용) 방석 종류와 크기 (앞서 다룬 내용) 자세보조용구(PSD) 및 필요한 변경사항 중급 휠체어 주문 양식에 더 많은 정보가 기술되어 있을 수록, 첫 피팅(fitting) 때 더 정교하고 사용자에게 알맞은 휠체어가 준비 될 것입니다. 자세보조용구(PSD)는 다양하게 주문될 수 있기 때문에, 중급 휠체어 주문 양식에서 ‘자세보조용구(PSD) 또는 수정 요구사항’ 부분은 가장 복잡한 부분이 될 수 있다. 휠체어 서비스 인력은 중급 휠체어 주문 양식의 일부분인 ‘자세보조용구(PSD) 또는 수정 요구사항’을 다음과 같은 용도로 사용할 수 있습니다. 일반적인 자세보조용구(PSD) 목록에서 주문/선택하고자 하는(체그박스를 사용하여) 자세보조용구(PSD) 를 고 릅니다. 기타 종류의 자세보조용구(PSD)는 ‘기타’란에 적을 수 있습니다. 주문(선택)한 자세보조용구(PSD) 의 모양을 보여주고 치수를 제공하는 그림을 그릴 때 추가적인 정보를 적거나 그릴 때 주의: 중급 휠체어 주문 양식은 자세보조용구(PSD)가 어떻게 만들어져야 하는지 작성하지 않습니다. 이는 휠체어를 준비하는 휠체어 서비스 인력과 평가를 진행하는 휠체어 서비스 인력간의 논의를 통해 결정될 것입니다. 아래에는 중급 휠체어 주문 양식(치수는 미포함)의 완료된 ‘자세보조용구(PSD) 및 개조제작 요구사항’부분의 두 개의 예시입니다. 자세보조용구(PSD) 체크리스트 치수를 묘사/그림으로 제공 좌 석 / 방 석 단단한 좌석 추가 □ 전 좌골턱 (=3 12 이하) 좌석 전방 더 낮춤 좌□ 우 높힌 좌석 전방 □ 전방 경사를 위한 웨지 □ 골반 하부 올림 좌□ 우□ 골반 측면 패드 (=2) 좌□ 우□ 외측 허벅지 웨지 좌□ 우□ 외측 허벅지 패드 좌□ 우□ 내측 허벅지웨지(=10) □ 무릎 분리 패드 (=10) □ 기타 □ 기타 □ 좌 석 /등 받 이 좌석과 등받이 사이 각이 벌어짐 □ 좌석과 등받이 기울임(tilt) (틸트 기능) 등 받 이 단단한 등받이 추가 □ 골반 뒤 패드 (= 9) □ 등받이 모양 조정 □ 장력 조절가능 등받이 □ 뒤로 젖혀지는 등받이 □ 체간 측면 패드(=7) 좌 우□ 체간 측면 웨지(=7) 좌□ 우 기타 □ 자세보조용구(PSD) 체크리스트 치수를 묘사/그림으로 제공 트 레 이 / 팔 걸 이 트레이 □ 팔걸이 개조 좌□ 우□ 기타 □ 머 리 지 지 대 평편한 머리받이 (= 11) □ 곡선형 머리받이 (= 11) □ 기타 □ 하 퇴 지 지 대 발 받침대 올림 좌□ 우□ 발 받침대 웨지 좌 우□ 하퇴 지지대 좌□ 우□ 기타 □ 스 트 랩 골반 스트랩 종아리 스트랩 □ 발 스트랩 좌□ 우□ 어깨 벨트 □ 기타 □ 자세보조용구(PSD)의 주문(선택) – 골반 안정화 골반을 지지하고자 여러 가지 자세보조용구(PSD)가 사용됩니다. 하나의 자세보조용구(PSD)가 사용될 수도 있지만 여러 자세보조용구(PSD)을 함께 사용하면 그 작용도 극대화 될 수 있다는 것을 기억해야합니다. 이 세션에는 골반과 관련된 여러 자세 문제와 이를 지지해줄 자세보조용구(PSD)를 살펴 볼 것입니다. 휠체어 사용자를 바르게 앉게 하기 위해서는 먼저 골반을 안정시키는 것이 중요합니다. 골반이 수직 자세가 아닐 때 체간과 고관절 자세에 변화가 옵니다. 이와 같은 이유로, 골반을 안정화시키고 지지하는 것은 휠체어 사용자가 바르게 앉을 수 있게 도와주는 가장 중요한 점입니다. 골반에 제공된 지지는 다른 부위에 필요한 지지를 줄여줍니다. 문제: 골반 후방경사 및 전방 미끄러짐 필요한 지지 골반 후방경사에서 좀 더 중립적인 앉은 자세를 취하기 위해선 대부분 두 부분에 지지가 필요하다. 골반의 뒤쪽 후상장골극 높이에서의 지지 골반의 앞쪽 좌골(좌골조면)높이에서 지지 자세보조용구(PSD) 해결책 전 좌골 턱은 좌골 앞에 지지를 제공하고 다음과 같은 도움을 줍니다. 골반의 수직이 유지되게 도와줍니다 골반이 앞으로 미끄러지는 것을 막아줍니다 구부정한 자세로 앉아있는 경향을 줄여주게 도와줍니다. 전좌골턱은 좌골 바로 앞에 위치합니다. 골반 뒤 패드는 골반 윗 부분에 지지(후상장골극 높이)를 제공해 골반을 바르게 유지 시켜 줍니다. 골반 뒤 패드와 전 좌골 턱 조합은 휠체어 사용자가 더 바른 골반자세와 안정성 있게 앉을 수 있게 자주 사용됩니다. ‘ 골반 스트랩은 불수의적 움직임을 보이거나 앞으로 미끄러지는 경향을 보이는 사람에게 추가적인 지지를 제공합니다. 골반 스트랩은 골반이 제 위치에 있게 도와 주며 전좌골턱과 골반 뒤 패드가 지속적으로 지지를 제공하게 해줍니다. 문제: 골반의 측면 경사(구축된 비수평적인 골반) 필요한 지지 더 높은 좌골과 허벅지 아래에 다음과 같은 이유로 지지가 필요합니다 휠체어 사용자의 안정성을 증가시키기 위함 더 낮은 쪽의 골반에 불안전한 압력이 가해지지 않도록 하기 위함 자세보조용구(PSD) 해결책 골반아래 지지물을 추가로 올리는 것은 다음과 같은 내용에 도움이 됩니다. 휠체어 사용자를 위한 안정감을 증가시켜 줍니다. 더 낮은 쪽의 골반에 불안전한 압력이 가해지지 않도록 해줍니다. 골반 측면 패드는 골반에 추가적인 지지를 제공하고 골반 아래 지지물을 추가 한 모든 사람에게 추가되어야 합니다. 문제: 골반이 한쪽으로 치우친 경우 서로 다른 원인으로 같은 자세가 연출 될 수 있다는 것을 염두 해야 합니다. 두 그림에서 다음과 같은 문제를 볼 수 있습니다. 앞서 본 남자와 같이 – 골반이 측면으로 기울어진 (구축된 비수평적 인 골반) 남자의 골반은 왼쪽으로 치우쳐 있습니다. 척추 측만이 있는 여자 또한 골반이 왼쪽으로 치우칠 수 있습니다. 필요한 지지 양쪽 고관절 측면을 지지해줄 수 있습니다. 자세보조용구(PSD) 해결책 골반 측면 패드 문제: 골반 전방경사(골반이 앞쪽으로 기울어짐) 아동을 위한 골반 측면 패드 제공 아동은 성인보다 허벅지가 더 벌어진 앉은 자세를 갖고 있습니다. 이러한 자세는 고관절 발달과 건강에 중요합니다. 그렇기 때문에 골반 측면 패드가 아동의 허벅지를 밀어 모와진 자세로 있지 않게 하는 것이 매우 중요합니다. 필요한 지지 지지는 두 가지 방법으로 제공될 수 있습니다 골반(전상장골극(ASIS))의 앞쪽에서 뒤로 미는 지지와 좌골 아래 좌석의 각도를 변경하여 골반을 뒤로 기울어지도록 하는 방법이 있습니다. 자세보조용구(PSD)를 이용한 해결책 전방 경사를 위한 웨지는 골반이 등받이 뒤쪽으로 기울어지도록 조장합니다. 전방 경사를 위한 웨지는 좌골 바로 앞까지 적용해야 하고 허벅지 아래는 평행해야 합니다. 전방 결사를 위한 4-점 스트랩은 골반의 위와 앞에 지지를 제공하고 좀 더 중립적으로 앉은 자세를 조장합니다. 자세보조용구(PSD)의 주문(선택)-고관절 지지 만약 지지나 보정이 제공되지 않으면, 국소적인 고관절(hip)의 구축 또는 중립적이지 않은 자세가 전반적인 골반(pelvis) 자세에 영향을 주게됩니다. 국소적 고관절 지지(Supporting the Hips) 문제: 중립적인 앉은 자세(neutral sitting posture)를 하기 위해 한쪽 고관절을 구부릴 수 없다(체간과 허벅지 사이 각이 90 도 이상) 이 문제의 임시 해결책은 양쪽 좌골과 중립적으로 앉은 자세(neutral sitting posture)를 하기 위해 구부릴 수 있는 고관절의 허벅지 아래에 추가 지지물(폼)을 놓는 방법입니다. 자세보조용구(PSD)를 이용한 해결책 한쪽 좌석 앞부분을 내림(lower seat front on one side) – 이 지지는 방석 밑에 만들어 중립적으로 앉는 자세로 구부릴 수 없는 고관절을 지지합니다 (체간에서 허벅지 각이 90 도 이상) 참고: 최종 해결책은 중립적으로 앉은 자세로 구부릴 수 없는 고관절 쪽을 각지게 오려내는 방법입니다. 오려내는 각은 휠체어 사용자 고관절의 각에 달려있습니다 – 그러므로 평가 때 확인해야 합니다. 참고: 방석에 전 좌골턱은 아직 있습니다. 문제: 양쪽 고관절을 중립적인 앉은 자세로 구부릴 수 없다. (체간과 허벅지 사이 각이 90 도 이상) 이 문제의 일시적인 해결책은 양쪽 좌골 아래를 높이는 것(폼을 놓는 것) 입니다. 하지만, 휠체어 사용자가 휠체어 앞으로 미끄러지는 경향이 있어 이는 영구적 해결책이 될 수 없습니다. 자세보조용구(PSD) 해결책 착석에서 등받이 각이 조절되게 체간 허벅지 각의 범위를 더 크게 해줍니다. 좌석과 등받이 사이 각은 휠체어 사용자의 체간에서 허벅지 각에 따라 달라질 것이며, 이것은 평가 때 결정되어야 합니다. 가능한 영구적 해결책은 휠체어 사용자가 휠체어 앞으로 미끄러져 나가지 않게 하는 전좌골턱과 골반 스트랩 입니다. 문제: 한쪽 또는 양쪽 고관절을 앉은 자세에서 중립으로 펼 수 없다 (체간과 허벅지 사이 각이 90 도 이하) 이문제의 일시적인 해결책은 중립적으로 앉은 자세로 펼 수 없는(체간에서 허벅지 각이 90 도 이하) 허벅지 아래에 추가 지지물(단단한 폼의 웨지)을 놓는 방법입니다. 자세보조용구(PSD) 해결책 좌석 전방 올림 – 가능한 영구적인 해결책은 좌석 전방 올리는 법/ 허벅지 아래 좌골 앞에 웨지를 놓는 방법입니다. 이는 등받이와 좌석 사이 각을 줄여줍니다. 좌석전방을 올리는 정도는 휠체어 사용자의 체간에서 허벅지 각에 따라 달라질 것이며, 이것은 평가 때 결정되어야 합니다. 참고: 양쪽 좌골은 수평 면에 앉아야 합니다 자세보조용구(PSD)의 처방(선택) – 체간 지지 항상 먼저 골반을 안정화 시키고 체간을 지지해야 되는 점을 고려해야 됩니다. 많은 사람들의 체간과 관련된 자세 문제는 좋은 골반 지지로 개선되거나 해결될 수 있습니다. 체간 지지 문제: 구부정한 자세 - 체간은 앞으로 골반은 후방경사 자세 필요한 지지 최대한 중립적인 앉은 자세가 되도록 골반을 지지 체간이 자연스러운 만곡 형태가 되도록 등받이 지지 간혹 체간 전방에 지지가 필요 불수의적인 움직임, 높은 근 긴장도 또는 경련을 줄여주는 방법 몇몇 휠체어 사용자들은 좌석 전방을 올려 체간에서 허벅지 각을 중립적 각보다 더 작게하는 것이 불수의적인 움직임, 높은 근 긴장도, 경련을 줄여주는데 도움이 됩니다. 중요 - ‘웨지’의 시작은 항상 휠체어 사용자 좌골 앞에 있어야 합니다. 좌골은 평평한 면에 앉아야 합니다. 자세보조용구(PSD) 해결책 다음과 같은 방법으로 골반지지가 가능합니다 전좌골턱 골반 뒤 패드 골반 스트랩 (항상 필요한 것은 아닙니다) 골반 측면 패드 (항상 필요한 것은 아닙니다) 다음과 같은 방법으로 등받이 지지가 가능합니다. 등받이 모양 조절 – 체간을 위한 공간을 제공하고 등이 자연스러운 만곡 형태에 따라 등받이 모양 조절을 사용할 수 있습니다. 만약 등받이가 직선으로 위를 향하 기만 하면, 이는 휠체어 사용자를 앞으로 밀 것입니다. 이 등받이 모양의 수정은 자세보조용구(PSD) 해결책의 일부분입니다. 다음과 같은 방법으로 추가적인 지지가 가능합니다. 트레이 – 트레이는 휠체어 사용자의 체간을 바른 자세로 유지하는데 추가적인 지 지를 제공할 수 있습니다. 어깨 벨트 – 쉽게 처지거나 앞으로 숙여지는 휠체어 사용자를 위해 어깨 벨트가 도움을 줄 수 있습니다. 좌석과 등받이 기울임 – 다른 자세보조용구(PSD)를 함께 사용해도 좀 더 바른 앉 은 자세를 제공하지 못할 때, 좌석과 등받이가 같이 뒤로 기울어지면 도움을 줄 수 있습니다. 등받이는 척추의 자연스런 만곡을 따라야 합니다. 척추의 자연스런 만곡을 지지하는 윤곽 형태가 없고 직선이며 직각인 등받이는 대부분 다음과 같은 결과를 냅니다. 체간의 위쪽을 앞으로 밉니다. 휠체어 사용자로 하여금 골반을 앞으로 밀어 등받이에 등을 기대게 합니다. 많은 표준형 휠체어가 수직형태의 등받이가 부착되어 있습니다. 휠체어 사용자가 중립적인 자세로 편안하게 앉을 수 있도록 지지물에 대해 일부 수정이 필요할 수도 있습니다. 문제: 구부정한 자세 - 구축된 골반 후방경사와 체간이 앞으로 굽은 자세 필요한 지지 가능한 한 가장 중립적인 앉은 자세에서 골반을 지지 가능한 한 가장 중립적인 앉은 자세에서 체간 지지를 위한 등받이 지지대와 개선된 머리 정렬을 제공(앞을 더 잘 볼 수 있게) 자세보조용구(PSD) 해결책 얼마나 많은 조정이 필요하며 어떤 종류의 휠체어가 이용 가능한지에 따라 해결책은 달라집니다. 몇 가지 추천사항은 다음과 같습니다. 골반지지 전좌골턱 골반 뒤 패드와 구축된 골반 후방경사를 지지하고 받쳐주기 위해 좌석에서 등 받이 각도를 넓히는 것. 골반 스트랩 (항상 필요한 것은 아닙니다) 등받이 지지대 뒤로 기울어지는 등받이 : 구축된 체간의 만곡의 공간을 제공하고자 뒤로 기울 어지는 등받이를 사용할 수 있습니다. 이는 머리와 목의 더 나은 정렬을 만드 는데 도움을 줍니다. 이 해결책은 구축된 골방 후방 경사를 받쳐줄 수 있습니 다. (참고: 단단한 등받이에는 천이 씌워진 폼을 추가해야 합니다) 등받이 모양 조절 : 체간을 위한 공간을 제공하고, 자연스러운 만곡의 등 모양 에 맞도록 조절하여 사용 할 수 있습니다. 추가적인 지지장치 트레이 어깨 벨트 좌석과 등받이 기울어짐(tilt) 자세보조용구(PSD) 해결책을 이 순서로 생각하세요 골반과 고관절 → 체간 → 머리와 목 → 다리 문제: 체간이 한쪽으로 기대거나 기울어지는 자세 필요한 지지 골반 안정화 체간 측면에 지지 제공 자세보조용구(PSD) 해결책 체간 측면 웨지 – 휠체어 사용자의 체간이 등받이 중앙에 유지될 수 있게 가볍고 완만한 지지를 제공합니다. 체간 측면 패드 – 체간 측면 지지는 체간이 등받이 지지의 중앙에 유지될 수 있게 강하고 견고한 지지를 제공합니다. 만약 한 쪽에 측면에 패드가 있다면 반대편에도 항상 있어야 합니다 – 높이가 서로 다를 수 있습니다. 문제: 구축된 또는 유연성 있는 척추 측만 자세 필요한 지지 한 쪽 만곡의 정점(가장 돌출 된 지점)과 반대 쪽 만곡의 가장 위 부분과 아래 부분에 지지가 필요합니다. 자세보조용구(PSD) 해결책 골반 측면 패드와 결합된 체간 측면 패드 만약 자세가 유연성이 있으면, 이와 같은 지지로 휠체어 사용자는 중립적인 자세로 앉을 수 있습니다. 만약 자세가 구축되었다면, 가능한 한 중립적인 앉은 자세에서의 지지가 편안할 수 있습니다. 유연성이 있는 척추측만증인 휠체어 사용자에게 중립적인 앉기 자세에서 지지를 제공하면 유연성이 있는 불균형 골반이 교정될 수 있습니다. 자세보조용구(PSD)의 처방(선택) – 머리, 허벅지, 하퇴 지지 머리지지 문제: 머리가 뒤로, 앞으로, 옆으로 쉽게 떨어지는 자세 필요한 지지 머리받침대를 제공하기 전에 항상 먼저: - 휠체어 사용자의 골반을 안정화해야 합니다 - 체간이 안정화되고 골반의 균형을 맞추기 위해 적합한 체간 지지가 제 공 되어야 합니다 만약 휠체어 사용자가 지속적으로 머리를 똑바로 들고 있기가 어렵다면 - 먼저, 두개골 기저부에 지지가 제공되어야 합니다 - 만약 휠체어 사용자의 머리 측면에 필요한 지지가 확장될 수 있습니다 자세보조용구(PSD) 해결책 많은 종류의 머리받침대가 있습니다. 가장 자주 쓰이는 두 가지 머리받침대는 평편한 것과 곡선형 머리받침대 입니다. 평편한 머리받침대 – 평편한 머리받침대는 머리지 지를 제공하는 곡선형 등받이의 연장선입니다. 평편한 머리받침대는 머리 가 안정을 취할 수 있는 공간과 뒤로 떨어지는 것을 방지합니다 곡선형 머리받침대 – 곡선형 머리받침대는 머리의 기저부를 감싸는 모양을 하고 있습니다. 머리의 측면에 지지를 제공하고자 머리받침대가 옆으로 연장되고 앞으로 나올 수 있습니다. 곡선형 머리받침대는 휠체어 사용자 두개골의 기저부가 곡선형으로 인해 평편한 머리받침대보다 더 많은 지지를 제공합니다. 허벅지 지지 문제: 다리가 외측으로 벌어진 자세(외전) 필요한 지지 먼저 휠체어 사용자의 골반과 체간에 필요한 지지물을 제공 함으로써 안정화시켜야 합니다. 이는 다리가 좀 더 중립적인 앉은 자세로 되는데 도움이 될 수 있습니다. 허벅지 외측을 지지합니다. 자세보조용구(PSD) 해결책 외측 허벅지 웨지는 가볍고 완만한 지지를 제공할 것입니다 참고: 이 그림에는 외측 허벅지 웨지가 방석의 단단한 폼 층 위에 추가되었습니다. 단단한 폼은 전좌골턱에 내장되어있습니다. 부드러운 층의 폼이 전체 방석 위에 추가되어야 합니다. 외측 허벅지 패드는 강하고 견고한 지지를 제공할 것입니다. 참고 : 이 그림에는 허벅지 패드가 브라켓에 연결된 나무 좌석면에 부착되어 있습니다. 나무 좌석에는 방석이 놓일 자리가 있습니다. 문제: 다리가 내측으로 모아진 자세(내전) 필요한 지지 먼저 휠체어 사용자의 골반과 체간에 필요한 지지물을 제공함으로써 안정 화시켜야 합니다. 이는 다리가 좀 더 중립적인 앉은 자세로 되는데 도움이 될 수 있습니다. 허벅지 내측과 무릎 내측을 지지합니다. 자세보조용구(PSD) 해결책 내측 허벅지 웨지는 가볍고 완만한 지지를 제공할 것 입니다 머리받침대를 제공할 때 휠체어 사용자의 머리를 위한 머리받침대를 제공할 때, 머리의 자세는 골반과 체간의 좋은 자세에 달려있다는 사실을 항상 기억해야 합니다. 휠체어 사용자의 머리 앞에 지지물을 제공하는 것은 피하세요. 노트: 이 그림에는 내측 허벅지 웨지가 방석의 단단한 폼 층 위에 추가되었습니다. 단단한 폼은 전좌골턱에 내장되어있습니다. 부드러운 층의 폼이 전체 방석 위에 추가되어야 합니다. 무릎 분리 패드는 강하고 견고한 지지를 제공할 것 입니다. 참고 : 이 그림에는 무릎 분리 패드가 브라켓으로 나무 좌석 바닥에 붙어있습니다. 나무 좌석에 방석이 놓일 자리가 있습니다. 하지 및 발 지지 문제: 한쪽 또는 양쪽 무릎을 구부릴 수 있으나 중립적인 앉은자세 보다 작은 각도로 구축된 자세 (체간과 허벅지 사이 각이 90 도 이상) 해결책은 휠체어 사용자 개개인의 요구에 달려있습니다. 자세보조용구(PSD) 해결책 만약 가능하면 발 받침대를 뒤로 조절합니다 만약 가능하면 발 받침대의 각을 발에 맞게 조절합니다. 만약 불가능하면 발 받침대 웨지를 사용합니다. 지지와 보호를 위해 하퇴 앞에 스트랩을 제공합니다. 만약 좌석의 앞부분이 휠체어 사용자 다리의 뒤를 밀면, 좌석을 약간 줄이고 방석을 뒤로 비스듬하게 놓는 것이 필요할 것입니다. 키가 큰 휠체어 사용자는 좌석 앞을 올리거나 좌석과 등받 이를 젖히는 것을 고려해야 합니다. 이를 함으로서 휠체어 사용자의 다리는 더 높 아지고 더 앞에 있으니 표준 발 발 받침대의 조절 범위 안에 들어올 수 있습니다. 참고: 위에 조절사항을 이행할 때 앞바퀴가 발받침대나 휠체어 사용자 다리에 부딪히지 않고 돌 수 있는지 체 크해야 합니다. 만약 이 조절사항들이 이용 가능한 휠체어에서 가능하지 않거나 충분한 조절을 제공하지 못하면, 몇 가 지 변경사항이 필요합니다. 문제: 중립적인 앉은 자세로 한쪽 또는 양쪽 무릎을 구부릴 수 없는 자세 자세보조용구(PSD) 해결책 가능하다면 표준 거상 발걸이(standard elevating leg rest)를 제공합니다. 가능하다면 발받침대를 앞으로 조절합니다 가능하다면 세 바퀴 휠체어(3-wheeled)를 제공하는 걸 고려해봐야 합니다. 발받침대를 수평 중앙 바 위에 추가합니다. 나무나 금속을 덧대어 발받침대를 앞으로 확장합니다. 발받침대 길이를 더 앞으로 확장합니다 – 이는 용접을 필요로 하고 금속가공에 뛰 어난 기술지식과 기술을 가진 사람만이 행해야 합니다. 참고 : 어떤 해결책을 선택하던 전체 휠체어 길이는 최소화하는 것이 중요합니다. 4 단계: 재원과 주문 재원과 주문에 대한 종합적인 정보는 4단계: 휠체어 서비스 교육 교재 ‘재원과 주 문’ – 초급 참조 매뉴얼에서 볼 수 있습니다. 5 단계: 제품(휠체어) 준비 제품(휠체어) 준비 제품(휠체어) 준비는 휠체어 서비스 전달 과정에서 다섯 번째 단계입니다. 제품(휠체어) 준비는 휠체어설치와 선택된 자세보조용구(PSD)를 준비하는 것을 의미합니다. 중급 교육 프로그램에서는 대부분 휠체어를 피팅(fitting)이 필요하기 전의 일정 시점까지 밖에 준비하지 못합니다. 휠체어 서비스 단계 ‘제품(휠체어) 준비’와 ‘피팅(fitting)’은 휠체어가 잘 맞을 때까지 반복되어야 합니다. 첫 피팅(fitting) 전까지는 대부분 자세보조용구(PSD) 를 임시로 부착합니다. 이는 피팅(fitting) 이후에 휠체어와 자세보조용구(PSD) 에 수정사항이 있을 수 있기 때문입니다. 추가적인 자세지지는 여러 방법으로 제공될 수 있습니다. 몇 가지 해결책은 매우 간단하고 간단한 워크샵에서 만들 수 있습니다. 다른 해결책은 좀 더 복잡할 수 있으며 더 많은 기술과 시설이 필요합니다. 휠체어 서비스 인력은 자세보조용구(PSD) 자체를 제작하지 않아도 됩니다. 휠체어 서비스 인력은 기술자와 협력해서 일을 할 수 있습니다. 휠체어 서비스 인력은 기술자에게 무엇을 만들어야 하고 어떻게 작동해야 하는지 설명 할 수 있고, 기술자는 지역 내에서 조달 가능한 재료로 이것을 만들 수 있습니다. 휠체어 서비스 인력은 지속적으로 개입하여 최종 제품이 의도한대로 휠체어 사용자의 요구에 맞게 제작되도록 반드시 제작과정 지침을 제시해야 합니다. 종종 같은 지지를 받을 수 있는 다른 자세보조용구(PSD) 해결 방법이 있습니다. 일반적으로 해결 방법은 사용 가능한 자원에 달려 있습니다. 이는 다음과 같습니다. 이용 가능한 휠체어 종류 – 어떤 조절이 가능한지 가능한 재료 가능한 워크샵 시설과 도구 미리 만들어진 지지장치를 이용가능한지 – 예를 들어 골반 측면 패드, 체간 측면 패드, 스트랩과 머리받침대. 휠체어와 자세보조용구(PSD) 준비 계획과 실행 계획과 준비 휠체어 준비를 시작하기 전에 계획을 세우는 것이 중요합니다. 휠체어 준비가 다른 이에게 양도되거나 (예를 들어 워크샵에서 일하는 기술자에게) 또는 한 사람 이상이 휠체어를 준비하면 세심한 계획이 특히 중요합니다. 계획과 준비 과정은 다음과 같은 단계를 거칩니다. 중급 휠체어 처방(선택) 양식 검토: 양식에 있는 모든 정보를 모든 사람이 이해했는지 확인하세요 휠체어 준비를 할 수 있는 충분한 정보가 양식에 있는지 확인하세요. 예를 들어 필요한 모든 치수가 있나 요? 여러 자세보조용구(PSD) 의 설명이 충분히 자세한가요? 추가적인 상의 또는 설명이 필요한가요? 선택된 휠체어에 필요한 지지를 어떻게 구성할지 결정하기 사용할 휠체어를 보고 다음과 같이 물어보세요 - 필요한 지지를 제공하려면 실제 휠체어에 어떤 조절을 해야 하나요? - 어떤 자세보조용구(PSD) 가 이미 휠체어에 있나요? 만약 수정사항 또는 자세보조용구(PSD) 가 추가되어야 하면 다음을 결정하세요 - 사용 가능한 미리 만들어진 지지장치가 있나요? 있다면 어떻게 휠체어에 맞출 건가요? - 만약 수정사항 또는 자세보조용구(PSD) 가 원재료에서부터 만들어져야 하면 어떤 재료를 사용할 것이고, 자세보조용구(PSD) 는 어떻게 휠체어에 고정될 건가요? 어떻게 자세보조용구(PSD)와 휠체어가 같이 작동할지 생각하는 것을 기억하세요. 업무 리스트 준비하기: 휠체어를 준비하는데 수행해야 되는 업무 리스트를 작성하세요. 만약 한 사람 이상이 일을 하면 누가 어떤 업무를 담당하는지 결정하세요. 자세보조용구(PSD)를 만들 때 기억해야 하는 점 추가적인 자세 지지가 필요한 휠체어를 준비할 때 다음 네 가지 팁을 기억하세요. 1. 자세보조용구(PSD)는 적절한 지지를 제공해야 합니다 각각의 휠체어 사용자가 필요로 하는 지지는 달리합니다. 자세보조용구(PSD)는 개개인의 휠체어 사용자가 필요로 하는 지지를 적재적소에 제공해야 합니다. 2. 자세보조용구(PSD)와 휠체어는 전체 시스템처럼 같이 사용해야 합니다. 자세보조용구(PSD)를 휠체어에 추가하는 것은 전체를 바꿀 수 있습니다. 예를 들어 자세보조용구(PSD)를 추가하는 것은 휠체어 내부 치수를 바꿀 수 있습니다 . 3. 압력이 심한 부위가 생기지 않도록 해야 합니다. 자세보조용구(PSD)는 휠체어 사용자 몸의 특정 부분에 압력을 가할 수 있습니다. 예를 들어 만약 휠체어 사용자가 측면으로 기우는 것을 방지하기 위해 많은 지지가 필요한 경우, 체간 측면 패드 또한 심한 압력을 받는 부위가 될 수 있습니다. 이런 상황에는 표면적을 넓혀 압력을 받는 부위를 분산시키는 것을 고려해야 합니다. 항상 자세보조용구(PSD)와 스트랩 말단에 충분한 패드가 있는지 확인해야 합니다. 4. 자세보조용구(PSD)는 유용하고 사용자의 기능을 감소시키지 않게 합니다. 기억하세요 – 휠체어 사용자는 유용하고 사용하기 쉬우며 그들을 가능한 가장 활동적이게 해줄 수 있는 휠체어와 좌석을 필요로 합니다. 워크샵 안전 – 다섯 가지 안전 수칙: 워크샵에서는 발가락이 덮인 신발을 신으세요. 자르거나 구멍을 뚫을 때는 작업하는 것을 고정하세요 – 지그를 사용하거나 도움을 요청하세요. 전동 공구나 날카로운 도구를 사용할 때는 보안경을 사용하세요. 작업 영역과 통로를 정돈하고 깨끗하게 유지하세요 본인을 향해서나 남을 향해서 절대 자르지 마세요. 자세보조용구(PSD)와 수정하기 위해 필요한 재료와 도구 아래 표는 자세보조용구(PSD)를 만들기 위해 필요한 재료의 예시를 보여줍니다. 재료 자세보조용구(PSD) 및 변경사항에 쓰일 수 있는 재료 자세보조용구(PSD) 및 변경사항을 위한 재료를 선택할 때 볼 부분 금속/ 플라스틱/ 목재 금속/ 플라스틱/ 목재는 자세보조용구(PSD)의 구조를 구성합니다. 예) 딱딱한 좌석과 등받이 목재 또는 금속은 체간 측면 패드를 등받이에 부착시키는 브래킷으로 쓰일 수 있습니다. 12 mm 합판은 딱딱한 좌석과 등받이를 만드는데 매우 유용합니다. 이는 단단하나 상대적으로 가볍습니다. 마린 합판 (marine ply)이 가장 내구성이 좋으나 좀 더 비쌀 수 있습니다. 만약 가능하다면 3 mm 알루미늄 판과 6 mm 아크릴 또는 ABS 플라스틱 판 또한 딱딱한 등받이로 사용 될 수 있습니다. 주름을 판에 넣으면 강도를 더할 수 있습니다. 판 재료를 사용할 때는 휠체어 사용자의 안전을 위해 날카로운 가장자리를 없애거나 패드를 추가하여 좀 더 조심해야 합니다. 폼/ 패드 폼은 휠체어 사용자의 몸에 직접적으로 닿는 모든 자세보조용구(PSD)에 쓰입니다. 모양을 유지하는 단단한 폼은 적절한 지지를 제공하기 위해 필요한 자세보조용구(PSD)의 모양을 만듭니다. 부드러운 폼은 편안함과 압력을 줄이는데 쓰입니다. 폼이 쓰이는 예시는 다음과 같습니다. 폼은 압력을 분산시키고 편안 함을 위해 스트랩에 부착되어 야 합니다. 단단한 폼은 체간 측면 웨지 나 방석에 추가되어 외측 허 벅지 웨지 또는 내측 허벅지 웨지로 사용될 수 있습니다. 매우 단단한 폼(예: EVA)은 발 판 증강, 발판 웨지, 체간 측 면 패드로 사용될 수 있습니 다. 지역 안에서 구할 수 있는 폼을 찾기 위해 지역 시장과 폼, 신발, 매트리스, 가구 공장을 찾아봐야 합니다. 다른 강도와 다른 두께(25 mm 와 50 mm)의 폼을 지역 내에서 찾아 봅시다. EVA 는 자세보조용구(PSD)의 구조와 단단한 지지를 제공하는 매우 단단한 폼의 예시입니다. 가끔 EVA 는 신발을 제조하는 곳에서 찾을 수 있습니다. 슬리퍼를 만들 때 쓰이는 단단한 고무는 EVA 대용으로 쓰일 수 있습니다. 좋은 질의 칩 폼 (chip foam)은 중간 정도의 단단한 폼의 예시입니다. 칩 폼은 윤곽진/층을 이룬 방석의 바닥, 골반 뒤 패드나 궁둥뼈 앞 받침대, 단단한 등받이의 윤곽을 만드는데 쓰일 수 있습니다. 부드러운 ‘매트리스 폼’은 편안함을 주는 층에 쓰이는 부드러운 폼의 예시입니다. 가장 쉽게 찾을 수 있고 싼 ‘매우 부드러운’ 폼은 단단한 폼 기틀 없이는 압력을 완화하는 방석으로 적합하지 않습니다. 코이어(코코넛 섬유)는 단단한 폼 대신 사용될 수 있습니다. 재료 자세보조용구(PSD) 및 변경사항에 쓰일 수 있는 재료 자세보조용구(PSD) 및 변경사항을 위한 재료를 선택할 때 볼 부분 천 천은 자세보조용구(PSD)를 덮는데 쓰입니다. 내구성이 좋고 세척하기 쉬운(닦을 수 있던가 또는 세척 제거 가능) 천을 찾습니다. 만약 휠체어 사용자가 실금이 있는 경우, 방수가 되는 천은 좌석, 방석, 등받이로 유용합니다. 부드러운 티셔츠 소재(면 또는 면/라이크라(Lycra))는 머리받침대, 체간 측면 패드, 체간 측면 웨지로 유용합니다. 신축성 있는 천은 자세보조용구(PSD)의 모양에 맞도록 쉽게 만들 수 있습니다.. 보통, 합성섬유는 천연섬유보다 사람을 덥게 만듭니다. 몇 가지 다른 색상을 찾도록 해보고 가능하면 휠체어 사용자에게 선택권을 줍니다. 나일론 스트랩/ 벨크로/ 버클 나일론 스트랩/ 벨크로/ 버클은 골반 스트랩, 어깨 벨트, 종아리와 발 스트랩을 만들 때 쓰입니다. 25 mm, 35 mm, 50 mm 나일론 스트랩은 유용합니다. 스트랩이 넓을수록 압력은 골고루 퍼질 것입니다. 나일론 스트랩 끝을 녹이면 해지는 것을 방지할 것입니다. 면으로 된 스트랩은 훨씬 효과적이지 않습니다. . 클립 버클(책가방에 쓰이는 것과 같은)은 매우 사용하기 쉽습니다. 좋은 질의 버클을 사용해야 오래 사용할 수 있습니다. 버클을 열고 닫아봐서 쉽게 잠그고 풀 수 있는지, 당기지 않는 이상 열리지 않는지 테스트해봐야 합니다. 벨크로는 좋은 잠금 장치이지만 깨끗하게 유지되지 않는 이상 작동하지 않습니다. 부드러운 폼의 패드를 모든 스트랩 아래에 부착해서 휠체어 사용자 몸을 보호해야 합니다. 접착제 접착제는 목재와 폼을 붙일 때 쓰입니다. 목재 접착제(흔히 화이트 접착제(white glue) 또는 PVA)와 폼 접착제(접촉성 접착제, 신발 접착제, 옐로우 접착제(yellow glue))가 있습니다. 접착제를 사용하는 사람이 올바르게 사용할 줄 아는지 확인합니다. 잠금 장치 잠금 장치는 자세보조용구(PSD)를 휠체어에 고정시킬 때 쓰입니다. 유용한 잠금 장치는 다음과 같습니다. 볼트와 너트(가급적 고정 나사), 와셔. T-너트 (너트 대신 합판을 고정) 스테이플스(staples) (덮개 고정) 만약 자세보조용구(PSD)가 파손되었을 경우 위험할 수 있 으니 날카로운 나사 사용하지 마십시오. 작업장 시설과 도구: 정기적으로 자세보조용구(PSD)를 만드는 서비스는 작업장을 세팅하는 것이 유용하다. 작업장에는 작업대, 바이스, 재료와 도구 보관장소, 밝은 조명 그리고 환기시스템이 있어야 한다. . 아래 표는 자세보조용구(PSD)를 만드는데 도움을 주는 도구의 예시를 보여줍니다. 유용한 도구 사용되는 곳 손잡이톱(hand saw) 목재, 플라스틱, 금속을 전기 없이 자를 때 사용 전기 톱(electric saw) 목재, 플라스틱, 금속을 자르는 전자 장비(올바른 날을 사용하는지 확인하세요) 드릴과 드릴 비트(Drill and drill bits) 볼트를 위한 구멍을 만들 때 사용 날카롭고 단단한 날 (sharp, rigid blade) 폼을 전기 없이 자를 때 사용 스트랩톱(band saw) 목재, 플라스틱, 폼을 자르는 전자 장비 파일(file) 목재, 금속, 플라스틱의 모서리를 다듬을 때 사용 샌딩 머신(Sanding machine) 목재, 금속, 플라스틱의 모서리를 다듬는 전자 장비 스패너(Spanners) 너트와 볼트를 조일 때 사용 공업용 재봉틀(Industrial sewing machine) 천 덮개, 스트랩을 재봉 할 때 사용 자세보조용구(PSD)를 만드는 법 다음은 이 교육 프로그램에서 다루는 자세보조용구(PSD)를 어떻게 만드는지 제안합니다. 여러 원리는 다른 자세보조용구(PSD)에 적용할 수 있습니다. 좌골 앞 받침대 좌골 앞 받침대는 단단한 폼 또는 이와 비슷한 재료와 그 위에 부드러운 폼을 놓는 식으로 구성되어 있습니다. 받침대는 단단한 좌석의 부드러운 폼 아래 또는 층을 이루고 있는 폼 방석 사이에 놓습니다. 좌골 앞 받침대는 압력완화 방석의 일부분일 수 있습니다. 좌골 앞 받침대는 좌골 바로 앞에 위치합니다. 전방 좌석 내림(한쪽) 이 자세보조용구(PSD)는 폼 방석의 수정으로 처리할 수 있습니다. 좌석 전방의 단단한 폼(부드러운 폼이 아닌)을 원하는 각으로 자르세요. 제거된 폼 조각은 좌석 앞 쪽은 두껍고 골반이나 좌골 앞은 얇은 부분을 가진 웨지 모양일 것입니다. 만약 단단한 좌석이 사용되었고 큰 각을 필요로 하면 고관절 부분을 더 확장하기 위해 좌석 판의 일부분을 자를 수 있습니다. 메모 : 다른쪽 고관절을 구부린 자세를 유지함으로써 사용자가 좌석으로 미끄러지지 않게 할 수 있습니다.. 만약 큰 각을 필요로 하면 수정하기 전에 좌석의 바닥을 단단한 폼으로 만들 필요가 있을 수 있습니다. 하지만 날카로운 모서리는 안되고 다 비스듬하게 깎여야 합니다. 높은 좌석 면이 발판이나 등받이 높이가 문제가 안될지 확인해야 합니다. 전방 좌석 올림 좌석 전방 올리는 데는 여러 방법들이 있습니다. 다음과 같이 두 가지 방법이 추천 됩니다. 방석 앞부분 아래, 골반 바로 앞 쪽 끝에 단단한 폼 웨지를 놓습니다. 천으로 된 좌석을 제거하고 단단한 좌석을 놓습니다. 브래킷으로 좌석을 필요한 각으로 올립니다. 항상 단단한 좌석에는 방석을 제공 해 주세요. 전방 기울임(틸트)을 위한 웨지 전방 기울임(틸트)을 위한 웨지는 좌골 앞 받침대와 같은 방식으로 만들 수 있습니다. 단단한 폼의 기본 층은 방석의 모양을 만들고 부드러운 층이 위를 덮고 있습니다. 웨지는 좌골 아래 있어야 하고 좌골 바로 앞에서 멈춰야 한다. 허벅지 아래 방석은 평편해야 합니다. 골반 아래 올림 골반 아래를 올리는 것은 단단한 폼 또는 이와 비슷한 재료와 그 위에 부드러운 폼을 놓는 식으로 구성되어 있습니다. 양쪽 좌골이 같은 압력을 느낄 때까지 더 높은 쪽에 쌓습니다. 골반 측면 패드 얼만큼 지지가 필요한지와 어떻게 패드가 부착될지에 따라 골반 측면 패드는 다른 방법으로 만들어집니다. 추천안은 다음과 같습니다. 만약 패드를 위해 구조와 지지를 할 수 있는 단단한 팔걸이가 있다면, 골반 측면 패드는 포장된 폼의 단단한 조각을 팔걸이에 맞대어 받침으로서 만들 수 있습니다. 팔걸이가 열려있는 있는 경우(왼쪽 그림 참고), 단단한 팔걸이는 안쪽에 부드러운 폼을 붙인 목재 조각으로 만들 수 있습니다. 그리고 나서 천으로 재봉해야 합니다. 골반 측면 패드를 휠체어 프레임에나 단단한 좌석에 브래킷으로(그림참고) 고정합니다. 왼쪽 그림에서 , 브래킷과 볼트로 고정함으로써 휠체어 사용자를 보호하고 방석은 단단한 좌석 위에 놓습니다. 외측 허벅지 웨지 단단한 폼 블록(100 mm x 100 mm x 40 mm)을 대각선으로 잘라 두 개의 웨지로 만듭니다. 이 블록들은 휠체어 피팅에 사용하기 위해 보관합니다. 부드러운 폼 아래와 방석의 바닥 폼 위에 웨지를 붙입니다. 필요하면 모서리를 다듬어 주세요. 만약 성형된 폼 방석을 사용하고 있다면, 수평으로 방석을 자르고(윗면에서 약 20 mm 정도) 그 자리에 웨지를 붙입니다. 튀어나온 폼을 다듬어 주세요. 외측 허벅지 패드 이 패드는 체간 측면 패드와 비슷한 방법으로 만듭니다. 대부분 패드는 안쪽(사용자 다리와 접촉하는 부분)은 부드러운 폼으로 이루어지고 단단한 폼이 부착된 목재, 플라스틱 또는 금속 조각으로 만듭니다. 패드는 내구성이 좋고 편안함을 느낄 수 있는 천으로 감쌉니다. 패드는 금속 브라캣으로 단단한 좌석에 고정하거나 휠체어 좌석 레일에 고정할 수 있습니다. 내측 허벅지 웨지 웨지(50 mm 폭 x 100 mm 길이)를 반으로 잘라 같은 크기의 두 조각을 만듭니다. 이 폼들을 휠체어 피팅에 사용하기 위해 보관합니다. 폼 아래와 방석 바닥 폼 위에 붙입니다. 만약 성형된 폼 방석을 사용하고 있다면, 수평으로 방석을 자르고(윗면에서 약 20 mm 정도) 자리에 웨지를 붙입니다. 튀어나온 폼을 다듬어 주세요. 무릎 분리 패드 무릎 분리 패드는 대부분 금속, 플라스틱, 목재 조각과 위, 아래, 측면(사용자와 접촉하는 면)에 단단한 폼으로 만들어져 있습니다. 얇고 부드러운 폼 또한 단단한 폼 위에 쓰여 편안함을 제공합니다. 패드는 내구성이 좋고 편안을 느낄 수 있는 천으로 감쌉니다. 만약 휠체어 사용자가 무릎 분리 패드를 필요로 하면, 단단한 좌석을 제공하는 것이 좋습니다. 무릎 분리 패드는 단단한 좌석에 L 모양 브래킷(삽화에서 보이듯)으로 고정될 수 있습니다. 휠체어 사용자가 휠체어에 타고 내리기 쉬우며 간단하고 쉬운 방법 분리하거나 젖힐 수 있는 무릎 분리 패드가 필요합니다. 등받이 젖힘(리클라인) 등받이와 좌석 사이의 각도를 더 크게 만드는(90 도이상) 한 가지 방법은 원하는 각으로 단단한 폼 웨지를 단단한 등받이에 부착하는 방법입니다. 이는 부드러운 폼 층으로 감싸야 합니다. 좌석과 등받이 기울임 (틸트 기능) 몇몇 휠체어는 좌석과 등받이를 쉽게 젖힐 수 있는 기능을 가지고 있습니다. 다음의 제안들은 이 기능이 없는 대부분의 휠체어들에 대한 것입니다. 좌석과 등받이가 단단하고 안정적이지 않은 휠체어의 경우 단단한 형태의 웨지를 방석 앞쪽에 놓고 등받이를 뒤로 젖히거나 그에 맞게 맞춥니다. 캔버스 혹은 느슨한 좌석과 등받이는 단단하고 안정적인 좌석과 등받이로 교체해야 합니다. 좌석과 등받이 모두 원하는 각도로 조절하기 위해 브래킷을 장착하도록 합니다. 항상 견고한 등받이 위에 단단한 폼을 대도록 하고 그 위에 부드러운 폼 층과 천으로 감싸도록 합니다. 단단한 좌석에는 항상 방석을 사용하도록 합니다. 이 그림은 관에 단단한 좌석 또는 등받이를 부착할 때 사용하는 브래킷의 예시를 보여줍니다. 브래킷은 잠금 장치를 돌리면 풀 수 있습니다. 이것은 이동시에 좌석과 등받이가 분리될 수 있도록 해줍니다 (접이식 휠체어의 경우) 후방 골반 패드 후방 골반 패드는 많이 깊지 않아야 합니다. 휠체어 사용자에 따라 패드의 깊이는 20 mm 에서 30 mm 가 될 수 있습니다. 후상장골극(PSIS) 높이에서 패드는 항상 지지를 해줘야 합니다. 민감한 피부를 가졌거나 척추뼈의 돌출이 두드러지는 휠체어 사용자는 척추뼈가 닿는 부위의 폼을 깎아내어 압력이 집중되는 부위가 발생하는 것을 피할 수 있습니다. 후방 골반 패드를 만드는 여러 방법은 아래와 같습니다. 후방 골반 패드는 천을 덧씌운 단단한 폼을 느슨한 천 등받이 앞으로 묶어서 만들 수 있습니다. 패드는 등받이 기둥에 스트랩으로 묶어 고정할 수 있습니다. 단단한 폼으로 만든 후방 골반 패드는 견고한 등받이 위에 부착한 후 그 위로 부드러운 폼을 한층 덮어서 제작할 수도 있습니다. 부드러운 폼 층만으로도 등받이가 휠체어 사용자에게 충분히 편안할 것입니다. 만약 그렇지 않다면, 단단한 등받이 위에 단단한 폼 층, 그리고 그 위로 후방 골반 패드를 올리고 그 위에 부드러운 폼을 덮습니다. 만약 튼튼한 스트랩에 고정되어있다면, 후방 골반 패드를 부착하여 느슨한 천 등받이 뒤에서 지지를 해줄 수 있습니다. 이와 같은 경우에는 추가적인 종아리 스트랩을 원하는 높이에서 등받이 기둥에 걸어 고정시키고 필요한 정도로 벨크로를 사용하여 조일 수 있습니다. 등받이 젖힘(리클라인) 및 등받이 모양 조절 왜 뒤로 젖혀지는 등받이가 유용할 수 있는지에 대한 여러 가지 자세적인 이유가 있습니다. 만약 조절 가능한 특성을 가지고 있지 않거나 등받이의 장력이 조절되지 않는 휠체어를 가지고 있다면 휠체어를 수정함으로써 지지를 제공할 수 있습니다. 다음은 그에 대한 두가지 방법입니다. 느슨한 등받이가 있는 휠체어는 등받이 천을 제거하고 그 자리에 원하는 만큼 젖혀진 각도로 단단한 등받이를 고정시켜 넣습니다.. 단단한 등받이는 합판으로 만들 수 있습니다. (최소 12 mm 두께). 단단한 등받이를 등받이 기둥에 부착하기 위해 조절이 가능한 브래킷을 사용할 수 있습니다. 기존의 느슨한 등받이 천을 수정합니다. 등받이 기둥 옆쪽으로 양쪽에 등받이 천을 수직으 로 자르세요. 휠체어 사용자의 체간 이 골반 윗쪽으로 이완되며 앞으로 쓰러지지 않을 때까 지 서서히 자르는 길이를 늘 립니다. 최적의 자세를 찾을 때까지 휠체어 사용자의 체 간을 뒤에서 손으로 지지합 니다. 스트랩(50 mm 너비의 나일론)을 등받이 천과 천 사이로 넣어 엮고 말단을 등 받이 기둥에 감쌉니다. 스트랩과 등받이 천을 원하는 위치에서 바 느질합니다. 말단에 벨크로가 부착되고 길이가 적당한 부가적인 종아리 스트랩은 자주 사용됩니다. 벨크로를 사용하면 스트랩의 장력이 쉽게 조절됩니다. 대안으로는 작은 구멍을 내고 줄을 사용하는 것 입니다. 부드러운 폼 조각으로 등받이 천 안의 스트랩의 위와 앞을 덮을 수 있는데 이는 등받이 지지의 윗부분에 눌려 욕창이 발생할 위험을 줄여줄 수 있습니다. 체간 측면 패드 체간 측면 패드는 충분한 지지를 제공해야 하는 동시에 휠체어 사용자의 팔 운동을 방해하지 않을 정도로 충분히 얇아야 합니다. 패드의 주요 구조물은 금속, 플라스틱, 목재를 사용해서 만듭니다. 하지만 체간 측면 패드는 항상 단단한 폼과 그 위에 부드러운 폼 층으로 덮여있어야 합니다. 폼은 패드의 내측(휠체어 사용자와 접촉하는 부분)에 있어야 하고 패드의 상부를 감싸 덮어야 합니다. 전체 패드는 내구성이 좋고 편안하게 느낄 수 있는 천으로 감쌉니다. 체간 측면 패드는 평평하거나 휠체어 사용자의 몸에 맞는 모양으로 만들 수 있습니다. 패드의 모양을 몸에 맞게 변형한다면, 단단한 폼을 깎아내어 모양을 만드는 것이 가장 쉬울 것입니다. 모양을 낸 패드는 특별한 봉제 기술이 필요하고 신축성 있는 천으로 감싸야 합니다. 체간 측면 패드를 휠체어에 고정하는 두 가지 방법은 아래와 같습니다. 체간 측면 패드는 단단한 등받이에 고정할 수 있습니다. 그 후, 단단한 폼과 부드러운 폼으로 덮습니다. 체간 측면 패드는 휠체어의 등받이 기둥에 금속 브래킷으로 고정할 수 있습니다. 몸통 측면 패드 – 얇아야 합니다 만약 몸통 측면 패드가 너무 두꺼우면(2.5 cm 이상), 패드는 팔 움직임을 제한하고 팔의 안쪽을 압박할 수 있습니다. 이는 혈액의 흐름을 저하시키고 신경을 손상시킬 수 있으며 손의 기능에 방해가 될 수 있습니다. 얇지만 필요한 지지를 충분히 제공할 수 있는 튼튼한 재료를 사용해야 합니다. 체간 측면 웨지 체간 측면 웨지는 단단한 폼으로 만들고 부드러운 폼 아래 단단한 등받이에 부착합니다. 별도의 커버가 있는 외부 웨지-모양 패드를 등받이 위에 올려 사용할 수 있으며 이를 벨크로나 스트랩을 이용해 고정할 수 있습니다. 트레이 트레이는 합판(합판의 질과 강도에 따라 10 mm 에서 18 mm)으로 만드는 것이 가장 좋으며 스트랩 또는 금속, 목재 브래킷으로 휠체어 팔걸이에 부착할 수 있습니다. 트레이를 어떻게 휠체어에 부착할 지를 결정할 때는 모든 사람이 사용하기 쉬운 방법을 찾아야 합니다. 이는 비상 시에 트레이를 빠르게 제거할 수 있어야 하기 때문입니다. (예를 들어, 휠체어 사용자가 질식하는 중일 때) 머리받침대 평평한 머리받침대 평평한 머리받침대는 높은 등받이에 포함시켜 만들거나 단단한 등받이에 브래킷을 이용하여 따로 부착할 수 있습니다. 머리받침대는 목재/플라스틱 조각에 단단한 폼을 고정하고 그 위에 부드러운 폼 한 층으로 덮어 만들 수 있습니다. 등받이에 포함되어 만들어진 이 머리받침대는 휠체어 사용자의 신체 성장이나 변화에 따라 쉽게 조절이 가능하지는 않습니다. 브래킷으로 고정한 별도의 머리받침대는 앞뒤, 높낮이 조절이 가능합니다. 곡선형 머리받침대 곡선형 머리받침대는 단단한 폼을 목재/플라스틱 조각에 고정하고 부드러운 폼이나 비슷한 재료를 덮어 만들 수 있습니다. 곡선형 머리받침대는 머리의 아래 부분을 받칠 수 있는 받침대와 측면에서 머리가 옆으로 쓰러지는 것을 방지하는 웨지들을 포함할 수 있습니다. 완성된 머리받침대를 편안한 천으로 덮습니다. 머리받침대의 커버는 편안하고 모양에 따라 신축성이 좋은 티셔츠 천으로 만들 수 있습니다. 커버는 꼭 맞게 만들거나 살짝 느슨하게 만들 수 있습니다. 그리고 커버를 조이는 끈을 만들어서 고정시킬 수 있습니다. 곡선형 머리받침대를 만드는 방법에 관한 예시는 아래와 같습니다. 목재 골격을 준비하고 머리받침대를 고정시키기 위한 브래킷 구멍을 뚫는다. 단단한 폼으로 첫 겹을 입힌다. 측면 머리 지지를 위한 단단한 폼으로 웨지를 만든다. 머리 아래쪽(두개골의 바닥부위) 부분에 맞도록 폼 롤을 만들어 머리받침대의 바닥부위를 만든다. 부드러운 폼 층을 추가시켜 머리받침대 모양을 완성한다. 완성하기 위해서는 : 휠체어에 고 정시킵니다 커버를 씌웁 니다. 발판 높임과 발판 웨지 발판 높임에 쓰기 가장 좋은 재료는 매우 단단한 폼(EVA 또는 슬리퍼 창)입니다. 목재도 쓰이기는 하지만 목재는 부드러운지 또는 파편은 없는지 그리고 압력이 집중되는 위험은 없을지 확인해야 합니다. 발판 높임 매우 단단한 폼(EVA 또는 슬리퍼 창), 목재 또는 비슷한 재료를 블록 모양(약 100 mm x 200 mm x 20 mm)으로 자릅니다. 휠체어 피팅시 사용하기 위해 이 블록들의 여분을 보관해둡니다. 블록은 필요에 따라 발판에 부착합니다. 발판 웨지 발판 높이는 블록을 대각선으로 잘라 두 개의 웨지를 만듭니다. 몇 개의 블록은 긴 쪽으로 자르고 몇은 짧은 쪽으로 자릅니다. 휠체어 피팅시 사용하기 위해 이 블록들의 여분을 보관해둡니다. 발바닥을 지지하는 발판 웨지를 발판에 필요에 따라 부착합니다. 하부다리 지지대 단단한 좌석의 앞쪽을 연장시키게 되면 곧게 편 다리를 지지할 수 있습니다. 그러나 이것은 좁은 공간에서 회전하거나 휠체어를 운송 시 접는 것을 어렵게 할 수 있습니다. 골반 스트랩 골반 스트랩은 자동차 안전벨트 또는 책가방 스트랩에서 사용되는 나일론 스트랩 (나일론 웨빙) 재료로 만들 수 있습니다. 어린이들을 위한 스트랩 너비는 약 25 mm 이고 어른의 경우는 40 - 50 mm 입니다. 클립 버클은 가장 쉽고 빠르게 풀고 잠글 수 있는 장치입니다. 만약 이 것을 이용할 수 없다면, 벨크로도 사용될 수 있습니다. 벨크로가 (휠체어 사용자의 크기에 따라) 최소 100 mm 겹쳐질 수 있는지 확인하도록 합니다. 커버로 씌여진 패드를 스트랩과 사용자 사이(특히 버클이 있는 곳)에 붙이면 더욱 편안합니다. 스트랩의 끝부분을 어느 위치에서 고정해야 할까요? 대부분의 휠체어 사용자는 그림에서처럼 골반 앞부분 바로 아래에 골 반 스트랩의 끝부분을 고정할 것입니 다. 고정시키는 부분에 따라 스트랩이 몸을 당기는 각도가 달라질 것입 니다. 바로 골반 앞부분(전상장골극 (ASIS)) 바로 아래에 부착하게 되면 몸을 좌석 면에 90도로 당기면서 잡 아줄 것입니다 (그림과 같음). 좌석 뒤 쪽에 고정하게 되면 몸을 좌석 면 에서 45도로 당겨 잡아줄 것입니다. 전방 골방 경사를 가진 휠체어 사용 자를 위해서 디자인된 스트랩을 제외 하고는 잡아주는 각도가 45도에서 90도 사이가 되어야 합니다. 만약 휠체어 사용자가 고관절을 위나 앞으로 미는 경향이 있는 경우, 전방 경사 4 점 스트랩이 전방 골반 경사를 보이는 휠체어 사용자에 대한 지지를 제공할 수 있습니다. 골반 스트랩과 전방 경사 4 점 스트랩을 어떻게 휠체어에 고정시켜야 할까요? <단단한 좌석에 고정시킬 시> - 왼쪽 그림과 같이 단단한 좌석에 고정시킵니다. 스트랩 말단을 접고, 구멍을 낸 후 볼트와 함께 와셔와 너트(가급적 고정 나사)를 나무 사이 로 통과해 사용합니다. - 접힌 말단 사이에 놓인 와셔를 확인하세요. 이는 스트랩이 낡고 찢 어지는 속도를 늦춰줘 결국 스트랩의 장력을 제동시키는 스트랩 브레 이크 역할을 합니다. <휠체어 프레임에 고정시킬 시> - 휠체어 프레임을 감싸 돌고 플라스틱 또는 금속 슬라이드 버클(“트 라이글라이드(triglide), “더블 D-링(double D-ring) 또는 3-바 버클로도 알려짐)로 고정합니다. - 만약 제자리에 있다면 덮개 나사 또한 사용될 수 있습니다. 종아리 스트랩 만약 휠체어가 종아리 스트랩이 내장되어있지 않다면, 50 mm 나일론 스트랩에 벨크로를 바느질해 만들 수 있습니다. 종아리 스트랩은 휠체어 폭 만큼 약 두 배정도 길이입니다. 골반 끈 주의사항: 만약 골반 끈이 너무 느슨하면 휠체어 사용자의 신체 조절을 제한시키거나 미끄러져 내려갈 수 있습니다. 주의를 기울이지 않는다면 질식을 야기할 수 있습니다. 항상 보호자에게 올바르게 끈을 매는 방법을 정확하게 가르쳐주고 사용자를 지켜보지 않았을 때 위험한 점을 주의해야 합니다. 발 스트랩 발 스트랩은 25 mm 나일론 스트랩과 벨크로 또는 버클로 만들 수 있습니다. 한 쪽 끝은 접고 발판에 고정시키기 위해 나사가 들어갈 구멍을 만듭니다. 피부와의 마찰을 줄이고 압력을 분산시키기 위해 커버가 씐 패드를 사용해야 합니다. 어깨 벨트 좋은 어깨 벨트를 만들기 위해선 재봉틀과 재봉 경험이 있는 사람이 만드는 것이 좋습니다. 그리고 나일론 스트랩, 버클, 패드를 위한 부드러운 폼이 필요합니다. 몇 가지 팁은 다음과 같습니다. 특히 뼈가 튀어나온 부분에 어깨 패드를 사용하세요. 어깨 벨트 상부를 고정하는 곳이 휠체어 사용자의 어깨보다 높던가 같은 높이 에 위치하는지 확인해야 합니다. 만약 낮다면, 그 스트랩은 휠체어 사용자를 아래로 밀 것입니다. 절대 어깨 벨트 아래를 골반 스트랩에 고정하지 마세요. 이는 골반 스트랩을 끈을 사용하거나 제작할 때 팁들: 벨크로 또는 버클로 고정시키세요 휠체어 사용자와 접촉하는 부분은 패드를 부착하세요 – 이는 압력을 분산시켜 편안 하게 해줍니다. 끈은 단단한 좌석, 등받이에 고정되거나 슬라이드 버클(“트라이글라이드(triglide), “더 블 D-링(double D-ring) 또는 3-바 버클로도 알려짐)로 휠체어 프레임을 감싸 돌 수 있습니다. 종종 휠체어에 부착되어진 종아리 끈은 다른 용도로 쓰일 수 있습니다. 예를 들어, 등받이 천을 변경/조절할 때 사용될 수 있습니다. 위로 들어 올립니다. 그림에서 보이는 가슴 벨트는 어깨 벨트가 제자리에 있게 해주고 체간 전면을 지지합니다. 휠체어 안전과 준비 체크리스트를 이행 제품(휠체어) 준비의 최종 부분은 휠체어가 안전하고 사용할 수 있는지, 그리고 모든 부분이 제대로 작동하는지 체크하는 것입니다. 다음 장에 있는 휠체어 안전과 준비 체크리스트는 빠진 것이 없는지 확인하는데 도움이 될 것입니다. 휠체어 서비스 인력은 이 체크리스트를 복사하여 센터에 붙여 휠체어를 준비할 때마다 상기하면 됩니다. 휠체어 안전과 준비 체크리스트는 휠체어 사용자가 피팅을 위해 오기 전에 완료해야 합니다. 만약 휠체어 안전과 준비에 문제가 발견되면 휠체어 서비스 인력은 다음을 해야 합니다. 피팅 전에 문제를 해결/수리합니다. 수리를 위해 휠체어를 휠체어 수리점에 돌려줍니다. 휠체어 공급자에 연락해 문제 해결에 도움을 요청합니다. 어깨 벨트 주의사항: 몸에 꼭 맞는 골반 끈은 어깨 벨트나 가슴 벨트를 사용할 때에는 항상 사용해야 합니다. 이렇게 하지 않으면, 목 조름을 야기할 수 있습니다. 체크리스트: 휠체어가 안전하고 사용할 준비가 되었나요? 자세유지장치를 포함한 휠체어 전체 자세유지장치가 단단히 고정되어있다. □ 날카로운 모서리가 없다 □ 손상되거나 긁힌 부분이 없다 □ 휠체어가 일직선으로 똑바로 간다. □ 앞 캐스터 휠 잘 돌아간다. □ 포크를 안 건들이고 돈다. □ 볼트가 꽉 조여있다. □ 앞 캐스터 배럴 캐스터 포크가 잘 돌아간다. □ 뒷바퀴 잘 돌아간다. □ 차축 볼트가 조여져 있다. □ 타이어에 올바르게 공기를 넣었다 (엄지로 누르면 5 mm 이하로 눌린다) □ 뒷바퀴 추진장치가 안전하다. □ 브레이크 제대로 작동한다. □ 발 받침대 벌 받침대가 단단히 붙어있다. □ 프레임 접이식 휠체어 – 휠체어가 쉽게 접히고 펴진다. □ 접이식 등받이 휠체어 – 등받이가 쉽게 접히고 펴진다. □ 방석 방석이 덮개 안에 올바르게 있다. □ 방석이 휠체어 위에 올바르게 있다 □ 방석 덮개 천이 꽉 조이나 너무 조이진 않는다 □ 만약 휠체어가 고체 좌석이라면 방석이 고체 좌석을 완벽하게 덮고 있다. □ 6 단계: 피팅 피팅은 휠체어 서비스 전달의 8 단계 중 여섯 번째 단계입니다. 피팅 중에는 휠체어 사용자와 휠체어 서비스 인력이 휠체어와 자세보조용구(PSD)가 잘 맞고, 최대한 편안하고 중립적으로 앉은 자세인지를 확인합니다. 피팅을 이행하는 방법 이번 장에 있는 중급 휠체어 피팅 체크리스트를 사용하여 피팅할 때 사용하세요. 다음과 같은 순서로 체크하세요. 휠체어 준비 휠체어와 자세보조용구(PSD)가 올바르게 맞는지 확인 자세 확인 압력 확인 휠체어가 움직일 때 올바르게 맞는지 확인 *추가사항이 있는지 결정 휠체어가 준비되었습니까? 사용자를 위해 휠체어를 항상 준비해둬야 합니다. 기억하세요: 추가적인 자세지지가 필요한 휠체어 사용자는 그렇지 않은 사용자보다 피팅에 소요되는 시간이 오래 걸립니다. 이는 더 많은 조절사항이 필요하기 때문입니다. 휠체어 사용자는 피팅에 시간이 더 소요될 수 있다는 것을 알아야 합니다. 휠체어를 조절할 때 그들은 휠체어를 타고 내려봐야 합니다. 만약 많은 조절사항이 있으면 두 번째 피팅을 위해 와야 합니다. 자세보조용구(PSD)와 휠체어가 올바르게 맞는지 확인 휠체어 너비 올바른 피팅 꼭 맞아야 합니다 확인할 부분: 고관절이 팔걸이 또는 골반 측면 패드 사이에서 편하게 맞아야 합니다. 허벅지가 팔걸이, 사이드 가드 또는 골반 측면 패드 사이 에서 편하게 맞고 허벅지를 압박하지 않아야 합니다. 이 는 골반 측면 패드가 너무 앞으로 연장되었을 때 나타납 니다. 체간 등받이 기둥, 체간 측면 웨지, 체간 측면 패드 사이 에서 편하게 맞아야 합니다. 휠체어 깊이 올바른 피팅 무릎 뒤와 좌석/방석 사이에는 최소 30 mm 공간이 있어야 합니다. 확인할 부분: 휠체어 사용자가 중립적으로 앉은 자세와 근접하고 편안 해야 합니다. 확인하는 법: 무릎 뒤와 방석 사이로 손을 넣어보세요. 30 mm 공간이 있는지 확인하세요. 손을 쓸어내려서 종아리가 좌석/방석 과 맞닿아 있지 않게 하세요. 양쪽 다 확인하세요. 만약 왼쪽과 오른쪽이 다르다면 짧 은 다리를 처방에 맞게 조정하세요 다리가 긴 휠체어 사용자에선 공간이 더 클 수 있습니다. 60 mm 까지 허용됩니다. 정확하게 맞춰주면 허벅지 지지를 잘 할 것 입니다.. 이는 좌골에 가해지는 압력을 줄여주고 욕창을 줄여줍니다. 만약 시트 길이가 너무 길다면 휠체어 사용자는 똑바로 앉을 수 없을 것입니다. 골반 확인할 부분: 전 좌골턱은 좌골 바로 앞에 있어야 합니다 (휠체어 사용 자의 고관절 아래에 손을 넣어 확인하세요) 골반 뒤 패드는 후상장골극(PSIS)를 지지하고 하부 몸통 을 밀지 않습니다. 골반 측 패드는 잘 맞아야 하고 고관절 위에 위치하지 않 도록 합니다. 골반 스트랩은 단단히 조여질수 있도록 해야 하고, 휠체 어 사용자의 피부가 압박되지 않도록 합니다.(휠체어 사 용자가 스트랩 사이로 손을 넣어 확인 합니다.) 체간 확인할 부분: 체간 측면 패드는 겨드랑이에 압력을 가하도록 배치하면 안 됩니다. 휠체어 사용자 겨드랑이와 체간 측면 패드 윗부분 사이에 최소 50 mm 정도 공간이 있어야 합니다. 어깨 벨트는 피부를 압박하지 않고 편안해야 합니다. 트레이는 팔뚝과 팔꿈치를 지지하고 복부를 밀지 않아야 합 니다. 잘라서 변형한 트레이는 몸과 가까울 수 있습니다. 하 지만 휠체어 사용자 피부에 맞닿지 말아야 합니다. 등받이 높이와 기울임(tilt)을 확인합니다. 머리받침대 올바른 피팅 머리받침대는 휠체어 사용자 머리의 기저부를 지지해야 합 니다. 확인할 부분: 머리받침대는 휠체어 사용자 머리를 균형 있고 바른 자세로 지지해야 합니다. 허벅지 확인할 부분: 휠체어 사용자 허벅지와 허벅지 지지장치(외측 허벅지 패드, 내측 허벅지 웨지 또는 무릎 분리 패드 포함)에 심한 압력 이 없어야 합니다. 무릎 분리 패드는 사타구니에 압력을 가하지 말아야 합니다. 사타구니에서 무릎 분리 패드는 어린이는 40 – 60 mm 정도, 어른은 60 – 100 mm 정도 떨어져 있어야 합니다. 발 받침대 높이 올바른 피팅 허벅지는 공간 없이 좌석/방석 위에서 충분히 지지 받고 발도 공간 없이 발 받침대 위에서 충분히 지지를 받습니다. 확인하는 법: 허벅지와 좌석/방석 사이에 손을 넣어보세요. 공간이 없고 허벅지 전반에 걸쳐 동일한 압력이 있어야 합니다. 발판 위의 발을 보세요. 발은 공간 없이 앞뒤 모두 지지 받 아야 합니다. 만약 허벅지 밑에 공간이 있다면 발판이 너무 높을 수 있습니다. 만약 발 밑에 공간이 있다면 발판이 너무 낮을 수 있습니다. 등받이 높이 올바른 피팅 휠체어 사용자에게 지지가 필요한 부분을 올바르게 맞추었다면 견갑골을 자유롭게 움직일 수 있어야 합니다 (만약 혼자서 나아가게 한다면). 확인하는 법: 휠체어 사용자에게 등받이가 편안한지 물어봅니다. 몸통이 고관절과 균형 잡혀있는지 관찰합니다 등받이 방해 없이 휠체어 사용자가 휠체어를 밀 수 있는가요? 등받이 높이는 휠체어 사용자의 필요사항에 달려있습니다. 혼자서 휠체어를 구동하는 사용자는 견갑골을 자유롭게 움직일 수 있게 하는 등받이가 필요합니다. 수직으로 앉아있기 힘든 휠체어 사용자는 더 많은 지지를 할 수 있도록 더 높은 등받이가 필요합니다. 휠체어 사용자 흉곽 아래 높이에서 지지하는 등받이가 좋은 휠체어 사용자는 다음과 같습니다. 몸이 건강하고 활동적인 사용자. 균형 있고 수직으로 앉을 수 있는 사용자. 자유롭게 움직일 수 있어야 하고 혼자서 휠체어를 구동할 수 있는 사용자. 등받이 높이 D (좌석에서 아래 흉곽까지) 휠체어 사용자의 견갑골 높이에서 지지하는 등받이가 좋은 휠체어 사용자는 다음과 같습니다. 쉽게 지칠 수 있는 사용자: 예를 들어 노인이나 진행성 상태 수직으로 앉기 힘든 사용자 이 등받이 높이는 어느 정도는 견갑골을 자유롭게 움직이게 하여 휠체어 사용자가 손으로 휠체어를 구동할 수 있게 합니다. 등받이 높이 E (좌석에서 아래 견갑골 까지) 쉽게 지치고 피곤해지는 휠체어 사용자는 뒤로 젖힘(recline) 등받이, 좌석과 등받이가 기울임(tilt)이 있고, 더 많은 지지가 필요하므로 어깨 위 높이까지 오는 높은 등받이가 있는 휠체어가 필요합니다 등받이 높이 F (좌석에서 어깨 까지) 뒷 바퀴 위치 – 손으로 추진하는 경우 올바른 피팅 손을 뒷바퀴 추진장치에 올렸을 때 휠체어 사용자의 팔꿈치가 직각이 되어야 합니다. 확인하는 법: 휠체어 사용자에게 뒷바퀴 추진장치 위를 잡아보게 합니다. 팔꿈치가 직각으로 굽어야 합니다. 또한 후면 바퀴가 균형을 위해 바르게 위치하였는지도 휠체 어 사용자와 확인합니다. (전면 움직임과 후면 안전을 위함) 만약 휠체어 사용자가 ‘안전한’(더 뒤로) 위치에 뒷바퀴가 있어야 하면, 이는 팔이 앞으로 나가는 위치보단 더 뒤쪽으로 두어야 한다는 뜻입니다. 이 절충을 휠체어 사용자에게 설명하세요. 좌석 높이 – 발로 추친하는 경우 올바른 피팅 휠체어 사용자가 수직으로 앉아 있고 등받이에 의해 골반 뒤가 편안하게 지지를 받는 상태에서 사용자가 지면에 발을 반듯이 놓을 수 있어야 합니다. 확인하는 법: 휠체어 사용자에게 휠체어를 타고 골반 뒤가 등받이를 닿는 상태에서 최대한 반듯하게 앉아보라 합니다. 발을 바닥에 반 듯이 놓을 수 있는지 확인합니다. 만약 좌석이 너무 높다면 휠체어 서비스 인력은 다음과 같은 방법을 시도해 볼 수 있습니다. 방석의 높이를 줄여보는 법 단단한 시트를 기존 좌석보다 낮게 부착하는 법 (기술적 도 움과 조언을 받으세요) 휠체어 사용자가 한 발로만 추진하고 다른 발은 발판 위에 놓은 경우 발판 위 다리의 좌골 아래 압력을 확인해봐야 합니다. 자세 확인 휠체어 사용자가 휠체어 어떻게 앉아있는지 앞과 옆에서 관찰해보세요. 사용자가 수직으로 앉아 있습니까? 휠체어 사용자가 가장 반듯하게 앉아있는 자세가 편안한지 보세요. 이는 손 시뮬레이션에서 확인한 자세와 비슷할 것입니다. 구체적으로 확인해야 할 부분: 골반이 똑바르고 평행합니까? (만약 가능하다면) 체간이 똑바르고 대칭입니까? (만약 가능하다면) 머리가 균형 잡혀있고 똑바릅니까? (만약 가능하다면) 다리와 발이 최대한 바르게 앉은 자세와 비슷하게 지지 합니까? 사용자가 어떻게 느끼는 물어보세요. 휠체어 사용자의 전반적인 앉은 자세를 본 후 각각의 자세보조용구(PSD)가 의도한 지지를 제공하는지 확인하세요. 구체적으로 기억해서 확인해야 하는 부분 (만약 제공한다면): 등받이 높이, 젖힘(recline)과 만곡 기울임(틸트) 골반 측면 패드와 체간 측면 패드 모든 허벅지와 하퇴 지지장치. 압력 확인 욕창 발생 위험이 있는 모든 휠체어 사용자는 좌골과 다른 위험 부위(고관절 또는 꼬리뼈 아래) 아래의 압력이 안전한지 확인하는 것이 피팅 단계에 포함됩니다. 단단한 지지를 제공하는 자세보조용구(PSD)를 사용하는 모든 휠체어 사용자는 신체부분과 자세보조용구(PSD) 사이의 압력을 확인해야 합니다. 지지는 단단해야지 조이면 안됩니다. 휠체어가 움직일 때 올바르게 맞는지 확인 피팅의 마지막 부분은 휠체어가 움직일 때 휠체어가 어떤지 확인하는 것입니다. 만약 휠체어 사용자가 스스로 휠체어를 밀지 못하면, 가족원/보호자에게 밀어달라 하고 관찰합니다. 확인해야 하는 부분: 등받이가 휠체어를 밀 때 휠체어 사용자의 견갑골이 자유롭게 움직 이게 하는가요? 휠체어가 움직이거나 밀 때 휠체어 사용자가 자세를 바꿔야 하거나 불편하고 불안정해 보이나요? 손으로 추진할 때: 후면 바퀴 위치가 휠체어 사용자가 밀 수 있을 만큼 올바른가요? 발로 추진 할 때: 좌석 높이와 깊이가 휠체어 사용자가 다리로 미 는데 있어 올바른가요? 자세지지가 제한 받지 않고 안전한 휠체어 기동성을 보장하나요? 중급 휠체어 피팅 체크리스트 1. 휠체어가 준비됐습니까? 휠체어가 안전한지 확인되었고 사용할 수 있게 준비됐으며 모든 부분이 작동하나요? □ 2. 휠체어와 자세보조용구(PSD)가 올바르게 맞는지 확인 휠체어 너비: 고관절이 팔걸이 또는 골반 측면 패드 사이에서 편안하게 맞아 야 합니다. 체간은 휠체어 프레임의 등받이 기둥 또는 체간 측면 패드 사 이에서 편하게 맞아야 합니다 허벅지가 팔걸이, 사이드 가드 또는 골반 측면 패드 사이에서 편하게 맞고 허벅지를 압박하지 않아야 합니다. □ 좌석 깊이: 각 무릎 뒤와 방석 사이에 30 mm 공간을 두어야 합니다. □ 골반: 전 좌골턱은 좌골 바로 앞에 있어야 합니다. 골반 후면 패드는 후상장골극(PSIS)를 지지해야 합니다. 골반 측면 패드가 고관절 위에 있지 않고 잘 맞는지 골반 스트랩이 단단하게 조일 수 있고 피부를 압박하지 않아야 합니다. □ 체간: 체간 측면 패드는 겨드랑이에 압력을 가하면 안됩니다. 겨드랑 이와 체간 측면 패드 윗 부분사이 최소 30 mm 정도 공간을 두 어야 합니다. 어깨 벨트는 피부를 압박하지 않고 편안해야 합니다. 트레이는 팔뚝과 팔꿈치를 지지하고 복부를 밀지 않아야 합니 다. 등받이 높이와 기울임(tilt)을 확인합니다. □ 머리받침대: 머리받침대는 휠체어 사용자 머리의 기저부를 지지해야 합니다. 머리받침대는 휠체어 사용자 머리를 균형 있고 반듯한 자세로 지지해야 합니다. □ 허벅지: 외측 허벅지 패드 또는 무릎 분리 패드로 인한 허벅지에 심한 압력 이 없어야 합니다. 무릎 분리 패드는 사타구니에서 어린이는 40 – 60 mm 정도, 어른 은 60 ~100 mm 정도 떨어져 있어야 합니다. □ 발판 높이: 허벅지는 공간 없이 방석에서 충분히 지지 받아야 합니다. 발은 공간 없이 발판 위에서 충분히 지지 받아야 합니다. 발 스트랩은 집히는 데 없이 단단하게 지지해야 합니다. 종아리 스트랩과 발꿈치 스트랩은 종아리와 다리를 지지합니다. □ 3. 자세 확인 휠체어 사용자가 편안한 상태에서 가장 중립적으로 앉은 자세로 앉아있는지 앞과 옆에서 확인합니다. 골반이 반듯하고 평행합니까? (혹은 편안한 상태에서 이와 가까운지) □ 몸통이 반듯하고 대칭입니까? (혹은 편안한 상태에서 이와 가까운지) □ 머리가 균형 잡혀있고 반듯합니까? (최대한 가능한 만큼) □ 다리와 발이 최대한 반듯하게 앉은 자세와 근접하게 지지 받고 있습니까? □ 모든 자세보조용구(PSD)가 의도한 지지를 제공하는지 확인하세요. 특별히 확인할 부분은 다음과 같습니다. (만약 제공한다면) 등받이 높이, 젖힘(recline)과 만곡 □ 기울임(tilt) □ 골반 측면 패드와 체간 측면 패드 □ 외측과 내측 허벅지 웨지, 외측 허벅지 패드와 하퇴 지지대 □ 15 분 후 자세에 변화가 있었는지 다시 한번 확인해보세요. □ 4. 압력 확인 양쪽 좌골 아래 압력을 확인하세요. 양쪽 압력이 안전한가요? 1 단계 = 안전: 손가락 끝이 5 mm 또는 그 이상 위아래로 꼼지락거릴 수 있다. 2 단계 = 주의: 손가락 끝이 꼼지락거릴 수 없지만 쉽게 뺄 수 있다. 3 단계 = 위험: 손가락 끝이 꽉 조인다. 쉽게 빼기 어렵다. □ 휠체어 사용자 몸과 패드와 스트랩을 포함하여 각 자세보조용구(PSD) 사이에 손가락을 넣어보세요. 자세보조용구(PSD)가 몸과 동일한 접촉을 하는가요? 압력은 안전한가요? □ 만약 휠체어 사용자가 특별하게 튀어나온 뼈, 혹이 있다면, 이 곳에 압력이 없는지 확인합니다. □ 5. 휠체어가 움직일 때 올바르게 맞는지 확인 등받이가 휠체어를 밀 때 휠체어 사용자의 견갑골이 자유롭게 움직이게 하는가요? □ 휠체어가 움직이거나 밀 때 휠체어 사용자가 자세를 바꿔야 하거나 불편하고 불안정해 보이나요? □ 손으로 밀 때: 뒷 바퀴 위치가 휠체어 사용자가 밀 수 있을 만큼 올바른가요? □ 발로 밀 때: 좌석 높이와 깊이가 휠체어 사용자가 다리로 미는데 있어 올바른가요? □ 자세지지가 제한 받지 않고 안전한 휠체어 기동성을 보장하나요? □ 6. 추가사항이 있는지 결정 추가적인 조치가 필요한가요? 휠체어 사용자 파일에 필요한 조치를 적어주세요. □ 7 단계: 사용자 교육 사용자 교육 휠체어에 대한 정보와 교육은 휠체어 사용자에게 많은 도움이 될 수 있습니다. 이 단계가 없으면 , 휠체어 사용자들에게 휠체어가 도움이 되지 못할 수 있습니다. 가족원/보호자가 같이 정보와 교육을 받는 것이 중요합니다. 무엇이 휠체어 사용자를 위한 유용한 기술일까요? 휠체어 서비스 인력은 오랫동안 휠체어를 유지하는 법, 휠체어를 안전하고 효율적이게 사용하는 법, 건강을 유지하는 법을 휠체어 사용자에게 가르쳐 줄 수 있습니다. 다음은 모든 휠체어 사용자에게 가르칠 수 있는 좋은 기술입니다. 휠체어 조작법 이동할 때 휠체어를 접고 드는 법 이동할 때 떼어내야 하는 자세보조용구(PSD)를 장착하고 분리하는 법. 휠체어에 있는 특징을 사용하는 법 – 예를 들어 브레이크, 기울임(tilt)과 넘어 짐 방지 바, 자세보조용구(PSD)와 방석의 올바른 위치. 이동 (휠체어를 타고 내리는 법) 안전한 이동을 위해 다음을 고려해야 합니다. - 휠체어 사용자가 편안한가 - 도와주거나 들어주는 사람이 안전한가 휠체어에서 올바르게 앉는 법, 예를 들어 휠체어 사용자의 좌골이 전 좌골턱 뒤에 위치하는지 확인해야 합니다 자세보조용구(PSD)를 올바르게 조절하는 법 , 예를 들어 스트랩이 단단하게 조여져 제 기능을 하는가를 확인 합니다. 많은 휠체어 사용자가 스스로 휠체어를 타고 내릴 때 꼭 기억 해 야 합니다. 독립적으로나 과 보조적 이동은 휠체어 서비스 교육 교재에 (초급) 설명되어 있습니다. 휠체어 사용자가 휠체어에 얼마 동안 앉아야 하는지 많이 앉아있어 보지 않은 휠체어 사용자는 꼿꼿한 자세로 앉는 게 익숙해지는데 시간이 필요합니다. 이는 아이들에 경우 특히 그렇습니다. 휠체어 서비스 인력은 휠체어 사용자가 휠체어에 얼마 동안 앉아야 하는지에 대한 조언을 해줘야 합니다. 다음과 같은 가이드라인을 제시하면 됩니다. 만약 휠체어 사용자가 앉기에 익숙해지려면, 사용자는 같은 시간 동안 새로운 휠체 어에 앉으면 됩니다. 필요하다면 사용자는 점차적으로 시간을 늘릴 수 있습니다. 만약 휠체어 사용자가 앉기 경험이 없다면, 30분 이상 앉지 말고 휴식을 가져야 합 니다. 휠체어 사용자 또는 가족원/보호자에게 사용자가 휠체어에 앉은 후 압박 받은 부위 를 항상 확인하는 것을 가르쳐야 합니다. 휠체어 사용과 기동성 휠체어 서비스 인력이 휠체어 기동성에 대해 가르칠 수 있는 기술은 휠체어 사용자의 능력과 환경에 달려있습니다. 휠체어 사용자 각자 본인에게 맞는 최적의 휠체어 추진 방법을 가르치는 것 을 항상 기억해야 합니다. 올바르게 미는 법, 언덕과 계단 올라가고 내려가는 법, 앞 바퀴 드는 법과 같은 초급 휠체어 기동성 기 술은 휠체어 서비스 교육 교재 (초급 참고 매뉴얼)에 더 많은 정보가 있습니다. 욕창 예방 욕창은 뼈가 튀어나온 부분의 압력, 마찰, 쓸림에 의해 생깁니다. 반듯하게 앉기 어려움이 있는 휠체어 사용자는 다음을 생각해봐야 합니다 - 쓸림에 의해 욕창(뼈가 튀어 나온 부분이 연약한 조직을 밀어)이 생길 수 있으니 미끄러지지 않는지 확인해야 합니다. - 양쪽 좌골 아래 무게 배분이 동일한지 확인해야 합니다. 자세보조용구(PSD)를 사용하는 휠체어 사용자는 휠체어 또는 자세보조용구 (PSD)와 피부가 접촉하는 부분의 피부를 주기적으로 확인해야 합니다. 욕창을 예방하는 방법은 휠체어 서비스 교육 교재 (초급 참고 매뉴얼)에 더 많 은 정보가 있습니다. 자택 휠체어 관리 휠체어 사용자에게 휠체어를 자택에서 관리하는 기본 정보를 제공하는 것은 휠 체어 수명을 연장시킬 수 있습니다. 휠체어 사용자가 휠체어와 방석을 자택에서 관리하는 여섯 가지 방법은 휠체어 서비스 교육 교재- 초급에서 가르쳐줬습니다. 이 정보는 중급 휠체어 사용자에게도 적용됩니다. 몇 가지 추가적인 관리는 자세보조용구(PSD)가 제대로 작동하는지 확인하는 것 입니다. 문제가 있을 시 해야 할 것 휠체어 사용자는 아래의 문제를 포함하여 기타 문제가 발생했을 시 어떻게 대처해야 할지 알아야 합니다. 휠체어 수리 받아야 합니다. 휠체어가 편안하지 않거나 잘 맞지 않습니다. 이와 같은 문제가 생기면, 휠체어 사용자는 휠체어 서비스에 연락을 해 도움과 조언을 구해야 합니다. 휠체어 사용자가 휠체어 서비스 센터에 어떻게 연락 할 줄 아는지 확인해야 합니다. 휠체어 사용자 교육을 성공적이게 만드는 방법 무엇을 휠체어 사용자가 이미 아는지 알아야 합니다. 설명하고 예시를 보여주고 그리고 휠체어 사용자가 연습할 수 있게 해줍니다. 모든 사람이 이해할 수 있는 용어를 사용합니다. 휠체어 사용자가 다른 휠체어 사용자를 가르치게 합니다. 좋은 의사소통 기술을 사용합니다. 격려합니다. 기억하세요 – 연습은 새로운 기술을 배울 때 중요합니다. 새로운 기술을 가르칠 때 항상 먼저 예시를 보여주고 난 후 휠체어 사용자에게 연습할 기회를 주도록 해야 합니다. 중급 휠체어 사용자 교육 체크리스트 가르칠 기술 가르친 기술 휠체어 조작법 휠체어 접고 드는 법 □ □ 이동할 때 떼어내야 하는 자세보조용구(PSD)를 장착하고 분리하는 법. □ □ 빠르게 바퀴 분리하는 법 □ □ 브레이크 사용법 □ □ 기울임(tilt)과 넘어짐 방지 바 (사용시) □ □ 휠체어 사용자가 휠체어에 있을 때 자세보조용구(PSD)의 올바른 위치 □ □ 제대로 된 위치를 포함한 방석 사용법 □ □ 이동(transfer) 스스로 이동(transfer) □ □ 보조 받는 이동(transfer) □ □ 기타 □ □ 휠체어 사용과 기동성 제대로 미는 법 (휠체어 사용자가 선호하는 방법으로) □ □ 언덕 위 아래 □ □ 계단 위 아래 □ □ 거친 땅 위 □ □ 앞 바퀴 드는 법 □ □ 얼마나 휠체어에 앉아 있어야 하는지 (추가적인 자세 지지가 필요한 어린이와 어른) □ □ 보조적으로 밀어줌 □ □ 욕창 예방 욕창 예방을 위해 높은 압력 부위 확인하기 □ □ 압력완화 보호대 □ □ 잘 먹고 물 많이 마시기 □ □ 욕창이 생겼을 시 해야 할 일 □ □ 자택 휠체어 관리 휠체어 청소; 방석과 커버 세탁과 건조 □ □ 움직이는 부분 기름칠 □ □ 타이어 공기 주입 □ □ 너트와 볼트 조임 □ □ 바퀴살 조임 □ □ 덮개 확인 □ □ 녹 확인 □ □ 방석 확인 □ □ 문제가 있을 시 해야 할 것 휠체어가 수리가 필요하다 □ □ 휠체어가 편안하지 않거나 잘 맞지 않는다. □ □ 8 단계: 유지, 수리와 사후관리 유지, 수리와 사후관리에 대한 정보는 휠체어 서비스 교육 교재 – 초급에서 다뤘습니다. 중급에서는 추가적인 지지가 있는 휠체어를 사용하는 휠체어 사용자를 위한 사후관리의 중요성을 논의합니다. 사후관리 사후관리는 휠체어 서비스 전달체계의 여덟번째 단계의 일부분입니다. 사후관리의 개요 모든 휠체어 사용자는 사후관리가 중요합니다. 하지만 다음과 같은 사람에게 특히 중요합니다. 어린이 욕창 발생 위험이 있는 휠체어 사용자 진행성 상태인 휠체어 사용자 추가적인 자세지지가 휠체어에 있는 휠체어 사용자 교육, 설명을 이해하는데 어려움을 겪는 휠체어 사용자 대부분의 중급 휠체어 사용자는 추가적 자세지지가 필요합니다. 그러므로 사후관리가 특히 중요합니다. 사후관리 휠체어 사용자의 필요에 따라 사후관리가 필요한 최적의 시간이 다르기 때문에 언제 사후관리가 이뤄져야 하는지에 대한 규칙은 없습니다. 하지만, 휠체어를 제공한지 6 주 이내에 사후관리는 휠체어 사용자가 휠체어가 잘 작동하는지 확인하게 해주고 보강교육을 할 수 있게 해줘 매우 유용합니다. 어린이는 매 3 개월에서 6 개월마다 사후관리를 해주는 것이 이상적입니다. 이는 어린이가 성장하면서 필요한 부분들이 달라지기 때문입니다. 사후관리는 다음의 장소에서 이뤄질 수 있습니다. 휠체어 사용자의 자택 휠체어 서비스 센터 휠체어 서비스 인력과 사용자가 편리한 모든 장소 휠체어 사용자가 휠체어 서비스 센터로 갈 수 있는 지와 휠체어 서비스 인력이 휠체어 사용자 자택으로 갈 수 있는지에 따라 장소는 달라집니다. 사후관리는 다음과 같은 여러 가지 방법으로 관리될 수 있습니다. 휠체어 사용자는 휠체어를 받을 때 사후관리 약속을 잡을 수 있습니다. 사후관리는 휠체어 사용자 자택이나 휠체어 서비스 센터에서 행해질 수 있습니다. 방문을 통한 사후관리는 사후관리를 이행할 수 있도록 훈련을 받은 지역사회중심 재활사업 인력에 의한 규칙적인 지역사회 방문의 일부분일 수 있습니다. 유선을 통한 사후관리는 이동이 어렵고 전화 접속이 가능할 때 이루어 진다. 휠체어 사후관리 양식 휠체어 사후관리 양식(아래에 첨부된)은 방문 사후관리를 할 때 질문과 해야 할 일에 대해 정리된 것이다. 휠체어 사후관리 양식은 향후 취해야 할 조치를 적을 수 있다. 일반적 사후관리 조치 일반적인 사후관리 조치는 다음을 포함합니다. 더 많은 조언과 교육을 제공 예를 들어 만약 휠체어 사용자가 휠체어를 예상한 것만큼 사용하지 않다면 이는 사용자가 혼자 있을 때 휠체어를 타고 내리는데 자신감이 없어서 일수 있습니다. 이러한 문제를 해결하기 위해서 이동(transfer) 훈련을 더 해야 합니다 휠체어를 재조절 가벼운 수리 이행 항상 휠체어 사용자를 격려하고 가족원/보호자가 휠체어를 자택에 가져가 관리하게 합니다. 만약 고장 난 부분이 당장 수리될 수 없다면, 휠체어 서비스 인력이 휠체어 사용자가 수리를 처리할 수 있게 도와줄 수 있습니다. 휠체어 사용자는 지지 또는 보조를 위한 다른 서비스를 참조한다. 뚜시따 방문 사후관리 뚜시따는 일곱 살이며 누나와 부모님과 함께 삽니다. 그는 근이영양증을 앓고 있으며 휠체어 서비스를 통해 일년 전에 휠체어를 받았습니다. 그때는 짧은 거리를 걸을 수 있었습니다. 그는 스스로 서서 휠체어를 타고 내릴 수 있었습니다. 당시 학교에 가기 어려워 휠체어를 찾게 되었다고 말했었습니다. 사후관리 위한 방문시 뚜시따는 이제는 스스로 휠체어를 타고 내리기 힘들다고 했습니다. 그는 학교에서 오후가 되면 피곤하고 불편하다고 했습니다. 이는 학교 수업에 집중하기 힘들게 한다고 합니다. 그의 휠체어는 적당한 크기이고 중간 정도로 느슨한 등받이와 간단한 방석이 있습니다. 사후관리 동안 휠체어 서비스 인력은 다음을 시행했습니다. 뚜시따가 어떻게 휠체어를 타고 내리는지 알아봤습니다. 뚜시따는 휠체어에서 본인 몸을 드는데 어려움을 겪었습니다. 휠체어 서비스 인력은 뚜시따에게 미끄럼 판으로 훨씬 쉽게 이동하는 법을 가르쳐 주었습니다. 뚜시따의 추가적인 자세 지지를 검토했습니다. 그 결과, 뚜시따가 더 나은 지지를 받 기 위해서 더 높은 등받이가 필요하고 또한 압력완화 및 자세지지가 가능한 쿠션이 필요함을 결정하였습니다. 휠체어 서비스 인력은 피팅을 준비하기 위해 치수를 쟀습 니다. 뚜시따의 새로운 등받이와 방석 피팅을 위해 휠체어 서비스 센터 방문 예약을 했습니다. 휠체어 사후관리 양식 1. 휠체어 사용자 정보 휠체어 사용자 이름: 번호: 피팅 날짜: 사후관리 날짜: 사후관리 담당자 이름: 사후관리 장소: 휠체어 사용자 자택 □ 휠체어 서비스 센터 □ 기타: _________________________________________________ 2. 인터뷰 취할 조치 기록란 당신은 휠체어를 필요한 만큼 충분히 사용하나요? 네 □ 아니오 □ 만약 아니라면 왜 그런가요? 휠체어를 사용하는데 문제가 있나요? 네 □ 아니오 □ 만약 그렇다면 무엇이 문제인가요? 휠체어 사용하는데 있어 묻고 싶은 것이 있나요? 네 □ 아니오 □ 만약 그렇다면 어떤걸 묻고 싶나요? 추가 교육이 필요한가요? 욕창이 있나요? 네 □ 아니오 □ 좀 더 자세히 설명해주세요(위치) 당신의 휠체어에 대한 만족도를 1-5 로 매긴다면? (5: 매우 만족 1: 매우 불만족) 수준: 의견: 3. 휠체어와 방석 확인 휠체어가 제대로 작동하고 사용하기 안전한가요? 네 □ 아니오 □ 방석이 제대로 작동하고 사용하기 안전한가요? 네 □ 아니오 □ 만약 둘 중 하나라도 아니라면, 무엇이 문제인가요? 4. 피팅 확인 휠체어가 올바르게 맞나요? 네 □ 아니오 □ 만약 아니라면 무엇이 문제인가요? 압력 확인 단계 (1= 안전, 2= 주의, 3= 위험) (사용자가 욕창 발생의 위험이 있는 경우) 좌 우 휠체어 사용자가 가만히 있을 때, 이동시에, 그리고 하루 동안 사용할 때 편안하게 똑바로 앉아있나요? 네 □ 아니오 □ 만약 아니라면 무엇이 문제인가요?
pz{ynv þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄĎğĀĢúĖ Ą ĆĜĩ ċĈě ùđĖ ĀĐĭ ėĎĖąćĞĩ Ģúğĩ ėēĨ ďċ
pz{ynv þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄĎğĀĢúĖ Ą ĆĜĩ ċĈě ùđĖ ĀĐĭ ėĎĖąćĞĩ Ģúğĩ ėēĨ ďċ Ƅǐ ƇƐǑ ƒƫƇƆƙǗ ƃƀƞƋƗǕ ƁƜƐƞƌƫƕƀƬƋƍǒ ƐƞƆƬƈǚ ƘǗ ƖƁǞ ǚ ƙǗ ƃ ƀƞƋ ƙƜ Ƌƞ ƭƒ ƫƕƀƍǒ ƙǗ ƃƀƞƋƙƜƋƞƭƒƫƕƀƭƇǚ ƚǐ ƌƗǑ ƇƀƞƋƪƍƐƞƗƞƪƕƜƗǑ ƇƩƎǒ ƆƪƎǙ ƗǞ ƞƕǐ ƌƀƞƋƐǑ ƒƬƋƕƞƖƀǐ ƌƙǗ ƃƀƞƋ ƀƞƋƐǐ ƇƊƜƋƞƗƞƀǗ Ƌ ff fi fl ffi ƁƙƃƗƜƘƜƕǐ ƇƙƞƩƒƕǑ ƀƞƩƅǑǙ ƃƩƍǐ ƋƎǖǚ ƚǐ ƌƎǑ ƇƅƙƌƐǟƃƪƈǙ ƗǞ ƞƕǐ ƌƂǕ ƋƋƜƐƞƌƪƕƜƂƖƞƒƅǔǙ Ɨǐ ƇƁƙƃƗ Ɯƌǐ ƌƐƞƗƞƕƞƖ ƬƋƀǞ ƕƜƋǒ ƊǒǙ ƒǒ ƂƖƞƒƌǞǙ ƗƙƇƂǙ ƙƃƀǐ ƋƕƜƘƖǙ ƞƃƗƜƌǐ ƌƐƞƗƞƙǐ ƃƀǑ ƇƪƕƜƕƞƖ ƗƜƌǐ ƌƐƞƗƞƙǐ ƃƀǑ ƇƈǗ ǚ ƋƗƜƌǐ ƌƄƜƈǚ ƙƃƒǒ ƀƞƋƎǖ ƀƒǐ ƇƪƕƜƉǔ ƀƈǚ ƙƃ ƅǕ Ƈ ƏǓ ƀ ƙǗ ƌƚǗ ƒ ƀƞƋ ƌǞ ƕǑ ƀƞƋ ƕǗ Ƈ ƩƁǐ Ƌ ƕƜƇǐ ƌ ƍƞƋ ƀƞƃ ff fi fl ! u z y 1 11 t wp{uv "|tpoy|®p{ spwn{nyvznytvq~q #~zny{y|ynyu~p{y|y #ny{yvns– ®yvpszny{xv~yryov®yv #ny{yvns– ®yvpszny{xvnyq®yv #ny{yvns– nynpzv®npnnnu~n nypnynp #ny{yvns– nynpzv®npnnnu~n ny}n{qzpny{xv vztx #ny{yvns– nypnyp®n #nynpoyzvyv #nynypt nyn {ny14%– nyp npnnn £yxv #nynypt nyn {ny14%– nyvu~n #nynypt nyn {ny14%– nyvq #nynypt nyn {ny14%– ny{xv nyv nnoouy {qzpqwvnynn|pq~y poy – snynp¢n {qzpqwvnynn|pq~y poy – snynpx{p~ ny~tvyuzpoypz{ynv #ny}nz|t #nyvwny #nyzvnu nyu{vnyqpq|y {qzpqwvny{y|y nynyptpoy nyn ny nn|pq~y poy ny{zpoy £uny}nz|t – snynp¢n {qzpqwvny{y|y nynyptpoy nyn ny nn|pq~y poy ny{zpoy £uny}nz|t – snynpx{p~ny~tvyovpoypz{ynv ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ýĝ ĀĆĕĐğü tp}nzpz{ynvrnnzz~u¢zu¢yny}nz ~ynvy uu£n~u¢vpoyzztvxyzvyv® £u npnsv pnts sv|ts|®qvnyy{xv vz ®®v~q~ upyvqvtp wp{uv novtp}nzyy~~p®y®nuxovznx ny®v£p®novnzny nyznypoynypyytpny}nzy wts f ~wyyov|tpoy|®pzpoy®qzu¢vxqvnyovo w f ~wyy~ynvy®pzny}nzyny znyptypz{y nv f{z{vxupov~ynvy nyznypoy f ~xyy~zovny znypoyuz|®qvnynyts ypz ®uvn®znzpz~yry ftp}nzyy nup}nz|ts~pnyyvns fzypnytuy®pnovny znypoy~synyznyy vns wp{uv nov{}n pov|oyy~~p®y®nuxov znxny®v£p®novnzny nyznypoy{}n pov|o {nzzp}n p®wts®puz~p®yx®nuov|o }nz{}n pov|o{nznuywnnyzyss zpy u¢zzuxvv ywp{uv |onuuyov{}n p zvyyxp rw{y $ ćĞĩ ĥþĩ ĎğĀĢúĖ ĄćĞĩ ăĚĨ ĦĀĩ ĆĕĤđÿĀýėùùėĄēĒüēĖąăĨ ėăėü ĢĉĚĨ ċĢāĚ ċ ùėĄĤÿĄĹėùąėĄ f n¢vxyynov®y~yv®vqvuz®v£puoyqyovnpwn y fnuvxyw{y|ts fuzqoyqy syz£nzy{ vznxy®yv®vqv nz|tswyy xv oyqyyoy®syz £nzy|®yv®vqvyyvqvt ps®qywnz~y ċĖĄüĨ ėÿĐĭĨ ėĥĀĥĄùėĄĤÿĄģĎĕēĖąĹėùąėĄ" ċĖĄÿėùúěĩ ĄĐĭ ėĎĖąúĖĩĄāĒĄģĎĕąĭ "ÿĩĒĄ đÿĖü"āĭ ėģĸĨ üģĎĕăĨ ėāĨ ėüħċĚ ćğĄģĄďĥĀāĭĨ ùĖąďĨ ėċĖĄüĨ ėÿĐĭĨ ėĥĀĥĄùėĄēĖąĹėùąėĄ" oyqyyoy®syz £nzy|tsxy¢vvqv{uo uvovwzyz ¢vqv oyqyyoy®sy wz£nzy |tsxy¢vnsqv {wno¢v no¢v ùėĄĀĜĨ ċ f qxy~sspyyq¢v®®vqv®®z sov fp®¢syqxvpvm f nyyvqvt āĭ ėģĸĨ üģĎĕăĨ ėāĨ ėüħċĚ ćğĄģĄďĥĀāĭĨ ùĖąďĨ ėċĖĄüĨ ėÿĐĭĨ ėĥĀĥĄùėĄĀĜĨ ċ" f yv®vqvps® ov®y vv{ py v pv{yoy®v f yv®vqvy®yvb vopc f yyv®vqv{y|y ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv % ĉėąĎďċùėĄĆĕĢċĚ ĄćğĄģĎĕùėĄĐĭ ėĉėĀĆĕĢċĚ ĄćğĄ f pnnynznov®ypup¢vtpxrov®z£s ®ypsoynz£snnov®y ùĝĨċ nyzvqzy vns®zov|yypqnz nyu¢vpoy qv f nuyppovnyzvqzy vns|yqnznyu ¢vpoy f xyuzptvyny}nzpppw{y{ sp f svuxy®qvnnz|tpoyyqny ùėĄąėĀĢýĖ ąĐĕ ĹĒü ĤĆĎĚ ĤĒ ûďėċĒĨĒĄĢĉÿ " ùĝĨ ċ nyzvqzy vns®zov|yypqnz nyu¢vpoy qv f nuyppovnyzvqzy vns|yqnznyu ¢vpoy f xyuzptvyny}nzpppw{y{ sp f svuxy®qvnnz|tpoyyqny Ĥčùùĩ ėċĢĄĜĩ ĒĢĐĜĨ Ēċ ùėĄąėĀĢýĖ ąĦú ĐĖĄđĠĖ ü ùĩ ėċĢĄĜĩ Ēùĕāĝù ùėĄĢĸĖ üāĚ ăĚĨ ûďą ûĝċąĭĨ ĦĀĩ ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv # ùĝĨ ċ nyzvqzy vns®zov|yypqnz nyu¢vpoy qv f nuyppovnyzvqzy vns|yqnznyu ¢vpoy f xyuzptvyny}nzpppw{y{ sp f svuxy®qvnnz|tpoyyqny ĐĕĹĒüĉę ùėĄ Ēĭ ėċĕĉėĀ ąĖĄđėĢĎĜĨ Ēü ùėĄùę ĄùėĄ ĀĜĨ ċđĠĜ ùėĄùĜ Ą $ùĝĨ ċ nyzvqzy vns®zov|yypqnz nyu¢vpoy qv f nuyppovnyzvqzy vns|yqnznyu ¢vpoy f xyuzptvyny}nzpppw{y{ sp f svuxy®qvnnz|tpoyyqny ùĕĀĞùĐĖĄđĠĖ ü ĤđďĨ ĐĕĉėąĒėùėĄ ăĚĨ ēĩ ėÿģēüúěĩ Ą āğďČĨ ėüùĩ ėċ ĢĄĜĩ ĒĢĐĜĨ Ēċ ĉĕÿėĀĆėùę Ą ĐĖĄĢĐĖĩ ĄĢĎĜ ĒĀ ģúüāğďČĞĨ đĠ ėÿýĝ Ā ĉĕÿėĀĆĕĐėĀ ùėĄĢûĜĨ ĒĄĦđď ĐĕĤĉùĢûĜĨ ĒĄ ÿĩ ėÿ ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv % % ùėĄĆĕĢċĚ ĄēĨ ėüùėÿ²ăĨ ėĄĖĨ üĤĀÿąĭĨ ċĚ ùėĄĆĕûĒü ĉĜĩ Ą ĂėĄúĒüăĨ ėĄĖĨ ü f pnny~znpny{y{v svpqnz®y vqvt®npn nn{y{v f qxyynxy{ywv¢vy®npnnn®®zsovxyy uvnpnpny{y{v svpqnzuy® ovvnsov fr qxyynxyv®yovnpnnn~zny{y{v yvnsovowv ăĨėùĕĀĞùùğùģĒď úĺĄđĠĜ ģāĩċúĭĩ ĐĖ üĢùĀúĒüăĨ ėĄùĨ ĺďùĖąăĨ ėăėüăĚĨ ĆĨ ĺĄĦĆúĒü ąĝùûğĄĢąęĨ üĎĭ ėāğďđğ ďģĎĕûĭ úėúĒüąĝùûğĄ v{®v¢ v{®v v v{®vov ny£y &% ùėĄĆĕĢċĚ ĄēĨ ėüùėÿ²ăĨ ėĄĖĨ üĤĀÿąĭĨ ċĚ ùėĄĆĕûĒü ùėĄģāĩċăĨ ėĄĖĨ ü f qzq{yuyov®yvovqyov zq{yuyov®yvwnpyov zq{yuyov®yvwnpy¢ zq{yuyov®yvwnpy¢– ny £ynpnnn ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ' f qzq{yuyunvov~zy®n®yvovznxyyzupv ăĨ ėĄĖĨ üĤĀÿąĭĨ ċĚ ùėĄĆĕûĒüđĠĜ ēĒüēĖą ®zs q®yv®zy{xv vz ăĨ ėĄĖĨ üĤĀÿąĭĨ ċĚ ùėĄĆĕûĒüđĠĜ ēĒüēĖą ®zs q®yv®zy{xv vz ăĨ ėĄĖĨ üĤĀÿąĭĨ ċĚ ùėĄĆĕûĒüđĠĜ ēĒüēĖą ®zs q®yv®zy{xv vz ăĨ ėĄĖĨ üĤĀÿąĭĨ ċĚ ùėĄĆĕûĒüđĠĜ ēĒüēĖą ®zs q®yv®zy{xv vz f qzq{yuyunvov~zy®n®yvovznxyyzupv ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv % ùėĄĆĕĢċĚ ĄēĨ ėüùėÿ²ùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğù ģĒďģĎĕĐĕĤĉù ùėĄĢēĖ ĀùėĄùďĀ f pyynynpzv®npnnnu~nyqxy®upv{y|tp oyynov®y fzy®n|ypzuzqxy®upv{y|tpoyynov®yuuy bnynpzv®npnnnu~ncovzzny{ypoy pz{ynvov tov|tp®¢vùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù npzvnpnnn~vny zozopnyvov u~nyyy npnnnupypz~vnypz p z u~nupnvv ®yv{nnqpz op zp @@@@@@@ tsp zp @@@@@@ rnpnnnzup~vnyp u~nzupnvv ®yv{nnqp– vpsyvtx tov|tp®uvùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù npzvnpnnn~vny zozopnyvov u~nyyy npnnnupypz~vnypz p z u~nupnvv ®yv{nnqpz op zp @@@@@@@ tsp zp @@@@@@ rnpnnnzup~vnyp u~nzupnvv ®yv{nnqp– vpsyvtx tov|tp®uùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù npzvnpnnn~vny zozopnyvov u~nyyy npnnnupypz~vnypz p z u~nupnvv ®yv{nnqpz op zp @@@@@@@ tsp zp @@@@@@ rnpnnnzup~vnyp u~nzupnvv ®yv{nnqp– vpsyvtx % ùėĄĆĕĢċĚ ĄēĨ ėüùėÿ²ùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒď ģĎĕĐĕĤĉù ùėĄĈě ùĆĕāę ąĖ ĀùėĄĆĕûĒüđĠĜ ēĒüēĖąþğĨ ďûėď f yqvov|tpoy f uz|tpoyqxy qpuynpnnnov|tpoyupypz~vnyp zu~nnvo ®yv{nnqp z vq nnoznyvu f pupuynynpzv®npnnnu~novzz{y|ypoypz {ynv qpuy|tpoyw{yqvyvtxqvyvtxuz|t poyqxy f z{ny pnpzvyvtxqyyv®vyvtxqy~zv y{yypw"4*4 swn"OUFSJPS4VQFSJPS*MJBD4QJOF { ®vpy¢ npntvny 4BN ùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù 4BNs{~nyu£vz upyvqvtppsqyv|ynynp zv®npnnnu~n®y~z f npnnnov4BNup~vnyp ®vpz"4*4 f u~ntsov4BNupnvpv upn ®yv{nnq4BNwzu~ noovyznvo ®yv {nnq vq nnonv nvu vq nno ovzvoy{yvu npzvnpnnn~vny zozop nyvovu~nyyy npnnnupypz~vnypz p zp u~nupnvv ®yv{nnqpz op zp @@@@@@@ tsp zp @@@@@@ rnpnnnzup~vnyp u~nzu pnvv ®yv{nnqp– vpsyv tx 4BNw{yqvyvtxyz y z .BSUIB ùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù .BSUIBs{{y~sponuz yvupsvpuvun ypnqnysvywz s|y nynpzv®npnnnu~n ®y~z f npnnnov.BSUIBup~vnyp ®vpz"4*4 f u~n®vuvov.BSUIBzupnvo ®yv{nnqp vq nnonvnvu v q nnoovu~n®vuvzv y{yvu npzvnpnnn~vny zozop nyvovu~nyyy npnnnupypz~vnypz y z u~nupnvv ®yv{nnqpz op zp @@@@@@@ tsp zp @@@@@@ rnpnnnzup~vnyp u~nzu pnvv ®yv{nnqp– vpsyv tx .BSUIBqvnyyvtxyz y z ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv 4FSFO ùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù 4FSFOs{{y{qvq svyspyny pqvy vovo®vuvzv4FSFOxy {psnyyvoonyqp {®v~y|ynynpzv®npn nnu~n®y~z f npnnnov4FSFOzup~v nypnpnnnzvoov uvnzvts f u~n®vuvzvov4FSFOup nvo ®yv{nnqp npzvnpnnn~vny z ozopnyvovu~nyyy npnnnupypz~vnypz y z u~nupnvv ®yv{nnqpz op zp @@@@@@@ tsp zp @@@@@@ rnpnnnzup~vnyp u ~nzupnvv ®yv{nnqp– vpsyvtx 4FSFOqvnyyvtxyz y z +PF ùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù +PFs{{y{qvqsv yspyny pqvyv ovo®vuvzv|ynynpzv ®npnnnu~n®y~z f npnnnov+PFup~vnyp ®vpz"4*4 f u~noov+PFupnvo ®yv{nnqpvupnypn qu~ntsovzup{p n ®yv{nnqp v q nnoysnvu vq nnoovy vu npzvnpnnn~vny z ozopnyvovu~nyyy npnnnupypz~vnypz y z u~nupnvv ®yv{nnqpz op zp @@@@@@@ tsp zp @@@@@@ rnpnnnzup~vnyp u ~nzupnvv ®yv{nnqp– v psyvtx +PFqvnyyvtxyz y z % ùėĄĆĕĢċĚ ĄēĨ ėüùėÿ²ùėĄĢēĖ ĀùėĄďĖĀģăù ( ) * ) + , s{~nyu£vupyvqvtppszy{xv y v ypnq~zys szupyvppynyv{py vxv® nysy{¢ypoy{wzyovpvorp~ qvnyq~y|q¢ov~ upy oynypvsoyovy |yovny{yvnszztnywvps®pps~ynvy znypoy f y|y|ynywvps®pupov ùėĄýĭ ėĎĒüĀĩďÿċĜ āĩĒüùėĄċĚ ģĄďĆĕûĒüđĠĜ ģĄďēĒüĢĉĜĨ Ēĥđĩ ĄĖĨ üĥĄăĨ ė Ćğùùĕāę đĠĜ ĥùĩ ûĺüùĖąăĨ ėĆğùùĕāę ăĚĨ ĐĝĀĢăğĨ ėăĚĨ Đĕąėÿāğď uzquyovvnsr®yv{nnqy{y{pĀĩďÿùėĄĆĕûĒüĀĩďÿċĜ £syrzp £sz ĐĨďĄ ģċĨĄ ąĭĨ ®zs quy®yvup®s®ppps|tpo y sny {xv vzpsģĎĕ®zs quyny{xv vz® u¢v ~zyp®yvyynpnnn q ăĨ ėĄĖĨ üĐĝĀăĩ ėÿnpnnnv{py v quynvv¢s¢v zpyov qpuyny zpy¢ psny{xv vzqnz ®vuvov vv{¢¢s¢v onwyoy– n v zynno{u®{nnq ģĄďĆĕûĒüđĠĜ ģĄďēĒüăĚĨ āĩĒüùėĄ f yvpy¢ovnpnvyv f yvpy vovnpnnn– zy{u®{nnqq{vnyz y{qn f y{xv~vzz f yvpyovq– ~tsnu qxvnv f yv®vuvzvovnpnnnu~n~nu npn nnxvnv f yvpyyovnno~pz nnoopoy – vnnopyy f rp u~nts u~no nno ots oo oqyts oqyo f qpuynyp®nvnspp®®yww{yqvp~ upnpoyuz.BEBWJ f pnyp®n ynzv¢sutn¢vxyynoy~nyuyuyApnyp®nA ovzz{y|ypoypz{ynv ¢q{ f ®ywz{ny pnyp®nxn zyyv®rnqvpyp w.BEBWJ npnnn®v{py vxv®nys
f ®ywpnyp®npp~®zs xuvo¢pztvovrpuz ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ùėĄĢēĖ ĀùėĄďĖĀģăù ùėĄďĖĀģăùēĨ ėüùėÿ ċċ ùėĄďĖĀģăùĒğ üĆĕùĒąĎğĀĢúĖ Ą ċċ xnv xnzyyvxuvovzyvqy " xnvu~n xnvzyyv 1 s v v|yvovnpnnn # xnzyyv py vnpnnn py v o
L #zn– xnzyyv rxsqnqvny ty®uy n
3 C xszxv L s v vuy®vovzyyv zyvqy s v vuy®vovzyyv ~yuznyozxypoypsqy 3 xuvovzyvqy % zyyv uyxvnpn s v vuy®vovzyyv uy®vovzyvqy p®n% & ' – psoynzxqvnyov|tpoy & zyyv uynpn F zyyv uy®vovz nypp{v {ny14% G xnvq s v v|yv vpy ovq ) zyyv o nnoy
L )zn s vuvup v uy®vovzyyvuy®vov|y v vovq {zvqny wvps
3 * zyyv uy®vovnpnnn 14*4
s v vuy®vovzyyv xuvxvnvov|yvnpnnn py v + s v v o xnvov|ysn o K zyyv ~yovn n s v vuy®vovzyyv xvnvovy{xv 11 L py vovnpnnn npn vyv -znq– s vwnyv v wpqyovrynynpnvyv y ypnyp®nvns bzyyvcy~y|zy®npnvyvyv®v % ùėĄĢĎĜ ĒùĎğĀĢúĖ ĄģĎĕĢąėĕēĒüĄĖĨ ü f npzvpoy® y®vryqxyvp f pnynov®y~qzxrq{y fr®yzyw rx®zswnx}nov®y ēĞąģąąþĚ ďę ĀģĎĕĐĕĉėąģďĀĎĩĒċ ûĭ ėĂėċ ûĭ ėāĒą poy zyppoy p£u®up~ py®v|y¢py®zzzz~v sy sv poy zyppoy pwysx upnnyxysszzypvs®up sy sv poy zyppoy pwysx upnnyxysszz®vovpvs®up sy sv ~z rptyuypoyqxyypuz nyoyuvxyss ®ny®{ f zny~z f ~zo f ~zyv vv f {s poy zyppoy p®nov®yxp w{ypoy®vs®upynyxyssps tnyoyuvu®y sy sv poyp r vzzt poyp r uyvzzqy poyp r vzzqy ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ùėĄđĠĝ ĀćĨĒĄùėĄùğ ĀăĖą ûĭ ėĂėċ ûĭ ėāĒą ®yup yzvyv{~pppy v}nz ypp®®y y{yzvyv p|y nynp®z sy sv yzypzvyv p|ynynp®z r – ypwpp{vpoyovvs~ f ~ny p|ynynp®z f nyvz®®v~q ®yup yy zvyv{~pp py v}nz ~wynynyyp x®y®y ny spp x¢ov|~ ùėĄúĖąĢûĜĨ ĒĄĎğĀĢúĖ Ą ûĭ ėĂėċ ûĭ ėāĒą yvqvtypoy vyq¢v®p~ ®yspoypsqyvz npzv f ysp oyov®y svpov ®yv®vny~z f wzuy®vovozspsnvz ov ®yoyunov®ynv v –vuyz f wpq¢vov vup{zpz r{zp – ywp q¢vnyozxypoyp oyz poyp¢vy v}nzzyyv®up {zxuvpz uvyw{y{ spyp ûĝ ĄĐğċąĖĀùėĄēĒüēĖąăĨ ėăėüùėĄþğ üāğď ûĭ ėĂėċ ûĭ ėāĒą poyp r zyvo®snoy poyp r zyyv®ov poyp r yv vzz{zxxv p poyp r v{nz~q®rnn zz~ nyvznytvq~q ®yzw{yqv®zs oyznv {nzpvn ~vqzpoy yy® nyvznytvq~qn~ ûďėċĐėċėĀĆĖąĦĀĩ ûĭ ėĂėċ ûĭ ėāĒą poyp r xup{zpq{y f xuvzyvqy f zyvqy f zyvqyxy{ v{¢p f yv v{zxuvoy vp f yv vy{ vp f nyvynv nyvovzyyv yv v
ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv zzuvpoypz{ynv f®ypwupzzyuzpoyqxy®ty nup}nz r uy~qyx}nov®yrw{y þĜĨ ĎğĀĢúĖ Ą ćĞĩ ćĕĎę ĀćĞĩ ĐĕĸĒü úĕĸėĀăĚĨ ċĚ ĥđĩ Ąĭĩ ėĸĖùĎďċ ĎėÿĎĕĒĺĀ Ĥûü xv®qsq ~zp xsxv ģĄďĒĚ üđĠĖ ü nvsn|z ovqsq {zxxvp ąĨĒĄēĒüĄĖĨ ü nvsn|z ovqsq {zxxvp ĢąėĕĄĖĨ ü zzvyv zy xvv{y ov y ąĨĒĄďėüāĚ Ą xv® rpnp y Ďĭĩ ĸĩ ėĄĩĒÿ t uy|uynv ovqsq xnv Ďĭĩ đĠĖ ü t uy|uynv ozs ovqsq xnv ny~up{zp uyovqy rpnp Ģąù xysnuy xysns y ąĨĒĄďėüģúĄ nv u y xv® rpnp y ûĖĄÿĞĩ xys ĒĝĆĕùĒĄ36' uspuynn uspzxv uspz uspqy ®yny{y |yvqpyov rp y{xv |yvnpnnn pyov y ùėĄďĖĀģăùāğďĢĎĜ ĒùùėĄĆĖąģĎĕúĒąĢúĀùėĄĆĖą ùėĄďĖĀģăù rp oy yo¢p qv zn®n o¢p
ĒĖ ĄĄĚĩ ĐėċėĀĆĖą ĦĀĩ ąĭ " úĒąĢúĀùėĄĆĖą oz opny{z®{y{p uzpoyy ģċĨĄ ąĭĨ ûďėċùďĩ ėüąĨĒĄĄĖĨ ü ûďėċĢĎę ùąĨĒĄĄĖĨ ü ûďėċĐĞ üąĨĒĄĄĖĨ ü ûďėċĐĞ üúĒüąĨĒĄďėü āĚ Ą ģĄďĒĚ üđĠĖ üĢĒĄĦĆđĠĖ ü ĦĀĩ ûďėċĐĞ üąĨĒĄďėüāĚ Ą ċĝċąĨĒĄďėüāĚ Ą ûďėċĐĞ üûĖĄÿĞĩ ûďėċÿėďĤûü ûďėċÿėďĉĜĩ ĄĎĭĩ ċĝċĎĕđďĨ ėüģĄďĒĚ ü đĠĖ üđėąĨĒĄĄĖĨ ü ûďėċĒĨ ĺüĥĄ ùėüđėď ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv zzuvpoypz{ynv f®ypwupzzyuzpoyqxy®ty nup}nz r uy~qyx}nov®yrw{y þĜĨ ĎğĀĢúĖ Ą ćĞĩ ćĕĎę ĀćĞĩ ĐĕĸĒü úĕĸėĀăĚĨ ċĚ ĥđĩ Ąĭĩ ėĸĖùĎďċ ĎėÿĎĕĒĺĀ Ĥûü xv®qsq ~zp xsxv ģĄďĒĚ üđĠĖ ü nvsn|z ovqsq {zxxvp ąĨĒĄēĒüĄĖĨ ü nvsn|z ovqsq {zxxvp ĢąėĕĄĖĨ ü zzvyv zy xvv{y ov y ąĨĒĄďėüāĚ Ą xv® rpnp y Ďĭĩ ĸĩ ėĄĩĒÿ t uy|uynv ovqsq xnv Ďĭĩ đĠĖ ü t uy|uynv ozs ovqsq xnv ny~up{zp uyovqy rpnp Ģąù xysnuy xysns y ąĨĒĄďėüģúĄ nv u y xv® rpnp y ûĖĄÿĞĩ xys ĒĝĆĕùĒĄ36' uspuynn uspzxv uspz uspqy ®yny{y |yvqpyov rp y{xv |yvnpnnn pyov y ùėĄďĖĀģăùāğďĢĎĜ ĒùùėĄĆĖąģĎĕúĒąĢúĀùėĄĆĖą ùėĄďĖĀģăù rp oy yo¢p qv zn®n o¢p
ĒĖ ĄĄĚĩ ĐėċėĀĆĖą ĦĀĩ ąĭ " úĒąĢúĀùėĄĆĖą oz opny{z®{y{p uzpoyy ģċĨĄ ąĭĨ ûďėċùďĩ ėüąĨĒĄĄĖĨ ü ûďėċĢĎę ùąĨĒĄĄĖĨ ü ûďėċĐĞ üąĨĒĄĄĖĨ ü ûďėċĐĞ üúĒüąĨĒĄďėü āĚ Ą ģĄďĒĚ üđĠĖ üĢĒĄĦĆđĠĖ üĦĀĩ ûďėċĐĞ üąĨĒĄďėüāĚ Ą ċĝċąĨĒĄďėüāĚ Ą ûďėċĐĞ üûĖĄÿĞĩ ûďėċÿėďĤûü ûďėċÿėďĉĜĩ ĄĎĭĩ ċĝċĎĕđďĨ ėüģĄďĒĚ ü đĠĖ üđėąĨĒĄĄĖĨ ü ûďėċĒĨ ĺüĥĄùėüđėď ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv zzuvpoypz{ynv f®ypwupzzyuzpoyqxy®ty nup}nz r uy~qyx}nov®yrw{y þĜĨ ĎğĀĢúĖ Ą ćĞĩ ćĕĎę ĀćĞĩ ĐĕĸĒü úĕĸėĀăĚĨ ċĚ ĥđĩ Ąĭĩ ėĸĖùĎďċ ĎėÿĎĕĒĺĀ Ĥûü xv®qsq ~zp xsxv ģĄďĒĚ üđĠĖ ü nvsn|z ovqsq {zxxvp ąĨĒĄēĒüĄĖĨ ü nvsn|z ovqsq {zxxvp ĢąėĕĄĖĨ ü zzvyv zy xvv{y ov y ąĨĒĄďėüāĚ Ą xv® rpnp y Ďĭĩ ĸĩ ėĄĩĒÿ t uy|uynv ovqsq xnv Ďĭĩ đĠĖ ü t uy|uynv ozs ovqsq xnv ny~up{zp uyovqy rpnp Ģąù xysnuy xysns y ąĨĒĄďėüģúĄ nv u y xv® rpnp y ûĖĄÿĞĩ xys ĒĝĆĕùĒĄ36' uspuynn uspzxv uspz uspqy ®yny{y |yvqpyov rp y{xv |yvnpnnnpyov y ùėĄďĖĀģăùāğďĢĎĜ ĒùùėĄĆĖąģĎĕúĒąĢúĀùėĄĆĖą ùėĄďĖĀģăù rp oy yo¢p qv zn®n o¢p
ĒĖ ĄĄĚĩ ĐėċėĀĆĖą ĦĀĩ ąĭ " úĒąĢúĀùėĄĆĖą oz opny{z®{y{p uzpoyy
ģċĨĄ ąĭĨ ûďėċùďĩ ėüąĨĒĄĄĖĨ ü ûďėċĢĎę ùąĨĒĄĄĖĨ ü ûďėċĐĞ üąĨĒĄĄĖĨ ü ûďėċĐĞ üúĒüąĨĒĄďėü āĚ Ą ģĄďĒĚ üđĠĖ üĢĒĄĦĆđĠĖ üĦĀĩ ûďėċĐĞ üąĨĒĄďėüāĚ Ą ċĝċąĨĒĄďėüāĚ Ą ûďėċĐĞ üûĖĄÿĞĩ ûďėċÿėďĤûü ûďėċÿėďĉĜĩ ĄĎĭĩ ċĝċĎĕđďĨ ėüģĄďĒĚ ü đĠĖ üđėąĨĒĄĄĖĨ ü ûďėċĒĨ ĺüĥĄùėüđėď ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv % ùėĄùĭ ėĄğĀĥþĩ ùėĄĢĎĜ Ēù ĒĝĆĕùĒĄ36'²ùėĄĢēĖ Ā ĥđĩ ùĕĀĞùùğùģĒďĹĖĩ Ąûğ ü zzuvpoypz{ynv f ynnz|tpoypsnyt|ywnuybnypnyp®ncov zz{y|ypoypz{ynv ~o¢p®£ uuvz qov .BSJBOysvus{pzny{y|ynyznypoy ~ynvyznypoypqpuyww{yqv{ny14%q{y~p uynnov£yxv f ryvnynpnvyv f |yvnpnnnpy v f uspuynn nyp®nvnsov.BSJBOspyqqvov ùėĄĢēĖ ĀùėĄďĖĀģăù ùėĄďĖĀģăùēĨ ėüùėÿ ċċ ùėĄďĖĀģăùĒğ üĆĕùĒąĎğĀĢúĖ Ą ċċ ûďėċùďĩ ėüûďėċĢĎę ùąĨĒĄĄĖĨ üģĎĕûďėċĐĞ üúĒüąĨĒĄďėüāĚ Ą " xnvu~n xnvzyyv 1 s v v|yvovnpnnn # xnzyyv py vnpn nn py v o
L #zn– xnzyyv rxsqnqvny ty®uy n
3 C xszxv L s v vuy®vovzyyv zyvqy s v vuy®vovzyyv ~yuznyozxypoypsqy 3 ûďėċĐĞ üúĒüąĨĒĄďėüāĚ Ą % zyyv uyxvnpn s v vuy®vovzyyv uy®vovzyvqy p®n% & ' – psoynzxqvnyov|tpoy & zyyv uynpn F zyyv uy®vovz ùėĄĀĖĀģĆüģĎĕđĠĜ ĒĝĆĕùĒĄ36' G xnvq s v v|yv vpy ovq ùėĄďĖĀģăùēĨ ėüùėÿ ċċ ùėĄďĖĀģăùĒğ üĆĕùĒąĎğĀĢúĖ Ą ċċ ) zyyv o nnoy L )zn s vĐĞ üĐĝĀ vuy®vovzyyvuy®v ov|yv vovq {zvq nywvps
3 * zyyv uy®vovnpnnn 14*4
s v vuy®vovzyyv xuvxvnvov|yvnpnnn py v + s v v o xnvov|ysn o K zyyv ~yovn n s v vuy®vovzyyv xvnvovy{xv 11 L py vovnpnnn npnv yv -znq– s vwny v v wpqyovrynynpnv yv y ypnyp®nvns bzyyvcy~y|zy®npnvyvyv®v f ~o¢pqvuz.BSJBO uvzqynvzvo uzrynynpnvyv |yvnpnnnpy v ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv % ùėĄùĭ ėĄğĀĥþĩ ùėĄĢĎĜ Ēù ĒĝĆĕùĒĄ36'²ùėĄēĒü ĐĕĤĉù u~noov4JFOOBzupnvo ®yv{nnqp uyy vq nnoovy snvu y vny{y|ytyvtx vu nv®vnpnvyvnnotsov tvts yvy ®qvt soy pznynyptzvyv®ryvnynpnvyv uy¢zyyv®qv ovo ~vzu~noov f ®zs{ny14%ov4JFOOByuyb{ny14% nypp{v®w {ycovzznynyptpoypz{ynvovtzq{yv £szy®w{yqvzno¢pqv ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ąĨĒ ĄĄ ĖĨ ü Ģą ėĕē Ēü ĄĖĨ ü ~zyyvovqsq ryvnynpnvyv zn
uy¢zyyv® pqvL 3 uy¢zyyv®snuvoy vuznyv{®v¢ yvunvnpnnnL 3 |yvnpnnnpyov
L 3 vnnopyyn L 3 |yvnnopyyn L 3 vnnopyy |ysn o y y 3PCFSUzupnvu~novo ®yv{nnqp uyy vq nnoovy snvu y vny{y|ytyvtx vu unvnpnvyv®vuvov tvts yvy®qvt soy pznynyptpoy® vzyyv yv vnvoy~vzownpyu~nov f ®zs{ny14%ov3PCFSUyuyb{ny14% nypp{v®w {ycovzznynyptpoypz{ynvovtzq{yv £szy®w{yqvzno¢pqv ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ąĨĒ ĄĄ ĖĨ ü ģĎ ĕģ Ąď ĒĚü đĠĖü {p vzyyv yv v xvovzyyvyv v xvynv
ģĄ ďĒĚ üđĠĖ ü ~yv vzzovqsq |yvnpnnnpy v {zztvovyv v yv v®up{zxxvp yv vy{ vp |yvqpyov L 3 vqpyov L 3 y Ăė Ā ąĨĒ Ąď ėü ģú Ą rp pp{vzyvoy L 3 y ģĄ ďĆ ĕû Ēü đğď y{xv zzzy
y{xv zzztv y ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ģĄ ďē Ēü úė ĐĨď ĄĎ ĝĨċ yvuzyvqy L 3 vzyvqy L 3 yvouy L 3 y Đė ÿē ĖĀ uspuynn uspzxv uspqy L 3 uspz y % ùėĄùĭ ėĄğĀĥþĩ ùėĄĢĎĜ Ēù ĒĝĆĕùĒĄ36'²ùėĄēĒüĎĭ ėāğď .BSLs{nyzpwzouy vpzuvpoy®yv v zzoyzyyvpoyovo¢p®rnqvzvyv{y yzy .BSLunysnynyyvqvt vovnvynwy{®v¢ ypoyovnvspvt®v|¢vnvnpnvyvzy ov f y|yzwnny{y|yov.BSL ov f up {ny14%pp~ts .BSLyvqvtpypoyov tqqv{ny14%uz®®vqqvvv{ny14% y{xvvov®y~ts®y f ®yup uv{nyvz y n.BSLp yp pstpoy {wzyov xpnnzny{y{v®up~uzyyvzvyv yv vovpoy fwqvpnqpzynpnnn u~nJq f tpoypup®®ypz~upv uy® ovn y®yw ny{xv vz®.BSLqvnypyp ®yvpszny{xv vzùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù npzvnpnnn~vny zoz opnyvovu~nyyy npnnnupypz~vnypz y5z u~nupnvv ®yv{nnqpz u~nop5zp @@@@@@@ u~ntsp5 zp @@@@@@ rnpnnnzup~vnypđĠĜ u ~nzupnvo ®yv{nnqp– v psyvtx ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ùėĄýĭ ėĎĒüĀĩďÿċĜ āĩĒüùėĄċĚ ģĄďĆĕûĒüđĠĜ ģĄďēĒüĢĉĜĨ Ēĥđĩ ĄĖĨ üĥĄăĨ ė Ćğùùĕāę đĠĜ ĥùĩ ûĺüùĖąăĨ ėĆğùùĕāę ăĚĨ ĐĝĀĢăğĨ ėăĚĨ Đĕąėÿāğď uzquyovvnsr®yv{nnqy{y{pĀĩďÿùėĄĆĕûĒüĀĩďÿċĜ £syrzp £sz ĐĨďĄ ģċĨĄ ąĭĨ ®zs quy®yvup®s®ppps|tpo y s ny{xv vzpsģĎĕ®zs quy ny{xv vz®u¢v ~zyp®yvyynpnnn 3 q 3 3 u~nts 3 u~no 3 nno 3 ots3 oo 3 oqyts 3 oqyo 3 ~yvqvt .BSLqvny fny{xv®ovv py vovnpnnn ®vuvvupy vovnpnnn s{py¢ fny{xvzpy vnpn ov zznynypt nyn poypz{ynv úĭĩ ċĞĄćĞĩ ĥþĩ ĎğĀĢúĖ Ą þĜĨ úĒüćĞĩ ĥþĩ ĎğĀĢúĖ Ą ĢĎùăĚ ďĖĄăĚ ĆĕĢċĚ ĄćğĄ ďĖĄăĚ ĆĖąĎğĀĢúĖ Ą ĥđĩ ĢĹėĕĐğċ þĜĨ ćĞĩ ĆĕĢċĚ ĄćğĄ ĆĕĢĉĀúĕĸėĀģĎĕùėĄāę ĀāĖĩ üĎğĀĢúĖ Ą ĆĕĢĉĀĎğĀĢúĖ Ą oysnypoy® ov úĕĸėĀāĨėüħúĒüĎğĀĢúĖ Ą ċċ xnvzyyv xnzyyv xuvovzyvqy xuvzyvqy ùėĄāę ĀāĖĩ üĎğĀĢúĖ Ą q¢v v ĒĜĨ Ąħ xv ĆĕĢĉĀģĎĕúĕĸėĀĢąėĕēĒüĄĖĨ ü ĆĕĢĉĀĢąėĕēĒüĄĖĨ ü úĕĸėĀ qvzvyv p|ynynp®z ĒĝĆĕùĒĄ36'đĠĜ ùėĄĀĖĀģĆüăĚĨ ýĭ ėĢĆĖ Ą ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ąĨĒ ĄĄ ĖĨ ü Ģą ėĕē Ēü ĄĖĨ ü ~zyyvovqsq ryvnynpnvyv zn uy¢zyyv® pqv L 3 uy¢zyyv®snuvoy vuznyv{®v¢ yvunvnpnnn L 3 |yvnpnnnpyov L 3 vnnopyyn L 3 |yvnnopyyn L 3 vnnopyy |ysn o y y ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ąĨĒ ĄĄ ĖĨ üģ Ďĕ ģĄ ďĒĚ üđĠĖ ü {p vzyyv yv v xvovzyyvyv v xvynv ģĄ ďĒĚ üđĠĖ ü ~yv vzzovqsq |yvnpnnnpy v {zztvovyv v yv v®up{zxxvp yv vy{ vp |yvqpyov L 3 vqpyov L 3 y Ăė Ā ąĨĒ Ąď ėüģ úĄ rp pp{vzyvoy L 3 y ģĄ ďĆ ĕû Ēü đğď y{xv zzzy y{xv zzztv y ģĄ ďē Ēü úė ĐĨď ĄĎ ĝĨċ yvuzyvqy L 3 vzyvqy L 3 yvouy L 3 y Đė ÿē ĖĀ uspuynn uspzxv uspqy L 3 uspz y ĎėÿĢþĖ Ąúĭĩ āğùĎğ ü ćĞĩ ĥþĩ ĎğĀĢúĖ Ą ćĞĩ ĆĕĢċĚ Ą ćğĄ ćĞĩ ýĖĀùėĄùėĄ ąĭ Ďę ùėĄĎğĀĢúĖ Ą +PTFQIJOFs{nyzpwzouy vuzytyyzp yutn® yovzpy®vrynspzpoy®~y®stv n~yvsuzxzxovynys|y~ypy®zz~vyzyov upspoypsqyvp¢s¢vyy®~yz~vpoy o¢p®rnqvuzyv vzyyvzzovxv®z vyv®tzy¢ +PTFQIJOFzuzsqypoynv~zysnoyynyspoyps qyvyvps®npnnny{ v npnnnv{ v ®q ovynv{¢ f y|yzwnny{y|yov+PTFQIJOF ov f up {ny14%pp~ts +PTFQIJOFyvqvtpypoyov f tqqv{ny14%qqvvv{ny14%y{xvvov ®y~ts®y f ®yup uv{nyvz y n+PTFQIpyp pstpoy{w zyov xpnnzny{y{v®up~uzyyvzvyvyv vovpoy f wqvpnqpzynpnnn u~nJq f tpoypup®®ypz~upv uy® ovn y®yw ny{xv vz®+PTFQIJOFqvnypyp ®yvpszny{xv vz ùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù npzvnpnnn~vny zoz opnynvovu~nyyy npnnnupypz~vnypz y5z u~nupnvv ®yv{nnqpz u~nop zp5vu tsu~ny5 z @@@@@@ rnpnnnzup~vnypđĠĜ u ~nzupnvo ®yv{nnqp– v psyvtx ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ùėĄýĭ ėĎĒüĀĩďÿċĜ āĩĒüùėĄċĚ ģĄďĆĕûĒüđĠĜ ģĄďēĒüĢĉĜĨ Ēĥđĩ ĄĖĨ üĥĄăĨ ė Ćğùùĕāę ĥùĩ ûĺüùĖąăĨ ėĆğùùĕāę ăĚĨ ĐĝĀĢăğĨ ėăĚĨ Đĕąėÿāğď uzquyovvnsr®yv{nnqy{y{pĀĩďÿùėĄĆĕûĒüĀĩďÿċĜ £syrzp £sz ĐĨďĄ ģċĨĄ ąĭĨ ®zs quy®yvup®s®ppps|tpoyps ny{xv vzpsģĎĕ®zs quy ny{xv vz®u¢v ~zyp®yvyynpnnn 3 q 3 3 u~nts 3 u~no 3 nno 3 ots3 oo 3 oqyts 3 oqyo 3 +PTFQIJOFzupyvqvty®yv {nnqp®yvup®sov y f qnv{®v¢ f vv{®v¢ f npnnnv{®v v ®yvovpoypsyv ny{xvq{y f yvtxnvnpnv yvnnots f uvvupy vnpnnn ny{xvzzu~pquz quyuy®v zznynypt nyn poypz{ynv úĭĩ ċĞĄćĞĩ ĥþĩ ĎğĀĢúĖ Ą þĜĨ úĒüćĞĩ ĥþĩ ĎğĀĢúĖ Ą ĢĎùăĚ ďĖĄăĚ ĆĕĢċĚ ĄćğĄ ďĖĄăĚ ĆĖąĎğĀĢúĖ Ą ĥđĩ ĢĹėĕĐğċ þĜĨ ćĞĩ ĆĕĢċĚ ĄćğĄ ĆĕĢĉĀúĕĸėĀģĎĕùėĄāę ĀāĖĩ üĎğĀĢúĖ Ą ĆĕĢĉĀĎğĀĢúĖ Ą oysnypoy® ov úĕĸėĀāĨėüħúĒüĎğĀĢúĖ Ą ċċ xnvzyyv xnzyyv xuvovzyvqy xuvzyvqy ùėĄāę ĀāĖĩ üĎğĀĢúĖ Ą q¢v v y xv ĆĕĢĉĀģĎĕúĕĸėĀĢąėĕēĒüĄĖĨ ü ĆĕĢĉĀĢąėĕēĒüĄĖĨ ü úĕĸėĀ qvzvyv p|ynynp®z ĒĝĆĕùĒĄ36'đĠĜ ùėĄĀĖĀģĆüăĚĨ ýĭ ėĢĆĖ Ą ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ąĨĒ ĄĄ ĖĨ ü Ģą ėĕē Ēü ĄĖĨ ü ~zyyvovqsq ryvnynpnvyv zn uy¢zyyv® pqv L 3 uy¢zyyv®snuvoy vuznyv{®v¢ yvunvnpnnn L 3 |yvnpnnnpyov L 3 vnnopyyn L 3 |yvnnopyyn L 3 vnnopyy |ysn o y y ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ąĨĒ ĄĄ ĖĨ ü ģĎ ĕ ģĄ ďĒ Ěüđ ĠĖü {p vzyyv yv v xvovzyyvyv v xvynv
ģĄ ďĒ Ěüđ ĠĖü ~yv vzzovqsq |yvnpnnnpy v {zztvovyv v yv v®up{zxxvp yv vy{ vp |yvqpyov L 3 vqpyov L 3 y Ăė Ā ąĨĒ Ąď ėü ģú Ą rp pp{vzyvoy L 3 y ģĄ ďĆ ĕû Ēü đğď y{xv zzzy y{xv zzztv y ģĄ ďē Ēü úė ĐĨď ĄĎ ĝĨċ yvuzyvqy L 3 vzyvqy L 3 yvouy L 3 y Đė ÿē ĖĀ uspuynn uspzxv uspqy L 3 uspz y ĎėÿĢþĖ Ąúĭĩ āğùĎğü ćĞĩ ĥþĩ ĎğĀĢúĖ Ą ćĞĩ ĆĕĢċĚ ĄćğĄ ćĞĩ ýĖĀùėĄùėĄ ąĭ Ďę ùėĄĎğĀĢúĖ Ą 4JBOs{~nyu¢vpoyzz~ zonyo¢ppnys® zyvqyzznv{pzyyvyv vzzoyzrpzz vyvpoyxnzyyv®rnqvuz qynv¢s¢v ~ovzp s~nosv{ury®qv~noups{ yttypstpoyypnqzvxv~non{ 4JBOupspoy psqyvp¢s¢vy~y|®z~v4JBOupyvqvtp{yuy pszny{xv ts vwny®qov sops {nnqyq{®v¢{®vzvtsyp npnnnovsn oyzvoy¢nrs®vunpnvyvzvtso sn vovxnv{nnquzsyov4JBOqvny up yov ynnzpnysxyypspoyovv f y|yzwnny{y|yov4JBO ov f up {ny14%pp~ts 4JBOyvqvtpypoyovtqqv {ny14%qqvvv{ny14%y{xvvov®y~ts®y f ®yup uv{nyvz y n4JBOpyp pstpoy{wzy ov xpnnzny{y{v®uppuzyyvzvyvyv vov poy f wqvpnqpzynpnnn u~nJq f tpoypup®®ypz~upv uy® ovn y®yw ny {xv vz®4JBOqvnypyp ®yvpszny{xv vz ùėĄùďĀĢąęĨ üăĨ ėùĕĀĞùùğùģĒďģĎĕĐĕĤĉù npzvnpnnn~vny zoz opnynvovu~nyyy npnnnupypz~vnypz y5z u~nupnvv ®yv{nnqpz u~nop zp5vu u~ntsp zp5vu rnpnnnzup~vnypđĠĜ u ~nzupnvo ®yv{nnqp– v psyvtx ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ùėĄýĭ ėĎĒüĀĩďÿċĜ āĩĒüùėĄċĚ ģĄďĆĕûĒüđĠĜ ģĄďēĒüĢĉĜĨ Ēĥđĩ ĄĖĨ üĥĄăĨėĆğùùĕāę ĥùĩ ûĺüùĖąăĨėĆğùùĕāę ăĚĨ ĐĝĀĢăğĨ ėăĚĨ Đĕąėÿāğď uzquyovvnsr®yv{nnqy{y{pĀĩďÿùėĄĆĕûĒüĀĩďÿċĜ £syrzp £sz ĐĨďĄ ģċĨĄ ąĭĨ ®zs quy®yvup®s®ppps|tpoyps ny{xv vzpsģĎĕ®zs quy ny{xv vz®u¢v ~zyp®yvyynpnnn q u~nts u~no nno ots oo oqyts oqyo 4JBOupyvy®yv{nnqp ypnqpsu~n®vuv nvony vq nnoy{yvu ~yvqvt4JBOqvny f nyvps vzztxnvnno®vuvzv f tzv¢vvqovovnpnnnovpswz ¢ypsny{xv®ysypy vovnpnnnov f vzv¢vuqovovq pswz¢yyv {xv®qvnyzvtsyuvnzvo¢s¢v f ny{xvzzynpn py¢ovn zznynypt nyn poypz{ynv úĭĩ ċĞĄćĞĩ ĥþĩ ĎğĀĢúĖ Ą þĜĨ úĒüćĞĩ ĥþĩ ĎğĀĢúĖ Ą ĢĎùăĚ ďĖĄăĚ ĆĕĢċĚ ĄćğĄ ďĖĄăĚ ĆĖąĎğĀĢúĖ Ąĥđĩ ĢĹėĕĐğċ þĜĨ ćĞĩ ĆĕĢċĚ ĄćğĄ ĆĕĢĉĀúĕĸėĀģĎĕùėĄāę ĀāĖĩ üĎğĀĢúĖ Ą ĆĕĢĉĀĎğĀĢúĖ Ą oysnypoy® ov úĕĸėĀāĨėüħúĒüĎğĀĢúĖ Ą ċċ xnvzyyv xnzyyv xuvovzy vqy xuvzyvqy ùėĄāę ĀāĖĩ üĎğĀĢúĖ Ą q¢v v y xv ĆĕĢĉĀģĎĕúĕĸėĀĢąėĕēĒüĄĖĨ ü ĆĕĢĉĀĢąėĕēĒüĄĖĨ ü úĕĸėĀ qvzvyv p|ynynp®z ĒĝĆĕùĒĄ36'đĠĜ ùėĄĀĖĀģĆüăĚĨ ýĭ ėĢĆĖ Ą ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ąĨĒ ĄĄ ĖĨ ü Ģą ėĕē Ēü ĄĖĨ ü ~zyyvovqsq ryvnynpnvyv zn
uy¢zyyv® pqv L 3 uy¢zyyv®snuvoy vuznyv{®v¢ yvunvnpnnn L 3 |yvnpnnnpyov L 3 vnnopyyn L 3 |yvnnopyyn L 3 vnnopyy |ysn o y y ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ĎėÿùėĄùďĀĐĭ ėĎĖą36' Ēĕăę ąėÿģāĩċēĞąģĎĕąĒùúĕĸėĀ ąĨĒ ĄĄ ĖĨ ü ģĎ ĕ ģĄ ďĒĚ üđĠĖ ü {p vzyyv yv v xvovzyyvyv v xvynv
ģĄ ďĒĚ üđĠĖ ü ~yv vzzovqsq |yvnpnnnpy v {zztvovyv v yv v®up{zxxvp yv vy{ vp |yvqpyov L 3 vqpyov L 3 y Ăė Ā ąĨĒ Ąď ėü ģú Ą rp pp{vzyvoy L 3 y ģĄ ďĆ ĕ ûĒ üđ ğď y{xv zzzy y{xv zzztv y ģĄ ďē Ēü úė ĐĨď ĄĎ ĝĨċ yvuzyvqy L 3 vzyvqy L 3 yvouy L 3 y Đė ÿē ĖĀ uspuynn uspzxv uspqy L 3 uspz y ĎėÿĢþĖ Ąúĭĩ āğùĎğü ćĞĩ ĥþĩ ĎğĀĢúĖ Ą ćĞĩ ĆĕĢċĚ ĄćğĄ ćĞĩ ýĖĀùėĄùėĄ ąĭ Ďę ùėĄĎğĀĢúĖ Ą % ùėĄùĭ ėĄğĀĥþĩ ùėĄĢĎĜ Ēù ĒĝĆĕùĒĄ36'²ùėĄĆĕûĒü đğ ďùėĄēĒüùğùúėģĎĕúėĐĨďĄĎĝĨċ yqzxrq{y +POBIppny{y|yy vny wvps®y~zoov+POBInw{ ®vov nvn qrny{xv ts n ys®yupyoovnzu®yv{nnqp onnyn f ®yxpny{y{vp®®yuppqnzpoy zvyv~ts yvps®oy®yv {nnqp 4BNptpoyy{yuv{ny zpwz oovoyovovxv yny{y|y®y~zoov4BNopoyq ®yuppv oovnwnnyu®yv {nnqpypnqytv¢s¢vps® oy®yv{nnqn4BNunpypvn f ®yxpny{y{vp®®yuppqnzpoy zvyv~ts yvps®oy®yv {nnqp &MJKBIpwpoyovup~zp upyuyp s{wnzypnov pypnq vovwz~z oovoponyy vny{y|y®y ~z&MJKBIupyvy®yv{nnqpps ny{xvnysoovupyvy®yv {nnqp f ®yxpny{y{vp®®yuppqnzpoy zvyv~ts yvps®oy® {nnqp ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv Ćĕāę ąĖĀāğďýę ü ùėĄùĕùĺċćĕĎę ĀāĕĉĖĄ ĎğĀĢúĖ Ą ²ĎėÿùėĄ ùďĀĸĩ ėďĺù f tqqvov~ts®yv|ynn poy{ny14% – znq¢n p®ypz®¢nxywrnpup – qpuyw|wz|ptzuz¢n – £sq¢nyup ąĒùģāĨĎĕĸĩ ėďĺùĢĆĖ ĄĎėÿùėĄ ąĝùûğĄ ēĖąćę ĀþĒą ĹėÿĢĒğ ėĢċĜĨ Ē Đĭ ėĢĎĖ ĀģĎĩď " " Ćĕāę ąĖĀāğďýę ü ùėĄùĕùĺċćĕĎę ĀāĕĉĖĄ ĎğĀĢúĖ Ą ²ĎėÿùėĄ ùďĀûďėċĆĒĀĦĉģĎĕùėĄĉĩĒċĥþĩüėĄĐĭ ėĎĖąĎğĀĢúĖ ĄĎĕĀĖąĆėĄùėü pyysnynpx{p~x~tvyopoypz{ynv~ z{nypoy{p~~ |tpoyvt ăĖüĹğ ĀĎğĀĢúĖ ĄĎďċăĖüĒĝĆĕùĒĄ36' zozx zuyus s opop poyxy®{yyuyt Ďĭĩ ĸĩ ė £ypvpu £ypszu~pnzo yp y¢yp ĢĎğ ėúėĎĭĩ ĸĩ ė o¢£ypvpu Ďĭĩ đĠĖ ü £ypvpu ypny~ y¢yp puzvvrnqv t{npzv vuprnzzopzny ozsx{p~ Ģąù tvypvrnqv ąĨĒĄďėüāĚ Ą zyvqyrn{nzv¢y¢£yxv Ĥûü uzpoyzz~zony– poy~zonvnpvvsps uzpoy®zyvqyzz~zv– zyvqy~znvnpvvsps ĢąėĕĄĖĨ ü zvyvy zvrnqv zvyvqv®vpoyvrnqv | zvyv¢y¢qz¢yny{ rpoyzyyvovxv®zvyvqv{n zyyvovxv®yyvquy ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv " # % ùėĄĈě ùĒğąēğċćĞĩ ĥþĩ f y¢vyv|tpoyovx}nov®ywzn®y yyp f qpuyw®nupp®|tpoyw{yqvy~ uptzvsvnup oy£ovowpupsnynpuzny}nz|tpoypz{ynv ¢q{ f nzpzp¢®ov|tpoy ~ynvy z ypoy xyyxzx|zsvp |tpoyznxy®p¢®ov~ynvy znypoyxy}nuyv¢su ®nu y nutnyyntxpz b®p ny}nz|tpoy{uz |yupc®®zsy~nyov{xvvov®y - . / 0 1 ) +PTIVBs{~nyu¢vnyxy ®xzxzpzz n®y yprnnypt pz poypnys®{ y14%tv uspzq |yvovnpnnn|yvovq+PTIVB|¢v® zvy s|yvovqprnu¢v ~nzyv~up ~tsz{nyz |np®zwn|yvovq poy£ov+PTIVBxyuzpnyvtvysp poyv{py vyz vxvxwnnzxyunyqvtynyysv®yn ypoy{ tvupn wn®v{puznypy®v|y~ypy®zz oyvozr¢yuz nyoyuvpoy v®uprpnpzyyvup{pnwnxvp oyp +PTIVB{vyyzyy®ntnyzpsnyznyoyuv®wp psvyyzy~ yypsyuo¢pys~ov{y nvynnzpoyovw~ppyy z +PTIVBpuzny{zpoy£ov £uovy 6DQJLWD 4BOHJUBsu{npnuy v x svsnynyxy { uyusxunv{sxuyovnpnuy vov ~ovznx svsnynyxzxnysnyoz rsywnynuz®uvss 4BOHJUB nyznypoyuzny{zpoy®pov £utv {s uspnpnnn |yvovnpnnnzvztvovyv v~ nynynp®zzysxynpnuy vovsvzvyv p|ynynp®z~nz~®vuv~onvyrpoy wznsvpsxz{ovypnqpz~wzup ynzssyvovyny "$ .LP6RP ,JN4PNs{nyzpwz {nyyws| s~ xznynynynpnuy v®nv{¢xv® ,JN4PNzupyoyp uuov®v£pz ypnqovzno wxyyvsps yny{y|yrnz{y|xuvnp|np®z~ws s z upxy {vpxs|np®znyypp wnnyyyy qv npzpoy®povpoyzv v p|ynynp®z {ny14%~ts ,JN4PNyvpuzsqnovy|p ponyyp£s~{zpoy £u~nz ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv " % snynpuzny}nzz|tpoypz{ynv ăĖùĐĕăĚĨ āĩĒüĐĒĄ ăĖùĐĕăĚĨ ĦĀĩ ĐĒĄģĎĩď ùėĄýĖĀùėĄĎğĀĢúĖ Ą ny~znysnpoy nyrpnny{nzoxyuz{ny14%®w{yqv rpnuznyoyuvxyss nyt{s nytzn nyvrzny{y rt q¢v®rnqvov{ny14%y®|tpoyypoy nytzvyv®vnyvq¢vvrnqv ùėĄĢûĜĨ ĒĄÿĩ ėÿ nyxysspsqyv nyxysspsnyts y ùėĄĥþĩ ĎğĀĢúĖ ĄģĎĕùėĄĢûĜĨ ĒĄĦđďĦĆċė nyspoyvrnqv pst®®nov|tpoy oyvyyxs oyvoyp ®v~y®zz~v |tpoyzvxvx yvypoypy{yp uzpnys| s®x qvny{nyvznytvq~q nyszznyts ùėĄĆĩĒüùĖĄģćùğĀăĖą npzv|np®zzy®nynp®zuv nysn~ p|ynynp®z nypppy s uv®qvprnp|np®z "& ăĖùĐĕăĚĨ āĩĒüĐĒĄ ăĖùĐĕăĚĨ ĦĀĩ ĐĒĄģĎĩď ďę ăĚ ùėĄĢąęĨ üģÿüĀĞ ģĎĎğĀĢúĖ ĄČĞĨ ĢēĜ ĒĄ ypoy vtpzvuv{n zv yv v uyyuy®xy¢vovpoy uzvpoy yypqypq| ¢y xvppoy npzvy z npzvo£v npzvzvyv ĐęĨ üăĚĨ āĩĒüĢēĖ ĀĂĩ ėċĚ ąĖ Ąđė poyqvnynyu{v poyz~p zuzsq ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv " ' % ùėĄēĨďċģēüēĨďċĥýùĖĄ f nnzpyu¢y®uz®v£pnnnz|tpoy®nov®ypny uv®nov®ypy zpyu¢xyoq{y úĭĩ ċĞĄăĚĨ ĦĀĩ ēĖąýėùùėĄĆĕĢċĚ ĄćğĄ f {£sov|tpoy {y svwvq nypoy f xqvny®vvnsovow f xqvnypyrtpovow f poy z– poyyqzu¢vpxqvnyovow z f ny xuv { pnynp|np®z f ®nyspoy f ®yvpszny{xv vz f |yovnynp®npnnnu~n f |yovnywvps ĎğĀĢúĖ ĄģĎĕĢąėĕēĒüĄĖĨ üăĚĨ ùĭ ėĄğĀĥþĩ ĢĎĜ Ēù f {~ppoy f {~pzvyv f {ny14%Tqv®rnnypt ùėĄĆĖąĥđĩ ĢĹėĕĐğċ f zy qv®rnzy{zpoy £uw{yqvpznynoz – r uv yrnnoyp ùėĄĈě ùĒğąēğąćĞĩ ĥþĩ f |tpoynpqpuyww{yqv svpyny}nz|t ûĭ ėĢđĖ Ąāę þğċúĒüćĞĩ ĥþĩ ĎğĀĢúĖ Ą f vwnpzpoy– |tpoyxxp yxqtz ģćĄùėĄāę ĀāėċćğĄ f pnypnywpqypuznyqpq|y % ùėĄąĭ ėĎĝ üēĖùĐėùėĄĐĩĒċģĆüģĎĕùėĄāę ĀāėċćğĄ f yqvov|tpoy f pupzznyqpq|ypoyuz|t poyqxy f ®zszy®n®nnypyyny®qvp 7KXVLWKD 5IVTJUIBs{uyy~sov{y~spnyu pzpoy|ynyznypoy¢v{nyyyyyupsvps uyuppnyxysszzyonwnpoyppsqyvzn qvnypoy~~zysnyny{vy ynyqpq|y 5IVTJUIBznpynv~zysynyon wnpoyovpsqyvunszuzsqyqyzsvyyp ysnynyu®poyovo¢p®rnqv yv vzzoypz xvnvzvyvzzvsps®uzsq rnvo wpypz5IVTJUIB~wupnzpoyovzn~wwn ( , 2 3 4 4 ) .JSFMMBs{~nyu¢v|py|vosyyq p®vryp zpoyzzprzuuv{nyyqvn zv{n y14%~upypoy pznynyptzvyvty®nypp{v ~|yvnpnnn py vuyv vovpoy ynyqpq|y.JSFMMBzntpoy przuov®ny~ {nzwnq p svyw{yqvu{vvuv®zpyynpzvpoy ~ynvyznypoy~zvpoy y s|yvnpnnnpy vp pv{ ®vzyyvzvyv{npzyz s rnvo wpypz~wupnzpoyov.JSFMMB xyywn 5 2 / 1 4 ) 6STVMBs{~nyu¢vnv~vnzsovyxyv{uyuvov zppzpoy®{ny14%{ppynyy wz{spsnyqpt¢np~pnyy £sqpq|yxv®pov~ov znzpyyzpwynyyvpoyvonwnpoy vwn¢vtv ~nouv p yst®vnpnovovnnz¢vy|yvovquvuyp wyzy z ~ynvyznypoytn ury®{yuyqoyspy6STVMB~ov ~npzv|¢vov~ynvyznypoyyyst®~nonpzvpoy ~zyu®{y®v|yvovqpnpzz rnvo wpypz~no~wupnzpoyov6STVMB ~ov xyywn ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ģąąĊĒċùėĄāę ĀāėċćğĄĎğĀĢúĖ Ą úĭĩ ċĞĄćĞĩ ĥþĩ ĎğĀĢúĖ Ą tov|tpoy@@@@@@@@@@@@@@@@@@@@@@@@@ n®@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ y®{zpoy £u@@@@@@@@@@@@@@@@@@ y®qpq|y@@@@@@@@@@@@@@@@@@@@@@ tovznxy®pyynyqpq|y@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ nyqpq|ypyyyov|tpoy uyznypoy zyy@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ ùėĄĐĭ ėĉėĀ ąĖĄăě ùùėĄĀĭ ė ĢĄĚ ĄăĚĨ āĩĒüĢēĖ Ā ®ynvtpoyov®y sq®®yqvnyz y z rz– sy sv ®yzy qvynytpoyov®yz z r– zy y sv ®yxrqvnnznytpoyov®yz z r– xr svw{yqvny}nz~qz |tpoy|np®zpz z ®zzs wp®qvpz
®ywwpypzx~wqnzpoyov®yupwn– yz~wy~w®up ypz xxp y ùėĄùďĀĢąęĨ üĎğĀĢúĖ ĄģĎĕĢąėĕēĒüĄĖĨ ü poyyu~ztvypp{p~ynytyz y z zvyvyu~ztvypp{p~ynyt yz y z rzuzyp¢v zy y sv ùėĄùďĀĢąęĨ üûďėċĉĭ ĀĚ poyx£u~pvrnqvyz y z rz– zy y sv pz®puznynp®z {p~ qy~ z{p~ r|txuvnp|np®z ts o |tpoyyvqvtvuzsqzyz¢vqv xyss {q p y z rz– zy y sv ģąąĊĒċùėĄāę ĀāėċćğĄĎğĀĢúĖ Ą úĭĩ ċĞĄćĞĩ ĥþĩ ĎğĀĢúĖ Ą tov|tpoy@@@@@@@@@@@@@@@@@@@@@@@@@ n®@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ y®{zpoy £u@@@@@@@@@@@@@@@@@@ y®qpq|y@@@@@@@@@@@@@@@@@@@@@@ tovznxy®pyynyqpq|y@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ nyqpq|ypyyyov|tpoy uyznypoy zyy@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ ùėĄĐĭ ėĉėĀ ąĖĄăě ùùėĄĀĭ ė ĢĄĚ ĄăĚĨ āĩĒüĢēĖ Ā ®ynvtpoyov®y sq®®yqvnyz y z rz– sy sv ®yzy qvynytpoyov®yz z r– zy y sv ®yxrqvnnznytpoyov®yz z r– xr svw{yqvny}nz~qz |tpoy|np®zpz z ®zzs wp®qvpz
®ywwpypzx~wqnzpoyov®yupwn– yz~wy~w®up ypz xxp y ùėĄùďĀĢąęĨ üĎğĀĢúĖ ĄģĎĕĢąėĕēĒüĄĖĨ ü poyyu~ztvypp{p~ynytyz y z zvyvyu~ztvypp{p~ynyt yz y z rzuzyp¢v zy y sv ùėĄùďĀĢąęĨ üûďėċĉĭ ĀĚ poyx£u~pvrnqvyz y z rz– zy y sv pz®puznynp®z {p~ qy~ z{p~ r|txuvnp|np®z ts o |tpoyyvqvtvuzsqzyz¢vqv xyss {q p y z rz– zy y sv ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv ģąąĊĒċùėĄāę ĀāėċćğĄĎğĀĢúĖ Ą úĭĩ ċĞĄćĞĩ ĥþĩ ĎğĀĢúĖ Ą tov|tpoy@@@@@@@@@@@@@@@@@@@@@@@@@ n®@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ y®{zpoy £u@@@@@@@@@@@@@@@@@@ y®qpq|y@@@@@@@@@@@@@@@@@@@@@@ tovznxy®pyynyqpq|y@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ nyqpq|ypyyyov|tpoy uyznypoy zyy@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ ùėĄĐĭ ėĉėĀ ąĖĄăě ùùėĄĀĭ ė ĢĄĚ ĄăĚĨ āĩĒüĢēĖ Ā ®ynvtpoyov®y sq®®yqvnyz y z rz– sy sv ®yzy qvynytpoyov®yz z r– zy y sv ®yxrqvnnznytpoyov®yz z r– xr svw{yqvny}nz~qz |tpoy|np®zpz z ®zzs wp®qvpz
®ywwpypzx~wqnzpoyov®yupwn– yz~wy~w®up ypz xxp y ùėĄùďĀĢąęĨ üĎğĀĢúĖ ĄģĎĕĢąėĕēĒüĄĖĨ ü poyyu~ztvypp{p~ynytyz y z zvyvyu~ztvypp{p~ynyt yz y z rzuzyp¢v zy y sv ùėĄùďĀĢąęĨ üûďėċĉĭ ĀĚ poyx£u~pvrnqvyz y z rz– zy y sv pz®puznynp®z {p~ qy~ z{p~ r|txuvnp|np®z ts o |tpoyyvqvtvuzsqzyz¢vqv xyss {q p y z rz– zy y sv # " Ćĕāę ąĖĀāğďýę ü ùėĄĆĕĢċĚ ĄćğĄùėĄùĭ ėĄğĀĥþĩĎğĀĢúĖ Ą ùėĄ ĢĎĜ Ēù ùėĄùĕùĺċćĕĎę ĀāĕĉĖĄ ĎğĀĢúĖ Ą ùėĄĆĖąĎğĀĢúĖ Ąĥđĩ ĢĹėĕĐğċģĎĕùėĄĈě ùĒğąēğċćĞĩ ĥþĩ nynn|pq~y poy – snynp¢n f tqqvov~ts®yv|ynn poy{ny14%uz ny{zpoy £uxv®po|t – znq¢n p®ypz®¢nxywrnpup – qpuyw|wz|ptzuz¢n – £sq¢nyup ąĒùģāĨĎĕĸĩ ėďĺùĢĆĖ ĄĎėÿùėĄ ąĝùûğĄ ēĖąćę ĀþĒą ĹėÿĢĒğ ėĢċĜĨ Ē Đĭ ėĢĎĖ ĀģĎĩď ĎğĀĢúĖ Ą þĝĀĈě ùĒğ ąēğċùėĄąĭ Ďę ùėĄ pz{ynv # # Ćĕāę ąĖĀāğďýę ü ùėĄĆĕĢċĚ ĄćğĄùėĄùĭ ėĄğĀĥþĩĎğĀĢúĖ Ą ùėĄĢĎĜ Ēù ùėĄ ùĕùĺċćĕĎę ĀāĕĉĖĄ ĎğĀĢúĖ Ą ùėĄĆĖąĎğĀĢúĖ Ąĥđĩ ĢĹėĕĐğċģĎĕùėĄĈě ùĒğąēğċćĞĩ ĥþĩ f pyysnynpx{p~x~tvyopoypz{ynv~ z{nypoyy~ |tpoyv snynpx{p~x~ovpoypz{ynv ăĖüĹğ ĀĎğĀĢúĖ ĄĎďċăĖüĒĝĆĕùĒĄ36' zozx zuyus s opop poyxy®{yyuyt Ďĭĩ ĸĩ ė £ypvpu £ypszu~pnzo yp y¢yp ĢĎğ ėúėĎĭĩ ĸĩ ė o¢£ypvpu Ďĭĩ đĠĖ ü £ypvpu ypny~ y¢yp puzvvrnqv t{npzv vuprnzzopzny ozsx{p~ Ģąù tvypvrnqv ąĨĒĄďėüāĚ Ą zyvqyrn{nzv¢y¢£yxv Ĥûü uzpoyzz~zony– poy~zonvnpvvsps uzpoy®zyvqyzz~zv– zyvqy~znvnpvvsps ĢąėĕĄĖĨ ü zvyvy zvrnqv zvyvqv®vpoyvrnqv | zvyv¢y¢qz¢yny{ rpoyzyyvovxv®zvyvqv{n zyyvovxv®yyvquy #$ *4#/ Đĭ ėĎĖąúĭĩ ċĞĄĢĉĚĨ ċĢāĚ ċĥđĩ āę ĀāĭĨ đė 8PSME)FBMUI0SHBOJ[BUJPO vnyyn
"WFOVF"QQJB $)(FOFWB 4XJU[FSMBOE ® n XXXXIPJOUEJTBCJMJUJFTFOEBS!XIPJOU
WHO/NMH/VIP/DAR/13.02 ອອກ ແບບ ໂດຍ Inís Communication – www.iniscommunication.com ລົດເຂັນ ຊຸດຝຶກອົບຮົມການ ບໍລິການ ລະດັບປານກາງ ເດັ ກ ນ້ ອ ຍ ແ ລ ະ ລົ ດ ເຂັ ນ ລົດເຂັນແລະແນວຮອງຮັບທ່າທາງພິເສດສາມາດຊ່ວຍໃຫ້ເດັກນ້ອຍ: ການ ນ�າ ສົ່ງ ໄວ ແຕ່ ຕົ້ນໆ ສ�າລັບ ລົດ ເຂັນ ແລະ ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ພິ ເສດ ແມ່ນ ສ�າຄັນ ຫຼາຍ. ເຄື່ອນ ໄຫວ ໄປມາ ໄດ້ ສື່ສານ ໄດ້ ກິນ ດ້ວຍ ຕົນ ເອງ ໄດ້ ໄປ ໂຮງຮຽນ ໄດ້ ຫຼິ້ນກັບ ໝູ່ ເ ພື່ອນ ໄດ້ ພາຍໃນອາຍຸໜ່ຶງປີ – ເດັກນ້ອຍ ສ່ວນ ໃຫຍ່ ສາມາດ ນັ່ງ ໄດ້ ດ້ວຍ ຕົນ ເອງ; ແລະ ກ�າລັງ ດຶງ ຕົນ ເອງ ຂຶ້ນ ຢືນ ພາຍໃນອາຍຸສອງປີ – ເດັກນ້ອຍ ສ່ວນ ໃຫຍ່ ສາມາດ ຍ່າງ ໄດ້ ດ້ວຍ ຕົນ ເອງ ເດັກນ້ອຍທ່ີມີຄວາມລໍາບາກໃນການເຮັດສ່ິງເຫ່ົຼານ້ີອາດຈະຈໍາເປັນຕ້ອງມີລົດເຂັນແລະ ອຸປະກອນຮອງຮັບການຊົງຕົວພິເສດ.ຈ່ົງນໍາສ່ົງຫາການປະເມີ່ນຜົນລົດເຂັນ. WHO/NMH/VIP/DAR/13.02 ອອກ ແບບ ໂດຍ Inís Communication – www.iniscommunication.com ລົດເຂັນ ຊຸດຝຶກອົບຮົມການ ບໍລິການ ລະດັບປານກາງ ທ່ າທ າງ ຕ່ າງ ໆ ເດັກນ້ອຍ ຜູ້ ທີ່ ໃຊ້ ລົດ ເຂັນ ແລະ ມີ ຄວາມ ສາມາດ ຈ�າກັດ ໃນ ການ ປ່ຽນ ຕ�າ ແໜ່ ງ ຫຼື ທ່າ ທາງ ຂອງ ເຂົາ ເຈົ້າ – ຕ້ອງການ ແນວ ຮອງ ຮັບ ໃນ ທ່າ ທາງ ຕ່າງໆ ໃນ ຕອນ ກາງ ເວັນ ແລະ ກາງຄືນ. ການນ່ັງ ການຢືນ ການນອນ ການ ຢືນ ຊ່ວຍສ້າງ ຂ�້ ຕ�່ ສະ ໂພ ກ ແລະ ການ ກົ່ງ ປົກກະຕິ ຂອງລ�າ ຕົວ/ກະດູກ ສັນຫຼັງ. ການຢືນ ຍັງ ຢືດກ້າມ ຊີ້ນ ບ�ລິ ເວນ ສະ ໂພ ກ, ຫົວ ເຂົ່າ ແລະ ຂ�້ ຕີນ ແລະ ຊ່ວຍ ປ້ອງ ກັນ ບ�່ ໃຫ້ ຂ�້ ຕ�່ ເຫຼົ່ານ້ີ ແຂງ. ໃຫກ້ານ ຮອງຮບັສ�າລບັ ເດກັນອ້ຍ ໃນ ເວລາ ນອນ ເພ່ືອ ຊວ່ຍ ພວກ ເຂາົ ຫຼິນ້ ແລະ ນອນ ໄດ ້ຢາ່ງ ສະບາຍ ຕວົ. ໃນ ເວລາ ເດັກນ້ອຍ ບ�່ ສາມາ ດຢືນ ໄດ້ ດ້ວຍ ຕົນ ເອງ, ໂຄງ ຊ່ວຍ ຢືນ ສາມາດ ໄດ້. ບາງ ວິທີ ທີ່ ແຕກ ຕ່າງ ກັນ ເພ່ືອ ປະຄອງ ເດັກນ້ອຍ ໃຫ້ ນັ່ງ ໃກ້ ກັບ ພ້ືນ ຫຼາຍຂຶ້ນ ມີ: ຜ້າ ຫົ່ມ, ໂຟມ, ຜ້າ ເຊັດ ໂຕ ຫຼື ໝອນ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບທີ່ ເໝາະ ສົມ. ນັ່ງ ຂາ ຄາບ ທ່ອນ ໄມ້, ລູກ ກິ້ງ ຫຼື ຜ້າ ຫົ່ມ ທີ່ ມ້ວນ ແໜ້ນ. ນັ່ງ ໂດຍ ມີ ການ ປະຄອງ ຫຼືຊ່ວຍ ເຫຼືອຈາກ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ ງ ແຍງ . ນັ່ງ ໃນ ບ່ອນ ນັ່ງ ທີ່ ມີ ການຮອງ ຮັບ ເຊິ່ງຕ�່າ ຫາ ພ້ືນ. WHO/NMH/VIP/DAR/13.02 ອອກ ແບບ ໂດຍ Inís Communication – www.iniscommunication.com ລົດເຂັນ ຊຸດຝຶກອົບຮົມການ ບໍລິການ ລະດັບປານກາງ ໂອ້ລົມ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ: ພວກ ເຂົາຮູ້ ຫຍັງ ແດ່, ແລະ ພວກ ເຂົາ ຢາກ ຮຽນ ຮູ້ ຫຍັງ? ໃຊ້ ລາຍການ ກວດ ເພື່ອ ຈື່ ສິ່ງ ສ�າຄັນ ຕ່າງໆ ເພ່ືອ ສອນ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ລ າຍ ກ ານ ກ ວ ດ ສໍ າລັ ບ ກ ານ ຝຶ ກ ອົ ບ ຮົ ບ ຜູ້ ໃຊ້ ລົ ດ ເຂັ ນ ປ ານ ກ າງ ການຈັດການລົດເຂັນ ການພັບ ແລະ ການ ຍົກ ລົດ ເຂັນ ການ ຖອດອອກ ແລະ ການ ປະກອບ ເຂົ້າ ຄືນ ສ�າລັບ ອຸປະກອນ PSD ທີ່ ຈ�າ ເປັນ ຕ້ອງ ຖອດ ອອກ ສ�າລັບ ການ ຂົນ ສົ່ງ ເຄື່ອນຍ້າຍ ການ ໃຊ້ ລ�້ ປ່ອຍ ໄວ ການ ໃຊ້ ເບ ກ ການອ່ຽງ ແລະ ແຖບ ກັນ ປີ້ນ (ຖ້າ ໃຊ້) ຕ�າ ແໜ່ ງທີ່ ຖືກຕ້ອງ ຂອງ ອຸປະກອນ PSD ໃນ ເວລາ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຢູ່ ໃນ ລົດ ເຂັນ ການ ໃຊ້ ເບາະ ຮອງ ນັ່ງ ລວມທັງ ການວາ ງຕ�າ ແໜ່ ງຢ່າງ ຖືກຕ້ອງ ການໃຊ້ລົດເຂັນແລະການເຄ່ືອນໄຫວໄປມາ ການ ຍູ້ ລົດ ເຂັນ ຢ່າງ ຖືກຕ້ອງ ໂດຍ ໃຊ້ ວິທີ ທີ່ ມັກ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຂຶ້ນ ແລະ ລົງ ເນີນ ຄ້ອຍ ຂຶ້ນ ແລະ ລົງ ຂັ້ນ ໄດ ຢູ່ ເທິງ ພື້ນ ທີ່ ບ�່ ຮາບ ພຽງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບາງ ຄັ້ງ ຄາວ ນັ່ງ ໃນ ລົດ ເຂັນ ດົນ ປານ ໃດ (ສ�າລັບ ເດັກນ້ອຍ ແລະ ຜູ້ ໃຫຍ່ ທີ່ ມີ ຄວາມ ຕ້ອງການ ດ້ານ ທ່າ ທາງ ລະດັບ ປານ ກາງ) ການ ຍູ້ ແບບ ມີ ການ ຊ່ວຍ ເຫຼືອ ການປ້ອງກັນແຜກົດທັບ ກວດ ເບິ່ງ ແຜກົ ດທັບ ຢູ່ ບ�ລິ ເວນ ທີ່ ມີ ການ ກົ ດທັບ ສູງ ການ ຍົກ ເພື່ອ ຫຼຸດຜ່ອນ ການ ກົ ດທັບ ກິນ ໄດ້ ດີ ແລະ ດື່ມ ນ�້າຫຼາຍ ສິ່ງ ທີ່ ຕ້ອງ ເຮັດ ຖ້າ ເກີດ ແຜ ກົດ ທັບ ການເຄ່ືອນຍ້າຍ ການ ເຄື່ອນ ຍ້າຍ ດ້ວຍ ຕົນ ເອງ ຫຼື ການ ເຄື່ອນ ຍ້າຍ ໂດຍ ມີ ການ ຊ່ວຍ ເຫຼືອ ສອນ ວິທີ ການ ເຄື່ອນ ຍ້າຍ ທີ່ ເໝາະ ສົມ ທີ່ ສຸດ ສ�າລັບຜູ້ ໃຊ້ລົດ ເຂັນ. ສ່ິງທ່ີຕ້ອງເຮັດຖ້າມີບັນຫາ ລົດ ເຂັນ ຕ້ອງການ ມີ ການ ສ້ອມ ແປງ ລົດ ເຂັນ ບ�່ ພ�ດີ ຫຼື ບ�່ ສະ ບາຍ ຕົວ ວິທີການເບ່ິງແຍງຮັກສາລົດເຂັນຢູ່ເຮືອນ ອະນາ ໄມ ລົດ ເຂັນ; ລ້າງ ແລະ ເຊັດ ເບາະ ຮອງ ແລະ ສິ່ງ ປົກ ຫຸ້ມ ເບາະ ຮອງ ນັ່ງ ໃຫ້ ແຫ້ງ ໃສ່ ນ�້າມັນ ສ່ວນ ທີ່ ເຄື່ອນ ເໜັງ ຂອງ ລົດ ເຂັນ ສູບ ລົມ ຢາງ ລົດ ເຂັນ ຫັນ ນັອດ ໂຕ ແມ່ ແລະ ນັອດ ໂຕ ຜູ້ ໃຫ້ ແໜ້ນ ເຄັ່ງ ດິ້ວ ລ�້ ລົດ ເຂັນ ກວດ ເບິ່ງ ແນວ ຫຸ້ມ ເບາະ ກວດ ເບິ່ງຂີ້ໝ້ຽງ ກວດ ເບິ່ງ ເບາະ ຮອງ ນັ່ງ WHO/NMH/VIP/DAR/13.02 ອອກ ແບບ ໂດຍ Inís Communication – www.iniscommunication.com ລົດເຂັນ ຊຸດຝຶກອົບຮົມການ ບໍລິການ ລະດັບປານກາງ ສາຍຮັດ ສາຍຮັດ ສ່ວນ ກົກ ແອວ ສາຍຮັດອ່ຽງ ໄປ ໜ້າສີ່ ຈຸດ ສາຍຮັດ ບີ ແຄ່ງ ສາຍຮັດ ຕີນ ສາຍຮັດ ບ່າ ໄຫຼ່ ຕ າຕ ະລ າງ ອຸ ປ ະກ ອ ນ ຮ ອ ງຮັ ບ ກ ານ ຊົ ງຕົ ວ ( P SD ) ບ່ອນນ່ັງ/ເບາະຮອງນ່ັງ ຖ້ານ ຮອງກ່ອນ ກະດູກ ຮອງ ນັ່ງ ດາ້ນ ໜາ້ ບອ່ນ ນັງ່ ສວ່ນ ລຸມ່ ( ຂາ້ງ ໜຶງ່) ດ້ານ ໜ້າ ບ່ອນ ນັ່ງ ທີ່ ຍົກສູງ ຂຶ້ນ ຫຼີ້ມຮອງ ສ�າລັບ ການ ອ່ຽງ ໄປທາງ ໜ້າ ແນວ ຮອງ ຢູ່ ກ້ອງ ກະດູກ ກົກ ແອວ ແຜ່ນ ຮອງກະດູກ ກົກ ແອວ ດ້ານ ຂ້າງ ບ່ອນນ່ັງ/ເບາະຮອງນ່ັງ ບ່ອນນ່ັງແລະແນວອີງຫັຼງ ຫຼີ້ມຮອງ ກົກຂາ ດ້ານ ນອກ ແຜ່ນ ຮອງ ກົກຂາ ດ້ານ ນອກ ຫຼີ້ມຮອງ ກົກຂາ ດ້ານ ໃນ ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ມຸມ ເປີດ ລະຫວ່າງ ບ່ອນ ນັ່ງ ຫາ ແນວ ອີງ ຫຼັງ ຄວາມ ອ່ຽງຂອງບ່ອນ ນັ່ງ ແລະ ແນວ ອີງ ຫຼັງ (ຄວາມ ອ່ຽງ ໃນ ບ່ອນ ຫວ່າງ) ແນວອີງຫັຼງ ແຜ່ນ ຮອງ ກະດກູ ກກົ ແອວ ດາ້ນ ຫຼງັ ປບັຮບູຊງົ ຂອງ ແນ ວອງີ ຫຼງັ ແນວ ອງີ ຫຼງັທີ ່ສາມາດ ປບັ ຄວາມ ເຄັງ່ ໄດ້ ການ ເອນ ແນວ ອງີ ຫຼງັ ແຜ່ນ ຮອງລ�າ ຕວົ ດາ້ນ ຂາ້ງ ຫຼີມ້ ຮອງລ�າ ຕວົ ດາ້ນ ຂາ້ງ ຖາດ ແນວປະຄອງຫົວ ແນວຮອງຂາສ່ວນລຸ່ມ ຖາດ ແນວ ອີງ ຫົວ ແບບ ແບນ ແນວ ອີງ ຫົວ ແບບ ມີ ຮູບ ຊົງ ແນວ ຮອງ ເສີມ ບ່ອນ ວາງ ຕີນ ຫຼີ້ມຮອງ ບ່ອນ ວາງ ຕີນ ແນວ ຮອງ ຂາ ສ່ວນລຸ່ມ 6 7 3 2 1 4 5 11 13 8 12 9 10
ລະດັບ ປານ ກາງ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ ຄູ່ ມື ອ້າງ ອີງ ສໍາລັບ ຜູ້ ເຂ້ົາ ຮ່ວມ ້ ແຟ້ມໜ້າ້ ປົກ້ ້
ລະດັບ ປານ ກາງ ຄູ່ ມື ອ້າງ ອີງ ສໍາລັບ ຜູ້ ເຂ້ົາ ຮ່ວມ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ ຈັດພິມໂດຍອົງການສຸຂະພາບໂລກໃນປີ 2013 ພາຍໃຕ້ຫົວຂໍ ້ Wheelchair Service Training Package – Intermediate Level © ອົງ ການ ອະ ນາ ໄມ ໂລກ ປີ 2013 ອົງການອະນາໄມໂລກໄດ້ຮັບສິ ດການແປພາສາແລະສິ ດເຜີຍແຜ່ສໍ າລັບການພິມໃນລາວກັບອົງການ ການພັດທະນາສາກົນ (USAID) ຂອງສະຫະລັດອາເມລິ ກາເຊິ່ ງເປັນຜູ້ຮັບຜິດຊອບພຽງແຕ່ສໍ າລັບຄຸນນະພາບແລະຄວາມຊື່ ສັດຂອງສ ະບັບພາສາລາວ. ໃນກໍລະນີ ທີ່ ມີ ຄວາມບໍ່ ສອດຄ່ອງກັນລະຫວ່າງສະບັບພາສາອັງກິດແລະລາວ, ສະບັບພາສາອັງກິດຕ້ົນສະບັບຈະຕ້ອງມີ ການຜູກມັດແລະຖື ກຕ້ອງ. ຊຸດ ຝຶ ກ ອົບຮົມ ການ ບໍ ລິ ການ ລົດ ເຂັ ນ ລະດັບ ປານ ກາງ © USAID 2017 ປະມວນ ຄໍາສັບ ຄໍາ ສັບ ຕ່ໍ ໄປ ນ້ີ ທີ່ ຖືກໃຊ້ ໃນຕະຫຼອດ ຊຸດ ການ ຝຶກ ອົບ ຮົບ ນ້ີ ມີ ນິຍາມ ຄວາມ ໝາຍ ດັ່ງ ລຸ່ມນ້ີ. ລົດ ເຂັນ ທ່ີ ເໝາະ ສົມ ລົດ ເຂັນ ທີ່ ຕອບ ສະໜອງ ຄວາມ ຕ້ອງ ການ ຂອງ ຜູ້ ໃຊ້ ແລະ ເງ່ືອນ ໄຂ ສະພາບ ແວດ ລ້ອມ; ໃຫ້ ຄວາມ ພໍດີ ທີ່ ເໝາ ະສົມ ແລະ ການ ຮອງ ຮັບ ທ່າ ທາງ ຕ່າງໆ; ປອດ ໄພ ແລະ ໃຊ້ ໄດ້ ຍາວ ນານ; ມີ ໃຫ້ ຢູ່ ໃນ ປະ ເທດ ນ້ັນໆ; ແລະ ສາມາດ ມີ ແລະ ໄດ້ ຮັບ ການ ບໍາລຸງ ສ້ອມ ແປງ ແລະ ການ ບໍລິການທ່ີ ຍືນ ຍົງ ໃນ ປະ ເທດ ນ້ັນໆດ້ວຍ ລາຄາ ທີ່ ສາມາດ ຊ້ື ໄດ້. ລົດ ເຂັນ ແບບ ໃຊ້ ມື ລົດ ເຂັນ ທີ່ ຖືກ ຂັບ ເຄື່ອນ ໂດຍ ຜູ້ ໃຊ້ ຫຼື ຍູ້ ໂດຍ ບຸກຄົນ ອື່ນ. ອຸ ປະ ກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ (PSD) ອຸປະກອນປະຄອງ ຮ່າ ງກາຍທ່ີ ໃຫ້ການປະຄອງ ຫຼືຮອງ ຮັບທ່າ ງທາງການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ – ອົງ ປະກອບສໍາຄັນ ຂອງ ການ ບໍລິການ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ລົດ ເຂັນ ອຸ ປະ ກອນ ທີ່ ໃຫ້ ການ ເຄື່ອນ ທີ່ ໄປ ມາ ທີ່ ມີ ລໍ້ ແລະ ຮອງ ຮັບ ການ ນ່ັງ ສໍາ ລັບ ບຸກ ຄົນ ທີ່ ມີ ຄວາມ ລໍາ ບາກ ໃນ ການ ຍ່າງ ຫຼື ການ ເຄື່ອນ ໄຫວ ໄປ ມາ. ການ ດັດ ແປງ ລົດ ເຂັນ ການ ປ່ຽນ ແປງ ທີ່ ເຮັດກັບ ລົດ ເຂັນ. ການ ສະ ໜອງ ລົດ ເຂັນ ຄໍາ ສັບ ລວມສໍາລັບ ການ ອອກ ແບບ, ການ ຜະລິດ, ການ ສະໜອງ ແລະ ການ ໃຫ້ການ ບໍລິການ ບໍາລຸງ ສ້ອມ ແປງ ລົດ ເຂັນ. ການ ບໍ ລິ ການ ລົດ ເຂັນ ສ່ວນນ້ັນ ຂອງ ການ ສະ ໜອງ ລົດ ເຂັນ ແມ່ນກ່ຽວ ຂ້ອງ ກັບ ສະ ໜອງ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ໃຫ້ ແກ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ພະ ນັກ ງານ ບໍ ລິ ການ ລົດ ເຂັນ ບຸກ ຄົນ ທີ່ ມີ ທັກ ສະ ໃນ ການ ສະ ໜອງ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບຸກ ຄົນ ທີ່ ມີ ຄວາມ ລໍາ ບ າກ ໃນ ການ ຍ່າງ ຫຼື ເຄື່ອນ ໄຫວໄປ ມາ ແລະ ໃຊ້ ລົດ ເຂັນ ສໍາ ລັບ ເຄື່ອນ ໄຫວ ໄປ ມາ. ສ າ ລ ະ ບາ ນ VII ບົດນໍາ 1 ກ່ຽວກັບຊຸດຝຶກອົບຮົມການບໍລິການລົດເຂັນ: ລະດັບປານກາງ 6 A: ຄວາມຮູ້ຫັຼກ A.1: ຜູ້ ໃຊ ້ລດົ ເຂນັ ຜູ້ ທີ ່ໄດ້ ປະ ໂຫຍ ດຈາກ ອປຸະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ 13 A.2: ເດກັນ້ອຍ ພິການ 20 B. ຂ້ັນ ຕອນ ການ ບໍລິການ ລົດ ເຂັນ. 21 ຂ້ັນ ຕອນ 1: ການ ນໍາ ສ່ົງ ແລະ ການ ນັດ ໝາຍ 21 ຂ້ັນ ຕອນ 2: ການ ປະ ເມີນ ຜົນ 21 ພາບ ລວມການ ປະ ເມີນ ຜົນ ແລະ ການ ສໍາພາດ ປະ ເມີນ ຜົນ 49 ການ ປະ ເມີນ ຮ່າງກາຍ – ທາ່ ນ່ັງ ໂດຍ ບໍ ່ມີ ການ ປະຄອງຫຼຮືອງ ຮັບ 54 ການ ປະ ເມີນ ຮ່າງກາຍ – ການກວດ ເບິງ່ ທາ່ ກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກ 59 ການ ປະ ເມີນ ຮ່າງກາຍ – ການ ຈາໍລອງ ດວ້ຍ ມື 63 ການ ປະ ເມີນ ຮ່າງກາຍ – ການ ເຮດັ ການ ວດັ ແທກ 71 ຂ້ັນ ຕອນ 3: Prescription (selection) 71 ການ ເລອືກ ລດົ ເຂນັ ແລະ ເບາະ ຮອງ ນ່ັງ 80 ການ ກໍານົດ ໃຊ ້(ການ ເລອືກ) ອປຸະກອນ PSD – ພາກສະ ເໜີ 94 ການ ກໍານົດ ໃຊ ້(ການ ເລອືກ) ອປຸະກອນ PSD – ການ ເຮດັ ໃຫ ້ກະດູກ ກົກ ແອວ ໝ້ັນຄົງ 98 ການ ກໍານົດ ໃຊ ້(ການ ເລອືກ) ອປຸະກອນ PSD – ການ ຮອງ ສະ ໂພ ກ 100 ການ ກໍານົດ ໃຊ ້(ການ ເລອືກ) ອປຸະກອນ PSD – ການ ຮອງ ລາໍ ຕົວ 104 ການ ກໍານົດ ໃຊ ້(ການ ເລອືກ) ອປຸະກອນ PSD – ການ ປະຄອງ ຫວົ, ການ ຮອງ ກົກຂາ ແລະ ຂາ ສ່ວນ ລຸມ່ 107 ຂ້ັນ ຕອນ 4: ການ ໃຫ ້ທນຶ ແລະ ການ ສ່ັງ ຊ້ື 107 ຂ້ັນ ຕອນ 5: ການ ກະກຽມ ຜະລິດ ຕະພັນ (ລດົ ເຂນັ) 108 ການວາງ ແຜນ ແລະ ການ ດາໍ ເນີນ ການ ກະກຽມ ລດົ ເຂນັ ແລະ ອປຸະກອນ PSD 109 ສ່ິງ ທີ ່ຕ້ອງ ຈື ່ໃນ ເວລາ ເຮດັ ອປຸະກອນ PSD 110 ວດັ ສະດຸ ແລະ ເຄືອ່ງມື ທີ ່ຈາໍ ເປນັ ໃນ ການ ເຮດັ ອປຸະກອນ PSD ແລະ ການ ດດັ ແປງ 112 ວທິ ີເຮດັ ອປຸະ ກອນ PSD 128 ການ ດາໍ ເນີນ ການ ກວດ ຄວາມ ປອດ ໄພ ແລະ ຄວາມພ້ອມ ໃຊ ້ງານ ຂອງ ລດົ ເຂນັ 129 ລາຍ ການກວດ ຄວາມ ປອດ ໄພ ແລະ ຄວາມ ພ້ອມ ໃຊ ້ງານຂອງລົດ ເຂນັລະດັບ ປານ ກາງ 130 ຂ້ັນ ຕອນ 6: ການ ປບັ ໃຫ ້ເໝາະ ສົມ 139 ຂ້ັນ ຕອນ 7: ການ ຝຶກ ອບົ ຮົມ ຜູ້ ໃຊ້ 139 ທກັ ສະ ທີ ່ເປນັ ປະ ໂຫຍ ດສໍາລັບຜູ້ ໃຊ ້ລດົ ເຂນັ ມີ ຫຍງັ ແດ?່ 144 ຂ້ັນ ຕອນ 8: ການ ບາໍລຸງ ຮັກສາ, ການ ສ້ອມ ແປງ ແລະ ການ ຕິດຕາມ ຜົນ 144 ການ ຄຸມ້ ຄອງ ກາ ນຕິດຕາມ ຜົນ 145 ການ ດາໍ ເນີນທ່ົວ ໄປ ໃການ ຕິດຕາມ ຜົນ ບົດ ນໍາ ລົດ ເຂັນ ແມ່ນ ໜຶ່ງ ໃນ ອຸປະກອນ ຊ່ວຍ ທີ່ ໃຊ້ ຫຼາຍທ່ີ ສຸດ ເພ່ືອສ່ົງ ເສີມການ ເຄື່ອນ ໄຫວ ໄປ ມາ ດ້ວຍ ຕົນ ເອງ ເຊິ່ງ ແມ່ນ ເງ່ືອນ ໄຂ ທີ່ ຕ້ອງ ມີ ກ່ອນ ສໍາລັບ ການ ຊົມ ໃຊ້ ສິດທິ ມະນຸດ ຕ່າງໆ ແລະ ການ ດໍາ ເນີນ ຊີວິ ດຢ່າງ ມີ ກຽດ ແລະ ຊ່ວຍ ຄົນ ພິການ ໃຫ້ ກາຍ ເປັນສະມາຊິກທ່ີ ປະກອບສ່ວນ ຫຼາຍຂ້ຶນ ຂອງ ຊຸມ ຊົນ ຂອງ ເຂົາ ເຈົ້າ. ສໍາລັບ ຄົນ ພິການ ຫຼາຍຄົນ, ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ, ມີ ການ ອອກ ແບບ ມາ ເປັນ ຢ່າງ ດີ ແລະ ມີ ກາ ນ ປັບ ໃຫ້ ເໝາະ ສົມພໍດີ ສາມາດ ເປັນ ບາດກ້າວ ທໍາ ອິດ ກ້າວ ໄປ ສູ່ ການ ໄດ້ ເຂ້ົາ ຮ່ວມ ແລະ ການ ມີ ສ່ວນ ຮ່ວມ ໃນ ສັງຄົມ. ກົດ ລະບຽບ ມາດຕະຖານ ອົງການ ສະຫະ ປະຊາ ຊາດວ່າ ດ້ວຍ ການ ສ້າງ ໂອກາດ ເທົ່າ ທຽມ ກັນ ສໍາລັບ ຄົນ ພິການ, ສົນທິສັນຍາ ວ່າ ດ້ວຍ ສິດທິ ຄົນ ພິການ ແລະ ມະຕິ ຕົກລົງ ຂອງ ສະມັດຊາ ສຸຂະພາບ ໂລກ WHA58.23, ເຊິ່ງກ່ຽວ ກັບ ຂ້ອງ ກັບ ຄວາມ ພິການ ລວມທັງ ການ ປ້ອງ ກັນ, ການ ຄຸ້ມ ຄອງ ແລະ ການ ຟ້ືນ ຟູ, ທັງ ໝົດ ລ້ວນ ແຕ່ ເນ້ັນ ໜັກ ເຖິງ ຄວາມ ສໍາຄັນ ຂອງ ລົດ ເຂັນ ແລະ ອຸປະກອນ ຊ່ວຍ ອື່ນ. ເພ່ືອ ຮັບປະກັນ ໃຫ້ ຄົນ ພິການ ສາມາດ ເຂົ້າ ເຖິງ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ, ໂດຍ ສະ ເພາະ ໃນ ບັນດາ ປະ ເທດ ທີ່ ມີ ຊັບພະຍາກອນ ຈໍາກັດ , ອົງການ WHO ໄດ້ ພັດທະນາ ຂ້ໍ ແນະນໍາ ກ່ຽວ ກັບ ການ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ໃນ ສະຖານ ທ່ີ ທ່ີ ມີ ຊັບພະຍາກອນ ຈໍາກັດ, ໂດຍ ຮ່ວມ ມື ກັບ ອົງການພັດທະນາ ລະຫວ່າງ ປະ ເທດ ຂອງ ສະຫະລັດ (USAID) ແລະ ສະມາຄົມກາ ຍະ ອຸປະກອນ ແລະ ອຸປະກອນ ທຽມ ລະຫວ່າງ ປະ ເທດ (ISPO). ເພ່ືອ ຝຶກ ອົບຮົມ ຊັບພະຍາກອນ ມະນຸດ ໃນຈໍານວນ ທີ່ ພຽງພໍ ຢ່າງ ເໝາະ ສົມ ແລະ ອໍານວຍ ຄວາມ ສະດວກ ໃຫ້ ແກ່ ລະບົບ ສະໜອງ ລົດ ເຂັນ ທີ່ ດີ ໂດຍ ອີງ ໃສ່ ຂ້ໍ ແນະນໍາ ລົດ ເຂັນ, ອົງການ WHO ໄດ້ ລິ ເລີ ່ມພັດທະນາ ຊຸດ ຫັຼກສູດ ຝຶກ ອົ ບຮົມ ການ ບໍລິການ ລົດ ເຂັນ (WSTP) ສໍາລັບລະດບັ ຕ່າງໆ ຂອງ ພະນັກງານ ສຸຂະພາບ ແລະ ການ ຟ້ື ນຟູ ທີ່ ຮັບຜິດຊອບ ຄຸ້ມ ຄອງ ການ ຊ່ວຍ ເຫຼືອ ໃນ ລະດັບ ຕ່າງໆ ຕາມ ທີ່ ອະທິບາຍ ໄວ້ ໃນ ຂ້ໍ ແນະນໍາ ລົດ ເຂັນ. ຫຼັງຈາກ ການ ເຜີຍ ແຜ່ ຢ່າງປະສົບ ຜົນສໍາ ເລັດ ຂອງ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ (WSTP-B) ໃນ ເດືອນ ມິຖຸນາ 2012, ພວກ ເຮົາ ມີ ຄວາມ ຍິນ ດີ ນໍາ ສະ ເໜີ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ປານ ກາງ (WSTP-I). ນອກຈາກ ການ ຂະຫຍາຍ ທັກ ສະ ແລະ ຄວາມ ຮູ້ ທີ່ ໄດ້ ຮັບ ຈາກ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ ແລ້ວ; ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ປານ ກາງ ມີ ການ ເນ້ັນ ໜັກ ເພ່ີມ ຂ້ຶນ ໃສ່ ເດັກນ້ອຍ, ເພາະວ່າ ເດັກນ້ອຍ ຫຼາຍໆ ຄົນ, ເນ່ືອງ ຈາກ ລັກສະນະ ຄວາມ ພິການ ດ້ານ ພັດທະນາ ການ ທີ່ ມັກ ພົບ ເຫັນ, ຈໍາ ເປັນ ຕ້ອງ ມີ ລົດ ເຂັນ ສໍາລັບ ທັງ ການ ເຄື່ອນ ໄຫວ ໄປມາ ແລະ ການ ຮອງ ຮັບ ທ່າ ທາງ ການ ຊົງ ຕົວ ຕ່າງໆ. Alana Officer Robert Horvath ຜູ້ ປະສານ ງານ ຜູ້ ຈັດການ ທ ີມງານ ຝ່າຍ ຄວາມ ພິການ ແລະ ການ ຟ້ືນ ຟູ ແຜນ ງານ ສໍາລັບ ປະຊາກອນ ທີ ່ອອ່ນ ແອ ພະ ແນ ກຄວາມ ຮຸນ ແຮງ ແລະ ສູນ ຄວາມ ເປນັ ເລດີດາ້ນ ປະຊາທິປະ ໄຕ, ກາ ນປ້ອງ ກັນ ການ ບາດ ເຈບັ ແລະ ຄວາມ ພິການ ສິດທ ິມະນຸດ ແລະ ການ ປກົ ຄອງ ອົງການ ອະນາ ໄມ ໂລກ ອົງການ ພັດທະນາ ລະຫວ່າງ ປະ ເທດ ຂອງ ສະຫະລັດ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 1 ກ່ຽວ ກັບ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ : ລະດັບ ປານ ກາງ ພາກ ສະ ເໜີ ຫຼັງຈາກ ການ ເຜີຍ ແຜ່ ໃນ ປີ 2008 ຂອງ ຂ້ໍ ແນະນໍາ ກ່ຽວ ກັບ ການ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ໃນ ສະຖານ ທ່ີ ທ່ີ ມີ ຊັບພະຍາກອນ ຈໍາກັດ(1) ແລະ ໃນ ປີ 2012 ຂອງ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ (WSTP-B); ອົງການ ອະນາ ໄມ ໂລກ (WHO) ໂດຍ ຮ່ວມ ມື ກັບ ອົງການ ພັດທະນາ ລະຫວ່າງ ປະ ເທດ ຂອງສະຫະລັດ (USAID) ໄດ້ ພັດທະນາ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ປານ ກາງ (WSTP-I). ຊຸດ ຝຶກ ອົບຮົມ WSTP ລະດັບ ປານ ກາງ ແມ່ນ ສ່ວນ ທີ ສອງ ຂອງ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ (WSTP) ຂອງ ອົງການ WHO ທີ່ ເນ້ັນ ໜັກ ຫຼາຍຂ້ຶນ ໃສ່ ການ ແກ້ ໄຂ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ຄົນ ທີ່ ມີ ຄວາມ ລໍາບາກ ໃນ ການ ຍ່າງ ແລະ ການ ເຄື່ອນ ໄຫວ ໄປມາ ແລະ ຍັງ ມີ ການ ຄວບ ຄຸມ ລໍາ ຕົວ ທີ່ ບໍ່ ໄດ້ ດີ ນໍາ ອີກ. ໃນ ຂະນະ ທີ່ ພັດທະນາ ຊຸດ ຝຶກ ອົບຮົມ ນ້ີ, ໄດ້ ມີ ການ ເອົາ ໃຈ ໃສ່ ເປັນ ພິ ເສດຕ່ໍ ກັບ ການ ສະໜອງ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ສໍາລັບ ເດັກນ້ອຍທີ່ ມີ ການ ຄວບ ຄຸມ ລໍາ ຕົວ ບໍ່ ໄດ້ ດີ ແລະ ບໍ່ ສາມາດ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້ ດ້ວຍ ຕົນ ເອງ. ລົ ດ ເຂັນ ແມ່ນ ໜຶ່ງ ໃນ ອຸປະກອນ ຊ່ວຍທີ່ ມັກ ໃຊ້ ຫຼາຍທ່ີ ສຸດ ເພ່ືອ ໃຫ້ ສາມາດ ເຄື່ອນ ໄຫວ ໄປມາ ໄດ້. ສໍາລັບ ຄົນທ່ີ ມີ ຄວາມລໍາບາກ ໃນ ການ ຍ່າງ, ລົດ ເຂັນ ເຊິ່ງຕອບ ສະໜອງ ຄວາມຕ້ອງການດ້ານ ຮ່າງກາຍ, ຮູບ ແບບ ການ ດໍາ ເນີນ ຊີວິດ ແລະ ສະພາບ ແວດ ລ້ອມ ແມ່ນ ເຄື່ອງມື ທີ່ ສໍາຄັນ ທີ່ ສຸດທີ່ ເຮັດ ໃຫ້ ພວກ ເຂົາ ສາມາດ ມີ ສຸຂະພາບ, ຄວາມ ເປັນ ຢູ່ ດ້ານ ສັງຄົມ ແລະ ເສດຖະກິດ ທີ່ ປັບປຸງ ດີ ຂ້ຶນ ຢ່າງ ຫຼວງຫຼາຍ. ການສາມາດ ເຄື່ອນ ໄຫວ ໄປມາ ເປີດ ໂອກາດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄດ້ ສຶກສາຮ່ໍາຮຽນ, ເຮັດ ວຽກ ແລະ ເຂົ້າ ຮ່ວມ ໃນ ກິດຈະກໍາ ວັດ ທະນະ ທໍາ ເຊັ່ນດຽວ ກັບ ການ ເຂົ້າ ເຖິງ ການ ບໍລິການ ຕ່າໆ ເຊັ່ນ ວ່າ ການ ດູ ແລ ເບິ່ງ ແຍງ ສຸຂະພາບ. ຄວາມ ສໍາຄັນ ຂອງ ການ ເຄື່ອນ ໄຫວ ໄປມາ ໄດ້ ຖືກ ລບຸ ໄວ້ ໃນ ສົນທິສັນຍາຂອງ ອົງການ ສະຫະ ປະຊາ ຊາດ ວ່າ ດ້ວຍ ສິດທິ ຄົນ ພິການ (UNCRPD), ເຊິ່ງສ່ົງ ເສີມ ໃຫ້ ມີ ìມາດ ຕະການ ທີ່ ມີ ປະສິດທິ ຜົນ ເພ່ືອ ຮັບປະກັນ ໃຫ້ມີ ການ ເຄື່ອນ ໄຫວ ໄປມາ ໄດ້ ດ້ວຍ ຕົນ ເອງ ໂດຍ ມີ ການ ເພ່ິງ ຕົນ ເອງ ຫຼາຍທ່ີ ສຸດ ເທົ່າ ທີ່ ຈະ ເປັນ ໄປ ໄດ້ ສໍາລັບ ຄົນ ພິການî. ເພ່ືອ ຮັບປະກັນ ການ ເຄື່ອນ ໄຫວ ໄປ ມາ ດ້ວຍ ຕົນ ເອງ ຢ່າງ ມີ ປະສິດທິ ຜົນ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ມີ ລົດ ເຂັນ ທີ່ ປັບ ໃຫ້ ເໝາະ ສົມຢ່າງ ຖືກຕ້ອງ ແລະ ຕອບ ສະໜອງ ຄວາມ ຕ້ອງການ ສະ ເພາະ ຂອງ ເຂົາ ເຈົ້າ. ນ້ີ ຮຽກຮ້ອງ ໃຫ້ ມີ ວິທີ ການ ທີ່ ຕອບ ສະໜອງ ຕ່ໍ ກັບ ຄວາມ ຕ້ອງການ ສະ ເພາະ ບຸກຄົນ. ວິທີ ທີ່ ມີ ປະສິດທິຜົນ ໃນ ການ ຕອບ ສະໜອງ ຄວາມ ຕ້ອງການ ສະ ເພາະ ບຸກຄົນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແມ່ນ ການ ສະໜອງ ລົດ ເຂັນ ຜ່ານ ການ ບໍລິການ ລົດ ເຂັນ. ແນວ ໃດ ກໍ ຕາມ, ສະຖິຕິ ສະ ແດງ ໃຫ້ ເຫັນ ວ່າ ໃນ ຕົວ ຈິງ ນ້ອຍກວ່າ 5% ຂອງ ຜູ້ ຕ້ອງການ ລົດ ເຂັນ ມີ ການ ເຂົ້າ ເຖິງ ລົດ ເຂັນ ທີ່ ມີ ການ ປັບ ໃຫ້ ເໝາະ ສົມ ຢ່າງ ຖືກຕ້ອງ. ນອກ ນ້ັນ, ຍັງ ມີ ໂອກາດ ການ ຝຶກ ອົບຮົມ ທີ່ ຈາໍ ເປັນ ສໍາລັບ ພະນັກງານ ເພ່ືອ ສ້າງ ທັກ ສະ ທີ່ ຈໍາ ເປັນ ໃນ ການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ຢ່າງ ມີ ປະສິດທິ ຜົນ. 1 ອົງ ການ ອະ ນາ ໄມ ໂລກ ຂ້ໍ ແນະນໍາ ກ່ຽ ວກັບ ການ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ມື ໃນ ສະຖານ ທີ່ ທີ່ ມີ ຊັບພະຍາກອນ ຈໍາກັດ. Geneva, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, ເຂົ້າ ຫາ ວັນ ທີ 15 ທັນວາ 2011). 2ຊຸດ ຝຶກ ອົບຮົມ WSTP-I ມີ ຈຸດປະສົງ ສະໜັບສະໜູນ ການ ຝຶກ ອົບຮົມ ພະນັກງານ ທີ່ ເຮັດ ໜ້າ ທີ່ ດ້ານການ ປິ່ນປົວ ແລະ ດ້ານ ເຕັກນິກ ໃນ ການ ບໍລິການ ລົດ ເຂັນ ( ເບິ່ງ ຂ້ໍ ແນະນໍາ ກ່ຽວ ກັບ ການ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ໃນ ສະຖານ ທີ່ ທີ່ ມີ ຊັບພະຍາກອນ ຈໍາກັດ, ຕາຕະລາງ 4.2) ໃນ ລະດັບ ປານ ກາງ. ຊຸດ ຝຶກ ອົບຮົມ ສະໜັບສະໜູນ ການ ສອນ ທິດ ສະ ດີ ແລະ ການ ປະຕິບັດຕົວ ຈິງ ທີ່ຈໍາ ເປັນ ເພ່ືອ ເລີ່ ມ ເຮັດ ວຽກ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ຈໍາ ເປັນ ຕ້ອງ ມີ ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ ເພ່ືອ ສາມາດ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້. ຊຸດຝຶກ ອົບຮົມ ລວມ ມີ ວິທີປະ ເມີນ ຄວາມ ຕ້ອງການ ສະ ເພາະ ບຸກຄົນ; ຊ່ວຍ ໃນ ການ ເລືອກ ແລະ ການ ຕິດ ຕ້ັງ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ທີ່ ສຸດ ທີ່ ມີ ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ; ຝຶກ ອົບຮົມ ຜູ້ ໃຊ້ ແລະ ຜູ້ ໃຫ້ການ ເບິ່ງ ແຍງກ່ຽວ ກັບ ວິທີ ໃຊ້ ແລະ ບໍາລຸງ ຮັກສາ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ແລະ ດໍາ ເນີນ ການ ຕິດຕາມ ຜົນ. ຊຸດ ຝຶກ ອົບຮົມ ສາມາດ ດໍາ ເນີນ ໃນ 35-40 ຊ່ົວ ໂມງ, ແນວ ໃດ ກ່ໍຕາມ ໄລຍະ ເວລາ ນ້ີ ສາມາດ ຂະຫຍາຍ ອອກ ຫຼືຫຼຸດລົງ ໄດ້ ອີງ ຕາມ ຄວາມ ຈໍາ ເປັນສ ະ ເພາະ ແລະ ຊັບ ພະຍາກອນ ທີ່ ມີ ໃຫ້ ໃນ ແຕ່ ລະສະ ພາບ ການ. ສ່ົງ ເສີມ ໃຫ້ ມີ ການ ຝຶກ ຫັດ ເພ່ີມ ເຕີມ ກັບ ຄູ ສອນ ເພ່ືອ ສ້າງ ຄວາມ ເຂົ້າ ໃຈ ແລະ ສົ່ງ ເສີມ ຄວາມ ສາມາດ ສໍາລັບ ການ ເຮັດ ວຽກ ດ້ວຍ ຕົນ ເອງ. ຊຸ ດຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ ມີ ຈຸດປະສົງ ສະໜອງ ໃຫ້ ເປັນ ຫຼັກສູດ ຝຶກ ອົບຮົມ ໄລຍະ ສ້ັນ ແບບ ແຍກ ດ່ຽວ ສໍາລັບ ພະນັກງານ ຜູ້ ທີ່ ເຮັດ ວຽກ ໃນ ຂົງ ເຂດ ນ້ີ ແລ້ວ ແລະ ເສ່ືອ ມສານ ເຂົ້າ ໃນ ຫຼັກສູດ ຝຶກອົບຮົມ ຕ່າງໆ ສໍາລັບ ພະນັກງານຝ່າຍສຸຂະພາບ ແລະ ການ ຟ້ືນ ຟູ. ຜູ້ ຝຶກ ອົບຮົມ ເ ປ້ົາໝາຍ ຊຸດ ຝຶກ ອົບຮົມ ນ້ີ ແມ່ນ ສໍາລັບ ພະນັກງານ ຫຼື ອາສາ ສະໝັກທຸກ ຄົນທ່ີ ຄາດ ວ່າ ຈະ ດໍາ ເນີນ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ຢູ່ ໃນ ສະຖານ ທີ່ ເຮັດ ວຽກ ຂອງ ເຂົາ ເຈົ້າ. ນ້ີ ອາດ ຈະ ລວມ ເອົາ ພະນັກງານ ຝ່າຍ ສຸຂະພາບ, ການ ຟ້ືນ ຟູ ຫຼື ຝ່າຍ ເຕັກນິກ ເຊັ່ນ ວ່າ ນັກ ອາຊີບ ບໍາບັດ, ນັກ ກາ ຍະ ພາບ ບໍາບັດ, ຜູ້ ຊ່ຽວຊານ ອະ ໄວ ຍະ ວະ ທຽມ, ຜູ້ ຊ່ຽວຊານອຸປະກອນ ປະຄອງ ຮ່າງກາຍ, ພະນັກງານ ເບິ່ງ ແຍ ງສຸຂະພາບ ແລະ ພະນັກງານ ຟ້ືນ ຟູ ຂ້ັນ ຊຸມ ຊົນ (CBR). ຈຸດປະສົງ ຊຸດ ຝຶກ ອົ ບຮົມ ລະດັບ ປານ ກາງ ຖືກ ອອກ ແບບ ມາ ເພ່ືອ ສະໜັບສະໜູນ ການ ຝຶກ ອົບຮົມ ພະນັກງານ ຫຼື ອາສາ ສະໝັກ ເ ພ່ືອ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ແລະ ເບາະ ຮອງ ນ່ັງ ທີ່ ເໝາະ ສົມ ໃຫ້ ແກ່ ເດັກ ຍິງ , ເດັກ ຊາຍ, ແມ່ຍິງ ແລະ ຜູ້ ຊາຍ ຜູ້ ທີ່ ຕ້ອງການ ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າທາງ ເພ່ີມ ເຕີມ ເພ່ືອ ໃຫ້ ສາມາດ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້. ຈຸດປະສົງ ຫຼັກຂອງ ຊຸດ ຝຶກ ອົບຮົມ ນ້ີ ແມ່ນ ເພ່ືອ ພັດທະນາ ທັກ ສະ ແລະ ຄວາມ ຮູ້ ຂອງ ບຸກຄະລາ ກອນ ທັງ ໝົດ ທີ່ ກ່ຽວຂ້ອງ ກັບ ການ ໃຫ້ ການບໍລິກາ ນ ລົດ ເຂັນ. ການ ດໍາ ເນີນ ຊຸດ ການ ຝຶກ ອົບຮົມ ນ້ີ ຈະ ຊ່ວຍ : ï ເພ່ີມ ຈໍານວນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ທີ່ ໄດ້ ຮັບ ລົດ ເຂັນ ທີ່ ຕອບ ສະໜອງ ຄວາມ ຕ້ອງການ ຂອງ ເຂົາ ເຈົ້າ; ï ເພ່ີມຈໍາ ນວນ ພະນັກງານ ທີ່ ໄດ້ ຮັບ ການ ຝຶກ ອົບຮົມ ໃນ ການ ໃຫ້ ບໍລິການ ລົດ ເຊັນ ລະດັບ ປານ ກາງ; ï ປັບປຸງ ຄວາມ ສາມາດ ຂອງ ພະນັກງານ ໃຫ້ການ ບໍລິການ ລົດ ເຂັນ; ï ເພ່ີມ ຄຸນ ນະພາ ບຂອງ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ ສໍາລັບ ຜູ້ ທີ່ ຕ້ອງການ ການ ຊ່ວຍ ເຫຼືອ ໃນ ລະດັບ ທີ່ ສູງ ກວ່າ ເມ່ືອທຽບ ກັບ ລະດັບ ພ້ືນຖານ; ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 3 ï ລວມ ເອົາ ຊຸດ ຝຶກ ອົບຮົມ ນ້ີ ໃນ ຫຼັກ ສູດ ຝຶກ ອົ ບຮົມຜູ້ ຊ່ວຍ ແພດ/ການຟ້ືນ ຟູ ຮ່າງກາຍ ແລະ ï ບັນລຸ ໄດ້ ການ ເຊື່ອມ ສານ ທີ່ ດີກ ວ່າ ຂອງ ການ ໃຫ້ ບໍລິ ການ ລົດ ເຂັນ ຢູ່ ພາຍ ໃນ ການ ບໍລິການ ຟ້ືນ ຟູ ຮ່າງກາຍ. ຂອບ ເຂດ ຊຸດ ຝຶກ ອົບຮົມນ້ີກວມ ເອົາ: ï ວິທີ ປະ ເມີນ ຄວາ ມຕ້ອງການດ້ານ ການ ເຄື່ອນ ໄຫວ ໄປມາ ແລະ ການ ຮອງຮັບ ທ່າ ທາງຂອງ ເດັກນ້ອຍ ແລະ ຜູ້ ໃຫຍ່ ຜູ້ ທີ່ ຕ້ອງການ ລົດ ເຂັນ ທີ່ ມີ ການ ຮອງ ຮັບ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ ï ວິທີ ເຮັດ ວຽກ ກັບ ເຂົາ ເຈົ້າ ເພ່ືອ ລະບຸ ວິທີ ແກ້ ໄຂ ທີ່ ດີ ທີ່ ສຸດ ສໍາລັບ ການ ເຄື່ອນ ໄຫວ ໄປມາ; ï ຄວາມ ຮູ້ ແລະ ເຄັດ ລັບ ປະຕິບັດ ຕົວ ຈິງ ທີ່ ຈໍາ ເປັນ ເພ່ືອ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ທີ່ ມີ ເບາະ ຮອງ ນ່ັງ ທີ່ ເໝາະ ສົມ ແລະ ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ; ï ການ ຝຶກ ອົບຮົມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ບ່ອນ ທີ່ ເໝາະສົມ ຄົນ ໃນ ຄອບຄົວ /ຜູ້ ໃຫ້ການ ເບິ່ງ ແຍງ ຂອງ ເຂົາ ເຈົ້າ ເພ່ືອ ໃຊ້ ປະ ໂຫຍ ດສູງ ສຸດ ຈາກ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ; ï ການ ຕິດຕາມ ຜົນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເພ່ືອ ຮັບປະກັນ ວ່າ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ສືບ ຕ່ໍ ຕອບ ສະໜອງ ໄດ້ ຄວາ ມຕ້ອງກາ ນຂອງ ເຂົາ ເຈົ້າ. ຄວາມ ຮູ້ ແລະ ທັກ ສະ ທ່ີ ຈໍາ ເປັນ ປະສົບ ກາ ນຜ່ານ ມາ ໃນ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ ແມ່ນ ສ່ິງ ສໍາຄັນ ຈໍາ ເປັນສໍາລັບ ຜູ້ ເຂົ້າ ຮ່ວມ ເພ່ືອ ໄດ້ ປະ ໂຫຍ ດສູງ ສຸດ ຈາກ ການ ຝຶກ ອົບຮົມ ລະດັບ ປານ ກາງ ນ້ີ. ຫຼັກສູດ ຝຶກ ອົບຮົມ ລະດັບ ປານ ກາງ ນ້ີ ໄດ້ ຖືກ ອອກ ແບບ ມາ ໂດຍ ຖື ວ່າ ຜູ້ ເຂົ້າ ຮ່ວມ ສາມາດ ສະ ແດງ ຄວາມ ສາມາດ ທີ່ ສອນ ໃນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ ຂອງ ອົງການ WHO ແລະ ມີ ປະສົບ ການ ຕົວ ຈິງ ໃນ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ ລະດັ ບພ້ືນຖານ ແລ້ວ. ໂຄງ ສ້າງ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ : ລະດັບ ປານ ກາງ ຖືກ ອອກ ແບບ ມາ ເພ່ືອ ໃຫ້ດໍາ ເນີນ ກາ ນຝຶກ ໂດ ຍ ຄູ ຝຶກ ທີ່ ມີ ທັກ ສະ ໃນ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ແລະ ສາມາດ ສະ ແດງຄວາມ ສາມາດ ທີ່ ສອນ ຢູ່ ໃນ ຫຼັກສູດ ຝຶກ ອົບ ນ້ີ ໄດ້ ຢ່າງ ໝ້ັນ ໃຈ. ມີ ຊັບພະຍາກ ອນດ້ານ ການ ສອນ ຢ່າງ ຫຼວງຫຼາຍ ເຊິ່ງລວມທັງ: ï ປື້ ມຄູ່ ມື ຄູ ຝຶກ ແລະ ເຄື່ອງມື ຂອງ ຄູ ຝຶກ; ï ປື້ ມຄູ່ ມື ອ້າງ ອີງ ສໍາລັບ ຜູ້ ເຂົ້າ ຮ່ວມ ( ເອີ້ນ ວ່າ ປື້ ມຄູ່ ມື ອ້າງ ອີງ); ï ປື້ ມຝຶກ ຫັດ ຂອງ ຜູ້ ເຂົ້າ ຮ່ວມ; ï ແບບ ຟອມຕ່າງໆ ຂອງການ ບໍ ລິ ການ ລົດ ເຂັນ; ï ລາຍການ ກວດການ ບໍ ລິ ການ ລົດ ເຂັນ; ï ອຸປະກອນ ຊ່ວຍ ດ້ານ ພາບ ລວມທັງ ສະ ໄລ PowerPoint, ວິ ດີ ໂອ ແລະ ໂປດສະ ເຕ້ີ. 4ຂະ ບວນກາ ນພັດທະນາ ຫຼັງຈາກ ການ ເຜີ ຍ ແຜ່ ຂ້ໍ ແນະນໍາກ່ຽວ ກັບ ການ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ໃນ ສະຖານ ທີ່ ທີ່ ມີ ຊັບພະຍາກອນ ຈໍາກັດ, WHO ໄດ້ ສ້າງ ຄະນະ ເຮັດ ວຽກ ເພ່ືອ ພັດທະ ນາ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ. ກອງ ປະຊຸມ ຄະນະ ເຮັດ ວຽກ ຄັ້ງ ທໍາ ອິດ ໄດ້ ຖືກ ຈັດ ຂ້ຶນ ໂດຍ WHO ໃນ ເດືອນ ຕຸລາ 2008 ເພ່ືອ ຕັດສິນ ກໍານົດຂອບ ເຂດ ແລະ ເນ້ືອ ຫາ ຂອງ ຊຸກ ຝຶກ ອົບຮົມ. ຫຼັງຈາກ ການ ເຜີຍ ແຜ່ ແລະ ການ ໄດ້ ຮັບ ຄໍາ ຕິ ຊົມ ຈາກ ຜູ້ ຊ່ຽວຊານ ໃນ ຂົງ ເຂດ ນ້ີຫຼາຍກວ່າ 20 ທ່ານ ກ່ຽວ ກັບ ເນ້ືອ ຫາ ຊຸກ ຝຶກ ອົບຮົມ ທີ່ສ ະ ເໜີ ມາ, ຄະນະ ຜູ້ ປະກອບ ສ່ວນ ຫຼັກ ໄດ້ ເຮັດ ວຽກ ເພ່ືອ ກະກຽມ ແຕ່ ລະ ຊຸດ ຝຶກ ອົບຮົມ ສໍາລັບ ການ ທົດ ລອງ ໃນ ພາກ ສະໜາມ. ໃນ ປີ 2011, ຊຸດ ຝຶກ ອົບຮົມລະດັບ ປາ ນກາງ ໄດ້ ຖືກ ທົດ ລອງ ໃນ ປະ ເທດ ໂຣມາ ເນຍ, ເຄັນ ຢາ ແລະ ຕີ ມໍ ຕາ ເວັນ ອອກ. ສະມາຊິກ ຂອງ ຄະນະ ເຮັດ ວຽກ ຊຸດຝຶກ ອົບຮົມ ລົດ ເຂັນ ຂອງອົງການ WHO ໄດ້ດໍາ ເນີນ ການ ສັງ ເກດ ແຕ່ ລະກາ ນທົດ ລອງ. ຄໍາ ເຫັນ ຕິ ຊົມ ຈາກ ຄູ ຝຶກ, ຜູ້ ເຂົ້າ ຮ່ວມ ຝຶກ ອົບຮົມ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ເຂົ້າ ຮ່ວມ ໃນ ພາກ ປະຕິບັດ ຕົວຈິງ ໄດ້ ຖືກ ເອົາ ລວມ ເຂົ້າ ໃນ ຮ່າ ງສຸດ ທ້າຍ. ນອກຈາກ ການ ຝຶກ ທົດ ລອງ ແລ້ວ, ຊຸດ ຝຶກ ອົບຮົມ ລະດັບ ປານ ກາງ ຍັງ ຖືກ ສ່ົງ ວຽນ ສໍາລັບ ການ ທົບ ທວນ ແລະ ກວດ ແກ້ ໃນອົງການ ລະດັບ ດຽວ ກັນ. ຜູ້ ຊ່ຽວຊານ ລົດ ເຂັນ 15 ທ່ານ ໄດ້ ກວດ ທົບ ທວນ ເອກະສານດ່ັງກ່າວ ແລະ ຄໍາ ຕິ ຊົມ ແລະ ຄໍາ ເຫັນ ປະກອບສ່ວນ ທີ່ ມີຄ່າ ຂອງ ເຂົາ ເຈົ້າ ໄດ້ ຖືກ ພິຈາລະນາ ໃນ ການ ສ້າງ ເອກະສານສະບັບ ສຸດ ທ້າຍ. ຜູ້ ຂຽນທັງ ໝົດ ທີ່ ເຂົ້າ ຮ່ວມ ການ ພັດທະນາ ຊຸກ ຝຶກ ອົບຮົມ ໄດ້ ເຮັດ ສໍາ ເລັດ ຄໍາ ຖະ ແຫຼງສິດຜົນປະ ໂຫຍ ດ (DOI) ແລະ ບໍ່ ມີ ໃຜ ຖະ ແຫຼງການ ຂັດ ແຍ່ງ ຜົນ ປະ ໂຫຍ ດ ໃດໆ ທີ່ ກ່ຽວຂ້ອງ ກັບ ຫົວ ຂ້ໍ ນ້ີ. ຊຸດຝຶກ ອົບຮົມ ໄດ້ ຮັບ ອະນຸມັດ ໂດຍ.... ໃນ ວັນ ທີ.... ວິທີ ໃຊ້ ຄູ່ ມື ອ້າງ ອີງ ຄູ່ ມື ອ້າງ ອີງນ້ີ ໃຫ້ ຂ້ໍ ມູນ ສັງ ລວມກ່ຽວ ກັບ ຄວາມ ຮູ້ ທີ່ ມີ ໃຫ້ ໃນການ ຝຶກ ອົບຮົມ ລະດັບ ປານ ກາງ ກ່ຽວ ກັບການ ບໍລິການ ລົດ ເຂັນ . ຜູ້ ເຂົ້າ ຮ່ວມ ອາດ ຈະ ໃຊ້ຄູ່ ມື ອ້າງ ອີງ ຫຼັງຈາກສ້ິນ ສຸດ ຫຼັກສູດ ຝຶກ ອົບຮົມ ເພ່ືອ ເຕືອນ ຄວາມ ຈໍາຕົນ ເອງ ກ່ຽວ ກັບຂໍ້ ສໍາຄັນ ທີ່ ໄດ້ຮຽນ ຮູ້ ໃນ ແຕ່ ລະຕອນຂອງ ການ ຝຶກ ອົບຮົມ. ຄູ່ ມື ແບ່ງ ອອກ ເປັນ ສອງ ສ່ວນ: A: ຄວາມ ຮູ້ ຫຼັກ B: ຂ້ັນ ຕອນ ການ ບໍລິການ ລົດ ເຂັນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 5 A: ຄວາມ ຮູ້ ຫັຼກ – ສ່ວນ ນ້ີ ລວມມີ ຂ້ໍ ມູນ ທີ່ ກ່ຽວຂ້ອງ ກັບ ທຸ ກຂ້ັນ ຕອນ ຂອງ ການ ບໍລິການ ລົດ ເຂັນ. ໃນ ບາ ງສະພາບ ການ, ໂດຍ ຂ້ຶນ ກັບ ຄວາມ ຕ້ອງ ການ ຮຽນ ຮູ້ ຂອງ ຜູ້ ເຂົ້າ ຮ່ວມ, ຄູ ຝຶກ ອາດ ຈະ ເລືອກ ເພ່ີມ ຂ້ໍ ມູນ ຕ່ືມ ອີກ ໃສ່ ສ່ວນ ນ້ີ. B: ຂ້ັນ ຕອນ ການ ບໍລິການ ລົດ ເຂັນ – ສ່ວນ ນ້ີ ລວມມີ ຂ້ໍ ມູນ ທີ່ ຈະ ຊ່ວຍ ຜູ້ ເຂົ້າ ຮ່ວມ ດໍາ ເນີນ ການ ແຕ່ລະ ຂ້ັນ ຕອນ ໃນ ແປດ ຂ້ັນ ຕອນ ຂອງ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ ( ເບິ່ງ ຂ້ໍ ແນະນໍາ ກ່ຽວ ກັບ ການ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ໃນ ສະຖານ ທ່ີ ທ່ີ ມີ ຊັບພະຍາກອນ ຈໍາກັດ (2) ຂອງ ອົງການ ອະນາ ໄມ ໂລກ, ໜ້າ 76) ໃນ ລະດັບ ປານ ກາງ. ການ ຝຶກ ອົບຮົມ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ ລະດັບ ພ້ືນຖານ ແລະ ປານ ກາງ ເພ່ືອ ຊ່ວຍ ສະໜອງ ການ ຝຶກ ອົບຮົມ ທີ່ ຖືກຕ້ອງ ສໍາລັບ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ຂອງ WHO ໃຫ້ການ ຝຶກອົບຮົມ ໃນ ສອງ ລະດັບ – ພ້ືນຖານ ແລະ ປານ ກາງ. • ລະດັບ ພ້ືນຖານ ສອນ ຜູ້ ເຂົ້າ ຮ່ວມ ວິທີ ສະໜອງ ລົດ ເຂັນ ໃຫ້ ແກ່ ເດັກນ້ອຍ ແລະ ຜູ້ ໃຫຍ່ທີ່ ມີຄວາມ ລໍາບາກ ໃນ ການ ຍ່າງ ແລະ ການ ເຄື່ອນ ໄຫວ ໄປມາ ແຕ່ ຍັງ ສາມາດ ນ່ັງ ຕັ້ງ ຊ່ື ໄດ້ ໂດຍ ບໍ່ ມີ ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ເພ່ີມ ເຕີມ. • ລະດັບ ປານ ກາງ ສອນ ຜູ້ ເຂົ້າ ຮ່ວມ ວິດ ທີ ສະໜອງ ລົດ ເຂັນ ໃຫ້ ແກ່ ເດັກນ້ອຍ ແລະ ຜູ້ ໃຫຍ່ທີ່ ຈໍາ ເປັນ ຕ້ອງ ມີ ແນວປະ ຄອງຫຼືຮອງ ຮັບ ເພ່ີມ ເຕີມ ເພ່ືອ ນ່ັງຕ້ັງ ຊ່ື ໄດ້. ຫຼັກສູດ ຝຶກ ອົບຮົມລະດັບ ປານ ກາງ ສ້າງ ຈາກ ຂ້ໍ ມູນ ແລະ ທັກ ສະ ທີ່ ຜູ້ ເຂົ້າ ຮ່ວມ ໄດ້ ຮັບ ຈາກ ລະດັບ ພ້ືນຖານ. 2 ອົງ ການ ອະ ນາ ໄມ ໂລກ ຂ້ໍ ແນະນໍາ ກ່ຽ ວກັບ ການ ສະໜອງ ລົດ ເຂັນ ແບບ ໃຊ້ ມື ໃນ ສະຖານ ທີ່ ທີ່ ມີ ຊັບພະຍາກອນ ຈໍາກັດ. Geneva, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, ເຂົ້າ ຫາ ວັນ ທີ 15 ທັນວາ 2011). 6A: ຄວາມ ຮູ້ ຫັຼກ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 7 A.1: ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ທ່ີ ໄດ້ ປະ ໂຫຍ ດຈາກ ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແມ່ນ ບຸກຄົນ ຜູ້ ທີ່ ມີ ລົ ດ ເຂັນ ຢູ່ ແລ້ວ ຫຼື ຜູ້ ທີ່ ສາມາດ ໄດ້ ປະ ໂຫຍ ດຈາກ ການ ໃຊ້ ລົດ ເຂັນ ເພາະວ່າ ຄວາມ ສາມາດ ໃນ ການ ຍ່າງ ຂອງ ເຂົາ ເຈົ້າ ມີ ຈໍາກັດ. ຜູ້ ໃຊ້ ລົດ ເຂັນລວມມີ: ï ເດັກນ້ອຍ, ຜູ້ ໃຫຍ່ ແລະ ຜູ້ ສູງ ອາຍຸ; ເດັກ ຍິງ, ເດັກ ຊາຍ, ແມ່ຍິງ ແລະ ຜູ້ ຊາຍ; ï ຄົນ ທີ່ ມີ ບັນຫາ ສຸຂະພາບ, ວິຖີຊີວິດ, ບົດບາດ ໃນ ການ ດໍາ ເນີນ ຊີວິດ ແລະ ພ້ືນຖານ ທີ່ ແຕກ ຕ່າງ ກັນ; ï ຄົນທ່ີ ອາ ໄສ ແລະ ເຮັດ ວຽກ ຢູ່ ໃນ ສະພາບ ແວດ ລ້ອມ ແຕກ ຕ່າ ກັນ ລວມທັງ ເຂດ ຊົນນະບົດ, ເຄິ່ງຕົວ ເມືອງ ແລະ ຕົວ ເມືອງ ໃຫຍ່. ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແຕ່ລະຄົນ ຈະ ແຕກຕ່າງ ກັນ. ແນວ ໃດ ກໍ ຕາມ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ທຸກ ຄົນ ຈໍາ ເປັນ ຕ້ອງມີ ລົດ ເຂັນ ທ່ີ ເໝາະ ສົມ. ລົດ ເຂັນ ທີ່ ປັບ ໃຫ້ ເໝາະ ສົມ ເປັນ ຢ່າງ ດີ ແຕ່ ລ ະ ຄັນ ໃຫ້ການ ຮອ ງຮັບ ທ່າ ທາງ ຕ່າງໆ ແກ່ ຜູ້ ໃຊ້. ແນວ ອີງ ຫຼັງ, ເບາະ ນ່ັງ, ແນວ ຮອງ ຕີນ ແລະ ແນວ ຮອງ ແຂນ ທັງ ໝົດ ໃຫ້ການ ຮອງ ຮັບ ທ່າທາງ ຕ່າງໆ ໃນ ເວລາ ປັບ ໃຫ້ ເໝາະ ສົມ ກັບ ຂະໜາດ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ແນວ ໃດ ກໍຕາມ, ເດັກນ້ອຍ ແລະ ຜູ້ ໃຫຍ່ ຫຼາຍໆ ຄົນ ຈໍາ ເປັນ ຕ້ອງ ມີ ການປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ໃນ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ. ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ສາມາດ ຖືກ ສະໜອງ ໃຫ້ ໂດຍ ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ (PSD) – ເຊິ່ງ ເປັນ ອຸປະກອນປະຄອງ ຮ່າງກາຍ ທີ່ ໃຫ້ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ແມ່ນ ອົງ ປະກອບ ສໍາຄັນ ຂອງ ການ ບໍລິ ການ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ນ້ີ ລວມມີ ການ ເພ່ີມ ໃສ່ ຫຼື ການ ດັດ ແປງ ຕ່າງໆ ຕ່ໍ ກັບ ລົດ ເຂັນ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ໃນຕະຫຼອດ ຄູ່ ມື ນ້ີ, ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ (ຮອງ ຮັບ ທ່າ ທາງ) ເອີ້ນ ວ່າສ້ັນໆ ວ່າ ອຸປະກອນ PSD. ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ທ່ີ ໄດ້ ປະ ໂຫຍ ດຈາກ ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ ບາງ ຄົນ ບໍ່ ສາມາດ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້ ໂດຍ ບໍ່ ມີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ ເພ່ີມ ເຕີມ. ບາງ ຄົນ ຕ້ອງການ ການ ຮອງ ຮັບ ເພ່ີມ ເຕີມ ຢ່າງ ຫຼວງຫຼາຍ ແລະ ບາງ ຄົນ ຕ້ອງການ ພຽງແຕ່ການ ປ່ຽນ ແປງ ສອງ ສາມ ຢ່າງ ເທົ່ານ້ັນ ຕ່ໍ ກັບ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ. ສາມາດ ໃຫ້ ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ໄດ້ ໃນ ວິ ທີ ແຕກ ຕ່າງ ກັນ. ບາງ ວິທີການແກ້ໄຂແມ່ນງ່າຍດາຍທ່ີສຸດ ແລະ ສາມາດຖືກ ເຮັດ ໄດ້ ໃນ ໂຮງ ສ້ອມ ແປງ ລະດັບພ້ືນຖານ. ວິທີ ແກ້ ໄຂ ອື່ນ ອາດ ຈະ ສັບສົນ ກວ່າ. ເມ່ືອ ໃດຈໍາ ເປັນ ຕ້ອງ ມີ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ? ຜູ້ ຄົນ ຕ້ອງການ ການ ຮອງ ຮັບ ທ່າ ທາງ ຫຼືການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ ຍ້ອນ ເຫດຜົນ ແຕກ ຕ່າງ ກັນ. ໂດຍ ປົກກະຕິ ແລ້ວ ມັນ ຈະ ແຈ້ງ ເມ່ືອ ລົດ ເຂັນ ບໍ່ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ພຽງພໍ ເພ່ືອ ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້ ຕາມ ທີ່ ອະທິບາຍ ໄວ້້ຂ້າງ ລຸ່ມ. ສ່ວນ ຫຼາຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຫຼື ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ດູ ແລ ຈະ ມີ ຄໍາ ແນ ະນໍາ ທີ່ ດີ ກ່ຽວ ກັບ ການ ຮອງ ຮັບ ເພ່ີມ ເຕີມ ທີ່ ພວກ ເຂົາ ອາດ ຈະ ຕ້ອງການ. 8 ເຫດຜົນ ສໍາລັບ ການ ຕ້ອງການ ການ ຮອງ ຮັບ ເພ່ີມ ເຕີມ ລວມມີ: ï ບໍ່ ສາມາດ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້; ï ບໍ່ ສາມາດ ຄວບ ຄຸມ ການ ເຄື່ອນ ເໜັງ ໄດ້ ຫຼື ກ້າມ ເນ້ືອ ກະຕຸກ; ï ຂ້ໍ ຕ່ໍ ແຂງ; ï ຄວາມ ແໜ້ນ; ï ອ່ອນ ເພຍ; ï ອິດ ເ ມ່ືອຍ; ï ເຈັບ ຫຼື ບໍ່ ສະບາຍ ຕົວ; ï ລໍາບາກ ໃນ ການຊົງ ຕົວ ໃຫ້ ທ່ຽງ. ຄໍາ ນິຍາມ: ອຸ ປະ ກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ (PSD) ອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ຫຼື ຮອງ ຮັບ ທ່າ ທາງ (PSD) ແມ່ນ ອຸປະກອນປະຄອງ ຮ່າງກາຍ ທີ່ ໃຫ້ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ອຸປະກອນ PSD ແມ່ນ ອົງ ປະກອບ ສໍາຄັນ ຂອງ ການ ບໍລິ ການ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ການ ປະຄອງ ຫືຼຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ຊ່ວຍ ໄດ້ ແນວ ໃດ? ມີ ສ່ີ ຮູບ ແບບທີ່ ສໍາຄັນ ຫຼາຍທ່ີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ສາມາດ ໃຫ້ ປະ ໂຫຍ ດ ແກ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ; 1. ປັ ບປຸງ ການ ຊົງ ຕົວ, ທ່າ ທາງ ແລະ ຄວາມ ໝ້ັນຄົງ ການ ປັບປຸງ ການ ຊົງ ຕົວ, ທ່າ ທາງ ແລະ ຄວາມ ໝ້ັນຄົງ ສາມາດ ຊ່ວ່ຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ດໍາ ເນີນ ກິດຈະກໍາ ທີ່ ເປັນ ໄປ ໄດ້ ບໍ່ ໄດ້ ຫຼື ຍາກ ຫຼາຍສໍາລັບ ພວ ກ ເຂົາ ຖ້າ ບໍ່ ມີ ແນວ ປະຄອງຫຼືຮອງ ຮັບທ່າ ທາງ ເພ່ີມ ເຕີມ. 2. ປັບປຸງ ຄວາມ ສະບາຍ ຕົວ ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ສາມາດ ເຮັດ ໃຫ້ ລົດ ເຂັນ ສະບາຍ ຕົວ ຫຼາຍຂ້ຶນ ແລະ ສາມາດ ເພ່ີມ ເວລາ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ນ່ັງ ໃນ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ກ່ອນ ທີ່ ຈະ ອິດ ເມ່ືອຍ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 9 3. ຊ່ວຍ ປ້ອງ ກັນ ການ ເກີດ ແຜ ກົດທັບ ແຜ ກົ ດທັບ ສາມາດ ເກີດ ຂ້ຶນ ໄດ້ ຢ່າງ ວ່ອງ ໄວ. ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ທີ່ ດີຊ່ວຍ ປ້ອງ ກັນ ແຜ ກົ ດທັບ ໂດຍ ການ ຮັບປະກັນ ວ່າສ່ວນ ໃດ ໜຶ່ງ ຂອງ ຮ່າງກາຍ ບໍ່ຖືກ ກົ ດທັບ ຫຼືຮຸກ ຖູ ຫຼາຍ ເກີນ ໄປ. ຜົນ ປະ ໂຫຍ ດອັນ ໜຶ່ງ ຂອງ ກາ ນນ່ັງ ຕ້ັງ ຊ່ື ມີ ຢູ່ ວ່າ ນ້ໍາໜັກ ຈະ ກ ະ ຈາ ຍຢ່າງ ເທົ່າ ກັນ. ນ້ີ ຊ່ວຍ ຫຼຸດຜ່ອນ ຄວາມ ສ່ຽງຂອງ ການ ເກີດ ແຜ ກົ ດທັບ. ໃນ ເວລາ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ນ່ັງ ຕ້ັງ ຊ່ື, ນ້ໍາໜັກ ກະຈາ ຍຢ່າງ ບໍ່ ສະ ເໝີ ກັນ. ສ່ວນ ໜຶ່ງ ຂອງ ຮ່າ ງກາຍ ຈະ ຮັບ ນ້ໍາໜັກ ຫຼາຍກວ່າ ສ່ວນ ອື່ນ. ຖ້າ ນ້ໍາໜັກ ເພ່ີມ ເຕີມ ກົ ດທັບ ໃສ່ ຜິວໜັງ ທີ່ຢູ່ ເທິງ ບໍລິ ເວນທີ່ ມີ ກະດູກ, ມີ ຄວາມ ສ່ຽງ ສູງ ທີ່ ຈະ ເກີດ ແຜ ກົ ດທັບ. ຕົວຢ່າງ ຂອງ ບໍລິ ເວນ ທີ່ ມີ ກະດູກ ລວມມີ ບໍລິ ເວນກະ ດູກ ຮອງ ນ່ັງ (ປຸ່ມ ນ່ັງ ກະດູກ ກ້ົນ), ບໍລິ ເວນກະດູກ ຂ້າງ, ສະ ໂພ ກ (ກະດູກ ຕ້ົນ ຂາ), ກະດູກ ສັນຫັຼງ (ສັນຫັຼງ) ຫຼື ກະດູກ ຫາງ (ກະດູກ ກ້ົນກົບ). ໃນ ເວລາ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ມີ ການ ຮອງ ຮັບ ທີ່ ດີ, ຜູ້ກ່ຽວ ມັກ ຈະ ເລື່ອນ ໄຫຼຢູ່ ເທິງ ບ່ອນ ນ່ັງ. ນ້ີ ກ່ໍ ໃຫ້ ເກີດການ ຮຸກ ຖູ ເຊິ່ງ ເຮັດ ໃຫ້ ເກີດ ແຜ ກົ ດທັບ. ກາ ນ່ັງ ທີ່ ມີ ການ ຮອງ ຮັບ ທີ່ ດີ ປ້ອງ ກັນການ ເລື່ອນ ໄຫຼ ແລະ ການ ຮຸກ ຖູ. 4. ຊ່ວຍ ເຮັດ ໃ ຫ້ຊ້າ ລົງ ຫືຼ ປ້ອງ ກັນ ການ ເກີດ ບັນຫາ ເລ່ືອງ ທ່າ ທາງ ໃນ ອະນາຄົດ ການ ປະຄອງ ຫຼືຮອ ງຮັບ ທ່າ ທາງ ທີ່ ດີ ສາມາດ ປ້ອງ ກັນ ບັນຫາ ເລື່ອງ ການ ພັດທະນາ ທ່າ ທາງ ທີ່ ບໍ່ ດີ. ຖ້າ ບັນຫາ ເລື່ອງ ທ່າ ທາງ ເລີ່ ມມີ ແລ້ວ, ການປະ ຄອງ ຫຼື ຮອງ ຮັບ ທ່າ ທາງ ທີ່ ດີ ສາມາດ ເຮັດ ໃ ຫ້ຊ້າ ລົງ ຫຼື ປ້ອງ ກັນ ບໍ່ ໃຫ້ ມັນ ຮ້າຍ ແຮງ ໄປ ກວ່າ ນ້ີ. ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາ ງທ່ີ ດີ ໃນ ການ ນອນ, ການ ນ່ັງ ແລະ ການ ຢືນ ໂດຍ ເລີ່ ມ ໄວ ແຕ່ ຕ້ົນໆ ແມ່ນສ່ິງ ສໍາຄັນ ຫຼາຍ. 10 ການ ກິນ ແລະ ການ ດ່ືມ ຢ່າງ ປອດ ໄພ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບາງ ຄົນ ທີ່ ມີ ຄວາມ ລໍາບາກ ໃນ ການ ນ່ັງ ຕ້ັງ ຊ່ື ຍັງ ມີ ບັນຫາ ເລື່ອງ ການ ກືນຢ່າງປອດ ໄພ ນໍາ ອີກ. ສໍາລັບ ຄົນ ເຫຼົ່ານ້ີ, ການ ກິນ ແລະ ການ ດື່ມ ສາມາດ ເປັນ ເລື່ອງ ທີ່ ບໍ່ ສະບາ ຍ, ບາງ ຄັ້ງ ກໍ ເປັນຕາ ຢ້ານ ແລະ ຫຼາຍໆ ຄັ້ງ ກໍ ເປັນ ອັນຕະລາຍ. ເມ່ືອ ຄົນ ມີ ຄວາມ ລໍາບາກ ໃນ ການກືນ ຢ່າງ ປອດ ໄພ, ຊ້ິນ ສ່ວນ ນ້ອຍໆ ຂອງອາຫານ ສາມາດ ຫຼົງ ເຂົ້າ ໄປ ໃນ ປອດ ໄດ້. ນ້ີ ສາມາດ ກໍ ໃຫ້ ເກີດ ການ ຕິດ ເຊື້ອ ຢູ່ ເອິກ, ເຮັດ ໃຫ້ ພວກ ເຂົາ ເຈັບ ປ່ວຍ ຫຼື ແມ້ກະທ້ັງນໍາ ໄປ ສູ່ ການ ເສຍ ຊີວິດ. ແນວ ປະຄອງຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ໃນລົດ ເຂັນ ຮັບປະກັນ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນສາມາດ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້ ໃນ ເວລາ ກິນ ແລະ ດື່ມ. ການ ປບັປງຸ ການ ປະຄອງ ຫຼຮືອງ ຮັບ ທາ່ ທາງ ແມນ່ ສ່ວນ ໜຶງ່ ຂອງ ວທິີ ແກ ້ໄຂ ສໍາລັບ ທກຸ ຄນົທ່ີ ມີ ບນັຫາ ເລືອ່ງ ການ ກືນ ເທົາ່ ນ້ັນ. ຖາ້ ໄປ ເປນັ ໄປ ໄດ້, ເດກັນ້ອຍ ຫຼ ືຜູ້ ໃຫຍ ່ທີ ່ມີ ບນັຫາ ເລືອ່ງ ກາ ນກືນ ຄວນ ຖກື ນໍາ ສ່ົງ ຫາ ບາງ ຄນົທ່ີ ມີ ປະສົບ ການ ໃນ ການ ຄຸມ້ ຄອງ ອາການ ນ້ີ. ນ້ີ ສາມາດ ເປນັ ແພດ ເດກັ, ນັກ ບາໍບັດ ແກ ້ໄຂ ການ ເວົາ້ ຫຼື ພະນັກງານດູ ແລສຂຸະພາບ ຫຼ ື ແພ ດຊມຸ ຊົນ ຜູ້ ທີມີ່ ຄວາມ ຮູ້ ແລະ ການ ຝຶກ ອບົຮມົ ໃນ ການ ຊ່ວຍ ເຫຼອືຄນົ ຄຸມ້ ຄອງ ບນັຫາ ເລືອ່ງ ການ ກືນ. ຜູ້ ໃຊ້ ລົດ ເຂັນ ຕ້ອງການ ຫຍັງ? ຜູ້ ໃຊ້ ລົດ ເຂັນ ຕ້ອງການ ສະບາຍ ຕົວ ແລະ ສາມາດ ດໍາ ເນີນ ຊີວິດ ຂອງ ເຂົາ ເຈົ້າ ໄດ້. ມັນ ສໍາຄັນ ວ່າ ແນວ ປະຄອງ ຫຼືຮອງຮັບ ເພ່ີມ ເຕີມ ໃນ ລົດ ເຂັນ ບໍ່ ເຮັດ ໃຫ້ ກິດຈະກໍາ ປະຈໍາ ວັນ ຍາກ ຂ້ຶນ. ຕົວຢ່າງ, ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ບໍ່ ຄວນ ໄປ ລົບ ກວນ ການ ເຄື່ອນ ຍ້າຍ ເຂົ້າ ແລະ ອອກ ຈາກລົດ ເຂັນ, ການ ຂັບ ເຄື່ອນ ລົດ ເຂັນ, ການ ເຂົ້າ ເຖິງ ໂຕະ ຫຼືພ້ືນ ທີ່ ເຮັດ ວຽກ ແລະ ການ ຂົນ ສ່ົງ ເດີນທາງ. ລົດ ເຂັນ ແລະ ແນວປະຄອງ ຫຼື ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ຄວນ: ï ໃຊ້ ໄດ້ ຈິງ ແລະ ໃຊ້ ງ່າຍ; ï ສະບາຍ ຕົວ ແລະ ບໍ່ ກໍ ໃຫ້ ເກີດ ຄວາມ ບໍ່ ສະບາຍ ຕົວ ເພ່ີມ ເຕີມ; ï ຊ່ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເຮັດ ສ່ິງ ຕ່າງໆ ແລະ ບໍ່ ເຮັດ ໃຫ້ ພວກ ເຂົາ ຫຍຸ້ງຍາກ ຂ້ຶນ; ï ມີ ຮູບ ຮ່າງ ສວຍ ງາມ ແລະ ບໍ່ ëປະ ເຈີດ ປ ະ ເ ຈີ້í ເກີນ ໄປ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 11 ບາງ ຄັ້ງຜູ້ ໃຊ້ ລົດ ເຂັນ ພົບ ວ່າ ມັນ ຍາກ ໃນ ການ ສ້າງ ຄວາມ ຄຸ້ນ ເຄີ ຍກັບ ລົດ ເຂັນ ທີ່ ມີ ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ມີ ເຫດຜົນ ແຕກ ຕ່າງ ກັນ ສໍາລັບ ສ່ິງ ນ້ີ ເຊິ່ງລວມມີ: ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ອາດ ຈະ ຄຸ້ນ ເຄີຍ ກັບ ການ ນ່ັງ ໃນ ທ່າ ທາງ ສະ ເພາະ. ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ເຊິ່ງປ່ຽນ ທ່າ ທີ່ ຄຸ້ນ ເຄີຍ ຂອງ ເຂົາ ເຈົ້າ, ຮູ້ ບໍ່ ສະບາຍ ຕົວ ຫຼື ຈໍາກັດ; ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ອາດ ຈະ ບໍ່ ເຂົ້າ ໃຈຍ້ອນ ຫຍັງ ຈິ່ງ ມີ ການ ກໍານົດ ໃຊ້ ແນວ ປະຄອງ ຫຼືຮອ ງຮັບ ເພ່ີມ ເຕີມ; ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ອາດ ຈະ ຮູ້ສຶກ ວ່າ ແນວ ປະຄອງ ຫຼືຮອ ງຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ບໍ່ ສວຍ ງາມ ແລະ ເຮັດ ໃຫ້ ຄວາມ ພິການ ຂອງ ເຂົາ ເຈົ້າ ເບິ່ງ ເຫັນ ໄດ້ ຈະ ແຈ້ງ ຂ້ຶນ. ຍອ້ນ ເຫດ ຜົ ນ ເຫຼົາ່ນ້ີ, ມັນ ສໍາຄັນ ຫາຼຍວ່າ ພະນັກ ງງານ ບລໍກິານ ລດົ ເຂນັ ຕ້ອງ ເຮດັ ວຽກຢາ່ງ ໃກ້ຊິດ ກັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ແລະ ຄອບຄວົ/ຜູ້ ເບິງ່ ແຍງ ເຂົາ ເຈົາ້ ໃນ ຕະຫຼອດຂັນ້ ຕອນການ ປະ ເມີນ ຜົນ, ການກໍານົດ ໃຊ,້ ການ ປບັລດົ ເຂັນ ໃຫ ້ເໝາະ ສົມ, ການ ຝຶກ ອບົຮມົ ຜູ້ ໃຊ ້ ແລະ ການ ຕິດຕາມ ຜົນ. ປກຶສາ ຫາລື ວທິ ີແກ ້ໄຂ ກັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ສະ ເໝີ ແລະ ເຄາົລົບ ຄາໍ ຄດິ ເຫນັ ແລະ ກາ ນຕັດສິນ ໃຈ ສຸດ ທາ້ຍ ຂອງ ເຂາົ ເຈົາ້ ສະ ເໝີ. ວິທີ ທີ່ ດີ ສຸດ ໃນ ການ ຮັບປະກັນ ວ່າ ແນວ ປະຄອງ ຫຼື ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ຈະ ຖືກ ໃຊ້ ໂດຍຜູ້ ໃຊ້ ລົດ ເຂັນ ແມ່ນ: ï ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ເຂົາ ເຈົ້າ ເຂົ້າ ຮ່ວມ ຢ່າງ ເຕັມ ສ່ວນ ໃນ ການ ປະ ເມີນ ຜົນ, ການກໍານົດ ໃຊ້, ການ ປັບ ລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ, ການ ຝຶກ ອົບຮົມ ຜູ້ ໃຊ້ ແລະ ການ ຕິດຕາມ ຜົນ; ï ຊ່ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ເຂົາ ເຈົ້າ ໃຫ້ ເຂົ້າ ໃຈ ວ່າຍ້ອນ ຫຍັງ ແລະ ແນວ ປະຄອງ ຫຼືຮອ ງຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ຈະ ຊ່ວຍ ພວກ ເຂົາ ແນວ ໃດ; ï ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເຮັດ ການ ຕັດສິນ ໃຈ ສຸດ ທ້າຍ ສະ ເໝີ. ທ່າ ທາງ ທ່ີ ດີ ສາມາດ ເພ່ີມ ການ ເຄົາ ເລົບ ຕົນ ເອງ ຜົນ ປະ ໂຫຍ ດສໍາຄັນ ຂອງ ແນວ ປະຄອງ ຫຼືຮອ ງຮັບ ທ່າ ທາງເພ່ີມ ເຕີມມີ ຢູ່ ວ່າ ມັນ ສາມາດ ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຮູ້ສຶກ ດີ ກ່ຽວ ກັບ ຕົນ ເອງ. ການ ໄດ້ ຮັບ ການ ປະຄອງ ຫຼືຮອງຮັບ ທີ່ ດີ ໃນ ທ່າ ນ່ັງ ຕ້ັງ ຊ່ື ກວ່າສາມາດ ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຮູ້ສຶກໝ້ັນ ໃຈ. ດ້ວຍ ແນວປະຄອງ ຫຼື ຮອງ ຮັບ ທີ່ ເໝາະ ສົມ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ມີ ສ່ວນຮ່ວມ ເພ່ີມ ຂ້ຶນ ໃນ ການ ດໍາ ເນີນ ຊີວິດ ໃນ ຊຸມ ຊົນ. ຕົວຢ່າງ, ການ ສາມາດ ເຄື່ອນ ໄຫວ ໄປມາ ແລະ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ເຮັດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ໄປ ເຮັດ ວຽກ ຫຼື ໄປ ໂຮງຮຽນ ; ໄປ ຢາມ ໝູ່ ເພ່ືອນ; ເຂົ້າ ຮ່ວມ ພິທິທາງ ສາສະໜາ ຫຼື ກິດຈະກໍາ ຊຸມ ຊົນ ອື່ນ ໄດ້. 12 ລາຍການ ກວດ ເພ່ືອ ຊ່ວຍ ຮັບປະກັນ ວ່າ ລົດ ເຂັນ ທ່ີ ມີ ແນວ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ຕອບ ສະໜອງ ໄດ້ ຄວາມ ຕ້ອງກາ ນຂອງ ຜູ້ ໃຊ້ ລາຍການ ກວດ ຕ່ໍ ໄປ ນ້ີ ສາມາດ ຊ່ວຍ ໃຫ້ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຮັບປະກັນ ວ່າ ແນວ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ທີ່ ພວກ ເຂົາ ກໍານົດ ໃຫ້ ໃຊ້ ແມ່ນ ເປັນ ໄປ ໄດ້ ຫຼາຍທ່ີ ສຸດ ທີ່ ຈະ ປະສົບ ຜົນສໍາ ເລັດ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ລາຍການ ກວດ: ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ຂອງ ເຂົາ ເຈົ້າ ໄດ້ ເຂົ້າ ຮ່ວມ ຢ່າງ ເຕັມ ສ່ວນ ໃນ ການຕັດສິນ ໃຈ ການ ກໍານົດ ໃຊ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ລອງ ລົດ ເຂັນ ທີ່ ມີ ອຸປະກອນ PSD ທີ່ ກໍາ ນົດ ໃຊ້ ກ່ອນ ທີ່ ມັນ ຈະ ຖືກ ເຮັດ ເປັນ ສຸດ ທ້າຍ (ຢູ່ ສູນ ບໍລິການ ແລະ ຢູ່ ເຮືອນ ຖ້າ ເປັນ ໄປ ໄດ້) ແລະ ໃ ຫ້ຄໍາ ຕິ ຊົມ ຂອງ ເຂົາ ເຈົ້າ ລົດ ເຂັນ ແລະ ອຸປະ ກອນ PSD ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເຮັດ ສ່ິງ ຕ່າງໆ ທີ່ ເຂົາ ເຈົ້າ ຕ້ອງການ ເຮັດ: ï ອຸປະກອນ PSD ປັບປຸງ ຄວາມ ສາມາດ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃນ ການ ເຮັດ ສ່ິງ ຕ່າງໆ ï ອຸປະກອນ PSD ບໍ່ ຂັດຂວາງ ການ ເຄື່ອນ ຍ້າຍ ເຂົ້າ ແລະ ອອກ ຈາກ ລົດ ເຂັນ ໄດ້ ງ່າຍ ດາຍ ï ອຸປະກອນ PSD ບໍ່ ເຮັດ ໃຫ້ ລົດ ເຂັນ ໂດຍ ລວມໜັກ ເກີນ ໄປ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ສະບາຍ ຕົວ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ: ï ອຸປະກອນ PSD ໃຫ້ການ ປະຄອງ ຫຼືຮອ ງຮັບ ແລະ ໃຫ້ ຜູ້ ໃຊ້ລົດ ເຂັນ ນ່ັງ ໃນ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ໄດ້ ດົນ ກວ່າການ ບໍ່ ມີ ອຸປະກອນ PSD ï ອຸປະກອນ PSD ໃຫ້ການ ປະຄອງ ຫຼືຮອງຮັບ ທີ່ ພຽງພໍ ແລະ ບໍ່ ເຮັດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ໃກ້ ກັບ ທ່າ ນ່ັງ ປົກກະຕິ ຫຼາຍກວ່າ ທີ່ ມັນ ສະບາຍ ຕົວ ສໍາລັບ ເຂົາ ເຈົ້າ. ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ເບິ່ງ ສວຍ ງາມ ແລະ ເຂົ້າກັນ ດີ (ຕ່ໍ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ) ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ແ ມ່ນປອດ ໄພ: ï ວຽກ ລະອຽດ ຂອງ ອຸປະກອນ PSD ແມ່ນ ລຽບ ນຽນ ແລະ ມີ ແນວ ຮອງ ເສີມທ່ີ ດີ ແລະ ການຫຸຼດຜ່ອນ ການ ກົ ດທັບ ï ການ ປ່ຽນ ດ້ານ ໂຄ ງສ້າງ ໃດໆ ຕ່ໍ ກັບ ໂຄງ ປະກອບ ລົດ ເຂັນ ແມ່ນ ໄດ້ ຖືກ ກວດ ກາ ໂດຍ ບຸກຄົນ ທີ່ ເໝາະ ສົມ ï ລົດ ເຂັນ ບໍ່ປີ້ນ ໄປ ທາງ ໜ້າ, ທາງ ຫຼັງ ຫຼື ທາງ ຂ້າງ ໄດ້ ງ່າຍ ໃນ ເວລາ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຢູ່ ໃນ ລົດ ເຂັນ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ແ ມ່ນ ໃຊ້ ໄດ້ ຈິງ: ï ແນວ ຫຸ້ມ ເບາະ ສາມາດ ອະນາ ໄມ ໄດ້ ຫຼື ຖອດ ອອກ ສໍາລັບ ການ ຊັກ ລ້າງ ໄດ້ ï ຈໍານວນ ຊ້ີນ ສ່ວນ ແຍກ ກັນ ແມ່ນ ມີໜ້ອຍ ທີ່ ສຸດ ເທົ່າ ທີ່ ຈະ ເປັນ ໄປ ໄດ້ ເພ່ື ອປ້ອງ ກັນ ບໍ່ ໃຫ້ ພວກ ມັນ ເສຍ/ຖືກ ໃຊ້ ຢ່າງ ບໍ່ ຖືກຕ້ອງ ï ສາມາດ ເອົາ ລົດ ເຂັນ ໃສ່ ໃນ ລົດ ໃຫຍ່/ລົດ ຂົນ ສ່ົງ ສາທາລະນະ ໄດ້ ຢ່າງ ງ່າຍດາຍ ï ລົດ ເຂັນ ເໝາະ ສົມ ກັບ ການ ໃຊ້ ໃນ ເຮືອນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 13 A.2: ເດັກນ້ອຍ ພິການ ເມ່ືອ ໃຫ້ ລົດ ເຂັນ ແກ່ ເດັກນ້ອຍ , ມັນ ສໍາຄັນ ໃນ ການ ຄິດ ກ່ຽວ ກັບ ວ່າຊີວິດຂອງ ເດັກນ້ອຍ ແມ່ນ ແຕກ ຕ່າງ ຈາກ ຜູ້ ໃຫຍ່. ຄວາມ ແຕກຕ່າງ ເຫຼົ່ານ້ີ ມີ ຜົນ ຕ່ໍ ກັບ ແບບ ວິທີ ທີ່ ພະນັກງານ ລົດ ເຂັນ ເຮັດ ວຽກ ກັບ ເດັກນ້ອຍ ແລະ ການ ເລືອກ ກ່ຽວ ກັບ ລົດ ເຂັນ ແລະ ແນ ວປະຄອງ ຫຼືຮອ ງຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ບາງ ຄວາມ ແຕກ ຕ່າງ ທີ່ ສໍາຄັນ ແມ່ນ: ï ບັນດາ ກິດຈະກໍາ ທີ່ ເດັກນ້ອຍ ດໍາ ເນີນ ແມ່ນ ແຕກ ຕ່າງ ຈາກ ກິດຈະກໍາ ຂອງ ຜູ້ ໃຫຍ່ (ການຫ້ິຼນ, ໄປ ໂຮງຮຽນ); ï ປົກກະຕິ ແລ້ວ ເດັກນ້ອຍຈະ ບໍ່ ຢູ່ ບໍ່ ເຊົາ ແລະ ບໍ່ ມັກ ຢູ່ ບ່ອນ ເກ່ົາ ເປັນ ເວລາ ດົນ ນານ; ï ເດ ັກນ້ອຍຢູ່ໃນການດູແລເບິ່ງແຍງຂອງຜູ້ໃຫຍ່; ï ເດັກນ້ອຍບໍ່ສາມາດເວ້ົາສະໜັບສະ ໜູນ ຕົນ ເອງ ໄດ້ ສະ ເໝີ ໄປ; ï ເດັກນ້ອຍ ກໍາລັງ ພັດທະນາ; ï ເດັກນ້ອຍ ມີ ທ່າ ນ່ັງ ທີ່ ແຕກ ຕ່າງ ຈາກ ຜູ້ ໃຫຍ່; ï ເດັກນ້ອຍ ກໍາລັງ ເຕີບ ໃຫຍ່ ; ລົດ ເຂັນ ທ່ີ ຕອບ ສະໜອງ ຄວາມ ຕ້ອງການ ຂອງ ເດັກນ້ອຍ ລົດ ເຂັນ ທີ່ ເດັກນ້ອຍ ໃຊ້ ຄວນ ຊ່ວຍ ພວກ ເຂົາ ໃຫ້ ເປັນ ສ່ວນໜຶ່ງ ຂອງ ກິດຈະກໍາ ທີ່ ເດັກນ້ອຍ ເຮັດ ໃນ ແຕ່ ລ ະ ວັນ. ຄຸນສົມບັດ ໃຊ້ ງານ ໃນ ລົດ ເຂັນ ທີ່ ສໍາຄັນ ສໍາລັ ບ ເດັກນ້ອຍ ລວມມີ: ï ຖ້າ ເດັກນ້ອຍຍູ້ ລົດ ເຂັນ ດ້ວຍ ຕົນ ເອງ, ລົດ ເຂັນ ຄວນ: – ພໍດີ ເພ່ືອ ໃຫ້ ເຂົາ ເຈົ້າ ຍື່ນ ມື ເຖິງ ຂອບ ຍູ້ ລົດ ເຂັນ ໄດ້ ຢ່າງ ສະບາຍ ຕົວ; – ມີ ນ້ໍາໜັກ ເບົາ ພຽງພໍ ສໍາລັບ ເດັກນ້ອຍ ໃນ ການ ຄວບ ຄຸມ, ໂດຍ ສະພາະ ໃນການ ຂ້ຶນ ຫຼື ລົງ ຄ້ອຍ. ï ພະຍາຍາມ ຮັບປະກັນ ໃຫ້ ສາມາດ ເບິ່ງ ເຫັນ ເດັກນ້ອຍ ຫຼາຍກວ່າ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ. ï ຄັນຍູ້ ເສີມ ສາມາດ ຊ່ວຍ ໃຫ້ ຄົນ ໃນ ຄອບຄົວ ຫຼື ຜູ້ ເບິ່ງ ແຍງ ຍູ້ ລົດ ເຂັນ ໄດ້ ໂດຍ ບໍ່ ຈໍາ ເປັນ ຕ້ອງ ຂົດ ໂຕ. ï ລົດ ເຂັນ ທີ່ ສາມາດ ຂ່ີ ຢູ່ ເທິງ ພ້ືນ ທີ່ ບໍ່ ຮາບ ພຽງ ແລະ ອ່ອນ ເຊັ່ນ ວ່າ ເດີ່ນ ຫຍ້າ ແລະ ຊາຍ ຈະ ເຮັດ ໃຫ້ ມັນ ງ່າຍ ຂ້ຶນ ສໍາລັບ ເດັກນ້ອຍ ໃນ ການຫ້ິຼນກັບ ໝູ່ ຂອງ ເຂົາ ເຈົ້າ. 14 ï ລົດ ເຂັນຂອງ ເ ດັກ ນ້ອຍ ຄວນ ເຮັດ ໃຫ້ ເຂົາ ເຈົ້າ ງ່າຍຂ້ຶນ ໃນ ການ ໄປ ໂຮງຮຽນ: – ຖ້າ ເດັກນ້ອຍ ສ່ວນ ໃຫຍ່ ໃນ ຊຸມ ຊົນ ຂອງ ເດັກ ນ້ັນ ພາກັນ ຍ່າງ ໄປ ໂຮງຮຽນ – ໃຫ້ ຄິດ ກ່ຽວ ກັບ ວ່າ ລົດ ເຂັນ ສາມາດ ເດີນທາງຢູ່ ເທິງ ເສ້ັນທາງ ເຫຼົ່ານ້ັນ ໄດ້ ບໍ? ເດັກນ້ອຍ ຕ້ອງການ ລົດ ເຂັນ ທີ່ ດີ ສໍາລັບ ພ້ືນ ດິນ ທີ່ ບໍ່ ຮາບ ພຽງ ບໍ? – ຖ້າ ເດັກນ້ອຍ ຈະ ໄປ ໂຮງຮຽນ ໃນ ລົດ ຂົນ ສ່ົງ (ຕົວຢ່າງ ລົດ ໃຫຍ່, ລົດ ເມ, ລົດ ລາກ, ລົດ ແທັກ ຊີ), ໃຫ້ ຄິດ ກ່ຽວ ກັບ ວ່າ ລົດ ເຂັນ ຈະ ຖືກ ຂົນ ສ່ົງ ແນວ ໃດ. ï ລົດ ເຂັນ ຄວນ ເຮັດ ໃຫ້ ເຂົາ ເຈົ້າ ງ່າຍຂ້ຶນ ໃນ ການຢູ່ ທີ່ ໂຮງຮຽນ: ເດັກນ້ອຍ ຄວນ ສາ ມາດ ດຶງ ຕົວ ຢືນ ຂ້ຶນ ເພ່ືອ ນ່ັງ ໃນ ໂຕະ ຫຼື ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ມີ ຖາດ ເພ່ືອ ເປັນ ພ້ືນ ຜິວ ເຮັດ ວຽກ. ໃຫ້ ດີ ແທ້, ລົດ ເຂັນ ຂອງ ເດັກນ້ອຍ ຄວນ: ï ເຮັດ ໃຫ້ ເດັກນ້ອຍ ສາມາດຍູ້ ພວກ ມັນ ໄດ້ (ຖ້າ ພວກ ເຂົາ ສາມາດ); ï ມີ ຄັ ຍູ້ ເພ່ືອ ໃຫ້ ຜູ້ ໃຫຍ່ ຊ່ວຍ ຍູ້ ລົດ ເຂັນ; ï ສາມາດ ຂ່ີ ຢູ່ ເທິງພ້ືນ ດິນ ທີ່ ບໍ່ ຮາບ ພຽງ ແລະ ອ່ອນ ເຊັ່ນ ວ່າ ເດີ່ນ ຫຍ້າ ແລະ ຊາຍ; ï ເຮັດ ໃຫ້ ເດັກນ້ອ ຍງ່າຍ ຂ້ຶນ ໃນ ການ ໄປ ຮອດ ໂຮງຮຽນ; ï ສວຍ ງາມ ພຽງພໍ ໃນ ເລື່ອ ງການ ອອກ ແບບ, ຂະໜາດ ແລະ ສີສັນ; ï ເຮັດ ໃຫ້ ເດັກນ້ອ ຍງ່າຍ ຂ້ຶນ ໃນ ການ ຢູ່ ທີ່ ໂຮງຮຽນ. ທ່າ ທາງ ຕ່າງໆ ໂດຍ ປົກກະຕິ ແລ້ວ ເດັກນ້ອຍ ບໍ່ ໃຊ້ ເວລາ ຫຼາຍ ໃນ ການ ນ່ັງ . ພວກ ເຂົາ ປ່ຽນກິດຈະກໍາທ່ີ ພວກ ເຂົາ ກໍາລັງ ເຮັດ ແລະ ທ່າ ທາງ ຂອງ ເຂົາ ເຈົ້າຫຼາຍໆ ຄັ້ງ ໃນລະຫວ່າງ ມ້ື. ນ້ີ ໝາຍ ຄວາມ ວ່າ ເຖິງ ແມ່ ນລົດ ເຂັນ ຈະ ສໍາຄັນ, ແຕ່ ເດັກນ້ອຍ ບໍ່ ຄວນ ໃຊ້ ເວລາ ໝົດ ມ້ື ຢູ່ ໃນ ລົດ ເຂັນ. ພະນັກງານ ບໍລິ ການ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ຄິດ ກ່ຽວ ກັບ ທ່າ ທາງອ່ືນ ທີ່ ເດັກນ້ອຍ ສາມາດ ໃຊ້ ໃນ ລະຫວ່າງ ມ້ື. ສ່ິງ ນ້ີ ສໍາຄັນ ໂດຍ ສະ ເພາະ ຖ້າ ເດັກນ້ອຍ ມີ ການ ເຄື່ອນ ໄຫວ ທີ່ ຈໍາ ກັດ, ມັກ ຈະ ນ່ັງ ໃນ ທ່າ ດຽວ ຢູ່ຕະຫຼອດ ເວລາ ແລະ ບໍ່ ສາມາດ ປ່ຽນ ທ່າ ໄດ້. ບາງ ຕົວຢ່າງ ຂອງ ທ່າທາງ ແລະ ຕໍາ ແໜ່ ງ ຕ່າງໆມີ: ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 15 ການ ນ່ັງ ບາງ ວິທີ ທີ່ ແຕກ ຕ່າງ ກັນ ເພ່ືອ ຊ່ວຍ ໃຫ້ ເດັກນ້ອຍ ນ່ັງ ດ້ວຍ ຕົນ ເອງ ໃຫ້ ໃກ້ ກັບພ້ືນ ຫຼາຍຂ້ຶນມີ: ï ນ່ັງ ຂາ ຈ່າງຄາບ ລູກ ກ້ິງ ຫຼື ຜ້າ ຫົ່ມ ທີ່ ມ້ວນ ແໜ້ນ. ï ນ່ັງ ໂດຍ ມີ ການ ປະຄອງ ຫຼືຊ່ວຍ ເຫຼືອຈາກຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ ງ ແຍງ : – ຮູບ ສະ ແດງ ນ້ີ ສະ ແດງ ໃຫ້ ເຫັນ ແມ່ ທີ່ ກໍາລັງ ປະຄອງ ລູກ ທີ່ ພິການ ຂອງ ລາວ ຢູ່ ລະຫວ່າງ ຂາ ຂອງ ລາວ ເພ່ືອ ຊ່ວຍ ໃຫ້ ລູກ ນ່ັງ ຕ້ັງ ຂ້ຶນເພ່ືອ ກິນ ເຂົ້າໜົມປັງ ໃນ ຂະນະ ທີ່ ປະຄອງ ລູກ ຄົນ ນ້ອຍ ກວ່າ ຂອງ ລາວ ເຊັ່ນ ກັນ. ï ໃຫ້ ບ່ອນ ນ່ັງ ທີ່ ມີ ການຮອງ ຮັບ ເຊິ່ງຕ່ໍາ ຫາ ພ້ືນ: – ບ່ອນ ນ່ັງ ແບບ ນ້ີ ແມ່ນ ມີ ລາຄາ ຖືກ ກວ່າ ລົດ ເຂັນ ທີ່ ມີ ບ່ອນ ນ່ັງ ທີ່ ມີ ການ ຮອງ ຮັບ ແລະ ສາມາດ ເປັນ ຕົວ ເລືອກ ທີ່ ດີ ສໍາລັບ ເດັກທ່ີ ຍັງ ນ້ອຍ. ການ ຢືນ ການ ຢືນ ແມ່ນທ່າ ທາງທ່ີ ສໍາຄັນ ໜຶ່ງສໍາລັບ ເດັກນ້ອຍ. ການ ຢືນ ແມ່ນ ສ່ວນ ສໍາຄັນ ຂອງ ພັດທະນາ ການ ຂອງ ເດັກນ້ອຍ ທຸ ກຄົນ. ການ ຢືນ ຊ່ວຍສ້າງ ຂ້ໍ ຕ່ໍ ສະ ໂພ ກ ແລະ ການ ກ່ົງ ປົກກະຕິ ຂອງລໍາ ຕົວ. ຜູ້ ໃດ ກໍ ຕາມ ທີ່ ໃຊ້ ເວລາ ຫຼວງຫຼາຍ ໃນ ການ ນ່ັງ ສາມາດ ເຮັດ ໃຫ້ ເກີດ ສະ ໂພ ກ , ຂ້ໍ ຕ່ໍ ຫົວ ເຂົ່າ ແລະ ຂໍ້ ຕີນ ແຂງ. ການຢືນ ຊ່ວຍ ຢືດກ້າມ ຊ້ີນ ບໍລິ ເວນ ສະ ໂພ ກ, ຫົວ ເຂົ່າ ແລະ ຂ້ໍ ຕີນ ແລະ ຊ່ວຍ ປ້ອງ ກັນ ບໍ່ ໃຫ້ ຂ້ໍ ຕ່ໍ ເຫຼົ່ານ້ີ ແຂງ. 16 ໃນ ເວລາ ເດັກນ້ອຍ ບໍ່ ສາມາ ດຢືນ ໄດ້ ດ້ວຍ ຕົນ ເອງ, ໂຄງ ຊ່ວຍ ຢືນ ສາມາດ ຊ່ວຍໄດ້. ເພ່ືອ ກໍານົດ ໃຊ້ ໂຄງ ຊ່ວຍ ຢືນ, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ເຂົ້າ ໃຈ ທ່າ ການ ຢືນ ຢ່າງ ຄົບ ຖ້ວນ ແລະ ຮູບ ແບບ ຕ່າງໆ ທີ່ ສາມາດ ປະຄອງ ຫຼືຮອ ງຮັບການ ຢືນ ໄດ້. ຖ້າກໍາລັງ ໃຫ້ ໂຄງ ຊ່ວຍ ຢືນ, ໃຫ້ ກວດ ເບິ່ງ ສະ ເໝີ ວ່າບ່ໍ ມີ ການກົ ດທັບ ໂດຍ ກົງ ຕ່ໍ ກັບໝາກບ້າຫົວ ເຂົ່າ ຂອງ ເດັກນ້ອຍ. ສະຖານ ທີ່ ທີ່ ດີ ສຸດ ໃນ ການ ຮອງ ຂາ ເພ່ືອ ປ້ອງ ກັນ ບໍ່ ໃຫ້ ຫົວ ເຂົ່າກ່ົງ ງໍ ແມ່ນ ຢູ່ກ້ອງ ໝາກບ້າຫົວ ເຂົ່າຢູ່ ເທິງ ກະດູກ ໜ້າ ແຄ່ງ. ຖາ້ ມີ ກາ ນ ໃຊໂ້ຄງ ຊ່ວຍ ຢນື, ພະ ນັກ ງານ ບລໍກິານ ລດົ ເຂນັ ຄວນ ແນະນໍາ ຄົນ ໃນ ຄອ ບຄົວ/ຜູ້ ໃຫ້ການ ເບິ່ງ ແຍງ ເດັກກ່ຽວ ກັບ ວ່າ ເດັກນ້ອຍ ຄວນ ໃຊ້ ໂຄງ ຊ່ວຍ ຢືນ ດົນ ປານ ໃດ ໃນ ແຕ່ ລ ະ ມ້ື. ນ້ີ ແມ່ນຄໍາ ແນະນໍາ ທົ່ວ ໄປ: ï ໃນ ເວລາ ແອບ ຢືນ ທໍາ ອິດ 5–10 ນາທີ ໃນ ແຕ່ລະ ມ້ື; ï ຢ່າ ປະ ໃຫ້ ເດັກນ້ອຍຢືນ ຢູ່ ໃນ ໂຄງຊ່ວຍ ຢືນ ດົນ ກວ່າ 1 ຊ່ົວ ໂມງ; ï ສະໜອງ ຖາດ ຫຼື ໂຕະ ແລະ ສ່ົງ ເສີມ ໃຫ້ ຄົນ ໃນຄອບຄົວ/ຜູ້ ໃຫ້ການ ເບິ່ງ ແຍງ ຊອກ ກິດຈະກໍາ ທີ່ ມ່ວນ ຊ່ືນ ທີ່ ເດັກ ສາມາດ ເຮັດ ໄດ້ ໃນ ໂຄງ ຊ່ວຍ ຢືນ. ï ໃນ ເວລາ ໃຫ້ ໂຄງ ຊ່ວຍ ຢືນ ແກ່ ເດັກນ້ອຍອາຍຸ ຕ່ໍາ ກວ່າ ຫ້າ ປີ, ມີ ບາງ ຢ່າງ ທີ່ ສໍາຄັນ ທີ່ ຕ້ອງ ຈື່: – ຂາ ຂອງ ເດັກນ້ອຍ ຄວນ ຈ່າງ ອອກ ຈາກ ກັນ ແລະ ຕີນ ຂອງ ເຂົາ ເຈົ້າ ຕ້ອງ ຫ່າງ ກັນ ຢ່າງ ໜ້ອຍ ເທົ່າ ກັບ ສະ ໂພ ກຫ່າງ ກັນ; – ຕີນ ແລະ ຫົວ ເຂົ່າ ຂອງ ເດັກນ້ອຍຄວນ ເດ່ ອອກ ນອກ ໜ້ອຍ ໜຶ່ງ; – ສະ ໂພ ກ ແລະ ຫົວ ເຂົ່າ ຂອງ ເດັກນ້ອຍຄວນກ່ົງ ໜ້ອຍ ໜຶ່ງ; – ຢ່າບັງຄັບໃຫ້ຫົວເຂົ່າ ແລະ ສະໂພກຂອງເດັກທ່ີຍັງນ້ອຍໃຫ້ຢຽ ດຊື່ທັງ ໝົດ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 17 ການ ນອນ ການ ນອນ ແມ່ນ ທ່າ ທາງສໍາຄັນອີກ ອັນ ອື່ນ. ສໍາລັບ ເດັກນ້ອຍ, ການ ນອນຫ້ິຼນ ຢູ່ ເທິງ ພ້ືນ ແມ່ນ ເລື່ອງ ທໍາ ມະ ຊາດ. ເດັກນ້ອຍ ອາດ ຈະ ຕ້ອງການ ບາງ ການ ຮອງ ຮັ ບຮ່າງກາຍ ເພ່ືອນ ອນ ຢ່າງ ສະບາຍ ຕົວຢູ່ ເທິງ ພ້ືນ. ຜ້າ ຫົ່ມ, ໂຟມ, ຜ້າ ເຊັດ ໂຕ ຫຼື ໝອນ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບທີ່ ເໝາະ ສົມ. ເດັກນ້ອຍ ອາຍຸ ຕ່ໍາ ກວ່າຫ້າ ປີ ຜູ້ ທີ່ ກໍາລັງ ນອນ ຂວ້າມຄວນ ມີ ແນວ ຮອງ ເປັນ ແບບ ທ່ອນ ມົນ ຢູ່ ກ້ອງ ເອິກ ຂອງ ເຂົາ ເຈົ້າ ເພ່ືອ ຮັກສາ ໃຫ້ ສະ ໂພ ກຢ່ ໃນ ທ່າ ກ່ົງ ໜ້ອຍ ໜຶ່ງ. ເດັກນ້ອຍ ໃຊ້ ໃຊ້ ເວລາ ຢ່າງ ຫຼວງຫຼາຍ ໃນ ການ ນອນ. ຖ້າ ເດັກນ້ອຍ ນອນ ໃນ ທ່າ ດຽວ ກັນ ທຸກໆ ຄືນ, ພວກ ມັນ ອາດ ຈະ ກາຍ ເຫັນ ທ່າ ຄົງ ທີ່ ຕາຍ ຕົວ ຫຼື ຮ່າງກາຍ ຈະ ແຂງ ຕົວ ໃນ ທ່າ ນ້ັນ. ພະນັກ ງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ໃຫ້ ຄໍາ ແນະນໍາ ແກ່ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ໃຫ້ການ ດູ ແລ ກ່ຽວ ກັບ ວິທີ ວາງທ່າ ທາງ ເດັກນ້ອຍ ໃນ ແບບ ຕ່າງ ໆ ໃນ ຂະນະ ທີ່ ພວກ ເຂົານອນຫັຼບຢູ່. ຈື່ ວ່າ – ຮັກສາ ໃຫ້ ສະ ໂພ ກ ແລະ ຫົວ ເຂົ່າ ຂອງ ເດັກນ້ອຍ ອາຍຸ ຕ່ໍາ ກວ່າ ຫ້າ ປີ ໃຫ້ ກ່ົງ ໜ້ອຍ ໜຶ່ງ ໃນ ທຸກ ທ່ານ ອນ ແລະ ທ່າ ຢືນ. ຄວາມສໍາຄັນຂອງການນໍາສ່ົງໄວ ແຕ່ຕ້ົນໆສໍາລັບເດັກນ້ອຍ ການ ນໍາ ສ່ົງ ໄວ ແຕ່ ຕ້ົນໆ ສໍາລັບ ເດັກນ້ອຍ ແມ່ນ ສໍາຄັນ ຫຼາຍ, ແນວ ໃດ ກໍ ຕາມ ພ່ໍ ແມ່ ຫຼື ແຫຼ່ງນໍາ ສ່ົງມັກ ຈະບໍ່ ນໍາ ສ່ົງ ເດັກນ້ອຍ ຫາ ລົດ ເຂັນ ຈົນ ກວ່າ ວ່າ ເດັກນ້ອຍ ໜັກ ເກີນ ໄປ ທີ່ ຈະ ອຸ້ມ ໄດ້. ບາງ ເຫດຜົນ ສໍາລັບ ສ່ິງ ນ້ີລວມມີ: ï ບາງຄ້ັງມີການຄິດວ່າ ຖ້າເອົາລົດເຂັນໃຫ້ເດັກນ້ອຍ, ເດັກນ້ອຍນັ້ນ ຈະ ບໍ່ ພະຍາຍາມ ຍ່າງ ອີກ ຕ່ໍ ໄປ; ï ໃນ ຂະນະ ທີ່ ເດັກຍັງ ນ້ອຍ ແລະ ເບົາ, ການ ອູ້ມ ເຂົາ ເຈົ້າ ແມ່ນ ງ່າຍ ກວ່າ ການ ຍູ້ ລົດ ເຂັນ ຜ່ານສ່ິງ ທີ່ ອາດ ຈະ ເປັນ ພ້ືນດິນ ທີ່ ຫຍຸ້ງຍາກ ແລະ ສະພາບ ແວດ ລ້ອມ ທີ່ ບໍ່ ສາມາດ ເຂົ້າ ເຖິງ ໄດ້; ï ພ່ໍ ແມ່ ອາດ ຈະ ບໍ່ ມີ ເງິນ ຊ້ື ລົດ ເຂັນ ແລະ ຈະ ເຮັດ ໃຫ້ຊັກ ຊ້າ ຈົນ ກວ່າ ວ່າ ມັນ ກາຍ ເປັນ ເລື່ອງ ຍາກ ເກີນ ໃນການ ອູ້ມ ເດັກນ້ອຍ. ມັນ ສໍາຄັນ ໃນ ການ ເຮັດ ໃຫ້ ພ່ໍ ແມ່ ແລະ ແຫຼ່ງນໍາ ສ່ົງ ເຂົ້າ ໃຈ ວ່າ ໂດຍ ປົກກະຕິ ແລ້ວ ລົດ ເຂັນ ຈະ ບໍ່ ຂັດຂວາງ ເດັກນ້ອຍ ຈາກ ການ ຍ່າງ. ມັນ ເປັນ ໄປ ໄດ້ ຫຼາຍກວ່າ ວ່າ ກາ ນ ໃຫ້ ລົດ ເຂັນ ທີ່ ມີ ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ທີ່ ດີ ຕ້ັງ ແຕ່ ຕ້ົນໆຈະ ຊ່ວຍ ເດັກ ໄດ້. 18 ນ້ີ ແມ່ນ ບາງ ເຫດຜົນ ຍ້ອນ ຫຍັງ ການ ນໍາ ສ່ົງ ໄວ ແຕ່ ຕ້ົນໆ ຈິ່ງ ດີກ ວ່າການ ຊັກ ຊ້າ: ï ເດັກ ນ້ອຍ ຜູ້ ທີ່ ມີ ຄວາມ ລໍາ ບາກ ໃນ ການ ນ່ັງ ໃຫ້ ຕ້ັງ ຊ່ື ສາ ມາດ ພັດ ທະ ນາ ບັນ ຫາ ດ້ານ ທ່າ ທາງ ໄດ້ ຖ້າ ບໍ່ ມີການ ປະ ຄອງຫຼືຮອ ງຮັບ ທີ່ ດີ. ຖ້າ ເດັກ ນ້ອຍ ຖືກ ນໍາ ສ່ົງ ຊັກ ຊ້າ ບາງ ບັນ ຫາ ດ້ານ ທ່າ ທາງ ອາດ ກາຍ ເປັນ ບັນຫາ ຖາວອນ. (3). ນ້ີ ສາ ມາດ ເຮັດ ໃຫ້ ມັນ ລໍາ ບາກ ສໍາ ລັບ ເດັກ ໃນ ກາ ນນ່ັງ ຢ່າງ ສະ ດວກ ສະ ບາຍ ແມ້ ກະ ທັງ ວ່າ ມີ ອຸປະກອນການ ປະ ຄອງການ ຊົງ ຕົວ. ï ໂດຍບໍ່ ມີ ປະ ສົບ ການ ໃນ ການ ນ່ັງ ແລະການ ເຄື່ອນ ໄຫວ ໄປມາ, ພັດ ທະ ນາການ ຂອງ ເດັກ ອາ ດ ຊັກ ຊ້າ ໄດ້. (3, 4). ï ສໍາ ລັບ ເດັກ ນ້ອຍ ຜູ້ ທີ່ ມີ ບາງ ຄວາມ ສາ ມາດ ຍ່າງ – ການ ໃຊ້ ລົດ ເຂັນ ອາດ ເຮັດ ໃຫ້ ຊິດ ວິດ ປະ ຈໍາ ວັນ ຂອງ ພວກ ເຂົາ ງ່າຍ ຂ້ືນ ແລະ ຊ່ວຍ ພວກ ເຂົາໃຫ້ ເຮັດ ສ່ິງ ຕ່າງໆ ໄດ້ຫຼາຍຂ້ືນ ໃນ ມ້ື ໜຶ່ງ (3). ຍ້ອນ ເຫດຜົນ ເຫຼົ່ານ້ີ ມັນ ດີກ ວ່າຖ້າ ເດັກນ້ອຍ ມາ ຫາ ການ ບໍລິການ ລົດ ເຂັນ ໄວ ແຕ່ ຕ້ົນໆ. ການ ໃຫ້ການ ສຶກສາ ພ່ໍ ແມ່ ແລະ ແຫ່ຼງນໍາ ສ່ົງ ພະນັກງານບໍລິການລົດ ເຂັນສາມາດ ມີ ບົດບາດ ສໍາຄັນ ໃນ ການສຶກ ສາ ອົບຮົມ ພ່ໍ ແມ່ ແລະ ແຫຼ່ງນໍາ ສ່ົງ ກ່ຽວ ກັບ ຄວາມ ສໍາຄັນ ຂອງ ການ ນໍາ ສ່ົງ ໄວ ແຕ່ ຕ້ົນໆ. ອາຍຸ ທີ່ ເດັກນ້ອ ຍບໍ່ ພິການ ຮຽນ ນ່ັງ, ຢືນ ແລະ ຍ່າງ ແມ່ນ ແຕກ ຕ່າງ ກັນ. ແນວ ໃດ ກໍ ຕາມ, ໂດຍ ທົ່ວ ໄປ ແລ້ວ ມີ ການ ເຫັນ ດີ ນໍາ ກັນ ວ່າ ເດັກນ້ອຍ ຄວນ ສາມາດ: ï ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້ ດ້ວຍ ຕົນ ເອງ ໂດຍ ບໍ່ ມີ ການ ຊ່ວຍ ເຫຼືອ ໃນ ລະຫວ່າງ 6–8 ເດືອນ; ï ດຶງ ຕົວ ເອງ ຂ້ຶນ ເພ່ືອ ລຸກ ຢືນ ໃນ ລະຫວ່າງ 8–10 ເດືອນ; ï ຢືນ ໄດ້ ດ້ວ ຍຕົນ ເອງ ໂດຍ ບໍ່ ມີ ການ ຊ່ວຍ ເຫຼືອ ແລະ ອາດ ຈະ ຍັງ ສາມາດ ຍ່າງ ໄດ້ ໂດຍ ມີ ກາ ນຈັບ ມື ໃນ ລະຫວ່າງ 10–12 ເດືອນ ແລະ ï ຍ່າ ໄດ້ ດ້ວຍ ຕົນ ເອງ ໃນ ລະຫວ່າງ 12–18 ເດືອນ. ການ ບໍລິການ ລົດ ເຂັນ ສາມາດ ສ່ົງ ເສີມ ເຄືອ ຂ່າຍ ການ ນໍາ ສ່ົງ ເພ່ືອ ນໍາ ສ່ົງ ເດັກນ້ອຍ ທີ່: ï ມີ ຄວາມ ລໍາບາກ ໃນ ການ ນ່ັງ ຕ້ັງ ຊ່ື ຫຼືບໍ່ ດຶງ ຕົວ ເອງ ລຸກ ຢືນ ພາຍ ໃນ ອາຍຸ 1 ປີ; ຫຼື ï ບໍ່ ຍ່າງ ໄດ້ ເອງເມ່ືອ ອາ ຍຸ 2 ປີ. ຢູ່ ບ່ອນ ທີ່ ມີ ແຜນ ງານ ການກວດ ເພ່ືອ ໃຫ້ການ ຊ່ວຍ ເຫຼືອ ໄວ ແຕ່ ຕ້ົນໆ ( ຕົວຢ່າງ ໃນ ບ່ອນ ແພດ ຊຸມ ຊົນ ໄດ້ ຮັບ ການ ຝຶກ ໃຫ້ ເຮັດ ການກວດ ເບິ່ງ ເດັກນ້ອຍສໍາລັບ ການ ຊ່ວຍ ເຫຼືອ ໄວ ແຕ່ ຕ້ົນໆ), ການ ບໍລິການ ລົດ ເຂັນ ສາມາດ ໃຫ້ ຂ້ໍ ມູນ ລະອຽດ ກວ່າແກ່ເຄືອຂ່າຍເຫ່ົຼານ້ີ. ຕົວຢ່າງ – ການບໍລິການລົດເຂັນສາມາດແນະນໍາ ວ່າ ເດັກນ້ອຍ ທີ່ ຖືກ ລະບຸ ວ່າ ມີ ບັນຫາ ທາງ ຮ່າງກາຍ ຫຼືຄວາ ມຊັກ ຊ້າ ດ້ານ ພັດທະນາ ການ ທີ່ ສໍາຄັນ ສາມາດ ຖືກ ນໍາ ສ່ົງ ຫາ ການ ບໍລິການ ລົ ດ ເຂັນ ເພ່ືອ ເຮັດ ການ ປະ ເມີນ ຜົນ ຫຼື ເອົາ ຄໍາ ແນະນໍາ. ສໍາລັບ ເດັກທ່ີ່ຍັງ ນ້ອຍໆ ທຸກ ຄົນ, ການ ບໍລິການ ລົດ ເຂັນ ອາດ ຈະ ໃຫ້ ບ່ອນ ນ່ັງ ທີ່ ມີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ ແທນ ລົດ ເຂັນ ກໍ ໄດ້ ໃນ ໄລຍະ ເບື້ອງ ຕ້ົນ. ນ້ີ ສາມາດ ຖືກ ໃຊ້ ຢູ່ ພາຍ ໃນ ເຮືອນ ຫຼື ໂຮງຮຽນ ລ້ຽງ ເດັກ. 3 ອົງ ການ ອະ ນາ ໄມ ໂລກ (1996). ສ່ົງ ເສີມ ພັດທະນາ ການ ຂອງ ເດັກ ເກີດ ໃໝ່ ແລະ ເດັກນ້ອຍ ທີ່ມີ ກະດູກ ສັນຫັຼງ ໂຫວ່ ແລະ ພາວະ ນ້ໍາຄ້າ ໃນ ໂພງ ສະໝອງ. ຄັດ ຂ້ໍ ມູນ ຈາກ http://whqlibdoc.who.int/hq/1996/WHO_RHB_96.5.pdf 4 ແຄັມ ເປ ນ ໂຄສະນາ ຕ້ານ ພະຍາດ ກ້າມ ເນ້ືອ ເສ່ືອ ມ. (2011). ການ ສະໜອງ ລົດ ເຂັນ ໃຫ້ ເດັກນ້ອຍ ແລະ ຜູ້ ໃຫຍ່ ທີ່ ເປັນ ພະຍາດ ກ້າມ ເນ້ືອ ເສ່ືອ ມ ແລະ ໂຣກ ກ້າມ ເນ້ືອ ຮ່ວມ ປະສາດ ອື່ນ: ຂ້ໍ ແນະນໍາ ກ່ຽວ ກັບ ວິທີ ປະຕິບັດ ທີ່ ດີ ສຸດ. ຄັດ ຂ້ໍ ມູນ ຈາກ http://www.muscular-dystrophy.org/ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 19 ວິທີ ປະຕິບັດ ທ່ີ ດີ ໃນ ເວລາ ເຮັດ ວຽກ ກັບ ເດັກນ້ອຍ ໃນ ທຸກ ຄັ້ງ ທີ່ ເຮັດ ວຽກ ກັບ ເດັກນ້ອຍ ມັນ ສໍາຄັນ ໃນ ການ ເຮັດ ວຽກ ໃນ ແບບ ທີ່ ທັງ ເຄົາລົບ ແລະ ປົກປ້ອງ ເດັກ ນອ້ຍ. ສ່ິງ ສໍາຄັນ ທີ່ ຕ້ອງ ຈື່ ມີ ຄື: ເຄົາ ລົບ ເດັກນ້ອຍ ໂດຍການ: ï ອະທິບາຍສ່ິງ ທີ່ ທ່ານ ກໍາລັງ ເຮັດ ແລະ ເຫດຜົນ ຍ້ອນ ຫຍັງ ໃນ ແບບ ທີ່ ພວກ ເຂົາ ສາມາດ ເຂົ້າ ໃຈ ໄດ້; ï ຂໍອະນຸຍາດ ກ່ອນ ທີ່ ຈະ ເລີ່ ມການ ປະ ເມີນ ຮ່າງກາຍ; ï ໃຫ້ ເດັກນ້ອຍ ເຂົ້າ ຮ່ວມ ໃນ ການ ຕັດສິນ ໃຈ ໃນ ແບບ ທີ່ ເໝາະ ສົມ ກັບ ອາຍຸ ຂອງ ເຂົາ ເຈົ້າ; ï ຖ້າ ປະ ເມີນ ເດັກ ຢູ່ ສູນ ບໍລິການ, ໃຫ້ ພະຍາຍາມ ສ້າງ ພ້ືນ ທີ່ ໃຫ້ ເປັນ ມິດກັບ ເດັກ ເທົ່າ ທີ່ ຈະ ເປັນ ໄປ ໄດ້. ຮັກສາ ໃຫ້ ເດັກ ປອດ ໄພ ໂດຍ ການ: ï ກວດ ເດັກ ໂດຍ ມີ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ຂອງ ເຂົາ ເຈົ້າ ຢູ່ ນໍາ ສະ ເໝີ; ï ອະນຸຍາດ ໃຫ້ ມີ ເວລາ ຢຸດ ພັກ ໃນ ລະຫວ່າງ ການກວດ ເພາະວ່າ ເດັກນ້ອຍ ສາມາດ ອິດ ເມ່ືອຍ ໄດ້ ງ່າຍ; ï ຂໍອະນຸຍາດ ຈາກ ເດັກ ແລະ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ເດັກ ກ່ອນ ທີ່ ຈະ ຖ່າຍຮູບ. 20 B. ຂ້ັນ ຕອນ ການ ບໍລິການ ລົດ ເຂັນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 21 ຂ້ັນ ຕອນ 1: ການ ນໍາ ສ່ົງ ແລະ ການ ນັດ ໝາຍ ï ເບິ່ງ ຂ້ັນ ຕອນ 1: ການ ນໍາ ສ່ົງ ແລະ ການ ນັດ ໝາຍ ຂອງ ຄູ່ ມື ອ້າງ ອີງຂອງຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ ສໍາລັບ ຂ້ໍ ມູນ ທົ່ວ ໄປ ກ່ຽວ ກັບ ການ ນໍາ ສ່ົງ ແລະ ການ ນັດ ໝາຍ. ï ເບິ່ງ ຊ່ວງ ຝຶກ ອົບຮົມ A.2: ເດັກນ້ອຍ ພິການຂອງ ຄູ່ ມື ອ້າງ ອີງ ນ້ີ ກ່ຽວກັບ ຄວາ ມສໍາຄັນ ຂອງ ການ ນໍາ ສ່ົງ ໄວ ແຕ່ ຕ້ົນໆ ສໍາລັບ ເດັກນ້ອຍ. ຂ້ັນ ຕອນ 2: ການ ປະ ເມີນ ຜົນ ພາບ ລວມການ ປະ ເມີນ ຜົນ ແລະ ການ ສໍາພາດ ປະ ເມີນ ຜົນ ການ ປະ ເມີນ ຜົນ ການ ປະ ເມີນ ຜົນ ແມ່ນ ຂ້ັນ ຕອນ ທີ ສອງ ຂອງ ການບໍ ລິ ການ ລົດ ເຂັນ. ຂ້ໍ ມູນ ທີ່ ເກັບ ໄດ້ ຈາກ ການ ປະ ເມີນ ຜົນ ຈະ ຊ່ວຍ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃນ ການ: ï ເລືອກ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ທີ່ ສຸດ ຈາກ ລົດ ເຂັນ ທີ່ ມີ ໃຫ້; ï ກໍາ ນົດວ່າຈໍາ ເປັນ ຕ້ອງມີການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ໃດ ແດ່; ï ຕັດສິນ ວ່າການ ຝຶກ ອົບຮົມ ຫຼື ການ ຊ່ວຍ ເຫຼືອ ໃດ ແດ່ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ, ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ອາດ ຈະ ຕ້ອງການ ເພ່ືອ ໃຊ້ ແລະ ບໍາລຸງ ຮັກສາ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ. ການປະ ເມີນ ຜົນ ໃນ ທັງ ລະ ດັບພ້ືນຖານ ແລະ ປານ ກາງ ຖືກ ດໍາ ເນີນ ໃນ ສອງ ສ່ວນ: ï ການ ສໍາພາດ ປະ ເມີນ ຜົນ; ï ການ ປະ ເມີນ ຮ່າງກາຍ. ການ ສໍາພາດ ປະ ເມີນ ຜົນ ສ່ວນທໍາ ອິດ ຂອງ ການ ປະ ເມີນ ຜົນ ແມ່ນ ການສໍາພາດ ປະ ເມີນ ຜົນ. ໃນລະຫວ່າງສ່ວນນ້ີຂອງການປະເມີນຜົນ ພະນັກງານບໍລິການລົດ ເຂັນ ເກັບ ເອົາ ຂ້ໍ ມູນ ກ່ຽວກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເຊິ່ງຈະ ຊ່ວຍ ລະບຸ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ທີ່ ສຸດ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ້ັນ. ອົງ ປະກອບ ການ ສໍາພາດ ປະ ເມີນ ຜົນ ຢູ່ ລະດັບ ພ້ືນຖານ ແລະ ປານ ກາງ ແມ່ນ ຄ້າຍຄື ກັນຫຼາຍ. ສ່ິງ ເຫຼົ່ານ້ີ ລວມມີ: ï ຂ້ໍ ມູນ ກ່ຽວ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ; ï ສະພາບ ຮ່າງກາຍ; ï ຮູບ ແບບ ຊີວິດ ແລະ ສະພາບ ແວດ ລ້ອມ; ï ລົດ ເຂັນ ທີ່ ມີ ຢູ່ ແລ້ວ. ເຖິງ ແມ່ນ ວ່າອົງ ປະກອບການ ສໍາພາດ ປະ ເມີນ ຜົນຢູ່ ລະດັບພ້ືນຖານ ແລະ ປານ ກາງ ແມ່ນ ຄ້າຍຄື ກັນຫຼາຍ, ແຕ່ ມີ ການ ເກັບ ເອົາ ຂ້ໍ ມູນ ຫຼາຍກວ່າ ໃນ ລະດັບ ປານ ກາງ ກ່ຽວກັບ ການ ບົ່ງ ມະຕິຂອງ ຜູ້ ໃຊ້ລົດ ເຂັນ ແລະ ບັນຫາຮ່າງກາຍ ຕ່າງໆ. 22 ແບບ ຟອມ ການ ປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະ ດັບ ປານ ກາງ: 1: ການ ສໍາພາດ ປະ ເມີນ ຜົນ ຂ້ໍ ມູນ ກ່ຽວ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຊ່ື ເລກທີ: ອາຍຸ: ຊາຍ ຍິງ ເບີ ໂທລະສັບ: ທີ່ ຢູ່: ເປົ້າ ໝາຍ: ສ່ວນ ëຂ້ໍ ມູນ ກ່ຽວ ກັບຜູ້ ໃຊ້ ລົດ ເຂັນí ຂອງ ແບບ ຟອມການ ປະ ເມີນຜົນລົດ ເຂັນລະດັບ ປານ ກາງ ມີ ຈຸດປະສົງ ດ້ານ ການ ບໍລິຫານ ແລະ ຮັບປະກັນ ໃຫ້ການ ບໍລິການ ລົດ ເຂັນ ມີຂ້ໍ ມູນ ບຸກຄົນ ແລະ ຂ້ໍ ມູນ ຕິດ ໍ ຕ່ໍ ພ້ືນຖານ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ນອກ ນ້ັນ ມັນ ຍັງ ຊ່ວຍ ການ ບໍລິການ ລົດ ເຂັນ ເກັບ ເອົາ ຂ້ໍ ມູນ ສະຖິຕິ ກ່ຽວ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມາ ໃຊ້ບໍລິການ ຢູ່ ສູນ. ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຄວນ ບັນທຶກ ໃສ່ ບ່ອນນ້ີ ອີກ ວ່າ ເປົ້າ ໝາຍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແມ່ນ ຫຍັງ ສໍາລັບ ລົດ ເຂັນ ໃໝ່ ຫຼື ປັບປຸງ ດີ ຂ້ຶນ. ຄໍາ ສັບ ë ເປົ້າ ໝາຍí ອາດ ຈະ ບໍ່ ຄຸ້ນ ເຄີຍ ຕ່ໍ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ມັນ ຂ້ຶນ ກັບ ພະນັກງານ ບໍ ລິ ການ ລົດ ເຂັນ ໃນ ການ ຖາມ ຄໍາ ຖາມ ຕ່າງໆ ເພ່ືອ ຊອກ ຮູ້ ວ່າ ເປົ້າ ໝາຍ ຫຼື ບັນດາ ເປົ້າ ໝາຍ ຂອງ ຜູ້ ໃຊ້ລົດ ເຂັນ ແມ່ນ ຫຍັງ. ສ່ິງ ຕ່ໍ ໄປ ນ້ີ ແມ່ນ ຕົວຢ່າງ ຂອງຄ ໍາຖາມ ທີ່ ເປັນ ໄປ ໄດ້ ທີ່ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ອາດ ຈະ ຖາມ ເພ່ືອ ຊອກ ຮູ້ ວ່າ ເປົ້າ ໝາຍ ຫຼື ບັນດາ ເປົ້າ ໝາຍ ຂອງ ຜູ້ ໃຊ້ລົດ ເຂັນ ແມ່ນ ຫຍັງ. ï ເປັນ ຫຍັງ ທ່ານ ຈິ່ງ ມາ ຫາ ການ ບໍລິ ການ ລົດ ເຂັນ ໃນ ມ້ື ນ້ີ? ï ລົດ ເຂັນ ຂອງ ທ່ານ ຄວນ ຈະ ຊ່ວຍ ທ່ານ ເຮັດ ຫຍັງ? ສ່ິງ ຕ່ໍ ໄປ ນ້ີ ແມ່ນ ຕົວຢ່າງ ຂອງ ເປົ້າ ໝາຍ ທີ່ ເປັນ ໄປ ໄດ້: ï ຂ້ອຍ ຕ້ອງການ ສາມາດ ໄປຫາ ນ້ໍາສ້າງ ເພ່ືອ ຕັກ ນ້ໍາ ໄດ້. ï ຂ້ອຍ ຕ້ອງການ ສາມາດ ເຂົ້າ ໃນ ລິບ ໄດ້ເພ່ືອ ເຂົ້າ ອອກ ອາພັດ ເມັນ ຂອງ ຂ້ອຍ . ï ຂ້ອຍ ຕ້ອງການ ສາມາດ ເອົາ ລົດ ເຂັນ ຂອງ ຂ້ອຍ ໃ ນລົດ ຂະໜາດ ນ້ອຍ ໄດ້. ï ຂ້ອຍ ຢາກ ຈະ ສະບາຍ ຕົວ ກວ່າ ນ້ີ ໃນ ເວລາ ນ່ັງ. ï ຂ້ອຍ ຕ້ອງການ ສາມາດ ນ່ັງ ໄດ້ ດົນ ກວ່າ ໃນ ລົດ ເຂັນ ຂອງ ຂ້ອຍ ກ່ອນ ທີ່ ຂ້ອຍ ຈະ ເມ່ືອຍ. ï ຂ້ອຍ ຕ້ອງ ການ ສາມາດ ເຂົ້າ ແລະ ອອກ ຈາກ ລົດ ເຂັນ ໄດ້ ດ້ວຍ ຕົນ ເອງ. ï ຂ້ອຍ ຕ້ອງການ ສາມາດ ນ່ັງ ຢູ່ ໂຕະ ເພ່ືອ ໃຊ້ ຄອມ ພິວ ເຕີ ໄດ້. ï ຂ້ອຍ ຢາກ ສາມາດ ໄປ ຢາມ ຄອບຄົວຂອງ ຂ້ອຍ ແລະ ຕ້ອງການ ລົດ ເຂັນ ທີ່ ສາມາດ ເອົາ ຂ້ຶນ ລົດ ເມ ໄດ້. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 23 ສະພາບ ຮ່າງກາຍ ການ ບ່ົງມະຕິ: ການ ບາດ ເຈັບ ສະໝອງ ສະໜອງ ພິການ ພະຍາດ ກ້າມ ເນ້ືອ ເສ່ືອ ມ ໂປ ລີ ໂອ ກະດູກ ສັນຫັຼງ ໂຫວ່ ການ ບາດ ເຈັບ ໄຂ ສັນຫັຼງ ອໍາມະພາດ ບໍ່ ຮູ້ຈັກ ອື່ນໆ ສະພາບ ເປັນ ໄປ ໄດ້ ວ່າ ຈະ ຮ້າຍ ແຮງ ຂ້ຶນ ແມ່ນ ບໍ? ແມ່ນ ບໍ່ ບັນຫາ ຮ່າງກາຍ: ບໍ່ ແຂງ ແຮງ ກ້າມ ເນ້ືອ ກະຕຸກ/ບໍ່ ສາມາດ ຄວບ ຄຸມ ການ ເຄື່ອນ ໄຫວ ໄດ້ ຄວາມ ຕຶງ ກ້າມ ເນ້ືອ (ສູງ/ຕ່ໍາ) ຕັດ ຂາ ສ່ວນລຸ່ມ: ເທິງ ຫົວ ເຂົ່າ ເບື້ອງ ຂວາ ລຸ່ມ ຫົວ ເຂົ່າ ເບື້ອງ ຂວາ ເທິງ ຫົວ ເຂົ່າ ເບື້ອງ ຊ້າຍ ລຸ່ມ ຫົວ ເຂົ່າ ເບື້ອງ ຂວາ ອ່ອນ ເພຍ ສະ ໂພ ກຫຸຼດ ໂບກ ໂຣກບ້າໝູ ບັນຫາ ເລື່ອງ ການ ກິນ, ການ ດື່ມ ຫຼື ການ ກືນ ອະທິບາຍ: ການ ເຈັບ ອະທິບາຍ ຈຸດ ທີ່ ຕ້ັງ: ບັນຫາ ການ ຍ່ຽວ ບັນຫາ ການ ຂັບ ຖ່າຍ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ບັນຫາ ການ ຍ່ຽວ ຫຼື ບັນຫາ ການ ຂັບ ຖ່າຍ, ມີ ການຄຸ້ມ ຄອງ ສ່ິງ ນ້ີ ບໍ? ແມ່ນ ບໍ່ ສ່ວນ ëການ ບົ່ງມະຕິ/ບັນຫາ ຮ່າງກາຍí ຂອງ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ມີ ຄວາມ ສໍາຄັນ ເພາະວ່າ ບາງ ລັກສະນະຂອງ ການ ບົ່ງມະຕິພະຍາດ ແລະ ບັນຫາ ຮ່າງກາຍ ຕ່າງໆ ສາມາດ ມີ ຜົນຕ່ໍ ກັບ ການ ເລືອກ ລົດ ເຂັນ ແລະ ອຸປະກອນຮອງ ຮັບທ່າ ທາງ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ. ຕາຕະລາງ ຢູ່ ໃນ ສອງ ສາມ ໜ້າ ຕ່ໍ ໄປ ນ້ີ ໃຫ້ ພາບ ລວມ ໂດຍ ຫຍໍ້ກ່ຽວ ກັບ ການ ບົ່ງມະຕິພະຍາດ ແລະ ບັນຫາ ຮ່າງກາຍ ຕ່າງໆ ທີ່ ລະບຸ ເປັນ ລາຍການ ຢູ່ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ມີ ການ ອະທິບາຍລັກສະນະ ພິ ເສດ ທີ່ ພົບ ເຫັນ ທົ່ວ ໄປ ຂອງ ແຕ່ ລະກາ ນບ່ົງມະຕິພະຍາດ/ບັນຫາ ຮ່າງກາຍ ທີ່ ກ່ຽວຂ້ອງ ກັບ ການ ສະໜອງ ລົດ ເຂັນ ແລະ ມີ ການ ໃຫ້ ຄໍາ ແນະນໍາ ສໍາລັບ ການ ສະໜອງ ລົ ດ ເຂັນ. 24 5 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 00 6) . ຄ ວ າມ ຜິດ ປົກ ກ ະ ຕິ ຂອ ງ ລ ະ ບ ົບ ປະ ສ າດ : ສິ່ ງ ທ ້າ ທ າຍ ດ້າ ນ ສາ ທ າລ ະ ນ ະ ສຸກ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m en ta l_ he al th /n eu ro lo gy /c ha pt er _3 _b _n eu ro _ di so rd er s_ pu bl ic _h _c ha lle ng es .p df 6 ອ ົງກ ານ ອະ ນ າ ໄ ມ ໂລ ກ , ສູ ນ ກາ ນ ບາ ດ ເຈ ັບ ທ າງ ສະ ໝ ອ ງ D ru ck er ຂ ອ ງກ ະ ຊ ວ ງ ປ ້ອ ງ ກັ ນ ປະ ເທ ດ ຂອ ງສ ະ ຫ ະ ລັ ດ , ໂ ຮ ງໝໍ M os s R eh ab H os pi ta l. (2 00 4) . ກ ານ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ສໍາ ລັ ບ ຄົ ນ ທີ່ ມີ ບ າດ ເຈ ັບ ທ າງ ສະ ໝ ອ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/h q/ 20 04 /W H O _D AR _0 1. 9_ en g. pd f 7 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 01 1) . ເ ຍ ື່ອ ຫ ຸ້ມ ສະ ໝ ອ ງ ອ ັກ ເສ ບ ຈາ ກ ເມ ນິງ ໂກ ໂຄ ຄັລ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m ed ia ce nt re /fa ct sh ee ts /fs 14 1/ en / ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ການ ບາດ ເຈັບ ສະ ໝອງ ກ ານ ບາ ດ ເຈ ັບ ສ ະ ໝ ອ ງ ໝ າຍ ເຖ ິງ ຄ ວ າມ ເສ ຍ ຫ າຍ ຕ່ າງ ໆ ຕໍ່ ກັ ບ ສະ ໝ ອ ງ ທ ີ່ ເກີ ດ ຂຶ້ນ ຫ ຼັງຈ າກ ກ ານ ເກີ ດ . ຄ ວ າມ ເສ ຍ ຫ າຍ ສາ ມ າດ ເກີ ດ ຈ າກ ອຸປ ະ ຕິ ເຫ ດ ຫ ຼື ກ ານ ກະ ທົ ບ ກ ະ ເທ ືອ ນ (5 ,6 ) , ກ ານ ຕິດ ເຊ ື້ອ ຢູ່ ສ ະ ໝ ອ ງ, ເ ຍ ື່ອ ຫ ຸ້ມ ສ ະ ໝ ອ ງ ອ ັກ ເສ ບ (7 ) , ໄຂ້ ຍຸງ ຂຶ້ນ ສະ ໝ ອ ງ, ກ ານ ຕິດ ເຫ ຼົ້າ ຫ ຼື ຢ າ ເສ ບ ຕິດ (5 ) . ບ ັນ ຫ າ ທ ີ່ ເກີ ດ ຈາ ກ ກາ ນ ບາ ດ ເຈ ັບ ສະ ໝ ອ ງ ແ ມ ່ນ ແ ຕ ກ ຕ່າ ງ ກັ ນ ໄປ ຂຶ້ນ ກັບ ສ່ວ ນ ຂອ ງ ສ ະ ໝ ອ ງ ທ ີ່ ຖືກ ເສ ຍ ຫ າຍ ແ ລ ະ ຄ ວ າມ ຮຸນ ແຮ ງ ຂ ອ ງ ກ ານ ບາ ດ ເຈ ັບ (6 ) . ກ ານ ບາ ດ ເຈ ັບ ສະ ໝ ອ ງ ສ າມ າດ ມີ ຜົ ນ ຕໍ່ ກັ ບ ທ ັງ ໝົ ດ ຮ ່າງ ກ າຍ ຫ ຼື ສ່ ວ ນ ໃດ ໜ ຶ່ງ ຂ ອ ງ ຮ່ າງ ກ າຍ ຂ ອ ງ ຄ ົ ນນັ້ ນ . ແ ນ ວ ໃດ ກໍ ຕ າມ ກ ານ ບ າດ ເຈ ັບ ສະ ໝ ອ ງ ແ ມ ່ນ ກາ ນ ບາ ດ ເຈ ັບ ຖາ ວ ອ ນ ຕໍ່ ກັບ ສະ ໝ ອ ງ, ແ ຕ່ ຜົນ ກະ ທົ ບ ຂອ ງ ກ ານ ບາ ດ ເຈ ັບ ຕໍ່ ກັ ບ ຄວ າມ ສາ ມ າດ ຂອ ງ ບ ຸກ ຄົ ນ ອາ ດ ຈະ ປ ່ຽນ ແປ ງ ເ ມື່ ອ ເວ ລ າ ຜ່ ານ ໄປ (6 ) . *ກ ະ ລຸ ນ າ ຮັ ບ ຊາ ບ ສໍາ ລັ ບ ຈຸດ ປ ະ ສົ ງ ຂ ອ ງຫຼັ ກ ສູ ດ ຝຶ ກ ອົບ ຮ ົມ ນີ້ ວ ່າ ຄ ໍາ ສ ັບກ ານ ບາ ດ ເຈ ັບ ສະ ໝ ອ ງ ໝ າ ຍ ເຖ ິງ ກ ານ ເຈ ັບ ສະ ໝ ອ ງ ແ ຕ່ ກໍາ ເນີ ດ ແລ ະ ຈ າກ ກາ ນ ກະ ທົ ບ ກ ະ ເທ ືອ ນ ເ ທ ົ່າ ນັ້ ນ . ï ຄ ວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ເຄ ື່ອ ນ ເໜ ັງ, ກ ານ ປ ະ ສ ານ ຮ່າ ງກ າຍ ແ ລ ະ ກ ານ ໃຊ ້ ກໍາ ລັ ງ ບ ໍ່ ໄດ້ ດີ (6 ) ; ï ກ ານ ຊົງ ຕົວ ໃນ ກ ານ ນັ່ງ ແ ລ ະ /ຫ ຼື ກ ານ ຢືນ ໍ ບໍ່ ໄ ດ້ ດີ (6 ) ; ï ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ (ຄ ວ າມ ແຂ ງ ຂ ອ ງກ້ າມ ເນື້ ອ ) ( 6) , ເ ຊ ິ່ງສ າມ າ ດ ເຮ ັດ ໃຫ ້ ທ ັງ ໝົ ດ ຮ່ າງ ກ າຍ ຢຽ ດ ຊື່ (ກ າ ນ ຂ ະ ຫ ຍ າຍ ເຕັ ມ ຂອ ງ ຮ່ າງ ກ າຍ ) ຫ ຼື ຂົ ດ ຕົວ ເຂ ົ້າ (ກ ານ ຂົດ ງໍ ເ ຕັ ມ ສ່ ວ ນ ຂ ອ ງ ຮ່ າ ງ ກ າຍ ); ï ຄ ວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ກິນ , ກ ານ ດື່ມ ແ ລ ະ ກ ານ ກື ນ (6 ) ; ï ຄ ວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ເວ ົ້າ, ກ ານ ໃຫ ້ ເຫ ດ ຜ ົນ ແ ລ ະ ກ ານ ເຂ ົ້າ ໃ ຈ (6 ) ; ï ກ ານ ປ່ຽ ນ ແປ ງ ໃ ນ ບຸກ ຄ ະ ລິກ ຫ ຼື ພຶ ດ ຕິ ກໍາ (6 ) ; ï ກ ານ ຊັກ ບ້າ ໝູ (6 ) ; ï ຄ ວ າມ ລໍາ ບາ ກ ໃນ ກາ ນ ຄວ ບ ຄຸມ ກາ ນ ຖ່າ ຍ ໜັ ກ ແ ລ ະ ຖ ່າຍ ເບ ົາ ເຊ ິ່ງ ເ ພີ່ ມ ຄວ າມ ສ່ຽ ງ ຂ ອ ງ ກ ານ ເກີ ດ ແຜ ກົດ ທ ັບ (6 ) . ຖ້າ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ບໍ່ ມີ ຄວ າມ ສາ ມ າດ ໃນ ກາ ນ ຂັ ບ ເຄ ື່ອ ນ ລ ົດ ເຂັ ນ ດ້ວ ຍ ແຂ ນ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ, ໃ ຫ ້ ລະ ບ ຸ ວ່າ ກ ານ ຂັ ບ ເຄ ື່ອ ນ ລ ົດ ເຂ ັນ ດ້ວ ຍ ຕີນ ຈະ ເປ ັນ ໄປ ໄດ້ ຫ ຼືບ ໍ່. ຊ ອ ກ ຮູ້ ວ ່າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ມີ ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ ຫ ຼືບ ໍ່ ເພ າະ ສິ່ ງ ນີ້ ອາ ດ ຈະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ຄ ວ າມ ແຂ ງ ແ ຮ ງຂ ອ ງ ອ ຸປ ະ ກ ອ ນ P SD . ກ ານ ຕິດ ຕ າມ ຜົນ ເລ ື້ອ ຍ ໆ ແມ ່ນ ສໍ າຄັ ນ ເ ພ າະ ວ່ າ ຄ ວ າມ ສ າມ າດ ທ າງ ຮ່າ ງກ າຍ ຂອ ງ ຂ ອ ງ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ອາ ດ ຈະ ປ່ຽ ນ ແປ ງ ເ ມື່ ອ ເວ ລ າ ຜ່ ານ ໄປ (6 ) . ນີ້ ໝ າຍ ຄວ າມ ວ່າ ຈໍາ ນ ວ ນ ແນ ວ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງ ຮັ ບ ທ ີ່ ຈໍາ ເປ ັນ ໃນ ລົດ ເຂ ັນ ອາ ດ ຈະ ປ່ຽ ນ ແປ ງ. ຮູ້ ຈ ັກ ແ ລ ະ ອ ່ອ ນ ໄຫ ວ ຕໍ່ ກັ ບ ກາ ນ ປ່ຽ ນ ແປ ງ ທ ີ່ ເປ ັນ ໄປ ໄດ້ ໃນ ບຸກ ຄ ະ ລິກ ຫ ຼື ພຶ ດ ຕິ ກໍາ ທ ີ່ ກ່ຽ ວ ຂ ້ອ ງ ກັ ບ ສະ ພ າບ ສຸ ຂ ະ ພ າບ ຂອ ງ ແ ຕ່ ລ ະ ຄົ ນ (6 ) . ສໍາ ລັ ບ ຂໍ້ ມູ ນ ກ່ຽ ວ ກັບ : ກ້ າມ ເນື້ ອ ຕ ຶງ – ສູ ງ ແລ ະ ຕໍ່ າ – ເບ ິ່ງ ໜ ້າ 34 . ໂຣ ກ ບ້ າໝູ – ເ ບ ິ່ງ ໜ ້າ 40 . ສາ ມ າດ ປ້ອ ງ ກັ ນ ແຜ ກົ ດ ທ ັບ ໄດ້ ແນ ວ ໃດ ? – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 25 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ສະໝອງ ພິການ ສ ະ ໜ ອ ງ ພິ ກ ານ ແມ ່ນ ໜ ຶ່ງ ໃ ນ ຄວ າມ ພິ ກ ານ ທ າງ ຮ່າ ງກ າຍ ທ ີ່ ພົ ບ ເຫ ັນ ຫ ຼາຍ ທີ່ ສຸດ ໃນ ເດ ັກ ນ້ ອ ຍ (8 ,9 ) ແ ລ ະ ມັ ນ ເກີ ດ ຈາ ກ ກາ ນ ບ າດ ເຈ ັບ ຕໍ່ ກັ ບ ສ ະ ໝ ອ ງ ທ ີ່ ກໍ າລັ ງພັ ດ ທ ະ ນ າ (1 0) . ຮູບ ແບ ບ ທ ີ່ ສະ ໝ ອ ງ ພິ ກ ານ ມີ ຜົ ນ ກະ ທົ ບ ຕໍ່ ກັ ບ ແຕ່ ລ ະ ຄ ົນ ແມ ່ນ ແ ຕ ກ ຕ່າ ງ ກັ ນ (1 0) , ແ ນ ວ ໃດ ກໍ ຕ າມ ສ່ ວ ນ ໃຫ ຍ ່ ແ ລ ້ວ ມັ ນ ກະ ທົ ບ ກັບ ແບ ບ ວິທ ີ ທ ີ່ ບຸກ ຄົ ນ ເຄ ື່ອ ນ ເໜ ັງ ຮ່ າງ ກ າຍ (8 ,1 0, 11 ) . ບ ໍ່ ແມ ່ນ ທ ຸກ ຄົນ ທີ່ ສ ະ ໝ ອ ງ ພິ ກ ານ ຈໍາ ເປ ັນ ຕ້ອ ງ ໃ ຊ ້ ລົດ ເຂ ັນ (1 0) . ແນ ວ ໃດ ກໍ ຕ າມ , ເ ດ ັກ ນ້ ອ ຍ ແ ລ ະ ຜູ້ ໃຫ ຍ ່ ທ ີ່ ສ ະ ໝ ອ ງ ພິ ກ ານ ຜູ້ ທ ີ່ ໃຊ ້ ລົດ ເຂ ັນ ມັ ກ ຈະ ຈໍາ ເປ ັນ ຕ້ ອ ງ ມີ ແນ ວ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງຮັ ບ ທ ່າ ທ າງ ເພີ່ ມ ເ ຕີ ມ ເພື່ ອ ໃຫ ້ ພ ວ ກ ເຂ ົາ ເ ຄ ື່ອ ນ ໄຫ ວ ຮ່າ ງກ າຍ ໄດ້ ແ ລ ະ ສ ະ ບ າຍ ຕົວ ໃນ ລົດ ເຂ ັນ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ. ï ຄ ວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ນອ ນ , ກ ານ ນັ່ງ ຫ ຼື ກ ານ ຢືນ (1 0) ; ï ກ ານ ຊົງ ຕົວ ບໍ່ ໄ ດ້ ດີ (1 0) ; ï ຄວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ຄວ ບ ຄຸມ ສ່ວ ນ ໜ ຶ່ງ ຂ ອ ງ ຮ່ າງ ກ າຍ ໃ ນ ຂະ ນ ະ ທ ີ່ ເຄ ື່ອ ນ ໄຫ ວ ສ່ວ ນ ອື່ນ – ຕົ ວ ຢ ່າງ , ກ ານ ນັ່ງ ນິ້ງ ໆ ໃນ ຂະ ນ ະ ທ ີ່ ຂຽ ນ ຫ ຼື ເຮ ັດ ກາ ນ ດື່ມ ຈາ ກ ຈອ ກ ແ ລ ະ ກ ານ ກືນ ; ï ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ ຫ ຼື ຕໍ່ າ (1 0) ; ï ກ້ າມ ເນື້ ອ ກະ ຕຸ ກ /ກ ານ ເຄ ື່ອ ນ ເໜ ັງ ທ ີ່ຄ ວ ບ ຄຸມ ບໍ່ ໄດ້ ; ï ກ ານ ປ ະ ສ ານ ຮ່າ ງກ າຍ ບໍ່ ໄ ດ້ ດີ (1 0) ; ï ແນ ວ ໂນ້ ມ ໃນ ກາ ນ ນັ່ງ ໃນ ທ ່າ ດ ຽວ ຕະ ຫຼ ອ ດ ເວ ລ າ (ທ ່າ ນັ່ ງທີ່ ເປ ັນ ນິ ໄສ ) ( 10 ) ; ï ຄ ວ າມ ກັງ ວົ ນ ທ າງ ຮ່າ ງກ າຍ ອື່ນ ເ ຊ ່ັນ ວ່າ ກ ານ ເບ ິ່ງ ເ ຫ ັນ , ກ ານ ໄດ້ ຍິນ , ໂ ຣ ກ ບ້ າໝູ , ຄ ວ າມ ລ ໍາບ າກ ໃນ ກ ານ ເວ ົ້າ ຫ ຼື ກ ານ ສື່ສ ານ (1 0) ; ï ຄ ວ າມ ລໍາ ບາ ກ ໃນ ກາ ນ ຄວ ບ ຄຸມ ກາ ນ ຖ່າ ຍ ໜັ ກ ແ ລ ະ ຖ ່າຍ ເບ ົາ ເຊ ິ່ງອ າດ ຈະ ເພີ່ ມ ຄວ າມ ສ່ຽ ງ ສໍ າລັ ບ ກາ ນ ເກີ ດ ແຜ ກົດ ທ ັບ (1 1, 8) . ï ສາ ມ າດ ເປ ັນ ເລ ື່ອ ງ ຍ າກ ໃນ ກາ ນ ສາ ມ າດ ໄປ ເຂ ົ້າ ຫ ້ອ ງ ນໍ້ າ ແລ ະ ນັ່ ງ ເ ທ ິງ ຫ ຼື ນັ່ ງ ຢ ່ອ ງຢໍ້ ເທ ິງ ຫ ົວ ວິດ ດ ້ວ ຍ ຕົນ ເອ ງ; ï ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ (ຫ ົວ ຂອ ງ ກ ະ ດູ ກ ຂາ ຫ ຼຸດ ອ ອ ກ ຈ າກ ເບ ົ້າສ ະ ໂພ ກ) ເ ຊ ິ່ງສ າມ າດ ຈໍາ ກັ ດ ກາ ນ ເຄ ື່ອ ນ ໄຫ ວ ແ ລ ະ ເ ຈ ັບ ປວ ດ . ï ສໍ າລັ ບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ສ່ວ ນ ໃຫ ຍ ່ ທ ີ່ ສະ ໝ ອ ງ ພິ ກ ານ , ກ ານ ປ ະ ຄ ອ ງ ຫ ຼື ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ທ ີ່ ດີ ແ ມ ່ນ ສໍາ ຄັ ນ ຫ ຼາຍ ເພື່ ອ ຊ່ວ ຍ ປັບ ປ ຸງ ທ ່າ ທ າງ , ກ ານ ຊົງ ຕົວ ແ ລ ະ ແ ບ ບ ວິທ ີ ທ ີ່ພ ວ ກ ເຂ ົາ ສ າມ າດ ຄວ ບ ຄຸມ ຮ່າ ງກ າຍ ຂ ອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ໃ ນ ກາ ນ ເຮ ັດ ສິ່ງ ຕ່າ ງໆ ໄດ້ ງ່າ ຍ ຂຶ້ນ . ï ຈົ່ງ ຮັບ ຊາ ບ ວ່າ ກ ານ ປ່ຽ ນ ແປ ງ ໃ ນ ທ ່າ ທ າງ ອາ ດ ຈະ ຮູ້ ສຶ ກ ແປ ກ ໃນ ຕອ ນ ທ ໍາ ອ ິດ ສໍາ ລັ ບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ທ ີ່ ສ ະ ໝ ອ ງ ພິ ກ ານ . ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ອາ ດ ຈະ ຕ້ອ ງກ ານ ເວ ລ າ ເ ພື່ ອ ປັບ ຕົວ . ຈ ົ່ງ ພິ ຈ າລ ະ ນ າ ປ ່ຽນ ແນ ວ ຮ ອ ງຮັ ບ ທ ່າ ທ າງ ເທ ື່ອ ລະ ໜ ້ອ ຍ ເພື່ ອ ໃຫ ້ຜູ້ ກ່ ຽວ ບ ັນ ລຸ ໄດ້ ທ ່າປົ ກ ກ ະ ຕິ ຫ ຼາຍ ຂຶ້ ນ ເມື່ ອ ເວ ລ າຜ່ ານ ໄປ . ï ບ ັນ ຫ າຮ່ າງ ກ າຍ ອື່ ນ ສ າມ າດ ມີ ຜົ ນ ກ ະ ທົ ບ ຕໍ່ ກັ ບ ວ ິທ ີ ແ ກ ້ ໄຂ ດ້ວ ຍ ລ ົດ ເຂ ັນ ແ ລ ະ ແ ນ ວ ຮ ອ ງຮັ ບ ທ ່າ ທ າງ ຕ່ າງ ໆ . ຊ ອ ກ ຮູ້ ໃ ນ ລະ ຫ ວ ່າງ ກາ ນ ປະ ເມີ ນ ຜົນ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂ ັນ ທ ີ່ ພິ ກ ານ ສະ ໝ ອ ງ ອ າດ ຈະ ມີ ຄ ວ າມ ຫ ຍຸ້ ງຍ າກ ອື່ນ ໃດ ແດ ່. ສໍາ ລັ ບ ຂໍ້ ມູ ນ ກ່ຽ ວ ກັບ : ï ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ – ເ ບ ິ່ງ ໜ ້າ 38 . 8 R os en ba um , P . ( 20 03 ). ສ ະ ໝ ອ ງ ພິ ກ ານ . ສິ່ ງ ທ ີ່ ພໍ່ ແມ ່ ແ ລ ະ ທ ່ານ ໝໍ ຕ້ອ ງກ ານ ຮູ້. ວ າລ ະ ສ ານ ກາ ນ ແພ ດ ບຣິ ດ ຕິ ຊ, 3 26 , 9 70 –9 74 9 C er eb ra l P al sy A us tra lia . ( n. d. ). ສ ະ ໝ ອ ງພິ ກ ານ – ຂໍ້ ເທ ັດ ຈິງ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .c er eb ra lp al sy au st ra lia .c om /in de x. ph p/ si te /le ar ni ng ce nt re /th ef ac ts 10 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (1 99 3) . ກ ານ ສົ່ງ ເສີ ມ ພັ ດ ທ ະ ນ າ ກ ານ ຂອ ງ ເ ດ ັກ ນ້ອ ຍ ທ ີ່ ສະ ໝ ອ ງພິ ກ ານ : ປ ື້ ມ ແ ນ ະ ນໍ າ ສໍ າລັ ບ ພ ະ ນັ ກ ງາ ນ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ລະ ດ ັບ ປາ ນ ກາ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho . in t/h q/ 19 93 /W H O _R H B_ 93 .1 .p df 11 K ig ge r, K. (2 00 6) . ສ ະ ໝ ອ ງ ພິ ກ ານ : ສ ະ ພ າບ ລວ ມ . ທ ່ານ ໝໍ ປະ ຈ ໍາ ຄ ອ ບ ຄ ົວ ອາ ເມ ລິ ກ າ, 7 3( 1) , 9 1– 10 0. 12 R oi je n, L ., Po st em a, K ., Li m be ek , v J. , & K up pe ve lt, v H . J . M . ( 20 01 ). ກ າ ນ ພັ ດ ທ ະ ນ າ ກ ານ ຄວ ບ ຄຸມ ກາ ນ ຍ່ຽ ວ ໃນ ເດ ັກ ນ້ ອ ຍ ແ ລ ະ ໄ ວ ໜ ຸ່ມ ທ ີ່ ສະ ໝ ອ ງ ພິ ກ ານ . ກ ານ ແພ ດ ດ້າ ນ ພັ ດ ທ ະ ນ າ ກ ານ ແ ລ ະ ປ ະ ສ າດ ວິດ ທ ະ ຍ າ ໃ ນ ເດ ັກ , 4 3, 1 03 –1 07 . 26 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ພະຍາດກ້ າມ ເນື ້ ອ ເສື ່ ອ ມ ພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມ ແ ບ ບ ດູ ຊີ ນ (D M D ) ແ ມ ່ນ ໜ ຶ່ງ ໃ ນ 2 0 ປ ະ ເພ ດ ຂ ອ ງພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມ . ພ ະ ຍ າດ ກ້ າມ ເນື້ ອ ເສື່ ອ ມ ທັ ງ ໝົ ດ ລ້ວ ນ ແຕ່ ສົ່ງ ຜົນ ເຮ ັດ ໃຫ ້ ກ້າ ມ ເນື້ ອ ອ່ອ ນ ເພ ຍ (9 ) . D M D ແ ມ ່ນ ພ ະ ຍ າດ ເປ ັນ ແ ຕ່ ກໍາ ເນີ ດທ ີ່ ເຮ ັດ ໃຫ ້ ກ້າ ມ ເນື້ ອ ຄ່ອ ຍ ໆ ອ່ອ ນ ເພ ຍ ເມື່ ອ ເວ ລ າ ຜ່ ານ ໄປ (1 0) . ກ້ າມ ເນື້ ອ ທ ີ່ ຊ່ວ ຍ ໃຫ ້ ຮ່າ ງກ າຍ ເຄ ື່ອ ນ ໄຫ ວ ໄປ ມ າ ໄ ດ້ ຮັບ ຜົນ ກ ະ ທົ ບ ກ່ອ ນ ໝູ່ (1 4) . ເ ມື່ ອ ພ ະ ຍ າດ ນີ້ ຂ ະ ຫ ຍ າຍ ຕົ ວ , ກ້ າມ ເນື້ ອ ຫ ົວ ໃຈ ແ ລ ະ ປ ອ ດ ກໍ່ ໄ ດ້ ຮັບ ຜົນ ກະ ທົ ບ ເຊ ັ່ນ ກັ ນ (1 4, 11 ) . ມັ ນ ເປ ັນ ພ ະ ຍ າດ ທ ີ່ ຂະ ຫ ຍ າຍ ຕົ ວ ເ ຊ ິ່ງໝ າຍ ຄວ າມ ວ່າ ຄ ົ ທ ີ່ ເປ ັນ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມຈ ະ ຄ່ອ ຍ ໆ ສູນ ເສ ຍ ຄວ າມ ສ າມ າດ ໃນ ກາ ນ ຍ່າ ງ (1 3, 14 ,1 2) , ແ ລ ະ ຈ ະ ຈໍາ ເປ ັນ ຕ້ອ ງ ໃຊ ້ ລົດ ເຂ ັນ (1 3) . ທ ໍາ ອ ິດ , ບ ຸກ ຄົ ນ ສາ ມ າດ ຂັບ ເຄ ື່ອ ນ ລົດ ເຂ ັນ ໄດ້ ດ້ວ ຍ ຕົນ ເອ ງ ໂ ດ ຍ ມີ ທ ່າ ທ າງ ທ ີ່ ດີ (1 3) . ແ ນ ວ ໃດ ກໍ ຕ າມ , ຄ ວ າມ ສາ ມ າດ ໃນ ກາ ນ ຮັກ ສ າ ທ ່າ ທ າງ ທ ີ່ ດີ ແ ລ ະ ຂັ ບ ເຄ ື່ອ ນ ລົດ ເຂ ັນ ດ້ວ ຍ ຕົນ ເອ ງ ຫ ຼຸດ ລ ົງ ເມື່ ອ ພ ະ ຍ າ ຍ າດ ຂະ ຫ ຍ າຍ ຕົ ວ (1 3) . ໝ າ ຍ ເຫ ດ : ພ ະ ຍ າດ ທ າງ ລະ ບ ົບ ປະ ສ າດ ທ ີ່ ຂ ະ ຫ ຍ າຍ ຕົ ວ ໄດ້ ອື່ນ ກໍ ມີ ລ ັກ ສ ະ ນ ະ ຄ້າ ຍ ຄື ກັນ ແ ລ ະ ຮ ຽກ ຮ້ ອ ງ ໃ ຫ ້ ວິທ ີ ກາ ນ ທ ີ່ ຄ້າ ຍ ຄື ກັນ ໃ ນ ເວ ລ າ ສ ະ ໜ ອ ງ ລ ົດ ເຂ ັນ ໃຫ ້. ï ເຈ ັບ ແ ລ ະ ບ ໍ່ ສະ ບ າຍ ຕົວ (1 3) ; ï ອ ິດ ເ ມື່ ອ ຍ (1 7) ; ï ກ້ າມ ເນື້ ອ ອ່ອ ນ ແຮ ງ ເ ທ ື່ອ ລະ ໜ ້ອ ຍ ; ໃ ນ ເວ ລ າ ທ ີ່ ບຸກ ຄົ ນ ນັ້ນ ຕ້ອ ງ ກ ານ ລົ ດ ເຂ ັນ , ກ້ າມ ເນື້ ອ ອ ່ອ ນ ແຮ ງ ຢ ູ່ ບໍລ ິ ເວ ນ ກົ ກ ແອ ວ , ລ ໍາ ຕົ ວ ແ ລ ະ ບ ່າ ໄ ຫຼ່ ມີ ຜົນ ກະ ທົ ບ ຕໍ່ ກັ ບ ທ ່າ ທ າງ (1 7) ; ï ທ ່າ ທ າງ ປ່ຽ ນ ແປ ງ: – ເນື່ ອ ງ ຈ າກ ກ້າ ມ ເນື້ ອ ທ ີ່ ອ່ອ ນ ແຮ ງ ຢ ູ່ ບໍລ ິ ເວ ນ ທ ້ອ ງ ແລ ະ ຂໍ້ ຕໍ່ສ ະ ໂພ ກ ບ ຸ ກຄົ ນ ທີ່ ເປ ັນ ພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມອ າ ດ ຈ ະ ນັ່ງ ໂດ ຍ ທ ີ່ ກະ ດູ ກ ກົກ ແອ ວ ອ່ຽ ງ ໄ ປ ທ າງ ໜ ້າ (ສ່ ວ ນ ເທ ິງ ຂ ອ ງກົ ກ ແອ ວ ເດ ່ ໄປ ໜ ້າ) ແ ລ ະ ຫ ຼັງຂົ ດ ຫ ຼາຍ ຂຶ້ ນ (ຫ ຼັງ ແ ອ ່ນ ) ( 17 ) ; – ເມື່ ອ ກ້າ ມ ເນື້ ອ ອ່ອ ນ ແຮ ງ ຂ ະ ຫ ຍ າ ຍ ຕົ ວ ຂຶ້ນ ມີ ຄວ າມ ສ່ຽ ງ ສູ ງ ທ ີ່ ກະ ດູ ກ ສັນ ຫຼັ ງຈ ະ ກົ່ງ ໄປ ດ ້ານ ຂ້າ ງ (ກ ະ ດູ ກ ສັນ ຫຼັ ງຂົ ດ ໄປ ຂ້າ ງ) (1 6) ; ï ຫ າຍ ໃຈ ຍາ ກ ເນື່ ອ ງ ຈ າກ ກາ ນປ່ ຽນ ແປ ງ ໃ ນ ທ ່າ ທ າງ ແ ລ ະ ກ້ າມ ເນື້ ອ ອ ່ອ ນ ແຮ ງ (1 7) ; ï ຄ ວ າມ ສ່ຽ ງ ເ ກີ ດ ແຜ ກົດ ທ ັບ ເນື່ ອ ງ ຈ າກ : – ປ ່ຽນ ທ ່າ ທ າງ ໄດ້ ຍາ ກ ; – ມີ ນໍ້ າໜັ ກ ເບ ົາ ເ ກີ ນ ໄປ ຫ ຼື ໜ ັກ ເກີ ນ ໄປ . ï ໃນ ທ ັນ ທີ ທ ີ່ ຄົນ ເປ ັນ ພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມ (ຫ ຼື ພ ະ ຍ າດ ທ າງ ປະ ສ າດ ທ ີ່ ຂະ ຫ ຍ າຍ ຕົ ວ ໄດ້ ອື່ນ ) ເລ ີ່ ມຕ້ ອ ງກ ານ ລົດ ເຂ ັນ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ໃ ນ ແຕ່ ລ ະ ວ ັນ , ຈ ໍາ ເ ປ ັນ ຕ້ອ ງ ເ ຮ ັດ ກ ານ ປະ ເມີ ນ ລ ະ ອ ຽດ ກ່ ຽວ ກັບ ກ ານ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງ ຮັ ບ ທ ່າ ທ າງ ຂອ ງ ເຂ ົາ ເ ຈ ົ້າ. ï ກ ານ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງ ຮັ ບ ທ ່າ ທ າງ ທ ີ່ ດີ ທ ີ່ ສະ ໜ ອ ງ ໃຫ ້ ໄວ ແຕ່ ຕົ້ນ ໆ ສາ ມ າດ ຊ່ວ ຍ ປ້ອ ງ ກັ ນ ບັນ ຫ າ ເລ ື່ອ ງທ່ າ ທ າງ ໃນ ອະ ນ າຄົ ດ ໄດ້ (1 7) . ï ກ ານ ປ ະ ຄ ອ ງຫຼື ຮ ອ ງຮັ ບ ທ ່າທ າງ ເພີ່ ມ ເຕີ ມ ຄ ວ ນ ເນັ້ ນ ໜ ັກ ໃສ່ ກາ ນ ຮອ ງ ຮັ ບ ທ ່າປົ ກ ກ ະ ຕິ ແ ລ ະ ໃຫ ້ກ ານ ຮອ ງ ຮັ ບ ເພີ່ ມ ຂຶ້ນ ເມື່ ອ ຈໍາ ເປ ັນ (1 7) . ï ອ ຸປ ະ ກ ອ ນ ໃສ່ ຕີນ ທ ີ່ ໃຫ ້ກ ານ ຮອ ງ ຮັ ບ ແ ລ ະ ບ ່ອ ນ ວ າງ ຕີນ ທ ີ່ ສາ ມ າດ ປັບ ມຸມ ໄດ້ ສາ ມ າດ ຊ່ວ ຍ ຮັ ກ ສ າ ທ ່າ ທ າງ ຕີ ນ ປົກ ກ ະ ຕິ (ຫ ຼື ໃ ກ້ ກັບ ປົກ ກ ະ ຕິ ) ໄດ້ . ໃ ນ ບ່ອ ນ ທ ີ່ ມີ ໃ ຫ ້, ອ ຸປ ະ ກ ອ ນ ປະ ຄ ອ ງ ຂໍ້ ຕີ ນ -ຕີ ນ (A FO ) ອ າດ ຈະ ເປ ັນປ ະ ໂຫ ຍ ດ ເ ຊ ັ່ນ ກັນ (1 7) . ï ແນ ວ ຮອ ງ ແ ຂ ນ ກໍສໍ າຄັ ນ ເມື່ ອ ກ້າ ມ ເນື່ ອ ອ ່ອ ນ ແ ຮ ງ ກ ະ ທົ ບ ກັບ ບ່າ ໄຫຼ່ (1 7) . ສໍາ ລັ ບ ຂໍ້ ມູ ນ ກ່ຽ ວ ກັບ : ï ກ ານ ເຈ ັບ – ເ ບ ິ່ງ ໜ ້າ 27 . ï ອິດ ເມື່ ອ ຍ – ເ ບ ິ່ງ ໜ ້າ 37 . ï ພ ະ ຍ າດ ທ ີ່ ຂະ ຫ ຍ າຍ ຕົ ວ – ເ ບ ິ່ງ ໜ ້າ 31 . 13 ແ ຄ ັມ ເປ ນ ໂ ຄ ສ ະ ນ າ ຕ້ ານ ພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມ. (2 00 2) . ພ ະ ຍ າດ ກ້ າມ ເນື້ ອ ເສື່ ອ ມ ແ ບ ບ ດ ູ ຊີ ນ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .m us cu la r- dy st ro ph y. or g/ 14 ສູ ນ ຄວ ບ ຄຸມ ແ ລ ະ ປ ້ອ ງ ກັ ນ ພ ະ ຍ າດ . ( n. d. ). ພ ະ ຍ າດ ກ້ າມ ເນື້ ອ ເສື່ ອ ມ ແ ບ ບ ດ ູ ຊີ ນ : ໃ ບ ຂໍ້ ເ ທ ັດ ຈິງ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .c dc .g ov /n cb dd d/ ac te ar ly /p df /p ar en ts _p df s/ D uc he nn e. pd f 15 N ew so m D av is , J . ( 19 80 ). ລ ະ ບ ົບ ຫ າຍ ໃຈ ໃນ ໂຣ ກ ກ້ າມ ເນື້ ອ ເສື່ ອ ມ. ໃ ບ ແຈ ້ງ ຂ່ າວ ທ າງ ກາ ນ ແພ ດ ບຣິ ດ ຕິ ຊ, 3 6, 1 35 –1 38 . 16 B ro ok e, M .H ., et a l. (1 98 9) . ພ ະ ຍ າດ ກ້ າມ ເນື້ ອ ເສື່ ອ ມ ແ ບ ບ ດ ູ ຊີ ນ : ຮູ ບ ແບ ບ ຂອ ງ ກ ານ ແຜ່ ຂະ ຫ ຍ າຍ ທ າງ ຄລ ີ ນິກ ແ ລ ະ ຜົ ນ ກະ ທົ ບ ຂອ ງ ກ ານ ບໍາ ບັ ດ ແບ ບ ມີ ກ ານ ຊ່ວ ຍ ເຫ ຼືອ . ປ ະ ສ າດ ວິທ ະ ຍ າ, 3 9, 47 5– 48 1. 17 ແ ຄ ັມ ເປ ນ ໂ ຄ ສ ະ ນ າ ຕ້ ານ ພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມ. (2 01 1) . ກ ານ ສະ ໜ ອ ງ ລ ົດ ເຂ ັນ ໃຫ ້ ເດ ັກ ນ້ ອ ຍ ແ ລ ະ ຜູ້ ໃຫ ຍ ່ ທ ີ່ ເປ ັນ ພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມ ແລ ະ ໂ ຣ ກ ກ້າ ມ ເນື້ ອ ຮ່ວ ມ ປະ ສ າດ ອື່ນ : ຂໍ້ ແນ ະ ນໍ າ ກ່ ຽວ ກັບ ວິທ ີ ປ ະ ຕິ ບ ັດ ທ ີ່ ດີ ສຸ ດ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .m us cu la r- dy st ro ph y. or g/ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 27 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ໂປ ລີ ໂອ ໂປ ລີ ໂ ອ ແມ ່ນ ພ ະ ຍ າດ ຕິດ ເຊ ື້ອ ທ ີ່ ເກີ ດ ຈາ ກ ໄວ ຣັ ສ (1 8) . ໄ ວ ຣັ ສ ໂຈ ມ ຕີ ພ ຽງ ແຕ່ ເສັ້ ນ ປ ະ ສ າດ ທ ີ່ ຄວ ບ ຄຸມ ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ຮ່ າງ ກ າຍ (1 9, 2 0) . ໜ ຶ່ງ ໃ ນ 2 00 ຄ ົນ ທີ່ ເປ ັນ ໂປ ລີ ໂ ອ ຈະ ພັ ດ ທ ະ ນ າ ບ າງ ຮູບ ແບ ບ ຂອ ງ ກ້ າມ ເນື້ ອ ເປ ້ຍ ຫ ຼ່ອ ຍ ຖ າວ ອ ນ ທ ີ່ ເປ ັນ ຜົນ ຕາ ມ ມາ (1 8) . ໂດ ຍ ປົກ ກ ະ ຕິ ແລ ້ວ ໂ ປ ລີ ໂ ອ ເກີ ດ ກັບ ເດ ັກ ນ້ ອ ຍ ອ າຍຸ ຕໍ່າ ກວ່ າ ຫ ້າ ປ ີ (1 8) . ຈ ໍານ ວ ນ ປະ ເທ ດ ທ ີ່ ຖືກ ຜົ ນ ກະ ທົ ບ ຈາ ກ ໂປ ລີ ໂ ອ ໄດ້ ຫ ຼຸດ ຈ ໍາ ນ ວ ນ ລົງ ຢ່າ ງ ຫ ຼວ ງຫຼ າຍ ໃນ ຊຸມ ທ ົດ ສະ ວັດ ທ ີ່ ຜ່າ ນ ມາ (1 8) . ï ກ ານ ສູນ ເສ ຍ ກາ ນ ເຄ ື່ອ ນ ໄຫ ວ ໃນ ກ້າ ມ ເນື້ ອ ທ ີ່ ຖືກ ຜົ ນ ກະ ທົ ບ (ອ ໍາມ ະ ພ າດ ) – ໂ ດ ຍ ປົກ ກ ະ ຕິ ແມ ່ນ ຂ າ ທ ັງ ສ ອ ງ ເ ບ ື້ອ ງ (1 9) ; ï ຂ າ ຈ ່ອ ຍ ຜ ອ ມ ແ ລ ະ ໂ ດ ຍ ບໍລ ິ ເວ ນ ກົ້ນ ເ ນື່ ອ ງ ຈ າກ ກ້ າມ ເນື້ ອ ທ ີ່ ຈ່ອ ຍ ລົງ ; ï ທ ່າ ຄ ົງ ທ ີ່ ທ ີ່ ບໍ່ ແ ມ ່ນ ທ ່າປົ ກ ກ ະ ຕິ ຢູ່ ບ ໍລ ິ ເວ ນ ຂໍ້ ຕີ ນ , ຫ ົວ ເຂ ົ່າ ແລ ະ ສ ະ ໂພ ກ (1 9) ; ï ກ້ າມ ເນື້ ອ ບໍລ ິ ເວ ນ ລໍາ ຕົວ ອ່ອ ນ ແຮ ງ (1 9) . ໃ ນ ກໍ ລ ະ ນີ ນີ້, ກ ະ ດູ ກ ສັນ ຫຼັ ງກົ່ ງຄົ ງ ທ ີ່ ຕາ ຍ ຕົວ ອ າດ ຈ ະ ເກີ ດ ຂຶ້ນ – ລ ວ ມ ທ ັງພ າວ ະ ກະ ດູ ກ ສັນ ຫຼັ ງຂົ ດ ໄປ ດ້າ ນ ຂ້າ ງ, ບ ໍລ ິ ເວ ນ ຊ່ວ ງ ອ ົກ ກົ່ງ ເພີ່ ມ ຂຶ້ ນ (ຫ ຼັງກົ່ ງ) , ສ່ ວ ນ ກົ ກ ແອ ວ ອ່ຽ ງ ໄ ປ ທ າງ ໜ ້າ ແລ ະ ຫ ຼັງຂົ ດ ຫ ຼາຍ ຂຶ້ ນ (ຫ ຼັງ ແ ອ ່ນ ) ( 19 ) ; ï ມີ ກາ ນ ພັ ດ ທ ະ ນ າ ແ ຂ ນ ທ ີ່ ແຂ ງ ແ ຮ ງ ເ ພື່ ອ ຊົດ ເຊ ີຍ ຄ ວ າມ ອ່ອ ນ ແຮ ງ ໃ ນ ຂ າ ຂ ອ ງ ເ ຂ ົາ ເ ຈ ົ້າ. ï ຄ ົ ນທີ່ ເປ ັນ ໂ ປ ລີ ໂ ອ ມັກ ຈະ ຊອ ກ ພົ ບ ວິທ ີ ເຄ ື່ອ ນ ໄຫ ວ ຮ່ າງ ກ າຍ ແ ລ ະ ດ ໍາ ເ ນີ ນ ກິດ ຈ ະ ກໍ າ ຕ່ າງ ໆ ເ ຖ ິງ ແ ມ ່ນ ຈະ ເປ ັນ ເປ ້ຍ ຫ ຼ່ອ ຍ ແ ລ ະ ມີ ບ ັນ ຫ າ ດ ້ານ ທ ່າ ທ າງ ທ ີ່ ພ ວ ກ ເຂ ົາ ອ າດ ຈະ ມີ. ï ສໍ າລັ ບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ – ໃ ຫ ້ ໂອ ້ ລົມ ກັບ ຄົນ ນັ້ນ ກ່ຽ ວ ກັບ ກ ານ ຮອ ງຮັ ບ ທ ່າ ທ າງ ໃດ ທ ີ່ ຜູ້ກ່ ຽວ ຕ້ອ ງກ ານ . ພິ ຈ າລ ະ ນ າ ຜົ ນ ກະ ທົ ບ ຂອ ງ ກ ານ ແກ ້ ໄຂ ທ ່າ ທ າງ ໃຫ ້ ຖ ືກ ຕ້ ອ ງ ຢ ່າງ ລະ ອ ຽດ . ຕົ ວ ຢ ່າງ – ບ າງ ຄົນ ທ ີ່ ເປ ັນ ໂປ ລ ີ ໂອ ນັ່ງ ໂດ ຍ ທ ີ່ ຂ້າ ຈ່າ ງອ ອ ກ ຈາ ກ ກັ ນ ຫ ຼື ຂ າ ໄ ຂ ວ ່ກັ ນ ແ ລ ະ ນີ້ ຊ່ວ ຍ ໃຫ ້ ພ ວ ກ ເຂ ົາ ຊົ ງ ຕົ ວ ໄດ້ . ກ ານ ພ ະ ຍ າຍ າມ ແກ ້ ໄຂ ສິ່ງ ນີ້ ອ າດ ຈະ ໃຫ ້ ເຮ ັດ ກາ ນ ຊົງ ຕົ ວ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ຂີ້ ຮ້ າຍ ລົງ – ສ ະ ນັ້ນ ເ ຮ ັດ ໃຫ ້ ພ ວ ກ ເຂົ າ ເ ພິ່ ງ ຕົ ນ ເອ ງ ໄ ດ້ ໜ ້ອ ຍ ລົງ . ï ເພ າະ ວ່ າ ຄ ົນ ເປ ັນ ໂປ ລີ ໂ ອ ຫ ຼາຍ ໆ ຄົນ ມີ ແ ຂ ນ ທ ີ່ ແຂ ງ ແ ຮ ງ: – ຮັ ບ ປ ະ ກັ ນ ວ່າ ລົດ ເຂ ັນ ຖືກ ຕິດ ຕັ້ງ ເພື່ ອ ເຮ ັດ ໃຫ ້ ມີ ທ ່າ ກ ານ ຂັບ ເຄ ື່ອ ນ ລົດ ເຂ ັນ ທ ີ່ ມີ ປ ະ ສິ ດ ທ ິພ າບ ; – ພິ ຈ າລ ະ ນ າ ແ ນ ະ ນໍ າ ລ ົດ ເຂ ັນ ແບ ບ ສ າມ ລໍ້ (ບ ່ອ ນ ທ ີ່ ມີ ໃ ຫ ້) ເ ພ າະ ວ່ າ ນີ້ ແມ ່ນ ທ າງ ເລ ືອ ກ ກາ ນ ເຄ ື່ອ ນ ໄຫ ວ ໄປ ມ າ ທ ີ່ ດີ ສໍ າລັ ບ ໄລ ຍ ະ ທ າງ ໄກ . ï ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ທ ີ່ ເປ ັນ ໂປ ລີ ໂ ອ ມີ ລ ໍາ ຕົ ວ ທ ີ່ ສັ້ນ – ໃ ຫ ້ ພິ ຈ າລ ະ ນ າ ເ ພີ່ ມ ຄວ າມ ສູງ ຂອ ງ ເ ບ າະ ຮ ອ ງ ນັ່ ງ ເ ພື່ ອ ວ າງ ພ ວ ກ ເຂ ົາ ໃ ນ ຕໍາ ແ ໜ ່ງທີ່ ມີ ປ ະ ສິ ດ ທ ິພ າບ ກວ່ າ ສໍ າລັ ບ ກາ ນ ຍູ້ ລ ົດ ເຂ ັນ . ສໍ າລັ ບ ຂໍ້ ມູ ນ ເພີ່ ມ ເ ຕີ ມ ກ່ ຽວ ກັບ : ï ກາ ນ ຕິດ ຕັ້ງ ລົດ ເຂ ັນ ສໍາ ລັ ບ ກາ ນ ຍູ້ ດ ້ວ ຍ ແຂ ນ – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບ ໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . 18 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 01 2) . ພ ະ ຍ າດ ໂປ ລີ ໂ ອ ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m ed ia ce nt re /fa ct sh ee ts /fs 11 4/ en / 19 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (1 99 3) . ກ ານ ຜ່ າຕັ ດ ເພື່ ອ ຟື້ ນ ຟູ ຈ າກ ຮ່ າງ ກ າຍ ຜິດ ຮູ ບ ຮ ່າງ ເ ນື່ ອ ງ ຈ າກ ພ ະ ຍ າດ ໂປ ລິໂ ອ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/p ub lic at io ns /1 99 3/ 92 41 54 45 70 .p df 20 ໂ ຄ ງກ ານ ກວ ດ ລ້າ ງ ໂ ປ ລີ ໂ ອ ທ ົ່ວ ໂລ ກ . ( n. d. ). ໂປ ລີ ໂ ອ ແ ລ ະ ກ າ ນ ປ້ ອ ງ ກັ ນ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .p ol io er ad ic at io n. or g/ Po lio an dp re ve nt io n. as px 28 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ກະດູ ກ ສັ ນຫຼ ັງ ໂຫວ່ ກ ະ ດູ ກ ສັນ ຫຼັ ງ ໂ ຫ ວ ່ ເກີ ດ ຂຶ້ນ ກ່ອ ນ ກໍາ ເນີ ດ (2 1, 2 2) . ກ ະ ດູ ກ ສັນ ຫຼັ ງບໍ່ ປ ິດ ແຈ ບ ຢູ່ ບ ໍລ ິ ເວ ນ ເສັ້ ນ ປະ ສ າດ ໄຂ ສັ ນ ຫຼັ ງ ເຊ ິ່ງປ ະ ໃຫ ້ ພ ວ ກ ມັນ ບໍ່ ໄ ດ້ ຮັບ ກາ ນ ປ ົກ ປ້ອ ງ (2 1, 2 2) . ຜົ ນ ຕ າມ ມາ , ບ າງ ສ່ວ ນ ຂ ອ ງ ໄ ຂ ສັນ ຫຼັ ງ ເຊ ິ່ງຢູ່ ກ້ ອ ງ ກ ະ ດູ ກ ເຫ ຼົ່ານີ້ ອ າດ ຈະ ພັ ດ ທ ະ ນ າ ຢ່າ ງບໍ່ ຖ ືກ ຕ້ ອ ງ ຫ ຼື ໄ ດ້ ຮັບ ຄວ າມ ເສ ຍ ຫ າຍ (2 1) . ຄ ວ າມ ເສ ຍ ຫ າຍ ຕໍ່ ກັ ບ ໄ ຂ ສັ ນ ຫຼັ ງອ າດ ຈະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກາ ນ ຄວ ບ ຄຸມ ກາ ນ ຖ່າ ຍ ເບ ົາ ແລ ະ ກ ານ ຖ່ າຍ ໝັ ກ (2 1, 1 8, 1 9) . ກ ະ ດູ ກ ສັນ ຫຼັ ງ ໂ ຫ ວ ່ສ າມ າດ ມີ ຜົ ນ ກະ ທົ ບ ຕໍ່ ຄ ົນ ເຮ ົາ ຢ ່າງ ແ ຕ ກ ຕ່ າງ ກັນ ໂ ດ ຍ ຂຶ້ນ ກັບ ຂະ ໜ າດ ຂ ອ ງ ບ ໍລ ິ ເວ ນ ທ ີ່ ຖືກ ກະ ທົ ບ ແ ລ ະ ລ ະ ດ ັບ ຄວ າມ ເສ ຍ ຫ າຍ ຂອ ງ ເ ສັ້ ນ ປ ະ ສ າດ (2 1) . ï ຄ ວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ເຄ ື່ອ ນ ເໜ ັງ ຮ່ າ ງ ກ າຍ ຈະ ຂຶ້ ນ ກັບ ບ່ອ ນ ທ ີ່ ກະ ດູ ກ ສັນ ຫຼັ ງ ໂ ຫ ວ ່ຕັ້ ງ ຢ ູ່ ເທ ິງ ກ ະ ດູ ກ ສັນ ຫຼັ ງ ແລ ະ ເ ສັ້ ນ ປ ະ ສ າດ ແ ລ ະ ໄຂ ສັ ນ ຫຼັ ງມີ ຄວ າມ ເສ ຍ ຫ າຍ ຫ ຼາຍ ປ ານ ໃດ (2 1) ; ï ຄ ວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ຄວ ບ ຄຸມ ຂີ້ ຍ ່ຽວ (2 1) ; ï ສ າມ າດ ຍ່າ ງ ໄ ດ້ ໄລ ຍ ະ ທ າງ ສັ້ນ ໆ ໂດ ຍ ກາ ນ ໃຊ ້ ອ ຸປ ະ ກ ອ ນ ຊ່ວ ຍ ເຄ ື່ອ ນ ທ ີ່ (2 1) ; ï ອ າດ ຈະ ມີຮ ອ ຍ ໃຄ ່ ຢູ່ ໃ ນ ລະ ດ ັບ ໄຂ ສັນ ຫຼັ ງ ເຊ ິ່ງ ແ ມ ່ນ ຄວ າມ ເສ ຍ ຫ າຍ ເນື່ ອ ງ ຈ າກ ກະ ດູ ກ ສັນ ຫຼັ ງບໍ່ ພັ ດ ທ ະ ນ າ ຢ ່າງ ຖືກ ຕ້ ອ ງ ( ໂ ດ ຍ ສະ ເພ າະ ຖ ້າ ບ ໍ່ ເຄ ີ ຍມີ ກາ ນຜ່ າຕັ ດ ຊ່ວ ຍ ເຫ ຼືອ ມ າ ກ່ ອ ນ ) ( 21 ) ; ï ກາ ນ ຄວ ບ ຄຸມ ກ້າ ມ ເນື້ ອ ແ ລ ະ ຄ ວ າມ ຮູ້ສຶ ກ ທ ີ່ ຫ ຼຸດ ລ ົງ ເ ຮ ັດ ໃຫ ້ກ ານ ນັ່ງ ຕັ້ງ ຊື່ ຍ າກ ຂຶ້ນ ; ï ອ າດ ຈະ ມີ ຫ ົວ ໃຫ ຍ ່ ກວ່ າ (ພ າວ ະ ນໍ້າ ຄ້າ ງ ໃ ນ ໂພ ງ ສ ະ ໝ ອ ງ) ເ ຊ ິ່ງ ເ ກີ ດ ຈາ ກ ກາ ນສ ະ ສົມ ຂອ ງ ແ ຫ ຼວ (2 1) . ກ ານ ປິ່ນ ປົ ວ ຕົ້ນ ຕໍ ສໍາ ລັ ບ ພ າວ ະ ນໍ້າ ຄ້າ ງ ໃ ນ ໂພ ງ ສ ະ ໝ ອ ງ ແ ມ ່ນ ກາ ນ ຜ່ າຕັ ດ ໃສ່ ëທ ໍ່ ລະ ບ າຍ í ເຊ ິ່ງອ ະ ນຸ ຍ າດ ໃຫ ້ຂ ອ ງ ແ ຫ ຼວ ທ ີ່ ຄ້າ ງ ຢ ູ່ ລະ ບ າຍ ອ ອ ກ – ໂ ດ ຍ ປົກ ກ ະ ຕິ ລ ະ ບ າຍ ສູ່ ທ ້ອ ງ ຂ ອ ງ ເດ ັກ ນ້ ອ ຍ (2 1) . ຖ ້າ ຂ ອ ງ ແ ຫ ຼວ ສ ະ ສົມ ບໍ່ ໄ ດ້ ຮັບ ກາ ນ ປ ິ່ນ ປົ ວ ມັ ນ ສາ ມ າດ ກໍ່ ໃຫ ້ ເກີ ດ ຄວ າມ ເສ ຍ ຫ າຍ ຂ ອ ງ ສ ະ ໝ ອ ງ; ï ມີ ຄວ າມ ສ່ຽ ງ ເ ກີ ດ ແຜ ກົ ດ ທ ັບ ເ ນື່ ອ ງ ຈ າກ ກາ ນ ຂ າດ ຄວ າມ ຮູ້ສຶ ກ ຢູ່ ຕໍ່ າ ກ ວ່ າລ ະ ດັ ບ ກາ ນ ບາ ດ ເຈ ັບ ແ ລ ະ ກ ານ ມີ ຄ ວ າມ ຊຸ່ມ ຖ ້າ ບ ໍ່ ມີ ກ າ ນ ຄ ວ ບ ຄຸມ ກ າ ນ ຍ່ ຽວ ແ ລ ະ ກ ານ ຖ່ າຍ ໝັ ກ ຢ່າ ງ ມີ ປະ ສິ ດ ທ ິ ຜົນ (2 1) . ï ຮັ ບ ປ ະ ກັ ນ ວ່າ ລົດ ເຂ ັນ ຖືກ ຕິດ ຕັ້ງ ເພື່ ອ ເຮ ັດ ໃຫ ້ ສ າມ າດ ຂັບ ເຄ ື່ອ ນ ລົດ ເຂ ັນ ໄ ດ ້ຢ ່າງ ມີ ປ ະ ສິ ດ ທ ິພ າບ . ï ຈ ໍານ ວ ນ ຂອ ງ ແ ນ ວ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ຈະ ຂຶ້ນ ກັບ ລ ະ ດັ ບ ກາ ນ ບາ ດ ເຈ ັບ . ລ ະ ດັ ບ ກາ ນ ເຈ ັບ ຍິ່ງ ສູ ງ ເທ ົ່າ ໃດ ກໍ່ ຕ້ອ ງກ ານ ແນ ວ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ຫ ຼາຍ ເທ ົ່າ ນັ້ ນ . ï ຖ້າ ຈໍາ ເປ ັນ ຕ້ອ ງ ໃ ສ່ ອຸປ ະ ກ ອ ນ ພ ະ ຍຸ ງຮ່ າງ ກ າຍ ໃນ ກ າງ ເວ ັນ , ຮ້ ອ ງ ຂໍ ໃຫ ້ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ໃສ່ ອຸປ ະ ກ ອ ນ ພ ະ ຍຸ ງກ ຮ່ າງ ກ າຍ ໃນ ລະ ຫ ວ ່າງ ກາ ນ ປະ ເມີ ນ ລົດ ເຂ ັນ . ï ຖ ້າ ມີ ຮອ ຍ ໃຄ ່, ຫ ຼີກ ເວ ັ້ນ ກ ານ ກົ ດ ທ ັບ ໃສ່ ບໍລ ິ ເວ ນ ນັ້ນ . ນີ້ ອາ ດ ຈະ ຈໍາ ເ ປ ັນ ຕ້ອ ງ ປ ັບ ຮູບ ຮ່າ ງ ແ ນ ວ ອີງ ຫ ຼັງ ຫ ຼື ປ ັບ ເບ າະ ຫ ຸ້ມ ແນ ວ ອີງ ຫ ຼັງ ເ ພື່ ອ ຮອ ງ ຮັ ບ ຮອ ຍ ໃຄ ່ ນັ້ນ . ï ກ ານ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງ ຮັ ບ ທ ່າ ທ າງ ທ ີ່ ດີ ທ ີ່ ສະ ໜ ອ ງ ໃ ຫ ້ ໄວ ແຕ່ ຕົ້ນ ໆ ສ າມ າດ ຊ່ ວ ຍ ປ້ ອ ງ ກັ ນ ບັ ນ ຫ າ ເ ລື່ ອ ງທ່ າ ທ າງ ໄດ້ (2 0) . ສິ່ ງ ນີ້ ສໍາ ຄັນ ໂດ ຍ ສະ ເພ າະ ໃນ ເວ ລ າ ຈ ະ ເລ ີ ນ ເ ຕີ ບ ໂຕ . ï ຖ ້າ ເ ດ ັກ ນ້ ອ ຍ ມີ ëທ ໍ່ ລະ ບ າຍ í, ໃຫ ້ ລະ ມັ ດ ລ ະ ວ ັງ ຕໍ າ ແ ໜ ່ ງຂ ອ ງ ມັ ນ ຖ ້າ ໃ ຫ ້ ແນ ວ ປະ ຄ ອ ງ ຫ ົວ . ï ຖ ້າ ເ ດ ັກ ນ້ ອ ຍ ມີພ າວ ະ ນໍ້າ ຄ້າ ງ ໃ ນ ໂພ ງ ສ ະ ໝ ອ ງ ເຊ ິ່ງບໍ່ ໄດ້ ຮັບ ກາ ນ ປິ່ນ ປົ ວ , ໃ ຫ ້ ນໍາ ສົ່ງ ເດ ັ ກນັ້ ນ ຫ າ ທ ່ານ ໝໍ . ສໍາ ລັ ບ ຂໍ້ ມູ ນ ກ່ຽ ວ ກັບ : ï ກາ ນ ຕິດ ຕັ້ງ ລົດ ເຂ ັນ ສໍາ ລັ ບ ກາ ນ ຍູ້ ດ ້ວ ຍ ແຂ ນ – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບ ໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . ï ສາ ມ າດ ປ້ອ ງ ກັ ນ ແຜ ກົ ດ ທ ັບ ໄດ້ ແນ ວ ໃດ ? – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . 21 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (1 99 6) . ສົ່ ງ ເ ສີ ມ ພັ ດ ທ ະ ນ າ ກ ານ ຂອ ງ ເ ດ ັກ ເກີ ດ ໃໝ່ ແ ລ ະ ເ ດ ັກ ນ້ ອ ຍ ທ ີ່ມີ ກະ ດູ ກ ສັນ ຫຼັ ງ ໂ ຫ ວ ່ ແ ລ ະ ພ າວ ະ ນໍ້າ ຄ້ າ ໃ ນ ໂພ ງ ສ ະ ໝ ອ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/ hq /1 99 6/ W H O _R H B_ 96 .5 .p df 22 M al on e, P ., W he el er , R ., & W illi am s, J . ( 19 94 ). ກ ານ ຄວ ບ ຄຸມ ຂີ້ ຍ ່ຽວ ໃນ ຜູ້ ປ່ວ ຍ ທ ີ່ ກະ ດູ ກ ສັນ ຫຼັ ງ ໂ ຫ ວ ່: ຜົ ນ ຮັບ ໄລ ຍ ະ ຍາ ວ . ແ ຟ້ ມ ຂໍ້ ມູນ ພ ະ ຍ າດ ໃນ ໄວ ເດ ັກ , 7 0, 1 07 –1 10 . 23 M cD on ne ll, G . V ., M cC an n, J . P . ( 20 00 ). ບ ັນ ຫ າ ກ່ ຽວ ກັບ ກາ ນ ຄຸ້ມ ຄອ ງ ກ ານ ແພ ດ ໃນ ຜູ້ ໃ ຫ ຍ ່ ທ ີ່ ມີກ ະ ດູ ກ ສັນ ຫຼັ ງ ໂ ຫ ວ ່. ລ ະ ບ ົບ ປະ ສ າດ ຂອ ງ ເ ດ ັກ , 1 6, 2 22 –2 27 . 24 ແ ຄ ັມ ເປ ນ ໂ ຄ ສ ະ ນ າ ຕ້ ານ ພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມ. (2 01 1) . ກ ານ ສະ ໜ ອ ງ ລ ົດ ເຂ ັນ ໃຫ ້ ເດ ັກ ນ້ ອ ຍ ແ ລ ະ ຜູ້ ໃຫ ຍ ່ ທ ີ່ ເປ ັນ ພ ະ ຍ າດ ກ້າ ມ ເນື້ ອ ເສື່ ອ ມ ແລ ະ ໂ ຣ ກ ກ້າ ມ ເນື້ ອ ຮ່ວ ມ ປະ ສ າດ ອື່ນ : ຂໍ້ ແນ ະ ນໍ າ ກ່ ຽວ ກັບ ວິທ ີ ປ ະ ຕິ ບ ັດ ທ ີ່ ດີ ສຸ ດ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .m us cu la r- dy st ro ph y. or g/ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 29 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ການ ບາດ ເຈັບ ໄຂ ສັ ນຫຼ ັງ ກ ານ ບາ ດ ເຈ ັບ ໄຂ ສັນ ຫຼັ ງ (S C I) ແມ ່ນ ຄ ວ າມ ເສ ຍ ຫ າຍ ຕໍ່ກັ ບ ໄຂ ສັ ນ ຫຼັ ງທີ່ ສົ່ງ ຜົນ ໃຫ ້ ກາ ເຄ ື່ອ ນ ໄຫ ວ ຮ່າ ງກ າຍ ແ ລ ະ /ຫ ຼື ຄ ວ າມ ຮູ້ສຶ ກ ຫ ຼຸດ ລ ົງ ຕໍ່ າ ກ ວ່ າ ລ ະ ດ ັບ ກ ານ ບາ ດ ເຈ ັບ (2 5) . ໄ ຂ ສັ ນ ຫຼັ ງຍັ ງ ເ ຮ ັດ ໜ ້າ ທ ີ່ຄ ວ ບ ຄຸມ ກ ານ ຖ່ າຍ ເບ ົາ ແລ ະ ກ ານ ຖ່ າຍ ໝັ ກ ສ ະ ນັ້ນ ສິ່ ງ ເ ຫ ຼົ່ານີ້ ອາ ດ ຈະ ຖືກ ກະ ທົ ບ ຫ ຼັງຈ າກ ກາ ນ ບາ ດ ເ ຈ ັບ (2 6) . ກ ານ ບາ ດ ເຈ ັບ S C I ອ າດ ຈະ ເກີ ດ ຈາ ກ ອຸປ ະ ຕິ ເຫ ດ , ຄ ວ າມ ຮຸນ ແຮ ງ, ພ ະ ຍ າດ ຫ ຼື ກ ານ ຕິດ ເຊ ື້ອ (2 6) . ຜົ ນ ກ ະ ທົ ບ ຂອ ງ ກ ານ ບາ ດ ເຈ ັບ ໄຂ ສັນ ຫຼັ ງ ແ ມ ່ນ ຂຶ້ນ ກັບ ປ ະ ເພ ດ ແ ລ ະ ລ ະ ດ ັບ ຂອ ງ ກ ານ ບາ ດ ເຈ ັບ (2 6) . ປ ະ ເ ພ ດ : ກ ານ ບາ ດ ເຈ ັບ ສົມ ບູ ນ ແມ ່ນ ເມື່ ອ ບຸກ ຄົ ນ ບໍ່ ມີ ຄ ວ າມ ຮູ້ສຶ ກ ຫ ຼື ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ໂດ ຍ ຕັ້ງ ໃຈ ຢູ່ ລ ຸ່ມ ສ່ ວ ນ ທ ີ່ ເສ ຍ ຫ າຍ ຂອ ງ ໄ ຂ ສັນ ຫຼັ ງ (2 6) . ກ ານ ບາ ດ ເຈ ັບ ບໍ່ ສົ ມ ບູ ນ ແມ ່ນ ເມື່ ອ ບຸກ ຄົ ນ ມີ ບ າງ ຄວ າມ ຮູ້ສຶ ກ ຫ ຼື ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ໂດ ຍ ຕັ້ງ ໃຈ ຢູ່ ລ ຸ່ມ ສ່ວ ນ ທ ີ່ ເສ ຍ ຫ າຍ ຂອ ງ ໄ ຂ ສັ ນ ຫຼັ ງ (2 6) . ລ ະດັ ບ : ລ ະ ດ ັບ ຂອ ງ ກ ານ ບາ ດ ເຈ ັບ ໄຂ ສັນ ຫຼັ ງສ າມ າດ ອ ະ ທ ິບ າຍ ເປ ັນ ອໍາ ມ ະ ພ າດ ແຂ ນຂ າ ສ ອ ງ ຂ້ າງ / ອ ໍາມ ະ ພ າດ ສີ່ ຂ າ, ອ ໍາມ ະ ພ າດ ເຄ ິ່ງ ລ ຸ່ມ ລ ະ ດັ ບ ສູງ , ອ ໍາມ ະ ພ າດ ເຄ ິ່ງລຸ່ ມ ລະ ດ ັບ ຕໍ່າ (2 6) . ອ ໍາມ ະ ພ າດ ແຂ ນ ຂ າ ສ ອ ງ ຂ້ າງ /ອ ໍາມ ະ ພ າດ ສີ່ ຂ າ ເ ກີ ດ ຂຶ້ນ ຢູ່ ຄ ໍ, ແ ລ ະ ກ ະ ທົ ບ ກັບ ແຂ ນ , ລ ໍາ ຕົ ວ , ກົ ກ ແອ ວ ແ ລ ະ ຂ າ (2 6) . ອ ໍາມ ະ ພ າດ ເຄ ິ່ງລຸ່ ມ ລະ ດ ັບ ສູງ ເກີ ດ ຂຶ້ນ ຢູ່ ຫ ຼັງສ່ ວ ນ ເທ ິງ, ແ ລ ະ ກ ະ ທົ ບ ກັບ ລໍາ ຕົວ , ກົ ກ ແອ ວ ແ ລ ະ ຂ າ (2 6, 2 7) . ແ ຂ ນ ບໍ່ ໄ ດ້ ຮັບ ຜົນ ກະ ທົ ບ . ອ ໍາມ ະ ພ າດ ເຄ ິ່ງລຸ່ ມ ລະ ດ ັບ ຕໍ່ າ ເ ກີ ດ ຂຶ້ນ ຢູ່ ຫ ຼັງສ່ ວ ນ ລ ຸ່ມ , ແ ລ ະ ກ ະ ທົ ບ ກັບ ຂາ (2 6) . ກົ ກ ແອ ວ ອາ ດ ຈະ ໄດ້ ຮັບ ຜົນ ກະ ທົ ບ ເຊ ັ່ນ ກັນ (2 2) . ï ສູນ ເສ ຍ ກາ ນ ເຄ ື່ອ ນ ໄຫ ວ ຮ່າ ງກ າຍ ແ ລ ະ ຄ ວ າມ ຮູ້ ສຶ ກ ທ ັງ ໝົ ດ ຖ ້າ ແ ມ ່ນ ກ ານ ບາ ດ ເຈ ັບ ສົມ ບູ ນ ຫ ຼື ສູ ນ ເສ ຍ ກາ ນ ເຄ ື່ອ ນ ໄຫ ວ ຮ່າ ງກ າຍ ແ ລ ະ ຄ ວ າມ ຮູ້ ສຶ ກ ບາ ງ ສ່ ວ ນ ຖ ້າ ແ ມ ່ນ ກາ ນ ບາ ດ ເຈ ັບ ບ ໍ່ ສົມ ບູ ນ (2 6) ; ï ເດ ັກ ນ້ ອ ຍ ແ ລ ະ ຜູ້ ໃຫ ຍ ່ ທ ີ່ ເປ ັນ ອໍາ ມ ະ ພ າດ ແຂ ນ ຂ າ ສ ອ ງ ຂ້ າງ /ອ ໍາມ ະ ພ າດ ສີ່ ຂ າ ແລ ະ ອ ໍາມ ະ ພ າດ ເຄ ິ່ງລຸ່ ມ ລະ ດ ັບ ສູງ ຈ ະ ມີ ກ ານ ຊົງ ຕົວ ທ ີ່ ບໍ່ ດ ີ ເ ນື່ ອ ງຈ າກ ກາ ນ ສູນ ເສ ຍ ກາ ນ ຄວ ບ ຄຸມ ກ້ າມ ເນື້ ອ ເຄ ື່ອ ນ ໄຫ ວ ແ ລ ະ ຄ ວ າມ ຮູ້ສຶ ກ ບໍລ ິ ເວ ນ ລ ໍາ ຕົ ວ . ນີ້ ເຮ ັດ ໃຫ ້ກ ານ ນັ່ງ ຕັ້ງ ຊື່ ຍ າກ ຂຶ້ນ ແ ລ ະ ບ ັນ ຫ າ ທ ່າ ທ າງ ໃນ ໄລ ຍ ະ ຍາ ວ ສາ ມ າດ ເກີ ດ ຂຶ້ນ ໄດ້ ໄວ ຖ ້າ ບ ໍ່ ມີ ກ ານ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງ ຮັ ບ ທ ີ່ ຖືກ ຕ້ ອ ງ ຈ າກ ລົດ ເຂ ັນ ; ï ຄ ວ າມ ລາໍ ບ າກ ທ ີ ່ເປ ນັ ໄປ ໄດ້ ໃນ ກາ ນ ຄວ ບ ຄມຸ ກາ ນ ຂີ້ ຍ່ຽ ວ (2 6) ; ï ກ້ າມ ເນື້ ອ ກະ ຕຸ ກ ທ ີ່ ເປ ັນ ໄປ ໄດ້ /ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ທ ີ່ ຄ ວ ບ ຄຸມ ບໍ່ ໄດ້ ຂ ອ ງ ຂ າ ສ່ ວ ນ ລຸ່ມ (2 6) ; ï ເດ ັກ ນ້ ອ ຍ ແ ລ ະ ຜູ້ ໃຫ ຍ ່ ທ ີ່ ມີ SC I ມີ ຄວ າມ ສ່ຽ ງ ເກີ ດ ແຜ ກົ ດ ທ ັບ ເ ນື່ ອ ງ ຈ າກ : – ບ ໍ່ ມີ ຄ ວ າມ ຮູ້ສຶ ກ ຕໍ່າ ກວ່ າ ລ ະ ດ ັບ ກາ ນ ບາ ດ ເຈ ັບ (2 6) ; – ມີ ຄວ າມ ຊຸ່ມ ຖ້າ ບໍ່ ມີ ກາ ນ ຄຸ້ມ ຄອ ງ ກ ານ ຖ່າ ຍ ໝັ ກ ແ ລ ະ ກ ານ ຖ່າ ຍ ເບ ົາ ຢ ່າງ ມີ ປ ະ ສິ ດ ທ ິ ຜົນ . ï ກໍາ ນົ ດ ໃຊ ້ ເບ າະ ຮອ ງ ນັ່ ງ ທ ີ່ ຫ ຼຸດ ຜ່ ອ ນ ກາ ນ ກົ ດ ທ ັບ ສະ ເໝີ ເ ພື່ ອ ຊ່ວ ຍ ປ້ອ ງ ກັ ນ ແຜ ກົ ດ ທ ັບ . ï ຈ ໍານ ວ ນ ແນ ວ ປະ ຄອ ງ ຫ ຼືຮ ອ ງຮັ ບ ທ ີ່ ຈໍາ ເປ ັນ ສໍ າລັ ບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ທ ີ່ ມີ SC I ຈ ະ ຂຶ້ນ ກັບ ລ ະ ດ ັບ ກາ ນ ບາ ດ ເຈ ັບ . ລ ະ ດັ ບ ກາ ນ ເຈ ັບ ຍິ່ງ ສູ ງ ເ ທ ົ່າ ໃ ດ ກໍ່ ຕ້ອ ງກ ານ ແນ ວ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ຫ ຼາຍ ເທ ົ່າ ນັ້ ນ . ( 27 ) . ï ໃນ ໄລ ຍ ະ ຕົ້ນ ໆ ຫ ຼັງຈ າກ ກາ ນ ບາ ດ ເຈ ັບ , ກ ານ ຮ ອ ງ ຮັ ບ ເພີ່ ມ ເຕີ ມ ສໍາ ລັ ບ ລໍາ ຕົວ ແ ລ ະ ແ ຂ ນ ອ າດ ຈະ ຈໍາ ເປ ັນ – ໂ ດ ຍ ສະ ເພ າະ ສໍ າລັ ບ ກາ ນ ບ າດ ເຈ ັບ ລະ ດັ ບ ສູງ . ï ຜູ້ ເປ ັນ ອໍາ ມ ະ ພ າດ ເຄ ິ່ງລຸ່ ມ ສ່ວ ນ ໃຫ ຍ ່ ແ ລ ະ ຜູ້ ເປ ັນ ອໍາ ມ ະ ພ າດ ແຂ ນ ຂາ ສອ ງ ຂ້ າງ ບາ ງ ຄ ົນ ສ າມ າດ ຂັ ບ ເຄ ື່ອ ນ ລົດ ເຂ ັນ ໄດ້ ດ້ວ ຍ ຕົນ ເອ ງ ຢ ່າງ ມີ ປ ະ ສິ ດ ທ ິ ຜົນ (2 6) . ຮັ ບ ປ ະ ກັ ນ ວ່າ ລົດ ເຂ ັນ ຖືກ ຕິດ ຕັ້ງ ເພື່ ອ ໃຫ ້ ມີ ທ ່າ ກ ານ ຂັບ ເຄ ື່ອ ນ ລ ົດ ເຂ ັນ ໄ ດ ້ຢ ່າງ ມີ ປ ະ ສິ ດ ທ ິພ າບ . ສໍາ ລັ ບ ຂໍ້ ມູ ນ ກ່ຽ ວ ກັບ : ï ກາ ນ ຕິດ ຕັ້ງ ລົດ ເຂ ັນ ສໍາ ລັ ບ ກາ ນ ຍູ້ ດ ້ວ ຍ ແຂ ນ – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບ ໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . ï ສາ ມ າດ ປ້ອ ງ ກັ ນ ແຜ ກົ ດ ທ ັບ ໄດ້ ແນ ວ ໃດ ? – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບ ໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . 25 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (1 99 6) . ກ ານ ສົ່ງ ເສີ ມ ກາ ນ ເພິ່ ງ ຕົ ນ ເອ ງຫ ຼັງຈ າກ ກາ ນ ບາ ດ ເຈ ັບ ໄຂ ສັນ ຫຼັ ງ: ປ ື້ ມ ຄ ູ່ ມືສໍ າລັ ບ ພ ະ ນັ ກ ງາ ນ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ລະ ດ ັບ ປາ ນ ກາ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/ hq /1 99 6/ W H O _R H B_ 96 .4 .p df 26 B ro m le y, I. (2 00 6) . ອ ໍາມ ະ ພ າດ ແຂ ນ ຂາ ສອ ງ ຂ້ າງ ແ ລ ະ ອ ໍາມ ະ ພ າດ ຮ່າ ງ ກ າຍ ສ່ວ ນ ລ ຸ່ມ : ຄ ູ່ ມື ແ ນ ະ ນໍ າ ສໍ າລັ ບ ນັ ກ ກາ ຍະ ພ າບ ບໍາ ບັ ດ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// xa .y im g. co m /k q/ gr ou ps /1 67 49 86 7/ 21 44 24 41 49 /n am e/ Te tra pl eg ia +a nd +P ar ap le gi a. pd f 30 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ອໍາມະພາດ ອ ໍາມ ະ ພ າດ ແມ ່ນ ກາ ນ ບ າດ ເຈ ັບ ສະ ໝ ອ ງ ປ ະ ເພ ດ ໜ ຶ່ງ ທ ີ່ ເກີ ດ ຈາ ກ ກ ານ ບໍ່ ສ າມ າດ ລໍາ ລ ຽງ ເລ ືອ ດ ໄປ ລ້ຽ ງ ສ ະ ໝ ອ ງ ໄດ້ (2 7, 2 8, 2 9, 3 0, 3 1) . ຄ ວ າມ ເສ ຍ ຫ າຍ ຫ ຼື ພ ະ ຍ າດ ສາ ມ າດ ເຮ ັດ ໃຫ ້ ເສັ້ ນ ເລ ືອ ດ ອຸດ ຕັນ ຫ ຼື ແ ຕ ກ ໄດ້ ເ ຊ ິ່ງ ເ ຮ ັດ ໃຫ ້ ສ່ວ ນ ນັ້ນ ຂອ ງ ສ ະ ໝ ອ ງ ເ ສ ຍ ຫ າຍ ຫ ຼື ຕ າຍ (2 8, 2 9, 3 0, 3 1, 3 2) . ຮູບ ແບ ບ ທ ີ່ ອໍາ ມ ະ ພ າດ ມີ ຜົນ ກະ ທົ ບ ຕໍ່ ກັ ບ ແ ຕ່ ລ ະ ຄ ົນ ແມ ່ນ ແຕ ກ ຕ່າ ງ ກັ ນ ເ ຊ ິ່ງຂຶ້ ນ ກັບ ບໍລ ິ ເວ ນ ຂອ ງ ສ ະ ໝ ອ ງ ທ ີ່ ຖືກ ກະ ທົ ບ ແ ລ ະ ມັ ນ ຖືກ ກ ະ ທົ ບ ຮ ້າຍ ແຮ ງ ສໍ່ າ ໃ ດ (2 9, 3 1) – ແ ນ ວ ໃດ ກໍ ຕ າມ ສ່ ວ ນ ຫ ຼາຍ ແລ ້ວ ພ ຽງ ແຕ່ ເຄ ິ່ງສ່ ວ ນ ຂອ ງ ຮ່ າ ງ ກ າຍ ໄດ້ ຮັບ ຜົນ ກະ ທົ ບ (ອ ໍາມ ະ ພ າດ ເຄ ິ່ງຝ່ າຍ ) ( 28 , 3 1, 28 ) . ï ອ ່ອ ນ ແຮ ງ, ຄ ວ ບ ຄຸມ ກ້າ ມ ເນື້ ອ ໄດ້ ໜ ້ອ ຍ ລົງ ແ ລ ະ ບ າງ ຄັ້ງ ເ ຈ ັບ ປວ ດ ຮ ່າງ ກ າຍ ຂ້າ ງ ທ ີ່ ຖືກ ກະ ທົ ບ (ມີ ຜົນ ກ ະ ທົ ບ ຕໍ່ ກັ ບ ແຂ ນ , ລ ໍາ ຕົ ວ ແ ລ ະ ຂ າ) (2 8) ; ï ຄ ວ າມ ຮູ້ສຶ ກ ຫ ຼຸດ ລ ົງ ຫ ຼື ປ ່ຽນ ແປ ງ ຢ ູ່ ຂ້າ ງ ຮ່ າງ ກ າຍ ທີ່ ຖືກ ກ ະ ທົ ບ (2 8) ; ï ອ າດ ຈະ ບໍ່ ຮູ້ ສຶ ກ ຂ້າ ງຮ່ າງ ກ າຍ ທ ີ່ ຖືກ ກະ ທົ ບ ແ ລ ະ ສິ່ ງ ນີ້ ອາ ດ ຈະ ນໍາ ໄປ ສູ່ ຄ ວ າມ ສ່ຽ ງ ທ ີ່ ເພີ່ ມ ຂຶ້ນ ຂອ ງ ກ ານ ລົ້ມ ໃນ ລະ ຫ ວ ່າງ ກາ ນ ເຄ ື່ອ ນ ຍ້າ ຍ (2 8) ; ï ອ າດ ຈະ ມີ ຄ ວ າມ ລໍາ ບ າກ ໃນ ກ ານ ນັ່ງ ຕັ້ງ ຊື່ ໂ ດ ຍ ມີ ແ ນ ວ ໂນ້ ມ ເອ ນ ຫ ຼື ອ ່ຽງ ໄປ ຫ າດ້ ານ ຂ້າ ງ ຂ ອ ງ ຮ່ າງ ກ າຍ ທ ີ່ ຖືກ ກະ ທົ ບ (2 8) ; ï ອ າດ ຈະ ສາ ມ າດ ຢືນ ໄດ້ , ແ ລ ະ ຍ ່າງ ໄດ້ ສອ ງ ສ າມ ກ້ າວ (ອ າດ ຈະ ໃຊ ້ ທ ່າ ຍ ່າງ ແຕ ກ ຕ່າ ງ ກັ ນ ) ( 28 ) ; ï ອ າດ ຈະ ມີ ຄ ວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ເວ ົ້າ ແລ ະ ກ ານ ກືນ ເ ຊ ິ່ງ ເ ຮ ັດ ໃຫ ້ກ ານ ກິນ ແ ລ ະ ກ ານ ດື່ມ ຍ າກ ຂຶ້ນ (2 8) ; ï ອ າດ ຈະ ມີ ຄ ວ າມ ລໍາ ບ າກ ໃນ ກາ ນ ຄວ ບ ຄຸມ ກາ ນ ຖ ່າຍ ໝັ ກ ແ ລ ະ ກ ານ ຖ່ າຍ ເບ ົາ (2 8) , ແ ລ ະ ມັ ນ ສ າມ າດ ຫ ຍ ຸ້ງຍ າກ ໃນ ກາ ນ ສາ ມ າດ ໄປ ເຂ ົ້າ ຫ ້ອ ງ ນໍ້ າ ໄ ດ້ ທ ັນ ເວ ລ າ. ï ໃຫ ້ ແນ ວ ປະ ຄ ອ ງຫ ຼືຮ ອ ງ ຮັ ບ ທ ່າ ທ າງ ເພື່ ອ ສົ່ງ ເສີ ມ ກ ານ ຊົງ ຕົວ ແ ລ ະ ທ ່າ ທ າງ ທີ່ ສົມ ສ່ ວ ນ (ທ ັງ ສ ອ ງດ້ ານ ຄື ກັ ນ ). ï ບ່ອ ນ ວາ ງ ຕີ ນ ແບ ບ ພ ິກ ຂຶ້ນ ຫ ຼື ຫ ວ ່ຽງ ໄປ ມ າ ໄ ດ້ ມັກ ຈ ະ ເປ ັນ ປ ະ ໂຫ ຍ ດສໍ າລັ ບ ຜູ້ ໃຊ ້ລ ົດ ເຂ ັນ ທ ີ່ ເປ ັນ ອ ໍາມ ະ ພ າດ ຜູ້ ທ ີ່ ສາ ມ າດ ເຮ ັດ ກາ ນ ເຄ ື່ອ ນ ຍ້າ ຍ ແບ ບ ຢ ືນ ໄດ້ . ï ເພ າະ ວ່ າ ແ ຂ ນ ຂ້າ ງ ໜ ຶ່ງ ມັ ກ ຈະ ຖືກ ກະ ທົ ບ , ຫ ຼາຍ ຄ ົ ນ ເ ປ ັນ ອໍາ ມ ະ ພ າດ ບໍ່ ສ າມ າດ ຍູ້ ລ ົດ ເຂ ັນ ດ້ວ ຍ ແຂ ນ ຂ ອ ງ ເ ຂ ົ າ ເ ຈ ົ້າ ໄ ດ້ . ກ ວ ດ ເບ ິ່ງວ່ າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ສ າມ າດ ຂັບ ເຄ ື່ອ ນ ລົດ ເຂ ັນ ດ້ວ ຍ ແຂ ນ ທ ີ່ ບໍ່ ຖ ືກ ກ ະ ທົ ບ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ແລ ະ ດ ັນ ດ້ວ ຍ ຂາ ທ ີ່ ບໍ່ ຖ ືກ ກ ະ ທົ ບ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ໄ ດ້ ຫ ຼືບ ໍ່. ï ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ມີ ບ ັນ ຫ າ ອ ື່ນ ເ ຊ ິ່ງຍັ ງ ບ ໍ່ ໄດ້ ຮັບ ກາ ນ ແ ກ ້ ໄຂ , ໃ ຫ ້ ນໍາ ສົ່ງ ເຂ ົາ ເ ຈ ົ້າ ຫ າ ຄ ວ າມ ຊ່ວ ຍ ເຫ ຼືອ ເພີ່ ມ ເຕີ ມ ຖ້າ ມີ ໃຫ ້. ສໍ າລັ ບ ຂໍ້ ມູ ນ ເພີ່ ມ ເ ຕີ ມ ກ່ ຽວ ກັບ : ï ກາ ນ ຕິດ ຕັ້ງ ລົດ ເຂ ັນ ສໍາ ລັ ບ ກາ ນ ຂັບ ເຄ ື່ອ ນ ດ້ວ ຍ ຕີນ – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບ ໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . 27 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (1 99 9) . ກ ານ ສົ່ງ ເສີ ມ ກາ ນ ເພິ່ ງ ຕົ ນ ເອ ງ ຫ ຼັງຈ າກ ເປ ັນ ອໍາ ມ ະ ພ າດ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/h q/ 19 99 /W H O _D AR _9 9. 2. pd f 28 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 01 2) . ອ ໍາມ ະ ພ າດ , ພ າວ ະ ຫ ຼອ ດ ເລ ືອ ດ ໃນ ສະ ໝ ອ ງ ແ ຕ ກ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/t op ic s/ ce re br ov as cu la r_ ac ci de nt /e n/ 29 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 00 6) . ຄ ວ າມ ຜິດ ປົກ ກ ະ ຕິ ຂອ ງ ລ ະ ບ ົບ ປະ ສ າດ : ສິ່ ງ ທ ້າ ທ າຍ ດ້າ ນ ສາ ທ າລ ະ ນ ະ ສຸກ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m en ta l_ he al th /n eu ro lo gy /c ha pt er _3 _b _n eu ro _ di so rd er s_ pu bl ic _h _c ha lle ng es .p df 30 C ol lin s, C . ( 20 07 ). ພ ະ ຍ າດ ວິທ ະ ຍ າ ແລ ະ ກ ານ ຈັ ດ ປະ ເພ ດ ອໍາ ມ ະ ພ າດ . ມ າດ ຕ ະ ຖ ານ ກາ ນ ພ ະ ຍ າບ ານ , 2 1( 28 ), 35 –3 9. 31 F riz ze l, J. (2 00 5) . ເ ສັ້ ນ ເລ ືອ ດ ໃນ ສະ ໝ ອ ງ ແ ຕ ກ ກະ ທັ ນ ຫັ ນ : ພ ະ ຍ າດ ວິທ ະ ຍ າ, ກ ານ ບົ່ງ ມ ະ ຕິ ແ ລ ະ ກ ານ ປິ່ນ ປົ ວ . ວ ິທ ີ ປະ ຕິ ບັດ ຂັ້ນ ສູງ ໃນ ກາ ນ ດູ ແ ລ ກະ ທັ ນ ຫັ ນ ແ ລ ະ ກ ານ ດູ ແ ລ ຂ ັ້ນ ວິ ກິ ດ , 1 6( 4) , 42 1– 44 0. 32 H er m an , B ., et a l. (1 98 2) . ລ ະ ບ າດ ວິທ ະ ຍ າ ຂ ອ ງ ອ ໍາມ ະ ພ າດ ເສັ້ ນ ເລ ືອ ດ ໃນ ສ ະ ໝ ອ ງ ແ ຕ ກ ໃນ T ilb ur g, ປ ະ ເທ ດ ເນ ເທ ີ ແລ ນ . ທ ະ ບ ຽນ ອ ັດ ຕ າກ ານ ເກີ ດ ອໍາ ມ ະ ພ າດ ອີ ງ ຕ າມ ປະ ຊ າກ ອ ນ : 2 . ອ ັດ ຕ າ ກ ານ ເກີ ດ , ພ າບ ທ າງ ຄລ ີ ນິກ ເບ ື້ອ ງຕົ້ ນ ແ ລ ະ ກ ານ ດູ ແ ລ ທ າງ ກາ ນ ແພ ດ , ແ ລ ະ ກໍ ລ ະ ນີ ກາ ນ ເສ ຍ ຊີວ ິດ ໃນ ສາ ມ ອາ ທິ ດ . ອ ໍາມ ະ ພ າດ , 1 3( 5) , 6 29 –6 34 . ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 31 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ອາການ ເຈັບ ປ່ ວຍ ທີ ່ ຂະຫຍາຍ ໄດ້ ບາ ງ ອ າກ ານ ຫຼື ຄ ວ າມ ເຈ ັບ ປ່ວ ຍ ແມ ່ນ ຂະ ຫ ຍ າຍ ຕົ ວ ໄດ້ ເ ມື່ ອ ເວ ລ າ ຜ່ ານ ໄປ . ສິ່ ງ ເ ຫ ຼົ່ານີ້ ເອ ີ້ນ ວ່າ ອ າກ ານ ເຈັ ບ ປ່ວ ຍ ທ ີ່ ຂະ ຫ ຍ າຍ ໄດ້ . ບ າງ ອາ ກ ານ ເຈ ັບ ປ່ວ ຍ ທ ີ່ ຂະ ຫ ຍ າ ຍ ໄດ້ ທ ີ່ ພົ ບ ເຫ ັນ ທ ົ່ວ ໄປ ມີ: ï ພ ະ ຍ າດ ກ້ າມ ເນື້ ອ ເສື່ ອ ມ; ï ພ ະ ຍ າດ ພ າຄິ ນ ສັ ນ ; ï ເສັ້ ນ ເລ ືອ ດ ແຂ ງ ຕົ ວ ຫ ຼາຍ ຈຸ ດ ; ແ ລ ະ ï ພ ະ ຍ າດ ເສັ້ ນ ປ ະ ສ າດ ກາ ນ ເຄ ື່ອ ນ ໄຫ ວ . ກ ານ ໃຫ ້ ກາ ນ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງ ຮັ ບ ທ ີ່ ຖືກ ຕ້ ອ ງ ໃ ນ ເວ ລ າ ທ ີ່ ຖືກ ຕ້ ອ ງ ສ າມ າດ ຊ່ວ ຍ ປ້ອ ງ ກັ ນ ບັນ ຫ າ ທ ່າ ທ າງ ໄດ້ . ນີ້ ສ າມ າດ ຮັບ ປ ະ ກັ ນ ໃຫ ້ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ສາ ມ າດ ສືບ ຕໍ່ ດ ໍາ ເ ນີ ນ ຊີວ ິດ ໄດ້ ຢ່າ ງ ຄ ົບ ຖ້ວ ນ ທ ີ່ ສຸດ ເປ ັນ ເວ ລ າ ດ ົນ ທ ີ່ ສຸດ ເທ ົ່າ ທ ີ່ ຈະ ເປ ັນ ໄປ ໄດ້ . ບ າງ ປັດ ໃຈ ສະ ເພ າະ ທ ີ່ ຕ້ອ ງ ເ ອ ົາ ໃ ຈ ໃສ່ : ï ກ ານ ຊັກ ຊ້າ ໃນ ກ າ ນ ປ ະ ເມີ ນ ຜົນ ສາ ມ າດ ເຮ ັດ ໃຫ ້ ບັນ ຫ າທ່ າ ທ າງ ຮ້າ ຍ ແຮ ງ ຂ້ຶ ນ . ï ກາ ນ ຊັກ ຊ້າ ລະ ຫ ວ ່າງ ກາ ນ ປະ ເມີ ນ ຜົນ ແ ລ ະ ກ ານ ສະ ໜ ອ ງ ລ ົດ ເຂ ັນ ອາ ດ ຈະ ໝ າຍ ເຖ ິງ ວ ່າ ລ ົດ ເຂ ັນ ແ ລ ະ / ຫ ຼືບ ່ອ ນ ນັ່ງ ອາ ດ ຈະ ບໍ່ ເ ໝ າະ ສົມ ອີກ ໃນ ເວ ລ າ ທ ີ່ ສະ ໜ ອ ງ ໃ ຫ ້; ï ກ ານ ຕິດ ຕ າມ ຜົນ ເລ ື້ອ ຍ ໆ ແມ ່ນ ສິ່ງ ສໍາ ຄັ ນ ເ ພ າະ ວ່ າ ຄ ວ າມ ຕ້ອ ງກ ານ ແນ ວ ຮອ ງ ຮັ ບ ດ້າ ນ ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ແ ລ ະ ທ ່າ ທ າງ ສ າມ າດ ປ່ຽ ນ ແປ ງ ໄ ດ້ ວ່ອ ງ ໄ ວ . ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ມີ ກ ານ ບົ່ງ ມ ະ ຕິ ພ ະ ຍ າດ ທ ີ່ ບໍ່ ມີ ໃນ ລ າຍ ກ ານ , ໃ ຫ ້ຂ ຽນ ຊື່ ຂ ອ ງກ ານ ບົ່ ງມ ະ ຕິ ພ ະ ຍ າດ ນັ້ ນ . ຖ ້າ ທ ່ານ ໍ ບໍ່ ຮູ້ ກ່ຽ ວ ກັບ ກາ ນ ບົ່ງ ມ ະ ຕິ ພ ະ ຍ າດ ນີ້ , ມັ ນ ເປ ັນ ກາ ນ ດີ ໃ ນ ກາ ນ ຊອ ກ ຮູ້ ເ ພີ່ ມ ເຕີ ມ ກ່ຽ ວ ກັບ ມັນ . ຄ ິດ ກ່ຽ ວ ກັບ ລັກ ສ ະ ນ ະ ພິ ເສ ດ ຕົ້ນ ຕໍ ຂອ ງ ກ ານ ບົ່ ງມ ະ ຕິ ພ ະ ຍ າດ ນີ້ ແ ລ ະ ສິ່ ງ ນີ້ ຈະ ມີ ຜົ ນ ແນ ວ ໃດ ຕໍ່ ກັ ບ ກາ ນ ເລ ືອ ກ ລົດ ເຂ ນັ . ຈ ະ ເ ປັ ນ ແ ນ ວ ໃດ ຖ້ າ ບໍ່ ຮູ້ ຈັ ກ ກ ານ ບົ່ ງມ ະຕິ ພ ະຍ າດ ຫຼື ອ າກ ານ ? ບາ ງ ຄ ັ້ງ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ອາ ດ ຈະ ບໍ່ ຮູ້ ຊື່ ຂ ອ ງ ພ ະ ຍ າດ ຫ ຼື ອ າກ ານ ເຈ ັບ ປ່ວ ຍ . ມັ ນ ຍັງ ເປ ັນ ໄປ ໄດ້ ວ່າ ບໍ່ ມີ ກາ ນ ບົ່ງ ມ ະ ຕິ ພ ະ ຍ າດ ໃດ ໆ . ໃ ນ ກໍລ ະ ນີ ນີ້ ໃຫ ້ ລ ະ ບ ຸ ບັນ ຫ າ ຮ່ າງ ກ າຍ ສະ ເພ າະ ຕ່າ ງໆ ແ ລ ະ ສື ບ ຕໍ່ ກ ານ ປະ ເມີ ນຜົ ນ . ບ າງ ບັ ນ ຫ າ ຮ່ າງ ກ າຍ ທີ່ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ອາ ດ ຈະ ປະ ສົ ບ ສາ ມ າດ ມີ ຜົ ນ ກະ ທົ ບ ໂດ ຍ ກົງ ຕໍ່ ກັ ບ ກາ ນ ເລ ືອ ກ ລົດ ເຂ ັນ ທ ີ່ ເໝ າະ ສົມ ທ ີ່ ສຸດ . 32 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ອ່ ອນ ແອ ຄ ົ ນທີ່ ບໍ່ ແ ຂ ງ ແ ຮ ງ ມັ ກ ຈ ະ ອິດ ເມື່ ອ ຍ ໄດ້ ງ່າ ຍ , ໂດ ຍ ປົກ ກ ະ ຕິ ແລ ້ວ ມີ ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ຮ່ າງ ກ າຍ ໜ ້ອ ຍ ກວ່ າ ແ ລ ະ ອ ່ອ ນ ແອ ກ ວ່າ ເມື່ ອ ກ່ອ ນ ແ ລ ະ ອ າດ ຈ ະ ຍ່າ ງ ຊ້ າ ຫ ຼາຍ (3 3) . ຜູ້ ສູງ ອາ ຍຸ ມີ ຄ ວ າມ ສ່ຽ ງ ສູ ງ ກ ວ່ າ ໃ ນ ກາ ນ ອ່ອ ນ ແ ອ ບ ໍ່ ແຂ ງ ແ ຮ ງ (3 4, 3 0, 31 ,) . ໂດ ຍ ທ ົ່ວ ໄປ ຜູ້ ສູງ ອາ ຍຸ ທ ີ່ ອ່ອ ແອ ບໍ່ ແ ຂ ງ ແ ຮ ງ ໄດ້ ຮັບ ລົດ ເຂ ັນ ພື້ ນ ຖ ານ ໂ ດ ຍ ບໍ່ ມີ ແນ ວ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ທ ີ່ ດີທ ີ່ ບໍ່ ຕ ອ ບ ສະ ໜ ອ ງ ໄ ດ້ ຄວ າມ ຕ້ອ ງກ າ ນ ຂ ອ ງ ເ ຂ ົາ ເ ຈ ົ້າ (3 2, 3 3) . ແ ນ ວ ໃດ ກໍ ຕ າມ , ກ ານ ໃຫ ້ ລ ົດ ເຂ ັນ ທ ີ່ ເໝ າະ ສົ ມ ທ ີ່ ມີ ແ ນ ວ ຮອ ງ ຮັ ບ ທ ່າທ າງ ທ ີ່ ດ ີ ແກ ່ ຄົນ ບໍ່ ແ ຂ ງ ແ ຮ ງ ແລ ະ ຜູ້ ສູງ ອາ ຍຸ ສ າມ າດ ມີ ຜົ ນ ກະ ທົ ບ ທ ີ່ ດີ ຫ ຼາຍ ຕໍ່ ກັບ ຄຸນ ນະ ພ າ ບ ຊ ີວ ິດ ຂອ ງ ຄ ົນ ນັ້ນ (3 7, 3 4, 3 5) . ï ເ ມື່ ອ ຍ ໄດ້ ງ່າ ຍ ; ï ມີ ຄວ າມ ແຮ ງ ທ ີ່ ຈໍາ ກັ ດ ໃນ ກາ ນ ຂັບ ເຄ ື່ອ ນ ລົດ ເຂ ັນ ດ ້ວ ຍ ຕົນ ເອ ງ; ï ອ າດ ຈະ ຍາ ກ ໃນ ກາ ນ ຮັກ ສ າ ທ ່າ ນັ່ ງ ຕັ້ ງ ຊື່ ເ ນື່ ອ ງ ຈ າກ ຄວ າມ ອິດ ເມື່ ອ ຍ ແ ລ ະ ກ ານ ອ່ອ ນ ແຮ ງ ທ ົ່ວ ໄປ ; ï ອ າ ຈ ະ ມີຄ ວ າມ ສ່ຽ ງ ເ ກີ ດ ແຜ ກົດ ທ ັບ ເນື່ ອ ງ ຈ າກ : – ຜິວ ໜ ັງ ທ ີ່ ບາ ງ/ ອ ່ອ ນ ເ ຊ ິ່ງຊໍ້ າ ໄ ດ້ ງ່າ ຍ ; – ເວ ລ າ ປ ິ່ນ ປົວ ຮອ ຍ ຊໍ້າ / ແ ຜ ໃຫ ້ ເຊ ົາ ຊ້ າ ກ ວ່ າ; – ຖ ້າ ອ ່ອ ນ ເພ ຍ ຫ ຼາຍ , ອ າດ ຈະ ບໍ່ ສ າມ າດ ປ່ຽ ນ ທ ່າ ໃໝ່ ໄດ້ ດ້ວ ຍ ຕົນ ເອ ງ. ï ປ ະ ເມີ ນ ຈໍາ ນ ວ ນ ກາ ນ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ທ ີ່ ຕ້ ອ ງກ ານ ຢ່ າງ ລະ ອ ຽດ – ໂ ດ ຍ ພິ ຈ າລ ະ ນ າ ວ ່າ ຍ ິ່ງ ຜູ້ ໃຊ້ ລ ົດ ເຂ ັນ ນັ່ງ ໃນ ລົດ ເຂ ັນ ດົນ ເທ ົ່າ ໃ ດ ຜູ້ ກ່ ຽວ ກໍ່ ເ ປ ັນ ໄປ ໄດ້ ວ່າ ຈະ ເມື່ ອ ຍ ຫ ຼາຍ ເທ ົ່າ ນັ້ ນ , ແ ລ ະ ກໍ່ ຈະ ຕ້ ອ ງກ ານ ຮອ ງ ຮັ ບ ຫ ຼາຍ ຂຶ້ ນ ເທ ົ່າ ນັ້ ນ . ï ຄ ຸນ ສົ ມ ບັ ດ ໃຊ ້ງາ ນ ຂອ ງ ລ ົດ ເຂ ັນ ທ ີ່ ອາ ດ ຈະ ເປ ັນ ປະ ໂຫ ຍ ດມີ ຄື: – ບ່ອ ນ ວາ ງ ແ ຂ ນ – ໃ ຫ ້ກ ານ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ເພີ່ ມ ເຕີ ມ ແ ລ ະ ຊ່ ວ ຍ ເລ ື່ອ ງ ກ ານ ຍູ້ ລ ົດ ເຂ ັນ ສໍາ ລັ ບ ກ ານ ເຄ ື່ອ ນ ຍ້າ ຍ ; – ບ ່ອ ນ ວາ ງ ຕີ ນ ທ ີ່ ຫ ວ ່ຽງ ອອ ກ ຈາ ກ ທ າງ ໄດ້ ເພື່ ອ ອ ໍານ ວ ຍ ຄວ າມ ສະ ດ ວ ກ ໃຫ ້ ແກ ່ ກາ ນ ເຄ ື່ອ ນ ຍ້າ ຍ ແ ບ ບ ຢືນ ສໍາ ລັ ບ ຜູ້ ທ ີ່ ສາ ມ າດ ຢືນ ໄດ້ ; – ຄ ັ ຍູ້ ເ ພື່ ອ ໃຫ ້ ຄົນ ອື່ນ ສາ ມ າດ ຊ່ ວ ຍ ຍູ້ ລ ົດ ເຂ ັນ ໄດ້ ; – ລ ົດ ເຂ ັນ ທ ີ່ ມີ ນໍ້ າໜັ ກ ເບ ົາ ເຊ ິ່ງຈ ະ ຕ້ອ ງກ ານ ແຮ ງ ໜ ້ອ ຍ ກວ່ າ ສໍ າລັ ບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ໃນ ກາ ນ ຍູ້ ດ ້ວ ຍ ຕົ ນ ເອ ງ. ສໍ າລັ ບ ຂໍ້ ມູ ນ ເພີ່ ມ ເ ຕີ ມ ກ່ ຽວ ກັບ : ï ສາ ມ າດ ປ້ອ ງ ກັ ນ ແຜ ກົ ດ ທ ັບ ໄດ້ ແນ ວ ໃດ ? – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . 33 F rie d, L ., et a l. (2 00 1) . ຄ ວ າມ ອ່ອ ນ ແອ ໃນ ຜູ້ ສູ ງ ອ າຍຸ : ຫ ຼັກ ຖ ານ ສ ະ ແດ ງ ປ ະ ກົ ດ ກາ ນ . ວ າລ ະ ສ ານ ກ່ ຽວ ກັບ ກ ານ ສຶກ ສ າ ຜູ້ ສູງ ອາ ຍຸ , 5 6, 1 46 –1 56 34 B or tz , W . ( 20 02 ). ກ ອ ບ ແນ ວ ຄວ າມ ຄິດ ກ່ຽ ວ ກັບ ຄວ າມ ອ່ອ ແອ : ກ ານ ທ ົບ ທ ວ ນ . ວ າລ ະ ສ ານ ກ່ຽ ວ ກັບ ກາ ນ ສຶກ ສ າ ຜູ້ ສູງ ອາ ຍຸ , 5 7A (5 ), M 28 3– M 28 8. 35 L an g, P ., M ic he l, J. P ., & Ze kr y, D . ( 20 09 ). ອ າກ ານ ຄວ າມ ອ່ອ ນ ແອ : ພ າວ ະ ຫ ັນ ປ່ ຽນ ໃນ ຂະ ບວ ນ ກ ານ ເຄ ື່ອ ນ ເໜ ັງ. ກ ານ ສຶກ ສ າ ຜູ້ ສູງ ອາ ຍຸ , 5 5, 5 39 -5 49 36 R ad er , J ., Jo ne s, D ., & M ille r, L. (2 00 0) . ຄ ວ າ ມ ສໍ າຄັ ນ ຂອ ງ ບ ່ອ ນ ນັ່ງ ລົດ ເຂ ັນ ທ ີ່ ປັບ ສະ ເພ າະ ບຸກ ຄົ ນ ສໍ າລັ ບ ຜູ້ ສູ ງ ອ າຍຸ ທ ີ່ ບໍ່ ແ ຂ ງ ແ ຮ ງ. ວ າລ ະ ສ ານ ກ່ ຽວ ກັບ ກ ານ ພ ະ ຍ າບ ານ ຜູ້ ສູ ງ ອ າຍຸ , 2 6, 2 4- 32 37 K ra si lo vs ky , G . ( 19 93 ). ກ ານ ປະ ເມີ ນ ຜົນ ບ່ອ ນ ນັ່ງ ແ ລ ະ ກ ານ ຄຸ້ມ ຄອ ງ ໃ ນ ປະ ຊ າກ ອ ນ ຢູ່ ສ ະ ຖາ ນ ພ ະ ຍ າບ ານ . ກ າ ຍ ະ ບໍາ ບັ ດ ແ ລ ະ ກິ ດ ຈ ະ ກ ໍາ ບ ໍາບັ ດ ໃນ ຜູ້ ປ ່ວ ຍ ສູງ ອາ ຍຸ , 1 1( 2) , 2 5– 38 . 38 T re fle r, E. , F itz ge ra ld , S ., H ob so n, D ., Bu rs ic k, T ., & Jo se ph , R . ( 20 04 ). ຜົ ນ ຮັບ ຂອ ງ ກ ານ ຊ່ວ ຍ ເຫ ຼືອ ດ ້ວ ຍ ລ ະ ບ ົບ ລົດ ເຂ ັນ ກັບ ຜູ້ ຢ ູ່ ອາ ໄສ ຂອ ງ ສ ະ ຖ ານ ດູ ແ ລ ໄລ ຍ ະ ຍາ ວ . ເ ຕັ ກ ໂນ ໂລ ຊີ ຊ່ ວ ຍ , 1 6, 18 –2 7. 39 ສ ະ ມ າຄົ ມ ພ ະ ຍ າດ ຮັນ ຕິງ ຕັນ ແຫ ່ງ ອ າ ເ ມ ລິ ກ າ. (2 01 0) . ກ າ ຍ ະ ບໍາ ບັ ດ ແ ລ ະ ກິ ດ ຈ ະ ກ ໍາ ບ ໍາບັ ດ : ຊຸ ດ ປື້ ມ ຄູ່ ມືແ ນ ະ ນໍ າ ຄ ອ ບ ຄ ົວ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .h ds a. or g/ im ag es /c on te nt /1 /1 /1 16 97 .p df ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 33 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ກ້ າມ ເນື ້ ອ ກະຕຸ ກ/ການ ເຄື ່ ອນ ເໜັງ ທີ ່ ຄວບ ຄຸ ມ ບໍ ່ ໄດ້ ບ າງ ຄົນ ມີ ບ ັນ ຫ າ ເ ລ ື່ອ ງ ກ ານ ເຄ ື່ອ ນ ເໜ ັງ ແ ບ ບ ກ ະ ທັ ນ ຫັ ນ ທ ີ່ ຄວ ບ ຄຸມ ບໍ່ ໄ ດ້ . ສິ່ ງ ເ ຫ ຼົ່ານີ້ ສາ ມ າດ ເອ ີ້ນ ວ່າ ກ້າ ມ ເນື້ ອ ກະ ຕຸ ກ . ສ າມ າດ ເກີ ດ ກ້າ ມ ເນື້ ອ ກະ ຕຸ ກ ໃນ ຫ ຼາຍ ຮູ ບ ແບ ບ ແ ຕ ກ ຕ່າ ງ ກັ ນ ເ ຊ ິ່ງລ ວ ມ ມີ : ï ຢ ູ່ຈ ຸດ ຕໍາ ແໜ ່ ງຂ ອ ງ ສ ະ ໂພ ກ, ຫ ົວ ເຂ ົ່າ ແລ ະ ຂໍ້ ຕີ ນ ; ï ກາ ນ ສໍາ ພັ ດ ; ï ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ຂອ ງ ລ ົດ ເຂ ັນ , ໂ ດ ຍ ສ ະ ເ ພ າະ ຜ່ ານ ພື້ ນ ດິນ ທ ີ່ ບໍ່ ຮ າບ ພ ຽງ /ກັ ນ ດ ານ . ï ຊ ອ ກ ຮູ້ ກ ານ ເຄ ື່ອ ນ ເໜ ັງ ທ ີ່ ຄວ ບ ຄຸມ ບໍ່ ໄ ດ້ ມີ ຜົ ນ ກະ ທົ ບ ແນ ວ ໃດ ຕໍ່ ກັ ບ ຜູ້ ໃ ຊ ້ລ ົດ ເຂ ັນ ແ ລ ະ ແ ກ ້ ໄຂ ບັນ ຫ າ ກັ ບ ເຂ ົາ ເຈ ົ້າ. ï ບ າງ ແນ ວ ຮອ ງ ຫ ຼື ກ ານ ດັດ ປັບ ຕໍ່ກັ ບ ລ ົດ ເຂ ັນ ອາ ດ ຈະ ຊ່ວ ຍ ຫ ຼຸດ ຜ່ ອ ນ ກ້າ ມ ເນື້ ອ ກະ ຕຸ ກ ແ ລ ະ ກ ານ ເຄ ື່ອ ນ ເ ໜ ັງ ທ ີ່ ຄວ ບ ຄຸມ ບໍ່ ໄ ດ້ ເ ຊ ິ່ງລ ວ ມ ມີ : – ກ ານ ຮອ ງ ຮັ ບ ເພື່ ອ ຊ່ວ ຍ ຄວ ບ ຄຸມ ທ ່າ ຂ ອ ງກ ະ ດູ ກ ກົກ ແອ ວ ; – ກ ານ ປັບ ມຸ ມ ລະ ຫ ວ ່າງ ບ່ອ ນ ນັ່ ງຫ າ ແ ນ ວ ອີງ ຫ ຼັງຂ ອ ງ ລ ົດ ເຂ ັນ ເພື່ ອ ໃຫ ້ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ນັ່ງ ໂດ ຍ ທ ີ່ ສະ ໂພ ກກົ່ ງ ກ ວ່ າ ທ ່າ ປ ົກ ກ ະ ຕິ ໜ ້ອ ຍ ໜ ຶ່ງ; – ຈ ັດ ວາ ງ ຕໍ າ ແ ໜ ່ງ ບ ່ອ ນ ວາ ງ ຕີ ນ ເ ພື່ ອ ໃຫ ້ ຫ ົວ ເຂ ົ່າ ກົ່ ຫ ຼາຍ ກ ວ່ າ ທ ່າ ປ ົກ ກ ະ ຕິ ໜ ້ອ ຍ ໜ ຶ່ງ, ëພັ ບ í ຕີ ນ ເຂ ົ້າ; – ລ ອ ງ ມຸ ມ ຕ່າ ງໆ ຂອ ງ ບ ່ອ ນ ວາ ງ ຕີ ນ . ï ສ າຍ ຮັ ດ ອາ ດ ຈະ ໃຫ ້ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ມີ ກ ານ ຄວ ບ ຄຸມ ດີ ຂຶ້ ນ ຕໍ່ ກັ ບ ຂາ ແ ລ ະ ຕີ ນຂ ອ ງ ເ ຂ ົາ ເ ຈ ົ້າ. ຖ ້າ ມີ ກາ ນ ໃຊ ້ ສ າຍ ຮັ ດ , ມັ ນ ຄວ ນ ຮັດ ດ້ວ ຍ ສ າຍ V el cr o ເພື່ ອ ວ່າ ມັນ ຈະ ມ າຍ ອອ ກ ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ລົ້ ມ ອອ ກ ຈາ ກ ລົດ ເຂ ັນ . ï ຖ ້າ ກ ານ ເຄ ື່ອ ນ ເໜ ັງ ແ ຮ ງ ຫ ຼາຍ , ໃ ຫ ້ ພິ ຈ າລ ະ ນ າ: – ແນ ວ ຮອ ງບ່ ອ ນ ນັ່ງ ແ ລ ະ ແ ນ ວ ອີງ ຫ ຼັງ ແ ບ ບ ແຂ ງ; – ເລ ືອ ກ ລົດ ເຂ ັນ ທ ີ່ ມີ ຕໍ າ ແ ໜ ່ ງລໍ້ ຫ ຼັງທີ່ ສ າມ າດ ປັບ ໄດ້ . ລ ໍ້ ຫ ຼັງສ າມ າດ ຖືກ ປັ ບ ໃຫ ້ຢ ູ່ ໃນ ຕໍາ ແໜ ່ ງທີ່ ëປ ອ ດ ໄພ í ເພື່ ອ ເຮ ັດ ໃຫ ້ລ ົດ ເຂ ັນ ໝັ້ ນ ຄົ ງ ກ ວ່ າ; – ໃຫ ້ ທ ່ອ ນ ກັ ນ ປີ້ ນ ເພື່ ອປ ້ອ ງ ກັ ນ ບໍ່ ໃ ຫ ້ ລົດ ເຂ ັນ ປີ້ນ ໄປ ທ າງ ຫ ຼັງ. – ນີ້ ແມ ່ນ ຍ້ອ ນ ຫ ຍ ັງ ມັ ນ ຈິ່ງ ສໍາ ຄັ ນ ຫ ຼາຍ ສໍ າລັ ບ ຜູ້ ໃ ຊ້ລ ົດ ເຂ ັນ ໃນ ກາ ນ ລ ອ ງ ຂັ ບ ເຄ ື່ອ ນ ລົດ ເຂ ັນ ໃນ ຕ ອ ນ້ າຍ ກ ານ ປັບ ໃຫ ້ ເໝ າະ ສົມ ເ ພື່ ອ ເບ ິ່ງວ່ າ ອ າກ ານ ກ້າ ມ ເນື້ ອ ກະ ຕຸ ກ ຈະ ເກີ ດ ຂຶ້ນ ຫ ຼືບ ໍ່. 34 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຄວາມ ຕຶງ ກ້ າມ ເນື ້ ອ – ສູ ງ ແລະ ຕໍ ່ າ ຄ ໍາ ສັ ບ ກ້າ ມ ເນື້ ອ ຕຶ ງ ໝ າຍ ເຖ ິງກ ານ ບີ ບ ຕົວ /ກ ານ ເຄ ັ່ງ ຕຶ ງ ໃ ນ ກ້າ ມ ເນື້ ອ ໃ ນ ເວ ລ າ ທ ີ່ ມັນ ກໍາ ລັ ງ ເ ຄ ື່ອ ນ ເໜ ັງ (4 0) . ຄ ວ າມ ຕຶງ ຂອ ງກ້ າມ ເນື້ ອ ປົກ ກ ະ ຕິ ອ ະ ນຸ ຍ າດ ໃຫ ້ ແຂ ນ ຂາ ຫ ຼື ຂໍ້ ຕໍ່ ຖ ືກ ເຄ ື່ອ ນ ເໜ ັງ ຢ ່າງ ອ ິດ ສ ະ ຫຼ ະ ແ ລ ະ ງ່ າຍ ດ າຍ . ແ ນ ວ ໃດ ກໍ ຕ າມ ບ າງ ຄົນ ອາ ດ ຈະ ມີ ຄ ວ າມ ຕຶງ ຂອ ງກ້ າມ ເນື້ ອ ທ ີ່ ສູງ ຫ ຼືຕໍ່ າ ເ ກີ ນ ໄປ . ຄ ວ າມ ຕຶ ງ ກ້ າມ ເນື້ ອ ສູ ງ: ມີ ກາ ນ ບີ ບ ຕົວ /ຄ ວ າມ ເຄ ັ່ງ ຕຶ ງ ຫ ຼາຍ ກ ວ່ າ – ສ ະ ນັ້ນ ມັ ນ ຈິ່ງ ຍາ ກ ກວ່ າ ໃ ນ ກ ານ ເຄ ື່ອ ນ ເ ໜ ັງ ແ ຂ ນຂ າ ຫ ຼື ຂໍ້ ຕໍ່ (4 1) . ຄ ົນ ທີ່ ມີ ກ້ າມ ເນື້ ອ ຕຶ ງ ສູ ງ ໂ ດ ຍ ປົກ ກ ະ ຕິ ຈະ ພົ ບ ວ່າ ມັນ ຍ າກ /ອ ຶດ ອັດ ໃນ ກາ ນ ເຄ ື່ອ ນ ເໜ ັງ ແ ຂ ນຂ າ ຫ ຼື ຂໍ້ ຕໍ່ ທ ີ່ ຖືກ ກະ ທົ ບ ແ ລ ະ ກ ານ ເຄ ື່ອ ນ ເໜ ັງ ອ າດ ຈະ ຊ້າ . ບ າງ ຄົ ນ ທີ່ ມີ ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ ສາ ມ າດ ເຄ ື່ອ ນ ເໜ ັງ ໄ ດ້ ໃນ ບາ ງຮູ ບ ແບ ບ ëຄ ົງ ທ ີ່í ສ ະ ເພ າະ ເທ ົ່າ ນັ້ ນ (4 2) . ຖ ້າ ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ ຫ ຼາຍ , ກ ານ ເຄ ື່ອ ນ ເໜ ັງ ກໍ່ ເກື ອ ບ ວ່າ ເປ ັນ ໄປ ໄດ້ ບໍ່ ໄ ດ້ . (ສື ບຕໍ່ ໃນ ໜ ້າ ຕໍ່ ໄປ ) ລ ະ ດ ັບ ຄວ າມ ຫ ຍ ຸ້ງຍ າກ ທ ີ່ ເກີ ດ ຈາ ກ ຄວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ແມ ່ນ ຂຶ້ນ ກັບ ວ່າ ບັນ ຫ າ ນັ້ ນ ຮ້າ ຍ ແຮ ງ ສໍ່ າ ໃ ດ ແ ລ ະ ກ້ າມ ເນື້ ອ ໃດ ຖືກ ກະ ທົ ບ . ບ າງ ຄວ າມ ຫ ຍ ຸ້ງຍ າກ ທ ີ່ ເປ ັນ ໄປ ໄດ້ ສໍາ ລັ ບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ຜູ້ ທ ີ່ ມີ ບ ັນ ຫ າ ເ ລ ື່ອ ງຄ ວ າມ ຕຶງ ກ້ າມ ເນື້ ອ ລວ ມ ມີ : ï ກ ານ ຊົງ ຕົວ ຫ ຼຸດ ລ ົງ (4 2) ; ï ລ ໍາບ າກ ໃນ ກາ ນ ນັ່ງ ໃຫ ້ຕັ້ ງ ຊື່ ແ ລ ະ ສ ະ ບ າຍ ຕົວ (4 3) ; ï ກ ານ ຄ ວ ບ ຄຸ ມ ກ້ າມ ເນື້ ອ ຫ ຼຸດ ລ ົງ (4 3) , ເຊ ິງ່ສ າມ າດ ມີ ຜົ ນ ຕໍ່ ກັ ບ ວ າ່ ຜູ້ ໃຊ້ ລດົ ເຂ ນັ ສາ ມ າດ ດາໍ ເນີ ນ ໜ ້າ ວ ຽກ ຕ່ າງ ໆ ໄດ້ ແນ ວ ໃດ ລ ວ ມ ທ ັງ ກ ານ ຂັ ບ ເຄ ື່ອ ນ ລົ ດ ເຂ ັນ ແ ລ ະ ກ ານ ເຄ ື່ອ ນ ຍ້າ ຍ ; (ສື ບຕໍ່ ໃນ ໜ ້າ ຕໍ່ ໄປ ) ໃນ ເວ ລ າ ສໍ າພັ ດ ຫ ຼື ຊ່ ວ ຍ ເຫ ຼືອ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ທ ີ່ ມີ ຄ ວ າມ ຕຶ ງ ກ້ າມ ເນື້ ອ ສູງ ຫ ຼື ຕໍ່ າ, ເ ຄ ັດ ລັບ ເຫ ຼົ່ານີ້ ອາ ດ ຈະ ຊ່ວ ຍ ໄດ້ : ï ອ ະ ທ ິບ າຍ ສິ່ງ ທ ີ່ ທ ່ານ ຈະ ເຮ ັດ ກ່ ອ ນ ທ ີ່ ທ ່ານ ຈະ ເຮ ັດ ມັ ນ (4 2) ; ï ເຄ ື່ອ ນ ຍ້າ ຍ ຊ້າ ໆ ແ ລ ະ ອ ະ ນຸ ຍ າດ ໃຫ ້ ມີ ເ ວ ລ າ ສໍ າລັ ບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ທ ີ່ ມີ ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ຕໍ່ າ ຫ ຼື ສູ ງ ເ ພື່ ອ ຕອ ບ ສ ະ ໜ ອ ງ; ï ໃຫ ້ ກາ ນ ປ ະ ຄ ອ ງ ທ ີ່ ແໜ ້ນ ໜ າ, ສ ະ ບ າຍ ຕົວ ດ້ວ ຍ ມ ື ແ ລ ະ ຂ າ ຂ ອ ງ ທ ່ານ ເ ພື່ ອ ໃຫ ້ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ມີ ກ ານ ປ ະ ຄ ອ ງ ທ ີ່ ດີ; ï ໃນ ເວ ລ າ ທ ີ່ ຄວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ ເຮ ັດ ໃຫ ້ ທ ັງ ໝົ ດ ຮ່ າງ ກ າຍ ຫ ຼື ທ ັງ ໝົ ດ ແຂ ນ ຂາ ຢຽ ດ ຊື່, ບ າງ ຄັ້ງ ສ າມ າດ ເຮ ັດ ໃຫ ້ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ຢ່ອ ນ ຍາ ນ ລົງ ໂດ ຍ ກາ ນ ເບ ັດ ງໍ ຂໍ້ ຕໍ່ ອ ັນ ໜ ຶ່ງ. ຕົ ວ ຢ ່າງ , ຖ ້າ ທ ັງ ໝົ ດ ຂ າ ຢ ຽດ ຊື່, ກ ານ ເບ ັດ ງໍ ຫ ົວ ຂໍ້ ຫ ຼື ສ ະ ໂພ ກ ສ າມ າດ ຊ່ ວ ຍ ຫ ຼຸດ ຜ່ ອ ນ ຄວ າມ ຕຶງ ໄດ້ . (ສື ບຕໍ່ ໃນ ໜ ້າ ຕໍ່ ໄປ ) 40 M ar tin , K ., Ka lte nm ar k, T ., Le w al le n, A ., Sm ith , C ., & Yo sh id a, A . ( 20 07 ). ລ ັກ ສ ະ ນ ະ ທ າງ ຄລ ີ ນິກ ຂ ອ ງພ າວ ະ ກ້າ ມ ເນື້ ອ ຕຶງ ຕົ ວ ນ້ອ ຍ : ກ ານ ສໍາ ຫ ຼວ ດ ນ ັກ ກາ ຍະ ພ າບ ບໍາ ບັ ດ ແ ລ ະ ກິ ດ ຈ ະ ກ ໍາ ບ ໍາບັ ດ ໃນ ເດ ັກ . ກ າ ຍ ະ ພ າບ ບໍາ ບັ ດ ໃນ ເດ ັກ , 1 9, 2 17 –2 26 . 41 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (1 99 3) . ກ ານ ສົ່ງ ເສີ ມ ພັ ດ ທ ະ ນ າ ກ ານ ຂອ ງ ເ ດ ັກ ນ້ອ ຍ ທ ີ່ ສະ ໝ ອ ງພິ ກ ານ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/h q/ 19 93 /W H O _R H B_ 93 .1 .p df 42 ອ ົງກ ານ ອະ ນ າ ໄ ມ ໂລ ກ , ສູ ນ ກາ ນ ບາ ດ ເຈ ັບ ທ າງ ສະ ໝ ອ ງ D ru ck er ຂ ອ ງກ ະ ຊ ວ ງ ປ ້ອ ງ ກັ ນ ປະ ເທ ດ ຂອ ງສ ະ ຫ ະ ລັ ດ , ໂ ຮ ງໝໍ M os sR eh ab H os pi ta l. (2 00 4) . ກ ານ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ສໍາ ລັ ບ ຄົ ນ ທີ່ ມີ ບ າດ ເຈ ັບ ທ າງ ສະ ໝ ອ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/h q/ 20 04 /W H O _D AR _0 1. 9_ en g. pd f ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 35 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຄວາມ ຕຶງ ກ້ າມ ເນື ້ ອ – ສູ ງ ແລະ ຕໍ ່ າ (ສືບ ຕໍ ່ ) ຄ ວ າມ ຕຶ ງ ຕໍ່ າ: ມີ ຄວ າມ ເຄ ັ່ງ ຕຶ ງ ທ ີ່ ໜ ້ອ ຍ ກ ວ ່າ – ສ ະ ນັ້ນ ມັ ນ ຈິ່ງ ງ່າ ຍ ໃນ ກາ ນ ເຄ ື່ອ ນ ເ ໜ ັງ ແ ຂ ນ ຂ າ ຫ ຼື ຂໍ້ ຕໍ່ ໂ ດ ຍ ບໍ່ ຕັ້ ງ ໃ ຈ (4 1) . ແ ນ ວ ໃດ ກໍ ຕ າມ , ບ ຸກ ຄົ ນ ທ ີ່ ມີ ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ຕໍ່າ ອ າດ ຈະ ພົ ບ ວ ່າ ມັ ນ ຍ າກ ໃນ ກາ ນ ເລ ີ່ ມກ ານ ເຄ ື່ອ ນ ເໜ ັງ, ແ ລ ະ ອ າດ ຈະ ຍ ັງ ມີ ຄວ າມ ຍາ ກ ໃນ ກາ ນ ຄວ ບ ຄຸມ ກາ ນ ເຄ ື່ອ ນ ເໜ ັງ ຂ ອ ງ ເ ຂ ົາ ເ ຈ ົ້າ. ຄ ວ າມ ຕຶ ງກ້ າມ ເນື້ ອ ຕໍ່ າບ າງ ຄັ້ ງເ ອີ້ ນ ວ່ າ ëກ້ າມ ເນື້ ອ ອ່ອ ນ ຕົວ ຫ ຼື ຢ ່ອ ນ ຍ ານ í ( 41 ) . ຖ ້າ ຄ ວ າມ ຕຶງ ຕໍ່າ ຫຼ າຍ , ມັ ນ ອາ ດ ຈະ ຍ າກ ຫ ຼາຍ ທ ີ່ ບຸກ ຄົ ນ ຈະ ເຄ ື່ອ ນ ເໜ ັງ ໄ ດ້ . ໃຜ ແ ດ່ ມີ ບັ ນ ຫ າ ເ ລື່ ອ ງຄ ວ າມ ຕຶ ງ ຂ ອ ງ ກ້ າມ ເນື້ ອ ? ບ ັນ ຫ າ ເ ລ ື່ອ ງ ຄ ວ າ ມ ຕຶ ງ ຂ ອ ງ ກ້ າມ ເນື້ ອ ສ າມ າດ ເປ ັນ ບັນ ຫ າ ສໍ າລັ ບ ຜູ້ ໃ ຊ້ລ ົດ ເຂ ັນ ໄດ້ . ມັ ນ ແ ມ ່ນ ບັນ ຫ າ ທ ີ່ ພົ ບ ເຫ ັນ ທ ົ ່ວ ໄປ ສໍາ ລັ ບ ຄົ ນ ທີ່ ມີ ສ ະ ໝ ອ ງ ພິ ກ ານ (4 2) , ກ ານ ບາ ດ ເຈ ັບ ສ ະ ໝ ອ ງ (4 3) , S C I ( 39 ) , ແລ ະ ອ ໍາມ ະ ພ າດ (4 0) . ï ເມື່ ອ ມີ ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ທ ີ່ ຂ້ອ ນ ຂ້າ ງ ສູ ງ ຫ ຼື ຕໍ່ າຫຼ າຍ , ສ າມ າດ ມີ ຄ ວ າມ ຍາ ກ ໃນ ກາ ນ ກິນ , ດ ື່ມ , ກື ນ ແ ລ ະ ຫ າຍ ໃຈ (4 1) . ກ ານ ສະ ໝັ ກ ອາ ຫ ານ (ຫ າຍ ໃຈ ເອ ົາ ຊີ້ ນ ສ່ວ ນ ອາ ຫ ານ ຫ ຼືຂ ອ ງ ແ ຫ ຼວ ເຂ ົ້າ ໄປ ) ແ ມ ່ນ ບັນ ຫ າ ທ ີ່ ອັນ ຕ ະ ລ າຍ ເຖ ິງ ຊີ ວ ິດ (4 3) ; ï ຄ ວ າມ ສ່ຽ ງ ທ ີ່ ເພີ່ ມ ຂຶ້ນ ຂອ ງ ກ ານ ເກີ ດ ທ ່າ ທ າງ ທ ີ່ ບໍ່ ປ ົກ ກ ະ ຕິ (4 2) . ສໍ າລັ ບ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ບາ ງຄົ ນ , ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູ ງ ສ າມ າດ ຕຶງ ສູງ ຍິ່ງ ຂຶ້ນ ດ້ວ ຍ ອາ ລົ ມ ຫ ຼື ໃ ນ ເວ ລ າ ທ ີ່ ຜູ້ ກ່ ຽວ ພ ະ ຍ າຍ າມ ຢ່າ ງ ໜ ັກ ໃນ ກາ ນ ເຮ ັດ ບ າງ ຢ່າ ງ (4 2, 4 3) ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ ແ ລ ະ ຕໍ່ າ ສ າມ າດ ເປ ັນ ປັ ດ ໃຈ ສ່ຽ ງ ສໍ າລັ ບ ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ (4 2) . ຈໍາ ນ ວ ນ ກາ ນ ປະ ຄ ອ ງ ຫ ຼື ຮອ ງຮັ ບ ທ ່າ ທ າງ ທີ່ ຈໍາ ເປ ັນ ຈ ະ ຂຶ້ນ ກັບ ກາ ນ ປະ ເມີ ນ ຜົນ ຂອ ງ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ . ແ ນ ວ ໃດ ກໍ ຕ າມ ບ າງ ຂໍ້ພິ ຈ າລ ະ ນ າ ສ ະ ເພ າະ ສໍາ ລັ ບ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ທ ີ່ ມີ ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ ລວ ມ ມີ : ï ກ ານ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງຮັ ບ ທ ່າ ທ າງ ຕ້ອ ງ ຖ ືກ ເຮ ັດ ໃຫ ້ ແ ຂ ງ ແ ຮ ງ ພ ຽງ ພໍ ເພື່ ອ ໃຫ ້ ມີປ ະ ສິ ດ ທ ິ ຜົນ ກັບ ຄວ າມ ຕຶ ງ ກ້ າມ ເນື້ ອ ທ ີ່ ສູງ ; ï ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ ສາ ມ າດ ກໍ່ ໃ ຫ ້ ເກີ ດ ຈຸດ ກົ ດ ທ ັບ ສູງ ລະ ຫ ວ ່າງ ຮ່າ ງກ າຍ ຂອ ງ ຜູ້ ໃຊ ້ ກັບ ລົດ ເຂ ັນ . ຫ ຼຸດ ຜ່ ອ ນ ສິ່ງ ນີ້ ໂ ດ ຍ ກາ ນ ກະ ຈ າຍ ແຮ ງ ກົ ດ ໄປ ທ ົ່ວ ບໍລ ິ ເວ ນ ພື້ ນ ຜິວ ທ ີ່ ໃຫ ຍ ່ ກວ່ າ. ກ ວ ດ ເບ ິ່ງ ກ ານ ກົ ດ ທ ັບ . ສ ອ ນ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ຫ ຼື ຄ ົນ ໃນ ຄອ ບ ຄ ົວ /ຜູ້ ເບ ິ່ງ ແ ຍ ງ ຂ ອ ງ ລ າວ ໃຫ ້ ກວ ດ ຜິວ ໜ ັງ ເ ພື່ ອ ເບ ິ່ງ ສັ ນ ຍ ານ ຂ ອ ງ ກ ານ ກົ ດ ທ ັບ ; ï ກ ານ ຫຼຸ ດ ມຸ ມ ລະ ຫ ວ ່າງ ກົກ ຂ າ ຫ າ ລ ໍາ ຕົ ວ ສາ ມ າດ ຊ່ ວ ຍ ຫ ຼຸດ ຜ່ ອ ນ ຮູບ ແບ ບ ທ ີ່ ແຂ ງ ແ ຮ ງ ຂ ອ ງຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ສູງ . 43 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (1 99 6) . ກ ານ ສົ່ງ ເສີ ມ ກາ ນ ເພິ່ ງ ຕົ ນ ເອ ງຫ ຼັງຈ າກ ກາ ນ ບາ ດ ເຈ ັບ ໄຂ ສັນ ຫຼັ ງ: ປ ື້ ມ ຄ ູ່ ມືສໍ າລັ ບ ພ ະ ນັ ກ ງາ ນ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ລະ ດ ັບ ປາ ນ ກາ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/ hq /1 99 6/ W H O _R H B_ 96 .4 .p df 44 ສ າ ມ າ ຄ ົມ ໂຣ ກ ຫົ ວ ໃຈ ແ ລ ະ ອ ໍາມ ະ ພ າດ ແຫ ່ງ ສ ະ ຫ ະ ລັ ດ . ( n. d. ). ພ າວ ະ ກ້າ ມ ເນື້ ອ ຫ ົດ ເກັ ງ. h ttp :// w w w .s tro ke as so ci at io n. or g/ ST R O KE O R G /L ife Af te rS tro ke /R eg ai ni ng In de pe nd en ce / Ph ys ic al C ha lle ng es /S pa st ic ity _U C M _3 09 77 0_ Ar tic le .js p 45 R ed st on e, F ., & W es t, J. (2 00 4) . ຄ ວ າມ ສໍາ ຄັ ນ ຂອ ງ ກ ານ ຄວ ບ ຄຸມ ທ ່າ ທ າງ ສໍາ ລັ ບ ກາ ນ ປ້ ອ ນ ອາ ຫ ານ . ກ ານ ພ ະ ຍ າບ ານ ເດ ັກ , 3 0, 9 7- 10 0. 46 D ris co ll, S ., & Sk in ne r, J. (2 00 8) . ອ າກ ານ ແຊ ກ ຊ້ອ ນ ດ້າ ນ ກ້າ ມ ເນື້ ອ ແ ລ ະ ກ ະ ດູ ກ ຂອ ງພ ະ ຍ າດ ກ້ າມ ເນື້ ອ ຮ່ວ ມ ປະ ສ າດ ໃນ ເດ ັກ . ຄ ລ ີ ນິກ ກາ ນ ຢາ ແ ລ ະ ກ າ ນ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ແຫ ່ງ ອ າ ເ ມ ລິ ກ າ ເ ໜ ືອ , 1 9, 16 3– 19 4. 36 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ການ ຕັ ດຂາ ສ່ ວນ ລຸ ່ ມ ກ ານ ຕັດ ຂ າ ສ່ ວ ນ ລຸ່ມ ອ າດ ຈະ ເກີ ດ ຂຶ້ນ ອັນ ເປ ັນ ຜົນ ຈາ ກ ກ ານ ບ າດ ເຈ ັບ ພ າຍ ນອ ກ ເຊ ັ່ ນວ່ າ ອ ຸປ ະ ຕິ ເຫ ດ ທ າ ງ ຖ ະ ໜົ ນ , ກ ານ ບ າດ ເຈ ັບ ຈາ ກ ກາ ນ ເຮ ັດ ວຽ ກ ຫ ຼື ກ ານ ບາ ດ ເຈ ັບ ຈາ ກ ສົງ ຄ າມ (4 7, 48 , 4 9) . ໃນ ບາ ງ ສ ະ ພ າບ ກາ ນ ອ ື່ນ , ກ ານ ຕັດ ຂ າ ສ່ ວ ນ ລຸ່ມ ອາ ດ ຈະ ແມ ່ນ ກ ານ ຜ່ າຕັ ດ ທ ີ່ ວາ ງ ແ ຜ ນ ໄວ້ . ຈ ໍານ ວ ນ ຄົນ ນັບ ມື້ ນັ ບ ເພີ່ ມ ຂຶ້ນ ມີ ກ ານ ຕັດ ຂາ ສ່ວ ນ ລຸ່ມ ຂ້າ ງດ ຽວ ຫ ຼື ທ ັງ ສ ອ ງ ຂ້ າງ ອ ັນ ເປ ັນຜົ ນ ມາ ຈາ ກ ພ ະ ຍ າດ ເບ ົາຫ ວ ານ (5 0, 5 1, 5 2) . ຫ ຼາຍ ໆ ຄົນ ຜູ້ ທ ີ່ ຖືກ ຕັດ ຂ າ ຂ້ າງ ດຽ ວ ຫ ຼື ທ ັງ ສ ອ ງ ຂ້ າງ ຍັງ ສາ ມ າດ ສືບ ຕໍ່ ຍ ່າງ ໄດ້ ໂດ ຍ ກາ ນ ໃຊ ້ ອະ ໄວ ຍ ະ ທ ຽມ ແ ລ ະ /ຫ ຼື ເ ຄ ື່ອ ງຊ່ ວ ຍ ຍ່າ ງ (4 8, 4 9) . ແ ນ ວ ໃດ ກໍ ຕ າມ , ບ າງ ຄົນ ອາ ດ ຈະ ຈໍາ ເປ ັນ ຕ້ອ ງ ມີ ລົດ ເຂ ັນ ສໍາ ລັ ບ ບາ ງ ເ ວ ລ າ ຫ ຼື ຕ ະ ຫຼ ອ ດ ເວ ລ າ (4 8, 4 9, 50 ) . ï ສາ ມ າດ ເຄ ື່ອ ນ ໄຫ ວ ໄດ້ ດີຫ ຼາຍ ໃນ ລົດ ເຂ ັນ ຖ ້າ ພ ວ ກ ເຂ ົາ ໄ ດ້ ຮັບ ກາ ນ ຊ່ວ ຍ ເຫ ຼືອ ເພື່ ອ ຮຽ ນ ຮູ້ ທ ັກ ສ ະ ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ໄປ ມ າ ໂ ດ ຍ ກາ ນ ໃຊ ້ລ ົດ ເຂ ັນ . ï ກ ານ ຊົງ ຕົວ ຂອ ງລົ ດ ເຂ ັນ ປ່ຽ ນ ແປ ງ ເພ າະ ວ່ າ ມີ ນໍ້ າໜ້ ອ ຍ ກວ່ າຢູ່ ສ່ວ ນ ໜ ້າ ຂ ອ ງລົ ດ ເຂ ັນ ; ï ຜູ້ ທ ີ່ ຖືກ ຕັດ ຂາ ທ ີ່ ເປ ັນ ເບ ົາຫ ວ ານ ອາ ດ ຈະ ມີ ຄ ວ າມ ສ່ ຽງ ສູງ ກວ່ າ ໃ ນ ກາ ນ ເກີ ດ ແຜ ກົດ ທ ັບ ເ ພ າະ ວ່ າ ຜິ ວ ໜ ັງ ອ າດ ຈະ ບໍ່ ເ ຊ ົາ ໄ ດ້ ງ່າ ຍ ຈາ ກ ຮອ ຍ ບາ ດ ຫ ຼື ຮ ອ ຍ ຊໍ້າ (4 9) . ï ໃນ ເວ ລ າ ຕິ ດຕັ້ ງ ລ ົດ ເຂ ັນ ເປ ັນ ຄັ້ງ ທ ໍາ ອ ິດ ໃຫ ້ ແກ ່ ຄົ ນ ທີ່ ຖ ືກ ຕັດ ແຂ ນຂ າ, ໃ ຫ ້ ຕັ້ງ ລໍ້ຫ ຼັງຢູ່ ຕໍາ ແໜ ່ ງຫຼັ ງສຸ ດ (ຖ ້າ ປ ັບ ໄດ້ ) ເ ພື່ ອ ຫ ຼຸດ ຜ່ ອ ນ ໂອ ກ າດ ທ ີ່ ລົດ ເຂ ັນ ຈະ ປິ້ນ ໄປ ທ າງ ໜ ້າ. ຜູ້ ໃຊ ້ ທ ີ່ ເຄ ື່ອ ນ ໄຫ ວ ໄດ້ ອາ ດ ຈະ ຮຽ ນ ຮູ້ ກ ານ ຊົງ ຕົວ ລົດ ເຂ ັນ ໄດ້ ຢ່າ ງ ວ ່ອ ງ ໄ ວ ແ ລ ະ ຈ າກ ນັ້ນ ຍ ້າຍ ລໍ້ ຫ ຼັງ ໄ ປ ທ າງ ໜ ້າ. ï ໃນ ເວ ລ າ ສ ອ ນ ທ ັກ ສະ ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ໄປ ມ າ: – ໃຫ ້ ລະ ມັ ດ ລ ະ ວ ັງ ສ ະ ເໝີ ໃນ ເວ ລ າ ທ ີ່ ຜູ້ ຖ ືກ ຕັດ ຂາ ລ ອ ງ ໃ ຊ ້ ລົດ ເຂ ັນ ໃນ ຄັ້ງ ທ ໍາ ອ ິດ ; – ສ ອ ນ ທ ັກ ສະ ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ໄປ ມ າ ຢ ່າ ງລ ະ ມັ ດ ລ ະ ວ ັງ ເພ າະ ວ່ າ ມີ ໂອ ກ າດ ທ ີ່ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ຈະ ປີ້ນ ຂວ ້າມ ໄປ ທ າງ ຫ ຼັງ. ï ມັ ນ ສໍາ ຄັ ນ ໃນ ກາ ນ ຮູ້ ວ ່າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ມັກ ໃສ່ ຂາ ທ ຽມ ຂ ອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ໃ ນ ເວ ລ າ ໃ ຊ ້ ລົດ ເຂ ັນ ຫ ຼືບ ໍ່, ເ ພ າະ ວ່ າ ນີ້ ອ າດ ຈະ ປ່ຽ ນ ແປ ງ ຄ ວ າມ ເໝ າະ ສົມ ຂອ ງ ລ ົດ ເຂ ັນ . ສໍ າລັ ບ ຂໍ້ ມູ ນ ເພີ່ ມ ເ ຕີ ມ ກ່ ຽວ ກັບ : ï ສາ ມ າດ ປ້ອ ງ ກັ ນ ແຜ ກົ ດ ທ ັບ ໄດ້ ແນ ວ ໃດ ? – ເບ ິ່ງ ຄ ູ່ ມື ອ ້າງ ອີງ ສໍາ ລັ ບ ຊ ຸດ ຝຶກ ອົບ ຮ ົມ ກາ ນ ບໍລ ິກ ານ ລົດ ເຂ ັນ – ລ ະ ດ ັບ ພື້ ນ ຖ ານ . 47 B ur ge r, H ., M ar in ce k, C ., & Is ak ov , E . ( 19 97 ). ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ຂອ ງ ຄ ົນ ຫຼັ ງຈ າກ ກາ ນ ຕັດ ຂ າ ສ່ ວ ນ ລ ຸ່ມ . ຄ ວ າມ ພິ ກ ານ ແ ລ ະ ກ ານ ຟື້ ນ ຟູ , 1 9( 7) , 2 72 –2 77 . 48 N ar an g, I. , M at hu r, P. , S in gh , P ., & Ja pe , V . ( 19 84 ). ຄ ວ າມ ສາ ມ າດ ດ້າ ນ ກາ ນ ເຄ ື່ອ ນ ໄຫ ວ ຂອ ງ ຜູ້ ທ ີ່ ຖືກ ຕັດ ຂ າ ສ່ ວ ນ ລຸ່ມ . ວ າລ ະ ສ ານ ສາ ກົ ນ ກ່ຽ ວ ກັບ ອ ະ ໄຍ ວ ະ ທ ຽມ ແ ລ ະ ອ ຸປ ະ ກ ອ ນ ພ ະ ຍຸ ງ ຮ່ າງ ກ າຍ , 8, 4 3– 51 . 49 ອ ົງກ ານ ອະ ນ າ ໄ ມ ໂລ ກ , ກ ະ ຊ ວ ງ ປ ້ອ ງ ກັ ນ ປະ ເທ ດ ສະ ຫ ະ ລັ ດ , ໂ ຄ ງກ ານ ຟື້ ນ ຟູ ຜູ້ ຖ ືກ ຕັດ ແຂ ນ ຂາ M os s R eh ab ໂ ຮ ງໝໍ M os s R eh ab . ( 20 04 ). ກ ານ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ຂອ ງ ຜູ້ ທ ີ່ ຖືກ ຕັດ ແຂ ນ ຂາ . ຄ ັດ ຂໍ້ ມູ ນ ຈ າກ h ttp :// w w w .p os na .o rg /n ew s/ Am pu ta tio ns .p df 50 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 00 5) . ວ ັນ ເບ ົາ ຫ ວ ານ ໂລ ກ : ມີ ຫ ຼາຍ ຄົ ນ ເກີ ນ ໄປ ທ ີ່ ສູນ ເສ ຍ ຂາ ສ່ວ ນ ລຸ່ມ ໂດ ຍ ບໍ່ ຈ ໍາ ເ ປ ັນ ເນື່ ອ ງ ຈ າກ ເບ ົາຫ ວ ານ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m ed ia ce nt re /n ew s/ re le as es /2 00 5/ pr 61 /e n/ 51 P ec or ro , R ., R ei be r, G ., & Bu rg er ss , E . ( 19 90 ). ເສັ້ ນ ທ າງ ໄປ ສູ່ ກ ານ ຕັດ ແຂ ນ ຂາ ເນື່ ອ ງ ຈ າກ ເບ ົາຫ ວ ານ : ພື້ ນ ຖ ານ ສໍາ ລັ ບ ກາ ນ ປ້ອ ງ ກັ ນ . ກ ານ ດູ ແ ລ ເບ ົາຫ ວ ານ , 1 3( 5) , 5 13 –5 21 . 52 T ra ut ne r, C ., H aa st er t, B. , G ia ni , G ., & Be rg er , M . ( 19 96 ). ອ ັດ ຕ າ ກ ານ ຕັດ ຂາ ສ່ວ ນ ລຸ່ມ ແ ລ ະ ພ ະ ຍ າດ ເບ ົາຫ ວ ານ . ກ ານ ດູ ແ ລ ເບ ົາຫ ວ ານ , 1 9( 9) , 1 00 6- 10 09 . 53 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 01 0) . ກ ານ ຄຸ້ມ ຄອ ງ ບ າດ ແຜ ແ ລ ະ ກ ານ ບວ ມ ນໍ້າ ເຫ ຼືອ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/p ub lic at io ns /2 01 0/ 97 89 24 15 99 13 9_ en g. pd f ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 37 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຄວາມອິດ ເມື ່ ອຍ ຜູ້ ໃຊ້ ລດົ ເຂ ນັ ບາ ງ ຄ ນົ ອາ ດ ຈະ ອດິ ເມື່ ອ ຍ ເປ ນັ ປະ ຈ າໍ ໃນ ລະ ຫ ວ ່າງ ມື້. ນີ້ ອາ ດ ຈະ ເປ ັນ ຍ້ອ ນ ຄວ າ ມ ພ ະ ຍ າຍ າມ ແ ລ ະ ພ ະ ລັ ງງ ານ ເພີ່ ມ ເຕີ ມ ທ ີ່ ພ ວ ກ ເຂ ົາ ໃ ຊ ້ ເພື່ ອ ນັ່ງ ຕັ້ງ ຊື່ ແລ ະ ເ ຮ ັດ ກິດ ຈ ະ ກ ໍາ ຕ່ າງ ໆ ຫ ຼື ລ ັກ ສ ະ ນ ະ ຂອ ງ ອ າກ ານ ເຈ ັບ ປ່ວ ຍ ຂອ ງ ເຂ ົາ ເ ຈ ົ້າ. ຄ ວ າມ ອິດ ເມື່ ອ ຍ ສາ ມ າດ ເປ ັນ ບັນ ຫ າ ສໍ າລັ ບ ຜູ້ ສູ ງ ອ າຍຸ ບາ ງ ຄ ົນ ຫ ຼື ບ າງ ຄົ ນ ທີ່ ມີ ອ າກ ານ ເຈ ັບ ປ່ວ ຍ ຂ ະ ຫ ຍ າຍ ຕົ ວ (5 0, 5 1) . ï ອາ ດ ຈະ ສາ ມ າດ ນັ່ງ ຕັ້ງ ຊື່ ໄດ້ , ແ ນ ວ ໃດ ກໍ ຕ າມ ບ ໍ່ ສ າມ າດ ນັ່ ງ ຕັ້ ງ ຊື່ ເປ ັນ ເວ ລ າ ດ ົນ ໄດ້ ເ ນື່ ອ ງ ຈ າກ ຄ ວ າມ ອິດ ເມື່ ອ ຍ ; ï ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ພົ ບ ວ່າ ມັນ ຍາ ກ ໃນ ກາ ນ ຮັກ ສ າ ທ ່າ ນັ່ ງ ຕັ້ ງ ຊື່ ເນື່ ອ ງ ຈ າກ ຄວ າມ ເມື່ ອ ຍ , ພ ວ ກ ເຂ ົາ ມີ ຄວ າມ ສ່ຽ ງ ເ ພີ່ ມ ຂຶ້ນ ທ ີ່ ຈະ ພັ ດ ທ ະ ນ າ ບ ັນ ຫ າ ດ ້ານ ທ່ າ ທ າງ . ï ລອ ງ ຊ ອ ກ ຮູ້ ວ ່າ ແ ມ ່ນ ຫ ຍ ັງ ທ ີ່ ເຮ ັດ ໃຫ ້ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ເມື່ ອ ຍ . ນີ້ ຈະ ຊ່ວ ຍ ໃຫ ້ ທ ່ານ ຮູ້ ວ ິທ ີ ແກ ້ ໄຂ ທ ີ່ ດີ ສຸ ດ ສໍ າລັ ບ ເຂ ົາ ເ ຈ ົ້າ. ï ໃນ ເວ ລ າ ຕັ ດ ສິ ນ ວ່າ ຈະ ໃຫ ້ກ ານ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ຫ ຼາຍ ປ ານ ໃດ , ໃ ຫ ້ ພິ ຈ າ ລ ະ ນ າ ຜົ ນ ກະ ທົ ບ ຂອ ງ ຄ ວ າມ ອິດ ເມື່ ອ ຍ . ໃ ນ ລະ ຫ ວ ່າງ ກາ ນ ປະ ເມີ ນ ຜົ ນ ລ ົດ ເຂ ັນ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ອາ ດ ຈະ ມີ ແ ຮ ງ ຫ ຼາຍ ກ ວ່ າ ແ ລ ະ ປ ະ ກົ ດ ວ່າ ຈໍາ ເປ ັນ ຕ້ອ ງ ມີ ກາ ນ ຮ ອ ງ ຮັ ບ ທ ີ່ ໜ ້ອ ຍ ກວ່ າ. ຈ ົ່ ງປຶ ກ ສ າ ຫ າລື ຢ່າ ງ ລ ະ ອ ຽດ ກັບ ຜູ້ ໃ ຊ ້ ລ ົດ ເຂ ັນ ກ່ຽ ວ ກັບ ວ່າ ລາ ວ ຕ້ອ ງກ ານ ກາ ນ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ຫ ຼາຍ ປ ານ ໃດ ໃ ນ ເວ ລ າ ທ ີ່ ພ ວ ກ ເຂ ົາ ອ ິ ດ ເມື່ ອ ຍ ທ ີ່ ສຸດ . ï ພິ ຈ າລ ະ ນ າ ທ ່າ ພັ ກ ຜ່ ອ ນ ທ າງ ເລ ືອ ກ – ຕົ ວ ຢ ່າງ ຖ າດ ທ ີ່ ມີ ເ ບ າະ ຮອ ງ ນັ່ ງ ສ າມ າດ ເຮ ັດ ໃຫ ້ ບາ ງ ຄ ົນ ເອ ນ ໄປ ໜ ້າ ຢ ູ່ ເທ ິງ ແ ຂ ນ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ໄ ດ້ ; ກ ານ ອ່ ຽງ ໃນ ກາ ງຫ າວ ແມ ່ນ ທ ່າ ພັ ກ ຜ່ ອ ນ ອີກ ອັນ ໜ ຶ່ງ. ï ກ ານ ວ າງ ແຜ ນ ມີ ກ າ ກ ພັ ກ ຜ່ ອ ນ ຢູ່ ນ ອ ກ ລົດ ເຂ ັນ ໃນ ລ ະ ຫ ວ ່າງ ມື້ ອ າດ ຈະ ເຮ ັດ ໃຫ ້ ມັນ ເປ ັນ ໄປ ໄດ້ ໃນ ກາ ນ ນັ່ ງ ຢ ່າງ ສະ ບ າ ຍ ຕົ ວ ກວ່ າ ເ ປ ັນ ເວ ລ າ ດ ົນ ກວ່ າ. 54 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 00 8) . A tla s: ແ ຫ ຼ່ງຄ ວ າມ ຊ່ວ ຍ ເຫ ຼືອ ກ່ຽ ວ ກັບ ກາ ນ ແຂ ງ ຕົ ວ ຂອ ງ ເ ນື້ ອ ເຍ ື່ອ ຫ ຼາຍ ຈຸ ດ ໃນ ໂລ ກ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m en ta l_ he al th /n eu ro lo gy /A tla s_ M S_ W EB .p df 55 ມູ ນນິ ທ ິ ພ ະ ຍ າດ ພ າຄິ ນ ສັ ນ . ( n. d. ). ຄວ າມ ອິ ດ ເມື່ ອ ຍ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .p df .o rg /e n/ fa tig ue _p df 38 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ສະ ໂພ ກທີ ່ ຫຼ ຸ ດ ໂບກ ມີ ກາ ນ ເກີ ດ ສະ ໂພ ກຫຼຸ ດ ໂບ ກ ໃນ ອັດ ຕ າ ທ ີ່ ສູງ ກວ່ າ ໃນ ເດ ັກ ນ້ ອ ຍ ຜູ້ ທ ີ່ ບໍ່ ເ ຄ ີຍ ສາ ມ າດ ຍ່າ ງ ໄ ດ້ ດ້ວ ຍ ຕົນ ເອ ງ (5 6, 5 7, 5 8) . ນີ້ ເປ ັນ ຍ້ອ ນ ວ່າ ໂບ ກ ( ເ ບ ົ້າ ຫ ົວ ກ ະ ດູ ກ ຕົ້ນ ຂາ ) ຢ ູ່ ກະ ດູ ກ ກົກ ແອ ວ ອ່ອ ນ ໃນ ເວ ລ າ ທ ີ່ ເດ ັກ ເກີ ດ , ແ ລ ະ ຫ ົວ ມົນ ຂອ ງກ ະ ດູ ກ ໂຄ ນ ຂ າປັ ບ ຮູ ງ ຮ່ າງ ເປ ັນ ໂບ ກ ໃ ນ ເວ ລ າ ທ ີ່ ຂາ ເຄ ື່ອ ນ ເໜ ັງ, ຫ ຼື ໃ ນ ເວ ລ າ ທ ີ່ ນໍ້າ ໜັ ກ ຍູ້ ຜ່ ານ ມັນ ໃນ ເວ ລ າ ຢ ືນ . ຖ ້າ ຂໍ້ ຕໍ່ ສ ະ ໂພ ກບໍ່ ເຂ ົ້າ ຮູ ບ ຢ່າ ງ ຖ ື ກ ຕ້ ອ ງ, ນີ້ ສ າມ າດ ນໍາ ໄປ ສູ່ ກ ານ ຫຼຸ ດ ໂບ ກ ໄດ້ . ມັ ນ ຍັງ ພົ ບ ເຫ ັນ ຫ ຼາຍ ທີ່ ສຸດ ໃນ ເດ ັກ ນ້ ອ ຍ ຜູ້ ທ ີ່ ມີ ກ້ າມ ເນື້ ອ ເຄ ັ່ງ ແລ ະ ຄ ວ າມ ຕຶງ ສູ ງ ຢ ູ່ ບໍລ ິ ເວ ນ ສະ ໂພ ກ ແລ ະ ກົ ກ ແອ ວ ແ ລ ະ ມັ ກ ນັ່ງ ຫ ຼື ນ ອ ນ ໂດ ຍ ທ ີ່ ຂ າ ອ່ຽ ງ ໄ ປ ຂ້າ ງ ໜ ຶ່ງ (5 5) . ນີ້ ສາ ມ າດ ເປ ັນ ບັນ ຫ າ ສໍ າລັ ບ ຄົ ນ ທີ່ ສະ ໝ ອ ງ ພິ ກ ານ (5 7, 6 0) ຫ ຼື ມີ ກາ ນ ບ າດ ເຈ ັບ ສະ ໝ ອ ງ ເ ນື່ ອ ງ ຈ າກ ກະ ທົ ບ ກະ ເທ ືອ ນ (6 0) . (ສື ບຕໍ່ ໃນ ໜ ້າ ຕໍ່ ໄປ ) ï ບ າງ ກາ ນ ບົ່ງ ຊີ້ ທ ີ່ ບຸກ ຄົ ນ ອາ ດ ຈະ ມີ ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ / ເ ຄ ື່ອ ນ ຍ້າ ຍ ແ ມ ່ນ : – ຂ າ ຂ້ າງ ໜ ຶ່ງ ປ ະ ກົ ດ ວ່າ ສັ້ນ ກວ່ າ ອ ີກ ຂ້າ ງ (6 0) ; – ຂາ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ມັ ກ ຈະ ຢູ່ ໃ ນ ຕໍາ ແໜ ່ ງທີ່ ໃກ້ ກວ່ າ ກັ ບ ເສັ້ ນ ເຄ ິ່ງກ າງ ; – ມີ ກາ ນ ເຈ ັບ ເມື່ ອ ສະ ໂພ ກ ເ ຄ ື່ອ ນ ເໜ ັງ (6 0) ; – ໃນ ເວ ລ າດໍ າເ ນີ ນ ກ ານ ເຄື່ ອ ນ ເໜ ັງສ ະ ໂພ ກ ມັ ນ ອ າດ ຈະ ເປ ັນ ໄປ ບໍ່ ໄ ດ້ ໃນ ກາ ນ ເອ ົາ ກົ ກ ຂ າ ໄ ວ້ ຕໍາ ແໜ ່ ງປົ ກ ກ ະ ຕິ ຫ ຼື ຢ ູ່ ດ້າ ນ ນອ ກ ຂອ ງ ຮ່ າງ ກ າຍ ; – ມັ ນ ເປ ັນ ໄປ ບໍ່ ໄ ດ້ ໃນ ກາ ນ ຢຽ ດ ສະ ໂພ ກອ ອ ກ ເຕັ ມ . ï ກ ານ ຄົ້ນ ຄວ ້າ ວ ິ ໄຈ ສະ ແດ ງ ໃ ຫ ້ ເຫ ັນ ວ່າ ສິ່ ງ ຕໍ່ ໄປ ນີ້ ສ າມ າດ ຊ່ວ ຍ ຫ ຼຸດ ຜ່ ອ ນ ແນ ວ ໂນ້ ມ ກ ານ ເກີ ດ ສະ ໂພ ກຫຼຸ ດ ໂບ ກ ໄດ້ . – ໃຫ ້ ແນ ວ ຮອ ງ ທ ່າ ປ ົກ ກ ະ ຕິ ໃນ ກາ ນ ນັ່ງ ແ ລ ະ ກ ານ ນອ ນ ນັບ ຕັ້ງ ແຕ່ ອາ ຍຸ ຍັງ ນ້ອ ຍ . ສໍ າລັ ບ ເດ ັກ ນ້ ອ ຍ ນີ້ ລ ວ ມ ມີ ກ ານ ຮອ ງ ສ ະ ໂພ ກ/ ກົ ກ ຂ າ ໃ ນ ບ ໍລ ິ ເວ ນ ກາ ງ ຂ າ (6 1, 6 2) ; – ກ ານ ຢືນ ໃນ ທ ່າ ປ ົກ ກ ະ ຕິ (ຕົ ວ ຢ ່າງ ໃ ນ ໂຄ ງ ຊ່ ວ ຍ ຢືນ ) ( 63 ) . (ສື ບຕໍ່ ໃນ ໜ ້າ ຕໍ່ ໄປ ) 56 S oo , B ., et a l. (2 00 6) . ສ ະ ໂພ ກ ເ ຄ ື່ອ ນ ຍ້າ ຍ ໃນ ຜູ້ ທ ີ່ສ ະ ໝ ອ ງ ພິ ກ ານ . ວ າລ ະ ສ ານ ກ່ຽ ວ ກັບ ກາ ນ ຜ່ າຕັ ດ ກະ ດູ ກ ແ ລ ະ ຂໍ້ ຕໍ່, 8 8, 1 21 –1 29 . 57 S cr ut to n, D ., Ba ird , G ., & Sm ee to n, N . ( 20 01 ). ຄ ວ າມ ຜິດ ປົກ ກ ະ ຕິ ຂອ ງ ສ ະ ໂພ ກ ໃ ນ ຄົນ ສະ ໝ ອ ງ ພິ ກ ານ ທ ັງ ສ ອ ງ ຂ້ າງ : ອ ັດ ຕ າ ກ ານ ເກີ ດ ແ ລ ະ ປ ະ ຫ ວ ັດ ທ າງ ທ ໍາ ມ ະ ຊາ ດ ໃນ ເດ ັກ ອາ ຍຸ 1 8 ເດ ືອ ນ ຫ າ 5 ປ ີ. ກ ານ ແພ ດ ດ້າ ນ ພັ ດ ທ ະ ນ າ ກ ານ ແ ລ ະ ປ ະ ສ າດ ວິດ ທ ະ ຍ າ ໃ ນ ເດ ັກ , 4 3, 4 86 -6 00 58 L on st ei n, J ., & Be ck , K . ( 19 86 ). ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ ແ ລ ະ ຂໍ້ ຕໍ່ ເ ຄ ື່ອ ນ ຍ້າ ຍ ບາ ງ ສ່ ວ ນ ໃນ ຜູ້ ພິ ກ ານ ສະ ໝ ອ ງ. ວ າລ ະ ສ ານ ກ່ຽ ວ ກັບ ອຸປ ະ ກ ອ ນ ພ ະ ຍຸ ງ ໃ ນ ເດ ັກ , 6 , 5 21 –5 26 . 59 ໂ ຮ ງໝໍ ເດ ັກ B os to n. (n .d .). ປ ື້ ມຄູ່ ມື ສໍ າລັ ບ ກາ ນ ຜ່ າຕັ ດ ສະ ໂພ ກ ໃ ນ ເດ ັກ ທ ີ່ ພິ ກ ານ ສະ ໝ ອ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// ch ild re ns ho sp ita l.o rg /c lin ic al se rv ic es /S ite 11 66 /D oc um en ts /C P. LE .B oo k. w eb 2. pd f 60 ອ ົງກ ານ ອະ ນ າ ໄ ມ ໂລ ກ , ສູ ນ ກາ ນ ບາ ດ ເຈ ັບ ທ າງ ສະ ໝ ອ ງ D ru ck er ຂ ອ ງກ ະ ຊ ວ ງ ປ ້ອ ງ ກັ ນ ປະ ເທ ດ ຂອ ງສ ະ ຫ ະ ລັ ດ , ໂ ຮ ງໝໍ M os sR eh ab H os pi ta l. (2 00 4) . ກ ານ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ສໍາ ລັ ບ ຄົ ນ ທີ່ ມີ ບ າດ ເຈ ັບ ທ າງ ສະ ໝ ອ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/h q/ 20 04 /W H O _D AR _0 1. 9_ en g. pd f 61 P ou nt ne y, T ., M an dy , A ., G re en , E ., & G ar d, P . ( 20 09 ). ກ ານ ເຄ ື່ອ ນ ຍ້າ ຍ ແ ລ ະ ກ ານ ຫຼຸ ດ ໂບ ກ ຂອ ງ ສ ະ ໂພ ກ ໃ ນ ຜູ້ ພິ ກ ານ ສະ ໝ ອ ງ – ກ ານ ສຶກ ສ າກ່ ຽວ ກັບ ປະ ສິ ດ ທ ິ ຜົນ ຂ ອ ງ ແ ຜ ນ ງາ ນ ຄຸ້ມ ຄອ ງ ທ ່າ ທ າງ . ກ ານ ຄົ້ນ ຄ ວ ້າ ວ ິ ໄຈ ດ້າ ກ າ ຍ ະ ບໍາ ບັ ດ ລະ ຫ ວ ່າງ ປະ ເທ ດ , 1 4( 2) , 1 16 –1 27 . 62 ສູ ນ ສຸຂ ະ ພ າບ ສໍາ ລັ ບ ເດ ັກ . ( 20 11 ). ຫ ຼັກ ຖ ານ ສໍາ ລັ ບ ວິທ ີ ປະ ຕິ ບ ັດ : ກ ານ ເຝົ້ າ ລ ະ ວ ັງ ແລ ະ ກ ານ ຄຸ້ມ ຄອ ງ ສ ະ ໂພ ກ ເ ຄ ື່ອ ນ ຍ້າ ຍ ແ ລ ະ ຫ ຼຸດ ໂບ ກ ໃນ ເດ ັກ ທ ີ່ ມີ ຄ ວ າມ ຜິດ ປົກ ກ ະ ຕິ ຂອ ງ ເ ສັ້ ນ ປ ະ ສ າດ ເຄ ື່ອ ນ ໄຫ ວ ເຊ ິ່ງລ ວ ມ ທັ ງ ສ ະ ໝ ອ ງ ພິ ກ ານ . Va nc ou ve r, BC : T an ja M ay so n. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 39 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ສະ ໂພ ກຫຼ ຸ ດ ໂບກ (ສືບ ຕໍ ່ ) ສໍ າລັ ບ ເດ ັກ ນ້ ອ ຍ ທ ີ່ ບໍ່ ທ ັນ ຍ່າ ງ ເ ທ ື່ອ ແ ລ ະ ມີ ແນ ວ ໂນ້ ມ ຈ ະ ນອ ນ ໂດ ຍ ທ ີ່ ຂ້າ ງ ທ ັງ ສ ອ ງ ຂ້ າງ ພັ ບ ໄປ ຂ້າ ງດ ຽວ ( ແ ບ ບ ລົມ ພັ ດ ): ສ ະ ໂພ ກ ເຊ ິ່ງ ໃ ກ້ ທ ີ່ ສຸດ ກັບ ເສັ້ ນ ເຄ ິ່ງກ າງ ຂ ອ ງ ຮ່ າງ ກ າຍ (ຫ ຸບ ເຂ ົ້າ ເ ຄ ິ່ງກ າງ ) ແ ລ ະ ປ ິ່ນ ເຂ ົ້າ (ໝູ ນ ຢູ່ ພ າຍ ໃນ ) ແ ມ ່ນ ສະ ໂພ ກທີ່ ເປ ັນ ໄປ ໄດ້ ທ ີ່ ສຸດ ທ ີ່ ຈະ ຫ ຼຸດ ໂບ ກ (6 3) . ເມື່ ອ ເດ ັກ ນ້ ອ ຍ ມີ ຄ ວ າມ ຕຶງ ກ້າ ມ ເນື້ ອ ຕໍ່າ ຢູ່ ບໍລ ິ ເວ ນ ຂໍ້ ຕໍ່ ສ ະ ໂພ ກ, ພ ວ ກ ເຂ ົາ ສ າມ າດ ມີ ຄ ວ າມ ສ່ຽ ງ ເກີ ດ ສະ ໂພ ກຍ້ າຍ ບ່ອ ນ ໄດ້ . ນີ້ ເປ ັນ ຍ້ອ ນ ວ່າ ກ້າ ມ ເນື້ ອ ແ ລ ະ ເ ອ ັນ ບໍ່ ແ ຂ ງ ແ ຮ ງ ພ ຽງ ພໍ ເພື່ ອ ຢຶດ ສ ອ ງ ສ່ ວ ນ ຂອ ງ ຂໍ້ ຕໍ່ ສ ະ ໂພ ກ ເ ຂ ົ້າກັ ນ ( ເ ບ ົ້າ ຫ ົວ ກະ ດູ ກ ຕົ້ ນ ຂາ ແ ລ ະ ຫ ົວ ກະ ດູ ກ ຂາ ). ສ ະ ໂພ ກທີ່ ຫ ຼຸດ ໂບ ກ ບ ໍ່ ເຈ ັບ ສະ ເໝີ ໄປ (6 4, 6 5, 6 6) . ï ໃນ ເວ ລ າ ປ ະ ເ ມີ ນ ເດ ັກ ນ້ ອ ຍ ຫ ຼື ຜູ້ ໃຫ ຍ ່ທ ີ່ ມີ ສັ ນ ຍ ານ ບົ່ງ ຊີ້ ເ ຖ ິງ ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ ທ ີ່ ເປ ັນ ໄປ ໄດ້ , ໃ ຫ ້ ເຄ ື່ອ ນ ຍ ້າຍ ສ ະ ໂພ ກ ເ ບ ົາ ໆ ແ ລ ະ ຫ ຼີກ ເວ ັ້ນ ກ ານ ເຮ ັດ ໃຫ ້ ເຈ ັບ . ï ຖ ້າ ທ ່ານ ບໍ່ ແ ນ ່ ໃຈ ວ່າ ເດ ັກ ນ້ ອ ຍ ຫ ຼື ຜູ້ ໃຫ ຍ ່ ມີ ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ ຫ ຼືບ ໍ່ ໃ ຫ ້ ນໍາ ສົ່ງ ເດ ັກ ນັ້ນ ຫ າ ທ ່ານ ໝໍ / ແ ພ ດ ເດ ັກ ຫ ຼື ນັ ກ ກາ ຍະ ບໍາ ບັ ດ ທ ີ່ ມີ ປ ະ ສົ ບ ກາ ນ (ຖ ້າ ເ ປ ັນ ໄປ ໄດ້ ) ເ ພື່ ອ ຂໍ ຄ ໍາ ແ ນ ະ ນໍ າ ເ ພີ່ ມ ເຕີ ມ . ï ໃນ ເວ ລ າ ສ ະ ໜ ອ ງ ລ ົດ ເຂ ັນ ແ ລ ະ ກ ານ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ສໍ າລັ ບ ເດ ັກ ນ້ອ ຍ ຫ ຼື ຜູ້ ໃຫ ຍ ່ ທ ີ່ ມີ ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ ຫ ຼື ສົ ງ ໄ ສ ວ່າ ມີ ສ ະ ໂພ ກ ຫຼຸ ດ ໂບ ກ : – ຫ ຼີກ ເວ ັ້ນ ທ່ າ ທ າງ ຕ່າ ງໆ ທ ີ່ ຈະ ເຮ ັດ ໃຫ ້ ເຈ ັບ ; – ຮ ອ ງສ່ ວ ນ ກົກ ແອ ວ ແ ລ ະ ລ ໍາ ຕົ ວ ໃນ ທ ່າ ປ ົກ ກ ະ ຕິ ( ໃ ກ້ ກັບ ທ ່າ ປ ົກ ກ ະ ຕິ ເທ ົ່າ ທ ີ່ ຈະ ເປ ັນ ໄປ ໄດ້ ); ຈ າກ ນັ້ນ ຮ ອ ງ ສ ະ ໂພ ກ ແລ ະ ກົ ກ ຂ າ ໃ ກ້ ກັບ ທ ່າ ປ ົກ ກ ະ ຕິ ເທ ົ່າ ທ ີ່ ຈະ ເປ ັນ ໄປ ໄດ້ . ຫ ຼີກ ເວ ັ້ນ ëກ ານ ແກ ້ ໄຂ ເກີ ນ ໄປ í ສໍ າລັ ບ ທ ່າ ຂ າ ເພ າະ ວ່ າ ອ ັນ ນີ້ ອ າດ ຈະ ເຮ ັດ ໃຫ ້ ກະ ດູ ກ ກົກ ແອ ວ ເຄ ື່ອ ນ ຍ້ າ ຍ ໜ ີ ຈາ ກ ທ ່າ ປ ົກ ກ ະ ຕິ ແ ລ ະ /ຫ ຼື ເຮ ັດ ໃຫ ້ ເຈ ັບ ປວ ດ ; – ກວ ດ ເບ ິ່ງ ວ ່າ ບ ຸກ ຄົ ນ ນັ້ນ ນອ ນ ໃນ ທ ່າ ໃ ດ . ແ ນ ະ ນໍ າ ກ່ ຽວ ກັບ ທ ່ານ ອນ ທ ີ່ ຫ ຼີກ ເວ ັ້ນ ທ່ າ ລ ົມ ພັ ດ ຂອ ງ ຂ າ ແລ ະ ບ ໍ່ ໃຫ ້ຂ າຖື ກ ບີ ບ ເຂ ົ້າກັ ນ ແໜ ້ນ ເກີ ນ ໄປ . 63 P op e, P . ( 20 07 ). ຄ ວ າມ ພິ ກ ານ ທ າງ ລ ະ ບົ ບ ປະ ສ າດ ທ ີ່ ຮ້າ ຍ ແຮ ງ ແລ ະ ສັ ບ ສົ ນ : ກ ານ ຄຸ້ມ ຄອ ງ ອ າກ ານ ທ າງ ຮ່າ ງກ າຍ . P hi la de lp hi a: E ls ev ie r L im ite d. 64 S he rk , H ., Pa sq ua rie llo , P ., & D oh er ty , J . ( 20 08 ). ສ ະ ໂພ ກ ຫ ຼຸດ ໂບ ກ ໃນ ຜູ້ ທ ີ່ສ ະ ໝ ອ ງ ພິ ກ ານ : ກ ານ ເລ ືອ ກ ສໍາ ລັ ບ ກາ ນ ປິ່ນ ປົ ວ . ກ ານ ແພ ດ ດ້າ ນ ພັ ດ ທ ະ ນ າ ກ ານ ແ ລ ະ ປ ະ ສ າດ ວິດ ທ ະ ຍ າ ໃ ນ ເດ ັກ , 25 (6 ), 73 8– 74 6. 65 M or ea u, M . e t a l. (1 97 9) . ປ ະ ຫ ວ ັດ ທ າງ ທ ໍາ ມ ະ ຊາ ດ ຂອ ງ ສ ະ ໂພ ກຫຼຸ ດ ໂບ ກ ໃນ ຜູ້ ສະ ໜ ອ ງ ພິ ກ ານ ທ ີ່ ຊັກ ກະ ຕຸ ກ . ກ ານ ແພ ດ ດ້າ ນ ພັ ດ ທ ະ ນ າ ກ ານ ແ ລ ະ ປ ະ ສ າດ ວິດ ທ ະ ຍ າ ໃ ນ ເດ ັກ , 2 1( 6) , 7 49 -7 53 . 66 K na pp , R ., & C or te s, H . ( 20 02 ). ສ ະ ໂພ ກ ຫ ຼຸດ ໂບ ກ ທ ີ່ ບໍ່ ໄ ດ້ ຮັບ ກາ ນ ປິ່ນ ປົ ວ ໃນ ຜູ້ ທ ີ່ສ ະ ໝ ອ ງ ພິ ກ ານ . ວ າລ ະ ສ ານ ກ່ຽ ວ ກັບ ອຸປ ະ ກ ອ ນ ພ ະ ຍຸ ງ ໃ ນ ເດ ັກ , 2 2, 6 68 -6 71 . 40 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ໂຣກບ້ າໝູ ໂຣ ກ ບ້ າ ໝູ ແມ ່ນ ກາ ນ ຂັດ ຂ ວ າງ ກິດ ຈ ະ ກໍ າ ປ ົກ ກ ະ ຕິ ຂອ ງ ສ ະ ໝ ອ ງ ທ ີ່ ສົ່ງ ຜົນ ໃຫ ້ ເກີ ດ ອາ ກ ານ ຊັ ກ ບ້ າໝູ (6 7, 6 8, 6 9, 7 0) . ຢ ູ່ ພ າຍ ໃຕ້ ສະ ພ າບ ກ ານ ສ ະ ເພ າະ ບ ຸກ ຄົ ນ ໃດ ໆ ກໍ ສ າມ າດ ມີ ອ າກ ານ ຊັ ກ ໄດ້ (7 0) . ຄ ໍາ ສັ ບ ໂຣ ກ ບ້ າໝູ ຖືກ ໃຊ ້ ພ ຽງ ແຕ່ ສໍ າລັ ບ ອ າ ກ ານ ຊັກ ທ ີ່ ເກີ ດ ຂຶ້ນ ປ ະ ຈ ໍາ ແລ ະ ບໍ່ ມີ ສາ ເຫ ດ (6 9, 7 0) . (ສື ບຕໍ່ ໃນ ໜ ້າ ຕໍ່ ໄປ ) ສິ່ ງ ທ ີ່ ຕ້ອ ງ ເ ຮ ັດ ຖ້າ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ມີ ອ າກ ານ ຊັກ ໃນ ລ ະ ຫ ວ ່າງ ກາ ນ ປ ະ ເມີ ນ ຜົ ນ ລົດ ເຂ ັນ : ໃນ ເລ າ ທ ີ່ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ມີ ກ ານ ຊັກ ເລ ັກ ນ້ອ ຍ , ໃ ຫ ້ ລໍຖ ້າ ໃຫ ້ ອາ ກ ານ ຊັກ ເຊ ົາ ຈາ ກ ນັ້ນ ສື ບ ຕໍ່ ກ ານ ປະ ເມີ ນ ຜົ ນ . ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ມີ ກ ານ ຊັກ ຮຸນ ແຮ ງ ສິ່ ງ ສໍ າຄັ ນ ທ ໍາ ອ ິດ ແມ ່ນ ກາ ນ ປົກ ປ້ອ ງ ຜູ້ ກ່ ຽວ ຈາ ກ ກາ ນ ບາ ດ ເຈ ັບ (7 1) . ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ລົ້ມ ໄປ ທ າງ ໜ້ າ, ໃ ຫ ້ ພ ະ ຍ າຍ າມ ບັນ ເທ ົາ ກ ານ ລົ້ມ . ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ແມ ່ນ ເດ ັກ ນ້ ອ ຍ ຫ ຼື ຜູ້ ໃຫ ຍ ່ທ ີ່ ໂຕ ນ້ອ ຍ , ມັ ນ ອາ ດ ຈະ ເປ ັນ ໄປ ໄດ້ ໃນ ກາ ນ ຍົກ ພ ວ ກ ເຂ ົາ ຂຶ້ ນ ເທ ິງ ພື້ ນ . ຖ ້າ ຜູ້ ກ່ ຽວ ແ ມ ່ນ ຜູ້ ໃ ຫ ຍ ່ ທ ີ່ ໂຕ ໃຫ ຍ ່, ມັ ນ ຈໍາ ເປ ັນ ສໍາ ລັ ບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ໃນ ກາ ນ ຄົງ ຢູ່ ບ ່ອ ນ ທ ີ່ ຜູ້ກ່ ຽວ ຢູ່ ( ເ ນື່ ອ ງ ຈ າກ ຄ ວ າມ ສ່ຽ ງ ເ ກີ ດ ກາ ນ ບາ ດ ເຈ ັບ ທ ີ່ ເປ ັນ ໄປ ໄດ້ ຕໍ່ ກັ ບ ຜູ້ ທ ີ່ ໃຫ ້ກ ານ ຊ່ວ ຍ ເຫ ຼືອ ) ແ ລ ະ ເ ມື່ ອ ອາ ກ ານ ຊັກ ຢຸດ ເຊ ົາ, ໃຫ ້ ຄ່ອ ຍ ໆ ຍົກ ຜູ້ກ່ ຽວ ຂຶ້ນ ດ້ວ ຍ ມີ ກ ານ ຊ່ວ ຍ ເຫ ຼືອ ຂ ອ ງ ເພື່ ອ ນ ຮ່ວ ມ ງາ ນ /ຄ ົນ ໃນ ຄອ ບ ຄ ົວ ຫ ຼື ຜູ້ ໃຫ ້ກ ານ ເບ ິ່ງ ແ ຍ ງ. (ສື ບຕໍ່ ໃນ ໜ ້າ ຕໍ່ ໄປ ) ໃນ ເວ ລ າ ໃ ຫ ້ ລົດ ເຂ ັນ ແກ ່ ຜູ້ ທ ີ່ ເປ ັນ ໂຣ ກ ບ້ າໝູ ໃ ຫ ້ ຈື່ ວ ່າ: ï ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ຈໍາ ເປ ັນ ຕ້ອ ງ ມີ ສາ ຍ ຮັ ດ ທ ີ່ ສາ ມ າດ ເປ ີດ ໄດ້ ງ່າ ຍ ດາ ຍ ເພື່ ອ ຊ່ວ ຍ ພ ວ ກ ເຂ ົາ ອ ອ ກ ຈາ ກ ລົ ດ ເຂ ັນ ; (ສື ບຕໍ່ ໃນ ໜ ້າ ຕໍ່ ໄປ ) 67 M cN am ar a, J . ( 19 94 ). ພື້ ນ ຖ ານ ດ້າ ນ ເຊ ລ ແລ ະ ໂ ມ ເລ ກຸນ ຂອ ງ ໂ ຣ ກ ບ້ າໝູ . ວ າລ ະ ສ ານ ກ່ຽ ວ ກັບ ປະ ສ າດ ວິທ ະ ຍ າ, 1 4( 6) , 3 41 3– 34 25 . 68 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 00 5) . A tla s: ກ ານ ດູ ແ ລ ໂຣ ກ ບ້ າໝູ ໃນ ໂລ ກ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m en ta l_ he al th /n eu ro lo gy /E pi le ps y_ at la s_ r1 .p df 69 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 00 2) . ໂ ຣ ກ ບ້ າໝູ : ປ ື້ ມຄູ່ ມື ສໍ າລັ ບ ເຈ ົ້າ ໜ ້າກ ານ ແພ ດ ແ ລ ະ ຄ ລ ີ ນິກ ໃນ ອາ ຝຣິ ກ າ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m en ta l_ he al th /m ed ia /e n/ 63 9. pd f 70 ອ ົງ ກ ານ ອະ ນາ ໄມ ໂລ ກ (2 00 6) . ຄ ວ າມ ຜິດ ປົກ ກ ະ ຕິ ຂອ ງ ລ ະ ບ ົບ ປະ ສ າດ : ສິ່ ງ ທ ້າ ທ າຍ ດ້າ ນ ສາ ທ າລ ະ ນ ະ ສຸກ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .w ho .in t/m en ta l_ he al th /n eu ro lo gy /c ha pt er _3 _a _n eu ro _ di so rd er s_ pu bl ic _h _c ha lle ng es .p df 71 ມູ ນ ນິທ ິ ໂຣ ກ ບ້ າໝູ . ( n. d. ). ກ ານ ຊ່ວ ຍ ເຫ ຼືອ ຂ ັ້ນ ຕົ້ນ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .e pi le ps yf ou nd at io n. or g/ ab ou te pi le ps y/ fir st ai d/ in de x. cf m ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 41 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ໂຣກບ້ າໝູ (ສືບ ຕໍ ່ ) ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ບາ ງ ຄ ົນ ອາ ດ ຈະ ເປ ັນ ບ້າ ໝູ . ກ ານ ຊັ ກ ອາ ດ ຈະ ເປ ັນ ບາ ງສ່ ວ ນ ຫ ຼື ທ ົ່ວ ຮ່າ ງກ າຍ (7 0) . ໃ ນ ລະ ຫ ວ ່າງ ກາ ນ ຊັກ ບາ ງ ສ່ ວ ນ ຂ ອ ງ ຮ່ າງ ກ າຍ ບ ຸກ ຄົ ນ ອາ ດ ຈະ ບໍ່ສູ ນ ເສ ຍ ສະ ຕິ ຮູ້ ສຶ ກ (7 0) . ຖ ້າ ບ ໍ່ ສູນ ເສ ຍ ສະ ຕິ ຮູ້ ສຶ ກ ອ າກ ານ ຊັກ ແ ກ ່ຍ າວ ນ້ອ ຍ ກວ່ າ ໜ ຶ່ງ ນ າທີ ແ ລ ະ ໂ ດ ຍ ປົກ ກ ະ ຕິ ບ ຸກ ຄົ ນ ກໍາ ລັ ງ ມີ ກາ ນ ເຄ ື່ອ ນ ເໜ ັງ ຮ່ າງ ກ າຍ ທ ີ່ ຄ ວ ບ ຄຸມ ບໍ່ ໄ ດ້ (7 2) . ຖ ້າ ກ າຍ ເປ ັນ ສູ ນ ເສ ຍ ສະ ຕິ ຮູ້ ສຶ ກ , ອ າກ ານ ຊັກ ແກ ່ຍ າວ ໜ ຶ່ງ ຫ ຼື ສ ອ ງ ນ າທີ ແ ລ ະ ບ ຸກ ຄົ ນ ຮັ ບ ຮູ້ ສິ່ ງ ທ ີ່ ເກີ ດ ຂຶ້ນ ໄດ້ ໜ ້ອ ຍ ໜ ຶ່ງ ແຕ່ ບ ໍ່ ສາ ມ າດ ຕ ອ ບ ສະ ໜ ອ ງ ຫ ຼື ປ ່ຽນ ແປ ງ ພຶ ດ ຕິ ກໍາ ຂ ອ ງ ລ າວ ໄດ້ (7 0, 7 3) . ໃ ນ ລະ ຫ ວ ່າງ ກາ ນ ຊັກ ທ ົ່ວ ໂຕ , ບ ຸກ ຄົ ນ ສູນ ເສ ຍ ສະ ຕິ ຮູ້ສຶ ກ ທ ັງ ໝົ ດ (7 0) . ບ ຸກ ຄົ ນ ທ ີ່ ເກີ ດ ອ າກ ານ ຊັກ ທ ົ່ວ ໂຕ ອ າດ ຈະ ລົ້ມ ລົງ ທ ັນ ທີ ໂດ ຍ ບໍ່ ຮູ້ ສຶ ກ ຕົວ ແ ລ ະ ເ ຮ ັດ ໃຫ ້ ຕົນ ເອ ງ ບ າດ ເຈ ັບ (7 0) . ໃນ ລະ ຫ ວ ່າງ ກາ ນ ຊັກ : ï ຢ ່າ ພ ະ ຍ າ ຍ າມ ເອ ົາ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ອອ ກ ຈາ ກ ລົດ ເຂ ັນ – ເ ວ ັ້ນ ເສ ຍ ແຕ່ ວ່າ ມີ ອ າຫ ານ , ນໍ້ າ ຫ ຼື ຮ າກ ໃນ ປາ ກ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ. ໃ ນ ກໍລ ະ ນີ ນີ້, ໃ ຫ ້ ເອ ົາ ຜູ້ ໃຊ ້ ລ ົດ ເຂ ັນ ອອ ກ ຈາ ກ ລົດ ເຂ ັນ ແ ລ ະ ໃ ຫ ້ ເຂ ົາ ເ ຈ ົ້າ ນ ອ ນ ຫ ງ່ຽ ງ ຂ້ າງ , ເ ພື່ ອ ໃຫ ້ ນໍ້າ ລ າຍ ແ ລ ະ ຂີ້ ມູ ກ ສ າມ າດ ໄຫຼ ອ ອ ກ ຈາ ກ ປາ ກ ໄດ້ (7 0, 7 3) ; ï ສ້ າງ ພື້ ນ ທ ີ່ ຫ ວ ່າງ ອ້ອ ມ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ເພື່ ອ ປົກ ປ້ອ ງ ຜູ້ ກ່ ຽວ ຈາ ກ ກາ ນ ບາ ດ ເຈ ັບ ຫ ຼື ຍ ້າຍ ເຂ ົາ ເ ຈ ົ້າ ອ ອ ກ ຈ າກ ສິ່ງ ຕ່າ ງໆ ທ ີ່ ສາ ມ າດ ເປ ັ ນອັ ນ ຕ ະ ລ າຍ ຕໍ່ ກັ ບ ເຂ ົາ ເ ຈ ົ້າ ໄ ດ້ (7 0) ; ï ປ ົກ ປ້ ອ ງ ຫ ົວ ຂອ ງ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ໂ ດ ຍ ກາ ນ ວ າງ ແ ຜ່ ນ ຮອ ງ ອ ່ອ ນ ໃສ່ ກ້ອ ງ ຫ ົວ (7 0, 7 3) ; ï ມ າຍ ເສື້ ອ ຜ້າ ທ ີ່ ຄັບ ອອ ກ , ເ ອ ົາ ວ ັດ ຖ ຸ ຕ່າ ງ ໆ ທ ີ່ ສ າມ າດ ເປ ັ ອັນ ຕ ະ ລ າຍ ຕໍ່ ກັ ບ ເຂ ົາ ເ ຈ ົ້າ ອ ອ ກ ແ ລ ະ ຮັ ບ ປ ະ ກັ ນ ວ່າ ລົດ ເຂ ັນ ແມ ່ນ ປອ ດ ໄພ (7 0, 7 3) ; ï ບ ັນ ທຶ ກ ໄລ ຍ ະ ເວ ລ າ ກ ານ ຊັກ ແ ລ ະ ໃ ຫ ້ ຂໍ້ ມູ ນ ນີ້ ແ ກ ່ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ຫ ຼື ຜູ້ ເບ ິ່ງ ແ ຍ ງ ເ ຂ ົາ ເ ຈ ົາ ຫ ຼັງຈ າ ກ ານ ຊັ ກ (7 0) . ລໍຖ ້າ ຢ ່າງ ໃຈ ເຢ ັນ ກັບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ຈ ົນ ກວ່ າ ວ ່າ ອ າກ ານ ຊັກ ຢຸດ ເຊ ົາ. ຂໍ ກາ ນ ຊ່ວ ຍ ເຫ ຼືອ ທ າງ ກາ ນ ແ ພ ດ ຖ ້າ: ï ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ບໍ່ ຟື້ ນ ຄືນ ສະ ຕິ ເ ມ່ື ອ ອາ ກ ານ ຊັກ ສິ້ນ ສຸ ດ ແລ ້ວ (6 9) ; ï ກ ານ ຊັກ ແກ ່ຍ າວ ກວ່ າ ຫ ້າ ນ າທີ (7 0) . ï ຖ້າ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ມັກ ມີ ອ າກ ານ ຊັກ ເ ຊ ິ່ງ ໃ ຫ ້ ຜູ້ກ່ ຽວ ລ ົ້ມ ໄປ ທ າງ ໜ ້າ ແ ບ ບ ກະ ທັ ນ ຫັ ນ , ໃ ຫ ້ ຮອ ງ ຖ າດ ຂ ອ ງ ຜູ້ ກ່ ຽວ (ຖ ້າ ໃ ຊ ້) ເ ພື່ ອ ປ້ອ ງ ກັ ນ ບໍ່ ໃ ຫ ້ ຫ ົວ ຂອ ງ ຜູ້ ກ່ ຽວ ໄດ້ ຮັບ ບາ ດ ເຈ ັບ ; ï ຖ ້າ ຜູ້ ໃ ຊ້ ລ ົດ ເຂ ັນ ເປ ັນ ໂຣ ກ ບ້ າໝູ ເ ຊ ິ່ງບໍ່ ໄດ້ ຮັບ ກາ ນ ປ ິ່ນ ປົ ວ , ໃ ຫ ້ ນໍາ ສົ່ງ ຜູ້ກ່ ຽວ ຫ າ ທ ່ານ ໝໍ . 72 ໂ ຣ ກ ບ້ າໝູ ອ ົດ ສະ ຕາ ລີ. (2 00 9) . ກ ານ ຊ່ວ ຍ ເຫ ຼືອ ຂ ັ້ນ ຕົ້ນ ສໍາ ລັ ບ ກາ ນ ຊັກ . ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .e pi le ps ya us tra lia .n et /u se rD at a/ do cs /F irs t% 20 Ai d% 20 Br oc hu re % 20 09 .p df 73 ໂ ຣ ກ ບ້ າໝູ ກ າ ນ າ ດ າ. (n .d .). ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// ol d. ep ile ps yc an ad a. te st .g la ci er -d ig ita l.c om /s ca ns /b ro ch ur e/ se iz ur es Fi rs tA id .h tm l 74 ໂ ຣ ກ ບ້ າໝູ ກ າ ນ າ ດ າ. (n .d .). ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w w w .e pi le ps y. ca /e n- C A/ D ia gn os is -a nd -T re at m en t/F irs t- Ai d. ht m l 42 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ບັ ນຫາ ເລື ່ ອງ ການ ກິນ, ການ ດື ່ ມ ແລະ ການ ກືນ ເດ ັກ ນ້ ອ ຍ ແ ລ ະ ຜູ້ ໃຫ ຍ ່ ບາ ງ ຄ ົນ ອາ ດ ຈະ ມີ ຄ ວ າມ ຍ າກ ໃນ ກາ ນ ກິນ , ກ ານ ດ ື່ມ ແ ລ ະ ກ ານ ກືນ . ຄວ າມ ຍ າກ ໃນ ກາ ນ ກິນ ແ ລ ະ ກ ານ ດື່ມ ອາ ດ ຈະ ເກີ ດ ຈາ ກ ບັນ ຫ າ ໃ ນ ກາ ນ ກິ ນ ອາ ຫ ານ ຫ ຼື ດ ື່ມ ທ າງ ປາ ກ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ. ຕົ ວ ຢ ່າງ , ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ມີ ຄ ວ າມ ຍາ ກ ໃນ ກາ ນ ຄວ ບ ຄຸມ ແຂ ນ ຫ ຼື ມື ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ພ ວ ກ ເຂ ົາ ບ ໍ່ ສາ ມ າດ ຄ ວ ບ ຄຸມ ກາ ນ ກິນ ຫ ຼື ກ ານ ດື່ມ ໄດ້ ຢ ່າງ ງ່າ ຍ ດ າຍ . ອີກ ຢ່າ ງ ໜ ຶ່ງ, ຄ ວ າມ ຍາ ກ ອາ ດ ຈະ ເກີ ດ ບ ັນ ຫ າ ເ ລ ື່ອ ງ ກ້ າມ ເນື້ ອ ບໍລ ິ ເວ ນ ຫ ົວ , ຄ ໍ, ປ າກ ແ ລ ະ ສ່ ວ ນ ອື່ນ ທີ່ ຄວ ບ ຄຸມ ກາ ນ ກືນ (7 5) . ກ ານ ຊົງ ຕົວ ບໍ່ ໄ ດ້ ດີ, ຄ ວ າມ ຍາ ກ ໃນ ກາ ນ ນັ່ງ ຕັ້ງ ຊື່ ແລ ະ ຄ ວ າມ ຍາ ກ ໃນ ກາ ນ ຮັກ ສ າ ທ ່າ ຕັ້ ງ ຊື່ ແ ລ ະ ດ ຸ່ນ ດ່ ຽງ ຂ ອ ງ ຫ ົວ ສາ ມ າດ ເຮ ັດ ໃຫ ້ ສິ່ງ ນີ້ ຮ້ າຍ ແຮ ງ ຂຶ້ ນ (7 6) . ບັນ ຫ າ ກ ານ ກືນ ສາ ມ າດ ເຮ ັດ ໃຫ ້ ອາ ຫ ານ ຫ ຼື ເ ຄ ື່ອ ງ ດ ື່ມ ເຂ ົ້າ ໄ ປ ໃນ ປອ ດ ໄດ້ . ສິ່ ງ ນີ້ ສາ ມ າດ ນໍາ ໄປ ສູ່ ກ ານ ຕິ ດ ເຊ ື້ອ ຢູ່ ເ ອ ິກ (7 7, 7 8, 7 9, 8 0, 8 1) , ເ ຊ ິ່ງສ າມ າດ ເຮ ັດ ໃຫ ້ ຄົນ ເກີ ດ ກາ ນ ເຈັ ບ ປ່ວ ຍ ທ ີ່ ອັນ ຕະ ລ າຍ ໄດ້ (8 2) . ສັນ ຍ ານ ບົ່ງ ບອ ກ ວ່າ ບຸກ ຄົ ນ ມີ ບ ັນ ຫ າ ເ ລ ື່ອ ງ ກ ານ ກືນ ລວ ມ ມີ : ï ມັ ກ ຈະ ໄອ ໃນ ເວ ລ າ ດ ື່ມ (8 3) ; ï ມັ ກ ຈະ ສະ ໝັ ກ ໃນ ເວ ລ າ ກິ ນ ຫ ຼື ດ ື່ມ (8 4) ; ï ນໍ້ າລ າຍ ແລ ະ ຂີ້ມູ ກ ໄຂ ຍ້ອ ຍ ຢ່າ ງ ຕໍ່ ເນື່ ອ ງ. ໃນ ເວ ລ າ ໃ ຫ ້ ລົດ ເຂ ັນ ແກ ່ ຜູ້ ທ ີ່ ມີ ບ ັນ ຫ າ ເ ລ ື່ອ ງ ກ ານ ກິນ , ກ ານ ດື່ມ ແ ລ ະ ກ ານ ກືນ ຈ ົ່ງ ຈ ື່ ວ່າ : ï ກ ານ ຮອ ງ ຮັ ບ ທ ່າ ທ າງ ທ ີ່ ດີ ສ າມ າດ ປັບ ປ ຸງ ກ ານ ຊົງ ຕົ ວ , ທ ່າ ທ າງ , ກ ານ ຄວ ບ ຄຸມ ຫ ົວ ແ ລ ະ ມື ແ ລ ະ ຫ ຼຸດ ຜ່ ອ ນ ບັນ ຫ າ ເ ລ ື່ອ ງ ກ ານ ກິນ , ກ ານ ດື່ມ ແ ລ ະ ກ ານ ກືນ ໄດ້ ; ï ຖ າດ ຮອ ງ ແລ ະ /ຫ ຼື ແນ ວ ປະ ຄ ອ ງ ຫ ົວ ມັກ ຈະ ຈໍາ ເປ ັນ . ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ມີ ບ ັນ ຫ າ ເ ລ ື່ອ ງ ກ ານ ກືນ ທ ີ່ ບໍ່ ໄ ດ້ ຮັບ ກ ານ ແກ ້ ໄຂ , ໃ ຫ ້ ນໍາ ສົ່ງ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ຫ າ ບ າງ ຄົ ທ ີ່ ສ າມ າດ ຊ່ວ ຍ ໄດ້ . ຕົ ວ ຢ ່າງ , ໝໍ ຊ່ ຽວ ຊ ານ ພ ະ ຍ າດ ເດ ັກ , ນັ ກ ບໍາ ບັ ດ ແກ ້ ໄຂ ກາ ນ ເວ ົ້າ, ນັ ກ ກິ ດຈ ະ ກໍາ ບໍາ ບັ ດ ຫ ຼື ພ ະ ນັ ກ ງາ ນ ແພ ດ ເດ ັກ ທ ີ່ ມີ ປ ະ ສົ ບ ກາ ນ . 75 L og em an n, J ., & By te ll, D . ( 19 79 ). ຄ ວ າມ ຜິດ ປົກ ກ ະ ຕິ ໃນ ກາ ນ ກືນ ໃນ ສາ ມ ປ ະ ເພ ດ ຂອ ງຜູ້ ປ່ວ ຍ ທ ີ່ ຜ່າ ຕັ ດ ຫ ົວ ແ ລ ະ ຄ ໍ. ມ ະ ເຮ ັງ, 4 4, 1 07 5– 11 05 . 76 R ed st on e, F ., & W es t, J. (2 00 4) . ຄ ວ າມ ສໍາ ຄັ ນ ຂອ ງ ກ ານ ຄວ ບ ຄຸມ ທ ່າ ທ າງ ສໍາ ລັ ບ ກາ ນ ປ້ ອ ນ ອາ ຫ ານ . ກ ານ ພ ະ ຍ າບ ານ ໃນ ເດ ັກ , 3 0( 2) , 9 7– 10 0. 77 T ea se ll, R ., M cr ae , M ., M ar ch uk , Y ., & Fi ne st on e, H . ( 19 96 ). ປ ອ ດ ອັກ ເສ ບ ທ ີ່ ກ່ຽ ວ ຂ ້ອ ງ ກັ ບ ກາ ນ ສະ ໝັ ກ ອາ ຫ ານ ຫ ຼັງຈ າກ ເສັ້ ນ ເລ ືອ ກ ໃນ ສະ ໝ ອ ງ ແ ຕ ກ . A rc h Ph ys M ed R eh ab , 7 7, 77 –7 09 . 78 L ou gh lin , G . ( 19 89 ). ຜົ ນ ຕາ ມ ມາ ໃນ ລະ ບ ົບ ທ າງ ເດ ີນ ຫ າຍ ໃຈ ຈ າກ ກາ ນ ກືນ ທ ີ່ ຜິດ ປົກ ກ ະ ຕິ ແ ລ ະ ກ ານ ສະ ໝັ ກ ອາ ຫ ານ . ກ າ ນ ກື ນ ລໍາ ບ າກ , 3 , 1 26 –1 30 . 79 ອ ົງກ ານ ອະ ນ າ ໄ ມ ໂລ ກ , ສູ ນ ກາ ນ ບາ ດ ເຈ ັບ ທ າງ ສະ ໝ ອ ງ D ru ck er ຂ ອ ງກ ະ ຊ ວ ງ ປ ້ອ ງ ກັ ນ ປະ ເທ ດ ຂອ ງສ ະ ຫ ະ ລັ ດ , ໂ ຮ ງໝໍ M os sR eh ab H os pi ta l. (2 00 4) . ກ ານ ຟື້ ນ ຟູ ຮ່າ ງກ າຍ ສໍາ ລັ ບ ຄົ ນ ທີ່ ມີ ບ າດ ເຈ ັບ ທ າງ ສະ ໝ ອ ງ. ຄ ັດ ຂໍ້ ມູ ນ ຈາ ກ h ttp :// w hq lib do c. w ho .in t/h q/ 20 04 /W H O _D AR _0 1. 9_ en g. pd f 80 S ch m id t, J. , H ol as , M ., H al vo rs on , K ., & R ed in g, M . ( 19 94 ). ຫ ຼັກ ຖ ານ ຈາ ກ ກາ ນ ສາ ຍ ວິ ດ ີ ໂອ ຟ ລູ ໂອ ໂຣ ສ ໂຄ ບ ກ່ຽ ວ ກັບ ກາ ນ ສະ ໝັ ກ ອາ ຫ ານ ຄ າດ ເດ ົາ ປ ອ ດ ອັກ ເສ ບ ແ ລ ະ ກ ານ ເສ ຍ ຊີວ ິດ ແ ຕ່ ບ ໍ່ ແມ ່ນ ກ ານ ຂາ ດ ນໍ້າ ຫ ຼັງຈ າກ ເສັ້ ນ ເລ ືອ ດ ໃນ ສະ ໝ ອ ງ ແ ຕ ກ . ກ າ ນ ກື ນ ລໍາ ບ າກ , 9 , 7 -1 1. 81 P er ry , L ., & Lo ve , C . ( 20 01 ). ກ ານ ກ ວ ດ ເບ ິ່ງ ກ ານ ກືນ ລໍາ ບ າກ ແ ລ ະ ກ ານ ສະ ໝັ ກ ອາ ຫ ານ ໃນ ຜູ້ ປ ່ວ ຍ ເສັ້ ນ ເລ ືອ ດ ໃນ ສະ ໝ ອ ງ ແ ຕ ກ ກະ ທັ ນ ຫັ ນ . ກ ານ ທ ົບ ທ ວ ນ ຢ່າ ງ ເ ປ ັນ ລະ ບ ົບ . ກ ານ ບໍ່ ສ າມ າດ ເວ ົ້າ ໄ ດ້ , 16 , 7 –1 8. 82 h ttp :// w w w .w ho .in t/m ed ia ce nt re /fa ct sh ee ts /fs 33 1/ en / 83 P ra ss e, J . & K ik an o, G . ( 20 09 ). ສ ະ ພ າບ ລວ ມ ກ່ ຽວ ກັບ ກາ ນ ບໍ່ ສ າມ າດ ເວ ົ້າ ໄ ດ້ ໃນ ເດ ັກ . ກຸ ມ ມ ານ ເວ ດ ສາ ດ ທ າງ ຄລ ີ ນິກ , 4 8( 3) , 2 47 -2 51 . ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 43 ຂໍ້ ມູ ນ ທົ່ ວ ໄປ ລັ ກ ສ ະນ ະ ທົ່ ວ ໄປ ທີ່ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ຂໍ້ ພິ ຈ າລ ະນ າ ສໍ າລັ ບ ກ ານ ສ ະໜ ອ ງ ລົ ດ ເຂັ ນ ການເຈັບ ï ມັ ນ ສໍ າຄັ ນ ຫຼ າຍ ໃນ ກ ານ ຮູ້ ວ ່າຜູ້ ໃຊ ້ລ ົດ ເຂ ັນ ມີ ກ ານ ເຈັ ບ ບ ່ອ ນ ໃດ ເ ພ າະ ວ່ ານີ້ ອ າດ ຈ ະ ມີ ຜົ ນ ຕໍ່ ກັ ບ ຄ ວ າມ ສ າມ າດ ນັ່ ງໄ ດ້ ຢ ່າງ ສ ະ ບ າຍ ຕົ ວ ໃນ ລ ົດ ເຂ ັນ ຂ ອ ງເ ຂົ າເ ຈ ົ້າ. ï ຖ ້າຜູ້ ໃຊ ້ລ ົດ ເຂ ັນ ມີ ກ ານ ເຈັ ບ ເປ ັນ ປ ະ ຈ ໍາ, ພ ະ ນັ ກ ງາ ນ ບໍ ລ ິກ ານ ລົດ ເຂ ັນ ຄວ ນ ນໍາ ສົ່ງ ເຂ ົາ ເຈ ົ້າ ຫ າ ທ ່ານ ໝໍ /ຄ ລ ີ ນິກ ດູ ແລ ສຸຂ ະ ພ າບ ເພື່ ອ ລະ ບ ຸ ສ າ ເ ຫ ດ ຂອ ງ ກ ານ ເຈ ັບ , ເ ພ ະ ວ່າ ກ ານ ລະ ເລ ີຍ ກ ານ ເຈ ັບ ສາ ມ າດ ເປ ັນ ອັ ນ ຕ ະ ລ າຍ ໄດ້ . ï ເພື່ ອ ຫ ຼີກ ເວ ັ້ນ ກ ານ ເຈ ັບ ໃນ ລະ ຫ ວ ່າງ ກາ ນ ປະ ເມີ ນ ຜົ ນ ລົດ ເຂ ັນ : – ຖ າມ ວ່າ ມີ ທ ່າ ທ າງ ໃດ ທ ີ່ ເຮ ັດ ໃຫ ້ກ ານ ເຈ ັບ ຮ້າ ຍ ແ ຮ ງ ຂຶ້ ນ ບໍ; ຄ ວ ນ ຫ ຼີກ ເວ ັ້ນ ທ່ າທ າງ ດັ່ງ ກ່ າວ ; – ຖ າມ ວ່າ ມີ ກ ານ ເຄ ື່ອ ນ ໄຫ ວ ຫ ຼື ທ ່າ ທ າງ ໃດ ທ ີ່ ເຮ ັດ ໃຫ ້ກ ານ ເຈ ັບ ໜ ້ອ ຍ ລົງ ; ຕ້ ອ ງ ພິ ຈ າລ ະ ນ າ ທ ່າ ທ າງ ເຫ ຼົ່ານີ້ ໃນ ລະ ຫ ວ ່າງ ກາ ນ ປະ ເມີ ນ ຜົນ ລົດ ເຂ ັນ ; – ຖ ້າ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ບໍ່ ສ າມ າດ ສື່ສ ານ ດ້ວ ຍ ຄໍາ ເວ ົ້າ ໄດ້ , ໃ ຫ ້ຊ ອ ກ ວິທ ີ ອື່ນ ເພື່ ອ ສື່ສ ານ ກ່ອ ນ ທ ີ່ ຈະ ເລ ີ່ ມ ກ ານ ປະ ເມີ ນ ຜົນ ລົ ດ ເຂ ັນ ; – ກ ານ ປະ ຄ ອ ງ ຫ ຼືຮ ອ ງຮັ ບ ທ ີ່ ດີ ແລ ະ ກ ານ ປ່ ຽນ ທ ່າ ສ າມ າດ ປ້ອ ງ ກັ ນ ຫ ຼື ຫ ຼຸດ ຄ ວ າມ ເຈ ັບ ລົງ ໄດ້ . ບັ ນຫາ ການ ຍ່ ຽວ ແລະ ການ ຂັ ບ ຖ່ າຍ ï ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ບາ ງ ຄ ົນ ສາ ມ າດ ມີ ຄ ວ າມ ຍາ ກ ໃນ ກ ານ ຄວ ບ ຄຸມ ກາ ນ ຍ່ຽ ວ ຫ ຼື ກ ານ ຂັບ ຖ່າ ຍ . ບ ັນ ຫ າ ເ ຫ ຼົ່ານີ້ ມັກ ຈະ ສາ ມ າດ ຖືກ ຄຸ້ມ ຄອ ງ ໄ ດ້ ດ ້ວ ຍ ກາ ນ ໃຊ ້ ອຸປ ະ ກ ອ ນ ທ ີ່ ເໝ າະ ສົມ ( ເ ຊັ່ ນ ວ່າ ທ ໍ່ ແຍ ່ ຍ່ຽ ວ ), ກ ານ ໃຊ ້ ຢາ , ກ ານ ຝຶກ ກ ານ ຍ່ ຽວ ແ ລ ະ ກ ານ ຂັບ ຖ່າ ຍ . ï ມັ ນ ສໍາ ຄັ ນ ໃ ນ ກາ ນ ລະ ບ ຸ ວ່າ ໃຜ ໃນ ເຂ ດພື້ ນ ທ ີ່ ຂ ອ ງ ທ ່ານ ສາ ມ າດ ໃຫ ້ ຄໍາ ແນ ະ ນໍ າ ແລ ະ ກ ານ ຝຶ ກ ອົ ບ ຮ ົມ ເພື່ ອ ຫ ຼີກ ເວ ັ້ນ ອ າກ ານ ແຊ ກ ຊ້ອ ນ ເຫ ຼົ່ານີ້ ( ຕົ ວ ຢ ່າງ , ທ ່ານ ໝໍ ຊ່ຽ ວ ຊ ານ ແ ລ ະ ພ ະ ຍ າບ ານ ). ï ບ າງ ຄັ້ງ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ຜູ້ ທ ີ່ ຄວ ບ ຄຸມ ກາ ນ ຍ່ຽ ວ ຫ ຼື ກ ານ ຂັບ ຖ ່າຍ ບໍ່ ໄ ດ້ ດີ ມີ ຄວ າມ ຍາ ກ ໃນ າກ ນສື່ ສ ານ ໃນ ເວ ລ າ ທ ີ່ ພ ວ ກ ເຂ ົາ ຕ້ ອ ງກ ານ ເຂ ົ້າ ຫ ້ອ ງ ນໍ້ າ. ພ ວ ກ ເຂ ົາ ມີ ຄວ າມ ສ່ຽ ງ ເ ກີ ດ ອຸປ ະ ຕິ ເຫ ດ ຍ່ຽ ວ ເຮ ່ຍ ຫ ຼື ຂີ້ ເຮ ່ຍ ໄດ້ . ï ພ ະ ນັ ກ ງາ ນ ບໍລ ິກ ານ ລົດ ເຂ ັນ ຈໍາ ເປ ັນ ຕ້ອ ງ ຮູ້ ວ່າ ໃນ ເວ ລ າ ເ ຮ ັດ ວຽ ກ ກັບ ຜູ້ ໃ ຊ ້ ລົດ ເຂ ັນ ຜູ້ ທ ີ່ ມີ ບ ັນ ຫ າ ເລ ື່ອ ງກ ານ ຍ່ຽ ວ ຫ ຼື ກ ານ ຂັບ ຖ່າ ຍ ມັ ນ ເປ ັນ ໄປ ໄດ້ ວ ່າ ພ ວ ກ ເຂ ົາ ອ າດ ຈະ ໄດ້ ຮັບ ຄວ າມ ເປ ິ ເປ ື້ອ ນ . ສິ່ ງ ອ ໍານ ວ ຍ ຄວ າມ ສະ ດ ວ ກ ກາ ນ ລ້າ ງ ມື ທ ີ່ ດີ ແລ ະ ວ ິທ ີ ອະ ນ າ ໄ ມ ພື້ ນ ທ ີ່ ຄລ ີ ນິກ ແ ມ ່ນ ສິ່ງ ສໍາ ຄັ ນ . ï ເບ າະ ຮອ ງ ນັ່ ງ ທ ີ່ປ ຽກ ຊຸ່ມ ຫ ຼື ເ ປ ິ ເປ ື້ອ ນ ສ າມ າດ ເຮ ັ ດ ໃຫ ້ ຜິວ ໜ ັງ ເ ສ ຍ ຫ າຍ ໄດ້ . ນ ອ ກ ນັ້ນ , ແ ບ ັກ ທ ີ ເຣ ຍ ໃນ ອາ ຈ ົມ ກໍ່ ນໍ າ ໄ ປ ສູ່ ແ ຜກົ ດທ ັບ ທ ີ່ ຕິດ ເຊ ື້ອ ໄດ້ ຢ່າ ງ ວ ່ອ ງ ໄ ວ . ສິ່ ງ ເ ສ ດ ເຫ ຼືອ ໃນ ນໍ້າ ຍ່ຽ ວ ແ ລ ະ ອ າຈ ົມ ສ າມ າດ ເຮ ັດ ໃຫ ້ ແຜ ຕິດ ເຊ ື້ອ ແ ລ ະ ເ ຜົ າ ໄ ໝ້ ຜິ ວ ໜ ັງ ໄ ດ້ . ï ເບ າະ ຮອ ງ ນັ່ ງ ແລ ະ ແ ນ ວ ຫ ຸ້ມ ເບ າະ ຄວ ນ ສາ ມ າດ ຖ ອ ດ ອອ ກ ໄດ້ ງ່າ ຍ ດ າຍ ເ ພື່ ອ ໃຫ ້ ຜູ້ ໃ ຊ ້/ຜູ້ ເບ ິ່ງ ແ ຍ ງ ອ ະ ນ າ ໄ ມ ພ ວ ກ ມັນ ໄດ້ . ï ໃຫ ້ ເບ າະ ຮອ ງ ນັ່ ງ ທ ີ່ ມີ ແ ນ ວ ຫ ຸ້ມ ເບ າະ ແບ ບ ກັນ ນໍ້າ ໄດ້ . ຖ ້າ ເ ປ ັນ ໄປ ໄດ້ ໃ ຫ ້ ແນ ວ ຫ ຸ້ມ ສອ ງ ອ ັນ ເພື່ ອ ໃຫ ້ ຜູ້ ໃຊ້ ລົດ ເຂ ັນ ສືບ ຕໍ່ ກິ ດ ຈ ະ ກໍາ ປະ ຈ ໍາ ວ ັນ ຂອ ງ ເ ຂ ົາ ເ ຈ ົ້າ ໄດ້ ໃ ນ ຂະ ນ ະ ທ ີ່ ແນ ວ ຫ ຸ້ມ ເບ າະ ອັນ ໜ ຶ່ງ ຕ າກ ແຫ ້ງ ຢ ູ່. ï ຖ ້າ ບ ໍ່ ມີ ແ ນ ວ ຫ ຸ້ມ ເບ າະ ແບ ບ ກັນ ນໍ້າ ໄດ້ , ໃ ຫ ້ ເບ າະ ຮ ອ ງ ນັ່ ງ ສ ອ ງອັ ນ . ï ນໍ າ ສົ່ ງ ຜູ້ ໃຊ ້ ລົດ ເຂ ັນ ຫ າ ບ າງ ຄົ ນ ທີ່ ສາ ມ າດ ຊ່ວ ຍ ພ ວ ກ ເຂ ົາ ຄ ຸ້ມ ຄອ ງ ກ ານ ຂັບ ຖ່າ ຍ ແ ລ ະ ກ ານ ຍ່ຽ ວ ເພື່ ອ ໃຫ ້ ມີ ສຸ ຂ ະ ພ າບ ດີ ແລ ະ ຫ ຼີກ ເວ ັ້ນ ອຸ ປ ະ ຕິ ເຫ ດ . 44 ຮູບ ແບບ ຊີວິດ ແລະ ສະພາບ ແວດ ລ້ອມ ອະທິບາຍ ບ່ອນ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈະ ໃຊ້ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ: ໄລຍະ ທາງ ທີ່ ເດີນທາງ ໄປມາ ໃນ ແຕ່ ລະ ວັນ: ບໍ່ ເກີນ 1 ກມ 1–5 ກມ ຫຼາຍກວ່າ 5 ກມ ຊ່ົວ ໂມງ ຕ່ໍ ມ້ື ໂດຍ ໃຊ້ ລົດ ເຂັນ: ນ້ອຍ ກວ່າ 1 1–3 3–5 5–8 ຫຼາຍກວ່າ 8 ເມ່ືອອ ອກຈາກ ລົດ ເຂັນ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ຫຼື ນອນ ຢູ່ ໃສ ແລະ ແນວ ໃດ (ທ່າ ທາງ ແລະ ພ້ືນ ຜິວ)? ການ ເຄື່ອນ ຍ້າຍ: ດ້ວຍ ຕົນ ເອງ ມີ ການ ຊ່ວຍ ເຫຼືອ ແບບ ຢືນ ບໍ່ ແມ່ນ ແບບ ຢືນ ແບບ ຍົກ ຂ້ຶນ ອື່ນໆ ປະ ເພດ ຂອງ ວິດຖ່າຍ (ຖ້າ ເຄື່ອນ ຍ້າຍ ໄປ ເຂົ້າວິດຖ່າຍ): ແບບ ນ່ັງ ຢ່ອງຢ້ໍ ແບບ ຕາ ເວັນ ຕົກ ແບບ ດັດ ປັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມັກ ໃຊ້ ການ ຂົນ ສ່ົງ ສາທາລະນະ/ລົດ ສ່ວນ ຕົວ ບໍ? ແມ່ນ ບໍ່ ຖ້າ ແມ່ນ, ຊະນິດ ໃດ: ລົ ດ ໃຫຍ່ ລົດແທັກ ຊີ ລົດ ເມ ອື່ນໆ ສ່ວນ ëຮູບ ແບບ ຊີວິດ ແລະ ສະພາບ ແວ ດລ້ອມí ຂອງ ແບບ ຟອມ ປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ເກັບ ເອົາ ຂ້ໍ ມູນ ກ່ຽວ ກັບ ບ່ອນ ທີ່ ຜູ້້ ໃຊ້ ລົດ ເຂັນ ດໍາ ເນີນ ຊີ ວິດ ແລະ ສ່ິງ ຕ່າງໆ ທີ່ ຜູ້ກ່ຽວ ຈໍາ ເປັນ ຕ້ອງ ເຮັດ ໃນ ລົດ ເຂັນ ຂອ ງ ເຂົາ ເຈົ້າ. ມັນ ສໍາຄັນ ໃນ ການ ພິຈາລະນາ ວ່າ ລົດ ເຂັນ ແລະ ອຸປະກອນ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມທ່ີ ສະໜອງ ໃຫ້ ຈະ ຊ່ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຄຸ້ມ ຄອງ ຄວາມ ສາມາດ ຂອງ ເຂົາ ເຈົ້າ ໃຫ້ ດີ ທີ່ ສຸດ ໂດຍ ຄໍານຶງ ເຖິງ ສະພາບ ແວດ ລ້ອມ ໂດຍ ກົງ ແລະ ຮູບ ແບບ ຊີວິດ ຂອງ ເຂົາ ເຈົ້າ. ຄໍາ ຖາມ ກ່ຽວ ກັບຮູບ ແບບ ຊີວິດ ແລະ ສະພາບ ແວດ ລ້ອມ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົ ດ ເຂັນລະດັບ ປານ ກາງ ການ ສົນທະນາ ອະທິບາຍ ບ່ອນ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈະ ໃຊ້ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ï ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ໃຊ້ ໄດ້ ຈິງ ສໍາລັບ ເຮືອນ , ບ່ອນ ເຮັດ ວຽກ ຫຼື ໂຮງຮຽນຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ຕົວຢ່າງ: – ຖ້າ ລົດ ເຂັນ ຈະ ຖືກ ໃຊ້ ຢູ່ ເຮືອນ, ຜູ້ ໃຊ້ ລົດ ເຂັນຕ້ອງການ ສາມາດ ເຄື່ອນ ໄຫວ ໄປມາ ຢູ່ ໃນ ເຮືອນ ໄດ້ ຢ່າງ ງ່າຍດາຍ ເພ່ືອ ດໍາ ເນີນ ກິດຈະກໍາ ປະຈໍາ ວັນ ທີ່ ສໍາຄັນ; – ຜູ້ ໃຊ້ລົດ ເຂັນ ທີ່ ເຮັດ ວຽກ ຢູ່ ຫ້ອງການ ຈະ ຕ້ອງການ ລົດ ເຂັນ ທີ່ ສາມາດ ເຂົ້າກັນ ກັບ ພ້ືນ ທີ່ ຫ້ອງການ ໄດ້ ຢ່າງ ງ່າຍດາຍ ໄດ້; – ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ໄປ ໂຮງຮຽນ ຈະ ຕ້ອງການ ລົດ ເຂັນ ທີ່ ໃຊ້ ໄດ້ ຢ່າ ງສະດວກ ຢູ່ ໃນ ຫ້ອງ ຮຽນ ແລະ ຢູ່ ກ້ອງ ໂຕະ ຫຼື ຈະ ຕ້ອງການ ມີ ຖາດ ທີ່ ຕິດ ຕ້ັງ ໃສ່ ລົດ ເຂັນ; – ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ຈໍາ ເປັນ ຕ້ອງ ເດີນທາງ ໄປ ຕະຫຼາດ ຫຼື ໄປ ເຮັດ ວຽກ ຕາມ ເສ້ັນທາ ງທ່ີບໍ່ ລຽບ ຕ້ອງການ ລົດ ເຂັນ ທີ່ ໃຊ້ ໄດ້ ດີ ໃນ ສະພາບ ພ້ຶນດິນ ທີ່ ບໍ່ ຮາບ ພຽງ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 45 ຄໍາ ຖາມ ກ່ຽວ ກັບຮູບ ແບບ ຊີວິດ ແລະ ສະພາບ ແວດ ລ້ອມ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົ ດ ເຂັນລະດັບ ປານ ກາງ ການ ສົນທະນາ ໄລຍະ ທາງ ທີ່ ເດີນທາງ ໄປມາ ໃນ ແຕ່ ລະ ວັນ ï ຄືກັບ ບາງ ຄົນ ທີ່ ອາດ ຈະ ຍ່າງ ເອົາຖ້າ ໄປ ໃກ້ໆ, ແຕ່ ໃຊ້ ລົດຖີບ ຖ້າ ໄປ ໄກໆ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃຊ້ ລົດ ເຂັນ ສໍາລັບ ໄລຍະ ທາງ ໃກ້ໆ ແລະ ລົດ ສາມ ລໍ້ ສໍາລັບ ໄລຍະ ທາ ໄກ ກວ່າ. ï ລົດ ສາມ ລໍ້ ໃຊ້ ແຮງໜ້ອຍ ກວ່າ ເພ່ືອ ໄປ ໄດ້ ໃນ ໄລຍະ ທາງ ດຽວ ກັນ ແລະ ໄວ ກວ່າ. ຊ່ົວ ໂມງ ຕ່ໍ ມ້ື ໂດຍ ໃຊ້ ລົດ ເຂັນ ï ຜູ້ ໃຊ້ລົດ ເຂັນ ຍິ່ງ ນ່ັງ ໃນ ລົດ ເຂັນ ດົນ ເທົ່າ ໃດ, ກ່ໍ ຍິ່ງ ມີ ຄວາມ ສ່ຽງ ເກີດ ການອິ ດ ເມ່ືອຍ ຫຼື ແຜ ກົ ດທັບຫຼາຍຂ້ຶນ ເທົ່າ ນ້ັນ. ຈົ່ງ ຄິດ ກ່ຽວ ກັບ ວ່າການ ຮອງ ຮັບ ຫຼາຍປານ ໃດ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຕ້ອງການ ແລະ ເບາະ ຮອງ ນ່ັງ ໃຫ້ການ ຫຼຸດຜ່ອນ ການ ກົ ດທັບ ແລະ ຄວາມ ສະບາຍ ຕົວ ພຽງພໍ ຫຼືບໍ່. ï ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ë ເຄື່ອນ ໄຫວ ໄດ້í ໃນ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ໃນ ລະຫວ່າງ ມ້ື, ລົດ ເຂັນ ຄວນ ຖືກ ຕິດ ຕ້ັງ ເພ່ືອ ເຮັດ ໃຫ້ ການຍູ້ ແລະ ກິດຈະກໍາ ອື່ນ ມີ ປະສິດທິ ຜົນ ເທົ່າ ທີ່ ເປັນ ໄປ ໄດ້. ຕໍາ ແໜ່ ງຂອງ ລໍ້ ແມ່ນ ສໍາຄັນ ຫຼາຍ. ນອກ ນ້ັນ ມັນ ຍັງ ສໍາຄັນ ໃນ ການກວດ ເ ບິ່ງ ວ່າ ແນວ ອີງ ຫຼັງຮອງ ຮັບຮ່າງກາຍຜູ້ ໃຊ້ ລົດ ເຂັນ, ແຕ່ ບໍ່ ຈໍາກັດ ອິ ດສະຫຼະຂອງ ການ ເຄື່ອນ ໄຫວ ຂອງ ກະ ດູກ ຫົວ ໄຫ່ຼ. ເມ່ືອອ ອກຈາກ ລົດ ເຂັນ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ຫຼື ນອນ ຢູ່ ໃສ ແລະ ແນວ ໃດ (ທ່າ ທາງ ແລະ ພ້ືນ ຜິວ)? ï ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຢູ່ ໃນ ຕໍາ ແໜ່ ງດຽວ ເປັນ ເວລາ ດົນ, ຜູ້ກ່ຽວ ສາມາດ ແຂງ ຕົວ ແລະ ຕິ ດ ຄ້າງ ໃນ ຕໍາ ແໜ່ ງນ້ັນ. ມັນ ອາດ ຈະ ເປັນ ໄປ ບໍ່ ໄດ້ ໃນ ການ ນ່ັງ ຢ່າງ ສະບາຍ ຕົວ ໃນ ລົດ ເຂັນ. ï ມັນ ສໍາຄັນ ຫຼາຍ ໃນ ການຫີຼກ ເວັ້ນສະພາບ ການ ນ້ີ ແລະ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ທາງ ເລືອກ ຕ່າງໆ ກ່ຽວ ກັບ ທ່າ ທີ່ ສະບາຍ ຕົວ ໃນ ການ ນ່ັງ ຫຼື ນອນ ເມ່ືອ ບໍ່ ຢູ່ ໃນ ລົດ ເຂັນ. ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ຫຼື ນອນ ໃນ ທ່າ ດຽວ ຕະຫຼອດບໍ? – ຖ້າ ເປັນ ໄປ ໄດ້, ຮ້ອງ ຂໍ ໃຫ້ ລາວ ສະ ແດງ ທ່າ ດັ່ງກ່າວ; – ມັນ ສໍາຄັນ ໃນ ການ ຮູ້ ວ່າ ທ່າ ທີ່ ມັກ ແມ່ນ ແນວ ໃດ ເພ່ືອ ໃຫ້ສາມາດ ແນະນໍາ ທ່າ ëກົງກັນຂ້າມí (ປີ້ນ ກັນ) ໄດ້. ມັນ ອາດ ຈະ ບໍ່ເປັນ ໄປ ໄດ້ ສະ ເໝີ ໃນ ການປ່ຽນ ເປັນ ທ່າ ëກົງກັນຂ້າມí ໃນ ທັນທີ. ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄດ້ ໃຊ້ ທ່າ ທີ່ ມັກ ຂອງ ລາວ ເປັນ ເວລາ ດົນ ນານ ແລ້ວ, ການ ປ່ຽນ ເປັນ ທ່າ ກົງກັນຂ້າມ ໂດຍ ສ້ິນ ເຊີງ ໃນ ທັນທີ ອາດ ຈະ ເປັນ ການ ບໍ່ ສະບາຍ ຕົວ ເກີນ ໄປ, ແປກ ແລະ ເປັນຕາ ຢ້ານ; – ຊອກ ຫາ ວິທີ ທີ່ ຮອງ ຮັບ ລໍາ ຕົວ ແລະ ແຂນ ຂາ ເພ່ືອ ໃຫ້ ພວກ ມັນ ຢູ່ ໃນທ່າ ປົກກະຕິ ແລະ ສະບາຍ ຕົວ ກວ່າ. ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ປ່ຽນ ທ່າ ທາງ ຂອງ ລາວ ໄດ້ ບໍ? – ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ສາມາດ ປ່ຽນ ທ່າ, ລາວ ມີ ຄວາມ ສ່ຽງ ຫຼາຍຂ້ຶນ ທີ່ ຈະ ເກີດ ບັນຫາ ເລື່ອງທ່າ ທາງ ຫຼື ແຜ ກົ ດທັບ. 46 ຄໍາ ຖາມ ກ່ຽວ ກັບຮູບ ແບບ ຊີວິດ ແລະ ສະພາບ ແວດ ລ້ອມ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົ ດ ເຂັນລະດັບ ປານ ກາງ ການ ສົນທະນາ ການ ເຄື່ອນ ຍ້າຍ ï ບ່ອນ ວາງ ແຂນ ແລະ ບ່ອນ ວາງ ຕີນ ສາມາດ ມີ ຜົນ ຕ່ໍ ກັບ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເຂົ້າ ອອກລົດ ເຂັນ ໄດ້ ແນວ ໃດ: – ສໍາລັບ ການ ເຄື່ອນ ຍ້າຍ ແບບ ຢືນ, ມັນ ເປັນ ປະ ໂຫຍ ດ ໃນ ການ ມີ ບ່ອນ ວາງ ຕີນ ທີ່ ຫວ່ຽງ ອອກ ຈາກ ທທາງ ໄດ້ ແລະ ບ່ອນ ວາງ ແຂນ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ໃຊ້ ເພ່ືອ ຍູ້ ໂຕ ລຸກ ຂ້ຶນ; – ສໍາລັບ ການ ເຄື່ອນ ຍ້າຍ ແບບ ບໍ່ ຢືນ, ບ່ອນ ວາງ ແຂນ ທີ່ ສາມາດ ຖອດ ອອກ ໄດ້ ຫຼື ບ່ອນ ວາງ ແຂນ ທີ່ ໄປ ຕາມ ຮູບຊົງ ຂອ ງລ້ໍ ສາມາດ ເຮັດ ໃຫ້ການ ເຄື່ອນ ຍ້າຍ ງ່າຍ ຂ້ຶນ; – ໃນ ເວລາ ໃຫ້ ແນວ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ, ໃຫ້ ກວດ ເບິ່ງ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ເຄື່ອນ ຍ້າຍ ໄດ້ ງ່າຍດາຍ ຫຼືບໍ່. ຕົວຢ່າງ , ໂດຍ ການ ເພ່ີມ ບ່ອນ ນ່ັງ ຫຼື ເບາະ ຮອງ ນ່ັງ ທີ່ ມີຫຼີ້ມຮອງ, ມັນ ອາດ ຈະ ຍາກ ຂ້ຶນ ສໍາລັບ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ໃນ ການ ເຄື່ອນ ຍ້າຍ. ການ ປ່ຽນ ເຕັກນິກ ອາດ ຈະ ຈໍາ ເປັນ ຫຼື ເລືອກອຸປະກອນ PSD ອື່ນ. ປະ ເພດ ຂອງ ວິດຖ່າຍ ï ປະ ເພດ ວິດຖ່າຍ ແລະ ການ ເຂົ້າ ເຖິງ ວິດຖ່າຍ ຈະ ມີ ຜົນ ຕ່ໍ ກັບ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ໃຊ້ ວິດຖ່າຍ ນ້ັນ ໄດ້ ງ່າຍສ່ໍາ ໃດ. ï ມັນ ອາດ ຈະ ເປັນ ໄປ ບໍ່ ໄດ້ໃນ ການ ໃຊ້ວິດຖ່າຍ ເນ່ືອງ ຈາກ ແບບ ຂອງ ວິດຖ່າຍ. ຕົວຢ່າງ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ສ່ວນ ໃຫຍ່ ພົບ ວ່າ ມັນ ຍາກ ຫຼາຍ ໃນ ການ ໃຊ້ ວິດຖ່າຍ ແບບ ນ່ັງ ຢ່ອງ ຢໍ້. ï ໂດຍ ການ ຖາມ ກ່ຽວ ກັບ ວິດຖ່າຍ ແລະ ບ່ອນ ທີ່ ວິດ ຖ່າຍ ຕ້ັງ ຢູ່, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ໃຫ້ ຄໍາ ແນະນໍາ ກ່ຽວ ກັບ ວິທີ ເຄື່ອນ ຍ້າຍ ໄປ ຫາ ແລະ ຈາກ ວິດຖ່າຍ. ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ອາດ ຈະ ໃຫ້ ຄໍາ ແນະນໍາ ກ່ຽວ ກັບ ວິທີ ດັດ ປັບ ວິດຖ່າຍ ນໍາ ອີກ. ຜູ້ ໃຊ້ ລົດ ເຂັນ ມັກ ໃຊ້ ການ ຂົນ ສ່ົງ ສາທາລະນະ/ລົດ ສ່ວນ ຕົວ ບໍ? ï ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃຊ້ ການ ຂົນ ສ່ົງ ເລື້ ອຍໆ, ລາວຈໍາ ເປັນ ຕ້ອງ ສາມາດ ຂົນສ່ົງລົດ ເຂັນ ໄດ້ ຢ່າງ ງ່າຍດາຍ. ຄຸນສົມບັດ ຕ່າງໆ ຂອງ ລົດ ເຂັນ ເຊິ່ງ ເຮັດ ໃຫ້ການຂົນ ສ່ົງ ລົດ ເຂັນ ງ່າຍ ຂ້ຶນ ລວມມີ ສ່ິງ ຕ່ໍ ໄປ ນ້ີ: – ລົດ ເຂັນ ທີ່ ເບົາ ກວ່າ ແມ່ນ ງ່າຍ ກວ່າ ໃນ ການ ຍົກ ເຂົ້າ ແລະ ອອກ; – ລໍ້ ທີ່ ສາມາດ ຖອດ ອອກ ໄດ້ ແລະ ໂຄງ ແລະ/ຫຼື ແນວ ອີງ ຫຼັງ ແບບ ພັບ ໄດ້ ເຮັດ ໃຫ້ ຂົນ ສ່ົງ ລົດ ເຂັນ ໄດ້ ງ່າຍ ກວ່າ. ï ຖ້າ ໃຊ້ ການ ຂົນ ສ່ົງ ສາທາລະນະ, ສ່ວນ ທີ່ ສາມາດ ຖອດ ອອກ ໄດ້ ສາມາດ ເປັນ ຂ້ໍ ໄດ້ ປຽບ, ເພາະ ນ້ີ ເຮັດ ໃຫ້ ບັນທຸກ ລົດ ເຂັນ ໄດ້ ງ່າຍ ຂ້ຶນ. ແນວ ໃດ ກໍ ຕາມ, ສ່ວນ ທີ່ ສາມາດ ຖອດ ອອກ ໄດ້ ອາດ ຈະ ເປັນ ຂ້ໍ ເສຍປຽບ ເຊັ່ນ ກັນ ເພາະວ່າ ສ່ວນດັ່ງກ່າວ ອາດ ຈະ ຖືກ ແຍກ ອອກ ແລະ ສູນ ເສຍ ຫຼື ຖືກ ລັກ ໄດ້. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 47 ລົດ ເຂັນ ທ່ີ ມີ ຢູ່ ແລ້ວ (ຖ້າ ບຸກຄົນ ມີ ລົດ ເຂັນ ຢູ່ ແລ້ວ) ລົດ ເຂັນ ນ້ັນ ຕອບ ສະໜອງ ໄດ້ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ້ ບໍ? ແມ່ນ ບໍ່ ລົດ ເຂັນ ນ້ັນ ຕອບ ສະໜອງ ໄດ້ ເງ່ືອນ ໄຂ ດ້ານ ສະພາບ ແວດ ລ້ອມ ຂອງ ຜູ້ ໃຊ້ ບໍ? ແມ່ນ ບໍ່ ລົດ ເຂັນ ໃຫ້ ເໝາ ະສົມພໍດີ ແລະ ການ ຮອງ ຮັບ ທ່າ ທາງ ຕ່າງໆບໍ? ແມ່ນ ບໍ່ ລົດ ເຂັນ ປອດ ໄພ ແລະ ທົນ ທາ ນບໍ? (ພິຈາລະນາ ວ່າ ມີ ເບາະ ຮອງ ນ່ັງຫືຼບໍ່) ແມ່ນ ບໍ່ ເບາະ ຮອງ ນ່ັງ ນ້ັນ ໃຫ້ການ ບັນ ເທົາ ການ ກົ ດທັບ ທີ່ ເໝາະ ສົມ (ຖ້າ ຜູ້ ໃຊ້ ມີ ຄວາມ ສ່ຽງ ເກີດ ແຜ ກົ ດທັບ) ແມ່ນຫືຼບໍ່? ແມ່ນ ບໍ່ ຄໍາ ເຫັນ: ------------------------------------------------------------------------ ຖ້າ ແມ່ນຕ່ໍ ກັບ ທຸກ ຄໍາ ຖາມ, ຜູ້ ໃຊ້ ອາດ ຈະ ບໍ່ ຈໍາ ເປັນ ຕ້ອງ ມີ ລົດ ເຂັນ ໃໝ່. ຖ້າ ບໍ່ ຕ່ໍກັບ ຄໍາ ຖາມ ໃດ ໆ ກໍ ຕາມ ເຫຼົ່ານ້ີ, ຜູ້ ໃຊ້ ຕ້ອງການ ມີ ລົດ ເຂັນ ຫຼື ເບາະ ຮອງ ນ່ັງ ໃໝ່; ຫືຼ ລົດ ເຂັນ ຫຼື ເບາະ ຮອງ ນ່ັງທ່ີ ມີ ຢູ່ ແລ້ວຈໍາ ເປັນ ຕ້ອງ ມີ ການ ສ້ອມ ແປງ ຫຼື ການ ດດັ ແປງ . ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ລົດ ເຂັນ ຢູ່ ແລ້ວ, ມັນ ສໍາຄັນ ໃນ ການ ຊອກ ຮູ້ ວ່າ ລົດ ເຂັນ ນ້ັນ ຕອບ ສະ ໜອງ ໄດ້ ຄວາມ ຕ້ອງການ ຂອງ ລາວ ຫຼືບໍ່. ສ່ວນ ëລົດ ເຂັນ ທີ່ ມີ ຢູ່ ແລ້ວí ຂອງ ແບບ ຟອມປະ ເມີນຜົນ ລົດ ເຂັນ ລະດັບ ປາ ນກາງ ຊ່ວຍ ແນະນໍາ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃນ ການ ປະ ເມີນ ວ່າ ລົດ ເຂັນ ທີ່ ມີ ຢູ່ ແລ້ວ ນ້ັນ ເໝາະ ສົມ ສໍາລັບ ຜູ້ ໃຊ້ລົດ ເຂັນ ນ້ັນ ຫຼືບໍ່. ໃນ ເວລາ ກວດ ເບິ່ງ ສະພາບ ຂອງ ລົດ ເຂັນ, ໃຫ້ ເບິ່ງ ພ້ືນ ຜິວຕ່າງໆ ເພາະວ່າ ສ່ິງ ເຫຼົ່ານ້ີສາມາດ ໃຫ້ ການ ຊ້ີ ບອກ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກໍາລັງ ນ່ັງ ແນວ ໃດ . ຕົວຢ່າງ, ເບາະ ຮອງ ນ່ັງ ທີ່ບຸ້ມ ຫຼຸບຂ້າງ ໜຶ່ງ ສາມາດ ໝາຍ ເຖິງ ວ່າ ມີ ການ ກົ ດທັບ ຫຼາຍກວ່າ ຢູ່ ກະດູກ ຮອງ ນ່ັງ ເບື້ອງ ໜຶ່ງ; ບ່ອນ ວາງ ແຂນ ທີ່ ເສຍ ຫາຍ ຢູ່ ຂ້າງ ໜຶ່ງ ອາ ດຈະ ໝາຍ ເຖິງ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກໍາລັງ ອ່ຽງ ໂຕ ຢ່າງ ໜັກ ໄປ ຂ້າງ ນ້ັນ. ຖ້າ ທ່ານ ພົບ ເຫັນ ສ່ິງ ຜິດ ປົກກະຕິ ໃດໆ, ໃຫ້ ຖາມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກ່ຽວ ກັບ ມັນ. ຖ້າ ລົດ ເຂັນ ບໍ່ ຕອບ ສະໜອງ ໄດ້ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ, ພະນັກງາ ນບໍລິການ ລົດ ເຂັນຄວນ ຊອກ ຮູ້ ວ່າ ຍ້ອນ ຫຍັງ. ບາງ ຄັ້ງ ລົດ ເຂັນ ເໝາະ ສົມ, ແຕ່ ອາດ ຈະ ບໍ່ ຖືກ ດັດ ປັບ ຢ່າງຖືກຕ້ອງ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ການ ດັດ ແປງ, ແນວ ຮອງ ຮັບ ທ່າ ງທາງ ເພ່ີມ ເຕີມ ຫຼື ການ ສ້ອມ ແປງ ອາດ ຈະ ຊ່ວຍ ໄດ້. ທັກ ສະການ ສ່ືສານ ທ່ີ ດີ ໃນ ລະຫວ່າງ ການ ສໍາພາດປະ ເມີນ ຜົນ ການ ໃຊ້ ທັກ ສະການ ສ່ືສານ ທີ່ ດີ ແມ່ນ ສໍາຄັນ ສະ ເໝີ ເພ່ືອ ຊ່ວຍ ເກັບ ເອົາ ຂ້ໍ ມູນ ທີ່ ຖືກຕ້ອງ ໃນ ແບບ ທີ່ ເຄົາລົບ ແລະ ອ່ອນ ໄຫວ ຕ່ໍ ກັບ ຄວາມ ຮູ້ສຶກ ແລະ ຄວາມ ຕ້ອ ງການ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ບາງ ວິທີ ເພ່ືອ ຊ່ວ ຍ ເຮັດ ໃຫ້ການ ສໍາພາດ ປະ ເມີນ ຜົນ ດໍາ ເນີນ ໄປ ດ້ວຍ ດີ ມີ ຄື: ï ໃຫ້ ເອີ້ນ ວ່າ ຜູ້ ໃຊ້ ລົ ດ ເຂັນ ສະ ເໝີ ເວັ້ນ ເສຍ ແຕ່ ວ່າ ພວກ ເຂົາ ແມ່ນ ເດັກນ້ອຍໆ ຫຼື ພວກ ເຂົາ ບໍ່ ສາມາດ ເຂົ້າ ໃຈ ຫຼື ຕອບ ຄໍາ ຖາມ ຂອງ ທ່ານ ໄດ້; ï ອະທິບາຍ ຕ່ໍ ກັບ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ວ່າ ຂ້ໍ ມູນ ທີ່ ລາວ ສະໜອງ ໃຫ້ ຈະ ຊ່ວຍ ເລືອກ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ທີ່ ສຸດ ເ ພ່ືອຕອບ ສະໜອງ ຄວາມ ຕ້ອງກາ ນຂອງລາວ; 48 ï ບໍ່ ຈໍາ ເປັນ ຕ້ອງ ຖາມຄໍາ ຖາມ ຕາມລໍາດັບ ທີ່ ໃຫ້ ໄວ້ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ບາງ ຄັ້ງ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ຈະ ໃຫ້ຂ້ໍ ມູນ ກ່ອນ ທີ່ ຈະ ຖາມ, ຫຼື ມັນ ອາດ ຈະ ເປັນ ທໍາ ມະ ຊາດ ກວ່າ ໃນ ການ ຖາມ ຄໍາ ຖາມ ຕາມ ລໍາດັບ ອື່ນ. ບາງ ຄັ້ງ, ການ ສ່ືສານ ຜ່ານ ຄໍາ ເວົ້າ ອາດ ຈະ ເປັນ ເລື່ອງ ຍາກ. ຕົວຢ່າງ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ອາດ ຈະ ບໍ່ ສາມາດ ໄດ້ ຍິນ ຫຼື ອາດ ຈະ ບໍ່ ສາມ າດ ເວົ້າ ໄດ້ ຈະ ແຈ້ງ ພຽງພໍ ເພ່ືອ ໃຫ້ ທ່ານ ເຂົ້າ ໃຈ. ເມ່ືອ ການ ສ່ືສານ ມີ ຄວາມ ຫຍຸ້ງຍາກ, ໃຫ້ ລອງ ຊອກ ວິທີສ່ືສານ ໂດຍ ກົງ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ຖາມ ຄົນ ທີ່ ຮູ້ ຈັກຜູ້ ໃຊ້ ລົດ ເຂັນ ເປັນ ຢ່າງ ດີ, ວິທີ ທີ່ ທ່ານ ສາມາດ ສ່ືສານ ໄດ້ ດີ ທີ່ ສຸດ. ໃຊ້ ເວລາ ເພ່ືອ ເຂົ້າ ໃຈ ແບບ ວິທີ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສ່ືສານ. ຖ້າ ທ່ານ ບໍ່ ສາມາດ ຊອກ ວິທີ ສ່ືສານ ໂດຍ ກົງ, ຈົ່ງ ຮັບປະກັນ ວ່າ ທ່ານ ມີ ບາງ ຄົນ ທີ່ ຮູ້ຈັກ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເປັນຢ່າງ ດີ ຢູ່ ໃກ້ໆ ຕະຫຼອດ ເວລາ. ຮ້ອງ ຂໍ ໃຫ້ ບຸກຄົນ ນ້ີ ຊ່ວຍທ່ານ ສ່ືສານ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ອື່ນ. ກາ ນຮັບ ຮູ້ ການ ເຈັບ ໃນ ເວລາຜູ້ ໃຊ້ ລົດ ເຂັນ ບ່ໍ ສາມາດ ເວ້ົາ ໄດ້ ເມ່ືອຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ສາມາດ ເວົ້າ ໄດ້, ມັນ ສາມາດ ຍາກ ສໍາລັບ ເຂົາ ເຈົ້າ ໃນ ການ ບອກ ວ່າ ພວກ ເຂົາ ກໍາລັງ ເຈັບ. ແນວ ໃດ ກໍ ຕາມ, ມັນ ສໍາຄັນ ສໍາລັບ ພະນັກງານ ບໍລິກາ ນລົດ ເຂັນ ໃນ ກາ ນຮູ້ ວ່າ ອັນ ໃດທີ່ ພວກ ເຂົາ ເຮັດ ກໍາລັງ ເຮັດ ໃຫ້ ເຈັບ ຫຼື ເພ່ີມຄວາມ ເຈັບ ປວດ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ສັນຍານທ່ີ ບ່ໍ ແມ່ນ ຄໍາ ເວ້ົາ ທ່ີ ສະ ແດງ ເຖິງ ການ ເຈັບ ສາມາດ ລວມມີ: ï ຮອ້ງ ໄຫ້, ຮ້ອງ ດັງ, ກະວົນກະວາຍ ຫຼື ເຫື່ອ ອອກ; ï ຍູ້ ມືຂອງ ຜູ້ ປະ ເມີນ ຜົນ ອອກ ໄປ ຫຼື ພະຍາຍາມ ຍັບ ໜີ; ï ຂັດ ຂືນການ ເຄື່ອນ ເໜັງ ຫຼື ບໍ່ ສາມາດ ຮັກສາ ທ່າ ທາງ ສະ ເພາະ ໄດ້; ï ສະ ແດງ ອອກ ທາງ ໃບ ໜ້າ – ເຮັດ ໜ້າ ຫຍຸ້ງ ແລະ/ຫຼື ໜ້າ ບິດ ບ້ຽວ; ï ຮູບ ແບບ ທີ່ ບາງ ຄົນ ນ່ັງ, ຟືນ ຫຼື ຍ່າງ. ຮັບປະກັນ ວ່າ ທ່ານ ບ່ໍ ເຮັດ ໃຫ້ ເຈັບ ຫືຼ ເພ່ີມ ຄວາມ ເຈັບ ທ່ີ ມີ ຢູ່ ແລ້ວ ໂດຍ ການ: ï ສ່ົ ງ ເສີມ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບອກ ໃຫ້ ທ່ານ ຮູ້ ຖ້າ ລາວ ເຈັບ ໃນ ລະຫວ່າງ ການ ປະ ເມີນ ຜົນ; ï ຖ້າ ການ ສ່ືສານ ລໍາບາກ – ຕົກລົງ ກັນ ເລື່ອງ ສັນຍານ ບົ່ງ ບອກ ຄວາມ ເຈັບ ກ່ອນ ທີ່ ຈະ ເລີ່ ມການ ປະ ເມີນ ຜົນ; ï ຫຼີກ ເວັ້ນທ່າ ທາງ ຕ່າງໆ ທີ່ ເຮັດ ໃຫ້ການ ເຈັບ ຮ້າຍ ແຮງ ຂ້ຶນ; ï ໃຊ້ ທ່າ ທາງ ຫຼື ການ ເຄື່ອນ ເໜັງ ຕ່າງໆ ທີ່ ເຮັດ ໃຫ້ ເຈັບ ໜ້ອຍ ລົງ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 49 ການ ປະ ເມີນ ຮ່າງກາຍ – ທ່າ ນ່ັງ ໂດຍ ບ່ໍ ມີ ການ ປະຄອງຫືຼຮອງ ຮັບ ການ ປະ ເມີນຮ່າງກາຍ ແມ່ນ ສ່ວນ ທີ ສອງ ຂອງ ການ ປະ ເມີນ ຜົນ. ມັນ ລວມມີ: ï ລະບຸການ ມີ ຢູ່, ຄວາມ ສ່ຽງ ຫຼື ປະຫວັດ ການ ເກີດ ແຜ ກົ ດທັບ; ï ລະບຸວິທີ ການ ຍູ້ ລົດ ເຂັນ; ï ຊອກ ຮູ້ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ແນວ ໃດ ແລະ ແນວ ປະຄອງຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ໃດ ແດ ທີ່ ລາວ ອາດ ຈະ ຕ້ອງການຜ່ານ: – ການ ສ່ັງ ເກດ ທ່າ ນ່ັງ ໂດຍ ບໍ່ ມີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ; – ການ ດໍາ ເນີນການກວດ ທ່າ ກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກ; ການກວດ ທ່າ ກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກຊ່ວຍ ເຂົ້າ ໃຈ ວ່າ ບັນຫາ ຕ່າງໆ ຢູ່ ບໍລິ ເວນ ກົກ ແອວ ຫຼື ສະ ໂພ ກອາດ ຈະ ມີ ຜົນ ແນວ ໃດ ຕ່ໍ ກັບ ທ່າ ນ່ັງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ; – ການ ດໍາ ເນີນ ກາ ນຈໍາລອງ ດ້ວຍ ມື. ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ໃຊ້ ມື ຂອງ ເຂົາ ເຈົ້າ ເພ່ືອ ëຈໍາລອງí ການ ປະຄອງຫຼືຮອງ ຮັບ ທີ່ ລົດ ເຂັນ ແລະ ແນວ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ອາດ ຈະ ໃຫ້; ï ການ ເຮັດ ການ ວັດ ແທກ. ຂ້ໍ ມູນ ຈາກ ແຕ່ ລະ ສ່ວນ ເຫຼົ່ານ້ີ ຂອງ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ຈະ ຊ່ວຍ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຕັດສິນ ໃຈວ່າການ ປະຄອງ ຫຼືຮອງຮັບ ຫຼາຍປານ ໃດ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ມີ. ການກວດ ເບ່ິງ ການ ມີ ຢູ່, ຄວາມ ສ່ຽງ ຫືຼ ປະຫວັດ ການ ເ ກີດ ແຜ ກົ ດທັບ ແລະ ວິທີ ຍູ້ ລົດ ເຂັນ ການ ມີ ຢູ່, ຄວາມ ສ່ຽງ ຫືຼ ປະຫວັດ ການ ເກີດ ແຜ ກົ ດທັບ /// = ບໍ່ ມີ ຄວາມ ຮູ້ສຶກ O = ແຜ ກົ ດທັບ ໃນ ເມ່ືອ ກ່ອນ = ແຜ ກົ ດທັບ ໃນ ປະຈຸ ບັນ ສາມາດ ຮູ້ສຶກ ໄດ້ ປົກກະຕິ ແມ່ນບໍ? ແມ່ນ ບໍ່ ເຄີຍ ມີ ແຜກົດ ທັບ ໃນ ເມ່ືອ ກ່ອນ ແມ່ນ ບໍ? ແມ່ນ ບໍ່ ມີ ແຜກົດ ທັບ ໃນປະຈຸ ບັນ ແມ່ນບໍ? ແມ່ນ ບໍ່ ຖ້າ ແມ່ນ, ມັນ ແມ່ນ ແຜ ເປີດ ( ໄລຍະ 1–4) ແມ່ນບໍ? ແມ່ນ ບໍ່ ໄລຍະ ເວລາ ແລະ ສາ ເຫດ: ບຸກຄົນ ນ້ີ ມີ ຄວາມ ສ່ຽງ* ເກີດ ແຜ ກົ ດທັບ ແມ່ນ ບໍ? ແມ່ນ ບໍ່ *ບຸກຄົນ ຜູ້ ທີ່ ບໍ່ ສາມາດ ຮູ້ສຶກ ໄດ້ ຫືຼ ມີ 3 ປັດ ໃຈ ສ່ຽງ ຂ້ຶນ ໄປ ແມ່ນມີ ຄວາມ ສ່ຽງ ເກ ີດ ແຜ ກົດທັບ. ປັດ ໃຈ ສ່ຽງ: ບໍ່ ສາມາດ ເຄື່ອນ ເໜັງ ໄດ້, ຄວາມ ຊຸ່ມ, ທ່າ ທາງ ບໍ່ ດີ, ແຜ ກົ ດທັບ ໃນ ເມ່ືອ ກ່ອນ/ປະຈຸ ບັນ, ການ ກິນ ອາຫານ ບໍ່ ດີ, ສູງ ອາຍຸ, ມີນ້ໍາໜັກ ໜ້ອຍ ຫຼື ຫຼາຍ ເກີນ ໄປ. 50 ວິທີ ການ ຍູ້ ລົດ ເຂັນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈະ ຍູ້ ລົດ ເຂັນ ຂອງ ລາວ ແນວ ໃດ? ທັງ ສອງ ແຂນ ແຂນ ຊ້າຍ ແຂນຂວາ ທັງສອງ ຂາ ຂາ ຊ້າຍ ຂາ ຂວາ ຍູ້ ໂດຍ ຜູ້ ຊ່ວຍ ເຫຼືອ ຄໍາ ຄິດເຫັນ: ທ່າ ນ່ັງ ຕ້ັງ ຊ່ື ຕົວ ຫຍໍ້ ທີ່ ໃຊ້ ທົ່ວ ໄປ ໃນ ຂ້ໍ ນ້ີ ໂຄງ ສ້າງທາງ ຮ່າງກາຍ ຕົວ ຫຍໍ້ ປຸ່ມ ເທິງ ດ້ານ ໜ້າ ກະດູກ ເຊີງ ການ ASIS ປຸ່ມ ເທິງ ດ້ານ ຫຼັງ ກະດູກ ເຊີງ ການ PSIS ປຸ່ມ ນ່ັງ ກະດູກ ກ້ົນ IT ຜູ້ ໃຊ້ ລົດ ເຂັນ ແຕ່ລະຄົນ ສາມາດ ນ່ັງ ໃນ ທ່າ ຕ້ັງ ຊ່ື ຫືຼ ທ່າ ປົກກະຕິ ໄດ້ ບໍ? ບໍ່ ແມ່ນ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທຸກ ຄົນ ຈະ ສາມາດ ນ່ັງ ໃນ ທ່າຕ້ັງ ຊ່ື ໄດ້ ເຖິງ ແມ່ນ ຈະ ມີ ກາ ນປະຄອງ ຫຼືຮອງ ຮັບ ກ່ໍຕາມ. ຜູ້ ໃຊ້ລົດ ເຂັນ ຜູ້ ທີ່ ມີ ຄວາມ ຍາກ ໃນ ການ ນ່ັງ ຕັ້ງ ຊ່ື ຈະ ສະ ແດງ ຫຼາກຫຼາຍທ່າ ນ່ັງ ຕ່າງໆ . ທ່າຕ່າງໆ ເກີດ ຈາກ ສ່ວນໜຶ່ງ (ຫຼື ຫຼາຍສ່ວນ) ຂອງ ຮ່າງກາຍ ບໍ່ ຢູ່ ໃນ ທ່າ ປົກກະຕິ. ໃນ ລະຫວ່າງ ການ ປະ ເມີນ ຜົນ, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ຊອກ ທ່າ ນ່ັງ ທີ່ ຕ້ັງ ຊ່ື ທີ່ ສຸດ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ນ່ັງ ໄດ້ ຢ່າງ ປອດ ໄພ ແລະ ສະບາຍ ຕົວ ແລະ ຮັກສາ ໄວ້ ໂດຍ ບໍ່ ສູນ ເສຍ ເຄື່ອນ ໄຫວ ອື່ນ. ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ຄວນ ຮອງ ຮັບ ທ່ານ້ີ. ມີ ຜົນ ສຸດ ທ້າຍ ຕ່າງ ກັນ ສາມ ຢ່າງ ທີ່ ສາມາດ ພົບ ໄດ້ ໃນ ເວລາ ປະ ເມີນ ທ່າ ທາງ. ສ່ິງ ເຫຼົ່ານ້ີ ລວມມີ: • ທ່າ ຄົງ ທ່ີ - ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ສ່ວນ ຮ່າງກາຍ ທີ່ ëຄົງ ທີ່í. ດ້ວຍ ການ ໃຊ້ ແຮງ ເບົາໆ ບໍ່ ມີການ ເຄື່ອນ ເໜັງ (ບໍ່ ຄວນ ໃຊ້ ແຮງ ໜັກ). ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຄວນ ໃຫ້ ແນວປະຄອງ ຫຼື ແນວຮອງ ເພ່ືອ ຮອງ ຮັບທ່າ (ຄົງ ທີ່) ທີ່ ບໍ່ ປົກກະຕິນ້ັນ. • ທ່າ ທ່ີປັບ ປ່ຽນ ເປັນ ທ່າ ປົກກະຕິ – ດ້ວຍ ການ ໃຊ້ ແຮງ ເບົາໆ ສາມາດ ນໍາ ເອົາສ່ວນ ຂອງ ຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ບໍ່ ຢູ່ ໃນ ທ່າ ປົກກະຕິ ໄປ ສູ່ ທ່າ ປົກກະຕິ ໄດ້. ໃນ ສະພາບ ການ ນ້ີ ຄວນ ໃຫ້ ແນວ ປະຄອງ ຫຼື ຮອງ ຮັບ ທີ່ ຖືກຕ້ອງ ເພ່ືອ ຊ່ວຍ ໃຫ້ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ຮັກສາ ທ່ານ່ັງ ປົກກະຕິ. • ທ່າ ທ່ີສາມາດປັບ ບາງ ສ່ວນ ເປັນ ທ່າ ປົກກະຕິ – ດ້ວຍ ການ ໃຊ້ ແຮງ ເບົາໆ ສາມາດ ນໍາ ເອົາພຽງ ບາງສ່ວນ ຂອງ ຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ບໍ່ ຢູ່ ໃນ ທ່າ ປົກກະຕິ ໄປ ສູ່ ທ່າ ປົກກະຕິ . ໃນ ສະພາບ ການ ນ້ີ ໃຫ້ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ເພ່ືອ ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ໃກ້ ກັບ ທ່າປົກກະຕິ ເທົ່າ ທີ່ ຈະ ສະບາຍ ຕົວ ແລະ ເຄື່ອນ ເໜັງ ໄດ້ ສໍາລັບ ເຂົາ ເຈົ້າ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 51 ທ່າ ນ່ັງ ຕ້ັງ ຊ່ື ສໍາລັບ ເດັກ ນ້ອຍໆ ເດັກນ້ອຍ ຕ່ໍາ ກວ່າ ຫ້າ ປີ ບໍ່ ມີ ທ່ານ ນ່ັງ ຕ້ັງ ຊ່ື ແບບ ດຽວ ກັນ ກັບ ເດັກ ທີ່ ໃຫຍ່ ກວ່າ ແລະ ຜູ້ ໃຫຍ່. ທ່າ ນ່ັງ ພັດທະນາ ໃນ ຕະຫຼອດຫ້າ ປີ ທໍາ ອິດ ຂອງ ຊີວິດ ເດັກນ້ອຍ. ຄວາມ ແຕກ ຕ່າງ ສໍາຄັນ ທີ່ ສຸດ ກ່ອນ ອາຍຸ ຫ້າ ປີ ແມ່ນ: ï ຫຼັງຂອງ ເດັກນ້ອຍ ແບນ ແລະ ບໍ່ ມີ ການ ກ່ົງ ຢູ່ບໍລິ ເວນ ແອວ ຫຼື ໜ້າ ເອິກ; ï ຫູ ແລະ ສະ ໂພ ກຂອງ ເດັກນ້ອຍ ຢູ່ ໃນ ເສ້ັນ ຊ່ື ກັນ ແນວ ໃດ ກໍ ຕາມ ບ່າ ໄຫ່ຼຂອງ ເຂົາ ເຈົ້າ ເດ່ ໄປ ໜ້າ ໜ້ອ ຍໜຶ່ງ. ï ຂາ ມ້ວນ ອອກ ແລະ ຈ່າງ ອອກ ຈາ ກັນ – ບໍ່ ຂະໜານ ກັນ. ໃນ ເວລາ ເຮັດ ວຽກ ກັບ ເດັກນ້ອຍ ອາຍຸ ຕ່ໍາ ກວ່າ ຫ້າ ປີ, ພະນັກງາ ນບໍລິກາ ນລົ ດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ຈື່ ວ່າ ເດັກນ້ອຍ ອາຍຸ ຕ່ໍາ ກວ່າ ຫ້າ ປີ ບໍ່ ຄວນ ໄດ້ ຮັບ ແນວ ປະຄອງ ຫຼືຮອງ ຮັບ ທີ່ສ່ົງ ເສີມ ທ່າ ນ່ັງ ຕ້ັງ ຊ່ື ຂອງ ຜູ້ ໃຫຍ່. ນີ້ ຈະ ບໍ່ ສະບາຍ ຕົວ ແລະ ສາມາດ ກ່ໍ ອັນຕະລາຍ ຕ່ໍ ກັບ ເດັກນ້ອຍ ໄດ້. ການ ສັງ ເກດທ່າ ນ່ັງ ຈຸດ ເລີ່ ມຕ້ົນ ເພ່ືອ ເຂົ້າ ໃຈ ທ່າ ທາງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ການ ຮອງ ຮັບ ໃດ ແດ່ ທີ່ ຈໍາ ເປັນ ແມ່ນ ການ ສັງ ເກີດ ເບິ່ງ ທ່າ ນ່ັງ ຂອງ ລາວ – ໂດຍ ບໍ່ ມີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ. ສໍາລັບສ່ວນ ນ້ີ ຂອງ ການ ປະ ເມີນ ຮ່າງກາຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງຢູ່ ເທິງ ຕຽງ ປະ ເມີນ ຜົນ. ຮັບປະກັນ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແມ່ນ ປອດ ໄພ ແລະ ມີ ການ ຮອງ ຮັບຕີນ ຂອງ ລາວ . ໃຫ້ ຜູ້ ຊ່ວຍ ຫຼື ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ນ່ັງ ກັບ ລາວ ຖ້າ ລາວ ບໍ່ ສາມາດ ນ່ັງ ດ້ວຍ ຕົນ ເອງ ໄດ້ຢ່າງ ປອດ ໄພ. ສັງ ເກ ດ ເບິ່ງ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ນ່ັງ ໃນ ທ່ານ່ັງ ປົກກະຕິ/ຕ້ັງ ຊ່ື ໄດ້ ໂດຍ ບໍ່ ມີ ການ ປະຄອງ ຫຼືຊ່ວຍ ເຫຼືອ ໄດ້ ຫຼືບໍ່. ຈຸດປະສົງ ຂອງ ການ ສັງ ເກດ ເບິ່ງ ທ່ານ ນ່ັງ ໂດຍ ບໍ່ ມີ ການປະຄອງ ຫຼືຊ່ວຍ ເຫຼືອ ແມ່ນ ເພ່ືອ ເຂົ້າ ໃຈ ວ່າ ແນວ ໂນ້ມ/ນິ ໄສ ດ້ານທ່າ ທາງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ການ ສັງ ເກດ ເບິ່ ງທ່າ ນ່ັງ ແມ່ນ ທັກ ສະ ເຊິ່ງ ໃຊ້ ເວລາ ແລະ ການ ຝຶກປະຕິບັດ ເພ່ືອ ພັດທະນາ. 52 ວິທີບອກວ່າຜູ້ໃຊ້ລົດເຂັນກໍາລັງນ່ັງຕ້ັງຊ່ືຫືຼບ່ໍ ທ່ານ່ັງຕ້ັງຊ່ືທີ່ອະທິບາຍໃນທ່ີນ້ີຄວນຖືກໃຍ້ໂດຍພະນັກງານບໍລິການລົດເຂັນເປັນຂ້ໍແນະນໍາ. ໃນເວລາເຮັດວຽກກັບຜູ້ໃຊ້ລົດເຂັນ, ຈຸດປະສົງແມ່ນເພ່ືອປະຄອງຫຼືຮອງ ຮັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແຕ່ລະຄົນ ໃຫ້ ໃກ້ ຄຽງກັບ ທ່າ ນ້ີ ເທົ່າ ທີ່ ຈະສະບາຍ ຕົວ, ເຄື່ອນ ເໜັງ ໄດ້ ແລະ ເຮັດ ໄດ້ ສໍາລັບ ເຂົາ ເຈົ້າ. ເບ່ິງ ຈາກ ດ້ານ ຂ້າງ ແລະ ກວດ ເບ່ິງ: ກະດູກ ກົກ ແອວ ຕ້ັງ ຊ່ື – ລະດັບ ASIS ແລະ PSIS; ລໍາ ຕົວ ຕ້ັງ ຊ່ື; ຫຼັງ ໄປ ຕາມ ສາມ ສ່ວນ ກ່ົງຕາມ ທໍາ ມະ ຊາດ; ຜູ້ ໃຫຍ່ – ຫູ, ບ່າ ໄຫ່ຼ ແລະ ສະ ໂພ ກຢູ່ ແນວ ຊ່ື ກັນ. ເດັກນ້ອຍ – ຫູ ແລະ ສະ ໂພ ກຢູ່ ໃນ ແນວ ຊ່ື ກັນ ແລະ ບ່າ ໄຫ່ຼ ເດ່ ໄປ ໜ້າໜ້ອຍ ໜຶ່ງ; ສະ ໂພ ກກ່ົງ ເຂົ້າ ຫາ ປະມານ 90 ອົງສາ; ຫົວ ເຂົ່າ ແລະ ຂ້ໍ ຕີນ ກ່ົງ ເຂົ້າ ຫາປະມານ 90 ອົງສາ; ສ້ົນ ນ່ອງ ຢູ່ ກ້ອງ ຫົວ ເຂົ່າ ໂດຍ ກົງ ຫຼື ເດ່ ໄປ ໜ້າ ຫຼື ຫຼັງໜ້ອຍ ໜຶ່ງ; ຕີນ ຮາບ ພຽງ ກັບ ພ້ືນ ຫຼື ບ່ອນ ວາງ ຕີນ. ເບ່ິງ ຈາກ ດ້ານ ໜ້າ ແລະ ກວດ ເບ່ິງ: ກະດູກ ກົກ ແອວພຽງ ກັນ – ASIS ທັງ ສອງ ເບື້ອງ ພຽງ ກັນ; ບ່າ ໄຫ່ຼພຽງ ກັນ ແລະ ຜ່ອນຄາຍ, ແຂນ ເຄື່ອນ ໄຫວ ໄດ້ ຢ່າງ ອິດສະຫຼະ; ຂາ ເປີດ ອອກ ໜ້ອຍ ໜຶ່ງ (ຈ່າ ງອອກ); ຫົວ ຕ້ັງ ຊ່ື ແລະ ດຸ່ນດ່ຽງ ທົ່ວ ຮ່າງກາຍ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 53 ກາ ນບັນທຶກ ທ່າ ທາງ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ມີ ບ່ອນ ຫວ່າງ ໃຫ້ ບັນທຶກ ທ່າ ນ່ັງ ໂດ ຍບໍ່ ມີ ການ ປະຄອງ ຫຼືຮອງຮັບ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ທ່າ ນ່ັງ ໂດຍ ບ່ໍ ມີ ການ ປະຄອງ ຫືຼຮອງ ຮັບ: ອະທິບາຍ ຫຼື ແຕ້ມ ທ່ານ່ັງ ທີ່ ບໍ່ ມີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ: ບັນທຶກ ນ້ີ ຈະ ຊ່ວຍ ໃຫ້ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຈື່ ທ່າ ນ່ັງ ຂອງ ຜູ້ ໃຊ້ລົດ ເຂັນ ຫຼັງຈາກ ການ ປະ ເມີນ ຜົນ. ມັນຍັງ ສາມາດ ຊ່ວຍ ໃຫ້ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຕິດຕາມ ການ ປ່ຽນ ແປງ ໃນ ທ່ານ່ັງ ຂອງ ຜູ້ ໃຊ້ ລົ ດ ເຂັນ ເມ່ືອ ເວລາ ຜ່ານ ໄປ ໄດ້ ນໍາ ອີກ. ມີ ສອງ ສາມ ວິທີ ທີ່ ຕ່າງ ກັນ ເພ່ືອ ບັນທຶກ ທ່າ ນ່ັງ ເ ຊ່ິງລວມມີ: ï ອະທິບາຍ ທ່າ ນ່ັງ ເປັນ ຄໍາ ເວົ້າ; ï ແຕ້ມ ທ່າ ນ່ັງ; ï ຖ່າຍຮູບ ( ໂດຍ ມີ ການ ອະນຸຍາດຈາກຜູ້ ໃຊ້ ລົດ ເຂັນ ເທົ່າ ນ້ັນ). ຂ້າງ ລຸ່ມ ແມ່ນ ຕົວຢ່າງ ຂອງ ການ ແຕ້ມ ເສ້ັນ ງ່າຍໆ ທີ່ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ບັນທຶກ ທ່າ ນ່ັງ. ການ ແຕ້ມ ເສ້ັນ ທ່າ ນ່ັງຈາກ ດ້ານ ຂ້າງ. ການ ແຕ້ມ ເສ້ັນ ທ່າ ນ່ັງຈາກ ດ້ານ ໜ້າ. ຈ່ື ວ່າ! ï ບໍ່ ແມ່ນ ທຸກ ຄົນ ຈະ ສາມາດ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້. ï ໃນ ລະຫວ່າງ ການ ປະ ເມີນ ຜົນ, ພະນັກ ງານ ບໍລິການ ລົດ ເຂັນ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເຮັດ ວຽກ ຮ່ວມ ກັນ ເພ່ືອ ຊອກ ຮູ້ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ນ່ັງ ໃກ້ ກັບ ທ່າ ນ່ັງ ຕ້ັງ ຊ່ື ຢ່າງ ສະບາຍ ຕົວ ໄດ້ສ່ໍາ ໃດ. ï ລົດ ເຂັນ ທີ່ ມີ ອຸປະກອນ ຮອງ ຮັບ ທ່າ ທາ ງ ເພ່ີມ ເຕີມ ຄວນ ຊ່ວຍ ປະຄອງ ຫຼືຮອງ ຮັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃຫ້ ນ່ັງ ໄດ້ ໃກ້ ກັບ ທ່າ ຕ້ັງ ຊ່ື ເທົ່າ ທີ່ ຈະ ສະບາຍ ຕົວ ສໍາລັບ ເຂົາ ເຈົ້າ. 54 ການ ປະ ເມີນ ຮ່າງກາຍ – ການກວດ ເບ່ິງ ທ່າ ກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກ ການກວດ ເບ່ິງ ທ່າກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກ ສ່ິງ ທີ່ ກໍາລັງ ເກີດ ຂ້ຶນ ຢູ່ ບໍລິ ເວນ ກົກ ແອວ ແລະ ສະ ໂພ ກມີ ຜົນ ຕ່ໍ ກັບທ່າ ນ່ັງ. ໃນ ສ່ວນ ນ້ີ ຂອງ ການ ປະ ເມີນ ຜົນ ພ ະນັກ ງານ ບໍລິການລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ຊອກ ຮູ້ວ່າ: ï ກະດູກກົ ກ ແອວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນພຽງ ກັນຫືຼບໍ່ ເມ່ືອ ເບິ່ງ ຈາກ ດ້ານ ໜ້າ (ນ້ີ ອາດ ຈະ ໂດຍ ມີ ຫຼື ບໍ່ ມີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ); ï ສະ ໂພ ກ ຂອງຜູ້ ໃຊ້ ລົດ ເຂັນສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ (ມຸມ ລະຫວ່າງ ລໍາ ຕົວ ຫາ ກົກຂາ ກວ້າງ ກວ່າ 90 ອົງສາ) ຫຼືບໍ່. ນ້ີ ອາດ ຈະ ໂດຍ ມີ ຫຼື ບໍ່ ມີ ການ ປະຄອງ ຫຼືຮອ ງຮັບ. ຖ້າ ກະດູກກົກ ແອວ ບໍ່ ພຽງ ກັນ ຫຼື ສະ ໂພ ກບ່ໍ ສາມາດ ກ່ົງ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ (ມຸມ ລະຫວ່າງ ລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ), ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຕ້ອງ ຊອກ ຮູ້ ຂ້ໍ ມູນ ເພ່ີມ ເຕີມ. ມັນ ສໍາຄັນ ໃນ ການ ຮູ້ ວ່າ: ï ຜູ້ ໃຊ້ ລົດ ເຂັນສາມາດ ນ່ັງ ໃນ ທ່າ ປົກກະຕິ ໂດຍ ມີ ການ ປະ ຄອງ ຫຼືຮອງ ຮັບ ໄດ້ ບໍ? ï ຖ້າ ບໍ່ – ລາວ ສາມາດ ນ່ັງ ໄດ້ ໃກ້ສ່ໍາ ໃດ ກັບ ທ່າ ນ່ັງປົກກະຕິ? ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ສາມາດ ນ່ັງ ໃນ ທ່ານ່ັງ ປົກກະຕິ ໄດ້, ມັນ ຍັງ ສໍາຄັນ ໃນ ການ ຮູ້ ວ່າຄວາມ ຍາກ ແມ່ນ ເນ່ືອງ ຈາກ: ï ຂີດ ຈໍາກັດ (ຫຼື ຂ້ໍ ຈໍາກັດ) ຢູ່ ເທິງ ກະດູກ ກົກ ແອວ ( ໃນ ກະດູກ ສັນຫັຼງສ່ວນ ແອວ); ຫຼື ï ຂີດ ຈໍາກັດ ຢູ່ ພາຍ ໃນ ກະດູກ ກົກ ແອວ (ຢູ່ ຂ້ໍ ຕ່ໍ ສະ ໂພ ກ). ເພ່ືອ ໃຫ້ ພະນັກງານບໍລິການ ລົດ ເຂັນ ຕອບ ທຸກ ຄໍາ ຖາມ ຂ້າງ ເທິງ ມັນ ຈໍາ ເປັນ ຕ້ອງ ດໍາ ເນີນສ່ວນ ëການກວດ ເບິ່ງ ທ່າ ກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກí ຂອງ ການ ປະ ເມີນ ຜົນ. ນ້ີ ບໍ່ ແມ່ນ ການ ປະ ເມີນຂອບ ເຂດ ການ ເຄື່ອນ ໄຫວ ເຕັມ. ຈຸດປະສົງ ຂອງ ການກວດ ເບິ່ງ ກະດູກ ກົ ກ ແອວ ແລະ ສະ ໂພ ກທ່ີ ສອນ ໃນ ການ ຝຶກ ອົບຮົມ ນ້ີ ແມ່ນ ພຽງ ແຕ່ເພ່ືອລະບຸ ປັດ ໃຈ ຕ່າງໆ ທີ່ ກ່າວ ເຖິງ ຂ້າງ ເທິງ. ພະນັກງານ ບໍລິ ການ ລົດ ເຂັນ ທີ່ ມີ ທັກ ສະອາດ ຈະ ເລືອກ ດໍາ ເນີນ ຂອບ ເຂດການ ເຄື່ອນ ໄຫວ ເຕັມ ເພ່ືອ ເກັບ ເອົາ ຂ້ໍ ມູນ ລະອຽດ ກວ່າ ກໍ ໄດ້. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 55 ການ ດໍາ ເນີນການກວດ ທ່າ ກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກ ກະກຽມ: ï ອະທິບາຍ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສ່ິງ ທີ່ ທ່ານ ກໍາລັງ ຈະ ເຮັດ ແລະ ຍ້ອນ ຫຍັງ ມັນ ຈິ່ງ ສໍາຄັນ; ï ຮ້ອງ ຂໍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນອນ ຫງາຍ ຢູ່ ເທິງ ຕຽງ ປະ ເມີນ ຜົນ. (ໝາຍ ເຫດ: ໃນ ການ ສອນ ເຫຼົ່ານ້ີ, ບຸກຄົນ ທີ່ ດໍາ ເນີນ ການ ກວດ ເບິ່ງທ່າ ກະດູ ກກົກ ແອວ ແລະ ສະ ໂພ ກ ເອີ້ນ ວ່າ ëຜູ້ ປະ ເມີນí ແລະ ບຸກຄົນ ທີ່ ຊ່ວຍ ຜູ້ ປະ ເມີນ ເອີ້ນ ວ່າ ëຜູ້ ຊ່ວຍí ຜູ້ ທີ່ ສາມາດ ເປັນ ເພ່ືອນ ຮ່ວມ ງານ, ຜູ້ ຊ່ວຍ ທີ່ ຜ່ານ ການຝຶກ ອົບຮົມ, ຄົນ ໃນ ຄອບຄົວ ຫຼື ຜູ້ ເບິ່ງ ແຍງ ຜູ້ ໃຊ້ ລົດ ເຂັນ). ການກວດ ເບ່ິງ ທ່າ ກະດູກ ກົກ ແອວ: ï ຜູ້ ປະ ເມີນ ກ່ົງ ຫົວ ເຂົ່າ ທັງ ສອງ ຂ້າງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໜ້ອຍໜຶ່ງ ແລະ ໃຫ້ ແນວ ຮອງ ຈໍານວນ ໜຶ່ງ ເຊິ່ງຊ່ວຍ ບັນ ເທົາ ຄວາມ ເຄັ່ງ ຢູ່ ສະ ໂພ ກ; ï ຜູ້ ຊ່ວຍ ວາງ ມື ຂອງ ເຂົາ ເຈົ້າ ແປະ ໃສ່ ລໍາ ຕົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນຢ່າງ ແໜ້ນ ຢູ່ ບໍລິ ເວນ ກະດູກ ຂ້າງ ສ່ວນ ລຸ່ມ; ï ຜູ້ ປະ ເມີນ ຈັບ ກະດູກ ກົກ ແອວ ເບົາໆ ດ້ວຍ ໂປ້ ມື ຢູ່ ASIS; ï ຜູ້ ປະ ເມີນ ກວດ ເບິ່ງ ວ່າ ໂປ້ ມື/ASIS ພຽງ ກັນຫືຼບໍ່; ï ຖ້າ ບໍ່ ພຽງ ກັນ, ຜູ້ ປະ ເມີນ ພະຍາຍາມ ຈັດ ກະດູກ ກົກ ແອວ ເບົາໆ ແຕ່ ໜັກ ແໜ້ນ ເພ່ືອ ASIS ທັງ ສອງ ຂ້າງຢູ່ ໃນ ລະດັບ ພຽງ ກັນ; ï ຜູ້ ຊ່ວຍ ລາຍ ງານ ວ່າ ລາວ ຮູ້ສຶກ ວ່າ ລໍາ ຕົວ ເໜັງ ຕີງ ຫຼືບໍ່ ເຊິ່ງໝາຍ ຄວາມ ວ່າ ມີ ບາງ ຂ້ໍ ຈໍາກັດ ຕ່ໍ ກັບ ການ ເຄື່ອງ ເໜັງ; ï ບັນທຶກ ມັນ ເປັນ ໄປ ໄດ້ ໃນ ການ ນໍາ ເອົາ ກະດູກ ກົກ ແອວ ເຂົ້າ ໃກ້ ທ່າ ປົກກະຕິ/ພຽງ ກັນ ໄດ້ ໃກ້ ຄຽງ ສ່ໍາ ໃດ; ï ຜູ້ ປະ ເ ມີນບັນທຶກວ່າ ກະດູກ ກົກ ແອວ ສາມາດ ພຽງ ກັນ ໄດ້ ຫຼືບໍ່ ຢູ່ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ການກວດ ເບ່ິງ ທ່າ ສະ ໂພ ກ: ï ຜູ້ ຊ່ວຍ ຈັບ ກົກ ແອວ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເບົາ ໆ ແຕ່ ໜັກ ແໜ້ນ; ï ຜູ້ ປະ ເມີນ ກ່ົງ ຂາ ທີ່ ບໍ່ຖືກ ທົດ ສອບ ຂ້ຶນ ໜ້ອຍ ໜຶ່ງ ຢູ່ ຫົວ ເຂົ່າ, ໂດຍ ວາງ ຕີນ ໃສ່ ເ ສ່ື ອ. ນ້ີ ຊ່ວຍ ຫຼຸດຜ່ອນ ຄວາມ ເຄັ່ງ ຢູ່ ສວ່ນສະ ໂພ ກທ່ີ ກໍາລັງ ຖືກ ທົດ ສອບ. ຂາ ເບື້ອງ ນ້ີອາດ ຈໍາ ເປັນ ຕ້ອງ ມີ ແນວ ຮອງ. 56 ການກວດ ເບ່ິງ ທ່າ ສະ ໂພ ກ: ï ຜູ້ ປະ ເມີນ ຍ້າຍ ຂາ ທີ່ ຖືກ ທົດ ສອບ ເບົາໆ ໄປ ສູ່ ທ່າ ນ່ັງປົກກະຕິ; ï ຜູ້ ຊ່ວຍ ລາຍ ງານ ວ່າ ລາວ ຮູ້ສຶກ ວ່າ ກົກ ແອວ ເໜັງ ຕີງ ຫຼືບໍ່ ເຊິ່ງໝາຍ ຄວາມ ວ່າ ມີ ບາງ ຂ້ໍ ຈໍາກັດ ຕ່ໍ ກັບ ການ ເຄື່ອງ ເໜັງ; ï ຜູ້ ປະ ເມີນ ຮູ້ສຶກ ວ່າ ຂ້ໍ ຕ່ໍ ສະ ໂພ ກສາມາດ ເຄື່ອນ ເໜັງ ໄດ້ ຢ່າງ ອິດສະຫຼະສ່ໍາ ໃດ; ï ຜູ້ ປະ ເມີນ ເຮັດ ແບບ ດຽວ ກັນ ຢູ່ ສະ ໂພ ກອີກ ຂ້າງ ແລະ ປຽບທຽບ; ï ຜູ້ ປະ ເມີນ ບັນທຶກ ວ່າ ສະ ໂພ ກ ເບື້ອງ ຂວາ ແລະ ຊ້າຍ ສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ຫຼືບໍ່ ຢູ່ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນລະດັບ ປານ ກາງ. ï ຜູ້ ປະ ເມີນ ບັນທຶກ ວ່າສະໂພກແຕ່ລະເບື້ອງສາມາດບັນລຸ ໄດ້ ໃກ້ ສ່ໍາ ໃດ ກັບ ທ່າ ປົກກະຕິ ດ້ວຍເຄື່ອງ ແທກ ມຸມ ໂດຍ ການ ຊ່ວຍ ເຫຼືອຂອງ ຜູ້ ຊ່ວຍ; ï ຜູ້ ປະ ເມີນ ວາງ ຈຸດຕ້ັງ ແກນ ຂອງ ເຄື່ອງ ແທກມຸມ ໃສ່ ຂ້ໍ ຕ່ໍ ສະ ໂພ ກ. ຜູ້ ປະ ເມີນ ວາງ ຕ ໍາ ແໜ່ ງ ແຂນ ຂ້າງ ໜຶ່ງ ຂອງ ເຄື່ອງ ແທກ ມຸມ ຕາມ ກະດູກ ກົກຂາ ແລະ ອີກ ຂ້າງ ຊ່ື ຕາມ ລໍາ ຕົວ; ï ຜູ້ ປະ ເມີ ນຈັບ ສອງ ແຂນ ໃສ່ ເຂົ້າກັນ ໃຫ້ ແໜ້ນ; ï ຜູ້ ປະ ເມີນ ບັນທຶກການ ວັດ ແທກລະດັບ ມຸມ ຂອງ ສະ ໂພ ກຂວາ ແລະ ຊ້າຍ ໃສ່ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະ ດັບ ປານ ກາງ. ນອກ ນ້ັນ ຜູ້ ປະ ເມີນ ຜົນ ຍັງ ສາມາດ ແຕ້ມ ມຸມ ຂອງ ເຄື່ອງ ແທ ກມຸມ ໃສ່ ແຜ່ນ ເຈ້ຍ ແຍກ ຕ່າງຫາກ ຫຼື ໃສ່ ດ້ານ ຫຼັງຂອງ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 57 ກາ ບັນທຶກ ການກວດ ທ່າ ກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກ ການກວດ ເບ່ິງ ທ່າກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກ ກວດ ເບິ່ງ ວ່າ ກະດູກ ກົກ ແອວ ພຽງ ກັນຫືຼບໍ່ ແລະ ຂອ ບ ເຂດ ການ ງໍ ຂອງ ສະ ໂພ ກ ໃນ ເວລາ ນອນ ກະດູກ ກົກ ແອວ ສາມາດ ຢູ່ ໃນ ລະດັບພຽງ ກັນ ໄດ້ ບໍ? ແມ່ນ ບໍ່ ສະ ໂພ ກສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ບໍ? ສະ ໂພ ກຂວາ: ໄດ້ ບໍ່ ໄດ້ ມຸມ:------------- ສະ ໂພ ກຊ້າຍ: ໄດ້ ບໍ່ ໄດ້ ມຸມ:------------- ຖ້າ ກະດູກ ກົກ ແອວ ບໍ່ ສາມາດ ພຽງ ກັນ ໄດ້ ຫຼື ສະ ໂພ ກບ່ໍ ສາ ມາດກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ – ໃຫ້ ຮອງ ດ້ວຍ ແນວ ຮອງ ຊ່ົວຄາວ. ບັນທຶກ ຜົນ ການ ກວດ ກະດູ ກກົກ ແອວ ແລະ ສະ ໂພ ກ ໃສ່ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ໝາຍ ໃສ່ ວ່າ ກະດູ ກກົກ ແອວ ສາມາດ ພຽງ ກັນ ໄດ້ ຫຼືບໍ່. ຈາກ ນ້ັນ ໝາຍ ໃສ່ ສະ ໂພ ກ ແຕ່ລະ ເບື້ອງ ສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ (ມຸມ 90 ອົງສາ) ໄດ້ ຫຼືບໍ່. ຖ້າ ສະ ໂພ ກຂວາ ຫຼື ຊ້າຍ (ຫຼື ທັງ ສອງ) ບໍ່ ສາ ມາດກ່ົງ ເຂົາ້ ຫາ ທາ່ ນ່ັງ ປກົກະຕິ ໄດ້ (ມຸມ ລະຫວາ່ງ ລາໍ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ), ໃຫ້ ບັນທຶກ ມຸມ. ດັ່ງ ທີ່ ກ່າວ ເຖິງ ຂ້າງ ເທິງ, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຍັງ ສາມາດ ແຕ້ມ ມຸມ ຂອງ ເຄື່ອງ ແທ ກມຸມ ໃສ່ ແຜ່ນ ເຈ້ຍ ແຍກ ຕ່າງຫາກ ຫຼື ໃສ່ ດ້ານ ຫຼັງຂອງ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ແນວ ຮອງ ຊ່ົວຄາວ ສໍາລັບ ກະດູ ກກົກ ແອວ ທ່ີ ບ່ໍ ພຽງ ກັນ ຄົງ ທ່ີ ແລະ ສໍາລັບ ສະ ໂພ ກທ່ີ ບ່ໍ ສາມາດ ກ່ົງ ເຂ້ົາ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ (ມຸມ ລະຫວ່າງ ລໍາ ຕົວ ຫາ ກົກ ຂາ ຫຼາຍກວ່າ 90 ອົງສາ) ຖ້າ ກະດູກກົກ ແອວ ບໍ່ ສາມາດພຽງ ກັນ ຫຼື ສະ ໂພ ກບ່ໍ ສາມາດ ກ່ົງ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ (ມຸມ ລະຫວ່າງ ລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ), ມັນ ຈະ ຈໍາ ເປັນ ຕ້ອງ ມີ ການ ຮອງ ໃ ນທ່າ ທີ່ ບໍ່ ປົກກະຕິ ໃນ ລົດ ເຂັນ ສຸດ ທ້າຍ. ເພ່ືອ ສືບ ຕ່ໍ ການ ປະ ເມີນ ຜົນ, ຄວນ ເຮັດແນວ ຮອງ ຊ່ົວຄາວ ເພ່ືອ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ຢູ່ ເທິງ. ໃນ ລະຫວ່າງ ການ ປະ ເມີນ ຜົນ, ແນວ ຮອ ງຊ່ົວຄາວ ຈະ: ï ຊ່ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ຢ່າງ ໝ້ັນຄົງ ແລະ ຊົງ ຕົວ ໄດ້ ດີກ ວ່າ; ï ຢຸດ ຜູ້ ໃຊ້ ລົດ ເຂັນຈາກ ການ ຊົດ ເຊີຍ ສໍາລັບ ກະດູກ ກົກ ແອວ ທີ່ ບໍ່ ພຽງ ກັນ ຫຼື ສໍາລັບ ສະ ໂພ ກທ່ີ ບໍ່ ສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ (ມຸມ ລະຫວ່າງ ລໍາ ຕົວ ຫາ ກົກ ຂາ ຫຼາຍກວ່າ 90 ອົງສາ); ï ອະນຸຍາດ ໃຫ້ພ ະນັກ ງານບໍລິການ ລົດ ເຂັນ ດໍາ ເນີນ ການ ປະ ເມີນ ຜົນ ແລະ ເອົາ ໃຈ ໃສ່ ສ່ວນ ທີ່ ເຫຼືອຂອງ ທ່າ ທາງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເຊິ່ງລວມທັງ ກະດູກ ກົ ກ ແອວ, ລໍາ ຕົວ, ຫົວ, ຄໍ ແລະ ຂາ. ແນວ ຮອງ ຊ່ົວຄາວ ສາມາດ ຖືກ ເຮັດ ຈາກ ໂຟມ ແຂງ ໄດ້. ຕາຕະລາງ ລຸ່ມ ນ້ີ ສະ ແດງ ບັນຫາ ທ່າ ທາງ ຕ່າງໆ, ແນວ ຮອງ ຊ່ົວຄາວ ແລະ ແນວ ຮອງ ຖາວອນ ທີ່ ເປັນ ໄປ ໄດ້ ສໍາລັບ ບັນຫາ ເຫຼົ່ານ້ີ. 58 ບັນຫາ ທ່າ ທາງ ແນວ ຮອງ ຊ່ົວຄາວ ແນວ ຮອງ ຖາວອນ (ຕິດ ຕ້ັງ ໃສ່ ເບາະ ຮອງ ນ່ັງ ຂອງຜູ້ ໃຊ້ ລົດ ເຂັນ) ກະດູກ ກົກ ແອວ ບໍ່ພຽງກັນ ຄົງ ທີ່ (ອ່ຽງ ໄປ ທາງ ຂ້າງ) ເພ່ີມ ການ ຮອງ ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ກົກຂາ ທີ່ ສູງ ກວ່າ ສະ ໂພ ກບ່ໍ ສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ( ມຸມ ລະຫວ່າງລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ) ເພ່ີມ ການ ຮອງ ຢູ່ ກ້ອງກະດູກ ຮອງ ນ່ັງ ທັງ ສອງ ເບື້ອງ ແລະ ກົກຂາ ຂອງ ສະ ໂພກທ່ີ ບໍ່ ສາມາດກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ – ຂອບ ທີ່ ຄົມ ຈໍາ ເປັນ ຕ້ອງ ເຮັດ ໃຫ້ ເປັນ ມຸ ມອ່ຽງກ່ອນ ການ ລອງ ສະ ໂພ ກທັງ ສອງບ່ໍ ສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ( ມຸມ ລະຫວ່າງລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ) ເພ່ີມ ການ ຮອງ ເພ່ືອ ເພ່ີມ ມຸມ ລະຫວ່າງ ບ່ອນ ນ່ັງ ຫາ ແນວ ອີງ ຫຼັງ. ສະ ໂພ ກຂ້າງ ໜຶ່ງ ຫືຼ ທັງ ສອງຂ້າງບ່ໍ ສາມາດ ເປີດ ກວ້າງ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ( ມຸມ ລະຫວ່າງລໍາ ຕົວ ຫາ ກົກຂາ ໜ້ອຍກວ່າ 90 ອົງສາ) ໃຫ້ ແນວ ຮອງ ທີ່ ມີ ຮູບ ຮ່າງເປັນຫ້ີຼມຢູ່ ດ້ານ ໜ້າ ຂອງ ກະດູກ ຮອງ ນ່ັງ ຢູ່ ກ້ອງ ກົກຂາ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 59 ການ ປະ ເມີນ ຮ່າງກາຍ – ການ ຈໍາລອງ ດ້ວຍ ມື ການຈໍາລອ ງດ້ວຍ ມື ຊ່ວຍ ລະບຸ ແນວ ຮອງ ຫຼື ແນວ ປະຄອງ ໃດ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ມີ. ໃນ ລະ ຫວ່າງ ກາ ນຈໍາລອງ ດ້ວຍ ມື, ພະນັກ ງານບໍລິການ ລົດ ເຂັນ ໃຊ້ ມື ຂອງ ເຂົາ ເຈົ້າ ເພ່ືອ ຊອກ ຮູ້ ວ່າ: ï ຜູ້ ໃຊ້ ລົດ ເຂັນສາມາດ ນ່ັງ ໃນ ທ່າ ປົກກະຕິ ໂດຍ ມີ ການ ປະ ຄອງ ຫຼືຮອງ ຮັບ ໄດ້ ບໍ? ï ຖ້າ ບໍ່ – ລາວ ສາມາດ ນ່ັງ ໄດ້ ໃກ້ສ່ໍາ ໃດ ກັບ ທ່າ ນ່ັງປົກກະຕິ? ï ການ ປະຄອງ ຫຼືການ ຮອງ ຮັບໃດ ແດ່ ທີ່ ຈໍາ ເປັນ ແລະ ຢູ່ ໃສ. ໃນ ລະຫວ່າງກາ ນຈໍາລອງ ດ້ວຍ ມື, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ເຮັດ ວຽກ ກັບ ຜູ້ ໃຊ້ ລົ ດ ເຂັນ ແລະ ຜູ້ ຊ່ວຍ ຫຼື ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ເພ່ືອ ໃຫ້ການ ປະຄອງ ຫຼືຮອງ ຮັບ ດ້ວຍ ມື. ວິທີ ດໍາ ເນີນ ການ ຈໍາລອງ ດ້ວຍ ມື ດ້ານ ສໍາຄັນ ຕ່າງໆ ທີ່ ຕ້ອງ ຈື່ ໃນ ເວລາ ເຮັດ ການຈໍາລອງ ດ້ວຍ ມື ມີ ຄື: ກະກຽມ ï ອະທິບາຍ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສ່ິງ ທີ່ ທ່ານ ກໍາລັງ ຈະ ເຮັດ ແລະ ຍ້ອນ ຫຍັງ . ï ຮ້ອງ ຂໍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ເທິງ ພ້ືນ ຜິວ ແບນທີ່ ແຂງ ແຕ່ມີ ແນວ ຮອງ. ກ່ອງ ປະ ເມີນ ຜົນ ແມ່ນ ດີ ທີ ສຸດ, ພະນັກງານ ບໍລິການລົດ ເຂັນ ແລະ ຜູ້ ຊ່ວຍ ຫູ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ສາມາດ ເຂົ້າ ເຖິງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄດ້ ຢ່າງ ງ່າຍດາຍ ເພ່ືອ ໃຫ້ການ ປະຄອງ ຫຼືຮອງ ຮັບ ຈາກ ດ້ານ ໜ້າ, ດ້ານຫັຼງ ແລະ ດ້ານຂ້າງ. ï ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ສາມາດ ນ່ັງ ໄດ້ ຢ່າງ ປອດ ໄພ ໂດຍ ບໍ່ ມີ ການ ປະຄອງ ໃຫ້ ຜູ້ ຊ່ວຍ ຫຼື ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ຊ່ວຍ ປະຄອງ ເຂົ າ ເຈົ້າ. ï ຮັບປະກັນ ວ່າ ຕີນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ແນວ ຮອງ ຮັບຢູ່ ໃນ ຄວາມ ສູງ ທີ່ ຖືກຕ້ອງ ສໍາລັບ ເຂົາ ເຈົ້າ. ຖ້າ ກະດູກກົກ ແອວ ບໍ່ ພຽງ ກັນ ຫຼື ຖ້າ ໜຶ່ງ ໃນສະ ໂພ ກບ່ໍ ສາມາດ ກ່ົງ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ (ມຸມ ລະຫວ່າງ ລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ), ໃຫ້ ແນວ ຮອງ ຊ່ົວຄາວ ຕາ ມທ່ີ ອະທິບາຍ ໄວ້ ໃນ ຫົ ວຂໍ້ ກ່ອນ ນ້ີ. ເຮັດ ວຽກ ເປັນ ທີ ມ ï ມັນ ມັກ ຈະ ຈໍາ ເປັນ ໃນ ການ ມີຫຼາຍກວ່າໜ່ຶງ ຄົນ. ï ຂໍ ຄວາມ ຊ່ວຍ ເຫຼືອຈາກ ຜູ້ ຊ່ວຍ ຜູ້ ທີ່ ສາມາດ ເປັນ ເພ່ືອນ ຮ່ວມ ງານ, ຜູ້ ຊ່ວຍ ທີ່ຜ່ານ ການ ຝຶກ ອົບຮົມ, ຄົນ ໃນ ຄອບຄົວ ຫຼື ຜູ້ ເບິ່ງ ແຍງ. ï ການໃຫ້ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ເຂົ້າ ຮ່ວມ ຈະ ຊ່ວຍ ໃຫ້ ລາວ ເ ຂ້ົາ ໃຈ ວິທີ ແກ້ ໄຂ ດ້ວຍ PSD ສຸດ ທ້າຍ ໄດ້ ດີ ຂ້ຶນ. 60 ໃຊ້ ການ ສ່ືສານ ທ່ີ ດີ ï ພະນັກງານບໍລິການ ລົດ ເຂັນ ຄວນ ສ່ືສານ ຢ່າງ ອ່ອນ ໂຍນ ( ໃຫ້ ດີ ແທ້ ໃນ ພາສາ ທ້ອງ ຖິ່ນ) ກັບ ຜູ້ ໃຊ້ ແລະ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ. ï ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ສາມາດ ເວົ້າ ໄດ້, ໃຫ້ ຊອກ ວິທີການ ສ່ື ສານທ່ີ ເໝາະ ສົມ ກັບ ເຂົາ ເຈົ້າ ແລະ ໃຊ້ ມັນ. ï ຈື່ ວ່າ ຕ້ອງ ອະທິບາຍ ຕ່ໍກກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສ່ິງ ທີ່ ທ່ານ ກໍາລັງ ເຮັດ ຢູ່ ແຕ່ລະ ຂ້ັນ ຕອນ. ï ຂໍ ເອົາ ຄໍາ ຕິ ຊົມ ຈາກ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຫຼັງຈາກ ແຕ່ ລະກາ ນປ່ຽນ ແປງ. ຄິດ ຢ່າງ ລະອຽດ ກ່ຽວ ກັບ ສ່ິງ ທ່ີ ມື ຂອງ ທ່ານ ກໍາລັງ ເຮັດ ï ມື ຂອງ ທ່ານ ກໍາລັງ ໃຫ້ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທີ່ ໃນ ພາຍຫັຼງຈະ ຖື ກສະໜອງ ໃຫ້ ໂດຍ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD. ໃນ ລະຫວ່າງ ກາ ນຈໍາລອງ ດ້ວຍ ມື, ໃຫ້ ເອົາ ໃຈ ໃສ່ຢ່າງ ລະອຽດ ຕ່ໍກັບ: – ບ່ອນ ທີ່ ມື ຂອງ ທ່ານ ວາງ ໃສ່; – ທິດ ທາງ ຂອງ ກໍາລັງ ແຮງ/ການ ປະຄອງຫຼື ຮອງ ຮັບ; – ແຮງ/ການປະຄອງ ຫຼື ຮອງ ຮັບຫຼາຍປານ ໃດ ທີ່ ກໍາລັງ ຖືກ ໃຊ້; – ພ້ືນ ທີ່ ພ້ືນ ຜິວຫຼາຍປານ ໃດ ທີ່ ມື ຂອງ ທ່ານ ກໍາລັງ ກວມ ເອົາ (ຕົວຢ່າງ, ທ່ານກໍາລັງ ໃຊ້ ພຽງ ແຕ່ ນ້ີວມື ດຽວ ຫຼື ທັງໝົດ ຝ່າມື); – ຖ້າ ມັນ ເຢັນ, ໃຫ້ອົບ ອຸ່ນມື ຂອງ ທ່ານ ກ່ອນ ທີ່ ຈະ ເລີ່ ມກາ ນຈໍາລອງ ດ້ວຍມື . ï ຂ້ໍ ມູນ ນ້ີ ຈະ ຊ່ວຍ ທ່ານ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ສຸດ ທ້າຍ. ໃຫ້ການ ຮອງ ຮັບ ຢູ່ ກະດູກ ກົກ ແອວ ກ່ອນ ສະ ເໝີ ï ທ່າ ກະດູກ ກົກ ແອວ ມຈະ ມີ ຜົນ ຕ່ໍກກັບ ສ່ວນທີ່ ເຫຼືອຂອງ ຮ່າງກາຍ. ï ຖ້າ ກະດູກ ກົກ ແອວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນບ່ໍ ຢູ່ ໃນ ທ່າ ປົກກະຕິ, ໃຫ້ ໃຊ້ ມື ຂອງ ທ່ານ ກ ຕຸ້ນ ກະດູກ ກົກ ແອວ ໄປ ສູ່ ທ່າປົກກະຕິ. ï ເມ່ືອ ມີ ການ ຮອງ ຮັບ ກະດູກ ກົກ ແອວ ແລ້ວ, ໃຫ້ ສຸມ ໃສ່ ສ່ວນ ອື່ນ ຂອງ ຮ່າງກາຍຕາມລໍາດັບ ນ້ີ: – ລໍາ ຕົວ/ ແຂນ; – ຫົວ ແລະ ຄໍ; – ສະ ໂພ ກ ແລະ ກົກຂາ; – ຂາ ສ່ວນ ລຸ່ມ. ເຮັດ ການ ປ່ຽນ ແປງ ດຽວ ຕ່ໍ ຄ້ັງ ï ເຮັດ ການ ປ່ຽນ ແປງ ອັນດຽວ ຕ່ໍ ຄັ້ງສະ ເໝີ. ຕົ ວຢ່າງ – ຢ່າ ພະຍາຍາມ ລ ອງປ່ຽນ ທ່າ ຂອ ງລໍາ ຕົວ ພ້ອມ ກັນ ກັບ ການ ປ່ຽນ ທ່າ ກະດູກ ກົກ ແອວ. ï ສັງ ເກດ ເບິ່ງ ວ່າການ ປ່ຽນ ໃນ ສ່ວນ ໜຶ່ງ ຂອງ ຮ່າງກາຍ ມີ ຜົນ ຕ່ໍ ກັບ ສ່ວນ ອື່ນ ແນວ ໃດ. ï ຖາມ ເອົາ ຄໍາ ຕິ ຊົມ ຈາກ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 61 ເພ່ືອ ເລ່ີ ມສ່ວນກາ ນຈໍາລອງ ດ້ວຍ ມືຂອງ ການ ປະ ເມີນ ຮ່າງກາຍ: ï ຄຸ ເຂົ່າ ຫຼື ນ່ັງ ຢ່ອງ ຢໍ້ຢູ່ ຕ່ໍໜ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ; ï ວາງ ມື ເບົາໆ ໃສ່ ສອງ ຂ້າງ ຂອງ ກະດູກ ກົກ ແອວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ; ï ຖ້າ ກະດູກ ກົກ ແອວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນບ່ໍ ຢູ່ ໃນ ທ່າ ປົກກະຕິ – ໃຫ້ ໃຊ້ ມື ເພ່ືອ ນໍາ ເອົາ ກະດູກ ກົກ ແອວ ໄປ ໃຫ້ ກັບ ທ່າປົກກະຕິ ເທົ່າ ທີ່ ສະບາຍ ຕົວ; ï ຢ່າ ໃຊ້ ກໍາລັງແຮງ ຫຼາຍ; ï ຊອກ ຮູ້ ວ່າ ສາມາດ ປະຄອງ ຫຼືຮອງ ກະດູກ ກົກ ແອວ ໃຫ້ ໃກ້ ກັບ ທ່າ ປົກກະຕິ ໄດ້ ສ່ໍາ ໃດ; ï ສັງ ເກດ ເບິ່ງ ວ່າກາ ນ ເຄື່ອນ ຍ້າຍ ກະດູກ ກົ ກ ແອວ ຫາ ທ່າປົກກະຕິ ມີ ຜົນ ແນວ ໃດ ຕ່ໍ ກັບ ລໍາ ຕົວ, ສະ ໂພ ກ, ຫົວ ແລະ ຄໍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ï ເມ່ືອ ມີ ການ ຮອງ ກະດູກ ກົກ ແອ ວ ໃຫ້ ໃກ້ ກັບ ທ່າ ປົກກະຕິ ເທົ່າ ທີ່ ຈະ ເປັນ ໄປ ໄດ້, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ພິຈາລະນາ ວ່າການ ປະຄອງ ຫຼືການ ຮອງ ໃດ ແດ່ ທີ່ ຈໍາ ເປັນ ຢູ່ ສ່ວນ ລໍາ ຕົວ; ï ບອກ ໃຫ້ ຜູ້ ຊ່ວຍ ຈັບ ລໍາ ຕົວ ໃນ ທ່າ ທີ່ ທ່ານ ໄດ້ ລະບຸ ວ່າ ë ໃກ້ທີ່ ສຸດກັບ ທ່າ ປົກກະຕິ ເທົ່າ ທີ່ ຈະ ເປັນ ໄປ ໄປ ດ້í ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ້ີ; ï ອະທິບາຍ ຢ່າງ ລະອຽດ ແກ່ ຜູ້ ຊ່ວຍ ກ່ຽວ ກັບ ບ່ອນ ທີ່ ຕ້ອງ ຈັບ ແລະ ວິທີ ຈັບ ສ່ວນ ກົກ ແອວ. ກວດ ເບິ່ງວ່າ ລາວ ສາມາດ ເຮັດ ສ່ິງ ນ້ີ ໄດ້ ກ່ອນ ທີ່ ຈະ ດໍາ ເນີນ ຕ່ໍ. ໃຫ້ການ ປະ ຄອງ ຫືຼຮອງ ຮັບ ຢູ່ ລໍາ ຕົວ (ຖ້າ ຈໍາ ເປັນ): ສໍາລັບ ສ່ວນ ກົກ ແອວ, ຖ້າລໍາ ຕົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ຢູ່ ໃ ນທ່ານ່ັງປົກກະຕິ, ໃຫ້ ໃຊ້ ມື ຂອງ ທ່ານ ເພ່ືອ ໃຫ້ການ ປະຄອງ. ເຮັດ ວຽກ ຕາມ ລໍາດັບ ນ້ີ: ï ເຮັດ ໃຫ້ສ່ວນ ກົກ ແອວ ໝ້ັນຄົງ ດ້ວຍ ມື ຂອງ ທ່ານ; ï ຢຽດ ລໍາ ຕົວ ໃຫ້ ຊ່ື ເພ່ືອ ໃຫ້ ບ່າ ໄຫ່ຼທັງ ສອງ ພຽງ ກັນ (ຫຼື ໃກ້ ກັບ ລະດັບ ພຽງ ກັນ ເທົ່າ ທີ່ ຈະ ເປັນ ໄປ ໄດ້) ໂດຍ ການ ໃຫ້ການ ປະຄອງ ດ້ວຍ ມື ຂອງ ທ່ານ ຢູ່ ທັງ ສອງ ຂ້າງ ຂອງ ລໍາ ຕົວ; ï ນໍາ ເອົາ ລໍາ ຕົວ ຕ້ັງ ຊ່ື ໂດຍ ທີ່ ຫົວ ແລະ ຄໍ ດຸ່ນດ່ຽງຕ່ໍ ກັບ ສ່ວນ ກົ ກ ແອວ ໂດຍ ການ ໃຫ້ການ ປະຄອງ ຢູ່ ດ້ານຫັຼງ ແລະ ບາງ ຄັ້ງ ຢູ່ ດ້ານ ໜ້າດ້ວຍ ມື ຂອງ ທ່ານ; ï ສັງ ເກດ ເບິ່ງ ໂຄງ ຮ່າງ ຂອງ ກະດູກ ກົກ ແອວ ແລະ ລໍາ ຕົວ ຈາກ ດ້ານ ຂ້າງ. ນ້ີ ແມ່ນສໍາຄັນ ໃນ ການວາງ ແຜນ ຮູບ ຮ່າງ ຂອງ ແນວ ອີງ ຫຼັງ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ດີ ສຸດ. 62 ເອົາ ໃຈ ໃສ່ ຢ່າງ ໃກ້ຊິດ ຕ່ໍ ກັບ ວ່າການ ປະຄອງ ລໍາ ຕົວ ມີ ຜົນ ແນວ ໃດ ຕ່ໍ ກັບ ສ່ວນ ທີ່ ເຫຼືອຂອງ ຮ່າງກາຍ. ຕົວຢ່າງ, ການ ປະຄອງລໍາ ຕົວ ຊ່ວຍ ປັບປຸງ ທ່າ ທາງ ຂອງຫົວ ແລະ ຄໍ ຢູ່ ບໍ? ເຖິງ ແມ່ນ ຈະ ມີ ການ ປະຄອງ ກົກ ແອວ ແລະ ລໍາ ຕົວ ທີ່ ດີ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ບາງ ຄົນ ອາດ ຈະ ພົບ ວ່າ ມັນ ຍາກ ໃນການ ຄຶງ ຫົວ ໃຫ້ ຕ້ັງ ຊ່ື. ບາງ ຄໍາ ແນະນໍາ ເພ່ືອ ຊ່ວຍ ປັບປຸງທ່າ ຫົວ ແລະ ຄໍ ມີ ຄື: ï ອະນຸຍາດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເອນ ໄປ ຫຼັງໜ້ອຍ ໜຶ່ງ; ï ສັງ ເກດ ເບິ່ງ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ຊົງ ຕົ ວສ່ວນ ຫົວຕ່ໍ ກັບ ລໍາ ຕົວ ຂອງ ເຂົາ ເຈົ້າ ໄດ້ດີ ຂ້ຶນ ຫຼືບໍ່; ï ໃຫ້ການ ປະຄອງ ເພ່ີມ ເຕີມ ສໍາລັບ ແຂນ. ໃນ ລະຫວ່າງ ກາ ນຈໍາລອງ ດ້ວຍ ມື, ຖາມ ຜູ້ ຊ່ວຍທີ່ ປະຄອງ ສ່ວນ ກົກ ແອວວ່າ ລາວ ຮູ້ສຶກ ການ ປ່ຽນ ແປງ ໃດໆ ບໍ ໃນ ເວລາ ທີ່ ທ່ານ ປະຄອງ ລໍາ ຕົວ. ຈື່ ວ່າ ຕ້ອງ ຖາມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສໍາລັບ ຄໍາ ຕິ ຊົມ ຂອງ ເຂົາ ເຈົ້າ. ໃຫ້ການ ປະຄອງ ຫືຼການ ຮອງ ສໍາລັບ ສ່ວນ ອ່ືນ ຂອງ ຮ່າງກາຍ (ຖ້າ ຈໍາ ເປັນ) ï ເມ່ືອ ມີ ການ ປະຄອງ ສ່ວນ ກົກ ແອວ ແລະ ລໍາ ຕົວ ໃນ ທ່າ ນ່ັງ ປົກກະຕິ ຫຼາຍທ່ີ ສຸດ ເທົ່າ ທີ່ ສະບາຍ ຕົວ ແລ້ວ, ໃຫ້ ກວດ ເບິ່ງ ທ່າ ຂອງ ຫົວ ແລະ ຄໍ, ສະ ໂພ ກ, ກົກຂາ ແລະ ຂາ ສ່ວນ ລຸ່ມ. ï ໃ ຊ້ມື ຂອງ ທ່ານ ເພ່ືອ ຊອກ ຮູ້ ວ່າ ແຕ່ ລະ ສ່ວນ ຮ່າງກາຍ ສາມາດ ເຄື່ອນ ຍ້າຍ ຢ່າງ ສະບາຍ ຕົວ ໄດ້ ໃກ້ ກັບ ທ່າປົກກະຕິ ສ່ໍາ ໃດ. ສືບ ຕ່ໍ ກວດ ເບິ່ງ ວ່າການ ປ່ຽນ ແປງ ຕ່າງໆ ມີ ຜົນ ແນວ ໃດ ຕ່ໍ ກັບ ສ່ວນ ທີ່ ເຫຼືອຂອງ ຮ່າງກາຍ. ສືບ ຕ່ໍ ຖາມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສໍາລັບ ຄໍາ ຕິ ຊົມ ຂອງ ເຂົາ ເຈົ້າ. ການ ບັນທຶກ ຜົນ ຈາກ ກາ ນຈໍາລອງ ດ້ວຍ ມື ຜົນ ຂອງ ກາ ນຈໍາລອງ ດ້ວຍ ມືຖືກ ບັນທຶກ ໃສ່ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ມີ ບ່ອນ ຫວ່າງ ເພ່ືອ: ï ບັນທຶກ ດ້ວຍ ການ ໝາຍ ເອົາ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ບັນລຸ ໄດ້ ທ່າ ນ່ັງ ປົກກະຕິ ສໍາລັບ ແຕ່ ລະ ສ່ວນ ຮ່າງກາຍ ຫຼືບໍ່ ໂດຍ ການປະຄອງ ດ້ວຍ ມື; ï ອະທິບາຍ ຫຼື ແຕ້ມ ເ ສ້ັນ ທ່າ ນ່ັງ ສຸດ ທ້າຍ ທີ່ ບັນລຸ ໄດ້ ໂດຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໂດຍ ມີ ການ ປະຄອງ ຫຼືຮອງ ດ້ວ ຍມື; ແລະ ï ອະທິບາຍ ຫຼື ແຕ້ມ ເສ້ັນ ການ ປະຄອງ ຫຼືການ ຮອງ ທີ່ ສະໜອງ ແກ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເພ່ືອ ບັນລຸ ໄດ້ ທ່າ ນ່ັງ ນ້ັນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 63 ກາ ນຈໍາລອງ ດ້ວຍ ມື: ຕ້ອງການ ມີ ແນວ ປະຄອງຫືຼ ແນວ ຮອງ ເພ່ືອ ໃຫ້ ນ່ັງ ໃນ ທ່າ ປົກກະຕິ / ໃກ້ ຄຽງ ກັບ ທ່າ ປົກກະຕິ ທ່ີ ສຸດ ເທ່ົາ ທ່ີ ສະບາຍ ຕົວ ສໍາລັບ ແຕ່ ລະສ່ວນຂອງ ຮ່າງກາຍ: ຖ້າ ທ່າ ນ່ັງ ປົກກະຕິ ແມ່ນ ເປັນ ໄປ ໄດ້ ໂດຍ ມີການ ປະຄອງ ດ້ວຍ ມື, ໃຫ້ ໝາຍ ແມ່ນ. ຖ້າ ບໍ່ ໄດ້, ໃຫ້ ໝາຍ ບໍ່. ສ່ວນ ແມ່ນ ບໍ່ ອະທິບາຍ ຫຼື ແຕ້ມ ເສ້ັນ ທ່າ ນ່ັງ ສຸດ ທ້າຍ ທີ່ ເຮັດ ໄດ້ ໂດຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໂດຍ ມີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ ດ້ວຍ ມື ແລະ ອະທິບາຍ ຫຼື ແຕ້ມ ເສ້ັນ ການປະຄອງຫືຼ ຮອງ ຮັບທີ່ ສະໜອງ ໃຫ້ ເພ່ືອ ບັນລຸ ໄດ້ ທ່າ ນ່ັງ ນ້ັນ. ກະດູກ ກົກ ແອວ ລໍາ ຕົວ ຫົວ ສະໂພກຊ້າຍ ສະໂພກຂວາ ກົກຂາ ຫົວເຂົ່າຊ້າຍ ຫົວເຂົ່າຂວາ ຂ້ໍຕີນຊ້າຍ ຂ້ໍຕີນຂວາ ການ ປະ ເມີນ ຮ່າງກາຍ – ການ ເຮັດ ການ ວັດ ແທກ ການ ວັດ ແທກ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເພ່ືອ ເລືອກ ຂະໜາດ ລົດ ເຂັນ ທ່ີ ຖືກຕ້ອງ ແລະ ທ່ີ ຕ້ັງ ຂອງ ອຸປະກອນ PSD ຢູ່ ໃນ ສ່ວນການ ວັດ ແທກ ຂອງ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປາ ນກາງ ມີ ການ ວັດ ແທກ ຮ່າງກາຍ ສິບ ສອງ ຢ່າງ ທີ່ ລະບຸ ໄວ້. ການ ວັດ ແທກ ຫ້າ ຢ່າງ ແມ່ນ ການ ວັດ ແທກ ແບບ ດຽວ ກັນ ກັບ ທີ່ ໄດ້ ນໍາ ສະ ເໜີ ໃນ ເມ່ືອ ກ່ອນ ໃນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິກາ ນລົດ ເຂັນ – ລະດັບ ພ້ືນ ຖານ. ມີ ການ ເພ່ີມ ການ ວັດ ແທກ ຮ່າງກາຍ ສໍາລັບ ຄວາມ ສູງ ຂອງ ແນວ ອີ ງຫັຼງ ໃສ່ ແບບ ຟອມ ປະ ເມີນ ຜົນລົດ ເຂັນ ລະດັບ ປານ ກາງ. ການ ວັດ ແທກ ແຕ່ບ່ອນ ນ່ັງ ຫາ ສ່ວນ ເທິງ ຂອງ ບ່າ ໄຫ່ຼຖືກ ໃຊ້ ເພ່ືອ ວັດ ແທກຜູ້ ໃຊ້ ລົດ ເຂັນ ສໍາລັບ ແນວ ອີງຫັຼງທ່ີ ສູງ. ມີ ການ ວັດ ແທກ ຫົກ ຢ່າງ ອື່ນ ອີກ ເ ຊ່ິງຈະ ຊ່ວຍ ຕັດສິນ ຂະໜາດ ແລະ/ຫຼືທີ່ ຕ້ັງ ຂອງ ອຸປະກອນ PSD. ບາງ ຄັ້ງ ມັນ ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ເຮັດ ການ ວັດ ແທກ ເພ່ີມ ເຕີມ, ໂດຍ ຂ້ຶນ ກັບ ອຸປະກອນ PSD ທີ່ ກໍານົດ ໃຊ້. ມີ ບ່ອນ ຫວ່າງ ຢູ່ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ເພ່ືອ ໃຫ້ ບັນທຶກ ການ ວັດ ແທກອື່ນ. 64 ການ ວັດ ແທກ ຮ່າງກາຍ ກ່ຽວ ຂ້ອງ ກັບ ຂະໜາດ ແລະ ທ່ີ ຕ້ັງ ຂອງ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ແນວ ໃດ ການ ວັດ ແທກ ຮ່າງກາຍ ແຕ່ລະ ຢ່າງ ທີ່ ຖືກ ເຮັດ ແມ່ນ ກ່ຽວຂ້ອງ ກັບ ຂະໜາດ ຂອງ ລົດ ເຂັນ ຫຼື ຈຸດ ທີ່ ຕັ້ງ ແລະ ຂະໜາດ ຂອງ ອຸປະກອນ PSD. ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ການ ວັດ ແທກ ຮ່າ ງກາຍ ຖືກ ລະບຸ ໄວ້ ຢູ່ ດ້ານ ຂ້າງ ເບື້ອງຊ້າຍ ມື ແລະ ອົງ ປະກອບ ທີ່ ການ ວັດ ແທກ ຮ່າງກາຍ ແຕ່ລະ ຢ່າງ ກ່ຽວຂ້ອງ ກັບ ແມ່ນ ລະບຸ ໄວ້ ຢູ່ ເບື້ອງ ຂວາ ມື. ຕົວຢ່າງ: ï ຄວາມ ກວ້າງ ສະ ໂພ ກຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ (ການ ວັດ ແທກ ຮ່າ ງກາຍ A) ເທົ່າ ກັບ ຄວາມ ກວ້າງ ບ່ອນ ນ່ັງ ຂອງລົດ ເຂັນ ຫຼື ໄລຍະ ຫ່າງ ລະຫວ່າງ ແຜ່ນ ຮອງ ຂ້າງ ກົກ ແອວ (ການ ວັດ ແທກ ອົງ ປະກອບ 1 ຫຼື 2); ï ບ່ອນ ນ່ັງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຫາ ຂ້ີ ແຮ້ (ການ ວັດ ແທກ H) ລົບ ໃຫ ້30 ມມ ແມ່ນ ໄລຍະ ຫ່າງ ສູງສຸດ ລະຫວ່າງ ສ່ວນ ເທິງ ຂອ ເບາະ ຮອງ ນ່ັງ ຫາ ສ່ວນ ເທິງ ຂອງ ແຜ່ນ ຮອງ /ຫຼີ້ມຮອງຂ້າງ ລໍາ ຕົວ (ການ ວັດ ແທກ ອົງ ປະກອບ ລົດ ເຂັນ 8). ຕົວຢ່າງ ຂ້າງ ເທິງ ສະ ແດງ ໃຫ້ ເຫັນ ວ່າການ ວັດ ແທກ ຮ່າງກາຍ ບໍ່ ເທົ່າ ກັບ ການ ວັດ ແທກ ອົງ ປະກອບ ລົດ ເຂັນ ສະ ເໝີ ໄປ ແລະ ຈໍາ ເປັນ ຕ້ອງ ມີບາງ ການ ຄິດ ໄລ່. ໃນ ບາງ ກໍລະນີ ມີ ສູດ ເພ່ືອ ຊ່ວຍ ຄິດ ໄລ່ ການ ວັດ ແທກ ອົງ ປະກອບ ລົດ ເຂັນ. ມັກ ຈໍາ ເປັນ ຕ້ອງການ ມີ ການ ດັດ ປັບ ໃນ ເວລາ ປັບລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ. ແນວ ໃດ ກໍ ຕາມ ການ ວັດ ແທກ ຮ່າ ງກາຍ ທີ່ ຖືກຕ້ອງ ສາມາດ ຊ່ວຍ ກະກຽມ ລົດ ເຂັນ ເປັນ ຢ່າງ ດີ ໄວ້ ກ່ອນ ການ ປບັ ໃຫ້ ເໝາະ ສົມ ຄັ້ງ ທໍາ ອິດ. ຮູ ບສະ ແດງ ໃນ ແບບ ຟອມປະ ເມີນ ຜົນ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ຊ່ວຍ ຊ້ີ ນໍາ ພະນັກ ງານ ບໍລິ ການ ລົດ ເຂັນ ໃນ ເວລາ ທີ່ ພວກ ເຂົາ ເຮັດ ການ ວັດ ແທກ ຮ່າງກາຍ ແລະ ກ່ຽວພັນພວກ ມັນ ກັບ ຈຸດ ທີ່ ຕ້ັງ ແລະ ຂະໜາດຂອງອຸປະກອນ PSD. G H B C D E F I K L J ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 65 ການ ເຮັດ ການ ວັດ ແທກ ການ ວັດ ແທກ ຮ່າງກາຍ (ມມ) ການ ວັດ ແທກ ອົງ ປະກອບ ລົດ ເຂັນ (ມມ) ຄວາມ ກວ້າງ, ຄວາມ ເລິກບ່ອນ ນ່ັງ ແລະ ຄວາມ ສູງ ຂອງ ບ່ອນ ວາງ ຕີນ A ຄວາມ ກວ້າງ ສະ ໂພ ກ = ຄວາມ ກວ້າ ງບ່ອນ ນ່ັງ ຫຼື 1 = ໄລຍະ ຫາ່ງ ລະຫວາ່ງ ແຜ່ນ ຮອງ ຂ້າງກະດູກ ກົກ ແອວ 2 B ຄວາມ ເລກິ ບອ່ນ ນ່ັງ (ດາ້ນ ຫຼງັກະດູກ ກົກ ແອວ ຫາ ດາ້ນ ຫຼງັຫົວ ເຂົາ່) L B ລບົ ໃຫ ້30–50 ມມ = ຄວາມ ເລກິ ບອ່ນ ນ່ັງ (ຖາ້ຄວາມ ຍາວ L, R ແຕກ ຕ່າງ ກັນ, ໃຫ ້ໃຊ້ ອນັ ທີ ່ສ້ັນ ກວ່າ) 3 R C ຄວາມ ຍາວ ບ ີແຄງ່ L = ໄລຍະ ຫວາ່ງ ລະຫວາ່ງ ສ່ວນ ເທງິ ຂອງ ບອ່ນ ນ່ັງ ຫາ ບອ່ນ ວາງ ຕີນ ຫຼື = ໄລຍະ ຫວາ່ງ ລະຫວາ່ງ ສ່ວນ ເທງິ ຂອງ ບອ່ນ ນ່ັງ ຫາ ພ້ືນ ສໍາລັບ ການ ຂັບ ເຄືອ່ນ ລດົ ເຂນັ ດວ້ຍ ຕີນ 4 R 5 ຄວາມ ສູງ ແນວ ອີ ງຫັຼງ D ບອ່ນ ນ່ັງ* ຫາ ສ່ວນ ລຸມ່ ໂຄງ ກະດູກ = ໄລຍະ ຫາ່ງ ລະຫວາ່ງ ສ່ວນ ເທງິ ຂອງ ບອ່ນ ນ່ັງ ຫາ ສ່ວນ ເທງິ ຂອງ ບອ່ນ ວາງ ຕີນ (ວດັ ແທກ D, E ຫຼ ືF – ໂດຍ ຂ້ຶນ ກັບ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ) 6 E ບອ່ນ ນ່ັງ* ຫາ ສ່ວນ ລຸມ່ ກະດູກ ຫວົ ໄຫ່ຼ F ບອ່ນ ນ່ັງ* ຫາ ສ່ວນ ເທງິ ຂອງ ບາ່ ໄຫ່ຼ ການ ດັດ ແປງ ແລະ/ຫືຼ ອຸປະກອນ PSD G ຄວາມ ກວ້າງ ລາໍ ຕົວ = ໄລຍະ ຫາ່ງ ລະຫວາ່ງ ແຜ່ນ ຮອງ/ຫຼີມ້ຮອງ ດາ້ນ ຂ້າງ ລາໍ ຕົວ 7 H ບອ່ນ ນ່ັງ * ຫາ ຂ້ີ ແຮ ີ້(ກົກ ແຂນ) L H ລບົ ອອກ30 ມມ = ໄລຍະ ຫາ່ງສູ ງສຸດ ລະຫວາ່ງ ສ່ວນ ເທງິ ຂອງ ບອ່ນ ນ່ັງ ແລະ ສ່ວນ ເທງິ ຂອງ ແຜ່ນ ຮອງ/ຫຼີມ້ຮອງ ຂ້າງ ລາໍ ຕົວ (ປບັ ອງີ ຕາມ ການ ຈາໍລອງດ້ວຍ ມື) 8 R I ບອ່ນ ນ່ັງ* ຫາ ສ່ວນ ເທງິ ຂອງ ກະດູກ ກົກ ແອວ (PSIS) = ໄລຍະ ຫາ່ງ ລະຫວາ່ງ ສ່ວນ ເທງິ ຂອ ງບ່ອນ ນ່ັງ ຫາ ຄວາມ ສູງ ເຄິງ່ກາງ ຂອງ ແຜ່ນ ຮອງກະດູກ ກົກ ແອວດາ້ນ ຫຼງັ 9 J ໄລຍະ ຫາ່ງ ລະຫວາ່ງ ຫວົ ເຂົາ່ = ຄວາມ ກວ້າງ ຂອງ ແຜ່ນ ແຍກ ຫວົ ເຂົາ່ 10 K ບອ່ນ ນ່ັງ* ຫາ ພ້ືນ ຂອງ ກະ ໂຫກຼຫົວ = ໄລຍະ ຫາ່ງ ລະຫວາ່ງ ສ່ວນ ເທງິ ຂອງ ບອ່ນ ນ່ັງ ຫາ ເຄິງ່ກາງຂອງ ແນວ ປະຄອງ ຫວົ 11 L ດາ້ນ ຫຼງັຂອງ ກະດູກ ກົກ ແອວ ຫາ ກະດູກ ຮອງ ນ່ັງ L ບວກ ຕ່ືມ 20–40 ມມ = ໄລຍະ ຫາ່ງ ຈາກ ແນວ ອງີ ຫຼງັຫາ ຈດຸ ເລີ ່ມຕ້ົນ ຂອງ ຖານ ກ່ອນກະດູກ ຮອງ ນ່ັງ. 12 ອືນ່ ໆ * ໃນ ເວລາ ເຮັດ ການ ວັດ ແທກ ຮ່າງກາຍ, ëບ່ອນ ນ່ັງí ແມ່ນພ້ືນ ຜິວ ບ່ອນ ທີ່ ກະດູກ ຮອງ ນ່ັງນ່ັງ ຢູ່ ເທິງ. 66 ວິທີ ເຮັດ ການ ວັດ ແທກ ທ່ີ ຖືກ ຕ້ອງ ຄວາ ມຜິດພາດ ໃນ ການ ວັດ ແທກ ສາມາດ ກ່ໍ ໃຫ້ ເກີດ ບັນຫາ ໃຫຍ່ ໄດ້. ແນວ ໃດ ກໍ ຕາມ ບາງ ຄັ້ງການ ເຮັດ ການ ວັດ ແທກ ທີ່ ຖືກຕ້ອງ ສາມາດ ເປັນ ເລື່ອງ ຍາກ. ນ້ີ ໂດຍ ສະ ເພາະ ແລ້ວ ແມ່ນ ບັນຫາ ເມ່ືອ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໂຕ ນ້ອຍ ຫຼາຍ ຫຼື ພົບ ວ່າ ມັນ ຍາກ ໃນ ການ ນ່ັງ ບໍ່ ຕີງ ຫຼື ມີ ຄວາມ ຍາກ ໃນ ການ ນ່ັງ ຕ້ັງ ຊື່. ບາງ ວິທີ ເພ່ືອ ຊ່ວຍ ເຮັດ ການ ວັ ດ ແທກ ທີ່ ຖືກຕ້ອງ ລວມມີ: ï ໃຊ້ ສາຍ ວັດ ແທກ ແບບ ແຂງ – ບໍ່ ແມ່ນ ສາຍ ວັດ ແທກ ແບບ ëສາຍ ອ່ອນí; ສາຍ ວັດ ແທກ ແບບ ແຂງ ຈະ ບໍ່ ງໍ ຫຼາຍ, ເຊິ່ງງສ່ົງ ຜົນ ໃຫ້ ເກີດ ການ ວັດ ແທກ ທີ່ ບໍ່ ຖືກຕ້ອງ; ï ການ ໃຊ້ ເຄື່ອງ ວັດ ແທກ ຄາ ລິບ ເປີ ສາມາດ ເພ່ີມ ຄວາມ ຖືກຕ້ອງ ແນ່ ນອນຂອງ ການ ວັດ ແທກ ໄດ້. ï ເຮັດ ການ ວັດ ແທກ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃນ ເວລາ ນ່ັງ ຕ້ັງ ຊ່ື, ໃນ ທ່າ ນ່ັງ ທີ່ ຖືກ ລະບຸ ວ່າ ເປັນ ທ່າ ຕ້ັງ ຊ່ື ທີ່ ສຸດ, ສະບາຍ ຕົວ ແລະ ເຄື່ອນ ເໜັງ ໄດ້ ສໍາລັບ ເຂົາ ເຈົ້າ ໃນ ລະຫວ່າງ ກາ ນຈໍາລອງ ດ້ວຍ ມື. ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຖືກ ວັດ ແທກ ໃນ ເວລາ ທີ່ ນອນ ລົງ, ການ ວັດ ແທກ ຈະ ບໍ່ ຖືກຕ້ອງ ແນ່ນອນ ເພາະວ່າ ໃນ ເວລາ ນອນ ຢູ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ອາດ ຈະ ຢຽດ ຕົວ ຫຼື ຍືດຕົວ ອອກ. ມັນ ດີກ ວ່າ ໃນ ການ ຂໍ ການ ຊ່ວຍ ເຫຼືອ ເພ່ືອ ປະຄອງ ຜູ້ ໃຊ້ ໃຫ້ ນ່ັງ ຕ້ັງ ຊ່ື ດີກ ວ່າ ຈະ ໃຫ້ ພວກ ເຂົາ ນອນ ລົງ. ວິທີ ວັດ ແທກ: ອົງ ປະກອບ ລົດ ເຂັນ: ຄໍາ ເຫັນ: A: ຄວາມ ກວ້າງ ສະ ໂພ ກ ບ່ອນ ນ່ັງ (ຄວາມກວ້າງ) ກວດ ເບິ່ງ ວ່າ ບໍ່ ມີ ຫຍັງ ໃນ ຖົງ ໂສ້ງ ເສ້ືອຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກ່ອນ ທີ່ ຈະ ວັດ ແທກ. ວັດ ແທກ ສະ ໂພ ກຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຫຼື ສ່ວນ ກວ້າງ ສຸດ ຂອງກົກຂາ ຂອງ ລາວ. ຈັບຄລິບ ບອດ ສອ ງອັນ ແນບ ກັບ ແຕ່ ລະ ດ້ານ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເພ່ືອ ຊ່ວຍ ໃຫ້ ໄດ້ ຮັບ ການ ວັດ ແທກ ທີ່ ຖືກຕ້ອງ. ສາມາດ ໃຊ້ ເຄື່ອງ ວັດ ແທກ ຄາ ລິບ ເປີ . ຄວາມ ກວ້າງ ສະ ໂພ ກ ເທົ່າ ກັບ ຄວາມ ກວ້າງ ບ່ອນ ນ່ັງ ຫຼື ໄລຍະ ຫ່າງ ລະຫວ່າງ ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ. ຖ້າ ມີ ການ ໃຫ້ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົ ກ ແອ ວ, ຄວາມ ກວ້າງ ບ່ອນ ນ່ັງ ລົດ ເຂັນ ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ກວ້າງ ກວ່າ. ພະຍາຍາມ ຮັກສາ ຄວາມ ກວ້າງ ຂອງ ລົດ ເຂັນ ໃຫ້ ໜ້ອຍ ສຸດ. ໃນ ປະ ເທດ ທີ່ ມີ ສະພາບ ອາກາດໜາວ ບອ່ນ ທີ ່ອາດ ຈາໍ ເປນັ ຕ້ອງ ໃສ່ເສ້ືອ ໜາ, ອາດຈໍາ ເປັນ ຕ້ອງ ມີ ການ ເພ່ືອ ໄວ້ ຈໍານວນ ໜຶ່ງ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 67 ວິທີ ວັດ ແທກ: ອົງ ປະກອບ ລົດ ເຂັນ: ຄໍາ ເຫັນ: B: ຄວາມ ເລິກ ບ່ອນນ່ັງ ບ່ອນນ່ັງ (ຄວາມ ເລິກ) ວາງ ຄລບິ ບອດ ໃສ່ດາ້ນ ຫຼຂັອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ເພ່ືອ ຊ່ວຍ ໃຫ ້ໄດ້ ຮັບ ການ ວດັ ແທກ ທີ່ ຖກືຕ້ອງ. ວດັ ແທກ ຈາກ ດາ້ນ ຫຼງັຂອງ ກະດູກ ກົກ ແອວ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຫາ ດາ້ນ ຫຼງັຂອງ ຫວົ ເຂົາ່ ຂອງ ລາວ ໃນ ເສ້ັນ ຊ່ື. ວັດ ແທກ ຂາ ສອງ ຂ້າງ ສະ ເໝີ. ຖ້າ ມີ ຄວາມ ແຕກ ຕ່າງ ລະຫວ່າງ ຂ້າງ ຊ້າຍ ແລະ ຂວາ, ໃຫ້ ກວດ ເບິ່ງ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກໍາລັງ ນ່ັງ ຕ້ັງ ຊ່ື ໂດຍ ທີ່ ກະດູກ ກົກ ແອວ ພຽງ ກັນຫືຼບໍ່. ຖ້າ ຍັງ ມີ ຄວາມ ແຕກ ຕ່າງ ຢູ່, ໃຫ້ ເຮັດ ການ ກໍານົດ ໃ ຊ້ລົດ ເຂັນ ສໍາລັບ ຂ້າງ ທີ່ ສ້ັນ ກວ່າ. ຄວາມ ເລິ ກບ່ອນ ນ່ັງ ລົບ ໃຫ້ 30–50 ມມ ເທົ່າ ກັບ ຄວາມ ເລິກ ຂອງ ບ່ອນ ນ່ັງ ຂອງ ລົດ ເຂັນ. ສໍາລັບ ຜູ້ ໃຊ້ລົດ ເຂັນ ທີ່ ຫົວ ເຂົ່າ ກ່ົງ ໜ້ອຍ ກວ່າ 90 ອົງສາ ຫຼາຍ, ຄວາມ ເລິກ ບ່ອນ ນ່ັງ ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ສ້ັນ ກວ່າ ໜ້ອຍ ໜຶ່ງ. ເບິ່ງ ກ່ອງ `ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ກະດູກ ກົກ ແອວ ອ່ຽງ ໄປ ຫຼັງຄົງ ທີ່ ຫຼື ລໍາ ຕົວ ກ່ົງ ໄປ ໜ້າ ຄົງ ທີ່`. ສໍາລັບຜູ້ ໃຊ້ ລົດ ເຂັນ ທ່ີ ມີ ກະດູກ ກົກ ແອວ ອ່ຽງ ໄປ ຫັຼງຄົງ ທ່ີ ຫືຼ ລໍາ ຕົວ ກ່ົງ ໄປ ໜ້າ ຄົງ ທ່ີ` ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ການ ອ່ຽງ ໄປ ຫຼັງຄົງ ທີ່ ຂອງ ກະດູກ ກົກ ແອວ ຫຼື ລໍາ ຕົວ ກ່ົງ ໄປ ໜ້າ ຄົງ ທີ່, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ຄິດ ກ່ຽວ ກັບ ວ່າຈະ ຮອງ ຮັບ ສ່ວນ ນ້ີ ແນວ ໃດ ໃນ ລົດ ເຂັນ. ນ້ີ ອາດ ຈະ ປ່ຽນ ແປງ ແບບ ວິທີ ເຮັດການ ວັດ ແທກຄວາມ ເລິກ ບ່ອນ ນ່ັງ. ï ຖ້າ ແນວ ອີງ ຫຼັງ ເອນ ໄປ ຫຼັງ (ອ່ຽງ ໄປ ຫຼັງ) ເພ່ືອ ຮອງ ຮັບ ກະດູກ ກົກ ແອວ/ລໍາ ຕົວ, ໃຫ້ ວັດ ແທກ ຈາກ ດ້ານ ຫຼັງຂອງ ກະດູ ກກົກ ແອວ ຫາ ດ້ານ ຫຼັງຂອງ ຫົວ ເຂົ່າ ເປັນ ເສ້ັນ ຊ່ື ຕາມ ທີ່ ອະທິບາຍ ຢູ່ ຂ້າງ ເທິງ. ï ຖ້າ ແນວ ອີງ ຫຼັງບ່ໍ ເອນ ໄປ ຫຼັງ, ຈະ ເຮັດ ແນວ ຮອງ ເພ່ືອ ຮອງຮັບ ກະດູກ ກົກ ແອວ/ລໍາ ຕົວ ຢູ່ ພາຍ ໃນ ພ້ືນ ທີ່ຫວ່າງ ຂອງ ຄວາມ ເລິກ ບ່ອນ ນ່ັງ. ວັດ ແທກ ຈາກຈຸດ ຫຼັງສຸດຂອງ ຮ່າງກາຍ (ລໍາ ຕົວ/ກະດູກ ກົກ ແອວ) ເພ່ືອ ຮັບປະກັນ ໃຫ້ ມີ ຄວາມ ເລິກ ບ່ອນ ນ່ັງ ພຽງພໍ ດັ່ງ ທີ່ ສະ ແດງ ໃນຮູບ ສະ ແດງ . 68 ວິທີ ວັດ ແທກ: ອົງ ປະກອບ ລົດ ເຂັນ: ຄໍາ ເຫັນ: C: ຄວາມ ຍາວ ບີ ແຄ່ງ ບ່ອນ ວາງ ຕີນ (ຄວາມ ສູງ ) ວດັ ແທກ ຈາກ ດາ້ນ ຫຼງັຂອງ ຫວົ ເຂົາ່ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຫາ ພ້ືນ ສ້ົນນ່ອງ ຂອງ ລາວ. ຮັບປະກັນ ວາ່ ຂ້ໍ ຕີ ນຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ກ່ົງ ໃນ ລະດບັ 90 ອງົສາ (iຖາ້ ເປນັ ໄປ ໄດ້). ວດັ ແທກ ຂາ ສອງ ຂ້າງ ສະ ເໝີ. ຖາ້ ຜູ້ ໃຊ ້ລດົ ເຂນັ ໃສ່ ເກີບ, ໃຫ ້ວດັ ແທກ ໂດຍ ໃສ່ ເກີບ ທີ ່ລາວ ມັກ ໃສ່ເປນັ ສ່ວນ ໃຫຍ.່ ຖາ້ ຕີນຄົງ ທີ ່ໂດຍ ຝ່າຕີນ ຂົດ ງໍ (ຊ້ີ ລງົ ລຸມ່), ໃຫ ້ວດັ ແທກ ຫາ ນ້ີ ຕີນ. ຄວາມສູງ ຍາວ ຂອງບີ ແຄງ່ ເທົາ່ ກັບ ສ່ວນ ເທງິ ຂອງ ເບາະ ຮອງ ນ່ັງ ຫາ ບອ່ນ ວາງ ຕີນ ຫຼື ສ່ວນ ເທງິ ຂອງ ບອ່ນ ວາງ ຕີນ ຫາ ພ້ືນ ຖາ້ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຂັບ ເຄືອ່ນ ລດົ ເຂນັ ດວ້ຍ ຕີນ. ຈດຸ ທີ ່ຕັ້ງ ທີ ່ແນນ່ອນຂອງ ບອ່ນ ວາງ ຕີນຈະ ປຽ່ນ ແປງ ໜອ້ຍ ໜຶງ່ ໂດຍ ຂ້ຶນ ກັບ ວາ່ ເບາະ ຮອງ ນ່ັງ ບບີ ອດັ ສ່ໍາ ໃດ ໃນ ເວລາ ທີ ່ຜູ້ ໃຊ ້ລດົ ເຂນັ ນ່ັງ ຢູ ່ເທງິມັນ. ການ ດດັ ປບັ ສຸດ ທາ້ຍ ແມນ່ ຈາໍ ເປນັ ສະ ເໝີ ໃນ ເວລາ ປບັ ລດົ ເຂນັ ໃຫ ້ເໝາະສົມ. D, E ແລະ F ແນວ ອີງ ຫັຼງ (ຄວາມ ສູງ) D: ບອ່ນ ນ່ັງຫາ ສ່ວນ ລຸມ່ ກະດູກຂ້າງ: ວດັ ແທກ ຈາກ ບອ່ ນນ່ັງ ຂອງ ຜູ້ ໃຊລ້ດົ ເຂນັ ຫາ ພ້ືນ ຂອງ ກະດູກ ຂ້າງ. ເພ່ືອ ຊ່ວຍ ຊອກ ຫາ ພ້ືນ ກະດູກ ຂ້າງ, ໃຫ ້ວາງ ມື ໃສ່ ສອງ ຂ້າງ ຂອງ ກະດູກ ກົກ ແອວ. ບບີມື ເບາົໆ ເຂົາ້ ໃນ ແລະ ເລືອ່ນ ມື ຂ້ຶນ ເທງິ. ພ້ືນ ຂອງ ກະດູກ ຂ້າງ ຢູ ່ເທງິ ແປະ ກັບ ແອວ. ການ ວດັ ແທກ D, E ແລະ F ຊ່ວຍ ຕັດສິນ ຄວາມ ສູງ ຂອງ ແນວ ອງີ ຫຼງັ. ຄວາມ ສູງ ຂ້ຶນ ກັບ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊລ້ດົ ເ ຂັນ. ຂ້ໍ ມູນ ຈາກ ການ ປະ ເມີນ ຜົນ ຈະ ຊ້ີ ບອກ ພະນັກງານ ບລໍກິານ ລດົ ເຂນັ ໃນ ການ ຕັດສິນ ວາ່ ແນວ ອງີ ຫຼງັຈໍາ ເປນັ ຕ້ອງ ສູງ ເທົາ່ ໃດ ເພ່ືອ ໃຫກ້ານ ຮອງ ຮັບ ທີ ່ຖກືຕ້ອງ ສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ຖາ້ ແນວ ອງີ ຫຼງັ ຈາໍ ເປນັ ຕ້ອງເອນ ຫຼ ືອຽ່ງ ໄປ ຫຼງັ ໃນ ກາງຫາວ, ຄວາມ ສູງ ແນວ ອງີ ຫຼງັຕ້ອງ ຢາ່ງ ໜອ້ຍ ຕ້ອງ ມາດຕະຖານ (ບໍ ່ເກີນ ພ້ືນ ຂອງ ກະດູກ ຫວົ ໄຫ່ຼຂອງ ຜູ້ ໃຊ້ ລດົ ເຂນັ). ຈື ່ວາ່ ຕ້ອງ ພິຈາລະນາ ວາ່ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຈະ ຂັບ ເຄືອ່ນ ລດົ ເຂນັ ດວ້ຍ ຕົນ ເອງ ຫຼບືໍ,່ ພວ ກ ເຂາົ ຕ້ອງການ ມີ ອດິສະຫຼ ະ ໃນ ການ ເຄືອ່ນ ເໜງັ ຫວົ ໄຫ່ຼຂອງ ເຂາົ ເຈົາ້. E: ບອ່ນ ນ່ັງຫາ ສ່ວນ ລຸມ່ ກະດູກ ຫວົ ໄຫ່ຼ: ວດັ ແທກ ຈາກ ບອ່ ນນ່ັງ ຂອງ ຜູ້ ໃຊລ້ດົ ເຂນັ ຫາ ພ້ືນ ຂອງ ກະດູກ ຫວົ ໄຫ່ຼ ເປນັ ເສ້ັນ ແນວ ຕ້ັງ. ເພ່ືອ ຊ່ວຍ ຊອກ ຫາ ພ້ືນ ຂອງ ກະດູກ ຫວົ ໄຫ່ຼ ບອກ ໃຫ ້ຜູ້ ໃຊລ້ດົ ເຂນັຍິກ ບາ່ ໄຫ່ຼຂອງ ເຂາົ ເຈົາ້. F: ບອ່ນ ນ່ັງຫາ ສ່ວນ ເທງິ ຂອງ ບາ່ ໄຫ່ຼ: ວດັ ແທກ ຈາກ ບອ່ ນນ່ັງ ຂອງ ຜູ້ ໃຊລ້ດົ ເຂນັ ຫາ ສ່ວນ ເທງິ ຂອງ ບາ່ ໄຫ່ຼ. G: ຄວາມ ກວ້າງ ລໍາ ຕົວ ແຜ່ນ ຫືຼ ຫ້ີຼມຮອງ ຂ້າງ ລໍາ ຕົວ ( ໄລຍະ ຫ່າງ ລະຫວ່າງ) ວດັ ແທກ ຄວາມ ກວ້າງ ຂອງ ລາໍ ຕົວ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຢູ່ ກ້ອງ ແປະ ກັບ ຂ້ີ ແຮ ້(ກ້ອງ ກົກ ແຂນ). ຄວາມ ກວ້າງ ລາໍ ຕົວ ແມນ່ ໄລຍະ ຫວາ່ງ ລະຫວາ່ງ ແຜນ ຮອງ ຫຼ ືຫຼີມ້ຮອງຂ້າງລໍາ ຕົວ. ຕໍາ ແໜ ່ງສຸດ ທາ້ຍ ຂອງ ແຜນ່ ຮອງ ຫຼ ືຫຼີມ້ຮອງ ຂ້າ ງລໍາ ຕົວ ອາດ ຈະ ປຽ່ນ ແປງ ໃນ ລະຫວາ່ງ ການ ປບັ ລດົ ເຂນັ ໃຫ ້ເໝາະສົມ ຖາ້ ພວກ ເຮາົ ຕ້ອງ ຖກື ວາງ ຢູ ່ກ້ອງ ແປະ ກັບ ຂ້ີ ແຮ.້ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 69 ວິທີ ວັດ ແທກ: ອົງ ປະກອບ ລົດ ເຂັນ: ຄໍາ ເຫັນ: H: ບ່ອນ ນ່ັງ ຫາ ຂ້ີ ແຮ້ (ກົກ ແຂນ) ແຜ່ນ ຫືຼ ຫ້ີຼມຮອງ ຂ້າງ ລໍາ ຕົວ ( ຄວາມ ສູງ) ວ ັດ ແທກ ຈາກ ບອ່ນ ນ່ັງ ຫາ ຂ້ີ ແຮ ້(ກົກ ແຂນ). ການ ວດັ ແທກ ບອ່ນ ນ່ັງ ຫາ ຂ້ີ ແຮ ້ລບົ ໃຫ ້30 ມມ ແມນ່ ໄລຍະ ຫາ່ງ ສູງ ສຸດ ລະຫວາ່ງ ສ່ວນ ເທງິ ຂອງ ເບາະ ຮອງ ນ່ັງ ຫາ ສ່ວນ ເທງິ ຂອງ ແຜນ່ ຮອງ/ ຫຼີມ້ຮອງ ຂ້າ ລາໍ ຕົວ. ການ ວດັ ແທກ ນ້ີ ແມນ່ ການ ຊ້ີນໍາ. ຄວາມ ສູງ ສຸດ ທາ້ຍ ຂ້ຶນ ກັບ ການ ປະ ເມີນ ຜົນ ແລະ ການ ປບັ ລດົ ເຂນັ ໃຫ ້ເໝາະ ສົມ. ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ບໍ ່ຄວນ ສູງ ພຽງພໍ ທີ ່ຈະ ເຮດັ ໃຫ ້ເກີດ ການ ກົດ ທບັ ໃສ່ຂ້ີ ແຮ ້(ກົກ ແຂນ). ນ້ີ ສາມາດ ບໍ ່ສະບາຍ ຕົວ ແລະ ສ້າງ ຄວາມ ເສຍ ຫາຍຖາ ວ ອນ ຕ່ໍ ເສ້ັນປະສາດ ໄດ້. ຄວນ ໃຫ ້ຫາ່ງ ຢາ່ງ ໜອ້ຍ 30 ມມ ລະຫວາ່ງ ສ່ວນ ເທງິ ຂອງ ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ຫາຂ້ີ ແຮ.້ ເບິງ່ ກ່ອງ `ການ ວດັ ແທກ ແນວ ຮອງ ຂ້າງ ລາໍ ຕົວ ສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ທີພ່າ ວະ ກະດູກ ສັນຫັຼງຂົດ `. ການ ວັດ ແທກ ແນວ ຮອງ ຂ້າງ ລໍາ ຕົວ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທ່ີ ມີ ພາວະ ກະດູກ ສັນຫັຼງຂົດ (ລໍາ ຕົວ ຂົດ ໄປ ທາງ ຂ້າງ) ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີລໍາ ຕົວ ຂົດ ໄປ ທາງ ຂ້າງ (ກະດູກ ສັນຫັຼງຂົດ) ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ຂ້າງ ໜຶ່ງ ອາດ ຈະ ຕ່ໍາ ກວ່າ ອີກ ຂ້າງ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ໃນ ບ່ອນ ທີ່ ຈໍາ ເປັນ. ດ່ັງ ທີ່ ປະກົດ ໃນຮູບ ສະ ແດງ, ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ຢູ່ ຂ້າງ ໜຶ່ງ ຈະ ຢູ່ ໃນ ëຈຸດ ສູງ ສຸດí ຂອງ ສ່ວນກ່ົງ. ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ຢູ່ ອີກ ຂ້າງ ຈະ ຢູ່ ກ້ອງ ແປະ ກັບ ຂ້ີ ແຮ້. ຈື່ ວ່າ – ເມ່ືອ ໃຫ້ ແຜ່ນ ຮອງ ຂ້າງລໍາ ຕົວ ສໍາລັບ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ທີ່ ມີ ກະດູກ ສັນຫັຼງຂົດ, ຕ້ອງ ໃຫ ້ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ຢູ ່ທງັ ສອງ ຂ້າງນໍາ ອີກ. 70 ວິທີ ວັດ ແທກ: ອົງ ປະກອບ ລົດ ເຂັນ: ຄໍາ ເຫັນ: I: ບ່ອນ ນ່ັງຫາ ສ່ວນ ເທິງ ຂອງ ກະດູກ ກົກ ແອວ (PSIS) ແຜ່ນ ຮອງຫັຼງ ກ ະ ດູກ ກົ ກ ແອວ ( ເຄ່ິງກາງ-ສູງ) ວດັ ແທກ ຈາກບ່ອນ ນ່ັງຫາ ສ່ວນ ເທງິ ຂອງ ກະດູກ ກົກ ແອວ (PSIS). ການ ວດັ ແທກບອ່ນ ນ່ັງ ຫາ ສ່ວນ ເທງິ ຂອງ ກະດູກ ກົກ ແອວ (PSIS) ຖກື ໃຊ ້ເພ່ືອ ຊອກ ຫາ ຄວາມ ສູງ ເຄິງ່ກາງຂອງ ແຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອວ. ຄວາມ ເລກິ (ຄວາມ ໜາ) ຂອງ ແຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອ ວແມນ່ ຂ້ຶນ ກັບ ຜົນ ຂອງ ການ ປະ ເມີນ ຜົນ. J: ໄລຍະ ຫ່າງ ລະຫວ່າງ ຫົວ ເຂ່ົາ ແຜ່ນ ແຍກ ຫົວ ເຂ່ົາ ວດັ ແທກ ໄລຍະຫ່າງ ລະຫວາ່ງ ຫວົ ເຂົາ່ສອງ ເບືອ້ງ – ໂດຍ ຫວົ ເຂ່ົາ ວາງ ໃຫ ້ໃກ້ ກັບ ທາ່ ປກົກະຕິ ທີ ່ສຸດ ເທົາ່ ທີ່ ຈະ ສະບາຍ ຕົວ ສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ໄລຍະ ຫາ່ງ ລະຫວາ່ງ ຫວົ ເ ຂ່ົາສອງ ເບືອ້ງ ເທົາ່ ກັບ ຄວາມ ກວ້າງ ຂອງ ແຜ່ນ ແຍກ ຫວົ ເຂົາ່. ໄລຍະ ຫາ່ງ ຈະ ຂ້ຶນ ກັບ ທາ່ ນ່ັງ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. K: ບ່ອນ ນ່ັງຫາ ພ້ືນ ກະ ໂຫຼກຫົວ ແນວ ປະ ຄອງ ຫົວ (ຄວາມ ສູງ) ວ ັດ ແທກ ຈາກ ບອ່ນ ນ່ັງ ຫາພ້ືນ ກະ ໂຫກຼຫົວ. ການ ວດັແທກຈາກບອ່ນນ່ັງ ຫາພ້ືນກະໂຫຼກຫົວຊວ່ຍ ຊອກ ຈດຸ ທີ ່ຕັ້ງ ຂອງ ແນວ ປະຄອງ ຫວົ. I: ດ້ານ ຫັຼງຂອງ ກະດູກ ກົກ ແອວ ຫາ ກະດູກ ຮອງ ນ່ັງ ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ວດັ ແທກ ຈາກ ດາ້ນ ຫຼງັຂອງ ກະດູກ ກົກ ແອວ ຫາ ກະດູກ ຮອງ ນ່ັງ. ຈາກ ດາ້ນ ຂ້າງ ຂອງ ຜູ້ ໃຊລ້ດົ ເຂນັ ໃຫ ້ວາ ງມື ຂອງ ທາ່ນ (ຝ່າມື ຫງາຍ ຂ້ຶນ) ໃສ່ ກ້ອງ ກ້ົນ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ເພ່ືອ ຊອກ ຫາ ກະດູກ ຮອງ ນ່ັງ. ຊອກຫາ ກະດູກ ຮອງ ນ່ັງດ້ວຍນິວ້ມື ໜຶງ່ – ແລະ ຈາກ ນ້ັນ ເອາົ ມື ຂອງ ທາ່ນ ອອກ ທາງ ຂ້າງ ຂອງ ຜູ້ ໃ ຊ້ລ ົດ ເຂນັ. ວດັ ແທກ ຈາກ ດາ້ນ ຫຼງັຂອງ ກະດູກ ກົກ ແອວ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຫາ ນ້ິວມື ທີຢູ່ ່ກະດູກ ຮອງ ນ່ັງ. ພະນັກງານ ບລໍກິານ ລດົ ເຂນັ ອາດ ຈະ ໝາຍ ຢູ ່ເທງິ ຕຽງ ປະ ເມີນ ຜົນ ໃນ ບາງ ວທິ ີ(ຕົວຢາ່ງ ໝາຍ ດວ້ຍ ສໍ ຂາວ) ລຽບ ຕາມ ຕົວ ຜູ້ ໃຊ ້ລດົ ເຂນັ ເປນັ ເສ້ັນຕາມ ກະດູກ ຮອງ ນ່ັງ ຂອງ ເຂາົ ເຈົາ້ ແລະ ວດັ ແທກ ຈາກ ບອ່ນທີ ່ໝາຍ ໄວ້ ຫາ ດາ້ນຫັຼງຂອງ ກະດູກ ກົກ ແອວ. ການ ວດັ ແທກ ຈາກ ຫຼງັຂອງ ກະດູກ ກົກ ແອວ ຫາ ກະດູກ ຮອງ ນ່ັງ ບວກ ກັບ 20–40 ມມ ແມນ່ ໄລຍະ ຫາ່ງຈາກ ແນວ ອງີ ຫຼງັຫາ ຈດຸ ເລີ ່ມຕ້ົນ ຂອງ ຖາ້ນ ຮອງ ກະດູກ ຮອງ ນ່ັງ. ຖາ້ ຜູ້ ໃຊ ້ລດົ ເຂນັ ມີ ກະດູກ ກົກ ແອວ ທີ ່ອຽ່ງ ໄປ ຫຼງັຄົງ ທີ ່ຫຼ ືລາໍ ຕົວ ທີ ່ກ່ົງ ໄປ ໜາ້ ຄງົ ທີ ່ ການ ວດັ ແທກ ອາດ ຈະ ແຕກ ຕ່າງ ກັນ ( ເບິງ່ ກ່ອງ `ສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ທີ ່ມີ ກະດູກ ກົກ ແອວ ອຽ່ງ ໄປ ຫຼງັຄົງ ທີ ່ຫຼ ືລາໍ ຕົວ ກ່ົງ ໄປ ໜາ້ ຄງົ ທີ່` ). ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 71 ຈ່ົງ ຈ່ື ວ່າ: ï ໃນ ເວລາ ເຮັດ ການ ວັດ ແທກ ຮ່າງກາຍ, ëບ່ອນ ນ່ັງí ແມ່ນພ້ືນ ຜິວ ບ່ອນ ທີ່ ກະດູກ ຮອງ ນ່ັງນ່ັງ ຢູ່ ເທິງ. ï ສໍາລັບ ທຸກ ການ ວັດ ແທກ ທາງ ຕ້ັງ (C,D,E,F,H,I,K); ຈຸດ ທີ່ ຕ້ັງ ຂອງ ອົງ ປະກອບ ທີ່ ກົ ກັນຈະ ຖືກ ຜົນ ກະທົບ ຈາກ ການ ປ່ຽນ ແປງ ຕ່ໍ ກັບ ຄວາມ ສູງບ່ອນ ນ່ັງ ແລະ ເບາະ ຮອງ ນ່ັງ. ï ຈຸດ ທີ່ ຕ້ັງ ທີ່ ແນ່ນອນ ຂອງ ທຸກ ອົງປະກອບ ລົດ ເຂັນ ຈະ ຖືກ ກວດ ຢູ່ ສະ ເໝີ ໃນ ເວລາ ເຮັດ ການ ປັບ ໃຫ້ ເໝາະ ສົມ. ຂ້ັນ ຕອນ 3: ການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ (ການ ເລືອກ) ການ ເລືອກ ລົດ ເຂັນ ແລະ ເບາະ ຮອງ ນ່ັງ ກາ ນກໍານົດ ໃຊ້ລົດ ເຂັນ (ການ ເລືອກ) ແມ່ນ ຂ້ັນ ຕອນທີ ສາມ ໃນ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ. ການ ກໍານົດ ໃຊ້/ການ ເລືອກ ລົດ ເຂັນໝາຍ ເຖິງ ການ ຊອກ ຫາ ຄວາມ ເຂົ້າກັນ ທີ່ ດີ ທີ່ ສຸດ ທີ່ ເປັນ ໄປ ໄດ້ ລະຫວ່າງລົດ ເຂັນ ທີ່ ມີ ໃຫ້ກັບ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ໃນ ເວລາ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ຕ້ອງການ ມີ ການປະຄອງ ຫຼື ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ເພ່ືອ ນ່ັງ ໄດ້ ຕ້ັງ ຊ່ື, ການ ກໍານົດ ໃຊ້ ລວມມີ: ï ເລືອກ ປະ ເພດ ແລະ ຂະໜາດ ຂອງ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ທີ່ ສຸດ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ; ï ອະທິບາຍ ການ ຕິດ ຕ້ັງ ສະ ເພາະ ຕ່າງໆ ສໍາລັບ ລົດ ເຂັນ ນ້ັນ; ï ເລືອກ ປະ ເພດ ແລະ ຂະໜາດ ຂອງ ເບາະ ຮອງ ນ່ັງ; ï ເລືອກ ວ່າ ອຸປະກອນ PSD ຫຼື ການ ດັດ ແປງ ໃດ ແດ່ ທີ່ ຈໍາ ເປັນ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ທີ່ ຕ້ອງການແກ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ; ການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ຖືກ ຕັດສິນ ໂດຍ ມີ ການ ເຂົ້າ ຮ່ວມ ຢ່າງ ເຕັມ ສ່ວນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ໃນ ແບບ ຟອມການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ທີ່ ໃຊ້ ໃນ ຫຼັກສູດ ຝຶກ ອົບຮົມ ນ້ີ, ຈໍາ ເປັນ ຕ້ອງ ມີ ສາມ ລາຍ ເຊັນ ເ ຊ່ິງລວມມີ ຜູ້ ໃຊ້ ລົດ ເຂັນ, ຜູ້ ປະ ເມີນ (ພະນັກ ງານ ບໍລິ ການ ລົດ ເຂັນ) ແລະ ຜູ້ ຈັດການ ບໍລິ ການ ລົດ ເຂັນ. ປະ ເພດ ຂອງ ລົດ ເຂັນ ແລະ ເບາະ ຮອງ ນ່ັງ ປະ ເພດ ຂອງ ລົດ ເຂັນ ເພ່ືອ ກໍານົດ ໃຊ້ ລົດ ເຂັນ, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ຮູ້ ສ່ິງ ເຫຼົ່ານ້ີ ກ່ຽວ ກັບ ລົດ ເຂັນ; ï ປະ ເພດ ຂອ ງ ໂຄງ ລົດ ເຂັນ; ï ຂະໜາດ ທີ່ ມີ ໃຫ້ ແລະ ຂອບ ເຂດ ຂະໜາດ; ï ຄຸນສົມບັດ ໃຊ້ ງານ ທີ່ ມີ ໃຫ້; ï ການ ປັບ ທີ່ ເປັນ ໄປ ໄດ້ ແລະ ຂອບ ເຂດ ການ ປັບ. 72 ຄວາມ ຮູ້ ນ້ີ ຈະ ຊ່ວຍ ໃຫ້ ພະນັກງານ ບໍ ລິ ການ ລົດ ເຂັນ ເລືອກ ລົດ ເຂັນ ທີ່ ເໝາະ ສົມ ທີ່ ສຸດ ສໍາລັບ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ແລະ ອະທິບາຍ ວ່າ ມັນ ຄວນ ຖືກ ຕິດ ຕ້ັງ ແນວ ໃດ. ສ່ວນ ທີ່ ກ່ຽວຂ້ອງ ຂອງ ແບບ ຟອມການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ແມ່ນ ສະ ແດງຢູ່ ຂ້າງ ລຸ່ມ. 2. ປະ ເພດ, ຂະໜາດ ແລະ ການ ຕິດ ຕ້ັງ ລົດ ເຂັນ ປະ ເພດ ລົດ ເຂັນ (ຂຽນ ລາຍການ ລົດ ເຂັນ ທີ່ ມີ ໃຫ້ ຢູ່ ຂ້າງລຸ່ມ) ຂະໜາດຕ່າງໆ ຂອງ ລົດ ເຂັນ (ມມ) ຄວາມ ກວ້າ ງບ່ອນ ນ່ັງ ຄວາມ ເລິກ ບ່ອນນ່ັງ ຄວາມ ສູງ ແນວ ອີງ ຫຼັງ ຄວາມ ສູງ ບ່ອນ ວາງ ຕີນ ການ ຕິດ ຕ້ັງ ລົດ ເຂັນ ຕໍາ ແໜ່ ງລ້ໍ ຫຼັງ ອື່ນໆ: ການ ອ່ຽງ ປະ ເພດ ຂອງ ໂຄງ ລົດ ເຂັນ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ຮູ້ ປະ ເພດ ຂອງ ໂຄງ ລົດ ເຂັນ ທີ່ ມີ ໃຫ້ ໃນ ທ້ອງ ຖິ່ນ. ຕົວຢ່າງ ລົດ ເຂັນ ແມ່ນລົດ ເຂັນ ປະ ເພດດ ສາມ ລໍ້ ຫຼື ສ່ີ ລໍ້; ມີ ໂຄງ ແບບ ພັບ ໄດ້ ຫຼື ໂຄງ ແຂງ ຕາຍ ຕົວ; ໂຄງ ອ່ຽງ; ພ້ືນ ລໍ້ ຍາວ ຫຼື ສ້ັນ. ສໍາລັບ ຂ້ໍ ມູນ ເພ່ີມ ເຕີມ ກ່ຽວ ກັບປະ ເພດ ຕ່າງໆ ຂອງ ໂຄງ ລົດ ເຂັນ, ໃຫ້ ເບິ່ງ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 73 ຂະໜາດ ທ່ີ ມີ ໃຫ້ ແລະ ຂອບ ເຂດ ຂະໜາດ ຂະໜາດ ລົດ ເຂັນ ໂດຍ ປົກກະຕິ ຖືກ ອະທິບາຍ ໂດຍ ຄວາມ ກວ້າງ ບ່ອນ ນ່ັງ ແລະ ຄວາມ ເລິກ ບ່ອນ ນ່ັງຂອງລົດ ເຂັນ. ຄວາມ ກວ້າງບ່ອນ ນ່ັງ ຂອງ ລົດ ເຂັນ ຖືກ ວັດ ແທກ ຈາກ ດ້ານ ນອກ ຂອງ າວບ່ອນ ນ່ັງຫາ ດ້ານ ນອກ ຂອງ າວ ບ່ອນ ນ່ັງ ອີກ ຂ້າງ ຫຼື ລະຫວ່າງ ບ່ອນ ວາງ ແຂນ ຖ້າ ບ່ອນ ວາງ ແຂນ ຕ້ັງ ຢູ່ ເທິງ ຮາວ ບ່ອນ ນ່ັງ. ຄວາມ ເລິກ ກບ່ອນ ນ່ັງ ຂອງ ລົດ ເຂັນ ຖືກ ວັດ ແທກ ຈາກ ດ້ານ ໜ້າ ຂອງ ບ່ອນ ນ່ັງ ຫາ ແນວ ອີ ງຫັຼງ. ຂະໜາດທ່ີ ສໍາຄັນ ອື່ນ ຂອງ ລົດ ເຂັນ ລວມມີ: ï ຄວາມ ສູງ ຂອງ ບ່ອນ ນ່ັງ ຫາ ພ້ືນ (ນ້ີ ສາມາດ ສໍາຄັນ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ຂັບ ເຄື່ອນ ລົດ ເຂັນ ດ້ວຍ ຕີນ); ï ຄວາມ ສູງຂອ ງ ແນວ ອີງ ຫຼັງ. ຄຸນສົມບັດ ໃຊ້ ງານ ທ່ີ ມີ ໃຫ້ ຄຸນສົມບັດ ທີ່ ເປັນ ໄປ ໄດ້ ລວມມີ ປະ ເພດ ຂອງ ບ່ອນນ່ັງ, ແນວ ອີງ ຫຼັງ, ບ່ອນ ວາງ ຕີນ, ບ່ອນ ວາງ ແຂນ, ລໍ້ ໜ້າ, ລໍ້ ຫຼັງ ແລະ ອຸປະກອນ PSD (ຕົວຢ່າງ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ, ແນວ ປະຄອງຫົວ, ສາຍຮັດ). ການ ປັບ ທ່ີ ເປັນ ໄປ ໄດ້ ແລະ ຂອບ ເຂດ ການ ປັບ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຄວນ ຄຸ້ນ ເຄີຍ ກັບ ຂອບ ເຂດ ການ ປັບ ຕ່າງ ໆ ຂອງ ລົດ ເຂັນທ່ີ ມີ ໃຫ້ ໃນ ທ້ອງ ຖິ່ນ. ນ້ີ ລວມມີ ການ ຕ້ັງ ຢູ່ ຈຸດ ສູງ ສຸດ ແລະ ຕ່ໍາ ສຸດ ສໍາລັບ ບ່ອນ ວາງ ຕີນ, ຄວາມ ສູງ ຂອງ ແນວ ອີ ງຫັຼງສາມາດ ປັບ ໄດ້ ຫຼືບໍ່, ແລະ ມີ ການ ປັບ ທີ່ ເປັນ ໄປ ໄດ້ ໃນ ຈຸດ ແກນ ເພົາ ລໍ້ ຫຼັງຫືຼບໍ່. ເພ່ືອ ຊອກ ຮູ້ ëຂອບ ເຂດການ ປັບí ຂອງ ອົງ ປະກອບ ທີ່ ສາມາດ ປັບ ໄດ້ ມັນ ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ວັດ ແທກ ການ ປັບ ຕ່ໍາ ສຸດ ແລະ ສູງ ສຸດ. ບາງ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ມີ ຄຸນສົມບັດ ໃຊ້ ງານ ຫຼື ການ ປັບ ຫຼາຍກວ່າ ປະ ເພດ ອື່ນ. ບາງ ຄຸນສົມບັດ ຫຼື ການ ປັບ ສາມາດ ເປັນ ປະ ໂຫຍ ດຫຼາຍສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ຕ້ອງການ ມີ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ຄຸນສົມບັດ ເຫຼົ່ານ້ີ ລວມມີ: 74 ບ່ອນ ວາ ງຕີນ ແບບ ປັບ ໄດ້: ລົດ ເ ຂັນ ສ່ວນ ໃຫຍ່ ມີ ບ່ອນ ວາງ ຕີນ ທີ່ ສາມາດ ປັບ ຂ້ຶນ ແລະ ລົງ ໄດ້. ລົດ ເຂັນ ບາງຄັນ ມີ ການ ປັບ ເພ່ີມ ເຕີມ ເ ຊ່ິງລວມມີ: ï ບ່ອນ ວາງ ຕີນ ສາມາດ ຍ້າຍ ໄປ ໜ້າ ຫຼື ຫຼັງ ໄດ້; ï ມຸມ ບ່ອນ ວາ ງຕີນສາມາດ ປັບ ເພ່ີມ ຂ້ຶນ ຫຼື ຫຼຸດລົງ ໄດ້. ການ ປັບ ເຫຼົ່ານ້ີ ໃຫ້ ຄວາມ ສາມາດ ປັບ ປ່ຽນ ສໍາລັບ ບ່ອນ ທີ່ ຕີນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈະ ວາງ ໄວ້. ການ ຍົກ ບ່ອນ ຮອງ ຂາ ຂ້ຶນ: ການຍົນບ່ອນຮອງຂາຂ້ຶນສາມາດຊ່ວຍຍົກໃຫ້ຕີນສູງຂ້ຶນໂດຍທີ່ຫົວ ເຂົ່າເດ່ອອກ. ນ້ີສາມາດເປັນປະໂຫຍດສໍາລັບຜູ້ໃຊ້ລົດເຂັນຜູ້ທີ່ບໍ່ສາ ມາດກ່ົງຫົວເຂົ່າຫາທ່ານ່ັງປົກກະຕິໄດ້. ການເອນແນວ ອີງ ຫັຼງ : ການເອນແນວອີງຫັຼງ (ອ່ຽງແນວອີງຫັຼງໄປທາງຫັຼງ) ສາມາດຊ່ວຍຮອງຮັບ: ï ສະ ໂພ ກທ່ີບໍ່ ສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ( ມຸມ ລະຫວ່າງລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ); ï ກະດູກກົກແອວອ່ຽງໄປຫັຼງຄົງທ່ີ; ï ທ່າກົງຄົງທ່ີຂອງລໍາຕົວສ່ວນລຸ່ມ. ການ ອ່ຽງ ໃນ ກາງຫາວ ລົດເຂັນບາງຄັນມີສ່ິງທ່ີເອີ້ນວ່າ ëການອ່ຽງໃນກາງຫາວí. ນ້ີໝາຍຄວາມວ່າແນວອີງຫັຼງ ແລະ ບ່ອນນ່ັງອ່ຽງໄປຫັຼງພ້ອມກັນ. ມຸມເປີດແຕ່ບ່ອນນ່ັງຫາແນວອີງຫັຼງແມ່ນຍັງຄືເກ່ົາ. ຕໍາແໜ່ງຂອງ ບ່ອນນ່ັງທ່ີອ່ຽງໄປສາມາດຊ່ວຍ: ï ການອ່ຽງໄປດ້ານຫັຼງຄົງທ່ີຂອງກະດູກກົກແອວໂດຍທີ່ ມີ ການ ຂົດ ຫຍໍ້ ຂອງສະໂພກ ແລະ ຫົວເຂົ່າ; ï ການອົດທົນໃນການນ່ັງບ່ໍໄດ້ດົນ ຫຼື ຄວາມບ່ໍສະບາຍຕົວໃນລະຫວ່າງ ການ ນ່ັງ ປົກກະຕິ; ï ເພ່ືອ ເພ່ີມ ຄວາມ ສະບາຍ ຕົວ ແລະ ການ ພັກຜ່ອນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 75 ບ່ອນ ນ່ັງ ແບບ ແຂງ ຕາຍ ຕົວ: ລົດ ເຂັນ ບາງ ຄົນ ມີ ພ້ືນບ່ອນ ນ່ັງແບບແຂງ ຕາຍ ຕົວ ແທນທີ່ ຈະ ເປັນ ບ່ອນ ນ່ັງ ແບບ ໂຍກ ໄປມາ ໄດ້. ນ້ີ ສາມາດ ໃຫ້: ï ຖານ ທີ່ ດີ ເພ່ືອ ສ້າງ ແນວ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມສໍາລັບ ກະ ດູ ກກົກ ແອວ ແລະ ສະ ໂພ ກ; ï ຄວາມ ໝ້ັນ ຄົງ ຫຼາຍກວ່າ ບ່ອນ ນ່ັງ ແບບ ໂຍກ ໄປມາ ໄດ້. ນ້ີ ສາມາດ ເປັນ ປະ ໂຫຍ ດ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ການ ເຄື່ອນ ເໜັງ ແຮງທີ່ ຄວບ ຄຸມ ບໍ່ໄດ້ ຫຼື ມີ ນ້ໍາໜັກ ຫຼາຍ. ແນວ ອີງ ຫັຼງ ແບບ ແຂງ ຕາຍ ຕົວ: ລົດ ເຂັນ ບາງ ຄັນ ມີ ແນວ ອີງ ຫຼັ ງ ແບບ ແຂງ ຕາຍ ຕົວ. ຄື ກັນ ກັບ ບ່ອນ ນ່ັງ ແບບ ແຂງ ຕາຍ ຕົວ, ນ້ີ ສາມາດ ໃຫ້ ຖານ ທີ່ ດີ ສໍາລັບ ເສີມ ແນວ ຮອງ ຮັບ ທ່າ ທາ ງ ເພ່ີມ ເຕີມ. ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ຕາຍ ຕົວ ຍັງ ສາມາດ ໃຫ້: ï ຄວາມ ໝ້ັນ ຄົງ ຫຼາຍກວ່າ ແນວ ອີງ ຫຼງ ແບບ ໂຍກ ໄປມາ ໄດ້. ນ້ີ ສາມາດ ເປັນ ປະ ໂຫຍ ດ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ການ ເຄື່ອນ ເໜັງ ແຮງທີ່ ຄວບ ຄຸມ ບໍ່ໄດ້; ï ການ ຮອງ ຮັ ບ ຫຼາຍຂ້ຶນ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ສູງ ກວ່າ ແລະ ໜັກ ກວ່າ ແລະ/ຫຼື ມີ ລໍາ ຕົວ ທີ່ ອ່ອນ ຍວບ ຫຼາຍ. ຮູບປະກອບ ສະ ແດງ ໃຫ້ ເຫັນ ແນວ ອີງ ຫຼັງທ່ີ ແຂງ ຕາຍ ຕົວ ທີ່ ມີ ໂຟມ ເພ່ີ່ມ ໃສ່ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ລໍາ ຕົວ ໃນ ບ່ອນ ທີ່ ຖືກຕ້ອງ, ແລະ ແຜ່ນ ຮອງ ຂ້າງ ຈັບ ໃສ່ ແນວ ອີງ ຫຼັງ. ລົດ ເຂັນ ບາງ ຄັນ ມາ ພ້ອມ ກັບ ແນວ ອີງ ຫຼັງ ແບບປັບ ຄວາມ ເຄັ່ງ ໄດ້ ແທນ ແນວ ອີງ ຫຼັງ ໂຍກ ໄປມາ ໄດ້ ແບບທໍາ ມະ ດາ. ແນວ ອີງ ຫຼັບ ແບບ ປັບ ຄວາມ ເຄັ່ງ ໄດ້ ອະນຸຍາດ ໃຫ້ ມີການ ປັບ ການ ຮອງ ຮັບ ທີ່ ສະໜອງ ໃຫ້ ໂດຍ ແນວ ອີງ ຫຼັງ ໄດ້ ຢ່າງ ງ່າຍດາຍ. ສາຍຮັດ ສະ ເພາະຖືກ ດຶງ ໃຫ້ ເຄັ່ງ ຂ້ຶນ ຫຼື ມາຍ ໃຫ້ ຍານ ລົງ ໄດ້ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ຫຼາຍຂ້ຶນ ຫຼື ໜ້ອຍ ລົງ. ມັນ ບໍ່ ຈໍາ ເປັນ ໃນ ກາ ນມີ ທຸກ ຄຸ ນສົມບັດ ເຫຼົ່ານ້ີ ເພ່ືອ ໃຫ້ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາ ງ ເພ່ີມ ເຕີມ. ຫຼາຍໆ ຄຸນສົມບັດ ໃຊ້ ງານ ດັ່ງກ່າວ ສາມາດ ຖືກ ເຮັດ ເປັນ ການ ດັດ ແປງຕ່ໍ ກັບ ລົດ ເຂັນ ແບບ ໃຊ້ ແຮງ ຄົນ ພ້ືນຖານ. ການ ເກັບ ເອົາ ຂ້ໍ ມູນ ກ່ຽວ ກັບ ລົດ ເຂັນ ທ່ີ ມີ ໃຫ້ ໃນ ທ້ອງ ຖ່ິນ ແບບ ຟອມສັງ ລວມລົດ ເຂັນ ລະດັບ ປານ ກາງ ໃນ ໜ້າ ຕ່ໍ ໄປ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ເກັບ ເອົາ ແລະ ບັນທຶກ ຂ້ໍ ມູນ ກ່ຽວ ກັບ ລົດ ເຂັນ ທີ່ ມີ ໃຫ້ ໃນ ທ້ອງ ຖິ່ນ. 76 ສ່ິງ ທ່ີ ຕ້ອງ ພິຈາ ລະ ນາ ກ່ອນ ທ່ີ່ຈະ ດັດ ແປງ ລົດ ເຂັນ ໃນ ເວລາ ເລືອກ ລົດ ເຂັນທ່ີ ຈະ ຈໍາ ເປັນ ຕ້ອງ ມີ ການ ດັດ ແປງ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ຕ້ອງການ ໂດຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຄວນ ພິຈາລະນາ: ï ລົດ ເຂັນ ຢູ່ ໃນ ສະພາບໃຊ້ງານໄດ້ ດີ ຫຼືບໍ່? ï ວັດ ສະດຸທີ່ ມີ ໃນ ທ້ອງ ຖິ່ນ ແລະ ແບບ ວິທີ ທີ່ ສ່ິງ ຕ່າງໆ ຖືກ ເຮັດ ໃນ ທ້ອງ ຖິ່ນ ໃຊ້ ໄດ້ ກັບ ລົດ ເຂັນ ນ້ີ ບໍ? ï ຖ້າ ລົດ ເຂັນ ເສຍ ຫາຍ, ຊ້ີນ ສ່ວນ ຕ່າງໆ ສາມາດ ຖືກ ສ້ອມ ແປງ ຫຼື ປ່ຽນ ໃໝ່ ໃນ ທ້ອງ ຖິ່ນ ໄດ້ ບໍ? ປະ ເພດ ເບາະ ຮອງ ນ່ັງ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຄວນ ຮູ້ ປະ ເພດ ເບາະ ຮອງ ນ່ັງທ່ີ ມີ ໃຫ້ ສໍາລັບ ເຂົາ ເຈົ້າ ເພ່ືອ ກໍານົດ ໃຊ້. ຄຸນສົມບັດ ໃຊ້ ງານ ທີ່ ຈະ ຕ້ອງພິຈາລະນາ ເຖິງ: ï ວັດ ສະດຸ ທີ່ ເບາະ ຮອງ ນ່ັງ ຜະລິດ ຈາກ; ï ເບາະ ຮອງ ນ່ັງ ໃຫ້ການບັນ ເທົາ ການກົດທັບ ຫຼືບໍ່; ï ມັນ ງ່າຍສ່ໍາ ໃດ ໃນການ ດັດ ແປງ ເບາະ ຮອງ ນ່ັງ; ï ແນວ ຫຸ້ມ ເບາະ ຮອງ ນ່ັງ ກັນ ນ້ໍາ ໄດ້ ຫຼືບໍ່. ສໍາລັບ ຂ້ໍ ມູນ ເພ່ີມ ເຕີມ ກ່ຽວ ກັບ ເບາະ ຮອງ ນ່ັງ ລວມທັງ ເບາະ ຮອງ ນ່ັງບັນ ເທົາ ການ ກົ ດທັບ, ໃຫ້ ເບິ່ງ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ. ປະ ເພດ ແລະ ຂະໜາດ ຂອງ ເບາະ ຮອງ ນ່ັງທ່ີ ເລືອກ ຖືກ ບັນທຶກ ຢູ່ ໃນ ແບບ ຟອມການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ຢູ່ ໃນ ສ່ວນ ëປະ ເພດ ແລະ ຂະ ໜາດ ຂອງ ເບາະ ຮອງ ນ່ັງí. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 77 3. ປະ ເພດ ແລະ ຂະໜາດ ເບາະ ຮອງ ນ່ັງ ປະ ເພດ ເບາະ ຮອງ ນ່ັງ ຂະໜາດ ຕົວຢ່າງ ເບາະ ຮອງ ນ່ັງ ບັນ ເທົາ ກາ ນກົດທັບ ຖ້າ ເບາະ ຮອງ ນ່ັງ ຈໍາ ເປັນ ຕ້ອງມີ ກາ ນດັດ ແປງ ເພ່ືອ ສ້າງ ອຸປະກອນ PSD ທີ່ ຖືກຕ້ອງ – ລາຍ ລະອຽດ ຂອງສ່ິງ ນ້ີ ແມ່ນ ອະທິບາຍ ໄວ້ ຢູ່ ໃນ ຂ້ໍ ຕ່ໍໆ ໄປ ໃນ ແບບ ຟອມການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປາ ນກາງ. ແບບ ຟອມ ສັງ ລວມ ລົດ ເຂັນ ລະ ດັບ ປ ານ ກາງ ຊ່ື ລົດ ເຂັນ: ໃສ່ ຮູບ ພາບ ທີ່ ນ້ີ: ຜູ້ ຜະລິດ/ຜູ້ ສະໜອງ: ຂະໜາດ ທີ່ ມີ ໃຫ້: ນ້ໍາໜັກ ລວມ: ລາຍ ລະອຽດ: ໂຄງ: ຄົງ ທີ່/ ຕາຍ ຕົວ ພັບ ໄດ້ ຄວາມ ຍາວ ໂຄງ ແນວ ອີງ ຫັຼງ: ແກວ່ງ ໂຍກ/ຜ້າ ໃບ ແຂງ ຕາຍ ຕົວ ປັບ ຄວາມ ເຄັ່ງ ໄດ້ ບ່ອນຮອງ ນ່ັງ: ແກວ່ງ ໂຍກ/ຜ້າ ໃບ ແຂງ ຕາຍ ຕົວ ປັບ ຄວາມ ເຄັ່ງ ໄດ້ ເບາະ ນ່ັງ: ບໍ່ ມີ ເບາະ ຮອງ ນ່ັງ ໂຟມ ແບນ ມີ ໂຄງ ຮ່າງ ເປ ັນ ໂຟມ ຂອງ ແຫຼວ ອື່ນໆ ບ່ອນ ວາງ ຕີນ: ຄົງ ທີ່ ຖອດ ອອກ ໄດ້ ອື່ນໆ: ລ້ໍ ໜ້ານ້ອຍ: ໃຊ້ ລົມ ເສ້ັນ ຜ່າ ສູນ ກາງ: ແຂງ ຕາຍ ຕົວ ຄວາມ ກວ້າງ: ລ້ໍ ຫັຼງ: ໃຊ້ ລົມ ເສ້ັນ ຜ່າ ສູນ ກາງ: ຂອບ ຍູ້ ແຂງ ຕາຍ ຕົວ ຄວາມ ກວ້າງ: ແກນ ເພົາ ສາມາດ ປັບ ໄດ້ ໄສ້ ໃນ ແຂງ ຕັນ ຖອດ ອອກ ໄດ້ ເບ ກ: ຄັນ ໂຍກ ສ້ັນ ຄັນ ໂຍກ ຍາວ ອື່ນໆ: ບ່ອນ ວາງ ແຂນ ກ່ົງ ສ່ີຫຼ່ຽມ ອື່ນໆ: ຄົງ ທີ່ ຖອດ ອອກ ໄດ້ ອື່ນໆ: ຄັນຍູ້ ຄັນຍູ້ ອຸປະກອນ PSD: ສາຍຮັດ ກົກ ແອວ ສາຍຮັດ ບີ ແຄ່ງ ສາຍຮັດ ບ່າ ໄຫ່ຼ ສາຍຮັດ ຕີນ ທ່ອນ ກັນ ປີ້ນ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ຖາດ ແນວ ປະຄອງ ຫົວ ແຜ່ນ ຮອງຂ້າງກະດູກ ກົກ ແອວ ອື່ນໆ: 78 ການ ວັດ ແທກ, ຕົວ ເລືອກການ ປັບ ແລະ ຂອບ ເຂດ ການ ປັບ: ການ ວັດ ແທກ (ຖ້າ ລົດ ເຂັນ ມີ ໃຫ້ ໃນ ຂະໜາດ ຕ່າງໆ ໃຫ້ ບອກ ທຸກ ຂະໜາດ) ອັນ ນ້ີ ສາມາດປັບ ໄດ້ ບໍ? ຂອບ ເຂດ ການ ປັບ (ຂອບ ເຂດ ການ ປັບ ທີ່ ເປັນ ໄປ ໄດ້ ສໍາລັບ ລົດ ເຂັນ ນ້ີ) ແມ່ນ ບ່ໍ ຄວາມ ກວ້າ ງບ່ອນ ນ່ັງ ຄວາມ ເລິກ ບ່ອນນ່ັງ ຄວາມ ສູງ ບ່ອນ ນ່ັງ ຄວາມ ສູງ ແນວ ອີງ ຫັຼງ ການ ເອນ ແນວ ອີງ ຫັຼງ ຄວາມ ສູງ ບ່ອນ ວາງ ຕີນ ມຸມ ບ່ອນ ວາງ ຕີນ ຄວາມ ສູງຄັນຍູ້ ຄວາມ ຍາວ ໂຄງ ຄວາມ ຍາວ ພ້ືນ ລ້ໍ ມຸມ ລະຫວ່າງ ແນວ ອີງ ຫັຼງຫາ ບ່ອນ ນ່ັງ ການອ່ຽງ ໃນ ກາງຫາວ ແບບ ຟອມ ການ ກໍາ ນົດ ໃຊ້ (ການ ເລືອກ) ລົດ ເຂັນ ລະ ດັບ ປານ ກາງ ແບບ ຟອມນ້ີ ແມ່ນ ສໍາລັບ ກາ ນ ບັນທຶກ ການ ເລືອກ ລົດ ເຂັນ, ເບາະ ຮອງ ນ່ັງ ແລະ ອຸປະກ ອນ PSD ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ທີ່ ບໍ່ ສາມາດ ນ່ັງ ຕ້ັງ ຊ່ື ໄດ້ ຢ່າງ ສະບາຍ ຕົວ ໂດຍ ບໍ່ ມີ ການ ປະຄອງ ຫຼືຮອງ ຮັບ. ຮັກສາ ແບບ ຟອມນ້ີ ໄວ້ ໃນ ແຟ້ມຂ້ໍ ມູນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. 1. ຂ້ໍ ມູນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຊ່ື ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ: ເລກທີ: ວັນ ທີ ປະ ເມີນ ຜົນ: ວັນ ທີ ປັບ ລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ: ຊ່ື ຜູ້ ປະ ເມີນ ຜົນ: 2. ປະ ເພດ, ຂະໜາດ ແລະ ການ ຕິດ ຕ້ັງ ລົດ ເຂັນ ປະ ເພດ ລົດ ເຂັນ (ຂຽນ ລາຍການ ລົດ ເຂັນ ທີ່ ມີ ໃຫ້ ຢູ່ ຂ້າງລຸ່ມ) ຂະໜາດຕ່າງໆ ຂອງ ລົດ ເຂັນ (ມມ) ຄວາມ ກວ້າ ງບ່ອນ ນ່ັງ ຄວາມ ເລິກ ບ່ອນນ່ັງ ຄວາມ ສູງ ແນວ ອີງ ຫຼັງ ຄວາມ ສູງ ບ່ອນ ວາງ ຕີນ ການ ຕິດ ຕ້ັງ ລົດ ເຂັນ ຕໍາ ແໜ່ ງລ້ໍ ຫຼັງ ອື່ນໆ: ການ ອ່ຽງ 3. ປະ ເພດ ແລະ ຂະໜາດ ເບາະ ຮອງ ນ່ັງ ປະ ເພດ ເບາະ ຮອງ ນ່ັງ ຂະໜາດ ຕົວຢ່າງ ເບາະ ຮອງ ນ່ັງ ຫຼຸດຜ່ອນ ກາ ກົດທັບ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 79 4. ອຸປະກອນ PSD ຫືຼ ການ ດັດ ແປງ ທ່ີ ຈໍາ ເປັນ ລາຍການ ກວດ ສໍາລັບ PSD ອະທິບາຍ/ ແຕ້ມ ຮູບ ແລະ ບອກ ຂະໜາດ ບ່ ອ ນ ນັ່ ງ / ເບ າະ ຮ ອ ງ ນັ່ ງ ເພ່ີມ ບອ່ນ ນ່ັງ ແຂງ ຕາ ຍຕົວ ຖາ້ນ ຮອງ ກະດູກ ຮອງ ນ່ັງ (= 3 ລບົ ໃຫ ້12) ສ່ວນ ໜາ້ ບອ່ນ ນ່ັງ ທີຫ່ຼດຸຕ່ໍາລົງ L R ສ່ວນ ໜາ້ ບອ່ນ ນ່ັງ ທີ ່ຍກົສູງ ຂ້ຶນ ຫຼີມ້ຮອງ ສໍາລັບ ການ ອຽ່ງ ໄປທາງ ໜາ້ ແນວ ຮອງ ເສີມຢູ່ ກ້ອງ ກະດູກ ກົກ ແອວ L R ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ (= 2) L R ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ນອກ L R ແຜ່ນ ຮອງ ກົກຂາ ດາ້ນ ນອກ L R ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ໃນ (= 10) ແຜ່ນ ແຍກ ຫວົ ເຂົາ່ (= 10) ອືນ່ໆ ອືນ່ໆ ລາຍການ ກວດ ສໍາລັບ PSD ອະທິບາຍ/ ແຕ້ມ ຮູບ ແລະ ບອກ ຂະໜາດ ບ່ ອ ນ ນັ່ ງ ແ ລ ະ ແ ນ ວ ອີ ງ ຫຼັ ງ ມຸມ ເປດີ ລະຫວາ່ງ ບອ່ນ ນ່ັງ ຫາ ແນວ ອງີ ຫຼງັ ການ ອຽ່ງຂອງບ່ອນ ນ່ັງ ແລະ ແນວ ອງີ ຫຼງັ (ການ ອຽ່ງ ໃນ ກາງຫາວ) ແ ນ ວ ອີ ງ ຫຼັ ງ ເພ່ີມ ແນວ ອງີ ຫຼງັ ແບບ ແຂງ ຕາ ຍຕົວ ແຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອວ (= 9) ປບັຮບູຊງົ ຂອງ ແນ ວອງີ ຫຼງັ ແນວ ອງີ ຫຼງັທ່ີ ສາມາດ ປບັ ຄວາມ ເຄັງ່ ໄດ້ ການ ເອນ ແນວ ອງີ ຫຼງັ ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ (= 7) L R ຫຼີມ້ຮອງ ຂ້າງ ລາໍ ຕົວ (= 7) L R ອືນ່ໆ ຖ າດ / ບ່ ອ ນ ວ າງ ແ ຂ ນ ຖາດ ດດັ ແປງ ບອ່ນ ວາງ ແຂນ L R ອືນ່ໆ 80 ແ ນ ວ ປ ະ ຄ ອ ງ ຫົ ວ ແນວ ປະຄອງ ຫວົ ແບບ ແບນ (= 11) ແນວ ປະຄອງ ຫວົ ແບບ ມີ ຮູບຊງົ (= 11) ອືນ່ໆ ແ ນ ວ ຮ ອ ງ ຂ າ ສ່ ວ ນ ລຸ່ ມ ແນວ ຮອງ ເສີມ ບອ່ນ ວາງ ຕີນ L R ຫຼີມ້ຮອງ ບອ່ນ ວາງ ຕີນ L R ແນວ ຮອງ ຂາ ສ່ວນລຸມ່ L R ອືນ່ໆ ສ າຍ ຮັ ດ ສາຍຮັດ ກົກ ແອວ ສາຍຮັດ ບ ີແຄງ່ ສາຍຮັດ ຕີນ L R ສາຍຮັດ ບາ່ ໄຫ່ຼ ອືນ່ໆ 5. ລາຍ ເຊັນ ຂ້ໍ ຕົກລົງ ຜູ້ ໃຊ້ ລົດ ເຂັນ: ຜູ້ ປະ ເມີນ ຜົນ: ຜູ້ ຈັດການ ການ ບໍລິການ ລົດ ເຂັນ: ການ ກໍານົດ ໃຊ້ (ການ ເລືອກ) ອຸປະກອນ PSD – ພາກສະ ເໜີ ມີຫຼາຍໆ ແບບ ແຕກ ຕ່າງ ກັນ ຂອງ ອຸປະກອນ PSD ແລະ ຫຼາຍວິທີ ແຕກ ຕ່າງ ກັນ ທີ່ ລົດ ເຂັນ ສາມາດ ຖືກ ດັດ ແປງ ເພ່ືອ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ມັກ ຈະ ລວມຫຼາຍໆ ອຸປະກອນ PSD ເຂົ້າກັນ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ໜຶ່ງ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ໂດຍ ລວມທີ່ ລາວ ຕ້ອງການ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 81 ອຸປະກອນ PSD ແມ່ນ ຫຍັງ? ອຸປະກອນຮອງ ຮັບ ການ ຊົງ ຕົວ (PSD) ແມ່ນ ອຸປະກອນ ປະຄອງ ຮ່າງກາຍທ່ີ ໃຫ້ການປະຄອງ ຫຼືຮອງ ຮັບທ່າ ງທາງການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ – ອົງ ປະກອບສໍາຄັນ ຂອງ ການ ບໍລິການ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ຕາຕະລາງອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ (PSD) (ຕ່ໍ ໄປ ເອີ້ນ ວ່າ ຕາຕະລາງ PSD) ແລະ ຕາຕະລາງ ອ້າງ ອີງອຸປະກອນ ຮອງຮັບ ການ ຊົງ ຕົວ (PSD) (ຕ່ໍ ໄປ ເອີ້ນ ວ່າ ຕາຕະລາງ ອ້າ ງອີງ PSD) ໃນ ໜ້າ ຕ່ໍ ໄປໆ ນ້ີ ໃຫ້ ພາບ ລວມກ່ຽວ ກັບ ອຸປະກອນ PSD ຕ່າງໆ ທີ່ ນໍາ ສະ ເໜີ ໃນ ຕະຫຼອດຫຼັກ ສູດ ຝຶກ ອົບຮົມ ນ້ີ. ບາງ ຕົວຢ່າງ ຂອງ ອຸປະກອນ PSD ແມ່ນ ສະ ແດງ ໃນ ຮູບ ປະກອບ ຂ້າງ ລຸ່ມ. ຊ່ື ຕ່າງ ກັນ ສໍາລັບ ສ່ິງ ດຽວ ກັນ ອຸປະກອນ PSD ດຽວ ກັນ ອາດ ຈະ ມີ ຊ່ື ຕ່າງໆ ກັນ ໂດຍ ຂ້ຶນ ກັບການ ບໍລິການ ລົດ ເຂັນ, ສະຖານ ທີ່ ຫຼື ຜູ້ ຜະລິດ. ໃນ ປື້ ມຄູ່ ມືອ້າງ ອີງ ນ້ີ ໄດ້ ມີ ການ ໃຫ້ ຊ່ື ທີ່ ອະ ທິບາຍ ງ່າຍ ສຸດ ສໍາລັບ ອຸປະກອນ PSD ແຕ່ ລະ ຢ່າງ. ໃນ ແຕ່ ລະກາ ນບໍລິການ ລົດ ເຂັນ, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂນັ ສາມາດ ໃຊ້ ຄໍາສັບ ທີ່ ຄຸ້ນ ເຄີ ຍທີ່ ສຸດ ແລະ ສະບາຍ ທີ່ ສຸດ ສໍາ ລັບ ເຂົາ ເຈົ້າ. ສາຍຮັດ ກົກ ແອວ ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ສາຍຮັດ ຕີນ ແຜ່ນ ຮອງຂ້າງກະດູກ ກົກ ແອວ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ແນວ ອີງ ຫຼັງ ແບບ ສູງ ສາຍຮັດ ບ່າ ໄຫ່ຼ ແນວ ປະຄອງ ຫົວ 82 ຕາ ຕະ ລາງ ອຸ ປະ ກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ (PSD) ບ່ອນ ນ່ັງ/ເບາະ ຮອງ ນ່ັງ ຖາ້ນ ຮອງກ່ອນ ກະດູກ ຮອງ ນ່ັງ ດາ້ນ ໜາ້ ບອ່ນ ນ່ັງ ທີຕ່ໍ່າລົງ (ໜຶງ່ ຂ້າງ) ດາ້ນ ໜາ້ ບອ່ນ ນ່ັງ ທີ ່ຍກົສູງ ຂ້ຶນ ຫຼີມ້ຮອງ ສໍາລັບ ການ ອຽ່ງ ໄປທາງ ໜາ້ ແນວ ຮອງ ຢູ ່ກ້ອງ ກະດູກ ກົກ ແອວ ແຜ່ນ ຮອງຂ້າງກະດູກ ກົກ ແອວ ບ່ອນ ນ່ັງ/ເບາະ ຮອງ ນ່ັງ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫັຼງ ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ນອກ ແຜ່ນ ຮອງ ກົກຂາ ດາ້ນ ນອກ ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ໃນ ແຜ່ນ ແຍກ ຫວົ ເຂົາ່ ມຸມ ເປດີ ລະຫວາ່ງ ບອ່ນ ນ່ັງ ຫາ ແນວ ອງີ ຫຼງັ ການ ອຽ່ງຂອງບ່ອນ ນ່ັງ ແລະ ແນວ ອງີ ຫຼງັ (ການ ອຽ່ງ ໃນ ກາງຫາວ) ແນວ ອີງ ຫັຼງ ແຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອວ ປບັຮບູຊງົ ຂອງ ແນ ວອງີ ຫຼງັ ແນວ ອງີ ຫຼງັທ່ີ ສາມາດ ປບັ ຄວາມ ເຄັງ່ ໄດ້ ການ ເອນ ແນວ ອງີ ຫຼງັ ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ຫຼີມ້ຮອງ ຂ້າງ ລາໍ ຕົວ ຖາດ ແນວ ປະ ຄອງ ຫົວ ແນວ ຮອງ ຂາ ສ່ວນລຸ່ມ ຖາດ ແນວ ປະຄອງ ຫວົແບບ ແບນ ແນວ ປະຄອງ ຫວົແບບ ມີ ຮູບ ຊົງ ແນວ ຮອງ ເສີມ ບອ່ນ ວາງ ຕີນ ຫຼີມ້ຮອງ ບອ່ນ ວາງ ຕີນ ແນວ ຮອງ ຂາ ສ່ວນລຸມ່ ສາຍຮັດ ສາຍຮັດ ກົກ ແອວ ສາຍຮັດ ສ່ີ ຈດຸປອ້ງ ກັນການ ອຽ່ງ ໄປ ທາງ ໜາ້ ສາຍຮັດ ບ ີແຄງ່ ສາຍຮັດ ຕີນ ສາຍຮັດ ບາ່ ໄຫ່ຼ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 83 ຕາ ຕະ ລາງ ອ້າງ ອີງອຸ ປະ ກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ (PSD) PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ບ່ອນ ນ່ັງ/ເບາະ ຮອງ ນ່ັງ ຖາ້ນ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຖາ້ນ ຮອງກະດູກ ຮອງ ນ່ັງຊ່ວຍ: ï ຮັກສາ ໃຫ ້ກະດູ ກກົກ ແອວ ຕ້ັງ ຊ່ື; ï ຢດຸ ກະດູກ ກົກ ແອວ ບໍ ່ໃຫ ້ເລືອ່ນ ໄປ ທາງ ໜາ້; ï ຫຼດຸຜ່ອນແນວໂນມ້ໃນການນ່ັງດ້ວຍທາ່ຫັຼ ງຂົດ. ຈດຸ ເລີ ່ມຕ້ົນ ຂອງ ຖາ້ນ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຄວນຕິດ ແປະ ກັບ ດາ້ນ ໜາ້ ຂອງ ກະດູກ ຮອງ ນ່ັງ. ດາ້ນ ໜາ້ ບອ່ນ ນ່ັງທ່ີ ຕ່ໍາ ລງົ (ໜຶງ່ ຂ້າງ) ການຫຸຼດດາ້ນ ໜາ້ ບອ່ນ ນ່ັງ ໃຫ ້ຕ່ໍາລົງຢູ່ ຂ້າງໜ່ຶງ ດັງ່ ທີ ່ສະ ແດງ ສາມາດ ຊ່ວຍ ຮອງ ຮັບ ສະ ໂພ ກ ເບືອ້ງ ໜຶງ່ ທີ ່ບໍ ່ກ່ົງ ເຂົາ້ ຫາ ທາ່ ປກົກະຕິ ສໍາລັບ ການ ນ່ັງ (ມຸມ ລາໍ ຕົວ ຫາ ກົກຂາ ຫາຼຍກວ່າ 90 ອງົສາ). ປະລມິານ ທີ ່ບອ່ນ ນ່ັງ ຖກື ຫຼດຸຕ່ໍາ ລງົ ຈະ ຂ້ຶນ ກັບ ມຸມ ຂອງສະ ໂພ ກຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ຄວນ ມີ ການສໍາ ພັດທີ ່ເທ່າົ ກັນ ຢູ ່ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ກົກຂາ ທງັ ສອງ ຂ້າງ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ສ່ວນ ໜາ້ ບອ່ນ ນ່ັງ ທີ ່ຍກົສູງ ຂ້ຶນ ການ ຍກົ ສ່ວນ ໜາ້ ຂອງ ບອ່ນ ນ່ັງ ຂ້ຶນ ສາມາດ ຮອງ ຮັບ ສະ ໂພກທັງ ສອງຂ້າງບ່ໍ ສາມາດ ເປດີ ກວ້າງ ຫາ ທາ່ ນ່ັງ ປກົກະຕິ ໄດ້ ( ມຸມ ລະຫວາ່ງລໍາ ຕົວ ຫາ ກົກຂາ ໜອ້ຍກວາ່ 90 ອງົສາ). ການ ຍກົສ່ວນ ໜາ້ ຂອງ ບອ່ນ ນ່ັງຂ້ຶນ ຍງັ ສາມາດ ຊ່ວຍ ຫຼດຸການ ເຄືອ່ນ ເໜງັ ແຮງ ທີ່ ຄວບ ຄມຸ ບໍ ່ໄດ້ ເຊິງ່ ເຮດັ ໃຫ ້ຮ່າງກາຍ ຢຽດ ຊ່ື . ປະລມິານ ທີ ່ບອ່ນ ນ່ັງ ຖກື ຍກົ ຂ້ຶນ ຢູ່ ສ່ວນໜາ້ ຈະ ຂ້ຶນ ກັບ ມຸມ ລະຫວາ່ງ ລາໍ ຕົວ ຫາ ກົກຂາ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ຄວນ ມີ ການສໍາ ພັດທີ ່ເທ່າົ ກັນ ຢູ ່ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ກົກຂາ ທງັ ສອງ ຂ້າງ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ຫຼີມ້ຮອງ ສໍາລັບ ການ ອຽ່ງ ໄປທາງ ໜາ້ ຫຼີມ້ຮອງ ທີ ່ອຽ່ງ ເນີນ ໄປ ທາງ ຫຼງັທ່ີ ວາງ ຢູ ່ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ສາມາດ ເປນັ ປະ ໂຫຍ ດສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ທີ ່ມີ ກະດູກ ກົກ ແອວ ອຽ່ງ ໄປ ທາງ ໜາ້. ຫຼີມ້ຮອງ ສ່ົງ ເສີມ ໃຫ ້ກະດູ ກກົກ ແອວ ເອນໄປ ທາງ ຫຼງັ. ຫຼີມ້ຮອງ ສໍາລັບ ການ ອຽ່ງ ໄປ ຫຼງັຢຸດ ຢູ່ ແປະ ກັບ ດາ້ນ ໜາ້ ຂອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ພຽງ ກັນ ຢູ ່ກ້ອງ ກົກຂາ. ໃນ ເວລາ ໃຫຫ້ຼີມ້ຮອງ ສໍາລັບ ການ ອຽ່ງ ໄປ ທາງ ຫຼງັ, ë ໃຫ ້ຈາໍລອງí ຫຼິມ້ຮອງ ກ່ອນ ໃນ ລະຫວາ່ງ ການ ປະ ເມີນ ຜົນ. ນ້ີ ຈະ ອະນຸຍາດ ໃຫ ້ຜູ້ ໃຊລ້ດົ ເຂນັ ຮູ້ສຶກ ໄດ້ ເຖງິ ຜົນ ຂອງ ຫຼີມ້ຮອງ ນ້ັນ, ແລະ ເພ່ືອ ໃຫ ້ພະນັກງານ ບລໍກິານ ລດົ ເຂນັ ແລະ ຜູ້ ໃຊ ້ລດົ ເຂນັຊອກ ຮູ້ ມຸມ ທີ ່ດ ີສຸດ ແລະ ປະ ເ ມີ ນວ່າ ຫຼີມ້ຮອງ ນ້ັນ ມີ ປະສິດທ ິຜົນ ສ່ໍາ ໃດ. 84 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ແນວ ຮອງ ເສີມຢູ່ ກ້ອງ ກະດູກ ກົກ ແອວ ແນວ ຮອງ ເສີມ ສາມາດ ຖກື ໃຊ ້ເພ່ືອ ຮອງ ຮັບ ຜູ້ ໃຊລ້ດົ ເຂນັ ທີ ່ມີ ກະດູກ ກົກ ແອວ ບໍ ່ພຽງ ກັນ ຄງົ ທີ.່ ແນວ ຮອງ ເສີມ ຊ່ວຍ: ï ເພ່ີມ ຄວາມ ໝ້ັນຄົງ ໃຫ ້ແກຜູ້່ ໃ ຊ້ລດົ ເຂນັ; ï ຫຼກີ ເວັນ້ການ ກົ ດທບັ ທີ ່ບໍ ່ປອດ ໄພ ຕ່ໍ ກັບ ດາ້ນ ຕ່ໍາ ກວ່າ ຂອງ ກະດູກ ກົກ ແອວ. ແນວ ຮອງ ເສີມ ຢູ ່ກ້ອງ ກະດູກ ກົກ ແອວ ແລະ ກົກຂາ ທີ ່ສູງ ກວ່າ. ຄວນ ມີ ການສໍາ ພັດທີ ່ເທ່າົ ກັນ ຢູ ່ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ກົກຂາ ທງັ ສອງ ຂ້າງ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ໃນ ເວລາ ໃຫ ້ແນວ ຮອງ ເສີມ ຢູ ່ກ້ອງ ກະດູກ ກົກ ແອວ ມັນ ອາດ ຈະ ຈາໍ ເປນັ ໃນ ການ ປບັ ບອ່ນ ວາງ ຕີນ (ຂ້າງ ໜຶງ່ ອາດ ຈະ ຈາໍ ເປນັ ຕ້ອງ ສູງ ກວ່າ ອກີ ຂ້າງ). ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ຍງັ ຈະ ຊ່ວຍ ຮອງ ຮັບກະດູກ ກົກ ແອວ ແລະ ຄວນ ຖກື ເພ່ີມ ໃຫ ້ສໍາລັບ ທກຸ ຄ ົນທ່ີ ມີ ແນວ ຮ ອງ ເສີມ ຢູ ່ກ້ອງກະດູກ ກົກ ແອວ. ແຜ່ນ ຮອງຂ້າງກະດູກ ກົກ ແອວ ແຜ່ນ ຮອງຂ້າງກະດູກ ກົກ ແອວ ຊ່ວຍ: ï ຢດຸ ກະດູກ ກົກ ແອວ ບໍ ່ໃຫ ້ເຄືອ່ ນ ໄປ ທາງຂ້າງບ່ອນ ທີ ່ລດົ ເຂນັ ກວ້າງ ເກີນ ໄປ ຫຼື ບອ່ນ ທີ ່ສະ ໂພ ກ ແຄ ບກວາ່ ລາໍ ຕົວ; ï ຫຼດຸຜ່ອນ ແນວ ໂນ້ມສໍາລັບ ກະດູກ ກົກ ແອວ ທີ ່ຈະ ອຽ່ງ ໄປ ທາງ ຂ້າງ. ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ຄວນ ສໍາພັດຢາ່ງ ແໜນ້ ກັບ ທງັ ສອ ງຂ້າງ ຂອງ ກະດູກ ກົກ ແອວ. ຈື ່ວາ່ ເດກັ ນ້ອຍໆ ຄວນ ນ່ັງ ໂດຍ ທີ ່ກົກຂາ ຂອງ ເຂາົ ເຈົາ້ຈ່າງ ອອກ ກວ່າ ຜູ້ ໃຫຍ.່ ດວ້ຍ ເຫດຜນົ ນ້ີ, ຈົງ່ ຮັບປະກັນ ວາ່ ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ບໍ ່ເດ ່ໄປ ໜາ້ ເກີນ ໄປ ແລະ ຍູ ້ກັບ ກົກຂາ ເດກັນ້ອຍ ເຂົາ້ກັນ. ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ນອກ ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ນອກ ສາມາດ ໃຫກ້ານ ຮອງ ຮັບ ທີ ່ອອ່ນ ໂຍນ ເພ່ືອ: ï ຊ່ວຍ ຮັກສາ ການຈັດແນວ ປກົກະຕິ ຂອງ ກົກຂາ; ï ຫຼດຸ ແນວ ໂນ້ມສໍາລັບ ຂາ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ທີ ່ຈະຂດົ ເຂົາ້ ຫຼ ື ເດ ່ອອກ ດາ້ນ ນອກ. ຫຼີມ້ຮອງກົກຂາ ດາ້ນ ນອກ ຄວນ ຮອງ ກົກຂາ ຢາ່ງ ສະບາຍ ຕົວ ໃນ ແນວ ຂາ ປກົກະຕິ ໃນ ເວລາຜູ້ ໃຊ ້ລດົ ເຂນັບ່ໍ ເຄືອ່ນ ເໜງັ ແລະ ເຄືອ່ນ ເໜງັ. ຖາ້ ສືບ ຕ່ໍ ມີ ແນວ ໂນ້ມທ່ີ ກົກຂາ ຈະ ລົມ້ ຫຼື ເອນ ໄປ ດາ້ນ ນອກ, ການ ຮອງ ທີ່ ແໜນ້ໜາກວ່າ ອາດ ຈະ ຈາໍ ເປນັ ( ເບິງ່ ແຜ່ນ ຮອງ ກົກຂາ ດາ້ນ ນອກ). ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 85 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ແຜ່ນ ຮອງ ກົກຂາ ດາ້ນ ນອກ ແຜ່ນ ຮອງ ກົກຂາ ດາ້ນ ນອກ ສາມາດ ໃຫກ້ານ ຮອງ ທີ ່ແໜນ້ໜາ ເພ່ືອ ຊ່ວຍປອ້ງ ກັນ ຂາ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ບໍ ່ໃຫ ້ລົມ້ ຫຼ ື ເອ ນ ໄປດ້ານນອກ. ແຜ່ນຮອງກົກຂາ ດາ້ນ ນອກ ຄວນ ຮອງ ກົກຂາ ຢາ່ງ ສະບາຍ ຕົວ ໃນ ແນວ ຂາ ປກົກະຕິ ໃນ ເວລາຜູ້ ໃຊ ້ລດົ ເຂນັບ່ໍ ເຄືອ່ນ ເໜງັ ແລະ ເຄືອ່ນ ເໜງັ. ຄວນ ມີ ການສໍາ ພັດທີ ່ພຽງ ກັນ ລະຫວາ່ງ ແຜ່ນ ຮອງ ແລະ ຂາ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ໃນ ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ໃນ ໃຫກ້ານ ຮອງ ທີ ່ອອ່ນ ໂຍນ ເພ່ືອ ຊ່ວຍ: ï ຮັກສາ ການຈັດແນວ ປກົກະຕິ ຂອງ ກົກຂາ; ï ຫຼດຸ ແນວ ໂນ້ມທ່ີ ຂາ ຈະ ພັບ ເຂົາ້ ຫາ ກັນ/ດງຶ ເຂົາ້ ດາ້ນ ໃນ. ຫຼີມ້ຮອງກົກຂາ ດາ້ນ ໃນ ຄວນ ຮອງ ກົກຂາ ຢາ່ງ ສະບາຍ ຕົວ ໃນ ແນວ ຂາ ປກົກະຕິ ໃນ ເວລາຜູ້ ໃຊ ້ລດົ ເຂນັບ່ໍ ເຄືອ່ນ ເໜງັ ແລະ ເຄືອ່ນ ເໜງັ. ກວດ ເບິງ່ ວາ່ຫຼີມ້ຮອງກົກຂາບ່ໍເຮດັໃຫຜູ້້ ໃຊລ້ດົເຂນັຍາກຂ້ຶນ ໃນ ການ ເຄືອ່ນຍາ້ຍ ເຂົາ້ ແລະ ອອກ ຈາກ ລດົ ເຂນັ. ແຜ່ນ ແຍກ ຫວົ ເຂົາ່ ແຜ່ນ ແຍກ ຫວົ ເຂົາ່ ໃຫກ້ານ ຮອງ ຮັບ ທີ່ ແໜນ້ໜາ ເພ່ືອ ຊ່ວຍ ຮັກສາ ກາ ນຈດັ ແນວ ປກົກະຕິຂອງ ກົກຂາ. ແຜ່ນ ແຍກ ຫວົ ເຂາົ ສາມາດ ເປນັ ປະ ໂຫຍ ດຫາຼຍສໍາລັບ ຄນົ ທີ ່ມີ ແນວ ໂນ້ມສູງທ່ີ ຈະ ພັບ ຂາ ເຂົາ້ ຫາ ກັນ. ແຜ່ນ ແຍກ ຫວົ ເຂົາ່ຄວນ ຮອງ ຮັບກົກຂາ ຢາ່ງ ສະບາຍ ຕົວ ໃນ ແນວ ຂາ ປກົກະຕິ ໃນ ເວລາຜູ້ ໃຊ ້ລດົ ເຂນັບ່ໍ ເຄືອ່ນ ເໜງັ ແລະ ເຄືອ່ນ ເໜງັ. ຄວນ ມີ ການສໍາ ພັດທີ ່ເທ່າົ ກັນຕ່ໍ ກັບ ຫວົ ເຂົາ່ ແລະ ກົກຂາ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ແຜ່ນ ແຍກ ຫວົ ເຂົາ່ ບໍ ່ຄວນສໍາ ພັດກັບ ບລໍິ ເວນມຸມ ກົກຂາ ເລຍີ. ໃຫ ້ຖາ້ນ ຮອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ສາຍຮັດ ກົກ ແອ ວ ຖາ້ ມີ ຄວາມ ສ່ຽງ ທີ ່ຜູ້ ໃຊ ້ລດົ ເຂນັ ຈະ ເລືອ່ນ ໄປ ໜາ້ ຫາ ແຜ່ນ ແຍກ ຫວົ ເຂົາ່. 86 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫັຼງ ມຸມ ເປດີ ລະຫວາ່ງ ບອ່ນ ນ່ັງ ຫາ ແນວ ອງີ ຫຼງັ ການ ເປດີ (ການ ເພ່ີມ) ມຸມ ລະຫວາ່ງ ບອ່ນ ນ່ັງ ຫາ ແນວ ອງີ ຫຼງັສາມາດ ເປນັ ປະ ໂຫຍ ດສໍາລັບຜູ້ ໃຊ ້ລດົ ເຂນັ ທີ ່ມີ ກະດູກ ກົກ ແອວ ອຽ່ງ ໄປ ຫຼງັຄົງ ທີ ່ຫຼ ືສະ ໂພ ກຄົງ ທີ.່ ມຸມ ທີ ່ເພ່ີມ ຂ້ຶນ ຮອງ ຮັບ ທາ່ ປກົກະຕິ ແລະ ໃຫກ້ານ ຮອງ ຮັບ ທີ ່ແໜນ້ໜາ ເພ່ືອ ເພ່ີມ ຄວາມ ສະບາຍ ຕົວ ແລະ ຊ່ວຍ ປອ້ງ ກັນ ການ ປຽ່ນ ແປງ ທາ່ ເພ່ີມ ເຕີມ. ຄວນ ມີ ການ ສໍາພັດທີ ່ເທົາ່ ກັນ ຢູ ່ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ, ຢູ່ ດາ້ນ ຫຼງັຂອງ ກະດູກ ກົກ ແອວ ຂອງ ເຂາົ ເຈົາ້, ຫຼງັສ່ວນ ລຸມ່ ແລະ ສ່ວນ ເທງິ. ນ້ີ ອາດ ຈະ ຈາໍ ເປນັ ຕ້ອງ ມີ ໂຄງຮ່າງ ຂອງ ໂຟມຈໍາ ນວນ ໜຶງ່ ເພ່ືອ ໃຫກ້ານ ຮອງ ຮັບ ແລະ ການ ສໍາພັດທີ ່ເໝາະ ສົມ. ໃນ ເວລາ ເປດີ ມຸມ ແຕ່ ບອ່ນ ນ່ັງ ຫາ ແນວ ອງີ ຫຼງັ, ຕ້ອງ ເອາົ ໃຈ ໃສ່ ເພ່ືອ ຮັບປະກັນ ວາ່ ຜູ້ ໃຊ ້ລດົ ເຂນັ ບໍ ່ເລືອ່ນ ໄປ ທາງ ໜາ້ ໃນ ລດົ ເຂນັ. ນ້ີ ສາມາດ ກ່ໍ ໃຫ ້ເກີດ ëການ ຮຸກ ຖíູ ເຊິງ່ສາມາດ ພັດທະນາ ເປນັ ແຜ ກົດທບັ ໄດ້. ການ ອຽ່ງຂອງ ບອ່ນ ນ່ັງ ແລະ ແນວ ອງີ ຫຼງັ(ການ ອຽ່ງ ໃນ ກາງຫາວ) ການ ອຽ່ງຂອງບ່ອນ ນ່ັງ ແລະ ແນວ ອີ ງຫັຼງພ້ອມ ກັນ ສາມາດ ຊ່ວຍ: ï ຈດັ ແນວ ລາໍ ຕົວ ສ່ວນ ເທງິ ແລະ ຫວົ ໃຫ ້ຢູ່ ໃນ ທາ່ ປກົກະຕິ ຫຼງັຈາກ ທາ່ ລາໍ ຕົວ ກົ່ງ ຄງົ ທີ ່ໄດ້ ຖກື ຮອງ ຮັບ ຖາ້ຍັງ ມີ ຄວາມ ເຄັງ່ ບາງ ສ່ວນ ຢູ ່ເທງິ ຫວົ; ï ຈດັ ແນວ ລາໍ ຕົວ ສ່ວນ ເທງິ ແລະ ຫວົ ໃຫ ້ຢູ່ ໃນ ທາ່ ຕ້ັງ ຊ່ື ສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ທີ ່ມີ ລາໍ ຕົວ ອອ່ນຍວບ ຫາຼຍ. ຄວນ ພະຍາຍາມ ເຮດັການ ອຽ່ງບອ່ນ ນ່ັງ ແລະ ແນວ ອງີ ຫຼງັພ້ອມ ກັນ ຖາ້ ທກຸ ການ ຮອງ ຮັບ ອືນ່ ສໍາລັບ ກົກ ແອວ ແລະ ຕົວ ບໍ ່ໄດ້ຜົນ ເທືອ່. ສັງ ເກດ ເບິງ່ ຜົນ ຂອງ ການ ອຽ່ງຢາ່ງ ໃກ້ຊິດ ເພ່ືອ ຕັດ ສິນ ກໍານົດ ມຸມ ທີ ່ດ ີສຸດ ແລະ ມັນ ມີ ຜົນ ແນວ ໃດ . ໃນ ທາ່ ການ ອຽ່ງສຸດ ທາ້ຍ, ຜູ້ ໃຊ ້ລດົ ເຂນັ ຄວນ ຮູ້ສຶກ ສະບາຍ ຕົວ ແລະ ທາ່ ນ່ັງ ຂອງ ເຂົາ ເຈົາ້ ຄວນ ໃກ້ ກັບ ທາ່ນ ປກົກະຕິ ຫາຼຍທ່ີ ສຸດ ເທົາ່ ທີ ່ເປນັ ໄປ ໄດ້ ສໍາລັບ ເຂາົ ເຈົາ້. ແນວ ອີງ ຫັຼງ ແຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອວ ໃຫກ້ານ ຮອງ ຢູ ່ສ່ວນ ເທງິ ຂອງ ກະ ດກູ ກົກ ແອວ ເພ່ືອ ຮັກສາ ໃຫ ້ມັນ ຕັ້ງ ຊ່ື. ໂດຍ ປກົກະຕິ ແລວ້ ມີ ການ ໃຫແ້ຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອວ ຮ່ວມ ກັບ ຖາ້ນ ຮອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ອາດ ຈະ ຖກື ໃຫ ້ຮ່ວມ ກບັ ສາຍຮັດ ກົກ ແອວ ນໍາ ອກີ. ແຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອວ ຄວນ ໃຫກ້ານ ສໍາພັດທີ ່ແໜນ້ ໜາ ຢູດ່າ້ນ ຫຼງັຂອງ ກະດູກ ກົກ ແອວ, ຢູ ່ລະດບັ ຂອງ PSIS, ແລະ ສ່ົງ ເສີມກະດູກ ກົກ ແອວ ໃຫ ້ຢູ ່ໃນ ທາ່ ນ່ັງ ຕ້ັງ ຊື ່ທີປ່ກົກະຕິ. ກວດເບິງ່ວ່າບ່ໍມີການກົດທບັທີແ່ຮງຕ່ໍກັ ບຂໍ ້ກະດູກ ສັນຫັຼງລະຫວ່າງ PSIS ທງັ ສອງ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 87 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ປບັຮບູຊງົ ຂອງ ແນ ວອງີ ຫຼງັ ປບັ ຮູບ ຮ່າງ ຂອງ ແນວ ອງີ ຫຼງັ ເພ່ືອ ຮອງ ຮັບທາ່ ນ່ັງປົກກະຕິ ຂອງ ລາໍ ຕົວ ໄດ້ ດກີ ວາ່ (ສ່ວນ ກ່ົງ ປກົກະຕິ) ຫຼ ືຮອງ ຮັບ ທາ່ ຄງົ ທີ ່ບໍ່ ປກົກະຕິ ຂອງ ລາໍ ຕົວ. ມີ ວທິ ີຕ່າງໆ ເພ່ືອ ປບັ ຮູບ ຮ່າງ ແນວ ອງີ ຫຼງັ ເຊິງ່ລວມມີ: ï ການ ດດັ ແປງ ຜ້າຫຸ້ມ ແນວ ອງີ ຫຼງັ ແລະ ເພ່ີມ ແຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອວ (ຮູບ ປະກອບ ທາໍ ອດິ); ï ການ ໃຫ ້ແນວ ອງີ ຫຼງັທ່ີ ເປນັ ໂຟມ ແບບ ມີ ຮູບ ຮ່າງ ໃສ່ ເທງິ ແນວ ອງີ ຫຼງັ ແບບ ແຂງ; ï ການ ໃຊ ້ແນວ ອງີ ຫຼງັທ່ີ ປບັ ຄວາມ ເຄັງ່ ໄດ້ (ຮູບ ປະກອບທ ີສອງ). ເມ່ື ອປບັ ແລວ້, ແນວ ອງີ ຫຼງັຄວນ ໃຫກ້ານ ສໍາ ພັດທີ ່ເທົາ່ ກັນ ສໍາລັບ ຫຼງັສ່ວນ ລຸມ່, ເຄິງ່ກາງ ແລະ ສ່ວນ ເທງິ. ຖາ້ ທາ່ ປກົກະຕິ ແມນ່ ເປ ັນ ໄປ ໄດ້, ແນວ ອງີ ຫງຼຄວນ ຮອງ ຮັບກະດູກ ກົກ ແອວ ໃນ ທາ່ ຕ້ັງ ຊ່ື, ແລະ ຮອງຮັບ ສ່ວນ ກ່ົງ ປກົກະຕິ ຂອງ ລາໍ ຕົວ. ຖາ້ ທາ່ ປກົ ກະຕິ ເປນັ ໄປ ບໍ ່ໄດ້, ແນວ ອງີ ຫຼງັຄວນ ຮອງ ຮັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ໃຫ ້ຢູ່ ໃນທ່າ ທີ ່ໃກ້ຄຽງ ກັບ ທາ່ ປກົ ກ ະຕິ ທີ ່ສຸດ ເທົາ່ ທີ ່ເປນັ ໄປ ໄດ້. ແນວ ອງີ ຫຼງັທ່ີ ສາມາດ ປບັ ຄວາມ ເຄັງ່ ໄດ້ ການ ເອນ ແນວ ອງີ ຫຼງັ ແນວອງີຫັຼງເອນໄປຫັຼງສາມາດຊ່ວຍຮອງ ຮັບ: ï ສະ ໂພ ກທ່ີບໍ ່ສາມາດ ກ່ົງ ເຂົາ້ ຫາ ຕໍາແໜງ່ການນ່ັງ ປກົກະຕິ ໄດ້ ( ມຸມ ລະຫວາ່ງລໍາ ຕົວ ຫາ ກົກຂາ ຫາຼຍກວ່າ 90 ອງົສາ); ï ກະດູກກົກແອວອຽ່ງໄປຫັຼງຄົງທ່ີ; ï ທາ່ກົງຄົງທ່ີຂອງລໍາຕົວສ່ວນລຸມ່; ï ຮອງຮັບລາໍຕົວທີກ່ົ່ງໄປໜ້າຄົງທ່ີ; ï ຈດັແນວລາໍຕົວ ແລະ ຫວົ. ຖາ້ນຮອງກະດູກຮອງນ່ັງ, ສາຍຮັດກົກແອວ ແລະ/ຫຼ ືຫຼີມ້ຮອງ ຢູ ່ສ່ວນໜາ້ ຂອງ ເບາະ ຮອງ ນ່ັງ ຈະ ຊ່ວຍ ປອ້ງ ກັນ ການ ເລືອ່ນ ໄປ ໜາ້. ກວດ ເບິງ່ ວາ່ການ ເອນ ແນວອງີ ຫຼງັກໍາລັງ ຮອງ ຮັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ໃນ ການຈັດ ແນວ ທີ ່ດ ີສຸດ ທີ ່ເປນັ ໄປ ໄດ້ ສໍາລັບ ເຂາົ ເຈົາ້. ຮັບປະກັນ ວາ່ ມີ ການ ສໍາພັດທີ ່ເທົາ່ ກັນ ລະຫວາ່ງ ຫຼງັຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ແລະ ແນວອງີ ຫຼງັ. ກວດ ເບິງ່ ວາ່ ຜູ້ ໃຊ ້ລດົ ເຂນັ ບໍ ່ເລືອ່ນ ໄປ ໜາ້. ຖາ້ນຮອງກະດູກຮອງນ່ັງ, ສາຍຮັດກົກແອວ ແລະ/ຫຼ ືຫຼີມ້ຮອງ ຢູ່ ສ່ວນໜາ້ ຂອງ ເບາະ ຮອງ ນ່ັງ ຈະ ຊ່ວຍ ປອ້ງ ກັນ ການ ເລືອ່ນ ໄປ ໜາ້. 88 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ໃຫກ້ານ ຮອງ ທີ ່ແໜນ້ ໜາ ເພ່ືອ ຊ່ວຍຮກັສາ ລາໍ ຕົວ ໃຫ ້ຢູ່ ເຄິງ່ກາງຂອງ ແນວ ຮອງ ຮັບ ຫຼງັ. ຖາ້ ມີ ການ ໃຫແ້ຜນ່ ຮອງ ຂ້າງ ລາໍ ຕົວຂາ້ງ ໜຶງ່, ມັກ ຈະ ມີ ການ ໃຫ ້ແຜ່ນ ຮອງ ລາໍ ຕົວ ອກີ ຢູ ່ຂ້າງ ກົງກັນ ຂ້າມ ສະ ເໝີ. ແຜ່ນ ຮອງຂ້າງ ລາໍ ຕົວ ຄວນ ຢູ ່ຕ່ໍາ ກວ່າ ຂ້ີ ແຮ ້(ກົກ ແຂນ) ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຢາ່ງ ໜອ້ຍ 50 ມມ ແລະ ເດ ່ໄປ ໜາ້ ເທົາ່ ທີ ່ຈາໍ ເປນັ ເທົາ່ ນ້ັນ. ຄວນ ມີ ແຮງກົ ດທບັ ທີ ່ເທ່າົ ກັບ ລະຫວາ່ງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ແລະ ແຜ່ນ ຮອງ ແລະ ບໍ່ ມີ ຈດຸ ທີ ່ມີ ແຮງ ກົ ດທບັ ສູງ. ຖາ້ຈໍາ ເປນັ ຕ້ອງ ມີການຮອງທ່ີແໜນ້ໜາ – ເພ່ີມຂະໜາດຂອງ ແຜ່ນ ຮອງ ເພ່ືອ ກະຈາຍ ກາ ນກົ ດທບັ, ແລະ ຮັບປະກັນວ່າ ມີ ການ ຮອງ ທີ ່ພຽງພໍ. ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ຄວນຈະ ບາງ ເທົາ່ ທີ ່ຈະ ເປນັ ໄປ ໄດ້ ເພ່ືອ ອະນຸຍາດ ໃຫ້ ແຂນ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ແ ກວ່ງ ໄປມາ ໄດ້ ຢາ່ງ ອດິສະຫຼະ. ຫຼີມ້ຮອງ ຂ້າງ ລາໍ ຕົວ ໃຫກ້ານ ຮອງ ທີ ່ອອ່ນ ໂຍນ ເພ່ືອ ຊ່ວຍ ຮັກສາ ໃຫ້ ລາໍ ຕົວ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຢູ ່ເຄິງ່ກາ ງ ຂອງ ແນວ ອງີ ຫຼງັ. ເຫຼົາ່ນ້ີ ເປນັ ປະ ໂຫຍ ດ ເມ່ືອ ພຽງ ແຕ່ ຈາໍ ເປນັ ຕ້ອງ ມີ ຈາໍນວນ ການ ຮອງ ຮັບນ້ອຍໆ ເທົາ່ ນ້ັນ. ຫຼີມ້ຮອງ ຂ້າງ ລາໍ ຕົວ ຄວນຊ່ວຍ ຮັກສາ ຜູ້ ໃຊ ້ລດົ ເຂນັ ໃຫ ້ຢູ ່ໃນ ທາ່ ນ່ັງ ທີສົ່ມ ດນຸກັນ (ລາໍ ຕົວ ຢູ ່ເຄິງ່ກາງຂອງ ແນວ ອງີ ຫຼງັ). ຫຼີມ້ຄວນ ຢູ ່ລຸມ່ ຂ້ີ ແຮ ້(ກົກ ແຂນ) ແລະ ເດ ່ໄປ ໜາ້ ເທົາ່ ທີ ່ຈາໍ ເປນັ ເທົາ່ນ້ັນ. ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ທີ ່ໃຊ ້ກັບ ແຜ່ນ ຮອງ ຂ້າງ ກະດູ ກກົກ ແອວ ສາມາດ ໃຊກ້ານ ໃຊ ້ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ຮ່ວມ ກັບ ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ເພ່ືອ ໃຫກ້ານ ຮອງ ສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຜູ້ ທີ ່ມີ ລາໍ ຕົວ ກ່ົງ ໄປ ດາ້ນ ຂ້າງ (ກະດູກ ສັນຫັຼງຂົດ). ມີ ການ ປບັ ແຜ່ນ ຮອງ ເພ່ືອ ໃຫກ້ານ ຮອງ ຢູ່ ສ່ວນ ເທງິ ຂອງ ສ່ວນ ກ່ົງ, ຢູຈ່ອມສຸດ ຂອ ງສ່ວນ ກ່ົງ (ຂ້າງ ກົງກັນຂ້າມ) ແລະ ຢູ ່ພ້ືນ ຂອງ ສ່ວນ ກ່ົງ. ຈາໍ ເປນັ ຕ້ອງ ມີແຜ່ນຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ຢູ ່ທງັ ສອງ ຂ້າງ ເພ່ືອ ຮັກສາ ໃຫ ້ກະດູກ ກົກ ແອວ ຢ່ ູໃຈກາງ ຂອງ ບອ່ນນ່ັງ. ການ ໃຫກ້ານ ຮອງ ຢູ ່ໃນ ທາ່ ປກົກະຕິຂອງ ບາງ ຄນົ ທີ ່ມີ ກະດູກ ສັນຫັຼງຂົດທີ ່ປບັ ປຽ່ນ ໄດ້ ອາດ ຈະ ແກ ້ໄຂ ກະດູກ ກົກ ແອວ ທີ ່ບໍ ່ພຽງ ກັນ ທີ່ ປບັ ປຽ່ນ ໄດ້. ຖາ້ ທາ່ ນ່ັງ ສາມາດ ປບັ ປຽ່ນ ໄດ້, ຜູ້ ໃຊລ້ດົ ເຂນັ ອາດ ຈະ ສາມາດ ນ່ັງ ໃນ ທາ່ ນ່ັງ ປກົກະຕິ ໄດ້. ຖາ້ ທາ່ ນ່ັງ ແມນ່ ຄງົ ທີ,່ ຮອງ ໃຫ ້ນ່ັງ ໄດ້ ໃກ້ ຄຽງ ກັບ ທາ່ປົກກະຕິ ທີ່ ສຸດ ເທົາ່ ທີ ່ຈະ ສະບາຍ ຕົວ. ຮັບປະກັນ ວາ່ ມີ ການກົ ດທບັທີ ່ເທົາ່ ກັນ ລະຫວາ່ງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ແລະ ແຕ່ລະ ແຜ່ນ ຮອງ. ກວດ ເບິງ່ ຈດຸ ກົ ດທບັ ສູງ. ຖາ້ຈໍາ ເປນັ ຕ້ອງ ມີການຮອງທ່ີແໜນ້ໜາ – ເພ່ີມຂະໜາດຂອງ ແຜ່ນ ຮອງ ເພ່ືອ ກະຈາຍ ກາ ນກົ ດທບັ, ແລະ ຮັບປະກັນວ່າ ມີ ການ ຮອງ ທີ ່ພຽງພໍ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 89 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ແນວ ຮອງ ຫຼງັ ແບບ ເປນັ ເບົາ້ ແນວ ຮອງ ຫຼງັ ແບບ ເປນັ ເບົາ້ ສາມາດ ຖກື ໃຊ ້ເພ່ືອ ໃຫກ້ານ ປະຄອງ ຫຼ ືການຮອງ ຮັບສໍາລັບ ທາ່ ຕ່າງໆ ຂອງ ລາໍ ຕົວ ລວມທງັ ການ ລົມ້ ໄປ ໜາ້ ແລະ ລາໍ ຕົວ ກ່ົງ. ແນວ ຮອງ ຫຼງັຕິດ ໃສ່ໂຄງ ຂອງ ລດົ ເຂນັກັບ ແນວ ອງີ ຫຼງັ ຫຼ ືສາຍຮັດ. ທາງ ເລອືກ ນ້ີ ບໍ ່ມີ ໃນ ລະດບັ ປານ ກາງ. ຖາດ ຖາດ ຖາດ ສາມາດ ເປນັ ປະ ໂຫຍ ດ ໃນ ຫາຼຍຮູບ ແບບ ເ ຊ່ິງລວມມີ: ï ໃຫກ້ານ ຮອງ ຮັບ ແຂນ ເຊິງ່ສາມາດ ຊ່ວຍ ຫຼດຸ ແນວ ໂນ້ມທ່ີ ນ້ໍາໜັກ ແຂນ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຈະ ດງຶ ລາໍ ຕົວ ລງົ ລຸມ່ ແລະ ໄປ ໜາ້; ï ໃຫ ້ຜູ້ ໃຊ ້ລດົ ເຂນັ ມີ ພ້ືນ ຜິວ ທີ ່ໃກ້ ກັບ ລາໍ ຕົວ ຂອງ ເຂາົ ເຈົາ້ ເພ່ືອ ເຮດັ ວຽກ/ຫຼິນ້ຢູ່ ເທງິ. ໂດຍ ປກົກະຕິ ແລວ້ ຖາດ ຖກື ວາງ ຕໍາ ແຕ່ງ ຢູ ່ເທງິ ຄວາມ ສູງ ແຂນ ສອກ. ຕໍາແໜງ່ທ່ີສູງກວ່າ ອາດ ຈະ ຖກື ໃຊ ້ຖາ້ ຈດຸປະສົງ ຂອງ ຖາດ ແມນ່ ເພ່ືອ ໃຫກ້ານ ຮອງ ຮັບ ທາ່ ທາງ ເພ່ີ ມ ເຕີມ. ບໍ ່ຄວນ ໃຊ ້ຖາດ ເພ່ືອ ëຈາໍກັດí ຜູ້ ໃຊ ້ລດົ ເຂນັ ໃຫ ້ຢູ ່ໃ ນບ່ອນ ນ່ັງ ຂອງ ເຂ ົາ ເຈົາ້. ຖາດ ບໍ ່ຄວນ ກ່ໍ ໃຫ ້ເກີດ ການ ກົ ດທບັ ໃດໆ ຕ່ໍ ກັບ ຜູ້ ໃຊ.້ ແນວ ປະຄອງ ຫວົ ແນວ ປະຄອງ ຫວົແບບ ແບນ ແນວ ປະຄອງ ຫວົ ແບບ ແບນ ໃຫ ້ບອ່ນ ພັກຜ່ອນສໍາລັບ ຫວົ ແລະ ຢດຸ ບໍ ່ໃຫ ້ຫ ົລົມ້ ໄປ ທາງ ຫຼງັ. ແນວ ປະຄອງ ຫວົຄວນ ໃຫກ້ານ ຮອງ ຮັບ ທີ ່ດ ີ ໃນ ຂະ ນ ທີ ່ຜູ້ ໃຊບ້ໍ ່ເໜງັຕີງ ແລະ/ຫຼື ເຄືອ່ນ ເໜງັ. ແນວ ປະຄອງ ຫວົຄວນ ສໍາພັດ ກັບ ຫວົ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ຢູ ່ພ້ືນ ຂອງ ກະ ໂຫກຼຫົວ. ກວດ ເບິງ່ ວາ່ ແນວ ປະຄອງ ຫວົກໍາລັງ ໃຫກ້ານ ຮອງ ຮັບ ໃນ ແນວ ທີ ່ຖກືຕ້ອງ – ແລະ ບໍ ່ຍູ ້ຫວົ ຂອ ງຜູ້ ໃຊ ້ລດົ ເຂນັ ໄປ ທາງ ໜາ້ ຫຼ ືປອ່ຍ ໃຫ ້ຫວົ ຂອງ ເຂາົ ເຈ້າົ ລົມ້ ໄປ ທາງ ຫຼງັ. ຫຼກີ ເວັນ້ການ ໃຫກ້າ ນຮອງ ຮັບ ຕ່ໍ ກັບ ດາ້ນ ໜາ້ ຂອງ ຫວົ ຂອງ ຜູ້ ໃຊລ້ດົ ເຂນັ. ແນວ ປະຄອງ ຫວົແບບ ມີ ຮູບ ຊົງ ແນວ ອງີ ຫ ົວ ແບບ ມີ ຮູ ບຊງົ ໃຫກ້ານ ຮອງ ຮັບ ຫາຼຍກວ່າ ແນວ ປະຄອງ ຫວົແບບ ແບນ ໂດຍ ການ ໃຫ ້ໂຄງ ຮ່າງ ອອ້ມ ພ້ືນກະ ໂຫກຼຫົວຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ແນວ ຮອງ ຂາ ສ່ວນລຸ່ມ ແນວ ຮອງ ເສີມ ບອ່ນ ວາງ ຕີນ ສາມາດ ໃຊ ້ແນວ ຮອງ ເສີມ ບອ່ນ ວາງ ຕີນ ເມ່ືອ ຕີນ ຂ້າງ ໜຶງ່ ຫຼ ືທງັ ສອງ ຂ້າງ ບໍ ່ສາມາດ ຮອດ ບອ່ນ ວາ ງຕີນ ( ແລະ ບອ່ນ ວາງ ຕີນ ໄດ້ ຖກື ປບັ ຂ້ຶນ ສູງ ສຸດ ແລວ້). ກວດ ເບິງ່ ວາ່ ມີ ການ ສໍາພັດທີ ່ເທົາ່ກັນ ຢູ່ ກ້ອງ ຕີນ ທງັ ສອງ ຂ້າງ. 90 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ຫຼີມ້ຮອງ ບອ່ນ ວາງ ຕີນ ສາມາດ ໃຊຫ້ຼີມ້ຮອງ ບອ່ນ ວາງ ຕີນ ເພ່ືອ ຮອງ ຮັບ ທາ່ ຄງົ ທີ ່ທີ ່ໍບໍ ່ເປນັ ປກົກະຕິ ຂອງ ຕີນ. ຫຼີມ້ຮອງ ບອ່ນ ວາງ ຕີນ ສາມາດ ຊ່ວຍ ປອ້ງ ກັນ ການ ປຽ່ນ ແປງ ເພ່ີມ ອກີ ໃນ ຂ້ໍ ຕີນ. ຈດຸປະສົງ ຂອງຫ້ີຼມຮອງ ບອ່ນ ວາງ ຕີນ ແມນ່ ເພ່ືອ ເພ່ີມບໍລ ິເວນ ສໍ າ ພັດຂອງ ບອ່ນ ວາງ ຕີນ ກັບ ຕີນ ຂອງ ຜູ້ ໃຊ້ ລ ົດ ເຂັນ. ຫຼີມ້ຮອງ ບອ່ນ ວາງ ຕີນຖືກ ເຮັດ ເປນັ ສະ ເພາະ ບກຸຄົນ ໂດຍຂຶນ້ ກັບ ການ ຮອງ ຮັບ ທີ່ ຕີນ ຂອງ ຜູ້ ໃຊ້ ລດົ ເຂັນຕ້ອງການ. ກວດ ເບິງ່ ວາ່ ມີ ການ ສໍາພັດທີ ່ເທົາ່ກັນ ຢູ່ ກ້ອງ ຕີນ ທງັ ສອງ ຂ້າງ. ແນວ ຮອງ ຂາ ສ່ວນລຸມ່ ສາມາດ ໃ ຊ້ ແນວ ຮອງ ຂາ ສ່ວນ ລຸມ່ ຕ່າງໆ ເພ່ືອ ຮອງ ຮັບ ທາ່ ຜິດ ປກົກະຕິ ຄງົ ທີ ່ຂອງ ຂາ ສ່ວນ ລຸມ່ ລ ວມທງັ ຫວົ ເຂົາ່ ທີ ່ບໍ ່ສາ ມາ ດກ່ົງ ເຂົາ້ ຫາ 90 ອງົສາ (ມຸມ ລາໍ ຕົວ ຫາ ກົກຂາ ຫາຼຍກວ່າ 90 ອງົສາ). ມີ ການ ອະທບິາຍວທິ ີແກ ້ໄຂ ຕ່າງໆ ແລະ ຄວາມ ເໝາະ ສົມ ຂອງ ພວກ ມັນ ເພ່ີມ ເຕີມ ໃນ ຫວົ ຂ້ໍ ການ ກະກຽມຜະລິດ ຕະພັນ (ລດົ ເຂນັ) ສາຍຮັດ ສາຍຮັດ ກົກ ແອວ ສາຍຮັດ ກົກ ແອວ ຊ່ວຍ ຈບັ ຢດຶກະດູກ ກົກ ແຂວ້ ໃຫ ້ເຂົາ້ ທີ.່ ມັນ ເປ ັນ ປະ ໂຫຍ ດ ໂດຍ ສະ ເພາະ ສໍາລັບ ຄນົ ທີ ່ມີ ການ ເຄືອ່ນ ເໜງັ ທີ ່ຄວບ ຄມຸ ບໍ ່ໄດ້ ແລະ/ຫຼ ື ແນວ ໂນ້ມທ່ີ ຈະ ເລືອ່ນ ໄປ ໜາ້. ສາຍຮັດ ກົກ ແອວ ມັກ ຈະ ຖກື ໃຊ ້ຮ່ວມ ກັບ ຖາ້ ນຮອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ແຜ່ນ ຮອງ ຫຼງັກະດູກ ກົກ ແອວ. ສາຍຮັດ ກົກ ແອວ ຄວນ ໃຫກ້ານ ສໍາ ພັດ ເທົາ່ ກັນ ຢາ່ງ ແໜນ້ໜາ. ບໍ ່ຄວນ ມີ ຈດຸ ທີ ່ມີ ການ ກົ ດທບັ ສູງ. ການ ຮອງ ເສີມ ຢູ່ ເທງິ ສາຍຮັດ ບອ່ນ ທີ ່ມັນ ສໍາພັດກັບ ກົກຂາ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ແມນ່ ສ່ິງ ສໍາຄັນ. ບອ່ນ ທີ ່ຕິດ ສາຍຮັດ ໃສ່ ລດົ ເຂນັ ຈະ ມີ ຜົນ ຕ່ໍ ກັບ ມຸມ/ທດິ ທາງ ຂອງ ການດຶງ. 45º 90º ມຸມ ອາດ ຈະ ຢູ ່ລະຫວາ່ງ 45 ຫາ 90 ອງົສາ. ມຸມ ທີ ່ດ ີທີ ່ສຸດຈະ ແຕກ ຕ່າງ ກັນ ໄປ ໂດຍ ຂ້ຶນ ກັບ ຄວາມ ຈາໍ ເປນັ ຕົວ ຈງິ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ຈົງ່ປະ ເມີນ, ໂອ ້ລມົ ແລະ ຖາ້ ເປນັ ໄປ ໄດ້ ທດົ ລອງ ມຸມ ຂອງ ສາຍຮັດ ກົກ ແອວ ກັບ ຜູ້ ໃຊລ້ດົ ເຂນັ ສະ ເໝີ ເພ່ືອ ເບິງ່ ວາ່ ມຸມ ໃດມີ ປະສິດທ ິຜົນ ທີ ່ສຸດ ແລະ ສະບາຍ ຕົ ວທີ ່ສຸດ ສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 91 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ສາຍຮັດ ສ່ີ ຈດຸປອ້ງ ກັນການ ອຽ່ງ ໄປ ທາງ ໜາ້ ສາຍຮັດ ສ່ີ ຈດຸປອ້ງ ກັນການ ອຽ່ງ ໄປ ໜາ້ ໃຫກ້ານ ຮອງ ຮັບ ສໍາລັບຜູ້ ໃຊ ້ລດົ ເຂນັ ທີ ່ມີ ກະດູກ ກົກ ແອວ ອຽ່ງ ໄປ ໜາ້. ສາຍຮັດ ສາມາດ ຊ່ວຍ ນໍາ ກະດູກ ກົກ ແອວ ໄປ ສູ່ ທາ່ ນ່ັງ ປກົກະຕິ ກວ່າ ຫຼ ື ໃຫກ້ານ ຮອງ ຮັບ ເພ່ືອ ປອ້ງ ກັນ ບໍ ່ໃຫ ້ກະດູກ ກົກ ແອວ ອຽ່ງ ໄປ ໜາ້ ເພ່ີມ ເຕີມ ອກີ. ສາມາດ ໃຫສ້າຍຮັດ ນ້ີຮ່ວມ ກັບ ຫຼີມ້ຮອງ ປອ້ງ ກັນ ການ ອຽ່ງ ໄປ ໜາ້ ຢູ ່ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ຈົງ່ ຮັບ ຊາບ ວາ່ ສາຍຮັດ ເກາະ ລງົ ລຸມ່ ໃສ່ ຮາວບ່ອນ ນ່ັງ; ແລະ ໄປ ຫຼງັ ໃສ່ ແລວ ຕ້ັງ ຊ່ື ຂອງ ແນວ ອ ີງຫັຼງ. ສາຍຮັດ ບໍ ່ຄວນ ສາມາດ ເລືອ່ນ ຂ້ຶນ ຫາ ທອ້ງ ໄດ້. ມັນ ສໍາຄັນ ວາ່ ທກຸ ສາຍຮັດ ເຊິງ່ ໃຫກ້ານ ຮອງ ຮັບ ຜ່ານສອງ ASIS ແມນ່ມີ ການ ຮອງ ເສີມ ທີ ່ດ ີ ເພ່ືອ ຫຼດຸຜ່ອນຄວາມ ສ່ຽງ ເກີດ ແຜ ກົດ ທບັ. ສາຍຮັດ ບ ີແຄງ່ ສາຍຮັດ ບ ີແຄງ່ ສາມາດ ຊ່ວຍ ປອ້ງ ກັນ ຂາ ທີ ່ຍາວ ກວ່າ ບໍ ່ໃຫ ້ລົມ້ ໄປ ຫຼງັ. ບາງ ຄັງ້ ມີ ການ ໃຫສ້າຍຮັດ ເຫຼົາ່ນ້ີ ເປນັ ມາດຕະຖານ ກັບ ລດົ ເຂນັ. ສາຍຮັດ ຕີນ ປະ ເພດ ຕ່າງໆ ໃຫກ້ານ ຮອງ ຮັບ ເພ່ືອ ຊ່ວຍ ເຮດັ ໃຫ ້ຕີນ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ໝ້ັນຄົງ ແລະ ຊ່ວຍ ຮັກສາ ຕີນ ບໍ ່ໃຫ້ ເຄືອ່ນ ໄປ ໜາ້/ ໄປ ຫຼງັ. ສາຍຮັດ ຕີນ – ຢູ ່ຫຼງັສ້ົນ ນ່ອງ ສາຍຮັດ ຢູ ່ຫຼງັສ້ົນ ນ່ອງ ຊ່ວຍ ປອ້ງ ກັນບ່ໍ ໃຫ ້ຕີນ ເລືອ່ນ ໄປ ທາງ ຫຼງັ. ນ້ີ ສາມາດ ໃຊຮ່້ວມ ກັບ ສາຍຮັດ ບ ີແຄງ່ ເພ່ືອ ໃຫກ້ານ ຮອງ ຮັບ ຫາຼຍຂ້ຶນ. ສາຍຮັດ ຕີນ ຄວນ ໃຫກ້ານ ກົ ດທບັທີ ່ເທົາ່ ກັນ ແລະ ມີ ການ ຮອງ ທີ ່ດ ີ – ໂດຍ ສະ ເພາະ ຖາ້ ຜູ້ ໃຊ ້ລດົ ເຂນັ ບໍ ່ໃສ່ ເກີບ. ສາຍຮັດ ຕີນ – ອອ້ມ ຂ້ໍ ຕີນ ສາຍຮັດ ຕີນ ອອ້ມ ຂ້ໍ ຕີນ ຊ່ວຍ ຮັກສາ ບໍ ່ໃຫ ້ຕີນ ເຄືອ່ນ ໄປ ໜາ້ ແລະ ບໍ ່ໃຫ ້ສ້ົນ ນ່ອງ ຍກົ ຂ້ຶນ. ສາຍຮັດ – ເທງິ ຫຼງັຕີນ ສາຍຮັດ ເທງິ ຫຼງັຕີນ ຊ່ວຍ ຮັກສາ ບໍ ່ໃຫ ້ນ້ີວ ຕີນ ຍກົ ຂ້ຶນ. 92 PSD ຈຸດປະສົງ ຄວາມ ພໍດີ ສາຍຮັດ ບາ່ ໄຫ່ຼ ສາຍຮັດ ບາ່ ໄຫ່ຼສາມາດ ຊ່ວຍ ຮັກສາ ໃຫ ້ລາໍ ຕົວ ຕ້ັງ ຊ່ື ໃນ ເວລາ ການ ຮອງ ກະດູກ ກົ ກ ແອວ, ການ ຮອງ ລາໍ ຕົວ ແລະ ການ ອຽ່ງບອ່ນ ນ່ັງ ແລະ ຫຼງັ ບໍ ່ໄດ້ ຮັບ ຜົນ. ສາຍຮັດ ບາ່ ໄຫ່ຼທີ ່ສະ ແດງ ໃນ ຮູບ ປະ ກອບ ມີ ສາຍຮັດ ໜາ້ ເອກິ ເ ຊ່ີ ງ ໃຫກ້ານປະຄອງ ແລະ ຮອງ ຮັບ ເພ່ີມ ເຕີມ. ສາຍຮັດ ໜາ້ ເອກິ ຍງັ ຊ່ວຍ ຮັກສາ ໃຫ ້ສາຍຮັດ ບາ່ ໄຫ່ຼຢູ ່ໃນ ຕໍາ ແ ໜງ່ທ່ີ ຖກືຕ້ອງ. ສາຍຮັດ ບາ່ ໄຫ່ຼຄວນ ຖກື ໃຊ ້ຮ່ວມ ກັບ ສາຍຮັດ ກົກ ແອວ ສະ ເໝີ. ຢາ່ ກໍານົດ ໃຊສ້າຍຮັດ ບາ່ ໄຫ່ຼ ໂດຍ ບໍ ່ມີ ສາຍຮັດ ກົກ ແອວ. ຖາ້ ໃຊ ້ໂດຍ ບໍ ່ມີ ສາຍຮັດ ກົກ ແອວ, ຜູ້ ໃຊ ້ສາມາດ ເ ລືອ່ນ ລງົ ແລະ ສາຍຮັດ ສາມາດ ກ່ໍ ໃຫ້ ເກີດການບີບຮດັ ໄດ້. ກ ວດ ເບິງ່ ວາ່ ມີ ການ ຮອງ ພຽງພໍ ໃນ ບອ່ນ ທີ ່ສາຍຮັດ ໄ ຂວບ່າ່ ໄຫ່ຼຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ສາຍຮັດ ໜາ້ ເອກິ (ດັງ່ທ່ີ ສະ ແດງ ໃນ ຮູບ ປະກອບ) ສາມາດ ຊ່ວຍ ຮັກສາ ໃຫ ້ສາຍ ຮັບ ບາ່ ໄຫ່ຼ ເຂົາ້ ທີ.່ ສາຍຮັດ ບາ່ ໄຫ່ຼຄວນຮັດ ຢູ ່ຄວາມ ສູງ ດຽວ ກັນ ຫຼ ືສູງ ກວ່າ ບາ່ ໄຫ່ຼຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ. ນ້ີ ຫຼກີ ເວັນ້ສາຍຮັດ ທີ ່ກົດ ແຮງ ຮັດ ລງົ ໃສ່ ບາ່ ໄຫ່ຼຂອງຜູ້ ໃຊ ້ລດົ ເຂນັ ໃນ ເວລາ ຮັດ ຢູ.່ ກາ ນ ບັນທຶກ ອຸປະກອນ PSD ໃນ ແບບ ຟອມການ ກໍານົດ ໃຊ້ (ການ ເລືອກ) ລົດ ເຂັນ ລະດັບ ປານ ກາງ ຈຸດປະສົງ ຂອງ ແບບ ຟອມກໍານົດ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປາ ນກາງ ແມ່ນ ເພ່ືອ ໃຫ້ ຂ້ໍ ມູນ ທີ່ ຈະ ແຈ້ງ ແກ່ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ທີ່ ກະກຽມ ລົດ ເຂັນ ກ່ຽວ ກັບ: ï ປະ ເພດ , ຂະໜາດ ແລະ ການ ຕິດ ຕ້ັງ ລົດ ເຂັນ ( ເວົ້າ ເຖິງ ກ່ອນ ນ້ີ); ï ປະ ເພດ ແລະ ຂະໜາດຂອງ ເບາະ ຮອງ ນ່ັງ ( ເວົ້າ ເຖິງ ກ່ອນ ນ້ີ ເຊ່ັນ ກັນ); ï ອຸປະກອນ PSD ຫຼື ການ ດັດ ແປງ ທີ່ ຈໍາ ເປັນ. ຂ້ໍ ມູນ ທີ່ ໃຫ້ຢູ່ ໃນ ແບບ ຟອມການ ກໍານົດ ໃຊ້ ລົດ ເຂັນລະດັບປານກາງ ຍິ່ງ ລະອຽດ ເທົ່າ ໃດ, ລົດ ເຂັນ ກ່ໍ ຈະ ຖືກ ກະກຽມ ໄດ້ ຖືກຕ້ອງ ເທົາ ນ້ັນ ສໍາລັບ ກາ ນປັບ ໃຫ້ ເໝາະ ສົມ ຄັ້ງ ທໍາ ອິດ. ເພາະວ່າ ສາມາດ ມີ ຄວາມ ແຕກ ຕ່າງຢ່າງຫຼວງຫຼາຍ ໃນ ອຸປະກອນ PSD ທີ່ ຖືກ ກໍານົດ ໃຊ້, ëອຸປະກອນ PSD ຫຼື ການ ດັດ ແປ ງທ່ີ ຈໍາ ເປັນí ແມ່ນ ສ່ວນ ສັບສົນ ທີ່ ສຸດ ຂອງ ແບບ ຟອມການກໍານົດ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປານ ກາງ. ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ໃຊ້ ëອຸປະກອນ PSD ຫຼື ການ ດັດ ແປງ ທີ່ ຈໍາ ເປັນí ຂອງ ແບບ ຟອມການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ເພ່ືອ: ï ເລືອກ ວ່າອຸປະກອນ PSD ໃດ ແດ່ ທີ່ ພວກ ເຂົາ ຕ້ອງການ ກໍານົດ ໃຊ້/ ເລືອກ (ໂດຍ ໃຊ້ກ່ອງ ໝາຍ ເອົາ) ຈາກ ລາຍການ ອຸປະກອນ PSD ທີ່ ໃຊ້ ທົ່ວ ໄປ. ນອກ ນ້ັນ ຍັງ ມີ ບ່ອນ ຫວ່າງ ເພ່ືອ ລະບຸ ອຸປະກອນ PSD ປະ ເພ ດອື່ນ ຢູ່ ກ້ອງ ຂ້ໍ ëອື່ນໆí; ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 93 ï ແຕ້ມ ຜ່ານ ຮູບ ແຕ້ມ ເປັນ ເງົາ ເພ່ືອ ສະ ແດງ ຮູບ ຮ່າງ ແລະ ໃຫ້ ຂະໜາດ ສໍາລັບ ອຸປະກອນ PSD ທີ່ ພວກ ເຂົາ ໄດ້ ກໍານົດ ໃຊ້ ( ເລືອກ); ï ຂຽນ ຫຼື ແຕ້ມຮ່າງ ຂ້ໍ ມູນ ເພ່ີມ ເຕີມ ຕ່າງໆ. ໝາຍ ເຫດ: ແບບຟອມການກໍານົດໃຊ້ລົດເຂັນລະດັບປານ ກາງ ບໍ່ ຈໍາ ເປັນ ຕ້ອງ ບອກ ວ່າ ຄວນ ເຮັດ ອຸປະກອນ PSD ແນວ ໃດ. ສາມາດ ຕັດສິນ ສິງ ນ້ີ ໃນ ການ ໂ ອ້ລົມ ກັນ ລະຫວ່າງ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ທີ່ ກະກຽມ ລົດ ເຂັນ ກັບ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຜູ້ ທີ່ ໄດ້ ດໍາ ເນີນ ການ ປະ ເມີນ ຜົນ. ຂ້າງ ລຸ່ມ ແມ່ນ ສອງ ຕົວຢ່າງ ຂອງສ່ວນ ‘ອຸປະກອນ PSD ຫືຼ ການ ດັດ ແປງ ທ່ີ ຈໍາ ເປັນ’ຂອງ ແບບ ຟອມການ ກໍານົດ ໃຊ້ ລົດ ເຂັນ ລະດັບປານ ກາງ (ບ່ໍ ລວມ ເອົາຂະໜາດ). ລາຍການ ກວດ ສໍາລັບ PSD ອະທິບາຍ/ ແຕ້ມ ຮູບ ແລະ ບອກ ຂະໜາດ ບ່ ອ ນ ນັ່ ງ/ ເບ າະ ຮ ອ ງ ນັ່ ງ ເພ່ີມ ບ່ອນ ນ່ັງ ແຂງ ຕາ ຍຕົວ ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ (=3 ລົບ 12) ສ່ວນ ໜ້າ ບ່ອນ ນ່ັງ ທີ່ຫຼຸດຕ່ໍາລົງ L R ສ່ວນ ໜ້າ ບ່ອນ ນ່ັງ ທີ່ ຍົກສູງ ຂ້ຶນ ຫຼີ້ມຮອງ ສໍາລັບ ການ ອ່ຽງ ໄປທາງ ໜ້າ ແນວ ຮອງ ເສີມຢູ່ ກ້ອງ ກະດູກ ກົກ ແອວ L R ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ (= 2) L R ຫຼີ້ມຮອງ ກົກຂາ ດ້ານ ນອກ L R ແຜ່ນ ຮອງ ກົກຂາ ດ້ານ ນອກ L R ຫຼີ້ມຮອງ ກົກຂາ ດ້ານ ໃນ (= 10) ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ (= 10) ອື່ນໆ ອື່ນໆ ບ່ ອ ນ ນັ່ ງ ແ ລ ະ ແ ນ ວ ອີ ງ ຫຼັ ງ ມຸມ ເປີດ ລະຫວ່າງ ບ່ອນ ນ່ັງ ຫາ ແນວ ອີງ ຫຼັງ ການ ອ່ຽງ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງ (ການ ອ່ຽງ ໃນ ກາງຫາວ) ແ ນ ວ ອີ ງ ຫຼັ ງ ເພ່ີມ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ຕາ ຍຕົວ ແຜ່ນ ຮອງ ຫຼັງກະດູກ ກົກ ແອວ (= 9) ປັບຮູບຊົງ ຂອງ ແນ ວອີງ ຫຼັງ ແນວ ອີງ ຫຼັງທ່ີ ສາມາດ ປັບ ຄວາມ ເຄັ່ງ ໄດ້ ການ ເອນ ແນວ ອີງ ຫຼັງ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ (= 7) L R ຫຼີ້ມຮອງ ຂ້າງ ລໍາ ຕົວ(= 7) L R ອື່ນໆ 94 ລາຍການ ກວດ ສໍາລັບ PSD ອະທິບາຍ/ ແຕ້ມ ຮູບ ແລະ ບອກ ຂະໜາດ ຖ າດ / ບ່ ອ ນ ວ າງ ແ ຂ ນ ຖາດ ດັດ ແປງ ບ່ອນ ວາງ ແຂນ L R ອື່ນໆ ແ ນ ວ ປ ະ ຄ ອ ງ ຫົ ວ ແນວ ປະຄອງ ຫົວ ແບບ ແບນ (= 11) ແນວ ປະຄອງ ຫົວ ແບບ ມີ ຮູບຊົງ (= 11) ອື່ນໆ ແ ນ ວ ຮ ອ ງ ຂ າ ສ່ ວ ນ ລຸ່ ມ ແນວ ຮອງ ເສີມ ບ່ອນ ວາງ ຕີນ L R ຫຼີ້ມຮອງ ບ່ອນ ວາງ ຕີນ L R ແນວ ຮອງ ຂາ ສ່ວນລຸ່ມ L R ອື່ນໆ ສ າຍ ຮັ ດ ສາຍຮັດ ກົກ ແອວ ສາຍຮັດ ບີ ແຄ່ງ ສາຍຮັດ ຕີນ L R ສາຍຮັດ ບ່າ ໄຫ່ຼ ອື່ນໆ ການ ກໍານົດ ໃຊ້ (ການ ເລືອກ) ອຸປະກອນ PSD – ການ ເຮັດ ໃຫ້ ກະດູກ ກົກ ແອວ ໝ້ັນຄົງ ຈໍານວນ ອຸປະກອນ PSD ຖືກ ໃຊ້ ເພ່ືອ ໃຫ້ການ ຮອ ງຮັບ ແກ່ ກະດູກ ກົກ ແອວ. ມັນ ສໍາຄັນ ໃນ ການ ຈື່ ວ່າ ເຖິງ ແມ່ນອຸປະກອນ PSD ສາມາດ ຖືກ ໃຊ້ ແຍກ ກັນ ຕ່າງຫາກ, ແຕ່ຫຼາຍໆ ອຸປະກອນ PSD ໃຊ້ ໄດ້ ຮ່ວມ ກັນ. ຊ່ວງ ຝຶກ ອົບຮົມ ນ້ີ ອະ ທິບາຍ ບັນຫາ ທ່າ ທາງ ຕ່າງໆ ທີ່ ກ່ຽວຂ້ອງ ກັບ ກະດູກ ກົກ ແອວ ແລະ ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ທີ່ ເປັນ ໄປ ໄດ້. ການ ເຮັດ ໃຫ້ ກະດູກ ກົກ ແອວ ໝ້ັ ນຄົງ ກ່ອນ ແມ່ນ ສ່ິງ ສໍາ ຄັນ ທ່ີ ສຸດ ທ່ີ ຕ້ອງ ເຮັດ ເພ່ືອ ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ໄດ້ ຕ້ັງ ຊ່ື ï ໃນ ເວລາ ທີ່ ກະດູກ ກົກ ແອວ ບ່ໍ ຢູ່ ໃນ ທ່າ ຕ້ັງ ຊ່ື, ກ່ໍ ຈະ ມີ ການ ປ່ຽນ ແປງ ຕ່ໍ ກັບ ທ່າ ລໍາ ຕົວ ແລະ ສະ ໂພ ກ ເຊັ່ນ ກັນ. ï ດ້ວຍ ເຫດຜົນ ນ້ີ, ການ ຮອງ ຮັບ ຫຼື ການ ເຮັດ ໃຫ້ ກະດູກ ກົກ ແອວ ໝ້ັ ນຄົງ ຈິ່ງ ແມ່ນ ສ່ິງ ສໍາ ຄັນ ທີ່ ສຸດ ທີ່ ຕ້ອງ ເຮັດ ເພ່ືອ ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ໄດ້ ຕ້ັງ ຊ່ື. ï ການ ຮອງ ຮັບ ທີ ່ໃຫ ້ຢູ ່ກະດູກ ກົກ ແອວ ສາມາດ ຫຼດຸຄວາມ ຕ້ອງການ ສໍາລັບ ການ ຮອ ງຮັບຢູ ່ບອ່ນ ອືນ່. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 95 ບັນຫາ: ກະດູກ ກົກ ແອວ ອ່ຽງ ໄປ ດ້ານ ຫັຼງ ແລະ/ ຫືຼ ເລ່ືອນ ໄປ ໜ້າ ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ເພ່ືອນໍາເອົາການອ່ຽງຂອງກະດູກກົກແອວມາສູ່ທາ່ນ່ັງປົກກະຕິກວ່າ, ໂດຍປກົກະຕິແລວ້ ຈາໍເປັນຕ້ອງມີການປະຄອງຫືຼຮອງຮັບຢູສ່ອງບໍລເິວນ: ï ຢູ່ດ້ານຫັຼງຂອງກະດູກກົກແອວຢູ່ລະດັບ PSIS; ï ຢູດ່າ້ນໜ້າຂອງກະດູກກົກແອວຢູກ່ະດູກຮອງນ່ັງ (ປຸມ່ ນ່ັງ ກະດູກ ກ້ົນ). ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ໃຫ້ການ ຮອງ ຮັບຢູ່ ດ້ານ ໜ້າຂອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ຊ່ວຍ: ï ຮັກສາ ໃຫ້ ກະດູ ກກົກ ແອວ ຕ້ັງ ຊ່ື; ï ຢຸດ ກະດູກ ກົກ ແອວ ບໍ່ ໃຫ້ ເລື່ອນ ໄປ ທາງ ໜ້າ; ï ຫຼຸດຜ່ອນແນວໂນ້ມໃນການນ່ັງດ້ວຍທ່າຫັຼງຂົດ. ຖາ້ນ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຄວນ ນ່ັງ ແປະ ກັບ ດາ້ນ ໜາ້ ຂອງ ກະດູກ ຮອງ ນ່ັງ. ແຜ່ນ ຮອງ ຫັຼງກະດູກກົກ ແອວ ໃຫກ້າ ນຮອງ ຮັບຢູ ່ສ່ວນ ເທງິ ຂອງ ກະດູກ ກົກ ແອວ (ຢູ ່ລະດບັ PSIS) ແລະ ຊ່ວຍຮກັສາ ໃຫ ້ກະດູກ ກົກ ແອວ ຕ້ັງ ຊ່ື. ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ແຜ່ນຮອງ ຫຼັງກະດູກ ກົກ ແ ອວມັກ ຈະ ຖືກ ໃຊ້ ຮ່ວມ ກັນ ເພ່ືອ ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ລົດ ເຂັນ ນ່ັງ ດ້ວຍ ກະດູກ ກົກ ແອວ ຕ້ັງ ຊ່ື ກວ່າ ແລະ ມີ ຄວາມໝ້ັນຄົງ ກວ່າ. ສາຍຮັດ ກົກ ແອວ ສາມາດ ໃຫ້ການ ຮອ ງຮັບ ເພ່ີມ ເຕີມ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ການ ເຄື່ອນ ເໜັງ ທີ່ ຄວບ ຄຸມ ບໍ່ ໄດ້ ແລະ/ຫຼື ແນວ ໂນ້ມທ່ີ ຈະ ເລື່ອນ ໄປ ໜ້າ. ສາຍຮັດ ກົກ ແອວ ຊ່ວຍຮັກສາ ໃຫ້ ກະດູກ ກົກ ແອວ ເຂົ້າ ທີ່, ເພ່ືອ ໃຫ້ ຖ້າ ນຮອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ແຜ່ນ ຮອງ ຫຼັງກະດູກ ກົກ ແອວ ສືບ ຕ່ໍ ໃຫ້ການ ຮອງ ຮັບ. 96 ບັນຫາ: ກະດູກ ກົກ ແອວອ່ຽງ ໄປ ທາງ ຂ້າງ (ກະດູ ກກົກ ແອວບ່ໍ ພຽງ ກັນຄົງ ທ່ີ) ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ຈໍາ ເປັນ ຕ້ອງ ມີ ແນວ ຮອງ ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ກົກຂາ ທີ່ ສູງ ກວ່າ ເພ່ືອ: ï ເພ່ີມ ຄວາມ ໝ້ັນຄົງ ໃຫ້ ແກ່ຜູ້ ໃ ຊ້ລົດ ເຂັນ; ï ຊ່ວຍ ຫຼີກ ເວັ້ນທ່າ ນ່ັງ ທີ່ ບໍ່ ປອດ ໄພ ຢູ່ ຂ້າງ ທີ່ ຕ່ໍາ ກວ່າ ຂອງ ກະດູກ ກົກ ແອວ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ແນວ ຮອງ ເສີມ ຢູ່ ກ້ອງ ກະດູກ ກົກ ແອວ ຊ່ວຍ : ï ເພ່ີມ ຄວາມ ໝ້ັນຄົງ ໃຫ້ ແກ່ຜູ້ ໃ ຊ້ລົດ ເຂັນ; ï ຫຼີກ ເວັ້ນການ ກົ ດທັບ ທີ່ ບໍ່ ປອດ ໄພ ຕ່ໍ ກັບ ດ້ານ ຕ່ໍາ ກວ່າ ຂອງ ກະດູກ ກົກ ແອວ. ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ໃຫ້ການ ຮອງ ຮັບ ເພ່ີມ ເຕີມ ສໍາລັບ ກະດູກ ກົກ ແອວ ແລະ ຄວນ ຖືກ ເພ່ີມ ໃຫ້ ສໍາລັບ ທຸກ ຄົ ນທ່ີ ມີ ແນວ ຮ ອງ ເສີມ ຢູ່ ກ້ອງກະດູກ ກົກ ແອວ. ບັນຫາ: ກະດູກ ກົກ ແອວ ຍ້າຍ ໄປ ຂ້າງ ໜ່ຶງ ບັນຫາ ນ້ີ ມັກ ຈະ ກ່ຽວ ຂ້ອງ ກັບ ບັນຫາ ທ່າ ທາງ ອື່ນ. ໃນ ສອງ ຮູບ ປະກອບ ທ່ານ ສາມາດ ເຫັນ: ï ຜູ້ ຊາຍ ຄົນ ດຽວ ກັນ ຈາກ ກ່ອນ ນ້ີ – ຜູ້ ທີ່ ມີ ກະດູກ ກົກ ແອວ ອ່ຽງ ໄປ ທາງ ຂ້າງ (ກະດູກ ກົກ ແອວ ບໍ່ ພຽງ ກັນ ຄົງ ທີ່) ແລະ ກະດູກ ກົກ ແອວ ຂອງ ລາວ ອ່ຽງ ໄປ ຊ້າຍ ຫຼາຍກວ່າ; ï ແມ່ຍິງທ່ີ ມີ ກະດູກ ສັນຫັຼງກ່ົງ ໄປ ທາງ ຂ້າງ, ກະດູກ ກົກ ແອວ ຂອງລາວ ຍັງ ອ່ຽງ ໄປ ທາງ ຊ້າຍຫຼາຍກວ່າ ນໍາ ອີກ. ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ສາມາດ ໃຫ້ ແນວ ປະຄອງ ຫຼືຮອ ງຮັບ ຢູ່ ທາງ ຂ້າງ ຂອງ ທັງ ສອງ ສະ ໂພ ກ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 97 ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ແຜ່ນ ຮອງຂ້າງກະດູກ ກົກ ແອວ : ການ ໃຫ້ ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ສໍາລັບ ເດັກນ້ອຍ ເດັກ ນ້ອຍໆ ຄວນ ນ່ັງ ໂດຍ ທີ່ ກົກຂາ ຂອງ ເຂົາ ເຈົ້າຈ່າງ ອອກ ກວ່າ ຜູ້ ໃຫຍ່. ນ້ີ ແມ່ນ ສ່ິງ ສໍາຄັນ ສໍາລັບ ສຸຂະພາບ ແລະ ການພັດທະນາ ຂອງ ຂ້ໍ ຕ່ໍ ສະ ໂພ ກຂອງ ເຂົາ ເຈົ້າ. ນ້ີ ໝາຍ ຄວາມ ວ່າ ມັນ ສໍາຄັນ ໂດຍ ສະ ເພາະ ສໍາລັບ ເດັກນ້ອຍ ທີ່ ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວຕ້ອງບ່ໍຍູ້ກົກຂາຂອງເດັກນ້ອຍເຂົ້າກັນ. ບັນຫາ: ກະດູກ ກົກ ແອວ ອ່ຽງ ໄປ ທາງ ໜ້າ (ກະດູກ ກົກ ແອວ ອ່ຽງ ໄປ ໜ້າ) 98 ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ສາມາດ ໃຫ້ ແນວ ຮອງ ໃນ ສອງ ວິທີ ຄື: ï ແນວ ຮອງຢູ່ ດ້ານ ໜ້າ ຂອງ ກະດູກ ກົກ ແອວ (ASIS) ທີ່ ຍູ້ ໄປ ຫຼັງ; ແລະ ï ສ່ົງ ເສີມ ໃຫ້ ກະດູກ ກົກ ແອວ ເອນ ໄປ ທາງ ຫຼັງ ໂດຍ ການ ປ່ຽນ ມຸມ ຂອງ ບ່ອນ ນ່ັງ ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ຫ້ີຼມຮອງສໍາລັບ ການ ອ່ຽງ ໄປ ທາງ ໜ້າ ສ່ົງ ເສີມ ໃຫ້ ກະດູກ ກົກ ແອວ ເອນ ໄປ ທາງ ຫຼັງຫາ ແນວ ອີງ ຫຼັງ. ຫຼີ້ມຮອງ ສໍາລັບ ການ ອ່ຽງ ໄປ ຫຼັງຢຸດ ຢູ່ ແປະ ກັບ ດ້ານ ໜ້າ ຂອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ພຽງ ກັນ ຢູ່ ກ້ອງ ກົກຂາ. ສາຍຮັດ ສ່ີ ຈຸດ ປ້ອງ ກັນ ການ ອ່ຍງ ໄປໜ້າ ໃຫ້ການ ຮອ ງຮັບ ຢູ່ ສ່ວນ ເທິງ ຂອງ ແລະ ດ້ານ ໜ້າ ຂອງ ກະດູກ ກົກ ແອວ ທີ່ ສ່ົງ ເສີມທ່າ ນ່ັງ ທີ່ ເປັນປົກກະຕິ ຫຼາຍກວ່າ. ການ ກໍານົດ ໃຊ້ (ການ ເລືອກ) ອຸປະກອນ PSD – ການ ຮອງ ສະ ໂພ ກ ມັນ ສໍາຄັ ນ ໃນ ການ ຈື່ວ່າທ່າຄົງທ່ີ/ບໍ່ເປັນປົກກະຕິຂອງສະໂພກຈະ ມີ ຜົນ ກະທົບ ກັບ ທ່າ ກະດູກ ກົກ ແອວ ຖ້າ ບໍ່ ມີ ການ ຮອງຮັບ . ການ ຮອງ ສະ ໂພ ກ ບັນຫາ: ສະ ໂພ ກຂ້າງ ໜ່ຶງບ່ໍ ສາມາດ ກ່ົງ ເຂ້ົາ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ( ມຸມ ລະຫວ່າງລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ) ວິທີ ແກ້ ໄຂຊ່ົວຄາວ ສໍາລັບ ບັນຫາ ນ້ີ ແມ່ນ ການ ວາງ ແນວ ຮອງ ເສີມ ( ໂຟມ) ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ກົກຂາ ຂອງ ສະ ໂພ ກທ່ີ ສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່ານ່ັງ ປົກກະຕິ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ການຫຸຼດດ້ານ ໜ້າ ບ່ອນ ນ່ັງ ໃຫ້ ຕ່ໍາລົງຢູ່ ຂ້າງໜ່ຶງ – ແນວ ຮອງ ແບບ ນ້ີ ສາມາດຖືກ ສ້າງ ຕິດ ກັບ ເບາະ ຮອງ ນ່ັງ ເພ່ືອ ຮອງ ຮັບສະ ໂພ ກ ທີ່ ບໍ່ ກ່ົງ ເຂົ້າ ຫາ ທ່າ ປົກກະຕິສໍາລັບ ການ ນ່ັງ (ມຸມ ລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ). ໝາຍ ເຫດ: ວິທີ ແກ້ ໄຂ ສຸດ ທ້າຍ ແ ມ່ນການ ເຮັດ ການ ຕັດ ອອກ ເປັນມຸມ ຢູ່ ຂ້າງ ສະ ໂພ ກທ່ີ ບ່ໍ ສາມາດ ກ່ົງ ເຂົ້າ ຫາ ທ່ານ່ັງ ປົກກະຕິ. ມຸມ ຂອງ ສ່ວນ ທີ່ ຕັດ ອອກ ໃນ ໂຟມຈະ ຂ້ຶນ ກັບ ມຸມ ຂອງ ສະ ໂພ ກຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ – ສະ ນ້ັນ ຄວນ ຈະ ມີ ການກວດ ເບິ່ງ ສ່ິງ ນ້ີ ໃນ ການ ປະ ເມີນ ຜົນ. ໝາຍ ເຫດ: ຍັງ ມີ ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ໃນ ເບາະ ຮອງ ນ່ັງ ອີກ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 99 ບັນຫາ: ສະ ໂພ ກທັງ ສອງບ່ໍ ສາມາດ ກ່ົງ ເຂ້ົາ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ( ມຸມ ລະຫວ່າງລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ) ວິທີ ການ ແກ້ ໄຂ ຊ່ົວຄາວ ສໍາລັບ ບັນຫາ ນ້ີ ແມ່ນ ການວາງ ແນວ ຮອງ ເສີມ ( ໂຟມ) ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ. ແນວ ໃດ ກໍ ຕາມ, ນ້ີ ບໍ່ ສາມ າດ ໃຫ້ຜົນ ເປັ ນ ວິທີ ແກ້ ໄຂ ຖາວອນ ເພາະວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈະ ມີ ແນ ວ ໂນ້ມ ເລື່ອນ ໄປ ໜ້າ ອອກ ຈາກ ລົດ ເຂັນ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ມຸມ ເປີດ ແຕ່ ບ່ອນ ນ່ັງ ຫາ ແນວ ອີງ ຫັຼງ ຈະ ອະນຸຍາດ ໃຫ້ ມີ ມຸມ ແຕ່ ລໍາ ຕົວ ຫາ ກົກຂາ ທີ່ ກວ້າງ ກວ່າ. ມຸມ ລະຫວ່າງ ບ່ອນ ນ່ັງ ຫາ ແນວ ອີງ ຫຼັງຈະ ຂ້ຶນ ກັບ ມຸມ ແຕ່ ລໍາ ຕົວ ຫາ ກົກຂາ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ – ແລະ ນີ້ ຈະ ຖືກ ຕັດສິນ ໃນ ລະຫວ່ງການ ປະ ເມີນ ຜົນ. ວິທີ ແກ້ ໄຂ ຖາວອນ ທີ່ ເປັນ ໄປ ໄດ້ ແມ່ນ ການ ມີ ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ສາຍຮັດ ກົກ ແອວ, ເຊິ່ງຈະ ຢຸດ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ໃຫ້ ເລື່ອນ ໄປ ໜ້າ ອອກ ຈາກ ລົ ດ ເຂັນ. ບັນຫາ: ສະ ໂພ ກຂ້າງ ໜ່ຶງ ຫຼື ທັງ ສອງຂ້າງບ່ໍ ສາມາດ ເປີດ ກວ້າງ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ( ມຸມ ລະຫວ່າງລໍາ ຕົວ ຫາ ກົກຂາ ໜ້ອຍກວ່າ 90 ອົງສາ) ວິທີ ແກ້ ໄຂ ຊ່ົວຄາວ ສໍາລັບ ບນັຫາ ນ້ີ ແມນ່ ການວາງ ແນວ ຮອງ ເສີມ (ຫຼີມ້ຮອງ ທ່ີ ່ເປນັ ໂຟມ ແຂງ) ຢູ ່ກ້ອງ ກົກຂາທ່ີ ບໍ ່ສາມາດ ເປດີ ກວ້າງ ຫາ ທາ່ ນ່ັງ ປກົກະຕິ ໄດ້ (ມຸມ ແຕ່ ລາໍ ຕົວ ຫາ ກົກຂາ ໜອ້ຍ ກວ່າ 90 ອງົສາ). ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ຍົກ ສ່ວນ ໜ້າ ຂອງ ບ່ອນ ນ່ັງ ຂ້ຶນ – ວິທີ ແກ້ ໄຂ ຖາວອນ ທີ່ ເປັນ ໄປ ໄດ້ ແມ່ນ ການ ຍົກ ສ່ວນ ໜ້າ ບ່ອນ ນ່ັງ ຂ້ຶນ/ວາງ ຫຼີ້ມຮອງ ໃສ່ ດ້ານ ໜ້າ ຂອງ ກະດູກ ຮອງ ນ່ັງ/ຢູ່ ກ້ອງ ກົກຂາ. ສ່ິງ ນ້ີ ຫຼຸດຜ່ອນ ມຸມ ລະຫວ່າງ ບ່ອນ ນັ່ງ ຫາ ແນວ ອີງ ຫຼັງ. ປະລິມານ ທີ່ ສ່ວນໜ້າ ຂອງ ບ່ອນ ນ່ັງ ຖືກ ຍົກ ຂ້ຶນຈະ ຂ້ຶນ ກັບ ມຸມ ແຕ່ ລໍາ ຕົວ ຫາ ກົກຂາ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ – ສະ ນ້ັນ ນ້ີ ຄວນຖືກ ຕັດສິນ ໃນ ລະຫວ່າງການ ປະ ເມີນ ຜົນ. ໝາຍ ເຫດ: ກະດູກຮອງ ນ່ັງ ທັງ ສອງ ຄວນ ນ່ັງ ຢູ່ ເທິງ ພ້ືນ ຜິວ ທີ່ ພຽງ ກັນ. 100 ການ ຊ່ວຍຫຸຼດຜ່ອນ ການ ເຄ່ືອນ ໜັງ ທ່ີ ຄວບ ຄຸມ ບ່ໍ ໄດ້, ຄວາມ ຕຶງ ສູງ ຫືຼ ກ້າມ ເນ້ືອ ກະຕຸກ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບາງ ຄົນ, ການ ຍົກ ສ່ວນ ໜ້າ ບ່ອນ ນ່ັງ ຂ້ຶນ ເພ່ືອ ຫຼຸດມຸມ ລະຫວ່າງ ລໍາ ຕົວ ຫາ ກົກ ຂາ ຢູ່ ສະ ໂພ ກ ໃຫ້ ໜ້ອຍ ກວ່າທ່າປົກກະຕິ ສາມາດ ຊ່ວຍ ຫຼຸດກາ ນ ເຄື່ອນ ເໜັງ ທີ່ ຄວບ ຄຸມ ບໍ່ ໄດ້, ຄວາມ ຕຶງ ສູງ ຫຼື ກ້າມ ເນ້ືອ ກະຕຸກ. ຈົ່ງ ຈື່ ວ່າ – ຈຸດ ເລີ່ ມຕ້ົນ ຂອງ ëຫຼີ້ມຮອງí ຄວນ ຈະ ຢູ່ ດ້ານ ໜ້າ ຂອງ ກະດູກ ຮອງ ນ່ັງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ກະດູກ ຮອງ ນ່ັງ ຂອງ ເຂົາ ເຈົ້າ ຄວນ ນ່ັງ ຢູ່ ເທິງພ້ືນ ຜິວ ທີ່ ພຽງ ກັນ. ການ ກໍານົດ ໃຊ້ (ການ ເລືອກ) ອຸປະກອນ PSD – ການ ຮອງ ລໍາ ຕົວ ມັນ ສໍາຄັນ ໃນ ການ ພິຈາລະນາ ວິທີ ເຮັດ ໃຫ້ ກະດູກ ກົກ ແອວ ໝ້ັນຄົງ ກ່ອນ, ແລະ ຈາກ ນ້ັນ ຈິ່ງຮອງ ລໍາ ຕົວ. ສໍາລັບ ຫຼາຍໆ ຄົນ, ບັນຫາ ທ່າທາງ ທີ່ ກ່ຽວຂ້ອງ ກັບ ລໍາ ຕົວ ສາມາດ ໄດ້ ຮັບ ການ ແກ້ ໄຂ ຫຼື ປັບປຸງ ໃຫ້ ດີ ຂ້ຶນ ໄດ້ ດ້ວຍ ແນວ ຮອງ ກະດູກ ກົກ ແອວທີ່ ດີ. ການ ຮອງ ລໍາ ຕົວ ບັນຫາ: ທ່າ ຫັຼງຂົດ, ລໍາ ຕົວ ເອນ ໄປ ໜ້າ ແລະ ກະດູກກົກ ແອວ ອ່ຽງ ໄປຫັຼງ ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ï ແນວ ປະຄອງ ຫຼື ແນວ ຮອງ ເພ່ືອ ນໍາ ເອົາ ກະ ດູກ ກົກ ແອວ ໃຫ້ ໃກ້ ຄຽງ ກັບ ທ່າ ນ່ັງ ປົກກະຕິ ທີ່ ສຸດ ເທົ່າທ່ີ ຈະ ເປັນ ໄປ ໄດ້. ï ການ ຮອງ ຮັບ ແນວ ອີງ ຫຼັງ ເຊິ່ງອະ ນຸຍາດ ໃຫ້ ການກ່ົງ ຕາມ ທໍາ ມະ ຊາດ ຂອງລໍາ ຕົວ. ï ບາງ ຄັ້ງ ກ່ໍ ຈໍາ ເປັນ ຕ້ອງ ມີ ການ ຮອງ ຢູ່ ດ້ານ ໜ້າ ຂອງ ລໍາ ຕົວ ເຊັ່ນ ກັນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 101 ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ï ການ ຮອງຮັບ ກະດູ ກກົກ ແອວ ທີ່ ໃຫ້ ໂດຍ: – ຖ້ານ ຮອງກ່ອນ ກະດູກ ຮອງ ນ່ັງ; – ແຜ່ນ ຮອງ ຫັຼງກະດູກ ກົກ ແອວ; – ສາຍຮັດ ກົກ ແອວ (ບໍ່ ຈໍາ ເປັນ ສະ ເໝີ ໄປ); – ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ (ບໍ່ ຈໍາ ເປັນ ສະ ເໝີ ໄປ). ï ການ ຮອງຮັບ ແນວ ອີງ ຫຼັງ ທີ່ ໃຫ້ ໂດຍ: – ການ ປັບ ຮູບຊົງ ແນວ ອີງ ຫັຼງ – ເພ່ືອ ໃຫ້ ບ່ອນ ວ່າງ ສໍາລັບ ລໍາ ຕົວ ແລະ ປ່ອຍ ໃຫ້ຫຼັງ ໄປ ຕາມ ການ ກ່ົງ ງໍ ຕາມ ທໍາ ມະ ຊາດ. ຖ້າ ແນວ ອີງ ຫຼັງສືບ ຕ່ໍ ຢຽດ ໄປ ໜ້າ, ມັນ ຈະ ຍູ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄປ ໜ້າ. ການ ດັດ ແປງ ນ້ີ ຕ່ໍ ກັບຮູບຊົງ ແນວ ອີ ງຫັຼງ ແມ່ນ ສ່ວນ ໜຶ່ງ ຂອງ ວິທີ ແກ້ ໄຂ ດ້ວຍ ອຸປະກອນ PSD ສໍາລັບ ລາວ. ສາມາດ ໃຫ້ການ ຮອງ ຮັບ ເພ່ີມ ເຕີມ ໄດ້ ໂດຍ : • ຖາດ – ຖາດ ສາມາດ ໃຫ້ການ ຮອງ ຮັບ ເພ່ີມ ເຕີມ ເພ່ືອ ຊ່ວຍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຮັກສາ ທ່າ ລໍາ ຕົວ ຕ້ັງ ຊ່ື. • ສາຍຮັດ ບ່າ ໄຫ່ຼ – ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ອິດ ເ ມ່ືອຍງ່າຍ, ຫຼື ລົ້ມ ໄປ ທາງ ໜ້າ – ສາຍຮັດ ບ່າ ໄຫ່ຼສາມາດຊ່ວຍ ໄດ້. • ການ ອ່ຽງບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫັຼງ – ໃນ ເວລາ ທີ່ ອຸປະກອນ PSD ອື່ນ ທີ່ ໃຊ້ ຮ່ວມ ກັນ ຊ່ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃຫ້ ນ່ັງ ຕ້ັງ ຊ່ື ກ ວ່າ ໄດ້, ການ ອ່ຽງບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງພ້ອມ ກັນ ອາດ ຈະ ຊ່ວຍ ໄດ້. ແນວ ອີງ ຫັຼງຈໍາ ເປັນ ຕ້ອງ ໄປ ຕາມ ສ່ວນ ໂຄ້ງ ຕາມ ທໍາ ມະ ຊາດຂອງ ກະດູກ ສັນຫັຼງ ແນວ ອີງ ຫຼັງທ່ີ ຢຽດ ຕ້ັງ ຊ່ື ທີ່ ບໍ່ ມີ ໂຄງ ຮ່າງ ເພ່ືອ ຮອງ ຮັບ ສ່ວນ ໂຄ້ງ ຕາມ ທໍາ ມະ ຊາດ ຂອ ງກະດູກ ສັນຫັຼງ ໂດຍ ປົກກະ ຕິ ແລ້ວ ຈະ: ï ຍູ້ ສ່ວນ ເທິງ ຂອງ ລໍາ ຕົວ ໄປ ທາງ ໜ້າ; ï ສ່ົງ ເສີມ ໃຫ້ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ຍ້າຍ ກ ະ ດູກ ກົກ ແອວ ຂອງ ເຂົາ ເຈົ້າ ໄປ ທາງ ໜ້າ, ເພ່ືອ ໃຫ້ ຜູ້ກ່ຽວ ສາມາດ ເອນ ໄປ ຫຼັງຫາ ແນວ ອີງ ຫຼັງ. ແຕ່ ໜ້າ ເສຍດາຍ, ຫຼາຍໆ ລົດ ເຂັນ ມາດຕະຖານ ມາ ພ້ອມ ກັບ ແນວ ອີງ ຫຼັງ ແບບຢຽດ ຊ່ື ຂ້ຶນ ແລະ ລົງ. ໂດຍ ປົກກະຕິ ແລ້ວ ຈໍາ ເປັນ ຕ້ອງ ມີບາງ ການ ດັດ ແປງ ເພ່ືອ ຮອງ ຮັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເພ່ືອ ໃຫ້ ຜູ້ກ່ຽວ ສາມາ ດ ນ່ັງ ໄດ້ ໃນ ທ່ານ ປົກກະຕິ ຢ່າງ ສະບາ ຍຕົວ. 102 ບັນຫາ: ທ່າ ຫັຼງຂົດ, ກະດູກ ກົກ ແ ອວອ່ຽ ໄປ ຫັຼງຄົງ ທ່ີ ແລະ ລໍາ ຕົວ ກ່ົງ ໄປ ໜ້າ ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ï ແນວ ປະຄອງ ຫຼື ແນວ ຮອງ ເພ່ືອ ນໍາ ເອົາ ກະ ດູກ ກົກ ແອວ ໃຫ້ ໃກ້ ຄຽງ ກັບ ທ່າ ນ່ັງ ປົກກະຕິ ທີ່ ສຸດ ເທົ່າທ່ີ ຈະ ເປັນ ໄປ ໄດ້. ï ການ ຮອງ ແນວ ອີງ ຫຼັງ ເພ່ືອ ຮອງ ຮັບ ລໍາ ຕົວ ໃຫ້ ໃກ້ ຄຽງ ກັບ ທ່ານ ນ່ັ ງປົກກະຕິ ທີ່ ສຸດ ເທົ່າ ທີ່ ຈະ ເປັນ ໄ ປ ໄດ້ ແລະ ໃຫ້ການ ຈັດ ແນວ ຂອງ ຫົ ວທີ່ ດີ ສາມາດ ເ ບິ່ງ ໄປ ໜ້າ ໄດ້ ຫຼາຍກວ່າ). ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ວິທີ ແກ້ ໄຂ ຈະ ແຕກ ຕ່າ ງກັນ ໂດຍ ຂ້ຶນ ກັບ ວ່າຈໍາ ເປັນ ຕ້ອງ ມີກາ ນຮອງ ຮັບ ຫຼາຍປານ ໃດ ແລະ ປະ ເພດ ຂອງ ລົດ ເຂັນ ທີ່ ມີ ໃຫ້. ບາງ ຄໍາ ແນະນໍາ ແມ່ນ ມີ ໃນ ລາຍການ ຂ້າງ ລຸ່ມ. ï ການ ຮອງຮັບ ກະດູ ກກົກ ແອວ ທີ່ ໃຫ້ ໂດຍ: – ຖ້ານ ຮອງກ່ອນ ກະດູກ ຮອງ ນ່ັງ; – ແຜ່ນຮອງຂ້າງກະດູກກົກແອວ ແລະ ການເປີດມຸມລະຫວ່າງບ່ອນນ່ັງຫາ ແນວອີງຫັຼງ ເພ່ືອຮອງຮັບ ແລະ ປະຄອງ ການ ອ່ຽງ ໄປ ຫຼັງ ແບບ ຄົງ ທີ່ ຂອງ ກະດູກກົກ ແອວ; – ສາຍຮັດ ກົກ ແອວ (ບໍ່ ຈໍາ ເປັນ ສະ ເໝີ ໄປ). ï ການ ຮອງຮັບ ແນວ ອີງ ຫຼັງ ທີ່ ໃຫ້ ໂດຍ: – ການ ເອນ ແນວ ອີງ ຫັຼງ – ເພ່ືອ ໃຫ້ ບ່ອນ ຫວ່າງ ສໍາລັບ ສ່ວນ ໂຄ້ງ ຄົງ ທີ່ ຂອງ ລໍາ ຕົວ. ນ້ີ ອາດ ຈະ ຊ່ວຍ ສ້າງ ການຈັດ ແນວ ທີ່ ດີກ ວ່າ ສໍາລັບ ຫົວ ແລະ ຄໍ. ວິທີ ແກ້ ໄຂ ນ້ີ ຈະ ຍັງ ຮອງ ຮັບ ການ ອ່ຽງ ໄຫັຼງ ແບບຄົງ ທີ ຂອງ ກະດູກ ກົກ ແອວ ນໍາ ອີກ. (ໝາຍ ເຫດ: ຈໍາ ເປັນ ຕ້ອງ ເພ່ີມໂຟມ ຫຸ້ມ ເບາະ ໃສ່ ແນວ ອີງ ຫຼັງທ່ີ ແຂງ). – ການ ປັບ ຮູບຊົງ ແນວ ອີງ ຫັຼງ – ເພ່ືອ ໃຫ້ ບ່ອນ ວ່າງ ສໍາລັບ ລໍາ ຕົວ ແລະ ປ່ອຍ ໃຫ້ຫຼັງ ໄປ ຕາມ ການ ກ່ົງ ງໍ ຕາມ ທໍາ ມະ ຊາດ. ນອກ ນ້ັນ ສາມາດ ໃຫ້ການ ຮອງ ຮັບ ເພ່ີມ ເຕີມ ໄດ້ ໂດຍ : – ຖາດ; – ສາຍຮັດ ບ່າ ໄຫ່ຼ; – ການ ອ່ຽງຂອງບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫັຼງ. ຄິດ ກ່ຽວ ກັບ ວິທີ ແກ້ ໄຂ ດ້ວຍ ອຸປະກອນ PSD ຕາມ ລໍາດັບ ນ້ີ ກະດູກ ກົກ ແອວ ແລະ ສະ ໂພ ກ ລໍາ ຕົວ ຫົວ ແລະ ຄໍາ ຂາ ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 103 ບັນຫາ: ລໍາ ຕົວ ອ່ຽງ ຫືຼ ລ້ົມ ໄ ປຂ້າງ ໜ່ຶງ ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ï ເຮັດ ໃຫ້ ກະດູກ ກົກ ແອວ ໝ້ັນຄົງ. ï ໃຫ້ການ ຮອງ ຮັບ ຢູ່ ດ້ານ ຂ້າງ ຂອງ ລໍາ ຕົວ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD • ຫ້ີຼມຮອງ ຂ້າງ ລໍາ ຕົວ – ໃຫ້ການ ຮອງ ທີ່ ອ່ອນ ໂຍນ ເພ່ືອ ຊ່ວຍ ຮັກສາ ໃຫ້ ລໍາ ຕົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຢູ່ ເຄິ່ງກາ ງ ຂອງ ແນວ ອີງ ຫຼັງ. • ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ – t ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ໃຫກ້ານ ຮອງ ທີ ່ແໜນ້ ໜາ ເພ່ືອ ຊ່ວຍຮກັສາ ລາໍ ຕົວ ໃຫ ້ຢູ ່ເຄິງ່ກາງຂອງ ແນວ ຮອງ ຮັບ ຫຼງັ. ຖ້າ ມີ ການ ໃຫ້ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວຂ້າງ ໜຶ່ງ, ມັກ ຈະ ມີ ການ ໃຫ້ ແຜ່ນ ຮອງ ລໍາ ຕົວ ອີກ ຢູ່ ຂ້າງ ກົງກັນ ຂ້າມກັນ ສະ ເໝີ – ອາດ ຈະ ຢູ່ ໃນ ລະດັບທີ່ ແຕກ ຕ່າງ ກັນ. ບັນຫາ: ກະດູກ ສັນຫັຼງ ໂຄ້ງ ໄປ ທາງ ຂ້າງ ແບບ ຄົງ ທ່ີ ຫືຼ ປັ ບປ່ຽນ ໄດ້. ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ï ການ ຮອງ ຮັບ ຢູ່ ຈອມ ຍອດ ຂອງ ສ່ວນ ໂຄ້ງ ຢູ່ ຂ້າງ ໜຶ່ງ ແລະ ສ່ວນ ເທິງ ແລະ ພ້ືນ ຂອງ ສ່ວນ ໂຄ້ງ ໃນ ອີກ ຂ້າງໜ່ຶງ. 104 ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD • ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ທີ່ ໃຊ້ ຮ່ວມກັບ ແຜ່ນຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ. ຖ້າ ທ່າ ສາມາດ ປັບ ປ່ຽນ ໄດ້, ດ້ວຍ ການ ຮອງ ຮັບ ນ້ີ ຜູ້ ໃຊ້ລົດ ເຂັນ ອາດ ຈະ ສາມາດ ນ່ັງ ໃນ ທ່າ ປົກກະຕິ ໄດ້. ຖ້າ ທ່າ ຄົງ ທີ່, ຮອງ ໃຫ້ ນ່ັງ ໄດ້ ໃກ້ ຄຽງ ກັບ ທ່ານ່ັງປົກກະຕິ ທີ່ ສຸດ ເທົ່າ ທີ່ ຈະ ສະບາຍ ຕົວ. ການ ໃຫ້ການ ຮອງ ຢູ່ ໃນ ທ່າ ນ່ັງປົກກະຕິສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ກະດູກ ສັນຫັຼງຂົດທີ່ ປັບ ປ່ຽນ ໄດ້ ອາດ ຈະ ແກ້ ໄຂ ກະດູກ ກົກ ແອວ ທີ່ ບໍ່ ພຽງ ກັນ ທີ່ ປັບ ປ່ຽນ ໄດ້. ການ ກໍານົດ ໃຊ້ (ການ ເລືອກ) ອຸປະກອນ PSD – ການ ປະຄອງ ຫົວ, ການ ຮອງ ກົກຂາ ແລະ ຂາ ສ່ວນ ລຸ່ມ ກາ ນປະຄອງ ຫົວ ບັນຫາ: ຫົວ ມັກ ຈະ ລ້ົມ ໄປ ຫັຼງ, ໄປ ໜ້າ ຫືຼ ໄປ ທາງ ຂ້າງ ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ï ກ່ອນ ທີ່ ຈະ ໃຫ້ ແນວ ປະຄອງ ຫົວ – ໃຫ້ ... ກ່ອນ ສະ ເໝີ: – ເຮັດ ໃຫ້ ກະດູກ ກົກ ແອວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໝ້ັນຄົງ; – ໃຫ້ການ ຮອງ ຮັບ ລໍາ ຕົວ ທີ່ ດີ ທີ່ ຮັບປະກັນ ວ່າ ລໍາ ຕົວ ໝ້ັນຄົງ ແລະ ດຸ່ນດ່ຽງທຽບ ກັບ ກະດູກ ກົກ ແອວ. ï ຖ້າຜູ້ ໃຊ້ ລົດ ເຂັນ ສືບ ຕ່ໍ ພົບ ຄວາມ ຍາກ ໃນ ການ ຄຶ ງຫົວ ຂອງ ເຂົາ ເຈົ້າ ໃຫ້ ຕ້ັງ ຊ່ື, ຄ ວນ ໃຫ້ກາ ນປະຄອງ: – ທໍາ ອິດ ຢູ່ ພ້ືນ ຂອງ ກະ ໂຫຼກຫົວ; – ຖ້າ ຈໍາ ເປັນ ການ ປະຄອງສາມ າດຂະຫຍາຍ ໄປ ອ້ອມ ດ້ານ ຂ້າງ ຫົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD ມີ ແນວຮອງຫຼື ແນວປະຄອງ ຫົວຫຼາຍໆ ປະ ເພດ ແຕກ ຕ່າງ ກັນ. ແນວ ປະຄອງ ຫົວ ສອງ ຢ່າງ ທີ່ ໃຊ້ ຫຼາຍທ່ີ ສຸດ ແມ່ນ ແນວ ປະຄອງ ຫົວ ແບບ ແບນ ແລະ ແບບ ມີ ຮູບຊົງ. • ແນ ວປະຄອງ ຫົວ ແບບ ແບນ – ແນ ວປະຄອງຫົວ ແບບ ແບນ ແມ່ນ ສ່ວນ ຂະຫຍາຍ ຂອງ ແນວອີງ ຫຼັງ ເຊິ່ງມີ ໂຄງ ຮ່າງ ເພ່ືອ ໃຫ້ການ ຮອງ ຫຼືການ ປະຄອງ ສໍາລັບ ຫົວ. ແນວ ປະຄອງ ຫົວ ແບບ ແບນ ໃຫ້ ບ່ອນ ພັກຜ່ອນສໍາລັບ ຫົວ ແລະ ຢຸດ ບໍ່ ໃຫ້ ຫົ ລົ້ມ ໄປ ທາງ ຫຼັງ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 105 • ແນວ ປະຄອງ ຫົວ ແບບ ມີ ຮູ ບຊົງ – ແນວ ປະຄອງ ຫົວ ແບບ ມີ ຮູ ບຊົງ ມີ ຮູບຊົງ ເປັນ ëຈອກí ຮອງ ຮັບ ພ້ືນ ຂອງ ຫົວ. ມັນ ອາດ ຈະ ຖືກ ຂະຫຍາຍ ຢູ່ ດ້ານ ຂ້າງ ແລະ ເດ່ ໄປ ໜ້າ ເພ່ືອ ໃຫ້ການ ປະຄອງ ຫຼືຮອງ ຮັບ ເພ່ີມ ເຕີມຢູ່ ດ້ານ ຂ້າງ ຂອງ ຫົວ. ແນວ ອີງ ຫົ ວ ແບບ ມີ ຮູ ບຊົງ ໃຫ້ການ ຮອງ ຮັບ ຫຼາຍກວ່າ ແນວ ປະຄອງ ຫົວແບບ ແບນ ໂດຍ ການ ໃຫ້ ໂຄງ ຮ່າງ ອ້ອມ ພ້ືນກະ ໂຫຼກຫົວຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ໃນ ເວລາ ໃຫ້ ແນວປະຄອງ ຫົວ: ໃນ ເວລາ ໃຫ້ການ ປະຄອງ ຫຼືຮອງ ຮັບ ຫົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ, ໃຫ້ ຈື່ ສະ ເໝີ ວ່າ ທ່າຂອງ ຫົວຍັງ ຂ້ຶນ ກັບ ທ່າ ທີ່ ດີ ຂອງ ກະດູກ ກົກ ແອວ ແລະ ລໍາ ຕົວ ນໍາ ອີກ. ຫຼີກ ເວັ້ນການ ໃຫ້ ການ ປະຄອງ ຢູ່ ສ່ວນ ໜ້າ ຂອງ ຫົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ການ ຮອງ ກົກຂາ ບັນຫາ: ຂາ ເດ່ ອອກ ນອກ (ຈ່າງ ອອກ) ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ï ກ່ອນ ອື່ນ ຮັບປະກັນ ວ່າ ກົກ ແອວ ແລະ ລໍາ ຕົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄດ້ ຮັບ ການ ເຮັດ ໃຫ້ ໝ້ັນຄົງ ໂດຍ ການ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ຈໍາ ເປັນ. ນ້ີ ອາດ ຈະ ຊ່ວຍນໍາ ເຂົາ ຫຂາ ກັບ ເຂົ້າ ສູ່ ທ່າ ນ່ັງ ປົກ ກະຕິກ ວ່າ. ï ການ ຮອງ ຢູ່ ດ້ານ ນອກ ຂອງ ກົກຂາ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD • ຫ້ີຼມຮອງ ກົກຂາ ດ້ານ ນອກ ຈະ ໃຫ້ການ ຮອງ ທີ່ ອ່ອນ ໂຍນ. ໝາຍ ເຫດ: ໃນ ຮູບ ປະກອບ ນ້ີ ຫຼີ້ມຮອງ ກົກຂາ ໄດ້ ຖືກ ເພ່ີມ ໃສ່ ຊ້ັນ ໂຟມທ່ີ ແຂງ ຂອງ ເບາະ ຮອງ ນ່ັງ. ໂຟມທ່ີ ແຂງ ມີ ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຕິດ ຢູ່. ຊ້ັນ ໂຟມທ່ີ ອ່ອນຄວນ ຖືກ ເພ່ີມ ໃສ່ ສ່ວນ ເທິງ ຂອງ ເບາະ ຮອງ ນ່ັງ ທັງ ໝົດ. • ແຜ່ນຮອງ ກົກຂາ ດ້ານ ນອກ ຈະ ໃຫ້ການ ຮອງ ທີ່ ແໜ້ນໜາ. ໝາຍ ເຫດ: ໃນ ຮູບ ສະ ແດງ ນ້ີ ແຜ່ນ ຮອງ ກົກຂາ ຖືກ ຕິດ ໃສ່ ກັບ ພ້ືນ ບ່ອນ ນ່ັງ ທີ່ ເປັນ ໄມ້ ໂດຍ ມີ ເຫຼັກເກາະ. ເຮັດ ໃຫ້ ມີ ບ່ອນ ຫວ່າງ ສໍາລັບ ເບາະ ຮອງ ນ່ັງ ເພ່ືອ ວາ ໃສ່ ເທິງ ບ່ອນ ນ່ັງ ທີ່ ເປັນ ໄມ້. 106 ບັນຫາ: ຂາ ຫົດ ເຂ້ົາ (ຫຸບ ເຂ້ົາ) ແນວ ປະຄອງ ຫືຼ ແນວຮອງ ທ່ີ ຕ້ອງການ ï ກ່ອນ ອື່ນ ຮັບປະກັນ ວ່າ ກົກ ແອວ ແລະ ລໍາ ຕົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄດ້ ຮັບ ການ ເຮັດ ໃຫ້ ໝ້ັນຄົງ ໂດຍ ການ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ຈໍາ ເປັນ. ນ້ີ ອາດ ຈະ ຊ່ວຍນໍາ ເຂົາ ຫຂາ ກັບ ເຂົ້າ ສູ່ ທ່າ ນ່ັງ ປົກ ກະຕິກ ວ່າ. ï ການ ຮອງ ຢູ່ ດ້ານ ໃນ ຂອງ ກົກຂາ ແລະ ດ້ານ ໃນ ຂອງຫົ ວ ເຂົ່າ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD • ຫ້ີຼມຮອງ ກົກຂາ ດ້ານ ໃນ ຈະ ໃຫ້ການ ຮອງ ທີ່ ອ່ອນ ໂຍນ. ໝາຍ ເຫດ: ໃນ ຮູບ ປະກອບ ນ້ີ ຫຼີມ້ຮອງ ກົກຂາ ໄດ້ ຖກື ເພ່ີມ ໃສ່ ຊ້ັນ ໂຟມທ່ີ ແຂງ ຂອງ ເບາະ ຮອງ ນ່ັງ. ໂຟມທ່ີ ແຂງ ມີ ຖາ້ນ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຕິດ ຢູ.່ ຊ້ັນ ໂຟມທ່ີ ອອ່ນຄວນ ຖກື ເພ່ີມ ໃສ່ ສ່ວນ ເທງິ ຂອງ ເບາະ ຮອງ ນ່ັງ ທງັ ໝົດ. ï ແຜ່ນ ແຍກ ຫົວ ເຂ່ົາ ຈະ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ແໜ້ນໜາ. ໝາຍ ເຫດ: ໃນ ຮູບ ສະ ແດງ ນ້ີ ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ຖືກ ຕິດ ໃສ່ ກັບ ພ້ືນ ບ່ອນ ນ່ັງ ທີ່ ເປັນ ໄມ້ ໂດຍ ມີ ເຫຼັກເກາະ. ເຮັດ ໃຫ້ ມີ ບ່ອນ ຫວ່າງ ສໍາລັບ ເບາະ ຮອງ ນ່ັງ ເພ່ືອ ວາ ໃສ່ ເທິງ ບ່ອນ ນ່ັງ ທີ່ ເປັນ ໄມ້. ກາ ນຮອງ ຂາ ສ່ວນ ລຸ່ມ ແລະ ຕີນ ບັນຫາ: ຫົວ ເຂ່ົາຂ້າງ ໜ່ຶງ ຫືຼ ທັງ ສອງ ຂ້າງ ກ່ົງ ແລະ ຄົງ ທ່ີໜ້ອຍ ກວ່າ ທ່າ ນ່ັງ ປົກກະຕິ ( ມຸມ ລະຫວ່າງລໍາ ຕົວ ຫາ ກົກຂາ ຫຼາຍກວ່າ 90 ອົງສາ) ວິທີ ແກ້ ໄຂ ຈະ ຂ້ຶນ ກັບ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ້ລົດ ເ ຂັນ ແຕ່ລະຄົນ. ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD: ï ປັບ ບ່ອນ ວາງ ຕີນ ໄປທາງ ຫຼັງຖ້າ ເປັນ ໄປ ໄດ້. ï ປັບ ມຸມ ຂອງ ບ່ອນ ວາງ ຕີນ ເພ່ືອ ໃຫ້ ເຂົ້ າ ກັບ ຕີນ ຖ້າ ເປັນ ໄປ ໄດ້. ຖ້າ ນ້ີ ເປັນ ໄປບ່ໍ ໄດ້, ໃຫ້ ໃຊ້ ຫຼີ້ມຮອງ ບ່ອນ ວາງ ຕີນ. ï ໃຫ້ສາຍຮັດ ແກ່ດ້ານ ໜ້າ ຂອງ ຂາ ສ່ວນ ລຸ່ມສໍາລັບ ການ ຮອງ ຮັບ ແລະ ກາ ນປົກ ປ້ອງ. ï ຖ້າ ດ້ານ ຂອງ ບ່ອນ ນ່ັງ ກໍາລັງ ຍູ້ ດ້ານ ຫຼັງຂາ ຂອງ ຜູ້ ໃຊ້ລົດ ເຂັນ ມັນ ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ເຮັດ ໃຫ້ ບ່ອນ ນ່ັງ ສ້ັນ ລົງ ໜ້ອຍ ໜຶ່ງ, ແລະ ປັບ ມຸມ ເບາະ ນ່ັງ ໄປ ດ້ານ ຫຼັງ. ï ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ສູງ ໃຫ້ ພິຈາລະນາ ຍົກ ດ້ານ ໜ້າ ບ່ອນ ນ່ັງ ຂ້ຶນ ຫຼື ອ່ຽງບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງ. ໂດຍ ການ ເຮັດ ສ່ິງ ນ້ີ ຕີນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈະ ສູງ ກວ່າ, ໄປ ໜ້າຫຼາຍກວ່າ ແລະ ເປັນ ໄປ ໄດ້ ທີ່ ຈະຢູ່ ໃນຂອ ບ ເຂດ ການຈັດ ແນວ ຂອງ ບ່ອນ ວາງ ຕີນ ມາດຕະຖານ. ໝາຍ ເຫດ: ï ໃນ ເວລາ ເຮັດ ການ ປັບ ໃດ ໜຶ່ງ ຂ້າງ ເທິງ – ໃຫ້ ກວດ ເບິ່ງ ວ່າ ລໍ້ ໜ້າ ຍັງ ສາມາດ ໝູນ ໄດ້ ເຕັມ ສ່ວນ ໂດຍ ບໍ່ ຕໍາ ກັບ ບ່ອນ ວາງ ຕີນ ຫຼື ຕີນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ï ຖ້າ ການ ປັບ ເຫຼົ່ານ້ີ ເປັນ ໄປ ໄດ້ ບໍ່ ໄດ້ ຕ່ໍ ກັບ ລົດ ເຂັນ ທີ່ ມີ ໃຫ້ ຫຼື ບໍ່ ໃຫ້ການ ປັບ ທີ່ ພຽງພໍ, ບາງ ການ ດັດ ແປງ ກ່ໍ ອາດ ຈະ ຈໍາ ເປັນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 107 ບັນຫາ: ຫົວ ເຂ່ົາ ໜ່ຶງ ຫືຼ ທັງ ສອງ ຂ້າງ ບ່ໍ ສາມ າດກ່ົງ ຫາ ທ່າ ນ່ັງ ປົກກະຕິ ໄດ້ ວິທີ ແກ້ ໄຂ ດ້ວຍອຸປະກອນ PSD: ï ໃຫ້ ບ່ອນ ຮອງ ຂາ ທີ່ ຍົກ ຂ້ຶນ ໄດ້ ຕາມ ມາດຕະຖານຖ້າ ມີ. ï ປັບ ບ່ອນ ວາງ ຕີນ ໄປທາງໜ້າຖ້າ ເປັນ ໄປ ໄດ້. ï ພິຈາລະນາ ໃຫ້ ລົດ ເຂັນ ແບບ 3 ລໍ້ ຖ້າ ມີ. ເພ່ີມ ບ່ອນ ວາງ ຕີນ ໃສ່ ສ່ວນ ເທິງ ຂອງ ທ່ອນ ໃຈກາ ງທາງ ນອນ. ï ຂະຫຍາຍ ບ່ອນ ວາງ ຕີນ ໄປ ທາງ ໜ້າ ໂດຍ ການ ເພ່ີມ ໄມ້ ຫຼື ໂລຫະ ໃສ່. ï ຂະຫຍາຍ ແນວ ນ ແຂວນບ່ອນ ວາງ ຕີນ ໃຫ້ ໄປ ໜ້າ ຕ່ືມ ອີກ – ນ້ີ ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ມີ ການ ເຊື່ອມ ຈອດ ແລະ ຄວນ ຖືກ ດໍາ ເນີນ ໂດຍ ບຸກຄົນ ທີ່ ມີ ຄວາມ ຮູ້ດ້ານ ການ ຊ່າງ ທີ່ ດີ ເລີດ ແລະ ທັກ ສະ ເລື່ອງ ວຽກ ໂລຫະ. ໝາຍ ເຫດ: ບໍ່ ວ່າ ຈະ ຕັດສິນ ວິທີ ແກ້ ໄຂ ໃດ ກໍ ຕາມ – ມັນ ສໍາຄັນ ໃນ ການ ພະຍາ ຍາມຮັບປະກັນ ວ່າຄວາມ ຍາວ ໂດຍ ລວມຂອງ ລົດ ເຂັນ ຖືກ ຮັກສາ ໃຫ້ ຕ່ໍາ ສຸດ. ຂ້ັນ ຕອນ 4: ການ ໃຫ້ ທຶນ ແລະ ການ ສ່ັງ ຊ້ື ï ເບິ່ງ ຂ້ັນ ຕອນ 4: ການ ໃຫ້ ທຶນ ແລະ ການ ສ່ັງ ຊ້ື ໃນປ້ື ມຄູ່ ມືອ້າງ ອີງຂອງຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ ສໍາລັບ ຂ້ໍ ມູນ ທົ່ວ ໄປ ກ່ຽວ ກັບ ການ ໃຫ້ ທຶນ ແລະ ການ ສ່ັງ ຊ້ື. ຂ້ັນ ຕອນ 5: ການ ກະກຽມ ຜະລິດ ຕະພັນ (ລົດ ເຂັນ) ການ ກະກຽມ ຜະລິດ ຕະພັນ (ລົດ ເຂັນ) ການ ກະກຽມ ຜະລິດ ຕະພັນ (ລົດ ເຂັນ) ແມ່ນ ຂ້ັນ ຕອນທີ ຫ້າ ໃນ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ. ກາ ນກະກຽມ ຜະລິດ ຕະພັນ (ລົດ ເຂັນ) ໝາຍ ເຖິງ ການ ປະກອບ ລົດ ເຂັນ ແລະ ການ ກະກຽມ ອຸປະກອນ PSD ຕ່າງໆ ທີ່ ໄດ້ ຖືກ ກໍານົດ ໃຊ້ ( ເລືອກ) ແລ້ວ. ຢູ່ ໃນ ຫຼັກສູດ ຝຶກ ອົບຮົມ ລະດັບ ປານ ກາງ ໂດຍ ປົກກະຕິ ແລ້ວ ມັນພຽງ ແ ຕ່ ເປັນ ໄປ ໄດ້ ໃນ ການ ກະກຽມ ລົດ ເຂັນ ໃຫ້ຢູ່ ໃນ ຈຸດ ສ ະ ເພາະ ໃດ ໜຶ່ງ ເທົ່າ ນ້ັນ ກ່ອນ ທີ່ ຈໍາ ເປັນ ຕ້ອງ ມີ ກາ ນປັບ ໃຫ້ ເໝາະ ສົມ. ຂ້ັນ ຕອນ ëການ ກະກຽມ ຜະລິດ ຕະພັນ (ລົດ ເຂັນ)í ແລະ ëກາ ນປະກອບ ໃຫ້ ເໝາະ ສົມí ຂອງ ການ ບໍລິການ ລົດ ເຂັນອາດ ຈະ ຖືກ ເຮັດ ຊ້ໍາ ຄືນ ຈົນ ກວ່າ ວ່າ ລົດ ເຂັນ ທີ່ ເໝາະສົມ ຢ່າງ ຖືກຕ້ອງ. ໂດຍ ປົກກະຕິ ຈະ ບໍ່ ຕິດ ແໜ້ນອຸ ປະກອນ PSD ໃຫ້ ເຂົ້າ ທີ່ ຢ່າງ ເຕັມ ສ່ວນ ກ່ອນ ເຮັດ ການ ປັບ ໃຫ້ ເໝາະ ສົມ ຄັ້ງທໍາ ອິດ. ນ້ີ ເພ່ືອ ຮັບປະກັນ ໃຫ້ ສາມາດ ເຮ ັດການ ປັບ ສາມາດຕ່າງໆ ຕ່ໍ ກັບ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ໄດ້ ຫຼັງຈາກ ການ ປັບ ໃຫ້ ເໝາະ ສົມ. ສາມາດ ໃຫ້ ການ ປະຄອງ ຫຼືຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ໄດ້ ໃນ ວິ ທີ ແຕກ ຕ່າງ ກັນ. ບາງ ວິທີການແກ້ໄຂແມ່ນງ່າຍດາຍທ່ີສຸດ ແລະ ສາມາດຖືກ ເຮັດ ໄດ້ ໃນ ໂຮງ ສ້ອມ ແປງງ່າຍດາຍ. ວິທີແກ້ໄຂອ່ືນອາດຈະສັບສົນກວ່າ ແລະ ຈໍາເປັນຕ້ອງມີທັກສະດ້ານ ເຕັກນິກ ການ ຊ່າງ ແລະ ສ່ິງອໍານວຍຄວາມສະດວກຫຼາຍກວ່າ. ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ບໍ່ ຈໍາ ເປັນ ຕ້ອງ ຜະລິດອຸປະກອນ PSD ເອົາ ເອງ ກ່ໍ ໄດ້. ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ເຮັດ ວຽກ ຮ່ວ ມ ກັບ ບັນດາ ນາຍ ຊ່າງ . ພະນັກງານບໍລິການ ລົດ ເຂັນ ສາມາດ 108 ອະທິບາຍ ສ່ິງ ທີ່ ພວກ ເຂົາ ຕ້ອງການ ໃຫ້ ສ້າງ ແລະ ມັນ ຄວນ ໃຊ້ ງານ ແນວ ໃດ ແລະ ນາຍ ຊ່າງ ສາມາດ ຄິດ ໄລ່ ວ່າ ຈະ ສາມາດ ສ້າງ ສ່ິງ ນ້ີ ແນ ວ ໃດ ດ້ວຍ ວັດ ສະດຸ ທີ່ ມີ ຢູ່ ໃນ ທ້ອງ ຖິ່ນ. ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ຮັກສາ ເຂົ້າ ຮ່ວມ ແລະ ຊ້ີ ນໍາ ຂະ ບວນການ ປະດິດ ເພ່ືອ ຮັບປະກັນ ວ່າ ຜະລິດ ຕະພັນ ສຸດ ທ້າຍ ຕອບ ສະໜອງ ໄດ້ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ກໍານົດ ໄວ້. ມັກ ຈະ ມີ ວິທີ ແກ້ ໄຂ ດ້ວຍ ອຸປະກອນ PSD ແຕກ ຕ່າງ ກັນ ທີ່ ຈະ ບັນລຸ ໄດ້ ການ ຮອງ ຮັບ ແບບ ດຽວ ກັນ. ວິທີ ແກ້ ໄຂ ທີ່ ໃຊ້ ໂດຍ ປົກກະຕິ ຈະ ຂ້ຶນ ກັບ ຊັບພະຍາກອນ ທີ່ ມີ ໃຫ້. ສ່ິງ ນ້ີ ລວມມີ: ï ປະ ເພດ ຂອງ ລົດ ເຂັນ ທີ່ ມີ ໃຫ້ – ແລະ ກາ ນປັບ ໃດ ແດ່ ທີ່ ເປັນ ໄປ ໄດ້; ï ວັດ ສະດຸ ທີ່ ມີ ໃຫ້; ï ສ່ິງ ອໍານວຍ ຄວາມ ສະ ດວກ ໂຮງ ສ້ອມ ແປງ ແລະ ເຄື່ອງມື ທີ່ ມີ ໃຫ້; ï ມີ ແນວ ຮອງ ຫຼື ແນ ວປະຄອງທີ່ ຜະລິດ ໄວ້ ກ່ອນ ແລ້ວ ຫຼືບໍ່ – ຕົວຢ່າງ ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ, ແຜ່ນ ຮອ ງຂ້າ ງລໍາ ຕົວ, ສາຍຮດ ແລະ ແນວ ປະ ຄອງຫົວ. ການວາງ ແຜນ ແລະ ການ ດໍາ ເນີນ ການ ກະກຽມ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ວາງ ແຜນ ແລະ ກະກຽມ ກ່ອນ ເລີ່ ມ ກະກຽມລົດ ເຂັນ, ມັນ ສໍາຄັນ ໃນ ການວາງ ແຜນ ໜ້າ ວຽກ . ການວາງ ແຜນ ທີ່ ລະອຽດ ແມ່ນ ສໍາຄັນ ໂດຍ ສະ ເພາະ ຖ້າ ວຽກ ກະກຽມ ລົດ ເຂັນ ກໍາລັງ ຖືກ ມອບ ໝາຍ ໃຫ້ ແກ່ ຄົນ ອື່ນ (ຕົວຢ່າງ ນາຍ ຊ່າງ ທີ່ ເຮັດ ວຽກ ຢູ່ ໃນ ໂຮງ ສ້ ອມ ແປງ); ຫຼື ຖ້າ ມີຫຼາຍກວ່າ ໜຶ່ງ ຄົນ ຈະ ກະກຽມ ລົດ ເຂັນ. ການວາງ ແຜນ ແລະ ການ ກະກຽມ ອາດ ຈະ ລວມມີ ຂ້ັນ ຕອນຕ່ໍ ໄປ ນ້ີ: ກວດ ເບ່ິງ ແບບ ຟອມການ ກໍານົດ ໃຊ້ (ການ ເລືອກ) ລົດ ເຂັນ ລະດັບ ປານ ກາງ: ï ຮັບປະກັນ ວ່າ ທຸກ ຄົນ ເຂົ້າ ໃຈທຸກ ຂ້ໍ ມູນ ຢູ່ ໃນ ແບບ ຟອມນ້ັນ; ï ຮັບປະກັນ ວ່າ ມີ ຂ້ໍ ມູນ ພຽງພໍ ຢູ່ ໃນ ແບບ ຟອມ ເພ່ືອ ໃຫ້ ສາມາດ ກະກຽມ ລົດ ເຂັນ ໄດ້. ຕົວຢ່າງ – ມີທຸກຂະໜາດທ່ີຕ້ອງການຢູ່ໃນນ້ັນແລ້ວບໍ? ການອະທິບາຍລາຍລະອຽດຂອງອຸປະກອນ PSD ຕ່າງໆພຽງພໍແລ້ວຫຼືບໍ່? ອາດຈະຈໍາເປັນຕ້ອງມີການສົນທະນາ ຫຼື ການອະທິບາຍຊ້ີແຈ້ງເພ່ີມເຕີມ. ຕັດສິນໃຈວິທີ ບັນລຸ ໄດ້ ກາ ນຮອງ ຮັບ ທ່ີ ຈໍາ ເປັນ ໃນ ລົດ ເຂັນ ທ່ີ ເລືອກ: ï ກວດ ເບິ່ງລົດ ເຂັນ ທີ່ ຈະ ຖືກ ໃຊ້ ແລະ ຖາມ: – ສາມາດ ເຮັດ ການ ປັບ ໃດ ໄດ້ ແດ່ ຕ່ໍ ກັບ ລົດ ເຂັນຕົວ ຈິງ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ຈໍາ ເປັນ? – ອຸປະກອນ PSD ໃດ ແດ່ ທີ່ຢູ່ ເທິງ ລົດ ເຂັນ ແລ້ວ? ï ຖ້າ ຈໍາ ເປັນ ຕ້ອງ ເພ່ີມ ການ ດັດ ແປງ ຫຼື ອຸປະກອນ PSD, ໃຫ້ ຕັດສິນ ໃຈ: – ມີ ແນວ ຮອງ ທີ່ ຜະລິດ ໄວ້ ກ່ອນ ທີ່ ສາມາດ ຖືກ ໃຊ້ ຫຼືບໍ່? ຖ້າ ມີ – ສ່ິງ ເຫຼົ່ານ້ີ ຈະ ຖືກ ປະກອບ ໃສ່ ລົດ ເຂັນ ແນວ ໃດ? – ຖ້າ ຈໍາ ເປັນ ຕ້ອງ ເຮັດ ການ ດັດ ແປງ ຫຼື ອຸປະກອນ PSD ຈາກ ວັດ ຖຸດິບ – ວັດ ສະດຸ ໃດ ແດ່ ຈະ ຖືກ ໃຊ້ ແລະ ອຸປະກອນ PSD ຈະ ຖືກ ແກ້ ໄຂ ແນວ ໃດ ຕ່ໍ ກັບ ລົດ ເຂັນ? ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 109 ï ຈົ່ງ ຈື່ ວ່າ ຕ້ອງ ຄິດ ກ່ຽວ ກັບ ວ່າ ອຸປະກອນ PSD ແລະ ລົດ ເຂັນ ຈະ ໃຊ້ ໄດ້ ຮ່ວມ ກັນ ແນວ ໃດ. ກະກຽມ ລາຍການ ໜ້າ ວຽກ: ï ລະບຸ ໜ້າ ວຽກ ທີ່ ຈໍາ ເປັນ ຕ້ອງ ດໍາ ເນີນ ເພ່ືອ ກະກຽມ ລົດ ເຂັນ; ï ຖ້າ ຫຼາຍກວ່າ ໜຶ່ງ ຄົນ ກໍາລັງ ເຮັດ ວຽກ – ໃຫ້ ຕັດສິນ ໃຈ ວ່າ ໃຜ ຈະ ຮັບຜິດຊອບ ໜ້າ ວຽກ ໃດ. ສ່ິງ ທ່ີ ຕ້ອງ ຈ່ື ໃນ ເວລາ ເຮັດ ອຸປະກອນ PSD ໃນ ເວລາ ກະກຽມ ລົດ ເຂັນ ທີ່ ມີ ແນວ ຮອງ ຮັບ ທ່າທາງ ເພ່ີມ ເຕີມ, ໃຫ້ ຈື່ ສ່ີ ເຄັດ ລັບ ຕ່ໍ ໄປ ນ້ີ: 1. ອຸປະກອນ PSD ຄວນ ໃຫ້ການ ຮອງ ຮັບ ທ່ີ ພຽງພໍ ຈໍານວນ ການ ຮອງ ຮັບ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແຕ່ລະຄົນ ຈະ ແຕກຕ່າງ ກັນ. ອຸປະກອນ PSD ຄວນ ໃຫ້ການ ຮອ ງຮັບ ທີ່ ຕ້ອງການ ໂດຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ, ໃນ ບ່ອນ ທີ່ ຖືກຕ້ອງ ແລະ ຕ່ໍ ກັບ ຈໍາ ນວນບໍລິ ເວນ ພ້ືນຜິວທີ່ ຖືກ ຕ້ອງ. 2. ອຸ ປະກອນ PSD ແລະ ລົດ ເຂັນ ເຮັດ ວຽກ ຮ່ວມ ກັນເປັນ ລະບົບ ທັງ ໝົດ ການ ເພ່ີມ ແນວ ຮອງ ຮັບ ທ່າ ທາງ ໃສ່ ລົດ ເຂັນ ສາມາດ ປ່ຽນ ລະບົບ ໂດຍ ລວມ ໄດ້. ຕົວຢ່າງ , ການ ເພ່ີມ ອຸປະກອນ PSD ອາດ ຈະ ປ່ຽນ ຂະໜາດ ພາຍ ໃນ ຂອງລົດ ເຂັນ. 3. ຫີຼກ ເວ້ັນການ ສ້າງ ບໍລິ ເວນ ທ່ີ ມີ ການກົ ດທັບ ສູງ ບາ ງຄ້ັງ ອຸປະກອນ PSD ສາມາດ ກ່ໍ ໃຫ້ ເກີດ ການ ກົ ດທັບ ຕ່ໍ ກັບ ສ່ວນ ສະ ເພາະ ໃດ ໜຶ່ງ ຂອງ ຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ຕົວຢ່າງ, ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຕ້ອງການ ການ ຮອງ ຮັບ ຢ່າງ ຫຼວງຫຼາຍ ເພ່ືອປ້ອງ ກັນ ບໍ່ ໃຫ້ ເຂົາ ເຈົ້າ ເອນ ໄປດ້ານ ຂ້າງ, ແຜ່ນ ຮອງຂ້າງ ລໍາ ຕົວ ສາມາດ ເປັນ ບ່ອນ ທີ່ ມີ ການ ກົ ດທັບ ສູງ. ໃນ ສະພາບ ການ ແບບ ນ້ີ, ໃຫ້ ພິຈາລະນາ ແຜ່ ກ ະ ຈາ ຍ ກໍາລັງ ແຮງ ໂດຍ ການ ເພ່ີມ ບໍລິ ເວນ ພ້ືນ ຜິວ. ຈົ່ງ ຮັບປະກັນ ສະ ເໝີ ວ່າ ມີ ການ ຮອງ ທີ່ ພຽງພໍ ໃນ ອຸປະກອນ PSD ແລະ ຢູ່ ຫ້ອງ ສາຍຮັດ. 4. ຮັບປະກັນ ວ່າອຸປະກອນ PSD ແມ່ນ ໃຊ້ ໄດ້ ຈິງ ແລະ ບ່ໍ ໃຫ້ການ ເຄ່ືອນ ໄຫວຮ່າງກາຍ ຫຸຼດລົງ ຈົ່ງ ຈື່ ວ່າ – ຜູ້ ໃຊ້ ລົດ ເຂັນ ຕ້ອງການ ລົດ ເຂັນ ແລະ ບ່ອນ ນ່ັງ ທີ່ ໃຊ້ ໄດ້ ຈິງ ແລະ ໃຊ້ ໄດ້ ງ່າຍ, ແລະ ຊ່ວຍ ພວກ ເຂົາ ໃຫ້ ເຄື່ອນ ໄຫວ ໄດ້ ຫຼາຍ ເທົ່າ ທີ່ ຈະ ເປັນ ໄປ ໄດ້. ຄວາມ ປອດ ໄພ ຂອງ ໂຮງ ສ້ອມ ແປງ – ກົດ ຄວາມ ປອດ ໄພ ຫ້າ ຂ້ໍ: ï ໃສ່ ເກີບ ທີ່ ປົ ກປິດ ຕີນຢູ່ ໃນ ໂຮງ ສ້ອ ມ ແປງ. ï ຮັກສາ ຊ້ິນ ງານ ຂອງ ທ່ານ ໃຫ້ ປອດ ໄພ ໃນ ເວລາ ຕັດ ຫຼື ເຈາະ – ໃຊ້ ເຄື່ອງໜີບ ຫຼື ຮ້ອງ ຂໍ ການ ຊ່ວຍ ເຫຼືອ. ï ໃຊ້ ແວ່ນຕາ ນິລະ ໄພ ໃນ ເວລາ ໃຊ້ ເຄື່ອງມື ໄຟຟ້າ ຫຼື ເຄື່ອງ ທີ່ ມີ ຄົມ ອື່ນ. ï ຮັກສາ ພ້ືນ ທີ່ ເຮັດ ວຽກ ແລະ ທາງ ຍ່າງ ໃຫ້ ເປັນ ລະບຽບ ແລະ ສະອາດ. ï ຢ່າ ຕັດ ເຂົ້າ ຫາ ຕົ ວ ເອງ ຫຼື ຄົນ ອື່ນ. 110 ວັດ ສະດຸ ແລະ ເຄ່ືອງມື ທ່ີ ຈໍາ ເປັນ ໃນ ການ ເຮັດ ອຸປະກອນ PSD ແລະ ການ ດັດ ແປງ ຕາຕະລາງ ຂ້າງ ລຸ່ມ ໃຫ້ ຕົວຢ່າງ ຂອງ ວັດ ສະດຸ ທີ່ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ເຮັດ ອຸປະກອນ PSD. ວັດ ສະ ດຸ ອຸປະກອນ PSD ຫືຼ ການ ດັດ ແປງ ທ່ີ ວັດ ສະດຸ ອາດ ຈະ ຖືກ ໃຊ້ ສໍາລັບ: ສ່ິງ ທ່ີ ຕ້ອງ ກວດ ເບ່ິງ ໃນ ເວລາ ເລືອກ ວັດ ສ ະດຸ ສໍາລັບ ອຸປະກອນ PSD ຫືຼ ການ ດັດ ແປງ: ໂລຫະ/ ປລັສຕິກ/ ໄມ້ ໂລຫະ/ປລັສຕິກ/ ໄມ້ ປະກອບ ເປັນ ໂຄງ ຮ່າງ ຂອງ ອຸປະກອນ PSD ຕົວຢ່າງ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງທ່ີ ແຂງຕາຍ ຕົວ. ສາມາດ ໃຊ້ ໄມ້ ຫຼື ໂລຫະ ເພ່ືອ ສ້າງ ແນວ ອີງ ຫຼັງ ເພ່ືອ ຈັບ ຢຶດ ແຜ່ນຮອງ ຂ້າງ ລໍາ ຕົວ ໃສ່ ກັບ ແນ ວອີງຫັຼງ. ໄມ້ອັດ 12 ມມ ເປັນ ປະ ໂຫຍ ດຫຼາຍສໍາລັບ ການ ເຮັດ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ. ມັນ ແຂງ ແຕ່ ຂ້ອນ ຂ້າງ ມີ ນ້ໍາໜັກ ເບົາ. ໄມ້ອັດ ທະ ເລ ແມ່ນ ຕົວ ເລືອກ ທີ່ ທົນ ທານ ທີ່ ສຸດ; ແນວ ໃດ ກໍ ຕາມ ມັນ ສາມາດ ມີ ລາຄາ ແພງ . ແຜ່ນອາ ລູມີ ນຽມ 3 ມມ ແລະ ແຜ່ນປລັສຕິກ acrylic ຫຼຶ ABS ໜາ 6 ມມ ຖ້າ ມີ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ເຮັດ ແນວ ຮອງ ຫຼັງ ແບບ ແຂງຕາຍ ຕົວ. ການ ເພ່ີມ ແນວ ພັບ ໃສ່ແຜ່ນ ສາມາດ ເພ່ີມ ຄວາມ ແຂງ ຂ້ຶນ ອີກ. ໃນ ເວລາ ໃຊ້ ວັດ ສະດຸ ທີ່ ເປັນ ແຜ່ນ, ໃຫ້ ເອົາ ໃຈ ໃສ່ ເພ່ີມ ເຕີ ມ ເພ່ືອ ເອົາ ອອກ ຫຼືຮອງ ຂອບ ທີ່ຄົມ ເພ່ືອ ຄວາມ ປອດ ໄພ ຂອງ ຜູ້ ໃຊ້ລົດ ເຂັນ. ໂຟມ/ການ ໃສ່ ນວມ ຮອງ ໂຟມຖືກ ໃຊ້ ຢູ່ ເທິງທຸກ ອຸປະກອນ PSD ໃນບໍລິ ເວນ ຕ່າງໆ ທີ່ ສໍາພັດ ໂດຍ ກົງກັບ ຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ໂຟມ ແຂງ, ເຊິ່ງມີ ຮູບ ຮ່າງ ຄົງ ທີ່ ຖືກ ໃຊ້ ເພ່ືອ ຈັດ ຮູບ ຮ່າງ ຂອງ PSD ທີ່ ພວກ ເຂົາ ຕ້ອງການ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ຖື ກຕ້ອງ. ໂຟມທ່ີ ອ່ອນ ກວ່າ ຖືກ ໃຊ້ ເພ່ືອ ເພ່ີມ ຄວາມ ສະບາຍຕົວ ແລະ ຫຼຸດຜ່ອນ ການ ກົ ດທັບ. ຕົວຢ່າງ ຂອງ ການ ໃຊ້ ໂຟມ: ï ຄວນ ເພ່ີມ ໂຟມ ໃສ່ ສາຍ ຮັດ ເພ່ືອກະຈາຍ ກາ ນກົ ດທັບ ແລະ ເພ່ີມ ຄວາມ ສະບາຍ ຕົວ. ï ສາມາດ ໃຊ້ ໂຟມ ແຂງ ເພ່ືອ ເຮັດ ຫຼີ້ມ ຮອງຂ້າງ ລໍາ ຕົວ ຫຼື ເພ່ີມ ໃສ່ ເບາະ ນ່ັງ ເພ່ືອ ເຮັດ ຫຼີ້ມຮອງກົກຂາ ດ້ານ ນອກ ຫຼື ຫຼີ້ມຮອງ ກົກຂາ ດ້ານ ໃນ. ï ໂຟມທ່ີ ແຂງ ຫຼາຍ (ຕົວຢ່າງ ໂຟມ EVA) ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ແນວ ຮອງ ເສີມ ບ່ອນ ວາ ງຕີນ ຫຼື ຫຼີ້ມຮອງ ບ່ອນ ວາງ ຕີນ ແລະ ແຜ່ນ ຮອງ ຂ້າງລໍາ ຕົວ . ຊອກ ເບິ່ງ ໃນຕະຫຼາດທ້ອງ ຖິ່ນ ແລະ ໄປ ເບິ່ງ ໂຮງງານ ຜະລິດ ໂຟມ, ເກີບ, ເສ່ືອ ແລະ ເຄື່ອງ ເຟີ ນີ ເຈີ ເພ່ືອ ຊອກ ຫາ ໂຟມທ່ີ ມີ ໃຫ້ ຢູ່ ພາຍ ໃນ ທ້ອງ ຖິ່ນ. ລອງ ຊອກ ຫາ ຕົວຢ່າງ ໂຟມ ໃນ ທ້ອງ ຖິ່ນ ທີ່ ມີ ຄວາມ ໜາ ແຕກຕ່າງ ກັນ (25 ມມ ຫາ 50 ມມ) ແລະ ຄວາມ ແຂງ ແຕກ ຕ່າງ ກັນ. ໂຟມ EVA ແມ່ນ ຕົວຢ່າງ ຂອງ ໂຟມທ່ີ ແຂງ ຫຼາຍ ເຊິ່ງດີ ສໍາລັບ ການ ໃຫ້ ການ ຮອງຮັບ ແລະ ໂຄງ ສ້າງ ທີ່ ແຂງ ສໍາລັບ ອຸປະກອນ PSD. ບາງ ຄັ້ງ ກ່ໍ ສາມາດ ພົບ ໂຟມ EVA ໄດ້ ຢູ່ໃນ ບ່ອນ ຜະລິດ ເກີບ. ຢາງ ແຂງທ່ີ ໃຊ້ ເພ່ືອ ເຮັດ ເກີບ ແຕະ ກ່ໍ ສາມາດ ຖືກ ໃຊ້ ແທນ ໂຟມ EVA ໄດ້. ໂຟມຊິ ບຄຸນ ນະພາ ບດີ ແມ່ນ ຕົວຢ່າງ ຂອງ ໂຟມທ່ີ ມີ ຄວາມ ແຂງ ປານ ກາງ. ໂຟມຊິ ບສາມາດ ຖືກ ໃຊ້ ເປັນ ຖານ ຂອງ ເບາະນ່ັງ ທີ່ ເປັນ ໂຄງ/ ເປັນ ຊ້ັນ ເພ່ືອ ເຮັດ ແຜ່ນ ຮອງ ກະດູກ ກົກ ແ ອວດ້ານ ຫຼັງ ຫຼືຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຫຼື ເພ່ືອ ເປັນ ໂຄງສໍາລັບ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ. ì ໂຟມ ເສ່ືອî ທີ່ ນຸ້ມ ແມ່ນ ຕົວຢ່າງ ຂອງ ໂຟມທ່ີອ່ອນ ທີ່ ໃຊ້ ສໍາລັບ ຊ້ັນ ຮອງເພ່ືອ ຄວາມ ສະບາຍ ຕົວ. ໂຟມ ìອ່ອນ ນຸ້ມທ່ີ ສຸດî ທີ່ ມີ ໃຫ້ ທົ່ວ ໄປ ແລະ ລາຄາ ບໍ່ ແພງ ບໍ່ ເໝາະ ສົມ ສໍາລັບ ການ ເຮັດ ເບາະບັນ ເທົາ ການ ກົ ດທັບ ໂດຍ ບໍ່ ມີ ຖານ ໂຟມທ່ີ ແຂງ ກວ່າ. ກາບ ໝາກພ້າວ ( ໃຍ ກາກ ໝາກພ້າວ) ສາມາດ ຖືກ ໃຊ້ ແທນ ໂຟມທ່ີ ແຂງ ໄດ້. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 111 ວັດ ສະ ດຸ ອຸປະກອນ PSD ຫືຼ ການ ດັດ ແປງ ທ່ີ ວັດ ສະດຸ ອາດ ຈະ ຖືກ ໃຊ້ ສໍາລັບ: ສ່ິງ ທ່ີ ຕ້ອງ ກວດ ເບ່ິງ ໃນ ເວລາ ເລືອກ ວັດ ສ ະດຸ ສໍາລັບ ອຸປະກອນ PSD ຫືຼ ການ ດັດ ແປງ: ຜ້າ ແພ ຜ້າ ແພ ຖືກ ໃຊ້ ເພ່ືອ ປົກ ອຸປະກອນ PSD. ໃຫ້ ຊອກ ຫາ ຜ້າ ແພ ທີ່ທົນ ທານ ແລະ ອະນາ ໄມ ໄດ້ ງ່າຍ (ດ້ວຍ ການ ເຊັດ ຫຼື ເອົາ ອອກ ມາ ຊັກ). ຜ້າ ກັນ ນ້ໍາ ແມ່ນ ດີ ສໍາລັບ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນຄວບ ຄຸມ ການ ຂ້ີຍ່ຽວ ບໍ່ ໄດ້. ວັດ ສະດຸ ປະ ເພດ ເສື້ອ ຍືດທີ່ ອ່ອນ ນຸ້ມ (ຜ້າ ຝ້າຍ ຫຼື ຜ້າ ຝ້າຍ/ລີ ຄຣາ) ສາມາດ ຖືກ ໃຊ້ ສໍາລັບ ແນວປະຄອງ ຫົວ ແລະ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ແລະ ຫຼີ້ມຮອງ ຂ້າງ ລໍາ ຕົວ. ຜ້າ ແພ ທີ່ ຍືດຂະຫຍາຍ ໄດ້ ຈະ ເຂົ້ າ ກັບ ຮູບຊົງ ຂອງ ອຸປະກອນ PSD ໄດ້ ງ່າຍ ກວ່າ. ຜ້າສັງ ເຄາະ ໂດຍປົກກະຕິ ແລ້ວ ຈະ ເຮັດ ໃຫ້ ຄົນ ເຮົາ ຮ້ອນ ກວ່າ ຜ້າ ທໍາ ມະ ຊາດ. ຖ້າ ສ່ິງ ນ້ີເປັນ ໄປ ໄດ້, ໃຫ້ພະຍາຍາ ມີ ຢ່າງ ໜ້ອຍສອງ ສາມ ສີ ແຕກ ຕ່າງ ກັນ ແລະ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເລືອກ. ສາຍ ເສ້ັນ ແບນ ໄນ ລອນ/ ແທັບ ຢຶດຕິດ Velcro / ຫົວ ເຂັມຄັດ ສາຍ ເສ້ັນ ແບນ ໄນ ລອນ/ ແທັບ ຢຶດຕິດ Velcro/ຫົວ ເຂັມຄັດ ຖືກ ໃຊ້ ເພື່ອ ເຮັດ ສາຍຮັດ ເຊິ່ງລວມມີ ສາຍຮັດ ກົກ ແອວ, ຮາ ຍຮັດ ບ່າ ໄຫ່ຼ, ສາຍຮັດບີ ແຄ່ງ ແລະ ຕີນ. ສາຍ ເນ້ັນ ແບນ ໄນ ລອນ 25 ມມ, 35 ມມ ແລະ 50 ມມ ແມ່ນ ດີ ຫຼາຍ. ສາຍຮັດ ຍິ່ງ ໃຫຍ່ ເທົ່າ ໃດ, ແຮງ ກົ ດທັບ ກ່ໍ ຈະ ສະ ເໝີ ກັນ ເທົ່າ ນ້ັນ. ການ ຈູດ ສ້ົນ ສຸດ ຂອງ ສາຍ ເນ້ັນ ແບນ ໄນ ລອນ ຈະ ເຮັດ ໃຫ້ ເສັ້ນ ໃຍ ພວກມັນ ບໍ່ຫຼຸດອອກ. ຜ້າ ຝ້າຍ ມີ ປະສິດທິ ຜົນ ໜ້ອຍ ກວ່າ ຫຼາຍ. ຫົວ ເຂັມຄັດ ( ເຊັ່ນ ວ່າ ອັນ ທີ່ ໃຊ້ ຢູ່ ໃນຖົງ ເປ້) ສາມາດ ໃຊ້ ໄດ້ ງ່າຍ ທີ່ ສຸດ. ໃຊ້ ຫົວ ເຂັມຄັດ ຄຸນ ນະພາ ບດີ ຖ້າ ມີ ໃຫ້ ເພາະວ່າມັນ ຈະ ໃຊ້ ໄດ້ ດົນ ກວ່າ. ທົດ ລອງ ພວກ ມັນ ໂດຍ ການ ສູບ ພວກ ມັນ ໃສ່ ກັນ ແລະ ພະຍາຍາມ ດຶງ ພວກ ມັນ ອອກ. ພວກ ມັນ ຄວນ ຈັບ ຕິດ ກັນ ແລະ ບໍ່ຫຼຸດອອກ ງ່າຍໆ, ແລະ ບໍ່ຫຼຸດອອກ ຈາກ ກັນ ເວັ້ນ ເສຍ ແຕ່ວ່າ ມີ ການ ປ່ອຍ ແລ້ວ. ແຖບ ຕິດ Velcro ແມ່ນ ແນວ ຢຶດເກາະ ທີ່ ດີ, ແນວ ໃດ ກ່ໍຕາມ ຈໍາ ເປັນ ຕ້ອງ ຮັກສາ ໃຫ້ ມັນ ສະອາດ ຖ້າ ບໍ່ ດັ່ງ ນ້ັນ ມັນ ຈະ ໃຊ້ ບໍ່ ໄດ້. ຄວນ ໃສ່ ແຜ່ນ ຮອງທ່ີ ເປັນ ໂຟມອ່ອນຢູ່ ກ້ອງ ສາຍຮັດ ທຸກ ອັນ ເພ່ືອ ປົກ ປ້ອງ ຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ້ລົ ດ ເຂັນ. ກາວ ກາວ ຖືກ ໃຊ້ ເພ່ືອ ຕິດ ໄມ້ ແລະ ໂຟມ . ໃຊ້ ກາ ວຕິດ ໄມ້ ( ໂດຍ ທົ່ວ ໄປ ເອີ້ນ ວ່າ ກາວ ຂາວ ຫຼືກາວ PVA) ແລະ ກາວ ຕິດ ໂຟມ (ການ ຕິດ ສໍາພັດ, ກາວຕິດ ເກີບ ຫຼື ກາວ ເຫຼືອງ). ຮັບປະກັນ ວ່າ ທຸກ ຄົ ນທ່ີ ໃຊ້ ກາວ ຮູ້ ວິທີ ໃຊ້ ພວກ ມັນ ຢ່າງ ຖືກຕ້ອງ. ແນວ ຢຶດເກາະ ແນວຢຶດ ເກາະ ຖືກ ໃຊ້ ເພ່ືອ ຕິດ ອຸປະກອນ PSD ໃສ່ ກັບ ລົດ ເຂັນ. ແນວ ເກາະ ທີ່ ເປັນ ປະ ໂຫຍ ດລວມມີ: ï ກຽວ ທີ່ ມີ ນັອດຫັນ ຈັບ (ດີ ແທ້ ແມ່ນ ນັອດລັອກ) ແລະ ແຫວນ ຮອງ; ï ນັອດ ໂຕ T (ຕິດ ກັບ ໄມ້ອັດ ແທນ ນັອດທໍາ ມະ ດາ); ï ເຫຼັກຫຍິບ (ສໍາລັບ ການ ຫຍິບຕິດ ແນວ ຫຸ້ມ ເບາະ). ຫຼີກລຽງ ການ ໃຊ້ ນັອດ ກຽວແຫຼມ ເພາະວ່າ ພວກ ມັນ ຈະ ເປັ ນອັນຕະລາຍ ຖ້າ ອຸປະກອນ PSD ເພ. 112 ສ່ິງ ອໍານວຍ ຄວາມ ສະ ດວກ ໂຮງ ສ້ອມ ແປງ ແລະ ເຄ່ືອງມື : ການ ບໍລິການ ທີ່ ກໍາລັງ ສ້າງອຸປະກອນ PSD ຢ່າງ ເປັນ ປົກກະຕິ ຈະ ໄດ້ ປະ ໂຫຍ ດຈາກ ການ ສ້າງ ຕ້ັງ ພ້ືນ ທີ່ ໂຮງ ສ້ອມ ແປງ ເຊິ່ງມີ ໂຕະ ເຮັດ ວຽກນາຍ ຊ່າງ ແລະ ຄີມ ຈັບ, ພ້ືນ ທີ່ ເກັບ ມ້ຽນວັດ ສະດຸ ແລະ ເຄື່ອງມື, ແສງ ສະຫວ່າງ ແລະ ການ ລະບາຍ ອາກາດ ທີ່ ດີ. ຕາຕະລາງ ຂ້າງ ລຸ່ມ ໃຫ້ ຕົວຢ່າງ ຂອງ ເຄື່ອງມື ທີ່ຈະ ຊ່ວຍ ໄດ້ ໃນ ການ ສ້າງ ອຸປະກອນ PSD. ເຄ່ືອງມື ທ່ີ ເປັນປະ ໂຫຍ ດ: ຖືກ ໃຊ້ ສໍາລັບ : ເລື່ອຍ ມື ຕັດໄມ້, ປລັດສະຕິກ ຫຼື ໂລຫະໂດຍບໍ່ມີໄຟຟ້າ. ເລື່ອຍໄຟຟ້າ ຕັດໄມ້, ປລັດສະຕິກ ຫຼື ໂລຫະ (ກວດເບິ່ງວ່າໃຊ້ໃບເລື່ອຍທີ່ ຖືກຕ້ອງ ສໍາລັບ ວັດ ສະດຸ ທີ່ ຈະ ຕັດ) ຢູ່ ບ່ອນ ທີ່ ມີ ໄຟຟ້າ. ສະຫວ່ານ ເຈາະ ແລະ ດອກ ສະ ຫວ່ານ ເຈາະຮູ ສໍາລັບ ນັອດ ໂຕ ຜູ້. ໃບ ເລື່ອຍທີ່ຄົມ ແລະ ແຂງ ຕັດ ໂຟມ ໂດຍ ບໍ່ ມີ ໄຟຟ້າ. ເລື່ອຍ ມື ຕັດ ໄມ້, ປລັກ ສະຕິ ກ ແລະ ໂຟມຢູ່ ບ່ອນ ທີ່ ມີ ໄຟຟ້າ. ເຫຼັກສະ ໄບ ເຫຼົາຂອບ ໄມ້, ໂລຫະ ຫຼື ປລັດ ສະຕິ ກ ໃຫ້ ລຽບ. ເຄື່ອງ ຈັກຂັດ ຊາຍ ເຫຼົາຂອບ ໄມ້, ໂລຫະ ຫຼື ປລັດ ສະຕິ ກ ໃຫ້ ລຽບ ຢູ່ ບ່ອນ ທີ່ ມີ ໄຟຟ້າ. ກະ ແຈ ເລື່ອນ ຫັນ ນັອດ ໂຕ ແມ່ ແລະ ນັອດ ໂຕ ຜູ້ ໃຫ້ ແໜ້ນ ເຄື່ອງ ຫຍິບ ອຸດສາຫະກໍາ ຫຍິບ ຜ້າ ຫຸ້ມ ເບາະ, ຜ້າ ປົກ ແລະ ສາຍຮັດ. ວິທີ ເຮັດ ອຸປະ ກອນ PSD ສ່ິງ ຕ່ໍ ໄ ປນ້ີ ໃຫ້ ຄໍາ ແນະນໍາ ສໍາລັບ ວິທີ ເຮັດ ອຸປະກອນ PSD ທີ່ ເວົ້າ ເຖິງ ໃນ ຫຼັກສູດ ຝຶກ ອົບຮົມ ນ້ີ. ສາມາດ ນໍາ ໃຊ້ຫຼາຍໆ ຫຼັກການຕ່ໍ ກັບ ອຸປະ ກອນ PSD ອື່ນ. ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຖືກ ເຮັດ ຈາກ ແຜ່ນ ໂຟມທ່ີ ແຂງ ຫຼື ວັດ ສະດຸ ຄ້າຍຄື ກັນ ທີ່ ມີ ໂຟມອ່ອນ ນຸ້ມປົກ ເທິງ. ສາມາດ ວາງ ຖ້ານ ຮອງ ໃສ່ ກ້ອງ ໂຟມອ່ອນ ຂອງ ບ່ອ ນນ່ັງ ທີ່ ແຂງ ຫຼື ລະຫວ່ງສອງ ຊ້ັນ ຂອງ ເບາະ ຮອງ ນ່ັງ ທີ່ ມີ ໂຟມ ເປັນ ຊ້ັນ. ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ອາດ ຈະ ເປັນ ສ່ວນ ໜຶ່ງ ຂອງ ເບາະ ຮອງ ນ່ັງ ບັນ ເທົາ ການ ກົ ດທັບ. ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຄວນ ຕິດ ແປະ ກັບ ດ້ານ ໜ້າ ຂອງ ກະດູກ ຮອງ ນ່ັງ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 113 ດ້ານ ໜ້າ ບ່ອນ ນ່ັງທ່ີ ຕ່ໍາ ລົງ (ໜ່ຶງ ຂ້າງ) ສາມາດ ຄຸ້ມ ຄອງອຸປະກອນ PSD ໄດ້ ໂດຍ ການ ດັດ ແປງ ເບາະ ຮອງ ນ່ັງ ແບບ ໂຟມ. ຕັດ ໂຟມ ແຂງ ອອກ (ບໍ່ ແມ່ນ ໂຟມອ່ອນ) ຢູ່ ດ້ານ ໜ້າ ຂອງ ບ່ອນ ນ່ັງ ເປັນ ມຸມ ທີ່ ຕ້ອງການ. ແຜ່ນ ໂຟມທ່ີ ຕັດ ອອກ ຈະ ແມ່ນ ຫຼີ້ມຮອງ ທີ່ ມີ ສ້ົນ ໜາ ຢູ່ ດ້ານ ໜ້າ ຂອງ ບ່ອນ ນ່ັງ ແລະ ສ້ົນ ບາງ ຢູ່ ດ້ານ ໜ້າ ຂອງ ກະດູກ ກົກ ແອວ ຫຼື ກະດູກ ຮອງ ນ່ັງ. ຖ້າ ໃຊ້ ບ່ອນ ນ່ັງ ແຂງ ແລະ ຈໍາ ເປັນ ຕ້ອງ ມີ ມຸມ ກວ້າງ, ສາມາດ ຕັດ ສ່ວນ ໜຶ່ງ ຂອງ ກະດານ ບ່ອນ ນ່ັງ ອອກ ເພ່ືອ ອະນຸຍາດ ໃຫ້ ສະ ໂພ ກ ເປີດອອກ ກວ່າ. ໝາຍ ເຫດ: ໂດຍ ການ ຮັກສາ ໃຫ້ ສະ ໂພ ກອີກ ຂ້າງ ກ່ົງ ມັນ ງ່າຍ ກວ່າ ສໍາລັບ ຜູ້ ໃ ຊ້ໃນ ການ ຮັກສາບ່ໍ ໃຫ້ ເລື່ອນ ໄປ ໜ້າ ໃນ ບ່ອນນ່ັງ. ຖ້າ ຕ້ອງການ ມີມຸມ ກວ້າງ ມັນ ອາດ ຈະ ຈໍາ ເປັນ ໃນ ການຮອງ ເສີມ ທັງ ໝົດ ບ່ອນ ນ່ັງ ດ້ວຍ ໂຟມ ແຂງ ຢູ່ ສ່ວນ ລຸ່ມ ກ່ອນ ທີ່ ຈະ ດັດ ແປງ ແຕ່ ຮັບປະກັນ ບໍ່ ໃຫ້ ຂອບ ຄົມ – ຂອບ ທັງ ໝົດ ຈໍາ ເປັນ ຕ້ອງ ໄດ້ ລົບ ມຸມ. ກວດ ເບິ່ງ ວ່າ ພ້ືນ ຜິວ ບ່ອນ ນ່ັງ ທີ່ ສູງ ກວ່າ ຈະ ບໍ່ ກ່ໍ ໃຫ້ ເກີດ ບັນຫາ ກັບ ຄວາມ ສູງບ່ອນ ວາງ ຕີນ ຫຼື ແນວ ອີງ ຫຼັງ. ສ່ວນ ໜ້າ ບ່ອນ ນ່ັງ ທ່ີ ຍົກສູງ ຂ້ຶນ ອາດ ຈະ ຍົກສ່ວນ ໜ້າ ບ່ອນ ນ່ັງ ຂ້ຶນ ໃນ ແບບ ວິທີ ແຕກ ຕ່າງ ກັນ. ສອງ ຄໍາ ແນະນໍາ ມີ ຄື: ວາງ ຫຼີ້ມຮອງ ທີ່ ເປັນ ໂຟມ ແຂງ ຢູ່ ກ້ອ ງສ່ວນ ໜ້າ ຂອງ ເບາະ ຮອງ ນ່ັງ ໂດຍ ສຸດ ພໍດີ ຢູ່ ດ້ານ ໜ້າ ຂອງ ກະດູກ ກົກ ແອວ. 114 ເອົາ ບ່ອນ ນ່ັງ ແບບ ຜ້າ ໃບອອກ ແລະ ໃຫ້ບ່ອນນ່ັງແບບແຂງ. ເຊື່ອມ ຕ່ໍບ່ອນນ່ັງກັບ ແນວ ອີງ ຫຼັງຢູ່ ໃນ ມຸມ ທີ່ ຈໍາ ເປັນ. ໃຫ້ ເບາະ ຮອງ ນ່ັງ ທີ່ ມີ ບ່ອນ ນ່ັງ ແບບ ແຂງ ສະ ເໝີ. ຫ້ີຼມຮອງ ສໍາລັບ ການ ອ່ຽງ ໄປທາງ ໜ້າ ສາມາດ ເຮ ັດຫຼີ້ມຮອງ ສໍາລັບ ການ ອ່ຽງ ໄປ ໜ້າ ໄດ້ ໂດຍ ການ ໃຊ້ ຫຼັກການ ດຽວ ກັນ ກັບ ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ. ຊ້ັນ ຖານ ທີ່ ເປັນ ໂຟມ ແຂງ ໃຫ້ ຮູ ບຊົງ ສໍາລັບ ເບາະ ຮອງ ນ່ັງ ແລະ ຊ້ັນ ໂຟມອ່ອນ ຖືກ ວາງ ປົກ ໜ້າ ເທິງ. ຫຼີ້ມຮອງ ຄວນ ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ຢຸດ ພໍດີ ຢູ່ ດ້ານ ຂອງ ກະ ດູກ ຮອງ ນ່ັງ. ເບາະ ຮອງ ນ່ັງ ຄວນ ພຽງ ກັນ ຢູ່ ກ້ອງ ກົກຂາ. ແນວ ຮອງ ເສີມຢູ່ ກ້ອງ ກະດູກ ກົກ ແອວ ແນວ ຮອງ ເສີມ ຢູ່ ກ້ອງ ກະດູກ ກົກ ແອວ ຖືກ ເຮັດ ຈາກ ແຜ່ນ ໂຟມທ່ີ ແຂງ ຫຼື ວັດ ສະດຸ ຄ້າຍຄື ກັນ ທີ່ ມີ ຊ້ັນອ່ອນ ນຸ້ມປົກ ເທິງ. ຮອງ ເສີມ ຢູ່ ກ້ອງ ຂ້າງກົກຂາຈົນ ກວ່າ ວ່າ ຄວາມ ກົ ດທັບ ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ທັງ ສອງ ເບື້ອງຮູ້ສຶກ ຄື ກັນ. ແຜ່ນ ຮອງຂ້າງກະດູກ ກົກ ແອວ ສາມາດ ເຮັດແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ໃນ ຫຼາຍ ແບບ ແຕກ ຕ່າ ງກັນ ໂດ ຍຂຶ້ນ ກັບ ລົດ ເຂັນ ທີ່ ພວກ ມັນ ຈະ ຖືກ ຕິດ ໃສ່ ແລະ ການ ຮອງ ຮັບ ຫຼາຍປານ ໃດ ທີ່ ຕ້ອງການ. ບາງ ຄໍາ ແນະນໍາ ລວມມີ: ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 115 ï ຖ້າ ມີ ບ່ອນ ວາງ ແຂນ ທີ່ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ໃຫ້ ໂຄງ ຮ່າງ/ການ ຮອງ ສໍາລັບ ແຜ່ນ ຮອງ, ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ສາມາ ຖືກ ເຮັດ ຈາກ ແຜ່ນ ໂຟມຫຸ້ມ ເບາະ ທີ່ ແຂງ ຕິດ ໃສ່ ກັບ ບ່ອນ ວາງ ແຂນ. ຢູ່ ບ່ອນ ທີ່ ບ່ອນ ວາງ ແຂນ ເປີດ ຢູ່ (ຕາມ ຮູບ ປະ ກອບ ນ້ີ ຢູ່ ເບ້ືອງຊ້າຍ ມື), ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ແບບ ແຂງ ອາດ ຈະ ຖືກ ເຮັດ ຈາກ ແຜ່ນ ໄມ້ ທີ່ ມີ ໂຟມອ່ອນ ກວ່າ ຕິດ ໃສ່ ດ້ານ ໃນ. ນ້ີ ຄວນ ຈະ ຖືກ ຫຸ້ມ ເບາະ. ຕິດ ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ໃສ່ ໂຄງ ລົດ ເຂັນ ຫຼື ບ່ອນ ນ່ັງ ທີ່ ແຂງ (ດັ່ງ ທີ່ ສະ ແດງ) ທີ່ ມີ ເຫຼັກ ເກາະ. ໃນ ຮູບ ສະ ແດງ ຢູ່ ເບື້ອງ ຊ້າຍ, ເບາະ ຮອງ ນ່ັງ ຈະ ຢູ່ ສ່ວນ ເທິງ ຂອງ ເບາະ ນ່ັງ ແບບ ແຂງ, ໂດຍ ປົກ ປ້ອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈາກ ເຫຼັກ ເກາະ ແລະ ນັອດ. ຫ້ີຼມຮອງ ກົກຂາ ດ້ານ ນອກ ຕັດ ທ່ອນ ໂຟມຊະນິດ ແຂງ (100 ມມ x 100 ມມ x 40 ມມ) ເປັນ ແນວ ອ່ຽງ ເຄິ່ງໜ່ຶງ ເພ່ືອ ສ້າງ ຫຼີ້ມຮອງ ສອງ ອັນ. ຮັກສາ ສ່ວນ ທີ່ ເຫຼືອຂອງ ທ່ອນ ໂຟມ ເຫຼົ່ານ້ີ ໄວ້ ໃຊ້ ໃນ ລະຫວ່າງ ການ ປັບ ລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ. ຕິດ ກາວ ຫຼີ້ມຮອງ ໃສ່ ກັບ ໂຟມທ່ີ ເປັນ ຖານ ຂອງ ເບາະ ຮອງ ນ່ັງ ແລະ ຢູ່ ກ້ອງ ໂຟມທ່ີ ອ່ອນ. ຕັດເລັມແຈ ຕາມ ທີ່ ຈໍາ ເປັນ. 116 ຖ້າ ໃຊ້ ເບາະ ຮອງ ນ່ັງ ແບບ ຕິດ ໂຟມ, ຊອຍ ເບາະ ຮອງ ນ່ັງ ທາງ ນອນ (ປະມານ 20 ມມຈາກ ພ້ືນ ຜິ ວສ່ວນ ເທິງ) ແລະ ຕິດ ກາວ ຫຼີ້ມ ໃຫ້ ເຂົ້າ ທີ່. ຕັດ ເລັມ ສ່ວນ ໂຟມທ່ີ ພ້ົນ ອອກ ມາ. ແຜ່ນ ຮອງ ກົກຂາ ດ້ານ ນອກ ແຜ່ນ ຮອງ ເຫຼົ່ານ້ີ ຖືກ ເຮັດ ໃນ ແບບ ທີ່ ຄ້າຍ ຄື ກັນ ກັບ ແຜ່ນ ຮອງຂ້າງລໍາ ຕົວ. ໂດຍປົກກະຕິແລ້ວ ພວ ກມັນ ຖືກ ເຮັດ ຈາກ ແຜ່ນ ໄມ້, ປລັດ ສະຕິ ກ ຫຼື ໂລຫະ ທີ່ມີ ໂຟມ ແຂງ ຢູ່ ດ້ານ ໃນ (ຂ້າງ ທີ່ ສໍາພັດກັບ ຂາ ຜູ້ ໃຊ້) ແລະ ຊ້ັນ ໂຟມອ່ອນ. ແຜ່ນ ຮອງ ຖືກ ຫຸ້ມດ້ວຍ ຜ້າ ຫຸ້ມ ທີ່ທົນ ທານ ແລະ ສະບາຍ ຕົວ. ແຜ່ນ ຮອງ ສາມາດ ຕິດ ຄົງ ທີ່ ໃສ່ ກັບ ບ່ອນ ນ່ັງ ທີ່ ແຂງ ດ້ວຍ ເຫຼັກ ເກາະ ຫຼື ເກາະ ຕິດ ໃສ່ ຮາວ ບ່ອນ ນ່ັງ ລົດ ເຂັນ. ຫ້ີຼມຮອງ ກົກຂາ ດ້ານ ໃນ ຕັດຫຼີ້ມຮອງ (ກວ້າງ 50 ມມ x ຍາວ 100 ມມ) ເປັນ ເຄິ່ງໜ່ຶງ ເພ່ືອ ສ້າງ ສອງ ແຜ່ນ ທີ່ ເທົ່າ ກັນ. ຮັກສາ ສ່ວນ ທີ່ ເຫຼືອຂອງ ໂຟມ ເຫຼົ່ານ້ີ ໄວ້ ໃຊ້ ໃນ ລະຫວ່າງ ການ ປັບ ລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ. ຕິດ ກາວ ໃສ່ ໂຟມທ່ີ ເປັນ ຖານ ຂອງ ເບາະ ຮອງ ນ່ັງ ແລະ ຢູ່ ກ້ອງ ໂຟມທ່ີ ອ່ອນ. ຖ້າ ໃຊ້ ເບາະ ຮອງ ນ່ັງ ແບບ ຕິດ ໂຟມ, ຊອຍ ເບາະ ຮອງ ນ່ັງ ທາງ ນອນ (ປະມານ 20 ມມຈາກ ພ້ືນ ຜິ ວສ່ວນ ເທິງ) ແລະ ຕິດ ກາວ ໃຫ້ ເຂົ້າ ທີ່. ຕັດ ເລັມ ສ່ວນ ໂຟມທ່ີ ພ້ົນ ອອກ ມາ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 117 ແຜ່ນ ແຍກ ຫົວ ເຂ່ົາ ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ມັກ ຈະ ຖືກ ເຮັດ ຈາກ ແຜ່ນ ໂລຫະ , ປລັດ ສະຕິ ກ ຫຼື ໄມ້ ທີ່ ມີ ໂຟມ ແຂ ງປົກ ເທິງ, ຂ້າງ ແລະ ຫຼັງ (ພ້ືນ ຜິວ ທີ່ ສໍາພັດກັບ ຜູ້ ໃຊ້). ສາມາດ ໃຊ້ ໂຟມບາງອ່ອນ ປົກ ເທິງ ໂຟມ ແຂງ ເພ່ືອ ຄວາມ ສະບາຍ ຕົວ. ແຜ່ນ ຮອງ ອາດ ຈະ ຖືກ ຫຸ້ມດ້ວຍ ຜ້າ ຫຸ້ມ ທີ່ທົນ ທານ ແລະ ສະບາຍ ຕົວ. ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນຕ້ອງການ ມີ ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ, ມັນ ດີ ທີ່ ສຸດ ໃນ ການ ໃຫ້ ພວກ ມັນ ກັບ ບ່ອນ ນ່ັງ ແຂງ ຕາຍ ຕົວ. ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ສາມາດ ຕິດ ໃສ່ ບ່ອນ ນ່ັງ ແຂງທີ່ ມີ ເຫຼັກ ເກາະ ຮູບ ໂຕ L (ດັ່ງ ຮູບ ສະ ແດງ). ວິທີ ງ່າຍດາຍ ແລະ ໃຊ້ ງ່າຍ ໃນ ການ ເອົາ ອອກ ຫຼື ຫວ່ຽງ ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ແມ່ນຈໍາ ເປັນ , ເພ່ືອ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ເຄື່ອນ ຍ້າຍ ເຂົ້າ ແລະ ອອກ ຈາກ ລົດ ເຂັນ ໄດ້ ງ່າຍ. ມຸມ ເປີດ ລະຫວ່າງ ບ່ອນ ນ່ັງ ຫາ ແນວ ອີງ ຫັຼງ ວິທີ ໜຶ່ງ ໃນ ການ ເຮັດ ໃຫ້ ມຸມ ແຕ່ບ່ອນ ນ່ັງ ຫາ ແນວ ອີງ ຫຼັງເປີດ ອອກກວ່າ ແມ່ນ ການ ເພ່ີມ ຫຼີ້ມຮອງ ແບບ ໂຟມ ແຂງ ໃສ່ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ຢູ່ ໃນ ມຸມ ທີ່ ຕ້ອງການ. ນ້ີ ຄວນ ຈະ ຖືກ ປົກ ດ້ວຍ ຊ້ັນ ໂຟ ມທ່ີ ອ່ອນ. ການ ອ່ຽງ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫັຼງ (ການ ອ່ຽງ ໃນ ກາງຫາວ) ບາງ ລົດ ເຂັນ ລວມມີ ຄຸນສົມບັດ ເຊິ່ງອະນຸຍາດ ໃຫ້ ທ່ານ ອ່ຽງບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງ ໄດ້ ງ່າຍດາຍ. ຄໍາ ແນະນໍາ ຕ່ໍ ໄປ ນ້ີ ແມ່ນ ສໍາລັບ ລົດ ເຂັນ ສ່ວນ ໃຫຍ່ ທີ່ ໃຊ້ ກັນ ເຊິ່ງບ່ໍ ມີ ຄຸນສົມບັດ ນ້ີ. 118 ສໍາລັບ ລົດ ເຂັນ ໂດຍ ບໍ່ ມີ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງທ່ີ ແຂງ ໃຫ້ ວາງ ຫຼີ້ມຮອງ ແບບ ໂຟມ ແຂງ ຢູ່ ກ້ອງ ດ້ານ ໜ້າ ຂອງ ເບາະ ຮອງ ນ່ັງ ແລະ ປັບ ຫຼື ເອນ ແນວ ອີງ ຫຼັງ. ປ່ຽນ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງ ແບບ ຜ້າ ໃບ/ ແກວ່ງ ໂຍກ ໄດ້ ດ້ວຍ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ. ຕິດ ເຫຼັກ ເກາະ ເພ່ືອ ບັນລຸ ໄດ້ ມຸມ ທີ່ ຕ້ອງການ ສໍາລັບ ທັງ ບ່ອນ ນ່ັງ ແລະ ເຫຼັກ ເກາະ. ຈັດ ລຽງ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ທີ່ ມີ ໂຟມ ແຂງ ແລະ ຈາກ ນ້ັນ ຊ້ັນ ໂຟມອ່ອນ ແລະ ແນວ ຫຸ້ມ ເບາະ. ໃຫ້ ເບາະ ຮອງ ນ່ັງ ທີ່ ມີ ບ່ອນ ນ່ັງ ແບບ ແຂງ ສະ ເໝີ. ຮູບ ສະ ແດງ ນ້ີ ໃຫ້ ຕົວຢ່າງ ເພ່ີມ ເຕີມກ່ຽວ ກັບ ເຫຼັກ ເກາະ ທີ່ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ຕິດ ບ່ອນ ນ່ັງ ຫຼື ແນວ ອີ ງຫັຼງ ແບບ ແຂງ ໃສ່ ທໍ່. ເຫຼັກ ເກາະ ສາມາດ ເປີດ ອອກ ໄດ້ ໂດຍ ກາ ນຫັນ ເຫຼັກລັອກ. ນ້ີ ອະນຸຍາດ ໃຫ້ ເອົາ ບ່ອນ ນ່ັງ ແລະ ແນວ ອີງ ຫຼັງອອກ ໄດ້ ສໍາລັບ ການ ຂົນ ສ່ົງ (ຖ້າ ລົດ ເຂັນ ແມ່ນ ລົດ ເຂັນ ແບບ ພັບ ໄ ຂວ່). ແຜ່ນ ຮອງ ຫັຼງກະດູກ ກົກ ແອວ ແຜ່ນ ຮອງ ຫຼັງກະດູກ ກົກ ແອວ ບໍ່ ຄວນ ຢູ່ ເລິກ ເກີນ ໄປ. ໂດຍ ຂ້ຶນ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ, ແຜ່ນ ຮອງ ອາ ດຈະ ເລິກ 20–30 ມມ. ແຜ່ນ ຮອງ ຄວນ ໃຫ້ການ ຮອງ ຮັບ ຢູ່ ລະດັບ PSIS ສະ ເໝີ. ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ຜິວໜັງ ອ່ອນ ໄຫວ ຫຼື ກະດູກ ສັນຫັຼງທ່ີ ມີ ແຕ່ ກະດູກ, ສາມາດ ເຈາະ ໂຟມ ໃຫ້ ຊອດ ບ່ອນ ທີ່ ມັນ ຊອດ ຜ່ານ ກະດູກ ສັນຫັຼງ ເພ່ືອ ຫຼີກ ເວັ້ນການ ກ່ໍ ໃຫ້ ເກີດບໍລິ ເວນ ກົ ດທັບ. ວິທີ ຕ່າງໆ ໃນ ການ ເຮັດ ແຜ່ນ ຮອງ ຫຼັງກະດູກ ກົ ກ ແອວ ແມ່ນ ສະ ແດງ ຢູ່ ຂ້າງ ລຸ່ມ: ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 119 ແຜ່ນ ຮອງ ຫຼັງກະດູກ ກົກ ແອວ ສາມາດ ຖືກ ເຮັດ ຈາກ ແຜ່ນ ໂຟມຫຸ້ມ ເບາະ ແຂງ ທີ່ ຮັດ ຢູ່ ດ້ານ ໜ້າ ຂອງ ຜ້າ ຫຸ້ມ ແນວ ອີງ ຫຼັງ ແບບ ໂຍກ ໄປມາ ໄດ້. ສາມາດ ຮັດ ສ່ິງ ນ້ີ ດ້ວຍ ສາຍຮັດ ໃສ່ ກັບ ເສົາ ຕ້ັງ ຂອງ ແນວ ອີງ ຫຼັງ. ແຜ່ນ ໂຟມ ແຂງ ທີ່ ປະກອບ ເປັນ ແຜ່ນ ຮອງ ຫຼັງກະດູ ກກົກ ແອ ວອາດ ຈະ ຖືກ ເ ຊ່ື ອມຕ່ໍ ກັບ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ທີ່ ມີ ຊ້ັນ ໂຟມອ່ອນປົກ ເທິງ. ຄວນ ມີ ຊ້ັນ ໂຟມອ່ອນ ທີ່ ພຽງພໍ ເພ່ືອ ຮັບປະກັນ ວ່າ ທັງ ໝົດ ແນວ ອີງ ຫຼັງ ແມ່ນ ສະບາຍ ຕົວ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ຖ້າ ບໍ່, ຄວນ ວາງຊ້ັນ ໂຟມ ແຂງ ໃສ່ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ, ຈາກ ນ້ັນ ວາງ ແຜ່ນ ຮອງ ຫຼັງກະດູກ ກົ ກ ແອວ ແລະ ໂຟມອ່ອນ ປົກ ເທິງ. ຖ້າ ເຊື່ອມ ຕ່ໍ ກັບ ສາຍຮັດ ແຂງ ແຮງ, ສາມາດ ຕິດ ແຜ່ນ ຮອງ ຫຼັງກະດູກກົກ ແອວ ໃສ່ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ຈາກ ດ້ານ ຫຼັງຂອງ ຜ້າ ຫຸ້ມ ແນວ ອີງ ຫຼັງ ແບບ ໂຍກ ໄປມາ ໄດ້. ໃນ ກໍລະນີ ນ້ີ ສາມາດ ຜູກສາຍຮັດ ບີ ແຄ່ງ ເພ່ີມ ເຕີມ ໃນ ບໍລິ ເວນ ເສົາ ຕ້ັງ ຊ່ື ຂອງ ແນວ ອີງ ຫຼັງຢູ່ ໃນ ລະດັບ ຄວາມ ສູງ ທີ່ ຕ້ອງການ ແລະ ປັບ ເຄ່ັງ ຕາມ ທີ່ ຈໍາ ເປັນ ໂດຍ ໃຊ້ ສາຍຕິດ Velcro. ການ ເອນ ແນວ ອີງ ຫັຼງ ແລະ/ຫືຼ ປັບ ຮູບ ຊົງ ຂອງ ແນວ ອີງ ຫັຼງ ມີ ເຫດຜົນ ດ້ານ ທ່າ ທາງ ທີ່ ແຕກ ຕ່າງ ກັນ ທີ່ ອະທິບາຍຍ້ອນ ຫຍັງ ມັນ ຈິ່ງ ສາມາດ ເປັນ ປະ ໂຫຍ ດ ໃນ ການ ເອນ ແນວ ອີງ ຫຼັງ. ຖ້າ ລົດ ເຂັນ ບໍ່ ມີ ຄຸນສົມບັດ ທີ່ ປັບ ໄດ້ ທີ່ ມາ ພ້ອມ ໃນ ຕົວ ຫຼື ບໍ່ ມີ ແນວ ອີງ ຫຼັງ ແບບ ປັບ ຄວາມ ເຄັ່ງ ໄດ້, ສາມາດ ເຮັດ ການ ຮອງ ຮັບ ໄດ້ ໂດຍ ການ ດັດ ແປງລົດ ເຂັນ. ລຸ່ມ ນ້ີ ແມ່ນ ສອງ ທາງ ເລືອກ: 120 ດ້ວຍ ລົດ ເຂັນ ທີ່ ມີ ແນວ ອີງ ຫຼັງ ແບບ ໂຍກ ໄປມາ ໄດ້, ໃຫ້ ເອົາ ຜ້າ ຫຸ້ມ ແນວ ອີງ ຫຼັງອອກ ແລະ ຕິດ ຕ້ັງແນວ ອີງ ຫັຼງ ແບບ ແຂງ ຢູ່ ໃ ນມຸມ ເອນ ທ່ີ ຕ້ອງການ. ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ສາມາດ ເຮັດ ຈາກ ໄມ້ອັດ (ຢ່າງ ໜ້ອຍຕ້ອງ ໜາ 12 ມມ). ເຫຼັກ ເກາະ ແບບ ປັບ ໄດ້ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ຕິດ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ໃສ່ ຂາ ຕ້ັງ ຂອງ ແນວອີງ ຫຼັງ. ດັດ ແປງ ຜ້າ ຫຸ້ມ ແນວ ອີງ ຫຼັງ ແບບ ໂຍກ ໄປມາ ໄດ້ທີ່ ມີ ຢູ່ ແລ້ວ: ï ເຮັດ ການ ຕັດ ທາງ ຕ້ັງ ສອງ ສ່ວນ ຜ່ານ ຜ້າ ຫຸ້ມ ແນວ ອີງ ຫຼັງຢູ່ ຂ້າງ ກັບ ຂາ ຕ້ັງ ແນວ ອີງ ຫຼັງ. ï ຄ່ອຍໆ ເພ່ີມ ຄວາມ ຍາວ ຂອງ ການ ຕັດ ຈົນ ກວ່າ ວ່າ ລໍາ ຕົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ຜ່ອນຄາຍ ຢູ່ບໍລິ ເວນ ກົກ ແອວ ແລະ ບໍ່ ຂົດ ໄປ ທາງ ໜ້າ. ï ປະຄອງ ລໍາ ຕົວ ຂອງ ຜູ້ ໃຊ້ລົດ ເຂັນ ດ້ວຍ ມື ຂອງ ທ່ານ ຈາກ ເບື້ອງ ຫັງ ຜ້າ ຫຸ້ມ ຈົນ ວກວ່າ ວ່າທ່ານ ພົບ ຕໍາ ແໜ່ງທ່ີ ດີ ສຸດ. ï ສອດ ສາຍຮັດ ( ແຜ່ນ ຜ້າ ໄນ ລອນ ກວ້າງ 50 ມມ) ລະຫວ່າງ ຊ້ັນ ຕ່າງໆ ຂອງ ຜ້າ ຫຸ້ມ ແນວ ອີງ ຫຼັງ ແລະ ຜູກ ສ້ົນ ສຸດ ອ້ອມ ຂາ ຕ້ັງຂອງ ແນວ ອີງ ຫຼັງ. ຫຍິບ ສາຍຮັດ ແລະ ຜ້າຫຸ້ມ ແນວ ອີງ ຫຼັງຢູ່ ຕ ໍາ ແໜ່ ງທ່ີ ຕ້ອງການ. ï ສາມາດ ໃຊ້ ສາຍຮັດ ບີ ແຄ່ງ ເພ່ີມ ເຕີມ ເລື້ອຍໆ ໄດ້ ເ ຊ່ິງມີ ແຖບ ຕິດ Velcro ຢູ່ ສ້ົນ ສຸດ ແລະ ມີ ຄວາມ ຍາວ ທີ່ ຖືກຕ້ອງ. ດ້ວຍ ແຖບ ຕິດ Velcro, ຄວາມ ເຄັ່ງສາຍ ຮັດ ສາມາດ ຖືກ ປັບ ໄດ້ ຢ່າງ ງ່າຍດາຍ. ອີກ ວິທີ ໜຶ່ງ, ໃຫ້ ໃຊ້ຮູ ຮ້ອຍ ເຊືອກ ແລະ ສາຍ ເຊືອກ. ï ສາມາດ ໃຊ້ ແຜ່ນ ໂຟມອ່ອນ ນຸ້ມ ເພ່ືອ ປົກ ເທິງ ແລະ ດ້ານ ໜ້າ ຂອງ ສາຍຮັດ ຢູ່ ໃນ ຜ້າ ຫຸ້ມ ແນວ ອີງ ຫຼັງ. ນ້ີ ຈະ ຫຼຸດຜ່ອນ ຄວາມສ່ຽງ ເກີດ ແຜ ກົ ດທັບ ຕ່ໍ ກັບ ສ່ວ ນ ເທິງ ຂອງ ການ ຮອງ ຮັບແນວ ອີງ ຫຼັງ. ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ແຜ່ນ ຮອງ ຂ້າງລໍາ ຕົວ ຈໍາ ເປັນ ຕ້ອງ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ແໜ້ນໜາ ແລະ ໃນ ເວລາ ດຽວ ກັນ ຄວນ ມີ ຂະໜາດ ບາງ ພຽງພໍ ເພ່ືອ ບໍ່ ຈໍາກັດ ການ ເຄື່ອນ ເໜັງ ຂອງ ແຂນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ໂຄງ ສ້າງ ຫຼັງຂອງ ແຜ່ນ ຮອງ ອາດ ຈະ ຖືກ ເຮັດ ຈາກ ໂລຫະ, ປລັດ ສະຕິ ກ ຫຼື ໄມ້. ແນວ ໃດ ກໍ ຕາມ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ຈໍາ ເປັນ ຕ້ອງ ຫຸ້ມ ດ້ວຍ ໂຟມທ່ີ ມີ ຊ້ັນ ໂຟມອ່ອນ ນຸ້ມຢູ່ ທາງ ເທິງສະ ເໝີ. ໂຟມຄວນ ຢູ່ ດ້ານ ໃນ ຂອງ ແຜ່ນ ຮອງ (ບ່ອນ ທີ່ ມັນສໍາ ພັດກັບ ຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ) ແລະ ຫຸ້ມ ເອົາ ສ່ວນ ເທິງ ຂອງ ແຜ່ນ ຮອງ. ຈາກ ນ້ັນທັງ ໝົດ ແຜ່ນ ຮອງ ຖືກ ຫຸ້ມດ້ວຍ ຜ້າ ຫຸ້ມ ທີ່ທົນ ທານ ແລະ ສະບາຍ ຕົວ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 121 ແຜ່ນ ຮອງຂ້າ ງລໍາ ຕົວ ອາດ ຈະ ເປັນ ແບບ ແບນ ຫຼື ມີ ຮູບຊົງ ເພ່ືອ ໃຫ້ ເຂົ້ າ ກັບ ຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ຖ້າ ພວກ ມັນ ມີ ຮູບຊົງ, ວິທີ ທີ່ ງ່າຍ ທີ່ ສຸດ ໃນ ການ ສ້າງ ຮູບຊົງ ແມ່ນ ການ ເຈາະຮູບຊົງ ໃສ່ ໂຟມທ່ີ ແຂງ. ແຜ່ນ ຮອງ ທີ່ ມີ ຮູບຊົງ ຈໍາ ເປັນ ຕ້ອງ ມີ ທັກ ສະກາ ນຫຍິບ ທີ່ ພິ ເສດ ແລະ ຜ້າ ຫຸ້ມ ເຊິ່ງສາມາດຍືດ ໄດ້. ສອງ ວິທີ ແຕກ ຕ່າງ ກັນ ໃນ ການ ຮັດ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ໃສ່ ລົດ ເຂັນ ແມ່ນ ສະ ແດ ງຢູ່ ຂ້າງ ລຸ່ມ: ອາດ ຈະ ຕິດແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ໃສ່ ກັບ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ຕາຍ ຕົວ ເຊິ່ງຈາ ກນ້ັນ ຖືກ ປົກ ຫຸ້ມ ໃນ ໂຟມຊະນິດ ແຂງ ແລະ ຊ້ັນ ໂຟມອ່ອນ. ອາດ ຈະ ຕິດ ແຜ່ນ ຮອງ ຂ້າງລໍາ ຕົວ ໃສ່ ຂາ ຕ້ັງ ແນ ວອີງ ຫຼັງຂອງ ລົດ ເຂັນ ທີ່ ມີ ເຫຼັກ ເກາະ ເປັນ ໂລຫະ ໄດ້. ແຜ່ນ ຮອງ ຂ້າ ງລໍາ ຕົວ – ຈໍາ ເປັນ ຕ້ອງ ບາງ ຖ້າ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ ໜາ ເກີນ ໄປ (ໜາ ກວ່າ 2.5 ຊມ) ແຜ່ນ ຮອງ ຈະ ຈໍາ ກັດ ການ ເຄື່ອນ ເໜັງ ຂອງ ແຂນ ແລະ ສາມາດ ກົ ດທັບ ໃສ່ ກ້ອງ ຂອງ ກົກ ແຂນ. ນ້ີ ສາມາດ ຫຼຸດຜ່ອນ ການ ໄຫຼວຽນ ຂອງ ເລືອດ, ເຮັດ ໃຫ້ ເສ້ັນ ປະສາດ ເສຍ ຫາຍ ແລະ ລົບ ກວນ ການ ເຄື່ອນ ເໜັງ ຂອງ ມື. ໃຊ້ ວັດ ສະດຸ ທີ່ ບາງ ກວ່າ ທີ່ ແຂງ ແຮງ ພຽງພໍ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ຕ້ອງການ. 122 ຫ້ີຼມຮອງ ຂ້າງ ລໍາ ຕົວ ຫຼີ້ມຮອງ ຂ້າງລໍາ ຕົວ ສາມາດ ຖືກ ເຮັດ ຈາກ ໂຟມທ່ີ ແຂງ ແລະ ລວມ ເຂົ້າ ໃສ່ ແນວ ຮອງ ແນ ວອີງ ຫຼັງ ແບບ ແຂງ ຕາຍ ຕົວ ຢູ່ ກ້ອງ ຊ້ັນ ໂຟມທ່ີ ອ່ອນ. ແຜ່ນ ຮອງ ຮູບຊົງ ຄືຫຼີ້ມຮອງ ພາຍ ນອກທ່ີ ມີ ແນວ ຫຸ້ມ ແຍກ ຕ່າງຫາກ ຍັງ ສາມາດ ຖືກ ໃຊ້ ຢູ່ ເທິງ ພ້ືນ ຜິວ ຂອງ ແນວ ອີງ ຫຼັງ. ສາມາດ ຮັດ ຕິດ ສ່ິງ ນ້ີ ດ້ວຍ ແຖບ ຕິດ Velcro ຫຼື ສາຍຮັດ. ຖາດ ຖາດ ເຮັດ ໄດ້ ດີ ສຸດ ຈາກ ໄມ້ອັດ (10 ມມ ຫາ 18 ມມ ໂດຍ ຂ້ຶນ ກັບ ຄຸນ ນະພາ ບ/ຄວາມ ແຂງ ຂອງ ໄມ້ອັດ) ແລະ ສາມາດ ຖືກ ຕິດ ໃສ່ ບ່ອນ ວາງ ແຂນ ລົດ ເຂັນ ດ້ວຍ ສາຍຮັດ ຫຼື ແນວ ເກາະ ທີ່ ເປັນ ໂລຫະ ຫຼື ໄມ້. ໃນ ເວ ລາ ຕັດສິນ ວ່າ ຈະ ຕິດ ຖາດ ແນວ ໃດ ໃສ່ ລົດ ເຂັນ, ໃຫ້ ຊອກ ຫາ ວິທີ ທີ່ ໃຊ້ ງ່າຍ ສໍາລັບ ທຸກ ຄົນ. ນ້ີ ເພ່ືອ ໃຫ້ ທຸກ ຄົນ ສາມາດ ເອົາ ຖາດ ອອກ ໄດ້ ຢ່າງ ງ່າຍດາຍ ໃນ ກໍລະນີ ສຸກ ເສີນ (ຕົວຢ່າງ ວ່າ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເກີດ ມີ ຂອງ ຄາ ຄໍ ແລະ ຫາຍ ໃຈ ບໍ່ ອອກ. ແນວ ປະຄອງ ຫົວ ແນວ ປະຄອງ ຫົວແບບ ແບນ ສາມາດ ລວມ ເອົາ ແນວ ປະຄອງ ຫົວ ແບບ ແບນ ເຂົ້າ ໃນ ການ ຮອງ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ຕາຍ ຕົວ ຫຼື ຕິດ ໃສ່ ການ ຮອງ ແນວ ອີງ ຫຼັງ ແບບ ແຂງ ຕາຍ ຕົວ ດ້ວຍ ເຫຼັກ ເກາະ. ແນວ ປະຄອງ ຫົວ ຖືກ ສ້າງ ຈາກ ໂຟມ ແຂງ ທີ່ ຕິດ ໃສ່ ແຜ່ນ ໄມ້/ປລັດ ສະຕິ ກ, ປົກ ດ້ວຍ ຊ້ັນ ໂຟມອ່ອນ ນຸ້ມ. ທາງ ເລືອກ ນ້ີ ບໍ່ ໃຫ້ການ ປັບ ທີ່ ງ່າຍ ສໍາລັບ ການ ໃຫຍ່ ຂ້ຶນ ຫຼື ການ ປ່ຽນ ແປງ ໃນ ຮ່າງກາຍຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ແນວ ປະຄອງ ແບບ ແຍກ ຕ່າງຫາກ ທີ່ ຕິດ ກັບ ແນວ ອີງ ຫຼັງອະນຸຍາດ ໃຫ້ ມີ ການ ປັບ ໄປ ໜ້າ, ໄປ ຫຼັງ ແລະ ຄວາມ ສູງ ໄດ້. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 123 ແນວ ປະຄອງ ຫົວແບບ ມີ ຮູບ ຊົງ ແນວ ປະຄອງ ຫົ ວທີ່ ມີ ຮູບຊົງ ສາມາດ ຖືກ ເຮັດ ດ້ວຍ ໂຟມທ່ີ ແຂງ ທີ່ ຕິດ ໃສ່ ກັບ ແຜ່ນ ໄມ້/ປລັດ ສະຕິ ກ ແລະ ຫຸ້ມ ດ້ວຍ ໂຟມອ່ອນ ນຸ້ມ ຫຼື ວັດ ສະດຸ ຄ້າຍຄື ກັນ. ແນວ ປະຄອງ ຫົ ວທີ່ ມີ ຮູບຊົງສາມາດ ລວມມີ ຖ້ານ ເພ່ືອ ຮອງ ຮັບ ພ້ືນ ກະ ໂຫຼກຫົວ ແລະ ຫຼີ້ມ ຮອງ ໃສ່ ດ້ານ ຂ້າງ ເ ພ່ືອຊ່ວຍ ປະຄອງ ຫົວ ບໍ່ ໃຫ້ ລົ້ມ ໄປ ດ້ານ ຂ້າງ. ຜ້າ ຫຸ້ມ ທີ່ ສະບາຍ ຕົວ ຖືກ ໃຊ້ ເພ່ືອ ຫຸ້ມ ແນວປະຄອງ ຫົ ວທີ່ ສໍາ ເລັດ ແລ້ວ. ຜ້າ ຫຸ້ມ ສາມາດ ເຮັດ ຈາກ ຜ້າ ເສື້ອຍືດ ເພາະວ່າ ມັນ ສະບາຍ ຕົວ ແລະ ຍືດ ໄດ້ ເພ່ືອ ເຂົ້ າກັບ ຮູບຊົງ ຂອງ ແນວປະຄອງ ຫົວ. ຜ້າ ຫຸ້ມ ສາມາດ ຖືກ ເຮັດ ໃຫ້ ຕິດ ແໜ້ນ ຫຼື ຫຼົ່ມໜ້ອຍ ໜຶ່ງ ກໍ ໄດ້. ìສາຍ ດຶງî ສາມາດ ເຮັດ ໃຫ້ ຜ້າ ຫຸ້ມ ແໜ້ນໜາ ໄດ້. ຕົວຢ່າງ ຂອງ ວິທີ ເຮັດ ແນວ ປະຄອງ ຫົ ວທີ່ ມີຮູບຊົງ ແມ່ນສະ ແດ ຢູ່ ຂ້າ ງລຸ່ມ: 1. 2. 3. ຖານ ທີ ່ເປນັ ໄມ້ ທີ ່ມີ ຮູ ເຈາະ ເພ່ືອ ຕິດ ໃສ່ ກັບ ເຫຼກັ ເກາະແນວ ປະຄອງ ຫວົ. ຊ້ັນ ທາໍ ອດິ ທີ ່ເປນັ ໂຟມ ແຂງ. ຫຼີມ້ຮອງ ທີ ່ເປນັ ໂຟມ ແຂງ ເພ່ືອ ໃຫກ້ານ ຮອງ ຮັບ ດາ້ນ ຂ້າງ ສໍາລັບ ຫວົ. 4. 5. ພັບ ໂຟມ ເພ່ືອ ເປັນ ຖານ ຂອງ ແນວ ປະຄອງ ຫົວ, ເພ່ືອ ໃຫ້ ພໍດີ ຢູ່ ກ້ອງ ພ້ືນ ກະ ໂຫຼກຫົວ. ຊ້ັນ ໂຟມອ່ອນ ທີ່ ເພ່ີມ ໃສ່. ຮູ ບຊົງ ແນວປະຄອງ ຫົ ວທີ່ ສໍາ ເລັດ ແລ້ວ. ເພ່ືອ ເຮັດ ສໍາ ເລັດ: ï ຕິດ ແນວ ປະຄອງ ຫົວ ໃສ່ ລົດ ເຂັນ; ï ຫຸ້ມ ເບາະ. 124 ແນວ ຮອງ ເສີມ ບ່ອນ ວາງ ຕີນ ແລະ ຫ້ີຼມຮອງ ບ່ອນ ວາງ ຕີນ ໜຶ່ ງ ໃນ ວັດ ສະດຸ ທີ່ ດີ ສຸດ ເພ່ືອ ໃຊ້ ສໍາລັບ ແນວ ຮອງ ເສີມ ຕີນ ແມ່ນ ໂຟມທ່ີ ແຂງ ຫຼາຍ ( ໂຟມ EVA ຫຼື ພ້ືນ ເກີບ ແຕະ). ອາ ດຈະ ໃຊ້ ໄມ້ ກໍ ໄດ້, ແນວ ໃດ ກໍ ຕາມ ຮັບປະກັນ ວ່າ ໄມ້ ຕ້ອງ ລຽບ ນຽນ ໂດຍ ບໍ່ ມີຮອຍ ແຕກ ແລະ ບໍ່ ມີ ຄວາມ ສ່ຽງ ເກີດ ການ ກົ ດທັບ. ແນວ ຮອງ ເສີມ ບ່ອນ ວາງ ຕີນ ຕັດ ໂຟມ ແຂງ ຫຼາຍ ( ໂຟມ EVA ຫຼື ພ້ືນ ເກີບ ແຕະ), ໄມ້ ຫຼື ວັດ ສະດຸ ທີ່ ຄ້າຍຄື ກັນ ໃຫ້ ເປັນ ຮູບ ຊົງທ່ອນ ສ່ີຫຼ່ຽມ (ປະມານ 100 ມມ x 200 ມມ x 20 ມມ). ຮັກສາ ສ່ວນ ທີ່ ເຫຼືອຂອງ ທ່ອນ ໂຟມ ເຫຼົ່ານ້ີ ໄວ້ ໃຊ້ ໃນ ລະຫວ່າງ ການ ປັບ ລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ. ຕິດ ກາວ ທ່ອນ ໃສ່ ກັບ ບ່ອນ ວາ ງຕີນ ຕາມ ທີ່ ຈໍາ ເປັນ. ຫ້ີຼມຮອງ ບ່ອນ ວາງ ຕີນ ຕັດ ທ່ອນ ຮອງ ເສີມ ບ່ອນ ວາງ ຕີນ ເປັນ ແນວ ອ່ຽງ ເຄິ່ງໜ່ຶງ ເພ່ືອ ສ້າງ ຫຼີ້ມຮອງ ບ່ອນ ວາງ ຕີນ ສອງ ອັນ. ຕັດ ບາງ ທ່ອນ ຕາມ ຂ້າງ ຍາວ ແລະ ບາງ ສ່ວນ ຕາມ ຂ້າງ ສ້ັນ. ຮັກສາ ສ່ວນ ທີ່ ເຫຼືອຂອງ ທ່ອນ ໂຟມ ເຫຼົ່ານ້ີ ໄວ້ ໃຊ້ ໃນ ລະຫວ່າງ ການ ປັບ ລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ. ຕິດ ຫຼີ້ມຮອງ ບ່ອນ ວາ ງຕີນ ໃສ່ ບ່ອນ ວາງ ຕີນ ຕາມ ທີ່ ຈໍາ ເປັນ ເພ່ືອ ຮອງ ຮັບ ພ້ືນ ຕີນ. ແນວ ຮອງ ຂາ ສ່ວນລຸ່ມ ບ່ອນ ນ່ັງ ແຂງ ສາມາດ ຖືກ ເຮັດ ເພ່ືອ ເດ່ ໄປ ໜ້າ ຈາກ ດ້ານ ໜ້າ ຂອງ ບ່ອນ ນ່ັງ ເພ່ືອ ຮອງ ຮັບ ຂາ ທີ່ ຢຽດ ຊ່ື. ນ້ີ ອາດ ຈະ ເຮັດ ໃຫ້ການ ລ້ຽ ວ ໃນ ພ້ືນ ທີ່ ແຄບ ແລະ ການລ້ົມ ລົດ ເຂັນ ເພ່ືອ ຂົນ ສ່ົງ ຍາກ ຂ້ຶນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 125 ສາຍຮັດ ກົກ ແອວ ສາຍຮັດ ກົກ ແອວ ສາມາດ ຖືກ ເຮັດ ຈາກ ສາຍ ຮັດໄນ ລອນ ເຊ່ັ່ນວ່າ ສາຍຮັດ ທີ່ ພົບ ໃນ ສາຍ ນິລະ ໄພ ບ່ອນ ນ່ັງ ໃນ ລົດ ໃຫຍ່ ຫຼື ສາຍຮັດ ຢູ່ ເທິງ ຖົງ ເປ້. ຄວາມ ກວ້າງ ຂອງ ສາຍຮັດ ສາມາດ ກວ້າງປະມານ 25 ມມ ສໍາລັບ ເດັກນ້ອຍ ແລະ ປະມານ 40–50 ມມ ສໍາລັບ ຜູ້ ໃຫຍ່. ຫົວເຂັມຄັດແບບຄລິບແມ່ນງ່າຍທ່ີສຸດໃນການເປີດຂຶ້ນ ແລະ ເຮັດກັບຄືນ ຢ່າງ ວ່ອງ ໄວ. ຖ້າ ສ່ິງ ເຫຼົ່ານ້ີ ບໍ່ ມີ ໃຫ້, ແຖບ ຕິດ Velcro ກ່ໍ ໃຊ້ ໄດ້ ເຊັ່ນ ກັນ. ຮັບປະກັນ ວ່າ ມີ ແຖບ ຕິດ Velcro ທີ່ ທັບ ກັນ ຢ່າງ ໜ້ອຍ 100 ມມ ( ໂດຍ ຂ້ຶນ ກັບ ຂະໜາດ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ). ການ ຮອງ ທີ່ ມີ ແນວ ປົກ ລະຫວ່າງ ສາຍຮັດ ແລະ ຜູ້ ໃຊ້ ( ໂດຍ ສະ ເພາະ ຢູ່ ບ່ອນ ຫົວ ເຂັມຄັດ) ແມ່ນ ສະບາຍ ຕົວ. ຈະ ຮັດ ສ້ົນ ຂອງ ສາຍຮັດ ຢູ່ ບ່ອນ ໃດ? ï ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສ່ວນ ໃຫຍ່, ສ້ົນ ຂອງ ສາຍຮັດ ກົກ ແອວ ຮັດ ໂດຍ ກົງ ຢູ່ ກ້ອ ງສ່ວນ ໜ້າ ຂອງ ກະດູກ ກົກ ແອວ ດັ່ງ ສະ ແດງ ໃນ ຮູບ. ï ການ ປ່ຽນ ຈຸດ ທີ່ ຕ້ັງ ຂອງ ການ ຕິດ ຄັດ ຈະ ອະນຸຍາດ ໃຫ້ ສາຍຮັດ ດຶງ ຮ່າງກາຍ ຈາກ ມຸ ມຕ່າງໆ. ການວາງ ການ ຕິດ ຄັດ ໂດຍ ກົງ ຢູ່ ກ້ອ ງສ່ວນ ໜ້າ ຂອງ ກະດູກ ກົກ ແອວ (ASIS) ຈະ ດຶງ ຢູ່ ມຸມ 90 ອົງສາ ຫາ ພ້ືນ ຜິວ ບ່ອນ ນ່ັງ (ຕາມ ທີ່ ສະ ແດງ ໃນ ຮູບ ສະ ແດງ). ການວາງ ສາຍຮັດຢູ່ ດ້ານ ຫຼັງຂອງ ບ່ອນ ນ່ັງ ຈະ ດຶງຢູ່ມຸມ 45 ອົງສາ ຫາ ພ້ືນ ຜິວ ບ່ອນ ນ່ັງ. ມຸມ ການ ດຶງ ຈະ ຢູ່ ລະຫວ່າງ 45–90 ອົງສາ ເວັ້ນ ເສຍ ແຕ່ ວ່າ ສາຍຮັດ ຖືກ ອອກ ແບບ ມາ ເພ່ືອ ໃຫ້ການ ຮອງ ຮັບ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ກະດູກ ກົກ ແອ ວອ່ຽງ ໄປ ໜ້າ. ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ແນວ ໂນ້ມຍູ້ ສະ ໂພ ກຂ້ຶນ ຫຼື ໄປ ໜ້າ, ສາຍຮັດ ສ່ີ ຈຸດ ສໍາລັບ ການ ອ່ຽງ ໄປ ໜ້າ ໃຫ້ການ ຮອງ ຮັບ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ກະດູກ ກົກ ແອວ ອ່ຽງ ໄປ ໜ້າ. 126 ຄໍາ ເຕືອນ ສາຍຮັດ ກົກ ແອວ: ຖ້າ ສາຍຮັດ ກົກ ແອວ ຫຼົມ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ການ ຄວບ ຄຸມ ຮ່າງກາຍ ແລະ/ຫຼື ການ ຮັບ ຮູ້ ທີ່ ຈໍາກັດ ສາມາດ ເລື່ອ ນລົງ ໄດ້. ຖ້າ ບໍ່ມີ ການ ເຝ້ົາ ເບິ່ງ, ການບີບ ຮັດ ອາດ ຈະ ເກີດ ຂ້ຶນ ໄດ້. ໃຫ້ ສອນ ຜູ້ ເບິ່ງ ແຍງ ວິທີຕິດ ສາຍຮັດ ຢ່າງ ຖືກຕ້ອງ ແລະ ເຕືອນ ເຂົາ ເຈົ້າ ກ່ຽວ ກັບ ຄວາມ ສ່ຽງ ຂອງ ການ ປະ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ໄວ້ ໂດຍ ບໍ່ ມີ ຄົນ ເບິ່ງ. ສາ ຍຮັດ ກະດູກ ກົກ ແອວ ແລະ ສາຍຮັດ ສ່ີ ຈຸດ ສໍາລັບ ການ ອ່ຽງ ໄປ ໜ້າ ຖືກຮັດ ແນວ ໃດ ໃສ່ ກັບ ລົດ ເຂັນ? ï ເພ່ືອ ຮັດ ສາຍຮັດ ໃສ່ ບ່ອນ ນ່ັງ ທີ່ ແຂງ: – ຮັດ ໃສ່ ບ່ອນ ນ່ັງ ທີ່ ແຂງ ຕາມ ທີ່ ສະ ແດງ ໃນ ຮູ ບປະກອບ ຢູ່ ເບື້ອງ ຊ້າຍ. ພັບ ສ້ົນ ສາຍຮັດ, ເຈາະ ຮູ ຫຼື ໃຊ້ ນັອດຫັນຜ່ານ ໄມ້ພ້ອມ ກັບ ແຫວນ ຮອງ ສອງ ອັນ ແລະ ນັອດ ໂຕ ແມ່ (ດີ ແທ້ ແມ່ນ ນັອດ ໂຕ ແມ່ ແບບ ລັອກ); – ໃຫ້ ວາງ ແຫວນ ຮອງ ຢູ່ ລະຫວ່າງ ສ້ົ ນທ່ີ ພັບ. ນ້ີ ຊ່ວຍ ເຮັດ ໃຫ້ການ ຫຼຸ້ຍຫ້ຽນ ແລະ ຈີກ ຂາດ ຕ່ໍ ກັບ ໃຍ ຜ້າ ຊ້າ ລົງ ເຊິ່ງ ໃນ ທີ່ ສຸດສາມາດ ເຮັດ ໃຫ້ສາຍຮັດ ເສຍ ຫາຍ ໄດ້. ï ເພ່ືອ ຮັດ ສາຍຮັດ ໃສ່ ໂຄງ ລົດ ເຂັນ: – ມັດ ອ້ອມ ໂຄງ ລົດ ເຂັນ ແລະ ຕິດ ກັບ ຫົວ ເຂັມຄັດ ແບບ ເລື່ອນ ທີ່ ເປັນ ປລັດ ສະຕິ ກ ຫຼື ໂລຫະ (ຍັງ ເອີ້ນ ວ່າ ìສາມ ງ່າມî, ì ແຫວນ D ຄູ່î ຫຼືຫົວ ເຂັມຄັດ 3 ທ່ອນ); – ສາມາດໃຊ້ນັອດກຽວແນວຫຸ້ມເບາະ ຖ້າມັນຢູ່ໃນຕໍາແໜ່ງທ່ີຖືກຕ້ອງ. ສາຍຮັດ ບີ ແຄ່ງ ຖ້າລົດເຂັນບ່ໍມາພ້ອມກັບສາຍຮັດບີແຄ່ງ, ສາມາດເຮັດຂຶ້ນໄດ້ໂດຍການ ຫຍິບ ແຖບ ຕິດ Velcro ໃສ່ ແຜ່ນ ສາຍຮັດ ແບນ ໄນ ລອນ 50 ມມ. ສາຍຮັດ ບີ ແຄ່ງ ຄວນ ຍາວ ປະມານ ສອງ ເທົ່າ ຂອງ ຄວາມ ຍາວ ລົດ ເຂັນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 127 ສາຍຮັດ ຕີນ ສາຍຮັດ ຕີນ ສາມາດ ຖືກ ເຮັດ ຈາກ ສາຍຮັດ ແບນ ໄນ ລອນ 25 ມມ ແລະ ແຖບ ຕິດ Velcro ຫຼື ຫົວ ເຂັມຄັດ. ສ້ົນ ໜຶ່ງ ສາມາດ ພັບ ໄດ້ ແລະ ເຈາະ ຮູ ຜ່ານ ມັນ ສໍາລັບ ຫັນ ນັອດ ເຊິ່ງສາມາດ ຕິດ ມັນ ໃສ່ ກັບ ບ່ອນ ວາງ ຕີນ ໄດ້. ຄວນ ໃຊ້ ແຜ່ນ ຮອງ ທີ່ ມີ ແນວ ປົກ ເພ່ືອ ຮັກສາ ສາຍຮັ ດຕີນ ບໍ່ ໃຫ້ ຮຸກ ຖູ ກັບ ຜິວໜັງ ແລະ ກະຈາຍການ ກົ ດທັບ. ເຄັດ ລັບ ສໍາລັບ ການ ປະດິດ ແລະ ກາ ນ ໃຊ້ ສາຍຮັດ: ï ຮັດ ສາຍຮັດ ດ້ວຍ ແຖບ ຕິດ Velcro ຫຼື ຫົວ ເຂັມຄັດ. ï ເພ່ີມ ການ ຮອງ ໃສ່ ສາຍຮັດ ບ່ອນ ທີ່ ມັນ ສໍາພັດກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ – ນ້ີ ເຮັດ ໃຫ້ ມັນ ສະບາຍ ຕົວ ກວ່າ ໂດຍ ການ ກະຈາຍ ການ ກົ ດທັບ. ï ສາມາດ ຫັນ ນັອດຈັບ ສາຍຮັດ ໃສ່ ກັບ ບ່ອນ ນ່ັງ ຫຼື ແນວ ອີງ ຫຼັງທ່ີ ແຂງ ຫຼື ມັດ ຕິດກັບ ໂຄງ ລົດ ເຂັນ ທີ່ ມີ ຫົວ ເຂັ ມຄັດ ແບບ ເລື່ອນ (ຍັງ ເອີ້ນ ວ່າ ຫົວ ສາມ ງ່າມ, ແຫວນ D ຄູ່ ຫຼື ຫົວ ສາມ ແຖບ). ï ສາຍຮັດ ບີ ແຄ່ງ ເຊິ່ງມັກ ຈະ ມາ ພ້ອມ ກັບ ລົດ ເຂັນ ສາມາດ ຖືກ ໃຊ້ ໃນ ແບບ ວິທີ ອື່ນ ໄດ້. ຕົວຢ່າງ ສາຍຮັ ດບີ ແຄ່ງ ສາມາດ ຖືກ ໃຊ້ ເພ່ືອ ດັດ ແປງ/ປັບ ຜ້າ ຫຸ້ມ ແນວ ອີງ ຫຼັງ. ສາຍຮັດ ບ່າ ໄຫ່ຼ ເພ່ືອ ເຮັດ ສາຍຮັດ ບ່າ ໄຫ່ຼ ມັນ ດີ ທີ່ ສຸດ ໃນ ການ ໃຊ້ ຈັກ ຫຍິບ ແລະ ຄົນ ທີ່ ມີປະສົບ ການ ດ້ານ ການ ຫຍິບ. ທ່ານ ຈະ ຈໍາ ເປັນ ຕ້ອງ ມີສາ ຍ ເສ້ັນ ແບນ ໄນ ລອນ, ຫົວ ເຂັມຄັດ ແລະ ໂຟມອ່ອນ ນຸ້ມສໍາລັບ ການ ຮອງ. ບາງ ເຄັດ ລັບ ລວມມີ: ï ໃຫ້ການ ຮອງ ເສີມ ຕ່ໍ ກັບ ບ່າ ໄຫ່ຼ ໂດຍ ສະ ເພາະ ບ່ອນ ທີ່ ມີ ກະດູກ ຫຼາຍ. ï ຮັບປະກັນ ວ່າ ສ້ົນ ຕ່ໍ ສໍາລັບ ສ່ວນ ເທິງ ຂອງ ສາຍຮັດ ບ່າ ໄຫ່ຼ ແມ່ນ ຢູ່ ໃນ ລະດັບ ດຽວ ກັນ ຫຼື ສູງ ກວ່າ ສ່ວນ ເທິງ ຂອງ ບ່າ ໄຫ່ຼຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໜ້ອຍ ໜຶ່ງ. ຖ້າ ມັນ ຕ່ໍາ ກວ່າ, ສາຍຮັດ ຈະ ດຶງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ລົງ. ï ຢ່າ ຕິດ ສ່ວນ ລຸ່ມ ຂອງ ສາຍຮັດ ບ່າ ໄຫ່ຼ ໃສ່ ກັບ ສາຍຮັດ ກົກ ແອວ. ນ້ີ ຈະ ດຶງ ສາຍຮັດ ກົກ ແອວ ຂ້ຶນ. ï ສາຍຮັດໜ້າ ເອິກ ເຊັ່ນ ວ່າ ອັນ ທີ່ ສະ ແດງ ໃນ ຮູ ບປະກອບ ນ້ີ ຊ່ວຍ ຮັກສາ ໃຫ້ ສາຍຮັດ ບ່າ ໄຫ່ຼ ເຂົ້າ ທີ່ ແລະ ໃຫ້ການ ຮອງ ຮັບຢູ່ ສ່ວນ ໜ້າ ຂອງ ລໍາ ຕົວ. 128 ຄໍາ ເຕືອນ ກ່ຽວ ກັບ ສາຍຮັດ ບ່າ ໄຫ່ຼ: ຕ້ອງ ໃຊ້ສາຍຮັດ ກົກ ແອວ ທີ່ບ ໃຫ້ ຄຽງ ທີ່ ສຸດ ແລ້ວ ຢູ່ ຕະຫຼອດ ເວລາ ໃນ ເວລາ ໃຊ້ ສາຍຮັ ດບ່າ ໄຫ່ຼ ຫຼື ສາຍຮັດ ໜ້າ ເອິກ. ການ ບໍ່ ເຮັດ ແບບ ນ້ີ ສາມາດ ນໍາ ໄປ ສູ່ ການບີບ ຮັດ ໄດ້. ການ ດໍາ ເນີນ ການ ກວດ ຄວາມ ປອດ ໄພ ແລະ ຄວາມພ້ອມ ໃຊ້ ງານ ຂອງ ລົດ ເຂັນ ສ່ວນ ສຸດ ທ້າຍ ຂອງ ການ ກະກຽມ ຜະລິດ ຕະພັນ (ລົດ ເຂັນ) ແມ່ນ ການກວດ ວ່າ ລົດ ເຂັນ ແມ່ນ ປອດ ໄພ ແລະ ພ້ອມ ນໍາ ໃຊ້ ແລ້ວ ແລະ ທຸກ ສ່ວນ ໃຊ້ ໄດ້ ຢ່າງ ຖືກຕ້ອງ. ລາຍການ ກວດ ຄວາມ ປອດ ໄພ ແລະ ຄວາມ ພ້ອມ ໃຊ້ງານ ຂອງ ລົດ ເຂັນ ຢູ່ ໃນ ໜ້າ ຕ່ໍ ໄ ປ ຊ່ວຍ ຮັບປະກັນບ່ໍ ໃຫ້ ລືມອັນ ໃດ. ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ອັດ ສໍາ ເນົາ ລາຍການ ກວດ ນ້ີ ແລະ ປັກ ມັນ ໄວ້ ໃນ ສູນ ບໍລິການ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ເປັນ ການ ແຈ້ງ ເຕືອນ ໃນ ແຕ່ ລະ ຄັ້ງ ທີ່ ພວກ ເຂົາ ກະກຽມ ລົດ ເຂັນ. ລາຍການ ກວດ ຄວາມ ປອດ ໄພ ແລະ ຄວາມ ພ້ອມ ໃຊ້ ງານ ລົດ ເຂັນ ຄວນ ຖືກ ເຮັດ ສໍາ ເລັດ ກ່ອນທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈະ ມາ ຮອດ ສໍາລັບ ກາ ນປັບ ໃຫ້ ເໝາະ ສົມ. ຖ້າ ມີ ບັນຫາ ທີ່ ຖືກ ລະບຸໃນ ລະຫວ່າງການ ກວດ ຄວາມ ໄພ ແລະ ຄວາມ ພ້ອມ ໃຊ້ ງານ ຂອງ ລົດ ເຂັນ, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ອາດ ຈະ ເຮັດ ສ່ິງ ຕ່ໍ ໄປນ້ີ: ï ສ້ອມ ແປງ/ ແກ້ ໄຂ ບັນຫາ ກ່ອນ ການ ປັບ ໃຫ້ ເໝາະ ສົມ; ï ສ່ົງ ລົດ ເຂັນ ກັບ ຄືນ ຫາ ໂຮງ ສ້ອມ ແປງ ລົດ ເຂັນ ເພ່ືອ ເຮັດ ການ ແກ້ ໄຂ; ï ຕິດ ຕ່ໍ ຫາ ຜູ້ ຈໍາໜ່າຍ ລົດ ເຂັນ ແລະ ຮ້ອງ ຂໍ ຄວາມ ຊ່ວຍ ເຫຼືອ ເລື່ອງ ການ ແກ້ ໄຂ ບັນຫາ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 129 ລາຍ ການກວດ ຄວາມ ປອດ ໄພ ແລະ ຄວາມ ພ້ອມ ໃຊ້ ງານຂອງລົດ ເຂັນລະດັບ ປານ ກາງ ລາຍການ ກວດ: ລົດ ເຂັນ ປອດ ໄພ ແລະ ພ້ອມ ໃຊ້ ແລ້ວ ບໍ? ທັງ ໝົດ ລົດ ເຂັນ ລວມທັງອຸປະກອນ PSD ມີ ການ ຕິດ ຕ້ັງ ອຸປະກອນ PSD ຢ່າງ ແໜ້ນໜາ ບໍ່ມີ ຂອບ ຄົມ ແຫຼມ ບໍ່ ມີ ສ່ວນ ເສຍ ຫາຍ ຫຼື ຂູດ ຂີດ ລົດ ເຂັນ ເຄື່ອນ ທີ່ ເປັນ ແນວ ເສ້ັນ ຊ່ື ລ້ໍ ໜ້າ ໝູນ ໄດ້ ຢ່າງ ອິດສະຫຼະ ໝູນ ໂດຍ ບໍ່ ສໍາພັດ ກັບຂາ ລໍ້ ນັອດຫັ ນ ແໜ້ນ ດີ ເລົາ ຂາລ້ໍ ໜ້າ ຂາ ລໍ້ ໜ້າ ໝູນ ໄດ້ ຢ່າງ ອິດສະຫຼະ ລ້ໍ ຫັຼງ ໝູນ ໄດ້ ຢ່າງ ອິດສະຫຼະ ນັອດ ແກນ ເພົາ ຫັນ ແໜ້ນ ດີ ໄດ້ ສູບ ລົມ ຢາງ ຢ່າງ ຖືກຕ້ອງ ( ໃຊ້ ໂປ້ ມື ກົດ ເບິ່ງ, ລໍ້ ຢາງ ສາມາດ ຖືກ ບີບ ເຂົ້າ ໄດ້ ບໍ່ ເກີນ 5 ມມ) ຂອບ ຍູ້ມີ ຄວາມ ປອດ ໄພ ເບ ກ ໃຊ້ ງານ ໄດ້ ຢ່າງ ຖືກຕ້ອງ ບ່ອນ ວາງ ຕີນ ບ່ອນ ວາງ ຕີນ ຖືກ ປະກອບ ຢ່າງ ແໜ້ນໜາ ໝ້ັນຄົງ ໂຄງ ສໍາລັບ ລົດ ເຂັນ ແບບ ພັບ ໄຂ ວ່ກັນ – ລົດ ເຂັນ ພັບ ເຂົ້າ ແລະ ກາງ ອອກ ໄດ້ ຢ່າງງ່າຍດາຍ ສໍາລັບ ລົດ ເຂັນ ທີ່ ມີ ບ່ອນ ວາງ ຕີນ ແບບ ພັບ ລົງ – ບ່ອນ ວາງ ຕີນພັບ ແລະ ກາງ ອອກ ໄດ້ ຢ່າງ ງ່າຍດາຍ ເບາະ ນ່ັງ ເບາະ ຮອງ ນ່ັງ ມີ ແນວ ຫຸ້ມ ເບາະ ຢ່າງ ຖືກຕ້ອງ ເບາະ ຮອງ ນ່ັງ ຕ້ັງ ຢູ່ ເທິງ ລົດ ເຂັນ ຢ່າງ ຖືກຕ້ອງ ຜູ້ ຫຸ້ມເບາະ ຮອງ ນ່ັງ ແໜ້ນໜາ ແຕ່ບໍ່ ແໜ້ນ ເກີນ ໄປ ຖ້າ ລົດ ເຂັນ ມີ ບ່ອນ ນ່ັງ ແຂງ ຄົງ ທີ່: ເບາະ ຮອງ ນ່ັງ ຕ້ອງ ປົກ ຫຸ້ມ ບ່ອນ ນ່ັງ ແຂງ ຄົງ ທີ່ ນ້ັນ ຢ່າງ ເຕັມ ສ່ວນ 130 ຂ້ັນ ຕອນ 6: ການ ປັບ ໃຫ້ ເໝາະ ສົມ ການ ປັບ ໃຫ້ ເໝາະ ສົມ ແມ່ນ ຂ້ັນ ຕອນ ທີ ແປດ ຂອງ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ. ໃນ ລະຫວ່າງ ການ ປັບ ໃຫ້ ເໝາະ ສົມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຮັບປະກັນ ວ່າ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ເຂົ້າກັນ ໄດ້ ດີ ແລະ ຮອງ ຮັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃຫ້ ຢູ່ ໃນ ທ່າ ໃກ້ຄຽງທີ່ ສຸດ ກັບ ທ່າ ນ່ັ ງປົກກະຕິ ຢ່າງ ສະບາຍ ຕົວ. ວິທີ ດໍາ ເນີນ ການ ປັບ ໃຫ້ ເໝາະ ສົມ ໃຊ້ ລາຍການ ກວດກາ ນປັບ ລົດ ເຂັນລະດັບ ປານ ກາງ ໃຫ້ ເໝາະ ສົມຢູ່ ໃນ ໜ້າ ຕ່ໍ ໄປ ເພ່ືອ ຊ້ີ ນໍາ ທ່ານ ໃນ ລະຫວ່າງ ກາ ນັບ ໃຫ້ ເໝາະ ສົມ. ກວດ ຕາມ ລໍາດັບ ນ້ີ: ï ລົດ ເຂັນ ພ້ອມ ນໍາ ໃຊ້ ແລ້ວ ບໍ? ï ກວດ ເບິ່ງຄວາມ ເໝາະ ສົມ ພໍດີຂອງ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ; ï ກວດ ເບິ່ງ ທ່າ ທາງ; ï ກວດ ເບິ່ງ ການ ກົດທັບ; ï ກວດ ຄວາມ ເໝາະ ສົມ ພໍດີ ໃນ ຂະນະ ທີ່ ລົດ ເຂັນ ກໍາລັງ ເຄື່ອນ ທີ່; ï * ຕັດສິນ ໃຈ ວ່າ ຈໍາ ເປັນ ຕ້ອງ ມີ ການ ດໍາ ເນີນ ການ ເພ່ີມ ເຕີມ ຫຼືບໍ່. ຈ່ົງ ຈ່ື ວ່າ: ການ ປັບ ລົດ ເຂັນ ໃຫ້ ເໝະສົມ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ຈໍາ ເປັນ ຕ້ອງ ມີ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ຈະ ໃຊ້ ເວລາ ດົນ ກວ່າ ສໍາລັບ ຜູ້ ໃຊ້ ທີ່ ບໍ່ ຕ້ອງການ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ນ້ີ ແມ່ນ ຍ້ອນ ວ່າ ມີຫຼາຍການ ປັບກວ່າທ່ີ ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ໄດ້ ເຮັດ. ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ຮູ້ ວ່າການ ປັບ ໃຫ້ ເໝາະ ສົມ ອາດ ຈະ ໃຊ້ ເວລາ ຫຼາຍກວ່າ. ພວກ ເຂົາ ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ເຂົ້າໆ ອອກໆ ລົດ ເຂັນ ໃນ ຂະນະ ທີ່ ເຮັດ ການປັບ. ï ນອກ ນ້ັນ ພວກ ເຂົາ ອາດ ຈະ ຈໍາ ເປ ັນ ຕ້ອງ ກັບ ຄືນ ມາ ເຮັດ ກາ ນປັບ ໃຫ້ ເໝາະ ສົມ ຄັ້ງ ທີ ສອງ ຖ້າ ຈໍາ ເປັນຕ້ອງ ເຮັດ ຫຼາຍໆ ການ ປ່ຽນ ແປງ. ລົດ ເຂັນ ພ້ອມ ນໍາ ໃຊ້ ແລ້ວ ບໍ? ກວດ ໃຫ້ ແນ່ ໃຈ ສະ ເໝີ ວ່າ ລົດ ເຂັນ ແມ່ນ ພ້ອມ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນທົດ ລອງ ໃຊ້ ແລ້ວ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 131 ກວດ ເບ່ິງຄວາມ ເໝາະ ສົມ ພໍດີຂອງ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ຄວາມ ກວ້າງ ຂອງ ລົດ ເຂັນ ຄວາມ ພໍດີທີ່ ຖືກຕ້ອງ: ຄວນ ພໍດີ ໄດ້ ໃກ້ ຄຽງ ທີ່ ສຸດ. ຮັບປະກັນ ວ່າ: ï ສະ ໂພ ກ ເຂົ້າ ຮູບ ຢ່າງ ສະບາຍ ຕົວ ຢູ່ ລະຫວ່າງ ບ່ອນ ວາງ ແຂນ ຫຼື ແຜ່ນ ຮອງ ຂ້າງກະດູກ ກົກ ແອວ; ï ກົກຂາ ເຂົ້າ ຮູບ ພໍດີ ລະຫວ່າງ ບ່ອນ ວາງ ແຂນ, ແນວບັງຕົມ/ ແນ ວປ້ອງ ກັນ ຂອບ ຫຼື ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ແລະ ບໍ່ ຍູ້ ເຂົ້າ ຫາ ກັນ; ນ້ີ ອາດ ຈະ ເກີດ ຂ້ຶນ ຖ້າ ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ເດ່ ໄປ ໜ້າ ເກີນ ໄປ; ï ລໍາ ຕົວ ເຂົ້າ ຮູ ບຢ່າງ ສະບາຍ ຕົວ ຢູ່ ລະຫວ່າງ ຂາ ຕ້ັງ ແນວ ອີ ງຫັຼງ ແລະ/ຫຼື ຫຼີ້ມຮອງ ຂ້າ ງລໍາ ຕົວ ຫຼື ແຜ່ນ ຮອງ ຂ້າງລໍາ ຕົວ. ຄວາມ ເລິກ ບ່ອນນ່ັງ ຄວາມ ພໍດີທີ່ ຖືກຕ້ອງ: ຄວນ ມີຊ່ອງ ຫວ່າງຢ່າງ ໜ້ອຍ 30 ມມ ລະຫວ່າງ ຫຼັງຫົວ ເຂົ່າ ຫາ ໜ້າ ບ່ອນ ນ່ັງ/ ເບາະ ຮອງ ນ່ັງ. ຮັບປະກັນ ວ່າ: ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ກໍາລັງ ນ່ັງ ໃກ້ ຄຽງ ກັບ ທ່າ ນ່ັງ ປົກກະຕິ ທີ່ ສຸດ ເທົ່າ ຈະ ສະບາຍ ຕົວ ສໍາລັບ ເຂົາ ເຈົ້າ; ວິທີ ກວດ ເບິ່ງ: ï ເລື່ອນ ມື ເຂົ້າ ລະຫວ່າງ ຫຼັງຫົວ ເຂົ່າ ກັບ ເບາະ ຮອງ ນ່ັງ. ກວດ ເບິ່ງ ວ່າ ມີຊ່ອງ ຫວ່າງ ຢ່າງ ໜ້ອຍ 30 ມມ. ເລື່ອນ ມື ລົງ ຫາ ຫຼັງບ່ີ ແຄ່ງ ແລະ ຮັບປະກັນ ວ່າ ບີ ແຄ່ງ ບໍ່ ສໍາພັດກັບ ບ່ອນ ນ່ັງ/ ເບາະ ຮອງ ນ່ັງ. ï ກວດ ເບິ່ງ ທັງ ສອງ ຂ້າງ. ຖ້າ ມີ ຄວາມ ແຕກ ຕ່າງ ລະຫວ່າງ ຂ້າງ ຂວາ ແລະ ຂ້າງ ຊ້າຍ, ໃຫ້ ໃຊ້ ຄ່າ ວັດ ແທກຂາ ທີ່ ສ້ັນ ກວ່າ ເພ່ືອ ເຮັດ ການ ເລືອກ ສໍາລັບ ການກໍານົດ ໃຊ້. ອາດ ຈະ ມີ ຊ່ອງ ຫວ່າງ ຫຼາຍກວ່າ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ຂາ ຍາວ; ບໍ່ ເກີນ 60 ມມ ແມ່ ນສາມາດ ຍອມຮັບ ໄດ້. ຄວາມ ພໍດີ ທີ່ ຖືກຕ້ອງ ໃຫ້ການ ຮອງ ຮັບທີ່ ດີ ສໍາລັບ ກົກຂາ. ນ້ີ ຈະ ຫຼຸດການ ກົ ດທັບ ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ແລະ ຊ່ວຍ ຢຸດການ ເກີດ ແຜ ກົດທັບ. ຖ້າ ຄວາມ ຍາວ ບ່ອນ ນ່ັງ ຍາວ ເກີນ ໄປ, ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈະ ບໍ່ ສາມາດ ນ່ັງ ໄດ້ ຕັ້ງ ຊ່ື. ກະດູກ ກົກ ແອວ ຮັບປະກັນ ວ່າ: ï ຖ້າ ນຮອງ ກະດູກ ຮອງ ນ່ັງ ແປະ ຕິດ ກັບ ສ່ວນ ໜ້າ ຂອງ ກະດູກ ຮອງ ນ່ັງ (ວາງ ມື ຂອງ ທ່ານ ຢູ່ ກ້ອງ ກ້ົນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເພ່ືອ ກວດ); ï ແຜ່ນ ຮອງ ຫຼັງກະດູກ ກົກ ແອວ ໃຫ້ການ ຮອງ ຢູ່ PSIS ແລະ ບໍ່ ຍູ້ ລໍາ ຕົວ ສ່ວນ ລຸ່ມ. ï ແຜ່ນຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ເຂົ້າ ຮູບ ຢ່າງ ພໍດີ ຕົວ ແລະ ບໍ່ ຕ້ັງ ຢູ່ ເທິງ ຂ້ໍ ຕ່ໍ ສະ ໂພ ກ; ï ສາມາດ ເຄັ່ງສາຍຮັ ດກົກ ແອວ ໃຫ້ ແໜ້ນ ແລະ ບໍ່ ໜີບ ຜິວໜັງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ (ສອດ ມື ເຂົ້າ ລະຫວ່າ ງສາຍຮັດ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເພ່ືອ ກວດ ເບິ່ງ). 132 ລໍາ ຕົວ ຮັບປະກັນ ວ່າ: ï ແຜ່ນ ຮອງຂ້າງ ລໍາ ຕົວ ບໍ່ ວາງ ການ ກົ ດທັບ ໃສ່ ຂ້ີ ແຮ້. ຄວນມີຊ່ອງ ວ່າງຢ່າງໜ້ອຍ 50 ມມ ລະຫວ່າ ງຂ້ີ ແຮ້ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ສ່ວນ ເທິງ ຂອງ ແຜ່ນ ຮອງ ລໍາ ຕົວ. ï ສາມາດ ຕິດສາຍຮັດ ບ່າ ໄຫ່ຼ ໄດ້ ຢ່າ ງສະບາຍ ຕົວ ແລະ ມັນ ບໍ່ ໜີບ ຜິວໜັງ. ï ຖາດ ຮອງ ຮັບ ຄວາມ ຍາວ ຂອງ ແຂນທ່ອນປາຍ ແລະ ຂ້ໍສອກ ແລະ ບໍ່ ຍູ້ ກັບ ທ້ອງ. ຖາດ ທີ່ ມີ ການ ດັດ ແປງ ອາ ດຈະ ໃກ້ ກັບ ຮ່າງກາຍ, ແຕ່ ແນວ ໃດ ກໍ ຕາມ ມັນ ບໍ່ ຄວນ ສໍາພັດ ຫຼື ຖູ ກັບ ຜິວໜັງ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ï ກວດ ເບິ່ງ ຄວາມ ສູງ ແລະ ການ ອ່ຽງຂອງ ແນວ ອີງ ຫຼັງ. ແນວ ປະຄອງ ຫົວ ຄວາມ ພໍດີທີ່ ຖືກຕ້ອງ: ï ແນວ ປະຄອງ ຫົວຄວນປະຄອງ ຫົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຢູ່ ພ້ືນ ຂອງ ກະ ໂຫຼກຫົວ. ຮັບປະກັນ ວ່າ: ï ແນວ ປະຄອງ ຫົວ ແມ່ ນປະຄອງ ຫຼື ຮອງ ຮັບ ຫົວ ຂອງຜູ້ ໃຊ້ ໃຫ້ ຢູ່ ໃນ ທ່າ ສົມດຸ່ນ ແລະ ຕ້ັງ ຊ່ື. ກົກຂາ ຮັບປະກັນ ວ່າ: ï ບໍ່ ມີ ການ ກົ ດທັບ ສູງ ຢູ່ ລະຫວ່າງ ກົກຂາ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກັບ ແນວ ຮອງ ຂາຕ່າງໆ ( ເຊັ່ນ ວ່າ ແຜ່ນ ຮອງ ກົກຂາ ດ້ານ ນອກ, ຫຼີ້ມຮອງ ກົກຂາ ດ້ານ ໃນ ຫຼື ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ). ï ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ກໍາລັງ ບໍ່ ສ້າງ ການ ກົ ດທັບ ຕ່ໍ ກັບ ບໍລິ ເວນມຸມ ກົກຂາ. ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ຄວນ ຢູ່ ຫ່າງ ປະມານ 40–60 ມມ ຈາກ ບໍລິ ເວນ ມຸມ ກົກຂາ ສໍາລັບ ເດັກນ້ອຍ ແລະ 60–100 ມມ ສໍາລັບ ຜູ້ ໃຫຍ່. ຄວາມ ສູງ ບ່ອນ ວາງ ຕີນ ຄວາມ ພໍດີທີ່ ຖືກຕ້ອງ: ມີ ການ ຮອງ ກົກຂາຢ່າງ ຄົບ ຖ້ວນ ຢູ່ ບ່ອນ ນ່ັງ/ ເບາະ ຮອງ ນ່ັງ ໂດຍບໍ່ ໃຫ້ ມີ ຊ່ອງ ວ່າງ ແລະ ມີການ ຮອງ ຕີນ ຢ່າງ ຄົບ ຖ້ວນ ຢູ່ ບ່ອນ ວາງ ຕີນ ໂດ ຍບໍ່ ມີ ຊ່ອງ ວ່າງ. ວິທີ ກວດ ເບິ່ງ: ï ເລື່ອນ ມື ລະຫວ່າງ ກົກຂາ ແລະ ບ່ອນ ນ່ັງ/ ເບາະ ຮອງ ນ່ັງ. ຄວນ ມີ ການ ກົ ດທັບ ເທົ່າ ກັນ ລຽບ ຕາມ ກົກຂາ ແລະ ບໍ່ ມີ ຊ່ອງ ວ່າງ. ï ກວດ ເບິ່ງ ຕີນ ຢູ່ ເທິງ ບ່ອນ ວາງ ຕີນ. ຄວນ ມີ ການ ຮອງ ຕີນ ຢູ່ ດ້ານ ໜ້າ ແລະ ດ້ານຫັຼງ ໂດ ຍບໍ່ ມີ ຊ່ອງ ວ່າງ. ຖ້າ ມີ ຊ່ອງ ວ່າງ ຢູ່ ກ້ອງ ກົກຂາ, ບ່ອນ ວາງ ຕີນ ອາດ ຈະ ສູງ ເກີນ ໄປ. ຖ້າ ມີ ຊ່ອງ ວ່າງ ຢູ່ ກ້ອງຕີນ, ບ່ອນ ວາງ ຕີນ ອາດ ຈະ ຕ່ໍາເກີນ ໄປ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 133 ຄວາມ ສູງ ແນວ ອີງ ຫັຼງ ຄວາມ ພໍດີທີ່ ຖືກຕ້ອງ: ຄວາມ ພໍດີ ທີ່ ຖືກຕ້ອງ ຄວນ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຕ້ອງການ ແລະ ອະນຸຍາດ ໃຫ້ ຜູ້ ໃຊ້ລົດ ເຂັນ ມີ ອິດ ສະຫຼະ ໃນ ການ ເຄື່ອນ ເໜັງ ກະດູກ ຫົວ ໄຫ່ຼຂອງ ລາວ ເພ່ືອ ຍູ້ ລົດ ເຂັນ (ຖ້າ ຂັບ ເຄື່ອນ ລົດ ເຂັນ ດ້ວຍ ຕົນ ເອງ). ວິທີ ກວດ ເບິ່ງ: ï ຖາມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ວ່າ ແນວ ອີງ ຫຼັງສະບາຍ ຕົວ ຫຼືບໍ່; ï ສັງ ເກດ ເບິ່ງ ວ່າ ລໍາ ຕົວ ດຸ່ນດ່ຽງ ຫຼືບໍ່ ທຽບ ກັບ ສະ ໂພ ກ; ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ຍູ້ ລົດ ເຂັນ ໂດຍທີ່ ແນວ ອີງ ຫຼັງບ່ໍ ລົບ ກວນ ຫຼືບໍ່? ຄວາມ ສູງ ຂອງ ແນວ ອີງ ຫຼັງຂ້ຶນ ກັບ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ້ລົດ ເ ຂັນ. ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ຍູ້ ລົດ ເຂັນ ດ້ວຍ ຕົນ ເອງ ຕ້ອງການ ມີ ແນວ ອີ ງຫັຼງທ່ີ ອະນຸຍາດ ໃຫ້ ຫົວ ໄຫຼ່ຂອງ ເຂົາ ເຈົ້າ ເຄື່ອນ ເໜັງ ໄດ້ ຢ່າງ ເສລີ. ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ຄວາມ ຍາກ ໃນ ການ ນ່ັງ ຕ້ັງ ຊ່ື ອາດ ຈະ ຈໍາ ເປັນ ຕ້ອງ ມີ ແນວ ອີງ ຫຼັງທ່ີ ສູງ ກວ່າ ເຊິ່ງ ໃຫ້ການ ຮອງ ຮັບ ຫຼາຍກວ່າ. ແນວ ອີງ ຫຼັງທ່ີ ໃຫ້ການ ຮອງ ຮັບ ຢູ່ ລະດັບ ພ້ືນ ກະດູກ ຂ້າງ ຂອງຜູ້ ໃຊ້ ລົດ ເຂັນ ແມ່ນ ຄວາມ ສູງ ທີ່ ດີ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ: ï ຍັງ ແຂງ ແຮງ ແລະ ເຄື່ອນ ໄຫວ ໄດ້; ï ສາມາດ ນ່ັງ ຕັ້ງ ຊ່ື ໄດ້ ຢ່າງ ງ່າຍດາຍດ້ວຍ ຄວາມ ດຸ່ນດ່ຽງ ທີ່ ດີ; ï ຈະ ຂັບ ເຄື່ອນ ລົດ ເຂັນ ດ້ວ ຍຕົນ ເອງ ຢ່າງ ຫ້າວຫັນ ແລະ ຕ້ອງການ ເສລີພາບທ່ີ ດີ ໃນ ການ ເຄື່ອນ ທີ່. ຄວາມ ສູງ ແນວ ອີ ງຫັຼງ D (ບ່ອນ ນ່ັງຫາ ພ້ືນ ກະດູກຂ້າງ). ແນວ ອີງ ຫຼັງທ່ີ ໃຫ້ການ ຮອງ ຮັບ ຢູ່ ລະດັບ ພ້ືນ ກະດູກ ຫົວ ໄຫ່ຼ ຂອງຜູ້ ໃຊ້ ລົດ ເຂັນ ແມ່ນ ຄວາມ ສູງ ທີ່ ດີ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ: ï ເປັນ ໄປ ໄດ້ ວ່າ ຈະ ອິດ ເມ່ືອຍ ໄວ: ຕົວຢ່າງ ຜູ້ ສູງ ອາຍຸ ຫຼື ຜູ້ ມີ ພະຍາດ ຂະຫຍາຍຕົວ; ï ມີ ຄວາມ ຍາກຈໍາ ນວນ ໜຶ່ງ ໃນ ການ ນ່ັງ ຕ້ັງ ຊ່ື. ຄວາມ ສູງ ແນວ ອີງ ຫຼັງຍັງ ອະນຸຍາດ ໃຫ້ ມີ ບາງ ເສລີພາບ ຂອງ ການ ເຄື່ອນ ໄຫວ ຢູ່ ບໍລິ ເວນ ກະດູກ ຫົວ ໄຫ່ຼສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເພ່ືອ ຂັບ ເຄື່ອນ ລົດ ເຂັນ ດ້ວຍ ແຂນ ຂອ ງ ເຂົາ ເຈົ້າ. ຄວາມ ສູງ ແນວ ອີ ງຫັຼງ E (ບ່ອນ ນ່ັງຫາ ພ້ືນ ກະດູກ ຫົວ ໄຫ່ຼ). ແນວ ອີງ ຫຼັງທ່ີ ສູງ ກວ່າ ເຊິ່ງ ໃຫ້ການ ຮອງ ຮັບ ຢູ່ ລະດັບ ສ່ວນ ເທິງ ຂອງ ບ່າ ໄຫ່ຼ ແມ່ນ ຄວາມ ສູງ ທີ່ ດີ ສໍາລັບ ຜູ້ ໃຊ້ ລົ ດ ເຂັນ ຜູ້ ທີ່ ຕ້ອງການ ກາ ນຮອງ ຮັບ ເພ່ີມ ເຕີ ມ; ມີ ການ ເອນ ແນວ ອີງ ຫຼັງ; ມີ ການ ອ່ຽງບ່ອນນ່ັງ ແລະ ແນວ ອີງ ຫຼັງ (ການ ອ່ຽງ ໃນ ກາງຫາວ); ອິດ ເມ່ືອຍ/ອ່ອນ ເພຍ ໄດ້ ງ່າຍ. ຄວາມ ສູງ ແນວ ອີ ງຫັຼງ F (ບ່ອນ ນ່ັງຫາ ສ່ວນ ເທິງ ບ່າ ໄຫ່ຼ). ຕໍາ ແໜ່ງລ້ໍ ຫັຼງ – ສໍາລັບ ການ ຂັບ ເຄ່ືອນ ດ້ວຍ ມື ຄວາມ ພໍດີທີ່ ຖືກຕ້ອງ: ໃນ ເວລາ ວາງ ມື ໃສ່ ຂອບ ຍູ້, ແຂນ ສອກ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຄວນ ຢູ່ ໃ ນມຸມ ທີ່ ຖືກຕ້ອງ. ວິທີ ກວດ ເບິ່ງ: ï ບອກ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈັບ ຂອບ ຍູ້ ຢູ່ ສ່ວນ ເທິງ ຂອງ ລໍ້. ແຂນ ສອກ ຄວນ ກ່ົງ ຢູ່ ໃນມຸມ 90 ອົງສາ; ï ນອກ ນ້ັນ ໃຫ້ ກວດ ນໍາ ຜູ້ ໃຊ້ ລົດ ເຂັນ ວ່າ ລໍ້ ຫຼັງຢູ່ ໃນ ຕໍາ ແໜ່ ງທ່ີ ຖືກຕ້ອງຫືຼບໍ່ ສໍາລັບ ຄວາມ ດຸນ ດ່ຽງ ( ໄປ ໜ້າ ສໍາລັບ ເຄື່ອນ ທີ່, ໄປ ຫຼັງ ສໍາລັບ ຄວາມ ປອດ ໄພ). 134 ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຕ້ອງການ ໃຫ້ ລໍ້ ຫຼັງຢູ່ ໃນຕໍາ ແໜ່ ງ ëປອດ ໄພí ( ໄປ ຫຼັງໜ້ອຍ ໜຶ່ງ), ນ້ີ ອາດ ຈະ ໝາຍ ຄວາມ ວ່າ ແຂນ ຂອ ງ ເຂົາ ເຈົ້າ ຈະ ໄປ ຫຼັງຫຼາຍກວ່າ ຕໍາ ແໜ່ ງທ່ີ ເໝາະ ສົມ ສໍາລັບ ການ ຂັບ ເຄື່ອນ ລົດ ເຂັນ. ອະທິບາຍການ ໄດ້ ຢ່າງ ເສຍ ຢ່າງ ນ້ີ ໃຫ້ ແກ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ຖ້າ ເຮັດ ການ ປັບ ຕ່ໍ ກັບ ຕໍາ ແໜ່ ງລ້ໍ ຫຼັງ, ຈະ ຈໍາ ເປັນ ຕ້ອງ ປັບ ແລະ ກວດຄືນ ເບ ກ ເຊັ່ນ ກັນ. ຄວາມ ສູງ ບ່ອນ ນ່ັງ – ສໍາລັບ ການ ຂັບ ເຄ່ືອນ ດ້ວຍ ຕີນ ຄວາມ ພໍດີທີ່ ຖືກຕ້ອງ: ï ດ້ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ນ່ັງ ໄດ້ ຕ້ັງ ຊ່ື ແລະ ຫຼັງຂອງ ກະດູກ ກົກ ແອວ ມີ ກາ ນຮອ ງຮັບ ຢ່າງ ສະບາ ຍຕົວ ດ້ວຍ ແນວ ອີງ ຫຼັງ, ລາວ ຄວນ ຈະ ສາມາດ ພັກ ຕີນ ຂອງ ລາວຢູ່ ເທິງ ພ້ືນ ໄດ້. ວິທີ ກວດ ເບິ່ງ: ï ຮ້ອ ງຂໍ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ຕ້ັງ ຊ່ື ຫຼື ໃກ້ ຄຽງ ກັບ ທ່າ ນ່ັງ ຕ້ັງ ຊ່ື ເທົ່າ ທີ່ ຈະ ສະບາຍ ຕົວ ໃນ ລົດ ເຂັນ, ໂດຍ ທີ່ດ້ານ ຫຼັງຂອງ ກະດູກ ກົ ກ ແອວ ສໍາພັດກັບ ແນວ ອີງ ຫຼັງ. ກວດ ເບິ່ງ ວ່າ ຕີນ ຂອງ ເຂົາ ເຈົ້າ ສາມາດ ແປະ ກັບ ພ້ືນ ໄດ້ ຫຼືບໍ່. ຖ້າ ຄວາມ ສູງ ບ່ອນ ນ່ັງ ສູງ ເກີນ ໄປ, ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ພະຍາຍາມ: ï ຫຼຸດຄວາມ ສູງ ຂອງ ເບາະ ຮອງ ນ່ັງ ລົງ; ï ຕິດບ່ອນນ່ັງແຂງໃຫ້ຕ່ໍາກວ່າບ່ອນນ່ັງເດີມ (ຂໍເອົາຄໍາແນະນໍາ ຫຼື ການ ຊ່ວຍ ເຫຼືອຈາກ ຊ່າງ ເພ່ືອ ເຮັດ ສ່ິງ ນ້ີ). ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ທີ່ຂັບ ເຄື່ອນ ດ້ວຍ ຕີນ ຂ້າງ ດຽວ ເທົ່າ ນ້ັນ, ໂດຍ ທີ່ ຕີນ ອີກ ຂ້າງ ວາງ ຢູ່ ເທິງ ບ່ອນ ວາງ ຕີນ – ໃຫ້ ກວດ ເບິ່ງ ກາ ນກົ ດທັບ ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ຂອງ ຂ້າງ ທີ່ ກໍາລັງ ວາງ ຢູ່ ເທິງບ່ອນ ວາງ ຕີນ. ກວດ ເບ່ິງ ທ່າ ທາງ ສັງ ເກດ ເບິ່ງ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກໍາລັງ ນ່ັງ ແນວ ໃດ ຢູ່ໃນ ລົດ ເຂັນ ຈາກ ດ້າ ນໜ້າ ແລະ ຈາກ ຂ້າງ ດ້ານ. ລາວ ກໍາລັງ ນ່ັງ ໃນ ທ່າຕ້ັງ ຊ່ື ບໍ? ກວດ ເບິ່ງ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກໍາລັງ ນ່ັງ ໃນ ທ່າ ນ່ັງ ຕ້ັງ ຊ່ື ເທົ່າ ທີ່ ເຂົາ ເຈົ້າ ສະບາຍ ຕົວ ຫຼືບໍ່. ນ້ີ ຄວນ ຈະ ໃກ້ຄຽງ ທີ່ ສຸດ ກັບ ທ່າ ນ່ັງ ທີ່ ລະບຸ ໃນ ການ ຈໍາລອງດ້ວຍ ມື. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 135 ໂດຍ ສະ ເພາະ , ໃຫ້ ກວດ ເບິ່ງ ວ່າ: ï ກະດູກ ກົກ ແອວ ຕ້ັງ ຊ່ື ແລະ ພຽງ ກັນ ບໍ? (ຖ້າ ເປັນ ໄປ ໄດ້) ï ລໍາ ຕົວ ຕ້ັງ ຊ່ື ແລະ ໄດ້ ສັດສ່ວນ ບໍ? (ຖ້າ ເປັນ ໄປ ໄດ້) ï ຫົວ ດຸ່ນດ່ຽງ ແລະ ຕ້ັງ ຊ່ື ບໍ? (ຖ້າ ເປັນ ໄປ ໄດ້) ï ຂາ ແລະ ຕີນ ຖືກ ຮອງ ຮັບ ໃຫ້ ໃກ້ ຄຽງ ທີ່ສຸດ ກັບ ທ່ານ ນ່ັງ ຕ້ັງ ຊ່ື ເທົ່າ ທີ່ ຈະ ເປັນ ໄດ້ບໍ? ï ຖາມ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຮູ້ສຶກ ແນວ ໃດ. ຫຼັງຈາກ ກວດ ເບິ່ງ ທ່າ ນ່ັງ ໂດຍ ລວມຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລ້ວ, ໃຫ້ ກວດ ເບິ່ງ ວ່າ ແຕ່ ລະ ອຸປະກອນ PSD ກໍາລັງ ໃຫ້ການ ຮອງ ຮັງ ຕາມ ທີ່ ຕ້ັງ ໃຈ ໄວ້ຫຼືບໍ່. ໂດຍ ສະ ເພາະ ແລ້ວ, ໃຫ້ ຈື່ ວ່າ ຕ້ອງ ກວດ (ຖ້າ ໄດ້ ໃຫ້): ï ຄວາມ ສູງ , ການ ເອນ ແລະ ໂຄງ ຮ່າງ ບ່ອນ ອີງ ຫຼັງ; ï ການ ອ່ຽງ ໃນ ກາງຫາວ ï ແຜ່ນ ຮອງ ຂ້າງ ກົກ ແອວ ແລະ ແຜ່ນ ຮອງ ຂ້າງ ລໍາ ຕົວ; ï ແນວ ຮອງ ກົກຂາ ແລະ ແນວ ຮອງ ຂາ ສ່ວນລຸ່ມ ຕ່າງໆ. ກວດ ເບ່ິງ ການ ກົດທັບ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແຕ່ ລ ະ ຄົນ ຜູ້ ທີ່ ມີ ຄວາມ ສ່ຽງ ເກ ີດ ແຜ ກົ ດທັບ, ຂ້ັນ ຕອນ ປັບ ໃຫ້ ເໝາະສົມ ລວມມີ ການກວດ ເບິ່ງ ວ່າກາ ນກົ ດທັບ ແມ່ນ ປອດ ໄພຢູ່ ກ້ອງ ກະດູກຮອງ ນ່ັງ ແລະ ບໍລິ ເວນ ອື່ນ ທີ່ ມີ ຄວາມ ສ່ຽງ (ຕົວຢ່າງ ຢູ່ ກ້ອງ ຂ້ໍ ຕ່ໍ ສະ ໂພກ ຫຼື ກະດູກ ກ້ົນກົບ). ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແຕ່ລະຄົນ ຜູ້ ທີ່ ກໍາລັງ ໃຊ້ ອຸປະກອນ PSD ທີ່ ໃຫ້ການ ຮອງ ຮັບ ທີ່ ແໜ້ນໜາ – ກວດ ເບິ່ງ ການ ກົ ດທັບ ລະຫວ່າ ຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກັບ ອຸປະກອນ PSD. ການ ຮອງ ຮັບ ຄວນ ຮູ້ສຶກ ວ່າ ແໜ້ນໜາພໍ ດີ – ແຕ່ ບໍ່ ແໜ້ນ ເກີນ ໄປ. 136 ກວດ ຄວາມ ເໝາະ ສົມ ພໍດີ ໃນ ຂະນະ ທ່ີ ລົດ ເຂັນ ກໍາລັງ ເຄ່ືອນ ທ່ີ ສ່ວນ ສຸດ ທ້າຍ ຂອງ ການ ປັບ ໃຫ້ ເໝາະ ສົມ ແມ່ນ ການກວດ ເບິ່ງ ວ່າ ລົດ ເຂັນ ເໝາະ ສົມ ຫຼືບໍ່ ໃນ ເວລາ ທີ່ ລົດ ເຂັນ ເຄື່ອນ ທີ່. ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບໍ່ ສາມາດ ຍູ້ ລົດ ເຂັນ ໄດ້ ດ້ວຍຕົນ ເອງ, ຮ້ອ ງຂໍ ໃຫ້ ຄົນ ໃນ ຄອ ບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ຍູ້ ພວກ ມັນ ໃນ ຂະນະ ທີ່ ທ່ານ ສັງ ເກດ ເບິ່ງ. ສ່ິງ ທີ່ ຕ້ອງ ຊອກ ຫາ: ï ແນວ ອີງ ຫຼັງອະນຸຍາດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ອິດສະຫຼະ ໃນ ການ ເຄື່ອນ ເໜັງ ກະດູກ ຫົວ ໄຫ່ຼຂອງ ເຂົາ ເຈົ້າ ເພ່ືອ ຍູ້ ລົດ ເຂັນ ບໍ? ï ການ ເຄື່ອນ ເໜັງ ຂອງ ລົດ ເຂັນ ຫຼື ການ ຍູ້ ລົດ ເຂັນ ເຮັ ດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ປ່ຽນ ທ່າ ທາງ ຂອງ ເຂົາ ເຈົ້າ ຫຼື ຮູ້ສຶກ ບໍ່ ສະບາຍ ຕົວ ຫຼື ບໍ່ ໝ້ັນຄົງ ໃນ ແບບ ໃດ ໜຶ່ງ ບໍ? ï ການ ຂັບ ເຄື່ອນລົດ ເຂັນ ດ້ວຍ ມື: ຕໍາ ແໜ່ ງລ້ໍ ລົດ ເຂັ ນ ແມ່ນຖືກຕ້ອງ ເພ່ືອ ໃຫ້ຜູ້ ໃຊ້ ລົດ ເຂັນ ຍູ້ ລົດ ເຂັນ ໄດ້ ດີ ເທົ່າ ທີ່ ເຂົາ ເຈົ້າ ສາມາດ ແລ້ວ ບໍ? ï ການ ຂັບ ເຄື່ອນ ລົດ ເຂັນ ດ້ວຍ ຕີນ: ຄວາມ ສູງ ບ່ອນ ນ່ັງ ແລະ ຄວາມ ເລິກບ່ອນ ນ່ັງ ແມ່ນ ຖືກຕ້ອງ ເພ່ືອ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຍູ້ ລົດ ເຂັນ ດ້ວຍ ຂາ ຂອງ ເຂົາ ເຈົ້າ ບໍ? ï ການ ຮອງ ຮັບ ທ່າ ທາງ ອະນຸຍາດ ໃຫ້ ມີ ການ ເຄື່ອນ ໄຫວ ໄປ ມາ ດ້ວຍລົດ ເຂັນ ຢ່າງ ບໍ່ ຈໍາກັດ ແລະ ປອດ ໄພ ບໍ? ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 137 ລາຍ ກາ ນກວ ດ ສໍາລັບ ກາ ນປັບ ລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ ລະ ດັບ ປານ ກາງ 1. ລົດ ເຂັນ ພ້ອມ ນໍາ ໃຊ້ ແລ້ວ ບໍ? ລົດ ເຂັນ ໄດ້ ຖືກ ກວດກາ ເພ່ືອ ຮັບປະກັນ ວ່າ ມັນ ປອດ ໄພ ແລະ ພ້ອມ ໃຊ້ ແລະ ທຸກ ສ່ວນ ແມ່ນ ໃຊ້ ໄດ້ ດີ ບໍ? 2. ກວດ ເບ່ິງຄວາມ ເໝາະ ສົມ ພໍດີຂອງ ລົດ ເຂັນ ແລະ ອຸປະກອນ PSD ຄວາມ ກວ້າງ ຂອງ ລົດ ເຂັນ : ï ສະ ໂພ ກ ເຂົ້າ ຮູບ ຢ່າງ ສະບາຍ ຕົວ ຢູ່ ລະຫວ່າງ ບ່ອນ ວາງ ແຂນ ຫຼື ແຜ່ນ ຮອງ ຂ້າງກະດູກ ກົກ ແອວ; ï ລໍາ ຕົວ ເຂົ້າ ທີ່ ຢ່າງ ສະບາຍ ຕົວ ລະຫວ່າງ ໂຄງ ລົດ ເຂັນ ກັບ ທໍ່ ແນວ ອີງ ຫຼັງ ຫຼື ແຜ່ນ ຮອງ ລໍາ ຕົວ; ï ກົກຂາ ເຂົ້າ ທີ່ ຢ່າງ ສະບາຍ ຕົວ ລະຫວ່າງ ບ່ອນ ວາງ ແຂນ, ແນວ ບັງຕົມ/ ແນວ ປ້ອງ ກັນ ຫຼື ແຜ່ນ ຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ແລະ ບໍ່ ຍູ້ ເຂົ້າ ຫາ ກັນ. ຄວາມ ເລິກ ບ່ອນນ່ັງ: ï ມີ ຊ່ອງ ວ່າງ 30 ມມ ລະຫວ່າງ ຫຼັງຫົວ ເຂົ່າ ແຕ່ລະ ຂ້າງກັບ ເບາະ ຮອງ ນ່ັງ. ກະດູກ ກົກ ແອວ: ï ຖ້ານ ຮອງ ກະດູກ ຮອງ ນ່ັງ ຄວນ ຕິດແປະ ກັບ ດ້ານ ໜ້າ ຂອງ ກະດູກ ຮອງ ນ່ັງ; ï ແຜ່ນ ຮອງ ຫຼັງກະດູກ ກົກ ແອວ ໃຫ້ການ ຮອງ ຮັບ ຢູ່ PSIS; ï ແຜ່ນຮອງ ຂ້າງ ກະດູກ ກົກ ແອວ ເຂົ້າ ຮູບ ຢ່າງ ພໍດີ ຕົວ ແລະ ບໍ່ ຕ້ັງ ຢູ່ ເທິງ ຂ້ໍ ຕ່ໍ ສະ ໂພ ກ; ï ສາຍຮັດ ກົກ ແອວສາມາດຖືກ ຮັດ ຢ່າງ ແໜ້ນໜາ ແລະ ບໍ່ໜີບ ຜິວໜັງ. ລໍາ ຕົວ: ï ແຜ່ນ ຮອງຂ້າງ ລໍາ ຕົວ ບໍ່ ວາງ ການ ກົ ດທັບ ໃສ່ ຂ້ີ ແຮ້. ຄວນມີຊ່ອງ ວ່າງຢ່າງໜ້ອຍ 30 ມມ ລະຫວ່າ ງຂ້ີ ແຮ້ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ສ່ວນ ເທິງ ຂອງ ແຜ່ນ ຮອງ ລໍາ ຕົວ; ï ສາມາດ ຕິດສາຍຮັດ ບ່າ ໄຫ່ຼ ໄດ້ ຢ່າ ງສະບາຍ ຕົວ ແລະ ມັນ ບໍ່ ໜີບ ຜິວໜັງ; ï ຖາດ ຮອງ ຮັບ ຄວາມ ຍາວ ຂອງ ແຂນທ່ອນປາຍ ແລະ ຂ້ໍສອກ ແລະ ບໍ່ ຍູ້ ກັບ ທ້ອງ; ï ກວດ ເບິ່ງ ຄວາມ ສູງ ແລະ ການ ອ່ຽງຂອງ ແນວ ອີງ ຫຼັງ. ແນວ ປະຄອງ ຫົວ: ï ແນວ ປະຄອງ ຫົວຄວນປະຄອງ ຫົວ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຢູ່ ພ້ືນ ຂອງ ກະ ໂຫຼກຫົວ; ï ປະຄອງ ຫຼື ຮອງ ຮັບ ຫົວ ຂອງຜູ້ ໃຊ້ ໃຫ້ ຢູ່ ໃນ ທ່າ ສົມດຸນ ແລະ ຕ້ັງ ຊ່ື. 138 ກົກຂາ: ï ບໍ່ ມີ ການ ກົ ດທັບສູງ ຢູ່ ກົກຂາ ທີ່ ເກີດ ຈາກ ແຜ່ນ ຮອງ ກົກຂາ ດ້ານ ນອກ ຫຼື ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ; ï ແຜ່ນ ແຍກ ຫົວ ເຂົ່າ ແມ່ນ ຫ່າງ ປະມານ 40–60 ມມ ຈາກ ບໍລິ ເວນ ມຸມ ກົກຂາ ສໍາລັບ ເດັກນ້ອຍ ແລະ 60–100 ມມ ສໍາລັບ ຜູ້ ໃຫຍ່. ຄວາມ ສູງ ບ່ອນ ວາງ ຕີນ: ï ມີ ການ ຮອງ ກົກຂາ ຢ່າງ ຄົບ ຖ້ວນ ຢູ່ ເທິງ ເບາະ ຮອງ ນ່ັງ ໂດຍ ບໍ່ ມີ ຊ່ອງ ວ່າງ. ມີ ການ ຮອງຕີນ ຢ່າງ ຄົບ ຖ້ວນ ຢູ່ ເທິງ ບ່ອນ ວາງ ຕີນ ໂດຍ ບໍ່ ມີ ຊ່ອງ ວ່າງ; ï ສາມາດ ຕິດສາຍຮັດ ຕີນ ໄດ້ ຢ່າງ ແໜ້ນໜາ ໂດຍ ບໍ່ ໜີບ ຜິວ ໜັງ; ï ສາຍຮັດ ບີ ແຄ່ງ ແລະ ສາຍຮັດຕີນ ຢູ່ ຫຼັງ ສ້ົນ ນ່ອງ ໃຫ້ການ ຮອງ ຮັບ ບີ ແຄ່ງ ແລະ ຕີນ ໄດ້ ດີ. 3. ກວດ ເບ່ິງ ທ່າ ທາງ ກວດ ເບິງ່ ຈາກ ດາ້ນ ໜາ້ ແລະ ດາ້ນ ຂ້າງ ເພ່ືອ ເບິງ່ ວາ່ຜູ້ ໃຊ ້ລດົ ເຂນັ ກໍາລັງ ນ່ັງ ໃກ້ ຄຽງ ກັບ ທາ່ ນ່ັງ ປກົກະຕິ ທີ ່ສຸດ ເທົາ່ ຈະ ສະບາຍ ຕົວ ສໍາລັບ ເຂາົ ເຈົາ້ ຫຼບືໍ:່ ï ກະດູກ ກົກ ແອວ ຂອງ ເຂາົ ເຈົາ້ ຕ້ັງ ຊ່ື ແລະ ພຽງ ກັນ (ຫຼ ືໃກ້ ຄຽງ ກັບ ອນັ ີນ້ີ ໂດຍທີ ່ມັນ ສະບາຍຕົວສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ) ບ?ໍ ï ລາໍ ຕົວ ຕ້ັງ ຊ່ື ແລະ ສົມສ່ວນ (ຫຼ ືໃກ້ ຄຽງ ກັບ ອນັ ີນ້ີ ໂດຍທີ ່ມັນ ສະບາຍຕົວສໍາລັບ ຜູ້ ໃຊ ້ລດົ ເຂນັ) ບ?ໍ ï ຫວົ ດຸນ່ດ່ຽງ ແລະ ຕ້ັງ ຊ່ື (ຫາຼຍທ່ີ ສຸດ ເທົາ່ ທີ ່ເປນັ ໄປ ໄດ້) ບ?ໍ ï ຂາ ແລະ ຕີນ ຖກື ຮອງ ຮັບ ໃຫ ້ໃກ້ ຄຽງ ທີສຸ່ດ ກັບ ທາ່ນ ນ່ັງ ປກົກະຕິ ເທົາ່ ທີ ່ຈະ ເປນັ ໄດ້ບ?ໍ ກວດ ເບິງ່ ວາ່ ທ ຸກ ອປຸະກອນ PSD ກໍາລັງ ໃຫກ້ານ ຮອງ ຮັບ ຕາມ ທີ ່ຕ້ັງ ໃຈ ໄວ້. ໂດຍ ສະ ເພາະ ໃຫ ້ກວດ ເບິງ່ (ຖາ້ ໄດ້ ໃຫ)້: ï ຄວາມ ສູງ , ການ ເອນ ແລະ ໂຄງ ຮ່າງ ຂອງ ແນວ ອງີ ຫຼງັ ï ການອ່ຽງ ໃນ ກາງຫາວ ï ແຜ່ນ ຮອງ ຂ້າງ ກົກ ແອວ ແລະ ແຜ່ນ ຮອງ ຂ້າງ ລາໍ ຕົວ ï ຫຼີມ້ຮອງ ກົກຂາ ດາ້ນ ນອກ ແລະ ດາ້ນ ໃນ, ແຜ່ນ ຮອງ ກົກຂາ ດາ້ນ ນອກ ແລະ ແນວ ຮອງ ຂາ ສ່ວນ ລຸມ່ ກວດ ເບິງ່ ທາ່ ທາງ ອກີ ຄັງ້ ຫຼງັຈາກ 15 ນາທີ ເພ່ືອ ເບິງ່ ວາ່ ມີ ການ ປຽ່ນ ແປງ ໃດໆ ຫຼບືໍ່ 4. ກວດ ເບ່ິງ ການ ກົດທັບ ກວດ ເບິງ່ ການ ກົ ດທບັ ຢູ ່ກ້ອງ ກະດູກ ຮອງ ນ່ັງ ທງັ ສອງ. ການ ກົ ດທບັ ແມນ່ ປອດ ໄພ ຢູ ່ທງັ ສອງ ຂ້າງ ບ?ໍ ລະດບັ 1 = ປອດ ໄພ: ປາຍ ນ້ິວມື ສາມາດ ກະດິກ ຂ້ຶນ ລງົ ໄດ້ 5 ມມ ຂ້ຶນ ໄປ. ລະດບັ 2 = ເຕືອນ ໄພ: ປາຍ ນ້ິວມື ບໍ ່ສາມາດ ກະດິກ ໄດ້, ແຕ່ ສາມາດ ເລືອ່ນ ອອກ ໄດ້ ຢາ່ງ ງ່າຍດາຍ. ລະດບັ 3 = ບໍ ່ປອດ ໄພ: ປາຍ ນ້ິວມື ຖກື ບບີ ຮັດ ຢາ່ງ ແໜນ້. ມັນ ຍາກ ໃນ ການ ເລືອ່ ນປາຍ ນ້ິວມື ອອກ. ວາງ ນ້ິວມືຂອງ ທາ່ນ ຢູ ່ລະຫວາ່ງຮ່າງກາຍ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ ແລະ ແຕ່ລະ ແນວ ຮອງຮັບ ທາ່ ທາງ ລວມທງັ ແຜນ່ ຮອງ ແລະ ສາ ຍຮດັ. ແນວ ຮອງ ຮັບທາ່ ທາງ ເຮດັ ໃຫ ້ມີ ການ ສໍາພັດ ຢາ່ງ ເທົາ່ ກັນ ກັບ ຮ່າງກາຍ ບ?ໍ ການກົດທບັ ປອດ ໄພ ບ?ໍ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີສ່ວນ ນູນອອກ ທີ່ ເປັນ ກະດູກ, ຮອຍ ໃຄ່ ຫຼື ຮອຍ ຊ້ໍາ – ໃຫ້ ກວດ ເບິ່ງ ວ່າ ມີ ການ ກົ ດທັບ ຢູ່ ບໍລິ ເວນ ເຫຼົ່ານ້ີ ຫຼືບໍ່. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 139 5. ກວດ ຄວາມ ເໝາະ ສົມ ພໍດີ ໃນ ຂະນະ ທ່ີ ລົດ ເຂັນ ກໍາລັງ ເຄ່ືອນ ທ່ີ ແນວ ອີງ ຫຼັງອະນຸຍາດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ເຄື່ອນ ເໜັງ ກະດູກ ຫົວ ໄຫ່ຼຂອງ ເຂົາ ເຈົ້າ ເພ່ືອ ຍູ້ ລົດ ເຂັນ ໄດ້ ບໍ? ການ ເຄື່ອນ ເໜັງ ຂອງ ລົດ ເຂັນ ຫຼື ການ ຍູ້ ລົດ ເຂັນ ເຮັ ດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ປ່ຽນ ທ່າ ທາງ ຂອງ ເຂົາ ເຈົ້າ ຫຼື ຮູ້ສຶກ ບໍ່ ສະບາຍ ຕົວ ຫຼື ບໍ່ ໝ້ັນຄົງ ໃນ ແບບ ໃດ ໜຶ່ງ ບໍ? ການ ຂັບ ເຄື່ອນລົດ ເຂັນ ດ້ວຍ ມື: ຕໍາ ແໜ່ ງລ້ໍ ລົດ ເຂັ ນ ແມ່ນຖືກຕ້ອງ ເພ່ືອ ໃຫ້ຜູ້ ໃຊ້ ລົດ ເຂັນ ຍູ້ ລົດ ເຂັນ ໄດ້ ດີ ເທົ່າ ທີ່ ເຂົາ ເຈົ້າ ສາມາດ ແລ້ວ ບໍ? ການ ຂັບ ເຄື່ອນ ລົດ ເຂັນ ດ້ວຍ ຕີນ: ຄວາມ ສູງ ແລະ ຄວາມ ເລິກບ່ອນ ນ່ັງ ແມ່ນ ຖືກຕ້ອງ ເພ່ືອ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຍູ້ ລົດ ເຂັນ ດ້ວຍ ຂາ ຂອງ ເຂົາ ເຈົ້າ ບໍ? ການ ຮອງ ຮັບ ທ່າ ທາງ ອະນຸຍາດ ໃຫ້ ມີ ການ ເຄື່ອນ ໄຫວ ໄປ ມາ ດ້ວຍລົດ ເຂັນ ຢ່າງ ບໍ່ ຈໍາກັດ ແລະ ປອດ ໄພ ບໍ? 6. ຕັດສິນ ໃຈ ວ່າ ຈໍາ ເປັນ ຕ້ອງ ມີ ການ ດໍາ ເນີນ ການ ເພ່ີມ ເຕີມ ຫືຼບ່ໍ ຈໍາ ເປັນ ຕ້ອງມີ ການ ດໍາ ເນີນ ການ ເພ່ີມ ເຕີມ ໃດໆບໍ? ຂຽນ ການ ດໍາ ເນີນ ການ ຕ່າງໆ ໄວ້ ໃນ ແຟ້ມຂ້ໍ ມູນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ຂ້ັນ ຕອນ 7: ການ ຝຶກ ອົບ ຮົມ ຜູ້ ໃຊ້ ການ ຝຶກ ອົບ ຮົມ ຜູ້ ໃຊ້ ຂ້ໍ ມູນ ແລະ ການ ຝຶກ ອົບຮົມ ກ່ຽວ ກັບ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ສາມາດ ຊ່ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຫຼາຍໆ ຄົນ ໄດ້ ປະ ໂຫຍ ດຢ່າງ ແທ້ ຈິງ ຈາກ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ. ຖ້າ ບໍ່ ມີ ຂ້ັນ ຕອນ ນ້ີ, ມັນ ເປັນ ໄປ ໄດ້ ວ່າ ລົດ ເຂັນ ຈະ ບໍ່ຊ່ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄດ້ ຫຼາຍ ເທົ່າ ທີ່ ມັນ ສາມາດ ຊ່ວຍ. ມັນ ສໍາຄັນ ວ່າ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ຍັງ ໄດ້ ຮັບ ຂ້ໍ ມູນ ແລະ ການ ຝຶກ ອົບຮົມ ນໍາ ອີກ. ທັກ ສະ ທ່ີ ເປັນ ປະ ໂຫຍ ດສໍາລັບຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ຫຍັງ ແດ່? ພະນັກງາ ນບໍລິການ ລົດ ເຂັນ ສາມາດ ສອນທັກ ສະ ຕ່າງໆ ໃຫ້ ແກ່ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ເພ່ືອ ຊ່ວຍ ໃຫ້ ພວກ ເຂົາ ມີ ສຸຂະພາບ ດີ, ໃຊ້ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ຢ່າງ ປອດ ໄພ ແລະ ມີ ປະສິດທິພາບ, ແລະ ເບິ່ງ ແຍງ ຮັກສາ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ເພ່ືອ ໃຫ້ ມັນ ໃຊ້ ໄດ້ ດົນ ກວ່າ. ສ່ິງ ຕ່ໍ ໄປ ນ້ີ ແມ່ນ ທັກ ສະ ທີ່ ດີ ເພ່ືອ ສອນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທຸກ ຄົນ: ການຈັດການລົດ ເຂັນ: ï ວິທີ ພັບ ແລະ ຍົກ ລົດ ເຂັນ ສໍາລັບ ການ ຂົນ ສ່ົງ. ï ວິທີ ຖອດອອກ ແລະ ປະກອບ ເຂົ້າ ຄືນ ສໍາລັບ ອຸປະກອນ PSD ທີ່ ຈໍາ ເປັນ ຕ້ອງ ໄດ້ຖອດ ອອກ ສໍາລັບ ການ ຂົນ ສ່ົງ ເຄື່ອນຍ້າຍ ï ວິທີ ໃຊ້ ຄຸນສົມບັດ ໃຊ້ ງານ ຕ່າງໆ ຢູ່ ໃນ ລົດ ເຂັນ – ຕົວຢ່າງ ການ ໃຊ້ ເບ ກ, ການ ອ່ຽງ ແລະ ທ່ອນ ກັນ ລົດ ເຂັນປ້ີນ, ຕໍາ ແໜ່ ງທ່ີ ຖືກຕ້ອງ ຂອງ ອຸປະກອນ PSD ແລະ ເບາະ ຮອງ ນ່ັງ. 140 ຜູ້ ໃຊ້ ລົດ ເຂັນ ຄວນ ນ່ັງ ໃນ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈ້ົາ ດົນ ປານ ໃດ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບາງ ຄົນ ຜູ້ ທີ່ ບໍ່ ໄດ້ ນ່ັງ ຫຼາຍປານ ໃດ, ມັນ ອາດ ຈະ ໃຊ້ ເວລາ ເພ່ືອ ໃຫ້ ພວກ ເຂົາ ຄຸ້ນ ເຄີຍ ກັບ ການ ນ່ັງ ໃນ ທ່າ ຕ້ັງ ຊ່ື. ນ້ີ ສາມາດ ເປັນ ເລື່ອງ ຈິງ ໂດຍ ສະ ເພາະ ສໍາລັບ ເດັກນ້ອຍ. ພະນັກງານ ບໍ ລິ ການ ລົດ ເຂັນ ຈໍາ ເປັນ ຕ້ອງ ແນະນໍາ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຄວນ ນ່ັງ ໃນ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ ດົນ ປານ ໃດ. ໃຫ້ ຄໍາ ແນະນໍາ ເຫຼົ່ານ້ີ: ï ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນຄຸ້ນ ເຄີຍ ກັບ ການ ນ່ັງ , ຜູ້ກ່ຽວ ຄວນ ໃຊ້ ຈໍານວນ ເວລາ ດຽວ ກັນ ໃນ ການ ນ່ັງ ໃນ ລົດ ເຂັນ ໃໝ່ ຂອງ ເຂົາ ເຈົ້າ. ຜູ້ກ່ຽວ ສາມາດ ຄ່ອຍໆ ເພ່ີມ ເວລາ ຂ້ຶນ, ຖ້າ ຈໍາ ເປັນ. ï ຖ້າ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ບໍ່ ເຄີຍ ລຸກ ນ່ັງ , ໃຫ້ ເລີ່ ມບ່ໍ ເກີນ 30 ນາທີ ແລະ ໃຫ້ ພັກ. ï ສອນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຫຼື ຄົນ ໃນ ຄອບຄົວ/ ຜູ້ ເບິ່ ງ ແຍງ ໃຫ້ ກວດ ເບິ່ງ ບໍລິ ເວນ ກົ ດທັບ ຢູ່ ສະ ເໝີ ຫຼັງຈາກ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄດ້ ນ່ັງ ໃນ ລົດ ເຂັນ. ການ ເຄ່ືອນ ຍ້າຍ (ວິທີ ເຂ້ົາ ແລະ ອອກ ຈາກ ລົດ ເຂັນ ): ï ວິທີ ເຄື່ອນ ຍ້າຍ ຢ່າງ ປອດ ໄພ ເຊິ່ງ: – ສະບາຍ ຕົວ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ; ແລະ – ປອດ ໄພ ສໍາລັບ ບຸກຄົນ ທີ່ ຊ່ ວຍ ເຫຼືອ ຫຼື ຍົກ. ï ວິທີ ນ່ັງ ໃຫ້ ຖືກຕ້ອງ ໃນ ລົດ ເຂັນ (ຕົວຢ່າງ ການ ຮັບປະກັນ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນຢູ່ ໃນ ຕໍາ ແໜ່ ງທ່ີ ດີ ໃນ ລົດ ເຂັນ ໂດຍ ທີ່ ກະດູກ ຮອງ ນ່ັງ ຢູ່ ຫຼັງຖ້ານ ຮອງ ກະດູ ກຮອງ ນ່ັງ). ï ວິທີ ປັບ ອຸປະກອນ PSD ຢ່າງ ຖືກຕ້ອງ – ຕົວຢ່າງ ຕ້ອງ ຮັດ ສາຍຮັດ ໃຫ້ ແໜ້ນ ສ່ໍາ ໃດ ເພ່ືອ ໃຫ້ ໃຊ້ ງານ ຢ່າງ ຖືກຕ້ອງ. ï ຈື່ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຫຼາຍໆ ຄົນ ຈະ ບໍ່ ສາມາດ ເຂົ້າ ແລະ ອອກ ຈາກ ລົດ ເຂັນ ໄດ້ ດ້ວຍ ຕົນ ເອງ. ການ ເຄື່ອນ ຍ້າຍ ດ້ວຍ ຕົນ ເອງ ແລະ ມີ ຄົນ ຊ່ວຍ ແມ່ນ ຖື ກ ອະ ທິບາຍ ຢູ່ ໃນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ປານ ກາງ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 141 ການ ໃຊ້ ລົດ ເຂັນ ແລະ ການ ເຄ່ືອນ ໄຫວ ໄປມາ: ï ທັກ ສະ ທີ່ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສອນ ສໍາລັບ ການ ເຄື່ອນ ໄຫວ ໄປ ມາ ດ້ວຍ ລົ ດ ເຂັນ ຈະ ຂ້ຶນ ກັບ ຄວາມສາມາດ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ສະພາບ ແວດ ລ້ອມ ຂອງ ເຂົາ ເຈົ້າ. ï ຈົ່ງ ຈື່ ວ່າ ຕ້ອງ ໄດ້ ສອນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ວິທີ ທີ່ ດີ ສຸດ ໃນ ການ ຂັບ ເຄື່ອນ ລົດ ເຂັນ ໂດຍ ໃຫ້ ເໝາະ ສົມ ກັບ ຄວາມ ສາມາດ ຂອງ ເຂົາ ເຈົ້າ. ï ຂ້ໍ ມູນ ເພ່ີມ ເຕີມ ກ່ຽວ ກັບ ທັກ ສະການ ເຄື່ອນ ໄຫວ ໄປ ມາ ດ້ວຍ ລົດ ເຂັນ ເຊິ່ງລວມທັງ ການ ຍູ້ ລົດ ເຂັນຢ່າງ ຖືກຕ້ອງ, ການ ຂ້ຶນ ແລະ ການລົງ ເນີນ ແລະ ຂ້ັນ ໄດ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂັນ ບາງ ຄັ້ງ ຄາວ ແມ່ນ ມີ ໃຫ້ ຢູ່ ໃນ ຄູ່ ມື ອ້າງ ອີງ ຂອຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ. ການ ປ້ອງ ກັນ ແຜກົດ ທັບ: ï ແຜ ກົ ດທັບ ເກີດ ຈາກ ການ ກົ ດທັບ ໃສ່ ບໍລິ ເວນ ກະດູກ, ການ ຮຸກ ຖູ ແລະ ການ ສຽດ ສີ. ï ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນຜູ້ທີ່ອາດຈະມີຄວາມຍາກໃນການນ່ັງຕ້ັງຊ່ື, ໃຫ້ຄິດກ່ຽວກັບ: – ການ ຮັບປະກັນ ວ່າ ພວກ ເຂົາ ບໍ່ ເລື່ອນ ໄຫຼ – ເຊິ່ງສາມາດກ່ ໃຫ້ ເກີດ ແຜ ກົ ດທັບ ໄດ້ ຈາກ ການ ສຽດ ສີ (ບໍລິ ເວນ ກະດູກ ເລື່ອນ ໄຫຼ ເທິງ ເນ້ືອ ເຍື່ອທີ່ ອ່ອນ); – ຮັບປະກັນ ໃຫ້ ນ້ໍາ ກະຈາຍ ຢ່າງ ສະ ເ ໝີ ກັນ ຢູ່ ກ້ອງ ກະດູກ ຮອງ ນ່ັງ. ï ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ທີ່ ໃຊ້ ອຸປະກອນ PSD, ຮັບປະກັນ ວ່າ ພວກ ເຂົາ ກວດ ເບິ່ງ ຜິວ ໜັງ ໃນ ທຸກ ບ່ອນ ທີ່ສໍາ ພັດ ກັບລົດ ເຂັນ ຫຼື ອຸປະກອນ PSD. ï ລາຍ ລະອຽດ ເພ່ີມ ເຕີມ ກ່ຽວ ກັບ ກາ ນປ້ອງ ກັນ ແຜ ກົ ດທັບ ແມ່ນ ມີ ໃຫ້ ໃນ ຄູ່ ມື ອ້າງ ອີງ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ. ວິທີ ການ ເບ່ິງ ແຍງ ດູ ແລລົດ ເຂັນ ຢູ່ ເຮືອນ: ï ການ ໃຫ້ ຂ້ໍ ມູນ ພ້ືນ ຖານ ແກ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກ່ຽວ ກັບ ວິທີດູ ແລ ຮັກສາ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າຢູ່ ເຮືອນ ສາມາດ ຊ່ວຍ ເພ່ືອ ອາຍຸ ໃຊ້ ງານ ຂອງ ລົດ ເຂັນ ໄດ້. ï ມີ ຫົກ ຢ່າງ ທີ່ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສາມາດ ເຮັດ ຢູ່ ເຮືອນ ເພ່ືອ ເບິ່ງ ແຍງ ລົດ ເຂັນ ແລະ ເບາະ ຮອງ ນ່ັງ ຂອງ ເຂົາ ເຈົ້າ ທີ່ ສອນ ໄວ້ ຢູ່ ໃນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັບ ພ້ືນຖານ. ຂ້ໍ ມູນ ນ້ີ ນໍາ ໃຊ້ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ເຊັ່ນ ກັນ. ບາງ ການ ດູ ແລ ຮັກສາ ເພ່ີມ ເຕີມ ສາມາດ ຖືກ ດໍາ ເນີນ ເພ່ືອ ກວດ ເບິ່ງ ວ່າ ອຸປະກອນ PSD ຢູ່ ໃນ ສະພາບ ໃຊ້ ງານ ໄດ້ ດີ ຫຼືບໍ່. 142 ສ່ິງ ທ່ີ ຕ້ອງ ເຮັດ ຖ້າ ມີ ບັນຫາ: ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈໍາ ເປ ັນ ຕ້ອງ ຮູ້ ສ່ິງ ທີ່ ຕ້ອງ ເຮັດ ຖ້າ ມີ ບັນຫາ ໃດ ໜຶ່ງ. ບັນຫາ ອາດ ລວມມີ: ï ລົດ ເຂັນ ຕ້ອງການ ການ ສ້ອມ ແປງ; ï ລົດ ເຂັນ ບໍ່ ພໍດີ ຫຼື ບໍ່ ສະ ບາຍ ຕົວ. ສໍາລັບ ບັນຫາ ໃດ ໜຶ່ງ ເຫຼົ່ານ້ີ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຄວນ ສາມາດ ຕິດ ຕ່ໍ ຫາ ພະນັກງານ ບໍລິກາ ນລົດ ເຂັນ ເພ່ືອ ຂໍ ຄວາມ ຊ່ວຍ ເຫຼືອ ແລະ ຄໍາ ແນະນໍາ. ຮັບປະກັນ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຮູ້ ວິທີ ຕິດ ຕ່ໍ ພົວພັນ ກັບ ສູນ ບໍລິການ ລົດ ເຂັນ. ວິທີ ເຮັດ ໃຫ້ການ ຝຶກ ອົບຮົມ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສໍາ ເລັດ ຜົນ ï ຊອກ ຮູ້ ວ່າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຮູ້ຈັກ ຫຍັງ ແດ່ ແລ້ວ. ï ອະທິບາຍ, ສາທິດ ໃຫ້ ເບິ່ງ ແລະ ຈາກ ນ້ັນ ອະນຸຍາດ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຝຶກປະຕິບັດ. ï ໃຊ້ ພາສາ ທີ່ ທຸກ ຄົນ ສາມາດ ເຂົ້າ ໃຈ ໄດ້. ï ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສອນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຄົນ ອື່ນ. ï ໃຊ້ ທັກ ສະ ການ ສ່ືສານ ທີ່ ດີ. ï ໃຫ້ການ ສ່ົງ ເສີມ. ຈົ່ງ ຈື່ ວ່າ – ການ ຝຶກ ປະຕິບັດ ແມ່ນ ສໍາຄັນ ຫຼາຍ ໃນ ເວລາ ຮຽນ ຮູ້ ທັກ ສະ ໃໝ່. ລອງ ສອນ ທັກ ສະ ໃດ ໜຶ່ງ ກ່ອນ ໂດຍ ການ ສາທິດ ໃຫ້ ເບິ່ງ ແລະ ຈາກ ນ້ັນ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ໂອກາດ ຝຶກ ປະຕິບັດ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 143 ລາຍ ການກວດ ສໍາລັບການ ຝຶກ ອົບ ຮົບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ລະ ດັບ ປານ ກາງ ທັກ ສະ ທ່ີ ຕ້ອງ ສອນ ທັກ ສະ ທ່ີ ໄດ້ ສອນ ແລ້ວ ການຈັດການລົດ ເຂັນ ການພັບ ແລະ ການ ຍກົ ລດົ ເຂນັ ການ ຖອດອອກ ແລະ ການ ປະກອບ ເຂົາ້ ຄນື ສໍາລັບ ອປຸະກອນ PSD ທີ ່ຈາໍ ເປນັ ຕ້ອງ ຖອດ ອອກ ສໍາລັບ ການ ຂົນ ສ່ົງ ເຄືອ່ນຍາ້ຍ ການ ໃຊ້ລໍ ້ປອ່ຍ ໄວ ການ ໃຊ້ ເບ ກ ການອ່ຽງ ແລະ ແຖບ ກັນ ປີນ້ (ຖາ້ ໃຊ)້ ຕໍາ ແໜ ່ງທ່ີ ຖກືຕ້ອງ ຂອງ ອປຸະກອນ PSD ໃນ ເວລາ ທີ ່ຜູ້ ໃຊ ້ລດົ ເຂນັ ຢູ ່ໃນ ລດົ ເຂນັ ການ ໃຊ້ ເບາະ ຮອງ ນ່ັງ ລວມທງັ ການວາ ງຕໍາ ແໜ ່ງຢ່າງ ຖກືຕ້ອງ ການ ເຄ່ືອນ ຍ້າຍ ການ ເຄືອ່ນ ຍາ້ຍ ດວ້ຍ ຕົນ ເອງ ການ ເຄືອ່ນ ຍາ້ຍ ໂດຍ ມີ ການ ຊ່ວຍ ເຫຼອື ອືນ່ໆ ການ ໃຊ້ ລົດ ເຂັນ ແລະ ການ ເຄ່ືອນ ໄຫວ ໄປມາ ການ ຍູ ້ລດົ ເຂັນ ຢາ່ງ ຖກືຕ້ອງ (ໂດຍ ໃຊ ້ວທິ ີທີ ່ມັກ ຂອງ ຜູ້ ໃຊ ້ລດົ ເຂນັ) ຂ້ຶນ ແລະ ລງົ ເນີນ ຄອ້ຍ ຂ້ຶນ ແລະ ລງົ ຂ້ັນ ໄດ ຢູ ່ເທງິ ພ້ືນ ທີ ່ບໍ ່ຮາບ ພຽງ ຜູ້ ໃຊ້ ລດົ ເຂັນ ບາງ ຄັງ້ ຄາວ ນ່ັງ ໃນ ລດົ ເຂັນ ດນົ ປານ ໃດ (ສໍາລັບ ເດກັນ້ອຍ ແລະ ຜູ້ ໃຫຍ ່ທີ ່ມີ ຄວາມ ຕ້ອງການອຸປະກອນ ຮອງ ຮັບ ການ ຊົງ ຕົວ ເພ່ີມ ເຕີມ) ການ ຍູ ້ແບບ ມີ ການ ຊ່ວຍ ເຫຼອື ການ ປ້ອງ ກັນ ແຜກົດ ທັບ ກວດ ເບິງ່ ແຜກົ ດທບັ ຢູ ່ບລໍ ິເວນ ທີ ່ມີ ການ ກົ ດທບັ ສູງ ການ ຍກົ ເພ່ືອ ຫຼດຸຜ່ອນ ການ ກົ ດທບັ ກິນ ໄດ້ ດ ີ ແລະ ດືມ່ ນ້ໍາຫຼາຍ ສ່ິງ ທີ ່ຕ້ອງ ເຮັດ ຖາ້ ເກີດ ແຜ ກົດ ທບັ ວິທີ ການ ເບ່ິງ ແຍງ ດູ ແລລົດ ເຂັນ ຢູ່ ເຮືອນ ອະນາ ໄມ ລດົ ເຂນັ; ລາ້ງ ແລະ ເຊດັ ເບາະ ຮອງ ແລະ ສ່ິງ ປກົ ຫຸມ້ ເບາະ ຮອງ ນ່ັງ ໃຫ ້ແຫງ້ ໃສ່ ນ້ໍາມັນ ສ່ວນ ທີ ່ເຄືອ່ນ ເໜງັ ຂອງ ລດົ ເຂນັ ສູບ ລມົ ຢາງ ລດົ ເຂນັ ຫນັ ນັອດ ໂຕ ແມ ່ ແລະ ນັອດ ໂຕ ຜູ້ ໃຫ ້ແໜນ້ ເຄັງ່ ດິວ້ ລໍ ້ລດົ ເຂນັ ກວດ ເບິງ່ ແນວ ຫຸມ້ ເບາະ ກວດ ເບິງ່ຂ້ີໝ້ຽງ ກວດ ເບິງ່ ເບາະ ຮອງ ນ່ັງ ສ່ິງ ທ່ີ ຕ້ອງ ເຮັດ ຖ້າ ມີ ບັນຫາ ລດົ ເຂັນ ຕ້ອງການ ມີ ການ ສ້ອມ ແປງ ລດົ ເຂັນ ບໍ ່ພໍດ ີຫຼ ືບໍ ່ສະ ບາຍ ຕົວ 144 ຂ້ັນ ຕອນ 8: ການ ບໍາລຸງ ຮັກສາ, ການ ສ້ອມ ແປງ ແລະ ການ ຕິດຕາມ ຜົນ ຂ້ໍ ມູນ ກ່ຽວ ກັບ ການ ບໍາລຸຸງຮັກສາ, ການ ສ້ອມ ແປງ ແລະ ການ ຕິດຕາມ ຜົນ ແມ່ນ ມີ ຢູ່ ໃນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລົດ ເຂັນ – ລະດັ ບ ພ້ືນຖານ. ໃນ ລະດັບ ປານ ກາງ ມີ ການ ເວົ້າ ເຖິງຄວາມ ສໍາ ຄັນ ສະ ເພາະ ຂອງ ການ ຕິດຕາມ ຜົ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ທີ່ ໃຊ້ ລົດ ເຂັນ ທີ່ ມີ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ. ການ ຕິດຕາມ ຜົນ ການ ຕິດຕາມ ຜົນ ແມ່ນ ສ່ວນໜຶ່ງ ຂອງ ຂ້ັນ ຕອນ ທີ ແປດ ໃນ ການ ໃຫ້ ບໍລິການ ລົດ ເຂັນ. ສະພາບ ລວມຂອງ ການ ຕິດຕາມ ຜົນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ທັງ ໝົດ ໄດ້ ຮັບ ຜົນ ປະ ໂຫຍດ ຈາກ ການ ຕິດ ຕາມຜົນ. ແນວ ໃດ ກໍ ຕາມ, ການ ຕິດຕາມ ຜົນ ສໍາຄັນ ທີ່ ສຸດສໍາລັບ: ï ເດັກນ້ອຍ; ï ຜູ້ໃຊ້ລົດເຂັນທ່ີມີຄວາມສ່ຽງເກີດແຜກົດທັບ; ï ຜູ້ໃຊ້ລົດເຂັນຜູ້ທີ່ມີອາການພະຍາດ ຂະຫຍາຍຕົວ; ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ທີ່ ຕ້ອງການ ມີ ການ ຮອ ງຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ໃນ ລົດ ເຂັນ ຂອງ ເຂົາ ເຈົ້າ; ï ຜູ້ ໃຊ້ ລົດ ເຂັນ ຜູ້ ທີ່ ມີ ຄວາມ ຍາກ ໃນ ເລື່ອງ ການ ຝຶກ ອົບຮົມ ຫຼື ການ ສອນ ທີ່ ເອົາ ໃຫ້ ເຂົາ ເຈົ້າ. ຜູ້ ໃຊ້ ລົດ ເຂັນ ລະດັບ ປານ ກາງ ສ່ວນ ໃຫຍ່ ຈໍາ ເປັນ ຕ້ອງ ມີ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ – ສະ ນ້ັນ ການ ຕິດຕາມ ຜົນ ຈິ່ງ ສໍາຄັນ ເປັນ ພິ ເສດ. ການ ຄຸ້ມ ຄອງ ກາ ນຕິດຕາມ ຜົນ ບໍ່ ມີ ກົດ ລະ ບຽບ ກ່ຽວ ກັບ ວ່າການ ຕິດ ຕາມ ຜົນ ຄວນ ເກີດ ຂ້ືນ ເມ່ືອ ໃດ, ເພາະວ່າເວລາທ່ີດີສຸດ ໃນ ການ ຕິດຕາມ ຜົນ ຈະ ຂ້ຶນ ກັບ ຄວາມ ຕ້ອງການ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ. ແນວ ໃດ ກໍ ຕາມ ໃນບ່ອນ ທີ່ ເປັນ ໄປ ໄດ້ ການ ຕິດຕາມຜົນ ພາຍ ໃນ ຫົກ ເດືອນ ຫຼັງຈາກ ການ ໃຫ້ລົດ ເຂັນສາມາດ ເປັນ ປະ ໂຫຍ ດຫຼາຍ ເພ່ືອ ຮັບປະກັນ ວາ່ ລົດ ເຂັນຍັງ ໃຊ້ ໄດ້ ດີສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ເພ່ືອ ສະໜັບສະໜູນ ການ ຝຶກ ອົ ບຮົມ ຜູ້ ໃຊ້. ສໍາລັບ ເດັກນ້ອຍ, ມັນ ເປັນ ການ ດີ ຖ້າ ການ ຕິດຕາມ ຜົນ ແມ່ນ ທຸກໆ ສາມ ຫາ ຫົກ ເດືອນ. ນ້ີ ເພາະວ່າ ຄວາມ ຕ້ອງການ ຂອງ ເດັກ ນ້ອ ຍປ່ຽນ ແປງ ຢ່າ ງວ່ອງ ໄວ ເມ່ືອ ເຂົາ ເຈົ້າ ເຕີບ ໃຫຍ່. ການ ຕິດຕາມ ຜົນ ສາມາດ ຖືກ ດໍາ ເນີນ: ï ຢູ່ ເຮືອນ ຂອງຜູ້ ໃຊ້ ລົດ ເຂັນ; ຫຼື ï ຢູ່ ສູນ ບໍລິ ການ ລົດ ເຂັນ; ï ຢູ່ ບ່ອນ ອື່ນ ທີ່ ເໝາະ ສົມ ສໍາລັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ພະນັກງາ ນບໍລິການລົດ ເຂັນ. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 145 ສະຖານທ່ີ ຂ້ຶນ ກັບ ວ່າ ຜູ້ ໃ ຊ້ລົດ ເຂັນ ສາມາດ ເດີນ ທາງ ໄປ ຫາ ສູນ ບໍລິການ ລົດ ເຂັນ ໄດ້ ຫຼືບໍ່ ແລະ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ສາມາດ ເດີນທາງ ໄປ ເຮືອນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໄດ້ ຫຼືບໍ່. ສາມາດ ຄຸ້ມ ຄອງການ ຕິດຕາມ ຜົນ ໄດ້ ໃນ ຫຼາຍວິທີ ແຕກ ຕ່າງ ກັນ ເຊິ່ງລວມມີ: ï ອາດ ຈະ ເຮັດ ກາ ນນັດ ໝາຍ ຕິດຕາມ ຜົນ ກັບ ຜູ້ ໃຊ້ ລົດ ເຂັນ ໃນ ເວລາ ພວກ ເຂົາ ໄດ້ ຮັບ ລົດ ເຂັນ; ï ການ ຕິດຕາມ ຜົນ ອາດ ຈະ ຖືກ ດໍາ ເນີນ ຢູ່ ເຮືອນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຫຼື ຢູ່ ສູນ ບໍ ລິ ການ ລົດ ເຂັນ; ï ການ ໄປ ຢ້ຽມຢາມ ຕິດຕາມ ຜົນ ອາດ ຈະ ເປັນ ສ່ວນ ໜຶ່ງ ຂອງ ການ ຢ້ຽມຢາມ ປົກກະຕິຕ່ໍ ກັບ ຊຸມ ຊົນ ໂດຍ ພະນັກງານ ຟ້ືນ ຟູ ຂ້ັນ ຊຸມ ຊົນ (CBR) ຜູ້ ທີ່ ໄດ້ ຮັບ ການ ຝຶກ ອົບຮົມ ໃຫ້ ດໍາ ເນີນ ການຕິດຕາມ ຜົນ; ï ການ ຕິດຕາມ ຜົນ ທາງ ໂທລະສັບ ອາດ ຈະ ຖືກ ດໍາ ເນີນ ໃນ ບ່ອນ ທີ່ ການ ຂົນ ສ່ົງ ເດີນທາງ ຫຍຸ້ງຍາກ ແລະ ຜູ້ ໃຊ້ ລົດ ເຂັນ ມີ ການ ເຂົ້າ ເຖິງ ໂທລະສັບ. ແບບ ຟອມການ ຕິດຕາມ ຜົນ ລົດ ເຂັນ ແບບ ຟອມການ ຕິດຕາມ ຜົນ ລົດ ເຂັນ (ສະ ແດງ ຢູ່ ຂ້າງ ລຸ່ມ) ຈະ ຊ່ວຍ ໃຫ້ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຈື່ ວ່າ ຄໍາ ຖາມ ຫຍັງ ທີ່ ຕ້ອງ ຖາມ ແລະ ສ່ິງທ່ີ ຕ້ອງ ເຮັດ ໃນ ການ ຢ້ຽມຢາມ ຕິດຕາມ ຜົນ. ແບບ ຟອມການຕິດຕາມ ຜົນ ລົດ ເຂັນ ຍັງ ມີ ບ່ອນ ໃຫ້ ຂຽນ ການ ດໍາ ເນີນ ການ ຕ່າງໆ ທີ່ ຈໍາ ເປັນ ຕ້ອງດໍາ ເນີນ. ການ ດໍາ ເນີນທ່ົວ ໄປ ໃການ ຕິດຕາມ ຜົນ ການ ດໍາ ເນີນທ່ົວ ໄປ ໃການ ຕິດຕາມ ຜົນ ລວມມີ: • ໃຫ້ ຄໍາ ແນະ ນໍາ ຫືຼ ການ ຝຶກ ອົບ ຮົມ ເພ່ີມ ເຕີມ. ຕົວຢ່າງ ຖ້າ ຜູ້ ໃຊ້ ລົດ ເຂັນ ກໍາລັງ ບໍ່ ໃຊ້ ລົດ ເຂັນ ຂອງ ເຂົ າ ເຈົ້າ ຕາມ ທີ່ ຄາດ ໄວ້, ມັນ ອາດ ຈະ ເປັນ ຍ້ອນ ວ່າ ພວກ ເຂົາ ບໍ່ ໝ້ັນ ໃຈ ກ່ຽວ ກັບ ວ່າວ ກ ເຂົາ ສາມາດ ເຂົ້າ ແລະ ອອກ ຈາກ ລົດ ເຂັນ ໄດ້ ໃນ ເວລາ ທີ່ ພວກ ເຂົາ ຢູ່ ຄົນ ດຽວ. ການ ຝຶກ ອົບຮົມ ເພ່ີມ ເຕີມ ໃນ ການ ເຂົ້າ ອອກ ລົດ ເຂັນ ສາມາ ຊ່ວຍ ແກ້ ໄຂ ບັນຫາ ນ້ີ ໄດ້. • ການ ປັບ ລົດ ເຂັນ ຄືນ ໃໝ່. • ການ ດໍາ ເນີນ ການ ສ້ອມ ແປງ ຂະ ໜາດ ນ້ອຍ. ສ່ົງ ເ ສີມ ໃຫ້ ຜູ້ ໃຊ້ ລົດ ເຂັນ ແລະ ຄົນ ໃນ ຄອບຄົວ/ຜູ້ ເບິ່ງ ແຍງ ເຂົາ ເຈົ້າ ບໍາລຸງ ຮັກສາ ລົດ ເຂັນ ໂດຍ ການ ເບິ່ ງ ແຍງ ດູ ແລ ລົດ ເຂັນ ຢູ່ ເຮືອນ. ນອກ ນ້ັນ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ ຍັງ ສາມາດ ຊ່ວຍ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຈັດ ຫາ ການ ສ້ອມ ແປງ ຖ້າ ມັນ ເປັນ ໄປ ໄດ້ ບໍ່ ໄດ້ ໃນ ການ ແກ້ ໄຂ ສ່ວນ ທີ່ ເສຍ ຫາຍ ໃນ ທັນທີ. • ການ ນໍາ ສ່ົງຜູ້ ໃຊ້ ລົດ ເຂັນ ຫາ ການ ບໍ ລິ ການ ອ່ືນ ສໍາ ລັບ ການ ສະ ໜັບ ສະ ໜູນ ຫືຼ ຊ່ວຍ ເຫືຼອ. 146 ການ ຢ້ຽມ ຢາມ ຕິດຕາມ ຜົນ ຕ່ໍ ກັບ Thusitha Thusitha ອາຍຸ 7 ປີ ແລະ ອາ ໄສ ຢູ່ ເຮືອນ ນໍາ ພ່ໍ ແມ່ ແລະ ເອື້ອຍຂອງ ລາວ. ລາວ ເປັນ ພະຍາດກ້າມ ເນ້ືອ ເສ່ືອ ມ ແລະ ໄດ້ ຮັບ ລົດ ເຂັນ ຜ່ານ ການ ບໍລິການ ລົດ ເຂັນ ເມ່ືອ ໜຶ່ງ ປີ ກ່ອນ ນ້ີ. ໃນ ເວລາ ນ້ັນ ລາວ ສາມ າດຍ່າງ ໄດ້ ໄລຍະ ສ້ັນໆ. ລາວສາມາດ ເຮັດ ການ ເຄື່ອນ ຍ້າຍ ແບບ ຢືນ ເຂົ້າ ແລະ ອອກ ຈາກ ລົດ ເຂັນ ໄດ້ ດ້ວຍ ຕົນ ເອງ. ລາວ ບອກ ວ່າ ລາວ ຕ້ອງການ ລົດ ເຂັນ ເພາະວ່າ ລາວ ພົບ ວ່າ ມັນ ຍາກ ໃນ ການ ໄປ ໂຮງຮຽນ. ຢູ່ ໃນ ການ ຢ້ຽມຢາມ ຕິດຕາມ ຜົນ, Thusitha ບອກ ວ່າ ດຽວ ນ້ີ ລາວ ກໍາລັງ ພົບ ວ່າ ມັນ ຍາ ໃນ ການ ເຂົ້າ ແລະ ອອກ ຈາກ ລົດ ເຂັນ ຂອງ ລາວ ດ້ວຍ ຕົນ ເອງ. ລາວ ຮູ້ສຶກ ເມ່ືອຍ ແລະ ບໍ່ ສະບາຍ ຕົວ ໃນ ຕອນ ບ່າຍ ຢູ່ ໂຮງຮຽນ. ນ້ີ ເຮັດ ໃຫ້ ມັນ ຍາກ ໃນ ການ ມີ ສາ ມະ ທິ. ລົດ ເຂັນ ຂອງ ລາວ ມີ ຂະໜາດ ທີ່ ຖືກຕ້ອງ, ມີ ແນວ ອີງ ຫຼັງ ແບບ ແຂວນ ຢູ່ ລະດັບ ເຄິ່ງກາງ ແລະ ມີ ເບາະ ຮອງ ນ່ັງ ແບບ ງ່າຍດາຍ ທີ່ ສະບາຍ ຕົວ. ໃນ ລະຫວ່າງ ການ ຕິດຕາມ ຜົນ ພະນັກງານ ບໍລິການ ລົດ ເຂັນ: ï ໄດ້ ຮູ້ ວ່າ Thusitha ເຂົ້າ ອອກ ຈາກ ລົດ ເຂັນ ຂອງ ລາວ ແນວ ໃດ. Thusitha ກໍາລັງ ພົບ ຄວາມ ຍາກ ໃນ ການ ຍົ ກຕົນ ເອງ ອອກ ຈາກ ລົດ ເຂັນ. ພະນັກງານ ບໍລິ ລົດ ເຂັນ ໄດ້ ສອນ Thusitha ວິທີ ເຄື່ອນ ຍ້າຍ ດ້ວຍ ກະ ດານ ເລື່ອນ ເຊິ່ງລາວ ພົບ ວ່າ ມັນ ງ່າຍ ຂ້ຶນ ຫຼາຍ. ï ໄດ້ ກວດ ເບິ່ງ ການ ຮອງ ຮັບ ທ່າ ທາງ ເພ່ີມ ເຕີມ ຂອງ Thusitha. ໄດ້ ມີ ການ ຕັດສິນ ໃຈ ວ່າ Thusitha ຈະ ໄດ້ ຮັບ ການ ຮອງ ຮັບ ດີ ຂ້ຶນດ້ວຍ ແນວ ອີງ ຫຼັງທ່ີ ສູງ ກວ່າ ແລະ ເບາະ ຮອງ ນ່ັງ ທີ່ ຄວບ ຄຸມ ທ່າ ທາງ ໄດ້ ແລະ ບັນ ເທົາ ການ ກົ ດທັບ. ພະນັກງານ ບໍລິ ການ ລົດ ເຂັນ ໄດ້ ເຮັດ ການ ວັດ ແທກທີ່ຈໍາ ເປັນ ເພ່ືອ ໃຫ້ ສາມາດ ກະກຽມ ສ່ິງ ນ້ີ ສໍາລັບ ການ ປັບ ໃຫ້ ເໝາະ ສົມ. ໄດ້ ເຮັດ ການ ນັດ ໝາຍ ເພ່ືອ ໃຫ້ Thusitha ມ າ ສູນ ບໍລິການ ລົດ ເຂັນ ເພ່ືອ ເຮັດ ການ ປັບ ໃຫ້ ເໝາະ ສົມ ສໍາລັບ ແນວ ອີງ ຫຼັງ ແລະ ເບາະ ຮອງ ນ່ັງ ໃໝ່. ລົດ ເຂັນ ຊຸດ ຝຶກ ອົບຮົມ ການ ບໍລິການ ລະດັບ ປານ ກາງ 147 ແບບ ຟອມການ ຕິດຕາມ ຜົນ ລົດ ເຂັນ 1. ຂ້ໍ ມູນ ຜູ້ ໃຊ້ ລົດ ເຂັນ ຊ່ື ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ: ເລກທີ: ວັນ ທີ ປັບ ລົດ ເຂັນ ໃຫ້ ເໝາະ ສົມ: ວັນ ທີ ຕິດຕາມ ຜົນ: ຊ່ື ຂອງ ບຸກຄົນ ທີ່ ດໍາ ເນີນ ການ ຕິດຕາມ ຜົນ: ການ ຕິດຕາມ ຜົນ ດໍາ ເນີນ ຢູ່: ເຮືອນ ຂອງ ຜູ້ ໃຊ້ ລົດ ເຂັນ ສູນ ບໍລິການ ລົດ ເຂັນ ບ່ອນ ອື່ນ: --------------------------------------------------------- 2. ການ ສໍາພາດ ບັນທຶກ ການ ດໍາ ເນີນການທ່ີ ຕ້ອງ ເຮັດ: ທາ່ນ ກໍາລັງ ໃຊ ້ລ ົດ ເຂນັ ຂອງ ທາ່ນຫຼາຍຕາມ ທີ ່ທາ່ນ ຕ້ອງການ ບ?ໍ ແມ່ນ ບໍ່ ຖາ້ ບໍ ່– ຍອ້ນ ຫຍງັ? ທາ່ນ ມີ ບນັຫາ ຕ່າງໆ ໃນ ການ ໃຊ ້ລດົ ເຂນັ ຂອງ ທາ່ນ ບ?ໍ ແມ່ນ ບໍ່ ຖາ້ ແມນ່ – ບນັຫາ ແມນ່ ຫຍງັ? ທາ່ນ ມີ ຄາໍ ຖາມຕ່າງໆ ກ່ຽວ ກັບ ການ ໃຊ ້ລດົ ເຂນັ ຂອງ ທາ່ນ ບ?ໍ ມີ ບໍ່ມີ ຖາ້ ມີ – ຄາໍ ຖາມ ຫຍງັ. ຈາໍ ເປນັ ຕ້ອງ ມີ ການ ຝຶກ ອບົຮມົ ເພ່ີມ ເຕີມ ບ?ໍ ທາ່ນ ມີ ອປຸະກອນ ຊ່ວຍ ໃດໆ ບ?ໍ ມີ ບໍ່ມີ ອະທບິາຍ (ຈດຸ ທີ ່ຕ້ັງ) ທາ່ນ ຈະ ຈດັ ອນັ ດບັ ຄວາມ ພໍ ໃຈຕ່ໍ ກັບ ລດົ ເຂນັ ຂອງ ທາ່ນສ່ໍາ ໃດ ຈາກ 1–5? (5 ແມນ່ພໍ ໃຈ ທີ ່ສຸດ ແລະ 1 ແມນ່ບ່ໍ ພໍ ໃຈ ) ອັນ ດັບ: ຄາໍ ຄດິເຫນັ: 3. ການກວດ ເບ່ິງ ລົດ ເຂັນ ແລະ ເບາະ ຮອງ ນ່ັງ ລດົ ເຂັນ ຢູ ່ໃນ ສະພາບ ໃຊ ້ງານ ໄດ້ ດ ີ ແລະ ປອດ ໄພ ໃນ ການ ໃຊ ້ແມນ່ບໍ? ແມ່ນ ບໍ່ ເບາະ ຮອງ ນ່ັງ ຢູ ່ໃນ ສະພາບ ໃຊ ້ງານ ໄດ້ ດ ີ ແລະ ປອດ ໄພ ໃນ ການ ໃຊ ້ແມນ່ບໍ? ແມ່ນ ບໍ່ ຖາ້ ບໍ ່ສໍາລັບ ອນັ ໃດ ໜຶງ່, ບນັຫາ ແມນ່ ຫຍງັ? 4. ການກວດ ເບ່ິງ ຄວາມພໍດີ ລດົ ເຂັນມີ ຄວາມ ເໝາະ ສົມ ພໍດ ີຢາ່ງ ຖກືຕ້ອງ ແມນ່ ບ?ໍ ແມ່ນ ບໍ່ ຖາ້ ບໍ ່– ບນັຫາ ແມນ່ ຫຍງັ? ລະດັບ ການ ທດົ ສອບ ການ ກົ ດທບັ (1 = ປອດ ໄພ, 2 = ເຕືອນ ໄພ, 3 = ບໍ່ ປອດ ໄພ) (ຖາ້ຜູ້ໃຊ້ລດົເຂນັມີຄວາມສ່ຽງເກີດແຜກົດທບັ) ຊ້າຍ: ຂວາ: ຜູ້ ໃຊ້ ລົດ ເຂັນ ນ່ັງ ຕ້ັງ ຊ່ື ຢ່າງ ສະບາຍ ຕົວ ແມ່ນ ບໍ ໃນ ເວລາ ບໍ່ ເໜັງ ຕີງ, ເຄື່ອນ ຍ້າຍ ໄປມາ ແລະ ຕະຫຼອດມື້? ແມ່ນ ບໍ່ ຖ້າ ບໍ່ – ບັນຫາ ແມ່ນ ຫຍັງ? 148 ສໍາລັບ ຂ້ໍ ມູນ ເພ່ີ ມ ເຕີມ, ໃຫ້ ຕິດ ຕ່ໍ ຫາ. World Health Organization (ອົງ ການ ອະ ນາ ໄມ ໂລກ) 20, Avenue Appia CH-1211 Geneva 27 Switzerland ໂທ: (+ 41 22) 791-2715 ແຟັກ: (+ 41 22) 791-4874 www.who.int/disabilities/en/ ISBN 978 92 4 150576 5 ກະລຸນາ ໃຊ້ ແຟ້ມໜ້າ ປົກ
中級 ⾞椅⼦サービス教習パッケージ 受講者⽤参考書 英語版原著者・制作者・協⼒者⼀覧： 編集者: Chapal Khasnabis, Kylie Mines 執筆者: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, Rebecca Jackson Stoeckle 査読者: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri, Ritu Ghosh, Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan, Diane E. Ward イラストレーター: Melissa Puust 写真著作権者: David Constantine, Jesse Moss, Chapal Khasnabis ビデオ著作権者: Chapal Khasnabis, Amanda McBaine, Jesse Moss 実施試験教習員: Andrew Congdon, Mirela Creanga, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Raducan, Andrew Rose 資⾦協⼒: ⽶国国際開発庁 (USAID), オーストラリア国際開発庁 (AUSAID) 提携団体: ASSERT 東ティモール [国⽴リハビリテーションセンター, 現 CNR], ケニア⾝体障害 者協会 (APDK), ソロモン諸島保健医療サービス省・地域に根ざしたリハビリテーショ ン局, 教育開発センター (EDC), ハンディキャップ・インターナショナル, ⾚⼗字国際 委員会 (ICRC), 国際義肢装具学会 (ISPO), キリマンジャロ脊髄損傷者協会 (KASI), モビリティ・インディア, モティベーション・オーストラリア, モティベーション慈善 基⾦ (Motivation), モティベーション・ルーマニア, タンザニア義肢装具技術者訓練セ ンター (TATCOT) Published by the World Health Organization in 2013 under the title Wheelchair Service Training Package: Reference Manual for Participants: Intermediate Level © World Health Organization 2013 The World Health Organization has granted a translation and publication permission for an edition in Japanese to the Japan Association of Wheelchair and Seating (JAWS), which is solely responsible for the quality and faithfulness of the Japanese translation. In the event of any inconsistency between the English and the Japanese editions, the original English edition shall be the binding and authentic edition. 中級⾞椅⼦サービス教習パッケージ・受講者⽤参考書 © Japan Association of Wheelchair and Seating (JAWS) 2022 2022 年 1 ⽉ 29 ⽇発⾏ 原著者： 世界保健機関 (WHO) 翻訳・制作者： ⽇本⾞椅⼦シーティング協会国際委員会・アジア姿勢保持プロジェクト (ASAP) 発⾏所： ⼀般社団法⼈ ⽇本⾞椅⼦シーティング協会 (JAWS) 〒105-0013 東京都港区浜松町 2-7-15 三電舎ビル 2 階 電話 03-6435-0365 FAX 03-6435-0365 URL http://www.j-aws.jp 訳者解説 本書は、世界保健機関（WHO）が 2013 年に発⾏した ”Wheelchair Service Training Package: Reference Manual for Participants: Intermediate Level” の全訳である。「はじめに」で述べている通り、本書を含む この「中級⾞椅⼦サービス教習パッケージ」は、2008 年刊 ”Guidelines on the Provision of Manual Wheelchair Service in Less-resourced Settings”（邦訳「⼿動⾞椅⼦供与の世界ガイドライン 低リソース 状況の克服に向けて」、⽇本⾞椅⼦シーティング協会刊、以下「ガイドライン」と略）を受けたものである。 「ガイドライン」ではその⼀章を割き、現場で⾞椅⼦サービス提供に携わる職員や、⾞椅⼦ユーザーの掘り 起こしや⾒極め、⾞椅⼦サービスへの紹介・相談、さらに⾞椅⼦供与政策の開発や推進に当たる、さまざま な関係者向けの教習あるいは⼈材育成の重要さを強調している。本書を含む「中級⾞椅⼦サービス教習パッ ケージ」、およびそれと連なる⾞椅⼦サービス教習パッケージ群は、その問題提起に対するWHO⾃⾝からの 実践的回答であり、上記「ガイドライン」のいわば各論をなすものである。 したがって、本書を読み、活⽤するに当たっては、「ガイドライン」を併読してWHOが提起する⾞椅⼦供与 システムを把握することを強く推奨する。また各⾞椅⼦サービス教習パッケージでも、「ガイドライン」は参 考資料あるいは副教材に挙げられている。 関連する出版物 ⾞椅⼦や姿勢保持に関連して、WHOからは、⽶国国際開発庁（USAID）などの協⼒のもとで以下の出版物が 刊⾏されている： 1. ⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に向けて (Guidelines on the Provision of Manual Wheelchair Service in Less-resourced Settings, 2008) 2. 低リソース状況での移動⽀援機器供与に関する共同⽅針提⾔書：個⼈的移動性に関する障害者の権利に 関する条約（CRPD）履⾏に向けた⼀歩 (Joint position paper on the provision of mobility devices in less-resourced settings : a step towards implementation of the Convention on the Rights of Persons with Disabilities (CRPD) related to personal mobility, 2011) 3. 基礎⾞椅⼦サービス教習パッケージ (Wheelchair Service Training Package ‒ Basic level, 2012) 4. 中級⾞椅⼦サービス教習パッケージ (Wheelchair Service Training Package ‒ Intermediate level, 2013) 5. 管理者向け・関係者向け⾞椅⼦サービス教習パッケージ (Wheelchair Service Training Package for Managers and Stakeholders, 2015) 6. ⾞椅⼦サービス教習員向け教習パッケージ (Wheelchair Service Training of Trainers package, 2017) 1. は、主に低・中所得国向けに作成された、⾞椅⼦供与事業・政策策定の指針であるが、先進⼯業国にとっ ても極めて重要な内容を含む、グローバルな⽂献である。 2. はいわば 1. の三年⽬のフォローアップで、内容は、1.（の実⾏は、すなわち「障害者の権利に関する条約」 の履⾏に向かうことである）の提⽰にもかかわらず低リソース状況での移動⽀援機器普及が遅々として進ま ない現状報告、改善を阻む問題点の指摘、およびその克服に向けた政策提⾔などである。 3-5. は 1-2. が強調する、職員研修/⼈材育成のための教習パッケージである。 3. そして本書を含む 4. は⾞椅⼦の供与や適合に現場で携わる職員向けの実践的・総合的な技能教習パッケ ージで、「⾞椅⼦サービス提供の 8ステップ」（基礎⾞椅⼦サービス教習パッケージ受講者⽤参考書 p.9-10を 参照）として整理される⾞椅⼦サービス提供の全プロセスについて、⼈権、国際法、コミュニケーション、 ⾝体評価などの理論的授業から⾞椅⼦の乗り⽅、処⽅、適合、改造、メンテナンスなどの演習および実習に ⾄る、基礎レベルにおいて必要なすべての技能と知識を教習する、包括的という意味で（分野ごとにさまざ まな組織や場⾯で教えられることはあっても）それまでに「ありそうでなかった」プログラムである。教材 も、受講者⽤参考書（本書）・ワークブックのみならず教習員⽤指導書（講習準備の⼿引きや必要機材リスト、 授業の計画およびシナリオも含む）、プレゼンテーションスライド、動画、受講者および教習員の評価表、意 識啓発⽤ポスター、各種書式（参加登録簿から当事者の写真撮影許可書など）を網羅し、教習の内容のみな らず、実施・運営・評価⽅法のマニュアルまでを完備している。 特に 3. は、⾞椅⼦の基礎技能教習教材として途上国のみならず世界に広く普及しており、例えば⽶国では国 際⾞椅⼦専⾨家学会（ISWP）がその教習を実施している。 また 4. は、3. を修了したのち現場経験を積んだ職員向けの次の段階の教習パッケージで、姿勢保持ニーズ のある⾞椅⼦ユーザー、特に⼦どもへの対応に重点を置いている。姿勢保持については途上国を含む世界で 広く実施可能な、普通型⾞椅⼦に改造を加え、姿勢⽀持具を追加する範囲での対応を取り上げている。 5. は 2部に分かれ、それぞれ⾞椅⼦供与に携わる事業体の管理職向け教習、および⾞椅⼦供与関係者（当事 者や実務家のみならず⾏政担当者、政治家、企業家、資⾦供与者、メディアなども含む）向け意識啓発ワー クショップの実施パッケージである。 6. はさらに 3-5. で指導に当たる⼈材の⼒量育成、いわば「教育者を教育する」ためのパッケージである。 これらの教習パッケージは、その内容のみならず研修設計の点でも優れて現代的であり、訳者は⾞椅⼦、姿 勢保持、国際協⼒のみならず、広く教育や研修に関わる⽅々に読まれることを期待している。 ⽤語と⾒取り図 ただ⽇本の読者にとって、本書を読み進むなかで難しく感じられるのは、「⾞椅⼦供与」「⾞椅⼦サービス」 「⾞椅⼦サービス提供」「⾞椅⼦のサービスステップ」といった聞き慣れない（⾞椅⼦に伴うサービスを体系 的に概念化し、必須のものと定義した点で上記「ガイドライン」は画期的であるため）概念であろう。 これらの意味は、本書の「⽤語」および本⽂でも説明されているが、各国での優れた実践例などを踏まえ、 ⽇本の制度とは別の観点で WHO が構想した⾞椅⼦供与の理想像を俯瞰するには、これではまだ⾜りまい。 ⽇本語版「ガイドライン」には、訳者らで独⾃に作成した全体的な概念構成の⾒取り図を訳者解説の直後に 付録している。ご参考にしていただければ幸甚である。 おわりに、本書の翻訳には、公益財団法⼈⽇本社会福祉弘済会より研究助成（2021年度）をいただきました。 ここに⼼より御礼を申し上げます。翻訳の確認と校閲については、以下の⽅々のご協⼒をいただきました。 ここにお名前を記し、謝辞に代えさせていただきます。 浦川純⼆、沖ちなみ、⽊下義博、鷹野真利、中村詩⼦、⻄⽅倫彰、宮本泰輔、⼭崎雅幸（敬称略） 2022年1⽉29⽇ ⽇本⾞椅⼦シーティング協会国際委員会・アジア姿勢保持プロジェクト（担当：松本和志） 訳注： • 本書は Wheelchair Service Training Package: Reference Manual for Participants: Intermediate Level, WHO, 2013. の全訳である。底本には英語版（https://www.who.int/publications/i/item/9789241505765） を⽤いた。 • 本書の翻訳出版は、⼀般社団法⼈⽇本⾞椅⼦シーティング協会の、資料作成事業の⼀環である。 • 本書は、WHOより⾮営利（販売は費⽤回収⽬的でのみ可）での翻訳出版許可を取得している。 • ⽇本語版翻訳に関する著作権および⽂責は、すべて⼀般社団法⼈⽇本⾞椅⼦シーティング協会に帰属する。 • 翻訳および編集作業は、同協会国際委員会・アジア姿勢保持プロジェクト（ASAP）で⾏なった。 • 本書を転載する際は⽇本⾞椅⼦シーティング協会までご連絡（連絡先は⾒返しを参照）頂きたい。 • 英語原⽂と⽇本語訳⽂の間に内容の齟齬がある場合は原則として英語版を正とするが、誤記、団体の名称・ 住所・URLで変更されているものなどは、WHOに確認のうえ訳者で⼀部修正している。 • 国際連合の条約など政策⽂書で複数⾔語の正⽂が定められているものは、英語版の参照先を記した。 • 政策⽂書の⽇本語訳は、既存の訳を参考にしつつ、訳者で独⾃に訳出したものである。 • インターネット上の参考⽂献のURL閲覧⽇は、すべて2022年1⽉28⽇である。 • 本⽂中、原⽂にない訳者による補⾜は［ ］に⼊れて⽰している。 • 脚注について、⽂中の脚注番号がカッコ（ ）⼊りのものは原注、（ ）なしのものは訳注を⽰す。 • 原⽂の主な⽤語と本書での訳語は、原則として下表の通り対照させている。なるべく原著に忠実に、かつ 既存の⽤語との紛らわしさを避け、簡明さを失わないよう努めた。本書出版時点の国際標準化機構（ISO 7176-26:2007）、⽇本⼯業規格（JIS T9201:2016）との異同などは、下表および⽂中の脚注で⽰している • 脚注の [⽤語集] は ⾞いす・シーティング⽤語集, ⾞いす・シーティング⽤語検討委員会, 2005. を指す。 英語⽤語 ⽇本語訳語 additional postural support 付加姿勢⽀持［基本的な⾞椅⼦にもともと備わっている以上の、改造や増設によ って付加された姿勢⽀持(⼒)。中級教習で扱う内容］ armrest ひじ掛け［ISO7176-26:2007: arm support, JIS T9201:2016: アームサポート］ assessment 事前評価［事後評価を含むevaluationと区別するため］ backrest 背もたれ［ISO7176-26: 2007: back support, JIS T9201: 2016: バックサポート］ calf 下腿、［特にその部位を指す場合］ふくらはぎ community-based 地域に根ざした footrest ⾜台［ISO7176-26:2007: foot support, JIS T9201: 2016: フットサポート］ neutral sitting posture ニュートラルな座位姿勢［解釈には諸説あるが、本書での意味はp.52を参照］ personal mobility ［主に⾏為を指して］個⼈的移動、［主に機能を指して］個⼈的移動性 postural support 姿勢⽀持 product preparation 製品の下準備 referral 紹介・相談 seat 座⾯［ISO7176-26:2007: seat, JIS T9201: 2016: シート］ seating 座位保持 service delivery サービス提供 sitting upright まっすぐに座る［解釈には諸説あるが、本書での意味はp.52を参照］ training 教習、［条約などで定訳がある場合］研修 upholstery 張り布 user ［指⽰内容が明⽩な場合］⾞椅⼦ユーザー、ユーザー wheelchair provision ⾞椅⼦供与 wheelchair services ［⾏為］⾞椅⼦サービス、［事業・事業組織］⾞椅⼦サービス事業、 ［施設・所在地］⾞椅⼦サービス事業所 ⽤語 以下、教習パッケージ全体を通して⽤いることばを下記の通り定義する。 適正な⾞椅⼦ ユーザーのニーズおよび環境条件に合い、適切にフィットして姿勢を ⽀え、安全で耐久性があり、国内に⽤意され、⼊⼿、メンテナンス、 継続したサービスが国内で、無理のない価格で可能な⾞椅⼦。 ⼿動⾞椅⼦ ユーザーがこぐ、あるいは他の⼈が押す⾞椅⼦。 姿勢⽀持具（PSD） 付加姿勢⽀持をもたらす物理的装置：中級レベルの⾞椅⼦サービスに おいて不可⽋な要素である。［詳しい説明は本⽂を参照］ ⾞椅⼦ 歩⾏や移動に困難がある⼈へ、⾞輪による移動性および座位⽀持をも たらす機器。 ⾞椅⼦の改造 ⾞椅⼦に加える変化。 ⾞椅⼦供与 ⾞椅⼦の設計・⽣産・供給・サービス提供の総称。 ⾞椅⼦サービス ⾞椅⼦供与の⼀部で、ユーザーへ適正な⾞椅⼦を供与する関わり。 ⾞椅⼦サービス職員 適正な⾞椅⼦の供与に習熟した⼈。 ⾞椅⼦ユーザー 歩⾏や移動に困難があり、移動に⾞椅⼦を使う⼈。 もくじ まえがき IX 中級⾞椅⼦サービス教習パッケージについて 1 A: 必須知識 6 A.1: 付加姿勢⽀持が有益な⾞椅⼦ユーザー 7 A.2: 障害児 13 B: ⾞椅⼦サービスのステップ 20 ステップ 1: 紹介・相談および⾯接予約 21 ステップ 2: 事前評価 21 事前評価の概略・事前評価インタビュー 21 ⾝体的事前評価 ‒ ⽀えなしの座位姿勢 49 ⾝体的事前評価 ‒ ⾻盤と股関節の姿勢チェック 54 ⾝体的事前評価 ‒ ハンド・シミュレーション 59 ⾝体的事前評価 ‒ ⾝体計測 63 ステップ 3: 処⽅（選択） 71 ⾞椅⼦およびクッションの選択 71 姿勢⽀持具の処⽅（選択）‒ はじめに 80 姿勢⽀持具の処⽅（選択） - ⾻盤を安定させる 94 姿勢⽀持具の処⽅（選択） - 股関節を⽀える 98 姿勢⽀持具の処⽅（選択） - 体幹を⽀える 100 姿勢⽀持具の処⽅（選択） - 頭・⼤腿・下腿を⽀える 104 ステップ 4: 資⾦調達および発注 107 ステップ５: 製品（⾞椅⼦）の下準備 107 ⾞椅⼦および姿勢⽀持具の下準備を計画し実施する 108 姿勢⽀持具をつくる際の留意事項 109 姿勢⽀持具および改造部づくりに必要な材料および⼯具 110 姿勢⽀持具のつくり⽅ 112 ⾞椅⼦の安全・準備完了確認表を使⽤する 128 中級⾞椅⼦の安全・準備完了確認表 129 ステップ 6: フィッティング 130 ステップ 7: ユーザー教習 139 ⾞椅⼦ユーザーの役に⽴つ技能とは？ 139 ステップ 8: メンテナンス・修理・フォローアップ 144 フォローアップの運⽤ 144 フォローアップでいっぱんに⾏なうこと 145 まえがき ⾞椅⼦は、⼈権を享受し、尊厳をもって⽣きる前提である個⼈的移動性を⾼めるために最もよく使 われる⽀援機器の⼀つで、障害者が地域のより⽣産的な⼀員となることを⽀えるものです。多くの ⼈びとにとり、適正で、巧みにデザインされ、ぴたりと合った⾞椅⼦は、社会へのインクルージョ ンと参加に向かう最初の⼀歩となるのです。 国際連合「障害者の機会平等化に関する基準規則」「障害者の権利に関する条約」および世界保健 総会 WHA58.23 決議［第 58 回世界保健総会決議第 23 号］は障害の予防・管理・リハビリテーシ ョンに関わるものですが、そのいずれもが、⾞椅⼦その他の⽀援機器の重要さを強調しています。 障害者の適正な⾞椅⼦へのアクセスを、とくに世界の低リソース地域において保証するため、世界 保健機関（WHO）は「⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に向けて」を⽶ 国国際開発庁（USAID）および国際義肢装具学会（ISPO）との協働のもとに作成しました。 この「⾞椅⼦ガイドライン」を基に、じゅうぶんな数の⼈材を適正に育て、⾞椅⼦の優れた提供シ ステムを促進するため、上記ガイドラインの⾻⼦に沿って WHO が先導して作成したのが「⾞椅⼦ サービス教習パッケージ（WSTP）」シリーズで、さまざまなレベルの介⼊を展開する任務を負う、 さまざまなレベルの保健・リハビリテーション職員へ向けたものです。2012 年 6 ⽉に発⾏し、好 評を博した「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」に続き、この「中級⾞椅⼦サービス 教習パッケージ（WSTPi）」を世に送り出すことを私どもは喜んでおります。中級⾞椅⼦サービス 教習パッケージでは、基礎⾞椅⼦サービス教習パッケージで得られた技能や知識を押し拡げること に加え、多くの⼦どもたちが、⼀般的な発達障害の性質ゆえに⾞椅⼦に移動性と姿勢⽀持の両⽅を 求めることから、⼦どもにより多く焦点を合わせています。 アラナ・オフィサー コーディネーター 障害・リハビリテーションチーム 暴⼒・傷害の予防および障害局 世界保健機関 ロバート・ホーヴァス マネージャー 弱者のためのプログラム ⺠主主義・⼈権・ガヴァナンス拠点センター ⽶国国際開発庁 中級⾞椅⼦サービス教習パッケージ 1 中級⾞椅⼦サービス教習パッケージについて はじめに 2008 年の「⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に向けて」(1)、2012 年の 「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」の発⾏に続き、世界保健機関（WHO）は⽶国国 際開発庁（USAID）と協働し、この「中級⾞椅⼦サービス教習パッケージ（WSTPi）」を作成した。 WHO の「⾞椅⼦サービス教習パッケージ（WSTP）」シリーズの中で中級 WSTP は第２部に当た り、歩⾏や移動が困難で体幹のコントロールが乏しい、重度障害者のニーズへの対処により重点を 置いている。この教習パッケージ作成のあいだ特に念頭に置いていたのは、体幹コントロールに乏 しく、⾃⼒ではまっすぐに座れない⼦どもへ適正な⾞椅⼦を供与することであった。 ⾞椅⼦は、個⼈的移動を可能にするために最もよく使われる⽀援機器の⼀つである。歩⾏に困難が ある⼈びとにとって、その⾝体・⽣活様式・環境のニーズを満たす⾞椅⼦は不可⽋な道具であり、 健康・社会・経済における幸福を広く向上させるものである。移動性は⾞椅⼦ユーザーへ、学び、 働き、⽂化活動に関わり、保健医療などのサービスを利⽤する機会を開く。 移動性の重要さは、国際連合「障害者の権利に関する条約」（UNCRPD）にも反映しており、そこ では、「最⼤限に⾃⽴した個⼈的移動を障害者へ保証するための実効ある施策」を提⾔している。 個⼈的移動性を実効あらしめるには、⾞椅⼦ユーザーに⾞椅⼦、それも正しく⾃分にフィットし、 ⾃⾝に特有のニーズを満たすものが必要である。これには、個別ニーズに対応するアプローチが求 められる。 ⾞椅⼦ユーザーの個別ニーズを満たす効果的な⽅法は、⾞椅⼦サービスを通した⾞椅⼦の供与であ る。しかし統計によると、きちんとフィットさせた⾞椅⼦をじっさいに利⽤できているのは⾞椅⼦ を必要とする⼈びとの 5 %にも満たない。加えて、職員が教習を受け、⾞椅⼦を効果的に処⽅する ために必要な技能を得る機会も限られている。 1 Guidelines on the Provision of Manual Wheelchair Service in Less-resourced Settings [⼿動⾞椅 ⼦供与の世界ガイドライン 低リソース状況の克服に向けて], WHO, 2008 (https://www.who.int/public ations/i/item/9789241547482 ). [邦訳: ⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に 向けて, ⽇本⾞椅⼦シーティング協会, 2022.] 2 受講者⽤参考書 この WSTPi（中級⾞椅⼦サービス教習パッケージ）がめざすのは、⾞椅⼦サービスにおいて中級レ ベルの臨床および技術的任務（「⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に向け て」表 4.2 を参照）を果たす、職員への教習を⽀援することである。本教習パッケージは、まっす ぐに座れるためには付加姿勢⽀持が必要な⾞椅⼦ユーザーとの仕事を始めるに当たって求められ る、理論と実技の伝授を助ける。本教習パッケージの内容は、個別ニーズの事前評価、付加姿勢⽀ 持を備えた最も適正な⾞椅⼦を選択し設定する⽀援、⾞椅⼦ユーザーおよび介助者への⾞椅⼦の使 ⽤およびメンテナンス⽅法の教習、フォローアップ実施などのやり⽅である。 本教習パッケージは 35〜40時間で履修できるが、この期間は、各々の状況に特有のニーズや利⽤ できるリソースに従って伸縮してもよい。さらに師匠に付いて修練することを、実⼒を積み重ね、 独⽴して働く技量を⾼めるために奨励する。 ⾞椅⼦サービス教習パッケージがめざすのは、すでに現場で働いている職員への独⽴した短期教習 プログラムとして、また保健・リハビリテーション職員への教習プログラムに組み込んで伝授され ることである。 対象者 この教習パッケージの対象は、中級レベルの⾞椅⼦サービス提供を職場で実施すると想定される、 すべての職員やボランティアである。これには作業療法⼠、理学療法⼠、義肢装具⼠、地域保健職 員、地域に根ざしたリハビリテーション2（CBR）職員などの、保健・リハビリテーション・技術職 が含まれる3。 ⽬的 中級教習パッケージは、まっすぐに座れるためには付加姿勢⽀持が必要な男⼥の⼦どもや⼤⼈へ、 適正な⼿動⾞椅⼦およびクッションを供与するために、職員やボランティアが受ける教習を⽀援す るようデザインされている。 この教習パッケージの主⽬的は、⾞椅⼦サービス提供に携わる職員の技能および知識の育成である。 この教習パッケージの実施は、以下の役に⽴つ： • ⾃分のニーズを満たす⾞椅⼦を⼿にする、⾞椅⼦ユーザーが増加する。 • 中級⾞椅⼦サービス提供の教習を受けた職員が増加する。 • ⾞椅⼦サービス提供職員の能⼒が向上する。 • 基礎レベルよりも⾼度な介⼊が必要な⼈びとに対する、⾞椅⼦サービス提供の質が向上する。 2 [原⽂] community-based rehabilitation. [訳注]「地域リハビリテーション」とは区別される場合もあるため. 3 [訳注] 本教習の全部あるいは⼀部には, ⽇本であればリハビリテーション医, 介助福祉⼠・社会福祉⼠・ケアマネー ジャー・福祉⽤具専⾨相談員などの福祉専⾨職, 福祉⾏政職員, 特別⽀援教師なども対象者に含まれよう. 中級⾞椅⼦サービス教習パッケージ 3 • 正規のパラメディカル/リハビリテーションの教習プログラムへ、この教習パッケージが盛り込 まれる。 • ⾞椅⼦サービス提供の、リハビリテーションサービスへのより⼤きな統合が達成される。 対象範囲 本教習パッケージで取り上げるのは： • 付加姿勢⽀持を備えた⾞椅⼦が必要な⼦どもや⼤⼈への、移動および姿勢⽀持へのニーズの事前 評価のやり⽅。 • 移動⽀援の可能な最適解を⾒極めるための、上記の⼈びととの関わり⽅。 • 適切なクッションと付加姿勢⽀持を備えた、⼿動⾞椅⼦の供与に必要な知識および実践的コツ。 • ⾞椅⼦ユーザー、また適切ならばその家族/介助者が、⾞椅⼦を最⾼に活⽤するための教習。 • ⾞椅⼦ユーザーへの、⾃分の⾞椅⼦がニーズを満たし続けるためのフォローアップ。 必要な知識および技能 ⾞椅⼦サービス提供の経験をすでに有していることが、受講者がこの中級教習から最⼤限の成果を 得るために不可⽋である。中級教習プログラムのデザインは、WHO の「基礎⾞椅⼦サービス教習 パッケージ（WSTPb）」で教わる能⼒を発揮でき、かつ基礎レベル⾞椅⼦サービス提供の実践経験 がある受講者を想定している。 構成 「中級⾞椅⼦サービス教習パッケージ」は、中級レベルの⾞椅⼦サービス提供に熟達し、またこの 教習プログラムが教える能⼒を、⾃信をもってやってみせられる教習員が伝授するようにデザイン されている。教習教材は、以下の通り多岐にわたる： • 教習員⽤指導書および教習員⽤ツール • 受講者⽤参考書（以下「参考書」とも略） • 受講者⽤ワークブック • ⾞椅⼦サービスの各フォーム • ⾞椅⼦サービスの各確認表 • パワーポイントのスライド、ビデオ、ポスターなどの視覚資料 4 受講者⽤参考書 作成経緯 「⼿動⾞椅⼦供与の世界ガイドライン」の出版に続き、WHO は、⾞椅⼦サービス教習パッケージ の作業部会を編成した。第⼀回の作業部会会合は、WHO が 2008 年 10 ⽉に招集し、教習パッケー ジの対象範囲および内容を決定した。続けて 20 ⼈超の、教習パッケージの内容として提案された 分野の専⾨家による閲覧およびフィードバックを受け、執筆者のコアグループが各々の実施試験⽤ 教習パッケージの準備に当たった。 2011 年、中級教習パッケージはルーマニア、ケニア、東ティモールで実施試験を⾏なった。各実施 試験を、WHO ⾞椅⼦教習パッケージ作業部会メンバーが観察した。実習授業に参加した教習員・ 受講者・⾞椅⼦ユーザーからのフィードバックが、最終稿に組み込まれた。実施試験に加えて中級 教習パッケージは査読に付された。15 ⼈の⾞椅⼦専⾨家が⽂書を査読し、その貴重なフィードバ ックや教⽰を参考にして、この⽂書が完成した。 教習パッケージの作成に加わった著者全員が利益関係宣⾔書（DOI）を発⾏したが、内容に関する 利益相反を宣⾔した者は皆無であった。 受講者⽤参考書の使い⽅ この参考書は、中級⾞椅⼦サービス提供教習が与える知識のまとめである。受講者は教習プログラ ムの後、各授業で学んだ要点の再確認に本参考書を活⽤するとよい。本書は、以下の２部に分かれ ている： A: 必須知識 B: ⾞椅⼦サービスのステップ 中級⾞椅⼦サービス教習パッケージ 5 A: 必須知識 ‒ この部で取り上げる情報は、⾞椅⼦サービスの全ステップに関連する。事情によ っては、受講者の学習ニーズに応じ、教習員はこの部へさらに情報を追加する選択をしてもよい。 B: ⾞椅⼦サービスのステップ ‒ この部で取り上げる情報は、受講者が、⾞椅⼦サービス提供の ８ステップ（WHO「⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に向けて」(4)、p.76 を参照）の各々を、中級レベルで実施するために役⽴つものである。 基礎および中級レベルの⾞椅⼦サービス提供教習 ⾞椅⼦サービス職員へ適切な教習を提供できるよう、WHO 教習パッケージには基礎および中級と いう、２レベルの教習を設けている。 • 基礎レベル では受講者へ、歩⾏や移動が困難ではあるものの、付加姿勢⽀持なしでまっすぐに 座れる⼦どもや⼤⼈への、⾞椅⼦供与のやり⽅を教える。 • 中級レベル では受講者へ、まっすぐに座るには付加姿勢⽀持を必要とする⼦どもや⼤⼈への、 ⾞椅⼦供与のやり⽅を教える。 中級レベルの教習プログラムは、受講者が基礎レベルで得る情報や技能を⼟台に構築している。 4 Guidelines on the Provision of Manual Wheelchair Service in Less-resourced Settings [⼿動⾞椅 ⼦供与の世界ガイドライン 低リソース状況の克服に向けて], WHO, 2008 (https://www.who.int/public ations/i/item/9789241547482 ). [邦訳: ⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に 向けて, ⽇本⾞椅⼦シーティング協会, 2022.] 6 A: 必須知識 中級⾞椅⼦サービス教習パッケージ 7 A.1: 付加姿勢⽀持が有益な⾞椅⼦ユーザー ⾞椅⼦ユーザーとは、歩く能⼒が限られているため、すでに⾞椅⼦を持っている、あるいは⾞椅⼦ を使うのが有益な⼈びとのことである。⾞椅⼦ユーザーの中には： • ⼦ども、⼤⼈、⾼齢者、少⼥、少年、⼥性、男性、 • さまざまな健康状態、⽣活様式、⽣活上の役割や背景をもつ⼈びと、 • さまざまな環境、例えば農村、⽚⽥舎、都会で暮らし、働く⼈びとがいる。 ⾞椅⼦ユーザーによって、ニーズはさまざまであろう。しかし、みな適正な⾞椅⼦を必要としてい る点は同じである。 よくフィットした⾞椅⼦はすべて、⾞椅⼦ユーザーへ何らかの姿勢⽀持を与えている。背もたれ、 クッション、⾜台、ひじ掛けは、調整して⾞椅⼦ユーザーの体格に合わせることで姿勢を⽀える。 しかし多くの⼦どもや⼤⼈には、その⾞椅⼦に姿勢⽀持を付加する必要がある。 付加姿勢⽀持5は姿勢⽀持具（Postural Support Device, PSD）、すなわち付加姿勢⽀持をもたらす 物理的装置によって与えられる。姿勢⽀持具は中級⾞椅⼦サービスの不可⽋な要素で、これには付 加姿勢⽀持を備えるための、⾞椅⼦へのあらゆる追加や改造が含まれる。この参考書全体を通して、 「PSD」とは姿勢⽀持具を指す。 付加姿勢⽀持が有益な⾞椅⼦ユーザー ⽀えを付加しなければ、まっすぐに座れない⼈もいる。⽀えの付加がたくさん必要な⼈もいれば、 ⾞椅⼦にちょっと⼿を加えるだけでよい⼈もいる。付加姿勢⽀持は、さまざまなやり⽅でつくれる。 たいへん簡便な解決策で、簡素な⼯房でつくれるものもある。他のもっと複雑な解決策もある。 いつ付加姿勢⽀持が必要なのか？ 付加姿勢⽀持が必要になる理由はさまざまである。⾞椅⼦が、⾞椅⼦ユーザーがまっすぐに座るた めのじゅうぶんな⽀えを与えていないことが明らかであるのは、たいてい以下のような場合である。 えてして⾞椅⼦ユーザーあるいは家族/介助者⾃⾝から、どんな⽀えがさらに必要か、よい提案が あるものだ。 5 [原⽂] additional postural support 8 受講者⽤参考書 ⽀えの付加を必要とする理由の例： • まっすぐに座れない • 制御できない運動6や筋攣縮7［きんれんしゅく］ • 関節の硬直8 • ［筋の］緊張9 • 虚弱さ • 疲労 • 痛みや不快感 • バランスを取るのが困難 定義：姿勢⽀持具（Postural Support Device, PSD） 姿勢⽀持具とは、付加姿勢⽀持をもたらす物理的装置のことである。 姿勢⽀持具は、中級⾞椅⼦サービスの不可⽋な要素である。 付加姿勢⽀持はどう役に⽴つのか？ 付加姿勢⽀持は、４つの⾮常に重要な⾯で、⾞椅⼦ユーザーのためになる。 １. バランス・姿勢・安定性を改善する バランス・姿勢・安定性の改善によって、⾞椅⼦ユーザーは、 付加姿勢⽀持なしでは不可能か、たいへん困難な活動をやり遂 げられるようになる。 ２. 快適さを向上させる 付加姿勢⽀持は⾞椅⼦をはるかに快適にし、⾞椅⼦ユーザー が、くたびれるまで⾞椅⼦に座れる時間も延びる。 6 [原⽂] uncontrolled movements 7 [原⽂] spasms 8 [原⽂] joint stiffness 9 [原⽂] tightness. [訳注] 教習員⽤指導書の表現に揃えて、語を補った. 中級⾞椅⼦サービス教習パッケージ 9 ３. 褥瘡発⽣を予防する 褥瘡はたちどころに起こる。よい姿勢⽀持は、⾝体の⼀部に荷 重がかかり過ぎないようにし、褥瘡防⽌に役⽴つ。 まっすぐに座るとよいことの⼀つは、体重が均等に分散するこ とである。これは、褥瘡の危険を減らすのに役⽴つ。 ⾞椅⼦ユーザーがまっすぐに座らないと、体重は不均等に分散 する。⾝体の⼀部へ、他の部分より余分に体重がかかる。そう した追加荷重が⾻ばった部位を覆う⽪膚に加わると、褥瘡の危 険が⾼くなる。 ⾻ばった部位には、例えば座⾻、肋⾻、股関節（⼤転⼦）、脊椎、 尾⾻などがある。 ⾞椅⼦ユーザーは、しっかり⽀えられないと座⾯の上で滑りが ちになる。これは剪断を引き起こし、褥瘡につながる。しっか り⽀えられて座ることが、滑りや剪断［せんだん］を防ぐ。 ４. 将来、姿勢の問題が悪化するのを遅らせるか、予防する よい姿勢⽀持は、姿勢にまつわる問題が起こるのを防ぐことができる。姿勢の問題がすでに起きて いれば、よい姿勢⽀持は、その悪化を遅らせ、あるいは防ぐことができる。寝そべり、座り、⽴っ ている時のよい姿勢⽀持を、なるべく早く始めることが⼤切だ。 10 受講者⽤参考書 安全に⾷べ、飲むこと まっすぐに座るのが難しい⾞椅⼦ユーザーには、安全な飲み 込みに問題を抱える⼈もいる。こうした⼈びとにとって、⾷べ たり飲んだりすることは不快で、時には恐ろしく、えてして危 険なことなのだ。安全に飲み込むのが困難な場合、⾷べ物や飲 み物の⼀部が肺に⼊ってしまうことがある。これは肺感染を 引き起こして重篤化するか、窒息を起こして死に⾄ることさ えある。 ⾞椅⼦への付加姿勢⽀持によって、⾞椅⼦ユーザーは、まっす ぐに座って⾷べたり飲んだりできるようになる。 姿勢⽀持の改善は、飲み込みに問題があるどんな⼈の場合も、 解決策の⼀部に過ぎない。できるだけ、飲み込みに問題がある ⼦どもや⼤⼈は、対処した経験がある⼈へ紹介・相談すべき だ。例えば⼩児科医・⾔語療法⼠・地域保健ワーカーで、飲み 込みの問題へ対処する知識や訓練を積んだ⼈などである。 ⾞椅⼦ユーザーは何を望んでいるのか？ ⾞椅⼦ユーザーは快適に、前向きに⽣きることを望んでいる。⾞椅⼦への付加姿勢⽀持のせいで、 ⽇常活動がやりにくくならないようにすることは重要である。 例えば付加姿勢⽀持部が、⾞椅⼦を乗り降りし、⾞椅⼦をこぎ、机や作業スペースへ近寄り、移動 するのを妨げてはならない。 ⾞椅⼦や付加姿勢⽀持部は、つねに以下のようであること： • 実⽤的で使いやすい。 • 快適で余計な不快感を引き起こさない。 • ⾞椅⼦ユーザーがものごとを⾏なう役に⽴ち、より困難にし ない。 • ⾒た⽬がよく、「悪⽬⽴ち」しない10。 10 [原⽂] look good and not to be too ʻobviousʼ 中級⾞椅⼦サービス教習パッケージ 11 ⾞椅⼦ユーザーが、付加姿勢⽀持を備えた⾞椅⼦に違和感を持つこともある。理由は以下のように さまざまである： • ⾞椅⼦ユーザーがある決まった座り⽅に慣れている。付加姿勢⽀持が習慣になった姿勢を変える ので、不快や制約を感じる。 • ⾞椅⼦ユーザーが、なぜその付加姿勢⽀持が処⽅されたのか、理解していない。 • ⾞椅⼦ユーザーが、付加姿勢⽀持部がカッコ悪く、障害が⽬⽴ってしまう11と感じる。 これらの理由に対して、⼤事なことは、⾞椅⼦サービス職員が事前評価、処⽅、フィッティング、 ユーザー教習、フォローアップのステップを通して、⾞椅⼦ユーザーおよび家族/介助者に寄り添 って働くことだ。つねに解決策を⾞椅⼦ユーザーと話し合い、つねに彼らの意⾒および最終決定を 尊重せよ。 付加姿勢⽀持を⾞椅⼦ユーザーに使ってもらうために最善の⽅策は： • 事前評価、処⽅、フィッティング、フォローアップへ、そのユーザーおよび家族/介助者の全⾯的 な参画を得る12。 • ⾞椅⼦ユーザーおよび家族/介助者に、なぜ、どのように付加姿勢⽀持が役⽴つのか理解しても らう。 • つねに、最終決定を⾞椅⼦ユーザーに委ねる。 よい姿勢が⾃信を⾼める よい付加姿勢⽀持が有益である重要な点に、⾞椅⼦ユーザーが、 ⾃分⾃⾝をよりよいものと感じられる13ことがある。よりまっす ぐな姿勢でしっかりと⽀えられることで、⾞椅⼦ユーザーはより ⾃信を持つことができる。 適切な⽀えがあれば、⾞椅⼦ユーザーは、地域⽣活により多く参 画できる。例えば、移動性および付加姿勢⽀持によって、⾞椅⼦ ユーザーは仕事や学校へ⾏き、友だちを訪ね、宗教儀式などの地 域活動へ参加できるようになる。 11 [原⽂] the additional postural support does not look good and makes his/her disability more obvious. 12 [原⽂] involve 13 [原⽂] feel good about themselves 12 受講者⽤参考書 付加姿勢⽀持付き⾞椅⼦が、ユーザーのニーズを満たすかどうかの確認表 下の確認表は、⾞椅⼦サービス職員が、⾃分が処⽅した付加姿勢⽀持が⾞椅⼦ユーザーに対して最 ⼤限の成果を収められそうか、確かめるのに役⽴つ。 確認表： ✔ ⾞椅⼦ユーザーおよび家族/介助者が、処⽅の決定に全⾯的に参画している。 □ ⾞椅⼦ユーザーが、処⽅した姿勢⽀持具付きの⾞椅⼦を完成前に（サービスセンターで、 またできれば家庭で）試し、フィードバックを与えられる。 □ ⾞椅⼦および姿勢⽀持具が、⾞椅⼦ユーザーがやりたいことをやるのに役⽴っている： • 姿勢⽀持具が、⾞椅⼦ユーザーがものごとをやる能⼒を向上させている。 □ • 姿勢⽀持具が、⾞椅⼦を乗り降りする妨げになっていない。 □ • 姿勢⽀持具によって、⾞椅⼦全体が重すぎになっていない。 □ ⾞椅⼦と姿勢⽀持具が、⾞椅⼦ユーザーにとって快適である： • 姿勢⽀持具がもたらす⽀えによって、⾞椅⼦ユーザーが姿勢⽀持具なしよりも⻑時間、 ⾞椅⼦に座れている。 □ • 姿勢⽀持具のもたらす⽀えが必要最⼩限で、座位姿勢を、⾞椅⼦ユーザーが快適な範囲 よりも起こしすぎていない。 □ ⾞椅⼦と姿勢⽀持具の⾒た⽬が（⾞椅⼦ユーザーにとって）よい。 □ ⾞椅⼦と姿勢⽀持具が安全である： □ • 姿勢⽀持具の仕上げがすべて滑らかで、じゅうぶん緩衝材が⼊り除圧している。 □ • ⾞椅⼦フレームに加えた構造上の変化を、有資格者が検査している。 □ • ⾞椅⼦が、⾞椅⼦ユーザーが座った状態で、簡単には前・後・横に転倒しない。 □ ⾞椅⼦と姿勢⽀持具が実⽤的である： • 張り布は清掃できるか、外して洗える。 □ • 部品点数が最⼩限で、紛失や誤⽤を防いでいる。 □ • ⾞椅⼦が、⾃動⾞や公共交通機関へ簡単に載せられる。 □ • ⾞椅⼦が、⾞椅⼦ユーザーの家の中へ簡単に収まる。 □ 中級⾞椅⼦サービス教習パッケージ 13 A.2: 障害児 ⼦どもへ⾞椅⼦を供与する際には、⼦どもの⽣活が⼤⼈とはどう違うのか、よく考えることが⼤切 だ。これらの違いは、⾞椅⼦サービス職員の⼦どもとの関わり⽅や、⾞椅⼦および付加姿勢⽀持の 選択に影響する。重要な違いとしては： • ⼦どもが⾏なう活動（遊び、学校）は、⼤⼈の活動とは異なる。 • ⼦どもは、いっぱんにたいへん活発で、同じ姿勢に⻑時間とどまらない。 • ⼦どもは、⼤⼈たちの保護を受ける。 • ⼦どもは、いつも⾃分を⾔い表せるとは限らない。 • ⼦どもは、発達過程にある。 • ⼩さい⼦どもの座位姿勢は、⼤⼈とは異なる。 • ⼦どもは、成⻑過程にある。 ⼦どものニーズに応える⾞椅⼦ ⼦どもが使う⾞椅⼦は、⼦どもたちが⽇々⾏なう活動の⼀員となるために役⽴つものでなければな らない。⼦どもにとって重要な⾞椅⼦の特⾊の例： • ⼦ども⾃⾝で⾞椅⼦をこぐ場合、⾞椅⼦は： o ぴたりとフィットしてハンドリムへ楽に⼿が届き、 o とくに坂の登り下りで⼦どもが操作できるくらい、 じゅうぶん軽量でなければならない。 • 必ず、⾞椅⼦よりも⼦どもが⽬⽴つようにせよ14。 • ⼿押しハンドルを延⻑すると、家族や介助者が、かがまないで⾞椅⼦を押せる。 • 草地や砂地など、凸凹な軟らかい地⾯を乗り越えられる⾞椅⼦があれば、⼦どもは友達と遊ぶの が容易になる。 14 [原⽂] Try always make sure the child is more visible than his/her wheelchair. 14 受講者⽤参考書 • ⼦どもの⾞椅⼦は、通学を楽にするものであること。 o 対象児の地域では、⼦どもの多くが歩いて通学する 場合に考慮すること：⾞椅⼦はその路を⾏けるか？ 対象児には荒れ地に強い⾞椅⼦が必要かどうか？ o 対象児が交通機関（例えば⾞、バス、リキシャー、 タクシー）で学校へ通う場合は、⾞椅⼦の運び⽅を 考慮せよ。 • ⾞椅⼦は、学校⽣活を快適にするものであること。対象 児が机に着席できるものであるべきで、さもなければ 作業台として⾞椅⼦にテーブルが必要である。 理想的には、⼦どもの⾞椅⼦は以下のようであること： • （できる場合は）⼦どもが⾃⼒でこげ、 • ⼤⼈が介助できるよう⼿押しハンドルを備え、 • 草地や砂地など、凸凹な軟らかい地⾯を乗り越えられ、 • ⼦どもの通学を楽にし、 • デザイン、サイズ、⾊についてじゅうぶん魅⼒的15で、 • ⼦どもの学校⽣活が快適になるもの。 さまざまな体位 ⼦どもはふつう、⻑時間座っていない。⼀⽇のうちに、⾏なう活動や体位16を何度も変える。つま り、⾞椅⼦は重要ではあるけれども、⼦どもたちは⼀⽇じゅう⾞椅⼦に座っているべきではないの である。 ⾞椅⼦サービス職員は、⼦どもが⼀⽇のうちに取れる、他の体位についても考慮すべきである。こ れは動きが⾮常に限られ、いつも同じ姿勢で座りがちで体位を変えられない⼦どもには特に重要で ある。 以下、さまざまな姿勢および体位の例を挙げる： 15 [原⽂] attractive enough 16 [原⽂] position. [訳注] 本書を通して position は「体位」posture は「姿勢」と訳し分けている. 中級⾞椅⼦サービス教習パッケージ 15 座る（座位） ⼦どもが床の近くに⾃⼒で座るように⽀える、さまざまなやり⽅としては： • ⼤きいロールクッション17や固く巻いた⽑布に、また がって座る。 • 家族/介助者が⽀えて座る。 o 左図は、⺟親が、障害児を脚の間で⽀え、座って ビスケットを⾷べられるようにし、同時に下の⼦ を抱えている様⼦である。 • 床⾯に対して低い座位保持シート18を供与する： o こうしたシートは座位保持付き⾞椅⼦より安価 で、⼩さい⼦どもへのよい選択肢である。 ⽴つ（⽴位） ⽴位は、⼦どもにとって重要な体位の⼀つである。⽴つことは、あらゆる⼦どもの発達において重 要な部分である。⽴つことは、股関節および体幹の正常なカーブの形成を促す。 座って⻑時間過ごすと、だれでも股・膝・⾜関節が硬くなる。⽴つことで股・膝・⾜関節周りの筋 ⾁が伸び、これらの関節の硬直を防ぐ。 17 [原⽂] a roller 18 [原⽂] supportive seat 16 受講者⽤参考書 ⾃⼒で⽴てない⼦どもには、⽴位台が有効である。⽴位 台を処⽅するには、⾞椅⼦サービス職員は⽴位姿勢お よび⽴位を⽀えるさまざまなやり⽅を、じゅうぶん理 解している必要がある。 ⽴位台を供与する際には、⼦どもの膝蓋に直接圧⼒が かからないよう、つねに確認せよ。膝が曲がらないよう に脚を⽀える最適な部位は、膝蓋のすぐ下の脛⾻のと ころである。 ⽴位台を使うさい、⾞椅⼦サービス職員は家族/介助者 へ、⼀⽇にどれくらい⻑時間、⼦どもが⽴位台を使うべ きか指⽰しなければならない。⼀般的な指針は： • 最初、1⽇ 5〜10分から始める。 • ⼦どもを 1 時間以上、⽴位台へ⽴たせっ放しにしな い。 • トレイかテーブルを備え、⼦どもが⽴位台に⽴ちな がらできる、楽しい活動を⾒つけるよう家族/介助者 を促す。 • 5 歳未満の⼦どもに⽴位台を供与する際の、重要な 留意事項： o ⼦どもの両脚が開き、両⾜が臀部の幅以上に離れ るようにすべき。 o ⼦どもの⾜と膝は、わずかに外側を向くべき。 o ⼦どもの股関節と膝は、少し屈曲するべき。 o 絶対に、⼩さい⼦どもに膝および股関節を完全に まっすぐ伸ばすよう強いてはならない。 中級⾞椅⼦サービス教習パッケージ 17 寝そべる（臥位） 臥位は、もう⼀つの重要な体位である。⼦どもにとって 床に寝そべって遊ぶのは⾃然なことだ。 ⼦どもが⼼地よく床に寝そべるために、⽀えが必要な場 合もある。⽑布、発泡材、タオル、枕が、⽀えに活⽤で きる。 5歳未満の⼦どもが腹ばいで寝そべる時は、胸19の下に はロールクッション20を⼊れて⽀え、股関節は少し屈曲 した姿勢に保つべきである。 ⼦どもは⻑時間寝て過ごす。⼦どもが毎晩同じ姿勢で寝 ていると、その姿勢で固定、あるいは硬直することがあ る。⾞椅⼦サービス職員は家族/介助者へ、⼦どもが寝 ている間、さまざまな姿勢を取らせる⽅法について助⾔ を与えられる。 留意事項：5歳未満の⼦どもの股関節と膝は、寝たり⽴ ったりの体位では、つねに少し屈曲させておく。 ⼦どもを早期紹介する重要さ ⼦どもを早いうちに紹介・相談することは重要だが、親や紹介・相談元は、⼦どもが重すぎて抱え られなくなって初めて、⾞椅⼦を求めて⼦どもを紹介・相談することが多い。その理由のいくつか の例： • ⼦どもに⾞椅⼦を与えたら、もう歩こうとしなくなるだろうと考えている場合がある。 • ⼦どもが⼩さくて軽いうちは、難しい地形やアクセスの悪い環境は、⾞椅⼦で何とかするより抱 えて運ぶ⽅が楽である。 • 親に⾞椅⼦へ⽀払う資⾦がなく、遅らせているうちに⼦どもが抱えられなくなる。 重要なことは、親および紹介・相談元に、ふつう⾞椅⼦は⼦どもが歩く妨げにならないのだと安⼼ してもらうことである。しっかりした姿勢⽀持を備えた⾞椅⼦を早期に供与するのは、より⼦ども のためになる。 19 [原⽂] chest. [訳注] 教習員⽤指導書では「⾻盤 pelvis」となっているが, 図に合わせてこちらを採った. しかし, こうした姿勢では胸と同時に⾻盤下にも⽀えを⼊れ, 股関節を少し屈曲させて保つようにすべきである。 20 [原⽂] a roll 18 受講者⽤参考書 早期紹介の⽅が遅れるよりもよい理由を挙げると： • まっすぐに座るのが難しい⼦どもは、適切に⽀えなければ姿勢の問題が発⽣する。⼦どもは紹介・ 相談が遅れると、姿勢の問題が固定してしまうことがある(21)。そうなると、⼦どもは⽀えても快 適に座るのが難しくなる。 • 座り、移動できた経験がないと、⼦どもの発達は遅れる(22, 22)。 • 多少歩く能⼒がある⼦どもでも、⾞椅⼦を使うと⽇常⽣活が楽になり、⼀⽇により多くのことが できるようになる(22)。 以上の理由から、⼦どもたちは⾞椅⼦サービスを早く利⽤する⽅がよい。 親および紹介・相談元への教育 ⾞椅⼦サービス職員は、親や紹介・相談元へ、早期紹介の重要さを教育する役割を果たせる。 障害がない⼦どもでも、座り、⽴ち、歩くようになる年齢は⼈それぞれである。しかし、⼦どもは 以下のことができるようになると⼀般に合意されている： • ⽣後 6〜8 か⽉で、⽀えなしに⾃分でまっすぐに座る。 • ⽣後 8〜10 か⽉で、つかまり⽴ちする。 • ⽣後 10〜12 か⽉で、⽀えなしでひとり⽴ちし、つかまって歩ける。 • ⽣後 12〜18 か⽉で、ひとりで歩く。 ⾞椅⼦サービス事業は紹介・相談ネットワークへ、以下のような⼦どもは紹介・相談するよう要請 するとよい： • 満１歳になっても、まっすぐに座るのが難しいか⽴ち上がらない、または • 満２歳になっても、ひとりで歩かない。 早期介⼊検診プログラムがある（例えば、地域保健ワーカーが早期介⼊のための⼩児検診の訓練を 受けている）ところでは、⾞椅⼦サービス事業は、これらのネットワークへより詳しく情報提供す るとよい。例えば、著しい⾝体の障害・発達の遅れが認められた⼦どもはすべて、事前評価や指導 のため⾞椅⼦サービスへ紹介・相談してほしい旨を⾞椅⼦サービス事業から提案できる。 ⼩さい⼦どもの場合、⾞椅⼦サービス事業は、初期の段階では⾞椅⼦の代わりに座位保持シートを 提案してもよい。これは家や保育所の中で遊ぶのに使える。 21 [原注] World Health Organization. (1996). Promoting the development of infants and young children with spina bifida and hydrocephalus. (https://apps.who.int/iris/handle/10665/63950 ) 22 [原注] Muscular Dystrophy Campaign. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. (http://www.muscular-dystrophy.org/) 中級⾞椅⼦サービス教習パッケージ 19 ⼦どもと関わる際の優れた実践 ⼦どもと関わる時、つねに⼤切なことは、⼦どもを尊重し、同時に保護するように23接すること である。主な留意事項は： ⼦どもを尊重するために： • ⾃分がやっていること、およびなぜやるのかを、分かってもらえるように説明する。 • ⾝体的事前評価を始める前に、許可を求める。 • 意思決定において、その年齢にふさわしいやり⽅で⼦どもの参画を得る24。 • ⼦どもとサービスセンターで⾯接する場合は、なるべく⼦どもが親しみやすい場所にしてお く。 ⼦どもの安全を保つために： • ⼦どもとは、必ず家族/介助者の同席のもとで⾯接する。 • ⼦どもはすぐ退屈するので、⾯接の間に休憩時間を取る。 • 写真を撮る前に、その⼦どもおよび家族/介助者の許可を得る。 23 [原⽂] in a way that both respects and protects children 24 [原⽂] involving children in decision making in a way that suits their age 20 B: ⾞椅⼦サービスのステップ 中級⾞椅⼦サービス教習パッケージ 21 ステップ 1: 紹介・相談および⾯接予約 • 紹介・相談および⾯接予約全般についての情報は、「基礎⾞椅⼦サービス教習パッケージ受講者 ⽤参考書」の「ステップ 1: 紹介・相談および⾯接予約」を参照。 • ⼦どもに対する早期紹介の重要さについては、この参考書の授業「A.2 障害児」を参照。 ステップ 2: 事前評価 事前評価の概略・事前評価インタビュー 事前評価 事前評価は、⾞椅⼦サービスの第２のステップである。事前評価で収集した情報は、⾞椅⼦サービ ス職員および⾞椅⼦ユーザーにとって、以下を⾏なうのに役⽴つ： • ⼿に⼊るものの中から、最適な⾞椅⼦を選ぶ。 • 可能な付加姿勢⽀持のうち、何が必要なのかを⾒出す。 • ⾞椅⼦ユーザー、およびその家族/介助者が、⾞椅⼦を使い、メンテナンスするためにどんな教 習や⽀援が必要なのか決定する。 事前評価は、基礎レベルも中級も、ともに以下の 2 パートからなる： • 事前評価インタビュー • ⾝体的事前評価 事前評価インタビュー 事前評価の最初のパートは、事前評価インタビューである。事前評価のこのパートで、⾞椅⼦サー ビス職員は⾞椅⼦ユーザーに関する情報を集め、それは、そのユーザーに最適な⾞椅⼦を⾒定める のに役⽴つ。 事前評価インタビューの構成要素は、基礎レベルも中級も⾮常に似通っている。その内容は： • ⾞椅⼦ユーザーに関する情報 • ⾝体条件 • ⽣活様式および環境 • 既存の⾞椅⼦ 事前評価インタビューの構成要素が基礎レベルも中級も⾮常に似通っているとはいえ、中級では⾞ 椅⼦ユーザーの疾患や⾝体的問題に関する情報をより多く集める。 22 受講者⽤参考書 中級⾞椅⼦事前評価フォーム I: 事前評価インタビュー ⾞椅⼦ユーザーに関する情報 名前： 番号： 年齢： 男性 □ ⼥性 □ 電話番号： 住所： ゴール： 中級⾞椅⼦事前評価フォームの「⾞椅⼦ユーザーに関する情報」の部分は事務管理が⽬的で、⾞椅 ⼦サービス事業が、⾞椅⼦ユーザーの基本的な個⼈および連絡先情報を確保するためである。また ⾞椅⼦サービス事業は、サービスを利⽤した⾞椅⼦ユーザーに関する統計情報を集められる。 また⾞椅⼦サービス職員は、新規の、あるいは改善した⾞椅⼦に対する⾞椅⼦ユーザーのゴールが 何か、も記録しておくべきだ。「ゴール」ということばに、⾞椅⼦ユーザーはなじみが薄いかもしれ ない。⾞椅⼦ユーザーのゴールが何か質問して⾒つけ出すのは、⾞椅⼦サービス職員の務めである。 以下は、⾞椅⼦サービス職員が、⾞椅⼦ユーザーのゴールが何か⾒つけるための、考えられる質問 の例である： • きょうは、どうして⾞椅⼦サービス事業所へ来られたのですか？ • ⾞椅⼦が、何をなさる役に⽴てばいいのでしょうか？ 以下は、考えられるゴールの例である： • ⽔汲みのために、井⼾まで⾏けるようになりたい。 • ⾃分のアパートへ⾏くために、エレベーターに乗れるようになりたい。 • ⾞椅⼦を、⼩型⾞に載せられるようにしたい。 • もっと⼼地よく座りたい。 • ⾞椅⼦に、もっと⻑時間、くたびれないで座れるようにしたい。 • ⾃分で⾞椅⼦を乗り降りできるようにしたい。 • 机の前に座って、コンピューターを使えるようにしたい。 • 家族を訪ねられるようにしたいので、バスに載せられる⾞椅⼦が欲しい。 中級⾞椅⼦サービス教習パッケージ 23 ⾝体条件 疾患： 脳損傷□ 脳性⿇痺□ 筋ジストロフィー□ ポリオ□ ⼆分脊椎□ 脊髄損傷□ 脳⾎管障害25□ 不明□ その他□ 疾患は悪化しそうか？ はい□ いいえ□ ⾝体的問題： フレイル（虚弱）□ 筋攣縮/制御できない運動□ 筋緊張（⾼/低）□ 下肢切断：右膝上□ 右膝下□ 左膝上□ 左膝下□ 疲労□ 股関節脱⾅□ てんかん□ ⾷べる、飲む、飲み込みに関する問題□ 詳細： 痛み□ 部位を詳しく： 膀胱の問題□ 腸の問題□ 膀胱や腸の問題がある⾞椅⼦ユーザーについて、管理できているかどうか。 はい□ いいえ□ 中級⾞椅⼦事前評価フォームの「疾患/⾝体的問題」の箇所が重要であるのは、さまざまな疾患や ⾝体的問題の特徴は⾞椅⼦や付加姿勢⽀持具の選択に影響するからである。 以下数ページにわたって掲げる表は、中級⾞椅⼦事前評価フォームに列記した、さまざまな疾患や ⾝体的問題のあらましである。それぞれの疾患/⾝体的問題の⼀般的特徴のうち⾞椅⼦供与に関係 するもの、および⾞椅⼦供与に関する提案を⽰した。 25 [原⽂] brain stroke. [訳注] 本書 p.30 の説明内容に合致するよう, こちらの訳語を採った. 24 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 注1 概要2 ⾞椅⼦供与に影響する⼀般的特徴3 ⾞椅⼦供与における留意事項 脳 損 傷 脳損傷4とは、出⽣後に起こ る脳の傷害すべてを指す。 傷害の原因は、事故、外傷 (5,6)、脳の感染症、髄膜炎(7)、 脳マラリア、アルコール、薬 物の乱⽤(5)など。 脳損傷が引き起こす障害は さまざまで、脳の傷害部位 や損傷程度による(6)。脳損 傷は本⼈の⾝体の全体ある いは⼀部に影響を及ぼす。 脳損傷による脳の損傷じたいは変化しなくても、そ の損傷の本⼈の能⼒への影響は、時間と共に変化す る(6)。 ＊この教習プログラムの⽬的から、「脳損傷」の語は 後天的かつ外傷性の脳傷害のみを指すことに注意。 • 運動が困難で、協調性や⼒に乏しい (6)。 • 座る、および/または⽴つバランスに 乏しい(6)。 • ⾼い筋緊張（筋⾁の硬直）(6)。そのた め⾝体全体が伸びる（全⾝性伸展） か丸まる（全⾝性屈曲）場合がある。 • ⾷べ、飲み、飲み込む際の困難(6)。 • 話し、推論し、理解する際の困難(6)。 • 性格やふるまいの変化(6)。 • 発作(6)。 • 腸や膀胱のコントロールが難しく、 それで褥瘡発⽣の危険が⾼まる(6)。 ⾞椅⼦を腕でこげない⾞椅⼦ユーザーの場合、⾜ でこげるかどうか⾒定めよ。 ⾞椅⼦ユーザーの筋緊張が、姿勢⽀持具に必要な 強度に影響するほど⾼いかどうか⾒出せ。⾞椅⼦ ユーザーの⾝体能⼒は時間と共に変わるため(6)、 ひんぱんなフォローアップが重要。これは、⾞椅 ⼦へ座る際に必要な⽀えの量が変わりうること を意味する。 本⼈の健康状態に応じて、性格やふるまいが変化 しうること(6)を認識し、それに敏感であれ。 参照： • ⾼い/低い筋緊張（p.34) • てんかん（p.40) • 褥瘡はどうやったら防げるか？ o 基礎⾞椅⼦サービス教習パッケージ受講者 ⽤参考書を参照。 1 [訳注] 以下, 脚注番号 5〜84 は原⽂のまま.. 2 [原⽂] general information 3 [原⽂] common characteristics 4 [原⽂] brain injury 5 World Health Organization. (2006). Neurological disorders: Public health challenges. (https://www.who.int/publications/i/item/9789241563369 ) 6 World Health Organization, United States Department of Defense Drucker Brain Injury Center, Moss Rehab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. (https://apps.who.int/iris/handle/10665/69231 ) 7 World Health Organization. (2011). Meningococcal meningitis. (https://www.who.int/news-room/fact-sheets/detail/meningococcal-meningitis ) W H E E LC H A IR SE RV IC E T R A IN IN G PA C K A G E IN T ER M ED IAT E LEV EL 23 24 5 World Health Organization. (2006). Neurological disorders: Public health challenges. Retrieved from http://www.who.int/mental_health/neurology/chapter_3_b_neuro_ disorders_public_h_challenges.pdf 6 World Health Organization, United States Department of Defense Drucker Brain Injury Center, Moss Rehab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. Retrieved from http://whqlibdoc.who.int/hq/2004/WHO_DAR_01.9_eng.pdf 7 World Health Organization. (2011). Meningococcal meningitis. Retrieved from http://www.who.int/mediacentre/factsheets/fs141/en/ General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision B ra in In ju ry Brain injury refers to any damage to the brain that occurs after birth. Damage can be caused by an accident or trauma (5,6), brain infection, meningitis (7), cerebral malaria, alcohol or drug abuse (5). The problems caused by a brain injury vary depending on the part of the brain that has been damaged and the severity of the injury (6). Brain injuries can affect a person’s whole body, or a part of the body. Even though brain injury is a permanent injury to the brain, the effects of the injury on the person’s abilities might change over time (6). *Please note for the purposes of this training programme the term brain injury refers to acquired and traumatic brain injury only. r dif!culty with moving, poor coordination and strength (6); r poor sitting and/or standing balance (6); r high muscle tone (stiffness of muscles) (6), which can cause the whole body to straighten (full body extension) or curl up (full body "exion); r dif!culty with eating, drinking and swallowing (6); r dif!culty with talking, reasoning and understanding (6); r changes in personality or behaviour (6); r seizure (6); r dif!culty controlling bowel and bladder, which increases the risks of development of pressure sores (6). If the wheelchair user does not have the ability to propel their wheelchair with their arms, identify whether foot propelling would be possible. Find out if the wheelchair user has high muscle tone as this may affect the strength required of PSDs. Frequent follow up is important as the wheelchair user’s physical abilities may change over time (6). This means that the amount of support needed in the wheelchair may change. Be aware and sensitive to possible changes in ersonality or behaviour related to individual’s health condition (6). For information on: Muscle tone – high and low – see page 34. Epilepsy – see page 40. How can pressure sores be prevented? – see the Wheelchair Service Training Package – Basic Level Reference Manual. 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 25 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 脳 性 ⿇ 痺 脳性⿇痺は、⼩児 期の⾝体障害のう ち、最も多いもの の⼀つで(8, 9)、発 達中の脳の損傷に よって起こる(10)。 脳性⿇痺の影響の 仕⽅は⼈によって さまざまだが(10)、 最も⼀般的なのは 運動への障害である(8, 10, 11)。脳性⿇痺があ る⼈に、みな⾞椅⼦が必要とは限らない(10)。 しかし、脳性⿇痺がある⼦どもや⼤⼈で⾞椅 ⼦を使う⼈には、⾞椅⼦に座ってうまく機能 を発揮し快適であるために、付加姿勢⽀持が 必要なことが多い。 • 寝そべる、座る、⽴ち上がるのが困難(10)。 • バランスに乏しい(10)。 • ⾝体の⼀部を動かしながら、他の部分を制御 するのが困難。例えば、じっと座ったまま書 く、コップの飲み物を飲む、飲み込むなど。 • ⾼い/低い筋緊張(10)。 • 筋攣縮/制御できない運動。 • 協調運動に乏しい(10)。 • つねに同じ（習慣的）姿勢で座る傾向(10)。 • 視覚、聴覚、てんかん、発話およびコミュニ ケーションの困難など、他の⾝体的問題(10)。 • 腸や膀胱の制御が難しく、それで褥瘡発⽣の 危険が⾼まることがある(11,)。12 • ひとりでトイレに⾏き、トイレに座る、ある いはしゃがむのが難しいことがある。 • 股関節脱⾅（⼤腿⾻頭が寛⾻⾅から外れるこ と）は、運動の制限や痛みを伴う。 • 脳性⿇痺がある多くの⾞椅⼦ユーザーにと り、適切な姿勢⽀持は姿勢、バランス、何かす るための⾝体のコントロールしやすさの改善 に役⽴つため重要。 • 脳性⿇痺がある⾞椅⼦ユーザーにとり、姿勢 の変化には、はじめ違和感が伴うかもしれな いので注意。適応に時間を要する⾞椅⼦ユー ザーもあろう。よりニュートラルな姿勢にな るのに時間をかけられるよう、姿勢⽀持を 徐々に変えることを検討せよ。 • 他の⾝体的問題が、⾞椅⼦や姿勢⽀持の解決 策に影響することもある。事前評価で、脳性 ⿇痺がある⾞椅⼦ユーザーが抱える、他の困 難を⾒出せ。 参照： • 股関節脱⾅（p.38) 8 Rosenbaum, P. (2003). Cerebral palsy. What parents and doctors want to know. British Medical Journal, 326, 970-974. (https://www.researchgate.net/publication/10776930_Cerebral_palsy_What_parents_and_doctors_want_to_know) 9 Cerebral Palsy Australia. (n.d.). Cerebral palsy ‒ the facts. Retrieved from http://www.cerebralpalsyaustralia.com/index.php/site/learningcentre/thefacts 10 World Health Organization. (1993). Promoting the development of young children with cerebral palsy: A guide for mid-level rehabilitation workers. (https://apps.who.int/iris/handle/10665/62696) 11 Kigger, K. (2006). Cerebral Palsy: An overview. American Family Physician, 73(1), 91-100. 12 Roijen, L., Postema, K., Limbeek, vJ., & Kuppevelt, vH. J. M. (2001). Development of bladder control in children and adolescents with cerebral palsy. Developmental Medicine and Child Neurology, 43, 103-107. W H E E LC H A IR SE R V IC E T R A IN IN G PA C K A G E IN T ER M ED IA T E LEV EL 25 26 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision M us cu la r dy st ro ph y Duchenne muscular dystrophy (DMD) is one of 20 types of muscular dystrophy. All the muscular dystrophies result in muscle weakness (9). DMD is an inherited condition that weakens the muscles gradually over time (10). The muscles that help the body to move are affected !rst (14). As the condition progresses, the muscles of the heart and lungs are also affected (14,11). It is progressive, which means that people who have muscular dystrophy gradually lose the ability to walk (13,14,12), and will require a wheelchair (13). At !rst, a person can independently propel the wheelchair with a good posture (13). However, the ability to maintain good posture and propel themselves decreases as the condition progresses (13). Note: some other progressive neurological conditions have similar features and require similar approaches when providing a wheelchair. r pain and discomfort (13); r fatigue (17); r progressive muscle weakness; by the time the person needs a wheelchair, weakness around the pelvis, trunk and shoulders affects posture (17); r changes in posture: – due to weak muscles around the stomach and the hip joint a person with muscular dystrophy may sit with their pelvis in anterior pelvis tilt (top of pelvis forward) and an increased lumbar curve (lordosis) (17); – as muscle weakness progresses there is a high risk of the spine curving sideways (scoliosis) (16); r dif!culties in breathing due to changes in posture and muscle weakness (17); r a risk of developing a pressure sore due to: – dif!culty changing position; – being under-weight or over-weight. r As soon as someone with muscular dystrophy (or other progressive neurological conditions) begins to need their wheelchair on a daily basis, a thorough assessment of their postural support is needed. r Good postural support provided early can help to prevent future postural problems (17). r Additional postural support should focus on supporting a neutral posture and providing increased support as needed (17). r Supportive footwear and angle adjustable footrests can help maintain a neutral (or close to neutral) feet position. Where available, an ankle- foot orthosis (AFO) may also be helpful (17). r Arm support is important when weakness affects the shoulders (17). For information on: r Pain – see page 27. r Fatigue – see page 37. r Progressive conditions – see page 31. 13 Muscular Dystrophy Campaign. (2002). Duchenne muscular dystrophy. Retrieved from http://www.muscular-dystrophy.org/ 14 Centers for Disease Control and Prevention. (n.d.). Duchenne muscular dystrophy: Fact sheet. Retrieved from http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/ Duchenne.pdf 15 Newsom Davis, J. (1980). The respiratory system in muscular dystrophy. British Medical Bulletin, 36, 135–138. 16 Brooke, M.H., et al. (1989). Duchenne muscular dystrophy: Patterns of clinical progression and effects of supportive therapy. Neurology, 39, 475–481. 17 Muscular Dystrophy Campaign. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision C er eb ra l p al sy Cerebral palsy is one of the most common childhood physical disabilities (8,9) and is caused by an injury to the developing brain (10). The way in which cerebral palsy affects each person is different (10), however most commonly it affects the way that a person moves (8,10,11). Not every person with cerebral palsy needs to use a wheelchair (10). However, children and adults with cerebral palsy who use a wheelchair frequently require additional postural support for them to be functional and comfortable in their wheelchair. r dif!culty with lying, sitting or standing up (10); r poor balance (10); r dif!culty controlling one part of the body whilst moving another – for example, sitting still while writing or taking a drink from a cup and swallowing; r high or low muscle tone (10); r spasms/uncontrolled movements; r poor coordination (10); r a tendency to sit in the same posture all the time (habitual posture) (10); r other physical concerns such as visual, hearing, epilepsy, speech or communication dif!culties (10); r may have dif!culty controlling their bowel and bladder, which may increase the risk for development of pressure sores (11,8); r can be dif!cult to be able to get to a toilet and sit on or squat over the toilet independently; r hip dislocation (the head of the femur comes out of the hip socket), which can limit movement and be painful. r For most wheelchair users with cerebral palsy, good postural support is important to help improve posture, balance and how easily they can control their body to do things. r Be aware that changes in posture may at !rst feel strange for a wheelchair user with cerebral palsy. The wheelchair user may need time to adjust. Consider changing postural support gradually to allow him/her to reach a more neutral posture over time. r Other physical issues can have an impact upon the wheelchair and postural support solutions. Find out during the assessment what other dif!culties a wheelchair user with cerebral palsy may have. For information on: r Hip dislocation – see page 38. 8 Rosenbaum, P. (2 03). Cerebral palsy. What par nts and doctors want to know. British Medical Journal, 326, 970–974 9 Cerebral Palsy Australia. (n.d.). C rebral palsy – the facts. Retrieved from http://www.cere ralpalsyaus alia.com/index.php/site/lear ingcentre/thefacts 10 World Health Organization. (1993). Promoting the development of young children with cerebral palsy: A guide for mid-level rehabilitation workers. Retrieved from http:// whqlibdoc.who.int/hq/1993/WHO_RHB_93.1.pdf 11 Kigger, K. (2006). Cerebral Palsy: An overview. American Family Physician, 73(1), 91–100. 12 Roijen, L., Postema, K., Limbeek, vJ., & Kuppevelt, vH. J. M. (2001). Development of bladder control in children and adolescents with cerebral palsy. Developmental Medicine and Child Neurology, 43, 103–107. 26 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 筋 ジ ス ト ロ フ - . デュシェンヌ型筋ジストロ フィー（DMD）は 20種ある 筋ジストロフィーの⼀つ。 どの筋ジストロフィーも、筋 ⼒低下をもたらす(13)。 DMD は遺伝性疾患で、時間 と共に徐々に筋⾁を弱めて ⾏く(14)。⾝体運動の筋⾁が、 最初に障害を受ける(14)。症状 が進むと、⼼臓や肺の筋⾁が障害を受ける(14, 15)。 進⾏性であるため、筋ジストロフィーを患う⼈は 徐々に歩く能⼒を失い(13, 14, 16)、⾞椅⼦が必要にな る(17)。はじめはよい姿勢で、⾃⼒で⾞椅⼦をこげる (13)。しかし、よい姿勢を保って⾃⼒でこぐ能⼒は、 症状が進むにつれ低下する(13)。 注記：他の進⾏性神経疾患にも似た特徴のものがあ り、⾞椅⼦を供与するさい同様のアプローチが必要。 • 痛みや不快感(13)。 • 疲労(17)。 • 進⾏性の筋⼒低下：⾞椅⼦が必要にな る頃には⾻盤、体幹、肩の衰弱のため姿 勢が悪化(17)。 • 姿勢の変化： o 腹部と股関節周りの筋⾁が弱いた め、筋ジストロフィーの⼈は座ると ⾻盤前傾（⾻盤の上端が前に出る） で、腰椎のカーブが急（脊柱前弯）(17)。 o 筋⼒低下が進むにつれ脊椎が横にカ ーブ（側弯）する危険が⾼まる(16)。 • 姿勢変化と筋⼒低下による呼吸困難 (17)。 • 褥瘡発⽣の危険。原因は： o 姿勢を変えるのが難しい。 o 低体重や過体重。 • 筋ジストロフィー（あるいは他の進⾏性神 経疾患）の⼈が、⽇常的に⾞椅⼦を必要とす るようになったら、直ちに徹底的な姿勢⽀ 持の事前評価が必要。 • しっかりした姿勢⽀持を早期に供すると将 来の姿勢にまつわる問題の予防に役⽴つ (17)。 • 付加姿勢⽀持はニュートラルな姿勢を⽀え 必要に従い⽀えを増やすことが⽬標(17)。 • ⽀持的な履き物や⾓度可変式⾜台は、ニュ ートラルな（あるいはニュートラルに近い） ⾜の位置の維持に役⽴つ。⼿に⼊れば、短下 肢装具（AFO）は有効(17)。 • ひじ掛けは、筋⼒低下が肩に及んでいる場 合に重要(17)。 参照： • 痛み（p.27) • 疲労（p.37) • 進⾏性疾患（p.31) 13 Muscular Dystrophy Campaign. (2002). Duchenne muscular dystrophy. Retrieved from http://www.muscular-dystrophy.org/ 14 Centers for Disease Control and Prevention. (n.d.). Duchenne muscular dystrophy: Fact sheet. Retrieved from http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/Duchenne.pdf. 15 Newsom Davis, J. (1980). The respiratory system in muscular dystrophy. British Medical Bulletin, 36, 135-138. 16 Brooke, M.H., et al. (1989). Duchenne muscular dystrophy: Patterns of clinical progression and effects of supportive therapy. Neurology, 39, 475‒481. 17 Muscular Dystrophy Campaign. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ W H E E LC H A IR SE RV IC E T R A IN IN G PA C K A G E IN T ER M ED IAT E LEV EL 25 26 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision M us cu la r dy st ro ph y Duchenne muscular dystrophy (DMD) is one of 20 types of muscular dystrophy. All the muscular dystrophies result in muscle weakness (9). DMD is an inherited condition that weakens the muscles gradually over time (10). The muscles that help the body to move are affected !rst (14). As the condition progresses, the muscles of the heart and lungs are also affected (14,11). It is progressive, which means that people who have muscular dystrophy gradually lose the ability to walk (13,14,12), and will require a wheelchair (13). At !rst, a person can independently propel the wheelchair with a good posture (13). However, the ability to maintain good posture and propel themselves decreases as the condition progresses (13). Note: some other progressive neurological conditions have similar features and require similar approaches when providing a wheelchair. r pain and discomfort (13); r fatigue (17); r progressive muscle weakness; by the time the person needs a wheelchair, weakness around the pelvis, trunk and shoulders affects posture (17); r changes in posture: – due to weak muscles around the stomach and the hip joint a person with muscular dystrophy may sit with their pelvis in anterior pelvis tilt (top of pelvis forward) and an increased lumbar curve (lordosis) (17); – as muscle weakness progresses there is a high risk of the spine curving sideways (scoliosis) (16); r dif!culties in breathing due to changes in posture and muscle weakness (17); r a risk of developing a pressure sore due to: – dif!culty changing position; – being under-weight or over-weight. r As soon as someone with muscular dystrophy (or other progressive neurological conditions) begins to need their wheelchair on a daily basis, a thorough assessment of their postural support is needed. r Good postural support provided early can help to prevent future postural problems (17). r Additional postural support should focus on supporting a neutral posture and providing increased support as needed (17). r Supportive footwear and angle adjustable footrests can help maintain a neutral (or close to neutral) feet position. Where available, an ankle- foot orthosis (AFO) may also be helpful (17). r Arm support is important when weakness affects the shoulders (17). For information on: r Pain – see page 27. r Fatigue – see page 37. r Progressive conditions – see page 31. 13 Muscular Dystrophy Campaign. (2002). Duchenne muscular dystrophy. Retrieved from http://www.muscular-dystrophy.org/ 14 Centers for Disease Control and Prevention. (n.d.). Duchenne muscular dystrophy: Fact sheet. Retrieved from http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/ Duchenne.pdf 15 Newsom Davis, J. (1980). The respiratory system in muscular dystrophy. British Medical Bulletin, 36, 135–138. 16 Brooke, M.H., et al. (1989). Duchenne muscular dystrophy: Patterns of clinical progression and effects of supportive therapy. Neurology, 39, 475–481. 17 Muscular Dystrophy Campaign. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 27 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 ポ リ オ ポリオはウイルスが引き起こす感染症の⼀つである (18)。そのウイルスは、運動を司る神経のみを攻撃す る(19, 20)。 ポリオに罹った 200 ⼈に 1 ⼈は、筋⾁の永久的⿇痺 という転帰をたどる(18)。 ポリオは、ふつう 5歳未満の⼦どもに感染する(18)。 ポリオ感染国の数は、ここ数 10 年で劇的に減った (18)。 • ふつう両脚での、患部の筋⾁の運動機 能の喪失（筋⿇痺）(19)。 • 筋萎縮により、脚、およびしばしば臀部 が痩せている。 • ⾜⾸、膝、股関節周りの、ニュートラル でないまま固まった姿勢(19)。 • 体幹の筋⾁の衰弱(19)。この場合、側弯、 胸椎の弯曲の増⼤（後弯）、⾻盤前傾、 腰椎の弯曲の増⼤(前弯)など、脊柱に固 まった弯曲が⽣じる場合もある(19)。 • 脚の弱さを埋め合わせるため、腕⼒が 発達する。 • ポリオの⼈は、筋⿇痺やどんな姿勢の問題 が起きても、移動し、さまざまな活動を果た す⽅法を⾒つけていることが多い。 • あらゆる⾞椅⼦ユーザーと同様、どんな姿 勢⽀持が欲しいのか、本⼈と話し合え。あら ゆる姿勢矯正の影響を、慎重に検討せよ。例 えば、ポリオ患者には、バランスを取るため 脚を⼤きく開き、あるいは組んで座る⼈が いる。これらを矯正しようとすると、バラン スを悪化させ、⾃⽴を損なう可能性がある。 • 多くのポリオ患者には腕⼒があるので： o ⾞椅⼦が、効率よくこげる位置を取れる 設定になっているか確かめよ。 o 3輪⾞の提案を（⼿に⼊れば）検討せよ。 これは⻑距離移動に適した選択肢。 • ポリオを患う⾞椅⼦ユーザーの体幹が短縮 していれば、クッション厚さを増し、より効 率よくこげる位置にすることを検討。 参照： • ⼿こぎ⾞椅⼦の設定：基礎⾞椅⼦サービス 教習パッケージ受講者⽤参考書を参照。 18 World Health Organization. (2012). Poliomyelitis. (https://www.who.int/news-room/fact-sheets/detail/poliomyelitis) 19 World Health Organization. (1993). Rehabilitation surgery for deformities due to poliomyelitis. (https://apps.who.int/iris/handle/10665/37907) 20 Polio Global Eradication Initiative. (n.d.). Polio and prevention. (https://polioeradication.org/polio-today/polio-prevention/) W H E E LC H A IR SE RV IC E T R A IN IN G PA C K A G E IN T ER M ED IAT E LEV EL 27 28 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision P ol io Polio is an infectious disease caused by a virus (18). The virus only attacks the nerves that control movement (19, 20). One in 200 people who have polio develop some form of permanent muscle paralysis as a result (18). Polio usually affects children under the age of !ve (18). The number of countries that are affected by polio has dramatically decreased in recent decades (18). r loss of movement in affected muscles (paralysis) – usually of both legs (19); r thin legs and often buttocks due to muscle wasting; r !xed non-neutral posture around the ankles, knees and hips (19); r weakness in the trunk muscles (19). In this case, !xed curves of the spine may develop – including scoliosis, increased thoracic curve (kyphosis), anterior pelvis tilt and increased lumbar curve (lordosis) (19); r strong arms developed to compensate for the weakness in their legs. r People with polio have often found ways to move and carry out different activities despite the paralysis and any postural problems that they may have developed. r As for any wheelchair user – talk with the person about what postural support he/she wants. Carefully consider the effect of any postural correction. For example – some people with polio sit with their legs further apart or cross-legged and this helps them to balance. Trying to correct this could make their balance worse – and therefore make them less independent. r As many people with polio have strong arms: – make sure the wheelchair is set up to enable an ef!cient propelling position; – consider suggesting a tricycle (where available) as this is a good mobility option for longer distances. r If a wheelchair user with polio has a shortened trunk – consider increasing the height of the cushion to place them in a more ef!cient position for pushing. For more information on: r Wheelchair set up for arm propelling – see the Wheelchair Service Training Package – Basic Level Reference Manual. 18 World Health Organization. (2012). Poliomyelitis. Retrieved from http://www.who.int/mediacentre/factsheets/fs114/en/ 19 World Health Organization. (1993). Rehabilitation surgery for deformities due to poliomyelitis. Retrieved from http://whqlibdoc.who.int/ publications/1993/9241544570.pdf 20 Polio Global Eradication Initiative. (n.d.). Polio and prevention. Retrieved from http://www.polioeradication.org/Polioandprevention.aspx General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision Sp in a B i! da Spina bi!da occurs before birth (21, 22). The bones of the spine do not close fully around the spinal nerves, leaving them unprotected (21, 22). As a result, the part of the spinal cord, which lies under these bones, may not develop correctly or be damaged (21). Damage to the spinal cord might affect the control of the bladder and bowels (21, 18, 19). Spina bi!da can affect people differently, depending on the size of the area affected and the level of nerve damage (21). r movement dif!culties will depend on where the spina bi!da is located over the spine and how much nerve and spine cord damage is present (21); r dif!culty controlling the bladder and bowel (21); r able to walk short distances with the use of mobility devices (21); r may have a bulge at the level of spinal cord, which is damage due to the spine not developing properly (particularly if there has been no surgical intervention) (21); r reduced muscle control and sensation makes sitting upright more dif!cult; r may have a larger head (hydrocephalus) caused by a build-up of "uid (21). The main treatment for hydrocephalus is to surgically insert a ‘shunt’, which allows the trapped "uid to drain away – usually into the child’s stomach (21). If the build-up is not treated it can lead to damage of the brain; r at risk of developing a pressure sore due to lack of sensation below the level of the injury and the presence of moisture if bowel and bladder is not effectively managed (21). r Ensure the wheelchair is set up to enable ef!cient propelling. r The amount of postural support will depend on the level of injury. The higher the level, the more support is likely to be needed. r If orthotics are to be worn in the day, ask the wheelchair user to wear their orthotics during the wheelchair assessment. r If a bulge is present, avoid any pressure on that area. This may require shaping the backrest or adjusting the backrest upholstery to accommodate the bulge. r Good postural support provided early can help to prevent postural problems (20). This is particularly important at times of growth. r If a child has a ‘shunt’, be aware of its position if providing a headrest. r If the child has hydrocephalus, which is not being treated, refer him/her to a doctor. For information on: r Wheelchair set up for arm propelling – see the Wheelchair Service Training Package – Basic Level Reference Manual. r How can pressure sores be prevented? – see the Wheelchair Service Training Package – Basic Level Reference Manual. 21 World Health Organization. (1996). Promoting the development of infants and young children with spina bi!da and hydrocephalus. Retrieved from http://whqlibdoc.who. int/hq/1996/WHO_RHB_96.5.pdf 22 Malone, P., Wheeler, R., & Williams, J. (1994). Continence in patients with spina bi!da: Long terms results. Archives of Disease in Childhood, 70, 107–110. 23 McDonnell, G. V., McCann, J. P. (2000). Issues of medical management in adults with spina bi!da. Child’s Nervous System, 16, 222–227. 24 Muscular Dystrophy Campain. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ 28 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 ⼆ 分 脊 椎 ⼆分脊椎は、出⽣ 前 に 起 こ る ( 21 , 22)。脊髄神経が脊 椎の⾻に完全に 覆われないと無 防備な状態にな り(21, 22)、その結 果、⾻の内側を⾛ る脊髄が正常に 発達しないか損傷する(21)。 脊髄の損傷により、腸や膀胱のコ ントロールが障害を受けること がある(21, 22, 23)。 ⼆分脊椎の影響は⼈によりさま ざまで、障害を受けた範囲の⼤き さや神経損傷部位の⾼さによる (21)。 • 運動障害は、⼆分脊椎の脊椎上の位置や、 神経や脊髄の損傷程度により異なる(21)。 • 腸や膀胱のコントロールが難しい(21)。 • 移動⽀援具を使い短い距離を歩ける(21)。 • 脊椎が適切に発達しないための損傷によ り（特に外科的介⼊がない場合）、その脊 髄の⾼さに瘤起を⽣じる場合もある(21)。 • 筋⾁のコントロールや感覚の低下によ り、まっすぐに座るのが難しくなる。 • 体液が溜まり頭が⼤きくなること（⽔頭 症）がある(21)。⽔頭症への⼀般的治療は、 「シャント」を外科的に挿⼊し溜まった 体液を通常⼦どもの腹内へ排出する(21)。 滞留物を処置しないと、脳に損傷を来た しうる。 • 損傷部位より下の感覚がなく、腸や膀胱 の問題へ効果的に対処しなければ⽔分が 溜まるため、褥瘡発⽣の危険がある(21)。 • ⾞椅⼦が効率よくこげるよう設定されているか確認。 • 姿勢⽀持の量は、損傷部位の⾼さによる。⾼くなるほど、よ り多くの⽀えが必要となろう。 • ⽇中は装具を着ける場合、⾞椅⼦ユーザーには、⾞椅⼦事前 評価では装具を着けてもらうこと。 • 瘤起があれば、その部位へのどんな圧⼒も避けよ。このため、 瘤起に形状が合うように背もたれを成形するか、背もたれの 張り布を調整する必要があろう。 • 適切な姿勢⽀持を早期に供することが、姿勢にまつわる問題 を防ぐ(20)。これは、特に成⻑期で重要。 • 「シャント」を⼊れた⼦どもにヘッドレストを設える場合 は、その位置に注意。 • 治療されていない⽔頭症の⼦どもは医師へ紹介・相談せよ。 参照： • ⼿こぎ⾞椅⼦の設定：基礎⾞椅⼦サービス教習パッケージ受 講者⽤参考書を参照。 • 褥瘡はどうやったら防げるか？：基礎⾞椅⼦サービス教習パ ッケージ受講者⽤参考書を参照。(24) 21 World Health Organization. (1996). Promoting the development of infants and young children with spina bifida and hydrocephalus. (https://apps.who.int/iris/handle/10665/63950 ) 22 Malone, P., Wheeler, R., & Williams, J. (1994). Continence in patients with spina bifida: Long terms results. Archives of Disease in Childhood, 70, 107- 110. 23 McDonnell, G.V., McCann, J. P. (2000). Issues of medical management in adults with spina bifida. Childʼs Nervous System, 16, 222-227. 24 Muscular Dystrophy Campaign. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ W H E E LC H A IR SE R V IC E T R A IN IN G PA C K A G E IN T ER M ED IA T E LEV EL 27 28 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision S pi na B i! da Spina bi!da occurs before birth (21, 22). The bones of the spine do not close fully around the spinal nerves, leaving them unprotected (21, 22). As a result, the part of the spinal cord, which lies under these bones, may not develop correctly or be damaged (21). Damage to the spinal cord might affect the control of the bladder and bowels (21, 18, 19). Spina bi!da can affect people differently, depending on the size of the area affected and the level of nerve damage (21). r movement dif!culties will depend on where the spina bi!da is located over the spine and how much nerve and spine cord damage is present (21); r dif!culty controlling the bladder and bowel (21); r able to walk short distances with the use of mobility devices (21); r may have a bulge at the level of spinal cord, which is damage due to the spine not developing properly (particularly if there has been no surgical intervention) (21); r reduced muscle control and sensation makes sitting upright more dif!cult; r may have a larger head (hydrocephalus) caused by a build-up of "uid (21). The main treatment for hydrocephalus is to surgically insert a ‘shunt’, which allows the trapped "uid to drain away – usually into the child’s stomach (21). If the build-up is not treated it can lead to damage of the brain; r at risk of developing a pressure sore due to lack of sensation below the level of the injury and the presence of moisture if bowel and bladder is not effectively managed (21). r Ensure the wheelchair is set up to enable ef!cient propelling. r The amount of postural support will depend on the level of injury. The higher the level, the more support is likely to be needed. r If orthotics are to be worn in the day, ask the wheelchair user to wear their orthotics during the wheelchair assessment. r If a bulge is present, avoid any pressure on that area. This may require shaping the backrest or adjusting the backrest upholstery to accommodate the bulge. r Good postural support provided early can help to prevent postural problems (20). This is particularly important at times of growth. r If a child has a ‘shunt’, be aware of its position if providing a headrest. r If the child has hydrocephalus, which is not being treated, refer him/her to a doctor. For information on: r Wheelchair set up for arm propelling – see the Wheelchair Service Training Package – Basic Level Reference Manual. r How can pressure sores be prevented? – see the Wheelchair Service Training Package – Basic Level Reference Manual. 21 World Health Organization. (1996). Promoting the development of infants and young children with spina bi!da and hydrocephalus. Retrieved from http://whqlibdoc.who. int/hq/1996/WHO_RHB_96.5.pdf 22 Malone, P., Wheeler, R., & Williams, J. (1994). Continence in patients with spina bi!da: Long terms results. Archives of Disease in Childhood, 70, 107–110. 23 McDonnell, G. V., McCann, J. P. (2000). Issues of medical managem nt in adults with spina bi!da. C ild’s Nervous System, 16, 222–227. 24 Muscular Dystrophy Campain. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. Retrieved from http://www.muscular-dystrophy.org/ 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 29 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 脊 髄 損 傷 脊髄損傷（SCI）は脊髄の損 傷の結果、損傷より低い部 位で運動や感覚が減少する ことである(25)。脊髄は腸や 膀胱も制御するため、損傷 後、これらが障害を受ける こともある(26)。 脊髄損傷は事故、暴⼒、疾病、感染などによって起こる。 脊髄損傷の影響は、損傷の種類やその部位の⾼さによ って異なる(26)。 分類：完全損傷とは、感覚や⾃発運動が、脊髄の損傷部 位より下に全くない場合を指す(26)。不完全損傷とは、 感覚や⾃発運動が、脊髄の損傷部位より下にも多少あ る場合を指す(26)。 ⾼さ：脊髄損傷を負った⾼さによって、四肢⿇痺、⾼位 対⿇痺、低位対⿇痺と表す(26)。四肢⿇痺は頸部から起 きて両腕、体幹、⾻盤、両脚が障害を受ける(26)。⾼位対 ⿇痺は背部から起き体幹、⾻盤、両脚が障害を受け、両 腕は受けない(26, 27)。低位対⿇痺は腰部から起き両脚が 障害を受ける(26)。⾻盤が障害を受ける場合もある(22)。 • 完全損傷であれば運動および感覚が完 全に失われ、不完全損傷であれば運動 や感覚が部分的に失われる(26)。 • 四肢⿇痺および⾼位対⿇痺の⼦どもや ⼤⼈は、体幹周りの筋運動のコントロ ールや感覚が失われているため、バラ ンスに乏しい。このため、まっすぐに座 るのが難しく、⾞椅⼦の適切な⽀えが なければ、⻑期にわたる姿勢の問題が 直ちに⽣じる(26)。 • 腸や膀胱の制御が難しい可能性(26)。 • 下肢に筋攣縮や制御できない運動が起 こる可能性(26)。 • 脊髄損傷がある⼦どもや⼤⼈には、褥 瘡発⽣の危険がある。理由は： o 損傷部位より下の感覚を失っている ため。 o 腸や膀胱の問題を効果的に管理しな ければ、⽔分が溜まるため。 • 褥瘡予防のため、必ず除圧クッションを 処⽅。 • 脊髄損傷のある⾞椅⼦ユーザーに必要な 姿勢⽀持の量は、損傷部位の⾼さによる。 部位が⾼いほど、より多くの⽀えが必要 であろう(27)。 • 損傷後の初期段階では、特に損傷部位が ⾼い場合、体幹と腕へ付加姿勢⽀持が必 要になろう。 • 対⿇痺者の多く、また四肢⿇痺者でも⼀ 部は、⾃⼒で⾞椅⼦をたいへん効率よく こげる(26)。⾞椅⼦が効率的にこげる位置 に設定されているか確かめよ。 参照： • ⼿こぎ⾞椅⼦の設定：基礎⾞椅⼦サービス 教習パッケージ受講者⽤参考書を参照。 • 褥瘡はどうやったら防げるか？：基礎⾞ 椅⼦サービス教習パッケージ受講者⽤参 考書を参照。 25 World Health Organization. (1996). Promoting independence following a spinal cord injury: A manual for mid-level rehabilitation workers. (http s://apps.who.int/iris/handle/10665/63599) 26 Bromley, I. (2006). Tetraplegia and paraplegia: A guide for physiotherapists. (https://www.elsevier.com/books/tetraplegia-and-paraplegia/bromle y/978-0-443-10180-9) W H E E LC H A IR SE RV IC E T R A IN IN G PA C K A G E IN T ER M ED IA T E LEV EL 29 30 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision Sp in al C or d In ju ry A spinal cord injury (SCI) is damage to the spinal cord that results in reduced movement and/or sensation below the level of the injury(25). The spinal cord also controls the bladder and bowels so these may also be affected after injury (26). A SCI may be caused by an accident, violence, disease or infection (26). The effects of spinal cord injury depend on the type and level of the injury (26). Type: A complete injury is when a person has no sensation or voluntary movement below the damaged part of the spinal cord (26). An incomplete injury is when the person has some sensation or voluntary movement below the damaged part of the spinal cord (26). Level: The level of spinal cord injury can be described as tetraplegia/quadriplegia, high level paraplegia or low level paraplegia (26). A quadriplegia/tetraplegia occurs in the neck, and the arms, trunk, pelvis and legs are affected (26). A high level paraplegia occurs in the upper back, and the trunk, pelvis and legs are affected (26, 27). The arms are not affected. A low level paraplegia occurs in the lower back and the legs are affected (26). The pelvis may also be affected (22). r complete loss of movement and sensation if the injury is complete or partial loss of movement and sensation if the injury is incomplete (26); r children and adults with quadriplegia/ tetraplegia and high level paraplegia will have poor balance due to the loss of muscle movement control and sensation around the trunk. This makes sitting upright more dif!cult and long-term postural problems can develop quickly without the correct support from the wheelchair; r possible dif!culty with controlling bowel or bladder (26); r potential spasms/uncontrolled movements of lower legs (26); r children and adults with a SCI are at risk of developing a pressure sore due to: – lack of sensation below the level of the injury (26); – presence of moisture if their bowel and bladder is not effectively managed. r Always prescribe a pressure relief cushion to help prevent pressure sores. r The amount of postural support required for a wheelchair user with an SCI will depend on the level of injury. The higher the level, the more postural support is likely to be needed (27). r In the early stages after injury, additional support for the trunk and arms may be necessary – particularly for high level injuries. r Most paraplegics and some quadriplegics/tetraplegics can self- propel very effectively (26). Ensure the wheelchair is set up to enable an ef!cient propelling position. For information on: r Wheelchair set up for arm propelling – see the Wheelchair Service Training Package – Basic Level Reference Manual. r How can pressure sores be prevented? – see the Wheelchair Service Training Package – Basic Level Reference Manual. 25 World Health Organization. (1996). Promoting independence following a spinal cord injury: A manual for mid-level rehabilitation workers. Retrieved from http:// whqlibdoc.who.int/hq/1996/WHO_RHB_96.4.pdf 26 Bromley, I. (2006). Tetraplegia and paraplegia: A guide for physiotherapists. Retrieved from http://xa.yimg.com/kq/groups/16749867/2144244149/name/ Tetraplegia+and+Paraplegia.pdf General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision St ro ke Stroke is a type of brain injury caused by a failure of the blood supply to the brain (27, 28, 29, 30, 31). Damage or disease can cause blood vessels to block or burst, causing damage or death to that part of the brain (28, 29, 30, 31, 32). How a stroke affects each individual varies, depending on the area of the brain, which has been affected and how severely it has been affected (29, 31) – however often just one side of the body is affected (hemiplegia) (28, 31, 28). r Weakness, less muscle control and sometimes pain on the affected side of the body (affecting the arm, trunk and leg) (28); r reduced or altered sensation on side of the body, which has been affected (28); r may have a lack of awareness of side of the body, which has been affected and this may lead to increased risk of falls during transfers (28); r may have dif!culty sitting upright with a tendency to lean or fall towards the affected side of the body (28); r may be able to stand up, and take a few steps (maybe using different gait) (28); r may have dif!culty speaking, as well as swallowing, which makes eating and drinking dif!cult (28); r may have dif!culty controlling bowel and bladder (28), and it can also be dif!cult to be able to get to a toilet quickly enough. r Provide postural support to encourage a balanced and symmetrical (both sides the same) posture. r Flip up or swing away footrests are often very helpful for wheelchair users with a stroke who can manage a standing transfer. r As one arm is likely to be affected, many people who have had a stroke cannot push the wheelchair using their arms. Find out if a wheelchair user can propel with their unaffected arm and steer with their unaffected leg. r If the wheelchair user has other problems, which are not yet being addressed, refer them for further help if available. For more information on: r Wheelchair set up for foot propelling – see the Wheelchair Service Training Package – Basic Level Reference Manual. 27 World Health Organization. (1999). Promoting independence following a stroke. Retrieved from http://whqlibdoc.who.int/hq/1999/WHO_DAR_99.2.pdf 28 World Health Organization. (2012). Stroke, Cerebrovascular accident. Retrieved from http://www.who.int/topics/cerebrovascular_accident/en/ 29 World Health Organization. (2006). Neurological disorders: Public health challenges. Retrieved from http://www.who.int/mental_health/neurology/chapter_3_b_neuro_ disorders_public_h_challenges.pdf 30 Collins, C. (2007). Pathophysiology and classi!cation of stroke. Nursing Standard, 21(28), 35–39. 31 Frizzel, J. (2005). Acute stroke: Pathophysiology, diagnosis, and treatment. Advanced Practice in Acute and Critical Care, 16(4), 421–440. 32 Herman, B., et al. (1982). Epidemiology of stroke in Tilburg, the Netherlands. The population-based stroke incidence register: 2. Incidence, initial clinical picture and medical care, and three-week case fatality. Stroke, 13(5), 629–634. 30 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 脳 ⾎ 管 障 害 脳⾎管障害は、 脳 損 傷 の ⼀種 で、脳への⾎液 供給不全によっ て起こる (27 , 28 , 29, 30, 31)。 損傷や疾患によ って⾎管が閉塞 または破裂し、 脳の当該部分に 損傷や壊死を引き起こす(28, 29, 30, 31, 32)。 脳⾎管障害の各⼈への影響の仕⽅は、障害を 受けた脳の部位および障害の重さによって 異なる(29, 31)が、⾝体の⽚側だけが障害を受 けること（⽚⿇痺）が多い(28, 31, 32)。 • ⾝体の障害を受けた側（腕、体幹、脚を障害）の 虚弱さ、筋コントロールの乏しさ、時には痛み (28)。 • ⾝体の障害を受けた側の、感覚の低下や異変(28)。 • ⾝体の障害を受けた側へ意識が及ばないことが あり、これは移乗時に転倒する危険を増す(28)。 • ⾝体の障害を受けた側へ傾くか倒れる傾向があ り、まっすぐに座るのが困難なことがある(28)。 • ⽴ち上がれて、（歩き⽅はさまざまでも）数歩は 歩ける場合もある(28)。 • 発話の他に飲み込みも困難な場合があり、⾷べた り飲んだりが難しくなる(28)。 • 腸や膀胱のコントロールが難しい場合があり、ま たトイレまでじゅうぶん早く⾏くのが難しい場 合もある(28)。 • バランスが取れた、対称な（左右が同じ） 姿勢を促すように姿勢⽀持を設ける。 • 跳ね上げ式や開き式の⾜台は、脳⾎管障害 を患った⾞椅⼦ユーザーで⽴ち上がって 移乗できる⼈には⾮常に役⽴つことが多 い。 • ⽚腕が障害を受けることが多いため、脳⾎ 管障害を患った⼈の多くは、両腕で⾞椅⼦ をこげない。⾞椅⼦ユーザーが、障害がな い⽅の腕でこぎ、障害がない⽅の脚で操縦 できるかどうか⾒極めよ。 • ⾞椅⼦ユーザーが他にも問題を抱え、その 対処がされていない場合、さらに利⽤でき る⽀援があれば紹介・相談せよ。 参照： • ⾜こぎ⾞椅⼦の設定：基礎⾞椅⼦サービス 教習パッケージ受講者⽤参考書を参照。 27 World Health Organization. (1999). Promoting independence following a stroke. (https://apps.who.int/iris/handle/10665/42350) 28 World Health Organization. (2012). Stroke, Cerebrovascular accident. (http://www.who.int/topics/cerebrovascular_accident/en/) 29 World Health Organization. (2006). Neurological disorders: Public health challenges. (https://www.who.int/mental_health/neurology/chapter_3_b _neuro_disorders_public_h_challenges.pdf) 30 Collins, C. (2007). Pathophysiology and classification of stroke. Nursing Standard, 21(28), 35-39. 31 Frizzel, J. (2005). Acute stroke: Pathophysiology, diagnosis, and treatment. Advanced Practice in Acute and Critical Care, 16(4), 421-440. 32 Herman, B., et al. (1982). Epidemiology of stroke in Tilburg, the Netherlands. The population-based stroke incidence register: 2. Incidence, initial clinical picture and medical care, and three-week case fatality. Stroke, 13(5), 629-634. W H E E LC H A IR SE R V IC E T R A IN IN G PA C K A G E IN T ER M ED IA T E LEV EL 29 30 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision St ro ke Stroke is a type of brain injury caused by a failure of the blood supply to the brain (27, 28, 29, 30, 31). Damage or disease can cause blood vessels to block or burst, causing damage or death to that part of the brain (28, 29, 30, 31, 32). How a stroke affects each individual varies, depending on the area of the brain, which has been affected and how severely it has been affected (29, 31) – however often just one side of the body is affected (hemiplegia) (28, 31, 28). r Weakness, less muscle control and sometimes pain on the affected side of the body (affecting the arm, trunk and leg) (28); r reduced or altered sensation on side of the body, which has been affected (28); r may have a lack of awareness of side of the body, which has been affected and this may lead to increased risk of falls during transfers (28); r may have dif!culty sitting upright with a tendency to lean or fall towards the affected side of the body (28); r may be able to stand up, and take a few steps (maybe using different gait) (28); r may have dif!culty speaking, as well as swallowing, which makes eating and drinking dif!cult (28); r may have dif!culty controlling bowel and bladder (28), and it can also be dif!cult to be able to get to a toilet quickly enough. r Provide postural support to encourage a balanced and symmetrical (both sides the same) posture. r Flip up or swing away footrests are often very helpful for wheelchair users with a stroke who can manage a standing transfer. r As one arm is likely to be affected, many people who have had a stroke cannot push the wheelchair using their arms. Find out if a wheelchair user can propel with their unaffected arm and steer with their unaffected leg. r If the wheelchair user has other problems, which are not yet being addressed, refer them for further help if available. For more information on: r Wheelchair set up for foot propelling – see the Wheelchair Service Training Package – Basic Level Reference Manual. 27 World Health Organization. (1999). Promoting independence following a stroke. Retrieved from http://whqlibdoc.who.int/hq/1999/WHO_DAR_99.2.pdf 28 World Health Organization. (2012). Strok , Cer brovascul r accident. Retrieved from http://www.who.int/topics/cerebrovascular_accident/en/ 29 World Health Organization. (2006). Neurological disorders: Public health challenges. Retrieved from http://www.who.int/mental_health/neurology/chapter_3_b_neuro_ disorders_public_h_challenges.pdf 30 Collins, C. (2007). Pathophysiology and classi!cation of stroke. Nursing Standard, 21(28), 35–39. 31 Frizzel, J. (2005). Acute stroke: Pathophysiology, diagnosis, and treatment. Advanced Practice in Acute and Critical Care, 16(4), 421–440. 32 Herman, B., et al. (1982). Epidemiology of stroke in Tilburg, the Netherlands. The population-based stroke incidence register: 2. Incidence, initial clinical picture and medical care, and three-week case fatality. Stroke, 13(5), 629–634. 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 31 概要 ⾞椅⼦供与における留意事項 進 ⾏ 性 疾 患 疾患には、時と共に悪化するものも知られてい る。それらは進⾏性疾患として知られる。⼀般的 な進⾏性疾患の例： • 筋ジストロフィー • パーキンソン病 • 多発性硬化症 • 運動ニューロン疾患 適切な⽀えを適切な時点で供することが、姿勢にまつわる問題の予防になる。これは、⾞椅 ⼦ユーザーが、できる限り活き活きとした⼈⽣を、できるだけ⻑く続けられるようにする。 以下の要素は、必ず考慮に⼊れる必要がある： • 事前評価の遅れは、姿勢が悪化する原因となる。 • 事前評価から供与までが遅れると、⾞椅⼦および/または座位保持が、供与された頃にはす でに合わなくなっている場合がある。 • 移動や姿勢⽀持へのニーズは急変することがあり、ひんぱんなフォローアップが重要。 ⾞椅⼦ユーザーの疾患が⼀覧表にない場合は、その診断名を書き留めておくこと。もしその疾患について知らなければ、それについてより詳しく 調べるよう奨める。その疾患の主要な特⾊、およびそれが⾞椅⼦の選択にどう影響するかを考えよ。 疾患や疾病が何か分からない場合は？ ⾞椅⼦ユーザーが、⾃分の疾患や疾病の名称を知らないこともある。診断がついていない場合もありうる。その場合は何か特有の⾝体的問題が ないか⾒定め、事前評価を続けよ。 ⾞椅⼦ユーザーが負っている⾝体的問題には、最適な⾞椅⼦の選択に直接影響を及ぼすものもある。 32 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 フ レ イ ル︵ 虚 弱 ︶ フレイル（虚弱）の⼈はすぐ に疲労しがちで、以前に⽐ べて⾝体を動かさず、虚弱 で、歩くのが⾮常に遅くな る(33)。 ⾼齢者はフレイルになる危 険が⾼い(34, 30, 31)。フレイル の⾼齢者には、ごく基本的な⾞椅⼦でしっかり した姿勢⽀持もない、ニーズに合わないものが 与えられることが多い(32, 33)。しかし、しっかり した姿勢⽀持を備えた適正な⾞椅⼦を虚弱な ⼈やフレイルの⾼齢者へ供与すると、その⽣活 の質へ⾮常によい影響を与える(37, 34, 35) 。 • 疲労しやすい。 • ⾞椅⼦を⾃分でこぐ⼒に限りがある。 • 疲労や全⾝の虚弱さのため、まっすぐ な姿勢を保つのが難しい場合もある。 • 以下の理由から、褥瘡発⽣の危険があ る。 o 薄い/紙のような（硬く乾燥した）⽪ 膚は傷つきやすい。 o 傷/ただれの治癒に時間がかかる。 o たいへん虚弱な場合、⾃⼒で姿勢を 直せない。 ［訳註：(35)は順序を調整。(36)は原著本⽂ に脚注番号なし(37)は順序を調整。(38)は原 著本⽂に脚注番号なし。(39)は後出。］ • 必要な姿勢⽀持の量を慎重に事前評価せよ。⾞椅 ⼦ユーザーは、⾞椅⼦に⻑時間座るほど、より疲 労し、より多く⽀えが必要になることを考慮せよ。 • 役⽴つ⾞椅⼦の特⾊としては： o ひじ掛け：姿勢⽀持を付加し、移乗のためにプ ッシュアップする⽀えになる。 o ⽴てる⼈が⽴ち上がっての移乗をやりやすい、 開き式で動線を塞がない⾜台。 o 他の⼈が⼿こぎを補助できる⼿押しハンドル。 o 軽量な⾞椅⼦は、⾞椅⼦ユーザーの⾃⼒でこぐ 労⼒が少なくて済む。 参照： • 褥瘡はどうやったら防げるか？：基礎⾞椅⼦サー ビス教習パッケージ受講者⽤参考書を参照。 33 Fried, L., et al. (2001). Frailty in older adults: Evidence for a phenotype. Journal of Gerontology, 56, 146-156. 34 Bortz, W. (2002). A conceptual framework of frailty: A review. Journal of Gerontology, 57A(5), M283-M288. 35 Lang, P., Michel, J. P., & Zekry, D. (2009). Frailty syndrome: A transitional state in dynamic process. Gerontology, 55, 539-549. 36 Rader, J., Jones, D., & Miller, L. (2000). The importance of individualized wheelchair seating for frail older adults. Journal of Gerontological Nursing, 26, 24-32. 37 Krasilovsky, G. (1993). Seating assessment and management in a nursing home population. Physical and Occupational Therapy in Geriatrics, 11(2), 25‒38. (https://www.tandfonline.com/doi/abs/10.1080/J148v11n02_03) 38 Trefler, E., Fitzgerald, S., Hobson, D., Bursick, T., & Joseph, R. (2004). Outcomes of wheelchair systems intervention with residents of long term care facilities. Assistive Technology, 16, 18-27. 39 Huntingtonʼs Disease Society of America. (2010). Physical and Occupational Therapy: Family guide series. (http://hdsa.org/wp-content/uploads /2015/03/PhysicalOccupationalTherapy_FamilyGuide.pdf) W H E E LC H A IR SE RV IC E T R A IN IN G PA C K A G E IN T ER M ED IA T E LEV EL 31 32 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision Fr ai l Frail people are likely to become tired easily, are usually less physically active and weaker than previously and may walk very slowly (33). Older adults are at a higher risk of being frail (34, 30, 31,). Often elderly people who are frail are given very basic wheelchairs without good postural support that do not meet their needs (32, 33). However, providing an appropriate wheelchair with good postural support for frail people and elderly people who are frail can have a very positive impact on the person’s quality of life (37, 34, 35). r get tired quickly; r have limited strength to self-propel; r may !nd it dif!cult to maintain an upright posture due to fatigue and general weakness; r may be at risk of developing a pressure sore due to: – thin/papery skin, which bruises easily; – slow healing time for bruises/sores; – if very weak, may be unable to reposition independently. r Assess the amount of postural support needed carefully – considering that the longer the wheelchair user sits in the wheelchair the more tired he/she is likely to become, and the more the support that may be required. r Wheelchair features that may be useful include: – armrests – provide additional postural support and assist with pushing up for transfers; – footrests that swing out of the way to facilitate standing transfers for those that are able to stand; – push handles to enable other people to assist with pushing; – a lightweight wheelchair, which will require less energy for the wheelchair user to push himself/ herself. For more information on: r How can pressure sores be prevented? – see the Wheelchair Service Training Package – Basic Level Reference Manual. 33 Fried, L., et al. (2001). Frailty in older adults: Evidence for a phenotype. Journal of Gerontology, 56, 146–156 34 Bortz, W. (2002). A conceptual fram work of frailty: A review. Journal of Gerontology, 57A(5), M283–M288. 35 Lang, P., Michel, J. P., & Zekry, D. (2009). Frailty syndrome: A transitional state in dynamic process. Gerontology, 55, 539–549. 36 Rader, J., Jones, D., & Miller, L. (2000). The importance of individualized wheelchair seating for frail older adults. Journal of Gerontological Nursing, 26, 24–32. 37 Krasilovsky, G. (1993). Seating assessment and management in a nursing home population. Physical and Occupational Therapy in Geriatrics, 11(2), 25–38. 38 Tre!er, E., Fitzgerald, S., Hobson, D., Bursick, T., & Joseph, R. (2004). Outcomes of wheelchair systems intervention with residents of long term care facilities. Assistive Technology, 16, 18–27. 39 Huntington’s Disease Society of America. (2010). Physical and Occupational Therapy: Family guide series. Retrieved from http://www.hdsa.org/images/ content/1/1/11697.pdf 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 33 概要 ⾞椅⼦供与における留意事項 筋 攣 縮﹇ き ん れ ん し M く ﹈/ 制 御 で き な い 運 動 突然の、制御できない運動の問題を抱える⼈ もいる。これは筋攣縮と呼ばれる。 筋攣縮を誘発する要因は、以下のようにさま ざまである： • 股関節、膝、⾜⾸の位置。 • 接触。 • ⾞椅⼦の動き、特に荒れた/凸凹の地⾯で。 • 制御できない運動が⾞椅⼦ユーザーにどう影響しているか、およびそれについて解決すべき問 題を⾒出す。 • ⾞椅⼦の⽀えや調節には、筋攣縮や制御不能な動きを減らす役に⽴つものがある。例えば： o ⾻盤姿勢をコントロールできるように⽀える。 o ⾞椅⼦の座⾯〜背もたれ⾓度を調節し、⾞椅⼦ユーザーが股関節をニュートラルよりわずか に屈曲させて座るようにする。 o ⾜台を、膝をニュートラルよりわずかに屈曲させ、⾜を「引き込める」位置にする。 o ⾜台⾓度を変えてみる。 • ベルトは、⾞椅⼦ユーザーの、脚や⾜のコントロールをよくする。ベルトを使う場合は⾯ファス ナー留めにし、⾞椅⼦ユーザーが⾞椅⼦から転落したら外れるようにする。 • 動きが⾮常に激しい場合は、以下を考慮せよ： o ソリッドな座⾯および背もたれの⽀え。 o 駆動輪位置が調節可能な⾞椅⼦を選択する。駆動輪を「安全」な位置に置くと、⾞椅⼦がより 安定し転倒しにくくなる。 o 転倒防⽌装置を備え、⾞椅⼦の後ろへの転倒を⽌める。 o こうした理由から、フィッティングの最後には⾞椅⼦ユーザーが⾞椅⼦をこぎ、筋攣縮を誘 発しないかどうか確かめることが⾮常に重要。 W H E E LC H A IR SE RV IC E T R A IN IN G PA C K A G E IN T ER M ED IA T E LEV EL 33 34 General information Considerations for wheelchair provision Sp as m s/ un co nt ro lle d m ov em en ts Some people have problems with sudden uncontrolled movements. These can be called spasms. Spasms can be triggered in different ways including: r the position of the person’s hip, knee and ankle; r touch; r movement of the wheelchair, particularly over rough/bumpy ground. r Find out how the uncontrolled movements affect the wheelchair user and problem solve with them. r Some supports or adjustments to the wheelchair may help to reduce spasms and uncontrolled movements including: – supporting to help control the posture of the pelvis; – adjusting the wheelchair seat to backrest angle so that the wheelchair user sits with their hips bent slightly more than neutral; – positioning the footrests so that the knees are bent slightly more than neutral, ‘tucking’ the feet in; – trying different angles of footrests. r Straps may help give a wheelchair user more control over their legs and feet. If a strap is used, it should fasten with Velcro so that it will release if the wheelchair user falls out of the wheelchair. r If the movements are very strong, consider: – a solid seat and backrest support; – selecting a wheelchair with an adjustable rear wheels position. The rear wheels can be positioned in the ‘safe’ position to make the wheelchair more stable/less tippy; – providing an anti-tip bar to stop the wheelchair from tipping over backwards. – This is why it is very important for a wheelchair user to propel the wheelchair at the end of a !tting, to see whether any spasms are triggered. 34 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 ⾼ い/ 低 い 筋 緊 張 筋緊張とは、静⽌した筋⾁を動かす時に⽣じ る抵抗/緊張を指す(40)。 正常な筋緊張は、⼿⾜や関節を⾃由かつ容易 に動かせるようにする。しかし、筋緊張が⾼す ぎる、あるいは低すぎる⼈もいる。 ⾼い筋緊張：抵抗/緊張がより強いことで、従 って⼿⾜や関節を動かすのが難しい(41)。筋緊 張が⾼い⼈は、ふつう障害を受けた⼿⾜や関 節を動かすのを難しく/ぎこちなく、動きを鈍 く感じる。筋緊張が⾼い⼈には、ある「固定し た」パターンの動きしかできない⼈もいる(42)。 筋緊張がたいへん⾼いと、ほとんどの動きが 不可能である。 （次⾴へ続く） 筋緊張から⽣じる困難の程度は、その問題 がどれくらい重度で、どの筋⾁が障害を受 けたかによる。筋緊張に問題がある⾞椅⼦ ユーザーに起こる困難の例： • バランスの低下(42)。 • ⼼地よくまっすぐに座るのが困難(43)。 • 筋コントロールの低下(43)。これは⾞椅 ⼦ユーザーが、⾞椅⼦をこぐ、移乗する などのさまざまな課題を、どれだけ容 易にやりこなせるかに影響する。 （次⾴へ続く） 筋緊張が⾼い、あるいは低い⾞椅⼦ユーザー［の⾝ 体］に触れ、または移動を⼿伝う際に役⽴つコツ： • 何をしようとしているのか、やる前に説明する (42)。 • ゆっくりと動かし、筋緊張が⾼い、あるいは低い ⾞椅⼦ユーザーが反応できるだけの時間を与え る。 • ⾞椅⼦ユーザーがじゅうぶん⽀えられるよう、⼿ や腕でしっかりした快適な⽀えを供する。 • 著しく⾼い筋緊張によって⾝体や四肢全体が伸張 した場合、緊張は関節を屈曲すると緩和すること がある。例えば脚全体が伸びている時、膝や股関 節を屈曲すると緊張が抑制される。 （次⾴へ続く） 40 Martin, K., Kaltenmark, T., Lewallen, A., Smith, C., & Yoshida, A. (2007). Clinical characteristics of hypotonia: A survey of pediatric physical and occupational therapists. Pediatric Physical Therapy, 19, 217-226. 41 World Health Organization. (1993). Promoting the development of young children with cerebral palsy. (https://apps.who.int/iris/handle/10665/62696) 42 World Health Organization, United States Department of Defense, Drucker Brain Injury Center MossRhab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. (https://apps.who.int/iris/handle/10665/69231) 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 35 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 ⾼ い/ 低 い 筋 緊 張︵ 続 き ︶ 低い筋緊張：抵抗がより少ないことで、従って ⼿⾜や関節の受動的な動きはやりやすい(41)。し かし、筋緊張が低い⼈は動き出すのを難しく、 また動きをコントロールするのを難しく感じ ることもある。低い筋緊張を「虚弱」「弛緩」と 表現することもある(41)。筋緊張がたいへん低い と、動くのが⾮常に困難になることがある。 筋緊張の問題を抱えるのはどんな⼈？：筋緊張 にまつわる問題が、難題となる⾞椅⼦ユーザー もいる。脳性⿇痺(42)、脳損傷(43)、脊髄損傷(39)、 脳⾎管障害(40)を抱える⼈に、よく起こる問題で ある。 ［訳註： (44)(45)(46)は原著本⽂に脚注番号なし］ • 筋緊張が相当に⾼い、あるいは低い と、⾷べ、飲み、飲み込み、呼吸する のに⽀障をきたしうる(41)。誤嚥（⾷べ 物や液体の⼀部の吸⼊）は⽣命に関わ る問題である(43)。 • ニュートラルでないまま固まった姿 勢になる危険が増す(42)。 ⾞椅⼦ユーザーによっては、感情が⾼ぶ り、あるいは⼀⽣懸命何かをやろうとす ると、筋緊張が著しく⾼まる(42, 43)。 ⾼い、あるいは低い筋緊張は、股関節脱 ⾅(42)の危険因⼦である。 姿勢⽀持の必要量は、⾞椅⼦ユーザーへの事前評価 による。しかし、筋緊張の⾼い⾞椅⼦ユーザーへ特に 配慮することとして： • 姿勢⽀持部は、⾼い筋緊張に対して効果的である よう、じゅうぶん頑丈につくること。 • ⾼い筋緊張は、ユーザーの⾝体と⾞椅⼦の間に、 ⾼い圧⼒がかかる点を⽣じる。広い⾯積に⼒を分 散させて、これを緩和せよ。圧⼒を検査せよ。⾞椅 ⼦ユーザーやその家族/介助者には、圧迫痕がない か⽪膚を調べるよう指導せよ。 • ⼤腿〜体幹の⾓度を⼩さくすると、強い過緊張パ ターンの抑制に役⽴つ。 43 World Health Organization. (1996). Promoting independence following a spinal cord injury: A manual for midlevel rehabilitation workers. (https://apps.who.int/iris/handle/10665/63599) 44 American Heart and Stroke Association. (n.d.). Spasticity. (https://www.stroke.org/en/about-stroke/effects-of-stroke/physical-effects-of-stroke/p hysical-impact/spasticity) 45 Redstone, F., & West, J. (2004). The importance of postural control for feeding. Pediatric Nursing, 30, 97-100. 46 Driscoll, S., & Skinner, J. (2008). Musculoskeletal complications of neuromuscular disease in children. Physical Medicine and Rehabilitation Clinics of North America, 19, 163-194. 36 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 下 肢 切 断 下肢切断は外傷、例 えば交通事故、労働 災害、戦傷の結果起 こる(47, 48, 49)。 その他の状況では、 計画的な外科⼿術 として、下肢切断が ⾏なわれる場合も ある。糖尿病の合併 症により、⽚脚または両脚を切断する⼈は 増えている(50, 51, 52)。 ⽚脚または両脚を切断した多くの⼈は、義 肢および/または歩⾏器を使って歩き続け られる(48, 49)。しかし⼀時的あるいは常時、 ⾞椅⼦が必要となる⼈もいる(48, 49, 50)。 • ⽀援を受け、よい⾞椅⼦の移動技能 を学べれば、⾞椅⼦に乗ってたいへ ん活動的に過ごせる。 • 椅⼦部分の前⽅にかかる体重が少な いため、⾞椅⼦のバランスは変わっ てくる。 • 糖尿病を患って下肢切断した⼈は、 切り傷や打撲からの⽪膚の治りが良 くないため、褥瘡発⽣の危険が⾼い (49)。 ［訳註： (53)は原著本⽂に脚注番号なし］ • 下肢切断者へ初めての⾞椅⼦を設定する際は、駆動輪を （調整が利けば）最も後位置に取り付け、⾞椅⼦の後⽅ 転倒の可能性を減らす。活動的ユーザーはバランスの取 り⽅をすぐに学ぶので、そこで駆動輪を前に移す。 • 移動技能を教える時は、 o 下肢切断した⼈が⾞椅⼦を初めて試す時には、つねに 気を付けよ。 o 後⽅転倒する可能性が⾼い⾞椅⼦ユーザーなので、移 動技能はていねいに教えよ。 • ⾞椅⼦ユーザーが、⾞椅⼦に乗る際に義⾜の装着を希望 するかどうか知っておくことが、それによって⾞椅⼦の フィッティングも変わるので重要。 参照： • 褥瘡はどうやったら防げるか？：基礎⾞椅⼦サービス教 習パッケージ受講者⽤参考書を参照。 47 Burger, H., Marincek, C., & Isakov, E. (1997). Mobility of persons after traumatic lower limb amputation. Disability and Rehabilitation, 19(7), 272-277. 48 Narang, I., Mathur, P., Singh, P., & Jape,V. (1984). Functional capabilities of lower limb amputees. Prosthetic and Orthotics International, 8, 43-51. 49 World Health Organization, United States Department of Defence, Moss Rehab Amputee Rehabilitation Program Moss Rehab Hospital. (2004). The rehabilitation of people with amputations. (https://www.researchgate.net/publication/265907887_Rehabilitation_of_People_with_Lower-Limb_ Amputations) 50 World Health Organization. (2005). World diabetes day: Too many people are losing lower limbs unnecessary to diabetes. (https://apps.who.int /mediacentre/news/releases/2005/pr61/en/index.html) 51 Pecoraro, R., Reiber, G., & Burgerss, E. (1990). Pathways to diabetic limb amputation: Basis for prevention. Diabetes Care, 13(5), 513‒521. 52 Trautner, C., Haastert, B., Giani, G., & Berger, M. (1996). Incidence of lower limb amputations and diabetes. Diabetes Care, 19(9), 1006‒1009. 53 World Health Organization. (2010). Wound and lymphoedema management. (https://apps.who.int/iris/handle/10665/44279) W H E E LC H A IR SE R V IC E T R A IN IN G PA C K A G E IN T ER M ED IA T E LEV EL 35 36 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision L ow er L im b A m pu ta ti on Lower limb amputation may happen as a result of trauma, e.g. road traf!c accident, work injury or war injury (47, 48, 49). In other situations, lower limb amputation may be a planned surgical procedure. An increasing number of people have a unilateral or bilateral lower limb amputation as a secondary issue associated with diabetes (50, 51, 52). Many people who have had one or both limbs amputated will be able to continue to walk with the use of prosthetics and/or walking aids (48, 49). However, some people may need a wheelchair for some time or all the time (48, 49, 50). r can be very active in a wheelchair if they are provided with the help to learn good wheelchair mobility skills; r the wheelchair balance changes as there is less weight at the front of the chair; r amputees who have diabetes may be at a greater risk of developing pressure sores as their skin may not heal well from cuts or knocks (49). r When setting up a wheelchair for the !rst time for a person with an amputation, set the rear wheels in the furthest back position (if adjustable) to reduce the chance of the wheelchair tipping backwards. Active users may quickly learn to balance the wheelchair, and then move the rear wheels forward. r When teaching mobility skills: – always be careful when an amputee !rst tries a wheelchair; – teach mobility skills carefully as there is a greater chance that the wheelchair user will tip backwards. r It is important to know whether the wheelchair user would prefer to wear their prosthetic limb(s) when using the wheelchair, as this may change the !t of the wheelchair. For more information on: r How can pressure sores be prevented? – see the Wheelchair Service Training P ckage – Basic Level Reference Manual. 47 Burger, H., Marincek, C., & Isakov, E. (1997). Mobility of persons after traumatic lower limb mputation. Disability and Rehabilitation, 19(7), 272–277. 48 Narang, I., Mathu , P., Singh, P., & Jape, V. (1984). Functional capacities of lower limb amputees. Prosthetics and Orthotics International, 8, 43–51. 49 World Health Organization, United State Department of Defence, Moss R hab Amputee Rehabilitation Pr gram Moss Rehab Hospital. (2004). The rehabilitation of people with amputations. Retrieved from http://www.posna.org/news/Amputations.pdf 50 World Health Organization. (2005). World diabetes day: Too many people are losing lower limbs unnecessary to diabetes. Retrieved from http://www.who.int/ mediacentre/news/releases/2005/pr61/en/ 51 Pecorro, R., Reiber, G., & Burgerss, E. (1990). Pathways to diabetic limb amputation: Basis for prevention. Diabetes Care, 13(5), 513–521. 52 Trautner, C., Haastert, B., Giani, G., & Berger, M. (1996). Incidence of lower limb amputations and diabetes. Diabetes Care, 19(9), 1006–1009. 53 World Health Organization. (2010). Wound and lymphoedema management. Retrieved from http://whqlibdoc.who.int/publications/2010/9789241599139_eng.pdf 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 37 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 疲 労 ⾞椅⼦ユーザーには、１⽇の間に、決ま ってくたびれてしまう⼈もいる。これ は、まっすぐに座って活動をやり遂げる ことに労⼒やエネルギーを余分に費や すため、あるいは疾患の性質によるもの である。 ⾼齢者および進⾏性疾患を患う⼈には、 疲労が問題となることがある(54, 55)。 • まっすぐに座れても、疲労するため、⻑ 時間まっすぐな姿勢を保てない。 • 疲労のためにまっすぐな姿勢を保つのが 難しい⾞椅⼦ユーザーには、姿勢の問題 が起こる危険が⼤きくなる。 • ⾞椅⼦ユーザーのくたびれる原因を⾒出すよう努め よ。これは最良の解決策を⾒つけるのに役⽴つ。 • 設ける姿勢⽀持の量を決める時は、疲労の影響を考慮 せよ。⾞椅⼦事前評価の間は、⾞椅⼦ユーザーにまだ エネルギーがあり、あまり⽀えを必要としないように ⾒えるかもしれない。いちばんくたびれた時にどれだ け⽀える必要があるのか、⾞椅⼦ユーザーとじっくり 話し合うこと。 • 代わりの休息姿勢を検討せよ。例えば、クッションの 効いたテーブルがあれば、前へ腕を突いてもたれかか れる⼈もいる。他の休息体位として、ティルトインス ペース［背座のティルト］を選べる。 • ⼀⽇の間に、計画的に⾞椅⼦を降りて休憩すると、よ り⻑時間、快適に座れる。 54 World Health Organization. (2008). Atlas: Multiple sclerosis resources in the world. (https://apps.who.int/iris/handle/10665/43968) 55 Parkinsonʼs Disease Foundation. (n.d.). Fatigue. (https://www.parkinson.org/Understanding-Parkinsons/Symptoms/Non-Movement- Symptoms/Fatigue) 38 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与における留意事項 股 関 節 脱 ⾅ 股関節脱⾅は、⾃⼒で歩けたことがない⼦どもに⾼い割合で⾒ られる(56, 57, 58)。これは、⾻盤の［⼤腿⾻頭を受ける］くぼみ （寛⾻⾅）は、⼦どもの出⽣時には軟らかく、脚が動いている 時、あるいは⽴っている時にそこへ体重がかかることで、球形 の⼤腿⾻頭がそこへ押し付けられてくぼみを形成するからで ある。股関節が適切に形成されない場合、それは脱⾅の原因と なる。 股関節脱⾅は、股関節や⾻盤周りの筋⾁が硬直して緊張が⾼ く、座ったり寝そべったりすると両脚がつねに左右⽚⽅に倒れ る傾向がある⼦どもにも、たいへんよく⾒られる(59)。これは脳 性⿇痺(57, 60)や脳損傷(60)がある⼈では問題となる。 （次⾴へ続く） • 股関節が脱⾅/亜脱⾅を起こしている⼈に⾒られる徴候： o ⽚脚がもう⽚⽅より短く⾒える(60)。 o 脚の位置が、つねに⾝体の正中線に寄っている。 o 股関節を動かすと痛みがある(60)。 o 股関節可動域が、⼤腿をニュートラルな位置や⾝体の外側へ運べない。 o 股関節を完全に伸ばせない。 • 研究によれば、次のことは股関節脱⾅の傾向を抑える： o 早いうちから、座り、寝そべる際にはニュートラルな姿勢で⽀える。⼩さい ⼦どもの場合、これは股関節/⼤腿を外転させて⽀えることも含む(61, 62)。 o ニュートラルな姿勢で（例えば⽴位台に）⽴つ(63)。 （次⾴へ続く） 56 Soo, B., et al. (2006). Hip displacement in cerebral palsy. The Journal of Bone and Joint Surgery, 88, 121-129. 57 Scrutton, D., Baird, G., & Smeeton, N. (2001). Hip dysplasia in bilateral cerebral palsy: incidence and natural history in children aged 18 months to 5 years. Developmental Medicine and Child Neurology, 43, 486-600. 58 Lonstein, J., & Beck, K. (1986). Hip dislocation and subluxation in cerebral palsy. Journal of Pediatric Orthopaedics, 6, 521-526. 59 Childrenʼs Hospital Boston. (n.d.). A guidebook for hip surgery in children with cerebral palsy. (https://www.childrenshospital.org/-/media/Centers- and-Services/Programs/A_E/Cerebral-Palsy-Program/CPLEBookweb2) 60 World Health Organization, United States Department of Defense, Drucker Brain Injury Center MossRhab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. (http://whqlibdoc.who.int/hq/2004/WHO_DAR_01.9_eng.pdf) 61 Pountney,T., Mandy,A., Green, E., & Gard, P. (2009). Hip subluxation and dislocation in cerebral palsy ‒ a prospective study on the effectiveness of postural management programmes. Physiotherapy Research International, 14(2), 116-127. 62 Health Centre for Children. (2011). Evidence for practice: Surveillance and management of hip displacement and dislocation in children with neuromotor disorders including cerebral palsy. Vancouver, BC: Tanja Mayson. (http://www.r82.com/media/411811/surveillance_and_management _of_hip_displacement_and_dislocation_in_children_with_cp.pdf) 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 39 概要 ⾞椅⼦供与における留意事項 股 関 節 脱 ⾅︵ 続 き ︶ 歩いたことがなく、また寝そべると両脚が左右⽚⽅に倒れる （ウィンドスウェプト）傾向があるか、股関節が⾝体の正中線 寄りに閉じ（内転し）て内側に巻き込んで（内旋して）いる⼦ どもが、最も脱⾅しやすい(63)。 股関節周りの筋緊張が低い⼦どもの場合も、やはり股関節脱⾅ の危険がある。これは、筋⾁や腱の強さがじゅうぶんでなく、 股関節の⼆つの部分（寛⾻⾅と⼤腿⾻頭）をつなぎ留めておけ ないためである。脱⾅した股関節が、つねに痛みを伴うとは限 らない(64, 65, 66)。 • 事前評価する⼦ども、あるいは⼤⼈に股関節脱⾅の可能性を⽰す徴候が少し でもあれば、股関節は優しく動かし、痛みを引き起こさないようにせよ。 • ⼦どもや⼤⼈に股関節脱⾅があるかどうか分からなければ、（可能ならば）医 師/⼩児科医、経験豊かな理学療法⼠へ紹介・相談して指導を求めよ。 • 股関節脱⾅がある、あるいは股関節脱⾅の疑いがある⼦どもや⼤⼈へ、⾞椅 ⼦や姿勢⽀持を供与する際には： o 痛みを引き起こす姿勢を避けよ。 o ⾻盤と体幹をニュートラルに（なるべくニュートラルに近づけて）⽀え、そ れから股関節と⼤腿をなるべくニュートラルに近づけて⽀えよ。脚の姿勢 の「矯正しすぎ」は、⾻盤が動いてニュートラルから逸脱し、かつ/または 痛みを引き起こすので避けよ。 o 本⼈が眠っている時の姿勢を確かめよ。両脚がウィンドスウェプトになっ た、または互いに固く閉じた姿勢で眠るのは避けるよう指導せよ。 