Exploring The World of Wheelchair Seating and Positioning

Picture this scenario; you have a patient who has been paraplegic as a result of an injury 8 years ago, did just fine for the first 5 or so years and then began to have issues with skin breakdown. The ulcers were minor at first, and then the patient presented with an eschar that ended up being a Stage 4 ischial pressure ulcer. Attempts over several months were made to heal to no avail. The decision was made to proceed with a reconstructive flap, which was done—and the patient spent the required time on bed rest. The ulcer is eventually determined healed, and the patient is ready to proceed with a sitting program again. He has a sports type of wheelchair, which he has used since his injury. The patient has his cushion, which he wants to return to using but you have concerns that this was the same system used prior when he broke down. To learn how to handle this situation, the author interviewed Stephanie Tanguay OTR/L, ATP an employee of Motion Concepts, Tonawanda, N.Y. Dot Weir (DW): Tell me about yourself. Stephanie Tanguay (ST): I’ve been an occupational therapist since the mid 80’s. I trained at Eastern Michigan University, and for the first 13 years I worked at a freestanding rehab center, The Rehabilitation Institute of Michigan, which is part of the Detroit Medical Center. I then spent 7 years working as a RTS (a rehabilitation technology supplier), so on the equipment provision side of things. For the past five and a half years I have been working for Motion Concepts, a company based out of the greater Toronto area with US distribution and customer service out of Tonawanda, N.Y. Our company creates an extensive range of power positioning systems such as tilt and recline seat systems for pressure redistribution and elevating seat features to enhance functional access to various height areas of the environment. We also manufacture a line of seating products, which are designed to meet the positioning and pressure distribution needs of a wide range of consumers. I specifically work with the MaTRx line of seating and back products and accessories that can complement almost any mobility system, power or manual. In the role of Clinical Education Specialist I travel the entire U.S. and parts of Canada meeting with clinicians and providers to educate them about our product line. DW: How did you develop such an interest in the specialty of seating? ST: In my first job I had the unique opportunity as an occupational therapist to rotate to different units, which were very specialized for brain injury, neurology, stroke, spinal cord injury (SCI), even a rheumatology unit, as well as a general physical medicine and rehab unit, which included orthopedics. An interesting aspect of how the program ran was that in the SCI unit, the Physical Therapists (PT’s) were responsible for the prescription of manual chairs and the Occupational Therapists (OT’s) were responsible for the prescription of powered chairs. It wasn’t an “un-crossable” line though and over time, we became more collaborative with both disciplines working more closely together. When I rotated to SCI unit, they didn’t have a seating clinic so I went to my supervisor with the anticipation of being mentored in how to properly prescribe power wheelchairs. Instead, I was told to just call a DME Dealer, and that they would tell me what the patient needed. At that time, there wasn’t a lot of info available regarding the different chairs and seat surfaces in terms of the various features and comparing and contrasting between them. There didn’t seem to be a process, and I thought that I, as the therapist for the patient, should be the one deciding what features would best meet the patients’ needs. That was more than 20 years ago. Now there are a number of very excellent providers available, which we’ll also talk about, but it is still so important for the OT’s and PT’s to be involved to be able to really match the specific needs of the patient with the features needed in a chair. It’s important to know the hand function, the ability to transfer and type of arm rests that will be needed, for example if the arm comes off, lifts, latches, locks, etc. The needs will be different for someone with limited trunk balance as another example, or special difficulties with their feet requiring specialized lower extremity supports. A lot of the challenge is created by the billing guidelines for Medicare patients (which can also effect reimbursement from other funding and insurance). There are complicated issues for evaluation time lines, documentation and diagnosis qualification criteria. DW: Well, this is definitely not a “one size fits all” proposition! What are some other challenges? ST: Another challenge is with the patient who has been in a chair for a long time, and using the same cushion for the whole time, which is perhaps like the patient you described in your introduction of the topic. One challenge is that if you think about it, this particular chair and cushion and the way the patient sits on that cushion have been an extension of their body for a long period of time. Let’s put it into a real