Pediatric Seating and MobilityEvaluation to Delivery
2
Sally Mallory
PT, ATP, CPST
Throughout the Day
Throughout the Years
Providing Seating and Mobility Solutions
Throughout the Continuum of Care
Team approach
child
Family
TherapistsEquipment Specialist
Manufacturer
5
The Seating Process
Referral
Client Interview
Physical Assessment
Determination of Equipment
Measurement and Translation to Equipment Choices
Simulation
Prescription with Letter of Medical Necessity
Follow-Up
Ordering and Assembling
Delivery, Check Out, Training
Client Interview
• General Information
• Medical History
• Environmental Accessibility
• Client / Caregiver Goals
• Existing Mobility Equipment Issues
• Transportation
• Self-management Skills
• Funding
Goals Of Seating
• Promote normal skeletal alignment & accommodate structural issues
• Promote functional posture & movement
• Facilitate balance in muscle tone
• Promote healthy skin
• Consider comfort & future growth/changes of client
• Promote healthy physiological functioning
• Promote greatest independence in ADL/mobility
• Accessibility in client environments & easy transport
Create a Good Functional Sitting Position
• Always start with a stable base
o Stable base (pelvis, thighs and feet)
o Balance (trunk, shoulders and head)
o Mobility (head, arms and hands)
• Skeletal alignment/mobility
• ROM limitations
• Neuro-motor status (muscle tone)
• Primitive reflexes
• Movement abnormalities
• Muscle strength/endurance
• Sensory issues
• Respiratory/cardiovascular issues
• Bowel/bladder management
• Activities of daily living
• Skin integrity
Physical Assessment
Skeletal Alignment
• Normal alignment and considerations
o Child and adult
• Abnormal alignment
o Causes and possible solutions
Physical Assessment
Skeletal System: Child Spine
Physical Assessment
Birth
•270 cartilaginous bones
•Spine-kyphotic
Birth to 3 years
•1 month- cervical lordosis
•12-15 months- pseudo lumbar lordosis
•3 years- true lumbar lordosis
11-19 years
•75% of height attained
•50% of adult weight
•Bone ossification complete by 20 year
20-25 years
•206 bones calcified
Skeletal System: Adult Spine
• Pelvis influences spine
• Lower extremity alignment influences pelvis
• Influence pelvis thru sacrum not lumbar spine
• Maintain normal curves of spine
• Head balances on spine
• Holistic approach
Physical Assessment
Normal Seated Posture
Physical Assessment
Pelvis and Spine Issues
Physical Assessment
Lordosis
Pelvic Tilt: Goal is Neutral
Physical Assessment
Neutral Anterior tilt Posterior tilt
Posterior Pelvic Tilt: Problems
• Sacral sitting, increases pressures
• Pelvic floor muscles off
• Respiratory compromise
• Increases kyphosis, decreases lordosis
• Decreases visual field
• Neck hyperextension
• Swallow difficulty
• Upper extremity function compromise
Physical Assessment
Factors Changing Pelvic Tilt
Physical Assessment
If the seat is too deep
If the child has limited hip flexion
If spasticity is very strong
May create a posterior tilt
If abducted with external rotation
May create a posterior tilt
If there is hyper lordosis with tight hamstrings or if the foot plate is mounted too high
May create an anterior tilt
Posterior Pelvic Tilt
• Undercut seat
• Front rigging angleLimited ROM hamstrings
• Head placement in space
• Tilt in Space frame
• Support/stabilize pelvis and torso
Abnormal Reflexes: TLRLow tone
Muscle weakness/paralysis
• Reduce seat depth
Seat depth too long
• Small child ½” webbing
• Below ASIS 45-60 angle 2pt., 4pt beltPelvic belt location or webbing size
Physical Assessment
Causes Possible Solutions
Posterior Pelvic Tilt
• Pelvic Harness
• 4 point pelvic belt
• Anti-thrust seat
• Dynamic back
Extensor thrust
• Open seat to back angle
• Custom cut seatLimited hip flexion
• Caution with tight hamstrings
Elevating leg rests
Physical Assessment
Causes Possible Solutions
Seat Depth & Support Through Thighs
• The seat depth must be from the back of the pelvis to about 2 fingers width from the hollow of the knee sitting on a flat or backward tilted seat
• If the seat is tilted forward, the seat depth must be shorter to accommodate knee flexion because the feet will be pulled a little backwards
Physical Assessment
Pelvic Positioning
• Hip belt always a must for stable positioning (2 point or 4 point)
• Strap mounting
o One in front of the greater trochantero One behind the greater trochanter
• Important to mount the straps as close to the child's body as possible
Physical Assessment
Pelvic Positioning
• Pelvic (sit on) harness
• The child sits on the harness
