Specialist Seating/Postural Management Assessment

ICES Partnership Nottingham City & Nottinghamshire

Specialist Seating/Postural Management Assessment Provision of Equipment for Children: Specialist Seating/Postural Management Assessment Tool

May 2012

Nottingham & Nottinghamshire Integrated Equipment Service (ICES)

Version 4.0 dated 8.6.12 1 ICES Partnership Nottingham City & Nottinghamshire

Specialist Seating/Postural Management Assessment

Date of Assessment: Assessor:

Child’s Name: Address:

Tel: Home

Tel: Mobile Postcode:

BRC client ID: ID Number: School: (BRC client ID NHS No: Consultant: plus the one specific to Framework: GP Practice Code: your organisation) 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 Postural Requirements / Observations 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 Date: (OT/Physio) Team Manager Date: (Budget Holder)

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.

4.3 Braked Castors - Chairs can come with a variety of usually two brakes or four brakes. If 2 braked, these are usually placed at the rear of the chair. In some instances you may feel 4 brakes would be beneficial to ensure the chair remains still for transfers in and out. Recommend checking on assessment as to whether the chair as standard has 2 or 4 brakes wheels.

4.4 Static or Star base  Static base (no wheels). May be used if child is able to self transfer / child is a baby or if rocking type chair is in use  Wheeled base - consider number of braked castors required - whether wheels are swivel to ease movement  Star base (often acceptable to family’s on first chair as footprint is smaller than hi / low bases)  Hi low base (always on wheels) – can facilitate independent transfers/ hoisted transfers. For use when the chair is needed for a variety of activities such as social interaction and then up to family table

4.5 Hi-Lo Base - Many chairs are now supplied with a base which can have height adjustment. Often these will facilitate a low down transfer such as for a child who may be independent. The chair can then be raised to facilitate use up to a table or work top. The action of the raising can be hydraulic or by electric. Some hydraulic chairs may need some manual assistance.

 If a child becomes heavy the manual assist chairs can become quite hard to operate. Electrically operated chairs are more expensive and require regular charging  Note the leg position of children if being pushed up to a worktop. Is there enough space if their legs gain in length for them to get safely under the worktop  Check the range of height adjustment  Advise keeping the chair lower if the child rocks, or strongly extends. If they are to be left alone at any time in the chair as the increased height heightens any risk of the chair being able to be tipped over

4.6 Tilt in Space - is particularly recommended for those individuals that present with:

 Posterior pelvic tilt (sliding down chair/sacral sitting often associated with extensor tone and patterns of movement)

 individuals at risk of pressure areas  individuals using communication tools that need to remain in position  discomfort whilst seated for long periods  problems with sitting tolerance  generally difficult to seat individuals that require optimum support and positioning assistance in the form of postural accessories

Whilst maintaining the physical angles at hips, knees and ankles the tilt offers a change in orientation and redistributes pressure thus eliminating shearing forces often associated with recline mechanism. It is therefore beneficial in reducing risk of pressure sores and damage to skin integrity and allows the user to alternate position throughout use.

Transfers can become an issue in that the seat to floor height is raised with tilt systems. It may also be difficult to position at tables without a height adjustability option.

5 Miscellaneous

5.1 Covers - Consider whether the seat has removable covers for washing or a wipe down finishing. Is the child able to manage their temperature regulation themselves. Will the covers be constantly in the wash, leaving the seat unusable or can the seat be used without the covers.

5.2 Colour of covers - Do NOT offer colour choices, all chairs and chairs purchased through ICES must be neutral non gender specific.

6 Other Definitions

6.1 Chailey Score - The Chailey approach is a method of assessing postural ability in children with movement disorders and is a validated assessment tool. It considers a child’s posture in each of five positions – lying supine (face up), lying prone (face down), floor sitting, box sitting and standing. Each of these postures has between six and eight descriptors with level 1 being greatest abnormality and asymmetry and the top level (level 6 in some areas and 8 in others) representing normal. The detailed breakdown of skills, within each level are a useful guide to therapists as to areas of specific weakness to work on.

6.2 Oxford Assessment - a comprehensive range of trunk, upper and lower limb measures to assist in prescribing supportive postural equipment.

