There Are So Many Cushion Options: Where do I start?



Over the next several weeks, we will be discussing cushions and how to choose the right cushion for your client. It can be challenging to pick a cushion for a client when there are so many options out there today. Some of the questions I commonly get are: Where should I start? How do I narrow down the options? What will work best for my client? Can I just keep them on the same cushion they already have?


Let’s start by first considering the client goals and your goals as the therapist. These might include goals such as: positioning goals, skin protection goals, or function-based goals. Often, we might have multiple goals for seating that we are trying to meet. Take a look at the chart below. Here are a few examples of goals that we might be trying to meet with the cushion. We have to remember that one cushion may not be able to achieve all of our goals, but what is most important? Where can we have overlap? How can we achieve the best outcome for our client?




Once you decide what goals you are trying to accomplish then you can begin to look at what design of cushions you should be considering. Let’s consider two examples.
Client 1: The therapist’s goal and the client’s goal are both to maintain the client’s posture thereby allowing the client to have increased function. The current cushion does not maintain the client’s position, allowing the client to collapse into a posterior pelvic tilt and therefore decreasing their range of motion with shoulder flexion for overhead activities.
Client 2: The therapist’s goal is skin protection. The client has a history of multiple pressure injuries on his ischial tuberosities bilaterally. The client has been limited in their sitting tolerance due to pressure and therefore the therapist is looking for the best possible skin protection cushion for their client.

For these examples above would the Client 1 and Client 2 benefit from the same cushion? Perhaps, but not likely. Look at the example of two cushions below. Which cushion would you trial with each client?


You could trial both cushions for each client, but in this case if we had to choose, we would choose the air-cell based cushion for client 2 and the contoured foam cushion for client 1. How did I come to this conclusion?


The next step is to understand the design and materials of cushions to determine when or why you might choose one cushion over another. Next week we will begin with discussing the design behind cushions and how they work.
For this week it is important to remember that there is not one cushion that works for every client! In fact, every client even with the same cushion will have a unique interaction. We can even go as far to say that the same client on the same cushion will likely have a different interaction with that cushion each time they sit on it as they sit slightly different each time and many clients move around throughout their day.


What Causes Pressure Injuries? 



We just finished discussing backrests over the past several blogs.  We will now move onto another support surface: Cushions.  But first, I want to take one step back and discuss pressure. Pressure is one of the reasons that we all spend so much time considering the support surfaces for our clients.  Today we will have a little review on pressure from Ana Endsjo, US Clinical Education Manager LTC Division.
When we talk about wounds caused by pressure, we often only consider the pressure on our bottom. However, pressure can be created by any support surface that comes in contact with the body such as the: the backrest, cushion, arm rests, and head support.
So, let’s clarify the definition of pressure when considering it from the seated posture.
Pressure is a continuous force applied on or against an object through direct contact. In seating, equipment such as the seat and/or back support surface is in constant contact with the body, creating peak pressures.
Peak pressure is a constant pressure directly under or against the bony prominences that will cause a pressure injury without proper pressure redistribution through appropriate cushion and back support choices. Peak pressures are commonly found at the ITs, sacrum, coccyx, and on the spinous process, injuring the skin and underlying tissue, muscle, and, in extreme cases, bone.
 Pressure from a seated posture comes from:
  • downward pressure from gravity
  • upward pressure from the seat surface
  • horizontal pressure along the spine from the back support
When these peak pressures are not addressed through proper pressure redistribution techniques with the appropriate cushion and back support, the skin, tissue, and bone is compromised. Sustained loading against the back support and/or seat surface causes constant compression of that skin and tissue under a bony prominence, leading to a pressure injury. The degree of injury depends on the layers of skin impacted.
It is important that we as therapists begin to understand the critical role that the seated posture plays in the prevention and treatment of pressure injuries.
Thank you Ana.
The next several blogs we will be discussing cushions. From materials of cushions to what type of cushion will be best for your client, cushions can vary greatly, and it can be challenging to look at a room full of cushions and know which ones to pick for your client.


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.

What Happens After the Mat Assessment?


