| How many times
have we been involved in the design and delivery of a seating/mobility
system and later discovered that everything isn’t as hunky-dory
as we thought? Occasionally, even the best-crafted seating systems
may not function properly after delivery due to the mere fact that
it is not being used in the manner intended. Sometimes, we even
discover that the system’s design and structure (though ideal
for the consumer’s physical requirements) is simply not compatible
to the living arrangements or lifestyle of our client. A lot of
thought and medical knowledge may have gone into the seating/mobility
system’s composition but once it leaves the shop or clinic
all of that professional and technical know-how may not translate
into a successful, well-suited arrangement. This type of temporary
negative outcome may result from a simple design oversight or it
may have nothing to do with the physical make-up of the seating/mobility
system at all.
Our goal as professionals is to minimize these ill-fated mismatch
scenarios as much as possible. Regrettably, there is no single or
simple assessment tool used within this industry that can precisely
outline the seating and positioning equipment requirements for the
myriad of body types, disabilities and living arrangements presented
by the wheelchair dependant population we serve. Nonetheless, whether
presented with the simplest or the most complex client profile,
there are a number of influencing variables (beyond the basic technical
perspective) that must be considered to assure any degree of seating/mobility
success. Included within this list are the:
- Client’s physiological disposition and postural requirements
- Caretaker’s interaction with the consumer and their equipment
- Environmental and lifestyle constraints
- Goals/intent for the project as outlined during the assessment
- Seating system structure, composition and design
- Influencing factors after delivery
Before we proceed further, let me clarify that within the context
of this discussion, “success” in defined as a process
and continuum that includes achieving predefined goals and objectives
and recognizing that those goals extends far beyond the delivery
date of any custom made product. On the other hand (and though correctable),
“failure” is defined by the consumer’s inability
to realize the benefits and goals scripted on their behave and as
outlined in the measures of best practice or letters of justification.
So, with that in mind, not every item on the above or following
checklists will apply to every client or project. Likewise, uncovering
these variables may be easier with some clients than with others.
Take for example the architectural obstacles within an apartment
as compared to those of an institutional setting. Consider also
the assessment regimen of an adult with a newly acquired disability
versus a consumer with decades of experience and knowing firsthand
what intricate details to look out for in a seating/mobility system.
The awareness on our part of these potentially influencing variables
will no doubt impact the framework of any seating/mobility project
we encounter. On the other hand, the likelihood for a negative outcome
will increase over time if a significant influencing variable is
present but overlooked or worse yet, not given sufficient consideration.
So, lets take a closer look at the list and their potential impact
on the long-term success/failure of the finished product:
The Client’s Physiological Disposition And Postural
Requirements
Every assessment process must include basic, universally recognized
information about the client, such as: body and ROM measurements,
determination of skin pressure tolerance and posture/stability requirements,
etc. A diagnosis will provide many clues as well but we cannot presume
that every case (with a similar Dx) will present with similar physical
support or postural alignment requirements. For many consumers who
are lifetime dependant upon a wheelchair there will be additional
physiological or body orientation requirements that are either constant
or episodic and will ultimately impact the shape, function and viability
of their seating/mobility system. The following is a list of physiological
variables that should be considered at the time of the posture assessment
and prior to the mold making sessions:
Fatigue
It occurs often enough to mention that a lack of sleep or excessive
fatigue due to chronic pain (or other reason) on the day of assessment
can significantly influence the postural alignment of the entire
upper body and may yield misleading results or conclusions. Ask
your client or their entourage whether the posture you observe today
is typical or not and what differences are present under rested
conditions.
Medications
Medications that affect muscle tone, thinking clarity or create
physical lethargy but are not taken (or overdosed) on the day of
assessment may yield a picture of incorrect postural norms. Also,
ask whether the type, modality or strength of medications will change
in the near future.
Pain
Chronic pain can be a biggie. Make sure both you and your client
have a full understanding of its origins and if necessary, request
a formal medical assessment. Even if you manage to create a sitting
environment that can reduce the stress that is causing the pain
your client may not realize the benefit of the improvement until
the affected tissues have had a time to heal. Also consider this;
if your client’s physician can’t solve the problem what
chance do you have?
