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Why Wheelchair Belts Should Not Be Mounted Like Car Seatbelts | S2 EP2 with Barend ter Haar

• Wheel Chat • Season 2 • Episode 2

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Episode 2 of Season 2 is here! 

This episode of Wheel Chat answers a deceptively simple clinical question: how do we use standards to make better wheelchair seating decisions, especially when the common default is not necessarily the best clinical option?

Justin speaks with Barend about ISO standards, pelvic belt positioning, four-point belt use, wheelchair transport tie-downs, cushion testing and pressure injury prevention. 

The practical takeaways are clear: wheelchair belts are positioning devices, not car seatbelts; cushion choice should consider tissue viability, positioning and function; and pressure injury prevention is far easier than treatment.

Barend has decades of experience in wheelchair seating and standards development. Listen in for a practical, clinician-friendly conversation that turns standards into everyday prescription decisions.

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

Intro and Barend's background

SPEAKER_01

Welcome to Wheelchat, ladies and gentlemen. Today I am on my own. I don't have Antoine with me. He's a busy man and he couldn't make this episode, but I was not going to miss this episode with Barend, who's an incredible man who knows a lot about wheelchairs and has been around for a lot longer than me. He's been doing content for a lot longer than Willie works. So I'm super stoked to have him on, not just for his background, but also his development into the ISO standards of wheelchairs and seating. So, Barend, first of all, welcome to the core. Where are you calling in from today?

SPEAKER_00

I'm calling from a little village in North Somerset, somewhere between Bristol and Bath, in the nice corner of England. No, I get around. We've got uh standards meetings coming up at uh next month in Holland, and then I'll be flying on out to lecture at Atsa in Brisbane. So I get around a bit, even though I'm supposed to be retired. The more retired I get, the more busy I get.

SPEAKER_01

Well, for those who are just listening and not watching, Byron only looks about 25, but he's been in the industry for probably longer. Byron, would you mind telling the guests who haven't heard of you what is it that you've done in your career and why should everyone be listening to you today?

SPEAKER_00

I came to wheelchair seating and wheelchairs probably about 40 years ago. I was involved in a small setup company in the UK that was making a specialist wheelchair for small children in the days when early childhood mobility wasn't really an accepted area. They felt it would be unsafe to give a child power until at least about five. And of course, we learn a lot about spatial awareness in our first couple years of life. So I worked with a couple based in Cambridge who had invented a wheelchair where the child could press a button, get down to the floor and play, and then press the button the other way and go back up to a table. And they could interchange the seat with a standing frame because standing is just as important, particularly for children, for bone development and everything else. So that was a great introduction to the areas of assistive products and technology.

SPEAKER_01

There you go. Mate, and I just want to repeat to everybody that's 40 years experience in this world. And yeah, it's an incredible work that you've done so far, working with kids and getting them mobile. What is it that you do now with your day? I know you say you're semi-retired, but mate, come on, you're never retired. What's going on now?

SPEAKER_00

I'm still involved as the director of a company in the UK called the ES Healthcare. And we have a sister company based in Adelaide called Healthcare Innovations Australia. And from there we are have been over the years finding best in-class products from different parts of the world that we can bring into the respective countries. But uh behind that, I've been heavily involved with wheelchair seating standards from the day they were set up about 30 years ago. So that's been going on for some time now. And uh in those standards, we've now got a suite of best part of 15 published standards, and quite a few more are in the pipeline. There's one being developed on assessments, one being developed on dynamic seating, and what do we actually mean by that, and so forth. A lot of interesting stuff. And for me, it's the value of meeting up with the international experts from around the world and distilling their knowledge, because I I'm no expert on anything. I pick up everything sick secondhand, but then I try to distill it out again in a way that other people can enjoy and understand.

SPEAKER_01

Yeah, I think it's one of those things, the more you learn about something, the more you realise, wow, I don't know anything about this topic. Like I'm like dynamic seating. I know plenty about dynamic seating. That's fine. And I'm sure there's an expert in dynamic seeding that would

What ISO standards are and why they matter

SPEAKER_01

run circles around me. So it's awesome you're you're bringing everyone together. But for for people who don't know, what are ISO standards in general and why do we need them in wheelchair seating?

SPEAKER_00

ISO standards are a means that everywhere in the world is doing the same thing consistently, talking the same language. I think a good example might be if you are painting your backroom and suddenly run out of paint when you go and buy another part of the paint, because international standards, you know it's going to be the same colour as you run out of, so you don't have suddenly two-tone back room. Uh, interesting area was, of course, uh, where we drive. There are standards for some countries drive on the right hand side of the road, like in Australia, UK, and others on the left. Sweden used to drive on the right, but they found that when people were going to from Norway or Denmark or whatever, they're having a nasty accident. So back in September 1967, they decided we're all going to move over to driving on the left. So there's one hour in the early morning when nobody could drive, and then after that, everybody had moved to the other side of the road. So standards are quite useful, and some of them are useful for in the wheelchair world. We've got a series of standards for testing wheelchairs to see that they are strong enough that they perform in certain ways that will be consistent. So when you know you've passed the standard, those can be descriptive tanders or they can be fast past fail standards. We have crash testing uh standards where uh you can have a wheelchair being tested for its safety in the crash. Most of the testing to date has tended to be how safe the other people in the vehicle as compared with how safe the uh occupant of the wheelchair is.

