Custom Contoured Seating: Ensuring Successful Outcomes

Transcription

1 Custom Contoured Seating: Ensuring Successful Outcomes Kelly Waugh, PT, MAPT, ATP 2014 The Regents of the University of Colorado, a body corporate. All rights reserved. Created by Assistive Technology Partners.

2 Disclosure statement: I, Kelly Waugh, do not have an affiliation (financial or otherwise) with an equipment, medical device or communications organization. Assistive Technology Partners is a unique program within the Department of Bioengineering, College of Engineering & Applied Sciences at the University of Colorado Denver campus.

3 Tech Act Data Collection Where do you live? Metro vs Non-Metro

4 Tech Act Data Collection Who do you represent? (choose only one)

5 Custom Contoured Seating: Ensuring Successful Outcomes I. INTRODUCTION II. BASIC CLINICAL CONCEPTS III. CLINICAL ASSESSMENT IV. TECHNOLOGY ASSESSMENT V. IMPLEMENTATION

6 Custom Contoured Seating Custom contoured seating (CCS) = surfaces are shaped to match the unique contours of the person s body This is a generic term to describe a type of seating; not product specific

7 What contributes to a successful outcome for custom contoured seating? 8 critical factors: 1. CCS is indicated and appropriate for the person 2. A thorough clinical assessment prior to the shape capture has resulted in: Prioritized goals Postural Alignment Plan (PAL) Justification for CCS Shape capture plan 3. The features of the recommended CCS product match the unique characteristics and needs of client

8 What contributes to a successful outcome for custom contoured seating? 4. Appropriate specification of wheelchair frame parameters that support seating objectives and PAL 5. Successful shape capture Desired postural alignment achieved and maintained Even, intimate contact achieved with the materials 6. Accurate shape translation 7. Accurate fabrication For Indirect Methods 8. Accurate integration of final seating components into wheelchair base

9 Joint Motion Terminology & Body Planes Body movement defined by: 1. The plane through which the body limb moves Sagittal Frontal Transverse The Three Body Planes 2. For example, flexion/extension occurs in sagittal plane The Standing Anatomical Position is the zero reference for joint range of motion values

10 Postural deviations in the sitting position can also be described as occurring in these same three planes Three perspectives: SIDE view SAGITTAL plane deviations FRONT view FRONTAL plane deviations TOP view TRANSVERSE plane deviations

11 Describing wheelchair seated posture Using terms for joint motion Most clinicians use terms for joint motion to describe postural deviations in the sitting position. Mrs. Jones sits in her wheelchair with a posterior pelvic tilt, left pelvic obliquity, right pelvic rotation, trunk laterally flexed right. Her hips are extended, abducted and externally rotated. Why is this not adequate for our field? Terms are frequently used inaccurately Doesn t provide a measure of orientation in space Does not help with prescription of seating support surface angles

12 Body segment terminology The use of body segment terminology, instead of joint terminology, is useful for our field. The body can be divided into segments, and each segment given a name Dividing the body into segments Can describe seated posture by measuring orientation of segments Can relate orientation of body segments to the orientation of their supporting surface Helps define and label seating supports

13 Terms and Definitions Seating Support Surface Angles Seat to Back Support Angle 95 These support surface angles describe the angular orientation of the three primary seating support surfaces relative to each other in the sagittal plane 120 Lower Leg Support/Foot Support Angle 105 Seat to Lower Leg Support Angle.these are NOT the same as the wheelchair frame angles

14 Seating support surface angles Seat to Back Support Angle These angles DO NOT describe the posture of the seated person! Seat to Lower Leg Support Angle Lower Leg Support/Foot Support Angle

15 Terms and Definitions Relative Body Segment Angles Thigh to Trunk Angle These Body Segment Angles describe the relative angle between two adjacent body segments in the sagittal plane. Lower Leg to Foot Angle Thigh to Lower Leg Angle Body segment angles describe a static position, not a range of motion; however a person s joint flexibility will affect their body segment angles in the sitting position

16 Relationship between Relative Body Segment Angles and Seating Support Surface Angles If seated person s body segments are parallel to the corresponding support surfaces, then these angles are the same BSA = SSA

