Sharon Pratt: Aligning Outcomes

I was recently asked these questions in preparation for contribution to a magazine article. As I thought about the answers, I realized that I get asked these questions a lot in my educational events. I am sharing the questions as well as my answers here in the hope to get some comments, thoughts, questions from interested readers.

QUESTIONS: Provided by Magazine Editor:

ANSWERS: Provided by Sharon Pratt, PT. Seating Solutions LLC

1) In brief, what are the main tasks a wheelchair seat cushion should accomplish for a wheelchair user?

• The primary four functions of a wheelchair seat cushion are as follow
  • Preserve skin integrity
  • Accommodate and/or correct dysfunctional postural alignment
  • Optimize functional stability
  • Facilitate function from a mobility and physiological perspective

2)  How does a high-quality, properly fitted seat cushion impact a client’s clinical condition, skin health, comfort and daily functionality?

• I consider my job as “taking the work out of sitting for my clients” In doing so, each time I am involved with a wheelchair / seating prescription, I like to envision the “sitting footprint” of the client. The seat support is a critical component of the Inferior seating support surface (Inferior sitting footprint). I personally like to think of optimizing the clients sitting “footprint” every time I prescribe a seating system. The seat cushion is of course just one critical component of this – another critical inferior support surface is the foot support. It should be noted that the seat support can’t provide a successful outcome in isolation. Other components, such as a back support for example, are also necessary to consider in the big picture.
• When a client is fitted correctly for their wheelchair seat cushion, they should have the predetermined goals in the areas of skin integrity preservation, positioning, stability and function satisfied with positive outcomes which overall should be clearly measurable in terms of sitting tolerance for example. Some clinicians choose to use interface pressure measurement as a tool to assist with measuring outcomes. The number one indictor for success can often be the “ lack of skin integrity issues”.

3)  What signs of wear should a provider or clinician looks for when inspecting a seat cushion?

• The client, or provider or clinician should check regularly for signs such as
  • Foam compression sets that have a negative impact on the client, for example leaving the client without the necessary “cushioning effect”
  • Holes or punctures in cells or compartments that contain fluid/air
  • Migration or loss of fluid/air beneath the areas of the pelvis needing greatest protection – for example beneath the Ischial tuberosities.
  • Tears in the cover that was designed for that particular cushion

4)  What are the signs that a seat cushion should be serviced/replaced?

• Any of the above

5) Cover: What tasks should a seat cushion cover accomplish?

The cushion cover should at a minimum;

• Be stretchy enough to allow optimal immersion of the buttocks into the cushion material without hammocking and negating the benefits of the prescribed cushion materials
• Help manage the negative impact of moisture and heat on the clients skin (microclimatic features)
• Protect the cushion material
• Provide easy removal, washing and drying

6) What role does it play in the overall function of a seat cushion?

• The cover can be instrumental to the success of the cushion performance in terms of posture, skin and function management. For this reason as well as for the purposes outlined above, it is extremely important that the cover that was designed for use with the cushion is in fact the one that is always used.

7) What signs should clinicians and providers look for when assessing whether a seat cushion cover should be replaced with a new one?

• The wheelchair user, clinician and supplier should be vigilant for the following signs of cover wear and tear
  • Tears in the fabric
  • Broken zippers
  • Hammocking perhaps due to shrinkage
  • Missing components that may have been built into the cover for the purposes of postural management or skin protection for example fluid pads / foam inserts etc.

8) Base: What is the job of the seat cushion’s base — the part of the cushion nearest the seat of the wheelchair?

• The job of the cushions base where there is a visible or palpable structural base is typically to;
  • Provide a stable base of support
  • Provide a surface for attaching positioning components

9) What kinds of materials are typically used for a cushion base, and why?

• Typically the bases that are intended to provide postural stability are made of some type of foam.
• Why? Because foam depending on the type can be of varying firmness, can be open or closed cell structure leading some variations to have the potential for cutting/carving and/or added to… 

10)  Middle/Top Layers: What are the purposes of the seat cushion’s middle/top layers, which are on top of the seat cushion’s base? What purposes do cutouts or indentations in foam potentially serve? Many different types of materials — including foams of varying thicknesses and densities, gel inserts, etc. — are used in this area of the cushion. What do these different media accomplish?