SPEAKER_01

Really? What is that because people are like they catapult in the chair into other people?

SPEAKER_00

They're worried about bits of the chair flying off and hitting other people in a bus or in a car or something like that. There you go. On the anecdotal

Crash testing and occupant safety

SPEAKER_00

front, I was at a uh meeting in in the States shortly after the Part 19 crashworthiness test had first come out, and they said, Oh, we've had the first crashworthy wheelchair involved in an accident, and uh it's stood up to the accident. But unfortunately the occupant died. So there's now a new leader of the of that group of standards called Ali, and he's based in Australia. So he's leading the group, and I think the movement is now to try and have a look more about how the occupant of the wheelchair might be protected. Cars give you comfort z pr uh uh protection safety zones when they crash. Wheelchairs aren't designed like that at the moment. They're more designed for the people in the environment. So uh getting the human touch has come in, and that's really what we've invited and done as we developed the wheelchair seating standards. We've got more standards that look at how the individual and the seating system is affected. We've got one on pressure mapping or guidelines to pressure mapping in there. We've got one which we'll come to in a moment, I think, is where the best place is to put a belt on a wheelchair to position somebody rather than as a belt to protect somebody from flying out of their seat in an accident. So what you have in your chair when you get into the plane or what you have in your car is goes around your waist in a certain way that stops you from flying out of the seat. What we have in a wheelchair is completely different. It is designed to try and position somebody in a most effective position for function and also get them in a position where we're not pulling down too much on the bones or their pelvis

Pelvic belt positioning and the 45-degree trap

SPEAKER_00

into their soft tissues and causing tissue damage. So if you anybody see anybody in a wheelchair with the belt at a 45 degrees, that person has come from the airline industry or the automotive industry, but they haven't come from proper training in wheelchair seating. The best way of thinking it for me is that you would think of a pelvis as being a big ball, the biggest distance across a ball is its diameter, and the forty-five degree position of a belt is its uh is its going across its diameter, so that's the biggest distance the ball will have. So people have died as a result of submarining underneath the belt in wheelchairs, and even in cars, and the best position for that belt is straight for most people, with a tendency to a posterior tilt, is straight across the thighs, flat across the thighs, that's a much shorter distance, and there's no way a normal pelvis will be able to submarine underneath that. For safety it works. For looking after how you are uh using your wheelchair, it works. You can stretch, lean a lot further forward when you're not being held down on your pelvis, and it's much more functional all the way around. So don't treat your wheelchair belt as a safety device, treat it as a positioning device, and you may be going in the right direction. There's still in Australia some uh rather erroneous advice going out. And the standard that came out and that started off as a British standard, a BS8625, and it's now an ISO standard, ISO 16840 Part 15, which is adopted in Australia as well. And this gives the advice to people how to apply the positioning belt and not treat it as a car safety belt. So not just the seat belts, but also chest harnesses, any of the parts of the anatomy that needs uh secondary support, there's advice given us best practice, exceptions around the world. Let's move forward that way.

SPEAKER_01

Yes, and just for those who are listening, what I'm gonna do is I'm just gonna pull up on the screen the one of your blogs that you've done about how to mount a belt. And you've included a screenshot of this ISO standard of how to mount a belt. So for those who are just listening, what we're seeing here is two pictures side by side of people like sitting on the side, like a skeleton image, and one of the belts is mounted at a 90 degrees and the other one is at a 60 degree, meaning that the belt where the belt's mounted is about 60 degrees from the seat pan of the angle of there. So if you imagine 45 being a 45 degree slice, 60 degree would be closer to the it being upright. And from what we can see in the image, it is in front of the greater trochanter. So this section over here, the little bump that's on the side of your thigh on your femur, that's where it is. So Byron, tell me, why does it need to be in front of this GT, from your understanding?

