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Indications for when to use custom seating to promote function and reduce progression of asymmetry, pressure injury risk, and pain

When assessing a person’s wheelchair seating, there are many factors to consider. Their skin health, seating history with its successes and failures, transfer style, level of activity and ability to maintain adjustable seating are just a few of these considerations. Also, a consideration is the complexity and correctability of their posture if they present with asymmetries in their positioning. As the evaluation progresses, the mental decision tree of the therapist and Complex Rehab Technology supplier may conclude that custom seating is an optimal choice.

While custom seating is often the superior option given the ability to create a unique system to meet a user’s unique needs, there needs to be great consideration of the greater clinical picture which can include caregiver need and level of involvement, the presence of multiple caregivers, and the ability of the user and/or their caregivers to consistently and properly position the user in the system.

This article examines the evolution of custom seating, the impact of technological advancements, funding considerations, research on its benefits — including potential effects on scoliosis and asymmetry progression — and clinical factors in choosing custom versus standard seating options.

Historical Perspective

The evolution of wheelchair seating systems reflects significant advancements in the rehabilitation field. Early wheelchair models prioritized mobility and transportation with little regard for posture, skin integrity or long-term comfort. These early wheelchairs were heavy and were minimally adjustable. Early seating options were typically planar, not matching the contours of the human body. In the mid-20th century, attention began to shift toward addressing pressure injuries and postural deformities resulting from prolonged sitting and uncorrected postural asymmetry. Initially, seating options were limited to basic cushions and backrests, often using foam or rubber materials with minimal contouring.

Early wheelchairs, dating back to the 16th century, focused on basic mobility and were often commissioned for individuals with specific conditions like gout or arthritis. These early designs often included features like adjustable backrests and legrests but lacked the sophisticated postural support and pressure management of later custom seating. 

The rise of customization and specialization throughout the years can be seen in this timeline as documented by Tom Borcherding and Hymie Pogir in their article “CRT Pioneers and Innovators throughout History” on LUCI.com:¹

• John Rogers (University of TN, Memphis; Rancho Los Amigos) pioneer of custom seating utilizing bean bag and vacuum technology (the “Desmo System”), and first-generation pressure sensors. Circa late 1960s. In the early 1980s, pioneers like Mike Silverman (PinDot Products) started using computer-aided design (CAD) in the commercialization of custom molded seating. 
• Robert H. Graebe (ROHO Inc.) pioneer of the original pressure relieving cushion (the “ROHO Cushion”) that has benefited millions of individuals across the world. Circa 1968.
• Joan Bergman (University of Alabama) pioneer who used weather balloons to develop early solutions in custom molded seating. Circa late 1970s.
• Marty Carlson (Gillette Children’s Hospital; Tamarack Habilitation) pioneer of the sitting support orthosis and numerous other orthotics-based principles and designs that influenced modern day wheelchair seating. Circa 1978.
• E. Fernald State School (Boston) pioneer of the first planar seating simulator used internally by Elaine Cox first at the State School in Boston then later in Florida to help with care for the institutionalized client and the transition to community-based homes. Circa late 1970s.
• Michael Bullard pioneer of the Flamingo Seating Simulator – the first commercially available planar simulator. Circa early 1980s.
• Doug Hobson (University of Tennessee – Memphis) pioneer of custom seating using a vacuum and bead seat design. Circa early 1980s.
• Mike Silverman (PinDot Products) pioneer of using computer-aided design in the commercialization of custom molded seating. Circa 1982.
• Rick Jay (Jay Medical) pioneer of the first wheelchair cushion to utilize the pressure-equalizing benefits of fluid incorporating a stable foam base (the “Jay Cushion”). Circa 1983.
• Simon Margolis pioneer of the Bi-Angular Back and the Sub-Asis Bar, and influencer over many of today’s CRT practices.
• Allen Siekman (Stanford University; Beneficial Designs) pioneer of the Anti-Thrust Seat (circa late 1970s) and forerunner of dynamic seating (circa 1990s). Also instrumental in the development of international wheelchair seating standards and testing.
• Kerry Jones and Cathy Bazata (Rehabilitation Technology Center) pioneers and early influencers of seating and positioning principles incorporated today by numerous manufacturers. Circa 1983.
• Jody Whitmyer (Whitmyer Biomechanix). Pioneer of numerous head positioning solutions. Circa 1988.
• Matthew Kosh, David Hintzman (Bodypoint) pioneers of body-contoured hip belt pads and harnesses, the 4-point hip belt and dynamic postural supports that maintain posture while allowing for movement. Circa mid-1990s.
• Leslie Fitzsimmons (Lakeview Cerebral Palsy School + Stealth Products) pioneer of the i2i head positioning system (original name the “Fitz Headrest”). Circa 2001.
• Tom Hetzel and Joe Bieganek (Ride Designs/Aspen Seating) pioneers of commercialized Orthotic and Prosthetic wheelchair seating wherein pressure and shear stress are intentionally and specifically applied to low-risk anatomy, thus allowing the cushion contours to be separated from the high-risk areas (off-loading). Circa 1998.
• This period also saw the establishment of specialized wheelchair seating clinics in North America and Europe, focused on assessing, fitting and providing custom seating solutions. 
• Dynamic seating, which allows for controlled movement and postural adjustments, also emerged, with early examples like the EndoFlex by PinDot Products.

