The Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) has published two position papers.
The first — “RESNA Position on Assistive Technology for Lying Posture Care Management (LPCM)” — is a new paper on the importance of postural support in the lying orientation as “a key element of 24-hour posture care management which aims to improve quality of life and prevent secondary complications,” the organization said in an April 2 news announcement. “This paper educates and educates for the appropriate use of lying posture care management by outlining the need for such intervention and providing appropriate definitions, current evidence and best practices.”
The second paper — “RESNA Position on the Application of Tilt, Recline and Elevating Leg Rests for Wheelchairs: Literature Update 2023” — is an update of the position paper originally published in 2015. “It reviews the current literature on these various seat functions available on both power and manual wheelchairs, including tilt, recline, and elevating and articulating leg rests,” the announcement said.
Understanding what LPCM is … and isn’t
The authors of the LPCM paper are Patricia O’Toole, MAT, MSOT, OTR/L, ATP, Clear Path Occupational Therapy, Seattle, Washington; Tamara Kittelson, executive director of Posture 24/7, Minneapolis, Minnesota; Lee Ann Hoffman, OTD, MSc., OTR, ATP/SMS, CAPS, affiliated with the University of St. Augustine for Health Services in Dallas, Texas; Jennifer Hutson, Ph.D., OTR/L, ATP, St. Catherine University, St. Paul, Minnesota; and Kourtni Bopes, OTD, OTR/L, Central Wisconsin Center, Madison, Wisconsin.
The paper seeks “to educate and advocate for the appropriate use of lying posture care management to prevent secondary complications and improve function and health outcomes for people with movement limitations,” the authors said.
The authors advocate for supine positioning while in a lying position because it “optimizes musculoskeletal alignment in ways that are not possible with other horizontal orientations and maximizes pressure distribution,” the paper said. For children and adults unable to safely lie in a supine position, “supports can also be applied by side-lying or semi-side-lying,” the authors added.
Ultimately, the goal of LPCM is to enable a person with limited movement “to lie in increasingly symmetrical positions through skillful placement of therapeutic supports,” the paper said. “The purpose of LPCM, as part of 24-hour PCM [posture care management], is to protect healthy posture and maximize the user’s everyday function when otherwise, the individual may spend yours in habitual, asymmetrical, unsupported lying postures.”
The paper also clarifies types of assistive technology — including safety or enclosed beds, adjustable hospital beds, support surfaces, body-worn orthotics, and movement-limiting supports used as restraints — that are not LPCM systems when used on their own.
LPCM applies to people of any age who have limited movement, the authors noted. “When lying unsupported, these individuals may spend up to 12 hours per day in the same destructive postures, which equates to 4,368 hours per year (Rodby-Bousquet & Ágústsson, 2021; Sato et al., 2014),” the paper said. “These extended periods are associated with preventable body shape distortions (e.g. hip dislocation, spinal curvature, rib cage compression or rotation) known to arise from being in extended periods of asymmetry (Ágústsson et al., 2019; Casey et al., 2022a; Casey et al., 2022b; Fulford & Brown, 1976; Hill & Goldsmith, 2010; Holmes et al., 2019, 2021a; Porter et al., 2007, 2008; Rodby-Bousquet, & Ágústsson, 2021; Rodby-Bousquet et al., 2013; Sato, 2020).”
Updating RESNA’s position on tilt, recline, elevating leg rests
RESNA also released a 2023 literature update for its paper on tilt, recline, and elevating leg rests.
The new version of the paper affirms the importance of activities of daily living (ADLs), defined as basic self-care such as toileting, eating and bathing; more complex instrumental activities of daily living (IADLs), such as cooking, managing transportation, and managing personal finances; and mobility-related activities of daily living (MRADLs).
“This 2023 position builds on prior works and clinical consensus statements by Dicianno et al., (2009) and Dicianno et al., (2015) to update RESNA’s position on the clinical application of tilt, recline and elevating leg rests,” the updated paper said. “RESNA asserts that these functions are medically necessary for disease management, safety and overall function.”
Tilt, recline and elevating leg rests support a wide range of goals, the paper added, including improving transfer safety and biomechanics; postural realignment and corrective/accommodated positioning; providing postural support for access to tilt and independent propulsion of the wheelchair; improved physiological functioning; pressure redistribution and tissue perfusion; improved pain management; decreased fatigue; and improved sitting tolerance and participation.
RESNA also recommends that licensed clinical medical professionals who have earned Assistive Technology Professional (ATP) or Seating and Mobility Specialist (SMS) certification and equipment suppliers with the ATP or SMS certification “be involved in all evaluations to minimize risks of adverse events and promote quality outcomes.”
The updated paper includes contraindications for tilt, recline and/or elevating leg rests, and also provides guidance on newer technology, such as anterior tilt.
The paper then provides rationale for its position, including explanations of tilt, tilt in space, recline, tilt and recline used together, elevating leg rests, and center-mount elevating/articulating foot platforms. Information on new research — such as how seat functions can be incorporated into 24-hour positioning regimens, and how newer technology such as tilt in space and dynamic positioning can impact pressure relief and tissue perfusion — is also included.
And the paper highlighted how greater activity levels are linked to a greater likelihood of power wheelchair acceptance among wheelchair riders. “Stenberg et al. (2016) found that participants reported higher device acceptance when their power wheelchair met needs beyond simple ambulation, such as providing standing and tilting functions for reaching or pain relief,” the paper said.
The authors of the update were Jillian Kenderish, MOTR/L, ATP/SMS, Magee Rehabilitation Hospital
Jefferson Health Systems; Tabatha James, ATP/SMS, OTR, Numotion; Rebecca Russell, PT, DPT, ATP,
UPMC Center for Assistive Technology; Heather Cianciolo OTR/L, ATP/SMS, regional clinical education manager, Permobil Americas; Jennith Bernstein, PT, DPT, ATP/SMS, clinical affairs manager, Permobil; and Grace Denfeld, OTR/L, The Afya Foundation of America.
Position papers are free to download from the RESNA website.
