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Pediatric Seating and MobilityEvaluation to Delivery

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Sally Mallory, PT, ATP, CPST214-763-9173

Sally@Convaid.com

Thank you to our contributors• All of the children and their families, caregivers and therapists

• Missy Ball, PT

• Sally Mallory, PT, ATP, CPST

• Jo McConnell, PT

• Bente Storm, PT

• Helle Rasmussen, PhD, PT

• Lynda Reagan, PT

• Megan Salley, MOTR/L

• Elaine Westlake, PT, DPT, MA

• Julie Kobak, MA, CCC-SLP

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Our family of products

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Team approach

child

Family

Therapists

Equipment Specialist

Teachers

Manufacturer

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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

Client Interview• General Information

• Medical History

• Environmental Accessibility

• Client / Caregiver Goals

• Existing Mobility Equipment Issues

• Transportation

• Self-management Skills

• Funding

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Ameria Video

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Before and After

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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

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• 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)

Create a Good Functional Sitting Position

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

Mat Assessment

Mat Assessment

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Mat Assessment

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Mat Assessment

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Mat Assessment

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Skeletal Alignment• Typical alignment and considerations

o Child and adult

• Atypical alignment

o Causes and possible solutions

Skeletal System: Child Spine

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

Spinal Column Development

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• 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

Skeletal System: Adult Spine

Normal Seated Posture

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Pelvis and Spine Issues

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Lordosis Kyphosis Scoliosis

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Anterior Tilt

Pelvic Tilt: Goal is NeutralNeutral Posterior Tilt

Neutral Posterior tilt

• 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

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Posterior Pelvic Tilt: Problems

Factors Changing Pelvic Tilt

If the seat is too deepIf the child has limited hip flexionIf spasticity is very strong

If abduction/external rotation of the hip

If hyper lordosis with tight hamstringsIf the foot plate is mounted too high

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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 web size

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 seat

Limited hip flexion

• Caution with tight hamstrings• Change to non-elevating leg rests• Lumbar support, check seat depthElevating leg rests

Causes Possible Solutions

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• 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, because the feet then will be pulled a little backwards

Seat Depth & Support Through Thighs

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• 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

Pelvic Positioning

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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

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Case Study

• Posterior Pelvic Tilt/Kyphosis

• Promote neutral pelvis

o Pelvic belto Anti thrust seat

• Trunk 2 point control

o Thoracic cue: Convaid R82 butterfly vest

o Chest support

• Wheel placement

• Tray

Photos courtesy of Missy Ball, PT

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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

Possible Solutions

Client with ArthrogryposisPhoto courtesy of Missy Ball, PT

Pelvic Positioning

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Pelvic Rotation Pelvic Normal Pelvic Obliquity

Pelvic Positioning: Solutions

The anti thrust seat is designed to prevent the pelvis from sliding forward

An anti-thrust seat gives space for the ischial tuberosities as they are about 1 inch deeper into the cushion than the thighs

Laterals for the pelvis and thighs give stability and symmetryAbduction supports keep the knees in neutral alignment and can reduce tone

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Pelvic Positioning: Anti-thrust

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

• Causes

o Imbalance of spinal musculature

o Asymmetrical tone

o ATNR

o Pelvic obliquity

o Muscle paresis/paralysis

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Scoliosis

• 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.

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Scoliosis Solution: 3-point Principle

Flexible Pelvis in balance

Rigid Pelvis in balance

Head in balance

Photos courtesy of Missy Ball, PT

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• 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

Scoliosis Solution: Contoured Back Cushion

Scoliosis Solution: Multiple Adjustments

Lateral thoracic supportsWidth adjustment-minimum 6”chest width

Back height adjustment

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Scoliosis Solution: Lateral Trunk Supports

Swing away supports Fixed supports

• 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

• Cross Vest:

Solutions: Anterior Chest Supports

• 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

Solutions: Tray

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Solutions: Trunk Control & UE Assistance

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)

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, foot choicesExcessive abduction

Problems Solutions

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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 may be preventable

• Early surveillance program includes:

• Radiography

• Clinical Examination

• Preventive Positioning

• Reimer’s Migration Percentage (MP)