• Comes up between the legs and is mounted with the straps ~45˚to the back of the seat
• Good alternative to the 4 point belt for the smaller children
Physical Assessment
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• Posterior Pelvic Tilt/Kyphosis
• Promote neutral pelvis
o Pelvic belt
o Anti thrust seat
• Trunk 2 point control
o Thoracic cue: Convaid R82 butterfly vest
o Chest support
• Wheel placement
• Tray
Case Study
Anterior Pelvic Tilt
• Effective placement of pelvic belt
• Capture pelvis with seat shape
• Belly binder
• UE & Chest support
Flexible
• Custom molded or shaped back
Structural
Physical Assessment
Possible Solutions
Client with Arthrogryposis
Pelvic Positioning
Physical Assessment
Pelvic ObliquityPelvic Normal Pelvic Rotation
Pelvic Positioning: Solutions
Physical Assessment
The anti thrust seat is designed to prevent the pelvis from sliding forward
An anti-thrust seat gives increased depth for the ischial tuberosities as they are about 1 inch deeper into the cushion than the thighs
Laterals for the pelvis and thighs provide stability and symmetry
Abduction supports keep the knees in neutral alignment and can reduce tone
Pelvic Positioning: Anti-thrust
Physical Assessment
Pressure mapping of a 3cm cushion on a flat surface
Pressure mapping of the same 3 cm cushion, but with wedges to build up the front of the seat
Scoliosis
• Causes
o Imbalance of spinal musculature
o Asymmetrical tone
o ATNR
o Pelvic obliquity
o Muscle paresis/paralysis
Physical Assessment
Scoliosis: Both Flexible & Structural
Physical Assessment
• Flexible:
o 3 point lateral trunk & hip support system
o Subtle curved back with lateral supports
• Structural:
o For mild/moderate- severe
o Grid back, foam in place, custom molded back
Scoliosis Solutions
Holmes, et al. Management of scoliosis with special seating for the non-
ambulant spastic CP population- a biomechanical study. Clin Biomech, Jul 2003
18(6):480-487.
Scoliosis Solution: 3-point Principle
Physical Assessment
Flexible Pelvis in balance
Rigid Pelvis in balance
Head in balance
Scoliosis Solution: Contoured Back Cushion
• The back cushion can be built up with wedges or trunk supports to give support and to help the child stay in midline
• A lumbar support for smaller children is not needed (before three years old) because they have not developed a normal lumbar curve. For older children, lumbar support may assist in positioning the child correctly
Physical Assessment
Scoliosis Solution: A Back with Multiple Adjustments
Physical Assessment
Lateral thoracic supports
Width adjustment-
minimum 6”chest width
Back height adjustment
Scoliosis Solution: Lateral Trunk Supports
Physical Assessment
Swing away supports Fixed supports
Scoliosis Solutions: Anterior Chest Support
• Shoulder straps should always pull from shoulder height or above
• Back pack straps: Static or dynamic; no abdominal contact
• Butterfly: Sternum pull only, clavicle pads slip
• H-strap: Clavicle pull with anterior buckle for alignment
• Full thoracic: Sternum input, anterior chest pull, clavicle pull, g-tube clearance, consider breast relief
• Strap risers: For headrest clearance and proper posterior pull
Physical Assessment
Scoliosis Solutions: Tray
• Can facilitate symmetry
• Can create stability for head and trunk alignment
• Angling of the tray may improve the alignment of the upper body and may be used for the visually impaired
Physical Assessment
Solutions: Trunk Control & UE Assistance
Physical Assessment
Upper Arm Supports Overarm Supports Chest Vest
Tray Height and Angle Adjustable Armrests
Lower Extremity Range of Motion
• Seat to back angle
• Frame choice
• Seat options
Hip: Flexion limitations
(Hip extensor flexibility)
• Front rigging angle
• ClearanceKnee: Popliteal angle (Hamstring flexibility)
• Overall chair depth
• Adjustable foot plate, foot choicesAnkle: ROM/Orthotics (Calf muscle flexibility)
Physical Assessment
Joint Issues Chair Considerations
Lower Extremity Issues
• Medial/lateral thigh padsWindswept lower extremities
• Open seat to back angle
• Custom split seatPainful hip
• Open seat to back angle
• Custom split seatDislocation/subluxation
• Asymmetrical seat depthLeg length discrepancy
• Medial thigh padExcessive adduction
• Lateral thigh pad
• Adjustable foot plate, footrest style or strapping choices
Excessive abduction
Physical Assessment
Problems Solutions
Lower Extremity Research
• Robb, Hägglund (2013). Hip surveillance and management of the displaced hip in cerebral
palsy. J Child Orthop Nov 7(5): 407–413.
