ATP Series

The Positioning Help You Need

"Secondary" Components Play Primary Roles in Maximizing Client Function

Positioning HelpIn any complex rehab discussion on seating, certain topics come up every time: tilt and recline, elevating legrests, wheelchair cushions, backrests and customized seating systems, for example.

But there are other components that play critical roles in establishing and maintaining the positioning that clients need to achieve optimal functioning while in their chairs. Belts, harnesses, straps, buckles and similar products are oft en thought of as secondary supporting players in seating & positioning. But in reality, they enable clinicians and providers to fine-tune overall seating systems for maximum benefit in a number of areas, all leading to more productive and successful days for wheelchair users.

What Anterior Support Can Accomplish

Despite their often humble sizes compared to larger, weightier tilt systems or backrests, these “other” positioning components have welldefined roles to play in overall seating.

“Every piece of equipment needs to work together to allow the greatest amount of function, comfort and independence of the user,” says Dave Hintzman, owner/president of Bodypoint. “It’s important to look at each belt, harness or buckle and understand how it can work within the foundational goals of the end user.

“With that in mind we see the seat, back and foot supports as sort of the foundational elements, and we see tilt and recline also being important in terms of pressure relief and positioning during the course of the day. But those components all address the posterior surfaces of the body. With our products, we’re really looking at what’s going on with the anterior side of the body for both pelvic and trunk support. They assist in providing alignment, they help in maintaining position through the course of the day, they provide stability to allow for more function: We’re talking about reach, better swallowing, better visual field, conserving energy and improved organ function.”

Jim Dyes, director of marketing & sales for Therafin Corp., explains, “When the therapist does the evaluation and has found the neutral position for that individual to be in, then they need something that is going to support that. If they have weak trunk control, they
may have lateral trunk supports, and then to supplement that, to really keep them back in their system, it would take an anterior support, whether it’s a butterfly vest or a chest strap.

“I look at it as an orchestra: You have to have all these different pieces to perform. You’ve got your seat and your back, but that anterior support helps to complete the whole thing. It helps to keep that person in the right position.”

Dyes points out that some clients need “uncompromising” supports that don’t flex. But for others, dynamic variations of static components can offer critical help to consumers who have the strength and ability to move — for instance, to lean or reach forward — but not the ability to get back into their original positions, where they need to be to access the joystick, for example.

“Based on their prognoses and diagnoses, they may need freedom to move,” Dyes says of those consumers. “A dynamic solution is best for them: They can move and stretch, but then they come back into place. The system holds them in position.”

Despite their many abilities, the components are not meant to act as safety restraints, the way automotive or roller coaster seat belts do.

Rather, Dyes says the positioning components can offer clients “security” and balance and stability.

“It’s not a safety device, but it is a positioning device. It is a critical piece,” he says.

A New Level of Detail

Seat belts in cars and airplanes are designed and engineered to keep users in their seats. The belts have to fit people of different sizes and shapes, which may make it difficult for them to fit anyone very comfortably.

Positioning components, on the other hand, are meant to be custom placed and fitted to ensure a functional fit that doesn’t slip or interfere with the user’s activities. In addition, these components are designed with a dizzying level of detail in mind. No detail seems too small to be considered during the manufacturing process.

Take, for example, the humble belt or strap buckle. On a backpack or in an airplane, it’s meant simply to be strong enough to hold straps together. But the assistive technology world takes buckle design to a whole new level of scrutiny.

Says Dyes: “In the past, if you’ve had a buckle that wasn’t flat on the surface — for instance, if a child leans forward to get a crayon —and the buckle doesn’t sit quite right, it could possibly loosen up. He could lean forward to grab the crayon, but then the [system] doesn’t pull him back into place.”

Compare that to a buckle design that “goes over the contoured surface, such as a shoulder, and continues to hold in position,” Dyes says. ‘They can flex and move around, but because of the way that the buckle is designed, it holds them in place and will bring them back and keep them secure.”

Hintzman says his company offers a buckle with “a modular component cover that allows you to make a choice of easy access or no access, and it’s got a security cover on it so the person can’t accidentally open it.” That option can be helpful, he explains, for clinicians and ATPs working with clients who have cognitive issues.

Engineers creating these components have several priorities to build into their designs. For instance, Hintzman says adjustability is “hugely important.” He adds, “One of the things I would like to see on every evaluation and assessment form is the angle of presentation for the anterior trunk and the anterior pelvic supports.”