• MP > 30-33°= hip displacement

• MP > 90-100°= hip dislocation

• MP > 33 consider hip surgery

• Hip displacement is directly related to GMFCS levels

Lower Extremity Research• 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

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Lower Extremity: Scissoring or Excessive Adduction

Lower Extremity and Hip Alignment Options

Trekker Width Adjustable Pelvic & Lateral Thigh Support With/Without

Armrests

Rodeo Align Cushion Cruiser or Rodeo Position Cushion

EZ Rider Lateral Thigh Support

EZ Rider Medial Thigh Support

Lower Extremity Solution: Cushion

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• Hip abduction/adduction

• Seat depth differences

• Lateral trunk pads

• Lateral and medial thigh pads

• Seat depth and width

• Back height and width

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Solutions: Multi-Adjustablex:panda

Solutions: Multi-Adjustable

Swing-awaylaterals

Fixed Laterals Hip ABD/ADD Seat depth differences

Foot Position

• Width and depth is important

• Single or parted foot plate

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• Muscle weakness• Forward flexion

• Capital hyperextension

• Forward flexion with rotation and/or lateral flexion

• ATNR: Rotation & asymmetrical extension

• Extensor Thrust• Head trigger

• Head Banger

• Head Shape/Size Abnormal

Head Issues

Solutions: Head Rests• Provide support

• Create symmetry

• Provide stable base

• Correct and maintain position

• Mount switches

• R82- 18 headrest options

Seating Challenges

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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 capabilityMovement

Posture

Position vs. Posture

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

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The Challenge• Seating specialist

o Promote optimal postural alignment without restricting movement potential and 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

Components of Postural Control

Posture

Musculoskeletal

Neuromotor

SensorySystems

SensoryMotor

Strategies

CognitiveInfluence

Internal Maps

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• Tone Types: Floppy, spastic, rigid, athetoid, ataxic

• Dynamic Joint Stiffness o Force Generationo Grading Force (scaling)

• Balance in Muscle Execution o Co-activationo Reciprocal inhibition

• Muscle Contraction o Initiate, Sustain, Terminate

• Coordinationo Sequencing & Timing

• Muscle Synergyo Coupling muscles for task

Neuromotor Status: Muscle Tone & Coordination

Posture

Musculoskeletal

Neuromotor

SensorySystems

SensoryMotor

Strategies

CognitiveInfluence

Internal Maps

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Motor types

Neuromotor Status• 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

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Neuromotor Status• Hypertonic – Spastico Imbalance of muscle activity about jointo Poor ability to grade & scale forceo Coordination limited

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Sensory Systems Influencing Posture

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

Posture

Musculoskeletal

Neuromotor

SensorySystems

SensoryMotor

Strategies

CognitiveInfluence

Internal Maps

Sensory: Seating Choices• Frame orientation

Visual

• Head support not blocking ears

Auditory

• Back seat shape• Upholstery material/texture• Medium

Somatosensory

• Frame orientation, tilt, recline

Vestibular

Case Study: Kye• 10 years old

• Dravet Syndrome

• Seizure disorder

• Needs

o Low tone, crouched gait, ambulation fatigue

o Sensory-processing issues, easily overstimulated, stress induced seizures

o Post-ictal state, reduced responsiveness, requires oxygen

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Convaid Rodeo

• Provides for:

o Postural support

o Security, reduced stimulation

- Harness

- Oversized canopy

oMedical needs

- Recline post-ictal

- Medical basket for O2

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Seating Solution

Sensory Input & Feedback• 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

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• Typical Development

• Atypical Development

Sensory Motor Strategies = Motor Development

PosturePosture

MusculoskeletalMusculoskeletal

Neuromotor Neuromotor

SensorySystemsSensorySystems

SensoryMotor

Strategies

CognitiveInfluenceCognitiveInfluence

Internal Maps

Internal Maps

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• For the first 3-5 month

oMidline orientation

oHead raising/extension

oRotation within the body

o Extension and abduction of limbs

o Equilibrium reactions in prone and supine

Typical Motor Development

Typical Motor Development• 6-7 months: Ring sit• Sit without UE support• Good head & trunk control• UE free to explore toys & environmento Visual perceptualo Visual spatialo Aids cognitive development o Aids feeding independentlyo Oral motor development precursor to speech acquisition

