Wheel Chat - Your Go-To Mobility Podcast

Wheel Chat: Episode 10 – Rethinking Assessments & Dynamic Seating with Bart Van der Heyden

• Wheel Chat • Season 1 • Episode 10

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In this episode of Wheel Chat, hosts Anthony Mitchell and Justin Boulos are joined by internationally respected physiotherapist and educator Bart Van der Heyden for a thought-provoking conversation on the realities of wheelchair assessments, dynamic seating, and why function—not just posture—must guide our clinical decisions.

With decades of hands-on experience in seating and mobility, Bart challenges outdated thinking and shares practical tools that empower clinicians to provide more meaningful, client-centred solutions. If you’ve ever been frustrated by rigid forms, confusing tone presentations, or “by-the-book” assessments that don’t work in the real world—this episode is for you.

What’s in this episode?

  • What dynamic seating really means—and why it’s more than just extensor tone
  • Who benefits from dynamic support (hint: it's a much broader group than you think)
  • How to use hands-on, functional strategies to guide assessments
  • Rethinking mat evaluations: tone vs. true range of motion
  • When forms fail clinicians—and how to replace them with real clinical reasoning
  • Navigating complex cases by focusing on client goals, not just clinical checklists

Whether you're a therapist, assistive tech professional, or new to the world of seating and mobility, this episode is full of fresh ideas, practical advice, and experience-backed insights that will inspire your next assessment.

Connect with Bart Van der Heyden:

👉 LinkedIn: https://www.linkedin.com/in/bartvanderheydenpt/

 Learn more about Super Seating:

🌐 Website: https://www.super-seating.com/

Email us :
We’d love to hear from you. If you have any questions about this podcast, please email us at wheelchatpod@gmail.com

Follow us : TikTok : https://www.tiktok.com/@wheelchat_podcast

Instagram : https://www.instagram.com/wheelchat_podcast/

Disclaimer: The views and opinions expressed in this podcast are solely those of Anthony and Justin.

Anthony: Hello everyone and welcome to our next episode of Wheel Chat. I'm Anton Mitchell and this is Justin Boulos. Justin, how are you? 

Justin: Good day everyone. Good to see everybody and it's good to have another guest on to the podcast. I think these are going to be the flavor of all our podcast. As much as I enjoy chatting to you Anton I think after our last one it's just, it's nice to have someone to just just drill in a bunch of questions.

So, Bart strap in!

Anthony: Absolutely. No, you're absolutely right. We're absolutely honored to have Bart Van der Heyden with us today, this morning with us. this morning for me, this evening for Justin and this morning for Bart. Bart, how are you?

Bart: I'm good. Thank you. Thank you guys. Hi Justin. Hi Anton. Good morning!

Anthony: it's fab; good morning to you and it's fabulous to have you. Just to tell you a little bit, our listeners about Bart, Bart you are a professional physical, therapist, if I can get that out. You're, also have been for over 19 years specialising in wheelchair seating and mobility along with wound care. You're based in Belgium currently Bart, is that correct?

Bart: Correct. France, Belgium.

Anthony: Exactly. 

Bart: Very beautiful city. Almost as beautiful as Melbourne or wherever you are Justin or is it Sydney? 

Justin: Sydney. Sydney, over here. I'm sure Belgium is, is beautiful. 

Anthony: Yeah, I mean I'm going to throw Leeds into the mix. Leeds has got a lot of pull against these two major cities but we'll, leave it there! Bart, are you okay just to tell us and our listeners, because I have a big spiel here but actually I think it's even nicer for you just to tell us a little bit about your history and how you get to being with us on our podcast today.

Bart: Um, easy question: Justin invited me! So, I'm here because of Justin. Yeah, I'm a physio. I'm, towards the old side. I'm, I studied physical therapy back home in Belgium, in Ghent, and then I moved from Belgium to Germany. I was a physio working in a private clinic with only cerebral palsy, so we saw children at the age of 16 months, up till about 16, 18 years. And that was an unbelievable experience. That was early nineties. We had a fantastic, had a fantastic boss who was, specialised in cerebral palsy. He did crazy things, so we worked actually in Germany. We were probably one of the first clinics to experiment with dynamic seating. So we had custom braces that were cut and they were hinged together with an orthopedic technician. We did that, and then we had, we used elastic straps and that was tone management because we thought, it's incredible that we do Bobath therapy but then we sit them in a static environment. So that was something, that, that was, that we experimented with and back then, 'oh, you can't do that because it was, it's very dangerous. Your kid is going to have deformities.' Look, we are all doing it now you know, so it's not a special thing anymore. So we did that in the nineties. What else?

Yeah. And then I got a call and then they said, 'well, there was a call.' And the guy says, "Well Bart, you want to work in the United States?"

And I said, "Well, yeah, I'm young, I'm single, sounds interesting. Let's do it!"

You know, so let's do it. So I did that and that was interesting because we also did wound care there; as physios and OTs they do wound care.

