Assistive Technology: Ask the Expert with Jean Minkel
Topic: "Seating for Function--Providing Postural Support to Persons with Neuromotor Dysfunction"
November 29, 2001
Jean L. Minkel, MA, PT is an educator and master clinician widely recognized for her expertise in assistive technology. She currently directs Minkel Consulting, a company providing educational and consulting services to clinicians, consumers, manufacturers and payers. She is the author and director of the videotape series: Spending or Investing: Funding Assistive Technology and co-author of the book A Guide to Wheelchair Selection and The Manual Wheelchair Training Guide. Ms. Minkel has over a decade of experience in seating and mobility service delivery to clients of all ages. She has lectured extensively in the United States, Canada, Europe and China.
Thank you, Jean, for your time and effort, and to EVERYONE who participated in the discussion. We would very much appreciate your EVALUATION of this discussion. This can be done quickly online at http://gucdc.georgetown.edu/evalsurv.html. Please put your e-mail address in the "Comments" area at the end of the survey and we will add you to our database to receive announcements of products and activities relating to assistive technology from The Consortium for Children and Youth with Disabilities and Special Health Care Needs.
Again, thank you Jean and everyone!
Mary
Nov. 29, 2001 at 14:08:57
Hello- if a person is considering a power wc for independent mobility (regardless of dx or onset) and this is first power base, what would typically be expected to demonstrate independence is use? Thank you
Jean Minkel
Nov. 29, 2001 at 15:59:15
Q- Hello- if a person is considering a power wc for independent mobility (regardless of dx or onset) and this is first power base, what would typically be expected to demonstrate independence is use?
A- What is expected and how long will it take the person to demonstrate the skill are obviously two VERY differnt questions. I bring up the time needed to demonstrate the skills just to emphasis - that in a supportive envirnoment, with lots of well-presented, structured instruction - many people with significant developmental disabilities have become successful power chair users.
To be little more specific - a couple of miminal requiremnets are necessary. Is there a consistent motion that can be identified which would allow the person to activate the wheelchair control (control can be a joystick, or speciality control like Sip'n Puff or Switch operated controls - even fiber optic switches can be used.) Providing there is is an access site the REALLY KEY FUNCTION to be demonstrated is the ability to STOP the chair, once moving. Power mobility is not so different than driving a car - SAFETY of the person and OTHERS in the environment will need to be demonstrated (at some point -maybe not at the first visit) before a power chair can be recommended.
I suggest initial explorations of power mobility be done is wide open areas - (ideally without a whole lot of extra people -initially - to reduce the "excitment" and expectation"). Can the person fairly early on figure out - when I "touch" this - I move (fairly basic cause and effect) - without cause and effect - the skills needed to demonstrate SAFE , functional mobility may be too difficult to develop.
If cause and effect is present - "needed" driving skills depends very much of the "mobility demands" of the environment. Indoors/ Outdoors - the size of the doorways - need to negogiate elevators, finished (tile, carpeted) surfaces verse uneven or rough terrain. At a very minimium - the ability to control FORWARD, REVERSE, RIGHT , LEFT - Pull up to a table and stop - Pull back away from a table - Turn into a hallway - travel safely with others in the area (these skills will atleast allow someone to move around the environment safely.
I always like to at least give the person the chance to try and let the performance determine "next steps" in the treatment plan.
Nov. 29, 2001 at 14:02:36
Do you have an opinion as to the minimum experience/training for persons performing wheelchair evaluations on children?
Jean Minkel
Nov. 29, 2001 at 15:38:07
Q- Do you have an opinion as to the minimum experience/training for persons performing wheelchair evaluations on children?
A - If you have been reading the series of postings, I guess it will not suprize you that I have an opinion!! You asked for my opinion - therefore I will share it with you. I feel strongly that any professional should recognize (and admit -that is the hard part) his/her scope of competence. I am currenly the Chair of the Professional Standards Board for RESNA - the Board manages the Credentialing Program for AT Service Providers (ATP AND ATS) and have given this issue alot of thought.
I (emphasis on I -personal opinion) view a "wheelchair evaluation" - as an EVALUATION - it requires the ability to collect and SYNTHESIS the essential information to develop a "treatment plan" - what supports are needed to allow the user to perform what functions in what envirnoments - I need trial equipment and whenever possible a "test drive" in the natural use environment. I work every closely with the client (and support network) AND with a Supplier. (I can not make this recommendation alone---too many things to consider).
