Finding the Comfort Zone

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March 2003

By Sheila Buck, BScOT, ATP

What is comfort? Wheelchair users have been found to identify discomfort as having pain, feeling the need to move, feeling unstable or physically tired, feeling a burning sensation, sliding out of the wheelchair, and several other components. Alternately, the feeling of comfort included feeling good, feeling supported in the right places, feeling little pressure under the buttocks, feeling stable, and feeling satisfied.¹ Able-bodied individuals are able to get relief from discomfort while sitting by making small postural adjustments that maintain tolerable levels of discomfort.² Persons with decreased neuromuscular function or orthopedic changes are often unable to adjust their body position to redistribute forces, leading to intolerable periods of discomfort. Populations most affected by seating discomfort issues are those with primarily motor impairments with little or no sensory involvement, often indicated by the aging population.

With respect to seating and mobility technology, discomfort and lack of independent mobility can also limit sensory stimulation, accessibility to interactions, opportunities for meaningful communication, and opportunities to maximize function. Inappropriate or lack of supportive seating can create pain through poor posture, inflexible joint ranges, and peak pressure points because of an inability to shift or alter pressures. Pain can therefore become a primary focus in the aging population and further create impaired mobility, decreased participation in pleasurable activities, increased dependence in activities of daily living, increased resistance to care, and confused or aggressive behaviors. Comfort problems can lead to individuals retreating to bed for much of the day. This can lead to obvious impaired function, poor quality of life, and medical problems such as pneumonia, bed-induced ischemic ulcer, and overall withdrawal from life’s activities.²

Appropriate seating programs must therefore be developed in order to prevent physical and cognitive deterioration, but also to decrease pain factors in clients as they age. Current wheelchair technology has been designed mainly for pressure relief of sensory-impaired individuals, and therefore does not meet the needs of the elderly, sensory-intact population. Comfort must be addressed clinically from the outset, even if the client is not identified as being at risk for pressure ulcer formation. Often, funding agencies will not consider subjective pain or discomfort as a legitimate medical necessity for funding. Therefore, physiological or functional goals must be identified that are affected by lack of sitting tolerance induced by pain or discomfort.

SEATING GOALS

Goals of seating the elderly may include reduction of pain and fatigue, and increasing comfort, support, and security. They want to maintain autonomy and interaction with their environment, as well as their overall function, dignity, and self-esteem.

As clients with medical, physical, and mental conditions age, we must deal with their inherent orthopedic, muscular, and internal organ changes. Often, the trunk becomes severely curved with the force of gravity on weak muscles. Sliding out of chairs or falling to the side becomes a common complaint, with protective fetal positioning occurring. We need to determine how much pain and fear of falling influence a client’s activity level. Fragile bones due to osteoporosis complicate the mobility of stiff joints. Weak hearts, decreased lung capacity, and arthritic changes decrease strength for manipulating assistive technology.

Human beings are adaptive. When a system can no longer accommodate to changes in function, physical stature, or psychosocial needs, the aging body will likely adapt to the equipment currently in use, whether or not it provides the necessary posture for function. This is a greater risk with the cognitively impaired population, where they are not aware of, or cannot communicate, the changes happening. Further deformities in postural alignment will occur as a result of the body changing without a change in seating. In providing assistive technology for this population, we must assess the need for change and allow for adaptability in equipment design. Prescription and timeliness of reassessment are needed to accommodate to the aging changes, and must maintain not only alignment but comfort.

It is also imperative that the seating system not be used as a therapeutic tool for stretching or in hopes of increasing neuromotor postural control. Constant work of the muscles will induce fatigue in clients where body strength has already diminished because of the aging process. This increased fatigue can enhance the likelihood of pain at the stretched or overworked muscle, creating the increased likelihood of further sliding owing to the lack of ability to reposition, or verbal/behavioral gestures indicating the need to remove oneself from the system. Overall functioning is then again at risk of being depleted. Therefore, therapeutic interventions must be considered as a separate entity from one’s comfort sitting posture, or indeed be directed through a system that is dynamic to allow for changes in positioning when determining the need for therapy and/or comfort seating.

Change is difficult for the elderly to adjust to, and so we must find methods to assist them in determining their needs. Comfort for one person may have a whole different meaning than that for the next.

