Effective Solutions for Complex Seating Needs

Author: Tamara Cheney Reynolds, OTR/L
Published: 03 September 2008

Some of the Most Difficult Seating Dilemmas:

  1. Decubitis on heels, buttocks, or back
  2. Sliding from a wheelchair
  3. Difficulty self propelling
  4. Leaning to one side
  5. Scoliosis, Kyphosis or neck "stacking" interfering with comfort, safety and swallowing
  6. Agitation from attempts to stand despite inability to do so
  7. Uncontrolled or excessive movement (ex. Huntington’s)

In order to address the above seating issues, the following need to be considered:

  1. Basic OT Process
    1. Basic OT Assessment
    2. Skin assessment of past, current or potential skin breakdown
    3. Cognitive evaluation (throughout the day)
    4. Full ROM measure of neck, trunk, hips, proximal extremities
    5. Mat assessment of trunk control, trunk rotation, scoliosis and sitting tolerance
  2. Basic Elements of Proper Seating
    1. Seat Width (Consider individual’s preference- ex. Women tend to sit with legs crossed and could tolerate a smaller seat width than a man of the same size)
    2. Seat Depth
    3. Seat Height
    4. Hip Angle
    5. Trunk Stability
    6. Armrest Height
    7. Footrest Height
    8. Flat vs Sling Seat and Back Surface
    9. Prevention of Skin Breakdown (Temperature, moisture and pressure combined with time)

Targeted Seating Solutions

Decubiti and/or Knee Contractures

Excessive pressure on heels due to knee flexion contractures forces feet against surface of bed or wheelchair foot support.

Compounded by slide in wheelchair prompting staff to further elevate legrest in wheelchair causing increased slide and pressure

Solutions:

  1. Footrest properly adjusted to accommodate knee ROM, (comfortably) knee bracing and other intervention as appropriate, pressure products on heels

Decubiti on Seating Surface

  1. Issues to Assess/Solutions
    1. Heat and Moisture Retention- Seating surface should be breathable to allow dissipation of heat and moisture. This is very important to look at along with pressure
  2. Distribution of Pressure:
    1. Adequate seat depth
    2. Hips on appropriate seating surface to avoid excessive pressure on one ischial side
    3. Footrest height adjustment
    4. Pressure distribution using tilt in space option
    5. Pressure distribution using calf support (helps displace pressure over a greater area)

Sliding Forward in Chair

  1. Issues to Assess/Solutions
    1. Hip and pelvic range of motion (Wheelchair may need recline option if individual can not comfortably sit at 90°)
    2. Height of seating surface from floor
    3. Pelvic thrust/involuntary movement
    4. Lap belt usage (should be across upper thighs or hips)
    5. Knee flexion contractures

Difficulty Self Propelling

  1. Issues to Assess/Solutions
    1. Proper seat height (distance from popliteal area to floor)
    2. Ease of chair rolling

Trunk Rolling, Scoliosis and Neck Stacking

  1. Issues to Assess
    1. Pelvic levelling
    2. Trunk control
    3. Seating tolerance/endurance
    4. Areas of pressure related to imbalance
    5. Pain from sitting (Standard wheelchairs are designed for transporting, not designed for sitting, thus can cause great discomfort over a long period of sitting)
    6. Location of head in relationship to hips:
      1. Want to achieve Head over Hips position for better socialization, safety and swallowing
    7. Skin integrity along the spine

Solutions:

  1. Tilt in space wheelchair that allows gravity to pull chest open and upright rather than off to the side or forward, decreasing pain and pressure and increasing sitting tolerance
  2. Lateral supports for trunk stability or to help compensate Scoliosis
  3. Firm, supportive seating surface (Broda’s Comfort Tension Seating™) or compensatory seating surface as appropriate

Agitation and Attempt to Stand

  1. Issues to Assess/Solutions
    1. Cognition throughout the day, evening and night
    2. Current use of restraints (Some restraints can cause discomfort; It is important to give some individuals the ability to mobilize – The Broda Pedal chair helps encourage mobility
    3. Ability to stand as well as potential to improve strength, balance and motor planning for safe standing

Excessive Movement Disorders

  1. Issues to Assess/Solutions
    1. Ability of the chair to absorb energy generated by excessive movement as well as chair stability- Broda 785 with HSP Huntington’s Padding is ideal
    2. Pelvic thrust/Pelvic slide
    3. Seat depth to provide stable seating surface and displace pressure among the shaft of the femur
    4. Tilt and recline to promote appropriate seating position- Broda tilt in space pulls the user back using gravity.
    5. Ease in repositioning the chair
    6. Ease of transfers in and out of chair as well as ease of caregiver use of the chair
    7. Ability of chair to transition through phases of the disease process to be fiscally responsible of resource.