Power Seat Functions: Examining the Myths. Why Consider Power Seating? Learning Objectives. What is Evidence Based Practice?(EBP)

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Learning Objectives Power Seat Functions: Examining the Myths Developed by: Amy

Identify the most commonly utilized power seat functions and list the benefits and

Discuss how the quadriceps and hamstring muscle groups impact the use of power seat

Descirbe how various power seat functions are used in everyday life, and verbalize

1 Learning Objectives Power Seat Functions: Examining the Myths Developed by: Amy Morgan, PT, ATP Magdalena Love, OTR, ATP Permobil, Inc. Identify the most commonly utilized power seat functions and list the benefits and potential drawbacks of each. Discuss how the quadriceps and hamstring muscle groups impact the use of power seat functions. Descirbe how various power seat functions are used in everyday life, and verbalize the impact of this on an individual's risk for skin breakdown. Why Consider Power Seating? Pressure Relief Functional Benefits ADLs Catheterization Safe Transfers Management of Medical Issues Spasticity Orthostatic Hypotension Improved Sitting Tolerance 4 What is Evidence Based Practice?(EBP) ASSESSMENT Current research Clinical Experience Needs, values, & preferences of those who are affected Best Practices

2 Pressure Relief Cushions CAN: (Andriaasen, Asbeck, Lindeman, vand der Woude, de Groot, & Post, 2013) Protect skin Enhance comfort Improve posture Create stability Correct or Accommodate Deformities Henley, 2010 Pressure Relief Cushions CANNOT: Eliminate the need for pressure relief movements Prevent ischemic events (pressure ulcers) The same thing for every patient Henley, 2010 Pressure Relief - EBP How Often? Every minutes How Long? 1-3 minutes What Angles are Necessary? More is better (at least 45 degrees tilt) In what order? Tilt before recline - reduces shear PVA PU Clinical Practice Guidelines Pressure Ulcers What are factors that contribute to skin breakdown? Sustained deformations of soft tissues usually under bony prominences. Intrinsic factors General health status Mobility status Nutritional status Age History of PUs Drugs/medications Muscle atrophy Circulatory health Etc. Ayello, Baranoski, Lyder, & Cuddigan, 2004) Pressure Ulcers - Extrinsic Factors Pressure Not changing positions often enough, surface/ contact area/immersion, tight or wrinkled clothing, etc. Shearing Less pressure needed to cause skin breakdown when shearing forces are occurring May not be visible on the skin s surface (deep Friction Not a primary cause of pressure ulcers but rather surface injuries Can exacerbate existing skin breakdown Skin Microclimate (Heat and humidity) Ayello, Baranoski, Lyder, & Cuddigan, 2004) pressure-ulcer-knowledge/pressure-ulcerrisk-factors/ pressure-ulcer-knowledge/pressure-ulcerrisk-factors/

A note about pressure mapping Measures surface pressure Does not measure blood flow, shearing, or deep tissue loading May not represent how as person is

to skin breakdown Compared to able-bodied individuals, persons with a neurological impairment pressure map differently.

Power Tilt Power Tilt Seat to back angle remains consistent Maintains proper position relative to devices mounted on seat Pressure relief Reduce risk of

Kendall Power Tilt - EBP More tilt is better for pressure relief Inverse relationship between tilt angle and pressure at the sitting surface.

