The Benefits of Dynamic Seating For Individuals with Abnormal Tone Patterns. Disclaimer Paid consultant with Invacare. Learning Objectives 10/10/2018

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1 Jill Sparacio, OTR/L, ATP/SMS, ABDA The Benefits of Dynamic Seating For Individuals with Abnormal Tone Patterns Disclaimer Paid consultant with Invacare o No financial relationships with other manufacturers o Importance of establishing relationships with manufacturers Learning Objectives Participants will be able to Identify 2 common tone patterns that can interfere with seated posture. 2. List 3 factors that need to be considered when evaluating clients for dynamic components. 3. Match 3 different dynamic components with the body parts that are impacted by their use. 1

2 Difference between suspension and dynamic What are the differences? Do each serve the same function? Can they be used in conjunction with each other? Sus-pen-sion 1. the action of suspending someone or something or the condition of being suspended, in particular. 2. the system of springs and shock absorbers by which a vehicle is cushioned from road conditions. Suspension Functional comfort o Mobility Management, April 2018 Intention: add some type of cushion between what the terrain is providing and what the end user is actually experiencing Provides downward force, traction and leverage of wc to terrain Sensitive to type of spring used (soft or hard), weight of system and end user 2

3 Suspension Ultimate function of a good, balanced suspension: Allow someone to navigate smaller obstacles safely, smoothly and with almost no jarring or movement of the seat Suspension Can add to durability of wc: o Decreased vibration and rattling of the wc allows equipment to hold up longer Can result in: o increased comfort, o moderation of tone (less elicitation of spasticity, extensor tone leads to overall improved head and trunk positioning, o decreased pressure injuries Wheelchair Suspension Parts of a mobility system that respond to energy created by moving over terrain/through environments o Can include dynamic components o Not all dynamic are suspension o Not all suspension are dynamic 3

4 Quadshox System to offer shock absorption to tilt in space bases o Designed by a tilt in space user o New product available for some bases, working on more o Not truly a dynamic option as we are talking about today responds to energy from user as well as environment. Dy-nam-ic: 1. (adjective) (of a process or system) characterized by constant change, activity or progress. 2. (noun) a force that stimulates change of progress within a system or process. 4

5 Dynamic Stability Stability infers still Consider use of the term dynamic stability Dynamic Stability A balance of dynamic movements in combination with stability results in improved function. What happens without dynamic stability? Dynamic Seating - Definition Components of a mobility system that respond to movement by the client o Allows for changes in position o Allows for absorption of energy or movement in response to force from the client What it is not: o Adjustability of base or seating o Dependent tilt or recline or elevating legrests 5

6 Dynamic vs. Suspension Dynamic responds to the end user Suspension responds to the environment But can one do the other s job? Dynamic vs. Suspension What drives dynamic? (or the need for movement) o Facilitation for a functional ability or outcome o Fill a demand for sensory stimulation o Influence of abnormal tone patterns o Drive for increased comfort Why Is Movement Important? Movement drives brain development o As infants move, their nervous systems begin to understand how their bodies work 6

7 What happens when there is a glitch? Causes of glitches : o Problems with musculoskeletal, neuromotor, sensory systems o Problems with the ability to effectively use or modulate sensory stimulation Processing Registering of input So what do we see? Typical Diagnoses That Elicit Abnormal Tone Patterns Neurological in presentation o Refers to injury/insult/disease process in central nervous system Spinal cord injury Traumatic brain injury Cerebral palsy o Can result from nerve issues outside of CNS Neuromuscular: ALS Muscular dystrophy Muscle Tone Categories Definition: state of tone/tension of muscles at rest Types: o Hypotonicity: state of low muscle tone, often involving decreased muscle strength o Hypertonicity: continual increase in muscle tension o o Spasticity: often confused with hypertonicity; hyper-reaction of muscle fibers in response to quick stretch Mixed presentation: muscle tone presentation is imbalanced with some groups hypotonic while others are hypertonic Fluctuating tone at rest, generally low tone; with elicitation of a motor request, imbalanced hypertonicity kicks in o Can be a learned movement pattern when active movement is not available otherwise; can be the result of primitive postural reflexes that were not properly integrated. 7

