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Pre-requisites
Positioning the Trunk: stabilizing the core
• We are assuming a neutral pelvis, or as close to possible during this discussion
Lange, M. 3/11
• The trunk must be positioned in context with the rest of the body • The position of the trunk is intimately related to the position of the pelvis
Michelle L. Lange, OTR, ABDA, ATP/SMS
Lateral Trunk Flexion: Scoliosis
• • • • •
Lateral Trunk Flexion - Scoliosis Forward Trunk Flexion - Kyphosis Trunk Extension - Lordosis Trunk Rotation Dynamic Options
Lange, M. 3/11
• Proximal stability increases distal, isolated control • A stable trunk can facilitate disassociation of the upper extremities • An extended trunk also facilitates disassociation of the upper extremities • Upper trunk extension and scapular retraction promote neck/head control • Forward and lateral movement of the trunk extends functional reach
Positioning Strategies: Trunk
Lange, M. 3/11
Importance of Trunk Position
Lateral Trunk Flexion
Lange, M. 3/11
Lange, M. 3/11
• Scoliosis may be C curve, S curve and/or rotational • Scoliosis may be flexible, partially flexible or fixed • Shoulders and/or pelvis frequently not level
C Curve
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Lateral Trunk Flexion with neck compensation
Lateral Trunk Flexion • Possible Causes: • increased tone on one side
Lateral neck flexion
• Muscle diseases, CVA, CP
Lange, M. 3/11
Lange, M. 3/11
• CP, TBI, CVA
• musculature imbalance, may have pelvic involvement • decreased trunk strength or decreased tone, causing asymmetrical posture • habitual posturing for functional activity or stability
S Curve begins
• CP, TBI
• fixed scoliosis
Lateral Trunk Flexion
Lateral trunk supports
• Interventions:
Lange, M. 3/11
• generic contoured back • lateral trunk supports (may need to be asymmetrically placed, one lower at the apex of lateral convexity) • anterior trunk supports to correct any rotation (see forward trunk flexion interventions)
Lange, M. 3/11
• if flexible:
Stealth – variety of angles Stealth
AEL
3 point control
• Interventions, continued:
For flexible scoliosis Lateral chest pad/support at apex of convex side Lateral chest pad/support high on concave side Lateral hip pad/support on concave side or both sides
• refer to physician to explore medical or surgical procedures, x-rays • TLSO • aggressively contoured or molded back to allow for fixed curvature of spine and/or rib cage • horizontal tilt under seat to right head, if pressure distribution is good
Lange, M. 3/11
• If fixed:
Lange, M. 3/11
• • • •
Lateral Trunk Flexion
Leckey
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TLSO
Seating System
Aspen
Lange, M. 3/11
Lange, M. 3/11
• Aggressively contoured • Molded
Rehab Designs of Colorado Leckey
Lateral Tilt
Otto Bock
Lateral Trunk Flexion • neutral alignment of trunk over pelvis, if flexible • minimize subsequent deformity in pelvic and lower extremity posture • level head over trunk for increased vision, social interaction • pressure distribution
Lange, M. 3/11
• Goals:
Lange, M. 3/11
• Fixed • Dynamic
Motion Concepts
Brian 14 years old, cerebral palsy Uncontrolled seizures Osteoporosis Chronic pneumonia Lives at home with family Significant lateral trunk flexion, fixed • Significant range limitations in hips and knees • Spends all his time on the floor or in bed
• Spine: fixed scoliosis, however he flexes past this into further scoliosis • Pelvis: oblique, right side high, part of right hip removed • Right LE: past girdlestone, external rotation, abduction, decreased hip flexion, shorter thigh than left, painful to movement • Left LE: external rotation, abduction, painful to movement
Lange, M. 3/11
• • • • • • •
Case Study
Lange, M. 3/11
Case Study
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Case Study
• He needed a new seating system ASAP
Forward Trunk Flexion: Kyphosis
• Current MWC did not have adequate seat to back angle adjustment • Quickie IRIS with manual reclining back
