Tip:
Highlight text to annotate it
X
[ Silence ]
>> I'm here to welcome you to the SCI forum tonight.
I'm a rehabilitation psychologist in the Department
of Rehabilitation Medicine at University of Washington.
And I'm the director
of the Spinal Cord Injury Model System here at UW.
The forums and the video recordings
in our online media content are all made possible by grand
from the national institute on disability
and rehabilitation research.
And we're grateful for that funding.
Tonight, we're very pleased to welcome Dr. Jennifer Hastings
who is the director of the school of physical therapy
at the University of Puget Sound and an expert in the area
of wheelchair-sitting.
Her presentation tonight is titled tips
for choosing the right wheelchair.
After Dr. Hastings presentation, we'll open things
up for the audience to ask questions.
So welcome Dr. Hastings.
[ Applause ]
>> Tips for choosing the right wheelchair.
Here we go.
First off, you have to be systematic, OK?
So you shouldn't just go online and see the coolest thing.
You shouldn't buy in the other marketing.
You have to have a system.
And the system that I'm going to suggest is on this slide, OK?
Now, I'm going to walk you through this.
But the most important thing is right there, OK?
A physical examination, I think there's a whole lot
of getting the wheelchairs,
getting the wheelchair equipment, getting cushions,
getting backrest without a physical exam.
And I'm going to try to explain
to you why that's a really bad idea.
The thing that it says on the bottom
in the yellow is a functional assessment.
We're going to walk through that to.
But it's basically, what is the equipment need to do, all right?
And then, we will take you through the next steps,
but I'm also going to recommend trials as really important, OK?
Because of you don't try a wheelchair
and you don't really know what you're getting.
And the other part is that chair has to be setup correctly, OK?
Because this is not really a trial if it's setup
for somebody entirely different size, shape,
and its physical ability than you.
So that's another piece.
I know that it's a challenging piece.
I know it's a challenging piece.
I know timelines are part of the problem.
So let's start with that functional assessment.
What does the wheelchair have to do?
Sounds like a stupid question.
It's like, well, I can't walk anymore.
So that's what my wheelchair is doing but, you know,
there's more than that.
Maybe, there's poor endurance.
That might be a reason why you need power
or power assist, OK, or ultralight.
And then, there's the paralyzed trunk, too little attention
to the paralyzed trunk.
There's a huge difference having stability your trunk or not
in terms of what you can and can't do in terms
of how you push the chair,
in terms of what the chair has to do for you, OK?
So that's an important and we'll walkthrough it.
So, while you're basically doing is you're figuring out what
that chair has to do for you and what the chair has to do
for you basically is support the right posture
and then support the things you need to do functionally, OK?
So posture, what the chair has to do and I'm going
to spend more time on this later, but the chair
and the way it shaped configured has to help you seat
in the best posture you can particularly in the presence
of a paralyze trunk, OK?
And the only way you know how to set that chair up is by doing
that physical examination and we're going to talk about that.
The functional needs are a little bit easier
and also more patient specific.
The postural support, meaning the orthotic support
at the wheelchair does.
There is some pretty specific rules about that.
Based on your physical exam,
how are you going to set the chair up?
OK. They're pretty specific and I'll get there.
Function is way more individual, OK?
So, it has to do with these parameters.
How much time do you spend in the wheelchair?
OK? What environment do you live in?
Are you in Seattle or Montana?
Right? Are you in an urban or rural area?
OK. How are you for wheelchair skills?
I'm going to go out in a limb and say, "More recently,
more people have lesser wheelchair skills."
OK? So, if you can't masterly used your wheelchair
in your environment meaning we at least opening doors
for yourself going up curves, that sort of thing,
then you're going to be more challenge in what used
to be considered not so should in aggressive environment, OK?
So that matters as well.
Ability to self-care, are you going to get dress
in your wheelchair, OK?
A therapist, a common therapist mistake is
to put an after-market, solid backrest on the chair
for somebody who's been using a wheelchair for a very long time.
And the therapist forgets to find
out whether the person dresses in their chair.
They dress in their chair.
They're going to tend the arc over the backrest.
And if that backrest does now solid in a little higher,
you've just made them not able to pull up and down pants, OK?
Which is sort of a big deal and usually is why
that equipment will fail, OK?
So thinking about what people do in the chair
and what their abilities are.
Let's expand that a little.
Can the individual uses the wheelchair transfer, OK,
at all or really, really easily?
At all means, they won't have any help and maybe they'll get
into the chair once or maybe they'll transfer
out of the chair into their drivers vehicle,
you know, the van seat.
But the rest of the day they're in the chair.
The person who transfers easily, they're going to hop
out of the chair to watch TV, out of the chair
to watch a movie, may be out of the chair
to eat at a restaurant, OK?
That's an entirely different need
for what the chair provides, right?
OK? So, one can be a real minimal chair, all right?
And the other has to provide more things.
The other issue is how much assistance they might need
from a caregiver, and if a caregiver has to do help
for that transfer, the chair has to be setup thinking
about ease for the caregiver.
OK. You're going to build that in a little bit, all right?
So if the time in the wheelchair is super limited
because they can transfer a lot.
The chair can be minimal, if they're going to be
in an all day, now we need more comfort.
We need pressure relief.
We need some more supports that we might not have
in the chair, otherwise, OK?
So you should have following the idea
of what does the chair have to do.
We haven't even look at what's out there on the market yet.
We're at the very first two boxes on that form, OK?
Now, I talk a little bit about the environment,
but let's expand that a little.
If you're going to use the wheelchair only indoor level
environment which is where we test them frequently
when we're trying them out in somebody's clinic
or hospital floor, right?
If that's where you are then you can specify, you can think
about all the parts for minimal roll resistance, OK?
But if you're going to use it on rough terrain, cross gravel
as you're daily driver.
If your chair is your mobility device, then you don't have
and using public transportation.
Now you need to be thinking about shock absorption, right?
You need to be thinking about durability.
You need to be thinking about long durability of a battery
if it say power chair, OK?
So you have to think about, again,
how is this chair used for the individual?
Again, I talked
about wheelchairs skills a little bit already
but propulsion skills is part of this too, OK?
If you can lift your casters, if you know how
to lighten your casters.
So that a little threshold or a little bump,
or a change in carpet density doesn't interfere with you,
that's going to be again an entirely different person
for what you can specify in that chair, then somebody
who can not to do that.
Who need to have, you know, larger casters to track
over things like threshold and cracks on the sidewalk, OK?
So, it's going to matter.
And then, again, for power and manual equipment,
but more for power, safety, judgment,
those kinds of things matter.
The ability for self-care-- we talked about that picking
up the pants and getting dressed in power chairs and also
in manual chairs, but self-cathing, OK?
Not just getting pants on, but what position to people need
to get into manage bladder is huge.
And that matters whether they're cathing,
or whether they're draining a leg bath, OK?
Most of the time the individual needs to shift forward,
bring their butt forward a little bit in order
to create a pelvic tilt a little bit.
In order to get some more instability and some space, OK?
If you over shorten things because of light weight
or because of posture thinking.
You might interfere with this very, very important function
of bladder management, OK?
So we have to think about that one in ADL as well.
OK.
ADL also has wheelchair height.
