DO NOT SIT WITHOUT PROPER FIT. Objectives. Recommendations 4/23/2014 CSMC Participants will be able to:

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1 DO NOT SIT WITHOUT PROPER FIT CSMC 2014 Presented by: Elizabeth Cole, MSPT, ATP Director of Clinical Rehab Services Objectives Participants will be able to: Match each anatomical measurement to the corresponding equipment parameter Describe how to translate each measurement into the appropriate equipment dimension, Identify all adverse effects of improper fit for each of the equipment parameters described in Objective #2 Recommendations Use flat firm surface with feet supported Position in most optimal sitting posture based on mat evaluation results Use rigid measuring tape Use measurement form Measure right and left sides if needed Record person s anatomical measurements, then translate to equipment measurements 1

2 Anatomical Measurements All measurements are the person s anatomical measurements Hip Width - A Determines seat width Position LEs in neutral or slight abduction Measure widest point of seated anatomy Accommodate for fixed deformities Hip Width - A Accommodating fixed deformities Measure widest point to widest point Fill in and support with lateral supports Fixed windswept legs Fixed hip abduction Fixed scoliosis 2

3 Keep chair as narrow as possible for posture and function In most cases use anatomical width for equipment width Possible exceptions: Lateral pads or hardware take up width Orthotics or prosthetics require added width Anticipated change in size Certain body types Chair too wide Pelvis not supported - obliquity, rotation Armrests too far away - lateral lean Wheels too far away - poor propulsion Increased overall width poor accessibility Chair too narrow: Pressure at hips and thighs Pelvic / trunk rotation Cannot fit lateral supports if needed Too wide Too narrow Just right 3

4 Buttock Thigh Depth - B Determines seat depth Measure from back of buttocks to back of knee Buttock Thigh Depth - B Must position person in his/her optimal posture to obtain accurate measurement Seat depth in neutral Seat depth in PPT Buttock Thigh Depth - B Fixed kyphosis Accommodate with open seat to back angle not longer seat depth 4

5 Final seat depth should be less than the anatomical measurement You must subtract something How deep should it be? As long as possible if needed for support and pressure redistribution Shorter for: Tight frame or knee angles LE propulsion Wheelchair accessibility Accommodate > 2" leg length discrepancy Asymmetric cut-out Should upholstery match short or long side? Accommodate for loss of seat depth due to solid back mounted in front of backposts 16" 14" 16" 16" 16" 18" 5

6 Seat too short Poor pressure redistribution under femurs Poor support of LEs in midline - hip abduction and external rotation Compromised side transfers Seat too long Pressure at back of knees causes sliding Longer frame length Interference with LE propulsion Too short Too long Just right Lower Leg Length - C Determines front STFH or legrest length Position user in optimal hip/knee position with foot well supported Measure from back of knee to bottom of foot 6

7 Subtract compressed cushion thickness Measure with recommended cushion if possible Add height for typical footwear, as needed Foot propellers Need good heel strike Consider access to environment Consider footplate clearance Seat height too high (knees pulled down): Poor ground access for foot propulsion Difficulty with transfers Hip adduction and internal rotation Poor clearance under tables/desks, into vans Seat height too low (knees raised up): Poor pressure redistribution under femurs Hip abduction and external rotation Insufficient ground clearance for footrest(s) Poor access to objects/surfaces Potential for posterior pelvic tilt Footrest too short (knees raised up): Poor pressure redistribution under femurs Hip abduction and external rotation Potential for posterior pelvic tilt Footrest too long (knees pulled down): Hip adduction and internal rotation Distal thigh pressure Risk of sliding and posterior pelvic tilt Trigger extensor tone? Poor foot support 7

8 Foot Depth and Width - D1, D2, D3 Measure with typical footwear, orthotics or prosthetics D1 and D2 determines dimensions of footplate, shoe-holder, foot box D3 determines width needed for feet in between front hangers or side frames D2 D3 D1 Foot support too short: Poor foot position and protection Poor loading of feet for pressure redistribution Pressure on ball of foot Foot support too long: Longer overall length of chair Could interfere with transfers Taper/angle too narrow: Pressure on sides of feet/ankles Risk of ankle/foot injury during transfers Scapula and Shoulder Heights E, F Landmarks for height of back support E - measure from seat surface to inferior angle (tip) of scapula F - measure from seat surface to top of shoulders 8

