ATP Series

Building a Better Backrest

Form, Functionality & the Future of Wheelchair Backs

BackrestIt has a deceptively simple name, and in some situations, perhaps there is little expected of a wheelchair backrest. Certainly, expectations on the durable medical equipment side of the industry can be quite basic.

But it’s a different story in complex rehab technology (CRT), where full-time wheelchair use puts more emphasis on maximum functionality out of every component.

We asked a range of CRT professionals about backrests from their perspectives:

  • Scott Brown, national sales manager, Stealth Products
  • Suzanne Eason, OT/L
  • Cindi Petito, OTR/L, ATP, CAPS, owner, CHAS Group
  • Jeff Rogers, senior JAY seating product manager, Sunrise Medical

In addition, we asked engineer/wheelchair user Todd Hargroder, Accessible Designs Inc., for his input (see sidebar).

Q: DME vs. CRT Backrests

Mobility Management: What are the main functions of a backrest that’s on a complex rehab power or manual wheelchair? How do those functions and expectations differ from the sling-style backrest on a general-use manual wheelchair or a captain’s-style back on a consumer power chair?

Jeff Rogers: If you look at sling upholstery, its primary job is to keep you from falling out. That’s about as much as it can really do. In some cases, it can be a little more involved, when it’s tension adjustable. But overall, its primary focus is to make sure you don’t go out the back.

Scott Brown: The primary function of a “backrest” is simply to provide the client with a posterior resting spot. The outcome is directed more toward comfort than positioning. Many of these products (e.g., sling style, captain’s style) do not integrate additional functions that would allow us to reposition the client, or accommodate for postural deformities, effectively within the mobility environment.

Suzanne Eason: When looking at someone who requires a great deal of postural support throughout the trunk, neck and head, we want to look for a back that complements what they can do and compensates for what they cannot do.

For example, a person may have a well-seated pelvis and lumbar area, but may collapse through the trunk and neck region — a backrest may need to be taller with well-fitting lateral supports. Off-the-shelf backs are often meant for someone with little to no postural asymmetries and may be more harmful than supporting without custom modifications.

Cindi Petito: With the exception of adjustable-tension, soft sling backs, where you can do some minor positioning for patients with kyphosis or posterior pelvic tilt, standard sling backs and captain seat backs are not adjustable and provide no positioning or skin-protection qualities. They cannot be changed or modified to meet the needs of a complex rehab client.

I would choose a sling back if the end-user wants to fold the manual chair, keep it lightweight, or has a preference for a sling back.

The main function [of a CRT back] is contoured support, both posterior and lateral support, and whether or not the back can be modified to meet individual needs of the client.

The second feature I look for with back support is the type of foam and fabric to meet the needs of those who have bony spinal prominences or heat issues.

The third feature would be if the back can be modified for complex rehab patients or is able to accommodate complex spinal deformities.

Q: Top Qualities in a Backrest

MM: What are the most important considerations when designing a complex rehab backrest? How crucial are such factors as backrest adjustability and backrest weight?

Scott Brown: Complex rehab “back supports” are designed with client accommodation in mind. These options provide us with a wide range of features, such as adjustable back height and seat/back angle, customization, removability, etc. This level of personalization results in a more function-driven outcome, addressing the postural needs that are unique to the individual.

Cindi Petito: Weight is the primary feature needed for wheelchair backs that are used on manual wheelchairs. Backrest adjustability is very critical in meeting the positioning needs of patients with progressive neuromuscular diseases. It is also critical for those where primary positioning needs are to accommodate complex spinal deformities.

The third consideration when thinking about adjustability is if the medical team recommends surgical (invasive and non-invasive) [interventions] and the patient’s posture will change. A modular backrest that can accommodate postural change is important in this scenario.

Suzanne Eason: Tilt-in-space frame systems are often used for complex rehab, especially if someone is not able to relieve pressure from their backs and bottoms through active movement. Tilt-in-space frames are very heavy, and because of this, I typically do not worry about the weight of the back.

A few things I would like in a custom complex back are adjustability, especially if the client is young or has a progressive condition — that the back is able to contour to all parts of the client’s body so they do not take excessive pressure, that the back is cool (temperature), has some dynamic movement and has a low visual profile so you see the person and not the chair.

Jeff Rogers: Trying to develop a back that’s really focused in a complex rehab environment — a lot of it is about adjustability, being able to move the backrest, to adjust it, to really focus on unique needs of that individual. My saying with cushions is no two butts are the same. I think the same applies to the backrest.

I think we err on the side of over-engineering, making sure that we have plenty of adjustment range, whether it be back angle or back height. That’s the key of the adjustability: making sure it fits well, supports the individual, helps them extend their day by making them able to sit longer.

We err on the side of having a lot of adjustment range, but we also start to tailor to those individuals that may need a certain thing: less adjustment on one side, more adjustment on the other. We try to tailor that if we can, but if we can give the dealer or the clinician more of an adjustment range, the better off they are, because they’re not going to have problems later when they can’t get it to fit the individual and have to either buy new parts or go with a different backrest.

