Hello, everyone. This is Mary Dubon and our guest, Noah, here. I'm here to introduce our speaker for today, which is Dr. Rinaldi. He is back to give us another lecture. We're really excited to have him here, and he's going to be speaking on seating assessment and solutions within the child with abnormal tone. Please hold your questions to the chat box to the end. She's excited. I hope you're enjoying some baby noise in the meantime, and take it away, Dr. Rinaldi. Thanks, Mary. It's all good. We live around baby noises. I mean, it's part of what we do, right? So I'm glad to be speaking again to you guys. This is going to be a little bit of a different talk, not so much evidence-based or anything like that. This is more of, I think, designed around how to look at doing something, specifically how you assess for seating systems. And I think this is critically important to get right because of the cost of these systems. And I think we've all dealt with this through insurance before where the wrong piece of equipment is supplied, and it's almost like pulling teeth to try to get that rectified with insurance. So it really is something because of the inherent cost to these, in addition to, and not to minimize, the impact that seating can have on a child. You've got to get it right. And we'll talk a little bit about that as we go through this. This is an area that I've absolutely loved being involved in over the course of my career for the past 27 years or so. Was heavily involved in seating evaluations at Children's Mercy Hospital in Kansas City when I was there, and was fortunate enough to learn from who I think is an absolute master in seating assessments and equipment assessments in Ann Moderson. And learned a ton from Ann over the course of years of doing this stuff. And kind of fell in love with seating evaluations and equipment. So this is an area that I really, really enjoy. And again, it's an area that I think is really critical to what we do. So I have absolutely no disclosures, financial or otherwise, with regard to this. So our objectives, and we're gonna go through these, is to understand the influences and effects that spasticity in particular has on positioning. As you know, these kids are complex. And I focus a lot on spasticity in this talk because I think one of the major problems you run into with getting effective seating is tone. We need to understand the basic principles of addressing tonal influences in seating. Be able to describe appropriate strategies for addressing tonal influences in seating. Be able to describe appropriate seating posture, what we really want to achieve with the individual ultimately. Describe the team approach to seating and positioning evaluations. I'll spend a little bit less time on that and more on the actual evaluation aspects of this. So tone management considerations. We need to, when we're evaluating kids for seating systems, we really need to consider the effects of contractures on patient posture and how that influences our ability to position them appropriately. What are the effects of spasticity on that individual's posture in that seating system? Things such as dystonia, what is their spasticity like? How do these things affect your ability to position them correctly? And there are practical considerations in the seating evaluation we think about tone as well. And I think this is actually a fairly large role for us as physiatrists. You know, should we wait for interventions to manage that tone before we go for appropriate seating or should we not wait for interventions? For instance, if you have a child who has high tone and contractures, is there something you can do about that high tone and those contractures that might facilitate better posture and better seating and positioning in that wheelchair, such as botulinum toxin injections, tendon lengthening procedures, so on and so forth. So we need to keep those things in mind too when we're evaluating seating in a child for positioning because simple interventions like that and more complex interventions like that may facilitate better seating and better posture in the wheelchair. So part of our role when we evaluate kids is to take those things into consideration as well. Sometimes if you go too quickly and too early for the seating, you may end up with something you don't like. We do take a team approach to this and I think this is critically important as well. Physicians do have a role in seating evaluation that go very strongly about that. I've seen way too many wheelchairs that have been specced out with all due respect to our therapist colleagues by PTs out in the community, specced out by the vendor themselves. And they're inappropriate. They don't position the kids correctly. They're not designed around functional goals for the child and they're just inappropriate seating systems. And you get caught having to redo the whole thing over again or modifying parts of it. And then you're dealing with insurance to make those modifications. You've got the financial considerations there. So a team approach, I think, is critical. Our role as physicians is to review the medical status of the patient, as I just talked about, and the goals for the evaluation and why you're seating that kid and what you want to achieve with that chair. The PTs and OTs, their role is to assess functional strength and potential, assess positioning, range of motion, tonal influences on the patient, and what physical limitations they may have for appropriate positioning and seating. And then the technology supplier or the vendor is there really to provide input on available technology equipment to meet those goals. They can assist in troubleshooting. I think a good vendor is absolutely worth their weight in gold. They can provide you really, really good input on what types of equipment is out there to achieve the goal. The really good vendors actually have a really good eye towards tone reduction strategies too. And I've been fortunate enough to work with a number of those individuals who really provide more than just the equipment aspect. They really provide very good input into better positioning. So it really is a team approach to this. And I'd encourage you, if you are working or seeing wheelchairs, working with seating evaluations to take a multidisciplinary approach to this process. The practical side as well is that insurance many times provide and requires multidisciplinary approaches. And most insurance programs and Medicaid programs require a physician's signature on a wheelchair prescription form. I don't like signing things I don't know. So what are the goals of appropriate seating? It's more than just mobility, right? So in a global sense, we're improving function with appropriate seating, and that can be mobility. That can be upper extremity functional use through a stable core and stable base of support and pelvis. It can be visual, improving visual access to their environment through appropriate trunk position. It can be improving respiratory and pulmonary