SEATING, POSITIONING & MOBILITY
Objectives:
1. Recognize seating and mobility problems that impact a person’s daily
function.
2. Determine when a referral should be generated and who the appropriate
recipient would be.
3. Communication of expectations related to an assistive technology request.
4. Identify key characteristics and qualifications of quality resources.
Presenters: Laurie Dubose, OTR/L
Senior Occupational Therapist
Woodrow Wilson Rehabilitation Center
Greta Nelson, PT, MS
Senior Physical Therapist
Woodrow Wilson Rehabilitation Center
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Seating, Positioning, and Mobility
INTRODUCTION
Assistive Technology associated with seating, positioning and mobility can be as
varied and complex as physical disabilities themselves. An interdisciplinary
approach to the complex problems regarding seating, positioning and mobility
yields the best solution. Attainment of appropriate assistive technology related to
seating, positioning and mobility could mean increased independence and
productivity for many DRS clients. Counselors are an integral team member and
their ability to recognize problems, ask the right questions and coordinate
resources is critical.
IDENTIFYING PROBLEMS THAT IMPACT FUNCTION
Clients with disabilities most commonly identified with seating, positioning and
mobility problems include those with: spinal cord injury, traumatic brain injury,
cerebral vascular accidents, cerebral palsy, multiple traumas, spina bifida,
amputations, cardiac diseases, metabolic disorders, diabetes and low back pain.
Consider the following potential problems and how they impact on the client’s
abilities to perform in environments related to the Individualized Plan for
Employment (IPE).
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Improper fit of existing technology
Broken or inappropriate technology
Compromised skin integrity and risk of skin breakdown
Poor biomechanical or ergonomic posture
Presence of pain or discomfort
Impaired balance
Diminished endurance or problems with fatigue
Inability to push, pull, reach, lift, and transport products from one area to
another
 Inaccessibility to home, school, work, community settings
 Lack of transportation to medical appointments, school, community, work
DETERMINING IF A REFERRAL SHOULD BE GENERATED
Common situations that warrant assistive technology team evaluation and
intervention:
 The client has had numerous prior services without resolution of the
problems and the previous technology may have been abandoned.
 Referral back to the original source who provided the intervention or
technology has not been able to resolve the issue.
 An exact duplicate of the technology (simple replacement of technology
that is meeting client’s needs) would not suffice.
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 The client’s vocational and avocational potential is uncertain. A referral is
indicated to explore options available prior to defining assistive technology
needs related to the IPE.
 The seating and mobility problem is impairing daily function, employability,
or goal attainment.
 Presence of one problem has multiple implications that require a holistic
and integrated team assessment.
 The problem is a matter of actual medical or vocational need rather than
client preference or convenience.
 The medical prognosis or general physical condition is worsening. This
may or may not be directly related to technology use.
The referring party should ensure that there is a funding source (medical,
vocational or other) authorized for the evaluation and technology.
SELECTING APPROPRIATE PROVIDERS/RESOURCES
Interdisciplinary team composition and capabilities are important. Seating,
positioning and mobility needs cover a broad spectrum, from the most basic to
the extremely complex. As seating, positioning and mobility needs vary from
client to client, so too does the composition of the interdisciplinary team. In short,
the makeup of the team is determined by the client’s needs. For clients with more
complex needs, or a broader scope of needs, an interdisciplinary team consisting
of multiple disciplines with specific areas of expertise will be required. As shown
below, up to sixteen disciplines are available to participate in the delivery of
seating, positioning and mobility services and technology.
Members of the seating and mobility interdisciplinary team may be composed of
any a/o all of the following:
 The Client: The client is the most important member of the team.
Whenever possible, he or she should participate actively in all steps of the
service delivery process. The client is responsible for identifying his or her
general needs, especially as they relate to the IPE, and communicating
these needs with relevant information to the team. The client should also
provide input and feedback to the team from beginning to end.
 The Client’s Family, Personal Caregivers or Primary Care Attendant:
If the client utilizes a personal care attendant, then that person should be
included on the team with the client’s consent. This person in all likelihood
will assist the client in the daily use, care and maintenance of the assistive
devices provided. Therefore, they have a key role in the selection of the
assistive technology. They need to be comfortable with the technology
and have the capability to use, care for and help maintain the device(s).
