The Basics of Wheelchair Seating and Positioning. Benefits of a Proper Seating Evaluation for Individuals with SCI
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1 Objectives Allison Greenwood, OTR/L, ATP Senior Occupational Therapist Outpatient Neurologic Therapy The Basics of Wheelchair Seating and Positioning 1. Identify criteria for referral for a seating evaluation 2. Understand steps and goals of a wheelchair seating evaluation 3. Understand principles of postural alignment and application of this information 4. Obtain a basic knowledge of manual vs power mobility 5. Identify seating considerations in a medical setting Benefits of a Proper Seating Evaluation for Individuals with SCI Enable and increase independence with wheeled mobility skills Maximize balance for UE reach and function Improve skin integrity and seated pressure distribution Increase postural alignment and minimize contractures Enhance physiological function When to Refer Clients for a Wheelchair Seating Evaluation Client has had a significant change in medical status Client is not sitting properly in their equipment Client s wheelchair is broken beyond repair Client presents with pressure sores Client is not able to functionally propel current wheelchair in their home When to NOT Refer a Client for a Wheelchair Seating Evaluation Client s injury has a good prognosis for recovery Client s only requires a w/c for community mobility Therapy goals are for independent household ambulation Client solely requires repairs from the DME vendor The 5 Year Rule Insurance will NOT provide a client with a new wheelchair if it is under 5 years old, unless a SIGNIFICANT change of condition has occurred If over 5 years old, there must be adequate repair needs to justify replacement vs. updating of the system Client requires only a standard (basic) manual wheelchair 1
2 Wheelchair and Seating Provision Process Goals of Proper Wheelchair Seating and Positioning 1. Referral 2. Interview 3. Seating Assessment 4. Determine goals and objectives with client 5. Equipment trial and simulation 6. Equipment prescription generation 7. Funding and procurement 8. Fitting, training and delivery 9. Follow-up Maximize a neutral seated position Provide a stable base of support for balance and functional independence Identify postural deformities Neutralize tone Minimize pain or discomfort Improve skin integrity What is normal posture? The Myth Pelvis with neutral or mild anterior tilt Spine neutral with slight lumbar lordosis Shoulders level and in line with pelvis Head neutral with ears over shoulders Feet rested and loaded Good seated balance that promotes independence and upper extremity function Many factors need to be considered ROM Presence of Abnormal Tone Effects of Gravity Ability to Function Gravity Postural (Mat) Evaluation Gravity can be used to provide additional support and to increase balance Always first observe patient in existing wheelchair to identify and issues Assess individual in supine before sitting, when gravity is not a factor 2
3 Seating Evaluation:Start at the Pelvis! Seating Evaluation: What s next Lower extremities: distribution and loading Trunk: symmetry and support Upper extremities: support for alignment, leverage for transfers, stability Pelvic tilt, obliquity, rotation Head: support for control, for use with power positioning Supine Evaluation Sitting Evaluation Measure ROM on a firm surface Hip flexion = pelvic tilt Hip ABD/ADD= pelvic rotation Hip rotation= pelvic obliquity Consider hamstring limitations Measure knee,ankle and foot ROM Evaluate trunk, head and shoulders for symmetry and abnormality Position individual on a firm surface with consideration of ROM limitations observed in supine Observe the effects of gravity on alignment Note amount of support required for alignment and balance Functional abilities in optimal position Applying Information Obtained from the Seating Assessment Clinical Applications Function must be considered!!!! Results of a seating assessment will determine the appropriate configuration of a wheelchair and which seating products will best meet the consumer s needs Effect of seated position on functional performance Effects of neutralizing tone- did the consumer use their abnormal tone to aid in function? 3
4 Manual vs. Power Mobility Wheelchairs and Seating Equipment Information Pros and cons must be considered, dependent on client need Power mobility= independence with limited motor function Manual wheelchairs= greater ease of transportability and access Anticipate future needs Age and endurance may influence the wheelchair decision Manual Wheelchairs Power Operated Vehicles Not generally appropriate for clients with SCI Insufficient trunk support Reaching for tiller negatively affects balance and alignment Not very maneuverable Power Wheelchairs Power Wheelchairs Necessary when a manual w/c and scooter do not meet client s needs Drive wheel position- forward, mid or rear wheel drive Power positioning functions- tilt, recline, etc. Mechanisms for driving, changing modes and operating power positioning and other controls 4
5 Seating Systems Seat Cushion Considerations Can be utilized for basic support/comfort, fixed or adjustable positioning assistance and/or seated pressure management Adequate positional support Effect on balance Maintenance Effect on transfers Pressure relieving capabilities Incontinence Consumer s previous experiences Back Supports Custom Molded Seating Systems Sling upholstery Adjustable tension upholstery Solid support Need for lateral or anterior stability Necessary when a client s postural deformities cannot be accommodated by a commercially available product Use of a corset for circumferential support Pressure Mapping Studies A pressure map is a computerized clinical tool for assessing pressure distribution. To use it, you place a thin, sensor mat on a wheelchair seat or a mattress surface. When your patient sits or lies on the mat, a computer screen displays a map of pressures, using colors, numbers, and a graphic image of the patient. Considerations for Clients with SCI Upon Discharge from an Medical Setting Definition obtained from: woundcareadvisor.com/pressuremapping 5
6 Impact of Standard Wheelchair Procurement for a Client with SCI Standard w/c rentals have been procured as a means to safely discharge clients from a medical setting Insurance companies don t discern between this and the need for a customized wheelchair, resulting in subsequent denials for more appropriate equipment Solutions: Impact of Standard Wheelchair Procurement for a Client with SCI Refer client for a Seating Evaluation Refer client to a therapist, who can work with a knowledgeable DME vendor Obtain a loaner wheelchair and/or seat cushion from a DME vendor Seat Cushions and Pressure Sores Providing Seating Intervention with Limited Resources Refrain from prescribing a pressure-relieving seat cushion for individuals with wounds without a formal evaluation The seat cushion is likely one, but not the only component of the seating issue Configuration of wheelchair Effects of postural deformities Client s compliance with pressure relief Use of seat wedge or change caster position to create seat slope Open back angle to obtain assist from gravity Use of a solid seat insert Increase back support- lumbar pad, solid back Use of recliner and manual tilt wheelchairs Obtain trial equipment from manufacturers or vendors A Quick Word about Insurance Authorization Multi-step process Time consuming In-home requirement 5-year rule For these reasons, it is imperative to get it right the first time!! Questions? Thank you so much for spending this hour with me!! Allison Greenwood, OTR/L, ATP agreenwood@umm.edu 6
7 References Website Resources and Picture Credits Angelo, J. & Lane, S. (eds.). (1997). Assistive Technology for Rehabilitation Therapists. Philadelphia, PA: F.A. Davis Company. Cook, A.M. & Hussey, S.M. (2000). Assistive Technologies: Principles and Practice (1 st ed.). St. Louis, MO: Mosby. Cook, A.M. & Hussey, S.M. (2002). Assistive Technologies: Principles and Practice (2 nd ed.). St. Louis, MO: Mosby. RESNA, ed. (2011) RESNA Wheelchair Service Provision Guide. Arlington, Va: RESNA. RESNA, ed. (1999). Fundamentals in Assistive Technology, 2 nd edition. Arlington, Va: RESNA. Maddox, S. (2003). Paralysis Resource Guide. Springfield, NJ: Christopher Reeve Paralysis Foundation
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