How much experience does therpist need to "lead the team" - depends a little on their professional experience. I feel experience as a treating therapist working with people (children) with CNS dysfuction is an essential foundation - (You have to know what TONE is....and how to facilitate changes in tone, for example). "Wheelchair Evals" - which I think are AT LEAST two pieces - Postural Support Needs and Mobility Needs (not to mentional functional and envirnomental assessments) are (in my mind) advanced clinical techniques which a therapist need to learn (and ideally be mentored, supervised and coached by an experienced seating and mobility therpist) - before being expected to perform alone. (I can't/won't do MacKenize mobilization without first developing the skills - why should "W/C" evaluations be any different.)
For a more objective answer - the minimal work related experience a therapist w/ a Bachelor's degree or higher needs to document to sit for the ATP exam is at least 25% work in AT for a min. of 2 years. (Sorry for the long winded answer - for other "eligibility requiremnts for the entry level ATP - see http://www.resna.org
Tess Rhodes, UIC
Nov. 29, 2001 at 14:01:23
What is the recommended minimum age for a child to have an electric mobility device?
Jean Minkel
Nov. 29, 2001 at 15:15:30
Q- What is the recommended minimum age for a child to have an electric mobility device?
A - Children's Power Mobility is one of my favorite subjects. Research has show that for children with age-appropriate cognitive development - whose mobility is impaired primary due to physical limitations - power mobility can be sucessful as young as eighteen months. Any mobility for an 18mth. old needs to be adult supervised. When introducing mobility to young children (and families) remind folks of the "progression" for kids learning to walk - just moving is what is important. With power mobility the key safety feature to assess is can the child STOP the device (at will or on verbal command).
Check out the work done a Rancho Los Amigos Hospital in Downey CA - on children and power mobility.
Tess Rhodes, UIC
Nov. 29, 2001 at 13:50:41
What type seating system is best for children with SMA who have very poor head and neck control?
Jean Minkel
Nov. 29, 2001 at 15:07:20
Q- What type seating system is best for children with SMA who have very poor head and neck control?
A- As I noted on an earlier posting - I have found children w/ SMA just a pleasure to work with, because they can often lead YOU to the position that works best for them. If the child has very low (or no) head and neck control (to even maintain the position once positioned) - I have seen children who do very well with an Orthotic approach. There are a couple of variations - Traditional body jacket,worn under clothes - some have been made with a posterior head support (mounted to the back of the body jacket). An alternate technique is to make an orthotic "sitting orthosis" - essentially a body jacket which extends across the hips and provides a seat for the lower extremities.
If the orthotic approach is too agressive, a custom molded seating system may work (need to decide if a body jacket will be used with a molded back?) - I would recommend simulating the support from a molded system - using a molding frame and be your own worst critic - is this posterior/lateral support - truely enough to allow this child to function?
Nov. 29, 2001 at 13:44:26
The facility I work for is planning to start a seating clinic. Do you have any suggestions on start-up and/or courses on topic of pediatric seating?
Jean Minkel
Nov. 29, 2001 at 14:52:36
Q- The facility I work for is planning to start a seating clinic. Do you have any suggestions on start-up and/or courses on topic of pediatric seating?
A- My first advice to have "frank" discussion with the facilty adminstration about the goals of a seating clinic. (I love service delivery and I love working in clinics, but if people think the clinic will be a "real" revenue producing activity - they (and you) could be very disappointed.
I would STRONGLY encourage you to make your staff development needs (to learn seating and mobility assessment practice and techniques) a pre-requiste prior to starting a clinic. A couple of options: Pre-conference workshop before the International Seating Symposium in Vancouver, BC - March 5/6- 2002 (http://www.sunnyhill.bc.ca)
Preconference Instructional Program - RESNA - June 27-28, 2002 - Minneapolis, MN - http://www.resna.org
(and at the risk of self-promotion) I teach a "traveling" woorkshop - "Sitting Solutions" the 2002 schedule is posted at http://www.tsstss.com
Nov. 29, 2001 at 13:27:18
What seating system would you recommend for a 13 month old child with spasticity and athetosis (diagnosis is periventricular leukomalacia) who commando crawls but cannot sit independently and does not bear weight through his feet in supported short sitting or standing? This child's family has not really come to terms with the fact that the child will not outgrow his impairments, so that is also a factor. They are also a low income family with limited living space. Is it possible to meet feeding/positioning/transportation needs with one product?
Jean Minkel
Nov. 29, 2001 at 14:41:29
Q- What seating system would you recommend for a 13 month old child with spasticity and athetosis (diagnosis is periventricular leukomalacia) who commando crawls but cannot sit independently and does not bear weight through his feet in supported short sitting or standing? This child's family has not really come to terms with the fact that the child will not outgrow his impairments, so that is also a factor. They are also a low income family with limited living space.
