Dynamic Seating: Webinar Transcript

by Ginny Paleg, PT

Below is a complete transcript of Ginny Paleg’s webinar for Rifton on Dynamic Seating.
Watch the Dynamic Seating Webinar.

Part 1

Intro/Sign in Slide 1

Ginny Paleg Slide 2 (00:12)
Hi there, and welcome to Rifton’s seminar on dynamic and functional seating. Today we’re going to talk about dynamic seating, we’re going to talk about their new activity chair, and then I’m going to share with you a case story about a kid that’s using it.

Ginny Paleg Slide 3 (00:17)
My name is Ginny Paleg. I’m a pediatric physical therapist from Silver Spring Maryland. I got my masters at Emory University, I just recently finished my doctorate at the University of Maryland, and I published my thesis on the evidence of supported standing programs. I hope you enjoy this presentation that we put together for you today.

Ginny Paleg Slide 4 (00:09)
Don’t get all scared now, but now we’re going to look at some research. I’m going to show you two studies on dynamic seating that make specific clinical suggestions for the kind of kid that it’s good for.

Ginny Paleg Slide 5 (00:04)
The first study comes out of a gait lab in Montana. Here’s what Dr. Hahn’s group did.

Ginny Paleg Slide 6 (00:44)
The study design was very simple. They found twelve kids who used wheelchairs and they gave each of them a wheelchair called a Kids ROCK™, this is a unique chair in that it allows you to extend at the hips and also at the knees, and the two motions are independent of each other. As far as I know this unit is no longer commercially available but it was around for a couple of years, and the nice part about it is that when the kid went into hip extension, the seat actually elevated a little bit which did a really nice job of keeping the pelvis right where it was supposed to be. So they randomized the kids to have either the Kids ROCK™, in the locked configuration or in the dynamic configuration, and then they measured the outcomes at zero, three months after they’d been in the chair, and six months after they’d been in the chair.

Ginny Paleg Slide 7 (00:08)
The measures they chose were standard range of motion, the modified Ashworth scale to measure spasticity, the Gross Motor Function Measure, and the PEDI.

Ginny Paleg Slide 8 (00:38)
Here’s the bummer of that research. Sometimes you design a great study, you get the right kids, you do all the right stuff, and still your results don’t end up being statistically significant. And that’s what happened to Dr. Hahn and his colleagues. He did a great study, but he might not have had enough kids to get enough statistical power, or it might be that the measures he used weren’t sensitive enough to pick up change in his kids. But in the end, none of his findings were statistically significant. But there were some interesting trends. Over time, both groups improved, especially in sitting and crawling, and both groups also improved for the categories of self care, mobility, and social functioning.

Ginny Paleg Slide 9 (01:32)
Some other interesting trends also emerged. There was an improvement in range of motion in the dynamic group over the static group. For the group that wasn’t allowed to move, that were left static, they actually got better in the GMFM for lying and sitting, and the ones that were allowed to move, got better at it in standing and walking. The authors concluded that this meant that the dynamic system was better for getting kids to get better at standing and walking, but I also want to caution you that there was an improvement in the dynamic group that didn’t happen for the static group, and vice versa, the static group got better at sitting and lying when the dynamic group didn’t. So they’re not statistically significant, and I don’t think it would change my practice pattern, but it would make me think that if I had a kid that really needed to get better at sitting and lying, that maybe those are the kids that I should leave static, and not give the dynamic option to. And the last trend they found was that the kids tend to normalize in their tone. Again, I don’t know how to interpret this finding because they used the modified Ashworth which isn’t meant to measure tone in kids with hypotonia, and they did have some kids with hypotonia, and it’s also been shown not to be reliable in the 2 to 3 rating which is where most of these kids fell. So if this study were to be repeated, I think I would hope that they would use a different measure of spasticity or hypertonia. But it was nice to see that letting the kid move really could decrease spasticity and that goes along with what we’ve seen in some other studies.