Respiration
A person’s body alignment and orientation-in-space can greatly
affect respiration. Verify whether limitations exist or if the client
will be changing to mechanical assistance in the near future.
Feeding
The propensity to aspirate food will dictate the orientation of
the consumer while being feed. For a client who has recently received
a G-tube (or is scheduled to receive one) there will be a strong
potential for weight gain. An individual, who is expected to feed
them self, will require good upper body stability and freedom for
gross arm movements.
Vision
Often overlooked, vision impairments can greatly influence head/neck
and spinal alignment. Impaired vision can also influence the manner
in how a power w/c is operated and where communication devices must
be placed. If in question, ask for a formal vision assessment before
the seating design is completed.
Communication
Vocal, eye movement or body movement communication can either be
enhanced or impaired by positioning aids. Always verify the modality
and have the client demonstrate their technique and ability.
Body Heat
Whether it’s the weather or an inability to regulate body
temperature, perspiration and skin surface humidity will greatly
influence how the finished product is upholstered, waterproofed
or coated. Also, skin that becomes macerated by prolonged exposure
to moisture is more vulnerable to breakdown.
Asensory Skin
While the buttock is the biggest concern, sensory impairment of
the hands can also create very unusual requirements for holding
the controller knob of a power w/c. Also, make sure you have a clear
understanding of how transfers (to and from the wheelchair) are
performed at the residence as it is during this act that many soft
tissue insults occur.
History or presence of pressure sores
Sitting tolerance, wound care modality, scares, clothing and upholstery
can either influence the shape or the effectiveness of a seating
system. The desire to sit and maintain mobility is a big obstacle
while an ischemic ulcer is present (chronic or otherwise). Obviously
no pressure against the wound is the best treatment in this scenario.
The only advice I can offer is that 4” high, 4 valve air-filled
cushions with selectively collapsed cells can’t be beat. Finally,
an employed consumer will always want to remain employed by any
means possible. In this context, don’t be surprised if you
find strong opposition to the recommendations you make in reference
to the principles of wound management and healing.
Orthopedic Deformities
Skeletal deformities can be compensatory, correctable or fixed.
They can be present at birth, surgically created, acquired over
time or the consequence of trauma. Remember that scoliosis is a
deformity that includes the spine, ribs and pelvis, usually increases
over time and is strongly influenced by the affects of gravity,
posture or functional activities. Combined with low tone, spinal/pelvic
deformities present some of the most difficult postural challenges.
For an adult using a tilt-in-system, fixed kyphosis should be supported
throughout the length of the curve. However, for somewhat flexible
kyphosis combined with a tilt-in-space system you will have to make
the judgment as to how much thoracic extension is possible and at
what angle the shoulder complex should be supported in the tilted
position.
Fixed or flexible kyphosis combined with a growing body presents
an entirely different set of concerns. The question becomes, how
much support should be provided above the apex of the curve? If
the backrest shoulder support section is adjustable then the future
is easy to accommodate for. If built incorrectly however, a molded
backrest could actually promote the progression of the kyphosis
as the skeleton continues to lengthen.
Head and Neck Stability
A forward flexed neck and head combined with kyphosis is no doubt
the single most difficult deformity to manage. Especially when the
forehead is either foreshortened or slants rearward. The most effective
tool seems to be a tilt-in-space feature if the chance for aspiration
is not an issue. The Hensinger Collar (and the like) seems to provide
some stability benefits, providing that the neck is not too long.
Still, no cervical collar will change the force momentum that causes
forward flexion. Furthermore, long-term dependency upon a collar
could promote further weakening of the supporting musculature.
Significant Asymmetry of the Upper Limbs
The most likely influence of a missing, malformed or neurologically
impaired upper limb is the listing of the trunk to the non-affected
side. This tendency to lean or rotate to one side is even more apparent
when the consumer operates a powered wheelchair. A de-rotational
harness may improve postural stability but it will limit other body
movements.
Arm Control in Sitting vs. Tilt or Recline
As seating designers, most of our efforts are to maximize arm and
hand function in an upright sitting position. Don’t forget
to assess the impact of either tilt or recline, especially with
clients diagnosed with a deteriorating muscle disorder. Posterior
or lateral arm supports may be required if your client is expected
to independently operate a tilt switch.