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 The Rehabilitation Counselor:
The counselor is responsible for
identifying with the client and others any potential needs, problems or
issues that the client may experience. He or she is also responsible for
making the appropriate referrals once seating, positioning and mobility
needs are identified. Additionally, the counselor needs to be familiar with
the resources that are available and the capabilities of the potential
service providers. Should additional disciplines (PT, OT, Rehabilitation
Engineering, etc.) be brought onto the team, the counselor should
determine why each discipline is needed and what the discipline is
expected to provide. Once the interdisciplinary team makes
recommendations, the counselor is responsible for reviewing the
recommendations and coordinating the purchase of the recommended
services or devices once approved. Finally the counselor assists in
following up on the delivery of the services and devices to ensure that the
client’s needs have been met.
 The Physician: The physician is frequently required to assess the client’s
medical status as they relate to the seating, positioning and mobility
issues. Many assistive technology funding sources require a certificate of
medical necessity signed by the physician before considering payment for
the technology.
 The Physical Therapist:
The physical therapist’s role may vary
depending upon the facility. WWRC’s Seating and Mobility team
designates the physical therapist (PT) as the team’s lead therapist for
seating, wheeled mobility and ambulatory devices. The PT screens
records to assess the client’s primary needs and shares this information
with other team members. The PT evaluates the client’s posture, strength,
range of motion, skin condition and functional mobility skills and needs as
baseline information for determining appropriate intervention options.
Clinical trials of these options allow the client and the team to determine
the best choice of either scooter, power or manual wheelchair or
ambulatory mobility devices.
 The Occupational Therapist: The occupational therapist’s role also
varies by facility. The occupational therapist on WWRC’s Seating and
Mobility team provides significant input for cushion selection, accessibility
and transportation options (compatibility with vehicle and wheelchair tiedown systems).
 The Durable Medical Equipment (DME) Vendor or Rehabilitation
Technology Supplier (RTS): The DME vendor assists the team in
identifying commercial devices that may meet the client’s needs. The
vendor should have an extensive knowledge of commercially available
equipment to include technical specifications, capabilities and limitations.
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The vendor should assist the team in acquiring equipment for trial or
extended evaluation prior to purchase as well as in acquiring equipment
for purchase. The vendor should assist the team in funding procurement,
fitting, training and ongoing service of the technology provided.
 The Rehabilitation Engineer: The role of the rehabilitation engineer
(RE) is to provide engineering and technical expertise to the team relevant
to meeting client needs when standard equipment is not appropriate. The
RE participates in the team evaluation assisting in problem identification
and analysis and proposing technical options for attaining the outcome
desired by the team. Often a mock-up of the design is fabricated for
further clinical evaluation and revision of the design plan prior to
fabrication of a definitive product. The RE is then incorporated into the
technology delivery so that device fabrication or modification is
customized to the client and the new mobility and seating system. The RE
is also responsible for educating the client and any caregivers regarding
special use or maintenance requirements of the custom devices and
providing follow-up services. The RE contributes significantly to the
capacity of the team by locating obscure commercial equipment that may
solve a client’s problem, modifying commercial equipment to yield a better
fit and function and designing custom equipment when commercial
solutions do not exist. Rehabilitation engineers use a structured approach
to solving problems based on scientific analysis, design theory and
product development principles.
 The Vocational Evaluator: The vocational evaluator (VE) is a necessary
interdisciplinary team member when a client possesses seating,
positioning or mobility problems that hinder a successful vocational
evaluation. The VE may also become involved when seating, positioning
or mobility issues arise while conducting a job analysis. The role of the VE
in these instances is to define for the team the job performance
expectations, to strategize alternative methods for performing job tasks or
functions and to assist the team in ensuring that these expectations are
met.
 The Employer: The employer should be part of the team when a client
possesses seating, positioning or mobility problems that are evident within
the work environment or present a barrier to potential employability. The
employer’s primary function is to define the essential job duties and
employer expectations so that the team may work to enable the client to
meet these expectations.
 The Client Advocate: When client advocates participate on the team,
their role is to ensure that the client’s needs are adequately represented
and considered. The advocate often acts as a liaison between agencies
involved in the client’s case.