Ginny Paleg Slide 10 (00:13)
Now here’s what I call some really good research. These great folks in Italy – what is it about Italy – the wine’s really good, the weather’s really good, Tuscany’s beautiful – Rome, Venice – and even their research!

Ginny Paleg Slide 11 (00:26)
Here’s what makes this research project so incredible. First what these guys did was round up 10 kids who were all the same – they all had spasticity, they all had dyskinesia or movement disorder, they were all affected in all four limbs, and they were all GMFCS type 5, non-ambulatory. That’s what I want to see, looking at the kind of kids that I work with. Then they brought the kids in the gait lab to make sure that their outcome measures were absolutely fantastic.

Ginny Paleg Slide 12 (00:43)
I know what you’re thinking, you’re thinking “Ginny, you are getting over excited about this Italian study.” But let me tell you what they found. They looked at the subjects, all ten of them, remember, they’re all the same, and they saw that when the chair was locked versus when the chair was able to move in and out of extension, they actually moved more and had more range of motion at the trunk when they were allowed to move. When the back of the chair was static, there was more torque and pressure against the back and the seat as well. The other thing that was really quite interesting is when they were static they tended to slip out of their chair, their pelvises slipped, and they went into posterior pelvic tilt. Versus, when they were allowed to go in and out of extension, their pelvises stayed right exactly where we wanted it to. Isn’t that cool?

Ginny Paleg Slide 13 (00:46)
Hold onto your hats now, you’re never going to believe what they found! When the kid was in the static seated position, they actually had more upper extremity dystonia or dyskinesia, than when they were allowed to move back and forth, in and out of back extension. Now let’s think about this for a second. Sit still in your chair and wave your arms around wildly and think that you’re a camera looking at a marker on your arms. Now pretend your back moves back and forward, in and out of extension and flexion at your hips, and your arms go wild. It would make sense of course that you would have more dystonia as the back is allowed to move, but no – no, that’s not what they found. They found it was actually less. And I think this is the incredible finding of this study, and the kinds of kids we ought to think about putting in dynamic seating first should be the kids with dystonia and dyskinesia.

Ginny Paleg Slide 14 (00:11)
Alright friends, it’s time to change gears now. Now we’re going to hear from some experts in the field of seating, Judi Rogers, Karen Reeves, and Martha Bloyer. Let’s start with Judi.

Ginny Paleg Slide 15 (00:15)
Now I’d like to introduce you to Judi Rogers. She’s an OT out in Los Angeles, and she’s going to share with you her perspective on why adaptive seating is so important in the classroom. And why good positioning can make all the difference for our kids. Pay close attention, you’re going to love this.

Part 2

Judi Rogers Slide 16 (00:41)
The seating most commonly used for non-ambulatory students in the classroom is a wheelchair. The problem is that wheelchairs are designed for transportation, which often includes long hours of passive sitting. For this reason wheelchairs typically provide relaxed or even semi-reclined sitting postures, especially for children with poor head and trunk control. On the other hand, effective participation in learning and eye-hand activities requires upright dynamically-balanced sitting posture. The reality is that in the absence of dynamic seating many students with disabilities are simply unable to participate in many classroom activities, even at the level of sustained visual focus.

Judi Rogers Slide 17 (01:06)
The adjustability and design of the new Rifton Activity Chairs make them an excellent option for all classroom seating and positioning needs. Their unique features allow them to be efficiently adjusted to support dynamic sitting balance with the ease and versatility of a top-of-the-line office chair, but with the added advantage of independent adjustability in seat and back angles. This feature allows the student to be repositioned from functional posture to relieving pressure to allowing a nap in just seconds. Frequent re-positioning is important for non-ambulatory students because it allows them to remain alert and pain-free throughout the school day. In addition, the wide range of adjustments and optional accessories provide the flexibility to meet the changing needs of a student for several years.
When outgrown the durability of the Activity chair will allow it to be refitted for another student, after thorough inspection by a PT, OT, or DME provider, of course. Please contact Rifton customer service regarding parts replacement anytime wear or damage to the Activity chair is evident.

