Seating & Positioning Series

Tilt by the Numbers

Combining Best Practices with Best Strategies to Create Real-Life Pressure Relief

TiltOn the surface, a tilt regimen for pressure relief can seem like a mathematical equation: How many degrees? For how many minutes? How many times a day? To offload how much weight?

But complicating this numbers game is the human factor: That every client’s skin health and breakdown risk is different, impacted by different circumstances, such as nutrition, age, moisture, heat, sensation or lack thereof. That each client has a diagnosis, but that each client is unique within that diagnosis. That each client has different seating equipment in addition to the tilt system: different backrests and seat cushions, different legrests, perhaps a recline system as well.

And of course, the human factor culminates in different personalities, lifestyles and behaviors. In fact, perhaps the only thing an ATP or seating clinician can count on is that a client will not perfectly adhere to best practice standards regarding how much to tilt, how oft en and how long.

That leaves seating professionals with the challenge of helping clients to develop weight-shift strategies that will work clinically as well as within the framework of everyday life.

Tilt Best-Practice Standards

Tilt recommendations vary somewhat from entity to entity, but the numbers from the commonly referenced Consortium of Spinal Cord Medicine, administered by Paralyzed Veterans of America (PVA), advises that wheelchair users activate their tilt systems every 15 to 30 minutes and remain in the tilted position at least one minute — which equates to tilting two to four times an hour.

Chris Maurer, MPT, ATP, at the seating & mobility clinic at Shepherd Center in Atlanta, calls those recommendations “a baseline.” While Maurer acknowledges that there’s no guarantee that tilting two to four times an hour will absolutely prevent all skin breakdown, she says for new patients in a rehab facility setting, “We start everybody off on that. It gives them somewhere to start.”

She also acknowledges, “When they go home, we know they don’t consistently do that. After they go home and everything settles down, I think the individual finds their own frequency at which they need to tilt to keep their skin healthy” — with further recognition, of course, that “some people do it correctly, and some people come back for skin surgery.”

Maggie Love, OTR, clinical education specialist for Permobil, calls the PVA guidelines “a great place to start.” But she adds, “Other factors need to be considered when developing a comprehensive skinmanagement program. Clients that have partial to full sensation may be less prone to skin breakdown because they will naturally shift their weight while uncomfortable. Younger clients with new injuries are less prone to skin breakdown. As the individual ages and the gluteal tissue atrophies, there is greater risk for skin breakdown.”

A Matter of Degrees

The other critical factor for pressure relief is the number of degrees that the wheelchair user tilts back.

In a research paper called “Use of Power Tilt Systems in Everyday Life” — published in Disability and Rehabilitation: Assistive Technology in January 2009 — authors Sharon Eve Sonenblum, Stephen Sprigle and Chris Maurer examined how and why consumers used tilt, and whether or not they used tilt to perform pressure-relieving weight shift s. Instrumentation attached to the power chairs recorded how often consumers tilted, how many degrees they tilted, and for how long.

The authors divided the amounts of tilt used by consumers into four categories: small (0° to 14°), medium (15° to 29°), large (30° to 44°) and extreme (greater than 45°).

One of the conclusions: “Although people used the [tilt] system frequently, so they were moving it a lot, it was seldom used for performing greater than 30° tilts,” Maurer says. Typically, she adds, tilts greater than 30° are considered pressure-relieving tilts.

“In a study prior to [the 2009 one], we looked at how does pressure change with increasing angles of tilt, and it turned out to be a linear relationship,” Maurer says. “Basically the farther you tilt, the more pressure off your seated area occurs. So basically to get the best benefit out of a tilt system as far as pressure relief is concerned, you need to tilt as far as the system goes. Your pressures continue to go down the farther the system goes, so you need to maximize your tilt.”

The 2009 study that used instrumentation to measure amounts of tilt, Maurer adds, “showed that pretty much nobody did that.”

The report did note that consumers used tilt frequently.

“Even subjects who spent 90 percent of their days in small tilt angles used the tilt feature at least once per hour,” Maurer says. Those participants routinely sat in a tilted position, but “still moved the system in and out of it, whatever degree they chose.”