3 A note about pressure mapping Measures surface pressure Does not measure blood flow, shearing, or deep tissue loading May not represent how as person is typically sitting after extended periods of time Numbers used for comparison in the same individual No studies have demonstrated that a particular mmhg leads to skin breakdown Compared to able-bodied individuals, persons with a neurological impairment pressure map differently. Higher peak pressures Different patterns in sacral loading during power seat function use How do you use pressure mapping within your setting? Power Tilt Power Tilt Seat to back angle remains consistent Maintains proper position relative to devices mounted on seat Pressure relief Reduce risk of pressure ulcers Postural stability Gravity assisted positioning Improved sitting tolerance Change in position Provides position of rest Reduces fatigue Meet Kendall Power Tilt - EBP More tilt is better for pressure relief Inverse relationship between tilt angle and pressure at the sitting surface. Significant pressure reduction starts at 30 tilt Maximum tilt = maximum pressure reduction (Sonenblum & Sprigle, 2011 The impact of tilting ) Separated between pressure and blood flow (Geisbrecht et al., 2011) Pressure Imaging! Upright vs. 30 deg. tilt

Power Tilt: Pressure Mapping Video How much do clients actually use?

behaviors Results: On average, participants spend 12.1 hours in a wheelchair daily.

Median user tilted every 27 min However pressure relieving tilts (defined as a tilt greater than 30 for

Majority of users were tilting for comfort, but not performing tilts for pressure relief.

Transfers Nose over Toes Functional compensation for limited hip flexion Tone Management Postural

maneuvers for pressure relief Pressure will be increased on the lower side Postural Support/Visual

ability to perform eating tasks from the table?

4 Power Tilt: Pressure Mapping Video How much do clients actually use? Sonenblum & Sprigle, Distinct Tilting Behaviors n=45; 1-2 week period Monitoring power tilting behaviors Results: On average, participants spend 12.1 hours in a wheelchair daily. Median position was 8 tilt. Median user tilted every 27 min However pressure relieving tilts (defined as a tilt greater than 30 for longer than 1 min) were performed on average once every 10 hours. Majority of users were tilting for comfort, but not performing tilts for pressure relief. Anterior Tilt Functional access forward Ready Position Assists with transfers Sit to Stand Lateral Transfers Nose over Toes Functional compensation for limited hip flexion Tone Management Postural support/balance Lateral Tilt Tilt operates in coronal or oblique planes Increases degree of freedom in maneuvers for pressure relief Pressure will be increased on the lower side Postural Support/Visual Orientation Especially with significant scoliosis What power seat function would increase Crystal s ability to perform eating tasks from the table? Power Recline Seat to back angle changes Risk of shearing and translation of positioning components Ideal for bowel/bladder management Catheterization/Lower body clothing management Respiratory Benefits Suctioning needs; Improved respiration Pressure Relief/Postural stability Improved sitting tolerance Change in position Provides position of rest Reduces fatigue

Power Recline - EBP Reduction of seat load during full recline: 61% Reduction of seat load in full tilt: 46% (Sprigle et al,

prior to shear reduction back interfaces No consistent method for measuring shearing forces Pressure Mapping Recline: Upright vs.

Two studies looked directly at shearing forces Hobson 1992 Aissaoui 2001 Able-bodied individuals Measured the translation of the

tilting posteriorly) Concluded that this wasn t an accurate way of measuring shearing Hobson 1992 Study Shearing Forces 70 mmhg

Study concluded that tilt decreases shearing and recline increases shearing Is this how we recommend that our clients use recline?

Maximum Pressure Relief with shear reduction Improved Sitting Tolerance / Comfort Functional Activities (toileting/lower body

5 Power Recline - EBP Reduction of seat load during full recline: 61% Reduction of seat load in full tilt: 46% (Sprigle et al, 2010) 120 recline decreased max pressures in the ITs but also caused the greatest IT shift (aka shearing) (Hobson, 1992) This was prior to shear reduction back interfaces No consistent method for measuring shearing forces Pressure Mapping Recline: Upright vs. 150 recline Power Recline & Shearing- EBP Deep shearing forces have the potential to cause widespread decreased vascular flow. Two studies looked directly at shearing forces Hobson 1992 Aissaoui 2001 Able-bodied individuals Measured the translation of the greater trochanter to seat surface Found that during recline, the pelvis actually moved backwards (most likely due to the pelvis tilting posteriorly) Concluded that this wasn t an accurate way of measuring shearing Hobson 1992 Study Shearing Forces 70 mmhg 10 mmhg 85 mmhg Neutral Position Tilt Recline Power Recline: Pressure Mapping Video Load cells measured Tangential Shear Forces Study concluded that tilt decreases shearing and recline increases shearing Is this how we recommend that our clients use recline? Power Tilt AND Recline Power Tilt AND Recline Why would someone need tilt/recline compared to a tilt only system? Maximum Pressure Relief with shear reduction Improved Sitting Tolerance / Comfort Functional Activities (toileting/lower body clothing mgmt., getting knees under a table) Respiration (respiratory care) Tone Management Position of Rest Medical Management (orthostatic hypotension)

