seventeenth international seating symposium · seventeenth international seating symposium •...

Seventeenth International Seating Symposium • February 22-24, 2001 • 1

Seventeenth InternationalSeating SymposiumSeating & Mobility for People with Disabilities

February 22–24, 2001

Rosen Centre HotelOrlando, FloridaU.S.A.

Sponsored by:• University of Pittsburgh

School of Health and Rehabilitation Sciences- Department of Rehabilitation Science and Technology- Rehabilitation Engineering Research Center on Wheelchair

Mobility (RERC)• Sunny Hill Medical Centre for Children• University of British Columbia• NIDRR - National Institute on Disability and Rehabilitation

Research• RESNA - The Rehabilitation Engineering and Assistive

Technology Society of North America

Presymposium Workshops

February 21, 2001Rosen Centre HotelOrlando, Florida

• Back to Basics and Beyond• The Business Side of Assistive

Technology• Funding Wheelchair Seating/

Mobility Technology andServices

• Kids vs. Adults: Is There aDifference in Seating?

Course Director: Elaine Trefler, MEd, OTR/L, FAOTA, ATPAssistant ProfessorUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technology

Announcing the First Annual

Chris Bar Research Forum

• Seventeenth International Seating Symposium • February 22-24, 20012


IndexFebruary 22-24, 2001

Schedule................................................................................................................................................................... 7-15Schedule at-a-glance.................................................................................................................................................... 6Faculty......................................................................................................................................................................17-26Hotel floor plans........................................................................................................................................................... 27Exhibitor hall floor plan................................................................................................................................................ 28Exhibitor list........................................................................................................................................................... 29-34

Thursday, February 22, 2001

Keynote Address: Zen and the Art of Wheelchair Maintenance................................................................................... 37

Paper Presentations

Innovations and Findings in Current Seating Research................................................................................... 39-40Chest Supports, Why They Are Not Working!................................................................................................. 41-44The Role of the Shoulder During Wheelchair Propulsion................................................................................. 45-46Development Of A Method Of Measuring Force Through a Kneeblock For Children With Cerebral Palsy............47-48

Instructional Courses

1. Power Chairs Features & Functions.......................................................................................................... 49-502. Dynamic Seating Components for Reduction in Spactic Activity and Enhancement of Function................. 51-573. When Ethics Isn’t Enough – Making Tough Decisions In A Changing Clinical Environment........................ 59-604. Cervical Flexion Problems and Possibilities..................................................................................................... 615. Can Therapuetic Positioning Effect Functional Outcomes?............................................................................. 636. Seating Interventions for Spinal Cord Injuries with Secondary Orthopedic Complications..........................65-667. Slip Sliding Away - Dealing with the Client that Slides............................................................................... 67-688. Mat Evaluation Techniques............................................................................................................................... 699. Innovative Solutions for Seating and Positioning............................................................................................ 7110. Pressure Mapping...................................................................................................................................... 73-7611. Factors for Integrating Wheelchairs and Transportation.................................................................................. 7712. Measuring and Recording Seated Posture - A Proposed Standard............................................................ 79-8113. Children in Power....................................................................................................................................... 83-8514. The Effects of Seating on Respiratory Function......................................................................................... 87-88

Seventeenth InternationalSeating Symposium


Friday, February 23, 2001

Track A: Issues in Pediatric Practice— Paper session

High Tech Solutions for a Special Needs Client............................................................................................... 91-93Parents versus Therapist: Views of Their Child’s Adaptive Seating System...................................................... 95-96A Retrospective Study of the Effect of Postural Management Programmes in the Managementof Hip Dislocation and Spinal Curvature in Bilateral Cerebral Palsy.................................................................. 97-98Developing Pre and Post Baclofen Pump Outcome Measures for Seating with Individualswith Cerebral Palsy.......................................................................................................................................... 99-100

Track B: Instructional Courses

15. Clinical Use of Simulation........................................................................................................................ 101-10316. Custom Contoured Seating - The Next Step........................................................................................... 105-10717. Personal Mobility, Vehicle Mobility…Strengthening the Link................................................................. 109-11018. Seating for People with Multiple Sclerosis in a Long Term Care Facility................................................. 111-11319. Mat Evaluation.......................................................................................................................................... 115-11720. Power Wheelchairs, a New Definition..................................................................................................... 119-12021. How to Avoid the Pitfalls in Assistive Technology Research................................................................... 121-12222. The Use of Technological Advances to Evaluate Seating and Positioning in Individuals

with Severe Orthopedic and Developmental Disabilities......................................................................... 123-12523. The Importance of the Therapist in the Wheelchair Decision-making Process for Older Adults............. 127-12924. Seating, Access, and Mobility II: Those Children Who Grow Up !.......................................................... 131-13225. The Use of Adjustable Modular Wheelchairs as Fleet............................................................................. 133-13726. Transport Wheelchairs...................................................................................................................................... 13927. The Seated Posture and Pressure Ulcer Connection.............................................................................. 141-14228. The Challenge of Optimal Seating for People with Joint Contratures...................................................... 143-14429. Back in Style............................................................................................................................................ 145-14830. Linking Clinical Presentation with Power Wheelchair Programming............................................................... 14931. Reimbursement - Rehab 101 —

All You Need to Know & More to Get Your Patient What They Really Need............................................. 151-15332. Application of Research Findings into Clinical Practice.......................................................................... 155-156

Track C: Chris Bar Research Forum............................................................................................................................. 157

Track D: Clinical Forum: Practice and Research— Paper Session

Teaching Clinical Rationale For Seating And Wheeled Mobility Prescription:A Randomized Controlled Trial Of Four Instructional Methods.................................................................... 159-163Quantification of Forces Associated with Full Body Extensor Thrust in Children.......................................... 165-169“What Consumer’s Bring to Wheelchair Selection” The Results of a Study.................................................. 171-173Back Support Options: Functional Outcomes for Persons with SCI............................................................. 175-176


Saturday, February 24, 2001

Paper Session

A Study on the Relationship Between Buttock-Seat Cushion Interface Pressure andPressure Ulcer Incidence in At-Risk Elderly Wheelchair Users.................................................................... 179-180Function and Performance of the Rocket Multidirectional Powered Wheelchair........................................... 181-184Factors Influencing Participation in Daily Activities Among Elderly Stroke SurvivorsThe Psychometric Properties of the Seating Identification Tool (SIT).......................................................... 185-186The Prevalence and Type of Wheelchair and Seating Needs Among the Institutionalized Elderly..................187-189Influence of Service Dogs in Psychosocial and Functional Outcomesas Measured by the Rosenberg Self-Esteem Scale and Revised Craig HandicapAssessment and Reporting Technique (Chart).............................................................................................. 189-191

SpecialSession

Policy Change: Can We Make A Difference................................................................................................... 191-195


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ceWednesday, February 21, 2001

7:00 am to 6:00 pm • Registration (Registration Desk 2)


8 :00 am • Registration and Continental Breakfast

8:30 am • Opening (Junior Ballroom)

9:00 am • Sunrise Medical Keynote Address Bardsley

10:00 am • General Session - Papers (Junior Ballroom)

11:00 am • Exhibit Hall opens/Walk-about Lunch

1:00 pm • Instructional Courses (One Hour)1.Fisher, Harding 2. Cooper, Dilabio, Broughton, Brown 3. Margolis 4. Pickett, Gunn 5. Saftler Savage 6. Tanguay 7. Tucker

2:00 pm • Break

2:30 pm • Instructional Courses (Two Hours)8. Bergen 9. Dilabio, Cooper, Broughton 10. Ferguson-Pell, Parry 11. Gallagher, Havard, Shipp 12. Hobson13. Kangas 14. Sparacio

4:30 pm • Adjournment

5:00 pm • Welcome Reception (Exhibit Hall)


7:30 am • Continental Breakfast (Exhibit Hall)

8:30 am • Track A : Paper Presentations Fisher/Liebel, McDonald, Pountney, Taylor

• Track B : Instructional Courses (One Hour)15. Waugh, Schmeler 16. Broughton, Cooper, Dilabio 17. Mogul-Rotman, Fisher, O’Neill 18. Saftler Savage

9:30 am • Break (Exhibit Hall)

10:30 am • Instructional Courses (One Hour)19. Minkel 20. Denison, Gayton 21. Fitzgerald 22. Hardwick 23. Jones 24. Kangas 25. Schmeler, Tovey

11:30 am • Lunch (on your own)/Exhibit Hall Open

1:00 pm • Instructional Courses (Two Hours)26. Hobson 27. Fleck, Roesler 28. Mangine, West 29. Hetzel 30. Tucker 31. Walker 32. Cooper, Fitzgerald

3:00 pm • Break (Exhibit Hall)

3:30 pm • Track C: Chris Bar Research Forum Bardsley, Brienza, Ferguson-Pell, Graebe, Levy, Sprigle, Taylor

• Track D: Clinical Forum – Practice and Research Cohen, Brown, Buning, May



8:00 am • Continental Breakfast (Ballroom Pre-function Area)

8:30 am • Paper Session Brienza, Fernie, Miller, Frost

10:00 am • Break

10:30 am • Special Session – Policy Change Minkel, Morris, Parry, Thomas, Warren,



SeventeenthInternationalSeating SymposiumAudience

Assistive technology practitioners (ATP)Assistive technology suppliers (ATS)EducatorsManufacturersPeople with disabilitiesPhysiciansRehabilitation engineersVocational rehabilitation counselors

Introduction

Presentations will cover evaluation, provision, research,and quality assurance issues in seating and mobility forpeople with physical disabilities. The symposium willinclude scientific and clinical papers, in-depthworkshops, panel sessions, and an extensive exhibithall.

Program Objectives

• Identify seating and mobility interventions for peoplewith physical disabilities

• Discuss service delivery practices• View current research• Recognize seating and mobility technologies

Materials available in alternate formats upon request.

Continuing Education Credit

The University of Pittsburgh, School of Health andRehabilitation Sciences awards Continuing Education Units toindividuals who enroll in certain educational activities. TheCEU is designated to give recognition to individuals whocontinue their education in order to keep up-to-date in theirprofession. One CEU is equivalent to 10 hours of participationin an organized continuing education activity. Each personshould claim only those hours of credit that he or she actuallyspent in the educational activity.

Health professionals are awarded up to 1.5 continuingeducation units (CEUs) for up to 15.0 hours of instruction.

Wednesday, February 21, 2001

7:00 AM - 6:00 PMRegistration (Registration Desk 2)



8:00 AMRegistration and Continental Breakfast

8:30 AMOpening (Junior Ballroom)

Clifford E. Brubaker, PhDDean, University of PittsburghSchool of Health and Rehabilitation Sciences

Rory Cooper PhDProfessor and Chairman , University of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technology

Elaine Trefler, MEd, OTR/L, FAOTA, ATPAssistant Professor, University of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technology

9:00 AMSunrise Medical Keynote Address

Zen and the Art of WheelchairMaintenance –Experiences On A Journey Through Seating

Geoff I. Bardsley, PhDTORT Centre, Ninewells Hospital, Dundee, Scotland

10:00 AMGeneral Session (Junior Ballroom)

Innovations and Findings in CurrentSeating ResearchShirley Fitzgerald, PhD

Chest Supports: Why They Are Not Working!Karen Kangas, OTR/L

The Role of the Shoulder During WheelchairPropulsionAlicia Koontz, MS, ATP

Development of a Method of Measuring ForceThrough a Kneeblock for Children with CerebralPalsyRachel McDonald, B.App.Sc.(OT),Post.Grad.Dip.(Biomechanics)

11:00 AMExhibit Hall opens (Grand Ballroom)

Walk-about Lunch (Exhibit Hall, included in tuition)

1:00 PMInstructional Courses (One Hour)

1. Power Chair: Features & Functions -Demonstration (Center Stage - Exhibit Hall)Kathryn Fisher, B.Sc., OT(C), David Harding

The recent explosion in choice of power wheelchairconfigurations has increased the opportunity to match aclient’s needs but has created confusion in theprescription process. This workshop will explore thedevelopment of power wheelchair drives and featuresand apply these options to clinical assessment factors.*Beginner

2. Dynamic Seating Components for Reduction inSpastic Activity and Enhancement of FunctionDavid Cooper, M.Sc, RT, Mark Dilabio, RT,Gord Broughton, RT, Dalthea Brown, MS, PT, ATP

Dynamic seating components that allow controlledmovement of the user present numerous advantages forpeople with uncontrolled spasticity and limited function.This workshop will review various approaches ofimplementing dynamic solutions and describetechniques with successful outcomes.*Intermediate


3. When Ethics Isn’t Enough – Making ToughDecisions in a Changing Clinical EnvironmentSimon Margolis, CO, ATS/P

Clinicians, both suppliers and practitioners, areconfronted daily with situations in which the ethical thingto do may not be the right thing to do. The presentation/discussion will address other factors to consider whenmaking clinical service delivery decisions.*Advanced

4. Cervical Flexion Problems and Possibilities ∆David (Scott) Pickett, CRTS, Michelle Gunn, ATP

This course will explore the problems related to seatingand positioning in persons with cervical flexion andcervical flexion with head extension. The selection andapplications of positioning interventions to correct oraccommodate, will also be discussed.*Intermediate

5. Can Therapeutic Positioning Effect FunctionalOutcomes?Faith Saftler Savage, PT, ATP

This workshop will teach how to develop functionaloutcomes for therapeutic positioning using theDisablement Model from the World Health Organization.Case studies will be used to illustrate the effectiveness ofthe model.*Beginner/Intermediate

6. Seating Interventions for People with SpinalCord Injuries with Secondary OrthopedicComplicationsStephanie Tanguay, OTR, ATP/S

Orthopedic changes and surgical interventions result incomplex seating needs for spinal cord injured clients.Case studies will illustrate custom systems required bysecondary diagnosis such as heterotrophic ossification,hip disarticulation, and hemipelvectomy. Orthotics andmolded seating solutions will be shown.*Beginner

7. Slip Sliding Away - Dealing with the Clientthat SlidesLois Tucker, OTR/L, ATP

Sliding is one of the most frequently observed patternsin our clients. We will discuss the issues that cause theclient to slide out of their optimal positioning, out oftheir wheelchair, and the positional, postural andfunctional problems that occur as a result. Preventiontechniques and ways to control the perpetual slide fromoccurring will be explored.*Intermediate

2:00 PMBreak

2:30 PMInstructional Courses (Two Hours)

8. Mat Evaluation - Demonstration(Center Stage, Exhibit Hall)Adrienne Bergen, PT, ATP, ATS, CRTS

Principles of a mat assessment will be combined withprescription and product options. Persons withdisabilities from the Orlando area will serve as clientsfor the demonstrations.*Beginner

9. Innovative Solutions for Seating andPositioningMark Dilabio, RT, David Cooper, M.Sc, RTGord Broughton, RT

From inexpensive and simple solutions to elaboratecreations, we have it all! Side, prone and supine lyers,slings for turning, walking aids, commode and cycleadaptations, inexpensive tilt, adapted furniture; theseare some of the ideas that we would like to pass on. Wealso have elaborate solutions that address specificneeds and will devote time to look at lateral tilt of sittingand recumbent positioning systems.* All


10. Pressure MappingMartin Ferguson-Pell, PhD, Emma Parry,SROT, ATP

Pressure mapping is gaining an increasingly importantplace in the toolkit of the seating specialist.Manufacturers rely upon pressure mapping data tocompare their products with competitors. The presentersof this session are working closely with the pressuremapping manufacturers to develop clinical guidelines andsupporting educational modules to promote the correctuse of the pressure mapping technologies.

Participants in this session will obtain an overview ofthese guidelines and gain an insight into how they may beincorporated into international standards for “pressuremapping devices”.* Intermediate-Advanced

11. Factors for Integrating Wheelchairs andTransportationMarty Gallagher, MS, LOTR, Ann Havard, LOTR,CDRS, Mike Shipp, MEd, CDRS

This workshop will present methods for accuratelymeasuring the key components in seating systems forclients requiring moderate to maximal positioning andpelvic stability/mobility. Measurement techniques for avariety of seating components will be taught.*Intermediate

12. Measuring and Recording Seated Posture -A Proposed StandardDouglas Hobson, PhD

Standardized terminology and definitions are required inorder to be able to accurately measure, record andcommunicate information about the posture of awheelchair-seated person. This session will presentproposed terms and definitions for an integratedgeometric reference system that permits themeasurement of a person’s seated posture relative to abaseline or neutral posture.*Advanced

13. Children in PowerKaren Kangas, OTR/L

All children can be functionally independent in mobilitywith today’s technology of seating and programmablemobility. Changing attitudes, obtaining new technologyand expertise, and learning to teach mobility will bediscussed using case studies.*Intermediate/Advanced

14. The Effects of Seating on RespiratoryFunctionJill Sparacio, OTR/L, ATP, ABDA

This course will discuss how to effectively evaluaterespiratory patterns and how to impact them throughthe use of postural supports. It will include strategiesused to enhance rather than limit respiratory functionthat is often compromised by neurological impairments.*Beginner

4:30 PMAdjournment

5:00 PMWelcome Reception (Exhibit Hall)



7:30 AMContinental Breakfast (Exhibit Hall)

8:30 AM

Track A: Paper PresentationsTrack B: Instructional Courses

Track A - Paper Presentations

Issues in Pediatric Practice (Junior Ballroom F)Moderator:

Jessica Presperin Pedersen, MBA,OTR/L, ATP

High Tech Solutions for a Special Needs ClientKathryn Fisher, B.Sc., OT(C), Gloria Liebel, OT (C)

Parent Versus Therapist: Views Of Their Child’sAdaptive Seating SystemRachel McDonald B.App.Sc.(OT), Post.Grad.Dip.(Biomechanics)

A Retrospective Study of the Effect of PosturalManagement Programmes in the Management of HipDislocation and Spinal Curvature in Bilateral CerebralPalsyTerry Pountney MA, MCSP

Developing Pre and Post Baclofen Pump OutcomeMeasures for Seating with Individuals withCerebral PalsySusan Johnson Taylor, OTR/L

8:30 AMInstructional Courses (One Hour)

15. Clinical Use of Simulation - Demonstration(Center Stage - Exhibit Hall)Kelly G. Waugh, MA, PT,Mark Schmeler, MS, OTR/L, ATP

Simulation is used clinically to determine optimalposture, facilitate measurement and enable consumersto understand the dynamics of various postural options.Both the process and several products will behighlighted in this session.*Beginner/Intermediate

16. Custom Contoured Seating – The Next StepGord Broughton, RT, David Cooper, M.Sc, RT,Mark Dilabio, RT

Making custom contoured positioning systems can beenhanced to improve growth potential, adjustability andease of use by making them modular. This workshopwill describe a modular approach to contoured seatingthat includes separating portions of the moulded shape,and inclusion of orthotic components and malleablesections using both custom and off the shelfcomponentry.*Intermediate

17. Personal Mobility, VehicleMobility...Strengthening the LinkBrenlee Mogul-Rotman, B.Sc.OT(C), OTR, ATP,Kathryn Fisher, B.Sc., OT(C), Terry O’Neill

This workshop will describe common problemsassociated with incompatibility of personal mobilityequipment and modified vehicles. Perspectives from aclinician, seating/mobility equipment vendor and vehiclemodification specialist will highlight the team approach.Case studies will be used to illustrate problemsexperienced as well as success in optimizing personaland community mobility.*Intermediate


18. Seating for People with Multiple Sclerosis(MS) in a Long Term Care FacilityFaith Saftler Savage, PT, ATP

This course will review the pathology and specificissues that effect the person with MS. Seatinginterventions will be discussed from basic manualmobility to power wheelchairs with tilt and head controlsystems. Long term care with multiple caregiversconcerns will also be covered.*Beginner/Intermediate

9:30 AMBreak (Exhibit Hall)

10:30 AMInstructional Courses (One Hour)

19. Mat Evaluation (Center Stage - Exhibit Hall)Jean Minkel, MA, PT

The mat assessment is one of the most criticalcomponents of a seating evaluation. An experiencedclinician will demonstrate the steps in the assessmentprocess and discuss the prescription implications.*Beginner

20. Power Wheelchairs: A New DefinitionIan Denison, PT, Doug Gayton, ATP

This session identifies the factors that contribute to theperformance of a powered wheelchair depending onwhether the wheel-drive of the chair is a front, center, orrear wheel drive. Strengths and weaknesses of eachconfiguration will be compared in the followingenvironments: indoors, outdoors, and off-road.*Intermediate

21. How to Avoid the Pitfalls in AssistiveTechnology ResearchShirley Fitzgerald, PhD

This workshop is designed to provide an understandingof basic research methods to the clinician. The first partof this session will be an overview to research and thenwill progress to an interactive session of problemsolving research issues. Bring ideas for researchprojects with you.*All

22. The Use of Technological Advances toEvaluate Seating and Positioning inIndividuals with Severe Orthopedic andDevelopmental DisabilitiesKaren Hardwick, PhD, OTR, FOATA

Technologies such as Doppler ultrasound, the ABI(Ankle Brachial Index), pressure mapping systems,pulse oximetry, and video fluoroscopy can assistclinicians to effectively evaluate individuals withprofound disabilities who cannot communicate verbally.These tools can provide objective measures to makeclinical decisions and also provide concrete data forresearch. This session will present case studiesillustrating each of the techniques described.*Intermediate/Advanced

23. The Importance of the Therapist in theWheelchair Decision-making Process forOlder AdultsDebbie Jones, PT

With fewer dollars available for durable medicalequipment (DME), the final decision-making processneeds to include a therapist. Too often wheelchairs aresupplied without a complete evaluation of the user todetermine individual needs. This can lead to poorlyfitted systems or systems that can not be modified asthe client progresses. This session will review theevaluation process, with the inclusion of case studies,and explain how to find a therapist that has theknowledge to perform wheelchair evaluations.*Intermediate


24. Seating, Access, and Mobility II: ThoseChildren Who Grow Up !Karen Kangas, OTR/L

With children who are non-speaking, have physicaldisabilities, and require alternative access for poweredmobility and other assistive technology, finally gettingthese systems to work is empowering. Then they growand change. Should the system of seating, access, andtechnology be replicated or, changed with them? Thissession will explore how to allow this transition tosupport the continued growth of these children, nowyoung adults, and face the ensuing complicated issuesinvolved.*Intermediate/Advanced

25. The Use of Adjustable Modular Wheelchairsas FleetMark Schmeler, MS, OTR/L, ATPElyn Tovey, PT

This presentation will focus on the strategies andoutcomes of using a modular manual wheelchair frameas a fleet concept. Outcomes have resulted in being ableto better fit people, meet needs in a more timelymanner, and have reduced the time and cost associatedwith repairs and modifications.*Intermediate

11:30 AMLunch (on your own)Exhibit Hall Open

1:00 PMInstructional Courses (Two Hours)

26. Transport Wheelchairs(Center Stage - Exhibit Hall)Douglas Hobson, PhD

Industry is responding to the need for wheelchairs thatcomply with the new industry standards for transportwheelchairs. Models of wheelchairs that meet thestandard will be presented and discussion about thespecial transport features will follow.*Intermediate

27. The Seated Posture and Pressure UlcerConnection ∆Cynthia Fleck, RN, BSN, ET, CWS,Tina Roesler, MS, PT, ABDA

This multidisciplinary session will address pressureulcer etiology and the direct impact of wheelchairconfiguration and cushion selection on skin integrity. Itwill also provide strategies for prevention and treatmentof ischemic ulcers in the seated client.*Intermediate/Advanced

28. The Challenge of Optimal Seating forPeople with Joint ContraturesMarygrace DiStasio Mangine, OTR/LCheryl T. West, MSPT

Total body contractures pose problems whendetermining appropriate seating and mobility systems.This session will introduce low and high technologyseating adaptations for maximizing function, increasingindependence, and attaining equal weight distribution.*Advanced

29. Back in StyleThomas Hetzel, PT, ATP

This course will outline the biomechanical principlesand clinical indicators to be considered when selecting aback support. Tips on evaluating current technologies inrespect to how they address the person to supportsurface and support surface-to-mobility base interfaceswill be covered.*Beginner/Intermediate

30. Linking Clinical Presentation with PowerWheelchair ProgrammingLois Tucker, OTR/L, ATP

This workshop will present guidelines and computersoftware for programming powered wheelchairs basedon client diagnosis, driver controller, and environmentalneeds. Clinical presentations will include discussionsrelated to clients, including those with physical andcognitive challenges.*Intermediate


31. Reimbursement - Rehab 101 — All You Needto Know & More to Get Your Client WhatThey Really NeedPeggy Walker, RN

Basic rules for reimbursement for durable medicalequipment, including mobility and seating/positioningequipment, will be presented. Reviewer perspectives,justification wording and custom vs. modification itemswill be discussed.*All

32: Application of Research Findings intoClinical Practice(One hour only)Rosemarie Cooper, MPT, Shirley Fitzgerald, PhD

Clinical research has a direct impact on clinical practice.This workshop will use research projects at the HumanEngineering Research Laboratories (HERL) to describehow research results have influenced the clinicalwheelchair prescription and provision process.*All

3:00 PMBreak (Exhibit Hall)

3:30 PM

Track C Chris Bar Research ForumTrack D Clinical Forum – Practice and Research

Track C:Chris Bar Research ForumSponsored by ROHO, Inc.

Chair: Geoff Bardsley, PhD TORT Centre, Ninewells Hospital, Dundee, Scotland

Participants:David Brienza, PhDMartin Ferguson-Pell, PhDRobert Graebe ∆Barbara Levy, PT, ATPSteven Sprigle, PhD, PTGeoff Taylor ∆

The 2001 Chris Bar Research Forum will be a BritishParliamentary-style Debate on the use of pressuremeasurement for the prevention and management ofpressure ulcers. The motion to be debated is asfollows:This House believes pressure measurement isirrelevant to the clinical practice of preventing andmanaging pressure ulcers.

Participation in the debate is encouraged

Track D:Clinical Forum – Practice and Research

Moderator: Lynn M. Bates, MPA, BS

Teaching Clinical Rationale For Seating AndWheeled Mobility Prescription: A RandomizedControlled Trial Of Four Instructional MethodsLaura Cohen, PT

Quantification of Forces Associated with FullBody Extensor Thrust in ChildrenDalthea Brown, MSPT, ATP

What Consumer’s Bring to WheelchairSelection:The Results of a StudyMary Ellen Buning, OT, OTR/L, ATP

Back Support Options: Functional Outcomes forPersons with SCILaura May, PhD

5:00 PMAdjournment



8:00 AMContinental Breakfast (Ballroom Pre-function Area)

8:30 AMPaper SessionModerator: David Cooper, M.Sc., RT

Sunny Hill Health Centre for Childern

A Study On The Relationship Between Buttock-Seat Cushion Interface Pressure And PressureUlcer Incidence In At-Risk Elderly WheelchairUsersDavid Brienza, PhD

Function and Performance of the RocketMultidirectional Powered Wheelchair ∆Geoff Fernie, PhD, PEng

The Psychometric Properties of the SeatingIdentification Tool (SIT)William Miller PhD, MScOT

The Prevalence and Type of Wheelchair andSeating Needs Among the InstitutionalizedElderlyWilliam Miller, PhD, MScOT

Influence of Service Dogs in Psychosocial andFunctional Outcomes as Measured by theRosenberg Self-Esteem Scale and Revised CraigHandicap Assessment and Reporting Technique(Chart)Karen Frost, MBA

10:00 AMBreak

10:30 AMSpecial Session – Policy Change: Can We Make ADifference (Junior Ballroom)

Moderator: Jean Minkel, MA, PTMinkel Consulting, New Windsor, NY

Panel MembersMorris (Mickey) Milner, PhD, PEng, CCEVice President of Research and DevelopmentBloorview MacMillan Centre, Toronto, ON, CanadaEmma Parry, SROTResearch Therapist, Centre for Disability Researchand Innovation, University College of London,United KingdomPeter Thomas,Esq.Attorney and Disability Advocate, Washington, D.C.Lori WarrenArtist/Parent, Orlando, FL

Feeling constrained by service delivery systems?Frustrated by funding problems? Ready to take out acontract on the Director of Special Education?Pondering how to get research dollars in a time ofcutbacks and consolidation? There is an old saying, “Ifyou are not part of the solution, perhaps you are part ofthe problem”. Come and hear this international panel ofconsumer, lawyer, clinician and administrator/researcherdiscuss current activities designed to create positivechange in systems of service delivery of assistivetechnology including funding. Each panel member hasexperience in being part of the solution. Hear about theirbattles and learn strategies used to effect change.

12:30 PMAdjournment

∆ Indicates presentation by a representative of aproduct manufacturer

All presenters are from the USA unless other wiseindicated.


Geoff Bardsley, PhDTayside Orthopaedic & Rehabilitation

Technology Centre, Ninewells Hospital,

Dundee DD1 9SY, Scotland.

E-mail: [email protected]

Zen and the Art of Wheelchair Maintenance• Keynote-Thursday, February 22, 2001, 9:00 AMChris Bar Research Forum• Special Session-Friday, February 23, 2001, 3:30 PM

Adrienne Bergen, PT, ATP, ATS, CRTS21 Roosevelt Dr.Valhalla, NY 10595E-mail: [email protected]

Evaluation Techniques• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PM

David Brienza, PhDUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technology5044 Forbes TowerPittsburgh, PA 15260E-mail: [email protected]

Chris Bar Research Forum• Special Session-Friday, February 23, 2001, 3:30 PMA Study On The Relationship Between Buttock-SeatCushion Interface Pressure And Pressure UlcerIncidence In At-Risk Elderly Wheelchair Users• Paper--Saturday, February 24, 2001, 8:30 AM

Gord Broughton, M.Sc., RTSunny Hill Health Centre for ChildrenTherapy Department3644 Slocan StreetVancouver, BC V5M 3E8Canada

Dynamic Seating Components for Reduction inSpastic Activity and Enhancement of Function• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PMInnovative Solutions for Seating and Positioning• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PMCustom Contoured Seating - The Next Step• 1 hour Instructional Course-Friday, February 23, 2001, 8:30 AM

Dalthea Brown, MS, PT, ATPUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technology5044 Forbes TowerPittsburgh, PA 15260E-mail: [email protected]

Dynamic Seating Components for Reduction inSpastic Activity and Enhancement of Function• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PMDevelopment Of A Dynamic Seating System Rigid-Body For Use In The Design Of DynamicSeating For Children Exhibiting Full Body ExtensorThrust• Paper-Friday, February 23, 2001, 3:30 PM

Seventeenth International SeatingSymposiumFaculty


Sheila Buck, B.Sc (OT), ATPTherapy Now!811 Graham Bell Ct.Milton, ON L9T 3T1CanadaE-mail: [email protected]

Back to Basics and Beyond• Pre Conference Workshop-Wednesday, February 21, 2001, 8:00 AM

Mary Ellen Buning, OTR, ATPUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technology5044 Forbes TowerPittsburgh, PA 15260E-mail: [email protected]

What Consumer’s Bring to Wheelchair Selection: TheResults of a Study• Paper-Friday, February 23, 2001, 3:30 PM

Corrinne CarriereCarriere Consulting532-268 Lakeshore Blvd.Oakville, ON L6J 7S4CanadaE-mail: [email protected]

The Business Side of Assistive Technology• Pre Conference Workshop-Wednesday, February 21, 2001, 8:00 AM

Laura Cohen, PT, ATPUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technology5044 Forbes TowerPittsburgh, PA 15260E-mail: [email protected]

Teaching Clinical Rationale For Seating And WheeledMobility Prescription: A Randomized Controlled TrialOf Four Instructional Methods• Paper-Friday, February 23, 2001, 3:30 PM

David Cooper, M.Sc., RTSunny Hill Health Centre for ChildrenTherapy Department3644 Slocan StreetVancouver, BC V5M 3E8CanadaE-mail: [email protected]


Rory Cooper, PhDUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and TechnologyDirector, Human Engineering Research Laboratories, VAPittsburgh Healthcare System5044 Forbes TowerPittsburgh, PA [email protected]

Funding Wheelchair Seating & Mobility Technologyand Services• Pre Conference Workshop-Wednesday, February 21, 2001, 8:00 AM

Rosemarie Cooper, MPTVA-Pittsburgh Healthcare SystemHERL, Building 47180 Highland DrivePittsburgh, PA 15206E-mail: [email protected]

Application of Research Findings into ClinicalPractice• 1 hour Instructional Course-Friday, February 23, 2001, 1:00 PM


Ian Denison, PTG F Strong - Vancouver Hospital, A Health SciencesCentre4255 Laurel StreetVancouver, BC V2Z 2G9E-mail: [email protected]

Power Wheelchairs, a New Definition• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AM

Gerry Dickerson, ATS, CRTSA&J Care Inc.8000 Cooper AvenueGlendale, NY 11385E-mail: [email protected]


Mark Dilabio, RTSunny Hill Health Centre for ChildrenTherapy Department3644 Slocan StreetVancouver, BC V5M 3E8


Marygrace DiStasio Mangine, OTR/LMagee Rehabilitation2216 South Clarion StreetPhiladelphia, PA 19148E-mail: [email protected]

The Challenge of Optimal Seating for People withJoint Contratures• 2 hour Instructional Course-Friday, February 23, 2001, 1:00 PM

Ann Eubank, OTR, ATPPermobile INC3729 HumphreySt. Louis, MO 63116E-mail: [email protected]


Martin Ferguson Pell, PhDUniversity College of LondonCenter for Disability Research & InnovationStanmore, United Kingdom HA7 4LPE-mail: [email protected]

Pressure Mapping• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PMChris Bar Research Forum• Special Session-Friday, February 23, 2001, 3:30 PM

Geoff Fernie, PhD, PEngCentre for Studies in AgingSunnybrook & Women’s College Health Sciences CentreU-B, 2075 Bayview AvenueToronto, ON M4N 3M5CanadaE-mail: [email protected]

Function and Performance of the RocketMultidirectional Powered Wheelchair• Paper-Saturday, February 24, 2001, 8:30 AM

Kathryn Fisher, B.Sc, OT(C)Therapy Supplies104 Bartley DriveToronto, ON M4A 1C5Canada

Power Chairs Features & Functions• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PMHigh Tech Solutions for a Special Needs Client• Paper-Friday, February 23, 2001, 8:30 AMPersonal Mobility, Vehicle Mobility...Strengthening the Link• 1 hour Instructional Course-Friday, February 23, 2001, 8:30 AM


Shirley Fitzgerald, PhDUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technologyand, VA-Pittsburgh Healthcare System Center ofExcellence for Wheelchairs and Related Technology5044 Forbes TowerPittsburgh, PA 15260E-mail: [email protected]

Innovations and Findings in Current SeatingResearch• Paper-Thursday, February 22, 2001, 1000How to Avoid the Pitfalls in Assistive TechnologyResearch• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AMApplication of Research Findings into ClinicalPractice• 1 hour Instructional Course-Friday, February 23, 2001, 1:00 PM

Cynthia Fleck, RN, BSN, ET, CWSCrown Therapeutics1538 N. Leavitt ST, BFChicago, IL 60622

The Seated Posture And Pressure Ulcer Connection• 2 hour Instructional Course-Friday, February 23, 2001, 1:00 PM

Karen Frost, MBAVA-Pittsburgh Healthcare SystemCenter of Excellence for Wheelchairs and RelatedTechnology, andUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and Technology5044 Forbes TowerPittsburgh, PA 15260E-mail: [email protected]

Influence Of Service Dogs In Psychosocial AndFunctional Outcomes As Measured By The RosenberSelf-Esteem Scale And Revised Craig HandicapAssessment And Reporting Technique (Chart)• Paper-Saturday, February 24, 2001, 8:30 AM

Marty Gallagher, MS, LOTRLouisiana Tech University711 S. ViennaRuston, LA 71270E-mail: [email protected]

Factors for Integrating Wheelchairs andTransportation• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PM

Doug Gayton, ATPG F Strong - Vancouver Hospital,A Health Sciences Centre4255 Laurel StreetVancouver, BC V2Z 2G9E-mail: [email protected]

Power Wheelchairs, a New Definition• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AM

Michelle Gunn, ATPWhitmyer Biomechanixs1833 Junwin Ct.Tallahassee, FL 32308E-mail: [email protected]

Cervical Flexion Problems and Possibilities• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PM

David HardingMotion Specialties101 Bartley DriveToronto, ON M4A 1C9Canada

Power Chairs Features & Functions• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PM


Karen Hardwick, PhD, OTR, FOATAAustin State School2203 West 35th StreetAustin, TX 78730E-mail: [email protected]

The Use of Technological Advances to EvaluateSeating and Positioning in Individuals with SevereOrthopedic and Developmental Disabilities• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AM

Ann Havard, LOTR, CDRSLouisiana Tech University711 S. ViennaRuston, LA 71270

Factors for Integrating Wheelchairs andTransportation• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PM

Thomas Hetzel, PT, ATPAspen Seating1032 E. Northampton Ct.Highlands Ranch, CO 80126E-mail: [email protected]

Back in Style• 2 hour Instructional Course-Friday, February 23, 2001, 1:00 PM

Douglas Hobson, PhDUniversity of PittsburghSchool of Health and Rehabilitation SciencesDepartment of Rehabilitation Science and TechnologyandRERC on Wheeled Mobility5044 Forbes TowerPittsburgh, PA 15260E-mail: [email protected]

Measuring and Recording Seated Posture - AProposed Standard• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PMTransport Wheelchairs• 2 hour Instructional Course-Friday, February 23, 2001, 1:00 PM

Susan Johnson Taylor, OTR/L288 East Ranney Ave.Vernon Hills, IL 60061E-mail: [email protected]; [email protected]

Developing Pre and Post Baclofen Pump OutcomeMeasures for Seating with Individuals with Cerebral Palsy• Paper-Friday, February 23, 2001, 8:30 AM

Debbie Jones, PT5225 S.W. Joshua StreetTualatin, OR 97062

The Importance of the Therapist in the WheelchairDecision-making Process for Older Adults• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AM

Karen Kangas, OTR/LR.D. 1Box 70Shamokin, PA 17872E-mail: [email protected]

Chest Supports, Why they are not working!• Paper-Thursday, February 22, 2001, 10:00 AMChildren in Power• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PMSeating, Access, and Mobility II: Those Children WhoGrow Up !• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AM

Alicia Koontz, MS, ATPVA-Pittsburgh Healthcare SystemRoom 151R-17180 Highland DrivePittsburgh, PA 15206E-mail: [email protected]

The Role of the Shoulder During WheelchairPropulsion• Paper-Thursday, February 22, 2001, 10:00 AM


Barbara Levy, PT, ATPThoms Rehabilitation HospitalSeating & Mobility Clinic68 Sweeten Creek RoadAsheville, NC 28803

Funding Wheelchair Seating & Mobility Technology,and Services• Pre Conference Workshop-Wednesday, February 21, 2001, 8:00 AMChris Bar Research Forum• Special Session-Friday, February 23, 2001, 3:30 PM

Gloria Liebel, OT (C)Bloorview MacMillan Centre35 Rumsey RoadToronto, ON M4G 1R8Canada

High Tech Solutions for a Special Needs Client• Paper-Friday, February 23, 2001, 8:30 AM

Simon Margolis, CO, ATS/PNational Seating and Mobility, IncPMB 5774190 Vinewood Lane #111Plymouth, MN 55442E-mail: [email protected]

When Ethics Isn’t Enough - Making Tough DecisionsIn A Changing Clinical Environment• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PM

Laura May, PhDUniversity of AlbertaDept. of Physical Therapy2-50 Corbett HallEdmonton, AB T6G 2G4

Back Support Options: Functional Outcomes forPersons with SCI• Paper-Friday, February 23, 2001, 3:30 PM

Rachel McDonald, B.App.Sc.(O.T.),Post.Grad.Dip.(Biomechanics)The Institute of Child Health and Great Ormond StreetHospital forChildren NHS TrustThe Wolfsom CentreMecklenbergh SquareLondon, WC1N 2APE-mail: [email protected]

Development Of A Method Of Measuring Force ThroughA Kneeblock For Children With Cerebral Palsy• Paper-Thursday, February 22, 2001, 1000Parents versus Therapists Views of their Child’sAdaptive Seating System• Paper-Friday, February 23, 2001, 8:30 AM

William Miller, PhD. MScOTSchool of Rehabilitation ScienceUniversity of British ColumbiaSchool of Rehabilitation SciencesFaculty of MedicineT325-2211 Wesbrook MallVancouver, BC V6T 2B5CanadaE-mail: [email protected]

The Prevalence And Type Of Wheelchair And SeatingNeeds Among The Institutionalized Elderly• Paper--Saturday, February 24, 2001, 8:30 AMThe Psychometric Properties Of The SeatingIdentification Tool (Sit)• Paper--Saturday, February 24, 2001, 8:30 AM

Morris Milner, PhD, P.Eng., CCEBloorview-MacMillan Centre350 Rumsey RoadToronto, ON M4G 1R8E-mail: [email protected]

Policy Change: Can We Make a Difference• Special Session--Saturday, February 24, 2001, 10:30 AM


Jean Minkel, MA, PTMinkelConsulting112 Chestnut AvenueNew Windsor, NY 12553E-mail: [email protected]

Mat Evaluation• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AMPolicy Change: Can We Make a Difference• Special Session-Saturday, February 24, 2001, 10:30 AM

Brenlee Mogul-Rotman, B.Sc., OT(C), OTR, ATPToward Independence34 Squire DriveRichmond Hill, ON L4S 1C6E-mail: [email protected]

Personal Mobility, Vehicle Mobility...Strengtheningthe Link• 1 hour Instructional Course-Friday, February 23, 2001, 8:30 AM

Cathy Mulholland, OTRMulholland Positioning Systems, IncP.O.Box 391Santa Paula, CA 93061E-mail: [email protected]

Kids Vs. Adults, Is There a Difference in Seating• Pre Conference Workshop.-Wednesday, February 21, 2001, 8:00 AM

Terry O’NeillKino Mobility Inc301140 Sheppard Avenue WestToronto, ON M3K 2A2

Personal Mobility, Vehicle Mobility...Strengtheningthe Link• 1 hour Instructional Course-Friday, February 23, 2001, 8:30 AM

Emma Parry, SROP, ATPUniversity College of LondonCenter for Disability Research & InnovationStanmore, HA7 4LPE-mail:

Pressure Mapping• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PMPolicy Change: Can We Make a Difference• Special Session--Saturday, February 24, 2001, 10:30 AM

Corrine Parver, J.D., P.T.Dickstein Shapiro Morin & Oshinsky, LLP2101 L Street NWWashington, DC 20037

The Business Side of Assistive Technology• Pre Conference Workshop-Wednesday, February 21, 2001, 8:00 AM

David (Scott) Pickett,Whitmyer Biomechanixs1833 Junwin Ct.Tallahassee, FL 32308E-mail: [email protected]

Cervical Flexion Problems and Possibilities• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PM

Terry Pountney, MA, MCSPChailey Heritage Clinical ServicesBeggars Wood RoadNorth Chailey, LewesEast Sussex, BN8 4JNE-mail: [email protected]

A Retrospective Study of the Effect of PosturalManagement Programmes in the Management of HipDislocation and Spinal Curvature in BilateralCerebral Palsy• Paper

- Friday, February 23, 2001, 8:30 AM


Jessica Presperin Pedersen, MBA, OTR/L, ATPPresperin Pedersen Associates5816 N. Moody AvenueChicago, IL 60646E-mail: [email protected]

Issues in Pediatric PracticeModerator - • Paper Session-Friday, February 23, 2001, 8:30 AM

Kathleen Riley, BS, PT, ATSNational Seating and Mobility113 Teaberry Ct.Mooresville, NC 28115E-mail: [email protected]

Kids vs. Adults, Is There A• Pre Conference Workshop-Wednesday, February 21, 2001, 8:00 AM

Tina Roesler, MS, PT, ABDACrown Therapeutics1538 N. Leavitt ST, BFChicago, IL 60622E-mail: [email protected]

The Seated Posture And Pressure Ulcer Connection• 2 hour Instructional Course-Friday, February 23, 2001, 1:00 PM

Faith Saftler Savage, PT, ATP74 Cottage StreetNatick, MA 07160E-mail: [email protected]

Can Therapuetic Positioning Effect FunctionalOutcomes?• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PMSeating for People with Multiple Sclerosis in a LongTerm Care Facility• 1 hour Instructional Course-Friday, February 23, 2001, 8:30 AM

Jack Sanders III, ATSClear Choice Health PlansBend, ORE-mail: [email protected]

Funding Wheelchair Seating & Mobility Technology,and Services• Pre Conference Workshop-Wednesday, February 21, 2001, 8:00 AM

Mark Schmeler, MS, OTR/L, ATPUniversity of Pittsburgh, School of Rehabilitation Scienceand TechnologyDepartment of Rehabilitation Science and Technology;Center for Assistive Technology, UPMC Health System3010 Forbes TowerPittsburgh, PA 15213E-mail: [email protected]

Funding Wheelchair Seating & Mobility Technology,and Services• Pre Conference Workshop-Wednesday, February 21, 2001, 8:00 AMClinical Use of Simulation• 1 hour Instructional Course-Friday, February 23, 2001, 8:30 AMThe Use of Adjustable Modular Wheelchairs as Fleet• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AM

Mike Shipp, MEd, CDRSLouisiana Tech University711 S. ViennaRuston, LA 71270

Factors for Integrating Wheelchairs and Tansportation• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PM

Jill Sparacio, OTR/L, ATP4600 Roslyn RoadDowners Grove, IL 60515E-mail: [email protected]

The Effects of Seating on Respiratory Function• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PM


Stephen Sprigle, PhD, PTCenter for Rehab TechnologyHelen Hayes HospitalRoute 9WWest Haverstraw, NY 10993E-mail: [email protected]

Chris Bar Research Forum• Special Session-Friday, February 23, 2001, 3:30 PM

Martin SzmalPride Mobility Products, Corp.182 Susquehanna Ave.Exeter, PA 18643Email: [email protected]


Stephanie Tanguay, OTR, ATP/SNational Seating and Mobility721 North VermontRoyal Oak, MI 48067E-mail: [email protected]

Seating Interventions for Spinal Cord Injuries withSecondary Orthopedic Complications• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PM

Geoff TaylorVerg, Inc120 Maryland AvenueWinnipeg, MB R3G 1L1CanadaE-mail: [email protected]

Chris Bar Research Forum• Special Session-Friday, February 23, 2001, 3:30 PM

Peter Thomas, EsqPowers, Pyles, Sutter *& Verville1875 I Street NWWashington, DC 20006-5409E-mail: [email protected]

Policy Change: Can We Make a Difference• Special Session--Saturday, February 24, 2001, 10:30 AM

Elaine Toskos, OTR, ATPRusk Institute for Rehabilitation Medicine400 East 34th St.New York, NY 10016-4998


Elyn Tovey, PTUPMC Rehabilitation Hospital1405 Shady AvenuePittsburgh, PA 15217E-mail: [email protected]

