Seating and Positioning Series

Time To Tilt!

How Tilt Works, Why It Works, & The Clients It Can Help

When discussing positioning options for seating & mobility clients, you can’t get far without considering tilt. While tilt is perhaps most immediately and commonly associated with pressure relief — especially when justifying tilt to funding sources — it’s also useful in a number of other clinical and lifestyle situations. The bigger question: Can those situations be justified to payors’ satisfaction?

Mobility Management asked several positioning experts about the mechanics of tilt, its potential benefits and applications, which seating & mobility clients it can typically help, and of course — what the funding situation is like. — Ed.

What Is Tilt?

Q: What are the physical logistics of tilt, i.e., what happens to the physical orientation of a person’s body when he moves from sitting upright to tilting? How does tilt differ from recline?

As its name suggests, tilt repositions a client by moving the seated client “backward,” so his head is lowered as his feet rise at the same time.

“Simply put, tilt causes you to shift from your bottom to your back,” says Cody Verrett, ATP, national sales director of Quantum Rehab. “You can imagine if you were in a sitting position in a chair, and a friend slowly tilts your backrest backwards, which shifts your weight almost entirely to your backrest. That’s essentially what tilt does. It uses an actuator to lift the person in that fashion, shifting their weight from their ITs or ischial tuberosities to their back, and displaces that pressure evenly across their entire back and redistributes it from their behind.”

Motion Concepts’ Stephanie Tanguay, OTR, ATP, clinical education specialist, described tilt as “a shift in weight-bearing — a transfer of weight-bearing from one part of the body to another. In an upright, seated posture, the majority of the body’s weight is at the seat surface interface — not all of the weight, of course, as a percentage of the body’s weight is on the forearms, if they are in weight-bearing contact with the armrests. As the system moves through the tilt range, that weight distribution is shifted onto the back support surface — in a traditional posterior tilt-in-space.”

Tilt and recline are often mentioned in the same breath, but there is an important difference, says Invacare Custom Manual Product Manager Jud Cummins.

“Although the recline function of a wheelchair has its benefits — comfort, eating, function — (recline) differs primarily from today’s tiltin- space chairs because it changes the consumer’s center of gravity,” Cummins says. “Modern tilt-in-space chairs provide those same benefits, plus pressure relief without changing the consumer’s center of gravity, which has a number of benefits to the consumer, caregiver and the engineer designing the chair.”

While moving even slightly in that “backward” direction is technically a form of tilting, Sunrise Medical’s VP of Clinical Content& Research, Tom Whelan, says that for tilt to effectively relieve pressure — the benefit perhaps most commonly associated with tilt, at least in the minds of funding sources — the degree of tilt has to be significant.

“The biggest justification for tilt is pressure relief,” he says. “But there’s been some work done, some studies done, on how far you have to tilt to get any significant pressure relief. And there’s still some debate on that. Some studies indicate that you have to pass 45 (degrees of tilt) to get significant pressure relief for off-loading of the ischial tuberosities. Clearly, you’ve got to at least approach 45 to get anything significant, and there’s plenty of evidence that says you’ve got to pass 30. There’s still some debate as to how meaningful is the relief and at what degree does it occur. But there’s no debate that you have to pass 30 to be able to get there.”

More later on those 30- to 45-degree tilt thresholds.

Which Clients Can Benefit from Tilt?

Q: What mobility-related diagnoses can typically benefit from tilt?

“We see a wide range of diagnoses utilizing tilt systems,” says Tanguay. “SCI, muscular dystrophy, multiple sclerosis, cerebral palsy (CP), spina bifida to name a few.” But Tanguay and the other positioning experts cautioned against using a diagnosis as the sole criterion when evaluating a client for tilt.

“More important to consider are the symptoms or conditions that tilt is prescribed to address,” Tanguay explains. As an example, she says, “Recline may be contraindicated for limitations of hip range of motion.”

“A diagnosis is less significant to justifying technology than a functional presentation,” Whelan says. “If I have a mild case of CP, I could be ambulatory, but I still have CP. Or I can be a quadriplegic (with CP): I could have neuromuscular involvement that prevents me from using my trunk, my arms, my head and my legs. I could be completely non-functional as a result of that diagnosis of CP.”

