by Eileen Yorke, OTL, ATP, SMS, and Syndi Granger, OTR/L
Getting a driver’s license is a major milestone for most people. It’s a sign of responsibility, skill, and, most of all, independence. It literally opens new roads and often requires a significant amount of research, negotiations, and decisions to find the right “set of wheels.” Similarly, determining the right wheelchair and custom seating system can involve a good deal of investigation, evaluation, and trial and error to ensure the right fit. Multiple steps are involved in determining the right vehicle for each client and helping them to make a well-informed decision. At the Kessler Institute for Rehabilitation Wheelchair Clinic, the client’s medical and functional needs are carefully examined, as well as their “must-haves.” Likewise, they are educated about the range of available seating options. The therapist, client, and product vendor then work closely together to determine the most appropriate “vehicle” for that individual.
EVALUATING NEEDS AND OPTIONS
The comprehensive evaluation process begins with an interview to review the client’s diagnosis, past medical history, skin health (past and present), and his/her functional needs, as well as the progression of the disease and even any weight gain/loss. In addition, particularly with pediatric patients, anticipated growth is essential to the decision process.
When purchasing a car, people typically ask themselves which options are mandatory, which would be nice to have, and which are unnecessary. Most of these decisions are based on lifestyle needs, comfort, aesthetics, and/or cost. Practicality, or perhaps functionality, usually dictates the decisions, especially as potential expenses increase. Car buyers may ask themselves whether they really need a turbo engine, or will a more efficient model suffice? Clinicians and clients must weigh similar variables when selecting a wheelchair seating system. For example, how will the client use the wheelchair? Identifying the functional use will help guide the team to suitable products for trials. If the individual is already using a wheelchair, is it meeting their needs? If not, what needs to be changed to enable him/her to perform activities of daily living or mobilize with greater independence?
Staff members also review insurance guidelines and discuss the authorization process with the client. A client can request a trial of any equipment, and it is our job to inform them of the costs and coverage involved so that they can make the most informed decision. In some cases, clients may choose to pay out-of-pocket for certain components of a wheelchair that may offer increased independence.
Just as there are multiple options when buying a car—say, a leather or cloth interior or increased lumbar support—there are important comfort considerations for wheelchair users. Clients undergo a thorough mat evaluation in both sitting and supine positions to identify any postural deficits and to determine whether they are fixed or flexible. In addition, the ability and flexibility of a client to sit upright with the head and/or trunk facing forward needs to be examined. A mat evaluation that focuses on the head/neck, shoulders, spine, rib cage, pelvis, and lower extremity range of motion will help the therapist in providing a supportive system to accommodate or improve any deficits.
TRIAL … and TRIAL AGAIN
Independent mobility is the goal of every client regardless of physical or functional deficits. The first step is assessing the individual’s ability to propel a manual wheelchair or operate a power wheelchair safely. Similar to automobiles, there are different models to choose from ranging from standard, lightweight manual wheelchairs to custom ultra-lightweight styles to power-assist or full-power options. The decision is influenced by how the client will use the wheelchair—whether for work, school, or community access, or primarily in the home. Some individuals may find that a more basic model meets their needs, while other active, “high-end” users may look for sleeker, more compact, and lightweight designs that will enable them to power through the day. For those clients who may not be able to propel long distances, a power-assist system can be added to a manual chair—a feature that can be helpful if navigating around a high school or college campus, or in an office setting.
A trial of equipment is essential, particularly when considering power mobility. Much like a car, power wheelchairs come in different drives: front wheel, mid-wheel, and rear wheel. The type of drive needed is again based on use, such as the need to fit though elevators and other tight spaces. In addition, power seat functions, including power tilt, recline, seat travel, and power legs, provide the client with the ability to independently reposition and perform weight-shifting throughout the day.
A variety of options for driving power wheelchairs are available. The client who can operate a standard joystick has a choice of different hand controls, such as large ball, stick, or T-shape. Individuals who lack sufficient hand control may opt for sip/puff, chin controls, head arrays, or other alternatives. Switches can be placed on a tray, knee adductors, foot supports, and/or locations on the chair to enable a client to power on/off and access power seat functions. Of course, not all clients are independent in mobility. With progressive diseases, such as cerebral palsy, multiple sclerosis, ALS, or Parkinson’s disease, independence may not be a safe option. Likewise, stroke survivors who experience visual spatial neglect also warrant special consideration. A manual tilt-in-space wheelchair may be required to allow the caregiver to reposition the individual throughout the day, provide them with pressure relief using the tilt features, and with modifications allow for a multitude of options for postural support.
