Page 8 - Seating & Positioning Handbook, 2022-2023

ATP Series
All About Asymmetries
time, there’s flexibility for that to progress into a worsening level of obliquity in that direction.”
So if a lack of intervention is likely to result in the asymmetry continuing to progress, then change is still possible.
“Yes, and change for the worst,” Giles said. “This is why we see, when that person comes [to clinic] a year later — no, they don’t have a right obliquity, but they have a worsened left obliquity. We say it’s not fixed unless it’s pathologically or surgically fused. If a surgeon fuses that joint and puts in pins and a rod, that is fused.
“We know that even rods can change and shift, so even those joints can still progress. And there are pathological fusions, like a severe [rheumatoid arthritis] or heterotopic ossification, where the bone kind of fuses. That joint is not going anywhere. It’s not likely to get worse, it’s not likely to get better.”
The terminology is important, Giles believes, to understanding how actions or inactions could impact the wheelchair rider’s future positioning. “When we talk about fixed versus flexible, we have to be accurate in our terms, because most of the time, those joints can get worse, and we want to prevent that.”
Seating Goals for Asymmetrical Postures
Giles keeps three goals in mind during the seating assess-
ment. “The three main goals of most of our seating systems are preserving or improving alignment,” she noted. “So — an align- ment goal, a functional goal, and then you’re trying to meet those two while maintaining skin safety.
“We have to try to maximize function and maximize proper alignment, while not sacrificing any level of skin care. And again, that skin care is very specific [to the client]. Are they pediatric, are they geriatric? What you’ll be able to do in alignment versus skin is specific to each case.”
Plus, Giles noted, most wheelchair riders come to clinic because something specific is bothering them. “There’s usually one reason they came in,” Giles said. “‘I have a sore’ or ‘I can’t transfer,’ or ‘My body hurts now that it’s in this alignment.’ There’s always a primary goal of why they’re coming in. I will prioritize those three items by level of importance to them.”
Giles said fine-tuning those three goals — dialing one up
a bit while dialing another down — is necessary to making
sure all needs are being met as well as possible. “If they have a wound and the skin is of the utmost importance, I might [move] alignment and posture down on the list for a while. Let’s allow you to sit, let’s preserve your skin and allow you to transfer. I will sacrifice my alignment goals for the preservation of skin. So those three things can be kind of jumbled.
“If you’ve got a kid with very low skin risk, that’s third on the list, because we don’t really have a lot of risk or concerns there. I can go bigger and put the functional [goals] and the alignment a little bit higher on my goal list.”
The Role of Secondary Postural Supports
While wheelchair backs and seat cushions are a big part of the positioning process, Roesler pointed out that secondary postural
supports are crucial to dialing in precise positioning — a requirement that can be extra important for the client presenting with an asymmetrical posture.
“They encourage you back to your original position,” Roesler said in explaining the role of supports such as harnesses and belts. “It’s important to remember that while a lot of people think of chest harnesses and pelvic belts as restraints, that’s completely the opposite of what Bodypoint believes [see sidebar]. It’s not a restraint. It should facilitate better function and keep that person stable. And in some cases, the supports just help [wheelchair users] to be stable when going over bumps in a power chair.”
While it’s easy to find cheap wheelchair restraints online, Roesler explained that secondary supports for clients with complex positioning needs are much more robust in function.
“The [Bodypoint] PivotFit harness has stretch or non-stretch [versions], depending on how strong you want that positioning to be at the chest and the upper extremities,” she said. “Also, it uses our Swivel Buckle, a round buckle that fits into a little circular receiver. It swivels just enough so if that person needs to function and move, the buckle moves with them and allows for some of that trunk motion without impeding them.”
That’s important because wheelchair riders move in multiple directions and rotate as they do. “We’re not only talking about moving very neatly in a single direction,” Roesler said. “There’s rotation as well. We will turn and reach for something on the left or the right. I especially like that buckle, because it really allows you a little bit more motion all the way through the harness.”
Complex seating supports are available in different versions that allow more or less movement while still promoting function. “Maybe someone needs a chest harness with firmer control,” Roesler said. “Maybe the harness is not flexible; maybe that’s what allows them to use their upper extremity to reach a joystick, for example, because they’re maintaining that upper-body stability. And the same thing with a pelvic positioning belt — if
I talk about harnesses, I always assume that they’ll also have a pelvic positioning belt. Because if my pelvis is moving around under the harness, it creates other issues.”
Roesler added that secondary postural supports should be part of the seating system’s configuration from the very begin- ning. “You can’t talk about cushions and backs unless you have a good base of support,” Roesler said by way of comparison. “You can’t just say, ‘We’re going to use this cushion, this back, these postural supports, so let’s just pick any chair,’ because it won’t work. They all interface together. So you have to consider the interface with all of those components together.”
Today’s postural supports can be precisely placed thanks to greater numbers of positioning options. Those options are partly needed, Roesler said, because supports must be compatible with such a large number of wheelchairs. “But also, we have so many different types [of supports] not just for the interface with the wheelchair, but also exactly where that strap needs to go.”
In the past, limited mounting options sometimes forced clini- cians to compromise, Roesler added. “When I was out in the field
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