Impact of Advances in Technology

Modern custom seating is a direct result of advances in research and technology. Modern custom seating is characterized by a focus on:

• Shape Capture: Using techniques like scanning and molding to accurately capture the user’s body shape.
• Advanced Materials: Utilizing a variety of materials like foams, gels and air cushions to provide support, pressure relief and comfort.
• Personalized Adjustments: Allowing for fine-tuning of seat depth, width, back height and other dimensions to meet individual needs. Custom seating allows for personalization of offloading, contours and other dimensions to create a system specified to the user’s body and functional needs. Many custom seating systems allow for modifications in the field or office with simple, everyday tools. This provides greater access by the user and their carers to have optimal outcomes.

Customization is now a key aspect of wheelchair design, with a wide range of options available to enhance mobility, posture and overall user experience. A wheelchair is no longer seen as just a mobility device to move from point A to point B, but also as a functional extension of the person. This progressive, more holistic mindset shift has also led to higher demand for customization of the entire system.

Over time, the field of seating and wheeled mobility has recognized that poor seating contributes to the progression of musculoskeletal asymmetries, pressure ulcers and pain. While there are certainly guiding principles that can be applied universally, the recognition that no two bodies are the same has also bolstered the expansion of the field of custom seating. This understanding led to the introduction of modular and custom seating systems designed to optimize function and prevent complications. Key milestones include the integration of pressure mapping in the 1990s and the rise of computer-aided design (CAD) for seating fabrication in the 2000s. Today, seating interventions should be guided by evidence, best clinical practices and person-centered care principles. As it is said, we can’t do better until we know better, but once we know better, we must do better.

Technological advancements have revolutionized wheelchair seating systems, particularly in the development of custom-contoured solutions. Custom seating now has the ability to incorporate some or all of the following:

• 3D Scanning and CAD/CAM: These technologies allow clinicians to capture precise anatomical details for users with complex postural needs. The digital design process ensures a high level of accuracy and reproducibility.
• Pressure Mapping Systems: These tools evaluate real-time pressure distribution, guiding clinicians in choosing or adjusting cushions to minimize risk areas.
• Advanced Materials: Innovations in foam composites, viscoelastic materials and air- or fluid-filled cells have improved pressure redistribution and comfort.
• Dynamic Seating: Some systems now include components that adjust position throughout the day to mimic weight shifts and reduce pressure buildup.

These tools enhance clinician and supplier ability to provide highly individualized interventions that improve clinical outcomes.

In summary, the history of custom seating for wheelchair users reflects a journey from basic mobility devices to sophisticated systems tailored to individual needs. This evolution has been driven by a combination of technological advancements, changing social attitudes and a growing understanding of the importance of postural support and pressure management. 

Funding Considerations

Despite the clear clinical need for custom seating, funding remains a significant challenge. Coverage varies by country, insurance provider and region. In the U.S., Medicare and Medicaid cover seating when medical necessity is established by documentation from the therapist and/or doctor. Private insurers often follow similar guidelines.

