Disclosure. Resources 12/3/2015. Property of JA Zollars & Rose Vallejo. Not to be copied without permission 1

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1 Sliding, Slouching and Squirming: The Nuts and Bolts of Seating (Part 2) Jean Anne Zollars, PT, DPT, MA Rose Vallejo, PT, ATP Disclosure Vallejo: No relevant financial relationship exists Zollars: Author of Special Seating: An Illustrated Guide. The presenters declare no conflict of interest or bias in the content of this presentation. Resources Not to be copied without permission 1

2 Focus of presentation: Seating for children with postural control issues, abnormal tone Not, children requiring pressure relieving cushions (spina bifida, spinal cord injury), or weakness (dystrophies, spinal muscular atrophy) Objectives: Upon completion of Part II, you will be able to: 1. Recognize common postural and movement patterns of children with neurological impairments that impact seating, mobility, and function. 2. Identify the concepts related to postural support features (not specific manufacturers brands) for a variety of postural issues. 3. Use hand simulation, then material simulation to decide the seating and mobility requirements of the user. 4. Provide clinical rationale for the seating and mobility features recommended. Outline 1. Introduction and review elements of the mat evaluation 2. Usage of hand simulation, then material simulation to decide the seating and mobility requirements of the user 3. Overview of postural supports (cushion types, hip positioning, back, trunk, head supports, etc.) for a variety of postural problems 4. Tips for Communicating with ATP (assistive technology provider) 5. Case examples- slides and discussion 6. Summary, Questions & Answers Not to be copied without permission 2

3 Seating/Mobility Assessment Basics Why does the person need an assessment? Main goals of the caregiver for the seating/mobility device. Present Seating/Mobility System What works? What does not work? Posture in Present Seating System (pelvis, thorax, legs, arms, head) Function in Present Seating System (important functional activity.how does this change posture?) Supine/Sidelying Mat Assessment From the posture in the present seating system, what is fixed, flexible, and what is the practical flexibility? Key ROM assessments: Pelvis to neutral at the spine and hips (so not in posterior or anterior pelvic tilt, rotation, tilt) Hips to neutral (flex to 90, come to 0-5 of abduction, neutral rotation) Knees to 90 of extension with hips flexed at 90 Ankles to 0 of dorsiflexion in neutral pronation/supination Spine to neutral flexion/extension and neutral lateral flexion Not to be copied without permission 3

4 Sitting Assessment & Hand Simulation Using your hands & body to provide postural support Person sits on flat, firm surface with feet supported Accommodate for joint limitations (ie. wedge for lack of hip flexion, pelvic obliquity) Hand simulation order Provide support at the pelvis first. Hand simulation order After the pelvis has been supported, provide support in this order: - hips and thighs - trunk/arms; - head and neck; - lower legs. Always make only one change at a time. Observe how changes in one part of the body affect other parts. Not to be copied without permission 4

5 What are your hands doing? Where are your hands? What is the direction of force/support? How much force/support? How much surface area? Effect of Gravity in Sitting: After the person s neutral posture is achieved, note the effects of tilting the system: Material simulaton Use materials: foams, duct tape, towels, straps to simulate or mock-up what your hands are trying to accomplish What works what does not work? Take a photo Not to be copied without permission 5

6 Seating System Back Support Seat Cushion Specific Postural Supports Seating system: Back Support: Purposes Support pelvis, sacrum, lumbar spine in person s neutral posture Allow for shape and space of buttocks Distribute forces to prevent excessive pressure against boney prominences Provide postural options Not to be copied without permission 6

7 Back support: Style Back support: Height If back height to spine of scapula, can contour back support or cut-outs so person can use arms. Custom planar back supports can be ordered from Freedom Designs and Stealth Products Not to be copied without permission 7

8 Seat Cushion: Purposes Provide stable base of support Provide pressure relief or space for boney prominences (ITs: 1 diameter) Accommodate for lack of hip flexion For some: allow weight shifting and movement For others: limit excessive movement Not to be copied without permission 8

9 Seat Cushion: Style firm, not squishy or sling Seat depth: Back of buttocks to ½ behind knees Leg length difference: If one leg is 1 longer than the other, the seat depth under longer leg needs to be longer. If not, what happens? Not to be copied without permission 9

