INTERNATIONAL FORUM--Specialized Seating Program in Riyadh
Laith A.A. Al-Falahi, PHD
Mohammed H.S. Al-Turaiki, PHD
ABSTRACT
Over the last 18 months, 77 severely disabled persons have
been provided with specialized seating systems. Most patients were children (75 percent). Sixty-five percent of the
patients were male and 35 percent female. The majority of
patients had cerebral palsy conditions (64 percent). Other
conditions included spinal cord injury (18 percent), muscular dystrophy (10 percent) and multiple orthopedic deformities (8 percent).
Various seating systems were prescribed. For 29 percent
of the cases, the Bead seat was prescribed because it was
found to have several advantages over its rivals, particularly
with respect to in-house fitting and manufacturing. The
Snug system (25 percent) was found unsatisfactory for children who had poor head control. The Pin-Dot modular
system was found to be suitable mostly for domestic and
institutional use. Some problems were also encountered
with other systems.
Key words: Seating systems, wheelchairs, Saudi Arabia
Introductions
The conventional wheelchair does little to provide support
to the spine or diminish abnormal reflex patterns, particularly in children with central nervous system disorders.
Many children with severe disabilities spend much time
each day seated in a wheelchair and receive only short
periods of therapy. A sling seat is contraindicated for these
patients because the hammock effect tends to adduct and
internally rotate the thighs, thereby strengthening the patient's extensor patterns and reducing the size of the effective base of support, with consequent reduction in stability. The sling seat and back provide neither a firm level
pelvic position nor resistance to sideward curvature of the
spine. As the spinal muscles become weaker, scoliosis may
develop with associated deformity, pain and restriction of
cardio-respiratory function (1).
A correct sitting position has profound effects on the
physical and psychological status of an individual with limited standing tolerance. Foam and plywood have been
used for many years to make wheelchair seats. Recently,
new designs for seating systems have increased emphasis
on providing appropriate seating for many categories of
severely disabled people. Studies have included surveys of
the state of the art (2,3,4), descriptions of specialized individual systems (5,6) and comparative cross-over projects
(7). Resource availability is a deciding factor in choosing
special seating systems (8). The benefits of the systems are
more comfort, easier communication, improved education
opportunities, better interaction with peers and better
prospects for independent movement. Good seating enables children to improve head and trunk control and manipulative skills through decreased abnormal muscle tone
and reflex patterns.
This article presents briefly the efforts made so far by the
Joint Centre for Research in Prosthetics & Orthotics
(JCRPO) to provide specialized seating services for all
categories of the disabled population, including children,
adults and the elderly. Several different types of newer
special seating systems were evaluated by considering patient responses, the resources needed to fabricate such
systems, and the advantages and problems found in using
them in the Kingdom of Saudi Arabia. Specialized seating
systems represented 3.1 percent of the total number of
cases requiring prosthetic/orthotic services at Riyadh Medical Rehabilitation Centre during 1991-92 (see Figure 1
).
Background
JCRPO was established in 1986 as a joint venture between
King Saud University and the Ministry of Health in Riyadh. From the beginning of the center's involvement in
seating, it has been apparent no information existed regarding special seating needs of the disabled population.
Since this information was considered essential to orient
the seating program toward relevant clinical problems, the
program's first stage involved a survey of the disabled
population attending Riyadh Medical Rehabilitation Centre clinics and care centers for severely disabled children in
Riyadh.
People with severe disabilities were found to have seating arrangements that were far from adequate. In most
cases, no appropriate seating system was available, and
patients were left to lie in bead bags or on the floor in very
poor postures that could rapidly lead to fixed deformities.
This situation, besides being inconsiderate and uncompassionate on the part of the community, is harmful physically
and psychologically to the disabled person as it isolates him
or her from the community.
Recent surveys in other parts of the world indicate that
out of every million people, nearly 700 require special
seating-70 percent of these are children (9). In the Kingdom of Saudi Arabia, this statistic translates into approximately 6,370 children and 2,730 adults who need special
seating. This figure is increasing throughout the country
because of improved medical care that results in wheelchair use as well as the greater longevity of Saudi citizens.
Therefore, to provide adequate, let alone optimal, seating
for all in need is clearly a major undertaking.