Judi Rogers Slide 18 (01:00)
Wheelchairs are designed to get the child from point “A” to point “B” safely, including when riding in adapted vans or buses. This means the child must be well-secured in a certified crash-tested seating system. Children with limited head and trunk control often require so many supports for safety that they are literally strapped in from head to toe. As therapists we know function requires balance and balance requires movement. And this type of super-support not only leaves no room for movement, it also denies students the opportunity to develop normal postural balance. For the student with physical disabilities, such as cerebral palsy, an adaptive seating system that actively supports motor development by allowing movement in small ranges can literally make the difference between participating in learning activities and just sitting on the sidelines. For these students active participation means not only educational access, but also hope for the self-sufficiency and opportunities that other children have.

Judi Rogers Slide 19 (01:27)
Asymmetrical postural deformities are an all too common reality for children with cerebral palsy and other neurological disabilities. Asymmetrical deformities, which include scoliosis, pelvic asymmetries and hip dislocation were, until recently, thought to be caused by brain injury. However, the fact that brain injury is static while the deformities consistently progress has led some researchers and physicians to question this long-held hypothesis. Research published in 2008 by researchers at Oxford-Brookes University demonstrates a significant correlation between asymmetrical postures maintained by low-mobility infants with CP and subsequent patterns of asymmetrical deformities. While the authors acknowledge that further research is needed, this study provides solid evidence that sustained asymmetrical positioning plays an important role in the development of deformity in children with cerebral palsy. It may also suggest that ill-fitting chairs have the potential to contribute to postural deformity in the same way ill-fitting shoes can contribute to foot deformities. The fact that children with CP are born with normal alignment and rarely exhibit fixed deformities prior to age 3 presents an unprecedented opportunity for school-based physical and occupational therapists to make a real difference in the quality of life for our physically disabled students as they grow into adulthood.
Judi Rogers Slide 20 (00:31)
This is why I was so excited when Rifton introduced their new Activity Chair. After years of frustration with wheelchairs that were poorly adjusted or just too small, I felt powerless to provide students with the well-fitting dynamic seating they needed to maximize their ability to participate and learn in the classroom. I’m currently working toward developing new research that will provide further evidence regarding the effects of dynamic seating on postural development and classroom participation in non-ambulatory students with cerebral palsy.

Ginny Paleg Slide 21 (00:03)
Thanks, Judi, that was awesome. Now let’s hear from Karen.

Ginny Paleg Slide 22 (00:16)
Now we’re going to hear from Karen Reeves. She’s a therapist who works in Georgia. She works in a public school system as well as a private practice. She’s going to talk to us more about some of the features of the Rifton Activity Chair, and how you can use them to improve kids’ abilities to assist and participate in ADL’s.

Karen Reeves Slide 23 (00:35)
The Hi-lo feature is very valuable for adaptive classroom seating. Being able to raise the seat height of the adaptive chair simply and easily, while the child is in the chair, means that transfers to and from a wheelchair into the chair can be done easily. On the Rifton Activity Chair the armrest removes very easily, making lateral transfers possible. The more simple and straightforward the transfer can be, the safer it is for the child and the less time it takes for staff. In addition, you reduce the risk of injury to the caregiver’s back.

Karen Reeves Slide 24 (00:27)
Another advantage of adaptive seating with Hi-lo adjustability is that the seating surface can be lowered to peer level for lower group activities. Unlike the wheelchair, a student can be much closer to the focus of interest, enabling increased peer socialization while in a good posture. This level of interaction can increase participation and even verbal responses or self-initiated communication.

Karen Reeves Slide 25 (00:32)
The simpler and easier the mechanism, the simpler and easier it is to adjust the Hi-lo up to various height table surfaces. It’s pretty ideal to be able to accommodate table heights from as low as pre-school up to adult-sized surfaces within seconds. With good positioning at the classroom table, computer table or cafeteria table, again, you can facilitate better peer and adult face-to-face interaction as well as the educational or feeding skills you may be working on while at a table.