Lange, M. 3/11
• Molded Seating to accommodate both the fixed scoliosis and significant range limitations in knees and hips Lange, M. 3/11
• He no longer fit in his prior manual wheelchair since last surgery • He had a recliner with sling seat and back that he used while in a spica cast following hip surgery • This is uncomfortable for him and does not have adequate support
Case Study
Forward Trunk Flexion
Lange, M. 3/11
Lange, M. 3/11
• Kyphosis can be at various levels of the spine • Kyphosis may be flexible, partially flexible or fixed • May be combined with neck hyperextension
Forward Trunk Flexion
Kyphosis with neck compensation
• Possible Causes:
• may occur from increased or floppy tone, abdominal weakness, poor trunk control, weak back extensors • increased tone (i.e. hamstrings) pulling pelvis back into posterior tilt • posterior pelvic tilt • habitual seating in an attempt to increase stability • fixed kyphosis
Lange, M. 3/11
Lange, M. 3/11
• flexion at hips, possibly due to increased tone • flexion at thoracic area • flexion at shoulder girdle with gravitational pull downward
• May be due to osteoporosis
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Forward Trunk Flexion
• Interventions:
• Anterior Trunk Supports
• if flexible:
• chest strap • shoulder straps • shoulder retractors
• anterior trunk support • posterior trunk support Lange, M. 3/11
• if fixed: • open seat to back angle to match pelvic angle • contoured back • tilt seating system to allow upright head
• • • •
Lange, M. 3/11
Forward Trunk Flexion
butterfly vests Abdominal supports tray support with build-up to support trunk TLSO
Therafin
Shoulder Straps
Lange, M. 3/11
• Does not promote upper trunk extension or scapular retraction
• Promotes upper trunk retraction and scapular retraction • Angle of pull • Placement across shoulders
Lange, M. 3/11
Chest Strap
• Mid clavicle • Don’t block head of humerous
Bodypoint chest harness Bodypoint
Vest
Shoulder Retractors
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• Can provide a cue to return to upright
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• Upper straps can promote some upper trunk extension and scapular retraction • Much of the contact is over the sternum • Prevent riding up • Use with adequate pelvic support to prevent slipping down and strangulation
AEL
Bodypoint Stayflex anterior trunk support
Stealth
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Shoulder Retractors
Abdominal Support
Lange, M. 3/11
Lange, M. 3/11
• Does not promote upper trunk extension or scapular retraction
Mulholland Aspen Seating
TLSO
Forward Trunk Flexion
• Orthotic reduces seating requirements • Seating system must be set up to accommodate the orthotic • Seating system may be too big or provide inadequate support if the client doesn’t wear the TLSO
• Posterior Trunk Support
Lange, M. 3/11
Lange, M. 3/11
• correct posterior pelvic tilt • increase trunk extension with biangular back, PSIS pad, etc.
Rehab Designs of Colorado
Biangular Back
Forward Trunk Flexion
• Maintains 90-95 degree pelvis to thigh angle • Allows extension of the upper back past the pelvis without losing position of the pelvis
• Fixed
Lange, M. 3/11
Lange, M. 3/11
• Open seat to back angle to match pelvic angle
Stealth
Rehabilitech
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Forward Trunk Flexion
Forward Trunk Flexion
• Fixed
• Fixed
Forward Trunk Flexion
Case Study • Andersen • Age 12, cerebral palsy • Multiple spinal deformities
increase head control trunk extension pressure distribution maintain good visual field
Lange, M. 3/11
• prevent spinal deformity and subsequent pelvic deformity • neutral alignment of trunk over pelvis • if flexible, anatomical alignment
• • • •
Scoliosis Kyphosis Lordosis Rotation
Lange, M. 3/11
• Goals
• • • •
Lange, M. 3/11
• Tilt system to allow upright head
Lange, M. 3/11
• Contoured back
• Could not hold head up • Uncomfortable!