• Muscles controlling pelvis active:o Hip extensors and oblique abdominalso Control weight shift across pelvis

R82.com

Less experienced sitter More experienced sitter

Typical Motor Development

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• 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

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Motor Development

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

Typical Atypical1m

• 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 short, rocks pelvis posterior & LE extend•Poor stability in shoulder & pelvis girdles

Capital Hyperextension Shoulder Extension & Internal Rotation/Adduction

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Atypical Development

Photos courtesy of Missy Ball, PT

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Solution

Angle adjustable tray with elbow blocks to promote effective weight bearing & shoulder girdle synergy

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Atypical Development

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• 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

• RA short, pulls pelvis posterior

• LE react in extension

Atypical Development

• Anterior Tilt

oMuscle re-education and strengthening

o If client cannot actively manage pelvis, then support through seating system options (Myhr von Wndt 1991; Cherng et al. 2009)

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Atypical Development: Solution

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Atypical Development: Solution

• Anterior Tilt

o Can be achieved with Trekker, Flyer, Kudu, Wombat

o Promotes:

Functional pelvic synergy/active sitting

Fine motor activities

Feeding

Speech

• Head control

• Trunk control

• Sitting balance

• Fine motor capability

• Transfer capability

• Ambulation capability or limitations

• Pressure relief capability

• Self care skills: feeding, dressing, toileting

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Motor Capability Assessment

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

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Case Study: Madi

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• 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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Case Study: Madi

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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 issues

Posture/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

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Measurements Critical for Equipment Choices

A. Shoulder

B. Chest Width

C. Hip Width

D. Width at Knee

E. Seat to Top of Head

F. Seat to Top of Shoulder (L,R)

G. Seat to Axilla (L,R) Armpit

H. Chests Dept (L,R) Back to Tip of Chest

I. Seat Dept (L,R) Actual- 2-3 Fingers

J. Seat to Footplate (L, R)

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• Frame Choice:

• Power Wheelchair

• Manual Wheelchair

o Dependento Self propelling

• Tilt-in Space

• Recline

• Combination

• Dynamic

Translate Client Measurements & Goals Into Equipment

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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)

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

Dependent Mobility: When?

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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: Home layout

2nd floor apartment

Daycare does not allow power mobility in center

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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

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

Orientation of Seating System in Space

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

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Orientation of Seating System in Space

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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

• 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

Tilt in Space: Posterior• 45o posterior tilt

• Rodeo without seating can accommodate third party seating

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• 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)

• Assists in transfers

Tilt in Space: Anterior

TrekkerTilt in Space (-10 to 45o)

Recline (170o)

Central Gravity Axis Tilt • Greater stability in full tilt

• Aligns center of gravity with center of rotationo Maintains client’s mass within the center of the frame

• Greater environmental accessibility - smaller footprinto 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

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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 Pano 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

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Convaid Rodeo Convaid Flyer

Case Study: Solutions

Case Study- Justine• Homeschooled- anterior tilt for table top activities

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Crocodile Gait Trainer

Case Study: SolutionsCarrot Car Seat

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Uses for Recline• Management of bladder 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

• 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

Seating Challenges

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Case Study: Hamza

Goals• Feeding goals/Visual scanning

Convaid R82 Chairs with Recline

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Rodeo

Convaid

Trekker

Convaid

Flyer

Convaid

Stingray

R82

x:panda on Stingray base

R82

x:panda on Multi-Frame

R82

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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

2

• 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.

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Extensor Thrust Effects

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

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Data collection

Optoelectronic system

Passive markers

Pressure mapping

DynamicSession

5 sec pause

Clap

10 sec pause

Clap

10 sec pause

Clap

10 sec pause

StaticSession

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

Dynamic Static

2

Pressure Distribution Results

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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

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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

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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

2

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, re-measure as needed, equipment ordered and assembled

Delivery/Checkout with original seating team•To ensure all items are correct

Follow-Up

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Letter of Medical Necessity

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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

Include pictures if possible (videos for appeal)

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

• 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

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1. Go to: www.brainsbuilder.com

2. Select “Take an assessment”

3. Enter Your Assessment ID:

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, ahodges@nrrts.org

Course Evaluation and

Certificate Instructions

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