Assuming that wheelchair users, by definition, all have some degree of mobility limitation, Whelan says the vast majority of them could benefit from tilt.

“When you think about the mobility-related presentations that benefit from tilt: Everybody benefits from tilt,” he says. “There is no person that doesn’t benefit from tilt except the (paraplegic client) that is the super para who can sit anywhere. That para can literally do what (able-bodied people) do.” Whelan says that if a client’s functional presentation shows that he’s retained the ability to move and control his posture and change it, “then you don’t need tilt. If that’s not true, you’re going to benefit from tilt.”

Whelan also uses the innate behaviors of an able-bodied person as a baseline when addressing whether a seating & mobility client could benefit from tilt.

“Now we’re back into the ‘How bad does it have to be before you can justify tilt?’” he explains. “’How much do you have to suffer before you need tilt?’ In my mind, it’s real simple: If you can’t do what an able-bodied person can do to relieve the effects of sitting, you are justified for tilt. It has nothing to do with if you’ve ever had skin-integrity issues.”

And finally, Verrett notes that it’s important to consider the progressive or non-progressive nature of a diagnosis while assessing a client for tilt.

“If it’s progressive in nature, it’s important that a provider prepare that product to meet that individual’s needs as time goes on,” he says. “So they kind of have to pull out their crystal ball and know that with an individual with a particular diagnosis, if it’s ALS or multiple sclerosis, depending on how they present today, there could be a significant change over just a short period of time.”

That assessment, Verrett says, should include how well the client is able to function not just during the relatively brief evaluation, but also throughout the day.

For instance, he says, if a provider is observing as a client repositions himself, performs pressure relief or transfers from a commode to a wheelchair, the provider has “to really assess how well are they doing it. Is it exhausting? What kind of fatigue level is created by that one particular instance in that evaluation? Would they really be able to do that functionally all day long, every day?”

What Other Clinical Benefits Does Tilt Offer?

Q: What other clinical or medical benefits can result from employing tilt?

“Tilt can have a dramatic impact on respiration,” Tanguay notes. “Even minimally kyphotic postures can restrict excursion and limit lung capacity. Posterior tilt can create a sagittal shift in the body. In this position, gravity can create some extension of the upper body and position the trunk for greater lung inhalation.”

Posterior tilt — with the client tilting “backward” as his feet rise simultaneously — is usually what we envision when we think of tilt systems. But Tanguay points out that tilting laterally — i.e., to one side or the other — can also offer clinical benefits.

“Lateral tilt and posterior tilt have been successfully utilized to address respiration (J. Sparacio) and dysphagia (K. Hardwick& R. Handley),” Tanguay says, adding that tilt can enable “positioning to improve visual field, head righting/positioning, reducing fatigue, gravity assist for positioning after transfers, (and) increasing footrest clearance while navigating some obstacles or curbs. Tilt is utilized for postural stability.”

In fact, Whelan believes postural relief is, practically speaking, probably the most common benefit of tilt.

“There’s research that shows very few people tilt past 30 (degrees), and people don’t tilt to any great degree with any great frequency,” Whelan says.

“So my argument is that the biggest use of tilt, if you talk about not the justification, but the actual use by end-users, is what I refer to as postural relief. If you’re in a wheelchair, there’s a very good likelihood that you’ve either lost the ability to use the muscles in your trunk to control your posture, or you have neuromuscular issues that challenge that: could be low tone, could be high tone. So what that means is you can’t sit and maintain your trunk posture by using your muscles. And in fact, even if you look at able-bodied people, they can’t do it.”

If you’re sitting in a chair as you read this, Whelan says, “I guarantee that you are moving, changing your position subtly, no less than every minute or two. You’re changing the muscle that’s fatigued so the muscle that’s holding your trunk up is a different muscle because that muscle can’t just stay in a constant state of stress for that long. Or you change your posture so you’re not using your muscles at all; you’re just resting on the ligamentation that’s holding your posture and your spine.”

That constant need to move and shift is no different for wheelchair users, Whelan says. “For the person in a wheelchair, they can’t do that, so they have to take a different path…. Comfort isn’t a medical necessity but sitting tolerance is, which is exactly the same thing.”