life scenario. You’ve had a 2002 Ford Explorer for 10 years, taking exquisite care of it, and it becomes totaled in an accident and you have to replace it. So you go to the Ford Dealership, and they let you try out a 2012 Ford Explorer. You immediately realize that it is very different, and you tell your salesman that you want a car that was just like your 2002, only to be told that the body style, the features and things that were very familiar to you no longer are being made, even though the 2012 is loaded with the very latest in technology. (A lot of people in our industry dislike the use of car to wheelchair analogies, but as a point of reference, the majority of people in our society have experience with automobiles). While this may seem way off, the same holds true for mobility and seating equipment. If a patient’s chair has just worn out and needs to be replaced, all of the very specific details of the old chair that the patient has lived with since injured may be very much changed, requiring adjustments and new training. Add to that the fact that if the patient has been hospitalized, or placed on bed rest because of a wound or surgery—perhaps when it comes time for seating—they may now have very different needs than they did before. The patient can get very frustrated and resentful of the change. This is where the input of PT’s and OT’s are critical to the adaptation of the patient as well as family members and caregivers and being very involved with the small nuances in teaching transfers, movement in the chair and designing appropriate and doable weight shifts, helping with range of motion, muscle strengthening, etc. An additional challenge is the need to evaluate the patient in the chair options that are being considered. The therapist evaluating the patient needs and recommending the equipment cannot work for the equipment provider. The ability to come to the clinic and have the chair options available can be a logistical nightmare. Some rehab facilities have sample chairs and equipment on hand to show and try with consumers. Sometimes the equipment samples may be available from an equipment provider/dealer. The very process can make it difficult to impossible to be evaluated by a credentialed professional. DW: So let’s talk about pressure mapping. How did you get started in this? ST: I had a department director in the early 90’s that was totally embracing of technology and very supportive of securing funding for us to have pressure mapping; it was a lot of money to spend at that time. We had one of the first commercially available systems that were computer based. The pads that we put on the chair to evaluate the patient on a cushion were quite thick and rigid (compared to the mats available today) and they had limited conform ability with heavy connections between each sensor. The rigidity of the pads didn’t allow them to conform to deep contours and could give rather skewed data; sometimes showing “hot spots” of pressure where there weren’t any. It was great for the time, but now the sensor mats are very thin and light. They drape much better and there are no bulky connectors between the sensors. The data we get is much more rapid versus the waiting time we had back then and much more detailed. But you still always have to understand the type of technology you are using; it can still be difficult to get objective and repeatable data. There is some interesting research coming out this year of a project looking at the repeatability and limitations of pressure mapping. It’s important to know that it cannot be the only tool that is used to make decisions for patients. If I pressure map you on a cushion today, and do the same tomorrow, the results should be the same. If there is a variance, that’s a problem, again, the need for more than one tool. DW: What are some other issues that you see? ST: There is a good reason to re-evaluate the patient’s seating after wound healing, but any patient should be followed over time. In the time lapse after the initial injury or onset of the condition, so much can change, such as tight hamstrings, decreased range of motion, tight hip flexors, and heterotrophic ossification (abnormal formation of true bone within extraskeletal soft tissues). Let’s say a patient has had a muscle flap over an ischial pressure ulcer. There’s a likelihood that the ischial tuberosity will be shaved down, just as a routine so it won’t protrude through the flap, or if there was osteomyelitis. This creates an obliquity, one side of the pelvis structure is now lower than the other, which can cause the patient to sit unevenly, ultimately causing a breakdown of the flap. This isn’t necessarily obvious to the view and it takes the therapists physically examining the patient; having them sit on a flat level surface, and palpate to look and feel for this change, and determine if they are possibly sitting oblique or if the pelvis is rotated posteriorly or anteriorly. This changes the weight bearing contact, and the seating must be adjusted for this. If a therapist can’t follow patient after they have ordered initial equipment, they may not ever see the patient in the chair. The