10 Specific Postural Supports Begin at the pelvis.if pelvis is not stable, the rest of the body will follow the pelvis. The body is a whole, one part affects another however, we need to address one part at a time. We will look at postural tendencies, ie. posterior pelvic tilt and seating supports. Specific Postural Supports Posterior pelvic tilt, thoracic kyphosis, and excessive hamstring tension Lateral pelvic tilt (obliquity) and scoliosis Pelvic rotation and scoliosis with rotation *Note: Usually it is a combination of the above we are breaking it into these categories for teaching purposes Pelvis: Posterior Tilt (rolled backward or sliding forward) Not to be copied without permission 10

11 PPT: Seating supports Back support Seat cushion Seat-to-back support angle Anterior pelvic supports Tilt Back supports Lower back support vs upper back support Lower back support: from seat cushion to top of pelvis think about supporting the pelvis and sacrum from behind (not lumbar spine) Upper back support: thoracic spine needs space to extend, to accommodate natural kyphosis Before trying a postural support: always go back to: What is the person s neutral posture? What are your hands doing to support the person s posture? If the person s joints are flexible, support them in their practical flexibility. If the joints are fixed, will accommodate the joints. Not to be copied without permission 11

12 Back supports: for flexible pelvis at lumbar spine, and hip flexion to 90º Bi-angular back If pelvis fixed: accommodate the lumbar spine Tilting the seating system can be accomplished through wheel and caster selection. Opening the back support angle can be accomplished by ordering angle adjustable back posts or a solid back with adjustable hardware. PPT: Seating supports Back support Seat cushion Seat-to-back support angle Anterior pelvic supports Tilt Not to be copied without permission 12

13 Seat Cushion: Purposes Provide stable base of support Provide pressure relief or space for boney prominences (ITs: 1 diameter) For some: allow weight shifting and movement For others: limit excessive movement Contoured cushion: IT space, very little postural control Varied densities of foam: more postural control than contoured Various manufacturers allow you to specify multiple foam types and the dimensions of each foam type. Some manufacturers to consider are Freedom Designs, Quickie AES and Stealth Products. Not to be copied without permission 13

14 Anti-thrust seat Modifications to ATS Various companies allow you to specify multiple foam types and dimensions of the each foam type. Some of the companies to consider are Freedom Designs, Quickie AES and Stealth Products. Not to be copied without permission 14

15 PPT: Seating supports Back support Seat cushion Seat-to-back support angle Anterior pelvic supports Tilt Seat-to-back support angle: If pelvis flexible, angle within range º If back support is flat: open S-B angle at least to 95º Not to be copied without permission 15

16 S-B angle corresponds to hip flexion angle, if pelvis is fixed at lumbar spine, or hip flexion less than 90º The back to seat angle can be accommodated by ordering adjustable back posts or ordering a solid back support with adjustable hardware. PPT: Seating supports Back support Seat cushion Seat-to-back support angle Anterior pelvic supports Tilt Anterior pelvic supports: postioning belts Go back to hand simulation: where and what angle are your hands providing pelvic control? Positioning belts need to be close to pelvis, if attached to wheelchair frame, should go inside lateral hip supports Not to be copied without permission 16

17 Anterior Pelvic Supports (positioning belts) PPT: Seating supports Back support Seat cushion Seat-to-back support angle Anterior pelvic supports Tilt Tilt: keep S-B angle, permanent or adjustable TIS? Not to be copied without permission 17

18 Trunk curved forward (kyphotic), and is flexible to neutral Relationship of upper to lower back support Anterior trunk supports Tilt-in-space Upper back support allows for posterior thoracic extension & kyphosis Firm contoured back support. If sling back is used, support behind by straps or firm support Not to be copied without permission 18

19 If the thoracic kyphosis is fixed. The seat-to-back support angle may need to be opened, and entire seating system tilted back. Anterior trunk supports: goals Provide stability, not limit functional movement Be safe: no choking Be padded, so not to irritate boney prominences Conform to shape of body *Your hands will guide you as to where, what direction of pull, how much support straps provide Not to be copied without permission 19