SPEAKER_00

That's well partly it means the belt is in a shorter distance than the diameter right across the uh pelvis. Secondly, it is holding the thighs down on the cushion, but it is not holding down the pelvis onto its soft tissues. But also the greater trichanta is more or less level with your hip joint, and hip joint is where you can bend. And so if you want to stretch forward, if you're not being held down uh there, you can then you can see on the left hand image that the person is leaning forward a bit. So if somebody's got a tendency towards what we call a posterior tilt, which most of us have, then this is the safest way of doing things. And in fact, you can do that with a friend. If you've got uh for those of you in the more professional areas access to belts, just try it on a chair in your kitchen or whatever, and see what it feels like if somebody stands behind you with the belt at 45 degrees as you might find in your car, and see where they can slide underneath it and how well it positions them. And also ask them to reach forward and see far how forward they can reach, and then move the belt over the thighs, that's on the left-hand picture, hold it down firmly, and get the person to see whether they can slip under it, and how much it controls position, and secondly, how far they can reach. And once you feel it, you remember it. But do we got ATSA coming up in the Sydney shortly, we've got ATSA coming up in Brisbane. Have a look at how many people in the wheelchair have got their belts in the wrong position.

SPEAKER_01

Everyone does. I was um I was doing some supervision with someone literally today, and I was telling them about our podcast, and I've got a training program, and on the training program, it explains this concept, and he was like, mate, I've just didn't know that. That's it's just where the belts have always been mounted. They've always been and it's kind of intuitive. I I get why people think 45 degrees would be where it's at, because it's kind of intuitive, that's where the car seats are. If you were to strap something down, you would just think 45 degrees is where it's at, but it does ignore the the human factor of it. Like, is it uncomfortable, the skeletal functions of what's going on, like where the where the hinge points are, where your bones are, where your GTs are, all these things. I think another reason why it goes into a 45 degree is because that's where the holes are on a wheelchair. So typically, you know, if you ask a technician to mount something, hey, mount a belt, he's good, he or she is gonna look for the holes in the chairs. You know, where can I double up a bracket? Where can I mount this bracket? And this is why it goes into a 45 degree. So I completely understand if you are listening and you have been mounting belts at a 45 degree angle, completely understand why you've been doing it. But hopefully, after listening to bar and and the ISO standards, you can understand that it's not gonna be as comfortable, it's not gonna be as effective in preventing someone from a posterior tilt. And I just want to add on what you what you're saying to the angle is important, but also how snug it is, right? Because you could have the belt angled in a beautiful angle, but as most lovely mothers would want, you know, I don't want to, you know, I always see moms they don't want to put on too tight for their children, but I always think if it's not being used as a force, if it's not snug, then it's not going to do anything for it. It's now going back to a figurative safety belt, which we know that's not what it's designed for.

SPEAKER_00

We have on the in the market two-point belts and four-point belts, and the points are how many bits at the end of the webbing you uh you attach. As you pointed out, that's not all

Two-point versus four-point belts

SPEAKER_00

chair most chairs don't have appropriate places where you can uh mount your belt easily uh without having to do something. And most uh respectable manufacturers supply uh mounting brackets that will go around the tubing, so you don't have to drill anything, and you can actually mount the belt right for the person. And from what we've seen with somebody with a tendency towards a posterior tilt, if the belt is mounted in the right place, as in those pictures we've seen, then the person will be well nicely secured, in a safe position, but have maximum functionality. Yes. People have been prescribing four-point belts because they've been putting part of the belt at about 45 degrees and not very safe, so they've been putting the other two straps on there. Four-point belt has got uh four straps instead of two straps.

SPEAKER_01

This is what I want to break down just for everyone who's just listened. I've just typed in four-point belt wheelchair onto Google Images. And Byron and I are both looking at images of every so there there'll be two sections of the belt. There's the padded section of the belt, and then there's the non-padded belt section of the belt. Now, Baron, looking at every single image uh on here that we are seeing, can you understand why four-point belts are not mounted correctly?

SPEAKER_00

Yeah, but the challenge is that they overprescribe from what I've seen. Is if you get your two-point belt in position, that padding will be nicely over the thighs, the person will be secure. There are uh circumstances where the person's anatomy is such that their pelvis may be wanting to go into anterior tilt, it may become just straightforward anterior tilt, which you often get with the Shen muscular dystrophy boys often some of the uh Asian population ages in that much more of anterior tilt. Uh there's also people who have a rotation of the pelvis, and there are areas where you actually want to pull back on the top of the pelvis, the ASIS we call the anterior superior iliac vines. And to do so, you want to protect the belt from going up into the soft tissues. That is where I would uh recommend having the smaller belt to attach the belt onto the frame, and the big part of the padded part will be attached to the back posts. So you can pull the top of the pelvis back, but to stop the belt from rising up to soft tissues, use the shorter ones and drop those down in front of the greater tricanters. It will restrict the movement to a certain extent, but that will get your pelvis into a much more neutral position, which and getting the pelvis in good position means that your back is straightened up, your head is in a better position for uh me talking to people, seeing people, functionality. So getting your belt right in position has some knock-on effects to all other parts of the body. Completely agree.