63 Pope, P. (2007). Severe and complex neurological disability: Management of the physical condition. Philadelphia: Elsevier Limited. (https://ww w.sciencedirect.com/book/9780750688253/severe-and-complex-neurological-disability) 64 Sherk, H., Pasquariello, P., & Doherty, J. (2008). Hip dislocation in cerebral palsy: Selection for treatment. Developmental Medicine and Child Neurology, 25(6), 738-746. 65 Moreau, M. et al. (1979). Natural history of the dislocated hip in spastic cerebral palsy. Developmental Medicine and Child Neurology, 21(6), 749-753. 66 Knapp, R., & Cortes, H. (2002). Untreated hip dislocation in cerebral palsy. Journal of Pediatric Orthopaedics, 22, 668-671. 40 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 て ん か ん てんかんとは、脳の正常な活動が阻害さ れて発作に⾄ることである(67, 68, 69, 70)。 発作は、状況しだいではだれにでも起き うるものだ(70)。「てんかん」の語は、誘発 されないでくり返し起こる発作に対して のみ⽤いる (69, 70)。 （次⾴へ続く） ⾞椅⼦ユーザーが、事前評価の最中に発作を起こした場合に やるべきこと： ⾞椅⼦ユーザーの発作が軽い場合は、鎮まるのを待ってから 事前評価を続ける。 ⾞椅⼦ユーザーの発作が激しい場合、最優先事項は、本⼈を ケガから護ることである(71)。⾞椅⼦ユーザーが前へ転倒し た場合は、その転倒が軽くなるようにせよ。⾞椅⼦ユーザー が⼦どもや⼩柄な⼤⼈の場合は、安全に抱えて床へ下ろすこ とが可能。⼤柄な⼤⼈の場合は、（介助者がケガをする危険 があるため）⾞椅⼦ユーザーをその場に留める必要があり、 発作が収まってから同僚/家族または介助者に⼿伝ってもら い、徐々に抱え上げる。 （次⾴へ続く） てんかんがある⼈へ、⾞椅⼦を供与す る際の留意事項： • ⾞椅⼦ユーザーには、⾞椅⼦から抜 け出せるよう、簡単に外せるベルト が必要。 （次⾴へ続く） 67 McNamara, J. (1994). Cellular and molecular basis of epilepsy. The Journal of Neuroschience, 14(6), 3413-3425. 68 World Health Organization. (2005). Atlas: Epilepsy care in the world. (https://apps.who.int/iris/handle/10665/43298) 69 World Health Organization. (2002). Epilepsy: A manual for medical and clinical officers in Africa. (https://apps.who.int/iris/handle/10665/67453) 70 World Health Organization. (2006). Neurological disorders: Public health challenges. (https://www.who.int/publications/i/item/9789241563369) 71 Epilepsy Foundation. (n.d.). First aid. (https://www.epilepsy.com/living-epilepsy/seizure-first-aid-and-safety) W H E E LC H A IR SE RV IC E T R A IN IN G PA C K A G E IN T ER M ED IAT E LEV EL 39 40 General information Common characteristics that may affect wheelchair provision Considerations for wheelchair provision E pi le ps y Epilepsy is a disruption of the normal activity of the brain that results in seizures (67, 68, 69, 70). Under certain circumstances anyone can have a seizure (70). The term epilepsy is used only for recurrent, unprovoked seizures (69, 70). (continued on the next page) What to do if a wheelchair user has a seizure during a wheelchair assessment: When a wheelchair user has a minor seizure, wait for it to be over and then continue with the assessment. If a wheelchair user has a major seizure the !rst priority is to protect him/ her from injury (71). If the wheelchair user falls forward, try to ease the fall. If the wheelchair user is a child or a small adult, it may be possible to safely lift them onto the "oor. If He/she is a large adult, it will be necessary for the wheelchair user to remain where he/ she is (due to potential risk of injury to those assisting) and once the seizure stops, gradually lift him/her with the help of co-workers/family members or caregivers. (continued on the next page) When providing a wheelchair for a person who has epilepsy remember: r the wheelchair user will need straps that can be undone easily to help them out of the wheelchair; (continued on the next page) 67 McNamara, J. (1994). Cellular and molecular basis of epilepsy. The Journal of Neuroscience, 14(6), 3413–3425. 68 World Health Organization. (2005). Atlas: Epilepsy care in the world. Retrieved from http://www.who.int/mental_health/neurology/Epilepsy_atlas_r1.pdf 69 World Health Organization. (2002). Epilepsy: A manula for medical and clinical of!cers in Africa. Retrieved from http://www.who.int/mental_health/media/en/639.pdf 70 World Health Organization. (2006). Neurological disorders: Public health challenges. Retrieved from http://www.who.int/mental_health/neurology/chapter_3_a_neuro_ disorders_public_h_challenges.pdf 71 Epilepsy Foundation. (n.d.). First aid. Retrieved from http:// w.epilepsyfoundation.org/aboutepilepsy/!rstaid/index.cfm 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 41 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 て ん か ん︵ 続 き ︶ ⾞椅⼦ユーザーには、てんかんを持つ⼈ もいる。発作は、部分発作か全般発作にな る(70)。部分発作では、本⼈の意識は障害 を受ける場合と障害を受けない場合とが ある(70)。意識が障害を受けない場合、発 作は１分も続かず、本⼈は通常、制御不能 な動きに襲われる(72)。意識が障害を受け る場合、発作は１〜２分続き、本⼈には何 が起きているのか、かすかには分かって いるが、反応したり動作を変えたりはで きない(70, 73)。全般発作では、本⼈は完全 に意識を失う(70)。全般発作に襲われると、 突然失神してケガをすることもある(70)。 発作の間は： • ⾞椅⼦ユーザーを⾞椅⼦から降ろそうとしてはならない、 ただし⼝の中に⾷べ物や⽔、嘔吐物がない限り。ある場合 は⾞椅⼦ユーザーを⾞椅⼦から降ろして横向きに寝かせ、 唾や粘液が⼝から流れ出るようにする(70, 73)。 • ⾞椅⼦ユーザーの周りに空間を設けてケガを防ぐか、危害 を及ぼしそうなものから遠ざけるよう動かす(70)。 • ⾞椅⼦ユーザーの頭部を、下に柔らかい緩衝材を敷いて保 護する(70, 73)。 • きつい⾐服はゆるめ、危害を及ぼしそうなあらゆるものを 遠ざけ、⾞椅⼦がしっかり固定されていることを確かめる (70, 73)。 • 発作の持続時間を計り、発作の後、その情報を⾞椅⼦ユー ザーか介助者へ伝える(70)。 発作が収まるまで、落ち着いて待つ。以下の場合は医療的対 応を求める： • 発作が終わっても、⾞椅⼦ユーザーの意識が戻らない(69)。 • 発作が５分以上続く(74)。 • ⾞椅⼦ユーザーがひんぱんに発作を 起こし、突然前へ倒れる場合は、（使 ⽤していれば）テーブルに緩衝材を 敷き、頭部をケガしないようにせよ。 • てんかんのある⾞椅⼦ユーザーが治 療を受けていない場合は、医師へ紹 介・相談せよ。 72 Epilepsy Australia. (2009). Seizure first aid. (http://www.epilepsyaustralia.net/seizure-first-aid/) 73 Epilepsy Canada. (n.d.). Retrieved from http://old.epilepsycanada.test.glacier-digital.com/scans/brochure/seizuresFirstAid.html 74 Epilepsy Canada. (n.d.). Retrieved from http://www.epilepsy.ca/en-CA/Diagnosis-and-Treatment/First-Aid.html 42 受 講 者 ⽤ 参 考 書 受講者⽤参考書 受講者⽤参考書 受講者⽤参考書 受 講 者 ⽤ 参 考 書 概要 ⾞椅⼦供与における留意事項 ⾷ べ る ・ 飲 む ・ 飲 み 込 み の 障 害 ⼦どもや⼤⼈で、⾷べ、飲み、飲み込むのが困難な⼈もいる。 ⾷べたり飲んだりの困難は、⾷べ物や飲み物を⼝へ運ぶことに問題があっ て起きることもある。例えば、⾞椅⼦ユーザーが腕や⼿のコントロールに 困難があると、⾷べたり飲んだりを簡単にはこなせない。 そうでなければ、頭、⾸、⼝の周りや飲み込みを制御する筋⾁の問題から、 困難が⽣じる場合もある(75)。バランスが悪くてまっすぐに座るのが難しく、 頭を起こしバランスの取れた位置に保つのが難しいと、問題は悪化する(76)。 飲み込みに問題があると、⾷べ物や飲み物が肺へ⼊ってしまうことがある。これは肺感染を引き起こ し(77, 78, 79, 80, 81)、そのため危篤状態に陥ることもある(82)。 飲み込みに問題がある場合の徴候の例： • 飲み物を飲む時によく咳き込む(83)。 • ⾷べたり飲んだりする時、よくむせる(84)。 • よだれが⽌まらない。 ⾷べ、飲み、飲み込むことに問題がある⼈ へ、⾞椅⼦を供与する際の留意事項： • 適切な姿勢⽀持は、バランス、姿勢、頭 や⼿のコントロールを改善し、⾷べ、飲 み、飲み込む際の問題を低減する。 • テーブルおよび/またはヘッドレスト が必要になることが多い。 飲み込みに問題のある⾞椅⼦ユーザーが 対処されていない場合は、⽀援できる⼈へ その⼈を紹介・相談せよ。例えば⼩児科医、 ⾔語療法⼠、作業療法⼠、経験豊富な児童 保健ワーカーなど。 75 Logemann, J., & Bytell, D. (1979). Swallowing disorders in three types of head and neck surgical patients. Cancer, 44, 1075-1105. 76 Redstone, F., & West, J. (2004).The importance of postural control for feeding. Pediatric Nursing, 30(2), 97-100. 77 Teasell, R., Mcrae, M., Marchuk,Y., & Finestone, H. (1996). Pneumonia associated with aspiration following stroke. Arch Phys Med Rehab, 77, 77-709. 78 Loughlin, G. (1989). Respiratory consequences of dysfunctional swallowing and aspiration. Dysphagia, 3, 126‒130. 79 World Health Organzation, United States Department of Defense, Drucker Brain Injury Center MossRhab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. (http://whqlibdoc.who.int/hq/2004/WHO_DAR_01.9_eng.pdf) 80 Schmidt, J., Holas, M., Halvorson, K., & Reding, M. (1994). Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia, 9, 7‒11. 81 Perry, L., & Love, C. (2001). Screening for dysphagia and aspiration in acute stroke: A systematic review. Dysphagia, 16, 7‒18. 82 https://www.who.int/en/news-room/fact-sheets/detail/pneumonia 83 Prasse, J. & Kikano, G. (2009). An overview of pediatric dysphagia. Clinical Pediatrics, 48(3), 247-251. 84 [訳註] 原著では, この脚注番号に対して出典は⽰されていない. W H E E LC H A IR SE RV IC E T R A IN IN G PA C K A G E IN T ER M ED IAT E LEV EL 41 42 General information Considerations for wheelchair provision P ro bl em s w it h ea ti ng , d ri nk in g an d sw al lo w in g Some children and adults may have dif!culties with eating, drinking and swallowing. Dif!culties with eating and drinking may be caused by problems taking the food or drink to their mouth. For example, if wheelchair users have dif!culty controlling their arms or hands they cannot easily manage eating or drinking. Alternatively, the dif!culty may be caused by problems with the muscles around the head, neck, mouth as well as those, which control swallowing (75). Poor balance, dif!culty sitting upright and dif!culty maintaining an upright and balanced position of the head can make this worse (76). Swallowing problems can cause food or drink to go into the lungs. This can potentially lead to chest infections (77, 78, 79, 80, 81), which can make the person dangerously ill (82). Signs that a person has problems with swallowing include: r often coughing when drinking (83); r often choking when eating r drinking (84); r constant drooling. When providing a wheelchair for a person who has problems with eating, drinking and swallowing remember: r good postural support can improve balance, posture, head and hand control and reduce problems with eating, drinking and swallowing; r a tray and/or a headrest are often needed. If a wheelchair user has problems with swallowing that are not being addressed, refer the wheelchair user to someone who can help. For example, a paediatrician, speech language therapist, occupational therapist or experienced child health worker. 75 Logemann, J., & Bytell, D. (1979). Swallowing disorders in three types of head and neck surgical patients. Cancer, 44, 1075–1105. 76 Redstone, F., & West, J. (2004). The importance of postural control for feeding. Pediatric Nursing, 30(2), 97–100. 77 Teasell, R., Mcrae, M., Marchuk, Y., & Finestone, H. (1996). Pneumonia associated with aspiration following stroke. Arch Phys Med Rehab, 77, 77–709. 78 Loughlin, G. (1989). Respiratory consequences of dysfunctional swallowing and aspiration. Dysphagia, 3, 126–130. 79 World Health Organzation, United States Department of Defense, Drucker Brain Injury Center MossRhab Hospital. (2004). Rehabilitation for persons with traumatic brain injury. Retrieved from http://whqlibdoc.who.int/hq/2004/WHO_DAR_01.9_eng.pdf 80 Schmidt, J., Holas, M., Halvorson, K., & Reding, M. (1994). Video!uoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia, 9, 7–11. 81 Perry, L., & Love, C. (2001). Screening for dysphagia and aspiration in acute stroke: A systematic review. Dysphasia, 16, 7–18. 82 http://www.who.int/mediacentre/factsheets/fs331/en/ 83 Prasse, J. & Kikano, G. (2009). An overview of pediatric dysphagia. Clinical Pediatrics, 48(3), 247–251. 中 級 ⾞ 椅 ⼦ サ ー ビ ス 教 習 パ ッ ケ ー ジ 43 概要 ⾞椅⼦供与に影響する⼀般的特徴 ⾞椅⼦供与における留意事項 痛 み • ⾞椅⼦ユーザーが、何か痛みを感 じていないか判ることは、⾮常に 重要だ。痛みは、⾞椅⼦へ快適に座 れるかどうかに影響するからであ る。 • ⾞椅⼦ユーザーに規則的な痛みがある場 合、⾞椅⼦サービス職員は医師/医院へ本⼈ を紹介・相談し、痛みの原因を⾒極めるべき である。痛みを無視すると、危険な場合もあ るからだ。 • ⾞椅⼦事前評価で痛みを引き起こさないために： o 痛みが増す姿勢があるかどうか尋ね、そうした姿勢 は避けること。 o 痛みが軽くなる動作や姿勢があるかどうか尋ね、そ れらの姿勢は、⾞椅⼦事前評価で必ず考慮せよ。 o ⾞椅⼦ユーザーが発話でコミュニケーションを取れ ない場合、⾞椅⼦事前評価を始める前に、他のコミ ュニケーション⽅法を⾒つけよ。 o しっかりした⽀えと体位変換は、痛みを予防または 軽減する。 膀 胱 や 腸 の 障 害 • 膀胱や腸のコントロールが困難な ⾞椅⼦ユーザーもいる。この問題 は、適切な器具（例：カテーテル）、 服薬、膀胱や腸の訓練プログラム によって管理できることが多い。 • ⾃分の地域で指導や訓練を与えら れる⼈（例えば専⾨の医師や看護 師）を⾒定めておくのは、これらの 合併症を避けるうえで重要。 • 膀胱や腸のコントロールに乏しい⾞椅⼦ユ ーザーで、トイレに⾏きたい時のコミュニ ケーションが困難な⼈もいる。そうした⼈ には、膀胱や腸のアクシデントに遭う危険 がある。 • ⾞椅⼦サービス職員は、膀胱や腸の問題が ある⾞椅⼦ユーザーと働く際には、汚れる 可能性を意識しておくべきである。よい⼿ 洗い設備と臨床区域の清掃⼿段が重要。 • 湿ったか汚れたクッションは、⽪膚を破壊 する原因となる。さらに糞便に含まれるバ クテリアが、感染による褥瘡をたちどころ にもたらす。尿や糞便中の⽼廃物は、傷⼝の 感染や⽪膚のただれをもたらす。 • クッションやカバーは、ユーザーや介助者が洗えるよ う簡単に取り外せるものにすること。 • クッションには防⽔カバーを施せ。できればカバーは 2枚供与し、1枚を乾かしながら、⾞椅⼦ユーザーが⽇ 常活動を続けられるようにせよ。 • 防⽔カバーが⼿に⼊らなければ、クッションを 2 枚供 与せよ。 • ⾞椅⼦ユーザーを、健康を保ち事故を避けるため、膀 胱や腸の管理を⽀援できる⼈へ紹介・相談せよ。 44 受講者⽤参考書 ⽣活様式および環境 ⾞椅⼦ユーザーが、どこで⾞椅⼦を使うかの詳細： １⽇の移動距離： 1 km以内□ 1〜5 km□ 5 km超□ １⽇に⾞椅⼦を使う時間数： １未満□ １〜３□ ３〜５□ ５〜８□ ８超□ ⾞椅⼦に座らない時、ユーザーがどこにどう座り、または寝そべるか（姿勢および接触⾯）： 移乗：⾃⼒で□ 介助して□ ⽴って□ ⽴たないで□ 抱え上げて□ その他□ トイレの種類（トイレへ移る場合）： しゃがみ式□ 洋式□ 適合済み1□ ⾞椅⼦ユーザーが公共の/私的な交通機関をひんぱんに使うかどうか： はい□ いいえ□ 「はい」の場合、種類： ⾃動⾞□ タクシー□ バス□ その他□ 中級⾞椅⼦事前評価フォームの「⽣活様式および環境」の箇所では、⾞椅⼦ユーザーがどこで⽣活 しているのか、および⾞椅⼦に乗ってやる必要があることに関する情報を集める。供与する⾞椅⼦ および付加姿勢⽀持が、⾞椅⼦ユーザーの能⼒を最⼤限に引き出すためにどのように役⽴つのか検 討するうえで、その⾝の回りの環境や⽣活様式を考慮することは重要である。 ⽣活様式および環境に関 する中級⾞椅⼦事前評価 フォームでの質問項⽬ 説明 ⾞椅⼦ユーザーが、どこ で⾞椅⼦を使うかの詳細 • ⾞椅⼦は、⾞椅⼦ユーザーの家、職場、学校などで実⽤的であるこ とが必要。例えば： o ⾞椅⼦を家で使う場合、⾞椅⼦ユーザーは家じゅうを楽に移動 でき、重要な⽇常活動を果たせる必要がある。 o 事務所で働く⾞椅⼦ユーザーには、事務所スペースへの収まり がよい⾞椅⼦が必要。 o 学校へ通う⾞椅⼦ユーザーには、教室や机の下へ楽に収まる⾞ 椅⼦が必要で、そうでなければ⾞椅⼦に組み付けたテーブルが 必要。 o 市場や働きに悪路を⾏く必要がある⾞椅⼦ユーザーには、荒れ 地でもうまく使える⾞椅⼦が必要。 1 [原⽂] adapted 中級⾞椅⼦サービス教習パッケージ 45 ⽣活様式および環境に関 する中級⾞椅⼦事前評価 フォームでの質問項⽬ 説明 １⽇の移動距離 • 短距離は歩くが、⻑距離には⾃転⾞を使う⼈と同様に、⾞椅⼦ユー ザーは短距離に⾞椅⼦、⻑距離には 3輪⾞を⽤いてもよい。 • 同じ距離を⾛るには、3輪⾞の⽅が労⼒は少なく、また速い。 １⽇に⾞椅⼦を使う時間 数 • ⾞椅⼦に座る時間が⻑いほど、疲労や褥瘡の危険が増す。⾞椅⼦ユ ーザーに⽀えがどれくらい必要か、またクッションが除圧と快適さ をもたらしているかどうか考慮せよ。 • ⽇中、「活動的」に⾞椅⼦を使う⼈には、⾞椅⼦をこぐなどの活動 を、なるべく効率的にやれるよう設定すべきである。⾞輪位置は重 要。また背もたれが、ユーザーを⽀えながらも肩甲⾻の⾃由な動き を制約していないかの確認も重要である。 ⾞椅⼦に座っていない 時、⾞椅⼦ユーザーがど こにどう座り、または寝 そべるか（姿勢および接 触⾯）？ • ⾞椅⼦ユーザーは⻑時間同じ体位でいると⾝体が硬くなり、ついに はその姿勢のままで固まってしまう。そうなると、⾞椅⼦へ快適に 座ることができなくなる。 • こうした状況を避け、⾞椅⼦に乗っていない時の、座る、寝そべる など快適な姿勢のさまざまな選択肢を⾞椅⼦ユーザーに与えられ ることが⾮常に重要。 • ⾞椅⼦ユーザーはいつも同じ姿勢で座り、寝そべっているのか？ o 可能ならば、その姿勢を取ってもらうようにせよ。 o 好みの姿勢を知っておくことは重要で、それによって「カウンタ ー」（対抗的な）姿勢を提案できる。「カウンター」姿勢を、直ち に取れるとは限らない。⾞椅⼦ユーザーが好みの姿勢に⻑いこ となじんでいた場合、全く反対の姿勢をいきなり取るのは、不快 感や違和感、ともすれば恐怖感が⼤きすぎるかもしれない。 o よりニュートラルで快適な姿勢が取れるような、体幹および四 肢の⽀え⽅を案出せよ。 • ⾞椅⼦ユーザーは、⾃⼒で姿勢を変えられるか？ o ⾞椅⼦ユーザーが姿勢を変えられない場合、姿勢や褥瘡の問題 が起こる危険が⾼い。 46 受講者⽤参考書 ⽣活様式および環境に関 する中級⾞椅⼦事前評価 フォームでの質問項⽬ 説明 移乗 • ひじ掛けと⾜台は、⾞椅⼦ユーザーの、⾞椅⼦を乗り降りするやり ⽅に影響する。 o ⽴ち上がって移乗する場合、動線を塞がない⾜台2およびプッシ ュアップに使えるひじ掛けが役に⽴つ。 o ⽴ち上がらない移乗の場合、着脱できる、あるいは⾞輪のへりに 沿った形状のひじ掛け［またはサイドガード］があると、移乗が 楽になる。 o 付加姿勢⽀持を設ける場合は、⾞椅⼦ユーザーが楽に移乗でき るか確かめよ。例えば、座⾯やクッションにウェッジ（くさび） を付加すると、⾞椅⼦ユーザーの移乗が難しくなることがある。 移乗技法の変更か別の姿勢⽀持具の選択が必要となろう。 トイレの種類 • トイレの種類およびトイレへの物理的アクセスは、⾞椅⼦ユーザー にとっての使いやすさに影響する。 • 設計によっては使えないトイレもある。例えば、ほとんどの⾞椅⼦ ユーザーにとり、しゃがみ式トイレを使うのは⾮常に困難である。 • ⾞椅⼦サービス職員は、トイレやトイレの場所について聞くこと で、トイレ移動の⽅法を助⾔できる場合もある。⾞椅⼦サービス職 員は、トイレを適合させる⽅法を助⾔してもよい。 ⾞椅⼦ユーザーが公共の /私的な交通機関をひん ぱんに使うかどうか • ⾞椅⼦ユーザーが交通機関をひんぱんに利⽤する場合、⾞椅⼦は簡 単に運べる必要がある。⾞椅⼦の輸送が楽になるさまざまな特⾊： o ⾞椅⼦は軽量なほど、持ち上げての乗せ降ろしが楽。 o 着脱式の⾞輪や折りたたみ式のフレームおよび/または背もた れがあると、⾞椅⼦を運ぶのが楽。 • 公共交通機関を使う場合、着脱できる部品には⾞椅⼦が載せやすく なる利点がある。ただし着脱できる部品には外れて紛失しやすい、 盗まれやすいといった難点もある。 2 [原⽂] footrests which can be moved out of the way. [訳注] 跳ね上げ式・開き式・着脱式などが含まれる. 中級⾞椅⼦サービス教習パッケージ 47 既存の⾞椅⼦（⾞椅⼦をすでに持っていれば） ⾞椅⼦は、ユーザーのニーズを満たしているか？ はい□ いいえ□ ⾞椅⼦は、ユーザーの環境条件に合っているか？ はい□ いいえ□ ⾞椅⼦は、適切にフィットして姿勢を⽀えているか？ はい□ いいえ□ ⾞椅⼦は安全で耐久性があるか（クッションがあるかどうかも考慮せよ）？ はい□ いいえ□ クッションは適切に除圧しているか（褥瘡の危険があるユーザーの場合）？ はい□ いいえ□ 注記：________________________________________________________________________________ すべての問いについて「はい」であれば、ユーザーに新しい⾞椅⼦は必要ない。もし「いいえ」が ⼀つでもあれば、そのユーザーには別の⾞椅⼦またはクッションが必要、あるいは既存の⾞椅⼦ま たはクッションに修理ないし改造が必要である。 ⾞椅⼦ユーザーがすでに⾞椅⼦を持っている場合は、それがユーザーのニーズを満たしているかど うか⾒極める必要がある。 中級⾞椅⼦事前評価フォームの「既存の⾞椅⼦」の箇所は、既存の⾞椅⼦が⾞椅⼦ユーザーにとり 適正かどうか、⾞椅⼦サービス職員および⾞椅⼦ユーザーが査定する⽬安となる。 ⾞椅⼦の状態を調べる際には、外⾒の観察から、⾞椅⼦ユーザーがどう座っているのか、を知る⼿ がかりが得られる。例えば、クッションの⽚側が凹んでいるのは、⽚側の座⾻により圧⼒がかかっ ていることを意味しよう。⽚側のひじ掛けが壊れていれば、⾞椅⼦ユーザーはそちら側に強く寄り かかっているのかもしれない。何であれ変わったことがあれば、それを⾞椅⼦ユーザーに尋ねよ。 ⾞椅⼦が、⾞椅⼦ユーザーのニーズを満たしていない場合、⾞椅⼦サービス職員はその理由を⾒出 さねばならない。⾞椅⼦が適正であっても、⾞椅⼦ユーザーに対する調整が適切でないこともある。 改造、付加姿勢⽀持、修理が有効であろう。 事前評価インタビューでの、優れたコミュニケーション技能 優れたコミュニケーション技能を⽤いるとは、⾞椅⼦ユーザーの感性やニーズへ敬意を払いつつ敏 感であることだが、それは正しい情報を集められるようにする、つねに重要な⽅法である。 事前評価インタビューを円滑に進めるために役⽴つやり⽅として： • ⼩さい⼦ども、あるいは問いへの理解や応答ができない⼈でない限り、つねに⾞椅⼦ユーザー本 ⼈に話しかけよ。 • ⾞椅⼦ユーザーに、提供いただく情報は、ニーズを満たすいちばん適正な⾞椅⼦を選ぶのに役⽴ つことを説明せよ。 48 受講者⽤参考書 • 質問を、中級⾞椅⼦事前評価フォーム上の順番通りに尋ねる必要はない。⾞椅⼦ユーザーによっ ては聞かれる前に⾃分から情報を提供することもあり、順番を変えて聞く⽅が⾃然な場合もある。 発話によるコミュニケーションが難しい場合もある。例 えば⾞椅⼦ユーザーが難聴であるか、明確に話せないた めに理解できないことがある。 コミュニケーションが難しい場合でも、⾞椅⼦ユーザー と直接コミュニケーションを取る途を探ること。⾞椅⼦ ユーザーをよく知っている⼈に、いちばんうまくコミュ ニケーションが取れるやり⽅を尋ねよ。⾞椅⼦ユーザー がコミュニケーションを取るやり⽅を、時間をかけて理 解せよ。 直接コミュニケーションを取る⽅法が判らない場合も、 だれか⽇頃から⾞椅⼦ユーザーを近しく知っている⼈が いないか確かめよ。その⼈に、⾞椅⼦ユーザーとコミュ ニケーションを取ってもらうようにせよ。 ⾞椅⼦ユーザーが話せない時に痛みを認識する 話すことができない⾞椅⼦ユーザーの場合、痛みがあっても伝えるのは困難である。それでも、 ⾞椅⼦サービス職員が、⾞椅⼦ユーザーの痛みを引き起こしたり、増したりすることを⾃分がし ていないか判ることは重要である。 痛みを感じた時の⾮⾔語サインの例： • 泣く、叫ぶ、もじもじする3、汗をかく。 • 評価者の⼿を押しのけるか、遠のけようとする。 • 動きに抵抗する、あるいは⼀つの姿勢でいられない。 • 表情による表現：眉をひそめる、および/または顔をしかめる。 • 座り⽅・⽴ち⽅・歩き⽅。 痛みを引き起こさない、またはすでに起きている痛みを増やさないために： • ⾞椅⼦ユーザーへ、事前評価中に痛みを覚えたら知らせるよう、強くお願いする。 • コミュニケーションが難しい場合は、事前評価の開始前に痛みを表すサインを決めておく。 • 痛みが悪化する姿勢を避ける。 • 痛みが軽くなる姿勢や動作をとる。 3 [原⽂] fidgeting WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 47 48 r questions do not need to be asked in the order given on the intermediate wheelchair assessment form. Sometimes wheelchair users will volunteer information before asked, or it may be more natural to ask questions in a different order. Sometimes, communicating through speech may be dif!cult. For example, the wheelchair user may not be able to hear or may not be able to speak clearly enough for you to understand. When communication is dif!cult, try to !nd a way to communicate directly with the wheelchair user. Ask the people who know the wheelchair user well, how you can best communicate. Take the time to understand how the wheelchair user communicates. If you cannot !nd a way to communicate directly, make sure that you have someone who knows the wheelchair user well close by at all times. Ask this person to help you communicate with the wheelchair user. Recognizing pain when a wheelchair user cannot speak When wheelchair users are unable to speak, it can be dif!cult for them to communicate that they are experiencing pain. However, it is important for the wheelchair service personnel to know if anything they are doing is causing or increasing a wheelchair user’s pain. Non-verbal signs of experiencing pain can include: r crying, shouting, !dgeting or sweating; r pushing the assessor’s hand away or trying to move away; r resisting a movement or being unable to maintain a speci!c posture; r expression on face – frowning and/or grimacing; r the way someone sits, stands or walks. Ensure that you do not cause or increase existing pain by: r encouraging the wheelchair user to let you know if he/she experiences pain uring assessment; r if communication is dif!cult – agree a signal for pain before starting the assessment; r avoiding positions that make pain worse; r using positions or movements that make pain less. 中級⾞椅⼦サービス教習パッケージ 49 ⾝体的事前評価 ‒ ⽀えなしの座位姿勢 ⾝体的事前評価は、事前評価の第２部である。その内容は： • 褥瘡の有無・危険・既往歴4の⾒定め。 • ［⾞椅⼦の］こぎ⽅の⾒定め。 • ⾞椅⼦ユーザーがどう座り、どんな付加姿勢⽀持が必要か、以下を通じて⾒出す： o ⽀えなしの座位姿勢の観察5。 o ⾻盤と股関節の姿勢チェック6の実施。⾻盤と股関節の姿勢チェックは、⾻盤や股関節周りの 問題が⾞椅⼦ユーザーの座位姿勢へどう影響しているか、理解するのに役⽴つ。 o ハンド・シミュレーション7の実施。⾞椅⼦サービス職員が⾃分の⼿を⽤い、⾞椅⼦および付 加姿勢⽀持がもたらすであろう⽀えを「模擬8」する。 • ⾝体計測。 中級⾞椅⼦事前評価フォームの以上の項⽬からの情報はそれぞれ、⾞椅⼦サービス職員が、⾞椅⼦ ユーザーにどれだけの⽀えが必要か判断するのに役⽴つ。 褥瘡の有無・危険・既往歴、⾞椅⼦のこぎ⽅の調査 褥瘡の有無・危険・既往歴 ///＝感覚がない ○＝過去の褥瘡9 ● ＝現存する褥瘡10 普通に感覚があるか？ 過去に褥瘡があったか？ 現在、褥瘡があるか？ あれば、傷が開いているか？ （ステージは 1〜４のどれか？） はい□ いいえ□ はい□ いいえ□ はい□ いいえ□ はい□ いいえ□ 期間および原因： 褥瘡の危険＊がある⼈か？ はい□ いいえ□ ＊褥瘡の危険があるのは、感覚がない、あるいは以下の褥瘡の危険因⼦を３つ以上抱える⼈。褥瘡の危 険因⼦：動けない、湿気、不良姿勢、過去/現在の褥瘡、栄養不良、⽼化、低体重や過体重 4 [原⽂] presence, risk of, or history of, pressure sores 5 [原⽂] observing sitting posture without support 6 [原⽂] pelvis and hip posture screen. . [訳注] 医療や診断⽬的の⾏為と受け取られる可能性のある訳語は避けた. 7 [原⽂] hand simulation 8 [原⽂] ʻsimulateʼ 9 [原⽂] previous 10 [原⽂] existing WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 49 50 Physical assessment – sitting posture without support Physical assessment is the second part of the assessment. It includes: r identifying the presence, risk of or history of pressure sores; r identifying the method of pushing; r !nding out how the wheelchair user sits and what additional postural support he or she may need through: – observing sitting posture without support; – carrying out a pelvis and hip posture screen. Pelvis and hip posture screening helps to understand how any problems around the pelvis or hips may be affecting the wheelchair user’s sitting posture; – carrying out hand simulation. The wheelchair service personnel uses their hands to ‘simulate’ the support that a wheelchair and additional postural supports may provide; r taking measurements. Information from each of these sections of the intermediate wheelchair assessment form will help wheelchair service personnel to decide how much support the wheelchair user needs. Review of presence, risk of or history of pressure sores and method of pushing Presence, risk of or history of pressure sores /// = does not feel O = previous pressure sore = existing pressure sore Can feel normally? Yes No Previous pressure sore? Yes No Current pressure sore? Yes No If yes, is it an open sore (stage 1–4)? Yes No Duration and cause: Is this person at risk* of a pressure sore? Yes No *A person who cannot feel or has 3 or more risk factors is at risk of pressure sores. Risk factors: cannot move, moisture, poor posture, previous/current pressure sore, poor diet, ageing, under or over weight. 50 受講者⽤参考書 ⾞椅⼦のこぎ⽅ ⾞椅⼦ユーザーはどうやって⾞椅⼦をこぐのか？ 両腕で□ 左腕で□ 右腕で□ 両脚で□ 左脚で□ 右脚で□ 介助者が押して□ 注記： まっすぐな座位姿勢 本項によく出てくる略語 解剖学的構造 略称 上前腸⾻棘 Anterior Superior Iliac Spine ASIS 上後腸⾻棘 Posterior Superior Iliac Spine PSIS 座⾻結節 Ischial Tuberosity IT どの⾞椅⼦ユーザーも、まっすぐに、あるいはニュートラルな姿勢で座れるのか？ たとえ⽀えがあっても、⾞椅⼦ユーザーが、みなまっすぐに座れるわけではない。 まっすぐに座るのが困難な⾞椅⼦ユーザーは、さまざまに異なる座位姿勢をとる。姿勢が異なる原 因は、⾝体の⼀つ以上の部分がニュートラルな位置にないことである。 事前評価では、⾞椅⼦サービス職員と⾞椅⼦ユーザーとで、⾞椅⼦ユーザーが、機能を損なわずに 安全かつ快適にとって保てる、いちばんまっすぐな座位姿勢を⾒つける必要がある。⾞椅⼦と姿勢 ⽀持具（PSDs）とで⽀えなければならないのは、その姿勢なのだ。 姿勢の事前評価から判明する最終結果は、以下 3 通りに分かれる： • 固まった姿勢11：⾞椅⼦ユーザーの⾝体に「固まった」部分がある場合。軽い⼒では動かない（強 い⼒は決して⽤いないこと）。⾞椅⼦サービス職員は、ニュートラルでない（まま固まった）姿勢 に形を合わせた12⽀えを設ける必要がある。 • ニュートラル姿勢になる柔軟さ13：軽い⼒で、⾞椅⼦ユーザーのニュートラルでない⾝体部分を 動かしてニュートラルにできる場合。この状況での正しい⽀えとは、⾞椅⼦ユーザーが、ニュー トラルな座位姿勢を保つのを⽀援するように設ける。 • ニュートラル姿勢途中の柔軟さ14：軽い⼒で、⾞椅⼦ユーザーのニュートラルでない⾝体部分を ニュートラルへの途中までなら動かせる場合。この状況での⽀えは、⾞椅⼦ユーザーが、快適か つ機能的な限りで、なるべくニュートラルに近い姿勢で座れるように設ける。 11 [原⽂] fixed posture 12 [原⽂] accommodate 13 [原⽂] flexible to neutral posture 14 [原⽂] flexible part way to neutral posture 中級⾞椅⼦サービス教習パッケージ 51 ⼩さい⼦どものまっすぐな座位姿勢 5 歳未満の⼦どものまっすぐな座位姿勢15は、もっと⼤きな⼦どもや⼤⼈と同じではない。座位姿 勢は、⽣後 5 年間は発達途上にあるものなのだ。 ５歳未満における最も重要な違い： • ⼦どもの背中は平らで、腰椎や胸郭のカーブがない。 • ⼦どもの⽿と股関節を結んだ線に対して、肩はわずか にその前に位置する。 • 両脚は外転して開いており、平⾏ではない。 ⾞椅⼦サービス職員は、５歳未満の⼦どもに関わるさい、 ⼤⼈にまっすぐな座位姿勢を促すような⽀えを５歳未満 の⼦どもに設けてはならないことに留意する必要があ る。それは⼦どもにとっては不快で、有害でさえある。 座位姿勢の観察 ⾞椅⼦ユーザーの姿勢、およびどんな⽀えが必要かを理 解する出発点は、⾞椅⼦ユーザーの座位姿勢を、⽀えな しで観察することである。 ⾝体的事前評価のこの部分では、⾞椅⼦ユーザーは評価 ベッドに座る。 ⾞椅⼦ユーザーが安全で、両⾜が⽀えられていることを 確かめよ。もし⾃⼒で安全に座れない場合は、家族/介助 者にいっしょに座ってもらうようにせよ。⾞椅⼦ユーザ ーが、⽀えなしでニュートラルな/まっすぐな座位姿勢16 を取れるかどうか観察せよ。 ⽀えなしの座位姿勢を観察する⽬的は、⾞椅⼦ユーザー の姿勢の傾向/習性を理解することだ。座位姿勢の観察は ⼀種の特技で、上達には時間と修練を要する。 15 [原⽂] neutral/upright sitting posture. [訳注] WHO の教習パッケージでは, この⼆つを同じ姿勢と定義している. 基礎⾞椅⼦サービス教習パッケージ受講者⽤参考書 p.13 を参照. 16 [原⽂] upright sitting posture WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 51 52 Upright sitting posture for young children Children under the age of !ve do not have the same upright sitting posture as older children and adults. The sitting posture develops over the !rst !ve years of the child’s life. The most important differences before the age of !ve are: r the child’s back is "at and there are no lumbar or thoracic curves; r the child’s ear and hips are in line however their shoulders are slightly further forward; r legs are rolled outwards and apart – not parallel. When working with children under the age of !ve, wheelchair service personnel need to remember that children under the age of !ve should not be given support that encourages an adult upright sitting posture. This would be uncomfortable and could cause harm to the child. Observing sitting posture A starting point for understanding the wheelchair user’s posture and what support may be needed is to observe his/her sitting posture – without support. For this part of the physical assessment the wheelchair user sits on an assessment bed. Make sure the wheelchair user is safe and that his/her feet are supported. Have an assistant or family member/caregiver sit with him/her if he/she cannot independently, sit safely. Observe whether the wheelchair user can sit in a neutral/upright sitting posture without support. The purpose of observing sitting posture without support is to understand the wheelchair user’s postural tendency/habits. Observing sitting posture is a skill, which takes time and practice to develop. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 51 52 Upright sitting posture for young children Children under the age of !ve do not have the same upright sitting posture as older children and adults. The sitting posture develops over the !rst !ve years of the child’s life. The most important differences before the age of !ve are: r the child’s back is "at and there are no lumbar or thoracic curves; r the child’s ear and hips are in line however their shoulders are slightly further forward; r legs are rolled outwards and apart – not parallel. W n working with children under the age of !ve, wheel hair ervice personnel need to em mber th t children under th age of !ve should not be given support that encourages an adult upright sit ing posture. This w uld be uncomfortable and could cause harm to the child. Observing sitting posture A starting point for u derstanding the wheelchair user’s p sture and what support may be needed is to observe hi /her sitting posture – without support. For this part of the physical assessment the wheelchair user sits on an assessment bed. Make sure the wheelchair user is safe and that his/her feet are supported. Have an assistant or family member/caregiver sit with him/her if he/she cannot independently, sit safely. Observe whether the wheelchair user can sit in a neutral/upright sitting post r with ut support. The purpose of observing sitting posture without support is to understand the wheelchair user’s postural tendency/habits. Observing sitting posture is a skill, which takes time and practice to develop. 52 受講者⽤参考書 ⾞椅⼦ユーザーがまっすぐに座っているかどうかの⾒分け⽅ ここで述べるまっすぐな座位姿勢とは、⾞椅⼦サービス職員が⽤いるための⽬安である。⾞椅⼦ ユーザーと関わる際にめざすべきは、それぞれの⾞椅⼦ユーザーを、本⼈に快適で機能的かつ実 ⽤的な限りで、できるだけこの姿勢に近づくように⽀えることである。 横から⾒て確認すること： ü ⾻盤がまっすぐに起きている：上前腸⾻棘（ASIS）と上後腸⾻棘（PSIS）とが⽔平である。 ü 体幹がまっすぐに起きている。 ü 背中が３つの⾃然なカーブを描いている。 ü ⼤⼈の場合：⽿、肩、股関節が⼀直線上にある。 ⼦どもの場合：⽿と股関節を結んだ線より、肩 がわずかに前に出ている。 ü 股関節がほぼ 90度に屈曲している。 ü 膝と⾜⾸がほぼ 90度に屈曲している。 ü かかとが膝の真下かわずかに前後にある。 ü ⾜が床あるいは⾜台にべったり着いている17。 正⾯から⾒て確認すること： ü ⾻盤が⽔平：左右の上前腸⾻棘（ASIS）が⽔平 である。 ü 両肩が⽔平でリラックスし、腕が⾃由に動く。 ü 脚がわずかに開いて（外転して）いる。 ü 頭がまっすぐに起き、⾝体の上でバランスが取 れている。 17 [原⽂] Feet flat on the floor or footrests. 中級⾞椅⼦サービス教習パッケージ 53 姿勢を記録する 中級⾞椅⼦事前評価フォームには、⾞椅⼦ユーザーの、⽀えなしの座位姿勢を記録する欄がある。 この記録は、⾞椅⼦サービス職員が、⾞椅 ⼦ユーザーの座位姿勢を事前評価の後で 思い出すのに役⽴つ。また、⾞椅⼦サービ ス職員が、⾞椅⼦ユーザーの座位姿勢の経 時的変化を追跡するのにも役⽴つ。 座位姿勢を記録する、いくつかの⽅法： • ことばで詳しく述べる。 • 絵を描く。 • 写真を（⾞椅⼦ユーザーの許可を得た場 合に限り）撮る。 下は、座位姿勢を記録するための、簡便な線画の例である。 座位姿勢を横から⾒た線画 座位姿勢を正⾯から⾒た線画 留意せよ！ • だれもがまっすぐに座れるわけではない。 • 事前評価では、⾞椅⼦サービス職員と⾞椅⼦ユーザーは協⼒して、その⾞椅⼦ユーザーが快適 に座って、どこまでまっすぐな姿勢に近づけるかを⾒出す。 • 付加姿勢⽀持を備えた⾞椅⼦は、⾞椅⼦ユーザーを⽀え、本⼈が快適な限りで、なるべくまっ すぐに座れるためのものである。 ⽀えなしの座位姿勢 ⽀えなしの座位姿勢を、詳述するか描く： 54 受講者⽤参考書 ⾝体的事前評価 ‒ ⾻盤と股関節の姿勢チェック ⾻盤と股関節の姿勢チェックとは 座位姿勢に影響するのは、⾻盤と股関節周辺で起きていることだ。事前評価のこの部分で、⾞椅⼦ サービス職員が⾒出すべきことは： • ⾞椅⼦ユーザーの⾻盤が、正⾯から⾒て⽔平かどうか（これは、⽀えがあってもなくてもよい）。 • ⾞椅⼦ユーザーの股関節が、ニュートラルな座位姿勢（体幹〜⼤腿の⾓度が 90 度になる）まで 屈曲するかどうか。これは、⽀えがあってもなくてもよい。 ⾻盤が⽔平でないか、股関節がニュートラルな座位姿 勢まで屈曲しない（体幹〜⼤腿の⾓度が 90度超の）場 合、⾞椅⼦サービス職員にはさらに情報を探る必要が ある。知ることが重要なのは： • ⾞椅⼦ユーザーは、⽀えがあればニュートラルな姿 勢で座れるか？ • そうでなければ、ニュートラルな姿勢にどこまで近 づけて座れるか？ ⾞椅⼦ユーザーがニュートラルな座位姿勢で座れない 場合、下のどちらのせいで困難なのかを知ることが重 要である： • ⾻盤より上（腰椎）に制限（あるいは制約）があるの か、あるいは • ⾻盤内（股関節）に制限があるのか。 ⾞椅⼦サービス職員が上の問いすべてに答えるには、 事前評価の「⾻盤と股関節の姿勢チェック」の実施が 必要である。 これは完全な関節可動域評価ではない。この教習プロ グラムで教える⾻盤と股関節チェックの⽬的は、上記 の要因を特定するためだけである。熟達した⾞椅⼦サ ービス職員であれば、より詳しい情報を集めるため、 完全な関節可動域評価の実施を選択してもよい。 中級⾞椅⼦サービス教習パッケージ 55 ⾻盤と股関節の姿勢チェックの実施 準備： • ⾞椅⼦ユーザーへ、何をしようとしているのか、なぜそれが重要なのかを説明する。 • ⾞椅⼦ユーザーに、評価ベッドへ仰向けに寝てもらう。 （注記：この解説では、⾻盤と股関節の姿勢チェックを実施する⼈を「評価者」、評価者を補助 する⼈を「助⼿」と呼び、後者は同僚、教習を受けた助⼿、家族や介助者が務めうる） ⾻盤姿勢を調べる： • 評価者は、⾞椅⼦ユーザーの両膝をわずか に屈曲させ、若⼲⽀える。これは股関節の 緊張を和らげるのに役⽴つ。 • 助⼿は両⼿を⾞椅⼦ユーザーの体幹の下肋 ⾻周りにしっかりと当てる。 • 評価者は両親指を ASIS の上に置きながら ⾻盤を優しく保持する。 • 評価者は両親指/ASIS が⽔平になっている か確認する。 • ⽔平でなければ、評価者は優しく、だがし っかりと左右の ASIS が⽔平になるように ⾻盤のアラインメントを整えてみる。 • 助⼿は、体幹が動くのを感じたら報せる。 それは動きに制約があることを意味する。 • ⾻盤をどれだけニュートラル/⽔平近くま で持って⾏けるかに注⽬。 • 評価者は⾻盤が⽔平になるかどうかを中級 ⾞椅⼦事前評価フォームに記録する。 股関節の姿勢を調べる： • 助⼿は優しく、だがしっかりと⾞椅⼦ユー ザーの⾻盤を保持する。 • 評価者は調べない⽅の脚の膝をわずかに屈 曲させ、⾜をベッドに置く。これは調べる ⽅の股関節の緊張を緩めるのによい。置い た⽅の脚に⽀えが必要な場合もある。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 55 56 Carrying out a pelvis and hip posture screen Prepare: r explain to the wheelchair user what you are going to do and why it is important; r ask the wheelchair user to lie down on their back on an assessment bed. (Note: in these instructions, the person carrying out a pelvis and hip posture screen is called the ‘assessor’ and the person who assists the assessors is called ‘assistant’, who could be a co-worker, trained assistant, family member or caregiver). Pelvis posture screen: r assessor bends both the wheelchair user’s knees slightly and provides some support, which helps to relieve tension on the hips; r assistant places their hands !rmly on the wheelchair user’s trunk, around their lower ribs; r assessor grips the pelvis gently with thumbs on the ASIS; r assessor checks if thumbs/ASIS are level; r if not level, assessor gently but !rmly tries to align the pelvis so that both ASIS are level; r assistant reports if he/she feels the trunk move, which means that there is some restriction to the movement; r note how close to neutral/level it is possible to bring the pelvis; r assessor records if the pelvis can be level on the intermediate wheelchair assessment form. Hip posture screen: r assistant gently but !rmly holds the wheelchair user’s pelvis; r assessor bends the leg that is not being tested slightly at the knee, resting the foot on the mat. This helps to reduce the tension in the hip being tested. This leg may need to be supported. WHE CHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 55 56 Carrying out a pelvis and hip posture screen Prepare: r explain to the wheelchair user what you are going to do and why it is important; r ask the wheelchair user to lie down on their back on an assessment bed. (Note: in these instructions, the person carrying out a pelvis and hip posture screen is called the ‘assessor’ and the person who assists the assessors is called ‘assistant’, who could be a co-worker, trained assistant, family member or caregiver). Pelvis posture screen: r assessor bends both the wheelchair u r’s kn es lightly and provides some support, whic helps to relieve tension on the hips; r assistant places their hands !rmly on the wheelchair user’s trunk, around their lower ribs; r assessor grips the pelvis gently with thumbs on the ASIS; r assessor checks if thumbs/ASIS are level; r if not level, assessor gently but !rmly tries to align the pelvis so that both ASIS are level; r assistant reports if he/she feels the trunk move, which means that there is some restriction to the movement; r note how close to neutral/l vel it is po sible to bring the pelvis; r a se sor records if the pelvis can be level on the intermediate wheelchair a se sment form. Hip posture screen: r assistant gently but !rmly holds the wheelchair user’s pelvis; r assessor bends the leg that is not being tested slightly at the knee, resting the foot on the mat. This helps to reduce the tension in the hip being tested. This leg may need to be supported. 56 受講者⽤参考書 股関節の姿勢を調べる： • 評価者は、調べる⽅の脚をニュートラルな 座位姿勢に向けて優しく動かす。 • 助⼿は、⾻盤が動くのを感じたら報せる。 それは動きに何らかの制限（制約）がある ことを意味する。 • 評価者は股関節がどれくらい⾃由に動ける か感じ取る。 • 評価者は、反対側も同じ⼿順で調べて⽐較 する。 • 評価者は、左右の股関節がニュートラルな 座位姿勢まで屈曲するかどうかを中級⾞椅 ⼦事前評価フォームに記録する。 • 評価者は、助⼿に⼿伝ってもらい、股関節 がどこまでニュートラルな座位姿勢に近づ けるか⾓度計を⽤いて記録する。 • 評価者は、⾓度計の回転軸を股関節に当て る。評価者は⾓度計の⽚⽅のアームを⼤腿 ⾻に沿わせ、もう⽚⽅のアームを体幹に沿 わせる。 • 評価者は、⾓度計の両⽅のアームをしっか りと保持する。 • 評価者は、左右の股関節で測った⾓度を、 中級⾞椅⼦事前評価フォームに記録する。 評価者は⾓度計の⾓度を別紙あるいは中級 ⾞椅⼦事前評価フォームの裏に描き取って もよい。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 55 56 Hip posture screen: r assessor gently moves the leg being tested into the neutral sitting posture; r assistant reports if he/she feels the pelvis move, which means that there is some limit (restriction) to the movement; r assessor feels how freely the hip joint can move; r assessor repeats on the other side and compares; r assessor records if right and left hip can bend to neutral sitting posture on the intermediate wheelchair assessment form. r assessor records how close to neutral posture each hip can reach with a goniometer with the help of an assistant; r assessor places the pivot point of the goniometer on the hip joint. Assessor positions one arm of the goniometer along the thigh bone and one arm in line with the trunk; r assessor holds the two arms together !rmly; r assessor records right and left hip angle degree measurements on the intermediate wheelchair assessment form. Assessor can also draw the angle of the goniometer on a separate piece of paper or on the back of the intermediate wheelchair assessment form. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 55 56 i st r scr : r assessor gently moves the l g being tested into the neutral sitting posture; r assi tant reports if he/she f els the pelvis move, which means that ther is ome limit (restriction) to the movement; r assessor feels how freely the hip joint can move; r assessor repeats on the other side and compares; r assessor records if right and left hip can bend to neutral sitting posture on the intermediate wheelchair assessment form. r assessor records how close to neutral posture each hip can reach with a goniometer with the help of an assistant; r assessor places the pivot point of the goniometer on the hip joint. Assessor positions one arm of the goniometer along the thigh bone and one arm in line with the trunk; r assessor holds the two arms together !rmly; r assessor records right and left hip angle degree measurements on the intermediate wheelchair assessment form. Assessor can also draw the angle of the goniometer on a separate piece of paper or on the back of the intermedi t wheelchair assessment form. 中級⾞椅⼦サービス教習パッケージ 57 ⾻盤と股関節の姿勢チェックを記録する ⾻盤と股関節の姿勢チェックの結果を、 中級⾞椅⼦事前評価フォームに記録する。 ⾻盤が⽔平になるかどうかに印を付ける。 次に、股関節がニュートラルな座位姿勢 （直⾓）まで屈曲するかどうかに印を付 ける。 右か左（あるいは両⽅）の股関節がニュー トラルな座位姿勢まで屈曲しない（体幹 〜⼤腿の⾓度が 90度超の）場合は、その ⾓度を記録する。 上述の通り、⾞椅⼦サービス職員は⾓度 計の⾓度を別紙あるいは中級⾞椅⼦事前 評価フォームの裏に描き取ってもよい。 ⽔平でないまま固まった⾻盤、またはニュートラルな座位姿勢まで屈曲しない（体 幹〜⼤腿の⾓度が 90 度超の）股関節への、⼀時的⽀持1 ⾻盤が⽔平にならないか、股関節がニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90度超の）場合、完成した⾞椅⼦でもニュートラルではない姿勢で⽀える必要がある。事前評価を 続けるには、⾞椅⼦ユーザーが座れるよう、⼀時的⽀持部を設ける必要がある。 事前評価での⼀時的⽀持部は、 • ⾞椅⼦ユーザーがより安定し、バランスよく座れるようにする。 • ⾞椅⼦ユーザーが、⽔平でない⾻盤やニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓ 度が 90度超の）股関節を代償2しないようにする。 • ⾞椅⼦サービス職員が事前評価を続け、⾞椅⼦ユーザーの他の部位の姿勢、例えば⾻盤・体幹・ 頭・⾸・脚などへ集中できるようにする。 ⼀時的⽀持部は、硬いウレタンフォームでつくれる。以下の表には、さまざまな姿勢の問題と⼀時 的⽀持部、およびこれらの問題に対する恒久的⽀持部を⽰す。 1 [原⽂] temporary supports 2 [原⽂] compensating ⾻盤と股関節の姿勢チェック ⾻盤が⽔平かどうか、および臥位姿勢での股関節の屈曲 可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 58 受講者⽤参考書 姿勢の問題 ⼀時的⽀持部 恒久的⽀持部（⾞椅⼦ユーザ ーのクッションにつくり込む） ⽔平でないまま固まった⾻盤（側 傾） ⾼い側の座⾻および⼤腿の下 を積み増す。 ⽚側の股関節が、ニュートラルな 座位姿勢まで屈曲しない（体幹〜 ⼤腿の⾓度が 90 度超） 左右の座⾻およびニュートラ ルな座位姿勢まで屈曲する側 の⼤腿の下を積み増し。鋭い ふちは試乗前に落とす。 左右の股関節が、ニュートラルな 座位姿勢まで屈曲しない（体幹〜 ⼤腿の⾓度が 90 度超） 積み増しを加え、座⾯と背も たれの間の⾓を⼤きくする。 ⽚側または両側の股関節が、ニュ ートラルな座位姿勢まで伸展し ない（体幹〜⼤腿の⾓度が 90 度 未満） ウェッジ（くさび）形の⽀え を、座⾻の前⽅かつ⼤腿の下 に設ける。 中級⾞椅⼦サービス教習パッケージ 59 ⾝体的事前評価 ‒ ハンド・シミュレーション ハンド・シミュレーションは、⾞椅⼦ユーザーに必要な⽀えが何か、⾒定めるために⾏なう。ハン ド・シミュレーションの間に、⾞椅⼦サービス職員が⾃らの⼿を使って⾒出すべきことは： • ⾞椅⼦ユーザーは、⽀えればニュートラルな姿勢で座れるか？ • 座れなければ、⾞椅⼦ユーザーはどこまでニュートラルな姿勢に近づけて座れるか？ • どんな⽀えが、どこに必要か。 ハンド・シミュレーションでは、⾞椅⼦サービス職員は⾞椅⼦ユーザー、および助⼿または家族/ 介助者と協働し、⼿で⽀えを設ける。 ハンド・シミュレーションのやり⽅ ハンド・シミュレーションの実施に際して、留意すべき重要部⾯： 準備 • ⾞椅⼦ユーザーへ、何をしようとしているのか、またその 理由を説明する。 • ⾞椅⼦ユーザーに、堅いが緩衝材の⼊った平らな⾯に座っ てもらう。⾞椅⼦サービス職員と助⼿または家族/介助者 の⼿が⾞椅⼦ユーザーへ容易に届き、前・後ろ・横から⽀ えられる評価ボックスが理想的。 • ⾞椅⼦ユーザーが⽀えなしでは安全に座れない場合は、家 族/介助者に⽀えてもらう。 • ⾞椅⼦ユーザーの両⾜が、正しい⾼さで⽀えられているか 確かめる。⾻盤が⽔平でない、あるいは股関節の⽚⽅がニ ュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度 が 90度超の）場合は、前の授業で説明したように⼀時的 ⽀持部を設ける。 チームで作業する • たいてい、⼀対より多くの⼿が必要。 • 助⼿の助けを借りよ。それには同僚、教習を受けた助⼿、 家族、介助者などが可能。 • 家族/介助者の参画が得られれば、最終的な姿勢⽀持具の 解決策に対する理解を深めてもらえる。 60 受講者⽤参考書 優れたコミュニケーションを⽤いる • ⾞椅⼦サービス職員は、ユーザーおよび家族/介助者とは和やかに（可能ならば⼟地の⾔葉で）3 コミュニケーションを取るべきである。 • 話せない⾞椅⼦ユーザーとは、適切なコミュニケーション⽅法を⾒つけ、それを⽤いよ。 • ⾞椅⼦ユーザーへ、作業段階ごとに何をやっているのか説明するのを忘れないように。 • 変化を加えるごとに、⾞椅⼦ユーザーへフィードバックを求めよ。 ⾃分の⼿が何をしているのか、注意深く考える • ⾃分の⼿が設けた⽀えを、後に⾞椅⼦や姿勢⽀持具が与えることになる。ハンド・シミュレーシ ョンの間、細⼼の注意を払うべきことは： o ⼿をどこに置いているか4。 o ⼒/⽀えの⽅向。 o どれくらいの⼒/⽀えを⽤いているか5。 o ⼿がどれくらいの広さの体表⾯を覆っているか6（例えば、使っているのは指⼀本だけか、あ るいは⼿全体か）。 o ⼿が冷えていたら、ハンド・シミュレーションを始める前に暖めておく。 • これらの情報は、最終的な⾞椅⼦および姿勢⽀持具の処⽅に役⽴つ。 つねに、最初に⾻盤を⽀える • ⾻盤姿勢は、⾝体の残りの部分へ影響を及ぼす。 • ユーザーの⾻盤がニュートラルでない場合は、⼿を使って⾻盤をニュートラルになる⽅へ促す。 • ⾻盤を⽀えたら、⾝体の他の部分へ、以下の順序で注意を集中して⾏く： o 体幹/腕 o 頭と⾸ o 股関節と⼤腿 o 下腿 いちどに変えるのは、⼀つずつ • いちどに変化を加えるのは、⼀つずつにせよ7。例えば、体幹の姿勢を⾻盤姿勢と同時に変えよう としてはならない。 • ⾝体の⼀か所の変化が、他の部分へどう影響するか観察せよ。 • ⾞椅⼦ユーザーへ、フィードバックを求めよ。 3 [原⽂] gently (preferably in local language) 4 [原⽂] where your hands are placed 5 [原⽂] how much force/support is being used 6 [原⽂] how much surface area your hands are covering 7 [原⽂] Always make only one change at a time. 中級⾞椅⼦サービス教習パッケージ 61 ⾝体的事前評価のハンド・シミュレーションを始めるために： • ⾞椅⼦ユーザーの前に、ひざまづくかしゃがむ。 • 両⼿を、そっと⾞椅⼦ユーザーの⾻盤の両側に置く。 • ⾞椅⼦ユーザーの⾻盤がニュートラルでない場合 は、⼿を使って⾻盤を、快適な限りでなるべくニュ ートラルに近づける。 • ⾮常に強い⼒を⽤いてはならない。 • どれだけニュートラルに近づけて⾻盤を⽀えられる か⾒出す。 • ⾻盤が、ニュートラルな⽅へ動くに従い⾞椅⼦ユー ザーの体幹・股関節・頭・⾸にどう影響するか観察。 • ⾻盤をなるべくニュートラルに近づけて⽀えて初め て、⾞椅⼦サービス職員は、どんな⽀えが体幹に必 要か考察できる。 • ⾞椅⼦ユーザーが「ニュートラルに最も近い」と⾃ 分が⾒定めた姿勢で、助⼿に⾻盤を⽀えてもらう。 • 助⼿へ、⾻盤のどこをどう⽀えるのか、ていねいに 説明する。助⼿にそれができていると確認してから、 次に移る。 （必要ならば）体幹を⽀える ⾻盤と同様、⾞椅⼦ユーザーの体幹がニュートラルな 座位姿勢にない場合は⼿を使って⽀えを設ける。作業 ⼿順は： • 両⼿で⾻盤を安定させる。 • 体幹をまっすぐ伸ばし、両肩が⽔平に（またはなる べく⽔平に近く）なるよう、両⼿で体幹の両側を⽀ える。 • ⾻盤の上での頭と⾸のバランスを保ちながら、両⼿ で背中、時には胸を⽀えて体幹をまっすぐに起こす。 • ⾻盤と体幹の輪郭を横から観察する。これは、最適 な⽀えをもたらす背もたれ形状を決めるのに重要。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 61 62 In order to begin hand simulation part of the physical assessment: r kneel or squat in front of the wheelchair user; r gently place hands on both sides of the wheelchair user’s pelvis; r if the wheelchair user’s pelvis is not in neutral – use hands to bring the pelvis as close to neutral as is comfortable; r do not use very strong force; r !nd how close to neutral the pelvis can be supported; r observe how moving the pelvis towards neutral affects the wheelchair user’s trunk, hips, head and neck. r when the pelvis is supported as close to neutral as possible, the wheelchair service personnel can then consider what support is needed at the trunk; r ask the assistant to hold the pelvis in the posture that you have identi!ed as ‘as close to neutral as possible’ for this wheelchair user; r explain carefully to the assistant where to hold and how to hold the pelvis. Check that he/she is able to do this before moving on. Provide support at the trunk (if needed): As for the pelvis, if the wheelchair user’s trunk is not in neutral sitting posture, use your hands to provide support. Work in this order: r stabilize the pelvis with your hands; r straighten out the trunk so both shoulders are level (or as close to level as is possible) by providing support with your hands at both sides of the trunk; r bring the trunk upright with head and neck balanced over the pelvis by providing support at the back and sometimes at the front with your hands; r observe the contour of the pelvis and trunk from the side. This is important to plan the shape of the backrest to provide the best support. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 61 62 In order to begin hand simulation part of the physical assessment: r kneel or squat in front of the wheelchair user; r gently place hands on both sides of the wheelchair user’s pelvis; r if the wheelchair user’s pelvis is not in neutral – use hands to bring the pelvis as close to neutral as is comfortable; r do not use very strong force; r !nd how close to neutral the pelvis can be supported; r obs rve how moving the p lvis towards n utral affects the wheelchair user’s trunk, hips, head and neck. r when the pelvis is supported as close to neutral as possible, the wheelchair service personnel can then consider what support is needed at the trunk; r ask the assistant to hold the pelvis in the posture that you have identi!ed as ‘as close to neutral as possible’ for this wheelchair user; r explain carefully to the assistant where to hold and how to hold the pelvis. Check that he/she is able to do this before moving on. Provide support at the trunk (if needed): As for th pelvis, if the wheelchair user’s trunk is not in neutral sitting posture, use your hands to provide support. Work in this order: r stabilize the pelvis with your hands; r straighten out the trunk so both shoulders are level (or as close to level as is possible) by providing support with your hands at both sides of the trunk; r bring the trunk upright wit head and nec balanced over the pelvis by p oviding s pport a the back and sometimes at the fr nt with your hands; r observe the contour of the pelvi and trunk from the sid . This is important t plan the shape of the backrest to provide the best support. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 61 62 In order to beg ha d simulation part of the physical ass ssment: r kneel or squat in front of the wheelchair user; r gently place hands on both sides of the wheelchair user’s pelvis; r if th wheelchair user’s pelvis is not in neutral – use hands to bring the pelvis as close to neutral as is comfortable; r do not use very strong force; r !nd how close to neutral the pelvis can be supported; r observe how moving the pelvis towards neutral affects the wheelchair user’s trunk, hips, head and neck. r when the pelvis is supported as close to neutral as p ssible, the wheelchair service personnel can then consider what support is n eded at the tr nk; ask th assistant to hold the pelvis in th postur that you hav identi! d as ‘as close to neutral as possible’ for this wh elchair user; r explain car fully to the assistant where to hold and h w to hold the elvis. Ch ck that /she is able to do t is before m ving on. Provide support at the trunk (if needed): As for the pelvis, if the whe lchair us r’s trunk is not in neutral sitting p sture, use your hands to provide support. Work in this order: r stabilize the pelvis with your hands; r straighten out the trunk so both shoulders are level (or as close to level as is possible) by providing support with your hands at both sides of the trunk; r bring the trunk upright with head and neck balanced over the pelvis by providing support at the back and sometimes at the front with your hands; r observe the contour of the pelvis and trunk from the side. This is important to plan the shape of the backrest to provide the best support. 62 受講者⽤参考書 体幹への⽀えが⾝体の他の部分へどう影響するかに、細⼼の注意を払え。例えば、体幹への⽀えは 頭や⾸の姿勢の改善に役⽴っているだろうか？⾻盤や体幹がしっかり⽀えられても、頭をまっすぐ に起こすのが難しい⾞椅⼦ユーザーもいる。⾸や頭の姿勢を改善するための提案としては： • ⾞椅⼦ユーザーに、少し後ろへのリクライニングを許容する。 • そうすることで、⾞椅⼦ユーザーが体幹の上で頭のバランスをうまく取れるかどうか観察する。 • 腕への⽀えを付加する。 ハンド・シミュレーションの間、⾻盤を⽀えている助⼿に、⾃分が体幹を⽀えるに従い、何か変化 を感じるか尋ねよ。⾞椅⼦ユーザーへ、つねにフィードバックを求めるのを忘れないように。 （必要ならば）⾝体の他の部位を⽀える • ⾻盤と体幹を、快適な限りで最もニュートラル な座位姿勢で⽀えてから、頭と⾸、股関節、⼤腿、 下腿の姿勢を調べよ。 • ⾃分の⼿を使って、それぞれの⾝体部位が快適 な動きでどこまでニュートラルに近づけるか⾒ 出せ。引き続き、それぞれの変化が⾝体の他の 部分にどう影響するか調べよ。引き続き⾞椅⼦ ユーザーへフィードバックを求めよ。 ハンド・シミュレーションの結果を記録する ハンド・シミュレーションの結果は中級⾞椅⼦事前評価フォームへ記録する。以下の欄がある： • ⾞椅⼦ユーザーが、⼿の⽀えで8ニュートラルな座位姿勢になったかどうか、それぞれの⾝体部位 について印を付けて記録。 • ⼿の⽀えで⾞椅⼦ユーザーがとれた最終的な座位姿勢を、記述するか線画で描く。 • その座位姿勢がとれるように⾞椅⼦ユーザーへ設けた⽀えを、記述するか線画で描く。 8 [原⽂] with hand support WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 61 62 Pay close attention to how trunk support affects the rest of the body. For example, does the trunk support help improve head and neck posture? Even with good pelvis and trunk support, some wheelchair users may !nd it hard to hold their head upright. Some suggestions to help improve head and neck posture are: r allow the wheelchair user to recline slightly backwards; r observe whether the wheelchair user is then able to better balance their head over their trunk; r provide additional support for the arms. During the hand simulation, ask the assistant supporting the pelvis if he/she feels any changes as you support the trunk. Remember to always ask the wheelchair user for their feedback. Provide support for other body parts (if needed) r Once the pelvis and trunk are supported in the most neutral sitting posture that is comfortable, check the posture of the head and neck, hips, thighs and lower legs. r Use your hands to !nd out how close to neutral each body part can comfortably move. Continue to check how any change affects the rest of the body. Continue to ask the wheelchair user for their feedback. Recording the results from a hand simulation Results of the hand simulation are recorded on the intermediate wheelchair assessment form. There is space to: r record with a tick whether the wheelchair user is able to achieve a neutral sitting posture for each body part with hand support; r describe or line draw the !nal sitting posture achieved by the wheelchair user with the hand support; and r describe or line draw the support provided for the wheelchair user to achieve that sitting posture. 中級⾞椅⼦サービス教習パッケージ 63 ハンド・シミュレーション：ニュートラルな姿勢で/快適な限りでニュートラルな 姿勢にできるだけ近づけて、座るために必要な⽀え 各⾝体部位が、⼿の⽀えでニュートラルな座位姿勢になれば「はい」、ならなければ「いいえ」に印。 部位 はい いいえ ⼿の⽀えで、⾞椅⼦ユーザーがとれた最終的な座位姿勢を記述す るか線画で描き、なおかつ、その座位姿勢がとれるように設けた ⽀えを記述するか線画で描く。 ⾻盤 □ □ 体幹 □ □ 頭 □ □ 左股関節 □ □ 右股関節 □ □ ⼤腿 □ □ 左膝 □ □ 右膝 □ □ 左⾜⾸ □ □ 右⾜⾸ □ □ ⾝体的事前評価 ‒ ⾝体計測 適切な⾞椅⼦のサイズおよび姿勢⽀持具の配置を選択するために⾞椅⼦ユーザーを 計測する 中級⾞椅⼦事前評価フォームには、12 か所の⾝体⼨法を列記している。⼨法のうち 5 つは、先に 「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」で紹介したものと同じである。中級⾞椅⼦事前 評価フォームでは背もたれ⾼の⼨法を１つ追加している。それは座⾯〜肩上端9［の⾼さ］の⾝体⼨ 法で、⾼い背もたれが適する⾞椅⼦ユーザーを測るために⽤いる。他の追加した⼨法６か所は、姿 勢⽀持具のサイズおよび/または位置を決めるためのものである。 姿勢⽀持具の処⽅によっては、さらに⼨法が必要になることもある。中級⾞椅⼦事前評価フォーム には、「その他」の⼨法の記録欄を設けている。 9 [原⽂] seat to top of shoulder, [ISO 7250-1:2017] shoulder height, sitting, [JIS Z8500:2002][⽤語集] 座位肩峰⾼ 64 受講者⽤参考書 ⾝体計測は、⾞椅⼦および姿勢⽀持具の、サイズおよび配置とどう関係するのか 測った各々の⾝体⼨法は、⾞椅⼦のサイズあるいは姿勢⽀持具の位置およびサイズに関係してくる。 中級⾞椅⼦事前評価フォームでは、⾝体⼨法を左側に列記し、それぞれの⾝体⼨法が関連する部材 およびその⼨法を右側に列記している。 例えば： • ⾞椅⼦ユーザーの座位臀幅10（⾝体⼨法 A）は⾞椅⼦の座幅11、または⾻盤側⽅パッドの間隔に等 しく（⾞椅⼦部材⼨法１ あるいは２ ）、 • ⾞椅⼦ユーザーの座⾯〜腋下（わきの下）12（⾝体⼨法 H）引く 30 mmが、クッション上端〜 体幹側⽅パッド/ウェッジ（くさび）上端の最⼤の間隔（⾞椅⼦部材⼨法８ ）になる。 上記の例は、⾝体⼨法がつねに⾞椅⼦の部材⼨法に等しいとは限らず、計算が必要な場合もあるこ とを⽰している。⾞椅⼦部材の⼨法を導けるよう、公式を載せたものもある。 フィッティングではたいてい修正が必要になる。しかし、⾝体⼨法を精確に測っておくと、初回フ ィッティングに先⽴つ、⾞椅⼦の下準備で役⽴つ。 中級⾞椅⼦事前評価フォームの図は、⾞椅⼦サービス職員が⾝体⼨法を測り、それを姿勢⽀持具の 位置やサイズへ関連付ける⼿引きとして役⽴つ。 10 [原⽂] hip width, [ISO 7250-1:2017] hip breadth, sitting, [JIS Z8500:2002][⽤語集] 座位臀幅 11 [原⽂] seat width, [ISO 7176-26:2007] seat width, [JIS T9201:2016][⽤語集] シート幅 12 [原⽂] seat to axilla, [ISO 16840-1:2006] axilla height, [⽤語集] 座位腋下⾼ WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 63 64 On the intermediate wheelchair assessment form the body measurements are listed on the left hand side and the components that each body measurement relates to are listed on the right hand side. For example: r a wheelchair user’s hip width (body measurement A) equals the wheelchair seat width or the distance between the pelvis side pads (component measurements 1 or 2); r a wheelchair user’s seat to axilla (armpit) (measurement H) less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges (wheelchair component measurement 8). The examples above demonstrate that the body measurement does not always equal the wheelchair component measurement and some calculations are needed. In some cases there is a formula to help work out the wheelchair component measurement. Adjustments are often needed at the !tting. However accurate body measurements can help to prepare the wheelchair well ahead of the !rst !tting. The illustrations on the intermediate wheelchair assessment form help to guide wheelchair service personnel as they take the body measurements and relate them to the location and size of PSDs. G H B C D E F I K L J WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 63 64 On the intermediate wheelchair assessment form the body measurements are listed on the left hand side and the components that each body measurement relates to are listed on the right hand side. For example: r a wheelchair user’s hip width (body measurement A) equals the wheelchair seat width or t e distance between the pelvis side pads (component m asurements 1 or 2); r a wheelchair user’s seat to axilla (armpit) (measurement H) less 30 mm is the m ximum distance be ween the top of the cushion and th top of trunk side pads/wedges (wheel hair compon nt measurement 8). The examples above demonstrate that the body measurement does not always equal the wheelchair component measurement and some calculations are needed. In some cases there is a formula to help work out the wheelchair component measurement. Adjustments are often needed at the !tting. However accurate body measurements can help to prepare the wheelchair well ahead of the !rst !tting. The illustrations on the intermediate wheelchair assessment form help to guide wheelchair service personnel as they take the body measurements and relate them to the location and size of PSDs. G H B C D E F I K L J 中級⾞椅⼦サービス教習パッケージ 65 ⾝体計測 ⾝体⼨法（mm） ⾞椅⼦各部の⼨法（mm） 座幅・座⾯奥⾏き13・⾜台〜座⾯⾼14 A 座位臀幅 ＝座幅、または 1 ＝⾻盤側⽅パッドの間隔 2 B 座底⻑15（⾻盤 背⾯〜膝裏） 右 B 引く 30〜50 mm＝座⾯奥⾏き（左右で 異なる場合は、短い⽅を採⽤） 3 左 C 座位下腿⻑16 右 ＝⾜台〜座⾯上端の間隔、 または ＝⾜こぎの場合、床⾯〜座⾯上端の間隔 4 左 5 背もたれ⾼ D 座⾯〜胸郭下端17 ＝座⾯上端〜背もたれ上端（⾞椅⼦ユー ザーのニーズにより D、E、F のどれか） 6 E 座⾯*〜肩甲⾻下端18 F 座⾯*〜肩上端 改造および/または姿勢⽀持具 G 体幹幅19 ＝体幹側⽅パッド20/ウェッジの間隔 7 H 座⾯*〜腋下（わ きの下） 右 H 引く 30 mm＝座⾯上端〜体幹側⽅パ ッド/ウェッジの間隔の最⼤値（ハンド・ シミュレーションに従い修正） 8 左 I 座⾯*〜⾻盤上端21 （上後腸⾻棘、PSIS） ＝座⾯上端〜⾻盤後⽅パッド22中央⾼さ の間隔 9 J 膝間距離23 ＝膝分離パッド24の幅 10 K 座⾯*〜頭蓋⾻底部25 ＝座⾯上端〜ヘッドレスト中央の間隔 11 L ⾻盤背⾯〜座⾻26 L ⾜す 20〜40 mm＝背もたれの⽀持部 〜座⾻前⽅（アンカー）サポート27の距離 12 13 [原⽂] wheelchair seat depth, [ISO 7176-26:2007] seat depth, [JIS T9201:2016][⽤語集] シート奥⾏ 14 [原⽂] footrests height, [ISO 7176-26:2007] foot support to seat, [JIS T9201:2016][⽤語集] フットサポート・シ ート間距離.「⾜台⾼」は床から⾜台までの⾼さを指すことが多いため, 訳語では区別した. 15 [原⽂] seat depth, [ISO 7250-1:2017] buttock-popliteal length, [JIS Z8500:2002] 座位臀-膝窩距離 16 [原⽂] calf length, [ISO 7250-1:2017] popliteal height, sitting, [JIS Z8500:2002] 座位膝窩⾼ 17 [原⽂] bottom of ribcage. 18 [原⽂] bottom of shoulder blade, [⽤語集] 座位肩甲⾻下⾓⾼. 19 [原⽂] trunk width, [ISO 7250-1:2017] chest breadth. ⽇本語では胸部横径, 胸部幅などに相当. 20 [原⽂] trunk side pads, [ISO 7176-26:2007] lateral trunk support, [⽤語集] 体側サポート. 他に「体幹パッド」. 21 [原⽂] seat to the top of the pelvis (PSIS) 22 [原⽂] rear pelvis pad, [ISO 7176-26:2007] posterior sacrum support, [⽤語集] ⾻盤後⽅サポート 23 [原⽂] distance between the knees 24 [原⽂] knee separator pad, [ISO 7176-26:2007] medial support, [⽤語集] 内転防⽌サポート 25 [原⽂] seat to base of skull 26 [原⽂] back of pelvis to seat bones 27 [原⽂] pre seat bone shelf, [ISO 7176-26:2007] anti-thrust seat. [⽤語集] 座⾻前⽅サポート 66 受講者⽤参考書 そ の 他 ＊⾝体計測における「座⾯」とは、座⾻が据わる表⾯である。 精確な測り⽅ 計測間違いは⼤問題の元である。しかし、精確な計測が困 難なこともある。これは、特に⾞椅⼦ユーザーがたいへん ⼩さいか、じっと座っていられない、またはまっすぐに座 るのが難しい場合である。 精確な計測を⾏なうために役⽴つやり⽅： • つねに硬い巻尺を⽤いること：「裁縫⽤」の巻尺ではな く。硬い巻尺はあまり曲がらないので、計測が不精確に ならない。 • ノギス28を⽤いると、計測の精確さが増す。 • ⾞椅⼦ユーザーが、ハンド・シミュレーションを通していちばんまっすぐで、快適で、機能的だ と確定した姿勢でまっすぐに座ったところを計測せよ。⾞椅⼦ユーザーを寝た姿勢で計測すると、 測定は精確にならない。なぜなら、寝た姿勢でいる時には、⾞椅⼦ユーザーは⾝体が伸びる、あ るいは⾃分で伸ばすことがあるからだ。⾞椅⼦ユーザーを⽀えるよう補助してもらい、まっすぐ な座位姿勢を取らせる⽅が、寝かせるよりもよい。 測り⽅： ⾞椅⼦部材： 注記： A: 座位臀幅 座⾯（幅） 測る前に、⾞椅⼦ユーザーのポケットが 空なのを確認する。⾞椅⼦ユーザーの臀 部または⼤腿の、いちばん広いところを 測る。 クリップボードを 2 枚、⾞椅⼦ユーザー の両側へ当てておくと、精確に測れる。 ノギスを⽤いてもよい。 座位臀幅は、座幅あるい は⾻盤側⽅パッドの間隔 に等しくなる。 ⾻盤側⽅パッドを設ける 場合、⾞椅⼦の座幅は、よ り広く取る必要がある。 ⾞椅⼦の幅は最⼩に保つ ようにせよ。 厚着することもある寒冷 地では多少ゆとりが必要。 28 [原⽂] calipers. [訳注] ⼤型のもの.「⾞椅⼦サービス教習パッケージ 管理者向け参考書補⾜資料」p.10 を参照. 中級⾞椅⼦サービス教習パッケージ 67 測り⽅： ⾞椅⼦部材： 注記： B: 座底⻑ 座⾯（奥⾏き） クリップボードを⾞椅⼦ユーザーの背 中へ当てておくと、精確に測れる。⾞椅 ⼦ユーザーの、⾻盤背⾯から膝裏までの 直線距離を測る。 つねに両脚を測る。 左右に差がある場合は、⾞椅⼦ユーザー が、⾻盤を⽔平にしてまっすぐに座って いることを確かめる。それでも差があれ ば、短い側の数値で⾞椅⼦を処⽅する。 座底⻑ 引く 30〜50 mm が、⾞椅⼦の座⾯奥⾏き に等しくなる。 膝が 90 度よりかなり鋭⾓ に曲がっている⾞椅⼦ユ ーザーの場合、座⾯奥⾏き は、やや短く取る必要があ る。 下掲コラム「⾻盤が後傾し たまま固まった、あるいは 体幹が前屈したまま固ま った⾞椅⼦ユーザーに対 して」を参照。 ⾻盤が後傾したまま固まった、あるいは体幹が前屈したまま固まった⾞椅⼦ユー ザーに対して ⾞椅⼦ユーザーが、⾻盤が後傾したまま固まっている、あるいは体幹が前屈したまま固まってい る場合、⾞椅⼦サービス職員は、これにどう⾞椅⼦の形を合わせるか考える必要がある。そのた めに座底⻑の測り⽅を変えることもある。 • 背もたれをリクライニングし（後ろへ傾け）て ⾻盤/体幹に形を合わせられる場合は、上述の通 り⾻盤背⾯から膝裏までの直線距離を測る。 • 背もたれがリクライニングし（後ろへ傾か）な い場合は、座⾯奥のスペースに⽀持部を設けて ⾻盤/体幹に形を合わせる。右図のように⾝体 （体幹/⾻盤）のいちばん後ろの点から測り、座 ⾯奥⾏きをじゅうぶん取れるようにする。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 67 68 How to measure: Wheelchair component: Comments: B: Seat depth Seat (depth) Place a clip board at the back of the wheelchair user to help get an accurate measurement. Measure from the back of the wheelchair user’s pelvis to the back of his/her knee in a straight line. Always measure both legs. If there is a difference between the left and right side, check that the wheelchair user is sitting upright with their pelvis level. If there is still a difference, make the wheelchair prescription for the shorter side. Seat depth less 30–50 mm equals the depth of the seat of the wheelchair. For a wheelchair user whose knees are bent a lot less than 90 degrees, the seat depth may need to be slightly shorter. See the box `For wheelchair users with a !xed posterior tilt of the pelvis or !xed forward bent trunk .` For wheelchair users with a !xed posterior tilt of the pelvis or !xed forward bent trunk If a wheelchair user has a !xed posterior tilt of the pelvis or !xed forward bent trunk, wheelchair service personnel need to think about how this will be accommodated in the wheelchair. This may change the way the seat depth measurement is taken. r If the backrest is reclined (tilted back) to accommodate the pelvis/ trunk, measure from the back of the pelvis to the back of the knee in a straight line as described above. r If the backrest does not recline, supports will be made to accommodate the pelvis/trunk within the seat depth space. Measure from the furthest back point of the body (trunk/pelvis) to ensure that enough seat depth is allowed, as shown in the illustration. 68 受講者⽤参考書 測り⽅： ⾞椅⼦部材： 注記： C: 座位下腿⻑ ⾜台（⾼さ） ⾞椅⼦ユーザーの膝裏からかかとの底 までを測る。⾞椅⼦ユーザーの⾜⾸が （可能ならば）90 度に屈曲しているの を確かめる。 つねに両脚を測る。⾞椅⼦ユーザーが靴 を履く場合は、ふだん履きの靴を履いて 測る。 ⾜が尖⾜（下向き）のまま固まっている 場合は、つま先までを測る。 座位下腿⻑は、⾜台〜ク ッション上端 または ⾜でこぐ⾞椅⼦ユーザー の場合は、床⾯〜クッシ ョン上端に等しくなる。 ⾜台のぴったりな位置は、 ⾞椅⼦ユーザーが座り、ク ッションがどれくらい圧 縮するかによって変わる。 フィッティングでの最終 調整が、つねに必要。 D, E, F 背もたれ（⾼さ） D: 座⾯〜胸郭下端［の⾼さ］： ⾞椅⼦ユーザーの座⾯〜胸郭下端を測 る。 胸郭下端を⾒つけるには、両⼿を⾻盤の 両側へ当てるとよい。両⼿を内側へ優し く絞り込みながら上へ滑らせる。胸郭下 端は、腰のすぐ上である。 ⼨法 D, E, Fは、背もたれ ⾼を決めるためのもので ある。 背もたれ⾼は、⾞椅⼦ユ ーザーのニーズによって 変わる。 事前評価からの情報は、 ⾞椅⼦サービス職員が、 ⾞椅⼦ユーザーを適切に ⽀えるには、どれくらい の⾼さの背もたれが必要 か決める⽬安となる。 背もたれのリクライニン グやティルトインスペー ス［背座のティルト］が必 要な場合、最低で標準（⾞ 椅⼦ユーザーの肩甲⾻下 端まで）の背もたれ⾼が必 要。 ⾞椅⼦ユーザーが⾞椅⼦ を⾃分でこぐかどうか、忘 れずに検討せよ。その場 合、肩甲⾻を⾃由に動かせ ることが必要。 E: 座⾯〜肩甲⾻下端［の⾼さ］： ⾞椅⼦ユーザーの座⾯から肩甲⾻下端 までを垂直に測る。 ⾞椅⼦ユーザーに肩をすくめてもらう と、肩甲⾻下端を⾒つけやすい。 F: 座⾯〜肩上端［の⾼さ］： ⾞椅⼦ユーザーの座⾯から肩の上端ま でを測る。 G: 体幹幅 体幹側⽅パッドあるいは ウェッジ（の間隔） ⾞椅⼦ユーザーの体幹幅を腋下（わきの 下）のすぐ下で測る。 体幹幅が、体幹側⽅パッ ドあるいはウェッジ（く さび）の間隔。 体幹側⽅パッドやウェッ ジの最終位置は、腋下より 下に取り付ける場合、フィ ッティングの間に変わる こともある。 中級⾞椅⼦サービス教習パッケージ 69 測り⽅： ⾞椅⼦部材： 注記： H: 座⾯〜腋下（わきの下）［の⾼さ］ 体幹側⽅パッドあるいは ウェッジ（の⾼さ） 座⾯から腋下（わきの下）までを測る。 座⾯〜腋下の⼨法 引く 30 mm が、クッション上 端と体幹側⽅パッド/ウ ェッジ上端の最⼤間隔。 この採⼨は⽬安である。最 終的な⾼さは、事前評価お よびフィッティングによ って変わる。 体幹側⽅パッドは、腋下 （わきの下）を圧迫するほ ど⾼くしてはならない。こ れは不快なうえ神経に永 久的損傷を引き起こしう る。つねに最低 30 mm の すき間を体幹側⽅パッド と腋下の間に設けること。 コラム「側弯がある⾞椅⼦ ユーザーへの体幹側⽅⽀ 持部の計測」を参照。 側弯（体幹の横⽅向への弯曲）がある⾞椅⼦ユーザーへの体幹側⽅⽀持部の計測 体幹に横⽅向への弯曲（側弯）がある⾞椅⼦ユーザーには、必要 ならば、⽚側の体幹側⽅パッドを反対側よりも低くして⽀える。 左図が⽰すように、⽚側の体幹側⽅パッドは弯曲の「頂点」に置 く。反対側の体幹側⽅パッドは、腋下のすぐ下に置く。 留意事項：側弯のある⾞椅⼦ユーザーへ体幹側⽅パッドを設け る場合は、⾻盤側⽅パッドも左右に設けよ。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 69 70 How to measure: Wheelchair component: Comments: H: Seat to axilla (armpit) Trunk side pads or wedges (height) Measure from the seat to the axilla (armpit). The seat to axilla measurement less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges. This measurement is a guide. The !nal height depends on the assessment and !tting. Trunk side pads should never be high enough to put pressure into the axilla (armpit). This can be uncomfortable and cause permanent nerve damage. There should always be at least 30 mm clearance between the top of a trunk side pad and the axilla. See the box `Measuring side trunk supports for a wheelchair user with scoliosis` . Measuring side trunk supports for a wheelchair user with scoliosis (sideways curved trunk) For a wheelchair user with a sideways curved trunk (scoliosis) one trunk side pad may be lower than the other to provide support where needed. As shown in the illustration, the trunk side pad on one side will be positioned at the ‘apex’ of the curve. The trunk side pad on the other side will be positioned just below the axilla. Remember – when providing trunk side pads for a wheelchair user with a scoliosis, also provide pelvis side pads on both sides. 70 受講者⽤参考書 測り⽅： ⾞椅⼦部材： 注記： I: 座⾯〜⾻盤上端（上後腸⾻棘、PSIS） ［の⾼さ］ ⾻盤後⽅パッド（中央の ⾼さ） 座⾯から⾻盤上端（上後腸⾻棘、PSIS） までを測る。 座⾯〜⾻盤上端（上後腸 ⾻棘、PSIS）の⼨法は、 ⾻盤後⽅パッド中央の⾼ さを決めるために⽤い る。 ⾻盤後⽅パッドの奥⾏き （厚み）は、事前評価の結 果しだいで変わる。 J: 膝間距離 膝分離パッド 両膝の間隔を測る：両膝を、⾞椅⼦ユーザ ーが快適な限りで、なるべくニュートラ ルへ近づけた位置で。 膝間距離が、膝分離パッ ドの幅に等しくなる。 この間隔は、⾞椅⼦ユー ザーの座位姿勢によって 変わる。 K: 座⾯〜頭蓋⾻底部［の⾼さ］ ヘッドレスト（⾼さ） 座⾯から頭蓋⾻底部までを測る。 座⾯から頭蓋⾻底部まで の⼨法は、ヘッドレスト の位置決めに⽤いる。 L: ⾻盤背⾯〜座⾻［の距離］ 座⾻前⽅（アンカー）サ ポート［の位置］ ⾻盤背⾯から座⾻までを測る。 ⾞椅⼦ユーザーの横から（掌を上に）⼿を ⾞椅⼦ユーザーの臀部の下に置き、座⾻ を探す。指の⼀本を座⾻に当て、続いて⾞ 椅⼦ユーザーの真横へ⼿を引き出す。⾞ 椅⼦ユーザーの⾻盤背⾯から座⾻へ置い た指までを測る。 ⾞椅⼦サービス職員は、⾞椅⼦ユーザー の脇へ、左右の座⾻を通る直線を何らか の⽅法（例えばチョーク）で評価ベッド上 に印し、その印から⾻盤背⾯までを測っ てもよい。 ⾻盤背⾯から座⾻までの 距離 ⾜す 20〜40 mm が、背もたれの⽀持部か ら座⾻前⽅（アンカー）サ ポートの始点までの距 離。 ⾞椅⼦ユーザーが⾻盤が 後傾したまま固まった、 あるいは体幹が前屈した まま固まった場合、計測 法は違ってくる（コラム 「⾻盤が後傾したまま固 まった、あるいは体幹が 前屈したまま固まった⾞ 椅⼦ユーザーに対して」 を参照）。 中級⾞椅⼦サービス教習パッケージ 71 留意事項： • ⾝体計測での「座⾯」とは、座⾻が据わる表⾯である。 • あらゆる垂直⽅向の⼨法（C, D, E, F, H, I, K）について、座⾯やクッションの⾼さのどんな変 更も、それらと関係する部材の配置に影響を及ぼす。 • あらゆる⾞椅⼦部材のぴったりな位置は、必ずフィッティングで確かめる。 ステップ 3: 処⽅（選択） ⾞椅⼦およびクッションの選択 処⽅（選択）は、⾞椅⼦サービス提供の第３ステップである。処⽅/選択とは、⼿に⼊る⾞椅⼦と⾞ 椅⼦ユーザーのニーズとの間に、可能な限り最⾼のマッチングを⾒出すことである。 ⾞椅⼦を、まっすぐに座るためには付加姿勢⽀持が必要な⾞椅⼦ユーザーへ処⽅する際の内容： • ⾞椅⼦ユーザーに最適な、⾞椅⼦の種類およびサイズの選択。 • その⾞椅⼦に特有な、あらゆる設定の詳細。 • クッションの、種類とサイズの選択。 • ⾞椅⼦ユーザーが求める付加姿勢⽀持を備えるために、どんな姿勢⽀持具や改造が必要かの選択。 処⽅は、つねに⾞椅⼦ユーザーとの全⾯的な協同のもとに決定する。この教習プログラムで⽤いる 中級⾞椅⼦処⽅（選択）フォームでは、三者の承認署名を求めている。すなわち⾞椅⼦ユーザー、 評価者（⾞椅⼦サービス職員）、⾞椅⼦サービス事業管理者である。 ⾞椅⼦およびクッションの種類 １. ⾞椅⼦の種類 ⾞椅⼦を処⽅するために、⾞椅⼦サービス職員が⾞椅⼦に関して知っておくべきこと： • フレームの種類 • ⼿に⼊るサイズおよびサイズ範囲 • 利⽤できる特⾊ • 調節可能部分および調節範囲 72 受講者⽤参考書 これらの知識は、⾞椅⼦サービス職員が⾞椅⼦ユーザーに最適な⾞椅⼦を選び、どう設定すべきか 説明するのに役⽴つ。以下、中級⾞椅⼦処⽅（選択）フォームの該当箇所を⽰す。 ２. ⾞椅⼦の種類・サイズ・設定 ⾞椅⼦の種類（⼿に⼊る⾞椅⼦を列記） ⾞椅⼦の⼨法（mm） □ 座幅 □ 座⾯奥⾏き □ 背もたれ⾼ □ ⾜台〜座⾯⾼ ⾞椅⼦の設定 駆動輪位置 その他： ティルト フレームの種類 ⾞椅⼦サービス職員は、現地で⼿に⼊るさまざま な種類のフレームについて知っておく必要があ る。例えば、3輪や 4輪の⾞椅⼦、クロス型折り たたみフレーム29あるいはリジッドフレーム30、 ティルト式フレーム31、⻑い、あるいは短いホイ ールベースなど。 さまざまな種類の⾞椅⼦フレームに関する詳細 は、基礎⾞椅⼦サービス教習パッケージを参照。 29 [原⽂] a cross-folding frame 30 [原⽂] rigid frame, [⽤語集] 固定式 31 [原⽂] tilting frame WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 71 72 This knowledge will help the wheelchair service personnel to select the most appropriate wheelchair for the wheelchair user and describe how it should be set up. The relevant part of the intermediate wheelchair prescription form is shown below. 2. Wheelchair type, size and set-up Type of wheelchair (list available wheelchairs below) Wheelchair dimensions (mm) Seat width Seat depth Backrest height Footrest height Wheelchair set-up Rear wheel position Other: Tilt The type of frame Wheelchair service personnel need to know the different types of frames that are available locally. For example is the wheelchair a three-wheel or four-wheel wheelchair; a cross-folding or rigid frame; tilting frame; long or short wheelbase. For more information about different types of wheelchair frames, refer to the Wheelchair Service Training Package – Basic Level. 中級⾞椅⼦サービス教習パッケージ 73 ⼿に⼊るサイズおよびサイズ範囲 通常、⾞椅⼦のサイズは座幅と座⾯奥⾏きで表わす。 ⾞椅⼦の座幅は、⽚⽅のシートパイプの外側からもう ⽚⽅の外側まで、あるいはひじ掛けがシートパイプ32 の真上に付いていれば、それどうしの間隔を測る。⾞ 椅⼦の座⾯奥⾏きは、座⾯の前縁から背もたれまでを 測る。 ⾞椅⼦の、その他の重要な⼨法： • 床⾯からの座⾯の⾼さ（これは、⾜でこぐ⾞椅⼦ユ ーザーにとって重要） • 背もたれ⾼ 利⽤できる特⾊ 特⾊には、座⾯、背もたれ、⾜台、ひじ掛け、キャスター輪、駆動輪、姿勢⽀持具（例えば、体幹 側⽅パッド、ヘッドレスト、ベルト類）などがありうる。 調節可能部分および調節範囲 ⾞椅⼦サービス職員は、地元で⼿に⼊る⾞椅⼦について、そのさまざまな調節範囲に精通している べきだ。これには、⾜台位置の最⾼から最低までの設定、背もたれ⾼が調節できるかどうか、駆動 輪の⾞軸位置を調節できるかどうか、などがある。 調節可能な部材の「調節範囲」を知るためには、最⾼と最低の調節位置を測る必要が⽣じる場合も ある。 他のものより多く、特⾊や調節機能を持つ⼿動⾞椅⼦もある。特⾊や調節機能の中には、付加姿勢 ⽀持が必要な⾞椅⼦ユーザーにとってたいへん役⽴つものがある。そうした特⾊の例： 32 [原⽂] seat rail, [JIS T9201:2016][⽤語集] シートパイプ WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 73 74 Size available and size range Wheelchair size is usually described by the wheelchair seat width and seat depth. The wheelchair seat width is measured from the outside of one seat rail to the outside of the opposite seat rail or between armrests if these sit on top of the seat rail. The wheelchair seat depth is measured from the front of the seat to the backrest. Other important wheelchair dimensions include: r the height of the seat to the !oor (this can be important for wheelchair users who propel with their feet); r the height of the backrest. Features available Possible features include the type of seat, backrest, footrests, armrests, castor wheel, rear wheel and PSDs (for example side trunk pads, headrest, straps). Adjustments possible and range of adjustment Wheelchair service personnel should be familiar with the different adjustment range of the locally available wheelchairs. This includes the highest and lowest setting for the footrests, whether the backrest height is adjustable, and whether there are adjustments possible in the rear axle position. To "nd the ‘adjustment range’ of any adjustable components it may be necessary to measure the lowest and highest adjustment. Some manual wheelchairs have more features or adjustments than others. Some features or adjustments can be very helpful for wheelchair users who need additional postural support. These features include: 74 受講者⽤参考書 調節できる⾜台： ほとんどの⾞椅⼦は、上下に調節できる⾜台を備えて いる。 ⾞椅⼦によって、以下のような調節機能が加わる： • 前後に移動できる⾜台 • 増減できる⾜台⾓度 これらの調節により、⾞椅⼦ユーザーの⾜の置き場所 を、より⾃由に変えられる。 挙上式レッグレスト： 挙上式レッグレスト33があれば、膝が伸びた状態で⾜ を⽀えられる。これは、膝をニュートラルまで曲げて 座れない⾞椅⼦ユーザーに役⽴つ。 背もたれの傾き調節： 背もたれのリクライニング（背もたれを後ろへ傾けら れること）は、以下に形を合わせるために役⽴つ： • ニュートラルな座位姿勢まで屈曲しない（体幹〜⼤ 腿の⾓度が 90度超の）股関節。 • 後傾したまま固まった⾻盤。 • 屈曲した姿勢のまま固まった体幹下部。 ティルトインスペース34： いわゆる「ティルトインスペース」を備えた⾞椅⼦も ある。これは、背もたれと座⾯が⼀体となって後ろへ 傾くものを指す。座⾯と背もたれの間の⾓度は変わら ない。傾けた背座位置が役⽴つ場合は： • 股関節や膝の屈曲に拘縮を伴う、後傾したまま固ま った⾻盤。 • 低い座位耐性（快適に座れる時間が短い）、あるいは 通常の座位姿勢では不快。 • 快適さとくつろぎを増すため。 33 [原⽂] elevating leg rests, [ISO 7250-1:2017] angle adjustable lower leg support, [JIS T9201:2016][⽤語集] 挙上 式フット・レッグサポート 34 [原⽂] tilt in space, [ISO 7176-26:2007] tilt, [JIS T9201:2016][⽤語集] ティルト. [訳注] ⽇本で⼀般的な「ティル ト」. tilt in space (または tilt-in-space) は ISO では⾮推奨⽤語となっているが, 海外の資料では単に「傾ける」 意味の tilt と区別してこの機能を特定する場合に⾞椅⼦に限らずよく使われるため, 原著も反映して訳出した. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 73 74 Adjustable footrests: Most wheelchairs have footrests that can be adjusted up and down. Some wheelchairs have additional adjustments including: r footrests can move forwards or backwards; r footrest angle can be increased or decreased. These adjustments give more !exibility for where the wheelchair user’s feet will be placed. Elevating leg rests: Elevating leg rests can help hold the foot up with the knee extended. This can be helpful for wheelchair users who cannot bend their knee to neutral for sitting. Backrest recline: Backrest recline (tilting the backrest rearwards) can help accommodate: r hips that cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees); r "xed posterior pelvis tilt; r "xed bent posture of the lower trunk. Tilt in space: Some wheelchairs have what is called ‘tilt in space’. This means that the backrest and the seat tilt back together. The open seat to backrest angle stays the same. Tilted seat position can help: r "xed posterior pelvis tilt with hip and knee !exion contractures; r low sitting tolerance or discomfort during normal sitting position; r to increase comfort and rest. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 73 74 Adjustable footrests: Most wheelchairs have footrests that can be adjusted up and down. Some wheelchairs have additional adjustments including: r footrests can move forwards or backwards; r footrest angle can be increased or decreased. These adjustments give more !exibility for where the wheelchair user’s feet will be placed. Elevating leg rests: Elevating leg rests can help hold the foot up with the knee extended. This can be helpful for wheelchair users who cannot bend their knee to neutral for sitting. Backrest recline: Backrest recline (tilting the backrest rearwards) can help accommodate: r hips that cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees); r "xed posterior pelvis tilt; r "xed bent posture of the lower trunk. Tilt in space: Some wheelchairs have what is called ‘tilt in space’. This means that the backrest and the seat tilt back together. The open seat to backrest angle stays the same. Tilted seat position can help: r "xed posterior pelvis tilt with hip and knee !exion contractures; r low sitting tolerance or discomfort during normal sitting position; r to increase comfort and rest. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 73 74 Adjustable footrests: Most wheelchairs have footrests that can be adjusted up and down. So e wheelchairs have additional adjustments including: r footrests can move forwards or backwards; r footrest angle can be increased or decreased. These a justments give more !exibility for where the heelchair user’s fe t will be placed. Elevating leg rests: Elevating leg rests can help hold the fo t up with the knee xtended. This can be helpful for wheelchair users who cannot bend their knee to neutral for sitting. Back est recline: Backrest recline (tilting the backrest rearwards) can help accommodate: r hips that cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees); r "xed posterior pelvis tilt; r "xed bent posture of the lower trunk. Tilt in space: Some wheelchairs have what is called ‘tilt in space’. This mea s that the backrest and th seat tilt back together. The open seat to backrest angle stays the same. Tilted seat position can help: r "xed posterior pelvis tilt with hip and knee !exion contractures; r low sitting tolerance or discomfort during normal sitting position; r to increase c mfort and rest. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 73 74 Adjustable footre ts: Most wheelchairs have footrests that can be adjusted up and do n. Some wheelchairs have additional adjustments including: r footrests can move forwards o backwar s; r footrest angle can be increased or decreased. These adjustments give more !exibility for where the wheelchair user’s feet will be placed. Elevating leg rests: Elevating leg rests can help hold the foot up with the knee xt nd d. This can be helpful for wheelchair user who cannot bend their knee to utral for sitting. Backrest recline: Backrest recline (tilting the backrest rearwards) can help commodate: r hips that cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees); r "xed posterior pelvis tilt; r "xed bent posture of the lower trunk. Tilt in space: Some wheelchairs have what is called ‘tilt in space’. This means that the backrest and the seat tilt back together. The open seat to backrest angle stays the same. Tilted seat position can help: r "xed posterior pelvis tilt with hip and knee !exion contractures; r low sitting tolerance or discomfort during normal sitting position; r to increase comfort a d rest. 中級⾞椅⼦サービス教習パッケージ 75 ソリッド座⾯： スリング35座⾯に代えて、ソリッド36座⾯を備えた⾞椅 ⼦もある。これがもたらすのは： • ⾻盤や股関節への付加姿勢⽀持を組み上げる、よい ⼟台。 • スリング座⾯より⾼い安定性。これは、⾞椅⼦ユー ザーの制御できない運動が著しい場合や、体重がた いへん重い場合に有効。 ソリッド背もたれ： ソリッド背もたれを備えた⾞椅⼦もある。ソリッド座 ⾯と同様、付加姿勢⽀持を組み付けるよい基盤になる。 他にソリッド背もたれがもたらすのは： • スリング/布製背もたれより⾼い安定性。これは、⾞ 椅⼦ユーザーの制御できない運動が著しい場合に役 ⽴つ。 • ⾝⻑が⾼く体重が重い、および/または体幹が⾮常に 弱い⾞椅⼦ユーザーへの、より⼤きい⽀え。 左図中央は、ソリッド背もたれにウレタンフォームを 付加して体幹を必要なところだけ⽀え、側⽅パッドを 背もたれへボルト留めしたものである。 単純なスリング背もたれに代えて、張り調整できる背 もたれを備えたものもある。張り調整背もたれは、背 もたれからの⽀えを簡単に調節できる。それぞれのベ ルトを引き締め、あるいは緩めることにより、⽀えを より多く、あるいは少なくできる。 付加姿勢⽀持をもたらすのに、これらの特⾊をすべて備える必要はない。上記の特⾊の多くは、基 礎的な⼿動⾞椅⼦を改造してつくり出せる。 地元で⼊⼿できる⾞椅⼦の情報を集める この後のページの中級⾞椅⼦概要フォームは、現地で⼿に⼊る⾞椅⼦に関する、情報の収集および 記録に活⽤できる。 35 [訳注] 布状素材を指し, 原⽂はスラング slung. 同義で⽇本での⼀般的呼称であるスリング sling として訳出. 36 [原⽂] solid. [訳注] ⽊・プラスチック・⾦属などの堅い素材のもの. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 75 76 Rigid seat: Some wheelchairs have a rigid seat base instead of a slung seat. This can provide: r a good base to build additional postural support for the pelvis and hips; r more stability than a slung seat. This can be useful if a wheelchair user has strong uncontrolled movements or is very heavy. Rigid backrest: Some wheelchairs have a rigid backrest. As for a rigid seat, this can provide a good base to build on additional postural support. A rigid backrest can also provide: r more stability than a slung/canvas backrest. This can be useful if a wheelchair user has strong uncontrolled movements; r more support for wheelchair users who are taller and heavier and/or have very !oppy trunks. The illustration shows a rigid backrest that has had foam added to provide support for the trunk in just the right place, and side support pads bolted onto the backrest. Some wheelchairs come with a tension adjustable backrest instead of a simple slung backrest. A tension adjustable backrest allows easy adjustment of the support provided by a backrest. The individual straps are pulled tighter or made looser to give more or less support. It is not necessary to have all of these features to provide additional postural support. Many of the features above can be made as modi"cations to a basic manual wheelchair. Gathering information about locally available wheelchairs The intermediate wheelchair summary form on the following page can be used to gather and record information about locally available wheelchairs. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 75 76 Rigid seat: Some wheelchairs have a rigid seat base instead of a slung seat. This can provide: r a good base to build additional postural support for the pelvis and hips; r more stability than a slung seat. This can be useful if a wheelchair user has strong uncontrolled movements or is very heavy. Rigid backrest: Some wheelchairs have a rigid backrest. As for a rigid seat, this can provide a good base to build on additional postural support. A rigid backrest can also provide: r more stability than a slung/canvas backrest. This can be useful if a wheelchair user has strong uncontrolled movements; r more support for wheelchair users who are taller and heavier and/or have very !oppy trunks. The illustration shows a rigid backrest that has had foam added to provide support for the trunk in just the right place, and side support pads bolted onto the backrest. Some wheelchairs come with a tension adjustable backrest instead of a simple slung b ckrest. A tension adjustable backrest allows easy adjustment of the support provided by a backrest. The individual straps are pulled tighter or made looser to give more or less support. It is not necessary to have all of these features to provide additional postural support. Many of the features above can be made as modi"cations to a basic manual wheelchair. Gathering information about locally available wheelchairs The intermediate wh elchair summary form on the followi g page can be used to gather and record information about locally available wheelchairs. 76 受講者⽤参考書 ⾞椅⼦を改造する前に考慮すべきこと ⾞椅⼦ユーザーが求める⽀えを備えるためには改造が必要な⾞椅⼦を選ぶさい、⾞椅⼦サービ ス職員が考慮すべきこと： • その⾞椅⼦の動作は正常か？ • 現地で⼿に⼊る材料、および現地でのものづくりのやり⽅が、その⾞椅⼦に適合するか？ • その⾞椅⼦が破損した場合、部品は現地で修理または交換できるか？ クッションの種類 ⾞椅⼦サービス職員は、処⽅のために⼊⼿できる、クッション の種類を分かっているべきである。 考慮すべき特⾊としては： • クッションが、どんな素材でできているか。 • クッションに、除圧効果があるかどうか。 • クッションの改造が、どれくらい簡単か。 • クッションカバーが、耐⽔性かどうか。 除圧クッションなどのクッションに関する詳細は「基礎⾞椅⼦ サービス教習パッケージ（WSTPb）」を参照。 選択したクッションの種類・サイズは、中級⾞椅⼦処⽅（選択）フォーム「クッションの種類・サ イズ」に記録。 中級⾞椅⼦サービス教習パッケージ 77 ３. クッションの種類・サイズ クッションの種類 サイズ 例：除圧クッション □ □ 適切な姿勢⽀持具をつくるためにクッションの改造が必要な場合、その詳細は、後述の中級⾞椅⼦ 処⽅（選択）フォームに記載。 中級⾞椅⼦概要フォーム ⾞椅⼦の名称： ここへ写真を挿⼊： 製造者/販売者： ⼿に⼊るサイズ： 全体重量： 詳細： フレーム 固定/リジッド □ 折りたたみ □ フレーム⻑： 背もたれ スリング/布 □ ソリッド □ 張り調整 □ 座⾯ スリング/布 □ ソリッド □ 張り調整 □ クッション クッションなし □ 平⾯ウレタン □ 成形37ウレタン □ 液体 □ その他 □ ⾜台 固定式 □ 着脱式 □ その他 キャスター輪 空気⼊り □ 直径： ソリッド □ 幅： 駆動輪 空気⼊り □ 直径： ハンドリム □ ソリッド □ 幅： 位置調節⾞軸 □ エアレスチューブ □ 着脱式 □ ブレーキ 短いレバー □ ⻑いレバー □ その他： ひじ掛け 曲線形状 □ 直線形状 □ その他： 固定式 □ 着脱式 □ その他： ⼿押しハンドル ⼿押しハンドル □ 姿勢⽀持具 ⾻盤ベルト □ 下腿ベルト □ 肩ハーネス □ ⾜ベルト □ 転倒防⽌装置 □ 体幹側⽅パッド □ テーブル □ ヘッドレスト □ ⾻盤側⽅パッド □ その他： 37 [原⽂] contoured, [ISO 7176-26:2007] pre-contoured, [⽤語集] コンター型 78 受講者⽤参考書 ⼨法、調節可能性、調節範囲 ⼨法 （複数サイズの⾞椅⼦が⼿に⼊ る場合は、サイズをすべて列挙） 調節可能か？ 調節範囲 （この⾞椅⼦につい て調節できる範囲） はい いいえ 座幅 □ □ 座⾯奥⾏き □ □ 座⾯⾼ □ □ 背もたれ⾼ □ □ 背もたれの傾き □ □ ⾜台〜座⾯⾼ □ □ ⾜台⾓度 □ □ ⼿押しハンドル⾼ □ □ 全⻑ □ □ ホイールベース⻑ □ □ 座⾯〜背もたれ⾓度 □ □ ティルトインスペース □ □ 中級⾞椅⼦処⽅（選択）フォーム このフォームには、⽀えなしでは⼼地よくまっすぐに座れない⾞椅⼦ユーザーへの⾞椅⼦、クッション、姿 勢⽀持具の選択を記録。このフォームは、⾞椅⼦ユーザーのファイルに保管。 １. ⾞椅⼦ユーザーに関する情報 ⾞椅⼦ユーザー名：_______________________________ 番号：_____________________________ 事前評価⽇：_____________________________________ フィッティング⽇：__________________ 事前評価担当者名：_______________________________ ２. ⾞椅⼦の種類・サイズ・設定 ⾞椅⼦の種類（⼿に⼊る⾞椅⼦を下に列記） ⾞椅⼦の⼨法（mm） □ 座幅 □ 座⾯奥⾏き □ 背もたれ⾼ □ ⾜台〜座⾯⾼ ⾞椅⼦の設定 駆動輪位置 その他： ティルト ３. クッションの種類・サイズ クッションの種類 サイズ 例：除圧クッション □ □ 中級⾞椅⼦サービス教習パッケージ 79 ４. 必要な姿勢⽀持具・改造 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯ ／ ク % シ ' ン ソリッド座⾯ □ 座⾻前⽅（アンカー）サポート （＝3 引く 12 ） □ 座⾯前⽅を下げる 左□ 右□ 座⾯前⽅のかさ上げ □ ⾻盤前傾⽤ウェッジ（くさび） □ ⾻盤下の積み増し 左□ 右□ ⾻盤側⽅パッド（= 2 ） 左□ 右□ ⼤腿外側パッド 左□ 右□ ⼤腿内側ウェッジ（＝10 ） □ 膝分離パッド（＝10 ） □ その他 □ その他 □ 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯ と 背 も た れ 座⾯〜背もたれ⾓度を開ける □ 座⾯＆背もたれティルト38 （ティルトインスペース） □ 背 も た れ ソリッド背もたれ □ ⾻盤後⽅パッド（＝9 ） □ 背もたれの形状調整 □ 張り調整背もたれ □ 背もたれのリクライニング □ 体幹側⽅パッド（＝7 ） 左□ 右□ 体幹側⽅ウェッジ（＝7 ） 左□ 右□ その他 □ テ / ブ ル/ ひ じ 掛 け テーブル □ ひじ掛けを改造 左□ 右□ その他 □ 38 [原⽂] seat and backrest tilt, [ISO 7176-26:2007] tilt, [JIS T9201:2016][⽤語集] ティルト. [訳注] ⽇本では, 早く からこの機能を備えた製品と共に「ティルト」の呼称が定着したため, 上のような但し書きは蛇⾜にも⾒えよう. 本書では p.86 の説明の通り,「他に有効な⼿が打てない場合の特殊機能/最終⼿段」と⾒なされている. 80 受講者⽤参考書 頭 の ⽀ え 平⾯ヘッドレスト（＝11 ） □ 成形ヘッドレスト（＝11 ） □ その他： □ 下 腿 ・ ⾜ の ⽀ え ⾜台の積み増し 左□ 右□ ⾜台ウェッジ（くさび） 左□ 右□ 下腿サポート 左□ 右□ その他： □ ベ ル ト ⾻盤ベルト □ 下腿ベルト □ ⾜ベルト 左□ 右□ 肩ハーネス □ その他： □ ５. 合意署名 ⾞椅⼦ユーザー：_____________________________ 事前評価者：_____________________________ ⾞椅⼦サービス事業管理者：______________________________________________________________ 姿勢⽀持具の処⽅（選択）‒ はじめに 姿勢⽀持具にはさまざまなデザインのものがあり、⾞椅⼦ユーザーへ付加姿勢⽀持をもたらすため の⾞椅⼦改造にもさまざまなやり⽅がある。⼀⼈の⾞椅⼦ユーザーに必要に⽀え全体をもたらすに は、いくつかの姿勢⽀持具を組み合わせるのが⼀般的である。 中級⾞椅⼦サービス教習パッケージ 81 姿勢⽀持具とは何か？ 姿勢⽀持具（Postural Support Device, 略称：PSD［単数形］、PSDs［複数形］）とは、付加姿勢⽀ 持をもたらす物理的装置のことで、中級⾞椅⼦サービスに不可⽋な要素である。この後のページの 姿勢⽀持具⼀覧表（以後、PSD表とも呼ぶ）および姿勢⽀持具参照表39（以後、PSD 参照表とも呼 ぶ）では、この教習プログラムを通して紹介する、さまざまな姿勢⽀持具の概観を与える。下図に、 姿勢⽀持具のいくつかの例を⽰す。 同じものに異なる名称 同じ姿勢⽀持具でも、⾞椅⼦サービス事業、地域、製造者によって名称が異なる場合がある。こ の参考書では、簡潔かつ説明的な名称でそれぞれの姿勢⽀持具を呼んでいる。各⾞椅⼦サービス 事業、⾞椅⼦サービス職員、⾞椅⼦ユーザーで、いちばんなじみがあってしっくり来る⽤語を使 ってよい。 39 [訳注] 英語原⽂や他の⽤語法との対照は, すでに触れたものも含め, まとめてこの表で脚注を付した. ヘッドレスト ⾼い背もたれ 体幹側⽅パッド ⾻盤側⽅パッド ⾻盤ベルト ⾜ベルト 膝分離パッド 肩ハーネス 82 受講者⽤参考書 姿勢⽀持具（PSD）⼀覧表 座⾯/クッション 座⾻前⽅（アン カー）サポート 座⾯前⽅（⽚側） を下げる 座⾯前⽅の かさ上げ ⾻盤前傾⽤ ウェッジ ⾻盤下の 積み増し ⾻盤側⽅パッド 座⾯/クッション 座⾯＆背もたれ ⼤腿外側 ウェッジ ⼤腿外側 パッド ⼤腿内側 ウェッジ 膝分離パッド 座⾯〜背もたれ ⾓度を開ける 座⾯＆背もたれテ ィルト（ティルト インスペース） 背もたれ ⾻盤後⽅ パッド 背もたれの 形状調整 張り調整 背もたれ 背もたれの リクライニング 体幹側⽅ パッド 体幹側⽅ ウェッジ テーブル ヘッドレスト 下腿の⽀え テーブル 平⾯ ヘッドレスト 成形 ヘッドレスト ⾜台の 積み増し ⾜台ウェッジ 下腿サポート ベルト ⾻盤ベルト ⾻盤前傾４点ベルト 下腿ベルト ⾜ベルト 肩ハーネス 中級⾞椅⼦サービス教習パッケージ 83 姿勢⽀持具（PSD）参照表 姿勢⽀持具 ⽬的 合わせ⽅ 座⾯/クッション 座⾻前⽅（アンカー） サポート40 座⾻前⽅（アンカー）サポートの 効果： • ⾻盤を起こしておく。 • ⾻盤の前滑りを⽌める。 • ずっこけた姿勢で座る傾向を 抑える。 座⾻前⽅（アンカー）サポートの始点 は、座⾻のすぐ前⽅に置く。 座⾯前⽅（⽚側）を 下げる 左図のように座⾯前⽅を⽚側だ け下げると、座ったときニュート ラルな姿勢まで屈曲しない（体幹 〜⼤腿の⾓度が 90 度超の）側の 股関節に形を合わせられる。 座⾯の下げ加減は、⾞椅⼦ユーザーの 股関節の⾓度による。 ⾞椅⼦ユーザーの、座⾻および⼤腿の 下の接触は均等であること。 座⾯前⽅のかさ上げ 座⾯前⽅を⾼くすると、ニュート ラルな姿勢まで伸展しない（体幹 〜⼤腿の⾓度が 90 度未満の）両 側の股関節に形を合わせられる。 座⾯前⽅を⾼くすると、⾝体が伸 ⻑する、激しい制御できない運動 や緊張を抑えられる場合がある。 座⾯の上げ加減は、⾞椅⼦ユーザーの 体幹〜⼤腿の⾓度による。 ⾞椅⼦ユーザーの、座⾻および⼤腿の 下の接触は均等であること。 ⾻盤前傾⽤ウェッジ41 （くさび） 後ろ下がりに傾斜した座⾻下の ウェッジは、⾻盤に柔軟さはある が前傾している⾞椅⼦ユーザー に効果的。 このウェッジは、⾻盤が後⽅へ起 きる（後傾する）よう促す。 ⾻盤前傾⽤ウェッジは、座⾻のすぐ前 ⽅で終わり、続く⼤腿の下では、⽔平で あるようにせよ。 ⾻盤前傾⽤ウェッジを設える場合は、 まずウェッジの「実⼨模型」42を事前評 価の間につくる。⾞椅⼦ユーザーは、こ れでウェッジの効果を体感でき、⾞椅 ⼦サービス職員と⾞椅⼦ユーザーとで 最適な⾓度を⾒つけ、ウェッジの効果 を評価できる。 40 [原⽂] pre seat bone shelf, [ISO 7176-26:2007] anti-thrust seat. [⽤語集] 座⾻前⽅サポート. [訳注] 原⽂の意味 は「座⾻前⽅の棚状段差」. 「アンカーサポート」と呼ばれることが⾮常に多いため訳語では折衷. 41 [原⽂] wedge for anterior tilt 42 [原⽂] ʻmock-upʼ 84 受講者⽤参考書 姿勢⽀持具 ⽬的 合わせ⽅ ⾻盤下の積み増し43 積み増しは、⾞椅⼦ユーザーの、 ⽔平でないまま固まった⾻盤に 形を合わせるために⽤いる。 積み増しの効果： • ⾞椅⼦ユーザーの安定を⾼め る。 • 低い側の⾻盤へ、危険なほどの 圧⼒がかかるのを避ける。 積み増すのは、⾼い側の座⾻と⼤腿の 下。 ⾞椅⼦ユーザーの、座⾻および⼤腿の 下の接触は均等であること。 ⾻盤下の積み増しを処⽅すると⾜台の （⽚⽅を反対側より⾼くする）調整が 必要になる場合もある。 ⾻盤側⽅パッドも⾻盤への⽀えに役⽴ つので、⾻盤下を積み増しした⼈には、 必ず付加すること。 ⾻盤側⽅パッド44 ⾻盤側⽅パッドの効果： • 椅⼦部分の幅が広すぎる、また は臀部が体幹より細い場合に、 ⾻盤が横にずれるのを⽌める。 • ⾻盤が横へ傾く傾向を抑える。 ⾻盤側⽅パッドは、⾻盤の両側にしっ かりとした接触をもたらす45ようにす べきである。 ⼩さい⼦どもは、⼤⼈よりも⼤腿を開 いて座るべきであることに留意せよ。 このため、⾻盤側⽅パッドが前に出す ぎて、⼦どもの⼤腿を圧し合わせてい ないことを確かめよ。 ⼤腿外側ウェッジ46 （くさび） ⼤腿外側ウェッジは、以下のよう な軽い⽀えをもたらす： • ⼤腿のニュートラルな⾝体配 列（アラインメント）を保つ。 • ⾞椅⼦ユーザーの脚が開く［外 転する］、または外旋する傾向 を抑える。 ⼤腿外側ウェッジは、⾞椅⼦ユーザー が静⽌し、また動いている時に、⼤腿を ニュートラルな⾝体配列（アラインメ ント）で快適に⽀えるものであること。 ⼤腿が倒れる、あるいは外転する傾向 が続く場合は、より強固な⽀えが必要 かもしれない（⼤腿外側パッドを参 照）。 43 [原⽂] build-up under pelvis 44 [原⽂] pelvis side pads, [ISO 7176-26:2007] lateral pelvic support, [⽤語集] ⾻盤側⽅サポート 45 [原⽂] provide firm contact on both sides of the pelvis 46 [原⽂] outside thigh wedge, [ISO 7176-26:2007] inferior upper leg support, [⽤語集] 外転防⽌サポート. [訳注] 原⽂の意味は訳語の通り. ISO ⽤語のʼinferiorʼは「劣った」ではなく「下位の・下からの（⽀え）」の意. 中級⾞椅⼦サービス教習パッケージ 85 姿勢⽀持具 ⽬的 合わせ⽅ ⼤腿外側パッド47 ⼤腿外側パッドは、強固な⽀えをもた らし、⾞椅⼦ユーザーの脚が外へ落ち る、または外旋するのを防ぐ。 ⼤腿外側パッドは、⾞椅⼦ユーザ ーが静⽌し、また動いている時に、 ⼤腿をニュートラルな⾝体配列 （アラインメント）で快適に⽀え るものであること。 パッドと⾞椅⼦ユーザーの脚との 接触は、均等であること。 ⼤腿内側ウェッジ48 （くさび） ⼤腿内側ウェッジは、以下のような軽 い⽀えをもたらす： • ⼤腿のニュートラルな⾝体配列（ア ラインメント）を保つ。 • ⾞椅⼦ユーザーの両脚が閉じる/重 なる傾向を抑える。 ⼤腿内側ウェッジは、⾞椅⼦ユー ザーが静⽌し、また動いている時 に、⼤腿をニュートラルな⾝体配 列（アラインメント）で快適に⽀ えるものであること。 ⼤腿ウェッジのせいで、⾞椅⼦ユ ーザーの⾞椅⼦の乗り降りが難し くなっていないか確かめよ。 膝分離パッド49 膝分離パッドは、強固な⽀えをもたら し、⼤腿のニュートラルな⾝体配列 （アラインメント）を保つ。 膝分離パッドは、両脚が閉じる傾向が 強い場合、たいへん有効である。 膝分離パッドは、⾞椅⼦ユーザー が静⽌し、また動いている時に、 ⼤腿をニュートラルな⾝体配列 （アラインメント）で快適に⽀え るものであること。 ⾞椅⼦ユーザーの膝および⼤腿の 接触は、均等であること。 膝分離パッドは、決して⿏径部に 触れてはならない。⾞椅⼦ユーザ ーが前滑りして膝分離パッドにぶ つかる危険がある場合は、座⾻前 ⽅（アンカー）サポートおよび⾻ 盤ベルト50を備えよ。 47 [原⽂] outside thigh pad, [ISO 7176-26:2007] lateral upper leg support, [⽤語集] 外転防⽌サポート 48 [原⽂] inside thigh wedge 49 [原⽂] knee separator pad, [ISO 7176-26:2007] medial support, [⽤語集] 内転防⽌サポート. [訳注] ⽇本では, 内 転防⽌パッド, ポメルと呼ばれることも多い. 英語資料では位置を明⽰して medial thigh support (「⼤腿の間の⽀ 持具」の意)と呼ばれることも多い. 50 [原⽂] pelvis strap 86 受講者⽤参考書 姿勢⽀持具 ⽬的 合わせ⽅ 座⾯＆背もたれ 座⾯〜背もたれ⾓度を開 ける51 座⾯〜背もたれ⾓度を開ける（⼤き くする）のは、⾻盤後傾のまま固ま っている、あるいは股関節が固まっ ている⾞椅⼦ユーザーに有効。 ⼤きくした⾓度のゆとりが、固まっ た姿勢に形を合わせ、強固な⽀えを 与えて快適さを向上し、将来、姿勢 がさらに変わるのを防ぐ。 ⾞椅⼦ユーザーの両座⾻の下、⾻ 盤背⾯、腰部、背部の接触は均等で あること。そのため、適切な⽀えと 接触をもたらすようウレタンフォ ームの成形が必要な場合もある。 座⾯〜背もたれ⾓度を開ける場 合、⾞椅⼦ユーザーが⾞椅⼦上で 前滑りしないよう、厳重に注意せ よ。これは、褥瘡を引き起こす「剪 断［せんだん］」の原因となる。 座⾯＆背もたれティルト (ティルトインスペース)52 座⾯と背もたれをいっしょに傾け ることの効果： • 屈曲したまま固まった体幹姿勢 に形を合わせた後も、頭に緊張が 残る場合に、体幹上部と頭の⾝体 配列（アラインメント）を整え て、まっすぐな姿勢にする。 • 体幹の⼒が⾮常に弱い⾞椅⼦ユ ーザーの、体幹上部と頭の⾝体配 列（アラインメント）を整えて、 まっすぐな姿勢にする。 座⾯と背もたれをいっしょに傾け るのは、他の⾻盤および体幹への ⽀えが、すべてうまく⾏かなかっ た場合にのみ試みること。 傾けた効果をていねいに観察し、 最適な⾓度、および効果の程度を 判断せよ。最終的な傾けた姿勢で は、⾞椅⼦ユーザーは快適で、その 座位姿勢は本⼈にとって最もニュ ートラルに近いものであること。 背もたれ ⾻盤後⽅パッド53 ⾻盤上端を⽀えて、⾻盤をまっすぐ に起こしておくためのもの。 ⾻盤後⽅パッドは、ふつう座⾻前⽅ （アンカー）サポートと組み合わせ て設え、また⾻盤ベルトを併⽤する 場合もある。 ⾻盤後⽅パッドは、上後腸⾻棘 （PSIS）の⾼さで⾻盤背⾯にしっ かり当たり、⾻盤がニュートラル でまっすぐに起きた座位姿勢をと るよう促すものであること。 左右の上後腸⾻棘（PSIS）の間の 椎⾻に、強い圧⼒がかかっていな いか確かめよ。 51 [原⽂] open seat to backrest angle 52 [原⽂] tilt in space, [ISO 7176-26:2007] tilt, [JIS T9201:2016][⽤語集] ティルト. [訳注] ⽇本で⼀般的な「ティル ト」. tilt in space (または tilt-in-space) の語は ISO ではすでに⾮推奨⽤語となっているが, 海外の資料では単に 「傾ける」意味の tilt と区別してこの機能を特定する場合に依然よく使われるため, 原著も反映して訳出した. 53 [原⽂] rear pelvis pad, [ISO 7176-26:2007] posterior sacrum support, [⽤語集] ⾻盤後⽅サポート. [訳注]「⾻盤 パッド」と呼ばれることも多い. 中級⾞椅⼦サービス教習パッケージ 87 姿勢⽀持具 ⽬的 合わせ⽅ 背もたれの形状調整54 背もたれの形状を修正し、体幹をニュ ートラルな座位姿勢（正常なカーブ） でよりしっかりと⽀え、ニュートラル でない姿勢のまま固まった体幹に形を 合わせる。 背もたれの形状調整には、以下のさま ざまなやり⽅がある： • 背もたれ布を加⼯し、⾻盤後⽅パッ ドを付加する（上図）。 • 成形ウレタンフォーム背もたれ55を ソリッド背もたれ上に取り付ける。 • 張り調整背もたれを⽤いる（下図）。 修正した背もたれは、背中の下部・ 中央部・上部に均等な接触をもた らすこと。 ニュートラルな姿勢をとれる場 合、背もたれが、⾻盤をまっすぐ に起きた姿勢で⽀え、体幹を正常 なカーブで⽀えること。 完全にニュートラルな姿勢を取れ ない場合、背もたれは、⾞椅⼦ユ ーザーをできる限りニュートラル に近い姿勢で⽀えること。 張り調整背もたれ56 背もたれの リクライニング57 背もたれのリクライニングは、以下に 形を合わせるために有効： • ニュートラルな姿勢まで屈曲しない （体幹〜⼤腿の⾓度が 90 度超の） 股関節。 • 後傾したまま固まった⾻盤。 • 屈曲したまま固まった姿勢の体幹下 部。 • 前⽅へ弯曲したまま固まった体幹に 形を合わせる。 • 体幹と頭の⾝体配列（アラインメン ト）を整える。 座⾻前⽅（アンカー）サポート、⾻盤ベ ルト、および/またはクッション前部の ウェッジ（くさび）は、前滑りを防ぐ。 背もたれのリクライニングが、⾞ 椅⼦ユーザーを、できる限り最適 な⾝体配列（アラインメント）で ⽀えているか確かめよ。 ⾞椅⼦ユーザーの背中と背もたれ とが、均等に接触するようにせよ。 ⾞椅⼦ユーザーが、前滑りしない か確かめよ。座⾻前⽅（アンカー） サポート、⾻盤ベルト、および/ま たはクッション前部のウェッジ （くさび）は、前滑りを防ぐ。 54 [原⽂] adjust backrest shape 55 [原⽂] shaped foam backrest 56 [原⽂] tension adjustable backrest 57 [原⽂] backrest recline 88 受講者⽤参考書 姿勢⽀持具 ⽬的 合わせ⽅ 体幹側⽅パッド58 体幹側⽅パッドは、強固な⽀えを与 え、体幹を背もたれ中央に保つ。 体幹側⽅パッドを⼀つ付けたら、必 ず反対側にもう⼀つ付ける。 体幹側⽅パッドは、必ず⾞椅⼦ユ ーザーの腋下（わきの下）より 30 mm 以上低くし、必要以上に前へ はみ出てはならない。 ⾞椅⼦ユーザーとパッドの間の圧 ⼒が均等で、強い圧⼒がかかる箇 所がないように。⽀えを強くした い場合は、パッドを⼤きくして圧 ⼒を分散し、緩衝材がじゅうぶん 効いているよう確かめよ。 体幹側⽅パッドはなるべく薄く し、⾞椅⼦ユーザーが腕を⾃由に 振れるようにすること。 体幹側⽅ウェッジ59 （くさび） 軽い⽀えを与え、⾞椅⼦ユーザーの 体幹を背もたれ中央に保つ。⽀えが 少しだけ必要な場合に便利である。 体幹側⽅ウェッジは、⾞椅⼦ユー ザーが左右対称な（体幹が背もた れ中央にある）座位姿勢を保つの に役⽴つこと。 ウェッジは腋下（わきの下）より下 に置き、必要以上に前へはみ出て はならない。 体幹側⽅パッドと⾻盤側 ⽅パッドを併⽤ 体幹側⽅パッドと⾻盤側⽅パッド の組み合わせは、体幹が横に弯曲 （側弯）している⾞椅⼦ユーザーを ⽀えるのに⽤いる。 各パッドが弯曲の上端、（反対側の） 頂点、下端を⽀えるよう調整する。 ⾻盤側⽅パッドは、⾻盤を座⾯中央 に保つため、左右に必要。 側弯で柔軟さがある⼈をニュート ラル［な姿勢］で⽀えると、柔軟だ が⽔平でない⾻盤が矯正される場 合がある。 座位姿勢に柔軟さがあれば、⾞椅 ⼦ユーザーは、ニュートラルな座 位姿勢で座れる。座位姿勢が固ま っている場合は、快適な限りでな るべくニュートラルに近づけて⽀ えよ。 ⾞椅⼦ユーザーと各パッドの間の 圧⼒を均等にせよ。強い圧⼒がか かる箇所がないか調べよ。⽀えを 強くしたい場合は、パッドを⼤き くして圧⼒を分散し、緩衝材がじ ゅうぶん効いているか確かめよ。 58 [原⽂] trunk side pads, [ISO 7176-26:2007] lateral trunk support, [⽤語集] 体側サポート.他に「体幹パッド」. 59 [原⽂] trunk side wedges 中級⾞椅⼦サービス教習パッケージ 89 姿勢⽀持具 ⽬的 合わせ⽅ モールド式60背サポート モールド式［型取り・成形した］背サポートは、前に倒れる、または弯曲 した体幹など、さまざまな体幹姿勢で⽀え、形を合わせるために使える。 この背サポートは、⾞椅⼦フレームに受け具やベルトで固定する。 この選択肢は、中級では取り上げない。 テーブル テーブル テーブルには、たくさんの⽤途があ る。例えば： • 腕を⽀え、⾞椅⼦ユーザーの腕の 重みが体幹を下や前に引っ張る傾 向を抑える。 • ⾞椅⼦ユーザーの⾝体の近くに、 作業する/遊ぶための天板を設け る。 テーブル位置は通常、ひじのすぐ 上の⾼さにする。付加姿勢⽀持を 与える⽬的で、それよりわずかに ⾼い位置にしてもよい。 テーブルを、⾞椅⼦ユーザーの座 席への「拘束」に⽤いてはならな い。テーブルは、ユーザーへいか なる圧⼒も及ぼしてはならない。 ヘッドレスト 平⾯ヘッドレスト61 平⾯ヘッドレストは、頭が休める場所 を設け、頭が後ろへ倒れるのを⾷い⽌ める。 ヘッドレストは、⾞椅⼦ユーザー が静⽌している、および/または動 いている時、しっかりと⽀えるも のであること。 ヘッドレストは、⾞椅⼦ユーザー の頭に頭蓋⾻底部で接すること。 ヘッドレストが正しい配置で⽀ え、⾞椅⼦ユーザーの頭を前へ押 したり、頭に後ろに倒れる余地を 与えたりしていないか確かめよ。 ⾞椅⼦ユーザーの頭を、前⽅で⽀ えるのは避けよ。 成形ヘッドレスト62 成形ヘッドレストは、⾞椅⼦ユーザー の頭蓋⾻底部の輪郭に沿っているた め、平⾯ヘッドレストより⼤きい⽀え をもたらす。 下腿の⽀え ⾜台の積み増し ⾜台の積み増しは、⽚⾜または両⾜が （⾜台位置を調整して最⾼にした場 合も）⾜台へ届かない場合に⽤いる。 左右の⾜底が、均等に接触してい るか確かめよ。 60 [原⽂] moulded (英語. ⽶語では molded), [ISO 7176-26:2007] custom-contoured, [⽤語集] モールド式 61 [原⽂] flat headrest 62 [原⽂] shaped headrest 90 受講者⽤参考書 姿勢⽀持具 ⽬的 合わせ⽅ ⾜台ウェッジ63 （くさび） ⾜台ウェッジは、ニュートラルでな い姿勢で固まった⾜の⽀えに使う。 ⾜台ウェッジは、⾜⾸がさらに変化 するのを防ぐ。 ⾜台ウェッジは、⾞椅⼦ユーザーの ⾜と、⾜台との接触⾯積を広げるこ とが⽬的。 ⾜台ウェッジは、⾞椅⼦ユーザーの ⾜に必要な⽀えに従い、個別製作す ることが多い。 左右の⾜底が、均等に接触している か確かめよ。 下腿サポート さまざまな下腿サポートが、90 度ま で曲がらない（体幹〜⼤腿の⾓度64が 90 度超の）膝関節など、ニュートラ ルでない姿勢で固まった下腿への⽀ えに⽤いられる。 さまざまな解決策およびその合わせ ⽅については、この後の製品（⾞椅 ⼦）の下準備に関する授業で説明。 ベルト ⾻盤ベルト ⾻盤ベルトは、⾻盤を定位置に保つ。 特に、制御できない運動および/また は前滑りの傾向がある⼈には有効。 ⾻盤ベルトは、座⾻前⽅（アンカー） サポートおよび⾻盤後⽅パッドと組 み合わせて⽤いることが多い。 ⾻盤ベルトは、しっかりと均等に接 触することが必要。強い圧⼒がかか る箇所があってはならない。ベルト には、⾞椅⼦ユーザーの⼤腿との接 触部分に緩衝材を施すことが重要。 ベルトの⾞椅⼦への取り付け位置 が、引っ張る⾓度/⽅向を左右する。 ⾓度は 45〜90 度にする。最も効果 的な⾓度は、⾞椅⼦ユーザーのニー ズによって異なる。 ⾻盤ベルトの⾓度は必ず⾞椅⼦ユー ザーと共に評価し、話し合い、でき れば試し、⾞椅⼦ユーザーにとり最 も効果的で快適な⾓度を⾒つけよ。 63 [原⽂] footrest wedges 64 [訳注] 原⽂のまま. 膝関節なので「⼤腿〜下腿の⾓度」のことと思われる. 中級⾞椅⼦サービス教習パッケージ 91 姿勢⽀持具 ⽬的 合わせ⽅ ⾻盤前傾４点ベルト65 ⾻盤前傾４点ベルトは、⾻盤が前傾し ている⾞椅⼦ユーザーを⽀える。 このベルトは、⾻盤をよりニュートラ ルな座位姿勢に持って⾏き、⾻盤がさ らに前傾するのを防ぐように⽀える。 このベルトは、⾞椅⼦ユーザーの座⾻ 下に置く⾻盤前傾⽤ウェッジと併⽤ 可能。 注記：ベルト下端はシートパイプ、 後端は背もたれパイプへ固定。 このベルトが、腹部までせり上が る可能性があってはならない。 左右の上前腸⾻棘（ASIS）上で⽀ えるあらゆるベルトには、褥瘡の 危険を減らすためにじゅうぶん緩 衝材を効かせることが重要。 下腿ベルト66 下腿ベルトは、下腿が後ろへ落ち込むのを防ぐ。 このベルトが、⾞椅⼦に標準装備されている場合もある。 ⾜ベルトには、⾞椅⼦ユーザーの⾜を⽀えて安定させ、また⾜が前後に動かないよう保つ、さまざま な種類のものがある。 ⾜ベルト：かかとの 後ろ かかとの後ろのベルトは、⾜が後ろへ 滑るのを防ぐ。これは、よりしっかり ⽀えるため下腿ベルトと併⽤できる。 ⾜ベルトは、均等な圧⼒をもたら し、じゅうぶん緩衝材が効いてい るようにせよ（特に⾞椅⼦ユーザ ーが靴を履かない場合）。 ⾜ベルト：⾜⾸の周り ⾜⾸周りの⾜ベルトは、⾜が前に動い たり、かかとが持ち上がったりしない ように保つ。 ⾜ベルト：⾜甲の上 ⾜甲の上の⾜ベルトは、つま先が持ち 上がらないように保つ。 65 [原⽂] anterior tilt four-point strap 66 [原⽂] calf strap, [ISO 7176-26:2007] posterior lower leg support, [⽤語集] レッグサポート. [訳注] 本書では特に ベルト状のものを指しており, 後の章でその応⽤や改造, 製作について述べているため, 限定的に訳出した. 92 受講者⽤参考書 姿勢⽀持具 ⽬的 合わせ⽅ 肩ハーネス 肩ハーネスは、⾻盤を⽀え、体幹を⽀ え、背もたれと座⾯を傾けてもうまく ⾏かない場合に、体幹をまっすぐに保 てるようにする。 左図の肩ハーネスは、胸ベルトを備え て⽀えを増している。胸ベルトは肩ベ ルトを正しい位置へ保つのに役⽴つ。 肩ハーネスは、必ず⾻盤ベルトと併⽤。 絶対に、⾻盤ベルトなしで肩ハー ネスを処⽅してはならない。⾻盤 ベルトなしでの使⽤は、ユーザー が滑り落ちた時にベルトで⾸が絞 まる可能性がある。 ベルトが肩に掛かる部分に、じゅ うぶん緩衝材が効いているか確か めよ。 胸ベルト（左図を参照）があると、 肩ベルトを定位置へ保てる。 肩ベルトは、ユーザーの肩以上の ⾼さに固定せよ。そうすると、ベル トを締めた時に、⾞椅⼦ユーザー の肩へ下向きの⼒がかかるのを防 げる。 中級⾞椅⼦処⽅（選択）フォームに姿勢⽀持具を記録する 中級⾞椅⼦処⽅（選択）フォームの⽬的は、⾞椅⼦を下準備する⾞椅⼦サービス職員へ、以下につ いて明確な情報を与えることである： • ⾞椅⼦の種類・サイズ・設定（前述） • クッションの種類・サイズ（前述） • 必要な姿勢⽀持具・改造 中級⾞椅⼦処⽅（選択）フォームへ盛り込む情報が詳しいほど、⾞椅⼦の初回フィッティングに向 けた下準備が精確になる。 処⽅できる姿勢⽀持具に多種多様なものがあるため、「必要な姿勢⽀持具・改造」は中級⾞椅⼦処 ⽅（選択）フォームの中で最も複雑な箇所である。 ⾞椅⼦サービス職員は、中級⾞椅⼦処⽅（選択）フォームの「必要な姿勢⽀持具・改造」の箇所を、 以下のことに活⽤できる： • 処⽅/選択したい姿勢⽀持具を、（チェック欄を使い）⼀般的な姿勢⽀持具の⼀覧表から選ぶ。他 の種類の姿勢⽀持具を記⼊するための「その他」欄も設けている。 中級⾞椅⼦サービス教習パッケージ 93 • 投影図に重ね描きして、処⽅（選択）した姿勢⽀持具の形状を⽰し、⼨法を与える。 • 追加情報があれば、書き込むか描くかする。 注記：中級⾞椅⼦処⽅（選択）フォームで、必ずしも姿勢⽀持具のつくり⽅まで述べる必要はない。こ れは、⾞椅⼦を下準備する⾞椅⼦サービス職員と事前評価に当たった⾞椅⼦サービス職員とで、話し合 って決めればよい。 以下は、中級⾞椅⼦の処⽅（選択）フォームの「姿勢⽀持具または改造」箇所の完成例２ 例である。（⼨法は省略） 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯/ ク % シ ' ン ソリッド座⾯ □ 座⾻前⽅（アンカー）サポート （＝3 引く 12 ） ✔ 座⾯前⽅を下げる 左□ 右✔ 座⾯前⽅のかさ上げ □ ⾻盤前傾⽤ウェッジ（くさび） □ ⾻盤下の積み増し 左□ 右□ ⾻盤側⽅パッド（= 2 ） 左□ 右□ ⼤腿外側パッド 左□ 右□ ⼤腿内側ウェッジ（＝10 ） □ 膝分離パッド（＝10 ） □ その他 □ その他 □ 座 ⾯ ＆ 背 も た れ 座⾯〜背もたれ⾓度を開ける □ 座⾯＆背もたれティルト （ティルトインスペース） ✔ 背 も た れ ソリッド背もたれ □ ⾻盤後⽅パッド（= 9 ） □ 背もたれの形状調整 □ 張り調整背もたれ □ 背もたれのリクライニング □ 体幹側⽅パッド（＝7 ） 左✔ 右□ 体幹側⽅ウェッジ（＝7 ） 左□ 右✔ その他 □ 94 受講者⽤参考書 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ テ / ブ ル/ ひ じ 掛 け テーブル □ ひじ掛けを改造 左□ 右□ その他 □ その他： □ 頭 部 の ⽀ 持 具 平⾯ヘッドレスト（＝11 ） □ 成形ヘッドレスト（＝11 ） □ その他： □ 下 腿 ・ ⾜ の ⽀ え ⾜台の積み増し 左□ 右□ ⾜台ウェッジ（くさび） 左□ 右□ 下腿サポート 左□ 右□ その他： □ ベ ル ト ⾻盤ベルト □ 下腿ベルト □ ⾜ベルト 左□ 右□ 肩ハーネス □ その他： □ 姿勢⽀持具の処⽅（選択） - ⾻盤を安定させる ⾻盤を⽀えるためには、いくつもの姿勢⽀持具が使われる。重要な留意事項：姿勢⽀持具は単独で ⽤いることもできるが、その多くは合わせ技で働くものである。この授業では、⾻盤に関連するさ まざまな姿勢の問題、および可能な姿勢⽀持の解決策を⾒て⾏く。 まず⾻盤を安定させることが、⾞椅⼦ユーザーがまっすぐに座るよう⽀援する上 で最重要 • ⾻盤がまっすぐに起きた位置にない場合、体幹や股関節の位置にも変化が⽣じる。 • したがって、⾻盤を⽀え、または安定させることが、⾞椅⼦ユーザーがまっすぐに座れるよう にするうえで最も重要。 • ⾻盤を⽀えることにより、他のあらゆる箇所で⽀えの必要を減らせる。 中級⾞椅⼦サービス教習パッケージ 95 問題：⾻盤が後傾および/または前滑りする 必要な⽀え 後傾している⾻盤をよりニュートラルな座位姿勢へ持っ て⾏く場合、たいてい２か所に⽀えが必要で： • 上後腸⾻棘（PSIS）の⾼さで⾻盤背⾯と、 • 座⾻（座⾻結節）の位置で⾻盤の前⽅を⽀える。 姿勢⽀持具の解決策 座⾻前⽅（アンカー）サポートは座⾻の前⽅を⽀え： • ⾻盤をまっすぐに起こして保ち、 • ⾻盤が前⽅へ滑るのを⽌め、 • ずっこけた姿勢で座る傾向を減らす。 座⾻前⽅（アンカー）サポートは、座⾻のちょうど前⽅に 据える。 ⾻盤後⽅パッドは⾻盤を上端（上後腸⾻棘（PSIS）の⾼ さ）で⽀え、⾻盤をまっすぐに起こして保つ。 座⾻前⽅（アンカー）サポートと⾻盤後⽅パッドの組み 合わせは、⾞椅⼦ユーザーが⾻盤をよりまっすぐに起こ し、安定して座れるようにするために、よく⽤いられる。 ⾻盤ベルトは、制御できない運動および/または前⽅へ滑 る傾向がある⾞椅⼦ユーザーへ⽀持を付加する。⾻盤ベ ルトは⾻盤を定位置に保つため、座⾻前⽅（アンカー）サ ポートと⾻盤後⽅パッドの⽀えが⻑続きする。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in posterior tilt and/or slides forward Support needed To bring the pelvis from posterior tilt to more neutral sitting posture, support is usually needed in two areas: r at the back of the pelvis at the level PSIS; r at the front of the pelvis at the seat bones (ischial tuberosities). PSD solutions A pre seat bone shelf provides support in front of the seat bones and helps to: r keep the pelvis upright; r stop the pelvis from sliding forward; r reduce a tendency to sit with a slumped posture. The pre seat bone shelf sits just in front of the seat bones. A rear pelvis pad provides support at the top of the pelvis (at the level of PSIS) and helps to keep the pelvis upright. The combination of a pre seat bone shelf and rear pelvis pad is often used to help wheelchair users to sit with a more upright pelvis and with more stability. A pelvis strap can provide additional support for wheelchair users who have uncontrolled movements and/ or a tendency to slide forwards. The pelvis strap helps to keep the pelvis in place, so that the pre seat bone shelf and the rear pelvis pad continue to provide support. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in posterior tilt and/or slides forward Support needed To bring the pelvis from post rior til to more neutral sitting posture, support is usually needed in two areas: r at the back of the pelvis at the level PSIS; r at the front of the pelvis at the seat bones (ischial tuberosities). PSD solutions A pre seat bone shelf provides support in front of the seat bones and helps to: r keep the pelvis upright; r stop the pelvis from sliding forwa d; r reduce a tendency to sit with a slumped posture. The pre seat bone shelf sits just in front of the seat bones. A rear pelvis pad provides support at the top of the pelvis (at the level of PSIS) and helps to keep the pelvis upright. The combination of a pre seat bone shelf and rear pelvis pad is often used to help wheelchair users to sit with a more upright pelvis and with more stability. A pelvis strap can provide additional support for wheelchair users who have uncontrolled movements and/ or a tendency to slide forwards. The pelvis strap helps to keep the pelvis in place, so that the pre seat bone shelf and the rear pelvis pad continue to provide support. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in posterior tilt and/or slides forward Support needed To bring the pelvis from posterior tilt to more neutral sitting posture, support is usually needed in two areas: r at the back of the pelvis at the level PSIS; r at the front of the elvis at the seat bones (ischial tuberosities). PSD solutions A pre seat bone shelf provides support in front of the seat bones and helps to: r keep the pelvis upright; r stop the pelvis from sliding forward; r reduce a tendency to sit with a slumped posture. The p seat bo e sh lf its just in front of t eat bones. A rear p lvis pad provides s pport at the top of the pelvis (at the level of PSIS) and helps to ke p the pelvis upright. The combination of a pre seat bone shelf and rear pelvis pad is often used to help wheelcha r users to sit with a more upright pelvis and with more stability. A pelvis strap can provide additional support for wheelchair u e s who have uncontr lled movements and/ or a tendency to slide f rwards. The pelvis strap helps to keep the pelvis in place, s th t the pre seat bone shelf and the rear pelvis pad continue to provide support. 96 受講者⽤参考書 問題：⾻盤が側傾している（⽔平でないまま固まった⾻盤） 必要な⽀え ⾼い側の座⾻と⼤腿の下を⽀える必要があり、それにより： • ⾞椅⼦ユーザーの安定が向上し、 • 低い側の⾻盤へ、危険なほど圧⼒がかかるのを避けられる。 姿勢⽀持具の解決策 ⾻盤下を積み増しすることで： • ⾞椅⼦ユーザーの安定が向上する。 • 低い側の⾻盤へ、危険なほど圧⼒がかかるのを避けられる。 ⾻盤側⽅パッドは、⾻盤へいっそうの⽀えをもたらすので、⾻盤 下を積み増しした⼈には必ず付加すること。 問題：⾻盤が⽚側に寄る この問題は、えてして他の姿勢の問題と結び付 いている。右図の⼆枚から判るように： • 前項と同じ男性：⾻盤が横へ傾き（⽔平でない まま固まった⾻盤）、そのため⾻盤が左上がり になっている。 • ⼥性は脊柱が横へ弯曲しており、やはり⾻盤 が左上がりになっている。 必要な⽀え 左右の股関節の横に⽀えを設けるとよい。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in lateral tilt (!xed unlevel pelvis) Support needed Support is needed under the higher seat bone and thigh to: r increase stability for the wheelchair user; r help to avoid unsafe pressure on the lower side of the pelvis. PSD solutions A build-up under the pelvis helps to: r increase stability for the wheelchair user; r avoid unsafe pressure on the low side of the pelvis. Pelvis side pads provide further support for the pelvis and should be added for anyone with a build-up under the pelvis. Problem: Pelvis moves to one side This problem is often associated with other postural problems. In the two illustrations you can see: r the same man from earlier – who has lateral pelvis tilt (!xed unlevel pelvis) and his pelvis is more towards the left; r a woman with a sideways curve in her spine; her pelvis is also more towards the left. Support needed Support can be provided at the side of both hips. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in lateral tilt (!xed unlevel pelvis) Support needed Support is needed under the higher seat bone and thigh to: r increase stability for the wheelchair user; r help to avoid unsafe pressure on the lower side of the pelvis. PSD solutions A build-up under the pelvis helps to: r increase stability for the wheelchair us r; r avoid unsafe pressure on the low sid of the pelvis. Pelvis side pads provide further support for the pelvis and should be added for anyone with a build-up under the pelvis. Problem: Pelvis oves to ne side This problem is often associated with other postural problems. In the two illustrations you can see: r the same man from earlier – who has lateral pelvis tilt (!xed unlevel pelvis) and his pelvis is more towards the left; r a woman with a sideways curve in her spine; her pelvis is also more towards the left. Support needed Support can be provided at the side of both hips. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in lateral tilt (!xed unlevel pelvis) Support needed Support is needed under the higher seat bone and thigh to: r increase stability for the wheelchair user; r help to avoid unsafe pressure on the lower side of the pelvis. PSD solutions A build-up under the pelvis helps to: r increase stability for the wheelchair user; r avoid unsafe pressure on the low side of the pelvis. Pelvis side pads provide further supp t for the pelvis an should be added for anyone with a b ild-up under the pelvis. Problem: Pelvis moves to one side This problem is often associated with other postural problems. In the two illustrations you can see: r the same man from earlier – who has lateral pelvis tilt (!xed unlevel pelvis) and his pelvis is more towards the left; r a wo an with a si eways curve in her spine; er pelvis is also more towards the l ft. Support needed Support can be provided at the side of both hips. WHEELCHAIR SERVICE TRAINING PA KAGE INTERMEDIATE LEVEL 95 96 Problem: elvis is in lateral tilt (!xed unlevel p l Su port ne Support is needed under the igher seat bone and thigh to: r increase stability for the wheelchair us ; r help to avoid unsafe pressure on the lower side of the pelvis. PSD solutions A build-up under the pelvis helps to: r increase stability for the wheelcha r us r; r avoid n afe pressure on the low side of th pelvis. Pelvis side pads provide further support for the pelvis and should be added for anyone with a build-up under the pelvis. Problem: Pelvis moves to one side This problem is often associated with other postural problems. In the two illustrations you can see: r the same man from earlier – who has lateral pelvis tilt (!xed unlevel pelvis) and his pelvis is mo e tow rds the left; r a woman with a sideways curve in her spine; her pelvis is also more towards the left. Support needed Support can be provi d at the side of both hips. 中級⾞椅⼦サービス教習パッケージ 97 姿勢⽀持具の解決策 ⾻盤側⽅パッド。 ⼦どもに⾻盤側⽅パッドをつくる ⼩さい⼦どもは、⼤腿を⼤⼈より開いて座らせるべきである。 これは、股関節の健康と発達のために重要である。 つまり、⾻盤側⽅パッドが⼤腿を圧し合わせないことは、⼦どもに とってとりわけ重要なのである。 問題：⾻盤が前傾している（前⽅に傾いた⾻盤） WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 97 98 PSD solution Pelvis side pads. Providing pelvis side pads for children Young children should sit with their thighs more apart than adults. This is important for the health and development of their hip joints. This means it is particularly important for children that pelvis side pads do not push children’s thighs together. Problem: Pelvis is in anterior tilt (pelvis tilts forward) WH LCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 97 98 PSD solution Pelvis side pads. Providing pelvis side pads for children Young children should sit with their thighs more apart than adults. This is important for the health and development of their hip joints. This means it is particularly importa t for childr n that pelvis side pads do not push children’s thighs together. Problem: Pelvis is in anterior tilt (pelvis tilts forward) 98 受講者⽤参考書 必要な⽀え 2 通りの⽀えが可能： • ⾻盤前⾯（上前腸⾻棘、ASIS）を後向きに押す⽀え、および、 • 座⾻下の座⾯⾓度を変更し、⾻盤が後⽅へ起きるよう促す。 姿勢⽀持具の解決策 ⾻盤前傾⽤ウェッジ（くさび）は、⾻盤が背もたれに向けて後⽅ へ起きるよう促す。⾻盤前傾⽤ウェッジは座⾻のすぐ前で終わり、 ⼤腿の下では⽔平であるようにする。 ⾻盤前傾４点ベルトは、⾻盤前⾯を上縁で⽀え、よりニュートラ ルな座位姿勢を促す。 姿勢⽀持具の処⽅（選択） - 股関節を⽀える 重要な留意事項として、固まった/ニュートラルでない姿勢の股関節は、うまく形を合わせなけれ ば、⾻盤姿勢にも必ず影響を及ぼす。 股関節を⽀える 問題：⽚側の股関節が、ニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超） この問題への⼀時的対応策は、積み増し（のウレタンフォーム）を、左右の座⾻、および股関節が ニュートラルな座位姿勢まで屈曲する側の⼤腿の下に置くことである。 姿勢⽀持具の解決策 座⾯⽚側の前⽅を下げる：この⽀えはクッションにつくり 込み、ニュートラルに座れるまで屈曲しない（体幹〜⼤腿 の⾓度が 90度超の）股関節に形を合わせる。 注記：最終的な解決策は、ニュートラルに座れるところまで屈 曲しない側を、斜⾓を付けて切り取ることである。ウレタンフ ォームを切り取る⾓度は、⾞椅⼦ユーザーの股関節の⾓度に よって変わるので、事前評価の際に調べておくこと。 注記：座⾻前⽅（アンカー）サポートはクッションに付いたま まにする。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 97 98 Support needed Support can be provided in two ways: r support at the front of the pelvis (ASIS) pushing backwards; and r encouraging the pelvis to roll backwards by changing the angle of the seat under the seat bones. PSD solutions A wedge for anterior tilt encourages the pelvis to roll backwards towards the backrest. The wedge for anterior tilt should stop just in front of the seat bones and level out under the thighs. An anterior tilt four-point strap provides support at the top and front of the pelvis, encouraging a more neutral sitting posture. Prescription (selection) of PSDs – supporting the hips It is important to remember that any !xed/non-neutral postures of the hips will affect pelvis posture if not accommodated. Supporting the hips Problem: One hip cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) The temporary solution for this problem is to place a build-up (foam) under both seat bones and under the thigh of the hip that can bend to neutral sitting posture. PSD solutions Lower seat front on one side – This support can be built into the cushion to accommodate the hip that does not bend to neutral for sitting (trunk to thigh angle is more than 90 degrees). Note: The !nal solution is to make an angled cut-out on the side of the hip that cannot bend to neutral for sitting. The angle of the cut-out in the foam will depend on the angle of the wheelchair user’s hip – so this should be checked at the assessment. Note: There is still a pre seat bone shelf in the cushion. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 97 98 Support needed Support can be provided in two ways: r support at the front of the pelvis (ASIS) pushing backwards; and r encouraging the pelvis to roll backwards by changing the angle of the seat under the seat bones. PSD solutions A wedge for anterior tilt encourages the pelvis to roll backwards towards the backrest. The wedge for anterior tilt should stop just in front of th seat bones and level out under the thighs. An anterior tilt four-point strap provides support at the top and front of the pelvis, encouraging a more neutral sitting posture. Prescription (selection) of PSDs – supporting the hips It is important to remember that any !xed/non-neutral postures of the hips will affect pelvis posture if not accommodated. Supporting the hips Problem: O e hip cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) The temporary solution for this problem is to place a build-up (foam) under both seat bones and under the thigh of the hip that can bend to neutral sitting posture. PSD solutio s Lower seat front on one side – This support can be built into the cushion to accommodate the hip that does not bend to neutral for sitting (trunk to thigh angle is more than 90 degrees). Note: The !nal solution is to make an angled cut-out on the side of the hip that cannot bend to neutral for sitting. The angle of the cut-out in the foam will depend on the angle of the wheelchair user’s hip – so this should be check d at the s essme t. Note: There is still a pre seat bone shelf in the cushion. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 97 98 Support needed Support can be provided in two ways: r support at the front of the pelvis (ASIS) pushing backwards; and r encouraging the pelvis to roll backwards by changing the angle of the seat under the seat bones. PSD solutions A wedge for anterior tilt encourages the pelvis to roll backwards towards the backrest. The wedge for anterior tilt should stop just in front of the seat bones and level out under the thig s. An anterior tilt four-point strap provides support at the top and front of the pelvis, encouraging a more neutral sitting posture. Prescription (selection) of PSDs – supporting the hips It is important to remember that any !x d/non-neutral postures of the hips will affect pelvis posture if not accommodated. Supporting the hips Problem: One hip cannot bend to neutral sitting posture (trunk to thigh angle is m r than 90 degree ) The temporary solution for this problem is to place a build- p (foam) u der both seat bones and under t e thigh of the h p that can bend to neutral sitting posture. PSD solutions Lower seat front on one side – This support can be built into the cushion to accommodate the hip that does not bend to neutral for sitting (trunk to thigh angle is more than 90 degrees). Note: The !nal solution is to make an angled cut-out on the side of the hip that cannot bend to neutral for sitting. The angle of the cut-out in the foam will depend on the angle of the wheelchair user’s hip – so this should be checked at the assessment. Note: There is still a pre seat bone shelf in the cushion. 中級⾞椅⼦サービス教習パッケージ 99 問題：両側の股関節が、ニュートラルな座位姿勢ま で屈曲しない（体幹〜⼤腿の⾓度が 90 度超） この問題への⼀時的対応策は、積み増し（のウレタンフ ォーム）を、左右の座⾻下に置くことである。しかし、 ⾞椅⼦ユーザーが⾞椅⼦から前⽅へ滑り出がちになる ため、これは恒久的解決策にはならない。 姿勢⽀持具の解決策 座⾯〜背もたれ⾓度を開けると、より⼤きい⾓度の体幹 〜⼤腿に形を合わせられる。座⾯〜背もたれ⾓度は、⾞ 椅⼦ユーザーの体幹〜⼤腿の⾓度に従うため、事前評価 で決めておく必要がある。 恒久的な解決策として、座⾻前⽅（アンカー）サポート および⾻盤ベルトを備えることで、⾞椅⼦ユーザーが⾞ 椅⼦から前⽅へ滑り出るのを⽌められる。 問題：⽚側または両側の股関節が、ニュートラルな座位姿勢まで伸展しない（体幹〜⼤腿 の⾓度が 90 度未満） この問題への⼀時的な対応策は、積み増し（硬いウレタンフォーム製ウェッジ（くさび））を、ニュ ートラルな座位姿勢まで伸展しない（体幹〜⼤腿の⾓度が 90度未満の）⽚側/両側の⼤腿下に置く ことである。 姿勢⽀持具の解決策 座⾯前⽅のかさ上げ：恒久的な解決策として⼤腿下の座⾻ より前⽅にウェッジ（くさび）を置いて、座⾯前⽅を⾼く することが可能である。これで座⾯と背もたれの間の⾓度 が⼩さくなる。座⾯前⽅を⾼くする程度は、⾞椅⼦ユーザ ーの体幹〜⼤腿の⾓度に従うので、事前評価で決めておく 必要がある。 注記：座⾻は、左右とも⽔平⾯に据わったままにすること。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 99 100 Problem: Both hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) The temporary solution for this problem is to place a build-up (foam) under both seat bones. However, this cannot work as a permanent solution as the wheelchair user would tend to slide forward out of their wheelchair. PSD solutions An open seat to backrest angle will allow for the greater trunk to thigh angle. The angle between the seat and backrest will depend on the wheelchair user’s trunk to thigh angle – and this should be decided during the assessment. A possible permanent solution is to have a pre seat bone shelf and pelvis strap, which would stop the wheelchair user to slide forward out of their wheelchair. Problem: One or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees) The temporary solution for this problem is to place a build-up (wedge of !rm foam) under the thigh/s that cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees). PSD solution Raise the seat front – A possible permanent solution is to raise the seat front/place a wedge in front of the seat bones/under the thighs. This reduces the angle between the seat and the backrest. The amount that the seat front is raised will depend on the wheelchair user’s trunk to thigh angle – so this should be decided during the assessment. Note: Both seat bones should still sit on a level surface. SERVICE TRAI I INTERMEDIATE LEVEL 99 100 Proble : ot i l sitting postur (t t t i l i more than 90 r s) The te porary solution for this proble is to place a build-up (foam) under both seat bones. However, this cannot work as a permanent solution as the wheelchair user would tend to slide forward out of their wheelchair. PSD solutions An open seat to backrest angle will allow for the greater trunk to thigh angle. The angle between the seat and backrest will depend on the wheelchair user’s trunk to thigh angle – and this should be decided during the assessment. A possible permanent solution is to have a pre seat bone shelf and pelvis strap, which would stop the wheelchair user to slide forward out of their wheelchair. Problem: One or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees) The temporary solution for this problem is to place a build-up (wedge of !rm foam) under the thigh/s that cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees). PSD solution Raise the seat front – A possible permanent solution is to raise the seat fr t/place a wedge in fro t of the seat bone /under the thighs. This reduces the a gle betwe n the seat and backrest. The amount th t the s at front is raised will dep nd on the wheelchair user’s runk t th gh ngle – so this should b decided during the assessme t. Note: Both seat bones should still sit on a level surface. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 99 100 Problem: Both hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) The temporary solution for this problem is to place a build-up (foam) under both seat bones. However, this cannot work as a permanent solution as the wheelchair user would tend to slide forward out of their w elchair. PSD solutions An open seat to backrest angle will allow for the greater trunk to thigh angle. The angle between the seat and backrest will depend on the wheelchair user’s trunk to thigh angle – and this should be decided during the assessment. A possible permanent solution is to have a pre seat bone shelf and pelvis strap, which would stop the wheelchair u er to slide forward out f th ir wheelchair. Problem: One or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees) The temporary solution for this problem is to place a build-up (wedge of !rm foam) under the thigh/s tha cannot ope neutral sitting posture (trunk thigh angle less than 90 degrees). PSD solution Raise the se t front – A possible perman nt soluti n is to raise the seat fro t/place a wedge in front of the s at bones/under the thighs. This reduces the angle between the seat and the backrest. The amount that the seat front is raised will depend on the wheelchair user’s trunk to thigh angle – o this should be decided during the assessment. Note: Both seat bones should still sit on a level surface. 100 受講者⽤参考書 制御できない運動、⾼い筋緊張、筋攣縮の抑制を助ける ⾞椅⼦ユーザーによっては、座⾯前⽅を⾼くし、股関節の 体幹〜⼤腿の⾓度をニュートラルより⼩さくすると、制御 できない運動、⾼い筋緊張、筋攣縮を抑えられる。 留意事項：「ウェッジ（くさび形）」の始点は、必ず⾞椅⼦ ユーザーの座⾻より前⽅に取る。座⾻は⽔平⾯に据える。 姿勢⽀持具の処⽅（選択） - 体幹を⽀える つねに、まずどうやって⾻盤を安定させるか考え、体幹への⽀えをその次に考えることが重要だ。 体幹にまつわる姿勢の問題は、多くの場合、⾻盤をしっかり⽀えることで解決、あるいは改善する。 体幹を⽀える 問題：円背の姿勢、体幹が前にせり出し、⾻盤が後傾している 必要な⽀え • ⾻盤を、できるだけニュートラルな座位姿勢に近づける⽀え。 • 体幹の⾃然なカーブに沿った、背もたれの⽀え。 • 体幹の前⾯に⽀えが必要な場合もある。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in posterior tilt and/or slides forward Support needed To bring the pelvis from posterior tilt to more neutral sitting posture, support is usually needed in two areas: r at the back of the pelvis at the level PSIS; r at the front of the pelvis at the seat bones (ischial tuberosities). PSD solutions A pre seat bone shelf provides support in front of the seat bones and helps to: r keep the pelvis upright; r stop the pelvis from sliding forward; r reduce a tendency to sit with a slumped posture. The pre seat bone shelf sits just in front of the seat bones. A rear pelvis pad provides support at the top of the pelvis (at the level of PSIS) and helps to keep the pelvis upright. The combination of a pre seat bone shelf and rear pelvis pad is often used to help wheelchair users to sit with a more upright pelvis and with more stability. A pelvis strap can provide additional support for wheelchair users who have uncontrolled movements and/ or a tendency to slide forwards. The pelvis strap helps to keep the pelvis in place, so that the pre seat bone shelf and the rear pelvis pad continue to provide support. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 99 100 Problem: Both hips cannot bend to neutral sitting posture (trunk to thigh angle is more than 90 degrees) The temporary solution for this problem is to place a build-up (foam) under both seat bones. However, this cannot work as a permanent solution as the wheelchair user would tend to slide forward out of their wheelchair. PSD solutions An open seat to backrest angle will allow for the greater trunk to thigh angle. The angle between the seat and backrest will depend on the wheelchair user’s trunk to thigh angle – and this should be decided during the assessment. A possible permanent solution is to have a pre seat bone shelf and pelvis strap, which would stop the wheelchair user to slide forward out of their wheelchair. Problem: One or both hips cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees) The temporary solution for this problem is to place a build-up (wedge of !rm foam) under the thigh/s that cannot open to neutral sitting posture (trunk to thigh angle less than 90 degrees). PSD solution Raise the seat front – A possible permanent solution is to raise the seat front/place a wedge in front of the seat bones/under the thighs. This reduces the angle between the seat and the backrest. The amount that the seat front is raised will depend on the wheelchair user’s trunk to thigh angle – so this should be decided during the assessment. Note: Both seat bones should still sit on a level surface. 中級⾞椅⼦サービス教習パッケージ 101 姿勢⽀持具の解決策 • ⾻盤を⽀えるもの： o 座⾻前⽅（アンカー）サポート o ⾻盤後⽅パッド o ⾻盤ベルト（つねに必要とは限らない） o ⾻盤側⽅パッド（つねに必要とは限らない） • 背もたれの⽀えをもたらすもの： o 背もたれの形状調整：体幹が収まる余地を設け、背中が⾃然 なカーブを描けるようにする。背もたれが平らで垂直なまま だと、⾞椅⼦ユーザーを前⽅へ押し出す。ここでは背もたれ 形状の修正も、姿勢⽀持具による解決策の⼀部である。 付加できる⽀え： • テーブル：テーブルは、⾞椅⼦ユーザーが、まっすぐな体幹姿勢 を保つための⽀えを付加する。 • 肩ハーネス：すぐにくたびれる、あるいは前へ倒れる⾞椅⼦ユー ザーには、肩ハーネスが有効。 • 座⾯＆背もたれティルト：他の姿勢⽀持具を組み合わせても、⾞ 椅⼦ユーザーがよりまっすぐに座れない場合は、座⾯と背もた れをいっしょに傾けるのが有効。 背もたれは、脊柱の⾃然なカーブに沿っていることが必要 脊柱の⾃然なカーブを⽀える形状でない、平らで直⽴し た背もたれは通常： • 体幹上部を前⽅へ押し出し、 • ⾞椅⼦ユーザーが⾻盤を前⽅へ動かすよう促すため、 背もたれへ寄りかかる格好にする。 残念なことに67、多くの標準的な⾞椅⼦が備えているのは 垂直で平らな背もたれである。ニュートラルな姿勢で快 適に座れるように⾞椅⼦ユーザーを⽀えるには、たいて い何らかの改造が必要になる。 67 [原⽂] unfortunately WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 95 96 Problem: Pelvis is in posterior tilt and/or slides forward Support needed To bring the pelvis from posterior tilt to more neutral sitting posture, support is usually needed in two areas: r at the back of the pelvis at the level PSIS; r at the front of the pelvis at the seat bones (ischial tuberosities). PSD solutions A pre seat bone shelf provides support in front of the seat bones and helps to: r keep the pelvis upright; r stop the pelvis from sliding forward; r reduce a tendency to sit with a slumped posture. The pre seat bone shelf sits just in front of the seat bones. A rear pelvis pad provides support at the top of the pelvis (at the level of PSIS) and helps to keep the pelvis upright. The combination of a pre seat bone shelf and rear pelvis pad is often used to help wheelchair users to sit with a more upright pelvis and with more stability. A pelvis strap can provide additional support for wheelchair users who have uncontrolled movements and/ or a tendency to slide forwards. The pelvis strap helps to keep the pelvis in place, so that the pre seat bone shelf and the rear pelvis pad continue to provide support. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 101 102 PSD solutions r Pelvis support is provided by: – pre seat bone shelf; – rear pelvis pad; – pelvis strap (not always necessary); – pelvis side pads (not always necessary). r Backrest support is provided by: – adjusting the backrest shape – to provide room for the trunk and allow the back to follow the natural curves. If the backrest continued straight upwards, it would push the wheelchair user forwards. This modi!cation to his backrest shape is part of the PSD solution for him. Additional support can be provided by: r tray – a tray can provide addition l suppo t to help a whe lchair user maintain n pright trunk posture. r shoulder harness – for a wheelchair user who tires easily, or falls forward – a shoulder harness can help. r se t and backrest tilt – when other PSDs combined have not elped a wheelchair user t sit more upright, tilting the s at and backrest together m y help. Backrests need to follow the natural curves of the spine A straight, upright backrest, that has no contouring to support the natural curves of the spine will usually either: r push the top of the trunk forward; r encourage a wheelchair user to move their pelvis forward, so that he/she can lean back into the backrest. Unfortunately, many standard wheelchairs come with a straight up and down backrest. Some modi!cation is usually needed to support the wheelchair user so that he/she can sit in the neutral posture comfortably. 102 受講者⽤参考書 問題：円背の姿勢、⾻盤が後傾したまま固まり、体幹が前⽅に弯 曲している 必要な⽀え • ⾻盤を、できる限りニュートラルな座位姿勢へ近づける⽀え。 • 体幹を、できる限りニュートラルな座位姿勢に近づけて⽀え、頭の ⾝体配列（アラインメント）を改善（より正⾯を向けるように）す る背もたれの⽀え。 姿勢⽀持具の解決策 形をどれくらい合わせる必要があるか、また⼿に⼊る⾞椅⼦の種類が 何かによって解決策は変わる。以下、提案を挙げる。 • ⾻盤を⽀えるもの： o 座⾻前⽅（アンカー）サポート o ⾻盤後⽅パッドおよび座⾯〜背もたれ⾓度を開けることで、後 傾したまま固まった⾻盤に形を合わせ、かつ⽀える。 o ⾻盤ベルト（つねに必要とは限らない） • 背もたれの⽀えをもたらすもの： o 背もたれのリクライニングは、体幹の固まった弯曲が収まるス ペースを設ける。これは、頭や⾸のよりよい⾝体配列（アライン メント）を⽣む。この解決策は、後傾したまま固まった⾻盤に形 を合わせる場合にも使える（注記：ソリッド背もたれには、必ず 張り布を施したウレタンフォームを付加すること）。 o 背もたれの形状調整は、体幹が収まる余地を設け、背中が⾃然 なカーブを描けるようにする。 付加［姿勢］⽀持のうち他に可能なもの： o テーブル o 肩ハーネス o 座⾯＆背もたれティルト 姿勢⽀持具の解決策は、この順序で考えよ ⾻盤および股関節 体幹 頭と⾸ 脚 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 101 102 Problem: Slumped posture, pelvis is in !xed posterior tilt and trunk curved forward Support needed r Support to bring the pelvis as close to neutral sitting posture as possible. r Backrest support to support the trunk as close to neutral sitting posture as possible and provide an improved head alignment (more able to look forward). PSD solutions The solutions will vary depending on how much accommodation is required and the type of wheelchairs available. Some suggestions are listed below. r Pelvis support is provided by: – pre seat bone shelf; – rear pelvis pad AND opening up the seat to backrest angle to accommodate and support the !xed pelvis posterior tilt; – pelvis strap (not always necessary). r Backrest support is provided by: – backrest recline – to provide room for the !xed curve of the trunk. This may help to create a better alignment for the head and neck. This solution would also accommodate the !xed pelvis posterior tilt. (Note: upholstered foam needs to be added to any solid backrest). – adjusting the backrest shape – to provide room for the trunk and allow the back to follow the natural curves. Additional support can also be provided by: – tray; – shoulder harness; – seat and backrest tilt. Think about PSD solutions in this order Pelvis and hips Trunk Head and neck Legs WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 101 102 Problem: Slumped posture, pelvis is in !xed posterior tilt and trunk curved forward Support needed r Support to bring the pelvis as close to neutral sitting posture as possible. r Backrest support to support the trunk as close to neutral sitting posture as possible and provide an improved head alignment (more able to look forward). PSD sol tions The solutions will vary depending on how much accommodation is required and the type of wheelchairs available. Some suggestions are listed below. r Pelvis support is provided by: – pre seat bone shelf; – rear pelvis pad AND opening up the seat to backrest angle to accommodate and support the !xed pelvis posterior tilt; – pelvis strap (not always necessary). r Backrest support is provided by: – backrest recline – to provide room for the !xed curve of the trunk. This may help to create a better alignment for the head and neck. This solution would also accommodate the !xed pelvis posterior tilt. (Note: upholstered foam needs to be added to any solid backrest). – adjusting the backrest shape – to provide room for the trunk and allow the back to follow the natural curves. Additional support can also be provided by: – tray; – shoulder harness; – seat and backrest tilt. Think about PSD solutions in this order Pelvis and hips Trunk Head and neck Legs 中級⾞椅⼦サービス教習パッケージ 103 問題：体幹が左右⽚⽅へ傾く、あるいは倒れる 必要な⽀え • ⾻盤を安定させる。 • 体幹の側⽅に⽀えを設ける。 姿勢⽀持具の解決策 • 体幹側⽅ウェッジ（くさび）は軽い⽀えを与え、⾞椅⼦ユ ーザーの体幹を背もたれ中央に保つよう助ける。 • 体幹側⽅パッド：体幹側⽅サポートは強固な⽀えを与え、 体幹を背もたれ中央に保つよう助ける。 体幹側⽅パッドを⼀つ付けたら、必ず反対側にもう⼀つ付け る。⾼さを違える場合もある。 問題：固まっているにせよ柔軟さがあるにせよ、脊椎が 横へ弯曲している 必要な⽀え • ⽚側で弯曲の頂点68と、その反対側で弯曲の上端と下端と を⽀える。 68 [原⽂] apex WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 103 104 Problem: Trunk leans or falls to one side Support needed r Stabilize pelvis. r Provide support at the side of the trunk. PSD solutions r Trunk side wedges – provide gentle support to help maintain the wheelchair user’s trunk in the centre of the backrest. r Trunk side pads – trunk side supports provide !rm support to help keep the trunk in the centre of the backrest support. If one trunk side pad is provided, another one is always provided on the opposite side – may be at a different level. Problem: Fixed or !exible sideways curve of the spine. Support needed r Support on the apex of the curve on one side and the top and bottom of the curve on the other side. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 103 104 Problem: Trunk leans or falls to one side Support needed r Stabilize pelvis. r Provide support at the side of the trunk. PSD solutions r Trunk side wedges – provide gentle support to help maintain the wheelchair user’s trunk in the centre of the backrest. r Trunk side pads – trunk side supports provide !rm support to help keep the trunk in the c ntre of th backrest support. If one trunk side pad is provided, another one is always provided on the opposite side – may be at a different level. Problem: Fixed or !exible sideways curve of the spine. Support needed r Support on the apex of the curve on one side and the top and bottom of the curve on the other side. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 103 104 Problem: Trunk leans or falls to one side Support needed r Stabilize pelvis. r Provide support at the side of the trunk. PSD solutions r Trunk side wedges – provide gentle support to help maintain the wheelchair user’s trunk in the centre of the backrest. r Trunk side pads – trunk side supports provide !rm support to help keep the trunk in the centre of the backrest support. If one trunk side pad is provided, another on is always provided on the opposite side – may be at a different lev l. Problem: Fixed or !exible sideways curve of the spine. Support needed r Support on the apex of the curve on one side and the top and bottom of the curve on the other side. WHEELCHAIR SERVICE TRAIN G PACKAGE INTERMEDIATE LEVEL 103 104 Problem: Trunk leans or falls to one side Support needed r Stabilize pelvis. r Provide support at the side of the trunk. PSD solutions r Trunk sid w dges – provid gentle su port to maintain the wheelchair user’s trunk in the centre f the backrest. r Trunk side pads – trunk side supports provide !rm support to help keep the trunk in the centre of the backrest support. If one t unk si e pad is provided, another one is always provided on the opposite side – may be at a different level. Problem: Fixed ! xible sideways curve of the spine. Support needed r Support on the apex of the curve on one side and the top and bottom of the curve on the other side. 104 受講者⽤参考書 姿勢⽀持具の解決策 • 体幹側⽅パッドと⾻盤側⽅パッドを併⽤。 姿勢に柔軟さがある場合は、⾞椅⼦ユーザーが、この⽀えに よってニュートラルな姿勢で座れる場合もある。姿勢が固ま っていれば、快適な限りで、できるだけニュートラルな座位 姿勢へ近づけて⽀えよ。側弯で柔軟さがある⾞椅⼦ユーザー をニュートラルに⽀えると、柔軟だが⽔平でない⾻盤が矯正 される場合もある。 姿勢⽀持具の処⽅（選択） - 頭・⼤腿・下腿を⽀える 頭を⽀える 問題：頭が後・前・横に倒れがち 必要な⽀え • ヘッドレストを供与する前に、必ず最初に： o ⾞椅⼦ユーザーの⾻盤を安定させ、 o 体幹をしっかりと⽀え、体幹が⾻盤の上で安定しバランス が取れるようにする。 • ⾞椅⼦ユーザーが、それでも頭を起こしておくのが難しけれ ば⽀えを設けるべきで： o まず頭蓋⾻底部へ。 o 必要ならば、⽀えは⾞椅⼦ユーザーの頭の側⾯へ広げても よい。 姿勢⽀持具の解決策 ヘッドレストの種類は多種多様である。広く⽤いられているの は、平⾯ヘッドレスト、成形ヘッドレストの 2種である。 • 平⾯ヘッドレスト：平⾯ヘッドレストは、背もたれを延⻑し て頭も⽀えるように成形したものである。平⾯ヘッドレスト は頭が休める場所を設け、頭が後ろへ倒れるのを⽌める。