17 Frontal absolute body segment angles Frontal body segment angles measure the orientation of a single body segment in the frontal plane with respect to either the horizontal or vertical The angle of the sternum with respect to the vertical, viewed from the front The angle of the pelvis with respect to the horizontal, viewed from the front The angle of the whole trunk with respect to the vertical, viewed from the front

18 Sagittal absolute body segment angles Sagittal body segment angles measure the orientation of a single body segment in the sagittal plane with respect to either the horizontal or vertical The angle of the trunk with respect to the vertical, viewed from the side The angle of the pelvis with respect to the horizontal, viewed from the side The angle of the thigh with respect to the horizontal, viewed from the side

19 Transverse absolute body segment angles Transverse body segment angles measure the orientation of a single body segment in the transverse plane with respect to either the wheelchair X or Z axis The angle of the trunk with respect to the wheelchair, viewed from the top The angle of the pelvis with respect to the wheelchair, viewed from the top TRANSVERSE THIGH ANGLE The angle of the thigh with respect to the wheelchair, viewed from the top

20 Custom Contoured Seating: Ensuring Successful Outcomes I. INTRODUCTION II. BASIC CLINICAL CONCEPTS III. CLINICAL ASSESSMENT IV. TECHNOLOGY ASSESSMENT V. IMPLEMENTATION

21 II. BASIC CLINICAL CONCEPTS A. Indications and Objectives for Custom Contoured Seating B. Advantages of Custom Contoured Seating C. Disadvantages/Contraindications of Custom Contoured Seating

22 Indications for Custom Contoured Seating 1. Significant skeletal or joint deformity 2. Excessive abnormal, uncontrolled movement due to motor incoordination or spasticity 3. Excessive postural collapse in the spine and pelvis due to paralysis, extreme weakness and/or low muscle tone which results in Significant postural asymmetry Inadequate postural stability to support optimal health/function Skin breakdown Pain

23 Objectives for Custom Contoured Seating Strategy = apply intimate surface contact to areas of the body which are contoured in order to achieve the following objectives 1. Accommodate moderate to severe deformity 2. Inhibit/block abnormal movement patterns 3. Prevent postural collapse In order to maintain optimal alignment, provide postural stability, optimize health, improve comfort and prevent skin breakdown 4. Decrease pain and/or prevent skin breakdown by optimizing pressure distribution and/or pressure re-distribution (off loading)

24 CASE 1 - Indication: Spinal deformity and joint contractures resulting in significant postural asymmetry and risk of skin breakdown Fig 1 Fig 2 Objectives: Accommodate deformity/contractures to achieve optimal alignment of the core and to distribute pressure for prevention of skin breakdown

25 CASE 2 - Indication: Abnormal movement and spasticity resulting in poor alignment and inadequate proximal stability to support functional head and upper extremity movement. Risk of increasing spinal deformity.

26 CASE 2 - Objective: Stabilize proximally in optimal pelvic/spinal alignment for improved distal mobility and function, using custom contoured seat and back support Ready to be evaluated for power wheelchair using alternative drive controls!

27 CASE 3 - Indication: Severe motor ataxia (uncontrolled movement) resulting in poor proximal stability, distal fixing and decreased functional mobility Fig 1: Client has severe Ataxia.he fixes for stability, with very poor motor control distally Fig 2: Assessing joystick control using simulator, with linear seating.. Fig 3: Assessing joystick control with custom contoured surfaces. Increased proximal stability resulted in improved joystick control

28 CASE 3 - Objective: Stabilize proximally for improved distal mobility and function, using custom contoured backrest, contoured seat and arm troughs Before distal fixing to compensate for poor proximal stability New power wheelchair.note method of grasping joystick on right, and selfstabilizing left arm

29 CASE 5 - Indication: Total postural collapse due to muscle paralysis + scoliosis + weight. (muscular dystrophy) resulting in significant postural asymmetry and pain Fig 1: Front view - Severe left pelvic obliquity and left convex C-curve scoliosis, partially flexible Fig 2: Side view - Severe posterior pelvic tilt and kyphosis, partially flexible

30 CASE 5 - Objectives: (1) Improve stability and alignment using custom contoured back support; (2) Decrease severe buttock pain using Roho Quatro seat cushion Fig 2: Fitting stage Fig 1: Before NOTE: Using an air seat cushion with custom contoured back support was very risky..why? Fig 3: Final. (Versaform pillow used to stabilize arms for optimal control of mini MEC joystick using thumb)