Is it possible to meet feeding/positioning/transportation needs with one product?
A- I do not feel ONE product can meet all these needs - most especially the transportation needs - However - a 13 month child may still fit in alot of commerically available children's equipment (availble through a Toys 'R Us, etc) - which is MUCH less expensive the "Medical Equpment". I would suggest several "next steps" - Review current equipment: 1. Car Seat - current fit - could a "toddler" size fit - be very careful not to change any of the "crash tested" features of a commerical car seat. Adding towel rolls to the sides to add lateral stability id OK, but for example, don't change the straps.
2. Feeding - Is there a high chair in the home - can it me modified with a triwall or foam to add stability?
3. Positioning - How/when and for what activities will the child need to be "positioned" when not in the high chair. (Could a commerical bath "ring seat" be adapted for floor sitting activities?) These are important questions because floor seating is handled quite differently then "table top activities".
Mom's arms may be a place that this child is positioned alot - does she have good handling skills?
I would also encourage the team to explore getting the child on Medicaid -so that future equipment needs can be funded when the commerical devices are no longer appropriate
cnadeau
Nov. 29, 2001 at 13:13:25
Are there generally accepted / established criteria for wheelchair options such as the tilt/ in space feature. Seems that we get an awfully lot of these requests
Aside from wheelchair vendors (many are now selling to Medicare clients via TV and on line advertising and simply drop shipping to the client !)what others are involved in the selection process of a wheelchair (PTs / OTs ) and what have you found to be their training backround.
Jean Minkel
Nov. 29, 2001 at 14:27:49
Q -Are there generally accepted / established criteria for wheelchair options such as the tilt/ in space feature. Seems that we get an awfully lot of these requests.
A - While the evidence-based literature, especially in peer-reviewed articles is admittedly very thin - I do beleive there are some "standards of practice" that an experienced therapist uses in determining the the need for W/C options like tilt 'n space. The challenge in Seatin and Mobility is the diffiuclty in interpertation of Medical Necessity as opposed to Functionally Important (That discussion could fill the afternoon). Specifically I look at tilt'n Space for two primary reasons - 1. a mechanical means of pressure relief for a person not able to shift their own position sufficiently to aloow bloodflow around the ITs. 2. Functional shift from a "ready position"(upright to forward leaning to be engaged in a activity) to a "leisure" position - tilt back off from the line a gravity - a more relaxed seated psotion. Those seated persons (non-disabled and disabled alike) who can dynamicaly change their seated postion DO - a thousand times a day - those with more compromised postural support control shoudl have to be STUCK in one singular seated position (a another Minkel soapbox)
Q- Aside from wheelchair vendors (many are now selling to Medicare clients via TV and on line advertising and simply drop shipping to the client !)what others are involved in the selection process of a wheelchair (PTs / OTs ) and what have you found to be their training backround.
A - Suppliers (as well as therapists and other service providers in Assistive Technology) have the option to demonstrate their "equipment specialization" by earning the RESNA certfication - for suppliers- Assitive Technology Supplier (ATS) or for pracitioners -Assistive TEchnology Practioner (ATP). (SEE http://WWW.RESNA.ORG for full listing) Further suppliers can be members of NRRTS - a registry of REHAB suppliers (credentialed NRRTS members use the designation CRTS). LOOK FOR AND ASK PROVIDERS IF THEY HAVE ANY CERTIFICATION.
Who should be invovled? - Primarily the client and their DIRECT care network (family, friends, paid staff) - Truely apart of decision making - not just handed a completed order with not actual experience with any trial equipment. Secondly a therapist (OT and/or PT - ideally who has either direct expreience working with the client or has specialized seating and mobility assessment experience (ATP).
Trish Larbalestrier, RPT -- Patient "H."
Nov. 29, 2001 at 10:19:02
I am writing to you today regarding a student who is receiving P.T. who is enrolled in the hospital/ homebound program in a county in Florida. He is 6 years old and diagnosed with non shunted hydrocephalus and severe spastic quadriparetic cerebral palsy. I truly have never seen such severe extension tone. All movements are governed by severe abnormal reflexes (mostly ATNR) and tone. He is not on any medications for tone reduction and has minimal orthopedic concerns at this time.
