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.”

PHOTOS COURTESY THE AUTHOR, ALAN TOMBS, JULIA BROWN & SEATING/MOBILITY TEAM

“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.

PHOTOS COURTESY THE AUTHOR, ALAN TOMBS, JULIA BROWN & SEATING/MOBILITY TEAM

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