Could using tilt to make those frequent if small adjustments in positioning be similar to the type of constant shifting and fidgeting that able-bodied people do while sitting in office chairs, for instance?

Sharon Sonenblum, Ph.D., senior research engineer at the Center for Assistive Technology & Environmental Access, Georgia Tech, thinks that’s an apt metaphor.

“It has always been our belief that in general, activity is good,” she says.

Sonenblum and Sprigle authored another tilt-related study in 2011, published in the Journal of Tissue Viability, called, “The Impact of Tilting on Blood Flow and Localized Tissue Loading.” Sonenblum says the research “looked at how the buttocks respond to tilts, and found that even when you do a small movement, the blood flow to the region increases. So there are physiological benefits to the small movements. And our current ongoing work is looking at whether people who move — i.e., shift , fidget — more frequently have fewer pressure ulcers than people who don’t move that much, in addition to studying their actual pressure reliefs.

“We weren’t made to sit stationary.”

Why Don’t Consumers Tilt Enough?

The 2009 study on how and why consumers use their tilt systems uncovered some interesting information on why clients might not be as compliant as their clinicians would like them to be.

For instance, consumers cited a number of reasons for using tilt.

“Most subjects reported using their tilt for physiological reasons,” Maurer says. “A lot of people did it to address comfort or discomfort, rest and relaxation, functional independence and for posture.”

Some participants also specifically said they tilted to perform pressure relief. But Maurer says, “The subjects who reported pressure relief as a purpose for tilting didn’t perform more pressure-relieving tilts — those greater than 30° — or spend more time in larger or extreme tilts than anybody else. They were saying they were doing it for pressure relief, but compared to the others, they didn’t spend any more time in greater amounts of tilt.”

Why not? The answers are complicated, can be unique to the individual consumer, and can range from a lack of knowledge about the seating & mobility system to discomfort in social situations.

Equipment wise, Maurer says, “A lot of people I find are very scared of using the full range of the tilt: ‘I can’t go this far back, I’m going to slide right out of my chair.’ It’s scary to them that they can’t move their bodies: If the chair starts to tip, there’s nothing they can do about it. I think what’s important to have happen is to have the system delivered in a setting where a therapist and a supplier are together so the therapist can reiterate the need for the weight shift and its effect on the skin, and they can actually show the patient, bring them through the full range of tilt and prove to them that the chair isn’t going to fall over.”

Maurer says she’s tilted clients back, and then “I’ll hang on the back of the chair to show them: ‘Look, I’m sitting on the back of the chair with you in it and it’s still not going anywhere.’ Just to ease their fear that the chair is going to flip over on them.”

Perceived Compliance with Tilt

Other clients may believe they are achieving pressure-relieving tilts when they actually aren’t.

“Often, patients believe they are being compliant with the tilt regimen when they are not tilting enough to cause tissue reperfusion,” Love says. “It may not be as cut and dried as that, though. I think sometimes patients believe that while 45° to 50° of tilt is the best, some tilt must be ‘pretty good.’ However, the research and pressure mapping are showing that is not the case. This is where the pressure mapping system puts a visual to the therapist’s words and can be a beneficial educational tool. Pressure mapping was very helpful biofeedback for the clients to see that tilting 25-30° was not an adequate pressure relief.”

Other clients may have trouble achieving enough tilt to provide pressure relief because they typically sit with their systems tilted to begin with.

“You’re limited with how far the system tilts back,” Maurer says. “The system is only tilting to 50-55° degrees, probably. There are many people that sit at 25° to 30° degrees of tilt, and that’s their constant. So tilting back only gets them another 15° to 20°. People who sit in that mid range of tilt don’t get much more by going further back.”

And that 15-20° isn’t enough tilt to attain the amount of tilt needed to perform the pressure relief that clinicians are aiming for.

For those clients, Maurer says, “We tend to tell them, ‘You’ve got to go back, and you also have to come all the way up. Because then you have more degrees going forward, and that also changes pressure from where you were. At that point they’re sitting on their sacrum, so they’ve got to sit up for a short period of time as well as go fully back. The whole concept is that you’ve got to move your position in whichever direction you need to go depending on how you typically sit to change the pressure off that particular spot.”