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 103 104 PSD solutions r Trunk side pads combined with pelvis side pads. If the posture is !exible, with this support the wheelchair user may be able to sit in neutral posture. If the posture is "xed, support as close to neutral sitting posture as is comfortable. Providing support in neutral sitting posture for a wheelchair user with a !exible scoliosis may also correct a !exible unlevel pelvis. Prescription (selection) of PSDs – supporting the head, thighs and lower legs Supporting the head Problem: Head tends to fall backwards, forwards or sideways Support needed r Before providing headrest – always "rst: – stabilize the wheelchair user’s pelvis; – provide good trunk support ensuring that the trunk is stabilized and balanced over the pelvis. r If a wheelchair user continues to "nd it dif"cult to hold their head upright, support should be provided: – "rst at the base of the skull; – if necessary support can extend around the side of the wheelchair user’s head. PSD solutions There are many different types of headrests. Two commonly used headrests are !at and shaped headrests. r Flat headrest – a !at headrest is an extension of the backrest, which is contoured to provide support for the head. A !at headrest provides a resting place for the head and stops the head from falling backwards. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 103 104 PSD solutions r Trunk side pads combined with pelvis side pads. If the posture is !exible, with this support the wheelchair user may be able to sit in neutral posture. If the posture is "xed, support as close to neutral sitting posture as is comfortable. Providing support in ne tral sitting posture for a wheelchair user with a !exible scoliosis may also correct a !exible unlevel pelvis. Prescription (sel ction) of PSDs – supporting the head, thighs and lower legs Supporting the hea Problem: Head tends to fall backwards, forwards or sideways Support needed r Before providing headrest – always "rst: – stabilize the wheelchair user’s pelvis; – provide good trunk support ensuring that the trunk is stabilized and balanced over the pelvis. r If a wheelchair user continues to "nd it dif"cult to hold their head upright, support should be provided: – "rst at the base of the skull; – if necessary support can extend around the side of the wheelch ir user’s head. PSD solutions There are many different types of headrests. Two commonly used headrests are !at and shaped headrests. r Flat headrest – a !at headrest is an extension of the backrest, which is contoured to provide support for the head. A !at headrest provides a resting place for the head and stops the head from falling backwards. 中級⾞椅⼦サービス教習パッケージ 105 • 成形ヘッドレスト：成形ヘッドレストは、頭の底を「掌で受ける」 形をしている。この側⾯を前に延⻑し、頭の側⾯への⽀えを増やし てもよい。成形ヘッドレストは⾞椅⼦ユーザーの頭蓋⾻底部の輪郭 に沿っているため、平⾯ヘッドレストより⼤きい⽀えをもたらす。 ヘッドレストを設ける際には： ⾞椅⼦ユーザーの頭へ⽀えを設けるさい、頭の姿勢は⾻盤と体幹のよい姿勢にも左右されるこ とに、つねに留意せよ。 ⾞椅⼦ユーザーの頭の前⽅に⽀えを設けるのは避けよ。 ⼤腿を⽀える 問題：脚が外側に開く（外転する） 必要な⽀え • 必ず最初に、必要な⽀えを設けて⾞椅⼦ユーザーの⾻盤および体幹 を安定させる。これは、脚をよりニュートラルな座位姿勢へ持って⾏ くのに役⽴つ。 • ⼤腿の外側を⽀える。 姿勢⽀持具の解決策： • ⼤腿外側ウェッジは、軽い⽀えをもたらす。 注記：右図では、⼤腿外側のウェッジ（くさび）をクッションの硬いウレ タンフォーム層の上に付加している。硬いウレタンフォームには、座⾻前 ⽅（アンカー）サポートがつくり付けられている。クッション全体を覆う、 柔らかいウレタンフォームの層を付加すること。 • ⼤腿外側パッドは、強固な⽀えをもたらす。 注記：右図では、⼤腿パッドを、受け具を介して⽊製座⾯に取り付けてい る。⽊製座⾯の上には、クッションを置くスペースを設ける。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 105 106 r Shaped headrest – a shaped headrest is shaped to ‘cup’ the base of the head. It may be extended at the sides and come forward to give more support at the side of the head. A shaped headrest provides more support than a !at headrest by contouring around the base of the wheelchair user’s skull. When providing a headrest: When providing support for a wheelchair user`s head, always remember that the posture of the head depends also on good pelvis and trunk posture. Avoid providing support at the front of the wheelchair user`s head. Supporting the thighs Problem: Legs drawn outwards (abducted) Support needed r First ensure that the wheelchair user’s pelvis and trunk are stabilized by providing the support required. This may help to bring the legs into a more neutral sitting posture. r Support on the outside of the thighs. PSD solutions r Outside thigh wedges will provide gentle support. Note: In this illustration outside thigh wedges have been added onto a !rm foam layer of a cushion. The !rm foam has a pre seat bone shelf built in. A soft layer of foam should be added over the top of the whole cushion. r Outside thigh pads will provide "rm support. Note: In this illustration the thigh pad is attached to a wooden seat base with a bracket. Room is allowed for a cushion to be placed on top of the wooden seat. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 105 106 r Shaped headrest – a shaped headrest is shaped to ‘cup’ the base of the head. It may be extended at the sides and come forward to give more support at th side of the head. A sh p d headrest provides more support than a !at headrest by contouring around the base of the wheelchair user’s skull. When providing a headrest: When providing support for a wheelchair user`s head, always remember that the posture of the head depends also on good pelvis and trunk posture. Avoid providing support at the front of the wheelchair user`s head. Supporting the thighs Problem: Legs drawn outwards (abducted) Support needed r First ensure that he wheelchair us r’s pelvis and trunk are stabilized by providing the support required. This may help to bring the legs into a more neutral sitting posture. r Support on the outside of the thighs. PSD solutions r Outside thigh wedges will provide gentle support. Note: In this illustration outside thigh wedges have been added onto a !rm foam layer of a cushion. The !rm foam has a pre seat bone shelf built in. A soft layer of foam should be added over the top of the whole cushion. r Outside thigh pads will provide "rm support. Note: In this illustration the thigh pad is attached to a wooden seat base with a bracket. Room is allowed for a cushion to be placed on top of the wooden seat. WHEELCH IR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 105 106 r Shaped headrest – a shaped headrest is shaped to ‘cup’ the base f the head. It may b extended at the sides and come forward to give more support at the side of the head. A shaped headrest provides more support than a !at headrest by c ntouring around the base of the wheelchair user’s skull. When providing a headrest: When providing support for a wheelchair user`s head, always remember that the posture of the head depends also on good pelvis and trunk posture. Avoid providing support at the front of the wheelchair user`s head. Supporting the thighs Problem: Legs drawn out ards (abducted) Support needed r First ensure that the wheelchair user’s pelvis and trunk are stabilized by providing the support required. This may help to bring th legs into a more neutral sitting posture. r Support on the outside of the thighs. PSD solutions r Outside thigh wedges will provi gentl support. Note: In this illustration outside thigh wedges have been added onto a !rm foam layer of a cushion. The !rm foam has a pre seat bone shelf built in. A soft layer of foam should be added over the top of the whole cushion. r Outside thigh pads ill provide "rm support. Note: In this illustration the thigh pad is attached to a wooden seat base with a bracket. Room is allowed for a cushion to b placed on top of the wooden seat. 106 受講者⽤参考書 問題：脚が内側に閉じる（内転する） 必要な⽀え • 必ず最初に、必要な⽀えを設けて⾞椅⼦ユーザーの⾻盤および体幹を安定させ る。これは、脚をよりニュートラルな座位姿勢へ持って⾏くのを助ける。 • ⼤腿の内側および膝の内側を⽀える。 姿勢⽀持具の解決策 • ⼤腿内側のウェッジ（くさび）は、軽い⽀えをもたらす。 注記：右図では、⼤腿ウェッジをクッションの硬いウレタンフォーム層の上に付 加している。硬いウレタンフォームには、座⾻前⽅（アンカー）サポートが付い ている。クッション全体を覆う、柔らかいウレタンフォームの層を付加する。 • 膝分離パッドは、強固な⽀えをもたらす。 注記：右図では、膝分離パッドを、受け具を介して⽊製座⾯に取り付けている。 ⽊製座⾯の上には、クッションを置くスペースを設ける。 下腿と⾜を⽀える 問題：⽚膝または両膝が屈曲し、ニュートラルな座位姿勢より⼩さい⾓度のまま固まって いる（⼤腿〜下腿の⾓度が 90 度超69） 解決策は、それぞれの⾞椅⼦ユーザーのニーズによって異なる。 姿勢⽀持具の解決策 • 可能ならば、⾜台を調節して後ろへ移す。 • 可能ならば、⾜台⾓度を調節して⾜に合わせる。できなければ、⾜ 台ウェッジ（くさび）を⽤いる。 • ⽀えと保護のため、下腿の前にベルトを設ける。 • 座⾯前縁が⾞椅⼦ユーザーの⽚脚/両脚の裏を押していたら、座⾯ 奥⾏きを少し詰め、クッションに後ろへ斜⾓を付ける必要がある。 • 背が⾼い⾞椅⼦ユーザーには、座⾯前⽅のかさ上げ、あるいは座⾯ ＆背もたれティルトを検討せよ。これで⾞椅⼦ユーザーの⾜が⾼く なり、前に出て、標準的な⾜台の調節範囲に収まるかもしれない。 注記： • 上記のどんな調整を⾏なう場合でも、キャスターの回旋が⾃由なままで、⾜台や⾞椅⼦ユーザーの⾜ 69 [訳注] 原⽂のまま. 他の問題の記述と⽐較すると「90度未満」となるべきであろう. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 103 104 Problem: Trunk leans or falls to one side Support needed r Stabilize pelvis. r Provide support at the side of the trunk. PSD solutions r Trunk side wedges – provide gentle support to help maintain the wheelchair user’s trunk in the centre of the backrest. r Trunk side pads – trunk side supports provide !rm support to help keep the trunk in the centre of the backrest support. If one trunk side pad is provided, another one is always provided on the opposite side – may be at a different level. Problem: Fixed or !exible sideways curve of the spine. Support needed r Support on the apex of the curve on one side and the top and bottom of the curve on the other side. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 105 106 Problem: Legs drawn inwards (adducted) Support needed r First ensure that the wheelchair user’s pelvis and trunk are stabilized by providing the support required. This may help to bring the legs into a more neutral sitting posture. r Support on the inside of the thighs and the inside of the knees. PSD solutions r Inside thigh wedges will provide gentle support. Note: In this illustration a thigh wedge has been added onto a !rm foam layer of a cushion. The !rm foam has a pre seat bone shelf built in. A soft layer of foam should be added over the top of the whole cushion. r A knee separator pad will provide !rm support. Note: In this illustration the knee separator pad is attached to a wooden seat base with a bracket. Room is allowed for a cushion to be placed on top of the wooden seat. Supporting the lower legs and feet Problem: One or both knees bend and are !xed less than neutral sitting posture (trunk to thigh angle is more than 90 degrees) The solution will depend on the needs of the individual wheelchair user. PSD solutions: r Adjust the footrests backwards if possible. r Adjust the angle of the footrest to match the foot if possible. If this is not possible, use footrest wedges. r Provide a strap to the front of the lower legs for support and protection. r If the front of the seat is pushing on the back of the wheelchair user’s leg/legs it may be necessary to shorten the seat slightly, and bevel the cushion backwards. r For a tall wheelchair user consider raising the seat front or tilting the seat and backrest. By doing this the wheelchair user’s feet will be higher, more forward and possibly in the adjustment range of the standard footrests. Note: r When making any of the above adjustments – check that the castor wheels can still turn fully without bumping into the footrests or wheelchair user’s feet. r If these adjustments are not possible on the available wheelchairs or do not provide enough adjustment, some modi!cation may be necessary. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 105 106 Problem: Legs drawn inwards (adducted) Support needed r First ensure that the wheelchair user’s pelvis and trunk are stabilized by providing the support required. This may help to bring the legs into a more neutral sitting posture. r Support on the inside of the thighs and the inside of the knees. PSD solutions r Inside thigh wedges will provide gentle support. Note: In this illustration a thigh wedge has been added onto a !rm foam layer of a cushion. The !rm foam has a pre seat bone shelf built in. A soft layer of foam should be added over the top of the whole cushion. r A knee separator pad will provide !r support. Note: In this illustration the knee separator pad is attached to a ooden seat base ith a bracket. R om is allowed for a cushion to be placed on top of t e e eat. Su porting the lo er le s Problem: One or both knees tral si ting posture (trunk to thig l i s) The solution will depend on the needs f t i i i l l i s r. PSD solutions: r Adjust the footrests backwards if possible. r Adjust the angle of the footrest to atch the foot if possible. If this is not possible, use footrest wedges. r Provide a strap to the front of the lower legs for support and protection. r If the front of the seat is pushing on the back of the wheelchair user’s leg/legs it may be necessary to shorten the seat slightly, and bevel the cushion backwards. r For a tall wheelchair user consider raising the seat front or tilting the seat and backrest. By doing this the wheelchair user’s feet will be higher, more forward and possibly in the adjustment range of the standard footrests. Note: r When making any of the above adjustments – check that the castor wheels can still turn fully without bumping into the footrests or wheelchair user’s f t. r If these adjustments are not possible on the available wh elchairs o do not provide enough adjustment, some m di!cation may be necessa y. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 105 106 Problem: Legs drawn inwards (adducted) Support needed r First ensure that the wheelchair user’s pelv s and trunk are stabilized by providing the support required. This may help to bring the legs into a m re neutral sitting posture. r Support on the i sid of the thighs and the inside of the knees. PSD solutions r Inside thigh wedges will provide gentle support. Note: In this illustration a thigh wedge has been add d onto a !rm foam layer of a cushion. The !rm f am as a re seat bon shelf built in. A soft layer of foam should be added over the top of the whole cushion. r A knee separator pad will provide !rm support. Note: In this illustration the knee sepa ator pad is attached to a w oden seat base with a bracket. Room is allowed for a cushion to be placed on top of the wooden seat. Supporting the lower legs and feet Problem: One or both k ees bend and are !xed less than neutral sitting posture (trunk to thigh angle is more than 90 degrees) The solution will depend on the needs of the individual wheelchair user. PSD solutions: r Adjust the footrests backwards if possible. r Adjust the angle of the f otrest to match the foot if possible. If this is not possible, use footrest wedges. r Provide a strap to the front of the lower legs for support and protection. r If the front of the seat is pushing on the back of the wheelchair user’s leg/legs it may be necessary to shorten the seat slightly, and bevel the cushion backwards. r For a tall wheelchair user consider raising the seat front or tilting the seat a d backres . By doing this he wheelchair user’s feet will be higher, more forward and possibly in the adjustment range of the standard footrests. Note: r When making any of the above adjustments – check that the castor wheels can still turn fully without bumping into the footrests or wheelchair user’s feet. r If these adjustments are not possible on the available wheelchairs or do not provide enough adjustment, some modi!cation may be necessary. 中級⾞椅⼦サービス教習パッケージ 107 にぶつからないことを確かめよ。 • ⼿に⼊る⾞椅⼦でこれらの調整ができないかじゅうぶん調整できなければ、改造が必要なこともある。 問題：⽚膝または両膝が、ニュートラルな座位姿勢まで屈曲しない 姿勢⽀持具の解決策 • ⼿に⼊れば、標準的な挙上式レッグレストを供与。 • 可能ならば、⾜台を調節して前へ移す。 • 可能ならば、3輪⾞椅⼦を検討。⾜台は、中央の⽔平バー上に 取り付ける。 • ⾜台を、⽊あるいは⾦属を継ぎ⾜して前⽅へ延⻑。 • レッグパイプ70を前⽅へ延⻑：これは溶接が必要な場合がある ため、⾦属加⼯の知識と技能に⻑けた⼈が⾏なうべきである。 注記：どの解決策の場合も⾞椅⼦の全⻑を最⼩限にすることが重要。 ステップ 4: 資⾦調達および発注 • 資⾦調達および発注に関する情報全般は、「基礎⾞椅⼦教習パッケージ受講者⽤参考書 ステッ プ４：資⾦調達および発注」を参照。 ステップ５: 製品（⾞椅⼦）の下準備 製品（⾞椅⼦）の下準備 製品（⾞椅⼦）の下準備は、⾞椅⼦サービス提供における第５ステップである。製品（⾞椅⼦）の 下準備とは、処⽅（選択）通りに⾞椅⼦を設定し、あらゆる姿勢⽀持具を下準備することである。 中級教習プログラムでの⾞椅⼦の下準備は、通常、フィッティングが必要になる前のある段階まで しかできない。⾞椅⼦サービスの「製品（⾞椅⼦）の下準備」と「フィッティング」の 2 ステップ は、⾞椅⼦が適切にフィットするまでくり返される。初回フィッティング前には、姿勢⽀持具を決 まった位置に完全に固定しないことが多い。これは、⾞椅⼦および姿勢⽀持具をフィッティング後 も調節できるようにしておくためである。 付加姿勢⽀持は、さまざまなやり⽅で施せる。たいへん簡便な解決策で、簡素な⼯房でつくれるも のもある。他にもっと複雑で、熟練技能や設備が必要なものもある。 70 [原⽂] footrests hanger, [JIS T9201:2016][⽤語集] レッグパイプ WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 107 108 Problem: One or both knees cannot bend to neutral sitting posture PSD solutions: r Provide a standard elevating leg rest if available. r Adjust the footrests forward if possible. r Consider providing a 3-wheeled wheelchair if available. Add footrests to the top of the horizontal centre bar. r Extend the footrests forward by adding wood or metal. r Extend the footrest hanger to be more forward – this may require welding and should only be carried out by someone with excellent technical knowledge and skills with metalwork. Note: Whatever solution is decided – it is important to try to ensure that the overall length of the wheelchair is kept to a minimum. Step 4: Funding and ordering r See Step 4: Funding and ordering in the Wheelchair Service Training Package – Basic Level Reference Manual for general information about funding and ordering. Step 5: Product (wheelchair) preparation Product (wheelchair) preparation Product (wheelchair) preparation is the !fth step in wheelchair service delivery. Product (wheelchair) preparation means setting up the wheelchair and preparing any PSDs that have been prescribed (selected). At the intermediate level training programme it is usually only possible to prepare the wheelchair to a certain point before a !tting is needed. The wheelchair service steps ‘product (wheelchair) preparation’ and ‘!tting’ may be repeated until the wheelchair !ts correctly. Often PSDs are not fully !xed in place before the !rst !tting. This is to ensure that adjustments can be made to the wheelchair and PSDs after the !tting. Additional postural support can be provided in different ways. Some solutions are very simple, and can be made in a simple workshop. Other solutions may be more complicated and require more technical skill and facilities. Wheelchair service personnel do not have to fabricate PSDs themselves. Wheelchair service personnel can work in partnership with technicians. The 108 受講者⽤参考書 ⾞椅⼦サービス職員は⾃分⾃⾝で姿勢⽀持具を製造する必要はない。⾞椅⼦サービス職員には技師 と組んでの作業も可能だ。⾞椅⼦サービス職員が、何をつくる必要があり、どう機能すべきか説明 できれば、技師は地元で⼿に⼊る資材からそのつくり⽅を案出できる。⾞椅⼦サービス職員は、最 終製品が⾞椅⼦ユーザーのニーズを意図通りに満たせるよう、製造⼯程に居残って指導してもよい。 同じ⽀えを実現するのに、さまざまな姿勢⽀持具の解決策があることも多い。採⽤する解決策は、 ふつう⼿に⼊る資源によって決まる。例えば： • ⼿に⼊る⾞椅⼦の種類、およびどんな調節が可能か。 • ⼿に⼊る材料 • 利⽤できる⼯房の設備および⼯具 • 半完成品化した⽀持具が利⽤できるかどうか。例えば、⾻盤側⽅パッド、体幹側⽅パッド、ベル ト、ヘッドレストなど。 ⾞椅⼦および姿勢⽀持具の下準備を計画し実施する 計画と準備 ⾞椅⼦の下準備を始める前に、作業計画を⽴てることが⼤切だ。⾞椅⼦の下準備作業を他の⼈（例 えば⼯房で働く技師）へ引き継ぐ、または複数⼈で⾞椅⼦の下準備に当たる場合には、綿密な計画 がとりわけ重要になる。計画と準備で踏むステップは： 中級⾞椅⼦処⽅（選択）フォームを読み直す： • 全員が、フォーム上の情報をすべて理解しているか確認せよ。 • フォーム上の情報で、⾞椅⼦の下準備がじゅうぶんやれるか確認せよ。例えば、必要な⼨法がす べて出ているか？それぞれの姿勢⽀持具の仕様説明はじゅうぶん詳しいか？さらに議論や説明 が必要になる場合もある。 選択した⾞椅⼦で、どうやって必要な⽀えを達成するか決める： • 使⽤する⾞椅⼦を観察して問うてみよ： o どんな調整を⽬前の⾞椅⼦に施せば、必要な⽀えをもたらせるか？ o どんな姿勢⽀持具が、すでにこの⾞椅⼦に付いているか？ • 改造や姿勢⽀持具の付加が必要な場合、判断せよ： o 既製の⽀持具で使えるものがあるか？あれば、どうやってこの⾞椅⼦に取り付けられるか？ o 改造部や姿勢⽀持具を原材料からつくる必要がある場合、どんな材料を使い、どうやってそ の姿勢⽀持具を⾞椅⼦に固定すればよいか？ • 姿勢⽀持具と⾞椅⼦とがどう連動するのか、考えるのを忘れないようにせよ。 中級⾞椅⼦サービス教習パッケージ 109 タスク表を準備する： • ⾞椅⼦を下準備するために実施すべきタスクを列記せよ。 • 複数⼈で作業する場合は、だれがどのタスクを担当するか決めよ。 姿勢⽀持具をつくる際の留意事項 付加姿勢⽀持を備えた⾞椅⼦を下準備する際には、以下の勘どころに留意せよ： １. 姿勢⽀持具が与える⽀えは必要最⼩限に71 ⽀えの量は、個々の⾞椅⼦ユーザーによって違う。姿勢⽀持具は、⼀⼈ひとりの⾞椅⼦ユーザーが 必要とする⽀えを、正しい位置で、正しい広さの体表⾯72へもたらすべきである。 ２. 姿勢⽀持具と⾞椅⼦は⼀体となって連動している73 ⾞椅⼦に付加姿勢⽀持を設けると、システム全体が変わる可能性がある。例えば、姿勢⽀持具を付 加すると、⾞椅⼦の内⼨が変わる場合がある。 ３. 強い圧⼒が⽣じるところをつくらない 姿勢⽀持具が、⾞椅⼦ユーザーの⾝体の⼀部分への圧⼒を引き起こすことがある。例えば、⾞椅⼦ ユーザーが横へ傾くのを防ぐためには⼤きい⽀持⼒が必要な場合、体幹側⽅パッドが強い圧⼒が⽣ じる部分になりうる。 こうした状況では、接触⾯積を増やして⼒を分散することを検討せよ。つねに、姿勢⽀持具の表⾯ やベルトの内側に、じゅうぶん緩衝材が効いているか確かめよ。 ４. 姿勢⽀持具は実⽤的で機能を損なわないように 留意事項：⾞椅⼦ユーザーが求める⾞椅⼦および座位保持とは、実⽤的で扱いやすく、できる限り 活動的になれるものである。 ⼯房での安全 ‒ 安全のための５つのルール： • ⼯房では、⾜を覆う靴を履く。 • 切断や⽳開けをする時は、部材をしっかり固定する：治具を⽤いるか補助を頼む。 • 電動⼯具や、その他の鋭利な⼯具を使う時は、安全メガネをかける。 • 作業区域や通路は整理整頓し、清潔に保つ。 • ⾃分⾃⾝や他⼈に向かって切らない。 71 [原⽂] PSDs should provide just enough support 72 [原⽂] in the right place, and over the right amount of surface area 73 [原⽂] PSDs and wheelchairs work together as a whole system 110 受講者⽤参考書 姿勢⽀持具および改造部づくりに必要な材料および⼯具 下表は、姿勢⽀持具の製作に使う材料の例である。 材料 姿勢⽀持具や改造部への⽤途： 姿勢⽀持具や改造部の材料を選ぶ際の留意点： ⾦ 属/ プ ラ ス チ * ク/ ⽊ 材 ⾦属/プラスチック/⽊材は姿勢⽀持 具の構造体を形づくる。例えばソリッ ド座⾯や背もたれなど。 ⽊材あるいは⾦属は、体幹側⽅パッド を背もたれへ固定する受け具に使え る。 12 mm厚の合板は、ソリッド座⾯や背もたれをつくる のにたいへん便利である。丈夫だが⽐較的軽い。マリ ン［耐⽔］合板は、最も耐久性があるが⾼価。 3 mm厚のアルミ板および 6 mm厚のアクリルまたは ABS樹脂板が⼿に⼊れば、ソリッド背もたれの製作に 使える。板を折り返すと剛性が増す。 どんな板材を⽤いる場合も、⾞椅⼦ユーザーの安全の ため、鋭い⾓を取り除くか覆うよう、特に注意を払う。 ウ レ タ ン フ 3 4 ム/ 緩 衝 材 ウレタンフォームは、あらゆる姿勢⽀ 持具で、姿勢⽀持具が⾞椅⼦ユーザー の⾝体へ直接触れる部分に⽤いる。 形状を保てる硬いウレタンフォーム は、姿勢⽀持具に、的確な⽀えに必要 な形状を与えるために⽤いる。 柔らかいウレタンフォームは、快適さ を⾼め、減圧するために⽤いる。 ウレタンフォームの使⽤例： • ベルトにはウレタンフォームを付 加し、圧⼒を分散して快適さを⾼ めること。 • 硬いウレタンフォームは、体幹側 ⽅ウェッジ（くさび）の製作に使 え、クッションに付加して、⼤腿外 側ウェッジや⼤腿内側ウェッジの 製作に使える。 • （EVA74など）たいへん硬いウレタ ンフォームは、⾜台の積み増しや ⾜台ウェッジ、また体幹側⽅パッ ドの製作に使える。 現地の市場を調べ、ウレタンフォーム、靴、マットレ ス、家具⼯場を訪ねて、現地で⼿に⼊るウレタンフォ ームを探す。 現地に出回る、さまざまな厚さ（25 mmおよび 50 mm） とさまざまな硬さのウレタンフォームを探す。 EVAは⾮常に硬いウレタンフォームの⼀例で、姿勢⽀ 持具に強固な⽀えと構造を与える。EVAは、靴の製造 所で⾒つかることがある。 ビーチサンダル製造⽤の硬いゴムは、EVAの代⽤にな る。 良質なチップウレタンフォーム75は、中程度に硬いウ レタンフォームの⼀例。チップウレタンは成形/多層 構造クッションの基層、⾻盤後⽅パッド、座⾻前⽅（ア ンカー）サポートづくり、ソリッド背もたれの成形に 使える。 柔らかい「マットレス⽤ウレタンフォーム」は、⼼地 よい層に使う柔らかいウレタンフォームの⼀例。 最も広く⼿に⼊り、最も安価な「超柔軟」ウレタンフ ォームは、硬いウレタンフォームの基層なしに、単独 で除圧クッションをつくるには不適切である。 コイヤ ［ーまたはコイア］76（ココナッツ繊維）は、硬 いウレタンフォームの代⽤になる。 74 [訳注] Ethylene-vinyl acetate の略, エチレン酢酸ビニル. 発泡体はバスマットや靴のミッドソールなどに⽤いる. 75 [原⽂] chip foam 76 [訳注] ロープや⽞関マットの他, 天然ゴムで繊維をコーティングしたものがクッション素材に⽤いられている. 中級⾞椅⼦サービス教習パッケージ 111 材料 姿勢⽀持具や改造部への⽤途： 姿勢⽀持具や改造の材料を選ぶ際の留意点： 布 布は姿勢⽀持具のカバーに使う。 耐久性があり、（拭くか取り外して洗濯して）清潔にし やすい布を探す。耐⽔⽣地は、⾞椅⼦ユーザーに失禁 がある場合、座⾯、クッション、背もたれに便利。柔 らかい T シャツのような素材（⽊綿や綿/ライクラ混 紡）はヘッドレスト、体幹側⽅パッド、体幹側⽅ウェ ッジに使える。伸縮する⽣地の⽅が、姿勢⽀持具の形 状に合わせやすい。 通常、合成繊維は天然繊維より⾝体に熱がこもる。 最低数種類は違う⾊を揃え、可能であれば⾞椅⼦ユー ザーに選んでもらう。 ナ イ ロ ン ベ ル ト 地/ ⾯ フ A ス ナ 4/ バ * ク ル ナイロンベルト地/⾯ファスナー/バ ックルは、⾻盤ベルト、肩ハーネス、 下腿ベルト、⾜ベルトなど、ベルト類 の製作に使う。 25 mm、35 mm、50 mm幅のナイロンベルト地が便 利。ベルトは、幅広いほど圧⼒が均等になる。ナイロ ンベルト地の切り端は溶かし、ほつれ⽌めする。綿ベ ルト地は、効果がたいへん劣る。 （バックパックに使うような）ワンタッチバックル は、たいへん使いやすい。⼿に⼊れば、⻑持ちするよ う品質のよいものを⽤いる。試験は、バックルを留め た状態で引き離してみる。着脱しやすく、外さない限 り引き離されないものにする。 ⾯ファスナーはよい留め具だが、掃除しておかないと 効かなくなる。 ベルトの内側には、必ず柔らかいウレタンフォームの 緩衝材を⼊れ、⾞椅⼦ユーザーの⾝体を保護する。 接 着 剤 接着剤は、⽊材やウレタンフォームの 接合に使う。 ⽊⼯⽤接着剤（いっぱんに⽩ボンドや PVAとして知ら れる）およびウレタンフォーム⽤接着剤（ゴム系接着 剤、靴⽤接着剤、⻩⾊ボンド）を常備しておく。 接着剤を⽤いる⼈が、正しい使い⽅を知っているよう にする。 接 合 部 品 接合部品は、姿勢⽀持具の⾞椅⼦への 取り付けに使う。 次の接合部品が便利： • ボルトとナット（ロックナットが好適）、ワッシャー • Tナット（ナット代わりに、合板に⾷い込んで固定） • ステープル（張り布固定⽤） 尖ったネジの使⽤は、姿勢⽀持具が破損した時に危険 なので避ける。 112 受講者⽤参考書 ⼯房の設備および⼯具：⽇常的に姿勢⽀持具をつくるサービス事業所では、⼯房スペースを建ち 上げ、作業台、万⼒、材料や⼯具の保管場所、よい照明と換気を設けておくと便利である。下表に、 姿勢⽀持具づくりに役⽴つ⼯具の例を⽰す。 便利な⼯具： ⽤途： ⼿動ノコギリ ⽊材、プラスチック、⾦属を、電気を使わずに切る。 電動ノコギリ 電源があるところで、⽊材、プラスチック、⾦属（切る材料に合う刃 を使っているか確かめよ）を切る。 ドリルとドリルビット ボルト⽳を開ける。 鋭くて硬い刃物 発泡材を、電気を使わずに切る。 バンドソー 電源があるところで、⽊材、プラスチック、⾦属、発泡材を切る。 ヤスリ ⽊材、プラスチック、⾦属の⾓を滑らかにする。 サンダー 電気があるところで、⽊材、プラスチック、⾦属の⾓を滑らかにする。 スパナ ボルトとナットを締める。 ⼯業⽤ミシン 布製の張り布・カバー・ベルトを縫う。 姿勢⽀持具のつくり⽅ 以下、この教習プログラムで取り上げた姿勢⽀持具のつくり⽅を⽰す。原則の多くは、その他の姿 勢⽀持具にも当てはまる。 座⾻前⽅（アンカー）サポート 座⾻前⽅（アンカー）サポートは、⼀個の硬いウレタンフ ォームか似たような素材でつくり、上に柔らかいウレタン フォームを敷く。 座⾻前⽅（アンカー）サポートは、ソリッド座⾯なら柔ら かいウレタンフォームの下、多層構造ウレタンフォームク ッションなら⼆つの層の間に置ける。 座⾻前⽅（アンカー）サポートは、除圧クッションの⼀部 であってもよい。 座⾻前⽅（アンカー）サポートは座⾻のすぐ前⽅に据える。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 111 112 Workshop facilities and tools: A service that is making PSDs on a regular basis will bene!t from setting up a workshop space, which has a workbench and vice, storage areas for materials and tools, good lighting and ventilation. The table below gives examples of tools that will help to make PSDs. Useful tools: Used for: Hand saw Cutting wood, plastic or metal with no electricity. Electric saw Cutting wood, plastic or metal (check that the correct blade is used for the materials being cut) where there is electricity. Drill and drill bits Making holes for bolts. Sharp, rigid blade Cutting foam with no electricity. Band saw Cutting wood, plastic and foam where there is electricity. File Smoothing the edges of wood, metal or plastic. Sanding machine Smoothing the edges of wood, metal or plastic where there is electricity. Spanners Tightening nuts and bolts. Industrial sewing machine Sewing fabric upholstery, covers and straps. How to make PSDs The following gives suggestions for how to make the PSDs covered in this training programme. Many of the principles can be applied to other PSDs. Pre seat bone shelf A pre seat bone shelf is made of a piece of !rm foam or similar material with a soft foam over the top. The shelf can be placed under the soft foam of a solid seat or between two layers of a layered foam cushion. A pre seat bone shelf may be part of a pressure relief cushion. A pre seat bone shelf sits just in front of the seat bones. 中級⾞椅⼦サービス教習パッケージ 113 座⾯前⽅（の⽚側）を下げる この姿勢⽀持具は、ウレタンフォームクッションの改造で 間に合わせられる。 座⾯前⽅の硬い（柔らかい⽅ではない）ウレタンフォーム を、望みの⾓度で切り取る。 切り取ったウレタンフォーム⽚はくさび形で、分厚い⽅が 座⾯前縁、尖端が⾻盤ないし座⾻のすぐ前⽅に当たる。 ソリッド座⾯を⽤いて⼤きい⾓度が必要な場合は、座板も ⼀部切り取り、股関節がもっと開くようにしてもよい。 注記：反対側の股関節を屈曲させておくと、⾞椅⼦に座った ユーザーの前滑りを防ぎやすくなる。 ⼤きい⾓度が必要な場合は、改造する前に硬いウレタンフ ォームを下に敷き、座⾯全体を積み増ししてもよいが、鋭 い⾓ができないよう、⾓はすべて⾯取りすべきである。 座⾯を⾼くしても、⾜台や背もたれの⾼さに不具合が⽣じ ないか確かめよ。 座⾯前⽅のかさ上げ 座⾯前⽅を⾼くするには、さまざまな⽅法がある。⼆つ挙げると： ⾻盤のすぐ前⽅で終わる、硬いウレタンフォームのウェッ ジ（くさび）をクッション前部の下に敷く。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 113 114 Lower seat front (one side) This PSD can be managed by modifying a foam cushion. Cut away the !rm foam (not the soft foam) at the front of the seat to the desired angle. The piece of foam removed will be wedge shaped with the thick end at the front of the seat and the thin end just in front of the pelvis or seat bones. If a solid seat is used, and a large angle is needed, part of the seat board can also be cut away to allow hip to open more. Note: By keeping the other hip bent it is easier for the user to keep from sliding forward in the seat. If a large angle is required it may be necessary to build up the entire seat with !rm foam at the bottom before modifying but ensure no sharp edge – all the edges need to be bevelled. Check that a higher seat surface will not cause problems with the footrests or backrest height. Raised seat front The seat front may be raised in different ways. Two suggestions are: Place a !rm foam wedge under the front of the cushion, ending just in front of the pelvis. WHE LCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 113 114 Lower seat front (one side) This PSD can be managed by modifying a foam cushion. Cut away the !rm foam (not the soft foam) at the front of the seat to the desired angle. The piece of foam removed will be wedge shaped with the thick end at the front of the seat and the thin end just in front of the pelvis or seat bones. If a solid seat is used, and a large angle is needed, part of the seat board can also be cut away to allow hip to open more. Note: By keeping the other hip bent it is easier for the user to keep from sliding forward in the seat. If a large angle is required it may be necessary to build up the entire seat with !rm foam at the bottom before modifying but ensure no sharp edge – all the edges need to be b vell d. Check that a higher seat surface will not cause problems with the footrests or backrest height. Raised seat front The seat front may be raised in different ways. Two suggestions are: Place a !rm foam wedge under the front of the cushion, ending just in front of the pelvis. WHE LCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 113 114 Lower seat front (one side) This PSD can be managed by modifying a foam cushion. Cut away the !rm foam (not the soft foam) at the front of the seat to the desired angle. The piece of foam removed will be wedge shaped with the t ick end at the front of th seat and th thin end just in front of the pelvis or seat bon s. If a solid seat is used, a d a large angle is needed, part of the seat board can also be cut away to allow hip to open more. Note: By ke ping the other hip bent it is easier for the user to keep from sliding forward in the seat. If a large angle is required it may be necessary to build up the entire seat with !rm foam at the bottom before modifying but ensure no sharp edge – all the edges need to be bevelled. Check that a higher seat surface will not cause problems with the footrests or backrest height. Raised seat front The seat front may be raised in different ways. Two suggestions are: Place a !rm foam wedge under the front of the cushion, ending just in front of the pelvis. 114 受講者⽤参考書 布製座⾯を取り去り、ソリッド座⾯を設ける。座⾯は、受け 具を介して必要な⾓度で取り付ける。 ソリッド座⾯には、つねにクッションを施すこと。 ⾻盤前傾⽤ウェッジ ⾻盤前傾⽤ウェッジ（くさび）は、座⾻前⽅（アンカー）サ ポートと同じ要領でつくれる。硬いウレタンフォームの基 層でクッションに形状を与え、柔らかいウレタンフォーム 層を上に重ねる。 ウェッジ（くさび）部分が座⾻の下に位置し、座⾻のすぐ 前⽅で終わるようにする。⼤腿下では、クッションは⽔平 でなければならない。 ⾻盤下の積み増し ⾻盤下の積み増しは、硬いウレタンフォームか似たような 素材でつくり、柔らかい層を上に重ねる。 ⾼い側の下を、左右の座⾻下で圧⼒が均等に感じられると ころまで積み増しする。 ⾻盤側⽅パッド ⾻盤側⽅パッドをつくるにはさまざまなやり⽅があり、固定する⾞椅⼦や、どれくらい⽀えが必要 かによって変わる。いくつか提⽰すると： WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 113 114 Remove the canvas seat and provide a solid seat. Mount the seat with brackets at the angle that is needed. Always provide a cushion with a solid seat. Wedge for anterior tilt A wedge for anterior tilt can be made using the same principle as a pre seat bone shelf. A base layer of !rm foam provides the shape for the cushion, and a soft layer of foam is placed over the top. The wedge should be under the seat bones, and stop just in front of the seat bones. The cushion should be level under the thighs. Build-up under pelvis A build-up under the pelvis is made from !rm foam or similar material with a soft layer over the top. Build-up under the high side until the pressure under both seat bones feels the same. Pelvis side pads Pelvis side pads can be made in different ways depending on the wheelchair they will be fastened to and how much support is needed. Some suggestions are: I SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 113 114 Remove the canvas seat and provide a solid seat. Mount the seat with brackets at the angle that is needed. Always provide a cushion with a solid seat. Wedge for anterior tilt A wedge for anterior tilt can be made using the same principle as a pre seat bone shelf. A base layer of !rm foam provides the shape for the cushion, and a soft layer of foam is placed over the top. The wedge should be under the seat bones, and stop just in front of the seat bones. The cushion should be level under the thighs. Build-up under pelvis A build-up under the pelvis is made from !rm foam or similar material with a soft layer over the top. Build-up under the high side until the pressure under both seat bones feels the same. Pelvis side pads Pelvis side pads can be made in different ways depending on the wheelchair they will be fastened to and how much support is needed. Some suggestions are: WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 113 114 Remove the canvas eat and provide a solid seat. ount the seat with brackets at the angle tha is needed. lways provide a cushion with a solid seat. Wedge for anteri il edge for anterior tilt can be made using the e principle as a pre seat bone shelf. A base layer f r foam provides the shape for the cushion, a soft layer of foam is placed over the top. The edge should be under the seat bones, and stop just in front of the seat bones. The cushion should be level under the thighs. Build-up under pelvis A build-up under the pelvis is made from !rm foam or similar material with a soft layer ove the top. Build-up under the high side until the pressure under both seat bones feels the same. Pelvis side pads Pelvi ide pads can be made in different ways depending on the wheelchair they will be fastened to and how much support is needed. Some sugg stions are: 中級⾞椅⼦サービス教習パッケージ 115 ソリッドな［サイドガードのある］ひじ掛けで77、パッド へ構造/⽀えを与えられる場合は、⾻盤側⽅パッドはカバ ーを施した硬いウレタンフォームでつくり、ひじ掛け［ま たはサイドガード］に当てて取り付けられる。 ひじ掛けの下が（左図のように）空いている［サイドガー ドがない］場合は、内側に柔らかいウレタンフォームを接 着した⽊⽚で⾻盤側⽅パッドをつくってもよい。この場 合はカバーを施すべきである。 ⾻盤側⽅パッドは、⾞椅⼦のフレームかソリッド座⾯に、 受け具（左図を参照）を介して取り付ける。 左図のような場合は、クッションをソリッド座⾯の上に 置き、⾞椅⼦ユーザーを受け具やボルトから保護せよ。 ⼤腿外側ウェッジ 硬いウレタンフォームブロック（100 mm x 100 mm x 40 mm）を対⾓線で⼆等分し、ウェッジ（くさび）を２個つ くる。⾞椅⼦フィッティングに備えて、こうしたブロック はつくり溜めておくようにせよ。 ウェッジを基層ウレタンフォーム上に接着し、柔らかい ウレタンフォームを上に置く。必要に応じて⾓を落とす。 77 [原⽂] if there are solid armrests. [訳注] じっさいの製品および上図に即して語を補った. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 115 116 r if there are solid armrests that can be used to provide structure/support for the pad, a pelvis side pad can be made from a !rm piece of upholstered foam mounted against the armrest. Where the armrest is open (as in this illustration on the left), a solid pelvis side pad may be made from a piece of wood with softer foam glued onto the inside. This should then be upholstered. Mount the pelvis side pad to either the wheelchair frame or a solid seat (as shown) with a bracket. In the illustration on the left, a cushion would then sit on top of the solid seat, protecting the wheelchair user from the bracket and bolts. Outside thigh wedges Cut blocks of !rm foam (100 mm x 100 mm x 40 mm) diagonally in half to create two wedges. Keep a stock of these blocks for use during !tting wheelchairs. Glue the wedge onto the base foam of a cushion and under the soft foam. Trim corners as needed. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 115 116 r if there are solid armrests that can be used to provide structure/support for the pad, a pelvis sid pad can be ade from a !rm pi ce of upholstered foam mounted against the armrest. Where the armrest is open (as in this illustration on the l f ), a solid pelvis side pad may be made from a pi ce of wood with softer foam glued onto the insid . This should then be upholstered. Mount the pelvis side pad to either the wheelchair frame or a solid seat (as shown) with a bracket. In the illustration on the left, a cushion would then sit on top of the solid seat, protecting the wheelchair user from the bracket and bolts. Outside thigh Cut blocks of !rm foam (100 mm x 100 mm x 40 mm) diagonally in half to create two wedges. Keep a stock of these blocks for use during !tting wheelchairs. Glue the w dge onto the base foam of a cushion and under the soft foam. Trim corners as needed. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 115 116 ere are solid armrests hat can be us d to r vide structure/support for the pad, a pelvis side pad can be made from a !rm piece of upholstered foam mounted against the armrest. Where the armrest is open (as in this illustration on the left), a solid pelvis side pad may be made from a piece of wood with softer foam glued onto the inside. This should then be upholstered. Mount the pelvis side pad to either the wheelchair frame or a solid seat (as shown) with a bracket. In th illustration on the left, a cushion would then sit on top of the solid seat, protecting the wheelchair user from the bracket and bolts. Outside thigh wedges Cut blocks of !rm foam (100 mm x 100 mm x 40 mm) diagonally in half to create two wedges. Keep a stock of these blocks for use during !tting wheelchairs. Glue the wedge onto the base foam of a cushion and under the soft foam. Trim corners as needed. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 115 116 r if there are solid armrests that can be used to provid structure/support for he pad, a pelvis side pad can be made from a !rm piece of upholstered foam mounted against the armrest. Where the armrest is open (as in this illustration on the left), a solid pelvis side pad may be m de from a pi c of wood wi h s ft r fo m glued ont the insid . This should then b upholstered. Mount the pelvis side pad to either the wheelchair frame or a solid seat (as shown) with a bracket. In the illustration on the left, a cushion would then sit on t p of the solid seat, protecting th wheelchair user from the bracket and bolts. Outside thigh wedges Cut blocks of !rm foam (100 mm x 100 mm x 40 mm) diagonally in half to create two wedges. Keep a stock of these blocks for use during !tting wheel hairs. Glue the wedge onto the base foam of a cushion and under the soft foam. Trim corners as needed. 116 受講者⽤参考書 成形ウレタンフォームクッションを⽤いる場合は、クッシ ョンへ⽔平（上⾯から約 20 mm下）に切り込みを⼊れ、 所定の位置へウェッジを接着する。はみ出たウレタンフォ ームは切り落とす。 ⼤腿外側パッド このパッドは、体幹側⽅パッドと同じようにしてつくる。 ふつうは⽊⽚、プラスチック、⾦属などでつくり、内側（ユ ーザーの脚に接する側）に硬いウレタンフォーム、その上 に柔らかいウレタンフォーム層を重ねる。 パッドは、耐久性のある肌触りのよい布でカバーする。 このパッドは、ソリッド座⾯に受け具を介して、あるいは ⾞椅⼦のシートパイプ上に受け具で固定する。 ⼤腿内側ウェッジ ウェッジ（幅 50 mm x ⻑さ 100 mm）を半分に切り、⼆ つの同じ形のものをつくる。⾞椅⼦フィッティングに備え て、つくり溜めておくようにせよ。クッションの基層ウレ タンフォーム上に接着し、柔らかいウレタンフォームを上 に置く。 成形ウレタンフォームクッションを⽤いる場合は、クッシ ョンへ⽔平（上⾯から約 20 mm下）に切り込みを⼊れ、 所定の位置へ接着する。はみ出たウレタンフォームは切り 落とす。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 115 116 If using a moulded foam cushion, slice the cushion horizontally (approximately 20 mm from the top surface) and glue the wedge in place. Trim off any foam that sticks out. Outside thigh pads These pads are made in a similar way to trunk side pads. Usually they are made of a piece of wood, plastic or metal with !rm foam on the inside (the side that contacts the users leg) and a soft foam layer. The pad is covered with a durable, comfortable fabric. The pad can be !xed to a solid seat with a metal bracket or bracketed onto the wheelchair seat rail. Inside thigh wedge Cut a wedge (50 mm wide x 100 mm long) in half to create two equal pieces. Keep a stock of foam for use during !tting wheelchairs. Glue onto the base foam of a cushion and under the soft foam. If using a moulded foam cushion, slice the cushion horizontally (approximately 20 mm from the top surface) and glue in place. Trim off any foam that sticks out. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 115 116 If using a moulded foam cushion, slice the cushion horizontally (approximately 20 mm from the top surface) and glue the wedge in place. Trim off any foam that sticks out. Outside thigh pads These pads are made in a similar way to trunk side pads. Usually they are made of a piece of wood, plastic or metal with !rm foam on the inside (the side that contacts the users leg) and a soft foam layer. The pad is cov red with a durable, comfortable fabric. The pad can be !xed to a solid seat with a metal bracket or bracketed onto the wheelchair seat rail. Inside thigh wedge Cut a wedge (50 mm wide x 100 mm long) in half to create two equal pieces. Keep a stock of foam for use during !tting wheelchairs. Glue onto the base foam of a cushion and under the soft foam. If using a moulded foam cushion, slice the cushion horizontally (approximately 20 mm from the top surface) and glue in place. Trim off any foam that sticks out. WHE LCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 115 116 If using a moulded foam cushion, slice the cushion horizontally (approximately 20 mm from the top surface) and glue the wedge in place. Trim off any foam that sticks out. Outside thigh pads These pads are made in a similar way to trunk side pads. Usually they are made of a piece of wood, plastic or m tal with !rm foam on the inside (the side that contacts the users leg) and a soft foam layer. The pad is covered with a durable, comfortable fabric. The pad can be !xed to a solid seat with a metal bracket or bracketed nto the wheelchair seat rail. Inside thigh wedge Cut a wedge (50 mm wide x 100 mm long) in half to create two equal pieces. Keep a stock of foam or us during !tting wh elchairs. Glue onto the base foam of a cushion and under the soft f am. If using a moulded foam cushion, slice the cushion horizontally (approxi ately 20 mm from the top surface) and glue in place. Trim off any foam that sticks out. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 115 116 If using a moulded foam cushion, slice the cushion horizontally (approximately 20 mm from the top surface) and glue the wedge in place. Trim off any f am that sticks ut. Outside thigh pads These pads are made in a similar way to trunk side pads. Usually they are made of a piece of wood, plastic or metal with !rm foam on the inside (the side that contacts the users leg) and a soft foam layer. The pad is cov ed with a durable, comfortable fabric. The pad can be !xed to a solid seat with a metal bracket or bracketed onto the wheelchair seat rail. Inside thigh wedge Cut a wedge (50 mm wide x 100 mm long) in half to create two equal pieces. Keep a stock of foam for use during !tting heelchairs. lue onto the base foa of a cushion and under the s ft foam. If si g a ulded foa cushion, slice the cushion ri ta ly (appr xi ately 20 from the top f ) a glue in place. Tri o f any foam that ti s t. 中級⾞椅⼦サービス教習パッケージ 117 膝分離パッド 膝分離パッドは、⾦属、プラスチック、⽊などでつく り、上⾯・側⾯・背⾯（ユーザーに接する各⾯）を硬い ウレタンフォームにすることが多い。快適さのため、 薄く柔らかいウレタンフォームで硬いウレタンフォー ムを覆ってもよい。パッドには、耐久性があり肌触り のよい布でカバーを施す。 ⾞椅⼦ユーザーに膝分離パッドが必要な場合は、ソリ ッド座⾯を備えるのが最善である。 膝分離パッドは、ソリッド座⾯に（左図のような）L 字 型受け具で固定する。 膝分離パッドには、⾞椅⼦ユーザーが⾞椅⼦を乗り降 りできるよう、着脱か開閉できる簡便なしくみが必要。 座⾯〜背もたれ⾓度を開ける 座⾯〜背もたれ⾓度を開ける⼀法は、硬いウレタンフ ォームのウェッジ（くさび）を望みの⾓度でソリッド 背もたれの上に取り付けることだ。これは、柔らかい ウレタンフォームの層で覆わなければならない。 座⾯＆背もたれティルト（ティルトインスペース） ⾞椅⼦の中には、座⾯と背もたれを容易にティルトできる機能を備えたものもある。以下は、そ うした機能を持たない⼤半の⾞椅⼦に対する提案である。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 117 118 Knee separator pad Knee separator pads are often made of a piece of metal, plastic or wood with !rm foam on the top, sides and back (the surfaces that contact the user). Thin, soft foam can also be used over the !rm foam for comfort. The pad may be covered with a durable, comfortable fabric. If a wheelchair user needs a knee separator pad, it is best to provide them with a rigid seat. The knee separator pad can be !xed to a solid seat with an L-shaped bracket (as illustrated). A simple and easy way to remove or swing away the knee separator pad is needed, so that the wheelchair user can transfer in and out of the wheelchair. Open seat to backrest angle One way to make a more open seat to backrest angle is to add a !rm foam wedge onto a solid backrest at the desired angle. This should be covered with a soft foam layer. Seat and backrest tilt (tilt in space) Some wheelchairs include a feature, which allows you to tilt the seat and backrest easily. The following suggestions are for the majority of wheelchairs in use, which do not have this feature. WHE CHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 117 118 Knee separator pad Knee separator pads are often made of a piece of metal, plastic or wood with !rm foam on the top, sides and back (the surfaces that contact the user). Thin, soft foam can also be used over the !rm foam f r comfort. The pad may be covered with a durable, comfort le fabric. If a wheelchair user needs a knee separator pad, it is best to provide them with a rigid seat. The knee separator pad can be !xed to a solid seat with a L-shaped bracket (as illustr ted). A simple and easy way to remove or swing away the knee separator pad is needed, so that the wheelchair user can transfer in and out of the wheelchair. Open seat to backrest ang One ay to make a more open seat to backrest angle is to add a !rm foam wedge onto a solid backrest at the desired angle. This should be covered with a soft foam layer. Seat and backrest tilt (tilt in space) Some wheelchairs include a feature, which allows you to tilt the seat and backrest easily. The following suggestions are for the majority of wheelchairs in use, which do not have this feature. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 117 118 Knee separator pad Knee separator pads are often made of a piece of metal, plastic or wood with !rm foam on the top, sides and back (the surfaces that contact the user). Thin, soft foam can also be used over the !rm foam for comfort. The pad may be covered with a durable, mfortable fabric. If a wheelchair user needs a knee separator pad, it is best to provide them with a rigid seat. The knee separator pad can be !xed to a solid seat with an L-shaped bracket (as illustrated). A simpl and easy way to remove or swing away e knee separator pad is needed, so that the wheelchair user can transfer in and out of the wheelchair. Open seat to backrest angle One way to make a more open seat to backrest angle is to add a !rm foam wedge onto a solid backrest at the desired angle. This should be covered with a soft foam layer. Seat and backrest tilt (tilt in space) Some wheelc i include a feature, w ich allows you to tilt the seat and backrest easily. The f ll i g su gestions are for the majority of wheelchairs in use, which do not have this feature. 118 受講者⽤参考書 ソリッド座⾯と背もたれを備えていない⾞椅⼦の場合は、硬 いウレタンフォームのウェッジ（くさび）をクッション前部 の下に置き、背もたれを調整あるいは傾ける。 布/スリングの座⾯・背もたれを、ソリッド座⾯・背もたれ に交換する。 望みの⾓度にできる受け具を、座⾯・背もたれ両⽅に取り付 ける。 必ずソリッド背もたれには、硬いウレタンフォーム層、柔ら かいウレタンフォーム層、張り布を順に貼り重ねる。ソリッ ド座⾯には、つねにクッションを施すこと。 左図に、ソリッド座⾯や背もたれにパイプを取り付ける受け 具の⼀例を⽰す。 この受け具は、ロック⼩物を回転して解除できる。 これにより、座⾯および背もたれを（クロス型折りたたみフ レームの⾞椅⼦ならば）運搬のために取り外せる。 ⾻盤後⽅パッド ⾻盤後⽅パッドは前後に厚すぎないこと。⾞椅⼦ユーザーにもよるが厚さ 20〜30 mmになろう。 このパッドは、つねに上後腸⾻棘（PSIS）の⾼さで⽀えなければならない。 ⽪膚が敏感な、または腰椎部が⾻ばっている⾞椅⼦ユーザーの場合は、腰椎と交差する箇所のウレ タンフォームを削り取れば、圧迫する部分が⽣じるのを避けられる。 以下、⾻盤後⽅パッドのさまざまなつくり⽅を⽰す： WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 117 118 For wheelchairs without a solid seat and backrest place a !rm foam wedge under the front of the cushion and adjust or recline the backrest. Replace a canvas/slung seat and backrest with a solid seat and backrest. Attach the brackets to achieve the desired angle for both the seat and the backrest. Always line a solid backrest with !rm foam and then a soft foam layer and upholster. Always provide a cushion with a solid seat. This illustration provides an example of a bracket that can be used to attach a solid seat or backrest to a tube. The bracket can be undone by swivelling the locking piece. This allows the seat and backrest to be removed for transport (if the wheelchair is a cross-folding wheelchair). Rear pelvis pad A rear pelvis pad should not be very deep. Depending on the wheelchair user, the pad may be 20–30 mm deep. The pad should always provide support at the level of the PSIS. For wheelchair users with sensitive skin or a particularly bony spine, the foam can be carved away where it passes across the spine to avoid causing a pressure area. Different ways to make a rear pelvis pad are shown below: WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 117 118 For wheelchairs without a solid seat and backrest place a !rm foam wedge under the front of the cushion and adjust or recline the backrest. Replace a canvas/slung seat and backrest with a solid seat and backrest. Attach the brackets to achieve the desired angle for both the seat and the backrest. Always line a solid backrest with !rm foam and then a soft foam layer and upholster. Always provide a cushion with a solid seat. This illustration provides an example of a bracket that can be used to attach a solid seat or backrest to a tube. The bracket can be undone by swivelling the locking piece. This allows the seat and backrest to be removed for transport (if the wheelchair is a cross-folding wheelchair). Rear pelvis pad A rear pelvis pad should not be very deep. Depending on the wheelchair user, the pad may be 20–30 mm deep. The pad should always provide support at the level of the PSIS. For wheelchair users with s nsitive skin r a particularly bony spine, the foam can be carved away where it passes across the spine to avoid causing a pressure area. Different ways to make a rear pelvis pad are shown below: 中級⾞椅⼦サービス教習パッケージ 119 ⾻盤後⽅パッドを、張り布を施した硬いウレタンフォームで つくり、背もたれスリング前⾯にベルトで取り付ける。これ は、背もたれパイプにベルト留めできる。 硬いウレタンフォームを成形した⾻盤後⽅パッドをソリッ ド背もたれに取り付け、上を柔らかいウレタンフォーム層で 覆ってもよい。 その場合の柔らかいウレタンフォーム層は、⾞椅⼦ユーザー にとって背もたれ全体がじゅうぶん快適になるものが必要。 それがない場合は、硬いウレタンフォーム層をソリッド背も たれの上に置き、次に⾻盤後⽅パッド、それから柔らかいウ レタンフォームを重ねる。 強⼒なベルトに取り付ければ、⾻盤後⽅パッドを背もたれス リング布の背後に組み付けて⽀えを設けてもよい。 この場合は下腿ベルトを⼀本、背もたれパイプに望みの⾼さ に巻きつけ、必要に応じて⾯ファスナーで締めるようにつく れる。 背もたれのリクライニングおよび/または背もたれの形状調整 姿勢にまつわるさまざまな理由から、背もたれをリクライニングできると便利である。これが⾞椅 ⼦に調節機能として装備されておらず、張り調整背もたれでもない場合は、⾞椅⼦を改造してそう した⽀えをつくれる。以下、⼆つの選択肢を⽰す： WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 119 120 A rear pelvis pad can be made from a piece of !rm upholstered foam strapped in front of a slung backrest fabric. This can be fastened with straps to the backrest uprights. A piece of !rm foam forming the rear pelvis pad may be mounted to a solid backrest with a layer of soft foam over the top. The soft foam layer should be suf!cient to ensure that the whole of the backrest is comfortable for the wheelchair user. If not, a !rm foam layer should be placed on the solid backrest, then the rear pelvis pad, and soft foam over the top. If mounted to a strong strap, a rear pelvis pad can be mounted to provide support from behind a slung backrest fabric. In this case an additional calf strap can be looped around the backrest uprights at the desired height and tightened as needed using the Velcro. Backrest recline and/or adjust backrest shape There are different postural reasons why it can be helpful to be able to recline a backrest. If a wheelchair does not have this as a ready-made adjustable feature or there is no tension adjustable backrest, the support can be made by modifying the wheelchair. Below are two options: WHE CHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 119 120 A rear pelvis pad can be made from a piece of !rm upholstered foa strapped in front of a slung backrest fabric. Thi c n be faste ed with straps to the backrest uprights. A piece of !rm foam forming the rear pelvis pad may be mounted to a solid backrest with a layer of soft foam over the top. The soft foam layer should be suf!cient to nsure that the whole of the backrest is comfortable for the wheelchair user. If not, a !rm foam layer should be placed on the solid backrest, then the rear pelvis pad, and soft foam over the top. If mounted to a strong strap, a rear pelvis pad can be mounted to provide support from behind a slung backrest fabric. In this case an additional calf strap can be looped around the backrest pri hts at the desired height and tightened as needed using the Velcro. Backrest recli e and/or adjust backrest s a e There are different postural reasons why it can be helpful to be able to recline a backrest. If a wheelchair does not have this as a ready-made adjustable feature or there is no tension adjustable backrest, the support can be made by modifying the wheelchair. Below are two options: WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 119 120 A rear pelvis pad can be made from a piece of !rm upholstered foam strapped in front of a slung backrest fabric. This can be fastened with straps to the backrest uprights. A piece of !rm foam forming the rear pelvis pad may be mounted to a solid backrest with a layer of soft foam over the top. The soft foam layer should be suf!cient to ensure that the whole of the backrest is comfortable for the wheelchair user. If not, a !rm foam layer should be placed on the solid backrest, then the rear pelvis pad, and soft foam over the top. If mounted to a strong strap, a rear pelvis pad can be mounted to provide support from behind a slung backrest fabric. In this case an additional calf strap can be looped around the backrest uprights at the desired height and tightened as needed using the Velcro. Backrest recline and/or adjust backrest shape There are different postural reasons why it can be helpful to be able to recline a backrest. If a wheelchair does not have this as a ready-made adjustable feature or there is no tension adjustable backrest, the support can be made by modifying the wheelchair. Below are two options: 120 受講者⽤参考書 スリング背もたれの⾞椅⼦の場合は背もたれ布を取り去り、 ソリッド背もたれを望みのリクライニング⾓度で固定する。 ソリッド背もたれは（厚さ 12 mm以上の）合板でつくれる。 ソリッド背もたれを背もたれフレームへ取り付けるには、調 節できる受け具が使える。 既製のスリング背もたれを改造するには： • 背もたれ布の、左右の背もたれパイプの隣 2 か所へ垂直に 切り込みを⼊れる［左図］。 • 切り込みの深さを、⾞椅⼦ユーザーの体幹が⾻盤の上でリ ラックスし、前に崩れなくなるまで徐々に増やす。 • ⾞椅⼦ユーザーの体幹は、最良の位置が⾒つかるまで、背 もたれ布の後ろから⼿で⽀えよ［左図］。 • （幅 50 mmナイロン地の）ベルトを背もたれ布の重なり の間を通し、端を背もたれフレームに巻きつける。ベルト と背もたれ布を望みの位置で縫い合わせる。 • 予備の下腿ベルトを使うことが多いが、それは端に⾯ファ スナーが付いており、⻑さもちょうどよいからである。⾯ ファスナーを使えば、ベルトの張りを簡単に調節できる。 その代替にはハトメと紐を⽤いる。 • 柔らかいウレタンフォームを⼀枚、背もたれ布を通すベル トの上⽅および前⽅にかぶせるとよい。これは、背もたれ の上縁が当たって褥瘡が起こる危険を減らす。 体幹側⽅パッド 体幹側⽅パッドは強固な⽀えをもたらす必要があるが、同時に⾞椅⼦ユーザーの腕の動きを制約し ないよう、じゅうぶん薄くなければならない。 パッドの主構造は⾦属、プラスチック、⽊などでつくる。また、体幹側⽅パッドはつねに硬いウレ タンフォームと、その上の柔らかいウレタンフォーム層で覆う必要がある。ウレタンフォームは、 パッドの内側（⾞椅⼦ユーザーの⾝体に触れる側）および上側を覆うべきである。そしてパッド全 体には、耐久性のある⼼地よい布でカバーを施す。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 119 120 With a wheelchair that has a slung backrest, remove the backrest fabric and !x a solid backrest at the desired reclined angle. The solid backrest could be made of plywood (at least 12 mm thick). Adjustable brackets can be used to attach the solid back to the backrest uprights. Modify the existing slung backrest fabric: r Make two vertical cuts through the backrest fabric next to the backrest uprights. r Gradually increase the length of the cuts until the wheelchair user’s trunk can relax over the pelvis and not slump forward. r Support the wheelchair user’s trunk with your hand from behind the fabric until you !nd the best position. r Thread a strap (50 mm-wide nylon) between the layers of the backrest fabric and loop the ends around the backrest uprights. Stitch the strap and the backrest fabric at the desired position. r An additional calf strap can often be used, which has Velcro at the ends and is the correct length. With Velcro, the strap tension can be adjusted easily. Alternatively, use eyelets and string. r A piece of soft foam can be used to cover the top and front of the strap inside the backrest fabric. This will reduce the risk of developing pressure sores against the top of the backrest support. Trunk side pads Trunk side pads need to provide !rm support, and at the same time should be thin enough to not restrict movement of the wheelchair user’s arms. The main structure of the pad may be made from metal, plastic or wood. However trunk side pads always need to be covered in !rm foam with a soft foam layer over the top. The foam should be on the inside of the pad (where it contacts the WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 119 120 With a wheelchair that has a slung backrest, remove the backrest fab ic nd !x a solid backrest at the desired reclined angle. The solid backrest could be made of plywood (at lea t 12 mm thick). Adjustable brackets can be used to attach the solid back to the backrest uprights. Modify the existing slung backrest fabric: r Make two vertical cuts through the backrest fabric next to th backrest uprights. r Gradually increase the length of the cuts until the wheelchair user’s trunk can relax over the pelvis and not slump forward. r Support the wheelchair user’s trunk with your hand from behind the fabric until you !nd the best position. r Thread a strap (50 mm-wide nylon) between the layers of the backrest fabric and loop the ends around the backrest uprights. Stitch the strap and the backrest fabric at the desired position. r An additional calf strap can often be used, which has Velcro at the ends and is the correct length. With Velcro, the strap tension can be adjusted easily. Alternatively, use eyelets and string. r A piece of soft foam can be used to cover the top and front of the strap inside the backrest fabric. This will reduce the risk of developing pressure sores against the top of the backrest support. Trunk side pads Trunk side pads need to provide !rm support, and at the same time should be thin enough to not restrict movement of the wheelchair user’s arms. The main structure of the pad may be made from metal, plastic or wood. However trunk side pads always need to be covered in !rm foam with a soft foam layer over the top. The foam should be on the inside of the pad (where it contacts the HEEL I SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 119 120 With a whe lchair that has a slung backrest, remove the backrest fabric and !x a olid ckrest at th desired reclined gle. The solid backrest could be made of plywood (at least 12 m thick). Adjustable brackets can be used to attach the solid back o the b re t uprights. Modify the existing slung backrest fabric: r Make two vertical cuts through the backrest fabric next to the backrest uprights. r Gradually increas the leng h of the cuts until the wheelchair us r’ trunk can relax over he pelvis and not slump forward. r Support the wheelchair user’s trunk with your hand f om behind the fabric until you !nd the best position. r Thread a strap (50 mm-wide nylon) between the layers of the backrest fabric a d loop the ends around the backrest uprights. Stitch the strap and the backr st fab ic at the desired position. r An additional calf strap can oft n be used, which has Velcr at the ends and is the correct length. With Velcro, strap tension can be adjusted easily. A ternatively, use yelets and string. r A piece of sof foam can b used to cover the top and front of the strap i side the backrest fabric. This will reduc the risk of dev loping pressure sores against the top of the backrest support. Trunk side pads Trunk side pads need to provide !rm support, and at the same time should be thin enough to not restric movement of the wheelchair user’s rms. The main structure of the pad may be made from metal, plastic or wood. However trunk side pads always n ed to be covere in !r foam with a s ft foam layer over the top. The foam should on th inside of the pad (where it contacts the 中級⾞椅⼦サービス教習パッケージ 121 体幹側⽅パッドは平坦でも、⾞椅⼦ユーザーの⾝体に合わせて成形してもよい。成形する場合は、 硬いウレタンフォームを削って形づくるのがいちばん簡単だ。成形したパッドには、特別な縫製技 能および伸縮性のあるカバー⽣地が必要になる。 以下、体幹側⽅パッドの固定⽅法を 2 通り⽰す： 体幹側⽅パッドをソリッド背もたれに固定し、それか ら硬いウレタンフォーム、さらに柔らかいウレタンフ ォームの層で覆う。 体幹側⽅パッドを、背もたれパイプに⾦属受け具を介 して固定してもよい。 体幹側⽅パッド ‒ 薄くする必要 体幹側⽅パッドが厚すぎる（厚さ 2.5 cm超ある）と、パッ ドで腕の動きが制約され、また腕の内側が圧迫される。 これは⾎流を減少させ、神経を損傷し、⼿の動きを妨げる。 必要な⽀えをもたらすためにじゅうぶんな強度があれば、 より薄い素材を使うようにせよ。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 121 122 wheelchair user’s body) and wrap over the top of the pad. The whole pad is then covered with a durable, comfortable fabric. Trunk side pads may be !at, or shaped to match the wheelchair user’s body. If they are shaped, the easiest way to create the shape is to carve the shape into "rm foam. A shaped pad will need special sewing skills and a cover fabric, which can stretch. Two different ways to fasten trunk side pads to the wheelchair are shown below: A trunk side pad may be fastened to a rigid backrest, which is then covered in "rm foam and a soft foam layer. A trunk side pad may be fastened to the backrest uprights of the wheelchair with a metal bracket. Trunk side pads – need to be thin If a trunk side pad is too thick (over 2.5 cm) the pad will restrict arm movement and can also press on the underside of the arm. This can reduce blood !ow, damage nerves and interfere with hand function. Use thinner materials that are strong enough to provide the support needed. WHE LCHAIR SERVICE TRAINI G PACKAGE INTERMEDIATE LEVEL 121 122 wheelchair user’s body) and wrap over the top of the pad. The whole pad is then cover d with a durable, comfortable fabric. Trunk side pads may be !at, or shaped to match t e wheelchair user’s body. If they are shaped, the easie t way to create the shape is to carve the shape into "rm foam. A shaped pad will need special sewing skills and a cover fabric, whic can stretch. Two different ways to fasten trunk side pads to the wheelchair are shown below: A trunk side pad may be fastened to a rigid backrest, which is then covered in "rm foam and a soft foam layer. A trunk side pad may be fastened to the backrest uprights of the wheelchair with a metal bracket. Trunk side pads – need to be thin If a trunk side pad is too thick (over 2.5 cm) the pad will restrict arm movement and can also press on the underside of the arm. This can reduce blood !ow, damage nerves and interfere with hand function. Use thinner materials that are strong enough to provide the support needed. 122 受講者⽤参考書 体幹側⽅ウェッジ 体幹側⽅ウェッジ（くさび）は硬いウレタンフォームでつ くり、ソリッド背もたれに組み付けて、柔らかいウレタン フォーム層の下に置ける。 個別にカバーを施したウェッジ（くさび）形の外付けパッ ドを、背もたれ上に付けるのも便利である。これは⾯ファ スナーかベルトで固定する。 テーブル テーブルは合板（板の品質/強さにより厚さ 10〜18 mm） でつくるのが最善で、⾞椅⼦のひじ掛けにベルトか⽊製受 け具で取り付けることが可能。 テーブルの⾞椅⼦への取り付け⽅法を決める際には、だれ にでもやりやすい⽅法を⾒出せ。そうすれば緊急時（例え ば、⾞椅⼦ユーザーが窒息した場合）に、テーブルがだれ にでも即座に取り外せる。 ヘッドレスト 平⾯ヘッドレスト 平⾯ヘッドレストは、⾼いソリッド背もたれにつくり込む か、ソリッド背もたれへ受け具を介して取り付ける。 このヘッドレスト［左図］は、硬いウレタンフォームでつ くって⽊/プラスチック上に固定し、柔らかいウレタンフ ォーム層で覆っている。 このやり⽅では、⾞椅⼦ユーザーの⾝体の成⻑や変化に対 して簡単に調節できない。 独⽴したヘッドレストを受け具を介して取り付ければ、前 後や⾼さを調節できる。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 121 122 Trunk side wedges A trunk side wedge can be made from !rm foam and incorporated into a rigid backrest support, under the soft foam layer. An external wedge-shaped pad with a separate cover can also be used on the surface of a backrest. This can be fastened with Velcro or straps. Tray A tray is best made of plywood (10 mm to 18 mm depending on the quality/strength of the plywood) and can be attached to the wheelchair armrests with straps or metal or wooden brackets. When deciding how a tray will be attached to the wheelchair, !nd a method that is easy for everyone to use. This is so that anyone can remove the tray quickly in an emergency (for example, if the wheelchair user is choking). Headrest Flat headrest A #at headrest can either be included in a tall rigid backrest support or attached to the rigid backrest support with a bracket. The headrest is made from !rm foam !xed onto a piece of wood/plastic, covered with a soft foam layer. This option does not offer easy adjustment for growth or changes in the wheelchair user’s body. A separate headrest attached with a bracket allows for forward, backward and height adjustment. WH LCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 121 122 Trunk side wedges A trunk side wedge can be made from !rm foam and incorporated into a rigid backrest support, under the soft foam layer. An external wedge-shaped pad with a separate cover can also be used on the surface of a backrest. This can be fastened with Velcro or straps. Tray A tray is best made of plywood (10 mm to 18 mm depending on th qua ity/strength of the plywood) and ca be a tached o th wheelchair armrests with straps or metal or wooden bra kets. When deciding how a tray will be attached to the wheelchair, !nd a method that is easy for everyone to use. This is so that anyone can remove the tray quickly in an emergency (for example, if the wheelchair user is choking). Headrest Flat headrest A #at headrest can either be included in a tall rigid backrest support or attached to the rigid backrest support with a bracket. The headrest is made from !rm foam !xed onto a piece of w od/plastic, cov red with a soft foam layer. This option does not offer easy adjustment for growth or changes in the wheelchair user’s body. A separate headrest attached with a bracket allows for forward, backward and height adjustment. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 12 1 2 Trunk side wedges A trunk side wedge can be made from !rm foam and incorporated into a rigid backrest support, under the soft foam layer. An external wedge-shaped pad with a separate cover can also be used on the surface of a backrest. This can be fastened with Velcro or straps. Tray A tray is best made of plywood (10 mm to 18 mm depending on the quality/strength of the plywood) and can be attached to the wheelchair ar rests with straps or metal or wooden brackets. When deciding how a tray will be attached to the w eelchair, !nd a method that is easy for everyone to use. This is so that anyone can remove the tray quickly in an emergency (for example, if the wheelchair user is choking). Headrest Flat headrest A #at headrest can either be included in a tall rigid b ckrest support or attached to the rigid backrest support with a bracket. The headrest is made from !rm foam !xed onto a piece of wood/plastic, covered with a soft foam layer. This option does not offer easy adjustment for growth or changes in the wheelchair user’s body. A separat headrest attached with a bracket allows for forward, backw rd and eight adjus ment. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 121 122 Trunk side wedges A trunk side wedge can be made from !rm foam and incorporated into a rigid backrest support, under the soft foam layer. An external wedge-shaped pad with a separate cover can also be used on the surface of a backrest. This can be fastened with Velcro or straps. Tray A tray is best made of plywood (10 mm to 18 mm depending on the qualit /strength of the plywood) and can be at ached to the wheelchair armrests with straps or etal r w d brackets. When deciding how a tray will be attached to the w elchair, !nd a me hod that is easy for everyone to use. This is so that anyone c n remov t tray quickly in an emerge cy (for xample, if the wheelchair user is choki g). Headrest Flat headrest A #at headrest can either be included in a tall rigid backrest support or attached to the rigid backrest support with a bracket. The headrest is made from !rm foam !xed onto a pi ce of wood/plastic, covered with a soft foam layer. This option does n t offer easy adjust ent for growth or changes in the wheelchair user’s body. A separate headrest attached with a bracket allows for forward, backward an eight adjustment. 中級⾞椅⼦サービス教習パッケージ 123 成形ヘッドレスト 成形ヘッドレストは、硬いウレタンフォームを⽊/プラスチック上に固定し、柔らかいウレタンフ ォームか似たような素材で覆ってつくれる。成形ヘッドレストには、頭蓋⾻底部を⽀える棚状部分 や、頭が横倒れしないように⽀えるウェッジ（くさび）をつくり込める。 完成したヘッドレストのカバーには、⼼地よい布地を⽤いる。カバーは、⼼地よく、またヘッドレ ストの形状に従い伸縮するため、Tシャツ⽣地でつくれる。カバーはぴったり密着しても、やや緩 くてもよい。カバーは「引き紐」で閉じられる。 以下、成形ヘッドレストのつくり⽅の⼀例を⽰す： ⽊台に、ヘッドレスト受け具への 取り付け⽳を開ける。 硬いウレタンフォームの最基 層。 頭を左右から⽀える、硬いウ レタンフォームのウェッジ。 ヘッドレスト底部になり、頭蓋⾻ 底部の下にフィットする、ロール 状のウレタンフォーム 柔らかいウレタンフォーム層 を加える。ヘッドレストの 成形が完了。 仕上げ： • ヘッドレストを⾞椅⼦に 取り付け、 • 張り布を施す。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 123 124 Shaped headrest A shaped headrest can be made with !rm foam !xed onto a piece of wood/plastic and covered with soft foam or similar material. The shaped headrest can include a shelf to support the base of the skull and wedges to the sides to help hold the head from falling sideways. A comfortable fabric is used to cover the !nished headrest. The cover can be made with T-shirt fabric as it is comfortable and stretches to follow the shape of the headrest. The cover can be made close-!tting or slightly loose. A “pull string” can secure the cover. An example of how to make a shaped headrest is shown below: 1. 2. 3. Wooden base with holes drilled to be mounted onto headrest bracket. Firm foam !rst layer. Firm foam wedges to provide side support for the head. 4. 5. Foam roll for the base of the headrest, to !t under the base of the skull. Soft layer of foam added. Headrest shape complete. To complete: r mount the headrest to the wheelchair; r upholster. I I I E INTERMEDIATE LEVEL 123 124 a e ith !r foa !xed onto a piece of wo d/plastic i ft f r si ilar aterial. The shaped headrest can include s f t e skul and edges to the sides to help hold the i i s. i i s t c ver the !nished headrest. The cover can be i f i s it is c fortable and stretches to follow the shape of ade close-!tting or slightly loose. A “pull string” . a shaped headrest is shown below: . 2. 3. e ase it les drilled t be unted onto headrest bracket. Fir f a !rst layer. Firm foam wedges to provide side support for the head. 4. 5. Foam roll for the base of the headrest, to !t under the base of the skull. Soft layer of foam added. Headrest shape complete. To complete: r mount the headrest to the wheelchair; r upholster. 124 受講者⽤参考書 ⾜台の積み増しおよび⾜台ウェッジ ⾜台の積み増しに使える最適な素材の⼀つは、たいへん硬いウレタンフォーム（EVA あるいはビー チサンダルの底）である。⽊を⽤いてもよいが、その⽊が滑らかでトゲがなく、圧迫する危険がな いことを確かめよ。 ⾜台の積み増し たいへん硬いウレタンフォーム（EVA あるいはビーチ サンダルの底）、⽊、あるいは同様の素材をブロック （およそ 100 mm x 200 mm x 20 mm）状に切る。こ れらのブロックは、⾞椅⼦フィッティングに備えてつ くり溜めておくようにせよ。 必要に応じて、ブロックを⾜台へ接着。 ⾜台ウェッジ ⾜台積み増し⽤ブロックを対⾓線で⼆等分すると、⾜ 台ウェッジ（くさび）が⼆個できる。あるブロックは ⻑辺に沿って、他は短辺に沿って切る。これらのブロ ックは、⾞椅⼦フィッティングに備えてつくり溜めて おくようにせよ。 ⾜底を⽀える必要に応じて、⾜台ウェッジを⾜台に取 り付ける。 下腿サポート ソリッド座⾯であれば、座⾯前縁より前⽅へ延⻑し、 伸展した脚への⽀えをつくれる。 これは、⾞椅⼦の狭いスペースでの転回や、運搬のた めの折りたたみを難しくする場合がある。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 123 124 Footrest build-ups and footrest wedges One of the best materials to use for foot build-ups is very !rm foam (EVA or the sole from "ip-"ops). Wood may also be used, however ensure that the wood is smooth, without splinters, and there is no pressure risk. Footrest build-ups Cut very !rm foam (EVA or "ip-"op sole), wood or other similar material into block shapes (approximately 100 mm x 200 mm x 20 mm). Keep a stock of these blocks for use during wheelchair !tting. Glue the blocks to the footrests as needed. Footrest wedges Cut footrest build-up blocks diagonally in half to create two footrest wedges. Cut some blocks along the long side and some along the short side. Keep a stock of these blocks for use during wheelchair !tting. Attach a footrest wedge to the footrest as needed to support the sole of the foot. Lower leg supports A solid seat can be made to extend forward from the front of the seat to support a straight leg. This may make turning in small spaces and collapsing the wheelchair for transport dif!cult. 中級⾞椅⼦サービス教習パッケージ 125 ⾻盤ベルト ⾻盤ベルトは、⾃動⾞のシートベルトやバックパックの ストラップに使う、ナイロンベルト地でつくれる。 幅は、⼦ども⽤には約 25 mm、⼤⼈⽤は約 40〜50 mm がよい。 素早く着脱するには、ワンタッチバックルが最も簡便で ある。⼿に⼊らなければ⾯ファスナーも使える。⾯ファ スナーは、（⾞椅⼦ユーザーの体格にもよるが）最低 100 mm重ねよ。 カバーを施した緩衝材をベルトとユーザーの間（特にバ ックル部分）に⼊れると、さらに快適である。 ベルト端はどこに固定すべきか？ • ほとんどの⾞椅⼦ユーザーには、⾻盤ベルトの端は、 左図のように⾻盤前縁の真下で固定する。 • 取り付け位置を変えることで、ベルトが⾝体を引っ張 る⾓度を変えられる。⾻盤前縁（上前腸⾻棘）の真下 で取り付けると、座⾯に対して（左図のように）直⾓ に引く。ベルトを座⾯後端に取り付けると、座⾯に対 して 45度の⾓度で引く。引く⾓度は、45〜90度の間 にすること。ただし、⾻盤前傾がある⾞椅⼦ユーザー を⽀える設計は別である。 ⾞椅⼦ユーザーの臀部が上や前⽅へ押し出されがちな 場合は、⾻盤前傾４点ベルトが⾻盤前傾のある⾞椅⼦ユ ーザーを⽀える。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 125 126 Pelvis strap A pelvis strap can be made of nylon webbing such as the webbing found in a car seat belt or straps on a backpack. The width of the strap can be about 25 mm wide for children and about 40–50 mm for adults. Clip buckles are the easiest to do up and undo quickly. If these are unavailable, Velcro also works well. Make sure there is at least 100 mm (depending on the size of the wheelchair user) of overlapping Velcro. A covered padding between the strap and the user (particularly where the buckle is), is more comfortable. Where to fasten the ends of the strap? r For most wheelchair users, the ends of the pelvis strap fasten directly below the front of the pelvis, as illustrated. r Changing the location of the attachment will allow the strap to pull on the body from different angles. Placing the attachment directly below the front of the pelvis (ASIS) will pull at 90 degrees to the seat surface (as shown in the illustration). Placing the strap at the back of the seat will pull at 45 degrees to the seat surface. The angle of pull should be between 45–90 degrees unless the strap is designed to provide support for a wheelchair user with an anterior pelvis tilt. If the wheelchair user tends to push the hips up or forward, an anterior tilt four-point strap provides support for a wheelchair user with anterior pelvis tilt. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 125 126 Pelvis strap A pelvis strap can be made of nylon webbing such as the webbing found in a car seat belt or straps on a backpack. The width of the strap can be about 25 mm wide for c ildren and about 40–50 mm for adults. Clip buckles are the easiest to do up and undo quickly. If t se are unavailable, Vel ro also w rks well. Make sure there is at least 100 mm (depending on the size of the wheelchair user) of overlapping Velcro. A covered padding between the strap and the user (particularly where the buckle is), is more comfortable. Where to fasten the ends of the strap? r For most wheelchair users, the ends of the pelvis strap fasten directly below the front of the pelvis, as illustrated. r Changing the location of the attachment will all w the strap to pull on the body from different angles. Placing the attachment directly below the front of the pelvis (ASIS) will pull at 90 degrees to the seat surface (as shown in the illustration). Placing the strap at the back of the seat will pull at 45 degrees to the seat surface. The angle of pull should be between 45–90 degrees unless the strap is designed to provide support for a wheelchair user with an anterior pelvis tilt. If the wheelchair user tends to push the hips up or forward, an anterior tilt four-point strap provides support for a wheelchair user with anterior pelvis tilt. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 125 126 Pelvis strap A pelvis strap can be made of nylon webbing such as the webbing found in a car seat belt or straps on a backpack. The width of the strap can be about 25 mm wide for children and about 40–50 mm for adults. Clip buckles are the easiest to do up and undo quickly. If these are unavailable, Velcro also works well. Make sure there is at least 100 mm (depending on the size of the wheelchair user) of overlapping Velcro. A covered padding between the strap and the user (particularly where the buckle is), is more comfortable. Where to fasten the ends of the strap? r For most wheelchair users, the ends of the pelvis strap fasten dir ctly below the front of the pelvis, as illustrated. r Changing the location of the attachment will allow the strap to pull on the body from different angles. Placing the attachment directly below the front of the pelvis (ASIS) will pull at 90 degrees to the seat surface (as shown in the illustration). Placing the strap at the back of the seat will pull at 45 degrees to the seat surface. The angle of pull should be between 45–90 degrees unless the strap is designed to provide support for a wheelc air user with an anterior pelvis tilt. If the wheelchair user tends to push the hips up or forward, an anterior tilt four-point strap provides support for a wheelchair user with anterior pelvis tilt. 126 受講者⽤参考書 ⾻盤ベルトについての警告 ⾻盤ベルトがゆるすぎると、⾝体のコントロールおよび/または意識に障害がある⾞椅⼦ユーザ ーは滑り落ちる可能性がある。付き添いがいないと、⾸が絞まることもある。つねに介助者には 正しい装着法を教え、本⼈を付き添いなしで放置するのは危険だと警告せよ。 ⾻盤ベルトや⾻盤前傾４点ベルトは、どうやって⾞椅 ⼦へ取り付けるのか？ • ベルトをソリッド座⾯へ取り付ける場合： o 左図のようにソリッド座⾯へ取り付ける。ベルト 端を折り返し、［ほつれ⽌めにベルトの］⽳を溶 かし、ボルトを板に通してワッシャー２枚とナッ ト（ロックナットが望ましい）を⽤いる。 o ワッシャーの 1枚を、折り返しへ挟み込むことに 注意。これはベルトが切れる原因となる摩耗を遅 らせる。 • ベルトを⾞椅⼦フレームへ取り付ける場合： o ⾞椅⼦フレームに巻き付け、プラスチックか⾦属 製のスライドバックル（トリグライド、ダブル D リング、３本バックルとも呼ばれる）で固定。 o 位置が正しければ、タッピングねじも使える。 下腿ベルト ⾞椅⼦に下腿ベルトが付属していない場合は、50 mm 幅のナイロンベルト地に⾯ファスナーを縫い付けてつ くれる。 下腿ベルトの⻑さは、⾞椅⼦の幅の約２倍必要である。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 125 126 Pelvis strap warning: If a pelvis strap is too loose, a wheelchair user with limited physical control and/ or awareness can slide down. If not attended, strangulation may result. Always teach caregivers how to do up the strap correctly and warn them of the risks of leaving a person unattended. How is the pelvis strap and anterior tilt four-point strap fastened to the wheelchair? r To fasten the strap to a solid seat: – fasten to a solid seat as shown in the illustration to the left. Fold the end of the strap, melt a hole and use a bolt through the wood along with two washers and a nut (preferably a locking nut); – note the washer placed between the folded end. This helps to slow down wear and tear on the webbing, which can eventually make the strap break. r To fasten the strap to a wheelchair frame: – loop around the wheelchair frame and !x with a plastic or metal slide buckle (also known as “tri- glide”, “double D-ring” or 3-bar buckle); – the upholstery screw can also be used if it is in the correct position. Calf strap If the wheelchair does not come with a calf strap, one can be made by sewing Velcro onto a piece of 50 mm nylon webbing. The calf strap should be approximately twice as long as the width of the wheelchair. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 125 126 Pelvis strap warning: If a pelvis strap is too loose, a wheelchair user with limited physical control and/ or awareness can slide down. If not attended, strangulation may result. Always teach caregivers how t do up th strap correctly and warn them of the risks of leaving a person unattended. How is the pelvis strap and anterior tilt four-point strap fastened to the wheelchair? r To fasten the strap to a solid seat: – fasten to a solid seat as shown in the illustration to the left. Fold the end of the strap, melt a hole and use a bolt through the wood along with two washers and a n t (pr ferably a locking nut); – not the washer placed between the folded end. This helps to slow down wear and tear on t e webbing, which can eventually make the strap break. r To fasten the strap to a wheelchair frame: – loop around the wheelchair frame and !x with a plastic or metal slide buckle (also known as “tri- glide”, “double D-ring” or 3-bar buckle); – the upholstery screw can also be used if it is in the correct position. Calf strap If the wheelchair does not come with a calf strap, one can be made by sewing Velcro onto a piece of 50 mm nylon webbing. The calf strap should be approximately twice as long as the width of the wheelchair. 中級⾞椅⼦サービス教習パッケージ 127 ⾜ベルト ⾜ベルトは、25 mm 幅のナイロンベルト地と、⾯ファス ナーかバックルでつくれる。 ⼀端は折り返してから［ほつれ⽌めにベルトの］ネジ⽳を 溶かし、⾜台へ固定してもよい。 ⾜ベルトが⽪膚を擦らないよう、また圧⼒を分散するため、 カバーを施した緩衝材を⽤いること。 ベルトをつくり、使う際のコツ • ベルトは、⾯ファスナーかバックル留めにする。 • ⾞椅⼦ユーザーへ接触する部分には、ベルトに緩衝材を⼊れる：圧⼒が分散され、より快適。 • ベルトはソリッド座⾯や背もたれにボルト留めするか、⾞椅⼦フレームに巻き付けてスライ ドバックル（トリグライド、ダブル D リング、３本バックルとも呼ばれる）で固定する。 • たいてい⾞椅⼦に付属している下腿ベルトは、他の⽤途にも使える。例えば、下腿ベルトは背 もたれ布の改造/調整に使える。 肩ハーネス 肩ハーネスをつくるにはミシンを使⽤し、縫製の経験者に頼むのがいちばんだ。ナイロンベルト地、 バックル、緩衝材の柔らかいウレタンフォームが必要である。いくつかのコツとして： • 緩衝材を肩の上、とくに⾻ばったところに⼊れる。 • 肩ハーネス上端の固定点は、⾞椅⼦ユーザーの肩の 上端と同じ⾼さか少し上にする。それより下だと、⾞ 椅⼦ユーザーを引きずり下ろしてしまう。 • 肩ハーネスの下端を、決して⾻盤ベルトに固定して はならない。⾻盤ベルトを吊り上げてしまう。 • 左図のような胸パーツは、肩ハーネスを定位置に保 ち、体幹前⾯に⽀えをもたらす。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 127 128 Foot straps Foot straps can be made from 25 mm nylon webbing and Velcro or buckles. One end can be folded and a hole burned through it for a screw, which can !x it to the footrest. A covered pad should be used to keep the foot strap from rubbing against the skin and to distribute pressure. Tips for fabricating and using straps: r Fasten straps with Velcro or a buckle. r Add padding onto the strap where it contacts the wheelchair user – this makes it more comfortable by spreading the pressure. r Straps can be bolted to a solid seat or backrest or looped around the wheelchair frame with a slide buckle (also known as tri-glide, double D-ring or 3-bar buckle). r Calf straps, which often come with a wheelchair, can be used in other ways. For example, a calf strap can be used to modify/adjust backrest fabric. Shoulder harness To make a shoulder harness it is best to use a sewing machine and a person with sewing experience. You will need nylon webbing, buckles, and soft foam for padding. Some tips include: r Provide padding over the shoulder, particularly where it is bony. r Ensure that the !xing point for the top of the shoulder harness strap is at the same level or slightly higher than the top of the wheelchair user’s shoulder. If it is lower, the strap will pull the wheelchair user down. r Never !x the bottom of a shoulder harness strap to a pelvis strap. This will pull the pelvis strap up. r A chest piece, such as the one in this illustration, helps to keep the shoulder harness straps in place and provides support at the front of the trunk. 128 受講者⽤参考書 肩ハーネスの注意事項 きっちり締まる⾻盤ベルトを、肩ハーネスや胸ベルト使⽤時には必ず⽤いよ。これをやらない と、⾸が絞まりかねない。 ⾞椅⼦の安全・準備完了確認表を使⽤する 製品（⾞椅⼦）の下準備の最終段階は、⾞椅⼦が使⽤するのに安全で準備できており、すべての部 分が正しく動作することの確認である。 次ページの⾞椅⼦の安全・準備完了確認表は、何か取りこぼしがないか確認するのに役⽴つ。⾞椅 ⼦サービス職員はこの確認表をコピーし、⾞椅⼦サービスセンターに貼って、⾞椅⼦を下準備する ごとのリマインダーとして使える。 ⾞椅⼦の安全・準備完了確認表は、⾞椅⼦ユーザーがフィッティングに訪れる前に仕上がっている べきである。 ⾞椅⼦の安全・準備完了確認で問題を発⾒したら、⾞椅⼦サービス職員にできることは： • フィッティングより前に、問題点を補修/修理する。 • ⾞椅⼦を、⾞椅⼦製造所へ送り返して修理してもらう。 • ⾞椅⼦の供給者へ連絡し、問題点の修理を依頼する。 中級⾞椅⼦サービス教習パッケージ 129 中級⾞椅⼦の安全・準備完了確認表 確認表：⾞椅⼦は使⽤するのに安全で準備できているか？ 姿勢⽀持具を含む⾞椅⼦全体 姿勢⽀持具が、よく緩衝材が施され、しっかり固定されている78 □ 鋭い⾓がない79 □ 部品に破損や傷がない □ ⾞椅⼦がまっすぐ⾛る □ 前⽅キャスター輪 ⾃由に回転する □ キャスターフォークに接触しないで回転する □ ボルトが固く締まっている □ 前⽅キャスター受け具 キャスターが⾃由に旋回する □ 駆動輪 ⾃由に回転する □ ⾞軸ボルトが固く締まっている □ タイヤへ適切に空気が⼊っている（親指の圧⼒で、凹みが 5 mm未満） □ ハンドリムがしっかり取り付けられている □ ブレーキ 適切に働く □ ⾜台 ⾜台がしっかり取り付けられている □ フレーム クロス型折りたたみ式⾞椅⼦の場合：容易に折りたためて開ける □ 背もたれ前倒し式⾞椅⼦の場合：背もたれを容易に折りたためて開ける □ クッション クッションがカバーに正しく収まっている □ クッションが⾞椅⼦に正しく載っている □ クッションカバーはぴったり合っているが、きつ過ぎない □ ⾞椅⼦がソリッド座⾯を備えている場合：クッションがソリッド座⾯全体を覆っている □ 78 [訳注] 他の教材ではこの項⽬は表の 2 番⽬に置かれ, ⽂⾯は「姿勢⽀持具が、よく緩衝材が施され、しっかり固定 されている」となっている. 79 [訳注] 他の教材では, この項⽬は表の 1 番⽬に置かれている. 130 受講者⽤参考書 ステップ 6: フィッティング フィッティングは、⾞椅⼦サービス提供の８ステップの６番めである。フィッティングでは、⾞椅 ⼦ユーザーと⾞椅⼦サービス職員とで、⾞椅⼦および姿勢⽀持具がうまくフィットし、⾞椅⼦ユー ザーを快適で、なるべくニュートラルな座位姿勢に近づけて⽀えていることを確かめる。 フィッティングの実施⽅法 次ページの中級⾞椅⼦フィッティング確認表を、フィッティングの指針として活⽤せよ。以下の順 序で確認せよ： • ⾞椅⼦は準備できているか？ • ⾞椅⼦および姿勢⽀持具のフィッティングの確認 • 姿勢の確認 • 圧⼒の確認 • ⾞椅⼦が動いている状態でのフィッティングの確認 • さらにやるべきことがあるかどうかの判断80 留意事項： 付加姿勢⽀持が必要な⾞椅⼦ユーザーへの⾞椅⼦フィッティングには、付加姿勢⽀持が必要な い⾞椅⼦ユーザーより時間がかかる。それは、より多くの調整を⾏なう必要があるためだ。 • ⾞椅⼦ユーザーは、フィッティングにより時間がかかることを知っておく必要がある。調整し ている間に、⾞椅⼦を乗り降りする必要が出てくる場合もある。 • 多くの変更が必要であれば、再度フィッティングに来てもらう必要も出てくる。 ⾞椅⼦は準備できているか？ ⾞椅⼦は、⾞椅⼦ユーザーが試⽤するよう準備できているか、必ず確かめよ。 80 [原⽂] Decide any further action is required. 中級⾞椅⼦サービス教習パッケージ 131 ⾞椅⼦および姿勢⽀持具のフィッティングの確認 ⾞椅⼦の幅 正しいフィッティング： ぴたりとフィットしなければならない。 確かめよ： • 臀部がひじ掛けまたは⾻盤側⽅パッドの間に⼼地よくフィットして いる。 • ⼤腿が、ひじ掛けあるいは泥よけ/サイドガード、⾻盤側⽅パッドの 間に⼼地よくフィットし、圧迫し合って（⾻盤側⽅パッドが前に出 すぎると起こることがある）いない。 • 体幹が、背もたれフレームや体幹側⽅ウェッジあるいは体幹側⽅パ ッドの間に⼼地よくフィットしている。 座⾯奥⾏き 正しいフィッティング： 膝裏と座⾯/クッション前縁の間に、最低 30 mmすき間がある。 確かめよ： • ⾞椅⼦ユーザーが、快適な限りで、なるべくニュートラルに近い座 位姿勢で座っている。 確かめ⽅： • ⼿を膝裏とクッションの間で滑らせ、最低 30 mmすき間があること を確かめる。⼿をふくらはぎ後⾯に沿って滑らせ、ふくらはぎが座 ⾯/クッションに触れないことを確かめる。 • 左右両側とも確かめる。左右で差がある場合、処⽅には短い側の脚 の⼨法を選ぶ。 脚の⻑い⾞椅⼦ユーザーの場合、すき間はさらに⼤きくてもよく、 60 mmまでが許容範囲。 正しくフィットすると、⼤腿がしっかりと⽀えられる。これは座⾻ 下の圧⼒を減らし、褥瘡を⾷い⽌めるのに役⽴つ。座⾯奥⾏きが⻑ すぎると、⾞椅⼦ユーザーはまっすぐに座れない。 ⾻盤 確かめよ： • 座⾻前⽅（アンカー）サポートが座⾻のすぐ前⽅に据わっている（⼿ を⾞椅⼦ユーザーの臀部の下に置いて確認）。 • ⾻盤後⽅パッドが上後腸⾻棘（PSIS）のところで⽀え、体幹下部を 押していない。 • ⾻盤側⽅パッドが寄り添うようにフィットし、股関節にかかってい ない。 • ⾻盤ベルトがしっかり締まり、⾞椅⼦ユーザーの⽪膚を挟まない（⼿ をベルトと⾞椅⼦ユーザーの間で滑らせて確認）。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 125 126 Pelvis strap A pelvis strap can be made of nylon webbing such as the webbing found in a car seat belt or straps on a backpack. The width of the strap can be about 25 mm wide for children and about 40–50 mm for adults. Clip buckles are the easiest to do up and undo quickly. If these are unavailable, Velcro also works well. Make sure there is at least 100 mm (depending on the size of the wheelchair user) of overlapping Velcro. A covered padding between the strap and the user (particularly where the buckle is), is more comfortable. Where to fasten the ends of the strap? r For most wheelchair users, the ends of the pelvis strap fasten directly below the front of the pelvis, as illustrated. r Changing the location of the attachment will allow the strap to pull on the body from different angles. Placing the attachment directly below the front of the pelvis (ASIS) will pull at 90 degrees to the seat surface (as shown in the illustration). Placing the strap at the back of the seat will pull at 45 degrees to the seat surface. The angle of pull should be between 45–90 degrees unless the strap is designed to provide support for a wheelchair user with an anterior pelvis tilt. If the wheelchair user tends to push the hips up or forward, an anterior tilt four-point strap provides support for a wheelchair user with anterior pelvis tilt. 132 受講者⽤参考書 体幹 確かめよ： • 体幹側⽅パッドが、わきの下をいっさい圧迫しない位置にある。⾞ 椅⼦ユーザーのわきの下と体幹側⽅パッド上端が、30 mm以上離れ ている。 • 肩ハーネスの装着が快適で、⽪膚を挟まない。 • テーブルが前腕とひじの全体を⽀え、腹部を圧迫しない。テーブル の切り取り（カットアウト）部分が⾝体にぴったり沿うよう調製さ れ、しかし⾞椅⼦ユーザーの⽪膚と触れたり擦れたりしていない。 • 背もたれの⾼さと傾きを確認。 ヘッドレスト 正しいフィッティング： ヘッドレストが、⾞椅⼦ユーザーの頭を頭蓋⾻底部で⽀えている。 確かめよ： • ヘッドレストがユーザーの頭を、バランスが取れ、まっすぐに起き た姿勢で⽀えている。 ⼤腿 確かめよ： • ⾞椅⼦ユーザーの⼤腿と⼤腿⽀持具（⼤腿外側パッド、⼤腿内側ウ ェッジ、膝分離パッドなど）の間に強い圧⼒が⽣じていない。 • 膝分離パッドが⿏径部にいっさい圧⼒を加えていない。膝分離パッ ドは⿏径部から、⼦どもで 40〜60 mm、⼤⼈で 60〜100 mm離す。 ⾜台〜座⾯⾼ 正しいフィッティング： 座⾯/クッションが⼤腿全体をすき間なく⽀え、⾜台が⾜全体をす き間なく⽀えている。 確かめ⽅： • ⼿を⼤腿と座⾯/クッションとの間で滑らせる。圧⼒が、⼤腿全体に わたって均等にかかり、すき間がないこと。 • ⾜台に乗っている⾜を観察する。⾜の前も後ろも、すき間なく⽀え られていること。 ⼤腿下にすき間がある場合は、⾜台が⾼すぎる。⾜底下にすき間が ある場合は、⾜台が低すぎる。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 117 118 Knee separator pad Knee separator pads are often made of a piece of metal, plastic or wood with !rm foam on the top, sides and back (the surfaces that contact the user). Thin, soft foam can also be used over the !rm foam for comfort. The pad may be covered with a durable, comfortable fabric. If a wheelchair user needs a knee separator pad, it is best to provide them with a rigid seat. The knee separator pad can be !xed to a solid seat with an L-shaped bracket (as illustrated). A simple and easy way to remove or swing away the knee separator pad is needed, so that the wheelchair user can transfer in and out of the wheelchair. Open seat to backrest angle One way to make a more open seat to backrest angle is to add a !rm foam wedge onto a solid backrest at the desired angle. This should be covered with a soft foam layer. Seat and backrest tilt (tilt in space) Some wheelchairs include a feature, which allows you to tilt the seat and backrest easily. The following suggestions are for the majority of wheelchairs in use, which do not have this feature. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 121 122 wheelchair user’s body) and wrap over the top of the pad. The whole pad is then covered with a durable, comfortable fabric. Trunk side pads may be !at, or shaped to match the wheelchair user’s body. If they are shaped, the easiest way to create the shape is to carve the shape into "rm foam. A shaped pad will need special sewing skills and a cover fabric, which can stretch. Two different ways to fasten trunk side pads to the wheelchair are shown below: A trunk side pad may be fastened to a rigid backrest, which is then covered in "rm foam and a soft foam layer. A trunk side pad may be fastened to the backrest uprights of the wheelchair with a metal bracket. Trunk side pads – need to be thin If a trunk side pad is too thick (over 2.5 cm) the pad will restrict arm movement and can also press on the underside of the arm. This can reduce blood !ow, damage nerves and interfere with hand function. Use thinner materials that are strong enough to provide the support needed. 中級⾞椅⼦サービス教習パッケージ 133 背もたれ⾼ 正しいフィッティング： 正しくフィットすると、⾞椅⼦ユーザーが必要とする⽀えが与えら れ、活動的な⾞椅⼦ユーザーは、（⾃⾛する場合）肩甲⾻を⾃由に動 かしてこげる。 確かめ⽅： • ⾞椅⼦ユーザーに、背もたれが快適かどうか尋ねる。 • 体幹が、臀部の上でバランスが取れているかどうか観察する。 • ⾞椅⼦ユーザーは、背もたれに邪魔されないで⾞椅⼦をこげているか？ 背もたれ⾼は、⾞椅⼦ユーザーのニーズによって異なる。⾃⼒でこぐ⾞椅⼦ユーザーには、肩甲 ⾻を⾃由に動かせる背もたれが必要だ。まっすぐに座るのが難しい⾞椅⼦ユーザーには、より⽀ えが多い、より⾼い背もたれが必要になる。 ⾞椅⼦ユーザーの胸郭下端まで⽀える⾼さの背もたれが向いてい るのは、⾞椅⼦ユーザーが： • 健康で活動的。 • 容易に、バランスよくまっすぐに座れる。 • 積極的に⾃⼒でこぐため、動きに⼤きな⾃由度が必要。 背もたれ⾼ D（座⾯〜胸郭下端） ⾞椅⼦ユーザーの肩甲⾻下端まで⽀える⾼さの背もたれが向いて いるのは、⾞椅⼦ユーザーが： • すぐにくたびれがち（例：⾼齢や進⾏性疾患のため）。 • まっすぐに座るのが難しい。 • ⾞椅⼦ユーザーは腕で⾞椅⼦をこげる。 背もたれ⾼ E（座⾯〜肩甲⾻下端） さらに⾼い肩上端まで⽀える背もたれは、⾞椅⼦ユーザーにもっと⽀えが必要な場合、背もたれ のリクライニングを⽤いる場合、座⾯＆背もたれティルト（ティルトインスペース）を⽤いる場 合、疲れやすい/くたびれやすい場合に有効。 背もたれ⾼ F（座⾯〜肩上端） 駆動輪位置：⼿こぎ⽤ 正しいフィッティング： ⼿をハンドリムへ置いた時、⾞椅⼦ユーザーのひじが直⾓になる。 確かめ⽅： • ⾞椅⼦ユーザーに、⾞輪頂部のハンドリムを握ってもらう。ひじが 直⾓に曲がっていなければならない。 • また、駆動輪位置（前の⽅が活動的、後ろの⽅が安全）がバランスを 取るために適切かどうかも、⾞椅⼦ユーザーと確認せよ。 134 受講者⽤参考書 ⾞椅⼦ユーザーに、駆動輪を「安全」な（より後ろの）位置に置く 必要がある場合、腕は、こぐのに理想的な位置より後ろに来ざるを 得ない。この妥協は、⾞椅⼦ユーザーへ説明せよ。 駆動輪位置を調整した場合は、つねにブレーキの調整および再確認 が必要。 座⾯⾼：⾜こぎ⽤ 正しいフィッティング： ⾞椅⼦ユーザーがまっすぐに座り、⾻盤背⾯を背もたれが快適に⽀ えている状態で、⾜を床⾯にべったり置ける。 確かめ⽅： • ⾞椅⼦ユーザーに、まっすぐに、あるいは快適な限りでなるべくま っすぐに、⾻盤背⾯が背もたれへ触れるように⾞椅⼦に座ってもら う。両⾜が床⾯にべったり着くかどうか確かめる。 座⾯が⾼すぎる場合に、⾞椅⼦サービス職員が試みること： • クッションの厚みを減らす。 • ソリッド座⾯を、もとの座⾯より低い位置に取り付ける（これを⾏ なうには、技術指導なり⽀援を得よ）。 ⾞椅⼦ユーザーが⽚⾜だけでこぎ、反対側の⾜は⾜台に置いたまま の場合は、⾜台へ置く⾜の側の、座⾻下の圧⼒を調べよ。 姿勢の確認 ⾞椅⼦ユーザーが⾞椅⼦へどう座っているか、正⾯と横から 観察せよ。まっすぐな姿勢で座っているだろうか？ ⾞椅⼦ユーザーが、快適な限りでなるべくまっすぐな姿勢で 座っているかどうか調べよ。それは、ハンド・シミュレーシ ョンで⾒定めた姿勢に近いものであるはずだ。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 133 134 If the wheelchair user needs the rear wheels to be positioned in the ‘safe’ (further back) position, this may mean that their arms are further back than is ideal for propelling. Explain this compromise to the wheelchair user. If any adjustments are made to the rear wheels position, the brakes will also need to be adjusted and rechecked. Seat height – for foot propelling Correct !t: r With the wheelchair user sitting upright, and the back of their pelvis comfortably supported by the backrest, he/she should be able to rest their feet "at on the "oor. How to check: r ask the wheelchair user to sit upright or as close to upright as is comfortable in the wheelchair, with the back of their pelvis touching the backrest. Check whether their feet can sit "at on the "oor. If the seat height is too high, wheelchair service personnel can try: r reducing the height of the cushion; r attaching a solid seat lower than the original seat (get technical advice or support to do this). For a wheelchair user who is propelling with only one foot, with the other foot resting on the footrest – check the pressure under the seat bone of the side that is resting on the footrest. Check posture Observe how the wheelchair user is sitting in the wheelchair from the front and from the side. Is he/she sitting in an upright posture? Look to see whether the wheelchair user is sitting in as upright a posture as is comfortable for them. This should be close to the posture identi!ed in the hand simulation. 中級⾞椅⼦サービス教習パッケージ 135 特に確かめること： • ⾻盤は（可能ならば）まっすぐに起きて⽔平か？ • 体幹は（可能ならば）まっすぐに起きて左右対称か？ • 頭は（可能ならば）バランスが取れてまっすぐに起きてい るか？ • 脚と⾜は、まっすぐな座位姿勢になるべく近くなるよう、 ⽀えられているか？ • ⾞椅⼦ユーザーには、どんな感じか尋ねよ。 ⾞椅⼦ユーザーの座位姿勢全体を観察したあと、各々の姿勢⽀持具が、意図通りに⽀えているか確 かめよ。特に、（供与していれば）忘れずに調べるべきもの81は： • 背もたれの⾼さ・傾き・形状 • ティルトインスペース • ⾻盤側⽅パッドおよび体幹側⽅パッド • ⼤腿および下腿の⽀持具すべて 圧⼒の確認 褥瘡発⽣の危険があるすべての⾞椅⼦ユーザーには、座⾻下は じめ危険があるすべての部位（例：股関節、尾⾻）で圧⼒が安 全かどうかの確認が、フィッティングの作業⼿順に含まれる。 強固な⽀えをもたらす姿勢⽀持具を⽤いるすべての⾞椅⼦ユ ーザーに対して、⾞椅⼦ユーザーの⾝体と姿勢⽀持具の間の圧 ⼒を調べよ。しっかりとした⽀えが感じられるべきだが、窮屈 であってはならない。 81 [訳注] 教習員⽤指導書では, 項⽬として「ヘッドレスト」が加わっている. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 135 136 Speci!cally, check: r is the pelvis upright and level? (if possible) r is the trunk upright and symmetrical? (if possible) r is the head balanced and upright? (if possible) r are legs and feet supported as close to upright sitting posture as possible? r ask the wheelchair user how he/she feels. After looking at the wheelchair user’s overall sitting posture, check that each PSD is providing support as intended. Speci!cally, remember to check (if provided): r backrest height, recline and contours; r tilt in space; r pelvis side pads and trunk side pads; r any thigh and lower leg supports. Check pressure For every wheelchair user who is at risk of developing a pressure sore, the !tting step includes checking whether the pressure is safe under the seat bones and any other area at risk (e.g. under hip joint or tail bone). For every wheelchair user who is using PSDs that provide !rm support – check the pressure between the wheelchair user’s body part and the PSD. Support should feel !rm – but not tight. WH LCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 135 136 Speci!cally, check: r is the pelvis upright and level? (if possible) r is the trunk upright and symmetrical? (if possible) r is the head balanced and upright? (if possible) r are legs and feet supported as close to upright sitting posture as possible? r ask the wheelchair user how he/she feels. After looking at the wheelchair user’s overall sitting posture, check that each PSD is providing support as intended. Speci!cally, remember to check (if provided): r backrest height, recline and contours; r tilt in space; r pelvis side pads and trunk side pads; r any thigh and lower leg supports. Check pressure For ev ry wheelchair u r who is at risk of developing a pressure sore, the !tting step includes checking whether the pressure is safe under the seat bones and any other area at risk (e.g. under hip joint or tail bone). For every wheelchair user who is using PSDs that provide !rm support – check the pressure between the wheelchair user’s body part and the PSD. Support should feel !rm – but not tight. 136 受講者⽤参考書 ⾞椅⼦が動いている状態でのフィッティングの確認 フィッティングの最終段階は、⾞椅⼦ユーザーが動いている状態で⾞椅⼦のフィッティングがどう かの確認である。⾞椅⼦ユーザーが⾞椅⼦を⾃⼒でこげない場合は家族/介助者に押してもらい、 その間に観察する。 着⽬点： • 背もたれは、⾞椅⼦ユーザーが肩甲⾻を⾃ 由に動かしてこげるようになっているか？ • ⾞椅⼦の動きやこぐ動作によって、⾞椅⼦ ユーザーに、何らかの姿勢変化、不快感、不 安定感が⽣じていないか？ • ⼿こぎの場合：駆動輪位置は、⾞椅⼦ユーザ ーができる限りうまくこぐために適切か？ • ⾜こぎの場合：座⾯⾼および座⾯奥⾏きは、 ⾞椅⼦ユーザーが⾜でこぐために適切か？ • 姿勢⽀持部は、⾞椅⼦による移動を制約せ ず安全にしているか？ WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 135 136 Check !t while the wheelchair is moving The !nal part of !tting is to check how the wheelchair !ts when the wheelchair is moving. If a wheelchair user cannot push the wheelchair themselves, ask a family member/caregiver to push them while you observe. What to look for: r does the backrest allow the wheelchair user freedom to move their shoulder blades to push? r does movement of the wheelchair or the action of pushing cause the wheelchair user to change their posture or feel uncomfortable or unstable in any way? r Hand propelling: Is the rear wheels position correct for the wheelchair user to push as well as he/she can? r Foot propelling: Are the seat height and seat depth correct for the wheelchair user to push with their legs? r Do the posture supports allow for unrestricted and safe wheelchair mobility? 中級⾞椅⼦サービス教習パッケージ 137 中級⾞椅⼦フィッティング確認表 １. ⾞椅⼦は準備できているか？ ⾞椅⼦が安全に使⽤でき、すべての部分が動作することは確認済みか？ □ ２. ⾞椅⼦および姿勢⽀持具のフィッティングの確認 ⾞椅⼦の幅： • 臀部がひじ掛けまたは⾻盤側⽅パッドの間に⼼地よくフィ ットし、 • 体幹が、⾞椅⼦の背もたれパイプまたは体幹側⽅パッドの間 に⼼地よくフィットし、 • ⼤腿が、ひじ掛け、泥よけ/サイドガードまたは⾻盤側⽅パッ ドの間に⼼地よくフィットし、圧迫し合っていない。 □ 座⾯奥⾏き： • 左右の膝裏と座⾯/クッションの間に、30 mmのすき間。 □ ⾻盤： • 座⾻前⽅（アンカー）サポートが座⾻のすぐ前に据わり、 • ⾻盤後⽅パッドが上後腸⾻棘（PSIS）のところを⽀え、 • ⾻盤側⽅パッドが寄り添うようにフィットして股関節にか からず、 • ⾻盤ベルトがきっちり締まり、⽪膚を挟んでいない。 □ 体幹： • 体幹側⽅パッドが、わきの下をいっさい圧迫しない位置にあ り、わきの下と体幹側⽅パッド上端が 30 mm以上離れ、 • 肩ハーネスの装着が快適で、⽪膚を挟んでおらず、 • テーブルが前腕とひじの全体を⽀え、腹部を圧迫しない。 • 背もたれの⾼さと傾きを確認。 □ ヘッドレスト： • ヘッドレストは、通常⾞椅⼦ユーザーの頭を頭蓋⾻底部で⽀ える。 • ユーザーの頭を、バランスが取れまっすぐに起きた姿勢で⽀ える。 □ WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 125 126 Pelvis strap A pelvis strap can be made of nylon webbing such as the webbing found in a car seat belt or straps on a backpack. The width of the strap can be about 25 mm wide for children and about 40–50 mm for adults. Clip buckles are the easiest to do up and undo quickly. If these are unavailable, Velcro also works well. Make sure there is at least 100 mm (depending on the size of the wheelchair user) of overlapping Velcro. A covered padding between the strap and the user (particularly where the buckle is), is more comfortable. Where to fasten the ends of the strap? r For most wheelchair users, the ends of the pelvis strap fasten directly below the front of the pelvis, as illustrated. r Changing the location of the attachment will allow the strap to pull on the body from different angles. Placing the attachment directly below the front of the pelvis (ASIS) will pull at 90 degrees to the seat surface (as shown in the illustration). Placing the strap at the back of the seat will pull at 45 degrees to the seat surface. The angle of pull should be between 45–90 degrees unless the strap is designed to provide support for a wheelchair user with an anterior pelvis tilt. If the wheelchair user tends to push the hips up or forward, an anterior tilt four-point strap provides support for a wheelchair user with anterior pelvis tilt. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 121 122 wheelchair user’s body) and wrap over the top of the pad. The whole pad is then covered with a durable, comfortable fabric. Trunk side pads may be !at, or shaped to match the wheelchair user’s body. If they are shaped, the easiest way to create the shape is to carve the shape into "rm foam. A shaped pad will need special sewing skills and a cover fabric, which can stretch. Two different ways to fasten trunk side pads to the wheelchair are shown below: A trunk side pad may be fastened to a rigid backrest, which is then covered in "rm foam and a soft foam layer. A trunk side pad may be fastened to the backrest uprights of the wheelchair with a metal bracket. Trunk side pads – need to be thin If a trunk side pad is too thick (over 2.5 cm) t e pad will restrict arm movement and can also press on the underside of the arm. This can reduce blood !ow, damage nerves and interfere with hand function. Use thinner materials that are strong enough to provide the support needed. 138 受講者⽤参考書 ⼤腿： • ⼤腿外側パッド、膝分離パッドによって強い圧⼒が⽣じてお らず、 • 膝分離パッドが、⿏径部から⼦どもで 40〜60 mm、⼤⼈で 60〜100 mm離れている。 □ ⾜台〜座⾯⾼： • クッションが⼤腿全体を、⾜台が⾜全体をすき間なく⽀え、 • ⾜ベルトがしっかり留められて締めつけておらず、 • 下腿ベルトおよびかかとの後ろのベルトが、ふくらはぎおよ び⾜を⽀えている。 □ ３. 姿勢の確認 ⾞椅⼦ユーザーが、快適な限りで、なるべくまっすぐに座っているかどうか、正⾯と横か ら⾒て確認： • ⾻盤がまっすぐに起き⽔平（か快適な限りで、なるべくそれに近づいている）か？ □ • 体幹がまっすぐに起き左右対称（か快適な限りで、なるべくそれに近づいている）か？ □ • 頭はバランスが取れ、（なるべく）まっすぐに起きているか？ □ • 脚と⾜が、できる限りニュートラルに近くなるように⽀えられているか？ □ すべての姿勢⽀持具が意図通りに⽀えているか確認。特に（供与したら）確認すべきもの： • 背もたれの⾼さ・傾き・形状 □ • ティルトインスペース［ティルト］ □ • ⾻盤側⽅パッドおよび体幹側⽅パッド □ • ⼤腿外側および内側ウェッジ（くさび）、⼤腿外側パッド、下腿サポート □ 15 分後、姿勢に変化が起きていないか確認 □ ４. 圧⼒の確認 左右の座⾻下の圧⼒を調べる。両側とも安全かどうか？ レベル１＝安全：指先を上下に 5 mm以上くねらせられる82。 レベル２＝注意：指先はくねらせられないが、容易に引き抜ける。 レベル３＝危険：指先が固く締めつけられる。指を引き抜くのが困難。 □ 指を⾞椅⼦ユーザーの⾝体と、パッドやベルトなどそれぞれの姿勢⽀持部の間に置く。 姿勢⽀持部は⾝体へ均等に接触しているか？圧⼒は安全か？ □ ⾞椅⼦ユーザーに、著しい⾻ばった突起、隆起、こぶがある場合は、それらの部位に圧⼒ がかかっていないか確かめる。 □ 82 [原⽂] Fingertips can wriggle up and down 5 mm or more. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 117 118 Knee separator pad Knee separator pads are often made of a piece of metal, plastic or wood with !rm foam on the top, sides and back (the surfaces that contact the user). Thin, soft foam can also be used over the !rm foam for comfort. The pad may be covered with a durable, comfortable fabric. If a wheelchair user needs a knee separator pad, it is best to provide them with a rigid seat. The knee separator pad can be !xed to a solid seat with an L-shaped bracket (as illustrated). A simple and easy way to remove or swing away the knee separator pad is needed, so that the wheelchair user can transfer in and out of the wheelchair. Open seat to backrest angle One way to make a more open seat to backrest angle is to add a !rm foam wedge onto a solid backrest at the desired angle. This should be covered with a soft foam layer. Seat and backrest tilt (tilt in space) Some wheelchairs include a feature, which allows you to tilt the seat and backrest easily. The following suggestions are for the majority of wheelchairs in use, which do not have this feature. 中級⾞椅⼦サービス教習パッケージ 139 ５. ⾞椅⼦が動いている状態でのフィッティングの確認 背もたれは、⾞椅⼦ユーザーが、肩甲⾻を動かしてこげるようになっているか？ □ ⾞椅⼦の動きやこぐ動作によって、⾞椅⼦ユーザーに姿勢変化、不快感、不安定感が⽣じて いないか？ □ ⼿こぎの場合：駆動輪位置は、⾞椅⼦ユーザーができる限りうまくこぐために適切か？ □ ⾜こぎの場合：座⾯⾼および座⾯奥⾏きは、⾞椅⼦ユーザーが⾜でこぐために適切か？ □ 姿勢⽀持は、⾞椅⼦による移動を制約せず安全にしているか？ □ ６. さらにやるべきことがあるかどうかの判断 さらにやるべきことがあるか？⾞椅⼦ユーザーのファイルに、やるべきことはすべて記⼊。 □ ステップ 7: ユーザー教習 ユーザー教習 ⾞椅⼦に関する情報提供と教習を受けることで、多くの⾞椅⼦ユーザーにとって、⾞椅⼦が本当に 有益なものとなる。このステップが抜けると、みすみす⾞椅⼦が、⾞椅⼦ユーザーの役に⽴たない こともある。家族/介助者にとっても、情報提供と教習を受けることは⼤切だ。 ⾞椅⼦ユーザーの役に⽴つ技能とは？ ⾞椅⼦サービス職員は、健康を保ち、⾞椅⼦を安全にかつ効率よく使い、⾞椅⼦を⼿⼊れして⻑持 ちさせるために役⽴つ技能を、⾞椅⼦ユーザーへ教えられる。あらゆる⾞椅⼦ユーザーに教えると よい技能は以下の通り： ⾞椅⼦の取り扱い： • ⾞椅⼦を運搬するための、折りたたみ⽅および持ち上げ⽅。 • 運搬のために取り外す必要がある、姿勢⽀持具すべての脱着 ⽅法。 • ⾞椅⼦の機能の使⽤⽅法。例えば、ブレーキ、ティルト機能、 転倒防⽌装置の使い⽅、姿勢⽀持具やクッションの正しい位 置。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 139 140 5. Check !t while the wheelchair is moving Does the backrest allow the wheelchair user to move their shoulder blades to push? Does movement of the wheelchair or the action of pushing cause the wheelchair user to change their posture or feel uncomfortable or unstable in any way? Hand propelling: Is the rear wheel position correct for the wheelchair user to push as well as he/she can? Foot propelling: Is the seat height and depth correct for the user to push with their leg/s? Do the posture supports allow for unrestricted and safe wheelchair mobility? 6. Decide if any further action is required Is there any further action necessary? Write any actions in the wheelchair user’s !le. Step 7: User training User training Information and training about their wheelchair can help many wheelchair users really bene!t from their wheelchair. Without this step, it is possible that the wheelchair will not help the wheelchair user as much as it could. It is important that family members/caregivers also receive the information and training. What are helpful skills for wheelchair users? Wheelchair service personnel can teach wheelchair users skills to help them to stay healthy, use their wheelchair safely and ef!ciently, and care for their wheelchair so that it will last longer. The following are good skills to teach all wheelchair users: Wheelchair handling: r How to fold and lift the wheelchair for transport. r How to take off and put back on any PSDs that need to come off for transport. r How to use features on the wheelchair – for example use of brakes, tilting and anti-tip bar, correct position of PSDs and cushion. 140 受講者⽤参考書 ⾞椅⼦ユーザーは、どれくらい⻑時間、⾞椅⼦に座るべきか あまり座った経験がない⾞椅⼦ユーザーの場合、まっすぐな姿勢で座るのに慣れるまでに時間 がかかる場合がある。これは、とりわけ⼦どもの場合そうだ。⾞椅⼦サービス職員は、⾞椅⼦ユ ーザーがどれくらい⻑く⾞椅⼦に座るべきか助⾔する必要がある。以下の指針を伝えよ： • ⾞椅⼦ユーザーが座るのに慣れていれば、新しい⾞椅⼦には、それと同じくらいの時間座るべ きである。必要ならば、徐々に時間を延ばしてもよい。 • 座った経験がない⾞椅⼦ユーザーの場合は、最初は 30分以下から始め、続いて休憩を取る。 • ⾞椅⼦ユーザーや家族/介助者に、⾞椅⼦ユーザーが⾞椅⼦に座った後には、圧⼒がかかった 部位を必ず調べるよう教えよ。 移乗（⾞椅⼦を乗り降りするやり⽅）： • 安全な移乗のやり⽅とは： o ⾞椅⼦ユーザーにとって快適で、かつ、 o 介助し、または抱え上げる⼈にとって安全なものである。 • ⾞椅⼦への正しい座り⽅（例えば、⾞椅⼦ユーザーが⾞椅⼦ のじゅうぶん後⽅に座り、座⾻が完全に座⾻前⽅（アンカー） サポートの後ろにあることの確認など）。 • 姿勢⽀持具の正しい調整⽅法。例えば、ベルトがちゃんと働 くためには、どれくらいしっかり締めなければならないか。 • 多くの⾞椅⼦ユーザーは、⾃分で⾞椅⼦を乗り降りできるこ とに留意せよ。⾃⼒での、あるいは介助による移乗に関する 説明は、「基礎⾞椅⼦サービス教習パッケージ」を参照。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 139 140 How long wheelchair users should sit in their wheelchair For some wheelchair users who have not been sitting very much, it may take time for them to become used to sitting in an upright posture. This can be particularly true for children. Wheelchair service personnel need to advise how long the wheelchair user should sit in their wheelchair. Give these guidelines: r If the wheelchair user is used to sitting up, he/she should spend the same amount of time sitting in their new wheelchair. He/she can gradually increase the time, if needed. r If the wheelchair user has not been sitting up, start with no more than 30 minutes followed by a break. r Teach the wheelchair user or family member/caregiver to always check for pressure areas after the wheelchair user has sat in the wheelchair. Transfers (how to get in and out of the wheelchair): r A safe transfer method, which is: – comfortable for the wheelchair user; and – safe for any person assisting or lifting. r How to sit correctly in the wheelchair (for example making sure that the wheelchair user is positioned well back in the wheelchair with seat bones behind any pre seat bone shelf). r How to adjust PSDs correctly – for example how !rmly straps need to be done up to work correctly. r Remember that many wheelchair users will be able to transfer in and out of the wheelchair on their own. Independent and assisted transfers are described in the Wheelchair Service Training Package – Basic Level. 中級⾞椅⼦サービス教習パッケージ 141 ⾞椅⼦の使⽤および移動： • ⾞椅⼦サービス職員が教える⾞椅⼦の移動技能は、⾞椅 ⼦ユーザーの能⼒および環境によって異なる。 • ⾞椅⼦ユーザーへ、本⼈の能⼒に合った最適なこぎ⽅を 教えるよう、つねに⼼がけよ。 • 正しいこぎ⽅、斜⾯や階段の登り下り、⼀時ウィリーな ど基礎的な⾞椅⼦の移動技能に関する詳細は「基礎⾞椅 ⼦サービス教習パッケージ受講者⽤参考書」を参照。 褥瘡予防： • 褥瘡の原因は、⾻ばった部位への圧⼒・摩擦・剪断。 • まっすぐに座るのが難しい⾞椅⼦ユーザーに対する留意 事項： o 滑らないようにする：剪断（⾻ばった部位が軟らかい 組織の上を滑ること）による褥瘡を引き起こすため。 o 左右の座⾻へ、体重を平均に分散させる。 • 姿勢⽀持具を⽤いる⾞椅⼦ユーザーについては、⾞椅⼦ や姿勢⽀持具が触れる部分の⽪膚を、定期的に調べる。 • 褥瘡予防に関する詳細は「基礎⾞椅⼦サービス教習パッ ケージ受講者⽤参考書」を参照。 家庭での⾞椅⼦の⼿⼊れ⽅法： • ⾞椅⼦ユーザーへの、家庭での⾞椅⼦のメンテナンス⽅ 法に関する基本情報の提供は、⾞椅⼦の寿命を延ばすこ とにつながる。 • ⾞椅⼦ユーザーが家庭でできる、⾞椅⼦およびクッショ ンの⼿⼊れには 6 つあり、それは「基礎⾞椅⼦サービス 教習パッケージ」で教えている。その情報は、中級⾞椅 ⼦ユーザーにも該当する。姿勢⽀持具が正常に機能して いるか確認するため、追加の⼿⼊れを⾏なってもよい。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 141 142 Wheelchair use and mobility: r The skills that the wheelchair service personnel teach for wheelchair mobility will depend on the abilities of the wheelchair user and their environment. r Always remember to teach the wheelchair user the best way to propel that suits their abilities. r More information on basic wheelchair mobility skills including pushing correctly, going up and down slopes and steps and partial wheelie is available in the Wheelchair Service Training Package – Basic Level Reference Manual. Preventing pressure sores: r Pressure sores are caused by pressure on bony areas, friction and shear. r For wheelchair users who may have dif!culty sitting upright, think about: – ensuring they are not sliding – which can cause pressure sores from shear (bony areas sliding over soft tissue); – ensuring that weight distribution is even under both seat bones. r For wheelchair users who use PSDs, ensure they regularly check their skin wherever the wheelchair or PSDs are in contact. r More details on preventing pressure sores is given in the Wheelchair Service Training Package – Basic Level Reference Manual. How to care for a wheelchair at home: r Providing wheelchair users with basic information about how to maintain their wheelchair at home can help to increase the life of the wheelchair. r There are six things that the wheelchair users can do at home to look after their wheelchair and cushion taught in the Wheelchair Service Training Package – Basic Level. This information applies to the intermediate level wheelchair users as well. Some additional care can be taken to check that PSDs are in good working order. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 141 142 Wheelchair use and mobility: r The skills that the wheelchair service personnel teach for wheelchair mobility will depend on the abilities of the wheelchair user and their environment. r Always remember to teach the wheelchair user the best way to propel that suits their abilities. r More information on basic wheelchair mobility skills including pushing correctly, going up and down slopes and steps and partial heelie is available in the Wheelchair Service Training Package – Basic Level Reference Manual. Preventing pressure sores: r Pressure sores are caused by pressure on bony areas, friction and shear. r For whe lchair users who ma have dif!culty sitting upright, think about: – ensuring they are not sliding – which can cause pressure sores from shear (bony areas sliding over soft tissue); – ensuring that weight distribution is even under both seat bones. r For wheelchair users who use PSDs, ensure they regularly check their skin wherever the wheelchair or PSDs are in contact. r More details on preventing pressure sores is given in the Wheelchair Service Training Package – Basic Level Reference Manual. How to care for a wheelchair at home: r Providi g wheelchair users with basic information about how to maintain their wheelchair at home can help to increase the life of the wheelchair. r There are six things that the heelchair users can do at home t look after their wheelc air and cushion taught in Wheelc air Service Training Package – Basic Level. This information applies to the intermediat level wheelchair users as well. Some addit al care can b taken to check that PSDs are in good working order. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 141 142 Wheelchair use and mobility: r The skills that the wheelchair service personnel teach for wheelchair mobility will depend on the abilities of the wheelchair user and their environment. r Always remember to teach the wheelchair user the best way to propel that suits their abilities. r More information on basic wheelchair mobility skills including pushing correctly, going up and down slopes and steps and partial wheelie is available in the Wheelchair Service Training Package – Basic Level Reference Manual. Preventing pressure sores: r Pressure sores are aused by pressure on bony areas, friction and shear. r For wheelchair users who may have dif!culty sitting upright, think about: – ensuring t ey are not sliding – w ich can ca se pressure sores from shear (bony areas sliding over soft tissue); – ensuring that weight distribution is even under both seat bones. r For wheelchair users who use PSDs, nsure they regularly ch ck their skin wherever the wheelchair or PSDs ar in contact. r More details on pr venting pressur sor s is given in the Whe lchair Service Training Package – Basic Level Refe nce Manual. How to care for a wheelchair at home: r Providing wheelchair us rs with basic information abou how to maintain their wheelchair at home can help to increase the life of the wheelchair. r There are six things that the wheelchair users can do at home to look after their wheelchair and cushion taught in the Whe lchair Service Training Package – Basic Level. This information applies to the intermediate level wheelchair users as well. Some additional care can be taken to check that PSDs are in good working order. 142 受講者⽤参考書 問題が起きたらどうするか： ⾞椅⼦ユーザーは、何か問題が起きたらどうすべきか知っておく必要がある。問題には以下のよう なものがある： • ⾞椅⼦に修理が必要になった。 • ⾞椅⼦がフィットしない、あるいは快適でない。 こうした問題に対して、⾞椅⼦ユーザーは⾞椅⼦サービス事業へ連絡し、⽀援と助⾔を受けられる べきである。⾞椅⼦ユーザーが、⾞椅⼦サービスセンターへの連絡⽅法を知っているか確かめよ。 ⾞椅⼦ユーザー教習がうまく⾏くコツ • ⾞椅⼦ユーザーが、何をすでに知っているか⾒出す。 • 説明し、やって⾒せてから⾞椅⼦ユーザーに練習してもらう。 • だれもが理解できることばを⽤いる。 • ⾞椅⼦ユーザーから、他の⾞椅⼦ユーザーへ教えてもらう。 • 優れたコミュニケーション技能を⽤いる。 • 励ます者であれ83。 留意事項：練習は、どんな新しい技能を学ぶ際にも重要である。技能を教えるには、つねにまず やって⾒せ、それから⾞椅⼦ユーザーへ練習機会を与えるようにせよ。 83 [原⽂] Be encouraging. 中級⾞椅⼦サービス教習パッケージ 143 中級⾞椅⼦ユーザー教習確認表 教える べき技能 教えた 技能 ⾞椅⼦の取り扱い ⾞椅⼦の折りたたみ⽅および持ち上げ⽅ □ □ 運搬のために外す必要がある、すべての姿勢⽀持具の脱着⽅法 □ □ クイックリリース⾞輪の扱い⽅ □ □ ブレーキの使い⽅ □ □ ティルト機能および転倒防⽌装置（使⽤する場合） □ □ ⾞椅⼦ユーザーが⾞椅⼦へ座った時の、姿勢⽀持具の正しい位置 □ □ 正しい置き⽅など、クッションの扱い⽅ □ □ 移乗 ⾃⼒での移乗 □ □ 介助による移乗 □ □ その他 □ □ ⾞椅⼦の使⽤および移動 正しいこぎ⽅（⾞椅⼦ユーザーが好む⽅法による） □ □ 斜⾯の登り下り □ □ 階段の昇り降り □ □ 荒れ地 □ □ ⼀時ウィリー □ □ どれくらい⻑時間、⾞椅⼦に座るべきか（付加姿勢⽀持が必要な⼦どもお よび⼤⼈について） □ □ 介助での押し⽅ □ □ 褥瘡予防 強い圧⼒がかかる部位の褥瘡を検査 □ □ 除圧動作 □ □ よい⾷事をし、たくさん⽔を飲む □ □ 褥瘡ができたらどうするか □ □ 家庭での⾞椅⼦の⼿⼊れ ⾞椅⼦の掃除：クッションとクッションカバーを洗って乾かす □ □ 可動部への注油 □ □ タイヤの空気⼊れ □ □ ボルトとナットを締める □ □ スポークを張る □ □ 張り布を調べる □ □ サビを調べる □ □ クッションを調べる □ □ 問題が起きたらどうするか ⾞椅⼦に修理が必要になったら □ □ ⾞椅⼦がフィットしない、あるいは快適でない場合 □ □ 144 受講者⽤参考書 ステップ 8: メンテナンス・修理・フォローアップ メンテナンス・修理・フォローアップに関する情報は、「基礎⾞椅⼦サービス教習パッケージ」で取 り上げている。中級では、付加姿勢⽀持を備えた⾞椅⼦を使う⾞椅⼦ユーザーにとっての、フォロ ーアップの特別な重要さについて説明する。 フォローアップ フォローアップは、⾞椅⼦サービス提供の第８ステップの⼀部である。 フォローアップのあらまし すべての⾞椅⼦ユーザーにとってフォローアップは有益である。しかし、フォローアップがとりわ け重要なのが： • ⼦ども、 • 褥瘡発⽣の危険がある⾞椅⼦ユーザー、 • 進⾏性疾患がある⾞椅⼦ユーザー、 • ⾞椅⼦に付加姿勢⽀持が必要な⾞椅⼦ユーザー、 • これまでに受けた教習なり指導で、何か困難があった⾞椅⼦ユーザーである。 ほとんどの中級⾞椅⼦ユーザーには付加姿勢⽀持が必要であるため、フォローアップはとりわけ重 要になる。 フォローアップの運⽤ フォローアップをいつやるか、について決まりはない。それは、フォローアップに最適な時期が⾞ 椅⼦ユーザーのニーズによるからである。しかし可能な限り、⾞椅⼦が渡ってから６週間以内にフ ォローアップし、⾞椅⼦が⾞椅⼦ユーザーに対してうまく働いているか確かめ、ユーザー教習を補 強するのは⾮常に有益である。⼦どもには、３〜６か⽉おきにフォローアップできれば理想的であ る。なぜなら、⼦どものニーズは成⻑に伴い急激に変化するからだ。 フォローアップ実施は： • ⾞椅⼦ユーザーの家、 • ⾞椅⼦サービスセンター、 • その他、⾞椅⼦ユーザーおよび⾞椅⼦サービス職員に都合が良い場所でできる。 中級⾞椅⼦サービス教習パッケージ 145 場所は、⾞椅⼦ユーザーが⾞椅⼦サービスセンターまで移動できるかどうか、また⾞椅⼦サービス 職員が⾞椅⼦ユーザーの家まで移動できるかどうかによる。 フォローアップの運⽤にはさまざまなやり⽅があり、例えば： • ⾞椅⼦ユーザーが⾃分の⾞椅⼦を受け取った時に、フォローアップの⾯接予約を⼊れる。 • フォローアップを、⾞椅⼦ユーザーの家で、あるいは⾞椅⼦サービスセンターで実施する。 • フォローアップ訪問を、フォローアップ実施の訓練を受けた、地域に根ざしたリハビリテーショ ン（CBR）職員が、地域への定期訪問の⼀環として⾏なってもよい。 • 移動は困難だが、⾞椅⼦ユーザーが電話に出られるところでは、電話フォローアップを実施して もよい。 ⾞椅⼦フォローアップフォーム ⾞椅⼦フォローアップフォーム（下掲）は、⾞椅⼦サービス職員がフォローアップ訪問で何を質問 し、何をやるべきか思い出すのに役⽴つ。⾞椅⼦フォローアップフォームには、さらにやるべきこ とを書き留める欄も設けている。 フォローアップでいっぱんに⾏なうこと フォローアップでいっぱんに⾏なわれる内容は： • さらに指導や教習を提供する。 例えば⾞椅⼦ユーザーが、予想したほど⾞椅⼦を使っていない場合、それは、ひとりでいる時にも ⾞椅⼦を乗り降りできる⾃信がないせいかもしれない。さらに移乗の教習を⾏なうことが、その問 題解決に役⽴ちうる。 • ⾞椅⼦を再調整する。 • 細かい修理を実施する。 家庭での⾞椅⼦の⼿⼊れを⾏なって⾞椅⼦を維持管理するよう、つねに⾞椅⼦ユーザーおよび家族 /介助者へ奨励せよ。⾞椅⼦サービス職員は、⾞椅⼦サービス職員は、壊れた部品がすぐには直せ ない場合、⾞椅⼦ユーザーが修理を段取る⼿伝いをしてもよい。 • ⾞椅⼦ユーザーを、⽀援や協⼒を得られる他のサービスへ紹介・相談する。 146 受講者⽤参考書 トゥーシタへのフォローアップ訪問 トゥーシタは７歳、かれの両親・姉と家で暮らしている。筋ジストロフィーを抱え、１年前に⾞ 椅⼦サービス事業所を通じて⾞椅⼦を⼿に⼊れた。その頃は、短い距離なら歩けた。⽴ち上がっ ての移乗で、⾃⼒で⾞椅⼦を乗り降りできた。「学校へ⾏くのが⼤変だから、⾞椅⼦が欲しかっ た」と語っていた。 フォローアップ訪問で、トゥーシタは「いまでは⾃分で⾞椅⼦を乗り降りするのが難しくなって いる」と告げた。学校では、午後にはくたびれ、不快になってしまう。そのため集中⼒が持たな い。かれの⾞椅⼦は適切なサイズで、⾼さが中程度のスリング背もたれと簡素な除圧クッション が付いている。 フォローアップで⾞椅⼦サービス職員は： • トゥーシタが、⾞椅⼦を乗り降りするやり⽅を⾒出した。トゥーシタには、⾞椅⼦から⾝体を 起こすのが困難だった。⾞椅⼦サービス職員は、トゥーシタにとってはるかに容易だと判っ た、スライディングボードを⽤いた移乗⽅法を教えた。 • トゥーシタへの付加姿勢⽀持を⾒直した。そこで、より⾼い背もたれ、および姿勢コントロー ルと除圧を備えたクッションがあれば、トゥーシタはさらにしっかりと⽀えられると判断し た。⾞椅⼦サービス職員は、これらをフィッティングに向けて下準備するために必要な計測を ⾏なった。 新しい背もたれおよびクッションのフィッティングのためにトゥーシタが⾞椅⼦サービスセン ターを訪れる⾯接予約を⼊れた。 中級⾞椅⼦サービス教習パッケージ 147 ⾞椅⼦フォローアップフォーム １. ⾞椅⼦ユーザーの情報 ⾞椅⼦ユーザー名：__________________________________ 番号：___________________________ フィッティング⽇：__________________________________ フォローアップ⽇：_______________ フォローアップ実施者名：_______________________________________________________________ フォローアップ実施場所： ⾞椅⼦ユーザーの家□ ⾞椅⼦サービスセンター□ その他□：_______________________________________________ ２. インタビュー さらにやるべきことを記録 ⾞椅⼦を、思う存分使えていますか？ はい□ いいえ□ 「いいえ」の場合：なぜですか？ ⾞椅⼦を使ううえで、何か問題はありますか？ はい□ いいえ□ 「はい」の場合：それは何ですか？ ⾞椅⼦を使ううえで、何か疑問はありますか？ はい□ いいえ□ 「はい」の場合：どんな疑問ですか？さらに教習が必要ですか？ 褥瘡がありますか？ はい□ いいえ□ 「はい」の場合：詳細（部位および程度） ⾞椅⼦への満⾜度を５段階で評価してください （１＝満⾜していない、５＝⾮常に満⾜） 評価： コメント： ３. ⾞椅⼦およびクッションの確認 ⾞椅⼦は正常に働き、安全に使えていますか？ はい□ いいえ□ クッションは正常に働き、安全に使えていますか？ はい□ いいえ□ ⼀つでも「いいえ」の場合、何が問題なのでしょうか？ ４. フィッティングの確認 ⾞椅⼦は、うまくフィットしていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 圧⼒検査の評価（１＝安全、２＝注意、３＝危険） （褥瘡発⽣の危険があるユーザーについて） 左： 右： 静⽌している時・動いている時・⼀⽇中、ユーザー は⼼地よくまっすぐに座っていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 中級⾞椅⼦サービス教習パッケージ 受講者⽤参考書 著作・制作︓ 世界保健機関（WHO） ＊⽇本語版翻訳・発⾏︓ ⼀般社団法⼈ ⽇本⾞椅⼦シーティング協会（JAWS） ⽇本⾞椅⼦シーティング協会国際委員会・ アジア姿勢保持プロジェクト（ASAP） ＊本書の⽇本語版作成に当たり、公益財団法⼈ ⽇本社会福祉弘済会より研究助成を頂きました。
中級 車椅子 サービス教習パッケ ージ 子 ど も と 車 椅 子 車椅子と付加姿勢支持が子どもたちの役に立つこと： 車椅子と付加姿勢支持への早期紹介は重要。 移動 コミュニケーション 自分で食べる 通学 友達と遊ぶ 満１歳までに：多くの子どもはひとりで座れ、つかまり立ちができる。 満２歳までに：多くの子どもはひとりで歩ける。 これらを行なうのが難しい子どもは、車椅子と付加姿勢支持が必要かもしれない。 車椅子事前評価へ紹介・相談すること。 世界保健機関(WHO), 中級車椅子サービス教習パッケージ, 2013. 日本語版制作：一般社団法人日本車椅子シーティング協会(JAWS)・アジア姿勢保持プロジェクト(ASAP) WHO/NMH/VIP/DAR/13.02 Design by Inís Communication – www.iniscommunication.com さ ま ざ ま な 体 位 車椅子を使う、体位や姿勢を変える能力が限られている子どもに は、日中や夜中、さまざまな体位への支えが必要。 座る 立つ 寝る 立つことは、股関節および体幹/脊柱の正常なカーブ の形成を助ける。 立つことで股・膝・足関節周りの 筋肉が伸び、これらの関節が硬直するのを防ぐ。 子どもが寝そべって気持ちよく眠り、遊べるように支える。 自力で立てない子どもには立位台が有効。 床の近くに座る子どもへの、さまざまな支え方 支えには毛布、発泡材、タオル、枕が活用できる。 丸太、ロールクッション、 固く巻いた毛布にまたがる。 家族や介助者に支え られて座る。 床面から低い座位保持座椅子 に座る。 中級 車椅子 サービス教習パッケ ージ 世界保健機関(WHO), 中級車椅子サービス教習パッケージ, 2013. 日本語版制作：一般社団法人日本車椅子シーティング協会(JAWS)・アジア姿勢保持プロジェクト(ASAP) WHO/NMH/VIP/DAR/13.02 Design by Inís Communication – www.iniscommunication.com 車椅子ユーザーと話し合うこと：ユーザーが何を知っていて何を学びたいのか？車椅子 ユーザーへ教えるべき重要事項を思い出すため、このチェック表を活用すること。 車椅子の取り扱い 移乗 問題が起きたらどうするか 車椅子の取り回しおよび移動 家庭での車椅子の手入れ方法 褥瘡予防 車 椅 子 ユ ー ザ ー 教 習 チ ェ ッ ク 表 中 級 車椅子の折りたたみ方および持ち上げ方 運搬のために外す必要がある、すべての姿勢支持具の脱着方法 クイックリリース車輪の扱い方 ブレーキの使い方 ティルト機能および転倒防止装置(使用する場合) 車椅子ユーザーが車椅子へ座った時の、姿勢支持具の正しい位置 正しい置き方など、クッションの扱い方 正しいこぎ方：車椅子ユーザーが好む方法で 斜面の登り下り 階段の昇り降り 荒れ地 一時ウィリー どれくらい長時間、車椅子に座るべきか(中級の姿勢支持ニーズのある子どもおよび大人) 介助での押し方 強い圧力がかかる部位の褥瘡を検査 除圧動作 よい食事をし、たくさん水を飲む 褥瘡ができたらどうするか 自力での移乗、または 介助による移乗 各車椅子ユーザーに最適な移乗方法を 教えること。 車椅子に修理が必要になったら 車椅子がフィットしない、あるいは快適でない場合 車椅子の掃除:クッションとクッションカバーを洗って乾かす 可動部への注油 タイヤの空気入れ ボルトとナットを締める スポークを張る 張り布を調べる サビを調べる クッションを調べる 中級 車椅子 サービス教習パッケ ージ 世界保健機関(WHO), 中級車椅子サービス教習パッケージ, 2013. 日本語版制作：一般社団法人日本車椅子シーティング協会(JAWS)・アジア姿勢保持プロジェクト(ASAP) WHO/NMH/VIP/DAR/13.02 Design by Inís Communication – www.iniscommunication.com ベルト 骨盤ベルト 骨盤前傾４点ベルト 下腿ベルト 足ベルト 肩ハーネス 姿 勢 支 持 具 (P SD )一 覧 表 座面/クッション 座骨前方(アンカー) サポート 座面前方(片側) を下げる 座面前方の かさ上げ 骨盤前傾用 ウェッジ 骨盤下の積み増し 骨盤側方パッド 座面/クッション 座面＆背もたれ 大腿外側ウェッジ 大腿外側パッド 大腿内側ウェッジ 膝分離パッド 座面～背もたれ 角度を開ける 座面&背もたれティルト (ティルトインスペース) 背もたれ 骨盤後方パッド 背もたれの形状調整 張り調整背もたれ 背もたれの リクライニング 体幹側方パッド 体幹側方ウェッジ テーブル 頭の支え 下腿・足の支え テーブル 平面ヘッドレスト 成形ヘッドレスト 足台の積み増し 足台ウェッジ 下腿サポート 6 7 3 2 1 4 5 11 13 8 12 9 10 中級 車椅子 サービス教習パッケ ージ 世界保健機関(WHO), 中級車椅子サービス教習パッケージ, 2013. 日本語版制作：一般社団法人日本車椅子シーティング協会(JAWS)・アジア姿勢保持プロジェクト(ASAP) WHO/NMH/VIP/DAR/13.02 Design by Inís Communication – www.iniscommunication.com
