DME

Blog posts of '2019' 'November'

Seating Assessments  - The What, Where, When and Why

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It still amazes me when I am involved with a complex seating assessment and the user advises that this is the first time they have had a MAT assessment done or they haven’t had this type of assessment since they were a child. As I heard this again last week from an active full time wheelchair user with significant non-reducible asymmetries, I decided to talk about the MAT component of the seating assessment this week!

Are you doing MAT assessments as part of a seating assessment? Are you a wheelchair user that has never heard of a MAT assessment? This week we will take you through a seating assessment and discuss the what, where, when and why of a MAT assessment.

Getting Started

 

 

This flowchart is part of the online workshop for spinal seating NSW – there is a link at the end of the blog to the online course

What is involved in a mobility and seating assessment? If someone’s mobility impairment requires them to complete all mobility and activities of daily living from the wheelchair they should have a seating assessment. The seating assessment will include the assessor discussing the mobility needs, documenting historical information in relation to the impairment, looking at and measuring any existing wheelchair and seating, looking at the home environment, discussing goals, discussing other environments, the MAT and taking measurements.

Seating assessments are usually completed by Occupational Therapists or Physiotherapists. For some funding systems you need to see a therapist who has met the funder’s minimum requirements through a competency pathway, others may state an OT or PT, in which case you should look for a therapist who is experienced in Wheelchair and seating prescription.

A seating assessment should identify postural and functional goals and then taking a biomechanical approach, identify how to support the posture to meet the user’s goals. Both the therapist and the user should wear loose, comfortable clothing that will not restrict movement. For best outcome, a seating assessment should be done prior to the identification of potential trial equipment. The trial parameters will be identified at this assessment and then appropriate seating. (IMAGE A)

What is a MAT?

MAT is an acronym for Mechanical Assessment Tool. When completed in full it has 3 parts to it, the first part is the seated evaluation where the therapist will identify the posture whilst sitting in the existing chair. This part of the assessment can assist in identification of any postural issues currently being experienced in the existing system. The therapist will potentially feel your hip bones to ascertain how symmetrical you are sitting as well as making notes about how you are sitting and about your current equipment. It is good to articulate what is liked and not liked about your current equipment during this process. The therapist wants to determine what’s working and what could be improved so it’s good to talk about any difficulties being experienced with the current wheelchair or seating. Any places or tasks are identified that could be completed but are limited due to the existing seating or mobility device.

 

 

The next part of the assessment requires a supine evaluation (Supine means lying on back). This is around identifying the amount of movement in hip, knee and ankle joints. Essentially, they are looking at the capacity the body has to be in a seated position. The assessor will passively move legs into positions required for sitting and feel for tone and how much range of movement there is. It doesn’t matter if you can’t move your legs, the therapist will do it for you. They may measure this movement using a special ruler called a goniometer (Image 5, of goniometer ) or they may just take note of the movement range.

The 3rd part of the assessment is the simulation or the unsupported sitting component. This involves mocking up the ideal seated position based on the information from the first two parts of the assessment and taking measurements in this position for any new seating that may be required. This assessment is more crucial for people that are unable to sit without support as this will determine what and how much support the seating in the wheelchair needs to provide. The measurements are taken once the positioning has been determined to ensure the sizing will appropriately support needs. (Image 6 MEASURMENTS IMAGE)

When is a MAT done?

A MAT will usually be done prior to trialling a new wheelchair or seating system. It may also be done as part of a review of existing equipment to assist in determining if that equipment is still meeting needs. A MAT can assist in determining if there have been any physical changes in posture or range from the last time the seating or mobility base was prescribed. Completion of a MAT will assist in identification of the correct supports so it should be completed prior to the identification of a trial wheelchair.

Where is a MAT done?

A MAT assessment should be done on a plinth (Treatment bed) this surface is firm so enables the therapist to determine the movements fluidity and range without the impact of a soft surface hiding the movements. This is why seating clinics will often get clients to attend an assessment at their facility prior to setting up a trial at home. Some modifications to the MAT process may be necessary if completing in a person’s home or community setting without access to a plinth; If the seating assessment is completed in the community the therapist may bring a massage table. If done on an air alternating mattress, consider putting it to transfer mode or deflating it. If appropriate the assessment can sometimes be carried out on the floor.

