ATP Series

Seating As We Age

Why the Aging Process Can Make Evaluations & Technology Choices More Complex

Seating As We AgeAge, we are told, is just a number. And happily, there are many intellectual and social pursuits that can help our minds to stay active and “young.”

Physically, however, time does impact our bodies — every day, and certainly over a lifetime. And the natural aging cycle can be much more complex for a person who is aging with a disability, even if that disability is not progressive in nature.

When Do We Start Showing Our Age?

Aging is not, of course, something that happens all at once, but rather a process that happens to us all along.

Steven Reeve, MOTR/L, regional manager northwest U.S. for Quantum Rehab, points out, “Technically, we start aging the day we are born, although we consider a person as ‘young old’ around 65 to 74, ‘middle old’ around 75 to 84, and ‘old old’ around 85-plus.”

So at what point should ATPs and clinicians start expecting to see signs of aging in their seating & mobility clients?

“Disease and illness can magnify the aging process at any time,” Reeve says, “so questions about how a client feels when they move, or limitations and struggles they are experiencing, should be asked about at all ages.”

Magdalena Love, OTR, ATP, clinical education specialist for Permobil, says that according to a 2005 Campbell, Sheets & Strong study, “Individuals with a chronic disability may be at risk for aging conditions at an earlier age than non-disabled peers. Consequently, screening questions should be directed to adults generally, rather than targeting a specific age. Furthermore, lifestyle factors — diet, exercise, etc. — influence secondary health conditions significantly.”

What Does Aging Look Like?

Asked how the natural aging process affects us, Love says, “Mobility limitations occur with advanced age in individuals with and without neurological injuries. Aging is a lifelong process, and the rate of age-related changes is very individual. When the aging process is superimposed on any disability, it can be difficult to tease out the differences between the two.”

So in physical terms, how does mobility-related aging typically present?

“As we age, we see a decreased elasticity in the connective tissue throughout the body,” Reeve says. “This causes decreased range of motion and tighter joint capsules, ligaments and tendons along with less flexibility. Many of these processes can be slowed through proper exercise and stretching, but they cannot be overcome.”

Reeve adds that our muscles are also impacted: “It is also well known that we lose muscle mass as we age. So in later years, our muscular activity becomes less efficient, which means it takes more effort to accomplish our daily activities. When we add in the increase in sedentary activities as we age, you see a drastic decrease in overall stamina and functional endurance.”

Changes to range of motion and physical stamina may be among the more obvious mobility-related issues of aging, but Love points out that other physical changes could also impact the ability to successfully use a mobility system. “Visual changes are common in individuals over the age of 40,” she says. “Presyopia is a condition where the ability of the eye to change focus declines — hence why reading small print at reading distances is more difficult. Other visual changes more common in aging populations include cataracts, diabetic retinopathy, glaucoma and macular degeneration. Oft en under-diagnosed, visual impairments pose a safety risk during mobility tasks. Visual screening tests should be standard during any mobility evaluation.”

Reeve adds, “Hearing is impacted in a similar manner: As we grow, the structure of the inner ear changes, and there is a decrease to our inner ear hair cells (which cannot regenerate), which leaves us less responsive to sound.”

When Aging Combines with a Disability

The multi-faceted aging process becomes even more complex when the person aging has an existing mobility-related disability.

Love notes, “In a study by Campbell, Sheets & Strong (2005), it was found that there was ‘accelerated aging’ in individuals with a disability — where these individuals experienced common age-related secondary conditions at an earlier age due to their disability. Common secondary occurrences include pain, fatigue and weakness. While common, this is not normal and should be addressed by the healthcare team.”

These secondary occurrences can have a significant impact on clients’ everyday activities. “All of these conditions can contribute to difficulty with transfers, propelling a wheelchair, or lifting objects (Sheets, 2010),” Love says. “In addition, muscular atrophy, skin integrity changes and changes in fatty deposits may place individuals at even greater risk for skin breakdown.”

Additionally, Reeve says seating & mobility professionals may encounter other conditions that can become more common as we age.

“ATPs and clinicians should definitely be prepared for working with common conditions of aging, such as osteoarthritis, osteoporosis, diabetes, loss of lung volume, age-related macular degeneration,” he explains. “These common conditions will affect the healthy as well as the disabled, but may be more profound in those dealing with illness and disease.”

Poor positioning can cause additional problems, he says.

“As we mature in age, we are prone to morph into our postures of comfort. If a person is not positioned well, they are at greater risk for developing postural abnormalities that negatively impact their circulation, breathing and other aspects of their everyday function as well as mobility independence.”

Taking osteoporosis into account is important when making some decisions about equipment interventions, Love points out.

“Knowing the at-risk groups for osteoporosis is important for treating clinicians and ATPs, especially when prescribing equipment such as standing wheelchairs or standing frames that place the individual in weight-bearing positions. With arthritis and joint pain, the healthcare team needs to be aware of any painful range of motion limitations and choose the seating system accordingly.”

Aging & the Seating/Mobility Evaluation

The true challenge, of course, is determining how all of the above — the natural aging process, secondary conditions that may impact clients with disabilities, and diseases that may be more prevalent as clients age — should be addressed when creating a seating & mobility system. And that process begins by determining how a particular client has been impacted.

“During the assessment for mobility equipment, administration of a comprehensive range-of-motion and manual muscle testing needs to be completed by the evaluating clinician,” Love says. “Past that, the healthcare team should ask subjective questions regarding pain during functional activities. Performing transfers, propelling a wheelchair up an incline, dressing ADLs, and lifting weighted objects above shoulder level are common activities that are reported as increasingly difficult for aging individuals.”

