Accomodate or Intervene?

As the saying goes, if it were easy, everyone would be doing it, right?

So goes the work of the complex rehab seating team, charged with
recommending and building best-case scenarios for wheelchair users
of every age and size, with permanent, sometimes progressive diagnoses
and each with a unique history, set of challenges and set of goals.

So as your team goes through the assessment process, you’ve got a
choice to make. Do you generally accept your client’s current posture
and support it, using various seating options?

Or do you try to change that posture, perhaps in hopes of interrupting
scoliosis, or in hopes of improving your client’s ability to self
propel, to see the environment, to socialize?

Do you meet your client where he or she is and accommodate that
posture? Or do you intervene and change that posture for good?

Old-School Thinking & New Practicalities

Seating philosophies, like almost anything else, evolve with the times.

Not so long ago, for example, 90° was a measurement to aspire to —
never mind that just about no one, regardless of ability or disability,
finds that sort of rigid positioning to be comfortable or sustainable.

Happily, that perspective seems to have largely given way to a more
practical one.

“For a lot of time,” says Patrick Meeker, MS, PT, CWS, VP of global
sales for ROHO Inc., “we wanted to make people look really good in the
chair or in their seated position. And then we slowly found out — Wow,
that looks good to me, but it doesn’t make them very functional, or it
increases their pain.”

So with those imperfect posture goals relegated to the past, seating
professionals face another decision — to intervene to try to literally
shape a client’s future posture, or to accommodate what exists and
support it as well as they can.

What’s the best way to make that decision? What factors should the
seating team consider?

And are accommodation and intervention mutually exclusive, or for
at least some clients, are the strategies best when they work together?

When to Intervene

“Our bodies are so quick to adapt to the positions we are in day to day,
whether we are in a chair or not!” says Stacey Mullis, OTR/L, ATP,
director of clinical education for Comfort Company. “This is what
makes the decision to
intervene or accommodate
more difficult.”

Mullis adds that there is nothing
simple — and often nothing quick — about a
well-considered postural intervention.

“Often when we intervene, we are altering the
delicate balance that our muscles/tendons have found
to accommodate the position we have been in,” she says.
“When we attempt to change this, there can be stretching of
these structures that can lead to discomfort and/or pain. This
discomfort can go away fairly quickly if the abnormal posture is recent.
But for someone who has spent years in a particular posture, it can be
very painful to change it. One way to address this is to be progressive
with our intervention. Begin by reducing the deformity in smaller
increments to allow for the muscles and tendons to adapt, and gradually
progress to the desired posture.”

Because of the complexity and impact of intervention, it’s not always
the best decision. But sometimes, it’s probably the right move.

“An example of when I think it would be important to intervene,”
Mullis adds, “would be when a deformity begins to interfere with respiration
or digestion, such as with a severe curvature of the spine. I would
trial intervening, as these issues deal with their overall health and
function. One thing to be aware of with a reducible deformity is the
amount of intervention to impose. Too much at once can lead to significant
pain, discomfort and even decreased function. In my example of
respiration and digestion, maybe a small amount of correction of the
curvature will be enough to improve these two areas, and minimize
pain and/or discomfort from the correction.”

Cindi Petito, OTR/L, ATP, CAPS, CHAS Group Health Care Corp.,
says it’s important to understand a client’s full medical background before deciding to intervene.

“One factor includes properly
evaluating clients’ full medical history
of their spinal and postural deformities
and the secondary health issues that are
occurring as a result,” she says. “For example, if
a client has a flexible positional scoliosis resulting
in the lower ribs collapsing into the pelvis, and the
client is having pulmonary and digestive complications
as a result of this posture, then intervention in this case
should be considered rather than accommodation.”

And if intervention is to be successful, the entire seating team,
including client and caregivers, need to accept that change may not
come easily.

“Intervention is applicable in situations where the client can tolerate
the level of correction necessary to achieve a clinical benefit,” says Greg
Sims, ATP, CEO of Matrix Seating USA. “If a client is highly functioning
in their current, non-ideal position, and suffers anxiety or pain
from the intervention, accommodation is likely the best modality.”

The Importance of Function

Indeed, a client’s function, or lack of it, is one of the most important
factors the seating team can study when making their decision to
accommodate or intervene.

“First and foremost, my number one goal is to increase function,”
Meeker says. And while improving a client’s posture carries a number
of obvious intrinsic benefits, Meeker adds that other functional
improvements can also be realized.

“The other thing I’m really watching is people’s head function and
head control,” he says. “I was doing a session five or six years ago in
Australia, and I was working with the guys from Bodypoint. They
showed me a chart of people’s visual acuity and the color spectrum. I
really started to pay attention to it when I’m driving: if I don’t move my
head or I don’t have good control of my head, what colors I see [beyond]
20° straight ahead. You lose all of that, all those colors, in your peripheral
vision. In community ambulation, if I’ve got someone whose head
is always cocked to the right and they’re driving their power chair, that
means they’re always driving with one eye being dominant, and they’re
mostly driving with their peripheral vision.”