OK? So, what are you doing?
What are you doing throughout the day?
How-- what is the clearance that your knees need to go under?
OK? What environment are you in?
Are you going to school?
Are you going to work?
Are you going to work where you only have one work station
and you can get it modified to suit your needs?
Or are you a mobile employee who's going in and out
of a number of environments where the tables are going
to usually be more closer to standard and you might want
to be able to get under those.
OK? So, this is what I mean when I say ADL work as well.
Transportation, another mistake that's made by a lot
of therapist upgrading long term user's chairs is to forget
to find out where that chair goes in their car, OK?
Years, and years, and years ago when we were trying
to get everybody into the rigid wheelchairs,
they were a number-- I had a number of fails
because the individuals could not find them stowing the
wheelchair into the car that way that's necessary
by taking wheel off but it seems too hard,
didn't matter the chair was 30 pounds lighter,
it still seems too hard, OK?
So there are something's that long term users have--
did just-- at hobbit, they're not going to change.
Or sometimes a space, remember a car, I mean,
wheelchairs are pretty darn expensive,
but cars are more expensive.
So the vehicle that the person already owns probably needs
to be respected in terms
of how is your chair going to fit in there.
OK? The other issues, if the individuals are going to ride
in the chair to drive.
Strongly, strongly recommend against this, OK,
strongly recommend against it.
It is true that the tie down systems hold the chairs,
it is not true that anything
on your chair is stress tested at an accident level.
So, everything that's bolted on by a therapist or a vendor
or something else, you know, it's a give point
in an accident, and that makes it highly dangerous.
It is way better to transfer into a vehicle seat and drive
from there for your safety.
But then I will also say, if you can't transfer,
and yet you can drive, driving is more important,
and that's a choice that I respect you might decide
to make, OK, because it's a huge for your independents
and I understand that.
But in terms of specifying a chair, we need to figure
out what's going on with how that person is riding
in a vehicle and how we should be setting it up.
Maintenance matters too.
If you lived in an urban area and you have multiple people
that can potential maintain your chair or get you parts.
That's one thing.
But if we're talking about Montana, way up in Alaska,
or even-- well, actually in Eastern Washington,
you're pretty good because we have some
of our manufacturers over here.
But there are places where you're going
to have a hard time getting equipment, OK?
Another thing you might want to think about is also
where is the manufacture versus where you live in terms
of replacement parts and even communication
with a therapist and the user.
So, if you have a free hour time differential.
If you're down to two different pieces of equipment,
and one is local, and your time is not necessarily next to orbit
in your time zone, and what is not, you may want to think
about that when you're figuring out the final decision, OK?
All right.
Now, most of what I've talked about is sort
of spinal cord specific so far.
But remember, spinal cord injured comes kind of all times
in life and some of these other things might already be going
on, OK?
Or they might get added to your spinal cord injury overtime.
I hope, and I'm here to tell you memory and age doesn't matter
with everything else is going on.
So cognitive abilities, unfortunately declined
as we age a little bit, you could also get something
like a stroke or another neurologic condition,
or you might have it ahead of time, OK?
We like to believe that spinal cord injury,
most people spinal cord injury are cognitively intact, right?
We really like to believe that but, you know what?
It's a lot of force caused that injury.
And your head got shake around, OK?
And you remember the shaken baby syndrome?
You know, all about these other things that are not you
that probably need a little head injury.
I realized in us we don't want to talk about it,
but there's a likely hood that you're not a 100 percent
in the brain capacities, OK?
We have a ton of functional reserve
which means we can compensate and that's how most
of you feel like you're fine, OK?
And you're probably acting fine.
But when you get older those little [inaudible]
to the head start showing up to, OK, so, just to know.
But cardiac, pulmonary, if you've been a smoker or are now,
these things matter too.
Visual perception matters particular in a power chair.
So again , these are all issue that as you're thinking
about what chair some as you get you need to think about.
Now, so, what we've done on that schematic,
there were two yellow boxes, one had physical exam
and we haven't really done that yet.
In the other said, functional exam.
That's what we've done.
I'm going to go back to the physical exam a little bit more,
but basically you're then going to come up with a list
of what equipment will meet all your names.
OK? And you start there, and you start there instead
of the equipment that's out there
that you saw that was cool.
What meets my needs?
And then you start there and I'm going
to really strongly recommend simple before complex.
The main reason there is the more things, the more weight,
the more possible breakage, OK?
So that's again, that's kind of my priorities.
OK? Now, we're going to get to the posture
and the physical part.
So, this is my baby.
This is my research here.
This is what I think is probably missing in most of what we do.
We as the spinal cord injury professionals
about muscular skeletal pain and spinal cord injury,
about chronic pain and spinal cord injury
that is not neurogenic.
I think most of this is postural or at least a huge amount of it
that we can intervene on is based on the posture.
So, I think that the seating and how you set your chair
up matters for your posture.
And so I think it's really, really important
that you have a postural evaluation.
Now, that means, getting out of your chair.
That means, out of your chair, on a firm surface mat.
The therapist with a tape measure and a goniometer,
everybody goniometer, I mean, I know that's a big technical term
but you all have been to rehab, right?
That ridiculous name for the thing, the piece of plastic
that swings back and forth, right?
It measures angles.
OK? You need the therapist and you need
to understand the limitations PROM,
if you're pregnant means premature ruptured of membranes.
But, if you're not pregnant and your spinal cord injured,
it means, passive range of motion, OK?
And that means how far can your limbs move
when they are passively moved.
And why it matters is your chair is going
to be a static system, right?
And if your body doesn't move freely into the angles setup
by your chair, we're going to have some problems.
OK. So, posture evaluation looks like this, this is the process,
the individual you are sitting
in something even a hospital chair or something, OK?
And I, the therapist, I'm going to look
at what you look like in that chair.
And I'm going to look through some particular points,
sort of systematically.
I'm going to look at your shoulders.
I'm going to look at your hips.
I'm going to look at where your legs are.
I'm going to look at your sternum.
I'm not going to walk you
through everything I'm going to look at.
But I'm doing a very objective observation.
What I'm trying to find
out is how are you sitting, right, in that chair.
Then I'm going to pull you out of that chair
because that chair is holding you up at least
to some extent, right?
I'm going to pull you out of that chair and I'm going to look
at what you look like now.
What I'm doing is I'm comparing these two things
and that's telling me what was that chair doing to you.
OK? Did you look better in whatever you came in?
Or do you look better without it?
I got to tell you a whole bunch of times.
You look better without it
which means the chair itself is creating postural problems, OK?
Then you go supine, supine means laying down flat in your back.
Flat in your back, I'm taking your limbs, your legs,
primarily, but to some extend your arms
and definitely you're trunk,
and finding out how it moves, how flexible it is.
What I'm doing now is comparing those two, and that's telling me
if I took gravity out of the picture,
can I get you straight, right?
If I put you on a stretching machine, grab your feet,
and grab your shoulders and stretch.
Can I get you straight?
Or are you bend, may be because your original fusion was not put
in completely straight or may be because you broke femur
and the range of motion not the same there, and it stocked, OK?
So there might be something's that I'm going to find
that are fixed or not flexible.
Then while you're out of the chair, I'm going to take
that tape measure and my goniometer.