Skeletal Fusions of the Spine or Hips
Existing or planned fusions will dictate how the body must be supported
or aligned. If such interventions are planned, determine whether
the system can be modified later or whether the entire project should
be postponed. Some clients must wear a body jacket or other orthotic
brace while seated. Make sure their orthosis accompanies them to
the assessment and that the seating system provides accommodation
for any such devices.
High-Level Lower Body Amputations
Listing to one side can be a problem for someone with a very high-level
absence of the lower limb (either congenital or surgical). In the
case of a hip-disarticulation or hemipelvectomy much of the anatomical
support structure is missing and must be compensated for within
the profile of any fabricated support surface. The stability, firmness
and shape of the support structure will influence the client’s
upper body and hand function stability and can even help prevent
a future soft tissue or organ hernia.
Lower Leg and Foot Alignment
Many individuals who have spent months or even years in bed tend
to develop multiple deformities of their skeletal alignment. Consequently,
when a seating system is designed, a big question arises as to what
to do if either or both legs are fixed so that the lower portions
project laterally, outside the framework of the wheelchair. In minor
cases the frame can be ordered wider (if practical). However, with
severe cases or when a wider frame is not practical, I am of the
belief that the person’s entire body should be rotated to
fit within the parameters of the wheelchair base. If not done so,
accommodating for leg positioning outside the framework of the wheelchair
can yield a design that is too wide to fit through the average doorway
or hallway, especially in an apartment setting. Skewing of the shoulder/head/vision
complex can be accommodated for once the individual arrives to their
activity area.
The Growing Skeleton
In pediatrics the question always arises as to how many years of
growth-accommodation will the seating system provide? That question
is easier to answer by reviewing how many skeletal deformities currently
exist and what is the expected rate of progression of these or other
consequential deformities? Also question whether a low-cost planar
system will provide the necessary support for severely pronounced
deformities. And finally, question whether or not the existing deformities
can be corrected either with therapy or by way of surgery? No matter
the conclusions, the end products design must also provide accommodation
for growth and sequential postural alignment changes.
The Caretaker’s Interaction With The Client And Their
Equipment
No seating system should be manufactured without the input of the
consumer and their principle caretakers (if applicable). Training
on: the purpose for, and the appropriate use and care of the seating
system and mobility base are key elements in the success/failure
of any seating/mobility system. The instructions given to the principle
caregiver(s) at the time of delivery must later be shared with everyone
who will (at one time or another) care for the consumer/client or
charge. The consumer or principle caregiver(s) should be advised
to train in turn all the following:
- All levels of family members, relatives and friends
- Hired caretakers and 24 hour shift personnel
- Nurses and aids at medical care facilities
- Daycare or program training personnel
- Summer camp personnel
- Classroom personnel
- Transport personnel
The most common breakdown in the transfer of information is with
the night or weekend staff at any of the above facilities or agencies.
A good supplementing tool is to label each moveable component of
the wheelchair and the seating system so that these crucial elements
can be quickly identified to others. Also remember that parts, which
completely detach from the system, are more likely to be lost or
forgotten during transport.
An organized, caring and considerate caregiver can be heaven sent
but I find that many caretakers will strive to improve upon seating
systems (after delivery) by interjecting additional pillow, pads
or other props. Though done with good intentions, any additional
padding will usually have the effect of elevating or moving the
consumer up or away from other support structures, control systems
or switches. It should be explained to caregivers that a properly
made seating system does not require ancillary supports or additional
surface-softening mediums such as sheepskin or egg crate foam.
Here’s a side note; far too often I’ve meet caretakers
who simply do not have the physical capability to properly transfer
and position their charge into and out of the wheelchair. Unfortunately,
in many homes that I’ve visited there simply is no space for
a mechanical or ceiling lift and (for various reasons) the disparity
between the physical stature of the client and caretaker just does
not make sense. Under these circumstances injuries to either or
both parties is a real possibility. This is a hard obstacle to overcome
but still must be acknowledged discussed with the principles if
you intend to minimize future home visits.