The Use of Adjustable Modular Wheelchairs as Fleet• 1 hour Instructional Course-Friday, February 23, 2001, 10:30 AM

Lois Tucker, OTR/L, ATPNational Seating & Mobility436 White RoadMineopla, NY 11501E-mail: [email protected]

Slip Sliding Away - Dealing with the client that slides• 1 hour Instructional Course-Thursday, February 22, 2001, 1:00 PMLinking Clinical Presentation with Power WheelchairProgramming• 2 hour Instructional Course-Friday, February 23, 2001, 1:00 PM


Peggy Walker, RNU S Rehab - Division of VGM1063 Langford RoadBlythewood, SC 29016E-mail: [email protected]

Reimbursement - Rehab 101 — All You Need ToKnow & More To Get Your Patient What They ReallyNeed• 2 hour Instructional Course

-Friday, February 23, 2001, 1:00 PM

Lori Warren7608 Apple Tree CircleOrlando, FL 32819E-mail: [email protected]

Policy Change: Can We Make a DifferenceSpec Session--Saturday, February 24, 2001, 10:30 AM

Kelly Waugh, MA, PTChildren’s Specialized Hospital, Mountainside, NJ37 Valentine Rd.New Providence, NJ 07974E-mail: [email protected]

Measuring and Recording Seated Posture - AProposed Standard• 2 hour Instructional Course-Thursday, February 22, 2001, 2:30 PMClinical Use of Simulation• 1 hour Instructional Course-Friday, February 23, 2001, 8:30 AM

Cheryl T. West, MSPTMagee Rehabilitation2216 South Clarion StreetPhiladelphia, PA 19148E-mail: [email protected]

The Challenge of Optimal Seating for People withJoint Contratures• 2 hour Instructional Course-Friday, February 23, 2001, 1:00 PM


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Seventeenth International SeatingSymposiumExhibitors

Accelerated Rehab Design32025 Industrial Park DriveOlathe, TX 77362Randy PotterPhone: 888-397-4063Fax: 888-397-0307Booth Number: 18

Action Products, Inc.22 North MulberryHagerstown, MD 21740Fred NelsonPhone: 800-228-7763Fax: 877-732-2073Booth Number: 9

Adaptive Engineering Lab, Inc.17907 Bothell-Everett Hwy.Mill Creek, WA 98012Donald WanetPhone: 800-327-6080Fax: 800-368-0785Email: [email protected] Number: 31-32-39-40

Adaptive Equipment Systems6224-A Preston AvenueLivermore, CA 94550Don GordonPhone: 800-611-4237Fax: 800-511-4237Booth Number: S 1-2-3

Altimate Medical IncP.O. Box 180Morton, MN 56270Jackie KaufenbergPhone: 507-697-6393Fax: 507-697-6900Booth Number: 24

Aquila Corporation206 1st Avenue NEClarks Grove, MN 56016Steve KohlmanPhone: 888-878-1141Fax: 507-345-3816Email: [email protected] Number: 13

Artsco, Inc9535 Route 30Irwin, PA 15642Mark MalagodiPhone: 724-863-1160Fax: 724-863-3559Email: [email protected] Number: 23

Aurora MinistriesP.O. Box 621Bradenton, FL 34206Scott MosherPhone: 941-748-4100Fax: 941-748-4100Booth Number: 8

Barrier Free Lifts, Inc.9230 Prince William StreetManassas, VA 20110Teresa KirkPhone: 800-582-8732Fax: 703-361-7861Booth Number: 25

Bodypoint Designs, Inc.Suite 300Seattle, WA 98104Elisa LouisPhone: 206-405-4555Fax: 206-405-4556Email: [email protected] Number: 56


Broda Seating385 Phillip St.Waterloo, ON N2L 5R8CANADADavid HeapPhone: 519-746-8080Fax: 519-746-8616Booth Number: 48

CF Rehab1003 International DriveOakdale, PA 15071Jerry ClarkePhone: 724-695-2122Fax: 724-695-2922Email: [email protected] Number: 78

Chauffer Mobility/Electric Mobility591 Mantua Blvd.Sewell, NJ 08080Joe SchwabPhone: 800-548-7905 EX 3021Fax: 856-468-1703Booth Number: 62-63

Clarke Health Care1003 International DriveOakdale, PA 15071Jerry ClarkePhone: 724-695-2122Email: [email protected] Number: 80

Cleveland Medical Devices, Inc.Suite 130Cleveland, OH 44106Bernard TarverPhone: 216-791-6720Fax: 216-791-6739Booth Number: 16

Convaid, Inc.2830 California StreetTorrance, CA 90503Gina WornsonPhone: 310-618-0111Fax: 310-618-8811Email: [email protected] Number: 61

Crown Therapeutics Inc./Roho International, Inc100 N. Florida AvenueBelleville, IL 62221Julie ReppPhone: 800-851-3449Fax: 618-277-9561Email: [email protected] Number: 35-36

Frank Mobility Systems1003 International DriveOakdale, PA 15071Jerry ClarkePhone: 724-695-2122Email: [email protected] Number: 79

Freedom Designs2241 Madera RoadSimi Valley, CA 93065Tyler RobuckPhone: 805-582-0077Fax: 805-583-2840Booth Number: 29

Frog LegsP.O. Box 465Vinton, IA 52349David KaufmanPhone: 319-472-4972Email: [email protected] Number: 77

Graham-Field, Inc./Everest & Jennings81 Spence StreetBay Shore, NY 11706Charlene AlbrechtPhone: 631-439-5628Fax: 631-439-5637:Booth Number: 12

Homecrest Healthcare140 Madison AvenueWadena, MN 56482Gary HansonPhone: 800-346-4852Fax: 800-346-4858Email: [email protected] Number: 19


Independence Providers, Inc. - LifeStand29A Marble AvenuePleasantville, NY 10570Pat ConlonPhone: 914-741-0350Fax: 914-741-0354Booth Number: 76

InterCo GmbH (Gesellschaft für Planung und Vertrieb vonReha-Hilfen) Im Auel 5053783 EitorfGERMANYUte MarkwaldPhone: 49 2243 4001Fax.: 49 2243 4003E-Mail: [email protected] Number: 47

InvacareOne Invacare WayElyria, OH 44036-2125Shawn VinsonPhone: 800-333-6900Fax: 800-678-4682Email: [email protected] Number: 33-34-37-38

KCI8023 Vantage DriveSan Antonio, TX 78230Cyndi ErpPhone: 210-255-6364Fax: 201-255-6981Booth Number: 5

LEVO USA140 Howell Road, Suite ETyrone, GA 30290Tracy DorwarthPhone: 770-486-0033Fax: 770-486-6096Booth Number: 10

MedBloc, Inc.Suite 112Tonawanda, NY 14150Ann DeWittPhone: 888-433-6818Fax: 716-447-0030Email: [email protected] Number: 73-74

Metalcraft Industries, Inc.399 N. Burr Oak AvenueOregon, WI 53575Bob JonesPhone: 608-835-3232Fax: 608-835-9180Email: [email protected] Number: 28

Moving Solutions, Inc2550 Wisconsin AvenueDowners Grove, IL 60515Mark NiedbalekPhone: 630--963-9693Fax: 630-963-4212Booth Number: S 6

Mulholland Positioning Systems, Inc.P.O. Box 391Santa Paula, CA 93061Cathy MulhollandPhone: 805-525-7165Fax: 805-933-1082Email: [email protected] Number: 75

NRRTSNational Registry of Rehabilitation TechnologySuppliersP.O.Box 4033Lago Vista, TX 78645Judy VancePhone: 512-267-6832Fax: 512-267-6833Email: [email protected]

Nimble Inc.201 Millway AvenueConcord, ON L4K 5K8CANADAPhone: 905-760-8744Fax: 905-760-8746Booth Number: 11

Otto Bock Rehab300 Xenium LaneMinneapolis, MN 55441Debbie PickarPhone: 763-519-6186Booth Number: 49-50


Permobile Inc.6 B Gill StreetWoburn, MA 01801David IammarinoPhone: 800-736-0925 Ex 255Fax: 800-231-3556Email: [email protected] Number: 54-55-68-69

Position Dynamics2636 289th PlaceAdel, IA 50003Shawn O’ToolePhone: 515-993-5001Fax: 515-993-4172Booth Number: 6

Prairie Seating Corp.7515 Linder AvenueSkokie, IL 60077Karin TrenkenschuPhone: 847-568-0001Fax: 847-568-0002Booth Number: 67

Pride Mobility Products Corp.182 Susquehanna AvenueExter, PA 18643Mary Beth GillespiePhone: 800-800-8586Fax: 800-800-1636Email: [email protected] Number: 70-71-72

Rehab Management Magazine6701 Center Drive, W.Los Angeles, CA 90045Jody RichPhone: 310-642-4400Fax: 310-641-0831Booth Number: 17

RESNASUITE 15401700 N. Moore StreetArlington, VA 22209Phone: 703-524-6686Fax:: 703-524-6630email: [email protected] Number: F 3

Sammons Preston4 Sammons CourtBolingbrook, IL 60440Pete GarganoPhone: 630-226-1300Fax: 630-226-1389Email: [email protected] Number: 59

Sand Therapeutic5234 36th AvenueHudsonville, MI 49426Greg ZorovichPhone: 616-662-103Booth Number: 42-53

Signature 2000489 West Exchange StAkron, OH 44302Todd DinnerPhone: 800/335-0320Fax: 330-376-9723Booth Number: 20

Snug Seat, Inc.P.O. Box 1739Matthews, NC 28106-1739Kirk MackenziePhone: 800-336-7684Fax: 704-882-0751Email: [email protected] Number: 30-41

Southwest Assistive Technology Inc.P.O. Box 639West Haverstraw, NY 10993Trudy Posner, MS, OTR/LPhone: 845-947-0377Booth Number: 7

Star Cushion Products2221 Country RoadBelleville, IL 62221Kevin FraserPhone: 618-355-0510Fax: 618-355-0512Booth Number: 4


Stealth Products, Inc1706 Colt DriveMarble Falls, TX 78654Lorenzo RomeroPhone: 830-693-1981Fax: 830-693-1991Booth Number: S 4

Sunrise Medical, Inc.7477 East Dry Creek ParkwayLongmont, CO 80503Jamie PostlePhone: 303-218-4600Fax: 303-218-4575Booth Number: 43-44-51-52

Supracor, Inc.2050 Corporate Ct.San Jose, CA 95131-1753Libby Kneeland WilliamsPhone: 408-432-1616Fax: 408-432-1975Email: [email protected] Number: 1-2

Tekscan, Inc.307 West First StreetSouth Boston, MA 02127Julie LombardiPhone: 617-464-4500Fax: 617-464-4266Booth Number: S5

Teftec Corp.6929 Old Spring Branch RoadSpring Branch, TX 78070Janet FinchPhone: 830-885-7588Fax: 830-885-7586Booth Number: 14-15-26-27

TherAdapt Products, Inc.17W163 Oak LaneBensenville, IL 60106-4919Julie PirianoPhone: 630-834-2461Fax: 630-834-2478Email: [email protected] Number: 60

TiSport1427 East Third AvenueKennewick, WA 99337Marty BallPhone: 509-586-6117Fax: 509-586-2413Email: [email protected] Number: 45-46

University of PittsburghSchool of Health & Rehabilitation SciencesDepartment of Rehabilitation Science andTechnologyRERC on Wheeled Mobility5044 Forbes TowerPittsburgh, PA 15206Phone: 412-383-6596Fax: 412-383-6597Booth Number: F 2

Uplife Technologies IncUnit 125Dartmouth, NSCANADAB3B 1M2Michael SperawPhone: 800-387-0896Fax: 902-422-0798Email: [email protected] Number: 3

Varilite4000 1st Avenue, SouthSeattle, WA 98134Kevin ColemanPhone: 206-676-1452Fax: 206-343-5795Email: [email protected] Number: 21-22

Wenzelite Re/hab Supplies220-36th StreetBrooklyn, NY 11232Pearl GoldsteinPhone: 718-768-8002Fax: 718-768-8020Email: [email protected] Number: 64


Whitmyer Biomechanix, Inc.1833 Junwin CourtTallahassee, FL 32308Mitchell KomisarPhone: 850-656-9448Fax 850-656-9139)Email: [email protected] Number: 57-58-65-66


Zen and the Art of WheelchairMaintenance – Experiences On AJourney Through Seating

Geoff I. Bardsley, PhD

AbstractWhat follows is based on actual occurrences.Although much has been changed for rhetoricalpurposes, it must be regarded in its essence as fact.However, it should in no way be associated with thatgreat body of wisdom relating to orthodox ZenBuddhist practice. It’s not very factual onwheelchairs either.

Reviews ‘Bardsley is not propounding a brand newphilosophy for our acceptance or rejection. He isrediscovering an ancient and universal tradition,illuminating it by his own very peculiar method, andrestating it in terms which he hopes will strike homeeffectively …. All I can really say is that he struckwith brilliantly enlightening effect on the mind ofthis reviewer.’Auchtermuchty Herald

‘A miracle ……….. sparkles like an electricwheelchair.’Forfar Village Voice

‘Bardsley is the nut at the still centre of the turningwheel’Crianlarich Chronicle

‘You should read this paper on the road, on a

mountainside, at the bottom of the ocean. It shouldbe a set paper in any serious course of any study, somulti-applicable are its intentions. For instance, ifyou wanted to be a wheelchair mechanic it shouldbe read before any technical material. If you wantedto be a man of God, it should be read before youdecide to be. And if you wanted to write a book, itshould be read before you invest in a wordprocessor…. Read the goddam thing and you’ll seewhat I mean. The very heart of things - that’s whereBardsley is coming from’Dundee Street Life

Bibliography

Pirsig, R.M.(1974) Zen and the Art of MotorcycleMaintenance, Pubs: Bodley Head.

Wilson, C. (1999) Achieving Quality in Health,Pubs: Garaci


Innovations and Findings in CurrentSeating ResearchShirley Fitzgerald, PhD

In today’s healthcare arena, clinicians are understress to treat patients with the most appropriate andup to date care. One way to get this information is toread professional journals targeted for assistivetechnology, mobility and seating. Unfortunately,due to demands imposed upon the clinician from thehealthcare system, clinicians need to care for morepatients in a shorter period of time, resulting in lesstime spent in reading professional journals.Therefore, the purpose of this session is to reviewliterature that has been published from January 1999to December 2000 (2 years) that focused on seatingresearch and advances.

Literature searches were conducted withinMEDLINE and CINAHL. Other search engineswere used as well, but with no new articles werefound. Keywords used to identify possible articlesincluded wheelchairs, seating, seating systems,cushions, posture, pressure sores, spasticity, tone andkyphosis. Combinations of the key words allowedfor limiting the search to relevant articles. The samesearch strategy was completed in all search engines.In addition, proceedings that were available to theauthor from RESNA and other conferences (years1999, 2000) were also reviewed to identify relevantfindings within the wheelchair seating research.Although every effort was made to make the list allinclusive, it is possible that relevant research hasbeen published, but has not been identified due tothe varied keywords that authors use to identify theirwork. Should I have missed some work, it is purelyby accident, and no intent to neglect research.

In December of 2000, numerous articles wereidentified by both MEDLINE and CINAHL that hadbeen published in the past 2 years encompassingdifferent aspects of seating, wheelchairs andmobility. Upon review of the information available(title, abstract), a decision was made about theinclusion of the article in this presentation. If thefocus of the article was seating related it has beenincluded. If the focus of the article was moreproduct related (informational only) or was a reviewarticle concerning seating issues, the reference was

noted, but has not been included for review withinthis talk. Table 1 shows the focus of articles that willbe presented.

Table 1: Focus of Articles• Seating: Pressure Ulcers; Cushions• Seating – Posture• Spasticity and Tone• Wheelchairs : Transportation

Mobility issuesBiomechanics

Seating with respect to pressure ulcers, managementof pressure and the integration of cushions to aid inpressure relief have had the greatest amount ofresearch completed on it in the past several years.Included in these research findings are studies thathave examined comparisons between different typesof cushions and amount of pressure, cushions versustilt-in-space chairs to relieve pressure, andmattresses designed to aid in pressure relief.Somewhat interrelated, research has also beenconducted on pressure and posture with differentwheelchair seating systems. For example awheelchair with different types of leg rests maymodify posture but also decrease pressure for theindividual. Some research has examined the use ofindividualized programs to retrain subjects on howto sit, thereby helping with seated posture.

The research conducted in spasticity research hasfocused primarily on injections of Botulinum toxin.Various studies have shown that injections canreduce spasticity in both children and adults. Otherstudies have encompassed the validity of thependulum test for assessing spasticity and treatingspasticity with an exercise regime.

Research on wheelchairs has included issues intransportation (i.e. stability of SCI subjects indynamic settings, wheelchair restraint systems),new types of wheelchairs such as the power assistedmanual wheelchairs, as well as the biomechanics ofwheelchair propulsion.


Studies will be described with results and limitationsemphasized. This review of the literature should bebeneficial to all clinicians who have little time toread, and yet want to be more knowledgeable fortheir patients concerning the research that has beencompleted.

Selected ReferencesAissaoui R, Heydar S, Dansereau J, Lacoste M.Biomechanical analysis of legrest support of occupiedwheelchairs: comparison between a conventional andcompensatory legrest. (2000) IEEE Trans on RehabEngineer, 8(1):140-148.Beiring-Sorensen F, Schroder AK, Wilhelmsen M, LombergB, Nielsen H, Hoiby N. Bacterialcontamination of bathwater from spinal cord lesionedpatients with pressure ulcers exercising in the water. (2000)Spinal Cord,38(2):100-105.Bertocci GE, Esteireiro J, Cooper RA, Young TM, ThomasC. Testing and evaluation of wheelchaircaster assemblies subjected to dynamic crash loading. (1999)J Rehab Res Dev, 36(1):32-41.Bolin I, Bodin P, Kreuter M. Sitting position: posture andperformance in C5-C6 tetraplegia. (2000) Spinal Cord,38(7):425-434.Boninger ML, Baldwin M, Cooper RA, Koontz A, Chan L.Manual wheelchair pushrim biomechanicsand axle position. (2000)Arch Phys Med Rehabil, 81(5):608-613.Brienza DM, Lin CT, Karg PE. A method for custom-contoured cushion design using interfacepressure measurements. (1999)IEEE Trans on RehabEngineer, 7(1):99-108.Burns SP, Betz KL. Seating pressures with conventional anddynamic wheelchair cushions. (1999) Arch Phys MedRehabil,80(5):566-571.Defloor T, Grypdonck MHF. Do pressure relief cushionsreally relieve pressure(2000)Western J NursingResearch,22(3):335-350.Defloor T, Grypdonck MHF.Sitting posture and preventionof pressure ulcers.(1999) Applied NursingResearch,12(3):136-142.DiGiovine M, Cooper RA, Boninger ML, Lawrence BM,VanSickle DP, Rentschler AJ. User Assessmentof Manual Wheelchair Ride Comfort and Ergonomics.(2000)Arch Phys Med Rehabil,81:490-494.Ebe K, Griffen MJ. Quantitative prediction of overall seatdiscomfort. (2000)Ergonmics, 43(6):791-806.Ferrarin M, Ludwig N. Analysis of thermal properties ofwheelchair cushions with thermography.(2000) Medical & Biological Engineering & Computing,38(1):31-34.Fowler EG, Nwigwe AI, Ho TW. Sensitivity of the pendulumtest for assessing spasticity in persons with cerebral palsy.(2000) Dev Medicine Child Neurology,42(3):182-189.Garber S, Rintala DH, Hart KA, Fuhrer ML. Pressure ulcerrisk in spinal cord injury: predictors of ulcer status over 3years. (2000) Arch Phys Med Rehabil,81(4):465-471.Goodman CM, Cohen V, Armenta A, Thornby J, NetscherDT. Evaluation of results and treatmentvariables for pressure ulcers in 48 veteran spinal cord-injured patients. (1999)Annals of Plastic Surgery, 42(6):665-672.

Gray D. Pressure ulcer prevention and treatment: theTransair range. (1999). British J Nursing8(7):456-458.Holdon KR, Titus MO. The effect of tiagabine on spasticityin children with intractable epilepsy: apilot study. (1999)Pediatric Neurology,21(4):728-730.Kamper DG, Adams TC, Reger SI, Parnianpour M, Barin K,Linden M. A low-cost, portable system forthe assissement of the postural response of wheelchair usersto perturbations. (1999)IEEE Trans on Rehab Engineer,7(4):435-42.Kamper DG, Barin K, Parnianpour M. Reger S, Weed H.Preliminary investigation of the lateralpostural stability of spinal cord injured individuals subjectedto dynamic perturbations. (1999) SpinalCord,37(1):40-46.McCarthy JJ, Betz RR. The relationship between tighthamstrings and lumbar hypolordosis in childrenwith cerebral palsy. (2000) Spine,25(2):211-213.Pellow TR A comparison of interface pressure readings towheelchair cushions and positioning: Apilot study. (1999)Can J Occup Ther, 66(3):140-149.Phillips VL, Temkin A, Vesmarovich S, Burns R, Idleman L.“ Using telehealth interventions to preventpressure ulcers in newly injured spianl cord injury patientspost-discharge. (1999)International JTechnology Assessment in Health Care,15(4):749-755.Reid D, Rigby P, Ryan” Functional impact of a rigid pelvicstabilitzer on children with cerebralpalsy who use wheelchairs: Users’ and caregivers’perceptions. (1999) Pediatric Rehabilitation,3(3):101-118.Rodriquez AA, McGinn M, Chappell R. Botulinum toxinkinjection of spastic finger flexors inhemiplegic patients. (2000) A J Phys Med Rehabil, 79(1):44-47.Sherwood AM, Graves DE, Priebe MM. Altered motorcontrol and spasticiy after spinal cord injury:subjective and objective assessment. (2000) J Rehab ResDev, 37(1):41-52.Skold C, Levi R, Seiger A. Spasticity after traumatic spinalcord injury: nature, severity, and location.(1999)Arch Phys Med Rehabil 80(12):1548-1557.Suputtitada A. Managing spasticity in pediatric cerebralpalsy using a very low dose of botulinum toxintype A: preliminary report. (2000) A J Phys Med Rehabil,79(4):320-326.Tavakoli K, Rutkowski S, Cope C, Hassall M, Barnett R,Richards M, Vandervord J. Recurrence rates ofischial sores in para- and tetraplegics treated with hamstringflaps: An 8 year study. (1999)British JPlastic Surgery, 52(6):476-479.Tefft D, Guerette P, Furumasu J. Cognitive predictors ofyoung children’s readiness for poweredmobility. (1999)Dev Med Child Neurology, 41(10):665-670.Visser C, Eksteen CA. The efficacy of the Simplified AirCushion (SAC) compared to the polyurethanefoam cushion with regard to ischial tuberosity interfacepressure relief. (1999)S Afr JPhysiother,55(4):3-6.Weiss-Lambrou R, Tremblay C, LeBlanc R, Lacoste M,Dansereau J. Wheelchair seating aids: howsatisfied are consumers? (1999)Assistive Technology,11(1):43-53.Wissel J, Muller J, Dressnandt J, Heinen F, Naumann M,Topka H, Poewe W. Management of spasticityassociated pain with botulinum toxin A. (2000)J PainSymptom Management,20(1):44-49.


Chest Supports: Why They Are NotWorking!Karen Kangas, OTR/L

Introduction:

I am not talking about patients who have had aspinal cord injury or a muscular atrophy ordystrophy. Chest supports for them are critical inholding up a body which is losing control. Thispaper is focusing on children and adults withcerebral palsy, traumatic brain injury, and othermotor cortex dysfunctions.

For many individuals with hypertonicity, orcombined hyper and hypotonicity, chest supports arenot working. The adult or child can be readilyobserved to be hanging on the chest supports,collapsing their trunks into the support, rather thanbeing assisted by the support to remain upright.

These individuals often exhibit sensory processingproblems (not to be mistaken with sensory loss, norloss of sensation). Allow me to share someassessment and equipment strategies which canassist in you with a better understanding of how thebody is interpreting its postures in order to supportan upright posture.

Adaptive Seating as is currently implemented:

When we see children or adults who demonstratehypertonicity we may often at closer examinationdetermine lower tone in their trunks with increasedtone in the extremities. We may see increasedhyperextension, or what may appear as obligatoryprimitive reflex responses, like an asymmetricaltonic neck reflex, or a symmetrical tonic neck reflex.

Our “job” in seating was to create seating whichwould decrease or control this tone, to allow them tosit in an upright posture.

We presumed that an upright posture was the postureneeded to then be able to do things.

As the general “rule” we created a particular type ofseating which decreased tone, or we hoped would.(This was a result of the belief that the tone wasinvoluntary and reflexive in nature, preventing theindividual from controlling her body). Some ofthese “rules” were and are:

When extensor tone is demonstrated, the body of thepatient is flexed. This is primarily done at the pelvisand hips, wedging the seat, to place the knees higherthan the pelvis. This type of seat may also bereferred to as an “anti-thrust” seat. The underlyingtheory here is that to stop the extension, flexion atthe hips will be provided by the seat, thus “breakingup” the tone. Often when this is accomplished thetrunk will then collapse onto the thighs, or moveforward. Trunk lateral supports and a chest strap(varying ones are used, “butterfly” configurations,“H-straps”, “X” straps) are then used to assist inpulling the trunk back up and against a planar back.The head is then supported with a head rest.

For many individuals with high tone, or increasedextensor tone, this works for just about as long asthe seating clinic visit takes. However, in less thanan hour, the patient is “hanging on” to the chestsupports, falling or almost pushing forward ontothem, or hanging on to the chest support, whilepushing out at the pelvis (“thrusting”).

The next solution has been to increase the angle orwedge of the seat, add a pommel of indeterminatesize (to add abduction as well as hip flexion),increase the size or curve of the trunk laterals, andincrease the size or weight of the chest straps, or addscapular retractors (bars from the back of the top ofthe back which are padded and go over the top of theshoulder and land at the collarbone on the front).


With many patients, this still does not assist inhead control, but rather then head then slides into ahyperextended posture, with the occiput resting onthe upper back. At this point we place them often,into a tilt-in-space chair and tilt the chair almost toits full 45 degrees of tilt, and leave them there allday. Or, if the individual is brought up to an uprightposture, it is only for a few short minutes until thetrunk “falling forward” occurs.

Unfortunately, this reasoning is flawed. This seatingdoes not work, and certainly the patient is not able tobe in an upright posture.

This reasoning is reasoning of anatomy, and somebio-mechanics, which based on physics, is perhapsunderstandable, but human beings are not bio-mechanical, nor anatomical, but rather areneurophysiological.

That means that at any moment in time multiplesystems are integrated and functioning regulating,and changing, always moving, always changing,always working. These systems adjust internallyand externally, and it is no wonder we have haddifficulty interpreting the body, we are still trying tounderstand these processes at all. They includebiological, chemical, electrical, magnetic, as well asforce, levers, and time. (I don’t have enough time togo into all of this, but wanted to simply make thepoint of the complication here.)

I want to today, simply bring it some increasedinformation about the sensory system, its integrationin the body, and how it directly relates to uprightpostural control.

Integration of Systems in the Body:Upright trunk (and subsequent head) control is basedon sensory integration rather than on “motor”control. Motor control is in fact, sensory integrativecontrol in nature. In short, muscle stimulation andregulation is based on information not just simply tothe motor cortex, but also the integration of thevestibular/equilibrium system (the body’srelationship to gravity) and the tactile/kinesthetic/proprioceptive systems (the body’s relationship to itsinternal structures to the external ones)

Seating systems must support these principles andoften chest supports do not.

Individuals who are not mobile and not ambulatoryhave little active, STRONG, experience withgravity, and are most often asked to remain evenmore “stable” by “not moving.” These individualshave difficulty learning how to integrate varioussensory-motor skills, especially upright postures foradequate body postural use and extremity isolation.

Why does this matter? In human beings withinearth’s gravity, body control is interpreted andperformed when the body understands itsrelationship to gravity, primarily through theactivation of the vestibular system, its ability toweight bear (interpreted through motorproprioceptors), and to stably, yet dynamically reactto gravity. This requires weight bearing through thepelvis, through the thighs, through the knees,through the calves, through the feet. In order toweight bear, the body must hold itself. It cannot betotally supported. Total support asks the body to“give up” or “give in” to the surface, as if to rest orsleep, as we all do, or attempt to do each night. Thisgiving in or giving up of righting reactions, isnecessary for rejuvenation of our very activevestibular and equilibrium systems needed allwaking day long.

We all move from holding ourselves up, to giving ina little, to regaining upright postures, to giving in alittle. Imagine yourself at a desk, working at akeyboard, as I am now, writing this paper. As youconcentrate your body moves forward, on the chair,the trunk especially, holding the hands up over thekeyboard, the feet holding on the the floor, the pelvisslightly anteriorly tilted. When a sentence iscompleted, and new thoughts are created, and thehands lift from the keyboard, a rest occurs. Thisresting posture, is a giving up of uprightness. Thepelvis shifts posteriorly, the trunk collapses, and theback finds the back of the chair. The legs are nolonger weight bearing, and the pelvis itself, is nowleaning against the back of the chair. When workbegins again, the trunk and pelvis simultaneously,almost, lift up, and move forward, and the handswork some more.

This is weight shifting, and upright posture. Itoccurs without furniture support. It occurs at thefront of the chair, controlled by the body and theperson’s intent.


be weight bearing. The hamstrings and quadricepsmust also be weight bearing, not overly holding, oroverly shortening. (This can be easily felt whentreating the patient, by a certified therapist, physicalor occupational. A weight bearing limb is activelyholding, while an overly holding limb, can bedemonstrating increased spasticity, NOT weightbearing.) The body must have tone, and use tone tohold itself, so power and tone must be evident.

In general, I use a process of assessment. I willwork on a bench or a mat table depending on thesize of the patient. The height of the bench or tablemust be identical to the leg length of the patientwhen seated. I then place the patient in a seatedposture, at the edge of the bench (or mat table). Myown trunk will become the back support of the chair,and will move the patient forward into a seatedposture, placing weight bearing onto the pelvis, andthe lower extremities. I can readily tell when thereis weight bearing, or collapsing, where the point ofcontrols are, and how the patient is able to react tomoving into a seated posture, and then back out of it.If the patient’s trunk collapses onto my hands as Iassist her in an upright posture, or I have greatdifficulty getting the patient into an upright posture,as the head and neck do not appear to extend, or theopposite, there is so much extension that the patientalmost “pops” out of my hands, I know that I amseeing postural insecurity, and probably a lack orexperience or ability in activating the weight bearingand equilibrium systems, with an over dependenceon the tactile system.

If the patient is a child, I will first add a “barrier”vest. This is just what it sounds like. A vest whichprevents my hands from being felt on the trunk. Nosingular point of contact can be felt, and the patientcan then be moved throughout treatment, or into anupright posture easily, without trunk collapse. Iwork with orthotists and construct a plastazote vest.This vest is then NOT strong enough to totallysupport the patient, it is simply a hard barrier withinwhich the patient can have experiences of movingwithout feeling hands, or other objects which createtheir “tactile” reaction. The child is then able toweight bear in the pelvis (while they are in treatmentor how we have created their seating system) andlearn to integrate the use of the shoulder girdle withthe pelvic girdle, learning increased uprightalignment. This vest is firm, yet not hard. It canthen be tolerated by the body readily, and does nottake over support from the body. The body must dothe work, but this vest prevents a tactile reaction.

If a seatbelt were added to my desk chair, and ashoulder harness, I would have a great deal ofdifficulty getting this paper done. I would end uphanging on the straps as I rested.

This is what is happening and should happen to allhuman beings. We collapse with rest, we move intouprightness to work, and this shifting is critical tothe entire range of control of the process ofuprightness. Postures are not snapshots, they arevideos. Posture is always changing, reacting, andmoving, working with gravity, working, andmoving.

Now, with children and adults who not only have alack of experience of mobility and ambulation (thestrongest range of postures of uprightness) andwhose bodies are already having some difficultyinterpreting data, another reaction comes into play.This is an involuntary trunk collapsing, protective innature, like most reflexes. When any pressure isplaced on the chest, the trunk moves into thepressure. It is as if, the support is telling the body tocome to it. (I think that this is another form of the“snuggle” response, seen in young infants, when thechild is supported, the tactile/kinesthetic system isactivated the the infant moves into, closer to,mother).

Reflexes are always managed by active weightbearing and equilibrium. The vestibular system is sopowerful, that its control of the body almost alwayssuper-imposes itself on all other systems. In short,active and voluntary control, and purposefulmovement control reflexes, or overpower theircontrol of the body.

Let me try a quick summary. We are providing toomuch support, and support in the wrong places, ifwe want seating to assist in an individual’s controlof upright postures, especially at the trunk and head.Its really as simple as that.

Recognizing this postural insecurity in the trunk isnot difficult. It is obvious in observation of thepatient in their seating system. What is needed, arestrategies which truly provide support, rather than ahindrance to upright posture.

Treatment and Equipment Strategies:

In order to hold one’s self in an upright posture,weight bearing must be active, and obvious. Thepelvis must be able to weight shift, be mobile, and


This works well with smaller children. The vest canbe used in therapy, and within a standard seatingsystem. It is used for short periods frequently, orworn all day, for time of less than 6 months. It isused to simply allow the body to learn to do what italready knows to do, but hasn’t had the opportunityto do because too much stuff has been in the way.

The vest is then used for the trunk, the wedge isremoved from the seat, as well as any pommel. Thetrunk is brought forward, a bit in front of the pelvis,and a slight (very small) anterior tilt may be addedunder the ischial tuberosities on the seat. Thissystem is mounted on a tilt in space chair, so thatwhen the chair is tilted at about 10-15 degrees, thechild will be able to “rest.” No seating position isright if it is the ONLY position, we must developseating systems that allow a range of movement andsupport to occur.

Powered tilt on a powered chair is even better, as thechild can learn to control the support independently.The vest is used during tasks, when the child isforward. It is a treatment technique not adaptiveseating equipment. It is to be used temporarily, withtreatment. It is a method by which the child canlearn to use her body herself. This is NOT ananswer to trunk control. It is a method by which theindividual learns trunk and by the way, head control.

With larger children, or with adults, a vest is notable to be used, (with the exception of an individualwho has a scoliosis, orthotic jacket for spinal controlalready, then treatment with it on, can occur andseating changes can use it, too), as the type ofmaterial I prefer would collapse and to make it“harder” would then prevent them from controllingtheir bodies, and would simply take over for them.

Instead, bilateral trunk supports from the rear, longenough to touch the pelvis to the scapulae, NOTcurving around to the front, can be used, with again,a flatter seat, an anteriorly tilted seat, no pommel,and an ACTIVITY to be participated in, especiallywith the head. This position can be simulated withfirm towel rolls or blanket rolls, make just to fit.The support is then all along the spine, with nosingle point of contact, and subsequently the body isnot stimulated to use a tactile response. To stimulatethe vestibular system, this person then, with me, ismost often, provided with a powered mobilitysystem with head access, so that control of anactivity is obvious, and movement is occurring tothem, as well as them controlling it.

Summary:

It is so difficult to try and explain a difficult conceptin a short space and time. I hope I have at leastpeaked your curiosity, and have assisted you inlooking much further into the range of humanpostures. I have been honored to have the bestteachers in the world, my patients. They have taughtme how the body works, and that it best works whenit is unencumbered, supported (but not restrained)and actively involved in interesting tasks. Seating,to me, as learned through them, is a process ofmovements, not a chair, and the supports needed,must be flexible, and allow them to learn control oftheir bodies, through experience with life and itscontrol of activities. We are a complicated species,and our understanding, even of ourselves, is justbeginning.


The Role of the Shoulder DuringWheelchair PropulsionAlicia Koontz, MS, ATP

Shoulder pain and injury is prevalent in highpercentages among individuals who use manualwheelchairs (1-3) and for many it seems that earlysigns of shoulder micro trauma may be unknowinglypresent. In a study conducted by Lal on theshoulders of 53 patients with spinal cord injuries72% had radiological evidence of degenerativeshoulder changes but only 11% complained of painin the shoulders (4). In the group that demonstratedshoulder injury, the acromioclavicular joint waspredominantly affected. In a prospective magneticresonance imaging (MRI) study of the shoulders of18 wheelchair users shoulder abnormalities aboutthe coracoacromial arch (formed by the acromion,corocoacromial ligament, and coracoid process)were common and were not always associated withpain (5). The average ages of the patients in thesestudies were 37 and 35 years respectively. Whilefurther shoulder pathology is expected withadvanced age, exposure to putative mechanicalforces from pushing a wheelchair and weightbearing activities will likely increase one’s risk indeveloping shoulder abnormalities.

With the repetitive upward loading of the shoulderthat occurs when weight bearing or when pushing awheelchair, counteractive forces from the shoulderdepressors are necessary to prevent displacement ofthe humeral head superiorly from the glenoid cavityof the scapula. Most researchers agree that muscleimbalance is an additional factor in the developmentand perpetuation of shoulder injury. Burnham andcolleagues in their study of wheelchair athletes withparaplegia and unimpaired athletes found that theratio of shoulder abduction to adduction strengthwas significantly higher in the athletes withparaplegia suggesting a relative weakness ofshoulder adduction to abduction as compared to theunimpaired athletes (6). The ratio of strength forabduction/adduction was even further exaggeratedamong the wheelchair athletes who showed signs ofimpingement. Without the counteracting force ofthe shoulder depressors, the deltoid will pull the

humeral head upwards into the coracoacromial archcompromising the space available for the rotatorcuff tendons which further increases the likelihoodof an impingement problem. Athletes withparaplegia who showed signs of impingement werealso significantly weaker in internal and externalrotation as compared to those without impingement.Hence, an effective preventative method forbalancing muscle strength among wheelchair usersmay involve a strength training regime emphasizingstrengthening of the shoulder adductor muscles(latissimus dorsi, teres major and lower fibers of thepectoralis major) and the internal rotators(subscapularis and anterior deltoid) and externalrotators (infraspinatus and posterior deltoid).

Shoulder joint pain and injury may also result fromthe repetitive application of forces when pushing awheelchair. In Lal’s study, a positive relationshipwas found between individuals with a higher level ofwheelchair activity and beginning signs ofdegenerative changes in the shoulders (4). Whileweight-bearing and pressure relief maneuversinvolve very large impact loads on the shoulder, theloading does not occur as frequently as inwheelchair propulsion. With subsequent applicationof low shoulder stresses, the shoulder cartilagerepair mechanism is likely disturbed resulting in thebeginning signs of micro trauma as indicatedpreviously. Then when the weakened shoulder issubjected to a very large impact load like whatgenerally occurs when performing a transfer, a moreserious injury like a rotator cuff tear may occur.

Recent studies have focused on identifying keywheelchair propulsion variables associated withshoulder injury among MWUs. Propulsion forces atthe pushrim have been significantly linked tomagnetic resonance imaging evidence of shoulderdysfunction in 26 MWUs (7). The strongestcorrelation was between the vertically directed forcecomponent and the MRI scores for coroacoacromialligament edema and thickening. The coracoacromial


ligament is located slightly anterior and superior tothe head of the humerus. The vertical forcecomponent tends to push the humeral head upfurther into the joint applying increased pressureagainst the ligament resulting in the subsequentsigns of trauma. Fourteen wheelchair users fromthis prospective study returned after two years andwere tested under the same protocol (8). Seven ofthese wheelchair users showed an increase in theirshoulder MRI abnormalities. Interestingly, thisgroup also used greater forces to propel theirwheelchairs at each speed tested the first time theywere evaluated. Moreover, individuals whopropelled with a peak weight normalized force ofgreater than 5% were significantly more likely tohave increased shoulder abnormalities over time.This finding suggests that altering propulsiontechnique or using devices that reduce the amount ofshoulder injuries.

During wheelchair propulsion at the extreme ends ofits range of motion, the shoulder is subjected to peakloading conditions (9). It is at this point that theshoulder may be the most susceptible to injury.Modification of propulsion technique, optimizationof the user’s wheelchair configuration as well asappropriate seating and positioning may improve thebiomechanics of propulsion and reduce theprevalence of shoulder problems. Boninger andcolleagues found that individuals whose shoulderswere further behind the rear wheel axle contactedthe pushrim behind the top dead center of the rim(10). At this position, stronger muscles can berecruited to deliver power to the rims whichultimately leads to a reduction in frequency of theapplied forces. While moving the rear wheel axlefurther forward compromises stability of the chairand user comfort, it was shown to decrease strokefrequency, increase contact angle, and reduce therate of loading on the hand which all are factors thatmay aid in the reduction or prevention of shoulderpain and/or injury.

The impact of shoulder pain/injury is both personaland financial. The personal impact can range fromcurtailing one’s activities to near total dependenceon others. The financial impacts are also notinsignificant. Understanding the mechanisms ofshoulder injury can help to identify MWUs who areat risk for developing shoulder abnormalities.Interventions among MWUs should focus onstrength training of the opposing muscles groups,provision of wheelchair training, and optimization ofthe biomechanics of wheelchair propulsion through

appropriate wheelchair prescription and set-up.Current investigations on wheelchair propulsionbiomechanics are leaning toward longitudinalstudies which are necessary to identify injuriousbiomechanical factors related to early shoulder jointabnormalities among MWUs and to evaluate theeffectiveness of intervention.

References

(1) Sie IH, Waters RL, Adkins RH, Gellman H.Upper extremity pain in the post-rehabilitationspinal cord injured patient. Arch Phys Med & Rehab1992; 73(1):44-48.(2) Nichols PJ, Norman PA, Ennis JR. Wheelchairuser’s shoulder? Shoulder pain in patients withspinal cord lesions. Scand J Rehab Med 1979;11(1):29-32.(3) Bayley JC, Cochran TP, Sledge CB. The weight-bearing shoulder. The impingement syndrome inparaplegics. J Bone Joint Surg [Am] 1987; 69:676-678.(4) Lal S. Premature degenerative shoulder changesin spinal cord injury patients. Spinal Cord 1998;36(3):186-189.(5) Towers JD, Boninger ML, Chandnani VP,Cooper RA. MRI findings in the shoulders ofwheelchair users. 84th RSNA Scientific Assemblyand Annual Meeting 1998.(6) Burnham RS, May L, Nelson E, Steadward R ,Reid DC. Shoulder pain in wheelchair athletes. Therole of muscle imbalance. Amer J of Sports Med1993; 21(2):238-242.(7) Koontz AM, Boninger ML, Towers J, CooperRA, Baldwin MA. Wheelchair propulsion forces andMRI evidence of shoulder impairment. Proceedingsof the 23rd Annual Meeting of the American Societyof Biomechanics, Oct 21-23 1999, Pittsburgh, PA;296-297.(8) Dicianno BE, Boninger ML, Towers JD, KoontzAM, Cooper RA. Wheelchair propulsion forces andMRI evidence of shoulder injury. Abstracts of theAnnual Meeting of the Association of AcademicPhysiatrists 2000, in press.(9) Koontz AM, Boninger ML, Cooper RA, Fay BT.Relating shoulder joint forces and range of motionduring wheelchair propulsion. Proceedings of the24th Annual Meeting of the American Society ofBiomechanics, July 19-22, 2000, Chicago, IL; 209-210.(10) Boninger ML, Baldwin MA, Cooper RA,Koontz AM, Chan L. Manual wheelchair pushrimbiomechanics and axle position. Arch of Phys Med& Rehab 2000; 81:608-613.


Development of a Method of MeasuringForce Through a Kneeblock forChildren with Cerebral PalsyRachel McDonald, B.App.Sc.(OT),Post.Grad.Dip.(Biomechanics)

Introduction

Many of the adaptive seating systems used in theUnited Kingdom with children with cerebral palsyuse a sacral pad and kneeblock system to control thepelvis. The system has been developed alongbiomechanical principles, and the aim to stabilise thechild’s pelvis and lower body in order for them toattain and uphold an erect trunk posture. There is astrong belief among practitioners that these systemsare effective. However objective evidence to backup clinical practice is lacking. Secondly, the amountof force necessary both to achieve the clinical effectand acceptable to the child is not known. This paperdiscusses a method to measure the force/pressurerelationship including a pilot study with childrenwith cerebral palsy and a pilot study with normalchildren. The overall aim of the larger project is togather objective information about the efficacy ofthis seating system for children with cerebral palsy

Background

The objective of this type of seating system (using asacral pad and kneeblock) is to apply forces to thepelvis to create a ‘moment’ (turning effect) by thesacral pad to push the pelvis into a neutral position,which is then balanced and maintained by anopposing counterforce at the kneeblock (Green &Nelham, 1991, Mulcahy et al, 1988). At present,published information about the efficacy of this typeof system is of a descriptive nature only (Reid &Rigby, 1996).

Research Questions

1. Are the forces applied through a kneeblock andthe resultant pressure measured at a sacral padproportional to each other?2. Are the force and pressure consistent over timefor children with cerebral palsy?

Method

A force transduction device was developed. Thisconsists of strain gauges attached to the normalkneeblock and was developed in conjunction withKings College Hospital Medical Engineering andPhysics Department (London UK). Pressure at thesacral pad was measured using a commerciallyavailable skin interface pressure device (The OxfordPressure Monitor) is used. In order to ensure thatthe position of the device exactly mimics that of thechild’s own kneeblock, a jig has also been developedwhich measures the exact position of the child’skneeblock, which is then reproduced in the forcetransducer device.

Initially four children with cerebral palsy were seenon twice, over two days. The children’s age rangedfrom 8 to 12 years and all children had four limbinvolvement, of either predominantly dystonic orpredominantly spastic type. Two of the childrenwore spinal jackets

Seven normal children also took part in the pilotproject. They ranged in age from 4 to 12 years ofage, and spent a morning or afternoon session usingthe special seating system. Data was collected atseveral different points.


Results and Future plans

The initial data collection with children withcerebral palsy showed no identifiable relationshipbetween the amount of pressure measured at thesacral pad and force applied through the kneeblocks.The force applied was found to range between 5 and25 newtons in the children and was not consistent ineither amount or direction over the two days. It wasthen decided to pilot the sacral pad and kneeblockmeasurement system with children who did not havepostural difficulties to establish a model of therelationship between force at the kneeblocks andpressure at the sacrum.

Mean force and mean pressure were collected andanalysed together in the normal children andconsistent relationship was found. Regressionanalysis was performed and a positive correlation of.777 between Force and Pressure was shown. Therelationship can be expressed as:

Mean Force (N) = -15 + 0.01 Pressure (Pa)

The relationship, together with 95% ConfidenceInterval is shown below

Having found a linear relationship with normalchildren, the next stage of the project is to explorethis further with the main cohort of children withcerebral palsy who use this system, and assess thisrelationship over time. How children of differenttype and distribution of muscle tone respond to thesystem will also be determined. The results maythen have implications for individuals using thesystem, and together with the other measures used inthe project, may influence clinical practice forseating clinicians.