• Hip Dislocation is preventable
• Early Surveillance program includes:
o Radiography
o Clinical Examination
o Preventive Positioning
• Reimer’s Migration Percentage (MP)
o MP > 30-33°= hip displacement
o MP > 90-100°= hip dislocation
o MP > 33 consider hip surgery
• Hip Displacement is directly related to GMFCS levels
Physical Assessment
Lower Extremity Research
Physical Assessment
• McLean, et. al. Positioning for Hip Health: A Clinical Resource, Sunny Hill Heath Centre for Children BC, Canada
• Position in HIP ABDUCTION + HIP EXTENSION for hip health
• Positions: supine, sitting, standing & walking
5 months-2 years
•Sitting:
•Hip Abduction 15-30o
•Hip ER 5-15o
•Per tolerance
2-6 years
•Sitting
•Hip Abduction 15-30o
•Hip ER 5-10o
•Per tolerance up to 6 hr/day
6 years-skeletal maturity
•Sitting
•Hip Abduction 15-30o
•Hip ER 5-10o
•Per feeding, FM, mobility needs
Lower Extremity: Windswept
• Anchor pelvis and maintain lower extremity alignment
Physical Assessment
Trekker Pommel and lateral thigh
support
Cruiser or Rodeo Position Cushion
EZ Rider Medial Thigh
Support
Lower Extremity: Scissoring or Excessive Adduction
Physical Assessment
Lower Extremity: Hip Abduction
Physical Assessment
Trekker Width Adjustable Pelvic &
Lateral Thigh Support
With/Without Armrests
Rodeo Align Cushion
Cruiser or Rodeo Position Cushion
EZ Rider Lateral Thigh
Support
Lower Extremity Solution: Cushion
Physical Assessment
Solutions: Multi-Adjustable System
• Hip abduction/adduction
• Seat depth differences
• Lateral trunk pads
• Lateral and medial thigh pads
• Seat depth and width
• Back height and width
Physical Assessment
Solutions: Multi-Adjustable Features
Swing-awaylaterals
Fixed Laterals Hip ABD/ADD Seat depth differences
Physical Assessment
Foot Position
Physical Assessment
• Width, height and depth is important
• Single or parted
Head Issues
• Muscle weaknesso Forward flexion
• Capital hyperextension
• Forward flexion with rotation and/or lateral flexion
• ATNR: Rotation & asymmetrical extension
• Extensor Thrusto Head trigger
• Head Banger
• Head Shape/Size Abnormal
Physical Assessment
Solutions: Head Rests
• Provide support
• Create symmetry
• Provide stable base
• Correct and maintain position
• Mount switches
Physical Assessment
Motor Function
• Postural Stability
o Maintains the center of body (COM) over the base of support
• Postural Orientation
o Provides appropriate relationship between body parts to the environment for a task
• Quality of posture
o Determines motor skill capability
Physical Assessment 2
Movement
Posture
Position vs. Posture
Physical Assessment 2
Position
Static
Muscle inactive
Absent response to sensory input
Focus: Skeletal alignment & pressure distribution
Function not enhanced
Posture
Dynamic
State of readiness
Sensory responsive; adaptive
Focus: Skeletal mobility & motor function
Function enhanced
Postural Control: Interrelationship
Physical Assessment 2
Sensory Motor
The Challenge
• Seating specialist
o Promote optimal postural alignment without restricting movement potential and without restricting the flow of sensory information for postural control
• Manufacturer
o Develop more fluid systems, that interact & are responsive to client’s changing postural needs for movement in functional tasks
Physical Assessment 2
Components of Postural Control
Physical Assessment 2
Posture
Musculo
skeletal
Neuro
motor
Sensory
Systems
Sensory
Motor Strategies
Cognitive
Influence
Internal
Maps
Neuromotor Status: Muscle Tone & Coordination
Physical Assessment 2
Posture
Musculo
skeletal
Neuro
motor
Sensory
Systems
Sensory
Motor
Strategies
Cognitive
Inf luence
Internal
Maps
• Tone Types: Floppy, spastic, rigid, athetoid, ataxic
• Dynamic Joint Stiffness
o Force Generation
o Grading Force (scaling)
• Balance in Muscle Execution
o Co-activation
o Reciprocal inhibition
• Muscle Contraction
o Initiate, Sustain, Terminate
• Coordination
