Wheel Chat - Your Go-To Mobility Podcast

Wheel Chat: Episode 11 – MAT Assessments, Hip Subluxation & the Science of Seating with Rubén Serrano

• Wheel Chat • Season 1 • Episode 11

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In this episode of Wheel Chat, hosts Anthony Mitchell and Justin Boulos are joined by Spanish occupational therapist and clinical educator Rubén Serrano, known for his evidence-based content on wheelchair seating and biomechanics. Broadcasting all the way from Spain, Rubén brings clarity, passion, and precision to the often misunderstood world of MAT assessments, hip development, and seating strategies for complex postures.

From biomechanical insights to real-world clinical challenges, this episode explores what it really means to provide intelligent, functional, and safe wheelchair seating—backed by science, not guesswork.

What’s in this episode?

  • Why MAT (Mechanical Assessment Tool) assessments matter—and how to do them right
  • Understanding hip subluxation, internal rotation, and the biomechanics behind seating decisions
  • Standing vs. seating: What really helps prevent hip dislocation in children?
  • The truth about pommels, abductors, and contoured cushions
  • How tight hamstrings, spinal alignment, and pelvic rotation all connect
  • Real talk on clinical decision-making, cultural differences, and user goals
  • Why assessments must go beyond checklists and embrace function, tolerance, and anatomy

 Whether you're new to MAT assessments or looking to deepen your understanding of complex seating needs, this episode delivers practical takeaways and thought-provoking perspectives.  A must-listen for therapists, ATPs, and anyone striving to turn clinical theory into real-world seating solutions. 

Connect with Rubén Serrano:

📸 Instagram: https://www.instagram.com/rubenserrano_to/

👉 LinkedIn: https://www.linkedin.com/in/rub%C3%A9n-serrano-b0bba141/

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 and welcome back to Wheel Chat! Wheel Chat! Good afternoon, good morning, good evening, wherever we're coming to you from. I am Anton and this is- 

Justin: Wheel Chat! Anton. Anton. I love how much gusto you come in on the morning mate. It's like the break of dawn where you are and you're just like, I'm ready to go! So excited for today. 

Anthony: Thanks Justin, but I'm gonna have to be honest with the, with the listeners. I have slept in guys. It is 6:00am in the morning here; well, it's now 6:30. Our most fabulous, wonderful, understanding guest who Justin is going to introduce in a moment has been extremely understanding. I don't know if it's been a good thing or a bad thing for him that he's had to chat to you for half an hour to kill time, but... nah, I'm only joking! It's been, thank you guys. And apologies listeners, although you hasn't affected you guys. I am now alive and well and enjoying. So without further ado, Justin, can you introduce our most amazing guest?

Justin: I would, yeah, it would be my honour. So this is, we have, Rubén Ser- Serrano? Is that how you say it, Rubén? 

Rubén: Yes. Serrano. It sounds in Spanish, but it's okay. 

Justin: Rubén, who's an occupational therapist and a clinical educator on seating and mobility, who's been doing it for about 15 years; really knowledgeable guy. I first stumbled upon him on Instagram, seen him post a bunch of content about wheelchairs and seating, but it is all in Spanish, so I can't appreciate it! But it looks like he's talking about some dope stuff, so I cannot wait to hear what it actually means in English. So I brought him onto the podcast.

Rubén , good morning to you. 

Rubén: Good morning. Thank you. Thank you both of you for the invitation. Thank you for the advice; maybe I need to start to add subtitles in English! Because I think if I start to do it in English, speaking myself in English, probably I'm going to lose all my followers but maybe-

Anthony: Do it in English!

Justin: Do it in English. Tell me Rubén about your Instagram page and we'll put it in the show notes as well. It's Rubén Serrano_TO which is, is that OT backwards? What's 'TO'? 

Rubén: Yeah, 'TO' is 'terapeuta ocupacional'. It would be the same that OT = Occupational therapies. In Spanish, the adjectives is going after the name no?

Anthony: It sounds so much sexier, doesn't it? 

Justin: The way you said it. 

Anthony: Yeah. Yeah. What do you do? I'm an occupational therapist. What do you do? I'm a- 

Justin: Occupational, no, no therapy of, I can't remember what you just said. 

Anthony: I don't even know what you said Rubén but it sounded amazing. No, I'm only joking.

Yeah, No, I'm- 

Rubén: The good thing in my family, my sister is OT too and my father is called 'Theo'; it is like Theo, no.

Anthony: Yeah.

Rubén: So I can say that in my family we are all 'TO's, because in Spanish Theo, it sounds like 'TO'. 