health by getting better diaphragmatic excursion when they breathe through better trunk position and better trunk posture. And it can be through improving feeding too. Upright posture, stable base of support, stable trunk leads to better control in swallowing. Seating, appropriate seating can also be utilized to maintain general health considerations such as appropriate skin integrity. We don't want skin breakdown when they're seating or sitting. We want to maintain appropriate pulmonary status that I just talked about, and then musculoskeletal health as well. Comfort is important, right? Many of our kids spend their entire day in a wheelchair or the chunk of their day in a wheelchair. So it's got to be comfortable. Those goals of seating include comfort. You have to have the patient comfortable. And then postural stabilization for many of the reasons I just mentioned. That's a key goal when you're evaluating seating. So what are the impacts of proper seating? Well, you can normalize or decrease abnormal neurologic influences on the body. You can maintain or limit changes in range of motion. Now, the key to that is you don't want to utilize the wheelchair to treat range of motion, okay? Not the goal of a wheelchair. You do that, the kid's going to hate being in that wheelchair. But appropriate positioning and seating can limit changes in range of motion or maintain range. You manage pressure, prevent skin breakdown through proper seating. As we mentioned on the previous slide, you can increase stability for upper extremity functional skills, improve tolerance and comfort for sitting as we talked about, enhance pulmonary function and speech production, and decrease fatigue and increase functional endurance. If the child is in a well-rested position with good postural support and comfortable, they're going to be expending less energy to maintain appropriate positioning on their own, right? So well-supported seating can also improve functional endurance. So there are a lot of reasons to get this right. It's more than just moving from point A to point B. The wheelchair is much more than that if you do these correctly. So think about all of these things when you're evaluating for a wheelchair. What is benchmark posture and fit? Well, there are certain goals we want to achieve when we're positioning a patient in a wheelchair and we try to achieve these goals. Number one, and I think this is the most important aspect is you really need to look for a level and stable pelvis. That's not necessarily achieved with planar seating either. You want the hips to the rear of that seat. You want that pelvis in a nice, stable, supportive position. Ultimately, you're shooting for about 90 to 95 degrees of hip flexion if the patient has flexible hips. That will help improve a more upright pelvic position and provides for better weight transfer and weight distribution, as we'll talk about shortly. You want feet flat on the surface, okay? I don't like feet dangling out in space. I don't like feet getting caught up behind the foot plates. You want feet flat on the foot plate ideally because that becomes part of your weight distribution. And ultimately, you want weight distributed evenly. If you're looking for comfort and prevention of skin breakdown, you've got to have that weight distributed appropriately. So you really have three points in my mind where you're looking for weight distribution. One is in your ischial tuberosities. That's going to be the brunt of it, obviously. You want weight distributed through the lumbar spine as well. So you want good seat back contact with the patient's spine and then you want weight distributed through the proximal and distal thighs. That is super important. I don't want thighs and legs that are kind of floating in space, pivoting off the ischial tuberosities. I want them in contact with the seat cushion, not too much pressure on them, but I do want them in contact with the seat cushion to provide better weight distribution and better stability. Other benchmarks we look for include an upright trunk that's forward-facing. So that makes sense, right? You want the trunk forward-facing as much as you can get. In conjunction with that, though, you want the eyes and the visual access level in forward-facing too. So sometimes to achieve that, we might have to have the trunk turn slightly to one side or the other. Ultimately, visual access to their environment is critical, to an individual's environment is critical. So you have to balance sometimes that forward-facing trunk posture with that forward-facing visual access. You want body weight distributed appropriately in the chair itself, between the front casters and the rear wheels. So where's the center of gravity of the individual in the actual seating system and wheelchair itself? I try to achieve midline arm positioning. That's super important for folks who use power-based systems or have a tray on front that they're using equipment on, communication devices, and so forth. I definitely want pressure off the popliteal fossa by the seat edge. That's a common mistake I see made quite often, is the seat actually comes a little bit too far forward on the patient as pressing into the back of the calves or the popliteal fossa. And finally, I want the shoulders relaxed and the arms supported. Arm support's part of provision of truncal stability. So I want the arms in a good supportive position. I don't want them hanging out in space. I want them on the armrest. I want them on the support tray. I want them in a position where they can be supported appropriately. So those are really the 10 points that you're looking for when you assess for seating and when you assess a patient in clinic whether or not they're fitting their wheelchair anymore. So if nothing else, the rest of this talk, remember those 10 points. Okay, so we've talked about appropriate positioning. We've talked about some of the functional goals for positioning. Now, what kind of gets in the way of doing those things? Spasticity, and as I mentioned at the opening, spasticity is going to be a big point of this talk because it's probably the one major thing we struggle with, I think, in trying to achieve appropriate positioning in wheelchairs is spasticity and what effect that has on what we're trying to accomplish. So the goal is to assess an individual's postural influences and how that influences posture. Makes sense, right? So that's where the therapist comes in handy in your evaluations. And it can be a precarious balancing act as most kids will kind of show combinations and mixtures of all of these influences, whether they're primitive reflexes, whether it's dystonia, whether it's spasticity, whether there's ataxia involved, you're kind of going to get mixes of these things influencing what you're trying to accomplish with the seating. But it can be a little difficult at times, but there's some key principles and key concepts that we think about when we're trying to position these kids. So what are the postural influences