Power Tilt_ Recline or Both

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					                Power Tilt, Recline or Both
               The evaluation of a client for a tilt or recline system requires
               looking at all aspects of medical and environmental needs.

               By David Kreutz, PT

                    he ability to use tilt, recline or         sideration of the relative importance of

                                                                                                              the user and seating system when com-
                    both can address a variety of user         the following:                                 paring different manufacturers.
                    needs. For people who are physi-               • Medical issues.                              Tilt systems have also been found to
            cally unable to alter their sitting pres-              • Medical complications.                   be effective in reducing sitting pressures,
             sures, changing positions for pressure                • Desired functional outcomes.             but to a slightly lesser extent. Research has
            distribution is one of the most effective              • Environmental considerations.             shown that a minimum of 45 degrees is
            methods for prevention of skin sores.                  Establishing a list for each of the four   required for adequate pressure distribution.
                              Independent position             items will help the team and the client set        While in tilt, a person actually shifts
                              changes are also neces-          and prioritize goals. It is then important     weight from his or her sitting interface
                              sary for people who              to test these goals through simulation of      onto the back. Although this is an ade-
The procedure for             experience postural              the power seating system and evaluate          quate pressure shift for most people,
                              hypotension and dysre-           the effectiveness of the functional activi-    some may experience only a small reduc-
setting a fixed               flexia.                          ties while using a power seating system.       tion in sitting pressure.
                                  Another benefit is that      Once this is completed, the team can               Interface pressure-mapping systems
degree of tilt and            postural alignment can be        begin to compare specific technology           can provide objective measurement of
its impact on the             improved by changing             considerations to determine the most           interface pressures and can be used to
                              the orientation of the           appropriate seating system.                    determine the effectiveness of power tilt
total degrees of              body and seating system                                                         systems in distributing pressure. Concern
                             relative to the pull of            Review of Medical Issues                      about the degree of pressure reduction
travel varies                 gravity. This so-called          II4 Pressure Distribution                      with positional changes may become
considerably from             gravity-assisted position-       One of the major reasons for using a           more important if the user requires a
                             ing can address some of           power seating system is for pressure dis-      fixed degree of tilt (about 10 degrees) for
one manufacturer             the postural support              tribution. For clients who lack sensation      balance. The seating team needs to evalu-
                             needs of the user and at          and/or who are unable to change posi-          ate the impact the total degree of tilt has
to the next.                 the same time allow for           tions, pressure distribution is a key com-     on pressure distribution. However, the
                             improved function.                ponent in preventing skin breakdown.           procedure for setting a fixed degree of tilt
                Most people who use power seating                  Power recline systems were one of          and its impact on the total degrees of
            systems are either dependent or have               the first mechanical methods that allowed      travel varies considerably from one man-
            severely impaired sitting balance. Power           someone to redistribute pressure for pres-     ufacturer to the next. This should be care-
            seating systems used with other postural           sure sore prevention. By reclining, the        fully explained to the client and evaluated
            supports can dramatically improve sitting          person distributes his or her sitting pres-    with simulation.
            balance. Increased comfort can lead to             sure over a larger area and allows blood           In cases in which powered tilt has
            increased sitting tolerance, which may not         to return to the ischemic areas.               been selected for meeting the goals of
            be possible without a power seating system.            Today, power reclining systems are         postural stability or inhibiting spasticity,
                Determining the optimal seating sys-           still one of the most effective means of       but is inadequate for pressure distribu-
            tem/user match, however, depends on                distributing pressure, but one may find        tion, it may be necessary to combine tilt
            much more than just these medical                  considerable differences in the degree of      and recline. Using a combination tilt and
            issues. The best match evolves from con-           recline and the amount of shear between        recline requires sequencing the operation

                                                 T E   A   M   R E H A B      R E P O R T      29
   Table 1. Medical Considerations When Evaluating Tilt and Recline Power Seating
   Consideration             Tilt        Recline Comments

   Spasticity                  +            -            Tilt systems do not elicit spasticity to the extent that a power recline
                                                         system will, because they maintain static joint angle and muscle
                                                         lengths during positional changes.
                               **            +           Water runs downhill. Tilt systems may interfere with this if catheter
   management                                            tubing is not carefully routed to prevent the flow of urine from revers-
                                                         ing. Access for intermittent catheterization may also be a problem in
                                                         a power tilt system and should be assessed.

   Hip flexion                 +            -            Tilt systems with adjustable seat and back angles that can be adjusted
   contracture                                           to less than 90 degrees will accommodate this type of contracture.
   greater than 9V

   Hip extension               +             +           Tilt systems must have an adjustable seat-to-back angle to accommo-
   contracture                                           date such contractures. Recline systems should have adjustable limit
                                                         switches to prevent the seat-to-back angle from being closed beyond
                                                         the available hip range. Otherwise, the reclining back will push the
                                                         person off the seat.

   Visual orientation +                      +           Both systems provide a mechanism to compensate for a fotward head
                                                         posture and improve their visual orientation and comfort.