References:

1. Green E.M. & Nelham, R.L.(1991).Development of sitting ability assessment ofchildren with a motor handicap and prescription ofappropriate seating systems. Prosthetics andOrthotics International, 15, 203—16.

2. Mulcahy, C M. Pountney, T, Nelham, R L,Green, E M, and Billington, G D. (1988). Adaptiveseating for motor handicap. Problems, a Solution,assessment and prescription. British Journal ofOccupational Therapy 51(10), 347-352.

3. Reid, D. & Rigby, P. (1996). Development ofimproved anterior pelvic stabilization devices forchildren with cerebral palsy. Physical andOccupational Therapy in Pediatrics 16 (3), 91-96.


Power Chair: Features & FunctionsKathryn Fisher, B.Sc, OT(C), David Harding

Power wheelchair drive configurations have beengreatly expanded in the past few years. It isimportant for both clients and prescribing therapiststo understand how differences in driveconfigurations affect maneuverability anddrivability. The goal of this workshop is to providethe prescribing therapist with a greater awareness ofthese designs in order optimize the matching ofequipment to the needs of the client.

Performance Characteristics These performancecharacteristics must be considered in the assessmentprocess: Speed Torque Turning Radius StabilityManeuverability and Tractability Slope TransitionCapability Suspension

This workshop will examine only thosecharacteristics that affect a client’s ability tonegotiate their environment.

Rear-, Front-, Mid-Wheel Drives There is a greatdeal of controversy surrounding the criteria bywhich we categorize drive locations. In general, amid-wheel drive will have the system center ofgravity (C of G) somewhere over the drive wheels.A rear-wheel drive will have the C of G well aheadof the drive wheels and a front-wheel drive will havethe C of G well behind the drive wheels. There areseveral problems associated with trying to applythese criteria as a means of categorizing drivelocations. First, the system C of G is determined bythe combination of the client and the chair. Manycurrent designs allow for fore/aft adjustment of theseat frame, thereby changing the C of G. One chairmight have the C of G directly over the drive wheelsfor one client but have it well behind the drivewheels for another, depending on body massdistribution and seat frame location. C of G can alsobe affected by tilt/recline systems, ventilators andseating.

Initiating Turns The location of the drive wheelsdetermines how soon a turn needs to be initiated. Ingeneral, the turn has to be started at the point wherethe drive wheels are sufficiently far enough into thespace into which the turn is being made. Consider,for example, a 90º left turn from one hallway (A)into another (B) where the left drive wheel will be

stopped while the right will be going forward. Thechair must be driven forward until the drive wheelsare a few inches past the leading edge of theintersecting hallway. When the chair is turnedsharply, it will pivot 90º around the left drive wheel.The point of pivot(the center of the tire’s contactpatch(must be sufficiently past the left wall of theintersecting hallway ‘B’ so that there is enoughclearance for the parts of the chair that protrudelaterally from the pivot point. This will include 1/2of the width of the drive tire, any other chair partssuch as arm pads, joystick box, etc., plus sufficientclearance between the chair and left wall. With arear drive chair, most of the chair’s length will bebeyond the intersecting hall’s leading edge when theturn is initiated. This means that hallway ‘B’ mustbe wide enough to allow the length of thechair(measured diagonally from the pivot point tothe front, right corner(to clear the far corner of theintersection of the hallways. With a front-drivechair, most of the chair will be behind this point.This requires that hallway ‘A’ be wide enough toaccommodate the swing of the rear end of the chair.This is the distance from the pivot point to the right,rear corner of the chair. With a mid-driveconfiguration, hallway ‘A’ must be wide enough toallow the swing of the portion of the chair measuredfrom the pivot point to the right, rear corner andhallway ‘B’ must accommodate the distance fromthe pivot point to the front, right corner. Otherturning strategies will affect maneuverability.Veering and multi-point turns will be necessary forsome situations.

If a similar left turn is made such that the right drivewheel rotates forward and the left backward, thechair must be driven further past the leading wall ofthe intersecting hallway since the pivot point of theturn will be mid-way between the two drive wheels.

Front and Rear End Swing Much of a chair’smaneuverability can be defined by the layout of theenvironment within which the chair is driven. Arear-drive chair is characterized by the front endswinging during a turn. A front-drive chair swingsthe rear end. Mid-drive chairs swing both front andrear. No one design can be said to turn more sharplythan another. What makes one design more


maneuverable than another is dependant on theclearances and obstacle locations within the turningspace. As noted above, clearance for front- and rear-end swing is an important factor in determining achair’s maneuverability. Mid-drive chairs, ingeneral, have better maneuverability because theprotrusion of the front and rear ends is to a lesserdegree outside the length (in plan) of the seatedoccupant and the drive wheels are within this length.A rear-drive chair, in contrast, will typically be setup with the occupant wholly in front of the drivewheels. The portion that swings during a turn willinclude the entire occupant length. A turn such asone from hallway ‘A’ to hallway ‘B’ will be easilyaccomplished if hallway ‘B’ is wide enough to allowthe front end to swing, otherwise a multi-point turnwill be necessary. A front-drive chair typically has aconsiderable length of frame behind the occupant.The same turn from ‘A’ to ‘B’ will require hallway‘A’ to be wide enough for the rear end to swing. Amid-drive configuration will be able to complete thisturn more easily since the length of the chair is moreor less equally proportioned between the front andrear. This means that neither hallway needs to bewider than the other.

Suspension Suspension is provided on wheelchairsfor two reasons: to provide shock absorption and tomaintain wheel contact on uneven surfaces. Anydrive configuration that allows the front and rearnon-drive wheels to contact the groundsimultaneously during normal driving will requiresome form of suspension. Such is the case withvirtually all mid-drive designs. On changes in slope,for example, the drive wheels can lose traction if thesuspension travel is insufficient to provideuninterrupted contact with the ground. Many mid-drive designs suffer from inadequate suspension and,consequently, hang up on ramps, curb cuts,thresholds and other surface irregularities.Slope Transition When a power chair is driven fromone plane to another, where there is a rapidtransition, there can be a tendency for the drivewheels to lose traction. This is caused by theinability of the front and rear wheels (either castersor anti-tippers) to accommodate for the change ingrade. This accommodation is usually made throughthe design of the suspension. True front-wheel drivechairs do not have front anti-tippers and thereforewill not have this problem.

Anti-Tippers Anti-tippers are required when thedesign of the chair allows for the center of gravity tomove beyond (either forward or rearward) the baseof support (contact points) of the chair. This can becaused by driving on inclined surfaces or because of

inertia (during hard braking or when popping‘wheelies’ during acceleration). Mid-drive chairsrequire either caster or anti-tip wheels at the frontsince they have a tendency to rock forward duringdeceleration. Front-drive designs may need frontanti-tippers if the rear portion of the chair is notsufficiently weighted to prevent forward tipping.Rear-drive chairs usually have rear anti-tippers toprevent the chairs from flipping over backwardswhile accelerating or while on inclines.

Other Client Considerations Design features thataffect the optimization of the prescription involveseating needs and cognitive factors.

Seat Frame Flexibility The degree of seat frameadjustability may be a factor that will affect theperformance of a power chair. A large seatingsystem, for example, may require the seat frame tobe moved rearward in order to keep the C of Gwithin the desirable range. A mid-drive chair withthe C of G too far forward will tend to pitch forwardduring braking or deceleration. A rear-drive chairwith a disproportionate load on the casters willexperience steering resistance and reduced traction.Many power chairs offer the ability to adjust the seatframe fore and aft.

Cognition Some users with cognitive impairmentmay find rear-wheel drive designs easier to learnbecause the part of the chair that swings is withinview. Front-drive chairs, in particular, may poseproblems because of the degree of obstructedmovement of the chair.

Foot Position In general, front-drive chairs and somemid-drive chairs more easily allow for 90º footposition since the casters are in the rear. Becausecasters require a space within which they swivel,this area is not available for foot placement. Mid-drive configurations such as the various Jazzymodels and the E&J Solaire utilize rear casters andnon-swivel front anti-tip wheels. This design, likefront-drive designs, provides ample clearance for 90ºfootrests. The Quickie 424 has casters at the front.Foot placement at 90º is somewhat restricted toallow for the caster swivel. The Rocket casters areplaced far forward, thereby eliminating thepossibility of 90º footrests. In general, rear-drivedesigns utilize front casters and are unsuitable for90º footrests.


Dynamic Seating Components for theReduction of Spastic Activityand Enhancement of FunctionDavid Cooper, M.Sc., Mark Dilabio, RT,Gord Broughton, RT, Dalthea Brown, MS, PT, ATP

Dynamic Seating Components for the Reductionof Spastic Activity and Enhancement of Function

David Cooper, M.Sc., Mark Dilabio, GordBroughton,Elaine Antoniuk PT, and Janice Evans,PT

Dynamic seating components that allow movementin a controlled manner have the potential of reducingthe strength and duration of uncontrolled spasms.They also reduce the harm that might be caused byposture controls during spastic activity. Others havereported promising results with the implementationof dynamic back supports, (Conner 1997, and Ault etal 1997), and our clinical observations in 13 of 14cases have been very positive. Similar results haveoccurred with a few applications of dynamic headsupports. Dynamic supports have also been usedsuccessfully for improving controlled head and armmovement where there is purposeful functionalmovement but assistive support is needed.

The types of supports we are reporting on allowmovement of the client while providing support. Inthis context, dynamic does not mean ‘adjustable’ andit does not include support systems that allow theclient to move within the system. A portion of theclients we serve need posture control systems thatallow movement while providing direction andcontrol to the movement, then return or assist returnto the preferred posture. The clients we are usingthese systems with are predominantly ones withsevere neuromuscular impairment, typically a strongadolescent with spastic quadriplegia and theasymmetry and contracture problems associatedwith it.

Several manufacturers have produced componentswith dynamic function. For example WhitmyerBiomechanix has a forehead strap that allowsrotation while supporting the head from fallingforward and there are a variety of shoulder straps/chest harnesses with elastic webbing or neoprenethat allow forward flexion of the trunk withassistance to return to upright. These components

are not widely applicable as dynamic systems. Formany they are used as a non-dynamic support. Butfor those that can utilize the dynamic component,the benefits can be appreciable. Care must be takenwhen recommending these systems. They havepotential harmful effects. Case in point is springloaded footrest hangers that introduce a rotationmovement as the person extends. For the wrongclient this could have damaging effects.

Dynamic back supportsDynamic back supports enable the client to extend,pushing the back support rearward with resistance.When the client relaxes, the back support returns theclient to the upright position. Freedom Designs andProduct Design Group both have dynamic backfeatures in their product line.

We have provided 14 dynamic back supports overthe last three years. They have been provided toadolescents with strong extensor spasm. Several ofthe clients were using rigid or semi-rigid pelvic bars.The problems being addressed included excessivefull body extension requiring management. Theclients had severe comfort or pressure problems dueto the excessive forces on either their scapularregion or due to their pelvic controls. The dynamicbacks have been beneficial for all but one client. Ineach case the strength and duration of the spasmswere reduced. The one client it did not help was not


relaxing after the extension, remaining fullyextended. The system would not return her to hermore upright sitting posture.

The dynamic back systems were of two basic types:

Wheelchair modification: The first method involvedmodification of the client’s wheelchair by allowingit to articulate where the back uprights attach to theseat rails, (figure 1). Most of these systems wereadded to Action and Quickie tilt manualwheelchairs. These modifications were relativelysimple and did not require permanent change to thewheelchair. In its later incarnations it included theaddition of springs, the hardware to hold them,movement limits (stops) for upright and back, and alockout mechanism to remove the dynamic actionwhen desired. The spring tension and movementranges were fine tuned for each client.

Figure 1: Wheelchair modification to providedynamic back mechanism. Both sides of thewheelchair were modified. Left: without themovement limits or lockout mechanism. Springtension adjustment was by a combination if slidingthe ‘T’ clamp down the wheelchair uprights andsliding the springs along their mounting tubes.

The amount of movement was small. The top of theback would move a maximum of two inches. Thiswas fortunate since the pivot of the mechanism wasnot aligned with the anatomical pivot. Since themovement was slight there was no problem withrelative height changes between the back supportand client’s back.Integrated dynamic back: The second method,(figure 2), involved a joint incorporated into theposture control system. The spring action came fromeither a flat spring across the hinged joint or elasticmaterial, (foam), between the two boards of thebackrest. With this system it was possible to placethe joint to coincide with an approximation of the

anatomical extension point. Therefore, the pelvisremained relatively immobile while the trunk aboveit extended back. Typically this system was usedwith clients with weaker extensor spasm.

Figure 2: The integrated version of the dynamicback, during construction.

One of the limitations with both these systems wasthe return force. Since we were reliant on springs forthe return force, it could not be greater that theextension force. It was felt that in some instancesthat the action would be more appropriate if therewas a way to monitor the forces involved and whenthe extension spasm was finished the system wouldreturn the back to upright regardless of the forcesrequired.

The initial systems did not have a lockoutmechanism. This was a problem with the‘wheelchair modified’ system for caregivers whenpushing the chair on rough ground or over obstaclessuch as curbs. This was not a problem with the‘integrated’ system since the wheelchair frame wasnot altered.

Dynamic head support systems were used forextension and rotation of the head. In two instancesthey operated similar to the dynamic back supports;i.e.: for periods of strong extensor spasm, (figure 3).In two instances they were configured to enhancecontrolled head movements. With weak springs itallowed the headrest to move back as the personextended or rotated their head. This allowed a morenatural movement than would happen with a rigidheadrest. In another application the headrest wasspring loaded to absorb the shocks of a young childbanging his head backwards. Freedom Designs nowhas a spring loaded headrest that provides this shockabsorption function.


Figure 3: Dynamic headrest to allow the head tomove back during strong extension.

In 1994 we did extensive work to come up with aheadrest that would keep the head upright whileallowing the person to rotate his head. To this endwe held a design contest for the 10th InternationalSeating Symposium in Vancouver. Other than therather ingenious work being done by Jody Whitmyerand colleagues there was next to no work being donein this area. Quickie came out with a rotatingheadrest shortly after that but it had a limited rangeof movement. We came up with two versions of aheadrest that provided full support and effectivelylocked the head in the position we wanted whileallowing rotary movement, (figure 4).

Figure 4: Left: the initial version of the rotating headrest allowed 45degrees of rotation both ways while holding the head securely.Right: the second version a double sliding track that allowed a full90 degrees of rotation both ways.

The problem with our head support systems was thateven though we achieved the objective of isolating acertain movement it was too restrictive. The twochildren we were working with had increasedfunction. But the movement they had voluntarycontrol of was not restricted to the single axes ofrotation that we had imposed. Though we hadachieved our initial goals the applications failed.

Dynamic arm supportsDynamic arm supports improve the client’s functionby enabling them to reach more effectively. Thereare commercially available products, (e.g.: ErgoRestand Otto Bock), that provide forearm support thatallow movement. A modification that we find usefulfor the Otto Boch components is to add a slidingmechanism that allows the forearm support to moveforward while it rotates. With this system the clienthas a supported reach.

SummaryDynamic components have shown a lot of promisefor the reduction of spastic activity. Many of theclients using these systems are also undergoing othertreatments for their spastic activity. Therefore, wemust be careful not to jump to any conclusions as totheir effectiveness. A rigorous study of the effect ofblocking and allowing movement with spasm isrequired before any conclusions can be made. Nonethe less, there seems to be some benefit of allowingmovement with resistance in lessening thedetrimental effects of spasm. The addition ofdynamic components to gain this effect is notcomplex. The use of dynamic components toincrease a client’s function is very specific to theclient and the application.


References:Ault, H. et al (1997). Design of a Dynamic Seatingsystem for Clients with Extensor Spasms. In RESNAproceedings, Pittsburgh.

Conner, P.S. (1997). A Bit of Freedom For Full-Body Extensor Thrust – A Non-Static PositioningApproach. In proceedings of the ThirteenthInternational Seating Symposium, Pittsburgh, p185-187.

Manufacturers:Freedom Designs Inc.www.freedomdesigns.com2241 Madera Road, Simi Valley, California, 93065

Product Design Group www.prodgroup.com 8385St. George Street, Suite #10, Vancouver, BC,Canada,V5X P3,

Whitmyer Biomechanix Inc. www.whitbio.com1833 Junwin Court, Tallahassee, Florida, 32308

ErogRest www.ergorest.comErgonomic Logic Inc.9370 Gateway Dr., Reno, Nevada 89511

Intelec Marketing Inc 2455 Ste-Marie, Mascouche,Quebec , J7K 3C2

Otto Bock Orthopedic Industry www.ottobock.com3000 Xenuim Lane North, Minneapolis, MN 55441

2897 Brighton Road, Oakville, Ontario L6W 5S3

IntroductionSitting is a dynamic activity that requires a varietyof postures and postural adjustments. Themaintenance of static postures over a long period oftime results in postural stress, fatigue, agitation,discomfort, pain, and tension. In special populationsit also can result in an increase in spasticity and overtime can lead to muscle contractures. OccupationalSafety and Health Administration (OSHA) classifies“maintaining the same posture” and “sitting for longperiods of time” as conditions that are ergonomicrisk factors contributing to musculoskeletaldisorders (MSD) (OSHA, 2000). Therecommendation to prevent such incidences fromoccurring is frequent posture changes, but for many

Current Status in Dynamic Seating Components

Dalthea Brown, MS, PT, ATPRERC, University of Pittsburgh

people who sit in wheelchair this is an impossibletask. To compound the problem, current seatingtechnology is not designed to permit movementwithin the system. In fact the opposite applies.Lapbelts and anterior trunk supports are designed tofit snuggly to provide support and preventmovement. But movement is “essential formaintaining physical fitness and perceptualalertness. It provides the sensory feedback andfeedforward mechanisms necessary for thedevelopment of visual, vertical, directional andtemporal orientation and the perception of touch”(Ward 1994).

Dynamic Seating Technology Available toConsumersWhile clinicians are approaching the issue ofallowing movement within the system on a case-by-case basis (Conner 1996), (Ault, Girardi et al. 1997),Tables 1 and 2 show dynamic technology that areproduced and marketed for a broader base of endusers. Many were produced initially for a specificperson but favorable results and continued requestsfor special modifications lead manufacturers to therealization that it may be worth their time and effortto mass-produce these once “one of a kind” items.Information obtained from product literature reviewson seating technology designed to permit movementcan be seen in Table 1. The Bentley wheelchair byPDG utilizes an extra long and wide wheelchair baseequipped with shock absorbers in the seat and backto take more abuse and/or heavy loading than mostother chairs (Mundy 1999). The seat is low to theground so that it can be foot propelled even whiletilted. The Homecrest’s Rock N’ Go is a wheelchairdesigned to rock, providing comfort while alsooffering mobility (Homecrest 1999). The Rocker X2001 (Crown Therapeutic Inc Distributor) is amarketed as a “kinetic motion” wheelchair. It wasdeveloped to prevent pressure ulcers (Eyer 1999).The chair has multiple position rocking so thatrocking can occur through a 1/2 to 3/4 of an inchrange anywhere in the rock cycle. FreedomDesign’s does not market its Spectrum as a dynamicchair, but there is a small degree of movement of theback panel (Freedom Designs 2000). Rifton is theonly manufacturer that has modified a positioningclassroom chair with an option to place it on amobile base. The spring in the seat allows the chairto tilt forward taking advantage of the more activeanterior tilt of the pelvis. It also tilts backwardswhen a more relaxed leisure activity or rest is thegoal. It can also be locked to prevent movement ifso desired (Thompson 1999).


The end users suggested by most of themanufacturers were individuals with some type ofmovement disorder. Mostly elderly clients andindividuals with dementia and/or Alzheimer’s wasthe suggested clientele. PDG also directed theirproduct towards individuals with Huntington’Chorea and others with athetoid movements. TheRX Rocker Corporation is also directing it’smodified WMD at post-surgical intensive care unitpatients.

The movement allowed by each of these devices isthat of a rocking motion. The description of thedynamic component of most utilized somecombination using the word “spring”, whether it was“spring-like” (Rifton), spring loaded (PDG), heavyduty coil or gas spring (Miller’s) or “leaf spring”(Rx Rocker). Rock ‘N Go (Homecrest) is the onlyWMD that uses a rocking mechanism. Themovement in the Freedom Design’s system is acephalo-caudal glide provided by the free-floatingring that attaches the back panel of the seatingsystem to the back canes of the wheelchair.Extension of the sitter results in the attachment ringsliding upward, which produces a small increase inthe seat-to-back and knee extension angles of theseating system and its occupant. The FreedomDesign’s is the only system that results in a changein the open hip angle, however slight it may be.

The reported benefits of using the equipmentessentially fell into 6 categories. Categories 1 and 2included promoting the use of available movementpatterns (Rifton) and reducing the potential forinjury to client (PDG). Category 3 includedpreventing equipment breakage (Miller’s) whilejustification number 4 included providing comfort(Homecrest, and RX Rocker). Category 5 includedtherapy through the ability to move and mobility (RxRocker) while category 6 included reducing the needfor restraint (Homecrest.).

Table 2 represents dynamic components that arebeing added to wheelchairs. Miller’s footrestpermits movement not only in a downward directionbut also allows a small degree of rotation as well.The positioning accessories by Bodypoint, AEL andDaher permit movement of the user but restricts theamplitude of that movement as a result of thematerials used in the fabrication of the components.The lycra and nylon covered rubatex material allowsthe accessories to conform to and move with thebody. Whitmyer Biomechanix Inc (WBI) is the onlymanufacturer to tackle positioning of the head. The

dynamic forehead support (DFS) strap attaches toWBI’s soft head support system by a pulley systemand crosses over the forehead to provide the neededanterior head support. The DFS is not compatiblewith all WBI head supports.

CONCLUSION

Clinicians and manufacturers are strategizing how toincorporate movement into systems that traditionallyhave been focused on stabilizing an individual so asto prevent movement in certain parts of the body.The disadvantages of maintaining static postures arewell understood. But significant difficulties emergein the integration of stability and mobility. Whereshould the movement occur? How much movementshould a system allow? At what point doescontrolled movement become out of control? Thesequestions and many more of this nature confrontindividuals attempting to integrate these todiametrically opposed concepts. It is challenges ofthis nature that require innovative design solutionsto bridge the gap between what is and what ispossible.

References

1. Ault, H., M. Girardi, et al. (1997). Design of aDynamic Seating System for Clients with ExtensorSpasms. Annual RESNA Conference, Pittsburgh,PA, 187-189

2. Connor, P. (1997). A Bit of Freedom for Full-Body Extensor Thrust- A Non-Static PositioningApproach, International Seating Symposium,Pittsburgh, PA, 185-187

3. Occupational Safety and Health Administration,O. (2000). Ergonomics Program Standard- JobHazard Analysis and Control, OSHA; http://www.osha-slc.gov/ergonomics-standard/fedregabbrversion.html - 64k

4. Ward, D. (1994). Prescriptive Seating forWheeled Mobility. Kansas City, Missouri,HealthWealth International.


List of Manufacturers

1. Adaptive Engineering Lab Inc P. O. Box 12930,Mill Creek, WA 98012-6390; http://inter800.com/pages/03276080.htm

2. Bodypoint Designs; http://www.bodypoint.com/

3. Daher Manufacturing, Inc, Unit #5-16 MazenodRoad; Winnepeg, Manitoba R2J 4H2; http://www.daherproducts.com/

4. Freedom Designs, Inc, 2241 Madera Road, SimiValley CA 93065; http://www.freedomdesigns.com/

5. Homecrest Healthcare; http://www.crestmarkinternational.com/Pages/health.html

6. Miller’s Adaptive Technologies, 2023 RomigRoad, Akron OH 44320;

7. Product Design Group, http://www.prodgroup.com http://www.prodgroup.com

8. Crown Therapeutics, Inc 100 N. Florida Ave,Belleville, IL 62221; http://www.crownthera.com/pdf/rxrockersellsht.pdf

9. Rifton Equipment, P. O. Box 901, Route 213Rifton, NY 12471; http://www.rifton.com/

10. Whitmyer Biomechanix Inc, 1833 Junwin Court,Tallahassee FL 32308; http://www.headsupport.com/


When Ethics isn’t Enough – MakingTough Decisions in a Changing ClinicalEnvironment

Simon A. Margolis, CO, ATS/P

I would imagine that as practitioners of a caring andhealing profession we all consider ourselves to beethical and moral people. We would probably saythat we put the best interests of our clients first andforemost.

What happens when it is unclear if this is the bestthing to do for us as individuals - or for ourprofession and industry in general?

In making effective, appropriate clinical decisionsshould we consider the needs of all the stakeholdersin the provision of Re/habilitation Technologyproducts and services? These might include theclient; the referring professional; the company orfacility that employs the referrer; the governmentregulatory agency; the funding source; therehabilitation technology supplier or themanufacturer. Each of these people and entities maybe viewed as having a legitimate concern and stakein the process.

Here are two examples of when our clinicaldecisions and advocacy for our individual clientsmay end up having an overall negative effect onaccess and funding for clinically appropriate seatingand wheeled mobility:

1) An occupational therapist and physical therapistagree to do home visits within a 30 mile radius oftheir assistive technology facility. The commonbilling practice is that they may only bill for theamount of time they actually spend with the client.Because their evaluation is considered co-treatment,each can only bill for one half of the time they spendwith the client. For a typical home visit each of thetherapists spends a total of four hours but are onlyable to bill one. To compound the problem – it

seems to be generally agreed that in assistivetechnology there is approximately one additionalhour of paperwork for every hour of client contact.

Is this an ethical issue? After all, one might say thatthe client was seen and his/her home setting wasappropriately evaluated. Is there, however, a short orlong term impact of this practice on the otherstakeholders - specifically the therapists and thefacility they work for?

2) With the Internet emerging as a alternative sourcefor information and products, many questions ariseas to how professionals in Re/habilitationTechnology might act and respond to this newmedium. It would seem on one hand that there is abenefit to the consumer when they can “shoparound” and get the best deal on the products theyneed. Especially when it is a second purchase by anexperienced consumer. Is there are problem, though,when these Internet sites do not differentiatebetween the consumer, nor the products, that requirean assessment and evaluation by a therapist and/or arehabilitation technology supplier and those thatdon’t.

Are there ethical questions that therapists,rehabilitation engineers and suppliers need to facearound this issue?

There may be two ethical principles that come intoplay – that of beneficence and autonomy. Autonomyis a strong ethical driver – we should respect theclient’s preferences and desire. We should allowpeople the “dignity of risk”. On the other hand,beneficence – the ethical imperative for us to getgood results and avoid bad consequences frominterventions with clients – may even be morecompelling.


We might consider asking two questions to helpunderstand our responsibilities in this situation.• Is there a reasonable probability that clients who

receive products over the Internet willexperience negative consequences, includinglack of service and follow-up?

• Will people who receive complex systems viathe Internet - without the benefit of evaluationand assessment by a clinician and appropriatespecification, fitting, delivery and follow-up by aqualified RTS - experience negativeconsequences?

Apart from theses ethical issues –are theresignificant implications brought about by thisdistribution network for the rehabilitationtechnology supplier and the company they work for?Are there implications for therapists working inseating and wheeled mobility?

Other Factors

Ethical considerations aside, there are three otherfactors that we might consider when faced withdifficult clinical service delivery issues - including“want vs. need”, cost of treatment and intervention,personal risk and others.

Technical issues – There are situations that arise thatdo not allow us to make the optimal clinical decisiondespite our desire to serve the best interests of theclient or what they want or need.

Prudence – This includes situation when it mightcause us physical, emotional or financial harm to dowhat is “right” for the client. One example might bedoing an evaluation or delivery in a client’s homewhere we feel unsafe or in physical danger.

Law – There are things that we are prohibitedfrom doing by statute and regulation. To do thesethings, even in pursuit of the best interests of ourclients, can have significant negative impact.

How then do we reconcile these issues?

How then do we do what’s right for everyonein the process?

I only have answers for me – what about you?

Simon A. Margolis, CO, ATS/PNational Seating and Mobility, Inc.PMB 5774190 Vinewood Lane #111Plymouth, MN 55442(763) 559-8153FAX (763) [email protected]


Learning Objectives:

1. Recognize the need to thoroughly evaluate aclient to determine tonal patterns, range ofmotion, and positioning needs.

2. Recognize when a head positioning problem ismore caused by seating

3. Understand the concepts of three pointpositioning and opposing forces

4. Recognize points of force needed to achievedesired outcomes

5. HAVE FUN!

Cervical Flexion Problems andPossibilitiesDavid (Scott) Pickett, CRTS, Michelle Gunn, ATP

Introduction:

The presenters of this course have been workingdirectly with clients in the field of seating andmobility, collectively, for thirteen years. Some ofthe most difficult questions we have been asked overthe years have been about cervical flexion issues.This course will deal directly with this topic. Ourgoal in this session will center on giving theparticipants a detailed understanding of cervicalflexion issues so that they can better identify thecauses and find more effective solutions to theseproblems on their own. Cookie cutter approachesand absolute answers are not our intent. Althoughwe work for Whitmyer Biomechanix, it is not ourintent to be product specific. We will use genericclinical terms to describe what products werecommend. Class participation will be openlysolicited and possibly rewarded.


Can Therapeutic Positioning EffectFunctional Outcomes?Faith Saftler Savage, PT, ATP, Nancy Waglow, MS, MEd

Functional outcomes have become an importantfactor in the past several years to identify the type ofservices for individuals to meet their potential(s).Developing functional outcomes can be challengingfor individuals with moderate to severe physical andmental impairment. The Disablement Model fromthe World Health Organization assists health careproviders by focussing on assessment strategies andidentifying functional targets for personal outcomemeasures. The Disablement Model provides termsand definitions for uniform terminology. Areascovered include pathophysiology, impairments,functional limitations, disability and societalbarriers/handicap. A person’ strengths, preferencesand potentials must first be discussed beforedetermining what is disabling the person fromreaching his/her potential and developing functionaloutcomes. This course will investigate theDisablement Model as a method to developfunctional outcomes.

Following is a list of questions that will beaddressed during this presentation:• What are functional outcomes?• Why are functional outcomes important?• What kind of functional outcomes can you

expect from a person who is severely physicallyand mentally challenged? Moderatelychallenged? Minimally challenged?

• How does therapeutic positioning support theattainment of functional outcomes?

• Does it matter where you live (long-term carefacility, group home) when discussing functionaloutcomes?

• What disciplines assist in developing functionaloutcomes? How do you improve communicationbetween disciplines?

• What knowledge base is important whendetermining functional outcomes?

• What is the cost analysis to providing services?• How do we encourage adequate staffing in

facilities and homes to adequately address theneeds of individuals to achieve functionaloutcomes?

• How does the Disablement Model assist us withdetermining functional outcomes?

An environment needs to be created that supports allindividuals with opportunities to improve theirindependence at home, work and leisure. Theseareas may include health issues (respiratory status,gastrointestinal status, neurological status,orthopedic status, skin integrity status, nutritionalstatus); functional issues (toileting, bathing,dressing, eating, communication, transfers,mobility); environmental issues (environmentalcontrol, transportation, accessibility) and behavioralissues.

People with physical and mental disabilities arereceiving services at long-term care facilities, grouphomes, and through supported living. It is importantto determine if these services are appropriate andadequate to assist each individual in attaining theirfull potential. If a person is unable to communicateverbally, how do we know if they are satisfied withtheir life? How does this person know that there areother things in life that they have not experiencedthat may be extremely satisfying? How do wepromote change for individuals whose lives havebeen static? How do we determine what the personwants to do and how do we support them?

Health care professionals need to be able torecognize a person’ strengths and abilities andminimize the barriers and limitations that haveprevented individuals from achieving independencein the past. They must stay on the cutting edge oftherapy and technology to continue to assistindividuals in independence. The following chartassists us in determining what makes a day valuablefor all individuals.


Seating Interventions for Spinal CordInjuries With Secondary OrthopedicComplications

Stephanie Tanguay, OTR, ATP/S,CRTS

It is estimated that more than 200,000 persons withspinal cord injuries live in the United States. Someof the greatest challenges for the seating teaminvolve S.C.I. clients whose medical condition hasbeen complicated with secondary diagnosis.Pressure sores, osteomyelitis, heterotopicossification and surgical interventions such asshaved ischials, lower extremity amputations, hipdisaticulation and hemipelvectomy all requirecustomized seating strategies.

The SCI model systems reported 17-23.5% of SCIpatients develop at least one pressure sore withintwo years of onset. It is unrealistic to expect referralof these clients to seating clinics for earlyintervention. While some hospital systems cancapture these clients early on, it is more likely thatreferrals to clinicians or contact with rehabilitationtechnology suppliers occur following surgicalprocedures. According to Zacharkow (1), the mostcommon site for pressure sores to occur is the skinoverlying the ischial tuberosities. The two mostsignificant postural risk factures in the onset ofpressure sores are pelvic obliquity and decreasedlumbar lordisis - Zachorkow (2). The resultingposterior pelvic rotation resulting in greater than50% of sacral coccygeal sores developing as a resultof sitting according to Barton & Barton (3).Due to the close proximity of the ischial tuberosities,femoral heads and the sacral-coccygeal region to theskins surface, pressure sores in these areasfrequently result in infections includingosteomyelitis. The surgical interventions to removeinfected bone result in significant alteration to theorthopedic structures responsible for maintainingseating posture. As an example – if a paraplegicclient developed a unilateral pressure sore as a resultof a pelvic obliquity, shaving the ischial tuberosity

would not prevent the reoccurrence of the sore.Without seating intervention, the obliquity will bemore significant, as will the resulting scoliosis andother orthopedic complications. Risk forreoccurrence of the pressure sore remains high.Heterotopic ossification (H.O.), the formation ofextraosseous bone, occurs in up to 49% of S.C.I.patients. H. O. primarily occurs in hips, knees,shoulders and elbows where bone actually formswithin muscle and connective tissue, limitingpassive and active joint range of motion. Yashon (4)lists pressure sores development as a potentialcomplication of this abnormal bone growth.

Hussard (5) reported a unilateral pressure soreassociated with heterotopic bone formation in thehip joint. Limitation of hip flexion resulted inincreased pressure of the ischial tuberosity duringsitting. While H.O. can perpetuate orthopedicchallenges for seating interventions, the rate atwhich these cells develop can be rapid. Through,accurate documentation of range of motion ishelpful to justify the needs for equipment andseating modifications. The only resolution to thebony growth is surgery, which cannot be performeduntil the H.O. has stopped developing. Surgery isdifficult and can require removal of orthopedicstructures involved (such as femoral head resectionto free a hip joint). Accommodation is requiredwhen H. O. is present. Post-operatively identifyingthe viable structures for support and pressuredistribution and designing a seating system toachieve that is most important. Custom fabricationor molded seating and adjustable or customizedwheelchair frames may be necessary toaccommodate the postural needs of these clients.Consider the concept of maximizing weightdistribution at the seating surface. The ischials andcoccyx provide the structure of pelvic stability. The


femurs provide a large area to distribute pressurewith low risk of pressure sores. When one or bothfemurs is/are disconnected from the pelvis, thefemur is free floating and unable to support bodyweight away from the pelvis. Hip dislocation andhip disarticulation both have this result.Hemipelvectary – the resection of part of the pelvisin addition to the amputation of the lower extremity-leaves few options for seating intervention.Orthopedic management is one option. Minkel andBishoff (6) describe the casting process used tocreate a body orthotic support. These devices can beused to provide stability and pressure distribution.This intervention can be helpful withhemipelvectomy and bilateral hip dislocation ordisarticulation. In the same way that a prostheticsocket is fabricated to distribute surface contactevenly, this prosthetic “socket” for the body willdistribute pressure and provide support.When attempting to achieve solutions for clientswith such secondary conditions, the combinedefforts of clinicians, rehabilitation technologysuppliers, orthotists and surgical and rehabphysicians is imperative to achieve successfuloutcomes.

1,2 Zacharkow, D. Posture: Sitting, Standing, ChairDesign and Exercise. Springfield, IL. Charles C. Thomas,1988

3 Barton, A., Barton, M. The Management andPrevention ofPressure Sores, London, England: Faber and Faber,1981.

4 Yashon, D. Spinal Injury 1986 Appleton, CenturyCrofts

5 Hussard, G. H. Heterotopic Bone Formation Aboutthe Hip and Unilateral Decubitus Ulcers in SpinalCord Injury. Archives of Phy. Medicine andRehabilitation 56:355-358, 1975.

6 Minkel, J.L. and Bishoff, T. Orthotic SeatingInterventions Thirteenth International SeatingSymposium, 1997.


“Slip Sliding Away”Dealing with the Client that Slides

Lois E. Tucker, OTR/L, ATP

7. Visual field shift• Visual Midline Shift Syndrome, Dr Padula

8. Tonal pattern• Extensor tone

9. Primitive reflexes• STNR• Positive supporting• Extensor thrust• Tonic Lab

10. Kyphosis• Sliding to see• Sliding to eat• Sliding to breathe

11. Low back support• Sliding makes the back higher

12. Slippery surfaces• Friction creates resistance, that opposite

force needed to stop or slow down themovement

13. No other means of movement• If you don’t give people a way to move their

body, they will find.

14. Behavioral• Sliding down in my chair means someone

will pay attention to me long enough to pickme back up.

Why Does Sliding Occur?

“The rounder the object the more likely it will roll.”“When two shapes don’t compliment one anotherthey are less likely to stay together”

1. Instability at the base of support• Slide to allow gravity to take over the

function of stabilizing the body

2. “The end range” – Placing people at or beyondthe physical capabilities of a joint leavesthem no where to move but out of position• Range of motion limitation at the hips• Range of motion limitation at the hamstrings• Range limitations at the pelvis and lower

back

3. Incorrect seat to floor height for functionalmobility• Foot propulsion• Standing transfers

4. Poorly supported lower extremities• Lack of contact with the foot• Positioned to low• Elevating legrest

5. Seat Depth• To long for actual depth• To long for function

6. Reclined back with a horizontal seat• Setting the pelvis in a posterior posture sets

the body in motion.


15. Transportation• Taken for a ride

16. Rider/Caretakers ability to properly position• Lift and drop vs. place and position

17. Better push on the wheels• The more wheel you contact the more

efficient each push

18. Restraints• When you block a movement, where do you

place the force?

Sliding

Leads to:1. Poor posture

2. Shear and Friction

3. Pressure/Discomfort/Pressure Sores4. Contractures

5. Swallowing Difficulty

6. Respiratory Compromise

7. Functional Limitations• Reach• Driver control access

8. Safety Risks and Restraints

9. Proximal Instability

10. Visual Field Limitations

What is the “key” to stopping the pattern of theslide?

Understanding the “The Law of Inertia”. – Inertia isthe tendency for something at rest to stay at rest andfor something in motion to stay in motion. A forceis required to set an object in motion. It willcontinue to move in a straight line at a constantvelocity unless another force acts on it. Sir IssacNewton

Don’t enable it; prevent it!

Seating and Wheelchair Configurations

Chairs• Tilt, slants and slopes:

• Squeeze, dump and bucket:

Seating• Shape• Linear/planar• Contoured, how much?• Molded

• Material – Do you want to prevent the effectsof shear when you slide or do you want toprevent sliding?

• Air• Gel / Fluid• Foam

• Cover• Material:• Loose or tightly fitted• Smooth and slippery or gripping like

Dycem?

• Pile• Does it work for you or against you?

• Orientation

• Positioning holders

• Belts, angles and pulls.

• Sub-ASIS Bar; torture device or appropriateintervention?

• Distal Knee Block, Crazy Glue and otherideas for containment.

• Wheel and/or drive control access

• Seat to Floor Height

• Armrest Height

• Footrest Configuration

• Access to Function


Matt EvaluationAdrienne Falk Bergen PT ATP/S CRTS

During the 30 years that I have been doingassessments for seating and wheeled mobility I havelearned that a thorough assessment always results ina better result. Whenever a short cut is taken, andsome critical information is missed, the result isusually less than satisfactory. This results in a needto “patch” the final product to make it work.Patching takes extra time, and since neither time, northe materials needed to make the “patch” can bebilled to a third party funder, everyone looses. Theconsumer must wait longer to get their equipment,and the equipment may be less than optimal. Theclinician and supplier must spend added hours onfittings, delivery and followup. The supplier usuallywinds up supplying additional parts and/orequipment, or in the worst case taking the equipmentback and paying a restocking fee to themanufacturer.

In an effort to standardize the assessment processand assist newer clinicians in gathering information,a series of forms were devised and posted on myweb site, RehabCentral.com. Each of the formsguides the team along a path that will ensure athorough assessment. The process begins with agood intake interview to gather pertinentinformation that may affect the intervention planand/or the final outcome. This must includeinformation about the entire environment where theequipment will be used. The environment includesthe home, transport methods and comments aboutany other locales where the equipment will beutilized. Assessment of the client in his existingequipment and discussions about the equipment withthe family and the consumer give the examinersvaluable information about what has and has notworked in the past. It affords the team anopportunity to describe the user’s posture andfunction in the equipment he already owns. Aphotograph is usually helpful in supporting thewritten word.

This initial intake should be followed by a completemat evaluation in both supine (gravity eliminated)and sitting (gravity added, accommodation made forROM limitations found in supine). This portion ofthe assessment will allow the examiners to see theunderlying potential for good postural alignmentwithout the influence of gravity. Once anyinterfering limitations are noted the client is broughtto sitting with accommodation for the limitation.Support is given as needed to produce the best resultpossible, and the examiner notes how much supportis required and whether or not the posture can becorrected. Simulation at this stage is very helpful,whether with the examiner’s hands or a simulator.The simulator leaves the examiner’s free to movearound the supported client, make changes andobserve over a long period of time.

This detailed assessment is recorded, along withcomplete measurements to provide a baseline fromwhich intervention planning can begin. Onceintervention planning and product trials arecomplete the complete recommendation can bewritten and justified using the forms included in theJustify section of the site. If questions come upduring the funding process, or during the orderingphase, the complete assessment document can beused for further decision making, often withouthaving to revisit with the client. Fittings anddelivery should then go smoothly.


Innovative Solutions for Seating andPositioningMark Dilabio, RT, David Cooper, M.Sc, R, Gord Broughton, RT

Innovation: simply put, is a change in the way ofdoing things.

Due to time and cost constraints, we sometimes limitourselves by not seeing past the prescribed use ofitems, or to see the use of it in basic form.

One example of this type of situation could bedescribed as follows. Many companies manufactureswing away trunk laterals. Each company hasapproached the mechanics in different ways, butwhat remains is the fact that they hold a fixedposition until they are swung away.

Being able to look/see this equipment at its baselevel will enable you to see a much broader usagesuch as:

• Swing down pelvic lateral for ease of sidetransfer• Swing up shoulder retraction for shoulderstabilisation during power chair driving and removalto allow client to work at a desk.

Following this concept, let’s look at anothersituation. You require a small head support for an18-month-old child; your agency typically uses OttoBock equipment. All the standard Otto Bockheadrests are too big. What can you do? You couldlook at the Otto Bock lateral pads with the ball joint.They come in several sizes, the smallest one being3” height x 5” wide complete with ball joint forangle adjustment.

Another approach to innovation would beassociation of the common areas of differentindustries. Examples I’d like to bring to yourattention are the wheelchair and bicycle industries.The commonality is tube structure construction.Almost anything that can be mounted on a bicycleframe (lights, horns, bells, etc) can be mounted on awheelchair frame.

A very practical example of this is the use of

mountain bike bar ends as a second height set ofhandles on a wheelchair back cane. See FIGURE 1.

FIGURE. 1 Mountain bike bar end and back cane.

These are examples of low-tech solutions which useexisting products in innovative ways. There aremany other unique and exciting products that can beadapted for seating and positioning. One example isusing drum kit hardware, which is inexpensive andsturdy, for mounting switches, computers, etc. Also,most marine motors and accessories are 12 volt DCand are easily adapted to power wheelchairs


Pressure Mapping- Uses and AbusesMartin Ferguson-Pell, PhD, Emma Parry, SROT, ATP

Learning objectives– Become aware of the potential inaccuracies of

pressure mapping systems and the differencesbetween pressure mapping products

– Learn how to use pressure mapping in clinicalpractice. Learn how to implement protocols forcorrect use, maintenance and calibration

– Learn how to correctly interpret results frompressure mapping systems

– Become aware of ongoing work to developinternational standards for pressure mappingdata which is likely to be used for the disclosureof product information in the future

Why are shearmeasurements elusive?• Shear sensors do exist for research• Very sensitive to friction coefficients of skin,clothing and support surface• Very sensitive to repositioning - difficult toreproduce the same sitting conditions each time• Unsure how to interpret the results

Transfer of forces• In the sitting position, lines of force for:– head and trunk pass through pelvis– arms may be supported by armrests– legs supported by footrests and along thighs

• At each point of contact a distribution of forces isgenerated, influenced by:– the amplitude and direction of the force– characteristics of soft tissues & underlyinganatomy– characteristics of the support surface

Force, pressure, shear & friction• Forces may be generated by gravity acting on thebody, or dynamically when the body moves, such asduring propulsion or transfers. Normal forces areperpendicular to the surface of the body and shearforces are tangential to it• Pressure (normal stress) is determined by dividingan applied force by the area perpendicular to it• Shear is a force acting on tangentially to a bodythat changes its shape

• Friction is a force that opposes a shear force. Itsmaximum value before slipping is influenced by thesize of the normal force, the frictional properties ofthe surfaces in contact and the prevailing shear force

Background - Why measure pressure?• In an ideal world we would measure thedistribution of all forces at seating interface and howthis affects tissues mechanically and physiologically• A map of the pressure distribution beneath theclient provides some information about the transferof normal (vertical to skin) forces between the bodyand the support system• Clinical experience and some (weak etiologicalevidence) supports at least two strategies for bodysupport to reduce pressure sore risk:– achieve uniform pressure distribution– redistribute body forces from bony areas to areaswith more tissue bulk• Pressure mapping allows us to see if we areachieving this on an individual patient basis, inquantitative terms

Pressure and time relationship• Controlled animal studies demonstrate clearrelationship between pressure amplitude andduration of loading to produce ulceration• However models may not be transferrable tohumans• Relationship is substantially altered by clinicalstatus of patient• Pressure in real life is not uniform• Real life produces many cycles of loading:tolerance to repetitive loads is unknown

Accessories• Autocalibrator• Multiplexer• Videoport• Remote trigger• Modem and video for remote operation


What do the numbers mean?• Although there have been a number of publicationsproviding guideline maximum pressures, theevidence supporting them is not strong• We recommend that you use numerical informationto make comparisons for different support surfacesbeing tested for an individual.• Remember that pressure mapping is a tool tosupport a clinical problem solving process for anindividual client.• Be very cautious in making generalisedcomparisons between support products based onnumerical data.