Documentation must link the seating system to one or more of the following:

• Prevention of pressure injuries
• Mitigation of postural deformities
• Pain reduction
• Functional improvement

The Centers for Medicare and Medicaid Services requires sufficient documentation for a higher complexity of support. Per CMS Pub. 100-03 (Medicare National Coverage Determinations Manual), Chapter 1, Sections 280.1, 280.3, the user must meet criteria for position and pressure relief seat or back and have documentation as to why the prefabricated items do not meet their needs. Additionally, “there [must be] a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiary’s seating and positioning needs. The PT or OT may have no financial relationship with the supplier.”

This additional documentation can include detailed clinical justification, such as documentation of skin breakdown (stage, location, onset), pressure mapping data and equipment trials. Some payers limit replacement frequency, making it essential to select systems that accommodate user growth or disease progression.

Clinicians and suppliers must be well-versed in funding criteria and advocate strongly for their clients through documentation and appeal processes when necessary.

Purpose of Custom Seating

Custom seating is prescribed to achieve several clinical and functional goals:

1. Support Optimal Function: Postural alignment enhances upper extremity function, head control and endurance.
2. Prevent or Minimize Postural Asymmetries: For individuals with neuromuscular conditions, scoliosis, pelvic obliquity, contractures and windswept deformities can worsen over time without intervention.
3. Reduce Pressure Injury Risk: Redistributing pressure over a broader area theoretically reduces the risk of skin breakdown. Custom contouring of seating products can provide significantly more contact and, therefore, pressure distribution than modular seating products with standard contours.
4. Alleviate Pain: Proper support reduces muscular strain and joint compression.
5. Improve Participation: Comfortable, stable seating facilitates engagement in activities of daily living, education and community life.

Does it do what it is supposed to do?

These are all desirable goals for the end user. However, outcomes do not always reflect the achievement of these goals, which leads one to ask if custom seating does achieve really meet the desired goals. Given that custom seating is comparatively new in the industry, we are just now able to review data from users who have been in custom seating systems for years versus those who have not. Fortunately, historical and emerging research support the effectiveness of custom seating:

