No Room for Discomfort

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January/February 2003

By Barbara Crane, MA, PT, ATP; and Douglas Hobson, PhD

Resolving discomfort for individuals who use wheelchairs is a difficult clinical issue. Wheelchair seating attempts to fulfill many competing goals including supporting posture, managing pressure, promoting function, and enabling safe transportation.

Discomfort has been recognized as an important issue for individuals who use wheelchairs. Discomfort, often progressing to pain, may lead to equipment abandonment, decreased consumer satisfaction, and an inability to function throughout the day. Discomfort can be a difficult problem to address using currently available seating technology. This is because current technology has been designed primarily to address needs related to postural support and/or pressure management, and not with the goal of optimal comfort in mind. In a 1999 study of consumer satisfaction with wheelchair devices, Weiss-Lambrou et al found that while comfort was the most important consumer criterion for satisfaction, it was the factor about their wheelchairs that participants deemed the least satisfying.¹ In three separate studies of seating needs of elderly nursing home residents, discomfort was also reported as a significant and prevalent problem.^2-4

While clinicians have long recognized the problems related to discomfort, research related to wheelchair seating discomfort has been sparse. There are a handful of studies designed to look at consumer satisfaction that have identified discomfort as a problem.^1,5-7 There are also a few that have attempted to examine the concepts of comfort and discomfort as they relate to individuals who use wheelchairs.^8-11 These studies have begun to examine discomfort within a disability context, but have not identified a comprehensive, effective methodology for assessing comfort or resolving discomfort.

The role of discomfort is the focus of a research study currently being undertaken as a component of the Rehabilitation Engineering Research Center (RERC) on Wheeled Mobility at the University of Pittsburgh. The researchers are trying to answer the following questions:

Is comfort important to individuals who use wheelchairs throughout the day?
Is discomfort a problem for these individuals?
Does this discomfort limit their ability to sit as long as they would like to?
Does it limit their functional capacity during the day?
Can a valid clinical tool be developed that will assist clinicians and wheelchair users to quantify their seating discomfort?

The first stage of this research study has revealed some important and valuable information regarding these goals.

RESEARCH METHODS

The detailed methodology used in this research was presented at the International Seating Symposium in 2002.¹² Following is a brief summary. Nine full-time wheelchair users were recruited from the greater Pittsburgh area for participation in two separate research tasks. The first task involved completion of an informational interview directed by a questionnaire. Information obtained from the participants included: demographics, information regarding the participants’ current wheelchair and occurrence of discomfort and related problems, and individuals’ comments regarding the design of an “ideal” wheelchair seating system. Several of these subjects also participated in a limited test of a prototype dynamic wheelchair seating system in order to provide the researchers with feedback and help guide future design criteria. All procedures used in this study were approved by the University of Pittsburgh’s Institutional Review Board prior to recruitment of participants.

SUBJECT DEMOGRAPHICS

Participants ranged in age from 18 to 66 years old with an average age of 41 years old. The participants included both men and women, and diagnoses included amyotrophic lateral sclerosis, muscular dystrophy, multiple sclerosis, and polio or post polio syndrome. The participants had varying amounts of experience using wheelchairs, but all were full-time wheelchair users at the time of participation. Several individuals used powered mobility devices with powered seating options such as tilt or recline or both (see Table 1).

Table 1. Description of study participant demographics.

TEST SEAT

The test seat used for this part of the study consisted of a customized truck seat mounted on a power wheelchair base. This seat had six inflatable air bladders—four in the seat area and two in the back—that were controlled through a custom, push-button interface and could be adjusted directly by the subjects. The chair also had traditional power adjustable seat features including seat tilt, back recline, and elevating legrests.

KEY FINDINGS

Given the small sample size and the potential bias related to subject selection, one must exercise caution in forming any definitive conclusions from this preliminary study. However, there are some very interesting trends that were observed and that are shared below.

Discomfort is a prevalent problem.

These individuals spent an average of 15 hours per day in their wheelchairs. They reported three main reasons for getting out of their chairs—discomfort, fatigue, and environmental demand (ie, the schedule of their attendant care or primary caregiver). All of the participants reported experiencing discomfort and more than half experienced discomfort on a daily basis. All reported that they routinely ignored discomfort in order to participate in their daily activities. Low back and buttock pain were reported by almost all of the participants. Most individuals reported limited options for relief of discomfort. These options included: getting out of their chairs, taking pain medication, asking someone to reposition or shift them in the chair, or using their tilt or recline feature (if present). When asked about a history of skin breakdown problems, more than half of these individuals reported that they had experienced at least one episode of skin breakdown since they began using wheelchairs full time, in spite of the fact that they all had intact sensation of their lower body. Consumers believe comfort is important.

The participants were asked to rank the most important attributes or functions of a wheelchair. Comfort was tied with mobility as the most important attribute of a wheelchair, the ability to adjust multiple features was second, independent use of all features of the chair was third, the ability to perform self-care tasks in the chair was fourth, and safety was fifth.

Seating adjustability is key.

