The Siting Footprint

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Prepared and presented by Sharon Pratt, PT
Sharon Pratt Consulting
[email protected]
0&123+14.#/
• I am an independent consultant
• The opinions expressed in this program are my own
opinions only.
• This presentation is sponsored by Sunrise Medical
Sharon Pratt, PT
3/30/12
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3/30/12
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• Center of mass of the entire body is located over the
feet
• These are our supporting area
• Lets experience the varying muscle reactions that
occur with changing support area..
Sharon Pratt, PT
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Standing on one
foot: Increased
work and
increased
pressures with
decreased
contact area.
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When seated, the center of
mass of the trunk is only
over the pelvis with the
ischial bones as the
supporting area
Sharon Pratt, PT
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• Where are all the loading surfaces?
• Consider: Inferior, Posterior: Lateral and Anterior
• What impact does gravity have?
• How can we maximize the footprint?
• What is the optimal footprint – Is there one?
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• Average sized person
• Atrophied buttocks
• Bariatric shapes
• Body shapes and sizes
vary tremendously
• Adult Pelvic sizes vary
very little…..
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•
Important for
• lateral stability and /or
• redirecting load from the
ITs to the trochanters
Approx. 1.75”-2.5 “
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When viewing the sitting
profile from back to
front…
Where does the pelvis
stop and femurs begin…
Think laterally as well as
anteriorly from an inferior
surface perspective…
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Sharon Pratt, PT
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Ask ourselves….
• Is our client IN their cushion or ON their cushion?
• This is translated into depth of immersion…. As well
as conformation/envelopment
• Consider cushion material
• Consider thickness of material
• Consider cover over top of cushion material
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Consider:
Sharon Pratt, PT
•
Hamstrings
•
Calf size
•
Transfer technique
•
Foot Propelling
•
Chair set up
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•
•
•
•
Pelvis: consider ischia's and ramus
Thighs: consider the trochanters and femurs
Feet:
Forearms… plus and negative
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In the absence of
posterior support the
cushion cannot be
successful and sitting
is even MORE work
Sharon Pratt, PT
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Does the sacrum like taking a
load!. Or does it need support?
Sharon Pratt, PT
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•
•
•
•
•
Sacrum: needs respect
Lumbar-thoracic area
Upper thoracic: only when tilted or reclined
Occipital shelf
Calf pads in elevating leg rests….. Think about the
implications…
plications…
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Think carefully about this….
• Forehead… is it really designed for load bearing?
• Chest…
• Sternum…
• Knees
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• Do we want to provide
Anterior supports 1st?
Or
• Do we try to get
Posterior load bearing
1st?
• First we need to know if
this is fixed or flexible
and/or functional?
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•
•
•
•
•
•
Chest harnesses
Trays (Upper Extremity supports)
Pelvic positioning straps
Knee blocks
Foot straps – Shoe holders
Anteri h
Anterior
head
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raps
ra
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•
•
•
•
•
•
Where to put them…
Are we trying to match what our clinical hands do?
Are we EVER disappointed? ☺ "
Do they ever go out of alignment?
What happens with the winter coat ……
How do we know how much or how little is best?
Sharon Pratt, PT
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Lateral…..
• head
• thoracic
• pelvic
• thigh
• knee
• foot
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Primary Support Surfaces:
# Inferior
# Posterior
May need gravity to assist as long as its functional
How much orientation is necessary?
# 5-15°
# 45-60°
Primary Assistants….
# Anterior Supports
# Lateral Supports
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Help all of us address and create solutions for the
• Postural
• Functional and
• Skin Integrity
……Needs of our wheelchair seated clients
Sharon Pratt, PT
3/30/12
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Prepared and presented by:
Sharon Pratt, PT
[email protected]
21
!STOP!
Step Back … lets think together!
When selecting seating and mobility for our clients- do we
ever catch ourselves choosing band aids as we seek
solutions?
Prepared and presented by:
Sharon Pratt, PT
[email protected]
0&123+14.#/
• I am an independent consultant
• The opinions expressed in this program are my own
opinions only.
• This presentation is sponsored by Sunrise Medical
Sharon Pratt, PT
3/30/12
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• I believe I have been known to put band aids on
the symptoms because I didn’t identify the Cause
of the problem
• Lets think of some examples….
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•
•
•
•
•
•
•
Sliding
Scissored legs
Leaning laterally
Falling forward
“Increased tonal patterns”
“Feet wont stay on footplates”
Windswept lower extremities…
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•
•
•
•
•
•
Pelvic straps
Wedge cushions
Medial thigh supports(abductors or pommels)
Elevating leg rests
Dicem☺
Tilt
• …… Yes indeed … We may well be crazy☺
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Unaccommodated….
• Bilateral limited hip flexion
• Increased extensor tone
• Posterior pelvic tilt with kyphotic posture
• Tight hamstrings
Imagine if we dealt with these issues and created
solutions rather than reaching for the Band-Aids?
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VERY
Hip range of motion relative to the pelvis is critical for
optimal balanced seating for function….
Lets look at
• Bilateral limitations and
• Unilateral limitations
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Unaccommodated
hamstrings
Sharon Pratt, PT
Accommodated
hamstrings
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•
Falling forward
•
Fatigue
•
Feet not staying on
footplates
What Band-Aids do we see?
What could we do
differently?
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If this is a fixed APT
Sharon Pratt, PT
We could introduce gravity with tilt?