Currently, he is seated in a Quickie tilt in space frame with a solid I back and solid seat. The wheelchair is also equipped with standard laterals, hip guides, foot plates with foot straps, comfort 1 head rest,Bodypoint dual pull seat belt and soft Ottoboch chest harness. When H. is in his wheelchair he is usually without socks and shoes and does not have his feet strapped in and his legs are extended over the foot rests and he hangs by his hips on the seat belt. When his feet are strapped in, his extension tone creates a translation of his femur over his stationary tibia. This week when I arrived at his house, I found that the private O.T. had removed his foot plates and placed a towel under his thighs. I haven't talked to her yet as to why she did this but I have been in contact with the company that provided the wheelchair to attempt to obtain a diffrent seating system. At this point, I have suggested an anti-thrust seat cushion and possibly a sub ASIS bar. We have also considered closing the seat to back angle some. I'm not sure , however, this will be enough and am concerned he will need a whole new seating system (Contour U Vs. Sillhouette?) What else can I do to keep his hips in the seat and break his severe extension tone?
Jean Minkel
Nov. 29, 2001 at 14:08:57
Q- He is 6 years old and diagnosed with non shunted hydrocephalus and severe spastic quadriparetic cerebral palsy. I truly have never seen such severe extension tone. All movements are governed by severe abnormal reflexes (mostly ATNR) and tone. He is not on any medications for tone reduction and has minimal orthopedic concerns at this time.
A - I have to start with a another Minkel soapbox - Seating (Alone) may not solve these problems and it is OK to say other Medical inteventions will need to be explored prior to recommending a new seating system. As posted earlier - I am aware of some positive gains with children with SEVERE extensor tone when a Baclofen pump has been used for tone reduction.
Along with more agressive medical management, I would STRONGLY recommend a full Mat Assessment - out of the current chair - to determine two things: The available passive range of motion at his hips and knees - when he is in the least stress position (ideally supine with head in midline and neutral extension). If he has the range to flex his hips greater than 90 degrees - then I would hold him and see if I can positioning him in my own arms (lap, using my truck for support as needed) - to see if I CAN find (and hold him in ) a tone reducing position. In my expereince - I can not ask a seating system to do more than I can do when I am holding the child. If you find a postion, see if you can replicate the position in a "simulated" trial before recommending.
Katherine Swick -- Patient "T."
Nov. 29, 2001 at 10:14:45
I work for Brazosport ISD. I have a young lady, three years old who has a form of Dystonia (mitochondrial chephals myopathy). Her muscles are hardening. She takes hundreds of Botox injections and muscle relaxers. These injections help to loosen her muscles. When it is close to the time for her to receive her injections she has a difficult time finding a position that is not painful or uncomfortable for her. The teacher is currently working on having her sit for a few minutes in a Rifton or a Tumble Forms. She cries when in the chairs, but we don't know if it is because she has never had to sit in a chair or if she is in pain. She has little control of her right side. Her arm will spasm and her leg is only slightly better than that. Her only means of independence is to roll, and mom does let her do that a lot. The other problem that T. has is her weight. The disease causes her to burn an amazing amount of calories. The parents try to feed her everything that they can but she mainly drinks Pedisure for the extra calories, an extreme financial burden on the parents The disease is degenerative. Onset of the disease was at 15 mos. The doctors don't know very much about the disease, it is very rare (especially in children). They have told her that she will begin to experience seizures and eventually have a large one that will take her away. So far, she has not had any seizures. Any information that you could provide would be greatly appreciated. kswick@brazosport.tenet.edu
Jean Minkel
Nov. 29, 2001 at 13:58:06
Q-I have a young lady, three years old who has a form of Dystonia (mitochondrial chephals myopathy).
A - I too an unfamilair with this diagnosis and would not want to go too much further without a greater understanding of the disease.
The two thoughts that come to mind(COMPLETE SPECULATION)- I would ask the physician if a Baclofen pump might have any value for this little girl - the more constant application of medication MAY make daily management a littl easier.
The second thought is to wonder if the SEATED position is the "preferred" position. I would suggest a thorough Mat Assessment to check the available PASSIVE range of Motion (especially when awaiting next injections) to be sure she has the range at her hips and knees to sit. Alternate postioning can include - Supine Standing, Side Lyer, or even a Kneeler.
Kara Lee-Lexington, KY
Nov. 29, 2001 at 10:10:17
1) What is the most stable midwheel drive configuration you have found that will allow a seat to floor height of 22 inches or more (to accommodate a very tall man with progressive ataxia who lives in a mobile home, in this instance). We are currently working with Pride Mobility to see what we can do with a Versaseat to add to the stability of such a seating system.
2) What is the most effective means of seating you have found to work for clients with progressive cerebellar ataxic diseases? I currently have a 200# plus client who slides out of his manual wheelchair; we have added a 4-point body point seatbelt and are working on dumping his chair gradually to see if we can avoid using a knee block system by affording him the stability of a slightly forward flexed position, from which he is a little more stable in his ability to stay seated.