Participants also ranked the necessity or importance of adjustability for various parts of the chair. Here is a ranked list from most important to least important:

Adjustable location control mechanism
Adjustable legrests
Adjustable seat temperature (if possible)
Adjustable armrests
Adjustable head support
Adjustable lateral supports
Adjustable seat belt

During the testing of a prototype dynamic seating intervention, several subjects actually reported improving levels of comfort after being in the prototype seat for a longer duration because of their ability to “fine-tune” the adjustments and make the seat more comfortable as time progressed. Several subjects described the importance of adjustability during this phase. Several subjects had suggestions for other adjustable features they believed would be important for comfort including adjustable head and neck supports, adjustable arm and trunk lateral supports, and adjustable lower extremity supports.

Low back support is very important.

Related to comfort, all of the participants reported a sensation of increased back support, which made the prototype seat more comfortable than their own chairs. All of the participants preferred having the ability to adjust the amount of lumbar support that the chair provided.

Users want independence and control of all features.

All of the participants who tested the prototype seat commented on the importance of the wheelchair user being in direct control of all of the adjustments possible. In terms of the dynamic nature of the prototype seating, three of the participants reported that the dynamic elements would be critical in attaining and maintaining a comfortable level of seating over a long duration. One of these participants indicated that having these dynamic features would allow him to perform postural shifts that would prevent him from getting stiff and sore over time. More dynamic seating may offer a solution.

In terms of overall comfort, the majority of the participants believed that the test seat was very comfortable and the majority of them believed it was more comfortable than any wheelchair seat they had experienced. The comfort levels of the participants were followed over time and the initial comfort response and follow-up responses remained similar for all subjects. The participants who tested the prototype found all of the dynamic elements helpful in attaining optimal comfort. Overall, participant response was very positive and supported the assumptions concerning the essential design criteria for optimizing comfort in the wheelchair. The results of this preliminary test indicated that the introduction of dynamic seating, at least in a short duration test, enhanced the comfort of the participants sitting in the chair.

CONCLUSIONS

In summary, all of the study participants indicated comfort is very important to them. This may have been influenced by the decision to specifically recruit individuals for this study who typically have had problems with seating discomfort. The individuals in the study unanimously agreed that discomfort is a significant problem for them, even if they were able to ignore discomfort in order to function (which most stated they did). As to the third question, the results are more difficult to interpret. When asked directly if discomfort limited their time in their chairs or limited function, all replied in the negative. However, when asked what they did in order to relieve discomfort, one third reported that they got out of their chairs.

Limitations of this preliminary study include: a small convenience sample of individuals, recruiting individuals who specifically have problems with discomfort, and difficulties with the subjects understanding the meaning of the specific questions, which led to inconsistent explanations and interview content. These factors limit the generalizability of these results to a larger population. In spite of the limitations, this information adds to our understanding of the problem of discomfort and has formed the basis for more in-depth studies.

ACKNOWLEDGEMENTS

This project was funded through the National Institute on Disability Rehabilitation and Research, grant #H133E990001, and conducted as a component of the Rehabilitation Engineering Research Center on Wheeled Mobility at the University of Pittsburgh. This project is directed by Douglas Hobson, PhD. Technical assistance in questionnaire construction was provided by Shirley Fitzgerald, PhD. Technical assistance in the design and construction of the test seat was provided by Carnegie Mellon University, and Mark Freidman in Pittsburgh.

Barbara Crane, MA, PT, ATP, is research associate and Douglas Hobson, PhD, is professor emeritus at the University of Pittsburgh. More information on this project may be found at: www.RERCWM.pitt.edu Then go to Research Tasks-R-2.

REFERENCES

Weiss-Lambrou R, Tremblay C, LeBlanc R, Lacoste M, Dansereau J. Wheelchair seating aids: how satisfied are consumers? Assistive Technology. 1999;11:43-53.
Shaw G, Taylor S. A survey of wheelchair seating problems of the institutionalized elderly. Assistive Technology. 1991;3:5-10.
Shaw G. Wheelchair seat comfort for the institutionalized elderly. Assistive Technology. 1992;3:11-23.
Shaw CG. Seat cushion comparison for nursing home wheelchair users. Assistive Technology. 1993;5:92-105.
Batavia AI, Hammer GS. Toward the development of consumer-based criteria for the evaluation of assistive devices. J Rehabil Res Dev. 1990;27:425-436.
Zacharkow D. Posture: Sitting, Standing, Chair Design and Exercise. Springfield, Ill: Charles C. Thomas; 1988:77-93.
Troy BS, Cooper RA, Robertson RN, Grey TL. An analysis of work postures of manual wheelchair users in the office environment. J Rehabil Res Dev. 1997;34:151-161.
Monette M, Weiss-Lambrou R, Dansereau J. In search of a better understanding of wheelchair sitting comfort and discomfort. RESNA Annual Conference, Long Beach, Calif: RESNA Press; 1999:218-220.
Boothby B. Seating by design. Physiotherapy. 1984;70:44-47.
Chesney D, Hsu L, Wright W, Axelson P. Immediate improvements in wheelchair mobility and comfort with use of the adjustable back support shaping system. RESNA Conference Proceedings, Arlington, VA: RESNA Press; 1995;15:288-290.
Nelham RL. Principles and practice in the manufacture of seating for the handicapped. Physiotherapy. 1984;70:54-58.
Crane B, Hobson D. The importance of comfort to wheelchair users—a preliminary study. The 18th International Seating Symposium. Vol 1. Vancouver, BC, Canada: Interprofessional Continuing Education, University of British Columbia; 2002.

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January/February 2003