• Hosking (2024) conducted a longitudinal, retrospective cohort study showing that children with neurologic and neuromuscular disorders using custom-contoured seating had slower scoliosis progression than those using modular systems. They did this by retrospectively evaluating the comparative effect of two wheelchair seating systems, Custom-Contoured Wheelchair Seating and Modular Wheelchair Seating, on scoliosis progression in children with neuromuscular and neurologic disorders and to determine any predictors for scoliosis progression. The participants consisted of 75 males and females with a mean age of 10.5 years old at the time of seating intervention, from 2012 to 2022. Of the 75 participants enrolled, 51% had cerebral palsy. The interventions were two specialized wheelchair seating systems, CCS and MWS. The main outcome measure was the effect of the seat type on Cobb angle over time. Fifty were issued CCS and 25 were issued MWS. Baseline Cobb angle was 32.9±18.9° for the MWS group and 48.0±31.0° for the CCS group. The generalized least squares model demonstrated that time since seating intervention, seating type and baseline scoliosis severity were all predictive of scoliosis progression. Condition, gender and age at interventions were not predictive. The research showed that the velocity of scoliosis progression in these children with neuromuscular conditions was slowed in the CCS compared to the MWS group, although scoliosis deteriorated regardless of intervention. ²
• Hosking (2025) also performed a scoping review, finding that custom-contoured seating improves skin integrity, pain levels and postural alignment in users with neuromuscular disorders. Researchers conducted a review using 17 full-text articles from 2021-2022, exploring outcomes related to “(1) posture and musculoskeletal deformity, (2) quantitative measures of body structures and functions, and (3) qualitative perceptions, opinions, and quality of life indicators.” This review identified a significant gap in the literature regarding the effects of custom-contoured seating on cardiopulmonary function, pressure injury management and upper limb function. While no evidence suggested increased risk compared to alternative seating options, custom-contoured seating was consistently associated with high levels of user satisfaction, comfort and functionality. The findings alsoindicated immediate improvements in postural alignment; however, the long-term impact on the progression of musculoskeletal deformities remains unclear. The primary aim of this review was to assess the existing evidence on custom-contoured seating for wheelchair users with neuromuscular disorders, synthesize current knowledge, guide clinical practice and highlight areas for future research.³
• de Mare et al. (2023) proposed that contouring the seating base would positively impact the pressure distribution effectiveness and reduce user discomfort with prolonged sitting. They studied 13 healthy participants who each tried three differently contoured seating surfaces and rated their perceived comfort sitting on each. Pressure mapping measures were also taken. Results found that contoured seating bases rated more favorably for pressure distribution, reduction in peak pressures of buttocks and reduction of discomfort, which may help in long-term skin preservation. This article also highlights the need for research to examine the effect of contouring on stability, as well as to compare the effects of contoured seating bases and contoured cushions. ⁴
• Similarly, Tasker et al. (2014) also used able-bodied participants’ ratings of sitting discomfort and pressure mapping measures on different contoured seat cushions. Thirty-one participants sat with limited movement for 30 minutes in three sessions and rated perceived discomfort while the pressure-mapping interface simultaneously measured peak pressures. This study showed a correlation between discomfort and high pressures, with the least of both on a more custom contoured cushion. While the findings of this study and those of de Mare et al. (2023) support the notion that custom contoured seating will increase sitting tolerance by decreasing discomfort and improving pressure distribution, thereby decreasing risk of skin breakdown, findings are somewhat limited to the neurologic population, as all participants were able-bodied.
• Lephart et al. (2015) cite a school setting case study comparing the impact of planar versus custom back seating systems in a 19-year-old young man with quadriplegic cerebral palsy and neurological scoliosis. The study measured oxygen saturation (SaO₂), heart rate, respiration rate, body temperature, processing time to activate switches and response accuracy. The young man had improved accuracy with decreased processing time and variability with all vital sign measures when using the custom back. Per the study, “SaO₂ levels increased from ‘distressed’ to ‘normal’ while using the custom molded back. [DB4] While the study also cites that fatigue and motivation may impact overall scoring, he did appear more functional when supported by the custom back.⁶
• Sonenblum et al. (2018) studied real-time tissue deformation by various seating products in four participants with chronic spinal cord injury who had documented atrophy of tissue around the bony prominences of the pelvis. Using  FONAR Upright MRI, participants were scanned sitting without pelvic support with buttocks fully suspended and then sitting on three different contours of cushion — a high profile ROHO cushion, foam Matrx Vi cushion[DB5] , and offloading Ride Designs Java cushion. Multiplanar scans were analyzed to provide 3D renderings and measurements of tissue thickness and shape. The results showed that while buttock deformation occurred on all three cushion types, the deformation was different for each type. Bulk tissue thickness reduction at the ischium occurred more in the immersion style cushions of ROHO and Matrx Vi compared to the off-loading orthotic style of the Ride Java cushion. The findings of this study were varied and appeared individualized, but the overall results that decreased tissue thickness reduction on the off-loading design is to be considered in persons presenting with tissue atrophy in the pelvis. ⁷
• Ride Designs (2017) presentation at ISS 2017 (International Seating Symposium) presented research findings from the 1970s to the present that emphasized early intervention with custom seating yields better outcomes than waiting until significant deformity has occurred. Their key argument was that custom-molded seating should be considered an early, not late, intervention for individuals —especially children — with significant neuromuscular disabilities. Early implementation can prevent or reduce postural, physiologicaland functional decline, while improving quality of life. As a child grows and develops, the custom seating should support optimal posture and function. Research and clinical experience show that waiting too long can result in structural damage such as scoliosis, pelvic obliquity, skin breakdown and internal dysfunctions, which may be nonreversible or require highly invasive and complex surgeries to correct. Planar and generic contoured seating options often have compromised support and effectiveness over time. Growth mechanisms in traditional seating often limit the precision of proximal support, which is critical for stability. Given the natural mechanics of the human body, our body adapts to forces. This is seen in Wolff’s Law, which describes how bones adapt and remodel in response to the mechanical stresses placed upon them. Essentially, bones become stronger and thicker in response to increased loads and can become weaker and thinner with decreased loads. This is foundational for how we apply forces to the human body for the purposes of corrective positioning. Children with cerebral palsy, for example, are at high risk of scoliosis due to the distortional forces of spasticity. Custom seating can be used to sustain the child’s posture in an optimally corrected posture against these forces to potentially reduce the risk for scoliosis, which may also help delay or avoid spinal surgery. Custom seating using an orthotic approach may also help support recovery post-surgery. Adults who are done growing may also benefit from custom seating post adult-onset injury or disease to maintain proper posture, as well as to mitigate pressure injury risks. Advanced custom seating supports posture and skin health and can adapt to changes like weight loss or tissue atrophy. They conclude that custom molded seating is not just a last resort but a proactive, primary intervention that should be used early in care planning. Modern technology supports pediatric and adult users more effectively than traditional systems, providing long-term health and functional benefits.⁸

While individual outcomes vary, data suggest that when seating is more similar to the user’s unique morphology and monitored over time, the risk of complications decreases significantly.