Karen Reeves Slide 26 (00:50)
Because of the quick, easy adjustment, another benefit of the Hi-lo feature is that both therapists and classroom staff can utilize it to facilitate sit-to-stand transfer practice. Sit-to-stand transfers are as easy as tilting the seat forward and raising the chair. The Hi-lo foot pump lets you elevate or lower the seat height to the desired position, and then you can use the tilt-in-space to angle the seat forward. The foot rest is easily moved back out of the way under the seat. Doing this gives the child the opportunity to practice sit-to-stand transfers as a natural transition numerous times throughout his or her school day.
This practice both strengthens the lower extremities and enables the motor learning that is necessary for this to become a more independent skill.

Ginny Paleg Slide 27 (00:17)
Wow, Karen, that was really cool. Especially the way you used the chair to tip forward, and then help the child to transfer in and out of the chair on their own – I think sit-to-stand transfers are the most important thing I can teach my kids with GMFCS Level 4 and 5. Now let’s hear from Martha.

Ginny Paleg Slide 28 (00:13)
Now you’re in for a real treat. We’re going to listen to Martha Bloyer, a professor at Florida International University. She’s going to talk about the backrest and seat angles, and how positioning options can effect activity, function, and participation.

Martha Bloyer Slide 29 (00:55)
The Activity Chair allows various seat-to-back angle adjustment. The adjustability allows for therapists, teachers and parents to achieve the desired results of positioning. As an example, the backrest can be placed in a position that closes the angles of the hips, by placing the backrest forward. This position can inhibit extensor tone in a child with increased pelvic thrusting. The seat can be placed with an anterior tilt promoting an increased anterior pelvic tilt, stability and upright posture. The angle adjustable foot rest can be positioned posterior, enabling a closed angle at the knees, which further assists with stability and decreased extensor tone. In order to use the dominant upper extremity for functional tasks such as writing, feeding or accessing an assistive device, a spastic upper extremity can be positioned and stabilized using the arm prompts.

Martha Bloyer Slide 30 (00:35)
Once again, the purpose for adjustability of seat-to-back angles is to promote pelvic stability, postural control, the ability to activate muscles and to improve upper extremity function. Some children will require anterior inclination of the seat with the backrest reclined or placed in a position that opens the angle at the hips. This position has been found to help facilitate improved head control by decreasing a rounded and kyphotic posture. In turn, this position will help with increased visual field and attention to activity.

Martha Bloyer Slide 31 (00:55)
In contrast to the previous example of the child with high tone, the backrest positioned in a straight or forward leaning position, in conjunction with placing the feet in a level or even anterior position can promote increased muscle extension activation in a child with low tone. These positions and increased trunk extension can improve the child’s ability to sit up straighter—improving their overall ability to attend to class or other activities. Footrest position will allow weight-bearing and muscle activation through the feet by providing total contact to the plantar surface of the foot. A properly positioned pelvis has been found to improve upper-extremity function by providing pelvic stability for distal control. The armrest can be positioned at various heights, further improving upper-extremity weight-bearing and functionality.

Martha Bloyer Slide 32 (00:41)
The recline capabilities where the seat-to-back changes and either opens or closes—will allow for rest periods from active-sitting postures. The tilt-in-space capabilities, where the seat-to-back angle remains the same, and the center of mass of the child moves forward or backwards—can be used for pressure relief in children that are unable to actively change position. It can also allow for positioning for feeding with children that have peg tubes or even with children with seizure disorders. The Activity Chair allows the caregivers, parents, and therapists to use accessories as needed to achieve the desired functional outcome.

Part 3

Ginny Paleg Slide33 (00:15)
This is Ginny Paleg again. Now I’d like to put together all the incredible stuff that we’ve heard from all the presenters, and try to put it in perspective of the classroom, the house, or a clinical setting, and to do that I’m going to illustrate it with a little guy that I’ve seen in my practice named Hunter.

