ICES Partnership Nottingham City & Nottinghamshire
Integrated Community Equipment Service
Provision of Equipment for Children:
Specialist Seating/Postural Management
Assessment Tool
May 2012
Nottingham & Nottinghamshire Integrated Equipment Service (ICES)
Specialist Seating/Postural Management AssessmentDate of Assessment: / Assessor:
Child’s Name: / Address:
DOB:
Tel: Home
Tel: Mobile / Postcode:
ID Number:
(BRC client ID plus the one specific to your organisation) / BRC client ID: / School:
NHS No: / Consultant:
Framework: / GP Practice Code:
Carefirst: / GP Address:
Diagnosis/Disability: / Assessments: (attach if relevant)
(Chailey/oxford)
Present Situation (seating currently in use if known):
What the carer feels they need for the child:
Where will the chair be used? (environment suitability):
For what activities will the chair be used? (eg relaxation, feeding/eating, play):
Will the child be supervised in the chair?
How long does the child currently spend in seating? (time/frequency):
Carer motivation, limitations, etc:
Measurements
Height cm
Weight cm
Hip width cm (a)
Floor to back of knee cm (b)
Seat base cm (c)
Seat base to mid scapula cm (h)
Seat Base to top of shoulders cm (d)
Seat Base to top of head cm (e)
Shoulder width cm (f)
Arm rest height – base to elbow cm (g)
Postural and Functional Observations
Observations / Postural Requirements / Potential Solutions
1. Pelvis/Hip Position
2. Trunk Control / Sitting Balance
3. Extensor Spasm
Muscle Tone / Reflexes
4. Head Control / Neck
5. Left Leg & Foot Position
6. Right Leg & Foot Position
7. Left Arm / Hand Function
8. Right Arm / Hand Function
9. Mobility
10. Transfers
11. Behaviour
12. Risk of tipping chair
13. Sensory Function
14. Skin Condition
15. Continence
16. Swallow/suction needs – risk of aspiration
17. Eating / Drinking
18. Respiratory (oxygen/ventilators)
19. Other
Seating Accessories Required – see appendix A
Summary
To include type of seating/positioning equipment required: fully supportive height adjustable seat or floor based 90/90 seat with anti tipping
Possible Options to consider: see Appendix B as a starting point:
Signatures/Authorisation
Clinician
(OT/Physio) / Date:
Team Manager
(Budget Holder) / Date:
Budget to be charged
Appendix A
Seating Options
LOW 90/90 floor based seating
MEDIUM increased postural support,
Hi/lo option, wheeled base
HIGH multi-adjustable hi/lo, tilt in space,
fully supportable seating system
1 Seat Base Options
1.1 Flat - Generally used for children who have low level sitting needs and have a symmetrical sitting position and good sitting stability.
1.2 Ramped/contoured - Shaping of the seat cushion can be used to encourage pelvic stability and symmetry, and encourage alignment of lower limb joints. It can also be used specific positioning such as hip abduction. The shaping is normally predominantly placed along the inner or outer aspect of the thighs, or in front of the gluteal crease. This accommodates the difference in thigh dimensions and supports the femurs in a horizontal position.
1.3 Moulded - Individually moulded seats are used for children and young people who are generally unable to use any of the other types of seating base. When the child’s posture is significantly asymmetrical moulded seating is able to accommodate and support the posture for maximum comfort. By ensuring that there is maximum body contact with the seat there is a reduction in the risk of tissue trauma and the development of pressure sores.
1.4 Split - Accommodates leg length discrepancy.
1.5 Saddle/Straddle- Normally can be tilted forwards to encourage anterior tilt of the pelvis with and extended spinal posture. For improved hip stability as well as trunk and lower limb alignment. Children who have high muscle tone in their legs may find that sitting in abduction in a saddle or straddle style seat helps to reduce their tone.
2 Back Options
2.1 Flat Back – This is the most basic of back rests suitable for children who have independent trunk control or who need a little bit of extra support required in conjunction with trunk supports.