31 II. BASIC CLINICAL CONCEPTS A. Indications and Objectives for Custom Contoured Seating B. Advantages of Custom Contoured Seating C. Disadvantages/Contraindications of Custom Contoured Seating

32 B. Advantages of Custom Contoured Seating (vs. planar or generic contour) 1. When indicated, it can address clinical objectives better than planar or generic contoured seating Greater surface area contact creates increased stability, alignment, and skin protection leading to improved health, comfort and function 2. Can be aesthetically more pleasing Less hardware and pads, cleaner smoother look 3. Easier maintenance Less hardware to repair/adjust

33 II. BASIC CLINICAL CONCEPTS A. Indications and Objectives for Custom Contoured Seating B. Advantages of Custom Contoured Seating C. Disadvantages/Contraindications of Custom Contoured Seating

34 C. Disadvantages of Custom Contoured Seating 1. Limited adjustment for growth, change or error (depending on product) 2. Limits dynamic movement (depending on aggressiveness of shape) and may therefore interfere with movements needed for function 3. Support surfaces do not swing away or remove for transfers, unless custom adaptations are made 4. Generally incompatible with adjustable recline Product innovation is beginning to address some of these traditional disadvantages of custom contour 5. More costly and labor intensive

35 C. Disadvantages of Custom Contoured Seating (continued) 6. Requires considerable skill to do shape capture process well 7. Risks (and costs) of error can be high (if non-adjustable)

36 Assessing risk of poor outcome Degree of risk depends upon (1) the type of contouring technology being used (2) the characteristics of the client (3) technology available for the shape capture process (4) the skill of the seating practitioners involved (5) Caregiver skill & consistency in positioning Ask yourself: How will we achieve / maintain the desired posture while capturing the shape, with this client, using available product choices? What extra resources are needed in order to achieve/maintain desired alignment while capturing the shape? Do we have access to needed supports/technology? How experienced are team members with the product being considered Is client likely to be positioned consistently in the system? What are the risks if client changes or is inconsistently positioned, with this product?

37 RED FLAGS Proceed with caution when considering custom contoured seating in these situations: Client uses independent movement of their trunk (leaning to side, for example) to function Client likes to move in their wheelchair, shifting their weight or readjusting their body on their own Client independently transfers in/out of wheelchair Client s body is likely to change significantly due to growth or other changes (growing child, upcoming surgery, weight)

38 CHECK YOUR LEARNING: What contributes to a successful outcome for custom contoured seating? 1. CCS is indicated and appropriate for the person: Possible indications: Skeletal deformity/fixed contractures Excessive abnormal movement/tone Postural collapse Skin breakdown/pain Significant postural asymmetry inadequate postural stability What are the potential risks of doing CCS for this person? What is the potential for a positive outcome for this person?

39 Custom Contoured Seating: Ensuring Successful Outcomes I. INTRODUCTION II. BASIC CLINICAL CONCEPTS III. CLINICAL ASSESSMENT IV. TECHNOLOGY ASSESSMENT V. IMPLEMENTATION

40 III. THE CLINICAL ASSESSMENT Disclaimer: It s beyond scope of this presentation to instruct you in completing a comprehensive wheelchair seating assessment! Critical outcomes of seating assessment include: Prioritized goals A Postural Alignment Plan (PAL) Justification for CCS A shape capture plan Therapist s role: Therapist has primary responsibility for performing the clinical seating assessment Supplier s role: It is your job to support and possibly coach a therapist through this process, so you get the information you need

41 III. SEATING ASSESSMENT Critical Components A. Establish and Prioritize Goals B. Posture and Function Assessment C. Mat Exam D. Seating Simulation E. Implementation Plan

42 A. Establish and prioritize goals Goals are discussed during the initial client interview, and clarified as needed throughout the assessment process Goals can be categorized into the areas of Health, Comfort, or Function To prevent further spinal deformity (HEALTH) To decrease back pain (COMFORT) To be able to reach forward and use computer from wheelchair (FUNCTION)

43 A. Establish and prioritize goals Each team member may have different opinions and perspectives that should be considered; however the client s primary concerns and goals are paramount. Goals and strategies may need to be refined at end of assessment process, after you have more information about tradeoffs that will be required to achieve certain goals.