So that was interesting. I didn't know much about wound care. We didn't have that in Belgium. So they sent me on wound care courses and that's how I got involved in pressure injuries. You know, because then I saw that the protocol of the clinic for managing chronic wounds and perhaps also pressure injuries was outdated.

You know, they still use 'whirlpool' to, to loosen up; 'whirlpool treatment' to loosen up necrotic tissue.

Anthony: Yes.

Bart: So that was, that was then changed. So that was, it was great experience. And then I went back home and then I started consulting. I started consulting for manufacturers. And then about 15 years ago, I said,

"Well, I want to have my own clinic."

So I have my clinic, a clinic with my wife. She's also a physio. And we have a small team of young therapists, fantastic. And were not the biggest, but we try to do a great job with, with a great team. So that's what we do. And I still do training, independent training mainly for manufacturers but also clinicians, organisations, dealer organisations but also hospitals, on seating wound care, pressure injuries, ergonomics. Sometimes I'm outside of this industry too, like there was a company from Germany asking me input on tractors, tractor seats, you know so craziest things but very similar. Yeah, very similar sometimes to what we do. Different angle.

Anthony: Yeah.

Bart: Yeah. But, yeah, so that's me. Yeah. 

Anthony: So if you see Bart in a building site, don't panic. We know what he's doing. Well that's I mean, I don't know how you've got time for anything else Bart, that is an incredible story even just to get here. But with that, I know Justin and I are just hugely excited about having you on the podcast, letting our listeners be educated along with ourselves. You've got a huge wealth of knowledge in all these different areas and I think what's really important for us is that, what we are striving for, Justin and I know just from us chatting and having coffees and talking, is just we want to move forward now, right? We want, we want to develop and learn from the past, but not dwell on the past. Let's go forward, let's become newer in our thoughts, our approaches. You know, you talked about dynamic seating all that time ago. That must have been, at the time people thought you were absolutely bonkers let's be honest about it right?! But look at, like you say, now most manufacturers are offering a dynamic seating option, which is right. It's there; it seems obvious now,

so you know, to have you on to discuss these things. So Justin, where do you want to start? Because we've been chatting loads and I think having Bart on, where do you want to start? Let's kick it off! Let's give, let's really test Bart today! 

Justin: Let's do it! Let's do it! And again, for all the listeners I think a big thing with Anton and I is to have these guests, when we said we wanted to have guests on, was to further our learning. I love that what you said there mate, with like moving forward. Like, I want to move forward my learning. This is where you can't know everything. You're always learning. And so I think it's always good to learn from people who have more experience or have a specialty area to learn from.

Anthony: Yeah.

Justin: And then on that, you mentioned a lot about dynamic seating. Tell me what is it about dynamic seating that you think a lot of people have a misunderstanding about? And what is the purpose of dynamic seating? Why not just put people into their a static seats as we so commonly do? 

Bart: If I may, Justin and Anton, I love what you said. It's all, you guys want to move forward and you already, you have already my full support. I love that because that's basically what we need. We need more people that want to move forward so I love that and that's the secret. You guys need to, you need to bring this industry to the next level, so it's fantastic. So first of all respect for that! My support you got. And then dynamic seating I'm going to make a bold statement. Of course I have, I will get in trouble for this but imagine, I don't know. imagine that somebody puts you in a chair right, imagine that. You able body or person without the need for a wheelchair, but they would put you in a chair, in a wheelchair whatever, and they would expect you to sit in the same position for 12 hours. How would you like that? How would you like that? What would you do? Would you sit still in that chair? Probably not. And now you're putting a person with a disability, a person who suffers from an injury or who has a disability and he's, he or she is perhaps not able to control the muscles in a way that we think is normal, like people with cerebral palsy. Tone management is a challenge, right? It's a central nerve condition so it may not be possible for the, for these people to do it but they do the best they can, right? And you put them in a static environment and you expect them to sit nice, right? How is that possible? It's almost like how can you expect that?! I cannot do it?! But I expected from people with a disability who have less ability to, for instance, control posture. Who perhaps fatigue harder. Who perhaps don't understand what happens to them. And we put them in there and we still do that. You know, so how is that possible? Where is our... how is our thinking? I don't know.

Justin: First thing I want to dive into already is you mentioned cerebral palsy. I guess we can even go into subcat- I'm trying to really work out who is it for, because not everyone even has the muscle strength to move themselves around. So when you say it's cerebral palsy, is it people, like what type of cerebral palsy would they have for, anyone that's listening, what kind of cerebral palsy are they looking at where they might want to consider a dynamic, some sort of dynamic seating?

Bart: Perhaps we can dive into that but, go back on that. So dynamic seating, it depends how you define that. Dynamic seating... I've been, I'm also on the ISO 68 40 committee, in our field and we trying to actually also look into that, you know, what is dynamic seating?

What, how do you define it? Because if you cannot define it, you cannot measure it. So what I would see dynamic seating is that you have a possibility for postural variation you know. So posture is not necessarily the same posture all day. You have the chance to have postural variation. You can change your posture. Depending on physical activities that you want to pursue, perhaps depending on tone, something that does that. And in order to have postureial variation, you can probably say,

"What kind of posture, what variation do I facilitate to change, you know? What is the purpose? What is exactly facilitated to move? What type of movement is that? Is that resistance against the movement?"