o Sequencing & Timing
• Muscle Synergy
o Coupling muscles for task
Neuromotor Status
Physical Assessment 2
• Muscle Tone= force which a muscle resists being lengthened
• Hypotonic - Floppy
• Poor force generation or scaling
• Poor sustainability
• Limited control of termination
• Poor co-activation & reciprocal inhibition
• Limited coordination
Neuromotor Status
Physical Assessment 2
• Hypertonic – Spastic
o Imbalance of muscle activity about joint
o Poor ability to grade & scale force
o Coordination limited
Neuromotor Status
Physical Assessment 2
• Fluctuating Tone
Athetoid
Large amplitude, less frequent fluctuations
Damage in motor areas of brain
Mid range control an issue
Proximal stability an issue
Enjoy movement, risk taker
Ataxic
Low amplitude, frequent fluctuations
Damage to cerebellum
Intention tremor
Problems with balance, coordination, depth and perception
Not risk takers
Sensory Systems Influencing Posture
Physical Assessment 2
Posture
Musculoskeletal
Neuromotor
SensorySystems
SensoryMotor
Strategies
CognitiveInfluence
Internal Maps
Visual •Visual reference to space and objects
Auditory •Sound waves identify objects distance to client
Somatosensory-Tactile
•Discriminations shape/texture
•Helps body adapt to environmental changes
•Deep pressure, touch, vibration, pain
Somatosensory-Proprioception
•Provides info for body schema/position sense
•Provides info for timing/speed of movement
•Helps plan, learn and remember movement
Vestibular
•Provides info on body orientation to gravity
•Provides info on speed, direction of head motion
• Influences tone, equilibrium, arousal, bilateral coordination, directionality
Sensory: Seating Choices
Physical Assessment 2
• Frame orientation
Visual
• Head support not blocking ears
Auditory
• Back seat shape
• Upholstery material/texture
• MediumSomatosensory
• Frame orientation, tilt, recline
Vestibular
• 10 years old
• Dravet Syndrome
• Seizure disorder
o Low tone, crouched gate, ambulation fatigue
o Sensory-processing issues, easily overstimulated, stress induced seizures
o Post-ictal state, reduced responsiveness, requires oxygen
Case Study: Kye
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• Convaid Rodeo
• Provides for:
o Postural support
o Security, reduced stimulation
- Harness
- Oversized canopy
o Medical needs
- Recline post-ictal
- Medical basket for O2
Seating Solution
Sensory Input & Feedback
Physical Assessment 2
• Critical for motor development
• Feedback: Sensory used to modify motor output to hit mark
• Feed-forward: Postural adjustments made in anticipation of actual task requirements
• Individuals learn movement and postural adjustment through feedback, then perform them with feed-forward for automatic or habitual movements
Seating choices
Allow some movement potential in
system
Sensory Motor Strategies = Motor Development
Physical Assessment 2
Posture
Musculo
skeletal
Neuro
motor
Sensory
Systems
Sensory
Motor
Strategies
Cognitive
Influence
Internal
Maps
• Normal Development
• Abnormal Development
Normal Motor Development
Physical Assessment 2
• For the first 3-5 month
o Midline orientation
o Head raising/extension
o Rotation within the body
o Extension and abduction of limbs
o Equilibrium reactions in prone and supine
Normal Motor Development
• 6-7 months: Ring sit
• Sit without UE support
• Good head & trunk control
• UE free to explore toys & environment
o Visual perceptual
o Visual spatial
o Aids cognitive development
o Aids feeding independently
o Oral motor development precursor to speech acquisition
• Muscles controlling pelvis active:
o Hip extensors and oblique abdominals
o Control weight shift across pelvis
R82.com
Physical Assessment 2
Less experienced sitter More experienced sitter
Normal Motor Development
Physical Assessment 2
• From 6-10 month
o Active stable base
o Spine in a straight line
o Body and head balanced and hands free
