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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Custom Power Wheelchair Transfer System

Happy New Year Everyone! Welcome to the first post of the year 2015! As some of you may know, we are expecting our first little one in January 2015! My husband and I just moved and life has been busy in December….hence my MIA status. I still have lots to share with you over the next year but the posts may be a bit less frequent…but hang in there! Seating will continue to be super!

As a welcome back, I thought I would share some photos from Access Community Therapists’ Wheelchair Seating & Positioning Workshop that took place on November 27th and 28th at Motion Specialties. It was another great turnout and we just wanted to say THANK YOU to our client educators for helping us out again.

So, here is a system that was finished right before Christmas last year (2014). It was a custom transfer system that was fabricated on a Permobil M300 base. This base was provided by Fran Wilson, Sales Representative from Self Care Home Health Products. Chad Kania, Seating Technician, from Ability Health Care created the transfer system and built the custom seating system. This system was made for a client with Achondroplasia (Dwarfism). The goals of the system were to:

1) To improve her comfort and positioning
2) To improve her ability to transfer independently
3) To improve her ability to function independently in and around her home

Prior to this, this client had an 18″ wide x 18″ deep, standard power wheelchair with basic seating. She required the use of a step stool to get into it and sat in the system with her legs completely extended and made no contact with the backrest. This was causing her back pain as she essentially sat completely unsupported. Also, in order to get into the system itself, she needed someone to help her get the step stool every time she needed to transfer.

The biggest obstacle was of course….FUNDING! With some good old fashioned OT letter writing, this system was eventually cost shared by the Ministry of Social Development and Social Innovation and Community Living BC. MSDSI funded the wheelchair base and seating (The Permobil M300 with tilt and the seating system), while CLBC funded the power transfer system. YAY!

The seating system consisted of a foam-in-place backrest with fixed, flat, trunk laterals. The seat was made from carved foam. It was made with a custom drop at the front to allow for a bend at the clients’ knees. Pelvic laterals were also used to guide the clients’ pelvis into the system when she transferred.

Once the foam-in-place backrest and seat were fabricated, trialed, trimmed down and upholstered, here is what it looked like:

Once the seating was completed, custom armrests were made. The standard armrests were used as transfer aids. Custom mounting of the joystick was also needed to get it into a optimal position for driving. In addition, the foot platform was created with a roller blade wheel was installed at the bottom to prevent the system from scratching the wood floors in the home.

Since this system was delivered to the client, she has been using it for a variety of activities around her home such as:

i) Getting her coat out of the closet independently
ii) transferring in and out of bed independently
iii) using the sink in the bathroom
iv) getting to the table for meals and snacks independently
v) opening and closing doors independently

Hearing about all of these functional activities was like an OT dream! Here is a video of the system. This should help with visualizing how this system actually works!

Hope you enjoyed this post and thanks for checking in!

Seating is Super!

Cheryl

Access Pressure Workshop and Seating Tips and Tricks!

Happy Friday Everyone! Last week Access Community Therapists and Advanced Mobility Products hosted a workshop called “The Pressure is On: A Model of Practice for Occupational Therapists”. This was a 2-day intensive and interactive workshop on wound prevention, assessment, management and treatment. The workshop instructors included Jo-Anne Chisholm (OT), Joanne Yip (OT), Heather McMurtry (RN, WOCN), Lindsay Alford (OT) and Cheryl Hon (Me!!..I’m an OT). It was a great workshop with a great turn out!

On the first day, we focused on an interdisciplinary model of practice for wound care and treatment. The images below capture some of the days events. Wound prevention equipment, cushions, mattresses and wound dressings galore! We also focused on preventing under and over prescription of medical equipment for wounds. This is such a big issue when it comes to wound care and prevention. The second day was all about Pressure Mapping. We even had help from some client educators who helped us practice pressure mapping skills and interpretation. Thanks again to everyone who was able to make it!

Now, onto some fun seating tips and tricks! I thought that I would share some of my recent seating mods, accessories and ideas. Perhaps these might work for some of your clients! Here we go!

Below is a wheelchair and seating system that was set-up by Jody Mair from Motion Specialties. This client had CP and required an arcufit belt for pelvic stability. Pelvic laterals were not an option for her because of the way she transferred and moved in her wheelchair. A swing away mount was used on her pelvic belt as her family needed to fold the back canes down in order to fit it into their vehicle. Without this mount, the back canes would not fold down far enough. Although swing away brackets were not as strong as solid brackets, for this client it was sufficient.

Next! A custom pelvic harness for an alternate positioning device/comfy chair. This comfy chair was custom fabricated by Russ Bain at Ability Health Care and the harness was made by Chad Kania. This comfy chair had power tilt and was made with custom carved foam cushions. The client that used this system had extremely limited hip flexion, significant postural deformities and was prone to skin breakdown due to constantly moist and fragile skin. Due to limited hip flexion, keeping this client in an upright position was extremely difficult. On his manual wheelchair, he had a foam-in-box seating system with a custom molded pelvic bar. We didn’t want to do the same in his comfy chair as this was meant for him to be positioned upright, but in a more relaxed position. So, this is what we did! A mesh fabric, posey-style pelvic harness that was secured with 2 clips on the sides. The mesh fabric was breathable to prevent moisture build up. The harness itself helped to prevent sliding down in the system, but was soft to prevent pressure and to enhance comfort.

