Prescription and development of adapted seating devices: learning from practice

Introduction: A significant part of the professional activity of physiotherapists and occupational therapists who assist people with motor disabilities is the prescription and sometimes the construction of adapted seats for wheelchairs. This is a complex task that involves practice, continued education, and material and technical resources. These work together to provide the patient's access to the adapted product. Objective: To understand how the prescription and adaptation of wheelchair seats occur in practice in a public institution. Methods: This study had a qualitative approach, applied nature, and exploratory objective. We utilized the case study strategy, conducted through semi-structured interviews, with seven professionals from a public state institution. The data obtained and analyzed were professionals’ practical experiences on seat adaptation for their patients. Results: We found divergences between practice and theory in the institution. The context in which the professionals operate, issues related to the institution, the production capacity of the adaptations, financial and time limitations, custom, lack of protocols and training in the area, and social and patient pressure are some of the causes of these divergencies. Conclusion: On the basis, we drew an overview of the prescription and construction of adapted seats by the institution and described the main elements that influence this practice. We believe that the training and updating of professionals, providing more resources, and a better process planning can reduce the divergences between practice and theory.


Introduction
When prescribing and adapting wheelchair seating devices, physiotherapists and occupational therapists (OTs) use their professional skills and training to achieve the best possible position to improve the quality of life of their patients. 1 These tasks are complex, so they require the cooperation between multiple professionals and patients, 2 and the training and updating of the professionals involved. 3 In an ideal prescription situation, the professional would be consulted from the beginning, where he/she would have all the necessary resources to prescribe and adapt seating devices using the newest technologies and would accompany the entire process. However, this situation does not seem to be the one that occurs in practice. What often happens is that patients arrive at the offices with poorly fitting adapted seating devices (ASD), recommended by shopkeepers, pharmacists, family members, and others. 4 In addition, are few such professionals, and they have few resources and little incentive to modernize the area.
Accordingly, we questioned how the process of prescribing ASD for wheelchairs, with a focus on postural positioning, is carried out in a public institution, specifically at the Santa Catarina Foundation for Special Education (FCEE), which is responsible for public policies of special education in the state of Santa Catarina. 5 We believe that there are gaps between theory and practice, and understanding how the process takes place can help identify factors to be improved both in practice and in theory.
To answer this question, we performed seven case studies through semi-structured interviews. 6 The study aimed to understand the role of OT professionals and physiotherapists, specifically concerning the assessment of patients for prescribing ASD focused on postural positioning. A specific aim was to evaluate the issues involved in the effective construction of ASD, as FCEE has a specialized division for this purpose.

Theoretical foundation
For people with severe disabilities, positioning equipment can make a big difference in their lives. 7,8 minimal support and release the person when they achieve a certain level of functionality. 14 Unlike these environments, rehabilitation clinics focus on the person's inclusion in society. In addition to improving functional capacities, they promote influence in product choice and provide training for its use. 15 Since it is a participatory procedure and focused on the user, even children should cooperate in the selection. 11, 16 In the prescription of more humanized ASD, there are four components: the activity to be performed, the person who will perform it, We tabulated and illustrated the descriptions made by the participants. The tabulations used the same separation by body part and ASD part made in the interviews so they could be correlated. Considerations were made from the analysis of patterns found in the interviews about the prescription of ASD by the participants for their patients. To preserve the identities of those involved, they were numbered from 1 to 6; for example, interviewee 1 (I1) who described patient 1 (P1), all of whom were referred to as male, even though some were female.