 

Why is a MAT done?

By biomechanical design, people are not built for sitting, our skeletal system would have very different shaped sitting bones if so. A MAT is completed to assist in understanding the capacity of a person’s seated position. If postural tendencies and reductions in range are not considered they can have a negative impact on positioning, pressure risk and function. By working out what position is optimal, the required supports can be identified to support that position and then replicated with a trial of potential equipment.

To effectively identify seating requirements, points of control and required supports, it is best practice to perform a MAT as part of the seating assessment.

If you are a therapist and work with users to identify mobility and seating equipment, then keep your MAT skills up to date! There is an online course you can do here: https://www.aci.health.nsw.gov.au/networks/spinal-cord-injury/spinal-seating/module-3/the-mechanical-assessment-tool-mat

We offer several hands-on workshops and education opportunities to assist in learning more about MAT or building confidence in skills to complete this assessment.

Contact tracee-lee.maginnity@permobil.com to find out more information. Our education team is also happy to discuss any learning opportunities or clinical dilemmas. 

 

 Tracee-Lee

Oceania Seating Symposium 2019 – A recap of the conference

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Last week over 450 delegates from all around the world gathered in Melbourne for the 2019 Oceania Seating Symposium. Permobil was there as a proud Platinum Sponsor. The International Seating Symposium first started in Vancouver in the early 1980s, alternating between USA and Canada each year. The symposium has continued to grow and has assisted the development of partner conferences in Ireland, Brazil, Asia and now Oceania!

It’s now a premier meeting attracting dedicated clinicians, researchers, manufacturers, and others who work in the area of seating and positioning, and wheeled mobility.

 

 

The first Oceania Seating Symposium (OSS) was held in Rotorua, New Zealand and was hosted by Seating to Go, a leading assessment and education provider.

This year was Australia’s first time to host OSS at the Melbourne Cricket Ground, and it was a huge success by all accounts.

Melanie Tran is a university student and UX designer for Ability Made and Hire Up. She opened the 3 day event with a Keynote on “How Opportunities Can Be Created Through Design and Technology”.

Melanie is an eloquent speaker who provided an insightful presentation, drawing on her experiences

 

 

Melanie was followed by renowned Paediatric therapist Lisa Kenyon, who presented the latest research and shared some therapist conceptions (or should I say misconceptions) on accessing powered mobility. I hope she challenged paediatric therapists through her case studies of very young and complex children to enable more children to gain access to independent movement opportunities. 

Kelly Waugh from USA presented several papers and workshops over the 3 days that were very well attended. I attended her head and neck positioning workshop where we were reminded about determining points of control in relation to the centre of mass and the importance of understanding these concepts and the bio-mechanical influences of specific joints.

 

 

Permobil Clinical Education specialist Rachel Fabiniak presented two clinical workshops, one on alternative drive access and another on upper extremities and manual wheelchair propulsion.

The sessions were in high demand and very popular. Attendees were taking up every available seat!

Our education team also presented on seating and powered Active Reach on the product education stage, as well as having lots of clinical discussions on our expo stands where the therapists had an opportunity to get hands-on with a range of products.

 

oppo

rtunity to get hands-on with a range of products.

 

 

Permobil Clinical Education specialist Rachel Fabiniak presented two clinical workshops, one on alternative drive access and another on upper extremities and manual wheelchair propulsion.

The sessions were in high demand and very popular. Attendees were taking up every available seat!

Our education team also presented on seating and powered Active Reach on the product education stage, as well as having lots of clinical discussions on our expo stands where the therapists had an opportunity to get hands-on with a range of products.

 

 

There was a great range of topics presented this year and too many highlights! As well as all the learning opportunities, OSS also provided networking opportunities. The conference dinner gave attendees a chance to get together socially.

A local indigenous dance group gave a beautiful performance and Mal Turnbull warmed the crowd up as the evening’s MC. A very tasty dinner was followed by dancing and it was great to see everyone have a chance to enjoy the evening.

It was also great talking to the therapists about their experiences at OSS. Everyone I spoke to felt it had been a very valuable learning opportunity, with more than a few saying it was the best conference they had been to. Therapists came from all over Australia and New Zealand to attend and it was great to meet one of the scholarship recipients – a rural therapist who was selected by the committee after writing about how her practice would benefit from attending.

