To understand why clients and caregivers
don’t always follow through with the
recommendations given by their Complex
Rehab seating teams, be honest: Do you
follow all the advice your dentist gives you
during checkups?

Angie Kiger, M.Ed., CTRS, ATP/SMS,
is the Clinical Strategy & Education
Manager for Sunrise Medical. She believes
that as the seating team prioritizes clinical
goals, they also need to know what clients
and caregivers face every day.

“The importance of building rapport
with the client: That to me dictates a lot on
where you’re going to go and where your
priorities are,” Kiger said. “Because custom
complex rehab is shaped to the individual,
as a clinician you’re trying to take measurements,
you’re looking at the diagnosis,
you’re looking at coding… and what’s
going to truly make or break you is what
happens in the real world with that client.

“It’s like when you go to the dentist
and your dentist says, ‘Have you been
flossing?’ And you say, ‘Absolutely, three
times a day.’ But you don’t say for how
many days. You can create the most therapeutic,
most supportive seating system
ever. But if your client doesn’t understand
or buy into why they need to be seated
and positioned properly, or their caregivers
don’t understand, then what you’re
doing is kind of futile.”

That disconnect can lead to equipment
that isn’t used optimally.

Kiger said, “When you talk about
seating functions — and you talk about
tilt and recline in particular, which a lot
of people focus on for pressure relief to
prevent or decrease the possibility of
contractures or pressure injuries — you
say, ‘We recommend this.’ But those
specific functions are only as good as the
person who actually does them.”

What Is the Reality?

So how can a clinical team learn about
clients and caregivers well enough to build
seating that will be used consistently?

“It’s not necessarily a standard form or
data evaluation process,” Kiger said. “You
have to really balance everything. I have
to find out: What is the reality? What is
actually going to happen? I’d rather understand
that and recommend equipment
that they’re more likely to use.”

Here, Kiger added, is where seating
decisions can get controversial. If you
believe the “best” seating system is the
one that’s consistently and correctly used,
then the best system isn’t necessarily the
most complex one. Sometimes, getting
clients to consistently and correctly use a
seating system requires compromise.

“I may not get 100 percent of what I
personally believe to be the best solution
for the client,” Kiger said. “However, I’d rather have, say, 80 percent and actual
usage of the system] than zero percent. If
I recommend what I want and I believe it’s
the best of the best, but the caregiver or
the end user says, ‘I don’t want to use it,’
and they continue to use their old seating
system or their old device, then how is that
helping?

“Why wouldn’t they use what we believe
to be clinically most appropriate? Most of
the time from the end users and caregivers,
you’ll hear it’s not practical or it’s
not functional.”

Nice to Meet You

Kiger described herself as a visual learner
who enjoys connecting with clients and
colleagues. Those traits are helpful in the
equipment decision-making process.

“Unfortunately due to things such as
requirements funding and productivity
standards mandated by employers, it’s like
‘Go, go, go, gotta check these boxes,’”
Kiger said. “I tell people: You need to
look in someone’s eyes and talk to them.
Because if you’re just looking down and
checking boxes on your evaluation or
order form, you aren’t necessarily reading
the non-verbal communication from the
client. Make the time to find out what their
day-to-day living is like.”

As Kiger asks questions, she’s collecting
clues: “’What did you do this weekend?
You went hiking? Awesome, which trail did
you go on? That’s a rocky trail, how did
you handle that? You took him out to eat?
What’d you have, how was it? Oh, yeah,
I’ve been there before.’ As you’re talking
with them, you’re picturing the restaurant
and the texture of what they’re eating, and
understanding what’s important to them.
‘How often do you go to that restaurant?
Every Friday night?’ So you know that
for this family, going out to dinner is
important.”

White Coat Syndrome can prevent
clients and caregivers from being frank
about their concerns. So being observant
is key. Kiger recalled a clinic appointment
with a young girl and her father.

“I was there on a power mobility evaluation,
and Dad just carried the child in,”
Kiger remembered. “I said, ‘Talk to me
about the wheelchair she uses at school
or at home.’ They had a tilt-in-space
wheelchair. I said, ‘Awesome, do you have
it with you today?’ And he said, ‘We do.’
I said, ‘Can I help you bring it in? I know
you came today without your wife, so I’m
happy to help you.’ And he took a deep
breath and said, ‘Sure.’