Verrett points out that respiration and digestion can be improved in some clients by tilting them to achieve a specific position, and there are other potential benefits as well.

“For someone who may be visually impaired in one particular field, if they can tilt back, they can have better vision depending on their body position, things like that,” he says. “But one that isn’t mentioned that I think is really important: A newly injured individual recovering from spinal cord injury (SCI) may absolutely require tilt just to be seated in a functional capacity. The tilt system combined with their body weight and gravity can hold them in a position of security, as opposed to sitting in a normal, parallel-to-the-floor kind of seated position. Tilt really maximizes body weight and gravity, and allows them to remain seated, upright and engaged for functional activities.”

SCI patients, Verrett notes, have “lost certain trunk control functions that they had prior to the injury” and have to “relearn their balance, and their core strength has to rebuild itself to some degree. What tilt will offer is the ability to adjust to that new strengthening of the core while allowing them to still be engaged and functional. If we didn’t have tilt, their backrest would have to be opened up very far into a reclined position, which doesn’t always lend itself to function.”

Verrett recalls working as a provider with hospitals that had SCI patients: “That was always a really big deal, the ability to get an individual with a new injury up and moving and reoriented to their power mobility surroundings. The faster, the better.”

And using tilt, along with the patient’s body weight and gravity, could make the patient feel more secure and stable in his wheelchair, which encouraged the patient to use the wheelchair more. “You’re readjusting to this new world, and that’s got to be incredibly frustrating and devastating,” Verrett says. “But the ability to be able to see other people, smile and interact can really bring that person full circle and make huge strides in their recovery.”

Without tilt to help secure the new SCI patient in his wheelchair, “they would be bedridden,” he says.

RESNA Provides Tilt Justification Support

Looking for justification for tilt from an entity that your referral sources and/or payors are likely to listen to? RESNA has a position paper called “RESNA Position on the Application of Tilt, Recline and Elevating Legrests for Wheelchairs.” The paper begins with the history and definitions of tilt, then discusses physiological effects ranging from spasticity to contractures and orthopedic deformities.

It also explains how repositioning can facilitate or improve other critical activities, such as transfers, feeding, speaking and bowel/bladder management. And yes, significant space is devoted to pressure relief, including the practicality of expecting wheelchair users to effectively perform pressure relief via pushups or forward/side leaning. Contact RESNA (resna.org) for more information on the position paper.

The Many Evolutions of Tilt

Q: What technologies have improved or enhanced tilt in seating systems?

While tilting or reclining a client to relieve pressure, improve posture, improve comfort, enhance stability, etc., is a relatively simple concept, it has not historically been a simply executed one.

“Manual and power tilt systems were originally pivot-style systems, which required longer mobility bases,” Tanguay says.

“With the first tilt-in-space chairs, the center of gravity of the person moved dramatically,” Whelan explains. “Your center of gravity in a seated posture is generally just in front of and just above your navel. That’s about where your center of gravity is. Now, picture a chair, and I’ve tilted you back: You can see that center of gravity is moving rearward substantially because you’re pivoting at a point that’s somewhere below that, which means that center of gravity is traveling on an arc posteriorly. The problem is that that center of gravity over your wheelbase defines your stability. So in order for a wheeled system to be stable, the center of gravity has to stay between the caster wheels and the rear wheels. If it moves posterior or anterior to either of those, the chair falls over. So when you tilt, you have to deal with that.”

Initially, Whelan says, industry wheelchair designers dealt with that issue in a simple way: “We just moved the rear wheels rearward to increase the base of stability, so it could move without becoming unstable.” But what those longer wheelbases gained in stability, they sacrificed in maneuverability. The wheelchairs required more room to make turns, which could cause big accessibility problems, especially indoors.

That challenge led to “sliding tilt” systems, “which move forward over the base as the seat system tilts rearward,” Tanguay says. That strategy could shorten the wheelbase required of wheelchairs that incorporated tilt systems. But even with sliding tilt designs, there was still another factor to consider, one that’s “a little harder to deal with and less well known because it’s clinical as opposed to technical,” Whelan says. “A lot of people in tilt-in-space chairs have an abnormal neuromuscular system. They have an abnormal development of balance.”