o This posture requires the least amount of effort to maintain the position
Motor Development
Physical Assessment 2
1m• Cervical extension
3m• Prone on forearms
• Midline orientation
4m• Lumbar extension “swimming”
6m• Hip ext/abdominals active
• Sitting without UE support
• Weight shift across pelvis
• LE dissociation
1m• Lack effective cervical extension
3m•Neck/head hyperextension & shoulder elevation
•Lack thoracic extension
4m•Humeral ext/add/IR used for spinal extension
•Prone: lack humeral flex/ER to prop on elbow
6m•Weak oblique abdominals & hip extension
•Poor sitting base
•Poor weight shift at pelvis
•Limited LE dissociation
•Rectus Abdominus is short: rocks pelvis posterior & LE extend
•Poor stability in shoulder & pelvic girdles
Normal Abnormal
Abnormal Development
Physical Assessment 2
Shoulder Extension
Internal Rotation/Adduction
Capital Hyperextension
Abnormal Development: Solution
Physical Assessment 2
Angle adjustable tray with elbow blocks to promote effective
weight bearing & shoulder girdle synergy
Abnormal Development
Physical Assessment 2
Abnormal Development
• Unable to manage weight shift at pelvis which is key to postural control
• Poor sitting base
• Poor pelvic weight shift
• Weak oblique abdominals
• Weak hip & spinal extension
• Rectus Abdominus short, pulls pelvis posterior
• LE react in extension
Physical Assessment 2
• Anterior Tilt
o Muscle re-education and strengthening
o If client cannot actively manage pelvis, than support through seating system options (Myhr von Wndt 1991; Cherng et al.
2009)
Abnormal Development: Solution
• Anterior Tilt
o Can be achieved with Trekker, Flyer, Kudu, Wombat Living
o Promotes:
▪ Functional pelvic synergy/active sitting
▪ Fine motor activities
▪ Feeding
▪ Speech
Abnormal Development: Solution
Motor Capability Assessment
• Head control
• Trunk control
• Sitting balance
• Fine motor capability
• Transfer capability
• Ambulation capability or limitations
• Pressure relief capability
• Self care skills: feeding, dressing, toileting
Physical Assessment 2
Other Considerations
• Physiologic Systems
o Respiratory Status
▪ Ventilator needs within life of new chair
o Renal/Bladder
o GI Issues
▪ Reflux▪ Bowel (e.g. voiding, constipation, absorption)
o Skin Issues
• Vision
• Cognitive Status
Physical Assessment 2
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Case Study: Madi
• 4 years old
• 5q14.3 Microdeletion Syndrome
• Developmental Delays
• Low tone in her trunk and neck with high tone in her UE and LE
• Extensor tone
• G-tube fed
• Visual deficits
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The Seating Process
Referral
Client Interview
Physical Assessment
Determination of Equipment
Measurement and Translation to Equipment Choices
Simulation
Prescription with Letter of Medical Necessity
Follow-Up
Ordering and Assembling
Delivery, Check Out, Training
Product Application
• Identify Major Client Problems
• Structural or flexible issues
• ROM limitationsSkeletal
• Abnormal muscle tone, muscle weakness
• Abnormal movement strategies
• Sensory issuesPosture/Movement
• Bowel/bladder management
• TransfersADL or Self Care
• Respiratory (vent)
• Gastrointestinal (g-tube)
• Skin
Other
• Home, school, work
• TransportationClient Environment
Seating Goals Specific to Client Needs
• Promote normal skeletal alignment & accommodate structural issues
• Promote functional posture & movement
• Facilitate balance in muscle tone
• Promote healthy skin
• Consider comfort & future growth/changes of client
• Promote healthy physiological functioning (RS, CV, GI)
• Promote greatest independence in ADL/mobility
• Accessibility in client environments & easy transport
Measurements Critical for Equipment Choices
Translate Client Measurements & Goals Into Equipment
• Frame Choice:
• Power Wheelchair
• Manual Wheelchair
o Dependent
o Self propelling
• Tilt-in Space
• Recline
• Combination
• Dynamic
Independent Mobility: Why?