Power Tilt & Recline - EBP 45 tilt/120 recline: 40.

more than does each system separately. Pressure mapping Tilt & Recline: Upright vs.

, 2013 Study Looked at skin and muscle reperfusion Significant skin reperfusion could be achieved by: > 35 tilt or > 15 tilt & 120

Recline: Pressure Mapping Video Power Elevating Legrests (PELRs) Reduces LE edema Must be combined with tilt and/or recline

circulation Pain management Let s Talk ANATOMY!

6 Power Tilt & Recline - EBP 45 tilt/120 recline: 40.5% weight shift (Aissaoui et al, 2001) The combination of tilt and back recline reduces the seat mean pressure and peak pressure more than does each system separately. Pressure mapping Tilt & Recline: Upright vs. 30 tilt/150 recline " Power Tilt & Recline EBP: Jan et al., 2013 Study Looked at skin and muscle reperfusion Significant skin reperfusion could be achieved by: > 35 tilt or > 15 tilt & 120 recline Significant muscle reperfusion achieved with: > 25 tilt and 120 recline Unable to be achieved with 35 tilt Power Tilt & Recline: Pressure Mapping Video Power Elevating Legrests (PELRs) Reduces LE edema Must be combined with tilt and/or recline Provides knee ROM Accommodates contractures Helps manage positioning (while using recline) Supports LE casts and splints Improves circulation Pain management Let s Talk ANATOMY!! Recline needs ELRs Quadriceps Group Quads Rectus Femoris Vastus Medialis Vastus Lateralis Vastus Intermedius Hamstrings Group Biceps Femoris Semimembranosus Semitendinosus RECLINE alone (or with TILT) - Stretches... Rectus Femoris Anterior Tilt of Pelvis Sliding - Shearing UNLESS... ELRs with RECLINE Provides relief of Rectus Femoris Controls Shearing/Sliding/Ant. Tilt

ELRs Need Recline ELRs (with Tilt or alone) - Stretch... Hamstrings Posterior Tilt of Pelvis Sliding - Shearing UNLESS... ELRs with RECLINE Provides relief of Hamstrings Controls Shearing/Sliding/ Post.

