24 hour Positioning

(including Seating and Wheeled Mobility)

Practice Guide for Occupational Therapists and
Physiotherapists who Support People with Disability
Document approval
The 24 hour Positioning (including Seating and Wheeled Mobility) Practice
Guide has been endorsed and approved by:

David Coyne
Director, Clinical Innovation and
Governance
Approved: January 2016

Document version control

Distribution: Internal and external

Document name: 24 hour Positioning (including Seating

and Wheeled Mobility) Practice
Guide

TRIM Reference: AH16/7251

Version: Version 1

Document status: Final

File name: 24 hour Positioning (including Seating

and Wheeled Mobility) Practice
Guide, V 1

Authoring unit: Clinical Innovation and Governance

Date: January 2016

Table of contents

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 Copyright 5
Disclaimer ........................................................................................................5
Family and Community Services occupational therapy and physiotherapy core
standards ........................................................................................................6
Common core standards..................................................................................7
1 Introduction to the 24 hour Positioning Practice Guide 8
1.1The purpose of this practice guide. .............................................................9
1.2 Evidence Based Practice in healthcare ......................................................9
1.3 How to use this practice guide .................................................................10
2 Background to 24 hour positioning 10
2.1 Principal participants in 24 hour positioning management ........................11
2.2 Historical perspective: Medical model versus social model of disability ....11
2.3 Applying the ICF framework to 24 hour positioning ..................................12
2.4 Models of Practice related to Assistive Technology (AT) ..........................12
3 Understanding 24 hour positioning 14
3.1 What is meant by 24 hour positioning? ....................................................14
3.2 Sitting, Standing & Lying ..........................................................................14
3.3 Postural Development..............................................................................15
3.4 The principles of positioning and seating intervention .............................16
4 Factors that can impact positioning 17
4.1 Muscle length changes ............................................................................17
4.2 Muscle tone changes ...............................................................................18
4.3 Spasticity 18
4.4 Dystonia 18
4.5 Rigidity 19
4.6 Clonus 19
4.7 Atypical pelvic conditions 19
4.7.1.Permanent of Inflexible Pelvic Tilt 19
4.7.2 Pelvic Obliquity 20
4.7.3 Pelvic Rotation 20
4.7.4 Permanent or inflexible pelvic rotation 20
4.8 Atypical spinal conditions 20
4.8.1 Scoliosis 21
4.8.2 Kyphosis 22
4.8.3.Lordosis 22
4.8.9 Other spinal issues 22
4.9 Hip subluxation and hip dislocation 22
5 Providing 24 hour positioning services in today’s world 23
5.1 Service provision and team configuration 23
5.2 Professional roles and Service Delivery Models 24
6 The 24 hour positioning service process 26
6.1 Step 1: Intake 28
6.2 Step 2: Assessment – Prescription 29
6.2.1 Goal Setting 29
6.2.2 Assessment 30
6.2.3. Prescription 33
6.3 Step 3 Technology Selection 33
6.3.1.Supplier Selection 33
6.3.2 Assistive technology trails 34
6.3.3 Home based trail & feedback 34

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 6.4 Step 4 Technology Evaluation 36
6.5 Step 5 Provision & Fitting 36
6.6 Step 6 Post Provision & Review 37
6.7 Step 7 Scheduled maintenance regime & timely repairs 38
6.8 Record keeping 39
7 Assistive Technology (AT) that aids 24 hour positioning 40
7.1 Assistive Technology 40
7.2 Night time positioning equipment 40
7.2.1 Guiding principles of night time positioning management 41
7.2.2 Low level night time support devices 42
7.2.3 Paediatric night time positioning systems: Sleep Systems 42
7.2.4 Specialised beds, mattress and overlays 43
7.2.5 Bed rails and bed posts 44
7.3 Supported Standing 45
7.3.1 Effectiveness of supported standing and assisted walking 45
7.4 Wheeled mobility – manual and powered 47
7.4.1 Manual wheelchairs 47
7.4.2 Powered wheelchairs 47
7.5 Mobility Scooters 49
7.6 Assistive technology & online procurements 52
7.7 Health and safety considerations when prescribing positioning
equipment 52
7.7.1 Pressure Care 52
7.7.2.Effectiveness of repositioning and seating technology on
pressure care management 53
7.8. Complying with relevant standards and legislation when prescribing
equipment 54
7.9 Airway Safety 54
7.9.1 Postural Chest Harnesses 54
7.9.2 Positioning for feeding/eating 54
8 Best practice occupational therapy & physiotherapy in 24 hour positioning 55
9 Conclusion 56
10 Appendices 57

References ……………………………………………………………... 95

Copyright

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The content of this guide has been developed by drawing from a range of
resources and people. The developers of this guide have endeavored to
acknowledge the source of the information provided in this guide. The guide
also has a number of hyperlinks to internet sites. Please be mindful of copyright
laws when accessing and utilising the information through hyperlinks. Some
content on external websites is provided for your information only, and may not
be reproduced without the author’s written consent.

Disclaimer
This resource was developed by the Clinical Innovation and Governance
Directorate of Ageing, Disability and Home Care in the Department of Family
and Community Services, New South Wales, Australia.

This practice guide has been developed to support practitioners1 who are
working with people with disability. It has been designed to promote consistent
and efficient good practice. It forms part of the supporting resource material for
the Core Standards Program developed by Family and Community Services.

This resource has references to Family and Community Services guidelines,

procedures and links, which may not be appropriate for practitioners working in
other settings. Practitioners in other workplaces should be guided by the terms
and conditions of their employment and current workplace.

Access to this document to practitioners working outside of Family and

Community Services has been provided in the interests of sharing resources.
The Information is made available on the understanding that Family and
Community Services and its employees and agents shall have no liability
(including liability by reason of negligence) to the users for any loss, damage,
cost or expense incurred or arising by reason of any person using or relying on
the information and whether caused by reason of any error, negligent act,
omission or misrepresentation in the Information or otherwise.

Reproduction of this document is subject to copyright and permission. Please

refer to the ADHC website disclaimer for more details
http://www.adhc.nsw.gov.au/copyright.

The guide is not considered to be the sole source of information on this topic
and as such practitioners should read this document in the context of one of
many possible resources to assist them in their work.

Practitioners should always refer to relevant professional practice standards.

The information is not intended to replace the application of clinical judgment to
each individual person with disability. Each recommendation should be
considered within the context of each individual person’s circumstances. When
using this information, it is strongly recommended practitioners seek input from
appropriate senior practitioners and experts before any adaption or use.

1
The term practitioner as used here includes dieticians, speech pathologists, occupational therapists,
physiotherapists, psychologists, behaviour support practitioners and nurses.

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The information contained in this practice guide is current as at January 2016
and may be subject to change. Whilst the information contained in this practice
guide has been compiled and presented with all due care, Family and
Community Services gives no assurance or warranty nor makes any
representation as to the accuracy or completeness or legitimacy of its content.

Family and Community Services takes no responsibility for the accuracy,

currency, reliability and correctness of any information included in the
Information provided by third parties nor for the accuracy, currency, reliability
and correctness of references to information sources (including internet content)
outside of Family and Community Services.

Background
Family and Community Services occupational therapy and
physiotherapy core standards
The core standards program outlines the current evidence on topics, and guides
practitioners in their application of this research evidence into practice. The core
standards program materials can be found at:
http://www.adhc.nsw.gov.au/sp/delivering_disability_services/core_standards.

Lead occupational therapists in Family and Community Services, at senior,

consultant, and practice leader levels, selected core standard topics by
consensus. Practitioners within and outside of Family and Community Services
have provided significant content and consultation in developing the core
standards.

This practice guide is part of the 24 hour Positioning (including Seating and
Wheeled Mobility) Core Standard. Other Family and Community Services
occupational therapy and physiotherapy core standards include:
• Mealtime management
• Sleep
• Environmental Modifications
• Play and Leisure
• Enhancing Participation in Individual and Community Life Activities
• Sensory processing.
The discipline specific core standards and the foundation common core
standards (see below) represent some of the more significant core knowledge
for occupational therapists and physiotherapists supporting people with
disabilities of all ages. Although they cannot cover all the knowledge required,
they aim to enhance the capacity of practitioners by providing a convenient and

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up to date summary of information. The core standards are intended to form part
of a practitioner’s learning plan as developed with a professional supervisor (see
Supervision Core Standards).

This practice guide provides a starting point for practitioners in accessing

knowledge about current evidence. Good practice integrates practice wisdom
(the proficiency and judgment gained from experience) with best available
evidence, and knowledge of local and individual circumstances (Straus,
Richardson, Glasziou, & Haynes, 2010). While there is commitment towards
evidence-based practice, the reality is that there is still very little evidence for
use by professionals when working with people with disability. Reasons for this
include the vast resources required to produce high level evidence, the rapidly
changing environment, and the complexity of the research required. Novak et al.
(2013) estimate that 30-40% of healthcare interventions are not guided by
evidence. This does not mean that these interventions cannot be used, but that
practitioners should use their clinical reasoning to determine the applicability to
the person they are supporting and monitor the intervention using person-
centred outcome measures. Of much greater concern is the fact that
approximately 20% of interventions provided are ineffectual, unnecessary, or
harmful (Novak et al., 2013) and these should be ceased. For more information
on this, see the Philosophies, Values and Beliefs Core Standards Program.

The information contained in the discipline specific practice guides may be

useful to others (e.g. carers, educators, other practitioners, and managers). The
core standards aim to support role and resource sharing, transdisciplinary work
and best practice to support person-centred outcomes. Be mindful that the core
standards should always be used in the context of the practitioner’s scope of
practice, their organisational policies and procedures, and their professional
obligations.

The discipline specific core standards are designed to be flexible in meeting

professional development needs for occupational therapists and
physiotherapists. Family and Community Services practice guides can be used
alone as resources or can form part of an induction program for someone who is
new to the area of practice. More comprehensively, the practice guides can be
used to extend professional learning, by formal appraisal of knowledge and
application of knowledge into practice. Within Family and Community Services
successful completion of a practice guide appraisal is formally recognised with a
certificate of achievement. It is highly recommended that the program be
incorporated into your existing supervision, professional development and work
goals, regardless of whether certification takes place.

Common core standards

The discipline specific practice guides are enhanced when used with the four
common core standards developed for cross-discipline use. The common core
standards include practice guides, appraisals, as well as video footage of
practitioners and family members discussing the relevance of the topic area.
Use of the core standards to develop knowledge, skill and recognition is outlined
in the Frequently Asked Questions document.

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The four common core standards are:

1. Professional Supervision
2. The Working Alliance
3. Philosophy, Values and Beliefs
4. Service Delivery Approaches

All these resources can be found at:

http://www.adhc.nsw.gov.au/sp/delivering_disability_services/core_standards.

1 Introduction to the 24 hour

Positioning (including Seating and
Wheeled Mobility) Practice Guide
Optimal 24 hour positioning,

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 ‘and seating can enable greater activity, including wider participation in
work, education and society as a whole, and produce health benefits’ for
both the person with disability and their carers.

(Dolan, 2012, p 1)

1.1 Purpose of this document

The purpose of this practice guide is to provide core standards of service for
optimal 24 hour positioning including seating and wheeled mobility. The topic
was selected as one of the core standards by consensus of the lead
occupational therapists and physiotherapists in FACS (senior, consultant, and
practice leader levels).

This is supported by work undertaken by Goldsmith (2009) and Clayton (2013)

in 24 hour positioning and by Greer and her colleagues (2012) literature critique
into mobile seating procurement (i.e. prescription-provision-training process) and
seating service delivery. These authors called for greater evidence to secure
service standards in positioning, seating and wheelchair provision. In essence:
satisfactory 24 hour positioning and mobile seating designed for function
(wheelchairs, scooters and prams for example) and restful outcomes are linked
to greater mobility and quality of life (Davies, De Souza, & Frank, 2003).

Where appropriate, the contents of this practice guide are informed by an

evidence based practice approach in which available literature is critiqued for
current practice effectiveness.
This 24 Hour Positioning (including Seating and Wheeled Mobility) practice
guide outlines:
• theory and practice around 24 hour positioning
• current evidence in 24 hour positioning
• how best to use this knowledge to improve person-centred outcomes for
people with disabilities.

1.2 Evidence Based Practice in healthcare

Evidence Based Practice describes a clinical practice approach that is a
‘conscientious, explicit and judicious use of current best practice’ (Sackett,
Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71). Australian Occupational
therapists McCluskey & Cusick (2002) describe evidence based practice (EBP)
as a process of searching for, critically appraising and then applying relevant
research findings to guide clinical practice for increasing clinical effectiveness.
Despite the push and commitment towards evidence based practice, the reality
is that there is still very little evidence for use by professionals when working

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with people with disabilities. Even less is available pertaining to Australian 24
hour positioning, seating and wheelchair-seating procurement (Edwards &
McCluskey, 2010). Reasons for this include the vast resources required to
produce high level evidence, the rapidly changing environment, and the
complexity of undertaking research at a high level.

1.3 How to use this practice guide

The 24 Hour Positioning (including Seating and Wheeled Mobility) Practice
Guide may be utilized in conjunction with information contained in other core
standards to enhance practice in this topic area (e.g. the Promoting Respiratory
Health Core Standard and the Mealtime Management Core Standard).
Sections of this practice guide may be of interest and relevance to other
practitioners (e.g. speech pathologists and nurses). The core standards aim to
support the clinical role and resource sharing within a trans-disciplinary
teamwork approach to enhance and support person-centred outcomes in an
evolving sector. A professional other than an occupational therapist or
physiotherapist may choose to complete this core standard and be appraised in
the content area if there is adequate support, supervision, opportunity and
relevance in developing these skills.
It is important to be mindful that the core standards should always be used in
the context of the practitioner’s scope of practice, their organisational policies
and procedures, and their professional obligations. As, at the time of writing
(2015) there is no Australian accreditation standards for 24 hour positioning,
seating and wheelchair-seating service provision for occupational therapists or
physiotherapists (Schmidt, 2015).
The work place should provide a clinical support person for guiding participation
and/or appraisal in this core standard. The support person should have an
extensive background in occupational therapy or physiotherapy and expertise in
24 hour positioning, seating and wheelchair prescription and procurement
(Braveman, 2006).

2 Background to 24 hour positioning

The content of section two covers the topics of:
• overview of the participants in 24 hour positioning
• a historical perspective
• International Classification of Functioning, Disability and Health (ICF) and
its application within the provision and intervention surrounding 24 hour
practice
• models of practice and theoretical frameworks pertinent to the umbrella of
assistive technology practice.

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2.1 Principal participants in 24 hour positioning
management
There are four principal participants (or stakeholders) present within the
provision of positioning and seating intervention.

These participants are the:

1. person or child living with disability and their care support network

2. clinical practitioners who prescribe, provide and monitor an intervention (i.e.

the occupational therapist/s and/or physiotherapist/s)

3. service providers who provide, fit and maintain technology and equipment
that are integral to a 24 hour positioning and seating system (i.e. as in the
suppliers and technicians)

4. funding system that governs the procurement process of services, resources

and technology associated with 24 hour positioning and seating systems
(Olson & DeRuyter, 2002).

As 24 hour positioning management sits under the assistive technology

umbrella, the next section provides a historical overview of the changing
perspective surrounding community attitude to disability, assistive technology
and community participation.

2.2 Historical perspective: Medical model versus social

model of disability
Assistive technology services have developed from the overarching
rehabilitation sector, where many of the assessment and interventions
originated within a context of recovery from injury, illness and associated
impairment (i.e. a medical model). The development of assistive technology
services has increasingly moved towards a person-centred needs-based
approach.

A person-centred needs-based approach describes a process where the service

provision focusses on the personal goals as established by one person with
disability or/ by a person’s family (de Jonge, Scherer, & Rodger, 2007).

While a needs-based approach provides structure to solve complex problems,

its critics say the focus on solving the problem can be overwhelmed by the
clinical process of assessment and intervention process to detriment of a
balanced partnership collaborating with the person (and the family/carers) for
outcome satisfaction (J. V. Scherer, Craddock, & MacKeough, 2011; Wielandt &
Scherer, 2004). Scherer and colleagues were some of the early pioneers of
applying an ICF framework to assistive technology procurement.

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The International Classification of Functioning, Disability and Health (ICF) –
introduced in the early 1990s by the World Health Organization (WHO) -
embraced a social model of disability. This model reorganises how disability is
perceived when compared to the historical medical model.

The medical model described disability as a personal impairment or difference,

whilst an ICF approach describes disability as a result of negative societal
attitude, lack of community acceptance and environmental barriers (Watson &
Woods, 2005).

The ICF approach focusses on the person’s health status, ability, capacity and
variations (biopsychosocial backgrounds) and the enablers that enhance
individual participation in their society (Ustun, 2010).

Applying an ICF approach empowers appropriately prescribed assistive

technologies as personal enablers that enhance functional capacity (see Figure
1), for example supportive seating that endorse functional postures (McDonald,
Surtees, & Wirz, 2004) for greater independence and engagement in activities
and occupations across the life domains.

2.3 Applying the ICF framework to 24 hour positioning

The application of 24 hour positioning requires a holistic approach aimed at
optimising functional posture for enhanced personal health and wellbeing
through greater social inclusion and community participation (refer to Arledge et
al., 2011; Lukersmith, 2012).
Applying an ICF framework to holistic 24 hour positioning requires a whole
person-occupation-environment-technology approach where all factors within
their physical-social-economic-political environments are considered (Kirby et
al., 2015; Routhier, Vincent, Desrosiers, & Nadeau, 2003; Rushton et al., 2014).
This requires a comprehensive understanding of how the person, their
positioning program and seating system fits within their family lifestyle,
residential and social environment (at home physically, culturally and psycho-
socially) and within their community (at work, at school and at play or leisure)
(Hardy, 2005 & Miller, 2008).

2.4 Models of Practice related to Assistive Technology (AT)

Successful matching of the personal needs of 24 hour positioning intervention
and technology is best undertaken using an appropriate model of practice.
There are a number of useful practice frameworks available to occupational
therapy and physiotherapy, however two models of practice are informed by an
ICF approach and target successful assistive technology (AT) outcomes aligned
to a person-occupation-environment-technology philosophy.
These are the Matching Person and Technology (MPT) Model designed by
psychologist Marcia Scherer (M. J. Scherer, 2002a, pp. 31-46) and the Human

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Activity Assistive Technology (HAAT) Model designed by Albert Cook and
Susan Hussey (bio-rehabilitation engineer and occupational therapist
respectively) (Cook & Polgar, 2015, pp. 1-16).
Both models of practice are focussed on a holistic system of fitting assistive
technology according to the individual’s personal capacity within the context of
their personal lifestyle and routine. A discrete difference between each model is
defined on their outcome focus.
Human Activity Assistive Technology
(HAAT) concepts are descriptive: described
by an interrelationship between the person,
the activity, the assistive technology and the
environment. The HAAT model focusses on
the person’s application of assistive
technology on activity within context of current
performance and its resulting adaption and
change with use. This translates well into
clinical practice, such as: enabling ‘someone
(a person with a disability) to do something
(an activity) somewhere (in the environment)’
(de Jonge et al., 2007, p. 35)

Matching Person and Technology

(MPT) attempts to explain the
‘psychosocial aspects of technology use’
and to measure effective AT outcome. The
MPT model focusses on the personal
capacity, motivations, attitudes, (AT user
factors), within their physical and psycho-
social context (milieu) where the assistive
technology is to be accepted and used (de
Jonge et al., 2007, p. 41). Scherer and
colleagues (M. J. Scherer, 2008b; M. J.
Scherer, Sax, Vanbiervliet, Cushman, &
Scherer, 2005) are focussed on matching
personal factors with technology use
aimed at enhancing self-image and
occupational participation.
Appropriate positioning and seating
outcomes enhance occupational
performance (Batavia, 2010; Devitt et al 2004; Donnelly, 2015; Gowran, 2013;
Mortenson & Miller, 2008; Plummer, 2010). Poorly matched person and
technology outcomes are linked to technology abandonment, that results in
greater reliance on care provision (Weiss-Lambrou, 2002; Wielandt & Scherer,
2004).