44 Example: Re-prioritizing goals at end of assessment Fig 1: Current seated posture Fig 2: Possible postural alignment goal - seating simulation with lateral trunk support and custom contoured seat Goals for health (skeletal alignment, breathing, prevention of skin breakdown) contradicted client s personal goals for comfort and function

45 SEATING ASSESSMENT Critical Components A. Establish and Prioritize Goals B. Posture and Function Assessment C. Mat Exam D. Seating Simulation E. Implementation Plan

46 B. Posture and Function Assessment 1. Assess Function What does this person need to be able to do from their wheelchair? What movements are important that this individual be able to do to function? This is critical in planning for a custom contour as you can t take away functional movement!

47 B. Posture and Function Assessment 2. Assess Transfers Is client independent in transfers? If so, will they still be able to transfer in/out of a CCS system? If dependent, how is the transfer done and by whom? If using a mechanical lift, is the sling left underneath the person? (Slings should be removed)

48 B. Posture and Function Assessment 3. Assess current seated posture in wheelchair Observe, feel and document alignment of pelvis, trunk, lower extremities and head in all three planes, or views (sagittal, frontal and transverse) Note abnormal tone and movement patterns that affect posture Measure and document relative body segment angles, and a few key absolute body segment angles as a baseline 4. Measure and document key angles and dimensions of current seating system

49 Assess postural deviations in Frontal and Transverse planes Severe left pelvic rotation and left pelvic obliquity, left trunk rotation; falls to the right with left convex C-curve Measure and document: Frontal pelvic angle Frontal sternal angle Transverse trunk angle Transverse pelvic angle

50 Assessing postural deviations in sagittal plane Measure person: 3 Relative Body Segment Angles Measure equipment: 3 Relative Support Surface Angles

51 SEATING ASSESSMENT Critical Components A. Establish and Prioritize Goals B. Posture and Function Assessment C. Mat Exam D. Seating Simulation E. Implementation Plan

52 MAT EXAM, Unsupported Sitting Assessment Fig 1 Fig 2 Fig 2 Skeletal deformities are often best viewed in a sitting position

53 MAT EXAM, Assessing joint flexibility During the mat exam, the therapist should assess Flexibility of the spine and pelvis, including head/neck Passive range of motion of the hips Hip flexion Hip Abduction/Adduction Hip Internal/External rotation At what point in range does pelvis move away from best alignment? Passive range of motion of the knees Knee extension with hips flexed (hamstring flexibility) Knee flexion Passive range of motion of the ankles Ankle dorsi/plantar flexion Passive range of motion of the UE general screening

54 Example: Assessing pelvic/spine mobility Fig 1: Postural tendency is left pelvic obliquity, left pelvic and trunk rotation Fig 2: Postural tendency is severe left pelvic obliquity Fig 3: Assessing flexibility of pelvis and spine in frontal plane can pelvis be leveled?

55 Example: Assessing passive hip abduction and adduction Fig. 1: Assessing right hip adduction Her hand is on the pelvis so that she can feel when the pelvis rotates, as that will be an indication of end range of hip abduction or adduction for seating Fig. 2: Assessing left hip abduction

56 Example: Assessing passive hip flexion range of motion Assessing hip flexion range of motion for seating. Fig. 1 Fig And then measuring end range of hip flexion to determine minimum thigh to trunk angle Fig. 3

57 Joint Motion, Body Segment Angles and Seating Angles Joint Motion Assessed Hip flexion (extension) Body Segment Angle Thigh to trunk angle Seating Angle Seat to back support angle Knee Extension (with hips flexed) Thigh to lower leg angle Seat to lower leg support angle Ankle DF (PF) Lower leg to foot angle Lower leg support / foot support angle 57

58 Measuring Hip Flexion to help determine optimal Thigh to Trunk Angle for sitting THIGH to TRUNK ANGLE Hip Flexion range of motion

59 Thigh to trunk angle Relationship to hip flexion angle More useful for prescribing desired seat to back support angle The angle between the thigh and the trunk, viewed from the side relationship to hip flexion angle

