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01/11/2019
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Challenges to Seating and
Positioning in Long Term Care:
Common seating misconceptions that get in the way
Ana Endsjo. MOTR/L, CLT
Moderated by:
Fawn Carson, OTD, OTR/L, ATP, Managing Editor, OccupationalTherapy.com
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Faculty Disclosure
Ana Endsjo– MOTR/L, CLT
National Education Manager, Permobil
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Learning Outcomes
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Name three common misconceptions that lead to poor posture in a wheelchair.
Name three reasons why a K0004 manual wheelchair is a better option than a
K0001, K0002 or K0003 manual wheelchair in the long term care setting.
Describe three negative consequences to the wheelchair user when using
elevating leg rests on a manual wheelchair.
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Optimal Seating System - It’s a Simple Equation
Together they allow for maximum contact
with the seat and back surface to:
• attain postural alignment
appropriate style cushion
correct model wheelchair+
optimal seating system=
• allow for pressure redistribution
• achieve postural stability+ appropriate back support
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Common Seating & Positioning Misconceptions in the LTC Setting
90/90/90
New Cushion
K0001 & K0002
Elevating legrests(ELRs)
90/90/90 is what to aim for with every resident
K0001 & K0002 standard wheelchairs are the economical choice in LTC
A new cushion is all you need to fix a positioning issue
Elevating Legrests (ELRs) are the better option when purchasing a chair
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Misconception #1
90/90/90 is what we aim for with every resident
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A train of thought started in the 1880s by a Prussian orthopedic surgeon (5)
Where did 90/90/90 come from?
No scientific proof behind this posture (5)
Based off militaristic culture of stiff, erect posture (5)
Old school optimal posture: 90º angles at knees, hips, ankles, elbows
Some individuals cannot achieve this posture; most cannot maintain it
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Changes in the elderly body, impossible to achieve 90/90/90
These residents have structural stress and strain that cause:
Age: 20 40 60 80
• Tight muscles
• Decreased flexibility often with flexion or extension
contractures of hips, knees and ankles
• Abnormal curvature of cervical, thoracic, lumbar spine
• Pain
• Decreased mobility
• Decreased strength / endurance To stop unwanted postures, pressure and pain, leading to wounds, contractures and falls, focus on what the resident can tolerate.
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Why not 90/90/90?
Studies suggest that optimal seat-to-back
angle is NOT 90º
Cornell University Ergonomics website puts the ideal seat-to-back angle in a healthy working individual at 100-110 degrees. (4)
A study performed on college students showed that the preferred seat-to-back angle for comfort is 105 degrees. (4)
A study with video display operators (VDT) showed that the
VDT operators preferred 105 degrees backward incline. (4)
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What happens in sitting?
Why not 90/90/90?
• 40-90% more stress on the back compared to standing
• 75% of our weight goes through our pelvis, leaving it susceptible to a pressure injury if not positioned correctly
• It is difficult and tiring to maintain an upright erect sitting posture against gravity
Posterior
Pelvic Tilt
Pelvic
Obliquity
Pelvic
Rotation
Anterior
Pelvic Tilt
Windswept
Deformity
Most individuals slide into abnormal postures that are easier to maintain
Seating specialists are working hard to change this train of thought and want to increase understanding of angles
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Finding the CORRECT angle is important because is the key to decreased risk of falls
and wound development
Increased the risk of a fall from the chair
Without opening the seat-to-back angle enough:
• Less contact is made with the back and seat surface
• Unable to stabilize the pelvis, spine, or extremities
Increased the risk of fall and wound development
If we open the seat-to-back angle too much:
(recline back chairs for example)
• We promote sliding, slouching, and leaning in the chair
• Peak pressures develop at bony prominences
Consequences of using “ “ angles
instead of the right angles
Increased the risk of wound/pressure injury development
If we don’t consider the ROM limitations of the resident:
• It’s impossible to match wheelchair angles to the resident’s joints
• Residents slide into abnormal postures
• Peak pressures develop at bony prominences
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Look at what the resident’s body is doing and consider that seat angles depend on the individual’s ROM, muscle integrity, and joint integrity
What should we aim for?
