Wheelchair Seating & Positioning
Laura Staton, OTR/L, RYT
Staten Island University Hospital
The pelvis links the vertebral column with the LE’s and defines the base of the trunk.
Pelvic bowl formed by 2 pelvic bones (ilium, ischium, pubis) and sacrum.
Important bony landmarks are ASIS, PSIS and ischial tuberosity (sitting bone).
The 2 pelvis bones attach to the sacrum at the sacroiliac joints with strong ligaments. The SI joints so firmly bind the pelvis to the sacrum that each tilt, rotation and postural shift affects the spine.
A posterior tilt flattens/rounds the lower spine, the anterior tilt increases lordosis.
It’s not the just the pelvis that has to be back in the chair, it’s the sitting bones, which insure proper positioning of the pelvic bowl, sacrum & spine.
The spine has 4 curvatures: 2 concave (cervical & lumbar) and two convex (thoracic & sacral).
Cervical & lumbar are lordotic curvatures.
Thoracic & sacral are kyphotic curvatures.
In fetus, the entire spine is kyphotic and curvatures develop as we crawl, sit & walk (specifically the cervical and lumbar curvatures).
All four curvatures act together as a flexible springboard to maintain our upright posture and balance.
When seated, the curvatures are more difficult to maintain (especially with tight hip flexors).
Intervertebral discs are comprised of a gelatinous inner core called the nucleus pulposus (approx 15% of total mass) and confined by the fibrous ring of the annulus fibrosus.
As the spine ages (20-70) the disc dehydrates and vertebral bone loss occurs. The annulus fibrosus takes more weight with compressive forces.
Forward flexion of the spine posteriorly herniates the spine.
Posterolateral herniations are the most common and typically the cause of nerve pain due to the proximity of the nerve root.
Approximately 95% of posterolateral lumbar herniations are at the L4-L5 or L5-S1 vertebral level.
Spinal extension is good for posterolateral herniated discs, flexion is not.
Tonic Labryinthine Reflexes
TLR is an infant reflex which helps baby to master head and neck control, increase tone in trunk and self correct posture & head alignment.
Forward/prone: As head curls in to flexion entire body, UE/LE’s and trunk curl into flexion.
Backwards/extension: As head extends the entire body, UE/LE’s and trunk curl unfold in to extension
Tone can effect w/c positioning
Forward/Prone TLR – pull your knees up towards your chest and notice what happens to your lower back and trunk: Hip Fx, Kyphosis, Parkinson’s, Spinal Stenosis, MS, CVA, SCI.
Backwards/Supine TLR- Sit on edge of chair and extend head and legs out straight and notice what happens to your body: CVA, SCI, Neurological Disorders, TBI.
What Can We Do To Help?
Prioritize w/c positioning as a part of your scope of practice and treatment time.
Do not be afraid to problem solve with patient (client centered care) and make changes.
Ask for help if you can’t figure out what to do.
Educate yourself and the patient.
Change if it does not work.
Questions to Ask Yourself!
Do they LOOK comfortable in chair?
What are patients here for?
Where do they have pain?
What is their static sitting posture/balance?
Are the hip flexors excessively tight?
Are they w/c bound at home?
Do they complain of pain after sitting in chair?
Are they excessively stiff when they get up?
What Improves Wheelchair Positioning?
The right fit of w/c.
Good usage of equipment (SSI, lumbar support, cushions, back support, lateral support, arm tray, calf panels, knee spreader).
The spine and pelvis (as much!) in alignment as possible.
Neutral pelvis with IT bones touching back of seat.
Back support to reduce pain & increase thoracic spinal /neck extension.
Lateral leaning supported.
Feet and limbs supported.
Basic Guidelines to Follow.
With a THR ALWAYS have a SSI.
With a Hip FX, Stenosis, Low Back Pain, Spinal Surgery, kyphosis – SSI may be highly appropriate.
With kyphosis and back/neck pain lumbar support should be considered.
Any skin breakdown or history of skin breakdown use a specialized cushion.
With excessive lateral leaning consider a specialized cushion to prevent skin breakdown on one side.
Consider a knee spreader to assists with organizing alignment.
With a CVA check to see if they need lateral support? Knee spreader?
If very tight hip flexors use extra cushion to elevate pelvis and stretch front of thighs.
Moore and Dalley (2006). Clinically Oriented Anatomy, 5th edition, Lippincott Williams & Wilkins, Baltimore, MD.
Lasater, Judith (2009). Yogabody: Anatomy, Kinesiology, and Asana. Rodmell Press, Berkeley, CA. H. D. Coulter (2001). Anatomy of Hatha Yoga, Published by Body & Breath, Inc. Albany CA.
Last week I taught a chair yoga class at Publishers Clearing House in Chelsea as part of their corporate wellness day. Dues to space (and time) limitations we ended up doing two 30-minute sessions. Although not easy to interrupt deskwork fever to do a mindful yoga practice in the middle of the day, the participants were elegant, thoughtful and positive in attendance and approach. As expected, lots of very tight hamstrings, hip flexors, rounded shoulders and tight pectorals. Computer time breeds a collapsed chest and tight neck and shoulders, so the back/neck/chest stretches were helpful and immediately helped to re-calibrate posture. Additionally, often the fancy ergonomic office chairs are don’t provide enough lumbar support so an addition cushion is helpful. Literally, even a 10-minute yoga breather can break up the physical stress and re-pattern towards better alignment. A cheat sheet of yoga poses were provided.
I decided to bite the bullet the last weeks of August and begin my study of Integrative Yoga Therapy at Kripalu Mass. Integrative Yoga Therapy was started by Joseph and Lillian LePage and is based on a multi limbed approach to yoga therapy integrating asana, pranayama, mudra, Yoga Nidra, mantra, and meditation into a unifying whole – either for therapeutic group classes or private sessions.