Data manipulation• Averaging reduces large variations in the display ofdata for neighboring sensors that are attributable tovarious measurement errors• Interpolation is used to make the display lessgrainy. The software “guesses” what the pressurereadings are between sensors.• Equilibration is part of the calibration process thatensures that differences in sensitivity betweensensors are accounted for.

Calibration• Should be performed regularly, frequency dependsupon manufacturer’s guidelines, frequency of use,and newness of sensor pad.• When setting up to calibrate you may need todecide whether you want the software to correct forhysteresis and/or creep. This is usually desirable butdoes not completely eliminate these errors.Sources of measurementerror in pressure mapping systems• Hysteresis: output differs depending upon whetherthe pressure is increasing or decreasing• Creep: output keeps increases with time eventhough the pressure is constant• Limited spatial resolution: The number of sensorson the mat is too small to detect very localized areasof pressure difference

Pressure sensor thickness effect errorCreepHysteresisInterpreting data• ALWAYS try to validate physically what you seeon the screen• ALWAYS check what display mode you are usingand consider whether this is the most suitable for thesituation• ~80% of the time, changes in distribution validatethe expected outcome of the intervention

• Check, double check and recheck (and involveyour client)Quality issues• Storage of mats– never fold– store flat or in original packing (usually looselyrolled)• Care of mats– never pull or carry by the cable (or handle forTekscan)– don’t pivot on the mat– don’t pull on the corners when the mat is under aclientCare of mats (continued)– protect from torque and shearing by using anisolation bag and/or cover provided with the mat– use corners to position the mat on the seatingsurface gently (not whilst the client is on it!)– follow the manufacturers cleaning instructions• Keep your mat calibrated

Glossary of Terms

Calibration is the method by which the digital outputis converted to an actual unit of pressure such asmmHg. Calibration enables comparison of theoutput of the same sensor in various environmentsand allows comparison of calibrated outputs ofvarious sensors.

Saturation pressure is the point at which the sensoroutput no longer varies with applied pressure (thelevel of pressure at which this occurs (or the display)varies with different sensors and with the way thecalibration was performed). A potential source oferror.

A Threshold is created when the lower limitdisplayed is increased from ‘0’. All pressures belowthis level are disregarded, so as to suppress thedisplay of noise.

Equilibration. The sensitivity of each sensor in thematrix differs somewhat from it’s neighbours. Thesoftware used by the mapping systemsaccommodates for these differences duringcalibration, and this process is called ‘equilibration’,and is usually performed automatically during thecalibration process.

Averaging. Most mapping systems have a featurethat smoothes out large differences betweenneighbouring sensors. This Is achieved by taking theaverage between adjacent sensors. Manufacturershave different formulas for performing this


averaging process. Care must be taken to ensure thatreal local feedback and pressure are not lost in thisprocess.

Repeatability is the ability of a device to respond inthe same way to the same pressure applied multipletimes.

Hysteresis is the difference in the sensor outputresponse depending upon whether the appliedpressure is increasing or decreasing. A potentialsource of error.

Creep is the change in sensor (and system) outputwhen a constant pressure is applied over a period oftime. A potential source of error.

Noise. After a period of use, or in the presence ofelectromagnetic interference, a sensor may indicate‘noise’ as low level pressure Which usuallyfluctuates with time. The effect of this can bereduced by setting a noise threshold using thesoftware. A potential source of error.

Sensitivity is a measure of the amount of pressureneeded to generate a given unit of change in theoutput. For example, a very sensitive system wouldgive a full scale output (red display) at a much lowerpressure than a less sensitive system.

Spatial resolution is a measure of the ability of amapping system to discriminate between two ormore pressure features separated by a givendistance.

Curvature Effect. Some sensors produce an outputwhen they are draped over curved surfaces. Somesensors give different readings when loaded with thesame pressure, depending upon whether they are ona flat or curved surface.

Interpolation. All mapping systems use a techniquein displaying their data that will make the imagesmooth, rather than the mosaic that would appear ifyou drew each sensor on the screen and representedit’s output by a square of colour. This process iscalled ‘interpolation’ and is rather like making apicture by joining the dots.

Forces may be generated by gravity acting on thebody, or dynamically when the body moves, such asduring propulsion or transfers. Normal forces areperpendicular to the surface of the body and shearforces are tangential to it.

Pressure (normal stress) is determined by dividingan applied force by the area perpendicular to it.

Shear force is a force acting tangentially to a bodythat changes its shape.

Friction force is a force that opposes a shear force.It’s maximum value occurs before slipping which isinfluenced by the size of the normal force, thefrictional properties of the surfaces in contact andthe prevailing shear force.

Reference List

Ferguson-Pell, M., Cardi, M. (1992) Pressuremapping systems Team Rehab Report October

Ferguson-Pell, M., Cardi, M. (1993) Prototypedevelopment and comparative evaluation ofwheelchair pressure mapping system AssistiveTechnology 5: 78-97

Ferguson-Pell, M., Minkel, J. (1995) An overview ofpressure mapping tools and their application in theseating clinic Proceedings of the 11th InternationalSeating Symposium

Force Sensing Array Vision 3.1 User Manual (2ndEdition) Vista Medical Ltd

Garber, S., Krauskop, T. et al (1978) System forClinically Evaluating Pressure Relief CushionsAmerican Journal for Occupational Therapy 32:565-70

Lipka, D., Vidaud, K., Tanquay, S., Ferguson-Pell,M., Krentz, D., Levy, B., Minkel, J. (1997) Thepressure’s on- clinical application of pressuremapping Proceedings of the 13th InternationalSeating Symposium

Schmeler, M., Buning, M.E. (1999) Pressuremapping. Lecture presentedat www.wheelchairnet.org

Shapcott, N., Levy, B. (1999) By the numbers TeamRehab Report January

X-sensor Pressure Mapping System Users GuideVersion 3.07 X-sensor Technology Corporation(1998)


www.clevemed.com

www.novel.de

www.talleymedical.co.uk

www.tekscan.com

www.vistamedical.org

www.xsensor.com

Manufacturers of Pressure Mapping Systems

Contact details:Company Telephone number Web page Email

Xsensor (USA) 403 205 4012 http://www.xsensor.com/ [email protected]

Tekscan, Inc (USA) 617 464 4500 http://www.tekscan.com/ (mail from internet site)

Talley Medical(UK) 01794 503500 http://www.talleymedical.co.uk [email protected]

Cleveland MedicalDevices, Inc (USA) (toll free)1877-clevemed http://www.clevemed.com [email protected]

Vista Medical Ltd (USA) 800 563 7676 http://www.vistamedical.org [email protected]

Novel (USA) 651 221-0505 http://novel.de [email protected]


Factors for Intergrating Wheelchairsand TransportationMarty Gallagher, MS, LOTR, ATP; Ann Havard, LOTR,CDRS, ATP; Mike Shipp, M.Ed., CDRS

I Introduction

II Sedans

A. Wheelchair ConsiderationsB. Vehicle Entry/ExitC. Wheelchair Transportation Options

III Pickup Trucks

A. Wheelchair ConsiderationsD. Vehicle Entry/ExitE. Wheelchair Transportation Options

IV Sport Utility Vehicles

A. Wheelchair ConsiderationsB. Vehicle Entry/ExitC. Wheelchair Transportation Options

V Mini Vans

A. Wheelchair ConsiderationsB. Vehicle Entry/ExitC. Driver Transferring From a WheelchairD. Driving From a Wheelchair

VI Full Size Vans

A. Wheelchair ConsiderationsE. Vehicle Entry/ExitF. Driver Transferring From a WheelchairG. Driving From a Wheelchair

VIIPassenger Transportation

A. SedansB. Pickup TrucksC. Sport Utility VehiclesD. Vans


Measuring and Recording SeatedPosture - A Proposed StandardDouglas Hobson, PhD, Kelly Waugh, MA, PT,Barbara Crane, MA, PT

Rationale

Standardized terminology and definitions arerequired in order to be able to accurately measure,record and communicate information about theposture of a wheelchair-seated person. This sessionwill present a proposed a new conceptual frameworkand related terms and definitions for an integratedsystem that permits the measurement of a person’swheelchair seated posture relative to a baseline orneutral posture.

Wheelchair seating and positioning has developedinto a sub-specialty of rehabilitation services. As inmost new clinical endeavors initial, advances arebased on clinical observation and largely trial anderror problem solving. In order to advance the field,areas of scientific rigor must now be identifieddeveloped where practical. Also, due to theincreased complexity of products and services, it isimportant that we develop the tools and terminologynecessary to communicate more effectively. Wemust also do this in order to further advanceprofessional recognition in the rapidly emergingfield of specialized seating.Widely accepted industry terminology for measuringand recording wheelchair seated posture that isgrounded on accepted clinical practice and scientificmethodology could, over time, significantly advancethe field in the areas indicated above. In order tohave widespread industry acceptance, the plan is touse the ANSI/RESNA and ISO standardsdevelopment forums to bring the key constituentstogether and produce a product that will ultimatelyform the essence of worldwide standard.

Purpose/Objectives

1) Provide the clinician with an objective way toassess and track the client’s posture over time incomparison to a standard reference.

This will help in the determination (quantification)of the effectiveness of clinical interventions. Thiswill also allow more effective and efficientprescription of seating surfaces with properparameters to provide adequate support. Theinformation obtained will also enable the proper setup of a seating simulator and ultimately a prescribedseating system. In addition to these clinical goals,these measures will allow comparison of clinicaloutcomes within a facility or between comparablefacilities.

2) Provide an industry-wide standardizedmethodology for defining and measuring seatedposture upon which commercial products can bebased that will automate the quantification ofwheelchair seated posture.

3) To lay a widely accepted foundation for theconduct and communication of future research thatcan further advance the science and clinicalsignificance of seating measurement, recording andintra-disciplinary information exchange.

For example, the proposed standard methodologycould provide an effective means of reporting three-dimensional research of the seated posture. Havinga consistent method of reporting research outcomeswill allow researchers to more effectively compareresults and communicate with their clinicalcolleagues.

4. To establish the structured framework that willallow electronic transmission of posturalmeasurement data for use by manufacturers,clinicians, and researchers.


History of Seating Terminology Development

In the early 1990’s, Sig09 of RESNA formed aworking group under the leadership of Drs. Medhatand Hobson. The purpose of this group was todevelop a seating terminology manual and the resultwas Standardization of Terminology and DescriptiveMethods for Specialized Seating (1992). Sig09reorganized this group in 1997 to update this manualunder the leadership of Kelly Waugh. In 1998, thegroup became the ANSI/RESNA WG-TD (workinggroup on terms and definitions) in order to developan ANSI/RESNA standard on terms and definitions.This group first met in June of 1998 and continues tomeet annually at the RESNA conference. Threeadditional groups on wheelchair seating standardsformed at the same time. All RESNA groupscontinue to meet annually to review the ISO workand further the US position.

At about the same time, four parallel groups wereestablished in ISO (WG-11) to develop the samestandards for the international community. TheWorking Group first met in March of 1999. ThisISO, or International Organization forStandardization, is a worldwide federation ofnational standards bodies from 130 countries. This isa non-governmental organization established in1947. The technical committee responsible for thedevelopment of wheelchair standards is the ISO TC173. The subcommittee responsible for seatingstandards is SC-1/WG-1: Wheelchair SeatingSub Group I is responsible for development of ISO16840-Part 1: Body and Seat Measures. KellyWaugh and Marisa Samuelsson are the co-chairs ofSG-I.

The American standards development organizationis the American National Standards Institute (ANSI).The functional component of this organization is thetechnical committee, which is responsible for thedevelopment of US standards and US collaborationwith ISO. RESNA has been designated by ANSI asits standards development body in technology anddisability.

Ultimately, the RESNA group decided to merge theirefforts with the ISO group (WG-11) in order togenerate the four seating standards. After this task iscompleted, the ISO standard will be adapted for useby the ANSI/RESNA working group. The WG-TDcommittee approved this collaboration in June 1999.

The ISO group meets several times per year and theWG-TD continues to meet only at the annualRESNA conference.

Current DevelopmentsThe current draft of the Wheelchair Seating Standard— Part 1:Body and Seat Measures contains fourmajor sections. These include: the geometricreference system for the seated person, definitionsfor anthropometric and postural dimensions of theseated posture, definitions for the orientation,placement and dimensions of seating supportsurfaces, and a glossary of related seating terms.

The geometric reference system for the seatedperson establishes and defines a system that enablesmeasurement of a seated individual. These includeabsolute positioning in relationship to theenvironment as well as relative body segmentpositions. The geometric reference systemestablishes a three dimensional axis system made upof two horizontal axes (X and Y) and a vertical axis(Z). A system for determining rotation in thissystem is established and a 0,0,0 location has beendetermined. In addition to this, the SeatedReference Position is indicated and a measurementmethod for referencing positions that vary from thisposition is established. This forms the basis onwhich all of the other sections are built.

The next two sections relate to defining andmeasuring postural dimensions of a seated personand orientation and dimensions of seating supportsurfaces. Defining the postural dimensions of aseated person involves establishing methods fordetermining linear dimensions and angulardimensions. The angular dimensions are furtherdivided into absolute angles referenced to the SeatedReference Position and relative angles whichreference adjacent body segments to each other. Theseating support surfaces must be described in termsof orientation, placement, and dimensions. This isdone through the use of a centroid, or geometriccenter of the surface. The centroid is used toestablish the linear placement and angularorientation of the surface regardless of its size, andthe linear dimensions are used to establish theoverall size of the surface.

The final section of the proposed standard is theglossary of related seating terms. This glossary isused to define all terms used in the standard that arespecific to measurement and definition of the seatedposture.


Future Plans

Part I of 16840 is scheduled for completion by ISOby fall, 2003. When the document has beenessentially adopted by the ISO, the WG-TD groupwill then review the document and makerecommendations to the ANSI/RESNA WheelchairStandards Committee. The resulting document willthen be voted upon by the committee for acceptanceas US standard. This will then be followed by thedevelopment and dissemination of guidelines forimplementation of the standard.

More InformationThere are several WWW sites that can provide

more information:ISO

http://www.iso.ch/welcome.html

Wheelchair Standards http://www.wheelchairstandards.pitt.edu

RERC on Wheeled Mobility http://www.rerc.pitt.edu

ANSI http://www.ansi.org

RESNA http://www.resna.org — (RSWS is the RESNA subcommittee on wheelchairstandards)Standards participants

WG-TD members:Kelly Waugh, MA, PT (chair)Charles Radville, ATP (original co-chair)Rachid Aissoui, PhDPeter AxelsonDr. Christopher BarGeoff BardsleyAdrienne Bergen, PT, ATP/SCliff BrubakerJean Dansereau, PhDKim Davis, MSPTGerry Dickerson, RTSKentin GearhartCheryl Griebel, PTJanice Hunt Herman, PTDoug Hobson, PhDKay Koch Hurst, OTSimon MargolisM. A. Medhat, MD, PhDJessica Presperin-PedersenFaith Saftler SavageKirk SiquelandStephanie Tanguay, OTClaude Valiquette, DP, CPKarin Wierzbicki, PT

ISO Subgroup I:

Kelly Waugh (Co-chair)Denise ChesneyDoug Hobson, PhDMaria Samuelsson, (Co-chair)Brend ta HaarJack de VriesAndre BagheriTakenobu InoueHideyudi HiroseVictor Paquet


Children in PowerKaren Kangas, OTR/L

Introduction:To obtain a powered chair for a child in the past, itwas believed that requirements included specificprerequisite cognitive and motor skills. However,with today’s assistive technology of seating andprogrammable mobility systems all children cannow become functionally independent in theirmobility. Changing these attitudes, obtaining thenew knowledge, using appropriate equipment, andlearning how to teach mobility will all be discussedwith real cases.

It is critical to consider all children seen in therapyas candidates for powered mobility. In the pasttherapists evaluated the need for powered mobilityon the basis of an arbitrary hierarchy. Thisassessment regarded the child as “ready & capable”or “not ready & not capable.” This hierarchyfocused solely on the “presumed”attributes (or lackof flexibility of the attributes) and function of thepowered wheelchairs rather than any “presumed”need for mobility of the individual child. In short, ahierarchy of children’s prerequisite “readiness”skills was developed in direct response to the lack offlexible powered chair systems. The individualchild was then “judged” rather than the equipment’slimitations .

This hierarchy appeared to exist in contradiction toaccepted standards of practice of rehabilitation. Thestrong emphasis of treatment of independentambulation did include functional mobility and earlyon included the use of manual wheelchairs. It was afoundation of standard practice to recognize thatambulation and functional mobility were critical. Infact, occupational and physical therapists were thefirst professional groups to be looking towardsadaptive equipment and treatment techniques whichwould assist children in mastering mobility.

However, when it came to powered mobility, thissame standard of practice did not apply, it was notconsidered to be a viable treatment technique oreven standard adaptive equipment. It was a “lastresort” and only for those children who could provein advance “readiness” skills.

With the microchip technology available todaywithin powered chairs, the focus of “readiness” mustchange. The need for more bold and courageoustreatment must include each child’s ability to gainindependent mobility through the use of power.This assumption then precludes that all previouslyheld biases towards age, cognitive characteristics, orphysical disabilities when considering a child as acandidate for power change. The only prerequisiteto power now is the child’s desire to be mobile.

In this session, I will demonstrate how poweredmobility is both a treatment technique and adaptiveequipment necessary for independent mobility(ambulation). It must be utilized as a standard ofpractice so that children can develop independentmobility.

Teaching Powered Mobility, not Driving:Not only did we establish hierarchies of readiness,we also developed without thinking, I might add,methods of teaching, based on “driving.”

We thought that giving someone a powered chairwas most like giving them a car, and we proceededto teach them as we were taught to drive. And whenand how were we taught to drive? First of all, wewere already experienced ambulators, andexperienced hand users, and experienced taskaccomplishes. We came to driving with a rich past,and a capable, competent body. We had alreadymastered a bicycle, many riding toys, skating,dancing, and running. We also came with greatdesire, for the independence of control. Ourteachers, however, came to this situation with greattrepidation. They knew how much a “crash” couldentail, not only in expense, but in dangerous bodilyharm. Their primary job, was to try and ensureSAFE control.

In order to do that, they took the student and avehicle to an open unfamiliar parking lot. Thestudent was then taught some of what skills might beneeded before approaching the environment to bemanaged, the ROAD. In this environment braking,


turning, stopping short, starting quickly, lookingboth ways, all of this was considered. Windy roads,control of staying on the right, keeping the eyesforward, but also in the rear view mirror, all wasemphasized.

The real skills needed were these: when the studententered the car, they were to maneuver it from astopped position onto a path which would lead to aspecific place. Once on the path, the car must stayon the right, (while the driver is on the left) and animaginary line is picked with the eyes, between twolines, a middle line, and a side line, on the road.While the foot is pushing on an accelerator, and thehands, in view, are on a steering wheel, stay straight,but watch all around you. Read landmarks, andstreet signs, and watch carefully. Watch all otherdrivers, but never let your eyes leave the road. Keepyour hands on the wheel, and pay attention. Watchwhere you are going. Don’t go too fast. Don’t gotoo slowly. Always be safe.

Now, let’s consider an infant and toddler learning towalk. Do we set up cones and teach them right andleft? Do we tell them to watch where you aregoing? Do we make them walk only on the rightside? Do we instruct them the entire time they arewalking, and do we stand over them, hovering, andinstructing every moment? Do we insist that theywalk over to us, first, and then on a predeterminedpathway, we think is good? I am afraid if we did dothis, no child would have walked.

When teaching a child to ride a bicycle, are the samestrategies used? Do we take them between cones?Do we tell them to look out, look behind, watch out?No, we stand with them, we work with them whenboth of us are ready to work, we work for shortperiods of time, and we hold onto the bicycle,making sure that the bicycle is managed, and thechild is assured by our very presence, that they willnot fall, and that the bicycle is under control. Thechild then slowly begins to take control as we allowit. We give up control as we see the child managingthe bicycle.

First and foremost we need to understand how toteach mobility. To a child who has never had controlof their body before, this powered chair is going tobe her legs. We need to encourage her and teach heras if she were learning to walk, using somestrategies of teaching equipment like we would inteaching a bicycle.

We need totally change our approach in teachingdriving to children. It must much more resemble thesupport required for ambulation. The powered chairto a young child, is a first form of independentmobility, walking some of the time. We must giveup many of our ideas, past strategies andunderstandings of how we used powered chairs withadults. Our children are not going out by themselvesonto a road, or off to work. Our children arelearning to move.

These principles must be taken into consideration.

1. Familiar environment, small space, parentsfirst

2. Immediate success and independent control3. Control of Speed4. Going and stopping, vs. forward (Turning,

circling)5. Switch site/access6. Forward Direction7. No reverse at first

Assessment of Seating and Positioning for Access

1. Task Performance Position2. Consistency/Reliability of Switch Access3. Head vs. Hand switch access4. Equipment Needed

a. Programmable electronics, multiple drivesb. Tilt?c. Two chairsd. Joystick laste. Visual display, not visible

Training/Treatment Required

1. Time needed2. Environments to be trained in3. Strategies to include

a. Never crashingb. Managing doorways later, how to teachc. Experience, experience, experience

4. Methodsa. Practice drillsb. Activity for forwardc. Wandering/Strollingd. Risk taking/unpredictability


SummaryThe use of single switches initially with children inpowered chairs has really allowed an observable,easy progression, controlled by them, from the verybeginning, to be ultimately, extremely successful.Many children progress easily and readily to ajoystick. Others do not, but rather continue toprogress to multiple switch access.

Who is a successfully trained child? Who isindependently mobile? Independence must meanthat the child is doing the act by all by herself.However, the level of independence varies greatly.If a child were able to drive a chair on a walk aroundthe neighborhood, and her mother did not have topush her, and even if that child only controlled oneswitch which was forward, with the mother stillresponsible for the stops and turns, is this childindependent? Yes, this child is independent at thistask. Her mother can walk beside her, she is notpushing her, and the child is controlling the chair,independently. If a child could only do this, wouldthis make her a candidate for powered mobility?Yes, yes, yes.

In closing, a lot more time could be spent on howthe assessment process works, training strategieswhich have proven to be successful, and equipmentwhich is preferred. In a few pages, this isimpossible. Instead, as therapists, please think andtry various types of mobility with children.

Remember, it is the point of delivery at whichtreatment really begins. Training is treatment. Usewill define change, and functionality. Training mustoccur within the individual’s environment. It shouldnever be a “weekly” training, but rather sessions,more infrequent, but over a longer period of time.The system ordered needs to be flexible to allow forchange in use, and change in demand, both inseating, access, and chair performance.

Treatment and training need to come from reactionrather than control, expecting our children to tell uswhat they need and want, and by providing themwith rich, and satisfying, successful experiences.Providing them with patience, and supporting themwith faith in their own abilities to explore, and becurious is a greater gift. Wait for them to requestwhat they need, wait before telling them how to usethe equipment. Recognize that supporting anindividual’s own relationship with independence andsubsequent mobility, is the task, not teaching anindividual how to drive.

Continue to observe that mobility and the control ofmobility is an interaction which providesopportunities for competence. Continue to promotethe use of assistive technology, and to remember thatpowered mobility is crucial. Without independentmobility, it is difficult to interact. Withoutindependent mobility it is almost impossible to beincluded. Remember that mobility is an inherenthuman desire, and trust it to show itself.


The Effects of Seating on RespiratoryFunctionJill Sparacio, OTR/L, ATP, ABDA

Breathing is a dynamic, 3 dimensional activity thatis vital for function. Its efficiency is based on themobility-stability relationship that develops in thetrunk through the normal developmental sequence.As a result of neurological/neuromuscularimpairment, this ability can be greatly limited. Poorrespiratory skills can lead to many secondary diseaseprocesses ranging from lethargy to life threateningconditions. The use of seating components, oftennecessary for support, can further limit respiratoryabilities. During the seating and mobilityevaluation, respiratory skills are often overlooked.

In the able bodied individual, efficient respiration isreliant on a number of factors. These include anintact airway system, a properly functioning alveolarsystem, a properly functioning cardiovascularsystem and intact respiratory musculature. Themusculature needs to be addressed in terms ofstrength, alignment of muscular forces as well as thealignment of skeletal structures.

To fully understand how seating components caninfluence respiratory skills, one must understand thesequence of development that leads to efficientrespiration. The developmental process that allowsfor the maturation of motor skills is directly relatedto respiratory development. In newborns, the chestis a triangular shape with the shoulders rounded andribs aligned in a horizontal manner. The intercostalspacing is very narrow with little mobility amongthe ribs. The newborn relies on his diaphragm forbreathing as the abdominal and upper trunkmusculature has not yet developed. Respiratorymovement is restricted by contact with supportsurfaces. As the infant grows, extensor tone andmovement begin to balance the initial flexorpatterns. The anterior chest opens and the overallchest shape becomes more rectangular. The activeextension patterns and changes in muscle balanceresult in increased volume during inspiration with aresulting decrease in the rate of respiration. Sinceeach breath brings in a greater amount of air, the

infant can breath less often. At 6 months of age, theinfant remains a diaphragmatic breather but he cannow use upper anterior chest accessory muscles toassist.

From six to twelve months, the child develops theability to independently assume positions againstgravity. Respiration is no longer impacted bysupport surfaces. This upright posture allowsgravity and the developing abdominal muscles topull and rotate the ribs downward, resulting inelongation of the chest wall. This rib cage changeallows for development of the diaphragm, theabdominal and the intercostal muscles. Theintercostal spacing is increased which allows forgreater mobility. Primitive reflexes are integratedand a tonal balance between flexion and extension isachieved. This results in the stability-mobilityrelationship within the trunk that allows for efficientrespiration.

Abnormal chest development, whether congenital oracquired, results in respiratory limitations. Inchildren with injury prior to or at birth, this normalsequence of development does not evolve. In adultswho have incurred an injury resulting in neuro-muscular impairment, the stability mobilityrelationship is lost, making the various musclegroups inefficient. Skeletal changes also impactrespiration as muscle tension varies due tomalalignment.

There are two phases of respiration that need to beobserved, inspiration and expiration. Inspiration isan activity of extension while expiration is anactivity of flexion. If one’s trunk is in a flexedposition, efficient inspiration is difficult. Similarly,if one’s trunk is in an extended position, efficientexpiration is limited. If an individual is seated in aposterior pelvic tilt, general trunk flexion occurs,limiting inspiration. Anterior pelvic tilts result in alordotic pattern that increases spinal extension,limiting expiration. Since the diaphragm receives


stability from the lumbar spine, individuals withspinal changes can experience instability in theirdiaphragm. For these individuals, the diaphragmbecomes a trunk stabilizer instead of a primaryrespiratory muscle. Individuals with limited trunksupport often rely on their accessory muscles toassist in the phase that is most limited. This can beobserved through individuals who show littleexpansion of their rib cage and/or minimalabdominal movement. Instead, observation showsthat inhalation is accomplished through externalrotation and elevation of the shoulders. Upper trunkmusculature can often appear overdeveloped as aresult of its over-use.

If a trunk displays limitations in strength and lessefficient accessory muscles are used for respiration,the use of seating components can further limit theirability. The imposing of external supports toprovide stability can restrict the individual’smovements to breath. For example, if an individualrelies on trunk expansion to initiate inspiration andlateral trunk supports are placed firmly against therib cage, the necessary trunk expansion is thenlimited. Consideration needs to be taken whenadding external supports as to how they will impactrespiratory movement patterns. Options should bepursued to provide the lateral stabilization that isnecessary for the maintenance of an upright position.

Upper extremity positioning can also impactrespiratory skills. For example, shoulder blocks arefrequently used to maintain upper extremities out ofpositions of external rotation and abduction. Manyindividuals have compensated for poor respiratorycontrol through using this upper extremity pattern toassist in opening their chests, gaining a mechanicaladvantage for inspiration. Once the arms arepositioned in a more midlined manner, respiratoryeffort increases as well as the individual’s stress togain a full and efficient breath.

The use of seating components can greatly impact anindividual’s respiratory capabilities. Although thesecomponents are used to promote stability forfunction, they can instead create greater limitations.Care needs to be taken during the seating andmobility evaluation to insure that seatingcomponents facilitate alignment and the potential forfunction.

References:

Massery, M: Chest Development as a Component of

Normal Motor Development: Implications forPediatric Physical Therapists. Pediatric PhysicalTherapy, Vol. 3: 3-8, 1991.

Massery, M: What’s Positioning Go to Do With It?:Neurology Report, 18: 11-14, 1994.


High Tech Solutions for a Special NeedsClientKathryn Fisher, BSc (OT), OT (C), Gloria Liebel, OT (C)

Samantha is a 7 year old with athetoid cerebralpalsy . Over the past three years the team has beeninvolved in prescribing assistive technology toprovide her with opportunity to access herenvironment. Because of the complex needs of thisclient and the number of people involved in herdaily life, it became apparent that a process wasneeded to identify, trial, evaluate and integrate thevarious devices.

In this presentation we will discuss the rationale forusing various equipment that has been tried and whyit was successful or unsuccessful. We will include avideo of the client to show her functional level withand without the use of technology. In the 3 years theteam has included Samantha ,her family includinggrandparents, various and sundry professionalinterdisciplinary team members and a vendor .Co-ordination of this very large dedicated team provedto be part of the process and the struggle .

The question still remains have we achieved thegoal of improving Samantha’s quality of life.

Process;

MAT assessment to determine key points of stabilityfor Samantha

Problems; controlling pelvis, controlling head inspace, discouraging thrusting and excess movement.Safety issues. Increasing overall stability of herbody. Needed to determine the seat to back angleand the orientation in space.

Other assessments were going on at the same timebut it became apparent to all that if we didn’t findher optimum position and stabilize her she could notfunction. Eye pointing was not accurate. Noconsistent switch access points could be found.

Establish goals- talk to mother,and father, teachers ,therapists ( treating, communication, seating)

Priorize the goals identified-

Goals; positioning for function, mobility,communication, access for school work.independent mobility

Goals ; family- positioning, communication- motherwas not concerned with independence initially

Goals; Therapist- communication- (treatingtherapist and AC therapist)Seating therapist- positioning and mobility andexplore opportunity for independent mobiliy

Goals; Teachers- communication and positioning forfunctional school activities.

Goals- Samantha- comfort and some control overher head so that she could communicate and havesome control over her environment.. Everythingmust be purple.

Priorize the goals;

1. Positioning

2. Head control

3. Mobility manual w/c

4. Communication

5. Independent mobility- power w/c and walker( Long term goal)


Equipment trials; Manual tilt Zippie TS

1. KSS system, back with laterals, ultimate basewith adductors, pelvic-Y padded, ottobock headrest,tray with elbow blocks..

2. Jay fit—base worked but back didn’t

3. KSS system, back with laterals, ultimate basewith customization- adductors enlarged pommeland lateral thigh supports, wings (by grandfather)headrest ottobock, pelvic-y with gel pad ( she washaving shearing problems.) tray with the elbowblocks.

4. Large wheels on frame changed to small wheelsat the request of Samantha because they look morelike a power w/c.(our goal was to keep her hands outof the wheels- Sam had her own agenda)

5. Head rest- Whitmyer soft pro-series ( clinicaltrial made available by Whitmyer through KathyFisher) Allowed Sam to see her environment, .not ashot and provided intimate points of control ( suboccipital) Also allowed for switch mounting (switches always stay in the same place.) Ottobockblocked her vision was very hot.and difficult tomount switches..

6. Switches- swing aways were added. Initially left

7. RPS- rigid pelvic stabilizers presently known asthe embrace system (research project fromORTC)Provided the best stabilization of pelvis ,improved distal function discouraged excessmovement of both upper and lower extremities andhead. Sam found them comfortable and loves towear them; No shearing on ASIS (mother is happy)

8. Right lateral facial pad to help Sam stabilizeher head and give her a point to rest on when usingthe switch.

9. Power w/c training at school using single switchaccess and a scanner every week for 45 minutes withOTA and PTA

Team Meeting with all members

To review goals and review current system to see ifit provided the stability that Samantha needed tofunction and if we needed any adjustments includinggrowth, safety, extra support.

Reassessment- Mat – confirmed that the key pointsof stabilization were the pelvis-( successfullyaccomplished with the RPS.) Seat to back angle wasestablished at approx. 87 degrees promotingthoracic extension and positioning for function (TomHetzel). Dynamic tilt provided orientation in spacefor rest and gravity assistance where needed.( ByronGuisbert ) Head rest- whitmyer with the switches(swingaway) .Sam had grown and neededadjustments and more support in the sacral area.Extra padding of hangers and calf strap.Power assessment – Switch sites were limited to herhead (side to side) and access was slow and she haddifficulty with mechanical switches hold andrelease, therefore we thought of proximity switches( head array)

New Goals;

1. Prepare for integrated school setting every one’sgoal

2. Independent mobility- Samantha’s goal

3. Provide better back support- therapist goal

4. walker- Mother’s goal

Equipment trials:

1.ASL head array , action power tiger w/c- trial isnow in new school and the person training Sam isnot the person who prescribed the equipment . Issuesre ; complexity of the equipment . Servicing andmaintaining the w/c. How much time is allotted fordriving in this setting. ( note Sam is a competentdriver and had 2 years to learn there was never aquestion about cognition only how to set up thesystem for her.)

2. Back support- symetrix integrated with thewhitmeyer and the base with the RPS. Providesgreat support and control of the sacral area andallows for growth and adjustment as needed. Is cooland helps Sam control her temperature because it isnot such an intimate fit.


3. Smartwalk integrated with the whitmyer headrest.First opportunity for Sam to move in a standingposition and make eye contact with her peers andher sister ( huge impact on Sam and her family –increase in upper extremity control and in headcontrol and sound production.)

What have we learned?

The paradigm works and we followed it withoutrealizing. It helped us to organize our thoughts andgoals and gave us some direction because we couldwork on several things at the same time withoutlosing focus. We could integrate our goals.

There is a method to the madness- for every pieceadded there was a reason and this helped us justifythe prescription for our funding agency and for newtherapists and people who are working with Sam.

We don’t have to reinvent the wheel every time Samchanges we have a system that can change and growwith her.

Problems;

Equipment is sophisticated and not caregiverfriendly for new staff. Needs to be adjusted for Samvery specifically . Trial equipment is limited andnot specific to her needs because of thecustomization required. Funding is an issue becauseshe has soo many needs. Education of the integratedsetting and family( who is responsible for trainingand education of set up ) Accessibility of homeenvironment and transportation issues.


Parents Versus Therapists Views OfTheir Child’s Adaptive Seating SystemRachael McDonald, B.App.Sc.(O.T.). Post Grad Dip(Biomechanics) SROT, PAM’s Research Training Fellow

BackgroundThis paper will discuss the development and pilot ofa measure to explore the difference between parents’and therapists’ views of adaptive seating systemsprovided for their children with cerebral palsy.

Clinicians and parents/users often have differingperceptions of their child’s equipment. Research oncompliance and agreement has mainly been studiedin terms of compliance with augmentativecommunication devices (Ko et al 1998, Clarke et al2000, Murphy et al, 1994). Some of the findings ofthis research can be transferred to look atcompliance and understanding of families andclinicians needs for adaptive seating systems inwheelchairs. White (1997) showed that there is aneed for greater collaboration between therapists,carers and users of special seating systems. This islikely to have an effect both on compliance in usingthe system as well as overall satisfaction with theservice the family receives from their primaryseating therapist.

Two similar questionnaires have been developed inorder to address this. The first questionnaire isdesigned for parents and the second for therapistsdealing with adaptive seating. The questionnaire hasboth quantitative and qualitative sections and isdivided into the areas of Ease of Use, Appearance,Seated Function and Comfort. A separate qualitativesection to ascertain background information (such ashow long the child spends in the seating system,how long they have had the seat) is also included inthe questionnaire. There is a further section askingwhat the parent/therapist like and do not like aboutthe seating system.

There was not an opportunity of ask the childrenthemselves about their view of the wheelchair/seating system at this stage. This was a decisionbased on the difficulties that the children had inparticular with development and communication.There was not the time to perform a study with userscomprehensively, and a decision that to do so wouldbe tokenism. However, this is an exceptionallyimportant topic and must be addressed in future.

Research Questions

1. What is the purpose of providing adaptiveseating systems for children with cerebral palsy?

2. What do parents and therapists think are the keyissues when discussing their child’s seating system?

MethodAn initial questionnaire was given to 6 parents and 6therapists to complete, and an interview followed.The questionnaires were then modified in terms ofstyle and language. All parents and therapistsagreed with the subject content, except one parentwho objected to the attractiveness questionnaire.With the exception of one parent who felt theywould like safety to be included, the parents andtherapists did not feel any other topics should beincluded.

Following the modifications, the questionnaireswere sent out again to 5 therapists and 5 parents, andinterviews performed. The questionnaires were sentout several times to each individual to checkagreement. The purpose of the interviews was tocheck the reliability of the questionnaire informationand to gather information as to the topics/areas thatwere important to the interviewees. The interviewswere manually recorded using a pen and paper andalso recorded on a dictaphone to assess reliability ofrecorded information.


The reliability of the questionnaires was found to besatisfactory.

Results and Future Plans

Because the parents and therapists were eachlooking at individual children, the results of thequantitative analysis was varied and no discernablepattern emerged. Interestingly though, whilst theparents’ responses were wide and varied, thetherapist’s responses were quite similar, eventhought they were talking about different childrenand conditions. However, all the therapists hadchosen to answer the questionnaire using childrenwhose seating they found challenging.

There was general agreement between therapists andparents that the seating systems were providedprimarily for postural management. This wasimportant to the parents, who reported that they usedthe chairs consistently for this reason even thoughtthey actively disliked the chairs in nearly all cases.Therapists however, reported that though the chairshad been provided for a valid reason they weregenerally inadequate and did not perform their rolesatisfactorily. Therapists expressed dissatisfactionwith the range of chairs available to them.

There was agreement between clinicians and parentsthat most seating systems were quite unattractive,but this mattered more for the parents. Commentssuch as ‘I wouldn’t choose to have this equipment inmy house if it wasn’t doing X some good’ werefrequently heard from the parental interviews.Parents were also concerned with environmentalissues – such as storage, ease of getting the chair inand out of their home or car.

Both parents and therapists said that they found thequestionnaires useful and would like to have theopportunity to answer such questions prior toattending a wheelchair/seating clinic. Commentswere made that this could aid communication at thetime of the appointment. .

The next stage in the project will assess the opinionsof parents and therapists thoughts on the seatingsystems and wheelchairs of the same children.

References

1. Clarke, M.T., McConachie, H.R., Wood, P. andPrice, K. (2000). Speech and language therapyprovision for children using augmentative andalternative communication systems. EuropeanJournal of Special Needs Education, In Press.

2. Ko, L.B., McConachie, H. and Jolleff, N.(1998).Outcome of recommendations for augmentativecommunication in children. Child: Care, Health andDevelopment, 24(3), 195-205.

3. Murphy, J., Collins, S. and Moodie,E.(1994).The limited use of AAC Systems.Communication Patterns, 8(3), 9-12.

4. White, E.A. (1997). An investigation into therequirements for an effective district-basedwheelchair service. PhD Thesis, University of Kentat Canterbury.


A Retrospective Study of the Effect ofPostural Management Programmes inthe Management of Hip Dislocation andSpinal Curvature in Bilateral CerebralPalsyTerry Pountney MA, MCSP, Elizabeth Green MD BA HonsDCH, Eur Ing Roy Nelham CEng., FIPEM, SRCS, AnneMandy PhD

Hip subluxation and dislocation in children withcerebral palsy has a well documented history andmorbidity. The incidence of hip dislocation in theUK is approximately 60% of children with bilateralcerebral who do not walk independently. This paperwill present a study of children with bilateralcerebral palsy who had various posturalmanagement and surgical interventions to controlhip deformity.

The most widely accepted theoretical model of hipsubluxation /dislocation is that an imbalance ofmuscle length and strength around the hip leads toacetabular dysplasia and consequent hip subluxation.Muscle spasticity is implicated. Current knowledgeof musculoskeletal plasticity, however, suggests thatapparent spasticity has a greater component ofmuscle and connective tissue shortening thanneurological hyperexcitability. This suggests thatimbalance of muscle length and strength and theconsequent impact on bony development should bepreventable. Maintenance of muscle length andstrength, loadbearing and joint compression arelogical preventative measures. Research on normalinfants’ postures has provided biomechanical data toform the theoretical basis of 24 hour posturalmanagement equipment.

Prior to this, surgery has been the main treatmentapproach to controlling hip dislocation but manychildren undergo two or three surgical interventionsfor their hips followed by later spinal surgery. These

episodes of surgery are traumatic for the child andfamily and costly to the National Health Service.

The Chailey approach to postural management isbased on more than 15 years of research and clinicalpractice at Chailey Heritage Clinical Services toimprove the physical and functional abilities andreduce deformity for children with bilateral cerebralpalsy. The Chailey approach involves provision ofpositioning equipment for lying, sitting, standingand cycling and hands on treatment and activeexercise over the 24 hour period. The equipment isdesigned to position the children at higher levels ofphysical ability by altering the biomechanics of theposture and is provided in the lying, sitting andstanding positions (the Chailey Levels of PhysicalAbility in lying, sitting and standing have beenvalidated). It aims to normalise the forces to allowthe musculoskeletal system to remain intact.

This study reviewed a retrospective cohort of 60children and young adults with bilateral cerebralpalsy using locally recommended levels of posturalmanagement and surgical intervention. Length of thereview period ranged from1.2 years - 24.4 years(mean 7.3 years). Medical therapy and rehabilitationengineering notes were reviewed and measurementsof X rays were made. The cohort were from East andWest Sussex, Oxfordshire. Hip status wasdetermined by the migration percentage and wascategorised as both hips safe, 1 hip safe or neitherhip safe.


Postural management interventions were dividedinto 3 groups for analysis. Category 1: use of allChailey Adjustable Support Systems(CAPS) in lyingsitting and standing; Category 2: 2 items of CAPS(either lying & sitting or sitting & standing);Category 3: use of the CAPS seat only and/or anyother postural supports.

A total of 446 hip Xrays were measured, mean of 7.4(range 1 - 16) per child. Children using “All CAPS”prior to hip subluxation maintained significantlymore hip integrity than other groups (Fishers Exactp < 0.001). 36 children (60%) in the study group hadhip surgery, 21 of whom had a second surgicalintervention . Across the range of surgicalinterventions, children undergoing hip surgery hadsignificantly worse hip outcomes than the groupwho did not have surgery ((2 p <0.001). 3individual case studies show commonly occurringsequences of events.

This study indicates that the Chailey approach totwenty four hour postural management can provide asuccessful conservative means of preventing hipdislocation if implemented prior to the developmentof hip problems. A current prospective study aims toconfirm these findings.

Main contact for correspondence and main author:

Mrs Terry Pountney MA MCSPResearch PhysiotherapistChailey Heritage Clinical ServicesNorth ChaileyEast Sussex BN8 4JN

Additional authors

Dr Elizabeth Green MD BA Hons DCHConsultant in Paediatric Rehabilitation &Neurodevelopmental PaediatricsClinical ManagerChailey Heritage Clinical Services

Eur Ing Roy Nelham CEng., FIPEM, SRCSConsultant Clinical EngineerDirector of Rehabilitation EngineeringChailey Heritage Clinical Services

Dr Anne Mandy PhDResearch FellowUniversity of Brighton


Effects of the Use of Intrathecal

Baclofen on Seating and FunctionSusan Johnson Taylor, OTR/L, Deborah Gaebler-Spira, MD,Sue Mukherjee, MD

It has become more common in the past few years touse the Baclofen Pump as a means to controlspasticity. Because of the sometimes dramaticchanges in tone, there is usually a concommittentchange in the support necessary to obtain andmaintain the seated position. This paper will reviewthe decision-making processes for recommendationfor Baclofen pump insertion, as well as therapygoals for post-pump insertion. Additionally, initialresults of a post pump questionnaire with clientswho received Baclofen pumps will be reviewed.

Spasticity is a motor disorder characterized byvelocity- dependent resistance to a passive stretch,resulting in exaggerated tendon jerks andhyperexcitability of the stretch reflex. This is causedby an imbalance between excitatory and inhibitoryimpulses to the alpha motor neurons. The clinical/functional consequences of spasticity can includeinterference with mobility and joint range of motion(passive and active). This leads to interference withsome or all functional and activities of daily living(ADL) skills, depending on the severity of thespasticity. Indications for consideration for aBaclofen Pump are multi-faceted, but generallyinclude clients who are unresponsive, or minimallyresponsive, to oral medication or for whom oralmedication for spasticity produces undesirable sideeffects, such as fatigue. Additionally, a drop of 1-2points must be noted on the Ashworth Scale.Interference with ADL care is also taken intoconsideration.

Baclofen is a gamma-butyric acid (GABA)agnonist. It is thought to act as a GABA agonist inthe spinal cord by reducing positive input to thealpha motor neuron. It is delivered into theintrathecal space viai a catheter from the implantedpump. The goals of ITB (intrathecal Baclofen)include reduction of spasticity, reduction of painassociated with spasticity, improvement of functionand facilitation of care by a caregiver.

While there are many positive effects of ITB, one ofthe possible side effects related to seating ishypotonia. Clinically, it was observed that someclients had developed the need for increased supportfrom their seating system as well as a tendencytoward pressure sores once the muscle bulk from thespacticity was reduced. A questionnaire wasdeveloped jointly between the RIC PhysicalMedicine and Rehab Dept and the RIC SeatingClinic. This questionnaire will be completed withapproximately 30 children and 15 adults withcerebral-based spasticity who have had ITB pumpinsertion for at least 3 months. They (and/or theircaregiver) are being questioned as they come backinto the medical clinic for pump refill. Questionnaireincludes the following areas:

• Age• Age at implant• GMFCS• Dignoses, with specific questions about the

presence of scoliosis, dislocated hip• History of surgery prior to pump insertion• Medications• Current dose of Baclofen• Previous seating system and problems related to

skin, orthopedic, others.• Changes in ADL, mobility (transfers, dressing,

wheelchair mobility, etc.)• Weight gain• Effect on pain• Hours of caregiver time required• Outside participation level: education/ vocation/

home/ insitution

The desired outcome will be to gather and analyzethis information and determine the types of physical/functional changes that may be expected with thisdiagnostic group, and how they may relate to seatingand other assistive equipment changes.


At the time this paper was written, results had justbegun to be gathered. There will be a compilation ofresults available by the end of February.

Susan Johnson Taylor, OTR/L is a resource clinicianat the Rehab Institute of Chicago (RIC) SeatingClinic

Dr Gaebler is a physician who specializes inpediatric PMR at the RIC.

Dr Mukherjee is a pediatric fellow in PMR at RIC


Clinical Use of SimulationKelly G. Waugh, MA, PT, Mark Schmeler, MS, OTR/L, ATP

by: Elaine Trefler, MEd, OTR/L, FAOTA, ATPwith permission: Team Rehah 10:2, 1999 pages 32 to 36

A simulator, according to Webster’s dictionary, is “adevice that theoperator uses to reproduce or epresentunder test conditions phenomena likely to occur inactual performance.”

