ATP Series: Case Study

Exceeding Expectations

Client: Scottie, 40 years old.
Diagnosis: Cerebral palsy with a history of pressure injuries.

Cerebral palsy case study


Scottie’s previous chair offered only posterior tilt. With his history of pressure injuries, Scottie needed more positioning options.

What is a power wheelchair supposed to look like? What is it supposed to accomplish? What can it accomplish when the seating & wheeled mobility team thinks creatively?

Meet Scottie, a 40-year-old whose medical records show a diagnosis of cerebral palsy, along with a pressure injury history.

But he also has significant postural issues that would require his seating & mobility team to seek additional functionality from the systems they used.

Initial Assessment

In addition to Scottie, the seating & mobility team was composed of Carl Mulberry, ATP, and Adam Roush of Columbus Medical Equipment; and Amy Morgan, PT, ATP, from Permobil.

“Scottie has used a three-switch head array to drive his mid-wheeldrive chair for many years,” Morgan said. “He is an extremely bright young man and is completely independent using the three-switch head array drive control system. Additionally, he operates an augmentative and alternative communications (AAC) device using a single-switch input with direct access.”

Re: Scottie

Anterior tilt: While many clients find it useful in performing activities of daily living that require reaching or leaning forward — including standing and pivoting and/or transferring — this case study demonstrates that anterior tilt has a wide range of uses, including comp ensating for a client’s positioning to provide an improved field of vision when operating the power chair.

Morgan noted that his home environment would not be an obstacle: “He was already using a power chair, so environmental access was not a limitation in this case. He lives in a group home with 24-hour assistance and uses accessible transportation to a participate in a regular day program.”

What did need to be considered: Scottie’s postural issues.

“Scottie has hip flexion limitations (L>R) with seated hip flexion of approximately 30°,” Morgan said. “He has chronic issues with skin breakdown on his sacrum due to atrophy, thin stature and abnormal posture (sacral sitting) creating excessive pressure on the sacrum. He’s currently using a power tilt-only system with no ability to independently change (open) the backrest angle. Because of this, he is sliding out of the system, weight-bearing on his sacrum and using knee blocks to help hold him in.”

Cerebral palsy


Scottie’s former switch system.

Challenges to Be Addressed

Due to multiple postural concerns, Scottie needed more options than posterior tilt-only positioning, Morgan said.

“Scottie has multiple orthopaedic issues and skeletal deformities/asymmetry along with a history of chronic skin breakdown on his sacrum that presented a challenge from a seating perspective,” she explained. “A custom-molded seating system was required to accommodate his significant postural deformities and provide pressure redistribution to reduce the risk of further or worsening skin breakdown.”

Anterior tilt is often chosen to facilitate transfers and to help clients reach forward. But for Scottie, it served an additional function.

Cerebral palsy power chair


Scottie used knee blocks to stay in place in his former chair.

“The most important thing that Scottie was missing is power seat functions to accommodate his postural deformities and allow him to function independently, including pressure relief and finding a position of comfort,” Morgan said. “Due to his significant lack of hip flexion, the anterior tilt feature is required to allow him to achieve appropriate visual orientation and see his path — as well as to avoid obstacles — for safety with driving. His postural deformities and lack of hip flexion also created challenges for him — for his line of sight — while driving his power wheelchair.”

Scottie was adept at driving with his head array, but the system itself was a bit makeshift, Morgan noted: “His current head array was duct taped together, and a separate switch for his communication device was also duct taped to the head array.”

mat evaluation


Scottie during his mat evaluation.

More Streamlined Solutions

The team chose a Permobil F3 Corpus power wheelchair with 20° of power anterior tilt; power tilt and recline; power elevating legrests; and power seat elevation.

The seating is an OBSS custom seat cushion and backrest. “The armrests were removed completely from this chair because Scottie did not use them, and they were just contributing to increased pressure on his arms medially,” Morgan said. “Instead, custom side guards were fabricated to attach switches and contain the custom molded seat.”

The knee blocks that are part of the anterior tilt package are used to help keep Scottie from sliding out of the seating system.

Since Scottie was an expert at head array driving, his new power chair features an Adaptive Switch Laboratories three-switch head array, along with a more streamlined setup. “In his new system,” Morgan said, “This three-axis head array drive control was duplicated with switches mounted on a swing-away mount to allow him direct access to his AAC device using the crown of his head,” Morgan said. “Additional switches were mounted on the side of the chair for On/Off and Menu access — primarily for power seating through a memory position.”

Cebral Palsy case study


One concern with the previous power wheelchair was that people saw it before they saw Scottie. The CRT team sought to change that.

The results: “Scottie is now able to independently adjust his position in space and transition between a posterior tilt/recline position, which is necessary for pressure relief and repositioning in the chair and an anteriorly tilted position to allow him to see where he is going as well as any obstacles in his path,” Morgan said. “His caregivers also have access to adjust seating to allow for proper position for self care and safe transfers.”

“Before” and “after” photos show the differences. “The system is much cleaner and streamlined compared to his previous chair,” Morgan noted. “You see Scottie first — and not all of his equipment.”

The lesson of Scottie’s power chair might be that functionality and efficiency come in many different packages. Removing armrests, for instance, isn’t right for all clients, but it was for Scottie.

 custom-molded seating, tilt and recline


The new power chair includes custom-molded seating, tilt and recline.

“It was interesting to see,” Morgan added, “how someone could incorporate totally custom-molded seating and still have access to the recline function — which was limited to ensure that the seating was not disrupted.”

Scottie’s system also makes the most of anterior tilt.

“The application for anterior tilt was very apparent… not just for functional reach or transfers, but instead as a means to allow Scottie to see where he is going,” Morgan said. “The memory position incorporating anterior tilt was invaluable, as it allowed him to operate multiple power functions through one single function on his power wheelchair. This provided greater efficiency and improved success for him.”

seating & mobility system


Scottie’s new seating & mobility system is mocked up and given a workout.

seating & mobility system


Anterior tilt gives Scottie a new and improved field of vision for driving his chair.

This article originally appeared in the June 2016 issue of Mobility Management.

In Support of Upper-Extremity Positioning