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 The School Teacher:
The teacher knows the student’s abilities,
educational goals and classroom integration requirements. He or she can
define problems or issues that arise in the school setting. The teacher can
assist in the ongoing monitoring and supervision of the team’s
recommendations once the student returns to school.
 The Speech-Language Pathologist:
For clients with speech or
language disabilities, the speech-language pathologist (SLP) may
participate on the team. The SLP defines augmentative or alternative
communication needs and assists the team in integrating any
communication devices with the seating, positioning and mobility
recommendations.
 The Rehabilitation Nurse: The rehabilitation nurse may be a member of
the team for clients who have medical or nursing issues that affect their
seating, positioning and mobility needs. Examples include clients with
decubitus ulcers and bowel or bladder incontinence issues. The nurse
assists in determining strategies to manage these medical/nursing issues
that are compatible with the seating, positioning and mobility interventions
being evaluated. The nurse may also provide valuable client education
regarding resources for improved management of these concerns.
 The Prosthetist/Orthotist: Prosthetists are involved in the assessment
and fabrication of artificial (prosthetic) limbs. Orthotists are involved in the
assessment and fabrication of braces (orthotic devices) to support or
replace lost function. These specialists provide ongoing assist with fitting
and adjustment to these devices in conjunction with therapists providing
client training in their use.
Assembling the appropriate disciplines for the seating, positioning and mobility
team is only a third of the battle. Of equal importance, is the creation of a team
that possesses the knowledge, skill and abilities needed to properly serve your
clients. Not every physical or occupational therapist specializes in seating,
positioning, splinting, prosthetics and wheeled mobility. Nor does every
rehabilitation engineer specialize in seating. Thus, it is extremely important that
you become familiar with the resources available and the capabilities of the
service providers in your area.
The following qualifications should be carefully evaluated and considered when
selecting appropriate providers/resources:
 Experience providing seating, wheelchair, prosthetic, and orthotic
evaluations and recommendations.
 Amount of hands-on experience with the particular disability.
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 Amount of experience with the technologies needed by the client.
 Provider credentials, certifications, and specialty training in the field.
 Classification as an authorized dealer of the recommended technology.
Identifying qualified, experienced, and competent service providers is just one
key component of the referral selection process. Of equal importance, is the
selection of resources that offer comprehensive, individualized, hands-on
evaluations to both determine and justify the most appropriate technologies to
match the individual’s needs. Trial evaluations provide the opportunity to
combine technologies and evaluate both their compatibility and functional impact
prior to purchase. Attainment of the most appropriate assistive technology
related to seating, positioning, and mobility contributes to maximizing a client’s
independence and productivity.
The following evaluation, procurement, and follow-up services should be sought
when evaluating and selecting appropriate providers/resources:
 Client and referral expectations are respected and considered.
 A logical, hands-on, individualized physical and functional evaluation is
performed.
 Education, training, and trial use of assistive technology options is
provided to determine the most appropriate assistive technologies. The
trials may occur as any/all of the following: formal evaluation, temporary
loaner/trial base, a/o a short-term trial/rental basis.
 Comparison, rationale, and justification are provided based upon trial
evaluation results of various technologies.
 Assistance is provided identifying all funding options and procuring
technologies recommended.
 Education and training in appropriate use, care, and maintenance is
provided to the client, family, caregivers, employers, and other.
 Follow-up is provided to determine the outcomes associated with
technology procurement. If less than desired outcomes occur, the
provider must demonstrate efforts to achieve customer satisfaction.
EVALUATION EXPECTATIONS
It is important that the client and the service provider are aware of your
expectations as the referral source. Clear, effective communicate to the client
and the provider should include:
 The goals and expectations for the requested evaluation (i.e., referral
needs and questions to be addressed).
 Whether it is acceptable to seek repair or modification to existing
equipment before recommending new technology.
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 Whether you are referring the client for equipment that is medically
necessary, vocationally needed, or a matter of client preference and the
impact of funding for each type of equipment need.
 That technology changes quickly and new equipment is continually
available while older models may be discontinued; thus, the client may
need to be open to trying a variety of new options.
 The goals and expertise of an independent vendor from the community
may be different from those of a therapist (who has no financial
investment in the equipment recommended for purchase). Consideration
to equipment procurement including: funding, equipment fit, accessibility,
and compatibility with other technology and functional implications may
vary.