Results
To facilitate the understanding of the results obtained with the interviews, we divided the chapter into two parts. In the first, we provided a contextualization of the prescription and adaptation process of a wheelchair as it happens in FCEE gathered from the various interviewees' responses. In the second, we compiled the interview results on the practical process of prescribing and adapting ASD for the specific cases others (I1 to I6) described real situations of a patient (P1 to P6) for which they prescribed an ASD.
The data collected from the interviews were organized in two tables: one for the patient's afflictions (Table 1) and the other for the ASD developed for these patients ( Table 2). In Table 1, which follows, the patients' disorders are separated by body part.
We can see from the analysis of Table 1  As in the first table, the ASD described in Table 2 are also arranged separately by body part, making it possible to make a direct comparison between the affection and the prescribed ASD. When the adaptation of part of the seating device was not present, this was indicated by "did not exist".
When analyzing Table 2, we can see that the expected seating device described was not found. For example, P6 had pelvis abduction but used a flat seat. This same patient did not use footrests, a factor that differs from the literature. 28 In addition, the use of lateral supports was found in most cases, despite the   Finally, P6 had a peculiarity in which he had more control with the lower limbs than upper limbs and therefore used his lower limbs to control the chair. This patient was also able to communicate his wants and needs, having more ability to adapt his seating device.
The patient did not use only his chair, where he was able to walk short distances and transfer from the chair without assistance. One of the adaptations made at the patient's request was removal of the footrest, which he said hindered locomotion. However, good foot positioning is important for good posture, 28 and its presence is recommended even if it is not used all the time.

Discussion
In FCEE we found a prolific activity in the prescription, In addition, abductors and belts are also present in most cases and fulfill positioning and patient safety functions since most patients had spastic movements.
In the second case, given the social stigma that can arise when patients use certain ASD, most professionals preferred the use of side supports over tables and trays, the use of fewer supports than necessary, and sometimes, especially in the last case (P6), the removal of essential elements such as the foot support. 17, 25,28 This stigma orders the "normalization" of people with disabilities wanting them to approach a position considered normal. We noticed, therefore, that some Another point in the discussion is the time spent between the ASD prescription and its manufacture.
Since there is a bidding process for its purchase and manufacture time, it will probably reach the end-user with some delay. This problem has the greatest impact on children, as they are still growing and undergo other bodily changes due to their health status. 17 Therefore, the seating device that was prescribed at a given moment can be delivered with the most diverse inconsistencies, as was the case with P1, for whom the seat was considered too small at the time of receiving the product. OT/physiotherapy. Also, the prescription process is not standardized, and it is up to the professional to make the decisions and write out the prescription.
Although it is not possible to generalize for the whole institution, since we did not interview all professionals, we noticed that the participants carefully considered the well-being, health, and safety of patients in their context.
The professionals work with the limitations imposed by the production processes to achieve the objectives of seating device adaptation in the best possible way.
It was also clear that there is a need to create specific and individualized objectives for each patient, and such was the case for P6, who had a mobility objective. In We surmised two hypotheses for the seating devices' selection patterns found in this study: the first concerning the variables influencing the production capacity of ASD and the second relating to the social stigma of using certain ASD. In the first case, concerning production capacity, we noticed that routinely when the literature recommends seating devices with a profile adapted to the anatomy, the professionals used flat seating devices with lateral supports, given the difficulty of producing

Conclusion
In this study, we evaluated the real situation of the practice of prescribing and adapting ASD by qualified professionals in the context of a state public institution.
We noticed that in this context the determination of an adequate posture is mediated by the patients' functional needs, wants, and tastes, as well as the production capacities of the seating device, financial resources, and manufacture time. As a consequence, the final results obtained differ from theoretical models considered ideal.
Although this is not necessarily the case with the results obtained by the study participants, it is important to highlight some elements that should be contemplated when performing this activity in practice. Also, there may be a loss of information in the process of transferring information about the adaptation needs to agents who will develop the seating device, thus resulting in a ASD that is not suitable for the target subject. It is therefore necessary to create robust and standardized communication systems with which good communication can be maintained.
In addition, we suggest that in future works a comparison be made between the results obtained in the prescription process of adapted seating devices and the functional capacity of individuals, preferably using functional recognized indices such as FIM (Functional Independence Measure Scale) or ICF (International Classification of Functionality) in an attempt to find relational patterns between these two elements. In this research, this was not done because these standards were not used universally in the selected institution,