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The Sandall Wood Barrell Seat Wheelchair
EQUIPMENT NOTE
The Sandall Wood Barrel1 Seat Wheelchair PAMELA CROME MCSP Senior Physiotherapist. Sandall Wood School. Doncaster
SPASTIC quadraplegic children often have problems with tight adductors or a windswept position, both of which can lead t o dislocation of the hip, pelvic obliquity, scoliosis and associated pain (Scrutton, 1989). Many techniques have been tried to prevent these problems, eg abduction splints, pommels, static barrel seats, carrying the children with legs around the waist, but often surgery is needed t o reduce the femoral head into the socket. The adductor tendon and sometimes the obturator nerve is cut t o varying degrees to allow abduction of the hip and reduction of the femoral head. The hips are held in abduction with broomstick plasters. After removal of the plaster the children go back to their wheelchairs and into postures which lead to the femoral head coming out of joint again and often to the adductor tendon shortening. Time spent each day with the legs abducted can help t o alleviate this but splints are uncomfortable and the static barrel seats are large, cumbersome pieces of equipment that are heavy and difficult t o move. Ideally the children's legs would be abducted for most of the day. An orthopaedic consultant in Doncaster approached the physiotherapy department in Sandall Wood School for Physically Handicapped Children with a request for a mobile barrel seat which would abduct the children's legs whenever they sat in it. The seat would have t o go indoors, outdoors, up kerbs, steps, through doors and in a family car, in other words everywhere the children went. It was at first thought that the best position for hip reduction was with the hip in abduction and extension. However, X-rays showed that the extension element was not needed as the hip reduced when a child was sitting with the hips in abduction and flexion.
Design Our aim was to produce a chair with the following features:
Fig 1
available, mobile, easily folded and can go outside. An 8LC with 12% in rear wheels was considered to be most suitable as it is very stable, with a seat width varying from 10 in to 14 in, and the back wheels are set well back out of the way giving room for the legs t o be abducted and reducing the likelihood of the legs getting caught in the wheels or brakes. For older and taller children a larger chair such as the 9LJ could be adapted but the width, height, stability, weight and wheel positions could cause problems. The modifications described refer only t o the 8LC model. The seat length, ie sacrum t o 1 in behind the knee, was reduced t o fit the child and a barrelled cushion was formed in plywood with a foam and vinyl cover in the new length (a) and width (b) of the seat canvas chosen, 4 in high at its apex (fig 1). The shape of the barrel encourages abduction, external rotation, and some reduction of the hip flexion present in sitting. Two L-shaped brackets were fitted t o the back of the cushion which hooked behind the seat canvas, stopping the cushion sliding forward. The child would sit with legs astride the cushion, legs hanging on either side of the frame of the chair; 30° of abduction was aimed for. Because the seat length is made t o fit the child the legs can also be brought forward with the feet on the footplates. This makes positioning the child in the chair easier and is also an alternative position for the child, the convex cushion encouraging the legs to fall into abduction and lateral rotation. Desk-type arms were added t o accommodate the abduction. The height of the arm (a) is determined by the normal height required for the child (allowing for a tray) plus 4 in to accommodate seat height (fig 2).
0 A convex barrelled seat. 0 Room for the legs t o be abducted. 0
Foot support external t o the frame of the chair.
0 Manoeuvrability. 0 Foldability. 0 Comfort and posture control.
The physiotherapy department contacted the Sheffield Disablement Services Authority whose technical officer was instrumental in the chair's design. It was decided t o adopt a DOH chair as this is readily
A
1 cushion 4 -in
The length of the arm (b) is determined by the distance from the back of the child's bottom t o the hip joint so abduction of the femur will not be restricted (fig 3). The back canvas is raised by 4-in t o the bend in the push handles t o allow for the 4 in seat cushion. If needed, a headrest extension can be fitted (fig 4).
A cut-out tray with the brackets fitting into the back of the armrests is provided (fig 7).
+ Fig 7
The DOH stability test of 12' forwards, sideways and rearwards was achieved with the child in the newly designed chair.
Problems Encountered
A pelvic strap is fitted at a 45O angle to the seat of the chair and fixed to the backrest at the height of the top of the seat cushion, in order to pull the child's pelvis back into the chair (fig 5).
The Velcro stirrups did not provide enough support for one child, and also opened when she put pressure on them. A flat footplate with straps was attached to the frame t o support the foot. Carers do not always position correctly and the child slips forwards or sideways. This was partly alleviated by the pelvic strap, but may be helped by a flattened back section of the cushion. Initially the tray was difficult t o put in place. This was solved by removing the small screws on the brackets t o allow the tray to be pulled forwards off the brackets. The back canvas being in t w o parts caused the child's back to become red. A longer one-piece canvas was made t o stop this.
Fig 5
A wide chest belt is attached to the chair at the appropriate height t o hold the child safely until he is positioned correctly and the tray is in place if needed (fig 6 ) .