 Funding guidelines often exist that may limit the amount of funds available
to cover the cost of technology or may limit coverage to a specified use or
location (i.e., Medicare and Medicaid generally only consider technology
for household mobility and function, school systems that purchase
technology for an individual may only allow technology to be used within
the school setting).
o Medically Necessary:
services and technology that directly
correlate with the client’s medical condition, ability to improve
independence (or decrease level of care required), and functional
mobility within the home environment.
o Not Medically Necessary: services and technology that relate to
school, work, community access, socialization, or client/caregiver
convenience
OUTCOMES
Today, assistive technology practitioners are becoming serious and systematic
about defining, measuring, and improving the quality of assistive technology
devices and services. Purchasers are learning to treat the procurement of health
care services much the way they treat other purchases: with decision base on
evidence of value for money. Organized systems of health care delivery are
seeking to define their claims of high quality with evidence, and they are working
to improve their performance. The thought of health care providers, clients, and
funding sources are changing from quality as a destination to quality
improvement as a journey – and outcomes management is playing a key role in
the process. Most importantly, outcomes management is providing direction
towards the achievement of a health care system that is empirically self-critical,
constantly learning, and continuously improving (Enthoven and Vorhaus, 1997).
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Factors to consider that will directly impact the functional outcomes associated
with any recommended technologies:
 Prognosis of client’s medical condition (e.g., progressive, stable,
improving)
 Willingness and motivation to use technology.
 Characteristics of applied settings (e.g., home, school, work, community,
and transportation).
 Education, training, and technology tolerance of client, family, caregivers,
employers a/o others.
 Local access to resources knowledgeable with care and maintenance.
TECHNOLOGIES AVAILABLE
There is a multitude of seating, positioning, and mobility devices available. Each
technology device offers specific and unique characteristics that may or may not
meet the needs and be consistent with the skills of the client. As a result,
technologies must be systematically evaluated to determine specific features and
custom configurations that most appropriate match the client’s individual needs
and abilities.
Power Wheelchairs: front wheel drive, mid-wheel drive, rear-wheel drive.
Specialty controls: hand, chin, breath, head, body switches.
Special Functions: seat lowering to floor level, seat elevation, standing, tilt,
recline, hybrid tilt-recline.
Power Operated Vehicles (POV): 3-wheeled scooters, 4-wheeled scooters
Manual Wheelchairs: folding frames, rigid frames, assisted propulsion.
Skin and Pressure Evaluation: pressure mapping.
Pressure Relieving Systems: cushions, tilt, recline, hybrid tilt-recline, standing
options (i.e., as part of wc, separate from wc).
Ambulatory Devices: walkers, crutches, canes.
Orthotics: knee-ankle-foot orthotics (KAFOs), ankle-foot orthotics (AFOs),
supramalleolar orthotics (SMOs), orthotics (shoe inserts), myo-orthotics
(electrical stimulation).
Prosthetics: above-knee (A/K), below-knee (B/K), ankle-foot.
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CASE STUDIES
Case Study A:
Landen was a 22 year old male with Duchene’s Muscular Dystrophy. He had
progressive muscle atrophy, reduction in physical function of all four limbs and
torso, and respiratory dysfunction. Prognosis of his disease was progressive.
He was dependent for all self-care, feeding, transfers, positioning in wc, and
pressure reliefs. Landen was also experiencing skin compromise due to
significant muscle atrophy. Attendant care was unreliable; wife also had a spinal
cord injury which prevented her from assisting in his care.
Landen had a power wc equipped with a hand control and power tilt mechanism.
He was no longer able to access the joystick to allow driving or operation of the
tilt mechanism. He relied on leaning and securing his torso against the laptray
for breath support; but, still continued to struggle for air during breathing. The
material composition of his cushion was compressed and worn.
Landen participated in a seating evaluation at WWRC including wife, OT, and
PT. Therapists recommended an ASL head array interface to operate the power
wc and allow independent pressure reliefs. A new cushion was recommended
based upon trials, skin checks, and pressure mapping results. A respiratory
therapist was consulted and recommended a pneumo-belt device to assist
respirations. Therapists recommended an anterior chest harness to promote
upright sitting and increase chest expansion abilities.
