Michelle L. Lange, OTR/L, ABDA, ATP/SMS
Jonathan is a 23 year old man with the diagnosis of cerebral palsy. I have seen him for evaluation of his positioning system and access to his speech generating device several times now. He also works closely with Lindsey Rae of Numotion in Colorado Springs, CO. For more information on Jonathan, please also see his Case Study. Jonathan has increased muscle tone – and I mean, INCREASED. He exerts tremendous forces throughout his body. He is on tone reducing medications, though these have had little impact. His spine is fused, yet he still has significant spinal extension. He has a molded seating system to help maintain his overall posture.
Jonathan would extend his neck with such force that he would push his trunk off the surface of the back and remain in neck hyperextension. This hyperextended position increased his risk of aspirating his secretions and resulted in him looking up at the ceiling most of the time. He also broke the static head support hardware multiple times. The head support was constantly loose and in need of adjustment.
Seating Dynamics dynamic head support hardware was placed on the wheelchair, however Jonathan initially continued to push into hyperextension (see Figure 1). The elastomers were changed to increase resistance and the head support hardware was adjusted. As a result, Jonathan was able to maintain a neutral head alignment and move into some extension without hyperextending his neck (see Figure 2). He has no longer broken the head support and mounting hardware and everything remains in the correct position.
Head position is also key to Jonathan’s communication. He uses a switch mounted by the left side of his head to access his speech generating device. Now that he can maintain his head position, he is able to activate this switch consistently.
Dynamic Back and Footrests
Although dynamic seating at the head was helping, Jonathan still exhibited forceful extension through his hips and knees. A Dynamic Back and Dynamic Footrests were considered. During the evaluation, a Dynamic Back was ‘simulated’ to determine if this may be beneficial for Jonathan. Jonathan was placed in a seated position on the edge of a mat table with the therapist behind him for support. He was allowed to extend at the hips (approximately 10 degrees) until his tone relaxed and then the therapist slowly brought him back to a neutral starting position. As this was successful in simulation, a Dynamic Rocker Back interface (DRBi) was recommended (click here to watch a video of this simulation).
Dynamic Footrests were ‘simulated’ during the evaluation by swinging the footrest hangers away to the sides of the wheelchair. Not able to leverage off the footplates, Jonathan demonstrated reduced lower extremity extension (click here to watch a video of this simulation). As a result, Dynamic Footrests were recommended, as well. He required the telescoping and elevating features. He does not require dynamic dorsi / plantarflexion as he wears AFOs.
Jonathan enjoys this new movement. Overall, he is staying in better contact with his molded seating system, rather than moving in relation to these surfaces as he used to do. He has not broken any components since receiving this equipment. Jonathan appears to be more relaxed and his body is quieter. And, he can communicate better using his switch to access his speech generating device. We hope to evaluate Jonathan for power mobility soon.
** This post was originally published on https://www.seatingdynamics.com/2020/08/17/dynamic-stories-jonathan-and-tone-that-wont-quit/