20 Anterior trunk supports: H-straps Strap attachment at or below shoulders H-strap with looped webbing provides options, can be elastic Chest straps Not good choice if person hangs over Strap Elastic, dynamic strap allow more respiratory expansion & movement If person leans into 1 lateral trunk support, can attach strap on inside of trunk support & pull to opposite side Not to be copied without permission 20

21 Anterior trunk supports: vests PPT, thoracic kyphosis: additional considerations: hamstrings Remember, checking knee extension. Not to be copied without permission 21

22 Lateral pelvic tilt: flexible How much support are your hands providing - a fingertip, a lot of pressure? How close are your hands to the pelvis? Lateral pelvic supports Not to be copied without permission 22

23 Lateral pelvic tilt: fixed -Position the head first, then accommodate pelvis/ spine by bringing the seat up to meet the pelvis Some manufactures that can create custom cushions according to your specifications are Freedom Designs, Stealth Products and Quickie AES. May also consider a custom mold seat. Some manufacturers that offer custom mold seating are Freedom Designs and Invacare PinDot. If you do not position the head first Pelvic rotation: flexible Angled positioning belt Rigid Sub-ASIS bar Not to be copied without permission 23

24 Pelvic rotation associated with windswept posture of LE s Wood, metal, hard plastic Soft foam Molded seat Some manufacturers that offer custom m seating are Freedom Designs and Invac PinDot. Not to be copied without permission 24

25 Pelvic rotation: fixed First position the head and eyes, then accommodate the fixed pelvic and spinal rotation. Usually molded systems are the best choice. Scoliosis: flexible What posture of head over pelvis does body feel balanced? How much support does the person need? What is the least amount of support? Do supports need to allow movement or provide more stability? Lateral trunk supports (LTS) Support a where spine curves out, b & c above & below a LTS should be thin, contoured to the body & padded Not to be copied without permission 25

26 Scoliosis with rotation: flexible In addition to anterior trunk straps Puller strap with force-localizing pad over forward rotating shoulder LTS curving around the front Rotatory scoliosis: fixed Position head first,accommodate spine/pelvis Some manufacturers that offer custom mold seating are Freedom Designs and Invacare PinDot. Not to be copied without permission 26

27 Hips: Adducted/internally rotated Can hips get to 0º abd/er easily? How much support is necessary to keep hips from adducting/int rotating? Remember medial thigh supports (adductors) should not press against the genitals Medial thigh supports (flexible hips) Medial thigh support (fixed hips) Not to be copied without permission 27

28 Hip abd/er & flexible May need lateral hip supports that extend to the end of the knee Hips: abducted & externally rotated & fixed.is abd or ER fixed? Accommodate lack of internal rotation by wedging footplates Head/neck Supports If head falls back/extends: Not to be copied without permission 28

29 If head falls to one side (laterally flexes), turns and pushes to one side (rotates), pushes back and turns (extends with rotation) If head falls to one side (laterally flexes), turns and pushes to one side (rotates), pushes back and turns (extends with rotation) Neck Rings Lateral Jaw & Head Support Not to be copied without permission 29

30 Head falls forward/moves excessively in all planes: First, make sure pelvis/trunk are in person s neutral. Next try different tilt in space angles, then perhaps: Not to be copied without permission 30

31 Summary: Seating/Mobility Assessment Basic User/Client: Wheelchair/Pressure Issues, no postural problems Client/User s Needs for Seating/Mobility Pressure Assessment Intermediate User/Client: Requires postural support also Gathering Background Information: health, environments, transportation, funding, present seating/mobility system Posture & Function in present seating/mobility system Mat Assessment: Joint limitations affecting seating posture Sitting Assessment & Hand Simulation Material Simulation/Mock-up Measurements Summary: Equipment Simulation/Selection Once the assessment has been completed, including the hand simulation and measurement, collaborate with the vendor to determine most appropriate equipment selection Wheelchair Base Seating System Seat base, cushion, hip positioning supports, hip belts Upper and lower back support, lateral trunk support, anterior trunk support Lower extremity support at thighs and feet Upper extremity support Head support Transport System Resources Mobility/ General Mobility Device Clinical Documentation Guide Medicare Policies for Mobility Assistive Equipment Not to be copied without permission 31

