Page 9 - Seating & Positioning Handbook, 2020

that IT [ischial tuberosity] off of their cushion, enough for me to slide my hand underneath and know that they’re not making a depression in the cushion? Maybe they have back canes they can hook onto, or an armrest they can hook onto if it’s tubular versus a flipback or removable?”
Chesney also evaluated the client’s ability to independently return to their original position, not just after weight shifts, but after daily activities, as well. ‘If you’re in a manual chair and you drop something, you might have to reach to the ground,” she pointed out. “Or if you fall forward, you need to be able to get back up. So you have them lean forward, clear weight off their sacrum, and then get back up. ‘Could you push with your arms to get back up? Could you progress and press up on your legs? Could you recover from that position?’”
HOW GOOD IS CAREGIVER SUPPORT?
Chesney added that having dependable and capable caregiver support could be very helpful if the client needs help reposition- ing after weight shifting. Price also said caregiver support or lack of it significantly impacts her equipment recommendations. She remembered a client who already had contractures when she started working with him. “He went home, didn’t have great care, came back in to do the seating eval, and knew he was going to a long-term care facility,” she said.
Knowing that removable seating components can easily get lost in facilities, Price said one of the seating team’s goals was ensuring a continuum of optimal positioning: “We did custom options built up within [the chair]. We had as few removable components as possible.
“With the [cushion] cover, I might do a reverse Dartex versus some- thing that might offer a little more breathability. [The reverse Dartex cover] might not be the best terms of reducing pressure injuries per se, but if we know it’s never going to get timely clean-up, and he’s having accidents, we’re going to have a bigger issue if there’s moisture there all the time. So it’s a lot of juggling. Those [facility-friendly options] would prioritize pretty high for me for a patient who does not have good carry-over of care. I’m going to select very different things than for somebody who is independent to do everything on their own and has good carry-over of care. It depends on our end user.”
Chesney explained this situation to her clients by focusing
on their primary goal: “If I’m not protecting your skin first and foremost, then you’re at risk for getting a wound. You go back to bed, which defeats the purpose of all your goals.’ That’s when I would look at a power chair, because they’re going to need these features to be able to do these techniques independently for the foreseeable future.”
CHALLENGES WITH POWER POSITIONING
Powered seating adds tilt (potentially anterior, posterior, and/ or lateral) and recline as resources, helpful for clients who can’t consistently do their own weight shifts without help.
But powered seating brings challenges as well.
“Within the diagnosis, there’s a lot of broad statements we
can make, but then you have to hone it down to the individual and what’s going on with them,” Price said. “Two ALS patients are very different. One of my ALS clients was working with a head array, and because of his body positioning, if during the day he slid down in his chair, he couldn’t access the head array anymore. We had to really look at his positioning differently. You have to look at people’s body types as you set up their seating system to make them successful, especially if they do have to access any alternative driving method. I would include joysticks in that too, but I mean specifically with alternative driving meth- ods, we really have to focus on that seating system and trying them in all positions they have to be in.”
Chesney said the seating team needs to see the client use powered seating to identify any potential problems caused by the repositioning. “You might think that when they tilt back, their arm is going to fall off the chair, and they already have decreased musculature there, so now I’m worried about a subluxation, I’m pulling the joint out of the socket,” she said as an example. “It’s important to understand the positioning component, but also to understand the programmability. This is for them to drive and be independent as a drive control, but it is still also a positioning feature when they tilt back.” It could be possible, for example, to disable the back pad when the client tilts so the back pad doesn’t respond to the client’s head contacting it.
Clients who don’t feel confident with power positioning could stop using it, which could put them at greater risk for pressure injuries. Chesney said it’s therefore important to investigate non-compliance rather than just assuming that some clients won’t use powered seating functions.
“Well, why?” she asked. “Is it that when they tilt back, they have a hard time breathing? Is it that they don’t like that they can’t see their environment? You have to ask why, because most likely, there’s a way to address it.”
HOW CRUCIAL IS COMFORT?
While CRT professionals sometimes flinch at the word “comfort,” in part because funding sources can perceive that word as vague and not medically necessary, comfort is critical to creating a seating system that will be optimally used.
“Some people will tell you: I’m not comfortable at all,” Price said. “And they just abandon the wheelchair. That’s why function is important, but you have to balance all three: ‘I care about your posture and your function and your comfort.’ Comfort’s going to be your client’s number one goal for the most part. If they’re not comfortable, they’re going to tell you. Even with your clients who
I prioritize function always, because I think that’s the most important piece of the puzzle. But you can’t do it at the cost of comfort — Heather Price
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