Speaking of tilting all the way back: Maurer suggests making sure that clients realize how much tilt their systems offer. In the 2009 study, “the perception of tilt angle was oft en misconceived. They thought they were all the way back, but they weren’t. They said, ‘This is my fully tilted chair,’ and then you’d press the button and they’d keep going back further. So they think they’re all the way there, but they’re not.”

Adding recline to the system can be another way to achieve pressure relief, Love says: “Research is also showing that 25-35° of tilt plus 120° of recline is the optimal pressure-relieving position — especially for patients with a spinal cord injury, as these individuals pressure map differently than control subjects, and put more pressure on the IT [ischial tuberosity] areas (Jan et al., 2013; Park & Jang, 2011).”

Elevating legrests (ELRs), Love adds, can also help to achieve optimal weight shift s for pressure relief. “Research has shown that using tilt in conjunction with recline and ELRs provides a better pressure shift than any of the power seat functions alone,” she explains.

When Life Gets in the Way

Some of those scenarios — not knowing how much tilt a system offers or being afraid that a fully tilted power chair will tip over — can be solved through demonstrations and education. Unfortunately, that’s not always the case.

“If was just an education issue, this would be an easily solved problem!” Love says. “A good portion of clients know they are not as compliant as they should be and still fail to follow the guidelines due to the same reasons some people don’t stick to their diets, or diabetics don’t check their blood sugar, etc. It’s a lifestyle change. Perhaps there are a portion of clients who also don’t believe that skin breakdown will happen to them: ‘I’m healthy and I move around a lot’ or ‘I’ve had a spinal cord injury for years and have never done pressure shifts as often as you have told me to.’ The reasons for non-compliance are very individual, and one needs to get to know the client in order to determine the reasons… in order to come up with solutions.”

Maurer points out that when properly and fully executed, “Tilt is a non-functional position. It highlights their disability, so they don’t want to. A lot of business workers are in meetings where they’re not going to pull back from their table and tilt no matter what I say.”

Therefore, outside-the-box thinking on the part of the ATP and clinician can be helpful.

“Standing can be very beneficial to decreasing the risk of pressure ulcers — and an integrated system that allows the user to stand without transferring out of the system can increase compliance,” Love says. “Standing is a very functional weight shift , in addition to having many other medical benefits, and may be perceived as more socially acceptable.”

The assistive technology providers can help to remove potential tilt barriers by making sure clients remain in control of the system throughout the tilt range. That’s especially a concern for clients who become progressively weaker and find it harder and harder to reposition their arms on wheelchair armrests.

“Make sure they can access their tilt buttons through the full range of tilt,” she says. “A lot of people who are weak lose contact with the switch when they’re tilted all the way back, so they’re scared and they can’t reach the switch to come back up. They limit how far back they go so they can reach the switch.”

Aiming for Long-Term Solutions

Using tilt to its maximum effectiveness requires a high level of education — and resolve — from everyone on the seating & mobility team, especially the client.

“It can be tempting to constantly harp on our patients to stick with the established PVA pressure ulcer guidelines,” Love says. “However, it is important to empower the individual to take control of their skin management, which can be an important step in longterm success.

“In addition, it is often more helpful to establish yourself as an advocate for the patient and encourage open and honest communication about skin management solutions. I almost think of the weight shift program as similar to a diet. We all know that we should eat healthy, small portions throughout the day as well as regularly exercise — however, we don’t always do this. We get tired, social obligations get in the way, etc. The most successful lifestyle changes are ones that are incorporated seamlessly in our daily lives — made convenient with minimal barriers.”

Sonenblum suggests taking time to train new tilt users: for example, “Make sure the client knows that a full tilt feels like [and] that they are comfortable, not afraid that the chair will tip over.”

And even those frequent less-than-extreme tilts can be encouraged, she says.

“Of course, there’s value in recommending that people move around between pressure reliefs. When they are not tilting all the way back, lots of small movements might help.”

This article originally appeared in the February 2014 issue of Mobility Management.

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