中級 ⾞椅⼦サービス教習パッケージ 教習員⽤指導書 英語版原著者・制作者・協⼒者⼀覧： 編集者: Chapal Khasnabis, Kylie Mines 執筆者: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, Rebecca Jackson Stoeckle 査読者: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri, Ritu Ghosh, Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan, Diane E. Ward イラストレーター: Melissa Puust 写真著作権者: David Constantine, Jesse Moss, Chapal Khasnabis ビデオ著作権者: Chapal Khasnabis, Amanda McBaine, Jesse Moss 実施試験教習員: Andrew Congdon, Mirela Creanga, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Raducan, Andrew Rose 資⾦協⼒: ⽶国国際開発庁 (USAID), オーストラリア国際開発庁 (AUSAID) 提携団体: ASSERT 東ティモール [国⽴リハビリテーションセンター, 現 CNR], ケニア⾝体障害 者協会 (APDK), ソロモン諸島保健医療サービス省・地域に根ざしたリハビリテーショ ン局, 教育開発センター (EDC), ハンディキャップ・インターナショナル, ⾚⼗字国際 委員会 (ICRC), 国際義肢装具学会 (ISPO), キリマンジャロ脊髄損傷者協会 (KASI), モビリティ・インディア, モティベーション・オーストラリア, モティベーション慈善 基⾦ (Motivation), モティベーション・ルーマニア, タンザニア義肢装具技術者訓練セ ンター (TATCOT) Published by the World Health Organization in 2013 under the title Wheelchair Service Training Package: Trainerʼs Manual: Intermediate Level © World Health Organization 2013 The World Health Organization has granted a translation and publication permission for an edition in Japanese to the Japan Association of Wheelchair and Seating (JAWS), which is solely responsible for the quality and faithfulness of the Japanese translation. In the event of any inconsistency between the English and the Japanese editions, the original English edition shall be the binding and authentic edition. 中級⾞椅⼦サービス教習パッケージ・教習員⽤指導書 © Japan Association of Wheelchair and Seating (JAWS) 2022 2022 年 1 ⽉ 29 ⽇発⾏ 原著者： 世界保健機関 (WHO) 翻訳・制作者： ⽇本⾞椅⼦シーティング協会国際委員会・アジア姿勢保持プロジェクト (ASAP) 発⾏所： ⼀般社団法⼈ ⽇本⾞椅⼦シーティング協会 (JAWS) 〒105-0013 東京都港区浜松町 2-7-15 三電舎ビル 2 階 電話 03-6435-0365 FAX 03-6435-0365 URL http://www.j-aws.jp 訳者解説 本書は、世界保健機関（WHO）が 2013 年に発⾏した ”Wheelchair Service Training Package: Trainerʼs Manual: Intermediate Level” の全訳である。「はじめに」で述べている通り、本書を含むこの「中級⾞椅⼦ サービス教習パッケージ」は、2008年刊 ”Guidelines on the Provision of Manual Wheelchair Service in Less-resourced Settings”（邦訳「⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に向けて」、 ⽇本⾞椅⼦シーティング協会刊、以下「ガイドライン」と略）を受けたものである。 「ガイドライン」ではその⼀章を割き、現場で⾞椅⼦サービス提供に携わる職員や、⾞椅⼦ユーザーの掘り 起こしや⾒極め、⾞椅⼦サービスへの紹介・相談、さらに⾞椅⼦供与政策の開発や推進に当たる、さまざま な関係者向けの教習あるいは⼈材育成の重要さを強調している。本書を含む「中級⾞椅⼦サービス教習パッ ケージ」、およびそれと連なる⾞椅⼦サービス教習パッケージ群は、その問題提起に対するWHO⾃⾝からの 実践的回答であり、上記「ガイドライン」のいわば各論をなすものである。 したがって、本書を読み、活⽤するに当たっては、「ガイドライン」を併読してWHOが提起する⾞椅⼦供与 システムを把握することを強く推奨する。また各⾞椅⼦サービス教習パッケージでも、「ガイドライン」は参 考資料あるいは副教材に挙げられている。 関連する出版物 ⾞椅⼦や姿勢保持に関連して、WHOからは、⽶国国際開発庁（USAID）などの協⼒のもとで以下の出版物が 刊⾏されている： 1. ⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に向けて (Guidelines on the Provision of Manual Wheelchair Service in Less-resourced Settings, 2008) 2. 低リソース状況での移動⽀援機器供与に関する共同⽅針提⾔書：個⼈的移動性に関する障害者の権利に 関する条約（CRPD）履⾏に向けた⼀歩 (Joint position paper on the provision of mobility devices in less-resourced settings : a step towards implementation of the Convention on the Rights of Persons with Disabilities (CRPD) related to personal mobility, 2011) 3. 基礎⾞椅⼦サービス教習パッケージ (Wheelchair Service Training Package ‒ Basic level, 2012) 4. 中級⾞椅⼦サービス教習パッケージ (Wheelchair Service Training Package ‒ Intermediate level, 2013) 5. 管理者向け・関係者向け⾞椅⼦サービス教習パッケージ (Wheelchair Service Training Package for Managers and Stakeholders, 2015) 6. ⾞椅⼦サービス教習員向け教習パッケージ (Wheelchair Service Training of Trainers package, 2017) 1. は、主に低・中所得国向けに作成された、⾞椅⼦供与事業・政策策定の指針であるが、先進⼯業国にとっ ても極めて重要な内容を含む、グローバルな⽂献である。 2. はいわば 1. の三年⽬のフォローアップで、内容は、1.（の実⾏は、すなわち「障害者の権利に関する条約」 の履⾏に向かうことである）の提⽰にもかかわらず低リソース状況での移動⽀援機器普及が遅々として進ま ない現状報告、改善を阻む問題点の指摘、およびその克服に向けた政策提⾔などである。 3-5. は 1-2. が強調する、職員研修/⼈材育成のための教習パッケージである。 3. そして本書を含む 4. は⾞椅⼦の供与や適合に現場で携わる職員向けの実践的・総合的な技能教習パッケ ージで、「⾞椅⼦サービス提供の 8ステップ」（基礎⾞椅⼦サービス教習パッケージ受講者⽤参考書 p.9-10を 参照）として整理される⾞椅⼦サービス提供の全プロセスについて、⼈権、国際法、コミュニケーション、 ⾝体評価などの理論的授業から⾞椅⼦の乗り⽅、処⽅、適合、改造、メンテナンスなどの演習および実習に ⾄る、基礎レベルにおいて必要なすべての技能と知識を教習する、包括的という意味で（分野ごとにさまざ まな組織や場⾯で教えられることはあっても）それまでに「ありそうでなかった」プログラムである。教材 も、受講者⽤参考書・ワークブックのみならず教習員⽤指導書（本書。講習準備の⼿引きや必要機材リスト、 授業の計画およびシナリオも含む）、プレゼンテーションスライド、動画、受講者および教習員の評価表、意 識啓発⽤ポスター、各種書式（参加登録簿から当事者の写真撮影許可書など）を網羅し、教習の内容のみな らず、実施・運営・評価⽅法のマニュアルまでを完備している。 特に 3. は、⾞椅⼦の基礎技能教習教材として途上国のみならず世界に広く普及しており、例えば⽶国では国 際⾞椅⼦専⾨家学会（ISWP）がその教習を実施している。 また 4. は、3. を修了したのち現場経験を積んだ職員向けの次の段階の教習パッケージで、姿勢保持ニーズ のある⾞椅⼦ユーザー、特に⼦どもへの対応に重点を置いている。姿勢保持については途上国を含む世界で 広く実施可能な、普通型⾞椅⼦に改造を加え、姿勢⽀持具を追加する範囲での対応を取り上げている。 5. は 2部に分かれ、それぞれ⾞椅⼦供与に携わる事業体の管理職向け教習、および⾞椅⼦供与関係者（当事 者や実務家のみならず⾏政担当者、政治家、企業家、資⾦供与者、メディアなども含む）向け意識啓発ワー クショップの実施パッケージである。 6. はさらに 3-5. で指導に当たる⼈材の⼒量育成、いわば「教育者を教育する」ためのパッケージである。 これらの教習パッケージは、その内容のみならず研修設計の点でも優れて現代的であり、訳者は⾞椅⼦、姿 勢保持、国際協⼒のみならず、広く教育や研修に関わる⽅々に読まれることを期待している。 ⽤語と⾒取り図 ただ⽇本の読者にとって、本書を読み進むなかで難しく感じられるのは、「⾞椅⼦供与」「⾞椅⼦サービス」 「⾞椅⼦サービス提供」「⾞椅⼦のサービスステップ」といった聞き慣れない（⾞椅⼦に伴うサービスを体系 的に概念化し、必須のものと定義した点で上記「ガイドライン」は画期的であるため）概念であろう。 これらの意味は、本書の「⽤語」および本⽂でも説明されているが、各国での優れた実践例などを踏まえ、 ⽇本の制度とは別の観点で WHO が構想した⾞椅⼦供与の理想像を俯瞰するには、これではまだ⾜りまい。 ⽇本語版「ガイドライン」には、訳者らで独⾃に作成した全体的な概念構成の⾒取り図を訳者解説の直後に 付録している。ご参考にしていただければ幸甚である。 おわりに、本書の翻訳には、公益財団法⼈⽇本社会福祉弘済会より研究助成（2021年度）をいただきました。 ここに⼼より御礼を申し上げます。翻訳の確認と校閲については、以下の⽅々のご協⼒をいただきました。 ここにお名前を記し、謝辞に代えさせていただきます。 浦川純⼆、沖ちなみ、⽊下義博、鷹野真利、中村詩⼦、⻄⽅倫彰、宮本泰輔、⼭崎雅幸（敬称略） 2022年1⽉29⽇ ⽇本⾞椅⼦シーティング協会国際委員会・アジア姿勢保持プロジェクト（担当：松本和志） 訳注： • 本書は Wheelchair Service Training Package: Trainerʼs Manual: Intermediate Level, WHO, 2013 の全訳 である。底本には英語版（https://www.who.int/publications/i/item/9789241505765）を⽤いた。 • 本書の翻訳出版は、⼀般社団法⼈⽇本⾞椅⼦シーティング協会の、資料作成事業の⼀環である。 • 本書は、WHOより⾮営利（販売は費⽤回収⽬的でのみ可）での翻訳出版許可を取得している。 • ⽇本語版翻訳に関する著作権および⽂責は、すべて⼀般社団法⼈⽇本⾞椅⼦シーティング協会に帰属する。 • 翻訳および編集作業は、同協会国際委員会・アジア姿勢保持プロジェクト（ASAP）で⾏なった。 • 本書を転載する際は⽇本⾞椅⼦シーティング協会までご連絡（連絡先は⾒返しを参照）頂きたい。 • 英語原⽂と⽇本語訳⽂の間に内容の齟齬がある場合は原則として英語版を正とするが、誤記、団体の名称・ 住所・URLで変更されているものなどは、WHOに確認のうえ訳者で⼀部修正している。 • 国際連合の条約など政策⽂書で複数⾔語の正⽂が定められているものは、英語版の参照先を記した。 • 政策⽂書の⽇本語訳は、既存の訳を参考にしつつ、訳者で独⾃に訳出したものである。 • インターネット上の参考⽂献のURL閲覧⽇は、すべて2022年1⽉28⽇である。 • 本⽂中、原⽂にない訳者による補⾜は［ ］に⼊れて⽰している。 • 脚注について、⽂中の脚注番号がカッコ（ ）⼊りのものは原注、（ ）なしのものは訳注を⽰す。 • 原⽂の主な⽤語と本書での訳語は、原則として下表の通り対照させている。なるべく原著に忠実に、かつ 既存の⽤語との紛らわしさを避け、簡明さを失わないよう努めた。本書出版時点の国際標準化機構（ISO 7176-26:2007）、⽇本⼯業規格（JIS T9201:2016）との異同などは、下表および⽂中の脚注で⽰している。 • 脚注の [⽤語集] は ⾞いす・シーティング⽤語集, ⾞いす・シーティング⽤語検討委員会, 2005. を指す。 英語⽤語 ⽇本語訳語 additional postural support 付加姿勢⽀持［基本的な⾞椅⼦にもともと備わっている以上の、改造や増設によ って付加された姿勢⽀持（⼒）。本書p.11も参照］ armrest ひじ掛け［ISO7176-26:2007: arm support, JIS T9201:2016: アームサポート］ assessment 事前評価［事後評価を含むevaluationと区別するため］ backrest 背もたれ［ISO7176-26: 2007: back support, JIS T9201: 2016: バックサポート］ calf 下腿、［特にその部位を指す場合］ふくらはぎ community-based 地域に根ざした footrest ⾜台［ISO7176-26:2007: foot support, JIS T9201: 2016: フットサポート］ neutral sitting posture ニュートラルな座位姿勢［本書での意味は基礎受講者⽤参考書p.13を参照］ personal mobility ［主に⾏為を指して］個⼈的移動、［主に機能を指して］個⼈的移動性 postural support 姿勢⽀持 product preparation 製品の下準備 referral 紹介・相談 seat 座⾯［ISO7176-26:2007: seat, JIS T9201: 2016: シート］ seating 座位保持 service delivery サービス提供 sitting upright まっすぐに座る［本書での意味は基礎受講者⽤参考書p.13を参照］ training 教習、［条約などで定訳がある場合］研修 upholstery 張り布 user ［指⽰内容が明⽩な場合］⾞椅⼦ユーザー、ユーザー wheelchair provision ⾞椅⼦供与 wheelchair services ［⾏為］⾞椅⼦サービス、［事業・事業組織］⾞椅⼦サービス事業、 ［施設・所在地］⾞椅⼦サービス事業所 ⽤語 以下、教習パッケージ全体を通して⽤いることばを下記の通り定義する。 適正な⾞椅⼦ ユーザーのニーズおよび環境条件に合い、適切にフィットして姿勢を ⽀え、安全で耐久性があり、国内に⽤意され、⼊⼿、メンテナンス、 継続したサービスが国内で、無理のない価格で可能な⾞椅⼦。 ⼿動⾞椅⼦ ユーザーがこぐ、あるいは他の⼈が押す⾞椅⼦。 姿勢⽀持具（PSD） 付加姿勢⽀持をもたらす物理的装置：中級レベルの⾞椅⼦サービスに おいて不可⽋な要素である。［詳しい説明は本書の授業計画を参照］ ⾞椅⼦ 歩⾏や移動に困難がある⼈へ、⾞輪による移動性および座位⽀持をも たらす機器。 ⾞椅⼦の改造 ⾞椅⼦に加える変化。 ⾞椅⼦供与 ⾞椅⼦の設計・⽣産・供給・サービス提供の総称。 ⾞椅⼦サービス ⾞椅⼦供与の⼀部で、ユーザーへ適正な⾞椅⼦を供与する関わり。 ⾞椅⼦サービス職員 適正な⾞椅⼦の供与に習熟した⼈。 ⾞椅⼦ユーザー 歩⾏や移動に困難があり、移動に⾞椅⼦を使う⼈。 もくじ 中級⾞椅⼦サービス教習パッケージについて 1 はじめに 1 対象者 2 ⽬的 2 対象範囲 3 教習員 3 開始までの流れ 4 1. 教習員への⼿引き 5 1.1 教習の概略 5 1.2 教習の時間割および期間 6 1.3 授業計画 6 1.4 パワーポイントのプレゼンテーション 7 1.5 受講者の進歩を観察/モニターする 7 1.6 実施のたびに教習プログラムを事後評価する 8 1.7 よい教習を実施するコツ 8 2. 教習パッケージ実施準備のやり⽅ 10 2.1 受講者の⾞椅⼦サービスネットワークを知る 10 2.2 ⾞椅⼦サービス提供における受講者の業務を明確にする 10 2.3 各授業計画をおさらいし、必要なら調整する 10 2.4 使⽤する⾞椅⼦、クッション、姿勢⽀持具を確定する 11 2.5 実習へ⾞椅⼦ユーザーを招く 11 2.6 実習のグループ分けを計画する 13 2.7 施設を準備する 14 2.8 教習の教材と資材を準備する 15 3. 授業計画の詳細 21 はじめに 22 A: 必須知識 29 A.1: 付加姿勢⽀持が有益な⾞椅⼦ユーザー 30 A.2: 障害児 41 B: ⾞椅⼦サービスのステップ 51 B.1: 事前評価の概略・事前評価インタビュー 52 B.2: ⾝体的事前評価−⽀えなしの座位姿勢 60 B.3: ⾝体的事前評価−⾻盤と股関節の姿勢チェック 77 B.4: ⾝体的事前評価−ハンド・シミュレーション 96 B.5: ⾝体的事前評価−⾝体計測 104 B.6: ⾞椅⼦およびクッションの選択 114 B.7: 姿勢⽀持具の処⽅（選択）−はじめに 126 B.8: 姿勢⽀持具の処⽅（選択）−⾻盤を安定させる 132 B.9: 姿勢⽀持具の処⽅（選択）−股関節を⽀える 147 B.10: 姿勢⽀持具の処⽅（選択）−体幹を⽀える 154 B.11: 姿勢⽀持具の処⽅（選択）−頭・⼤腿・下腿を⽀える 164 実習 1: 事前評価および処⽅（選択） 176 B.12: 製品（⾞椅⼦）の下準備 180 実習 2: 製品（⾞椅⼦）の下準備 191 B.13: フィッティング 194 B.14: ユーザー教習 205 実習 3: フィッティングおよびユーザー教習 212 B.15: 総まとめ 217 B.16: メンテナンス・修理・フォローアップ 219 実習 4: 事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ユーザー教習 227 B.17: 教習員からのフィードバック・討論・閉講式 232 付録 235 付録 1: 中級⾞椅⼦教習パッケージ時間割表 235 付録 2: 中級⾞椅⼦紹介・相談フォーム 237 付録 3: 中級⾞椅⼦事前評価フォーム 238 付録 4: 中級⾞椅⼦処⽅（選択）フォーム 243 付録 5: ⾞椅⼦概要フォーム 245 付録 6: 中級⾞椅⼦の安全・準備完了確認表 246 付録 7: 中級⾞椅⼦フィッティング確認表 247 付録 8: 中級⾞椅⼦ユーザー教習確認表 249 付録 9: ⾞椅⼦フォローアップフォーム 251 付録 10: 姿勢⽀持具（PSD）⼀覧表 252 付録 11: 硬いウレタンフォーム製ウェッジ 253 付録 12: 実習⽤⾞椅⼦ユーザー名簿 254 1 教習員⽤指導書 中級⾞椅⼦サービス教習パッケージについて はじめに 2008 年の「⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に向けて」(1)、2012 年の 「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」の発⾏に続き、世界保健機関（WHO）は⽶国国 際開発庁（USAID）と協働し、この「中級⾞椅⼦サービス教習パッケージ（WSTPi）」を作成した。 WHO の「⾞椅⼦サービス教習パッケージ（WSTP）」シリーズの中で中級 WSTP は第２部に当た り、歩⾏や移動が困難で体幹のコントロールが乏しい、重度障害者のニーズへの対処により重点を 置いている。この教習パッケージ作成のあいだ特に念頭に置いていたのは、体幹コントロールに乏 しく、⾃⼒ではまっすぐに座れない⼦どもへ適正な⾞椅⼦を供与することであった。 ⾞椅⼦は、個⼈的移動を可能にするために最もよく使われる⽀援機器の⼀つであるが、サービス供 与者には、⾞椅⼦ユーザーが最⼤限に⾃⽴した個⼈的移動を達成し、⽣産的で⾼い⽣活の質を享受 できるようにするための教習を受ける機会がほとんどない。 ⾞椅⼦⼈材は、世界中であまねく必要とされている。中級⾞椅⼦サービス教習パッケージがめざす のは、中級レベルで⾞椅⼦サービスの臨床的および技術的任務（「⼿動⾞椅⼦供与の世界ガイドラ イン」表 4.2 を参照）を果たす職員への教習を⽀援することである。本教習パッケージは、まっす ぐに座れるためには付加姿勢⽀持が必要な⾞椅⼦ユーザーとの仕事を始めるに当たって求められ る、理論と実技の伝授を助ける。本教習パッケージの内容は、個別ニーズの事前評価、付加姿勢⽀ 持を備えた最も適正な⾞椅⼦を選択し設定する⽀援、⾞椅⼦ユーザーおよび介助者への⾞椅⼦の使 ⽤およびメンテナンス⽅法の教習、フォローアップ実施などのやり⽅である。 本教習パッケージは 35〜40時間で履修できるが、この期間は各々の状況に特有のニーズや利⽤で きる資源に従って伸縮してもよい。さらに師匠に付いて修練することを、実⼒を積み重ね、独⽴し て働く技量を⾼めるために奨励する。 1 Guidelines on the Provision of Manual Wheelchair Service in Less-resourced Settings [⼿動⾞椅 ⼦供与の世界ガイドライン 低リソース状況の克服に向けて], WHO, 2008 (https://www.who.int/public ations/i/item/9789241547482 ). [邦訳: ⼿動⾞椅⼦供与の世界ガイドライン 低リソース状況の克服に 向けて, ⽇本⾞椅⼦シーティング協会, 2022.] 2 中級⾞椅⼦サービス教習パッケージ 中級⾞椅⼦サービス教習パッケージがめざすのは、すでに現場で働いている職員への独⽴した短期 教習プログラムとして、また保健・リハビリテーション職員への教習プログラムに組み込んで伝授 されることである。 対象者 この教習パッケージの対象は、中級レベルの⾞椅⼦サービス提供を職場で実施すると想定される、 すべての職員やボランティアである。これには保健・リハビリテーション・技術職員、地域保健職 員、地域に根ざしたリハビリテーション2（CBR）職員、作業療法⼠、理学療法⼠、義肢装具⼠、現 地の職⼈、技師、⾞椅⼦ユーザーが含まれる3。 ⾞椅⼦サービス提供の経験をすでに有していることが、受講者がこの中級教習から最⼤限の成果を 得るために不可⽋である。中級教習プログラムのデザインは、WHO の「基礎⾞椅⼦サービス教習 パッケージ（WSTPb）」で教わる能⼒を発揮でき、かつ基礎レベル⾞椅⼦サービス提供の実践経験 がある受講者を想定している。 ⽬的 中級教習パッケージは、まっすぐに座るには付加姿勢⽀持が必要な男⼥の⼦どもや⼤⼈へ、適正な ⼿動⾞椅⼦およびクッションを供与するために、職員やボランティアが受ける教習を⽀援するよう デザインされている。 この教習パッケージの主⽬的は、⾞椅⼦サービス提供に携わる職員の技能および知識の育成である。 この教習パッケージの実施は、以下の役に⽴つ： • ⾃分のニーズを満たす⾞椅⼦を⼿にする、⾞椅⼦ユーザーが増加する。 • 中級レベルの⾞椅⼦サービス提供教習を受けた職員が増加する。 • ⾞椅⼦サービス提供職員の能⼒が向上する。 • 基礎レベルよりも⾼度な介⼊が必要な⼈びとに対する、⾞椅⼦サービス提供の質が向上する。 • 正規のパラメディカル/リハビリテーションの教習プログラムへ、この教習パッケージが盛り込 まれる。 • ⾞椅⼦サービス提供の、リハビリテーションサービスへのより⼤きな統合が達成される。 2 [原⽂] community-based rehabilitation. [訳注] ⽇本語の「地域リハビリテーション」とは区別される場合もある ため, こちらの訳語を採った. 3 [訳注] 本教習の全部あるいは⼀部には, ⽇本であればリハビリテーション医, 介助福祉⼠・社会福祉⼠・ケアマネ ージャー・福祉⽤具専⾨相談員などの福祉専⾨職, 福祉⾏政職員, 特別⽀援教師なども対象者に含まれよう. 3 教習員⽤指導書 対象範囲 本教習パッケージで取り上げるのは： • 付加姿勢⽀持を備えた⾞椅⼦が必要な⼦どもや⼤⼈への、移動および姿勢⽀持へのニーズの事前 評価のやり⽅。 • 移動⽀援の可能な最適解を⾒極めるための、上記の⼈びととの関わり⽅。 • 適切なクッションと付加姿勢⽀持を備えた、⼿動⾞椅⼦の供与に必要な知識および実践的コツ。 • ⾞椅⼦ユーザー、また適切ならばその家族/介助者が、⾞椅⼦を最⾼に活⽤するための教習。 • ⾞椅⼦ユーザーへの、⾃分の⾞椅⼦がニーズを満たし続けるためのフォローアップ。 教習員 技能：この教習パッケージを伝授する教習員は、付加姿勢⽀持が必要な⼈への事前評価および⾞椅 ⼦の処⽅に熟達した者でなければならない。教習員はまた、現地で⼿に⼊る製品・資材・⼯具を⽤ いて、姿勢⽀持具を備えた⼿動⾞椅⼦の下準備を実⾏あるいは指揮できなければならない。教習員 は、⾃分⾃⾝が⾞椅⼦サービス提供分野の優れた臨床技能を有し、その実践経験を拠りどころにし てこの教習を実施できなければならない。またトレーナーとしての経験もあれば有益である。 ⾞椅⼦ユーザー：⾞椅⼦ユーザーを教習員チームに含めるよう、強く推奨する。⾞椅⼦ユーザー は、⾃分⾃⾝の経験を活かして、同様の障害がある⼈びとを教えることができる。受講者は⾞椅⼦ ユーザーから教習を受けることで、⾞椅⼦ユーザーが⾃⾝の⾞椅⼦を選択するうえで果たす中⼼的 役割を感得できる。 教習員の⼈数：受講者 8〜10 ⼈ごとに 2 ⼈の教習員を推奨する。この⽐率はとりわけ実習におい て、教習員が受講者へじゅうぶんな⽀援とフィードバックとを与えられ、また参加者全員が安全に 実習できるために重要である。経験豊富な⾞椅⼦ユーザーで教科と教習パッケージを熟知した⼈が いれば、それは教習プログラムにとって貴重な財産である。 4 中級⾞椅⼦サービス教習パッケージ 技術的⽀援：教習員には、この教程の重要な要素である実習をうまく進めるため、最低 1 名の、 中級レベルでの経験が豊かな⾞椅⼦技師に補助してもらうよう奨励する。 開始までの流れ 1. USB メモリ4（紙フォルダの内側に貼付）を教習で使⽤するコンピューターのハードディスク へコピーする。ハードディスクには最低 6GBの空きディスク容量が必要である5。 2. 「START」のファイルをクリックする。訓練員は、ここから WSTP 中級の各教材へ⾶べる6。 訓練員は、フォルダ階層を通って同じ教材へアクセスすることもできる。 3. 訓練員⽤指導書を開く。 3.1 「中級⾞いすサービス教習パッケージについて」と「訓練員への⼿引き」の章を読む。 3.2 （印刷版が⼿元にない場合）各訓練員へ訓練員⽤指導書を 1 冊ずつ注⽂するか、印刷し て製本しておく。 4. 時間割表を開き、各授業のハイパーリンクをクリックして授業のプレゼンテーションおよび動 画へアクセスする7。プレゼンテーションおよび（訓練員⽤指導書の）授業計画に沿って各授業 をおさらいし、内容、教材、⽅法論に習熟しておく。 5. 「教習パッケージ実施準備のやり⽅」の章の⼿引きに従い、すべての必要な準備を教習実施前 にじゅうぶんやっておく。「教習パッケージ実施準備のやり⽅」の章で⽰す通りに、教材と資材 をすべて準備しておく。 6. 教習を授けるいちばんよい⽅法は、教程をできるだけ順序通り、各授業へ割り当てた時間に従 って進めることである。 7. 教習の最初に、受講者へ教習教材⼀式、すなわち受講者⽤参考書（受講者 1 ⼈に 1 冊）、受講 者⽤ワークブック（受講者 1 ⼈に 1冊）、ポスターセット（受講者 1 ⼈に 1セット）を配布す る。これらの在庫がない場合は、USBメモリ8から印刷できる。 4 [訳注] 英語版の説明. 以下, 「USB メモリ」には⽇本語版教習パッケージの「ダウンロードフォルダ」がほぼ対応 するが, 翻訳を作成していないファイルもある. 5 [訳注] 英語版のまま. 6 [訳注] 英語版のみの機能. ⽇本語版では後述の授業計画に従い教習パッケージフォルダの階層を通って当該ファイ ルへアクセスできる. 7 [訳注] 同上. 8 [訳注] 英語版のみに付属. ⽇本語版では, 教習パッケージフォルダの各ファイルを開いて印刷. 5 教習員⽤指導書 1. 教習員への⼿引き 1.1 教習の概略 分 ⽇ あいさつ、⾃⼰紹介、概略 はじめに 60 第 １ ⽇ A: 必須知識 受講者へ、⾞椅⼦サービ スのステップに関する 授業をこなすために必 要な予備知識を与える 授業。 A.1 付加姿勢⽀持が有益な⾞椅⼦ユーザー 60 A.2 障害児 60 B: ⾞椅⼦サービスのステップ 事前評価 B.1 事前評価の概略・事前評価インタビュー 90 B.2 ⾝体的事前評価−⽀えなしの座位姿勢 90 B.3 ⾝体的事前評価−⾻盤と股関節の姿勢チェック 120 B.4 ハンド・シミュレーション 60 第 ２ ⽇ B.5 ⾝体計測 60 処⽅（選択） B.6 ⾞椅⼦およびクッションの選択 60 B.7 姿勢⽀持具の処⽅（選択）−はじめに 30 B.8 姿勢⽀持具の処⽅（選択）−⾻盤を安定させる 90 B.9 姿勢⽀持具の処⽅（選択）−股関節を⽀える 45 B.10 姿勢⽀持具の処⽅（選択）−体幹を⽀える 105 姿勢⽀持具の処⽅（選択）−体幹を⽀える 45 第 ３ ⽇ B.11 姿勢⽀持具の処⽅（選択）−頭・⼤腿・下腿を⽀える 120 実習 1：事前評価および処⽅（選択） 120 製品（⾞椅⼦）の下準備 B.12 製品（⾞椅⼦）の下準備 60 実習 2：製品（⾞椅⼦）の下準備 150 フィッティング B.13 フィッティング 60 第 ４ ⽇ ユーザー教習 B.14 ユーザー教習 60 実習 3：フィッティングおよびユーザー教習 150 B.15 総まとめ 120 メンテナンス・修理・ フォローアップ B.16 メンテナンス・修理・フォローアップ 60 第 ５ ⽇ 実習 4：事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ユーザ ー教習 300 B.17 教習員からのフィードバック・討論・閉講式 60 6 中級⾞椅⼦サービス教習パッケージ 1.2 教習の時間割および期間 この教習パッケージは連続した数⽇で、あるいは⼀定期間内で数ブロックに分けて実施する。中級 教習パッケージ教程を完結するには、最低 35〜40時間を要する。各授業を教えるのに必要な時間 の⾒積もりは、授業計画に載せている。 注記：各授業の教授に要する時間は、以下の要因により変わってくる： • 受講者の経験や技能 • 受講者全体の⼈数 • 現地で⼿に⼊る⾞椅⼦の台数 • ⾞椅⼦を調整し下準備するために要する時間 • 授業で通訳が必要かどうか • 追加教材を盛り込むかどうか これらの要因によって、教習プログラムの完結に要する時間は増減する。 5 ⽇間での時間割の⼀例を、付録 1 に載せた。この時間割および⽩紙の時間割ひな形は、USB メ モリ上にも⽤意している9。 教習員には、現地の事情および受講者の学習ニーズに合わせて、時間割を調整および修正するよう 強く奨励する。例えば： • 教習パッケージの授業を、既存の保健やリハビリテーションの教習プログラムへ組み込む。 • リハビリテーション職員が、本教習プログラムのある部⾯についてすでに教習を受けていれば、 そこに該当する授業が必須でないこともある。 • ⾞椅⼦の下準備にもっと時間が必要（例えば全部を組み⽴てねばならず）であれば、実習に参加 する⾞椅⼦ユーザーの数を減らすか、時間のゆとりを増やす必要があろう。 1.3 授業計画 授業ごとに載せた授業計画は、教習員が各授業を実施する上での⼿引きである。各授業計画は、以 下の情報で始まる。 • ⽬的：受講者が、授業が終わるまでにできるようになるべきこと。 • 教材：授業に必要な教材。 • 事前学習と状況：受講者に想定される事前学習または能⼒、および授業をさまざまな事情（また は状況）へ適合させるやり⽅。 9 [訳注] ⽇本語版は未作成. 7 教習員⽤指導書 • 準備：授業準備のやり⽅。 • あらすじ：授業の主な部分の組み⽴て。 授業計画の残りの部分は、トピックで分かれている。授業計画ではトピックごとに、そのトピック の情報をどう伝えるか解説している。注意することは： • 太字は教習員が⾏なう活動である（例：尋ねよ、やってみせよ、説明、動画を上映）10。 • コラムとして教習員が発する質問の解答を収めているが、⾃分で答えを考えるよう受講者を励ま すこと。 どの授業計画も、最後は要点のまとめである。要点を読み上げる代わりに教習員から受講者へ質問 し、受講者⾃⾝で要点を⾒出すよう励ましてもよい。 注意深く授業計画に沿って進めることで、教習員は各授業をうまく、また時間通りに教えることが できる。授業計画には、押さえるべきすべての必須な要点および実技を収録している。教習員には、 授業に⾃分⾃⾝の知識・技能・スタイルを取り⼊れるよう奨励する。 1.4 パワーポイントのプレゼンテーション ほとんどすべての授業に対して、パワーポイント（PPT）のプレゼンテーションスライドが⽤意さ れている。教習員に気を付けてほしいことだが、スライドには要点しか書かれていない。教習員は、 教習員⽤指導書で各スライドの横に載っている情報を教授し、すべての要点を確実に押さえなくて はならない。スライドを読み上げるのは避けよ。代わりに教習員⽤指導書を参照せよ。 1.5 受講者の進歩を観察/モニターする 教習員は、各受講者の進歩をていねいに観察しなければならない。進歩を観察するいちばん良い機 会は、実習中である。 各実習⽤の教習員⽤観察確認表は、USBメモリに収載11。 教習員はこの確認表を活⽤して： • 各受講者グループの進歩を、各実習時間に観察せよ。 • 優れた、および改善を要する実践の例を記録せよ：各フィードバックの場で話し合うため。 教習員⽤観察確認表は、教習員が各受講者の進歩について情報をより詳しく集めたい場合には修正 し、および/またはさらに発展させてよい。 10 [訳註] 分かりやすさのため、受講者への語りは「ですます調」、教習員への指⽰は「である調」で区別した。 11 [訳注] ⽇本語版は未作成. 8 中級⾞椅⼦サービス教習パッケージ 1.6 実施のたびに教習プログラムを事後評価する 教習プログラムを実施後に評価することは、それ⾃体が⼀つの優れた実践である。教習員は、教習 プログラムのあいだ受講者からのフィードバックを定期的に集めるとよい。教習員⾃⾝でも、教習 プログラムを教授しながら考察したことを記録しておくとよい。こうした情報は、教習員が教習プ ログラムを終わってから評価し、その強みや弱点を⾒極めることなどに役⽴つ。このことは、教習 員が教習パッケージ⾃体と将来に向けた⾃分⾃⾝の実施技能、その両⽅を改善するために役⽴つ。 教習プログラム評価フォームは、USBメモリに収めている。教習員はこのフォームを、各⾃のニー ズを満たすように修正または増補してもよい。 1.7 よい教習を実施するコツ しっかり準備しておく • 教習の前に、各授業計画をたんねんに読む。 • 配布資料に⾃信が持てることを確認しておく。 • 教習教材を取りまとめ、教室をきちんと準備しておく。 優れた⾞椅⼦サービス 実践の模範を⽰す • 受講者および⾞椅⼦ユーザーへ敬意を払う。 • ていねいな仕事ぶりを⽰す。 • つねに教室での安全に気を付ける。 • 時間を守り、時間割に沿って授業を進める。 情報を明確に伝える • はっきりと、落ち着いて話す。 • 教室の全員に聞こえているか確かめる。 • 理解されているか、質問して確かめる。 • ホワイトボードへの板書を、全員が読めるか確かめる。 • 要点は、くり返すことで強調する。 授業時間を管理する • 各授業の許容時間に注意し、時間を守るよう努める。 • 追加時間が必要になりそうであれば、初めに計画しておく。 • その⽇に予定されている授業は、すべて完了させる。 明確かつていねいに デモ12を⾏なう • 全員からはっきり⾒えていることを確かめる。 • 何が起こるのか説明し、やろうとしていることをことばで表す。 • ゆっくりとデモを⾏ない、必要ならくり返す。 受講者の技能を育成 する • 必ず、デモに続けて受講者が練習する機会を設ける。 • 初学者は、新しい情報の理解には時間がかかることに留意する。 ⼩グループ活動を 成功に導く • グループ活動をていねいに観察し、必要なら⼿助けする。 • ⼩グループの間を巡回し、各グループの進境を確かめる。 12 [原⽂] demonstrations. [訳注]「やってみせる・実演する」意味の「デモ」. 以下、本書を通じて同様. 9 教習員⽤指導書 ことばの違いに気を 付ける • 受講者が第⼆⾔語で受講している場合、理解しているか確かめ、必 要なら進度を落とす。 • ⾞椅⼦ユーザーと、その介助者の間のことばの違いに気を付ける。 • 必要な場⾯では通訳を通す。 受講者が、教習を通して 積極的に打ち込むよう促 す • 授業計画に⽰した、教習のさまざまなスタイルや⽅法を活⽤する。 • しゃべり過ぎないように：受講者⾃⾝が話し、議論するよう促す。 • いつも正解を与えるのではなく、受講者⾃⾝が答えを考えるのを促 すように質問する。 • 全員が話すよう励まし、⼀⼈の受講者が仕切らないようにする。 • 受講者が上⼿にやったら褒め、前向きなフィードバックを与える。 • 受講者に、いつ質問してもよいことを知らせる。 • 学びを、受講者の腑に落ちる実例へ結びつける。 • 教習をつねに楽しく！13 短い「ウォームアップ」 活動/ゲームを活⽤する • 注意を集中させるために、短いウォームアップ活動（5〜10 分）を 活⽤する。障害がある受講者にもインクルーシブな活動を⾏なう。 能⼒が異なる⼈びとの ニーズに配慮する • 視覚、聴覚、移動性にちがいがある、あらゆる受講者のニーズを考 慮する。それに従い、活動や教授への取り組み⽅に調整が必要にな る場合もある。 13 [原⽂] keep the training fun! 10 中級⾞椅⼦サービス教習パッケージ 2. 教習パッケージ実施準備のやり⽅ 2.1 受講者の⾞椅⼦サービスネットワークを知る 教習員は、実施地での⾞椅⼦供与のしくみをよく知っている必要がある。例えば： • 現地で⼿に⼊る⾞椅⼦、クッション、姿勢⽀持具（PSDs）の種類および供給者。 • ⾞椅⼦を下準備し、姿勢⽀持具をつくるために利⽤できる資材・⼯具・施設。 • 現地の⾞椅⼦サービスについて。例えば、提供するサービスのレベルなど。 • 現地の紹介・相談ネットワーク。 • 現地の⼈材、例えば教習実施を⽀援できる⾞椅⼦ユーザー。 • 必要に応じて、⾞椅⼦サービス職員が紹介・相談できる他のリハビリテーションサービス。 2.2 ⾞椅⼦サービス提供における受講者の業務を明確にする ⾞椅⼦サービス提供が、勤務先での受講者の業務全体にどう組み込まれているか⾒極めよ。例えば、 受講者の仕事は⾞椅⼦サービス提供のみなのか、それとも他の職務も担っているのか？ 受講者の⾞椅⼦サービス提供における業務を明確にせよ。例えば、教習で取り上げる臨床あるいは 技術⾯のみの仕事を求められる職員もいる。また臨床と技術、両⽅の業務を果たす⼈もいる これら予定されている業務は、教習開始前に明確にしておくこと。そうすれば教習員は、受講者に 予定されている任務へ教習を直結できる。教習実施前に現地教習員で調整して、教習を⾞椅⼦サー ビス事業で受講者が担う業務へ適合させる必要が⽣じる場合もあろう。 2.3 各授業計画をおさらいし、必要なら調整する 各授業計画をおさらいし、各授業の主任教習員を任命せよ。 授業の多くについて、現地の事情に応じた調整が必要となろう。さまざまな状況に合わせて授業を 調整するための提案は、各授業計画の初めに「事前学習と状況」欄で与えている。 11 教習員⽤指導書 2.4 使⽤する⾞椅⼦、クッション、姿勢⽀持具を確定する 教習で使⽤する⾞椅⼦・クッション・姿勢⽀持具の種類を確定せよ。それらは、受講者の勤務地で ⼿に⼊る製品でなければならない。⾞椅⼦の選択範囲が広ければ、それぞれの種類の適正な⾞椅⼦ から最もよい⾒本となるものを選べ。最も広く⼿に⼊るものを優先せよ。 各製品の特⾊を⾃分が熟知しているか確認せよ。各⾞椅⼦につき中級⾞椅⼦概要フォーム（USBメ モリの14⾞椅⼦サービス各種フォームを参照）を完成し、供給者から製品情報を集めよ。 2.5 実習へ⾞椅⼦ユーザーを招く 本教習パッケージで教わる技能を受講者が実習するには、⾞椅⼦ユーザーを相⼿に練習する必要が ある。教習プログラムの前に教習員は、実習へ参加する意思があり、また参加が可能な⾞椅⼦ユー ザーを⾒定めて招く必要がある。 下の確認表は、⾞椅⼦ユーザーを⾒極めるのに役⽴つ。 実習に参加する⾞椅⼦ユーザー確認表： 実習を⽀援するため、教習に参加することへ快く同意している □ まっすぐに座るには15付加姿勢⽀持が必要だが、⽀えればまっすぐに、あるいはまっすぐ に近い姿勢で座れる □ 教習プログラムへ気持ちよく参加できるくらい、じゅうぶん元気があり健康である □ 傷の開いた褥瘡がない □ 近所に住んでおり、実習へ参加するために遠距離を移動する必要がない □ 実習へ参加する時間がある □ 教習後に主催団体がフォローアップできるくらい、そのじゅうぶん近くに住んでいる □ ⾞椅⼦ユーザーが男⼥同数である □ さまざまな⾝体的ニーズにわたっている □ さまざまな年齢層にわたっている □ 14 [訳注] ⽇本語版では教習パッケージフォルダに収載. 15 [原⽂] to sit upright 12 中級⾞椅⼦サービス教習パッケージ ⾞椅⼦ユーザーは何⼈必要だろうか？ 実習に必要な⾞椅⼦ユーザー数は、受講者数によって変わる。通常、受講者は 2〜3 ⼈のグループ で１⼈の⾞椅⼦ユーザーと作業する。どの実習でも⾞椅⼦ユーザー数は 4 ⼈を超えない⽅がよく、 さもなければ教習員の進⾏・モニター・観察が難しくなる。 下表に、受講者 6〜8 ⼈および 8〜12 ⼈の教習プログラムで必要な、⾞椅⼦ユーザー数を⽰した。 受講者は 2〜4 ⼈のグループに分かれ、それぞれ１⼈の⾞椅⼦ユーザーと作業することになる。 理想的には、⾞椅⼦ユーザーひとりを相⼿に作業する受講者グループ 2 つに対して、教習員１⼈の 割合がよい。これならば教習員は実習を進⾏・モニター・観察でき、⾞椅⼦ユーザーの安全および よい学びを保証できる。 受講者数： 6〜8 8〜12 事前評価・処⽅・フィッティング・ユーザー教習 のための⾞椅⼦ユーザー数 実習 1・3 3 4 実習 4 3 4 必要な⾞椅⼦ユーザー志願者計： 6 8 実習に参加する⾞椅⼦ユーザーは何を知っておくべきだろうか? 実習に参加する⾞椅⼦ユーザーが知っておくべきことは： • 何が、実習へ参加すると起こるのか。 • いつ、どれくらいの期間、参加する必要があるか。 • ⾃分の家族/介助者との参加も歓迎される。 • 教習に参加することで、⾞椅⼦を⼿に⼊れられるかどうか。 教習員と主催/教習実施団体には，実習に参加するすべての⾞椅⼦ユーザーに、移動や参加の費⽤ を賄うため交通⼿段やお⾦を提供するよう強く奨励する。かれらが実習に参加している間の⾷事や 軽⾷は⽤意すべきである。教習員や主催/教習実施団体は、⾞椅⼦ユーザーが教習参加に費やした 時間に対する謝礼を⽀払ってもよい。 ⾞椅⼦ユーザーへの招聘状と同意書の⾒本は、教習パッケージ（USBメモリ16内「フォームおよび 確認表」を参照）に収めている。これを各々の事情に合わせて修正し、翻訳して（志願する）各々 の⾞椅⼦ユーザーへ送付し、じゅうぶんな情報を得た上で教習参加の選択ができるようにすべきで ある。 16 [訳注] ⽇本語版は未作成. 13 教習員⽤指導書 フォローアップ • 教習員や主催/教習実施団体は、教習に参加したあらゆる⾞椅⼦ユーザーをフォローアップする よう計画しておく必要がある。教習プログラム終了までに、⾞椅⼦ユーザーに対してすべて完了 しないこともありうるからだ。 • 主催/教習実施団体は、教習で⾞椅⼦を⼿に⼊れた⾞椅⼦ユーザーを⾞椅⼦の受け取りから 6〜8 週間以内にフォローアップすべきである。 どこで実習を⾏なうべきだろうか？ 静かで⼈⽬に触れないスペースを、⾞椅⼦ユーザーと作業する受講者の各グループに対して設営せ よ。可動式の⽬隠し⽤間仕切りを⽤いてスペースを区切り、⼈⽬に触れないようにしてもよい。 教習員は、実習のうち最低 1 つは地域で実施するよう調整するとよい。それは受講者の訪問受け⼊ れを希望する、⾞椅⼦ユーザーの家であってもよい。 地域訪問は、⾞椅⼦ユーザーが⾃⼰の使⽤環境で実際に直⾯する問題を、受講者へ強調するために よい。教習員がそれが可能かを判断するには、以下を考慮する必要がある： • 受講者の移動⼿段の有無。 • 異なる場所で全受講者をモニターし観察するために、教習員がじゅうぶんいるかどうか。 • ⾞椅⼦ユーザーが、受講者を⾃宅へ通すことにやぶさかでないかどうか。 • 地域の実施場所へ移動するために必要な追加時間。 2.6 実習のグループ分けを計画する 各グループの受講者は、3⼈を超えるべきではない。4 ⼈の 1グループより、2 ⼈の 2グループの ⽅がよい。その⽅が、受講者は学んだことを応⽤し、技能を向上させる機会に恵まれる。 教習員は、だれがどのグループに⼊るかを決める必要がある。これを受講者が決めるのに任せては ならない。受講者の技能や事情にしたがい、教習員は以下のようにグループを選ぶとよい。 • ⾃信のある受講者と、⾃信のない受講者でチームを組む。⾃信のある受講者は⾃信のない受講者 を引っ張って⾏ける。グループを注意深くモニター/観察し、全員が参加しているようにせよ。 • 将来いっしょに働く⼈たちでチームを組み、チームとしての技能を向上させる。 実習 １〜3では、同じ受講者の同じグループを保つようにせよ。実習 ４では、共同作業のできぐ あいに応じてグループを組み替えてもよい。 14 中級⾞椅⼦サービス教習パッケージ 各実習について、グループの中から「リーダー」を任命せよ。必ず、受講者全員にリーダーになる 機会があるようにせよ。リーダーには、全作業段階の実施を確認する責任を負うよう求めよ。リー ダーは⾞椅⼦ユーザー、および必要ならばその家族/介助者とのコミュニケーションの主役である。 2.7 施設を準備する 教習実施には、広い教室（またはスペース）を⼀つ使⽤するとよい。実習に参加する受講者および ⾞椅⼦ユーザーが楽に移動でき、また⼩グループに分かれられる、じゅうぶん広いスペースが必要 である。さらに作業台、昼⾷や軽⾷のための独⽴したスペース、清潔なトイレも必要だ。トイレを はじめあらゆる区域は、絶対に⾞椅⼦でアクセスしやすいこと。 下の確認表を、教習施設の下調べと準備に⽤いるとよい。 教習施設確認表 教室 講義区域 □ 受講者⽤椅⼦、および受講者がノートを取れる設備 □ 受講者が各 2〜3⼈の⼩グループに分かれられるスペース □ 最低 3台の⾞椅⼦を展⽰し、動かして回れるスペース □ 実習中、⾞椅⼦ユーザーが⼈⽬を避けられる仕切り □ じゅうぶんな照明および換気 □ 施錠可能/安全 □ 作業台/⼯房施設 各⼩グループに 1 台ずつの作業台 □ 昼⾷/軽⾷区域 清潔な⾷事区域 □ テーブルと椅⼦ □ 近くの⼿洗い場：清潔なタオルおよび⽯けん □ トイレ ⽔場、トイレットペーパー、⼿洗い設備、ゴミ⼊れを備えた清潔なトイレ □ 15 教習員⽤指導書 2.8 教習の教材と資材を準備する 印刷教材 教材 数量 ✔ 注/備考 マニュアル類・ワークブック・ポスター： 教習員⽤指導書 教習員 1⼈に 1 冊 □ WHOへ注⽂するか、印刷して製本。 受講者⽤参考書 受講者 1⼈に 1 冊 □ WHOへ注⽂するか、印刷して製本。 受講者⽤ワークブック 受講者 1⼈に 1 冊 □ WHOへ注⽂するか、印刷して製本。 ポスターセット 受講者 1⼈に 1部 □ WHOへ注⽂するか印刷。 教習プログラム⽤各種フォーム： 受講者登録フォーム 1 教習プログラムに 1部 □ 受講者の参加を記録するため、このフォ ームを使⽤。 名札 受講者および教習員 1⼈に 1 枚 □ 時間割表 受講者 1⼈に 1部 □ ⾒本は USB メモリに収載17。現地の事情 に合わせて修正。 写真撮影同意フォーム 受講者 1 ⼈に 1 通、 および⾞椅⼦ユーザ ー志願者 1⼈に 1 通 □ 主催/教習実施団体向けに修正し、現地語 に翻訳して、写真を撮られるすべての⼈ にこのフォームへ署名してもらう。 ⾞椅⼦ユーザーへの招 聘状および同意書 ⾞椅⼦ユーザー1 ⼈ に 1 通 □ 所収の招聘状⾒本を修正して、各⾞椅⼦ ユーザーを実習へ招聘。 実習⽤⾞椅⼦ユーザー 名簿 教習員 1⼈に 1部 □ このフォームを⽤いて各⾞椅⼦ユーザー の実習参加計画を⽴て、だれが、いつ参加 したかの記録として保管。 修了証 受講者 1⼈に 1部 □ 修了証は準備するか所収の書式を調整。 教習プログラム評価フォーム： 受講者⽤教習プログラ ム評価フォーム 受講者 1⼈に 1部 □ 各教習プログラム評価フォーム⾒本は、 教習員が必要に応じて調整してよい。 教習員⽤教習プログラ ム授業評価フォーム 1授業に 1部 □ 教習員⽤教習プログラ ム評価フォーム 教習員 1⼈に 1部 □ 17 [訳注] ⽇本語版は未作成.. 16 中級⾞椅⼦サービス教習パッケージ 実習向け教習員⽤観察確認表： 実習 1 教習員 1⼈に 1部 □ 印刷する。 実習 2 □ 実習 3 □ 実習 4 □ ⾞椅⼦サービスフォーム： 教習の最初に、受講者 1 ⼈につき⾞椅⼦サービスフォームの完全な 1 セットを配布せよ。実習に 必要な追加コピーは以下の通り： 中級⾞椅⼦紹介・相談フォ ーム ― □ 現地の事情に合わせて修正するか、⼿に ⼊れば現地の紹介・相談フォームを使⽤。 中級⾞椅⼦事前評価フォー ム ⾞椅⼦ユーザー1 ⼈に 1部 □ 現地の事情に合わせて修正：例えば、⾞ 椅⼦サービス事業の名称や現地のサービ ス事業が求める追加情報を加える。 中級⾞椅⼦処⽅（選択）フォ ーム ⾞椅⼦ユーザー1 ⼈に 1部 □ ⼿に⼊る⾞椅⼦のサイズ・種類・設定に 合わせて完成。 中級⾞椅⼦概要フォーム ⾞椅⼦ 1 台につき （完成した）1部 □ 教習プログラムが始まる前に、現地で⼿ に⼊る各⾞椅⼦ごとに 1部を完成。 ⾞椅⼦フォローアップフォ ーム ― □ 現地の事情に合わせて修正：例えば、⾞ 椅⼦サービス事業の名称や現地のサービ ス事業が求める追加情報を加える。 確認表： ラミネート済み中級⾞椅⼦ フィッティング確認表 受講者 1⼈に 1部 □ 各確認表は［教習パッケージフォルダの］ 「フォーム・確認表・図表」内の印刷教 材に収載。 ラミネート済み中級⾞椅⼦ ユーザー教習確認表 □ ラミネート済み中級⾞椅⼦ の安全・準備完了確認表 □ 図表： ラミネート済み姿勢⽀持具 （PSD）⼀覧表 受講者 1⼈に 1部 □ 図表は［教習パッケージフォルダの］「フ ォーム・確認表・図表」内に収載。 ポスター： ⼦どもと⾞椅⼦ 1 □ 受講者 1⼈に 1部 さまざまな体位 1 □ 姿勢⽀持具（PSD）⼀覧表 1 □ 中級⾞椅⼦ユーザー教習確認表 1 □ 17 教習員⽤指導書 器材 教習全般の器材： 物品 数量 注/備考 ⼤きなホワイトボード 1 □ ホワイトボードマーカー 3〜4本 □ プロジェクター 1 □ コンピューター 1 □ ポータブルスピーカー 1 セット □ 動画を聴き取る補助⽤。 紙コップ 受講者 1⼈に 1杯 □ ⽔飲み活動⽤ ボール 受講者 2 グループに 1個 □ キャッチボール活動⽤ 事前評価および処⽅⽤器材：⾞椅⼦の事前評価、処⽅、フィッティングのデモおよび練習⽤器材 物品 数量 注/備考 硬いウレタンフォームブロ ック。30 x 150 x 300 mm グループ数による が、10〜15個 □ 硬いウレタンフォームウェ ッジ（くさび）。 約 30 x 150 x 200 mm グループ数による が、10〜15個 □ 付録 11を参照。 ボール紙/プラスチック製ゴ ニオメーター/⾓度計 各グループに 1個 □ 巻尺 各グループに 1本 □ 硬い（軟らかい縫製⽤巻尺ではない） 巻き取り式巻尺でmm単位のもの ノギス18（あれば） 各グループに 1本 □ 評価ベッド 各グループに 1 台 □ ベンチ/評価ベッドまたは台。⾞椅⼦の 平均的な座⾯⾼と同じくらいのもの。 できれば硬い床⾯は避け、ベンチを⽤ いる場合は薄いウレタンフォームとカ バー、あるいはヨガマットを施す。 デジタルカメラ 1 台 □ あれば ⽬隠し⽤間仕切り 各グループに 1本 □ 実習に参加する⾞椅⼦ユーザーが、⼈ ⽬を避けられる⽬隠し ⾜乗せブロックのセット19 各グループに 1 組 □ 評価ベッドに座るさい、⾞椅⼦ユーザ ーの⾜を⽀える⽊製ブロック。いくつ か違う⾼さのものが必要。 使い捨て⼿袋（あれば） 受講者 1⼈に 1 組 □ 18 [原⽂] calipers. [訳注] ⼤型のもの.「⾞椅⼦サービス教習パッケージ 管理者向け参考書補⾜資料」p.10 を参照. 19 [原⽂] set of foot blocks. [訳注]「⾞椅⼦サービス教習パッケージ 管理者向け参考書補⾜資料」p.9 を参照. 18 中級⾞椅⼦サービス教習パッケージ ⾞椅⼦：⾞椅⼦ユーザーとの教習および実習⽤ 物品 数量 注/備考 教習⽤⾞椅⼦ 現地で⼿に⼊る⾞椅 ⼦各種を最低 1 台ず つ。受講者 2⼈当たり ⾞椅⼦ 1 台が理想 □ ⾞椅⼦がすべて正常に動作し、クッシ ョンが付いていることを確認。 ⾞椅⼦ユーザー志願者へ 供与する⾞椅⼦ 実習に参加する各⾞ 椅⼦ユーザーへ 1 台 □ ⾞椅⼦は、実習へ参加する⾞椅⼦ユー ザーへ最適なものを処⽅するのにじゅ うぶんなだけ揃っているべきである。 クッション：デモ⽤ 物品 数量 注/備考 ⽔平でないまま固まった⾻盤を⽀ えるために改造したクッション 1個 □ ニュートラルな座位姿勢まで屈曲 しない（体幹〜⼤腿の⾓度が 90 度 超の）股関節を⽀えるために改造し たクッション 1個 □ ⽚側または両側がニュートラルな 座位姿勢まで伸展しない（体幹〜⼤ 腿の⾓度が 90 度未満の）股関節を ⽀えるために改造したクッション 1個 □ 作業台および⼯具キット：実習に参加する⾞椅⼦ユーザーへ姿勢⽀持具を製作するためには、作 業台および基礎的な⼯具が必要である。教習員は、既製品の姿勢⽀持具の⼊⼿可能性および現地で ⼿に⼊る材料に従い、この⼀覧表を修正しなければならない。下表は⼀例である： 物品 数量 注/備考 作業台 受講者 3⼈に 1 台 □ 作業台または頑丈な机でよい。各作業 台に万⼒ 1 台があればたいへん有⽤。 ウレタンフォームナイフ20/ 電動ナイフ 受講者 6⼈に 1本 □ ⽬の細かい⾦ノコ刃は、ウレタンフォ ームナイフに使える。 ハサミ 受講者 6⼈に 1本 □ （できれば）⼤きいもの。 安全メガネ 受講者 1⼈に 1本 □ 切断を伴うあらゆる活動の際には、安 全メガネの着⽤が必要。 20 [原⽂] foam knife. [訳注]「⾞椅⼦サービス教習パッケージ 管理者向け参考書補⾜資料」p.18 を参照. 19 教習員⽤指導書 ⼯具（ノコギリ、ヤスリ、ハ ンマー、ドライバー） 受講者 3 ⼈に 1 セ ット □ ⼯具は姿勢⽀持具の製作に必要。必要 な⼯具の種類は使う材料しだい。 ⼯業⽤ミシンか、針と⽷ 1 台 □ ⼯業⽤ミシンはクッションカバーおよ び/または姿勢⽀持具の製作に必要。 だれにでも⼯業⽤ミシンを使う技能が あるわけではない。可能な選択肢： • すぐに仕上げてくれる現地の縫製業 者を⾒つける。 • 縫製技能に優れた⼈を、製品の下準 備のすべての授業に配置する。 教習が始まる前に、ミシンがうまく動 作することを確認せよ。 救急セット 1 セット □ 姿勢⽀持具（PSD）キット：下記の姿勢⽀持具の現地で⼿に⼊る⾒本があれば、この教習プログ ラムで教えるさまざまな⽀えのデモを助ける。下表は⼀案である。教習員は、広く⼊⼿できる既製 の姿勢⽀持具について、あらゆる⾒本を持っておくよう努めよ。 物品 数量 注/備考 ⾻盤側⽅パッド21 2個 □ ⼤腿外側パッド22 2個 □ 膝分離パッド23 1個 □ 張り調整24背もたれ 1 セット □ 体幹側⽅パッド25 2個 □ ヘッドレスト26 1個 □ ⾻盤ベルト 各グループに 1本 □ 下腿ベルト27 1本 □ ⾜ベルト 2本 □ 肩ハーネス 1 組 □ 21 [原⽂] pelvis side pads 22 [原⽂] outside thigh pad, [ISO 7176-26:2007] lateral upper leg support, [⽤語集] 外転防⽌サポート 23 [原⽂] knee separator pad, [ISO 7176-26:2007] medial support, [⽤語集] 内転防⽌サポート. [訳注] ⽇本では, 内 転防⽌パッド, ポメルと呼ばれることも多い. 英語資料では位置を明⽰して medial thigh support (「⼤腿の間の⽀ 持具」の意)と呼ばれることもある. 24 [原⽂][ISO 7176-26:2007] tension adjustable, [JIS T9201:2016][⽤語集] 張り調整式 25 [原⽂] trunk side pads, [ISO 7176-26:2007] lateral trunk support. ⽇本語では体幹パッド, 体側サポートなど. 26 [原⽂] headrest, [ISO 7176-26:2007] head support, [JIS T9201:2016][⽤語集] ヘッドサポート 27 [原⽂] calf strap. [訳注] ISO, JIS の⽤語ではベルト単体を指す名称がないため、本書ではこの訳語に統⼀。 20 中級⾞椅⼦サービス教習パッケージ 姿勢⽀持具の材料：実習に参加する⾞椅⼦ユーザーへ姿勢⽀持具を製作するには、下記の材料を 推奨する。下表は⽬安にすぎない。厳密な材料リストは、以下の項⽬によって変わる。 • ⾞椅⼦ユーザーに対して求められる解決策。 • 既製品の姿勢⽀持具の⼿に⼊りやすさ。 • 現地で⼿に⼊る、姿勢⽀持具の製作に使える材料。 • 選択する技術的解決策。 物品 数量 注/備考 硬いウレタンフォーム （例：チップウレタンフ ォーム） 数量は、上記に従って変わる。 ⼀案としては： • 硬いウレタンフォーム： 1000 x 1500 x 50 mmおよ び 1000 x 1500 x 20〜30 mmを各 1 枚。 • 柔かいウレタンフォーム： 上記の半量 □ 50 mm 厚のウレタンフォーム が⼿に⼊らない場合は、薄いも のを 2 枚貼り合わせるとよい。 柔らかいウレタンフォームは 圧縮すると多少抵抗が増す。 さらに詳しい情報は、受講者⽤ 参考書を参照。 柔かいウレタンフォーム □ ベルト地 • 幅広ベルト（50 mm幅）⽤ 20 m • 細いベルト（25 mm幅）⽤ 20 m □ 幅は供給しだいで違ってよい。 ベルト⽤バックル • 10〜12個（ベルト地と幅が 合うもの） □ ⽊材 数量は、上記に従って変わる。 □ さらに詳しい情報は、受講者⽤ 参考書を参照。 ⽊材⽤およびウレタンフ ォーム⽤接着剤 □ 張り布⽣地 □ EVA またはサンダル⽤ゴ ム □ あれば L 字⾦具 □ 各種ネジ、ボルト、ナッ ト、ワッシャー □ ⾯ファスナーまたは紐と ハトメ スリング背もたれの改造⽤ □ 21 教習員⽤指導書 3. 授業計画の詳細 22 中級⾞椅⼦サービス教習パッケージ はじめに ⽬ 的 この授業が終わるまでに、受講者が以下のようになること： ¨ 教習プログラムの⽬的を知っている。 ¨ 教習員および受講者の名前を知っている。 ¨ 教習プログラム時間割の概略が分かる。 ¨ 教習プログラムのあいだ留意すべき、重要なルールをすべて知っている。 教 材 この授業には： ¨ PPTスライド：はじめに ¨ 各受講者に受講者⽤参考書 ¨ 各受講者に受講者⽤ワークブック ¨ ⾞椅⼦サービスフォーム⼀式：各受講者に 1 セット ¨ 動画：⾞椅⼦サービス提供 ¨ 動画：⾞椅⼦サービスのステップ ¨ 各受講者に時間割表コピー ¨ 教習員および各受講者に名札 状 況 この授業は、教習を実施する各地の状況に合うよう修正せよ。例えば： ¨ ⽂化/状況に対して適切な開講式を追加。 ¨ 教習員および受講者に合わせ「教習員および受講者の⾃⼰紹介」を変更または修正。 ¨ 必要に応じて「庶務連絡および諸注意」のリストを変更、修正、または追加。 ¨ 教習プログラムを修正した場合は、教習プログラム概略のスライドを変更。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 あ ら す じ 1. （あれば）開講式 2. 教習員および受講者の⾃⼰紹介 3. 教習プログラム概略 4. 教習プログラム時間割表・受講者⽤参考書・受講者⽤ワークブック・⾞椅⼦サ ービスフォーム 5. 庶務連絡および受講者への諸注意 15 15 10 10 10 授業時間計 60 23 教習員⽤指導書 1. 開講式（15 分を想定） 本教習プログラムは、現地の⽂化や習慣に合わせた開講式をもって始めてもよい。 2. 教習員および受講者の⾃⼰紹介（15 分） 教習員：⾃⼰紹介せよ。⾃分の経歴および⾞椅⼦提供の経験に関して、概略を簡潔に伝えよ。 受講者に、名前、所属、教習プログラムで学びたいことについて、順番に⾃⼰紹介を求めよ。 名札を、参加登録時に配っていなければ配布せよ。 3. 教習プログラム概略（10 分） 説明：この教習プログラムの⽬的は、まっすぐに座 るには付加姿勢⽀持が必要な男⼥の⼦どもや⼤⼈へ の、適正な⼿動⾞椅⼦・クッション・姿勢⽀持の供 与を開始する、またはその能⼒を⾼めるための知識 や技能を受講者にもたらすことで、内容は： • ⾝体的事前評価、 • ⾞椅⼦、クッション、姿勢⽀持具の処⽅（選択）、 • 必要な改造/姿勢⽀持具を施した⾞椅⼦の下準備、 • フィッティング、 • ユーザー教習、 • メンテナンス・修理・フォローアップ などです。 動画を紹介：「⾞椅⼦サービス提供」：この短い動画では、WHO⾞椅⼦サービス 教習パッケージを簡潔に紹介しています。 動画を上映。 何か質問がないか尋ねよ。 24 中級⾞椅⼦サービス教習パッケージ 説明：中級⾞椅⼦サービス教習パッケージは、⼆部 に分かれています。すなわち： • A：必須知識、 • B：⾞椅⼦サービスのステップ です。 説明：必須知識の部は、授業 2 コマからなります。 すなわち： A.1：付加姿勢⽀持が有益な⾞椅⼦ユーザー、 A.2：障害児 です。 説明：⼈権とは、すべての⼈のものです。国際連合「障害者の権利に関する条約」（UNCRPD）の 核⼼は、障害者にもそうした権利があることを、すべての⼈が認めるようにすることです。 説明： • 条約は、50 のさまざまな条⽂からなります。 • 第 20 条は、「個⼈的移動性」に関わります。 25 教習員⽤指導書 説明：中級⾞椅⼦サービスの対象は、まっすぐに座 る1には改造や姿勢⽀持を加えた⾞椅⼦が必要な、 男⼥の⼦どもや⼤⼈です。 説明： • 受講者はご存じのように、⾞椅⼦サービスは⾞ 椅⼦ユーザーと協⼒し、適正な⾞椅⼦が各々の ⾞椅⼦ユーザーの⼿に⼊るようにします。 • ⾞椅⼦サービスは、⾞椅⼦供与における肝⼼か なめの要素なのです。 • 適正な⾞椅⼦の定義を読み上げよ： 説明： • それぞれの⾞椅⼦ユーザーにとっての「適正な ⾞椅⼦」は、その個別のニーズや環境条件によっ て、つねに違ってきます。 • また、それぞれの⾞椅⼦ユーザーにとっての「適 正な⾞椅⼦」は、その⾞椅⼦がどれくらい適切に フィットして姿勢を⽀えるかによっても、つね に違ってきます。 1 [原⽂] sitting upright 26 中級⾞椅⼦サービス教習パッケージ 説明： • ⾞椅⼦サービス職員は、付加姿勢⽀持がなけれ ばまっすぐに座れない⼈へ、⼿に⼊るもので最 適な、⾞椅⼦および姿勢⽀持を供与します。 • ⾞椅⼦サービス職員は、8 つのサービスステップ を踏んで、⾞椅⼦ユーザーが適正な⾞椅⼦を⼿ に⼊れ、最適な使い⽅ができるようにします。 質問：⾞椅⼦サービスの 8 ステップには何がありましたか？ 正解（⼀語⼀句同じである必要はな い）はすべて受けとめ承認せよ2。 答え： • 紹介・相談および⾯接予約 • 事前評価 • 処⽅（選択） • 資⾦調達および発注 • 製品（⾞椅⼦）の下準備 • フィッティング • ユーザー教習 • メンテナンス・修理・フォローアップ 動画を紹介：「⾞椅⼦サービスのステップ」：この短い動画では、基礎⾞椅⼦サー ビス教習プログラムで取り上げた、⾞椅⼦サービス提供の 8ステップを視聴しま す。受講者へ、動画を視聴して各サービスステップに注⽬するよう指⽰せよ。 動画を上映。何か質問がないか尋ねよ。 説明： • ⾞椅⼦サービス職員の役割は、まっすぐに座る には付加姿勢⽀持が必要な⼈びとへ、次の 8 つ の⾞椅⼦サービスステップを活⽤して、最適な ⾞椅⼦・クッション・姿勢⽀持を供することで す。 2 [原⽂] acknowledge. [訳注] 具体的には, 相⼿が答えたことをそのつど, ことば (反復, 要約, 評価などの) に表し て, 答えを受け取ったこと, およびその内容を確認すること. 27 教習員⽤指導書 説明：中級レベルでは、⾞椅⼦サービスステップにはより時間がかかるか、くり返す必要が出てく るものがあります。質問：⾞椅⼦へ付加姿勢⽀持が必要な⾞椅⼦ユーザーへ⾞椅⼦を供与するさい、 より多く時間がかかる、または複数回の実施が必要になるのは、⾞椅⼦サービスのどのステップで しょうか？ 答え： • 事前評価により多く時間がかかる。 • 製品（⾞椅⼦）の下準備により多く時間がかかる。 • フィッティングにより時間がかかる、あるいはくり返しが必要になる。 • 初回のフィッティング⾯接で解決策がはっきり⾒えなければ、フィッティングの間も事前評価 を継続することがある。 • ユーザー教習により時間がかかる。 説明： • この中級教習は、基礎レベル教習で得た知識を基に構築されています。 • その内容は： o まっすぐに座るには付加姿勢⽀持が必要な⾞椅⼦ユーザーに対する、移動性および姿勢保持 の最良の可能な解決策を⾒出すための、事前評価のやり⽅。 o ⾞椅⼦へ追加や改造を施して付加姿勢⽀持をもたらす、適正なクッションおよび姿勢⽀持具 を備えた⼿動⾞椅⼦の処⽅（選択）、下準備、フィッティングのやり⽅ o ユーザー教習：中級教習プログラムでは、姿勢⽀持具を⽤いる⾞椅⼦ユーザー（またはその 家族/介助者）が、⾞椅⼦を安全かつ効果的に使うために知っておくべき追加の情報と技能を 取り上げています。受講者には、付加姿勢⽀持が必要な⾞椅⼦ユーザーを相⼿に、このステ ップを実習する機会を設けています。 o フォローアップ：中級教習プログラムでは、フォローアップのプロセスを簡潔に復習し、受 講者には、付加姿勢⽀持が必要な⾞椅⼦ユーザーを相⼿に、このステップを実習する機会を 設けています。 • この教習プログラムでは、ステップ 1：紹介・相談および⾯接予約、ステップ 4：資⾦調達およ び発注、ステップ 8 の⼀部すなわちメンテナンスと修理は取り上げません。 各受講者へ、⾞椅⼦サービス提供での⾃分の業務を、ごく簡潔にまとめて順番に話すよう求めよ。 受講者には、以下を含めるよう求めよ： • すでに⾞椅⼦や姿勢⽀持具を供与したことがあるかどうか。 • ⾃分が関わった⼦どもや⼤⼈が、⾞椅⼦に付加姿勢⽀持を必要としているかどうか。 各受講者のまとめを受けとめ承認し、質問して各々の⾞椅⼦サービスにおける業務を明確にせよ。 28 中級⾞椅⼦サービス教習パッケージ 4. 教習プログラム時間割表・受講者⽤参考書・受講者⽤ワークブック・⾞椅⼦サ ービスフォーム（10 分） 各受講者へ、教習プログラム時間割表を 1 部ずつ配布せよ。 説明： • 教習プログラムは、理論/座学から始まります。 • それから受講者は、理論の授業で教わった技能について、協⼒を願い出た⾞椅⼦ユーザーを相⼿ に実習します。 各受講者へ、受講者⽤参考書を 1冊ずつ配布せよ。受講者に参考書へ記名するよう指⽰せよ。この 参考書には、追加の書き込みは何でもしてよいことを説明せよ。 各受講者へ、受講者⽤ワークブックを 1冊ずつ配布せよ。受講者にワークブックへ記名するよう指 ⽰せよ。このワークブックは教習全体を通して使うため、どの授業にも持参するよう説明せよ。 各受講者へ、⾞椅⼦サービスフォーム⼀式を 1セットずつ配布せよ。これらのフォームは教習全体 を通して使うため、どの授業にも持参するよう説明せよ。 5. 庶務連絡および受講者への諸注意（10 分） 必要に応じて、以下のことがらについて説明せよ： • トイレの場所。 • 宿泊について、だれに聞けばよいか。 • 受講者それぞれの帰りの旅程について、だれに聞けばよいか（細かく⽴ち⼊らないこと）。 • 緊急時にはどうするか。 必要に応じて、教習プログラム受講者への諸注意を説明せよ： • 各授業は時間通り始まります。受講者は必ず、毎⽇の始まりに遅れないよう出席し、休憩後には 時間までに授業へ戻って下さい。 • 受講者は、何か不明な点があれば必ず質問して下さい。 • すべての⾞椅⼦ユーザーを平等に遇し、その尊厳を尊重して下さい。 • 授業中、携帯電話はオフにしておいて下さい。 • 楽しんでね！3 3 [原⽂] have fun! 29 A: 必須知識 30 中級⾞椅⼦サービス教習パッケージ A.1: 付加姿勢⽀持が有益な⾞椅⼦ユーザー ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ ⾞椅⼦ユーザーが付加姿勢⽀持を必要とする、⾝体的および/または機能的な理由を 列挙する。 ¨ 付加姿勢⽀持が有益な点を、4つ列挙する。 ¨ ⾞椅⼦ユーザーが付加姿勢⽀持を備えた⾞椅⼦を拒絶するありそうな理由、およびど うしたら⾞椅⼦ユーザーが付加姿勢⽀持を使うようにできるか説明する。 教 材 この授業には： ¨ PPTスライド：A.1: 付加姿勢⽀持が有益な⾞椅⼦ユーザー ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 動画：適正な⾞椅⼦の有益さ ¨ 動画：姿勢⽀持具を⽤いる⼈びと ¨ 紙コップをたくさん、⽔差しに⼊れた飲料⽔、椅⼦、評価ベッド、ボール 事 前 学 習 事前学習： ¨ 付加姿勢⽀持なしでまっすぐに座れる⼈と座れない⼈に対するのでは、⾞椅⼦サービ ス提供に違いがあることを理解しておく。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ （受講者数により）2または 4か所での⼩グループ活動を、以下のように設営する： • 場所 1：椅⼦ 1脚およびボール 1個を置く。 • 場所 2：椅⼦、評価ベッド、飲料⽔の⼊った⽔差しを 1つずつと、紙コップをたくさ ん置く。 あ ら す じ 1. はじめに 2. 付加姿勢⽀持が有益な⾞椅⼦ユーザー 3. いつ付加姿勢⽀持が必要なのか？ 4. ⾞椅⼦ユーザーは何を望んでいるのか？ 5. 要点のまとめ 2 6 35 15 2 授業時間計 60 31 教習員⽤指導書 1. はじめに（2 分） 説明： • よくフィットした⾞椅⼦はすべて、⾞椅⼦ユーザーへ何らかの姿勢⽀持を与えています。背もた れ、クッション、⾜台、ひじ掛けは、調整して⾞椅⼦ユーザーの体格に合わせることで姿勢を⽀ えます。 • しかし多くの⼦どもや⼤⼈には、その⾞椅⼦に姿勢⽀持を付加する必要があります。付加姿勢⽀ 持1は、姿勢⽀持具によって与えられます。これは付加姿勢⽀持を備えるために処⽅される、⾞椅 ⼦へのあらゆる追加や改造のことです。受講者⽤参考書を通して「PSD」とは姿勢⽀持具を指し ます。 この授業で話し合うことは2： • 適正な⾞椅⼦の有益さ。 • だれにとって付加姿勢⽀持は有益か。 • いつ付加姿勢⽀持が必要か。 • 何を⾞椅⼦ユーザーは求めているのか。 この情報の有⽤な点は、受講者が⾞椅⼦ユーザー およびその家族や介助者などに対して、なぜ付加 姿勢⽀持が有益なのか、説明できるようになるこ とです。 2. 付加姿勢⽀持が有益な⾞椅⼦ユーザー（6 分） 動画を紹介：「適正な⾞椅⼦の有益さ」。この動画には、さまざまな活動に携わる、 多様な⾞椅⼦ユーザーが登場します。ほとんどの⼈の⾞椅⼦は付加姿勢⽀持を組 み込んでいます。すぐに⽬に留まるかもしれませんが、そうでなければクッショ ン/背もたれに隠れています。 受講者へ、⼈びとが⾏なう活動、および⾞椅⼦に施された付加姿勢⽀持のさまざ まを、注意深く視聴するよう指⽰せよ。それぞれの⾞椅⼦ユーザーによって、⾞ 椅⼦や⽀持具が異なることを指摘せよ。 動画を上映。 何か質問がないか尋ねよ。 1 [原⽂] additional postural support 2 [原⽂] In this session we will talk about [訳注] 原著の対話性やアクティブ・ラーニングを重視する姿勢を尊重し, 原⽂に近く訳出した. 32 中級⾞椅⼦サービス教習パッケージ 質問：動画に登場した⾞椅⼦ユーザーの活動には、何がありましたか？ 答え： • 料理 • ダンス • 通学/⼯芸 • キャッチボール • ウェイトリフティング/トレーニング • ⽝の散歩 • コンピューターの操作 • 働く • 髪を結う 3. いつ付加姿勢⽀持が必要なのか？（35 分） 質問：なぜ⼦どもや⼤⼈で、付加姿勢⽀持が必要な⼈がいるのでしょうか？⾞椅⼦および付加姿勢 ⽀持を求めて⾞椅⼦サービス事業所を訪れた⼦どもや⼤⼈について、その⾝体的あるいは機能的な 理由を考えてみて下さい。励まして回答を促せ。 答え： ⾝体的理由： • まっすぐに座れない。 • バランスに乏しい。 • 不安定感。 • 制御できない運動3や筋攣縮4［きんれんしゅく］。 • 褥瘡の発⽣。 • 関節の硬直5。 • 筋⾁の緊張6。 • 虚弱さ。 • 疲労。 • 痛みや不快感。 機能的理由： • 付加姿勢⽀持がないと、ものごとがやれなくなる。 • ひとりで安全に飲み、⾷べるのが困難。 • すぐにくたびれる。 • 抱える/付加姿勢⽀持を与えるのが、 家族では無理。 3 [原⽂] uncontrolled movements 4 [原⽂] spasms 5 [原⽂] joint stiffness 6 [原⽂] muscle tightness 33 教習員⽤指導書 説明： • 付加姿勢⽀持が必要とされる理由はさまざまで す。 • 付加姿勢⽀持は、次に挙げる４つの⾮常に重要 な⾯で、⾞椅⼦ユーザーのためになります。 • 付加姿勢⽀持は： 1. バランス・姿勢・安定性を改善します。 2. 快適さを向上させ、より⻑時間座れるよ うにします。 3. 褥瘡発⽣の予防に役⽴ちます。 4. 将来、姿勢の問題が悪化するのを遅らせ るか、予防するのに役⽴ちます。 説明： • しっかりした姿勢⽀持は、機能を向上させ、また ⾞椅⼦ユーザーが⾃尊⼼を⾼める助けになりま す。 • 総じて、しっかりした姿勢⽀持は、⾞椅⼦ユーザ ーの⽣活の質を⾼めるのに役⽴ちます。 説明：付加姿勢⽀持がもたらす重要な益の⼀つに、 バランス・姿勢・安定性の向上があります。 質問：よいバランス・姿勢・安定性が必要な活動に は何があるでしょうか？ 励まして回答を促せ。 答え： • 書きもの • ⾞椅⼦をこぐ • 料理 • ⾷べる・飲む • コミュニケーションを取る 34 中級⾞椅⼦サービス教習パッケージ 説明：これから、2 つの活動（キャッチボールおよび⽔飲み）をやってみましょう。受講者には、 これらの活動をバランス・姿勢・安定のよい状態で⾏ない、続いてバランス・姿勢・安定が悪い状 態で⾏なって、どんなぐあいか感じてもらいます。 ⼩グループ活動 グループ： 受講者を 3 ⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（A.1: 付加姿勢⽀持が有益な⾞椅⼦ユーザ ー）を開くよう指⽰せよ。 説明：キャッチボールと⽔飲み、2つの活動を⾏ないます。 各グループに、設営した場所（場所を指⽰）で活動を⾏なうよう説明せよ。 受講者へ、各⾃のワークブックに質問への回答を記⼊するよう指⽰せよ。 受講者へ、活動を両⽅で 10 分以内に完了するよう説明せよ。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 受講者へ、ワークブックの質問についてよく考えるよう念押しせよ： • ボールを投げ、キャッチするのはどれくらい簡単か？ • ステップ 2や 3はより難しいか？ • 体位や姿勢を変えると、ボールのキャッチしやすさにどう影響するか？ • 体位や姿勢を変えると、飲みやすさにどう影響するか？ あるグループが⽚⽅の活動を終えたら、そのグループを移動させよ。グルー プが素早く交替し続けるようにして、どのグループもそれぞれの活動を時間 内に終えるようにせよ。 必要なら受講者を先導せよ。 時間： 活動に 10 分、フィードバックに 10 分取っておけ。 35 教習員⽤指導書 フィードバック： 1. キャッチボール 質問：（椅⼦が傾き、それから揺れて）安定性が変わるにつれ、ボールを投 げ、キャッチするのは難しくなりましたか？ 励まして応答するよう促せ（キャッチボールはより難しくなり、より集中⼒ や努⼒が要求されるはず）。 説明：姿勢⽀持は、⾻盤や、⽀持が必要な他のあらゆる部分を⽀えることで 安定性を⾼めます。安定性が⾼まると、多くのことがやりやすくなります： 例えば⾞椅⼦をこぐ、書く、料理することや、話すことでさえそうです。 2. ⽔飲み 質問： • さまざまな座位姿勢で飲んでみて、どんな感じでしたか？ • 息が詰まったり、⽔でむせたりした⼈はいましたか？ 励まして応答するよう促せ（違う姿勢で⽔を飲むのを不快に、あるいは怖い と感じるかもしれない）。 説明： • まっすぐに座るのが難しい⼈びとにとって、⾷べたり飲んだりすることは 不快で、時には恐ろしく、えてして危険なことなのです。 • 安全な飲み込みが困難な場合、⾷べ物や飲み物の⼀部が肺に⼊ってしまう ことがあります。これは肺感染症を引き起こし、重篤化します。 • よい姿勢⽀持を設えると、頭部のコントロールが向上し、飲み込んだり⾷ べたりが容易かつ安全になります。 注釈：姿勢⽀持の改善は、飲み込みに問題があるどんな⼈の場合も、解決策 の⼀部に過ぎません。飲み込みに問題がある⼦どもや⼤⼈は、対処した経験 がある⼈へ紹介・相談すべきです。例えば⼩児科医・⾔語療法⼠・地域保健 ワーカーで飲み込みの問題へ対処する知識や訓練を積んだ⼈などです。 36 中級⾞椅⼦サービス教習パッケージ 説明： • 付加姿勢⽀持によるもう⼀つの重要な益は、褥 瘡発⽣を予防することです。 • 褥瘡の危険因⼦7は、「基礎⾞椅⼦サービス教習パ ッケージ（WSTPb）」で取り上げています。 質問：褥瘡の主な危険因⼦（⾞椅⼦ユーザーに褥瘡 が起こりやすくするもの）は何でしたか？ • 正解を受けとめ承認せよ 答え： • 感覚がない（感覚の低下） • 動けない • 汗、⽔分、失禁からの湿気 • 栄養不良および⽔分摂取不⾜ • ⽼化 • 体重（低体重や過体重） • 不良姿勢8 • 以前あったか、現在ある褥瘡9 • 外傷・衝撃・打撃 • 熱/発熱 • ⾍刺され 説明： • こちらが、「基礎⾞椅⼦サービス教習パッケージ （WSTPb）」で取り上げた、褥瘡の危険因⼦の⼀ 覧です。 • 「感覚がない（感覚の低下）」が太字なのは、感 覚が低下している⾞椅⼦ユーザーは、それだけ で褥瘡発⽣の危険に晒されているからです。 • 他の褥瘡の危険因⼦が 3 つ以上ある⾞椅⼦ユー ザーにも、褥瘡発⽣の危険10があります。 7 [原⽂] pressure sore risk factors 8 [原⽂] poor posture 9 [原⽂] previous or current pressure sore 10 [原⽂] risk of developing a pressure sore 37 教習員⽤指導書 説明： • 付加姿勢⽀持が必要な⾞椅⼦ユーザーの多くは 動けないか、不良姿勢があります。 • これらは、2 つとも褥瘡の危険因⼦です。 • つまり、付加姿勢⽀持が必要な⾞椅⼦ユーザー には、褥瘡発⽣の危険があるということです。 • 姿勢を改善するのは、この危険を減らすことに なります。 質問：なぜ不良姿勢には、褥瘡発⽣の危険があるのでしょうか？（不良姿勢は、どのように褥瘡を 助⻑するのでしょうか？） 答え：不良姿勢が原因となって： • ⾞椅⼦に座っていて滑り、「剪断［せんだん］」⼒11を引き起こす。 • 不均等な体重分布は⼀か所に⾼い圧⼒（例えば、⽚⽅の座⾻下で反対側より⾼い圧⼒）を引き 起こし、ただちに褥瘡を招く。 説明：褥瘡の危険を事前評価し、褥瘡予防のための解決策を処⽅し、⾞椅⼦ユーザーへ褥瘡の予防 ⽅法に関するよい情報を提供することは、中級⾞椅⼦供与の重要な⼀部です。 4. ⾞椅⼦ユーザーは何を望んでいるのか？（15 分） 説明： • ここまで、付加姿勢⽀持が⾞椅⼦ユーザーの役に⽴つ、さまざまな⾯をお話ししてきました。 • ところが、付加姿勢⽀持を備えて処⽅された⾞椅⼦に違和感を持つ⾞椅⼦ユーザーもいます。そ の⾞椅⼦を拒絶することさえあります。 質問：付加姿勢⽀持を備えた⾞椅⼦を供与したら⾞椅⼦ユーザーが使ってくれなかった、という経 験がある⼈はいませんか？その理由は何だと思いますか？ 励まして回答を促せ。理由を答えたら、その問題を避けるためには何かできるか、受講者へ問え。 必要なら、いくつかの例を提供せよ。 11 [原⽂] ʻshearingʼ forces 38 中級⾞椅⼦サービス教習パッケージ 答え： ⾞椅⼦ユーザーが付加姿勢⽀持を備えた⾞椅⼦ を拒否する理由： それを防ぐためにできること： • ⾞椅⼦ユーザーには、その⾞椅⼦または付加姿 勢⽀持が不快である。 • そのプロセスに、最⼤限ユーザーの参画を 得る。 • 仕上げの前に、機器を短期間試⽤するよう 段取ってみる。問題が出てきたら、試⽤後 に修正すればよい。 • ⾞椅⼦ユーザーの姿勢が変化し、⾞椅⼦/付加 姿勢⽀持がすでに快適ではない。 • 定期的フォローアップにより、機器がフィ ットし、快適であり続けるようにする。 • ⾞椅⼦ユーザーが、付加姿勢⽀持部があると⾃ 分の機能をうまく使えないと感じる。 • この問題にはさまざまな理由がありうる。よく ある 2つの理由として： o 付加姿勢⽀持部が実⽤的でなく、機能を妨 げている。例：姿勢⽀持部のために⾞椅⼦ の乗り降りが難しくなる。 o ⾞椅⼦や付加姿勢⽀持が⾞椅⼦ユーザー を「⽀え過ぎ」（慣れた姿勢と違いすぎ）て おり、⾞椅⼦ユーザーが新しい姿勢を不快 /アンバランスに感じる。 • 機器を仕上げる前に、⾞椅⼦ユーザーがや りたいこと（例えば移乗）をやれるか確か める。 • ⼀通りの座り⽅で⻑い間過ごしてきた⼈の 姿勢を、著しく変化させることは避ける。 すべてを⼀度にやるより、時間をかけて変 えて⾏くことを検討する。 • ⾞椅⼦ユーザーが、付加姿勢⽀持部の⾒かけを 嫌っている。 • ⾞椅⼦と付加姿勢⽀持部を、なるべく⼩さ くすっきりしたものにする。 答え： ⾞椅⼦ユーザーが付加 姿勢⽀持を備えた⾞椅 ⼦を拒否する理由： それを防ぐためにできること： • ⾞椅⼦ユーザー（ま たはその家族）が、そ れで「怠け者」あるい はひ弱になると信じ ている。 • 付加姿勢⽀持が有益な点を説明する。 • ⾞椅⼦ユーザ （ーおよびその家族）を、処⽅が正しければ、付加姿勢 ⽀持が⼈をひ弱にすることはないのだと安⼼させる。 • ⾞椅⼦サービス職員は、不良姿勢で座っていると、筋⾁や関節の⾝体 配列（アラインメント）が崩れると説明できる。これは筋⾁に圧迫や 伸展を引き起こして弱める。よい姿勢⽀持はよい⾝体配列を保つ。こ れは、筋⾁や関節が正しい位置でうまく機能するように保つ。 39 教習員⽤指導書 答え： ⾞椅⼦ユーザーが付加 姿勢⽀持を備えた⾞椅 ⼦を拒否する理由： それを防ぐためにできること： • （家・家の周り・地域 が）アクセスできる環 境ではない。 • ⾞椅⼦サービス職員は⾞椅⼦ユーザーとその家族へ、家や周囲の環 境をアクセスしやすくするための情報を与えられる。 • ⾞椅⼦ユーザーを、アクセス向上を⽀援できる組織へ紹介・相談： 例えば、地域に根ざしたリハビリテーションプログラム/職員へ。 説明：まとめると、⾞椅⼦や付加姿勢⽀持部は、次 のようであるべきです： • 実⽤的で使いやすい。 • 快適で余計な不快感を引き起こさない。 • ⾞椅⼦ユーザーがやりたいことをやるのに役⽴ ち、より困難にしない。 • ⾒た⽬がよく、「悪⽬⽴ち」しない12。 説明： 付加姿勢⽀持を⾞椅⼦ユーザーに使ってもらえるようにする最善の途は： • 事前評価、処⽅、フィッティングへ、その⾞椅⼦ユーザーの全⾯的な参画を得る13。 • ⾞椅⼦ユーザーに、なぜ、どのように付加姿勢⽀持が役⽴つのか理解してもらう。 • つねに、最終決定を⾞椅⼦ユーザーに委ねる。 動画を紹介：「姿勢⽀持具を⽤いる⼈びと」。この動画には、前の動画と同じ⾞椅 ⼦ユーザーが何⼈か登場します。⾞椅⼦ユーザーあるいは家族が、なぜ正しい姿 勢⽀持を備えた⾞椅⼦は役に⽴つと感じるのかを語ります。 動画を上映。 何か質問がないか尋ねよ。 質問：⾞椅⼦ユーザー（または介助者）が、姿勢⽀持が有⽤とした理由には何が ありましたか？励まして回答を促せ。 12 [原⽂] look good and not to be too ʻobviousʼ 13 [原⽂] involve 40 中級⾞椅⼦サービス教習パッケージ 答え： • フセインの⽗親いわく、かれ（フセイン）の⾞椅⼦は、⾝体へよりよくフィットしている。よ り快適で、⾞椅⼦からの⽀えが貧弱なために起きていたケガをしなくなった。 • ケーリいわく、体幹への⽀えによって⼒強さが増した。 • ミシェル（シェリー）の⺟親いわく、ミシェルの⾞椅⼦は彼⼥の⽣活の質を⾼めている。彼⼥ は安全に呼吸と⾷事ができ、姿勢がしっかり⽀えられている。 • ルアンの⺟親いわく、そのおかげで息⼦はより楽に⾷べられている。 • バシラいわく、彼⼥の⾞椅⼦は仕事をするのに役⽴っている。 受講者へ、受講者⽤参考書 p.12 の確認表を⾒るよう指⽰せよ。この確認表は、⾞椅⼦サービス職 員が、処⽅した付加姿勢⽀持が⾞椅⼦ユーザーへ最⼤限に奏功するか確かめるのに役⽴つ。 5. 要点のまとめ（2 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 41 教習員⽤指導書 A.2: 障害児 ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ ⾞椅⼦の特徴のうち、⼦どもにとって重要なものを 5つ以上詳述する。 ¨ 早期紹介・相談が⼦どもにとって重要である理由を、2つ以上説明する。 ¨ ⼦どもの安全および尊重を⽰す、⼦どもとの接し⽅を 7通り列挙する。 教 材 この授業には： ¨ PPTスライド：A.2: 障害児 ¨ 受講者⽤参考書 ¨ ポスター：⼦どもと⾞椅⼦ ¨ ポスター：さまざまな体位 ¨ 中級⾞椅⼦紹介・相談フォーム 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 主催/教習実施団体あるいは受講者の所属組織に、⼦どもの安全⽅針があるかどうか。 場合によっては、⼦どもを相⼿にした実習を始める前に、全受講者が⼦どもの安全⽅ 針のコピーを受け取り、署名しておくことが重要になる。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、授業計画を読み通す。 ¨ 「⼦どもと⾞椅⼦」ポスターを掲⽰しておく。 ¨ 「さまざまな体位」ポスターを掲⽰しておく。 あ ら す じ 1. はじめに 2. ⼦どものニーズに応える⾞椅⼦ 3. さまざまな体位 4. ⼦どものために、早いうちに紹介・相談することの⼤切さ 5. ⼦どもと働く 6. 要点のまとめ 2 10 15 10 20 3 授業時間計 60 42 中級⾞椅⼦サービス教習パッケージ 1. はじめに（2 分） 説明：⾞椅⼦を必要とする多くの⼦どもには、付加 姿勢⽀持も必要になります。そのため中級⾞椅⼦ 教習プログラムでは、⼦どもにはどんなニーズが あるのかお話ししておく必要があります。 この授業で話し合うことは： • ⼦どもの⽣活やニーズが⼤⼈とどう違い、適正 な⾞椅⼦は、⼦ども特有のニーズをどのように 満たすのか。 • これらの違いが、⾞椅⼦サービス職員の⼦ども との関わり⽅や、⾞椅⼦および付加姿勢⽀持の 選択へ、どう影響するのか。 • 早期紹介・相談の⼤切さ。 • ⼦どもの権利を尊重し保護するような、⼦ども との接し⽅。 2. ⼦どものニーズに応える⾞椅⼦（10 分） 説明：⼦どもの⽣活は、⼤⼈とは違います。⼦どもは、⼤⼈たちの保護を受けています。年齢に応 じて、そうした⼤⼈の⼿助けを得ながら決定をします。⼦どもは、よりひんぱんに活動を変え、た くさん動き回って遊びます。最も重要な違いは、⼦どもは学校へ通う必要があることです。 ⼦どもが使う⾞椅⼦は、⼦どもが⽇々⾏なう、平常 の活動への参加に役⽴つべきです。 質問：⾞椅⼦の特⾊のうち、⼦どもにとって重要な ものには何があるでしょうか？ 励まして回答を促せ。 43 教習員⽤指導書 答え： • ⼦ども⾃⾝がこぐ場合、⾞椅⼦は以下のようであること： o ぴたりとフィットしてハンドリムへ楽に⼿が届く。 o とくに坂の登り下りで⼦どもが操作できるくらい、じゅうぶん軽量である。 • 可能ならば、⾞椅⼦が（⾞椅⼦ではなく）⼦どもを⽬⽴たせること。 • ⼿押しハンドルを延⻑すると、家族/介助者が、かがまないで⾞椅⼦を押せる。 • 草地や砂地など、凸凹な軟らかい地⾯を乗り越えられる⾞椅⼦があれば、⼦どもは友達と遊ぶ のが容易になる。 • ⼦どもの⾞椅⼦は、通学を楽にするものであること。 o 対象児の地域では、⼦どもの多くが歩いて通学する場合に考慮すること：⾞椅⼦はその路 を⾏けるか？対象児には荒れ地に強い⾞椅⼦が必要かどうか？ o 対象児が交通機関（例えば⾞、バス、リキシャー、タクシー）で通学する場合は、⾞椅⼦ の運び⽅を考慮する。 • ⾞椅⼦は、学校⽣活を快適にするものであること。⾞椅⼦が机の下へ⼊り込めるかどうか、あ るいは⾞椅⼦に作業台としてテーブルが必要かどうか検討する。 要約： 理想的には、⼦どもの⾞椅⼦は次のようであるべ きです： • ⼦どもが（できる場合は）⾃⼒でこげ、 • ⾞椅⼦ではなく、⼦どもを⽬⽴たせ14、 • ⼤⼈が介助できるよう⼿押しハンドルを備え、 • 草地や砂地など、凸凹な軟らかい地⾯を乗り越 えられ、 • ⼦どもが通学しやすくなり、 • ⼦どもが学校⽣活を過ごしやすくなるもの。 3. さまざまな体位（15 分） 説明： • ⼦どもはふつう、⻑時間座っていません。⼀⽇のうちに、⾏なう活動や体位を何度も変えます。 • つまり、⾞椅⼦は重要ではあるけれども、⼦どもたちは⼀⽇じゅう⾞椅⼦に座っているべきでは ないのです。 • ⾞椅⼦サービス職員は、⼦どもやその家族/介助者と協⼒して、⼀⽇のうちに⼦どもが取れる、 さまざまな体位を⾒つけなければなりません。 • これは動きが⾮常に限られ、いつも同じ姿勢で座り、寝そべりがちな⼦どもには特に重要です。 14 [原⽂] emphasize the child ‒ not the wheelchair 44 中級⾞椅⼦サービス教習パッケージ 座る（座位） 説明： 座るために付加姿勢⽀持が必要な⼦どもには、⾞ 椅⼦に座る他にさまざまな⽀え⽅があります。 例えば： • ロールクッション15や固く巻いた⽑布に、またが って座る。 • 家族/介助者が⽀えて座る。スライドのイラスト は、⺟親が障害児を脚の間で⽀え、座ってビスケ ットを⾷べられるようにし、同時に下の⼦を抱 えている様⼦です。 • 床⾯に対して低い座位保持シート16を供与する： o こうしたシートは座位保持付き⾞椅⼦より 安価で、⼩さい⼦どもへのよい選択肢です。 ⽴つ（⽴位） 説明：⽴位は、⼦どもにとって重要な体位の⼀つです。 説明： • ⽴つことは、あらゆる⼦どもの発達において重 要な部分です。 • ⽴つことは、股関節および体幹の正常なカーブ の形成を促します。 • 座って⻑時間過ごすと、だれでも股・膝・⾜関節 が硬くなります。⽴つことで股・膝・⾜関節周り の筋⾁が伸び、これらの関節の硬直を防ぎます。 15 [原⽂] a roller 16 [原⽂] supportive seat 45 教習員⽤指導書 説明： • ⾃⼒で⽴てない⼦どもには、⽴位台が有効です。 • ⽴位台を処⽅するには、⽴位姿勢および⽴位を⽀えるさまざまなやり⽅を、⾞椅⼦サービス職員 がじゅうぶん理解していることが必要です。これは、この教習プログラムでは取り上げません。 • ですが⽴位台を供与する場合は、⼦どもの膝蓋に直接圧⼒がかからないよう、つねに確認しなさ い。膝が曲がらないように脚を⽀える最適な部位は、膝蓋のすぐ下の脛⾻のところです。 説明： 5歳未満の⼦どもに⽴位台を供与する際の、重要な 留意事項は： • ⼦どもの両脚が開き、両⾜が臀部の幅以上に離 れるべきです。 • ⼦どもの⾜と膝は、わずかに外側を向くべきで す。 • ⼦どもの股関節と膝は、わずかに屈曲するべき です。 • 絶対に、⼩さい⼦どもに膝および股関節を完全 にまっすぐ伸ばすよう強いてはなりません。 説明： • ⽴位台を使う場合は、⾞椅⼦サービス職員から家族/介助者へ、1⽇にどれくらい⻑時間、⼦ども が⽴位台を使うべきか指⽰しなければなりません。⼀般的な⽬安は： o 最初、1⽇ 5〜10分から始める。 o ⼦どもを 1時間以上、⽴位台へ⽴たせっ放しにしない。 o ⼦どもが⽴位台に⽴ちながらできる、楽しい活動を⾒つけるよう家族/介助者を促し、できる 限りテーブルかトレイを備える。 質問：⽴位台は、受講者の現場では⼿に⼊りますか？励まして回答を促せ。 寝そべる（臥位） 説明： 臥位は、もう⼀つの重要な体位です。⼦どもにとって床に寝そべって遊ぶのは⾃然なことです。 46 中級⾞椅⼦サービス教習パッケージ 説明： • ⾝体障害のある⼦どもが⼼地よく床に寝そべる には、何かしら⽀えが必要になるものです： o このイラストの⼦どもは、うつ伏せに寝た状 態で⽀えられています。 • 5歳未満の⼦どもが腹ばいで寝そべる時は、⾻盤 17の下にロールクッション18を⼊れて⽀え、股関 節は少し屈曲した姿勢に保つべきです。 質問：⼦どもを床で遊べるように⽀えるため、家族/介助者が活⽤できる素材には何があるでしょ うか？ 答え： • ⽑布 • 発泡材 • タオル • 枕 説明： • このイラストの⼦どもは、横向きに寝た状態で ⽀えられています • ⼦どもは、⻑時間寝て過ごします。⼦どもが毎晩 同じ姿勢で寝ていると、その姿勢のまま固定、あ るいは硬直することがあります。 • ⾞椅⼦サービス職員は、家族/介助者へ、⼦ども が寝ている間、さまざまな体位を取らせる⽅法 について助⾔を与えられます。 17 [原⽂] pelvis. [訳注]「⾻盤」. 教材の図では胸の下にロールクッションが⼊っているが, 同時に⾻盤下にも⽀えを ⼊れ, 股関節を少し屈曲させて保つべきである。 18 [原⽂] a roll 47 教習員⽤指導書 4. ⼦どもを早期紹介する重要さ（10 分） 説明：⼦どもを⾞椅⼦サービス事業へどうやって、 いつ紹介・相談するかについて、少しお話しします。 質問：受講者の経験では、⼦どもはたいへん⼩さい うちから紹介・相談されていますか、それとも親/紹 介・相談元は、その⼦が重すぎて抱えられなくなる まで待っていますか？ 励まして回答を促せ。 質問：なぜ親御さんの中には、⼦どもを⾞椅⼦事前 評価へ連れて来るのを渋る⼈がいるのでしょう か？励まして回答を促せ。 答え： • 親が、⼦どもが「治って」歩き始めるよう期待している。 • 親が、⼦どもに⾞椅⼦を与えたら、もう歩こうとしなくなるだろうと考えている。 • ⼦どもが⼩さくて軽いうちは、難しい地形やアクセスの悪い環境は、⾞椅⼦で何とかするより 抱えて運ぶ⽅が楽である。 • 親に⾞椅⼦へ⽀払う資⾦がなく、遅らせているうちに⼦どもが抱えられなくなる。 • 家族が、⼦どもに障害があることを知ったら、⼈びとが⾃分たちに偏⾒を持つのでは、という 罪悪感や怖れを抱いている。 説明： • ⾞椅⼦サービス職員は、親や紹介・相談元へ、早期紹介・相談の重要さを教育する役割を果たせ ます。 • 早期紹介・相談の⽅が遅れるよりもよい理由を挙げると： o まっすぐに座るのが難しい⼦どもは、適切に⽀えなければ姿勢の問題が発⽣します。⼦ども は紹介・相談が遅れると、姿勢の問題が固定してしまうことがあります(19)。そうなると、⼦ どもは⽀えても快適に座るのが難しくなります。 o 座り、移動できた経験がないと、⼦どもの発達は遅れます(18, 20）。 o 多少歩く能⼒がある⼦どもでも、⾞椅⼦を使うと⽇常⽣活が楽になり、⼀⽇により多くのこ とができるようになります(49)。 19 [原注] World Health Organization. (1996). Promoting the development of infants and young chi ldren with spina bifida and hydrocephalus. Retrieved from http://whqlibdoc.who.int/hq/1996/W HO_RHB_96.5.pdf 20 [原注] Muscular Dystrophy Campaign. (2011). Wheelchair provision for children and adults with muscular dystrophy and other neuromuscular conditions: Best practice guidelines. 48 中級⾞椅⼦サービス教習パッケージ • 重要なことは、親および紹介・相談元に、⾞椅⼦が⼦どもの歩く能⼒を妨げることはないのだ、 と安⼼してもらうことです。歩⾏を学んでいる間も、⾞椅⼦による移動性の体験は、他の多くの ⾯で⼦どもの発達に有益です。 質問：障害のない⼦どもは、ふつう何歳で次のことができるものでしょうか： • ⽀えなしに、⾃⼒でまっすぐに座るのは？励まして回答を促せ。 • つかまり⽴ちするのは？励まして回答を促せ。 • ひとりで歩くのは？励まして回答を促せ。 答え： • 多くの⼦どもの 場合： • ⽣後 6〜8か⽉で、⽀えなしに⾃分でまっすぐに座る。 • ⽣後 8〜10か⽉で、つかまり⽴ちする。 • ⽣後 10〜12か⽉で、⽀えなしでひとり⽴ちし、つかまって歩ける。 • ⽣後 12〜18か⽉で、ひとりで歩く。 説明：これらは、紹介・相談元が⾒極めを付けるた めの主な⽬安です。 説明：⾞椅⼦サービス事業は、紹介・相談ネットワ ークへ、次のような⼦どもは紹介・相談するよう要 請するとよいでしょう： • 満１歳になっても、まっすぐ座るのが難しいか⽴ ち上がらない、または • 満２歳になっても、ひとりで歩かない。 早期介⼊検診プログラムがある（例えば、地域保健 ワーカーが早期介⼊のための⼩児検診の訓練を受 けている）ところでは、⾞椅⼦サービス事業は、こ れらのネットワークへより詳しく情報提供すると よいでしょう。例えば、著しい⾝体の障害や発達遅 れが認められた⼦どもはすべて、⾞椅⼦サービスへ 紹介・相談してほしい旨を⾞椅⼦サービス事業から 提案できます。 49 教習員⽤指導書 教習員への注記：さらに詳しい情報を求める受講者もあろう。早期に座位保持を供与すると有益 な⼩さい⼦どもを⽰す追加指標を 2点挙げると： • 乳児（1歳未満）で、いつも⼀様な姿勢（まっすぐ過ぎる姿勢（伸展位）、あるいは丸まり過ぎ た姿勢（屈曲位））を取りがち、あるいは⼿⾜を動かし、伸ばし、回すのが簡単でないか、制御 できない運動がみられる⼦ども。 • 座れるが、同じ姿勢で座り、簡単に姿勢を変えられない⼦ども。いつも同じ体位で座ると、問 題を引き起こすことがある。 受講者へ、中級⾞椅⼦紹介・相談フォームを⾒るよう指⽰せよ。 説明： • このフォームは、紹介・相談組織が⾞椅⼦ユーザーを⾞椅⼦サービス事業へ紹介・相談するのに 活⽤できます。 • 各サービス事業所で、このフォームを各⾃のサービス内容に合うよう修正して構いません。 • このフォームには、先ほど説明した⽬安も載せています。 説明：⾞椅⼦サービスは、まだ軽くて抱えられる ⼩さい⼦どもには、⾞椅⼦の代わりに座位保持シ ートを提案してもよいでしょう。これを家の中で 使い、外ではその⼦を抱えるようにできます。 5. ⼦どもと働く（20 分） 説明：⼦どもと関わる時、つねに⼤切なことは、⼦どもを尊重し、同時に保護するように21接する ことです。 質問：⾞椅⼦サービス職員は、⼦どもが尊重され、保護されているために何ができるでしょうか？ 励まして回答を促せ。 21 [原⽂] in a way that both respects and protects children 50 中級⾞椅⼦サービス教習パッケージ 答え： • ⾃分がやろうとしていること、およびその理由を、つねに⼦どもへ説明する。 • 年齢にふさわしいやり⽅で、意思決定に⼦どもの参画を得る。 • ⼦どもが理解できるやり⽅で話す。これは、⼦どもへ何が起きているのか説明するための、⼦ どもが年齢や理解⼒に応じて理解できるやり⽅を⾒出すことである。 • 事前評価やフィッティングの間に、休憩時間を⾒込んでおく。 • ⼦どもと接する時は、必ず家族/介助者に同席してもらう。 • ⼦どもと⾯接する場所を、なるべく親しみやすくしておく。例えば、年齢に合ったおもちゃ/ 活動を⽤意しておく、⼦どもが喜ぶポスター/画像を飾っておくなど。 • 写真を撮る前に、その⼦どもおよび家族/介助者から許可を得る。 説明：主な留意事項としては： ⼦どもを尊重するために： • ⾃分がやっていること、およびなぜやるのかを、 分かってもらえるように説明する。 • ⾝体的事前評価を始める前に、許可を求める。 • 適正な⾞椅⼦を選ぶ際の意思決定に、⼦ども/そ の家族/介助者の参画を得る。 • ⼦どもとサービスセンターで⾯接する場合は、な るべく⼦どもが親しめる場所にしておく。 ⼦どもの安全を保つために： • ⼦どもとは、必ず家族/介助者の同席のもとで⾯接する。 • ⼦どもはすぐ退屈するので、⾯接の間に休憩時間を⾒込んでおく。 • 写真を撮る前に、その⼦どもおよび家族/介助者の許可を得る。 6. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 51 B: ⾞椅⼦サービスのステップ 52 中級⾞椅⼦サービス教習パッケージ B.1: 事前評価の概略・事前評価インタビュー ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 紹介・相談および⾯接予約の概略を⽰す。 ¨ 中級事前評価の 2つのパートを、簡潔に要約して⽰す。 ¨ ⾞椅⼦ユーザーが抱える疾患や⾝体的問題を 8つ以上列挙し、それらが⾞椅⼦供与に 及ぼす影響を述べる。 ¨ ⾞椅⼦サービス職員が、事前評価でのコミュニケーション技能を⾼めるための、さま ざまな⽅途を列挙する。 教 材 この授業には： ¨ PPT スライド：B: 紹介・相談および⾯接予約、B.1: 事前評価の概略・事前評価イン タビュー ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 動画：優れたコミュニケーション ¨ 中級⾞椅⼦事前評価フォーム 事 前 学 習 と 状 況 事前学習： ¨ さまざまな疾患/⾝体的問題の特⾊を理解しておく。例えば脳外傷、脳性⿇痺、筋ジス トロフィー、ポリオ、⼆分脊椎、脊髄損傷、脳⾎管障害1、下肢切断など。 ¨ 「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」から、8 つの⾞椅⼦サービスステ ップのステップ 1「紹介・相談および⾯接予約」を理解しておく。 ¨ 下記を含む基礎レベル事前評価： • ⾞椅⼦ユーザーの⽣活様式や使⽤環境と、⾞椅⼦処⽅との関係を理解する：「基礎⾞ 椅⼦サービス教習パッケージ（WSTPb）」を参照せよ。 • 既存の⾞椅⼦を査定し、それが⾞椅⼦ユーザーのニーズを満たしているかどうか⾒極 める。 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 現地で広く⾒られる特定の障害/⾝体的問題で、⾞椅⼦事前評価フォームへ追加し、授 業で説明すべきものがあるかどうか。 1 [原⽂] brain stroke. [訳注] 中級受講者⽤参考書 p.30 の説明内容に合致するよう, こちらの訳語を採った. 53 教習員⽤指導書 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 中級⾞椅⼦事前評価フォームを徹底的に復習し、事前評価インタビュー実施の練習を しておく。 ¨ 「基礎⾞椅⼦サービス教習パッケージ教習員⽤指導書」p.120〜125の、⾝体条件に関 する情報を復習しておく。 あ ら す じ 1. はじめに 2. 事前評価 3. 事前評価インタビュー 4. 事前評価インタビューでの、優れたコミュニケーション技能 5. 要点のまとめ 10 10 50 15 5 授業時間計 90 1. はじめに（10 分） 説明：紹介・相談および⾯接予約2は、⾞椅⼦サービ ス提供の最初のステップです。 「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」 のスライド B.1: 紹介・相談および⾯接予約を映し、 ステップ 1 の重要性を再認識させよ。 説明：この授業では受講者へ： • 事前評価の 2 つのパート、事前評価インタビュー および⾝体的事前評価を紹介します。 • 事前評価インタビューについて詳しく⾒ながら、 事前評価インタビューで集めた情報が、⾞椅⼦処 ⽅へどう影響するか、 • 事前評価での、優れたコミュニケーション技能3 の⼤切さ、 • ⾞椅⼦ユーザーが痛みを覚えている時、それを認 識する⽅法を検討します。 2 [訳注] 教材では左図の前に「はじめに」「紹介・相談元」「⾯接予約制」の復習⽤スライド 3枚が収められている. 3 [原⽂] good communication skills 54 中級⾞椅⼦サービス教習パッケージ 2. 事前評価（10 分） 説明：事前評価は、8 つの⾞椅⼦サービスステップ の 2番めです。事前評価で集めた情報は、⾞椅⼦サ ービス職員および⾞椅⼦ユーザーにとってたいへ ん有⽤です。 • 事前評価から得られる情報は、⾞椅⼦サービス職員および⾞椅⼦ユーザーが、次を⾏なうのに役 ⽴ちます： o ⼿に⼊るものの中から、最適な⾞椅⼦を選ぶ。 o 最も適正な⾞椅⼦部材、例えば姿勢⽀持具や付属品などを、⼿に⼊るものから選ぶ。 o ⾞椅⼦ユーザーおよび/またはその家族が⾞椅⼦を最⾼に活⽤するためには、どんな教習が必 要なのか⾒出す。 説明：事前評価は、基礎レベルでも中級でも、次の 2 パートを実施します： • 事前評価インタビュー • ⾝体的事前評価 3. 事前評価インタビュー（50 分） 説明：事前評価の最初のパートは、事前評価インタビューです。事前評価のこのパートで、⾞椅⼦ サービス職員は⾞椅⼦ユーザーに関する情報を集めます。この情報は、その⾞椅⼦ユーザーに最適 な⾞椅⼦を⾒定めるのに役⽴ちます。 55 教習員⽤指導書 説明： • 事前評価インタビューの構成要素は、基礎レベル も中級もたいへん似通っています。その内容は： o ⾞椅⼦ユーザーに関する情報 o ⾝体条件 o ⽣活様式および環境 o 既存の⾞椅⼦ • この中級プログラムでは、「基礎⾞椅⼦サービス 教習パッケージ（WSTPb）」で取り上げた情報は くり返しません。 • 受講者はこれらの情報の集め⽅、およびそれらが ⾞椅⼦処⽅へどう影響するのかを熟知している 必要があります。 • 受講者⽤参考書に、中級での追加情報も併せて、 簡潔なまとめを表にしています。 説明：事前評価インタビューの構成要素は基礎レベ ルも中級もたいへん似通っていますが、中級では⾞ 椅⼦ユーザーの疾患や⾝体的問題に関する情報を より多く集めます。 56 中級⾞椅⼦サービス教習パッケージ ⼩グループ活動 グループ： 受講者を 2〜4⼈ずつの⼩グループに分けよ。 指導内容： 各グループに番号（1〜5）を付与し、「受講者⽤ワークブック（B.1: 事前評 価の概略・事前評価インタビュー）」の適切な課題を割り当てよ。 受講者へ、⾃分のグループへ割り当てられたワークブックの質問に答える よう指⽰せよ。 説明：受講者は、次のものをこの活動の補助に使えます： • 受講者⽤参考書 • さまざまな疾患/⾝体的問題がある⼈びと/⾞椅⼦ユーザーと働き、そこ から学んだ⾃分⾃⾝の知識および経験。 説明：受講者には、割り当てた質問に答える時間が 20 分あります。各グル ープには、個々の疾患/⾝体的問題がある⼈へ⾞椅⼦を処⽅する際、気を付 けるべき 3つの⾯について全体へフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 各グループが、質問を理解しているか確かめよ。 受講者⽤参考書および⾃⾝の知識を活⽤するよう、受講グループを励ませ。 必要なら受講者を先導せよ。 時間： グループが準備するのに 20 分取っておけ。 各グループからのフィードバックおよび話し合いに 10 分ずつ取っておけ。 この活動の時間⾒積もりは、4 グループの参加を基準にしたことに注意。4 グループより少ないか多い場合は、適宜時間を調整せよ。 フィードバック： 各グループへ、個々の疾患/⾝体的問題がある⾞椅⼦ユーザーへ⾞椅⼦を処 ⽅する際に気を付けるべき 3つの⾯について、順番に詳述するよう指⽰せ よ。 正答を受けとめ承認し、誤解があれば訂正/明確にせよ。 注記：教習員は、受講者⽤参考書の注記を、各グループが適切な答えを⾒ 出したかどうか確かめるのに活⽤せよ。 57 教習員⽤指導書 4. 事前評価インタビューでの、優れたコミュニケーション技能（15 分） 説明： 優れたコミュニケーション技能を⽤いるとは、⾞椅⼦ユーザーの感性やニーズへ敬意を払い4つつ 敏感である5ことですが、それは正しい情報を集められるようにする、つねに重要な⽅法です。事前 評価インタビューを円滑に進めるために役⽴つやり⽅として： • ⼩さい⼦ども、あるいは問いへの理解や応答ができない⼈でない限り、つねに⾞椅⼦ユーザー本 ⼈に話しかけなさい。 • ⾞椅⼦ユーザーに、提供して頂く情報が、ニーズを満たすいちばん適正な⾞椅⼦を選ぶ助けにな ることを説明しなさい。 • 質問を、中級⾞椅⼦事前評価フォーム上の順番通りに尋ねる必要はありません。⾞椅⼦ユーザー によっては聞かれる前に⾃分から情報を提供することもあり、順番を変えて聞く⽅が⾃然な場合 もあります。 • 発話によるコミュニケーションが難しい場合もあります。例えば、⾞椅⼦ユーザーが難聴、ある いは明確に話せないために理解できないことがあります。 • コミュニケーションが難しい場合も、⾞椅⼦ユーザーと直接コミュニケーションを取る途を探り なさい。⾞椅⼦ユーザーをよく知っている⼈に、どうやったらコミュニケーションを取れるか聞 きなさい。⾞椅⼦ユーザーのコミュニケーションのやり⽅を、時間をかけて理解しなさい。 • 直接コミュニケーションを取る⽅法が判らない場合も、だれか⽇頃から⾞椅⼦ユーザーを近しく 知っている⼈がいないか確かめなさい。その⼈に、⾞椅⼦ユーザーとのコミュニケーションを取 ってもらうようにしなさい。 動画を紹介：「優れたコミュニケーション」。この動画では、⼈びとがコミュニケ ーションを取る、多種多様なやり⽅を視聴します。 受講グループを座っている場所によって（受講者が席を移る必要はない）半分ず つ 2つに分けよ。 説明：各グループは動画をよく視て、⼈びとがコミュニケーションを取る、さま ざまなやり⽅を書き出しなさい。受講者が着⽬すべきことは： • さまざまなコミュニケーションのやり⽅（例えば、⼿話） • 優れたコミュニケーション技法のさまざまな例（例えば、よいアイコンタクト） 動画を上映。 何か質問がないか尋ねよ。 4 [原⽂] respectful 5 [原⽂] sensitive 58 中級⾞椅⼦サービス教習パッケージ 各グループへ数分与え、さまざまなコミュニケーション⽅法、および優れたコミュニケーション技 法のさまざまな例を書き出して表にさせよ。 質問：動画の中の⼈びとがコミュニケーションを取るやり⽅には何がありましたか？ ⽚⽅のグループに、⾃らの表を読み上げるよう求めよ。回答を板書せよ。各項⽬について、他のグ ループにも同じ答えがあれば印を付けよ。そちらのグループに、他の答えがあるか尋ねよ。 答え： • さまざまな⾔語コミュニケーション： o 実演で補強した明確な話し⽅ o 説明して提⽰する o ⾳（発声6） • さまざまな⾮⾔語コミュニケーション： o ⾝ぶり o 視線で⽰す（アイポインティング） o うなずく o ⼿ぶり o つながりをつくる7 o 表情 o ⼿話 o 視線を交わす（アイコンタクト） o 触れる8 o 何らかの⼿段で、はい/いいえを⽰せるしくみ を⽤い、⾞椅⼦ユーザーが「はい」「いいえ」 で答えられる質問をする。 • 特殊なコミュニケーション⼿段 o コミュニケーション（⽀援）ボード o ヘッドポインター o コンピューター • コミュニケーションがよくなるため の、さまざまな⽅法： o 優れたアイコンタクト。 o ⾞椅⼦ユーザーと同じ⾼さになる ようかがむ/ひざまずく。 o 開放的でリラックスした反応に富 むボディランゲージ（⾞椅⼦ユー ザーと向き合い関⼼を⽰す）。 o コミュニケーションに困難がある ⼈へ、問いへ反応するためのじゅ うぶんな時間を与える。 動画を紹介：「優れたコミュニケーション」。受講者はこの動画をもう⼀度視聴し、 いくつの例を正しく掴めていたか確かめなさい。 動画を上映。 受講者が、初回の視聴で要点をいくつ⾒極めていたかを受けとめ承認せよ。 6 [原⽂] vocalizations 7 [原⽂] connecting 8 [原⽂] touch 59 教習員⽤指導書 説明：話すことができない⾞椅⼦ユーザーの場合、痛みがあっても伝えるのは困難です。それゆえ、 ⾞椅⼦サービス職員が、⾞椅⼦ユーザーに関わっている時に⾞椅⼦ユーザーの痛みを引き起こした り、増したりすることを⾃分がしていないか、判ることは重要です。質問：痛みがあることを、ふ つうどうやって⽰しますか？励まして回答を促せ。 答え： • 泣く9。 • 叫ぶ10。 • もじもじする11。 • 汗をかく。 • 評価者の⼿を押しのけるか、遠のけようとする。 • 動きに抵抗する、あるいは⼀つの姿勢で いられない。 • 表情による表現：眉をひそめる12、および /または顔をしかめる13。 • 座り⽅・⽴ち⽅・歩き⽅。 質問：痛みを引き起こしたり、すでにある痛みを増したりしていないか確かめるには、どうしたら いいでしょうか？ 答え： • ⾞椅⼦ユーザーへ、事前評価中に痛みを覚えたら知らせるよう、強くお願いする。 • コミュニケーションが難しい場合は、事前評価の開始前に痛みを表すサインを決めておく。 • 痛みが悪化する姿勢を避ける。 • 痛みが軽くなる姿勢や動作をとる。 5. 要点のまとめ（5 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 9 [原⽂] crying 10 [原⽂] shouting 11 [原⽂] fidgeting 12 [原⽂] frowning 13 [原⽂] grimacing 60 中級⾞椅⼦サービス教習パッケージ B.2: ⾝体的事前評価−⽀えなしの座位姿勢 ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ ⼦どもと⼤⼈との、まっすぐな座位姿勢の違いを、3つ列挙する。 ¨ 座位姿勢を観察し、ことば、絵、あるいは両⽅で記録する。 教 材 この授業には： ¨ PPTスライド：B.2: ⾝体的事前評価−⽀えなしの座位姿勢 ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 動画：⾝体的事前評価の概略 ¨ 中級⾞椅⼦事前評価フォーム ¨ 評価ベッドを各グループに 1 台ずつ ¨ ⾜乗せブロックを各グループに 1 セットずつ 事 前 学 習 と 状 況 事前学習： ¨ ⾝体的事前評価の「褥瘡の有無・危険・既往歴」の箇所を完成し、得られた情報が⾞ 椅⼦供与へどのように影響するのか、理解しておく。 ¨ ⾝体的事前評価の「こぎ⽅」の箇所を完成し、得られた情報が⾞椅⼦供与へどのよう に影響するのか、理解しておく。 ¨ 基本的な座位姿勢について： • まっすぐな座位姿勢の⾒分け⽅および⾔い表し⽅。 • まっすぐに座ることの有益な点を理解する。 ¨ 上前腸⾻棘（ASIS）、上後腸⾻棘（PSIS）、座⾻結節（ITs）など⾻部位の⾒定め⽅。 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 受講者へお互いの上前腸⾻棘および上後腸⾻棘を⾒つけるよう指⽰し、希望者を相⼿ にやってみせる際の、触ることにまつわる⽂化的問題に気を付ける。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 中級⾞椅⼦事前評価フォームを徹底的に復習し、⽀えなしの座位姿勢を⾔い表し、描 く練習をしておく。 ¨ 教室前⽅に、評価ベッドを 1 台置いておく。 ¨ 教室を、部屋の前⽅を囲んで受講者が半円形に座れるように配置しておく。 ¨ 評価ベッドを、教室内（あるいは室外/隣室）にぐるっと配置する。 61 教習員⽤指導書 あ ら す じ 1. はじめに 2. 褥瘡の有無・危険・既往歴およびこぎ⽅の復習 3. ⾝体的事前評価の概略 4. まっすぐな座位姿勢 5. ⼩さい⼦どものまっすぐな座位姿勢 6. ⾻盤は座位姿勢の基礎14 7. 座位姿勢を観察する 8. 姿勢を記録する 9. 要点のまとめ 5 5 5 20 5 20 8 20 2 授業時間計 90 1. はじめに（5 分） 説明：この授業では、⾝体的事前評価を紹介します。 これは事前評価の第 2 のパートです。 続いて「基礎⾞椅⼦サービス教習パッケージ」で紹 介した、⾝体的事前評価の次の 2項⽬を簡単に復習 します： • 褥瘡の有無・危険・既往歴15 • ［⾞椅⼦の］こぎ⽅16 説明：そして、⾝体的事前評価の「⽀えなしの座位姿勢17」の部分に焦点を当てます。そこで： • ⼤⼈と⼦どもの、まっすぐな座位姿勢18について復習します。 • ⾻盤が座位姿勢へどう影響するのか検討します。 • 座位姿勢を観察し、記録する練習をします。 14 [原⽂] foundation 15 [原⽂] presence, risk of, or history of, pressure sores 16 [原⽂] method of pushing 17 [原⽂] sitting posture without support 18 [原⽂] upright sitting posture 62 中級⾞椅⼦サービス教習パッケージ 説明：⾝体的事前評価の内容は： • 褥瘡の有無・危険・既往歴の⾒定め。 • ［⾞椅⼦の］こぎ⽅の⾒定め。 • ⾞椅⼦ユーザーがどう座り、どんな付加姿勢⽀持 が必要か、以下を通じて⾒出す： o ⽀えなしの座位姿勢の観察19。 o ⾻盤と股関節の姿勢チェック20の実施。 o ハンド・シミュレーション21の実施。 • ⾝体計測です。 質問：「ハンド・シミュレーション」という⽤語の意 味を知っている⼈はいますか？ 励まして回答を促せ。 答え： ハンド・シミュレーションとは、⾞椅⼦および 付加姿勢⽀持がもたらすであろう⽀えを、⼿を ⽤いて模擬すること。 2. 褥瘡の有無・危険・既往歴およびこぎ⽅の復習（5 分） 説明：中級の⾝体的事前評価の初めの 2項⽬は基礎レベル事前評価と同じで： • 褥瘡の有無・危険・既往歴、 • こぎ⽅です。 説明：この中級プログラムでは、「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」で取り上げた情 報はくり返しません。受講者は、これらの情報の集め⽅や、それが⾞椅⼦処⽅へどう影響するのか を熟知している必要があります。 19 [原⽂] observing sitting posture without support 20 [原⽂] pelvis and hip posture screen 21 [原⽂] hand simulation 63 教習員⽤指導書 説明：⾞椅⼦ユーザーに褥瘡発⽣の危険があるかど うか⾒出すことは、つねに重要です。 質問：事前評価のこの部⾯について、質問がある⼈ はいますか？どんな質問にも答えよ。 受講者へ再確認せよ： • ⾞椅⼦ユーザーから過去に褥瘡があった、または 現在褥瘡があると聞いたら、⾒せてもらうよう頼 みなさい。 • 事前評価に当たる⾞椅⼦サービス職員には、褥瘡 がどこにある（あった）か、また治療のために紹 介・相談する必要があるかどうか、正確に把握す ることがつねに重要です。 説明：基礎レベルの⾞椅⼦供与と全く同様に、どの こぎ⽅がその⾞椅⼦ユーザーにとって最良か、⾒定 めることは重要です。 質問：事前評価のこの部⾯について、質問がある⼈ はいますか？どんな質問にも答えよ。 受講者へ再確認せよ： • 最⼤限に⾃⽴して動けることは、基本的⼈権の⼀ つです22。たとえ少しでも⾃分でこげるのは、価 値あることなのです23。 • よい姿勢⽀持を設えると、⾞椅⼦ユーザーの⾃分 でこぐ能⼒は⾼まります。⾞椅⼦ユーザーがどの ように、またどれだけ⾃⾛できるか事前評価する 際には、このことを計算に⼊れておくべきです。 22 [原⽂] To be able to move with as much independence as possible is a human right.. 23 [原⽂] Even a small amount of independent pushing is worth having. 64 中級⾞椅⼦サービス教習パッケージ 3. ⾝体的事前評価の概略（5 分） 動画を紹介：「⾝体的事前評価の概略」。これから視聴する短い動画では、⾞椅⼦ サービス職員が⾞椅⼦ユーザーと協働して、⾞椅⼦ユーザーがどう座り、どんな 付加姿勢⽀持をもたらす必要があるのか、⾒出すやり⽅を概観します。動画に登 場する少⼥はエニスといいます。インタビューの後、評価者が踏む⼿順は： • ⽀えなしの座位姿勢の観察、 • ⾻盤と股関節の姿勢チェック、 • ハンド・シミュレーションの実施です。 動画を上映。 説明： • 動画では、⾞椅⼦サービス職員が、⾞椅⼦に座ったエニスの姿勢を観察してい るのを視ましたね。エニスは⾞椅⼦をすでに持っているので、エニスにどの姿 勢⽀持がすでにあり、またそれがどの程度彼⼥を⽀えているのか、知ることが 重要です。 • ⾞椅⼦サービス職員は、⾻盤と股関節の姿勢を調べ始める前にも、評価ベッド 上でのエニスの姿勢を観察していると考えておいて下さい。 何か質問がないか尋ねよ。 4. まっすぐな座位姿勢（20 分） ひとり希望者に、教室の前に出てきて、評価ベッドにまっすぐな姿勢で座るよう求めよ。 受講者へ、横から⾒た希望者の姿勢を、最初に⾻盤から始めて形容する24よう指⽰せよ。受講者に は、よく⾒えるように⽴ち上がるか移動が必要かもしれない。 答え（すべて押さえよ）： 横から⾒て： • ⾻盤がまっすぐに起きている。 • 体幹がまっすぐに起きている。 • 背中が⾃然なカーブを描いている。 • 頭と⾸がまっすぐに起き、⾝体の上でバランスが取れている。 • 股関節がほぼ 90 度に屈曲している。 • 膝と⾜⾸がほぼ 90 度に屈曲している。 • ⾜が床（あるいは⾜⽀持具）にべったり着いている25。 24 [原⽂] describe 25 [原⽂] feet resting flat on the floor (or foot support). [訳注] 本書で「⾜台」は footrest で統⼀されており、foot support（ISO ⽤語でいう本書の「⾜台」）は、付加的な姿勢⽀持具を指している。 65 教習員⽤指導書 受講者へ、希望者の姿勢を、こんどは正⾯から⾒て形容するよう指⽰せよ。今度も⾻盤から始める よう指⽰せよ。 答え（すべて押さえよ）： 正⾯から⾒て： • ⾻盤が⽔平である。 • 両肩が⽔平でリラックスしており、腕が⾃由に動く。 • ⼤腿が互いに並⾏か、わずかに外を向いている。 • 頭がまっすぐに起き、⾝体の上でバランスが取れている。 • 体幹が⼀直線状である26（曲がったり、⼀⽅へ傾いたりしていない）。 希望者に感謝を述べよ。 説明：ここで⾔い表してきた「まっすぐな座位姿勢」とは、受講者が⽬安として⽤いるためのもの です。⾞椅⼦ユーザーと関わる際にめざすべきは、それぞれの⾞椅⼦ユーザーが快適で、実⽤的か つ機能的な限りで、できるだけこの姿勢に近づくよう⽀えることです。 説明： • これまで、なぜまっすぐな姿勢で座ることが⼤切なのかお話ししてきましたが、だれもがまっす ぐに座れるわけではありません。 • 中級サービスにやって来る⾞椅⼦ユーザーの座位姿勢は、さまざまに異なるでしょう。 • 座位姿勢が異なる原因は、⾝体の⼀つ以上の部分がニュートラルな位置にないことです。 • 事前評価では、⾞椅⼦サービス職員と⾞椅⼦ユーザーとで、⾞椅⼦ユーザーが、機能を損なわず に安全かつ快適にとって保てる、いちばんまっすぐな座位姿勢を⾒つける必要があります。 • ⾞椅⼦と姿勢⽀持具（PSDs）とで⽀えなければならないのは、その姿勢なのです。 • 姿勢の事前評価から判明する最終結果は、次の 3通りに分かれます： • 固まった姿勢27 • ニュートラル姿勢になる柔軟さ28 • ニュートラル姿勢途中の柔軟さ29 26 [原⽂] trunk in a straight line 27 [原⽂] fixed posture 28 [原⽂] flexible to neutral posture 29 [原⽂] flexible part way to neutral posture 66 中級⾞椅⼦サービス教習パッケージ ⼩グループ活動 グループ： 受講者を 3⼈ずつのグループに分けよ。 指導内容： 受講者へ、下の⽤語 3つの意味は何か⾃分たちで話し合うよう指⽰せよ： • 固まった姿勢 • ニュートラル姿勢になる柔軟さ • ニュートラル姿勢途中の柔軟さ 受講者⽤参考書を調べず、これらの⽤語について、⾃分たち⾃⾝の理解にた どり着くよう指⽰せよ。 説明：受講者は、この活動にグループで 10 分使えます。それから全体に戻 っていっしょにフィードバックしてもらいます。 モニター： 各グループが質問を思い出せるよう、3つの⽤語が載ったスライドは映した ままにしておけ。 グループを注意深くモニターせよ。 受講者が、質問を理解しているか確かめよ。 必要なら受講者を先導せよ。 時間： 活動に 10 分取っておけ。 フィードバックに 5 分取っておけ。 フィードバック： グループの⼀つへ「固まった姿勢」を定義または説明するよう指⽰せよ。 • 定義/説明が明確であれば、回答を受けとめ承認せよ。明確でなければ、 他のグループへ説明を助けるよう求めよ。必要ならば教習員が説明せよ。 別のグループへ「ニュートラル姿勢になる柔軟さ」を定義または説明するよ う指⽰せよ。 • 定義/説明が明確であれば、回答を受けとめ承認せよ。そうでなければ、 他のグループへ説明を助けるよう求めよ。必要ならば教習員が説明せよ。 別のグループへ「ニュートラル姿勢途中の柔軟さ」を定義または説明するよ う指⽰せよ。 • 定義/説明が明確であれば、回答を受けとめ承認せよ。そうでなければ、 他のグループへ説明を助けるよう求めよ。必要ならば教習員が説明せよ。 答え： 固まった姿勢： • ⾞椅⼦ユーザーに「固まった」⾝体部分がある。軽 い⼒では動かない（強い⼒は決して⽤いないこと）。 ニュートラル姿勢 になる柔軟さ： • 軽い⼒で、⾞椅⼦ユーザーのニュートラルでない⾝ 体部分を動かしてニュートラルにできる。 ニュートラル姿勢 途中の柔軟さ： • 軽い⼒で、⾞椅⼦ユーザーのニュートラルでない⾝ 体部分をニュートラルへの途中まで動かせる。 67 教習員⽤指導書 説明： • これらの⽤語は、受講者⽤参考書で解説しています。⾞椅⼦サービス職員は、⾞椅⼦ユーザーへ ⽀えをこしらえるさい、その⾞椅⼦ユーザーがニュートラルな姿勢へ向かってどこまで柔軟なの か、注意深く検討することが⼤切です。 • 「固まった姿勢」とは、⾞椅⼦ユーザーの⾝体 に「固まった」部分がある場合です。軽い⼒で は動きません（決して強い⼒を⽤いてはなりま せん）。⾞椅⼦サービス職員は、ニュートラルで ない（固まった）姿勢に形を合わせて⽀えを設 ける必要があります。 • 「ニュートラル姿勢になる柔軟さ」とは、軽い⼒で、⾞椅⼦ユーザーのニュートラルでない⾝体 部分を動かしてニュートラルにできる場合です。この状況での正しい⽀えとは、⾞椅⼦ユーザー がニュートラルな座位姿勢を保つのを助けるように設けるものです。 • 「ニュートラル姿勢途中の柔軟さ」とは、軽い⼒で、⾞椅⼦ユーザーのニュートラルでない⾝体 部分を、ニュートラルへの途中までなら動かせる場合です。この状況での⽀えは、⾞椅⼦ユーザ ーが、快適かつ機能的な限りで、なるべくニュートラルに近い姿勢で座れるように設けます。 • ⾞椅⼦ユーザーを、快適または機能的なところよりもニュートラルに近づけた姿勢で⽀えると、 新たな問題を⽣み出しかねないことを忘れないで下さい。だからこそ事前評価は⾮常に重要で、 ⾞椅⼦ユーザーの快適さや機能は、「まっすぐな座位姿勢」へどこまで近づけて座れるか、に劣 らず考慮されるべきです。 5. ⼩さい⼦どものまっすぐな座位姿勢（5 分） 説明：5歳未満の⼦どものまっすぐな座位姿勢は、もっと⼤きな⼦どもや⼤⼈と同じではありませ ん。座位姿勢は、⽣後 5年間は発達途上にあるものなのです。 説明：このスライドの⼦どもは 3歳です。スライド の⼦ども、また⼤⼈も、まっすぐな座位姿勢を取っ ています。 質問：受講者から⾒て、⼦どもと⼤⼈の姿勢は何が 違いますか？ 励まして回答を促せ。 68 中級⾞椅⼦サービス教習パッケージ 答え： 5歳未満の⼦ども ⼤⼈ • 体幹はまっすぐに起きているが、腰椎や胸郭のカ ーブがない。 • ⼦どもの⽿と股関節を結んだ線に対して、肩はわ ずかにその前に位置している。 • 両脚は外転して開いており、平⾏ではない。 • 体幹はまっすぐに起き、背中が⾃然なカ ーブを描いている。 • ⽿、肩、股関節が⼀直線上にある。 • 両脚は互いに平⾏か、わずかに外を向い ている。 説明： ５歳未満における最も重要な違いとは： • ⼦どもの背中は平らで、腰椎や胸郭のカーブがあ りません。 • ⼦どもの⽿と股関節を結んだ線に対して、肩はわ ずかにその前に位置しています。 • 両脚は外転して開いており平⾏ではありません。 説明：⾞椅⼦サービス職員は、５歳未満の⼦どもに関わるさい、⼤⼈にまっすぐな座位姿勢を促す ような⽀えを５歳未満の⼦どもに設けてはならないことに留意する必要があります。それは⼦ども にとっては不快で、有害でさえあります。 6. ⾻盤は座位姿勢の基礎（20 分） 質問：⾻盤姿勢が変化すると、他の⾝体の部分にも影響するでしょうか？ 答え： • はい。⾻盤姿勢に動きや変化があると、つねに⾝体の他の部分へ影響する。 • ⾻盤は座位姿勢の「基礎」である。 説明： この点について、詳しく⾒て⾏きます。 ⾻盤が⾝体の他の部分へどう影響するか、を理解 することは、中級教習プログラムのたいへん重要 な部分です。 69 教習員⽤指導書 質問：このイラストで、上後腸⾻棘（PSIS）と上前 腸⾻棘（ASIS）はどこでしょうか？ 説明：横から⾒ると、ASIS と PSIS は同じ⾼さに なります。 説明：正⾯から⾒ると、左右の ASIS は⽔平になり ます。 ひとり希望者に、教室の前に出てきて、まっすぐな 姿勢で評価ベッドに座るよう求めよ。 希望者を相⼿に、ASIS と PSIS を探り当てるデモ をせよ。両⼿を希望者の⾻盤に当て、両⼿で⾻盤を 優しく保持するやり⽅を⽰せ。親指をそれぞれの ASIS上に置き、他の指を⾻盤背⾯に向けて曲げよ。 受講者へ、（この技法に慣れていなければ）お互い にこれをやってみるよう指⽰し、各々が、相⼿の ASIS および PSIS を⾒つけられるようにせよ。 希望者に感謝を述べよ。 質問：まっすぐな、あるいはニュートラルである以外に、どんな⾻盤姿勢があるでしょうか？ 答え（すべて押さえよ）： • 前傾/前⽅へ傾いている（ASISが PSISより低い、または⾻盤上縁が前に寄っている） • 後傾/後⽅へ倒れている（PSISが ASISより低い、または⾻盤上縁が後ろに寄っている） • 側傾/横へ傾斜している（⾻盤の⽚⽅が反対側より低い） • 回旋（⾻盤の⽚⽅が反対側に対して前⽅/後⽅へ回転）している 70 中級⾞椅⼦サービス教習パッケージ 本項によく出てくる略語 解剖学的構造 略称 上前腸⾻棘 Anterior Superior Iliac Spine ASIS 上後腸⾻棘 Posterior Superior Iliac Spine PSIS 座⾻結節 Ischial Tuberosity IT ⼩グループ活動 グループ： 受講者を 4⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.2: ⾝体的事前評価−⽀えなしの座位姿 勢: 座位姿勢の⼟台）を開くよう指⽰せよ。 説明：各グループで協⼒して、まっすぐな座位姿勢から前傾・後傾・側傾・ 回旋した時、まっすぐな座位姿勢にどんな変化が起こるか⾒極めなさい。 説明：受講者は、この活動にグループで 10 分使えます。それから全体に戻 っていっしょにフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 受講者が、質問を理解しているか確かめよ。 必要なら受講者を先導せよ。 時間： 活動に 10 分取っておけ。 フィードバックに 5 分取っておけ。 フィードバック： 質問：各グループは、⾻盤のそれぞれの姿勢に対し、他の部分の姿勢がどう 変化するか分かりましたか？ グループ 1 へ質問：前傾に対して姿勢にどんな変化が起きましたか？ グループ 2 へ質問：後傾に対して姿勢にどんな変化が起きましたか？ グループ 3 へ質問：側傾に対して姿勢にどんな変化が起きましたか？ グループ 4へ質問：回旋に対して姿勢にどんな変化が起きましたか？ 答え： ⾻盤姿勢： • 前傾 • 後傾 • 側傾 • 回旋 全⾝（主に体幹まわり）の姿勢： • 体幹が伸び、腰部の弯曲が⼤きくなる（前弯）。 • 体幹が丸まり/曲がり「円背」姿勢（後弯）を起こす。 • 体幹が横に曲がる（側弯）。 • 体幹も回旋する。 説明： • ⾻盤姿勢がつねに⾝体の他の部分へ影響を及ぼすことは、最も重要な留意 事項です。 • ⾞椅⼦ユーザーの姿勢を事前評価する時は、⾻盤の様⼦を観察することか ら始めなさい。姿勢⽀持を供する際はつねに、まず⾻盤を⽀えなさい。 71 教習員⽤指導書 7. 座位姿勢を観察する（8 分） 説明：⾞椅⼦ユーザーの姿勢、およびどんな⽀えが必要かを理解する出発点は、⾞椅⼦ユーザーの 座位姿勢を、⽀えなしで観察することです。 説明： • 事前評価での⾞椅⼦サービス職員は、すでにイン タビューの間にも⾞椅⼦ユーザーの姿勢を観察 し始めているものです。 • ⾝体的事前評価の初めに、⾞椅⼦ユーザーに評価 ベッドへ移乗してもらいなさい。 • ⾞椅⼦ユーザーが安全で、両⾜が⽀えられていることを確かめなさい。 • じゅうぶんに⽀え、安全に座れて倒れないようにしなさい。助⼿か家族/介助者に⽀えてもらう とよいでしょう。 • ⽀えなしの座位姿勢を観察する⽬的は、⾞椅⼦ユーザーの姿勢の傾向/習性を理解することです。 • 姿勢の観察は⼀種の特技で、上達には時間と修練が必要です。 • これから、異なる 4 つの座位姿勢を⾒て⾏きます。⾃分のさまざまな姿勢を観察する技能程度が 判るでしょう。 教習員への注記： • 最初に⾻盤、それから体幹、頭部、頸部、脚部の姿勢を観察するよう強調せよ。 • 受講者がこの活動を難しいと感じていれば、⾃分で感じられるよう、⾃⾝の姿勢を鏡に映して みるよう提案せよ。これは、それぞれの座位姿勢の違いへの理解と観察を助ける。 質問：受講者は、この⼈の姿勢を観察して何が分 かりますか？ 答え： • ⾻盤が前へ傾いている。 • 腰部が弯曲している。 • 肩が後ろへ引けている。 • ⾸が伸びている。 72 中級⾞椅⼦サービス教習パッケージ 質問：受講者は、この⼈の姿勢を観察して何が分 かりますか？ 答え： • ⾻盤が後ろへ倒れている。 • 股関節が⼤きく開いて（体幹〜⼤腿の⾓度が 90 度超になって）いる。 • 腰部が丸まっている。 • ⾸が少しだけ伸びている。 質問：受講者は、この⼈の姿勢を観察して何が分 かりますか？ 答え： • ⾻盤の右側が低い（つねに低い側で呼べ）。 • ⾻盤が、右側が後退するように回旋して⾒え る（⾮対称な座位姿勢は回旋を伴うことが多 いが、必ずというわけではない）。 • 脊柱が、右側にカーブの頂点が来るように、 横へ弯曲している。 • 両肩が⽔平でない（右側が低い）。 質問：受講者は、この⼈の姿勢を観察して何が分 かりますか？ 答え： • ⾻盤が、右側が後退する向きで回旋している （つねに、どの側がどの向きかで呼べ。例： 右側が後⽅へ）。 • 体幹がやや（左側が後⽅へ）回旋している。 • 右脚が外側に倒れて外旋し、左脚が内旋して いる。 教習員への注記：最後の姿勢について、受講者が体幹の回旋に気づきにくい場合には、問え： この少年の背中は背もたれにべったり着き、背中全体に均等な圧⼒がかかっているように⾒え ますか？ 73 教習員⽤指導書 8. 姿勢を記録する（20 分） 説明： • 中級⾞椅⼦事前評価フォームには⾞椅⼦ユーザー の、⽀えなしの座位姿勢を記録する欄があります。 • この記録は⾞椅⼦サービス職員にとって： o ⾞椅⼦ユーザーの座位姿勢を、事前評価の後で 思い出し、 o 経時的変化30を追跡するのに役⽴ちます。 座位姿勢を記録する⽅法には： • ことばで詳しく述べる：先ほど練習しました、 • 絵を描く、 • 写真を（⾞椅⼦ユーザーから許可を頂いた場合に 限り）撮るなどがあります。 説明： • 写真を利⽤できる場合、⾞椅⼦サービス事業所は 写真の撮影と保管に関する、明確な⽅針を定めて おく必要があります。 • 必ず、⾞椅⼦ユーザーから、⼦どもの場合は家族/ 介助者から許可を頂きなさい。 • 事前評価⽬的で撮影した写真は、必ず⾮公開にし なさい。 • 教習（や他のあらゆる）⽬的への写真使⽤は、⾞ 椅⼦ユーザーが特にそれを許可しない限り、やっ てはいけません。 • 姿勢の記録として写真を撮る場合は、横と正⾯か ら撮りなさい。他の構図も役に⽴ちます。 30 [原⽂] changes over time 74 中級⾞椅⼦サービス教習パッケージ 説明：姿勢を描くには、多少練習が要ります。しかし、ここに基本的な線画で姿勢を記録する簡便 なやり⽅があります。線画技法が上達すると、⾞椅⼦サービス職員には⾮常に便利で、また簡単か つ効果的に使えます。 説明：これは、横から⾒たまっすぐな座位姿勢を描 く簡便なやり⽅です： • 三⾓形で⾻盤を表します。 • うねった31線で脊柱を表します。 • 直線で脚を表します。 • 頭として丸を加えます。 説明： • この脊柱の線は、3つ（頚椎・胸椎・腰椎）の⾃ 然なカーブを表しています。 • 座⾻結節（IT）・上後腸⾻棘（PSIS）・上前腸⾻棘 （ASIS）は、三⾓形への点で表します。 受講者へ、線画を描くよう指⽰せよ。 説明：これは、正⾯から⾒たまっすぐな座位姿勢を 描く簡便なやり⽅です： • ⼆重の三⾓形で⾻盤を表します。 • ⼀直線で体幹を表します。 • 直線で⼤腿（このイラストでは短い線）と下腿 （下記「教習員への注記」を参照）を表します。 • このイラストでは、膝は⼤腿と下腿の間の⼩さ い丸で表し、⾜は⼩さい四⾓に描いています。 31 [原⽂] wavy 75 教習員⽤指導書 • 肩は横⼀直線にします。 • 頭は丸にします。 受講者へ、受講者⽤ワークブック（B.2: ⾝体的事 前評価−⽀えなしの座位姿勢: 姿勢を描く）を開 き、各⾃のワークブックのそれぞれのイラストの 隣に、⾃分で線画を描くよう指⽰せよ。 説明：受講者は、この簡便な姿勢の描き⽅を使って さまざまな姿勢を記録できるので、授業の残り時 間でそれを練習しましょう。 説明：⾞椅⼦ユーザーの⾻盤が回旋している場合、 このように⽮印の付いた曲線を描いて、⾻盤のど ちら側が後ろへ回旋しているのか表せます。 • 受講者へ、これを各⾃のワークブックへ描き写 すよう指⽰せよ。 教習員への注記：この授業で⽤いた線画の例は、個々⼈でしっくり来るよう調整/修正してよい。 例えば、脚の姿勢は上から⾒たように描くのを選ぶ⼈もあろう。こうすると、脚を正⾯から⾒た ように描いて「前後が詰まる32」効果を避けられる。説明した⽅式では、⼤腿は下腿より短く、 また⼤腿はわずかに外転して⾒える。 ⼩グループ活動 グループ： 受講者を 3⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.2: ⾝体的事前評価−⽀えなしの座位 姿勢: 姿勢を描く）に載っている姿勢を⾒るよう指⽰せよ。 これは実在の⼈物のイラストであると説明せよ。各グループで協⼒して、 ⾒ている座位姿勢を線画で、各⾃のワークブックの中級⾞椅⼦事前評価フ ォームの「⽀えなしの座位姿勢」の箇所へ記録するよう指⽰せよ。 説明：受講者は、この活動にグループで 10 分使えます。それから全体でい っしょにフィードバックしてもらいます。 32 [原⽂] ʻforeshorteningʼ 76 中級⾞椅⼦サービス教習パッケージ モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 必要なら受講者を先導せよ。 時間： 活動に 10 分取っておけ。 フィードバックに 5 分取っておけ。 フィードバック： ホワイトボードがあれば、それぞれのイラストを（⼀枚ずつ）ホワイトボ ードへ映せ。各グループ 1 名の受講者に、映写したそれぞれの姿勢に重ね て線画を描くよう指⽰せよ。ホワイトボードがなければ、受講者へ、教習 員が説明/ボードへ描画する間、それに従い各⾃で模写するよう指⽰せよ。 受講者に、線画⽅式を⽤いることに困難があれば、何でも話し合え。 線画とことばを組み合わせるのは有効であると説明せよ。 教習員⽤の線画の例題： 9. 要点のまとめ（2 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 77 教習員⽤指導書 B.3: ⾝体的事前評価−⾻盤と股関節の姿勢チェック ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ ⾞椅⼦ユーザーの⾻盤と股関節の姿勢チェックをやってみせ、以下を⾒出す： • ⾞椅⼦ユーザーの⾻盤が⽔平になるかどうか。 • 両股関節が、ニュートラルな座位姿勢まで屈曲するかどうか。 ¨ ⽔平でない⾻盤、およびニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度 が 90 度超の）⽚側または両側の股関節に、形を合わせる⼀時的⽀持部づくりをやっ てみせる。 教 材 この授業には： ¨ PPTスライド：B.3: ⾝体的事前評価−⾻盤と股関節の姿勢チェック ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 動画：⾻盤と股関節の姿勢チェック ¨ 動画：⼀時的⽀持 ¨ 中級⾞椅⼦事前評価フォーム ¨ 評価ベッドを、各グループに 1 台 ¨ ゴニオメーター/ボール紙製⾓度計を、各グループに 1本 ¨ 硬いウレタンフォームのブロックを、各グループに 1個 ¨ 硬いウレタンフォームのウェッジ（くさび）を、各グループに 1個 ¨ 固まった⽔平でない⾻盤を⽀えるために改造したクッション ¨ ⽚側がニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超の）股 関節を⽀えるために改造したクッション ¨ ⽚側または両側がニュートラルな座位姿勢まで伸展しない（体幹〜⼤腿の⾓度が 90度 未満の）股関節を⽀えるために改造したクッション 事 前 学 習 と 状 況 事前学習： ¨ ⾓度計を扱えると、必須ではないが有⽤である。 この授業は、受講者が働く状況に合うよう修正せよ： ¨ 事前評価がどこで実施されるかを考慮する。 ¨ 希望者を相⼿に⼀時的⽀持をやってみせる、また受講者へ互いに⾻盤と股関節の姿勢 チェックを実施するよう指⽰する際の、触ることにまつわる⽂化的問題に気を付ける。 78 中級⾞椅⼦サービス教習パッケージ 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 中級⾞椅⼦事前評価フォームを徹底的に復習し、⾻盤と股関節の姿勢チェックを実施 する練習をしておく。⼀時的⽀持を設ける練習をしておく。 ¨ 教室前⽅に、評価ベッドを 1 台置いておく。 ¨ 硬いウレタンフォームのブロックおよびウェッジ（くさび）を評価ベッド上に置き、 デモに使う準備をしておく。 ¨ 教室を、部屋の前⽅を囲んで受講者が半円形に座れるように配置しておく。 ¨ 評価ベッドを、教室内（あるいは室外/隣室）にぐるっと配置する。 あ ら す じ 1. はじめに 2. ⾻盤と股関節の姿勢チェック 3. 固まった⽔平でない（側傾した）⾻盤やニュートラルな座位姿勢まで屈曲しな い（体幹〜⼤腿の⾓度が 90 度超の）股関節への⼀時的⽀持 4. 固まった⽔平でない⾻盤への⼀時的⽀持のデモ 5. ニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超の）股 関節への⼀時的⽀持のデモ 6. ⼀時的⽀持の演習 7. 要点のまとめ 2 40 5 10 30 30 3 授業時間計 120 1. はじめに（2 分） 説明：この授業では引き続き、⾝体的事前評価について学びます。 この授業で話し合うことは： • ⾻盤と股関節の姿勢チェック33、 • ⾻盤や股関節の問題に対する、⼀時的⽀持34の 設え⽅です。 33 [原⽂] the pelvis and hip posture screen. [訳注] 医療や診断⽬的の⾏為ではないため, そう受け取られる可能性の ある訳語は避けた (原著の⽤語選びも同様の意図と考える). 34 [原⽂] temporary supports 79 教習員⽤指導書 2. ⾻盤と股関節の姿勢チェック（40 分） 教習員への注記：この教習プログラムで教授する⾻盤と股関節の姿勢チェックは、完全な関節可 動域評価35ではない。 ⾻盤： • 調べるのは、⾻盤が⽔平になるか、あるいはならないのか⾒極めることだけである。 • なぜなら、⽔平でない⾻盤には［椅⼦の］形を合わせ36なければ、⾝体的事前評価の次の段階 （ハンド・シミュレーション）は実施困難だからである。 股関節： • 股関節の屈曲のみを評価する。 • なぜなら、股関節を屈曲する時の固まった制約に［椅⼦の］形を合わせなければ、⾝体的事前 評価の次の段階（ハンド・シミュレーション）は実施困難だからである。 • 基準点あるいは原点37となるのは、股関節が屈曲したニュートラルな座位姿勢（体幹〜⼤腿の ⾓度が 90 度）である。受講者には、以下を⾒極めるよう教えよ： • ⾞椅⼦ユーザーは、⽀えがあればニュートラルな姿勢で座れるか？ • そうでなければ、ニュートラルな姿勢へどこまで近づけて座れるか？ • これは、⾞椅⼦の背もたれ〜座⾯の⾓度に直接関わってくる。 受講者へ、各⾃の中級⾞椅⼦事前評価フォームの「⾻盤と股関節の姿勢チェック」の箇所を⾒るよ う、指⽰せよ。 説明：⾻盤や股関節周辺で起きたことが、座位姿勢 に影響するのはお解りですね。事前評価のこの部 分で、⾞椅⼦サービス職員が⾒出すべきことは： • ⽀えのあるなしにかかわらず、⾞椅⼦ユーザー の⾻盤が正⾯から⾒て⽔平になるかどうか。 • ⽀えのあるなしにかかわらず、⾞椅⼦ユーザー の股関節がニュートラルな座位姿勢まで屈曲す るかどうか。 35 [原⽂] a full Range of Motion assessment 36 [原⽂] accommodating 37 [原⽂] the reference or starting point 80 中級⾞椅⼦サービス教習パッケージ 説明： • この⼦どもの⾻盤が⽔平で、股関節がニュート ラルな座位姿勢になっているのは判りますね。 • 事前評価する⾞椅⼦サービス供与者が、両⼿の 親指を⼦どもの上前腸⾻棘（ASIS）に当て、⾻ 盤が⽔平だとはっきり⾒抜いていることに注 ⽬して下さい。 質問：この男性の⾻盤は⽔平で、股関節はニュー トラルな座位姿勢になっているでしょうか？ • 答え： いいえ。 ⾻盤が⽔平でない、または股関節がニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超の）場合、⾞椅⼦サービス職員はさらに情報を探る必要があります。知るべき重要事項は： • ⾞椅⼦ユーザーは、⽀えがあればニュートラルな姿勢で座れるか？ • そうでなければ、ニュートラルな姿勢へどこまで近づけて座れるか？ 説明：⾻盤が、前傾・後傾・側傾・回旋など、さまざまに動けるのはご存じですよね。 受講者へ、⾃分の⾻盤をさまざまな⽅向へ動かし、その動きが実際に起こるのはどこか考察するよ う指⽰せよ。それを⾒つけるため、⼿を座⾻の下へ置くか、隣に座っている⼈を観察してもよい。 質問：⾻盤の動きは、どこで起こっていましたか？励まして回答を促せ。 最も重要な答え： • ⾻盤より上（腰椎）で。 • ⾻盤下部（股関節）で。 説明： ⾞椅⼦ユーザーがニュートラルな座位姿勢で座れない場合、⾻盤より上あるいは⾻盤下部、どちら に制限（あるいは制約）があるせいなのか、⾒出す必要があります。 81 教習員⽤指導書 説明：こちらはその⼀例です： • この男性は、ずっこけた姿勢［slumped posture］ で座り、⾻盤が後傾しています。 • ⾒ただけでは、この姿勢が⾻盤より上か⾻盤下 部（股関節）か、どちらの制限（制約）によっ て起きているのか何とも⾔えません。そこで⾻ 盤と股関節の姿勢チェックが必要になります。 説明：中級⾞椅⼦事前評価フォームの、このパー トでの最初の質問事項は： • ⾻盤が⽔平になるか？ 質問：なぜこれを判ることが重要なのでしょう？ 最も重要な答え： • ⾻盤が⽔平にならなければ、座位姿勢に影響 するから。 説明：⾻盤が⽔平になるかどうかを評価した後、 ⾞椅⼦サービス職員は、股関節がニュートラルな 座位姿勢まで屈曲するかどうかを⾒極めます。 強調：この評価は、完全な関節可動域評価ではあ りません。股関節を屈曲位で評価するのみで、そ こで⾒出すことは： • ⾞椅⼦ユーザーは、⽀えがあればニュートラル な姿勢で座れるか？ • できなければ、ニュートラルな姿勢へどこまで 近づけて座れるか？ 説明：このスライドの線画は、⽚側（⾚線で⽰し た⽅の脚）の股関節がニュートラルな座位姿勢で ないことを表しています。 質問：体幹と⼤腿（⾚線）の間の⾓度は、90 度よ り⼤きいでしょうか⼩さいでしょうか？励まし て回答を促せ。 82 中級⾞椅⼦サービス教習パッケージ 答え： • 90 度より⼩さい。（約 70 度） 説明：このスライドの線画は、⽚側（⾚線で⽰し た⽅の脚）の股関節がニュートラルな座位姿勢で ないことを表しています。 質問：体幹と⼤腿（⾚線）の間の⾓度は、90 度よ り⼤きいでしょうか⼩さいでしょうか？励まし て回答を促せ。 答え： • 90 度より⼤きい。（約 100 度） 質問：なぜ股関節がニュートラルな座位姿勢まで屈曲するかどうか、判ることが重要なのでしょう か？ 励まして回答を促せ。 答え： • ⽚側あるいは両側の股関節がニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超の）場合、⾞椅⼦ユーザーがまっすぐに座る能⼒に⽀障を来たす。 • そうした股関節には［椅⼦の］形を合わせる必要があり、それによって⾞椅⼦ユーザーは、⾻ 盤を（可能であれば）まっすぐに起こして座れる。 83 教習員⽤指導書 • ⾻盤が⽔平にならないか、⽚側または両側の股 関節がニュートラルな座位姿勢まで屈曲しない （体幹〜⼤腿の⾓度が 90 度超の）場合、完成し た⾞椅⼦は、ニュートラルではない座位姿勢で ⽀える必要があります。 • 事前評価を続けるには、⾞椅⼦ユーザーが座れ るよう⼀時的⽀持部をつくる必要があります。 • これについては、授業の後半で説明します。 動画を紹介：「⾻盤と股関節の姿勢チェック」：この短い動画では、⾻盤と股関節 の姿勢チェックを視聴します。受講者へ、動画の後でお互いに練習してもらうの で、注意深く視聴するよう指⽰せよ。 動画を上映。 何か質問がないか尋ねよ。 ⼩グループ活動 グループ： 受講者を 3⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.3: ⾝体的事前評価−⾻盤と股関節の 姿勢チェック: 姿勢チェックの実施）を開くよう指⽰せよ。 受講者へ、交替で⾞椅⼦ユーザー、助⼿、⾞椅⼦サービス職員役になるよ う指⽰せよ。⾻盤と股関節の姿勢チェックを実施する練習をしなさい。 各受講者へ、グループの中で各⼈が⾞椅⼦ユーザー役を務めた時の結果を、 各⾃のワークブックの中級⾞椅⼦事前評価フォームの「⾻盤と股関節の姿 勢チェック」の箇所へ記録するよう指⽰せよ。 説明：受講者は、この活動にグループで 20 分使えます。それから全体に戻 っていっしょにフィードバックしてもらいます。 モニター： 各グループを注意深くモニターし、⾞椅⼦サービス職員役の⼈について以 下を確認せよ： • 正しい位置にいる。 • ⼿を⾞椅⼦ユーザーの⾻盤、股関節、⼿⾜に正しく置いている。 • ⾞椅⼦ユーザーの膝を（ロールクッション/⽀えを膝下に置いて）屈曲さ せている。 • ⼿を「優しく」使い⾞椅⼦ユーザーを握りしめるか、挟みつけていない。 （グループが正しい⼿順を踏んでいるか確かめるには、下記「教習員への 注記」の「⾻盤と股関節の姿勢チェックの実施」以下を活⽤せよ。） どのグループも活動を理解しているか確かめよ。 必要なら受講者を先導せよ。 84 中級⾞椅⼦サービス教習パッケージ 時間： 活動に 20 分取っておけ。 フィードバックに 5 分取っておけ。 フィードバック： だれか、何か質問がないか尋ねよ。 質問：何も制約がない⼈の場合、グループでは中級⾞椅⼦事前評価フォー ムの「⾻盤と股関節の姿勢チェック」の箇所はどう記録しましたか？（⽩ 紙の中級⾞椅⼦事前評価フォームをホワイトボードへ映せ）。 回答：⾻盤が⽔平の「はい」、左右の股関節の「はい」へ印を付ける。 質問：制約のある⼈はいましたか？いる場合は、そのグループへさらに情 報を求めよ。 教習員への注記：教習員は、事前評価の「⾻盤と股関節の姿勢チェック」の箇所を教えるために、 ゴニオメーターかボール紙製⾓度計の、どちらを使うか選べる。参加者がゴニオメーターを使い 慣れていれば、それを選択するのが最善。参加者がゴニオメーターを使ったことがなければ単純 なボール紙製⾓度計で、⾓度を 45 度刻みに⽬盛ったものを使えばじゅうぶんである。 教習員への注記：⾻盤と股関節の姿勢チェックの実施：上記の⼩グループ活動をモニターする際 には、受講者が⾻盤と股関節の姿勢チェックを、以下の解説通りに実施しているか確かめよ。 準備 • ⾞椅⼦ユーザーへ何をしようとしているのか、なぜそれが重要なのかを説明する。 • ⾞椅⼦ユーザーへ、評価ベッドへ仰向けに寝てもらう。 注意：⾻盤と股関節の姿勢チェックを実施する⼈を「評価者」、評価者を補助する⼈を「助⼿」と 呼ぶ。後者は同僚、教習を受けた助⼿、家族や介助者などが務めうる。 ⾻盤姿勢を調べる： • 評価者は⾞椅⼦ユーザーの両膝をわずかに屈曲させ、若 ⼲⽀える。これは股関節の緊張を和らげるのに役⽴つ。 • 助⼿は両⼿を⾞椅⼦ユーザーの体幹の下肋⾻周りにし っかり当てる。 • 評価者は両親指を ASIS の上に置きながら⾻盤を優しく 保持する。 • 評価者は両親指/ASIS が⽔平になっているか確認する。 • ⽔平でなければ、評価者は優しく、だがしっかりと左右 の ASIS が⽔平になるように⾻盤のアラインメントを整 えてみる。 • 助⼿は、体幹が動くのを感じたら報せる。それは動きに 制約があることを意味する。 • ⾻盤をどれだけニュートラル/⽔平近くまで持って⾏け るかに注⽬。 • 評価者は⾻盤が⽔平になるかどうかを中級⾞椅⼦事前 評価フォームに記録する。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 5556 Carrying out a pelvis and hip posture screen Prepare: rexplain to the wheelchair user what you are going to do and why it is important; rask the wheelchair user to lie down on their back on an assessment bed. (Note: in these instructions, the person carrying out a pelvis and hip posture screen is called the ‘assessor’ and the person who assists the assessors is called ‘assistant’, who could be a co-worker, trained assistant, family member or caregiver). Pelvis posture screen: rassessor bends both the wheelchair user’s knees slightly and provides some support, which helps to relieve tension on the hips; rassistant places their hands !rmly on the wheelchair user’s trunk, around their lower ribs; rassessor grips the pelvis gently with thumbs on the ASIS; rassessor checks if thumbs/ASIS are level; rif not level, assessor gently but !rmly tries to align the pelvis so that both ASIS are level; rassistant reports if he/she feels the trunk move, which means that there is some restriction to the movement; rnote how close to neutral/level it is possible to bring the pelvis; rassessor records if the pelvis can be level on the intermediate wheelchair assessment form. Hip posture screen: rassistant gently but !rmly holds the wheelchair user’s pelvis; rassessor bends the leg that is not being tested slightly at the knee, resting the foot on the mat. This helps to reduce the tension in the hip being tested. This leg may need to be supported. 85 教習員⽤指導書 股関節の姿勢を調べる： • 助⼿は優しく、だがしっかりと⾞椅⼦ユーザーの⾻盤を 保持する。 • 評価者は調べない⽅の脚の膝をわずかに屈曲させ、⾜を ベッドに置く。これは調べる⽅の股関節の緊張を緩める のによい。置いた⽅の脚に⽀えが必要な場合もある。 • 評価者は、調べる⽅の脚をニュートラルな座位姿勢に向 けて優しく動かす。 • 助⼿は、⾻盤が動くのを感じたら報せる。それは動きに 何らかの制限（制約）があることを意味する。 • 評価者は股関節がどれくらい⾃由に動けるか感じ取る。 • 評価者は、反対側も同じ⼿順で調べて⽐較する。 • 評価者は、左右の股関節がニュートラルな座位姿勢まで 屈曲するかどうかを中級⾞椅⼦事前評価フォームに記 録する。 • 評価者は、助⼿に⼿伝ってもらい、股関節がどこまでニ ュートラルな座位姿勢に近づけるか⾓度計を⽤いて記 録する。 • 評価者は、⾓度計の回転軸を股関節に当てる。評価者は ⾓度計の⽚⽅のアームを⼤腿⾻に沿わせ、もう⽚⽅のア ームを体幹に沿わせる。 • 評価者は⾓度計の両⽅のアームをしっかりと保持する。 • 評価者は、左右の股関節で測った⾓度を、中級⾞椅⼦事 前評価フォームに記録する。評価者は⾓度計の⾓度を別 紙あるいは中級⾞椅⼦事前評価フォームの裏に描き取 ってもよい。 3. 固まった⽔平でない（側傾した）⾻盤やニュートラルな座位姿勢まで屈曲しな い（体幹〜⼤腿の⾓度が 90 度超の）股関節への⼀時的⽀持（5 分） 説明：⾻盤が⽔平にならないか、⽚側あるいは両側の股関節がニュートラルな座位姿勢まで屈曲し ない（体幹〜⼤腿の⾓度が 90 度超の）場合、完成した⾞椅⼦でもニュートラルではない姿勢で⽀ える必要があります。事前評価を続けるには、⾞椅⼦ユーザーが座れるよう、⼀時的⽀持部をつく る必要があります。 質問：なぜ事前評価を続けるためには、⾞椅⼦ユーザーは⼀時的⽀持部に座る必要があるのでしょ うか？ WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 55 56 Carrying out a pelvis and hip posture screen Prepare: r explain to the wheelchair user what you are going to do and why it is important; r ask the wheelchair user to lie down on their back on an assessment bed. (Note: in these instructions, the person carrying out a pelvis and hip posture screen is called the ‘assessor’ and the person who assists the assessors is called ‘assistant’, who could be a co-worker, trained assistant, family member or caregiver). Pelvis posture screen: r assessor bends both the wheelchair user’s knees slightly and provides some support, which helps to relieve tension on the hips; r assistant places their hands !rmly on the wheelchair user’s trunk, around their lower ribs; r assessor grips the pelvis gently with thumbs on the ASIS; r assessor checks if thumbs/ASIS are level; r if not level, assessor gently but !rmly tries to align the pelvis so that both ASIS are level; r assistant reports if he/she feels the trunk move, which means that there is some restriction to the movement; r note how close to neutral/level it is possible to bring the pelvis; r assessor records if the pelvis can be level on the intermediate wheelchair assessment form. Hip posture screen: r assistant gently but !rmly holds the wheelchair user’s pelvis; r assessor bends the leg that is not being tested slightly at the knee, resting the foot on the mat. This helps to reduce the tension in the hip being tested. This leg may need to be supported. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 55 56 Hip posture screen: r assessor gently moves the leg being tested into the neutral sitting posture; r assistant reports if he/she feels the pelvis move, which means that there is some limit (restriction) to the movement; r assessor feels how freely the hip joint can move; r assessor repeats on the other side and compares; r assessor records if right and left hip can bend to neutral sitting posture on the intermediate wheelchair assessment form. r assessor records how close to neutral posture each hip can reach with a goniometer with the help of an assistant; r assessor places the pivot point of the goniometer on the hip joint. Assessor positions one arm of the goniometer along the thigh bone and one arm in line with the trunk; r assessor holds the two arms together !rmly; r assessor records right and left hip angle degree measurements on the intermediate wheelchair assessment form. Assessor can also draw the angle of the goniometer on a separate piece of paper or on the back of the intermediate wheelchair assessment form. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 55 56 Hip posture screen: r assessor g ntly moves the leg being tested into th neutral sitting posture; r assistant reports if he/she feels the pelvis move, which means that there is some limit (restriction) to the movement; r assessor feels how freely the hip joint can move; r assessor repeats on the other side and compares; r assessor records if right and left hip can bend to neutral sitting posture on the intermediate wheelchair assessment form. r assessor records how close to neutral posture each hip can reach with a goniometer with the help of an assistant; r assessor places the pivot point of the goniometer on the hip joint. Assessor positions one arm of the goniometer along the thigh bone and one arm in line with the trunk; r assessor holds the two arms together !rmly; r assessor records right and left hip angle degree measurements on the intermediate wheelchair assessment form. Assessor can also draw the angle of the goniometer on a separate piece of paper or on the back of the intermediate wheelchair assessment form. 86 中級⾞椅⼦サービス教習パッケージ 答え： • 事前評価での⼀時的⽀持は： o ⾞椅⼦ユーザーがより安定し、バランスよく座れるようにする。 o ⾞椅⼦ユーザーが、⽔平でない⾻盤やニュートラルな座位姿勢まで屈曲しない（体幹〜⼤ 腿の⾓度が 90 度超の）股関節を代償38しないようにする。 o ⾞椅⼦サービス職員が事前評価を続け、⾞椅⼦ユーザーの他の部位の姿勢、例えば⾻盤・ 体幹・頭・⾸・脚などへ集中できるようにする。 説明：⼀時的⽀持が必要になるのは以下のような 場合です： • 固まった⽔平でない（側傾した）⾻盤 • ニュートラルな座位姿勢まで屈曲しない（体幹 〜⼤腿の⾓度が 90 度超の）⽚側の股関節 • ニュートラルな座位姿勢まで屈曲しない（体幹 〜⼤腿の⾓度が 90 度未満39の）両側の股関節 • ニュートラルな座位姿勢まで伸展しない（体幹 〜⼤腿の⾓度が 90 度未満の）⽚側または両側の 股関節 事前評価後、この⼀時的⽀持部は恒久的なものを ⾞椅⼦ユーザーのクッションにつくり込みます。 説明： • ⼀時的⽀持部は、硬いウレタンフォームのブロックでつくれます。 • クッションの基層と同じ素材でつくるのが理想です。 • 同じ素材を⽤いることで、素材の圧縮度合いが等しいため、事前評価中に材料の正確な⼨法を決 められます。 • この理由から、事前評価には硬いウレタンフォームのブロックとウェッジ（くさび）を⽤意して おくと便利です。 • 厚みの違うもの（例えば 10 mm・20 mm・30 mm）があれば、積み重ねた合計でさまざまな厚 みのものがつくれます。 硬いウレタンフォームのブロックとウェッジ（くさび）の⾒本を⽰せ。 38 [原⽂] compensating 39 [訳注] 原⽂のまま. 内容や受講者⽤参考書 p.58 の記述からみて,「90度超」が適切であろう. 87 教習員⽤指導書 4. 固まった40⽔平でない⾻盤への⼀時的⽀持のデモ（10 分） ひとり希望者に、教室の前に出てきて、評価ベッドに座るよう求めよ。 デモ： 説明： • 希望者に、⽔平でないまま固 まった（側傾した）⾻盤の状態 で座ってもらう。 ⾻盤が、⽔平でないまま固まってい る⾞椅⼦ユーザーの場合： • ⽚側の⾻盤と⼤腿に反対側より も余計に体重がかかります。これ は褥瘡の危険を⽣じます。また⾞ 椅⼦ユーザーは、⽚側だけに座る ので安定しません。 • ⾼い側の座⾻を⽀えるように、座 ⾯を持ち上げることが⽬標です。 • この⼀時的⽀持部は、⾼い側の下 に積み増し41をつくります。 • この⼀時的⽀持部は、座⾻および ⼤腿の下になければなりません。 この⽀えで、⾻盤姿勢は変わりま せん。 • しかし、⾼い側の座⾻の下に⽀え があることで、⾞椅⼦ユーザー は、よりバランスが取れ、座⾻下 の圧⼒が左右で均等だと感じる でしょう。 • 希望者の、⾼い側の座⾻の下 に⼀時的⽀持部を置く。 • ⼀時的⽀持部の前⽅が、⼤腿 を⽀えるところ（膝のすぐ裏） まで延びていることを確かめ る。 • 座⾯上で、各々の座⾻の下に 指を（掌を上向きに）置き、圧 ⼒検査のデモを⾏なう。 • これは体幹を⽀えて⾝体配列（ア ラインメント）を整えた状態で、 各々の座⾻の下に指を（掌を上向 きに）置いて検査できます。 希望者に感謝を述べよ。 40 [訳注] 教材プレゼンテーションには, このスライドの直後に No.16 として前の授業 B.2 の No.8 と同じスライドが デモ実施中に映写すると便利なリマインダーとして収載されている (本書では省略). 41 [原⽂] a build-up 88 中級⾞椅⼦サービス教習パッケージ 説明： • これで⾞椅⼦サービス職員は、残る⾻盤および 体幹の姿勢を事前評価できます。 • 完成した⾞椅⼦には、この⽀えをクッションに つくり込みます。 ⼿元にあれば、固まった⽔平でない⾻盤を⽀える ために改造したクッションを⽰せ。 教習員への注記： • 固まった⽔平でない⾻盤に対して、⼀時的⽀持部はその姿勢に形を合わせるようにする。それ は姿勢を矯正するものではない。 • 最終製品でも、⾞椅⼦ユーザーは⾮対称な姿勢のままである。⽚側の⾻盤および⼤腿は、反対 側より⾼くなる。膝および⾜台も、同じ側が⾼くなる。 • 固まった⽔平でない⾻盤への⼀時的⽀持をつくる場合： o ⽀持部が、⼤腿の下いっぱいに延びていることを確かめよ。⽀えが前⽅まで延びていない と、両⼤腿の下の体重負荷が不均等になるおそれがある。 o 座⾻前⽅（アンカー）サポートが残っていることを確かめよ。これは、剪断［せんだん］ を引き起こして褥瘡につながる前滑りの傾向を抑えるのに役⽴つ。 5. ニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超の）股関 節への⼀時的⽀持のデモ（30 分） 説明：これから、完全にニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超の） 股関節への⼀時的⽀持について⾒て⾏きます。 ひとり希望者に、教室の前に出てきて、評価ベッドに座るよう求めよ。 デモ： 説明： • 希望者に、右側の股関節を、体幹 〜⼤腿の⾓度が 90 度より⼤きく なるように固定して座ってもら う。 • ⽚側の股関節が硬くニュート ラルまで曲がらない（体幹〜 ⼤腿の⾓度が 90 度超の）状態 で座ると⾻盤が横へ傾くか、 後ろに倒れるか回旋します。 • これは⾻盤や体幹の不良姿勢 や、座⾻下での不均等な体重 負荷を引き起こします。 89 教習員⽤指導書 • 希望者の、左右 の座⾻および左 （股関節がニュ ートラルな座位 姿勢まで屈曲す る側）⼤腿の下 に、⼀時的⽀持 部を置く。 • 左右の座⾻、およびニュート ラルな座位姿勢まで屈曲する ⽅の⼤腿の下に積み増ししま す。これで、ニュートラルより ⼤きい⾓度で固まった股関節 が据わります。 • 積み増しには、股関節の制約 の程度に応じて、じゅうぶん ⽀えられる⾼さが必要です。 • 右⼤腿と評価ベッドとの間にで きた三⾓形のすき間を⽰す。 • ⼤腿と評価ベッドとの間に、 三⾓形のすき間ができます。 • この⾓度は、股関節の姿勢チ ェックで記録したものと同じ でなければなりません。 • こうして硬い股関節に形が合 い、⾻盤姿勢はニュートラル にならない原因とはなりませ ん。⾞椅⼦サービス職員は、こ れで残る⾻盤および体幹の姿 勢を事前評価できます。 希望者に感謝を述べよ。 説明： • 完成した⾞椅⼦には、この⼀時的⽀持部をクッ ションにつくり込み恒久的な⽀えを施します。 • クッションには、事前評価で確定した体幹〜⼤ 腿の⾓度で⼤腿を⽀えるウェッジ（くさび）をつ くり込みます。イラストは、その出来上がりの⼀ 例です。注意事項：この硬いウレタンフォーム形 状の上に、柔らかいウレタンフォーム層を置き なさい。クッションに鋭いふちがないことを確 かめなさい。 ⼿元にあれば、改造したクッションを⽰せ。 90 中級⾞椅⼦サービス教習パッケージ 教習員への注記： • なぜ、ウェッジ（くさび）形の⽀えを⼀時的⽀持に⽤いないのか、訝しがる受講者もあろう。 説明：⾞椅⼦ユーザーが座っている⾯が平らで、他に形を合わせる⼿⽴てがなければ、股関節 に可動域制限がある側の⼤腿の下にウェッジ形を切り出して⽀える必要があるでしょう。もち ろん、評価ベッドに切り込みを⼊れるのは現実的ではありません。そこで⾞椅⼦ユーザーを座 ⾯から持ち上げ、硬い側の股関節に形を合わせ42るようにします。 • 時間と資材を節約するため、その［可動域制限がある］⼤腿の下にはすき間を残し、したがっ て⼀時的⽀持部は両座⾻および反対側の⼤腿の下にだけ⼊ります。その⼤腿は、⼀時的⽀持部 のすき間へ斜めに下がります。完成したクッションではその⼤腿の下のすき間を埋めるため、 その⼤腿の下にウェッジ形の⽀えがつくられます。 • 恒久的⽀持部は、⾮対称なクッションになります。つまり、⽚⽅の膝および⾜台が、反対側よ り低くなるということです。これは、不安定さと剪断［せんだん］をいくらか引き起こすため、 ⾻盤ベルトなど他の姿勢⽀持具も併せて検討すべきです。これについては、教習プログラムの 後半で説明します。 説明：ここで、股関節が左右ともニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超の）⾞椅⼦ユーザーへの⼀時的⽀持について考えてみましょう。 質問：股関節が左右ともニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度超の） 場合、どんな⼀時的⽀持を⽤いるのがよいでしょうか？ ⼀⼈または⼆⼈の希望者に、前に出てやってみせるよう励ませ。他の⼈も提案を与えて援けてよい。 受講者が正解へたどり着くようにせよ。 答え： 両股関節がニュートラルな座位姿勢まで屈曲しない（両側とも 90 度超の）場合の⼀時的⽀持： • 両股関節を制約がある分だけ⼀時的に⽀えるため、左右の座⾻下に積み増しを設ける。 • 積み増しには、股関節の制約の程度に応じて、じゅうぶん⽀えられる⾼さが必要。 • ⼤腿と評価ベッドとの間に、三⾓形のすき間ができるだろう。 • その⾓度は、ゴニオメーターで記録したものと同じでなければならない。 • これで事前評価を続けられる。 42 [原⽂] accommodate 91 教習員⽤指導書 説明： • 股関節が両側ともニュートラルな座位姿勢まで 屈曲しない（体幹〜⼤腿の⾓度が 90 度超の）場 合は、左右の座⾻下を積み増しして⼀時的に⽀え られます。 説明：完成した⾞椅⼦で、この［⼀時的な］⽀えは クッションにつくり込みません。［恒久的な］⽀え は、座⾯と背もたれの間の⾓を広げてつくります。 質問：なぜこの恒久的⽀持部は、他の⼀時的⽀持部 同様、クッションにつくり込まないのでしょうか？ • 答え： ⾞椅⼦ユーザーが、座⾯の外へ前滑りしがちにな るため。これは⾞椅⼦に座っているのを困難に し、剪断［せんだん］を引き起こし、褥瘡発⽣に つながる。 質問：⽚側または両側の股関節がニュートラルな座位姿勢まで伸展しない（体幹〜⼤腿の⾓度が 90 度未満の）場合、どんな⼀時的⽀持を⽤いるのがよいでしょうか？ ⼀⼈または⼆⼈の希望者に前に出てやってみせるよう励ませ。他の⼈も提案を与えて援けてよい。 受講者が正解にたどり着くようにせよ。 答え： ⽚側または両側の股関節がニュートラルな座位姿勢まで伸展しない（体幹〜⼤腿の⾓度が 90 度 未満の）場合の⼀時的⽀持： • 座⾻の前⽅かつ⼤腿の下に、⼀時的⽀持を設ける。 • 硬いウレタンフォームのウェッジ（くさび）が最良。 • これで事前評価を続けられる。 92 中級⾞椅⼦サービス教習パッケージ 説明： • ⽚側または両側の股関節がニュートラルな座位 姿勢まで伸展しない（体幹〜⼤腿の⾓度が 90 度 未満の）場合は、左右の座⾻の前⽅かつ⼤腿の下 に⼀時的⽀持を設けます。 • ⼿に⼊れば、硬いウレタンフォームのウェッジ （くさび）が使えます。 • ない場合は、⼀時的⽀持であれば、⻑⽅形の硬い ウレタンフォームでも⼤丈夫です。 説明： • スライドのイラストは、⾞椅⼦のクッションにつ くり込んだ様⼦を⽰しています。 ⼿元にあればこの改造を施したクッションを⽰せ。 教習員への注記： なぜ⽚側の股関節のみに［可動域の］制約がある場合も両⼤腿の下に⽀えを設けるのか、訝しが る受講者もあろう。 答え： • ウェッジ（くさび）を、たいてい両⼤腿の下に⼊れるのは、⾞椅⼦ユーザーを左右対称にする ためです。 • ただし、ウェッジを［可動域の］制約がある脚の下だけに置く⽅がよい場合もあります。例え ば、ウェッジの形状のせいで⾞椅⼦ユーザーの移乗が難しくなる場合です。 動画を紹介：「⼀時的⽀持」。この短い動画ではリチャードの例を紹介します。リ チャードの⾻盤は⽔平ですが、股関節が両側ともニュートラルな座位姿勢までは 屈曲しません（体幹〜⼤腿の⾓度が 90 度超です）。この動画では、⾞椅⼦サービ ス職員がリチャードと協⼒して⾻盤と股関節の姿勢チェックを実施し、それから ⼀時的⽀持を設けるところを視聴します。 動画を上映。 何か質問がないか尋ねよ。 93 教習員⽤指導書 6. ⼀時的⽀持の演習（30 分） ⼩グループ活動 グループ： 受講者を 2〜3⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.3: ⾝体的事前評価−⾻盤と股関節の 姿勢チェック: ⼀時的⽀持の演習）の、それぞれの⾞椅⼦ユーザーの例話 を読むよう指⽰せよ。 説明：それぞれの⾞椅⼦ユーザーについて、受講者は、その⼈の⾻盤が⽔ 平になるかどうか、また股関節がニュートラルな座位姿勢まで屈曲するか どうか、判断する必要があります。 受講者へ、中級⾞椅⼦事前評価フォームの「⾻盤と股関節の姿勢チェック」 の箇所を完成し、その⾞椅⼦ユーザーに⼀時的⽀持が必要かどうか判断す るよう指⽰せよ。 受講者へ、それぞれの⾞椅⼦ユーザーに形を合わせて⼀時的⽀持部を設定 するよう指⽰せよ。 受講者へ、それぞれの⼀時的⽀持部を確認するよう指⽰せよ。 各受講者は、⼀時的⽀持部に座ってどんな感じかをみて下さい。 説明：受講者は、この活動にグループで 20 分使えます。それから全体に戻 っていっしょにフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 必要なら受講者を先導せよ。 受講者が、⼀時的⽀持部を正しく設定していることを確かめよ。 時間： 活動に 20 分取っておけ。 フィードバックに 10 分取っておけ。 フィードバック： ⼀つのグループへ、サムへの⼀時的⽀持部の設定を詳述するよう指⽰せよ。 別のグループへ、マーサへの⼀時的⽀持部の設定を詳述するよう指⽰せよ。 別のグループへ、セレンへの⼀時的⽀持部の設定を詳述するよう指⽰せよ。 別のグループへ、ジョーへの⼀時的⽀持部の設定を詳述するよう指⽰せよ。 だれか、何か質問がないか尋ねよ。 94 中級⾞椅⼦サービス教習パッケージ サム ⾻盤と股関節の姿勢チェック サムは４歳。脳性⿇痺があり、⾃⼒ではま っすぐに座れない。⾻盤と股関節の姿勢 チェックから判ったことは： • サムの⾻盤は⽔平にでき（左右の ASIS が⽔平で）、 • サムの左股関節は、楽にニュートラル な座位姿勢まで屈曲する。サムの右股 関節は痛みがあるため、ニュートラル な座位姿勢までは屈曲しない（体幹〜 ⼤腿の⾓度が 90 度超）。体幹と右⼤腿 の間の⾓度は約 105 度。 ⾻盤が⽔平かどうか、および寝た姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい✔ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ✔ ⾓度：105 度 左股関節 はい✔ いいえ□ ⾓度：90 度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 サムには⼀時的⽀持が必要か？ はい✔ いいえ□ ⽀えは両側の座⾻と左⼤腿の下へフィットさせる。右⼤腿は、下に⽀えがなく斜めに据わる。 マーサ ⾻盤と股関節の姿勢チェック マーサは 57 歳。重い関節炎を患ってい る。何歩か歩けるが、歩くのがたいへん苦 痛である。⾻盤と股関節の姿勢チェック から判ったことは： • マーサの⾻盤は⽔平にでき（左右の ASISが⽔平で）、 • マーサは両股関節がニュートラルな座 位姿勢まで屈曲しない（体幹〜⼤腿の ⾓度が 90 度超）。体幹と⼤腿の間の⾓ 度は両股関節とも約 100 度。 ⾻盤が⽔平かどうか、および寝た姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい✔ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ✔ ⾓度：100 度 左股関節 はい□ いいえ✔ ⾓度：100 度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 マーサには⼀時的⽀持が必要か？ はい✔ いいえ□ ⽀えは両座⾻下のみにフィットさせる。両⼤腿は下に⽀えがなく、⼤腿は左右とも斜めに据わる。 セレン ⾻盤と股関節の姿勢チェック セレンは 16 歳。⼦どもの頃ポリオを患 い、両脚に重度の拘縮がある。セレンはあ ぐらをかいて床を膝⾏する。⾻盤と股関 節の姿勢チェックから判ったことは： • セレンの⾻盤は⽔平にならず、右側が 左側より 20 mm⾼い。 • セレンの両股関節は、ニュートラルな 座位姿勢まで屈曲する。 ⾻盤が⽔平かどうか、および寝た姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ✔ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい✔ いいえ□ ⾓度：90 度 左股関節 はい✔ いいえ□ ⾓度：90 度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 95 教習員⽤指導書 セレンには⼀時的⽀持が必要か？ はい✔ いいえ□ ⽀えは、⾻盤の右側と右⼤腿の下へフィットさせる。 ジョー ⾻盤と股関節の姿勢チェック ジョーは 25 歳。⼦どもの頃ポリオを患 い、両脚に重度の拘縮がある。⾻盤と股関 節の姿勢チェックから判ったことは： • ジョーの⾻盤は⽔平にでき（左右の ASISが⽔平で）、 • ジョーの右股関節は、楽にニュートラ ルな座位姿勢まで屈曲する。しかし左 股関節は、ニュートラルな座位姿勢ま では伸展しない（体幹〜⼤腿の⾓度が 90 度未満）。体幹と⼤腿の間の⾓度は 70 度。 ⾻盤が⽔平かどうか、および寝た姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい✔ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい✔ いいえ□ ⾓度：90 度 左股関節 はい□ いいえ✔ ⾓度：70 度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 ジョーには⼀時的⽀持が必要か？ はい✔ いいえ□ ウェッジ（くさび）形の⽀えを、ジョーの座⾻の前⽅かつ両⼤腿の下へフィットさせる。ウェッ ジの⾓度は約 70 度にする（ジョーが希望するか、両⼤腿の下にウェッジがあるとジョーの移乗 能⼒に差し⽀える場合は、ウェッジは左⼤腿の下のみでもよい）。 7. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 96 中級⾞椅⼦サービス教習パッケージ B.4: ⾝体的事前評価−ハンド・シミュレーション ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 以下を⾒出すための、⼿の使い⽅（ハンド・シミュレーション）を詳述する： • ⾞椅⼦ユーザーが、⽀えればニュートラルな姿勢で座れるかどうか。 • 座れなければ、⾞椅⼦ユーザーが、快適に、どこまでニュートラルに近く座れるか。 • どんな⽀えが、どこに必要か。 ¨ ハンド・シミュレーションからの所⾒を、中級⾞椅⼦事前評価フォームへ記録する。 教 材 この授業には： ¨ PPTスライド：B.4: ⾝体的事前評価−ハンド・シミュレーション ¨ 受講者⽤参考書 ¨ 動画：ハンド・シミュレーションのデモ：ディーパク ¨ 動画：ハンド・シミュレーションのデモ：エニス ¨ 動画：ハンド・シミュレーションのデモ：バハティ ¨ 中級⾞椅⼦事前評価フォーム 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ ⼀時的⽀持に⽤いるブロックは、⾞椅⼦ユーザーへの完成した⾞椅⼦に使う可能性が 最も⾼いクッション基層と、同じ素材でつくるべきである。これは、クッション基層 の調整に必要な⼨法が、より実際通りに得られる効果をもたらす。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 中級⾞椅⼦事前評価フォームを徹底的に復習し、ハンド・シミュレーションを実施す る練習をしておく。 あ ら す じ 1. はじめに 2. ハンド・シミュレーションのやり⽅ 3. ハンド・シミュレーションの結果を記録する 4. 要点のまとめ 5 15 35 5 授業時間計 60 97 教習員⽤指導書 1. はじめに（5 分） 説明： • この授業では、「ハンド・シミュレーション」と 呼ばれる、⾝体的事前評価の次の部分をどうや ってやり遂げるかを話し合います。 • ハンド・シミュレーションで、⾞椅⼦サービス職 員が⾃らの⼿を使って⾒出すことは： o ⾞椅⼦ユーザーは、⽀えればニュートラルな 姿勢で座れるか？ o 座れなければ、⾞椅⼦ユーザーは、快適に、 どこまでニュートラルな姿勢に近づけて座 れるか？ o どんな⽀えが、どこに必要か。 ハンド・シミュレーションでは、⾞椅⼦サービス職 員は⾞椅⼦ユーザー、および助⼿または家族/介助 者と協働し、⼿で⽀えを供します。 説明： • これは、中級⾞椅⼦事前評価フォームの、ハン ド・シミュレーションの結果を記録する欄です。 • ハンド・シミュレーション結果の記録について は、この授業の後半で詳しくお話しします。 2. ハンド・シミュレーションのやり⽅（15 分） 動画を紹介：「ハンド・シミュレーションのデモ：ディーパク」。これから視聴す る動画で、⾞椅⼦サービス職員はディーパクという若い男性にハンド・シミュレ ーションを実施します。ディーパクはまっすぐに座っていません。 受講者へ、評価者と助⼿が何をやっているか注意深く視聴するよう指⽰せよ。 動画を上映。 何か質問がないか尋ねよ。 98 中級⾞椅⼦サービス教習パッケージ 説明： • ⼤切なことは、⾃分の⼿が何をしているのか、注意深く考察することです。⾃分の⼿が設けた⽀ えを、後に⾞椅⼦や姿勢⽀持具が与えることになるのです。 • ハンド・シミュレーションの間、細⼼の注意を払 うべきことは： o ⼿をどこに置いているか43。 o ⼒/⽀えの⽅向。 o どれくらい強い⼒/⽀えを⽤いているか44。 o ⼿がどれくらいの広さの体表⾯を覆ってい るか45（例えば、使っているのは指⼀本だけ か、あるいは⼿全体か）。 • これらの情報は、最終的な⾞椅⼦および姿勢⽀ 持具の処⽅に役⽴ちます。 受講者へ質問：先ほど視聴した動画ですが、ディーパクの⾝体のうち、⾞椅⼦サービス職員が最初 に⽀えたのはどこですか？励まして回答を促せ。 答え： • ⾻盤。 説明： • つねに、最初に⾻盤を⽀えなさい。なぜなら⾻盤 姿勢は⾝体の残りの部分へ影響を及ぼすからで す。 • ⾞椅⼦ユーザーの⾻盤がニュートラルでない場 合は、⼿を使って⾻盤をニュートラルになる⽅ へ促しなさい。 43 [原⽂] where your hands are placed 44 [原⽂] how much force/support is being used 45 [原⽂] how much surface area your hands are covering 99 教習員⽤指導書 • ⾻盤を⽀えたら、⾝体の他の部分へ、以下の順序 で注意を集中して⾏きなさい： o 体幹/腕 o 頭と⾸ o 股関節と⼤腿 o 下腿 • いちどに変化を加えるのは、つねに⼀つずつにしなさい46。例えば、体幹の姿勢を⾻盤姿勢と同 時に変えようとしてはなりません。 • 助⼿といっしょに作業しなさい：家族/介助者が可能でしょう。 • ⾝体の⼀か所の変化が、他の部分へどう影響するか観察しなさい。 • ⾞椅⼦ユーザーへ、フィードバックをお願いしなさい。 • ⾻盤と体幹の輪郭を、横から観察しなさい。これは、最適な⽀えをもたらすために、背もたれが 取るべき形状を設計するうえで重要です。 3. ハンド・シミュレーションの結果を記録する（35 分） 説明：ハンド・シミュレーションの結果は、中級⾞ 椅⼦事前評価フォームへ記録します。そこの欄に： • ⾞椅⼦ユーザーが、⼿の⽀えでニュートラルな 座位姿勢になったかどうか、それぞれの⾝体部 位について印を付けて記録する。 • ⼿の⽀えで⾞椅⼦ユーザーがとれた最終的な座 位姿勢を、記述するか線画で描く。 • その座位姿勢がとれるように⾞椅⼦ユーザーへ 供した⽀えを、記述するか線画で描く。 46 [原⽂] Always make only one change at a time. 100 中級⾞椅⼦サービス教習パッケージ 動画を紹介：「ハンド・シミュレーションのデモ：エニス」。これから、別のハン ド・シミュレーションの動画を視聴します。 説明： • これからエニスについて、もう少し⾒て⾏きます。この動画で、エニスは⺟親 と事前評価に参加しています。事前評価インタビューでエニスと⺟親は、エニ スの右股関節が脱⾅して⾮常に痛く、どんな動作も痛みを伴うと説明します。 • ⾞椅⼦サービス職員は、エニスが⽀えなしではまっすぐに座れないことを⾒抜 きます。彼⼥は座ると⾻盤が後傾し、体幹が前弯し、脚が左へ「ウィンドスウ ェプト」になり［倒れ］ます。 • ⾻盤と股関節の姿勢チェックを実施します。エニスの⾻盤は⽔平で、股関節は 両側ともニュートラルな座位姿勢まで屈曲することが判りました。しかし、彼 ⼥の右股関節は内転して（正中線の⽅へウィンドスウェプトになり［倒れて］）、 この姿勢のまま固まっています（矯正できません）。 • 注意深く視聴して下さい。後ほど、ハンド・シミュレーションから⾞椅⼦サー ビス職員がさらにどんな情報を⾒出したのか話し合います。 動画を上映。 何か質問がないか尋ねよ。 質問：エニスの最初の姿勢はどうでしたか？ 答え： • ⾻盤が後傾のまま固まっている。 • ⾻盤は⽔平ではなく、右側がわずかに⾼い。 • 体幹が曲がって/ずっこけて/崩れている。 • 両肩は⽔平（エニスの⺟親は彼⼥の両肩を持って⽀えている。エニスの姿勢は、⺟親が⼿を放 すと変わるかもしれない）。 • 右股関節が内転している（左へウィンドスウェプトになって［倒れて］いる）。 • 右⼤腿が、左より短い。 質問：⾞椅⼦サービス職員が最初に、それから 2・３・４番⽬に⽀えたのはどこ（エニスの⾝体の どの部位）でしたか？ 答え： • 最初：⾻盤背⾯への⽀え。 • 2番⽬：体幹背⾯への⽀え。 • 3番⽬：体幹側⾯への⽀え。 • 4番⽬：腕への⽀え。 101 教習員⽤指導書 このスライドを（あれば）ホワイトボードへ映せ。 説明：エニスについて、中級⾞椅⼦事前評価フォー ムのハンド・シミュレーションの部分を、いっしょ に完成して⾏きましょう。 （⾝体の各部位について）⼿の⽀えで、エニスがニ ュートラルな座位姿勢をとれたかどうか尋ねよ。 正答ごとに「はい」［か「いいえ」］に印を付けよ。 質問：エニスの最終的な姿勢を、どう表わせばよいでしょうか？ ホワイトボード上の中級⾞椅⼦事前評価フォームの該当欄へ、エニスの姿勢の詳細を書け/描け。 ホワイトボードがなければ、受講者へ、教習員がボードに説明を書く/描画するに従い、それを各 ⾃で写すよう指⽰せよ。 教習員への注記：この演習では受講者をよび、前に出てエニスの最終的な姿勢をホワイトボード へ描いてもらってもよい。 答え： ハンド・シミュレーション：ニュートラルな姿勢で/快適な限りでニュートラルな姿勢にできる だけ近づけて、座るために必要な⽀え 各⾝体部位が、⼿の⽀えでニュートラルな座位姿勢になれば「はい」、ならなければ「いいえ」に印。 部位 はい いいえ ⼿の⽀えで、⾞椅⼦ユーザーがとれた最終的な座位姿勢を記述するか 線画で描き、なおかつ、その座位姿勢がとれるように設けた⽀えを記 述するか線画で描く。 姿勢： • ⾻盤が後傾。 • 体幹〜⼤腿の⾓度が 90度超。 • 下背部が平ら（腰椎のカーブがない）で傾いている（まっすぐに起 きない）。 • 体幹上部はまっすぐに起きる。 • 頭は（腕を⽀えれば）まっすぐに起きる。 • 右脚が正中線の⽅へ内転（ウィンドスウェプト）。 注記：エニスの右⼤腿は、左⼤腿より短い。 設けた⽀え： • エニスの⾻盤背⾯へのしっかりした⽀え。 • エニスの体幹背⾯への⽀え。 • 体幹側⾯への軽い⽀え。 • （エニスの両腕を前に置いて）腕へ⽀えを供する。 ⾻盤 □ ✔ 体幹 □ ✔ 頭 ✔ □ 左股関節 ✔ □ 右股関節 ✔ □ ⼤腿 □ ✔ 左膝 ✔ □ 右膝 ✔ □ 左⾜⾸ ✔ □ 右⾜⾸ ✔ □ 102 中級⾞椅⼦サービス教習パッケージ 教習員への注記：エニスの右⼤腿へ、ニュートラルな座位姿勢へ持って⾏くための⽀えを供す る必要があるかどうか尋ねる受講者もあろう。事前評価がもたらす情報では、エニスは股関節 に（あらゆる動きや矯正に対して）痛みがあり、このことは、⽀えは（設けるにしても）なる べく最⼩にすべきだ、ということを⽰している。 動画を紹介：「ハンド・シミュレーションのデモ：バハティ」。これから、別のハ ンド・シミュレーションの動画を視聴します。 説明： • バハティは、地元のカレッジで経営学を勉強しています。 • 彼⼥の古い⾞椅⼦はぼろぼろで、うまく姿勢を⽀えてくれません。 • 事前評価インタビューでバハティは、⾞椅⼦に⼀⽇中座ると、とても疲れるこ とを説明しました。彼⼥のゴールは、もっと快適に⻑時間座れる⾞椅⼦を持つ ことで、それによって疲れが減り、学業もはかどります。 • 注意深く視聴して下さい。後ほど、ハンド・シミュレーションを通して⾞椅⼦ サービス職員が何を⾒抜いたのか話し合います。 動画を上映。 何か質問がないか尋ねよ。 質問：バハティの最初の姿勢はどうでしたか？ 答え： • ずっこけた座位姿勢 • ⾻盤が後傾。 • 体幹が曲がっている。 • 右股関節はニュートラルな座位姿勢より屈曲が⼤きく、⼤腿が外転している。 • 左股関節はニュートラルな座位姿勢より屈曲が⼩さく、⼤腿が外転している。 質問：⾞椅⼦サービス職員が最初に、それから 2・３番⽬に⽀えたのはどこ（バハティの体のどの 部位）でしたか？ 答え： • 最初：⾻盤背⾯への⽀え。 • 2番⽬：体幹下部の背⾯への⽀え。 • 3番⽬：腕への⽀え。 103 教習員⽤指導書 このスライドを（あれば）ホワイトボードへ映せ。 説明：エニスと同じく、バハティについても、中級 ⾞椅⼦事前評価フォームのハンド・シミュレーシ ョンの部分を、いっしょに完成して⾏きましょう。 （各⾝体部位について）⼿の⽀えで、バハティがニュートラルな座位姿勢をとれたかどうか尋ねよ。 正答ごとに「はい」［か「いいえ」］に印を付けよ。 質問：バハティの最終的な姿勢を、どう表わせばよいでしょうか？ ホワイトボード上の中級⾞椅⼦事前評価フォームの該当欄へ、バハティの姿勢の詳細を書け/描け。 質問：中級⾞椅⼦事前評価フォームのこの部分を完成するに当たり、何か質問がある⼈はいます か？どんな質問にも答えよ。 ホワイトボードがなければ、受講者へ、教習員がボードに説明を書く/描画するに従い、それを各 ⾃で写すよう指⽰せよ。 教習員への注記：この演習では受講者をよび、前に出てバハティの最終的な姿勢をホワイトボー ドに描いてもらってもよい。 答え： ハンド・シミュレーション：ニュートラルな姿勢で/快適な限りでニュートラルな姿勢にできる だけ近づけて、座るために必要な⽀え 各⾝体部位が、⼿の⽀えでニュートラルな座位姿勢になれば「はい」、ならなければ「いいえ」に印。 部位 はい いいえ ⼿の⽀えで、⾞椅⼦ユーザーがとれた最終的な座位姿勢を記述するか 線画で描き、なおかつ、その座位姿勢がとれるように設けた⽀えを記 述するか線画で描く。 姿勢： • ⾻盤はまっすぐに起き⽔平。 • 体幹はまっすぐに起きる。 設けた⽀え： • ⾻盤背⾯へのしっかりした⽀え。 • 体幹下部への⽀え。 • 腕を⽀えて、バハティの体幹上部の安定を保つ。 ⾻盤 ✔ □ 体幹 ✔ □ 頭 ✔ □ 左股関節 ✔ □ 右股関節 ✔ □ ⼤腿 ✔ □ 左膝 ✔ □ 右膝 ✔ □ 左⾜⾸ ✔ □ 右⾜⾸ ✔ □ 104 中級⾞椅⼦サービス教習パッケージ 教習員への注記：バハティには、⾻盤と体幹下部の背⾯をしっかりと⽀え、まっすぐな座位姿勢 を保てるようにする必要がある。彼⼥の体幹上部の安定は完全ではなく、前へ動きがちである。 腕を⽀えれば、体幹上部は安定する。 4. 要点のまとめ（5 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 B.5: ⾝体的事前評価−⾝体計測 ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ ⾝体計測の⽬的を説明する。 ¨ 姿勢⽀持具（PSDs）の適切なサイズと配置の選択に必要な、⼨法選びをやってみせる。 ¨ ⾝体計測をやってみせる。 ¨ 中級⾞椅⼦事前評価フォームを⽤いて、⾝体⼨法を記録する。 教 材 この授業には： ¨ PPTスライド：B.5: ⾝体的事前評価−⾝体計測 ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 中級⾞椅⼦事前評価フォーム ¨ 巻尺（または⼿に⼊り、いっぱんに使われていればノギス）：各グループに 1本 ¨ 評価ベッド：各グループに 1 台 105 教習員⽤指導書 事 前 学 習 と 状 況 事前学習： ¨ 「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」で講じる「⾝体計測の取り扱い」 （座位臀幅、座底⻑、座位下腿⻑、座⾯〜胸郭下端47［の⾼さ］または座⾯〜肩甲⾻下 端48［の⾼さ］） この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 希望者を相⼿に⾝体計測をやってみせる、また受講者へお互いに⾝体計測を練習する よう指⽰する際の、触ることにまつわる⽂化的問題に気を付ける。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、授業計画を読み通す。 ¨ 中級⾞椅⼦事前評価フォームを徹底的に復習し、⾝体計測の練習をしておく。 ¨ 教室前⽅に、評価ベッドを 1 台置いておく。 ¨ 教室を、部屋の前⽅を囲んで受講者が半円形に座れるように配置しておく。 ¨ 評価ベッドを、教室内（あるいは室外/隣室）にぐるっと配置する。 あ ら す じ 1. はじめに 2. 適切な⾞椅⼦サイズと姿勢⽀持具の配置を選ぶための⾞椅⼦ユーザーへの⾝ 体計測 3. ⾝体計測の演習 4. 要点のまとめ 2 25 30 3 授業時間計 60 1. はじめに（2 分） 説明：この授業では、最適な⾞椅⼦のサイズおよび 姿勢⽀持具（Postural Support Devices, PSDs）を 選択するための、⾞椅⼦ユーザーへの⾝体計測のや り⽅について話し合います。 47 [原⽂] bottom of ribcage. [訳注] 付録の⾝体計測表での名称, seat to bottom of ribcage に合わせて訳出した. 48 [原⽂] bottom of shoulder blade. [⽤語集] 座位肩甲⾻下⾓⾼. [訳注] 上に合わせる形で訳出した. 106 中級⾞椅⼦サービス教習パッケージ 2. 適切な⾞椅⼦サイズと姿勢⽀持具の配置を選ぶための⾞椅⼦ユーザーへの⾝体 計測（25 分） 教習員への注記：ここで教える⾝体⼨法のうち最初の 5 つは、「基礎⾞椅⼦サービス教習パッケ ージ（WSTPb）」で教わるものである。受講者はすでに、それらの⾝体⼨法は⾃信をもって精確 に測れるはずである。そうでない場合、教習員は、基礎レベルで教わった⾝体計測が⾃信をもっ て精確にやれない受講者すべてに対し、基礎⾞椅⼦サービス教習パッケージの「⾝体的事前評価」 の授業、特に「⾝体計測の取り扱い」に重点を置いて実施すべきである。 受講者へ、各⾃の中級⾞椅⼦事前評価フォームの「⾝体計測」の箇所を⾒るよう指⽰せよ。 説明： • 中級⾞椅⼦事前評価フォームには、12か所の⾝ 体⼨法を列記しています。 • ⼨法のうち 5 つは、先に「基礎⾞椅⼦サービス 教習パッケージ（WSTPb）」で紹介した⼨法と同 じです。 • 中級⾞椅⼦事前評価フォームでは背もたれ⾼の⼨法を１つ追加しています。それは座⾯〜肩上端 ［の⾼さ］の⾝体⼨法で、⾼い背もたれが適する⾞椅⼦ユーザーを測るために⽤います。 • 他の追加した⼨法６か所は、姿勢⽀持具のサイズおよび/または位置を決めるためのものです。 • 姿勢⽀持具の処⽅によっては、さらに⼨法が必要になることもあります。 • 中級⾞椅⼦事前評価フォームには、「その他」の⼨法の記録欄を設けています。 説明：中級⾞椅⼦事前評価フォームのこのイラス トは、それぞれの⾝体⼨法が、⾞椅⼦/姿勢⽀持具 にどう関連するのかを⽰しています。 質問：例えば「⼨法G: 体幹幅49」はどう⾞椅⼦に 関係する（これはどの⾞椅⼦部材の配置に役⽴つ） でしょうか？励まして回答を促せ。 • 答え： • 体幹側⽅のパッドまたはウェッジ（くさび） どうしの間隔。 49 [原⽂] trunk width, [ISO 7250-1:2017] chest breadth. ⽇本語では胸部横径, 胸部幅などに相当. 107 教習員⽤指導書 中級⾞椅⼦事前評価フォームの「⾝体計測」の箇所 が、以下のようになっていることを指摘せよ： • ⾝体⼨法を左側に列記し、各⾝体⼨法が関連す る⾞椅⼦部材⼨法を右側に列記します。 • ⾞椅⼦部材⼨法を導く公式を載せたものもあります。例えば、座底⻑50（⾻盤背⾯〜膝裏） 引く 30〜50 mm が、⾞椅⼦の座⾯奥⾏き51に 等しく なります。 説明： • ⾞椅⼦部材⼨法を導く公式がある⾝体⼨法については、⾝体計測実施の間に理想的な⾞椅⼦部材 ⼨法を求めておくと便利です。 • これは、後で⾞椅⼦ユーザーへの処⽅を準備する際に役⽴ちます。 • そうした⾝体⼨法としては： o ⼨法B（座底⻑）、 o ⼨法 H（座⾯〜腋下52［の⾼さ］）、 o ⼨法 L（⾻盤背⾯〜座⾻53［の距離］）があります。 ひとり希望者に、教室の前に出てきて、評価ベッドにまっすぐな姿勢で座るよう求めよ。 下記の教習員への注記を⼿引きに、それぞれの⾝体計測のやり⽅を簡潔にやってみせよ。すべての 受講者から、はっきり⾒えているか確かめよ。 教習員への注記：下記の要点を必ず強調せよ： • ⾝体計測でいう「座⾯54」とは、座⾻が据わる表⾯である。 • 計測するのは必ず、⾞椅⼦ユーザーが起きて座り、ハンド・シミュレーションを通して本⼈に とっていちばんまっすぐで、快適で、機能的だと確定した姿勢である。 • まっすぐに座るのが難しい⼈を計測する場合は、補助が必要なこともある。 • あらゆる垂直⽅向の⼨法（C, D, E, F, H, I, K）について、座⾯やクッションの⾼さのどんな変 更も、それらと関係する部材の配置に影響を及ぼす。 • あらゆる⾞椅⼦部材のぴったりな位置は、必ずフィッティングで確かめる。 50 [原⽂] seat depth, [ISO 7250-1:2017] buttock-popliteal length, [JIS Z8500:2002] 座位臀-膝窩距離 51 [原⽂] wheelchair seat depth, [ISO 7176-26:2007] seat depth, [JIS T9201:2016][⽤語集] シート奥⾏ 52 [原⽂] seat to axilla, [ISO 16840-1:2006] axilla height, [⽤語集] 座位腋下⾼ 53 [原⽂] back of pelvis to seat bones 54 [原⽂] ʻseatʼ 108 中級⾞椅⼦サービス教習パッケージ 測り⽅： ⾞椅⼦部材： 注記： A: 座位臀幅55 座幅56 測る前に、⾞椅⼦ユーザーのポケット が空なのを確認する。⾞椅⼦ユーザー の臀部または⼤腿の、いちばん幅広い ところを測る。 クリップボードを 2 枚、⾞椅⼦ユーザ ーの両側に当てておくと、精確に測れ る。ノギスを⽤いてもよい。 座位臀幅は、座幅あるい は⾻盤側⽅パッドの間 隔に等しくなる。 ⾻盤側⽅パッドを設ける場 合、⾞椅⼦の座幅は、より広く 取る必要がある。 ⾞椅⼦の幅は最⼩に保つよう にせよ。 厚着することもある寒冷地で は多少ゆとりが必要。 B: 座底⻑57 座⾯奥⾏き58 クリップボードを⾞椅⼦ユーザーの背 中に当てておくと、精確に測れる。⾞ 椅⼦ユーザーの、⾻盤背⾯から膝裏ま での直線距離を測る。 つねに両脚を測る。 左右差がある場合は、⾞椅⼦ユーザー が⾻盤を⽔平にしてまっすぐに座って いるか確かめる。それでも差があれば、 短い側に合わせて⾞椅⼦を処⽅。 座底⻑ 引く 30〜50 mm が、⾞椅⼦の座⾯ 奥⾏きに等しくなる。 膝が 90 度よりかなり鋭⾓に 曲がっている⾞椅⼦ユーザー の場合、座⾯奥⾏きはやや短 く取る必要がある。 受講者⽤参考書 p.67 コラム 「⾻盤が後傾したまま固まっ た、あるいは体幹が前屈した まま固まった⾞椅⼦ユーザー に対して」を参照。 C: 座位下腿⻑59 ⾜台〜座⾯⾼60 ⾞椅⼦ユーザーの膝裏からかかとの底 までを測る。⾞椅⼦ユーザーの⾜⾸が （可能ならば）90 度に屈曲しているの を確かめる。 つねに両脚を測る。⾞椅⼦ユーザーが 靴を履く場合は、ふだん履きの靴を履 いて測る。 ⾜が尖⾜（下向き）で固まっている場 合は、つま先までを測る。 座位下腿⻑は、⾜台〜ク ッション上端 または ⾜でこぐ⾞椅⼦ユーザ ーの場合は、床⾯〜クッ ション上端に等しくな る。 ⾜台のぴったりな位置は、⾞ 椅⼦ユーザーが座って、クッ ションがどれくらい圧縮する かによって変わる。 フィッティングでの最終調整 が、つねに必要。 55 [原⽂] hip width, [ISO 7250-1:2017] hip breadth, sitting, [JIS Z8500:2002][⽤語集] 座位臀幅 56 [原⽂] seat width, [ISO 7176-26:2007] seat width, [JIS T9201:2016][⽤語集] シート幅 57 [原⽂] seat depth, [ISO 7250-1:2017] buttock-popliteal length, [JIS Z8500:2002] 座位臀-膝窩距離 58 [原⽂] wheelchair seat depth, [ISO 7176-26:2007] seat depth, [JIS T9201:2016][⽤語集] シート奥⾏ 59 [原⽂] calf length, [ISO 7250-1:2017] popliteal height, sitting, [JIS Z8500:2002] 座位膝窩⾼ 60 [原⽂] footrests height, [ISO 7176-26:2007] foot support to seat, [JIS T9201:2016][⽤語集] フットサポート・シ ート間距離. 「⾜台⾼」は床から⾜台までの⾼さを指すことが多いため, 訳語では区別した. 109 教習員⽤指導書 測り⽅： ⾞椅⼦部材： 注記： D, E, F 背もたれ⾼61 D: 座⾯〜胸郭下端［の⾼さ］： ⾞椅⼦ユーザーの座⾯から胸郭下端ま でを測る。 胸郭下端を⾒つけるには、両⼿を⾻盤 の両側へ当てるとよい。両⼿を内側へ 軽く絞り込みながら上へ滑らせる。胸 郭下端は腰のすぐ上である。 ⼨法D, E, Fは、背もた れ⾼を決めるためのも のである。 背もたれ⾼は、⾞椅⼦ユ ーザーのニーズによっ て変わる。 事前評価からの情報は、 ⾞椅⼦サービス職員が、 ⾞椅⼦ユーザーを適切 に⽀えるには、どれくら いの⾼さの背もたれが 必要か決める⽬安とな る。 背もたれのリクライニングや ティルトインスペース［背座 のティルト］が必要な場合、最 低で標準（⾞椅⼦ユーザーの 肩甲⾻下端まで）の背もたれ ⾼が必要。 ⾞椅⼦ユーザーが⾞椅⼦を⾃ 分でこぐかどうか、忘れずに 検討せよ。その場合、肩甲⾻を ⾃由に動かせることが必要。 E: 座⾯〜肩甲⾻下端［の⾼さ］： ⾞椅⼦ユーザーの座⾯から肩甲⾻下端 までを垂直に測る。 ⾞椅⼦ユーザーに肩をすくめてもらう と、肩甲⾻下端を⾒つけやすい。 F: 座⾯〜肩上端62［の⾼さ］： ⾞椅⼦ユーザーの座⾯から肩の上端ま でを測る。 G: 体幹幅 体幹側⽅パッドあるい はウェッジの間隔 ⾞椅⼦ユーザーの体幹幅を、腋下（わ きの下）のすぐ下で測る。 体幹幅が、体幹側⽅パッ ドあるいはウェッジ（く さび）の間隔。 体幹側⽅パッドやウェッジの 最終位置は、腋下より下に取 り付ける場合、フィッティン グの間に変わることもある。 H: 座⾯〜腋下（わきの下）［の⾼さ］ 体幹側⽅パッドあるい はウェッジの⾼さ 座⾯から腋下（わきの下）までを測る。 座⾯〜腋下 引く 30 mmが、クッション上端 と体幹側⽅パッド/ウェ ッジ上端の最⼤間隔。 この採⼨は⽬安である。最終 的な⾼さは、事前評価とフィ ッティングによって変わる。 体幹側⽅パッドは、腋下（わき の下）を圧迫するほど⾼くし てはならない。これは不快な うえ神経に永久的損傷を引き 起こしうる。つねに最低 30 mm のすき間を体幹側⽅パッ ドと腋下の間に設けること。 61 [原⽂] backrest height, [ISO 7250-1:2017] back support height, [JIS Z8500:2002][⽤語集] バックサポート⾼ 62 [原⽂] seat to top of shoulder, [ISO 7250-1:2017] shoulder height, sitting, [JIS Z8500:2002][⽤語集] 座位肩峰⾼ 110 中級⾞椅⼦サービス教習パッケージ 参考書 p.69 コラム「側弯があ る⾞椅⼦ユーザーへの体幹側 ⽅⽀持部の計測」を参照。 測り⽅： ⾞椅⼦部材： 注記： I: 座⾯〜⾻盤上端（PSIS）63［の⾼さ］ ⾻盤後⽅パッド64（中央 の⾼さ） 座⾯から⾻盤上端（上後腸⾻棘、PSIS） までを測る。 座⾯〜⾻盤上端（PSIS） の⾼さは、⾻盤後⽅パッ ド中央の⾼さを決める のに⽤いる。 ⾻盤後⽅パッドの奥⾏き（厚 み）は、事前評価の結果しだい で変わる。 J: 膝間距離65 膝分離パッド 両膝の間隔を測る：両膝を、⾞椅⼦ユ ーザーが快適な限りで、なるべくニュ ートラルへ近づけた位置で。 膝間距離は、膝分離パッ ドの幅に等しくなる。 この間隔は、⾞椅⼦ユー ザーの座位姿勢によっ て変わる。 K: 座⾯〜頭蓋⾻底部66［の⾼さ］ ヘッドレスト⾼ 座⾯から頭蓋⾻底部までを測る。 座⾯から頭蓋⾻底部ま での⼨法は、ヘッドレス トの位置決めに⽤いる。 L: ⾻盤背⾯〜座⾻67［の距離］ 座⾻前⽅（アンカー）サ ポート68 ⾻盤背⾯から座⾻までを測る。 ⾞椅⼦ユーザーの横から⼿を（掌を上 にして）⾞椅⼦ユーザーの臀部の下に 置き、座⾻を探す。指の⼀本を座⾻に 当て、それから椅⼦ユーザーの真横へ ⼿を引き出す。⾞椅⼦ユーザーの⾻盤 背⾯から座⾻へ置いた指までの距離を 測る。 ⾻盤背⾯から座⾻まで の距離 ⾜す 20〜40 mmが、背もたれの⽀持 部から座⾻前⽅（アンカ ー）サポートの始点まで の距離。 ⾞椅⼦ユーザーが⾻盤後傾で 固まっているか体幹が前屈し て固まっている場合、計測法 は違ってくる（受講者⽤参考 書 p.67 コラム「⾻盤後傾で固 まっている、あるいは体幹が 前屈して固まっている⾞椅⼦ ユーザーに対して」を参照）。 63 [原⽂] seat to the top of the pelvis (PSIS) 64 [原⽂] rear pelvis pad 65 [原⽂] distance between the knees 66 [原⽂] seat to base of skull 67 [原⽂] back of pelvis to seat bones 68 [原⽂] pre seat bone shelf, [ISO 7176-26:2007] anti-thrust seat, [⽤語集] 座⾻前⽅サポート. [訳注] 原⽂の意味 は「座⾻前⽅の棚状段差」. 「アンカーサポート」と呼ばれることが⾮常に多いため訳語では折衷. 111 教習員⽤指導書 ⾞椅⼦サービス職員は、⾞椅⼦ユーザ ーの脇へ、左右の座⾻を通る直線を何 らかの⽅法（例えばチョーク）で評価 ベッド上に印し、その印から⾻盤背⾯ までを測ってもよい。 希望者に感謝を述べよ。 質問：受講者は怖がる、または⾝をよじらせる⼦どもを測ろうとする場合、どう対処しますか？ 答え： • 可能ならば、⼦どもが落ち着くまで時間を取る。 • ⼦どもを休憩させ、しばらく休んだ/何か⾷べたり飲んだりした後で再開する。 • 家族/介助者に、⼦どもを保護して安⼼させてもらう。 • ⼩さい⼦どもであれば、家族/介助者の膝の上に乗せて測れる。ただし、⾞椅⼦サービス職員 は、⼦どもがハンド・シミュレーションで⾒出したのと同じ「最終的な」姿勢になるよう、よ く気を付けねばならない。 3. ⾝体計測の演習（30 分） ⼩グループ活動 グループ： 全受講者を 3 グループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.5: ⾝体的事前評価−⾝体計測）の、 マダヴィの例話を読むよう指⽰せよ。巻尺（および⼿に⼊り、いっぱんに使 われていればノギス）を各グループへ 1個ずつ割り当てよ。 説明：受講者は、次のことを⾏なって下さい： • マダヴィの、完成したハンド・シミュレーションの結果を読みなさい。 • マダヴィへ⾞椅⼦を選べるには、どの⾝体計測が必要か判断しなさい。 • それらの計測をグループの最低 1 ⼈に⾏ない、各⾃のワークブックの中 級⾞椅⼦事前評価フォーム「⾝体計測」の箇所へ記⼊しなさい。 説明： • マダヴィには、軽度の固まった⾻盤後傾があります。受講者は、どうやっ たらマダヴィの座底⻑を適切に測れるか考える必要があります。 • マダヴィはテーブルを欲しがっているため、受講者は、テーブルを⽤意 できるためには、どの⼨法を測る必要があるかも考えねばなりません。 説明：受講者には、この活動を 20 分で完結し、それから全体に戻っていっ しょにフィードバックしてもらいます。 112 中級⾞椅⼦サービス教習パッケージ モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 必要に応じて、計測技法を訂正せよ。 必要なら受講者を先導せよ。 教習員への注記：受講者を、必要だと思われる⼨法が何か、⾒つけ出すこと に集中させよ。この段階では、さまざまな姿勢⽀持の解決策について、あま り細かく考えるべきではない。それは次の授業で取り上げる。 時間： 活動に 20 分取っておけ。 フィードバックに 10 分取っておけ。 フィードバック： 質問：受講者は、どの⼨法が必要か意⾒は⼀致しましたか？ 答え：⼨法 A, B, C, F G, H, I, J, Lです。 質問：受講者は、どうやったら座底⻑を適切に測れるでしょうか？励まして 回答を促し、少し話し合わせよ。要点を明⽰するためスライドを映せ。 説明：⾞椅⼦ユーザーが、⾻ 盤が後傾したまま固まって いるか、体幹が前屈したまま 固まっている場合、⾞椅⼦サ ービス職員は、これにどう⾞ 椅⼦の形を合わせるか考え る必要があります。そのため 座底⻑の測り⽅を変えるこ ともあります。 • 背もたれをリクライニン グして⾻盤/体幹に形を合 わせ69られる場合は、前述 の通り⾻盤背⾯から膝裏 の直線距離を測ります。 • 背もたれがリクライニン グしない場合は、座⾯奥の スペースに⽀持部を設け て⾻盤/体幹に形を合わせ ます。⾝体（体幹/⾻盤）の 後端から測り、スライドの 通り座⾯奥⾏きをじゅう ぶん取れるようにします。 69 [原⽂] accommodate 113 教習員⽤指導書 質問：受講者は、マダヴィのテーブルの⾼さおよびサイズ/形状を表⽰する には、どの⼨法を測りますか？励まして回答を促し、少し話し合わせよ。要 点をはっきり⽰すため、スライドを映せ。 説明： 理想的なテーブル⾼さを決め るに測るのはひじの⾼さで： • 座⾯上端から肩の⼒を抜 き直⾓に曲げたひじまで、 あるいは、 • ハンド・シミュレーション で⾒極めた、必要な⽀えに 合わせます（例えば、より 腕を⽀える少し⾼めのテ ーブルが役⽴つ⼈）。 テーブルを、どこまでマダヴ ィの体幹近くに置くか決める には、 • マダヴィの、体幹の奥⾏き （前後）を測ります。 テーブルでマダヴィの体幹を （スライドのイラストのよう に）取り巻く場合は： • （⾞椅⼦事前評価フォー ムの⾝体計測表の）体幹幅 を測ります。 4. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 114 中級⾞椅⼦サービス教習パッケージ B.6: ⾞椅⼦およびクッションの選択 ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 現地で⼿に⼊る⾞椅⼦およびクッションの、特⾊および調節可能性を詳述する。 ¨ 標準型⾞椅⼦の、付加姿勢⽀持を設けられるようにする便利な特⾊を列挙する。 教 材 この授業には： ¨ PPTスライド：B.6: ⾞椅⼦およびクッションの選択 ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 中級⾞椅⼦処⽅（選択）フォーム ¨ 現地で⼿に⼊る⾞椅⼦およびクッション：各種 1つずつ ¨ 供給者から得た、⾞椅⼦に関する⽂書情報（例えば、⾞椅⼦のカタログ/仕様書） ¨ 現地で⼿に⼊る各⾞椅⼦に関する、記⼊済みおよび⽩紙の中級⾞椅⼦概要フォーム 事 前 学 習 と 状 況 事前学習： ¨ 受講者がこの授業をこなすには、基礎的な⾞椅⼦の処⽅（選択）に関する、しっかり した実践的知識を有することが重要である。基礎レベル教習プログラムを最近受けた のでない受講者がいれば、基礎⾞椅⼦サービス教習パッケージ受講者⽤参考書「ステ ップ 3: 処⽅（選択）」を紹介し、予め読んでおくよう勧めよ。 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 受講者の作業環境で⼿に⼊る、⾞椅⼦およびクッション。 ¨ 受講者が現場のサービス事業/地域で⼊⼿できる、⾞椅⼦やクッションの選択肢を盛 り込んだ中級⾞椅⼦処⽅（選択）フォームの⾒本を準備しておく。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、授業計画を読み通す。 ¨ 現地で⼿に⼊る各⾞椅⼦に関する、⾞椅⼦概要フォームを完成しておく。教習員は、 製品のそれぞれに精通していなければならない。⾞椅⼦のサイズ、調節範囲、特⾊、 ⼿に⼊るオプションや姿勢⽀持具を知っておく必要がある。 ¨ 現地で⼿に⼊る⾞椅⼦およびクッションを、教習区域のあちこちに並べておく。それ らが正常に動作することを確かめておく。（あれば）供給者から得た⾞椅⼦に関する⽂ 書情報を⾞椅⼦に置いておく。⾞椅⼦⼀台⼀台にラベルしておく（例：⾞椅⼦ 1、2、 3、4）。 あ ら す じ 1. はじめに 2. ⾞椅⼦およびクッションの種類 3. 要点のまとめ 8 50 2 授業時間計 60 115 教習員⽤指導書 1. はじめに（8 分） 説明：処⽅（選択）は、⾞椅⼦サービス提供の第 3 ステップです。 処⽅（選択）とは、⼿に⼊る⾞椅⼦と⾞椅⼦ユーザ ーのニーズの間に、可能な限り最⾼のマッチング を⾒出すことです。 受講者へ、各⾃の中級⾞椅⼦処⽅（選択）フォーム を⾒るよう指⽰せよ。 説明： • この授業では、まっすぐに座るには付加姿勢⽀ 持が必要な⾞椅⼦ユーザーへの、⾞椅⼦および クッションの選択について話し合います。 • また、地元で⼿に⼊る⾞椅⼦について検討し、そ のさまざまな特⾊を、皆さんに熟知してもらい ます。 説明：処⽅の内容は： • ⾞椅⼦ユーザーに最適な、⾞椅⼦の種類および サイズの選択、 • その⾞椅⼦に特有な、あらゆる設定の詳細です。 質問：中級⾞椅⼦処⽅（選択）フォームのこの部分 には、例えば何について書く必要があるでしょう か？ 説明：ここには、姿勢⽀持具の詳細を書く欄はあり ません。それはフォームの後半で出てきます。 答え： • （安全な/活動的な）駆動輪位置 • ティルト 116 中級⾞椅⼦サービス教習パッケージ 説明：処⽅の他の内容として： • クッションの、種類とサイズの選択があります。 説明：クッションが、適切な姿勢⽀持具にするため に改造が必要な場合、その詳細は、中級⾞椅⼦処⽅ （選択）フォームの後半に記します。 説明：さらに処⽅の内容には： • ⾞椅⼦ユーザーが求める付加姿勢⽀持をもたら すために、どんな姿勢⽀持具や改造が必要かの 選択も含まれます。 説明： • このスライドは、中級⾞椅⼦処⽅（選択）フォー ムの⼀部だけを⽰しています。 • フォームのこの項⽬をどう記⼊して⾏くかは、 この後の授業で詳しく説明し、また実習で記⼊ の練習をして⾏きます。 説明： • 「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」で教えるのは、付加姿勢⽀持なしでまっすぐ に座れる⾞椅⼦ユーザーのために、最適な⾞椅⼦およびクッションを選択するやり⽅でした。適 正な⾞椅⼦の選択は、⾞椅⼦ユーザーの⾝体的な、および⽣活様式や環境によるニーズに基づき ます。 • 中級⾞椅⼦サービス教習プログラムでは、⾞椅⼦サービス職員は、姿勢⽀持がより多く必要にな ることを勘案する必要があります。 • 同時に、⾞椅⼦ユーザーの⽣活様式や環境によるニーズについても、よく考えなければならない ことは変わりません。 質問：「⽣活様式や環境による」ニーズには、例えば何があるでしょうか？ 117 教習員⽤指導書 答え： • ⾞椅⼦ユーザーが、どこで⾞椅⼦を使うか（例えば、屋内、屋外、荒れ地）。 • ⾞椅⼦ユーザーが、1⽇に移動する距離。 • ⾞椅⼦ユーザーがどれくらい⻑時間、⾞椅⼦に乗るか。 • 移乗のやり⽅。 • ⾞椅⼦ユーザーが使うトイレの種類。 • ⾞椅⼦ユーザーが、ひんぱんに公共交通機関を使うかどうか。 • ⾞椅⼦ユーザーが、⾞椅⼦に乗っていちばんやりたいことは何か。 留意事項： • 処⽅は、つねに⾞椅⼦ユーザーとの全⾯的な協 同のもとに決定します。 • この教習プログラムで⽤いる中級⾞椅⼦処⽅ （選択）フォームでは、三者の承認署名を求めて います。 • それは、⾞椅⼦ユーザー、評価者（⾞椅⼦サービ ス職員）、⾞椅⼦サービス事業管理者です。 2. ⾞椅⼦およびクッションの種類（50 分） 説明：これから、現地で⼿に⼊るさまざまな⾞椅⼦について⾒て⾏きます。⾞椅⼦処⽅のために、 ⾞椅⼦サービス職員は、⾞椅⼦について次のことがらを知っておく必要があります： 簡潔に説明： • フレームの種類：例えば、4輪⾞椅⼦か 3輪⾞椅 ⼦か、クロス型折りたたみフレーム70かリジッド フレーム71か、ティルト式フレーム72か、ホイー ルベースは⻑いか短いか。 70 [原⽂] a cross-folding frame 71 [原⽂] rigid frame, [⽤語集] 固定式 72 [原⽂] tilting frame 118 中級⾞椅⼦サービス教習パッケージ • ⼿に⼊るサイズおよびサイズ範囲：通常、⾞椅⼦のサイズは座幅と座⾯奥⾏きで表します。⾞椅 ⼦の座幅は、⽚⽅のシートパイプ*の外側からもう⽚⽅の外側まで、あるいはひじ掛けがシート パイプの真上に付いていれば、その間隔を測ります。座⾯奥⾏きは、座⾯の前縁から背もたれま でを測ります。［* 訳注: 原⽂では seat rail］ • 利⽤できる特⾊：例えば、座⾯、背もたれ、⾜台、ひじ掛け、キャスター輪、駆動輪、姿勢⽀持 具（例えば、体幹側⽅パッド、ヘッドレスト、ベルト類）の種類など。 • 調節可能部分および調節範囲：どの部材が調節できるか、およびその調節範囲を知っておくこと は重要です。 説明： • 他のものより多く、調節機能や特⾊を持つ⼿動 ⾞椅⼦もあります。 • 調節機能や特⾊の中には、付加姿勢⽀持が必要 な⾞椅⼦ユーザーにとってたいへん役⽴つもの があります。 • これから、特⾊や調節機能で、とりわけ役⽴つも のを⾒て⾏きます。 以下の要点をそれぞれ説明せよ： ほとんどの⾞椅⼦は、上下に調節できる⾜台を備 えています。 ⾞椅⼦によって、次の調節機能が加わります： • ⾼さ • 前後に移動できる⾜台 • 増減できる⾜台⾓度 これらの調節により、⾞椅⼦ユーザーの⾜の置き 場所を、より⾃由に変えられます。 挙上式レッグレスト**があれば、膝が伸びた状態 で⾜を⽀えられます。これは、膝をニュートラルま で曲げて座れない⾞椅⼦ユーザーに役⽴ちます。 ［** 訳注: 原⽂では elevating leg rest, [ISO 7250-1:2017] angle adjustable lower leg support, [JIS Z8500:2002] 挙上式 フット・レッグサポート］ 119 教習員⽤指導書 背もたれの傾きを調節できると、体幹を⽀える選 択肢が広がります。 背もたれのリクライニング（背もたれを後ろへ傾 けること）は、次へ形を合わせるのに役⽴ちます： • ニュートラルな座位姿勢まで屈曲しない（体幹 〜⼤腿の⾓度が 90 度超の）股関節。 • 後傾したまま固まった⾻盤。 • 屈曲した姿勢のまま固まった体幹下部。 いわゆる「ティルトインスペース73」を備えた⾞椅 ⼦もあります。 これは背もたれと座⾯が⼀体となって後ろへ傾く ものです。座⾯と背もたれの間の⾓度74は変わりま せん。ティルトした背座位置が役⽴つ場合は： • 股関節や膝の屈曲に拘縮を伴う、後傾したまま 固まった⾻盤。 • 低い座位耐性75（快適に座れる時間が短い）、あ るいは通常の座位姿勢では不快。 • 快適さとくつろぎを増すため。 スリング76座⾯に代えて、ソリッド77座⾯を備えた ⾞椅⼦もあります。これがもたらすのは： • ⾻盤や股関節への付加姿勢⽀持を組み上げる、 よい⼟台。 • スリング座⾯より⾼い安定性。これは、⾞椅⼦ユ ーザーの制御できない運動が著しい場合や、体 重がたいへん重い場合に有効です。 73 [原⽂] tilt in space, [ISO 7176-26:2007] tilt, [JIS T9201:2016][⽤語集] ティルト. [訳注] ⽇本で⼀般的な「ティル ト」. tilt in space (または tilt-in-space) は ISO では⾮推奨⽤語とされているが, 海外の資料では単に「傾ける」 意味の tilt と区別してこの機能を特定する場合に⾞椅⼦に限らずよく使われるため, 原著を反映して訳出した. 74 [原⽂] seat to backrest angle, [ISO 7176-26:2007] seat to back support angle, [JIS T9201: 2016] シートとバッ クサポートとの⾓度, [⽤語集] バックサポート⾓度 75 [原⽂] sitting tolerance 76 [訳注] 布状素材を指し, 原⽂はスラング slung. 同義で⽇本での⼀般的呼称であるスリング sling として訳出. 77 [原⽂] solid. [訳注] ⽊・プラスチック・⾦属などの堅い素材のもの. 120 中級⾞椅⼦サービス教習パッケージ ソリッド背もたれを備えた⾞椅⼦もあります。ソ リッド座⾯と同様、付加姿勢⽀持を組み付ける、よ い基盤になります。 他にソリッド背もたれがもたらすのは： • スリング/布製背もたれより⾼い安定性。これ は、⾞椅⼦ユーザーの制御できない運動が著し い場合に役⽴ちます。 • 背が⾼くて体重が重い、および/または体幹が⾮ 常に弱い⾞椅⼦ユーザーへの、より⼤きい⽀え。 スライドのイラストは、ソリッド背もたれにウレ タンフォームを付加して体幹を必要なところだけ ⽀え、側⽅パッドを背もたれへボルト留めしたも のです。 単純なスリング背もたれに代えて、張り調整背も たれを備えたものもあります。 張り調整背もたれは、背もたれの⽀えを簡単に調 節できます。個々のベルトを引き締め、あるいは緩 めることにより、⽀えをより多く、あるいは少なく できます。 多種多様な追加部材を組み込んで付加姿勢⽀持を 備えられるように設計した⾞椅⼦もあります。姿 勢⽀持のさまざまについては、次の授業でさらに 詳しくお話しします。 121 教習員⽤指導書 ⼩グループ活動 グループ： 受講者を 3⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.6: ⾞椅⼦およびクッションの選択） を開くよう指⽰せよ。 受講者へ、現地で⼿に⼊る⾞椅⼦を注意深く観察し、協⼒してワークブッ クの質問に答えるよう指⽰せよ。 説明：受講者には、この活動にグループで 30 分かけ、続いてグループから 全体に戻ってフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 受講者が、質問を理解しているか確かめよ。 必要なら受講者を先導せよ。 時間： 活動に 30 分取っておけ。 フィードバックに 15 分取っておけ。 教習員への注記： • 現地で⼿に⼊る⾞椅⼦が 4種類を超える場合は、さらに時間を取る。 フィードバック： 全体で、各質問について以下の要領で講評せよ： • 受講者に、進んで答えるよう求めよ。 • 全員⼀致しているか確かめよ。 • 不⼀致がなければ回答を（正解なら）受けとめ承認し、次の質問に移れ。 • 全員同じ答えでなければ、正解を引き出し、明確にせよ。 話し合いは短時間にとどめよ。 説明： • ⾞椅⼦サービス職員が、⼿に⼊る⾞椅⼦のさまざまな特⾊をよく分かっ ていることは⾮常に⼤切です。⾞椅⼦に精通することによってのみ、⾞ 椅⼦ユーザーが⾃分のニーズとベストマッチする⾞椅⼦を⾒つけるお⼿ 伝いができるのです。 • 受講者⽤ワークブック、および/または⾞椅⼦サービスフォーム⼀式から 中級⾞椅⼦概要フォームを⽰せ。説明：受講者はこの教習の後、このフ ォームを現場で⼿に⼊る⾞椅⼦について完成するとよいでしょう。 教習員への注記： • 以下の教習員への注記を、回答し、要点を強調したか確認するために参 照せよ。 • この授業の後、各⾞椅⼦についての完成した中級⾞椅⼦概要フォームを 掲⽰せよ。これを、⾞椅⼦ユーザーとの実習中に参照するとよい。 122 中級⾞椅⼦サービス教習パッケージ 教習員への注記： 1. ⽣活様式および環境 質問： 答え/教習員が強調すべき要点： どの⾞椅⼦（複数可）が、荒れた/凸 凹な地⾯を⾏くのに最適ですか？ 理由は？ ⾞椅⼦の荒れ地での使いやすさが向上する特⾊の例： • 3輪型。 • ⻑いホイールベース。 • 幅広い前⽅キャスター輪。 • （「マウンテンバイク」のような）幅広い駆動輪 • エアレスチューブは、パンクの問題を低減し、より耐久 性がある。 • 荒れ地で使う⾞椅⼦は消耗・破損が激しいため、耐久性 や地元での修理可能性も考慮すべきである。 どの⾞椅⼦（複数可）が⽴ち上がって の移乗をいちばん楽にできますか？ 理由は？ ⽴ち上がっての移乗を楽にする特⾊の例： • 開き式78⾜台 • プッシュアップできるひじ掛けは有⽤。 どの⾞椅⼦（複数可）が、横⽅向の移 乗をいちばん楽にできますか？ 理由は？ 横⽅向の移乗を楽にする特⾊の例： • 着脱式79ひじ掛け • 駆動輪のへりに沿った形状のひじ掛け［サイドガード］ それぞれの⾞椅⼦は、運搬のために どうやって折りたたみ、また分解し ますか？ ⼀般的な⽅式の例： • 折りたたみなし • クロス型折りたたみフレーム • 背もたれを倒して折りたたむ • クイックリリース⾞輪 あなたのグループでは、どの⾞椅⼦ （複数可）が公共交通機関での運搬 がいちばん楽だと考えますか？ 理由は？ 受講者へ、以下について考察するよう促せ： • 折りたたみ/分解に要する時間の⻑さ • 折りたたんだ/分解した状態でのパーツの軽さ • パーツが紛失するかどうか（例えば、⾞椅⼦を多くの部 材へ分解する場合） • 折りたたんだ/分解した状態の⾞椅⼦の⼩ささ どの⾞椅⼦（あれば）が空気⼊りタイ ヤを備えていますか？ どの⾞椅⼦（あれば）がエアレスチュ ーブを備えていますか？ どの⾞椅⼦（あれば）がノーパンクタ イヤを備えていますか？ 78 [原⽂] swing-away, [ISO 7176-26:2007] swing-away, [JIS T9201:2016][⽤語集] 開き式 79 [原⽂] removable, [ISO 7176-26:2007] removable, [JIS T9201:2016][⽤語集] 着脱式 123 教習員⽤指導書 2. 除圧 質問： 答え/教習員が強調すべき要点： 教室にはどんな種類のクッションが ありますか？ クッションは、以下に従い分類できる： • 主な素材 o ウレタンフォームクッション o ココナッツ繊維（コイヤー）製クッション o 空気充填クッション o 液体またはゲル充填クッション • 形状 o 平⾯80クッション o 成形81［⾝体形状に沿う起伏のある］クッション o モールド82［型取りした成形］クッション o 多層構造83クッション それらのうち、どれを除圧クッショ ンに分類しますか？ 理由は？ 除圧クッションには、以下のようなものがある： • 成形ウレタンフォームクッション • 成形した基層に、液体かゲルを載せたクッション • 空気充填クッション 受講者は、クッションを「除圧クッション」たらしめる要 素を識別できるべきである。その理由となるのは： • 以下のような輪郭/成形がある： o 座⾻下の「井⼾⽳84」（座⾻井［ざこつせい］85） o 座⾻前⽅にある棚状段差86［座⾻前⽅（アンカー） サポート］ o ⼤腿上部への、下からの⽀え o ⼤腿への溝あるいは凹み • ゲル/液体充填体は、圧⼒を分散する（注記：ゲル/液体 充填体は、上記のような輪郭のある、堅い成形ウレタン フォーム基層の上に置くべきである）。 80 [原⽂] flat, [JIS T9201:2016] [plane style を指して] 平⾯型 81 [原⽂] contoured, [ISO 7176-26:2007] pre-contoured, [⽤語集] コンター型 82 [原⽂] moulded (英語. ⽶語では molded), [ISO 7176-26:2007] custom-contoured, [JIS T9201:2016] モールド式 83 [原⽂] layered 84 [原⽂] “well” under the seat bones 85 [原⽂] seat bones well 86 [原⽂] a shelf before the seat bones. 後出の pre-seat bone shelf と同⼀. 124 中級⾞椅⼦サービス教習パッケージ 除圧クッション（あれば）について、 どれが次のような改造が⽐較的易し いと思いますか： • 除圧効果を⾼める。 • 付加姿勢⽀持をもたらす。 たいてい、ウレタンフォーム成形クッションの⽅が改造 しやすい。ウレタンは切ることができ、除圧のためにかさ 上げを追加できるからである。 ゲル/液体緩衝層が独⽴したユニットであれば、基層の改 変やかさ上げの追加などは容易で、後から緩衝層を置き 直せばよい。 詳しくは「基礎⾞椅⼦サービス教習パッケージ」の「クッ ション」の授業を参照。 教室にあるクッションカバーには、 どんな特⾊がありますか？ 受講者は、以下の特⾊を識別できよう： • 耐⽔性 • 耐久性 • 伸縮性（クッション形状にフィットしやすくなる） • 洗濯のため取り外せる 3. ⾞椅⼦のこぎ⽅ 質問： 答え/教習員が強調すべき要点： ⾞椅⼦へまっすぐに座りなさい。駆 動輪は⾃⼒でこぐのによい位置にあ りますか？確認しなさい： • 腕を⾃然に下へ垂らしなさい。⼿ が⾞軸の上にかかりますか？ • ハンドリムの頂部を、肩の真下で 握りなさい。ひじの⾓度は 90〜 120 度ですか？ • 駆動輪位置は調節可能ですか？も し調節済みなら、こぐ姿勢は改善 していますか？ 受講者が、⾞軸位置の調節によって、駆動輪位置を⾃⾛⽤ に改善できるかどうかに、着⽬したかどうか確かめよ。 教室にある⾞椅⼦で、座⾯⾼を調節 できるものがありますか？ それはどんな場合に役⽴ちますか？ 座⾯⾼を下げられると、⾜でこぎ進む⾞椅⼦ユーザーに 適切な設定ができる。 ただし、この特⾊は、多くの低リソース状況では⼀般的に ⼿に⼊るものではない。 4. 姿勢⽀持の特⾊ 質問： 答え/教習員が強調すべき要点： どの⾞椅⼦（あれば）が、挙上式レッ グレストを備えていますか？ どの⾞椅⼦（あれば）が、ソリッド座 ⾯を備えていますか？ どの⾞椅⼦（あれば）が、張り調整背 もたれを備えていますか？ 125 教習員⽤指導書 どの⾞椅⼦（あれば）が、付加姿勢⽀ 持をもたらすように設計した追加部 材を備えていますか？ 5. 調節可能性 質問： 答え/教習員が強調すべき要点： どの⾞椅⼦（あれば）で、次の調節が可能ですか？ • ⾜台〜座⾯⾼ • ⾜台⾓度 • ⾜台の前後移動 • 背もたれ⾼の上下 • 背もたれの傾き • ティルトインスペース 調節機能が多いほど、付加姿勢⽀持が必要な⾞椅⼦ユー ザーのために働く際に役⽴つ。 教習員への注記：ユーザー教習に関する以下の要点を、こ こで述べておいてもよい： • ⾞椅⼦ユーザーおよびその家族/介助者には、⾞椅⼦の 設定（または調節）の仕⽅が⾞椅⼦ユーザーへの姿勢⽀ 持に影響することを、つねに説明しなさい。調節可能な パーツは、必要がない限り再調整してはなりません。最 終フィッティングで決めた設定を保ち、調節がずれな いよう確認/固定しておくことが重要です。 3. 要点のまとめ（2 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 126 中級⾞椅⼦サービス教習パッケージ B.7: 姿勢⽀持具の処⽅（選択）−はじめに ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 「姿勢⽀持具」を定義する。 ¨ 中級⾞椅⼦処⽅（選択）フォームの⽬的を説明する。 教 材 この授業には： ¨ PPTスライド：B.7: 姿勢⽀持具の処⽅（選択）−はじめに ¨ 受講者⽤参考書 ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ 中級⾞椅⼦処⽅（選択）フォーム ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ 姿勢⽀持具キット 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 受講者の作業環境で⼿に⼊る姿勢⽀持具、姿勢⽀持具の材料および製作⽅法。 ¨ 受講者が、どこで⾞椅⼦ユーザーへフィッティングを実施するか、例えば、地域/ユー ザーの家、⼯房、⾞椅⼦サービスセンターなど。これは作業のやり⽅や姿勢⽀持具の 選択に影響する。 ¨ 中級⾞椅⼦処⽅（選択）フォームの⾒本を準備し、受講者が地元で⼊⼿できる、姿勢 ⽀持具の選択肢を盛り込んでおく。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、授業計画を読み通す。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 ¨ 姿勢⽀持具キットから⾒本の姿勢⽀持具を取り出し、まとめて教室前⽅のテーブル上 の、教習員が簡単に⼿に取れるところへ配置しておく。 ¨ 教室を、部屋の前⽅を囲んで受講者が半円形に座れるように配置しておく。 あ ら す じ 1. はじめに 2. 姿勢⽀持具（PSD, PSDs）とは何か？ 3. 中級⾞椅⼦処⽅（選択）フォームに姿勢⽀持具を記録する 4. 要点のまとめ 2 10 15 3 授業時間計 30 127 教習員⽤指導書 1. はじめに（2 分） 説明： • これから 5回の授業では、引き続き⾞椅⼦サービ ス提供の第 3ステップ、処⽅（選択）について学 んで⾏きます。前回の授業では、⾞椅⼦ユーザー に最適な種類の⾞椅⼦およびクッションを選ぶこ とを⾒てきました。 • この授業でお話しするのは： o 「姿勢⽀持具（PSD/PSDs）」という⽤語は、 どういう意味か。 o 中級⾞椅⼦処⽅（選択）フォームの最終部分。 • 次回以降の各授業で、これらの姿勢⽀持具につい て、さらに詳しく⾒て⾏きます。 • 留意事項：処⽅を完成する前に、選択した⾞椅⼦ が必要とされる姿勢⽀持を与えられるか確かめて おくことは重要です。 2. 姿勢⽀持具（PSD, PSDs）とは何か？（10 分） 各受講者へ、ラミネート済み姿勢⽀持具（PSD）⼀覧表（以後「PSD 表」とも呼ぶ）を配布せよ。 質問：「姿勢⽀持具」とは何でしょうか？励まして回答を促せ。 答え： • 姿勢⽀持具（Postural Support Device, 略称：PSD［単数形］、PSDs［複数形］）とは： o 付加姿勢⽀持をもたらすために⾞椅⼦へ追加する、あらゆる物理的装置。 o 姿勢⽀持具の例：ヘッドレスト、⾻盤ベルト、⾻盤側⽅パッドなど。 o 留意事項：⾞椅⼦の座⾯、背もたれ、⾜台、ひじ掛けもすべて姿勢⽀持をもたらす。 128 中級⾞椅⼦サービス教習パッケージ 説明：例えばスライドのイラストは、いくつかの姿 勢⽀持具の例を⽰しています。 質問：受講者には、どんな姿勢⽀持具があるか分か りますか？ 答え（受講者が異なる名称/⽤語を⽤いる場合も ある）： • 体幹側⽅パッド • 成形/形状加⼯背もたれ87と成形クッション • ⾻盤側⽅パッド • 座⾻前⽅（アンカー）サポート 説明： • 姿勢⽀持具にはさまざまなデザインのものがあり、⾞椅⼦ユーザーへ付加姿勢⽀持をもたらすた めの⾞椅⼦の設定のやり⽅もさまざまです。 • この教習プログラムでは、最も⼀般的に⽤いられる姿勢⽀持具を紹介します。 • この教習プログラムでは、名称として簡潔で説明的な⽤語で呼んでいます。同じものに違う⽤語 を宛てているのを聞いたことがある受講者もいるでしょう。各⾞椅⼦サービス事業、⾞椅⼦サー ビス職員、⾞椅⼦ユーザーは、いちばんなじみがあってしっくり来る⽤語を使って結構です。 • 姿勢⽀持具のつくり⽅は、この教習プログラムの後半で詳しくお話しします。 • 留意事項：多くの⾞椅⼦ユーザーの場合、これからお話しする姿勢⽀持具の解決策を複数組み合 わせることで、正しく全体的な解決をもたらす必要があります。 3. 中級⾞椅⼦処⽅（選択）フォームに姿勢⽀持具を記録する（15 分） 説明： • 中級⾞椅⼦処⽅（選択）フォームの⽬的は、⾞椅 ⼦の下準備を担当する⾞椅⼦サービス職員へ、次 の情報を与えることです： o ⾞椅⼦の種類・サイズ・設定（前述） o クッションの種類・サイズ（前述） o 必要な姿勢⽀持具・改造 87 [原⽂] contoured/shaped backrest 129 教習員⽤指導書 説明： • 事前評価から得られたすべての情報は、中級⾞椅⼦処⽅（選択）フォーム上で、⾞椅⼦ユーザー に必要な⾞椅⼦の明解な詳細仕様書へと翻訳されます。 • 中級⾞椅⼦処⽅（選択）フォームへ盛り込む情報が詳しいほど、⾞椅⼦の初回フィッティングに 向けた下準備が精確になります。 • 中級⾞椅⼦処⽅（選択）フォームでは、必ずしも姿勢⽀持具のつくり⽅まで述べる必要はありま せん。これは、⾞椅⼦の下準備を担当する⾞椅⼦サービス職員と事前評価に当たった⾞椅⼦サー ビス職員とで、話し合って決めればよいでしょう。 • ⾞椅⼦サービス事業所が違えば、たいてい違うやり⽅で⾞椅⼦処⽅に関する情報を記録している ものです。 受講者へ、各⾃の受講者⽤参考書を開き、この授業の章の末尾に載っている中級⾞椅⼦処⽅（選択） フォームの完成例を⾒るよう指⽰せよ。 説明：⾞椅⼦サービス職員は、中級⾞椅⼦処⽅（選 択）フォームの「必要な姿勢⽀持具・改造」の箇所 を次のことに使えます： • 処⽅/選択したい姿勢⽀持具を、（チェックボッ クスを使い）⼀般的な姿勢⽀持具の表から選び ます。他種の姿勢⽀持具を記⼊するために「その 他」欄も設けてあります。 • 投影図に重ね描きして、処⽅（選択）した姿勢⽀ 持具の形状および⼨法を⽰します。 • 追加情報があれば、書き込むか、描くかします。 • 姿勢⽀持具確認表に加え、受講者は⼨法も与え ておく必要があり、それにより姿勢⽀持具を正 しいサイズでつくり、⾞椅⼦の正しい場所へ配 置できます。 • 姿勢⽀持具（PSD）⼀覧表内の⼨法⾒取り図は、 受講者がそれぞれの姿勢⽀持具について必要に なる、さまざまな⼨法を考える⼿引きになりま す。 130 中級⾞椅⼦サービス教習パッケージ • フォーム上の「投影図」2 点は、受講者が処⽅し た姿勢⽀持具を描き、⼨法を⼊れる⽬安になり ます。 • このスライドで⽰した例は、中級⾞椅⼦処⽅（選 択）フォームの投影図および姿勢⽀持具確認表 を活⽤した、座⾻前⽅（アンカー）サポートおよ び右側を下げた座⾯前部の表し⽅です。 • 質問：⾞椅⼦ユーザーに対して、このように座⾯ の⽚側を下げる必要が出てくる理由が思い当た る⼈はいますか？正解を受けとめ承認せよ。 答え： • ⾞椅⼦ユーザーの右股関節が、完全に 90 度ま で曲がらないから。 • 説明：この例は、中級⾞椅⼦処⽅（選択）フォー ム 2 ページ⽬の、投影図および姿勢⽀持具確認 表の使い⽅を⽰しています。 • 質問：このフォームには、どの姿勢⽀持具を記録 していますか？受講者に、判らなければ参考書 の、姿勢⽀持具（PSD）⼀覧表と姿勢⽀持具 （PSD）参照表を当たるよう促せ。正解を受けと め承認せよ。 答え： • 座⾻前⽅（アンカー）サポート（フォーム 1ペ ージ⽬の姿勢⽀持具確認表で選択済み） • 左右の体幹側⽅パッド • 左の⾜台ウェッジ88（くさび） • ⾻盤ベルト89 88 [原⽂] footrest wedge 89 [原⽂] pelvis strap 131 教習員⽤指導書 説明：どちらの描画でも、⼨法線を追加していますね。これは、これらの姿勢⽀持具の製作に必要 な⼨法を⽰しています。 説明：次の授業を進めながら、姿勢⽀持具のサイズおよび位置を表すために必要な⼨法についてお 話しして⾏きます。また受講者は、実習でそのやり⽅を練習します。 4. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 132 中級⾞椅⼦サービス教習パッケージ B.8: 姿勢⽀持具の処⽅（選択）−⾻盤を安定させる ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ ⾻盤を安定させて⽀えるための、姿勢⽀持具について詳述する。 ¨ 座⾻前⽅（アンカー）サポートおよび⾻盤後⽅パッドの⼨法を指定する。 教 材 この授業には： ¨ PPTスライド：B.8: 姿勢⽀持具の処⽅（選択）−⾻盤を安定させる ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 動画：⾻盤前傾に対する姿勢⽀持の解決策 ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ 姿勢⽀持具キット ¨ ⾻盤ベルト：各グループに 1本 ¨ 評価ベッド：各グループに 1 台 ¨ 硬いウレタンフォームのブロック：各グループに 2〜3 個、硬いウレタンフォームの ウェッジ（くさび）：各グループに 1個 ¨ ⾞椅⼦：各グループに 1 台（できれば 3 種類以上にわたっていること） 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 受講者の作業環境で⼿に⼊る姿勢⽀持具、姿勢⽀持具の材料および製作⽅法。 ¨ 受講者が、どこで⾞椅⼦ユーザーへフィッティングを実施するか、例えば、地域/ユー ザーの家、⼯房、⾞椅⼦サービスセンターなど。これは作業のやり⽅や姿勢⽀持具の 選択に影響する。 ¨ やってみせる/受講者へ希望者のための⽀えを設けるよう指⽰する際の、触ることに まつわる⽂化的問題に気を付ける。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 ¨ 姿勢⽀持具キットから⾒本の姿勢⽀持具を取り出し、まとめて教室前⽅のテーブル上 の、教習員が簡単に⼿に取れるところへ配置しておく。 ¨ 教室前⽅に、評価ベッドを 1 台置いておく。 ¨ 教室を、部屋の前⽅を囲んで受講者が半円形に座れるように配置しておく。 133 教習員⽤指導書 あ ら す じ 1. はじめに 2. 問題：⾻盤が後傾および/または前滑りする 3. 問題：⾻盤が側傾している（固まった⽔平でない⾻盤） 4. 問題：⾻盤が⽚側に寄る 5. 問題：⾻盤が前傾している（前⽅に傾いた⾻盤） 5. 要点のまとめ 2 45 5 10 25 3 授業時間計 90 1. はじめに（2 分） 説明： • 今回の授業では、姿勢⽀持具のうち、⾻盤への ⽀えに使うものについて学びます。 • 留意事項：今回以降の授業では、姿勢⽀持具を 個別に⾒て⾏きますが、多くの姿勢⽀持具は合 わせ技で働くものです。 説明：⼤⼈をまっすぐに座るよう⽀える場合に、 最も⽀えが必要なのは⾝体の 2か所、すなわち： • ⾻盤と、 • 体幹です。 説明：最初に、⾻盤から⾒て⾏きます： • ⾻盤がまっすぐな姿勢にない場合、体幹や股関 節にも変化が⽣じます。 • したがって、⾻盤を⽀え、または安定させるこ とが、⾞椅⼦ユーザーがまっすぐに座れるよう にするうえで最も重要です。 • ⾻盤を⽀えることにより、⽀えの必要を他のあ らゆる部位で減らせます。 134 中級⾞椅⼦サービス教習パッケージ 説明：この授業から「B.11: 姿勢⽀持具の処⽅（選択）−頭・⼤腿・下腿を⽀える」の授業まで、 各事例は、「問題点」「必要な⽀え」「姿勢⽀持具の解決策」の順で⽰して⾏きます。授業によって、 構成が多少変わることもあります。 2. 問題：⾻盤が後傾および/または前滑りする（45 分） ⼿始めの姿勢は： • ⾻盤後傾です。 希望者ひとりに、教室の前に出てきて、問題を実演 してみせるよう求めよ。 受講者へ質問せよ：どんな⽀え（⼿の⽀え）があれ ば、希望者の⾻盤をニュートラルな座位姿勢へ近づ けられるでしょうか？ 受講者 1〜2 ⼈を招き、教室の前に出てきて、⾃分の ⼿で希望者に⽀えを供するデモを⾏なってもらえ。 受講者全体へ、必要なら助⾔を与えるよう励ませ。 教習員への注記：招いた受講者は、⾻盤背⾯へ⽀え を供していなければならない。 正しいデモを受けとめ承認せよ。 135 教習員⽤指導書 説明： 後傾している⾻盤をよりニュートラルな座位姿勢 へ持って⾏く場合、ふつう２か所に⽀えが必要で： • 招いた希望者が設けた通り、上後腸⾻棘（PSIS） の⾼さで⾻盤背⾯と、 • ⾻盤の前⽅、より正確には座⾻（座⾻結節）の前 ⽅を⽀えます。 座⾻の前⽅に⽀えがなければ、⾻盤は前⽅へずれ、 あるいは滑りがちになり、⾻盤背⾯への⽀えから 離れてしまいます。 質問：図が⽰すように座⾻の前⽅を⽀えるには、ど うしたらいいでしょうか？ 受講者（希望者）1〜2 ⼈を招き、教室の前に出て きて、どうやって座⾻の前⽅を⽀えればよいか、硬 いウレタンフォームブロックを使いデモを⾏なっ てもらえ。 教習員への注記：この間、招いた受講者の⼀⼈は⾻ 盤背⾯を⽀えていなければならない。 受講者全体へ、必要なら助⾔を与えるよう励ませ。 正しいデモを受けとめ承認せよ。 希望者へ感謝を述べよ。 受講者へ質問せよ：この⽀えを与えるのは、どの姿勢⽀持具でしょうか？受講者は、ヒントを得る には姿勢⽀持具（PSD）⼀覧表あるいは姿勢⽀持具（PSD）参照表を当たるとよいでしょう。 136 中級⾞椅⼦サービス教習パッケージ 座⾻前⽅（アンカー）サポートは、座⾻の前⽅に⽀ えをもたらします。 これは次の役に⽴ちます： • ⾻盤をまっすぐに起こして保ち、 • ⾻盤が前⽅へ滑るのを⽌め、 • ずっこけた姿勢で座る傾向を減らします。 座⾻前⽅（アンカー）サポートは、座⾻のちょうど 前⽅に据えます。 質問：座⾻前⽅（アンカー）サポートのクッション 上での位置を決めるには、どこの⾝体計測を⾏なう 必要があるでしょうか？ 答え： • ⾻盤背⾯〜座⾻［の距離］ 説明：⾻盤後⽅パッドは、⾻盤を上端（上後腸⾻棘 （PSIS）の⾼さ）で⽀えます。 これの効果は： • ⾻盤をまっすぐに起こして保つことです。 説明： • これら 2種類の姿勢⽀持具を、先のスライドと同 じ⾞椅⼦ユーザーへ設けているのが判りますね。 • 座⾻前⽅（アンカー）サポートと⾻盤後⽅パッド の⽀えで、この⾞椅⼦ユーザーはまっすぐに座る ことができました。 • 背もたれ⾓度をどれくらい後ろに傾けると、この ⾞椅⼦ユーザーのまっすぐに起きた体幹の⾃然な カーブが収まるのかに注⽬しなさい。 • 体幹をしっかりと⽀えることは、解決策全体の重 要な⼀部です。体幹への⽀えについては、この後 の授業で詳しくお話しします。 137 教習員⽤指導書 説明： • 座⾻前⽅（アンカー）サポートと⾻盤後⽅パッドの組み合わせは、⾞椅⼦ユーザーが（起点の姿 勢が固まった姿勢でない場合）⾻盤をよりまっすぐに起こし、安定して座れるようにするために よく⽤いられます。 • 次の活動で受講者には、これら広く⽤いられる姿勢⽀持具 2種の⼨法と位置を、中級⾞椅⼦処⽅ （選択）フォーム上へ書き表すやり⽅を練習してもらいます。 ⼩グループ活動 グループ： 受講者を 2⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.8: 姿勢⽀持具の処⽅（選択）−⾻盤を 安定させる）を開き、マリアンの例話を読むよう指⽰せよ。 受講者へ、協⼒して⾞椅⼦事前評価フォームの「⾝体計測」の結果を⽤い、 所載のスケッチへ適切な⼨法を追加するよう指⽰せよ。 説明：受講者が、この活動の参考に使えるのは： • 姿勢⽀持具（PSD）⼀覧表と、 • 姿勢⽀持具（PSD）参照表です。 説明：受講者には、この活動にグループで 10 分かけ、続いてグループから 全体に戻ってフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 受講者⽤参考書や各⾃の知識を活⽤するよう、各グループを励ませ。 必要なら受講者を先導せよ。 時間： 活動に 10 分取っておけ。 フィードバックに 5 分取っておけ。 フィードバック： スライドを映せ： 受講者へ質問せよ： • マリアンの背もたれ〜座⾻ 前⽅（アンカー）サポート 始点の間隔は、いくつにす べきでしょうか？ • 座⾯上端〜⾻盤後⽅パッド 中央の⾼さの間隔はいくつ にすべきでしょうか？ • 他の⼨法で役⽴つものは？ 説明：⾞椅⼦処⽅（選択）フォーム全体を完成するさい、姿勢⽀持具の⼨法 および配置を⽰すために、受講者はこうした注記を⼊れた⾒取り図を何枚で も描いて下さい。 138 中級⾞椅⼦サービス教習パッケージ 答え： • マリアンのための背もたれ〜座⾻前⽅（アンカー）サポート始点の間隔は、170〜190 mm（⾝ 体⼨法 L ⾜す 20〜40 mm）になる。 • マリアンのための、座⾯上端（座⾻が据わるところ）〜⾻盤後⽅パッド中央の⾼さの間隔は、 160 mmになる。 • 他の⼨法や情報で役⽴つものとしては： o ウレタンフォームの種類（例：柔らかいウレタンフォームを上にした硬いウレタンフォー ムで、座⾻前⽅（アンカー）サポートと⾻盤後⽅パッドの両⽅を製作）を指定。 o 座⾻前⽅（アンカー）サポートの⾼さを指定。⼤⼈では、通常 20〜30 mm。 o ⾻盤後⽅パッドの厚みを指定。これはハンド・シミュレーション/ユーザーのニーズによ って変わる。 説明：ここまで、座⾻前⽅（アンカー）サポートおよび⾻盤後⽅パッドについて⾒てきました。 質問：これらの⽀持具を⽤いる⾞椅⼦ユーザーに、制御できない運動、⾼い筋緊張、体が伸⻑する 筋攣縮（伸筋パターン）が⽣じた場合、何が起こるでしょうか？ 答え： • ⾞椅⼦ユーザーが、座⾻前⽅（アンカー）サポートや⾻盤後⽅パッドから逸脱する。 質問：これが起こるのを防ぐには、どの⽅向への⽀えを設ければよいでしょうか？ 希望者 1〜2 ⼈に、教室の前に出てきて、どこへ⽀えを設けるかデモを⾏なうよう求めよ。 答え： • ⼤腿の上を下向きに⽀える。 正しいデモを受けとめ承認せよ。 説明：右上の下向き⽮印は、⾞椅⼦ユーザーの⾻盤 を定位置に置いて⾻盤背⾯および座⾻の前⽅での ⽀えに当たるように保つ、追加の⽀えを表してい ます。 質問：どの姿勢⽀持具が、この⽀えをもたらすでし ょうか？ 答え： • ⾻盤ベルト。 139 教習員⽤指導書 説明： • ⾻盤ベルトは、⾻盤を定位置に保つのに役⽴ち ます。 • ⾻盤ベルトは、制御できない運動および/または 前⽅へ滑る傾向がある⾞椅⼦ユーザーに、とて も有効です。 • ⾻盤ベルトは⾻盤を定位置に保つため、座⾻前 ⽅（アンカー）サポートと⾻盤後⽅パッドの⽀え が⻑続きします。 • ベルトを⾞椅⼦へ取り付ける位置が、引っ張る ⾓度/⽅向を左右します。これは、⾻盤ベルトの 働きに直接影響します。 • ⾓度は、45〜90 度の間にします。 • いちばん効果的な⾓度は、⾞椅⼦ユーザーのニ ーズによって変わります。 • ⾻盤ベルトの⾓度については、つねに⾞椅⼦ユ ーザーといっしょに評価し、話し合い、できれば 試して、⾞椅⼦ユーザーにとって最も効果的か つ快適な⾓度を⾒つけて下さい。 ⾒本を使ってやってみせよ。 希望者へ感謝を述べよ。 ⼩グループ活動 グループ： 受講者を 3⼈ずつのグループに分けよ。 指導内容： 各グループへ、（できれば相異なる種類の）⾞椅⼦ 1 台および⾻盤ベルト 1本 ずつを割当てよ。受講者へ、以下の⾓度で引っ張るためには、⾻盤ベルトを ⾞椅⼦のどこへ取り付ければよいか、考えるよう指⽰せよ： • 45 度 • 60 度 • 90 度 説明：受講者には、この活動にグループで 5 分かけ、続いてグループから全 体に戻ってフィードバックしてもらいます。 140 中級⾞椅⼦サービス教習パッケージ モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 必要なら受講者を先導せよ。 時間： 活動に 5 分取っておけ。 フィードバックに 5 分取っておけ。 フィードバッ ク： 各種の⾞椅⼦につき 1 グループずつ、どこへ⾻盤ベルトを取り付ければ、引 っ張る⾓度が 45、60、90 度になるかデモを⾏なうよう指⽰せよ。 正しいデモを受けとめ承認せよ。 説明：⾞椅⼦の種類が違えば、違う解決策が必要になることもよくあります。 しかし、引っ張る⾓度は、⾞椅⼦ユーザーのニーズ（⾞椅⼦の設計ではなく） に従って決めなければなりません。 説明： • 制御できない運動、⾼い筋緊張、筋攣縮は股関節 の屈曲を強くして抑制できる場合があります。 • これは、⾞椅⼦ユーザーの両⼤腿の下へウェッジ （くさび形）を設け、⾞椅⼦座⾯の前⽅をかさ上 げしてつくれます。 • 注意点：ウェッジは、つねにスライドが⽰す通り、 座⾻の前⽅から始まるようにします。座⾻が据わ る⾯は⽔平でなければなりません。 質問：⾞椅⼦ユーザーの⾻盤が後傾したまま固まっており、⾻盤を起こして座れない場合、どんな ⽀えを設ければよいでしょうか？励まして回答を促せ。 答え： • ⾻盤後傾のまま固まっている⾞椅⼦ユーザーには、その姿勢に形を合わせるために、さらに調 整が必要なこともある。 • ⼀つの解決策は、座⾯〜背もたれの間の⾓度を⼤きくしてその⾻盤姿勢に形を合わせ、⾻盤が さらに後ろへ倒れるのを防ぐように⽀えることである。これを「座⾯〜背もたれ⾓度90を開け る」と呼ぶ（姿勢⽀持具（PSD）参照表を⾒よ）。 • 絶対に注意すべき点は、⾞椅⼦ユーザーが⾞椅⼦上で前⽅へ滑らないようにすることである。 これは、褥瘡発⽣の原因となる「剪断［せんだん］」を引き起こす。 • 座⾻前⽅（アンカー）サポート・⾻盤ベルト・座⾯前⽅のかさ上げは、前滑りを防ぐ。 90 [原⽂] seat to backrest angle, [ISO 7176-26:2007] seat to back support angle, [JIS T9201:2016][⽤語集] バック サポート⾓度 141 教習員⽤指導書 説明： • このイラストは、座⾯〜背もたれ⾓度を開ける やり⽅の⼀例を⽰しています。 • 留意事項：ウレタンフォームは、⾞椅⼦ユーザー が必要とするところを⽀えるように成形する必 要があります。 3. 問題：⾻盤が側傾している（⽔平でないまま固まった⾻盤）（5 分） 説明：ここから、⾻盤に関係する別の姿勢の問題を ⾒て⾏きます。 ⾞椅⼦ユーザーは、姿勢の問題を複数抱えている 場合もあることを忘れないで下さい。 次のような姿勢について⾒て⾏きます： • ⾻盤が側⽅へ傾いている/⽔平でないまま固ま った⾻盤（⽚⽅の上前腸⾻棘（ASIS）が反対側よ り⾼い）。 説明：この姿勢への⽀えについては、「B.3: ⾝体的 事前評価−⾻盤と股関節の姿勢チェック」の授業 で話し合いました。 質問：どんな姿勢⽀持具が解決するでしょうか？ 回答を受けとめ承認せよ。 ⾼い側の⾻盤の下を積み増しすることで： • ⾞椅⼦ユーザーの安定が向上し、 • 低い側の⾻盤へ、安全でないほどの圧⼒がかか るのを避けられます。 説明：座⾻や⼤腿の下は、均等に接触していなけれ ばなりません。⾜台の（どちらかを反対側より⾼く する）調整が必要になる場合もあります。 説明：スライドは、⾞椅⼦を後ろから⾒たところの イメージです。 142 中級⾞椅⼦サービス教習パッケージ 説明：⾻盤側⽅パッドも⾻盤を⽀えるので、⾻盤 の下を積み増しした⼈には、必ず付加しなさい。 4. 問題：⾻盤が⽚側に寄る（10 分） 説明：ここからさらにもう⼀つ、⾻盤に関係する姿勢の問題を⾒て⾏きます。 姿勢の問題： • ⾻盤が⽚側に寄る 説明： • これが⽣じる理由はさまざまです。 • この問題は、えてして他の姿勢の問題と結び付 いています。 • このスライドから判るように、 o 前項と同じ男性の場合：⾻盤が側傾し（⽔平 でないまま固まった⾻盤）、そのため⾻盤が 左上がりになっています。 o ⼥性は脊柱が横へ弯曲しています。やはり⾻ 盤が左上がりになっています。 質問：⾻盤を⾞椅⼦の中央に保つには、どこに⽀え を設ければよいでしょうか？正解を受けとめ承認 せよ。 答え： • 左右の股関節の横に⽀えを設ける。 143 教習員⽤指導書 質問：どんな姿勢⽀持具が解決するでしょうか？ 受講者は、姿勢⽀持具（PSD）参照表を当たってみ て下さい。 正解を受けとめ承認せよ。 答え： • ⾻盤側⽅パッド。 説明： • ⾻盤側⽅パッドは、⾻盤が横にずれるのを⽌め るのに役⽴ちます。 • ⾻盤側⽅パッドは、⾻盤の両側へしっかりと当 たっている必要があります。 留意事項： ⼩さい⼦どもは、⼤腿を⼤⼈よりも開いて座らせ るべきです。これは、股関節の健康と発達のために 重要です。つまり、⾻盤側⽅パッドが⼤腿を圧して 閉じ合わせないことは、⼦どもにとってとりわけ 重要なのです。 5. 問題：⾻盤が前傾している（前⽅に傾いた⾻盤）（25 分） 説明：もう⼀つの姿勢の問題に、⾻盤の前傾（前⽅ に傾いた⾻盤）があります。 受講者へ尋ねよ：⾻盤がよりニュートラルな座位姿勢を促すには、どんな⽀えを設ければよいでし ょうか？回答を受けとめ承認せよ。 144 中級⾞椅⼦サービス教習パッケージ 答え： • ⾻盤の前⾯（上前腸⾻棘（ASIS））を、後向きに押す⽀え。 • 後ろ下がりに傾斜したウェッジ（くさび）。 動画を紹介：「⾻盤前傾に対する姿勢⽀持の解決策」。この動画に登場するのはカ ーロ、⾻盤が前傾している⾞椅⼦ユーザーです。彼⼥のために講じた姿勢⽀持具 の解決策が分かるよう、注意深く視聴して下さい。動画の後で話し合います。 動画を上映。 何か質問がないか尋ねよ。 受講者へ尋ねよ：カーロが⾻盤をよりニュートラルな座位姿勢に近づけて座れるよう、どんな⽀え を設けていましたか？ 答え： • カーロが試したクッションには、⾻盤前傾⽤ウェッジ（後ろ下がりに傾斜したウェッジ）が付 いており、これで彼⼥の⾻盤をよりまっすぐに起こせるかどうかを⾒た。 • それから⾞椅⼦サービス職員は、⾻盤ベルトを試しに使い、⾻盤前傾４点ベルトがもたらすよ うな付加姿勢⽀持がカーロにさらに役⽴つかどうか⾒極めた。 説明： • ⾻盤前傾⽤ウェッジ91（後ろ下がりに傾斜したウ ェッジ）は、座⾻の下に置きます。これは⾻盤が 背もたれに向けて、後ろへ起きるよう促します。 • ⾻盤前傾⽤ウェッジは座⾻のすぐ前で終わり、 ⼤腿の下では⽔平であるようにします。 • この姿勢⽀持具を検討する際には、⾞椅⼦ユー ザーに試⽤してもらい、次のことを確認します： o どんな感じか。 o 効果的かどうか。 o どのくらいの⾓度が、⾞椅⼦ユーザーには快 適か。 指摘せよ：動画で⾞椅⼦サービス職員は、カーロに クッションがより快適に座るのに役⽴っているか どうか、尋ねていましたね。 91 [原⽂] wedge for anterior tilt 145 教習員⽤指導書 説明： • このイラストは、硬いウレタンフォームと柔らか いものとを組み合わせ、このウェッジ（くさび） をどうやってつくれるかを⽰しています。 説明： • ⽀えを⾻盤前⾯の上縁に設け、⾻盤をよりニュー トラルな座位姿勢へ持って⾏くことも可能です。 注釈せよ：動画で⾞椅⼦サービス職員はこうした⽀ えを設け、カーロにどんな感じか尋ねていましたね。 受講者へ、どの姿勢⽀持具がこの⽀えをもたらすか 尋ねよ。 • 答え： • ⾻盤前傾４点ベルト92。 説明： • このベルトは、前傾した⾻盤専⽤です。 • イラストでは、このベルトを下⽅でシートパイプ に、後⽅で背もたれフレーム93に固定しているこ とに注⽬しなさい。 • これは、ベルトが⾞椅⼦ユーザーの腹部までせり 上がるのを⽌めるためです。そうなると、たいへ ん不快です。 • 上前腸⾻棘（ASIS）の上に⽀えを供するあらゆる ベルトには、じゅうぶん緩衝材を⼊れて褥瘡の危 険を減らすことが重要です。 92 [原⽂] anterior tilt four-point strap 93 [原⽂] backrest uprights 146 中級⾞椅⼦サービス教習パッケージ 教習員への注記：動画に出てくるのは、単なる⼀本ベルトである。これを⽤いたのは、単にベル トがカーロにとって快適かどうかと、引っ張る⽅向を調べるためである。質問されたら、つくる 必要があるのは上記の理由から 4点ベルトであることを受講者へ説明せよ。 ⼩グループ活動 グループ： 受講者を 3⼈ずつのグループに分けよ。 指導内容： 各グループへ硬いウレタンフォームブロックを数個、（座るのにじゅうぶん ⼤きい）硬いウレタンフォームウェッジ 1個、⾻盤ベルト 1本を割当てよ。 受講者へ、グループで以下の作業をしばらくやってみるよう指⽰せよ： • ウレタンフォームを⽤い、どう座⾯を設定すれば、⾻盤が前傾姿勢からよ りまっすぐな姿勢へ「起きる」よう促せるか実験しなさい（⾻盤前傾⽤ウ ェッジをまねなさい）。 • ⾻盤ベルトを⽤い、⾻盤を前傾姿勢からよりニュートラルな座位姿勢へ促 すのに最も効果的な「引っ張る⽅向」を感じ取る実験をしなさい。 説明：受講者には、この活動にグループで 10 分かけ、続いてグループから 全体に戻ってフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 各受講者に、⾻盤姿勢へのウェッジの効果を感じる機会があるようにせよ。 必要なら受講者を先導せよ。 時間： 活動に 10 分取っておけ。 フィードバックに 5 分取っておけ。 フィードバック： 受講者全体へ尋ねよ：⾻盤前傾⽤ウェッジに座ると、⾻盤が後ろへ起きるよ う促されましたか？回答を受けとめ承認せよ。 受講者全体へ尋ねよ：⾻盤ベルトの最も効果的に引っ張る⾓度はどのくらい でしたか？回答を受けとめ承認せよ。 6. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 147 教習員⽤指導書 B.9: 姿勢⽀持具の処⽅（選択）−股関節を⽀える ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 股関節を⽀える姿勢⽀持具を詳述する。 ¨ 2つ以上の姿勢⽀持具について、製作に必要な⼨法を指定する。 教 材 この授業には： ¨ PPTスライド：B.9: 姿勢⽀持具の処⽅（選択）−股関節を⽀える ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ 姿勢⽀持具キット 事 前 学 習 と 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 受講者の作業環境で⼿に⼊る姿勢⽀持具、姿勢⽀持具の材料および製作⽅法。 ¨ 受講者が、どこで⾞椅⼦ユーザーへフィッティングを実施するか、例えば、地域/ユー ザーの家、⼯房、⾞椅⼦サービスセンターなど。これは作業のやり⽅や姿勢⽀持具の 選択に影響する。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、授業計画を読み通す。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 ¨ 姿勢⽀持具キットから⾒本の姿勢⽀持具を取り出し、まとめて教室前⽅のテーブル上 の、教習員が簡単に⼿に取れるところへ配置しておく。 あ ら す じ 1. はじめに 2. 股関節を⽀える 3. 中級⾞椅⼦処⽅（選択）フォーム「必要な姿勢⽀持具・改造」の項⽬を完成 する 4. 要点のまとめ 2 25 15 3 授業時間計 45 148 中級⾞椅⼦サービス教習パッケージ 1. はじめに（2 分） 説明： • この授業で⾒て⾏く姿勢⽀持具は、例えば次の ような、固まってニュートラルでない姿勢の股 関節へ形を合わせるのに役⽴ちます： o ⽚側の股関節が、ニュートラルな座位姿勢ま で屈曲しない（体幹〜⼤腿の⾓度が 90 度 超）。 o 両股関節が、ニュートラルな座位姿勢まで屈 曲しない（体幹〜⼤腿の⾓度が 90 度超）。 o ⽚側または両側の股関節が、ニュートラルな 座位姿勢まで伸展しない（体幹〜⼤腿の⾓度 が 90 度未満）。 • 留意事項：固まった/ニュートラルでない姿勢の股関節は、うまく形を合わせなければ⾻盤姿勢 にも必ず影響を及ぼします。「B.3: ⾝体的事前評価−⾻盤と股関節の姿勢チェック」の授業では、 ⼀時的⽀持を設けてこうした姿勢に形を合わせるやり⽅を⾒てきました。 • この授業では、そうした⼀時的⽀持部を恒久的姿勢⽀持具にするやり⽅を⾒て⾏きます。 • つねに留意すること：姿勢⽀持具は、ふつう単独では処⽅（選択）しません。多くの姿勢⽀持具 は、合わせ技で働くものです。 2. 股関節を⽀える（25 分） 問題：⽚側の股関節が、ニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90度超） 説明：これから、⽚側の股関節だけが、ニュートラルな座位姿勢まで屈曲しない（⽚側の股関節だ け体幹〜⼤腿の⾓度が 90 度超の）場合、どうすればよいか⾒て⾏きます。 質問：前に説明しましたが、この問題にはどんな⼀時的⽀持を設ければよかったでしょうか？ 答え： • 積み増し94（のウレタンフォーム）を、左右の座⾻、および股関節がニュートラルな座位姿勢 まで屈曲する（体幹〜⼤腿の⾓度が 90 度になる）側の⼤腿の下に置く。 94 [原⽂] build-up 149 教習員⽤指導書 説明： • この⽀えは、⽚側の座⾯前⽅を下げてクッショ ンへ恒久的につくり込み、ニュートラルな座位 姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90 度 超の）股関節に形を合わせることができます。 • 座⾯前⽅を下げるには：ウレタンフォームを切 り取る⾓度は、⾞椅⼦ユーザーの体幹〜⼤腿の ⾓度によって変わるため、⾝体的事前評価で調 べておく必要があります。 • 座⾻前⽅（アンカー）サポートを、クッションに 残すよう気を付けて下さい。 問題：両側の股関節が、ニュートラルな座位姿勢まで屈曲しない（体幹〜⼤腿の⾓度が 90度超） 説明： • 両側の股関節が、ニュートラルな座位姿勢まで 屈曲しない（体幹〜⼤腿の⾓度が 90 度超）場合 に、どうすればよいか⾒て⾏きます。 質問：この姿勢の問題に対する⼀時的⽀持は何で したか？ 答え： • 積み増し（のウレタンフォーム）を左右の座⾻ 下に置く。 質問：これは恒久的な解決策になるでしょうか？その理由/そうでない理由は？ 答え： • いいえ。⾞椅⼦ユーザーが、座⾯から前⽅へ滑り出がちになるため。 質問：代わりにどうすればよいでしょうか？ 答え： • 座⾯と背もたれの間の⾓度を広げ、体幹〜⼤腿の⾓度に合わせる。 • しっかりと背中へ⽀えを施し、ユーザーがなるべくまっすぐに座るようにする。 150 中級⾞椅⼦サービス教習パッケージ 両股関節ともニュートラルな座位姿勢まで屈曲し ない場合、取りうる解決策の⼀つは、座⾯と背もた れの間の⾓度を開ける（⼤きくする）ことです。 • 座⾯〜背もたれ⾓度を開けることで、より⼤き い⾓度の体幹〜⼤腿に形を合わせられます。 • その⾓度は⾞椅⼦ユーザーの体幹〜⼤腿の⾓度 に従うため、これは事前評価で決めておく必要 があります。 • 座⾻前⽅（アンカー）サポートおよび⾻盤ベルト を処⽅して、前滑りを防ぐようにしなさい。 問題：⽚側または両側の股関節が、ニュートラルな座位姿勢まで伸展しない 説明：股関節に関わるもう⼀つの姿勢の問題である、⽚側または両側の股関節がニュートラルに座 れるところまで伸展しない（体幹〜⼤腿の⾓度が 90 度未満の）場合について⾒て⾏きます。 全受講者へ、各⾃の席でこの姿勢を取ってみせるよう指⽰せよ。全員の股関節が、膝が股関節より ⾼くなるまで屈曲しているか確かめよ。 質問：だれか解決策を提案できますか？前に説明した、⼀時的解決策を思い出しなさい。励まして 回答を促せ。 答え： • 積み増し（硬いウレタンフォーム製ウェッジ（くさび））を、ニュートラルな座位姿勢まで伸 展しない（体幹〜⼤腿の⾓度が 90 度未満の）⽚側/両側の⼤腿下の座⾻より前⽅に置く。 151 教習員⽤指導書 説明： • 恒久的な解決策として、⼤腿下の座⾻より前⽅ にウェッジ（くさび）を置いて、座⾯前⽅を⾼く することが可能です。 • これで、座⾯と背もたれの間の⾓度が⼩さくな ります。座⾯前⽅を⾼くする程度は、⾞椅⼦ユー ザーの体幹〜⼤腿の⾓度に従います。これは事 前評価で決めておく必要があります。 • 座⾯前⽅を⾼くすると、⾝体の伸展をともなう 制御できない運動や⾼い筋緊張の抑制にも役⽴ ちます。 3. 中級⾞椅⼦処⽅（選択）フォーム「必要な姿勢⽀持具・改造」の項⽬を完成する （15 分） ⼩グループ活動 グループ： 受講者を 2〜3⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.9: 姿勢⽀持具の処⽅（選択）−股関節 を⽀える）を開き、各ユーザーの例話を読むよう指⽰せよ。 受講者へ、協⼒して⾞椅⼦処⽅フォームの「必要な姿勢⽀持具・改造」の箇 所へ、姿勢⽀持具について詳述するよう指⽰せよ。 説明：受講者が、この活動の参考に使えるのは： • 姿勢⽀持具（PSD）⼀覧表と、 • 姿勢⽀持具（PSD）参照表です。 説明：受講者には、この活動にグループで 10 分かけ、続いてグループから 全体に戻ってフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 各グループへ、姿勢⽀持具（PSD）⼀覧表および姿勢⽀持具（PSD）参照表 の活⽤を奨励せよ。 