GETTING CENTERED
by Cheryl D. Fields,
TeamRehab Report
The way a tilt frame
positions the rider in
space when it is in tilt
raises issues that do
not apply to other
wheelchair frames.
,,&s 9s.
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Figure 1
22 TeamRehab Report
t has been nearly 20 years since the first tilt- near the rear of the seat. These systems raise the
in-space wheelchair frames were made wheelchair rider’s knees above the center of grav,
commercially available. But in the past ity when in tilt. (SeeFigure 1)
A L five, a large influx of designs has emerged l Center pivot: The pivot axis is toward the center.
as manufacturers have developed new and im- There is a counterbalancing that occurs between
proved ways to build them and rehab profes- the front and rear of these frames when in tilt.
sionals have discovered the many applications (See Figure 2)
and benefits of tilt.
l Forward pivot: The frame pivots on a point
Not only are there more choices today, but located beneath the front of the seat. These
there are also more things to consider when try- frames lower the rider’s seat to achieve tilt. (See
ing to select the proper-tilt frame.TeamRehab Figure 3)
Report spoke with leading seating experts and l Floating pivot: The pivot axis moves. This type
wheelchair manufacturers in an effort to find out of pivot allows for a shorter wheelbase than the
what rehab teams should look for when trying other types of tilt frames and helps maintain the
to make the right client-to-product match with system’s stability. (See Figure 4)
The important factors to note about the locaa tilt frame.
tion of a tilt frame’s pivot axis are:
Defining Tilt-in-Space
l It directly affects how the rider is positioned
Tilt-in-space systems, also known as rotation-in- in space as he moves through the tilt mode;
space or orientation-in-space, are typically used l It affects chair balance and maneuverability;
by people who have poor postural control, ab- l In manual systems, it affects the caregiver’s
normal tone, contractures or skeletal deformities. ability to maneuver the tilting mechanism; and
These systems are designed to allow the rider’s l In power systems, the axis needs to be situated
center of gravity to be redistributed while main- so that the seat can achieve tilt without colliding
taining a fixed seat-to-back angle.
with the wheelchair’s power source.
To achieve this redistribution, the entire seating
The way a tilt frame positions the rider in space
mechanism can be tilted from front to back on when it is in tilt raises issues that do not apply
an axis located beneath the seat. There are to other wheelchair frames.
For example, a person with broad shoulders
basically four different types of pivoting mechanisms in tilt frames:
might have trouble using a frame that lowers him
l Rear pivot: The frame pivots on an axis located between the wheels when in tilt. The rehab team
should consider what happens to the rider’s upper extremities when in tilt.
Evaluating these considerations to find the best
solution is the job of the rehab team.
Another important feature of tilt frames is the
seat-to-back angle. Tilt frames are sometimes
viewed as having a seat-to-back angle that is fixed
at 90 degrees. In actuality, most can be adjusted
to a few degrees greater than 90.
The extent to which a tilt frame’s seat-to-back
angle can be opened varies from system to systern. On most, the angle cannot be closed to less
than 90 degrees.
When To Choose Tilt-in-Space
Tilt frames are beneficial because of their gravityassist characteristics. They can be used to manipulate gravity’s pull on the wheelchair rider’s body
to achieve certain goals. Some people cannot sit
in an upright position for prolonged periods without experiencing severe spasticity, digestive or
respiratory difficulties, or problems related to
physical deformity. Some of these same people
cannot tolerate recline.
For this population, tilt-in-space seating provides an opportunity to change position. A person can be upright for some functional activities
and in tilt for comfort or to rest.
“People have found tilt-in-space, as far as a
postural assist goes, is a real powerful thing," says
Kerry Jones, a rehab engineer and part of the
Figure 3
team at Memorial Hospital’s Rehabilitation
Technology Center, in Southbend, Ind.
Another advantage of tilt frames is that they
allow the user to change the direction of the
gravitational pull on the body and subsequently
modify the effects of gravity. Dystrophy clients
and people who are atonic, for example, cannot
fight the forces of gravity. Its constant pull on
their bodies can contribute to postural deformities if not addressed. Tilt can abate these problems by allowing people to change position.
Tilt can also be used for reasons of comfort.
In a tilt unit, the wheelchair rider’s weight can
be shifted while remaining in the chair. This not
only helps the person achieve better blood circulation, but it can also provide pressure relief.
“For those patients who are severely spastic,
we look for the tilt-in-space chair," says Antje
Hunt, MS., P.T., of Rancho Los Amigos Medical Center, Downey, Calif. Tilt gives her clients
the opportunity to change position for comfort
without aggravating spasticity.
Another advantage to tilt frames is their compatibility with contoured seating systems. Unlike
reclining systems, where shearing is an issue, there
is no movement in the seat-to-back angle to
dislodge the person in a tilt frame. Consequently, tilt frames have been described by some therapists as the only true zero-shear systems.
Improved respiration and easier feeding are
other benefits of tilt frames.
The rehab team
needs to evaluate how
a tilting system
will affect other
pieces of equipment
that need to interface
with the chair.
