Greg: Getting the active support he needs!

Background:
Greg is 36-year-old male and has a low thoracic level spinal cord injury (T10 ASIA). He lives a very active life with his wife and is a father to 3-year-old twins. Greg is a long-time wheelchair user as he sustained his spinal cord injury at age 18. He has been using a similar wheelchair setup since that time – a TiLite TR frame with the standard sling back support and ROHO Quadtro Select High Profile cushion. Overall, Greg’s wheelchair worked well for him. It allowed him to do all the activities he wanted and needed to do. The lightweight made for efficient propulsion and eased loading and unloading it into a vehicle. Although his wheelchair did “get the job done” so to speak, Greg felt that he sat slumped in his chair and that he did not have good upright posture and support. He also has a history of shoulder injuries and currently has partial tears of his rotator cuff bilaterally.

Seating & Positioning Concerns:
The ROHO cushion was selected due to Greg’s history of pressure injuries and flap surgery. The ROHO cushion provided excellent pressure reduction properties, although it did not provide optimal positioning components to assist with pelvic positioning and stability. Prior to using the ROHO cushion, Greg used a hybrid style gel cushion (Jay J2) that provided positioning and stability but did not provide sufficient pressure reducing properties.
The sling backrest was selected due to weight and convenience during transport. Prior to using the sling backrest, Greg used a solid backrest (Jay J3), although he reported that he would get “hot spots” of increased pressure when using it. The use of the sling backrest combined with the ROHO Quadtro cushion resulted in Greg sitting with a posterior pelvic tilt. This positioning also promoted a thoracic kyphosis with the shoulders protracted/rounded anteriorly (see photos below). This position places the head of the humerus behind the axle of the wheelchair which is not optimal for efficient push-stroke during propulsion and places Greg’s upper extremities at an increased risk for repetitive stress injuries.

Evaluation:
All of Greg’s seated postures (posterior pelvic tilt, kyphosis, shoulders protracted/rounded (anteriorly) were noted to be reducible or partially reducible. Additionally, Greg had a 1” left pelvic obliquity (low on left), also reducible. To correct these postures, we began by trialing a Tarta Original® Custom backrest with Greg. We adjusted the height so that the bottom of the back was right above the PSIS and the top of the back stopped at the lower thoracic area. Since Greg had good trunk control, the placement of the backrest provided posterior pelvic support in combination with the cushion and still allowed full upper extremity and upper thoracic spine mobility. We then selected a combination of staves and padding to fit Greg’s posture.

Next, we took Greg’s measurements to design a Stealth Custom Cushion specific to his needs. We wanted it to measure close to 4” tall to mimic the height of his current cushion. The cushion we ordered measured 16”W x 16”D. On top of a high-density foam base, we placed 3 foam layers for their pressure reducing properties – a bottom layer of 1” soft SunMate FRG, a middle layer of 1” X-Soft SunMate FRG, and a top layer of ½” XX-Soft SunMate FRG. Next, we placed a ½” anti-thrust component to assist in maintaining the position of the ischial tuberosities to prevent a posterior pelvic tilt. Additionally, we added an ultra-lite gel into a well to provide extra pressure reducing properties at the ITs. The gel was placed below 1” of foam to decrease gel migration and help keep the gel in place. Lastly, we included a solid seat insert with the addition of a 1” wedge kit to use on the left side to accommodate his obliquity. The final product was just slightly short of 4” tal (~3.75”), which worked well to meet Greg’s needs in terms of positioning & pressure reduction.

Results:
Greg immediately noticed the change in posture with the new backrest and cushion. He stated that he immediately felt supported and that he was sitting more upright. In the photo below you can see this change – the PSIS is now supported with the Tarta Original® Custom backrest along with pelvic support provided by the Stealth Custom Cushion. Supporting the PSIS promotes upright posture of the upper thoracic spine and optimal positioning of the UEs for propulsion – directly over the axle. The flexible feature was an added bonus for Greg because it allowed for natural movement of the spine and did not block movement like a solid backrest. After using the new seating system for over a month, Greg also noted a reduction in shoulder pain. After 5 months of use, Greg has no pressure issues or redness. The new cushion and back are mitigating pressure risk while providing optimal postural support for function.

Heather R. Price, OTR/L, ATP/SMS