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AANLCP Bathing Article November 2010


So you want to have a normal life even though you have a disability? As they say, “What a concept!!”Unfortunately, for many individuals with disabilities, some activities that are just part of a normal routine for the able-bodied, such as showering, are not an obvious option.

If normalcy is the objective for life, just what defines “normalcy” when considering hygiene alternatives? Really, there are several criteria: Safety, Accessibility, Independence, Thoroughness, Consistency, Dignity, Comfort, and Health, to name a few. Let’s look at each of these briefly.

Safety is an obvious critical requirement. When we take a shower, we usually are able to first reach in, set the water temperature to make sure that we are neither scalded nor chilled, then walk in, stand while the water runs over all parts of the body, step out as soon as the shower is completed to get dried off and dressed.

But, if you are in a wheelchair, doing each of these can present safety concerns. Reaching into a shower stall to set the temperature can be a challenge. If you can’t reach the controls ahead of time, you may have to transfer into the shower stall or bathtub, then try to reach the controls. When you turn on the water, it may be too hot, or too cold initially, but what can you do to avoid being hit by the water? Not much.

Transferring, too, is a safety issue. Getting from a wheelchair onto a transfer bench works if arms are strong, or if the person who is assisting is strong and can make the transfer. But slips, falls, drops can, and do, occur. Not infrequently there are accidents that result from simply having to get out of the wheelchair to get into a tub or shower.

And then, when the bath or shower is completed, getting dried and dressed quickly can be a challenge. And with individuals who have disabilities, there is oftentimes a heightened sensitivity to hypothermia. Clearly, the ability to get out of the tub or shower before that happens is best.

Corollary to the issue of access is independence, and the degree of assistance that may be required for bathing. Again, normalcy for able-bodied individuals affords the ability to do everything associated with bathing independently. But, if assistance is required from a care attendant, the choice of bathing alternative may be determined more for the comfort, convenience or even safety of the caregiver, not always to the benefit of the individual with the disability. While it is certainly true that many individuals with disabilities have no choice but to have assistance with bathing or showering, the alternatives that allow for maximum independence are going to be perceived as preferable.

Normalcy for bathing also usually means adequate water flow over the body. Truly, how many of us now even take tub baths? The reason we usually prefer showering is simply being able to get adequate and clean water flow over our entire body. Sitting in a tub does allow for water for the lower half of the body, but to be able to wash head and hair, or even to get enough water under skin folds or breasts is more difficult in a bathtub than in a shower. And for particularly “hairy” individuals, especially for large, hairy individuals, being able to get enough water over the entire body to adequately wash the skin and to remove soap residue, can be an issue in a bathtub. Not true in a shower.

Ultimately, though, the most important requirement for normal hygiene is simply health—both physical and mental. If you can’t get clean, really clean, there are a host of potential problems—infections, sores and skin breakdown, even breathing issues from inappropriate positioning. Then compound those issues with lack of comfort and loss of dignity when hygiene is inadequate, or dependent on others. Truly, one of the most basic requirements for a normal life, of being able to be truly clean, is a very real challenge for those with disabilities.

To this point, I have been simply defining the most obvious and generic of bathing requirements, but let’s also consider specific individual’s special needs like the needs of the mentally diminished, or the morbidly obese. When bathing an individual with Alzheimer’s or dementia, or a resistant or combative patient, the challenges multiply for the caregiver. While their needs are critical, safety for the caregiver becomes a bigger issue. Ideally, ensuring that the disabled individual is in the lowest risk position, as being kept in their own wheelchair or bed, lowers the risk for the caregiver as well. In the case of Alzheimer’s patients, oftentimes this also helps maintain mental comfort as well. Moves, changes of position, being “handled”, and other elements needed to effect a bath can increase the level of confusion or irritability. Even for older seniors, this can be more critical than for individuals with whom reasoning and explanation are easier.