I'm going to measure all of the parameters of the wheelchair.
This is all the angles.
What's the angle between the seat in the back?
How long is the seat depth?
What's the rear seat to floor, front seat to floor, angles, OK?
What I'm looking for is I'm looking for to your angles
to the motion that your body can do
and the angles in the chair match.
Do you fit?
Can you fit in the angles that are prescribed
or are they setting up some instabilities
that I can predict, OK?
So, I'm comparing your mobility with the chair.
So that's basically what a postural evaluation is.
I tell you that and I walk you through it
because if you have not had one,
then you have not had a seating evaluation even
if you paid for one, OK?
That's what it is supposed to be.
If somebody just say, "Oh, I think you should try and X."
You need this before you try that X, OK?
That's part of what we should do next.
Seating is therapy.
So all the therapy-- is there any therapist in this room?
Right. OK.
So the therapist in this room, it is therapy a lot
of therapist abdicate seating to a service department
at driver medical vendor.
So, again, I think this backrest needs to be adjusted.
Go take it to so-and-so and have them adjusted up.
You basically prescribe the therapeutic intervention
and you didn't follow up on it.
And you didn't assess whether you are right.
OK? So a number of other interventions that you can think
if you would never do without immediate assessment, OK?
And I think we need to take back and responsibly and I'm going
to walk you through it.
I know part of the problems we think we can't get paid for,
but perhaps, you can.
All right.
Now, here's an example of a gentlemen
who has a C8 spinal cord injury, OK,
and I will admit this is not the same day.
OK? In fact, on the right he's in definitive equipment
and even though he's wearing the same shirt.
It's not the same day.
On your left is the day that I evaluated it.
Contacted me for shoulder pain is shoulder pain went away.
His neck pain went away.
I'm going to suggest he looks all a heck of a lot better.
His wife thought he lost weight.
OK? Didn't lose a pound, but yes, looks like it.
OK? And that is a really important outcome, OK?
It's a very important outcome to look better.
I don't need to tell anybody in this room.
It's challenging to be disabled and cruising
around in a wheelchair.
It is not the most socially acceptable, you know,
person out there, right?
I mean, you're not-- you have to be strong to go out every day
and notice that so-and-so is talking to, you know,
your companion instead of you and assert
through that and I know that.
Now, also look worse, right?
Look worse.
So looking better, looking sharp is important.
It's a valid outcome.
So what is the seating intervention?
The seating intervention is this, any specification
or modification of a wheelchair configuration
or the user interface.
The user interface, the user interface means what you're
actually touching.
So the cushion under you, the backrest behind you,
it's a user interface, OK?
For the purpose of improving the users health, comfort,
function, or well-being, right?
Looks under well-being in my opinion, OK?
I am all over it's OK to just look better
and that's the only outcome I got.
All right.
Now, posture matters.
Posture matters a lot.
Now, the fellow on the left here.
All right.
Whatever. The guy in the orange shirt sitting next
to the young ladies.
The young lady in a white shirt showing us good posture, right?
Just happens to be there looking all perky.
The person and the chair is sitting
in very expensive equipment, all right?
Most of you recognize that.
We will not name the companies
but those are very expensive wheels.
It's a titanium chair that's very expensive
with an after-market backrest on it as well.
Top of the line equipment
and a horrendous posture, horrendous posture.
That is tetraplegic patient, I don't--
or individual, I don't know this person because he's
in new mobility may add, OK?
But I can tell by his arms that he's tetraplegic
and because it's 2003, he's tetraplegic.
The fellow on the right is a quadriplegic
because I rehab in '89, OK?
And he's six quadriplegic and he has no trunk muscle either
and that is a whole lot different looking posture, OK?
Now, I want to talk a little about skin,
because skin is really important in where I started in sort
of the advertised talk was pressure mapping.
So, that's where I started with my talk and I sort
of taking in every place else.
But skin and spinal cord injury, what happens?
We have a spinal cord injury and this set
of gray box has happened.
OK? The first one says immobility,
you can't move as well.
OK? You can't move as well.
Atrophy means every place
where you don't have functional muscles,
where the muscles aren't innervated anymore,
those muscles are getting smaller.
They physically shrink.
They actually get smaller in size
by telling anybody something you are surprise
to find out, probably not.
But nonetheless, that's what it is.
Atrophic change is a little bit more technical.
This is more about your skin, OK, and all your tissues.
It basically just means not as healthy, not as lubricated,
not as good as tensile strength, not as, not as.
OK? So for the skin, we are not as lubricated,
not as your sensory organs aren't there either.
We have all kinds of problems going on the skin, OK?
Thermoregulation, big word for temperature control, OK?
Temperature control, you lose some temperature control
with spinal cord injury depending
on your level of injury, right?
For the most part that's going to per skin matter
when you get hot, OK, and if particularly,
there is moisture in the area.
And this would not be sweat because that's what's lost,
and the evaporative sweating is loss, OK?
So, all of these things moisture
where it doesn't belong less muscle tissue
so that the bone is close into the surface, weaker skin, OK,
this sets up less tolerance for sitting
and for friction, et cetera, OK?
And then these two things are actually what setup
and more pressure.
In fact that you can't move as well, and the fact
that your bones are closer to the surface.
So you add those two together and you can get skin breakdown
or at least the potential for it,
much higher than without, OK?
So, in comes pressure mapping.
What is pressure mapping or what is it do?
A lot of pressure mapping system is a very flat sensor
that you put under your body or whatever you're worried
about the pressure on.
And on top of the cushion or whatever you're sitting on.
So it's between you and whatever surface you're wondering how
much pressure there is.
OK. It is an interface measure.
So interface means like this, the pressure
between those two points.
It doesn't measure in the other plains.
So it doesn't measure here, OK?
And it doesn't measure tissue perfusion.
Tissue perfusion means is their blood getting to the area
and why would we care about blood is
because blood carries oxygen and takes away waste product.
So is there getting oxygenation to the tissue,
pressure map doesn't tell us that, OK, does not tell us that.
It is interface pressure sensitive.
OK. So, and it doesn't mess with the shear seat.
Now, there's a correlation
between increase pressure and pressure ulcers.
Correlation means association.
It means people who have more pressures--
there's an association between that in pressure ulcers.
We are not clear that there is causation, OK?
And I say that because there's got to be something else
because there are people with very high pressures
and no pressure ulcers or source.
OK? However, we're pretty sure
that it's one of the factors, OK?
And that may be those people that have high pressures
and no source have some sort of protective thing as oppose
to other people, you know, missing--
well, I guess, missing
and having protected is the same, whatever.
Pressure mapping is a tool.
It's not the thing.
It's not the answer.
It's one of the tools that you probably want to put
in your seating assessment.
OK.
Now, that said, a lot of times, that's not going
to be one available and that doesn't mean you can't change
anything, OK?
Because, see, pressure mapping systems are pretty expensive
and they're not all over the place, so I don't want you
to think that you have to continue be afraid
of changing your sitting because nobody can map your pressures,
OK?
If you used a pressure map in combination
with everything else I've been telling you.
In my opinion, this is what it does.
If I've narrowed it down.
If I've gotten down to a couple of different cushions that meet
or wheelchair configurations equipment
that meet all of my client's needs.