Anthony: Yeah. 

Justin: There you go.

Rubén: Even my father is 'TO', so we are a 'TO' family.

Anthony: I love that.

Justin: That's awesome.

Anthony: I love that.

Rubén: It's a joke but it's okay.

Anthony: No, I like it.

Rubén: It's fine.

Anthony: Yeah. Yeah. 

Justin: I've got to ask this to start off; what made you first start posting about wheelchairs and seating? Because it's on like your, your own certain thing. So it's not necessarily a part of an organisation you're with, it's just, is this just your regular Instagram profile, or is this like a separate business one as well? 

Rubén: Actually, I started this Instagram account when I started to see that there was a lot of content of seating, but not always in a saying right things. So even I would say if you look at my Instagram account, it's like very, I try to take care a lot of the evidence behind of that, of the justification or, I don't know, trying to explain what's behind, or the science behind of seating, and that was the aim. It's totally personal actually. I try not to talk about brands. Obviously it is, it's very difficult not mix it with, not mixing with some brands because you know that the products are related sometimes with the features of the, of some products and what you can do with some of them. But I think it was important not to talk about products even more if you consider that I'm working in distribution and when I visit all the places trying to recommend something- "Oh, okay you are recommended me this because you are from this brand no?"

Justin: Yeah.

Rubén: So for that reason, it's quite difficult to find a lot of post talking about specific products. I try to talk about the science of seating behind those products. No, not the product actually. 

Justin: We got things like Professor Xavier over here as well. We've got the little, the doll, the figurines, like the ones behind you. 

Rubén: Well, if you can see I have a lot of dolls like that. And I have two Hammiees, but now I have ribcage. 

Justin: Yeah. Now the, the Hammie now has the ribcage as well for a 24 hour position in doesn't he?

Rubén: Yeah, exactly. 

Justin: So for those who don't know what if, who aren't watching at the moment, I'm just going through Rubén 's Instagram page and he's going through a product which is called the Hammie, which is a really good tool for educating people on how the body works. It's basically like a little figurine that has ropes and things attached to it. When you pull on one you see something else move for, for example like your hamstring, if you extend the knee, it may pull onto the hips and rotate the hips depending on how long you have the string or how flexible the person may be, which is it's a really cool tool. I want to get one. I'll get one one day. So Rubén , on your page that I'm currently giving you a big stalk at the moment, I see you doing a lot of stuff on the, the physical assessment. Is this what, I can't see what it says in Spanish, but it looks like you are teaching people how to do the, what we call the mechanical assessment tool which is the MAT evaluation, specifically with the physical side. So tell me about it with you specifically or maybe you'd be better at explaining to everybody what to you is the MAT assessment in terms of the physical assessment. What is it and when do you do it and, why do you do it in general? 

Rubén: Well actually I think one of the most difficult things in our industry is to make some decisions no? Because what's the reason why we decide to put one cushion or another? What's the reason we decide to put this trilateral in, in this position or in this other one? I think... I don't know, I'm going to talk about my experience in Spain mainly, but I think it's something that happens worldwide and actually I think that generally we are based in our good sight. So it's if I have an x-ray vision and I'm able to decide everything just saying 

"Oh, this shoulder is higher than the other one. Oh, it looks like this hip has like a pelvic obliquity. Oh, it this looks like he can correct this scoliosis" and everything is like an act of faith and I don't like, I'm sorry because what I'm going to say, but I'm not a faith man. I am a science man. So that's the reason I started to do MAT assessment. Actually, I don't know too many people in Spain who do or who practice with MAT assessment. Actually I always call it MAT assessment because I, we don't have any word for that in, in Spain or I think so. Maybe someone can correct me after listening this podcast. And one of the main reason, because I do this assessment or I try to do, I would say in the 95% of the... Well, I have to say, first of all I have to say that when I visit a center they saw me their most difficult case. So normally I need to do a MAT assessment.

 When they call me it's because they don't know what to do with that user. I'm sure you know this feeling. So- 

Anthony: We are called the problem solvers. That's what we're here for!

Rubén: Yeah. Yeah.

Anthony: Yeah. 

Rubén: It's interesting because you are in a position that someone called you from a rehabilitation centre or whatever, and you say 'okay, let's see if I can get their trust, their confidence no and do a good work. And always they put you in front of you the most difficult child they have, the most difficult user they have. 

Anthony: Yeah. Yeah. 

Rubén: And you say

"Okay, let's try."

Anthony: Yeah. I know exactly how it is and sometimes it's... I'm sure most of the time you can make it work but there are times where you have to be honest and say no.