   Switch access                                         The ability of the user to access a switch for operation of the power
                                                         seating system should be tested throughout the available range. If the
                                                         method interferes with switch access or limits the range of operation,
                                                         it may be necessary to look at different sites for switch placement or a
                                                         different method of position change.

   Need for custom-            +            -            The use of an aggressively contoured back in combination with power
   moldedseating                                         recline systems presents a problem. The offset of the axis of rotation
                                                         of the seating system is not the same as the person’s, Therefore,
                                                         when the person reclines, the backrest shears or moves relative to the
                                                         person. This causes the back to no longer fit appropriately.

   Transfers                                             The ease or difficulty of the transfer depends on the type of transfer
                                                         more than the type of seating system. Numerous transfer methods
                                                         and wheelchair options are available, which should restrict the use of
                                                         either system.

  + recommended         - not recommended            ** with careful consideration

of the system to ensure postural stability.  ty to improve his or her vertical sitting tol-       Conversely, a power reclining system
    The person should be instructed to tilt erance. By tilting or reclining, the person       opens the seat-to-back angle, taking away
to the maximum degree first to provide can get the center of gravity of the upper             the posterior pelvic support. This results in
postural stability. Subsequent activation of torso and head behind a more proximal            a loss of pelvic and spinal support and
the power recliner then improves the stabilized body part, thereby gaining bal-               may contribute to a more kyphotic sitting
amount of pressure distribution without ance and stability. The degree of recline             posture.
loss of posture. Care must be taken to close and tilt necessary to achieve this will vary
the recline angle and then use the tilt sys- from person to person.                           l OrthostaticHypotension
tem to return to a vertical position without     Tilt systems actually do a better job of     This is a condition that results in a signifi-
losing postural stability.                   this by changing the orientation of the entire   cant drop in blood pressure when the per-
                                             seating system while maintaining the con-        son is brought into a vertical sitting posi-
l Gravity-AssistedPositioning                tour and angle of the seat and back. This        tion. This condition is common among
Another medical issue for using a pow- means that the person should have nearly               people with low blood pressure or people
ered seating system is to use gravity to the same posture in a vertical position as he        who have been on extended bed rest. If
assist in positioning and function. A per- or she does when fully tilted. This posture is     not monitored or addressed with therapeu-
son who is dependent in sitting balance less likely to change as the person performs          tic interventions, the person could be
must rely on the seating system and gravi- this activity over time.                                                Continued on page 32

                                            3    0     M A R C H       1 9 9 7
                                                                                                      l Weight limit of the system
                                                  tion to these issues, medical complications or
                                                                                                        lWhat is the weight limit? Is this the weight
                                                  considerations must be taken into account when
                                                                                                         of the user or the combined weight of the
                                                  determining to use a tilt, recline, or a combina-
                                                                                                         seating system and user?
Continued from page 30                            tion tilt-and-recline system (See Table 1).
                                                                                                      H Stability of the system in a full tilted
brought to a vertical sitting position and lose        Once the medical and functional considera-
consciousness. Both power tilt and power tions have been outlined and prioritized, it is
                                                                                                      H Stability of the system in a full reclined
recline systems are effective in allowing the time to compare different manufacturers’                   position
person to change position to compensate for power seating systems. The following is a list
                                                                                                      l Dimensions
this drop in blood pressure. Interventions such of some of the technology considerations and
                                                                                                          What is the minimum and maximum seat

as abdominal binders and compression stock- related thought-provoking questions.
ings should also be considered to reduce the
                                                                                                          What is the overall length and width?

hypotension.                                       l Degrees of Tilt
                                                                                                      l Ability to add additional postural
                                                     l Is this adequate for pressure distribution?       supports
l Sitting Tolerance and Comfort                        Can a fixed degree of tilt be set into the
                                                                                                      l Optional components (head supports,
Sitting tolerance may be compromised in a             system for postural stability? If so, does this    arm supports, leg supports)
person with poor endurance and/or dependent           limit the total degree of tilt or have any
                                                                                                      l Ability to add other power features such
sitting balance. From a functional standpoint,        impact on the tilt mechanism?
                                                                                                         as seat elevator, standing, power elevating
some people may be able to function for 8 to l Degrees of Recline
 10 hours alone once given the ability to change       What is the maximum degree? Can it be
                                                                                                      l Ability to customize
positions for comfort and function, which             limited?
                                                                                                      H Growth capability in seat and back width
translates into increased independence.            l Degrees of each when used in combina-               as well as seat depth
Preference for tilt vs. recline as it pertains to     tion of tilt and recline
                                                                                                            What mechanisms are available for tie-
comfort depends entirely on the person sitting         Does combining tilt and recline limit the
                                                                                                         down in a van?
in the wheelchair.                                    degree of recline?
                                                                                                       l Warranty and cost
                                                      . Can the drive mechanism of the wheel-
Other Medical Considerations                          chair be locked out through limit switches?     David Kreutz, PT, is a seating specialist at
The issues identified above are the key medical       At what degree of tilt and recline? How is      Shepherd Center, 2020 Peachtree Road N.W.,
reasons for justifying this equipment. In addi-       this adjusted?                                  Atlanta, GA 30309; 404/352-2020.

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