ATP Series

Positioning Priorities

When seating must achieve so many goals, how do you choose what's most important?

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There’s an urgency to Complex Rehab Technology (CRT), not just for wheelchair bases, but for seating systems and components — seat cushions and backs, laterals and armrests, even cushion covers. By definition, CRT is medically necessary, and seating — to provide pressure relief, to facilitate activities of daily living (ADLs), to position head and extremities for the best visual field, the best propulsion — must perform so many tasks.

But when everything is important, how does the seating team prioritize? CRT often requires compromise, because every addition to a wheelchair potentially takes away or restricts some other function. So which goals come first?

THE VALUE OF BALANCE & COMPROMISE

Heather Price, OTR, ATP/SMS, is Stealth Products’ Regional Manager, Central South.

“It is incredibly client specific,” she said of how she prioritizes goals during a seating assessment. “I focus on three factors that are kind of broad. I’m going to focus on function, then posture, and then comfort.

“In my experience as a therapist, I’ve always prioritized function. I’m an occupational therapist, so that’s really important to me. But we need to consider the other areas, so we have to balance posture and balance comfort.”

Price referenced a former client with a high-thoracic injury in the T1 range: “He didn’t have full trunk control. He was very tall, probably 6'4" and 145 lbs. He had a non-reducible scoliosis, so we wanted to correct that. I was focusing on posture because we didn’t want to see further problems down the road. We did a custom mold for him, fit him beautifully. His posture was great.”

Six months later, the client was hospitalized with a pressure injury and returned to Price’s seating clinic. “It had nothing to do with seating,” Price said of the pressure injury. “It was due to laying in bed all day. He said, ‘When I was in my chair, I had a hard time pushing because of the contour of those laterals.’ Not all the time, but he was an active guy, and sometimes [the laterals] would interfere with his propulsion. And they interfered with independent transfers. He also said he felt pitched forward, which we thought was angle placement of the backrest. We tried to modify it, and we still couldn’t solve that problem.”

The seating choice that worked better proved that less can be more: “We ended up trying an off-the-shelf back that had a little bit of contour, a lot less than what he had. So it didn’t fully correct that scoliosis, but it was night-and-day [improvement] in function.”

This example demonstrates a common seating conundrum. “It’s hard as a therapist,” Price said, “because that’s what we’re taught: Focus on posture, we want to fix everything. But functionally, if he’s not going out and living his life, what good is it? If he’s not using his chair, it’s kind of a waste. That’s where you have to have that balancing act. I’m still focused on [posture], but not at the cost of function. And I think that can be applied broadly to any goals we’re looking at. I think the other two goals take a back seat to our functional goals.”

PROTECTING THE SKIN

Alex Chesney, OTR, ATP, is the Clinical Sales Manager focusing on education for Quantum Rehab. Of her previous tenure at TIRR Memorial Hermann in Houston, Chesney said, “Occupational therapists actually do the seating and wheeled mobility, and the physical therapists do bathroom equipment. At TIRR, we had the patients for 90 minutes a day, and we were required to do everything for them. We had to prioritize: ADLs, their wheelchair, when are we ordering the wheelchair, family training, technology. We were juggling it all, but it gave us a really good picture of how everything carried over because we were with them all day. So if I did switch anything on the seating system, I would notice it in my session while working on cooking or dressing. It helps that you get the full picture of how what you’re picking actually impacts them in other skills.”

That insight carries over to Chesney’s current strategy about choosing seating and positioning components.

“What’s hard with seating and mobility in clinic,” she said, “is when you see somebody really quick, or you focus on the positioning as far as [the client’s] body structure and what they look like and how they’re optimally positioned, we’re not always thinking about your transfer. What about caregivers? Does the client have anybody who can remove that lateral, do they have anybody that could help them get out of that deep contoured backrest?”

Given her tenure at TIRR, Chesney is always thinking about pressure injury risk. “Coming from that neurological background with spinal cord injury, they’re always at highest risk for pressure injuries,” she noted. “So that’s my bread and butter when I was looking at somebody for mobility equipment. You’re looking at their level of injury, their function, all those things. But a lot of times my first priority was ‘How am I going to protect your skin?’ From a positioning standpoint, it was ‘Do you have the strength to do a weight shift from a manual wheelchair?’”

Price took the client’s pressure injury history into consideration when prioritizing her goals: “If they come in and they already have a pressure injury, that’s something we’re definitely going to be focusing on. If their pressure injury or risk is
resulting from poor posture, then we’re going to focus on that posture component, versus when I’m teaching somebody just about relieving pressure; I think that falls under function, where we’re trying to keep all the body systems healthy.”

Some of the most challenging situations are with clients that Chesney nicknamed “in-betweeners,” who might be candidates to self-propel an ultralightweight manual wheelchair, or might end up in a power chair. “Maybe they have upper-extremity function, and you’re thinking, ‘If they got a little stronger, I can see that within a year, they could be a full-time manual wheelchair user. But right now, they’re pretty weak, so maybe power is going to help them more functionally.”

THE PRESSURE RELIEF HIERARCHY

For these clients, Chesney said she liked to try an ultralightweight manual wheelchair: ‘Can you do a weight shift? The recommended requirement right now in the SCI [spinal cord injury] literature is every 30 minutes for two minutes. Doing that depression weight shift, where they have to push up on their armrests or wheels and get clear of their buttocks, that’s extreme. You have to be a very strong para to do that.”

