Blog posts of '2019' 'March'

How do I choose a backrest for my client?
We have talked for a couple weeks now about backrests and the importance of choosing the right backrest for our client, but how do we make that final decision? There are so many backrest options out there and typically a client can benefit from more than just one option. Often, I am asked the question, “As a therapist should I know all the backrest options on the market?”  The answer is simple – NO. Your role as the therapist is to know what your client would benefit from for positioning, function, comfort, etc… Then, to communicate those needs to your supplier who can offer specific options. Remember that the client should have options, and your supplier will offer these.
This is not to say that every client should trial 5 different backrest options at the seating appointment, but instead to keep in mind that there are options.  We want to consider what the goals of the seating system are, and then determine when discussing or trialling a backrest option if that option is meeting those goals. Those goals being both your goals as the therapist and the goals of your client.
So now you have looked at a few backrest options and you think you found one that the client is happy with, what’s next?  We want to be able to show that our goals have been achieved. The best way we can do this is by completing outcome measures.  Outcome measures will give us objective feedback to truly show if the goals we were looking to accomplish have been met. Outcome measures are an important tool that we should be utilising during our wheelchair evaluation process, especially when it comes to funding.  Reviewers like to see outcome measures as these are not subjective to your opinion, but instead objectively give insight into the outcomes of the equipment you are trialling.
There are many options for outcome measures and we will have an upcoming blog dedicated to these, but for today let’s think about a few options. For example, we have a client and the goal for this client and his seating system was that he would have less pain in his back.  We could simply have the client complete the numeric pain rating scale in his current seating system and then with this new backrest option depending on how quickly the pain typically starts. This outcome seems simple but showing the difference in the numbers could be powerful or could give you the feedback that perhaps another backrest option is required.
Another example is the client that needs to be positioned well for stability but has to be able to reach within their environment in order to be independent.  Here we can think about a functional outcome measure like the modified functional reach test. This test will allow us to see how far our client can reach forward and can be compared to their previous seating system. It is important to remember that the set-up of the chair and cushion will largely impact this score, so be sure to have considered the whole seating system.  If you have not heard of the modified functional reach test, it is one of my favourites. I included the link to the exam below.
Remember that there are always numerous backrest options out there and likely more than one option will work for your client.
Modified Functional Reach Test:

Is the Standard Sling Back on a Manual Wheelchair a Good Option?



This week we will hear from Ana Endsjo, US clinical education manager for the LTC division, and her great thoughts on the replacing the sling back on a manual wheelchair. Thank you Ana!
I am going to make a bold statement: for every cushion purchased a back support should be purchased with it. No exceptions.

WHAT did she say??? You heard correctly!

I have been asked many times why I feel so strongly about replacing wheelchair sling backs to provide the optimal seating system for our patients. I will provide you with a multitude of reasons, which we will explore in a moment.



Almost immediately after making that statement, I get asked, “Why do manufacturers even bother putting a sling back on the chair if they are so ‘bad?’” Great question, and I use a shoe analogy to explain my reasoning. You can go out and purchase a $50 pair of sneakers from Shoe Depot or go to a specialised running store and purchase a $180 pair of sneakers, and they will have one thing in common: the thin, flimsy foam insert that every manufacturer must supply to release the product to the market. The shoe manufacturer must supply the bare minimum insert to protect a foot from minimal shock and trauma while wearing the shoe. However, the research and time manufacturing the highest quality shoe was not spent in making the foam insert; it was in every other aspect of the shoe.

The technology behind the shoe to allow for a comfortable, efficient, and injury-free stride sets it apart from the lower end models and not the thin, flimsy foam insert! Manufacturers understand that if you have a more complex podiatry need due to plantar fasciitis or Achilles tendonitis, etc, then you will have to replace the manufacturer insert with a more expensive, specialised insert or orthotic that can accommodate or correct the underlying issue. And this is the same situation with the sling back.