Case Study
Case Study
Lange, M. 3/11
• Required more open seat to back angle, as well as new mold of back, to allow him to balance head
Lange, M. 3/11
• Was not tolerating his molded seating system due to progressing spinal deformities
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Lordosis
Lordosis
Lordosis
Lordosis
• Possible Causes:
• Interventions: • • • • •
provide lower back support as needed biangular back may need to change seat to back angle do not over correct limited hip flexion may require anterior trunk support
Lange, M. 3/11
• if flexible:
Lange, M. 3/11
• tight hip flexors or over correction of tight hip flexors • increased tone pulling pelvis forward into an anterior tilt • habitual posturing in an attempt to lean forward for functional activities • “fixing” pattern to extend trunk against gravity (e.g. in conjunction with shoulder retraction)
Lange, M. 3/11
Lange, M. 3/11
• Hyperextension of the lumbar area • Often combined with anterior pelvic tilt
• if fixed: • molded seating system
Provides pressure over sternum
Aspen Seating
Lange, M. 3/11
Bodypoint Stayflex anterior trunk support
Abdominal Panel
Lange, M. 3/11
Vest
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Biangular Back
Lordosis • neutral alignment of trunk over pelvis • pressure distribution • reduce subsequent shoulder retraction and fixing to allow function • reduce subsequent anterior pelvic tilt
Lange, M. 3/11
Lange, M. 3/11
• Goals:
Stealth
Current Positioning
Case Study
Evaluation: Positioning
Lange, M. 3/11
• Aspen ASO • Demonstrates strong extension, lordosis, rotation and neck hyperextension • Agitated Lange, M. 3/11
Evaluation: Positioning • Another key point – his head • Joshua tended to hyperextend in response to pressure on the occiput • He also tended to “hook” under his current headrest Lange, M. 3/11
• Joshua’s “key point of control” was his trunk. If we could prevent the Lordotic extension, then the generalized extension and rotation were minimized
Lange, M. 3/11
• Joshua • Age 7 • Diagnosis: cerebral palsy
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Positioning Recommendations
Positioning Recommendations
• Belly binder
Lange, M. 3/11
• No pressure on the occiput • Anterior supports that prevented hooking
Lange, M. 3/11
• Stealth I2I headrest
• This controlled the lordotic extension
Aspen Seating
Current Access
Case Study: Joshua
• With his extension under control and his new headrest, Joshua was able to use shoulder elevation to activate a switch over his right shoulder with good isolation • Custom swing away assembly on the Stealth I2I headrest with an AbleNet Jellybean over the right shoulder and a speaker by the left ear
Lange, M. 3/11
Evaluation: Access
Lange, M. 3/11 Lange, M. 3/11
Trunk Rotation
Lange, M. 3/11
• Joshua was using his right hand to hit a switch placed on his tray. He was unable to do this without assistance. • Joshua utilized his ATNR to move his hand to the switch with assistance • He was unable to visually regard his SGD as a result
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Trunk Rotation
Trunk Rotation
• Single rotation • Dual rotation
• Interventions: • Correct pelvic rotation • if flexible:
• As client attempts to face forward
Anterior Trunk Support
• consider placing pelvis asymmetrically in seating system so that trunk and head face forward • molded back to distribute pressure
Lange, M. 3/11
• if fixed:
Trunk Rotation
• Unique solution for control of rotation on one side • Standard chest straps and vests are often are inadequate to control rotation due to angle of pull
• Goals:
Lange, M. 3/11
• if flexible: • neutral alignment of trunk over pelvis • correct pelvic rotation • May have to allow legs to windsweep
• if fixed: • pressure distribution • forward facing posture
Lange, M. 3/11
• pelvic rotation • see lateral flexion causes
• use anterior supports on forward side Lange, M. 3/11
• Often seen in combination with lateral flexion • Often seen in combination with pelvic rotation • Possible Causes:
• Allow pelvis to rotate if fixed and trunk needs to face forward
AEL
Case Study
• • • •
Trunk rotation Pelvic rotation Pelvic obliquity Limited ROM in right LE
• Increased muscle tone • ATNR
• Trunk rotation • Forward on right side
• Pelvic rotation • Forward on right side
• Pelvic obliquity • High on right side
• L LE extended • R LE int rotation • Spinal lordosis
