It’s simple math: Even clients who spend many hours a day in
their wheelchairs also spend many hours a day out of their
wheelchairs.

Julie Harkness, a Sales Representative for Motion (formerly
Motion Specialties), noted, “If [a wheelchair user] spends 12
hours in the wheelchair, then there’s an equal amount of time
where that posture has the potential to be adversely affected by
being in a position where it’s not supported.”

Ryan Rhodes, MS, OTR/L, ATP/SMS, Pediatric Sales Specialist
for Leckey at Sunrise Medical, concurred: “I like to look at [the
day] as a clock, as a big pie graph. How much of the time in a day
are we really in our wheelchairs? It is quite a bit of time, but even
12 hours is only half of the day. Twenty-four-hour positioning
is really important for the carry-over of what we’re trying to
address during our seating evaluation.”

When It’s Not the Wheelchair’s Fault

Harkness said when something goes wrong with a client using
a wheelchair — a pressure injury, for example — wheelchair
seating is immediately scrutinized. “My experience is that the
minute anyone gets any skin breakdown, [people think] it’s the
chair’s fault,” she said. “And at least 50 percent of the time, it’s
not the chair’s fault. It’s the commode, it’s the sling, it’s how
they’re lying in bed, it’s how they’re sliding down the bed.”

Those unsupported hours can cause all kinds of problems. “I
would say the bed is the biggest [problem] area, because most
of our clients spend at least 10 hours in bed,” Harkness noted.
“People will put the head of the bed up and not put the feet of the
bed up, and basically that creates a big slide. The tendency when
you’re on a slide is to push with your heels, and that’s where you
get heel breakdown.”

Unsupported hours in bed can eventually impact wheelchair
seating needs.

“We see a lot of postural deformities that result from lying
in bed,” Rhodes said. “Oftentimes, we see somebody with a
windswept deformity that’s a result of them always being on their
backs with their knees bent and those knees always falling to
one side for an extended period of time. Once we sit them up, we
can’t get those knees back to midline, so during the seating evaluation,
we have to accommodate that cushion and seating system
for a windswept deformity.”

“What we know is that the body for some reason, whether
it be muscle tone or reflexes, creates asymmetries,” Bollinger
said. “And then the body accommodates to those postures, and
eventually that accommodation becomes a habit, and then it
eventually becomes obligatory. And that is where we begin to
see skeletal changes. We see contractures, and that’s where we
start to see function being affected. We see bodily functions like digestion, respiration and elimination
being affected. So just by allowing these
asymmetries to become habitual and
eventually obligatory, we start to see that
affects so many areas.”

24-Hour Support
for Consistency

One major goal of managing posture
around the clock is to maintain the
optimal positioning that clients experience
while in their wheelchairs.
Maintaining postural support in bed or
during a hygiene regimen works to carry
over the positioning achieved in the
wheelchair.

“We’re trying to avoid fixed-deformity
postures, especially in the pediatric
population,” Rhodes said. “They may
present with very low tone, and if not
supported appropriately, that could result
in shortening of the muscles also known
as contracture onset, or they may fluctuate
in tone that will move them out of midline
if not provided with appropriate support,
also resulting in permanent deformities
if not supported correctly. For those with
low tone, we can provide appropriate
support and get them into a neutral and
safe position where they aren’t getting
pressure sores or contractures that result
in asymmetrical postures.

“For those with fluctuating tone, especially
those commonly presenting with
extensor tone patterns, we can provide
dynamic seating options that allow the
seating system to ‘give’ enough to allow
the individual to return back to a safe
position during those fluctuations.”

Bollinger pointed out the need to also
make sure the positioning supports whatever
activities the client is performing.
“The goal for me is always to capture and
create good alignment early on,” she said.
“So what’s the optimal position lying
down, what’s the optimal positioning in
sitting, what’s the optimal position in
standing? We need to look at the orientation
and try to create the body ‘neutral’ in
those positions.