Today’s positioning simulators are a far cry from thesimple measuring chair first used by therapists backin 1975 to help position severely disabled children.Those homemade prototypes evolved into themultipurpose simulator we know today. Manyassistive technology practitioners and suppliers havebeen simulating clients’ posture as part of acomprehensive evaluation process for years. Morerecently, we have been able to simulate theirdiffering abilities to drive powered chairs1 using avariety of powered wheelchair controls.

Now, therapists can simulate features of anugmentative/alternative communication system byusing feature simulation/matching forevaluation purposes such as ACES (AugmentativeCommunication Evaluation System) orcustomization of high-end AAC devices forsymbol options or board designs.

Why simulators?Facilities benefit in many ways, not all of themclinical, from using simulators. They satisfy avariety of purposes.

*Evaluation of the seated posture. Often therapistssee clients who come to them in poorly designedseating systems. The systems can be too small, thecomponents incorrect, or the combination of thecomponents inappropriate for the client’s presentneeds. In order to determine the most appropriatesystem, it is critical that clients be placed in theseated posture in the most appropriate componentsand configuration. They must also be given theopportunity to try the system for at least a shortperiod of time. In other words, we simulate the

optimum posture before deciding on the finalconfiguration and components. The more accurateour evaluation is, the more likely that the subsequentprescription will be appropriate for the client.*Evaluation of function. From the simulated optimalseated position, clients can then use their availablemotor skills for functional

activities. Operating powered mobility devices, thewell-seated person can more easily work AACdevices or ECU devices. The proximal stabilityprovided by the seating components enhances thedistal function often used for other control functions.In addition, simulation enables people with severeand multiple challenges to try several differentsystems without the purchase of expensiveequipment that they might not be able to operateefficiently.

*Education. Simulation can allow consumers tophysically experience what a therapist means by“best posture.” It also clearly demonstrates theconcept to their caregivers and third party payers.

*Communication with technical personnel.Measurements can be taken from the simulatorrather than from the client. For example, gravitywill often change a person’s measurements for seatback height from the lying or even supported sittingposture to the posture in a seating system.Measurements taken from the componentsthemselves are more accurate. There is nomiscommunication as to whether themeasurement is that of the person (thigh length, say)or the device (length of the seat component).

*Documentation. With the client in the optimalposture, photographs can be taken that are usefulwhen seeking third party payment for seatingtechnology.


*Saving of time and money. Setting up a simulatedposture using a simulator is much quicker thansimulating posture by placing components in awheelchair frame. A simulator can quickly bereadjusted for a variety of clients of different sizes,ages and disabilities throughout the day. Evaluationtime is efficiently spent. And because the simulatoris part of the evaluation, its use can be billed as partof the evaluation process.

*Documenting outcomes. Using a simulator enablespractitioners to document objective outcomes overtime. Specific dimensions will document growth,improvement in range of motion, or a client’s abilityto sit upright and function within the effects ofgravity.

HistoryIn 1975, at the University of Tennessee at Memphis,therapists working in the Rehabilitation Engineeringprogram requested a measuring chair to helpposition more severely disabled children forevaluation and measuring purposes.

At the time, measurements for seating systems weretaken with the clients on a mat. When they cameback for their system, the seating components,especially the backs, often did not fit. It becameobvious that for clients with neuromotor problems inparticular, measurements for a seating systemneeded to be taken while the clients were seated.

A simple measuring chair was built from plasticseating components on a metal frame. It sat on asmall table that enabled the therapist toreach the child from all angles. This measuring chairenabled the therapist to change the size of seat andback components, the length of the seat, and theheight of the back. It also accommodated variousneck and head supports, a lap belt, and variousanterior trunk supports. The original measuring chairallowed changes in recline, but there was no abilityto change tile.

Over time, the simple chair evolved into componentsthat were mounted on a powered wheelchair base sothat simulation of posture and powered wheelchairoperation could occur using the same device.

New UsesThe measuring chair was renamed the simulator atthe University of Tennessee when it was obviousthat it was being used for much more thanmeasuring children. The therapists had learned whatis now common practice: Simulators are useful forpersons with neuromotor impairment such ascerebral palsy and for those with traumatic headinjuries. Tonal changes often occur with thesepatients as their position in space — and thereforethe effects of gravity — are changed.

Simulators are also useful with elderly people orthose with cognitive impairments because therapistscan observe postural changes even if the clientcannot articulate such things as discomfort.As the concept of simulation was accepted in thefield, several commercial companies fabricatedsimulators to fill the market demand or to ensurecorrect use of their own product.

The Flamingo by Tallahassee TherapeuticEquipment (now defunct) was a simulator that couldbe used with both planar and custom components.The Kiss was developed for use with Pin DotProducts ContourU customseating components (nowowned by Invacare Corp.). The PSS-97 wasdeveloped as a molding frame for Prairie SeatingCorporation’s Reflection custom contouredcushions. More recently, Physipro, ofSherbrooke, Quebec, and Prairie Seating havedeveloped a simulatorfor planar components.

Wider Availability NeededFor many potential users, however, simulators arerelatively expensive and product specific. Some areno longer commercially available.

Therapists agree that the market needs a low costsimulator that can be used in simulation of posturefor persons who need either planar seating or customseating or a combination of both. And they wouldlike it to be easily transportable for use at remotesites or in the clinic.

The biggest barrier to widespread use, however, iscost. Ideally, all therapists doing seating evaluationsshould have access to a simulator either in their owndepartment or from the assistive technology supplier(ATS) that they work with. But according to onemanufacturer, price is the one component thatwill not change any time soon. “Low volume makesthem expensive,” says Adolf Trenkenschuh, director


of product development for Prairie Seating Corp. “IfI could build 100 at a time, I could build themcheaper. Right now I’m handmaking them myself.”

List prices can range up to $7,500, but Trenkenschuhsays he keeps his institutional and dealer cost below$5,000. “More facilities are buying them now,” hesays. “Dealers don’t have time to really playwith these things and become familiar with them.”He does note that those dealers who have boughtsimulators use them to help secure funding bysending photographs along with otherdfocumentation to payers.

Doing WithoutTherapists can use seating components to simulatethe seated posture before recommending the finalproduct combination by temporarily fitting a seatingsystem.

Products such as those designed by MetalcraftIndustries, Mulholland Positioning Systems andFreedom Designs are particularly suited tobeing temporarily fit for simulation purposes.

“Our approach lends itself to simulation in twoways,” says Bob Jones, marketing director forMetalcraft. “We have a lot more adjustability and wehave standard parts, so you can adjust withouttaking the person out of the system, and you can puta second person in later on with the system set adifferent way.” Modular systems like Metalcraft’sgenerally sell for less than $1,000.

With a simulator, however, the seating team canperform the simulation much more quickly andconsider solutions that encompass more than oneproduct line. Decisions based on actual trials withproducts and positions can save both time andmoney.

Looking AheadSimulation should ideally be done in both theevaluation clinic and in the environment in whichthe client will be using the seating system forfunction. Therapy departments or assistivetechnology service delivery programs that see manyclients a week for services might purchase thesimulator. Or the supplier might own the deviceand take it along to evaluations with therapists atdifferent locations.

In this age of service delivery programs’ striving forconsumer-centered and cost-efficient services, it is achallenge for professionals to provide consumerswith every opportunity to make good decisions.What better way is there for patients to participate inthe decisions relative to their posture than to tryvarious options and express their preferences basedon first hand experience?

As technology evolves, perhaps the scenario ofclients adjusting their own seat and back angles,changing contours and operating other technologiesin their virtual environment with a thought-controlled simulator is not too far in the future.

Elaine Trefler is an assistant professor and adviser inthe Department of Rehabilitation Science andTechnology at the University, of Pittsburgh; 5036Forbes Tower, Pittsburgh, PA 15260; 412/647-1278;e-mail: [email protected]

References1Schmeler, M. Performance validation of a poweredwheelchair mobility simulator. Proceedings of theEleventh Annual International Seating Symposium,Pittsburgh, PA. University ofPittsburgh Press 1995; 146-149.

2Kjelmann, E. Project “EMMI (Electronic Man-Machine Interface) Wheelchair Simulator”; Acomputer program used for selecting inputdevices for powered wheelchairs. Proceedings of theThirteenth Annual International Seating Symposium,Pittsburgh, PA. University of Pittsburgh Press 1997;352-255.

3Hasdai, A, Jessel, AS et al. Use of a computersimulator for training children with disabilities in theoperation of a powered wheelchair. AJOT 1998;52: 215-220.


SIDEBARSources

Invacare Corp.Elyria, OH; 800/333-690www.invacare.com

Prairie Seating Corp.Niles, IL; 800/588-0071www.prairieusa.com

Signature 2000Akron, OH; 800/227-2152

PhysiproSherbrooke, PQ; 800/668-2252

Metal CraftOregon, WI; 608/835-3232

Mulholland Positioning SystemsSanta Paula, CA; 800/543-4796www.dis-abilities.com/mulholland.htm

Freedom DesignsSimi Valley, CA; 800/331-8551www.freedomdesigns.com


Custom Contoured Seating –The Next StepGord Broughton, RT, David Cooper, M.Sc, RT,Mark Dilabio, RT

This paper is addressing the production of customcontoured seating and recumbent systems that arefabricated for people requiring an intimate fittingposture and pressure control system. These may beprovided for reasons of comfort or pressure controlcombined with posture control and they are usuallyprovided for people with severe asymmetries andcontractures. Regardless of the method used toproduce a contoured system there are severalenhancements that enable a more appropriate matchto the needs of the clients and their caregivers. Theseenhancements are in many ways dependent on theprocess. If the system is produced in house there areopportunities for innovation and trial that may nototherwise be available.

There are several fabrication methods for customcontoured seating systems. These methods involveone of three techniques for capturing the desiredfinished shape:

• the Foam in Place technique where the client isthe mold;

• making a mold, (either real or virtual), thatrepresents the desired shape of the person;Vacuum bag dilatancy casting and drape castingwould fall into this category and would includefabrication techniques such as Foam in Box,vacuum forming and most of the CAD CAMtechniques;

• and, the good old method of manually measuringthe body contours and reproducing them bycutting and gluing foam.

The second method is utilized by central fabricationfacilities where a mould is produced in the clinicalfacility, sent away for fabrication, then the finishedproduct is shipped back. Though this methodprovides access to custom contoured systems forclinical facilities without technical resources, it

limits the interactive trial and fitting process that isfundamental to optimizing the system for the user.This interactive process, that is often a headache forseating technicians, is fundamental for theadvancement of custom contoured seating.

Modular sectionsOne of the fundamentals for making these systemsmore appropriate is to make them modular. This hastwo primary effects, it increases adjustability andenables dynamic components.

Increased adjustability has advantages during fittingof the system enabling it to be fine tuned to theclient and for future changes in the client’s needs beit growth or progressive posture or physiologicalchanges. This concept provides a combination of theadvantages of a custom contoured system with amodular system. There are limitations in wheresplits can be made in the contours. Where the shapeis divided presents a disruption in the contour andcare must be taken not to introduce a pressure ridgein a potentially dangerous location.

The most common modularization is to split the seatportion from the back portion. This has manyadvantages:

• Back height and sitting depth can be adjusted aslong as the contours remain appropriate. Ifgrowth is expected it may be possible to adjustthe contours to accommodate future growth. Forexample, on the seat portion remove any lipbehind the buttocks and have the seat extendunder the back portion.

• Lateral adjustments of the seat and/or backportions is possible with appropriate hardware.These adjustments allow the back to be movedlaterally relative to the seat permitting lateraldisplacement of the trunk over the pelvis. Thisintroduces changes in pelvic obliquity and the


resultant spinal curvature above it. Lateraladjustments can also be used to change the positionin the wheelchair to accommodate for windswepthips.

• Lateral tilt adjustments of the back are possibleto alter orientation and when combined withlifting one side of the seat can provide minorlateral tilt.

• Rotation of the back portion forward on one sideenables the Therapist to play with rotation of thetrunk above the pelvis.

• Dynamic back supports for management of hipextensor spasm is possible when the back is notattached to the seat portion. This processinvolves incorporating a spring loaded reclinemechanism into the wheelchair frame.

An extension of the concept of modularization is toseparate the pelvic/thigh laterals from the seatportion of the seat. This permits:

• width adjustments in the pelvic and thighregions;

• placement of straps closer to the body for a moredirect angle of pull. This is also an advantage ofseparating the seat and back portions;

• removal of the laterals for easier inspection ofthe contours under the buttocks;

Separating the trunk laterals from the back enablesthem to be adjustable and/or removable or swingaway, figure 1.

• Adjustability is a definite bonus for easing thefitting process and for maintaining long termappropriateness of the system.

• Removable or swing away portions can beimportant for ingress and egress. There are manyways this can be addressed. A key feature isstability and ease of use. It is possible to havelarge sections swing away with conventionaltrunk lateral swing away hardware but in manyinstances it is important to double up on thehardware.

Other sections may be made swing away orremovable to provide access for care. For exampleon one sidelyer a small section was made to openlike a small door for access for G tube feeding.

Figure 1: Contoured trunk laterals attached to swingaway hardware

ReinforcingOne of the advantages to doing Foam-in-Boxcontoured seating is the ability to have large trunklaterals that intimately fit the trunk. Their shape,position and orientation are often critical to postureand pressure related goals of the system. Flexibilityin the laterals can compromise these goals. Howthey are reinforced or stiffened is critical.

There are two components to the reinforcement,figure 2. The first is to insert a plate inside the lateralor to its outer surface that adds stiffness to the lateraland helps maintain its shape. The second is a bracketthat connects the lateral to the back. The bracketshould allow lateral and angular adjustments of thetrunk lateral. The same method is used whether thelateral is separated as a modular piece or anintegrated part of the back support. Considerableadjustability is possible in both situations.

Figure 2: Diagram of reinforced trunk lateral using asolid plate inset into the outside of the lateral andtwo ‘L’ brackets attached to the rear surface of theback. Slots in the ‘L’ brackets allow width and angleadjustments. The view on the right is a cross sectionof the trunk lateral. The lateral may be part of theback or separated from it.


In extreme circumstances when the forces tending todistort or bend the lateral support are large, it maybe necessary to use cross braces to provide enoughstrength. These cross braces are imbedded in thefoam of the back portion of the system.

F igure 3: Diagram of cross bracing for extrastrength in the trunk lateral. The cross brace and ‘L’bracket are embedded in the foam of the backsupport.

There are circumstances when adjustability isimportant and pliable materials are used to enablechanging the shape of the support surface. Forexample, this may occur with small children whereforces are minimal and changes to the shape areexpected. In these instances thin soft metalreinforcing plates are used that can be shapedmanually without taking apart the seating system.

Reinforcing by this method also lends itself toproviding dynamic support. By careful selection ofthe connecting bracket controlled flexibility can beintroduced into the system. This enables portions ofthe seating system to be pushed out of the wayduring critical moments. For example it may beadvantageous for a trunk lateral to shift out of theway during extensor spasm to alleviate harmfulpressures then to return to their normal positionwhen the client relaxes.

Hybrid systemsAs well as hybrid systems that incorporate differenttypes of seats and backs it is also possible toincorporate orthotic components into customcontoured systems. In many instances we find thatwe are taking the mould while the client is wearingtheir TLSO. This seems redundant in that there isalready a functional shape in the TLSO but thesupport of the TLSO is important to maintainorientation of the trunk relative to the pelvis andhips.

We have had occasion to take portions of the TLSOand incorporate then into the back support. In theseinstances the TLSO has been made specifically forthis purpose being reinforced in the areas that weuse. Typically it would be the lateral support areasthat are used. They are cut out of the TLSO andattached to swing away hardware, Figure 4.

Figure 4: Portions taken from a TLSO forincorporation into a custom contoured seatingsystem.

SummaryIt should be possible for modularization of customcontoured seating systems in most applicationswhether made through commercial centralfabrication or at in-house facilities. This processgreatly increases the adjustability of the systemsallowing greater control of the final product.

To implement these concepts requires additionaltechnical resources in time and materials, but theimprovement to the clients’ comfort andfunctionality makes it well worth it.


Personal Mobility, VehicleMobility…Strengthening the LinkKathryn Fisher, B.Sc.O.T.(C), ATS, Brenlee Mogul-Rotman,B.SC.O.T.(C), OTR,ATP, Terry O’Neill

Seating and positioning while behind the wheel,whether it be driving from the factory seat or fromone’s wheelchair, is ideally accomplished throughcomfort, balance and stability. Drivers that do nothave a physical disability and do not require theassistance of a mobility device are subject to theforces that are exerted on a driver while makingturns, lane changes and multi-tasking. Most driverswithout a disability compensate while turning withthe assistance of trunk stability through leg supportand the use of lower body muscle groups. Thesedrivers can also use back muscles and armpositioning to maintain balance, which in turn,maintains vehicle control. Disabled drivers thatrequire simple hand controls to allow them to beindependent must understand the forces that arerequired to maintain vehicle control while driving.Use of adaptive devices to assist with driving avehicle forces the individual to have one hand on thesteering wheel and the other hand used foracceleration/deceleration and possible othercontrols. Balance, stability and function must bemaintained while using the adapted controls, andmany of the muscle groups used by the able-bodiedindividual are not available to use for the disableddriver. The personal mobility device (wheelchair)and the modified vehicle must provide the individualwith the necessary stability, function, and safetyfeatures in order to allow them to safely drive. Setup of the wheelchair and seating system, vehiclemodifications, and compatibility of both systems isparamount in the success of the individual’s abilityto maximize personal and community mobility.

As clinicians, our goal is to optimize functionalpotential of our clients, regardless of their disability.By utilizing available equipment and technology, weare better able to offer our clients enhancedindependence in personal and community mobility.Transportation within the community is an area ofmobility that contributes to an individual’scompletion of functional tasks and independence.

Many individuals with mild to severe functionallimitations are now able to drive independently. Athorough evaluation is paramount to ensure thatvehicle modification and personal mobility devicesare appropriate and compatible. Clinical evaluationwill determine level of necessary modifications andsuccess with the activity of driving. The clinicalevaluation must include:

• Diagnosis-presenting condition• Range of motion• Strength• Muscle tone• Sensation• Balance• Transfers• Skin integrity• Vision/hearing• Cognitive status• Perceptual status• Overall endurance and functional ability• Equipment use and type of equipment

Lifestyle of the client, life roles, preferences, socialneeds and psychosocial needs must all be consideredwithin the clinical evaluation and recommendationof equipment, abilities and need for adaptations andmodifications to drive safely and independently.The seating and mobility team and the vehiclemodification team must work together to ensure thatall client needs are met, and that equipment iscompatible to achieve overall mobility success forthe client in a time and cost effective manner.

The following outlines many of the features ofwheelchairs, considerations that must be taken fordriving and possible vehicle modifications andrecommendations. Many features andconsiderations overlap for both manual and powerwheelchairs.


Driving a vehicle is not only an expression of

autonomy and independence, but this activity

contributes to maintenance of family and social ties,

the running of households and the pursuit of vocational

and avocational activities. For our clients with

disabilities, beginning or resuming the activity of

driving is a major goal towards community

reintegration and independence. Traditionally,

transportation issues of our clients have been addressed

as a separate entity from seating and mobility issues.

With little consultation between clinicians and vehicle

modification specialists, numerous problems have

arisen, including access into and within the vehicle, use

of driving equipment, appropriate visual sightlines and

headroom, ability to transfer and ability to lock the

wheelchair in place. These issues usually result in

extra costs to the client, as changes are necessary to the

personal mobility device and/or the vehicle. Ideally, a

team approach to seating, mobility and vehicle

modifications will reduce unnecessary cost, time delay

and inconvenience to the end user.

Providing solutions to the end user is the ultimate goal

of the team.

References

Cook, A.M., Hussey, S.M. (1995). Assistive

Technologies: Principles and Practice. U.S.A.

Klavora, P., Young, M., Heslegrave, R. (2000). A

Review of a Major Driver Rehabilitation Centre: A

Ten-Year Client Profile. Canadian Journal Of

Occupational Therapy. Vol 67, No.2. pp. 128-134.


Seating for People with MultipleSclerosis (MS) in a Long Term CareFacilityFaith Saftler Savage, PT, ATP

The Boston Home is a unique facility in theNortheast that caters to individuals with MultipleSclerosis (MS). Programs have been developed inthe past 7 years that have a positive impact on thelives of the individuals at this facility. The seatingand positioning program will be highlighted in thiscourse.

Wheelchair positioning and mobility is a highpriority for all individuals at this facility. Individualswith MS experience many changes over a period ofyears. Systems need to be adjustable toaccommodate the changes. Areas of concern includeincreased muscle weakness with increased posturalchanges especially in the head/neck and trunk,increased tone that effects upper and lowerextremities, increased memory loss that effectsmobility, increased/decreased sensory awarenessthat effects ability to delineate pain and discomfortand psychological impact of the disease.

This course will review the pathology of MS andspecific issues that effect the person with MS.Seating interventions will be discussed from basicmanual mobility to power wheelchairs with tilt andhead control systems. The methods for modifyingsystems as person changes will be investigated. Themanagement of loaning facility manual wheelchairsto a person going into the community will also bediscussed. Long term care with multiple caregiversconcerns including wheelchair positioning, chargingof power wheelchairs, repairs of all wheelchairs andnotification of new problems will be covered in thispresentation.

Muscle Weakness and ExhaustionMuscle weakness and exhaustion have a major effecton a person with MS. As the individual losesstrength and functional abilities, dependence onmobility equipment increases. As a person losesupper extremity function, the need for powermobility increases. Power mobility may assist theindividual in conserving energy and decreasingexhaustion. If the person is also demonstrating a lossin trunk and head control, a tilt in space system maybe necessary. Most individuals start driving a powerwheelchair with their hand. If they lose this ability,they may need to be evaluated for a head controlsystem or a sip’n puff system. Electronic equipmenton the power wheelchairs should be adjustable tomeet the person’ changing needs.

Tone ManagementMany individuals demonstrate varying degrees ofdifficulty with managing involuntary musclecontractions. Spasticity can effect both upper andlower extremities and trunk. Range of motion maybe difficult to assess and actual shortening may notbe present. However, even without range limitations,an individual’ movement pattern will effect postureand function in their wheelchair andaccommodations need to be made to the seatingsystem.

Medications are frequently used to reduce spasticity.Knowledge regarding the various types ofmedication intervention is important for a betterunderstanding of short and long -term effects.Possible changes with medications include reductionof pain, increase in range of motion and decrease ofmuscle spasms. Although medications may make abig difference in spasticity management, wheelchairseating should be able to accommodate limitationsassociated with the spasticity. For instance, prior tomedication, an individual demonstrates limitations


in movement for knee extension and requires a seatto calfrest angle of 75°. After medication, the sameindividual now requires a seat to calfrest angle of90°. Although I would set the seat to calfrest angle at90°, I may also ensure that the footplates could bemoved rearward to accommodate increasedtightness/tone over time depending on the overallproblems that the individual presents and the type ofmedication being used.

Cognitive IssuesMany individuals with MS demonstrate short-termand/or long-term memory loss. Some individualsbenefit from cognitive retraining and specific cuesfor remembering. Many others can not be assisted inthis area. Cognition impacts wheeled mobility. Forinstance, an individual may be capable of propellinga manual wheelchair but “forget” that she can reachdown and complete the task. This person should beverbally encouraged to move the chair and mayalways require cues. Power mobility may beappropriate for an individual with increased upperextremity weakness but a careful assessment mustbe completed to ensure the individual is a safedriver. The person may “forget” how to stop thewheelchair or how to avoid other people inwheelchairs. Safety needs to be a priority so no oneis harmed.

Psychological ImpactMS effects a person’ quality of life. Althoughtechnology can improve a person’ quality of life,psychologically, the person may not be ready toaccept the technology. As the needs of a person withMS change: walking independently —› walkingwith cane or walker —› manual mobility —› powermobility so to does the acceptance of the varioustypes of equipment. The diversity of equipment andthe ability to trial equipment in the nursing homesetting assists individuals with acceptance but theprocess continues to take many months or evenyears.

Pain IssuesIndividuals with MS exhibit various types of painand this pain may be due to demyelination. It isimportant to determine the source of the pain. If aperson complains of foot pain, the footplate positionand shoes must be assessed to determine if this is thecause of the pain and modified accordingly.However, many times the seating position isappropriate and is not directly related to the pain. Inthose cases, the individual is referred to the doctorfor further evaluation and medication.

Weight ChangesIndividuals in the nursing home setting may gainweight. The weight gain may be associated withdecreased activity level (due to decreased strength/function), medication and/or fluid retention. Theincrease in weight effects the person’ width and fit ina wheelchair. Wheelchairs may have been orderedwith a fixed width since growth was not expectedand a new system would need to be purchased toaccommodate the changes. Consideration of possibleweight changes needs to be included in theprescription of equipment.

Pressure Sores, Urinary Tract Infections,IncontinenceManagement of these areas is a combination of goodpositioning and good nursing. Areas of concern toprevent the development of pressure sores andurinary tract infections include position in bed or inwheelchair, nutrition, infection control proceduresand types of padding for incontinence problems. Thetype of seat cushion and amount of incontinencepadding under a person’ buttocks also will effect thedevelopment of pressure sores and comfort.

Vision LossAnother area that effects people with MS is vision.Loss of vision can increase the difficulty of driving apower wheelchair but does not eliminate them fromdriving. It is important to determine if the person hasfunctional driving vision. This entails knowing if theperson is able to see the shape of another person orwheelchair, differentiating the walls and dooropenings for indoor driving. The person with visualloss needs to be observed to ensure they are safedrivers. Some individuals are safe in an indoorsetting but have difficulty when out in thecommunity. Outdoor driving skills include theability to differentiate curb cuts from the curb and tobe aware of the potholes in the road as well as cartraffic. Limitations on locations to drive may need tobe enforced to ensure safety.

General Nursing Home ConcernsThe Boston Home is home for 84 people. Fiftyresidents use power wheelchairs as their primarymeans of mobility with 34 residents using manualwheelchairs. The four major issues regardingwheelchairs effecting the home are safety,maintenance of equipment, charging powerwheelchairs and wheelchair positioning.


A complete assessment is performed to ensureindividuals will be safe in specified equipment. Ifsomeone is using a power wheelchair, and skillsdecline, reassessment of mobility is completed withadjustments to driving parameters performed asnecessary.

Equipment maintenance is a very important issue.Problem areas include module failure, joystickfailure, motor failure, tilt failure and battery failure.Residents experiencing problems with theirwheelchair must be assessed to determine if loanerequipment can temporarily fix the problem. Due tofunding issues and schedules of equipmentcompanies, repairs can take from 1 week to 3months so temporary solutions are important. Ifparts are unavailable to repair a person’ personalwheelchair, a spare chair is set-up to attempt to meettheir needs. If possible, a power wheelchair is usedto continue to promote independence.

Charging wheelchairs is the responsibility of theevening aides. Problems occur when aides don’tplug chargers into chairs, don’t turn chargers on ordon’t notice charger failure lights. Some of theseissues should be resolved when charging cabinetsare installed. These cabinets will house the chargersand have a master on/off switch. Elasticized cableswill be used so that it will be obvious if a charger isnot plugged into a wheelchair.

Positioning an individual properly in theirwheelchair is a constant challenge. Aides areinstructed in positioning but problems continue topersist. Improper positioning increases fatigue, painand functional abilities and good positioning is anongoing challenge.

The residents of The Boston Home are encouragedto be as independent as possible and to participate infacility and community activities. Appropriateseating and mobility equipment is an importantcomponent in encouraging this independence.


I. POSITIONING EVALUATION

1. Observe the individual in an unsupported sittingposition. Ask individual to raise their arms, ifpossible. Are they a:

A. Hands free sitterB. Hands dependent sitterC. Prop sitter

POSITION IN SUPINE ON A FIRM MAT

2. What are the available pelvic mobility and lowerextremity joint ranges?

A. Check available pelvic mobility:

1. Anterior/Posterior pelvic mobility:

a. Posterior rotation:Position yourself on one side of the person. Usingyour hand closest to their head, locate and hold theASIS closest to you. Use your arm closest to theirfeet to hold under their knees. Flex their hips andknees at the same time until the thighs rest on theirstomach and the buttocks has rocked up off the matsurface. Person is rolled up into a ball, lumbar spinerounded, pelvis is posteriorly tilted.

b. Anterior rotation:Start with thighs on chest position (see above).Keep one hand on the ASIS. With the other armbehind the knees, slowly extend the hips and kneesuntil the legs are straight. Take your arm out fromunder the knees and reach across the person’s bodyand slide your palm under the pelvis on the oppositeside of the body. (To gain leverage, if you arekneeling next to the client, you will need to assumea half-kneeling position and turn your body to facethe top half of the persons body.) Rock your ownbody back pulling on the backside of the pelvis tocreate an exaggerated lumbar lordosis and pull thepelvis into an anteriorly tilted position.

Mat EvaluationJean L. Minkel, MA, PT

2. Pelvic Obliquity:

Place each of your thumbs on the persons ASIS.Rest the web space of your hand and your indexfinger on the pelvic crest. Note the “resting”orientation of the pelvis. Kneeling next to theperson, place one arm under the knees, support thelegs in a flexed position. Pull both legs toward you,flexing the trunk on the side closest to you andextending the opposite side. Maintaining this trunkflexed position, let the feet rest on the mat and re-palpate the ASIS. The side closest to you should behigher than the opposite side. Move yourself to theother side and repeat the procedure. Can you returnthe pelvis to a midline position? If not, which sideis higher than the other?

3. Pelvic Rotation:

Start with the pelvis in a centered position. Positionyourself in a 1/2 kneeling position next to theperson. Place your palm on the ASIS closest to you.With your other hand reach behind the person andplace your hand over the posterior pelvic crest. Atthe same time, push down on the ASIS and pull upon the posterior pelvic crest to rotate the pelvis.Reverse you hand position. Slide your palm fromthe ASIS closest to you around the back to theposterior pelvic crest. Move your hand from theposterior crest forward and place your palm on theASIS. Repeat the rotation, this time in theopposition direction.

Before proceeding,

Position the pelvis in the best “corrected” positionpossible. Record findings about pelvic mobility onassessment form.

B. Check hip flexion in supine while palpatingthe pelvis in the best corrected position.

1. Hip Flexion with stable pelvis.


Kneel next to the person. With your hand, which isclosest to their head, hold the pelvis. Thumb onASIS, web space and index finger on crest. With theyour other hand hold the back of the leg closest toyou, under the knee and flex at the hip. As youmove the hip toward 90 degrees of flexion, slowdown. Concentrate on your thumb and index finger,when you feel movement of the pelvis under yourthumb, stop and observe the amount of hip flexion.Repeat the movement starting back with 45 degreesof flexion and slowly flexion until you feel thepelvis start to “rock”. Record results on form.Move to the other side of the body. Find and holdthe ASIS and pelvic crest. Position your arm underthe knee closest to you and repeat the procedure.Record results onform.

C. Knee extension with the hip flexed

1. Hamstring range - 2 joint muscle.

Maintain your position kneeling next to the person.Hold the ASIS and the pelvic crest with the handclosest to the person’s head. Slide the other armunder the knee and wrap your hand onto the kneecap, your elbow and forearm should be supportingthe lower leg. Flex the hip to range available,without pelvic rocking. Now extend the knee bypushing the knee cap and extending your elbowtoward the ceiling. As the knee extends, concentrateon any movement you may feel under your thumb,indicating the pelvis is being pulled into a posteriortilted position. Record your findings on form.Move to the other side and repeat the procedure.Record.

D. Hip abduction /adduction and rotations

1. Start with one leg extended on the mat. Flex theother leg at the hip and the knee. With a flexed hip,slowly abduct the hip and then adduct. Return to amidline position and rotate the lower leg, internallythen externally. Caution: Subluxed or dislocatedhips often have limitations in joint range, especiallyin abduction and possibly external rotation. Recordfindings on form.Move to the other side of the body and repeat bothprocedures with the other leg.

If the person naturally assumes a windsweptdeformity, it is critical to determine theavailable passive abduction and adduction range,and not position the hip into a neutralposition, if range is not available.

E. Ankle and Foot position:

Can the foot be positioned so that the sole of the footis a weight bearing area. If foot deformities preventthe sole from being a weight bearing area, determinewhich part of the foot will need to be supportedwhile in the sitting position. Holding a “corrected”foot position is most often best accomplished withan orthotic and not from extensive modifications tothe footrests.

3. Skin Inspection

A. Check all weight bearing areas1. Note areas of persistent redness2. Note size, shape and location of any open

areas3. Determine mechanism of trauma:

a. pressureb. shearc. moisture

Sitting - up: Integrate findings from supineevaluation into supported sitting

4. Sit the individual up against gravity.

A. Assist the person to assume a sitting positionover the edge of the mat. Ask to remove a shirt (orat very least lift the back of a shirt to see spine andpelvis. Position yourself behind the person, placingyour legs on either side of theirs and provide pelvicsupport with the inside of your thighs.

Position the hips in the available amount of flexionfound during the supine eval. Let knees flex underthe mat, if 90 degrees of flexion is not available withhips flexed.

Palpate spinous processes from cervical throughsacral regions.

1. Mobility of lumbar spine2. Scoliosis - flexibility3. Kyphosis - flexibility4. Hyperlordosis - flexibility


5. Determine location and amount of support toachieve and hold balanced position.

1. Maintain your leg position to provide pelvic.Position your hands on the trunk to providesupport and trunk control, then observe:

A. Head positionB. Upper/lower extremity positionC. Effect of tilt or recline

2. Determine whether you are able to “correct” intoa desired position or are you accommodating afixed position. How much force are you handsand legs applying to the person to hold thisposition? (Minimal, Moderate, Maximal force).

3. Can you find a “mutually agreed” position? Aposition which allows the person to be relaxed,functional and feel well supported. Can theperson or their caregivers get them into thisposition?

6. Record observations - See Evaluations Findings.

7. Put it altogether

A. Is the pelvis flexible or is it fixed in a position?

1. Will your intervention need to reduce a flexibledeformity or accommodate a fixed deformity?

B. Think about the recorded hip range in terms ofthe angle between the seat surface and thebackrest.

C. Do the hamstring muscles have enoughflexibility to allow the feet to rest on standardfoot plates?

To keep the hamstrings on slack, will the footplateneed to be closer to the front edge of the seat?

D. Are the spinal curves flexible or fixed?

1. Will your intervention need to reduce a flexibledeformity or accommodate a fixed deformity?

2. How much support is needed to maintain theagreed upon position?

3. Where will the supports need to be located?

Jean L. MinkelMinkel Consulting112 Chestnut Ave New Windsor, NY [email protected]


Redefining Power Wheelchairs

Ian Denison, PT; Doug Gayton, ATP

New power wheelchairs are being introduced at an incredible rate. New models have little in common with theirfore runners. In their efforts to avoid patent infringements and to bring us unique products, manufacturers havemade it difficult for us to pigeon hole chairs according to basic configuration. It used to be that a chair was eitherrear or front wheel drive. Not any more….

In an effort to identify the basic performance characteristics clinicians and clients at GF Strong Rehab Centretested a number of power wheelchairs. The initial need was to create a new definition for the variousconfigurations, a family tree if you like. This paper describes our attempt to make sense of the power wheelchairjungle.

Traditionally power chairs have been classifiedas Rear WHEEL drive (RWD), Mid wheeldrive (MWD), or Front wheel drive (FWD).

Our experience led us to classify chairsaccording to the drive wheel location relativeto the system centre of gravity (chair anduser). This classification makes it easier tounderstand and to predict how a chairperforms

The ratio of weight on the driving wheels for centre wheel drive chairs varies depending on the caster

location and whether the chair has suspension. I have tested chairs with ratios between 50% and 90% on

flat surfaces. In some instances it is relevant to consider CWD’s as a whole, in other instances they will be

split into High Ratio Centre Wheel Drive (HR CWD) and Low Ratio Centre Wheel Drive (LR CWD). LR

CWD have about 60% of their weight on the drive wheels and HR CWD about 85%.

New Definition

RWD MWD FWD

RWD

Low Ratio

60 6085 85Variable

Low RatioHigh Ratio High Ratio

CWD FWD


Factors Influencing Power Wheelchair Performance

Horizontal location of C of GThe horizontal centre of gravity location determineshow the weight is distributed between the drivingwheels and the auxiliary wheels. Regardless of thetire type or the surface being negotiated, reducingweight on the auxiliary wheels produces less drag.Increasing weight on the driving wheels producesmore traction.

Weight distribution is critical in determining howthe chair will perform for a given user in a givenenvironment. When a wheel has more weightpassing through it, the performance characteristicsof that wheel are more significant in determining thechair’s overall performance. Whenever the chair isbeing driven it is desirable to have as much weighton the driving wheels as possible.

SkiddingThe effect of weight distribution is evident whenchanging direction on slippery surfaces. Chairs withlots of weight on their casters will spin their drivewheels and continue skidding in the same directionfor a few feet. Those with most of the weight ontheir driving wheels produce minimal wheel spinand a much quicker turning response. Wheelchairbasketball players deal with skidding by poppingwheelies prior to making a quick turn. This puts allthe weight through the driving wheels eliminatingthe skid.

By this new definition the chairs included in our report are categorized as follows:

TrackingIf the centre of gravity is in front of the drive wheels(as in all RWD chairs) the chair wants to keep goingstraight. If the centre of gravity is behind the drivewheels (as in all FWD chairs) the rear wheels wantto overtake the drive wheels requiring frequentcorrections with the joystick.

These are just some of the characteristics discussedin this paper. The instructional session should leaveyou with a clear understanding of where new chairsfit in and an ability to predict their strengths andweaknesses.


How To Avoid The Pitfalls In AssistiveTechnology ResearchShirley G. Fitzgerald, PhD

Objective: Upon completion of this workshop, theparticipant will be able to

1. Understand the theoretical ‘threats to validity’and how they impact ‘real life’ research.

2. Design research projects that lessen the threats.

3. Understand how to devise solutions forcommonly occurring problems within theresearch environment.

Background:In the increasing development of technology forindividuals with disabilities, it is important to assessthe technology to make ensure that it truly makes aclinically significant difference. Why prescribe adevice that may be affordable, but is easilyabandoned because it does not fit the specific needsof an individual. Clinics may perform in house trialsto assess customer satisfaction with services orevaluate a new cushion that a vendor recommendedis crucial to increasing service and delivery. In orderto attain accurate results, it is crucial to understandthe problems that may arise.

The problem with research on human subjects is justthat, research on human subjects. Humans seldomhave, and seldom will be, consistent. Inconsistencyin the subjects combined with the inconsistencies ofthe research staff as well as environmentalinfluences can result in research that is not perfect.So how does one control for all the extraneousfactors that may happen in research, preserve thesanity of your staff and keep your subjects comingback for more?

To answer that question, one must remember whatthe goals of experimental research are as well as toremember what encompasses threats to internal andexternal validity. In experimental research, the idealgoals are:

1) Is there a true relationship between the variablesof Interest?

2) If that relationship exists, can one variable bedirectly related to the cause of the other, or are there other factors that were not thought about?

3) Given that a cause-and-effect relationship mostlikely exists, are the results accurate andgeneralizable to other situations, otherdisabilities and other technology?

Threats to validity of a research study can bethought of as any factor that will prevent the studyto achieve those previously mentioned goals. Thereare two categories of validity when assessing aresearch study: internal and external. Externalvalidity refers to the extent to which the results ofyour research can be generalized to otherpopulations and situations. Internal validity refers tothe extent to which the experimental treatment reallycaused the observed change in the subjectpopulation. True theorists of research methodologyhave given names to the threats to validity, and thesehave been summarized in Table 1. As rule of thumb,many of the threats can be controlled by way ofstudy design. For example, a randomized controlledclinical trial will impose more constraints on a studythan a cross-sectional mail survey, and thus willhave fewer threats to the validity of the study. Theworkshop will provide detailed information aboutwhich study designs eliminate the different types ofvalidity.


Table 1: Types and Descriptions of Validity

Type of Validity Specific Problems

Internal ValidityHistoryMaturationTestingInstrumentationsRegression Toward the MeanSelectionMortality/AttritionCompnsatory RivalryImitation of treatments

External ValidityInteraction with treatment and selectionInteraction of treatment and settingInteraction of treatment and historyPretest SensitizationPosttest Sensitization

Statistical ConclusionPower of the StudyViolation of statistical methodsReliabilityVariance

Construct ValidityOperational Definitions of variablesExperimental BiasHawthorne EffectMultiple-treatment interactions

But from a practical standpoint, the threats can bemore simply classified as those created by theparticipants (subjects, investigators) and theenvironment (place, time). Participants are definedas all those who take part in the research process.This includes the investigators, the clinicalcoordinators, interviewers and subjects or patients.The environment can be defined by the setting of theresearch study – either the laboratory atmosphere orthe natural constraints imposed upon researchsubjects. Should these threats be present in aresearch study, the validity of the study isjeopardized. Ideally, by being able to recognize thethreats and treating the problem, the research may becarried out with valid results.

Recognition of the problems (or possible problems)will be discussed including an overview of problemsthat commonly arise with the participants andenvironment. Detailed information on solutions tolesson the problems and thereby lesson the threats tovalidity will be provided. Examples from actualresearch projects will be provided and the audiencewill be encouraged to participate to discuss researchproblems that have been encountered.

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There are a number of technological advances thatare available for use in evaluation and fabrication ofseating and positioning systems for individuals whohave severe physical and developmental disabilities.Examples of these devices include Dopplerultrasound and the ABI (ankle Brachial Index) forinformation about circulation, computerizedpressure mapping to identify areas at risk for skinlesions, pulse oximetry to measure oxygensaturation, and videofluoroscopy to evaluatefunctional alignment of eating, swallowing, anddigestive systems. A new area for evaluationinvolves testing elderly individuals for vertigo orbalance disorder that could result in abnormalpostures or resistance to recline or tilt. Often,individuals with profound disabilities cannotcommunicate verbally or in other traditional ways.Because of the deficits in communication,information about fit, comfort, function, andpreference cannot be shared between providers andconsumers. The use of objective measurement toolscan give the clinician critical information about theskin, circulatory system, respiratory status, digestiveprocesses and other vital functions to ensure thepostural devices being provided meet the basicphysiologic needs of the consumer. Additionally,the results of assessments utilizing such tools canprovide concrete data for research in an area thatoften lacks opportunity for controlled study.

The Use of Technological AdvancesTo Evaluate Seating and Positioning inIndividuals with Severe Orthopedic andDevelopmental DisabilitiesKaren Hardwick, Ph.D., OTR, FAOTA; Susan Hanson, PT;Roxane Nichols, OTR; Christy Yeager, PT

Doppler UltrasoundHigh frequency ultrasound is a technique used todetect peripheral arterial pulses. When distal pulsesare not easily palpable or cannot be detected with aregular stethoscope, the Doppler can be used to findand measure blood flow. The equipment consists ofcrystals that emit and receive ultrasound wavesreflected by moving red blood cells (Medasonics,1998). Use of this technology during seatingevaluation can help to indicate the presence orabsence of peripheral blood flow in differentpositions as in supine, sitting, and in various degreesof recline and elevation of the lower extremities.

ABI (ANKLE BRACHIAL INDEX)The ABI is a standard noninvasive test used toassess the severity of peripheral arterial occlusivedisease. Positioning is effected when arterial flow isinsufficient and cannot move against gravity whenthe legs are elevated (Gardner and Montgomery,1998). The ABI is calculated by dividing the anklesystolic pressure by the brachial systolic pressure.

• ABI readings indicate:>1.0 = Normal0.8 – 1.0 = Mild peripheral arterial occlusive

disease (compression therapy shouldbe used with caution)

0.5 - 0.8 = Moderate peripheral arterial occlusivedisease (compression therapy iscontraindicated)

<0.5 = Severe occlusive disease, withreferral to a vascular specialist(compression therapy iscontraindicated)


• If the systolic pressure is exceedingly high, anABI is not considered accurate. This is commonamong diabetic patients where the vessels of thelower leg have become calcified and cannot becompressed by the blood pressure cuff (Collier,Boyd, and Merwarth, 1999).

Rubor of dependencyRubor of dependency is used to test the adequacy ofarterial circulation. This test is performed byplacing the individual in the supine position andnoting the color of the soles of the feet. Inindividuals with normal arterial circulation, the feetwill be pinkish in appearance. To perform this test:

• Elevate the legs to about 45 degrees. If a quickloss of color occurs, resulting in a dead grayishwhite appearance, arterial involvement may besuspected.

• Return legs to a dependent position, normalindividuals will display a quick pink flush in thefeet. If the arterial circulation is impaired, thecolor change may take longer than 30 seconds tooccur and will be a very bright red (McCulloch,1988).

When arterial insufficiency is suspected, considerthe following:• Use of gravity to facilitate circulation is

necessary for tissue health of dependentstructures (arms and legs).

• Define and confine tilt feature to the windowwhere the strongest Doppler signal is achieved.

• Assure adequate thigh support.

• Open knee angle slightly if possible.

• Provide foot support which reduces pressureareas and provides optimal support.

• Avoid constrictive clothing as elastic bandedsweats, socks, some house lippers, etc).

• Do not elevate feet or arms above the heart.

• Elevate head of bed at least 5 degrees or lowerfoot of bed at least 5 degrees.

• Careful skin monitoring.

• Encourage movement).If venous insufficiency is suspected thenconsider the following:

• Use the tilt to elevate feet above the heart.

• Schedule elevation times throughout the day.

• Open the knee angle slightly.

• Compressive hosiery.

• Encourage movement.

• Careful monitoring of skin.

It is possible for both arterial and venousinsufficiency to occur simultaneously. In this eventarterial problems rule decisions of elevation andcompression. For example compression may still beable to be used but at a milder degree, i.e. 20mm Hgvs 40mm Hg. Positioning can be used byspecifically defining the angle of tilt duringelevation.

Pulse oximetryPulse oximetry is a non-invasive technique tomeasure pulse rate and saturation of oxygen in theblood. The SaO2 is computed by measuringdifferences in the visible and infrared absorbance ofoxygenated and deoxygenated arterial blood(Mendelson, 1992). SaO2 should be at least 90% orabove. However, any condition that restricts bloodflow may result in inaccurate Sa02 readings.Because positioning can impact a person’s ability tobreathe adequately, thus compromising O2 intake, itis important to test individuals in the positions beingconsidered. For example, upright sitting inindividuals with low muscle tone, or kyphosis cancause collapse of the T-spine resulting in inadequateventilation and a drop in SaO2. Tilting the positionback slightly can open the trunk, ease ventilationand improve O2 levels. Similarly people withsevere scoliosis may not tolerate certain positions atall or become compromised over time. MonitoringSa02 for a proscibed period of time isrecommended.