• The purposes of the seat cushion’s middle/top layers are many.
• In consideration of product design and materials used, we have many factors to consider mostly depending upon the clinical goals. If for example, lateral stability is one of the goals for the client, a cushion may be selected for trial that is designed such that the ischials can sink into the materials at least 2” without bottoming out and the precontouring, if it exists, needs to respect the anatomical dimensions of the trochanters and femoral loading area.
• The cover and the materials beneath the cover need to work in harmony creating minimal tension so as to allow this optimal immersion of the ischials.
• If using a fluid material beneath the pelvis, segmentation becomes an important factor. This may reduce the flow of the fluid from one side to another, enhancing stability.
• If skin protection is an identified goal, we need to think about selecting materials that allow immersion without bottoming out as well as optimal envelopment with the goal of pressure redistribution. This means that we want the ischials to sink in while providing an optimal shape relationship with the clients’ unique buttocks and femoral shape so as we have an overall reduction in the magnitude of the pressure.
• A desirable shape relationship can be achieved with fluids for example that have in the design of the container low surface tension and a volume that permits the appropriate depth of immersion.
• Others use the intimacy of custom molding/shaping to achieve this intimate shape relationship.

 In summary I would like to share a check list that I use to help me look at all cushions with a critical eye…

1. Cover: How stretchable is it? How easy is it to get on and off for laundering?
2. Material inside the cover… what exactly is it? How does it behave?
3. What’s the immersion and envelopment possibility?Why does this matter?
4. Is the cushion customizable for unique positioning needs?
5. Is there adjustability for future changes?
6. What has been provided to manage potential shear forces?
7. What microbial factors are in place– How is heat and moisture managed?
8. What is the overall weight?
9. How will this cushion effect overall seated height when loaded and in use?
10. What’s the anticipated durability?

Goodbye to 2012 and a huge welcome to 2013! 2012 was a very busy year for me and already  the 2013 calendar is filling up at a rapid pace! I spent the first week of this year updating my website and adding dates and locations for events that are in the process of being finalized. Check it out! http://www.seatingsolutionsllc.com

If you have ideas on topics you would like to see posted over the next several months or on focus areas for webinars or live education events, I would love to hear your thoughts. As I begin my travels this week, I will also put together some thoughts and ideas! Here’s to a terrific 2013!

Boy, has September and October been busy travel months! I have been in Atlanta, Minneapolis, Columbus, Baltimore, Southern Illinois, and Germany! During this travel experience I’ve encountered many wonderful Clinicians, Suppliers and Clients. I have been trying to capture the most commonly asked questions during these events and to be honest there were many repeated excellent questions. Today I will summarize some of the most frequently asked questions related to the importance of back supports in the overall wheelchair seated success. These questions have been asked several times in many locations around the world. If anyone reading this has thoughts you would like to share on the importance of back supports, please leave a comment below. 

 Q1: When we sit, how are the positions of our back and our pelvis related to each other? For instance, if the pelvis is tilted to one side, how does that impact the position of the clients back against the back of the seating system/chair?

Think of it this way…  
•  The sacrum connects to the spine at S1/L5 
•  The sacrum’s position dictates the rest of the spine reaction 
•  The head is connected to and balances on top of the spine 
Therefore the position of the sacrum and pelvis must be considered when evaluating a persons trunk stability, head position and overall sitting balance.

Everything that happens with the hip/pelvis relationship and the pelvis/spine relationship effects EVERYTHING related to sitting. When the pelvis is in neutral alignment with respect to the sitting world, the spine (assuming there is flexibility) will be in its best alignment for optimal spinal stacking, exhibiting neutral/natural spinal curves. When the pelvis is rotated rearward (posterior pelvic tilt), the spine assumes a compensating kyphotic posture with flattened lordosis and likewise when the pelvis is oriented in an Anterior tilted position, the spine assumes a hyperextended – increased lordotic posture. Of course with a lateral pelvic tilted position, we can expect a compensating scoliosis. Given that the head is connected to and tries to balance on top of the spine or remain in a midline position, the head position will also be greatly impacted by what’s happening at the pelvis, hips and spine.

