Ask a Clinician: "The Wheelchair Isn’t the Only Seat"

While wheelchair seating is critical to how functional a consumer can be, it’s not the only seating a wheelchair user is likely to encounter in a typical day. For example, many wheelchair users use bath chairs for their hygiene regimens, and since those routines can be time consuming, optimal positioning is critical during those activities.

Raz Design’s Emma Friesen, Ph.D., discusses the importance of proper positioning throughout a wheelchair user’s day.

Q: Why is positioning (such as tilt) an important option in a bath/hygiene chair? Is it important to have positioning options available in a bath/hygiene chair if the client has those options in his or her wheelchair?

Emma Friesen: Seating interventions generally have four broad goals: comfort, posture management, functioning (including safety), and skin integrity (pressure management/care). These goals overlap, and positioning affects each one. Each client’s positioning needs will also depend on:

• the tasks and activities that they (and/or caregivers) are completing in the chair;

• the various environments where the chair will be used;

• any other assistive technologies that will also be used;

• their individual preferences and needs.

These same goals and positioning needs can apply to bath/hygiene chair interventions. If a client needs postural supports and options such as tilt in their wheelchair, it’s likely they’ll also need them in their bath/hygiene chair. In fact, even if the client doesn’t have a lot of postural support options in their wheelchair, they may need it in the bath/hygiene chair to meet their seating goals and needs. This is mainly because we can’t easily replicate a client’s wheelchair seating setup in a bath/hygiene chair. Why not? Well, there are three main reasons.

First, bath/hygiene chairs are used in wet and soapy environments. This means the fabrics and foams have to be waterproof and resistant to these chemicals. If a client uses a high-end cushion for pressure management in their wheelchair, we can’t replicate this in the bath/hygiene chair. Instead, we can use tilt in space to offload pressure from the vulnerable areas of the buttocks and onto the back support.

Second, bath/hygiene chairs are often used for toileting, which means the seat must be designed with an aperture (hole) and shape to allow under-seat access. This greatly reduces the seated surface area, which in turn will increase pressure on seated areas of the posterior thighs, buttocks and back. Tilt is a good option for offloading pressure onto the back, and also for improving comfort during long personal care routines.

Third, bath/hygiene chairs are usually designed to go over a toilet. The bath/hygiene chair frame must be wide enough, high enough and have enough clearance under the frame to go back fully over the toilet bowl. This means we have fewer options to configure and adjust the frame to address positioning, when compared with the wheelchair. For example, some clients set up their wheelchairs with substantial rake (or dump) to improve pelvic stability and to stop them from sliding forward. We can’t replicate this in a bath/hygiene chair, so instead rely on positioning options such as tilt to achieve stability and meet the goals of comfort, posture management, pressure management and functioning.

Q: What clinical outcomes can a positioning bath/hygiene chair achieve or influence?

Friesen: As we’ve already discussed, four broad goals of a seating intervention (comfort, functioning, pressure management and postural management) can also be applied to bath/hygiene chairs. Each client will then have their own specific needs, preferences and desired outcomes for using their bath/hygiene chair for specific activities, such as toileting and showering.

Since there is little published clinical research on tilt in space for bath/hygiene chairs, we need to use clinical reasoning in our assessments to determine if positioning options – such as tilt in space, postural support pads, positioning belts, frame configuration, and seat design – will help meet the clinical goals and needs of our clients. This means we can use existing clinical guidelines, such as the updated RESNA position paper Tilt, Recline, and Elevating Legrests for Wheelchairs, and assess if the same clinical reasons for using tilt in the wheelchair are relevant to the bath/hygiene chair. In doing this, we must also keep in mind that we don’t have the same range of positioning options that we do for the wheelchair, and therefore we need features such as tilt to safely achieve comfort, postural management, functional stability, and skin integrity (pressure management) for the client.

Q: In Europe, 24-hour postural support is a common goal for wheelchair users. But in North America, we haven’t talked as much about postural support for wheelchair users throughout the day. Do you think the 24-hour postural support is an important goal to consider?

Friesen: The conversation in North America is definitely changing. We’re seeing it discussed more by researchers, clinicians and product manufacturers, and RESNA recently launched a Special Interest Group on 24-hour posture management!

The 24-hour positioning and posture management idea recognizes that our clients adopt many different postures in sitting, standing and lying over a 24-hour period. They may use many different support surfaces, and have different positioning and postural support needs on each one.

As bath/hygiene chair manufacturers, we agree this is an important message. In the context of sitting, we’ve seen many examples of clients having well-scripted wheelchairs, but having unusable or even unsafe bath/hygiene chairs because the sitting needs weren’t a priority. As we say, the wheelchair isn’t the only seat!

Another aspect of 24-hour postural support and positioning is assessing how our clients move between the different sitting, standing and lying postures, and how they transfer among different support surfaces. We need to become more knowledgeable about transferring equipment (such as hoists, standing aids, slide boards, and grab bars), and how these interact with different pieces of equipment, such as the bed, the wheelchair, and bath/hygiene chairs.

As the research on 24-hour postural support and positioning progresses, we’ll get stronger and more robust evidence to support our clinical reasoning and clinical justification for equipment, and evidence that validates our use of holistic clinical assessments to meet our clients’ goals and needs.

Editor’s Note: Emma Friesen, Ph.D., is the Clinical Director for Raz Design Inc., a rehab shower commode manufacturer in Toronto, Canada. Emma is a Chartered Biomedical Engineer with expertise in complex rehab equipment, product usability and measuring outcomes of seating and positioning interventions. This story is sponsored by Raz Design.

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