Rubén: Exactly.

Anthony: Yeah. Yeah.

Rubén: The most important thing is to be honest and you are there to try to help. Sometimes you can do something very good and it's challenging. Sometimes you can help and it doesn't matter; well it matters but it's not important because you have done what you needed to do so, well that's the reason I do MAT assessment because I didn't want it to do something because I think is the best thing. I wanted to do something because I have assessed. And if I consider the biomechanics this is the best thing that we could do with this user. For that reason, I think that MAT assessment is important but it's even more important if you can understand biomechanics no? I don't know some, when I do my courses of MAT assessment, for example, I spend three hours or two or three hours talking about anatomy and biomechanics. And why? Because I think, obviously MAT assessment, well I'm going to try to explain what's MAT assessment first, if you want. MAT assessment is an assessment that you do in a mat. It's easy as that! Still here?! And obviously what you want to consider is what are the range of motions of some of that joints that are going to be involved in seating, like the knee, like the hips, like the trunk, like the neck. What, what's the range of motions without compensations that that user can reach without the gravity affecting him or affecting them. So, and once you have analysed all that movements, you can do it in seating. And try to make some decisions to transfer that to the seating unit no? What I always say is that's very important when you can understand anatomy and you can understand biomechanics. Why? Because I don't know, I'm going to try to put a, an easy example, but it's a technical example. I don't know, if we think about hamstrings for example, I think it's a typical case. We understand that it's a, I don't know if I'm going to say it well in English, but it's a biarticular joint or biarticular muscle, so it's, it's through two joints no; through the hips and through the, the knee. And obviously their origin is in the IT, the buttocks and their insertion, I don't know if that's the right word in English.

Justin: Yeah.

Rubén: And it ended in the tibia. I don't know, it is the same in, in?

Anthony: Yeah. That's right. The tibia is correct. And behind the back of the knee for, listeners. Yeah.

Rubén: Okay. Exactly. So two movements are going to be related with that tension or with that tightening of the muscle no? 

Anthony: Yeah. 

Rubén: If you move the flexion or extension of the hip, or if you move the extension or the flexion of the knee it's going to be involved in how tighten it is that muscle. And if that muscle is to tighten it, it's going to pull from the buttocks to the front and probably you are going to get some posterior tilt. So it would be more than interesting to understand that and probably, for example, I love to analyse the muscles in different planes. Actually, I don't know if you can see but I have some planes here from yesterday. I was doing a publication in my Instagram and when you analyse, for example, the hamstrings muscle in different planes, you can analyse or you can realise that hamstrings are extensors of the hip. They create also posterior tilt in a sagittal plane. But also when you talk in a transversal plane, if you for looking from the top, you are going to get internal rotation; or the hamstring going to make internal rotation. And also if you look at in the frontal view, you are going to get adduction.

So it's quite interesting because a lot of the users that you can assess with tightening hamstrings are also with internal rotation and adduction. So it's interesting all this things are happening together normally. And all the things are related with the anatomy and the biomechanics no? So how important is to assess this, to decide how are you going to seat this user no? So it's just one example, but I think it's a clear example to understand why it's important to assess that in order to, because obviously we have some objectives no? When we decide to make a seating with one user our objective is to avoid, I don't know, hip rotation or to improve breathing or to improve the function of the user in the wheelchair or to make the user to drive their wheelchair independently.

You have an objective, so if you want to get some of those objectives, you need to assess in order to decide what's to be, what's going to be the best for that user in that case.

For example, for me, hip luxation is quite important. It's something to avoid because I don't know if you look at the evidence that the research, it looks like that probably hip luxation is the first step. After the hip luxation appears, pelvic obliquity and after pelvic obliquity is going to appear as scoliosis. So probably if you know that the path is going to be like this one, maybe it's good to, to find something to stop the first step no? Or try to delay that step as much as you can no? This is true. 

Justin: Yeah and then how do you do that? So you mentioned that... when you said the first step is hip subluxation and so the, the leg coming out of your hip joint and then that leads to pelvic obliquity, so one hip higher, being higher than the other. What's causing that hip subluxation in the first place? Is that through growth? You talking about with children when they're young, they're getting hip subluxations or is this happen to adults who maybe start using a wheelchair in their thirties? How does one get hip subluxation just from sitting down? 

Rubén: Well I love that you made me this question, and it's a very, very interesting question because, I think... well sorry because probably I'm going to start to talk some technical things but I will try to explain it correctly, properly.

Justin: Explain it like to a 5-year-old.

Rubén: Yeah.

Justin: As if I'm five years old and you say there is a human body. 