Ginny Paleg Slide 34 (00:28)
Hunter came to my day care center when he was about a year old. He came with a KidKart®. The first thing we did was set him up in a stander. Then we started working in the gait trainer. He would only step when he had no shoes, no orthotics, and no socks. So, slowly we progressed him to be able to tolerate braces. We liked the Cascade™ system where you get two braces, so we could use a long solid brace for standing and then a shorter brace just to control his midfoot and hindfoot in stepping.

Ginny Paleg Slide 35 (01:18)
Darcy Fehlings has a new tool called the HAT – the Hypertonia Assessment Tool. If you use that tool it becomes clear that Hunter not only had spasticity and hypertonicity, but also had a lot of dyskinesia or movement disorder. For that, he received intrathecal Baclofen™ pump, which has really helped him maintain and control his muscles so that now he’s easier to position and change and get dressed and his mom’s been really happy with intrathecal Baclofen™ or the ITB pump. Another reason we got the pump was for comfort. He was really uncomfortable in a lot of the positions we put him in. He couldn’t tolerate more than 90° hip flexion on the left for a long time. Slowly over time using a stander we were able to stretch that out. He also uses a sleeping positioning system at night. His mobility goals are to move his gait trainer and get back to stepping. He stepped more before he had the ITB. But now we need to turn the pump up high enough so that he gets enough control so that he can be relaxed but that does interfere a bit with the stepping. We also want him to help more with transfers. Right now mom’s doing a lift, but we would like him to be able to take at least 50% of his weight in standing. In school, they’re trying to teach him how to make choices, they’re using a communication device, he did have some power chair trials that didn’t go as well as we’d hoped, but he does love to be in his stander.

Ginny Paleg Slide 36 (00:25)
We had a lot of trouble with his first seating system. He came to me with a system that was rigid, I couldn’t isolate the legs, he had a leg length discrepancy and there was really no way to compensate. Also, one leg he could flex to 90° comfortably, but the other one he couldn’t. And again, there really wasn’t a way in his seating system for me to accommodate that. I really wanted to open the seat angle, tip him anteriorly a little bit, and get him some better head support.

Ginny Paleg Slide 37 (00:29)
Getting Hunter comfortable in seating was just the beginning. I really wanted him to be able to transfer with minimal to moderate support, and I wanted him to be able to explore his environment on his own. Once he got comfortable and learned to trust his body, then he figured out how to step and move his gait trainer. In this picture, he’s having water play time so he doesn’t have any braces on, he’s a little low in the gait trainer, and the face he’s making, is ‘cause he does not want physical therapy right now, he is too busy playing at the water table.

Ginny Paleg Slide 38 (00:32)
They say in real estate that the most important thing is location, location, location. The most important thing in therapy is sometimes timing, timing, timing. Just when Hunter had grown out of his old Rifton positioning chair, and the family was looking for a new one, Rifton comes out with a dynamic chair. It was just perfect for Hunter. Can you see in this video how, when he has his startle reaction, and goes into extension, the chair allows him to, and then it brings him gently forward back to neutral, making sure his pelvis is in just the right place, where it started.

Ginny Paleg Slide 39 (00:46)
In this video, you are watching Hunter’s mom transfer him from his Activity Chair back into his wheelchair. The best thing is to line these things up at a 45° angle, so you’re just doing a pivot transfer. You lower the chair as far as you need to, to the ground, flip up the feet rests, put Hunter’s feet on the floor. Then you would tip the chair as far forward as you can, so that his hips are actually over his feet. You say, “One, two, three, nose-over-toes” or whatever little saying you have, and you help him to stand up. The idea is that over time, then Hunter would learn to push down with his legs and actually help with the transfer. For mom, she’s going to do a one person maximum assist lift. But what’s nice about this set up for her, is that she’s going downhill. I wish she would have had the chairs a little closer together, but she’s really good at it. Let’s watch.