Everything that they need to do
and are given me the posture that they need.
Then I'm picking between those two, and I want the one
with the better map, OK?
Because it's just that thing that lets me say, well,
these two-- sorts of all parts being equal, I'll go this one.
Or again, if I was looking in another equation,
all parts being equal, I might take the local person.
All parts being equal, I might take the one
that cost less money, right?
I mean, so, but you have to get to that equal part first,
and then this is-- decide.
Now, there's a few things that I want to point out.
All right.
This is a pressure map.
Pressure maps have these outputs screens that give you
for the most part colors, OK?
And some of you in-- all various magazine,
new mobility magazines, and the others, I mean,
as you've seen some of the vendors,
some of the cushion manufacturers will display a
pressure map, OK?
And this is part of their advertising, OK?
I'm going to submit to you, do not be suckered, or impressed,
or fooled, or anything by that.
Because a pressure map standing alone is pretty useless
information, OK?
So this is-- I'd say not a bad map, not a bad map.
But, you know, what I don't know?
I don't know the scale, OK?
I don't have the scale for the sensors.
Now the top of a scale is 200 millimeters in mercury
like when you pump up your blood pressure cuff, OK?
And the top of the pressure mapping scale is 200.
When you do a blood pressure on somebody, you normally pump
that cuff up to about 200, and then start letting it down,
or 180 is the way that you teach people.
This is not a bad map.
Yellow is not so bad.
Red is bad.
But this is a map and this is 10 minutes later.
I'll just let you seat here while we chat
about other things.
So it's important to also know when was that map taken.
What it look like later now.
And I also want you to know that this is the wound
that was present at the time of this map, OK?
So, again, pressure mapping is not sufficient.
It doesn't take the place of skin inspections.
It doesn't takes the place of an evaluation.
You also can't generalize.
So you can't look at that advertisement
and go all somebody's butt looked good on that cushion, OK?
So mind well, OK?
Because, in truth, you're individually or individually
in your pelvis size, individual in the amount of atrophy,
and your range of motion,
and your weight, et cetera, et cetera.
OK? So you can't do that.
It's comparative.
It's appropriate to compare different cushions
or configurations on the same day.
In my opinion, not even overtime with the same patient, OK?
And you have to be sure that the calibration is the same
and the scale is the same.
So again, now, this one shows you the scale over here, OK?
And so if you're looking at the scale, you can compare maps
on the same day of the same patient, and say, wow, you know,
of these if everything was equal, I definitely
like that far right corner one because the rest of them look
like they've got more pressure, right?
OK. However, position matters to.
Position matters huge, OK?
This is the same individual on the same cushion on the same day
in different positions, OK?
And these are literally not tilting the chair,
and I'm tilting the chair like that.
This is a little tag behind the knees, and putting them backward
of therapist thought they should be, all right?
Now I will submit to you that when the map looks
that different with a small positional change,
you might want to be someplace else to.
Because most of the patients can't maintain their posture
that tightly, right?
So they're not going to show up on that one down there.
This map, did anybody notice why it might look hotter
than the other ones?
I gave you the legend.
What's that?
It's 100, it's half of the other legend, OK?
So I would expect to see a lot more,
so really this top left one or maybe even all of them
at 200 would look fine.
The reason I lower this was
because I've had a very fragile skin,
person who'd already had multiple breakdowns
that we didn't want to open up again and we were thinking
about changing our position.
And we wanted to see where we, was it going to be risk.
OK? All right.
Also a dynamic assessment really very helpful.
So some of the systems are wireless, you can put the map
between you, you can go out and do things like, you know,
jump off curves, and do pushing, and things, and see whether
or not maybe the problem is something
about how you're pushing,
or how you're moving when you're pushing.
That's really nice.
But at the very least, if you're going
to bother the pressure map, you should simulate motion even
if you don't have a wireless one.
So somebody should be reaching through the ground.
They should be doing their pressure.
They should be pretending to push their chair.
So they're moving the preceded surface as if they were,
you know, really moving, OK?
Now, you can also use the pressure maps
to teach people the best pressure relief, all right?
So I mean I can go, OK, let's see if you can get enough relief
by leaning to the side or by leaning toward.
There is good evidence that foremost people of forward lean
and not even not dropping your chest to your knees,
but just a forward lean on like elbows
across your thighs is the best ischial pressure relief
that we can do at almost always clears people totally
and it's way easier than to lift, OK, and way better
for your shoulders to, so just in the left way.
But beware, a beautiful map,
a beautiful map doesn't negate the need for pressure release.
OK. You still have to move around.
Because, why?
Because we don't know where their pressure--
pressure associated with pressure ulcers if we don't know
that it's the cost, OK?
All right.
So, when I do pressure mapping.
I want to do it before and after an intervention.
And what I mean by intervention is wheelchair seating change.
Doesn't matter if it's going to be a cushion
or a backrest angle, OK?
So my preference is to do the map, then, and what I'm trying
to do is not make baseline any worse, OK?
That's what I'm trying to do.
Assuming that baseline has been OK, right?
So if they're coming to me
with a wound that's different then they're coming to me
because I've got a little back pain or I want
to get a new wheelchair because, OK?
All right.
So we're back to this.
So again, this spinal cord injury and it happens,
all the stuff happens.
This pressure intolerance happens
but posture basically affects these things, OK?
And it affects-- how does affect in mobility?
OK. Let me tell you about that.
You can be sitting in two stable of a posture,
if you're too stable, it's really hard for you to move,
and you're not going to move within that excursion
to change the pressures.
So you have to be in sort of depending on the fewer muscles
that you have under your disposal that you can use,
the more-- I know it's going to sound weird,
the more unstable you have to be, right?
Because, then you can--
your little bitty muscle can actually move your buddy,
where as if I put you in a super stable position.
Your limited motor ability is going
to be basically limited to, you know,
driving with your joint [inaudible], OK?
So you need to be thinking that way to.
All right.
So posture mediates the outcomes is just another slide,
sort of saying the same thing I talk
about pressure distribution already,
upper extremity biomechanics don't have time to talk
about that very much right now.
But the shoulder is attached here to your ribcage.
The scapula is free across your back.
It is obligatory to your spine, OK?
So if you're sitting in bad spinal posture,
by definition your upper extremity is
in bad mechanical used, OK, by definition, OK?
So good posture is prerequisite to move in your arms around.
Now if you weren't disabled and before you're disabled,
if you ever went to a physical therapist in the last decade,
they talked to you about core, OK?
Because that is what all the physical therapist
in the world are working on the strength in people's core.
What that means is your stability across your abs.
So that you have good posture,
so that you could have good mechanics and all of the rest
of your movements, OK?
So in spinal cord injury that's every bit an important
but we don't have abdominals to work with.
So we have to think about other ways to get our posture.
Respiratory function is on this list.
Posture matters for respiratory function.
How upright you are literally is your vital capacity.
If you get too close, you don't get as much air exchange.
Air matters because it carries oxygen and oxygen gets
to tissues and this tissue helps.
All right.
So, some of my early work was looking at the paralyzed trunk
and trying to figure out what I can do about it
because if I need to do something with the wheelchair
to make people sit better, what can I do?
And what I was able to show was that an acute.