What happens after the mat assessment? We have to use the results of the mat assessment and work as a team, utilising the skills of the therapist, the supplier, and the manufacturer to meet the clients’ seating needs. There are many roles and people involved in the seating evaluation process beyond the supplier and therapist including the client, family, teachers, nurses, etc… Today, we will focus on the role of the therapist. As a therapist becomes more experienced and comfortable with mat assessments they may start learning about specific products and the ways those products could work for their clients. Initially though, the role of the therapist is to be able to communicate to the supplier their findings from the mat assessment.


During the mat assessment the therapist should be assessing if their client is in a neutral posture, or if not, where the asymmetry is coming from. This doesn’t mean that you have to remember exactly how to name, for example, a pelvic rotation, but you want to be able to tell the supplier that the client’s pelvis sits further backward on the right side. Once we determine that there is a right hip rotation, then we need to assess if this hip rotation is reducible or non-reducible. You may have also heard this term referred to as fixed or flexible. If the asymmetry that we see can be reduced back towards neutral, it is flexible, or if it is “stuck” and non-reducible, then it is fixed. Knowing if the client has reducible or non-reducible asymmetries is important in determining the best products for the client. If someone has a reducible asymmetry, then we want to make sure products are selected to correct the asymmetry towards neutral. If the asymmetry is non-reducible, then we will have products to accommodate to this asymmetry and assist with prevention of furthering the asymmetry.

The other key questions we need to think about would include: What are the goals of the client? Let’s take for example a client that has scoliosis and is leaning to the right. We determine, based on our mat assessment, that this is a reducible asymmetry and that we can use positioning products to achieve an almost neutral seated posture. However, during our goal setting, the client explains the importance of being able to reach objects off the ground for maintaining his functional independence. How does this goal guide our practice? In this instance, with correcting his posture we may prevent him from leaning side to side to reach the ground. We need to be sure when we are choosing seating and positioning products that we remember MOBILITY is our ULTIMATE GOAL. The goals as the therapist may not match the same goals as the client. For this example, the therapist would need to consider both their positioning goals and the client’s functional goals.

We also need to remember that our clients change over time. Their goals change, their posture changes, and their needs will change. We want to remember that this equipment whether it is the wheelchair, or the seating on the wheelchair, will need to last a reasonable amount of time. Therefore, we need to keep in mind the long-term goals and anticipate any long-term changes that might occur.

Finally, before you choose your solution remember that you need to determine the cause before determining the solution. There will likely be problems that require more than one intervention, or different problems that may utilise the same intervention. Remember to keep the client’s goals and the ultimate goal of mobility in your mind as you work towards finding their seating solution.

Next week we will take a look at specifics behind the design of seating products and how we know what type of product to choose for our client when we are looking at all the options.

It All Begins with the Mat Assessment



We spoke last week about 24-hour positioning and its importance for the client, but how do we know what products to use and how to position our client? This all begins with the mat assessment. The mat assessment is where we will be able to determine any postural asymmetries, decreased range of motion, contractures, muscle tone, and so much more for the client’s seated position. Although the mat assessment typically will be utilised for the seated posture in the wheelchair, it can be beneficial for any surface the client may be on throughout their day. If you have never completed a mat assessment or are still new to the process – the most important piece of advice is to remember to breathe, get hands-on, and write down what you feel/see. Mat assessments can be scary when you first start, but ultimately it will provide you with the information you need to provide the best care to your client. So where do you begin?

Begin first by trying to find a hard surface for your client. Not every therapist will have access to a mat and that’s okay. It is important to try to find a firm surface so that you’re not getting false information back. The client’s safety and well-being are most important, so be sure to make sure your client is safe on the surface you choose.



You want to assess the client in both supine and sitting. The assessment in supine will allow you to not only assess the client without the effect of gravity, but it will also allow you to safely assess the client’s range of motion. I have included a few great resources below on mat assessments and a few helpful forms you can utilise. It is important to either have a form to fill out, or to write down what you see and feel as you go along. The last thing you want to do is finish the mat assessment and then forget what you have just done! Once the supine examination is over then you can complete the sitting examination.