8 Tone Issues Managing Tone o Understanding tone pattern Observation Mat evaluation Where does it start? How does it manifest itself? o Importance of clinical reasoning Typical Imbalanced Tone: Common Patterns Flexion Patterns Extension Patterns o Posterior pelvic tilt o General flexion in spine o Forward head position o Hips often flexed, externally rotated, abducted o Knees flexed o Feet dorsiflexed o UE s vary but often flexed, some shoulder adduction o Anterior pelvic tilt (sometimes) o General extension in spine o Extended head position o Hips often extended, internally rotated, adducted o Knees often extended o Feet plantarflexed o UE s vary but often extended at sides, some shoulder abduction and extension 8

9 Need for Dynamic Components How do we determine where movement is needed? Movement occurs at joints Tone patterns are usually triggered by specific joint movement In the evaluation process, watch pattern: o Where does it initiate? o Where does it travel to? o What allows it to dissipate? Types of Movement 3 distinct groups of movement o Movement for function o Movement to accommodate or lessen abnormal muscle tone/tonally driven o Movement for sensory stimulation Movement for Function Facilitation of function Example: brushing teeth with shoulder weakness What happens when movement is not available? o Loss of function o Discomfort o Equipment breakage if movement is gained and strong enough. 9

10 Accommodation of Movement Disorders Determining Need Consideration needs to be given throughout evaluation process o Not last minute, band aid approach o Discuss in depth in interview portion of evaluation Power of observation o Observe movements o Observe wear and tear on current equipment 10

11 Possible Benefits Also known as outcomes, goals.. o These are the reasons that translate into justification for funding Possible Goals Improve function by. o Improve sitting tolerance o Improve range of motion o Energy conservation o Improve strength o Provide vestibular stimulation organizing, calming o Decrease episodes of agitation o Increase level of alertness Determining Location Also observed during the evaluation process o Where is movement generated? Generally corresponding to body joints (axis point for movement) o Why is it generated? o Less is sometimes more..more dynamic components are not better 11

12 How Much Movement? How much resistance to movement is needed? How much movement excursion is needed? If excursion of movement is max d out, can the strength of the resistance return to midrange of the movement? o If yes, ok o If no, something needs to change What Kind of Movement? Suspension can provide dynamic opportunities 12

13 When Things Go Wrong.. Risk of injury to the client Risk of breakage of equipment o Impact on: Equipment use Funding Preventing Breakage and Injury What causes the breakage? Tonal imbalances/asymmetries o Hypertonicity o Fluctuating tone patterns Persistence of primitive reflexes o Forceful ATNR o STNR Movement disorders/involuntary movements o Desire to gain sensory stimulation Common Areas of Breakage oside frame oattaching hardware olegrest oheadrest/hardware 13

14 Equipment Breakage Side frame of wheelchair Equipment Breakage Solutions: o Dynamic frames o Dynamic rear cane/ seat frame 14

15 Possible Breakage Attaching Hardware Possible Breakage Hardware solutions o Determine where movement is elicited o Dynamic component needs to match movement location Attaching hardware vs. seat to back angle Possible Breakage Legrests o Breakage can occur any place in the legrest o Breakage occurs in the direction of the force Extension Rotation Combination of pattern 15

16 Possible Breakage Legrest Solutions Headrest Headrest 16

17 Headrest Other Dynamic Components Postural accessories o Anterior trunk supports, pelvic straps o Rigid fabric vs stretchy Possible Breakage Managing Breakage: Some dynamic solutions can have breakage o Can occur over time from: Repetitive use Imbalanced use Improper positioning in system (changes forces) 17

18 Clinical Applications Managing breakage: Questions? Jill Sparacio, OTR/L, ATP/SMS, ABDA Sparacio Consulting Services 18