SPEAKER_01

The the belt position is essentially meant to be used as a force to control the hips and do what you want. So completely agree that there are situations where you would mount the belt where the padded side is at the back and then the non-padded side maybe at the front. You might even have one opposite on either end depending on what you need. Essentially, what I would love to confirm with you is that the the belts are meant to be used as a force, and then the the non-padded part is meant to stop the belt riding up in a particular way. So if we are doing anterior tilt, then we would want it at a 45 because we're trying to push those ASIS back into that posterior tilt, but then we don't want it to move too far up, so we'd put the small straps at the front. What I see in practice, and as you would know, be doing this for 40 years, you know, the ratio of anterior tilt versus posterior tilt would probably be like 98 to 2, right? Almost everybody is in posterior tilt, and you would get the occasional anterior tilt situations, but most of the time you're mounting a belt, it's you're mounting it to stop someone from sliding forward. And I feel that the a lot of the images that can get used can mis, I don't know if that's what's misleading people or people just don't know, but it seems like from here the front, you know, if some if if the images that we're looking at, where again for those who listen in, the padded belt is at the back, the non-paded part is at the front, if someone was to slide forward, to me it seems like the non-padded part would be doing nothing. Like if you got some scissors and cut them and someone was sliding forward, it wouldn't really make a difference whether they were there or not. Would you agree?

SPEAKER_00

Yeah, I f if we look the images you've got, there's somebody on the left, I think in a skirt, where the belt is more or less at the 45 degrees, and there somebody's used the s smaller belt to stop that from rising into the soft tissues, but it isn't really doing a particularly good job of positioning the person because you can see the person is sliding underneath it. So it's it's not functional and it's not practical. So that's not a good example of how to use one. But that's how often you see them.

SPEAKER_01

I think if this person was like it kind of looks like it's 60 degrees mounted here.

SPEAKER_00

I think that looks more uh closer to 45, I'd say it's over the crater to counter.

SPEAKER_01

Hard to say. So I'd say let's let's say it's we want if if this was person was sliding forward, which it looks like the person is, we would want the the thick side of the belt mounted here. So closer towards 90. And then that should be enough. As you said, I agree. I think people just think four-point belt means more, but uh look, unless it's doing something, you don't necessarily need it. I think if you're going closer towards 90, that's when I would use the small strap to mount it here to stop the belt from going forward. Now the small strap is having a function. So for me personally, I've always mounted the if I'm doing 60 degrees, two point is fine. If I'm going closer towards 90, what can happen then is that we could get some tippiness, right? That someone could, as you slide forward, the belt could shift. And then in this example over here, where the belt's down to 90, it looks like you'd want an additional strap, a non-padded strap at the back to stop it from sliding forward. Bar end, as the man who's been right in the ISOs, would you agree?

SPEAKER_00

Just on that picture, an important element too, is you can see there's a bit of a pre-issal ridge underneath the uh underneath the pelvis. So basically what we're looking for is the the pelvis is a big ball and it's trying to roll. So one way of stopping the ball from rolling is to stop it from rolling forward at the bottom, and that is a small, doesn't have to be more than a couple of uh three or four millimetres ridge just to stop the bony bits of your pelvis from going forward. The next bit, of course, is that to stop it from rolling backwards you need probably a block, as we say, something behind the back of the pelvis. People talk about a lumbar support. A lumbar support is often um the wrong thing because people push into that and that gives them more of a posterior tilt. But if you put a block where you've put the little circle there, stops the pelvis from rotating backwards, and then the belt across the thighs adds on top of that. So in fact, you probably won't find it moving forward very much if you've got those other two elements nicely in place, giving you the neutral pelvis.

SPEAKER_01

Yeah. Again, for those who are listening, we're looking at the side view of the pelvis, picturing the pelvis as a ball, and we've got three arrows on the ball. We've got one coming up at the bottom at a 45 degree angle, we've got one coming up top where the belt's been mounted, and another one mounted, you know, from the back to the front to stop it from there. So we're like trying to triangulate this position of the pelvis to really secure it in. And if we are mounting it like this, bar end, where would I put if this was you as Mr. ISA standard, where would you put the non-padded hip belt in this section? The non-padded strap, I I should say.

SPEAKER_00

In this one, I wouldn't be using a non-padded strap because the two-point belt is position the person beautifully. Yeah. If the person was going if I was trying to deal with somebody with anterior tilt, which maybe the person has got there, I'd have the pad going out horizontally at across the top of the pelvis, and then I'd have the small strap coming down where the big blue strap is at the moment.

SPEAKER_01

Yeah, I get what you mean. So yeah, so this is essentially what you're doing. So you're saying four-point belts, you wouldn't you personally wouldn't use them to stop posterior tilt. You think two-point belt is all that you need. Yep. Excellent. It's good to hear it from the the man who makes the standards himself. And I think that's really important. I would love if I could request Baron, because I've had these discussions with therapists before, other ATPs who say, no, the belt needs to be mounted, you know, you need to mount the four-point belt, you need to put this the non-padded part forward. I would love it, Bahron, in your next committee meeting. You've got the diagram for a two-point belt. Do you think we could add a four-point belt diagram at all?