Lange, M. 3/11
Lynette Age 43 Cerebral palsy Posture
Lange, M. 3/11
• • • •
Case Study
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• Dynamic support may be required to assist with return to upright
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• Dynamic seating options allow movement of the trunk forward, rearward or laterally • Trunk forward movement is dependent on anterior pelvic movement
Dynamic Stability: the trunk without pelvic movement
• Much trunk movement is dependent on pelvic movement • If the pelvis is allowed to move forward into an anterior tilt, the trunk needs to move forward, as well • This forward movement may require additional stability to be functional and to facilitate return to upright
Lange, M. 3/11 Lange, M. 3/11
Dynamic Stability: the trunk with pelvic movement
Dynamic Options
• Trunk rearward movement is dependent on dynamic components
• Increased left lateral support to increase stability and in turn reduce extension • Right leg harness to reduce internal rotation • Abdominal binder to reduce lordosis which was contributing to rotation as a part of a pattern of movement • Right shoulder strap mounted at angle to reduce rotation
Dynamic Stability: the trunk • Allowing movement at the trunk has advantages and disadvantages
Lange, M. 3/11
• If the pelvis is held in a static position, the trunk can still move forward slightly (depending on flexibility), laterally and in rotation • These movements may require some stability to be functional
Lange, M. 3/11
• Evaluation • Lynette’s extension and rotation increased with effort • The extension appeared to be in response to instability. She felt she was “falling” to her left • Her positioning was also related to her driving method
Case Study
Lange, M. 3/11
Case Study
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Trunk dynamic stability: Disadvantages
Anterior Trunk supports
• Anterior Options:
Lange, M. 3/11
• Chest straps, vests, shoulder straps • Other • Dynamic backs
• If the client does not require anterior trunk support for stability and/or function, then do not add it • If the client only requires anterior trunk support for certain activities, only use it at those times
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• Disclaimers:
Trunk dynamic stability: Product Options • Posterior Options:
Lange, M. 3/11
Trunk dynamic stability: Product Options
Lange, M. 3/11
• Some clients will push a dynamic component to end range and maintain that position, rather than allowing the component to assist in a return to upright • Some clients “hang” on the support • Dynamic backs add weight and expense to the system
• Dynamic support may be better tolerated with increased compliance • Increases functional reach • Dynamic support may assist with return to upright
• • • •
Chest straps Shoulder straps Vests Made of dynamic material to allow some movement forward and assist with return to upright
Lange, M. 3/11
• Trunk forward movement allows the pelvis to assume an anterior tilt • Moving the trunk forward can assist with balance of the head, particularly in combination with anterior pelvic tilt which promotes trunk extension
Trunk dynamic stability: Advantages
Lange, M. 3/11
Trunk dynamic stability: Advantages
Therafin
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Other Options
Other Options • Theratogs
• Belly binder
Lange, M. 3/11
Lange, M. 3/11
• Wearable garments to provide increased proprioceptive input and support to the body, including the trunk • Allows movement and may reduce the need for other more restrictive trunk support options
• Provides stability at the lower trunk, allowing movement of the upper trunk
Aspen Seating
Snug Seat x:panda dynamic back
Dynamic Rocker Back
• Dynamic back • Locks out, if needed
Lange, M. 3/11
• www.degage.us
Lange, M. 3/11
• Degage • Installs between the seat frame and back canes • Allows 10 degrees of movement • Can lock it out
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Miller’s Dynamic Back
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Miller Dynamic Biangular Back
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Lange, M. 3/11
Thank You!
Lange, M. 3/11
Questions?
Contact Information: • Michelle L. Lange, OTR, ABDA, ATP/SMS
Lange, M. 3/11
•
[email protected] • www.atilange.com
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