Fig 6
Adjustable 'stirrups' made from webbing and Velcro are fitted to hold the feet in while the chair is being moved, and t o help prevent sideways slip. A footboard on the footplates, going back under the chair, will be needed if the seat length has been reduced.
fiwtherapb',June 1990, vol76, no 6
Fig 8: The adapted chair
317
One child lifted her knees over the roll. The front of the barrel seat cushion was wedged up t o prevent her from doing this. It was hoped that the chair would obviate the need for adductor release surgery, but children with very tight hip adductors find the chair uncomfortable. Users must be able t o achieve 30° of abduction bi-laterally. Introducing the Chair Staff concerned were told of the need and reasons for such a chair. The importance of getting the child sitting properly in the chair and the pelvis well back and central was emphasised. Parents also had t o be shown why the modifications had been done and h o w t o use the advantages the chair gives.
Other Advantages
It was found that this sitting position also improved back extension and head control. The chairs are now in use at schools in Doncaster for similar patients with mental handicap and have been very successful. ACKNOWLEDGMENT Thanks to the DSA and Richard Spooner the technical officer for making our ideas materialise, and to the children, parents and education staff with putting up with our innovations and their teething problems. I am also grateful to Mr J R Redden FRCSEd(Orth1,consultant orthopaedic surgeon, who first requested the seat. REFERENCE Scrutton, D (1989). ’The early management of hips in cerebral palsy’ Developmental Medicine and Child Neurology, 31, 108-116.
The B90 Journal Prize TWO CATEGORIES OF ENTRY 1. Students and newly qualified members You are invited to submit an article of 1,500 to 2,000 words based on
ANY TYPE OF COURSE WORK 2. All qualified members Entries in this category may be either
A CASE STUDY A paper describing the clinical management of one patient or a research study involving one subject.
or
A TREATMENT NOTE A short descriptive paper about a treatment approach or clinical technique. For more guidance on presentation please see the centre pages of the April 1 9 9 0 issue of Physiotherapy.
El00 prize in each category Closing date December 1, 1990
To enter the competition, please send your entry to ’Journal Prize’, Chartered Society of Physiotherapy, 14 Bedford Row, London WC1R 4ED. Complete and attach this form or a photocopy, but do not write your name on the entry itself. BLOCK CAPITALS
Name (MrlMrslMiss) .............................................................................
..........CSP membership number..............................
Category: COURSE WORKKASE STUDY/TREATMENT NOTE Address .............................................................................................................................................................................
..............................................................................................................................
Post code
..........................................
Entries will be acknowledged with a postcard, but will not be returned unless this is specifically requested. Winning entries will be published in Physiotherapy. The judges’ decision will be final.
318
PhYsbtherapy, June 1990, vol76, no 6
The Sandall Wood Barrel1 Seat Wheelchair PAMELA CROME MCSP Senior Physiotherapist. Sandall Wood School. Doncaster
SPASTIC quadraplegic children often have problems with tight adductors or a windswept position, both of which can lead t o dislocation of the hip, pelvic obliquity, scoliosis and associated pain (Scrutton, 1989). Many techniques have been tried to prevent these problems, eg abduction splints, pommels, static barrel seats, carrying the children with legs around the waist, but often surgery is needed t o reduce the femoral head into the socket. The adductor tendon and sometimes the obturator nerve is cut t o varying degrees to allow abduction of the hip and reduction of the femoral head. The hips are held in abduction with broomstick plasters. After removal of the plaster the children go back to their wheelchairs and into postures which lead to the femoral head coming out of joint again and often to the adductor tendon shortening. Time spent each day with the legs abducted can help t o alleviate this but splints are uncomfortable and the static barrel seats are large, cumbersome pieces of equipment that are heavy and difficult t o move. Ideally the children's legs would be abducted for most of the day. An orthopaedic consultant in Doncaster approached the physiotherapy department in Sandall Wood School for Physically Handicapped Children with a request for a mobile barrel seat which would abduct the children's legs whenever they sat in it. The seat would have t o go indoors, outdoors, up kerbs, steps, through doors and in a family car, in other words everywhere the children went. It was at first thought that the best position for hip reduction was with the hip in abduction and extension. However, X-rays showed that the extension element was not needed as the hip reduced when a child was sitting with the hips in abduction and flexion.
Design Our aim was to produce a chair with the following features:
Fig 1
available, mobile, easily folded and can go outside. An 8LC with 12% in rear wheels was considered to be most suitable as it is very stable, with a seat width varying from 10 in to 14 in, and the back wheels are set well back out of the way giving room for the legs t o be abducted and reducing the likelihood of the legs getting caught in the wheels or brakes. For older and taller children a larger chair such as the 9LJ could be adapted but the width, height, stability, weight and wheel positions could cause problems. The modifications described refer only t o the 8LC model. The seat length, ie sacrum t o 1 in behind the knee, was reduced t o fit the child and a barrelled cushion was formed in plywood with a foam and vinyl cover in the new length (a) and width (b) of the seat canvas chosen, 4 in high at its apex (fig 1). The shape of the barrel encourages abduction, external rotation, and some reduction of the hip flexion present in sitting. Two L-shaped brackets were fitted t o the back of the cushion which hooked behind the seat canvas, stopping the cushion sliding forward. The child would sit with legs astride the cushion, legs hanging on either side of the frame of the chair; 30° of abduction was aimed for. Because the seat length is made t o fit the child the legs can also be brought forward with the feet on the footplates. This makes positioning the child in the chair easier and is also an alternative position for the child, the convex cushion encouraging the legs to fall into abduction and lateral rotation. Desk-type arms were added t o accommodate the abduction. The height of the arm (a) is determined by the normal height required for the child (allowing for a tray) plus 4 in to accommodate seat height (fig 2).
