In Billy's exising seating system, he shows a moderate degree of left side flexion in the trunk combined with pelvic obliquity and rotation (up on left and forward on left). Billy is unable to achieve mid line position with his head. There is a high degree of pressure exerted onto the right hand side lateral which causes Billy pain and discomfort. The left hand side lateral does not achieve adequate support as it can not be set so high into the region of the left axilla that Billy develops pressure damage. The pressure damage normally occurs through out the day as the degree of left hand side flexion increases in relation to increased tone, noxious stimuli and fatigue.
A brief assessment of Billy in supine lying and supported sitting demonstrated that there is some correction in posture available - extension of the spine and reducing pelvic obliquity
Overcorrection of the pelvis demonstrated that the degree of left side flexion increased thus leading to poor head position
By accommodating Billy's obliquity using the castellated foam cushion, along with some correction from the Pelvic Cradle, a more neutral pelvic position was achieved. The leg guides accommodated Billy's windsweeping, helping to maintain the position of his pelvis. The complex laterals - the right one placed vertically, and the left one placed horizontally - helped Billy to sustain a more midline posture and better head position. Subjectively Billy was able to express that he felt safe and comfortable. There was also noticeable difference in the degree of extensor thrusting that is normally evident in the lower limbs.
Billy was formally issued with his KIT seat in January 2011.
Billy was reviewed in March 2012 as, since KIT issue he had a rollercoaster ride of ill health, hospital stays and dramatic weight loss and regain. You can see how thin he is in this photograph. However, at this review he had made a good recovery, and the footplates were able to be adjusted to a more midline position. This demonstrates that the ITB pump was having a positive effect on Billy’s muscle tone.
One problem noted (as seen in the photograph) was Billy’s head falling back into extension, and exacerbating his ATNR. An additional linked head rest bracket was manufactured by Leckey and fitted in July 2012.
A further review took place in August 2012, when no further adjustments of the KIT seat were needed. Billy’s carers reported that the modified headrest maintained Billy’s head position really well, and that there have been no incidents of saliva aspiration since it was fitted in July 2012. Apart from a replacement footstrap repair, there have been no other repairs required since January 2011.
Billy’s feet have remained supported in the more midline position.
The picture on the right shows the additional link in the headrest support and Billy’s improved head position.
Billy and his family had agreed to take part in a research project looking at the effect of postural support in seating on quality of movement, effect of unintentional movements, and abnormal reflexes.
Unfortunately due to a number of factors including Billy’s intermittent ill health and staffing pressures at his wheelchair service, the data was not able to be collected, and the research has been shelved for the time being. This is very frustrating for Billy’s therapist, but demonstrates how difficult formal research is with vulnerable clients like Billy. It also shows how important the Case History information becomes as a way of generating evidence.
Despite not being able generate “formal” evidence, Billy’s therapist has made a number of observations:
Billy’s posture and body shape changed several times due to the ITB pump, and repeated bouts of illness
Had Billy been using a moulded system as originally prescribed, he would have needed remoulded at least three times in the 19 months that he has had his KIT seat
As it was, Billy’s KIT was adjusted to meet his changing posture, which although time-consuming, the cost benefit outweighs the negatives
Billy’s mum also commented that the covers were easily laundered and therefore she could keep the KIT clean.
The team collectively feels that Billy has tested KIT to its limits, and that it has survived the challenges!