Rubén: I don't know how to say, I don't know how to say the neck of the femur. Well, it's a very important question because I think it's very important that we consider this from the, even from the birth. What I mean is when we were born we, our femur it's with another neck or femoral head angle. So we have something that technically is called a valgus, I don't know... The angle of the head of the femur, with the bone of the femurl, it's like 135 degrees. The problem of this is that the only, okay you have a picture of a valgus coxa that would be great. No, that doesn't matter. Well the thing is that when we born, when we were born, we have an open angle of this hip and of this femoral head and we need to weightbearing to make that head to get down. Why is this important? Because if this femoral head doesn't go down the risk of hip luxation is going to be bigger for several reasons because biomechanically when, if, I don't know if someone is going to see me, but if you imagine this, this hand is my acetabulum and this is my femoral head, when I go to abduction my femoral head is going out. It's going out from the acetabulum.

Despite of that, or however, if I do abduction obviously the femoral head is going to push harder against the acetabulum. The acetabulum and the femoral head, the development of the acetabulum and the femoral head is co-dependent, so that it means that they helps together to create their form or their shape. So for that reason, I think it's important that even if the development of the child is not the normal one or the regular one, you need to do standing and if it's possible with abduction. Because you need to make that round acetabulum as much as you can, and you try to make that femoral head as round as much as you can and abduction is going to help you for that and it's going and that weight bearing is going to help you not just with this mineral density. Also is going to help you with trying to bring that head down and to improve that angle between the bone and the femoral head. And this is very, very important because when you analyse the biomechanics of femoral head for example, we know that mid glute, mid glute is right? 

Anthony: That's correct. 

Rubén: Mid glute is a muscle from our butt it's the main abductor, it's the main muscle abductor probably. If you try to, it's difficult to explain a five years old, the moment arm of a muscle. But if you consider that this moment arm is the most important thing in terms of torque or maximum force created by a muscle, when you have the kind of angle of the, of where we were born in the femoral head it's much easier that the abductors muscles have more a mechanical advantage to make a strength than abductors. So that's one of the reasons why biomechanically it's even important to consider this in order to avoid hip luxation or subluxation. So I would say abduction is important mainly in, in a standing. Well sometimes I try to do some jokes when I giving classes to my students or when I am invited to universities to give some class and I say 

"Well sometimes we think that our users are Jean Claude Van Damme. But yeah, this is the reason Anton half understood me and I don't know if Justin knows who is Jean Claude Van Damme because he's younger. So nowadays people doesn't understand me when I mean this, but I think you understand me perfectly.

Justin: He can do the splits!

Anthony: Blood Sport, it's great. One of the best movies.

Rubén: Yeah. Yeah.

Justin: He's the king of, of abduction.

Anthony: Exactly. Exactly.

Justin: Just to, so just to clarify everything you're saying for everyone listening, so if you've got someone with a congenital condition, meaning that they're born with it and they're born without the ability to walk or to weight bear through their legs, standing is really, really important so that the hip joint develops properly. If we're born seated and we're constantly spending time in seated. We're gonna get hip subluxations. Do you see that happening in populations outside of kids born with a condition, or is it only with those who have always been seated? 

Rubén: Actually I think it's more related with not walking, exactly no? Because for example, I have tried to look for research in spinal cord injury and it also appears hip subluxation or hip luxation in the spinal cord injury, in children with a spinal cord injury. But they appear more as younger they get the injury. And as... I would say the risk increase as soon as they get the injury. So actually I would say, or I would dare to say that it's related with the development. So it's difficult if you have as a spinal cord injury in with 50 years and obviously you can have it probably. But I think it's going to be more difficult.

Justin: So it's more about age rather than the actual condition. So just because you got cerebral palsy or something it's not necessarily about that, it's more the fact that you are young and you haven't had the chance to develop properly, in that case. Okay, so that makes sense. So that means that look standing's important. And we could probably do a whole topic on standing. What does that mean for seating though? Do we need to be abducted when we're seating? Should we be seating all kids, say if there's any kids under 10 years old, should we be seating all of them in abduction? If they are not walking? 

Rubén: Yeah. I think it's an interesting topic too because abduction is important and when you read some hip surveillance guidelines or whatever, they tell you that you need to keep that abduction in a standing and seating. But I think that sometimes we misunderstood abduction with Jean Claude Van Damme no? I think-

Justin: Sorry, what was that? 

Rubén: Sorry I was meaning that we, we, misunderstood that when it's abduction and when it's too much abduction.

Justin: Yeah. Jean Claude Van Damme.