The authors' initial investigations centered on pediatric
demand. Literature was reviewed in detail to increase
knowledge of seating and posture control principles and to
discover the availability of commercial and custom-made
seating systems. As a result of their inquiries, the authors
decided to begin with a limited range of seating systems.
Selections initially consisted of the Pin-Dot modular system and later was extended to include the Canadian Posture Seating Centerb (CPSC) modular and Foam-in-Place
systems, and Beadc and Snug seatsd. With this range, it was
felt the great majority of problems for children and adults
could be solved. One team member attended an international symposium on seating and several short-term
courses to become acquainted with the different types of
seating systems. Several centers in the United States and
Canada were visited also.
Materials and Methods
The seating clinic at JCRPO was established in August
1990 to fill a gap in the field of rehabilitation. Before this
time, the center made few attempts to provide a simple
form of seating service, and there was no organized approach to the prescription of different seating systems to
meet the diversity of disabilities.
The foam-and-plywood system was the only seating option offered to the disabled population. It is the most
versatile system and is relatively inexpensive to fabricate.
However, obtaining an attractive, durable and effective
result depends on experienced and skilled staff. Next, a
molded polypropylene shell was provided, with added removable linings to accommodate growth and worn clothing. Special chairs and modifications to wheelchairs were
made as needed to compensate for deficiencies in available
seating devices, but this approach was inefficient and could
not meet demand.
Consequently, a specialized seating program was necessary to improve seating techniques, devices and services.
Persons with cerebral palsy and other upper-motor neuron
lesions represent the majority of cases that require specialized seating. Since they are largely non-vocal, these patients have a greater need for careful seating than most
groups, fewer alternative positions in which to spend their
time and little ability to change positions.
A multidisciplinary rehabilitation clinic was held once a
week in the JCRPO to evaluate the technical needs of
physically impaired patients and prescribe a system to best
solve each individual seating problem. Weekly clinics
brought a steady stream of patients through the seating
clinic where a team including a physiatrist, physical therapist, orthotist and bioengineer worked together to solve
general and individual problems. After a complete history
of the case was taken and a physical therapist performed a
physical exam, the case was presented to the entire team
for identification of problems, discussion and recommendation of an appropriate seating prescription. A prescription form was designed for completion by one of the therapists attending the clinic. Because of the various backgrounds and experiences of the team members, each one's
input contributed to developing a broad view of the problem, and consequently, a more complete evaluation and
recommendation. Once a prescription was recommended
for a seating system, the patient returned for appropriate
measurements, fitting sessions and training sessions, if required. The patient was given an appointment to come
back after a two-month interval as part of a standard follow-up procedure. Over the past 18 months, 77 patients
were provided with different types of seating systems.
Results
The major diagnostic groups were cerebral palsy, muscular
dystrophy and spinal cord injury (see Table 1
). Forty-nine
patients had cerebral palsy; nine had spinal cord injuries;
eight had muscular dystrophy; five had spina bifida; and six
had other impairments. These cases represented moderately and severely handicapped people ranging in age from
2 to 78 years. The results were analyzed according to age
and sex (see Figure 2
). An overall predominance of male to
female, with a ratio of 2.3:1, was noticed.
Forty-six out of 77 patients were less than 11 years old.
Many patients with neuromuscular and musculoskeletal
disorders had multiple problems. Among the 77 patients
seen, 67 had neuromuscular problems (see Table 2
). Seventeen patients had severe extensor thrust; 10 had hypotonia; four had asymmetrical tonic neck reflex; 17 had poor
head control; and 15 were dysarthric. Four were blind or
visually impaired. There were 131 musculoskeletal problems in the 77 patients. Spinal deformities were common:
22 patients had scoliosis, seven had kyphosis and two had
lordosis. Dislocated hip joints were present in 11 cases and
caused particularly difficult seating problems. Knee deformities were noted in 15 patients, ankle and foot deformities in 24, and upper-extremity deformities and weakness
in 10. Children with cerebral palsy presented the most
complex seating requirements. Fifteen had minimal, 18
had fair, and the remaining had normal head control. All
the children with cerebral palsy had markedly abnormal
motor function, manifested in spastic, athetoid or mixed
movement patterns. None sat independently or was expected to gain such function.
Several types of modular and custom-made seating systems-including the Bead seat, the Snug seat, the Pin-Dot
modular system, the CPSC modular and Foam-in-Place,
and the Jay-seat/backe -were provided (see Table 3
).