Environmental And Lifestyle Considerations
Seating Specialists should never penalize a client because of their
socioeconomic disposition. I strongly believe that the best test
of a well-designed seating/mobility system is that it will account
for the lifestyle and environmental constraints of both the residence
and the mode of transportation. Include into your assessment discussions
any potential conflicts with the following:
- Living environment architectural obstacles: apartment or small
living unit floor plan
- Community based activities: workplace or on-the-job training
site
- Transfer aids: floor or ceiling mounted devices, one or two
person lifts, standing pivot, etc.
- Consumer owned transport vehicles: none, compact, or accessible
van
- Public or emergency vehicles: bus, taxi, safety restraints
and tie downs
Most of these environmental and lifestyle considerations may have
already been accommodated for with clients who have previously purchased
seating/mobility system. Nonetheless, nothing takes the place of
a home visit to verify dimensions, turning radius, transfer obstacles,
etc. Remember, it’s easier, quicker and less expensive for
the consumer to move furniture, place offset hinges on doors or
designate the living room as a bedroom than it is to tear down walls
or redesign an entire floor plan.
No matter how simple or complex the project, the structure and
design features of the seating/mobility system should reflect the
following lifestyle considerations:
Will the system be disassembled on a routine bases by the occupant
or caregivers?
This will impact how the system is mounted to the wheelchair frame.
For multiple component systems the mounting hardware or attachment
mechanism will test the frustration level of the consumer or caretaker,
especially if this task is too difficult, soils clothing or perceived
to be impractical.
What is the most common daily transport vehicle?
Bus transport is a very common environment for equipment damage.
Most commonly, we find damage to the brakes from too much foot pressure
and the wheelchair frame from improper placement of tie downs.
Is airline travel anticipated?
This is also a high-risk environment for equipment damage or loss.
The caretaker/consumer should always provide very specific written
and verbal instruction to airline personnel on what should or should
not be done to the equipment during airline travel.
Will the consumer use the system as designed?
As seating specialists we have the power to dictate how a person
will sit and interact with their controls and surrounding environments
for up to five continuous years. However, no matter what we believe
is the best design options for the client, if they do not agree,
the system is likely to be altered, modified or minimized after
delivery. Fact is, although we may be the expert at designing or
building cushions, our client is always the expert at living in
them. So always keep an open mind to innovative alternatives. Allow
yourself to think outside the box when confronted with independent
tenacity that conflict with the industries conventional practices
or provisional theories.
It is also important to note here that it may be in your best interest
to not reveal the type of seating design you intend to construct
or assemble until after you have establish a rapport with your client.
First establish their experiences with previous systems then gain
their trust through your knowledge and understanding of the various
subjects and disciplines. It will then become easier to recommend
components or features that may contradict their misconceptions
or are outside their scope of experiences.
Goals/Intent For The Project As Defined During The Assessment
After taking inventory of the influencing variables listed above,
the assessment personnel must identify which factors will dictate
the structure and design of the seating/mobility system. That assembled
list will be incorporated into the below list of goals and intent
which are inherent to any body support system:
- Prevent skin trauma
- Provide a platform for mobility
- Provide safety, comfort and security
- Not to encumber care-giving activities
- Improve postural alignment and stability
- Accommodate orthopedic deformities and contractures
- Prevent sliding, listing or other undesirable movements
- Maintain or enhance function for ADL’s, occupational
or hobby activities
- Provide growth or adjustment features for a changing postural/physical
profile
Seating System Structure, Composition And Design
- Not all seating systems need to be big, elaborate assemblies
to gain the designation of “complex”. The complexity
of the design may simply be reflected in the inventory of influencing
variables and list of goals/intent compiled by the client’s
support entourage and the assessment personnel.
- Vanity and pride are real considerations in seating designs.
A strong willed consumer (or support entourage) may not comply
with equipment use if they believe that the end product detracts
from or hampers the image they wish to project either professionally
or socially. To be effective we need the willful cooperation of
our clients.
- Before a quote can be prepared, funding limitations and timeline
restrictions must be factored into the equation in order to determine
the final composition of the project. Don’t be surprised
that after all your efforts you find your best-practice solution
is later reconfigured by budget restrictions or coded funding
formulas.
- A trial fitting is a “must do” before any custom
multi-component project is completed. It is during this session
that all ideas and theories are tested for effectiveness. The
shape of the foam, alignment of the components, viability of hardware
and size or compatibility of accessories can also be noted for
adjustment or change. All modification notes should be reread
to all present for group consensus.