And then facilitation after you made that movement to go back to that neutral position. So I think these are all aspects of, that's how I would see postural, dynamic seating. But dynamic seating can be a lot of things in that sense because it can also be an adjustment that you make to standard wheelchair, for instance, you have somebody who has lower extremity movement and you're going to be careful, but you're going to perhaps say,

"Well instead of locking the feet at the foot supports with straps, I'm going perhaps to allow a, an elastic strap to support the lower extremities. And that absorbs energy and that energy then will be beneficial because then the pelvis will remain where it is, you know?"

So you're going to open a kinetic chain, you know, so the purpose of that would be it's after reflection, you say,

"If I'm allowing a segment to move, the distal part of that segment, if that moves that distal part, then I hope to gain control of a proximal segment."

So that's kind of the structure of thinking. If you have a closed kinetic change, so you're closing your distal movement then you lose control of your proximal movement when you have contraction or uncontrolled movement. So who's, who can this be beneficial for? Yeah. A lot of people say, 'oh, it has to be cerebral palsy.' But no, it can also be people with, dementia. It can also be people with MS, ataxia-Friedreich's ataxia- all people that have problems with controlling, controlling movements. But it can also be somebody who doesn't necessarily have a lot of movement but fatigues. So if we are sitting in the same alignment, you kind of in order to to sit upright you need to fight gravity and that's muscle energy; Postural muscles need to fight gravity otherwise you would collapse and you would fall, your head position would be wrong and all that. So if you have that, it might be interesting to say well fatigue will probably occur quicker when you sit in the same alignment. If you move a little bit, it probably is less fatiguing. So it's the same in your chair you know, you sit all the time. If I'm moving a little bit in that chair okay, I can go on for another couple of hours. So this basic seating ergonomics that is applicable to us, but also applicable to wheelchair use so it's, that's also dynamic seating because you're allowing a postural variation with the purpose of being functional, being less fatigue, being more comfortable, being aligned in your chair, whatever it is. Being happy, very important! It's not just about being in the right postures. Being happy, being able to do what, whatever it is that you want to do. So that to me is dynamic seating. Yeah, and it doesn't necessarily need to be an entire wheelchair. It can be components of or breaking down components. For instance another example could be abductor blocks you know, you have people with abductor blocks and then you have an asymmetrical tonic neck reflex or there is movement of lower extremities; isotonic movement perhaps. There's something going on and you have a big abductor block. And ISO terminology said,

"Well, you don't call it an abductor block, we call it now medial distal thigh support."

I was a bit crazy about that too. But then the reasoning behind that was that you don't put the abductor block at the pelvis. Right?

Anthony: Yeah.

Bart: So you put it  medial distal thigh support, you know, so it describes the location of where you place it so- 

Anthony: I'm not laughing at you Bart! I'm just laughing at sometimes the most ridiculous prescription forms you ever have and you think people are just like, 'what is that?! What is that?!' Right?! But yeah thank you for clarifying. Yeah, great. But no, it makes sense as you explain of course. Absolutely. 

Justin: Yeah, I'll just clarify just for, because with our viewers as well, it's not everyone is going to, there's a lot of... exactly what you were saying there Bart like terminology is everything.

But I guess basically to summarise what you're saying is that a dynamic seat and support is something that allows for some sort of postural movement, whether it be a backrest that can open and close on its own or leg rest they can go in and out. And the reason why you do that is because if somebody is trying to move and they're in a fixed position, so say someone wants to extend their legs and we tie their legs down, if they are trying to move their legs and they can't move their legs something else has got to give, right? And this is where the pelvis can come out or this is where back rest can break and things like that.

And I guess the reason why we want to allow that is not only to maintain someone's position but also to following what you said is to reduce fatigue and to increase a bit more comfort. That's a fair summary of what you've said so far? 

Bart: You of course did that much better than I did. 

Justin: I try to, because I know what you're saying, I think of some of the therapists that you might be working with and I'm like, I just really want to... people to drive home this point. Because everything you're saying is so correct and I just want to translate it into as, as simply as possible because I think it's such good stuff for people to know as to why this stuff exists.

And I suppose the questions for me that I would have is, I'm trying to think of which clients have I not necessarily considered it for that I probably should. And is there only the people obviously extending at the legs or is there other people that should be considering dynamic seating?

Bart: You could think, you know it's a thought process. The broader your thought process, the more you see it applicable you know. So what I, we, I think before you do something you should see/assess if it's appropriate, you know, so that's basically your assessment process. And that can be very simple you know, you can say,

"What would happen if I'm replacing something static or a static component with my hands?" You know, you support with your hands and you just say, what would happen if I support with my hands and if I guide a movement rather than inhibit a movement? Right? And where else do I see a benefit occurring? So, and that, that's a simple process. You just putting your hands somewhere; you explain of course to your client what you're doing. You put your hand there and then you just observe and see what happens to the rest of them. And then if that makes it, makes sense, then you probably have a good direction to move forward on, so it's as simple as that. So you use your hands as your postural support, your believable postural support that you place wherever. And then lets see what happens you know. 