3) What have you found to be the most effective and comfortable means of seating for some of your older (40's) clients with ataxic/athetoid cerebral palsy -- these clients are usually very thin and are developing arthritic problems but also have large span and uncontrolled movements that interfere with the ability to use footrests, etc.
Jean Minkel
Nov. 29, 2001 at 13:32:31
Q-1) What is the most stable midwheel drive configuration you have found that will allow a seat to floor height of 22 inches or more (to accommodate a very tall man with progressive ataxia who lives in a mobile home, in this instance). We are currently working with Pride Mobility to see what we can do with a Versaseat to add to the stability of such a seating system.
A - The most STABLE configuration (though not necessarily the most effective for OUTDOOR mobility) is a six- wheel configuration - the 2 swivel casters,the 2 stabilitizer wheels and the drive wheels all contacting the ground. Pride (especially their Rehab. Division - Quantum Rehab- is very accomdating to meeting special needs.
Jean Minkel
Nov. 29, 2001 at 13:43:59
Q -2) What is the most effective means of seating you have found to work for clients with progressive cerebellar ataxic diseases? I currently have a 200# plus client who slides out of his manual wheelchair; we have added a 4-point body point seatbelt and are working on dumping his chair gradually to see if we can avoid using a knee block system by affording him the stability of a slightly forward flexed position, from which he is a little more stable in his ability to stay seated.
A- I have found axatia to be a very challening motor control situation to manage in w/c seating. I am afraid I have more questions than answers: DOes the gentleman self-propel - could he be a candiate for power mobility? I ask because sometime the act of propulsion - with either hands or feet, "triggers" accessory motion. Can the gentleman communicate to you, altenate places where he can more comfortable sit - like a Lazy Boy recliner or a car seat. Again in my experience, by observing someone in the "non-W/C" seating arrangements, you may gain insight on how to set-up the chair to be more functional and comfortable
Jean Minkel
Nov. 29, 2001 at 13:50:21
Q -3) What have you found to be the most effective and comfortable means of seating for some of your older (40's) clients with ataxic/athetoid cerebral palsy -- these clients are usually very thin and are developing arthritic problems but also have large span and uncontrolled movements that interfere with the ability to use footrests, etc.
A- These clients have lived with their disability a very long time and can often direct you to which stategies work well for them in finding that "stabilizing" position/posture which allows them to function (however unorthodox the movement pattern may be). I have seen some success using RoHO cushions and backs with these clients- allow the movement and doen't resist it. With regard to footrest - PLEASE check the available hamstring range when the hip is FLEX (Look at the Popliteal Angle) - the footrest will need to be moved back closer to the front edge of the seat (if not under the seat - if the hamstring do not allow knee extension when the hip is flexed.
Anna Edwards, P.T.-- children w/hemiplegia
Nov. 28, 2001 at 09:43:40
Re: mobility for children with hemiplegia. I have worked with children using one-arm drive manual wheelchairs with limited success. At what cognitive age do you feel a child can successfully learn to steer a one-arm drive chair? Also, are there alternatives to the "rim drive" one-arm drive manual wheelchairs? I would appreciate any ideas you can share on this topic. Thank you.
Jean Minkel
Nov. 28, 2001 at 18:12:09
The following is my response to the question on mobility for children w/ hemiplagia -
Q - Re: mobility for children with hemiplegia. I have worked with children using one-arm drive manual wheelchairs with limited success. At what cognitive age do you feel a child can successfully learn to steer a one-arm drive chair? Also, are there alternatives to the "rim drive" one-arm drive manual wheelchairs?
A - Your experience of limited success is simlar to my own expereince. Operation of a douple-rim one arm drive system IS DIFFICULT. My experince is - if a child is going to "get it" - he/she will get it fairly quickly. One of the tricks to "getting it" is having the hand size to grasp both rims for forward propulsion and "almost sub-conscientiously" know which rim to turn for directing the chair right or left (that is the part I have trouble with....). I am not sure age is the determining factor (FYI - children as young as 18 months have been successful power chair users).
Alternatives to the two-rim approach inlcude: Lever -Drive Systems (check with you Sunrise/Quickie Rep. - they used to carry a lever system for Quickie chairs. The child pushes the lever to move the chair forward and the lever (which is attached to a caster) can be "turned" to direct the chair in either the R or L direction.
One hand - One Foot Technique - Depending on the seat to floor distance of the chair and the height of the child - the foot and hand can be used in combination to create propulsion and directional control. (ADVANCED tid-bit - Bengt Engstrom, Swedish therapist, presents a very compelling case to slightly anteriorly tilt the seat and use a shin "block" on the "effected" leg - to increase the efficiency of propulsion WITHOUT constantly sliding forward out of the chair, when using the foot and hand technique.