• A child usually explores the environment through crawling about 9-10 months of age
• This experience increases sensory input of vestibular, visual & somatosensory systems as body moves
• Increases trial & error: coupling of motor output to specific task
• Increases cognition through problem solving for barriers & visual spatial issues
• For the child needing assistance - walkers, gait trainers and wheeled standers need to be used as soon as developmentally appropriate
• For the non-mobile or non-ambulatory child, self propulsion with manual WC or power WC should be considered as early as 10-15 months if they have potential to be independent
Early Mobility: Why?
• Immobility associated with learned helplessness
• Established by age 4yr in children without functional mobility (Butler, 1991; Safford & Arbitman, 1975; Lewis & Goldberg, 1969)
• Decreased curiosity & initiative
• Poor academic achievement
• Poor social interaction skills (Kohn, 1977)
• Passive, dependent behavior
• Lack object permanence
• Dependent on vision to control posture (Bai & Berenthal, 1992)
• Poor visual spatial skills and memory (map testing difficult)
Dependent Mobility: When?
• Client is unable to self propel a manual WC
• Family does not have vehicle to transport a power chair or financial means to purchase appropriate vehicle
• Family not interested in power WC presently
• Environmental limitations:
o Home layout
o 2nd floor apartment
o Daycare does not allow power mobility in center
Tilt and/or Recline: Rationale
• Realign posture and enhance function
• Enhance visual orientation, speech, alertness, and arousal
• Improve physiological processes orthostatic hypotension, respiration, bowel/bladder function
• Improve transfer biomechanics
• Regulate spasticity/muscle tone by changing joint angles
• Accommodate/prevent contractures and orthopedic deformity
• Manage edema
• Pressure management
• Increase seating tolerance/comfort
• Independently change position to allow dynamic movement
RESNA 2015
White Paper
Tilt In Space
• Allows change in orientation to gravity
• No change in Seat to Back angle
• No change in relationship of client to
seating components
Standard Recline
• Allows change in orientation to gravity
• Change in Seat to Back angle
• Linear and Angular change in
relationship between seating
components and client
Orientation of Seating System in Space
Tilt in Space: Posterior
• Pressure relief
• Assist with skeletal alignment
• Promote functional posture
• Promote effective physiological function
o Orthostatic hypotension, GE reflux, respiration, digestion
• Aid feeding/swallow (Tilt 5-30°)
• Assist with venous return insufficiency or edema
• Aid in transfers: lifting
• Provide comfort
Pressure Relief
• TS and Recline affect pressure/perfusion of skin and muscle tissue at ischial tuberosity, less at sacrum.
