QUEST Volume 11, Number 3, MAY/JUNE 2004

Seating and Positioning: An Inside Look

by Kathy Wechsler

One of the best things about writing for Quest is the opportunity to learn about products available to help people, like myself, who use wheelchairs. Take seating and positioning, for example. Like many others, I had no idea that finding the correct seating system involved more than just getting a new cushion.

RTS Tim Regan of Western Medical shows the author that her wheelchairs sling seat causes her hips to rotate inward, pulling her knees together. Photos by Robin Stancliff

"Youre so overdue," said Jodi Bales, a registered occupational therapist (OT) at the Forbes Norris MDA/ALS Center at California Pacific Medical Center in San Francisco, when I told her that Ive never in my wheelchair-using life (11 years) had a seating evaluation. Since I have a progressive neuromuscular disease, Friedreichs ataxia, I should have my seating evaluated once a year, she said.

In an effort not to be hypocritical, I decided to get my own seating evaluated instead of just writing about how important it is. But before getting into my story, lets take a look at why evaluation of seating and positioning matters.

A Method to the Madness

"The reason its so important to have correct seating and positioning is to increase independence, accommodate for breathing and reduce loss of muscle function," said Bales. "Its particularly important for someone with neuromuscular disease because their body is always changing."

Sitting in the proper position allows you to do more for yourself because youre better able to reach farther to grab objects, use the joystick on your power wheelchair and feed yourself independently. When youre moving, sitting correctly enables you to look around and be aware of your surroundings, increasing your safety.

Improper positioning increases the risk of decubiti (pressure sores), which can be extremely painful and may even lead to hospitalization.

Pain is an obvious indication that you need to do something about your seating situation, but dont overlook the more subtle symptoms such as contractures (fixed joints) in the hips, knees and shoulders. Difficulty breathing and loss of range of motion in your neck are also clear signs that you need to visit an occupational or physical therapist (PT) for a seating evaluation.

"Many people, if theyre not in the right seating, have a lot more pain as well," Bales said. "That should be way at the top of the list. People get hip pain and back pain often."

You should also look into getting a seating evaluation if youre losing the ability to do things that you could do before, such as straightening your legs, turning your head or sitting up straight. Dont let it go if youre uncomfortable in any way.

Getting rid of pain is worth a little inconvenience.

"If there are problems that have been created from the seating components, then you need to see somebody probably immediately," said Tim Regan, an assistive technology supplier and certified rehabilitation technology supplier (RTS) at Western Medical in Tucson, Ariz.

Evaluating the Evaluation

	Regan demonstrates the adjustable nature of a biangular backrest.

"Evaluating seating and positioning is a team effort," said Bales, whos been an OT for 10 years. "The person in the wheelchair should be the captain of the team."

There are two ways to get a seating evaluation: You can either be evaluated by your OT or PT and then be assessed by the RTS at the wheelchair vendor; or you can be evaluated by both your OT/PT and the RTS at the same time and save yourself a trip.

Because of schedule conflicts, I chose the first option. I set up an appointment to see my PT, John Klune, at the University of Arizona Health Sciences Center in Tucson. He looked at my wheelchair, my trunk control and the way I sat in my chair.

Regan measures depth of Wechslers wheelchair seat.

In visiting Klune I learned that my posture was horrendous. He said I was leaning way too far back in my chair, with my rear end scooted forward, throwing my spinal alignment out of whack. The danger of sitting that way, Klune said, is that over time Im going to get stuck in that position, and I wont be able to sit up straight.

With his hand supporting my back, he pushed my spine up straighter and my shoulders forward. After 11 years of bad posture, I was surprised at how good sitting correctly felt. The key to proper alignment: ears over shoulders and shoulders over hips.

Klune was also unhappy with my sling seat. He wanted to see me on a solid surface. Without this support, my hips rotate inward, pulling my knees together.

Sitting like this for a long period of time can cause contractures in the hip muscles, and you cant get your legs apart. Then youd have to get them surgically released.

Assessing the Assessment

	Regan shows Wechsler that a more substantial lumbar support...

A week later, I met with Western Medicals Regan, who explained the importance of getting as much information as possible from the customer. For a new wheelchair user, hed ask about the proposed products use: Whats your life like? Where will the product be used? How long in the day do you sit in the wheelchair? These questions help the RTS understand exactly whats needed.

Im sitting in my power chair (an Action Ranger II Storm Series from Invacare) an average of 10 hours a day. I use it all day at work and then switch over to my manual wheelchair (also an Invacare) at home. Since I use the power chair most often, its the one that both Klune and Regan recommended working on first.