we worry about? Well, we've talked about spasticity and dystonia. There's also hypotonia, right? The hypotonic children take a different approach to seating. The postural reflexes play a big role in getting appropriate seating, including the ATNR, symmetric tonic neck reflex, extensor thrust, tonic labyrinthine reflex. These all play a role in appropriate positioning. And if you aren't getting the kids just balanced correctly in that wheelchair, all of these things can play a role in affecting that position. Contractures obviously play a role as well, including location of the contracture. Is it a knee flexion contracture? Is it a hip flexion contracture? Is it a rigid pelvis? What's going on there with that contracture that's going to influence your ability to position that kid? And what is the effect of that on pelvic positioning in particular? As I mentioned previously, everything when I evaluate a patient starts at the pelvis. You've got to have a good stable pelvis and then everything else will begin to fall in line around that. You know, what are the effects of contractures on weight distribution? What are the effects of contractures on truncal posture and spinal alignment? Does the patient have scoliosis? Do they have a kyphosis or lordosis? And how does that affect your ability to get them positioned appropriately and with good weight distribution and pressure distributions we talked about earlier? So you want to take all four of these categories into consideration when you're looking at what's influencing that ability for you to position that kid appropriately in the wheelchair. So just for brief review, some of the postural reflexes we just talked about include the ATNR, the offensors posture. Don't really run into that so much with seating as much as you would with the STNR or the TLR, particularly the TLR. The TLR is really important if you're looking at reclined features in wheelchairs. If you have a kid who has a retained tonic-labyrinthine reflex, if you recline them too much, you're going to get them into a position of tendency where they're going to want to go into extensor posture. Just like in a similar fashion as the STNR, if you have a child, you're not providing appropriate head support for them and they go into a position of neck flexion, well, then you're going to get some carryover, you're going to get some influences in the upper extremities and lower extremities, and that can affect the positioning as well. So if you have a child who demonstrates these reflexive patterns and has these reflexive patterns retained, you need to take that into consideration when you're trying to position this child appropriately because those can influence trunk position and pelvic width. I'm back. Let me share my screen again. I think I have to pull this back up for y'all. All right, awesome. Sorry about that, guys. So I'm not quite sure where that cut off. I'll go back to the beginning of this slide. So what are these steps to address these issues? It really is a basic approach and proceeds in a stepwise fashion. First, you want to determine the functional goals of seating. What is the purpose of getting this child in a wheelchair? What am I trying to achieve with that wheelchair? You want to then determine your positional goals, okay? And I think this is super important. This is a critical point to make. Am I going to accommodate that child's position in the wheelchair or am I going to try to correct their position in that wheelchair, okay? So I have fixed contractures with the patient. There's no way I'm going to correct that child's contractures. I have to accommodate their position around those contractures to some extent, okay? If however, they have flexible joints and a flexible spine and I can correct some of that, then I want to try to correct some of that to achieve those positional goals we talked about, okay? So accommodation versus correction. You can never force fixed position, stabilize the pelvis. I've said that multiple times now. It all begins with the pelvis. So get a nice stable pelvis and you really, really want to start from there. You then need to stabilize your extended base of support, including your thighs, legs, and feet. Again, you want good weight distribution. You want that base of support nice and stable. You then work to stabilize the trunk and then finally stabilize the head. So you start with the pelvis, you get into your base of support, you then stabilize the trunk, you then stabilize the head. Very easy, very direct approach to doing this appropriately. And if you do that, things will progress very nicely. Again, the key though, is you've got to have a good stable pelvis and a good functional position. Okay, so let's talk about some of the problems we encounter and some of the things, some of the considerations we can have to fix those problems, okay? Now we're going to start with the pelvis because that's been the crux of this whole talk. Stable pelvis, right? Got to have a stable pelvis. So problem number one, you have a patient with pelvic obliquity, what can you do? Well, the goal for that pelvic obliquity is to create stability in seating, right? And we want equal weight bearing and we want the pelvis to the rear of that seat, okay? So three things we've got to achieve even though we've gotten obliquity. If it's the fixed obliquity, meaning you can't correct that with that patient, you've got to accommodate that then, right? And you're going to accommodate with the goal of a balanced trunk and balanced head position, okay? So you're not going to force that pelvis into an upright horizontal posture. You have to accommodate a little bit. You can do that by providing a carved out leg trough on one side for the lower heavy pelvis to accommodate that unstable pelvis. If it's flexible, you can do a small unilateral seat buildup under the lower ischial tuberosity to then level out the pelvis. And we've got a couple of simple diagrams to show that. So with the fixed pelvic obliquity, you accommodate it by creating this trough on one side that then accounts for that lower heavy pelvis and lower leg. And this is a simple, I think, photographs of the trough cutout to provide a little bit more balance for that pelvic obliquity. I'm not trying to correct that pelvis position. I can't do that. I'm accommodating it so that the trunk and the head posture are stable. If it's flexible, as I just mentioned, you can provide a small wedge under that lower heavy pelvis to then get that pelvis in a nice horizontal position. So very simple, very straightforward solutions. The goal though is achieving this. That's what you ultimately want to achieve is a horizontal, stable trunk and stable head position. So again, fixed, you never correct a fixed. You accommodate for it. Flexible, you can correct. If you have, problem number two, if you have extensor posturing of the trunk of the posterior pelvic tilt, how do we correct that? Again, we want a stable pelvis. We can't have it in a posterior position. We want it upright. We