For the sitting examination, be sure your client is safe at all times! You may have to provide support by sitting behind your client or having a second person for safety. The seated examination will give you feedback on the client’s position with gravity, position of their head and trunk, their balance, and so much more. Here is where you can really get hands on and determine how much support the client will need in their wheelchair. I like to use my hands as laterals, chest straps, or as whatever positioning items I am thinking of to mimic their effects. Remember to give your client proper foot support during the sitting examination.



If I can give one piece of advice when learning mat assessments is to PRACTICE! Practice on your family and friends. Practice on other therapists. Feel comfortable with your process before you try to just jump two feet into a complicated mat assessment. The best way we can learn is through practice. Take a look at these great resources below and as always feel free to email/call with any clinical questions! I am here to help you.




Spinal Seating Modules

Mat Assessment Guide

Permobil Seating and Positioning Guide

24 Hour Positioning:

Should I be thinking about this for my client?



Before we can answer this question, we first need to make sure we understand what 24-hour positioning is. I briefly discussed this last week as 24-hour positioning will be one of the main 3 themes you hear about this year throughout our weekly blog posts.

Let’s think about a circle, clock, or a pie. Now, let’s break this clock up into 24 hours instead of the typical 12. Think about how much time you spent on each surface you sat, stood, or laid down on. How many hours were you sitting at your desk? How many hours were you laying in your bed over the last 24 hours?

Now let’s think about this clock for your client. How many hours does your client spend on the bed each day? What about their wheelchair or their favourite sofa? Maybe their clock would like this this:



What does this mean and why does it matter to us? It is important for us as a therapist and every team member involved in the procurement of complex rehab technology to be involved in the appropriate selection of this equipment.

Many if not most of our clients have decreased or limited mobility and/or sensation. This means that they are at a risk of skin breakdown. It also means that they may not be able to maintain a neutral posture, and without proper positioning the client may end up with postural asymmetries. These asymmetries such as scoliosis and pelvic obliquities can put the client at further risk of skin breakdown but can also affect their functional independence. Let’s think about an example. Imagine that you never had a back to your chair that you sat in at work. Would you sit up straight throughout your day or do you slowly allow your spine to curve and end up with some thoracic kyphosis?



For me, I constantly find myself “slouching” or going into a thoracic kyphosis throughout my day. Now, what happens if I didn’t have strong enough muscles in my trunk to fix my posture? I would be stuck in that “slouching” position for hours of my day and eventually over time my muscles would get tighter and that “slouching” position would be my new normal position. The cycle would continue to progress until perhaps my posture was bad enough to start causing me pain and a cascade of other impairments. This is what can happen to our clients if they are not properly positioned throughout their entire 24-hour day and it is not just with sitting. We can think about how even the positioning in bed can potentially have more of an impact than the wheelchair that the client is only sitting in. What if the client is in their bed for 8-12 hours a day and only 4-5 hours a day are spent in their wheelchair? Have we thought about how they are positioned in their bed? My favourite example to think about for bed positioning is the neck and head. Many times, our clients will have 3-4 pillows under their head for comfort, but what happens to the position of their neck? Now, some of the clients may need this positioning for medical management, but if the client is safe to have less pillows, we want to keep the neck closer to neutral. I see numerous clients that have pain in their neck and forward head position limiting both their vision and functional independence, but perhaps it is not just the position in the wheelchair that is the issue. Perhaps instead it is that the client needs changes to their positioning in the bed first.

We will continue to explore the topic of 24-hour positioning, but I hope you finish this blog today with the idea that positioning on every surface matters. It is crucial for us as part of the team to consider every surface that our client is on throughout their day and how their position on that surface can impact not just their positioning, but also their well-being, participation, and independence.





Happy New Year!
Permobil is excited for 2019 and we have BIG plans this year to keep bringing you the most up to date and top information, products, and service!

In order to provide the best blogs and education for this year, we decided to return to the root of why we are all here: The end-user. To accomplish this, we chose a few topics that affect our end-users daily. We will then use these topics, or themes, throughout the blog posts this year. It is important to remember that whether we are discussing specific products, features of wheelchairs, or general concepts, that everything points back to the end-user.
The blogs for 2019 will primarily focus on 3 main themes: Shoulder preservation, independent access, and 24-hour positioning.



