What to do about posterior pelvic tilt…?

Happy Wednesday Everyone!

Wishing everyone a Happy Occupational Therapy Month this October! This week Access Community Therapists is hosting a workshop on Friday and Saturday on Wheelchair seating and positioning in the community. Pictures to come! Lindsay Alford, OT and I will be presenting this year. So excited to be a part of this workshop once again. Today, I thought I would share with you some strategies for managing a flexible posterior pelvic tilt. Over the past few months I have actually had 4 clients with similar issues. They are as follows:

  1. A flexible posterior pelvic tilt.
  2. Limited/restricted hip flexion (meaning they were not able to achieve at least 90 degrees of hip flexion before causing the pelvis to move into posterior tilt).
  3. AND a fixed or only mildly improveable thoracic kyphosis.

Although these 3 issues don’t seem overly challenging on their own, together, they make seating and positioning incredibly difficult. For example, if you just accommodate for the kyphosis and limited hip flexion by opening the seat to back angle of the seat or allowing for thoracic relief through a modifyable backrest,  the client may fall into more posterior tilt and start sliding out of their wheelchair. Oh no!

Since I’ve had so many clients with the same 3 issues, I thought I would write about a few of the strategies I’ve used so that you can try them with your clients. Keep in mind, you must do a thorough mat assessment before implementing these strategies so that you know exactly what issue you are trying to address!

1. To address posterior pelvic tilt: Use a pre-ischial shelf or IT block to stop the ITs from moving forwards on the seat:

Above are two examples of pre-ishial shelfs on cushions. the image on the left is a custom built seat made with carved foam. The second is a commercial cushion (which is more on the mild contour end-but there are more aggressively contoured cushions available). Keep in mind that the more angular and high the build up is, the more control you will have.

2.  To address the kyphosis with limited hip flexion: Open the seat to back angle or have or cut down the front of the cushion to allow for a more open hip angle. I don’t have an image for this, this is a very specific and calculated strategy. Based on the client’s hip range, you open the seat to back angle to accommodate for a comfortable/functional hip range. You must do a mat assessment and sitting assessment to find out what this angle is! If a client has less hip range on one side compared to the other, make an assymmetrical front end where you allow one leg to rest lower than the other. This is extremely effective as it prevents you from positioning the client with too much open hip angle, which could result in the loss of control for the pelvis and hence….dum dum daaaa…..sliding!! *gasp!*

3. To control the pelvis and accommodate for a kyphosis: Use a backrest to (1) block the pelvis at the back and (2) provide enough thoracic relief for the kyphosis. 

The backrest above is the comfort company Acta-Relief backrest. I just prescribed this backrest for a client who needed a lumbar-sacral push and upper thoracic relief for his kyphosis. The adjustable straps are well placed and provide a good degree of support where you need it and can be loosened off to allow for more accommodation for the kyphotic part of a client’s back. You can also get laterals for this back to provide some good midline control or guidance. Other products like the Future Mobility Prism Truefitt backrest and the Dynamic Health Care’s Armadillo backrest could also be other options for milder cases. Armadillo backrest has been reported by my colleagues to be a bit narrow, but I haven’t tried this myself. Bi-angular backrests (which have a hinge in the back) can also work here.

The photos above here are of a custom backrest fabricated by Jeff Ducklow at Ability Health Care. This is a hybrid technique using carved foam backrest and foam in place. This client had very stiff pelvic mobility. In lying, her pelvis rested in anterior tilt, but as soon as her hips were flexed, she would fall into posterior tilt. In addition to this, she also presented with a lot of extensor tone. The flexibility in her spine (anterior/posteriorly) was also at a very specific point in her back. Therefore, we built up that part of her backrest to provide a push at her upper lumbar spine to try to prevent her pelvis from falling further into posterior tilt as well as to prevent her from collapsing forwards at her trunk. Once we achieved a good position with the carved foam, we then used foam in place (poured foam) to fill in the rest of the space to ensure good accommodation of her upper back kyphosis. Neat eh?

4. To prevent the pelvis from falling into posterior tilt: Use a supportive anterior pelvic support or belt:

The above two belts are custom belts however, even a four point lap belt can work here as well (although a 4-point belt won’t really help to control for rotation of the pelvis is that is an issue FYI). The placement of the belt is so important here. In these cases, the belt should be positioned under the ASIS to hold the pelvis back and down onto the seat. If it is positioned properly it will keep the pelvis back into the system and down onto the ischial well. When a good anterior support is used with a backrest and a pre-ischial shelf, they all work to prevent the pelvis from falling into posterior pelvic tilt. Ta da!

Keep in mind that if you are dealing with all three of these seating issues in one system, you will probably need to implement most, if not all of these strategies. I hope you liked these tips! Until next time:

Seating is Super!