So 90 degrees is a right angle, acute means tighter than 90.
Obtuse, or reclined, or open means wider than 90.
So if the sit to backrest is 90, acute is less
than 90 is what we needed to create better posture.
So we needed a less than 90 angle
to sit the backrest and positive seats.
So, a positive seats, that means the front of the seat slopes,
the front of the seat is higher than the butt of the seat.
OK. So that was work that I published in 2003.
And then my dissertation looked
at could I've been really changed somebody's
musculoskeletal pain, somebody's pain
by changing their wheelchair and yes I can.
OK. So what I was able to show is there was a real association
between musculoskeletal pain even
in long term wheelchair users and in fact sometimes more
so in long term wheelchair users.
And their posture and that we could fix it
or at least make it better by changes in their chair.
So what does that all mean?
OK. Most of you were in some sort of orthotic device
after breaking your spine.
Pairs wherein a TLSO, right?
They'd kept you from being able to bend and the points
to control were here, here,
and then there holding you from flexion.
Some of you were lucky enough to have it, could end across here,
a few probably had halos
that really wouldn't let you move at all.
But except for ones where they screw into your bones.
Orthotics work by what's called three-point system,
two points resisting one direction and then
at the access rotation on the other side.
OK. So that's what we need.
And in the fellow sitting
over here that's what I'm doing with the chairs, OK?
So I'll explain a little bit more.
It comes up later on how we do that.
But the main thing is, if your body can't move completely
into that range that I just said you had to have
between the seat and backrest angle.
Then it makes a problem instead of a correction
to stuff you in there.
OK, which is taking us back to that mat evaluation,
why it's so important to do that.
So if there are range of motion deficits, if there are problems,
and in spinal cord injury heterotopic ossification,
does anybody have it in the room or has anybody heard about it?
HO. Sometimes you only know the nicknames.
It's a bone where it doesn't belong
in a spinal cord injury often in the front
of the hip, blocking hip flexion.
It happens in traumatic brain injury as well
and I have a slide case that's actually traumatic brain injury
instead of spinal injury, but that's to show you.
OK. The concept is we want to optimize our postural alignment
because it decreases the work of just sitting there.
That's how you decrease the musculoskeletal pain.
This is true for able-bodied people,
as well as standing here.
You noticed that I'm standing as about straight as I can.
If I were to try to, you know, do the whole lecture like this,
first off I would not succeed very long.
I mean, already in my class you're not thinking
about holding this very long.
If I went like this, I'd have neck pain in a heartbeat, OK.
So alignment to decrease muscular work
against gravity is the concept, OK.
And then the other thing and this is really important
for a spinal cord injury, you have limits stability.
But let me show you how that works in standing.
I can reach to here with no problem.
I can reach a little further if I compensate
by sticking my butt up.
But if I really need to touch that, I'm going to have to step.
That's the limit of my stability.
OK. So in setting up wheelchair with the paralyzed trunk,
you don't expect to be able to reach both hands away
from your body like this.
If you can, you're sitting too stable.
If you can put both of your hands away from your body
like that without just falling over, you're sitting
in a position that you shouldn't be all day long.
You're sitting in a bad postural position.
Now, you're thinking, "Well but I have to do this."
Well, I'm going to argue, "No you don't."
What you need to do is you need to reach with one hand
and stabilize with the other and for those moments in time
like coughing that you really need both hands to be able
to function away from your chest.
You need to slide your butt forward and get
in that more stable position for the temporary time
that you need, and then get back out of it so that you're
in good alignment for musculoskeletal
to help the rest of time.
OK. The last thing here is the way
that you should be sitting in your wheelchair.
It should be best for pushing your wheelchair.
It should be best for breathing and pushing your wheelchair, OK.
And we compromise only for the people who absolutely can't get
out of their wheelchair and our best bet is
to have positional change which may basically mean some sort
of changing ability in the chair rather than having them sit
in just one posture all day if they can't get in and out.
So, how do we set these angles up?
All right.
Well first off, it's very, very important that you set the chair
in the angles up based on orthotic concepts.
Let me kind of share you what I mean.
Also, you can't forget the cushion and the backrest
and anything else you're sticking on.
But if you start with the stuff you're sticking on instead
of the frame of the angles, you're chasing your tail.
OK. You need to start with the angles of the chair
and making sure that those match the anatomy
and then go from there.
So, key is going to be your backrest angle.
Room for your thoracic curve what does that mean?
This is my lumbar curve here.
And if you where my hands are there's back
above it and that way.
OK. So if you go straight up from your lumbar.
You're not allowing room for what is a normal thoracic curve.
OK. Normal curves are curves
and the thorax should be a little bit back.
Proper seat depth knee angle and put support and I'm going
to show you what this means.
I'm also going to show you the relative position in space.
There are some misunderstandings about that seat slope.
OK. Many of people think that the slope is
to keep your butt back.
It's not. It's part of this relative tilt in space
that allows us to harness gravity.
If I lean forward just a little bit like this,
gravity which is coming straight down is on this side
of my axis rotation and I have
to hold my head up against it, OK?
What I want and why I stand
like this is I put gravity here basically helping me stand
up right.
OK. And what you want in a wheelchair is the same thing.
You want to harness gravity to help with trunk extension.
OK. Not have to fight it with muscle strength.
So this a computer simulation of that and the fellow
on the left is a classic-- this is actually J. Tomlinson's work
and he was saying, "You have to sit this way"
and he was advocating a 5 to 10 degrees recline in the backrest.
And I had a conversation with him and I said,
"I think you're wrong.
I think that we can get the stability
by our backrest angle."
And so the one on the right is what I do.
It's bringing the backrest back acute and what you end
up doing is you get your center of mass and the line
of gravity going like this.
And basically all of a sudden you're stable.
OK. He was suggesting his basic--
his big argument was that this is the best you can do
on the left and you had, to had, you had to run with anti-tippers
because people are going to be unstable to the rear.
And so my argument with him was not so much
about the postural alignment but also
that there's not instability of the rear if they're up on
over your pelvis because you're not [inaudible], OK?
So when there's truncal paralysis,
we have to set the wheelchair configuration
up to stabilize the pelvis and allowing normal curves, OK?
What that means is the backrest is at least--
the backrest is going to be stopping your pelvis
from rocking back which is the same thing as hip extension.
Basically, you're pelvis rocking back is opening
up this hip pain.
The backrest stops that, OK.
The seat slope, having the slope come up is
to make your pelvis not rock forward.
Now, not everybody can do this but those
of you who can, play along.
If you're sitting in a standard chair, I want you to sit
on the front edge of it.
And if you're in a wheelchair and you can do it, go ahead.
If you're in the front edge of your chair,
OK-- All right people.
Please now put your pelvis as anterior as you can get it.
So hold it in an arc,
really gives us a lumbar lordosis, right?
Nice anterior tilt, ready?
Feel like you got it and now you're going
to hold on to it there.
OK ready?
Now, take your right foot and put it over your left knee
but don't change that tilt.
[ Inaudible Remark ]
It's not possible, OK?
So what you're doing by bringing the seat slope
up is your bringing your thigh forward just like that.
