The term "cushion" can be used in a variety of different ways when it comes to wheelchairs and seating. When the seating is custom contoured/molded, it further enhances the individualization. This story highlights a client not only with unique custom seating, but also emphasizes the importance of investigation, education, and using all parts of the chair together to achieve an optimal outcome.
Meet Greg
Greg is a 22-year-old young man who entered my clinic with his mom, grandfather, and sister for a seating evaluation. His referral came from his wound care physician secondary to an unstageable wound on his right ischial tuberosity (IT) that would not heal. He was using a custom contoured/molded cushion with a foam-based seat with a 9-cell added air insert that was placed under the area of his right IT. His back cushion was also custom contoured/molded.
Custom contoured/molded cushions are specifically designed to "accommodate or correct a postural asymmetry or off-load specific bony prominences" (Kreutz, 2018). This can be a sought-after option for wheelchair users who need a high level of support and stability for daily activities due to the skin protection and comfort they can bring the user.
Greg communicates verbally, but due to his poor trunk, head, and neck position at the time of the initial evaluation, he had poor breath control causing increased difficulty communicating. He struggled to tell me that he was uncomfortable, that his bottom hurt, and that he was upset that he couldn't go to the movies or hang out with his friends.
Initial Evaluation
After the initial evaluation, multiple issues were revealed. He was poorly positioned in his wheelchair when he originally arrived. He was sitting with his trunk slightly twisted in his mold and was sliding forward out of his seat cushion. His previously captured custom contoured/molded back shape, which originally had full hip and trunk lateral supports molded to fit his body, was now ill-fitting due to weight gain and could not be modified. Greg's increased muscle tone caused visible shearing with all functional movement. In addition, pressure mapping revealed that the current seating was poorly fitting and improperly inflated, potentially increasing pressure on the wound. On the mat in supine, Greg presented with mild scoliosis and kyphosis, as well as pelvic obliquity and rotation. He had shorted hamstrings, which further pulled him into a posterior pelvic tilt (PPT), when he attempted to sit upright in his current system.
Custom cushion with overinflated air cells sitting fully upright
During the interview, Greg and his family shared that despite having a tilt-in-space wheelchair, he spent most of the day in an upright and non-tilted position. Caregivers manually transferred him into the wheelchair while it was upright without using the tilt function to assist. This made transferring difficult for Greg and his caregivers and did not help optimize his pelvis positioning or overall upright posture. Additionally, he did not have a consistent repositioning program.
Greg's current seating system no longer met his medical needs due to an unhealing skin wound and weight gain, which caused poor seating and inadequate support for essential functions like safe swallowing and adequate breath support for effective communication/talking. Consequently, he was eligible for a new seating system and a replacement frame, as his existing frame was over five years old, and his seating system was unable to be modified to meet his current needs.
Mobility and Seating Recommendation
Greg was recommended a QUICKIE IRIS with a Ride Custom AccuSoft cushion and Ride Custom back to meet his needs. Given his multiple characters, he required a cushion that was both supportive and forgiving. Secondary support accessories including a pelvic positioning belt, shoe holders, and knee block were also recommended. For Greg, stabilizing his lower body and pelvis not only prevented shearing, improving his skin integrity, but also enhanced his independent and efficient mobility in his upper body, head, and neck. This demonstrates the principle of "proximal stability for distal mobility."
Fitting and Follow-Up
When Greg came into the clinic to receive his new wheelchair frame and seating system, it was adjusted by the ATP per the therapist's recommendation to meet his needs. A benefit of utilizing complex rehab technology equipment is that these fine adjustments can be made on an individual basis. The infinitely adjustable FlexLoc® mounting system on the custom back allowed adjustment in every axis of movement, ensuring optimal balance and postural control. Height, depth, angle, and rotation could all be adjusted independently when mounted on the frame. The custom molded backrest was fabricated and further adjusted to appropriately support his kyphosis and scoliosis, as well as give him the proximal lateral support he required to be able to keep his head in midline. He was observed taking deeper breaths and he had an overall reduction in tonal influences, all of which were critical for Greg for safe swallowing and the breath control needed for talking.
The seat cushion was slightly modified by shaving it down to more precisely fit his contours. Pressure mapping indicated no increased pressure on his ischial tuberosities while seated on the AccuSoft cushion with his positioning supports properly positioned, even while moving and completing activities. The spacer mesh cover on the cushion and back allowed for improved assistance with airflow. This would assist with managing microclimate, especially in the summertime when he liked to be outside, and the increased temperature would increase his risk for skin breakdown.
Education and Training
At the time of fit and delivery, the family was also educated on how to properly use the full range of IRIS tilt to their advantage to transfer Greg in & out of the chair for his improved positioning and to assist with repositioning & pressure management. They could fully tilt the chair when assisting Greg into the chair and applying his positioning supports, which assisted with him being in the proper position. They also implemented the use of the tilt feature and a positioning reminder schedule, allowing Greg to spend parts of his day in a tilted position for better pressure management. Additionally, regular tilting alleviated discomfort and pain associated with prolonged sitting, improving overall comfort and support.
Three-Month Follow-Up
After a three-month follow-up after the delivery of his new chair and seating, Greg and his mother reported that the wound care physician was pleased and that his would had healed significantly, no longer needing surgical correction. Greg reported that he was comfortable in his chair, the family was able to go out more, which he enjoyed, and he liked being in his chair now.
Summary
As a wheelchair seating clinician, frustrations can run high at times with obstacles, denials, and hard choices to make. Often the most gratifying day in a seating clinic can be seeing a client not only look good in their seating system, but also feel good in their seating system. This IRIS tilt-in-space frame and Ride custom seating allowed Greg to get back to the things he enjoyed doing and to be seen doing them, which is the key goal for all clients and their families.
References
- Kreutz, D. (2018) Postural Support and Pressure Management Considerations for Hands-Free Sitters, Lange, M. L., & Minkel, J. Seating and wheeled mobility: a clinical resource guide (pp. 54-56). Slack Incorporated.
Lindsey Veety
PT, DPT, ATP/SMS - Clinical Education Manager, US Northeast