Anthony: I often say if we could sell hands we'd be really, really, wealthy. Yeah, for sure! No, I genuinely! No, I loved how you put it previous actually with the dynamic seating because what that did for me actually when I was listening to you Bart was, traditionally

for me with dynamic seating, I would have somebody with a high extensor pattern. So somebody who really hyperextends is what I would say a very natural presentation that I see, and they go into hyperextension, push off the back rest, their pelvis comes up and almost presenting like a banana effect; a reverse banana effect. And then when they come back down, they drop down, their pelvis is sitting ahead now of the back rest. So where you, when they transferred in, you had your bottom at the back of the user, they're now slipped down the seat in presentation and it's like 'ah, right.' So what I thought was, that was an excellent way of telling me actually 'no dynamic seating isn't just that.' Dynamic seating can be just operating the back rest, using tilt in space, changing position, allowing somebody, and I get that and I really like that. But what moves on from that, which I think is really important is what you just said then after, which is actually it's down to the assessment process. How do we know what that person needs? And that's down to the assessment process. And I really want to touch on that and I actually think that people listening or watching, myself included, I'm really intrigued to know what your opinion is on the assessment process. For people who have huge experience, that's one way they'll have their own way of doing it. They'll use maybe a map assessment etc, which we definitely want to talk about. But there's also you know meeting with, no disrespect, an elderly lady or gentleman who maybe doesn't present with such acute need... but how do we ensure that we are actually getting the right wheelchair / offering the right advice

to that individual as well as somebody who needs such a prescriptive wheelchair or solution? Can I put that to you and maybe help us with that? 

Bart: Well, help us I think you know, I think we all try to figure out what works best. I'm not saying I know more or I'm more enlighted than you are; absolutely not. But I have a very simple way of looking at things, you know, so I think if you're trying to do something, wouldn't it be very important that you know what it is that you're trying to do? What is- what it what? Try to define what it is that you're trying to achieve, right? Is it function? Is it prevention of sliding? Is it do more with your hands? It can be all kinds of things, and usually it's your client, it's what's relevant for your client. Sometimes you get carried away and you probably want to do things because you think it's important to do that but it should be about the wheelchair user right? What does he want? Simple example, you said long-term care facility, nursing homes. Well, you could say well the client sits in a kyphosis and slides in the wheelchair. But if they want to sit like this rather, than it's probably annoying for you, more annoying for you than for them right? So perhaps they want something else just like watch TV. I give a stupid example; perhaps it... it could be everything right? Or just relax, be comfortable when they sit in a chair. And then for them, they probably chose sliding as a good option, to get there. And you could say, 'well yeah, but the need that they wanted was being comfortable in their chair.' And then the reaction to that need was sliding. And then of course, perhaps sliding is not the best strategy or perhaps we can have other strategies to have... to fulfill that need but first of all understand why / what the need is.

So I'm, and that's sometimes difficult because you don't have a lot of time. But perhaps you can take advice from the family if the family's there. Take your time to find it out, because think about it, whatever you're going to do afterwards, if it's not going to be what the client has in mind, then basically you have to, you never succeed right? So it's probably important to think about that. 

Justin: It's funny you say that because I've actually got a client coming up soon that is, touches on that point where, what she wants- so she's in a Permobil M3 and she's got a lot of hip, let's just say hip displacement, right? There's internal rotation going on. It's just, it's just very hard to sit and I can get her good, but I've got to physically pull her back into the chair, get her hips right. But she does a standing transfer, and she's quite short, and she loves to do a standing transfer. She wants to go into her bathroom, hold onto her grab rail and plunk her bottom onto it. And then she drives back, reverses out of her bathroom and she sits in the chair in a very posterior tilted, like a very slouched position. And then I'm showing her how to use her power seat functions to independently reposition but she just really needs, she really needs a hoist transfer. And this is a tricky situation where, following what you said, but what does the client want? The client wants to stick to doing what they're doing, which is an independent standing transfer. But what I, and probably the OT want to do is do a hoist transfer because we can't sit her properly and there's going to be ongoing issues.

So there's always, there's sometimes that balance between, what do you want and what does the client want and how do you navigate those tricky situations? And Anton, you probably feel that you probably get the similar things as well. 

Anthony: Absolutely, and I'm intrigued actually Bart, what's your thoughts?

Bart: Ultimately it's going to be the user that decides, ultimately, because it's their chair right? If they want this, you have to do it. So the only thing you can do is inform them about a choice. So I, like what is the consequence of the choice. In your case Justin, what will be the consequence of transferring to daily life, you know, and what is expected to be a challenge then? So, the consequence and then it's their choice. Yeah. 

Justin: Yeah. And I would, I always say the same thing. I guess your role is to make sure the client is informed of the decision. And I guess what would be, what would you advise I tell her in terms of her hip position? I know I can't, I could probably show you a photo now, but let's just picture of someone's hips. She can't get back into the chair and she's not, she's in a destructive posture. Doesn't matter what the posture is. But because of her choice, she's in a destructive posture. Now I could say,

"Hey, that means you're in destructive posture."