Cheryl

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The 32nd International Seating Symposium

Happy Wednesday Everyone,

Lindsay Alford and I presented for the first time at the conference. We were definitely a bit nervous at the beginning! Hopefully we didn’t scare anyone away at the beginning! To everyone who was able to make it, thanks so much for coming. Hopefully you found our presentation on Balancing Function and Posture in Wheelchair Seating helpful in your practice. My appologies for this very late post. I’ve been meaning to share all of these new innovations from the ISS for a while now. But my oh my is working with a baby, or should I say toddler, a whole other ball game. And to think, I only have 1 so far! In any case, here are some updates from the ISS back in March.

Ride designs debuted their new Soft Fit cover for their custom ride cushions. As you can see in the images, the regular spacer cover is one layer of spacer fabric, whereas the Soft Fit has 3 layers of the famous material. The image of the under side of the cover shows how they cut out a diamond shape section for the well of the cushion. That’s to ensure that the consumer still gets the off loading properties of the cushion under such a thick cover. This is a really nice option for those who find the cushion a bit hard but don’t want to lose the unique off loading qualities of the Ride.

Ride Designs also had their tall Ride Java backrest as well as their new Ride Java cushion on display. As you can see there are pronounced scapular cut outs on the backrest,which is definitely a nice feature. As for the cushion, this is a nice commercial option for clients who would benefit from off loading their boney prominences but don’t quite need the full custom option. I’ve already trialed this one with a few of my clients!

Now here is a really cool product made by Joerns Healthcare. At the exhibits, they had their Dolfin Fluid Immersion Simulator mattress and cushion available to see and trial. This system is based off of a system that was used to transport military dolfins. Yes, that’s right, Military dolfins! Apparently, in order to transport dolfins, they need a system that will support their bodies so that they won’t collapse when they aren’t submerged under water. They used this technology in this mattress and cushion as it therefore helps to prevent collapse of the tissues in order to prevent and heal wounds and pressure ulcers. These products are available for rent as well so feel free to contact Joerns for more information.

Seating Dynamics had quite a few neat products this year. Here are some images of their dynamic footrest, backrest and head rest. The headrest was quite interesting as it has the option of being set up with a single-axis or multi-axis movements. The mounting hardware also seemed quite strong. Head positioning and tone are so complex when it comes to positioning. I am very interested in trying this item when the right client comes around.

Here is another innovative product at the ISS. Stealth Products had the Tarta Ergonomic backrest available to trial. Although this product is not yet available in Canada, it is an interesting design that provides the user with midline guidance and support, but is flexible. The modular design allows this backrest to flex backwards and side to side with the user. It is super comfortable and you can definitely see the utility of this product. Definitely worth a try for the right client!

Here are the B-Braver handrims. These handrims have a Polyisoprene non slip grip at the top. But what is truly unique about these handrims is the shape. They are rounded at the top and flat at the bottom. When holding on to them , they fit very nicely in your hand. These handrims were created by Marco Pilotto, a gentleman with C6 Quadriplegia. I always find products created by consumers to be so special. Marco was such a pleasure to meet as well. Passionate about his product that has worked so well for him as well as for many others. Marco, it was so lovely to have met you! Good luck with this product, it’s definitely a good one!

Invacare debuted their TDX SP 2 power base at the ISS. Unfortunately, this power base is not yet available in Canada. But some exciting features about this base include the new joystick with switch box for access to all the power seating functions, the improved power recline with shear and the streamlined power elevating legrests. The power recline with shear is super nice in that the backrest essentially stays in place when the system goes into recline. This may seem simple, but it’s definitely not common in many other power bases. The reason why this is useful is that if you have trunk laterals or a custom backrest for example, if there is not enough shear, the backrest will move up out of place when the system moves into recline. Then the client looses contact with their back contours or their laterals get pushed into the axillas or even past their axillas. The legrests are also unique as many manufacturers are moving away from swing away elevating legrests. This can be an issue for clients who need the swing away for specific purposes. I just actually had a client who used the swing away function to move their feet out of the way from the sink pipes in their bathroom but still needed the power elevating legrest function.

On another note, Invacare wanted me to announce that they are now cleared (since 2015) to sell power mobility in Canada without restrictions. YAY! Congratulations Invacare. It has been a long road, with a lot of hard work. Definitely looking forward to trialing the new TDX when it comes out here.

Invacare also had their new Libra cushion on display. This is a really nice foam cushion with fluid gel overlay in the well of the cushion. The well is contoured to offer some offloading of the coccyx and ischial tuberosities. The gel is also new and meant to be maintenance free. This is a super nice light weight cushion with some great pressure relieving properties. Definitely going to bring this one out for a trial and pressure mapping session! Stay tuned!

Power assist systems were everywhere at the ISS this year. Although these systems are not “new”, most of the manufacturers were launching new and improved versions of their products which was nice to see and demo. In the images above, I have the Twion (power assist),  E-fix (which converts a manual into a power drive wheelchair), Invacare e-motion wheels (power assist-no image) and the yamaha JWX-2, also known as the Sunrise Quickie X-tender and the yamaha wheelchair motor. Check out their websites for more information.

Freewheel also had a new product this year. They have actually created a way to mount their freewheel onto a manual folding frame! How exciting! They essentially created a removeable cross bar that can be added to most manual folding frames. A super nice addition to this line.