• Open or close the seat-to-back angle to accommodate for your resident’s degree of hip ROM. – allows the pelvis to reside in the intended area of the cushion
• Change seat-to-back angle to allow for more contact with the back support and seat surface.
– pressure redistribution off the bony prominences
• Change out a sling back and use a back support that allows you to conform to a resident’s curvature. – stabilization at the pelvis and spine
Fixed 90ºPelvis Pushed Forward
Peak Pressure at the Apex
Open STBAMatch Resident ROM
Increase Surface Contact
Open STBA + ContourOptimal Pressure
Redistribution
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Misconception #2
K0001 & K0002 standard wheelchairs are the economical choice in LTC
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Looking for Maximum Adjustability
Image Credit: Volvo
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Identifying the Common Wheelchair Models Seen in the LTC Setting
StandardK0001
Standard HemiK0002
LightweightK0003
High Strength Lightweight
K0004
Standard
K0001
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Description of K0001/K0002/K0003 wheelchairs (straight from the wheelchair dealers)
K0001/K0002 Getting warmer* with the K0003 OTHERWISE…
• bare necessities with no
outstanding features
• no frame adjustment or modifications
*K0003 has ability for slight adjustment
• made using different materials
making it 5-6lbs lighter
• ability to lower STFH by 2 inches
compared to a K0002 chair
The skeletons of these 3 wheelchair
models are EXACTLY THE SAME!
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Criteria for K0001/K0002/K0003 users
The appropriate individual for this equipment:
K0003 only:
• Sits with good postural control
• Has minimal or no postural deformities
• Sits in standard-sized chairs without compromise
• Has no discomfort or pain with prolonged sitting
• Uses this chair for short periods for short distances
• Can functionally propel the weight of the standard
wheelchair to complete all required daily activities
Has a physical condition that compromises ability to propel the weight of a standard chair, i.e. cardiac or pulmonary dysfunction
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Why does the LTC Resident need so much more than a basic wheelchair?
A minimum of a K0004 wheelchair frame
should be used for anyone:
ü Using the WC all or most of the day
ü Presenting with limited mobility or non-ambulatory ü With poor postural controlü Presenting with postural deformities
ü Needing a non-standard size chair to decrease sliding, slouching, and leaning
ü With discomfort or pain during prolonged sitting
ü Who can not functionally propel the weight of the standard wheelchair to complete all required daily activities
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1 - STFH (Seat to Floor Height) beyond just the hemi height setting
Adjustability is key when choosing a model wheelchair
Achievable adjustability in a chair:
2 - Armrest Height
3 - Seat-to-Back Angle
Look for a chair with maximum adjustability to be able
to quickly transfer from one body type to another!
4 - Back Height
5 - Ability to create a fixed tilt, “dump” in the seat 5
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4
3
1
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Standard Manual Wheelchair Comparison Chart
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HIT A HOME RUN!!!
Look for a wheelchair that can be molded
to various body types instead of trying to
mold various body types to one chair!
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Misconception #3
A new cushion is all that is needed to fix a positioning issue
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New cushions solve all seating issues
A seating referral comes across the desk due to:
• Pain in sitting
• A pressure injury
• A fall from the wheelchair
It MUST be the cushion’s fault, right?
WRONG!
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New cushions solve all seating issues
Keep in mind: Whole Body Seating Component Design It’s a Seating SYSTEM
The pelvis does not work
alone. Overall alignment
from the head all the way
to the ankle and foot is
impacted by the seating
system.
The best cushion can be
ineffective if not used in
combination with the
correct model wheelchair
and appropriate back
support.