If the client couldn’t manage a traditional push-up, Chesney tried alternatives: “Can they pull up to a surface, if they have limited trunk control? The surface has to be lower: Could they pull up to a chair, could they pull up to a therapy mat, and could they lean over, go to their left side and go to their right side, and clear that IT [ischial tuberosity] off of their cushion, enough for me to slide my hand underneath and know that they’re not making a depression in the cushion? Maybe they have back canes they can hook onto, or an armrest they can hook onto if it’s tubular versus a flipback or removable?”

Chesney also evaluated the client’s ability to independently return to their original position, not just after weight shifts, but after daily activities, as well. ‘If you’re in a manual chair and you drop something, you might have to reach to the ground,” she pointed out. “Or if you fall forward, you need to be able to get back up. So you have them lean forward, clear weight off their sacrum, and then get back up. ‘Could you push with your arms to get back up? Could you progress and press up on your legs? Could you recover from that position?’”

HOW GOOD IS CAREGIVER SUPPORT?

Chesney added that having dependable and capable caregiver support could be very helpful if the client needs help repositioning after weight shifting. Price also said caregiver support or lack of it significantly impacts her equipment recommendations. She remembered a client who already had contractures when she started working with him. “He went home, didn’t have great care, came back in to do the seating eval, and knew he was going to a long-term care facility,” she said.

Knowing that removable seating components can easily get lost in facilities, Price said one of the seating team’s goals was ensuring a continuum of optimal positioning: “We did custom options built up within [the chair]. We had as few removable components as possible.

“With the [cushion] cover, I might do a reverse Dartex versus something that might offer a little more breathability. [The reverse Dartex cover] might not be the best terms of reducing pressure injuries per se, but if we know it’s never going to get timely clean-up, and he’s having accidents, we’re going to have a bigger issue if there’s moisture there all the time. So it’s a lot of juggling. Those [facility-friendly options] would prioritize pretty high for me for a patient who does not have good carry-over of care. I’m going to select very different things than for somebody who is independent to do everything on their own and has good carry-over of care. It depends on our end user.”

Chesney explained this situation to her clients by focusing on their primary goal: “If I’m not protecting your skin first and foremost, then you’re at risk for getting a wound. You go back to bed, which defeats the purpose of all your goals.’ That’s when I would look at a power chair, because they’re going to need these features to be able to do these techniques independently for the foreseeable future.”

CHALLENGES WITH POWER POSITIONING

Powered seating adds tilt (potentially anterior, posterior, and/or lateral) and recline as resources, helpful for clients who can’t consistently do their own weight shifts without help.

But powered seating brings challenges as well.

“Within the diagnosis, there’s a lot of broad statements we can make, but then you have to hone it down to the individual
and what’s going on with them,” Price said. “Two ALS patients are very different. One of my ALS clients was working with a head array, and because of his body positioning, if during the day he slid down in his chair, he couldn’t access the head array anymore. We had to really look at his positioning differently. You have to look at people’s body types as you set up their seating system to make them successful, especially if they do have to access any alternative driving method. I would include joysticks in that too, but I mean specifically with alternative driving methods, we really have to focus on that seating system and trying them in all positions they have to be in.”

Chesney said the seating team needs to see the client use powered seating to identify any potential problems caused by the repositioning. “You might think that when they tilt back, their arm is going to fall off the chair, and they already have decreased musculature there, so now I’m worried about a subluxation, I’m pulling the joint out of the socket,” she said as an example. “It’s important to understand the positioning component, but also to understand the programmability. This is for them to drive and be independent as a drive control, but it is still also a positioning feature when they tilt back.” It could be possible, for example, to disable the back pad when the client tilts so the back pad doesn’t respond to the client’s head contacting it.

Clients who don’t feel confident with power positioning could stop using it, which could put them at greater risk for pressure injuries. Chesney said it’s therefore important to investigate non-compliance rather than just assuming that some clients won’t use powered seating functions.

“Well, why?” she asked. “Is it that when they tilt back, they have a hard time breathing? Is it that they don’t like that they can’t see their environment? You have to ask why, because most likely, there’s a way to address it.”

HOW CRUCIAL IS COMFORT?

While CRT professionals sometimes flinch at the word “comfort,” in part because funding sources can perceive that word as vague and not medically necessary, comfort is critical to creating a seating system that will be optimally used.

“Some people will tell you: I’m not comfortable at all,” Price said. “And they just abandon the wheelchair. That’s why function is important, but you have to balance all three: ‘I care about your posture and your function and your comfort.’ Comfort’s going to be your client’s number one goal for the most part. If they’re not comfortable, they’re going to tell you. Even with your clients who can’t verbalize, you’ll know they’re not comfortable. Sometimes there’s a lot of grimacing. Sometimes there will be a lot of vocalization that tells you: ‘I’m not okay with that.’

“I prioritize function always, because I think that’s the most important piece of the puzzle. But you can’t do it at the cost of comfort. If we don’t have the perfect fit for [a client] with his scoliosis, but he’s more comfortable and he’s more likely to be functional, then we’re going to give a little on that postural support to give him that comfort and to give him that function. It’s tough. If you can’t get all of them at 100 percent — and it’s quite rare that you’re going to get everything at 100 percent for very involved patients — I think it’s the balancing act of the three. As therapists and ATPs, we can be so fixated on positioning and getting everything correct that we forget that piece, and then you have abandonment of that equipment. You might have to give up a little bit in those other areas to achieve that comfort.”

Chesney agreed. “It’s important to let them know: It’s okay if you don’t like things. There’s tons of options, and your feedback is what helps me pick different things to try. It’s not hurting my feelings; you’re the one that has to sit in this. You need to be comfortable and happy with what we’re picking.”