And she's going to be like,

"I don't care. I don't even know what that means."

But what does this actually mean to her and why should she care that she's sitting in this way? So she's got cerebral palsy. She never got sleep systems as a kid. She never knew anything about seating. It was just here's your chair and away you go. And now it's caused a typical, unsupported posture for years.

What is the... what should I tell her as in terms of why it's important that we really explore this other option where you're not going to be as independent? 

Bart: So the need of a client, right, we were establishing that it's very important to understand that, but then it doesn't stop there, right? So in order for you to know exactly what it is, because I'm thinking here, 'who's this client? I never seen this client.' I got like two sentences of that client that you described. I feel like I know a little bit what direction you're going to go in but everybody's individual, right? So the next thing that I would do is, I would... how would you be sure what to expect if you don't know much more? And that, and then, I call that 'The BART method', you know 'The BART'. So Bart, me Bart right, so the first thing I need to know is brains, right? So you said brains about. I need to know a little bit of background. And that doesn't, that's your experience as a therapist. And then you could say,

"Well, CP, adult now, she's probably never used the sleep system."

So I expect scoliosis, fixed deformation, perhaps intrapelvic structural changes, abduction, internal rotation. I'm expecting hip limitations, subluxation, relaxation of the hip, contractions of the abductors; perhaps one influences scoliosis. Head position might be off, so I'm probably also not going to expect much in terms of progression with function or tone, you know, so perhaps it's, you know, it's not going to improve much, you know, so I probably can expect, a plateau phase of that user. I don't know, you know, you need to observe that but that's probably your brain, right?

Justin: Yeah.

Bart: And then of course you need to look into the specifics of things, right? So if you have a subluxation, what is then the specific situation? How will that impact- what is then the impact on the entire posture of a hip subluxation for instance, right?

So how, it's extremely crucial because for instance, if your right, if the client's right hip is fixed in terms of abduction and perhaps the seating system has a slight tendency towards providing abduction, the consequence will be a pelvic rotation. And a pelvic rotation will increase scoliosis and the scoliosis will provide an asymmetric arm support and the asymmetric head support will bend, shoulder support will then also bring a poor head position. Right, you see? So I need to understand that, and that's what we call the physical assessment perhaps. And I would look at components that will be fixed, you know, what about the feet? Are the feet and the planter flexion inversion, if they are fixed, how can I accommodate for that? All these things.

Justin: Yeah.

Bart: All these things. 

Justin: And all that stuff is happening I guess. And you're bang on in terms of what's happening.

And again, to translate for anyone who doesn't have the seating experience as Bart, basically what we're saying is if someone's knee, say your, right knee is trying to go in and it doesn't and it doesn't have the flexibility to go back out and you try to make it go out, it's going to twist your pelvis. Something's got to give and these are the things that can happen. And with her, she does have some flexibility in her posture. I'd more just worry like, because she's so short and she goes over a contoured cushion; really she needs a pommel because she does have that flexibility. But we can't use a pom wall, so we have to use a contoured cushion and she can't even get back into the chair. And I'm just trying to work out how do you, what is the informed consent that I should give her. So I said,

"Hey," we'll call her Kate.

"Kate if you continue to do standing transfers and not sit in your chair properly it's going to do..." what to you?

Bart: I would always try to relate it to function, right? So if you if- what would be the consequence if your transfers go wrong? You know because they have their life. What is then the impact of that? I don't know Kate's life in particular but how is she get along in the house? So what would be the impact if a transfer goes wrong? How would that impact her independence? That's how you need to translate. And then also with the postural aspect, you know what I also think is you should say,

"If you have poor posture it has proven impact on digestion, pressure injury, risk, head support, head support position, function, a lot of upper extremity function-"

Anthony: Breathing.

Bart: Yeah breathing, exactly. Yeah kind of a crucial one, breathing! So we know that, so inform them about that, but not just that, but like propose a pathway, so then propose a pathway because then if I know about it, but then the cure is going to be harder than the benefit, then I might not choose to do that you know? So what is the pathway that you're proposing? So I think that's another thing you have to do. Yeah. Yeah. 

Justin: I like that. I like that you said to focus on function because as much as we can talk about clinical benefits of things with clients, really what people care about is how they feel and what they can and can't do.

Bart: Exactly.

Justin: So I think focusing on that and then with the caveat of also it could kill you. You know a pressure, you can get a pressure injury and stuff. If for some reason the function of 'Like hey, if you fall you won't be able to do this or go out to do these other things', will just hit a bit harder than just 'you might get a pressure injury; whatever.'

Anthony: That's definitely resonated with me! That's definitely resonated with me what Bart said about function because I naturally go to explaining to clients,

"Oh no, this physically will happen. Internally you're going to have more pressure on this area, that area, and ultimately this will happen."