Here is a custom mounted cup holder and stylus holder that was fabricated by Wahbi Ghanbur at Advanced Mobility Products. This system was made for a client with Quadriplegia. This client uses a stylus in the community to reach and access buttons (such as elevator buttons) and pin pads in the community. If you haven’t noticed, most pin pads at store check-outs have a “security cover” over the buttons. For someone with Quadriplegia (or anyone who has difficulty isolating finger movements), these are next to impossible to access. The stylus is an effective tool here, IF it can be easily accessed by the person of course! So here was my solution to the problem: a custom mounted holder for the stylus! The cover at the top is actually made of soft rubber to prevent the stylus from falling out.

Here is a rather simple solution for feet on wheelchairs. GRIP TAPE! YAY for grip tape! I use grip tape quite often on footplates as it often helps to prevent feet from sliding off or out of position. This was a rather nice application of grip tape on a manual rigid wheelchair. As you can see, there is no actual plate, but wrapping the grip tape around the tubes was a nice way to keep the tape in place. This was also done by Wahbi at Advanced Mobility Products.

And last but definitely not least, here are some custom modifications that were designed and fabricated by Ed Bell at Advanced Mobility Products for a home weight machine. This system was made for a client with paraplegia who used a manual rigid frame wheelchair for mobility. The custom adaptations involved a custom thigh bar that was similar to those flip down bars on a chair lift at the ski hills or the flip down bars on an amusement park ride like the Coaster at the PNE. This helped to keep the client and wheelchair on the ground when using the weights and pulleys. In addition to this, the system also had custom clamps that secured to the front rigging of the wheelchair. This was needed to keep the front end of the wheelchair down and in place to prevent the client from flipping backwards when using the weights.

I hope you enjoyed some of my tips and tricks! Have a great weekend everyone!

Seating is Super!

Cheryl

Balancing Function and Posture. Custom Seating and Manual Wheelchairs

Happy Friday Everyone! It’s almost the weekend! Just wanted to share with you a system I finished for a client with Spina Bifida. This client self-propels around indoors, but also needed a system that would be caregiver friendly and could fold AND could also accommodate custom seating components. We selected the Quickie 2 wheelchair base as it was lightweight, but could still fold. The Quickie 2 is a versatile wheelchair that has adjustable centre of gravity, various castor sizes and seat to floor height options, angle and depth adjustable back canes, and armrest options. Because of the range of options, this wheelchair is therefore a nice light weight choice that can accommodate various seating components, which came in handy for this client. This wheelchair was provided by Motion Specialties.

Here are a couple of images from the fabrication process:

With regards to the seating, we created a custom contoured backrest shell and did a foam-in-place insert. See here for more information on custom seating techniques. A custom shell backrest was selected because my client’s trunk was quite short due to her scoliosis and severe lordosis. With this custom shell, we were able to create a very deep contour with the laterals but were also able to flare the bottom to clear her thighs and trim the top to allow for scapular clearance and improved self-propelling. The shell backrest is also quite light weight, which is important for any self-propeller! We then did a carved foam seat with sensus foam ischial well for increased comfort and also created contouring for her thighs. This provided stability as well as comfort for the client. One issue that came up, was when we improved her posture and trunk alignment, we accidentally brought her up too high to reach her wheels. Oops! In order to fix this, we actually cut out the sides of the cushion and dropped the cushion/seat  between the seat canes to bring her back closer to her hand rims. Phew! crisis averted! Thanks to Chad at Ability Health Care for completing the seating for this system.

Well that’s all for today! Time to enjoy the weekend. Thanks for checking in today!

Seating is Super!

Cheryl

Workshops, Whitehorse and Wheeling

Hello Everyone! Happy Monday! Last week was a busy week for Access Community Therapists Ltd. We held the “Seating and Positioning in the Community: Practical Applications” workshop at Motion Specialties in Burnaby on September 27th and 28th. Despite the torrential rains on Friday and Saturday, it was a great turn out and we had a lot of fun practicing landmarking, mat and sitting assessments and even got to work with some volunteer clients.  Here are some photos from the day. FYI, we are hosting the course again on November 29th and 30th. If you would like to register for the course, check out the Access website.

After the workshop, Jo-Anne Chisholm and I left for Whitehorse, YT. Yes, that’s right! Whitehorse in the Yukon Territories! Access Community Therapists does a seating clinic up there every 2-3 years. It’s an exciting and busy week. It feels almost like a seating marathon of sorts! On this trip, the technicians from Priority Posture Systems Ltd came with us to fabricate the seating systems and to complete various seating modifications for clients with quite complex needs. Unfortunately, I didn’t have a chance to take many photos on this trip, but here is one system that we did. It’s a planar foam “I” shaped backrest  with asymmetrical swing away trunk laterals and carved cushion with ischial block and built in pommel. This system also has an arcufit-style positioning belt and i2i headrest. What was quite interesting about this case, was that we originally spec’d a foam in place backrest. Unfortunately, when trying to fabricate the system, the foam in place could not hold the clients’ posture. We instead needed to proceed with a planar foam back, which provided much more support and control.

I’ve been meaning to post this up for a while now. Sorry for the delay! 2 weeks ago, we received a short presentation By Krista Best and Kate Keetch (Associates of Bill Miller from UBC) on wheelchair skills and the importance of teaching our clients how to improve their wheeling skills. Although most of the clients we see are long time wheelchair users, I definitely saw the benefit in wheelchair skills training. The benefits to our clients included things like, improved community access, shoulder preservation and improved posture and positioning when wheeling. During the presentation, we were offered a chance to try doing a wheelie. To keep us, or I should probably say “me” safe, 2 bricks were used to prevent the wheelchair from moving or rolling away, and an orange safety strap was secured to the crossbar for added security. This is what it looked like!

For more information on wheelchair skills, visit www.wheelchairskillsprogram.ca. This is a great website with assessment/training forms and research on wheelchair skills.

Thanks for reading! Seating is super!

Cheryl