1. Presented by Rose Vallejo, PT, DPT

2. Special thanks to Jean Anne Zollars for permission to use diagrams from her book and lecture. www.seatingzollars.com

3. Seating can:  Improve comfort  Relieve pressure  Support the body  Enhance function  Improve bodily functions ◦ Respiratory ◦ Digestive ◦ Swallowing  Change/adapt

4.  Position of seating components, static  Posture – alignment of the body at any one time, dynamic, alive, changing

5. The Neutral Posture

6. The Neutral Posture: a reference point The Person’s Neutral Posture  Person aligned, well-balanced, stable  Home base – place to come back to between extremes of movement  Relaxed, but ready for action  Not collapsed  Lab

7.  Support the person in his or her neutral posture  Allow and support the person so that she has postural options in which to function

9.  Gathering Background Info.  Physical Assessment  Objectives  Seating & Mobility Components  Measurements

10.  Posture in Present Seating/Mobility System  Functional Skills in Present Seating/Mobility System (When and for what is the wheelchair being used?)  Joint & Muscular Flexibility: supine/side lying  Balance & Postural Control in Sitting*  Assessment in Sitting: Flexibility & Postural Support*  Effect of Gravity in Sitting *  Pressure Assessment

11.  Pelvis  Trunk  Hips & legs  Knees  Ankles & feet  Head & neck  Shoulder girdles  Arms

24. Posture in Present Seating/Mobility System - Review Systematically look at: Pelvis, Trunk; Hips/Legs, Knees, Ankle/Feet, Head/Neck, Shoulder Girdles and Arms

26.  Lack of flexibility in the joints, muscles  Tone  Stiffness  Sensory system: hypersensitivity, vestibular, proprioceptive issues  Pain  Discomfort  Insecurity, fear  Problems with fit of the seating system

27.  Pelvis/Low Back  Trunk  Hips & legs  Knees  Ankles & feet  Head & neck  Shoulder girdles  Arms Noting: flexible to neutral, fixed, percentage of flexibility and *Practical Flexibility

28. Check the flexibility when the pelvis is:

29. Pelvis: Can it come to neutral, ie. if posterior or anterior pelvic tilt, can ASIS & PSIS align? With how much force? Think of Practical Flexibility.

33. Why is it important to check the practical flexibility of the lumbar spine & pelvis?

34. If the pelvis is flexible, it can be supported from behind by a sacral or pelvic support

40. Practice: pelvis & trunk flexibility Pelvis/Sacral mobility on lumbar spine to neutral? Trunk neutral flex/ext? Trunk neutral lateral flexion/rotation?

41. * Note: Instead of first describing a typical posture as we do in the other sections, we are describing the movement of hip flexion

42. Hip Flexion Stabilize the pelvis via the ASIS, PSIS. When the pelvis starts to rotate, STOP flexing the hip. We are looking for the “practical flexibility”. This angle helps to determine the “seat-to-back support angle”.

43. What if the hip flexion angle is less than 90 degrees?

46. If hip is adducted/internally rotated: check abduction Caution: hip subluxation/ dislocation

47. ….then check hip external rotation

48. If hip is externally rotated, abducted, check adduction

49. …then check internal rotation to neutral What happens if a kid is fixed in abduction/ external rotation, and feet are forced into shoeholders of a typical wheelchair?

50. Assess knee flexibility if knee tends to be:  Flexed  Extended

51. Typical Posture: knee flexed Movement to assess: extension to 90º Why is it important to stabilize the pelvis?????

53. Typical Posture: knee extended Movement to assess: flexion to 90º

54. Why is it important to check ankle/foot mobility?

57. Practice: hip/knee and ankle flexbility Hips flex to 90 degrees? Hips come to neutral Abd/Add, IR/ER? Knees flex to 90 with hips flexed to 90? Ankles come to 90 DF and neutral inv/ev?

58.  Using your hands & body to provide postural support  Person sits on flat, firm surface with feet supported  Accommodate for joint limitations (ie. wedge for lack of hip flexion, pelvic obliquity)

59. How are your hands providing support to the pelvis? While assessing trunk flexibility, note specifically how your hands are providing support to the trunk, to help the individual achieve the person’s neutral posture. Questions to keep in mind:  Where are your hands supporting, “correcting” or stabilizing the pelvis?  In what direction are your hands applying support?  How much force are you using to correct the person’s pelvic posture?  What is the least amount of support necessary to stabilize and/control the pelvis?  How much surface contact is necessary to provide the support?

60.  The goal is to help the person find HER neutral posture  This means where she relaxes in your hands  Quick: take a picture from the front & side

62. In addition to an appropriate sacral - pelvic support, using an anti-thrust seat block and positioning belt, can help prevent extensive thrusting

63. Contoured cushion: IT space, very little postural control

64. Anterior Pelvic Supports (positioning belts)

65. Points of Control

66. Trunk: hand simulation

67. Trunk & Head Most of our backs are not flat! The upper thorax needs room to extend The scapula needs freedom to move Where is the head balanced over the spine?

68. Hand Simulation: Hips & Legs

70. Postural support: shoulders & arms Where are your hands providing support? How much force or stability do your hands provide? In what direction does the force or stability come from your hands? What is the shape of the surface contact area of your hands?

73.  The goal is to help the person find HER neutral posture  This means where she relaxes in your hands  Quick: take a picture from the front & side

76.  Establish if your patient needs a basic/intermediate or advanced intervention ◦ Consult with seating clinician ◦ Consult with ATP ◦ Refer to Seating Clinic Attend additional Seating Positioning Educational Courses ◦ Mention course sign up

77.  http://www.cliniciansview.com/ http://www.cliniciansview.com/ Pediatric Seating and Mobility CEU on-line video course from Clinician's View (JA Zollars & Rose Vallejo)  On the Clinicians-View.com home page, click CEU Courses, then under Dressing and Positioning, you will see Pediatric Seating and MobilityClinicians-View.com home page

78.  Organization. "Wheelchair service training package: basic level/edited by Chapal Khasnabis and Kylie Mines." (2012).  Khasnabis, Chapal, Kylie Mines, and World Health Organization. "Wheelchair service training package: intermediate level/edited by Chapal Khasnabis and Kylie Mines." (2013). http://www.who.int/disabilities/technology/wheelchairpac kage/en/  Greer,Nancy, Michelle Brasure, Timothy J. Wilt; Wheeled Mobility (Wheelchair) Service Delivery: Scope of the Evidence. Annals of Internal Medicine. 2012 Jan; 156(2):141-146.  Zollars J.A. Special Seating: An Illustrated Guide – Revised Edition. Albuquerque, NM: Prickly Pear Publications; 2010. www.seatingzollars.com. www.seatingzollars.com  Batavia, Mitchell. The Wheelchair Evaluation: A Clinician's Guide. Jones & Bartlett Learning, 2009.

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