Rubén: Yeah. Jean Claude Van Damme, exactly! And that it's... that's right no? Because even if we consider the wheelchair that we are going to use, it's very difficult to mount some seating unit with a lot of abduction in a wheelchair no? I don't know if you have, I don't know I've seen some people that they want to create 60 degrees of abduction in seating and maybe you have a hip width of, I don't know, 30 centimeters. And you need to have 40 centimeters wheelchair or even more. And what happened with the other things? What kind of back rest are you going to mount where the laterals make the force when they have to be done? And what happened with the armrest? It's going to be very far and you're going to create an abduction in the shoulder that maybe is going to create some difficulties to make things in the midline. So we need to think in global no? And obviously it's important to avoid the abduction in seating because obviously you will be helping to, to, make this head to get out of the acetabulum. But obviously we are doing two hours per day of standing and we have good abduction or, fair abduction in seating. And we try to... I don't know for example, I don't know if you know this research but for me it's quite interesting because I don't like pommels. I don't like pommels, sorry and-

Justin: Why is that?

Rubén: There's a research- I think because pommel in Spain is called abductor block.

Anthony: Yeah.

Rubén: And I wouldn't say it's an abductor, I would say it's a-

Justin: It's an AB. 

Rubén: AB?

Justin: Yeah. So it's called an abductor block. 

Rubén: Yeah, that would be like the translation, the direct translation. That would be what we call in Spanish. And- 

Justin: It sounds like that means, like that translation is there is a block that is causing abduction, whereas it could be misunderstood as block as in like defense, like I'm blocking something from happening.

Rubén: Abductor pommel we are going to call it.

Justin: Yeah, exactly. Yeah. but I think, I think there could be room for, I think there could be room for misunderstanding in because like we might say a hip block might be something to like, block your hips from moving, because it's blocking. But then it could also just be like a block as in like a brick. Like something is a block, is an object.

Rubén: Exactly.

Justin: But it sounds like-

Rubén: For me that, yeah, for me that would be a, an abduction block not an abduction pommel or an abductor pommel and it could be something stupid, but I think it's important because it's not getting abduction and it's blocking the abduction, but it's not blocking the internal rotation. So if we are talking that when we have analysed the hamstrings and other muscles, we have children with adduction, internal rotation, why are we are just controlling adduction? Actually when we try to get some external rotation some of those adduction disappears no? Because it's like easier to get them to abduction when you get them a little bit of external rotation. Because probably external rotators and abductors are synergists as adductors and internal rotators. And it's quite common to see pictures of people with, with the pommel and obviously they have their legs separated but they are in internal rotation.

Anthony: Can I interject just for one minute? Because I think that's really important and I think you're, what you're saying is a hundred percent true. And we know this; we've, you've seen it many times. We've all seen it many times. I'm sure the listeners have as well. One of the things that I just wanted to move on, but within the same conversation is, over time a subluxed hip can also be dis- lead to dislocation. So, you know over time we see a lot of people with, dislocation okay. And therefore we don't, and not just with dislocation, but we do need to go with the external rotation, internal rotation. We don't want to always abduct; we want to adduct. We want to in, in essence, the presentation we're talking about is wind sweeping. So where the hips are going one way or the other, and we don't always want to fight against this. Everybody wants to make somebody look straight. And you're nodding your head and I'm sure Justin agrees as well. And what that does is when you try to make somebody look straight, right, so you want to move the hips into midline, you want everything to be in one. This actually is a negative for most of the clients of the presentation we are talking about. And I'm interested to know your take Rubén , how you manage that? Are you happy to accept that? What I'm saying is correct and sometimes and quite a lot with the customers, users that we're talking about? Or is there a different way of approaching that because I'm just interested in your opinion?

Rubén: I think you are a hundred percent right and that's one of the reasons we need to do MAT assessment because when I do MAT assessment I can assess what's the abduction of that hip and it's.... I love to do MAT assessment in these cases because when you move the hip to abduction, you can see how the opposite pelvic side it's going after you, it's going with you. When you look that, what do you prefer to have your legs looking at the front or you want to have your hips or your pelvic looking at the front avoiding to rotate the spinal, the spine no? 

Anthony: Yep. 

Rubén: In my opinion, obviously I want to keep the spine and the pelvic and the pelvis in the right position, because obviously inside or related with my pelvis and the spine, it's going to be a lot of organs-

Anthony: Yeah.

Rubén: Who are related with my surviving, which I think is one of the main objectives of, of us as professionals is to keep their, our users alive no? This is one of my main objectives every day. So you are right because sometimes we put the block and the legs looks right, but you are creating a rotation in the pelvis and after that it's going to follow the spine. So for that reason, it's very important to make a MAT assessment, for example, because you are going to discover if that movement is reduc- reducible? 

