Clinically Speaking

Case Study: 20 Years in Bed, Part 2

Imagine spending 20 years straight lying in bed, in an unsupported position and with no ability to optimally and frequently reposition yourself to maintain range of motion or prevent contractures.

Now imagine being the clinician who gets the call to help such a client become mobile, with the ultimate goal of once again being able to sit up and regain mobility via a wheelchair.

That’s what Lee Ann Hoffman, OT, MSc Rehabilitation: Posture Management, described in part 1 (July issue) of her work with client Alan Tombs, his family and the rest of his seating & mobility team. A gradual, but remarkably efficient postural plan started by moving Alan, who’d sustained a serious brain injury decades ago, into a more symmetrical position in bed. That led to preparing Alan to sit upright: “Careful and graded raising of the head of the bed to simulate a more ‘vertical’ than horizontal plane, with continuous observation for factors such as postural hypotension, was undertaken,” Hoffman noted.

Eventually, Alan was able to sit up via a custom-molded seating system. But the rehab team’s work still wasn’t finished. — Ed.

Positioning for Bathing

With the implementation of a graded ‘sitting-out’ plan, great gains were made, lasting up to four hours, three times a week — no pressure areas — thus providing a good foundation to build upon. This increased ability to sit out of bed was accompanied by an increase in endurance and stamina.

The neuro-OT was able to access the sensory room and other therapy areas in the unit to continue with the Sensory Modality Assessment and Rehabilitation Technique (SMART) assessment.

However, one vital area remained unaddressed, namely the shower chair commode (SCC). How many SCC commodes out there could actually accommodate the specific shape required? The simple answer was not one!

Here again, some clever team thinking and creative engineering gave rise to a SCC mobility base (by RAZ Design), with the addition of a Matrix EasyFit custom seat with integrated surface nodules. After a risk assessment-benefit analysis process, the decision to use Matrix EasyFit was made with the aim of allowing water during showering to actually make contact with the person. This is encapsulated in a term I have now coined as “maximum wettage.”

Wheelchair for someone that was 20 years in bed prior


“Maximum wettage” was the idea behind a custom shower commode chair.

Having done more than my fair share of “wash and dress” sessions as an OT, my concern was how else is someone going to get wet in the shower if there is no way the water can actually make contact with their skin?

An addition that we added to the shower chair commode was the attachment of a lower-limb mesh hammock (not included in the photos) to provide some degree of support and feedback to Alan’s lower limbs and feet when seated in the SCC.

Man in wheelchair to position him out of the bed


After 20 years, Alan was again upright and well positioned, with the chance to be more active every day.

Begin with the Basics

Alan’s case as described here is ongoing, and his 24-hour posture management program continues with frequent reviews and adjustments as progress is made.

If you ever get a phone call about seating someone who has complex positioning needs, do not decline your valuable assistance because you think it is impossible! Remember to revert to the basics of your profession — start with small steps using the building blocks of posture and the creation of a stable posture in lying, and then a stable posture in sitting.

Anything is possible — simply use your knowledge, imagination, creativity and teamwork!

Thanks to Alan Tombs and his sister Julia Brown, Phil Swan and Zeeshan Shafi from Contour 886, Bridget Churchill from Life4Living, Janet Radcliff from Symmetrikit and the QA Unit Rehabilitation staff, United Kingdom


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

In Support of Upper-Extremity Positioning