9 Measure with desired cushion and add thickness of compressed cushion Use measurements as guidelines Never end back at tip of scapula Back support must be: High enough to provide optimal support Low enough to allow optimal movement Back support too high: Interferes with UE propulsion and other ADLs Uncomfortable and promotes poor posture Improper pull of anterior trunk support straps Back support too low: Instability and poor trunk balance causing compensatory postures (PPT, scoliosis) Use UE for balance vs function Improper pull of anterior trunk support straps Back pain and fatigue 9

10 Which Back Height is Appropriate? Head Height G and H Determine height of headrest and overall height of person in wheelchair G measure from seat surface to occipital ledge H measure from seat surface to top of head Subtract back height from G to estimate length of headrest hardware Add H + seat to floor height + compressed cushion thickness for overall height of person in wheelchair G H Cushion thickness STFH 10

11 Appropriate headrest height is needed to: Support head in most optimal position Reduce fatigue, increase sitting tolerance Provide optimal position for vision, eating, swallowing, communication Prevent primitive reflexes Prevent trunk and pelvic deformities Allow access into van PSIS Height - I Determines height of posterior pelvic supports or hinge of back angle Measure from seat surface to PSIS Add anatomical measurement plus gap between back support and cushion to get height of posterior pelvic supports from cushion Add anatomical measurement plus compressed cushion thickness to get height of angle in backpost from seat rail Use anatomical measurement to get height of hinge of bi-angular back from seat support (if no gap) 11

12 Pelvic supports too high: Lumbar support instead of pelvic support Pelvic support too low: Pushes person forward in seat Pressure to sacral area Back angle too high or too low: Ineffective and uncomfortable Poor positioning of pelvis and trunk Chest Width - J Determines width of back support Determines type of lateral trunk support hardware (straight or offset) or cutout for I or T back Measure across person s chest at desired height Chest Width - J For type of hardware or cut-out Subtract trunk width from hip width 18" 15" = 3" Subtract combined thickness of lateral pads (2 x ½" = 1) from result above 3" 1 = 2" Divide this by 2 2" 2 = 1" 1" offset bracket or cutout is needed on each side 1" offsets Hip width = 18" Trunk width = 15" Lateral pads = ½" each 12

13 Laterals too far away Trunk not adequately supported in midline Insufficient support for stability No correction or accommodation of scoliosis Laterals too close Pressure on ribs Discomfort Shoulder Width - K Measure shoulder width to determine width of back support for person with asymmetrical shape Measure from acromion process to acromion process Accommodation asymmetric body dimensions 13

14 Back too wide Insufficient support for posture Poor wheel access Bulky hardware for lateral supports Back too narrow Pressure from back posts Discomfort, pain Trunk Depth - L Determines length of lateral trunk supports Measure across chest at appropriate height Consider body type Barrel chest Posterior tissue Lateral pads too short Inadequate trunk support Poor contour and contact with user Pressure on ribs Pain, discomfort Lateral pads too long Interfere with transfers Interfere with UE function Poor contour and contact with user 14

15 Forearm Depth - M Determines length of arm support Position UE in functional position Consider where support is needed Measure from elbow or back support to end of forearm or fingers Armrests too short Poor support under UEs Risk of hand contractures or edema Poor support for tray Compromises transfers Armrests too long Compromises environmental access Compromises access to power input device Compromises transfers Elbow Height - N Determines height of arm support Place UE in optimal, functional position Measure from seat support to underside of forearm Add compressed cushion thickness 15

16 Armrests too high Shoulder elevation / impingement Compromised UE function Poor posture Armrests too low Inadequate support for UE joint integrity Poor support for posture Poor access to tray, input device or other AT devices Elizabeth Cole, MSPT, ATP Director of Clinical Rehab Services 16