Page 10 - Seating & Positioning Handbook, 2021-2022
P. 10

ATP Series
Positioning the Extremities
wheelchair and seating functions. But why is lower-extremity positioning so important?
“That’s one of my pet peeves, when I see someone come into a seating clinic or I watch them in a wheelchair and they don’t have their feet supported,” Roesler said. “I can do as much positioning as I want to with the trunk, the pelvis, the upper extremities:
If my lower extremities aren’t supported, I no longer have that closed chain.
“I always use the term closed kinematic chain, which is a biome- chanics term. When you’re seated with your feet supported — your trunk and your pelvis, all the way down to your feet and all the way up to your head acts as one closed chain or one
unit. Whatever I do to one of those segments impacts the other segments. If my feet are dangling and pulling me forward, it impacts my entire trunk, my entire pelvis, my entire head, my upper extremities and my ability to control all of that.”
Footplates often get a bad rap: Depending on their placement, they can add to a chair’s length and raise the risk of running into walls during turns. They can get in the way during transfers.
Still, eliminating the footplate usually isn’t the best option.
Roesler said she’s “never [heard] a good explanation” when a footrest is missing from a wheelchair. “Maybe it was easier for the caregiver, and they didn’t realize the implications from a postural standpoint,” she said. “If my feet are dangling and my legs are dangling off the chair, it changes my postural position. It tends to pull me into a posterior tilt. It can also cut the circulation off at the back of your legs.
“Dangling feet are going to affect everything else you tried to do in the rest of that chain. It’s a closed chain as long as your feet are supported. Once you open up that chain, it’s like a noodle: shear, friction, posture abnormalities, posterior tilt. It can cause permanent postural abnormalities, like permanent plantar flexion or rotation. And then you have even a more difficult time when you try to support the lower extremities.”
Roesler pointed out how uncomfortable high barstools can be when legs dangle for any length of time. “Are you comfortable in that position?” she asked. “The only time I would ever say that dangling feet are okay is if someone, for example, has a severe
The Power of the Pen: How Journaling Can Help to Create Optimal Positioning
While Complex Rehab Technology is indeed complex, two of the most powerful tools in the quest for creating the opti- mally functional seating system might be a pen and a notebook.
In the hands of your client, a family member or caregiver, that notebook can gather the kind of information that’s diffi- cult to capture during relatively brief clinic appointments.
Positioning at Home
Gabriel Romero is VP of Sales & Marketing for Stealth Products. In addition to all the high-tech electronics and space-age mate- rials that Stealth Products uses, Romero is a big believer in the powers of observa- tion... including observations that aren’t necessarily possible when you’re seeing a client for just an hour at a time.
“You can’t expect that what [the family] sees all the time is also going to happen at a 9 a.m. clinic visit, when [clients] are well rested,” Romero pointed out. Instead, positioning difficulties “happen at 2 p.m. Or it’s an environment that triggers it: Maybe [positioning problems] happen more when they go outdoors and they start to bounce around in gravel and dirt,
and their positioning gets lost.”
That’s the type of information that clini-
cians and suppliers aren’t able to see. “That’s why it’s so important to journal,”
Romero said. “The more a family member journals when they get new equipment or when something’s changed... just journal for a month. You’ll start to see critical things in a month’s time.”
While taking detailed notes can be helpful at any time, Romero especially appreciates those notes when the seating team is trying a new regimen. “We used to tell people all the time when we were trying aggressive positioning: Look for redness. That redness doesn’t happen years afterwards; it starts to happen quickly, depending on the position. That’s a key thing.”
Romero advises family members
and caregivers to note any changes in behavior, no matter how subtle. Is the client seemingly trying to avoid making contact with an armrest, for example? Does a non-verbal wheelchair user suddenly seem reluctant to be in the wheelchair?
“If you see something different, if you see discomfort, if you notice excessive sweating — it’ll show you that something’s going on here and maybe some adjust- ments need to happen,” Romero said. “Something could be different with the cushion, something could be different with the back.”
Caregivers and family members are usually keenly aware of what’s routine behavior and what’s not — and when something different happens, Romero suggests they write it down so they can share notes — good and bad — with the seating team.
“It takes a village,” he said, “and the more that the village is prepared with information, the more we can talk about what’s being experienced. A parent
or spouse or loved one is always with them, and they know. They’ll know pretty quickly.” m

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