When SaO2 drops frequently consider the following:

• Avoid positions that cause such fluctuations.Positioning should enhance breathing ability.

• Design or modify the wheelchair/seating systemin positions that stabilize the readings such as anopen seat to back angle, various degrees of tilt inspace, rotation or derotation of the spine bycontouring or mounting of the seatingcomponents.

• Be cautious using prone positioning because incertain individuals diaphragmatic breathing canbe compromised and gastroesophageal reflux canbe facilitated.

PRESSURE MAPPINGPressure mapping refers to clinical use of a tool thatenables the user to identify areas of concern and toassist in positioning person’s at risk for pressuresores. The system utilizes an array of individualpressure sensing elements to determine the pressurebetween the individual being tested and the sittingsurface; then it presents the information inmeasurable units and as a color-coded display.Pressure is usually recorded in mmHg. Individualswho register low pressures, <80 mmHg, coupledwith no active skin problems, generally require noadditional intervention. Individuals who recordpressures higher than 80 mmHg may need additionalintervention that could include changing thecushion, altering angle of tilt, replacing thewheelchair frame, or other actions (Shapcott &Levy, 1999).

VIDEOFLUOROSCOPYVideofluoroscopic evaluation of swallowing refersto a moving X-ray examination of swallowing usingvarious densities of food and liquid impregnatedwith Barium, a radiopaque substance. Such studiesshould include oral, pharyngeal, esophageal, andgastric components to present a comprehensiveevaluation of dysphagia (Jones and Donner, 1991).Appropriate assessment should involve a routine thatincorporates both erect and recumbent positionsincluding supine and prone oblique positions toassess esophageal motility, gastroesophageal reflux,and gastric emptying.

Following evaluation, it is often necessary to utilizeindividualized positioning regiemes and equipmentto address the range of medical, orthopedic,respiratory, digestive, and neurologicalconsiderations that are frequently displayed byindividuals with developmental disabilities. Theuse of seating and positioning systems forindividuals with severe handicapping conditions canenhance daily living skills and basic digestive andrespiratory functions by assisting in alignment ofbody structures and by the use of gravity.Appropriate positioning may be upright, reclining,side-lying, sitting, standing, prone or a combinationof positioning routines depending on the problemthat is revealed during the assessment (Hardwick &Feichtinger, 1991; Morris and Klein 1987). Simplepositioning procedures may also be used to controlsymptoms of dysphagia in individuals who areambulatory. These include conservative antirefluxtechniques, such as raising the head of the bed to usegravity to control reflux, and maintaining uprightpositioning at least thirty minutes to an hour aftermeals.

Jones. B., & Donner, M.W. (1991). Interpreting thestudy. In Donner, M. W., & Jones, B. (Eds.),Normal and abnormal swallowing imaging indiagnosis and therapy (pp. 52-72). New York:Springer-Verlag.

Levine, M.S. & Rebesin, S.E. (1990, June).Radiological investigation of dysphagia.American Journal of Radiology, 154, 1157-1163.

McCulloch, J (1988). In O’Sullivan, S. & Schmitz(Eds.), Physical Rehabilitation: Assessment andTreatment, (pp. 377). Philidelphia: F.A. DavisCompany.

Shapcott, N. & Levy, B. (1999). By the numbers.TeamRehab Report, January,1999, 16-21.


The Importance of the Therapist in theWheelchair Decision-making Processfor Older AdultsDeborah A. Jones, PT

Currently it is common for wheelchair equipment tobe prescribed and procured either by a caregiver,user, physician or supplier without a therapistinvolvement. Occasionally with less complicatedclients, this will be satisfactory. But, often problemsoccur when a team approach is not utilized. Toomany seating interventions are not meeting theneeds of the individual user. Including anoccupational or physical therapist proficient inassessing the physical needs and the environmentaland specialized equipment needs of older adults inthe decision making process is key to success. Withfewer dollars available for durable medicalequipment (DME), it is important to provideequipment that will accommodate both the short-term and long-term goals for the user.

When individuals with complex needs purchase achair without proper assessment, the result is oftenpoorly fitted systems or systems that can’t bemodified as the client changes. However, fewprofessionals in the medical field know what to doabout it. What is needed is individualized seating.Individualized seating means identifying theperson’s body contours, range of motion, andorientation in space and implementing a seatingsystem that best positions and supports the personfor comfort and function.(Jones, Miller and Rader,1998). The occupational or physical therapist willneed to conduct a thorough seating and mobilityassessment and prescribe individual wheelchairs andseating systems that address the users needs, wantsand desires. Success is largely the result of thecombined efforts of knowledgeable and competentclinicians who, in collaboration with informedconsumers and caregivers, make decisions based onboth specific knowledge and experience (Cook andHussey, 1995).

If a physical assessment is not conducted,underlying problems such as hip flexion contracturesor other fixed deformities, skin issues and pressuremanagement, trunk alignment for upright control,respiratory complication and swallowingdysfunction will not be identified. In addition,progressive degenerative diseases may not be takeninto consideration resulting in the wheelchairneeding to be replaced because it cannot be modifiedto meet the changing needs of the client. The livingenvironment or vehicle will also need to bethoroughly assessed to determine the appropriatepriorities of the wheelchair and seatinginterventions. If the assessment does not cover allthese areas, inappropriate equipment may bepurchased and can have long term negativeconsequences for the user in the areas of posture,skin and pressure management, safety, comfort andoverall ability to function.

Here are some interdisciplinary perspectives on theneed for therapist involvement in wheelchairdecision-making:DME Supplier: Richard Kruse, President,Wheelchair Works, Inc.“There are several reasons a therapist needs to beinvolved in the evaluation to ensure proper fit of awheelchair. Due to the inexperience of the supplier,it is necessary to have a therapist to help assess theproper positioning and alignment of the patient inthe wheelchair. In addition, the therapist can makeequipment recommendations based on theprogression of the client’s diagnosis and help thesupplier understand the physical disability. Manytimes the therapist knows the client on a morepersonal level and therefore knows the client’s needsbetter than the supplier. With the therapist involved,the client also tends to feel at ease and participatesmore actively in the evaluation process. A therapistalso can help with reimbursement issues. Medicare


and other insurance companies require therapistinvolvement in the evaluation process in order forthe supplier to be reimbursed for the equipment.”

Case Manager: Diane L. Hansen, RN, MBADirector, Utilization/QI Management, MullikinMedical Centers

“I think most people, like me, who do not deal withthese issues on a daily, weekly or even monthlybasis would agree:

• things that we aren’t comfortable doing get putaside to be done ”tomorrow”;

• it’s hard to keep up-to-date on the morespecialized equipment;

• it’s not always easy to know what equipmentwill really improve a patient’s daily living orquality of life;

• insurance restrictions/plan benefits can make itdifficult to find the “right equipment” for a given patient’s needs.

Throughout my career, I have wished for someonewho understood patient equipment needs and myown needs as the case manager, potential payersource, or consultant reviewing plaintiff medicalbills or life care plans.Therefore, I look for a therapist who isknowledgeable about durable medical equipmentand seating assessment and can listen and suggestways to resolve my issue in a timely and cost-effective manner. A therapist who talks to me in“lay” terms but acknowledges my medicalknowledge. A therapist with acute and sub-acuterehabilitation experience so that long-term issues areconsidered with the initial purchase of equipment,especially for patients with progressive degeneratingconditions. The therapist needs to be independent ofthe DME company to provide a second opinion –about actual equipment, the quote itself, alternativeideas to accomplish the same goals, etc. and apatient’s advocate.”

Marie Valleroy, MD Rehabilitation Medicine“Why consult with a therapist for wheelchair fitting?A wheelchair purchase is a major durable medicalequipment expenditure. The wheelchair user mustoften live with the consequences for years,sometimes quite painfully, if the choice is notcarefully thought out. Physical or occupational

therapy involvement in wheelchair selection andfitting is the key to optimizing function and avoidingproblems as back pain and pressure sores. A therapyconsultation for wheelchair fitting is not only a goodinvestment, it is the right thing to do.”

Case Study:Seventy-four year old Mr. T began living in anursing home due to skin ulcers and swallowingcomplications from multiple sclerosis. He presentswith a severe forward head and right rotation of theneck. There is redness and moisture in the neckregion due to the prolonged poor positioning of thehead and neck. He said his head had been in thisposition for about two years. He says he would likeit if his head would remain upright so he could see.Although, he chooses to sit in and sleep in hisstationary lounge-style mechanical lift chair becauseit reclines slightly, lifts his legs to decrease pain andit is more comfortable than a bed or wheelchair. Hecan raise and lower his legs and recline slightly inthe chair by himself, if the controls are placed in hisright hand. . According to Mr. T and his wife, thismethod of sitting, reclining and sleeping has beengoing on for several years.He had acquired a Quickie P110 power wheelchairwith an 18” wide, 16” deep Comfortmate cushionand a J2 Tall back, just 6 months ago. But, the onlytime he uses his power wheelchair is to visit hisdoctor. He does not use the power wheelchair inother time because it is not comfortable and hecannot see where he was going.

According to the client and his wife, their physicianrecognized that Mr. T needed a power wheelchairand recommended that he contact a DME supplier.The supplier met with the patient and his wife attheir home. Mr. T’s main concern was getting thepower wheelchair into their Dodge Mini-van thathad a lift system. A power wheelchair, cushion andback system were selected for comfort and vanaccess. A therapist was not involved at this point, sono physical assessment was performed.

Due to Mr. T refusal to sit in his wheelchair, his poorpositioning and skin issues, a therapist wasconsulted. The physical assessment performed bythe therapist revealed that Mr. T had poor trunkcontrol, right torticolis, a coccyx and heel wound, 70degree right hip flexion and 15 degree hip externalrotation contracture, minimal external rotationcontrol at the right shoulder. Left hand is worse thanthe right. He is right handed. Also, he complains ofleg pain when he cannot move them with the


mechanical lift. With this information, it was evidentthat he needed a power wheelchair with power tilt-in-space to assist with his declining trunk control,pressure and pain management. He needed a cushionthat could accommodate his fixed hip contracture,distribute pressure for skin integrity and have moredepth for increase femoral support. He requires ahead support to assist in upright head control. Hiscontrols needed to be placed closer to midline foroptimal function. In addition, if the client wastransported in his van, he could enter in a tiltedposition.

The client’s case manager was contacted to revealthe new information. The P110 power wheelchairbase could not be used for a power tilt system.Therefore, a new power tilt wheelchair and cushionwere recommended with footplates set at 90 degreesand midline joystick mount and bilateral armtroughs for positioning. A flip-down Whitmeyerhead rest with forehead strap and pulley system wasrecommended along with a ROHO Quatro or J2Deep Contour cushion 18x18 and using the currentJ2 back system.

The case manager negotiated with the supplier toexchange the P110 for the recommended wheelchairand seating system and pay the extra for theupgrades.

Mr. T now sits in his power wheelchair everyday forseveral hours. His skin wounds have healed with theaccommodation of his hip, he now does not putextreme pressure on his coccyx. His neck rednesshas disappeared and his neck flexion and rotationhave improved with the combination of a Botoxinjection, stretching program, daily positioningpower tilt wheelchair and a power lounge chair thathas dual motors to fully recline like a bed and stillmove the lower extremities, if needed. With hisimproved head position, his chewing andswallowing has improved along with his ability tocough. Since he can drive his chair with bettercontrol and visual acuity, he attends activities, drivesthroughout the home and outside when weatherpermits. With his upright head position, it hasimproved his social interaction with other residents,friends and staff. He now can look at the person heis talking to and can watch the television with ease.This power wheelchair and seating system has methis individual needs and has made a huge differencein his quality of life.

References:Cook, A., & Hussey, S. (1995). AssistiveTechnology: Principles and Practice, Mosby-Yearbook Company, St. Louis, MO.

Jones, D., Miller, L., Rader, J., (1998). IndividulizedWheelchair Seating for Older Adults, ProvidenceMedical Center, Portland, OR.


Seating and Access II: Those ChildrenWho Grow Up!!Karen M. Kangas OTR/L

Introduction:

With children who are non-speaking, and havephysical disabilities and require alternative accessfor powered mobility, and for other assistivetechnology, finally getting these systems to work isempowering. Then, they grow and change. Shouldthe system of seating, access, and technology, bereplicated? Or, change with them. This session willexplore how to allow this transition to support thecontinued growth of these children, now youngadults, and face the ensuring complicated issuesinvolved.

It is an involved process to assist young children inbecoming more independent in their use of assistivetechnology, especially with alternative access.Adequate seating remains the foundation of theirability to use their bodies and to continue to gaincontrol and competence of the assistive technologythey are using. In this course, we will explore howto plan, or react to the changes that occur when theseyoung children become young adults. Which piecesof their current systems (seating, access, assistivetechnology, equipment) should be replicated, andwhich should change? How can the change besupported?

I will be sharing actual cases I have worked with forover 10 years , as the children have grown up intoyoung adults. The fact that all these children nowspend so much more time in their chairs is critical tofactor into the changes needed in their seating. Also,the goals of seating may also change. When theywere young and primarily control of tone wasneeded, now orthopedic changes may need to beaccommodated.

The need for programmable electronics; multipledrives in powered chairs; flexible, yet stable seatingsystems, including powered seating options; and theneeded support of treatment/training/ andimplementation strategies will be shared anddiscussed.

CASE STUDIESI. What changes occur

A. Bodies, themselves1. Growth2. Orthopedic changes3. Major Surgeries esp. spinal rod insertion,

baclofen pump4. Medication changes

B. Environmental Demands1. Long days in chair2. Multiple classroom environments at

school3. Addition of attendant/aide4. Transfers5. ADL needs

II. Equipment NeededA. Seating Changes

1. What used to work, doesn’t2. Where do we put the lower extremities?3. More flexibility can only come with

powered seat functions4. Front wheeled and mid-wheeled drive vs.

rear wheeled drive5. Angle adjustability, adjustability in all

lateral supports6.

B. Chairs, themselves1. Multiple, separate, programmable Drives

(in electronics)2. Powered chair with ECU controls3. Use of powered seating functions

a. Tiltb. Reclinec. Seat elevationd. Legrest elevatione. Combinations

4. Use of computer5. Communication device and mount


C. Traveling within the community1. Manual chair needed2. Van tie-down systems3. Transfers4. Accessibility

a. Restaurantb. Bathrooms

5. Leisure Activities

III. Therapy NeededA. Private vs. School Therapy

1. Frequency and Duration2. Working together

a. School therapist to clinicb. Clinic therapist to school

B. Feeding/Swallowing Studies (Radiology andits seating)

C. Tracking, not predicting what is needed

D. Transfers

E. Standing

IV. Costs involvedA. Not replacement chairsB. Integration of multiple funding sourcesC. Vocational Rehabilitation involvement

V. Looking to the futureA. Transition PlanningB. Work of private therapy vs. school therapyC. Developing critical pathways of equipment

necessary for total care/yetincreased independence

D. Research and compilation of equipmentneeds, for real, given the changesin institutionalization, ADA, and leaving theeducation system

E. If not college, what?

Summary:

We are now seeing children grow up within familiesand communities who never used to live in theseenvironments. These children were either shippedoff to institutions or never survived birth. As wehave developed as a society, encouraging theinclusion and appreciation of diversity, we mustforge pathways which allow continued equality, notsimply a different form or prejudice and isolation.

I know in this “cost conscious” world, we have allbeen led to believe, things cost too much, or we tryand prove they don’t. I am interested in what worksfor an individual, preventing injury and disease,supporting health and well being. Our whole societyis struggling with that, knowing how to use themedical system, how much is our ownresponsibility, well, we, as professionals, should stoppredicting stuff we don’t know. We are in a newage, a new time, coping with individuals who havebegun to benefit from our more open society. Wemust develop not research to prove what works, Ithink that type of clinical research will always beoutdated as it cannot follow long enough individualsbefore equipment changes itself, or we deprive folksof equipment for the sake of the study.

Studies used for drug efficacy are not the only typeof scientific data. When we learned about humandevelopment we did not develop a laboratory.Instead, a young father, a biologist, observed hisown growing children. Jean Piaget, simply ascientist and a father, in his observations, recordedhuman development, with excellent observations. Inhis scientific study he assisted in recording whatoccurred, and from that we are beginning tounderstand how human beings learn.

We need to do this same kind of “research.” Weneed to study what works, identify what doesn’t.We need to provide equipment, and assess why orwhy it doesn’t work. We need to observe, record,observe, record, and over time begin to understandwhat is needed to work. We do not have thisinformation. Yet, we have allowed others toanticipate the needs of our patients. We must beginto identify working strategies and share them witheach other. I hope the struggles of my best teachers,these kids I have watched grow up, will help us all,as we still attempt to help them and us, all livetogether in a more caring, and peaceful world.


Use of Modular High-StrengthLightweight Manual Wheelchairsas a FleetMark R. Schmeler, M.S., OTR/L, ATP, Nigel G. Shapcott,M.Sc., ATP, Elyn S. Tovey, PT, Michael J. Stonfer, ATS,CRTS

INTRODUCTION

Prescription and delivery of high-strengthlightweight (K0004) wheelchairs to individuals upondischarge from the hospital requires carefulassessment of needs and selection of a system thatcan be modified and adjusted as the new user’sneeds evolve (1, 2, 3, 4). Lack of flexibility canresult in decreased function and costly service callsto the person’s home following discharge.Clinicians are under productivity demands and havelimited time to spend trying to modify and adaptwheelchairs to meet a person’s needs. People arealso being discharged home from the hospital soonerand sometimes unexpectedly making it difficult topredict mobility needs and level of recovery that willcontinue after discharge. Errors in prescription andassembly of wheelchairs are also common especiallygiven the limited training clinicians obtain in theapplication of this technology.

For these reasons a collective project was developedand launched within the UPMC Health Systembetween the Center for Assistive Technology (CAT),the Rehabilitation Hospital (RH), and HomeMedical Equipment (HME) to identify strategies tobetter serve the needs of people being dischargedwith a rental manual wheelchair. As a somewhatself-contained system with responsibility for bothclinical and financial outcome, UPMC was alsointerested in looking at cost-effectiveness and cost-benefit of traditional wheelchair prescription andservice delivery practices and identifying cost savingalternatives.

The ETAC Twin manual wheelchair was identifiedas a potential “fleet type” highstrength lightweightwheelchair for rental and purchase to patients whoare discharged from UPMC RH. The ETAC Twin isdesigned and manufactured in Sweden where theytypically recycle wheelchairs and therefore designthem in a manner that is more durable and adjustableto meet the needs of multiple users as well asaddress a user’s changing needs. Specific featuresare as follows:

1) The back angle can be quickly adjusted with theuser in the wheelchair to accommodate a user’slimited hip range of motion, trunk deformity, andsitting balance.

2) The orientation of the seat angle can be adjustedto provide posterior tilt for wedging or anteriortilt for foot propulsion.

3) The seat to floor height can be adjusted toaccommodate individual leg length for footpropulsion, height for transfers, or access toworking surfaces.

4) The rear axle can be moved forward to promoteefficient push-rim access and propulsionbiomechanics using the upper extremities.

5) The rear axle can be moved rearward for alonger wheelbase and increased stability.

6) The adjustable tension back upholstery canaccommodate various back shapes and spinaldeformities without always having to equip thewheelchair with an expensive third partybackrest.


7) The cross frames can be switched toaccommodate various seat widths.

8) The standard angle adjustable footplates canaccommodate a user’s specific ankle position.

9) The standard height adjustable armrests canaccommodate a user’s specific arm support andtrunk stability needs.

10) The standard adjustable length footrests canaccommodate a user’s specific leg length.

11) The double cross frame and side framepotentially make the wheelchair stronger andless likely to fail.

PROBLEM ANALYSIS

Clinicians from the Center for Assistive Technologyand the Rehabilitation Hospital together with stafffrom Home Medical Equipment identified thefollowing problems in the procurement ofhighstrength lightweight wheelchairs at the time ofdischarge from the hospital:

1. HME has found on several occasions they weregiven very short notice of a person’s dischargeand need for a specialized wheelchair. The shortnotice made it challenging to locate and set-up asystem in time for discharge.

2. When the wheelchair was delivered to thehospital, it often either did not fit properly orneeded to be modified. This often resulted inhaving to return the wheelchair and redeliveranother one, which was costly in terms of time,labor, resources, and potential delay ofdischarge.

3. It was often difficult for therapists to determinethe specific configuration of a wheelchair tomeet a user’s needs without trying them first.This resulted in HME being requested to set-upand deliver multiple wheelchairs to the hospitalfor trial at the time of discharge.

4. Therapists had concerns that users do not haveadequate time to learn to operate or getexperience using their wheelchair prior todischarge. This is necessary in order to identifyany modifications or adjustments that might beneeded. This might also result in a service

person or RTS having to go to the home afterdischarge to make the modifications.

A pilot program was proposed to assess the overallcost-benefit of the ETAC Twin both to the end userand the Health System. The potential cost savingfactors included:

1) The Twin appears to be more durable in designas compared to other highstrength lightweightwheelchairs therefore service calls to the user’shome may be reduced. The potential increasedlongevity of the Twin may produce addedrevenue across the life cycle of the wheelchair asa rental unit.

2) The Twin can be easily adjusted by trainedclinicians eliminating the need to delivermultiple wheelchairs with differentconfigurations for clinical trial.

3) The Twin can be adjusted to address a user’sprogressive or improving needs without havingto change components or an entire wheelchair.The adjustments could also be done by clinicianseliminating the need to send a service person outto the home or facility.

4) Upon delivery, the Twin can also be adjusted tosuit the specific needs of the user eliminating theneed to bring the wheelchair back to the shop.

5) When a user no longer needs the Twin, it couldbe cleaned and readjusted for use by anotherperson.

6) An inventory of Twins and components could behoused at the Rehabilitation Hospital to be set upfor discharge eliminating the need to deliver aspecific wheelchair that sometimes does not fitor meet the needs of the user.

METHODOLOGY & IMPLEMENTATION PLAN

Problem AssessmentFor a period of two months UPMC Home MedicalEquipment monitored the number of wheelchairsthat were ordered by the Rehabilitation Hospital forpatient discharges. Specific information wasgathered related to number of mistakes or refusal ofa wheelchair that would warrant the need to send aservice person out to correct the situation or replacethe wheelchair. Results are shown in table 1.


Table 1: Highstrength Lightweight Wheelchair Orders forAugust/September 1999No. of K0004 Wheelchairs: 47No. of Errors/Rejections: 12Percent: 25.5%

Reason for Problem:• Need for different equipment after initial trial (5)• Change in discharge time or date (3)• Clinician provided inaccurate measurements (2)• Defection in product (1)• Equipment not delivered to specifications (1)

Clinician Training

A comprehensive inservice training program wasdeveloped and implemented at the RehabilitationHospital to all Physical Therapy personnel andothers involved in the provision of wheelchairtechnology. The inservices were carried out overfive one hour sessions during lunch hours or early inthe morning prior to patient treatment. Content ofthe sessions focused on assessment procedures,types of wheelchairs, clinical criteria and indicationsfor each type, and hands-on adjustability of theETAC Twin. The inservice content was also basedon existing courses in the Department ofRehabilitation Science & Technology curriculum atthe University of Pittsburgh.

Inventory & Other Resources

UPMC Home Medical Equipment provided aconsignment inventory of ETAC Twins andcomponents to be housed at the RehabilitationHospital. A Rehabilitation Engineer from the Centerfor Assistive Technology (NGS), assigned two halfdays a week to the hospital, was available to thetherapists and provided expertise in the initialidentification and fitting of appropriate candidatesfor this type of wheelchair. A Physical Therapist(EST) was also available on a daily basis to supportother clinicians interested in the wheelchair for anindividual. A Rehabilitation Technology Supplier(MJS) was also available at the hospital one morningper week to assist with the project initially and tomonitor the inventory.

Assessment

Individuals were identified by the team as beingpotential candidates for the ETAC wheelchair basedon the following; long-term need for a wheelchairfollowing discharge, need for specific seat to floorheight, limitations in lower extremity range ofmotion, flexible deformities of the spine orlimitations in trunk control, or difficulty propellingother less adjustable high-strength lightweightwheelchairs. Candidates were set-up in a loanerETAC to try as part of their in-patient rehabilitationprogram. The wheelchair was adjusted as neededfor optimal positioning, comfort, and function.Once it was determined the ETAC will suit theirneeds, a system was pulled from the consignmentinventory and configured to meet their needs.Individuals were provided with an opportunity touse the device prior to discharge to determine anyadditional adjustment needs. All necessarypaperwork was completed and signed by theattending physician prior to discharge. HMEreplenished the consignment inventory as needed.

Life-Cycle Durability Testing

Three ETAC Twin wheelchairs were also obtained toconduct ANSI/RESNA Durability testing in theHuman Engineering Research Laboratory at theUniversity of Pittsburgh (5). Results of this testingare to be compared to data that exists on othermanufacturer’s high-strength lightweightwheelchairs (6, 7). Specifically, a cost per cycleanalysis is of interest to determine cost-benefit ofusing ETAC Twins as compared to lower per unitcost alternatives.

RESULTS

Over a six-month period 13 ETAC Twins wereprocured to people upon discharge from theRehabilitation Hospital. Demographics aredescribed in table 2. Typical specifications for anorder included a 16” to 18” seat width; full-lengtharm pad to accommodate an arm trough; one brakeextension; swing away footrests; and all availableconfigurations of casters and rear wheels.


Table 2: Overview of Candidates who Received ETAC Twin Wheelchairs

No. of ETACs Provided: 13 Sex: 10 Males & 3 FemalesNo. Rejections/Errors: 0 Mean Age: 60.5 (SD 14.4)

Diagnoses: Discharge Setting:Hemiplegia (7) Alone (1)Quadriplegia (2) With Family Member (12)Paraplegia (2) First floor set-up in 2 story home (7)Multiple Sclerosis (1) Two story home – Bed bath upstairs (2)C1-C2 Instability (1) One story accessible home (2)

Apartment (1)Skilled Nursing Favcility (1)

Clinician Feedback

Feedback from the therapists was generally veryfavorable. They reported they liked having all theadjustability including; seat to floor height, seatangle, seat to back angle, and adjustable tensionback upholstery. They also felt the wheelchairs werelighter, more compact, and easier for the individualto self-propel with either their arms or feet or both.They further felt the swing away footrests,removable armrest assemblies, and wheel locks wereeasier to learn to operate by the user. Therapistsreported they disliked the difficulty in attachingcommon arm troughs necessary for people withupper extremity paralysis associated withhemiparesis. One therapist commented that it takeslonger to adjust as compared less adjustable systems.Others reported they would like more size optionsespecially widths greater than 20” and greaterweight capacities. Furthermore, they would likemore height for the back uprights with two boltfixings and a treaded tire option as part of thestandard option package.

Rejections & Errors

There were no reported problems with rejection of adevice or having to send someone to the home afterdischarge. There were also no reported delays indischarge associated with provision of the ETACTwin as people were already fitted and trained in theuse of the device upon discharge. Home MedicalEquipment also reported decreased need to havesingle wheelchairs delivered to the hospital by adelivery person due to the in-house consignmentinventory.

Following discharge there were only two incidentsof repair calls; one to replace a broken wheel lockextension and one incident of caster loosening by a

DISCUSSION

CostsThe manufacturer’s Suggested Retail Price (MSRP)of an ETAC Twin equipped with height adjustablearmrests, swing away footrests, and adjustable rearanti-tippers is currently about $1330 according tothe order form and price list dated January 2000.Other high-strength lightweight wheelchairs withfewer adjustable components commonly sold in theUnited States retail for about $1180 (according toorder forms and price lists dated September 6, 1999for Sunrise Medical’s Breezy 510 and Invacare’s9000XT dated March 1, 2000). The ETACessentially costs $150 more if one considers onlyMSRP. Wholesale cost to RehabilitationTechnology Suppliers is variable depending onprimary and secondary discounts however wholesalecost differences could be less than $100. (See Table3) This may be a very insignificant differenceespecially considering it costs approximately $50each time a service person goes out to home orfacility to adjust a wheelchair.


Table 3: Cost Comparison of Common K0004 Wheelchairs

Manufacture MSRP Wholesale Wholesale Difference to ETAC (40% & 20% discounts)

ETAC Twin $1330 $638 naBreezy 510 $1180 $566 Less $729000XT $1180 $566 Less $72

Life Cycle Cost AnalysisUnfortunately life cycle data analysis was notavailable at the time of press but will be provided atthe presentation. One can hypothesize though thatthe ETAC Twin has a longer life cycle than otherK0004 wheelchairs due to its composite side framedesign and double cross bracket construction.

Other Associated CostsIn this project there were no reported delays indischarge nor the need to return or the product foranother one at the time of discharge. Delays indischarge can be extremely costly especially in amanaged care environment. A consignment stockof fleet wheelchairs was also maintained at thehospital eliminating the need to deliver a singlewheelchair at a time. Stock was usually replaced ina larger number and at a time when other equipmentwas scheduled to be delivered to the hospital.

Overall clinician satisfaction with the wheelchairwas favorable as compared to their experience usingother types of wheelchairs. Unfortunately, there wasno formal survey of the end users perspective of thewheelchair however this would also be difficultgiven this was usually their first wheelchair andthere is no basis for comparison. The wheelchair ismore adjustable as compared to othermanufacturer’s K0004 wheelchairs therefore it canassumed will more readily meet specific individualneeds.

REFERENCES

1. Cooper, R. A. & Cooper, R. (1998). How to getthe maximum out of a manual wheelchair. PhysicalTherapy Products. Pp. 32, 33, 34.2. DiGiovine MM, Cooper RA, Boninger ML,Lawrence BL, VanSickle DP, Rentschler AJ. (2000)User assessment of manual wheelchair ride comfortand ergonomics, Archives of Physical MedicineRehabiitationl, 81(4):490-4.3. Cooper, R.A., Schmeler, M.R., Cooper, R., &Boninger, M.L. (2000, April/May) . AdvancedSeating Systems: Part II. Rehab Management, 13(3),pp. 60,62-64.4. Cooper, R.A., Schmeler, M.R., Cooper, R., &Boninger, M.L. (2000, February/March) . AdvancedSeating Systems: Part I. Rehab Management, 13(2),pp. 58, 60, 61.5. American National Standard for Wheelchairs,American National Standards Institute, New York,NY, 1998.6. Cooper, R.A., Boninger, M.L., & Rentschler, A.(1999). Evaluation of selected ultralight manualwheelchairs using ANSI/RESNA standards. Archivesof Physical Medicine & Rehabilitation. 80(4). 462-467.7. Cooper, R. A., Gonzalez, J.P. Lawrence, B.M.,Rentschler, A., Boninger, M.L., & VanSickle, D.P.(1997). Performance of selected lightweightwheelchairs on ANSI/RESNA tests. Archives ofPhysical Medicine & Rehabilitation. 78(10):1138-44


Transport WheelchairsDouglas A. Hobson

In April, 2000, ANSI/RESNA WC-19 was approved as US national voluntary industry standard for wheelchairsdesigned for use in motor vehicles. The whelchair industry is responding to the need for wheelchairs that complywith the new industry standard for transport wheelchairs. Models of wheelchairs that meet the standard will befeatured and discussion about the special transport features will follow. All those prescribing wheelchairs that areused as seats in motor vehicles are encouraged to participate.


The Posture-Pressure Connection: TheImportance of MultidisciplinarySeating Assessment in Prevention ofIschemic UlcersCynthia A. Fleck, RN, BSN, ET, CWS; Tina L. Roesler, MS,PT, ABDA

Often, when discussing the impact of seating andpositioning on a client’s life, we fail to consider thedirect implications of proper positioning on skinhealth and integrity. It is important to remember thatthe seated client is inherently at greater risk for skinbreakdown due to a myriad of factors including:prolonged pressure over a small surface area, lack ofmobility, impaired sensation, and inactivity. Whilethe list is more extensive, it is important to knowthat 85% of clients who are seated dependent willdevelop ischemic ulcers at some given time. Thereare steps that clinicians can take to minimize andprevent the impact of ischemic ulcers, a problemthat costs Medicare $2.2-$3.6 billion annually.

First, consider the extrinsic risk factors that we cancontrol. They are pressure, shear, friction andmoisture. Specifically, focus on pressure and thedirect correlation between wheelchair configuration,posture and pressure. Basic adjustments can have asignificant impact on pressure distribution and riskfor ischemic ulcers. For example, properly adjustedarmrests can decrease seated pressures by 25-35%.Other components to pay close attention to are legrest height, backrest height and angle, the type ofseat and back upholstery, and appropriate seat widthand depth. Each of these adjustments has an effecton normal seated posture and has the potential to putthe client at increased risk for skin breakdown andskeletal deformities.

Second, be sure to take a real team approach toseating and wound care. While some may prescribeto the old adage “Too many cooks spoil the pot”,when we talk about strategies to minimize effects ofischemic ulcers, this could not be more wrong.Consider the input of seating specialists, therapists,ET nurses, physicians, rehabilitation technologysuppliers, manufacturers’ representatives and theclient. Each has a unique perspective and set ofskills that can aid in making the best choice for theclient. Therapists and seating specialists understandthe physical and functional implications of seatingsystems and prescribed treatments, ET nurses cancontribute knowledge about the topical wound careoptions and the never-ending list of dressingchoices, physicians can contribute with a completemedical history and inform us of future medicalinterventions, and suppliers have an in depthknowledge of specific product and how it can beapplied to individual situations. Your manufacturers’representatives may also be able to provideclinicians and clients’ with valuable educationalopportunities regarding specific product and clinicalapplications of seating components. Of course, donot discount the client who will provide valuablefeedback regarding the effectiveness of currentinterventions and share their goals and needs.


Last, but not least, education must be an ongoingprocess involving all of the team members.Remember that education and repetition is the key toretention and prevention. Make it sink in, repeatconcepts regarding skin care, pressure relief, andnutrition often. Not only does this keep the teammembers on top of things, but the more the clienthears suggestions, the more likely that he or she willfollow through with that information. Do not beshy about showing the client what could happen as aresult of poor skin care. In this case, it is true that “apicture speaks a thousand words”. Give the clientownership of their skin health and give them theresponsibility of managing it. Also, remember thateach team member should constantly update his orher own wound care knowledge. Wound care andseating options are changing constantly and veryquickly; therefore, we can never idly sit by andassume that we understand all of the latest advancesin treatment and equipment choices.

With all of this in mind, we can make the bestdecision and equipment choices for our seateddependent clients. Take a holistic approach toseating and wound care and be open to new ideasand technologies. Choose the appropriateequipment and seating support surfaces from theonset and we may be able to prevent the debilitatingphysiological, physical, psychological, and socialeffects of ischemic ulcers.

Cynthia A. Fleck, RN, BSN, ET, CWSDirector of Global Training and EducationCrown Therapeutics, Inc. and ROHO, Inc.

Tina L. Roesler, MS, PT, ABDAClinical Applications ManagerCrown Therapeutics, Inc. and ROHO, Inc.

1-800-851-3449www.crownthera.com


The Challenge of Optimal Seating forPeople with Joint ContracturesMarygrace DiStasio Mangine, OTR/L; Cheryl T. West, MSPT

An appropriate seating system and wheelchair willenable clients with joint contractures to increasetheir quality of life, by allowing them to interactwith the world from a wheelchair level while alsopreventing further medical complications. It mayalso increase comfort by accommodatingdeformities of the extremities and trunk, which inturn decrease the risk of skin breakdown. Properseating and positioning equipment, along with anappropriate mobility base, can promote overallhealth with regards to improving respiratoryfunctioning, gastrointestinal functioning, andswallowing. The potential to increase functionalmobility and participation in self-care and previouslife roles increases dramatically with an appropriateseating system. In this session, several low and hightech seating adaptations will be discussed viapresentation of evaluative procedures and casestudies. The Magee Rehabilitation Hospitalequipment procurement process will be used as asystem example.

Significant joint contractures often influence andlimit the choice of equipment due to specialadaptations or custom modifications required. Someof these modifications are as simple as opening seatto back angles or as challenging as fabricatingcustom molded seating systems. A variety of seatbacks and cushions along with manual and powerwheelchairs will be discussed with emphasis onoptions for people with joint contractures in theupper extremities, trunk, and lower extremities.

Our clinical decision process will briefly bediscussed in determining appropriate seatingequipment systems for clients with joint contracturesas follows:

• Client interview, completion of screening forms• Assessment of clients’ functional status• Financial and funding considerations• Vendor identification• Postural evaluation• Client education and trial/evaluation of

equipment/wheelchairs• Documentation procedures• Submission to payment source• Interaction of potential seating and mobility

system in home/work environment

The Occupational and Physical Therapists at MageeRehabilitation perform initial evaluations todetermine overall function. While each disciplinelooks at different aspects of the client, theevaluations are performed jointly. OccupationalTherapist’s assess community re-entry, self care,kitchen, and homemaking as well as perform athorough upper extremity assessment that measuresavailable active and passive movement, strength,sensation, coordination, and tone. Visual,perceptual, and cognitive screens are performed asneeded to determine safety and ability for newlearning.

The Physical Therapists perform a comprehensivetrunk and lower extremity evaluation to determineactive and passive movement, strength, sensation,coordination and tone. Physical Therapists alsoassess the client’s mobility status including all typesof transfers, ambulation, bed mobility and basic/advanced wheelchair mobility skills.


Upon completion of the inpatient or outpatient initialevaluation, a discussion between physical andoccupational therapists occurs regarding the client’spresent level of function and primary equipmentneeds. Investigation of funding options is the nextstep in determining if a client has coverage forvarious types of durable medical equipment. If aninpatient, communication between therapy and casemanagement needs to take place prior to equipmentevaluation and ongoing throughout a client’sadmission. If an outpatient, it must be determinedif coverage for the outpatient evaluation exists, aswell as for the potential durable medical equipment.

A durable medical equipment vendor is choseneither before or after the evaluation and orderingprocess either through the payors choice or throughvendor rotation. The vendor then assists with theordering of the wheelchair and discusses thenecessary specifications, availability of loanermobility equipment, equipment maintenance,warranties, and training.

During the initial contact with Occupational andPhysical therapy a postural evaluation is completed,assessing flexibility and postural stability of theclient’s entire body. More often than not, pressuremapping is used as a tool to determine pressuredistribution of seating systems evaluated. The resultof this evaluation enables the therapists to determineappropriate seating intervention and mobility needsfor the client. Evaluation of a variety of equipmentis then conducted along with education on eachpiece of equipment. The client, family/caregiver, andtherapists (with the DME vendor input if applicable)together choose which seating system and mobilitybase is the most comfortable, safe, and functional. Avariety of environmental situations are discussed andassessed.

Both therapists document the client’s functionalstatus and results of the initial evaluation. Thetherapist(s) then writes a letter of medical necessityjustifying the need for the seating system andmobility base. The medical documentation isprocessed through case management, the attendingphysician and through our Equipment Office. TheEquipment Office is responsible for submittingpaperwork to the respective payor and vendor andtracking delivery or problems. Once the system isapproved and delivered, our clients return asoutpatients to be fitted and educated/trained with theprescribed equipment prior to home delivery. Followthrough in the home setting is the responsibility ofthe assigned vendor. Future issues can be addressedby the therapists in the lifetime Follow Up system ofcare.


Back in Style- Suggestions to the FieldThomas R. Hetzel, PT, ATP

INTRODUCTION:This course will outline the biomechanical principlesand clinical indicators to be considered whenselecting a wheelchair back support. Tips onevaluating current technologies in respect of theways they address the person-to-support-surface andsupport-surface-to-mobility-base interfaces will bepresented.

Upon completion of this program, participants will:1. Understand the roles a wheelchair back system

plays in supporting the pelvis and trunk in theeffort to optimize postural control and distalextremity function.

2. Expand their current assessment skills toinclude techniques for determining back supportcharacteristics as they relate to the key interfacesof person-to-support surface and support-surface-towheelchair.

3. Understand seating simulation strategies, andways to translate simulation results into finalgoals and product selection.

4. Recognize the intended application of severalcommercially available back support systems.

Biomechanical relationship of the pelvis and trunkin a balanced seated posture.

In a balanced seated posture, spinal curves are mostgreatly influenced by pelvic orientation:

Posterior pelvic tilt.• Reduction or reversal of lumbar lordosis• Increased thoracic kyphosis• Shoulders protract• If head rights:

• Increased cervical lordosis• Capital extension• Mouth tends to open• Unsafe swallow

• If head does not right or collapses:• Cervical kyphosis• Capital flexion• Head tends to fall forward, “chin on chest”

Anterior pelvic tilt.• Increased lumbar lordosis• Reduction or reversal of thoracic kyphosis• Shoulders retract• If head rights:

• Decreased cervical lordosis• Capital flexion• Mouth tends to close• Safe swallow

• If head does not right or collapses:• Cervical extension• Capital extension• Head tends to fall back

Pelvic Obliquity.• Initially, a compensatory lateral “C” curve with

the apex to the same side as the obliquity (lowside) is observed, and is most likely seen in thelumbar and thoracic spine.

• The shoulder on the side of the obliquity tends tobe elevated.

• If the head rights, then a compensatory curvewill be observed in the cervical spine with apexopposite obliquity.

• If head does not right, then the head will tend tofall laterally, opposite the obliquity.

• If the obliquity persists, then a compensatorycurve may progress in the thoracic spine withapex opposite the obliquity creating and “S”curve. This compensatory curve tends to level the shoulders.

Note that any lateral bending of the spine is linkedto a corresponding degree of rotation. It is thisrotational component that often leads to theprogression of a “rib hump” or anterior-posteriorspinal and thoracic cage deformity.In the case of pelvic rotation, a compensatory spinalrotation opposite that at the pelvis can be expected.


A brief summary statement of the above would bethat wherever the pelvis tends to posture, theshoulders and head will tend to go opposite. Thissimple statement is the cornerstone for back supportconfiguration and selection. It is also important toremember that it is not enough to simply recognizethe postural tendency. One must further evaluate todetermine the cause of the undesirable posturetargeted for correction.

Evaluating the individual for a back supportTime and space limit the degree to which thisprogram can focus on specific evaluation principles.It is recommended that participants withoutbackground in evaluation for seating and mobilitypursue programs which cover it in depth. Thegeneral order in which the physical evaluationproceeds is as follows:

Identification of postural tendency in currentequipment• Posterior• Anterior• Lateral

Postural control and functional skills in currentequipment.• Mobility• ADL• Transfers

Flexibility (Supine). The primary goal of the supineassessment is to establish true joint flexibility as itinfluences seated posture.• Pelvis• Lumbar spine• Hips• Hamstring• Thoracic spine• Cervical spine, head and neck• Shoulder complex and upper extremities

Flexibility (Sitting).The primary objective of the seated evaluation is todetermine where an individual can be supportedcomfortably and functionally within his/heravailable range of motion. A flexible component ofposture is not always a correctible component. Oncethe individual is in the seated position, both intrinsicand extrinsic factors work together to create acomplex constellation of influences on posturalcontrol. Seating and mobility features must beconsidered with respect to these influences.

AMOS and the Back SupportBack support features can be arranged around theacronym “AMOS”. The acronym is arranged belowin the order in which the features may best beconsidered:

• “A” represents Angles, or angular relationship ofsupports with respect to anatomic angles.

• “S” represents Shape, that is the shape of thesupports with respect to the shape of the sitter inhis/her corrected posture.

• “O” represents Orientation of the back supportwith respect to gravity, method of mobility, andenvironment.

• “M” represents Materials selected with respect tothe sitter’s requirements for support, comfort,and care of skin integrity.

Simulation of the parameters above is essential indetermining the proper back support.

The primary methods of simulation are:• Linear/planar simulation• Molded or dilatency simulation• Computer assisted design (CAD)• Equipment mock-up• Combination

The results of the simulation will help refine thefinal goals of the seating intervention, and establishproduct options. By first defining the supportparameters in terms of “AMOS”, one can thenassess the various options objectively.

Defining and evaluating back supports:ANGLES & SHAPESOne basic principle that is extremely important inthe selection of a back support is that the supportultimately has two responsibilities:1. Pelvic support2. Trunk support

With this in mind, and the relationship of the pelvisand the trunk discussed earlier, i.e. their tendency towork opposite of each other, one can begin tounderstand how to evaluate potential options for aconsumer. For example, assuming flexible andcorrectible postures, if the objective is to rotate thepelvis from a posterior tilt towards neutral, onemight attempt to close the seat-to-back angle. As theangle is closed and the pelvis is rocked forward, thetrunk will need to extend, but will be blocked by theback support. Conversely, if the objective is toaccommodate a kyphotic spine, one might attempt to


open the seat-to-back angle. As this is done, thepelvis will tilt posterior and the kyphosis mayactually increase.

Therefore, one parameter to consider is the ability toindependently adjust pelvic and thoracic support.This is accomplished in some commerciallyavailable systems through adjustment of shape,angles, or both. It may also be accomplished throughthe means in which a shape is “captured” forfabrication of a more custom shaped back support.This is an essential feature for correcting a flexiblepelvis and spine. One must be able to “capture” theoptimal shape, adjust a more generic shape, or adjustthe angular relationship of the pelvic and trunksupports to optimize flexible spinal postures.

Shape or contour is another consideration.

Traditionally, it has been taught that back supportsare categorized somewhere within the range betweenplanar and custom contour. Advantages anddisadvantages of both ends of the spectrum havebeen widely discussed. What needs to be considered,however, is where and how specific contour shouldbe applied in any system. One theme that isregularly accepted is that proximal stabilitypromotes greater freedom and “normalization” ofdistal mobility. To that end, it follows that byproviding contours specific to the stability of thepelvis, it may be possible to “open” the shapedistally to allow, or even promote, greater freedomof movement. In summary, the specificity, location,and depth of contour needed in a back support isdriven by the amount of control required proximallyto balance someone’s posture in an effort to realize adesired functional outcome distally.

ORIENTATION of the back support with respect togravity, mobility, and environment.

With respect to gravity, one needs to be able toadjust the back support to fully take advantage ofgravity for postural stabilization. This may beaccomplished through the mounting hardware forthe back support, or possibly through theconfiguration of the wheelchair itself.

The method of mobility is critical in determininghow to select and mount a back support. One mustrecognize that if a back support utilizes the fullwidth of the wheelchair, it may decrease seat depth.This results in a shift of the center of gravity of thesitter in relationship to the drive wheels of the chair,

and can dramatically reduce wheelchairperformance. If the back support fits between theback canes of the wheelchair, width of the supportmay be limited. Recent innovations in back supportdesign have reduced the impact on seat depth andwidth.

The back support must also fit the environment andlifestyle of the user. Weight, portability,manageability, design, safety, and numerous otherfactors contribute to back support selection.

MATERIALSIf a material touches the body it needs to address theparameters of comfort, support, and skin care. Onemust determine the priority in which these threeparameters need to be addressed. If the priority leansmore toward support, then a firm material may beindicated. The firmer the material used, the moreaccurate the shape must be to address the areas ofskin care and comfort. Issues of heat andperspiration also need to be considered whensupport and cover materials are determined.Maintenance and durability of the materials requiresconsideration as well.