Discussion
Children with cerebral palsy comprise the largest group in
need of specialized seating, and they present the most
complex seating requirements. Many children showed a
degree of increased extensor tone or, alternatively, generalized hypotonia.
Satisfactory comfort and functional aims were attainable
with all the seating systems provided. Minimal staff skills
were required to fabricate Pin-Dot and CPSC modular
systems. The Pin-Dot modular seating system permits seat
and back-angle adjustments and is designed to fit standard
size wheelchairs. Patients who received Pin-Dot modular
seating systems used Impala bases; in all cases, no interface
hardware was required. The Pin-Dot modular seating system with Impala base was found to be suitable mostly for
domestic and institutional use.
CPSC Foam-in-Place was difficult to fabricate in a controlled way, and the staff found the toxic foam components
unpleasant to handle. Yet, without central fabrication facilities for custom-made seating, Foam-in-Place can serve a
great number of patients with mild to moderate spinal
deformities.
The Bead system has great potential and adaptability.
The system's flexibility is probably one of its best features
and should have wide appeal. Total spinal support, relief
over bony prominences and other features can be incorporated very easily while the resin is forming. With the Bead
seat, all preceding work is evident, so hopefully a seat will
be made which fulfills all specified criteria. The advantage
of doing everything in-house is the therapist knows immediately if the seat will meet all requirements.
The authors' experience shows when seating systems
must be ordered from overseas, delays are common. Delays are a particular problem with modular systems, as the
patient must be measured before placing the order, and
any delays are directly experienced by the patient and his
parents/guardians. A big stock of various types of products
and components is not preferable because the number of
patients is not sufficient to justify a sizable investment in
one type of seating. Another problem with seating components manufactured overseas is wheelchair interfacing
hardware may not fit wheelchairs in use. Custom design
and eclectic use of various commercially available components can probably solve the most common problems encountered in clinic.
Follow-up was not an easy task with 93 percent of the
patients living outside Riyadh, especially when the lack of
awareness among patients and parents about seating and
its benefits is considered. This problem is compounded by
confusion about the differences between wheelchairs and
seating systems. Some system of follow-up is necessary so
maintenance problems can be handled early. Such a system should allow small modifications to be made as soon as
they are needed-as patients' clinical conditions change or
as growth occurs, allowing maximum benefit from the
equipment.
The most frequent and common obstacles are encountered in and around patients' homes. If the patient, his
family and other care-givers are involved in the planning of
the seating system and its mobility base, and are aware of
the aims of the seating team, it is much more likely that the
chair will be used effectively.
Lifestyle must be carefully considered. One of the problems in the Arabian society is the custom of sitting on the
floor for socializing and dining, which embarrasses patients
who use seating systems and any kind of mobility base.
Similarly, the chair must be compatible with whatever
transport the patient uses. Use of powered mobility is still
new to most practitioners although it is an option for patients with different diagnoses. No services are offered to
install van lifters for these patients.
The shopping centers, department stores, offices,
banks, some hospitals and primary care centers, and other
public buildings are not wheelchair-accessible, which
makes their services out of reach for both manual- and
power-driven wheelchair users. Awareness of the importance of accessibility to all categories of the population
needs to be built into Saudi educational systems in the near
future.
Experience in providing appropriate seating has demonstrated that such a service is in great demand and is essential to the modern management of the disabled population.
We suggest that interested institutions begin their seating
program with the minimally involved patient. Based on
this experience, they can then move forward to the more
complex seating challenges presented by the moderately
and severely impaired patients. The key factors are a thorough initial evaluation of the patient's needs and desires,
an appropriate choice of the seating system based on the
severity of disability, the difficulties likely to be met with
positioning the patient, and a willingness to persevere with
fabrication until a good result is obtained.
MOHAMMED H.S. AL-TURAIKI, PhD, is an orthotist/prosthetist, associate professor and consultant of Orthopedic
and Rehabilitation Bioengineering and the chairman of the
Biomedical Technology Department at King Saud University. He also serves as investigator and director general of the
Joint Centre for Research in Prosthetics & Orthotics and
Rehabilitation (JCRPO) Programmes, P.O. Box 27240,
Riyadh 11417, Kingdom of Saudi Arabia.
LAITH A.A. AL-FALAHI, PhD, is a bioengineer consultant and research coordinator at the JCRPO.
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