The sling back is just like that thin, flimsy foam insert in the shoe. It helps meet qualification for the wheelchair to be sold in the market but cannot accommodate or correct for any type of postural abnormality. Moreover, it will not be able to stabilise or create better pressure redistribution to prevent a fall or pressure injury in a seating system.

This important stability and prevention does not begin and end with the seat of the wheelchair. We have been singing songs since we were children that every bone, joint, and muscle is connected, affecting the movement and stability of the entire body. So, we shouldn’t focus solely on the pelvis and purchase only a cushion to fix a seating issue. It is all connected, and if we want the trunk, head, neck, and extremities to be better aligned, then we need to consider the critical role of the back support and how it affects the movement and stability of the pelvis and everything else below and above it.

A back support can allow you to:
• Optimise the wheelchair configuration by opening or closing seat-to-back angle
• Stabilise the spine/trunk more effectively to maximise alignment for increased independence with functional tasks
• Allow for the ability to immerse and contour to the spine for maximum contact and decreased risk of pressure injury development.

If the back support can do so much, now it is easier to see that the cushion alone cannot solve the seating issue. We should now realise that our patients deserve more than the, “thin, flimsy foam” insert and need a more specialised option that will allow for optimal stability, alignment, and function!


Ana Endsjo, MOTR/L, CLT
US Clinical Education Manager, LTC division
Ana Endsjo has worked as an occupational therapist since 2001 in a variety of treatment settings. She has mainly worked with the geriatric population, dedicated to the betterment of the treatment of the elderly in LTC centers. Her focus has been on seating and positioning and contracture management of the nursing home resident.



The Collapsing Position: Considering the backrest materials


As we continue our discussion on positioning the client in the wheelchair, we will begin looking at how products play a crucial role in the positioning of the client.  Let’s take an example of someone with thoracic kyphosis.  We determine based on our mat assessment that our client has a reducible, or flexible, thoracic kyphosis.  With proper support we are able to achieve a close to neutral, or midline, seated posture. Now we have to choose the backrest, cushion, and other positioning components on the wheelchair, along with the positioning of the chair itself, to maintain this neutral posture.  We want to try to keep our client as close to neutral as possible in order to prevent worsening of the kyphosis and other long-term negative effects. Today, we will focus on the backrest. How do we make sure our client is in this position? What types of products are we looking for?

The first key we have to remember is to not be distracted by what WE think is comfortable.  Each individual will have a unique interaction with their backrest. It is important for us to not just determine the backrest for our client based on what “feels good” to us, but instead to consider the options based on what we need to provide in support for our client.  Now, it is still important and a great idea for you to sit with and feel the products you are considering for your client, so you can see how they will be providing the support you are requesting.
Let’s go back to our client with the flexible kyphosis.  This client will require a backrest that gives them support, support to maintain their neutral posture.  I want to find something that will allow my client to be positioned in neutral without increasing their energy expenditure.  Can you imagine if you had to sit and stand in a perfect posture all day? Could you do it?  For this client, I want to provide a backrest that gives positive support, so that he/she can be in a close to neutral position at rest, requiring less effort by the client.  This is the perfect example of where we need to think about the backrest option for the client and their unique interaction. Often, I see therapists squeeze a backrest cushion and comment on how soft and squishy the cushion feels. While this may feel great for your hand, what happens to our client with kyphosis?
Imagine our client on the left, we have positioned them to neutral and now we stick this “super soft and squishy” backrest behind them.  We have now created the image on the right.  Our client, as they go to relax, will collapse into this backrest, pushing through that soft and squishy foam until they have reached their preferred kyphotic position. It isn’t just the kyphosis.  We may also begin then to see other secondary complications including cervical hyperextension to try to overcome the effects of the kyphosis.
Now, this is not to say that the “super soft and squishy” backrest cannot be used for some clients, but are we considering the needs of the client when choosing this option? We have to be sure that our client is not collapsing into the backrest that we have chosen for them, but instead being supported. Let’s move away from the idea of soft means comfortable for everyone and instead focus on what the needs of your client are and how through different positioning products those needs can be addressed.