Power/Scooter mobility - (this could be a Minkel soapbox) If the child has the cognitive/ perceptual abilities to self-propel using a chair - but mobility is inefficient in a manual chair - I would consider power. Getting around needs be efficient. If there will not be harm to the child or others in the envirnoment - let them be efficient (even if it means they need to use a power chair).
Anonymous -- Seating Systems Questions
Nov. 26, 2001 at 13:03:09
Could you please discuss the benefits/limitations of custom molded systems and planar systems? When would either of these systems be contraindicated? Not considering replacement due to growth or changes in weight, how long would a seating system typically last? Any particular products with greater durability?
Is power tilt or power recline more effective for pressure relief? Any research to date (pressure mapping) with either or both? When would it be required to have BOTH power tilt and power recline in combination? What is acheived using both in combination that cannot be acheived using either power tilt or power recline? If any- to what degree and how is this benefit measured?
Jean Minkel
Nov. 28, 2001 at 07:17:46
Could you please discuss the benefits/limitations of custom molded systems and planar systems?
The major differences between the two types of seating systems are: 1. adjustability 2. amount of contact Custom molded systems, if well molded, provide maximal contact and minimal adjustability.
The support provide by either system is primarily posterior (along the the posterior pelvis and the trunk) and lateral along the trunk.
I tend to use custom molding when the person has: 1. fixed skeletal deformity, including rotation of the pelvis and/or spine creating "multiple planes" needing support. OR 2. minimal skeletal deformity, but functions best when "total" support is provided at the pelvis and trunk to improve function head and/or upper extremity control.
I will use planar systmes when change is predictable. (Change can be either: improvement in postural stbility -for eaxmple during acute rehab phase for a person with Traumatic Brain Injury. or predictable loss in stability - progressive neurological conditions- the person may not need pelvic or lateral trunk support now, but in six months these supports may need to be added.
When would either of these systems be contraindicated?
Contraindicated is a strong word in the "art/science" world of seating and mobility. The question a provider needs to asks, which system (which I have access to) will provide the type of support this person needs to acheive functional seating. I am being "fuzzy" because, I have been spoiled and have been able to work w/ manufacturers and custom fabricators to "design" complex planar systems (with contoured foam, assymetrical and oblique laterl supports, etc).
As a Rule of Thumb - when you observe the person's trunk (that means taking off the shirt) and you are prodiving external support with your hands for supported sitting - if you observe multiple planes which will need support - consider molding - to "capture" each of those planes.
Be cautious, however, in using standard molded seat cushions for persons with (or at high risk for tissue trauma (skin breakdown)). Standard molded cushions do not tend to be "resilent". Custom modifications can be made to add gel ro air bladders for high risk clients - or you cna use just a molded backrest and "pressure relieving" seat cushion
2nd rule of thumb (may be more important than the first) - "try not to remove/impede function" - consider the impact of the seating system on transfers, propeling, ADLs, etc.
Not considering replacement due to growth or changes in weight, how long would a seating system typically last?
"That depends" - sorry I could not resist. When using planar systems, be aware that of the type of foams being used in the fabrication of the system - and be aware of the upholstery "attachment". Many foams - including polyeurthane and T-foams - have a "life" of about 12 months. After about 12 months, the cushion "bottoms out" - it does not "bounce back any more" - IT IS HARD. Ideally, the seat and or back cover has a zipper to allow access to the foam ( most essentially the seat cushion. Replacing foam is much more economical than replacing a whole system.
Because the "foam" in molded systems is not being repeatively compressed, there are less concerns about "botteming-out". The material chosen to cover the mold may have wear problem - Naugahyde (vinyl - like material wears well, but does not "breathe" - some of the more "fabric" covers tend to wear more quickly.
Obviously a person with very high or frequently fluctuating tone, puts more stress on a system than a person with low tone.
"Under normal operating conditions - WITH PROPER CARE AND MAINTENANCE- (this inlcudes cleaning and tighting of attachment hardware)- these systems can last 5 years.
Any particular products with greater durability? My best advice is network. Ask the supplier - call the manufacturer - ask which products have they designed for "increased durability" - I would also reocmmend checking to see if there is a developmental disability center in the area which maybe providing product to "chanllenging" clients - What have they found useful in creasing durebility.
There is such and interplay between the amount of support provided, the type of mobility base being used, the envirnoment in which the products are used - you need to think of the durability of the "system" not just one part.
Jean Minkel
Nov. 28, 2001 at 07:57:10
Is power tilt or power recline more effective for pressure relief?