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Table 1 Resources: Models of Practice

de Jonge, D., Scherer, M.J. & Rodger, S. (2007) Chapter Two: Review of
the Development of Assistive Technology Models (pp. 21-51) . In Assistive
technology in the workplace (pp 21-51). St Louis, Missouri: Mosby Elsevier.
Scherer. M. J. (Eds.) (2002). Chapter Two: Understanding the person
behind the technology (pp. 31-46). In Assistive Technology: Matching
Device and Consumer for successful rehabilitation. Washington: APA.
Cook, A. M. & Polgar, J. M. (Eds.) (2015). Framework for Assistive
Technologies (Chapter 2). In Cook & Hussey Assistive Technologies
Principles and Practice (3rd ed.). St Louis, Missouri: Mosby Elsevier. .

Giesbrecht, E. (2013). Application of the Human Activity Assistive

Technology model for occupational therapy research. Australian
Occupational Therapy Journal, 60, 230-240.

3 Understanding 24 hour positioning

3.1 What is meant by 24 hour positioning?
24 hour positioning and seating management programs describe a
comprehensive intervention that includes day and night postural management,
that is in seating, standing and lying (NHS Purchasing and Supply Agency,
2008). The management of 24 hour positioning and seating may include a
combination of therapy, assistive technology and pressure care management.
This comprehensive intervention approach is aimed at improving the quality of
daily comfort and function of the individual with mobility disability.

The goals of a 24 hour positioning management program are to:

• improve function and communication in sitting, standing and lying

• to maximise comfort

• enhance the ability to participate in their desired role, occupations across

their chosen environments.

(Mortenson & Miller, 2008; NHS Purchasing and Supply Agency; Rigby, Ryan, &
Campbell, 2009; Wynn & Wickham, 2009).

3.2 Sitting, Standing & Lying

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24 hour positioning suggests a holistic view of daily postures including optimal
postural alignment for comfortable resting (lying), standing and sitting.

• Lying occurs in supine (on one’s back), in prone (on one’s tummy) and in
side lying, where lying on one’s side is stabilised with flexed hips and
knees or is augmented with positioning intervention.

• Supported standing intervention aims to improve body system function as

well as improve wellbeing. Static standing and weight bearing is
recommended for maintaining healthy cardio-pulmonary and digestive
systems, for sustaining bone density, to improve posture, to stretch
muscles, activate joint range of motion and reduce muscle wasting and
as a pressure relieving activity (from prolonged sitting). Standing evokes
enhanced communication and socialising capacity and is linked to
enhanced self-confidence, self-esteem, self-image and overall quality of
life (Eng et al., 2001).

• Sitting in the correct chair improves the person’s psychological,

physiological and activity related function. By sitting in a chair which is
designed for meeting postural and functional needs, for pressure
management and for comfort, a person can more easily interact with their
environment, carry out simple personal tasks and improve their overall
well- being (Tierney, 2012).

3.3 Postural Development

Posture is unique to each individual depending on their physiological profile.

Understanding typical development is crucial. Physiotherapists and occupational
therapists need to know what is typical to understand when development is not
as expected.
In typical development, sitting skills develop at about 7 to 9 months, requiring
children to maintain control of head, trunk and extremities against the influence
of gravity (Nichols, Miller, Colby, & Pease, 1996; Wandel, 2000).
In prolonged sitting there is an increased risk of pelvic instability because of the
hip joint position and the ischial tuberosities become the load bearing points
(Reid, Rigby, & Ryan, 1999). Subsequently the body can quickly fatigue in a
seated position, often with the pelvis rolling back into a more relaxed position:
known as posterior pelvic tilt (Neville,2005).
In sitting, the foundation of postural control is the stable position of the pelvis.
The pelvis and the femurs become the base of support. When the pelvis
deviates from its neutral position there is a consequential effect on other body
segments and joints.
There are seven interconnecting components to human posture, these are:

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1. muscle tone and control
2. body shape, size, weight and height
3. effects of gravity
4. environmental factors (e.g. surface elements uneven/sloping); movement
(stationary/moving) and technology (interface with seating product)
5. occupational engagement: activity/task for self-care, work & play/leisure

6. time: length of desired postural control

7. personal bio-functional and psychosocial status (health & emotional

wellbeing).

Each of the above mentioned components are inter-related to a person/child’s

successful postural comfort, stability and functional performance (Alexander et
al., 2006; Leckey, 2011). A successful postural and/or seating outcome is
measured by the degree of comfort, stability and functional capacity.

3.4 The principles of positioning and seating intervention

Positioning, seating and mobility seating intervention should aspire to the
following fundamental principles:

• Stable Base: Provide proximal stability & a stable base of support

• Postural symmetry: promote and sustain skeletal alignment. A neutral
pelvis is the alignment of the pubic bones in coronal plane (frontal). A
neutrally aligned pelvis provides for equilibrium for sitting balance (P.
Harris et al., 2006) and comfort in lying.)
• Postural support & maintenance: prevent/arrest, correct or
accommodate skeletal deformity that can be caused by abnormal pull of
muscles on bones
• Maximise head control: Align vestibular system, maintain an even eye
level to promote physical, cognitive and sensory function (vision,
communication, swallowing)
• Optimal Comfort: promote postural tolerance, for comfort, for rest and to
manage fatigue. The body needs to change position and posture
throughout the day depending on activity (Arledge et al., 2011; Backcare
& Seating, 2013; Dicianno et al., 2009; Reid, 2002; Rosen et al., 2009)
• Functional activity: facilitate purposeful movement (or control abnormal
movement patterning) (Bushby et al., 2009; Carlberg & Haddenrs-Alga,
2005)

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 • Pressure redistribution and dispersal: promote pressure care
management and prevent skin breakdown where possible
• Promote wellness and safety: to facilitate health (i.e. cardiac,
respiratory, digestion) and nervous system function to minimise
pathology.

(Batavia, 2010; Cooper, 1998; Duffield, 2013; Lukersmith, 2012; Neville, 2005;
Pedersen, Lange, & Griebel, 2002; Plummer, 2010; Plummer et al., 2013; Pynt
& Higgs, 2010; Spinal Outreach Team, 2013; Zollars, 2010);

It is useful to note that historically the 90-90-90 sitting positioning, describes an

erect upright sitting posture - believed to be associated with a militaristic notion
of desired sitting - as being optimal sitting posture. Evidence emerges to
challenge this belief as the 90-90-90 sitting position may not promote function
especially when the capacity to maintain such an erect posture is compromised,
by fatigue. Holding this erect position is energy sapping. (Backcare & Seating,
2013; Bergen, Presperin, & Tallman, 1990).

It is acknowledged that optimal positioning is not always achievable. Each

person’s positioning will need to be individualised to ensure they can achieve
their positioning goals. Various considerations such as the requirements of the
person’s support people, the person’s lack of postural endurance and equipment
limitations can all impact on the person’s positioning.

4 Factors that can impact positioning

Neuro-motor disorders and central nervous system impairment may impact on a
person’s posture. Children with neuro-motor/neuromuscular dysfunction (such
as cerebral palsy, muscular dystrophy) may live with compromised postural
control.

People living with spinal cord injury and cerebral dysfunction (e.g. motor
neurone disease, multiple sclerosis) also experience compromised postural
control due to the damage to their central nervous system that affects muscle
tone, strength and control (Spinal Outreach Team, 2013).

4.1 Muscle length changes

Muscle length-related changes affect the ability of muscle to generate tension
and alter human movement. Changes in muscle length can occur following
immobilisation, due to pain, and in people with neurological impairments such as
cerebral palsy, acquired brain injury, neuromuscular diseases etc. They can
also be associated with orthopaedic problems such as fractures and sports
injuries.
Hof (2001) reports that when hypertonia is present, muscles remain excessively
shortened most of the time. Consequently the number of sarcomeres (myofibril

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of striated muscle) is reduced and a contracture develops when the muscle
fibres shorten permanently. A second type of contracture possibly occurs, as
normal muscle lengthening and bone growth is affected by changes in muscle
tone.

4.2 Muscle tone changes

Muscle tone is the resistance (or stiffness) felt in muscles as they are being
passively lengthened (K. Pearson & Gordon, 2001).

Hypotonia
Hypotonia describes decreased resistance to passive movement (Ada &
Canning, 2009). It can be due to problems with the brain, spinal cord, nerves or
muscles (US National Library of Medicine, 2013)
The characteristics most frequently observed in people with low muscle tone are
decreased strength, hypermobile joints, and increased flexibility (K. Martin,
Kaltenmark, Lewallen, Smith, & Yoshida, 2007). Hypotonia is categorised
separately to weakness (Ada & Canning, 2009).

Hypertonia
Hypertonia describes an abnormally increased resistance to externally imposed
movement about a joint. It can be caused by contracture (Vattanaslip, Ada, &
Crosbie, 2000), spasticity, dystonia, rigidity or in combination (Sanger et al.,
2003).

4.3 Spasticity
Spasticity is a velocity-dependant increase in tonic stretch reflexes (muscle
tone) with exaggerated tendon jerks resulting from hyper-excitability of the
stretch reflex (Adams & Hicks, 2005; Lance & Burke, 1974). Therefore in
spasticity one or both of the following is present
• Resistance to passive movement increases with the speed of stretch and
varies with the direction of joint movement,
• Resistance to passive movement rises rapidly above a threshold speed
or joint angle (Sanger et al., 2003).

4.4 Dystonia
Dystonia describes a disorder characterised by involuntary sustained or
intermittent muscle contractions causing twisting and repetitive movements,
abnormal postures or both (Steinbok, 2006).
Dystonia is classified by cause (primary or secondary dystonia), by age at onset
(early onset or late onset), and by distribution (e.g. focal, segmental, multifocal,
generalised and unilateral or hemidystonia).

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Table 2 Resources on dystonia

The Dystonia Society – Dystonia (2011) : A Guide to Good Practice.

Retrieved electronically from:
http://www.dystonia.org.uk/pdf/Professional%20Research/Good%20Practice%2
0Guide%20(amended%20Nov%202011).pdf

4.5 Rigidity
Rigidity is defined as hypertonia where there is:
• resistance to passive movement at very low speeds of movement, and it
does not depend on the speed of passive movement and does not have a
speed or angle threshold
• resistance to movement in both directions
• the limb does not tend to return to a particular position
• active movement in other muscle groups doesn’t cause involuntary
movement at the rigid joint, however rigidity can increase.
(Sanger et al., 2003).

4.6 Clonus
Clonus is the involuntary and rhythmic muscle contractions, usually seen in the
lower limbs. It is frequently present in the calf muscles.

4.7 Atypical pelvic conditions

Atypical pelvic conditions occur when a person’s musculoskeletal system is
adversely affected by trauma or neurological disorders. Atypical pelvic
conditions such as permanent pelvic tilt, pelvic rotation and pelvic obliquity affect
a person’s posture.

4.7.1 Permanent or Inflexible Pelvic Tilt

Permanent Pelvic Tilt describes an inflexible or fixed pelvic position, in anterior,
posterior tilt or tilted in asymmetry.
Inflexible Posterior Pelvic Tilt (as opposed to flexible posterior pelvic tilt)
describes a pelvis permanently locked/fixed in a tipped back position (i.e. when
the posterior superior iliac spine (PSIS) are higher than the anterior superior iliac
spine (ASIS). This is often associated postural complications, such as:
• increased kyphosis
• increased trunk flexion
• increased extension of lower limbs
• instability of trunk Increased pressure risk due to sacral sitting
• cervical neck extension
• hyper extension of the head

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 • collapsing of skeletal system impacting on respiratory function.
(Neville, 2005; Zollars, 2010).
Inflexible Anterior Pelvic tilt (as opposed to flexible anterior pelvic tilt)
describes a pelvis permanently tipped forward (i.e. where the ASIS are lower
than the PSIS). Permanent anterior pelvic tilt is used by some people to stabilize
into a functional sitting posture. This is often aligned with associated postural
complications, such as:
• increased lordosis
• increased extension of trunk (back arc) and pain
• increased flexion of extremities (where spasticity is present spinal
extension causes flexion of upper limbs (i.e. elbow, shoulders, wrists)
(Neville, 2005).

4.7.2 Pelvic obliquity

Pelvic obliquity (in sitting and standing) describes when one side of the
pelvis is higher (i.e. the right ASIS and left ASIS are not on a horizontal
plane).
• Pelvic obliquity is often associated with spinal scoliosis and/or hip range
of motion limitation (Zollars, 2010).
• Pelvic obliquity decreases sitting tolerance, and causes pain from pelvic
impingement onto the thorax. There may be resultant cardiopulmonary
complications (AI Tsirikos & Spielmann, 2007).

4.7.3 Pelvic rotation

Pelvic rotation is where one side of the pelvis is forward (i.e. right side of pelvis
is anterior to left side of pelvis) (Zollars, 2010).

4.7.4. Permanent or inflexible pelvic rotation,

Permanent or inflexible pelvic rotation commonly caused by hip range of motion
limitations. This is associated with poor stability and postural complications such
as:
• asymmetrical range of motion and muscle tone in trunk, hips and lower
extremities
• spinal rotation causing compensatory scoliotic spine
• appearance of leg length discrepancy due to ‘windswept’ posture (Neville,
2005).

4.8 Atypical spinal conditions

There are three common types of spinal conditions that impact on postural
control. These are scoliosis, kyphosis and lordosis.

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4.8.1 Scoliosis
Scoliosis describes an abnormal curvature of the spine of greater than 10
degrees (Driscoll & Skinner, 2008).
Scoliosis develops where the spine bends laterally (side to side) and rotates
along its vertical axis, causing sagittal alignment abnormality, such as seen in
kyphosis, lordosis and/or a rotational component.
Driscoll and Skinner (2008) report that neuromuscular scoliosis may lead to:
• functional deficits (e.g. decreased sitting balance and reduced
availability of the arms for functional tasks when used for balance)
• reduced neck, shoulder and spinal range of movement
• skin breakdown
• pain
• reduction in lung volumes and diaphragmatic heights as the scoliosis
becomes more severe
• pulmonary hypertension and right ventricular hypertrophy when it is
beyond 100 degrees.
Scoliosis is measured using the Cobb Method, a radiological method that
is outlined by Driscoll and Skinner (2008). It is classified as:
• mild if Cobb angle is 10 – 40 degrees,
• moderate if Cobb angle is 40 – 65 degrees,
• severe if Cobb angle is greater than 65 degrees.
Surgical intervention is considered where there is a progressive deformity that
compromises the ability to sit or stand, cardiac or pulmonary function, skin
integrity or personal care, or where there is pain. Whilst surgical intervention
may provide increased spinal stability and internal organ function, there can
also be a functional deficit for the individual, for example some individuals
have lost the capacity to independently transfer following spinal surgery due
to the increased trunk length in relation to upper limb length.

4.8.2 Kyphosis
Kyphosis describes an anterior-curvature of the thoracic or lower cervical region
of the spine associated with habitual seating in forward trunk flexion in attempt
to stabilize posture (Zollars, 2010). This is associated with complications such
as:
• postural discomfort and pain
• breathing difficulty associated spinal compression of lungs and airways
• physical function and sensation disturbance in extremities.

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4.8.3 Lordosis
Lordosis describes an excessive inward curvature of the lumbar region of the
spine, causing a swayback posture. This is associated with:
• tight hip flexors
• increased muscle tone pulling pelvis into anterior pelvic tilt
• fixed or permanent anterior pelvic tilt due habitual seating against gravity
(Zollars, 2010)
• rib cage compression causing difficulty with heart and lung function.
Atypical postural deformities can be affected by structural deformity often
caused by an imbalance of muscle tone or through trauma.

4.8.4 Other spinal issues

Cervical spondylotic myelopathy, myeloradiculopathy and atlanto axial instability
can occur in a person with cerebral palsy. Any person demonstrating a
functional deterioration or insidious change in their neurological status should be
immediately referred for a detailed screening to rule out developing upper
cervical instability (Onari, Kondo, Mihara, & Iwamura, 2002; A Tsirikos, Change,
Shah, & Miller, 2003).
Other bony and joint issues that may need to be addressed include hip
subluxation and hip dislocation.

4.9 Hip subluxation and hip dislocation

According to Scrutton & Baird (1997) a stable acetabulum socket is developed if
the femur head is well centred by 4-5 years of age. Hip instability in childhood is
more prone to gradual hip subluxation and to gradual hip dislocation.
Hip subluxation defines the state of the hip joint where the hip displacement is
between 10% to 99%. Subluxation is used interchangeably with displacement
(Wynter et al, 2014). .
Hip dislocation occurs when the ball–shaped head of the femur is completely
displaced laterally and comes out of the cup–shaped acetabulum (Wynter et al,
2014).
The Australian Hip Surveillance Guidelines for Children with Cerebral Palsy
(Wynter et al,.2014) outline the process of monitoring and identifying the critical
early indicators of hip displacement in children with cerebral palsy and like
conditions. The risk of hip displacement is directly related to the Gross Motor
Function Classification System (GMFCS) level. The guidelines outline when to
commence hip surveillance and the frequency of ongoing hip surveillance.

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5 Providing 24 hour positioning
services in today’s world
This section covers the following topics:
• Service provision & team configuration
• Professional roles & service delivery models

5.1 Service provision and team configuration

The provision of appropriate 24 hour positioning systems (including night-time
and a mobile seating systems) for a person with complex mobility and postural
needs requires expertise, access to competent prescribers and technology
services, and sustainable funding (Arledge et al., 2011; Cohen et al., 2013).

A range of positioning and seating related services are required including

clinical, technical, support/advocacy and funding provision.

Best practice advocates for person-centred collaborative partnerships where

multiple health and social disciplines collaborate with the person and their
support team (carer providers and family where appropriate) to make informed
decisions to address personal goals (de Jonge et al., 2007; Farley et al., 2003;
M. J. Scherer, 2002a).