For the obese individual, all of the above listed factors may exist, plus they now have to deal with the complications of excessive weight. They are not as easy to transfer, they oftentimes are not as stable in their balance and are at heightened risk of falling. When they do get into a tub or shower, they face more difficult issues with getting water in contact with skin under heavy folds, or even being able to reach all body parts.

While these are not the only factors for normalcy in bathing or showering, I’m sure you get the picture. Bathing for individuals with disabilities is a LOT more challenging than it is for the able-bodied.

Before getting into the different alternatives or solutions, keep in mind, too, that there are other challenges that are far more common for those with disabilities, such as travel and hotels that really do have very little idea of what is really needed for accessibility, or living situations, such as the differences in options available to renters versus homeowners, hospice patient needs, seniors, or those with very limited financial resources or those who live with other family members.

I could elaborate, but these are all pretty intuitively obvious as challenging circumstances beyond the bath itself.

So let’s look now at the options that exist for acceptable bathing, which really breaks down into two distinct categories: Bathtubs and Showers. I am specifically excluding sponge-bathing simply because of the obvious inadequacies of this alternative.

To compare and contrast the two alternatives of bathing or showering will help define the most appropriate alternative for an individual patient. But clearly, either of these can be the right solution in the right situation.

Bathtubs versus Showers. There are fundamental differences even though they are both to address the same requirement of hygiene. In truth, there are about five key differences:

  1. Passive water flow versus active water flow
  2. Amount of water available to cover the skin
  3. Cleanliness of the water
  4. Physical configurations
  5. Access to various parts of the body

Let’s first review the various bathtub options that are on the market, and outline the key characteristics and/or benefits of each.

The most traditional alternative is a bathtub, which is good for soaking, which can be important for foot cleaning or hydrating. But to use a traditional tub, either a step-in is required, or some type of slide mechanism. The downsides to the traditional tub, even with a slide, are the potentials for slipping or falling, caregiver assistance, (which is possible, but challenging), and washing hair and the upper body is difficult or less effective than showering, simply because this is a passive water solution.Reaching controls can be difficult, or even dangerous. We know of one client who was seated on a slide, attempted to reach for the bathtub controls because the water was too hot, but could not reach them and ended up falling from the bench into the tub plus getting scalded with the hot water before he was able to get assistance.

Walk-in tubs are currently being aggressively promoted commercially, and they do have the advantage over a traditional tub of easier walk-in. (Not necessarily easier than walking into a shower, but once in, it is easy to sit down.)The key word here, though, is “walking” into the tub. That, in itself, is often out of the question for many people with disabilities.

The other positive feature of the walk-in tub is simply that of any bathtub, i.e., the ability to soak which can be a real positive for adequate foot cleaning and even circulation.

But, there are some important concerns for these tubs as well. First is the potential for slipping and falling because of the need to walk in, and when walking out, the floor is wet and slippery.

Caregiver assistance is also quite challenging because there is really no way to easily reach in and around the patient to assist. Some assistance can be provided from the front of the unit, but rarely are these units installed with open access all the way around.

Issues of washing hair and the upper body are similar to a traditional tub, but one critical difference exists between the traditional tub and the walk-in tub, and that is the filling and emptying of the tub. With the traditional tub, one can wait to get into the tub until the tub is filled with water of the right temperature, and can step out of the water as soon as the bath is finished. But, with the walk-in tub, no water can be put into the tub until AFTER the bather is sitting inside the unit. And, when the bath is over, egress too needs to wait until the water is gone.

Because individuals with disabilities and seniors are often even more sensitive to hypothermia than able-bodied individuals, this wait for water draining simply exacerbates the body temperature concerns while sitting wet and naked waiting for the tub to drain.

And, of course, walk-in tubs almost always require a house remodel. So cost, too, is an issue. While the prices quoted in the media for these units may sound reasonable, these prices generally are only for the tub units themselves, NOT for all of the remodeling and plumbing changes that will need to be done as well.