Other Considerations:Sitting is dynamic. Consider how a particular backsupport can promote favorable, symmetrical restingpostures with good spinal alignment, yet allow for,maybe even promote active transitions to morefunctional postures.

Define the critical tasks and desired outcomes. Oneback support cannot be everything to one person. Itis imperative to know and guide intervention insupport of the most critical tasks needed to beaccomplished when sitting. Trying to address toomany tasks may dilute the overall effectiveness ofthe support and ultimately do nothing very well.Look for user adjustable seating parameters whenappropriate, and challenge manufacturers torecognize the need for and develop truly dynamicseating systems.

People change.Consider the prognosis of the individual. It is a rarecase where a person is beyond the point of possiblechange. All parameters considered need to also takeinto account the capacity for change be it growth,progression of a condition both positive or negative,living situation, transportation, etc…


SUMMARY:The wheelchair back support plays a critical role inthe support of safe, comfortable and functionalpostures. Knowledge of the roles the back supportplays, i.e. pelvic and trunk support, and thebiomechanical relationship of those posturalsegments in a balanced system are critical indetermining the most appropriate back supportoption. The evaluation for and simulation ofproduct features as they relate to angles, shapes,orientation, and materials will help direct aconsumer towards that optimal product option.Awareness of currently available technologies andhow to personalize them to best support theconsumer’s needs will help to ensure favorableoutcomes.

Tom Hetzel is part owner of Aspen Seating, LLC, adirect service manufacturer of specific seatingsystems for the most unique and complex of needs.Headquartered in Denver, Colorado, Aspen Seatingprovides outreach services nationally in areas ofmanufacturing, consultation, education andevaluation for individuals with the most severe,profound and unique seating requirements. Tom canbe reached at (303) 579-7078, or [email protected].


Linking Clinical Presentation withPower Wheelchair ProgrammingLois E. Tucker, OTR/L, ATP

Programming is the most important link to a powerwheelchair users success. Programming poweredmobility is also the one area many clinicians andrehab technology suppliers find intimidating. Thekey to programming a power chair is understandinghow the client’s physical and cognitive limitations,environment and choice of driver control impacts onthe programming parameters.

Physical conditions that impact programming caninclude, range of motion limitations, weakness,fatigue, spasticity and ataxia to name a few.Cognitive and perceptual differences like attention,memory and the speed at which information isprocessed will also require different settings. Theenvironment(s) the client will negotiate and thedriver controller they will use will modify theprogramming setup as well.

In this instructional session, each one of these issueswill be discussed. Guidelines will be provided toassist the dealer and clinician in the programmingprocess based on the client’s profile. Writtenhandouts will allow the participant to leave thesession with guidelines they can use in their ownclinical environments. New computer software willbe highlighted at the end of the session that can beused to simplify the programming process in thefield.


In all instances for any type of DME the medicalrecords must contain information which supports themedical necessity of the item ordered.

Canes/crutches are covered when prescribed by aphysician for a patients with a condition causingimpaired ambulation and when there is a potentialfor ambulation.

“a white cane for a blind person is non-coveredsince it is a “self help: item.”

Walkers -1. Standard walker is covered if prescribed byphysician for a patient with a medical conditionimpairing ambulation & there is a potential forambulation, AND there is a need for greater stabilityand security than provided by cane or crutches.

2. Heavy duty walker (K0458,K0459) is coveredfor patients who meet coverage criteria for astandard walker AND who weigh greater than 300pounds. Use ZX modifier.

3. E0147 - Heavy duty, multiple braking system,variable wheel resistance walker is covered forpatients who meet criteria for a standard walkerAND who are unable to use a standard walker due toa severe neurologic disorder or other conditioncausing the restricted use of one hand. (Obesity byitself is not sufficient reason for an E0147 walker)Manf. name, make, model & note or otherdocumentation from physician detailing functionallimitations which preclude the pt. using anothertype wheeled walker & diagnosis causing thislimitation.

Reimbursement - Rehab 101 — All YouNeed to Know & More to Get YourClient What They Really NeedPeggy Walker, RN

Enhancement accessories of walkers will be deniedas non-covered.

Leg extensions are covered for patients 6 feet tall ormore.

Bathroom equipment is non-covered. (anything thatgoes inside the bathroom door.)

Heavy duty commodes (K0457) width =to or > than23 inches – weight capacity 300 pounds or more.

Detachable arms (E0165) are covered when used tofacilitate transferring the patient or if the patient hasa body configuration that requires extra width.

Patient lifts (Hoyer or other types) - covered iftransfer between bed and a chair, wheelchair, orcommode requires the assistance of more than oneperson and, without the use of a lift, the patientwould be bed confined.

Lift Chairs - Patient must be able to ambulate oncestanding ( can not be used in conjunction with a w/cor pov (must be non-amb. with these)

1. have severe arthritis of hip or knee or havesevere neuromuscular disease.

2. must be a part of the physician’s course oftreatment & be prescribed to effect improvement, orarrest or retard deterioration in the patient’scondition.

3. patient must be completely incapable of standingup from any chair in his/her home. ( The fact that apatient has difficulty or is even incapable of gettingup fro a chair, particularly a low chair, is notsufficient justification for a seat lift mechanism.Almost all patients who are capable of ambulatingcan get out of an ordinary chair if the seat height is


appropriate and the chair has arms.)

4. Once standing, the patient must have the abilityto ambulate.

POVS:1. The patient’s cond. is such that a w/c is requiredfor pt. to move in their home.

2. Unable to operate a manual w/c.

3. Capable of safely operating the controls of aPOV.

4. and can transfer safely in & out of the POV &has adequate trunk stability to be able to safely ridein the POV.

BEDS: 1.Semi-electric — Pt. requires positioning of thebody in ways not feasible with an ordinary bed inorder to alleviate pair;

2. requires the head of the bed to be elevated morethan 30 degrees most of the time due to CHF,COPD, or problems with aspiration. Pillows orwedges must have been tried and failed to achievethe desired clinical outcome; or

3. requires traction equip. which can only beattached to a hospital bed.

Specialty Mattresses: Coverage1. Completely immobile - i.e. Pt. cannot makechanges inbody position without assistance

2. Limited mobility - ie pt. cannot independentlymake changes in body position significant enough toalleviate pressure.

3. any stage pressure ulcer on the trunk or pelvis

4. impaired nutritional status

5. fecal or urinary incontinence

6. altered sensory perception

7. compromised circulatory status

Group 1 ( mostly overlays ) Criteria 1, or criteria 2or 3 and at least one of 4-7.

Group 2 (powered pressure reducing mattresses)(Covered if meets: Criterion 1& 2 & 3 OR criterion4 OR criterion 5 & 6 below.)

1. Multiple stage II pressure ulcers located on trunkor pelvis

2. Pt. has been on a comprehensive ulcer treatmentprogram for at least the past month which hasincluded the use of a n appropriate group 1 supportsurface.

3. The ulcers have worsened or remained the sameover the past month.

4. Large or multiple stage III or IV pressureulcer(s) on the trunk or pelvis

5. Recent myocutaneous flap or skin graft for apressure ulcer on the trunk or pelvis (surgery withinthe past 60 days)

6. the patient has been on a group 2 or 3 supportsurface immediately prior to a recent discharge froma hospital or nursing facility (discharge within thepast 30 days).

Group 3 (air-fluidized bed) ALL of following

1. stage III (full thickness tissue loss) or stage IV(deep tissue destruction) pressure sore.

2. bedridden or chair bound as a result of severelylimited mobility.

3. in absence of an air-fluidized bed, the patientwould require institutionalization.

4. the air-fluidized bed is ordered in writing by thepatient’s attending physician based upon acomprehensive assessment and evaluation of thepatient after conservative treatment has been triedwithout success. Treatment should generally include:

a. education of patient and caregiver on theprevention and/or management of pressure ulcers.

b. Assessment by physician, nurse, or otherlicensed healthcare practitioner at least weekly;

c. appropriate turning & positioning.

d. Use of a group 2 support surface, if appropriate;


e. appropriate wound care.

f. appropriate management of moisture/incontinence;

g. Nutritional assessment and interventionconsistent with the overall plan of care.

The patient must generally have been on theconservative treatment program for at least onemonth prior to use of the air fluidized bed withworsening or no improvement of the ulcer. Theevaluation generally must be performed within aweek prior to initiation of therapy with the airfluidized bed.

5. A trained adult caregiver is available to assist thepatient with activities of daily living, fluid balance,dry skin care, repositioning, recognition andmanagement of altered mental status, dietary needs,prescribed treatments, and management and supportof the air-fluidized bed system and its problems sucha leakage.

6. A physician directs the home treatment regimen,and reevaluates and recertifies the need for the airfluidized bed on a monthly basis.

7. All other alternative equipment has beenconsidered and ruled out.

As in all cases there must be documentation inpatient files for Medical Necessity related to supportsurface ordered.


Application of Research Findings intoClinical Practice

Rosemarie Cooper, MPT; Shirley Fitzgerald, PhD

Clinical research has a direct impact on clinicalpractice. This lecture will introduce five of theseveral research studies conducted at the HumanEngineering Research Laboratories (HERL) and willshare with the audience on how the research resultshave and can influence the clinical wheelchairprescription and provision process.

Study 1:Evaluation of the a Pushrim Activated PowerAssisted Wheelchair

The purpose of this study was to evaluate theYamaha JWII electric-powered, add-on unit for amanual wheelchair. The Yamaha JWII is designedto reduce user-applied force needed to propel thechair by supplying additional torque proportional tothe user-applied force. The potential long-termsignificance will be to reduce the incidence of upperextremity injury and resulting pain, loss of functionand dependency in manual wheelchair users. It wasfound that the JWII decreased metabolic cost whencompared to a standard manual wheelchair at thesame workload. Both ergonomic and comfortmeasures were significantly higher for the JWII.Subjects were very satisfied with the ease andstability.

Study 2:The Efficacy of a Variable Compliance Joystick forAccessing the Graphical User Interface of a PersonalComputer

The goal of this research is to determine whether ajoystick equipped with compliance and dampingfeatures will help individuals with cerebral palsyachieve better computer cursor control than otherproportional interfaces.

A research joystick has been constructed which canbe configured to seventeen combinations ofcompliance and damping. One of these settingknown as the Commercial Baseline will beequivalent to most commercially made proportionaljoysticks (no damping and modest return spring)Individuals with cerebral palsy who have upperextremity athetosis or tremor experience significantdifficulties controlling rehabilitation technologysuch as wheelchairs, voice output communicationdevices and personal computers. In some cases, anindividual cannot use a proportional control at alland must instead use a single switch-scanninginterface, which is very tedious and slow. Animproved proportional joystick, which canmechanically filter out unintentional movement,would be beneficial.

Study 3:Effects of Cushion and Back Support DuringWheelchair Ride Comfort

In this study we investigate the change in vibrationand comfort with changes in wheelchair cushion andback support. Although cushion design has beenthoroughly investigated, the focus of theseinvestigations has been pressure sore prevention.How changes in cushion effect vibrationtransmission has not previously been explored.Improvements in back support have been shown toimprove comfort however, a systematic evaluationof these back supports has not occurred.The information gathered in this study will assistcushion back support manufacturers and designers.It also will explore the possibility of reducingsecondary pain through a simple and low-costintervention. Reduced secondary pain andimpairment and will lead to improved quality of lifefor veterans with disabilities.


Study 4:PVA Power Wheelchair comparison studyThis study is intended to provide valuableinformation about the durability, stability, costeffectiveness, and other characteristics of fivedifferent brands of power wheelchairs. Although thesafety and performance records of electric poweredwheelchairs are required for Food and DrugAdministration (FDA) approval of an electricpowered wheelchair, the results of these tests areoften not made available to the public.

Clinicians and wheelchair users can benefit fromthis information by making more informed choicesabout which type of power wheelchair is best suitedfor a particular individual.

Some initial results indicate that there are significantdifferences between the five different types of powerwheelchairs with respect to sections 01, 02, 03, 04,06, and 10. The results obtained from testing thewheelchairs to failure should also producesignificant differences with respect to durability andcost effectiveness. This study may be expanded inthe future to include new types of power wheelchairsand possibly power scooters.

Study 5:Wheelchair Ergonomics and Chronic PainPrevention

In our lab we have developed a device, theSMARTWheel, which is capable of measuring theforces at the rim of MWUs in their own chairs. Thedevice works by instrumenting the support beams ofa wheelchair rim in such a way as to allowmeasurement of torque and force on the rim in 3dimensions. We have successfully integrated thisdata with information on joint movement in aclinical workstation, the AIRWASP, to determinejoint moments and forces. With this detailed 3-Danalysis of wheelchair propulsion, we will attempt tocorrelate joint forces and moments with injury. Thespecific aims of this research are to reduce thefrequency, severity and duration of pain episodes inIWSCI through optimal wheelchair fitting orprovision of a cushioned high-friction push rim andto reduce the normal progression of peripheralpathology which occurs in IWSCI through optimalwheelchair fitting or provision of a cushioned high-friction push rim.

Information gathered in this study may help preventupper extremity injuries in MWUs, maysignificantly change the way wheelchairs aredesigned, and provide the means for implementingprotocols to instruct how individuals are taught topropel wheelchairs.

Speaker Information:Rosemarie Cooper, PTHuman Engineering Research LaboratoriesVA Pittsburgh Healthcare System7180 Highland DrivePittsburgh, PA 15206Phone: 412-365 4850Fax: 412-365 4858e-mail: cooper@ msx.upmc.edu


Chris Bar Research ForumThe motion to be debated is as follows: This House believespressure measurement is irrelevant to the clinical practice ofpreventing and managing pressure ulcers.

Two years ago, at this Symposium, our friend and colleague Chris Bar delivered a paper titled: Ethics ofIgnorance. He challenged us to ensure that practice is based on evidence. And he challenged us to admit that muchof what we practice today is not. He proposed that industry partners join with traditional sources of researchdollars to fund the type of clinical research needed to validate our practices in the field of seating and wheeledmobility. “ A more honest admission of ignorance might mean an increase in funding for research to both developimproved methods of determining the efficacy of products through a combination of standards and clinical trialsand to perform the studies thereafter”.

Chris died suddenly just weeks after the ISS. In honor of his creativity in design and thought, ROHO, Inc hasgenerously funded an annual research forum for the next five years. In the first forum we are trying to capture abit of the roguish nature of the man and join it with a serious research question. We will follow the style of theBritish Parliamentary-style debate with colleagues debating two sides of a research question. It should beenlightening and humorous. Chris would have enjoyed this session.

Participation in the debate is encouraged

Sponsored by ROHO, Inc.

Chair: Geoff Bardsley, PhD

Participants::David Brienza, PhDMartin Ferguson-Pell, PhDRobert GraebeBarbara Levy, PT, ATPSteven Sprigle, PhD, PTGeoff Taylor


TEACHING CLINICALRATIONALE FOR SEATING ANDWHEELED MOBILITYPRESCRIPTION: A RANDOMIZEDCONTROLLED TRIAL OF FOURINSTRUCTIONAL METHODSLaura J. Cohen PT, ATP; Shirley Fitzgerald, PhD; ElaineTrefler, MEd, OTR/L, FAOTA, ATP; Michael Boninger, MDVA Human Engineering and Research Laboratory, Universityof PittsburghDepartment of Rehabilitation Science and Technology, Schoolof Health and Rehabilitation Science, University of Pittsburgh

ABSTRACT:The appropriateness of a consumer’s seating andwheeled mobility system varies considerablydepending on the competence, proficiency andexperience of the professionals assisting the user [1-3]. The purpose of this study was to compare theeffectiveness of four educational interventions (selfstudy, workshop, internship or combination) todetermine which one is most effective in elevatingthe knowledge of entry-level physical andoccupational therapy clinicians. Results showed nosignificant change in pre/posttest score inrelationship to the type of intervention (p= 0.488).However, total hours of training compared to thechange in pre/posttest score were found to besignificant (p= .047).

BACKGROUND:The competence, proficiency and experience oftherapy professionals evaluating and prescribingwheelchairs and seating systems vary considerably[1-3]. A well-fitted seating and wheeled mobilitysystem promotes a more functional posture,

enhancing independent mobility, improving comfortand decreasing the risk of pressure sores andpostural deformity [1-5]. However, the availabilityof physical therapists (PT’s) and occupationaltherapists (OT’s) experienced and or speciallytrained to provide seating and wheeled mobilityprescription is limited [3, 6]. Many feel that targetedprofessional training will maximize the consumer/technology match [6]. A review of the literature hasnot revealed any research about the most effectivemeans to increase the level of competence andproficiency for professionals in the area of seatingand wheeled mobility prescription.

In the United States, the prevalence of persons withmobility impairments is increasing due to decreasingmortality rates. [7, 8] These trends result fromadvances in medical science and technology,increased survival rates at birth, increased lifeexpectancy, and aging of the U.S. population [8].The demand for assistive technology devices andservices is anticipated to continue to increase; theavailability of skilled service providers will not meet


this demand unless training opportunities aredeveloped to increase the supply of skilled ATpractitioners [6].

Individuals with mobility impairments have the mostpotential for success when there is a suitable matchbetween their needs and the equipment features [9]of the seating and mobility technology that they use.Failure to understand the factors involved inprescribing an appropriate wheelchair and seatingsystem may result in “technology abandonment,wasting of funding to replace poorly prescribedequipment, and the consumer being without neededequipment for longer duration.” [10, 11] Providingeffective educational programs to elevate the levelof competency and proficiency by whichprofessionals prescribe wheelchairs and seatingsystems will diminish such negative outcomes.

Health care professions can take measures topromote and protect the health, safety and welfare ofthe public by identifying specific competencies todelineate technology-related knowledge and skillsfor AT practitioners across the areas and levels ofpractice. [12-15] For example, in 1996, RESNA,The Rehabilitation Engineering and AssistiveTechnology Society of North America, instituted acredentialing program for Assistive TechnologyPractitioners (ATP’s) and Assistive TechnologySuppliers (ATP’s) to identify practitioners andsuppliers who have demonstrated a minimal level ofcompetence[16]. Entry-level PT and OT cliniciansshould be able to identify basic assistivetechnologies in their practice and be knowledgeableabout the many factors that are involved in obtainingappropriate assistive technology including seatingand mobility systems as well as recognize theimportance of referral to experts. This trainingshould be provided through their entry-leveleducation. Clinicians who desire to specialize in ATservice provision beyond entry-level need to pursueadditional advanced level technology competencies[12] through continued professional developmentand credentialing.

Presently, the most widely accepted means toparticipate in upgrading professional competence isparticipation in continuing education activities.However, the literature suggests that this does notguarantee competence throughout a person’s careerand there is sparse data to support the effectivenessof continuing education units (CEU’s) in changingtherapist behavior and influencing patient outcomes.[17, 18] Surprisingly, few studies have examined

whether education for practicing professionalschanges clinical behavior or patient outcome in anyarea of medical practice. [19] Systematic reviews ofliterature provide the best evidence on theeffectiveness of various educational interventions.The choice of an intervention should be guided bythe evidence on its effectiveness [20], however“without effective methods to translate importantfindings into changes in clinical practice, potentialbenefits for patients will not be realized and researchresources on clinical interventions will not beoptimized.” [21] The purpose of this study was todetermine which educational intervention (self studymaterials, workshop, internship or combination)would best elevate the level of expertise of theentry-level clinician, in the prescription of seatingand wheeled mobility systems. The results can helpguide the future training of assistive technology(AT) professionals.

METHODS:Second year masters and senior level bachelors PTand OT students from three universities were invitedto participate in this study to receive supplementalspecialized training for prescribing wheelchairs andseating systems. 37 students volunteered and 20students were randomly selected (10 each PT andOT). The students were randomized into one of fourtraining groups utilizing a stratified randomizationprocess to equally distribute PT and OT studentswith equal representation from the three universities.The training groups were as follows: 1) self study(written materials and videos, approximately 15hours to complete); 2) self study and attendance inan eight-hour workshop; 3) self study, attendance inan eight-hour workshop and two days of small groupobservation in a wheelchair service deliveryprogram; and 4) self study and two days of smallgroup observation in a wheelchair service deliveryprogram. All subjects gave written informed consentprior to participating.

All subjects received an extensive self-studyprogram consisting of a videotape [22, 23], twobooks [4, 24] and a training manual. The trainingmanual consisted of a compilation of book sections[5, 25], decision matrix [26], and a sampleevaluation form. The subjects were provided withlearning objectives, directions, assignments andexercises to work through the self-study program. Itwas estimated to take 15 hours to complete the self-study program.


The 8-hour workshop included presentations in matevaluation, common seating problems, equipmentfeatures (seats, backs, manual and powerwheelchairs), and funding. The workshop includedparticipatory lab sessions for the mat assessment andmeasurement section and case studies and problemsolving.

The subjects assigned to the clinical internshipgroup participated in a small group (4-6 students)orientation and observation in the Center forAssistive Technology seating clinic. The subjectswere oriented to the clinic procedures, provided withclinic evaluation and intake forms, and sampleguidelines for preparing an AT evaluation report.The small group was split up into subgroups andassigned to a clinical instructor. Clinic evaluationsand fittings were observed over a two-day period.The subjects were given an assignment to completea client evaluation and intake form and prepare anAT evaluation report. The students were providedfeedback on their report on the second internshipday.

A pretest was administered prior to subject groupassignment. The pretest consisted of viewing avideotaped seating and wheeled mobility evaluationand completing an assessment form. The subjectswere asked to identify the problems, goals, andrecommendations for the client presented [1, 25, 27].Upon completion of the study intervention, thesubjects completed a posttest utilizing the sameprocedure.

The following pretest/posttest grading system wasdeveloped. A list of common seating and mobilityproblems, goals and equipment features was createdby polling a group of “expert” clinicians. This listwas used as a checklist to transfer the data from thesubjects test sheets. The checklist sheet was thencompared to a “gold standard” answer key ofpotential “correct” answers for each client example,created by two expert clinicians. A score for eachsubject was tallied to include a total for all correct,incorrect and missing responses.

The scoring system was tested for interrater andintrarater reliability and was highly correlated (r2 >0.70) with p<0.05. Two independent scorers blindedto group assignment graded all pretests andposttests. Significance level was set at 0.05. Pre andposttest scores were first compared using a paired t-test. Then, change scores were created bysubtracting posttest scores from pretest scores.

Analysis of variance (ANOVA) was used todetermine if any significant differences existedbetween the four groups and the change scores. Todetermine if there was a relationship between hoursspent in study versus change in score, correlationswere completed.

RESULTS:The twenty subjects had a median age of 24.5 with arange from 22-48 years. 85% of the subjects werefemale and 15% were male. There was no significantdifference between groups with respect to age,gender, discipline and university.Since the interrater scores were highly correlated theaverage of the two scorers was calculated and usedto determine the difference between the pre andposttests resulting in a change in the grand total(cgt). The results showed no significant difference(p= 0.488) in cgt between training groups.The total number of hours of training wassignificantly related to change in test score(r2=0.612). As the number of hours increases thechange in correct grand total score between the preand posttest is improved. Hours of training weresignificant (p= 0.047) between the four groups, withgroup three having the highest average of hours(24.6 ( 4.8).


DISCUSSION:This study examined the relationship between thetype of educational intervention and the wheelchairseating and mobility prescription of entry-level PTand OT clinicians. The quality of the prescriptionwas calculated by taking the difference between thepre and post-tests scores of two sample patientevaluations.Results from this pilot study suggest that the type ofintervention may not be as influential on impactingthe quality of wheelchair seating and mobilityprescription as the total hours of education. Theseresults should be interpreted cautiously as the lengthof each educational intervention (weeks for selfstudy, hours of workshop, and length of internship)may not have been adequate to demonstrate adifference between interventions and the sample sizewas small. The development of a scoring system tointerpret the pre/posttest scores was found tocorrelate for two independent scorers. In the futurethis scoring system may be applicable to otherstudies testing educational interventions related toassistive technology.Future studies will be needed to determine if in facteducational interventions impact on the quality ofwheelchair seating and mobility services to theconsumer.

REFERENCES:1. Bergen, A.F., J. Presperin, and T. Tallman,Positioning for function: Wheelchairs and otherassistive technologies. 1990, Valahalla, NY: ValhallaRehabilitation Publications, Ltd. 387.2. Trefler, E., et al., Seating and mobility forpersons with physical disabilities. 1993, Tucson, AZ:Therapy Skill Builders. 293.3. Herman, J.H. and M.L. Lange, Seating andpositioning to manage spasticity after brain injury.NeuroRehabilitation, 1999. 12: p. 105-117.4. Zollars, J.A., Special seating: An illustratedguide. 1996, Minneapolis, MN: OttobockOrthopedic Industry, Inc.5. Trefler, E., Unit 8: Assistive technologyapplications, in Assistive technology trainingprogram for rehabilitation technology professionals,E. Trefler, Editor. 1998, University of Pittsburgh:Pittsburgh, PA. p. 8.1-8.74.6. Fifield, M.G. and M.B. Fifield, Education andtraining individuals involved in delivery of assistivetechnology devices. Technology and Disability,1997. 6: p. 77-88.7. Field, D., Powered mobility: A literature reviewillustrating the importance of a multifacetedapproach. Assistive Technology, 1999. 11(1): p. 20-33.8. Jones, M.L. and J.A. Sanford, People withMobility Impairments in the United States Today anin 2010. Assistive Technology, 1996. 8(1): p. 43-53.9. Batavia, A.I. and G.S. Hammer, Toward thedevelopment of consumer-based criteria for theevaluation of assistive devices. Journal ofRehabilitation Research and Development, 1990.27(4): p. 425-436.10. Cooper, R.A., E. Trefler, and D.A. Hobson,Wheelchairs and seating: Issues and practice.Technology and Disability, 1996. 5: p. 3-16.11. Angelo, J., et al., Brief or new: Identifying bestpractice in the occupational therapy assistivetechnology evaluation: An analysis of three focusgroups. The American Journal of OccupationalTherapy, 1997. 51(10): p. 916-920.12. Hammel, J. and J. Angelo, Technologycompetencies for occupational therapy practitioners.Assistive Technology, 1996. 8(1): p. 34-42.13. RESNA, RESNA guidelines for knowledge andskills for provision of assistive technology productsand services, . 1996, RESNA: Arlington, VA. p. 1-26.14. RESNA, RESNA guidelines for knowledge &skills for provision of specialty technology: seatingand mobility, . 1997, RESNA: Arlington, VA. p. 1-69.


15. Lenker, J.A., Professional education programs inrehabilitation engineering and assistive technology.Technology and Disability, 1998. 9: p. 37-48.16. RESNA, Candidates information bulletin, 5thedition, . 2000, RESNA.17. Grossman, J., Continuing competence in thehealth professions. The American Journal ofOccupational Therapy, 1998. 52(9): p. 709-715.18. Davis, D.A., et al., Evidence for theeffectiveness of CME: a review of 50 randomizedcontrolled trials. Journal of the American MedicalAssociation, 1992. 268: p. 1111-1117.19. Davis, D., et al., Impact of formal continuingmedical education: do conferences, workshops,rounds, and other traditional continuing educationactivities change physician behavior or health careoutcomes? The Journal of the American MedicalAssociation, 1999. 282(9): p. 867-874.20. Bero, L.A., et al., Getting research findings intopractice: closing the gap between research andpractice: an overview of systemic reviews ofinterventions to promote the implementation ofresearch findings. British Medical Journal, 1998.317(7156): p. 465-468.21. Freemantle, N., et al., Printed educationalmaterials: effects on professional practice and healthcare outcomes. The Cochrane Library, 2000(2).22. Trefler, E., Jamie Takes Control, . 1998,University of Pittsburgh: Pittsburgh, PA.23. Minkel, J., Funding Assistive Technology;Assessment, 1994, RESNA Press: Arlington, VA.24. Medhat, M.A. and D.A. Hobson, Standardizationof terminology and descriptive methods forspecialized seating: A reference manual. 1992,Arlington, VA: RESNA Press.25. Taylor, S.J. and D. Kreutz, Powered and manualwheelchair mobility, in Assistive technology forrehabilitation therapists, J. Angelo, Editor. 1997,F.A. Davis Company: Philadelphia. p. 117-158.26. The TRAID Project NYS Office of Advocate forPersons with Disabilities and New York StateDepartment of Health’s Bureau of Child &Adolescent Health, Draft State of New York Seating,Positioning and Wheeled Mobility Guidelines, .1999: Albany, NY.27. Herman, J.H., Therapeutic Seating and MobilityEvaluation Form, in Volume II: RESNA resourceguide for assistive technology outcomes: assessmentinstruments, tools, & checklists from the field, L.Vitaliti, Editor. 1996, RESNA: Arlington, VA. p. 90-107.

FUNDING ACKNOWLEDGEMENTS:The VA Center for Excellence for Wheelchair andRelated Technology, F2181C

CONTACT:Laura J. Cohen PT, ATP, Human EngineeringResearch LaboratoriesVA Pittsburgh Healthcare System 151R-1, 7180Highland DrivePittsburgh, PA 15206412-365-4850, [email protected] seating and wheeled mobility prescription


Quantification of Forces Associatedwith Full Body Extensor Thrust inChildrenDalthea Brown, MS, PT, ATP; Andrew P. Zeltwanger, B.S.;Gina Bertocci, Ph.D., P.E.

ABSTRACTWheelchair users with muscle spasticity manifestingin extensor thrust events are at risk for injury anddamage to their seating system. To reduce theserisks, a dynamic seating system that adjusts to allowdynamic movement throughout an extensor thrustevent, while still supporting the patient, has beenproposed. This study was designed to investigatethe characteristics of episodic extensor spasticity interms of peak seatback force and force-time history.The goal of this study was to input the force-timehistory into a computer model of a dynamic seatingsystem. This information is needed to guide thedesign of dynamic wheelchair seating systems.

BACKGROUNDChildren with Cerebral Palsy with abnormal muscletone presenting as full body extensor spasticity haveunique challenges in maintaining a functional seatedposture in their wheelchairs. The strong, persistentand often sudden increase in extensor tone has thepotential to result in abnormal posturing andthrusting out of the desired position.

Effects such as 1) loss of optimal body alignmentresulting in the need to be repositioned; 2)discomfort to the sitter; 3) bruising of body partsfrom broken or poorly fitting components; and 4)equipment breakage have been observed to occurafter intermittent extension episodes.

The concern of seating specialists is to attain andmaintain the client’s seated posture. Extensorthrusting is managed is to prevent the extensionpattern from developing. The control of the pelvisbecomes a crucial factor in this endeavor. Aproperly fitted wheeled mobility device is the firstline of defense. If the pelvis is still able to migrateforward, stabilization is attempted through pelvic

positioning devices, modifying the support surface,the use of lower extremity positioning aides and/ortherapeutic inhibition techniques. For a small few,extensor thrusting continues to interfere with theability to maintain a seated position. Manycaregivers have given in to the apparent need toextend and are utilizing an alternative seating systemthat is more forgiving of the sitters extensionmovements. Seating devices such as the Floorsitterand Carrie Seat by Tumbleforms are the devices ofchoice by some.

Clinicians and manufacturers are beginning tomodify standard wheelchairs on a case-by-case basisusing springs or shock absorbers to permit limitedmovement in the seating system [1,2,3].However, there is currently no documentationexamining movement as a feasible approach forindividuals exhibiting extensor thrusting. Whiletraditional therapeutic principles have dictated thatpreventing movement is the cornerstone fortreatment, some benefit has been seen withindividuals provided with modified chairs allowingsome movement [1,2,3].

RESEARCH QUESTIONOur long-term goal is to study the interaction ofwheelchair users exhibiting extensor thrust anddynamic seating systems. To accomplish this task,an instrumented laboratory dynamic seating systemwill be developed. Computer modeling can aid inthe selection of components and can predict theresponse of the dynamic seating system toindividuals having extensor thrust events whenutilizing the system. This study focused onexamining the force response of extensor thrust in aselect population and the development of a computermodel of dynamic seating.


The goal of this study was to use the computermodel to select the design specifications for theresistive elements that will control the seatback inthe instrumented laboratory system.

METHODTo select appropriate resistive elements to allow

for seat back rotation, clinical data was obtainedfrom individuals with a history of extensor thrustevents. Subjects were seated in their current seatingsystems with a Force Sensing Array (FSA) securedto the seatback (Figure 1). FSA data was collectedas the subjects were exposed to various auditory andvisual stimuli to elicit an extensor thrust. Themagnitude and location of the pressure on theseatback was recorded with the FSA mat throughoutthe duration of testing, which was approximately 30minutes.

The dimensions of a LaBac manual reclinerwheelchair (Figure2) were used to develop thecomputer model (Figure 3) utilizing WorkingModel 3D. The sliding elements and brake systemof the chair were replaced in the model with aspring-damper element, which allowed the seatbackto open as the subject extended against it. Themagnitude and location of the force recorded in theexperimental trials were entered as input to themodel. The values of the spring and dampingconstant were incrementally varied to determine theseat back response. Seatback opening angle,resistive element tension, and resistive elementlength were calculated and displayed (Figure 4) bythe model for each spring-damper combinationtested.

Figure 2 - LaBac Reclining Wheelchair to be modified as a dynamic seating system

RESULTSThere was a minimal reaction of the subjects to threepre-recorded sound burst intended to facilitate full-body extension. Table 1 shows subjectdemographics and the force (lbs) and torque (ft-lbs)each produced. Peak total forces for the groupranged from 18.9 to 236.1lbs. with a mean of 92.3 ±61.5 lbs. Peak torque values were calculated as theproduct of the maximum vertical centers of pressure(COP

v) times the peak force. Peak torque ranged

from 13.9 ft-pounds to 227.0 ft-pounds with a meanof 80.4 ± 58.9 ft-lbs. The COP

v ranged from 7.9

inches to 19.7 inches above level of the seat with amean of 14.6 ± 2.8 inches.


Figure 3 - Rigid-body Dynamic Model Figure 4 - Sample Model Output DescribingResistive Elements and Seatback Response

Table 1 - Subject demographics with peak force and peak torque data


Two key specifications where determined from theuse of the model:

1. The compressed length of the spring element wasdetermined to be 3.5 inches, which limits theseatback-opening angle to 150 deg. from horizontal.This was done to avoid the possibility of increasingextensor muscle activity upon reclining the subjects[4].

2. Spring-damper resistive elements are typicallycharacterized by the force needed for fullcompression or extension. By varying resistivecoefficients within the model, we determined therange of forces the element would be exposed towhile limiting the seatback to a rotation of nogreater than 150 deg. The range of forces was 115to 1200 lbs, depending on the subject.

DISCUSSIONForce and torque values showed tremendousvariability within and between subjects. Themaximum pressure that each sensor of the FSA matcan accurately measure is 200 mmHg, which isapproximately 4.7 pounds per sensor producing aceiling effect for 14 of the 18 subjects; a majorlimiting factor of this study. Over a one-half hourperiod of time, the number of sensors that registeredthis false peak ranged from less than 0.1% to 98%.Of the remaining 4 subjects unaffected by the falseceiling, 2 reached a maximum of 4.6 pounds persensor and 1 each peaked at 4.2 and 3.6 pounds persensor. The number of sensors registering at peakvalues among these 4 subjects ranged from less than0.1% to 0.5%.

Another problem encountered was that the size ofthe mat was larger than the seat back panels of theseating systems. This set-up permitted movement ofthe mat, potentially effecting the location of thecenter of pressure. A third factor to be consideredwas that it was assumed that by using a loud sound,an auditory startle could progress into an extensionevent however, this was not true in many cases. It isbelieved that one possible reason why subjects didnot respond to the stimulus was that it was not loudenough. Koch [5] stated that an auditory startle iselicited at greater than 80 decibel (dB) soundpressure level (SPL). The SPL of the facilitatingstimulus in this study was not measured but therecorded air horn blast is estimated at much less than80 dB.

The use of a computer modeling and simulationprogram allowed a wide variety of design variablesto be investigated without the expense of physicallybuilding and testing each different scenario. Byapplying the model, the spring-damping elementsand torque sensor ranges were specified for the nextphase of development and testing. Resistiveelements and sensors have been purchased andadapted to the LaBac Reclining Wheelchair (Fig. 2)to develop our dynamic seating system. Futurestudies will further define design criteria fordynamic seating systems.

CONCLUSIONThis study illustrates the effectiveness of computersimulation as a tool to model the Human - AssistiveTechnology interface. An instrumented laboratorydynamic seating system is under development to testthe response of wheelchair users who exhibitextensor thrust events to dynamic support in acontrolled setting. The dynamic seating system willbe a modification of a LaBac Manual RecliningWheelchair (Figure 2). The LaBac RecliningWheelchair requires an attendant to release thebrakes unlocking the seatback to move the seatbackfrom an upright to a reclined position, and returnupright. The modifications of the dynamic seatingsystem will remove the need for an outside party andallow the seatback angle to change in response to theuser.

REFERENCES1. Ault, H., Girardi, M., Henry, C. (1997). Designof a Dynamic Seating System for Clients withExtensor Spasticity, Annual RESNA Conference,Pittsburgh, PA, 187-1892. Connor, P. (1997). A Bit of Freedom for Full-Body Extensor Thrust- A Non-Static PositioningApproach, International Seating Symposium,Pittsburgh, PA, 185-1873. Evans, A.E., Nelson, W.B., (1996). A DynamicSolution to Seating Clients with Fluctuating MuscleTone, Annual RESNA Conference, Salt Lake City,Utah 189-1904. Nwaobi, OM, (1986). Effects of BodyOrientation in Space on Tonic Muscle Activity ofPatients with Cerebral Palsy, DevelopmentalMedicine & Child Neurology, 28, 41-44.5. Koch, M. (1999). “The Neurobiology of Startle”.Progress in Neurobiology, 59:107-128


ACKNOWLEDGEMENTSFunding for this study was provided to theUniversity of Pittsburgh, Rehabilitation EngineeringResearch Center on Wheeled Mobility by theNational Institute on Disability and RehabilitationResearch (NIDRR), US Department of Education,Washington, D.C. (Grant# H133E990001).Opinions expressed in this article are those of theauthors and not NIDRR

Dalthea Brown, MS, PT, ATP; Department ofRehabilitation Science and Technology, Universityof Pittsburgh, Forbes Tower, Suite 5044, Pittsburgh,PA 15260. [email protected]


What Consumers Contribute toWheelchair Selection: The Results of aStudyMary Ellen Buning, MS, OTR/L, ATP

Statement of the problem

The 1.4 million Americans of all ages (Jones &Sanford, 1996) who use manual and poweredmobility devices (Krause, Stoddard, & Gilmartin,1996) rely on mobility devices for independence inthe activities of their every day lives. Consumerswho are full time users of wheelchairs replace theirwheelchairs every 3 to 5 years (Cooper et al., 1997).These numbers lead to a conservative estimate that200,000 wheelchairs are purchased each year. Itfollows that information to support decision-makingin the selection of mobility devices would be neededperiodically by wheelchair users. Each replacementevent is an opportunity to reassess ones mobilityneeds and to reconsider the match between dailyliving realities and a mobility device. It is importantto maximize the outcomes of these events with thebest decision-making strategies and resources. Whilea partnership with an educated and informedassistive technology supplier or provider who canprovide expert advice is optimal, many individualslive in parts of the US where this expertise is lackingor available only at a great distance.

The Internet when used in homes, workplaces and incommunity libraries, etc., is being used to search forand locate information to assist in making informeddecisions. Recently, quality information onwheelchair technology, products and services, andwheelchair selection has also become available onthe Internet (Buning, 2000; Silverman & Bergen,2000). Data collected during routine. A surveycompleted by the Disability Statistics Center (Kaye,2000) suggests that only 25% of people withdisabilities use the Internet. However, the disabilitydefinition used in this survey excluded persons withdisabilities who are employed therefore this estimateseems too conservative. Persons with mobilityimpairments who have achieved educational and

employment goals appear to use the Internet to thesame extent as the general population (Schmalzer,1997). It seems intuitive that a person with amobility impairment, given a computer adapted tomeet his or her input and output needs, mayexperience even greater benefits from Internet usethan a typical user. Travel obstacles are eliminated,bad weather and inaccessible buildingscircumvented, and easy access to formal andinformal education, employment, social interaction,shopping, and entertainment are created.

The interest in and the extent of the participation ofconsumers in the wheelchair selection process arenot currently known nor is there research thatsubstantiates their use of the Internet as a source ofinformation to prepare for decision-making orselection. Following the development of acomprehensive website, WheelchairNet.org, a studywas designed to determine whether consumerreadiness to participate in decision-making could beaffected by use of this comprehensive website.

HypothesisSeveral hypotheses were developed for this study.First, participants in the experimental group withaccess to enhanced WWW resources will haveincreased scores on all study measures on locus ofcontrol, life goals, self-assessed wheeled mobilitydevice knowledge, desire for device characteristics,and readiness to participate in decision-making.Second, national participants are not significantlydifferent from participants in the Pittsburgh areawith its known geography, climate, and range ofrehabilitation and mobility device-related services.Third, consumers will rate WheelchairNet as ahelpful source of information.


MethodSeveral instruments were developed for the study. Ademographic questionnaire was developed to collectdata on participant’s education, years of wheelchairuse, prior wheelchair selection experience,accessibility of living environments, attitudes andadaptive behaviors. Additionally, three other surveyswere developed to the measure variables assumed toinfluence consumer participation in wheelchairdecision-making, i.e., clarity of personal goals,attitude toward decision-making and knowledgeabout wheelchairs. Validity and reliability of theseinstruments was assessed and reported (Buning, Inreview). Additionally, the Multidimensional HealthLocus of Control (Wallston & Wallston, 1978) wasused to assess attitudes of personal responsibility forhealth in the population sampled.

The study sample was comprised of Internet-using,community living persons 18 and older with staticimpairments that required them to use wheelchairsas a primary means of mobility. In order to use thenatural motivation of participants it was requiredthat their current wheelchair be older than threeyears. To control the influence of other sources ofinformation pertaining to wheelchair selection theywere also required to have not begun any actionsrelated to replacing this wheelchair. Participantswere required to use the WWW weekly andregularly communicate through email. Recruitmentoccurred by means of notices on electronic bulletinboards, listserves, and “electronic” word of mouthfrom informal networks of professionals andconsumers. All recruitment notices guided potentialparticipants to a study website containing completeinformation about the study and downloadable studydocuments. Those who were interested and felt theyqualified to participate supplied contact informationto the investigator through a form on the website. Atelephone interview ensued to guarantee thatparticipants were eligible and understood studyexpectations. Additionally, participants were askedto substantiate their wheelchair use by giving theirpermission for the investigator to contact their healthcare provider and obtain signed verification.Following receipt of the signed consent form(downloaded from the website), participants wererandomized to experimental or control groups.

All questionnaires were completed on the studywebsite using Lasso as an interactive interface witha FileMaker Pro 5 database designed to capturesurvey responses. Most communication withparticipants was by personalized email messages

automatically generated to advise them about studyphases completed and their next actions. Followingcompletion of the pretest questionnaires, participantsrandomized to the experimental group were givenaccess to a clone of WheelchairNet. Through use ofa login ID and password each of their visits and theiractivities during each visit to this site were recorded.

The control group after completing the pretest wasasked to use the Internet in usual ways withoutpurposely researching wheelchair-related topics.They were promised complete access to aninformation-rich website following their completionof posttest questionnaires. Both experimental andcontrol groups were given the post-test 6 weeks afterpretest completion.

A sample size of 70 was identified as sufficient todetermine a medium effect size with statisticalpower of .80 (Cohen, 1988). Efforts were made torecruit equivalent sized samples of participants fromboth the Pittsburgh area with its known geography,climate, and range of rehabilitation and mobilitydevice-related services and from all other regions ofthe United States. In reality it was very difficult torecruit participants in this region. Only 20participants from this region were recruited andrandomized.

AnalysisA full descriptive analysis of the data contained inthe demographic questionnaire will be used to fullyunderstand the sample’s history with wheelchairselection and their satisfaction with currentwheelchair and the selection process used to obtainit. Additionally, their attitudes toward theirimpairment, accessibility, and their expectations fortheir wheelchair’s performance will also be studied.

An analysis of covariance, using the pretest as thecovariate, will be used to compare the performanceof experimental and control groups on the three ofthe questionnaires administered pre and post. A chi-square analysis will determine if the access toinformation and interactions on WheelchairNetsignificantly affected consumer knowledge andconfidence related to the decision-making process. Aqualitative analysis of participant’s life goals will becompleted using NUD*IST (Richards, 1998) toidentify common mobility goals and daily livingthemes.


Anticipated results and discussionSince the period of data collection was extended,actual results from the study were not available forpublication in these proceedings. This informationwill be provided at the time of the presentation and,following the conference, formal results regardingthe impact of WheelchairNet on ConsumerDecision-Making will be published in peer reviewedjournals.

References:

Buning, M. E. (2000, February 24-26).WheelchairNet.org- A virtual community of peoplewho care about wheelchairs. Paper presented at theSixteenth International Seating Symposium,Vancouver, BC.

Buning, M. E. (In review, June 2001). Thedevelopment of validity and test-retest reliability formeasuring of the effect of WheelchairNet onwheelchair decision-making by consumers. Paper tobe presented at the 2001 Annual RESNAConference, Reno, NV.

Cohen, J. (1988). Statistical power analysis for thebehavioral sciences (3rd Ed.). New York: AcademicPress.

Cooper, R. A., Gonzalez, J., Lawrence, B.,Rentschler, A., Boninger, M. L., & VanSickle, D. P.(1997). Performance of selected lightweightwheelchairs on ANSI/RESNA tests. Archives ofPhysical Medicine and Rehabilitation, 78(10), 1138-1144.

Jones, M. L., & Sanford, J. A. (1996). People withmobility impairments in the United States today andin 2010. Assistive Technology, 8(1), 43-53.

Kaye, H. S. (2000). Computer and Internet UseAmong People with Disabilities (Disability StatisticsReport 13). San Francisco, CA: Disability StatisticsCenter, U.S. Department of Education, NationalInstitute on Disability and Rehabilitation Research(NIDRR).

Krause, L. E., Stoddard, S., & Gilmartin, D. (1996).Chartbook on disability in the United States, 1996.An InfoUse report. Washington, D.C.: NationalInstitute on Disability and Rehabilitation Research.

Richards, T. (1998). NUD*IST (Non-numericalunstructured data indexing searching and theorizing)Ver.4 . Melbourne, Australia: Qualitative Solutionsand Research Proprietary Ltd.,.

Schmalzer, S. (1997). Access to the world wide webfor people with disabilities. Point of Departure,Newsletter of The Technical Assistance aboutTransition and Rehabilitation Act Project, 3(1).

Silverman, M., & Bergen, A. F. (2000, February 24-26). RehabCentral.com. Paper presented at theSixteenth International Seating Symposium,Vancouver, BC.