A positioning and seating clinical team may consist of all, or some of these
disciplines: occupational therapy, physiotherapy, orthotics and prosthetics,
rehabilitation engineering, speech therapy, allied health assistants, dieticians,
and medical/rehabilitation specialists etc. (Batavia, 2010; Olson & DeRuyter,
2002; Spinal Outreach Team, 2013).

The provision and aim of clinical or therapy services focusses on addressing

both personalised goals within the holistic context of their lifestyle for maximising
participation opportunity (Australian Institute of Health and Welfare, 2006).

As previously noted a comprehensive positioning and seating intervention

encapsulates the input from the care providers, family care givers and attendant
care agencies.

A recent study by Schmidt (2015a) identified the important role care support
plays in providing physical and psychological support. Many of the family carers
act as the primary advocates on behalf of their family member. As such, care
providers are an important member of the service team during intervention
selection. Their ongoing carer role is pivotal in sustaining intervention once the
service providers have ceased.

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5.2 Professional roles and Service Delivery Models
The occupational therapist and physiotherapist’s role in 24 hour positioning can
be diverse and complex in nature. A therapist may need to prescribe postural
supports in various seating situations (e.g. high chairs, strollers, school chairs)
or may be involved in advising on a stander for school use.
As a result, teams could be made up of a variety of health practitioners including
occupational therapists, physiotherapists, speech pathologists, psychologists,
nurses, social workers, educators, dieticians, orthotists and technicians.
In Australia health and disability services teams are loosely provided as multi-
disciplinary, inter-disciplinary, trans-disciplinary or by a sole therapist service
(Schmidt, 2015a).
Table 3 below informed by Balin, 2015 assists to define these teams.

Multidisciplinary Interdisciplinary Transdisciplinary Key Worker Model

The team is made The team is made The team is made The key worker
up of the person up of the person up of experienced with support from
with disability &/or with disability &/or clinicians/ other team
carers and carers and a professionals, the members, works in
clinicians, who number of person with partnership with
provide services clinicians, who are disability, the family parents and other
independently of willing to share and /or carers. care givers
eachother. support amongst Team members are
the disciplines. equal. One team
member is chosen
by the team to be
the primary service
provider.

Where literature confer is for advocating for a multi-disciplinary team approach,

especially when 24 positioning and seating is complex (Arledge et al., 2011;
Batavia, 2010; Dolan, 2013; Reid et al., 2002).
Within the wheelchair-seating sector, a multi-disciplinary team consists of
distinct clinical and technical (workshop) teams backed with administration units.
Each team has a discrete role in providing a component of assessment-
prescription, intervention implementation review and monitoring and technology
manufacturing.
Smaller teams may organize themselves into an inter-disciplinary approach to
provide a focused comprehensive service. Both the multidisciplinary and
interdisciplinary teams have layered professional, clinical and technical
experience (i.e. from novice to expert) (Schmidt, 2015a).
If using the transdisciplinary approach to equipment prescription it is necessary
to consider the team member’s professional obligations. Some aspects of

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intervention can not be role released or delegated due to the specialist nature of
the intervention.
As, at the time of writing (2015) there is no Australian accreditation standards for
24 hour positioning, seating and wheelchair-seating service provision for
occupational therapists or physiotherapists (Schmidt, 2015).
This practice guide should always be used in the context of the practitioner’s
scope of practice, their organisational policies and procedures, and their
professional obligations.

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 6 The 24 hour positioning service
process
A systematic clinical reasoning process needs to be adopted when prescribing
seating/positioning equipment that will enhance function and comfort. A logical,
sequential approach with functional goals as the focus is recommended.

The table below informed by Schmidt (2013) offers a seven step process when
involved in equipment prescription.

Table 4: Seven step service processes for holistic positioning procurement

Process Descriptor
STEP 1 Intake commences the person-centred intervention based on a
Intake: initiates the service request or referral generated by the person with the
service intervention disability, their care provider or service provider (stakeholders)

STEP 2 I Goal setting: To establish & prioritise person-centred goals

Assessment- based on needs-led intentional prescription
prescription is a
dynamic three part II Assessment:
process that
encapsulates data • Mobility-postural assessment: personal bio-functional
collection, status (health, mobility, postural) performance & health
assessment, records and comprehensive functional assessment
identifying personal including MAT (Mechanical Assessment Tool) evaluation
needs and wants to of the person in need of positioning and seating services
establish goals that
inform prescription • Holistic data collection: seating and positioning interview
of intervention within the person’s family, cultural, economic, societal
sphere)
• Environmental evaluation: within environmental context
(built, natural, community) environments.
• Collaborative knowledge sharing/information transfer:
early education encourages informed, collaborative
decision making

III Prescription:

• Clinical reasoning: to establish a provisional

prescription for prototype trial

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STEP 3 Supplier Selection
Technology- • Selection of suitable supplier service is influenced by access
selection and availability of appropriate service providers within
incorporates three ‘acceptable’ reach of the person’s residence
decision making Technology demonstrations
components: • Decision making: A person-centred informed decision-
making process where most appropriate positioning
1. Supplier equipment is chosen from a suitable range of technology
selection
2. AT Home-based trial & feedback
demonstration • Prototype/Equipment trial: trial of wheelchair-seating or
3. Home trial of positioning prototype in the personal routine environments
prototype (at home, work/school and play/leisure) over an appropriate
trial period (minimum over several days)
• Person-centred decision-making: empowering person and
their associates (family, care providers and/or significant
others) to make informed decisions based on prototype trial
evaluation/feedback

STEP 4 I. Evaluating trial feedback

Technology • Listening to feedback: evaluating the stakeholders’ home-
evaluation critiques based trial feedback
and validates the
home-based trial II. Funding Justification:
based on the • Clinical-occupational justification: justifying technology
personal goals selection within a report format to access adequate funding

STEP 5 III. Provision:

Provision and • Assembly and supply: describes activities and services
fitting required to supply technology (including assembly,
construction and system integration) of wheeled base,
seating system, electronics and accessories or installing
positioning technology in-situ

IV. Fitting:
• Fitting person and technology: a multi-layered process to
customise wheelchair-seating or positioning system to meet
personal mobility and postural goals (i.e. for health
enhancement and safety ideally for self-initiated participation
across all desired life domains)

STEP 6 Service efficiency:

Post-provision • Service effectiveness: A measure to evaluate the
review effectiveness of the service provision in achieving person-
centred goals

Consumer satisfaction:
• Satisfactory outcome: a measure to evaluate the wheelchair

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 outcome from a safety, health, wellbeing satisfaction
perspective (i.e. does the technology provided enhance
occupational performance for desired social participation)

STEP 7 Maintenance:
Scheduled • Optimising performance: regular and scheduled
maintenance maintenance undertaken by knowledgeable service agent
regime & timely aimed at optimising equipment performance over its
repair intended lifespan (with consideration for reuse or destruction
when appropriate).
Timely repairs
• Reducing consumer inconvenience: ready access to
competent repair agency to limit unnecessary ‘down-time’
(access to loan equipment during repair to ease the
burden of care associated with inadequate wheeled-
mobility or poor quality postural positioning)

The following section goes through each step of the process and offers
supplementary information and resources.

6.1 Step 1: Intake

Intake commences the intervention based on request for support from or referral
generated by the person living with the disability, their care provider or service
provider (stakeholders).

There is an emphasis on triaging the referral at intake. Triage involves

prioritising referrals based on risk to a person’s health or condition.

There is referral support for early intervention where risk is anticipated, such as
early infancy for children with multiple disabilities.

The development of pressure ulcers and secondary cardio-pulmonary

complications aligned with musculoskeletal conditions (e.g. scoliosis) are also
triaged based on their real and potential health risk (Spinal Outreach Team,
2013).

A proactive intake process enables team leadership, allocation of resources

according the person’s needs and is aimed at providing timely and appropriate
level of person-centred services (Schmidt, 2015a; Scott, 2010).

Table 5 Resources on intake

Cerebral Palsy Alliance (2015). What is the GMFCS? Retrieve from:

https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/severity-of-
cerebral-palsy/gross-motor-function-classification-system/
NSW Agency for Clinical Innovation (ACI), (2009) Spinal Seating
Professional Development Program. Retrieve from:

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http://www.aci.health.nsw.gov.au/networks/spinal-cord-injury/spinal-seating

6.2 Step 2: Assessment - Prescription

Assessment-prescription is a dynamic three part process that encapsulates data
collection, assessment, and identifying personal needs and wants to establish
goals that inform prescription of intervention.

6.2.1 Goal Setting

The aim of this step is to establish & prioritise person-centred goals based.

Prescribing therapists are advised to understand the person’s decision making

capabilities, including their problem solving abilities, attitudes, motivations and
preferences when selecting and if using postural assistive technology as part of
their intervention (Eggers et al., 2009; M. J. Scherer et al., 2005).

Gowran (2012) found people who relied on daily wheeled mobility considered
their wheelchair as a body part: an essential component to their self-image. The
available literature shows engaged participation in the selection of wheelchair-
seating assistive technology provides greater satisfaction linked to enhanced
active participation (Kittel et al., 2002; Mortenson & Miller, 2008).

Literature shows the following tools are used to set and measure personalised
goals and performance change:

• Goal Attainment Scale (GAS): a method of scoring attainment of

individualised goals within an intervention session or over time (Ashford &
Turner-Stokes, 2009; Kenny & Gowran, 2014; McDougall & Wright, 2009;
Roe, 2013).

• Canadian Occupational Performance Measure (COPM): a protocol

tomeasure a person’s self-perceived change in performance over time
(Mortenson et al., 2007; Reid et al. 2002; Rigby et al., 2009).
Access to COPM (2000) is available from COAT Publications ACE.

• Wheelchair intervention Outcome Measure (WhOM): an individualized

goal-oriented measure of outcome after prescription (Mortenson et al.,
2008; Mortenson et al., 2007).
Access to WhOM is available from the University of British Columbia

There is no definitive evidence on the effectiveness of these tools for 24 hour

positioning; however all have commonality in:

• their focus on individualised approach to setting person-centred goals

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 • goal setting is undertaken in close collaboration with the person (to suit
their specific lifestyle context)

• their outcome of meeting goals are measured - by the individual - based

on their personal perception of change or acquisition of the goal/s
attainment.

The set goals inform the assessment and prescription approach, including the
therapeutic intervention and what assistive technology is selected.

6.2.2 Assessment
The World Health Organization (WHO) recommends a comprehensive
assessment for wheelchair prescription; and the same applies for 24 hour
positioning intervention: ‘every user requires an individual assessment, carried
out by a person or persons with the appropriate skills. The assessment should
be holistic, taking into account the lifestyle, living environment and physical
condition of the user. It is important that the user and, if appropriate, the family
are fully involved in the assessment. Depending on the complexity of the needs,
an assessment can take up to 2 hours’ (WHO, 2008, p. 80).

The assessment should include the following aspects:

• Mobility-postural assessment: personal bio-functional status (health,

mobility, postural) performance & health records and comprehensive
functional assessment including MAT (Mechanical Assessment Tool)
evaluation of the person in need of positioning and seating services.

• Holistic data collection: a seating interview with the person’s family,

considering their cultural, economic, societal supports. This should also
include any other health professionals involved eg. Speech pathologist, GP,
surgeons/specialists).

• Environmental evaluation: within environmental context (built, natural,

community) environments. This should include the person’s school, day
program, group home, workplace etc. It is also necessary to know how the
person travels to these environments (bus, taxi, family car etc).

• Collaborative knowledge sharing/information transfer: early education

encourages informed, collaborative decision making.

The following mobility- postural assessment protocols are in current use in 24

hour positioning and seating assessment (Pederson et al., 2002)
• Mechanical Assessment Tool (MAT) Evaluation
• Clinical Guidelines for Standardized wheelchair seating measures of the
body and support surfaces (Waugh & Crane, 2013)

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Each assessment records anthropometric (body) measurements at the
commencement of the intervention, to benchmark or measure ongoing change
(e.g. increase sensitivity to the early signs of asymmetry, and raise awareness
of the processes of its development).

The following section briefly explains these assessments.

MAT evaluation
Mechanical Assessment Tool or MAT evaluation, based on a biomechanical
model measures the person’s seating capacity, range of motion (ROM) and
muscle function (length, tone, strength). The MAT evaluation consists of three
parts.
• MAT Part 1. Upright sitting in current seating system
• MAT Part 2. Supine lying with minimal gravitational impact
• MAT Part 3. Upright (supported) sitting with gravity (NSW State
Spinal Cord Injury Service, 2009 Module 3)
The person’s posture needs to be examined in two planes: supine on a firm
surface and in sitting over the edge of a firm surface.
If the wheelchair is only for intermittent use such as fatigue management the
therapist should use clinical judgment to determine if a full MAT evaluation will
provide further information to inform best outcomes.
Batavia (2010) advise having two people to assist the MAT evaluation with
people with complex postures. Working in pairs allows one therapist to lead the
physical assessment, while another can provide trunk support, observe and
record.
The MAT Evaluation is a subjective assessment of an individual’s body
measurement and can vary depending on the assessor’s skill and professional
discipline.

It is strongly recommended that practitioners attend a MAT evaluation workshop

or complete an assessment with a senior practitioner when first doing seating
assessments.
See Appendix B for more information on MAT Evaluation technique and also the
Resource List below.

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Table 6 Resources for MAT Evaluation and Instructional Tools

Batavia, M. (2010). Clinical examination (Chapter 3). In M. Batavia, The Wheelchair

Evaluation (2nd ed.). Jones and Bartlett Publishers: Boston.
Novak, I., & Watson, E. (2005). Seating & positioning interactive CD-ROM. Allambie
Heights, N.S.W: Cerebral Palsy Institute.
State Spinal Cord Injury Service. (2009). BASIC MAT form. Spinal Seating Professional
Development Program. Retrieved from:
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0018/156060/m03_mat_basi
c.pdf
You Tube video material: Basic MAT evaluation technique
Last, J. (2008). Wheelchair Seating Mat Evaluation : Part 1- you tube:
https://www.youtube.com/watch?v=Is8WAT4i9ZU
Last, J. (2008) Wheelchair Seating Mat Evaluation : Part 2- you tube:
https://www.youtube.com/watch?v=Phy9p9J3SsY
You Tube video material: Advanced MAT evaluation technique /complex postures
Minkel, J. (2011). Mat Evaluation (RESNA) Part 1:
https://www.youtube.com/watch?v=yHjn4y9H-6M
Minkel, J. (2011). Mat Evaluation (RESNA) Part 2:
https://www.youtube.com/watch?v=J04eKjR49fI
Zollars, J.A. (2010) Special Seating: An Illustrated Guide. Revised edition. USA: Prickly
Pear Publications.

The Clinical Application Guide to Standardized Wheelchair

Seating Measures of the body and Seating Support Surfaces
(CAGS)
In an attempt to standardize the assessment process and the use of universal
terminology Waugh, Crane (2013) and colleagues have dedicated many years
to provide a standardized clinical guide for assessment and prescription of
specialised wheelchair and seating systems.

The Clinical Application Guide to Standardized Wheelchair Seating Measures of

the Body and Seating Support Surfaces (CAGS) aims to translate ‘a highly
technical international standard [ISO 16840] into a format and language that is
easier to understand and clinically useful’ (Waugh & Crane, preface page 1). In
its preliminary publication, the current edition of CAGS is directed to
assessment, selection and provision of wheelchair-seating using universal
language, measurement reference points and body axis. CAGS measures three
separate components: the human body, the wheelchair base and the seated
surface. These three measurements ensure the person is matched with the
seating system and this is integrated with the wheelchair base. It is currently in
its infancy, however the Clinical Application Guide to Standardized Wheelchair
Seating Measures has a promising future for standardising the manner wheeled
seating is procured; and as such has relevance to 24 hour positioning
assessment methodology.

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6.2.3 Prescription
This part of the process aims to establish a provisional prescription for the
equipment trial.

The following should be considered during this step.

• establish a final recommendation for the equipment trial that meets identified
goals and addresses priority needs of the person and their family/carer
• some compromise may be required to address functional needs and physical
needs. Any compromises need to be determined with the person and should
be documented.
To ensure the correct equipment is selected for trial, it is important to consider
the following:
i. WHERE will the equipment be used? (environment)
ii. HOW will the equipment be used? (function)
iii. WHO will use the equipment? (independence)
iv. Is the equipment COMPATIBLE with other devices e.g. feeding pumps,
communication devices, mounting systems?
v. Will the person be TRANSPORTED in their seating system/wheelchair in
a vehicle (consider if more than one vehicle)?
vi. What are the CURRENT vs. FUTURE needs?
vii. Does the equipment meet Australian safety standards?
viii. Is the equipment listed with the Therapeutic Goods Administration
(TGA)? If not, it can not be prescribed (unless officially exempt or
excluded).

6.3 Step 3 Technology Selection

This step incorporates three decision making components:

1. Supplier selection
2. Assistive Technology demonstration
3. Home-based trial of the equipment & feedback

6.3.1 Supplier Selection

Selection of a suitable supplier service is influenced by access and availability of
appropriate service providers within ‘acceptable’ reach of the person’s
residence.

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The vendor sector describes a range of suppliers, manufactures, technicians,
engineers, equipment specialists and salespersons who advise, educate, train,
provide, fit and customise a broad range of universal and rehabilitation
equipment.
There are numerous equipment suppliers throughout the state and across the
nation. These suppliers are often split into two groups, homecare and
rehabilitation.
1. Homecare or equipment dealers: provide a vast range of low level
technologies, devices and standard equipment for daily living activity
and independence.
2. Rehabilitation suppliers or expert wheelchair vendors: provide a range
of specialised seating and mobility technology, technical services and
specialist knowledge. Many rehabilitation suppliers also supply and
service a range of technologies across the 24 hour positioning
spectrum (e.g night time positioning equipment and supported
standing systems).

6.3.2 Assistive Technology trials

Once the equipment has been selected to demonstrate/trial it is the supplier’s
role to be the expert on the technology and in its application.
The therapist needs to be clear about the person-centred goals and to
communicate the personal goals and technology features required.
Successful outcomes are linked to adequate home-based equipment trials prior
to purchase, however not all seating, standing, lying products can be trialled
prior to purchase.

6.3.3 Home-based trial & feedback

Whilst considered best practice to ‘trial’ the equipment with the person in the
natural environment, it is recognized that particularly in rural and remote areas
this is not always feasible. Suppliers may not access that particular area, or be
willing to leave the equipment, or the cost of transporting the equipment may not
be viable.

In an ideal situation, the equipment could be trialled in the routine environments

(at home, work/school and play/leisure, transport) over an appropriate trial
period (ideally minimum over several days).

The therapist would also empower the person and their support network (family,
care providers, teachers and/or significant others) to make informed decisions
based on the equipment trial evaluation/feedback.

During this step it also necessary to ensure that any equipment selected
complies with relevant standards and legislation. See Appendix D. A
documented risk assessment should be conducted with all equipment trials.

