January/February 2006

New Wheelchair or New Solutions

By Gail Gilinsky, OTR, and Cindy Smith, PT

Informed evaluations help experts determine appropriate wheelchair seating solutions for patients’ individual requirements.

It is a typical weekday afternoon, and the Seating and Positioning Clinic staff are awaiting their next patient, who wheels through the door. The man, perched on the edge of his wheelchair, legs rolled out onto the legrest hangers, ribcage resting on his armrest, struggles to lift his chin off his chest. With a gruff voice, he says, “I need a new chair. This one hasn’t fit since I got it 3 years ago from my local vendor!” We are faced with the typical complex question: Does he indeed need a new chair or can modifications and adjustments make this chair fit him. This article will try to address a common scenario by discussing simple, cost-effective interventions to typical postural challenges.

An integral part of Craig Hospital’s spinal cord injury and traumatic brain injury programs is the Seating and Positioning Clinic (SPC) facilitated by Gail Gilinsky, OTR, Cindy Smith, PT, and Pat Cody, equipment consultant, with a combined 70 years of experience in wheelchair seating and positioning at Craig. Inpatients and outpatients are accompanied to the SPC by their primary physical and occupational therapists. A full evaluation in advance by the primary therapists includes, but is not limited to, strength and sensation, function, flexibility, skin, social situation (including caregivers, environment, driving needs, and vocation/avocation activities), and funding. The information from the evaluation is integrated into the SPC evaluation. Recommendations by the SPC staff are carried out by the primary therapists.

The effects of poor posture in wheelchair users have been widely reported for decades in professional literature. Skin breakdown, pain, contractures, respiratory complications, further neurological deficits, and decreased self-esteem are a few possible negative consequences. The development of durable medical equipment (DME) products to mitigate these issues has grown dramatically over the last 15 years. For the best clinical and cost-effective outcomes, complex seating and positioning issues are most appropriately addressed by experts who specialize in this field.

Increasing the height of the front of the seat relative to the rear helps to prevent hips from sliding forward while also providing full contact to legs for positioning and pressure distribution. This also stabilizes the pelvis for upper body functioning. Some wheelchairs can be adjusted for greater front to rear angle. Others will require the addition of a simple wedge underneath the cushion, which can be either purchased or fabricated. Evaluation can be done with the use of a three-ring binder. Although there is widespread belief that increasing seat angle will intensify ischial pressure, research has shown otherwise.¹ In situations where the patient has a significant anterior pelvic rotation with extreme lumbar lordosis, increasing the seat angle can help to rotate the pelvis back into a more neutral position. This will also increase the wheelchair user’s stability.

Back Gap

A significant gap (6-8 inches) between the wheelchair seat pan and the bottom of the back allows space for the pelvis to move back into the wheelchair. Without the pelvis back, it is virtually impossible to achieve neutral pelvic positioning. Without neutral pelvic positioning, the pelvis will continue to slide forward. Also, if there is soft tissue pushing the buttocks forward, then the client’s ischials will not be optimally placed for the design of the cushion.

Authors Gail Gilinsky, OTR, left, and Cindy Smith, PT, far right, adjust patient Candice Minear’s seating cushion.

Many times the back can simply be raised on the posts. The higher back height is often advantageous in gaining trunk control and also can allow for higher placement of laterals for scoliosis correction and stability. As long as the client does not have highly prominent sacral bones, the gap will safely allow the pelvis to slide back and be rotated to a neutral position when the wheelchair user does a full tilt in a power seating system.

Conversely, if the client has an exaggerated lumbar curve, decreasing that gap may help to posteriorly rotate and stabilize the pelvis for enhanced function, but only if the back is tall enough to support the upper trunk.²

Seat to Back Angle

Most wheelchairs now have adjustments to change the back post angle incrementally. Specialty backs have adjustment capabilities as well. Often, a more upright back angle will encourage a client to scoot forward on the seat or to sit all the time in a partial tilt to achieve trunk stability or an adequate visual field.

Wheelchair technician Timothy R. Case makes custom equipment modifications.

Footplate Adjustments

Generally, the further the feet are out in front of the wheelchair, the further the buttocks will be pulled forward on the seat. Moving heel loops back or increasing their length, loosening leg straps and calf panels, and moving footplates back or adjusting their height and angle will all decrease the tendency for sacral sitting as well as improve the turning radius of the wheelchair. Care must be taken to assure that the casters adequately clear the heels.

Elevating legrests can pull the person forward in the wheelchair and elicit extensor tone and are used only if standard legrests have been evaluated extensively and ruled out as an option.

Hip Guides

It is often difficult to keep the pelvis centered in the wheelchair. If pelvic obliquity is long-standing, the pelvis will shift laterally when attempts are made to correct the level. A simple hip guide can be fabricated from a gel armrest pad, a thin piece of wood with foam attached, or a low-placed lateral trunk support. This can provide the client or caregiver with a point of reference, keep the pelvis from migrating, and provide the third point of contact for scoliosis correction, asymmetric spasticity, and trunk stability.