want it stable for appropriate weight bearing. So how do we achieve that? Well, your goal, again, stable pelvis, equal weight bearing, upright pelvic position, pelvis to the rear. Those are always going to be our goals for pelvic positioning, right? I'm going to keep beating that into this. This is so important, I think. So what can we do to get rid of some of that extensor thrust and extensor posturing? The one thing that works very well is if you build in the pelvic well with antithrust or an ischial block, kind of you're sort of locking in the ischial tuberosities in a small well at the back of that seat. So the kids can't thrust out of that position. You can provide a slight posterior slope to the seat cushion to effectively close up that hip pelvis angle by about five to 10 degrees. You can provide seat contouring as well. That will help, again, provide sort of that pelvis to the rear of the seat cushion stability you're looking for. And then finally, you can change your pelvic belt mounting angles and provide it over the proximal femurs instead of over the pelvis itself. And I'll show you a picture of that. So this is a super easy trick that will actually take away leverage of that child. If you look at this diagram on the left, you can see their leverage point is their feet and their upper back. So they're gonna try to leverage out of that seat cushion. If you put that seat belt at a 90 degree angle over the proximal femurs, you are gonna take away all leverage advantage they have. They're not gonna be able to leverage out of that at all. So something as simple as doing that, you can break up their ability to go into an extensor posture. So I'll typically use combinations of the seat belt angle going to 90 degrees instead of coming off over the pelvis and then providing a small ischial block or pelvis wall or antithrust build in as you can see in that left diagram as well. Combinations of those two things should be able to break up that extensor posturing influence that they're wanting to achieve. Okay, so let's move on to the hips. A problem, a common problem we see with hip position is wind sweeping, right? It's something we're dealing with all the time. It seems in our more involved spastic quads. So what do we do for wind sweeping? Well, think about your goal. We've talked about goals previously of forward facing trunk and forward facing visual axis, right? Well, let's go back to think about the wind sweeping just like we thought about the pelvis. If it's fixed, you're never gonna be able to correct it. So you've got to accommodate that wind sweeping one direction, okay? You might be able to try to strike a balance between slight trunk rotation and slight accommodation for that wind sweeping more midline. But in general, you're gonna try to look for that position that's gonna be that balance between corrective and accommodative forces within an acceptable range of comfort and positioning. If you over correct, it's gonna be uncomfortable. So you don't wanna force their hips into a position just to get them looking better. Again, you can create a lot of discomfort and they're not gonna tolerate seating, okay? You can provide contoured seating to provide support in this sort of correct or accommodating position. You can provide a lateral thigh support to the adducted side to help correct a little bit, lateral hip support to the adducted side to keep them a little bit more centered, and then a medial thigh support to the adducted side to help prevent that leg from crossing midline so much. And so you're sort of supporting that position through the use of these lateral thigh supports, lateral hip supports and the medial thigh support to sort of keep them in that position comfortably. Again, you don't wanna over correct though. Any of these things you're putting in place can over correct, you don't wanna do that. But you need to proceed with caution when you're dealing with wind sweeping. So accommodating for the most part, slightly corrective in some cases. So again, simple diagram looking at placement of adductor wedges, abductor wedges to help position things. Again, I don't have lateral thigh supports or hip supports built into that diagram, but you can imagine how those would provide a little bit more centering forces for the thigh and for the hip. So again, I think the key with wind sweeping though, again, is striking that balance between accommodation and correction within a range of comfort and keeping trunk forward facing. Hip adduction. Again, we've got a lot of kids who scissor, right? That's the tonal influence in the lower extremities is scissoring and extension. So what do you do for adduction? This is an issue that really is quite interesting to me. And I see a lot of misuse of these types of corrections. The goals are the same for any pelvic and lower extremity position. You want stable pelvis and equal weight bearing, right? You want hips in neutral rotation and you want appropriate pressure relief and comfort. What you don't want is those child's hips adducted so far that so you got epicondyle and epicondyle pressure, right? Uncomfortable wrist skin breakdown. So you've got to do something to separate the hips a little bit. The simple solution is a medial thigh support built into the seat with custom molded seating. You can easily accomplish that. In most cases, that's going to be enough to prevent those knees from contacting each other. In severe cases, you can add a pommel or a wedge to the midline of the seat to provide support for the distal thighs, okay? To proceed with caution with this, we never want to use pommels or wedges to keep kids in their seat, okay? I've seen that mistake made a lot of times with wheelchairs where they'll put a pommel in there to keep the kids from extending and sliding forward on the seat cushion. Never do that. You've got to find solutions to that problem elsewhere like we've already talked about. So never use a pommel to keep the kids in their seat. The only role a pommel has or a wedge has is to keep the knees separated, okay? Too much soft tissue damage down there can happen if they're sliding straight down that pommel or that wedge. So be careful with applications of those. So simple diagram again, you've got hip adduction, you've got epicondyle and epicondyle pressure which is never a good thing. A simple contouring in the seat cushion in most cases will be enough to control that, okay? All right, so we've talked about pelvis, we've talked about hips a little bit. We're going to move down to legs as well now. A common problem we see is significant hamstring contractures, more hamstring flexor influences which leads to a posterior pelvic tilt and sacral weight bearing in the wheelchair which is what we don't want. We want an upright pelvis, right? Goal number one, upright stable pelvis. So what can we do for the kids who have super tight hamstrings that if you place them on stretch, you start rocking that pelvis backwards? What can we do? Well, again, we want to position them with an