Wheelchair users use seat positioning functions such as tilt, but many times not in the ways that their clinicians prefer, and not in ways that are optimally beneficial.
That’s one of the take-aways of a newly updated position paper called “RESNA Position on the Application of Tilt, Recline and Elevating Legrests for Wheelchairs Literature Update.”
Released in August 2015, the paper is an update of a 2009 version from the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA). This latest rendition revisits research discussed in the first paper and adds new research relevant to seat functions.
Pressure Relief Updates
The paper’s lead author is Brad Dicianno, M.D., University of Pittsburgh, Department of Physical Medicine & Rehabilitation. Dicianno’s fellow authors are Jenny Lieberman, MS, OTR/L, ATP, Mount Sinai Hospital, N.Y.; Mark Schmeler, Ph.D., OTR/L, ATP, University of Pittsburgh; Ana Elisa Schuler P. Souza, Ph.D., PT, Recife-PE, Brazil; Rosemarie Cooper, MPT, ATP, University of Pittsburgh; Michelle Lange, OTR, ABDA, ATP/SMS, Access to Independence, Arvada, Colo.; Hsinyi Liu, Ph.D., PT, University of Pittsburgh; and Yih-Kuen Jan, Ph.D., PT, University of Illinois Urbana-Champaign.
In an interview with Mobility Management, Dicianno noted that the team’s revision process included reviewing literature to determine which topics in the original paper had been augmented by additional research over the years.
“There were some clinical practice guidelines that have come out about different disability populations like spinal cord injury and muscular dystrophy that have talked about power seat functions being critical for daily tasks primarily related to self management,” Dicianno said. He explained the significance “that there are guidelines recognizing something like this as a medical intervention.”
Another study, he added, studied elevating legrests (ELRs) used in tandem with tilt.
“It was actually done on control individuals, not individuals with disabilities,” Dicianno says of the paper, “but it gave a little bit more evidence as to how elevating legrests work in combination with tilt and the impact on hemodynamics in the lower limbs. It gives some evidence that using legrests in combination with tilt might have an effect on things like lower-limb edema.”
But the topic most impacted by new research since 2009 was pressure relief.
“I would say that’s where most of the updates happened,” Dicianno said. “There is a section in the new paper that basically takes the old evidence, combines it with the new evidence and provides summary recommendations about tilt and recline and how they’re used in combination, and the effects that you’ll see on pressure relief.”
The updated paper indeed spends multiple pages on the subject of “Pressure Relief and Tissue Perfusion.” The original paper referenced the benefits of using tilt and recline together to relieve pressure; the updated version cites research that confirms those findings. In addition, the update includes more information on the range of tilt and recline needed to truly achieve skin perfusion. Degree ranges mentioned in the new paper are relatively high — for instance, at least 35° tilt combined with at least 100° of recline to gain skin perfusion over the ischial tuberosities, according to one study.
“There’s still no absolute gold standard, but this gives you some recommendations about how to use them in combination and to what extent,” Dicianno said. “Rather than black-and-white recommendations, they provide general guidelines about what extents of use will result in greater amounts of pressure relief.”
Having those guidelines is important in part because not all positioning systems are created equal — and not all clients follow their clinicians’ recommendations, either.
“There are some systems that actually don’t tilt back far enough to achieve the pressure relief that you want to get,” Dicianno said. “And there was also one other interesting article that demonstrated that many people are using their seat functions to reposition themselves based on discomfort in the chair, despite having been trained on the purpose for the seat functions and how they should be used.”
Rather than following clinical guidelines to relieve pressure to the extent of achieving skin perfusion, many clients tilt just enough to feel more comfortable — the equivalent of an able-bodied person fidgeting and shifting in an office chair.
“There’s a discrepancy between what we teach and what clients actually do, and so there needs to be a lot of work to re-educate clients and show them the extent to which you need to use these seat functions to get the medical benefit that you want to see with them,” Dicianno said.
The paper is divided into sections, including the clinical and functional benefits of tilt, recline and ELRs, overview of seat function use (i.e., how often consumers use positioning options), and how tilt, recline and ELRs impact posture realignment and function; physiologic and orthopaedic implications, transfers and spasticity; edema; and pain, fatigue and sitting tolerance. The different segments should make the paper easier to use in real-life scenarios, such as when a clinician or ATP wants to cite research as part of the documentation process.
While it might be tempting to just include the entire paper as documentation, Dicianno suggests it’s probably more effective to reference the portions of research that specifically impact the client you’re working with.
For instance, the process of justifying tilt could include explaining that the client cannot independently and consistently perform pressure-relieving maneuvers, and that he also has a history of pressure ulcers and lower-limb edema. Using tilt in combination with ELRs could help to manage that edema. But instead of attaching the entire RESNA paper — which the claim’s reviewer might not read — a better tactic is to state that there is a position paper on this topic, locate the relevant research within the paper, and then explain in bullet-point format that because the client’s condition matches up with conditions described in the research, he too could see medical benefits from using these technologies.
Dicianno explained that RESNA strives to update position papers every five years — a goal that means that by the time a paper has gone through the updating process and is formally released, additional relevant research papers have probably been published.
“We’re already aware of new ones that will probably impact the next [update],” Dicianno acknowledged.
And as for the topics in the original paper that really didn’t benefit from much subsequent research since 2009, Dicianno said there’s a silver lining there, too.
“The areas where there are gaps can be used in a positive way, because those are areas of needed research,” he noted. “So it certainly brings out areas where there’s not been a lot done and where we need good studies.”
Find the updated tilt, recline and ELRs paper, along with RESNA’s other position papers, in the Knowledge Center at resna.org.