60 Joint Motion, Body Segment Angles and Seating Angles Joint Motion Assessed Hip flexion (extension) Body Segment Angle Thigh to trunk angle Seating Angle Seat to back support angle Knee Extension (Flexion) Thigh to lower leg angle Seat to lower leg support angle Ankle DF (PF) Lower leg to foot angle Lower leg support / foot support angle 60

61 Measuring Knee Extension with hip flexed (Popliteal Angle) to help determine optimal Thigh to Lower Leg Angle for sitting Knee flexion angle THIGH to LOWER LEG ANGLE Same as Popliteal Angle

62 Thigh to lower leg angle Relationship to knee flexion angle The angle between the thigh and the lower leg, viewed from the side relationship to knee flexion angle

63 Joint Motion, Body Segment Angles and Seating Angles Joint Motion Assessed Hip flexion (extension) Body Segment Angle Thigh to trunk angle Seating Angle Seat to back support angle Knee Extension (Flexion) Thigh to lower leg angle Seat to lower leg support angle Ankle DF (PF) Lower leg to foot angle Lower leg support / foot support angle 63

64 Measuring Dorsiflexion/Plantarflexion to help determine optimal Lower Leg to Foot Angle for sitting LOWER LEG TO FOOT ANGLE -5 Dorsiflexion 95 = 5 degree plantarflexion contracture

65 Lower leg to foot angle Relationship to ankle dorsiflexion angle The angle between the lower leg and the foot, viewed from the side relationship to dorsiflexion angle

66 Translating joint range of motion values into corresponding body and seating angles If you position at their end range Passive Joint ROM HIP FLEXION 60 R, 80 L POPLITEAL ANGLE 100 R, 80 L ANKLE DORSIFLEXION 0 R, -10 L Corresponding Body Segment Angle Thigh to Trunk Angle 120 R, 100 L Thigh to Lower Leg Angle 100 R, 80 L Lower Leg to Foot Angle 90 R, 100 L Seating Support Surface Angle Seat to Back support Angle 120* Seat to L.Leg Support Angle 100 R, 80 L L.Leg/Foot Support Angle 90 R, 100 L *There are a lot of other options for seat/back angle if you are creative. For example if you are planning to do a custom contoured seat, you could set up the seat/back support angle at 110 degrees, then angle the right thigh downward 10 degrees to achieve the 120 thigh/trunk angle on that side

67 Example of supporting two different thigh/trunk angles in a custom contoured seating system Hint: To measure the seat to back support angle of a custom contoured seat and back support, approximate by measuring the flat mounting surfaces behind and under the cushions

68 Mat Exam Outcome From information gathered so far team should be able to. 1. Determine whether a neutral sitting posture can be achieved passively based on joint flexibility. And if not, determine client s best potential for alignment, gravity eliminated, in all areas of the body. Preliminary Postural Alignment Plan

69 Postural Alignment Plan includes: Body Segment Angles Thigh/Trunk Angles, R + L Thigh/LowerLeg Angles, R + L LowerLeg/Foot Angles, R + L This is the information you need from the therapist!! Based on end comfortable range of motion for seating Goal for alignment and orientation of body segments Pelvis level, rotated, oblique? Trunk midline or off center? Rotated? Neutral extension? LE s forward facing, windswept, Abd/Add, IR/ER? How does this person s lower extremities need to be aligned in order to achieve the maximum alignment in the pelvis/spine, trunk and head?

70 Mat Exam Outcome From information gathered so far team should be able to. 1. Determine a preliminary postural alignment plan 2. Develop a hypothesis regarding source of postural problems I think the reason Mr. Smith is sitting in a severely kyphotic posture is that his tight hamstrings are not being accommodated in his wheelchair 3. Obtain linear and angular body measurements, in order to delineate preliminary seating equipment angles and dimensions Allows set up of trial support surfaces in order to finalize postural plan/objectives and finalize equipment measures needed to support that resting posture

71 SEATING ASSESSMENT Critical Components A. Establish and Prioritize Goals B. Posture and Function Assessment C. Mat Exam D. Seating Simulation E. Implementation Plan

72 D. Seating Simulation Assessment in sitting position using mock-up of equipment surfaces to help simulate the desired seated posture and determine/finalize postural alignment objectives Test out your preliminary postural alignment plan Adding gravity may need to adjust postural objectives Test your hypothesis about source of postural problems Finalize seating objectives and required equipment properties Finalize Postural Alignment Plan (not based solely on mat exam) Take FINAL measurements with client sitting in the desired sitting posture/orientation

73 Seating Simulation using planar seating simulator Current posture Simulation of preliminary postural alignment plan What is causing him to sit like this? What do you think our hypothesis was based on mat exam findings?