AEL had a cool new trunk lateral hardware called the Omnilink  and it had loads of adjustability! Quite easy to actually adjust the components as well, which is so important when trying to get it into the “just right” position.

NXT and Vicair had some cool new hardware innovations. Check out that headrest mount that can be easily positioned out of the way. Also, check out the backrest quick release bar and the trunk lateral depth adjustment piece. Quite a nice feature if you ask me. Also, Vicair has made some improvements with their covers to make them more breatheable.

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I’ve featured the symmetric designs backrest before on the blog. But here is is again. Such a unique product. They have also made some improvements to make this system more durable and easy to adjust. They also have a new website, which is absolutely beautiful. Definitely a cool product that I would love to trial with the right client.

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Ki mobility had a power tilt system on display at the ISS. This system can be added onto their tilt in space wheelchair to make it easy for a client to access their own tilt. It was a really nice system and was super smooth.

Ottobock had two really cool products this year at the ISS. They had their new adjustable carbon fiber wheelchair called the Voyager Evolution wheelchair. They also had their Terra Flair cushion, which integrates Roho air cells at the back of a foam cushion. This was a very comfortable cushion. Definitely going to keep this one in mind for a trial!

 

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So that’s all for my ISS summary. I hope you found some products here that may help one of your clients in the future. I leave you with this picture of me and Lindsay right before we presented. We don’t look that nervous do we? Perhaps we hide it well! 😉

Thanks again for checking in! And remember, Seating is Super!

Cheryl

Standing Power Wheelchair with Added Seating Modifications

Happy Easter Everyone! I hope you were able to enjoy the long weekend. This weekend I was able to catch up on some much needed rest and errands. For once, I actually feel ready for the week to begin. So, to give you a start to the week, check out this power wheelchair I set up with the help of Motion Specialties! It’s a Ranger Express (rear wheel drive) power wheelchair with standing function. There are a few other manufacturers that offer the standing function, such as Permobil and Levo. The Ranger Express was chosen for this client because it was a rear wheel drive power base, the clients’ driving preference (most are usually front wheel drive) and because of the style and positioning of the knee blocks (which best suited this client during the trials). The stander function on power bases is a great addition, but involves a few considerations. Some of these considerations include access to funding (these things are expensive!), the ability of the client to move into a standing position from sitting (not as straight forward as it may seem….lots of positioning considerations here!) and safety (bone density issues, cognition and safety awareness). In addition, with regards to the base itself, many of them have a lower max speed and are set up with a front wheel drive, which some clients may not be used to.

In order to make this base work for my client, several modifications were required. This client had a backrest that she used in her power wheelchair and in her manual wheelchair. This meant that the backrest needed to be removeable from the new power base. Her backrest was made using a foam-in-place insert to accommodate her back contours. This insert was set up in a Jay 2 backrest shell. Typically, backrests are mounted and bolted on to the back plate of the Ranger wheelchair, preventing it from being removed.  Nathan, the technician from Motion Specialties, therefore designed a track-like system that allowed the backrest to be removed by sliding the back onto the plate instead. In addition, to maintain the appropriate amount of seat depth, Nathan essentially needed to move the whole back plate further back on the base…not a quick job by any means! You can see this below where Nathan is wearing green and Bill Randall, sales representative is wearing purple. I promised to post a flattering picture so hope you both are happy with this one! =)

Further customization was needed to increase the “shearing” of the backrest when the wheelchair went into standing. When we trialed the initial set-up with the client, the backrest moved up too high causing the laterals to move up too far up and into the client’s axillas. Nathan then made a custom bracket that allowed the backrest to move downwards more when using the standing function. See below:

The last few customizations included grip tape for the footplate and ankle huggers to prevent the client’s feet from losing positioning and moving into standing, a custom Body Point chest strap with custom auto style buckle sewn in by Nathan, and added velcro under the armrests to secure the chest strap when not in use. This was necessary to ensure the client’s ability to use the stander independently.

The modifications that were made by Nathan and Bill really made this system work for my client. Thanks so much for all your hard work! It really did make a difference for this client! The standing function itself was selected for the health benefits as well as to improve my clients’ independence and level of function. Here is a link to a resource by RESNA outlining some of the benefits of wheelchair standing devices. Hopefully this will help with your justification letters! Also, an exciting announcement! Access Community Therapists Ltd, is offering a wound/pressure management course called “The Pressure is On ” in June. It’s a two day practical course on wound assessment, pressure mapping and intervention. We will be hosting it on June 6th and 7th at Advanced Mobility Products in Burnaby, BC. Click on the link or visit the Access website to register. Jo-Anne Chisholm, OT, Joanne Yip, OT and Heather McMurtry, RN, WOCN will be the main instructors and I will also be there assisting with the break out sessions. Register soon as space does fill up quickly!

Thanks for checking in today! I hope you enjoyed the case and hope to see you at the pressure course!

Seating is Super!

Cheryl