7 ELRs Need Recline ELRs (with Tilt or alone) - Stretch... Hamstrings Posterior Tilt of Pelvis Sliding - Shearing UNLESS... ELRs with RECLINE Provides relief of Hamstrings Controls Shearing/Sliding/ Post. Tilt gpsmelbourne.org SO WHAT? TILT and RECLINE Controls Shearing/Sliding in Seating System Assistance of Gravity Still have issues with Rectus Femoris muscle length RECLINE and ELRs Accounts for Rectus Femoris muscle length Controls Shearing/Sliding SO WHAT? TILT only Patterns of use show ineffective pressure relief Provides no ROM at hip/knees; No impact on: Pain relief Tone management Management of joint contractures Case Example: Seat Function Dysfunction Ms. L would benefit from a powered wheelchair with tilt, recline, and ELRs however she is unable to tell the difference between tilt and recline, and has difficulty returning to a functional position following her weight shifts. Modifying the Task? Facilitating learning? TILT/RECLINE and ELRs work best TOGETHER! RESNA Position Paper on Tilt, Recline, and Elevating Legrests Best comprehensive overall summary of research examining multiple seat functions. Originally approved in April, Recently published in peer-reviewed journal. Definitions, Manual vs. Power, Posture, Function, Physiology, Case Studies (SB, CVA, CP, SCI) Dicianno, B.E., Arva, J.A., Lieberman, J., Schmeler, M., Souza, A., Phillips, K., Lange, M., Cooper, R., Davis, K., & Betz, K. (2009) RESNA Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs. Assistive Technology, 21: Summary of Evidence Use Clinical judgment! Tilt prior to recline reduces shear (Hobson, 1992; Aissaoui et al., 2001) Recline alone reduces seat surface pressure more than tilt alone (Sprigle et al, 2010; Hobson, 1992). Recline and tilt combined reduce surface pressure more than either PSF separately (Jan et al., 2013). Tilt and Recline (Aissaoui et al, 2001) or Standing (Sprigle et al, 2010) offers best pressure relief for seat and back. Clients rarely sit at upright angle (Sonenblum et al, 2011; Ding et al, 2008) Clients rarely access more than 30 degrees of tilt (Sonenblum et al, 2009), and more than 110 of recline (Ding et al, 2008). Comfort requires movement (Frank, De Souza & Frank, 2012; Porter et al, 2003; Vergara & Page, 2002)

Power Seat Elevation (Adjustable Seat Height) Improves independence with transfers Sit to stand, lateral transfers Improves functional reach/access Clients with UE weakness/limited ROM Reduces

Seat- Elevating Devices for Wheelchair Users Best comprehensive overall summary of research examining seat elevation. Originally approved in September, 2005.

(2009) RESNA Position on the Application of Seat-elevating Devices for Wheelchair Users. Assistive Technology, 21: 69-72. Power Seat-to-Floor Standing There s Nothing Like It!

handling by untrained caregivers Osteogenesis Imperfecta (OI) Why Stand? Examining the Evidence Metabolic affects of sitting Why NOT?

8 Power Seat Elevation (Adjustable Seat Height) Improves independence with transfers Sit to stand, lateral transfers Improves functional reach/access Clients with UE weakness/limited ROM Reduces cervical spine pain/stress Including headaches Improves visual attention Lip-reading also improved for better hearing Psycho-social benefits of seeing eye-to-eye RESNA Position on the Application of Seat- Elevating Devices for Wheelchair Users Best comprehensive overall summary of research examining seat elevation. Originally approved in September, Recently published in peer-reviewed journal. Definitions, Transfers, Reach, Psychological, Pediatric Uses, Case Studies (OI, CP, SMA) Arva, J.A., Schmeler, M., Lange, M., Lipka, D., Rosen, L. (2009) RESNA Position on the Application of Seat-elevating Devices for Wheelchair Users. Assistive Technology, 21: Power Seat-to-Floor Standing There s Nothing Like It! Promotes independent transfers Children, Adults with Dwarfism/Shorter Stature Improves access/reach to floor level Incorporates children into peer level activities Improves safety by reducing handling by untrained caregivers Osteogenesis Imperfecta (OI) Why Stand? Examining the Evidence Metabolic affects of sitting Why NOT? Potential Complications of Immobility Decreased Bone Mineral Density (BMD) Risk of Pressure Ulcers Development of Joint Contractures Impaired bowel and bladder functioning Impaired respiratory functioning Gastro-Intestinal problems Deitrick J, Whedon G, Shorr E. Effects of immobilization upon various metabolic and physiologic functions of normal men. American Journal of Medicine, 1948; 4: 3. Study of 123,216 men and women over a 14 year period. Results were independent of physical activity level. (Patel, et al., 2010) Mortality risk Low! High 48 Activity Levels (METs) High activity Low Activity