But actually we put the most horrendous pictures on cigarette packets, but people seem to smoke, right? So the physical reasoning might not be the driver for somebody to really comprehend, 'oh, this is why I ideally want it.' So I think function is a great shout actually. I think that people could envisage

"Oh, so what you're saying is if I don't potentially do this, I could fall and then that will result in that rather than-" 

Justin: Not going to the shops and not doing this other thing that I enjoy doing.

Anthony: Yeah.

Justin: I think that's really good.

Anthony: Yeah. No, me too.

Justin: But with this, with this assessment as well, following our last conversation around tone, one thing I struggle with is knowing what's tone and what's range of motion because you know where you work with those complex clients and maybe they're a bit excited or they're a bit nervous and you're trying to do a mat assessment, you're trying to understand someone's range of motion. And for me sometimes I feel like just doing the mat assessment gives me a false read in terms of what someone can actually do. Like I'll do an assessment and I'll see someone's hip range and I'm like, 'Ooh, we're going to have to have a backrest angle really far open.' Apologies for our listeners. Yeah, you can picture a really far backrest angle based on this assessment I've done. But really you sit them in the chair, they start to relax and then they're like

"Oh, what was the point of that assessment?"

We could have just sat them in the chair and see how they sit. So tell me with mat assessments and when you're working with people who have varying tones, because that's really where I do mat assessments, is just people who are like super stiff, in one way or another. How do you know the difference between what's excitement versus this is the end of their range of their muscle? 

Bart: I think it's a brilliant question Justin. I've been struggling with this for many years. But to be quite honest with you, I'll probably get in trouble for this so don't share my email address after this, but you know, I think these assessment forms that we currently use, and I looked at many assessment forms, you know they're always looking at snapshots in time, right? So imagine you work with somebody who has a problem with controlling their postural muscles or muscle activity in general. So people with tone, athetoid, cerebral palsy perhaps people with ataxia, all these options that you might have, you have to think they do movements, they do uncontrolled movements, right? That's what it is because of a central nerve disorder most of the time. And then the question really is if you look at it from an assessment, what are we trying to do with the physical part of the assessment?

We are trying to see if something that we prescribe as a fit, as an interface between our client is going to function, right? That might be a head support, back support, whatever it is. And then it also should inform us about how to adjust that. It should inform us what type of interface is going to be adequate for that client. How to adjust it is then the second consequence and then it should be enhancing function or the need of the client, right? So the need of the client tend to be often functional related. And then you have assessment forms. And the assessment forms are static. And they are very stupid in a way because they sometimes say... they look at, if you look at the physical assessment part, they look at every component separate. They look at 'oh, is your pelvis mobile right?' Oh yeah, it's mobile, it's mobile now. But perhaps when there is tone it isn't mobile, right? So it depends. And then you probably say, 'what do I do?' I probably go with the worst case. And the worst case might be a postureior pelvic tilt but then it doesn't say how far that postureior pelvic tilt is. And then the next box on that form is, 'oh, what about hip, angles? And what about knee angles? What about foot angles?' But it's like a whole thing that you have to connect to each other, right? And there's no form that does that. So then I said, if the form is not really helpful and you're spending two, two hours doing that and you don't get data from that, that you can use for your seating eval, then the only reason why you probably should fill that in is to, to kill time or perhaps for funding purposes that people understand what it's that you're doing, but it doesn't help you with your seating! It doesn't help you! So forget it, if it doesn't help you. But you see why you do it? Why? Because I have to do it for my boss, right? That's basically your answer. I have to do. But then what you can do is, and what I usually do is the following very controversial methods. I don't know if it makes sense to do it but if you have a younger user with tone, younger user make sure it's safe. But what I do is I transfer that kid on my lap. On my lap and one size view. So I'm, watching the kid on the side, right on my lap, and you can say,

"Wow, it is dangerous."

Yeah, it's dangerous. But what you can do is perhaps have a hoist transfer, right? And the kid is in the hoist. Or you have a colleague if it's possible or you have the family and you do, or you put mats so it's safe in case something would happen, but it's very useful because now the kid is on my lap and if I'm extending one knee, I'm opening the hip angle. If I'm... well it's difficult to show that but if the kid is on my lap right, and that, that's the back support of the kit, and that's the seat base of the kit. And if I'm extending one knee when the kid is sitting on my lap, I'm opening the hip angle. If I'm lifting or extending the other one, I'm closing the hip angle and then I can see what the effect is on that client. Then I usually allow interactions, so the kid plays with the mom, with the family, and then I see what happens over time. And then I put one arm elbow in the pelvic region and one hand in the thoracic region and then I can play with pelvic position and thoracic position, and I watch the head position of the kid as she's interacting or he's interacting with the parents. And then I do that a couple of times and then I have a good feel of where the push is, where is the flow, what position facilitates the best interaction with the parents, and I do that a couple of times. It's actually therapy because it's proprioceptive training. I'm facilitating upper extremity use. I'm facilitating interaction, so it's part of therapy. And it informs about seating. And then I make little notes of this and then I see if the direction of that support that I'm providing with my hands is consistent with the need for that client. And then I'm making advice. And then you can still trial that equipment but you have a much better feeling of what would work and what wouldn't work. Yeah. Yeah. It works. 

