ATP Series

Out-of-the-Box Seating, Ouside-the-Box Results

How a New Generation of Seating Technology Can Achieve a Custom Fit Without a Custom Build

Seating TechnologyCustom is an often-used word in complex rehab seating & wheeled mobility discussions, and for good reason.

Yes, there is absolutely a need to differentiate complex rehab technology clients — those with severe, permanent, possibly progressive conditions, often with a neuromuscular or genetic component — from clients with temporary loss of mobility, and from able-bodied seniors experiencing age-related strength and stamina changes.

But even within the realm of complex rehab clients, there are different levels of client complexity. There are situations so rare that an ATP or seating & mobility clinician may see it only once in a career — for instance, building a seating system for conjoined twins.

In most cases, though, the seating & mobility team works with clients with familiar diagnoses — spinal cord injury, cerebral palsy, muscular dystrophy, ALS, multiple sclerosis — but unique presentations, since each client differs in medical history, height and weight, environments, mobility goals, etc.

For some clients, a custom-built seating system is absolutely required. But given the range of options, materials and sizes now available, is it possible to start building a seating system using “out-of-the-box” products and then size and adjust them to achieve a one-of-a-kind fit?

A Wider Range of Materials

One of the factors that has made it possible to achieve better fit and better results is today’s wide range of materials.

Foam, of course, has long been a staple of wheelchair seating. But now there are different types of foam, including foam that does a far superior job of returning to its original shape when the client transfers off the cushion. Foams are also available in different stiffnesses, and different types of foam can be used in combination. Foam or foam layers can be contoured to produce different shapes and assist with positioning and stability.

In addition, seat cushions today include materials such as —

  • Air: In the form of multiple air cells that are stationary (e.g., ROHO Inc., Star Cushion); multiple air cells that are movable within the cushion (e.g., Vicair technology, Comfort Company); air bladders or compartments (e.g., Aquila Corp., VARILITE); or cushions whose single or main chamber is filled with air (e.g., EHOB).
  • Gel or Fluid: Contained in inserts or bladders used in combination with other materials, such as foam (e.g., Alex Orthopedic, Blue Chip Medical, Drive Medical, Invacare Corp./Motion Concepts, Ottobock, Quantum Rehab, JAY from Sunrise); or gel formed into stationary cells (e.g., AliMed).
  • Honeycomb: e.g., Supracor. To maximize the effectiveness of the different media, cushion engineers have also used different media in tandem — for example, adding air cells to a foam base to provide greater skin protection for highrisk areas (e.g., Ottobock’s Terra Flair, Quantum Rehab’s Synergy Spectrum Air, ROHO’s Hybrid Elite, Sunrise Medical’s JAY Fusion).

Varying the types of materials and using them in combination have enabled engineers to create products that offer both skin protection and positioning support, or to offload weight from high-risk areas.

It’s also enabled cushion manufacturers to offer more targeted, but still out-of-the-box products for clients who not long ago might have required a custom-made seating solution.

Creating a Custom Fit: Materials

So given the greater range of materials, of materials used in combination, and of the manufacturer’s ability in some cases to place contours, cells or bladders in custom-configured locations, is it possible to achieve a one-of-a-kind fit using products that are not custom made?

“If you take a look around, no two butts are the same, and in order for an ‘out-of-the-box’ cushion or back to work, you need the system to be flexible and forgiving in order to accommodate as many people as possible,” says Jeff Rogers, senior product manager for Sunrise Medical’s JAY seating division.

Rogers says versatility is critical to this strategy.

“At JAY, we rely on fluid to help with this, as it is able to conform to countless body types to properly support and protect against daily sitting,” he explains. “We have also learned that the means by which you support the fluid is important to be as forgiving as possible. For instance, in some cushions we provide a soft, forgiving foam top layer, but it’s supported by a harder structural foam. This combination of fluids and foams allows us to handle numerous types of bodies while remaining comfortable and supportive.

“But we understand that other mediums are also important. For instance, air inserts can also provide a flexible alternative to fluid — thus we made our products flexible enough to easily change from one system to the next.”

In addition to paying attention to the customizable properties of seat cushions, a seating professional who factors backrests into the equation can further fine-tune the seating system fit.

Asked how a wider range of materials makes it possible to accommodate a wider range of seating & positioning needs — for example, how a seat cushion that is customfit, but not custom-made, could help reduce a client’s future risk of skin breakdown at the ischial tuberosities, Nick Everington, national training director for Matrix Seating USA, says, “My first thought is that this cannot be achieved by using a standard seat or standard cushion that does not have customizable parts. Seating and positioning needs are not easily met just by simply adding a cushion. What would make it customizable would be the addition of an adjustable back, such as a JAY J2 deep contour system, to accommodate an obliquity, for example.”

Katherine Sims, director of marketing for Matrix Seating USA, adds another wrinkle into the materials discussion: a medium that she says mimics the customizability of a traditional custom-molded seating system, but is also adjustable to accommodate a client’s growth or changes in size.

“If presented with a client who has a history of skin breakdown and is at high risk of future pressure ulcers, our recommendation would be utilizing adjustable micro-modular seating (AMMS),” she says. “The leading AMMS system consists of interlocking nylon segments that create a custom mold with an open design. The open design allows for airflow, heat and moisture reduction. The pressure and shear-relieving thermo-elastic polymer cover (surface modules) allows for proper pressure distribution during incremental shape changes. These shape changes can be incrementally adjusted to reduce pressure in appropriate areas while maintaining proper pressure distribution elsewhere.”

Creating a Custom Fit: Cushion Design

Seat cushions have come a long way from the flat, uniform slabs of foam they once were. Many of today’s cushions for complex rehab clients use more than one type of foam, often layering the foams so, for example, a softer layer is closer to the client-cushion interface, and a stiffer layer is underneath to provide support (e.g., Dynamic Seating).