6.3 Gross Motor Function Classification Score (GMFCS): 5 levels to indicate level of gross motor function from Level 1 (walks without aids) to level 5 (mobility is severely limited).

APPENDIX B TABLE OF POSSIBLE CHAIRS WITH SIZING

Approx Seat Seat to Backrest User Seating age Seat width Notes depth footplate height height range All measurements in MM A2U 0845 2574967 Odyssey A 200-320 170-290 210-330 360-460 Odyssey B 280-400 200-330 230-380 420-520 Odyssey C 320-450 230-410 290-470 460-562 Consolor Ltd 01202 827650 Zitzi Delphi Pro 1 170-270 240/270/300 600-1000 Zitzi Delphi Pro 2 240-340 280/310/340 900-1200 Zitzi Delphi Pro 3 300-400 320/350/380 1100-1600 Zitzi Sharky 1 400-450 >400 125-160

Zitzi Sharky 2 450-500 >500 150-185 JCM 01733 405830 Sunbeam 3mth-3yr 150-275 165-365 0-280 250-450 StarX 1 1yr-4yr 200-300 175-355 130-300 330-390

StarX 2 4yr-8yr 250-350 210-405 130-350 365-425 2006/2007 Triton 1 185-305 185-360 140-360 320-460 The 2006/2007 Tritons have a 2006/2007 Triton 2 240-360 200-410 140-360 320-460 'pointed' foot pedal and are 2006/2007 Triton 3 340-460 240-460 200-425 400-600 raised/lowered on a gas ram requiring manual assist. The footplate hanger is reversible to 2006/2007 Triton 4 440-560 240-510 200-425 400-600 give a smaller seat to footplate height. 250-350 2010 Triton 0 150-300 150-275 130-210 220-320* 2010 Tritons have a 'round' foot 2010 Triton 1 225-325 170-325 215-295 350-475 pedal and are raised/lowered on a 2010 Triton 2 300-400 220-375 295-375 400-525 hydraulic mechanism. Triton 0 has 2010 Triton 3 375-475 270-425 360-440 475-625 a long sitting pad option. 2010 Triton 4 450-550 320-475 430-510 525-675 Seating Approx Seat Seat width Seat to Backrest User

age depth footplate height height range JCM (continued) 01733 405830 2010 Neptune 1 18mth-5yr 200-325 165-325 130-290 200-325 Have a gas ram raise/lower requiring manual assist but can be put on a Triton hydraulic base. 2010 Neptune 2 5yr-10yr 325-450 265-425 260-420 325-450 Doesn't control hip abduction. Covers washable at 30. Jupiter Junior 3yr-10yr 280-400 170-310 350-450 350-570 Both sizes recline from vertical to 25°. Tilt from horizontal to 20° Jupiter Senior 8yr-adult 360-500 220-380 470-550 480-630 back. Heritage Eclipse Adult 400-520 350-500 525-600 660-810 Jenx 0114 2853376 * Long sitting pad available. Seat depth can become 370-600 with Bee 4mth-5yr 110-350 * 130-250 85-345 270-360 long leg conversion (using 75mm back pad) Giraffe 9mth-4yr 150-310 130-230 120-350 270-360 No hi/lo base. Junior 1 1yr-5yr 210-305 170-330 175-280 300-420 Junior 2 3yr-8yr 240-320 170-330 240-380 350-470 Junior 3 5yr-12yr 275-390 170-330 240-420 400-520 Zeta 1 8yr-14yr 330-430 210-360 260-530 350-500

Zeta 2 12yr-18yr 410-530 250-390 260-530 450-660 Beta 1 1yr-5yr - -320 150-330 115-320 375-460 Beta 1 & 4 have not been in Beta 2 3yr-8yr - -400 150-330 165-335 390-495 production since 2010 but may still Beta 3 5yr-10yr - -465 150-330 260-380 430-535 be in stores. Inbuilt abduction roll to seat children in an abducted Beta 4 9+ 270-300 240-375 235-480 450-625 position. Gamma 1 1yr-5yr 185-265 160-330 170-310 350-455 Discontinued since 2010 Gamma 2 3yr-8yr 220-320 180-330 170-360 390-495 (superceded by the Junior). Can Gamma 3 5yr-10yr 270-370 180-330 170-360 430-535 be used with a X base or a Y base. Multiseat 4 285-450 200-440 250-470 465-590 Multiseat 5 355-520 200-440 250-470 525-660