upright pelvis so we're going to accommodate those tight hamstrings. Easiest way to do that is adjusting your front hanger angle and you can also do some simple cutouts to the front of that wheelchair seat to allow for, accommodate that increased knee flexion position, okay? So some cases you might have to position those feet a little bit more under the seat to shorten up those hamstrings and allow that pelvis to become more upright. And again, you do that to combinations of front hanger angle adjustments and seat cushion angling the front end of that seat cushion. Okay? You can open the seat to back angle about five degrees with a posterior wedge. That again, shortens up your hamstring length at the proximal portion of the hamstring. It might allow you a little bit more range out of the distal hamstring. Remember the hamstrings are two joint muscles, right? Knee and pelvis. So sometimes adjusting that pelvis at the seat to back angle will allow you to lengthen the hamstring out. Okay? And then for any extensor posturing you might have, again, pelvic wall issue blocks and antibody thrust can be put in place to decrease that extensor posturing in the kids. So a combination of front hanger angle, front seat edge cut out to allow the knees to position slightly under the seat cushion. And generally is all you're gonna need to do this to accommodate. So if you look at most wheelchairs that are out there, most times you're gonna have your front hanger angles about 30 degrees, somewhere in that range. But if you tighten that up a little bit towards closer to the seat edge, where you can get a 90 degree knee deflection angle, 90 degree pop the heel angle, you're gonna be able to accommodate many hamstring contractions, if not most all of them. Okay. Extensor posturing of the legs. We'll talk about foot positioning. Extensor posturing of the legs, you've talked a lot about that and how you can decrease that through some of the activities we've talked about. Well, you really need to decrease that also to provide a stable base of support and equal weight bearing. If you remember earlier on in the talk, we talked about your points of contact and how they're important to recognize and to get good weight distribution, including ischial tuberosities, lumbar spine, good weight support throughout your entire thigh. Foot position also is part of that base of support. So ideally we want our feet on foot plates and we want them in a good stable position. Okay. So how do you keep them in a stable position on the foot plate? You can use ankle straps. Those are commonly employed. Sometimes we use anterior calf straps to prevent those kids from going into extensor posturing. So a simple Velcro strap from one foot hanger across to the other foot hanger is enough to keep the kids on the foot plates. You can also use shoe holders. There are a number of those out on the market, different types, including rigid ones. There are some flexible ones on the market. There are different ones out there though that you can use to keep the feet in contact with the foot plates. So ideally you want the kids in a good stable position with feet on the foot plates. Now I'm gonna sort of provide a provision to that in that some kids don't like that, right? Some kids don't like their feet being held down. Tight straps can cause positive supporting reflex reactions. And some kids you just kind of a lot of, got to let them move their feet. They don't like their feet in shoe holders. They don't like their feet with ankle straps. So those are the kids that I really then turn towards that anterior calf strap concept. I want them to be able to move their feet around. They want to move their feet around. If you've got good weight distribution and support elsewhere, and they're not high risk for skin breakdown, you know, it's a nice option. It's a really nice option. Gives them a little bit of freedom of movement. So they're not so agitated in the wheelchair. Different designs here, rigid shoe holders on the left, more flexible shoe holders on the right. Flexible design shoe holders are kind of nice. Again, they do give the kids a little bit of that freedom of movement, provide a little bit more stable base of support for them. Not quite to the extent that a rigid shoe holder does, but still enough that it allows them a little bit of freedom of movement, but still have a stable base. Turning towards trunk. We've now talked about pelvis, lower extremity positioning and foot positioning and some of the problems we encounter and some simple ways to address those. Turning towards the trunk now, a common problem we run into is the hypotonic patient, right? We're going to turn our attention from spasticity towards hypotonia now. This is actually a little bit of an easier problem to solve. You don't have all these tonal influences affecting pelvic positioning, affecting leg position, head position, and so on. The goal for the hypotonic trunk, the goal for any trunk really, is upright trunk posture and stable forward visual access, right? We've talked about that somewhat ad nauseum with regard to other things that we've looked at. So appropriate contouring in your seat back for the hypotonic kid can allow you to achieve that. Typically you're going to provide a curved seat back that's going to help provide a little bit more trunk support for them. You can provide appropriate lumbar support buildings and sacral support buildings to provide more upright pelvic positioning, appropriate lumbar positioning, and appropriate spine positioning. If you're going to use lumbar supports, you've got to have a flexible spine though, and we're looking at correcting position in the hypotonic child. So most of the time they're going to have lumbar flexibility so you can put a support in there to get a little bit more natural lumbar position. Many times we use trunk laterals to help support the trunk. You can use custom foam seat backs to provide full contact and better trunk control. Really kind of depends upon what you're trying to achieve with the child. Sort of dictates what direction you're going to go. And then finally, interior trunk support systems. There are multiple systems out on the market that you can utilize to provide better trunk support for these kids. We tend to think about the H harnesses. We tend to think about flexible harnesses. It really comes down to what you're trying to achieve with that child when thinking about one versus the other. Is it a kid who moves around quite a bit and would benefit more from a flexible four-point harness system? Is it a kid who really doesn't need or really kind of digs off that flexibility and that movement? You can use a more rigid H harness design. So it really kind of depends on the child in terms of what you're trying to achieve with anterior trunk support systems. But in the hypotonic kids, it's pretty important that you do find that appropriate trunk support for them to keep them in that upright position. Looking at different designs here, obviously on the left, this