必要なら受講者を先導せよ。 時間： 活動に 10 分取っておけ。 フィードバックに 5 分取っておけ。 152 中級⾞椅⼦サービス教習パッケージ フィードバック： 受講者へ、姿勢⽀持具を描いてみた感想を尋ねよ。 多くの⼈にとり、姿勢⽀持具を正確に描けるようになるには練習が必要であ ることを⼼得よ。 スライドを映せ： 説明：次の⼨法が重要です： • A: 座⾻前⽅（アンカー）サ ポートの始点位置。 • B: 取るべき座⾻前⽅（アン カー）サポートの⾼さ。 • C: 左右の股関節に対する、 座⾯前縁の⾼さの差：これ が、シエンナの右股関節に 合わせる⾓度になります。 質問：どうやってこれらの⼨ 法を決めればよいでしょう？ 答え： • A: シエンナへの⾝体計測（⾻盤背⾯〜座⾻［の距離］）から、座⾻前⽅（ア ンカー）サポートの始点位置を決められる。 • B: 座⾻前⽅（アンカー）サポートの⾼さは、通常 25〜30 mm。 • C: ⼀時的⽀持部の⾼さを測り、⾼さ Cを決める。 スライドを映せ： 説明：次の⼨法が重要です： • A: 座⾻前⽅（アンカー）サ ポートの始点位置。 • B: 取るべき座⾻前⽅（アン カー）サポートの⾼さ。 • CとD両⽅で座⾯〜背もた れ⾓度を開けるために付加 するウェッジの製作に必要 な⼨法を与えます。 質問：どうやってこれらの⼨ 法を決めればよいでしょう？ 153 教習員⽤指導書 答え： • A: ロバートへの⾝体計測（⾻盤背⾯〜座⾻［の距離］）から、座⾻前⽅（ア ンカー）サポートの始点位置を決められる。 • 注記：この計測には、座⾯〜背もたれ⾓度を開けるために付加するウェッ ジ（くさび）を⾒込まねばならない。 • B: 座⾻前⽅（アンカー）サポートの⾼さは、通常 25〜30 mm。 • Cと D: これらの⼨法を決める最もよい⽅法は、ウェッジの「実⼨模型95」 をつくり、⾞椅⼦ユーザーと試してみることである。 説明：こうした姿勢⽀持具をつくる際は、初回フィッティングが終わるまで ウレタンフォームを既定の位置に接着しない⽅が賢明です。そうすれば姿勢 ⽀持具はまだ調節が利き、⾞椅⼦ユーザーへうまくフィットさせられます。 教習員への注記：ロバート向けの⾒本の⾒取り図では、背もたれ上のウェッジは、クッションの 上に追加する柔らかいウレタンフォーム層を、ウェッジの下へたくし⼊れるすき間ができるよう に配置している。この姿勢⽀持具にはさまざまな組み上げ⽅があるため、状況・素材・⼀般的な 技術的解法に応じた、個々のバリエーションを教習員から説明するとよい。 4. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 95 [原⽂] mock-up 154 中級⾞椅⼦サービス教習パッケージ B.10: 姿勢⽀持具の処⽅（選択）−体幹を⽀える ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 体幹を（可能であれば）ニュートラルな座位姿勢で⽀えるか、体幹を⾞椅⼦ユーザー が快適な限りでニュートラルな座位姿勢になるべく近づくように形を合わせる、改造 および姿勢⽀持具を詳述する。 ¨ ⾻盤、股関節、体幹を⽀えるように改造あるいは姿勢⽀持具を設ける、さまざまなや り⽅の問題解決に着⼿する。 ¨ 中級⾞椅⼦処⽅（選択）フォームを、補助を受けながら完成する。 教 材 この授業には： ¨ PPTスライド：B.10: 姿勢⽀持具の処⽅（選択）−体幹を⽀える ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ 中級⾞椅⼦処⽅（選択）フォーム ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ 姿勢⽀持具キット ¨ 姿勢⽀持具の材料 ¨ ⾞椅⼦：各グループに 1 台（各⾞椅⼦ユーザーの例話に出てくる⾞椅⼦と、なるべく 近いものを取り合わせる） ¨ 硬いウレタンフォームのブロック：各グループに 2〜3個 ¨ 硬いウレタンフォームのウェッジ（くさび）：各グループに 2〜3個 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 受講者の作業環境で⼿に⼊る姿勢⽀持具、姿勢⽀持具の材料および製作⽅法。 ¨ 受講者が、どこで⾞椅⼦ユーザーへフィッティングを実施するか、例えば、地域/ユー ザーの家、⼯房、⾞椅⼦サービスセンターなど。これは作業のやり⽅や姿勢⽀持具の 選択に影響する。 155 教習員⽤指導書 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、授業計画を読み通す。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 ¨ 姿勢⽀持具キット、材料、硬いウレタンフォームのブロックとウェッジ（くさび）を 取り出し、これらの器材を教室前⽅のテーブル上に置いておく。 ¨ 教室前⽅に、⾒本の⾞椅⼦をきちんと並べておく。 あ ら す じ 1. はじめに 2. 体幹を⽀える 3. 中級⾞椅⼦処⽅（選択）フォームを完成する 4. 要点のまとめ 2 115 30 3 授業時間計 150 1. はじめに（2 分） 説明： ここまでで⾒てきた姿勢⽀持具は、⾻盤および股 関節を安定させるものでした。 この授業では： • 体幹を⽀える姿勢⽀持具について学びます。 • つねに、まずどうやって⾻盤を安定させるか考 え、その次に体幹への⽀えを考えることが重要、 ということを説明します。体幹にまつわる姿勢 の問題は、多くの場合、⾻盤をしっかりと⽀える ことで解決、あるいは改善します。 この授業の⼤部分、受講者は⼩グループで作業し、 3⼈の異なる⾞椅⼦ユーザーへの、姿勢⽀持具の適 正解を求める問題を解いてもらいます。 この授業を通して受講者は、体幹への姿勢⽀持具 は単独では機能せず、たいてい⾻盤を、場合によっ ては股関節を⽀える姿勢⽀持具とも組み合わされ ていることを分かって下さい。 156 中級⾞椅⼦サービス教習パッケージ 2. 体幹を⽀える（115 分） 受講者全体での活動 グループ： この活動は、受講者全体で実⾏する。 指導内容： 受講者へ、壁の平らな部分を探し、テーブル/ベンチを壁に着けて置くよう 指⽰せよ。各受講者へ、テーブル/ベンチに⾃分の⾻盤を壁にぴったり当て て座るよう指⽰せよ。受講者に、できる限りまっすぐに座るよう説明せよ。 説明：受講者には、この姿勢で 5 分ほど座り、それから全体でフィードバッ クしてもらいます。 モニター： グループを注意深くモニターせよ。 どの受講者も活動を理解しているか確かめよ。 テーブル/ベンチが壁に着いているか、および各受講者が、⾻盤をまっすぐ に起こし壁にぴったり当てて座っているか確かめよ。 必要なら受講者を先導せよ。 時間： 活動に 5 分取っておけ。 フィードバックに 5 分取っておけ。 フィードバック： 質問：こうやって座るのは快適ですか？まっすぐに座れますか？ 答え： • 受講者は、壁が体幹上部を前⽅へ押し出しているように感じるか、 • ⾻盤を前⽅へ動かさなければまっすぐに座れない、と感じるはずだ。 説明： • これが快適でない理由は、 壁がまっすぐな座位姿勢を 妨げるからです。 • 壁があるため、体幹上部を ⾻盤の線より後ろへ動かす ことができません。 • これは、背もたれが平らな ⾞椅⼦に座っている⼈にと っても同様です。 説明：これまで、⾻盤を安定させるためのやり⽅をいろいろ⾒てきました。しかし、それに続いて どうすれば⾻盤の上で体幹を、（可能であれば）ニュートラルな座位姿勢で、あるいはニュートラ ルな座位姿勢になるべく近づけて⽀えられるか、に注⽬することもたいへん重要です。 157 教習員⽤指導書 ⼩グループ活動 グループ： 受講者を 3 グループに分けよ。 指導内容： 各グループに番号（1〜3）を付け、受講者⽤ワークブック（B.10: 姿勢⽀持 具の処⽅（選択）−体幹を⽀える）から適切な⾞椅⼦ユーザーの例話を割り 当てよ。 各グループへ、割り当てられた⾞椅⼦ユーザーの例話に出てくる⾞椅⼦に合 致する（なるべく近い）⾞椅⼦を与えよ。姿勢⽀持具の材料、硬いウレタン フォームのブロックとウェッジを、各グループへ割り当てよ。 説明： • 各グループで、担当の⾞椅⼦ユーザーの例話をよく注意して読みなさい。 • 各グループの⾞椅⼦ユーザーそれぞれに、相異なる個別ニーズがありま す。ただし、どの⾞椅⼦ユーザーについても、⾻盤と体幹への⽀えが必要 だと述べられています。⾞椅⼦ユーザーのうち⼆⼈は、固まっている⾻盤 という問題を抱えています。 • 各グループで、担当する例話に述べられた⾞椅⼦ユーザーが必要とする⽀ えを、どう設けるか決めて下さい。 • グループごとに、その姿勢⽀持具をつくるための、さまざまな選択肢とや り⽅を考えてみて下さい。 説明： • 受講者は、（教習員は使える材料を⽰せ）⽤意したさまざまな材料を⽤い、 与えた⾞椅⼦を使って解決案の「実⼨模型」を最低⼀つつくりなさい。 • 教習員には質問があればいつでもするよう、受講者を励ませ。 • 受講者は、担当の⾞椅⼦ユーザーの例話および解決案を、他のグループへ 発表する準備をしておいて下さい。 説明： • 受講者は、割り当てられた⾞椅⼦ユーザーの例話およびそれに伴う課題 を、60 分で完了して下さい。各グループには受講者全体へフィードバッ クし、姿勢の問題に対する可能な解決案を説明してもらいます。 受講者へ、⾞椅⼦ユーザーの各例話の後の中級⾞椅⼦処⽅（選択）フォーム には、まだ記⼊しないよう指⽰せよ。記⼊は、全グループから受講者全体へ のフィードバックが終わり、処⽅（選択）した解決案に全体が合意した後で。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 各グループを、与えられた⾞椅⼦および材料を活⽤して、担当の⾞椅⼦ユー ザーへ設える姿勢⽀持具の「実⼨模型」をつくるよう励ませ。 各グループが、⾻盤＋股関節➡体幹、の流れを踏んでいるか確かめよ。 必要なら受講者を先導せよ。 時間： 活動に 60 分取っておけ。 フィードバックに 45 分取っておけ。 158 中級⾞椅⼦サービス教習パッケージ フィードバック： 各グループへ、担当の⾞椅⼦ユーザーの例話を、他のグループへ発表するよ う指⽰せよ。受講者が押さえるべきことは： • 担当する⾞椅⼦ユーザーに関する、簡潔な要約。 • その⾞椅⼦ユーザーに必要な⽀えを設えるために、⾃分たちが編み出した 解決案を⽰す。 各グループが解決案を⼀つ発表するごとに、受講者全体へ尋ねよ： • この解決案には賛成ですか？理由は？ • この⽀えをもたらすやり⽅が他にありますか？ 他の技術的解決案で、⽤意される材料や器具しだいで可能なものを検討する よう、受講者を励ませ。 正解が得られているか確かめよ。混乱が⽣じたら、受講者全体で問題を解決 するよう励ませ。下記の「教習員への注記」を⼿引きとして活⽤せよ。 結論として：最優先事項は⾻盤を安定させることだ（または、させるべきだ）、 と各グループへ強調せよ。 教習員への注記： マークは 16 歳で、⾼い位置に脊髄損傷を負っています。背もたれと座⾯がスリングの⾞椅⼦を 持っています。その⾞椅⼦のサイズは適切で、柔らかくて平たいウレタンフォームクッションが 付いています。 マークは、まっすぐに座るのが困難です。かれの背中は丸まったままで、⾞椅⼦に座ると前へ滑 りがちです。かれの座⾻の下および肩甲⾻周りの⽪膚には、⾚斑96があります。 マークが⾞椅⼦へまっすぐに座るには、どの姿勢⽀持具を設ければよいか？ マークへの事前評価から分かることは、⽀えがあればニュートラルな姿勢で座れることだ。姿勢 ⽀持具のうち、マークをニュートラルな座位姿勢で⽀えるために使えるものは： ⾻盤： • 座⾻前⽅（アンカー）サポート：⾻盤をニュートラルな座位姿勢で⽀え、⾻盤後傾を防ぐ。 • ⾻盤後⽅パッド：⾻盤上縁を⽀えてニュートラルな座位姿勢に保ち、⾻盤後傾を防ぐ。 • ⾻盤ベルト（必要ならば）：⾻盤を正しい座位姿勢に保ち、マークが⾻盤後⽅パッドからずれ、 座⾻前⽅（アンカー）サポートから浮き上がらないよう⽌める。 体幹： • 背もたれ⾼を上げる：肩甲⾻への⽀えをもたらす（注記：マークが⾻盤をしっかりと⽀えられ て、よりまっすぐに座った場合、背もたれ⾼を上げる必要が出てくる）。 96 [原⽂] red marks 159 教習員⽤指導書 どうやってこれらの⽀えを、マークの⾞椅⼦へ付加すればよいか？ 1. 座⾯/クッション • マークには新たに、座⾻前⽅（アンカー）サポートと柔らかいウレタンフォームの表層を備え た成形クッションをつくる。 2. 背もたれ ⾻盤後⽅パッドを付加するには、下記のいくつかのやり⽅がある： • 選択肢 1：⻑さ調節できるパッド⼊りベルトを背もたれ布の前⾯に付加し、背もたれフレーム に回して固定する［受講者⽤参考書 p.119 l1を参照］。 • 選択肢 2：硬いウレタンフォームのブロックを背もたれ布の背⾯へ付加し、ベルトを背もたれ ⽀柱97に回して固定する。 • 選択肢 3：張り調整背もたれを付加し、マークの⾻盤上縁をしっかりと⽀えるよう設定する。 • 選択肢 4：スリング背もたれを取り除いてソリッド背もたれを付加する。硬いウレタンフォー ム層を柔らかいウレタンフォーム層が覆い、⼆層の間に硬いウレタンフォームの⾻盤後⽅パッ ドを挟んだものを背もたれに張りつける。背もたれは洗濯できる⽣地で覆う。この選択肢では、 ⾞椅⼦を折りたためなくなることがある。 背もたれ⾼を上げるには、下記のいくつかのやり⽅がある： • 選択肢 1：背もたれフレームが必要な⾼さまで延びれば、上部へ追加の布を取り付ける。 • 選択肢 2：背もたれフレームの⾼さが⾜りない場合は延⻑する。これには、背もたれフレーム を切断し、わずかに細い⽊の棒あるいは⾦属管を差し込む。棒や管は所定の位置へ（⽊なら） ボルト留めか（⾦属の種類によっては）溶接し、追加の背もたれ布を付加するか、必要な⾼さ まで延ばせる背もたれ（例えば張り調整背もたれ）と交換する。 • 選択肢 3：既存の背もたれ布を取り除き、適切な⾼さのソリッド背もたれを、ボルトで留める か受け具98を介して背もたれフレームへ取り付ける。この選択肢では、⾞椅⼦を折りたためな くなることがある。 3. ベルト類 • ⾻盤ベルトを、シートパイプへ取り付ける。 ジョセフィンは 35 歳、脊髄損傷を負っています。農村に住んでおり、地元の教会の活動的メン バーです。前に与えられたのはホイールベースが⻑い⾞椅⼦で、家族が村のがたがた道を楽に押 して⾏けるので、気に⼊っています。屋内の平坦なところでは、⾃分でも少しこげます。⾞椅⼦ のサイズはちょうどよく、ソリッド背もたれと座⾯を備えています。彼⼥は分厚くて平たいウレ タンフォームクッションを持っています。 ジョセフィンには、その⾞椅⼦に座るのは快適ではなく、⾃⼒でこぐのはもっと苦痛です。座っ ている時は⾻盤が後ろへ倒れ（⾻盤後傾）、体幹姿勢が前に弯曲［円背）しています。 97 [原⽂] backrest canes 98 [原⽂] bracket 160 中級⾞椅⼦サービス教習パッケージ ジョセフィンが⾞椅⼦へなるべくまっすぐに座るには、どの姿勢⽀持具を設ければよいか？ ジョセフィンへの事前評価で判明したのは、完全にニュートラルな座位姿勢では座れないこと だ。⾻盤は後傾して固まっており、右股関節はニュートラルな座位姿勢まで完全に屈曲しない（⾓ 度：100 度）。しかし彼⼥の座位姿勢は、座⾻下への⼀時的⽀持、⾻盤へのしっかりした⽀え、体 幹背⾯の⽀えによって改善して（よりまっすぐに起きて）いる。 姿勢⽀持具のうち、ジョセフィンがより安定してニュートラルに近い姿勢で座り、機能をよりよ く発揮できるよう⽀えるのに役⽴つものは： ⾻盤＋股関節： • 座⾻前⽅（アンカー）サポート：よりニュートラルな座位姿勢を促し、⾻盤の前滑りを防ぐ。 • 座⾯前⽅の右側を下げ、固まった右股関節に形を合わせる。 • ⾻盤ベルトを付加してもよい：⾻盤を座⾯後⽅に保ち、ジョセフィンが滑り上がって座⾻前⽅ （アンカー）サポートを乗り越えないよう⽌める。 体幹： • 座⾯〜背もたれ⾓度を開け、ジョセフィンの後傾したまま固まった⾻盤に形を合わせる。 • 背もたれの形状調整：丸まった［円背の］体幹を⽀える。 • フィッティングで、座⾯＆背もたれティルト（ティルトインスペース）を検討する：上記の⽀ えを使ってよりまっすぐに座ると、ジョセフィンの頭部が快適にならない場合に。 どうやってこれらの⽀えを、ジョセフィンの⾞椅⼦へ付加すればよいか？ 1. 座⾯/クッション • ジョセフィンの現在のクッションを改造するか新たにクッションをつくるかして、座⾻前⽅ （アンカー）サポートを備え、座⾯前⽅の右側を下げたものにする。 • クッションは、硬いウレタンフォーム層を柔らかいウレタンフォーム層で覆うようにする。 2. 背もたれ • 座⾯〜背もたれ⾓度を開けるには： o 選択肢 1：⾞椅⼦が、座⾯と背もたれの間の⾓度がリクライニング可能な設計の場合、⾞ 椅⼦を調節し、ジョセフィンの⾻盤後傾の程度に合わせて座⾯〜背もたれ⾓度を広げる。 o 選択肢 2：硬いウレタンフォームのウェッジ（くさび）を、ジョセフィンにとって快適で いちばんまっすぐな姿勢で⾻盤を⽀えるようにつくり、ソリッド背もたれへ接着する。硬 いウレタンフォームのウェッジとジョセフィンの体幹に合わせて成形したウレタンフォー ムは、柔らかいウレタンフォームの⼀層で覆う。洗濯できる布でカバーする。 • 背もたれ形状を修正する o 丸まった体幹を⽀え、それと形が合うように、背もたれの表⾯を成形する。必要な⽀えに 応じて、硬いウレタンフォームを使い必要な箇所に積み増しして形をつくる。完成した ら、背もたれの表⾯全体に柔らかいウレタンフォーム層を重ねる。付加したどのウレタン フォームも、ジョセフィンを前⽅へ押し出さないことを確かめる。 161 教習員⽤指導書 注記： • 上記の座⾯および背もたれの改造によって、有効な座⾯奥⾏きが短くなる場合がある。 • 受講者は、座⾯奥⾏きがじゅうぶんない場合にはどうするか考慮すべきである。 • 選択肢としては： o 選択肢 1：座板を前⽅へ移動できるかどうか調べる（その後、こぐ位置および［⾜が］⾜ 台に届くかを調べる）。 o 選択肢 2：背もたれをもっと後ろへ移動する。そのやり⽅の⼀つは、背もたれを、受け具 を介して背もたれフレームへ取り付けることである。その場合、背もたれフレームがジョ セフィンの上腕/体幹の邪魔にならず、肩を⾃由に動かせるか確かめよ。 3. ベルト類 • ⾻盤ベルトを、シートパイプへ取り付ける。 シアンは 3歳、脳性⿇痺を抱えています。⼿持ちの⼦どもサイズのクロス型折りたたみ式⾞椅⼦ は開き式⾜台を備え、座⾯と背もたれがスリングです。テーブルもクッションも付いていません。 ⾞椅⼦の座⾯奥⾏きは合っていますが、少し幅広です。両親は⾞を持っておらず、たいていの場 所には歩いて⾏きます。両親はかれを⾞椅⼦に乗せて近所を押して回れますが、抱えるだけのこ ともあります。シアンは、平坦なところでは⾃分でも少しこげます。 シアンは、⽀えなしでも短い時間ならまっすぐに座れます。10 分も経つと体幹が崩れ始め、いつ もは左前⽅へ倒れます。このため⾻盤の右側が持ち上がり、より体重が左座⾻へかかります。背 中のカーブは年齢相応です。シアンの⺟親は、かれに他の⼦どもと外で遊べるようになり、⾃分 で⾞椅⼦をこぐようになってほしいと願っています。 シアンが⾞椅⼦へなるべくまっすぐに座るためには、どの姿勢⽀持具を設ければよいか？ ⾻盤＋股関節： • 座⾻前⽅（アンカー）サポート：シアンの⾻盤をニュートラルな座位姿勢で座⾯後⽅に保つ。 • ⾻盤側⽅パッド：⾻盤がニュートラルな座位姿勢で、右側が持ち上がらないよう⽀える。 • ⾻盤ベルト：（3歳なので）安全のため、また⾻盤が持ち上がり⽀えから外れる場合に必要。 • 座⾯前⽅のかさ上げ：シアンの、体幹〜⼤腿の⾓度が 80 度の両股関節に形を合わせるため。 体幹： • 左右の体幹側⽅パッド：シアンの体幹をニュートラルな座位姿勢に保ち、左へ倒れるのを防ぐ。 • テーブル：テーブルはシアンの腕を⽀え、バランスを保ちやすくすることで、より⻑時間、ま っすぐな姿勢で過ごせるようにする。 • 肩ハーネス：少なくとも最初のうち、あるいはシアンがとてもくたびれた時に、胸と肩を背も たれへ着けておくために必要であろう。 • 座⾯＆背もたれティルト（ティルトインスペース）：シアンが左前⽅へ倒れ続ける場合に追加 してよい。 162 中級⾞椅⼦サービス教習パッケージ どうやってこれらの⽀えを、シアンの⾞椅⼦へ付加すればよいか？ 1. 座⾯/クッション • シアンへ、以下を備えたクッションをつくる： o 座⾻前⽅（アンカー）サポート。 o 座⾯前⽅のかさ上げ（座⾻前⽅（アンカー）サポートの始点からクッション前縁まで延 び、シアンの体幹〜⼤腿の⾓度に合ったウェッジ（くさび）を付加）。 • クッションは、スリング座⾯全体を覆う堅い板の上につくるとよい。こうすると、クッション をスリング上に置くよりも⽀えが⼤きくなる。堅い板を使わない場合は、スリング座⾯の形状 に合わせて、クッション底⾯を少し湾曲した形にする。 • ⾻盤側⽅パッドをつくる：張り布を施したブロックを、下記のいずれかへ取り付ける： o ひじ掛け/サイドガード（へ接着）。 o 座⾯または背もたれへ受け具を介して。 2. 背もたれ • 体幹側⽅パッドを付加する： o 選択肢 1：スリング背もたれをソリッド背もたれに交換し、体幹側⽅パッドを背もたれク ッションの背後で、ソリッド背もたれへ取り付ける。体幹側⽅⽀持具を適切な（シアンの ⾝体にじゅうぶん近い）位置に置けるよう、背もたれクッションを切る場合もある。あら ゆる受け具に、緩衝材が利いていることを確かめよ。 o 選択肢 2：体幹側⽅パッドの⽀持部を背もたれフレームへ、受け具を介して取り付ける。 受け具が、体幹側⽅⽀持具をシアンの⾝体にじゅうぶん近い位置へ近づけられる形状にな っていることを確かめよ。 3. 座⾯＆背もたれティルト（ティルトインスペース）： • 座⾯＆背もたれティルト（ティルトインスペース）が必要な場合は、上記のようにソリッド座 ⾯とソリッド背もたれとでつくるとよい。座⾯および背もたれを、受け具を介して取り付け、 座⾯および背もたれを傾けて配置する。座⾯〜背もたれ⾓度を変更してはならない。 • ティルトを加える場合、シアンにはヘッドレストが必要になることに留意せよ。 4. ベルト類 • ⾻盤ベルトをシートパイプへ取り付ける。 • 肩ハーネスをソリッド背もたれ（の上部と下部）に取り付ける。 5. テーブル • シアンにテーブルをつくる場合、⾝体を囲むようにすれば、ひじや前腕をテーブルに置いて⽀ えを増すことができる。 • テーブルは⾞椅⼦のひじ掛けに取り付け、簡単に着脱できることが必要である。 163 教習員⽤指導書 3. 中級⾞椅⼦処⽅（選択）フォームを完成する（30 分） ⼩グループ活動 グループ： 受講者へ、直前の活動と同じグループで作業するよう指⽰せよ。 指導内容： 受講者へ、各⾃のワークブックの中級⾞椅⼦処⽅（選択）フォームを、マー ク/ジョセフィン/シアンについて完成するよう指⽰せよ。 説明：各グループで完成するフォームは⼀つだけ、例話について⾃分たちが 作業した⾞椅⼦ユーザーのものだけです。 説明：受講者には、どの⾞椅⼦ユーザーの⾝体⼨法も与えられておらず、⼨ 法値は⼊れられませんが、どこの⼨法が必要かを記述/図⽰しなさい。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 フィードバックへ移る前に、各グループを巡回してそれぞれの中級⾞椅⼦処 ⽅（選択）フォームを調べ、それぞれのグループがどのくらい完了できたか 調べよ。受講者が困難にぶつかっていたら、すべてメモせよ。 必要なら受講者を先導せよ。 時間： 活動に 20 分取っておけ。 フィードバックに 10 分取っておけ。 フィードバック： 受講者へ、中級⾞椅⼦処⽅（選択）フォームを完成するうえで質問がないか 尋ねよ。 活動中にメモした困難なところを、すべて解明せよ。 4. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 164 中級⾞椅⼦サービス教習パッケージ B.11: 姿勢⽀持具の処⽅（選択）−頭・⼤腿・下腿を⽀える ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ ⾞椅⼦ユーザーの頭・⼤腿・下腿を⽀える、改造および姿勢⽀持具を詳述する。 教 材 この授業には： ¨ PPTスライド：B.11: 姿勢⽀持具の処⽅（選択）−頭・⼤腿・下腿を⽀える ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 動画：頭の⽀え ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ 姿勢⽀持具キット ¨ ⾞椅⼦：各グループに 1 台 ¨ ウレタンフォームクッション：各グループに 1個 事 前 学 習 と 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 受講者の作業環境で⼿に⼊る姿勢⽀持具、姿勢⽀持具の材料および製作⽅法。 ¨ 受講者が、どこで⾞椅⼦ユーザーへフィッティングを実施するか、例えば、地域/ユー ザーの家、⼯房、⾞椅⼦サービスセンターなど。これは作業のやり⽅や姿勢⽀持具の 選択に影響する。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 ¨ 姿勢⽀持具キットから⾒本の姿勢⽀持具を取り出し、まとめて教室前⽅のテーブル上 の、教習員が簡単に⼿に取れるところへ配置しておく。 ¨ 教室の前の⽅に、⾒本の⾞椅⼦をきちんと並べておく。 あ ら す じ 1. はじめに 2. 頭を⽀える 3. ⼤腿を⽀える 4. 下腿と⾜を⽀える 5. 要点のまとめ 2 25 60 30 3 授業時間計 120 165 教習員⽤指導書 1. はじめに（2 分） 説明： • ここまで、⾻盤を安定させ、問題のある股関節を ⽀え、体幹を⽀える、さまざまな姿勢⽀持具を⾒ てきました。 • 次に⾒て⾏く⼀連の姿勢⽀持具は、⾞椅⼦ユー ザーの頭、⼤腿、⾜を含めた下腿を⽀えることに 重点を置いたものです。 2. 頭を⽀える（25 分） 説明： • これまでに⾒てきた例話の⾞椅⼦ユーザーで、 ヘッドレストが必要な⼈はいませんでした。 • しかし、ヘッドレストが必要な⼦どもや⼤⼈も います。 質問：だれか、ヘッドレストが必要な⼦どもや⼤⼈ に関わったことはありますか？回答を受けとめ、 少し話し合わせよ。 166 中級⾞椅⼦サービス教習パッケージ • 問題： • 頭が後ろ・前・横へ倒れがちな場合。 説明： • このスライドのイラストは、頭を⾃分で起こし ておくのが難しい、幼い少年の様⼦です。 • イラストでは、⺟親が腕で少年の頭を⽀えてい るのが分かりますね。 質問：この少年への解決策としては、何が可能でしょうか？励まして回答を促せ。 答え： • 最初に：⾻盤と体幹へしっかりした⽀えを設け、少年をなるべく安定させる。これには： o ⾻盤：⾻盤後⽅パッド、座⾻前⽅（アンカー）サポート、⾻盤ベルト。 o 体幹：少年の体幹へ最適な⽀えをもたらす背もたれの形状調整、肩ハーネス、場合によっ てはティルトインスペース。 • これらの姿勢⽀持具は、頭部のコントロールを改善する。 • 少年が、それでも⾃分で頭を起こしておくのが難しければ、ヘッドレストを設ける。 教習員への注記：適切な⾻盤と体幹への⽀えを設ける重要性を強調せよ。その上で、それでもヘ ッドレストが必要かどうか検討する。 質問：頭のどこを⽀えればよいのでしょうか？ 答え： • 最初に、頭蓋⾻底部を⽀える。 • 必要ならば、⽀えは⾞椅⼦ユーザーの頭の左右へ広げてもよい。 教習員への注記：頭部ベルトを提案する受講者もあろう。この形態の⽀えはとても不快なことが あり、危険性も潜むため推奨できない。頭部ベルトを使うのは⾮常に特殊な状況で、かつ監視が ⾏き届いている場合に限るべきである。 167 教習員⽤指導書 説明： • このイラストは、頭蓋⾻底部に設けたヘッドレ ストを⽰しています。 ヘッドレストの種類は、多種多様です。この教習プログラムでは、2種類のヘッドレストについて お話しします。 説明： • ひとつは平⾯ヘッドレスト99です。 o これは、背もたれを延⻑したものです。 o この背もたれは、⾻盤および体幹の上部と下 部へ⽀えを与えるように成形し、さらに頭も ⽀えるように延⻑しています。 o 平⾯ヘッドレストは頭が休める場所を設け、 頭が後ろへ倒れるのを⽌めます。 • もう⼀つは成形ヘッドレスト100です。 o これは頭の底を「掌で受ける」形をしていま す。 o 成形ヘッドレストは側⾯を前に延⻑し、頭の 側⾯への⽀えを増やすこともできます。 o 成形ヘッドレストは、⾞椅⼦ユーザーの頭蓋 ⾻底部の輪郭に沿っているため、平⾯ヘッド レストより⼤きい⽀えを与えます。 教習員への注記：他種のヘッドレストが地元で⼿に⼊る（そして教習プログラムで提⽰できる） 場合は、それらを受講者に⾒せ、特⾊をすべて説明せよ。 99 [原⽂] flat headrest 100 [原⽂] shaped headrest 168 中級⾞椅⼦サービス教習パッケージ 動画を紹介：「頭の⽀え」。この動画に登場するのはマイケルという幼い少年で、 まっすぐに座って頭を起こしておくのが難しいため、⺟親が事前評価へ連れて来 ました。⾝体的事前評価で⾞椅⼦サービス職員が⾒出したことは： • マイケルの⾻盤は後傾したまま固まっている。 • マイケルは⾞椅⼦上で、前へ⾻盤を押し出して滑りがちである。 • マイケルの体幹上部と頭は前⽅へ倒れており、そこから頭を動かすと完全に起 きたところで頭部のコントロールを失い、頭が後ろへ倒れる。 ⾞椅⼦サービス職員が、マイケルに必要な姿勢⽀持が何か⾒極めるために踏んだ プロセス、およびそれをどうやって⾞椅⼦に設えたか視聴して下さい。 動画を上映。 何か質問がないか尋ねよ。 3. ⼤腿を⽀える（60 分） 説明：すでに、⾻盤を安定させ、問題のある股関節 を⽀え、体幹を⽀え、ヘッドレストを設けるところ まで⾒てきました。 これから、特に⼤腿への⽀えについて⾒て⾏き ます。 ⼩グループ活動 グループ： 受講者を 3 グループに分けよ。 指導内容： 各グループに⾞椅⼦とウレタンフォームクッションを 1つずつ与えよ。各グ ループへ受講者⽤ワークブック（B.11: 姿勢⽀持具の処⽅（選択）−頭・⼤ 腿・下腿を⽀える）の 3つの設問をすべて読み、問いに答えるよう指⽰せよ。 説明： • 各グループは、与えられた⾞椅⼦とウレタンフォームクッションを調べ、 ⾞椅⼦とウレタンフォームクッション（および他の材料や部材）で、どう すれば⾞椅⼦ユーザーに必要とする⽀えをつくれるか考えなさい。 • 考えることは： o ⾞椅⼦全体の設定。 o ⾞椅⼦ユーザーの全体像。 o どの姿勢⽀持具が⼤腿に必要か。 169 教習員⽤指導書 説明： 受講者には、この活動にグループで 30 分かけ、続いてグループから全体に 戻ってフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 必要なら受講者を先導せよ。 時間： 活動に 30 分取っておけ。 フィードバックに 30 分取っておけ。 フィードバック： グループの⼀つに、⾃分たちのジョナーへの 解決案について説明するよう求めよ。他のグ ループへ、違う提案があるか尋ねよ。 受講者が学習の要点（下の教習員への注記を 参照）をすべて押さえているか確かめよ。 ⼤腿外側ウェッジ101（くさび）のスライドを 映せ。 別のグループに、⾃分たちのサムへの解決案 について説明するよう求めよ。他のグループ へ、違う提案があるか尋ねよ。 受講者が学習の要点（下の教習員への注記を 参照）をすべて押さえているか確かめよ。 膝分離パッドのスライドを映せ。 別のグループに、⾃分たちのエリジャへの解 決案について説明するよう求めよ。他のグル ープへ、違う提案があるか尋ねよ。 受講者が学習の要点（下の教習員への注記を 参照）をすべて押さえているか確かめよ。 101 [原⽂] outside thigh wedge, [ISO 7176-26:2007] inferior upper leg support. [訳注] inferior = 下位の・下からの. 170 中級⾞椅⼦サービス教習パッケージ ⼤腿内側ウェッジ102（くさび）のスライドを 映せ。 教習員への注記： • ジョナーが事前評価 に来ました。ハンド・ シミュレーションで、 ジョナーの両脚は外 側へ落ち（外転し）が ちですが、軽く⽀えれ ば両脚をニュートラ ルな座位姿勢へ（膝を 揃えて）置けることが 分かりました。 • ⾞椅⼦およびクッシ ョンにどんな変更を 加えれば、両脚をニュ ートラルな座位姿勢 にして座れると思い ますか？ ジョナーの⾞椅⼦への可能な変更： • 背もたれは低くしてよい。 • 座⾯奥⾏きが短すぎるようなので、⻑くして よい。 • ⾜台が⾼すぎるようで、脚の姿勢の原因はそ れかもしれない。 • 総じて、この⾞椅⼦は⼩さすぎ、もっと⼤き いものが必要だろう。 ジョナーのクッションへの可能な変更： • 座⾻前⽅（アンカー）サポートがあれば、よ りまっすぐに座れるだろう（正⾯からは分か りにくいが、姿勢がずっこけて⾒える）。 • ⼤腿外側ウェッジ（くさび）は、⼤腿の整っ た⾝体配列（アラインメント）を保つ。 ⼤腿外側ウェッジはどうやってつくれるか？ • ウェッジをクッションの上に接着し、ぴった り合うカバーを施してつくる。 • クッション前端から切り込みを⼊れ、硬いウ レタンフォームのウェッジを挿し込んで接 着する。 要点： • ジョナーに必要なのは⼤腿への⽀えだが、全 体像も把握しておくべき。 • ジョナーの⼤腿は、軽く⽀えるだけでよいの で、ウェッジでじゅうぶん（ジョナーの事例 では、⼤腿外側パッドは不要）。 102 [原⽂] inside thigh wedge WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 105 106 r Shaped headrest – a shaped headrest is shaped to ‘cup’ the base of the head. It may be extended at the sides and come forward to give more support at the side of the head. A shaped headrest provides more support than a !at headrest by contouring around the base of the wheelchair user’s skull. When providing a headrest: When providing support for a wheelchair user`s head, always remember that the posture of the head depends also on good pelvis and trunk posture. Avoid providing support at the front of the wheelchair user`s head. Supporting the thighs Problem: Legs drawn outwards (abducted) Support needed r First ensure that the wheelchair user’s pelvis and trunk are stabilized by providing the support required. This may help to bring the legs into a more neutral sitting posture. r Support on the outside of the thighs. PSD solutions r Outside thigh wedges will provide gentle support. Note: In this illustration outside thigh wedges have been added onto a !rm foam layer of a cushion. The !rm foam has a pre seat bone shelf built in. A soft layer of foam should be added over the top of the whole cushion. r Outside thigh pads will provide "rm support. Note: In this illustration the thigh pad is attached to a wooden seat base with a bracket. Room is allowed for a cushion to be placed on top of the wooden seat. 171 教習員⽤指導書 • サムは、この⾞椅⼦を 使って２年になりま す。かれは頭に傷があ り、両脚はたいへん固 く閉じています。事前 評価で、サムの両脚は 内側へ閉じ合ってい るものの、膝どうしを 離せば、よりニュート ラルな座位姿勢を取 れることが分かりま した。しかし、これに はかなり⼒が必要で す。両膝をよりニュー トラルな座位姿勢に すると、サムはバラン スが良くなったと感 じます。 • ⾞椅⼦およびクッシ ョンにどんな変更を 加えれば、両脚をニュ ートラルな座位姿勢 にして座れると思い ますか？ サムの⾞椅⼦への可能な変更： • サムにはクッションが必要。 • 体幹側⽅パッド/ウェッジ（くさび）など、背 もたれの⽀えをもっと多く。 • ⾞椅⼦の幅が、サムには広すぎる。 • ⾜台が不揃いで、修理や交換が必要かもしれ ない。 • （スリング座⾯が助⻑する）⼤腿が内側へ閉 じる傾向を抑えるため、スリング座⾯からソ リッド座⾯への交換を検討するとよい。 • 総じて、この⾞椅⼦は⻑期間使⽤する⾞椅⼦ ユーザーには理想的でない。 サムのクッションへの可能な変更： • 姿勢を⽀えるための座⾻前⽅（アンカー）サ ポート。 • サムの両⼤腿を離しておくために⼒が要る ことから、膝分離パッドを選択。 膝分離パッドはどうやってつくれるか？ • スリング座⾯を硬い座⾯へ交換し、その上に 膝分離パッドを取り付けることを検討（装着 は、サムが着座してから座⾯下の受け具へ差 し込んで固定し、降りる時に取り外すように する）。 要点： • ジョナーと同様、全体像も把握すべき。 • サムの両⼤腿を離しておくために強い⼒が 必要ということは、かれの事例では⼤腿内側 ウェッジがもたらす軽い⽀えではなく、膝分 離パッドのような強固な⽀えが必要である ことを⽰している。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 103 104 Problem: Trunk leans or falls to one side Support needed r Stabilize pelvis. r Provide support at the side of the trunk. PSD solutions r Trunk side wedges – provide gentle support to help maintain the wheelchair user’s trunk in the centre of the backrest. r Trunk side pads – trunk side supports provide !rm support to help keep the trunk in the centre of the backrest support. If one trunk side pad is provided, another one is always provided on the opposite side – may be at a different level. Problem: Fixed or !exible sideways curve of the spine. Support needed r Support on the apex of the curve on one side and the top and bottom of the curve on the other side. 172 中級⾞椅⼦サービス教習パッケージ • エリジャは、かれの⾞ 椅⼦が折りたため、⾞ に載せて職場と往復 できることに満⾜し ています。しかし背中 に炎症があり、両脚が 互いに内旋します。事 前評価で、エリジャは ニュートラルな座位 姿勢で座れ、軽く⽀え れば両脚はニュート ラルな座位姿勢を取 れることが分かりま した。 • ⾞椅⼦およびクッシ ョンにどんな変更を 加えれば、両脚をニュ ートラルな座位姿勢 にして座れると思い ますか？ エリジャの⾞椅⼦への可能な変更： • 座⾯のスリングを張り、たるみを減らす。 • ⾜台〜座⾯⾼を調べる。 エリジャのクッションへの可能な変更： • 姿勢を⽀えるための座⾻前⽅（アンカー）サ ポート。 • ⼤腿内側ウェッジ（くさび）をエリジャのク ッションへ付加し、両⼤腿をニュートラルな 座位姿勢に保てるかどうか試す。 ⼤腿内側ウェッジはどうやってつくれるか？ • ウェッジをクッションの上に接着し、ぴった り合うカバーを施してつくる。 • クッション前端から切り込みを⼊れ、硬いウ レタンフォームのウェッジを挿し込んで接 着する。 要点： • 他と同様、全体像も把握すべき。 • エリジャは折りたためる⾞椅⼦を好むが、ソ リッド座⾯を付加するとそれが困難になる。 しかし、薄い板材をクッションカバーの中で クッションの下へ差し込むようにすると、⽀ えが増し、輸送も困難にはならない。 4. 下腿と⾜を⽀える（30 分） 説明：これから⾒て⾏く姿勢⽀持具は、下腿への ⽀えをもたらし、例えばニュートラルでない固ま った座位姿勢の⾜や膝を⽀えるか、その形に合わ せるものです。 留意事項：これらの解決策は、必要に応じて、⾞ 椅⼦ユーザーの⾻盤、体幹、頭、⾸に設ける⽀え と組み合わせます。 173 教習員⽤指導書 問題： • ⽚膝または両膝が屈曲し、ニュートラルな座位 姿勢より⼩さい⾓度のまま固まっている。 可能な姿勢⽀持具の解決策： • 可能ならば、⾜台を調節して後ろへ移します。 • 可能ならば、⾜台⾓度を調節して⾜に合わせま す。できなければ、⾜台ウェッジ（くさび）を ⽤います。 • ⽀えと保護のため、下腿の前にベルトを設けなさい。 • 座⾯前縁が、⾞椅⼦ユーザーの⽚/両脚の裏を押していないか確かめなさい。座⾯奥⾏きを少し 詰め、クッションに後ろへの斜⾓を付ける103必要があるかもしれません。 • 背が⾼い⾞椅⼦ユーザーには、座⾯前⽅のかさ上げか座⾯＆背もたれティルトを検討しなさい。 これで⾞椅⼦ユーザーの⾜が⾼くなり、前に出て、標準的な⾜台の調節範囲に収まるかもしれま せん。 これらの調整を⾏なう際には、キャスターの回旋が⾃由なままで、⾜台や⾞椅⼦ユーザーの⾜にぶ つからないことを確かめなさい。 ⼿に⼊る⾞椅⼦でこれらの調整ができないかじゅうぶんに調整できなければ、改造が必要なことも あります。 問題： • ⽚膝または両膝が、ニュートラルな座位姿勢ま で屈曲しない。 可能な姿勢⽀持具の解決策： • ⼿に⼊れば、標準的な挙上式レッグレストを供 与します。 • 可能ならば、⾜台を調節して前⽅へ移します。 • 可能ならば、3輪⾞椅⼦を検討しなさい。⾜台は、 中央の⽔平バー上に取り付けるようにします。 • ⾜台を、⽊あるいは⾦属を継ぎ⾜して、前⽅へ延⻑します。 • レッグパイプを前⽅へ延⻑します：これには溶接が必要な場合があるため、⾦属加⼯の知識と技 能に⻑けた⼈が⾏なうべきです。 どの解決策をとる場合も、⾞椅⼦の全⻑を最⼩限にすることは重要です。 103 [原⽂] bevel 174 中級⾞椅⼦サービス教習パッケージ 問題： • ⽚⾜または両⾜が⾜台へ届かず、⾜台を調節し ても⾼さがじゅうぶんでない。 可能な姿勢⽀持具の解決策： • ⾜台の積み増し104：両⽅または⽚⽅だけ、⾜台を （スライドのように）積み増しできます。 問題： • ⾜⾸がニュートラルでない姿勢のまま固まって いる。 可能な姿勢⽀持具の解決策： • ⾜台ウェッジ105（くさび）は現状の姿勢を⽀え、 さらに⾜⾸が変化するのを防ぐために⽤います。 ⾜台ウェッジは、⾞椅⼦ユーザーの⾜に必要な⽀ えに従い、たいてい個別につくります。 ⾜台ウェッジの⽬的は、⾜台が⾞椅⼦ユーザーの ⾜へ接触する⾯積を広げることです。 問題： • 下腿が後ろへ落ち込む。 可能な姿勢⽀持具の解決策： • 下腿ベルト：下腿ベルトはたいてい⾞椅⼦に標 準装備されていますが、ベルト地と⾯ファスナ ーでもつくれます。 104 [原⽂] footrest build-ups 105 [原⽂] footrest wedges. [訳注] 本書では割愛されているが, ここに No.20 のスライドが⼊る. 175 教習員⽤指導書 問題： • ⾜台に乗せた⾜に、制御できない運動があるか 不安定。 可能な姿勢⽀持具の解決策： • ⾜ベルト。 かかとの後ろのベルトは、⾜が後ろへ滑るのを防 ぐのに役⽴ちます。 ⾜⾸周りの⾜ベルトは、⾜が前に動いたり、かかと が持ち上がったりしないように保ちます。 ⾜甲の上の⾜ベルトは、つま先が持ち上がらない ように保ちます。 176 中級⾞椅⼦サービス教習パッケージ 5. 要点のまとめ（3 分） 説明：これらの要点は、これまでの授業で扱った姿 勢⽀持具すべてに当てはまります。 要点を読み上げよ。 何か質問がないか尋ねよ。 実習 1: 事前評価および処⽅（選択） ⽬ 的 この実習が終わるまでに、受講者が以下をできるようになること： ¨ 中級の⾞椅⼦事前評価実施を、グループで補助を受けながらやってみせる。 ¨ 中級の⾞椅⼦の処⽅（選択）作成を、グループで補助を受けながらやってみせる。 教 材 ¨ 教習員⽤観察確認表：実習 1 ¨ 写真撮影同意フォーム ¨ 中級⾞椅⼦事前評価フォームおよび中級⾞椅⼦処⽅（選択）フォーム ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ 各⾞椅⼦ユーザーに、評価ベッドおよび⽬隠しの仕切りがある、清潔で⼈⽬に触れな い事前評価スペース ¨ 硬いウレタンフォームのブロック：各グループに 2〜3個 ¨ 硬いウレタンフォームのウェッジ（くさび）：各グループに 2〜3個 ¨ （事前評価を地域で実施しない場合）⾒本の⾞椅⼦およびクッション ¨ デジタルカメラ ¨ 巻尺またはノギス：各グループに 1本、⾜乗せブロック：各グループに 1 セット 177 教習員⽤指導書 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ ⽂化的要素：例えば、事前評価を男⼥混合で実施するのが適切かどうか。 ¨ 受講者が、⾞椅⼦ユーザーに対して⾞椅⼦事前評価を実施する際の、触ることにまつ わる⽂化的問題に気を付ける。 ¨ ことばの要素：例えば、参加する⾞椅⼦ユーザーが、全受講者と共通のことばを話す かどうか。 ¨ ⾞椅⼦に関する事前評価や処⽅のさい主催/教習実施団体が必要とする⽂書：例えば、 そのサービスへアクセスする⾞椅⼦ユーザーについて、サービス事業で収集する必要 がある追加情報（例：紹介・相談元）。 ¨ 事前評価/処⽅中に起きた問題で、授業や教習内では対処しきれないものを、教習員が どう取り扱うか。例えば⾞椅⼦ユーザーの追加ニーズで、紹介・相談が必要、または 授業や教習プログラム中に供与や最終決定ができない移動⽀援機器/姿勢⽀持具が必 要な場合。 準 備 ¨ ⾞椅⼦ユーザー志願者と、時間や旅程を確認する。⾞椅⼦ユーザーおよびその家族/⽀ 援者には、軽⾷が⽤意されるようにする。 ¨ ⾞椅⼦ユーザーが到着しだい出迎え、実習開始までの待機場所へ案内する⼈を、1 ⼈ 任命する。 ¨ 各グループに、⽬隠しの仕切りが付いた評価ベッド 1 台を⽤意する。各種の事前評価 に必要な、すべての器材を評価ベッドに置く。 ¨ ⾒本の⾞椅⼦およびクッションが、正しく動作することを確かめる。 ¨ 受講者が 3グループを超えれば、他の教習員にグループのモニターを⼿伝ってもらう。 ¨ どの受講者どうしが、どの⾞椅⼦ユーザーと作業するか決めておく。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 あ ら す じ 1. 事前評価および処⽅実習： • 諸指⽰と段取り • 事前評価 • 処⽅（選択） • フィードバック 15 45 30 30 実習時間計 120 178 中級⾞椅⼦サービス教習パッケージ 1. 事前評価および処⽅の実習（120 分） 教習員への注記： 1. 写真： • 各⾞椅⼦ユーザーへ、その写真撮影に対する署名済みの写真撮影同意フォームを請求せよ。⾞ 椅⼦ユーザーが、⾃分の許可が任意のもので、撮影した写真をこの教習プログラムで、さらに 教習を実施する⽬的で使うのを理解しているか確かめよ。 • 実習中、許可を得た各⾞椅⼦ユーザーの写真を、以下のように撮影せよ： o 既存の⾞椅⼦に（⾞椅⼦を持っていれば）座っているところ（正⾯および横から）。 o ⾝体的事前評価中（⽀えなしの座位姿勢）。 2. 実習する受講者への観察： • 実習 1⽤「教習員⽤観察確認表」を⽤い、グループが実習の全作業段階を遂⾏しているか確か め、よく⽬にした優れた、あるいは改善を要する実践の例をフィードバックのためにメモせよ。 ⼩グループ活動 グループ： • 受講者を 3⼈ずつのグループに分けよ。 • 各グループのリーダーを任命せよ。 • 各グループへ、いっしょに作業する⾞椅⼦ユーザーの名前を伝えよ。 • 各グループへ作業場所を割り当てよ。 • 受講者へ、必要な器材がどこにあるか説明せよ。 指導内容： 以下をすべて説明せよ： 実習の⽬的： • この実習の⽬的は、⾞椅⼦ユーザーに対して、事前評価および処⽅（選択） を実施することです。 • 受講者は、きょういっしょに作業した同じ⾞椅⼦ユーザーと今後もいっし ょに作業し、教習プログラムの終盤で、きょう選択した⾞椅⼦をフィッテ ィングし、⾞椅⼦ユーザー教習を実施してもらいます。 • 教習プログラム中に⾞椅⼦ユーザーの⾞椅⼦を完全に仕上げられなかっ た場合も、⾞椅⼦が完成されるように⾞椅⼦ユーザーと調整します。受講 者は、それでもなるべく多くの作業をこなすようにして下さい。 リーダー： • 各グループのリーダーには、⾞椅⼦の事前評価および処⽅（選択）に関す る、全作業段階の実施を確認する責任があります。 • リーダーは、⾞椅⼦ユーザーやその家族/介助者と話す主役となって下さ い。これは同時にしゃべる⼈が多すぎて皆が混乱しないためです。 179 教習員⽤指導書 教習員による観察および⽀援： • 受講者は、補助や説明はいつでも求めて下さい。 • 実習の間じゅう、教習員は各グループをモニターし、必要に応じてできる 限り⽀援し、助⾔します。 • 事前評価が完了したら、受講者は教習員のひとりを呼び、来たら⾃分たち の中級⾞椅⼦事前評価フォームを確認させて下さい。 • 処⽅が完了したら、受講者は教習員のひとりを呼び、来たら⾃分たちの中 級⾞椅⼦処⽅（選択）フォームを確認させて下さい。 制限時間： • 事前評価を 45 分、処⽅（選択）を 30 分での完了が⽬標です。 • 受講者へ尋ねよ：事前評価の⼿順には何がありましたか？正解を受けとめ 承認せよ。 • 受講者へ尋ねよ：処⽅（選択）の⼿順には何がありましたか？正解を受け とめ承認せよ。 各サービスフォーム： • 中級⾞椅⼦事前評価フォームおよび中級⾞椅⼦処⽅（選択）フォームを、 各グループのリーダーへ 1部ずつ配布せよ。 • 実習の終わりに記⼊済み各サービスフォームを集め次の実習で配布せよ。 受講者へ、作業のどの段階でも積極的に⾞椅⼦ユーザーの参画を得なければ ならないことを念押しせよ。 質問：何か質問はありますか？どんな質問にも答えよ。 各グループへ、作業区域を整え、続いていっしょに作業する⾞椅⼦ユーザー へ⾃⼰紹介してから取りかかるよう指⽰せよ。 モニターおよび ⽀援： グループを注意深くモニターし、実習が安全に⾏われるようにし、受講者の 技能を観察し評価せよ。 教習員⽤観察確認表を⽤い、各グループへの所⾒を記録せよ。 実習全体を通して： • 時間を（⼝頭で、あるいは受講者全員から⾒えるように板書して）予告し、 受講者が時間をうまく使えるようにせよ。 • ⾞椅⼦ユーザーが、積極的に参画しているか確かめよ。 • どのグループメンバーも、積極的に参画しているか確かめよ。 実習の終わりに受講者へ、⾞椅⼦ユーザーへその参加に対して感謝を述べ、 処⽅（選択）した⾞椅⼦はこれから下準備し、次に授業へ参加いただいた時 には試⽤する準備ができていると説明するよう、指⽰せよ。 実習中に、写真撮影同意フォームへ署名した⾞椅⼦ユーザーを撮影せよ。 180 中級⾞椅⼦サービス教習パッケージ 時間： 諸指⽰と段取りに 15 分、事前評価の完了に 45 分、処⽅（選択）の完了に 30 分、フィードバックに 30 分取っておけ。 教習員⽤観察確認表に、時間経過を記せ。 フィードバック： 実習で⽬にした、優れた実践の例についてコメントせよ。 受講者に特に改善を要する⾯があれば、指摘せよ（個⼈をあげつらうな）。 質問：何か質問はありますか？ 教習員への注記：実習中は、時間経過によく気を付けることが⼤切。上記の時間配分はあくまで も⽬安で、受講者の経験、⾞椅⼦ユーザーのニーズ、段取りに要する時間に従って変動しうる。 教習員には、必要に応じた調整が求められよう。 B.12: 製品（⾞椅⼦）の下準備 ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 付加姿勢⽀持を必要とする⾞椅⼦ユーザーのための、⾞椅⼦および姿勢⽀持具の下準 備プロセスを詳述する。 教 材 この授業には： ¨ PPTスライド：B.12: 製品（⾞椅⼦）の下準備 ¨ 受講者⽤参考書 ¨ 動画：製品（⾞椅⼦）の下準備 ¨ 動画：⾜台に改造を加える ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ ラミネート済み中級⾞椅⼦の安全・準備完了確認表：各受講者に 1部ずつ ¨ 姿勢⽀持具キット ¨ 姿勢⽀持具の材料 ¨ 作業台または頑丈な机 181 教習員⽤指導書 事 前 学 習 と 状 況 事前学習： ¨ ⼿動⾞椅⼦を⾞椅⼦ユーザーの体格へ合致させる調整に関する情報は、「基礎⾞椅⼦ サービス教習パッケージ（WSTPb）」で取り上げている。この授業に臨む受講者は、 以下をすでにやれるべきである： • ⾞椅⼦を調整して、⽀えなしでまっすぐに座れる⾞椅⼦ユーザーへ物理的にフィット させる。 • ⾞椅⼦が、使⽤するのに安全で準備できているか、中級⾞椅⼦の安全・準備完了確認 表を⽤いて確認する。 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 現地で⼿に⼊る⾞椅⼦の種類。 ¨ どこで、どうやって、どんな材料で姿勢⽀持具の製作や改造を⾏なうか。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 ¨ 姿勢⽀持具キットから⾒本の姿勢⽀持具を取り出し、まとめて教室前⽅のテーブル（作 業台）上の、教習員が簡単に⼿に取れるところへ配置しておく。 ¨ 教室を、部屋の前⽅を囲んで受講者が半円形に座れるように配置しておく。 あ ら す じ 1. はじめに 2. ⾞椅⼦および姿勢⽀持具の下準備を計画・実施する 3. 姿勢⽀持具をつくる際の留意事項 4. 姿勢⽀持具および改造部づくりに必要な材料 5. 要点のまとめ 7 10 10 30 3 授業時間計 60 1. はじめに（7 分） 説明： • ⾞椅⼦サービス提供の第 5ステップは、製品（⾞ 椅⼦）の下準備です。 • 製品（⾞椅⼦）の下準備とは、処⽅（選択）通り に⾞椅⼦を設定し、あらゆる姿勢⽀持具を下準 備することです。 182 中級⾞椅⼦サービス教習パッケージ • 中級教習プログラムでの⾞椅⼦の下準備は、ふつ うフィッティングが必要になる前のある段階まで しかできません。 • ⾞椅⼦サービスの「製品（⾞椅⼦）の下準備」と 「フィッティング」の 2 ステップは、⾞椅⼦が適 切にフィットするまでくり返されます。 • 初回フィッティング前には、たいてい姿勢⽀持具 を決まった位置へ完全に固定しません。これは、 ⾞椅⼦および姿勢⽀持具をフィッティング後も調 節できるようにしておくためです。 質問：受講者は、姿勢⽀持具のうち、いちど⾞椅⼦ユーザーが⾞椅⼦に座ってから調整する必要が、 いちばん出てきそうなものは何だと思いますか？回答を受けとめ承認せよ。 答えには、下記の姿勢⽀持具その他がありうる： • ヘッドレスト、座⾻前⽅（アンカー）サポート、体幹側⽅パッド、⾜台〜座⾯⾼、⾜台へのあ らゆる改造など。 説明：これは、付加姿勢⽀持が必要な⼈へ⾞椅⼦を下準備する際の重要な留意事項です。可能な限 り、⾞椅⼦および姿勢⽀持具の下準備はフィッティング前になるべく多く済ませておくようにすべ きです。ただし、簡単に再調整できないものは、固定したり張り布を施したりしてはなりません。 説明：この授業では： • 製品の下準備を計画するやり⽅を話し合い、 • 姿勢⽀持具を下準備する際の、重要な留意事項 を列挙し、 • 姿勢⽀持具の製作に使える、さまざまな材料に ついて話し合います。 説明：この授業の直後に、受講者には⾞椅⼦の下準 備を、実習 1 で事前評価した⾞椅⼦ユーザーに対 してやってもらいます。 183 教習員⽤指導書 動画を紹介：「製品（⾞椅⼦）の下準備」 • この動画では、⾞椅⼦の下準備の⼀例を視聴します。動画に登場するのはアリ という⼦どもです。必要なほど⾞椅⼦からの⽀えがないため、⾞椅⼦の再評価 のために⾞椅⼦サービス事業所へ戻って来ました。 • アリには側弯（脊柱の横⽅向への弯曲）があり、⾻盤の⽚側が上がったまま固 まっています。体幹の筋⼒はたいへん弱いです。⾞椅⼦サービス職員は、アリ の⾞椅⼦がもたらす⽀えを増やすために作業します。 • 2⼈の⾞椅⼦職員が、どう密接に協⼒し、アリとその⺟親をあらゆる話し合い に加えているかに注⽬して下さい。 • また⼀つ変更/調整を加えるごとに、どうやって姿勢⽀持具のフィッティング を確かめているかにも注⽬して下さい。 動画を上映。 何か質問がないか尋ねよ。 2. ⾞椅⼦および姿勢⽀持具の下準備を計画し実施する（10 分） 説明： • この教習プログラムでは、次の順序で作業を進 めます： A: 計画と準備 B: フィッティング⽤の⾞椅⼦の調整と姿勢⽀持 具勢⽀持具の下準備 C: ⾞椅⼦の安全・準備完了確認の実施 A: 計画と準備 • ⾞椅⼦の下準備を始める前に、作業計画を⽴てることが⼤切です。 • ⾞椅⼦の下準備作業を他の⼈（例えば⼯房で働く技師）へ引き継ぐ、または複数⼈で⾞椅⼦の下 準備に当たる場合には、綿密な計画がとりわけ重要になります。 計画と準備で踏むステップは： • 中級⾞椅⼦処⽅（選択）フォームを読み直します： o 全員が、フォーム上の情報をすべて理解しているか確認しなさい。 o フォーム上の情報で、⾞椅⼦の下準備がじゅうぶんやれるか確認しなさい。例えば、必要な ⼨法がすべて出ているか？それぞれの姿勢⽀持具の仕様説明はじゅうぶん詳しいか？さらに 議論や説明が必要になる場合もあります。 184 中級⾞椅⼦サービス教習パッケージ • 選択した⾞椅⼦で、どうやって必要な⽀えを実現するか決めます： o 使⽤する⾞椅⼦を調べて、問うてみなさい： − どんな調整を⽬前の⾞椅⼦に施せば、必要な⽀えをもたらせるか？ − どんな姿勢⽀持具が、すでに⾞椅⼦に付いているか？ o 改造や姿勢⽀持具の追加が必要な場合、判断しなさい： − 既製の⽀持具で使えるものがあるか？もしあれば、どうやってこの⾞椅⼦に取り付けら れるか？ − 改造部や姿勢⽀持具を原材料からつくる必要がある場合、どんな材料を使い、どうやっ てその姿勢⽀持具を⾞椅⼦に固定すればよいか？ − 姿勢⽀持具と⾞椅⼦とがどう連動するのか、考えるのを忘れないようにしなさい。 • タスク表を準備します： o ⾞椅⼦を下準備するために実施すべきタスクを列記しなさい。 o 複数⼈で作業する場合は、だれがどのタスクを担当するか決めなさい。 B: フィッティング⽤の⾞椅⼦の調整と姿勢⽀持具の下準備 • 受講者⽤参考書 p.112-127 「姿勢⽀持具のつくり⽅」を参照しなさい。 C: ⾞椅⼦の安全・準備完了確認の実施 ⾞椅⼦の安全・準備完了確認表は、「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」で教わりまし たね。受講者へ、中級 WSTP 受講者⽤参考書の中級⾞椅⼦の安全・準備完了確認表を参照するよう 指⽰せよ。 質問：皆さん、この確認表を使うのには慣れていますか？この確認表の記⼊⽅法について、質問が ある⼈はいますか？どんな質問にも答えよ。 • この確認表は、⾞椅⼦ユーザーがフィッティングへ訪れる前に完成しているべきです。 • 各回のフィッティング後に、さらに調整が必要になることもあります。 • ⾞椅⼦は、調整や変更のたびに、使⽤するのに安全で準備できているか確かめる必要があります： ⾞椅⼦ユーザーが試⽤する前に。 説明：「製品（⾞椅⼦）の下準備」と「フィッティング」の 2 ステップは⾞椅⼦が正しくフィット するまで何度かくり返す必要があるかもしれないことを、覚えておいて下さい。 185 教習員⽤指導書 3. 姿勢⽀持具をつくる際の留意事項（10 分） 説明：教習プログラムの最初で、⾞椅⼦ユーザーが 何を欲しているのかお話ししました。⾞椅⼦およ び付加姿勢⽀持部は、必ず次のようにすることが 重要だとお話ししました： • 実⽤的で使いやすい。 • 快適で、余計な不快感を与えない。 • ⾞椅⼦ユーザーがやりたいことをやるのに役⽴ ち、より困難にしない。 • ⾒た⽬がよく、「悪⽬⽴ち」しない。 説明：次は、付加姿勢⽀持部を下準備する際の勘どころです： 1. 姿勢⽀持具からの⽀えは必要最⼩限106に 質問：実習で⾞椅⼦ユーザーと作業した時、いつも ⼿全体を使って⽀えましたか？励まして回答を促 せ。 答え： • 時には⼿全体で。 • 時には指先だけで。 • 時には⼿の⼀部で。 説明：⽀えの量は、個々の⾞椅⼦ユーザーによって違います。姿勢⽀持具は、⼀⼈ひとりの⾞椅⼦ ユーザーが必要とする⽀えを、正しい位置で、正しい広さの体表⾯へ107もたらすべきです。 106 [原⽂] PSDs should provide just enough support 107 [原⽂] in the right place, and over the right amount of surface area 186 中級⾞椅⼦サービス教習パッケージ 2. 姿勢⽀持具と⾞椅⼦は⼀体となって連動 する108 • ⾞椅⼦に付加姿勢⽀持を設けると、システム全 体が変わる可能性があります。 例えば： o 姿勢⽀持具を付加すると、⾞椅⼦の内⼨が変 わる場合があります。 質問：どの姿勢⽀持具が、最も⾞椅⼦部材の内⼨（例えば座幅や座⾯奥⾏き）へ影響しやすいと思 いますか？回答を受けとめ承認せよ。 答え： • ⾻盤側⽅パッドを付加すると、有効な座幅が狭まる。 • 背もたれ表⾯へ付加する姿勢⽀持具はすべて、有効な座⾯奥⾏きを「縮め」うる。例えば： o ⾻盤後⽅パッド o 座⾯〜背もたれ⾓度を開けるためのウェッジ（くさび）の付加 • クッションを追加するかクッションの厚さを増すと、⾞椅⼦に座った⾞椅⼦ユーザーの位置が ⾼くなる。そのため、じっさいのクッション上端〜背もたれ上端の間隔は短くなる。 説明：⾞椅⼦と姿勢⽀持具とがどう相互作⽤するかの他の例としては： • 姿勢⽀持具の付加（例えば、ヘッドレストや重い部材の付加）によって、⾞椅⼦の重⼼が変動し、 それで転倒しにくく、あるいはしやすくなることがあります。 3. 強い圧⼒が⽣じるところをつくらない 姿勢⽀持具が、⾞椅⼦ユーザーの⾝体のある⼀部 分への圧⼒を引き起こすことがあります。例えば： • ⾞椅⼦ユーザーが横へ傾くのを防ぐために⼤き い⽀持⼒が必要な場合、体幹側⽅パッドが強い 圧⼒が⽣じる部分になりえます。こうした状況 では、接触⾯積を増やして⼒を分散することを 検討しなさい。つねに、姿勢⽀持具の表⾯やベル トの内側に、じゅうぶん緩衝材が効いているか 確かめなさい。 108 [原⽂] PSDs and wheelchairs work together as a whole system 187 教習員⽤指導書 4. 姿勢⽀持具は実⽤的かつ機能を損なわな いように 質問：姿勢⽀持具が実⽤的で、かつ機能を損なわな いためには、何を考慮すべきでしょうか？ 答え： • ⾞椅⼦ユーザーが、⾞椅⼦を⾞のトランクに載せて運んでいる場合、付加したどの姿勢⽀持具 も収まることを確かめる。 • ⾞椅⼦ユーザーが⾃⼒移乗している場合：付加した姿勢⽀持具のために、移乗が難しくなって いないか？ • ブレーキは、⾞椅⼦ユーザー（または介助者）にとって操作しやすいままか？ • ⾞椅⼦ユーザーが、⾃⼒で⾞椅⼦をこげていた場合、依然できているか？ 説明：留意事項：⾞椅⼦ユーザーが求める⾞椅⼦および座位保持とは、実⽤的で使いやすく、でき る限り活動的になれるものです。 説明： • 姿勢⽀持具には、たいへん簡便で、簡素な⼯房でつくれるものもあります。他のもっと複雑で、 熟練技能や設備が必要なものもあります。 • ⾞椅⼦サービス職員は、⾃分⾃⾝で改造部や姿勢⽀持具を造作する必要はありません。技師と組 んで作業することも可能です。⾞椅⼦サービス職員が、何をつくる必要があり、どう機能すべき か説明できれば、技師は地元で⼿に⼊る資材や⼯具を⽤い、そのつくり⽅を案出できます。 4. 姿勢⽀持具および改造部づくりに必要な材料（30 分） 教習員への注記： • この項は、受講者が地元の資源から得られる材料、およびこの教習プログラムでのデモに使え る材料によって変わる。 • できればこの授業は、受講者が実習 2で姿勢⽀持具をつくるのと同じ⼯房/スペースで実施せ よ。材料を⼤きな作業台の上に並べ、受講者にその周りに集まるよう指⽰せよ。 188 中級⾞椅⼦サービス教習パッケージ 動画を紹介：「⾜台に改造を加える」。この動画で視聴するのは、⾞椅⼦サービス 職員が、⾜⾸の姿勢がニュートラルでないまま著しく固まっているタシのため に、⾜台へ改造を施す様⼦です。使った材料が分かるよう、注意深く視聴して下 さい。 動画を上映。 何か質問がないか尋ねよ。 質問：⾜台の改造に、どんな材料を使っていましたか？ 答え： • 硬い EVA109発泡材。 • ゴムのビーチサンダルも使った。 • ウレタンフォーム⽤糊/接着剤 下表の各種材料、およびこれらの材料でつくった各種姿勢⽀持具の⾒本を⽰せ。 どの材料が使え、また材料を選ぶさい何に留意すべきか説明せよ。 下の注記を⼿引きに⽤いよ。 材料 姿勢⽀持具や改造部への⽤途： 姿勢⽀持具や改造部の材料を選ぶ際の留意点： ⾦ 属/ プ ラ ス チ 8 ク/ ⽊ 材 ⾦属/プラスチック/⽊材は姿勢⽀持 具の構造体を形づくる。例えばソリッ ド座⾯や背もたれなど。 ⽊材あるいは⾦属は体幹側⽅パッドを 背もたれへ固定する受け具に使える。 12 mm厚の合板は、ソリッド座⾯や背もたれをつくる のにたいへん便利である。丈夫だが⽐較的軽い。マリ ン［耐⽔］合板は、最も耐久性があるが⾼価。 3 mm厚のアルミ板および 6 mm厚のアクリルまたは ABS樹脂板が⼿に⼊れば、ソリッド背もたれの製作に 使える。板を折り返すと剛性が増す。 どんな板材を⽤いる場合も、⾞椅⼦ユーザーの安全の ため、鋭い⾓を取り除くか覆うよう、特に注意を払う。 109 [訳注] Ethylene-vinyl acetate の略, エチレン酢酸ビニル. 発泡体はバスマットや靴のミッドソールなどに⽤いる. 189 教習員⽤指導書 ウ レ タ ン フ @ A ム/ 緩 衝 材 ウレタンフォームは、あらゆる姿勢⽀ 持具で、姿勢⽀持具が⾞椅⼦ユーザー の⾝体へ直接触れる部分に⽤いる。 形状を保てる硬いウレタンフォーム は、姿勢⽀持具に、的確な⽀えに必要 な形状を与えるために⽤いる。 柔らかいウレタンフォームは、快適さ を⾼め、減圧するために⽤いる。 ウレタンフォームの使⽤例： • ベルトにはウレタンフォームを付 加し、圧⼒を分散して快適さを⾼ めること。 • 硬いウレタンフォームは、体幹側 ⽅ウェッジ（くさび）の製作に使 え、クッションに付加して、⼤腿外 側ウェッジや⼤腿内側ウェッジの 製作に使える。 • （EVA など）たいへん硬いウレタ ンフォームは、⾜台の積み増しや ⾜台ウェッジ、また体幹側⽅パッ ドの製作に使える。 現地の市場を調べ、ウレタンフォーム、靴、マットレ ス、家具⼯場を訪ねて、現地で⼿に⼊るウレタンフォ ームを探す。 現地に出回る、さまざまな厚さ（25 mmおよび 50 mm） とさまざまな硬さのウレタンフォームを探す。 EVA は⾮常に硬いウレタンフォームの⼀例で、姿勢⽀ 持具に強固な⽀えと構造を与える。EVA は、靴の製造 所で⾒つかることがある。 ビーチサンダル製造⽤の硬いゴムは、EVA の代⽤に なる。 良質なチップウレタンフォーム110は、中程度に硬いウ レタンフォームの⼀例。チップウレタンは成形/多層 構造クッションの基層、⾻盤後⽅パッド、座⾻前⽅（ア ンカー）サポートづくり、ソリッド背もたれの成形に 使える。 柔らかい「マットレス⽤ウレタンフォーム」は、⼼地 よい層に使う柔らかいウレタンフォームの⼀例。 最も広く⼿に⼊り、最も安価な「超柔軟」ウレタンフ ォームは、硬いウレタンフォームの基層なしに、単独 で除圧クッションをつくるには不適切である。 コイヤー［またはコイア］111（ココナッツ繊維）は、 硬いウレタンフォームの代⽤になる。 布 布は姿勢⽀持具のカバーに使う。 耐久性があり、（拭くか取り外して洗濯して）清潔にし やすい布を探す。耐⽔⽣地は、⾞椅⼦ユーザーに失禁 がある場合、座⾯、クッション、背もたれに便利。柔 らかい T シャツのような素材（⽊綿や綿/ライクラ混 紡）はヘッドレスト、体幹側⽅パッド、体幹側⽅ウェ ッジに使える。伸縮する⽣地の⽅が、姿勢⽀持具の形 状に合わせやすい。 通常、合成繊維は天然繊維より⾝体に熱がこもる。 最低数種類は違う⾊を揃え、可能であれば⾞椅⼦ユー ザーに選んでもらう。 110 [原⽂] chip foam 111 [訳注] ロープや⽞関マットの他, 天然ゴムで繊維をコーティングしたものがクッション素材に⽤いられている. 190 中級⾞椅⼦サービス教習パッケージ ナ イ ロ ン ベ ル ト 地/ ⾯ フ N ス ナ A/ バ 8 ク ル ナイロンベルト地/⾯ファスナー/バ ックルは、⾻盤ベルト、肩ハーネス、 下腿ベルト、⾜ベルトなど、ベルト類 の製作に使う。 25 mm、35 mm、50 mm幅のナイロンベルト地が便 利。ベルトは、幅広いほど圧⼒が均等になる。ナイロ ンベルト地の切り端は溶かし、ほつれ⽌めする。綿ベ ルト地は、効果がたいへん劣る。 （バックパックに使うような）ワンタッチバックル は、たいへん使いやすい。⼿に⼊れば、⻑持ちするよ う品質のよいものを⽤いる。試験は、バックルを留め た状態で引き離してみる。着脱しやすく、外さない限 り引き離されないものにする。 ⾯ファスナーはよい留め具だが、掃除しておかないと 効かなくなる。 ベルトの内側には、必ず柔らかいウレタンフォームの 緩衝材を⼊れ、⾞椅⼦ユーザーの⾝体を保護する。 接 着 剤 接着剤は、⽊材やウレタンフォームの 接合に使う。 ⽊⼯⽤接着剤（いっぱんに⽩ボンドや PVA として知ら れる）およびウレタンフォーム⽤接着剤（コンタクト 型接着剤、靴⽤接着剤、⻩⾊ボンド）を常備しておく。 接着剤を⽤いる⼈が、正しい使い⽅を知っているよう にする。 接 合 部 品 接合部品は、姿勢⽀持具の⾞椅⼦への 取り付けに使う。 次の接合部品が便利： • ボルトとナット（ロックナットが好適）、ワッシャー • Tナット（ナット代わりに、合板に⾷い込んで固定） • ステープル（張り布固定⽤） 尖ったネジの使⽤は、姿勢⽀持具が破損した時に危険 なので避ける。 5. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 191 教習員⽤指導書 実習 2: 製品（⾞椅⼦）の下準備 ⽬ 的 この実習が終わるまでに、受講者が以下をできるようになること： ¨ 付加姿勢⽀持を必要とする⾞椅⼦ユーザーに対する、⾞椅⼦および姿勢⽀持具の下準 備を、グループで補助を受けながらやってみせる。 教 材 ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ 教習員⽤観察確認表：実習 2 ¨ 実習 1の中級⾞椅⼦事前評価フォームおよび中級⾞椅⼦処⽅（選択）フォームを、⽩ 紙のものと記⼊済みのもの ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ ラミネート済み中級⾞椅⼦の安全・準備完了確認表：各受講者に 1部ずつ ¨ 姿勢⽀持具キット ¨ ⾞椅⼦および姿勢⽀持具の材料 ¨ 作業台および⼯具キット：各グループに 1つずつ 事 前 学 習 と 状 況 事前学習： ¨ 基礎レベルの製品（⾞椅⼦）の下準備：「基礎⾞椅⼦サービス教習パッケージ」を参照。 ¨ ⾞椅⼦の安全・準備完了確認表の実施⽅法：「基礎⾞椅⼦サービス教習パッケージ」を 参照。 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 各⾃の勤務地で作業しなければならない、⾞椅⼦、姿勢⽀持具の材料、⼯具。 ¨ ⾞椅⼦の組み⽴てや、原材料からの製作にかかる作業量。教習員は、これらの要因に 応じて、この実習の時間（は教習プログラム全体の時間割に影響を及ぼしうる）を調 整する必要がある。 準 備 ¨ 製品（⾞椅⼦）の下準備に精通した技師に、教習員を補助し、受講者を⽀援してもら うよう段取っておく。 ¨ 受講者に、この実習では⾜を覆う靴を履くよう予告しておく。 ¨ 選択した⾞椅⼦を、作業場所へ運んでおく。 ¨ 各グループの作業場所を準備し、作業台、⼯具キットを揃え、姿勢⽀持具の材料を受 講者が効率よく作業できるように配置しておく。 ¨ 姿勢⽀持具キットから⾒本の姿勢⽀持具を取り出し、まとめて教室前⽅のテーブル（作 業台）上の、教習員が簡単に⼿に取れるところへ配置しておく。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 192 中級⾞椅⼦サービス教習パッケージ あ ら す じ 1. 製品（⾞椅⼦）の下準備： • 諸指⽰と段取り • 計画と準備 • フィッティング⽤の⾞椅⼦の調整と姿勢⽀持具の下準備 • ⾞椅⼦の安全・準備完了確認の実施 • フィードバック 10 15 80 15 30 実習時間計 150 1. 製品（⾞椅⼦）の下準備（150 分） 教習員への注記： 実習する受講者への観察： • 実習 2⽤「教習員⽤観察確認表」を⽤い、グループが実習の全作業段階を遂⾏していることを 確かめ、よく⽬にした優れた、あるいは改善を要する実践の例をフィードバックのためにメモ せよ。 ⼩グループ活動 グループ： • 受講者を、実習 1と同じグループに分けよ。 • 各グループのリーダ （ー実習 1と同じリーダーでも別の⼈でもよい）を任 命せよ。 • 各グループへ作業場所を割り当てよ。 • 受講者へ、必要な材料および⼯具がどこにあるか説明せよ。 指導内容： 以下をすべて説明せよ： 実習の⽬的： • この実習の⽬的は、実習 1で事前評価した⾞椅⼦ユーザーに対して、⾞椅 ⼦および姿勢⽀持具を下準備することです。 ⼯房での安全： ⼯具や材料を使って作業する前に、受講者は、次の安全のための５つのルー ルに留意しなさい： • ⼯房では、⾜を覆う靴を履く。 • 切断や⽳開けをする時は、部材をしっかり固定する。 • 電動⼯具や、その他の鋭利な⼯具を使う時は、安全メガネをかける。 • 作業区域や通路は整理整頓し、清潔に保つ。 • ⾃分⾃⾝や他⼈に向かって切らない。 193 教習員⽤指導書 リーダー： • 各グループのリーダーには、⾞椅⼦の下準備に関する全作業段階の実施を 確認する責任があります。 教習員による観察および⽀援： • 受講者は、補助や説明はいつでも求めて下さい。 • 実習の間じゅう、教習員は各グループをモニターし、必要に応じてできる 限り⽀援し、助⾔します。 各サービスフォーム： • 実習 1 からの、記⼊済みの中級⾞椅⼦事前評価フォームおよび中級⾞椅 ⼦処⽅（選択）フォームを、各グループのリーダーへ配布せよ。 • 実習の終わりに、記⼊済みの各サービスフォームを集め、次の実習で配布 せよ。 質問：何か質問はありますか？どんな質問にも答えよ。 モニターおよび ⽀援： グループを注意深くモニターし、実習が安全に⾏われるようにし、受講者の 技能を観察し評価せよ。 教習員⽤観察確認表を⽤い、各グループへの所⾒を記録せよ。 実習全体を通して： • 時間を（⼝頭で、あるいは受講者全員から⾒えるように板書して）予告し、 受講者が時間をうまく使えるようにせよ。 • どのグループメンバーも積極的に参画しているか確かめよ。 教習員への注記：技術的熟練度が、他より低い受講者もあろう。可能かつ適 切であれば、⾞椅⼦および姿勢⽀持具の下準備を練習するよう、全受講者を 励ませ。必要に応じて、できる限りの技術的⽀援を与えよ。 時間： • 受講者が、以下の時程に沿って⾏くようにせよ： o A: 計画と準備（15分） o 受講者へ、完了が必要なタスクを受講者⽤ワークブック（実習 2: 製 品（⾞椅⼦）の下準備−タスク確認表）に書き出すよう指⽰せよ。 o B: フィッティング⽤の⾞椅⼦の調整と姿勢⽀持具の下準備（80 分取 っておけ） o C: ⾞椅⼦の安全・準備完了確認の実施（15分取っておけ） o 受講者へ、受講者⽤ワークブック（実習 2: 製品（⾞椅⼦）の下準備 −中級⾞椅⼦の安全・準備完了確認表）の中級⾞椅⼦の安全・準備完 了確認表を⽤いるよう指⽰せよ。 o ステップが⼀つ完了するごとに、受講者は次のステップへ移る前に、 教習員と確認しなければならない。 194 中級⾞椅⼦サービス教習パッケージ o 30 分フィードバック。 • 製品（⾞椅⼦）の下準備が多く必要な場合は、より多くの時間が必要。 フィードバック： 各グループへ、⾃分たちが下準備した⾞椅⼦について、他のグループへ簡潔 に発表するよう指⽰せよ。どのグループも説明すべきことは： • どんな改造部や姿勢⽀持具をつくったか、またそれはなぜか。 • どうやって改造部や姿勢⽀持具をつくったか（使った材料、および⾞椅⼦ への搭載/取り付け⽅法）。 （1グループにつき 5〜7分取っておけ）。 発表が⼀つ終わるごとに、発表したグループへ何でも質問するよう、受講者 全体に 2〜3分与えよ。 実習で⽬にした、優れた実践の例について簡潔にコメントせよ。 受講者に、特に改善を要する⾯があれば簡潔に指摘せよ（個⼈をあげつらう な）。 質問：何か質問はありますか？ 教習員への注記：実習中は、時間経過によく気を付けることが⼤切。上記の時間配分はあくまで も⽬安で、受講者の経験、⾞椅⼦ユーザーのニーズ、段取りに要する時間に従って変動しうる。 教習員には、必要に応じた調整が求められよう。 B.13: フィッティング ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 付加姿勢⽀持を必要とする⾞椅⼦ユーザーに、姿勢⽀持具付き⾞椅⼦がフィットして いるか確かめるやり⽅を詳述する。 教 材 この授業には： ¨ PPTスライド：B.13: フィッティング ¨ 受講者⽤参考書 ¨ 動画：フィッティングのデモ：ディーパク ¨ 動画：フィッティングのデモ：カリーン ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ ラミネート済み中級⾞椅⼦フィッティング確認表：各受講者に 1部ずつ 195 教習員⽤指導書 事 前 学 習 と 状 況 事前学習： ¨ 「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」では、⽀えを付加しないでまっす ぐに座れる⾞椅⼦ユーザーへの、⾞椅⼦フィッティングを扱っている。中級レベルで も同様のステップを踏むが、この授業では、さらに詳細を加えている。 ¨ ⾞椅⼦ユーザーの、座⾻下の圧⼒検査の実施⽅法。受講者はこの授業に先⽴ち、その 実施に習熟していなければならない。 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 現地で広く⼿に⼊る、⾞椅⼦および姿勢⽀持具の種類。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 あ ら す じ 1. はじめに 2. フィッティングの実施⽅法 3. 要点のまとめ 2 55 3 授業時間計 60 1. はじめに（2 分） 説明： • フィッティングは、⾞椅⼦サービス提供の 8 ス テップの 6番めです。 • フィッティングでは、⾞椅⼦ユーザーと⾞椅⼦ サービス職員とで、⾞椅⼦および姿勢⽀持具が うまくフィットし、⾞椅⼦ユーザーを快適で、な るべくニュートラルな座位姿勢に近づけて⽀え ていることを確かめます。 • この授業では、中級⾞椅⼦フィッティング確認 表を導⼊し、⾞椅⼦フィッティングを実施する やり⽅について話し合います。 196 中級⾞椅⼦サービス教習パッケージ 2. フィッティングの実施⽅法（55 分） 説明： • 受講者の皆さんは、⾞椅⼦フィッティングのプ ロセスにはおなじみのはずです。 • 中級レベルでは、フィッティングにはより時間 がかかり、またくり返しが必要になることもあ ります。 ラミネート済み中級⾞椅⼦フィッティング確認表を配布せよ。 • この確認表は、⾞椅⼦サービス職員が、⾞椅⼦フィッティングの最重要事項を覚えておく⼿引き になります。 • 実践を積めば、このプロセスはより早く容易になります。 • 初めは確認表に従い、何も取りこぼしがないことを確かめて下さい。 確認表の、フィッティング⼿順を指摘せよ： 1. ⾞椅⼦は準備できているか？ 2. ⾞椅⼦および姿勢⽀持具のフィッティングの 確認 3. 姿勢の確認 4. 圧⼒の確認 5. ⾞椅⼦が動いている状態でのフィッティング の確認 6. さらにやるべきことがあるかどうかの判断112 質問：受講者が⾞椅⼦フィッティングを実施しそうな場所は、⾞椅⼦ユーザーの家ですか、あるい は⾞椅⼦サービスセンターですか？励まして回答を促せ。 説明：フィッティングの実施場所が、⾞椅⼦ユーザーの家であれ⾞椅⼦サービスセンターであれ、 次の器材は必ず持っておくようにしなさい： • ⾞椅⼦ユーザーの、中級⾞椅⼦事前評価フォームおよび中級⾞椅⼦処⽅（選択）フォーム、 • 巻尺またはノギス、 • ⾞椅⼦や姿勢⽀持具の調整に必要な⼯具すべて。 また、付加姿勢⽀持を試してみる場合に備え、ウレタンフォームを何個か持っておくと便利です。 112 [原⽂] Decide any further action is required. 197 教習員⽤指導書 動画を紹介：「フィッティングのデモ：ディーパク」。ここで、（前に視たことがあ る）ディーパクに⾞椅⼦をフィッティングする短い動画を視聴します。 受講者へ、注意深く視聴するよう指⽰せよ。 動画を上映。 何か質問がないか尋ねよ。 質問：なぜディーパクの右⾜下へのウレタンフォーム付加は重要なのでしょうか？ 答え：両⾜を完全に⽀えることで、より快適で、バランスを取りやすくなる。ウレタ ンフォームがなければ、ディーパクは⽚⽅の⾜台にしか接触がない。 質問：⾞椅⼦サービス職員は、追加のウレタンフォームを背もたれに当てて、ディー パクの体幹への⽀えを改善しました。これを背もたれへ恒久的に付加しておくには どうしたらいいでしょうか？ 答え：ウレタンフォームを、張り布の下で背もたれに接着する。 質問：なぜフィッティングを確認する際に、⾞椅⼦ユーザーにこいで（こげない場合 はだれかに押して）もらうことが重要なのでしょうか？ 答え：⾞椅⼦が動くと、あるいはこごうとして頑張ると、姿勢が変わるから。 説明： １. ⾞椅⼦は準備できているか？ 説明： • ⾞椅⼦が、⾞椅⼦ユーザーにより試⽤する準備が できているか、必ず確かめなさい。 • これは、中級⾞椅⼦の安全・準備完了確認表が完 成していることを意味します。 • これは、実践を重ねればすぐ確認できるようにな ります。 ２. ⾞椅⼦および姿勢⽀持具のフィッティング の確認 説明： • ⾞椅⼦フィッティングの間に、⾞椅⼦サービス職 員は、⾞椅⼦のフィッティングが正しいことを⾝ 体感覚で113確かめねばなりません。 • 次のいくつかのスライドで、⾞椅⼦および姿勢⽀ 持具の調べ⽅を⾒て⾏きます。 113 [原⽂] physically 198 中級⾞椅⼦サービス教習パッケージ ⾞椅⼦の幅を調べて確かめることは： • ⾞椅⼦ユーザーの臀部が、ひじ掛けまたは⾻盤側 ⽅パッドの間に⼼地よくフィットしている。 • ⾞椅⼦ユーザーの⼤腿が、ひじ掛けあるいは泥よ け/サイドガード、⾻盤側⽅パッドの間に⼼地よく フィットし圧迫し合っていない。これは⾻盤側⽅ パッドが前に出すぎると起こることがあります。 • ⾞椅⼦ユーザーの体幹が、背もたれフレームや体 幹側⽅ウェッジ/パッドの間に⼼地よくフィット している。 ⾞椅⼦の幅を調べるには： • 指を、⾞椅⼦ユーザーの⼤腿の外側で⾛らせます。 • 指が⼼地よくぴたりとフィットしなければなりま せん。 座⾯奥⾏きを調べて確かめることは： • ⾞椅⼦ユーザーが、快適な限りで、なるべくニュ ートラルに近い座位姿勢で座っている。 • 座⾯/クッションの前縁と膝裏の間には、最低 30 mm のすき間が必要です。脚の⻑い⾞椅⼦ユーザ ーの場合、すき間はさらに⼤きくてもよく、60 mm までが許容範囲です。 座⾯奥⾏きを調べるには： • ⼿を膝裏とクッションの間で滑らせなさい。指が 何本⼊るか数えなさい。 • ⼿をふくらはぎ後⾯に沿って滑らせ、ふくらはぎ が座⾯/クッションに触れないことを確かめなさ い。 • 左右両側とも確かめなさい。 • 左右で差がある場合、処⽅には短い側の脚の⼨法 を選びなさい。 199 教習員⽤指導書 ⾻盤を調べて確かめることは： • 座⾻前⽅（アンカー）サポートが座⾻のすぐ前⽅ に据わっている（⼿を⾞椅⼦ユーザーの臀部の下 に置いて確かめなさい）。 • ⾻盤後⽅パッドが上後腸⾻棘（PSIS）のところで ⽀え、体幹下部を押していない。 • ⾻盤側⽅パッドが寄り添うようにフィットし、股 関節にかかっていない。 • ⾻盤ベルトがしっかり締まり、⾞椅⼦ユーザーの ⽪膚を挟まない（⼿をベルトと⾞椅⼦ユーザーの 間で滑らせて確認しなさい）。 体幹を調べて確かめることは： • 体幹側⽅パッドまたは体幹側⽅ウェッジ（くさび） が、わきの下をいっさい圧迫しない位置にある。 ⾞椅⼦ユーザーのわきの下と体幹側⽅パッド上端 が、30 mm以上離れている。 • 肩ハーネスの装着が快適で、⽪膚を挟まない。 • テーブルが前腕とひじの全体を⽀え、腹部を圧迫 していない。テーブルの切り取り（カットアウト） 部分が⾝体にぴったり沿うよう調製され、しかし ⾞椅⼦ユーザーの⽪膚と触れたり擦れたりしてい ない。 背もたれの⾼さと傾きを確かめなさい。 ヘッドレストがフィットしているか調べなさい： • ヘッドレストは、⾞椅⼦ユーザーの頭を、頭蓋⾻ 底部で⽀えていなければなりません。 • ヘッドレストは、ユーザーの頭を、バランスが取 れ、まっすぐに起きた姿勢で⽀えなければなりま せん。 200 中級⾞椅⼦サービス教習パッケージ ⾞椅⼦ユーザーの⼤腿を調べて確かめることは： • ⾞椅⼦ユーザーの⼤腿と⼤腿⽀持具（⼤腿外側パ ッド、⼤腿内側ウェッジ、膝分離パッドなど）と の間に強い圧⼒が⽣じていない。 • 膝分離パッドが、⿏径部にいっさい圧⼒を加えて いない。 最後に、⾜台〜座⾯⾼を調べなさい： • 座⾯/クッションが⾞椅⼦ユーザーの⼤腿全体を、 ⾜台が⾜全体を、すき間なく⽀えているか確かめ なさい。 • 調べ⽅は： o ⼿を⼤腿と座⾯/クッションとの間で滑らせな さい。⼤腿全体にわたって圧⼒が均等で、すき 間があってはなりません。 o ⾜台に乗った⾜を観察しなさい。⾜の前も後 ろも、すき間なく⽀えられていなければなり ません。 （体幹〜⼤腿の⾓度が 90度未満） ３. 姿勢の確認 • ⾞椅⼦および姿勢⽀持具のフィットを確かめた ら、続いて⾞椅⼦サービス職員は、⾞椅⼦ユーザ ーの姿勢が、快適な限りでなるべくまっすぐに起 きていることを確かめなければなりません。 201 教習員⽤指導書 • ⾞椅⼦ユーザーの姿勢を、正⾯と横から観察しな さい。 • ⾞椅⼦ユーザーが、快適な限りでなるべくまっす ぐな姿勢で座っているかどうか調べなさい。それ は、ハンド・シミュレーションで⾒極めた姿勢に 近いものであるはずです。 • 正⾯と横から、特に確かめることは： o ⾻盤は（可能ならば）まっすぐに起きて⽔平 か？ o 体幹は（可能ならば）まっすぐに起きて左右対 称か？ o 頭は（可能ならば）バランスが取れてまっすぐ に起きているか？ o 脚と⾜は、まっすぐな座位姿勢になるべく近く なるように⽀えられているか？ • ⾞椅⼦ユーザーに、どんな感じか尋ねなさい。 • ⾞椅⼦ユーザーの座位姿勢全体を観察したあと、 各々の姿勢⽀持具が、意図通りに⽀えているか確 かめなさい。特に、（設けていれば）忘れずに調べ るべきものは： o 背もたれの⾼さ・傾き・形状調整 o ティルトインスペース o ヘッドレスト o ⾻盤側⽅パッドおよび体幹側⽅パッド o ⼤腿および下腿のあらゆる⽀持具 ４. 圧⼒の確認 202 中級⾞椅⼦サービス教習パッケージ • 褥瘡発⽣の危険があるすべての⾞椅⼦ユーザーに は、座⾻下はじめ危険があるすべての部位（例： 股関節、尾⾻）で圧⼒が安全かどうかの確認（「基 礎⾞椅⼦サービス教習パッケージ（WSTPb）」で 学んだ、⼿を使った圧⼒検査を⽤いる）が、フィ ッティングの作業⼿順に含まれます。 • 強固な⽀えを与える姿勢⽀持具を⽤いるすべての ⾞椅⼦ユーザーに対して、⾞椅⼦ユーザーの⾝体 と姿勢⽀持具の間の圧⼒を調べなさい。しっかり とした⽀えが感じられるべきですが、窮屈であっ てはなりません。 教習員への注記：褥瘡発⽣の危険があるすべての⾞椅⼦ユーザーに対する座⾻下の圧⼒検査のや り⽅は、基礎⾞椅⼦サービス教習パッケージで教えている。圧⼒検査を簡潔にやってみせるか、 基礎レベルの動画「圧⼒テストのデモ」を上映するか、受講者ひとりに実演してもらえ。 動画を紹介：「フィッティングのデモ：カリーン」。この短い動画で視聴するのは、 ⾞椅⼦サービス職員が、カリーンという少⼥の⾞椅⼦のフィッティングを確認す る様⼦です。⾞椅⼦サービス職員はあらゆる部材のフィッティングを調べ、すべ てのベルトがしっかりと、ただしキツすぎないようフィットしているか、注意深 く確かめます。 動画を上映。 何か質問がないか尋ねよ。 203 教習員⽤指導書 ５. ⾞椅⼦が動いている状態でのフィッティン グの確認 • ⾞椅⼦フィッティングの最終段階は、⾞椅⼦を、 動いている状態で調べることです。 着⽬点は： • 背もたれは、⾞椅⼦ユーザーが肩を⾃由に動か してこげるようになっているか？ • ⾞椅⼦の動きやこぐ動作によって、⾞椅⼦ユー ザーに、何らかの姿勢変化、不快感、不安定感が ⽣じていないか？ • ⼿こぎの場合：駆動輪位置は、⾞椅⼦ユーザーが できる限りうまくこぐために適切か？ • ⾜こぎの場合：座⾯⾼および座⾯奥⾏きは、⾞椅 ⼦ユーザーが⾜でこぐために適切か？ • 姿勢⽀持部は、⾞椅⼦による移動を制約せず安 全にしているか？ 説明：⾞椅⼦ユーザーが⾞椅⼦を⾃⼒でこげない場合は、家族/介助者に押してもらい、その間に 観察しなさい。 204 中級⾞椅⼦サービス教習パッケージ ６. さらにやるべきことがあるかどうかの判断 説明： • 以上、すべてを確認したら、⾞椅⼦ユーザーと⾞ 椅⼦サービス職員とで、さらにやるべきことがあ るかどうか、決める必要があります。 • 初回フィッティングの後で何かと調整が必要にな るのは、付加姿勢⽀持を必要とする⾞椅⼦ユーザ ーの場合、ごく当たり前のことです。 • 調整を加えたら、フィッティングのステップを最 初からくり返す必要があります。 • ⾞椅⼦サービス職員が実践を重ね、どこがフィッ トし、どこに調整が必要なのか勘付く経験を重ね るに従い、このプロセスは迅速になります。 説明：受講者には、⾞椅⼦ユーザーとフィッティングを練習する機会が、この教習プログラム中に 2回あります。 3. 要点のまとめ（3 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 205 教習員⽤指導書 B.14: ユーザー教習 ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ 改造あるいは姿勢⽀持具を施した⾞椅⼦を⼿にした⾞椅⼦ユーザーへ、⾞椅⼦サービ ス職員が教えるとよい 6つの技能を明⽰する。 ¨ ⾞椅⼦の技能を 3つ以上、受講者仲間へ教えるところをやってみせる。 教 材 この授業には： ¨ PPTスライド：B.14: ユーザー教習 ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ ポスター：「中級⾞椅⼦ユーザー教習確認表」 ¨ ラミネート済み中級⾞椅⼦ユーザー教習確認表：各受講者に 1部ずつ ¨ ⾞椅⼦：各グループに 1 台 事 前 学 習 と 状 況 事前学習： ¨ ⾞椅⼦ユーザー教習の詳細は、「基礎⾞椅⼦サービス教習パッケージ（WSTPb）」で取 り扱っている。 ¨ 教習員は、受講者がすでにこのステップに習熟し、基礎レベルの⾞椅⼦の取り扱い、 移乗、⾞椅⼦の使⽤および移動、褥瘡予防、家庭での⾞椅⼦の⼿⼊れ、問題が起きた らどうするか、を教える技能があるか確かめること。 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ ⾞椅⼦ユーザーおよびその家族/介助者へユーザー教習を提供できる、⽀援グループ やピアグループ114教習員がいるかどうか。 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、授業計画を読み通す。 ¨ 「中級⾞椅⼦ユーザー教習確認表」ポスターを掲⽰しておく。 あ ら す じ 1. はじめに 2. ユーザー教習：⾞椅⼦ユーザーの例話 3. 要点のまとめ 5 50 5 授業時間計 60 114 [原⽂] peer group. 仲間（当事者）グループ。同じ状況や問題を抱える⼈の集団。 206 中級⾞椅⼦サービス教習パッケージ 1. はじめに（5 分） 説明： • ユーザー教習は、⾞椅⼦サービス提供の第 7 ス テップです。 • 受講者は「基礎⾞椅⼦サービス教習パッケージ」 以来、このステップにはおなじみのはずです。 • 中級レベルで⾞椅⼦ユーザーが必要とする情報 は、異なる場合もあります。 • この授業では、3⼈の異なる⾞椅⼦ユーザーの例話に取り組み、中級の⾞椅⼦ユーザーおよびそ の家族/介助者が学ぶべき、重要事項のいくつかを明確にします。 質問：付加姿勢⽀持を備えた⾞椅⼦を使う⾞椅⼦ユーザー（およびその家族/介助者）に必要とな る、別の、または追加の情報/教習には何があるか思いつく⼈はいますか？励まして回答を促せ。 答え： • 付加姿勢⽀持の有益さに関する情報。 • 姿勢⽀持具の正しい使い⽅（どうフィットすべきか、問題が起きたらどうするか）。 • （とくに⼦どもの場合）⾞椅⼦および姿勢⽀持具へ、慣れて⾏くための情報。 • 姿勢⽀持具が付いた⾞椅⼦の、（例えば輸送のための）分解および組み⽴てのやり⽅。 • さまざまな種類の移乗⽅法：⾃⼒で⾞椅⼦を乗り降りできない⼈のために。 説明： • 受講者⽤参考書の「ユーザー教習」の単元に、この⾞椅⼦サービスステップに関する主要な情報 が載っています。 • 受講者⽤参考書の中級⾞椅⼦ユーザー教習確認表は、⾞椅⼦サービス職員が、⾞椅⼦ユーザーお よびその家族/介助者が知っておくべきことを⾒極め、またそれを教えるための⼿引きとして活 ⽤できます。すべてのことを、すべての⾞椅⼦ユーザーへ教える必要はありません。 • ではこれから 3⼈の異なる⾞椅⼦ユーザーの例話に取り組み、中級の⾞椅⼦ユーザーとその家 族/介助者が学ぶべき重要事項を⾒て⾏きましょう。 207 教習員⽤指導書 2. ユーザー教習：⾞椅⼦ユーザーの例話（50 分） ⼩グループ活動 グループ： 受講者を 3⼈ずつのグループに分けよ。 指導内容： • 各グループへ、受講者⽤ワークブック（B.14: ユーザー教習）の⾞椅⼦ユ ーザーの例話を、⼀話ずつ割り振れ。受講者が、各⾃受講者⽤参考書を持 っていることを確かめよ。 • 各グループへ、割り振られたワークブックの⾞椅⼦ユーザーの例話を読む よう指⽰せよ。 • ⾞椅⼦ユーザーの例話から得た情報に基づき、受講者へ、その⾞椅⼦ユー ザーが新しい⾞椅⼦を活⽤し、⼿⼊れするにはどんな技能を学ぶ必要があ るか判断し、また各⾃のワークブックの中級⾞椅⼦ユーザー教習確認表を 完成するよう指⽰せよ。 • グループの各⼈へ、配役を⼀つ（⾞椅⼦ユーザー、⾞椅⼦サービス職員、 ⾞椅⼦ユーザーの家族/介助者から）選ぶよう指⽰せよ。 • ⾞椅⼦サービス職員役になる各⼈へ、3 種以上の技能を中級⾞椅⼦ユーザ ー教習確認表から選び、⾞椅⼦ユーザーおよびその家族/介助者へ教える よう指⽰せよ。 • 受講者へ説明せよ：⾞椅⼦ユーザーの例話のうち 2 例は、1⼈で抱え上げ る必要がある⼦どもです。この技能は、⼤⼈相⼿には実⾏不可能です。受 講者は本当に抱え上げたりせず、説明しなさい。 • 受講者には、「⾞椅⼦ユーザー教習をうまくやれるコツ」をよく考えるよ う念押しせよ。「デモ」に続けて「練習」することの重要性を強調せよ。 • 受講者を、教えようとする技能についての情報を得るには、受講者⽤参考 書を参照するよう奨励せよ。 • 説明：受講者には、この活動 35 分かけ、続いてグループから全体に戻っ てフィードバックしてもらいます。 モニター： • グループを注意深くモニターせよ。 • どのグループも活動を理解しているか確かめよ。 • グループへ、受講者⽤参考書の活⽤を奨励せよ。 • 各グループが、その⾞椅⼦ユーザーおよび家族/介助者へ教えるべき適切 な技能を選択しているか確かめよ。 • サンギータの例話を読むグループが、さまざまな体位を取ること、ならび に⾞椅⼦および付加姿勢⽀持がサンギータにとって有益であることの説 明も、両親への情報に加えているか確かめよ。 • 安全に練習しているか確かめよ。 208 中級⾞椅⼦サービス教習パッケージ • どの技法も、必要なら訂正せよ。 • 必要なら、受講者を先導せよ。 時間： 活動に 35 分取っておけ。 フィードバックに 15 分取っておけ。 フィードバック： 各グループから 1⼈ずつに指⽰せよ： • 教習を実施した⾞椅⼦ユーザーについて、簡潔に説明しなさい。 • その⾞椅⼦ユーザーが学ぶべき、最も重要なことを列挙しなさい。 発表に沿って情報が⽋けていれば補い、細部が不正確であれば訂正せよ。 教習員への注記： ジョシュアは 6歳、脳性⿇痺を抱えています。制御できない運動の発作があります。処⽅（選択） された⼦ども⽤⾞椅⼦には、姿勢⽀持部として⾻盤ベルト、⾻盤側⽅パッド、体幹側⽅パッドな どが付いています。ジョシュアの⽪膚は薄く敏感なので、体幹側⽅パッドには、それで褥瘡が起 きないよう緩衝材を追加しています。 ジョシュアの新しい⾞椅⼦にはティルト機能があり、時には⾞椅⼦を後ろに倒し、あるいはもっ と垂直に起こしたりできます。転倒防⽌装置も付いており、荒れ地を越え、縁⽯を上がり下りす る時には解除できます。運搬のため、その⾞椅⼦の駆動輪は着脱式で、座⾯を⾞椅⼦フレームか ら取り外せます。 ジョシュアは毎朝幼稚園に通っています。幼稚園が⼿配した送迎サービスがかれを乗せて⾏きま す。その乗り物は⼩さなエンジン付き三輪⾞なので両親は⾞椅⼦が収まるか⼼配しています。 ジョシュアが新しい⾞椅⼦のフィッティングに来ました。⺟親もいっしょです。 受講者が教えるべき技能： 受講者が特に強調すべき点： ⾞椅⼦の取り扱い： • すべての技能 移乗： • 介助による移乗 ⾞椅⼦の使⽤および移動： • 介助での押し⽅ • どれくらい⻑時間、⾞椅⼦に座 るか ⾞椅⼦の取り扱い： ティルト： • ティルトを⽤いる理由を説明する：体幹のバランスおよび 頭を起こす。 • ティルトを安全に定位置で「ロック」する⽅法。 • ティルトを変更すべき時とその理由。 転倒防⽌装置： • 転倒防⽌装置の理由：⾞椅⼦が後ろへ転ぶのを⽌める。 • 転倒防⽌装置は、荒れ地を乗り越え、縁⽯を上がり下りす る妨げになるため、外出時には解除が必要。 209 教習員⽤指導書 褥瘡予防： • 褥瘡の検査 • 褥瘡ができたらどうするか 家庭での⾞椅⼦の⼿⼊れ： • すべての技能 問題が起きたらどうするか： • すべての技能 輸送のために取り外しが必要な、すべての姿勢⽀持具の取り 外しと復元： • 駆動輪の取り外し⽅。 • 座⾯の、フレームからの取り外し⽅。 • ⾞椅⼦の復元⽅法。 移乗： • 移乗する際は、膝を臀部より⾼く保つ。 • ⾻盤ベルトを締めるあいだ、ジョシュアの体幹を前かがみ に保つ。 • ⾻盤ベルトを、どれだけしっかり締めるべきか⽰す。 • ⾞椅⼦に乗ってからの、ジョシュアの位置の確認⽅法を強 調する：臀部を背もたれに当て、座⾻は座⾻前⽅（アンカ ー）サポートの背後、体幹側⽅パッドは⾝体に密着させる が、挟みつけないように。 ⾞椅⼦の使⽤および移動： • 屋内や屋外で、⺟親や友⼈が押す安全なやり⽅。 褥瘡予防： • ⾞椅⼦や姿勢⽀持具が⾝体に触れる、あらゆる部位の⽪膚 を調べる。 • 痕がなければ、⾞椅⼦に乗る時間を 1⽇ 10 分ずつ、最⼤ で 1 回 2時間まで増やす。 • ジョシュアの⽪膚を⾞椅⼦から降りるたびに調べる。 • ジョシュアに⾞椅⼦を降りた後で発⾚が出て 20分以上消 えない場合、消えるまで⾞椅⼦に座ってはならない。 サンギータは 3歳、⼆分脊椎を抱えています。移動が困難で、腰から下の感覚を失っており、脊 椎の下部に瘤起があります。両親によると、彼⼥は膀胱や腸の制御が困難で、しばしば尿路感染 が起きます。 サンギータが、初めての⾞椅⼦フィッティングに⾞椅⼦サービス事業所へ来ました。その⾞椅⼦ にはクイックリリース⾞輪、⾻盤ベルト、⾻盤側⽅パッドが付いており、背もたれは脊椎の瘤起 周辺の圧⼒を避けるよう形状調整しています。彼⼥は除圧クッションも持っています。彼⼥は両 親と来ています。両親は、彼⼥が⾞椅⼦を持ったら下肢装具を着けて歩こうとしなくなるのでは、 と⼼配しています。しかし彼⼥には、兄妹と外で遊べないことが不満なのです。 210 中級⾞椅⼦サービス教習パッケージ 受講者が教えるべき技能： 受講者が特に強調すべき点： ⾞椅⼦の取り扱い： • すべての技能 移乗： • ⾃⼒での移乗（下肢装具を着け て、および着けないで） ⾞椅⼦の使⽤および移動： • 正しいこぎ⽅、斜⾯、階段、転倒 防⽌装置の使い⽅ 褥瘡予防： • 褥瘡の検査 • 強調せよ：瘤起の周りの⽪膚に 痕がないか確かめる 家庭での⾞椅⼦の⼿⼊れ： • すべての技能 問題が起きたらどうするか： • すべての技能 泌尿器科医への紹介・相談： • 膀胱の管理と尿路感染の予防 移乗： • 両親へ、可能な限り⾃⽴し、⾃⼒で移乗することは、サン ギータにとってよいことだと説明する。 ⾞椅⼦の使⽤および移動： サンギータの両親を、⾞椅⼦はサンギータが歩く妨げにはな らないのだと安⼼させる。⾞椅⼦の有益さの説明例： • ⾞椅⼦があると、サンギータは外で兄妹に附いて⾏け、ま た健やかに活動的でいられます。 • ⾞椅⼦に座ると、サンギータの両⼿が⾃由になります：松 葉杖を握って動く代わりに、⾞椅⼦に座って両⼿を使い、 好きなことができます。 • ⾞椅⼦があると、サンギータはよい姿勢で座れ、姿勢にま つわる問題が起こるのを予防できます。 ⾞椅⼦に座る時間： • サンギータは、⾞椅⼦を 1⽇に 2〜3回、短時間（例：30 分）だけ使うところから始めるべきである。 • サンギータが⾞椅⼦に慣れるにつれ、時間を増やす。 • サンギータは、休憩なしで 2時間以上、⾞椅⼦に座っては ならない。 褥瘡予防： • ⾞椅⼦や姿勢⽀持具が⾝体に触れる、あらゆる部位の⽪膚 を調べる。 • 痕がなければ、⾞椅⼦に乗る時間を 1⽇ 10 分ずつ、最⼤ で 1 回 2時間まで増やす。 • サンギータに⾞椅⼦を降りた後で発⾚が出て 20分以上消 えない場合、消えるまで⾞椅⼦に座ってはならない。 紹介・相談： • サンギータには、しばしば尿路感染が起こるので、⾞椅⼦ サービス職員は、サンギータを医師へ紹介・相談し、膀胱 の安全な管理についての指導を求めるとよい。 211 教習員⽤指導書 キム・ソムは 40歳、15 年前に頭部を負傷しました。摂⾷に困難があるため、たいへん痩せてい ます。かれの脊椎は円背のまま固まっています。キム・ソムは⽴ち上がることができず、完全に ⺟親が頼りです。かれはしゃべれませんが、⺟親によると簡単な指⽰は分かるそうです。 事前評価で、痩せており、⾃⼒で動けず、以前（床に臥せっていたため）褥瘡があったことから、 褥瘡発⽣の危険があると判定されました。 かれは、最初の⾞椅⼦を⼿にしたばかりです。その⾞椅⼦は、キム・ソムがより快適に座れるよ う、除圧クッションと姿勢⽀持具を備えています。⺟親がかれの介助者で、⾞椅⼦フィッティン グの⾯接へいっしょに来ています。 受講者が教えるべき技能： 受講者が特に強調すべき点： ⾞椅⼦の取り扱い： • すべての技能（ティルトおよび 転倒防⽌装置を除く） 移乗： • 介助による移乗 ⾞椅⼦の使⽤および移動： • 介助での押し⽅ • どれくらい⻑時間、⾞椅⼦に座 るか 褥瘡予防： • 褥瘡の検査 • 褥瘡ができたらどうするか 家庭での⾞椅⼦の⼿⼊れ： • すべての技能 問題が起きたらどうするか： • すべての技能 移乗： • キム・ソムは成⼈ゆえ、2⼈で抱え上げることが重要。 • キム・ソムの⺟親と、どう彼⼥がキム・ソムの⾞椅⼦の乗 り降りを補助しているのか話し合う。だれか彼⼥を⼿伝う のか、彼⼥は安全な抱え上げ⽅を知っているか？ • 正しい移乗技法を確認する/教える。 • ⾞椅⼦に乗ってからの、キム・ソムの位置の確認⽅法を強 調する：臀部を背もたれに当て、座⾻は座⾻前⽅（アンカ ー）サポートの背後、体幹側⽅パッドは⾝体に密着させる が、挟み付けないように。 ⾞椅⼦の使⽤および移動： • キム・ソムの⺟親へ、荒れ地を乗り越え、斜⾯や階段を上 り下りする、安全な押し⽅を教える。 • 彼⼥と、キム・ソムを押して斜⾯を登り下りし、階段を昇 り降りしなければならない場合、どうやって⼿伝いを頼む のか話し合う。 褥瘡予防： • キム・ソムは、いちどに 2時間以上座ってはならない。 • 座る時間は、最初は 30 分から始め、徐々に増やす。 • ⾞椅⼦を降りたら、ただちに⽪膚の痕/発⾚を調べる。 • キム・ソムに⾞椅⼦を降りた後で発⾚が出て 20 分以上消 えない場合、消えるまで⾞椅⼦に座ってはならない。 家庭での⾞椅⼦の⼿⼊れ： • キム・ソムの⺟親に聞いて、だれか彼⼥にこの⼿伝いがで きる⼈を⾒出す。 212 中級⾞椅⼦サービス教習パッケージ 3. 要点のまとめ（5 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 実習 3: フィッティングおよびユーザー教習 ⽬ 的 この実習が終わるまでに、受講者が以下をできるようになること： ¨ 中級の⾞椅⼦フィッティングをやってみせる。 ¨ 中級のユーザー教習をやってみせる。 教 材 ¨ 教習員⽤観察確認表：実習 3 ¨ 写真撮影同意フォーム ¨ 実習 1の中級⾞椅⼦事前評価フォームおよび中級⾞椅⼦処⽅（選択）フォームを、⽩ 紙のものと記⼊済みのもの ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ポスター：「中級⾞椅⼦ユーザー教習確認表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ ラミネート済み中級⾞椅⼦フィッティング確認表：各受講者に 1部ずつ ¨ ラミネート済み中級⾞椅⼦ユーザー教習確認表：各受講者に 1部ずつ ¨ ⾞椅⼦ユーザーと作業する各グループへ、評価ベッドおよび⽬隠しの仕切りを備えた、 清潔で⼈⽬に触れないスペース ¨ 実習 2で下準備した、初回フィッティングの準備ができている⾞椅⼦ ¨ デジタルカメラ ¨ 巻尺またはノギス：各グループに 1本、⾜乗せブロック：各グループに 1 セット ¨ 姿勢⽀持具キットおよび⾞椅⼦調整⽤の⼯具キット：各グループに 1つずつ 213 教習員⽤指導書 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ ⽂化的要素：例えば、事前評価を男⼥混合で実施するのが適切かどうか。 ¨ 受講者が、⾞椅⼦ユーザーに対して⾞椅⼦事前評価を実施する際の、触ることにまつ わる⽂化的問題に気を付ける。 ¨ ことばの要素：例えば、参加する⾞椅⼦ユーザーが、全受講者と共通のことばを話す かどうか。 ¨ ⾞椅⼦に関する事前評価や処⽅のさい主催/教習実施団体が必要とする⽂書：例えば、 そのサービスへアクセスする⾞椅⼦ユーザーについて、サービス事業で収集する必要 がある追加情報（例：紹介・相談元）。 ¨ フィッティング中に起きた問題で、授業や教習プログラム内では対処しきれないもの を、教習員がどう取り扱うか。例えば、下準備した⾞椅⼦がフィットせず、フィット するように調整できない場合（の可能な解決策の⼀つは、さまざまなサイズの代替で きる⾞椅⼦を追加しておくことである）。 ¨ 教習プログラム後の、各⾞椅⼦ユーザーへのフォローアップをどう段取るか。 準 備 ¨ ⾞椅⼦ユーザー志願者と、時間や旅程を確認する。⾞椅⼦ユーザーおよびその家族/⽀ 援者には、軽⾷が⽤意されるようにする。 ¨ ⾞椅⼦ユーザーが到着しだい出迎え、実習開始までの待機場所へ案内する⼈を、1 ⼈ 任命する。 ¨ 各グループに、フィッティング区域を準備する（評価ベッドおよび⽬隠しの仕切り）。 ¨ フィッティングする⾞椅⼦の下準備が完了しているか確かめる（中級⾞椅⼦処⽅（選 択）フォームと照合し、中級⾞椅⼦の安全・準備完了確認表の完成を確認）。 ¨ 受講者が 3グループを超えれば、他の教習員にグループのモニターを⼿伝ってもらう。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 ¨ 「中級⾞椅⼦ユーザー教習確認表」ポスターを掲⽰しておく。 あ ら す じ 1. フィッティングおよびユーザー教習の実習： • 諸指⽰と段取り • フィッティング • ユーザー教習 15 90 45 実習時間計 150 214 中級⾞椅⼦サービス教習パッケージ 4. フィッティングおよびユーザー教習の実習（150 分） 教習員への注記： 1. 写真： • 各⾞椅⼦ユーザーへ、その写真撮影に対する署名⼊り同意書が請求済みか確かめよ。⾞椅⼦ユ ーザーが、⾃分の許可が任意のもので、撮影した写真をこの教習プログラムで、さらに教習を 実施する⽬的で使うのを理解しているか確かめよ。 • 実習中、許可を得た各⾞椅⼦ユーザーの写真を、以下のように撮影せよ。 o フィッティング後の、処⽅した⾞椅⼦に座っているところ（正⾯および横から）。 2. 実習へ参加する⾞椅⼦ユーザーのニーズを満たす： • 姿勢⽀持具付き⾞椅⼦が、実習時間内ですべて完成するとは限らない。 • 実習に参加したどの⾞椅⼦ユーザーの場合も、改めて⾯接予約が必要であれば、教習員は、主 催/教習実施団体が予約を取り、事前評価、処⽅（選択）、フィッティングに関するすべての情 報が、姿勢⽀持具の完成/⾞椅⼦の最終納品のために主催/教習実施団体へ引き継がれるように すべきである。 3. 実習する受講者への観察： • 実習 3⽤「教習員⽤観察確認表」を⽤い、グループが実習の全作業段階を遂⾏していることを 確かめ、またよく⽬にした優れた実践例をフィードバックのためにメモせよ。 ⼩グループ活動 グループ： • 受講者を、実習 1および 2と同じグループに分けよ。 • 各グループのリーダ （ー実習 1または 2と同じリーダーでも別の⼈でもよ い）を任命せよ。 • 各グループへ作業場所を割り当てよ。 • 受講者へ、材料および⼯具が、どこにあるか説明せよ。 215 教習員⽤指導書 指導内容： 以下をすべて説明せよ： 実習の⽬的： • この実習の⽬的は、⾞椅⼦サービス提供の 8ステップの 6番めと 7 番め、 つまりフィッティングとユーザー教習を、前の実習と同じ⾞椅⼦ユーザー に対して実施することです。 • 受講者が、⾞椅⼦ユーザーための⾞椅⼦を時間内に完成できない場合もあ ります。これは初回フィッティング、およびどんな改造/調整が必要にな るかによります。受講者は、それでも実習時間を活⽤し、できる限りの作 業をこなして下さい。⾞椅⼦を完成できなかった場合も、⾞椅⼦が完成さ れるように⾞椅⼦ユーザーと調整します。 リーダー： • 各グループのリーダーには全作業段階の実施を確認する責任があります。 • リーダーは、⾞椅⼦ユーザーやその家族/介助者と話す主役となって下さ い。これは同時にしゃべる⼈が多すぎて皆が混乱しないためです。 教習員による観察および⽀援： • 受講者は、補助や説明はいつでも求めて下さい。 • 実習の間じゅう、教習員は各グループをモニターし、必要に応じてできる 限り⽀援し、助⾔します。 • 説明：受講者は、適合に関わる問題が判明したら、教習員を呼んでそれを 確認させ、どんな改造/調整が必要か話し合って下さい。 • フィッティングが完了したら、受講者は教習員のひとりを呼び、来たらフ ィッティングを確認させて下さい。フィットしているのを教習員が確かめ るまで、ユーザー教習を始めてはなりません。 • ユーザー教習が完了したら、受講者は教習員のひとりを呼び、来たらグル ープや⾞椅⼦ユーザーと、何の教習を実施したか話し合って下さい。 制限時間： • 受講者は、（あらゆる調整も含め）フィッティングを 90 分、ユーザー教習 を 45 分での完了が⽬標です。 各サービスフォーム： • 前の実習からの、中級⾞椅⼦事前評価フォームおよび中級⾞椅⼦処⽅（選 択）フォームを、各グループのリーダーへ配布せよ。 • 各グループが、ラミネート済みの中級⾞椅⼦フィッティング確認表と中級 ⾞椅⼦ユーザー教習確認表を、最低 1部ずつ持っているか確かめよ。 216 中級⾞椅⼦サービス教習パッケージ 受講者へ尋ねよ：⾞椅⼦フィッティングの⼿順には何がありましたか？正解 を受けとめ承認せよ。 受講者へ、⾞椅⼦ユーザーに教える技能は、その⼈に当てはまるものだけに すべきだと念押しせよ。例えば、褥瘡発⽣の危険がない⼈に、除圧動作を教 える必要はない。 受講者へ、作業のどの段階でも積極的に⾞椅⼦ユーザーの参画を得なければ ならないことを念押しせよ。 質問：何か質問はありますか？どんな質問にも答えよ。 各グループへ、作業区域を整え、続いていっしょに作業する⾞椅⼦ユーザー を招いてから、取りかかるよう指⽰せよ。 モニターおよび ⽀援： 実習全体を通して： • 時間を（⼝頭で、あるいは受講者全員から⾒えるように板書して）予告し、 受講者が時間をうまく使えるようにせよ。 • ⾞椅⼦ユーザーが、積極的に参画しているのを確かめよ。 • どのグループメンバーも、積極的に参画しているのを確かめよ。 実習の終わりに受講者へ、⾞椅⼦ユーザーへその参加に対して感謝を述べる よう指⽰せよ。 実習中に、写真撮影同意フォームへ署名した⾞椅⼦ユーザーを撮影せよ。 時間： 諸指⽰と段取りに 15 分、フィッティング完了に 90 分、ユーザー教習完了に 45 分取っておけ。 フィードバック： B.15: 総まとめを参照。 教習員への注記：実習中は、時間経過によく気を付けることが⼤切。上記の時間配分はあくまで も⽬安で、受講者の経験、⾞椅⼦ユーザーのニーズ、段取りに要する時間に従って変動しうる。 教習員には、必要に応じた調整が求められよう。 217 教習員⽤指導書 B.15: 総まとめ ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ これまでの実習で担当した⾞椅⼦ユーザーについて、⾝体・環境・⽣活様式のニーズ、 解決策の処⽅（選択）、フィッティング、適切なユーザー教習などの概要を供する。 教 材 この授業には： ¨ 受講者⽤ワークブック ¨ （写真撮影同意フォームへ署名した）⾞椅⼦ユーザーの、実習での写真 準 備 ¨ 教材を取りまとめ、授業計画を読み通す。 ¨ ⾞椅⼦ユーザーの写真が、教習プログラム⽤コンピューターに保存されており、その 名前でファイル名が付いているのを確かめる。 あ ら す じ 1. はじめに 2. 受講者の準備 3. 受講者による発表および討論 5 30 85 授業時間計 120 1. はじめに（5 分） 説明： • この授業で、受講者には次の機会があります： o 受講者の全員と、これまで 3回の実習を通じて学んだことを共有する。 o 中級⾞椅⼦サービス提供について、まだ疑問があれば質問する。 o ⾃らの臨床論理を説明し、同輩に異論を唱えてもらう115。 115 [原⽂] be challenged by their colleagues 218 中級⾞椅⼦サービス教習パッケージ 2. 受講者の準備（30 分） ⼩グループ活動 グループ： これまで 3 回の実習を共にしたグループで、協働するよう指⽰せよ。 指導内容： 各グループへ、担当した⾞椅⼦ユーザーおよびそこで学んだことに関する、 10 分間の発表を準備するよう指⽰せよ。発表には、受講者⽤ワークブック （B.15: 総まとめ）の要点を盛り込むこと。 ⾞椅⼦ユーザーの写真は教習プログラム⽤コンピューターに⼊っており、 発表で話の説明に⽤いてよいことを説明せよ。 教習員への注記：受講者がコンピューターを使うのが苦⼿であれば、教習 員がかれらの写真を準備し、必要な時に映すことを説明せよ。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 必要なら、受講者を先導せよ。 時間： 受講者の準備に 30 分取っておけ。 フィードバック： 3. 受講者による発表および討論 を参照。 3. 受講者による発表および討論（85 分） 各グループへ、順番に発表するよう指⽰せよ。 受講者全体へ、発表の終わりに質問するよう奨励せよ： • 受講者へ、発表の間、各発表の終わりにする質問のメモを取っておくよう勧めよ。 • 受講者へ、発表チームの判断および取り組み⽅へ、異論を唱える116よう促せ。これが全受講者に よる議論、ディベート、より深い分析を⽣み出せば理想的である。 （グループ数によるが）それぞれの発表に 10分、質問に 5 分取っておけ。 各発表の終わりに： • 発表者のポジティブな点を含んだ、まとめの講評を与えよ。 • 各グループへ、その発表に感謝を述べよ。 116 [原⽂] challenge 219 教習員⽤指導書 全発表の終わりに： • 受講者へ、正解はたいてい⼀つではない、と念押しせよ。利⽤できる資源を最⼤限に活⽤しなが ら、⾞椅⼦ユーザーの総合的なニーズと願いを最⼤限に満たすためには、妥協が最善の解決策と なることもある。 教習員への注記： • 質問は、発表者の⾃らの判断に対する⾃信を引き出すためのもので、何か間違いをほのめかす ためのものではない。 • 質問や異論の伝え⽅は、友好的であること。 B.16: メンテナンス・修理・フォローアップ ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ フォローアップの内容を詳述する。 ¨ ⾞椅⼦ユーザーへの、⾞椅⼦フォローアップフォームを完成する。 教 材 この授業には： ¨ PPTスライド：B.16: メンテナンス・修理・フォローアップ ¨ 受講者⽤参考書 ¨ 受講者⽤ワークブック ¨ ⾞椅⼦フォローアップフォーム 事 前 学 習 と 状 況 事前学習： ¨ 中級⾞椅⼦フォローアップフォームは、基礎レベルのものと同⼀である。「基礎⾞椅⼦ サービス教習パッケージ（WSTPb）」を修了した受講者なら、このフォームには習熟 しているはずである。 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ 受講者の⾞椅⼦サービス事業における、フォローアップの運⽤形態。例えば、そのサ ービス事業では⾞椅⼦ユーザーの家庭でフォローアップを実施するか、⾞椅⼦ユーザ ーを⾞椅⼦サービスセンターへフォローアップに招くか、CBR（地域に根ざしたリハ ビリテーション）/地域社会の職員と調整してフォローアップを実施するか。 ¨ 受講者が所属する⾞椅⼦サービス事業にフォローアップのシステムがあるかどうか。 あれば、そのシステムを受講者へ説明せよ。かれらのフォローアップにおける業務は 何か説明せよ。 220 中級⾞椅⼦サービス教習パッケージ 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、授業計画を読み通す。 あ ら す じ 1. はじめに 2. フォローアップの概略 3. ⾞椅⼦フォローアップフォーム 4. フォローアップ演習 5. 要点のまとめ 2 8 10 35 5 授業時間計 60 1. はじめに（2 分） 説明： • メンテナンス・修理・フォローアップは、⾞椅⼦ サービス提供の第 8 ステップです。 • メンテナンス・修理・フォローアップに関する情 報は、「基礎⾞椅⼦サービス教習パッケージ」で 取り上げています。 • この授業では、基礎レベルで取り上げたフォロ ーアップに関する情報をおさらいし、付加姿勢 ⽀持を備えた⾞椅⼦を使う⾞椅⼦ユーザーにと っての、フォローアップの特別な重要さについ て考察します。 221 教習員⽤指導書 2. フォローアップの概略（8 分） 説明： • すべての⾞椅⼦ユーザーにとってフォローアッ プは有益です。フォローアップがとりわけ重要 なのが： o ⼦ども、 o 褥瘡発⽣の危険がある⾞椅⼦ユーザー、 o 進⾏性疾患がある⾞椅⼦ユーザー、 o ⾞椅⼦に付加姿勢⽀持が必要な⾞椅⼦ユー ザー、 o これまでに受けた教習なり指導で、何か困難 があった⾞椅⼦ユーザーです。 ほとんどの中級⾞椅⼦ユーザーは付加姿勢⽀持を 必要とするため、フォローアップはとりわけ重要 になります。 説明： • フォローアップをいつ⾏なうべきか、決まりは ありません。それは、フォローアップに最適な時 期が⾞椅⼦ユーザーのニーズによるからです。 • しかし可能な限り、⾞椅⼦が渡ってから６週間 以内にフォローアップし、⾞椅⼦が⾞椅⼦ユー ザーに対してうまく働いているか確かめ、ユー ザー教習を補強するのは⾮常に有益です。 • ⼦どもには、３〜６か⽉おきにフォローアップ できれば理想的です。なぜなら、⼦どものニーズ は成⻑に伴い急激に変化するからです。 222 中級⾞椅⼦サービス教習パッケージ • フォローアップ実施は： o ⾞椅⼦ユーザーの家、 o ⾞椅⼦サービスセンター、 o その他、⾞椅⼦ユーザーおよび⾞椅⼦サービ ス職員に都合がよい場所でできます。 • 場所は、⾞椅⼦ユーザーが⾞椅⼦サービスセン ターまで移動できるかどうか、また⾞椅⼦サー ビス職員が⾞椅⼦ユーザーの家まで移動できる かどうかによります。 質問：受講者が所属する⾞椅⼦サービスセンターでは、フォローアップをどのように運⽤すればよ いでしょうか（あるいは現在どう運⽤していますか）、すなわちフォローアップがどこで⾏なわれ、 どれくらいひんぱんにフォローアップが実施され、だれがフォローアップに責任を負い、どうやっ てフォローアップの⾯接予約を段取るようにしますか？ 励まして回答を促せ。 答え： • ⾃分の⾞椅⼦サービスセンターでは、フォローアップはそれほどひんぱんに実施していない、 と答える受講者もあろう。 • ⾞椅⼦ユーザーが⾃分の⾞椅⼦を受け取った時に、フォローアップの⾯接予約を⼊れる。 • フォローアップを、⾞椅⼦ユーザーの家、あるいは⾞椅⼦サービスセンターで実施する。 • フォローアップ訪問を、フォローアップ実施の教習を受けた、地域に根ざしたリハビリテーシ ョン（CBR）職員が、地域への定期訪問の⼀環として⾏なってもよい。 • 電話フォローアップを実施してもよい（例えば、移動は困難だが⾞椅⼦ユーザーが電話に出ら れるところ）。 • フォローアップの所要時間は、さまざまである。 教習員への注記：この機会に受講者と、かれらの⾞椅⼦サービスセンターでのフォローアップを どうやったら改善できるか、アイデアを話し合うとよい。話し合いの中からよいアイデアが出た ら、教習員はそれを⾞椅⼦サービス管理者へフィードバックするとよい。 223 教習員⽤指導書 3. ⾞椅⼦フォローアップフォーム（10 分） 説明： • 中級で⽤いる⾞椅⼦フォローアップフォームは、 「基礎⾞椅⼦サービス教習パッケージ」で使⽤し たフォローアップフォームと同じものです。 • つまり⾞椅⼦サービスでは、あらゆる⾞椅⼦ユー ザーに対して同じ⾞椅⼦フォローアップフォーム を使えるわけです。しかし、細かい点やフォロー アップでやることは、違う場合もあります。 • フォローアップは、次のことを⾏なう機会です： o ⾞椅⼦ユーザーから情報を集める。 o ⾞椅⼦がうまく動作しているか確認する。 o ⾞椅⼦のフィッティングを確認する。 • これらの情報をもとに、⾞椅⼦サービス職員は、 さらにやるべきことがあるか⾞椅⼦ユーザーと話 し合う必要があります。 受講者へ、各⾃の⾞椅⼦フォローアップフォームを参照するよう指⽰せよ。 説明：⾞椅⼦フォローアップフォームは、⾞椅⼦サービス職員がフォローアップ訪問で何を質問し、 何をやるべきか思い出すのに役⽴ちます。⾞椅⼦フォローアップフォームには、さらにやるべきこ とを書き留める欄も設けています。フォローアップでいっぱんに⾏なう内容は： さらに指導や教習を提供する。 • 例えば⾞椅⼦ユーザーが、予想したほど⾞椅⼦ を使っていない場合、それは、ひとりでいる時 に⾞椅⼦を乗り降りできる⾃信がないせいか もしれません。さらに移乗の教習を⾏なうこと が、その問題解決に役⽴つでしょう。 ⾞椅⼦を再調整する。 224 中級⾞椅⼦サービス教習パッケージ 細かい修理を実施する。 • 家庭での⾞椅⼦の⼿⼊れを⾏なって⾞椅⼦を維持管理するよう、つねに⾞椅⼦ユーザーおよび家 族/介助者へ奨励しなさい。⾞椅⼦サービス職員は、壊れた部品がすぐには直せない場合、⾞椅 ⼦ユーザーが修理を段取る⼿伝いをしてもよいでしょう。 必要なら⾞椅⼦ユーザーを、⽀援や協⼒を得られる他のサービスへ紹介・相談する。 質問：⾞椅⼦ユーザーが、褥瘡があると報せて来たら、何をすべきでしょうか？ 答え： • 褥瘡を⾒せてもらう（必ず、⼈⽬に触れない場所で⾏なう）。 • 褥瘡の部位と程度を記録する。 • 褥瘡の部位が、⾞椅⼦あるいは姿勢⽀持具と触れるところであれば、⾞椅⼦ユーザーは⾞椅⼦ の使⽤を停⽌すべきである。 • 褥瘡の程度がステージ 2以上であれば、専⾨家に処置を依頼する。 4. フォローアップ演習（35 分） ⼩グループ活動 グループ： 受講者を 3⼈ずつのグループに分けよ。 指導内容： 受講者へ、受講者⽤ワークブック（B.16: フォローアップ）の各⾞椅⼦ユー ザーの例話を読むよう指⽰せよ。各⾞椅⼦ユーザーについて、受講者は⾞椅 ⼦フォローアップフォームを完成し、やるべきことがあるか話し合って記録 しなければならない。 説明：受講者には、この活動にグループで 20 分かけ、続いてグループから 全体に戻ってフィードバックしてもらいます。 モニター： グループを注意深くモニターせよ。 どのグループも活動を理解しているか確かめよ。 必要なら、受講者を先導せよ。 時間： 活動に 20 分取っておけ。 フィードバックに 15 分取っておけ。 フィードバック： 各⾞椅⼦ユーザーの例話について、グループの⼀つへ、⾃分たちのグループ では、その⾞椅⼦ユーザーへのフォローアップでやることとして何を推奨す るか、簡潔に説明するよう指⽰せよ。受講者へ質問せよ：他のグループの⽅ から、さらにやるべきことについて何か提案がありますか？ 受講者が、学習の要点（下記「教習員への注記」を参照）をすべて押さえて いるか確かめよ。 225 教習員⽤指導書 教習員への注記： ⾞椅⼦ユーザーの例話： 解答および学習の要点： トゥーシタは７歳、かれの両親・姉と家で暮ら しています。筋ジストロフィーを抱え、１年前 に⾞椅⼦サービス事業を通じて⾞椅⼦を⼿に ⼊れました。その頃は、短い距離なら歩けまし た。⽴ち上がっての移乗で、⾃⼒で⾞椅⼦を乗 り降りできました。「学校へ⾏くのが⼤変だか ら、⾞椅⼦が欲しかった」と語っていました。 フォローアップ訪問で、トゥーシタは「いまで は⾃分で⾞椅⼦を乗り降りするのが難しくな っている」と告げました。学校では、午後には くたびれ、不快になってしまいます。そのため 集中⼒が持ちません。かれの⾞椅⼦は適切なサ イズで、⾼さが中程度のスリング背もたれと簡 素な除圧クッションが付いています。 トゥーシタに⾞椅⼦への満⾜度を採点しても らったところ、5点満点で 4点でした。 • トゥーシタが、どうやって⾞椅⼦を乗り降り しているか⾒出す。 • 別の種類の移乗技法で移乗が楽になるか検 討。例：スライディングボード、あるいは介 助による⽴ち上がっての移乗。 • 姿勢⽀持具を再評価。より⾼い背もたれ、張 り調整背もたれ、姿勢コントロールと除圧が できるクッションを検討。 • 疲労は進⾏性疾患では起こりやすい。昼休み 中に姿勢変換の必要があるか、それによって 午後、学校でより快適に過ごせ、集中できる かどうかを検討。 • 進⾏性疾患を抱える⼈には定期的フォロー アップが必要で、3〜6か⽉ごとが理想。必要 ならば、もっと早く来てもらうこと。 ミレラは 23 歳、ポリオを抱えています。蜂蜜 をつくり、地元の市場で売っています。2 年前、 前輪を取り付ければ 3輪⾞になる⾞椅⼦を⼿に ⼊れました。彼⼥には、⾞椅⼦へ姿勢⽀持具の 追加が必要でした。処⽅（選択）されたのは、 改造した多層構造ウレタンフォームクッショ ンでした。⾻盤後⽅パッドを⾞椅⼦の背もたれ に取り付けました。 フォローアップ訪問でミレラは「⾞椅⼦と 3輪 ⾞で、毎⽇市場へ往復している」と⾔います。 彼⼥は、さいきん⾞輪のパンク修理を 2 回もや らなければならなかったと告げました。⾞椅⼦ を調べて、⾞椅⼦サービス職員は、タイヤがか なり擦り減っているのに気づきました。また⾻ 盤後⽅パッドが座⾯までずり落ち、クッション はとても扁平でした。 ミレラに⾞椅⼦への満⾜度を採点してもらっ たところ、5点満点で 3点でした。 • タイヤ交換を段取る。 • タイヤの点検を勧める。 • なぜ⾻盤後⽅パッドがずれたのかを⾒出す。 定位置へ置き直して固定。それがミレラを正 しく⽀えているか調べる。 • ミレラへ、⾻盤後⽅パッドが据わるべき位置 について指導し、正しい位置にあるか確かめ るよう勧める。 • クッションからカバーを外し、ウレタンフォ ーム層の状態が正常か調べる。ウレタンフォ ーム層が圧縮されていない（扁平でない）か 確かめる。ウレタンフォームが扁平になって いたら、表層を柔らかいウレタンフォーム層 に交換する。 • ミレラを、⾻盤後⽅パッドやクッションを 含め、⾞椅⼦がしっかりと⽀えているか確 かめる。 226 中級⾞椅⼦サービス教習パッケージ ウルスラは 6歳、脳性⿇痺を抱えています。教 会の合唱隊で、姉といっしょに歌うのが好きで す。姿勢⽀持具の付いた⾞椅⼦を、8 か⽉前に ⼿に⼊れました。 彼⼥は胸部感染を患っていたため、初回のフォ ローアップ⾯接には来られませんでした。両親 は「近ごろは⾞椅⼦に乗っても満⾜そうでな く、1 時間もすると降りたいと訴える」と⾔い ます。両親は彼⼥の⽚⽅の体幹側⽅パッドのそ ばの肋⾻の上に⿊い瘢痕を⾒つけ、それが問題 なのでは、と⼼配しています。 ⾞椅⼦サービス職員は⼈⽬に触れない場所を 探し、ウルスラと両親に⽪膚を調べる許可を求 めました。⾞椅⼦サービス職員は⿊斑を確認し ました。また⾞椅⼦を観察し、体幹側⽅パッド のウレタンフォーム緩衝材が圧し潰されてい るのに気づきました。 ウルスラの⾞椅⼦への満⾜度について、両親の 採点は 5点満点で 4点でした。 • ウルスラと両親へ、彼⼥の肋⾻の上の瘡に は、瘢痕が消えるまでぜったい圧⼒を加えな いよう指導。 • ウルスラと両親へ、⾞椅⼦に乗る時間を減ら し、瘢痕が消えてから徐々に増やして⾏くよ う指導。 • 左右の体幹側⽅パッドのウレタンフォーム を交換。体幹側⽅パッドとウルスラの間で指 を滑らせて圧⼒を調べ、必要なら調整。 • ⼦どもは成⻑が早いので、姿勢の問題が起こ るのを防ぐには定期的なフォローアップが 必要で、3〜6か⽉ごとの定期フォローアップ が理想。 5. 要点のまとめ（5 分） 要点を読み上げよ。 何か質問がないか尋ねよ。 227 教習員⽤指導書 実習 4: 事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ ユーザー教習 ⽬ 的 この実習が終わるまでに、受講者が以下をできるようになること： ¨ グループで作業して、中級レベルの事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・ フィッティング・ユーザー教習をやってみせる。 教 材 ¨ 受講者⽤ワークブック ¨ 教習員⽤観察確認表：実習 4 ¨ 写真撮影同意フォーム ¨ 中級⾞椅⼦事前評価フォームおよび中級⾞椅⼦処⽅（選択）フォーム ¨ ポスター：「姿勢⽀持具（PSD）⼀覧表」 ¨ ポスター：「中級⾞椅⼦ユーザー教習確認表」 ¨ ラミネート済み姿勢⽀持具（PSD）⼀覧表：各受講者に 1部ずつ ¨ ラミネート済み中級⾞椅⼦フィッティング確認表：各受講者に 1部ずつ ¨ ラミネート済み中級⾞椅⼦ユーザー教習確認表：各受講者に 1部ずつ ¨ 各⾞椅⼦ユーザーに、評価ベッドおよび⽬隠しの仕切りがある、清潔で⼈⽬に触れな い事前評価スペース ¨ 硬いウレタンフォームのブロック：各グループに 2〜3個 ¨ 硬いウレタンフォームのウェッジ（くさび）：各グループに 2〜3個 ¨ 姿勢⽀持具の材料 ¨ 姿勢⽀持具キット ¨ 作業台および⼯具キット：各グループに 1つずつ ¨ ⾒本の⾞椅⼦およびクッション（事前評価を地域で実施しない場合） ¨ デジタルカメラ ¨ 巻尺またはノギス：各グループに 1本、⾜乗せブロック：各グループに 1 セット 228 中級⾞椅⼦サービス教習パッケージ 事 前 学 習 と 状 況 この授業は、受講者が働く状況に合うよう修正せよ。考えるべきことは： ¨ ⽂化的要素：例えば、事前評価を男⼥混合で実施するのが適切かどうか。 ¨ 受講者が、⾞椅⼦ユーザーに対して⾞椅⼦事前評価を実施する際の、触ることにまつ わる⽂化的問題に気を付ける。 ¨ ことばの要素：例えば、参加する⾞椅⼦ユーザーが、全受講者と共通のことばを話す かどうか。 ¨ ⾞椅⼦に関する事前評価や処⽅のさい主催/教習実施団体が必要とする⽂書：例えば、 そのサービスへアクセスする⾞椅⼦ユーザーについて、サービス事業で収集する必要 がある追加情報（例：紹介・相談元）。 ¨ 適合の過程で⽣じた問題で、授業や教習プログラム内では対処しきれないものを、教 習員がどう取り扱うか。 ¨ 教習プログラム後の、各⾞椅⼦ユーザーへのフォローアップをどう段取るか。 準 備 ¨ ⾞椅⼦ユーザー志願者と、時間や旅程を確認する。⾞椅⼦ユーザーおよびその家族/⽀ 援者には、軽⾷が⽤意されるようにする。 ¨ ⾞椅⼦ユーザーが到着しだい出迎え、実習開始までの待機場所へ案内する⼈を、1 ⼈ 任命する。 ¨ 各グループに、⽬隠しの仕切りが付いた評価ベッドを⽤意する。各種の事前評価に必 要な、すべての器材を評価ベッドに置く。 ¨ ⾒本の⾞椅⼦およびクッションが正常に動作することを確かめる。 ¨ 受講者が 3グループを超えれば、他の教習員にグループのモニターを⼿伝ってもらう。 ¨ どの受講者どうしが、どの⾞椅⼦ユーザーと作業するか決めておく。 ¨ 受講者に、この実習では⾜を覆う靴を履くよう予告しておく。 ¨ 各グループの作業場所を準備し、作業台、⼯具キットを揃え、姿勢⽀持具の材料を受 講者が効率よく作業できるように配置しておく。 ¨ 姿勢⽀持具キットから⾒本の姿勢⽀持具を取り出し、まとめて教室前⽅のテーブル（作 業台）上の、教習員が簡単に⼿に取れるところへ配置しておく。 ¨ 「姿勢⽀持具（PSD）⼀覧表」ポスターを掲⽰しておく。 ¨ 「中級⾞椅⼦ユーザー教習確認表」ポスターを掲⽰しておく。 229 教習員⽤指導書 あ ら す じ 1. 事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ユーザ ー教習： • 諸指⽰と段取り • 事前評価 • 処⽅（選択） • 製品（⾞椅⼦）の下準備 • フィッティング • ユーザー教習 15 45 30 120 45 45 実習時間計 300 1. 事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ユーザー 教習（300 分） 教習員への注記： 1. 写真： • 各⾞椅⼦ユーザーへ、その写真撮影に対する署名済みの写真撮影同意フォームを請求せよ。⾞ 椅⼦ユーザーが、⾃分の許可が任意のもので、撮影した写真をこの教習プログラムで、さらに 教習を実施する⽬的で使うのを理解しているか確かめよ。 • 実習の間、許可を得た各⾞椅⼦ユーザーの写真は、以下のように撮影せよ。 o 既存の⾞椅⼦に（⾞椅⼦を持っていれば）座っているところ（正⾯および横から）。 o ⾝体的事前評価中（⽀えなしの座位姿勢） o フィッティング後の、処⽅された⾞椅⼦に座っているところ（正⾯および横からの構図） 2. 実習へ参加した⾞椅⼦ユーザーのニーズを満たす： • ⾞椅⼦が、実習の与えられた時間で、すべて完成するとは限らない。 • 実習に参加したどの⾞椅⼦ユーザーの場合も、改めて⾯接予約が必要であれば、教習員は、主 催/教習実施団体が予約を取り、事前評価、処⽅（選択）、フィッティングに関するすべての情 報が引き継がれるようにすべきである。 3. 実習する受講者への観察： • 実習 4 ⽤「教習員⽤観察確認表」を⽤い、グループが実習の全作業段階を遂⾏していることを 確かめ、よく⽬にした優れた、あるいは改善を要する実践の例をフィードバックのためにメモ せよ。 230 中級⾞椅⼦サービス教習パッケージ ⼩グループ活動 グループ： • 受講者を 2〜3⼈ずつのグループに分けよ。 • 各グループのリーダーを任命せよ。 • 受講者へ、いっしょに作業する⾞椅⼦ユーザーの名前を伝えよ。 • どこに材料および⼯具があるか説明せよ。 • 受講者へ、どこに必要な器材があるか説明せよ。 指導内容： 以下をすべて説明せよ： 実習の⽬的： • この実習の⽬的は、⾞椅⼦ユーザーに対して、処⽅（選択）、製品（⾞椅 ⼦）の下準備、フィッティング、ユーザー教習を実施することです。 • 教習プログラム中に⾞椅⼦ユーザーの⾞椅⼦を完全に仕上げられなかっ た場合も、⾞椅⼦が完成されるように⾞椅⼦ユーザーと調整します。受講 者は、それでもなるべく多くの作業をこなすようにして下さい。 リーダー： • 各グループのリーダーには全作業段階の実施を確認する責任があります。 • リーダーは、⾞椅⼦ユーザーやその家族/介助者と話す主役となって下さ い。これは同時にしゃべる⼈が多すぎて皆が混乱しないためです。 教習員による観察および⽀援： • 受講者は、補助や説明はいつでも求めて下さい。 • 実習の間じゅう、教習員は各グループをモニターし、必要に応じてできる 限り⽀援し、助⾔します。 • サービスステップが⼀つ完了するごとに、受講者は教習員のひとりを呼 び、来たら次のステップを始める前に確認させて下さい。 制限時間： • 受講者は、事前評価を 45 分、処⽅（選択）を 30 分、製品（⾞椅⼦）の下 準備を 120 分、フィッティングを 45 分、ユーザー教習を 45 分での完了 が⽬標です。 受講者へ、⾞椅⼦を下準備している間、⾞椅⼦ユーザーには休憩や軽⾷が必 要であることを念押しせよ。 午前のお茶/昼⾷時間は取らなければならない。教習員は休憩の予定時間が 来たら全員へ知らせよ。 各サービスフォーム： • 中級⾞椅⼦事前評価フォームおよび中級⾞椅⼦処⽅（選択）フォームを、 各グループのリーダーへ配布せよ。 • 各グループが、ラミネート済みの中級⾞椅⼦フィッティング確認表と中級 ⾞椅⼦ユーザー教習確認表を、最低 1部ずつ持っているか確かめよ。 231 教習員⽤指導書 受講者へ、各⾃の受講者⽤ワークブック（実習 4: 事前評価・処⽅（選択）・ 製品（⾞椅⼦）の下準備・フィッティング・ユーザー教習）の「製品（⾞椅 ⼦）の下準備−タスク確認表」を⽤いて、やるべき作業を計画するよう指⽰ せよ。 受講者へ、各⾃の受講者⽤ワークブック（実習 4: 事前評価・処⽅（選択）・ 製品（⾞椅⼦）の下準備・フィッティング・ユーザー教習）の「中級⾞椅⼦ の安全・準備完了確認表」を⽤い、⾞椅⼦のフィッティングに使⽤する準備 ができているか、確かめるよう指⽰せよ。 受講者へ、作業のどの段階でも積極的に⾞椅⼦ユーザーの参画を得なければ ならないことを念押しせよ。 質問：何か質問はありますか？どんな質問にも答えよ。 各グループへ、作業区域を整え、続いていっしょに作業する⾞椅⼦ユーザー へ⾃⼰紹介してから取りかかるよう指⽰せよ。 モニターおよび ⽀援： グループを注意深くモニターし、実習が安全に⾏われるようにし、受講者の 技能を観察し評価せよ。 教習員⽤観察確認表を⽤い、各グループへの所⾒を記録せよ。 実習全体を通して： • 時間を（⼝頭で、あるいは受講者全員から⾒えるように板書して）予告し、 受講者が時間をうまく使えるようにせよ。 • ⾞椅⼦ユーザーが、積極的に参画しているのを確かめよ。 • どのグループメンバーも、積極的に参画しているのを確かめよ。 実習の終わりに受講者へ、⾞椅⼦ユーザーへ、その参加に対して感謝を述べ、 近⽇中に、主催/教習実施団体からフォローアップの⾯接予約が⼊ることを 説明するよう指⽰せよ。 実習中に、写真撮影同意フォームへ署名した⾞椅⼦ユーザーを撮影せよ。 時間： 諸指⽰と段取りに 15 分、事前評価の完了に 45 分、処⽅（選択）の完了に 30 分、製品（⾞椅⼦）の下準備に 120 分、フィッティングに 45 分、ユーザー 教習に 45 分取っておけ。 教習員⽤観察確認表に、時間経過を記せ。 教習員への注記：実習中は、時間経過によく気を付けることが⼤切。上記の時間配分はあくまで も⽬安で、受講者の経験、⾞椅⼦ユーザーのニーズ、段取りに要する時間に従って変動しうる。 教習員には、必要に応じた調整が求められよう。 232 中級⾞椅⼦サービス教習パッケージ B.17: 教習員からのフィードバック・討論・閉講式 ⽬ 的 この授業が終わるまでに、受講者が以下をできるようになること： ¨ ⾞椅⼦ユーザーと作業した最後の実習について、事前評価・処⽅・下準備・フィッテ ィングによって、⾞椅⼦が⾞椅⼦ユーザーの⾝体・環境・⽣活様式のニーズを満たす ようにし、適切なユーザー教習を実施したことを振り返る。 教 材 この授業には： ¨ PPTスライド：B.17: 教習員からのフィードバック・討論・閉講式 ¨ 動画：お⼟産のメッセージ ¨ 実習での、（写真撮影同意フォームへ署名した）⾞椅⼦ユーザーの写真 準 備 ¨ 教材を取りまとめ、PPTスライドを⾒直し、動画を視聴し、授業計画を読み通す。 ¨ 修了証が印刷され、教習員の署名済みであることを確かめる。 ¨ 主な関係者（例えば、資⾦供与者、障害者団体、サービス供与者、関連省庁）の代表 を招待し、閉講式に列席して修了証を授与してもらえないか検討する。 ¨ ⾞椅⼦ユーザーの写真が、教習プログラム⽤コンピューターに保存されており、その 名前でファイル名が付いているのを確かめる。 あ ら す じ 1. はじめに 2. 教習員からのフィードバック 3. 実習 4に参加した⾞椅⼦ユーザーに関する討論 4. 閉講式および修了証授与 2 20 30 8 授業時間計 60 1. はじめに（2 分） 説明： • この授業で、受講者には次の機会があります： o 直前の実習で、他のグループが担当した⾞椅⼦ユーザー、およびその⼈へ処⽅、下準備、フ ィッティングした⾞椅⼦の解決策について聴く。 o 教習員が直前の実習で⽬にした優れた実践例に関する総合的なフィードバックを聴き、失敗 例から学ぶ。 o 質問する。 233 教習員⽤指導書 2. 教習員からのフィードバック（20 分） 教習員⽤観察確認表：実習 4 を活⽤し、実習で⽬にした優れた実践の例を、全体で話し合え。 受講者に、特に改善を要する⾯があれば指摘せよ（個⼈をあげつらうな）。 質問：何か質問はありますか？ 3. 実習 4 に参加した⾞椅⼦ユーザーに関する討論（30 分） 教習員への注記： • これに使える時間は、直前の教習員からのフィードバックで押さえるべき要点の多少によって 変わる。重要なフィードバックを確実に与えることを優先し、それに従い授業を調整せよ。 各グループへ、順番に以下のように発表するよう指⽰せよ： • 実習に参加した⾞椅⼦ユーザーの、移動および⽀えに対するニーズを簡潔にまとめる。 • ⾃分たちが処⽅（選択）した解決策を述べる。 • 製品（⾞椅⼦）を下準備したやり⽅を述べる。 • フィッティングのプロセスおよび浮上した懸念を述べる。 • ⾞椅⼦ユーザーがどう⾞椅⼦を受け取り、またどのユーザー教習を実施したか解説する。 受講者全体へ、発表の終わりに質問するよう奨励せよ： • 受講者へ、発表の間、各発表の終わりにする質問のメモを取っておくよう勧めよ。 • 受講者へ、発表チームの判断および取り組み⽅へ、異論を唱えるよう促せ。これが全受講者によ る議論、ディベート、より深い分析を⽣み出せば理想的である。 （グループ数によるが）それぞれの発表に 5 分、質問に 5 分取っておけ。 グループが要点を図説できるよう、各⾞椅⼦ユーザーの写真を（実習中に撮影していれば）映せ。 234 中級⾞椅⼦サービス教習パッケージ 各発表の終わりに： • （教習員⽤観察確認表：実習 4 を活⽤して）そのグループが⾏なった優れた実践例を強調せよ。 • 各グループへ、その発表に感謝を述べよ。 全発表の終わりに： • 受講者へ、正解はたいてい⼀つではないことを念押しせよ。利⽤できる資源を最⼤限に活⽤しな がら、⾞椅⼦ユーザーの総合的なニーズと願いを最⼤限に満たすためには、妥協が最善の解決策 となることもある。 教習員への注記： • 質問は、発表者の⾃らの判断に対する⾃信を引き出すためのもので、何か間違いをほのめか すためのものではない。 • 質問や異論の伝え⽅は、友好的であること。 4. 閉講式および修了証授与（8 分） 動画を紹介：「お⼟産のメッセージ」 動画を上映。 教習員への注記： • 修了証授与や教習プログラム閉講のやり⽅は、教習員が望むものを選んでよい。 235 教習員⽤指導書 付録 付録 1: 中級⾞椅⼦教習パッケージ時間割表 ５⽇間 第 1 ⽇ 第 2 ⽇ 第 3 ⽇ 第 4 ⽇ 第 5 ⽇ 8:30 a.m. はじめに B.4: ⾝体的事 前評価−ハン ド・シミュレー ション B.10: 姿 勢 ⽀ 持具の処⽅（選 択）−体幹を⽀ える B.13: フ ィ ッ ティング B.16: メ ン テ ナンス・修理・ フォローアッ プ 8:45 9:00 9:15 B.11: 姿 勢 ⽀ 持具の処⽅（選 択）−頭・⼤腿・ 下腿を⽀える 9:30 A.1: 付加姿勢 ⽀ 持 が有益な ⾞ 椅 ⼦ ユ ー ザ ー B.5: ⾝体的事 前評価−⾝体 計測 B.14: ユ ー ザ ー教習 実 習 4: 事 前 評価・処⽅（選 択）・製品（⾞椅 ⼦）の下準備・ フィッティン グ・ユーザー教 習 9:45 10:00 10:15 10:30 A.2: 障害児 B.6: ⾞椅⼦お よ びクッショ ンの選択 ⾞ 椅 ⼦ ユ ー ザ ーの到着前に、 教 習 員 と 受 講 者 が製品確 認 に使える時間 10:45 11:00 11:00〜11:15：午前のお茶（時間 は現地の事情および授業計画に 合わせる） 11:00〜11:15：午前のお茶（時間 は現地の事情および授業計画に 合わせる） 11:15 A.2: 障害児 B.6: ⾞椅⼦お よ びクッショ ンの選択 11:15〜11:30： 午前のお茶 実習 3: フ ィ ッ テ ィ ングお よ び ユ ー ザ ー 教習 実習 4: 事 前 評価・処⽅（選 択）・製品（⾞椅 ⼦）の下準備・ フィッティン グ・ユーザー教 習 11:30 実習 1: 事 前 評価 お よ び処 ⽅（選択） 11:45 B.1: 事前評価 の概略・事前評 価 イ ンタビュ ー B.7: 姿勢⽀持 具の処⽅（選 択）−はじめに 12:00 12:15 p.m. B.8: 姿勢⽀持 具の処⽅（選 択）−⾻盤を安 定させる 12:30 12:45 236 中級⾞椅⼦サービス教習パッケージ 1:00〜2:00：昼⾷（時間は現地の事情に合わせ、授業計画に適合させる） 2:00 B.1: 事前評価 の概略・事前評 価 イ ンタビュ ー B.8: 姿勢⽀持 具の処⽅（選 択）−⾻盤を安 定させる 実 習 1: 事 前 評価 お よ び処 ⽅（選択） 実 習 3: フ ィ ッ テ ィ ングお よ び ユ ー ザ ー 教習 実 習 4: 事 前 評価・処⽅（選 択）・製品（⾞椅 ⼦）の下準備・ フィッティン グ・ユーザー教 習 2:15 B.2: ⾝体的事 前評価−⽀ え な し の 座 位 姿 勢 2:30 B.12: 製品（⾞ 椅⼦）の下準備 2:45 B.9: 姿勢⽀持 具の処⽅（選 択）−股関節を ⽀える B.15: 総 ま と め 3:00 3:15 3:15〜3:30：午後のお茶（時間は 現地の事情および授業計画に合 わせる） 3:15〜3:30：午後のお茶（時間は 現地の事情および授業計画に合 わせる） 3:30 B.2: ⾝体的事 前評価−⽀ え な し の 座 位 姿 勢 B.9: 姿勢⽀持 具の処⽅（選 択）−股関節を ⽀える 3:30〜3:45：午 後のお茶 B.15: 総 ま と め 実 習 4: 事 前 評価・処⽅（選 択）・製品（⾞椅 ⼦）の下準備・ フィッティン グ・ユーザー教 習 3:45 B.10: 姿 勢 ⽀ 持具の処⽅（選 択）−体幹を⽀ える 実 習 2: 製品 （⾞椅⼦）の下 準備 4:00 B.3: ⾝体的事 前評価−⾻盤 と股関節の 姿 勢チェック B.17: 教 習 員 からのフィー ドバック・討 論・閉講式 4:15 4:30 4:45 5:00 5:15 5:30 5:45 6:00 ＊スケジュールは、必要ならば教習員/教習機関で変更してよい。 237 教習員⽤指導書 付録 2: 中級⾞椅⼦紹介・相談フォーム 紹介・相談フォーム⾒本：このフォームは⾞椅⼦サービス事業に適合させて紹介・相談元へ配布 しておき、⾞椅⼦ユーザーを⾞椅⼦サービス事業へ紹介・相談する際に使ってもらう。 紹介・相談フォームのすべての項⽬に記⼊し、こちらへご郵送下さい： • ⾞椅⼦サービスの事業所名および住所： 紹介・相談者名： 紹介・相談者勤務先： 紹介・相談者連絡先（最もよい連絡⽅法）： ⾞椅⼦ユーザー名： ⽣年⽉⽇： 保護者/介助者名： 住所： ⾞椅⼦ユーザーへ連絡を取る⽅法？： 郵便□ ⾃分の電話□ 友⼈/隣⼈の電話□ 電話の場合、電話番号： 判っていれば、⾞椅⼦ユーザーの障害： 紹介・相談理由： • ⾞椅⼦を持たない • 持っている⾞椅⼦が壊れている • 持っている⾞椅⼦がニーズに合わない • ⼦どもの場合： o 満 1歳になってもまっすぐに座らない、ま たは⽴ち上がらない。 o 満 2歳になっても歩かない。 □ □ □ □ □ □ ⾞椅⼦ユーザーに関するその他の情報で、⾞椅⼦サービス事業者へ知らせておくのが重要と思 われることがあれば追加して下さい： ⾞椅⼦ユーザーは、⾞椅⼦サービス事業へ紹介・ 相談されることに同意していますか？ はい□ いいえ□ 紹介・相談者署名： 記⼊⽇： 238 中級⾞椅⼦サービス教習パッケージ 付録 3: 中級⾞椅⼦事前評価フォーム このフォームは、⽀えがなければ⼼地よくまっすぐに座れない⾞椅⼦ユーザーへの事前評価⽤。 容易にまっすぐに座れる⾞椅⼦ユーザーは、基礎レベル教習を受けた者が事前評価できる。この フォームは、⾞椅⼦ユーザーのファイルで保管。 事前評価者名：___________________________________ 事前評価年⽉⽇：____________________ 1. 事前評価インタビュー ⾞椅⼦ユーザーに関する情報 名前：___________________________________________ 番号：______________________________ 年齢：___________________________________________ 男性□ ⼥性□ 電話番号：_______________________________________ 住所：______________________________ _______________________________________________________________________________________ ゴール：_______________________________________________________________________________ ⾝体条件 疾患： 脳損傷□ 脳性⿇痺□ 筋ジストロフィー□ ポリオ□ ⼆分脊椎□ 脊髄損傷□ 脳⾎管障害□ 不明□ その他□___________________________________ 疾患は悪化しそうか？ はい□ いいえ□ ⾝体的問題： フレイル（虚弱）□ 筋攣縮/制御できない運動□ 筋緊張（⾼/低）□ 下肢切断：右膝上□ 右膝下□ 左膝上□ 左膝下□ 疲労□ 股関節脱⾅□ てんかん□ ⾷べる・飲む・飲み込みに関する問題□ 詳細：__________________________________________ 痛み□ 部位を詳しく：________________________________________________________________ 膀胱の問題□ 腸の問題□ 膀胱や腸の問題がある⾞椅⼦ユーザーについて、管理できているかどうか。 はい□ いいえ□ 239 教習員⽤指導書 ⽣活様式および環境 ⾞椅⼦ユーザーが、どこで⾞椅⼦を使うかの詳細：__________________________________________ _______________________________________________________________________________________ １⽇の移動距離： 1 km以内□ 1〜5 km□ 5 km超□ １⽇に⾞椅⼦を使う時間数： １未満□ １〜３□ ３〜５□ ５〜８□ ８超□ ⾞椅⼦に座らない時、ユーザーがどこにどう座り、または寝そべるか（姿勢および接触⾯）： _______________________________________________________________________________________ 移乗：⾃⼒で□ 介助して□ ⽴って□ ⽴たないで□ 抱え上げて□ その他□ トイレの種類（トイレへ移る場合）： しゃがみ式□ 洋式□ 適合済み117□ ⾞椅⼦ユーザーが公共の/私的な交通機関をひんぱんに使うかどうか： はい□ いいえ□ 「はい」の場合、種類： ⾃動⾞□ タクシー□ バス□ その他□__________________ 既存の⾞椅⼦（⾞椅⼦をすでに持っている場合） ⾞椅⼦は、ユーザーのニーズを満たしているか？ はい□ いいえ□ ⾞椅⼦は、ユーザーの環境条件に合っているか？ はい□ いいえ□ ⾞椅⼦は、適切にフィットして姿勢を⽀えているか？ はい□ いいえ□ ⾞椅⼦は安全で耐久性があるか（クッションがあるかどうかも考慮せよ）？ はい□ いいえ□ クッションは適切に除圧しているか（褥瘡の危険があるユーザーの場合）？ はい□ いいえ□ 注記：_________________________________________________________________________________ すべての問いについて「はい」であれば、ユーザーに新しい⾞椅⼦は必要ない。もし「いいえ」が⼀つ でもあれば、そのユーザーには別の⾞椅⼦またはクッションが必要、あるいは既存の⾞椅⼦またはクッ ションに修理ないし改造が必要である。 117 [原⽂] adapted 240 中級⾞椅⼦サービス教習パッケージ 2. ⾝体的事前評価 褥瘡の有無・危険・既往歴 /// ＝感覚がない ◯ ＝過去の褥瘡 ● ＝現存する褥瘡 普通に感覚があるか？ はい□ いいえ□ 過去に褥瘡があったか？ はい□ いいえ□ 現在、褥瘡があるか？ はい□ いいえ□ あれば、傷が開いているか？ はい□ いいえ□ （あるいはステージ 1〜４のどれか？） 期間および原因：_________________________ ________________________________________ ________________________________________ 褥瘡の危険＊がある⼈か？＊褥瘡の危険があるのは、感覚がないあるいは 以下の褥瘡の危険因⼦を３つ以上抱える⼈。褥瘡の危険因⼦：動けない、湿 気、不良姿勢、過去/現在の褥瘡、栄養不良、⽼化、低体重や過体重。 はい□ いいえ□ ⾞椅⼦のこぎ⽅ ⾞椅⼦ユーザーはどうやって⾞椅⼦をこぐのか？ 両腕で□ 左腕で□ 右腕で□ 両脚で□ 左脚で□ 右脚で□ 介助者が押して□ 注記：_________________________________________________________________________________ ⽀えなしの座位姿勢 ⾻盤と股関節の姿勢チェック ⽀えなしの座位姿勢を、詳述するか描 く： ⾻盤が⽔平かどうか、および臥位姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 49 50 Physical assessment – sitting posture without support Physical assessment is the second part of the assessment. It includes: r identifying the presence, risk of or history of pressure sores; r identifying the method of pushing; r !nding out how the wheelchair user sits and what additional postural support he or she may need through: – observing sitting posture without support; – carrying out a pelvis and hip posture screen. Pelvis and hip posture screening helps to understand how any problems around the pelvis or hips may be affecting the wheelchair user’s sitting posture; – carrying out hand simulation. The wheelchair service personnel uses their hands to ‘simulate’ the support that a wheelchair and additional postural supports may provide; r taking measurements. Information from each of these sections of the intermediate wheelchair assessment form will help wheelchair service personnel to decide how much support the wheelchair user needs. Review of presence, risk of or history of pressure sores and method of pushing Presence, risk of or history of pressure sores /// = does not feel O = previous pressure sore = existing pressure sore Can feel normally? Yes No Previous pressure sore? Yes No Current pressure sore? Yes No If yes, is it an open sore (stage 1–4)? Yes No Duration and cause: Is this person at risk* of a pressure sore? Yes No *A person who cannot feel or has 3 or more risk factors is at risk of pressure sores. Risk factors: cannot move, moisture, poor posture, previous/current pressure sore, poor diet, ageing, under or over weight. 241 教習員⽤指導書 ハンド・シミュレーション：ニュートラルな姿勢で/快適な限りでニュートラルな姿勢にで きるだけ近づけて座るために、必要な⽀え 各⾝体部位が、⼿の⽀えでニュートラルな座位姿勢になれば「はい」、ならなければ「いいえ」に印。 部位 はい いいえ ⼿の⽀えで、⾞椅⼦ユーザーがとれた最終的な座位姿勢を記述するか 線画で描き、なおかつ、その座位姿勢がとれるように設けた⽀えを記述 するか線画で描く。 ⾻盤 □ □ 体幹 □ □ 頭 □ □ 左股関節 □ □ 右股関節 □ □ ⼤腿 □ □ 左膝 □ □ 右膝 □ □ 左⾜⾸ □ □ 右⾜⾸ □ □ 242 中級⾞椅⼦サービス教習パッケージ ⾝体計測 ⾝体⼨法（mm） ⾞椅⼦各部の⼨法（mm） 座幅・座⾯奥⾏き・⾜台〜座⾯*⾼ A 座位臀幅 ＝座幅、または 1 ＝⾻盤側⽅パッドの間隔 2 B 座底⻑（⾻盤背 ⾯〜膝裏） 右 B 引く 30〜50 mm＝座⾯奥⾏き（左右 で異なる場合は、短い⽅を採⽤） 3 左 C 座位下腿⻑ 右 ＝⾜台〜座⾯上端の間隔、 または ＝⾜こぎの場合、床⾯〜座⾯上端の間隔 4 左 5 背もたれ⾼ D 座⾯*〜胸郭下端 ＝座⾯上端〜背もたれ上端（⾞椅⼦ユー ザーのニーズにより D、E、Fのどれか） 6 E 座⾯*〜肩甲⾻下端 F 座⾯*〜肩上端 改造および/または姿勢⽀持具 G 体幹幅 ＝体幹側⽅パッド/ウェッジの間隔 7 H 座⾯*〜腋下 （わきの下） 右 H 引く 30 mm＝座⾯上端〜体幹側⽅パ ッド/ウェッジの間隔の最⼤値（ハンド・ シミュレーションに従い修正） 8 左 I 座⾯*〜⾻盤上端 （上後腸⾻棘、PSIS） ＝座⾯上端〜⾻盤後⽅パッド中央⾼さの 間隔 9 J 膝間距離 ＝膝分離パッドの幅 10 K 座⾯*〜頭蓋⾻底部 ＝座⾯上端〜ヘッドレスト中央の間隔 11 L ⾻盤背⾯〜座⾻ L ⾜す 20〜40 mm＝背もたれの⽀持部 〜座⾻前⽅（アンカー）サポートの距離 12 そ の 他 ＊⾝体計測における「座⾯」とは、座⾻が据わる表⾯である。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 63 64 On the intermediate wheelchair assessment form the body measurements are listed on the left hand side and the components that each body measurement relates to are listed on the right hand side. For example: r a wheelchair user’s hip width (body measurement A) equals the wheelchair seat width or the distance between the pelvis side pads (component measurements 1 or 2); r a wheelchair user’s seat to axilla (armpit) (measurement H) less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges (wheelchair component measurement 8). The examples above demonstrate that the body measurement does not always equal the wheelchair component measurement and some calculations are needed. In some cases there is a formula to help work out the wheelchair component measurement. Adjustments are often needed at the !tting. However accurate body measurements can help to prepare the wheelchair well ahead of the !rst !tting. The illustrations on the intermediate wheelchair assessment form help to guide wheelchair service personnel as they take the body measurements and relate them to the location and size of PSDs. G H B C D E F I K L J WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 63 64 On the intermediate wheelchair assessment form the body measurements are listed on the l ft hand side and the co ponents t at each body measurem nt relates to are listed on the right hand side. For example: r a wheelchair user’s hip width (body measurement A) equals the wheelchair seat width or the distance between the p lvis sid pads (compon nt m asurements 1 or 2); r a wheelchair user’s seat to axilla (armpit) (measurement H) less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges (wheelchair component measurement 8). The examples above demonstrate that the body measurement does not always equal the wheelchair component measurement and some calculations are needed. In some cases there is a formula to help work out the wheelchair component measurement. Adjustments are often needed at the !tting. However accurate body measurements can help to prepare the wheelchair well ahead of the !rst !tting. The illustrations on the intermediate wheelchair assessment form help to guide wheelchair service personnel as they take the body measurements and relate them to the location and size of PSDs. G H B C D E F I K L J 243 教習員⽤指導書 付録 4: 中級⾞椅⼦処⽅（選択）フォーム この処⽅フォームには、⽀えなしでは⼼地よくまっすぐに座れない⾞椅⼦ユーザーへの⾞椅⼦、 クッション、姿勢⽀持具の選択を記録。このフォームは、⾞椅⼦ユーザーのファイルに保管。 1. ⾞椅⼦ユーザーに関する情報 ⾞椅⼦ユーザー名： 番号： 事前評価⽇： フィッティング⽇： 事前評価担当者名： 2. ⾞椅⼦の種類・サイズ・設定 ⾞椅⼦の種類（⼿に⼊る⾞椅⼦を列記） ⾞椅⼦の⼨法（mm） □ 座幅 □ 座⾯奥⾏き □ 背もたれ⾼ □ ⾜台〜座⾯⾼ ⾞椅⼦の設定 駆動輪位置 その他： ティルト 3. クッションの種類・サイズ クッションの種類 サイズ 例：除圧クッション □ □ 4. 必要な姿勢⽀持具・改造 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯/ ク ' シ ) ン ソリッド座⾯ □ 座⾻前⽅（アンカー）サポート （＝3 引く 12 ） □ 座⾯前⽅を下げる 左□ 右□ 座⾯前⽅のかさ上げ □ ⾻盤前傾⽤ウェッジ（くさび） □ ⾻盤下の積み増し 左□ 右□ ⾻盤側⽅パッド（= 2 ） 左□ 右□ ⼤腿外側パッド 左□ 右□ ⼤腿内側ウェッジ（= 10 ） □ 膝分離パッド（= 10 ） □ その他 □ その他 □ 244 中級⾞椅⼦サービス教習パッケージ 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯ ＆ 背 も た れ 座⾯〜背もたれ⾓度を開ける □ 座⾯＆背もたれティルト （ティルトインスペース） □ 背 も た れ ソリッド背もたれ □ ⾻盤後⽅パッド（= 9 ） □ 背もたれの形状調整 □ 張り調整背もたれ □ 背もたれのリクライニング □ 体幹側⽅パッド（= 7 ） 左□ 右□ 体幹側⽅ウェッジ（= 7 ） 左□ 右□ その他 □ テ 1 ブ ル/ ひ じ 掛 け テーブル □ ひじ掛けを改造 左□ 右□ その他 □ 頭 の ⽀ え 平⾯ヘッドレスト（= 11 ） □ 成形ヘッドレスト（= 11 ） □ その他： □ 下 腿 ・ ⾜ の ⽀ え ⾜台の積み増し 左□ 右□ ⾜台ウェッジ（くさび） 左□ 右□ 下腿サポート 左□ 右□ その他： □ ベ ル ト ⾻盤ベルト □ 下腿ベルト □ ⾜ベルト 左□ 右□ 肩ハーネス □ その他： □ 5. 合意署名 ⾞椅⼦ユーザー：__________________________ 事前評価者：__________________________ ⾞椅⼦サービス事業管理者：__________________________ 245 教習員⽤指導書 付録 5: ⾞椅⼦概要フォーム ⾞椅⼦の名称： ここへ写真を挿⼊： 製造者/供給者： ⼿に⼊るサイズ： 全体重量： 詳細： フレーム： 固定/リジッド □ 折りたたみ □ フレーム⻑： 背もたれ： スリング/布 □ ソリッド □ 張り調整 □ 座⾯： スリング/布 □ ソリッド □ 張り調整 □ クッション： クッションなし □ 平⾯ウレタン □ 成形ウレタン □ 液体 □ その他 □ ⾜台： 固定式 □ 着脱式 □ その他： キャスター輪： 空気⼊り □ 直径： ソリッド □ 幅： 駆動輪： 空気⼊り □ 直径： ハンドリム □ ソリッド □ 幅： 位置調節⾞軸 □ エアレスチューブ □ 着脱式 □ ブレーキ： 短いレバー □ ⻑いレバー □ その他： ひじ掛け： 曲線形状 □ 直線形状 □ その他： 固定式 □ 着脱式 □ その他： ⼿押しハンドル： ⼿押しハンドル □ 姿勢⽀持具 （PSDs）： ⾻盤ベルト □ 下腿ベルト □ 肩ハーネス □ ⾜ベルト □ 転倒防⽌装置 □ 体幹側⽅パッド □ テーブル □ ヘッドレスト □ ⾻盤側⽅パッド □ その他： ⼨法、調節可能性、調節範囲： ⼨法 （複数サイズの⾞椅⼦が⼿に⼊ る場合は、サイズをすべて列挙） 調節可能か？ 調節範囲 （この⾞椅⼦につい て調節できる範囲） はい いいえ 座幅 □ □ 座⾯奥⾏き □ □ 座⾯⾼ □ □ 246 中級⾞椅⼦サービス教習パッケージ 背もたれ⾼ □ □ 背もたれの傾き □ □ ⾜台〜座⾯⾼ □ □ ⾜台⾓度 □ □ ⼿押しハンドル⾼ □ □ 全⻑ □ □ ホイールベース⻑ □ □ 座⾯〜背もたれ⾓度 □ □ ティルトインスペース □ □ 付録 6: 中級⾞椅⼦の安全・準備完了確認表 姿勢⽀持具を含む⾞椅⼦全体 鋭い⾓がない □ 姿勢⽀持具が、よく緩衝材が施され、しっかり固定されている □ 部品に破損や傷がない □ ⾞椅⼦がまっすぐ⾛る □ 前⽅キャスター輪 ⾃由に回転する □ キャスターフォークに接触しないで回転する □ ボルトが固く締まっている □ 前⽅キャスター受け具 キャスターが⾃由に旋回する □ 駆動輪 ⾃由に回転する □ ⾞軸ボルトが固く締まっている □ タイヤへ適切に空気が⼊っている（親指の圧⼒で、凹みが 5 mm未満） □ ハンドリムがしっかり取り付けられている □ ブレーキ 適切に働く □ 247 教習員⽤指導書 ⾜台 ⾜台がしっかり取り付けられている □ フレーム クロス型折りたたみ式⾞椅⼦の場合：容易に折りたためて開ける □ 背もたれ前倒し式⾞椅⼦の場合：背もたれを容易に折りたためて開ける □ クッション クッションがカバーに正しく収まっている □ クッションが⾞椅⼦に正しく載っている □ クッションカバーはぴったり合っているが、きつ過ぎない □ ⾞椅⼦がソリッド座⾯を備えている場合：クッションがソリッド座⾯全体を覆っている □ 付録 7: 中級⾞椅⼦フィッティング確認表 1. ⾞椅⼦は準備できているか？ ⾞椅⼦が安全に使⽤でき、すべての部分が動作することは確認済みか？ □ 2. ⾞椅⼦および姿勢⽀持具のフィッティングの確認 ⾞椅⼦の幅： • 臀部がひじ掛けまたは⾻盤側⽅パッドの間に⼼地よくフィットし、 • 体幹が、⾞椅⼦フレームの背もたれパイプまたは体幹側⽅パッドの間 に⼼地よくフィットし、 • ⼤腿が、ひじ掛け、泥よけ/サイドガードまたは⾻盤側⽅パッドの間に ⼼地よくフィットし、圧迫し合っていない。 □ 座⾯奥⾏き： • 左右の膝裏と座⾯/クッションの間に、30 mmのすき間。 □ ⾻盤： • 座⾻前⽅（アンカー）サポートが座⾻のすぐ前⽅に据わり、 • ⾻盤後⽅パッドが上後腸⾻棘（PSIS）のところを⽀え、 • ⾻盤側⽅パッドが寄り添うようにフィットして股関節にかからず、 • ⾻盤ベルトがしっかり締まり、⽪膚を挟んでいない。 □ WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 125 126 Pelvis strap A pelvis strap can be made of nylon webbing such as the webbing found in a car seat belt or straps on a backpack. The width of the strap can be about 25 mm wide for children and about 40–50 mm for adults. Clip buckles are the easiest to do up and undo quickly. If these are unavailable, Velcro also works well. Make sure there is at least 100 mm (depending on the size of the wheelchair user) of overlapping Velcro. A covered padding between the strap and the user (particularly where the buckle is), is more comfortable. Where to fasten the ends of the strap? r For most wheelchair users, the ends of the pelvis strap fasten directly below the front of the pelvis, as illustrated. r Changing the location of the attachment will allow the strap to pull on the body from different angles. Placing the attachment directly below the front of the pelvis (ASIS) will pull at 90 degrees to the seat surface (as shown in the illustration). Placing the strap at the back of the seat will pull at 45 degrees to the seat surface. The angle of pull should be between 45–90 degrees unless the strap is designed to provide support for a wheelchair user with an anterior pelvis tilt. If the wheelchair user tends to push the hips up or forward, an anterior tilt four-point strap provides support for a wheelchair user with anterior pelvis tilt. 248 中級⾞椅⼦サービス教習パッケージ 体幹： • 体幹側⽅パッドが、わきの下をいっさい圧迫しない位置にあり、わき の下と体幹側⽅パッド上端が 30 mm以上離れ、 • 肩ハーネスの装着が快適で、⽪膚を挟んでおらず、 • テーブルが前腕とひじの全体を⽀え、腹部を圧迫しない。 • 背もたれの⾼さと傾きを確認。 □ ヘッドレスト： • ヘッドレストは、通常⾞椅⼦ユーザーの頭を頭蓋⾻底部で⽀える。 • ユーザーの頭を、バランスが取れまっすぐに起きた姿勢で⽀える。 □ ⼤腿： • ⼤腿外側パッド、膝分離パッドによって強い圧⼒が⽣じておらず、 • 膝分離パッドが、⿏径部から⼦どもで 40〜60 mm、⼤⼈で 60〜100 mm離れている。 □ ⾜台〜座⾯⾼： • クッションが⼤腿全体を、⾜台が⾜全体をすき間なく⽀え、 • ⾜ベルトがしっかり留められて締めつけておらず、 • 下腿ベルトおよびかかとの後ろのベルトが、ふくらはぎおよび⾜を⽀ えている。 □ 3. 姿勢の確認 ⾞椅⼦ユーザーが、快適な限りで、なるべくまっすぐに座っているかどうか、正⾯と横から ⾒て確認： • ⾻盤がまっすぐに起き⽔平（か快適な限りで、なるべくそれに近づいている） □ • 体幹がまっすぐに起き左右対称（か快適な限りで、なるべくそれに近づいている） □ • 頭はバランスが取れ、（なるべく）まっすぐに起きている □ • 脚と⾜が、できる限りニュートラルに近くなるように⽀えられている □ すべての姿勢⽀持具が意図通りに⽀えているか確認。特に（供与したら）確認すべきもの： • 背もたれの⾼さ・傾き・形状 □ • ティルトインスペース □ • ⾻盤側⽅パッドおよび体幹側⽅パッド □ • ⼤腿外側および内側ウェッジ（くさび）、⼤腿外側パッド、下腿サポート □ 15 分後、姿勢に変化が起きていないか確認 □ WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 117 118 Knee separator pad Knee separator pads are often made of a piece of metal, plastic or wood with !rm foam on the top, sides and back (the surfaces that contact the user). Thin, soft foam can also be used over the !rm foam for comfort. The pad may be covered with a durable, comfortable fabric. If a wheelchair user needs a knee separator pad, it is best to provide them with a rigid seat. The knee separator pad can be !xed to a solid seat with an L-shaped bracket (as illustrated). A simple and easy way to remove or swing away the knee separator pad is needed, so that the wheelchair user can transfer in and out of the wheelchair. Open seat to backrest angle One way to make a more open seat to backrest angle is to add a !rm foam wedge onto a solid backrest at the desired angle. This should be covered with a soft foam layer. Seat and backrest tilt (tilt in space) Some wheelchairs include a feature, which allows you to tilt the seat and backrest easily. The following suggestions are for the majority of wheelchairs in use, which do not have this feature. WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 121 122 wheelchair user’s body) and wrap over the top of the pad. The whole pad is then covered with a durable, comfortable fabric. Trunk side pads may be !at, or shaped to match the wheelchair user’s body. If they are shaped, the easiest way to create the shape is to carve the shape into "rm foam. A shaped pad will need special sewing skills and a cover fabric, which can stretch. Two different ways to fasten trunk side pads to the wheelchair are shown below: A trunk side pad may be fastened to a rigid backrest, which is then covered in "rm foam and a soft foam layer. A trunk side pad may be fastened to the backrest uprights of the wheelchair with a metal bracket. Trunk side pads – need to be thin If a trunk side pad is too thick (over 2.5 cm) the pad will restrict arm movement and can also press on the underside of the arm. This can reduce blood !ow, damage nerves and interfere with hand function. Use thinner materials that are strong enough to provide the support needed. 249 教習員⽤指導書 4. 圧⼒の確認 左右の座⾻下の圧⼒を調べる。両側とも安全かどうか？ レベル１＝安全：指先を上下に 5 mm以上くねらせられる。 レベル２＝注意：指先はくねらせられないが、容易に引き抜ける。 レベル３＝危険：指先が固く締めつけられる。指を引き抜くのが困難。 □ 指を、⾞椅⼦ユーザーの⾝体とパッドやベルトなどそれぞれの姿勢⽀持部の間に置く。 姿勢⽀持部は⾝体へ均等に接触しているか？圧⼒は安全か？ □ ⾞椅⼦ユーザーに、著しい⾻ばった突起、隆起、こぶがある場合は、それらの部位に圧⼒が かかっていないか確かめる。 □ 5. ⾞椅⼦が動いている状態でのフィッティングの確認 背もたれは、⾞椅⼦ユーザーが肩を⾃由に動かしてこげるようになっているか？ □ ⾞椅⼦の動きやこぐ動作によって、⾞椅⼦ユーザーに姿勢変化、不快感、不安定感が⽣じて いないか？ □ ⼿こぎの場合：駆動輪位置は、⾞椅⼦ユーザーができる限りうまくこぐために適切か？ □ ⾜こぎの場合：座⾯⾼および座⾯奥⾏きは、⾞椅⼦ユーザーが⾜でこぐために適切か？ □ 姿勢⽀持は、⾞椅⼦による移動を制約せず安全にしているか？ □ 6. さらにやるべきことがあるかどうかの判断 さらにやるべきことがあるか？⾞椅⼦ユーザーのファイルに、やるべきことはすべて記⼊。 □ 付録 8: 中級⾞椅⼦ユーザー教習確認表 教えるべき 技能 教えた 技能 注記 ⾞椅⼦の取り扱い ⾞椅⼦の折りたたみ⽅および持ち上げ⽅ □ □ 運搬のために取り外す必要がある、すべ ての姿勢⽀持具の脱着⽅法 □ □ クイックリリース⾞輪の扱い⽅ □ □ 250 中級⾞椅⼦サービス教習パッケージ ブレーキの使い⽅ □ □ ティルトおよび転倒防⽌装置 （使⽤する場合） □ □ ⾞椅⼦ユーザーが⾞椅⼦へ座った時の、 姿勢⽀持具の正しい位置 □ □ 正しい置き⽅など、クッションの扱い⽅ □ □ 移乗 ⾃⼒での移乗 □ □ 介助による移乗 □ □ その他 □ □ ⾞椅⼦の使⽤および移動 正しいこぎ⽅ （⾞椅⼦ユーザーが好む⽅法による） □ □ 斜⾯の登り下り □ □ 階段の昇り降り □ □ 荒れ地 □ □ ⼀時ウィリー □ □ どれくらい⻑時間、⾞椅⼦に座るべきか （付加姿勢⽀持が必要な⼦どもおよび⼤ ⼈の場合） □ □ 介助での押し⽅ □ □ 褥瘡予防 強い圧⼒がかかる部位の褥瘡を検査 □ □ 除圧動作 □ □ よい⾷事をし、たくさん⽔を飲む □ □ 褥瘡ができたらどうするか □ □ 家庭での⾞椅⼦の⼿⼊れ ⾞椅⼦の掃除：クッションとクッション カバーを洗って乾かす □ □ 可動部への注油 □ □ タイヤの空気⼊れ □ □ ボルトとナットを締める □ □ 251 教習員⽤指導書 スポークを張る □ □ 張り布を調べる □ □ サビを調べる □ □ クッションを調べる □ □ 問題が起きたらどうするか ⾞椅⼦に修理が必要になったら □ □ ⾞椅⼦がフィットしない、あるいは快適 でない場合 □ □ 付録 9: ⾞椅⼦フォローアップフォーム このフォームには、⾞椅⼦ユーザーに関する、フォローアップ訪問から得た情報を記録。 このフォームは、⾞椅⼦ユーザーのファイルに保管。 1. ⾞椅⼦ユーザーの情報 ⾞椅⼦ユーザー名：__________________________________ 番号：___________________________ フィッティング⽇：__________________________________ フォローアップ⽇：_______________ フォローアップ実施者名：_______________________________________________________________ フォローアップ実施場所： ⾞椅⼦ユーザーの家□ ⾞椅⼦サービスセンター□ その他□：_______________________________________________ 2. インタビュー さらにやるべきことを記録 ⾞椅⼦を、思う存分使えていますか？ はい□ いいえ□ 「いいえ」の場合：なぜですか？ ⾞椅⼦を使ううえで、何か問題はありますか？ はい□ いいえ□ 「はい」の場合：それは何ですか？ ⾞椅⼦を使ううえで、何か疑問はありますか？ はい□ いいえ□ 「はい」の場合：どんな疑問ですか？さらに教習が必要ですか？ 褥瘡がありますか？ はい□ いいえ□ 「はい」の場合：詳細（部位および程度） ⾞椅⼦への満⾜度を５段階で評価してください （１＝満⾜していない、５＝⾮常に満⾜） 評価： コメント： 252 中級⾞椅⼦サービス教習パッケージ 3. ⾞椅⼦およびクッションの確認 ⾞椅⼦は正常に働き、安全に使えていますか？ はい□ いいえ□ クッションは正常に働き、安全に使えていますか？ はい□ いいえ□ ⼀つでも「いいえ」の場合、何が問題なのでしょうか？ 4. フィッティングの確認 ⾞椅⼦は、うまくフィットしていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 圧⼒検査の評価（１＝安全、２＝注意、３＝危険） （褥瘡発⽣の危険があるユーザーについて） 左： 右： 静⽌している時・動いている時・⼀⽇じゅう、ユー ザーは⼼地よくまっすぐに座っていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 付録 10: 姿勢⽀持具（PSD）⼀覧表 座⾯/クッション 座⾻前⽅（アン カー）サポート 座⾯前⽅（⽚ 側）を下げる 座⾯前⽅の かさ上げ ⾻盤前傾⽤ ウェッジ ⾻盤下の 積み増し ⾻盤側⽅パッド 座⾯/クッション 座⾯＆背もたれ ⼤腿外側 ウェッジ ⼤腿外側 パッド ⼤腿内側 ウェッジ 膝分離パッド 座⾯〜背もたれ ⾓度を開ける 座⾯＆背もたれテ ィルト（ティルト インスペース） 253 教習員⽤指導書 背もたれ ⾻盤後⽅ パッド 背もたれの 形状調整 張り調整 背もたれ 背もたれの リクライニング 体幹側⽅ パッド 体幹側⽅ ウェッジ テーブル ヘッドレスト 下腿の⽀え テーブル 平⾯ ヘッドレスト 成形 ヘッドレスト ⾜台の積み増し ⾜台ウェッジ 下腿サポート ベルト ⾻盤ベルト ⾻盤前傾 ４点ベルト 下腿ベルト ⾜ベルト 肩ハーネス 付録 11: 硬いウレタンフォーム製ウェッジ 硬いウレタンフォーム製のウェッジ （くさび）は、⼀時的⽀持部に使える。 硬いウレタンフォームのウェッジは 単独で、あるいはより⾓度が急になる よう貼り合わせて⽤いる。右図のもの の⼨法は、30 mm x 150 mm x 200 mm である。これより⼩さめ、あるいは⼤ きめのウェッジもあると便利。 254 付録 12: 実習⽤⾞椅⼦ユーザー名簿 この確認表を⽤い、各実習について⾞椅⼦ユーザー志願者を管理し、⽇程を調整せよ。留意事項：⾞椅⼦ユーザーはつねに⾃らの意志で参加すべき である。可能な限り、その時間には報酬を払うべきだ。⾞椅⼦ユーザーの選定には、教習員⽤指導書の確認表を活⽤せよ。 実習 ⽇時 ⾞椅⼦ユーザー名 ジェンダー 年齢 障害/移動および姿勢⽀持へのニーズ 招待済 承諾済 移動の⼿配 実習 1 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 実習 2 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 実習 3 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 実習 4 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 中級⾞椅⼦サービス教習パッケージ 教習員⽤指導書 著作・制作︓ 世界保健機関（WHO） ＊⽇本語版翻訳・発⾏︓ ⼀般社団法⼈ ⽇本⾞椅⼦シーティング協会（JAWS） ⽇本⾞椅⼦シーティング協会国際委員会・ アジア姿勢保持プロジェクト（ASAP） ＊本書の⽇本語版作成に当たり、公益財団法⼈ ⽇本社会福祉弘済会の研究助成を頂きました。
中級 ⾞椅⼦サービス教習パッケージ 受講者⽤ワークブック 英語版原著者・制作者・協⼒者⼀覧： 編集者: Chapal Khasnabis, Kylie Mines 執筆者: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, Rebecca Jackson Stoeckle 査読者: Natasha Altin, Bill Armstrong, Johan Borg, Andrew Congdon, Nejla Essaafi Elkhadiri, Ritu Ghosh, Lauren Houpapa, R. Lee Kirby, Shona McDonald, Ray Mines, Alana Officer, Cher Smith, Mark Sullivan, Diane E. Ward イラストレーター: Melissa Puust 写真著作権者: David Constantine, Jesse Moss, Chapal Khasnabis ビデオ著作権者: Chapal Khasnabis, Amanda McBaine, Jesse Moss 実施試験訓練員: Andrew Congdon, Mirela Creanga, Nancy Mbugua, Charles Kanyi, Norah Keitany, Katharina Kiss, Seraphine Ongogo, Gabriela Raducan, Andrew Rose 資⾦協⼒: ⽶国国際開発庁 (USAID), オーストラリア国際開発庁 (AUSAID) 提携団体: ASSERT 東ティモール [国⽴リハビリテーションセンター, 現 CNR], ケニア⾝体障害 者協会 (APDK), ソロモン諸島保健医療サービス省・地域に根ざしたリハビリテーショ ン局, 教育開発センター (EDC), ハンディキャップ・インターナショナル, ⾚⼗字国際 委員会 (ICRC), 国際義肢装具学会 (ISPO), キリマンジャロ脊髄損傷者協会 (KASI), モビリティ・インディア, モティベーション・オーストラリア, モティベーション慈善 基⾦ (Motivation), モティベーション・ルーマニア, タンザニア義肢装具技術者訓練セ ンター (TATCOT) Published by the World Health Organization in 2013 under the title Wheelchair Service Training Package: Participantʼs Workbook: Intermediate Level © World Health Organization 2013 The World Health Organization has granted a translation and publication permission for an edition in Japanese to the Japan Association of Wheelchair and Seating (JAWS), which is solely responsible for the quality and faithfulness of the Japanese translation. In the event of any inconsistency between the English and the Japanese editions, the original English edition shall be the binding and authentic edition. 中級⾞椅⼦サービス教習パッケージ・受講者⽤ワークブック © Japan Association of Wheelchair and Seating (JAWS) 2022 2022 年 1 ⽉ 29 ⽇発⾏ 原著者： 世界保健機関 (WHO) 翻訳・制作者： ⽇本⾞椅⼦シーティング協会国際委員会・アジア姿勢保持プロジェクト (ASAP) 発⾏所： ⼀般社団法⼈ ⽇本⾞椅⼦シーティング協会 (JAWS) 〒105-0013 東京都港区浜松町 2-7-15 三電舎ビル 2 階 電話 03-6435-0365 FAX 03-6435-0365 URL http://www.j-aws.jp もくじ 本書の⽬的 1 A.1: 付加姿勢⽀持が有益な⾞椅⼦ユーザー 2 B.1: 事前評価の概略・事前評価インタビュー 3 B.2: ⾝体的事前評価−⽀えなしの座位姿勢: 座位姿勢の基礎 7 B.2: ⾝体的事前評価−⽀えなしの座位姿勢: 姿勢を描く 8 B.3: ⾝体的事前評価−⾻盤と股関節の姿勢チェック: チェックの実施 11 B.3: ⾝体的事前評価−⾻盤と股関節の姿勢チェック: ⼀時的⽀持の演習 12 B.5: ⾝体的事前評価−⾝体計測 14 B.6: ⾞椅⼦およびクッションの選択 16 B.8: 姿勢⽀持具の処⽅（選択）−⾻盤を安定させる 25 B.9: 姿勢⽀持具の処⽅（選択）−股関節を⽀える 27 B.10: 姿勢⽀持具の処⽅（選択）−体幹を⽀える 30 B.11: 姿勢⽀持具の処⽅（選択）−頭・⼤腿・下腿を⽀える 42 実習 2: 製品（⾞椅⼦）の下準備−タスク確認表 43 実習 2: 製品（⾞椅⼦）の下準備−中級⾞椅⼦の安全・準備完了確認表 44 B.14: ユーザー教習 45 B.15: 総まとめ 49 B.16: メンテナンス・修理・フォローアップ 50 実習 4: 事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ユーザー教習 −タスク確認表 54 実習 4: 事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ユーザー教習 −中級⾞椅⼦の安全・準備完了確認表 55 名前： 1 受講者⽤ワークブック 本書の⽬的 中級レベルの教習パッケージ（WSTPi）は、まっすぐに座るには付加姿勢⽀持が必要な男⼥の⼦ど もや⼤⼈へ、適正な⼿動⾞椅⼦およびクッションを供与するために職員およびボランティアが受け る教習を⽀援するようデザインされている。 この教習パッケージの主⽬的は、⾞椅⼦サービス提供に携わる職員の技能および知識の育成である。 この教習パッケージの実施は、以下の役に⽴つ： • ⾃分のニーズを満たす⾞椅⼦を⼿にする、⾞椅⼦ユーザーの数が増える。 • 中級レベルの⾞椅⼦サービス提供教習を受けた職員の数が増える。 • ⾞椅⼦サービス提供職員の能⼒が向上する。 • 基礎レベルよりも⾼度な介⼊が必要な⼈びとに対する、⾞椅⼦サービス提供の質が向上する。 • 正規のパラメディカル/リハビリテーションの教習プログラムへ、この教習パッケージが盛り込 まれる。 • ⾞椅⼦サービス提供の、リハビリテーションサービスへのより⼤きな統合が達成される。 この受講者⽤ワークブックの主⽬的は、⾞椅⼦サービス提供に携わる職員の技能および知識の育成 である。ワークブックには受講者の知識や技能をテストし、発展させるのに役⽴つ練習課題を載せ ている。ワークブックに載せた資料は、講義、プレゼンテーションスライド、受講者⽤参考書から 採ったもので、受講者がこのワークブックを⾃分⽤に持っておき、後のち必要になったら参照でき るようにしている。 2 中級⾞椅⼦サービス教習パッケージ A.1: 付加姿勢⽀持が有益な⾞椅⼦ユーザー 1. キャッチボール • グループから⼀⼈を選び、この活動の３つのステップを通して、椅⼦に座ってもらいなさい。 • あとの⼆⼈は助⼿を務めなさい。 • 各ステップで、椅⼦に座った⼈と助⼿の間で５回、キャッチボールをしなさい。 ステップ１：キャッチボールをする間、椅 ⼦に座った⼈はまっすぐに座り、⾜をべっ たり床に着ける。 ボールを投げ、キャッチするのはどれくらい簡単 だろうか？ ステップ 2、3 と進むにつれ、より難しくなるだろ うか？ なぜか？体位や姿勢を変えると、ボールのキャッ チしやすさにどう影響するだろうか？ ステップ２：キャッチボールをする間、助 ⼿の⼀⼈が椅⼦を、⽚側の脚 2 本を軸にし て傾け、静⽌させて保つ。 ステップ３：キャッチボールをする間、助 ⼿の⼀⼈が脚から脚へと不規則に椅⼦を 揺らす。 2. ⽔飲み • めいめい、下記のさまざまな体位や姿勢で⽔を飲みなさい。 • 各回２、３⼝だけにして、気をつけてやって下さい！ • まっすぐに座る。 体位や姿勢を変えると、⽔の飲みやすさにどう影響 するだろうか？ • 頭を真後ろへ反り返らせ（⿐を上に向 け）て椅⼦に座る。 • 「ずっこけた」姿勢で椅⼦に座る。 • 評価ベッドに寝転ぶ。 3 受講者⽤ワークブック B.1: 事前評価の概略・事前評価インタビュー • グループで協⼒し、グループ番号に対して割り当てた以下の質問すべてに答えなさい。 グループ１ 下記の疾患/⾝体的問題は、⾞椅⼦供与にどう影響するだろうか？ 例えば： • 疾患/⾝体的問題のどんな特徴が、⾞椅⼦供与に影響するだろうか？ • どんな⾞椅⼦の特⾊や教習が役⽴つだろうか？ • それぞれの場合、⾞椅⼦ユーザーについて何を知っておくことが重 要だろうか？ 脳損傷 ポリオ 疲労 4 中級⾞椅⼦サービス教習パッケージ グループ２ 下記の疾患/⾝体的問題は、⾞椅⼦供与にどう影響するだろうか？ 例えば： • 疾患/⾝体的問題のどんな特徴が、⾞椅⼦供与に影響するだろうか？ • どんな⾞椅⼦の特⾊や教習が役⽴つだろうか？ • それぞれの場合、⾞椅⼦ユーザーについて何を知っておくことが重 要だろうか？ 筋ジストロフィー 脊髄損傷 筋攣縮 ［きんれんしゅく］/ 制御できない運動 5 受講者⽤ワークブック グループ３ 下記の疾患/⾝体的問題は、⾞椅⼦供与にどう影響するだろうか？ 例えば： • 疾患/⾝体的問題のどんな特徴が、⾞椅⼦供与に影響するだろうか？ • どんな⾞椅⼦の特⾊や教習が役⽴つだろうか？ • それぞれの場合、⾞椅⼦ユーザーについて何を知っておくことが重 要だろうか？ 脳性⿇痺 脳⾎管障害 ⾷べる・飲む・ 飲み込みの 障害 6 中級⾞椅⼦サービス教習パッケージ グループ４ 下記の疾患/⾝体的問題は、⾞椅⼦供与にどう影響するだろうか？ 例えば： • 疾患/⾝体的問題のどんな特徴が、⾞椅⼦供与に影響するだろうか？ • どんな⾞椅⼦の特⾊や教習が役⽴つだろうか？ • それぞれの場合、⾞椅⼦ユーザーについて何を知っておくことが重 要だろうか？ ⼆分脊椎 進⾏性疾患 （例えば筋ジストロ フィー、パーキンソ ン病、多発性硬化症、 運 動 ニ ュ ー ロ ン 疾 患） 股関節脱⾅ 7 受講者⽤ワークブック B.2: ⾝体的事前評価−⽀えなしの座位姿勢: 座位姿勢の基礎 • 協⼒して、⾻盤姿勢が変わると、まっすぐに座った姿勢にどんな変化が起こるか⾒極めなさい。 • グループの各⼈がモデルになって、下記の⾻盤姿勢を⼀つとりなさい。他の⼈は、モデルの⾝体 の他の部分に、どんな変化が起こるか観察しなさい。 • 時間があれば、グループの各々でさまざまな⾻盤姿勢を試み、⾃分の⾝体に起こる変化を感じ取 りなさい。 ⾻盤姿勢 その⼈の姿勢の変化について、観察されたことを書き出すか、描くか しなさい。その⼈の体幹・頭・⾸・脚をよく⾒なさい。 前傾 後傾 側傾 回旋 8 中級⾞椅⼦サービス教習パッケージ B.2: ⾝体的事前評価−⽀えなしの座位姿勢: 姿勢を描く • それぞれの横に、⾃分で線画を描きなさい。 横から⾒た姿勢の線画 正⾯から⾒た姿勢の線画 正⾯から⾒た姿勢の線画―⾻盤の回旋 9 受講者⽤ワークブック • 下の枠内に、図中の⼈物の姿勢を記録する線画を描きなさい。 1. ⽀えなしの座位姿勢 ⽀えなしの座位姿勢を、記述するか描きなさい。 2. ⽀えなしの座位姿勢 ⽀えなしの座位姿勢を、記述するか描きなさい。 10 中級⾞椅⼦サービス教習パッケージ • 下の枠内に、図中の⼈物の姿勢を記録する線画を描きなさい。 3. ⽀えなしの座位姿勢 ⽀えなしの座位姿勢を、記述するか描きなさい。 4. ⽀えなしの座位姿勢 ⽀えなしの座位姿勢を、記述するか描きなさい。 11 受講者⽤ワークブック B.3: ⾝体的事前評価−⾻盤と股関節の姿勢チェック: チェックの実施 • グループ内で⾞椅⼦ユーザー役を務める各⼈に、⾻盤と股関節の姿勢チェックを実施しなさい。 • 下の、中級⾞椅⼦事前評価フォームの「⾻盤と股関節の姿勢チェック」の箇所に、グループ内で ⾞椅⼦ユーザー役を務めた各⼈の結果を記録しなさい。 ⾞椅⼦ユーザー１： ⾻盤と股関節の姿勢チェック ⾻盤が⽔平かどうか、および臥位姿勢での股関節の屈 曲可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 ⾞椅⼦ユーザー２： ⾻盤と股関節の姿勢チェック ⾻盤が⽔平かどうか、および臥位姿勢での股関節の屈曲 可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 ⾞椅⼦ユーザー３： ⾻盤と股関節の姿勢チェック ⾻盤が⽔平かどうか、および臥位姿勢での股関節の屈曲 可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 12 中級⾞椅⼦サービス教習パッケージ B.3: ⾝体的事前評価−⾻盤と股関節の姿勢チェック: ⼀時的⽀持の演習 • それぞれの⾞椅⼦ユーザーの例話を読みなさい。 • それぞれの⾞椅⼦ユーザーについて、その⼈の⾻盤が⽔平になるかどうか、また股関節がニュー トラルな座位姿勢まで曲がる（体幹〜⼤腿の⾓度が 90 度以下になる）かどうか、判断しなさい。 • 中級⾞椅⼦事前評価フォームの「⾻盤と股関節の姿勢チェック」の箇所を完成し、その⾞椅⼦ユ ーザーに⼀時的⽀持が必要かどうか判断し、各⾞椅⼦ユーザーへの⼀時的⽀持を設定しなさい。 • それぞれの⼀時的⽀持部は必ず確認し、各⼀時的⽀持部に座ってどんな感じなのか確かめなさい。 注記：ASIS とは上前腸⾻棘のことです。 サム ⾻盤と股関節の姿勢チェック サムは４歳。脳性⿇痺があり、⾃⼒で はまっすぐに座れない。⾻盤と股関節 の姿勢チェックから判ったことは： • サムの⾻盤は⽔平にでき（左右の ASIS が⽔平で）、 • サムの左股関節は、楽にニュートラ ルな座位姿勢まで屈曲する。サムの 右股関節は痛みがあるため、ニュー トラルな座位姿勢までは屈曲しない （体幹〜⼤腿の⾓度が 90 度超）。体 幹と右⼤腿の間の⾓度は約 105 度。 ⾻盤が⽔平かどうか、および臥位姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 サムには⼀時的⽀持部が必要か？ はい□ いいえ□ マーサ ⾻盤と股関節の姿勢チェック マーサは 57 歳。重い関節炎を患って いる。何歩か歩けるが、歩くのがたい へん苦痛である。⾻盤と股関節の姿勢 チェックから判ったことは： • マーサの⾻盤は⽔平にでき（左右の ASIS が⽔平で）、 • マーサは、両股関節がニュートラル な座位姿勢まで屈曲しない（体幹〜 ⼤腿の⾓度が 90 度超）。体幹と⼤腿 の間の⾓度は、両股関節ともに約 100 度。 ⾻盤が⽔平かどうか、および臥位姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 マーサには⼀時的⽀持部が必要か？ はい□ いいえ□ 13 受講者⽤ワークブック セレン ⾻盤と股関節の姿勢チェック セレンは16歳。⼦どもの頃ポリオを患い、 両脚に重度の拘縮がある。セレンはあぐ らをかいて床を膝⾏する。⾻盤と股関節 の姿勢チェックから判ったことは： • セレンの⾻盤は⽔平にならず、右側が 左側より 20 mm ⾼い。 • セレンの両股関節は、ニュートラルな 座位姿勢まで屈曲する。 ⾻盤が⽔平かどうか、および臥位姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 セレンには⼀時的⽀持部が必要か？ はい□ いいえ□ ジョー ⾻盤と股関節の姿勢チェック ジョーは25歳。⼦どもの頃ポリオを患い、 両脚に重度の拘縮がある。⾻盤と股関節 の姿勢チェックから判ったことは： • ジョーの⾻盤は⽔平にでき（左右の ASIS が⽔平で）、 • ジョーの右股関節は、楽にニュートラ ルな座位姿勢まで屈曲する。しかし左 股関節は、ニュートラルな座位姿勢ま では伸展しない（体幹〜⼤腿の⾓度が 90 度未満）。体幹と⼤腿の間の⾓度は 70 度。 ⾻盤が⽔平かどうか、および臥位姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい□ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ□ ⾓度 左股関節 はい□ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 ジョーには⼀時的⽀持部が必要か？ はい□ いいえ□ 14 中級⾞椅⼦サービス教習パッケージ B.5: ⾝体的事前評価−⾝体計測 マダヴィは 13 歳、脳性⿇痺を抱えています。⽀えなしでまっすぐに座れますが、たいへんく たびれるため⻑時間は座れません。軽度の⾻盤後傾のままで固まっており、いまの⾞椅⼦では 前滑りします。彼⼥はテーブルを欲しがっていて、テーブルなり天板を前に置くことで読書や 書き物、⾷事がもっと楽にできればと望んでいます。以下は、⾞椅⼦サービス職員が⾏なった ハンド・シミュレーションによる⾝体的事前評価の結果です。 • 下の、完成したハンド・シミュレーションの結果を読みなさい。 ハンド・シミュレーション：ニュートラルな姿勢で・快適な限りでニュートラルな 姿勢にできるだけ近づけて座るために、必要な⽀え 各⾝体部位が、⼿の⽀えでニュートラルな座位姿勢になれば「はい」、ならなければ「いいえ」に印。 部位 はい いいえ ⼿の⽀えで、⾞椅⼦ユーザーがとれた最終的な座位姿勢を記述するか 線画で描き、なおかつ、その座位姿勢がとれるように設けた⽀えを記 述するか線画で描く。 ⾻盤 □ □ 体幹 □ □ 最終的な姿勢：⾻盤後傾；体幹下部は両側からの⽀えがあれば、わず かに（横から⾒て）曲がっているが（前から⾒て）対称；頭はわずか に前⽅；脚に内側へ閉じる傾向があり、軽く⽀えれば⼤腿はニュート ラルになる。 必要な⽀え： • 座⾻前⽅の⽀え • ⾻盤後部の⽀え：ニュートラルにはしないがさらに倒れるのを防ぐ • 背中から肩までの⽀え • 体幹側⽅の⽀え：体幹を中央に保つ • ⾻盤/股関節側⽅の⽀え：⾻盤を中央に保つ • ⼤腿が閉じるのを防ぐ、⼤腿間の⽀え：⼤腿内側ウェッジ • テーブル 頭 □ □ 左股関節 □ □ 右股関節 □ □ ⼤腿 □ □ 左膝 □ □ 右膝 □ □ 左⾜⾸ □ □ 右⾜⾸ □ □ • マダヴィへ⾞椅⼦を選べるためには、どの⾝体計測が必要か判断しなさい。 • それらの計測をグループの最低 1 ⼈に⾏ない、中級⾞椅⼦事前評価フォーム「⾝体計測」の箇所 （次ページ）へ記⼊しなさい。 • どうやったら座底⻑を適切に測れるでし ょうか（マダヴィは軽度の⾻盤後傾のまま 固まっていることに留意しなさい）？ • マダヴィ⽤のテーブルの⾼さとサイズ/形 状を表わすには、どの⼨法を測りますか？ 15 受講者⽤ワークブック ⾝体計測 ⾝体⼨法（mm） ⾞椅⼦各部の⼨法（mm） 座幅・座⾯奥⾏き・⾜台〜座⾯⾼ A 座位臀幅 ＝座幅、または 1 ＝⾻盤側⽅パッドの間隔 2 B 座底⻑（⾻盤背 ⾯〜膝裏） 右 B 引く 30〜50 mm＝座⾯奥⾏き（左右 で異なる場合は、短い⽅を採る） 3 左 C 座位下腿⻑ 右 ＝⾜台〜座⾯上端の間隔、 または ＝⾜こぎの場合、床⾯〜座⾯上端の間隔 4 左 5 背もたれ⾼ D 座⾯＊〜胸郭下端 ＝座⾯上端〜背もたれ上端（⾞椅⼦ユー ザーのニーズにより D、E、F のどれか） 6 E 座⾯＊〜肩甲⾻下端 F 座⾯＊〜肩上端 改造および/または姿勢⽀持具 G 体幹幅 ＝体幹側⽅パッド/ウェッジの間隔 7 H 座 ⾯＊〜腋下 （わきの下） 右 H 引く 30 mm＝座⾯上端〜体幹側⽅パ ッド/ウェッジの間隔の最⼤値（ハンド・ シミュレーションに従い修正） 8 左 I 座 ⾯＊〜⾻ 盤 上端 （上後腸⾻棘、PSIS） ＝座⾯上端〜⾻盤後⽅パッド中央⾼さの 間隔 9 J 膝間距離 ＝膝分離パッドの幅 10 K 座⾯＊〜頭蓋⾻底部 ＝座⾯上端〜ヘッドレスト中央の間隔 11 L ⾻盤背⾯〜座⾻ L ⾜す 20〜40 mm＝背もたれの⽀持部 〜座⾻前⽅（アンカー）サポートの距離 12 そ の 他 ＊⾝体計測における「座⾯」とは、座⾻が据わる表⾯である。 WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 63 64 On the intermediate wheelchair assessment form the body measurements are listed on the left hand side and the components that each body measurement relates to are listed on the right hand side. For example: r a wheelchair user’s hip width (body measurement A) equals the wheelchair seat width or the distance between the pelvis side pads (component measurements 1 or 2); r a wheelchair user’s seat to axilla (armpit) (measurement H) less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges (wheelchair component measurement 8). The examples above demonstrate that the body measurement does not always equal the wheelchair component measurement and some calculations are needed. In some cases there is a formula to help work out the wheelchair component measurement. Adjustments are often needed at the !tting. However accurate body measurements can help to prepare the wheelchair well ahead of the !rst !tting. The illustrations on the intermediate wheelchair assessment form help to guide wheelchair service personnel as they take the body measurements and relate them to the location and size of PSDs. G H B C D E F I K L J WHEELCHAIR SERVICE TRAINING PACKAGE INTERMEDIATE LEVEL 63 64 On the intermediate wheelchair assessment form the body measurements are listed on the left hand side and the components that each body measurement relates to are listed on the right hand side. For example: r a wheelchair user’s hip width (body measurement A) equals the wheelchair seat width or the distance between the pelvis side pads (component measurements 1 or 2); r a wheelchair user’s seat to axilla (armpit) (measurement H) less 30 mm is the maximum distance between the top of the cushion and the top of trunk side pads/wedges (wheelchair component measurement 8). The examples above demonstrate that the body measurement does not always equal the wheelchair component measurement and some calculations are needed. In some cases there is a formula to help work out the wheelchair component measurement. Adjustments are often needed at the !tting. However accurate body measurements can help to prepare the wheelchair well ahead of the !rst !tting. The illustrations on the intermediate wheelchair assessment form help to guide wheelchair service personnel as they take the body measurements and relate them to the location and size of PSDs. G H B C D E F I K L J 16 中級⾞椅⼦サービス教習パッケージ B.6: ⾞椅⼦およびクッションの選択 • 地元で⼿に⼊る⾞椅⼦を、⼀つ⼀つ注意深く観察しなさい。 • グループで下の問いに答えなさい。 • 分からなかったら、訓練員に聞いて確認しなさい。 1. ⽣活様式および環境 問い： 答え： どの⾞椅⼦（複数可）が、荒れた/凸凹な地⾯を ⾏くのに最適ですか？ 理由は？ どの⾞椅⼦（複数可）が、⽴ち上がっての移乗 をいちばん楽にできますか？ 理由は？ どの⾞椅⼦（複数可）が、横⽅向の移乗をいち ばん楽にできますか？ 理由は？ それぞれの⾞椅⼦は、運搬のためにどうやって折 りたたみ、また分解しますか？よくある⽅法は以 下のものです： • 折りたたみなし • クロス型折りたたみ式 • 背もたれを倒して折りたたむ • クイックリリース⾞輪 あなたのグループでは、どの⾞椅⼦（複数可）が 公共交通機関での運搬がいちばん楽だと考えま すか？ 理由は？ どの⾞椅⼦（あれば）が空気⼊りタイヤを備えて いますか？ どの⾞椅⼦（あれば）がエアレスチューブを備え ていますか？ どの⾞椅⼦（あれば）がノーパンクタイヤを備え ていますか？ 17 受講者⽤ワークブック 2. 除圧 問い： 答え： 教室にはどんな種類のクッションがあります か？ それらのうち、どれを除圧クッションに分類しま すか？ 理由は？ 除圧クッション（あれば）について、どれが次の ような改造が⽐較的易しいと思いますか： • 除圧効果を⾼める。 • 付加姿勢⽀持を備える。 教室にあるクッションカバーには、どんな特⾊が ありますか？ 考察すること：耐⽔性、耐久性、伸縮性、⽣地の 厚み 3. ⾞椅⼦のこぎ⽅ 問い： 答え： ⾞椅⼦へまっすぐに座りなさい。駆動輪は⾃⼒で こぐのによい位置にありますか？確認しなさい： • 腕を⾃然に下へ垂らしなさい。⼿が⾞軸の上に かかりますか？ • ハンドリムの頂部を、肩の真下で握りなさい。 ひじの⾓度は 90〜120度ですか？ • 駆動輪位置は調節可能ですか？もし調節済み なら、こぐ姿勢は改善していますか？ 教室にある⾞椅⼦で、⾜台⾼を調節できるものが ありますか？ それはどんな場合に役⽴ちますか？ 18 中級⾞椅⼦サービス教習パッケージ 4. 姿勢⽀持の特⾊ 問い： 答え： どの⾞椅⼦（あれば）、挙上式レッグレストを備 えていますか？ どの⾞椅⼦（あれば）が、ソリッド座⾯を備えて いますか？ どの⾞椅⼦（あれば）が、張り調整背もたれを備 えていますか？ どの⾞椅⼦（あれば）が、付加姿勢⽀持を備える ように設計した追加部材を備えていますか？ （その部材についての説明や列記の必要はなく、 付加姿勢⽀持を備えた⾞椅⼦を⾒出せればよい） 5. 調節可能性 問い： 答え： どの⾞椅⼦（あれば）で、次の調節が可能ですか？ • ⾜台〜座⾯⾼ • ⾜台⾓度 • ⾜台の前後移動 • 背もたれ⾼の上下 • 背もたれの傾き • ティルトインスペース［座⾯＆背もたれティル ト］ 19 受講者⽤ワークブック 中級⾞椅⼦概要フォーム • 教習プログラムで使う⾞椅⼦ごとに、このフォームを完成しなさい（もっと部数が必要な場合は、 訓練員に請求しなさい）。 ⾞椅⼦の名称： 製造者/供給者： ⼿に⼊るサイズ： 全体重量 詳細： フレーム 固定/リジッド □ 折りたたみ □ フレーム⻑： 背もたれ スリング/布 □ ソリッド □ 張り調整 □ 座⾯ スリング/布 □ ソリッド □ 張り調整 □ クッション クッションなし □ 平⾯ウレタン □ 成形ウレタン □ 液体 □ その他 □ ⾜台 固定式 □ 着脱式 □ その他 キャスター輪 空気⼊り □ 直径： ソリッド □ 幅： 駆動輪 空気⼊り □ 直径： ハンドリム □ ソリッド □ 幅： 位置調節⾞軸 □ エアレスチューブ □ 着脱式 □ ブレーキ 短いレバー □ ⻑いレバー □ その他： ひじ掛け 曲線形状 □ 直線形状 □ その他： 固定式 □ 着脱式 □ その他： ⼿押しハンドル ⼿押しハンドル □ 姿勢⽀持具 ⾻盤ベルト □ 下腿ベルト □ 肩ハーネス □ ⾜ベルト □ 転倒防⽌装置 □ 体幹側⽅パッド □ テーブル □ ヘッドレスト □ ⾻盤側⽅パッド □ その他： 20 中級⾞椅⼦サービス教習パッケージ ⼨法、調節可能性、調節範囲 ⼨法 （複数サイズの⾞椅⼦が⼿に⼊ る場合は、サイズをすべて列挙） 調節可能か？ 調節範囲 （この⾞椅⼦につい て調節できる範囲） はい いいえ 座幅 □ □ 座⾯奥⾏き □ □ 座⾯⾼ □ □ 背もたれ⾼ □ □ 背もたれの傾き □ □ ⾜台〜座⾯⾼ □ □ ⾜台⾓度 □ □ ⼿押しハンドル⾼さ □ □ 全⻑ □ □ ホイールベース⻑ □ □ 座⾯〜背もたれ⾓度 □ □ ティルトインスペース □ □ 21 受講者⽤ワークブック 中級⾞椅⼦概要フォーム • 教習プログラムで使う⾞椅⼦ごとに、このフォームを完成しなさい（もっと部数が必要な場合は、 訓練員に請求しなさい）。 ⾞椅⼦の名称： 製造者/供給者： ⼿に⼊るサイズ： 全体重量 詳細： フレーム 固定/リジッド □ 折りたたみ □ フレーム⻑： 背もたれ スリング/布 □ ソリッド □ 張り調整 □ 座⾯ スリング/布 □ ソリッド □ 張り調整 □ クッション クッションなし □ 平⾯ウレタン □ 成形ウレタン □ 液体 □ その他 □ ⾜台 固定式 □ 着脱式 □ その他 キャスター輪 空気⼊り □ 直径： ソリッド □ 幅： 駆動輪 空気⼊り □ 直径： ハンドリム □ ソリッド □ 幅： 位置調節⾞軸 □ エアレスチューブ □ 着脱式 □ ブレーキ 短いレバー □ ⻑いレバー □ その他： ひじ掛け 曲線形状 □ 直線形状 □ その他： 固定式 □ 着脱式 □ その他： ⼿押しハンドル ⼿押しハンドル □ 姿勢⽀持具 ⾻盤ベルト □ 下腿ベルト □ 肩ハーネス □ ⾜ベルト □ 転倒防⽌装置 □ 体幹側⽅パッド □ テーブル □ ヘッドレスト □ ⾻盤側⽅パッド □ その他： 22 中級⾞椅⼦サービス教習パッケージ ⼨法、調節可能性、調節範囲 ⼨法 （複数サイズの⾞椅⼦が⼿に⼊ る場合は、サイズをすべて列挙） 調節可能か？ 調節範囲 （この⾞椅⼦につい て調節できる範囲） はい いいえ 座幅 □ □ 座⾯奥⾏き □ □ 座⾯⾼ □ □ 背もたれ⾼ □ □ 背もたれの傾き □ □ ⾜台〜座⾯⾼ □ □ ⾜台⾓度 □ □ ⼿押しハンドル⾼さ □ □ 全⻑ □ □ ホイールベース⻑ □ □ 座⾯〜背もたれ⾓度 □ □ ティルトインスペース □ □ 23 受講者⽤ワークブック 中級⾞椅⼦概要フォーム • 教習プログラムで使う⾞椅⼦ごとに、このフォームを完成しなさい（もっと部数が必要な場合は、 訓練員に請求しなさい）。 ⾞椅⼦の名称： 製造者/供給者： ⼿に⼊るサイズ： 全体重量 詳細： フレーム 固定/リジッド □ 折りたたみ □ フレーム⻑： 背もたれ スリング/布 □ ソリッド □ 張り調整 □ 座⾯ スリング/布 □ ソリッド □ 張り調整 □ クッション クッションなし □ 平⾯ウレタン □ 成形ウレタン □ 液体 □ その他 □ ⾜台 固定式 □ 着脱式 □ その他 キャスター輪 空気⼊り □ 直径： ソリッド □ 幅： 駆動輪 空気⼊り □ 直径： ハンドリム □ ソリッド □ 幅： 位置調節⾞軸 □ エアレスチューブ □ 着脱式 □ ブレーキ 短いレバー □ ⻑いレバー □ その他： ひじ掛け 曲線形状 □ 直線形状 □ その他： 固定式 □ 着脱式 □ その他： ⼿押しハンドル ⼿押しハンドル □ 姿勢⽀持具 ⾻盤ベルト □ 下腿ベルト □ 肩ハーネス □ ⾜ベルト □ 転倒防⽌装置 □ 体幹側⽅パッド □ テーブル □ ヘッドレスト □ ⾻盤側⽅パッド □ その他： 24 中級⾞椅⼦サービス教習パッケージ ⼨法、調節可能性、調節範囲 ⼨法 （複数サイズの⾞椅⼦が⼿に⼊ る場合は、サイズをすべて列挙） 調節可能か？ 調節範囲 （この⾞椅⼦につい て調節できる範囲） はい いいえ 座幅 □ □ 座⾯奥⾏き □ □ 座⾯⾼ □ □ 背もたれ⾼ □ □ 背もたれの傾き □ □ ⾜台〜座⾯⾼ □ □ ⾜台⾓度 □ □ ⼿押しハンドル⾼さ □ □ 全⻑ □ □ ホイールベース⻑ □ □ 座⾯〜背もたれ⾓度 □ □ ティルトインスペース □ □ 25 受講者⽤ワークブック B.8: 姿勢⽀持具の処⽅（選択）−⾻盤を安定させる 中級⾞椅⼦概要フォーム • ⾞椅⼦ユーザーについて読み、中級⾞椅⼦事前評価フォームの「⾝体計測」の結果を⽤いて、下 のスケッチに適切な⼨法を記⼊しなさい。 マリアンは 18歳の⼥性です。あなたの⾞椅⼦サービス事業所で事前評価を受けました。彼⼥と ⾞椅⼦サービス職員は、彼⼥の⾻盤を安定させるには以下の姿勢⽀持具が必要と判断しました： • 座⾻前⽅（アンカー）サポート • ⾻盤後⽅パッド • ⾻盤ベルト マリアンの⾝体⼨法は下表の通りです。 ⾝体計測 ⾝体⼨法（mm） ⾞椅⼦各部の⼨法（mm） 座幅・座⾯奥⾏き・⾜台〜座⾯⾼ A 座位臀幅 400 ＝座幅、または 1 ＝⾻盤側⽅パッドの間隔 2 B 座底⻑ （⾻盤背⾯〜膝裏） 右 420 B 引く 30〜50 mm＝座⾯奥⾏き（左右で異 なる場合は、短い⽅を採る） 3 380 左 420 380 C 座位下腿⻑ 右 420 ＝⾜台〜座⾯上端の間隔、 または ＝⾜こぎの場合、床⾯〜座⾯上端の間隔 4 左 420 5 背もたれ⾼ D 座⾯＊〜胸郭下端 ＝座⾯上端〜背もたれ上端（⾞椅⼦ユーザー のニーズによって D、E、F のどれか） 6 E 座⾯＊〜肩甲⾻下端 500 F 座⾯＊〜肩上端 改造および/または姿勢⽀持具 G 体幹幅 370 ＝体幹側⽅パッド/ウェッジの間隔 7 H 座⾯＊〜腋下 （わきの下） 右 480 H 引く 30 mm＝座⾯上端〜体幹側⽅パッド /ウェッジの間隔の最⼤値（ハンド・シミュレ ーションに従い修正） 8 450 左 480 450 I 座⾯＊〜⾻盤上端 （上後腸⾻棘、PSIS） 160 ＝座⾯上端〜⾻盤後⽅パッド中央⾼さの間隔 9 26 中級⾞椅⼦サービス教習パッケージ ⾝体⼨法（mm） ⾞椅⼦各部の⼨法（mm） J 膝間距離 ＝膝分離パッドの幅 10 K 座⾯＊〜頭蓋⾻底部 ＝座⾯上端〜ヘッドレスト中央の間隔 11 L ⾻盤背⾯〜座⾻ 150 L ⾜す 20〜40 mm＝背もたれの⽀持部〜座 ⾻前⽅（アンカー）サポートの距離 12 180 そ の 他 ＊⾝体計測における「座⾯」とは、座⾻が据わる表⾯のこと。 • 座⾻前⽅（アンカー）サポー トおよび⾻盤後⽅パッドの マリアン⽤の⼨法を、右欄の スケッチに追加しなさい。 27 受講者⽤ワークブック B.9: 姿勢⽀持具の処⽅（選択）−股関節を⽀える シエンナの右股関節は、ニュートラルな座位姿勢までは曲 がらないため、体幹〜⼤腿の⾓度が 90度超になります。 事前評価では、彼⼥は⼀時的⽀持部（ウレタンフォームを、 左右の座⾻および左⼤腿の下に積み増す）を使って、より まっすぐに座れました。 彼⼥に処⽅したクッションは座⾻前⽅（アンカー）サポー トを備え、右股関節に形が合うよう右側の座⾯前⽅を下げ たものです。 • シエンナの姿勢⽀持具を、下の中級⾞椅⼦処⽅フォームの「必要な姿勢⽀持具・改造」の箇所に 詳述しなさい。投影図を⽤い、⼨法を⼊れる必要があるところには印を付けなさい。 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯/ ク $ シ & ン ソリッド座⾯ □ 座⾻前⽅（アンカー）サポート （＝3 引く 12 ） □ 座⾯前⽅を下げる 左□ 右□ 座⾯前⽅のかさ上げ □ ⾻盤前傾⽤ウェッジ（くさび） □ ⾻盤下の積み増し 左□ 右□ ⾻盤側⽅パッド（= 2 ） 左□ 右□ ⼤腿外側パッド 左□ 右□ ⼤腿内側ウェッジ（= 10 ） □ 膝分離パッド（= 10 ） □ その他 □ その他 □ 28 中級⾞椅⼦サービス教習パッケージ ロバートの股関節は、ニュートラルな座位姿勢までは曲がら ないため、体幹〜⼤腿の⾓度は 90度超です。 事前評価では、かれは⼀時的⽀持部（ウレタンフォーム製で、 左右の座⾻の下をかさ上げする）を使って、よりまっすぐに座 れるようになりました。 かれに処⽅した⾞椅⼦は座⾯〜背もたれの⾓度を広げ、制約 のある股関節に形が合うようにしたものです。 • ロバートの姿勢⽀持具を、下の中級⾞椅⼦処⽅フォームの「必要な姿勢⽀持具・改造」の箇所に 詳述しなさい。投影図を⽤い、⼨法を⼊れる必要があるところには印を付けなさい。 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯ ＆ 背 も た れ 座⾯〜背もたれ⾓度を開ける □ 座⾯＆背もたれティルト （ティルトインスペース） □ 背 も た れ ソリッド背もたれ □ ⾻盤後⽅パッド（= 9） □ 背もたれの形状調整 □ 張り調整背もたれ □ 背もたれのリクライニング □ 体幹側⽅パッド（= 7 ） 左□ 右□ 体幹側⽅ウェッジ（= 7 ） 左□ 右□ その他 □ テ . ブ ル/ ひ じ 掛 け テーブル □ ひじ掛けを改造 左□ 右□ その他 □ 頭 の ⽀ え 平⾯ヘッドレスト（= 11 ） □ 成形ヘッドレスト（= 11 ） □ その他： □ 29 受講者⽤ワークブック 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 下 腿 ・ ⾜ の ⽀ え ⾜台の積み増し 左□ 右□ ⾜台ウェッジ（くさび） 左□ 右□ 下腿サポート 左□ 右□ その他： □ ベ ル ト ⾻盤ベルト □ 下腿ベルト □ ⾜ベルト 左□ 右□ 肩ハーネス □ その他： □ 30 中級⾞椅⼦サービス教習パッケージ B.10: 姿勢⽀持具の処⽅（選択）−体幹を⽀える 1. マークは 16歳、⾼い位置に脊髄損傷を負っています。背もたれと座⾯がスリングの⾞椅⼦を 持っています。その⾞椅⼦のサイズは適切で、柔らかくて平たいウレタンフォームクッションが 付いています。 マークは、まっすぐに座るのが困難です。かれの背中は丸まったままで、⾞椅⼦に座ると前へ滑 りがちです。かれの座⾻下および肩甲⾻周りの⽪膚には、⾚斑があります。 • マークへの事前評価（下掲）の結果を読みなさい。 • どの姿勢⽀持具を⽤いれば、マークは⾞椅⼦へまっすぐに座れるでしょうか？受講者⽤参考書の、 姿勢⽀持具⼀覧表および姿勢⽀持具参照表を参考にしなさい。 • どうやったら、現在ある⾞椅⼦を⽤いながら、マークへそれらの⽀持具を供与するか、つくれる でしょうか？⾞椅⼦の座⾯、クッション、背もたれへ付加できる変化を考えなさい。 • 働きかける流れに留意しなさい：⾻盤＋股関節➡体幹 • 与えられた⾞椅⼦および材料を⽤い、グループの他のメンバーへマークが必要とする⽀えをどう やって設けるか⽰しなさい。 ⽀えなしの座位姿勢 ⾻盤と股関節の姿勢チェック ⾻盤が⽔平かどうか、および臥位姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい✔ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい✔ いいえ□ ⾓度 左股関節 はい✔ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 31 受講者⽤ワークブック ハンド・シミュレーション：ニュートラルな姿勢で/快適な限りでニュートラルな姿 勢にできるだけ近づけて座るために、必要な⽀え 各⾝体部位が、⼿の⽀えでニュートラルな座位姿勢になれば「はい」、ならなければ「いいえ」に印。 部位 はい いいえ ⼿の⽀えで、⾞椅⼦ユーザーがとれた最終的な座位姿勢を記述するか 線画で描き、なおかつ、その座位姿勢がとれるように設けた⽀えを記 述するか線画で描く。 ⾻盤 ✔ □ 体幹 ✔ □ 頭 ✔ □ 左股関節 ✔ □ 右股関節 ✔ □ ⼤腿 ✔ □ 左膝 ✔ □ 右膝 ✔ □ 左⾜⾸ ✔ □ 右⾜⾸ ✔ □ まっすぐに座るために、マーク に必要なこと： • ⾻盤後⾯の強い（両⼿で⾻盤 背⾯を前⽅へ押した）⽀え。 • 肩甲⾻背⾯の軽い⽀え。 32 中級⾞椅⼦サービス教習パッケージ 中級⾞椅⼦処⽅（選択）フォーム 1. ⾞椅⼦ユーザーに関する情報 ⾞椅⼦ユーザー名： 番号： 事前評価⽇： フィッティング⽇： 事前評価担当者名： 2. ⾞椅⼦の種類、サイズ、セットアップ ⾞椅⼦の種類（⼿に⼊る⾞椅⼦を下に列記） ⾞椅⼦の⼨法（mm） □ 座幅 □ 座⾯奥⾏き □ 背もたれ⾼ □ ⾜台〜座⾯⾼ ⾞椅⼦のセットアップ 駆動輪位置 その他： ティルト 3. クッションの種類・サイズ クッションの種類 サイズ 例：除圧クッション □ □ 4. 必要な姿勢⽀持具・改造 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯/ ク $ シ & ン ソリッド座⾯ □ 座⾻前⽅（アンカー）サポート （＝3 引く 12 ） □ 座⾯前⽅を下げる 左□ 右□ 座⾯前⽅のかさ上げ □ ⾻盤前傾⽤ウェッジ（くさび） □ ⾻盤下の積み増し 左□ 右□ ⾻盤側⽅パッド（= 2 ） 左□ 右□ ⼤腿外側パッド 左□ 右□ ⼤腿内側ウェッジ（= 10 ） □ 膝分離パッド（= 10 ） □ その他 □ その他 □ 33 受講者⽤ワークブック 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯ ＆ 背 も た れ 座⾯〜背もたれ⾓度を開ける □ 座⾯＆背もたれティルト （ティルトインスペース） □ 背 も た れ ソリッド背もたれ □ ⾻盤後⽅パッド（= 9 ） □ 背もたれの形状調整 □ 張り調整背もたれ □ 背もたれのリクライニング □ 体幹側⽅パッド（= 7 ） 左□ 右□ 体幹側⽅ウェッジ（= 7 ） 左□ 右□ その他 □ テ . ブ ル/ ひ じ 掛 け テーブル □ ひじ掛けを改造 左□ 右□ その他 □ 頭 の ⽀ え 平⾯ヘッドレスト（= 11 ） □ 成形ヘッドレスト（= 11 ） □ その他： □ 下 腿 ・ ⾜ の ⽀ え ⾜台の積み増し 左□ 右□ ⾜台ウェッジ 左□ 右□ 下腿サポート 左□ 右□ その他： □ ベ ル ト ⾻盤ベルト □ 下腿ベルト □ ⾜ベルト 左□ 右□ 肩ハーネス □ その他： □ 5. 合意署名 ⾞椅⼦ユーザー： 事前評価者： ⾞椅⼦サービス 事業管理者： 34 中級⾞椅⼦サービス教習パッケージ 2. ジョセフィンは 35歳、脊髄損傷を負っています。農村に住んでおり、地元の教会の活動的メ ンバーです。前に与えられたのはホイールベースが⻑い⾞椅⼦で、家族が村のがたがた道を楽に 押して⾏けるので、気に⼊っています。屋内の平坦なところでは、⾃分でも少しこげます。⾞椅 ⼦のサイズはちょうどよく、ソリッド背もたれと座⾯を備えています。彼⼥は分厚くて平たいウ レタンフォームクッションを持っています。 ジョセフィンには、その⾞椅⼦に座るのは快適ではなく、⾃⼒でこぐのはもっと苦痛です。座っ ている時は⾻盤が後ろへ倒れ（⾻盤後傾）、体幹姿勢が前に弯曲（円背）しています。 • ジョセフィンへの事前評価の結果（下掲）を読みなさい。 • どの姿勢⽀持具を備えると、ジョセフィンが⾞椅⼦へまっすぐに座れるでしょうか？ • 受講者⽤参考書の、姿勢⽀持具⼀覧表および姿勢⽀持具参照表を参考にしなさい。 • どうやったら、現在持っている⾞椅⼦を⽤いながら、ジョセフィンへそれらの⽀持具を供与する かつくれるでしょうか？⾞椅⼦の座⾯、クッション、背もたれへ加えられる変化を考えなさい。 • 働きかける流れに留意しなさい：⾻盤＋股関節➡体幹 • 与えられた⾞椅⼦および材料を⽤い、グループの他のメンバーへジョセフィンが必要とする⽀え をどうやって設けるか⽰しなさい。 ⽀えなしの座位姿勢 ⾻盤と股関節の姿勢チェック ⾻盤が⽔平かどうか、および臥位姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい✔ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□いいえ✔ ⾓度：100度 左股関節 はい✔ いいえ□ ⾓度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 35 受講者⽤ワークブック ハンド・シミュレーション：ニュートラルな姿勢で/快適な限りでニュートラルな姿 勢にできるだけ近づけて座るために、必要な⽀え 各⾝体部位が、⼿の⽀えでニュートラルな座位姿勢になれば「はい」、ならなければ「いいえ」に印。 部位 はい いいえ ⼿の⽀えで、⾞椅⼦ユーザーがとれた最終的な座位姿勢を記述するか 線画で描き、なおかつ、その座位姿勢がとれるように設けた⽀えを記 述するか線画で描く。 ⾻盤 □ ✔ 体幹 □ ✔ 頭 □ ✔ 左股関節 ✔ □ 右股関節 □ ✔ ⼤腿 ✔ □ 左膝 ✔ □ 右膝 ✔ □ 左⾜⾸ ✔ □ 右⾜⾸ ✔ □ ジョセフィンはまっすぐに座れな かった。彼⼥の最終的な姿勢では： • 体幹は前に弯曲（円背）し、 • ⾻盤が後傾する。 彼⼥の姿勢は以下の⽀えによって 改善する： • 左右の座⾻および左⼤腿の下へ の⼀時的⽀持。 • ⾻盤後⽅への両⼿の⽀え、およ び体幹下部と上部全体への密着 した⽀え。 36 中級⾞椅⼦サービス教習パッケージ 中級⾞椅⼦処⽅（選択）フォーム 1. ⾞椅⼦ユーザーに関する情報 ⾞椅⼦ユーザー名： 番号： 事前評価⽇： フィッティング⽇： 事前評価担当者名： 2. ⾞椅⼦の種類、サイズ、セットアップ ⾞椅⼦の種類（⼿に⼊る⾞椅⼦を下に列記） ⾞椅⼦の⼨法（mm） □ 座幅 □ 座⾯奥⾏き □ 背もたれ⾼ □ ⾜台〜座⾯⾼ ⾞椅⼦のセットアップ 駆動輪位置 その他： ティルト 3. クッションの種類・サイズ クッションの種類 サイズ 例：除圧クッション □ □ 4. 必要な姿勢⽀持具・改造 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯/ ク $ シ & ン ソリッド座⾯ □ 座⾻前⽅（アンカー）サポート （＝3 引く 12 ） □ 座⾯前⽅を下げる 左□ 右□ 座⾯前⽅のかさ上げ □ ⾻盤前傾⽤ウェッジ（くさび） □ ⾻盤下の積み増し 左□ 右□ ⾻盤側⽅パッド（= 2 ） 左□ 右□ ⼤腿外側パッド 左□ 右□ ⼤腿内側ウェッジ（= 10 ） □ 膝分離パッド（= 10 ） □ その他 □ その他 □ 37 受講者⽤ワークブック 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯ ＆ 背 も た れ 座⾯〜背もたれ⾓度を開ける □ 座⾯＆背もたれティルト （ティルトインスペース） □ 背 も た れ ソリッド背もたれ □ ⾻盤後⽅パッド（= 9 ） □ 背もたれの形状調整 □ 張り調整背もたれ □ 背もたれのリクライニング □ 体幹側⽅パッド（= 7 ） 左□ 右□ 体幹側⽅ウェッジ（= 7 ） 左□ 右□ その他 □ テ . ブ ル/ ひ じ 掛 け テーブル □ ひじ掛けを改造 左□ 右□ その他 □ 頭 の ⽀ え 平⾯ヘッドレスト（= 11 ） □ 成形ヘッドレスト（= 11 ） □ その他： □ 下 腿 ・ ⾜ の ⽀ え ⾜台の積み増し 左□ 右□ ⾜台ウェッジ 左□ 右□ 下腿サポート 左□ 右□ その他： □ ベ ル ト ⾻盤ベルト □ 下腿ベルト □ ⾜ベルト 左□ 右□ 肩ハーネス □ その他： □ 5. 合意署名 ⾞椅⼦ユーザー： 事前評価者： ⾞椅⼦サービス 事業管理者： 38 中級⾞椅⼦サービス教習パッケージ 3. シアンは 3 歳、脳性⿇痺を抱えています。⼿持ちの⼦どもサイズのクロス型折りたたみ式⾞ 椅⼦は開き式⾜台を備え、座⾯と背もたれがスリングです。テーブルもクッションも付いていま せん。⾞椅⼦の座⾯奥⾏きは合っていますが、少し幅広です。両親は⾞を持っておらず、たいて いの場所には歩いて⾏きます。両親はかれを⾞椅⼦に乗せて近所を押して回れますが、抱えるだ けのこともあります。シアンは、平坦なところでは⾃分でも少しこげます。 シアンは、⽀えなしでも短い時間ならまっすぐに座れます。10 分も経つと体幹が崩れ始め、い つもは左前⽅へ倒れます。このため⾻盤の右側が持ち上がり、より体重が左座⾻へかかります。 背中のカーブは年齢相応です。シアンの⺟親は、かれに他の⼦どもと外で遊べるようになり、⾃ 分で⾞椅⼦をこぐようになってほしいと願っています。 • シアンへの事前評価の結果（下掲）を読みなさい。 • どの姿勢⽀持具を備えると、シアンは⾞椅⼦へ、いちばんまっすぐに座れるでしょう？受講者⽤ 参考書の、姿勢⽀持具⼀覧表および姿勢⽀持具参照表を参考に⽤いなさい。 • どうやったら、現在持っている⾞椅⼦を⽤いながら、シアンへそれらの⽀持具を供与するかつく れるでしょうか？⾞椅⼦の座⾯、クッション、背もたれへ加えられる変化を考えなさい。 • 働きかける流れに留意しなさい：⾻盤＋股関節➡体幹 • 与えられた⾞椅⼦および材料を⽤い、グループの他のメンバーへシアンが必要とする⽀えをどう やって設けるか⽰しなさい。 ⽀えなしの座位姿勢 ⾻盤と股関節の姿勢チェック ⾻盤が⽔平かどうか、および臥位姿勢での股関節の 屈曲可動域を調べる： ⾻盤が⽔平になるか？ はい✔ いいえ□ 股関節がニュートラルな座位姿勢まで屈曲するか？ 右股関節 はい□ いいえ✔ ⾓度：80度 左股関節 はい□ いいえ✔ ⾓度：80度 ⾻盤が⽔平にならないか、股関節がニュートラルな座位 姿勢まで屈曲しなければ⼀時的⽀持部で形を合わせる。 39 受講者⽤ワークブック ハンド・シミュレーション：ニュートラルな姿勢で/快適な限りでニュートラルな姿 勢にできるだけ近づけて座るために、必要な⽀え 各⾝体部位が、⼿の⽀えでニュートラルな座位姿勢になれば「はい」、ならなければ「いいえ」に印。 部位 はい いいえ ⼿の⽀えで、⾞椅⼦ユーザーがとれた最終的な座位姿勢を記述するか 線画で描き、なおかつ、その座位姿勢がとれるように設けた⽀えを記 述するか線画で描く。 ⾻盤 □ □ 体幹 □ □ 頭 □ □ 左股関節 □ □ 右股関節 □ □ ⼤腿 □ □ 左膝 □ □ 右膝 □ □ 左⾜⾸ □ □ 右⾜⾸ □ □ シアンは、ニュートラルな座位姿勢で座れるが、左右の股関 節が屈曲している（体幹〜⼤腿の⾓度が約 80度）。 まっすぐに座るために、シアンに必要なことは： • 左右の⼤腿の下の、ウレタンフォーム製ウェッジによる⼀ 時的⽀持。 • 左右の⼿で⾻盤の両側をしっかりと保持し、同時に⾻盤背 ⾯を軽く⽀える。 • 左右の⼿で体幹の両側をしっかりと保持する。左側を右側 よりわずかに⾼いところで⽀える必要があった。 • 肩甲⾻周りおよび胸郭前⾯の軽い⽀え。 40 中級⾞椅⼦サービス教習パッケージ 中級⾞椅⼦処⽅（選択）フォーム 1. ⾞椅⼦ユーザーに関する情報 ⾞椅⼦ユーザー名： 番号： 事前評価⽇： フィッティング⽇： 事前評価担当者名： 2. ⾞椅⼦の種類、サイズ、セットアップ ⾞椅⼦の種類（⼿に⼊る⾞椅⼦を下に列記） ⾞椅⼦の⼨法（mm） □ 座幅 □ 座⾯奥⾏き □ 背もたれ⾼ □ ⾜台〜座⾯⾼ ⾞椅⼦のセットアップ 駆動輪位置 その他： ティルト 3. クッションの種類・サイズ クッションの種類 サイズ 例：除圧クッション □ □ 4. 必要な姿勢⽀持具・改造 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯/ ク $ シ & ン ソリッド座⾯ □ 座⾻前⽅（アンカー）サポート （＝3 引く 12 ） □ 座⾯前⽅を下げる 左□ 右□ 座⾯前⽅のかさ上げ □ ⾻盤前傾⽤ウェッジ（くさび） □ ⾻盤下の積み増し 左□ 右□ ⾻盤側⽅パッド（= 2 ） 左□ 右□ ⼤腿外側パッド 左□ 右□ ⼤腿内側ウェッジ（= 10 ） □ 膝分離パッド（= 10 ） □ その他 □ その他 □ 41 受講者⽤ワークブック 姿勢⽀持具確認表 説明/絵および⼨法を記⼊ 座 ⾯ ＆ 背 も た れ 座⾯〜背もたれ⾓度を開ける □ 座⾯＆背もたれティルト （ティルトインスペース） □ 背 も た れ ソリッド背もたれ □ ⾻盤後⽅パッド（= 9 ） □ 背もたれの形状調整 □ 張り調整背もたれ □ 背もたれのリクライニング □ 体幹側⽅パッド（= 7 ） 左□ 右□ 体幹側⽅ウェッジ（= 7 ） 左□ 右□ その他 □ テ . ブ ル/ ひ じ 掛 け テーブル □ ひじ掛けを改造 左□ 右□ その他 □ 頭 の ⽀ え 平⾯ヘッドレスト（= 11 ） □ 成形ヘッドレスト（= 11 ） □ その他： □ 下 腿 ・ ⾜ の ⽀ え ⾜台の積み増し 左□ 右□ ⾜台ウェッジ 左□ 右□ 下腿サポート 左□ 右□ その他： □ ベ ル ト ⾻盤ベルト □ 下腿ベルト □ ⾜ベルト 左□ 右□ 肩ハーネス □ その他： □ 5. 合意署名 ⾞椅⼦ユーザー： 事前評価者： ⾞椅⼦サービス 事業管理者： 42 中級⾞椅⼦サービス教習パッケージ B.11: 姿勢⽀持具の処⽅（選択）−頭・⼤腿・下腿を⽀える 下の設問を読んで回答しなさい。 ジョナーが事前評価に来ました。ハンド・シミュレーション で、ジョナーの両脚は外側へ落ち（外転し）がちですが、軽く ⽀えれば両脚をニュートラルな座位姿勢へ（膝を揃えて）置け ることが分かりました。 • ⾞椅⼦およびクッションにどんな変更を加えれば、両脚を ニュートラルな座位姿勢にして座れると思いますか？ サムは、この⾞椅⼦を使って２年になります。かれは頭に傷が あり、両脚はたいへん固く閉じています。事前評価で、サムの 両脚は内側へ閉じ合っているものの、膝どうしを離せば、より ニュートラルな座位姿勢を取れることが分かりました。しか し、これにはかなり⼒が必要です。両膝をよりニュートラルな 座位姿勢にすると、サムはバランスが良くなったと感じます。 • ⾞椅⼦およびクッションにどんな変更を加えれば、両脚を ニュートラルな座位姿勢にして座れると思いますか？ エリジャは、かれの⾞椅⼦が折りたため、⾞に載せて職場と往 復できることに満⾜しています。しかし、背中に炎症があり、 両脚が互いに内旋しています。事前評価で、エリジャはニュー トラルな座位姿勢で座れ、軽く⽀えれば両脚はニュートラル な座位姿勢を取れることが分かりました。 • ⾞椅⼦およびクッションにどんな変更を加えれば、両脚を ニュートラルな座位姿勢にして座れると思いますか？ 43 受講者⽤ワークブック 実習 2: 製品（⾞椅⼦）の下準備−タスク確認表 • 下表を活⽤して、⾞椅⼦および姿勢⽀持具を計画し、下準備しなさい。 o 各タスクを（できれば完了すべき順に）列記しなさい。 o だれがそのタスクに責任を持つか決めなさい。 o 各タスクへ、完了するごとに印を付けなさい。 各タスクを列記 責任者 完了したら 印を付ける □ □ □ □ □ □ □ □ □ □ □ □ 44 中級⾞椅⼦サービス教習パッケージ 実習 2: 製品（⾞椅⼦）の下準備−中級⾞椅⼦の安全・準備完了確認表 中級⾞椅⼦の安全・準備完了確認表を⽤い、⾞椅⼦が安全で、⾞椅⼦ユーザーが試せるよう準備で きていることを確認しなさい。 姿勢⽀持具を含む⾞椅⼦全体1 鋭い⾓がない □ 部品に破損や傷がない □ ⾞椅⼦がまっすぐ⾛る □ 前⽅キャスター輪 ⾃由に回転する □ キャスターフォークに接触しないで回転する □ ボルトが固く締まっている □ 前⽅キャスター受け具 キャスターが⾃由に旋回する □ 駆動輪 ⾃由に回転する □ ⾞軸ボルトが固く締まっている □ タイヤへ適切に空気が⼊っている（親指の圧⼒で、凹みが 5 mm未満） □ ハンドリムがしっかり取り付けられている □ ブレーキ 適切に働く □ ⾜台 ⾜台がしっかり取り付けられている □ フレーム クロス型折りたたみ式⾞椅⼦の場合：容易に折りたためて開ける □ 背もたれ前倒し式⾞椅⼦の場合：背もたれを容易に折りたためて開ける □ クッション クッションがカバーに正しく収まっている □ クッションが⾞椅⼦に正しく載っている □ クッションカバーはぴったり合っているが、きつ過ぎない □ ⾞椅⼦がソリッド座⾯を備えている場合：クッションがソリッド座⾯全体を覆っている □ 1 [訳注] 指導書等のフォームでは「姿勢⽀持具が、よく緩衝材が施され、しっかり固定されている」の項⽬が加わる. 45 受講者⽤ワークブック B.14: ユーザー教習 • 下の⾞椅⼦ユーザーの例話のうち⼀つを読みなさい。どれを読むかは、訓練員が指定します。 • その⾞椅⼦ユーザーに、新しく⼿にした⾞椅⼦を活⽤し、⼿⼊れできるためには、どの技能が必 要か判断しなさい。次ページの中級⾞椅⼦ユーザー教習確認表を完成しなさい。 • ［受講者グループ内で］⾞椅⼦ユーザー、⾞椅⼦サービス職員、⾞椅⼦ユーザーの家族/介護者 のいずれかの配役を選びなさい。⾞椅⼦サービス職員役の⼈は、他のグループメンバーへ、３種 以上の技能を実際に教えなさい。受講者⽤参考書の、この授業のコラム「⾞椅⼦ユーザー教習が うまく⾏くコツ」の助⾔を活⽤しなさい。 ジョシュア ジョシュアは 6 歳、脳性⿇痺を抱えています。制御できない運動の発作があります。処⽅（選 択）された⼦ども⽤⾞椅⼦には、姿勢⽀持部として⾻盤ベルト、⾻盤側⽅パッド、体幹側⽅パ ッドなどが付いています。ジョシュアの⽪膚は薄く敏感なので、体幹側⽅パッドには、それで 褥瘡が起きないよう緩衝材を追加しています。 ジョシュアの新しい⾞椅⼦にはティルト機能があり、時には⾞椅⼦を後ろに倒し、あるいはも っと垂直に起こしたりできます。転倒防⽌装置も付いており、荒れた地⾯を越え、縁⽯を上が り下りする時には解除できます。運搬のため、その⾞椅⼦の駆動輪は着脱式で、座⾯を⾞椅⼦ フレームから取り外せます。 ジョシュアは毎朝幼稚園へ通っています。幼稚園が⼿配した送迎サービスがかれを乗せて⾏き ます。その乗り物は⼩さなエンジン付き三輪⾞なので両親は⾞椅⼦が収まるか⼼配しています。 ジョシュアが新しい⾞椅⼦のフィッティングに来ました。⺟親もいっしょです。 サンギータ サンギータは 3 歳、⼆分脊椎を抱えています。移動が困難で、腰から下の感覚を失っており、 脊椎の下部に瘤起があります。両親によると、彼⼥は膀胱や腸の制御が困難で、しばしば尿路 感染が起きます。 サンギータが、初めての⾞椅⼦フィッティングに⾞椅⼦サービス事業所へ来ました。その⾞椅 ⼦にはクイックリリース⾞輪、⾻盤ベルト、⾻盤側⽅パッドが付いており、背もたれは脊椎の 瘤起周辺の圧⼒を避けるよう形状調整しています。彼⼥は除圧クッションも持っています。彼 ⼥は両親と来ています。両親は、彼⼥が⾞椅⼦を持ったら下肢装具を使って歩こうとしなくな るのでは、と⼼配しています。しかし彼⼥には、兄妹と外で遊べないことが不満なのです。 46 中級⾞椅⼦サービス教習パッケージ キム・ソム キム・ソムは 40 歳、15 年前に頭部を損傷しました。かれは、摂⾷に困難があるため、たいへ ん痩せています。かれの脊椎は円背のまま固まっています。キム・ソムは⽴ち上がることがで きず、完全に⺟親が頼りです。かれはしゃべれませんが、⺟親によると簡単な指⽰は分かるそ うです。 事前評価で、痩せており、⾃⼒で動けず、以前（床に臥せっていたため）褥瘡があったことか ら、褥瘡発⽣の危険があると判定されました。 かれは、最初の⾞椅⼦を⼿にしたばかりです。その⾞椅⼦は、キム・ソムがより快適に座れる よう、除圧クッションと姿勢⽀持具を備えています。⺟親がかれの介護者で、⾞椅⼦フィッテ ィングの⾯接へいっしょに来ています。 47 受講者⽤ワークブック 中級⾞椅⼦ユーザー教習確認表 教えるべき 技能 教えた 技能 ⾞椅⼦の取り扱い ⾞椅⼦の折りたたみ⽅および持ち上げ⽅ □ □ 運搬のために外す必要がある、すべての姿勢⽀持具の脱着⽅法 □ □ クイックリリース⾞輪の扱い⽅ □ □ ブレーキの使い⽅ □ □ ティルトおよび転倒防⽌装置（使⽤する場合） □ □ ⾞椅⼦ユーザーが⾞椅⼦へ座った時の、姿勢⽀持具の正しい位置 □ □ 正しい置き⽅など、クッションの扱い⽅ □ □ 移乗 ⾃⼒での移乗 □ □ 介助による移乗 □ □ その他 □ □ ⾞椅⼦の使⽤および移動 正しいこぎ⽅（⾞椅⼦ユーザーが好む⽅法による） □ □ 斜⾯の登り下り □ □ 階段の昇り降り □ □ 荒れ地 □ □ ⼀時ウィリー □ □ どれくらい⻑時間、⾞椅⼦に座るか （付加的姿勢⽀持が必要な⼦どもおよび⼤⼈の場合） □ □ 介助での押し⽅ □ □ 褥瘡予防 強い圧⼒がかかる部位の褥瘡を検査 □ □ 除圧動作 □ □ よい⾷事をし、たくさん⽔を飲む □ □ 褥瘡ができたらどうするか □ □ 48 中級⾞椅⼦サービス教習パッケージ 教えるべき 技能 教えた 技能 家庭での⾞椅⼦の⼿⼊れ ⾞椅⼦の掃除；クッションとクッションカバーを洗って乾かす □ □ 可動部への注油 □ □ タイヤへの空気⼊れ □ □ ボルトとナットを締める □ □ スポークを張る □ □ 張り地を調べる □ □ サビを調べる □ □ クッションを調べる □ □ 問題が起きたらどうするか ⾞椅⼦に修理が必要になったら □ □ ⾞椅⼦がフィットしない、あるいは快適でない場合 □ □ 49 受講者⽤ワークブック B.15: 総まとめ • あなたのグループが担当した⾞椅⼦ユーザー、およびそこで学んだことに関する、受講者全体へ の 10 分間の発表を準備しなさい。 発表には、以下の項⽬を盛り込みなさい： 1. 事前評価で得た情報 • ⾞椅⼦ユーザーのゴール（なぜその⼈は⾞椅⼦を求めているのか） • ⾝体的ニーズ • ⽣活様式によるニーズ • すでに⾞椅⼦を持っているかどうか、また、その⾞椅⼦がニーズを満たしているかどうか • 褥瘡の有無・危険・既往歴 • ⾞椅⼦のこぎ⽅ • ⽀えなしの座位姿勢 • ⾻盤と股関節の姿勢チェックの結果 • ハンド・シミュレーションの結果 2. 処⽅（選択）した⾞椅⼦およびクッション • ⾞椅⼦の種類 • クッションの種類 • 処⽅したすべての姿勢⽀持具 3. フィッティング • フィッティングで⾒出した、解決すべき問題：あれば、どうやって解決したか？ 4. ユーザー教習 • ⾞椅⼦ユーザーとグループで、ユーザー教習で押さえる必要があると判断したことは何か？ 5. ⾞椅⼦ユーザーからのフィードバック • ⾞椅⼦を受け取った後に、⾞椅⼦ユーザーから何かコメント/フィードバックがあったか？ 6. フォローアップ計画 • フォローアップのためにどんな段取りをしたか？ 50 中級⾞椅⼦サービス教習パッケージ B.16: メンテナンス・修理・フォローアップ • それぞれの⾞椅⼦ユーザーの例話を読みなさい。 • 各⾞椅⼦ユーザーについての⾞椅⼦フォローアップフォームを完成しなさい。 • さらにやるべきことを話し合い、記録しなさい。 トゥーシタ トゥーシタは７歳、かれの両親・姉と家で暮らしています。筋ジストロフィーを抱え、１年前に ⾞椅⼦サービス事業を通じて⾞椅⼦を⼿に⼊れました。その頃は、短い距離なら歩けました。⽴ ち上がっての移乗で、⾃⼒で⾞椅⼦を乗り降りできました。「学校へ⾏くのが⼤変だから、⾞椅 ⼦が欲しかった」と語っていました。 フォローアップ訪問で、トゥーシタは「いまでは⾃分で⾞椅⼦を乗り降りするのが難しくなって いる」と告げました。学校では、午後にはくたびれ、不快になってしまいます。そのため集中⼒ が持ちません。かれの⾞椅⼦は適切なサイズで、⾼さが中程度のスリング背もたれと簡素な除圧 クッションが付いています。 トゥーシタに⾞椅⼦への満⾜度を採点してもらったところ、5点満点で 4点でした。 ミレラ ミレラは 23 歳、ポリオを抱えています。蜂蜜をつくり、地元の市場で売っています。2年前に、 前輪を取り付ければ 3 輪⾞になる⾞椅⼦を⼿に⼊れました。彼⼥には、⾞椅⼦へ姿勢⽀持具の 追加が必要でした。処⽅（選択）されたのは、改造した多層構造ウレタンフォームクッションで した。⾻盤後⽅パッドを⾞椅⼦の背もたれに取り付けました。 フォローアップ訪問でミレラは「⾞椅⼦と 3輪⾞で、毎⽇市場へ往復している」と⾔います。 彼⼥は、さいきん⾞輪のパンク修理を 2 回もやらなければならなかったと報せました。⾞椅⼦ を調べて、⾞椅⼦サービス職員はタイヤがかなり擦り減っているのに気づきました。また⾻盤後 ⽅パッドが座⾯までずり落ち、クッションはとても扁平でした。 ミレラに⾞椅⼦への満⾜度を採点してもらったところ、5点満点で 3点でした。 ウルスラ ウルスラは 6 歳、脳性⿇痺を抱えています。教会の合唱隊で、姉といっしょに歌うのが好きで す。姿勢⽀持具の付いた⾞椅⼦を、8か⽉前に⼿に⼊れました。 彼⼥は胸部感染を患っていたため、初回のフォローアップ⾯接には来られませんでした。両親は 「近ごろは⾞椅⼦に乗っても満⾜そうでなく、1 時間もすると降りたいと訴える」と⾔います。 両親は彼⼥の⽚⽅の体幹側⽅パッドのそばの肋⾻の上に⿊い瘢痕を⾒つけ、それが問題なので は、と⼼配しています。 ⾞椅⼦サービス職員は⼈⽬に触れない場所を探し、ウルスラと両親に、⽪膚を調べる許可を求め ました。⾞椅⼦サービス職員は⿊斑を確認しました。また⾞椅⼦を観察し、体幹側⽅パッドのウ レタンフォーム緩衝材が圧し潰されているのに気づきました。 ウルスラの⾞椅⼦への満⾜度について、両親の採点は 5点満点で 4点でした。 51 受講者⽤ワークブック ⾞椅⼦フォローアップフォーム 1. ⾞椅⼦ユーザーの情報 ⾞椅⼦ユーザー名： 番号： フィッティング⽇： フォローアップ⽇： フォローアップ実施者名： フォローアップ実施場所： ⾞椅⼦ユーザーの家 □ ⾞椅⼦サービスセンター □ その他： 2. インタビュー さらにやるべきことを記録 ⾞椅⼦を、思う存分使えていますか？ はい□ いいえ□ 「いいえ」の場合：なぜですか？ ⾞椅⼦を使ううえで、何か問題はありますか？ はい□ いいえ□ 「はい」の場合：それは何ですか？ ⾞椅⼦を使ううえで、何か疑問はありますか？ はい□ いいえ□ 「はい」の場合：どんな疑問ですか？さらに教習が必要ですか？ 褥瘡がありますか？ はい□ いいえ□ 「はい」の場合：詳細（部位および程度） ⾞椅⼦への満⾜度を５段階で評価してください （１＝満⾜していない、５＝⾮常に満⾜） 評価： コメント： 3. ⾞椅⼦およびクッションの確認 ⾞椅⼦は正常に働き、安全に使えていますか？ はい□ いいえ□ クッションは正常に働き、安全に使えていますか？ はい□ いいえ□ ⼀つでも「いいえ」の場合、何が問題なのでしょうか？ 4. フィッティングの確認 ⾞椅⼦は、うまくフィットしていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 圧⼒検査の評価（１＝安全、２＝注意、３＝危険） （褥瘡発⽣の危険があるユーザーについて） 左： 右： 静⽌している時・動いている時・⼀⽇じゅう、ユー ザーは⼼地よくまっすぐに座っていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 52 中級⾞椅⼦サービス教習パッケージ ⾞椅⼦フォローアップフォーム 1. ⾞椅⼦ユーザーの情報 ⾞椅⼦ユーザー名： 番号： フィッティング⽇： フォローアップ⽇： フォローアップ実施者名： フォローアップ実施場所： ⾞椅⼦ユーザーの家 □ ⾞椅⼦サービスセンター □ その他： 2. インタビュー さらにやるべきことを記録 ⾞椅⼦を、思う存分使えていますか？ はい□ いいえ□ 「いいえ」の場合：なぜですか？ ⾞椅⼦を使ううえで、何か問題はありますか？ はい□ いいえ□ 「はい」の場合：それは何ですか？ ⾞椅⼦を使ううえで、何か疑問はありますか？ はい□ いいえ□ 「はい」の場合：どんな疑問ですか？さらに教習が必要ですか？ 褥瘡がありますか？ はい□ いいえ□ 「はい」の場合：詳細（部位および程度） ⾞椅⼦への満⾜度を５段階で評価してください （１＝満⾜していない、５＝⾮常に満⾜） 評価： コメント： 3. ⾞椅⼦およびクッションの確認 ⾞椅⼦は正常に働き、安全に使えていますか？ はい□ いいえ□ クッションは正常に働き、安全に使えていますか？ はい□ いいえ□ ⼀つでも「いいえ」の場合、何が問題なのでしょうか？ 4. フィッティングの確認 ⾞椅⼦は、うまくフィットしていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 圧⼒検査の評価（１＝安全、２＝注意、３＝危険） （褥瘡発⽣の危険があるユーザーについて） 左： 右： 静⽌している時・動いている時・⼀⽇じゅう、ユー ザーは⼼地よくまっすぐに座っていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 53 受講者⽤ワークブック ⾞椅⼦フォローアップフォーム 1. ⾞椅⼦ユーザーの情報 ⾞椅⼦ユーザー名： 番号： フィッティング⽇： フォローアップ⽇： フォローアップ実施者名： フォローアップ実施場所： ⾞椅⼦ユーザーの家 □ ⾞椅⼦サービスセンター □ その他： 2. インタビュー さらにやるべきことを記録 ⾞椅⼦を、思う存分使えていますか？ はい□ いいえ□ 「いいえ」の場合：なぜですか？ ⾞椅⼦を使ううえで、何か問題はありますか？ はい□ いいえ□ 「はい」の場合：それは何ですか？ ⾞椅⼦を使ううえで、何か疑問はありますか？ はい□ いいえ□ 「はい」の場合：どんな疑問ですか？さらに教習が必要ですか？ 褥瘡がありますか？ はい□ いいえ□ 「はい」の場合：詳細（部位および程度） ⾞椅⼦への満⾜度を５段階で評価してください （１＝満⾜していない、５＝⾮常に満⾜） 評価： コメント： 3. ⾞椅⼦およびクッションの確認 ⾞椅⼦は正常に働き、安全に使えていますか？ はい□ いいえ□ クッションは正常に働き、安全に使えていますか？ はい□ いいえ□ ⼀つでも「いいえ」の場合、何が問題なのでしょうか？ 4. フィッティングの確認 ⾞椅⼦は、うまくフィットしていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 圧⼒検査の評価（１＝安全、２＝注意、３＝危険） （褥瘡発⽣の危険があるユーザーについて） 左： 右： 静⽌している時・動いている時・⼀⽇じゅう、ユー ザーは⼼地よくまっすぐに座っていますか？ はい□ いいえ□ 「いいえ」の場合：何が問題なのでしょうか？ 54 中級⾞椅⼦サービス教習パッケージ 実習 4: 事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ ユーザー教習 製品（⾞椅⼦）の下準備−タスク確認表 • 下表を活⽤して、⾞椅⼦および姿勢⽀持具を計画し、下準備しなさい。 o 各タスクを（できれば完了すべき順に）列記しなさい。 o だれがそのタスクに責任を持つか決めなさい。 o 各タスクへ、完了するごとに印を付けなさい。 各タスクを列記 責任者 完了したら 印を付ける □ □ □ □ □ □ □ □ □ □ □ □ 55 受講者⽤ワークブック 実習 4: 事前評価・処⽅（選択）・製品（⾞椅⼦）の下準備・フィッティング・ ユーザー教習 • 中級⾞椅⼦の安全・準備完了確認表を⽤い、⾞椅⼦が安全で、⾞椅⼦ユーザーが試せるよう準備 できていることを確認しなさい。 中級⾞椅⼦の安全・準備完了確認表 姿勢⽀持具を含む⾞椅⼦全体2 鋭い⾓がない □ 部品に破損や傷がない □ ⾞椅⼦がまっすぐ⾛る □ 前⽅キャスター輪 ⾃由に回転する □ キャスターフォークに接触しないで回転する □ ボルトが固く締まっている □ 前⽅キャスター受け具 キャスターが⾃由に旋回する □ 駆動輪 ⾃由に回転する □ ⾞軸ボルトが固く締まっている □ タイヤへ適切に空気が⼊っている（親指の圧⼒で、凹みが 5 mm未満） □ ハンドリムがしっかり取り付けられている □ ブレーキ 適切に働く □ ⾜台 ⾜台がしっかり取り付けられている □ フレーム クロス型折りたたみ式⾞椅⼦の場合：容易に折りたためて開ける □ 背もたれ前倒し式⾞椅⼦の場合：背もたれを容易に折りたためて開ける □ クッション クッションがカバーに正しく収まっている □ クッションが⾞椅⼦に正しく載っている □ クッションカバーはぴったり合っているが、きつ過ぎない □ ⾞椅⼦がソリッド座⾯を備えている場合：クッションがソリッド座⾯全体を覆っている □ 2 [訳注] 指導書等のフォームでは「姿勢⽀持具が、よく緩衝材が施され、しっかり固定されている」の項⽬が加わる. 訳注： • 本書は Wheelchair Service Training Package: Participantʼs Workbook: Intermediate Level, WHO, 2013. の全訳である。底本には英語版（https://www.who.int/publications/i/item/9789241505765）を⽤いた。 • 本書の翻訳出版は、⼀般社団法⼈⽇本⾞椅⼦シーティング協会の、資料作成事業の⼀環である。 • 本書は、WHOより⾮営利（販売は費⽤回収⽬的でのみ可）での翻訳出版許可を取得している。 • ⽇本語版翻訳に関する著作権および⽂責は、すべて⼀般社団法⼈⽇本⾞椅⼦シーティング協会に帰属する。 • 翻訳および編集作業は、同協会国際委員会・アジア姿勢保持プロジェクト（ASAP）で⾏なった。 • 本書を転載する際は⽇本⾞椅⼦シーティング協会までご連絡（連絡先は⾒返しを参照）頂きたい。 • 英語原⽂と⽇本語訳⽂の間に内容の齟齬がある場合は原則として英語版を正とするが、誤記、団体の名称・ 住所・URLで変更されているものなどは、WHOに確認のうえ訳者で⼀部修正している。 • 本⽂中、原⽂にない訳者による補⾜は［ ］に⼊れて⽰している。 • 原⽂の主な⽤語と本書での訳語は、原則として下表の通り対照させている。なるべく原著に忠実に、かつ 既存の⽤語との紛らわしさを避け、簡明さを失わないよう努めた。本書出版時点の国際標準化機構（ISO 7176-26:2007）、⽇本⼯業規格（JIS T9201:2016）との異同などは、下表および別冊の受講者⽤参考書の 脚注で⽰している。 英語⽤語 ⽇本語訳語 additional postural support 付加姿勢⽀持［基本的な⾞椅⼦にもともと備わっている以上の、改造や増設によ って付加された姿勢⽀持（⼒）。本書p.7も参照］ armrest ひじ掛け［ISO7176-26:2007: arm support, JIS T9201:2016: アームサポート］ assessment 事前評価［事後評価を含むevaluationと区別するため］ backrest 背もたれ［ISO7176-26: 2007: back support, JIS T9201: 2016: バックサポート］ calf 下腿、［特にその部位を指す場合］ふくらはぎ community-based 地域に根ざした footrest ⾜台［ISO7176-26:2007: foot support, JIS T9201: 2016: フットサポート］ neutral sitting posture ニュートラルな座位姿勢 personal mobility ［主に⾏為を指して］個⼈的移動、［主に機能を指して］個⼈的移動性 postural support 姿勢⽀持 product preparation 製品の下準備 referral 紹介・相談 seat 座⾯［ISO7176-26:2007: seat, JIS T9201: 2016: シート］ seating 座位保持 service delivery サービス提供 sitting upright まっすぐに座る［本書での意味はpp.を参照］ training 教習、［条約などで定訳がある場合］研修 upholstery 張り布 user ［指⽰内容が明⽩な場合］⾞椅⼦ユーザー、ユーザー wheelchair provision ⾞椅⼦供与 wheelchair services ［⾏為］⾞椅⼦サービス、［事業・事業組織］⾞椅⼦サービス事業、 ［施設・所在地］⾞椅⼦サービス事業所 中級⾞椅⼦サービス教習パッケージ 受講者⽤ワークブック 著作・制作︓ 世界保健機関（WHO） ＊⽇本語版翻訳・発⾏︓ ⼀般社団法⼈ ⽇本⾞椅⼦シーティング協会（JAWS） ⽇本⾞椅⼦シーティング協会国際委員会・ アジア姿勢保持プロジェクト（ASAP） ＊本書の⽇本語版作成に当たり、公益財団法⼈ ⽇本社会福祉弘済会より研究助成を頂きました。