November 17, 2013 Why$People$Need$to$Stand$ Three$Main$Reasons$

Dynamic Weight Bearing Shorter, More Frequent GI/Respiratory/Circulatory

UTI/Kidney Stones/Constipation/Bowel Accidents Summary of Evidence

Contractures Providing Prolonged Stretch Pressure Management Reduced

Standers Improves compliance with standing program (Shields 2005) Promotes

benefits of weight bearing Higher Frequency (Robling 2001; Eng 2001) Dynamic

means of pressure relief (Sprigle 2010) Reducing risk of pressure ulcers

9 November 17, 2013 Why$People$Need$to$Stand$ Three$Main$Reasons$ Health$Benefits$ Func<onal$Benefits$ Social$Benefits$ for Health Summary of Evidence Bone Mineral Density Dynamic Weight Bearing Shorter, More Frequent GI/Respiratory/Circulatory Higher Frequency of Standing Greater Impact Bowel/Bladder Reducing UTI/Kidney Stones/Constipation/Bowel Accidents Summary of Evidence Spasticity Immediate and Significant Effect - Beneficial for Function Contractures Providing Prolonged Stretch Pressure Management Reduced Frequency when Using Stander Best Pressure Relief Overall Wheelchair Standers Improves compliance with standing program (Shields 2005) Promotes functional independence Reduces cost of home modifications Greater medical benefits of weight bearing Higher Frequency (Robling 2001; Eng 2001) Dynamic Loading (Thompson et al 2000; Ward et al 2004) Provides superior and natural means of pressure relief (Sprigle 2010) Reducing risk of pressure ulcers Helps heal/treat current pressure ulcers Options for Standing Ambulation/Ambulatory Aids Quality of weight bearing? Separate Standing Devices Static or Dynamic Wheelchair Standing Devices Manual/Manual Manual/Power Power/Power

Power Standing Tight Sit to Stand Lay to Stand (Tilt Table)

Standers Best comprehensive overall summary of research

Recently updated - 2013 Benefits, Indications,

online for download Standing- Trial #1: Pressure Mapping

Functions (Funding Codes) Tilt (E1002) Recline (E1004) Tilt

Elevation (E2300) Standing (E2301) Seat to Floor (K0108)

Shearing and Sliding prohibit its use ELRs Used alone, can

10 Power Standing Tight Sit to Stand Lay to Stand (Tilt Table) Semi-Reclined Stand RESNA Position Paper on Wheelchair Standers Best comprehensive overall summary of research examining wheelchair standers. Recently updated Benefits, Indications, Contraindications, Case Studies (CP, MS, SCI) Available online for download Standing- Trial #1: Pressure Mapping Video Standing Trial #2: Pressure Mapping Video Power Seat Functions (Funding Codes) Tilt (E1002) Recline (E1004) Tilt AND Recline (E1007) Elevating Legrests (E1010/K0108) Seat Elevation (E2300) Standing (E2301) Seat to Floor (K0108) Tilt Tilt alone is enough and is used effectively Recline Shearing and Sliding prohibit its use ELRs Used alone, can manage edema in LEs Elevation Can t get funding to cover cost Standing Evidence is inconclusive; experimental/investigational

1 For more information please visit our website at: www.permobil.com Cited$Research$ Adriaansen, J., van Asbeck, F., Lindeman, E. v., de Groot, S., & Post, M. (2013).