SPEAKER_00

When the uh standard comes up for revision, which is every four or five years, that's a good request, and we'll see what we can do that time around. Do you want to just put me on the board, Bahron? Do you want me to order over a You're you're you're absolutely welcome to join. Uh anybody, any expert who's on this call, we are looking for more and more experts because the more input there is, the better the outcome.

SPEAKER_01

I may take you up on that.

SPEAKER_00

Approach uh and your uh Australian standards and say you'd like to be an expert. First of all, you have a mirror group, I believe, in Australia that After the standards to make sure they become Australian standards, but also they can put you forward to being on the international group. You could take part. We have uh hybrid meetings, so people who can't travel to the meeting can still join through Zoom. There's five parts to the tie-down standards referring to different ways of tying down. So there may be some designs where the manufacturer has said, my design is only safe if you tie it

Tie-down standards and transport safety

SPEAKER_00

down in six points rather than four points. But most vehicles will not have the system if you go into a bus or whatever, won't have a system necessarily to tie down at six points. So often what has happens is you find that you've got a system that ties down the chassis or the wheelchair, so whether there's somebody in it or not, and that would be four points for safety. And there may be a further uh band that goes around that holds the occupant of the chair in position as well. So that may be a lift at some point.

SPEAKER_01

You know what's always amazed to me is those dial docking plates. You know those pins that go in, you drive in, then click-click. How that thing holds it down more better than four, like how do you get stability through that? I'd I don't get it, but it works, right?

SPEAKER_00

Allegedly, yep. It's not my area of expertise. Speak to Ali, yes.

SPEAKER_01

The other area of expertise I want to chat to you about was so we had a lot of standards, pressure mapping, dynamic seating. One that you also do one is on pressure cushions. Can you be specific on what are the ISA standards around pressure cushions? Is this just like a fabric thing and you know, that makes sure it's safe, or is it actually about pressure care?

SPEAKER_00

When you're looking for a good cushion, again, if you look at my articles, I say what makes a good cushion, we end up with a checklist of about 30 different items that may or may not be important for that individual. And each person is different. So for example, some person may want to have a cushion that's got a slippery surface on it so they can slide in and out easily. Other people may want to have a sticky surface on it so they don't slide out easily. There are a s there's a series of tests that can be done on the cushion that look at its properties. They're not pass-fail tests on the whole. They are tests that give you an idea where you are on a scale. We're looking for a cushion. There's three elements I would be looking cushion. One is looking after aspects of your tissue viability, how well are you protecting your skin from breakdown? The second thing I'd be looking for is how well a cushion helps you position yourself.

Cushion standards and testing

SPEAKER_00

Is it supporting you in the right direction to give a good posture and to give you good functionality? And the third aspect for a cushion is functionality. Is it lightweight? Is it maintenance-free? A whole lot of things like that that are very personal and subjective. Comfort, of course, for most people in a wheelchair is probably the number one uh objective. That's the work that Barbara Crane did in Pittsburgh for her doctorate many years ago. But uh you can't measure comfort because it's subjective. However, there are aspects that you can measure. We've got things like a loaded contour depth, and it gives that gives you an idea of how much uh that cushion will let you immerse into it. And for some people they want to be heavily immersed, and others they don't because they can't get out of the cushion very easily. Uh and envelopment is important because you can immerse into something, but if it's a very tight membrane, you haven't got envelopment, and pressure is a force over area, so for you want to know how enveloped you are to see how much area you can spread the pressure across. So for some people where they've got very sensitive skin, envelopment is probably going to be very important. And there's things like impact damping. For somebody who's going in and out over rough ground and so forth, it is vibrations going through the wheelchair that are very fatiguing for the wheelchair user. And if you're regularly dropping off curbs, going over cobbles and so forth. If you've got good impact damping, you're not going to feel as much as if you have bad impact damping. That's the set of tests there. And there's things like horizontal stiffness and other couple of other tests that relate to how slippery the cover is. And all these uh tests, we look at the whole cushion, not at the individual components.

SPEAKER_01

So just to clarify, it's not just about, you know, gel does this. It's like, no, we look at the entire cushion in the way it's structured, this particular brand and this model, how does it go? And so, like, let's do an example. Like the the impact dampening is a great one because there's a lot of research that says the imp the the impact that wheelchairs have on users. Uh from one, I think there was one study that said it was like um oh, I can't remember the details of it. It said it was like working heavy tools. Like the like one day in a wheelchair was like the equivalent of using heavy tools in some it was something crazy.

SPEAKER_00

Pneumatic grill or something, you know.

SPEAKER_01

Yeah, but it was like I think it was about the loop wheels, and the loop wheels were talking about how the vibration dampening is important and the because you imagine if you're vibrated all the time, your muscles are making like little micro contractions and it exhausts you, it's really it gives you it makes you exhausted, makes you tired, makes you sore. So vibration dampening is a great one to look at. And so if I was to look at that standard specifically, would I be able to like if I'm looking at say a Blake medical cushion versus a Vicare versus a Rojo, and I'm thinking what's really important to me is vibration dampening. How would me as an occupational therapist be able to see where everything ranks compared to others? Is that available to the public?