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Table 7 Resources for suppliers and seating

Batavia, M. (2010). The Wheelchair Evaluation. A clinician’s guide. Jones and

Bartlett Publishers: Sudbury, Massachusetts.
Lukersmith, S. (2012). Guidelines for the prescription of a seating wheelchair.
Supplement 1: Wheelchair feature-Standing wheelchair. NSW: NSW
Government, Enable NSW and Lifetime Care Support Authority.

Neville, L. (2005). The Fundamental Principles of Seating and Positioning in

Children and Young People with Physical Disabilities. Thesis (BSc(Hons),
Ulster, Northern Ireland. Retrieved from
http://www.leckey.com/pdfs/The_fundamental_principles_of_seating_and_po
sitioning_in_children_and_young_people_with_physical_disabilities.pdf
Zollars, J. A. (2010). Special Seating: An Illustrated Guide. Prickly Pear
Publications: USA.
Online resources:

Independent Living Centres, ILC Australia (2011) Body supports and comfort.
Website electronically retrieved from:
http://ilcaustralia.org.au/search_category_paths/499

Independent Living Centres, ILC Australia (2011) Seating. Website

electronically retrieved from:
http://ilcaustralia.org.au/search_category_paths/1

Independent Living Centre-Australia (2011) Products Seating, Sleeping and

Tables: Retrieve electronically from:
http://ilcaustralia.org.au/search_categories/3
IRRD (Institute for Rehabilitation Research and Development) (2015). Basic
Principles of wheelchair seating. Online education. Retrieved from:
http://www.irrd.ca/education/presentation.asp?refname=e1b1
State Spinal Cord Injury Service. (2009). Spinal Seating Professional
Development Program. Retrieved from:
http://www.aci.health.nsw.gov.au/networks/spinal-cord-injury/spinal-seating

SPOT (2013). Seating systems for people with spinal cord injury. Assessment,
prescription and other considerations. Spinal Cord Injuries Service:
Queensland Government. Retrieved from:
https://www.health.qld.gov.au/qscis/documents/seating.pdf

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6.4 Step 4 – Technology Evaluation
This step critiques and validates the demonstration and/or home-based trial of
the equipment based on the personal goals.

Evaluating trial feedback

The therapist should evaluate the stakeholders’ home-based trial feedback
including what worked well and what didn’t work well. Further trials of equipment
may be required. Negotiation with the suppliers on different features of the
equipment may also be required to ensure a successful outcome. It is important
to document any feedback given by the stakeholders.

Funding Justification:
Once the equipment is selected, the prescribing therapist will need to obtain
quotes from suppliers. A report justifying the selection will need to be written to
obtain funding.

During this step the following should be considered.

• All parties should understand, and are in agreement with, decisions
made prior to ordering the equipment
• if the equipment is listed with the Therapeutic Goods Administration
(TGA) unless exempt/excluded and access the Australian Register of
Therapeutic Goods (ARTG) number (see Appendix D for further
information)
• the accuracy of the equipment quotes
For information on funding options see Appendix E.

6.5 Step 5 – Provision & Fitting

Once funding has been secured for equipment, it may be necessary to re-
measure and review the person to ensure that the prescribed equipment is still
appropriate and the correct size.
The therapist has a responsibility to support the person and their family/carer in
the equipment delivery process and ensure that the equipment meets the
agreed goals and is used appropriately.

The therapist (ideally the same therapist involved in the initial prescription) will
need to be involved in:

Provision
Assembly and supply: describes activities and services required to supply
technology (including assembly, construction and system integration) of
wheeled base, seating system, electronics and accessories or installing

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positioning technology in the person’s environment. This will usually be done
inconjunction with the supplier.

Fitting
Fitting person and technology: a multi-layered process to customise the
wheelchair-seating or positioning system to meet personal mobility and postural
goals (i.e. for health enhancement and safety ideally for self-initiated
participation across all desired life domains).

Upon delivery of equipment, the therapist should ensure that:

• equipment supplied is in accordance with the original prescription, and that all
components requested are provided
• assistance is provided to the supplier with the fitting of the equipment to the
person. This may involve repositioning pelvic belts, head supports, footplates
etc. for correct fit
• clear instructions are provided to the family/carer on the use, handling and
cleaning of the equipment, including risks and precautions. An information
sheet should be provided to the family/carer explaining this information. See
Appendix G for an example of a newly Prescribed Equipment Information
Sheet
• photographs are taken with consent to record and show families/carers the
exact positioning, in addition to the education and demonstration already
provided by the therapist. This is extremely useful for items such as sleep
systems, harnesses, or alternate seating systems. The photographs should be
copied and given to the family so that additional carers, e.g. respite,
grandparents etc can be made aware of the correct positioning
• additional training is provided (if required) to others involved in the use of the
equipment e.g. school staff, respite, day programs, group homes etc. Post-
provisional training of the safe application of assistive technology and
wheelchair manual handling is an identified essential component for a
successful outcome and is linked to developing positive clinical reasoning
(Plummer, 2010).
• supplier details are provided to the family with contact numbers (included on
the Equipment Information Sheet as well funder details/contacts (e.g. Enable
NSW etc.) for repairs and maintenance

• the supplier/manufacturer delivers all equipment in good working order, sets it

up correctly for the person’s use in liaison with the prescribing therapist, and
that the person and family/carer have received adequate training in its correct
use.

6.6 Step 6 – Post Provision & Review

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This process is aimed at measuring the effectiveness of the intervention, service
delivery and assistive wheelchair, seating and or postural support technology
provision (Di Marco, et al., 2003; Mortenson & Miller, 2008; White & Lemmer,
1998).
To complete this process the equipment should be reviewed within 1-6 weeks of
delivery to determine whether functional outcomes have been achieved using
the outcome measure identified in the Goal Setting stage of the prescription.
The review should consider:

Service efficiency
Service effectiveness: A measure to evaluate the effectiveness of the service
provision in achieving person-centred goals.

Consumer satisfaction
Satisfactory outcome: a measure to evaluate the equipment outcome from a
safety, health, wellbeing satisfaction perspective (i.e. does the technology
provided enhance occupational performance for desired social participation).

If the person’s goals have not been achieved, interventions used should be re-
examined and other hypotheses should be considered. This may also promote
the need for re-considering other domains (e.g. medical, environment,
communication and behaviour).

6.7 Step 7 – Scheduled Maintenance regime & timely

repairs
This step should focus on who will be responsible for providing maintenance
and timely repairs to the equipment.

Regular and scheduled maintenance needs to be undertaken by a

knowledgeable service agent aimed at optimising equipment performance over
its intended lifespan.

Access to a competent repair agency to limit unnecessary ‘down-time’ is also

required.

The therapist should inform the person and their carers of their responsibility to
clean and regularly check the equipment for safety issues and hygiene
purposes. Information on how to clean the equipment is usually found in the
supplier/manufacturer’s handbook.

All of this information should be included in a Newly Prescribed Equipment

Information Sheet. See Appendix G for an example.

Table 8 Equipment maintenance resources

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ILCNSW website provides resources regarding the basic maintenance of
wheelchairs.

Enable NSW currently funds the maintenance and repairs to equipment that
they have funded.

Maintaining your wheelchair

6.8 Record keeping

Documentation during all steps is vital. Documentation is the process of
recording information, so it is not lost. The aim of documenting facts, within a
specific time frame, acts as a form of formal communication. Common forms of
documentation are as case notes, report writing and writing funding applications.
When documenting reports about seating and 24 hour positioning equipment, it
is important to consider who the report will be going to and whether there are
specific requirements that need to be included in the report.
Plain language report writing is written with the general public in mind. It helps
make information about the topic more open, transparent and accessible.

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 7 Assistive Technology (AT) that
aids 24 hour positioning

7.1 Assistive Technology

Postural assistive technology are ‘devices designed to support an individual in
a symmetrical position when sitting, standing or lying’ (NHS Purchasing and
Supply Agency, 2008, p. 3).

The objectives of postural devices and technology are:

• to improve function, communication and cognitive skills

• to enhance participation within the environment

• for maximizing comfort

• helping to reduce muscle contractures and joint problems such as

subluxation (partial dislocation) or dislocation’ (p.3).

Assistive technology that aids 24 hour positioning could include: beds, feeding
chairs, wheelchairs, floor sitters, water chairs, sidelyers, sleep systems and
standing frames.

The person’s daily routine needs to be considered. Therapists need to carefully

weigh up the advantages and disadvantages of prescribing positioning
equipment across the 24 hour period.

Some important considerations may include:

• ease of use of the system
• the portability of the system (consider what environments the person will
need to access (respite, school, day program )
• the cost and maintenance
• the perceived benefits for the person.
These factors will ultimately influence both the person and their carers’ usage of
the positioning system.

7.2 Night time positioning equipment

Night time positioning equipment describes a range of products, devices and
technologies: from foam pillows, wedges and rolls, mattresses and adjustable
bedding through to specifically designed sleep systems and electronic beds.

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Sleep positioning systems are commercially available lying support systems that
may have a number of component parts, which are held in place by a base layer
of a sheet (Polak 2009 cited in Blake et al 2015).

Lying in supine and prone are the lowest functional postural positions (Case-
Smith & O'Brien, 2010; S. T. Martin & Kessler, 2006). One third of our time is
spent in bed (Collins, 2007; Innocente, 2014; Wynn & Wickham, 2009).

These authors state many destructive postures are formed through abnormality
of tone and movement and associated habitual lying patterns for long periods
overnight. These habitual lying patterns often became fixed distortions that
cause pain and discomfort into adulthood.

Goldsmith, Goldsmith and Goldsmith (2000) state the hours when a person/child
is lying asleep offers significant therapeutic opportunity.

Aligned with all positioning intervention, introduction of night time technology is

most effective when a family-centred approach is combined with technology
access and adequate funding, parental education, carer training, family sensitive
and time support (Goldsmith et al., 2000).

Goldsmith et al. warn that when any of these aforementioned factors are not
aligned, introduction of a sleep system and the motivation to accept night time
positioning routine may falter. Their study flagged a critical stage (around two
months) where parents experience a crisis of confidence –and if not well
supported – may give up the routine.

Sustaining a night time positioning program requires ongoing support and

monitoring, until the routine becomes easy and habitual.

7.2.1 Guiding principles of night time positioning

management
Prescribing night time positioning equipment can be an expensive, time
consuming process both for the family and the therapist. Incorporating night time
positioning equipment into a person’s routine is a significant commitment for the
carers.

To increase the opportunity for success the following factors need to be

considered

• Location: bed/sleep system site (home or residential care) with the

geographical place (metro/regional or remote Australia) and available
space (access room/power).
• AT access: access to, availability of and funding resource for appropriate
AT range.
• Technology services: access to, availability of competent technical
services at purchase and for after sale servicing and trust in
knowledgeable technicians/suppliers.

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 • User motivations: Personal attitude to change and accept new AT/night
time routines within their lifestyle/family environment.
• Care support: access, availability & motivation/attitude of care support,
manual handling abilities and overall health
• Prescriber expertise: therapist’s AT experience, knowledge, and drivers
(caseload demand & organisational culture).
• Financial: funding access/availability

Some types of nigh time positioning equipment are discussed below:

7.2.2 Low level night time support devices

Low level night time intervention may incorporate regular night time positioning
and the application of foam supports. Foam pillows, wedges or rolls are placed
specifically to support a neutral or symmetrical position (or as close to symmetry
as can be tolerated) designed to disperse pressure broadly and away from bony
protuberances (e.g. hips, pelvis, spine) and for comfort.

Careful night time monitoring and regular repositioning of the sleeping body are
recommended to ensure: the bed surface is level (horizontal) to avoid shear
forces, the supports (and bedding) are checked for potential or actual pressure
or friction points, the bedding is moisture free to minimise risk of pressure ulcer
development (Bluestein & Javaheri, 2008) and the respiratory system is not
being compromised by position.

The prescription of low level night time intervention needs to consider the
person’s health condition, comorbidity factors, their carer support and personal
capacity to reposition themselves.

The exact repositioning or turning regime varies depending on the person’s

health, cognition, sensation and medication. To prevent pressure ulcers forming,
Duncan (2007) recommends two hourly repositioning regime for high risk people
(acutely unwell, comatose or immobile in-patients) while the regime maybe a
little more flexible for healthier people living in the community who are
considered at less risk: ranging 2-3-4 hourly depending on the person’s health
and capacity (Lyder & Ayello, 2008).

For further information about sleep refer to the Supporting Sleep Practice Guide.

7.2.3 Paediatric Night Time Positioning: Sleep Systems

The literature reports on the use of sleeping systems for children with cerebral
palsy. A recent Cochrane review of sleep positioning systems (Blake et al.,
2015) highlighted the lack of well designed randomised control trails into the use
of sleep positioning systems. This review indicated that there is insufficient high
quality evidence for the effectiveness of sleep positioning systems to ease pain
and/ or to improve sleep. There are no randomised controlled trials that examine
the effectiveness of sleep positioning systems to reduce or prevent hip

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migration. The authors of this review concluded that there is limited evidence for
the use of sleep systems to prevent deformity.

In the absence of research evidence it is recommended that people with a

disability, their carers and supports review the available evidence to guide them
when considering using a night time positioning system and use sensitive
outcome measures to evaluate the use of the sleeping system.

It is important to consider the safe sleeping recommendations for children. For

more information refer to the Supporting Sleep Practice Guide

7.2.4 Specialised beds, mattress and overlays

A range of bed frames, mattresses and overlays and electronic bed systems are
available for all ages. The bed technology is available as simple, low technology
(manual) ranging to very sophisticated electronic technology.

Manual adjustable height beds: provide a manual height adjustment to sit bed
low to the floor to maximise child independent transfers and minimise the risk of
falling (although many are enclosed to stop climbing) and raise to carer height;

Powered adjustable ‘hi-lo’ beds: accommodate adjustable floor to bed height:

higher bed height for greater carer access and lower bed height to facilitate
transfers, or extremely low to the floor for personal falls minimisation. Most hi-lo
beds are operated by a remote control.

Electronic adjustable beds: accommodate a range of features including hi-lo

(adjustable bed height) and the person’s positioning and repositioning options:
including back support raiser, knee break and Trendelenburg tilt (head up or
head down/reverse tilt).

Electronic bed turning systems: The bed and mattress provide encapsulated
lateral turning (electronically automated) and a range of comprehensive
repositioning options can be remotely controlled (manually/with voice controlled
software) for upright sitting with Trendelenburg tilt.

There are a range of bed mattresses and mattress overlays available in

Australia. These may include using static pressure distributing material
(fabric/wool filled or air-floatation/gel) and dynamic systems (alternating
pressure redistributing property).

Mattress: as the primary bedding surface should have a firm, level bed base to
be an effective support surface. Unstable bed bases, sagging mattress supports
and old foam mattress should be upgraded prior to adding specialised
mattresses and/or mattress overlays.

Mattress overlay is the additional thinner layer applied over an existing

mattress. A range of foams mattress combinations and overlays are available in
a wide range of products.

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An overview of the most commonly used products are presented in Appendix H
informed by website (Independent Living Centres-Australia, 2011).

Prescription of the most appropriate mattress and/or overlay is determined by

personal need and established goals.

7.2.5 Bed rails and bed posts

When bed rails or bed posts are required, The US Food & Drug Administration
(FDA) advise care providers setting bed height on lowest setting to reduce the
risk of harm should the person exit the bed unaided (2000 revised 4/2010).

In 2015, Occupational Therapy Australia authored a Position Statement on

Provision of Bed Sticks and Poles. This paper assists occupational therapists in
understanding and mitigating risks associated with bed stick use.

Table 9 Resources for night time positioning equipment

Collins, F. (2007). The JCM Moonlite Sleep System: assisting in the provision of
24 hour postural support. International Journal of Therapy and Rehabilitation, 14,
7, 324-328.

Goldsmith, J., Goldsmith, S & Goldsmith, L (2000). Postural care at night within
a community setting: what the families say. Journal of the Association of Paediatric
Chartered Physiotherapists, 97, 14-32.

Independent Living Centre-Australia (2011) Products Seating, Sleeping and

Tables: Retrieve electronically from:
http://ilcaustralia.org.au/search_categories/3

NHS Purchasing and Supply Agency (2008). Buyers’ Guide: Night time postural
management equipment for children. CEP 08030.

Blake SF, Logan S, Humphreys G, Matthews J, Rogers M, Thompson-Coon J,

Wyatt K, Morris C. (2015) Sleep positioning systems for children with cerebral
palsy. Cochrane Database of Systematic Reviews 2015, Issue 11

Novita Children’s Services. Bed Safety Fact Sheet.

See Appendix H: Specialised beds, mattress and overlays

Independent Living Centres, ILC Australia (2011) Bedding. Website

electronically retrieved from:
http://ilcaustralia.org.au/search_categories/types/98

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Independent Living Centres, ILC Australia (2011) Sleeping. Website
electronically retrieved from:
http://ilcaustralia.org.au/search_category_paths/2

Independent Living Centres, ILC Australia (2011) Body supports and

comfort. Website electronically retrieved from:
http://ilcaustralia.org.au/search_category_paths/499

Independent Living Centres Advisory Service: Phone 1300 885 886

7.3 Supported Standing

Supported standing refers to the use of static and dynamic standing frames, tilt
tables and dynamic standing frames. Dynamic standing frames (DSF) provide
maximal support of the lower extremities in standing and minimal trunk support
to encourage balance and active upper body function.

Refer to Independent Living Centre-Australia website for comprehensive product

list on standing frames.

7.3.1 Effectiveness of supported standing and assisted

walking
A literature search retrieved two systematic reviews of static weight bearing
activities (which included the use of standing frames) directed to improving bone
mineral density in children with cerebral palsy (Hough, Boyd & Keating, 2010,
Pin, 2007). A third systematic review explored supported standing programs
across the ages (Glickman et al., 2010).

There is evidence supporting static weight bearing through the lower extremities
for increasing bone mineral density in the lumbar spine and femur in children
with cerebral palsy (Hough, Boyd & Keating, 2010, Pin, 2007). The association
between increased bone density and a reduction in fractures requires further
study (Pin, 2007).

There is some evidence to suggest that lower extremity static weight bearing
may temporarily reduce spasticity in the ankle plantar flexor muscles and some
evidential support for improved range of motion in the lower extremities linked to
the use of supported standing programs (Glickman et al., 2010). The beneficial
outcomes as reported by physiotherapists and adult users of supported standing
regimes included improved weight bearing, pressure relief, range of motion and
psychological well-being, however these are not supported by the available
research to date (Glickman et al., 2010).

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There is no available evidence to support or refute the use of static weight
bearing to reduce or prevent hip dysplasia, improve bowel or urinary function,
improve self-esteem or communication in children with cerebral palsy (Glickman
et al 2010).

The findings from these studies need to be interpreted with caution; the quality
of the studies is low. Conclusions are difficult to draw from the literature due to
significant variants in study design, interventions provided and outcomes
measured. The evidence supporting the use of standing frames is inconclusive.
The dosage of standing, how often, for how long and how much weight bearing
is required is unknown at present.