11 61 ANY QUESTIONS? COURSE COMPLETION CODE To obtain CEUs, attendees must sign in, stay for the entire course, complete an evaluation form, and write the following course code on the eval form: CL-CW For more information please visit our website at: Cited$Research$ Adriaansen, J., van Asbeck, F., Lindeman, E. v., de Groot, S., & Post, M. (2013). Secondary health conditions in persons with spinal cord injury for at least 10 years: design of a comprehensive long-term cross-sectional study. Perspectives in Rehabilitation: Developing Robust Research Designs, Aissaoui R, Lacoste M, Dansereau J. Analysis of sliding and pressure distribution during a repositioning of persons in a simulator chair. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 2001; 9(2): Arva, J., Paleg, G., Lange, M., Liberman, J., Schmeler, M., Dicianno, B., et al. (2009). RESNA Position on the Application of Wheelchair Standing Devices. Assistive Technology, Ayello, E., Baranoski, S., Lyder, C., & Cuddigan, J. Pressure ulcers. Wound Care Essentials: Practice Principles. Springhouse, PA: Lippincott Williams, & Wilkins, p Deitrick, J., Whedon, G., & Shorr, E. (1948). Effects of immobilization upon various metabolic and physiologic functions of normal men. American Journal of Medicine, 4(3). Cited$Research$ Ding D, Leister E, Cooper RA, Cooper R, Kelleher A, Fitzgerald SG, and Boninger ML, Usage of tilt-in-space recline, and elevation seating functions in natural environments of wheelchair users. Journal of Rehabilitation Research & Development, (7): p Dunn RB, Walter JS, Lucero Y, Weaver F, Langbein E, Fehr L, Johnson P, Riedy L. Follow-up assessment of standing mobility device users. Assistive Technology, 1998; 10(2): Goossens, R.H.M., C.J. Snijders, T.G. Holscher, et al. Shear stress measured on beds and wheelchairs. Scand J Rehabil Med 29 (1997): Henderson JL, Price SH, Brandstater ME, & Mandac BR. Efficacy of three measures to relieve pressure in seated persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation. 1994; 75: Hobson DA. Comparative effects of posture on pressure and shear at the body-seat interface. Journal of Rehabilitation Research and Development, 1992; 29(4): Cited Research Lacoste, M., Weiss-Lambrou, R., Allard, M., & Dansereau, J. Powered tilt/ recline systems: Why and how are they used? Assistive Technology, 15 (2003): Liu, H-Y.; Cooper, R.; Kelleher, A.; & Cooper, R.A. (2013). An interview study for developing a user guide for power seat function usage. Disability & Rehabilitation Assistive Technology, Early online, Panel for the Prediction and Prevention of Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guidelines, No. 3 AHCPR. Robling AG, Hinant FM, Burr DB, Turner CH. Shorter, more frequent mechanical loading sessions enhance bone mass. Medicine & Science in Sports &Exercise May: Schofield R, Poerter-Armstrong A, and Stinson M, Reviewing the Literature on the Effectiveness of Pressure Relieving Movements. Nursing Research and Practice, p

Monitoring standing wheelchair use after

Use of power tilt systems in everyday life.

Disability and Rehabilitation: Assistive

2010; 33(1): 58-64. Sprigle, S., Maurer, C.

12 Cited Research Shields, R., & Dudley-Jaroroski, S. (2005). Monitoring standing wheelchair use after spinal cord injury: a case report. Disability & Rehabilitation, Sonenblum SE, Sprigle S, Mauer CL. Use of power tilt systems in everyday life. Disability Rehabilitation Assistive Technology Jan; 4(1): Sonenblum, S.E. & Sprigle, S. (2011). Distinct tilting behaviors with power tilt-inspace systems. Disability and Rehabilitation: Assistive Technology, 6(6), Sprigle S, Mauer C, Sonenblum SE. Load redistribution in variable position wheelchairs in people with spinal cord injury. Journal of Spinal Cord Medicine. 2010; 33(1): Sprigle, S., Maurer, C., & Sorenblum, S. (2010). Load Redistribution in Variable Position Wheelchairs in People with Spinal Cord Injury. Journal of Spinal Cord Medicine, X

13 Program specific angles and intervals of time for clients to use power positioning. Track client compliance remotely.

Standing Up to Complications of SCI/D

Standing Up to Complications of SCI/D Disclosure Ginger Walls, PT, MS, NCS, ATP/SMS Full-time employee with Permobil Ginger Walls, PT, MS, NCS, ATP/SMS Regional Clinical Education Manager Permobil Learning