Clinical Considerations: For and Against

While research is favorable towards custom seating for sustained decreased in pain/discomfort and deformity and the promotion of function, there are many other clinical considerations to determine whether custom seating is the most appropriate solution for the user. Below are general considerations for and against custom seating.

For:

• Postural Management: This is essential for clients with fixed deformities or who are at risk of developing them. Users who have an unsuccessful history with standard “off-the-shelf” products to correct/sustain posture, especially those whose postural support needs are asymmetrical, should consider custom seating. Those with fixed or flexible scoliosis — just know how far you can correct. It is advised to avoid moving the user to max postural correction.
• Pressure Management: Pressure management is crucial for those with limited mobility and poor sensation. Users who have continued issues with skin breakdown or pain despite many changes to seating and compliance with active pressure relief strategies (pushups, repositioning, etc.) should be considered for custom seating to offload problematic areas precisely.
• Pain Reduction: Custom seating, with its personalized contour and targeted support, can benefit individuals with musculoskeletal or neuropathic pain.
• Function: Proper alignment facilitates better respiratory function, feeding and interaction with the environment. Users with postural instability related to their asymmetries, which impede their ability to perform functional and self-care tasks, are likely good candidates.
• Skin: Users who have continued issues with excessive moisture due to sweating or incontinence can benefit from greater airflow, which can be built into a custom design.

Against:

• Complexity of Fit: The complexity of custom seating requires skilled clinicians and CRT suppliers/seating technicians and often involves multiple fitting sessions. Some manufacturers require specific training and/or certification. Failure to shape, capture or fit correctly could cause harm to the user, increase costs from the need to remake the system, and decrease billable time for the supplier.
• User Tolerance: Some users may resist change or find initial seating uncomfortable.
• Adjustment Needs: Clients with rapidly changing conditions may outgrow or outpace the system.
• Cost: Can be prohibitively expensive without full funding.

General considerations when selecting manufacturer/product:

• Body temperature regulation: There are many variations of custom seating. Clients with body temperature regulation issues should be considered for more breathable products if users tend to be hot or sweat excessively to decrease the risk of moisture buildup and skin breakdown.
• Incontinence: Incontinence increases skin breakdown through maceration and persistent moisture, which makes the skin more likely to tear. Clients with significant incontinence issues seeking custom seating should be considered for custom seating products that are nonporous/nonabsorbent, such as Ride Custom 2 and Matrix USA custom seating products.

Environmental Considerations: For and Against

While the clinical picture for the user may lean favorably toward using custom seating, there are additional environmental considerations when deciding to use custom seating. These are to include, but not limited to:

For:

• Custom seating can be designed to integrate with user environments, including home, work and school settings. Examples include custom contouring for placement of power chair controls and support surfaces like trays.
• Proper positioning of the user will support their interaction with tables, desks and communication devices, as indicated in the research by Lephart et al. (2015).

Against:

• Large or uniquely contoured seating to accommodate/correct those with significant windswept, oblique or rotated postures may not fit through standard doorways or into vehicles.
• Heavier systems may reduce manual propulsion ability. Consider hardware and materials used when selecting custom seating for those who independentlypropel a manual wheelchair and for dependent manual mobility when caregivers are elderly or have limited ability to push a heavier wheelchair system.
• Consider how contours of seating will affect transfer techniques — use of lifts, lateral transfers with sliding boards and caregiver assistance (Where does the caregiver need to be positioned to safely support the user?).
• Multiple caregivers and caregiver turnover can present challenges in providing the necessary education to all caregivers on the proper positioning of the user in the custom seating system. Improper positioning can result in skin injury and pain; consider full contact foam seating, which is not so specific. Use caution when considering firmer products, such as Ride Custom 2, that require precise positioning.

