If you’ve worked in Complex Rehab
Technology long enough that
custom-molded seating summons
memories of plaster and tarps — or even if you’ve
just heard colleagues talk about those days —
you may think there’s little to love about it.

But custom-molded seating has significantly
evolved over the years… and maybe has been a
bit misunderstood from the start.

“This is so near and dear to my heart,” said
industry veteran Stefanie Laurence, BScOT,
OT Reg., Clinical Educator at Motion (formerly
Motion Specialties). “This is my favorite topic. I
love custom seating. It’s my passion. I’ve seen so
many changes over the years, and I’m amazed at
the results that we can get.”

And that’s just one reason to embrace custommolded
seating.

Custom Seating Can Help a Wide Range of Clients

Creating a custom mold can sound like a strategy to reserve for
the most complex clients. But in reality, it can be a great solution
for a much larger group of wheelchair users.

Asked when custom-molded seating should be considered for
clients, Mark Bisson, Product Manager of Manual Mobility & Seating for PinDot custom-molded seating from Invacare Corp.,
said, “Is off-the-shelf seating solution sufficient, and will it satisfy
what they need? If not, the team needs to ask ourselves, what are
we trying to accomplish, what are the goals and specific objectives
for the end user?”

Sam Hannah, ATP, CEO of Symmetric Designs, said custommolded
seating “should be considered for clients with complex
postural needs that might include scoliosis, kyphosis, lordosis
and other shapes needing specific support or off-loading. Custom
seating can ensure a well-supported posture for young growing
clients, especially those with poor trunk control, to ensure
they grow into a more functional and stable seated position. In
addition to considering their existing postural support needs,
custom seating should take into account the client’s level of independence, mobility device, lifestyle, age and future needs.”

Laurence said she has four criteria when considering custom
seating: “Number one: The client’s shape can’t be supported by
modular [seating]. That could be [due to] orthopaedic deformity.
The second: where [due to] tone or movement, whether voluntary
or involuntary, the hardware of modular just won’t hold up.
We need to build a more robust system, whether that’s through
seating or adding dynamic [components] into the chair. The first
thing I look at is whether by movement or tone, they’re blowing
everything apart.

“Number three is where the environment needs to be robust
and simple: Long-term care, a group home or somewhere there’s
multiple hands touching the system, and we need to make sure
that it doesn’t get reinterpreted by caregivers. The fourth is when
somebody needs a very minimal or a very specific support. You
can support the person in modular, but if we do custom, we can
probably cut the system in half.”

It’s More Adjustable & Flexible Than It Seems
Laurence notes that last criterion is a bit of an outlier, as custom
molded seating might conjure up images of huge, boxy systems.
But Laurence said it doesn’t have to be that way.

“I want to see the client first,” the said. “The seating should just
be supportive. I can get laterals that are only an inch thick with
custom, and with no hardware exposed, nothing that’s going
to rub against somebody. That’s remarkable when we’re trying
not to have an abrasion on somebody’s inner arm, or when we
need to make a lateral 3″ wide because it’s become an armrest or
arm block: We can do that. That’s the cool part about custom:
You can get the support where you want it. And the sky’s the
limit: You can have it as big or small as you want. Custom is only
limited by your imagination.”

Some forms of custom seating today are more adjustable by
design. Symmetric Designs refers to its Free Form Seating as
modular custom seating because it can be created to fit a client
now, and then can be adjusted to accommodate changes in weight,
growth, or posture. “Modular custom seating systems provide
the most flexibility to adapt to changing needs,” Hannah said.
“Modular systems usually consist of independently adjustable
components or modules that can be positioned and locked in
place. This allows for an adaptable system with more efficiency.
The ability to add or remove shell support and the ability to adjust
the contour provide a system that can adapt with the client and
result in better short- and long-term postural outcomes. Built-in
adjustment results in lower costs and better outcomes.

“There really is no substitution for a hands-on assessment
and fitting with skin checks to ensure a functional support is
provided to the client. Built-in adjustability of the equipment is crucial to ensure an accurate, proper fit that will provide a longterm
seating support.”

That adjustability even applies to the need to adapt to a
challenging environment. For example, what if custom seating
seems like the best plan, but the client lives in a region known
for its humidity and warm temperatures? Certain custom seating
systems can adapt. “Free Form’s Stimulite covers are hugely beneficial
to clients in hot climates,” Hannah said. “The combination
of a breathable custom seating shell and padding is an excellent
way to keep cool during these hot summer months. When Free
Form is padded with our Stimulite padding option, it provides a
fully ventilated seating system that dissipates heat and moisture
— essential for maintaining healthy skin.”

And adjusting even more traditional forms of custom seating
is possible, Laurence said: “I started doing custom seating before
there was modular seating. I started in the plywood, foam and
Naugahyde days. We can build in adjustability; we can modify
seating. Yesterday, I cut open a system and shaved away and
sealed it back up. Is that my preferred route? No. But I’m not
afraid to take a knife and a sander to it.

“You can build in forgiveness; you can build in ways to modify
it. When we put in aluminum reinforcements in a backrest, you
can bend it. Kids: You feed ’em, you water ’em, they grow. You’d
better plan for it.”