is, oops, go back. That's a simple T-back design with two lateral trunk supports built in. These are adjustable. They adjust up and down as well as in and out. So it's basically a simple T-back, planar T-back with adjustable lateral trunk supports. On the right is a custom foam seat back. You can see when you look at that, you can see that there is some contouring built into that probably to help correct for some scoliosis perhaps. But the trunk supports are built into the back and you've got some lumbar support built into the back as well. So custom foam backs, that tends to be the direction I like to go is with a custom foam back because I think you get much better skin protection and weight distribution with custom foam or custom designed backs. Scoliosis, obviously a lot of our kids have scoliosis. And when working with scoliosis in a wheelchair, again, you're gonna go back to those principles of correction versus accommodation, okay? For flexible scoliosis, you can correct that and you probably should try to correct that in seating. You can do that through lateral thoracic supports and pelvic hip pads through sort of that three-point correction concept. You can also do it through custom contoured molded seating systems, which is what I prefer. Again, I think with the custom molded seating systems, you're gonna be getting much better weight distribution and pressure distribution and better comfort. So my choice in correcting for flexible scoliosis is custom molded. I do it through custom molded systems if I can. That's my goal. For a rigid spine, you've got to accommodate it. You're never gonna correct a rigid spine, so you accommodate. And that's best achieved through contoured and custom molded seating systems again for appropriate weight distribution and pressure relief. So again, when you're dealing with scoliosis, you have to decide whether it's something you can correct or something you can accommodate, okay? Now, the key to this is seating systems will not significantly alter the natural progression of scoliosis. I get asked that by parents quite a bit, and it won't. It's like a TLSO, right? We all know that with neuromuscular scoliosis, TLSOs are never gonna stop that scoliosis progressing. It's not a solution to the scoliosis. It can slow it down and it can provide appropriate upright trunk posture. Same concept in seating. You're going to provide upright trunk posture. The goal is not to stop the scoliosis, okay? Some kids with scoliosis, you may simply want to put them in a TLSO and have them in a planar seating system. I've done that with a lot of kids and that works fine too, okay? So sometimes you have to work with the orthopedic surgeons in terms of determining what you want to do with the scoliosis before you can address their seating system. As I went back at the very beginning of this talk, we talked about our role as physicians is looking at sort of the medical side of things first and then building the seating system around those medical things, right? Well, this is a common area that we have to address sometimes is how are we going to manage that scoliosis? Work with the orthopedic surgeons to determine that. If they want the kid in the TLSO, great, then we're going to go planar seating system. If they want to eventually do posterior instrumentation fusion in that kid, that's going to completely alter your seating system. So if it's a child who's going for a PSIF in say six months, I'm not touching their wheelchair until the PSIF is done because anything I do right now is going to be dramatically different postoperatively, okay? So scoliosis I think is a little bit of a unique situation because there are medical interventions that may be pending and there are other interventions that you may be looking at to address that scoliosis. So it's a little bit of a unique situation in terms of seating and positioning. So determine the medical goals for the kid first before you do anything with the scoliotic patient and then go from there. So simple scoliotic correction, this is the three-point pressure system used traditionally to control scoliosis. And you can do this in seating, it's not hard. You have a lateral hip guide on one side, you have a lower lateral trunk support on one side and then your upper trunk support more towards the axle to provide that three-point correction. We do that quite often. Again, my preference is custom molded when I can, but sometimes we do use these three-point correction systems and even custom molded systems are going to kind of be based on the same premise, these same principles. And then upper extremities, we've talked a ton about back, we've talked a ton about pelvis, lower extremities. What about the arms? It's important too. We talked, you know, alluded to that early on. My goal is midline functional arm position so that they have functional access and then decreased extensor tendency in the extremities. The problems you run into are inappropriate arm positioning, arms hanging off the side of the wheelchair, shoulders retracted, shoulders and arms down around the wheels. I see this all the time. This is probably the number one problem I run into outside of inappropriate pelvic positioning is inappropriate arm position. Crazy what you see out there. Ideally, you want the arms resting on arm pads or you want an upper extremity support train in front of them where hands can be resting on that, but you want the arms at ease. You want them resting on something, not dangling off the back of the arm rest, okay? So solutions, there are all sorts of solutions to achieving appropriate supported arm position. For kids whose arms are falling off the back of the arm pad, and we see this commonly in tilt and space frames, right? Where you've got them in pitch and space now. Of course, the arms are gonna come off the back of the arm rest, okay? Now, something as simple as a shoulder protraction pad or an elbow protraction pad applied and tied to either the upper seat back or the back of the arm rest will be enough to keep the arms from sliding off backwards. You can also do trough arm rests. Not all arm rests are desk design, okay? Not all arm rests are tubular arm rests, and I'm not a fan of tubular arm rests at all. I think for kids who are highly functional in the upper extremities and really don't need arm rests, tubular arm rests are fine. And for kids who need upper extremity support position and control, you're looking at a desk arm rest, something with a flat surface on it that provides appropriate weight distribution for the forearm, okay? And again, you can apply blocks. You can apply elbow blocks to those. You can do trough designs where instead of a flat surface for the arm pads, more of a trough that the forearm kind of sits down in. Those don't have to be super aggressive either. They can be a very minimal trough design and still be enough to keep the arm on the arm pad. So work with your vendor. If you've got a kid whose arms are falling off either the side of the arm rest or off the