Environmental assessments during the evaluation phase are essential to ensure the seating solution enhances rather than hinders participation. Careful consideration should also be given to caregivers’ perceptions of the materials used. For example, if the materials are firm for offloading, it is important to educate caregivers as to the clinical reasoning and design intent to prevent rejection of the system due to caregiver perception that the material is “too hard” and therefore not helpful or uncomfortable to the user, especially if the user is insensate or not able to verbalize their own discomfort.

Professional Considerations: For and Against

Each therapist and CRT supplier is accountable for judging their professional abilities and capacities to create, supply and maintain/support the user in a custom-molded seating system. These considerations should include:

For:

• Represents a commitment to person-centered, evidence-based care.
• Facilitates interdisciplinary collaboration among therapists, CRT Suppliersand physicians.
• Enables measurable outcome tracking and ongoing client education.

Against:

• Requires significant time and clinical expertise. Some custom seating products require the supplier to be certified to supply and modify custom seating products. This can be challenging to schedule delivery and follow-ups if these are typically assigned to noncertified technicians.
• Demands familiarity with funding processes and documentation.
• Risk of overprescribing if not clinically warranted.

Ultimately, custom seating must be prescribed judiciously, balancing benefit with practicality, cost and client goals. Given the high complexity of considerations and their impact on the success of the custom seating system, it is strongly recommended that a supplier that is not experienced in the nuances of custom seating have support of a colleague that has experience and can guide the supplier. Manufacturer representatives can offer useful support, but the overall clinical picture must be presented and clinically justified by the supplier and prescribing therapist to ensure optimal outcomes.

Conclusion

Custom seating can play a pivotal role in preventing and managing secondary complications in wheelchair users when properly prescribed and designed. When selected and implemented appropriately, research consistently shows custom seating can slow the progression of deformities, reduce the risk of skin breakdown, alleviate pain, improve function and support meaningful participation in life roles. As technologies evolve and evidence grows, rehabilitation professionals must stay informed and advocate for seating solutions that truly support long-term function and well-being. Considerations for custom seating must go beyond medical needs and include professional, environmental, social and functional considerations to have the most successful outcomes.

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References

1. https[DB1] ://luci.com/2021/02/crt-pioneers-and-innovators-throughout-history/#:~:text=Allen%20Siekman%20(Stanford%20University;%20Beneficial,Circa%201998.
2. Hosking J. Impact of Wheelchair Seating Systems on Scoliosis Progression for Children with Neurologic and Neuromuscular Disorders: A Retrospective Study of Custom-Contoured Wheelchair Seating and Modular Wheelchair Seating. Arch Phys Med Rehabil. 2024;105(10):1921-1929. doi:10.1016/j.apmr.2024.06.007.
3. Hosking J. The clinical effectiveness of custom-contoured seating for wheelchair users with neuromuscular disorders: A scoping review. Assist Technol. 2025;37(1):41-53. doi:10.1080/10400435.2023.2250404.
4. de Mare L, de Groot B, de Koning F, Geers R, Tetteroo D. The influence of a contoured seating base on pressure distribution and discomfort. Disabil Rehabil Assist Technol. 2023;18(1):1-7. doi:10.1080/17483107.2021.1892841.
5. Tasker LH, Shapcott NG, Watkins AJ, Holland PM. The effect of seat shape on the risk of pressure ulcers using discomfort and interface pressure measurements. Prosthet Orthot Int. 2014 Feb;38(1):46-53. doi: 10.1177/0309364613486918. Epub 2013 May 17. PMID: 23685919.
6. Lephart K, Kaplan SL. Two Seating Systems’ Effects on an Adolescent with Cerebral Palsy and Severe Scoliosis. Pediatr Phys Ther. 2015 Fall;27(3):258-66. doi: 10.1097/PEP.0000000000000163. PMID: 26102166.
7. Sonenblum SE, Ma J, Sprigle SH, Hetzel TR, McKay Cathcart J. Measuring the impact of cushion design on buttocks tissue deformation: An MRI approach. J Tissue Viability. 2018 Aug;27(3):162-172. doi: 10.1016/j.jtv.2018.04.001. Epub 2018 May 9. PMID: 29804800.
8. Ride Designs. Early vs. Late Intervention in Custom Seating. International Seating Symposium 2017. https://ridedesigns.com/wp-content/uploads/2024/12/ISS2017_early_vs_late_intervention_custom.pdf

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Melanie may be reached at melanie.parker.pt@gmail.com.

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