In those cases, Whelan explains, mobility limitations have prevented the wheelchair-using client from developing a sense of balance that able-bodied people take for granted.

“When we were kids,” Whelan says, “we rolled down hills on purpose. When I was a kid, I would do everything I could to upset my balance. It’s part of our normal development. We’re trying to develop our vestibular system, so we stimulate it to develop it.”

Wheelchair users, however, may never have walked and therefore may have had far less opportunity to develop a sense of balance. Or traumatic brain injury may have affected that vestibular system.

“So,” Whelan says, “you put that kid in a tilt-in-space chair, you tilt him back, and as (his) head’s moving backward, (his) center of gravity is disturbed.” That can cause a physical reaction, Whelan says: “You see these kids in wheelchairs, especially kids with CP. You start tilting them and they go crazy. That’s because you’re disturbing their innate sense of stability, and they react to that.

“If you can design a system where that sense of stability is less disturbed during repositioning, you’ll get a clinical benefit. You’ll have less episodes of tone and less reaction from the client in the chair. If you’re conscious (of impending tilt) and you have the ability to control it, if you have a normal intellect, then you can rationalize ‘I’m not going to fall.’ But if I came up behind you and tilted back your chair, your feet would fly out and your arms would fly out, and you’d try to extend yourself to gain stability. That’s a normal reaction of the body.”

So the next evolution of tilt goes by a couple of different names, including center-of-gravity (CG) tilt or in Sunrise Medical’s case, Rotation In Space (RIS).

Verrett describes CG tilt this way: “As the chair tilts backwards, the pivot point there at the back-and-seat intersection begins to slowly come forward toward the area where the knees were. You can imagine it tilting back, but kind of rotating a little bit. That can make a huge difference in the overall size of the base that is necessary to keep it stable. So that’s been a big additional improvement to the industry, the advancement toward CG systems over single-pivot products.”

The end result of CG tilt, Verrett says, is the ability “to make the overall footprint of the product much smaller as the innovation of CG became much more readily acceptable. Essentially, as the weight’s shifting, by bringing that center of gravity forward, it minimizes the amount of stress and dynamics on the chair because all the weight isn’t just tipping out the back of the product.”

Whelan describes the idea behind Rotation In Space tilt as “very simple in concept and very difficult to develop. The idea is you pivot around the individual’s center of gravity. If the whole chair moves around that center of gravity, it never moves. It stays in one place. That’s what we refer to as Rotation In Space, because now you’re not tilting — tilting infers that you’re moving that center of gravity, where rotation infers that you’re moving about that center of gravity.”

Other tilt innovations, Verrett says, include lower seat-to-floor height options, as well as electronics that can be programmed to “remember” specific positions or certain functions, such as drive inhibits or limitations while tilt is being used.

“A provider can program a product specifically for that individual’s needs,” he explains. “A couple of good examples are individuals that use vans. (For) vehicle entrances, (they) may have to tilt back and still drive into the vehicle. Being able to do that electronically to the specific degree needs of that individual — that’s a big advantage for providers today.”

Thanks to today’s electronics, providers can work with the client to determine, then “lock in” certain tilt positions so the client automatically “can go back to that position each and every time,” Verrett says. “It takes all that guesswork out and makes life a lot better for consumers.”

When Is Tilt Appropriate?

Q: When should a provider consider recommending or including tilt in a seating system? What clinical considerations, diagnoses and other factors typically indicate that tilt should be considered?

“The inability to perform pressure relief, or to reposition oneself with frequency throughout the course of the day, would be very common reasons for the prescription of tilt in space,” Tanguay says. “Tilt is also utilized in combination with lower-extremity elevation for positioning to decrease lower-extremity edema.”

In addition to benefiting clients who need help with postural relief, Whelan says, “Respiratory and digestion benefit from posture more than they do from tilt. What tilt gives you is the ability to get an ideal posture to facilitate normal respiration and to facilitate digestion. You get this normal alignment of the trunk and body, but still allow for change of position. It’s really to some extent the result of the posture, and the tilt is just enabling you to control the posture and still get the repositioning.”