Figure 4
Sept./Oct. 1991 23
While they have proved useful for many people, tilt frames aren’t right for everyone.
“I’d never say that a person with ‘X’ condition should be using a tilt-in-space chair or any
other kind of chair," says Sue Wagner, P.T.,
physical therapy supervisor at Sharp Rehab
Center in San Diego. “It needs to be done case
by case."
Tilt-Specific Concerns
Moss II/Otto Bock
The universal, horizontal wheelbase is made of stainless
steel, and the push handle interface is made of lightweight, aluminum construction. There is a new hand
control for the tilt release and for the brake. Circle 346
on the reader service card.
Elementary Carrie Rover/Tumble Forms
Weighing 67 pounds, this folding stroller has an adjustable tilt seat and removable car seat insert. Circle
340 on the reader service card.
Tiger/Action Technology
This folding rigid chair IS capable of a 45-degree tilt.
The chair weighs 28 pounds, comes in 11 colors and
has a lifetime limited warranty on the frame It is available
custom-built only Circle 342 on the reader service card
Tarsys Tilt System/Tarsys Engineering
The Tarsys Tilt System IS a power tilt-in-space that IS
compatible with standard (non-recliner) power wheelchairs Seat frame IS 3/4-inch wider than nominal seat
size to allow downsizing of frame width Circle 329 on
the reader service card
Even after determining that a tilt frame is the best
option for your client, there are other issues to
address.
The rehab team needs to evaluate how a tilting
system will affect other pieces of equipment that
need to interface with the chair. A person who
uses a lap-top computer and a leg bag, for example, might have problems using some tilt systems
unless appropriate provisions are made.
There is also the issue of stability. Most tiltin-space systems are equipped with anti-tippers.
These devices are ordinarily attached to the rear
of the wheelchair base and are positioned to prevent the chair from tipping over while in tilt. Some
anti-tippers swivel up and down for the wheelchair pusher’s convenience, others are fixed or
removable.
The rehab team should always be clear about
the stability of a system. When possible, a team
member should get in the chair and conduct tests
personally.
If a system is unstable, ask the manufacturer
what can be done to fix the problem. In some
cases, the wheels can be moved back to increase
stability, but such adjustments should only be
made by a qualified supplier or manufacturer.
Transfers
Another question the team should ask is how the
wheelchair rider will be transferred in and out of
the wheelchair.
Rancho’s Hunt says she has had to take some
of her clients out of tilt chairs because family
members complained of transfer difficulties.
Some tilt units feature removable armrests and
footrests; on others, these parts swing away; stil1
others have fixed parts. Front-end design, seat
height and other factors may all affect transfers.
Once the team knows how a person’s transfers
are conducted, it should be able to select a tilt
frame that will accommodate those transferring
needs.
How Much Tilt is Enough?
OTF/Orthofab
This power tilt/recliner IS available in adult and pediatric
models, can achieve a 20-degree tilt and has a rigid
frame It weighs 206 pounds Circle 345 on the reader
service card
24 TeamRehab Report
MlC/LaBac Systems
The MIC IS the first manual tilt-in-space released by
LaBac Systems This frame features a 45-degree tilt,
a clean design and an adjustable seat-to-back angle
Circle 321 on the reader service card
Tilt frames also vary in degree of tilt. In this
respect, there are three different types of systems:
l Fixed-adjustable tilt: These require a tool to
change the degree of tilt.
l Manual-fixed tilt: The degree of tilt can be
changed easily without elaborate tools, usually
by squeezing a trigger located on the chair’s push
handles.
l Power-fixed tilt: These are manipulated by a
power switch. The switch can be configured for
Tilt frames are beneficial
because of their gravity-assist
characteristics. They can be used
to manipulate gravity’s pull
on the wheelchair rider’s body
to achieve certain goals.
access by the wheelchair rider, an attendant, or
both.
A small number of systems combine tilt with
a reclining mode, allowing the user to control not
only the degree of tilt, but the seat-to-backangle
as well. These tilt recliners are good for people
who need a fixed seat-to-back angle but whose
bodies might require a different degree of angle
from day to day.
With the variety of tilt degree options, it is
sometimes hard to decide how much tilt you need
in a system. Greg Peek, president ofLaBac Systems, says, “If the goal is to weight shift, 45
degrees of tilt ought to do it. If the goals are other
than weight shifts, significantly less than 45
degrees should do the job."
Others will tell you that 30 degrees of tilt is all
that is necessary. Yet some wheelchairs tilt as far
as 60 degrees. On the average, tilt-in-space frames
range between 30 to 45 degrees of tilt.
Memorial Hospital’s Jones says, “For some
people, 10 degrees of tilt is all that is needed. It
really depends upon the person."
Jessica Presperin, O.T.R./L, of Sharp Rehab
in San Diego, agrees. “For instance, right now
we’ve got a woman who has a fixed hip. She needs
to be able to get as low as she can in a tilt system
to take the pressure off of her buttocks," she told
TeamRehab Report.
Since everyone has different needs, the degree
of tilt that works for one person might not be the
same for another. It is the rehab team’s responsibility to determine how much tilt is required to
achieve the goals of each rider.