• Tilt used alone, >25° to achieve pressure relief and/or tissue perfusion at ischial tuberosity
• Recline 120o + ELR significantly reduced pressure
• Greatest reductions in pressure with combination
o Tilt of 35° with recline 100°
o Tilt of 25° with recline of 120°
• Greater angles = greater pressure relief
RESNA 2015
White Paper
Tilt in Space: Posterior
• 45o posterior tilt
• Rodeo without seating can accommodate After Market Seating
• Stingray
o Tilt in space 0-45o
o Full recline
o 180o turn-able seat
Tilt in Space: Posterior
• Increase muscle strength in spine/ hip extensors for functional pelvic synergy
• 95% functional tasks occur here
• Speech production, intelligibility, & feeding (Costigan & Light, 2011)
• Improvement in respiration (FVC) spastic CP (Shin, Byeon, & Kim 2015)
• Improvement in vital capacity & forced expiratory volume (Mac Neela, 1987; Nwaobi & Smith, 1986)
• Transfers
Tilt in Space: Anterior
Trekker
Tilt in Space (-10 to 45o)
Recline (170o)
Central Gravity Axis Tilt
• Greater stability in full tilt
• Aligns center of gravity with center of rotation
o Maintains client’s mass within the center of the frame
• Greater environmental accessibility - smaller footprint
o Access to tabletop activities
• Less weight transferred to casters when upright
o Reduces energy to push chair & caster repair issues
• Excellent frame for clients with sensory processing issues, extensor thrust, LE spasms, obesity
Central Gravity Axis Tilt
Convaid FLYER
Extremely lightweight
WC19 tested
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• Lightness of a stroller with growth & seating of a WC
• 5° Anterior Tilt- 40° Posterior Tilt
• Growth through Seat Pan
o 4” seat widtho 4” seat depth
• Accepts Convaid or After Market Seating
• Multiple wheel choices
• WC 19 crash tested
• Extremely lightweight; Portable base frame under 14 lbs.
• Seating without front rigging under 18 lbs.
Central Gravity Axis Tilt
Case Study: Justine
• 5 years old
• Ehlers-Danlos, Hypotonia and Coordination
Disturbance
• Frequent falls, skin breakdown and hypersensitivity
of her integumentary system
• Decreased balance and strength after 15 minutes of
ambulation without a device
• Current equipment:
o Scallop chair
o Carrot car seat for assistance in the car due to low
back pain
o Rodeo
• Chokes with thin liquids unless environmental
supports are in place
• Mom has same syndrome
Case Study: Solutions
Convaid Rodeo Convaid Flyer
Case Study- Justine
• Homeschooled- anterior tilt for table top activities
10
1
Crocodile Gait Trainer
Case Study: Solutions
Carrot Car Seat
Recline
• Management of bladder/catheterization to avoid urinary retention
• Pressure management
• Postural hypotension/blood pressure (SCI)
• Respiratory compromise
• Limited hip flexion
• Increase sitting tolerances (CP, SMA, SCI)
• Comfort
• Daily needs: sleep, G-tube feedings, diapering, trach care, post seizure
• Assist with transfers
• Manage edema or venous return insufficiency
Medicare and Medicaid Reimbursement Criteria
Tilt
Client at risk for developing pressure injury and unable to
perform functional weight shift
Increased or excessive muscle tone /spasticity related to a
medical condition that will not change for at least one year
Recline
Client at risk for developing pressure injury and unable to
perform functional weight shift
Client uses intermittent catheterization for bladder
management
Unable to transfer independently from W/C to bed
Used to manage increased tone or spasticity
Case Study: Hamza
Goals
• Feeding goals/Visual scanning
Convaid R82 Chairs with Recline
10
7
Rodeo
Convaid
Trekker
Convaid
Flyer
Convaid
Stingray
R82
x:panda on Stingray base
R82
x:panda on Multi-Frame
R82
Convaid R82 Tilt in Space & Recline
Posterior TS
•Rodeo
•Trekker
•Flyer
•Kudu
•Stingray,
•x:panda/multi-frame
Anterior TS
•Trekker
•Kudu
•Flyer
Central Axis TS
•Flyer
•Kudu
Adjustable TS Full Recline
•Trekker
•Flyer
•Stingray
Partial Recline
•Rodeo
•Kudu
•x:panda
Adjustable TS &
Recline
• Frame or seating components
• Possible uses:
o Extensor thrust /spasms
o Sensory processing issues
o Allow dynamic movement
o Reduce WC breakage
Dynamic Seating
Extensor Thrust
Hong, et al. (2006) Indentification of human-generated forces during extensor thrust.
International Journal of Precision Engineering and Manufacturing. 7(3): 66-71.
Extensor Thrust Effects
Figure : Motion tracking for (A) rigid and (B) dynamic seat back configurations
Patrangenaru, V. (2006) Development of Dynamic Seating System for High-tone Extensor
Thrust. Georgia Institute of Technology.