32 Resources Pediatric Seating and Mobility CEU on-line video course from Clinician's View (JA Zollars & Rose Vallejo) On the Clinicians-View.com home page, click CEU Courses, then under Dressing and Positioning, you will see Pediatric Seating and Mobility Resources com/resources Clinical Documentation Find Qualified Professionals Useful Policy Related References DME MAC Contractors Advocacy Groups Consumer Resources Resources /programs/atp/resources/wheelchairguide/pages/wh eelchairguideform.aspx Glossary of WC terms and definitions Clinical Application Guide to standardized WC seating measures of the body and seating support surfaces Not to be copied without permission 32

33 References McNamara L., Casey J. (2007). Seat inclinations affect the function of children with cerebral palsy: a review of the effect of different seat inclines. Disability Rehabilitation Assistive Technology. 2(6), Rigby P. J., Ryan S. E., Campbell K. A. (2009). Effect of adaptive seating devices on the activity performance of children with cerebral palsy. Archives of Physical Medicine in Rehabilitation. 90(8): Ryan S.E., Sawatzky B., Campbell K.A., Rigby P.J., Montpetit K., Roxborough L., McKeever P.D. (2014). Functional outcomes associated with adaptive seating interventions in children and youth with wheeled mobility needs. Archives of Physical Medicine & Rehabilitation. May;95(5): doi: /j.apmr Epub 2013 Sep 11. Stavness, C. (2006). The effect of positioning for children with cerebral palsy on upper-extremity function: a review of the evidence..physical and Occupational Therapy in Pediatrics, 26(3), Wright C., Casey J., Porter-Armstrong A. (2010). Establishing best practice in seating assessment for children with physical disabilities using qualitative methodologies. Disability Rehabilitation Assistive Technology. 5(1), Resources Organization. "Wheelchair service training package: basic level/edited by Chapal Khasnabis and Kylie Mines." (2012). Khasnabis, Chapal, Kylie Mines, and World Health Organization. "Wheelchair service training package: intermediate level/edited by Chapal Khasnabis and Kylie Mines." (2013). en/ Greer,Nancy, Michelle Brasure, Timothy J. Wilt; Wheeled Mobility (Wheelchair) Service Delivery: Scope of the Evidence. Annals of Internal Medicine Jan; 156(2): Zollars J.A. Special Seating: An Illustrated Guide Revised Edition. Albuquerque, NM: Prickly Pear Publications; Batavia, Mitchell. The Wheelchair Evaluation: A Clinician's Guide. Jones & Bartlett Learning, Assistive Technology/Seating & Wheeled Mobility (AT-SWM) 1. SIGN UP TODAY: A. Listserv B. Announcements C. Opportunities Not to be copied without permission 33

34 Patient s Name Alabama Medicaid Agency WHEELCHAIR / SEATING EVALUATION This form is a required attachment to the Alabama Medicaid Prior Review and Authorization Form (Form 342). It must be completed by an Alabama licensed Physical Therapist (PT)/Occupational Therapist (OT). Alabama Medicaid will only reimburse for the physical therapy evaluation for wheelchairs (manual with accessories and all power wheelchairs) for adults if the PT/OT is employed by a hospital enrolled with Alabama Medicaid and the evaluation must be performed in the hospital outpatient setting. Disclaimer: Alabama Medicaid Agency or its designee may request additional information to support the appropriateness of this request, including, but not limited to, a trial of the requested wheelchair to determine the recipient s ability to independently operate the wheelchair. If a wheelchair is unavailable for a trial, documentation must be submitted to justify the request. Start Time End Time Today s Date Referral Information Are you receiving services of any kind (therapy, nursing, school etc.)? Physician Phone Fax Case Manager / VR/IL counselor Phone Reason for Referral Patient Information Age Person accompanying patient Employment/School Other Daily Activities Handedness Right Left N/A Comments Diagnosis/Medical/Surgical History Height Weight Recent wt gain loss Vision Cognition Current Wheelchair / Seating System None Dependent Manual Tilt in Space Manual Scooter Power Manufacturer Model Serial # Age of chair Provider Funding Frame width Frame depth Overall width Overall length Cushion style age Solid back Yes No Type age Back height Front seat to floor height Rear seat to floor height Power: Drive Control Type Other seating components? Problems with chair? Goals for new WC/Equipment Modifiable Requires Replacement Comments # of hours spent in current WC Goal for time to be up in WC: Other DME owned? Home Environment Lives with # Levels to home House Apartment Condo/Townhome Mobile Home Asst Living LTCF Group Home Rural Urban Ramps Yes No Sidewalks Yes No Paved driveway Yes No Terrain flat rough hills grass gravel carpet other: Entrance stairs Yes No Number Rails? Accessibility issues Accommodation Plans Caretaker Primary Caregiver Patient spends time at home alone Yes No Hours alone Patient has homecare assistance or personal care attendant? Yes No Caretaker limitations Therapist name/date Form 384 Rev. 01/03/14 Form used with permission of UAB Page 1 of 7 Alabama Medicaid Agency

