Filling in the Background

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March 2002

By Susan Johnson Taylor, OTR/L

Anna has become used to sitting in a very specific way in her manual wheelchair. She is not very comfortable, but feels safe and supported with the size and height of the wheelchair. She has a powered wheelchair, but it feels "way too big" to her. The higher seat height makes transferring difficult for her and her mother. Additionally, she can no longer reach the joystick because of increases in shoulder and elbow contractures. She happened to be an inpatient, which provided the seating clinic with some time to try options for seating and joystick placement.

Successful seating and positioning requires attention to detail from information gathering to physical evaluation to ADLs and accessibility.

Years ago, the wheelchair environment was essentially an afterthought to rehabilitation. Yet many of our clients lived in their wheelchairs for all or most of their waking hours. It was not until the 1970s that attention began to be paid to the design and function of the wheelchair in relation to the person using it.

The wheelchair and any seating components have to fit into the client's life, assist with function, and, hopefully, not cause any harm. In some ways, it is tempting to try to simplify the evaluation process-leaping from an incomplete evaluation to the wide menu of equipment choices. Because of the individuality of our clients, the careful blend of science and art is what produces successful outcomes.

General Information Gathering
Do not assume you know why a client has come to see you. Ask him why he is seeing you and what his goals are for the evaluation. This helps set the tone and direction of the evaluation. A summary of the client's medical history relative to the wheelchair and seating system prescription is collected, including diagnoses, history of condition, associated problems, and medications. With our clients, we must first understand their diagnoses and the resulting ramifications on seating and mobility choices. Is it a relatively static diagnosis, like a spinal cord injury, or one that is likely to progress, such as multiple sclerosis? What are the physical characteristics of the diagnosis? For example, if you are working with a spinal cord injury patient, the evaluator should understand the type of injury, be aware that there is some degree of lack of sensation below the level of injury, and understand what key muscle groups come in at each spinal level. Add to that any associated conditions, eg, diabetes. If you have never seen a person with a certain diagnosis before, ask the client/caregiver about it, look it up, call another therapist, or talk to the doctor-just make sure you get the information.

The surgical history or plans for surgeries as they relate to obtaining a seated posture should be reviewed with the client/caregiver/physician. These are usually orthopedic surgeries about the spine, pelvis, or lower extremities that can change the shape of the client, thereby changing the type and shape of the seating recommended. Also included would be interventions for spasticity control, such as plans to insert a Baclofen pump or give botulinum toxin A injections. Both of these can dramatically change the type and nature of the necessary support.

Physical Evaluation
The evaluation should include an observation of posture in what the client is currently sitting in, before getting the client out of the wheelchair to observe and feel unsupported posture. Range of motion and limitations of the joints and spine, as well as the types and degree of abnormal tone or spasms, are noted as they relate to obtaining a supported seated posture that feels balanced and comfortable to the client. The evaluator and supplier look at the location of their hands while supporting the client and both see where support is necessary and feel how difficult it is to obtain the support, which provides an initial idea of the details of positioning the client. A discussion of skin integrity, and, if necessary, a skin inspection, should take place, which must include any history of pressure sores or irritated skin areas, or past history of surgery for pressure sores, as this can change the nature of support and materials used to achieve support.

aDLs
While functional and ADL skills, including accessibility and transportation, can be challenging to ascertain in a clinical environment, the therapist and supplier must understand and, when practical, observe how the client performs these skills. The idea is to facilitate function in these areas without providing components that impede function/transporting. For example, seemingly small changes in the seat height of a wheelchair can render a client unable to transfer to and from her chair or get into her vehicle. Part of the assessment should include measurements of the client's existing wheelchair and seating, a visit to the car or van used for her transport to look at and measure the available space, and a visit to her home, if possible. Key home measurements should be obtained, such as doorway widths, hall turning space, and number and height of stairs into the home entrance.

The Long-standing Wheelchair User
Any clinician who has worked with long-time wheelchair users knows how difficult an evaluation for supplemental or new equipment can be. Over the years, they have developed very specific ways of functioning in their wheelchairs and seating. In many cases, the type of wheelchair they are using is no longer available or available only in a different configuration than they are accustomed to.

Parts of their existing wheelchair may be used for specific functions. In addition to seating and wheelchair issues, clients' wheelchair environments can include other pieces of equipment, such as augmentative communication aids, cell phones, lights, and any number of devices that they need to be fully functional. On new equipment, it must be replicated as closely as possible. These clients know their bodies and what they can do very well. Large changes in how they function or sit are not likely to be met with much enthusiasm.

Part of understanding someone with a long-standing disability is learning how aging affects its manifestations. Reading up on issues like postpolio syndrome, the aging spinal cord-injured client, and conditions such as cerebral palsy can assist in understanding seating and mobility issues.

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March 2002