2.2 Contoured – Usually shaped symmetrically and providing support to the curves of the spine and / or give some side support. In some instances this type of back rest can be built up to suit the individual child’s contours and accommodate pronounced spinal curvature/deformity. This improves pressure relief as the weight is more evenly distributed. The R82 Wombat chair back is contoured and particularly effective in supporting kyphosis.
2.3 Adjustable Lumbar support/pad. Is provided to increase support to the lumbar curve. In younger children the lumbar curve may not be developed and this pad can sometimes be moved to encourage this area to develop correctly or used to provide support where it is needed.
2.4 Adjustable sacral support/pad. Is provided to increase support to the sacral area. When a child’s position is not correctable the pad may need adjusting to accommodate a deformity.
2.5 Dynamic - Allows children to extend and push back against relatively light resistance and then regain the desired sitting position without compromising pelvic position. A lockable option may be desirable for eating and drinking situations.
For Example: The R82 x:panda and the JCM Triton Dynamix have dynamic back supports that absorb the energy of extension and return the child to a functional seating position upon relaxation. These systems are useful for clients with a strong extensor spasm and varying muscle tone. Any extreme forces are absorbed, making it less susceptible to structural failure in the back and footplate.
The R82 x:panda allows the back to be locked if preferred for activities such as feeding.
The JCM Triton allows the strength of resistance and power of return to be set to suit the individual requirements of the user.
2.6 Recline - Some chairs have a backrest which can recline. This can be used for children who tire easily and need to have their hip angle opened up to provide a more relaxed posture. Also some children do not tolerate a full 90 / 90 position and require their hips to be slightly more opened on a regular basis. Some seating has an incremental approach to hip opening and chairs can be set according to the child's specific needs. In some cases families may be advised to leave the recline function alone once it has been set specifically for their child.
A recline option can make it difficult for the user to regain their original position. If accessories are necessary to encourage positioning then the recline can affect the set up of such. The recline can increase shearing forces and compromise skin integrity. It is also important to ensure that the recline facility does not encourage sacral sitting (sliding down chair – thereby encouraging posterior pelvic tilt). Such can contribute to shearing forces and pressure problems in addition to deformity.
2.7 Pressure Relief - Some specialist seating has pressure relieving cushions built into the seat base/back. Specialist pressure relieving cushions can be assessed for via the tissue viability nurse but cushions to fit paediatric seating are difficult to find.
3 Supports
3.1 Head Rests - A wide range of head supports are available to maintain optimum head position and support in resting or active positions.
Simple headrests can often be fitted on a multi-adjustable carrier which offers adjustment in three planes. This enables the correct height, angle and distance forward or backwards from the carrier to be achieved. Some companies will mount specialist headrests eg Whitmyer, Prowalk or i2i.
Multi Grip Head Rest - This comes on multi-adjustable carrier and offers very individual support for a wide range of children. Within the comfortable cover are "fingers" that can be moved and molded to create an infinite variety of support shapes that can control ATNR, help with feeding, address the problems of unilateral inattention and many other problems.
3.2 Hip Pads - To assist with correct positioning of the bottom and also add support along the length of the thigh.
· standard length
· extended bilaterally
· right leg extended
· left leg extended
3.3 Thoracic Laterals (Short/fixed) / Thoracic Laterals (Flip Away with Chest Strap)
· Thoracic Laterals – Required to help support posture, upper trunk control and sitting balance (fitted rib height, underneath armpits).
· Flip away laterals – Provided to assist with transfers (either hoist or slide).
· Fixed Laterals – Provided to support upper trunk control and sitting balance.
· Wrap Around Laterals – Provided when increased trunk control is required. Ideal for children who have sensory needs and would benefit from light pressure ‘snug fit’. May also reduce the need for a harness or waistcoat.
· Consider options when assessing girls around the age of puberty.
3.4 Waistcoat - Provides a higher level of upper body support, increased trunk control and sitting balance. Ideal for children who are low/high tone and require more support when sitting.
Clips – Required when only a slot is available to attach harness straps to chair.
3.5 Harness - Required for upper trunk control, to maintain positioning and to reduce the child bending/tipping forward in the chair.