Shoulder Preservation
Shoulder Preservation is extremely important as many end-users require their upper extremities for their mobility in addition to everything that we ask of our shoulders every day. This places the shoulders at a high risk for injury. Often, we think about this only with manual wheelchair propellers, but many power wheelchair users experience shoulder pain as well due to the increased requirement for overhead activities. This year we will focus on shoulder preservation by talking about the shoulder anatomy and physiology, the products on the market to assist with shoulder preservation, and how simple changes can make a big difference when it comes to the shoulder.
Independent Access
Independent access can vary from talking about our community that we live in, our home and its accessibility, or the equipment that the end-user utilises. No matter what the discussion is about though, the key is that every person has the right to the same technical standards. This year we will focus on what independent access truly means, the equipment and technology that is helping to allow for this, and how we can continue to design and develop ways to further allow independent access to everyone at the same standard that many of us live in our everyday lives.
24-Hour Positioning
Think about a clock and how you spend your time. If we think of this clock as 24 hours and separate it into sections of time for our clients, how much of this time is spent on different surfaces? Is the end-user always in their wheelchair? Or, are they on several different surfaces throughout those 24 hours? Many times, the wheelchair is perfectly fit to the end-user and provides the end-user with positioning to maintain a proper neutral posture. The problem is that this is not the only surface the end-user is sitting on throughout their day. What about the child that is using a power wheelchair for mobility in school and comes home to sit on the sofa. The child just spent 7 hours being perfectly positioned and now is slouched on the sofa for the next 3 hours. Does this negate the past 7 hours of positioning? We will explore this year how we can take that positioning, and skin protection, across 24 hours to ensure the best possible outcome for the end-user.
I hope that you will find these blogs useful and meaningful. 

VSC |  An App Designed for You



Can you imagine a world where the end-user would know the exact angles of their power wheelchair?


Where they would no longer have to guess if they were positioned correctly for pressure management? Or where they could easily go to an angle of tilt to access smaller entryways without the question of, “Did I tilt far enough back?”. All of this is now possible with Virtual Seating Coach by Permobil. You can now download a free app and pair with your power wheelchair to view your seat angles in real time.

To further discuss Virtual Seating Coach, this week we are going to hear from a guest blogger Stacey Mullis. Stacey is the director of Clinical Marketing for Permobil in the US and has over 20 years of experience as an occupational therapist.

Let’s face it: it can be overwhelming to learn every function that a power wheelchair has, every aspect of medical management, and manage daily ADL routines. Certainly, it’s helpful to be trained by a seating therapist on how often to change positions and the specific angles of changes. But to say that it becomes a habit right away? Not going to happen!

The University of Pittsburgh conducted a study on two groups of end users. Both groups received training on the frequency of position change as well as the angles/positions to go into. One of the groups was then provided with the Virtual Seating Coach app in addition to that training, and their use of power seat functions increased by 40%! It’s all about building habits, and the more automatic a behaviour becomes the less overwhelming it is.

How does VSC work?

Your seating therapist should have already done an extensive, thorough evaluation to get you into your current seating system. As a  result, he or she will know your clinical needs based on your medical and physical condition, your prognosis, and risk factors, and he or she can individualise a plan just for you! Although there are clinical practice guidelines, your therapist may find that you, for example, will benefit from four small changes in tilt/recline in an hour, then one longer more aggressive tilt and recline the next hour. In this case they will go into their clinic’s portal and assign you a specific regimen accessible through your app. It will literally coach and cue you on the following:

• Frequency of each tilt, recline, and power legs adjustment
• How long to stay in a position before coming out of it
• The angles you should be reaching in tilt, recline, and power legs with indicators that let you know you’ve reached them


Your therapist can set daily goals, and you can start noticing the benefit of this healthy habit of movement. The VSC app will automatically capture data as you utilise the power seat functions daily. This data will allow you and your therapist to monitor progress toward your repositioning goals.

The Virtual Seating Coach is one way you can be empowered to manage your care and decrease the health risks of immobility.