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Why?
Because when the pelvis
is anterior- the hamstrings
are pulled back with the
ischials… so allowing the
feet to rest further back
may relax the already
stressed hamstrings…
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Right Obliquity with
Compensating Scoliosis
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• An example of how it can be a symptom …….
• Try this: …
o Imagine extreme pain in right hip ( could also be limited hip
flexion or subluxation etc etc… )
o Get off it…
o Feel what happens in pelvis…. Do you experience a left
pelvic obliquity and/or left rotation (right side of pelvis
forwards)?
o Imagine now if we dealt with the right hip issue instead of
reacting to the presenting posture which is merely a
symptom
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• Thoughts from Sharon's
head!
o Level 1
o Level 2
o Level 3
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Example of level 2
Sharon Pratt, PT
Example of level 2
solution
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Example of Level 3
Example of level 3 solution
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• In Summary:
: result of inadequate support: correct it and everything is
level
: result of bone or muscle mass for example missing from
the underside: build up the low side to substitute for loss and
outcome will be level
Situation is fixed: must accommodate: build up under
high side to optimize the sitting footprint… remember thighs; feet:
shoulders may all be asymmetrical
o Thoughts from Sharon's head!
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Pelvic Rotation and Obliquity
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• Can be a symptom of…
o
o
o
o
o
o
o
Asymmetrical muscle tone (trunk and /or lower extremities)
Unaccommodated Asymmetrical hip abduction
Unaccommodated Asymmetrical hip adduction
Unaccommodated Asymmetrical hip flexion
Unaccommodated Leg length discrepancy
Posterior dislocated or subluxed hip
Unilateral foot propeller
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For me: these are the top 3 questions I must know the
answers to….
• Is there presence of redness or open wounds on the seated
surfaces?
o If yes = High Risk
• Is there a history of redness or open wounds on the seated
surface?
o If yes = High risk
• Can the client do an effective weight shift consistently?
o If no, for any reason = High risk
These clients likely need full pressure management
through the cushion, back support +/- weight shifting
technology
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Consider…
• Atrophy
• A lot of movement while seated
• Moisture/heat
Perhaps shear reduction and /or microclimatic factors
need to be considered
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• Always ask ourselves – does the posture have
flexible and or fixed components?
• Have we identified the cause of the problem or only
the symptom?
• Have we maximized the potential seating footprint
for optimal function and safety?
• Is the client comfortable and happy?!
• Is our documentation funding proof?
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If We Don’t Know These Clinical Things…
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Sharon Pratt, PT
3/30/12
96
Essential Clinical Questions
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Sharon Pratt, PT
3/30/12
97
38
Essential Clinical Questions
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Sharon Pratt, PT
3/30/12
98
How do we get the answers to those
questions?
•
•
•
•
•
•
H(,#.?&#C/
O++@&()$6,$,"#$23&#(,$&($,"#$#a&1,&()$1;1,#G/
O++@&()$6,$,"#$23&#(,$+4,$+7$,"#&.$#a&1,&()$1;1,#GQ/
!"#$"6(D1$+($611#11G#(,/
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<.#114.#$G6--&()E$C"6,$6.#$;+4.$#a-#.&#(2#1I/
Sharon Pratt, PT
3/30/12
99
39
O6DD#.$+7$(##D1
/
Clients whose needs for postural asymmetry
and skin protection cannot be met with
anything less than custom molded
Clients who use wheelchairs who have
moderate to aggressive asymmetrical
postures and who are at moderate to high
risk for skin integrity issues
Clients who use wheelchairs who have mild
to moderate asymmetrical postures and
who are at moderate to high risk for skin
integrity issues
Clients who use wheelchairs who have
symmetrical posture and who are at low to
moderate risk for skin integrity issues
Sharon Pratt, PT
3/30/12
100
O6DD#.$+7$1#6,&()$-.+D42,$1+34,&+(1
/
Custom made seating – molded
Custom made seating – linear and contoured
Off the shelf seating – customizable
Basic off the shelf seating – non customizable
Sharon Pratt, PT
3/30/12
101
40
O6DD#.$+7$2+G-3#a&,;$+7$S41,&`26,&+($
/
Clients positioning and skin needs cannot
be met with anything else. This is the
basic essential seating that is necessary
Clients positioning and skin needs
cannot be met with off the shelf seating
even if it is customizable
Asymmetrical postures cannot be
accommodated by basic seating and/
or client is at risk for skin integrity
issues
Everyone who needs a wheelchair needs
basic seati cushions and back supports
Sharon Pratt, PT
3/30/12
102
=#7#.#(2#1
/
• Most of the theories and descriptions are from
personal experience over 23 years working in the
field of seating and mobility
• Graphics used with permission from Sunrise Medical,
Ottobock, Leckey and ArjoHuntleigh
• Other reading references available upon request
• Please feel free to email at [email protected]
Sharon Pratt, PT
3/30/12
207
41
!RB\e$fLgQ$
!"#$%&"'()"%)**+%%"#$,&"'()-"%+.,$/0"./1"2(3$4$,'"(55(-,)/$,$+%6"!"&(5+"
'()"7/1"+.*&".%%+%%2+/,".%"8)4744$/09"*&.44+/0$/0"./1"8)/".%"!"1(:"
;
Prepared and presented by:
Sharon Pratt, PT
[email protected]
42