0 A convex barrelled seat. 0 Room for the legs t o be abducted. 0
Foot support external t o the frame of the chair.
0 Manoeuvrability. 0 Foldability. 0 Comfort and posture control.
The physiotherapy department contacted the Sheffield Disablement Services Authority whose technical officer was instrumental in the chair's design. It was decided t o adopt a DOH chair as this is readily
A
1 cushion 4 -in
The length of the arm (b) is determined by the distance from the back of the child's bottom t o the hip joint so abduction of the femur will not be restricted (fig 3). The back canvas is raised by 4-in t o the bend in the push handles t o allow for the 4 in seat cushion. If needed, a headrest extension can be fitted (fig 4).
A cut-out tray with the brackets fitting into the back of the armrests is provided (fig 7).
+ Fig 7
The DOH stability test of 12' forwards, sideways and rearwards was achieved with the child in the newly designed chair.
Problems Encountered
A pelvic strap is fitted at a 45O angle to the seat of the chair and fixed to the backrest at the height of the top of the seat cushion, in order to pull the child's pelvis back into the chair (fig 5).
The Velcro stirrups did not provide enough support for one child, and also opened when she put pressure on them. A flat footplate with straps was attached to the frame t o support the foot. Carers do not always position correctly and the child slips forwards or sideways. This was partly alleviated by the pelvic strap, but may be helped by a flattened back section of the cushion. Initially the tray was difficult t o put in place. This was solved by removing the small screws on the brackets t o allow the tray to be pulled forwards off the brackets. The back canvas being in t w o parts caused the child's back to become red. A longer one-piece canvas was made t o stop this.
Fig 5
A wide chest belt is attached to the chair at the appropriate height t o hold the child safely until he is positioned correctly and the tray is in place if needed (fig 6 ) .
Fig 6
Adjustable 'stirrups' made from webbing and Velcro are fitted to hold the feet in while the chair is being moved, and t o help prevent sideways slip. A footboard on the footplates, going back under the chair, will be needed if the seat length has been reduced.
fiwtherapb',June 1990, vol76, no 6
Fig 8: The adapted chair
317
One child lifted her knees over the roll. The front of the barrel seat cushion was wedged up t o prevent her from doing this. It was hoped that the chair would obviate the need for adductor release surgery, but children with very tight hip adductors find the chair uncomfortable. Users must be able t o achieve 30° of abduction bi-laterally. Introducing the Chair Staff concerned were told of the need and reasons for such a chair. The importance of getting the child sitting properly in the chair and the pelvis well back and central was emphasised. Parents also had t o be shown why the modifications had been done and h o w t o use the advantages the chair gives.
Other Advantages
It was found that this sitting position also improved back extension and head control. The chairs are now in use at schools in Doncaster for similar patients with mental handicap and have been very successful. ACKNOWLEDGMENT Thanks to the DSA and Richard Spooner the technical officer for making our ideas materialise, and to the children, parents and education staff with putting up with our innovations and their teething problems. I am also grateful to Mr J R Redden FRCSEd(Orth1,consultant orthopaedic surgeon, who first requested the seat. REFERENCE Scrutton, D (1989). ’The early management of hips in cerebral palsy’ Developmental Medicine and Child Neurology, 31, 108-116.
The B90 Journal Prize TWO CATEGORIES OF ENTRY 1. Students and newly qualified members You are invited to submit an article of 1,500 to 2,000 words based on
ANY TYPE OF COURSE WORK 2. All qualified members Entries in this category may be either
A CASE STUDY A paper describing the clinical management of one patient or a research study involving one subject.
or
A TREATMENT NOTE A short descriptive paper about a treatment approach or clinical technique. For more guidance on presentation please see the centre pages of the April 1 9 9 0 issue of Physiotherapy.
El00 prize in each category Closing date December 1, 1990
To enter the competition, please send your entry to ’Journal Prize’, Chartered Society of Physiotherapy, 14 Bedford Row, London WC1R 4ED. Complete and attach this form or a photocopy, but do not write your name on the entry itself. BLOCK CAPITALS
Name (MrlMrslMiss) .............................................................................
..........CSP membership number..............................
Category: COURSE WORKKASE STUDY/TREATMENT NOTE Address .............................................................................................................................................................................
..............................................................................................................................
Post code
..........................................
Entries will be acknowledged with a postcard, but will not be returned unless this is specifically requested. Winning entries will be published in Physiotherapy. The judges’ decision will be final.
318
PhYsbtherapy, June 1990, vol76, no 6