SPEAKER_00

Pittsburgh have done has done a test which is published available on their website, which has tested over 50 cushions. Uh they haven't, because of the agreements they had with the suppliers to do the testing, they haven't specified what their cushions are. But Permobile have actually reported which of their cushions. Uh there's in fact on the ISO TC173 website there's a link to a library, and those results are shown in that library there. So it's there's a nice graph of showing the scale for different cushions, and each one's got a letter against it. And Permobile has said which of the cushions in their domain belong where on that scale.

SPEAKER_01

Shouts out to Permabil for publishing their their data. Let's get everyone else doing the same thing. Is everyone do you think everyone's a bit worried about their data not being in their favor? It's so hard. Like it's it's so good that you've got these standards, and it's so good. Like, just if for anyone who's not following along, the standards are basically saying it's a level playing field. That if one person's measuring something, it's not marketing riff-raff, there is a agreed uh quantifiable amount of, say, vibration as an example, and this cushion fits this specific factor in on here on the scale. And if you get another cushion and it gets it gives you a rating, it's all going to be under the same rules. So I think it's really awesome that we get that's available. It's just access. I'm trying to think of like if if someone was practically listening to this and they think, oh, I want to know what the standards are and I want to know which one's right for my client. Are you saying the best way to go is through these Pitts this Pittsburgh study, which they they did 50 cushions, but we don't actually know which model did what, is that right?

SPEAKER_00

They d they don't specify which is which, no. They have broken them down into the US funding categories. That means nothing to us Australians. I don't want to hear about it. Whether it's high risk and things like that. So there are about six or eight different categories that uh artificially cushions are positioned in. So you've got adjustable cushions, for example, and how they define adjustable is maybe not the way you and I would do it, but they have their own the definitions.

SPEAKER_01

Yeah, okay. But one thing I've always been curious about is everybody claims that their pressure care is high. Or people often want to give you a rating. Like, is there a specific rating? Pressure care is probably too broad of a term. I know you've mentioned immersion envelopment, and pressure care is all about all of these, right? How much offloading does it, you know, give off the ITs? There's certain factors. Can we quantify? Like, is there something we could look to to be like, all right, uh these cushions pass uh a very high standard for pressure redistribution? And if someone is at high risk, if they're immobile, if they've had a history of pressure injuries, if they're you know got aged skin, all these uh these factors, then these cushions should be considered. Does something like that exist for people to practically use or no, not yet?

SPEAKER_00

Um the answer is there isn't the right isn't one right answer that can be used for everybody. See, microclimate, for example, in for a pressure stage one or stage two ulcer is probably much more important than pressure is for causing damage. Pressure tends to do damage to deep tissues, whereas microclimate and shear forces are doing more damage to the surface. So it's what the person's lifestyle is, how much of the time they're on a cushion and how active they are will have a lot of impact as to how well their cushion is interacting with them. You can get some physical characteristics and properties of a cushion, but those are only part of the story. So how would you define what is a good car? We have dozens of different models of cars on the road, and some of them appeal to people because they look nice and look pretty, some of them like the smell of them, some of them uh like the miles per gallon or what's uh a kil uh litres per kilometer that they get out of it. So what is important to one person buying a car is not the same as to the next person. So some people are going to want to carry a lot of large chunky things like wheelchairs around, so they're gonna have a bigger vehicle than somebody who's just driving around a city. I think the difficulty is trying to make it

Why pressure care cannot be reduced to one rating

SPEAKER_00

easy isn't an easy answer because no two of us are the same, and particularly by the time we're in a wheelchair, there are more challenges in our lives than there are for people who have more ambulance and have less mobility challenges.

SPEAKER_01

Yeah. So so given that there's so many options and there's so many factors to consider, what would be your general guidance to a clinician who knows the main cushions, who knows about the J-Fusion, who knows about the Roho, who knows about the the Vicare, like all these like major brands, and is trying to pick which one is right for the client, and they're not really sure all these factors, they don't have these 30 32 factors to consider and all the data to get with it. What would be your general advice on to how to trial a cushion and how to make sure it's the right one for your client?