The supplier expo was very busy! We really enjoyed showing everyone the range we had on stand and the feedback around our new products was positive and constructive. Therapists got a sneak peak of the Pushtracker E2 in action with the SmartDrive. This officially launches today so if you couldn’t make it to OSS and didn’t see the webinar, get in touch with your local dealer who now has all the details!

 

Tracee-Lee

 

 

 

 

 

Seating and Positioning – Achieving the right posture

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This week’s blog comes to you from the sky as we head to Melbourne, for Australia’s first ever Oceania Seating Symposium! We are excited to have this conference here in Australia. If you’re attending, please stop by and say hello. Rachel has two clinical presentations and we are both also presenting on the product stage. I will share a few conference highlights next week but for this week’s discussion we will continue with a seating theme.

Posterior Pelvic Tilt (PPT) and associated kyphosis are one of the most common and avoidable seating positions. When we talk about the pelvis being the foundation in sitting, we are referring to supporting the pelvis in a neutral position, but is this all about the cushion? … yes and no! The cushion can assist in maintaining a neutral position but if there is a tendency for a reducible PPT the primary point of control is the posterior aspect of the pelvis, so essentially comes from the backrest. Before we delve deeper into this point of control lets look at some common causations of PPT based on the equipment provided and how a cushion can assist or work against the goal.

Identifying some common causations of PPT

The most common causation in an equipment induced PPT is when the seat depth is too long. This is a crucial measurement. If it is longer than the femoral length (Popliteal to behind Glutes with neutral as possible pelvis) the user has no choice but to roll back into PPT to gain back support. Think about your big deep comfy couch. This is often designed with a long seat depth. Think about the functional activities we do on couch…its more about relaxation. When we sit on this deep seat length and we can’t sit back any further whilst still having our knees in a flexed position, our pelvis must roll back into a PPT for us to have contact on the backrest. The same happens in a wheelchair seat.

 

The other time we frequently see PPT is when we have not accommodated shortened hamstrings or reduced hip flexion. In these instances the seat to back angle and/or the hanger angle of the leg rests need to meet the users needs and postural requirements, if these do not meet the range of motion (ROM) identified within the MAT assessment of the user there is often a constant postural battle with PPT as the consequence.

The Cushion

As discussed earlier the seat depth is crucial and as such the cushion is also important. We need to ensure that the cushion depth and placement match the user’s measurements. When considering the product parameters of the cushion we need to pay attention to the Ischial well and ledge. In some modular cushions there are some IT adjustment options (where the ledge is located and how deep the well is) ideally you want the ledge to be just in front of the ITs to assist in reducing them from rolling back towards PPT. The depth of the well and the materials in the well also need to be considered in relation to the positioning and support requirements. Placement of a pelvic belt will also assist in supporting the pelvis and are part of the point of control solution.

So, what happens when you have an end user who has an appropriate seat depth, a reducible PPT and you have determined the ROM is appropriate. Where is the point of control to correct this positioning and support a neutral pelvis?

Just as our back is not flat, the contours of the backrest should be such that they support the end users shape and postural tendencies. In paediatric seating we may be further trying to assist in the development of the natural curves within the spine.

If the wheelchair is for occasional use, an upholstery backrest may meet the goals and needs of the user, however if the wheelchair is used for all mobility or functional tasks it is essential to consider alternatives. For some users this may mean a tension adjustable upholstery backrest which can be adjusted to provide support as required however for many a rigid backrest will be needed to provide the best support. Assessors and prescribers need to be aware of how to appropriately provide support with a rigid backrest to assist in the clinical reasoning process. For some backrests we can adjust the angle of support within the mounting bracketry and if the user has trunk innovation this may be enough. For some users, a pelvic block cut from a firm foam and placed under the backrest padding can make a significant difference. Other options have bespoke adjustments such as the Boa system within the Acta backrest, which uses a reel and cable system to provide supportive contours. If more contouring is required consideration of a customisable backrest where you can build a pelvic block into the backrest such as using the BAC system with the Dreamline backs may provide the contouring and positioning chosen. Essentially it is dependant on the degree of impairment and overall presentation on how aggressive and what type of supports are required. In all instances however we are trying to provide a rear low force that assists in pushing the pelvis from PPT towards neutral as the primary point of control and then provide opposite and equal forces to maintain using the cushion and pelvic belt.