74 Seating Simulation using planar seating simulator Current posture Desired posture simulated Seat to back support angle 115 Right side body segment angles: Thigh/trunk angle = 125 Thigh/lower leg angle = 120 Lower leg/foot angle = 105 Sagittal thigh angle = -10

75 Seating Simulation using planar seating simulator Current posture Desired posture simulated Seat to back support angle 115 Left side body segment angles: Thigh/trunk angle = 95 Thigh/lower leg angle = 100 Lower leg/foot angle = 100 Sagittal thigh angle = +20

76 Seating Simulation Can client function from this resting posture? Is this the OPTIMAL resting posture?

77 Objectives/equipment parameters for the head often cannot be determined until after client is seated in desired alignment Final seating measurements are taken with client sitting in desired posture/orientation/alignment How does this posture affect specification of wheelchair base dimensions and components?

78 Why bother doing a Planar Seating Simulation prior to shape capture? Doing planar simulation and determining final postural alignment plan at time of initial evaluation helps to: Justify need for custom contour Determine mobility base prescription Develop an efficient and accurate plan for the shape capture session

79 SEATING ASSESSMENT Critical Components A. Establish and Prioritize Goals B. Posture and Function Assessment C. Mat Exam D. Seating Simulation E. Implementation Plan

80 E. Implementation Plan 1. Finalize Postural Alignment Plan & Objectives 2. Confirm Justification for Custom Contoured Seating 3. Develop Plan for Shape Capture

81 This is the information you need from the therapist!! Final Resting Body Segment Angles measure with person sitting in desired alignment in simulation set up: Desired Thigh to Trunk Angle, R/L Desired Thigh to Lower Leg Angle, R/L Desired Lower Leg to Foot Angle, R/L 1. Finalize postural alignment plan Objectives for alignment and orientation of body Pelvis; Trunk/shoulders; Lower Extremities; Head/Neck Measure and document key absolute body segment angles Frontal and transverse pelvic angles Frontal sternal angle These are your measurable postural Transverse trunk and thigh angles alignment objectives Frontal lower leg angles

82 2. Confirm Justification for Custom Contour Discuss client specific pros and cons of custom contoured seating with client, family and team Discuss client specific pros and cons of other options: Custom linear/modular Adjustable contour Off the shelf generic contour Hybrid approach Is further trial needed of other product options or strategies?

83 3. Shape Capture Plan (depends on product) Write down your plan! (if you ve decided to use custom contour) Set up of shape capture equipment Critical angles and dimensions Head support and Foot support needs/placement Molding bag prep if doing indirect molding method Key clinical considerations to remember Key points of control to achieve postural alignment Active/functional movements to be allowed or encouraged Orientation in space issues (relationship between relative and absolute angles)

84 CHECK YOUR LEARNING: What contributes to a successful outcome for custom contoured seating? 2. A thorough clinical assessment prior to the shape capture has resulted in: Prioritized goals Health, Posture, Comfort, Function Postural Alignment Plan Body segment angles, relative and absolute Justification for custom contoured seating Shape capture plan Support surface angles and key dimensions Secondary support needs Key points of control

85 Custom Contoured Seating: Ensuring Successful Outcomes I. INTRODUCTION II. BASIC CLINICAL CONCEPTS III. CLINICAL ASSESSMENT IV. TECHNOLOGY ASSESSMENT V. IMPLEMENTATION

86 IV. TECHNOLOGY ASSESSMENT A. CCS Technologies and Methods B. Wheelchair and Seating Product Choice and Specification

87 A. CCS Technologies and Methods Parameters to Compare Direct vs. Indirect Methods

88 Parameters to Compare The primary differences between custom contouring technologies can be compared by looking at: Process Features Product Features