So that now what we're doing is we're limiting this anterior
motion of the pelvis
and basically we're stabilizing the pelvis from the rear
by the backrest from the front by the slope.
It's not to keep you not sliding forward.
It's literally to keep you not doing this, pitching forward.
OK. It's three-point uncontrolled.
OK. Now, this is sort of what it looks like.
OK. That sort of what it looks like.
It's a combination and the other thing it does--
remember if I have-- this is my lumbar support here,
my lumbar curve.
I said look above and you'll notice
that I have back above my head.
Well look what I have below my hand and that way, my butt, OK,
or the sacrum which is basically like this.
We need to allow that curve too.
So you have to have room for the sacrum posterior
of your lumbar support, OK.
When you have the sacrum posterior, then lumbar support,
and then thorax posterior, you're going to have as close
to normal spinal curves that you can get.
All right.
If you're putting the chair--
you know, if you want us rule of thumb, this is it.
This is from my work that I published in 2003,
basically a starting point for this slope.
Now, slope is a ratio.
This is the other mistake here all the time.
This is from users.
I've got a four-inched dump.
OK. Four-inched dump is meaningless information.
It doesn't tell me anything because slope is a ratio.
It's a fraction.
It's rise overrun.
It'll be just like saying, you know, on my ramp,
I got a four foot ramp, all right.
Well, which way?
I mean so because if they think it was fur feet--
well, you're not going to get up at all.
So again, this is rise overrun.
The difference is the rise between the front seat height
and the rear seat height.
And the run is the seat depth, OK, or therapist depending
on your company, usually the frame length.
So if you lengthen the frame,
that's the company's denominator.
So this is where we get mistakes
where somebody is been sitting beautifully
and they get a brand new chair, and they think well,
we'll just nudge the frame a little longer.
And all of a sudden they don't seem
to be sitting very well anymore.
It's because your just took that slope that was like this
and you flattened it because the denominator got longer.
OK. So it's a ratio, 0.25 for a paralyzed trunk.
That's a starting place.
That's a 16-inch seat depth with a four-inch difference, OK?
0.12 or 08 for that innervated trunk.
So your L1, your amputee.
They don't want to be on a dead-flat seat either
because if you put them on a dead-flat seat.
None of these chairs you noticed
for the able-bodied people are dead-flat, right?
You don't want to sit on a horizontal surface.
So even with intact musculature you want a little bit of a can.
But for paralyzed we need more, OK?
All right.
So this is the backrest concept.
It needs to be low enough at the right angle or contoured.
So if you go with a higher backrest, you just have
to remember what you're doing in contour.
So, oops, can you see that red, just barely?
There's a faint skinny red line drawn on there.
You see that?
And it kicks backward.
So after market backrest, you need to put them higher
and the top goes back because that's for the thorax
and the bottom comes forward
because that's your lumbar support.
Ergonomic seats.
Ergonomic seats are-- I mean you know what they are.
I bring this up because they are out there
and people have asked me about them.
The ergo seat is that flat the back of the seat
and then it pitches up, OK.
And a number of the companies are having it as an option
in their chairs and everybody thinks this is a great idea.
The concept is the cushions do that, right.
They have that little butt wall in the back
and then they come forward, we'll just do it on a chair.
The problem is if you have a paralyzed trunk,
they don't tilt in space.
So they don't do that harnessing gravity thing.
And so they don't work.
So that you need to have at least five degrees
of reared tilt to make a paralyzed trunk stable.
So I'm getting close to summary here.
Sitting is done after a postural evaluation.
You are trying to support normal spinal alignment.
That helps with your motor control.
It's the angles that matter, OK.
The angles of the wheelchair itself
and then the cushions in the backrest.
And mobility and health is maximized with optimal sitting.
And you think I'm done, but I'm not.
So we're going to fly through a couple because I want
to show you some examples, all right.
So key, key or the thigh length, the real thigh length, OK?
This, OK, is how I should be sitting, not this, right?
If I rock my pelvis back and then I measure,
it's a going to be lot longer, OK.
So that measure matters a lot.
Hamstring length.
Hamstring length matters because if you pull your foot rest
forward, you're going to be pulling on your hamstrings.
Why that matters is this little bone that we're all so fond
which is the ischial bone, the hamstring is attached to it.
So if my hamstrings are tight and I pull my foot forward,
my pelvis goes with it, OK.
Hip extension.
Nobody gets this.
The hip flexors are tight.
They're on the front.
Why should that matter?
I'm sitting, right?
Well the reason it matters is because you're also paralyzed.
So you're sitting and you don't have anything else pulling back,
so what happens is when you get tight in the hip flexors,
it pulls your spine forward.
You're going to feel like you're going to fall
over unless you slide your butt forward or really arc hard
which you'll see mostly in populations
like spina bifida and CP.
All right.
So I'm going to slide forward a minute.
Sagittal plane is this one, OK.
It matters.
Just believe me.
OK. Here you go.
We're ready to do some problem solving, all right.
Here we go.
Now, right at the top, I call these conflicts.
So you're to find the things--
I already taught you how to do seating eval.
What is the problem?
Anybody? So, yes, compared.
So this number and those two numbers, which I put right next
to each other conveniently seemed to be desperate, OK.
Now the foot rest angle--
and this other stuff is a little harder
because what happens is you're rocking
around in space, but look.
This is same chair.
There's not one piece of equipment different.
It's just adjusted, OK.
Now, I shortened the seat depth.
Those base wedge to try to close the angle
because this particular chair doesn't have that adjustment,
OK, and then bringing the foot rest back.
So I want you look at the two.
Remember I said sagittal plane first to just trust me.
That's what I corrected here - sagittal plane.
I didn't do anything to the front and
yet look at what happened, OK.
So that's just measuring
and then making the measurements fit.
This is the one that I told you about all ready HO.
I'm telling you the problem already.
HO, OK. HO happens in spinal cord injury as well and you need
to make sure you're paying attention to your range
of motion because it can be late onset.
Basically, this fellow whose mother he lived with
and his mother at this point in time was 74, and they got
into the point where he was falling out of the chair
to the front so many times that they were having to call 911
because his mother could never get him up anymore, OK.
Now, I'm telling you the problems I showed,
but just look for a minute.
This old chair-- it's an old quickie, it's a 90-degree weld,
OK, at the backrest which means that his hip should flex
at least to 90, okay, and it doesn't.
So basically this is the fixed, OK?
And again, I changed the foot rest,
but otherwise I'm using the same chair and just adjusting it.
I did add a wedge, but this time the wedge instead
of making it more acute is going the other way.
So what I did is I put the wedge like that, OK,
and then I rocked the chair a little bit
of space so he wouldn't fall.
And I followed him for two years and he never fell
out of the chair again, OK.
So, and look at how much more comfortable he looks
in the front.
So again this is just-- this is that physical exam thing
that I was talking about, all right.
Prevention science.
So what I just showed you were indicated sitting.
People look horrible.
It is indicated that we should fix it, OK, but prevention
and health promotion is way better, way better
That's what we should be doing right at the beginning.
So there's the take home points now.
We're getting there.
Big is worse for posture.
OK? If you have wiggle room, if you have too long
of a seat depth, it's going to put you
into a posterior pelvic tilt and that's bad.
Everything cascades negatively from there.