Ginny Paleg Slide 40 (00:08)
This chair is so easy to use, that even a little angel can pump it up, and also push it over carpet. The wheel bearings are just fantastic.

Sophia Forde Video Slide 41 (01:20)
It was easy to assemble because it came – it took Hailey and I probably about 30 minutes or so to put it up, because obviously I had to read certain things. But I like the fact that how it moves up and down, the hi-lo base, I love that. I also love the different harnesses that came with it, especially the butterfly harness, because Hunter’s so floppy, this really works very well with him. I like the ankle straps, the foot straps, it’s just everything about the chair so far I like. Compared to the old Rifton that he had, the Rifton – he had two of those, one he uses at home and one he uses at school, I like the fact that both of them work well, but I like the fact the hi-lo base it goes up and down, it’s easier for me to feed him, I did feed him his lunch in this today, it was very easy to do that, I like the headrest, easy to adjust to different angles depending on what he is doing. It’s just – everything about this chair so far I like. So far I have no complaints. Easy for a four-year-old to move around with Hunter in the chair, to move it up and down, the back pedal is pretty easy to do that also, so everything about it so far I really really like this chair. (You like it too, Hailey? Yes. Bye. Bye.)

Ginny Paleg Slide 42 (00:19)
Wow. I hope you had as much fun listening to this as we had making it. We hope you learned a lot of things about dynamic seating, and different ways to manage children in the classroom. If you have any questions or want some ideas, feel free to send us pictures and videos, we’d love to see what you’re doing and share what we’re doing. Thanks again for spending time with us today.

Slide 43 – Rifton (00:05)

Slide 44 – Sophia Forde Video (03:28)
Hi, my name is Sophia. And my son received the Rifton Activity chair, the 850 back in July of 2010. I must say first of all that I love, love, this chair. There are many features of the chair that is absolutely wonderful to the special needs community. The first thing I do love about the chair is that it was very very easy to assemble. The only thing that was required was a pen, believe it or not, that’s the only thing that was needed. The other thing is, Hunter adjusted very easily to being in the chair and also using the chair. The chair is absolutely wonderful. There are many features that I like about the chair, one is the tilt-in-space, that is absolutely great. Because with Hunter, my son Hunter, he has cerebral palsy, so he cannot sit up, he cannot stand on his own, so this chair depending on what activity he is doing I would need to adjust the angles, which is great. For instance, as I said, adjust the angles, I do do some of Hunter’s personal care needs, if I need to brush his teeth, I can do that easily in the chair. I have cut his hair while using the chair, and that way because of the different tilts, this was absolutely wonderful. The other great feature about the chair is the hi-lo base, that was absolutely great, it accommodates the different activities we are doing, the different heights that we will need to use the chair for Hunter, also my back greatly appreciated how I can bring the chair up to different heights depending on the activity I am doing with Hunter. The other great feature about the chair is the headrest. Very easily to adjust, depending on Hunter’s activity once again I can make the adjustments while Hunter is in the chair. This chair has a wonderful feature which is the back spring, and it makes the chair that Hunter can rock it while he’s sitting in it. I know most activity chairs they are just very stationary, but with this back spring, it actually can move the back so Hunter isn’t just sitting up in one position, if he’s excited when he’s doing an activity, the back actually moves, so it doesn’t feel like he’s always in one position. I would say the whole family loves the chair. My five year old, she can use the hi-lo base with her brother, she actually adjusts it according to whatever she’s doing with him so she loves the chair for that. It’s great for feeding, cause as I said once again we can adjust the chair at the angle with Hunter inside the chair. The chair is just absolutely wonderful for overall use, it can be used in a classroom, the chair can be used at home, any type of venue or anything like that, the chair is absolutely wonderful. Because we’ve been using the chair for about 6 months or so now and I have absolutely no complaints about the chair. I mean, overall, I love the Rifton hi lo base chair it is absolutely wonderful. And I would say that the special needs community has been waiting for a chair like this for a long time. Thank you.

Slide 45 – Rifton

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