“So we go out to his car, and it is a
four-door sedan with a folding tilt-in-space
wheelchair inside. He had taken off the
seating system and wedged it into the
trunk. The frame was somehow folded
and shimmied in beside the young lady’s
adaptive car seat. As he was taking it out,
he said, ‘We just do not bring this thing
out that much.’”

Kiger wondered how often the little girl
used her tilt-in-space wheelchair, since her
parents found it so difficult to transport.

“Dad said, ‘We have a stroller she still
fits in.’ I was assuming, based on her age,
that it was something off the shelf, maybe
an umbrella stroller that Mom and Dad put
her in.”

Though a standard stroller wasn’t as
beneficial for the child as her custom-fit
wheelchair, Kiger said she understood why
some clients and caregivers don’t follow
the seating team’s recommendations.

“I say, ‘We really want you to go with this
specific seating system because it could
decrease the likelihood that in five years,
she may develop contractures,’” Kiger
noted. “And the parents are thinking, ‘Five
years down the road? I have to worry about
five minutes from now, when I have to get
her in the car and take her to school.’ For
people with disabilities, it’s the here and
now. They don’t necessarily have the luxury
of thinking about down the road. If it’s
someone who has a degenerative condition,
like muscular dystrophy or ALS and
they could pass away, they might not want
to think about that. But also it’s just too
overwhelming to think about what’s going
to happen when that child is older, or when
the caregiver is older and physically has to
take care of their spouse.”

All Things Considered

CRT can require compromise. Sometimes
that means choosing seating systems that
clients and caregivers can manage well in
daily conditions.

“Be mindful of what’s going on,” Kiger
said. “The therapist and the supplier have
to really understand the entire picture.
It’s not just about the measurements and
‘This could potentially prevent a pressure
injury.’ Yes, it could. But if they have
multiple caregivers and they’re not putting
that cushion in properly or they’re not
positioning that headrest appropriately…
this is devil’s advocate, but if you went
with something a bit simpler to use, could
you decrease the potential of a different
sort of injury happening?”

Kiger recalled the introduction of
two seating systems for Sunrise’s Zippie
Voyage, a stroller-style wheelchair for kids.
The first system featured complex positioning
elements; the second was more
moderate in its positioning features.

“When we presented the moderate
seating to our clinical advisory board, I
remember a gasp in the room, like ‘Why
are you going down this road?’” Kiger
said. “Then I remember one of the therapists
spoke up: ‘I like this. It’s a happy
medium. I have some parents who see this
more clinically styled seating and don’t
want their kids to look clinical. It’s too
complicated for them to get those laterals
in the back and for them to make adjustments.
But with the moderate seating, I
can get them positioned pretty well. It’s
not everything I want clinically, in the ideal
world. But I’m positioning them pretty
well, and they’re going to be happy and
functional. And I know Mom and Dad can
use this version better and will be more
inclined to use the Voyage as opposed to
an umbrella stroller from a department
store.’”

Kiger pointed out that some clients
and families are fine with highly complex
systems: “There are some parents and end
users who can absolutely handle the most
complicated of complicated things: ‘Yup,
we got it.’”

But Kiger also remembered a client
from a group home who showed up to
clinic with a thoracic lateral mistakenly
positioned at his thigh.

“The family of someone who has severe
disabilities is getting these instructions
just on their seating and positioning,” she
noted. “Think about what they’re getting
from the orthotist, from the dietitian, from
the speech therapist, from their respiratory
therapist because the child might be
on a ventilator.

“More seating systems are becoming
easier to deal with and more practical.
That’s nice to see as an industry.”

Ultimately, Kiger said, the ideal seating
system provides beneficial support
and positioning while also fitting well
into a family’s everyday lifestyle and
environment.

“I really do buy into ‘Improving people’s
lives,’” Kiger says of Sunrise Medical’s
tagline. “I want them out there, living life.
That’s the ideal: We don’t want them to
have to think about it. We want them to
get into their chairs joyfully.”