“Clinicians should be well versed with range-of-motion testing,” Reeve says, “however, asking a client to perform basic movements will give much of the information you are looking for to begin making assessments. Putting your hands behind your head, reaching with both arms to the lumbar area of their back, touching their toes, crossing their legs and going from a sit to a stand are all tests that could provide insight into any functional limitations or mobility changes a client may be experiencing. Limitation in any of these movements will cause changes in how they perform their activities of daily living, and even function throughout the entire day.”

Reeve adds that clinicians might also be tipped off to mobility changes by observing the client who arrives for the evaluation.

“Some signs of the adjustments a person may make to compensate for a loss of function might be easy to notice,” he says. “Changes such as Velcro shoes or shoes that are large and loose, absence of socks, clothing that is partially tucked in or askew, and well-manicured hair in the front but uneven or messy in the back are a few indicators that something may have changed.

“Asking specific questions about ways their clients have modified their daily activities can provide insight into what course of treatment, interventions or equipment can aid in maintaining independence as long as possible.”

The Impact on Technology Choices

Every experienced seating & mobility clinician and ATP has clients they’ve been working with for many years and whose systems are therefore “dialed in” — when the clients come in for replacement wheelchairs, for instance, they know exactly what works for them and what they want.

But the aging process and accompanying changes in abilities and conditions can change that routine and call for re-evaluating the best strategies for that client.

“Whether it is propelling a manual chair or sustaining a position for controlling a joystick on a power chair,” Reeve says, “anytime you find range-of-motion limitation, you need to immediately assess for adapting the seating system for proper body alignment, support and functional reach, as well as for stamina, endurance and relative strength to perform the activity required.”

“When looking at manual wheelchair propulsion,” Love says, “it is common for individuals with shoulder pain to experience deficits in shoulder extension — where they experience pain while reaching back for the handrim. To compensate for this, the individual only reaches to the top of the handrim and must perform less efficient and more frequent push strokes, which places the shoulder at even further risk of breakdown. Perhaps the use of power assist or a power wheelchair would assist in preserving the shoulders during mobility tasks, while allowing the individual to still complete vital tasks, such as transfers and ADLs for independence.”

Love adds, “Of course, simply anticipating functional declines in age-related conditions is not enough for paying sources. One needs to document current functional deficits and pain.”

Technology to Maintain Function

Fortunately, there are interventions to help clients as they get older.

“There are many options to aid in positioning to increase functional posture: thoracic supports, pelvic or hip supports, planar back to a deep contour back, pelvic and trunk supports or straps, shoe boxes or shoe holders, as well as many differing types of seat cushions to build your base of support,” Reeve says.

Recognizing potential loss of function in hearing and vision as we age, Reeve adds, “The capabilities of the mobility device electronics have increased by adding various sounds, beeps and warnings to help the client with visual difficulty to continue use of a joystick even if they have difficulty clearly seeing the graphical user interface screens.”

For manual wheelchair users, adding power to the equation is another possible consideration — and thanks to new designs and technologies, there are more options for clients and mobility teams currently looking for support (see “Power Play, a story on power-assist and power add-on technology for manual wheelchairs, starting on page 21).

“Power-assist wheels and the use of power chairs can be considered when working with aging individuals,” Love says. “The use of tilt and recline can also be useful in promoting proper position, decreasing skin breakdown, and allowing for increased sitting tolerance. With visual impairments, considering where to mount the wheelchair displays and utilizing alternative cues (auditory or vibratory) can be useful in promoting independence.”

As Old As We Feel & Act

Aging is an undeniable part of life from the moment we are born, but knowing what to expect and knowing about technology options can go a long way toward helping clients to stay active throughout their lives — even if technology changes need to be made.

“It is important to remember that if we want the mobility device or seating system to help increase range of motion, strength or endurance, we should send the client to therapy or the gym,” Reeve says. “A seating system or mobility device can help the client accomplish their ADLs and ultimately increase the ability to interact socially. It will help slow or stop postural deformities. But it is not intended to repair what is already damaged. With all technology the most important step is to make sure the client will not injury themselves, their surroundings or anyone else they may encounter.”

another opinion

A “Radical Departure”

Mark E. SmithBeing 43, and having spastic cerebral palsy quadriplegia, I’ve used a power chair since the age of 5.

Not too long ago, my lower back developed chronic pain. After a ton of tests, it was discovered that having been seated for 38 years with fixed-angle backrests, the skeletal regions of my lower back were being compressed. It was then that my clinical team and I concluded that a possible solution was to move from a fixed-angle back to a power recline that I could adjust throughout the day.

This seemed a radical departure because a fixed-angle back allows me constant positioning stability, minimizing tone. However, with age and my lower back catching up with me, we opted for power recline.

And the results have been wonderful. By making small backrest angle adjustments throughout the day, I relieve much of the compression on my lower back. It would have been easy to stick with a fixed-angle back. But by questioning how seating changes may benefit me at 43, we’ve helped address one of my aging-with-a-disability issues.

— Mark E. Smith, Consumer Research & Public Relations Manager, Quantum Rehab


Verbrugge, L.M. & Jette, A.M. 1994. The Disablement Process. Social Science & Medicine, 38(1), 1-14.

Campbell ML, Sheets DS, Strong PS. 1999. Secondary health conditions among middle-aged individuals with chronic physical disabilities: Implications for “unmet needs” for services. Assistive Technology 11(2):3-18.

Sheets D. 2010. Aging with Physical Disability. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation. Available online:

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

In Support of Upper-Extremity Positioning