Realistically, bathtub slides and transfer devices end up being the more frequently recommended solution. These simple devices oftentimes are the simplest, and they do allow for reduced risk of slips and falls associated with getting into a tub. And, they are usually pretty easy to transport to different locations, so the individual with a disability can often have options for where they bathe. As long as there is a tub, they can take the transfer device to that tub.

The primary downsides for these devices are usually due to their mechanical nature. To select just one example, the Bella Vita by Drive Medical allows for the sliding then lowering of the individual into a tub. But if a bath or even body oils routinely come in contact with the device, the device can jam or slip.

Another key issue is simply due to the fact that the traditional bathtub is not really designed for the addition of a mechanical slide. Accordingly, the slide unit is oftentimes left in place during the bath and to pull the shower curtain around the tub leaves the slide area exposed to splash over or water dripping.

Bath chairs can reduce some of these issues, but the trade-off is again the transfer issue, and many of these are questionably stable in the tub and may be able to tip or slip. The biggest benefit to this alternative, though, is cost. Shower chairs can be not only affordable, they can be downright cheap. Since most third-party carriers, including Medicare, do NOT pay for bathing alternatives for individuals with disabilities, one cannot discount the importance of cost for many people.

So what, then are the showering alternatives? Really there are three: Shower chairs, shower remodeling, and portable showers.

Shower chairs share most of the attributes and disadvantages of bathtub chairs. Inexpensive, but they require the ability to either step into the shower or transfer to the shower chair. And, caregiver access and comfort can be even more problematic because of the need to actually get into the shower with their charge. But with a shower rather than a bath, once the individual is seated, affords better water flow, and easier head and hair washing.

Re-modeling for accessibility is clearly a wonderful alternative for those who can do it. The ability to modify the access to allow for a wheelchair to simply roll into the shower, and to allow for a configuration that is most appropriate for addressing the person’s condition, even for high quads and Cerebral Palsy patients, is clearly beneficial. But even this alternative has a few critical downsides: Expense, Inflexibility, and the requirement that you have to OWN the place that is going to be remodeled.

Caregiver assistance with permanent shower structures is really no better than that of bathtubs. In fact, with a re-modeled shower, the caregiver frequently has no choice but to get into the shower stall during the shower to be able to assist.

And, generally, accessibility remodels are even more expensive than regular shower remodels, simply because of the special accesses that need to be built in, as well as the various safety supports that are used in these which are not required in regular remodels. It is not uncommon for an accessibility remodel to cost $15,000 to $30,000 or more, depending on location and magnitude of the specific remodel.

The newest alternative that is now available is the portable wheelchair shower. This is a solution that has only been available for about five years, but it is one that gives the greatest flexibility for the greatest number of situations and is one that deserves consideration. The portable shower is designed specifically for individuals with disabilities, and in the case of the FAWSsit™ Fold Away Showers, there are four separate models to meet the needs of individuals who can use a standard sized wheelchair, for those who may need a little more space, those who require a very large unit, as for bariatrics, and a recliner model which gives a caregiver the ability to shower even an individual in a reclining wheelchair or a gurney.

The idea of the portable shower is essentially to give a full shower alternative when re-modeling is not possible, whether because of a renter situation or because of affordability. The portable shower can be set up anywhere there is access to a sink, and it can be accessed by the patient while staying seated in the wheelchair.

The key benefits to this alternative are safety, as the individual to be showered is able to stay seated in the wheelchair without requiring lifting or transferring. Water temperature can be set at the source of the water, so scalding is not a risk. A caregiver need not get into the shower with the client to help them with the shower, since access is made by simply reaching in from the outside of the shower stall. Even perineal access is simple by leaving the front curtain open so a caregiver can reach in.

Splash over is not an issue, since the shower stall is designed to keep the water in, even when the caregiver provides assistance from the outside.