Dynamic standing frames (DSF): There is scant data to support or refute the
effectiveness of dynamic standing frames on postural control or management.

Sit-to-Stand technology: There is very little research applied to the

effectiveness of sit-to-stand technology beyond the application of manual and
powered ‘standing-wheelchairs’ on function and wellbeing.

Sit-to-stand technology within standing wheelchair technology enables active

supported mobile standing (without transfers) to perform activities of daily living,
to socialise and access the environment whilst in supported upstanding
(Lukersmith, 2012). Upright standing activity and wheeled mobility function are
linked to physical and psychological wellbeing (Yang, Chen, Fang, Chang, &
Kuo, 2014).

Standing wheelchair technology has two transition phases: supported lift-to-

stand from sitting and stand-to-sit in reverse. There are a number of standing
wheelchair manufacturers and each varies in degrees of pelvic tilt, recline and
tilt-in-space options as well as the standing transitional mechanism.

When a person with disability, their support people and therapists are
considering using a standing frame as part of the person’s positioning program,
the evidence in the literature supporting standing frame usage should be
considered. People with disability, their carers and therapsits are encouraged to
use sensitive outcome measures to evaluate if their goals for using the standing
frame are being met.

Table 10 Resources for standing technology

Independent Living Centres Australian (2011) Walking & Standing Aids.

Website retrieve electronically from:
http://ilcaustralia.org.au/search_category_paths/11
Independent Living Centres Australian (2011) Standing Frames. Website
retrieve electronically from:
http://ilcaustralia.org.au/search_category_paths/300

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7.4 Wheeled mobility – manual and powered
Mobility is essential for participation in activities of daily living, fulfilling
meaningful roles and occupational engagement within one’s community (Hardy,
2005).
Wheeled mobility technology can be broadly categorised by manual or powered
locomotion. A range of wheeled walking technology provides both manual and
powered locomotion. This could include strollers, buggies and walkers.
This section provides an overview of the clinical considerations for the
prescription of wheelchair. Refer to Appendix I for details on wheelchair
technology and includes some of the considerations when selecting a manual
wheelchair.

7.4.1 Manual wheelchairs

Manual wheelchair mobility requires supported seating posture to cope with
wheeled locomotion. A prescribing therapist will be required to assess and
prescribe postural supports in various seating situations or for various tasks.
Initially consider mainstream commercially available options, which may require
the addition of extra support, such as a pelvic strap or foam inserts.
If mainstream technology is not suitable, then the therapist in collaboration with
the person and supplier will need to research, trial and experiment with
alternative and more sophisticated seating options for people with additional
postural needs.
The Independent Living Centre New South Wales website provides the most
comprehensive information about various equipment available in all categories,
including a list of supplier’s occupational therapists and physiotherapists can
refer to for more specific details. Anyone can access the @magic database on
the website and if you set up a login there are additional search features and
options including the ability to make equipment comparison tables and save
searches. To utilise the full benefits of the database and website contact the ILC
NSW for an information sheet or you can contact one of the therapists there who
can arrange to go through all the sites features with you.

7.4.2 Powered wheelchairs

There are a vast range of powered wheelchairs, from light rehab options, indoor-
outdoor wheelchair bases; customised powered bases with specialised seating
systems and heavy duty outdoor for robust work (refer to Appendix I for more
details on powered wheelchair bases).
Wheelchairs may be required for indoor/outdoor or distance mobility or even just
for specific tasks, such as for sport and shopping. In considering wheelchairs,
the therapist may also look at options such as powered mobility if suitable for
the person. “Where mobility is developing or restricting, powered mobility can
provide the interface between the individual and their participation in the tasks

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and routines that make up everyday life”. (Powered Mobility: Empowering
Participation, CP Alliance).
Many factors should be taken into consideration when determining powered
mobility for a person with disability. Historically, eligibility for powered mobility
has been based on an person’s cognitive skills, which ruled out potential people
whose development was delayed due to lack of opportunity, exposure and
access (Powered Mobility: Empowering Participation).
Therefore therapists should focus on matching technology to the skills of the
person including associated intervention/training programs, and opportunities to
practice skills and generalise to other environments.
Training programs may include opportunities for the person to independently
use their wheelchair or to transfer in/out of their wheelchair. Teaching
families/carers specific manual handling techniques in relation to pushing
wheelchairs, transporting or storing wheelchairs may also be required, and
should always be considered by the therapist.

Powered wheeled mobility requires seating systems that provide adequate

support for locomotion at speed (≤ 10 klm/hr), pressure care cushioning to
protect bony body parts from pressure points and friction (from vibration and
shear) and postural harnessing may provide additional trunk support.

While many standard (or entry level/light rehab) wheelchair bases come with
standard seating systems, the majority of powered wheelchair bases can be
integrated with specialised seating systems, either as an adaptive seating
and/or custom-made for an individual postural needs (refer to Independent
Living Centre – Australia for wheelchair products).

There is growing support, internationally and within Australia, in providing

powered mobility - particular indoor/outdoor wheelchairs – to encourage people
out into their community (Davies et al., 2003; Evans, Frank, Neophytou, & de
Souza, 2007; Frank et al., 2010; Hardy, 2005).

When prescribed and fitted appropriately, powered wheelchair seating systems

enable independent locomotion, enhance occupational participation with
community; and if used safely reduce the care burden (Hardy, 2005; Mortenson
et al., 2012; Mortenson & Miller, 2008; K Samuelsson & Wressel, 2008; Wressel
& Samuelsson, 2004).

Repositioning seating options provide greater functional independence. These

include seat elevators that increase the seating height for increasing the seated
person’s environmental access (e.g. pedestrian buttons), enhance socialisation
at close to standing height (e.g. enhances quality of conversations and reduces
neck strain/pain/discomfort) and enables greater community participation and
spontaneity (Schmidt, 2015a).

There is no requirement for driver registration when in control of a powered

wheelchair. Individual driver capacity requires assessment of cognitive and

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functional skill and education on safe use of powered mobility is essential
(Batavia, 2010; Edwards & McCluskey, 2010; Evans et al., 2007).

Table 11 Useful publications for wheelchair technology

Independent Living Centres- Australia: Buyers guide. Retrieve electronically

from: http://ilcnsw.asn.au/buyers_guides
USA Tech Guide provides reviews on specific wheelchairs: Retrieve
electronically from: http://www.usatechguide.org/
Anti-tip Bars and Safety: A Guide for Families and Carers. Authored by
Novita Children’s Services (2010). Retrieve electronically from:
http://www.novita.org.au/library/Factsheet-anti-tip_bars_safety.pdf
RESNA Position on the Application of Tilt, Recline, and Elevating Legrests
for Wheelchairs. Retrieve electronically from:
http://www.rstce.pitt.edu/rstce_resources/Resna_Position_on_Tilt_Recline_Elev
at_Legrest.pdf
Power Wheelchairs: A New Definition.
Titanium-Why?
Buggies, strollers and pushers
Buggies, Strollers and Pushers: buyer’s guide authored by Novita Children’s
Services.
Kimba Spring Safety: A guide for families and carers (2010).

7.5 Mobility Scooters

The prescription of a mobility scooter may be considered when a powered
wheelchair is not appropriate. A person may require a powered mobility device
due to low endurance levels, mobilising over long distances, or to complete
specific daily activities (e.g. shopping).
Mobility scooters are not advised for people who; require a high level of postural
support and/or have a vision impairment (this is dependent on the visual acuities
and peripheral vision documented by the eye care professional).
Currently, a scooter user is not required to undergo formal testing before using a
mobility scooter. However, to be eligible for funding through Enable NSW, a
person must have an assessment from a relevant health professional (e.g.
occupational therapist or physiotherapist) and their general practitioner.
Regulations may change in the future, and the prescribing therapist should
review these changes before prescribing a scooter.

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When prescribing a mobility scooter, the therapist should provide the person
with driver training and user guidelines to ensure the person is safe and
competent to drive the scooter.
A mobility scooter should be speed limited to 10 km/hour to ensure that the user
is considered pedestrian traffic under Road Transit Authority NSW Australian
Road Rule. Drivers of mobility scooters must also maintain a blood alcohol level
of less than 0.05.
If the scooter user has a progressive or deteriorating condition it is
recommended that consideration be given to a powered wheelchair for future
seating and postural needs.
Effective assistive technology prescription relies on access and availability to a
knowledgeable vendor sector that supplies, advises and services in technology
for people with disability and their therapists.

Table 12 Resources for wheeled and alternative seating

Motorised wheelchairs (Transport for NSW).

Enable NSW Prescription and Provision Guidelines: Mobility Scooters
(Enable NSW, 2011) Retrieve electronically from:
http://www.enable.health.nsw.gov.au/__data/assets/pdf_file/0012/263100/scoot
er_ppg_2011_final.pdf
Independent Living Centre NSW: Buyers Guides Index (for a range of
products including wheelchairs and scooters) scroll through 2 pages
commencing with: https://www.ilcnsw.asn.au/buyers_guides?page=1
Wheelchairs and Mobility Scooters A guide for safe travel in Queensland.
(Department of Transport and Main Roads, 2015b). Retrieve electronically from:
www.spinalcord.org
Travelling with a wheelchair or mobility Scooter (Department of Transport and
Main Roads, 2015a). Retrieve electronically from:
http://www.tmr.qld.gov.au/Travel-and-transport/Disability-access-and-
mobility/Travelling-with-a-wheelchair-or-mobility-scooter.aspx
EnableNSW Publications (2011). Guidelines for the prescription for a seated
wheelchair or mobility scooter for people with a traumatic brain injury or spinal
cord injury. Retrieve electronically from
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/167286/Guideline
s-on-Wheelchair-Prescription.pdf
Alternative seating and positioning resources
Cerebral Palsy Alliance (2011). A Guide to Sitting Upright. Technotalk, 20(3),
2-5.
Rigby, P.J., Ryan, S.E., & Campbell, K.A. 2009). Effect of adaptive seating
devices on the activity performance of children with cerebral palsy. Archives of

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Physical Medicine and Rehabilitation, 90(8), I1389-1395.
Independent Living Centre NSW: Assistive Technology Guide – Postural
Supports. Retrieve electronically from: https://www.ilcnsw.asn.au/items/2163
Michael, S,M. & Pountney, P.D. (2007). Tilted seat position for non-ambulant
individuals with neurological and neuromuscular impairment: A systematic
review. Clinical Rehabilitation, 21(12), 1063-74.Specialist seating and
positioning clinics in NSW
Northcott Disability Services: Customised wheelchairs and seating:
Cerebral Palsy Alliance:
Greystanes: Megalong Positioning Service:
http://www.greystanes.org.au/megalong-positioning-service.htm
Powered Wheelchairs
Arthanat, S. & Strobel, W. (2006). Wheelchair ergonomics: Implications for
vocational participation. Journal of Vocational Rehabilitation, 24, 97-109.
Novita children’s Services. Powered Mobility: a guide for families.
Axelson, P., Minkel, J., Perr, A., & Yamada, D. (2002) The Powered
Wheelchair Training Guide.
ILC-NSW. (2015). Guidelines to Assist you when Selecting a Scooter. Retrieve
electronically from:
http://ilc.com.au/wp-content/uploads/2015/08/Guide-to-Selecting-a-Scooter.pdf
ACCC (2010). Help cut mobility scooter accidents. Retrieve electronically from:
https://www.accc.gov.au/system/files/Help%20cut%20mobility%20scooter%20a
ccidents%20-%20v2.pdf
Enable NSW Medical Questionnaire: Request for Mobility Scooter. Retrieve
electronically from:
http://www.enable.health.nsw.gov.au/__data/assets/pdf_file/0018/262206/scoot
er_medical_assessment_2011.pdf
Enable NSW (2011). Prescription and Provision Guidelines: Mobility Scooters.
Retrieve electronically from:
http://www.enable.health.nsw.gov.au/__data/assets/pdf_file/0012/263100/scoot
er_ppg_2011_final.pdf
Independent Living Centre NSW: Buyers Guides Index (for a range of
products including wheelchairs and scooters) scroll through 2 pages. Retrieve
electronically from: https://www.ilcnsw.asn.au/buyers_guides?page=1

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7.6 Assistive Technology and Online procurement
There is a huge range of assistive technology available for purchase online.
While acquiring low level assistive technology online without trial (e.g. sheep
skin and continence covers) may be successful, the same may not be so
assured when acquiring more sophisticated and hi-tech technologies (e.g.
customised seating and wheelchair) through online purchasing.
Successful online wheelchair-seating procurement requires access to
competent prescription and technical services, at assessment, during the home-
based trial and for after-provision fitting.
Vendors and experienced occupational therapists warn of the difficulties
experienced when purchasing wheelchairs and scooters online. Called ‘orphans’
by some experienced prescribers, purchasing sophisticated technology, without
a pre-purchase trial is linked to less optimal outcomes. In addition, these
‘orphan’ purchases are rarely backed by reliable after-purchase servicing
needed to fine tune the person-occupation-technology-environmental fit required
to meet required occupational demands (Schmidt, 2015a).
Buying online, without a trial is linked to abandonment or reduced use of poorly
fitted wheelchairs or those not meeting anticipated expectations (Schmidt,
2015a).

7.7 Health and safety considerations when prescribing

positioning equipment

7.7.1 Pressure Care

The occupational therapist and physiotherapist have an important role to play in
pressure care and in working in collaboration with other professionals including
nurses.
The occupational therapy and physiotherapy role would focus on working with
the person and their family/carer on:
• Prevention in relation to movement and to equipment needs.
• Assessment – use of the Waterlow or Braden scales (Balzer et al., 2007).
• Equipment prescription for prevention and for ongoing care including;
cushions, seating, beds, mattresses, and 24-hr positioning systems.
• Transfer/manual handling techniques acknowledging the prevention of
“shear” forces effects in pressure care management, in collaboration with
the physiotherapist.

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Nursing staff would have a role in the assessment and treatment of pressure
areas including the:
• grades of pressure ulcers and appearances
• treatment of pressure ulcers and the ongoing management of skin care
• monitoring of skin integrity and other risk factors, with a focus on
prevention related to skin care and nutrition/drinking
• collaboration with the occupational therapist and physiotherapist as
required.
It is essential to consider the prevention of pressure ulcers in high risk people
when prescribing seating, 24-hr postural management, and positioning
equipment.
There is strong evidence that dynamic and static support mattresses and
overlays (high-specification foam mattresses, alternating pressure mattresses,
and medical grade sheepskins) decrease pressure ulcer incidence, with
alternating pressure mattresses more cost effective than alternating pressure
overlays (Novak, et al, 2013).
Pressure relief cushions and mattresses should be prescribed where indicated
based on the pressure care risk assessment scores.

7.7.2 Effectiveness of repositioning and seating technology

on pressure care management
Seating tilt-in-space and recline
Tilt-in-space and recline options in wheeled seating provides an opportunity to
self-weight shift and self-adjust in a tilted position, if tilted to 45 degrees (Kreutz,
1997).
Self-weight and repositioning assist in reducing pressure over bony body parts.
A literature review by (Harrand and Bannigan (2014) found little evidential
support that tilt-in-space seating in wheelchair was in reality being used for self-
positioning for pressure care management and was linked to enhanced
occupational engagement for wheelchair use.
Seat tilt from 35-40 degrees and recline from 100-120 degrees impacts on
effective functional activity and so is best applied during a less active period,
such as in relaxation.
Table 13 Resources for pressure care management

TECHNOTALK: TASC CP Alliance. What’s new in seating? Pressure

cushion review (Sept, 2006) (newsletter).
Pressure Area Care

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Pan Pacific Clinical Practice Guideline for the Prevention and Management
of Pressure Injury
Spinal Injuries Association
Waterlow Pressure Ulcer Prevention/Treatment Policy

7.8 Complying with relevant standards and legislation when

prescribing equipment
In the first instance it is preferable to prescribe equipment from a commercial
manufacturer. This may be sourced directly from the manufacturer or through a
sponsor (i.e. an Australian company that imports items from overseas). The
equipment should be used as intended by the manufacturer.
The Australian Register of Therapeutic Goods (ARTG) is a computer database
of therapeutic goods and was established under the Therapeutic Goods Act
1989 (Cwlth). Unless excluded or exempt, medical devices must be 'included' on
the ARTG before they may be supplied in, or exported from, Australia. If
prescribing equipment categorised as a medical device for a person with a
disability, occupational therapists and physiotherapists must ensure that the
item is listed on the eBS Australian Register of Therapeutic Goods Devices
(unless that item is exempt or excluded). See Appendix D for further information.

7.9 Airway Safety

Maintaining airway safety should be considered at all times while assessing and
prescribing any postural seating system or positioning system.
The key areas of focus are outlined below:

7.9.1 Postural Chest Harnesses

Postural supports are often prescribed in combination with seating and 24 hour
positioning systems. They may be placed on a wheelchair, standing frame or
floor sitter.
There are numerous inherent risks with harnesses, particularly to airway safety,
that must be taken into consideration before recommendations can be made.
The Postural Chest Harness Guidelines for Safe Prescription and Fitting should
be consulted when adding postural supports to seating systems. See Appendix
J for further details.

7.9.2 Positioning for feeding/eating

Airway safety should be considered in relation to positioning for feeding.
This encompasses many components including
• optimum positioning for clearing the airways,

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 • for management of saliva and
• for ensuring a safe and effective swallow.
A combined assessment with the speech pathologist is recommended, when
assessing a person who requires postural supports that will be used when they
are eating.
The degree of tilt, head position and type of harness, needs to be evaluated to
ensure airway safety.
For more information on feeding/eating see the Mealtime Management Core
standard.

8 Best practice occupational therapy

& physiotherapy in 24 hour
positioning
The effectiveness of occupational therapy and physiotherapy intervention, as
demonstrated throughout this practice guide, is best undertaken from a person-
centred approach that is collaborative and based on evidence-based principles.

The evidence directly pertaining to 24 hour positioning and seating is limited,

therefore the following should be applied to practice:

• acquire and sustain current knowledge through lifelong learning and

proactive networking
• understand typical posture, and the development of sitting and movement
• apply guiding principles of 24 hour positioning and seating intervention,
based on person-centred practice
• acquire competent assessment-prescription skills to establish person-
centred goals
• build trustworthy partnerships with all participants based on collaborative
trust and respect
• inspire team collaboration, information exchange and informed decision
making
• provide ongoing review to evaluate and monitor the person-occupation-
environment-technology fit (Eggers et al., 2009; Routhier et al., 2003).
Appendix L refers to current leading practices in 24 hour positioning supported
by evidence. Appendix M refers to 24 hour positioning interventions that are
unsupported for people with disability.