A full assessment is critical with each evaluation. Multiple conditions and dysfunction within the body will increase the speed at which changes occur and the likelihood that discomfort will be present. Special consideration needs to be taken for observation of at-risk skin areas over frail skin, bony protrusions, tone, and contractural changes from lack of movement and long-term hemiparesis. Potential for change, past hip fractures or bony changes, and ability to identify and communicate pain must be assessed. When cognitive function is also limited, it is critical that all team members are involved in determining assistive technology needs. Outcome documentation is critical for observing skin condition, respiratory distress, and behavioral changes that may indicate discomfort or pain.

Once an assessment has been completed to determine the client’s problems and potential for functioning, goals must be set and objectives stated for selecting assistive technology for each area. These goals must be appropriate to the client’s age as well as perceived level of functioning. Current pain levels may be so great that functioning has decreased or been lost. With appropriate comfort and support, the client may be able to complete components of a task at hand. Areas of goal determination may include function, mobility, and prevention of discomfort; pressure sores/shearing, postural deformity, and injury (to client and caregiver); accommodation to changes in weight, posture, and environment; and aging factors.

PHYSICAL CONSIDERATIONS

Common bodily changes that occur with aging and the effect these have on comfort may include:

Skeletal changes: calcium loss with increased fractures and nonunion healing, posterior pelvic tilt, kyphosis/scoliosis due to weak abdominal/back musculature, stiff and painful joints due to lack of movement or arthritic changes. Consider: increased shock absorption in mobility systems, pressure-relieving seating, correct seat-to-floor heights for foot propellers, adjustable seat-to-back and seat base angles, dynamic tilt, adjustable armrest heights, and support surfaces for feet and upper body.
Internal organs—muscle, heart and lungs: size and strength decrease, lungs become less pliable with less capacity, clients have less energy and tolerances for mobility or sitting, decreased blood flow creating less elasticity to skin. Consider: lightweight bases with proper setup to improve mobility—camber, axle position for center of gravity, rim position, or power bases, pressure-relieving cushions, and back supports.
Kidney and bladder: decreased size, less blood filtration, enlarged prostates. Consider: materials on covers, size of abductor pommels, ease of transfers to encourage toileting.
Stomach and intestines: decreased swallowing due to kyphotic changes, suppressed appetite, constipation, and lack of water consumption. Consider: dynamic tilt for positioning for feeding/swallowing, postural support for upright posture to open the abdominal cavity, trays for fluid containers.
Endocrine and glandular changes: hormonal changes resulting in fragile bones. Consider: shock-absorbing bases, pressure-relieving cushions and backs, comfort positioning versus correction.
Nervous system: decreased sensation to touch and temperature, slower movements due to decreased nerve activity to muscles, decreased balance and reaction timing. Consider: support surface temperatures, high pressure-relieving surfaces, plastic coated or larger handrims, maximum contours on support surfaces to maintain stability.
Sensory changes: poor vision for far, near, and colors; poor hearing; decreased taste and smell (decreased food intake with weight loss and poor skin conditions). Consider: bright visual colors, pressure-relieving surfaces, material textures, material softness, adjustable systems to accommodate weight changes.

SETTING PARAMETERS

Product parameters must be set based on the assessment of the client and the goals/objectives that have been set realistically based on the client’s age and goals for overall sitting/function. Parameters may include pressure considerations of continuity between surfaces, maximized surface contact, decreased peak pressures, and material considerations of softness (plushness), firmness, thermal regulation, breathable, and friction/texture. Postural support and pelvic stability can be gained through posterior pelvic support, posterior lateral rib cage support, thoracic extension, and provision for hip angle changes. Adjustability and dynamic capabilities are critical to maintain accommodation to changes.

By developing parameters, lengthy and tiring trials of inappropriate equipment can be avoided. Outcome data after trial will provide a record of benefits of the technology being prescribed. These benefits must be demonstrated to funding agencies, family, and staff. The most important outcome for clients is the increased comfort and feeling of safety that they gain from utilizing the assistive technology that has been carefully prescribed for them. Involvement in daily life activities and decision-making returns to the elderly the respect they deserve and desire.

Sheila Buck, BScOT, ATP, is owner of Therapy NOW! Inc, an occupational therapy company in Milton, Ontario, providing private consultation and education on seating and mobility assessments and prescriptions.

References

Monette M, Weiss-Lambrou R, Dansereau J. In search of a better understanding of wheelchair sitting comfort and discomfort. In: RESNA Annual Conference Proceedings. Arlington, Va: RESNA Press; 1999:218-220.
Hobson D, Crane B. State of the Science White Paper on Wheelchair Seating Comfort. Paper presented at: State of the Science Workshop, University of Pittsburgh; 2001.

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March 2003