35 WHEELCHAIR / SEATING EVALUATION Patient s Name Transportation Does patient drive? Yes No Need Driver s Eval? Car Van Public Transportation/Bus Ambulance Truck SUV Other Sits in WC during transport Yes No Where does WC go in the vehicle? Security Type Tie downs EZ Lock Does current WC fit in Van lift opening? Future Transportation Plans Need info on Lifts/Ramps? Communication Verbal WFL Difficult to understand Non-communicative Uses an augmentative communication device Manufacturer/Model AAC mount needed Comments Pain (location/ pain scale) UEs? Back? Other Comments Skin Condition/Integrity Independent for pressure relief Needs Assistance for pressure relief Unable to self position Method of pressure relief Frequency Sensation Intact Impaired Absent Level of sensation Skin breakdown present Yes No Description/Comments PMH of pressure ulcer Yes No Description/Comments Other risk factors Check all that apply bony prominences impaired nutritional status impaired circulation fecal incontinence urinary incontinence smoking Yes No Bowel Function Continent Incontinent Accidents - How Managed Bladder Function Continent Incontinent Accidents - How Managed Comments ADL Status (in reference to wheelchair use) Per Report of Patient or caregiver Dressing Eating Grooming/Hygiene Meal Prep Bathing Toileting Bed Mobility IADLs (laundry, shopping, etc ) Indep Assist Unable Indep W/ Equip Comments Current Mobility Status: Gait Distance Device Bracing Assist Gait Speed (m/s) Deviations Timed Up and Go Test Unable to ambulate Comments History of falls? Manual Wheelchair Mobility Method of propulsion Is the patient able to propel any type of manual WC even when well configured? If no, explain Power Wheelchair Mobility: Does the patient demonstrate the ability to independently (age appropriate independence) drive the PWC/POV safely? Yes No Explain. Therapist name/date Page 2 of 7 Form 384 Rev. 01/03/14 Form used with permission of UAB Alabama Medicaid Agency

36 WHEELCHAIR / SEATING EVALUATION Patient s Name Supine Evaluation Pelvic tilt: Pelvic obliquity: Pelvic rotation: Thoracic Kyphosis: Lordosis: Scoliosis: Fixed Flexible Comments ant. post. left right left right inc. dec. left right Sitting Evaluation Pelvic tilt: Pelvic obliquity: Pelvic rotation: Kyphosis: Lordosis: Scoliosis: Head: tilt Head: rotation Head: Cervical hyperextension LE abduction: left right LE adduction: left right UE position: Windswept left right Fixed Flexible Comments ant. post. left right left right inc. dec. left right left right left right ext flex forward Comments Key Muscles Shoulder flexion Shoulder abduction Range of Motion Shoulder ER Elbow flexion Elbow extension Wrist flexion Wrist extension Hand Grip (Dynamometer if possible) Hip flexion Knee flexion Knee extension Dorsiflexion Plantarflexion Knee ext./in Sitting Postural Tendency Anterior Posterior Insitting Left Lateral Right Lateral Foot Position (Note Fixed or Flexible ) Strength Muscle Tone** Left Right Left Right Left Right Head Control Good Adequate Limited Absent Edema Comments Therapist name/date Page 3 of 7 Form 384 Rev. 01/03/14 Form used with permission of UAB Alabama Medicaid Agency