Technology Has Greatly Improved

Those improvements apply to both “traditional” molding and the
new generation of modular, buildable seating.

“Custom seating has historically been very expensive, time
consuming and limited in its ability to adapt to changing needs,”
Hannah noted. “With new technology, seating prescriptions can
be done through apps on a tablet or smartphone and in much less
time. Technology that can generate accurate 3D models of contours
and shapes is readily available and more affordable than ever.”

Bisson said of how technology has impacted custom seating,
“Obviously, technology continues to evolve, and we try to take
advantage of new technology whenever possible. Our CLIP
program is a perfect example of scanning technology we provide
that’s resulted in faster and higher-quality imaging for mold
capture and resulting in time savings that are two-fold. One,
capturing the mold up front so that’s easier on everyone involved,
especially the client, where it can sometimes be a challenge for
them to be molded. With this technology, the molds that we
capture are better and more detailed. Because of this, we as a manufacturer can create a better mold, and we can do it more
quickly and eventually ship the products quicker to the supplier.”

Rick Weddle, Rehab Product Sales Specialist at PinDot, said,
“I was around in those days of making plaster casts. I used to go
into people’s homes with a simulator — and we used to do carves
before we even had molding simulators. Those were seven- or
eight-hour appointments, so when the simulator came along, that
was fantastic.

“[Prior to that] you were taking the mold, and then when you
finished, you were telling the family, ‘We’re going to have to
spread a tarp out in the living room and put the simulator on
it, and then I’m going to be dipping plaster casting strips into a
bucket of water.’ It was a two- or three-hour process, waiting for
the casts to set up. Compare that to now with the 3D imaging
technology that we have: We transfer the patient out of the
mold, you put your marker indicators on there for the computer
system, and within a matter of minutes, you have the 3D image.
I think from that aspect, it’s a huge time savings for the end users
because now that mold can be taken in their home and literally
that afternoon, the manufacturer has the information they need
to go to design and get it to production. It’s amazing.”

“I think the 3D imaging systems without question have
improved the quality of the molds, the capturing of the shapes and
the images,” Bisson agreed. “Before that, you had to literally carve
it out sometimes. And sometimes in years past, the mold didn’t
match the client’s true shape. We had to use tape measures, tape,
all kinds of tools to get it to fit. It would have taken literally hours
to capture a mold. Think of all the energy being utilized, and think
of the client. It was very taxing on them.”

Custom Seating Can Yield Incredible Results

“I think the expectation for a good image capture and a good
mold has increased,” Weddle said. “There’s a much higher
level of expectation from our providers and the end user as
well. As the image capturing technology improved, we were
still left with a little bit of a labor-intensive manufacturing
process, where a lot of the people in manufacturing still had to
look at that image and do some things by hand. Now we have
more accurate data coming in, and we have the manufacturing
methods to take that data and actually produce the end product
without it being nearly as labor intensive and get a more accurate
end product.”

And for some clients, custom seating offers the best, most
functional answer. Laurence remembered a client with both ALS and multiple sclerosis who because of her positioning hadn’t
been able to drive her power chair for some time.

“‘We want you to get her driving again,’” Laurence remembered
the rest of the seating team saying. “I’m not a miracle
worker. But we did a quick mold in her chair — and she could
move the joystick. She looked at me and said, ‘I love you.’ All the
people behind me were starting to cry. They hadn’t heard her
speak that loud, but now she could suddenly get a good breath,
and she could move the chair. That’s cool stuff.”

When Laurence recently saw a client in a group home, she
thought a modular system could work: “I always want to look at
modular first and rule it out. I’m always looking for as simple as
possible, what can be replaced easily, cost effectiveness. And then
we went to the person in charge of the home and laid out the
pros and cons of each system. She [was] in custom, and you see
the seating and not her. I’d love to see this little girl and see her.”

The home manager had two requests, Laurence recalled. First,
the manager wanted a system that couldn’t be easily changed or
“fiddled” with. Second: “She said, ‘I also need it to be ridiculously
incontinence proof. It’s a flood. The diapers just don’t hold it well
enough.’”

These multiple issues made Laurence reconsider custom
seating. “We said, ‘Okay, we’re going to stay with custom, but
here’s what we’re going to do. I want to cut her seating down.’
We molded, and I put the molding bags exactly where I wanted
the mold to stop. We finished molding, and said, ‘What do you
think?’ And [the manager] said, ‘Wow!’ That’s the power of
custom seating. The best results come when we have a team with
open communication.”

“It is a bit of a hierarchy,” Weddle said, in choosing custom as
the seating strategy. “The goal is always to do the least invasive
system, to provide the system that’s going to meet the goals of
the clinical team, yet at the same time be the easiest thing for the
caregivers to use. So, there is a hierarchy of what will work, and
what will work for the caregivers.”

“Don’t be scared by it,” Bisson said of custom seating. “I’ve had
the opportunity to speak with a number of ATPs who’ve captured
molds. I’ve talked to ATPs that have done it so many times, it’s
like second nature to them. And I think some of those ATPs who
are newer and haven’t had as many mold captures are sometimes
hesitant. That’s okay. We tell them: Use your skill set. You have
expertise. Be confident in what you can do. It’s an amazing tool
that will allow you to provide the end user the best possible
solution for them.”