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.




Did you know your Power Wheelchair could have Bluetooth?


We live in a connected world. A world full of phones, tablets, and computers. Most of us use technology every single day. For many of us, it is difficult to even be without technology for a few hours. We are constantly looking at our phones whether it is to see the time, make a call/text, or use one of the thousands of apps available to us. For individuals with impaired hand/upper extremity weakness, being able to fully use a phone or computer is not always possible.
For many years now, most power wheelchair manufacturers have integrated Bluetooth into their chairs. What does this mean? It means that the wheelchair user can have their phone, tablet or computer connected to their wheelchair. The power wheelchair can control their phone, tablet, or computer with their driving device. Bluetooth can be utilised with any driver control: joystick, head array, chin drive, etc…

The type of connection will depend on the type of device. For iPhones this connection will be through switches where a blue box will appear on the phone allowing for selection of items. For Android and Microsoft phones and computers this connection will be through mouse emulation where a mouse pointer will appear on the screen.

The video below is an example of a Bluetooth iPhone connection with switches. A big Thank You to Todd Stabelfeldt for posting this great video.
The best part about Bluetooth on the wheelchair? As a therapist you can set this up on your client’s wheelchair. The set up will vary slightly based on each manufacturer and the age of the wheelchair and also the type of joystick or speciality input device is being used.
Included below are two quick start guides for getting started with Bluetooth on both iDevices and Android/computers on Permobil power wheelchairs with the Permobil Joystick Module.

Independent Repositioning Mode:  Getting the Most Out of Your Power Seat Functions



We have been discussing the importance of power seat functions for the past couple blogs and what those power seat functions can do for the user. Often because of the limited mobility of the individual utilising the power wheelchair, power seat functions are used for pressure management. Pressure management or shifting weight off the user’s bottom is crucial to help to decrease the risk of skin breakdown. There are numerous research studies that discuss which combination of power seat functions are best for pressure management. The research shows that superior pressure relief may be achieved by utilising both posterior tilt and recline. Based on research by David Kreutz in 1997, the individual is recommended to initially move to a fully tilted position to stabilise the pelvis, and then follow with activation of the recline system so as to minimise loss of postural stability. Then reverse this order for coming back up to a driving or functional position: Recline and then tilt. This order is important because if the user starts for example with power recline they may lose their stable seated position or increase shearing to their sacrum. Commonly, users will have access to power posterior tilt, power recline, and power elevating legrests. In this case, the user should complete the following sequence for pressure management: posterior tilt, elevating legrests, recline. Then, reversing this order for coming back out to an upright driving position. When the user is fully tilted and reclined, this position is also helpful to reposition the user. Many users may be able to unweight their pelvis and shift their own hips in this unweighted position.

So, what is the challenge with utilising the sequence of posterior tilt, elevating legrests, and recline to maintain postural stability during pressure management? This sequence can be difficult for the user to remember, or maybe the user does not know the difference between recline and posterior tilt if they were not educated by their therapist or other seating specialist. This can create a fear for therapists and many will prescribe just posterior tilt in order to prevent the potentially negative effects of the 3 power seat functions when not used in the right sequence. Or, maybe the user is given all 3 power seat functions, but instructed to only use tilt for their pressure management. This is where it is important for manufacturers to see this limitation and develop a solution.

This solution for Permobil is called Independent Repositioning Mode or IRM. IRM comes standard on every F series, M3 and M5 power wheelchair.  This mode can be turned on to where the user can press a button on the controller, hit a switch, or use the actual joystick to enter the independent repositioning mode. Because the chair has smart actuators, when the switch for example is hit, the chair will take the client into a pre-set or therapist set amount of tilt, legrest elevation, and recline in the proper sequence one after the other. The user only has to know in this case to hit one button.  Users no longer have to worry about going all the way into posterior tilt before elevating their legs and then reclining. This feature is designed to take the stress and difficulty away from the user, but also empower the user to be able to be independent with their own pressure management.  Independent repositioning mode can also help with exactly what it says – repositioning. For some users, they are able to hit a button and go into this position so that they can independently repositioning their seated posture.  While the user can be set up for the standard IRM position, the therapist can also choose the final position of IRM so that this feature can be utilised for every users’ needs.

Click here for more information on power chairs.




Kreutz, D. 1997. Power tilt, recline or both. Team Rehab Report, March: 29–32.


Power Seat Functions  |  Elevation



Today we will look at the power seat function for elevation.  When we talk about elevation, we are referring to the raising up of the seat pan. You may also hear elevation referred to as seat elevate, or lift. Elevation can be beneficial to the user for functional, psycho-social, and physical benefits.

Let’s start with the functional benefits. The first benefit is the improvement of or independence with transfers.  Many people need to complete lateral transfers, where they slide across from their wheelchair to another surface such as the bed, toilet, or car. The difficulty with lateral transfers occurs when the user has to go from a lower surface to a higher surface. With seat elevate, most transfers out of the wheelchair can now be level or with a slight decline. The seat elevate can also be helpful with sit to stand transfers.

Another great function benefit of elevation is the improvement of the user’s vertical reach.  Often with sitting in a wheelchair, activities or tasks will become overhead.  This means that the user has to be able to reach overhead to complete this task or activity. Seat elevation may allow the user to increase their independence by completing overhead activities, and this can also lead to additional physical benefits. Overhead reaching could increase the user’s risk of shoulder impingement or perhaps the user does not have the strength in their arms or trunk to complete this task or activity, and with seat elevate this will no longer be a problem.  It’s not just about the shoulder.  There is also a large impact on the neck, or cervical spine, with constantly performing overhead activities or looking up throughout the users’ day. Seat elevation can reduce the potential problems of overhead reaching.


Finally, let’s touch on the psycho-social benefits. In a previous blog, I discussed this topic of being able to come to eye level with your peers. This seat elevation allows the user to come to eye level with their peers, promoting the user to be part of the conversation. Seat elevation gives the user the power to choose at what height they want to be.

There are of course are a few limitations even when the user is able to elevate.  Many times, I hear people talk about how with seat elevate they will be able to reach into all of the cabinets in their kitchen.  Now, this could be true, but for many users they can now get up to open the cabinet, and reach the first few items, but they will have difficulty reach all the way into the cabinet.  This is because the user is typically seated back and would have to lean forward in order to reach further into the cabinet. This is one example, but we can see that seat elevate while very beneficial for independence with some functional activities may not provide the solution for all tasks or activities. Last week we briefly discussed ActiveReach™ and its benefits with vertical reach. For those clients that are looking to get that further reach, have better access to their sink and kitchen, and to even further enhance their participation through active posture, ActiveReach™ that includes both elevation and anterior tilt might be the right choice.

Remember, not everyone will need seat elevate, but it is important to assess each individual and determine if the function is appropriate.