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9 Conclusion
Current evidence based practice advocates multi-modal approach to assistive
technology intervention supported by team collaboration and active knowledge
exchange and education for empowering knowledge ownership and informed
decision making (Reid, 2002; Schmidt, 2015a).
There is no one evidence based intervention approach identified for 24 hour
positioning intervention. Instead a range of clinical recommendations, often in
combination are provided. Therefore as effective occupational therapists and
physiotherapists considering the application of assistive technology for 24 hour
positioning intervention, it is important to adopt contemporary philosophies
values and beliefs, including lifelong learning to stay abreast of higher level
evidence based practices, where available.
Evidential support advocates realistic outcome measurement of intervention
should be both objective and subjective to truly understand intervention
effectiveness and efficacy. To achieve this, outcome measurement should be
undertaken in collaboration with all members of the intervention team (e.g.
service providers and service recipients) and should be ongoing to account for
changes in actual or perceived results.

The practice guide aims to provide occupational therapists and physiotherapists

with factors that play an important role in successful 24 hour positioning and
seating intervention. These factors are aimed at promoting proactive ownership
of one’s health condition and personal independence in making confident
informed decisions about engaging in timely intervention programs (i.e. who,
when, what, where and how).

In doing so, this practice guide encourages a therapeutic approach designed to

transfer knowledge to encourage and enhance informed communities of
practice, where people with disability and/or their care providers manage their
disability proactively, by selecting and directing services as and when needed.
Promoting effective transfer of knowledge requires collaborative team work, in
which each member is part of a trustworthy partnership with capacity and
confidence to seek support, information and services appropriately, to address
needs in a timely manner and without undue duress, across the individual’s
lifespan.

In an attempt to inform service providers, this practice guide provides basic

guidelines for occupational therapists and physiotherapist who provide,
prescribe and evaluate effective and efficient intervention to support 24 hour
positioning and seating care and management. Occupational therapists and
physiotherapists should combine the knowledge gained from this practice guide
with ongoing clinical experience, aligned with proactive broad and expert
support networks (for peer clinical support and technical advice) linked to
lifelong learning activity as recommended by best evidence based practice.

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10 Appendices
A Glossary of terms for Assistive Technology terminology
B MAT Evaluation
C Complying with relevant standards and legislation when
prescribing equipment
D Funding Options

E Risk assessment / clinical reasoning proforma

F Newly Prescribed Equipment Information Sheet
G Specialised Beds, mattresses and overlays
H Powered Mobility technology
I Example of Postural Chest Harness
Guidelines for Safe Prescription and Fitting
J Example of a Postural Chest Harness Consent form

K Current leading practices supported by evidence

L 24 hour positioning and seating interventions unsupported in

disabilities

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Appendix A: Glossary of terms for Assistive Technology
terminology
Terminology and definitions
Assistive
Technology Describes the combination of ‘hard and soft technologies’
(AT) (Waldron & Layton, 2008, p. 61) essential for appropriately
matching the person, their lifestyle with appropriate
technology. Hard technology (e.g.
wheelchairs/seating/electronics) is considered ineffectual
without the support services (soft technology) such as carer
support, service expertise and education.
Adaptive
positioning Describes a range of adaptive equipment designed and
& seating: used to accommodate a person’s postural disability to
promote greater personal participation, i.e. providing trunk
support for function and occupational engagement
(Mortenson et al., 2008; Reid et al., 2002)Therapeutic
positioning intervention, by comparison is aimed at changing
the course of a person’s disability – e.g. applying postural
symmetry to improve respiratory function and pulmonary
health (Barks, 2004)

Adaptive is any seating device, product or system designed to

seating increase, maintain and improve seated posture and control,
system endurance and activity performance for a variety of static
and dynamic tasks, roles and occupations. An adaptive
seating system is commonly a commercially available
product with inherent adaptability designed to be modified
specifically for each person (i.e. it has a multi-user
application).
Complex describes an individual's postural and mobility needs
seating (Carlson, 2010; Dicianno et al., 2009; DiMarco et al., 2003)

Custom- a personalised seating system manufactured to fit a specific

made person with postural impairment. This is manufactured as a
seating one-off or bespoke seating system according to a seating
prescription. (EnableNSW, 2011).
Customised commercial equipment selected, positioned, adjusted or
seating modified to suit individual need as directed by a therapist
(EnableNSW, 2011, p. 1)
Intentional describes a person-centred approach where technology is
prescription prescribed to meet current needs with adjustability for
anticipated future use (within a funding cycle, commonly 5-7
years) (Batavia, 2010; Batavia et al., 2001).
Night-time describes a combination technologies that support
positioning symmetrical lying during night time relaxation and sleep;
management requires a regime of carer input to monitor and reposition
equipment according to a turning schedule if required.

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(NTPE)
Range of Is the measurement of the movement around the joint.
Motion A goniometer is an instrument for measuring joint angles.
(ROM) Goniometry series: The Goniometer You tube video
retrieved from
https://www.youtube.com/watch?v=ZUF7tpkVAIY
Seating Describes a complete system comprising of seat and back
systems support structure, support surfaces (e.g. pressure care
products) and their attachment hardware (e.g. repositioning
systems) and software (e.g. harnesses), plus those
accessories deemed necessary (Arledge et al., 2011, p. 1)
Positioning Describes a range of postural management devices and
applications designed to support a person with disability in a
symmetrical position when sitting, standing or lying with the
aim to improve the person’s biopsychosocial health &
function: pulmonary, cardiac, digestive, physical and
performance function, communication and cognition skills;
enhance the person’s participation within their chosen
environment; maximise their postural support and overall
comfort; & assist in reducing muscle contractures and joint
problems (e.g. subluxation or dislocation).
24 hour Describes the practice of promoting optimal supported
positioning seating for functional activity and comfortable positioning for
and seating relaxation (throughout the entire day) to enhance personal
intervention biopsychosocial health and wellbeing while reducing the
impact on pathology (Neville, 2005).
Specialised a describes a prescribed wheeled base, manual or
wheelchair- powered, integrated with a scripted seating system (and
seating technologies) designed for a specific wheelchair occupant (a
system bespoke wheelchair system).

Standing Describes supportive static or dynamic equipment to provide

system positioning in an upright posture to promote weight bearing
through the lower limbs
Postural describes both a range of postural, positioning and seating
assistive related technologies (devices/equipment) and a range of
technology services and resources required to support their
procurement and ongoing integral use of posture related
assistive technology (Oishi, Mitchell, & Van de Loos, 2010;
Waldron & Layton, 2008).
Wheeled a seating system designed to position a person in a
mobility comfortable supported posture to manage wheeled
seating propulsion (manual or powered). This could be either
customised or modified adaptive seating system commonly
used for a pram/stroller or wheelchair. (NHS Purchasing and
Supply Agency, 2008; Ryan, 2012)

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Procurement describes a holistic process of wheelchair and seating provision
that includes services associated with assessment, provision,
funding and education/training (Mortenson & Miller, 2008).

Technology describes an appropriately provided wheelchair-seating system

enhanced enhances a consumer's occupational performance ((Batavia,
performance 2010; Hardy, 2005; Mortenson & Miller, 2008). Conversely, an
inappropriately provided wheelchair system hampers optimal
mobility, resulting in wheelchair avoidance or use-related injury,
and for some wheelchair abandonment (Chan & Chan, 2007, Di
Marco, Russell & Masters, 2003; Kittel, Di Marco & Stewart, 2002;
Mortenson & Miller, 2008).

Wheelchair
outcome describes the final wheelchair-seating system provided to the
consumer at the end of their seating service experience. A
satisfactory wheelchair outcome describes consumer’s enhanced
occupational performance where the provided wheelchair-seating
system enables active participation across all life domains and
desired roles.

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Appendix B: MAT Evaluation

MAT Evaluation PART 1

The initial sitting evaluation, where the current posture is recorded in relation
to the current seated position. Details of current equipment and equipment
measurements should also be recorded (Batavia, 2010). In this portion of the
assessment the therapist needs to locate the bony landmarks of the pelvis to
determine the seated pelvic orientation in the existing system. Position of the
limbs should also be noted. The trunk should be observed and any abnormal
deviations noted (Blewett, 2007). This phase of the assessment may highlight
any issues with current equipment and supports (Batavia, 2010; Dolan, 2013). It
also provides information on areas that need closer consideration in the supine
evaluation.
The following questions assist the seating assessment:
Ask the person being assessed (or their carer advocate): is this is their normal
positioning in the current equipment? Make sure they haven’t just repositioned
as this could mask symptoms of the system not working such as constant sliding
or inability for positioning to be maintained
Locate the Anterior Superior Iliac Spines (ASIS): is the pelvis neutral or oblique
in the sagittal or coronal planes?
Locate the Posterior Superior Iliac Spine (PSIS): determine if the pelvis is
neutral, posteriorly tilted or anteriorly tilted.
Are the femurs neutral, abducting or adducting (in relation to pelvis). Are they
internally or externally rotated?
What is the angle of knee flexion and ankle flexion? (A goniometer can assist
with accuracy in measuring the angle of the joints)
MAT Part 2: In supine (refer to video materials in Resources for MAT
Evaluation and Instructional Tools).
The supine evaluation indicates the potential capacity of postural positioning:
where passive Range of Motion (ROM) is measured in relation to the
requirements of sitting. These measurements are taken in supine (lying on a flat
surface), isolating the capacity of seated position ROM without the effects of
gravity. These measurements will then guide the clinical reasoning process that
guides the achievable postural position and identifies the supports that will be
required in the seating.
Spinal seating assessment form: NSW Spinal Cord Injury services: Assessment
part 2 (a diagrammatic form) can be retrieved from:
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0018/156060/m03_mat
_basic.pdf
The assessment form will guide the required ranges but at a minimum you need
to assess are:

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Flexibility of pelvis in all planes; anterior/posterior tilt, pelvic obliquity and
rotation. Note any limitations;
ROM of hip flexion is measured first. All subsequent ranges need to be
measured with the hip flexion at the end range you are considering sitting the
person in. Any reduced range must be accommodated due to the impact on the
pelvis once passive end range has been achieved. Hip flexion is measured from
anatomical neutral (0 degrees or achievable full extension) through flexion to
end range. Measure both legs, one leg at a time. Note the range for example 0 –
120 degrees would indicate the user can lie flat with legs in extension and you
can passively move through to full flexion This may also be recorded as NAD
(No Assessed Deformity). When measuring hip flexion you use one arm to
passively move the thigh towards the pelvis. Your other hand should be firmly
positioned on the ASIS. End range is indicated when you feel the pelvis start to
roll back into PPT (Posterior Pelvic tilt: Refer to Appendix B for details)
Hip abduction and adduction ROM is measured.
(NB – if person/child has a tendency to adduct it is more important to see the
abduction range or the ability to achieve a neutral range. As infant and children
presenting with adduction and internal rotation have had limited opportunities for
the hip fossa to develop are at greater risk of hip subluxation (Scrutton & Baird,
1997): you do not need to measure these to the end range.
To measure hip abduction you need to start with the hip flexed to end range as
already determined. Ensure the knee is in line with the ASIS as your starting
point. Like with hip flexion you will use your arm to passively take the leg
through its range. Your other hand is positioned on the opposite ASIS. End
range is indicated when you feel the pelvis start to lift up from the plinth.
Hip adduction is measured using the above technique, however for this range
you are feeling for when the same side ASIS starts to lift up.
Internal and external rotation ROM is measured from the same starting point as
abduction / adduction. With one arm you need to support the leg in this position,
the leg needs to be supported with the hip flexed to end range and the knee
stabilised. Although measuring rotation of the hip you may find it easier to
stabilise and measure whilst your body is facing away from this joint.
Hamstring ROM is measured from the same starting position as above. You are
measuring a bi-articular muscle (muscle that crosses over two joints) and as
such positioning of knee extension will impact on pelvic position.
It is essential to identify the ROM with pelvis neutral throughout the range. Take
the knee into full flexion, stabilise the pelvis and recheck neutral by locating the
ASIS and PSIS, then passively move the lower limb towards full knee extension.
Keep one finger behind the knee to feel for the tendon tension with the
exception of individuals with hypotonia not many people can achieve full knee
extension with the hip flexed to 90 degrees. As we are measuring all ranges
from anatomical neutral full knee extension is 0 degrees This range relates to
the hanger angle (e.g. if the end range is 90 degrees the person/child will not be
able to sit with 70 degree footplate hangers without rolling into posterior pelvic

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tilt or PPT).
To achieve the range hand simulation is the third component of a MAT
evaluation. Hand simulation
MAT Part 3: Upright (supported) sitting with the influence of gravity (refer
to video material in Resources for MAT Evaluation and Instructional Tools)
Incorporate the data collected using your clinical reasoning and judgment: the
external forces (gravity) are looked at to understand the required postural
supports for the person/child. Position the person or child as noted in you-tube
video (Last, 2007), as:
Sit the person/child on the edge of a firm hard surface (ideally a height
adjustable plinth) with feet supported (on the floor/or foot stool);
Where possible, have an assistant (therapist or carer) kneeling behind the
person in supported sitting. The assistant can then provide the points of control
required posteriorly and laterally, during the assessment;
You may use foam wedges to correct or accommodate a pelvic obliquity.
This is the supported sitting position that all measurements of the
person/child should be completed.

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 Appendix C: Complying with relevant standards and
legislation when prescribing equipment
Part of an occupational therapist and physiotherapist’s work involves prescribing
equipment for people with disability. In the first instance it is preferable to
prescribe equipment from a commercial manufacturer. This may be sourced
directly from the manufacturer or through a sponsor (i.e. an Australian company
that imports items from overseas). The equipment should be used as intended
by the manufacturer.
The Australian Register of Therapeutic Goods (ARTG) is a computer database
of therapeutic goods and was established under the Therapeutic Goods Act
1989 (Cwlth). Unless excluded or exempt, medical devices must be included on
the ARTG before they may be supplied in, or exported from, Australia. A
category of medical device is “any instrument, apparatus, material or other
article…for the purpose of…diagnosis, monitoring, treatment or compensation
for an injury or handicap”. If prescribing equipment categorised as a medical
device for a person with disability, physiotherapists must ensure that the item is
listed on the Australian Register of Therapeutic Goods (unless that item is
exempt or excluded). It is good practice to document the ARTG number in the
person’s progress notes.
It may be easiest in the first instance to request the ARTG identification number
from the supplier, and then access the website to confirm that the product is
appropriately registered. It should be noted that at times the supplier that the
occupational therapist and physiotherapist is ordering through is not the sponsor
who has the product listed on the ARTG. This is acceptable in situations where
that supplier has sourced the product from the sponsor. If however the supplier
has sourced it directly from the manufacturer themselves, they must have the
product listed on the ARTG. It can be helpful for organisations to collate a list of
medical devices commonly prescribed that have been confirmed as listed on the
ARTG. If a company advises that a product is excluded or exempt from listing on
the ARTG it is wise to have this confirmed in writing by them. If an occupational
therapist or physiotherapist believes that the product should be listed despite
advice from the supplier to the contrary, then the item should not be prescribed
and the specific case reviewed by the appropriate senior clinicians and legal
teams in the therapist’s organisation. More information is also available on the
TGA website at TGA - Health professional information and education. At times
manufacturers and / or suppliers discontinue items. Consequently they remove
these items from listing on the ARTG. If such an item has been prescribed for a
specific person and is still with that person, it does not need to be recalled
unless the product was discontinued for safety reasons. However, if these items
are in loan pools they should not be re-issued. Items that have been recalled or
discontinued for safety reasons should obviously not be issued, and if they are
recalled, the attending therapist may need to offer extra support at that time. It
is advisable for therapists to subscribe to the TGA’s email alert service which
advises when new alerts, recalls, monitoring communications and advisory
statements are published. Therefore, if therapists are issuing equipment from a
loan pool they should first check the item has not been discontinued by the
supplier and removed from the ARTG. This is also a consideration when looking

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at purchasing second hand equipment. The TGA website advises that there are
risks associated with issuing second hand medical devices and that it is not
advisable to buy second hand devices. Important considerations include:
• Is the product still covered by warranty?
• Are the instructions for use included?
• Is there a service provider who can undertake repairs?
• Has the device undergone any repairs or has it been
refurbished?

The Australian / New Zealand Standard Management Programs for Medical

Equipment (AS/NZS 3551:2012) outlines procedures for managing medical
equipment (around procurement, acceptance, maintenance activities and
disposal). This standard applies whether the equipment is owned by an
organisation (including in an organisation’s loan pool), owned privately, is on
loan, on hire, on trial or donated. This standard recommends pre-purchase
evaluation of the equipment to ensure it will meet the clinical needs of its users –
this should include developing an understanding of the needs of the user,
assessment of the usability and ongoing safety of the medical equipment, the
whole of life cost of the system – including purchase costs, consumables, parts,
maintenance, risk, availability of hardware and software upgrades and
installation costs.

At times therapists may choose to modify equipment, or make some equipment

from scratch for the person with disability. In Australia, the Therapeutic Goods
Administration administers therapeutic goods including medical devices. There
are a number of excluded goods, but some of the equipment that
physiotherapists make or modify is likely not to be excluded and is therefore
regulated under the Act.
Whether or not the equipment being made or fabricated falls within the excluded
category, it is recommended that all equipment being modified and/or made
meets basic safety and performance criteria embodied in the following essential
principle areas provided by the Therapeutic Goods Administration:
• use of medical devices not to compromise health and safety
• design and construction of medical devices to conform with safety
principles
• medical devices to be suitable for the intended purpose
• long term safety
• medical devices not to be adversely affected by transport or storage
• benefits of medical devices to outweigh any side effects
• chemical, physical and biological properties
• infection and microbial contamination
• construction and environmental properties

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 • medical devices with a measuring function
• protection against radiation
• medical devices connected to or equipped with an energy source
• information to be provided with medical devices
• clinical evidence.

For full details of what each essential principle involves visit: Essential Principles
Checklist (medical devices) .
In all instances of equipment prescription it is good practice to conduct a formal
documented risk assessment / clinical reasoning process as to whether that
piece of equipment is suitable for use by that particular person. See Appendix F
for an example of a risk assessment/clinical reasoning proforma. Written
information should be provided to the person and their carer when newly
prescribed equipment is issued. This would include a program outlining how to
incorporate the use of the equipment into the person’s daily routine and settings
and also information contained in the Newly Prescribed Equipment Information
sheet at Appendix G.
It is important to be mindful, when lending or sharing equipment, of roles and
responsibilities regarding infection control. Standard precautions apply for
physiotherapists to protect their health and the health of the people they have
contact with. Professional associations have information regarding specific
infection control processes which apply to particular disciplines. Organisational
policies and procedures on infection control should also be followed.

Additional information can be found in the Australian Guidelines for the

Prevention and Control of Infection in Healthcare (2010) - National Health and
Medical Research Council.

Any adverse events with medical devices should not only be dealt with
according to organisation policy and procedures, but also reported to the TGA at
TGA - Incident reporting.