SPEAKER_00

As an example, in Switzerland, for many years, what they've done is the professional has said, from my experience from your range of risk and your activities, these are the three cushions that I think you should look at. And then they give the chance for the individual to trial the three cushions. So there's a certain amount of professional input, and then there's the subjectivity that each person has, because the last thing you want is to spend a lot of money on a cushion, and then the person doesn't use it because they don't they find it's unstable, they're not comfortable on it, or for any other reason, or they find it's too heavy. The functionality size are important. You can have you know gel is works quite well for people because it you immerse into it easily and you get good envelopment, but it's heavyweight in many cases, and also often needs a lot of day-to-day maintenance on it. So what's a good cushion? You say a roho cushion, many people would say that gives you good envelopment, but if you have a puncture, you're in a mess. So uh the downsides, so you've got to look at has that person got a cat? Are is the cat likely to jump on there and puncture it? What is the circ circumstance? So it is really the assessment of the person and what the circumstances they're living in and what they want to do that's the starting point, and then that leads you down the road. So for me, used uh from those 30 points a checklist of listing at the top the name of a two or three cushions and the scoring for that individual, how important different points are, and you end up with a score at the bottom.

How to trial a cushion

SPEAKER_00

Oh, actually, from that person's point of view, what we try to do with that for that person, this one scores the most highly. So you can have an objective scoring and but you are looking at all the uh elements of a cushion that are important.

SPEAKER_01

Yeah, it's uh it's tricky, but I think from what I'm hearing you say is we essentially need to look at as many factors as we can, function comfort being one of them. Like they're easy ones to see because you can see them, you can visually measure them over pressure care. And obviously, pressure care is important, and you might do some some pressure mapping as well, which we can talk about perhaps on another episode. But essentially it's basically trial them, trial them slowly, trial them frequently check in. I think that would be the the guide, is what you're referring to is try this cushion, try it for a day.

SPEAKER_00

But cushions, time is the biggest enemy. And often when you've got somebody in a clinic for half an hour or whatever, you may feel not very nice now. But I've sat in many a lecture theatre, and after 20 minutes, I found that those chairs were not designed for sitting on, they're designed for stacking, and therefore I was getting very uncomfortable. I was okay in the first ten minutes, and that's the challenge is give somebody, if you can, a chance to trial something for a l extended period, doing what they normally do in their normal day.

SPEAKER_01

And I think just from a practical standpoint, if you listen to this saying, well, my supplier won't let me trial the cushion for a few days, I bet they would, but you probably just have to work with them. Like if you're in the community, I know that if you said to the supplier, hey, we're doing this trial here, if you leave it for the weekend or leave it for a few days, I can run to the client's house and drop it back to your warehouse in a few days. Like, or the client can perhaps do it, or one of their carers could do it. I think if you explore this option, most people want to get this right. The supplier doesn't want to be without their demos, but they would rather you be sure that this cushion's right than them come back to you and saying, Oh, you know, this cushion's wrong and you sold me the wrong one, and they don't want that headache. So I think we're all aligned and getting the right outcome. So trial on it for a few days and monitoring is important.

SPEAKER_00

In my experience, the spinal injury community is quite good at sharing advice with each other. And often a spinal injury, you are in an institution for quite a long time while you're getting rehabilitated. So quite often the old lags come in and give practical advice to the people who are newly on this pathway.

SPEAKER_01

Baron, one last question before we wrap up today. I just want to get your advice on if somebody has a pressure injury, depending on the stage, and does it even matter what stage it is, what cushion or strategy would you recommend? So, my understanding that the general rule is you've got a pressure injury, get off it. We need to get you off as much as possible, but for a lot of wheelchair users, that means being bedridden, sideline, supine line for weeks at a time, which we know is not realistically going to happen. So if they are going to be in a wheelchair and you know and go again, well, to your understanding, is that the is that doctor's orders as well? Get off get off the wound, is that the best protocol?

SPEAKER_00

This is why prevention is so much better than cure, because it takes it takes quite a short time to create the damage and a lot longer to repair it. And again, there's so many with tissue damage, there's so many intrinsic factors that can affect it. If you're diabetic, uh, for example, your wound healing ability is highly lowered, and you may be on different drugs for other problems that you've got, so forth. So basically, do whatever you can to avoid it. If you're looking at people with diabetics, for example, quite often they have lost a loss of feeling, and we see that with people with their footwear they end up with damage to their skin, and after a while it doesn't repair, and the next step is they got a lower leg amputation, and then the average length of life after that is about three years. So really prevention, if you're at risk, is is the number one uh route.

SPEAKER_01

I didn't know that about amputation. What is it about amputation that s suddenly reduces your life expectancy?

SPEAKER_00

It's all related to your diabetes and your sugar control and everything else, but it's uh it is very serious. See this is why diabetics are recommended

Pressure injuries, prevention and wound risk

SPEAKER_00

to have somebody inspect the bottom of their feet regularly and so forth. So but the same with the skin on their back side. Prevention's definitely the move.

SPEAKER_01

If the hat to sit on it, is there any recommendation, or is it like I can't even make a recommendation? You know, because I've heard people do Rojos and you tie off some cells, but then I worry about the donutting effect. I know with Vikare you can pull out some of the cells in certain compartments to offload the area. I know with the right designs they they're very heavy on the offloading and you can offload the area altogether. Like, is any of this a uh interim solution or a partial solution, or is it depends how far how far the tissue damage has gone.