In my "humble" opinion, the answer to your question is NO - one is not "more effective" than the other - they different advantages and disavantages Tilt - does not change the user's hip and/or knee angles, during the process of weight shifting - this can be essential for persons with contractures at the hip and/or knee or who have strong spasticity "triggered" by "opening the hips or knees" Recline - does open the hip and knee angles (providing passive ranging) and in doing so increases the surface area available for weightbearing.
ADVICE- if the person has the range to try either tilt or recline - let them experience the sensation of tilting AND of reclining - some people have strong reactions to one type of system over another. (If you have not tried these systems - you should - especially before recommending for others).
(see below for "angle of effectiveness")
Any research to date (pressure mapping) with either or both?
I (and others) have done informal assessments for tilt and recline using pressure mapping systems. I am not aware of a direct comaprison study. I will refer you to an article on "Efficacy of three measure to relieve pressure in seated persons w/SCI" (does not inlcude power tilt and/or recline) - Henderson JL, et al. Arch Phys Med Rehabil, 1994; 75:535-539.
When would it be required to have BOTH power tilt and power recline in combination?
Interstingly enough, in Canada, it is routine to provide both tilt and recline when the person needs power seating....(food for thought) When needing to justify both in the US, however, I can think of a couple of cicumstances: 1. Recline is the perferred method, but sliding out is a concern. With both systems. the user can tilt back (10-15 degrees - prevent sliding during recline) - then recline - opening up hips and knees. 2. Tilt is the preferred method of pressure relief; but ADL functions - "cathing", sliding supine transfers, etc) are more easily accomplished with a reliner.
(there are plenty more examples.....try and remember to meet the person's needs, then justify the need to the funding agency)
What is acheived using both in combination that cannot be acheived using either power tilt or power recline? I think the answer above begins to answer this question
If any- to what degree and how is this benefit measured?
If the power seating is being used primarily for pressure relieve, the measurable benefit should be "intact skin" - no "pressure sores" due to continous pressure during seating.
To unweight the buttocks - allow blood flow by the ITs, in a tilt system, the person will need to tilt (in many cases) back 45-60 degrees (from vertical) - if you watch the pressure distribution on a map during the tilting process - you will observe, the IT still bears the majority of weight through the first 40 degrees of tilt.
When reclining (with the legs elevating) , the surface area increase (weight bearing is being done on the backrest and legrests) - again if you observe the pressure mapper, you will see the pressure under the IT decreases as the trunk and legs increase the weight bearing load (often time in the first 20 degrees of recline.)
Cathy -- Seating for 7 y/o Girl Question
Nov. 26, 2001 at 12:55:06
One of my students is a 7y/o girl with a dx of spinal muscular atrophy - type 2. I have been working with her since she was 3. Her mm strength overall is approx. 2+ - 3/5 for the upper extremities, LE's 2-/5.
Neck strength is 2/5 - she can stack her neck and maintain an upright position and perform rotation. She is unable to bring her head to an upright position from flexion or extension without substituting other muscle groups in the neck.
Trunk mm strength is poor+, fair -. She is able to sit independently, and can accept very minimal challanges. She has a tendency to bear more weight on her L hip, causing shortening on the R. Sitting in this posture over time, and with the dx of SMA (which has a tendency for scoliosis), she now has structural changes in the thoracic area - Convexity is to the L. This little girl for the past year has worn a body jacket which is molded to accomodate these changes.
During her school day, she is transfered into a regular desk that has the chair attached. While I am not happy with the position or accomodations for her desk, I am respecting the little girl's and parents wishes for this.
At the present the seat of the desk has a moderatly dense cushion in place to bring her to the optimal height for desktop activities. A carved out back support (a lumbar support cushion) is being used as a back cushion against the chair back. It serves 2 purposes, to bring her closer to the desk top and provides her with the small amount of input needed to keep her from swaying from side to side. Her feet are positioned on a block so that she is grounded, and in a 90, 90, 90 position.
I have tried to make adjustments to the seating, but am still not satisfied. I feel that the cushion might be too soft still, which might further compromise the scoliosis. I also need to be concerned with her having enough support, for function during her entire school day. Any suggestions???
She uses a powered scooter for mobility. It has a gel cushion, and has a manual chair that the parents do not want her to use during her school day. The seating in the scooter is not optimal either, it is too soft, and she seams to be bottoming out lately. I have the w/c vendor coming out in 2 weeks to discuss new seating for that. Recommendations?????
I would appreciate any suggestions you might have in this matter to help with seating accomodations for this little girl. I feel we are limited because we are tied to this desk and chair combination that all the other students in the class are using for the next couple of years.