When someone asks me to problem solve their seat cushion challenges whether they are positional or skin integrity related, one of the first questions I ask is what kind of back support is being utilized and how the posterior sitting “footprint” presents. 

Q2. We often encounter situations where wheelchair backs and wheelchair seat cushions are completely separate components that are chosen and fitted separately from each other. Are there potential benefits of considering them more holistically, as part of a single seating solution rather than just as individual parts? If so, what are examples of those benefits?
 
I believe that the seat support and the back support have to be in harmony – both respecting the goals for overall sitting posture, function and skin protection. Whether the two are made together or are separate components ordered at the same or different times, they MUST work together to provide optimal inferior and posterior ,+/-  lateral  support  in alignment with gravity, and functional goals for the client. If this doesn’t happen, the likelihood of poor outcomes is greatly increased.  

One example of this might be the scenario where a cushion is prescribed that is designed for deep immersion of the pelvis. It might also be a goal that the back support prescribed respects the sacrum and provides optimal posterior lateral pelvis stabilization while facilitating thoracic extension. If all of these desired outcomes are not considered up front, and the back is prescribed separately from the cushion, it might be discovered at final fitting and delivery (which is never a good time to discover these things!), that the points of contact for the back support can’t be aligned optimally with the pelvis and spine due to the desired immersion in the seat cushion and relationship with back posts…

This could all have been avoided and the desired outcome for both the back support and the seat cushion achieved had the prescription process considered this at the time of assessment or during product trial. I always consider the back support at the same time as assessing for the seat support and mobility base if possible.
 
Q3. What impacts does the seat cushion and back, in combination, have on functions such as propulsion or pressure distribution? How do they impact the overall success of a wheeled mobility system? 
 
The impact of seat cushion and back support together has great impact on propulsion as well as on pressure management.  A well fitted back and seat support should maximize surface contact area in all the inferior and posterior aspects of the sitting body, where one can tolerate load and   respect body shapes and angles in a way that optimizes pelvic/spine & pelvic/hip stability. This will in turn enhance function and pressure distribution in a correctly fitted wheeled mobility base. Equally important throughout this whole discussion is foot positioning and loading in the presence of feet. A well fitted back support that respects both the clients need for support as well as freedom of movement will certainly optimize efficiency of propulsion.

If you’ve had any similar experiences, let me know in the comments below!

It’s so hard to believe that summer is almost at its end and we are full on into a very busy Fall… Fall is indeed my favorite time of the year! I love the Indian summer days and cool mornings and evenings that we have the pleasure of here in Colorado.

For me, Fall is a very busy season for clinical education and clinical wheeled mobility assessments. School’s are back in action and we are all seeking new and more information as well as getting our CEU hours in order to meet all annual deadlines!!!

I just dropped my oldest daughter off at University where she is so excited to begin her journey into the world of adulthood!!! Nothing could have prepared me for this transition I must admit

On the work front – I had the pleasure of working in Argentina a couple of weeks ago as they prepare for their 2013 Seating symposium. I enjoyed conducting 2 amazing days of clinical training with a group of eager clinicians, suppliers and manufacturers. We ended the 2-day program with a client who allowed us all to do hands on assessment techniques as we discussed the translation of the clinical findings into equipment parameters.

This young 22 year old gentleman presented with a traumatic brain injury acquired when he was 5 years old. He presented in his chair with a right obliquity (right side of pelvis low) and a right rotation (left side of pelvis forward) along with a compensating scoliosis. His right leg was held in what appeared to be visually as neutral alignment with a knee strap.