Problem:
Progressive disability resulting in progress loss of function
compromising his independence.
Referral Needed: Seating and mobility evaluation by PT and OT who then
identified need for Respiratory Therapist consultation.
Solution: Alternate interfacing and new cushion compatible with existing power
wc technology. Application of pneumo-belt for respiratory assist.
Follow-up Need: Progressive diagnosis.
Solution: Regularly scheduled follow-ups related to progressive changes in
physical function and needs.
Case Study B:
Annie was an 18-year-old female with severe Cerebral Palsy. She has ataxia
(uncontrolled movements) affecting all four limbs and her trunk. She was
dependent for transfers, eats independently after set-up, and requires maximal
assist for dressing. Cognitive abilities were intact and uncompromised.
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Seating, Positioning, and Mobility
Annie was referred to WWRC for vocational evaluation, and subsequently enrolls
in Business Education training program at WWRC.
Annie had a power wheelchair that is in good, functional working condition;
except bilateral commercial legrests and footplates were broken due to the
constant pressures exerted by her uncontrolled LE movements. She had poor
sitting posture, reduced balance, and suffered from postural fatigue during the
day; which compromised her abilities to perform ADL’s and work-related tasks.
She participated in a seating evaluation at WWRC including PT and OT.
Therapists recommended a solid back with lateral trunk supports to provide
increased trunk stability. Rehabilitation Engineering was consulted to re-design
her legrests and footplates.
Later during training, Annie developed back pain. A work site evaluation was
performed and changes recommended in her seating and workstation set-up to
promote better posture; thus, reducing back strain.
Problem: Poor posture leading to decreased performance in ADL’s and
workstation.
Referral Needed: Seating evaluation by OT and PT who then identified need for
Rehabilitation Engineering consultation.
Solution: increased trunk postural supports compatible with existing equipment
and workstation accessibility.
Follow-up Need: Developed pain at the workstation.
Solution: OT workstation evaluation and modification.
Case Study C:
Camden is a 30 year old male with primary diagnosis of C4 tetraplegia secondary
to a MVA in 1996. He is not able to volitionally use his arms, legs or trunk in any
manner. He uses a power wheelchair with a sip-and-puff mouth control to
independently operate his wheelchair and the power tilt pressure relieving
system.
He was enrolled in the Computer Assisted Drafting Training Program at WWRC.
Camden accessed his computer using a sip and puff Head Master. He was
experiencing moderate to severe neck pain after working on the computer for
several hours; requiring bedrest or medication that made him drowsy (interfering
with his training program).
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Seating, Positioning, and Mobility
Problem: Neck pain inhibiting participation in vocational training program.
Referral Needed: Seating and workstation evaluation by OT and PT.
Solution: Additional seating components and changes to existing seating system
configuration. The changes provided increased lateral trunk and arm support to
prevent excessive lateral torso lean and its associated awkward neck posturing
while working at the computer.
Caregivers were provided education on positioning him more optimally in his
technology. Camden was provided education on assessing his own posture and
how to instruct his caregivers to correct his positioning when needed.
The heights of both the computer screen and book support were adjusted at the
workstation to allow him more optimal position and posture throughout the day.
RESOURCES
For an appointment at WWRC: 540.332.7948 or 540.332.7017.
Cook AM and Hussey SM (2000). Assistive Technololgies:
Practice. St Louis: Mosby Year Book, Inc.
Principles and
Cushman L.A., Scherer, M.J. (1996). Measuring the relationship of assistive
technololgy use, functional status over time, and consumer-therapist perceptions
of AT. Assistive Technology, 8.2, 103-109.
Enthoven, A.C., Vorhaus, C.B. (1997). A vision of quality in health care delivery.
Health Affairs, 16 (3), 44-56.
Scherer, M.J. (1994).
Matching people with technology.
Management, 9, 128-130.
Rehabilitation
Scherer, M.J., Lane, J.P. (1997). Assessing consumer profiles of ‘ideal’ assistive
technologies in ten categories: an integration of quanititative and qualitative
methods. Disability and Rehabilitation, 19 (12), 538-535.
WEB RESOURCES
Rehabilitation Engineering and Assistive Technology Society of North America
(RESNA) http://www.resna.org/
WWRC, AT Services www.wwrc.net/ATServices/athome.html
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