A back support is just as
critical as the cushion in
an ideal seating system
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Back supports assist in maximizing optimal posture as they:
Role of the Back Support
• Allow for pressure redistribution to alleviate peak pressures on the spinous processes
• Immerse and envelop the spine for optimal contact
• Capture the curvature, whether normal or abnormal, for optimal upright, midline posture
• Allow for the addition of lateral trunk and head supports
• Replace the existing overstretched, hammocking sling back that has lost its shape and
can no longer stabilize the trunk as needed
Fixed 90ºPeak Pressure
on the Spine
Open STBAMore Surface Contact
Redistributes Pressure
Open STBA + ContourOptimal Pressure
Redistribution
Fixed 90ºPeak Pressure
at the Apex
Open STBAMore Surface Contact
Match Resident ROM
Open STBA + ContourOptimal Pressure
Redistribution
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Back Supports Help to Complete the Seating System
The cushion and back
support and wheelchair go
hand-in-hand to stabilize
the pelvis and spine for
optimal alignment
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Misconception #4
Elevating leg rests (ELRs) are the better option when purchasing a wheelchair
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ELRs are the better option
Why do clinicians/suppliers use ELRs?
• “Keep the hips back in the wheelchair”
• “Help reduce edema”
• “Decrease pressure on the pelvis”
• “Assist with LE alignment.”
So ELRs are the best option, right?
WRONG!
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ELRs Keep Hips Back in the Wheelchair, Right? WRONG!
• Elevating the legs pulls on already
tightened hamstrings
• ITs are pulled forward causing a
posterior pelvic tilt and sacral sitting
• Individual begins to slide forward out
of the wheelchair
The result is the exact opposite of
keeping the hips back in the seat!
ELRs do just the opposite if the hamstrings are tight!• ELRs do just the opposite!
• When we elevate the legs, we pull on already tightened hamstrings.
• The shortened hamstrings cause a greater pull on the pelvis, bringing the pelvis into a posterior pelvic tilt.
• The posterior pelvic tilt makes the pelvis slide forward, resulting in sacral sitting.
• The resident begins to slide forward out of the chair, the exact opposite of keeping the hips back in the chair!
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ELRs Reduce Edema, Right? WRONG!
Why is this wrong?
ELRs used on manual WCs (typically seen in
medical facilities) CANNOT reduce edema
ELRs on a manual WC can decrease
optimal circulation by cutting off blood flow
at the groin and inhibiting flow to the LEs
To decrease edema, the legs must be 30 cm ABOVE heart level. The
only way to achieve this with ELRs
is with a tilt-in-space wheelchair
Periodic elevation of the LEs with ELRs might help prevent edema
from developing, but it cannot reduce edema that is already there
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Talk to the IDT and consider other solutions for edema control
Make a schedule for your resident to balance time
spent sitting in chair vs. lying down with legs elevated
above heart level for maximum edema control.
Provide compression stockings to compress the
edema and stimulate circulation.
Reduce sodium intake as sodium increases fluid
retention.
Increase resident’s water intake as water flushes
excess sodium from the body.
Decrease resident’s caffeine intake as caffeinated drinks
contain a high level of sodium.
Develop a walking schedule or an exercise schedule for
your resident to increase circulation and fluid movement
by pumping fluid from the edematous lower extremity
back to the heart.
Encourage the nursing staff to review any medications
that may increase fluid retention such as hormone
replacement drugs, calcium channel blockers, anti-
depressants, and steroids known to increase edema.
Consider substitutions without this side effect.
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ELRs Decrease Pressure on the Pelvis, Right? WRONG!
• Increased pressure on bony prominences
of the ITs, sacrum, and coccyx
• Increased risk of wounds in those areas.
ELRs position pelvis in a posterior pelvic tilt
• Decreased femoral contact shifts pressure
back to the ITs and sacrum/coccyx
Elevating the legrest promotes knee flexion
• ELRs actually position the pelvis in a posterior pelvic tilt.