I think it’s critical [that a clinician or ATP can adjust a backrest in real time, while the client is in the clinic]. A lot of times, when a person gets fit for their chair or their back, they’re venturing in from 10 or 100 miles away. They may not come back into clinic again for months. So being able to adjust [the backrest] on the fly and have the back adapt to the individual with the things they have there at their disposal is critical because you may be hindering the person, who won’t have a backrest that fits for months until they can get back in and see that clinic or clinician again.

Q: What Will Backrest Innovation Look Like?

MM: Today’s CRT backrests are evolving — in materials and construction, in adjustability, in how they impact the client’s environment. What design/engineering innovations do you expect from tomorrow’s backrests?

Cindi Petito: Breathability and the client’s environment are important factors. When considering foams and covers for backs, using cooling foams and breathable covers that do not retain heat is very important for comfort and skin protection.

Suzanne Eason: Heating and cooling capabilities, computerized/mechanical adjustments throughout the day to allow for improved bodily functions and trunk flexibility.

Scott Brown: The design and construct of back supports continues to evolve. Introduction of lighter-weight materials such as carbon fiber provides a positive strength-to-weight ratio. New designs providing a higher degree of breathability to dissipate heat and moisture away from the client are being utilized.

Incorporating modularity, or the ability to quickly configure and modify components, expands our capability to manage change in condition over the course of the product use.

Jeff Rogers: When we launched this product [Sunrise’s new JAY J3 HV back with adjustable microclimate], we didn’t want to sacrifice adjustability, how the back functions, how it worked and how it interacts with the customer. Weight was definitely a big consideration. As you look at the more high-end types of wheelchairs in the market today, that’s the buzzword with every one of them: How much does it weigh, what’s its transport weight?

For this system, we saw an advantage for people with certain diagnoses who may have a tendency to present a certain way. Someone with multiple sclerosis has a tendency to have a hard time controlling their core body temperature. Same thing with a spinal cord injury. And we saw that need. That’s where we went with this. We truly saw a need out there, and if some [consumers] are able to pay for this, then great — let’s provide it and see how it goes, see how it evolves. If we can help this get rolling and our competitors start doing the same, I think it’s great. I think it’s providing a solution to a problem for our customers.

Q: What Should the Assessment Accomplish?

MM: When a seating team is trying to determine the ideal backrest for a wheelchair user, what factors should they consider? What questions should they ask of the wheelchair consumer?

Suzanne Eason: The client and their family are the first and most important consideration. Next is how much control the client has posturally. How much support they need and if their trunk can be aligned well or if they cannot be aligned well, what and how do they need to be accommodated specifically to see, breathe and interact with their environment.

Cindi Petito: The first factor a seating team should assess is does the client have any spinal or postural deformities? How much, if any, correction do you want to accomplish with the back, or do you want to accommodate?

I also assess pelvic positioning — do you need support through the back to support the PSIS to bring the pelvis position into neutral? Do you need to provide any pelvic positioning through the backrest?

Considering heat and skin integrity and any bony spinal prominences is very important. Do you want scapular support, or does the client need their scapulas free for upper-body function, such as propelling a wheelchair? Do they need lateral trunk support?

These are all important questions for the postural seating team to consider and ultimately determine the choice of backrest between aftermarket, aftermarket that can be customized, or a custom modular back that can be modified to meet the individual complex needs of the client.

Scott Brown: When determining the proper back support for your client, there are numerous considerations, which may include but are not limited to:

— What did they like/dislike about their previous back support?
— What level of positioning support is needed (e.g., back height, depth of contour, etc.)?
— Are we trying to correct a postural asymmetry or accommodate for a fixed deformity? This may determine whether a custom back is required or whether a pre-fabricated option is appropriate.
— Are lateral thoracic supports integrated into the design, or can they be added?
— Daily activities: What does their normal day look like? This can allow us to match the proper back design to maximize functional ability.
— What type of mobility device do they use, how adjustable is the seat depth, back angle, etc.? This may steer us toward different hardware attachment styles and variations.
— How important is the weight of the back support? If the client is in an ultralight wheelchair, we may want to consider carbon fiber as a material option to minimize added weight to the chair.
— How is the individual transported? Do they require a transport-certified back support?
— Do they fold their chair, and if so, do they need a removable back so they can fold the frame?
— How does the individual transfer in and out of their mobility device? This will be impacted by the type of lateral support introduced (e.g., integrated laterals may require a different type of transfer method than swing-away laterals).
— Do they have issues with heat buildup? Do we need to maximize breathability?
— Is a caregiver involved, and what is their level of involvement? This can often be a determining factor in the type of hardware selected for that individual.
— How much change in condition is anticipated? This may speak to the adaptability required in a back support.

Jeff Rogers: Is there one single question you can ask? No, I think [the assessment] just gets a little easier and comes with time.

But you can try to understand more about their environment and understand what they do. If you have someone that’s transferring on a daily basis and it’s problematic when something is confining them, you’re probably not going to want to do a deep backrest that really wraps around the body. You probably want to do swingaway laterals.

You’re going to try to understand what their day-to-day life looks like to help understand what back would suit them the best. And having that adjustability already in the back is going to help a lot so regardless of how close you get it, you know you can tweak it in the field.

This article originally appeared in the August 2017 issue of Mobility Management.

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