ATP Series

24-Hour Follow Through

Why Managing Posture in the Wheelchair Is Just Part of the Positioning Equation

boy laying on ground with wheelchair in background


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.”

This article originally appeared in the Jul/Aug 2021 issue of Mobility Management.

In Support of Upper-Extremity Positioning