PORTABLE SEATING ORTHOSIS FOR AN ADULT AMBULATORY SCOLIOSIS PATIENT

Maryann M. Girardi, B.S., P.T.

J. Helene Mosquers, M.A.

The Assistive Technology Center at Spaulding Rehabilitation Hospital, Boston MA

ABSTRACT

Custom seating and positioning systems have been developed and utilized by persons who use wheelchairs. Proper positioning and use of these commercial and custom systems in a static "wheelchair"environment is not new. The challenge in this case presentation is to develop a portable seating orthosis for an ambulatory consumer who would like to use the system in a variety of chairs in a variety of setting, including the consumer's ultimate goal of returning to work.

BACKGROUND

Mary is a 29 year old woman with a diagnosis of multiple congenital anomalies of the spine, thoracic-costal dysplasis and Klippel-Feil association. Her brother is similarly involved and this was most likely inherited from there father who had known spinal deformities.

X-rays show multiple abnormal thoracic vertebral bodies with butterfly type deformities, right thoracolumbar scoliosis, C2-C3 fusion, bony stenosis at C3, open disc space between C3 and C4 and between C4 and C5, fusion of C5-C6, and probably C7. There is a narrowing of the spinal cord distance at the level of C5. Mary demonstrates decreased strength and range of motion in hip abduction, adduction, internal and external rotation. She has decreased hamstring flexibility with increased hip extension range of motion. Upper extremities present with decreased strength in shoulder rotators bilaterally. Sitting posture is characterized by a pelvic obliquity ( right side lower), left lumbar, right thoracic and left cervical fixed curves.

Figure #1

Mary has a long history of intermittent neck pain radiating down her right arm. Over the past 2 years she has experienced increasing back pain, and has had to stop working full time as a preschool teacher. She has received intervals of physical therapy treatment for her back pain with improvement, but then experiences a recurrence of the pain. She received a plastic TLSO in 1/93 to support her spine and prevent further deformities. When using the TLSO she reports relief from the pain, but there is little carryover when she is out of the brace.

OBJECTIVE

Mary was seen at the Assistive Technology Center (ATEC) at Spaulding Rehabilitation Hospital in April of 1995 for evaluation for a portable seating orthosis to support her spine when she is not using her TLSO. She wanted a device that would work on any chair and would be easy to carry and set up.

Portable Orthosis

Thereby allowing her to be independent in using the device.

METHOD

Prior to her evaluation at ATEC, Mary had received a Contour U Molded back (See Figure #1). The problems with this back were:

1. It was free standing without a frame and it was difficult to get the correct height and orientation. 2. It was held in position by the pressure of her back against it. There were no straps or any way to secure it resulting in misalignment. Also, if she moved, the back fell off the chair. 3. The back didn't offer any support or relief. 4. The back was too heavy for her to carry alone. She needed the assistance of another person to carry it for her.

During her evaluation at ATEC, Mary experimented with several commercially available backs (Jay, Jay Modular, Jay 2, ROHO, Special Health Systems, and SHS Ultimate) without success. Mary stated that her only relief when out of the TLSO was to sit in an over-stuffed chair which is located in her home. She stated that this chair "engulfed and supported" her allowing her to rest. Because of her need to be mobile she found that the commercial backs were too heavy for portable use. Also, the commercial systems did not provide sufficient support, did not reduce fatigue due to the effects of gravity "pulling down"on her spine, and she experienced some degree of pain with each. Since Mary wishes to return to work she requested a lightweight system that she could transport daily.

During the evaluation, through the use of simulation, it was found that Mary needed 10 - 20 degrees of tilt to reduce the effects of gravity when sitting. It was also found that the commercial systems did not give enough support for her where it was needed and a custom molded seat back would be necessary. In addition to the above, the system must also include a molded seat surface to compensate for her fixed pelvic obliquity (See Figure #2) and decrease her need to use trunk musculature to balance the right side of her pelvis.

RESULTS

The physical therapist designed a portable seating system.

Figure #2

The ATEC design requirements: 1. Molded seat and back 2. Rigid frame that could be secured to various chairs 3. Lightweight with the ability to be carried independently 4. 10 degrees of tilt to take the spine out of the line of gravity allowing some of the weight bearing force to be directed posteriorly through the back 5. Allow Mary to be able to function and maintain the use of her upper extremities

Since ATEC doesn't have in house fabrication facilities it was necessary to make arrangements with a local vendor that provides custom fabrication services. The vendor chosen was Design-Able, of Raynham, MA. An initial fitting was done with Design-Able. Measurements were taken and material brainstorming was done. Design-Able developed the final specifications for design and fabrication of the system and ATEC was given a price quote.

Prior approval was obtained from the insurance company for the portable seating orthosis. Mary and the physical therapist scheduled a date to go to the vendor's facility to perform the molding. It was found during the molding, using the Silhouette Simulator that a 5 degree of tilt would be sufficient for relief. Extra support was needed along her right lumbar area. With the Silhouette system we were able to change the amount of support (by manually moving the individual sensors), until we found the optimal amount for Mary.

The following are the specifications of the final seating system: 1. Pin Dot Silhouette cushion for the molded seat back. 2. Kydex for the rigid base. 3. AEL Quick Link hardware for portability. 4. The whole system will be attached to chairs with straps and fastex buckles.

CONCLUSIONS

Mary has not yet received the portable setting orthosis as of this date. It is expected that delivery will take place December 13, 1995. The physical therapist will be involved with delivery of the system and follow up to ensure that the system works as expected.

Expected problems are: 1. The device will not fit every chair. Mary has been made aware of this and is planning on having specific chairs at home and at work (when she returns) to use with the device. She states that she feels it would be better to have the device on some of the time than to only have the option of the over-stuffed chair at home. 2. It is possible that she will fatigue due to over work of her neck muscles being tilted back. There may be the need to add a head rest component.

These problems will be corrected during follow up visits to ATEC.

At the time this paper was written the device was not delivered.

ACKNOWLEDGMENTS

The authors would like to thank Ms. Mary Algers for agreeing to be highlighted in this paper. We would also like to thank Design-Able of Raynham, Massachusetts and Spaulding Rehabilitation Hospital, as well as Dr. Edison Wong, ATEC Medical Director, Margaret Dellea, OTR/L for ATEC and Charles Henry of PKP Rehab for reviewing this paper before submission.

Maryann Girardi, B.S., P.T. J. Helene Mosquera, MA, Rehabilitation Technologist

Assistive Technology Center Spaulding Rehabilitation Hospital 125 Nashua Street Boston, MA 02114 617/589-4675Portable Seating Orthosis for an Adult Ambulatory Scoliosis Patient