"Then we usually do a mat evaluation with the client," said Regan. With the client lying on a mat, "we would take appropriate measurements, as far as hip width, chest width, shoulder width, sitting depth, top of shoulders and foot measurements."

Regan began by measuring the seat depth of my chair, which is too short for my leg length. He went on to measure my legs, feet and hips. Regan said there should be 1 inch to 1 1/2 inches between the back of the knee and the front of the seat edge.

Feet are measured to make sure the wheelchair footrests arent too high, putting pressure on the ischials (the pelvic bones).

 

...will enable her to have correct posture.

"If the footrest angle is too low or too high, then someone can develop foot drop," Bales said. "How the footrest is flipped up or pushed away, for example with Friedreichs ataxia, is very important because people with FA very often can still do a standing transfer if the footrests are not in the way."

She said many therapists forget to examine the arm position of people with neuromuscular diseases, adding that the armrests are just as important as the position of your back and feet.

"If your armrests are too high, then your neck becomes painful," Bales said. "Your shoulders are up too high and you start getting tight and contracted in your shoulders and your range of motion. If your armrests are too low, then you tend to slump over on one side."

Depending on your head control, Regan said, there are multiple headrests available that hed try to make as functional as possible.

The cushion is just one component of seating and positioning. Depending on your needs, the RTS will help you decide among air, foam and gel cushions. Some cushions are adjustable to correct or accommodate the pelvis, said Luke Bebeau, an assistive technology supplier and certified RTS at National Seating & Mobility in Wauwatosa, Wis. (See "A Look at Wheelchair Cushions," July-August 2003.)

Funding Fundamentals

In order to have MDA pay for my PT visit, I first visited my neurologist, Lawrence Z. Stern, MDAs medical consultant and director of Tucsons MDA clinic. He gave me a referral for a seating evaluation. MDA will pay for one OT or PT visit per year when prescribed by an MDA clinic physician.

MDA will pay up to $500 per year toward your seating improvements, which fall under the wheelchair repair allowance. This may cover replacing armrests, footrests, a solid back, a solid or sling seat, or a headrest.

While MDA does help, chances are good that youll need funding from other sources.

"Figuring out what to do for someone in their seating in their wheelchair is one thing," Bebeau said. "The other part of it is trying to get it approved and paid for. Theyre both challenging in their own right."

There has to be a medical need for a seating change, or your insurance company wont pay for it.

"Thats the job of the physician and the therapist to provide proper medical documentation to the insurance, Medicare or Medicaid, to prove that this patient requires this system," Bebeau said.

Be Patient

It doesnt all happen at once. Be prepared to try a variety of cushions and backs as well as to adjust different parts of your chair. Dont be surprised if it takes some tries before you get it right. It may take a few extra trips to the RTS, but your comfort is worth it.

You may need to test items for short periods of time to let your body get used to them, and the RTS should be willing to lend you items for a trial period.

Regan suggested I try a Jay Combi cushion (from Sunrise Medical) with a wooden seat insert to extend the seat depth of my chair. This will decrease the space between the back of my knees and the front of the cushion. The solid insert has another purpose: to help keep my hips from rotating, and the seat cushion has a built-in wedge between the thighs (abductor wedge).

Im also trying a Jay Combi lumbar support to be placed at the curve of my spine. If I find that the lumbar support isnt working, I may need to try a biangular back rest by Adaptive Engineering Lab.

Finding the right seating is kind of like finding your true love: You have to kiss a lot of toads before you find the prince.

Resources

Action Products
(800) 228-7763
www.actionproducts.com

Adaptive Engineering Lab
(800) 327-6080
www.aelseating.com

Genadyne Biotechnologies
(800) 208-2025
www.genadyne.com

Healthwares Manufacturing
(800) 492-7371
www.healthwares.com

Invacare
Seating & Positioning
(800) 333-6900
www.invacare.com/cgi-bin/imhqprd/ inv_catalog/prod_cat.jsp

Otto Bock Healthcare
(800) 328-4058
www.ottobockus.com

Prairie Seating
(800) 588-0071
www.prairieseating.com

Preferred Healthcare
Jay Cushion
(866) 553-5319
phc-online.com/jay.htm

Signature 2000
(814) 725-8731
www.signature2000.net

Sunrise Medical
Seating Products
(559) 292-2171
www.sunrisemedical.com

Varilite
Postural Support Systems
(800) 827-4548
www.varilite.com

Wheelchair University
Products & Services
(412) 383-6793
www.wheelchairnet.org