If you want more info on seating and positioning, please contact us. We have a range of workshops to assist you in your learning goals.

 

Tracee-Lee

 

 

 

Proximal Stability – Distal Ability

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In the world of therapy, we often hear the phrase, “Proximal Stability before Distal Ability”. Essentially, this is a principle of movement and relates to the development of core strength and stability at the trunk to promote movement and based on foundation concepts of kinematic chains.

The concept of kinematic chains was initially proposed by Franz Reuleaux, a mechanical engineer, in 1875. (F.Reuleaux, Kinematics of Machinery,1875). 80 years later, Dr. Arthur Steindler expanded upon Reauleax’s work and applied the concept to the human body and movement. Dr Steindler, MD, orthopaedic clinician and educator proposed that the extremities are rigid, overlapping segments in series and he defined the kinetic chain as a “combination of several successively arranged joints constituting a complex motor unit.” (Ellenbecker TS, Davies GJ. Closed kinetic chain exercise: a comprehensive guide to multiple joint exercise. Human Kinetics; 2001)

 

The human kinetic chain refers to the interrelated groups of body segments, connecting joints, and muscles working together and the portion of the spine to which they connect. Optimal movement requires structural alignment of the skeletal system and joints, and neuromuscular control. Impairment within any of these systems can affect movement. The upper kinetic chain consists of the fingers, wrists, forearms, elbows, upper arms, shoulders, shoulder blades, and spinal column. we must first have a stable chain of muscles that run from our core muscles to our shoulder to our elbow, wrist and then to our fingers.

We will now focus on the upper kinetic chain and the provision of assistive technologies to support proximal stability and consequently increase functional positioning in a wheelchair. So how can we support or create proximal stability and enable increased functional positioning?

 

 

For wheelchair users we need to first consider the foundation of the spinal column in a seated position, the pelvis. Correction of a reducible pelvic obliquity or rotation is one of the ways we can promote a stable base of support. When completing a seating assessment, it is important to consider the pelvis position in all planes and use sound clinical reasoning to identify the points of control. This in turn helps us identify the required product parameters of the seating which will assist in identifying appropriate seating options. 

Seat depth and width also need to be considered in order to gain proximal stability. If the seat is too wide the pelvis may lose lateral stability, too short or too long and it may be difficult to maintain a neutral pelvis in the sagittal plane. Last week’s blog looked at pelvic positioning belts which when correctly positioned can assist in pelvic stability.

Once the pelvis is stabilised, we can look to the trunk. For individuals that present with spinal asymmetry, when the posterior of the trunk is supported with appropriate contouring, we often find that the lateral supports don’t have to ‘work as hard’ resulting in less force being required.

For manual wheelchair users the chair configuration can also assist with Proximal stability;  “When a person has paralysis, hypotonia, incomplete motor coordination, an amputation, fatigue, impaired sitting balance, and they are unable to use their hip, thigh and trunk muscles for balance, the wheelchair or the seating system must do it for them. Seat slope creates that passive pelvic stability through the configuration of the wheelchair which allows the person to have better upper extremity function and endurance to perform their daily tasks.” (see Permobil USA Blog for more information on how seat slope and ergonomic seat can assist with proximal stability https://hub.permobil.com/blog/ergonomic-seating-manual-wheelchairs )

For power wheelchair users, proximal stability can assist in better control in chair operation. Arm rests should be at a height that stabilises the forearm with the shoulder in a neutral position; it is harder for many users to have fine motor control when the shoulder is abducted. If you have good proximal stability and the capacity for independent mobility but still struggling to control the mobility base, then consideration should initially look at a centre-mounted joystick position. This enables further stability of the more proximal shoulder and elbow joints, sometimes you may need to consider alternative access methods.

 

 

If you want more information on seating and positioning or mobilising wheelchairs, please contact me or alternatively Rachel, as Clinical Education Specialists we are here to assist you in ongoing educational opportunities including webinars, workshops, courses and one-on-one support. If you found this blog useful please feel free to share the link with others and sign up so you don’t miss future ones.

 

Tracee-Lee