Anthony: I love what you've just said there because I'm very hands on. That's how I do my assessments; always have. I've always found the prescription, I'm coming from a place, I'm not a PT, I'm not an occupational therapist. I've been doing assessments for 20 years now. But you find your own way. You you learn your own ways, but I think that the prescription form is obviously important in terms of prescription of the chair but then the assessment form is obviously equally important. But I think the practical side of the assessment is where you really gain from somebody who needs... your job, my job right is to look at somebody and then apply the principles of what they need towards the right seating. But like what you're saying, Bart is completely right. How do you physic- if you have 45 degree back angle, then 25 this, 30 oh thats great, but what does that mean? How do we apply it? What does that physically end up with the result? And what you're saying is hang on, no. Yes, all these things can be important. Must be important at times, but actually you're talking about a practical solution with physically understanding how their body is working, to then say

"Ah, okay I know what I now need to do but how am I going to do it? I now know."

I think that's a really clever way of doing it. So just so I've got it in my mind's eye Bart, because you explained it really well, but is the child when they transfer or the adult or whoever the transferring onto your lap, is their back toward on your chest or you like- 

Bart: Yeah, the back is so they are sideways, so I'm watching them sideways. Yeah. 

Anthony: Oh, they're sitting across your lap?

Bart: Yeah, across, across, yeah. Sorry, yeah. Across my lap.

Anthony: No, that's okay. That's okay. Alright. Okay.

Bart: And that the back support, and my leg position will influence the pelvic to tie angle, the hip angle. And then I can, the knee towards extension or towards flexion, and I can see a flexion of the knee in combination with closing the hip angle or opening the hip angle, and then in combination with pushing the pelvic force or releasing the pelvis. So giving more pelvic freedom or tilting the thoracic area force and backwards is, the best choice. 

Anthony: Yeah. 

Bart: Then I have a very good direction of something to trial you know. Then I can say to the equipment guy and I say

"Look, you know, I think this would probably work, you know, what kind of equipment would you recommend to make this happen, right?"

And then, and then, it's easy because products are easy but you need to know what the product should do. Yeah. Right yeah. 

Anthony: Yeah. No, I love that. I love that. 

Justin: I'll tell you what, I'll tell you what I do because when, by the time I'm caught in I get to bring out the equipment and I'm working with a power chair. Even if I'm not, I like to bring out a power chair and I've, I do I always speak to someone when they're really complex, they can lie down, right? So why not just get the power chair? And I just get that to a really open back rest angle. So when they hoist into the chair, I just chop them into the chair with a really open back rest angle, you know, exaggerate what we think the seated posture will be. And then once I get them in there, set up the laterals, adjust the hips. Then I slowly start to bring him up. And for me, I feel like that allows them to relax. And by the time they relax, he might bring the back rest up a bit more and a bit more.

And then you can start to see, 'hey, if I go any more than this, that's when something's got to give.' Remember what we said everyone, something's got to give. And when the muscles are at the end range, you're going to see something start to move, whether it be the pelvis or whatever. But that's always my thing. And it's similar to yours Bart in terms of it's just, a practical way of seeing what is actually happening when we transmit. 

Bart: Very similar, yeah, and I like it. You're basically using the function of that power chair to do the assessment for you, right?

Justin: Yeah.

Bart: Because you're going to close the hip back and then you're going to see at what point you see compensation happening. 

Justin: Yeah.

Bart: Very clever I think, yeah, it's very clever.

Justin: And I've always suggested, because there's no manual handling, it allows the clients to relax. You obviously they need to have a power chair around and as a clinician, clinicians won't have that for the assessment. But this is like, even if you are looking at tilt in space chair, I'll say, I'll just say to the supplier

"Hey, can you bring out a power chair? Because I really want to see what their range is."

I think it's going to be easier to set up, when it's just on a power chair. So yeah, that's just different ways to do these complex assessments. Anton, do you have anything yourself as well? Like what do you do when you have these complex ones.