Foam that is specially molded or contoured further enables a manufacturer to provide more aggressive support, stability and positioning, and to achieve a more customized fit.

“Just as in custom seating, one seat doesn’t fit everyone,” Rogers notes. “The same applies to out-of-the-box seating. That is why multiple cushions, back styles, shapes and contours are a must.

“In typical custom seating, the clinician or ATP is responsible for shaping and creating the profile needed. What we have done in out-of-the-box seating is used anthropometric data and over 30 years of seating experience to take the guesswork out of what the professional needs to choose from — there’s no need to create a 12" wide by 22" deep cushion out of the box, as an extremely small fraction of the population would meet this size.”

Cushion manufacturers who study anthropometric data — i.e., human measurements on a wide scale — can anticipate what sorts of designs and sizes will be most frequently needed.

“We use these points to help determine where the back contour should land on the back and what depth the well in the cushion should be for optimal support in the right spot, but we design-in flexibility so most people fit comfortably,” Rogers explains. “However, we also understand that [providers] need a selection to choose from, as one won’t do. And that’s why you will see a wide variety of cushions and backs to choose from.”

Many manufacturers can also offer some customizability — especially in sizing or the placement of certain components such as air cells — in seat cushions and backrests that are generally considered “out of the box” components. Inquiring about customizability can lead to a cushion or backrest with the exact features or locations of features you need without resorting to building a product from scratch.

Creating a Custom Fit: The Role of the Backrest

Today’s wider array of backrests and back positioning components can enable an ATP or clinician to further dial in the support they want for their client.

“It is extremely important to realize that you need a good seating solution, not just a good cushion or a good backrest,” Rogers says. “Because if you focus on the backrest and then the client doesn’t fit well into their cushion, then they can easily become out of position — and that great backrest becomes useless.

“With that, if your backrest is not able to easily adjust to the client, then the seating will become uncomfortable, and a person will experience some sort of issue, whether it be sitting tolerance or the worst experience, such as some sort of skin breakdown. This is why we make sure our backrests are comfortable (to allow for extended sitting tolerances) as well as supportive (to provide proper positioning).”

Says Everington, “Configuring contours and conforming a backrest to intricate shapes is the number-one goal when custom fitting a patient with complex rehab needs. The objective is to provide a more functional position and enable the client to perform activities of daily living. Spinal injuries, spinal lesions, stability and obliquity in the pelvis are all part of a clinical checklist. Many cushions can accommodate a condition presented by a patient. The question becomes What cushion has the potential for continuous postural management and correction?”

Creating a Custom Fit: Adjustability & Growth

One of the biggest challenges of building any custom-fit seating system is accommodating for change. Some of those changes, such as a pediatric client’s growth, can be anticipated. Others — such as weight gain or loss in adults, or changes in body size and shape due to the progression of a condition — can be tougher to plan for.

Of course, that generally doesn’t change the fact that funding sources require seating systems to last for years. The domino effect is that ATPs and clinicians usually need to factor adjustability into the equation.

“A cushion design which is able to accommodate a client’s changing positioning requirements is fundamental in today’s limiting funding environment,” says Greg Sims, president, Matrix Seating USA. “Too often, a client’s positioning needs are not accommodated if replacement cushions or additional parts are required because of funding limitations. Cushions with infinite growth and adjustability provide the greatest opportunity for continuous postural management, regardless of funding challenges.

“With plummeting reimbursement and stricter utilization policies, insurance companies have forced durable medical equipment providers to pursue options such as AMMS systems, [which] allow for growth and corresponding postural changes and continuous adjustments and configurations. The client does not require a brand new seating system every time these changes are necessary. Adjustments can be made by certified seating specialists and therapists to ensure that AMMS evolves when a change in shape occurs, or repositioning is required.”

Rogers adds that a backrest needs to fit well into a seating & mobility system that has components from a number of different manufacturers.

He points out that often, a backrest needs to “have width adjustability (to accommodate multiple wheelchair manufacturers), back-angle adjustment, height adjustment, as well as contour and lateral adjustment ranges to accommodate a wide variety of clients with different presentations. Overall, backrests also need to be able to work with the real estate provided by the wheelchair manufacturer. A lot of times, backrests need to figure out ways to navigate around obstacles — whether it be towel bars, armrests, tilt cables, manual recline struts, etc. — in order to mount in the proper position, but still not hinder the function of the wheelchair. The backrest needs to find a spot and still get to the proper position, and that is why adjustability is so important.”

Creating a Custom Fit: Every Client Is Unique

In the end, Everington says, seating components that offer some flexibility can be helpful not only in achieving an initial customized fit, but in enabling ATPs and clinicians to maintain a good fit even if the client changes.

“A seat or cushion that is easily manipulated to achieve a correct fit can accommodate a wide range of complex seating and positioning needs,” he says. “The choice of seat and/or cushion often depends on the condition of the patient and their future positioning needs secondary to their diagnosis. The questions are What is going to best suit the client now, and in the future? Are they stable enough? Does the clinical presentation suit the postural support that the client needs?

“Each cushion has a unique selling point, whether it is air, foam, gel or thermo-elastic polymer. Does the cushion design provide the unique postural support for this client?”

And the best news for the seating team is that companies who create these products recognize what ATPs and clinicians need given the current clinical and funding environments.

Says Greg Sims, “Manufacturers continue to focus on adding greater levels of adjustability and configurations to accommodate complex seating and positioning needs."

This article originally appeared in the April 2015 issue of Mobility Management.

In Support of Upper-Extremity Positioning