If it's too wide and you can slide yourself over,
now you're building a scoliosis.
That's a problem too, OK.
So anybody whose therapist or dealer says, "Well,
you might gain a little bit of weight."
Walk away.
You know don't need that chair small.
Therapist, don't let them gain weight.
We need to not gain weight in America.
We got a problem that way.
All right?
So we need to not have plan on bigger.
We need to get ourselves under control and we need
to be smaller for posture.
Too big of a backrest angle will always set up posterior tilt
and set up bad postures well too,
so we have to watch these angles.
Decision tree, OK, so should I go with a longer frame?
Is there a benefit to a longer frame?
Well, there's more stability in a longer frame.
Now we're not talking about too long a seat depth notice.
We're talking about the frame
because the seat depth can still fit the patient.
So if the seat depth fits the body,
a longer frame means I'm sitting more inside my chair instead of,
sort of, upon it, OK.
It means the frame will probably come forward of your legs
and give some leg containment instead
of being behind your legs and giving a little bit more you
to the world instead of wheelchairs.
So it's kind of what you decide you want.
One is being more in the other is being more on, OK.
Transfer handle.
So some people really like to have a part of their frame
up there that they can grab hold of and that helps them transfer.
For other people, that transfer handle is a transfer obstacle
and they get their legs all trapped
and they can no longer transfer.
So the functionality matters individually
on which way you're going to go.
Anytime you go bigger, it's going to be heavier, OK.
A longer frame has a longer turning radius,
so you better be thinking about that.
If you are lengthening a frame
on somebody who's had a long-term chair,
remember you need to fix your slope equation, right.
If you are lengthening something that fits just barely in,
for instance a car, you better be measuring that,
you better check, OK?
All right.
Now, what adjustments do you need?
OK, because this was the question
from the advisory group.
What should we do about how do we get a chair early
on that's also going to be good for me later?
All right.
Well, any chair.
You have to be able to change the center of gravity
after you own it, OK, particularly
if it's your first chair because chances are you don't have the
skills that you need to survive and hopefully you're going
to pick them and when you do we're going
to increase the dynamics of your chair
by moving the center of gravity.
Center of gravity is how far forward
of the backrest frame is your axle.
OK, that's what center of gravity is.
The inside seat to back angle,
you want adjustable on any chair, OK.
Folding chairs is a little harder to get,
but you still want it.
Backrest height and footrest height, you'll always need going
to have those adjustable because that's going to be if you want
to change your cushion, right, so you always need
to have those changed.
Now, here's where I'm going
to say the first compromise comes in.
Posture is really important.
I already said that.
I think posture is the most important thing except
for function, OK.
So if I can't get you transferring
out of the seat slope that makes you look absolutely beautiful,
then I'm going to compromise that slope for a little while
until your transfers get better because they will so long
as you can do them and they absolutely won't
if you can't do them, right?
So if a leave you with a marginal transfer,
I can guarantee you're not going to get better at them.
If I instead compromise a little and get the transfer doable
so that now you can do more, your mastery will get better
and then I can titrate back in the better posture, OK.
Everybody with me there?
Important point.
Also, here at the bottom, some of us are actually incomplete.
If we're incomplete, we really, really, really, want to be able
to adjust that seat slope
because too much slope is a bad thing if you low trunk.
All right, axle height--
if you're going to adjust the slope, you have to be able
to adjust the axle height.
That means you have to be able to adjust the caster housing
that mean and the back rest.
Now, you've just got a lot of stuff.
So the problem with that is all these things add weight,
add breakage, et cetera, but they're all needed.
So if you think you're going to have
to have an adjustable slope,
know that you need all of this, OK.
Really almost done.
First compromise, if you're going to adjust that slope,
that's a cantilever chair.
Cantilever chairs don't have an under frame, ZRA is one.
OK, so we look like that the old [inaudible].
If you decide to change the slope, this is what happens.
The footrest in space change, OK,
and people are not happy about that, OK.
So you need to make sure you're thinking about this
and the backrest thing.
Push arc also changes.
Push arc is really, really, really important.
If you lower somebody into their wheels or bring them back up out
of their wheels, now we have a big problem
with our push mechanics, OK?
Any added parts add weight and breakage.
Footrest, I think if there's a real potential for standing,
walking, or significant weight bearing during the transfers is
the only reason to consider getting removable footrest.
At this point in time, I'm going to tell you
that power chairs are different, but at this point in time
for a manual chair you probably want to keep your footrest
on because they're an integral part of keeping
that chair light and strong.
All right.
Last thing.
When do you need an expert?
If you have new, the key things here are new.
They have new skin problems.
If you have pain when you're pushing the chair.
If you have new posture problems.
If you have new instability or
and this is probably picture of too many people.
You've never been comfortable, able,
and stabling your chair, OK?
How do you find an expert?
I am remised.
I didn't get back to the slides.
I forgot to put the occupational therapist.
Occupational therapists are often very good at seating
as well, particularly power wheelchairs.
But there is American Physical Therapy Association,
and then there's RESNA, and on both of this places,
they have a find a PT or find a ATP.
There's my e-mail at the bottom.
[ Applause ]
So the question is different styles of cushions.
And I think what he wants is, you know,
what can one say about them, OK.
So, there are different technologies in cushions.
So the air cushions by designed are pressure distributing
cushions that are for the most part, not intended
to be postural support.
However, the air cushions contour
across a configured chair really nicely.
So in one way, if you have a really well configured chair an
air cushion is great, if you get really high risk skin,
and you need to put a cushion under yourself inside a car
that air-- the flexibility of it to contour to the seat
of the car is really beneficial.
The foam and gel cushions as a philosophy are trying
to be pressured distributive, but postural supportive.
So their job is to hold you in a postural position
and that's there-- that's-- and then distribute the pressure
but holding you in a postural position.
So if you think about somebody with a marginal transfer skill.
That cushion that holds you
in a postural position might just be the thing
that makes you not possible to transfer.
On the other hand, those are firmer basis.
And so the firm based sometimes allows people to transfer
who might not be, otherwise able
to if the based was a little too slithery, OK?
So, it's really individualistic.
There are-- so most of the cushions on the market
and the cushions that are been in the market
for the longest time are all pressured distribution cushions,
OK?
They're not trying to completely eliminate it,
just trying to distribute it over the best amount, OK?
And an air cushion is mostly an emergent concept
or you're supposed to sink in to it and be wrap,
like you're wrapping-- used up in a water in a bathtub, OK?
There's another philosophy which is the off-loading.
OK. An off loading means you're taking an area
like the [inaudible] that you consider to be a high risk area
and completely taken all pressure off
but which means it's being suspended.
So it's being suspended and the only way you can completely off
load that is by unloading other tissue.
OK? The theory is actually behind an NPT socket
So when an individual has an amputation
and then you used a prostatic leg, they were loading--
off-loading the distal, residual limb
because that's a high risk skin breakdown loading certain parts
that were tolerant of pressure.
The problem is we do not necessarily know that model,
the NPT model make sense for spinal cord injury bottom, OK?
There's a sort of difference
in what you are, and also physician.
Yeah? OK. The question was, can you talk
about is there a difference and-- correct me if I get wrong.