Wallston, B. S., & Wallston, K. A. (1978). Locus ofcontrol and health: A review of the literature. HealthEducation Monographs, 6(2), 107-116.


Back Support Options: FunctionalOutcomes in SCILaura May PhD, Carla Butt BSc PT, Karen Kolbinson BScPT, Linda Minor BSc PT.

Introduction & Rationale: For the person withspinal cord injury (SCI), the wheelchair and seatingsystem provide mobility, pressure relief, posturalsupport and comfort. Part of this system, the backsupport, influences sitting comfort, posturalalignment, buttock pressure and functional abilities.For portability, the standard sling back upholsteryhas been the choice of most wheelchairmanufacturers however, there are distinctdisadvantages. The material stretches, there islimited adjustability of the back, and this oftenresults in a postural position that is less thanoptimal. In addition to these static components, thenature of the seat and back can affect the wheelchairuser’s ability to propel themselves on variedsurfaces, up and down inclines and over obstaclessuch as curbs. Alternatives to the upholstered slingback include the Jay• J2 back and thePinDot•PaxBac™. Despite a lack of publishedscientific evidence, manufacturers of these seatingoptions claim multiple benefits such as protectionagainst spinal deformities, pressure sores anddiscomfort as well as improved function andappearance. Because of the cost of wheelchaircomponents, clinicians and their clients need tomake informed choices when selecting the mostappropriate wheelchair and seating options.

Purpose: The purpose of this study is to compare,from a clinical perspective, the functional outcomesfor individuals with a recent spinal cord injury whenusing a wheelchair with the traditional sling backand the manufactured J2 and PaxBac™ backsupports.

Subjects and Methods: A total of 28 individualswith a SCI less than 2 years duration who use awheelchair as their primary method of mobility. Todate, 21 individuals have completed the studyevaluations. In this patient as their own controldesign, a randomized crossover method is used todetermine the order of testing of the back supportalternatives. To determine adjustments and increasefamiliarity the participants undergo a “trial” periodof one to three days prior to testing. Four functionalactivities are then evaluated: timed forwardwheeling, measurement of maximum forwardvertical reach, timed ramp ascent, and maximumdistance in one push on a carpeted surface. As theseassessments were designed for this study, test-retestand inter-rater reliability was determined prior tocommencement of the study (r = .99). As anadditional outcome, participants answer asatisfaction questionnaire to assess comfort,appearance, ease of use, and overall function aftercompleting the tests with all three back supportalternatives. The total possible score is 20.

Results: The 21 participants, all with a level ofinjury above T10 (14 cervical, 7 thoracic), range inage from 17 to 71 years (mean = 30.3). The timesince injury ranges from 1 month to 13 months(mean = 3 months). The J2 facilitates the furthestreach when compared to the sling upholstery (p <.05). The PaxBac also promotes further reach thanthe sling upholstery but the results are notstatistically significant. The differences between theback supports for the ramp ascent activity approachsignificance (p = .06) with the fastest timeassociated with use of sling upholstery. The resultsfor the timed forward wheeling and the push oncarpet activities are not statistically significant andthe descriptive scores are essentially the same. Thesatisfaction questionnaire results indicate there is anoverall preference for the J2 (p < .05). Theindividual item analysis for the questionnaire shows


that the J2 has significantly higher scores for theitems relating to comfort and appearance (p < .01).Although not statistically significant, the J2 alsoscored higher for overall function and the slingupholstery scored highest for ease of use.Interestingly, more of the participants would chosethe J2, even if they were required to pay for it ontheir own.

Conclusions: The increased lumbar support andenhanced anterior pelvic tilt provided by the J2 andPaxBac appears to facilitate forward reaching. Itseems that the positioning facilitated by the backsupports does not affect the ability to perform timedforward wheeling. It is unclear how positioningaffects the strength test of the one stroke push sincethe participants demonstrated almost identicalperformance regardless of back support used. If thepositioning is the key element, it would be expectedthat the J2 and PaxBac would provide similarresults. The fastest times for ramp ascent when usingthe sling upholstery may be indicative of a “wraparound” effect providing security for the participantswhile performing this activity. It is unlikely thatpractice effects significantly influenced the resultssince the order of back support use was random. Asindicated by both the objective scores and thesubjective comments, the preference for the J2reflects satisfaction with comfort as well as a feelingof support and security. As we continue to collectdata until the final sample size is achieved andpower is improved, we expect that we may findsome other significant results. However, this studydoes provide information on clinically feasible teststhat may help the equipment decision process.

Laura May PhD, University of Alberta, Department

of Physical Therapy, Faculty of Rehabilitation

Medicine; Carla Butt BSc PT, Karen Kolbinson BSc

PT, Linda Minor BSc PT. Glenrose Rehabilitation

Hospital, Department of Physical Therapy


A Study On The Relationship BetweenButtock-Seat Cushion InterfacePressure And Pressure Ulcer IncidenceIn At-Risk Elderly Wheelchair Users

David M. Brienza‡, Patricia E. Karg‡, Mary Jo Geyer‡,Sheryl Kelsey†, and Elaine Trefler‡

Although interface pressure is the most commonparameter used for comparing support surfaceperformance, the relationship between interfacepressure and pressure ulcer (PU) incidence has notbeen adequately studied. As a secondary analysis ofdata from a randomized clincal trial, we studie therelationship between interface pressuremeasurements and pressure ulcer incidence.

Thirty-two subjects (male and female) wererecruited from two skilled nursing facilities. Criteriafor inclusion were: 65 years of age or older; BradenScore of 18 or less with a combined activity/mobility sub-scale score of 5 or less; a mobilityimpairment requiring the use of a wheelchair for 6or more hours per day; free of existing sitting-surface pressure ulcers; and could be accommodatedby the study wheelchair, including a body weight of250 pounds or less.

Subjects were randomized into generic Foam orpressure-reducing (PRC) seat cushion groups. Allsubjects received a seating assessment, including anindividually prescribed, highly adjustablewheelchair. Re-assessments and modifications weremade to the seating systems as needed throughoutthe study. The subjects assigned to the Foam groupreceived a generic, three-inch, convoluted foamcushion fitted with an incontinence cover and solidseat insert. The subjects assigned to the PRC groupreceived a cushion based on individual seating needsand interface pressure mapping. The pressure-reducing cushions were commercial cushions

designed specifically to improve tissue tolerance insitting by providing more surface area and/orreducing peak pressures over bony prominences ofthe sitting surface. If the pressure-reducing cushiondid not include a solid seat insert of incontinencecover, they were provided.

Weekly skin and risk assessments were performedby research staff simultaneously with the completionof the Braden Scale from the time of enrollment inthe study until the subject reached an endpointdefined as: first incidence of a pressure ulcer,discharge from the facility, voluntary withdrawalfrom the study, death or study end-date. TheNational Pressure Ulcer Advisory Panel definition ofa pressure ulcer and skin reaction classificationsystem were used. Lesions occurring on any aspectof the sitting surface, not just over bonyprominences, were documented as sitting-acquiredpressure ulcers. Exceptions to the required six-hoursitting time were documented weekly. Interfacepressures were recorded for all subjects during theinitial seating assessment, after a one-week re-assessment and as needed following modifications tothe seating system.

Of the 32 subjects that were eligible for the study, 17were randomized to standard foam cushions and 15were randomized to pressure-reducing cushions.Excluding death, discharge and transfer, there were14 and 11 in the Foam and PRC groups,respectively, who reached the endpoints of either apressure ulcer or end of the study period. No


significant differences were found between thegroups for the primary outcomes of pressure ulcerincidence, initial peak interface pressure and totaldays to endpoint (with or without inclusion of deathand discharge/transfers). Failure to reach statisticalsignificance was expected due to the small samplesize and low statistical power (0.21) of the pilotstudy.

Significant differences were found between thegroups for sitting-time variances (p<0.05). TheFoam group failed to meet the required minimumsitting-time of six hours per day more frequentlythan the PRC group. Additionally, the clinicaldetermination of postural asymmetries (p<.001) andpeak interface pressure measurement (p<.05) wereboth significantly more predictive of pressure ulcersite for the Foam group than for the PRC group;indicating the inability of the foam cushions tosupport or reduce deformities. A significantdifference also existed between the groups in termsof pressure ulcer location (p<.005). No ischialulcers occurred in the PRC group; indicating thatpressure-reducing cushions were more effective inpreventing these ulcers. Ischial ulcers areconsidered to be the primary sitting-acquired ulcers.No difference was found between the groups for theratio of total days subjects were rated as at-risk (<18Braden Score) to total study days.

Pressure ulcers developed in 16 of 32 subjects in thisstudy. This rate exceeded our expectations based onmore recent estimates of sitting-acquired pressureulcers. The incidence of pressure ulcers in the Foamgroup was 10/17 (59%). Three hundred subjects(150 per group) is the approximate sample size thatwould be needed in the multi-center study using thesame broad definition of a sitting-acquired pressureulcer as used in the pilot study. The broad definitionwas used to prevent the loss of clinically relevantdata necessary to project an adequate sample size forthe full-scale clinical trial. However, since ourresults indicated appropriate use of more restrictivedefinitions of “sitting-acquired pressure ulcers” suchas 1) exclusion of all shear injuries or 2) exclusionof all shear and non-ischial lesions, we would expectto have lower incidence rates. Using the mostrestrictive definition, a sample size of 100-200 (50to 100 per group) may be projected.

Data analyses of the pressure ulcer and no pressureulcer groups were also performed. Interfacepressure measured on wheelchair seat cushions washigher (p≤0.01 for both peak pressure and averageof highest four pressures) for patients whodeveloped pressure ulcers. Therefore, higherinterface pressures were associated with a higherincidence of pressure ulcers in this study;supporting the use of pressure measurements as anaid in determining pressure ulcer risk. Nosignificant group differences (p>0.05) weredemonstrated for initial Braden Scores, sitting-timevariances, or ratios of days at-risk to total days.


Function and Performance of theRocket Multi-directional PoweredWheelchairGeoff Fernie PhD PEng, Gerry Griggs, Pam Holliday PTMSc, Mauro Pacitto BASc, Phil Wilcox OCAD

IntroductionThe objective of this presentation is to provideinsight into the design process that was used indeveloping the multi-directional powered wheelchairknown as the RocketTM.. Typically, innovativedesign is accomplished by an iterative process. Aneed is identified and some brainstorming processresults in a concept that might be able to meet thatneed. Usually a series of prototypes are builtbeginning with very simple models and workingupward to fully-functioning pre-production units.Each prototype is evaluated against the needs,preferably including exposure to consumers.

The process is characterized by a sequence of partialsuccesses and failures. Inevitably, design decisionsmust be made that involve compromise. Typicalcompromises involve balancing performance againstcost or complexity, or some aspect of performanceagainst another aspect of performance (e.g. indoormanoeuverability versus outdoor performance). Webelieve that there is as much to be learned from thereporting of the ideas that were abandoned as fromthose that were pursued.

Outline of the Presentation1 Need for combination of indoor and outdoor

features2 Discussion of manoeuverability requirement3 Selection of mechanism to achieve multi-

directional movement4 Selection of control algorithm5 Discussion of requirements for outdoor

performance6 Selection of configuration and suspension s

ystem

1 Need for combination of indoor & outdoorfeatures

Early in the project, consumers told us that theywould not be able to afford the cost of two poweredchairs. The option of providing one that wasoptimized solely for indoor use was thereforerejected. In addition to the problem of cost, there isfrequently a significant amount of effort required totransfer between two chairs and the situation wheretravel outdoors is required to reach a different indoordestination could not be met easily with two separatechairs.

2 Discussion of manoeuverability requirement

2.1 Spinning 360° within the smallest possiblediameter circleAccessibility codes specify a 5' diameter turningcircle. Architectural drawings of living and workingenvironments show these 5' circles in each of therooms. If this could be reduced to a 4' diametercircle, then the area of the circle would be reducedby 36%. The most easily understood and leastambiguous method of reporting turning radius is tovisualize placing the wheelchair with its rider insidea cylindrical wall and determining the smallestdiameter of this cylinder that will still allow thechair to rotate through 360°. By this definition, it isclear that in order to achieve the smallest turningradius the chair should spin about the geometriccenter of the chair and rider combination.

2.2 Passing through narrow doorwaysSection 93 of the ANSI/RESNA standard requiresthat wheelchairs that are primarily intended forindoor use should not exceed an overall width of700 mm (approximately 27.5"). The CanadianBarrier-Free Code (CSA-B651-00) states that theminimum clear opening of doorways shall be 810


mm (approximately 32") when the door is open at90°. However, much narrower doorways are oftenencountered in people’s homes, especially to thebathroom

2.3 Lateral approach to objects where a frontalapproach is not possibleFunctional objectives often include getting as closeas possible to targets such as banking machines,sinks, refrigerators, cupboards and wall phoneswhere there is no toe room for a frontal approach. Ifthere is sufficient space, there is no problem sinceany chair can be driven parallel to the surface andpositioned close. However, space is usuallyrestricted and the situation is analogous toattempting to park a car close to the curb betweentwo other cars. Drivers quickly learn that it isnecessary to back into the space. This is ratherawkward but is a manoeuver that is necessary forwheelchairs that have their steering wheels (swivelcastors) at the front. Front wheel drive chairs, withtheir steerable wheels (swivels) at the back, have theadvantage of being able to do this in the forwardsdirections. But all vehicles need to have a spacelonger than the vehicle itself. The smaller the space,then the larger the number of shunting moves thatwill be needed to position close to the curb and thento exit. Since this is such a common situation, it wasdecided that there is a need to be able to movesideways.

2.4 Negotiating tight corners in restrictedpathwaysTwo common errors are made when attempting toexecute a manoeuver around a tight corner in a veryrestricted space. In the first, the approach is tooclose to the inside corner. This is particularly aproblem with rear wheel drive chairs. The situationis reached where there is no room to continueturning without hitting the inside corner. If theapproach is too wide, the chair may not be able toturn sufficiently because the back corner will hit theoutside wall. This is particularly a problem withfront wheel drive chairs. Both problems areexperienced to some degree when driving mid-wheeldrive chairs. A brief sideways movement, away fromthe inside corner or away from the outside wall willresolve this situation.

3 Selection of a Method to Implement Multi-directional Movement

Option 1: One central steerable wheel with outerswivel castorsThis option was rejected because of unstablesteering. Small changes in the resistance of thestabilizing wheels (e.g. contacting an obstruction)cause abrupt changes in steering direction becausethe single wheel has almost only point contact withthe ground and cannot exert a significant steeringmoment to keep the wheelchair on its originalcourse.

Option 2: Three or more steerable wheels (at leasttwo usually being driven)The use of three or more steerable wheels ispotentially a workable solution, but needs someform of hardware or software linkage so that thewheels steer appropriately together. It also,typically, needs a motor to control the steering, inaddition to drive motors. This option was rejectedbecause of a tendency to be more complex andcostly.

Option 3: Compound wheels which can provideboth forward and sideways motionThe various designs of compound wheels tend tohave poor obstacle and soft ground performance.This option was rejected because of the need forcombining indoor manoeuverability with outdoorperformance.

Option 4: Two central driven wheels on a steerableaxis with outer swivel castorsThis option involves mounting the usual pair ofwheelchair drive motors on an axis that is connectedto the body of the wheelchair by a vertical shaft.This shaft can be locked or can be allowed to rotatefreely about a vertical axis. If it is locked, then thechair will behave similarly to any other poweredchair and will steer by varying the speeds of the twomotors. If the vertical shaft is unlocked and isallowed to rotate, then the two motors can be used torotate the drive “tractor” alone instead of spinningthe whole chair. It can then be locked in the newposition and the chair can be driven with steeringalong this new vector. This option was selectedbecause of its simplicity. Only the two drive motorsare required. All that is required is the method oflocking the vertical shaft at the chosen angles.


4 Selection of control algorithm

The first control strategy defined two modes“transition” and “reaching”. When in “reaching”mode, movements of the joystick caused the chair torotate clockwise and anti-clockwise and to raise andlower. When in the “transition” mode, the joystickwould first be moved to its full extent in the desireddirection of travel and then released. The tractorwould move to align with this direction, such thatthe subsequent movement of the joystick wouldcause the chair to move along that axis and to steeras it moved. Various other control strategies wereconsidered, including providing an additional degreeof freedom to the joystick so that twisting the stickwould cause rotation; whereas, displacement of thejoystick would result in vector movements.

Tests with these early prototypes resulted in theobservation that users found it really only necessaryand much easier to just move in the forwards andsideways directions, since all of their maneuverscould be achieved by a combination of these moveswith steering. The most successful strategy wasfound to consist of a mode switch which selectedeither forwards or sideways driving. When theswitch is pressed, the control computer takes overand causes the realignment of the tractor. Usersfound it easier if the axes of the joystick wereautomatically rotated through 900 when the modechanged between forwards and sideways. Thus,when in sideways mode, pushing the joystick to oneside results in straight line movement in thedirection of the joystick. Moving the joystickupwards or downwards causes the chair to steer inthe usual manner to the left and the right to thatvector.

5 Discussion of requirements for outdoorperformanceIn considering what outdoor performance would berequired, the following were addressed:

• Ramps are considered to be the way ofincreasing accessibility to level changes forwheelchair users. North American cities areincreasingly incorporating curb cuts. It wasdetermined that the chair must be capable of rampsof at least 100 and, preferably, 150 with care.

• Curbs. A brief survey was conducted of curbheights in the greater Toronto area. The averagecurb height was found to be 5.3" and the average

distance that would be saved by being able totraverse up or down this curb height would be 72feet with typical timesaving of 15 seconds. Of the100 curbs that were measured, 44% were at or below4.5" and 73% at or below 5.5".

• Stairs or Flights of Outside Steps. Variousattempts have been made to design poweredwheelchairs that will safely and independentlyaccomplish flights of steps. To date, all of themhave been very complex and expensive. The generalview has been that it is easier to avoid stairs.Perhaps that will change in our future design, but thedecision was made not to attempt this task with thisproduct.

• It was decided that the chair should at least beable to travel on soft grass without becoming stuck.The ability to travel through soft sand and mud,although desirable, was determined to be beyond thecurrent design effort.

6 Selection of configuration and suspensionsystemWith two centrally-mounted wheels, it is necessaryto have swivel castors toward the outside to stop thechair tipping forwards, backwards or sideways. Theusual solution has been to place the drive wheelsslightly ahead or behind of the center of gravity andto provide anti-tip wheels that are either slightlyabove the ground or are spring loaded. This tends toproduce “lurching” and a sense of instability. Itwould also be impractical for sideways movement.

The selected strategy was to provide a firmly-attached swivel castor at each corner and to springload the central vertical shaft of the tractor, so that itcould rise above and fall below the level of thecastors maintaining continuous contact with theground. A spline allowed this to happen whilstmaintaining control of the angular orientation. Theadvantages of this system are stability for transfersand a very secure feeling. The disadvantages are thecost of the spline and the adverse effects of thedownward compression force on stability.


Most powered wheelchairs use two 12 volt batteries,but it was not possible to achieve the energy storagethat we required (equivalent to two group 24batteries) within the constraints of the chair. Theproblem was solved by using four smaller U1batteries. This provided the advantages of verycompact design, energy equivalent to a pair of U 24sand minimal additional cost. It also offers the futurepotential advantages of a 48 volt supply.

Note: The Rocket design is protected by patentsissued and pending.


The Psychometric Properties of theSeating Identification Tool (SIT)William C Miller, PhD, OT; Francine Miller, BScOT,Karen Trenholm, BScPT; Kris Goodman, BSc

There is a growing body of knowledge that supportsthe premise that an optimum fit between a personand their wheelchair/seating system will improvemobility, function and comfort while reducing theneed for restraint and repositioning and potentiallydecrease the incidence of decubiti ulcers. Clinicalexperience suggests that the fit is not alwaysoptimum and that frequently wheelchairs are used to‘store’ individuals, especially in long-term carefacilities. Ensuring that there is a good fitnecessitates that an individual, usually a therapistwith seating experience, assesses the situation.Unfortunately few long-term care facilities haveseating therapists on staff. The health care providersin long-term care facilities generally make thedecisions regarding the need for wheelchair andseating despite having little knowledge in this area.Identifying the need for assessment and interventionis the first step in ensuring appropriate equipment isprovided.

A review of the literature revealed that there was areno assessment tools that can aid health-careproviders who have limited understanding of issuesrelated to wheelchair and seating prescription, toidentify individuals who need a formal assessment.Given this dilemma a screening tool, the SeatingIdentification Tool (SIT), was designed to fill thisneed.

Development of the Seating Identification Tool(SIT)To develop the SIT we used a modified form of theDelphi-Technique. The seating team, consisting of aPT and OT developed a list of 25 items that wereconsidered important indicators of the need forwheelchair/seating intervention. The list wascirculated to 13 other health professionals in thefields of OT, PT and nursing in order to ensure that

all possible indicators were included. The final listwas compiled and operationalized into a questionformat and circulated to the 13 member panel forfeedback regarding the wording of the SIT items andidentification of those items that panel membersthought were critical to include.The SIT was subjected to two separate studies inorder to determine the reliability and validity. Thesecond study was conducted to assess thepsychometric properties after the SIT had beenmodified to improve the operationalization based onresults and feedback from the first study. In this talkwe present the results of the psychometric testing ofthe SIT from the second study. The study objectiveswere to assess the: i) inter-rater reliability; ii) test-retest reliability; and iii) the concurrent validity ofthe SIT.

Design/Participants/ProtocolA test-retest design was used to assess thepsychometric properties of the SIT on a sample of43 residents. The subjects were randomly selectedfrom a list of all wheelchair users at a long-term carefacility in London, Ontario, Canada. To be includedsubjects had to be 60 years of age or older and hadto be using a wheelchair as their primary seatingand/or mobility device. Two assessors, both healthcare providers with no wheelchair/seatingexperience, who knew the residents, were selected toadminister the SIT on two separate occasions, twoweeks apart. As there is no gold standard theassessment of an experienced seating therapistprovided an indication of the concurrent validity.The seating therapist assessed the subjects within 2-6 hours of the first application of the SIT. At no timedid the seating therapist have access to the results ofthe SIT.


Measurement/AnalysisThe SIT consists of 11 items that assess five areasrelated to seating (pressure areas, discomfortbehaviors, mobility, positioning, stability).Responses are recorded as either a yes (1) or no (0).A score is given for a positive response (yes) to allitems except item 10, which is reversed. Allresponses are scored as 1 except for items 1, 2, 4and 10, which are weighted as 2. The responses aresummed to provide an total score that ranges from 0to 13. A score of 2 or higher is indicative of a needfor a formal assessment.

The intra-class correlation coefficient (ICC) wasderived to assess total score test-retest and intra-raterreliability and Cohen’s Kappa was used to assessitem by item reliability. Sensitivity and specificitystatistics were derived to assess the validity of theSIT.

ResultsOne resident died before the final study wascomplete. Of the remaining 42 subjects, 40 werefemale. The sample had a mean age of 83.2 years.Inter-rater reliability was ICC=0.83 and the twoweek test-retest reliability was 0.86. Individual iteminter-rater agreement ranged from 0.29-1.00 andtest-retest agreement ranged from 0.25-1.00. Thesensitivity of the SIT was 100% and the specificitywas 65%. The positive predictive value was 80%.

DiscussionThe SIT was found to have good repeatability andvalidity when used among health care providers whohad little or no seating experience. It is possible thatfurther development of the SIT may improve thespecificity, however, as there are no seriousimplications resulting from having an assessment,improving the specificity is not considered to becritical. In summary the SIT is tool a that can assistuntrained health providers who work in nursingfacilities to identify individuals who need a formalseating/wheelchair assessment.


The Prevalence and Type of Wheelchairand Seating Needs among theInstitutionalized ElderlyWilliam C Miller, PhD, OT; Francine Miller, BScOT, JenniferA Forward, MClScOT, Kris Goodman, BSc; Karen Trenholm,BScPT

Most individuals who live in long-term carefacilities spend the majority of their time sitting inwheelchairs. Clinical experience suggests thatmaximal function and comfort are often overlookedwhen providing the individual with a wheelchair andseating system as the systems often do not fitindividual needs. Further, most residents do notreceive a formal wheelchair and seating assessment.This can lead to a variety of complications reducingquality of life and may indirectly lead to medicalcomplications and even premature death. Earlystudies suggest that the prevalence of the need forseating intervention in long-term care facilities rangefrom 40-80%, however, the limitations in the designof these studies limit the precision of the estimates.Further, estimates have not been provided forCanada. Knowledge of the demand for interventionnow may assist in preparing for the next 20 yearswhen the number of individuals aged 65 and over isexpected to double. This study was conducted toaddress two objectives; i) estimate the magnitude ofneed for a formal wheelchair and seatingassessment; and ii) determine the type of needamong residents of long-term care facilities inLondon-Middlesex Health Region of SouthwesternOntario Canada.

MethodAn institutionally based population study wasconducted to address the study objectives. Thesubjects for the study were drawn from all ten long-term care facilities in the London-Middlesex HealthRegion. A single list of all wheelchair users(approximately 1100 individuals) who were living inthe long-term care facilities was constructed and a

simple random sample of 255 subjects was selected.To be eligible for the study individuals had to bepermanent residents of the facility and using awheelchair as their primary source of mobility andseating device. Individuals were excluded if theyhad not been residing in the facility for at least 4weeks or if they were considered palliative.Measurement was conducted using the SeatingIdentification Tool (SIT). The SIT, a clinical screenspecifically developed to identify individuals whohave wheelchair and seating needs, has been foundto be reliable and evidence of validity has beenfound. Individuals who score two or more on theSIT are deemed to be in need of a formal seatingassessment. Data collection was conducted bynursing staff from each facility who were trained touse the SIT by the study coordinator and a memberof the Parkwood Hospital Seating Program.

ResultsThe final sample consisted of 169 individuals, 34men and 135 women, with an average age of 84.1years (SD=10.15). Of the other subjects selected forthe study 67 refused to participate, eight died, and 11moved or were no longer using a wheelchair. Themajority of the sample (63%) owned theirwheelchair, and 78% sat in their chair for eight ormore hours a day (average 8.93 hours, SD=2.86).A total of 106 (63%) subjects were found to be inneed of a formal evaluation with 64 (38%) subjectsidentified as having four or more problems withtheir wheelchair and/or seating device. Only 15%were identified as having no problems at all. Themost common problem was discomfort (46%)followed by the presence of red areas on thebuttocks (41%). Evidence of additional pressureareas was also identified in 22% who had red areas


on their back, while 21% had an open sore on eithertheir buttocks or back. Seating issues such asrepositioning were identified in at least one third ofthe sample.

Table 1 Frequency and Type of Wheelchair and Seating Problems

Frequency Proportion

Pressure

Red Area – Buttocks 70 41.4

Ulcer – Buttocks 27 16.0

Red Area – Back 37 21.9

Ulcer – Back 9 5.5

Discomfort 78 46.2

Mobility (difficulty propelling) 54 32.0

Seating issues

Repositioning required 61 36.1

Restraint used 42 24.9

Pillow/homemade supports used 25 14.8

Seat cushion not used 56 33.1

Stability (tipping) 12 7.1

N=169

Discussion

The majority (63%) of the sample who live in

London-Middlesex long-term care facilities may

benefit from a formal wheelchair and seating

assessment. The estimate falls in the middle of

earlier published estimates. It is difficult to

generalize this estimate to other regions of the

province of Ontario as London/Middlesex has

better than average access to health care services

than most regions and therefore it is likely this

estimate is conservative. Further study comparing

different regions of the province of Ontario is

recommended to determine if the degree is similar

in the various health regions. Pressure areas and

discomfort were identified as being the most

common type of problem.


Psychosocial and Functional Benefits ofService DogsKaren Frost MBA, Shirley Fitzgerald PhD, Diane CollinsMA, OTR/L, Natalie Sachs-Ericsson PhD

ABSTRACTThe population of wheelchair users has almostdoubled between 1980 and 19901, accelerating boththe development and use of assistive technologies toincrease independence for wheelchair users. Servicedogs have been used as a viable solution for manywheelchair users. In addition to reports of improvedlevel of independence and increased psychologicalwell-being, service dogs are reported to reduce theexpenditure of time and physical exertion by theowner, allowing individuals more efficient use oflimited energy. A comprehensive questionnaire wasadministered to investigate differences inpsychosocial and functional outcomes betweenwheelchair users who own a service dog (n=20) andwheelchair users who have not yet received a servicedog (n=29). Results indicate that service dogownership is associated with psychosocial benefits.

RATIONALEThe United States wheelchair user population iscurrently estimated at 1.4 million individuals2. Theneeds of this population have accelerated thedevelopment of assistive technologies to increaseindependence and enhance opportunities forwheelchair users. Service dogs have been used as aviable solution for many wheelchair users. Servicedogs are trained to retrieve items, pick up things thathave dropped, assist with opening and closing doors,help maintain sitting balance, help with mobilityissues such as pulling the wheelchair, assist withtransfers (body support/bracing) and seek emergencyhelp. They also provide constant companionship.Recent estimates indicate thatapproximately 10,000 individuals currently use aservice dog for mobility related impairments.In addition to reports of improved functioning, thereis a small but growing body of research indicatingthat people with disabilities who use a service dogreport improved psychological well-being, engage inmore social interactions and have more friends than

people with disabilities who do not utilize a servicedog. Scientific literature has shown thatpsychosocial factors play a significant role inadapting to, and living with, chronic conditions.Conditions such as spinal cord injury, multiplesclerosis, cerebral palsy and muscular dystrophyaffect not only physical function and well-being butalso significantly impact self-esteem and lead todistressing emotions such as anxiety, depression,resentment, and helplessness. The loss of key rolesand disruption of social interactions and future plansare also correlated with chronic conditions and cannegatively impact social functioning. We knowthrough numerous studies that an individual’s socialnetwork and social support system are related topsychological well-being and healthy functioning.The introduction of a service dog represents anintervention believed to positively affectpsychosocial aspects of an individual, leading toincreased social integration and social functioning.

Unfortunately, results of the existing research arelimited in generalizability due to the retrospectivenature of the majority of studies, small sample size,subjective self-report, and in some cases the use ofunvalidated measurement tools. This analysis is partof a pilot study designed to both validate existingpublished results regarding healthcare utilization andpsychosocial impact of service dogs, and to expandthe research through investigation of socialintegration and functional outcomes. This paperpresents the results of a cross-sectional analysis ofpsychosocial and functional data collected fromexisting service dog owners and individuals whohave not yet received a service dog.


METHODS

SubjectsThis pilot study has been conducted as a cross-sectional study. All subjects are >18 years of age,and use a wheelchair or scooter as their primarymeans of mobility. The S-DOG group is comprisedof individuals who own a service dog. The NO-SDOG group is comprised of individuals who arelisted on one of two national service dog agencywaiting lists. Subjects were identified and recruitedthrough one of two service dog agencies: PAWsWith a CauseÒ, or Canine Companions forIndependence. Selected subject demographic andsocioeconomic data is presented in Table 1.

InstrumentsPsychosocial well-being is measured using thefollowing three instruments: 1) Positive andNegative Affect Scale (PANAS) - a 20-item scaleassessing both positive and negative affect. Totalscores range from 10–50; 2) Rosenberg Self-Esteem(RSE) scale - a 10-item Guttman scale assessingself-esteem, with scores ranging from 10 (low self-esteem) to 40 (high self-esteem); and 3) SocialProvisions Scale (SPS) - a 24-item questionnaireassessing categories of perceived social support.SPS scores range from 24 (low social support) to 96(high social support).Functional outcomes and community integration aremeasured using the Craig Handicap Assessment(CHART). Dimensions analyzed for this report aremobility, occupation and social integration. For eachdimension, a total continuous score is calculated. Ascore of 100 equates to no handicap in anindividual’s ability to perform the particular item/function being measured.

Reliability and validity have been established andpublished in the literature for all psychosocial andfunctional questionnaires.

Data AnalysisAll questionnaires were scored according topublished guidelines. Statistical analysis wasperformed using SAS. For continuous variables, acomparison of results between groups wasperformed using the student t-test. For categoricalvariables, a comparison of results between groupswas performed using chi-square.

RESULTSQuestionnaires have been received, and data hasbeen analyzed for 20 S-DOG subjects and 29 NO-SDOG subjects. As presented in Table 1, there areno significant differences between the groups withrespect to age, gender, race, or years of disability oreducation. We have observed that S-DOG subjectswho are not employed are more likely to self-reporttheir employment status as due to personal choice,as compared to unemployed NO-SDOG subjects,who are more likely to self-report their employmentstatus as due to disability.

Analysis of psychosocial measures indicates thatlimited differences exist between these groups. Onthe PANAS, S-DOG participants scored as havinggreater positive affect (38+5) and less negativeaffect (16+4) as compared to the NO-SDOG group(means=34+7 and 19+6, respectively). Thesedifferences are statistically significant at p=0.04 forboth results. With respect to self-esteem, S-DOGparticipants exhibited modestly higher scores on theRSE (S-DOG mean =32+5) as compared to the NO-SDOG group (mean=30+6). No differences wereobserved regarding categories of social supportreceived by subjects, as measured using the SPS (S-DOG mean =66+4, NO-SDOG mean=66+5).

Analysis of functional and community integrationindicators using the CHART subscales indicatesdifferences in all three subscales examined. Existingservice dog owners self-reported slightly greaterhandicap in terms of mobility and occupationalstatus as compared to non-service dog owners(mobility subscale: S-DOG mean=81+13, NO-SDOG mean =82+19. occupation sub-scale: S-DOGmean=68+27, NO-SDOG mean=72+31). Withregard to social integration, S-DOG subjects alsoreported greater handicap (S-DOG mean=83+23) ascompared to non-service dog owners (NO-SDOGmean=95+9). Differences in social integration scoresare significant at p<0.02. Psychosocial andfunctional results are summarized in Figure 1.


Limitations of this study are sample size and cross-sectional design. Scientific evidence of changes inpsychosocial and functional outcomes over time as aresult of service dog ownership remains limited. It ispossible that scores from existing service dogowners participating in this study representsignificant improvements as compared to their pre-service dog ownership status. Future studies shouldfollow service dog recipients over time to determinelong-term psychosocial and functional benefitswithin this group.

REFERENCES

1McNeil, J. M. (1993). Americans with Disabilities:1991-1992. Data from the Survey of Income &Program Participation, (Census Bureau Series P70-33). Washington DC: US Dept of Commerce,Economics & Statistics Admin.

2National Center for Health Statistics (1992). PublicUse Data Documentation, National Health InterviewSurvey of Assistive Devices, 1990. Hyattsville, MD

ACKNOWLEDGEMENTSThe authors acknowledge the VeteransAdministration Center of Excellence on Wheelchairsand Related Technology, Pittsburgh HealthcareSystem for their support of this study. The opinionsexpressed herein are those of the authors and do notnecessarily reflect those of the funding agencies. Theauthors also thank PAWs For A CauseÒ and CanineCompanions for Independence for their assistance.

Karen L. Frost, MBA, Veterans AdministrationHuman Engineering Research Laboratory, 7180Highland Drive, Pittsburgh, PA 15206. 412-365-4850. Email: [email protected]


Panel MembersMorris (Mickey) Milner, PhD, PEng, CCEEmma Parry, SROTPeter Thomas,Esq.Lori Warren

An International panel will address the issues of changing policy related to assistive technology and seating/wheeled mobility. Mickey Milner presents the perspective of a research director at Bloorview MacMillan Centrein Toronto, Canada. He was instrumental in obtaining and administering 1.5 million dollars directed to a wideresearch endeavor focused on developing new products for persons with a disability and transferring them into thecommercial marketplace. Emma Parry, an Occupational Therapist in London, England has worked with a group ofresearchers and clinicians to demonstrate advanced service delivery methods can be used in an environment thathas been slow to change. The demonstration project, Scamp -Specialist Centre for Advanced Wheeled Mobilityand Positioning, has the hope of convincing consumers, professionals and government representatives to updateexisting service delivery practices. Peter Thomas is an attorney and a person with a disability. He has been veryactive in advocating for policy change in the government sector related to technical and other needs of personswith disabilities. His work includes policy changes to address both the technological and non-technical needs ofthe disability community. Last but not least, Lori Warren, a parent and advocate, will share her experience inopening doors in an educational environment for her daughter and others. She will share how persistence with asmile can be an effective tool for change.

The session will be lead by Jean Minkel, a professional experienced in service delivery, education and technologydevelopment. Jean’s broad background will ensure the discussion following the presentations is lively and yetfocused. Join us with your comments, problems and most important your positive experiences that have resultedin policy changes.

Policy Change:Can We Make A DifferenceModerator: Jean Minkel, MA, PT


The Ontario Rehabilitation TechnologyConsortium (ORTC): A project thathas made a difference

Morris (Mickey) Milner, Bloorview MacMillan CentreToronto, Ontario, Canada

Need for the Consortium The Ontario RehabilitationTechnology Consortium (ORTC) was initiated in1992 with a 10-year commitment from the OntarioMinistry of Health at the level of $1.5-million (Cdn)annually. It came about as a consequence of thevisions of a number of people who had much to dowith the initiation of the Province of Ontario’sAssistive Devices Program (ADP), whichcommenced in a phased manner from 1982 onwards.Essentially, ADP has, since its inception, providedup to 75% of the funding for a wide variety ofassistive technologies. The program expends inexcess of $100-million annually. The client isexpected to provide the balance of the fundingwhich may also come from various supportivecommunity agencies. It was evident that virtuallyall of the assistive devices made available by theprogram were being imported. With the availabletechnical and academic capabilities throughoutrehabilitation centres, clinics and universities itseemed logical to develop a program of research,development, and technology transfer which wouldaddress this shortcoming. The ADP AdvisoryCommittee to the then Minister of Health, in theearly 1990’s, initiated a Task Force to explore thismatter. The Task Force recommended theestablishment of a province-wide consortium tomake an appropriate address to the issue. This wassubsequently supported at all levels of the OntarioGovernment, and a request for proposals (RFP) forthe envisaged consortium was issued.

Initiation of the Consortium Essence of the RFP TheRFP expected an address to unmet needs throughR&D in rehabilitation technology relevant to thefollowing areas: Communication, Hearing,Mobility, Prosthetics and Orthotics, Respiration,

Seating and Vision. Developments were to bepertinent to safety, effectiveness, reliability andsuitability for consumers, and the consortium shouldpromote Ontario industry in the field of assistivedevices. It insisted on a partnership amongconsumers, researchers and developers, academicinstitutions, health care facilities, clinicians,industry, other granting bodies and governmentagencies, and the community. It was required thatthe consortium acquires matching resourcesamounting to at least $750,000 per year in cash orkind. Response to the RFP A response to the RFPwas initiated by the Rehabilitation EngineeringDepartment at what was then the Hugh MacMillanRehabilitation Centre (now Bloorview MacMillanCentre), which issued a province-wide invitation forpartnership in the proposed venture. Multiplemeetings were held in an effort to develop ameaningful proposal. Essential conditionsestablished by the key participants were teamplayers with significant track records in theattraction of funding, and the accomplishment of setobjectives, along with appropriate values relating toconsumer participation and industrial involvement.The submission was reviewed by researchers,consumers and government officials, and wassuccessful. In addition to the identified areas ofR&D, there were included a secretariat, based atBloorview MacMillan Centre, the PsychosocialEvaluation Team, and a commercialisation grouprelating to technology transfer and businessdevelopment. Institutions and related clinics include:Bloorview MacMillan Centre, Centre for Studies inAging - Sunnybrook and Women’s Health ScienceCentre, Ontario Institute for Studies in Education,Queen’s University, University of Toronto,University of Waterloo, University of WesternOntario, and West Park Hospital.


OcuTech VES-AF, a spectacle mounted autofocustelescope system.

Publications and Training A substantial amount ofintellectual activity has occurred: Significantnumbers of students have been trained in the field(e.g. 11 Ph.D. and 80 Masters degrees in diverserelated disciplines have been awarded to date);numerous publications and presentations have beenmade (on average, 41 refereed papers, 30 conferenceproceedings contributions and 55 presentationsannually) without compromise to commercializationof developed products.

The Future The ORTC can most certainly beregarded as a project that has made a substantialdifference to the field of rehabilitation engineering.

In its future thrusts, the ORTC expects to build on itsstrengths and its acquired knowledge and experienceto further meaningfully enhance the role oftechnology in rehabilitation. It is currentlyinteracting with provincial and federal grantingbodies to facilitate future funding to promote furtherendeavours along similar lines.

Administration of the ORTC Administration of theORTC on a day-to-day basis rests with each of theTeam Leaders in the areas identified above. Amanagement committee comprised of theConsortium Director, Team Leaders and Institutionalrepresentatives, develops annual plans, relatedbudgets and reports. Accountability of the enterpriseis to an Advisory Board with representation fromscientific, consumer, industry and service sectors.

Advancement of the ORTC The growth anddevelopment of the ORTC has been significant.From year to year the Ministry funding ofapproximately $1.5-million p.a. has been more thanmatched by funding in both cash and in-kindcontributions, well in excess of the expected$750,000. Intellectual Property A considerableamount of intellectual property, including manycommercialized devices has been generated. ORTCmembers hold 24 patents with 21 applicationspending. Job and Business Development Over 40jobs have been created in Ontario industry for 2000-2001, with over 8 jobs in the rest of Canada and theUSA. As the ORTC has matured, the culture ofbusiness has been embraced alongside scientificresearch thrusts. It has 31 active business partnersand has enabled the creation of 11 companies inOntario. The ORTC has been responsible for thecreation of several small high tech companies,especially in the areas of vision and mobilityproducts. Prior to its inception, no vision relatedindustry existed in Ontario. Creation of ProductsThe ORTC has produced some 25 highly innovativeproducts that have come to market, with 15 others atvarious stages of development/commercialization.Some of the products on the market are: WiViK(r) -a Windows-based Visual keyboard, KeyRep(r) -Word prediction and abbreviation expansioncapability to accompany WiViK(r), and WiVox(r) -Voice output for the system; Desired SensationLevel Method for fitting hearing aids; an accessiblebathtub; ToilevatorTM, a system to raise standardtoilets by several inches; StaxiTM, a porteringwheelchair; RocketTM, a highly manoeuvrable andversatile powered wheelchair; MyoMicroTM, aprogrammable prosthetic controller; The Maple LeafOrthosisTM, a post-operative hip abductor brace;Psychosocial Impact of Assistive Devices Scale(PIADS); Powered Upper-Extremity FunctionalIndex (PUFI); AquanautTM, an advanced toiletingsystem for children; JoeyTM, an adaptive seatingsystem and related components; VisableTM , ascientific calculator for people with low vision;Virtual Reality MouseTM, a tactile mouse; and,


Experiences of being ‘part of thesolution’ - an English perspective

Emma Parry, SROT, ATP, Clinical Director, SCAMP,Centre for Disability Research and Innovation UniversityCollege London

The services which provide wheelchairs and seatingto permanently disabled people in England haveundergone major and fundamental changes over thepast 15 years. People with disabilities in the UnitedKingdom lag far behind in the use of moderntechnologies which provide independence andfunctional mobility in our communities.

There is a plethora of evidence to show that the gapbetween what is possible and what is provided is notas simple as just the shortage of funding. Thesystems used to deliver these services appear to havemajor weaknesses. These weaknesses werehighlighted by the Audit Commission in their reportpublished in March 2000. The Audit Commissionidentified that investment in equipment servicesdelivers high quality at low cost. Specific problemswith wheelchair and special seating services wereidentified, stating that budgets are under pressure,and the application of local eligibility criteria makesprovision a lottery that is dependent on post code.Some trusts provide a wide range of wheelchairs andequipment without restriction on type or cost,whereas others have established tight eligibilitycriteria.

A further complicating factor in the provision ofwheelchair and seating services for the people of theUnited Kingdom is the cultural milieu in which welive. The typically British ‘stiff upper lip’ is a strongcultural issue. This creates difficulties for clinicianswhen evaluating people’s needs. It also createsdifficulties for people with disabilities when tryingto express their expectations and requirements.There is a ‘make do with what you have’ culture thatis perhaps a relic of the second world war andsubsequent depression.

Architectural barriers to independence are endemicwithin Britian. Historical buildings are notoriouslydifficult to adapt for disabled access, particularly ina sympathetic way. Recent legislation has changedthe regulations for new buildings, however it has yetto be tested. One opinion group states that thelegislation has no ‘teeth’, very similar to theDisability Discrimination Act that is being phasedon over a number of years. It is not justarchitectural barriers that people with disabilitiesmust overcome in order to live within Britishsociety, there are other less tangible barriers thatpresent equally problematic challenges toindependence.

There is definitely strong belief in the NationalHealth Service (NHS) which for many reasons isoften unable to deliver the ‘ideal’. Private healthcare is not universally popular, but is a growingindustry. From an industry perspective, there aretwo distinct markets in the UK; the NHS (purchasesmade by Wheelchair and Seating Services) andprivate (purchases made by individuals).

There are a growing number of clinically trainedindividuals employed within the private sector. TheBritish Health Care Traders Association introducedin 2000 a registration scheme for individualsemployed in the industry. This will in the future belinked to a competency programme, with the aim ofraising and assuring standards. These initiatives willserve to raise standards within the industry, and offerusers the opportunity of making an informed choice.

There have been numerous retrospective studies ofwheelchair and seating services in the past. Whatseemed to be missing was a practical demonstrationof how to provide the most effective service in the


UK context, studied rigorously in a prospectivemanner. The approach taken is one that is liberatedof the constraints imposed by the prevailingperspectives of these services and their historicallegacies. SCAMP (Specialist Centre for AdvancedWheeled Mobility and Positioning) is a two yearresearch programme funded by the National LotteryCharities Board and undertaken by the Centre forDisability Research and Innovation, UniversityCollege London in association with the charityASPIRE. The focus of SCAMP is to develop,through professional consensus, a best practicemodel for the provision of wheeled mobility andseating. The model will be evaluated in terms ofoutcomes for the clients.

One of the most important tools for evaluatingSCAMP’s best practice model is a web basedInternational Advisory Group (IAG). The IAG iscomprised of recognised ‘experts’ in the field ofwheeled mobility and seating from many differentcountries. Each client’s case is presented to the IAGvia a limited access website for feedback andguidance in terms of the development of the model.The IAG examines how the methods usedthroughout the intervention impact the practice ofassessment for wheelchairs and seating. Theoutcome measures include objective evaluation ofquality of life and functional level using recognisedevaluation tools. A cost-benefit analysis is beingcarried out, along with measurement of theconsumer’s satisfaction with the process andoutcomes using a questionnaire and interviewformat. A steering committee provides overallguidance for the direction of the project.

SCAMP will conclude its work by the end of 2001.Preliminary findings and experiences will bediscussed, illustrated with case studies.

seventeenth international seating symposium · seventeenth international seating symposium •...

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