Clients who rely mainly on peripheral vision while using their power
chairs in their communities will have a more difficult time discerning
colors, Meeker notes, such as those in traffic signals.

“So is there a way that I can control their head and get it better,
which is the correction part, to make them more visually functional
throughout the bulk of their visual space?”

“Being an occupational therapist, I always am thinking about
function,” Mullis says. “This is always on my mind as I look at posture.
I once saw a man who sat in a severe posterior pelvic tilt with a
significant C curve of the spine and a 5″ gibbous on the right side.
Surprisingly, his pelvis and spine had some flexibility, and the question
was whether to intervene with a more aggressive back support and a
more aggressive cushion. We attempted four different cushions and
three different back supports, and it always came back to function.
Every time we intervened and improved his posture, he had difficulty
with his activities of daily living. In this case, the client preferred that
we accommodate his current posture, as intervention would mean
decreased function or needing to learn new ways of doing daily tasks.”

When to Accommodate

With all the technology available today, postural intervention might
seem the obvious, and even responsible, path to take. But as Mullis
points out, intervention can have a huge impact on a client’s function,
and therefore, the client’s quality of life.

Stephanie Tanguay, OTR/L, ATP, clinical education specialist for
Motion Concepts, adds that accommodation isn’t just a decision to be
made by the seating team. Clients, their families and caregivers also
need to decide whether they can accommodate the technology, and its
impact, within their lives.

In the past, she notes, “There were people who were using custom
orthoses, like TLSOs [thoraco-lumbosacral orthoses] and body jackets
and suspension systems in their chairs. With more severely impacted
consumers, that’s the first thing we think of: You see a consumer who
has spastic quadriplegic cerebral palsy (CP) or a rotoscoliosis, and
that’s probably a long-term development of that condition. Our go-to
response would be to accommodate that. Accommodation is always
about trying to stave off it getting more severe, and I’m not going to find anything else that’s going to fit that body. I think it’s probably
an easy population to do that with, because it’s very historic.
You’d be in a group home or a workshop setting and see a
lot of other consumers with a similar diagnosis in a similar
seating system: Manual tilt chair, check. Molded seating
in back, check. The caregivers in those group homes are very
used to seeing that. It’s standard operating procedure.”

But introduce that postural system to a parent whose child is living
at home, and Tanguay says the typical response is markedly different.

“When you show something like that to somebody who’s never seen
that or worked with anybody who’s needed that, there’s a freak-out
factor sometimes,” she says. “My kid’s gotta be in that? So that can get
kind of tricky.”

Ask her about accommodation, and Tanguay talks not just about a
client’s posture, but also about how the technology will fit into a client’s
home and daily routine, because that part of the equation can enormously
impact the seating system’s ultimate success.

For instance, does the client — and any caregiving support in place
— have the ability to correctly use the seating system?

“The more aggressive your mold, the more you’re trying to ‘correct’
to prevent the severity,” Tanguay says. “A little bit of lateral contouring
in the trunk is one thing, but when I’m trying to keep your ribs from
touching your pelvis, I might be a little bit more aggressive. Then it’s
going to be more complicated for the consumer to be placed or to place
themselves in and out of it. They probably can’t do that. At a certain
point, a lot of orthopaedic changes or deformities are so severe that it’s
not even a possibility for them to do it. As a clinician, you still have to
consider what it takes to actually achieve the proper orientation of the
consumer into the system.”

While needing to adjust equipment choices to fit a situation like that
isn’t clinically optimal, it is a real-world scenario.

“I once worked with two boys who were really severely
involved,” Tanguay says. “They had spastic quadriplegia
CP, and they had an elderly mom who was literally caring
for them in their home. When we saw them in clinic, she
was doing still about 90 percent of their care by herself. She
had these little sling strollers, because that is what she could easily
put in and out of her car.”

Those umbrella-style strollers were terrible for the boys’ positioning,
but practically speaking, it’s what their mother could handle.

“So decision-making has to consider all those factors,” Tanguay
says. “If it’s too much for the caregiver, if it’s too complicated, if there
are multiple caregivers in a given day, you really may not be able to get
as aggressive or complicated as you’d like. Because if they don’t use it
properly, you can cause issues, too. You can have a really aggressive
mold or capture a really aggressive shape, trying again to prevent
bone-on-bone contact or whatever it is, but if the person is not perfectly
oriented to that mold, and if you can’t lift them and place them down
into it — if they have to drag their soft tissue to get into the seat, they’ve
displaced tissue. That soft tissue is not the shape it was when you
captured the seat mold.”

Accommodation As Art

If broadly speaking, all seating systems are interventions — technology
chosen to support and maximize a client’s function — then every
seating choice must accommodate its consumer to be effective.