back of the arm rest with built-in space systems. Very, very simple solutions to keeping the arms on the arm rests. And then head position. This is a really complex thing in my mind and something that can be very difficult to control. So you want visual access to your environment. The problem is you have a child whose head keeps dropping forward or keeps dropping to the side because they don't have good head control or they have tonal influences that are dictating one way or the other, okay? Again, it's a difficult thing to control. It really is. Possible solutions include posterior tilting of the seat and back. So like a tilt and space frame or a reclined seat back. Sometimes slight adjustments to that will be enough to get their head to rest back on a headrest. However, you have to be very careful about the TLR reflex. You don't want to position them too far back. Otherwise you might promote trunk extension, right? So you may exacerbate the problem. But posterior tilting of the seat and back sometimes is enough to get them to rest back on appropriate designed headrest. Sometimes we have to provide forehead straps, forehead pads. There are a number of products out in the market now that help provide or improve head positioning through forehead control. You have to be careful with those as well because what that can do is provide a pivot point now for their head and for their cervical spine. So I've seen in many cases for applications of forehead straps or forehead pads actually will create hyperextension of the C-spine and lead to discomfort and airway problems. So it's a tricky balance that you might be running into to prevent hyperextension of the C-spine because they're pivoting off these forehead straps and pads. Balance with positioning, posterior positioning or posterior tilting of the seat and back. So sometimes you have to try to strike a balance between these things. And then look at trunk posture. Many times inappropriate trunk posture is the main reason you've got inappropriate head position. So again, we work from pelvis to trunk to head. You want to go through that chain of sequence when you're positioning. So if the head, you can't get the head position correctly through some of these things, look at your trunk posture. The problem again with head position, I just talked about it a little bit is these undesirable reflexive postures including the ATNR, STNR, labyrinthine reflex. There are some things you can do to limit that. We talked about some of that stuff including occipital supports. You can put lateral attachments to prevent rotation of the head one way or the other. If they've got a very strong ATNR and like look at their head in one direction, you can put lateral attachments on the headrest to prevent rotation. And again, appropriate trunk positioning sometimes is going to be your means to prevent some of these undesirable reflexive postures that these kids may have. Couple of caveats with this is use attachments with caution. They can provide too much skin pressure. As I mentioned on the previous slide, forehead attachments can create neck hyperextension which can be an airway issue and too much tilt in your seat back can cause labyrinthine reflex responses. So be careful when you're doing these things. And it can be tough. That's what makes head positioning so hard I think in seating systems. A couple of different headrest designs that you're going to hear about, talk about. There's single piece curved headrest, very commonly used. It's got some mild curvature built into it to prevent heads from rotating one direction to the other, falling off one side or the other. Sometimes something simple is the right solution. There are microadjustable headrests. Again, these are lateral supports, occipital supports to help keep the head in a better position, trying to control things from the occiput or suboccipital area. And these laterals coming off help prevent the head from rotating one direction or the other, or falling off one side or the other. And then a three-piece microadjustable headrest or adjustable headrest has your centerpiece and then two wings that come off the side that allow you to position these at different angles for kids to achieve appropriate head positioning and head centering. So there are different products out in the market depending upon what you're trying to achieve with the child, what your postural reflexes are that are influencing head position. And then what is that child's reaction to different positions and different maneuvers trying to position them in neutral? This is where your vendor comes in extremely handy in providing you some ideas and input about what you can or can't do. And then skin integrity. You've got to maintain skin integrity. Appropriate positioning of the pelvis and trunk is paramount to doing that. You want to decrease pressure points through appropriate positioning. You want to decrease shearing tendencies by getting these kids in a stable position so they're not moving around on you. There's some considerations you can pull into play though if you're having skin breakdown, including pressure mapping that's commonly done now where the vendors can pressure map and look to find exactly where pressure points are. They do both static assessments and dynamic assessments to determine those things. And then you can provide appropriate pressure relieving measures to those specific areas. There are pressure relieving cushions out on the market as we're all well aware of, including air systems, memory foam systems, gel systems. There are cell-based systems out there and I'll show a couple of examples of that in a second. You can provide tilt, okay? So tilt will take a little bit of pressure off the pelvis and the legs. Kind of minimal effect though, because in many cases too much tilt again is going to feed into postural reflexes. So you can provide some tilt in some cases, but not a lot. Diligent weight shifting is another measure as we're all well aware of. We want these kids to be able to forward lean over their thighs at times. We want them to be able to do pushups if they have upper extremity and gross motor capacity. So a lot of it comes down to them doing the weight shifting. And then you can control of other compounding factors such as moisture, appropriate nutrition and such. So we've got to try to address skin integrity through what we're doing as well. This is super important for kids who are high risk for skin breakdown that some of these things are taken into consideration when we see kids. So a couple of examples of some different seating systems and designs. So this is a cell-based system. These are open air cells, much like a honeycomb. And there are a number of products out on the market that are based around this design. These are incredibly good for pressure relieving. In most cases, they're rigid enough to provide good pelvic support as well. This is a gel insert system. This is a commonly used system that's out on the market. So it's got a more rigid foam design with