On evaluation, he had limited abduction (could not achieve a midline position for sitting) in his right hip. How this presented was that when his right femur was brought into midline alignment his left side of pelvis came forwards (right rotation) as well as he developed a compensating scoliosis and obliquity. When his right femur was respected in the adducted position his pelvis and spine were neutral… This is not uncommon… the dilemma of course is “what to do”?

I saw 2 choices for his seating system goals.

1)  Respect the right abduction limitation and let the right hip/femur rest in its desired adducted position and align/support the right foot beneath the right knee (aka closer to the left foot). Seat shape and contour will have to respect this pelvic/hip asymmetry while optimizing the inferior sitting “(foot)”print. Support the neutral pelvic/spine relationship with the appropriate back support optimizing posterior sitting “(foot)”print.

2) Attempt to align the femurs and feet in a more “seating friendly neutral alignment” and recognize that the consequence is a right obliquity, right rotation and scoliosis with all the possible negative impacts such as skin integrity issues on the right Ischial tuberosity; pain; fatigue and respiratory limitations due to the compensating scoliosis over time.

My personal vote is to aim for option 1 if possible when looking at only the seating/mobility solutions.

This is what the seminar attendees also agreed upon. However, there may be times when the team do not all agree on this path.

In an ideal world, the client would seek medical consult and perhaps look beyond the seating mobility system for medical/surgical solutions.

In this case the client’s Mother who was in attendance is going to discuss all options with their medical/clinical team. What a terrific experience this was for all of us lucky enough to have had the opportunity to work with this client at this very fun education event.

Next week I will be presenting in Atlanta and well as in Columbus OH. I am very excited to work with the clinicians who attend these educational events.

In my July 9th blog post, we discussed the top 3 questions that I consider when initially determining the level of risk for skin integrity issues my wheelchair seated client may be. Upon asking these 3 questions… 

What if the client has never had a history, doesn’t have a presence of sitting surface skin integrity issues and is doing effective weight shifts consistently? Perhaps they don’t need technology to do the weight shift for them and perhaps they don’t need the cushion with the most pressure reducing materials or the cushion with the deepest level of immersion and envelopment, but before determining what kind of wheelchair seating properties the client will need we must also consider the following factors:

• Is the client very boney on the sitting surfaces? 
• Do they have a lot of atrophy?
• Are they very active – moving in  or from the seated position frequently?
• Do they experience heat and /or moisture issues at the sitting surface? 
• Could they be at risk of high shear forces on the sitting surface ? and/or could they need consideration for microclimatic issues? 

Although our client may have passed the first three questions, this does not mean they are not at risk! They may not be at the highest risk but they may certainly be at moderate risk. Shear reducing features in their seat cushion may be needed, as well as moisture/heat management properties in the cushion and cover materials.

These questions have not covered any aspect of the seating assessment (for example positioning, stability, function, etc.) other than those that the seat cushion can realistically address when it comes to skin integrity risk for the wheelchair seated client. 

There are many contributing risk factors for skin integrity issues beyond pressure, shear, heat and moisture and unfortunately many are beyond the scope of the wheeled mobility and seating solution. For example: Diabetes; Cancer; Poor nutrition; smoking etc…  

When I am doing wheeled mobility assessments, I find myself educating the client and family with respect to all the contributing risk factors. At the same time, I’m focusing on the factors that seating and mobility technology can realistically address should the client use the equipment as intended according to the recommended clinical protocols.When we consider the cost of treating decubitus ulcers as well as the number of related deaths annually, this truly is a very important section of our seating and wheeled mobility hands on assessment.

What are the 3 “must ask questions” that we should be able to answer for every client we assess for a wheeled mobility seating system?  These are the three questions I ask for every client every day.

Question one: Does the client have a history of skin integrity issues on the sitting surfaces? 

If the  answer is “yes” (and remember category 1  is redness only ) – then I believe the client is at HIGH RISK for recurrence.                

It’s important to understand the cause of the past history and if it is related to the seated position the wheeled mobility seating solution must address this.

Question two: Does the client have a presence today of any skin integrity issues on the sitting surfaces? 