89 Parameters to Compare Process Features 1. The method of capturing the desired body shape or contour This will affect your ability to achieve and maintain the client s desired posture while the shape is being captured 2. How the shape/contours are read to produce contour information (shape translation) 3. The process for translating the contour information into the actual seat and back supports (fabrication)

90 Parameters to Compare Product Features 1. Primary Materials what s it made of? Foam, Plastic/Orthotic shell, other materials Options or no options; Adjustability? 2. Surface Covering Options Stretchy vs. non stretchy; Water resistant/proof; Breathability Removable or not 3. Construction Features and Options Lateral support features depth of contour, min thickness; reinforcement; thinning; swing away, removable, wrap around Cut outs/recessed areas soft spots; gel/fluid/air inserts Belt notches, strap slots 4. Mounting Options

91 A. CCS Technologies and Methods Parameters to Compare Direct vs. Indirect Methods

92 Direct vs. Indirect Methods Direct: The medium that is used to capture the body contours actually becomes the final seat and back support, so there is no reading of the contour required, nor translation/fabrication Examples: FIPS: Foam-in-place Seating Shapeable Matrices/Adjustable Micro-Modular Seating (Matrix Seating; Symmetric Designs) Other new off the shelf products that offer adjustable contour (Comfort Company s Cable tensioning technology; Stealth s Tarta backrest)

93 Direct vs. Indirect Methods Indirect: The medium used to capture the body contours is not the final cushion. A particular medium is used to capture the body contours, then the contours are read and this contour information is translated into a final cushion using a variety of methods, depending upon the manufacturer Examples: Indirect vacuum consolidation methods, either carved foam or modified orthotic shell: Otto Bock, Ride Designs, PinDot, Prairie Seating, PRM

94 Indirect Vacuum Consolidation Most common indirect method In this method, a bag filled with small beads is used to capture the desired body contours in the sitting position. The client is seated in a special fitting chair that holds the manufacturer s molding bags. Air is then sucked out of bag using a pump, which progressively hardens the bag.

95 Indirect Vacuum Consolidation Once the desired posture and supporting bag shape is attained, the air is sucked out and the bags become rigid with the desired contour. After the client is transferred from the fitting chair, the bag s shape is then read in a variety of ways, depending on the manufacturers technology

96 IV. TECHNOLOGY ASSESSMENT A. CCS Technologies and Methods B. Wheelchair and Seating Product Choice and Specification

97 B. Wheelchair and Seating Product Choice and Specification 1. Discuss pros/cons of CCS product options with client, family and team The process features of the chosen product should enable you to achieve desired postural alignment while capturing the shape The product features match client s needs and preferences 2. Choose CCS product and then specify additional features as necessary per manufacturer s options 3. Specify type and size of wheelchair mobility base frame and components

98 Choose CCS product that has best potential for good outcome Remember the risk assessment. Ask yourself: How will we achieve / maintain the desired posture while capturing the shape, with this client, using available product choices? What extra resources are needed in order to achieve/maintain desired alignment while capturing the shape? Do we have access to needed supports/technology? How experienced are team members with the product being considered Is client likely to be positioned consistently in the system? What are the risks if client changes or is inconsistently positioned, with this product?

99 Specifying type and size of wheelchair mobility base/frame and components Features and dimensions of the wheelchair frame MUST allow the seating system to support the person in the desired postural alignment If a client needs to be seated with thighs windswept due to contractures of the hips, how will their feet be supported in this offset position? (Frame width; Style of lower leg support assembly and foot supports) If PAL is to seat the person with a right thigh to trunk angle of 95 degrees, and a left thigh to trunk angle of 120 degrees, what feature of the wheelchair frame needs to be specified to achieve this? (Seat frame to back post angle; STFH; Foot supports)

100 Specifying type and size of wheelchair mobility base/frame and components Highly encourage seating simulation (or even a mock shape capture) prior to final product specifications! With person seated in desired alignment during simulation, you can more accurately determine final specifications of seating and mobility base

101 CHECK YOUR LEARNING: What contributes to a successful outcome for custom contoured seating? 3. The features of the recommended CCS product match the unique characteristics and needs of client 4. Appropriate specification of wheelchair frame parameters that support seating objectives and PAL