SIMPLIFYING COMPLEX SEATING
Given the advances in wheelchair technology, the options for complex seating continue to evolve. It’s important that therapists not only stay ahead of the latest options, but carefully assess each client to determine the most appropriate seating system for that individual. Complex seating can best be described as “off-the-shelf” products with modifications or custom fabrication adapted for the individual’s physical and functional needs. An off-the-shelf product can be as simple as a tension adjustable back, or a solid back with or without contour. These products can be modified by the therapist with foam or air inserts to accommodate spinal abnormalities, decrease pain, and improve overall function. Cushions for support, stability, and positioning come with various properties such as air, gel, fluid, and foam. Air cushions, for example, are excellent for pressure redistribution, but may not provide the stability an active user requires. Gel, fluid, and foam may also provide pressure relief, along with the stability required to perform dynamic functional tasks. To ensure skin integrity, comfort and safety, a pressure mapping system can be used to assess the pressure distribution along the individual’s seated body surface. Pressure mapping enables therapists to compare cushions and back support, and to determine the best method of pressure relief.
At Kessler’s Wheelchair Clinic, several types of advanced custom seating are available to best meet clients’ physical, functional, and positioning needs. One example is a seating system that utilizes a computer to digitize the precise shape of a client’s spinal and pelvic deformities. It captures the client’s kyphosis, lordosis, and/or pelvic obliquity to provide custom-contoured back and seat cushions. This system also provides even weight distribution and shock absorption, as well as pressure relief and stability. Another option is foam-in-place seating that offers custom-contoured lumbar or lateral supports. With this product, the client is positioned in his/her chair on a special bag filled with a foam mixture that molds around the spine and pelvis, accommodating any abnormalities and helping to achieve good postural control and pressure relief.
Even though a client’s needs are complex, such as in cases of scoliosis, lordosis, and/or pelvic obliquities, custom molded systems either in a power or manual wheelchair may not be the appropriate solution. Custom seating systems are quite restrictive and provide maximal support to a client to increase postural alignment. For some individuals, this may inhibit their ability to use their upper extremities for functional tasks, such as reaching forward for items or to access the joystick for mobility or seat function control.
IT’S ALL ABOUT THE FIT
The single most important factor of any seating system is the “fit.” The therapy team needs to review not only the physical and functional needs of the client, but also his/her goals. Some clients want to be able to “sit up straight,” which may be challenging to those who have fixed musculoskeletal deformities. Other clients seek greater functionality—ie, using a joystick for mobility and reaching laterally for items as opposed to sitting up straight. The best route to take is to provide clients with the pros/cons of various products and to encourage them to trial different types of seating to determine which is optimal.
That also opens the door to an array of options or alternatives that can enhance the mobility experience. For example, adding lateral supports to a contoured back to provide increased postural alignment may be an alternative to custom seating. This will enable the client to remain functional for reaching and not be as restricted by the support system. The therapist and vendor may also recommend additional support such as arm troughs or upper extremity support systems to assist with trunk alignment and provide greater postural alignment. The use of a chest strap or chest harness may be used in conjunction with an “off-the-shelf ” or custom seating system for increased stability when out in the community. Likewise, lower extremity support is crucial in providing stability for functional tasks as well as mobilizing the wheelchair. Lastly, placement of the feet on a solid surface and proper lower extremity alignment are essential to a client’s functional support.
A wheelchair is only as good as the support system—the seat, back, and upper and lower extremity support. The combination of a solid back and appropriate cushioning can help maximize a client’s functional mobility and ability to perform self care. A system that provides too much or not enough support can inhibit performance of daily activities. In other words, fit and function need to be carefully weighed to ensure optimal mobility and independence.
A MORE LEVEL FIELD
Advances in technology have revolutionized wheelchair mechanics and design, giving users greater function and mobility. There are, for instance, wheelchairs that allow a person to stand or rise to eye level to engage in conversation or address an audience. These innovations have helped level the field both personally and professionally for wheelchair users, and have opened new avenues of self-sufficiency. The options available are limitless, but choosing the right “vehicle” comes down to understanding and meeting an individual’s specific needs, wants, and budget. Given the scope of features—from comfort and safety to functionality and durability—clinicians must work closely with the individual to customize complex seating and mobility, and get them on the road to greater independence. RM
Eileen Yorke, OTL, ATP, SMS, is an advanced clinical specialist at Kessler Institute for Rehabilitation. Yorke has been in practice for more than 20 years in various settings, including acute rehab and early intervention. She specializes in the area of wheelchair seating and positioning.
Syndi Granger, OTR/L, is a clinical specialist at Kessler Institute for Rehabilitation. For more information, contact [email protected].