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Appendix D: Funding options
Equipment can be highly expensive, and carers and families are often unable to
afford continued outlay for it. The therapist’s role may therefore involve seeking
funding for equipment in these situations.
Prescription and trial of equipment can be a lengthy process, with many and
varied factors influencing decisions and choices of equipment. It is important for
the therapist to consider ongoing maintenance and repair costs when initially
applying for equipment funding, particularly if the initial equipment is not through
EnableNSW.
The therapist should also ensure that all parties understand and are in
agreement with decisions made prior to ordering of equipment (including re-
measurement for confirming size and fit). This avoids expensive changes to the
prescription.
EnableNSW
EnableNSW was established in 2007 and has commenced implementation of
the major reforms based on recommendations made in the
PriceWaterHouseCooper “Review of the Program of Appliances for Disabled
People (PADP)” that were supported by the NSW Government. For further
information please refer to EnableNSW's website.
EnableNSW has clear guidelines about qualifications and experience required to
be an equipment prescriber. The prescription of equipment must be supervised
by an appropriately qualified person if you do not have the required experience.
To become an approved EnableNSW prescriber, therapists are required to
complete an application form found on the EnableNSW website.
EnableNSW usually requires therapists to complete an equipment evaluation
form following supply of the equipment. This form is available at the same
website.
Therapists can subscribe to the EnableNSW quarterly newsletter by emailing
contact details to EnableNSW [email protected]

Independent funding organisations

Alternative sources of funding such as charitable organisations may consider
providing funds for the purchase of equipment. The organisations that are
relevant to the person with a disability can vary, so the therapist should consult
with senior therapists to obtain a regional list. A list of some national charitable
organisations can be found below:
Variety Freedom Program
Lions Club – Australian Lions Children’s Mobility Foundation
St George Foundation

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When seeking funds from a charitable organisation, it is important to consider
the ongoing cost and maintenance of the equipment for the person and their
family/carer.

Equipment loan pools (ELPs)

Most public hospitals operate equipment loan pools (ELP) for short term loan of
basic hygiene technology, such as commodes or shower chairs, for the benefit
of inpatients and non inpatients. Equipment can be accessed at a cost to the
person. Enquiries should be made to the person’s local hospital. (Note:
EnableNSW does not have a loan pool service)
Organisations such as the NSW Paraplegic and Quadriplegic Association, the
Independent Living Centre
http://www.ilcnsw.asn.au/home/assistive_technology/second_hand_register.html
the Australian Quadriplegic Association and the Multiple Sclerosis Society
occasionally have items for loan.
The Cerebral Palsy Alliance’s Holiday Equipment Loan Pool is an initiative of
Children’s Services, North and East Region. Eligible people with a disability
may access a pool of portable, light weight equipment which will assist access,
the management of personal care and allow participation in social activities
during holidays away from home. For further information, contact the Ryde office
on Ph: (02) 8878 3500
Equipment can often be hired from equipment suppliers, at a cost including a
deposit.
Second-hand and recycled equipment
Second-hand and recycled equipment may be able to be sourced for free or at a
reasonable price in some instances. These may be sold via generic classifieds
website, or websites built specifically for second hand and unwanted disability
related equipment in Australia.
Equipment sourced this way should be subject to the same risk assessment and
prescription guidelines as other equipment noting that the risk of some items as
second hand is higher than when new (e.g car seats as they may have been in
an accident and hence would not be recommended). As part of the risk
assessment and management, more complex items (e.g those with mechanics)
should be serviced by an appropriately qualified provider (e.g ideally the original
supplier company of the item) and a certificate of the service outcome obtained
and recorded. Who organises this, and who carries the cost for this service, if
any, will need to be managed in the equipment prescription decision making.
See the Independent Living Centre guide for purchasing second hand
equipment for more information.

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Appendix E: Risk assessment / clinical reasoning proforma

Risk assessment / clinical reasoning

for (insert person’s name)’s (insert name of type of equipment being
assessed)

The purpose of this form is to assist practitioners in decision making

when prescribing equipment. It is not intended to replace organisational
Work Health and Safety Policies and Procedures.
Date:

Person’s name: Date of birth:

Person’s address:
Therapist conducting
risk assessment:
Goal/s of the
equipment
General benefits of
this type of equipment
(e.g. pressure care,
increase bone density,
increase participation
in activities etc.)
OPTION 1:
Equipment description (specify make and model):

ARTG number (if applicable):

Does the equipment meet the above goal/s (this should be determined in collaboration
with the person / carers)?

Potential benefits for this person with this specific model of equipment:

Potential risks for this person with this specific model of equipment:

Benefits outweigh risks Y/N (consider general benefits listed above and specific
benefits versus potential risks).

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Insert photo of (insert person’s name) in this equipment here (optional):

OPTION 2:

Equipment description:

ARTG number (if applicable):

Does the equipment meet the above goal/s (this should be determined in
collaboration with the person / carers)?

Potential benefits:

Potential risks:

Benefits outweigh risks Y/N

Insert photo of (insert person’s name) in this equipment here (optional):

NOTE: Copy and insert as many option tables and photos as is appropriate

EQUIPMENT MAKE AND MODEL CHOSEN (state reason(s) why):

Therapist:
Signature
Name
Position
Date

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Appendix F: A Newly Prescribed Equipment Information
Sheet proforma

Information Sheet
for (insert person’s name)’s newly prescribed (insert equipment name)

Date: Does this information sheet replace a Yes/No

previous sheet provided regarding the
same equipment?

Person’s name: Date of

birth:

Person’s
address:

Prescribing
therapist:
(including contact
details)

Equipment description: (including whether the equipment was fabricated or modified by

the organisation’s staff)

Equipment picture:

Date manufactured/made: ____/____/____ Date issued: ____/____/____

Supplier: (including contact details)

Funded by: Period of

warranty:
(New Equipment
only)

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Instructions:

What is (name)’s (equipment) for?

What is (name)’s goal in relation to use of this piece of equipment?

How (name)’s (equipment) should be used.

Where should (name) use the (equipment)?

When should (name) not use the (equipment)? (e.g. during transport, in a certain
environment etc.)

Where should (name)’s (equipment) be kept?

How should (name)’s (equipment) be handled?

How should (name)’s (equipment) be transported?

How to clean (name)’s (equipment) and ensure good hygiene (i.e. preventing cross
infection)

When should (insert person’s name) stop using the (equipment)? (e.g. out-grown,
equipment has expired, broken etc.)

Are there any warnings or risks when (name) uses the (equipment)? (e.g. choking
hazards, airway safety etc.)

Who to contact and when to contact when it’s time to review (name)’s (equipment).

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Additional instructions/pictures stored with the equipment?
Yes/No

Please note:
(Name) or his/her carers have the responsibility to ensure that the (equipment) is
maintained and cleaned as per instructions.

The (equipment) is intended for use only in its current form (see photo on page 1)
and for (name).

If the (equipment) gets damaged, no longer fits, or is not meeting (name) goals, then
(name) or his/her carers are responsible for requesting a review.

If (name) or his/her carers are unsure about anything to do with the (equipment),
they should contact (insert name of the prescribing therapist/role) at the (insert
organisation name and office) on (insert office main phone number).

Only the people currently trained by the prescribing therapist in using the
(equipment) with (name) are able to demonstrate the (equipment)’s use to others. If
these people are no longer available new people need to be trained. In this case
contact the organisation the prescribing therapist was from at the number above, or
the National Disability Insurance Agency to discuss options.

Prescribing therapist:

Signature

Name

Position

Phone number

Date

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Appendix G: Specialised beds, mattress and overlays
An overview of the most commonly used products are presented in the table
below (informed by website (Independent Living Centres-Australia, 2011).
Prescription of the most appropriate mattress and/or overlay is determined by
personal need and established goals.

Mattress and overlay products details

Product Application consideration

Fabric mattress overlays Requires a firm, bed frame base and mattress
Wool for any mattress overlay.
Sheepskin Wool filled overlays: (natural product if covered
Man-made fabrics with a natural fibre) provides warmth and
comfort. Recommended as a mattress overlay
for people under 50kgs. weight. (Other fibre
filled overlays are limited in their application for
pressure care management, as noted for wool
filled overlays).
Sheepskin overlays: a non-flexible natural fibre
suitable for warmth and comfort. There is
scant evidence in support of its pressure care
properties and will demote specialised
pressure care product when placed as
cushion/mattress topper.

FOAMS: Requires a firm, bed frame base: stable level

Foams, memory foams, foundation for any foam mattress;
gelfoams, latex
Foam mattress: made of a Combination foam mattress: lighter foam
range of flexible polyurethane density (‘toppers’) allows for body emersion
foams (of various densities) in with denser foam base layer prevents body
combination with memory emersion (thus arresting ‘bottoming out’);
and/or latex foams. Greater body emersion results in reduced air
circulation and potential increase in body
Polyurethane foams allow for temperature.
emersion (depending on Mattress life cycle depends on user
density) and return to original characteristics: e.g. weight, bed mobility
shape quickly (quick reshape (transfers/repositioning), moisture retention
properties) once weight is (sweat/continence) etc.
removed.
Foam life cycle ranges greatly
from 6 months -18months
before polyurethane structure
(foam integrity) begins to
weaken or breakdown.

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Memory or temper foam Memory foam (visco-elastic foams: memory
(visco-elastic foams): visco- foam (mattress with memory foam
elastic foams are a made- toppers/overlays) that encapsulates the body
made product designed with shape for broad pressure distribution. An
delayed reshaping properties advantage of its delayed reshaping property is:
(slow to returning to original a delayed foam shape return allows
structure). This delayed deoxygenation of parts of body immersed –
reshaping property provides when repositioned. Memory foams provide
broad pressure distribution for broad body pressure distribution, have benefits
body shape stability and for people with low bed mobility movement,
comfort. however can hamper bed mobility (rolling
over/transfers out) of people with minimal bed
mobility and can be associated with increase
body temperature (reduced air circulation).

Gelfoam: describes thin flexible foam that

Gelfoam a man-made fluid moves within a flexible skin like cover
foam encased within a flexible (available in range of sizes) that provides a
cell. shear reducing property.
Man-made foams are made of petro-chemicals
and may not be suitable for all occupants.

Latex rubber toppers: latex toppers provide

broad body emersion with a quick reshaping
Latex rubber foam: a natural property. Latex mattress toppers allow for
fibre that is heavier than most body emersion and body mobility however can
foams: be associated with increased body
temperature (reduced air circulation).
As latex mattresses/toppers are heavy,
consideration to carer safety during bed
making.
Combination foams applied over an inner
spring mattress base reduces the overall
mattress weight and encourages greater air
circulation.

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Air floatation systems Individual air filled cells: describes a number of
encourage air transfer or small light weight air filled cells (tetra shaped
movement to reduce pressure packs) encased within a flexible cover. The
points and friction while small air filled cells slide over each to allow for
accommodating body and accommodate body shape immersion
positioning. (e.g. Vicair pressure care products for strollers
There are number of products and seating).
types including:
• individual air filled cells; Enclosed cell air transfer systems: describes a
• enclosed cell air transfer system of interconnected cells that allow for air
systems to move across an enclosed system of cells.
• alternating air The relocation of air allows for weight
distribution systems distribution and to accommodate body shape
immersion (e.g. ROHO and roho-like
products).
Roho mattress inserts within a foam mattress
provide specific pressure care properties to
specific body sections (e.g. shoulders, hips).

Alternating air distribution systems: describes

a system of air filled cells scheduled to inflate-
deflate (electronically) for body deoxygenation
to relieve pressure points and friction. Most
‘alternating air mattresses’ are mattress
overlays that fit over an existing mattress and
are powered (with battery backup) and have
programmable cell inflation-deflation system
options. The alternating air mattress overlay is
useful during acute pressure ulcer/post-
surgery recovery (approx 2-3 months) and for
people with low/no bed mobility. Its unstable
surface properties are not conducive to
independent bed mobility or transfers, so
consider a air alternating overlays as a short
term product (maybe hired) during acute
stage, to be progressed to a static air filled
mattress (Roho-like mattress) or foam
combination mattress, as described above).

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Appendix H: Powered mobility technology
Powered mobility and clinical considerations

Entry level / light

Rehab options These types of chairs are often comparative to a manual
wheelchair with motors and batteries added. These bases
are most often rear wheel drive, with the main drive wheel
positioned behind the user. The electronic system may be
more basic and have more limited programing options.
Generally these models do not offer tilt or other powered
functions.
Some of these bases can be dismantled and folded for
transportation. Whilst this can be an attractive feature for the
participant, the components are individually heavy to lift into
a vehicle, as still consist of motors and batteries and as such
should not be recommended to dismantle on a regular basis.

Rear wheel drive In a rear wheel drive mobility base, the drive wheels are at
the rear of the wheelchair. The participant’s centre of gravity
is in front of the drive wheel. Rear wheel drive bases
generally have a larger turning arc than the other styles of
powered bases. Rear wheel drive bases are generally good
at going down slopes. Generally rear wheel drive bases are
easier for a carer to operate as the attendant control is
normally mounted at the rear of the chair thus the drive
wheel is closer to the carer operating.

Mid wheel drive In a mid-wheel or centre wheel drive mobility base, the drive
wheels are located in the middle of the base. The participant
sits above this drive wheel with the centre of gravity through
the drive wheel. This positioning enables the mobility base to
be turned within its footprint making it more manoeuvrable in
small areas. These chairs have 6 wheels 2 front castors 2
drive wheels and two rear castors.

System Describes the interface of electronic system (e.g. seating

Integration system repositioning system, environmental controls,
communication and electronic devices).
Consider the person’s communication needs. Whilst this can
be integrated with the powered mobility base with the
advantage of the person always having access to
communication, however if one requires repair or
maintenance then the person may be without mobility and
communication whilst repairs are completed.
Most Rehab bases will have the capacity to include a blue

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 tooth module, and or infrared, essentially operating devices
via the joystick. An example of this is to enable the joystick
to be the mouse mover for computer operation.

Actuators / seat With complex or rehab wheelchairs you can add various
functions seat functions. Ensure you are aware of any implications
that these may raise such as increased seat to floor height.
Some bases available now have the hardware or capacity to
add on features later. Some still require extensive resources,
time and costs to retro fit. It is best practice to ensure you
have identified all features prior to scripting the mobility
base. If there are features that may be required later due to
a degenerative condition ensure you know the capacity of
the base to ensure it will meet future needs

Seating repositioning technologies

Seating repositioning technologies:

Common technologies used to assist seating and posture adjustment and
repositioning maybe manual, powered or in combination. The follow describe
four common devices: Tilt in Space, Recline, Seat elevator and Supported sit to
stand assist.

Tilt in space This function has become a standard feature on most

(TIS) powered wheelchairs, with varying range from 30-60
degrees of tilt.
Combination of tilt-in-space and recline are key components
on pressure care management (Ding et al., 2008; Jan et al.,
2010). A combination of tilt and recline for active pressure
ulcer remediation is recommended between 35-25 degrees
tilt and between 100-120 degrees recline (Jan et al., 2010).
A recommended 45 degree tilt enables self-repositioning for
some people (Kreutz, 1997) to redistribute pressure to
reduce pressure points and friction. Seat tilt-in-space
reposition can provide a person some stability when going
down steep inclines.
A 5 degree anterior tilt range can often be set on complex
wheeled bases. Anterior tilt is recommended to improve
postural control and stability, enhances upper limb functional
control and may assist in maintaining standing transfers for
individuals with progressive neurological conditions Extensor
thrust can be evoked in posterior recline (Mcnamarra &
Casey, 2007).
Combination of tilt-in-space and recline are key components
on pressure care management (Ding et al., 2008; Jan et al.,
2010).

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Recline Historically recline is infrequently prescribed, however new
bodies of research coming out of Pittsburgh University are
challenging previous beliefs on optimal pressure relieving.
((Aissaoui, Lacoste, & Dansereau, 2001; Ding et al., 2008;
Hobson, 1992).
Advancements in technology have also reduced the amount
of shear a person experiences in reclining a wheelchair seat
which is making this a more viable option if required.
Functional uses of recline include access for personal care
tasks and some transfer styles. From a person centred
approach it provides another plane of movement which
assists in postural positional changes.

Seat Elevator Seat elevation enables the base to raise vertically. Whilst
this may enable someone to reach a high cupboard for
example the user is still limited to be within the base of
support of the wheelchair, a forward reach is still limited by
the shoulder position being significantly further back than the
front of the wheelchair, as such any barriers to reach outside
of base of support still impact on function so to reach the
cupboard the user may be required to access sideways.

Supported Sit to Assist Sit to Stand describes a mechanism that raises the
Stand Assist sitting person to almost upright standing (within a supported
seating system) for functional activity (e.g. accessing
pedestrian lights and elevator/lift controls and socialising
while standing at eye level).

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Appendix I: An example of Postural Chest Harness
Guidelines for safe prescription and fitting
Postural Chest Harness
Guidelines for Safe Prescription and Fitting

The following guidelines were written to assist occupational therapists and

physiotherapists with prescription and fitting of postural chest harnesses on
seating systems. The aims of these guidelines are to assist therapists to:

1) prescribe and mount chest harnesses for optimal postural support

2) promote airway safety when prescribing chest harnesses

Background Information on Postural Chest Harnesses

In 1999, a choking incident occurred in a seating system with a postural chest

harness. The girl died as a result of this accident. The coroner found that the
harness caused compression of the girl’s neck, and the two therapists who were
involved in the prescription of her seating were found to have contributed to the
death. An investigation by the relevant health complaints body found that
“There was inadequate communication between the two therapists… and
between the school occupational therapist and the child’s teacher”. It was also
found that the parents had not been adequately informed about the potential
risks associated with the postural harness (Victorian Harness Safety Industry
Working Group). As a result of this finding, various disability organisations
developed Best Practice Guidelines around the prescription of postural chest
harnesses.

Definition of Postural Chest Harness:

 The postural chest harness is part of a customised system which includes

pelvic and trunk supports.
 The harness stabilises a person’s body and assists optimal posture for
functional movement
- Cerebral Palsy Alliance (2010)

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 Postural Chest Harness

4-point pelvic strap

Thoracic lateral Curved

supports backrest

Benefits of Postural Chest Harness

 Postural harnesses provide anterior chest support

 In combination with a pelvic strap and thoracic support, the postural chest
harness provides trunk stability, helping the person to maximise control
over upper limbs, head and neck.
 During travel, a postural chest harness can help the person stay in an
upright position when the vehicle slows down –BUT it does not take the
place of a vehicle safety restraint. A postural chest harness will not act
as vehicle safety restraint in an accident situation.

Postural Chest Harnesses:

 Provide support anteriorly not laterally.

 They should always be accompanied by side supports e.g. side supports
of the chair, a curved backrest or thoracic supports mounted onto the
backrest.
 They should always be accompanied by a pelvic strap.

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  They should always be accompanied by support for the feet.
 They are only a component of a complete seating system

Postural Chest Harnesses:

 ARE NOT BEHAVIOURAL RESTRAINTS

 ARE NOT VEHICLE SAFETY RESTRAINTS

Components of a Postural Chest harness:

Adjustable upper straps mounted to backrest

Shoulder straps

Horizontal strap and buckle attachment

Lower Straps

Risks of a Postural Chest Harness:

1) Pelvic belt is missing or not fastened allowing the person to slide down in the
seat. As a result the horizontal strap of the harness can occlude the airway.