He adds that tilt can have a more direct impact for some clients who have trouble swallowing: “There are people that, as a result of their disability, may only be able to swallow at a very specific position of the head and neck and trunk. Tilt becomes a nice way of doing it. You can do it with recline, but there are people that require tilt just because they have to get to a very specific position for swallowing.”

And now another discussion of those 30- to 45-degree tilt thresholds. Earlier, it was mentioned that according to research studies, a significant amount of tilt is needed to adequately relieve pressure — that is, to redistribute body weight from mainly the pelvis to mainly the back. The actual numbers vary per study, but the consensus seems to be that clients need to tilt more than 30 degrees — and 45 degrees or more is better — to achieve pressure relief that will make a clinical difference. Not only that, but clients need to hold that tilted position AND tilt into that position frequently.

“If you think about the guidelines for pressure relief, they want you to completely lift your buttocks,” Whelan says. “They teach people that are spinal cord injured that you’re supposed to do a complete pressure relief every 15 minutes. So if you follow medical best practice, you’re supposed to (achieve) complete relief of the loading of the pelvis. That’s a lot of tilt. To completely offload the pelvis, you’ve got to go a long way, and you have to stay there a bit, and you’ve got to come back up, and you’ve got to do that with a frequency that very few people do.”

Compliance may be even more difficult for SCI clients who are attempting to relieve pressure without using tilt. “You’ll often see paraplegics lean forward and put their elbows on their knees,” Verrett says. “That kind of picks up the pressure from their ITs, as well. Those are ways that you can relieve that pressure without necessarily tilting.”

That being said, performing “push-ups” or other forms of pressure relief without the benefit of tilt can be very challenging, even for SCI patients with good upper-body strength. For SCI patients whose injuries are at a higher level, “if the individual doesn’t have that strength, like a high-level SCI or somebody who’s got a progressive situation with muscular dystrophy or multiple sclerosis or ALS, they’re unable to do that,” Verrett notes. “So tilt replaces that function.”

Tilt vs. Recline: Or When Are Both Appropriate?

Q: When could tilt be used in conjunction with recline? What clinical conditions, diagnoses, etc., would indicate that this combination could be helpful?

“Tilt can be used in conjunction with recline when the client can tolerate the change in hip angle — if it doesn’t cause repositioning or other impacts,” Whelan says. “For some people, a specific hip angle is indicated to reduce spasticity, so if you put them in recline and you change the hip angle, their spasticity increases, and recline is not indicated.”

In choosing between tilt and recline, Tanguay notes, “Spasticity may be a consideration. The change of hip flexion angle with recline can illicit a spastic response, which can alter the consumer’s posture/ position. This can result in shearing issues and can alter the orientation of positioning components like lateral thoracic supports or positioning-style headrests. This change can also alter functional access to switches.”

She adds, “There are certainly consumers who cannot off-load seat surface pressure with only tilt (or only recline). The combination of perhaps 150-plus degrees of recline with some tilt, or full posterior tilt (45-55 degrees) with some recline can be the solution. Pressure mapping with a tilt-and-recline system is a great way to determine the most effective pressure relief position, and it’s also a wonderful training tool for teaching consumers what positions achieve offload of seat surface pressure.”

In some cases, says Cummins, “combining tilt with recline can improve function, breathing, feeding and comfort. Though an appropriate degree of tilt might provide pressure relief and support for a consumer, it may not provide optimal peer interaction, which a reclining back could do.”

Is Tilt Being Funded?

Q: What is the funding climate currently like for tilt systems?

Given all the clinical and social benefits of tilt — from postural and pressure relief to facilitating respiration and digestion to encouraging interaction and eye contact with peers — are funding sources seeing the values of this positioning option? And are they opening their pocketbooks to pay for tilt?

“From the acute-care standpoint, I would say the climate is status quo,” Cummins says, “though when it comes to complex rehab, status quo means there are still states that have slashed reimbursement and/ or made the process harder for tilt-in-space reimbursement.”