When it comes to seating possibilities, “Most clients don’t know what
they don’t know,” Meeker says. “So if you give them the opportunity to
experience something categorically different from what they’ve been
experiencing, they might dismiss it outright, but if they give it a chance, they’ll think, ‘Wow, this is amazing.’ However, I do need to listen
to them. That’s a kind of trade-off in empowering your client
to help in the prescription of the devices.”

Listening to clients, Meeker explains, includes understanding
how and why their current positioning came to be.

“A lot of times, they’ve adapted their posture because they
don’t have support enough to keep their head in the right position,”
he says. “Or, let’s say I did a full musculoskeletal evaluation,
and they may not have the range to keep their head that way because of
their vertebral artery on that side. As soon as they straighten their head
out, it restricts the bloodflow, and they get dizzy. It’s not impossible.
So there are certain things you need to assess on a musculoskeletal
evaluation or mat eval.”

The seating team also needs to look at the impact of technology on
the client’s entire day.

“And you have to think: I’m sitting down, I’m at maximum 4′ tall, I
can’t see around stuff, my spine is twisted, I can’t see right, and I only have
control of one arm. It’s putting yourself in their position and saying, all
right: Now they’ve got a van, how are they going to get up the ramp? Is
the seat base too tall for them to get into their current mobility system?
How do they get up the ramp at their house?

“I can’t tell you how many houses I’ve gone to, where they’ve been
prescribed this awesome chair that worked in the hospital, and they
couldn’t even get into their house or their van. Therapists don’t
get the time anymore to do home evaluations because
no one pays for it. That’s why you have to ask the right
questions, and that takes time. I teach therapists that I talk
to: There’s a lot of down time in an eval. Ask questions. Ask:
Where do you live? Do you live in an apartment? Do you live in
a house? How big is your door in your bathroom, do you have any
idea? Can you move around?”

“One of the better [ideas] is to actually see how people do transfers in
the home,” Tanguay says. “In seating clinic, it’s a little skewed. I’ve got a
big mat and 5′ of clearance on all sides of it, it’s not an obtrusive height.
Then you go to deliver something to somebody’s home, and they do a
completely different kind of transfer to their bed. I’ve had that happen as
a provider: I drove to deliver a power chair with tilt and recline, but the
armrest did not move, and even though I had seen his caregivers do transfers
with him on the mat table to a manual chair — at home, the way they
did his transfer to his hospital bed was to fully recline his old chair and
use a sheet [to pull him across]. And woe is me to be delivering a power
chair that did not have an arm that came off and went all the way down. It
reclined, but they’d have to lift him or drag him over the armrest.”

Or Tanguay says, maybe a long-time caregiver has developed an
efficient transfer routine that will no longer work in conjunction with a
new seating system.

“So what’s more fair?” she says. “Am I going to get his caregiver
who’s been doing this for 15 years to change because I want to
do something different with the wheelchair? Or do I need
to make sure that I have a chair spec’d out that’s going to
allow them to still [carry on]?”

Understanding your client — not just clinically, but also how
he or she thinks, is motivated and feels — is critical, Meeker says.

“Sometimes I see someone who has stopped growing, and their
body has kind of collapsed into this posture, but they have maximized
their function and they can do some amazing things,” he says. “We are
all creatures of habit and we don’t ever do anything the hardest way. We
always do it the easiest way; it’s human nature. So I want to watch these
people in their chairs, how they’ve adapted their current chairs, and
how I can augment that, if at all possible, knowing full well that I may
be replicating everything to the best of my ability so I can keep them
exactly how they are and not let them get worse.

“I have to be willing to accept that my paternalistic view of seating & positioning might not be the best outcome for that client.”

“Getting the consumer to buy in is one point I can’t stress enough,”
Tanguay says. “And then, the functionality of it: Can they transfer?
Sometimes, people have mild issues with obliquity or scoliosis, and we
make decisions about changing things. From a functional standpoint,
it might be easier for them to propel or transfer with that, if we
start straightening them up. It may be that in a short period
of time, they adjust to having that correct orientation, and
they may be just fine. But they might come back to you and
say, ‘This is killing me, I can’t do this anymore. I want my
old [system] back.’ There are a lot of people who discard what
we prescribe, and maybe part of it is because we don’t listen well
enough on the front end.”

Meeker says, “As you meet more and more end users, you find some
of them are willing to change. But most of them aren’t. Most of them
want the same exact chair. Of course, chairs aren’t made the same exact
way for the most part; there’s always something new. And you’re having
to find a way to get them comfortable in a new environment and keep
them functional. Because even the smallest changes can make or break
someone being able to transfer on their own.”

He adds, “What we do is so much science, but we make our clients
better through art.” The industry has those gifted in science and others
who are artists, but Meeker says, “The best ones are the ones that can
combine both. There’s a bit of artistry in there, and then they have
interpersonal communications skills. I’m telling you, a great hand
touch and a polite way of explaining something for the 37th time goes a
long way into making positive changes last.”