leg troughs on each side, a medial buildup in the middle and some lateral buildup here. So the butt goes back here, the legs come out to the right and then gel inserts to provide good pressure to relieve the issue of tuberosities. Oops, why do I keep losing this? I'm in an air system. We've seen plenty of these out on the market. There are high profile air systems, low profile air systems, adjustable air systems. There are different products out in the market. They're very good for kids or patients who are at high risk for skin breakdown. The problem with air systems is they don't provide great pelvic stability. So they've got to have, in my mind, a patient has to have decent pelvic control and lower trunk control if they're going to sit in one of these in a good stable posture. And then finally, power-based systems are certainly something that are out there that we all think about. There are joystick driven systems and there are fully power-based systems where it's completely motor-driven movement through electronic drive controls, such as joysticks, pads, head arrays, sip and puff systems, so on and so forth. There are other drive systems out there that you can attach to manual wheelchairs that I know we're all well aware of that provide some power assist for patients who can still provide manual propulsion. The key to any power-based system is really, you have to identify candidates who can meet criteria to be in that type of system. The key to power-based wheelchairs, fully power-based wheelchairs, is you can fit kids as early as 18 months of age. They do need to demonstrate cause, effect and safety recognition, however, but we've clearly fit kids as young as 18 months in power-based systems. They can do it if they've got the cognitive ability to do it. And then power assist systems, as I just mentioned, these are small motors attached to the rear axle of the wheelchair and the spec fork placed on the wheel through manual propulsion. They can provide a single drive impulses to the wheel. They're highly adjustable. They're lightweight. I am a huge fan of these systems and ideally like them in conditions such as muscular dystrophies and neuromuscular conditions where we still wanna work on upper extremity strengthening and activity. We want the kids active with their upper extremities, but they don't have the endurance for say community-based independent mobility in a manual wheelchair. So smart drives, things like that, add these different products out on the market are very good for this type of application. So in conclusion, I am up against the hour here. In conclusion, remember sort of those 10 commandments regarding appropriate posture in a wheelchair. You want to make sure you're designing the wheelchair around those 10 key points, postural fit points. Keep functional goals in consideration at all times, guys. You know, that's what this is about. It's not just about moving from point A to point B. There clearly are other functional goals you have to take into consideration with seating. A solution for one child may not be a solution for another child. All kids are different. All kids have different degrees of contracture, spasticity, tone, discomfort. So think about that individual kid and be creative in what you're trying to accomplish with that kid. And always remember medical interventions may be a solution for some seating difficulties, okay? The child with scoliosis, as we talked about, is there a medical intervention that you might need to address first before you're going to seat that kid? Can we inject hamstrings to get better range of motion so we're not tucking knees up under the seat cushions so much? Are there lengthenings we can consider? So take medical interventions into consideration before you ultimately go for that seating, that final seat, okay? So lots of things to think about. Again, it's really a very cool area of practice, I think, and a lot of fun to be working with these more complex seating systems. So I am up against the hour here. I think we've got about three or four minutes for questions if anybody has any. Yeah, thank you so much. That was a really great overview of some practical suggestions there. We do have one question, and that is, can the hanger angle be modified after the fact, or is this something that has to be built into the original wheelchair? Well, you can, it's a great question. A lot of the times, insurance will allow you, if you can document medical necessity to make these modifications after you get the system, you can replace a standard foot hanger with a 90-degree hanger. We've done that before. So if we can document, okay, this kid has progressive contractures, they've got significant discomfort in the wheelchair, so it's not utilizable, we need to go to a 90-degree hanger. Most of the time, that stuff will be covered by insurance. Yeah, these simple modifications like that could be after the fact. We had another great question, too, about with truncal supports, can that replace the need for wearing a TLSO at least while in the chair? Yeah, absolutely. You can achieve good, upright, stable trunk support for a kid with scoliosis who is in a TLSO otherwise. You know, I tend to go more to a custom molded system to do that, but you can definitely achieve that. Most of the time, when the kids are in a TLSO already, though, you're probably just gonna go ahead and position them in the wheelchair in the TLSO. And, you know, you're gonna go for a planar system with maybe some lateral trunk supports to at least provide some truncal stability for them. But most of the time, if the kid's in a TLSO, you're gonna be positioning him in that wheelchair in that TLSO. Sorry, I had trouble getting up to my mute button there. It looks like those are the two questions. I think one question I actually have, too, is I've heard before that sometimes doing pressure mapping may not be covered by insurance. Is that something that you have run into or would you be surprised by? I've not run into that, Mary, but I wouldn't be shocked. You know, nothing surprises me anymore, quite honestly. I wouldn't be surprised by that. To me, that would be a very easy thing to appeal and get around, though. If you've got a child who's high risk for skin breakdown and decubit eye, pretty sure insurance is gonna pay, you know, for the pressure mapping versus that hospitalization. So I've not run into that personally, but I would think that would be pretty easy to appeal. Yeah, great. So we are like exactly on the hour, so it's actually perfect timing, sorry. So just as a reminder, you can get your CME credits through the AAPMNR website. So just go ahead and, you know, indicate that you were here. And if you know folks that missed the lecture today, it is recorded, and so we'll be up there. Thank you guys so much, Dr. Anandi, for your lecture, and thanks everyone for being here. Thanks, guys.

seating assessment

abnormal tone

positioning

functional goals

mobility

upper extremity use

visual access

respiratory health

feeding