As Sergio and I first approached Kripalu, I was regretting that I had recently read “Going Clear” a book about scientology that my friend Lisa Jean had raved about. In fact, moderately panicked about the whole situation and lack of coffee until 7:30am with a 5am wake up time, Sergio kindly drove to the nearest K mart and bought me a 20$ coffee maker and a pound of Peets coffee. I had three roommates; each one was awesome and very charming. A librarian who showed me a photo taken of her aura, a Bulgarian diplomat who also liked coffee, and psychologists who was training in yoga dance.
My colleagues were by large, thoughtful, professional yoga teachers and healers and the teachers committed professionals. We were in class from 6am-9pm almost every day and I have a binder that will take me a year to read. I went to tanglewood and listened to Beethoven’s 9th and cried, went swimming once, went to a “seedy” gay bar (which in Lenox looks likes Chelsea’s finest), took hour long hikes with Lisa and Helen when possible and was constantly trying to corrupt my friend Geetha with daily coffee. Mostly though, I sat and listened and practiced and learned and look forward to my next modules training at an Ashram, in Texas, in March. (Yikes).
Check out Sarah and I on Veria Living TV!
Cervical Stenosis: Is when the spinal canal is too small for the spinal cord. A normal canal diameter is approximately 13-15mm and a narrowing of the canal of less than 10mm diameter is associated with cervical stenosis. A canal of below 13mm is considered at risk for stenosis. Symptoms of cervical stenosis include neck pain and numbness, pain in one or both arms, and an electrical sensation that radiates downwards when the head moves. Radiculopathy are pinched nerves as they exit the spinal canal.
Management of spinal stenosis is aimed toward symptom relief and prevention of neurologic complications. Physical therapy with traction and strengthening exercises help relieve symptoms, muscular spasms and back pain. Decompression and inversion tables have also been used with success and varying amounts of benefit. Epidural steroids are also used to treat stenosis. Surgical interventions may be required in some cases.
Cervical stenosis can progress to myelopathy in one third of affected individuals. Myelopathy is defined as pathology of the spinal cord and spondylosis refers to the degenerative changes that occur in the spine.
Cervical Spondylosis Myelopathy (CSM) refers to the clinical presentation from these degenerative processes and is a common degenerative condition of the cervical spine. Degenerative changes of the cervical spine include degeneration of the joints, intervertebral discs, ligaments and connective tissue of the cervical vertebrae and symptoms can include neck and shoulder pain, suboccipital pain and headache, radicular (radiating nerve pain) symptoms. CSM is the most common cause of spinal cord dysfunction in adults older than 55 years has been observed in as many as 95% of asymptomatic individuals older than 65 years.
Lists are straightforward and make educated choices accessible. Here are a few commendable lists from Harvard Women’s Health Watch Newsletters:
October 2012 (volume 20, #2)
5 of the best exercises you’ll ever do:
Swimming: The perfect workout as the buoyancy of the water takes strain off joints. Good for individuals with osteoarthritis.
Tai Chi: Moving meditation good for body and mind and balance.
Strength Training: Strengthens age related muscle loss and increases metabolism.
Walking: Simple and effective
Kegels: Strengthens pelvic floor and supports the bladder
March 2013 (volume 20 #2)
12 Super foods you should be eating:
Salmon: Omega 3 fatty acids
Blueberries: High in antioxidants
Broccoli/Cruciferous Veggies: High Vitamin C and cancer fighting capabilities
Eggs: 6 grams of protein, Lutein (vision) & Choline (memory)
Greek Yogurt: Calcium, Vitamin D and Protein
Beans: Low fat protein, folate, potassium, magnesium & fiber
Walnuts: Healthiest of all nuts with high antioxidants, and omega 3 fatty acids
Oatmeal: Ideal breakfast because high in fiber and lowers cholesterol
Olive Oil: Monounsaturated fats can reduce cholesterol, prevent blood clots and helpcontrol blood sugar.
Tea: All types of tea are high in antioxidants
Quinoa: High in protein and essential amino acids (luecine), vitamins and minerals
Dark Chocolate: Beneficial for cholesterol, blood sugar and blood pressure (buy chocolate with 70% or more cocoa and no more than one ounce a day)
June 2013 (volume 20 #2)
8 Things you can do to prevent a stroke:
Lower Blood Pressure: maintain a BP of less than 120/80. No more than 1,500 milligrams of salt (1/2 a teaspoon) a day. Avoid high cholesterol foods (red meat, cheese, ice cream). Eat 4-5 cups of fruit and veggies every day and fish 2-3x a week plus daily servings of whole grains and low fat dairy. Exercise more – at least 30 minutes a day. QUIT SMOKING. Take BP medicine if you need it.
Lose Weight: Obesity raises odds of having a stroke (losing even 10 pounds makes a difference). Keep BMI at 25 or less. Limit trans fats, eat less than 2,0000 calories a day, daily exercise.
Exercise More: Exercise stands on its own as a stroke reducer.
Drink – in moderation: No more than one glass of red wine per day (5 ounces).
Take a baby aspirin: Aspirin helps blood clots from forming (check with your MD first!)
Treat Atrial Fibrillation: A-Fib is an irregular heartbeat which can cause clots to form in the heart and travel to the brain. If you have shortness of breath or heart palpitations SEE YOUR DOCTOR!
Treat Diabetes: Over time high blood sugar damages blood vessels.
Quit Smoking: Smoking thickens blood and increases arterial plaque build up. Use patches, pills, counseling, medicine… whatever works!