Asked what qualities clinicians and providers should seek in these components, Dyes says, “Definitely function is a big thing. I think aesthetics are very important, because you do have to deal with parents and caregivers and the world around, and you don’t want something that makes [the user] less attractive. You want to have something that’s ergonomic, that’s pleasing to the eye, that’s perceived as something that’s positive.”

On a practical level, Dyes adds, “It’s got to be easy to get on and off . I think from a functional standpoint, it really needs to serve a purpose in what you’re trying to accomplish with the team — you want to have a product that supports the overall goal of the positioning. And then the longevity of the product: It’s important to use quality materials and quality construction.”

When those qualities are lacking — when for instance a harness is time consuming to put on or take off — the result can be equipment that doesn’t get used.

Says Dyes, “We’ve seen so many times when we’ve gone into a facility or school, it’s either put on improperly or it’s not put on at all.”

Not All Created Equal

Consumers, funding sources and other entities not acutely aware of complex seating & positioning needs may have a false sense of familiarity with these types of positioning products. After all, who hasn’t put on a shoulder harness in a car, tightened a shoulder strap on a backpack, or watched a flight attendant demonstrate an aircraft seat belt?

The mistaken belief that a rehab positioning belt and buckle are just like those on a backpack can haunt the companies that manufacture these complex rehab products, the clinicians and providers who use them, and the consumers who benefit from them.

“That’s what’s so frustrating for us in terms of our current coding environment, this lack of granularity where a belt is a belt is a belt,” Hintzman says. “It’s not just the case. If that’s the way we treated it, our ability to work with our clients would have suffered a long, long time ago.”

“In our funding world today,” Dyes says, “it’s a fine balance between the product having longevity and having the product be affordable. We’ve got to have products that are going to have a long enough life and don’t require additional service, but at the same time, you can’t afford to go overboard with that, because then you can’t afford to purchase it initially.”

And ensuring that consumers do have access to these positioning components is crucial. In fact, though straps and harnesses are often incorrectly perceived as motion stifling and restraining by people not familiar with them (see sidebar), the truth is that active wheelchair users might be the ones who gain the most benefit from these highly specialized products.

As an example, Hintzman mentions “an active spinal cord injury guy in our community, a motivational speaker. We asked him if he’d be willing to try a (Bodypoint)” belt.”

He agreed, albeit a bit reluctantly, which isn’t uncommon, Hintzman says: “Usually, active users turn their noses up at that.
We went out and spent an afternoon with him, having him try a variety of different kinds of belts, and at the end of the day he said, ‘I had no idea. I never thought I would use a belt in my life.”

That consumer now uses a belt every day, and Hintzman says, “It has changed how he goes out with his kids: He can have them on his lap and not have to worry about them falling off . He can carry groceries on his lap where he didn’t do that before because he was always concerned about it.”

A huge benefit to users, Hintzman says, is the amount of energy they can save by using these components. “It’s certainly energy conservation. If you don’t have to spend your day trying to stabilize your pelvis or stabilize your body, if you’re not fighting that, you’re free to be able to use energy appropriately.”

For a schoolgirl who arrived home exhausted every day, adding a dynamic pelvic stabilization system to her new wheelchair gave her rehab team more flexibility in her seating.

“She wasn’t making it to her classes on time,” Hintzman said of the self-propeller. “Her mother was really concerned that she was going to fall behind in school. She’s a bright, bright kid, but just exhausted during the course of the day.”

Her new chair was set up with pelvic stabilization and a lesser amount of seat dump. The result: A chair that was easier and less tiring to push. “It changed her ability to get around at school,” Hintzman says.

Another benefit these seating components can offer: adjustability and flexibility regarding where they’re positioned on the chair and on the consumer.

Hintzman recalls working as part of a team that included a client in his 60s with a spinal cord injury. The man used public transportation daily, “but with the bus stopping and starting, he began sliding underneath his belt on the wheelchair,” Hintzman says. “The ATP said, ‘He has a very large belly and couldn’t wear his belt tightly to hold him in place because it was so uncomfortable and pressed against his bladder.’ So I said, ‘How about if we put the belt across the top of his lap?’ Instead of having it at 45°, we put it at 90°. We changed the belt, put it across the top of his legs, and she called me back a couple of weeks later and said, ‘He’s all over town, he’s back on the bus, he’s so happy over that one little change.’”

That seemingly minor, yet crucial change perhaps embodies the very best that these components can offer.

“He had a very nice power chair,” Hintzman points out. “He had a very good seating system. But it was unusable because the belt was not at the right angle.”

This article originally appeared in the April 2013 issue of Mobility Management.

In Support of Upper-Extremity Positioning