PHOTOS COURTESY THE CLIENT AND AMY MORGAN.

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.”

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.”

PHOTOS COURTESY THE CLIENT AND AMY MORGAN.

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.

PHOTOS COURTESY THE CLIENT AND AMY MORGAN.

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.”

PHOTOS COURTESY THE CLIENT AND AMY MORGAN.

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.”

PHOTOS COURTESY THE CLIENT AND AMY MORGAN.

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.

PHOTOS COURTESY THE CLIENT AND AMY MORGAN.

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.”

PHOTOS COURTESY THE CLIENT AND AMY MORGAN.

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

PHOTOS COURTESY THE CLIENT AND AMY MORGAN.

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