3.6 Lap Straps (2 point and 4 point) - Will provide correct hip alignment and prevent unwanted pelvic movement.
· Consider whether dual or single pull is required to ensure belt is tightened to the correct tension on each use.
· Padding or upholstery on the lap belt helps to distribute the pressure of the belt and reduces the potential for skin entrapment.
· 2 point is for basic positioning and less dependent children
· 4 point belt, which attaches at 2 points on each side of the chair, and provides a directional pull both downward and backward, holds the pelvis more securely making it suitable for clients with a lot of movement and moderate to severe positioning needs
3.7 Buckles - Buckles can come in a variety of forms
· Velcro – provides minimal support
· Clip buckle plastic (ensure there is no skin trapping risk)
· Metal Buckle (like seat belt)
· Safe buckles (which are difficult to press and for use when child may undo belt by themselves and put themselves at risk)
3.8 Abduction Block/Pommel - Abduction block otherwise known as a pommel.
Fits under the centre of seat base or can be moulded into the seat base. It helps with the alignment of the legs especially if the child has increased tone in their legs which as a result adopt a position of adduction
Note that not all chairs are able to have this retro fitted and may require adapting.
Also note that this is not an accessory to prevent child from slipping forward and if used as such could cause injury.
· Assists with prevention of wind sweeping
· (on toileting equipment this can assist with minimising urine escaping)
3.9 Knee Blocks - These are designed to maintain the pelvic position and keep the hips in neutral. They can also be used to correct pelvic rotation. However the incorrect use or placement of these can cause significant pain and damage. Only to be used if the hip joints are stable and the child’s orthopaedic surgeon has agreed that knee blocks are a safe way to proceed.
3.10 Footplate, Bootees, Sandals - All seating provision should include some kind of foot support to ensure feet are not left dangling. Improves pelvic and trunk stability.
· Single footplate without any straps (basic)
· Moulded foot plate or box (retains feet within a specific area)
· Two individual footplates - these provide a little more support and position the feet more accurately. Child will sometimes need the feet strapping into these to maintain their position. Useful if the child has a leg length discrepancy
Sandals can come in various forms and requires shoes to be worn.
· Sandals which specifically position the foot and is of the same size as the child’s shoe. This may have two straps and can be fitted by either going across the child’s foot or criss crossing over the child’s foot. The strapping should be determined as part of the assessment.
· Sandals may also be provided together with an ankle straps and a toe strap (if required)
· Snug feet / bootees /ankle huggers require details of the ankle circumference for fit. Assists with foot positioning and prevents incorrect foot positions. Secures the feet without being tight. Helps increase safety of child in the chair. Improves pelvic and trunk stability. Child may be able to use softer footwear (such as slippers)
3.11 Shoulder Protractors - Provided to prevent shoulder retraction and facilitate an improved posture during functional activity. Can also reduce the risk of entrapment down the side of the chair.
3.12 Elbow Blocks (small/large) - To encourage correct arm positioning to enable function. Ideal to reduce shoulder retraction and risk of arm entrapment especially for children who have jerky arm movements.
3.13 Arm Rests - To encourage balance, support upper trunk control and facilitate the fitting of a tray. Adjustable height angle and removable to facilitate slide transfers.
3.14 Tray - Different shapes, colours and materials make it possible to find exactly the right tray for the user. Some trays are made with an edge to keep toys etc. on the plate, while others are made without to provide more freedom of movement.
Some of the trays are made with one centre bar mounted in the armrest, making it possible to swing-away the tray before placing the user in the chair. Other trays are mounted with twin bars into both armrests.
Trays can often be padded if needed. Some users might benefit from using one of the transparent trays but this is not recommended where there is a visual impairment.
3.15 Grab bars/ rails - These can help to stabilise upper limbs to assist with hand function and self feeding and they can be used to attach toys to the tray. It is important to consider the height and position of a grab bar and how easily it can be moved out of the way to allow the whole tray to be used. Suction grab handles can be used on a tray with a smooth surface.
4 Bases
4.1 Skis - Improves the stability of the chair. Only use the correctly compatible parts for the chairs.
4.2 Wheels - Facilitates moving the chair. The number of brakes on the chair will vary from range to range.