Anthony: So I'm quite traditional in terms of, I'll always look at somebody in their existing chair just to get a picture of you know how they look right. And then I'll get them straight out onto a plinth and lie them in supine and go through the movements like a mat assessment and that actually is interesting because of course I'm making my measurements and what have you but actually I'm looking all the time. Physically, I'm looking at the pelvis where it's moving. So I've got my hands on the PSISs, moving around. I'm, so I'm coming bringing knee to chest, what's the range, hip range? So what I'm looking at all the time is when I'm bringing into flexion, when I'm bringing right knee, left knee etc. I've got my hands, so I've maybe got some assistance at the time, maybe somebody doing it with me and I've got my hands on hips and I'm really feeling actually, oh, I can feel that when somebody comes up at 45, 'ah, we've got rotation here', or we've got the obliquity is, is raised or lowered etc, dependent on that. So I'm really feeling, I'm always feeling, and then when I feel that I might get, I'm saying 'oh, okay, so we've got a left side obliquity, right side rotation, blah, blah, blah.' And then I want to then hoist them up, or sit them up if they're able to help and sit them on the side of the plinth or bench, whichever. And then I'm putting my hands under their bottom and I'm using the principles of what I have, and I'm actually physically doing it. And then if somebody can sit with maybe somebody on the side, I can then swap with them and I can get a feel to see actually, 'oh, they're leaning now, but if I raise / level the pelvis, or I try to square the pelvis, or maybe I want to drop the pelvis dependent, am I giving less support? Am I getting more support?' So I'm... I love the fact of what both of you have said. Actually, I'm going to take, I'm going to use certain things. My only thing is that sometimes we have such complex patients that you want to make sure that the seat depth is right on everything, right? If you've got somebody at 13 inches seat depth on their left and 15 on their right, if I sit them in a 16 inch depth they're immediately going to come into sacral posterior pelvic tilt because the seat depths incorrect. I suppose what I need to bare in mind is if I'm going to sit them in a wheelchair, it might not specifically have the right depth there and then using your principles Justin, of the power chair and showing it, but I'd like the fact that it will help on the practical level to, you'll see at that point where does the hips move forward? Where we maybe having more rotation? I just physically love getting my hands on the client. It sounds a bit wrong that, but I really, I really, I think that's the only way you can physically... I'm a very visual person, so if I see it and I feel it, I can then apply that and go, 'ah, this is what I want to do with the seat cushion or the back rest', or both, obviously. But that we all have our own ways of doing it, I think that's what this is really raised and I love that. And I think that goes back to what you were saying Bart is, forms are great but actually what do they do? Really?

Bart: Yeah.

Anthony: Right? What they're doing, they're giving evidence towards what we've done; to tick a box.

But actually who cares? If the person gets the wrong seating solution, we might have the best results of taking down all the right results. But if we've got the wrong seating solution, well we've not done our job right you know? So parents, husband, wife, more importantly, the end user if we've not, if we've not helped them, it doesn't matter if we give them the best report in the world and say, 'oh, there you go. That's how you are.' But you're uncomfortable and you can't watch TV now or you've got to be in bed for longer or this, that and the other. You know we've not done our job right. So I love this practical side. It's bringing up, it's evoking so much thoughts in my head while you guys are chatting, 'like oh, could we do this? Could we do that?' So I think, I'm sure people listening will have the same thoughts and everyone who is listening please feel free to send us emails in, send us questions. We can come back and try and answer these and, I'm sure Bart will be happy to try and answer those as well. We are, there's so much to talk about. We are very lucky that Bart is going to be with us for another episode, which we are absolutely delighted with. Justin, anything you want to do in closing on this episode? Anything you want to say? 

Justin: No, I just think that there's, yeah, you're right. There's so much things we can chat about but I think the main take home messages from this stuff is, yeah I guess for me what I've even taken from you Bart today is mostly when you're speaking to clients, really focus on the function impact. And so when you're speaking to them, like really try to get to what relates to them and that it's okay, like in terms of these forms, like I think those forms are probably what steer people away. But before we were on this call, you even saying that you really want to empower the younger generation to take on wheelchairs and seating

and I think a big fear of that is they look at these forms and they think, 'if I get this wrong, they're going to have the wrong chair.' Which to me, and to everyone listening, I feel like these forms, they can be useful. They can be like a guide, they can be like a guide to say- 

Bart: Yeah. 

Justin: It's just exactly what it is. Like it, it's a mechanical assessment tool. It's a tool to indicate what we're going to do for trial and on, and your tool is just one part of the puzzle. Because you might have done an assessment and you might have felt someone was really stiff. And then once they relaxed or once they had their injections or their medication or something, they're actually not that bad.

So it was just something to say

"Hey, I noticed it was like this, so let's trial this. But then on the trial we actually got this," and then you can go from there. So hopefully that empowers people a bit more. There was so much I wanted to ask you Bart do you want to come in maybe another time we could talk about a bunch of other questions I have for you?

Bart: Alright. Yeah. Alright. I love what you guys do. I think it's fantastic to do podcast.

Anthony: Thanks Bart. 

Bart: Much more interesting than reading, you know, so I think fantastic what you do. Love it. 

Anthony: Yeah, we've got so much more to talk about but luckily we have Bart on for another episode. Stay tuned for that. Guys, thanks for listening as always. It is an absolute pleasure, but please don't forget, Justin?

Justin: Like, comment and subscribe.

Anthony: Like, comment and subscribe guys.

Justin: Well just do one of them. Don't do all of them. Let's just say, just pick one today. 

Anthony: Yeah, pick one. Good shout, pick one. But guys, it's really important that you do because it allows us to really evaluate and move forward and give you content that you guys are looking for. We really appreciate you tuning in and we look forward to having you on our next chat. Thank you for listening to Wheel Chat. I'm going to close on one line that I've taken from Bart today, and that is

"If you can't define it, you can't measure it."

Justin: Can't measure it. Ah, yeah, I remember that as well. That's good. Thanks for listening.

Anthony: Take care guys. Thank you guys.

Justin: Thanks, Bart.