- Everything we do to support and stabilize sitting posture is
for the most part a fight against gravity. Gravity is the push
that shapes the bodies of our clients and it is our assignment
to offset its effects with technical solutions. Trunk pads, the
three-point pressure system, harnesses, counter balances, recesses,
wedges and a host of tools and principles are all parts of the
arsenal we draw from. Do they really work for people who are life
dependant on a wheelchair or do they just delay the inevitable.
The reality is that these tools and provisional theories serve
many additional purposes: Safety, stability, control, pressure
relief, enhancement of function, security, piece of mind and so
on. Our job is to apply the right tool and principle to the right
task without putting our clients at risk to “consequential”
physical harm. In other words it is that old axiom, “for
every action there is a…reaction”. Take time to step
back and visualize (through your minds eye) what those potential
consequences are.
Influencing Factors After Delivery
Ultimately, the amount of time per day a consumer uses their seating/mobility
system will dictate how effective the system is in achieving at
least some of the benefits and goals listed by the assessment team.
If, for example, your client becomes bedridden for long periods
of time (weeks or months) then, how they are positioned in bed during
that time span can potentially lead to fixed changes in their skeletal
alignment. Aside from pressure sores, the progression of contractures
is the number-one negative that influences the consumer’s
ability to use the system once they are able to become mobile again.
If a skin ulcer develops after delivery, don’t just assume
that the seating system is the likely initiator. Try and judge whether
it may have originated outside the seating system but has now become
exacerbated by it. Consider the client’s exposure to bathing
and toileting aids, transfer devices, or impact against other surfaces
during transfers, such as the w/c armrests. Also remember that sometimes
an insult to soft tissue may not develop into a visible pressure
sore until days later. Here again, wound care is important. How
a pressure sore is dressed can potentially cause even more harm
during this healing phase.
Cleansing, care and maintenance of the system after delivery are
subjects that should be thoroughly understood. Food and moisture
are breading grounds for insects and bacteria. The system should
be disassembled regularly for cleansing by hand (not a water hose).
Also, the practice of storing equipment outdoors at night (or due
to long periods of inactivity) can cause the system to rust, mildew
or breakdown prematurely.
Physiological changes such as excessive weight gain or loss, decrease
in muscle function, the progression of deformities or contractures,
the addition of respiratory aids or the absence of general maintenance
interventions such as physical therapy, can create the observation
that (months or years later) the seating system was not correctly
designed or possibly mal-constructed to begin with. For this reason
good documentation by the originating personnel (including photos)
can provide answers, resolve a lot of the speculation and outline
clues of what new influencing variables are now present as compared
to the time of the assessment and subsequent delivery. Assuming
that the same group of people will perform any reassessment, these
detailed records will also show if the system has been changed or
altered in the intervening time.
Conclusion
Sometimes the difference between success and failure in complex
seating/mobility designs is simply not having a full understanding
why a component, feature or goal works for one client but not the
other. That difference could be explained by any number of influencing
variables that are unique to each consumer and are at times beyond
the control of clinicians or vendors. Even so, whether faced with
the simplest or most complicated client profile these influencing
variables must be revealed and at least considered to assure any
degree of long-term success. It should be the goal of every seating
specialist to quickly and efficiently assess which variables are
most probable to impact the project at hand.
Within these variables the homecare/residence setting and support/entourage
personnel may have as much influence on success or failure than
any discussions, conclusions or blueprints drafted without their
consideration or input. Within the context of their influence and
in addition to the client’s physiological disposition, the
home setting/lifestyle evaluation is a pivotal part of the information
gathering process. Lastly, from a technical perspective, a workable
solution can be found no matter how difficult the task. Regrettably
however, the entire information gathering, product design and decision-making
process must be tempered with real-world timeline limits, funding
caps, coding restrictions and other non-technical parameters. For
everyone, the challenge becomes where to draw the lines of compromise
within the dichotomy of both realities.
It is my hope that the above insights and perspectives will add
clarity for the decision-making processes of your next seating/mobility
project. And, as you consider these esoteric points, ask yourself,
is this discussion part of the art or part of the science of our
profession?
Richard Xavier Cushmaster
CUSHMAKER.com
©Copyright June 16, 2005
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