102 Custom Contoured Seating: Ensuring Successful Outcomes I. INTRODUCTION II. BASIC CLINICAL CONCEPTS III. CLINICAL ASSESSMENT IV. TECHNOLOGY ASSESSMENT V. IMPLEMENTATION

103 V. IMPLEMENTATION Indirect Vacuum Consolidation technique A. The Shape Capture B. Shape Translation C. Fabrication D. Integration of final CCS product into wheelchair base E. Client Fitting/Delivery

104 A. The Shape Capture 1. Set up fitting chair (whatever you are capturing the shape in) Seating Angles, Seat Depth, other secondary supports 2. Prepare the bags Pre-shape bags for approximate contour Use additional blocks or wedges of foam with aggressive shapes 3. Position client in desired posture and orientation and shape bags for total contact Work proximal to distal Don t fold laterals Re-check postural objectives frequently

105 A. The Shape Capture 4. Take final measurements and photos Document postural alignment achieved, incl. body segment angles Measure final width within frame dimensions? 5. Shape translation product/manufacturer specific Bag prep marking for top of back, depth of seat, trim lines Digitizing/casting/scanning Filling out order forms What defines a successful shape capture?

106 What defines a successful shape capture? 1. Client s optimal seated posture must be achieved during the shape capture process for successful outcome I believe this is the most important factor contributing to successful outcome when doing indirect molded seating Client s desired optimal alignment is determined ahead of time, during the clinical assessment Achieve and maintain the desired postural alignment while you are capturing the shape of person s body

107 What defines a successful shape capture? 2. Intimate contact has been achieved between the molding medium and the contours of the person s body The shape of the bags should accurately reflect the contours of the person s posterior trunk, pelvis, buttocks and thighs This can be difficult to assess Lean person forward to view back support shape Transfer client out and check shape.does it match what you know about the client s shape?

108 B. Shape Translation How is the shape of the molding bags translated into contour information? Plaster cast Something is poured into shape to create positive mold Contours are digitized, to create an electronic file Product specific CRT supplier needs to have training and experience in the product; errors can be made during this stage

109 C. Fabrication Contour information is used to fabricate the final seat and back supports Fabrication process is product specific Accurate fabrication The shape of the final seat and back support matches the shape created during the shape capture Is the contour information intentionally modified before fabrication?

110 D. Integration of final CCS product into wheelchair base The final seat and back support components must be mounted into wheelchair frame in a manner which achieves desired support surface relative angles, and key dimensions Errors here will affect outcomes. For example. Is the foot support placement adjusted to achieve prescribed seat to lower leg support angles? Is back support placed and adjusted properly to achieve the desired effective seat depth and seat to back support angle?

111 E. Client Fitting/Delivery Prior to getting client into the new system: Review prioritized goals (what s the big important thing?) Review specifications for support surface relative angles and primary dimensions Review Postural Alignment Plan and seating objectives During fitting: Postural objectives and overall goals met? If having difficulty, review mat exam findings After fitting: Document final set up (angles/dimensions) especially if changed from original plan Document final postural alignment achieved (i.e., relative and absolute body segment angles)

112 CHECK YOUR LEARNING: What contributes to a successful outcome for custom contoured seating? 4. Successful shape capture Desired postural alignment achieved and maintained Even, intimate contact achieved with the materials 5. Accurate shape translation 6. Accurate fabrication 7. Accurate integration of final seating components into wheelchair base

113 What contributes to a successful outcome for custom contoured seating? 8 critical factors: 1. CCS is indicated and appropriate for the person 2. A thorough clinical assessment prior to the shape capture has resulted in: Prioritized goals Postural Alignment Plan (PAL) Justification for CCS Shape capture plan 3. The features of the recommended CCS product match the unique characteristics and needs of client

114 What contributes to a successful outcome for custom contoured seating? 4. Appropriate specification of wheelchair frame parameters that support seating objectives and PAL 5. Successful shape capture Desired postural alignment achieved and maintained Even, intimate contact achieved with the materials 6. Accurate shape translation 7. Accurate fabrication For Indirect Methods 8. Accurate integration of final seating components into wheelchair base

115 Kelly Waugh, PT, MAPT, ATP Assistive Technology Partners University of Colorado Denver Anschutz Medical Campus, Department of Bioengineering UCD Auraria Campus, th Street Denver, Colorado generalinfo@atpartners.edu