“Notoriously, we have had seating
systems for toileting where we have an open seat-to-back angle, and they’re supported, but in a kind of
relaxed position. But when you think about what position you
require for the process of elimination, the posture is more flexed.
So our traditional shower chair doesn’t necessarily translate over
to a toileting system. Firefly just came out with a toileting system
[GottaGo, which provides ‘supported squat’ positioning] that
incorporates these positions. It’s looking at the different activities
and what the need is for those activities — certainly providing all
that support in body-neutral positioning, but also what is required
to do that activity.”

24-Hour Support for Alternative Positioning

Sometimes, the goal is not to emulate wheelchair seating while
out of the wheelchair, but rather to achieve another clinical
benefit altogether.

“Currently we’re trying to get children into hip abduction,
when we stand them to try to develop that hip socket, the acetabulum,”
Bollinger said. “We’re offering up another position. We’re
trying to develop the hip with abducted standing to prevent
orthopaedic issues down the line. If we can get a good hip socket,
we can also hopefully prevent that hip dysplasia that comes
sometimes with kids that have overlying neurological issues.”

“We know that bones of young children are soft and moldable,
and we also know that an undeveloped acetabulum is more shallow
than a developed one,” Rhodes said. “Upright standing without
abduction does not deepen that acetabulum adequately, making the
femoral head reliant on soft tissues to hold the large joint in place.

“We see children with cerebral palsy born with very typical
hips. It’s lack of weight bearing, it’s fluctuations in tone that so
often cause the dislocated hips we see at an early age due to a
shallow and hardened acetabulum.”

Creating a 24/7 Positioning Plan

Bollinger believes 24-hour postural management should be a
formal part of the seating team’s strategy.

“I want to express the value of alternative positioning as part of a 24-hour postural plan,” she said. “As an old-school therapist, positioning
was always part of my treatment plan, and I think therapists
intuitively do that. But by creating a positioning plan, which
is 24-hour postural support, I think it really does draw attention
to the need, whereas it almost seems like it’s secondary now. By
saying we have 24-hour postural management, we’re attuned to
that. Some kids might have [entered] the pandemic without having
a plan in place. This pandemic really drew attention to that.”

Setting up a formal plan could remind the team to check all
of a client’s environments and activities, rather than just the
activities happening in the wheelchair. “It’s difficult in many
cases to look at the whole picture, especially if we’re seeing such
a snapshot of things,” Harkness said. “We don’t see the person in
bed most of the time; we don’t see what that looks like.”

A crucial factor to check, Harkness added, is transfers.

“I had issues in [a] long-term care [facility] where I had one
person say to me, ‘There’s a problem with the chair.’ I always try
to look at the [pressure] wound if I can, and there was a perfect
imprint of the shape of the sling on this person’s bottom. That’s
not the chair; that’s the sling. So all of those pieces need to be
looked at equally, and it’s not always just the chair’s issue.”

Harkness said she scrutinizes how clients transfer, because
clients who can’t properly transfer onto their sitting surfaces
won’t reap the benefits of that positioning. “I also see the person
in their home, and it’s amazing how often there will be something
you didn’t think of when you’re doing that wheelchair
prescription. I’m dispensing the chair in the person’s home. I
often see what that transfer looks like. You can transfer them
beautifully in the seating clinic, and then you go into the client’s
home, and you don’t have that capability.”

Harkness also picks up clues by people watching: “One of my
favorite things to do is to sit and observe. You watch and you see
how people shift. And you say, ‘I just saw you shift this way. Why
did you do that?’ A lot of times they won’t be even cognizant of
what they do or why they do it.”

For people with complex postures, everything matters. “Early
intervention is important, especially for our population with cerebral
palsy,” Rhodes said. When we have a fixed windswept deformity
or pelvic deformity, that affects all our joints surrounding
that. So now we’ve possibly introduced non-reducible pelvic rotations,
hip obliquities and scoliosis or things we can’t get back to
neutral anymore… because [they] weren’t lying in bed correctly.”

“You do need to look at the whole day, how someone transfers,
how they live their life,” Harkness said. “You can’t look at
one piece in isolation, because one thing affects everything else.
24-hour is the key.”