• Materials and Method:
• 10 children
o 6-12 years old
o GMCFS Level V
• Seating system x:panda
• Evaluated
o with a dynamic back
o with a static back
Research
Cimolin, et al. (2009) 3-D Quantitative evaluation of a rigid seating system and dynamic
seating system using 3D movement analysis in individuals with dystonic tetra paresis.
Disability and Rehabilitation: Assistive Technology: 4(4): 422-428.
x:panda Dynamic Back
Clients with extensor thrust or sensory processing issues
Dynamic Back:
Can open or lock out
Recline:
Pivot point near hip joint Less Shear/Skin
Deformation
Also can be locked out
Data collection
Optoelectronic system
Passive markers
Pressure mapping
Dynamic
Session
5 sec pause
Clap
10 sec pause
Clap
10 sec pause
Clap
10 sec pause
Static
Session
5 sec pause
Clap
10 sec pause
Clap
10 sec pause
Clap
10 sec pause
• Head
• Torso
• Upper extremities
• Lower extremities
• 6 markers on the seat to represent the movement of the back
Position of Markers
Static Dynamic
Pressure Distribution Results
Results & Impressions
• Greater ROM of head and trunk in the forward backward direction in dynamic configuration
• Greater ROM of trunk in vertical direction in static configuration meaning greater sliding of patient in static configuration
• Movements in UE’s larger in static versus dynamic configuration
Discussion
• Demonstrates that the seating system in dynamic configuration improves the stability and the comfort of the users during the extensor thrust
• The forward slide of the pelvis is limited significantly with the use of the dynamic system
• In some subjects the movements of the upper limbs are more contained and more smooth while in the dynamic system
Case Study: Taylor
• 8 years old with Cerebral Palsy
• Fluctuating muscle tone and has no
independent sitting balance
• Tends to push through the backrest as
part of his extensor pattern
• Mom has really struggled to position
him well due to his high tone
• Mom struggled to hold his pelvis in
previous seating like she had been
shown by her OT
• Mom found getting harness and belt
on was very difficult. She never had
enough hands
Postural Solutions
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Dynamic Seating Solution
• Dynamic back provided Taylor with enough
resistance while giving some ability for him
to push back with his extensor tone
• Tilt and recline functions are specially
designed to articulate around the hip and
allows gravity to assist positioning.
• Taylor’s pelvic position was maintained and
his spine was supported in neutral
alignment.
• The lateral and head supports stayed in the
desired position without any shear effect.
• Taylor was content and able to sit for longer
periods and his Mom found it much easier
to position him in his new seat.
Once Equipment Decision Made
Simulation with equipment if needed
Letter of Medical Necessity (LMN)
•All parts specifically justified for client’s issues
LMN and prescription sent by Equipment Specialist to third party payer
•Upon approval, equipment ordered and assembled
Delivery/Checkout with original seating team
•To ensure all items are correct
Follow-Up
Letter of Medical Necessity
• Written by Professional
• Paint a picture of the client
• Detail present equipment problems and reasons it can no longer be used
• Describe therapeutic goals for new equipment
• Describe trials/use with this equipment and others if necessary
• Provide clinical reasoning for each line item of equipment that is being requested
specific to client’s issues
• Clearly state problems that will occur without the procurement of this equipment
Delivery/Checkout
• Delivery occurs with original team present
• Check that all parts as per prescription are on the chair
• Ensure proper fit of client in new seating system
• Determine if seating goals have been met
• Parent and caregiver instruction
• If problems arise, specify what will be done and timeline for its accomplishment
• If practice is needed (e.g. power mobility), set up therapy sessions
Course Evaluation and Certificate Instructions
1. Go to: www.brainsbuilder.com
2. Select “Take an assessment”
3. Enter Your Assessment ID: (provided by presenter)
4. Enter Your Login: Convaid
5. Complete evaluation
6. Certificate of Completion will be sent to the email you provide in evaluation
Contact: Annette Hodges NRRTS [email protected]
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A Special Thanks to the Following Contributors:
K Missy Ball, MT, PT, ATP
Helle Matze Rasmussen, PT
Bente Storm, PT
Francis George, MSc, BSc, MCSP
Sally Mallory, PT, ATP, CPST
Julie Kobak, MA, CCC-SLP
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