37 WHEELCHAIR / SEATING EVALUATION Patient s Name Balance Transfers Sitting balance Standing balance Method: WFL - static and dynamic WFL Device Uses UE for balance in sitting Minimal assistance Independent Minimal assistance Moderate assistance Supervision Moderate assistance Maximum assistance assist Maximum assistance Unable Unable Device Needed Motor Skills Functional Reach Measurements in inches (taken in optimal position for fit of seating equipment) Seat to top of head Hip Width Footwear Shoulder Height R L Seat to Inf Angle R L Thigh Length: R L Seat to Elbow R L Lower Leg length: R L Elbow to Wrist R L Chest Width: Shoulder Width Trunk Depth: Widest Point Outside of Knees: Other Assessment/Trial of equipment: NOTE: A trial of equipment is highly recommended especially if this is new equipment or a change in equipment (i.e., MWC to PWC), recommendation of PWC for a child or someone with cognitive impairments of any level. It is also highly recommended that a home assessment and/or trial be completed by vendor &/or therapist to ensure the recommended equipment will meet the goals and the home is accessible. (Chairs/Cushions/Backs) Pressure mapping performed Yes No Results Outpatient follow up required: Yes No Education provided on various options? Yes No Photos taken? Yes No (Note: if yes, include consent form) Patient and/or caregiver in agreement with recommendations? Yes No Goals of Mobility (Check all that apply) The patient and/or caregiver actively participate in appointment for fitting and training with recommended equipment. The patient and/or caregiver will demonstrate adequate knowledge of safe and functional operation, use and care of the recommended equipment. Meet caregiver goals (specify ) Meet transportation/vocational/school needs (specify ) Provide independent in mobility in the home and motor related ADLs (MRADLs) in the community, such as Allow patient to be independent with ADLs such as Provide dependent mobility. Patient to be independent with pressure reliefs in the wheelchair. Provide wheelchair base that includes tilt. List goals for tilt Provide wheelchair base that includes recline. List goals for recline Goals for seating system for client Optimize pressure distribution to assist in the prevention of decubitus ulcers Provide corrective forces to assist with maintaining or improving posture (specify ) Accommodate and support client s posture: current seated postures and positions are not flexible or will not tolerate corrective forces. (specify ) Enhance physiological function such as breathing, swallowing, digestion. Reduce pain in the sitting position. Other Goals Therapist name/date Page 4 of 7 Form 384 Rev. 01/03/14 Form used with permission of UAB Alabama Medicaid Agency

38 WHEELCHAIR / SEATING EVALUATION Patient s Name Recommendations Equipment Justification Wheelchair Base Electronics/Controls Power Functions Color Seat width Seat Depth Seat to floor height Front Rear Back height Back type Trunk supports Armrest Type Arm support Drive Wheels/Tires Casters Hand rim Hangar Type Foot restraint Foot plate type Therapist name/date Page 5 of 7 Form 384 Rev. 01/03/14 Form used with permission of UAB Alabama Medicaid Agency

39 WHEELCHAIR / SEATING EVALUATION Patient s Name Seat type Cushion Hip guides Adductors Abductors Pelvic Belt Lap Tray Headrest Batteries Antitippers Push handles Wheel Locks Side guards Chest support Other Referrals Education/Information Provided I have no financial relationship with the supplier of equipment. Therapist name/date Page 6 of 7 Form 384 Rev. 01/03/14 Form used with permission of UAB Alabama Medicaid Agency

40 WHEELCHAIR / SEATING EVALUATION Patient s Name Comments: Please fill in all appropriate blanks to provide a thorough evaluation. If a section on the form is not applicable (NA) for the recipient/patient, NA will be acceptable in that section. ATP signature below denotes involvement in appropriate areas of this evaluation. Therapist name/date Telephone ATP name/date ATP telephone Vendor Name/NPI Form 384 Rev. 01/03/14 Form used with permission of UAB Page 7 of 7 Alabama Medicaid Agency