Is there a different between, if you've been injured for a while
and may be developed some contractures
and also have been habitual--
already using a system for a while
versus if you're getting setup for the first time, OK?
In terms of the concepts, there's no difference.
But in terms of the reality that longer term person,
you have to deal with potential loss of range of motion
that you didn't have to accommodate.
The most important thing is that I don't try
to stretch you with a wheelchair.
That if your tight somewhere, I accommodate that in the seating
so that I can allow the spine and everything else
to seat in the best posture.
It also-- it is true, my hobbit would be
if somebody's skin has been healthy with no skin breakdown.
I am very hesitant.
I'll change their posture alignment.
But I'm very hesitant to change their skin interface.
So meaning, their cushion, I will try really hard
to not move away from the same cushion technology
if the skin is been good.
And that's because we really still don't know enough
about skin.
And then like I said, everything is an association.
We're not quite sure what are cause is,
and if your skin is been doing well, why rock the boat.
Because skin breakdown is not a happy place to be, OK?
Now, that doesn't mean, and I will say, gosh, in 1996,
I wrote a paper which actually look like it was
about rotator cuff tear.
But it was in the back of the article,
there was some seating information and they were cases
that we did it at that time.
And the average was like 20 year old of their spinal cord injury
and one was 47 years old.
And we made changes that made a difference
in their muscular skeletal pain, and their posture,
and their seating comfort.
And so, my message their it's never-- it's just like smoking,
it's never too late to fix it.
I mean, it's just because you've been a long time some way,
it doesn't mean we can't make it better
and almost we always we can.
So, and some by the way, [inaudible], the change on one
of those people was to get them a bath bench.
They'll get a bath bench and instead of transfer in the tub.
The guy only took a bath three days a week, but transferring
to the bottom of the tub three days a week was enough
to chronically kind of reinjure your shoulder
and it never ever-- and once we got him,
level transfers that went away.
The question is would you recommend the seating evaluation
over some certain interval, OK?
Let me answer that too full.
First, I can wear shoes for really long time in [inaudible],
they're really, really, really comfortable.
And then when I get a new pair of exactly the same shoes
that I really used to like.
It turns out, you know, one of them is not comfortable, right?
So we do sort of slide into slap and get comfortable with it.
So I think it's still probably a good idea even if you feel
like you're sitting well to sometimes get it check,
but you'll be my threshold.
My threshold would be your equipment probably should be
replaced when it's starting to show where anyway,
when you're starting to get breakage in equipment.
That's probably good enough frequency
if you don't have the other things.
So, if you have pain with pushing,
have new skin breakdown, your posture is changing
and you notice it, your posture is changing and you're,
you know, significant other notices it.
Something like that that-- any of those the threshold is low.
If something is new is going on,
I get to see a seating person, OK?
If it just, you know, I wonder
if I should get check probably concurrent with your equipment,
but that said, cushions, I would like everybody
to do a better job on their cushions.
Wheelchair, there's some soft parts of your wheelchair
that you ought to pay the most attention to.
Because the hard parts are getting stronger and stronger,
if you got good equipment at the beginning,
your frame could may be last you forever, OK?
But the upholstery, the screw on parts, the wheel locks, OK?
If you've been replacing those things like on the third time,
it's probably time that a seating you go, OK?
Because the soft stuff should remind you.
Cushions, here's what I want you to start doing,
get a brand new cushion.
I want you to weigh it.
And I want you to record the weight.
I want you to measure it.
Measure how high it is.
Measure all of it.
So weight and measurement, OK?
And in this digital age, a nice digital photograph, OK?
And then every so often, weigh your cushion,
look at that photograph.
If you cushion is significantly lighter and its foam
or gel based or significantly heavier, either way,
and lighter if rubber based.
If it's lighter or heavier, it needs to be replaced, OK?
It's breaking down.
If it's heavier, it's probably collecting fluids,
maybe a couple or different times that you didn't know about
and you don't want it, OK?
So, heavier or lighter,
or changing that measurement, get a new one.
OK. The question is how many appointments
with the therapist would one have
for an adequate seating evaluation and trials to figure
out the best equipment that they should get
if it's a long term user getting new.
OK. Thing number one, it depends on whether
that long term user is very happy
and comfortable in their chair.
So if they believe that they are stable, able, and comfortable
in their chair, then there's not as much to do, OK?
And if they're also accurate, so their skin is good.
You look at them, right?
All that. One appointment on the mat, one appointment is
to do the full mat evaluation and that function evaluation
and you don't do trials that time at all.
Because the problem is you're doing the trials.
You didn't take enough sentences of that first information.
So what you want to do is you want that patient to come in
and you want that thorough mat evaluation
and that thorough function evaluation,
a lot of that its interview.
And then from there,
you sensitize it and you write a list.
Here is the appropriate equipment.
Here's what's out there that meets your needs.
Hand it to said user who goes away
and investigates the various manufactures and comes back
and says, "OK, I want trials," and this,
you make sure you get trials in probably two.
And you set the trials up to the real.
So that you put the chairs in the appropriate configuration
and you let him run them, OK?
Vendors in the room, the therapy says I need a trial
or for users says I need a trial giving them an 18 by 18
when they're 16 by 15 is not appropriate, worthless,
don't bother, don't bring them.
OK? Because all that is just showing him a picture,
it's just as affective.
Is that helpful?
Then I would say, really, usually if you're
on with your assessment.
But here's a thing, put them in there,
it's horrible, they hate it.
You need to do it some more, right?
But if you put them in there, they look good, they're happy,
and now it's just like, well, this one was a little heavier,
you know, you can sort it out that date.
But if you failed acknowledging, right?
I mean, if it didn't work the way it supposed to.
And I've done that.
These many years later, I mean the first ergo seat
that I order is in the room and it was liable.
It's like this is not going to work at all.
It's like I can't reach my wheels.
It's like, yup, I knew, when you're falling over.
So even when you think you've done it right,
sometimes you're not, OK?
And then you need more time.
Other questions?
[ Inaudible Remark ]
Comments on chairs for wheelchair basketball and rugby
and any sport or sport specific, or sport specific
and they are positions specific.
So, on the sport, some sports.
It depends on what position you play, or how you're playing it.
I think the rules are exactly the same.
The rules are exactly the same.
The chair needs to fit the user.
If the user has functional real mobility issues, then you get
to deny them the ability to bend that into the position they want
to get into because it's where the sports says they should be.
In other words, you have to respect their [inaudible].
If they have real lock of range of motion,
you the therapist says, this is your option
for how you play basketball, whatever, you don't get
to put your legs under here.
You have to have them in a different position
and then we'll go from there.
OK. So, respecting the anatomy is the most important thing
always, and that's one always
because if you don't respect the anatomy and angles,
you're going cause skin breakdown,
let alone postural problems.
Others? With sports, probably, one of the things
that I think you really need to realize was sports.
Some of those postures are intentionally horrible.
All right.
High-- low class rugby-- not low class.
Low classified, small numbered rugby players.
OK? They will tend to sit in a horrible postural tilt in order
to be stable in order to have a ball pocket.
That is fine for sports, horrible all the position.
So you need to be very careful
but you don't mirror a daily used chair to sport chair.
You have to think about the difference in posture.
[ Applause ]
[ Silence ]