Anthony: Yeah. 

Rubén: Or non reducible. 

Anthony: Yeah. 

Rubén: And if it's not reducible, until which position I can do it? Because how I take or how I make this decision if I don't know what's going to be the range or the right range? Or the right range without compensation? Or the right range without pushing other body segment follow the other one? What would be that range if I can't assess it and I can't measure it?

Even maybe if you are very experienced, maybe you don't need even measure it. But you need to assess it because I think sometimes clothes can lie to you. Sometimes users looks like very happy with some kind of things, and they are able to distract you from the thing no? So yeah that's important. And when I was talking actually about the research is that there, there is a research talk about medial thigh support, which would be this pommel with gross motor five, four and five in cerebral palsy spastic, in spastic cerebral palsy. And they realise that with the pommel they get more hip subluxation than without the pommel and it makes sense because if you have your adductors pulling harder from your bone, probably the pommel is going to be your fulcrum.

Anthony: Yeah. 

Rubén: And the head is going to be out, it's going to get out. So for that reason I think biomechanics is essential in seating and posture. 

Anthony: It's very interesting, Rubén. I love this conversation. I am, really this is my passion myself personally. So, you know I could talk for hours. But, but I think what I'm taking from what you're seeing is there is a need for abduction or adduction dependent on the user's needs at that specific time. But the way of managing that, you are not so keen in putting such a big pommel in, so a solid block, if we want to call it that abducts, so that separates. So just for the users abduction, AB-duction is where we are separating the knees in this particular conversation, where we're opening up that area and AD-duction is controlling the knees from, to close them, to bring them closer together, right? So we use a lot of contoured seat cushions myself personally, so things that have an abductor, an abduction block inside which we can reduce / increase. And what, is that something that you use? So, because do you use a lot of contoured seat cushions to control that area or are you using a flip up / flip down (excuse me) removable pommel at times? And the next question is, if we are going with the wind sweeping or we're using, we're not using a pommel as such, a block, with people who have spasticity if they engage, get excited, frustrated, upset, you often find that they're positioned, like us, like an anyone without a spasticity, they will contract, they will bring their knees together or they will bring them out dependent, but most likely they will bring them together when they're getting upset, anxious, funny; their showing emotion and we may not always want that to be the case, although we don't want to restrain of course so there'll be times where we're like, yeah. How would you manage that situation? 

Rubén: I'm going to start by the end because I don't know if I remember correctly the first one. 

Anthony: Sorry!

Rubén: So I'm going to start for the second one now sorry. And, well it's interesting, it's, it is very interesting this question because sometimes it's like, I don't know if you have assessed a tightened hamstrings but the user have an extension thrust, no? And or this dystonion, dystonic movements, and how do you decide what's the best solution for this kind of users that they need this movement or they are avoiding? Obviously if we understand again biomechanics and the muscles, we know that extensors are powerful than flexors, are more powerful than flexors. So, what normally we try to do is to close that angle because you are going to give more mechanical advantage to that flexors to avoid that hip extension. But what happen it, if the hamstrings are tightening? You have a big problem because you are, putting in more problems with the hamstring tightening so they are going to have more posterior tilt and it's, it would be like the opposite things that you need no? I think the best option in this cases, but in Spain it doesn't exist as solutions or are very expensive for that, it's these kind of systems that going with you. This kind of seating units that goes with you when you have this extensor thrust and comes with you when- 

Anthony: So dynamic seating? Dynamic seating Ruben?

Rubén: Yeah but I've seen different, I've seen different systems of dynamic seat. I've seen systems just with a spring in the back rest.

Anthony: Yep.

Rubén: And I've seen other systems where the seat goes after the user. And I think that's much more interesting. All of them are interesting, obviously.

Anthony: Yeah.

Rubén: But I think that's much more interesting because one of the problem when one user make this extensor thrust is that they lost their posture and when they come back to their position, they are not well positioned again. So I think these kind of seating systems help them to go with their movement, and going back. And help them to express their emotions sometimes and going back and you are not tightening more the hamstrings. So in these cases I think it would be interesting something like this, but sometimes it's not easy to get.

Normally it's quite expensive and in a country like mine, which is not reimbursed, it makes the thi- the things quite difficult.

Anthony: Yeah.

Rubén: And the second question, or the first one, I think it was related about how do you do it if you use contour cushions or not? For example, I've been working with, with the distribution of Spex products for, for seven years. And I love that kind of products.