2) Lower straps become loose and the harness is adjusted at the top of the
shoulder straps, eventually the horizontal strap rides up and can occlude the
airway.

3) Insufficient thoracic supports allowing the person to collapse to the side,

risking airway occlusion from the shoulder straps.

4) Chest harness is not positioned centrally allowing the shoulder straps to cut
across the person’s neck.

5) Chest harness is fitted too tightly impacting on respiration. There should be

enough space between the person’s chest and the horizontal strap for a hand to
be slipped underneath the horizontal strap.

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Recommended Postural Chest Harnesses:

H-Harness:

Boomerang
Harness:

The horizontal strap on the H-Harness and boomerang harness is positioned

below the sternum. In the event of a person sliding forward in their seat, the
horizontal strap is still likely to be well away from the airway. The buckle should
be done up at the front for quick release.

 Styles NOT recommended:

Chest harnesses using chest pads and chest straps compromise airway safety
due to their proximity to the airway. If the person slides forward in their seat, the
strap or pad can pose a choking hazard. The safety is further compromised if
the harness is not fastened at the front for quick release.

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Prescription of Postural Chest Harnesses

In the seating prescription process, postural chest harnesses are one of the last
supports considered when prescribing supportive seating. In order, therapists
should:

1) Secure the pelvis, in a neutral position if possible. Seating components

to consider are: pelvic straps (2 point, 4 point, 6 point) and thigh straps.
Pommels, hip guides and contouring in the cushion/seat may be required
to position the thighs. A pommel does not replace a pelvic strap.

2) Support the feet, either with foot boards or plates, and maybe secured
with ankle huggers or shoe-holders.

3) Adjust rake and tilt: consider the amount of rake in the seat (usually 5 –
10°) to keep the person comfortable and upright, or adjustable tilt-in-
space option for pressure care and comfort.

4) Provide lateral trunk support: if the person still has poor trunk control
after addressing the above, consider curved backrests or thoracic
supports.

5) Provide shoulder support: consider using, shoulder pads or shoulder-

keepers.

6) Provide anterior trunk support: consider tray and postural chest

harness. Determine the hardware required for mounting a chest harness
e.g. not recommended on a slung back wheelchair.

7) Provide neck and head supports: consider type of headrest required

for travel and for head control. Also consider need for head, chin or eye
control for powered mobility and technology access.

It is important that a postural chest harness does not reduce a person’s function
or development. Ideally all three therapies (occupational therapy, physiotherapy
and speech pathology) should be involved in the seating process, to ensure that
the person’s postural, communication, airway safety, transfer and activity needs
are met. Whilst a harness may provide trunk stability for tasks requiring fine
motor and oral-motor control, such as computer access or mealtime
management, it is also important to consider that the person may also need to
spend some time developing trunk control and core stability without the harness.

Safe Mounting and Fitting of Postural Chest Harnesses

For promotion of airway safety:

 the horizontal strap should be positioned below sternum

 the horizontal strap should fasten at the front

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Mounting Guidelines of Postural Chest Harnesses:

1) Position the horizontal strap buckle fastening in the centre and below
the sternum, level with the lower ribs

2) Secure the lower straps to pull down and toward the seat angle

3) Position the shoulder straps to mid-region of the clavicles

4) Mount the adjustable upper straps onto the backrest, to keep shoulder
straps in alignment.

Horizontal Strap of Harness

 The horizontal strap is used to prevent the shoulder straps from

sliding off the shoulders.
 The horizontal strap should be positioned at a central point below the
sternum, at the height of the lower ribs.
 The horizontal strap should be secured to the padded straps to
prevent it from sliding up towards the airway.
 Check position of PEG and if needed, position a little higher or lower
to clear the PEG.

Lower Straps of Harness

 The lower straps should be secured to the seating system so that they
cannot be easily adjusted or loosened with time.
 The pull of the lower straps should be down and angled towards the
seat angle.
 The lower straps can be mounted onto lower end of backrest (if the
angle is correct), the wheelchair frame or seat pan.

Adjustable Upper and Shoulder Straps of Harness

 Once the lower straps are secure, the upper straps should be used for
adjustment.
 The upper/shoulder straps should extend higher than the shoulders so
that they don’t apply downwards pressure on the person’s shoulders.
 Harness guides can be used to position the shoulder straps so that
they provide anterior support rather than downwards pressure.
 The shoulder straps should be positioned in the mid-region of the
clavicles.
 The shoulder straps should connect with the adjustable upper straps
via buckles.

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Seating Systems with Chest Strap

Some commercially available seating systems provide lateral trunk supports with
a connecting horizontal strap. These can be similar to a chest strap. The
purpose of these straps is not to provide anterior trunk support but to keep the
lateral supports in place.

Due to their proximity to the airway, these could pose a choking hazard if the
person was to slide forward (or downwards) in their chair. Therapists should
use the principles in the seating prescription process as above. They should
ensure that there is a pelvic belt securing the pelvis in the neutral position and
that the person’s feet are supported. Pommels, hip guides, and contouring for
the thighs in the seat can be provided to position the lower body. This is
essential to ensure the person does not slide down in the seat. When adjusting
the lateral supports in these systems, therapists should ensure that the
horizontal strap between the laterals is at least 2 cm away from the chest wall
(sufficient space for a hand to slide between the strap and the chest wall.

TumbleForm Feeder Seats – Harness Issues

A risk management study completed by Children’s Hospital Westmead has identified

that the harness supplied and used on Tumble Forms Feeder Seats do not meet
current best practice guidelines (Bray, Fulton, Petty, 2006).
Tumble Forms Feeder Seats are regularly prescribed and recommended by
occupational therapists for children who require support to sit upright.
These basic seats can be used with a wide variety of children with various levels of
support needs, and as a result are often commonly contained within CST loan pools.
Their benefit to the person and therapists as part of a loan pool is valuable, as they
can be used short term while other options are investigated or sourced.
The harness’ supplied with the Tumble Form Feeder Seats are considered a safety
harness and not a postural harness, with the later being more commonly prescribed by

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therapists. A number of risks with the supplied standard safety harness have been
identified in the risk management study completed by Children’s Hospital Westmead,
primarily that the supplied harness does not comply with the Best Practice Guidelines
for Promoting Airway Safety when Prescribing Seating Supports, The Spastic Centre
NSW (2002).
Tumble Form Feeder seats are still considered a valuable item of equipment to use in
the paediatric population; however only with a substitute postural support harness that
meets current best practice guidelines.
The Children’s Hospital Westmead has designed a replacement harness that meets
current best practice that can be purchased from them, or fabricated by an
appropriately qualified person.
Therapists are advised to not recommend Tumble Form Feeder Seats with the
supplied safety harness but recommend the harness designed by Children’s
Hospital Westmead to be used instead (either purchased or fabricated, pattern
available in Bray, Fulton, Petty, 2006).

Transport Safety Harness

Transport safety harnesses are used when a person has a tendency to release
the vehicle seat belt during travel and their understanding of the safety risk is
poor. A transport harness is not a postural support and is not prescribed to
assist upright sitting. When recommending a transport safety harness there are
many factors you need to consider. Please refer to the Transport Safety
Guidelines for People with a Disability developed by TranSPOT. As the
horizontal strap of the transport safety harness is higher than the sternum, the
therapist should take into consideration the person’s postural stability and
ensure that the person will not submarine or slide forward in the seat whist the
harness is secured. The therapist should provide education to the relevant carer
about not leaving the person left unsupervised with the transport harness in
place.

Documentation and Education to Carers

Education to the main carers should be provided by the therapists involved in

the prescription and mounting of postural chest harnesses. The carers to be
educated will depend on each client’s situation. The therapist should ensure
that the main carers understand:

 the potential choking risks associated with a postural chest harness

 that the horizontal strap should always be below the sternum and in the
centre of the trunk
 that the pelvic strap be fastened and the foot supports be in place before
applying the harness

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  that the lower straps of the harness be secured to the seat and should
not be easily adjustable
 the upper straps be used for adjustment
 to contact the therapist or raise a service request when the seating
components need adjusting or replacing.

The Safe use of a Chest Harness pamphlet can be provided to carers (Victorian
Harness Safety Industry Working Group, 2006).

References:

 Bray, Fulton, Petty (2006) Risk Management Study: Tumble Forms

Harness Project, The Children’s Hospital at Westmead
 Cerebral Palsy Alliance: Best Practice Guidelines for Promoting Airway
Safety when Prescribing Postural Supports (revised May 2010)
 Chan, T., Vike, G., Neuman T., & Clausen, J. (1997). Restraint Position
and Positional Asphyxia. Annals of Emergency Medicine 30(5): 578-586
 Dube, A. & Mitchell, E. (1986). Accidental Strangulation from Vest
Restraints. The Journal of American Medical Association. 256 (19): 2725-
2726
 Howard, J & Reay, D. (1998). Positional Asphyxia. Annals of Emergency
Medicine 32(19): 116-117
 Lange(1998) Anterior Trunk Supports OT Practice December
 Miles, S. (1996). A Case Study of Death by Physical Restraint: New
Lessons from a Photograph. The Journal of American Geriatric Society.
44(3): 291-292
 Perr (1998) Elements of Seating OT Practice October
 TranSPOT (2010) Transport Safety Guidelines for People with a Disability
 Victorian Harness Safety Industries Working Group (2006): Promoting
airway safety when prescribing harnesses for wheelchairs and other
seating devices.
 Zollars, J.A (1994) Special Seating: An Illustrated Guide (revised).
Albuquerque: Prickly Pears Publications.

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Appendix J: Example of a Postural Harness Consent Form
POSTURAL HARNESS CONSENT FORM1
Acknowledgement of information received
Re: [Person’s name]
I acknowledge and accept that: (please check the following boxes)
□ I have received, read and understand the content of the information sheet on Safe Use of a
Chest Harness

□ There may be other carers/pre-school staff/teachers not present today who will need to know
about the harness and I will be responsible for informing them about the ongoing care and
maintenance as well as the risks associated with its use.

□ Each postural harness is fitted according to a person’s individual needs, and will be solely
used for the above named client.

□ The actual and potential safety risks involved with the use of a postural harness, in particular
the risk of airway obstruction or restricted breathing, have been explained and understood.

□ There is the need for continued safety checking and maintenance requirements of this
postural harness, and I will be responsible for ensuring that it is used under correct supervision
at all times.

□ The postural harness is not a Roads and Traffic Authority (RTA) safety restraint.

□ The postural harness must be applied/fitted strictly in accordance with Postural Chest Harness
– Guidelines for Safe Prescription and Fitting (Feb, 2012)

□ The carer/guardian is responsible for monitoring the postural harness for the person’s growth
and postural changes, for example as sitting balance or strength changes. If there is a major
change in the person’s body size then contact the therapist, as the harness may need to be
reviewed.

□ ALWAYS ensure the person is supervised when wearing the postural harness (refer to the
person’s plan as provided with this harness).

I further acknowledge that:

1. The above information has been provided by [organisation] to assist me in making my own
decision regarding safe use of postural harness for __________________
2. I am free to obtain further independent advice from other relevant specialists regarding
postural harnesses.
3. [Organisation] does not accept responsibility for any use of the harness that is contrary to
the advice provided together with this consent

Name:___________________________________
Please circle the appropriate (parent/legally appointed guardian/carer)

Signed: _________________________________ Date:

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Appendix K: Current leading practices supported by
evidence
Intervention Reference
Evidence Based Practice in Assistive Technology (AT)
intervention: is the evidence based practice that guides clinical
decisions for integrating the appropriate assistive technology/ies for (Nicolson et al.,
a person with impairment that is suitable for their physical-psycho- 2012; Ryan,
social-environmental context. A positive assistive technology 2012)
outcome is measure by the degree of personal enhanced
occupational performance, participation and self-image.
Assistive Technology: is a term recognised by the ISO and WHO
ICF classification systems to describe any item, device, piece of (Independent
equipment - whether acquired off the shelf (commercial), modified, Living Centre
or customised and support resource or system - that is applied to WA, 2010;
increase, maintain or improve the functional capabilities for World Health
enhancing occupational engagement, participation and self-image Organization,
for a person with impairment and/or disability. 2001)
Standards ‘ISO 9999’ is a comprehensive list of assistive products
for persons with a disability which incorporates a range of activities
of daily living and instrumental activities of daily living. The (Independent
equipment covered in the product list covers anywhere a person Living Centre
with a disability would need some AT to complete a task (home, WA, 2010)
school, work or leisure)
and throughout their entire lifetime’ (p.8).
The International Classification of Functioning, Disability and
Health (ICF) is a framework for describing and organising
information on functioning and disability. It provides a standard (Ustun, 2010)
language and a conceptual basis for the definition and measurement
of health and disability (p.1).
Context-focused therapy: changing the task or the environment (Novak et al.,
(but not the person) to promote successful task performance. 2013b)

Goal directed/functional training: task specific practice of person (Novak et al.,

centered goal-based activities. 2013b)

Home programs: therapeutic practice of goal-based tasks by the

(Novak et al.,
person, led by the person and/or their carer and supported by the
2013b)
occupational therapist, in the home environment.

Working alliance: in particular, for children, the ability of Roberts (2004)

professionals to enhance the well-being of the entire family,
facilitating choice and control, and helping to navigate the complex Also see The
service system. Working
Alliance.
Early intervention and powered mobility:a child’s ability to drive a (Hardy, 2005;
powered wheelchair is defined by their cognitive readiness, rather Jones & Rivet,

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than a specific chronological age. Safe application of powered 2004)
mobility requires early supervision to enhance learning, however if
successful is related to independent movement and exploratory
play.

Primary service model: describes services commonly delivered by

the consumer’s locally based service. In Australia, the primary
therapist (occupational therapist and/or physiotherapist) is also the (Friesen et al.,
principal prescriber. The primary therapist’s seating and positioning 2014; Schmidt,
experience varies depending on clinician motivation, competing 2015a)
caseload and employer scope of service.

Consultation service model: this describes a secondary level of

service providing expert consultancy to assist the primary seating
service. The consultancy model provides expert advice on best (Eggers et al.,
practice, assists in valuating complex technology prescriptions (to 2009; Schmidt,
support the principal prescriber: the primary therapists). Some 2015a)
consultancy services also provide custom-made solutions.

Multi-skilled teamwork collaboration: a team approach is a (Arledge et al.,

service strategy used to manage complex postural-mobility disability 2011; Dolan,
caseloads. Blended teams of clinical and technical skills (either in- 2013; Donnelly,
house or outsourced externally) deepen the collaborative approach 2015; Eggers et
to problem-solving. Collaborative team communication (information al., 2009;
exchange and transfer of skills) strengthen team decision-making. Schmidt,
2015a)
Person-centred practice and outcome: where the consumer’s (Mortenson et
needs drive the selection of wheelchair-seating-postural technology al., 2008; K
and education designed to improve their specific wheeled-mobility Samuelsson,
and performance. The consumer is an equal partner in their Larsson, &
wheelchair procurement process. Their lived experiences and Thyberg, 1999;
knowledge inform their decision making. Schmidt,
2015a)
Assistive technology: defines any item, device or equipment
(commercially acquired or personally customised) used to enable
physical performance and functional capacity for people living with a
disability. Assistive technologies relevant to positioning and seating
are commonly postural supports, static and dynamic seating
systems and these require prescription expertise, service team Plummer, 2010;
proficiency to supply and fit appropriate postural and seating Schmidt et al.,
systems for people living with a disability, especially when 2015; Stanger &
incorporated within wheelchair system for functional wheeled Oresic, 2003;
mobility.
While some studies have indicated positive outcomes linked with
adaptive seating and pulmonary function, further evidence is
required.

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Considerable research has been undertaken to compare anterior
tilted seat angles on hand function and reach, however there is little
difference noted when comparing 50 anterior, neutral and 50
posterior seated angles on upper limb function for both children with
or without cerebral palsy.

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Appendix L: 24 hour positioning and seating interventions
unsupported in disabilities
Intervention Reference
Neurodevelopmental Treatment (NDT) and passive range of
motion are traditional, common interventions used for people with
disabilities. According to Bobath the goal of NDT is the (Butler &
establishment of normal motor development for children with Darrah, 2001;
cerebral palsy with the aim to prevent contractures and deformities Effgen &
(Butler & Darrah, 2001). Literature shows variable state of practice, McEwen, 2007;
poor adherence to continuing NDT education and confusion about Novak et al.,
current NDT state of practice. Therapist need to keep pace with 2013a;
NDT evolution experienced by Bobath & associates. Papavasiliou,
A focus of sufficient research to justify systematic reviews shows 2009; Stanger &
little evidence to support their effectiveness with respect to Oresic, 2003);
normalizing muscle tone or increasing and improving motor skill
attainment.

Sensory Integration (SI) originally developed by Ayres for children

with sensory processing difficulties. Sensory Integration has been
employed in the treatment of cerebral palsy over many years. There Patel (2005)
is limited evidence to show this is an effective treatment for children
with cerebral palsy.

Neuromuscular Electrical Stimulation (NES) has been used to (Papavasiliou,

increase muscle strength and motor control. While there is evidence 2009; Patel,
in support of the use and effectiveness of neuromuscular electrical 2005; Stanger &
stimulation in children with cerebral palsy, these studies were limited Oresic,
by compounding variables. 2003)Patel
(2005)

Conductive Education: developed in the 1940 by Peto based on a

concept where children with disabilities learn the same way as
typically developing children. Trained CE ‘conductors’ promote and
facilitate intended motor activity through repeated verbal
reinforcement, throughout each and every day. The effectiveness of (Papavasiliou,
conductive education in improving functional capacities of children 2009; Patel,
with cerebral palsy has not been established by controlled studies. 2005; Stanger &
One randomized trial (by Reddihough & colleagues in 1998) Oresic, 2003)
compared a conductive educational approach with equivalent
intensive traditional intervention with 66 participating children with
cerebral palsy. They found similar progress was exhibited by both
groups of children, indicating neither approach was more effective.

Patterning is a passive repetition of sequential steps of typical (Stanger &

development. The concept of patterning is based on the principle Oresic, 2003)
that typical infant development progresses through a pre-

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determined sequence and failure to complete any stage impairs
subsequent development. The effectiveness of patterning has not
been established, therefore not recommended for children with
cerebral palsy.

Vojta approach is based on newborn reflex patterns observed in

children with cerebral palsy interferes with postural development.
The Vojta approach postulates with appropriate stimulation of a
newborn reflex patterns can be provoked and activated in children (Patel, 2005)
with cerebral palsy to facilitate the development of reflex locomotion.
There is scant evidence available to support the Vojta approach as
an positioning intervention for children with cerebral palsy.

Hyperbaric oxygen therapy (HBOT): typically HBOT is aimed at

providing increase oxygen (1 hour given 1-2 times daily for 5-6 days
(40 treatment initially) to injured brain to revive dormant neurons (Patel, 2005)
and/or reduce brain edema. Insufficient evidence to determine
effectiveness and some injurious risk to children

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