He adds, ”It’s a different story altogether from the standpoint of a provider servicing long-term care facilities with tilt-in-space systems. It comes down to a lack of understanding, where certain Medicaids don’t see the clinical benefit of a tilt-in-space system as a complex, custom product unique to an individual needing postural support, pressure relief, all-day comfort.”

Whelan says, “There’s been a lot of challenges in the nursing home environment. It’s (been) fairly traditional in the Medicaid program that the minute you needed a tilt-in-space chair, Medicaid would pay for it because it was considered not a chair that the nursing home should have to provide. It was a ‘custom’ chair.”

But as states slash their health-care budgets, some Medicaid programs are rethinking their funding habits. “So with all the reimbursement pressures on the Medicaid system,” Whelan says, “You’ve seen more of a battle of ‘Wait a minute, we don’t want to have to pay for it anymore.’”

As tilt systems become more and more common — and tilt systems and wheelchairs become increasingly adjustable — Medicaid administrators began questioning whether it’s still their responsibility to pay for tilting chairs in long-term care settings.

“We went through a discussion with a Medicaid program on that very point,” Whelan says. “They stopped reimbursing tilt-in-space chairs for nursing home residents. (The tilt systems) didn’t fit the technical description of ‘custom’ anymore. Their big argument was the minute (the chairs) become adjustable where they can be changed and used by another client, it’s not custom anymore.

“In reality, it’s not like (the chairs) change themselves. They require a significant amount of adjustment, so they really still are custom. The language is the argument: You see language (such as) ‘Can’t be used by another resident.’ Well, how do you interpret that? If I buy $400 worth of parts and I change the chair, it CAN be used by another resident. So there are some states that have language that states, ‘Can’t be used by another resident at the same time.’ I can’t take this person out (of the chair) and put another person in it and (have them be able to) use the chair. Therefore, it’s a custom chair. Whereas, in other states it says, ‘Can never be used by another resident’ as the definition of ‘custom.’ So we’re working our way through that.”

Excluding certain long-term care issues caused by Medicaid semantics, Whelan says, “In general, funding for tilt in space, like any other technology in our industry, is becoming more routine and more recognized. I think the clinical prescription is driving the payors.”

Says Verrett, “The funding climate for tilt is relatively straightforward and regularly paid for by Medicare, Medicaid and private insurances. The ramifications of not funding tilt are astronomical compared to the associated costs. So funding sources readily fund and support tilt as a preventative measure to skin breakdown, which ultimately leads to costly hospital stays and surgeries, all of which dwarf the cost of tilt.”

Providers who do have problems getting tilt claims paid are “typically not justifying it appropriately,” Verrett says, but he adds that those scenarios are relatively uncommon.

“Most clinicians that operate in this space, in this industry, and most providers have perfected justification and the appropriate documentation necessary to justify and support tilt in space,” he says.

As for securing funding for tilt and recline systems together, Verrett says, “Technically speaking, the requirement for tilt and recline to be combined includes coverage criteria that the patient must first (1) meet the requirements for a PWC (power wheelchair) described in the Power Mobility Device LCD and (2) have a specialty evaluation completed by an OT, PT or physician with specific training and experience in rehabilitation wheelchair evaluations. In addition, (3) justification must include that the patient is at risk for development of a pressure ulcer and is unable to perform a functional weight shift or (4) the patient utilizes intermittent catheterization for bladder management and is unable to independently transfer or (5) the power seating system is needed to manage increased tone or spasticity.”

Given those requirements, he adds, “Individually justifying each component — tilt and recline separately — is an ideal approach for funding sources and will give the provider the best opportunity to secure funding. So for example, you would justify tilt based on the fact that the person is at risk for pressure ulcers and can’t perform weight shift independently. And then recline can be justified through their bladder management program or increased spasticity and tone.”

Time for Tilt!

For all the clinical, social and even long-term financial benefits of incorporating tilt into seating systems, the most common-sense one, Whelan suggests, is that tilt works to compensate for a very natural, very necessary ability that seating & mobility clients often lack.

“More repositioning and more change of posture more closely reflects the normal human condition,” he says. “Why deny it to people with disabilities when we wouldn’t deny it to ourselves?”

This article originally appeared in the February 2010 issue of Mobility Management.

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