pediatric seating and mobility - bellevue healthcare...•tone types: floppy, spastic, rigid,...

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

98

• 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

Thank You!

Sally Mallory, PT, ATP, CPST

214-763-9173

sally.mallory@yahoo.com

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 ahodges@nrrts.org

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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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