The team should also attempt to simulate the
most extreme tilted positions, so that it can determine how far is too far, for the wheelchair rider.
If a person feels posturally insecure or is unable
to see anything except the ceiling, then a lesser
degree of tilt might be preferred.
Series 2000/Gunnell
Featuring a 60-degree tilt, the Series 2000 is a combination tilt-in-space and recliner frame that tilts on a
rear pivot axis. Hip angle can be changed to meet individual need. Circle 330 on the reader service card.
The Folio TS95 fixed-position recliner is a Win-space
frame that is compatible with the Arrow TX, Lancer, Fortress and Quickie Designs P300 power-base wheelchairs.
It is available with a 60-degree tilt range and an 18-degree
range of seat-to-back adjustment. Circle 320 on the
reader service card.
Enduro Encore2/Wheel
This manual tilt frame is designed for adults who need
a lightweight system with extra width. It features a
45-degree tilt and can grow from 16 to 20 inches in width
and seat depth. Circle 324 on the reader service card.
Quickie TS/Quickie Designs
Designed for use by teens and adults, this new manual
tilt frame features quick-release axles and a fold-down
back for portability. It weighs 39 pounds and will achieve
a 45-degree tilt. Circle 326 on the reader service card.
Caregiver Considerations
Since many systems require a caregiver to activate
the tilt, it is essential to determine who the
primary caregiver is before a manual system is
ordered. Consider the following:
l Will the caregiver need help to tilt the system?
If the caregiver is physically incapable of operating the tilting mechanism, or has difficulty,
Cricket/Ortho-Kinetics I,,,,.
This folding stroller features a tilt ranqe of up to 45
degrees It has a steel frame, pneumatic tires and comes
in two models Circle 338 on the reader service card
Featuring tilt and recline capabilities, the Mulholland
VGF+ frame is designed to address long-term critical
seating needs and offers the widest range of positioning angles available, according to the manufacturer The
frame can be folded for storage and transportation Circle
325 on the reader service card
Sept./Oct. 1991 25
Tilt frames have been described by
some therapists as the only true
zero-shear systems.
.
Impala/l Pin Dot Products
The Impala Tilt-in-space frame will achieve a 29-degree
tilt and comes equjpped with gas cylinders to assist the
tilting mechanism. It also features an adjustable seatto-back angle Circle 328 on the reader service card
Jenna Base/Snug Seat
This tilt-in-space transporter allows parents to position
a child for all daily activities with minimum effort, according to the manufacturer. The 28-pound mobility base
folds down to fit rn most car trunks. It can handle children
up to 70 pounds The oversize wheels give rt a smooth
ride Circle 343 on the reader service card
Luv Base/Whitmyer Biomechanix Inc.
Described by the manufacturer as a mobility
base that doesn’t look like a wheelchair, the
Luv Base can accept a wide variety of
seating systems, features a gas cylinder to
assist with tilt and can achieve a 60-degree
tilt. Circle 332 on the reader service card.
I 8
3
you might
need to choose a powered tilt or one
with a gas cylinder. Although nearly every manual
tilt-in-space system tried byTeamRehab Report’s
reporter was described as “easy” to manipulate,
some were harder to use than others. A professional and the caregiver should always test the
tilt frame, with the wheelchair rider in place,
before prescribing it for the client.
l Where are the push handles located? A small
number of tilt-in-space units have adjustable push
handles, but most do not. Some requirethe caregiver to bend far forward to reach the push
handles when the chair is in tilt. Others have
handles that are fine when in tilt, but awkwardly
positioned when the seat is upright.
Some manufacturers offer attachments that
can be fitted to a chair to address these problems.
Others will customize the handles to a position
that is comfortable for the caregiver.
Knowing what the caregiver needs is often just
as critical as knowing the needs of the client in
order to provide the proper product-to-consumer
matc h.
Other Issues
Knowing where a system will be used is essential.
The team should find out whether a chair can
be turned 360 degrees, while in tilt, in hallways
and other small spaces.
A pediatric frame, for example, that expands
as a child matures, might work well when it is in
its smallest configuration, but could become unwieldy once expanded to full size.
The space needed to turn a system involves, not
only the parts in contact with the floor, but the
foot plates and push handles as well. Remember
that the position of these components changes
when the chair is in full tilt.
The terrain on which the chair must travel is
another consideration. A tilt frame that is likely
to be used in a rural community, or anywhere
where the ground may not be level, needs to have
exceptionally good balance.
There are more tilt-in-space options now than
ever before. Carefully evaluating the specialconsiderations related to using a tilt-in-space should
help you find the best product match for your
client. l
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Tedi-Stoller/Meyra
10. It features a tilt of up to 30 degrees and is adjustable
in the seat-to-back angle, legrests and head areas It IS
fully collapsible and the push handle moves to allow
pushing from forward or rear positions. Circle 333 on
the reader service card.
Bac 3000TS/Luconex
The Bac 3000TS IS a modular tilt-in-space
pediatric wheelchair that converts into a
mobil stander Circle 337 on the reader
service card