SPEAKER_00

If you've got an early stage one ulcer, it's likely to be a result of either microclimate or of shear forces. And therefore, uh what's causing the shear forces needs to be removed. And there is a material called glideware that is incorporated, in fact, into some of the comfort cushions that is extremely good at protecting the skin against shear because it that bit of the cushion moves with the skin. The shear forces are removed, so the shear forces are dispersed to other bits of tissue that can take them more readily.

SPEAKER_01

It seems like we need to see glideware and more cushions. You only see in the comfort company. I don't know if it's it's probably their patent and design.

SPEAKER_00

Permobile have got the rights to uh incorporate it. HIA, for example, and BES in the UK. We actually have glideware cushion overlays that you can put over the cushion. But also uh I know of instances where glideware has been made into complete clothing for people who've had burns or who've got uh skin condition where the skin sloughs off easily, it protects the skin. So it is a marvelous material. Uh you need some shear forces around the place to hold you in place, but you want the shear where you want it, so it's managing it, it's quite important.

SPEAKER_01

Yeah, shear is good. Shear is absolutely good, but on the posterior femurs, you know, on the lower parts of your bottom to like all these bits where we want to like hold you in, but not on the high-risk areas like your ITs. That's really good advice.

SPEAKER_00

The other thing, of course, is the breathability of the materials that you're sitting on. And there are cushions like the Vera Lite, which have a reticulated foam underneath the cover, so that helps the air to move and therefore helps the temperature and the moisture not to build up. So things like that should be considered. For me, the cover for most people is more important part of the cushion because that's closest to the skin, and we have many more stage one and stage two

Shear, microclimate and cushion covers

SPEAKER_00

ulcers, and those are the ones that have occurred because of what's happened at the skin level. So look at the skin interaction more and the cushion cover as a first priority.

SPEAKER_01

We might need to do a whole new episode on cushion covers. It sounds like it's another area, but we are out of time today, Byron. If for those who zoned out on your drive and you want a quick recap, if I was to recap everything that we've discussed today, we first spoke about the belts, and I love the analogy of your pelvis being in a ball, and we want to hold the ball into position, and we want to hold a bit with the issue, the shelf that goes underneath it, we want a posterior block at the back, and we want a belt, not at the widest point of the diameter, but at the shortest point, which is more at the front to really secure this belt and stop it from from rolling forward. And ideally, with the two-point two-point belt, a 60-degree angle is quite good. You could go to a 90-degree angle for a bit more comfort, and whilst I thought that would meet the need for a non-padded hip belt, bar and saying, Nope, once you're locked in, that should be good enough. And a four-point belt is more used to for anterior pelvic tilt or a rotation where you're trying to control someone's pelvis, but you don't want the belt to move, and that's what the lower strap could be. We also covered the ISO standards for vehicle positioning and knowing that you know there's certain there's developing standards around there, and then whether it be six-point or four-point will be up to the manufacturer. But most people would do a four-point tie-down. Then we covered cushions and ISO standards around that. So there are ISO standards that exist. Not all manufacturers post their results. Permeabil has. Shout out to Permabil. We will put those in the show notes for anyone who wants to have a look at it, and we encourage any other manufacturers to get amongst it so people can have some tangible, hard, quantitative data around wood chair cushions. But essentially, when you are trialing a cushion, if you're not sure what to do, focus on function. And if you are worried about pressure, trial it slowly over a few days, monitor the skin as much as possible because we want to prevent pressure injuries. Because if we don't, the treatment is a lot worse, as we discussed, can lead to sepsis, infections in the in the blood, amputations,

Justin recap and outro

SPEAKER_01

and ultimately death, which is not what we want. We want to prevent them because pressure injuries never heal, they only close. So we don't want any closed wounds on the body and given our risk even more for the next one. Baron, did I miss anything? That was all off the top of my head. I'm really proud of myself. Anyone listening? I didn't even read any notes. I was looking at Baron the whole time. Was that good?

SPEAKER_00

I'm glad I got the key messages across. Thank you very much for all your brilliant resume.

SPEAKER_01

Awesome. Alright, guys. Well, thank you so much for tuning in for today's pod. If you Baron, if people want to see your work or the amazing content that you're doing, where can they find it?

SPEAKER_00

I produce some a monthly article for a magazine in the UK called THIIS. Uh and the articles from that, and I've been doing that for six years now. Uh we have them published as blogs on the HIA website in Adelaide, on the Knowledge Hub, and the website is www.hiauus.net.au. You'll probably find my contact details there as well. I'm more than willing to receive emails with requests if I can point people in the right direction. That's what I like to do. And anybody who's going to be around in Brisbane at the uh second half of May, I look forward to seeing you there. I'll be talking about belts and harnesses and also what makes a good torso uh trunk support as well, will be one of my topics there.