Jean Minkel
Nov. 28, 2001 at 17:50:32
The following is my response to the case presentation of a 7 year old girl with SMA -
Q -I would appreciate any suggestions you might have in this matter to help with seating accomodations for this little girl. I feel we are limited because we are tied to this desk and chair combination that all the other students in the class are using for the next couple of years.
A - I was pleased to read that this little girl is using a body jacket - the rest of my response "assumes" (always a dangerous thing to do) that she wears the jacket when sitting in the classroom chair.
The advantage to the body jacket is that it will provide circumferencial support to the pelvis and trunk. This "intimate" fitting support - can replace the need for extensive external supports, mounted to a chair.
Children with SMA are wonderful to work with in that they can TELL you exactly where they need to be positioned in order to FUNCTION. FUNCTION is the absolute most important consideration for these children. The natural history of the disease WILL lead to scolosis (and there is NOT a whole lot you nor I can do to stop it from happening). Most important thing is to recommend ACTIVE monitoring by an Orthopedist and for you to work with the child in determining a FUNCTIONAL and COMFORTABLE position in the classroom and in the power mobility system.
Specifically, I would ask the child if she feels any discomfort or functional limitation in the current classroom set-up. If not ("it ain't broke -don't fix it). If (as you might suspect), her left hip gets sore following long periods of sitting, you may want to try a different cushion - perhaps one that lets you "add to the surface on the right side to (slightly) increase the weight bearing on the right hip - BE CAREFUL NOT TO NEGATIVELY INFLUENCE HER SITTING BALANCE AND HEAD POSITIONING. (Commerical options for trial can include (but is not limited to): Roho with 2 values (one for the right other for the left side), Viralite - Proform, air and foam combo cushion where you can adjust amount of air R vs. L., Jay cushion with an obliquity pad (or supplemental gel pad under the right side...ask your supplier for samples for trial.
With regard to the power mobility - is the scooter still working for her? - will she/parents consider a traditional power base chair? (which may accept power seating like power tilt - either now or in the future) - let her shift her own postion to maintain comfort.......
Lots of issues ---don't be afraid to ask the little girl - she may well lead YOU to the solution.
Sue LeHew - Hip Strap Question
Nov. 20, 2001 at 10:25:19
How important is use of a hip strap for power w/c users who have the tilt and recline features? I believe that use of the hip strap would keep the hips in a proper position when the chair is raised to an upright position.
Jean Minkel
Nov. 28, 2001 at 17:29:54
How important is use of a hip strap for power w/c users who have the tilt and recline features? I believe that use of the hip strap would keep the hips in a proper position when the chair is raised to an upright position.
This is actually a fairly complicated question. You are right in mentioning the function of a hip strap (or pelvic positioning belt) is to facilitate proper positioning of the pelvis. The belt applies force on the anterior surface of the pelvis, to "resist" forward movement of the pelvis. The placement of the belt on the wheelchair frame, can greatly influence the effectiveness of a particular belt. Belts attached to the frame crossing the hips at a 45 degree angle, tend to pull the pelvis back against the the backrest. Belts mounted to create a 60 degree angle to the hip, tend to push the thigh/pelvis down into the seat cushion (into a contour which may be present in the seat cushion.
When tilting, the seat to backrest angle does not change; therefore the function of the belt in upright sitting "should" remain the same during tilt and recovery motions.
When reclining, however, the "seat to backrest angle" opens - the backrest is moving away from the seat. If the backrest or seat do NOT slide during the recline and recovery cycle (shearing addressing features of a recliner) - then the user will slide forward as the backrest returns to upright.
If the chair in question has both tilt and recline a great method to reduce the sliding forward - is to evaluate the technique of tilting back 10-15 degrees (places the seat on an "uphill wedge" - then recline the backrest - the "uphil position of the seat, reduces the tendency to slide forward.
The bottom line - watch the movement of the person during "relief and recovery" cycles - Can you alter the technique and then align the moounting of the positioning belt in a "line of pull" to restrict the direction of movement.
DID YOU FIND THIS HELPFUL?
We would very much appreciate your EVALUATION of this discussion. This can be done quickly online at http://gucdc.georgetown.edu/evalsurv.html. Please put your e-mail address in the "Comments" area at the end of the survey and we will add you to our database to receive announcements of products and activities relating to assistive technology from The Consortium for Children and Youth with Disabilities and Special Health Care Needs.
Page Last Modified: 6 December 2001
This page is Bobby Approved
This Web page is a discussion forum of the Georgetown University Center for Child and Human Development which is funded by the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education under grant number H133B001200. The opinions contained herein are those of individuals other than the grantee and do not necessarily reflect those of the U.S. Department of Education.