Foot cleaning, and even soaking is simple. By simply allowing a little extra water to build up in the waste water pan before pumping it down the drain, foot health can be maintained as well as or better than in a tub. Even foot and toenail maintenance can be easily accomplished with a portable shower since the caregiver can access the feet without getting into the shower.

Because a shower head can be either hand held or mounted to the frame, at least with the FAWSsit, it is possible for many individuals with disabilities to do their own showering and to reach all body parts with the shower head, or to wash their hair with both hands free. Privacy curtains, too, can be in place for the client who is capable of doing their own bathing and thereby maintain dignity that might otherwise not be provided with other bathing solutions.

Because portable showers are available for rental as well as sale, even individuals with temporary disabilities, or in hospice, can still have the benefits of a real shower without having to pay the full purchase price for a unit. Portable showers cost approximately 1/10th what it would take to do a full accessibility remodel for a bathroom.

There are, however, some cautions when evaluating portable showers. Not all of the units offer the same level of safety or features and benefits. For example, there is one alternative which claims to be a “portable” shower, but which in truth requires approximately 90 minutes to construct each time it is moved, and a similar amount of time to take down. Furthermore, this alternative does not present as a complete unit, and for pricing purposes, the elements needed are priced “ala carte”. If not all of the components are purchased, however, the unit is simply not able to function as a complete, stand-alone shower.

There is another offering claiming to also be a portable shower unit, but elements of safety are truly concerning. While this unit claims to be the low cost alternative, it requires a caregiver to set it up, after the person is seated in the unit. The pan has no structural integrity except for foam edges, to hold the waste water. Water is heavy, and a unit like this is going to present a real risk of structural failure if the water pan is not kept empty at all times. That, too, is concerning because the pump to remove the waste water is considered “optional”, and the client is given the option to purchase their own pump. And, if a pump is included, it is left laying on the ground because the PVC frame is not strong enough to hold a pump off the ground. If water does escape the unit, (see above), you now have an unprotected electric pump coming in direct contact with water. That is a high risk alternative for potential electrocution!! The PVC frame is not intended to support a person, but it is critical that it has the ability to provide adequate structural support to hold a pump off the floor, to hold the waste water pan in place, even when water builds up, and to be a single unit which can be set up in less than one minute, oftentimes by the individual with the disability without caregiver assistance.

While solutions like these may look financially attractive at first consideration, these risks are simply too serious to ignore.

When the first, and patented, portable wheelchair shower, the FAWSsit™ Fold Away Wheelchair Shower was developed, all of these issues were given serious consideration and as a result, a custom pump was developed, and tested and approved by Underwriter Laboratories, to ensure safety. And it is designed to operate either wet or dry and to remove waste water at a rate that may even exceed the rate of water flow into the unit, thereby preventing unsafe water build up.“Garden” style pumps simply cannot deliver that degree of efficiency. With the FAWSsit, the pump is mounted on the frame, and the unit includes all required elements, including a reinforced, attached pan, reinforced drain hoses to prevent crushing under a wheelchair, a shower head which allows for water temperature setting and control at the faucet to prevent potential scalding, (a U.S. safety requirement), an anodized aluminum frame for structural support, and all other elements for a fully constructed, no tools required, product.

Furthermore, the FAWSsit™ is 100% made in the USA by a company owned by a service-connected disabled veteran whose primary interest is in manufacturing a product that is safe, effective, and honestly priced to reflect its quality.

To more graphically illustrate the pro’s and con’s of all of the various bathing and showering solutions discussed, attached is a decision support card which may help in the assessment of the most appropriate solution for the individual who is being cared for.

The bottom line is that every client situation is different, from temporarily to permanently disabled, to seniors who wish to age in place in their own homes, or to those with ALS or other degenerative conditions, the goal is to provide as much of a normal hygiene situation as possible. Not all solutions address the needs of all clients or patients. But there is no question that solutions are now available that are SAFE, EFFECTIVE, AFFORDABLE, AND APPROPRIATE. That is, after all, what normalcy is all about, right? Who would want any less?

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