Cushion Modifications

When wheelchair users feel the wheelchair is uncomfortable or does not fit, often it is a result of a cushion or seating system that is not providing adequate control or support of the pelvis and legs. A proper cushion is critical to the functionality and medical condition of wheelchair users. Getting the pelvis, hips, and legs centered and stable in a seating system can greatly improve comfort, function, and positioning in all other parts of the body. Very simple additions to the cushion can be done with accessories from the various cushion manufacturers. Modifications can also be accomplished by strategic placement of pieces of foam to further contour the cushion for correction or control. For example, adding a 1-inch-thick piece of foam to one trochanteric shelf of a cushion base can help to level the pelvis without increasing ischial pressure. Additionally, the bases of some cushions can be trimmed to correct for pelvic obliquity, leg length discrepancy, or lack of hip flexion.

Trunk Supports

Leaning, falling, poor balance, and inability to use arms are all common complaints that can frequently be alleviated with versatile trunk supports. Lateral trunk supports (laterals) are made by most, if not all, seating system manufacturers, but they need to be adjustable in all planes to be able to accommodate individual body types and needs. To achieve the best mechanical advantage, two laterals should be used, one at the apex of the curve on the convex side of a scoliosis and one high on the trunk on the concave side. For a client with significant asymmetrical strength or spasticity or with scoliosis, at least three points of contact are essential with the lowest point centering the pelvis (the hip guide).

It is always important to evaluate in static posture as well as during dynamic functional activities such as driving the wheelchair. Occasionally, a third lateral may be required to provide both correction and stability.

Adjustable, wearable, padded lumbosacral supports (corsets) are a good method of achieving cylindrical support and correction. They can provide balance, skin protection, control of postural hypotension, and elongation of the spine and are particularly effective with asymmetric spasticity. Often these are more functional and acceptable for a very active client than standard lateral supports.

Lumbar Supports

Lumbar supports can be very beneficial for posture, but only if the lumbar spine is flexible and only if they are sized and placed correctly. If the spine is not flexible, adding a lumbar pad will only push the hips forward in the wheelchair. Additionally, a lumbar pad placed too low will also push the buttocks forward. If it is too tall or placed too high, it will push the upper trunk forward and the client will scoot forward for stability.

Headrests

The presenting complaint of a client may be the ill-fitting headrest, but before addressing any headrest issues, it is imperative for the pelvis and trunk to be optimally positioned. If a person is sliding forward in the wheelchair, the headrest will get higher in relation to the head throughout the day. Keeping the pelvis and trunk in a stable position will allow the headrest to be supportive at all times. The purpose of the headrest in a person with adequate neck control is simply to support the head in a tilted or reclined position. If the headrest is too close, it will cause the upper body to be pushed forward; if it is too far back, it can cause problems with swallowing and visual fields. Most headrests can be adjusted on multiple planes to allow for optimal support.

Armrests and Drive Control Placement

Reaching for a drive control or an armrest can create scoliosis, rotation, and anterior collapse of the trunk. Adjusting these in height as well as fore and aft position can greatly affect comfort and function for a client. Switching the drive control to the nondominant arm can encourage reversal or trunk rotations and lateral curves. It can also free up the dominant extremity for function. Switching sip and puff or chin drive controls periodically can reduce tightness and neck pain caused by asymmetrical use. Armrest and drive control placements should be the final adjustments on the wheelchair after proximal stability and correction have been achieved.

Conclusion

Focused expertise, knowledge of marketplace products and resources, creativity, multiple trials, and, above all, an integrated interdisciplinary clinical team approach are the keys to cost-effective solutions for the maximum independence, zmedical health, comfort, and satisfaction of the wheelchair user. Further, follow-up and reevaluations are essential in maintaining successful seating interventions. Bodily changes over time may require periodic wheelchair modifications. The literature suggests annual comprehensive wheelchair evaluations for people with spinal cord injury.³ With health care costs increasing and insurance benefits for durable medical equipment decreasing, careful evaluation of all options to use existing equipment is pertinent before consideration of beginning anew. Health care and medical equipment providers should address consumers’ medical needs and satisfaction with accountability and cost-containment.

Gail Gilinsky, OTR, has worked at Craig Rehab Hospital, Englewood, Colo, since 1980, and was the director of occupational therapy for 11 years. Cindy Smith, PT, has worked at the facility for 16 years and is the outpatient therapy coordinator.

REFERENCES

1. Maurer C, Sprigle S. Effect of seat inclination on seated pressures of individuals with spinal cord injury. Phys Ther. 2004;84:255-261.
2. Sprigle S, Wootten M, Sawacha Z, Theilman G. Relationships among cushion-type, backrest height, seated posture, and reach of wheelchair users with spinal cord injury. J Spinal Cord Med. 2003;26:236-43.
3. Kreutz D. Life care planning for spinal cord injury: seating and mobility consideration. Topics in Spinal Cord Injury Rehabilitation. 2002;7(4):28-37.

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