ideal is that the equipment is delivered with the therapist and the patient together. There is also a tremendous and sometimes repeated education related to use of the chair, use of features, proper use of the seat cushion, back support, etc. Often when discharge time comes, an overload of information is provided to the patient and the family, and it can be overwhelming to the point that key teaching is not understood. The concept of repositioning needs to be started early and emphasized throughout the patient’s rehabilitation and reinforced periodically over time, years even. The use of pressure mapping is also great bio-feedback mechanism for patient education. You can have the patient perform pressure relief, weight shift, side-to-side, lift up, lean forward or any other moves and have them see the changes that result. It is a good time to emphasize frequency, how long to sustain it when tilting, how far back and how often. However, you would fill in this sentence: “The best pressure relief cushion is _______.”, if you sit on it statically and never do a weight shift, no cushion is going to overcome that. I have learned a whole lot more about seating from failures then successes. When something doesn’t turn out well, it’s a wake up call. I don’t believe we should ever think that we know everything. Many people put too much faith into the cushion without considering and teaching the effects of nutrition, smoking, circulation, and good skin care. There are so many more factors, which come into play. It’s also not simply about a certain brand name. Different cushion mediums or materials can be just as effective when coupled with more frequent movement patterns. Also, consumers can go for years with the same equipment without any skin problems, but one change in condition can drastically change that. DW: What other types of patients besides SCI do we need to consider for a seating clinic? ST: Any condition that impairs mobility and causes the need for significant time spent in a wheelchair. We see spina bifida, cerebral palsey, brain injury, ALS, multiple sclerosis, muscular dystrophy, stroke and severe advanced lymphedema resulting in mobility issues. We teach all patients that the optimum frequency of weight shifts are for 2 minutes every 15-20 minutes although it seems very few can keep up with that. We must re-assess and educate, balance it with technology. DW: What’s your advice for someone needing help finding a seating clinic for patients? Is there a registry or database listing of clinics that specialize in doing seating evaluations? ST: There is no real database, but a great way is to look for a certified Assistance Technology Professional. There is an organization called RESNA (Rehabilitation Engineering & Assistance Technology Society of North America). Their website is www.resna.org. They are a long standing organization and have certification for three specialties: Assistive Technology Professional (ATP), Seating & Mobility Specialist (SMS), and Rehabilitation Engineering Technologist (RET). It is an interdisciplinary group, with PT’s, OT’s, Speech Language Pathologists (SLP’s) Providers and Manufacturers. The link to their website to find a certified professional is https://web.resna.org/certification/certification-directory.dot. I would recommend searching for someone by geographic location and then call the facility where they work and ask if they have a seating clinic. Additionally, you want to work with an equipment provider that has met basic levels of knowledge, experience and education. NRRTS (National Registry of Rehabilitation Technology Suppliers) is a good place to start. This group has been around for about 20 years and their website is www.nrrts.org. Before this organization was formed, one could claim any level of knowledge related to serving this population of patient with such needs. NRRTS looks at base level education, requires references attesting to the level of knowledge and service as well as the funding process for equipment and their members adhere to the required code of ethics. They also have a yearly CE requirement, so members should be keeping up to date on new equipment and technologies. This is a great resource if a consumer is relocating to a different city of state and needs to find a rehab equipment provider to service, repair or provide their equipment. DW: Stephanie I have learned so much from this interview, you are as special as our mutual friend and colleague Laurie Rappl said you were. I think I have always placed high importance on the patient having the best in equipment, but have a deeper appreciation of the details that we were only able to scratch the surface on here. I do hope we can get you to contribute articles in the future to Today’s Wound Clinic. Any parting words of advice that we didn’t cover? ST: Just that all patients should be aligned with a dependable equipment provider that can provide a sustained relationship with over time. Although some patients go to regional rehab centers outside of their geographical area for rehab, ideally their chair, cushions and other needs can be purchased locally for rapid and continued support.