• The forced posterior pelvic tilt increases pressure on the bony prominences of the ITs, sacrum, and coccyx.
• Wound development risk is increased in those areas.
• Elevating the legrest promotes knee flexion, leading to decreased femoral contact, shifting the pressure back onto the ITs and sacrum/coccyx.
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ELRs assist with LE Alignment, Right? WRONG!
• Since less femoral contact with the seat
surface, it is easier for the leg to
internally/externally rotate or abduct/adduct.
• Legs then fall off legrests more easily.
• Windswept deformity is more prevalent.
• ELRs promote flexion of knees, hips, and
ankles increasing risk of contractures at
those joints.
ELRs prevent full femoral contact with the seat surface.
Elevating Leg Rests Standard Leg Rests
• ELRs prevent full femoral contact with the seat surface.
• Since less of the leg is making contact with the seat surface, it is easier for the leg to internally/externally rotate or abduct/adduct.
• Legs then fall off legrests more easily.
• Windswept deformity is more prevalent.
• ELRs promote flexion of knees, hips, and ankles increasing risk of contractures at those joints.
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Knowledge is Power!
Understand basic principles of seating
and positioning
Identify abnormal postures that place your
residents at high risk
Familiarize yourself with the misconceptions to
avoid them
Knowledge arms you with the tools to prescribe the best equipment to prevent and heal existing pressure injuries!
+ + =
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AfterBefore
Knowledge arms you with the tools to prescribe the best equipment to prevent and heal existing pressure injuries!
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References
1. NearSay. (2015, May 10). Adult wheelchairs categorized and explained - Northwest Pompano. Retrieved from
http://nearsay.com/c/44448/33117/adultwheelchairs-categorized-and-explained
2. Karman Healthcare. (2014). LT-K5 – 28 Lbs 18 Inch Seat Ultra Light Adjustable Wheelchair K0004. Retrieved from
http://www.karmanhealthcare.com/product/lightweight-wheelchairs/lt-k5/
3. Mounic, Gerard. (2014). Evaluation and seating strategies with regulatory guidelines, wheelchair seating and positioning improving
functional mobility and patient ADLs. Summit Professional Education Continuing Education Course. North Carolina, Asheville.
Lecture.
4. Cornell University. (2016). DEA 3250/6510 Class Notes: Sitting and Chair Design. Retrieved from
http://ergo.human.cornell.edu/DEA3250Flipbook/DEA3250notes/sitting.html
5. MacLeod, Dan. (2016). Favorite low cost success stories. Retrieved from http://www.danmacleod.com/Articles/rightangles.htm
6. Dicianno, B. E., Arva, J., Lieberman, M., Schmeler, M. R., Souza, A., Phillips, K, Betz, K. L. (2009). RESNA Position on the
application of tilt, recline, and elevating legrests for wheelchairs. Assistive Technology, 21(1),13-22. Available from
http://www.resna.org/sites/default/files/legacy/resources/position-papers/RESNA%20PP%20on%20Tilt%20Recline_2015.pdf
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References
7. Cole, Elizabeth. (2016). Causes and prevention of skin breakdown. US Rehab Seating and Mobility Master Program. Lecture.
8. Lange, Michelle L., and Jean Minkel. (2018). Seating and Wheeled Mobility: a Clinical Resource Guide. Thorofare, NJ: Slack
Incorporated.
9. Borisoff, J., & Mitchell, S. (2015) Dynamic wheeled mobility: Next chapter in the ultralight evolution. 31st International Seating
Symposium, Pittsburg, PA.
10. Jones, D., Radar, J. (2015.) Seating and mobility for older adults living in nursing homes: What has changed clinically in the past
20 years? Topics of Geriatric Rehabilitation, 31, 10-18.
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Thank youThank you
Ana Endsjo MOTR/L, CLTNational Education Manager, Permobil
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