Seating Approx Seat Seat width Seat to Backrest User age depth footplate height height

range Leckey 0800 318265 Squiggles 1yr-5yr 190-290 160-260 122.5-270 320-480 Mygo 1 3yr-10yr 270-420 200-325 215-350 360-470 Mygo 2 8yr-14yr 350-470 220-345 315-470 460-570 Kit 1 12yr-18yr 360-480 215-370 330-510 500-620 Kit 2 16yr-adult 410-560 215-370 330-510 560-675 Easy seat 1 1yr-3yr 175-250 125-225 150-230 225-285 Easy seat 2 2yr-5yr 225-300 150-250 220-300 265-340 Easy seat 3 3yr-8yr 250-350 225-325 250-350 325-425 Easy seat 4 6yr-11yr 300-400 275-375 300-420 400-500 Discontinued (produced in 1994), Whoosh no dimensions available. Produced in 4 sizes. Discontinued (produced in 2001), Advance seat no dimensions available. Produced in 3 sizes. R82 0121 5612222 Nandu 1 170-240 220 Nandu 2 210-280 250 Nandu 3 240-310 290 Nandu 4 280-360 320 Wombat Basic 1 160-290 210-300 280-340 Wombat Basic 2 230-360 280-370 310-280 Wombat Upgrade1 160-290 160-290 280-340 Wombat Upgrade 2 230-360 230-360 310-280 Wombat Upgrade 3 300-480 350-440 390-500 Panda Standard 1 220 220 290 Panda Standard 2 240 220 390 Panda Standard 2 1/2 280 250 410 Approx Seat Seat to Backrest User Seating age Seat width depth footplate height height range R82 (continued) 0121 5612222

Panda Standard 3 310 290 440 Panda Standard 4 360 320 520 Panda Standard 5 430 350 590

Panda Active 2 240 220 350 Panda Active 2 1/2 280 250 380 Panda Active 3 310 290 400 Panda Active 4 360 320 450 Panda Active 5 430 350 590 160, 200, X-Panda 1 160-260 270-370 240 200, 240, X-Panda 2 220-320 320-420 280 260, 310, X-Panda 3 260-390 350-470 360 360, 400, X-Panda 4 380-530 500-690 460 Seating Matters 028 777 66624 400, 450, Sorrento 500, 550 400, 450, Phoenix 500, 550 Smirthwaite 01626 835552 Heathfield 1 180-240 240 180-230 250 Heathfield 2 220-310 280 200-300 280 Heathfield 3 260-340 325 240-370 320 Juni 1 180-240 240 160-220 260 Approx Seat Seat to Backrest User Seating age Seat width depth footplate height height range Smirthwaite (continued) 01626 835552 Juni 2 220-300 280 200-280 290 Juni 3 260-360 325 240-340 325

Samba 1 180-280 300 150-170 310-605 Samba 2 245-340 345 200-250 310-605 Samba 3 300-400 345 255-335 310-605 Samba 4 375-500 400 310-460 310-605 Strato 1 220 250 180-280 270-400 Strato 2 260 290 180-280 270-400 Strato 3 300 370 270-350 410-550 Strato 4 350 450 330-420 410-550 Strato 5 400 450 400-500 490-660 Discontinued, no dimensions Jive available. Symmetrikit/Helping Hand company 01531 635388 Small not available in powered Tiltrite small 2yr-7yr 230-350 125-360 190-400 560-690 version. Tiltrite medium 340-500 200-500 270-470 585-820 Tiltrite large 340-500 200-650 395-595 685-920

ICES Document Review

Timescales: Review Annually

Document Authors:

Date Officer Position/Group 17.5.12 Sarah Bailey ICES Partnership Manager Frances Vint ICES Childrens Clinical Group Helen Dabbs Esme Hobbs Heather Patterson Ruth Keys Melanie Dean Sarah Hole Notts County Disabled Childrens Team

Version 4.0 dated 8.6.12 19