Anthony: But other cushions are available. 

Rubén: Yeah other cushions of obviously, all the cushions that you can imagine! Jay, Wincare, whatever.

Anthony: Yeah, of course.

Rubén: I was talking about that because my experience and it's a good example on a contour cushion no?

Anthony: Yeah, I'm joking. Yeah.

Rubén: But obviously it matters if the, for example, I have said that the research says in a spastic cerebral palsy, not all of them are, are spastic. Not all of them are gross motor four and five, and not all of them are people with cerebral palsy. So maybe you need to consider in every case what's the real solution for this unique case and obviously I rather a contour cushion which is soft and let you get in, than a pommel which is too hard and it's like it give you the input to push harder, even when you have some neurological condition. So I would tell you that the most important thing is to consider in every case, but I think that I love this kind of contour cushion when they need it and I have used it a lot and sometimes I have used other products that led me to respect the wind swept or other times I try to use something more flat and I try to do with I don't know, for example the leg harness of Bodypoint, for example when you can pull to a abduction or you can try to pull one more from, for, from one side and try to get this abduction and external rotation. For me, it's one of the best options to control abduction and external rotation. So I think it would depend, it's going to depend every case, in every case. But obviously when we talk about wind sweeping, and wind sweeping is very related with hip luxation, we should talk about how they sleep. Because how they sleep is going to be very related with this wind sweep normally. 

Justin: A hundred percent. I think the topic of sleep is a, is a whole other one. We should probably do another one on sleep and things like that, but yeah I think that in terms of what you said then around like pommels versus contour cushions, it's, you're right, it is... I would tend to agree with you that contour can be a lot better. It is tricky and what you mentioned, when they have a really high tone and maybe the contour cushion isn't enough, but then if they do have a really high tone, then a pommel could make it worse because then they could dislocate their hips out. And this is where I think cushions like the, you mentioned like the Spex Constructa cushion ones that really help guide the whole thigh, the whole way through to reduce that leverage point at the end of the knee could be, it could be a really good option for some users, providing it's not too difficult to get out of the way and the benefits of having a pommel that's removable if someone's doing a side transfer because, I think about the la- as you were saying that I was thinking of the last client I had who had a pommel who was, has spinal bifida and then he had the ability to do a side transfer. So having a pommel that was removable is really important to him for that reason, even though he still had quite a bit of internal rotations, so for those imagining this like he's... picture one of your ankles going in towards your body whilst the pommel was, was helping with he had one leg that was a bit windswept, so he had say his left leg was coming in towards his body too much and his right leg was rotating... we still went with a pommel for that reason because it was something that was removable. So exactly what you said, Rubén , in terms of taking each case for what it is because sometimes it could be good, sometimes it couldn't be. But this is what clinical judgment is all about. 

Rubén: Yeah but you have said something very interesting no? That it's, well we are considering just in a, an ideal user, which we are not considering the environment, we are not considering what they needed at home. And sometimes you need to mix these physical things with 'oh, he make the transfers independently and this it would be a problem' no, and we need a removable. So obviously we need to consider all these physical things that we have been talking about with all the daily life activities and how they mix with.

So we have a very difficult work that's it! 

Justin: Absolutely, I try to, I actually, I was even getting a haircut today and he is asking me what I do for a living, and then when you say 'I make bespoke wheelchairs', it's like 'oh, is that like for...' they just pick like design, like people don't even think about like what is a bespoke wheelchair. And you're like, oh there's just, there's so much to it. And you don't realise until you actually get into it, that bespoke doesn't mean a good paint job or spinner wheels. There's, there's a lot to it based on people's function and all that. I think that's a good place to end it there. But I do want to have some summarising points for the guests listening at home that we discussed. So I think the first thing we touched on was the MAT assessment and you feel the MAT assessment is really important because you're not so much a man of faith as you said! You're a man of science and clothes can lie to you, clients can lie to you, but what doesn't lie to you is the ability to assess someone in their body. I think then we touched on hip, hip positioning which is really interesting because whilst our goal is to get like a nice symmetrical, neutral posture for people, particularly in children, it is ideal to have some sort of abduction. And I think we're all still a bit, I'm not sure what the answer is in terms of seated abduction in terms of how much you need to be seated, how important is seated abduction to reduce the hip dislocation? And it's a message I probably keep asking a lot of guests because it comes up a lot. And I know I was talking to my rep from Medifab about it because I've got a hip surgeon that loves his children post-surgery in a lot of abduction. And sometimes I hear it's 12 weeks of abduction. Sometimes I hear it's five years. Like I've got clients that they're on their second wheelchair and they're, they've got their leg rests swapped around the other side because they're in that much abduction. So I still think, it makes me feel better that someone like you Rubén, who watches all the science and looking at everything, still isn't clear on the benefits of that much abduction in seating. And maybe it's something we could all learn together as to how beneficial is it. But you're right, there is definitely the practical aspect of seating in a lot of abduction. It's not very practical for a lot of kids. 