If the answer is YES then the client is at HIGH RISK. It’s our job to really pay attention and carefully analyze what the cause of the skin integrity issue is in order to determine whether it’s within the reasonable scope of what the seating and mobility system can address. Then we must prescribe accordingly.

Question three: Can the client do an effective, consistent, weight shift? And, if yes, are they doing it? 

If the client cannot perform an effective weight shift for whatever reason, then I believe they are at HIGH RISK. In the absence of human intervention, we must prescribe the technology which will do the weight shift for the client either manually or powered.

What do we have available to us in the complex world of rehab technology? I believe our best options are tilt (45-60 degrees to be used 15 mins every hour for example), or tilt plus recline, or recline only, or standing…or any combination. Anything that can offer consistent effective weight shfts.

Of course whatever we prescribe, we must also be specific with the application of how the prescribed technology is to be used including frequency, continuous checking of the skin,  washing and drying instructions,  use of slings and diapers, and any other appropriate tools at our disposal.  It’s our job to understand  what risk the client is at and why and then prescribe and justify the best solution available.

Please let me know if you have any thoughts on this vitally important topic.

I have just completed a tour of The Netherlands with seminars every day for a week! A common topic of discussion was the limited time that we as clinicians have for doing our seating and mobility assessments. With more demand for documentation, evidence, outcomes, etc., it often seems like there is simply not enough time in our work day. Does this thought resonate with you? 

I came to the conclusion years ago that if I only had 10 minutes for an assessment, I would use it by getting the patient supine and evaluating  the relationship between hip flexion and pelvic mobility relative to the seated position.

I am fully aware that in some clinical settings it is not so common to do a supine evaluation when conducting a wheeled mobility and seating assessment, but it is something I have learned over the years that is really quite valuable, and I strive to do it whenever possible.

For me, the supine position makes evaluating the hips relative to sitting much easier than if I were just to do a seated evaluation. It also allows us to get a clear picture of what happens to the pelvis/spine relationship when we evaluate lower extremity mid-line alignment relative to the seated position. The supine position allows us to clearly palpate the effect of hip flexion and hip ab/adduction on pelvic /spine mobility which in my opinion is critical information for optimal set up of the wheelchair and seating system. 

First, let’s imagine that our client presents in the chair in a posterior pelvic tilted position and is sliding… We don’t really know the cause of the problem but we are very aware of the symptoms … Sliding – kyphosis – potential sacral skin integrity issues, etc.

We get the client out of their chair and into supine on a firm, flat surface (mat table/plinth). Now with our hands behind the PSIS’s we can easily palpate for posterior, pelvic tilting as we take each hip towards 90 degrees of hip flexion, which may be required for successful sitting in the clients chair (depending upon set up). We can easily establish whether a true 90 degrees of hip flexion is available or not in the absence of posterior pelvic tilting and loss of lumbar lordosis. If we palpate posterior, pelvic tilting before 90 degrees of hip flexion is reached bilaterally, this will tell us how the client’s chair seat-to-back angle needs to be set up. With this information we can make realistic and functional decisions with the client and the caregiving team. 

Second , let’s imagine our client presenting in their chair with a left obliquity and left rotation (left side of pelvis low and right side of pelvis forward), with right hip adduction and perceived leg length discrepancy.  We take the client out of their chair and into a supine position for evaluation. We discover that the right hip cannot reach 90 degrees of true hip flexion without the pelvis tilting posteriorly and the lumbar lordosis being compromised. The left side is within normal limits for sitting . Now we have the choice of respecting the client’s limitations on the right side and perhaps opening the seat-to-back angle on that side, OR we can set the client up by addressing the obliquity and rotation, etc., but at the cost of future scoliosis/respiratory and skin complications. I personally like the idea of being able to choose based upon fact and not react to the symptoms. These choices are made much easier when we can do a supine evaluation.

These are just 2 examples that I like to use every day in my seminars to support the idea of taking the time to conduct thorough supine evaluations as part of the wheelchair seating assessment.