Page 11 - Seating & Positioning Handbook, 2021-2022

pressure injury on the bottom of their foot. Other than that, the feet should always be supported in some way for stability.”
Building Movement Into the Seating Strategy
One of the challenges of positioning extremities is that wheel- chair users move — intentionally as well as unintentionally — within seating systems. They reach and lean when performing daily activities or operating their chairs. They can also experi- ence tone and spasticity that moves them within their seat.
That’s why extremity support is particularly important, Roesler said. “Especially when you have someone with tone, they need
to be supported at their feet, but also supported correctly so
it doesn’t initiate more tone, say, when they go over a bump,”
she said. “That’s where you see more use of secondary postural supports: With a lot of pediatric clients, you see the use of
ankle huggers to help keep their feet in place. Or a calf support, either posterior or in front of the lower extremities, can really help while the person is trying to function. So maybe their tone doesn’t negatively impact what they’re doing, and maybe they can utilize their tone to help increase function as well.”
Some wheelchair users actually use their tone to perform activ- ities. “You’ll see a lot of people initiate their tone increases, and sometimes that helps them do functional tasks, like driving a power chair,” Roesler said. “You might see their tone increase in their lower extremities as they try to reach the joystick, for example.
“When I first started in seating and positioning, it was You want to control the tone and stop it. As we’ve learned more and really looked at what we’ve been doing, we’ve realized that some- times that tone that might be abnormal is helping them do some activities. We want to minimize the negative impact of it, but we don’t necessarily always want to eliminate it.”
That’s when dynamic postural supports can be helpful.
“I think that’s where secondary postural supports are different than seatbelts, for example,” Roesler said. “A lot of [Bodypoint’s] chest harnesses have a dual stretch so that they stretch when they need to. If you need to lean forward, you can. But because of the stretch, it’s also going to help you return back, because it does want to return to its original position. It’s not like a spring; it’s not that strong. But it gives you enough movement to be able to use your upper extremities or move within a range and then help you come back to the original resting position.”
Roesler added that dynamic supports can be adjusted per each client’s needs: “You can make a postural support be pretty tight and not have a lot of dynamic motion, but it’s always good to have a little bit. You don’t want so much that the pelvic belt or chest harness starts to slip, because that can become dangerous over time. But you do want it to have some motion. Even the type of buckle you use can impact how much or how little motion you get, depending on the configuration.”
Dynamic supports can be particularly useful for pediatric clients. “The example I always use is for kids,” Roesler said. “A lot of times we’re using postural supports with kids because one, we do want them to be safe. But we also want to give them some
postural support. We also know they tend to move around a lot more, so we don’t want to restrict that too much.
“We have a [Bodypoint] swivel buckle that allows the harness or belt to move laterally and rotate a little bit as the person moves in the chair. So it still has a firm hold and tries to keep your position, but it allows some movement in different directions, whereas a straight rehab latch or push-button buckle is pretty much fixed. You’ll still be allowed a little movement from the stretch in the belt itself, but it doesn’t move with you. So it may not be as comfortable, and if you have someone who’s asymmet- rical, it may not be as comfortable, either, because it might not distribute pressure the same way.”
Adapting Strategies to Get the Best Function
That’s the greatest challenge for upper- and lower-extremity posi- tioning: Each client needs a unique approach.
“Especially when it comes to driving a power chair for an individual with cerebral palsy — maybe they have to elicit tone to reach the joystick,” Roesler said. “It may not be normal, but they’ve developed it for function. Sometimes if we apply too many postural supports or correct it too much, we take that away.
When I started in seating, it was You want to control the tone and stop it. As we’ve learned more, we’ve realized that sometimes that tone is helping them do some activities— Tina Roesler
“I’ve seen that happen before: ‘Oh, look how nice and straight they’re sitting, and they have this nice belt and chest harness.’ And now they can’t drive their power chair for some reason. So it’s really important to look at that and realize tone isn’t always a bad thing. Some people have learned to live with it and make it useful for them. You don’t want tone to be so strong that it’s causing postural deformities or limiting what someone can do. But that’s where postural supports come in. If I have someone who has a lot of lower-extremity tone when they push a manual chair, for example, maybe use an anterior support on the lower extremities or a good pelvic positioning belt. Although they still might get tone, the belt helps them maintain lower-extremity position so they can still propel easily or more easily.”
Romero praised seating teams who take the time to fine-tune postural components for each client: “There are great ATPs that take their time and get adjustable armrests that can rotate in if they need to, or troughs that can rotate in. Sometimes it’s for comfort and positioning. It becomes critical for them because now they can be in their chair longer, which again is the ultimate goal for everyone.” m
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