Rubén: When I've read about these kind of things, the problem is that when someone does a research, they need to decide what's going to be the angle that we are going to try.

So probably I seen sometimes that they talk about 60 degrees of abduction and it has worked, but the problem sometimes is who's going to be the tolerance of the user? And I have seen other research that they talk about the maximum tolerance of the user. So the research, I'm a man of science, but I always try to deal with science with carefully no, because what do you want? To get 60 degrees of abduction or to get 30... 60 degrees of abduction for two hours or 30 degrees of abduction for eight hours? I think that would be a good question. And it doesn't appears in the research no? 

Justin: Maybe something for... if anyone's listening maybe they could know. But it is something I really want to know about because I do see a lot of children with cerebral palsy or some sort of congenital condition where... yeah, it's interesting. It's interesting to see again how much, what's the benefit of it? Is it even worth it? I really did appreciate the end of this conversation about the differences between pommel and contoured cushions. I've always preferred contoured cushions myself as well. I just think they're easier to maintain. They get, they provide external and internal rotation, or they guide internal and external rotation based of what you want. But yeah, in terms of doing side transfers or managing even doing extend transfers isn't always practical, but that's just the joy of what we do. We get to decide what's right for each client and there are manufacturers that do custom things. I did a custom cushion not long ago, that was like an extra tall pommel for her because she had, her knees were coming out and they were getting up of the standard contours, but she didn't need really high contours on the side. It was just going in so we did like one that was like extra tall, but that's the joys of what we do. I think if we understand the pros and cons of every option that's out there, that helps us make informed decisions for our clients. 

Anthony: I think that's so great. And actually I think Rubén , if you're open to it, we'd love to have you back on and I think next time let's talk about different presentations and how we would physically correct that. Let's go into the more practical side of things to help the listeners and the users understand why we do things and how we do things. I think that's really important- 

Justin: And studies.

Anthony: Yeah.

Justin: Are always fun.

Anthony: Yeah.

Justin: If we can get some consent from clients, from all of us, maybe all three of us can have a hunt for some really complex postures, get some case studies and we should talk about that for those who are able to watch the YouTube video. 

Anthony: Yeah. And I'll, we'll get a hip surgeon on as well. Let's put them to the test! 

Justin: Yeah. We should get out, out the doctor down here is named like Dr. Axe, which sounds like Dr. Axe which is, what a cool name for a surgeon like Dr. Axe, just like for an orthopedic surgeon just to be like "I'm Dr. Axe." 

Anthony: Oh, that'd be quite funny. But yeah, no, listen Rubén , it's been an absolute pleasure. Thank you for making the time with us this morning. I really appreciate it. I've learned loads. I've also confirmed quite a lot in my head while we're chatting.

So yeah, it's been just great. I'm sure everybody listening, watching, has really benefited as well so thank you so much. Justin, have a wonderful day. 

Justin: I will do. Thank you again, Rubén. 

Rubén: I would love to, to, thank you for inviting me to this podcast. Thank you for considering me even with my English, which I think it's incredible. 

Justin: Mate, first of all bravo to Rubén mate! Imagine having to explain all these complex topics and translating in real time! I don't know how you do it. I bet if you, if this is all in Spanish you'd be like, it'd be even better. But you've done a fantastic job to do it in English; I fully appreciate the difficulty. 

Anthony: Amazing.

Justin: It is difficult, but thank you again  Rubén.

Rubén: Thanks to you. Thanks to you. Pleasure for me.

Anthony: Guys! Oh no thank you, Rubén . Sorry. Yeah thank, listen everyone thanks for this. You've been listening to Wheel Chat. If you've enjoyed it please click, like and subscribe. It's very important for us to get your feedback. If you want to send us any messages, questions, also please feel free to do so and we will help in the next chapter. Justin, that leads us to say, just thank you so much. Have a wonderful rest of the week. I'm sure we'll catch up! Anything you want to close with and say "Hi" to our wonderful users. 

Justin: I just want to tell everyone that, 'Wheel' Chat to you next week. 

Anthony: Okay so from Rubén, Justin and myself, thanks for listening to Wheel Chat and we'll speak to you again soon. Take care, guys. 

Justin: Awesome. Thanks guys.