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Seating and positioning for disabled children and adults

Chapter 44Seating and positioning for
disabled children and adults
Jan Furumasu

Key Points
• The pelvis is key to seating and positioning.
• Points of control rely on a three-point system.
• Support is best with dispersed forces using large surface areas.
• Deformity is best accommodated rather than trying to correct.
• Support should not restrict daily activities.

People with disabilities are living longer, and their number is growing. In 2003, 34.3 million people
(12.1% of the population) in the United States (noninstitutionalized) had physical limitations in activities due
to a chronic condition. An estimated 1.6 million are wheelchair users. Baby boomers are coming of age and
are acquiring disabling conditions. By the year 2030, the number of elderly will double to 71.5 million.
Medical technology has improved the rate of survival for children and adults with disabilities and their long-
term management. Long-term debility is a major risk factor for pressure ulcers. Improvement in the survival
rate has increased the number of persons at risk for pressure sores. An estimated five million people in the
United States have chronic wounds. From 1.1 to 1.8 million people develop new ulcers each year, and the
financial cost and emotional burden are heavy. 4,49 The two groups at highest risk are the elderly and persons
with spinal cord injury (SCI).3,19 Advances in seating and mobility have made a difference in controlling
deformities, preventing pressure sores, and expanding the individual’s potential in life, ensuring participation
socially, educationally, and vocationally. Proper seating is like an external orthosis, important for support,
comfort, and pressure relief in sitting. 18 Better anatomical alignment of the pelvis and trunk enhances
physiological functions, such as swallowing and cardiopulmonary function, and affects upper extremity
function. Postural supports enhance functional movement by decreasing the influence of abnormal tone and
reflexes, thereby improving postural alignment and potential access to technologies, such as powered
mobility, communication devices, and computers (Fig. 44-1). The seating system should be as dynamic as
possible to allow for growth changes in a child or if a decline in function is anticipated. The seating system
must be user friendly for the person in the wheelchair and for the caregiver. The user, family, and caregivers
play a key role and must be interviewed extensively regarding the user’s medical and functional needs,
environmental considerations, and lifestyle issues.

Fig. 44-1 A, Young woman before evaluation of seating system. B, Same woman with seating system that provides
support and alignment, increasing functional abilities.

The best prescription involves an evaluation process by a team of professionals knowledgeable in the
medical issues. The evaluation should identify physical abilities and limitations, predict functional
capabilities, identify problems with existing seating, and set goals to match the user’s needs with the seating
technology. The end result will be the recommendation of a useful and functional system.

Evaluation process for seating and mobility systems

A seating and mobility system evaluation should address all aspects of a person’s medical and personal
lifestyle issues. The following categories should be assessed thoroughly.
Medical History: All medical diagnoses (primary and secondary) are important to identify and
document as well as whether the disability is stable, progressive, or fluctuates. Pertinent history that will have
an impact on mobility and positioning needs includes history of pressure sores, spasticity management,
medications, orthotic use, and sitting tolerance. A detailed interview regarding pressure sore development,
management, and successful treatment is important in preventing recurrence. Prior and future surgical
interventions, such as spinal fusion, muscle releases, and amputations will affect seating decisions. Prior
equipment use and identification of previous problems is helpful in justifying future seating intervention.
Physical Assessment: Physical assessment includes the person’s range of motion, skeletal alignment or
posture, motor strength or motor control of the head, trunk and extremities, sitting balance, sensation,
interfering tone, or reflexes. Is the muscle tone low or hypotonic? Does the client have hypertonicity, which
may require more aggressive seating components to control tonic movement?
Range of Motion: Range of motion of the joints and spine assesses whether postural supports can
correct or must accommodate perceived deformities. Flexibility and asymmetries of the hip and pelvis and
hamstring tightness are critical areas of assessment. Evaluating asymmetries in hip flexion, scoliosis, and
pelvic obliquities and determining whether the deformities are fixed or flexible is important to determining
successful solutions. Seating starts from the pelvis and hips, so assessment of pelvic obliquity, scoliosis, tight
hamstrings, and hip muscles is critical for ensuring proper positioning.
Reflex-Influenced Posturing: Is reflex-influenced posturing interfering with the patient’s functional
potential for maintaining the sitting position? For example, two influential primitive reflexes active in seated
posture are the tonic labyrinthine reflex, which causes extension of the head, trunk, and extremities as the
body tilts backward or reclines, and asymmetrical tonic neck reflexes, which cause rotation of head, trunk and
pelvis and potentially a windswept deformity. At times, this reflex posturing is functionally used to extend the
upper extremity in order to drive a power wheelchair or point to a communication device. Persons with
athetosis or dyskinetic-type movement disorders may use reflex posturing for stability in order to use their
extremities purposefully. The seating device may help inhibit unwanted movements and permit functional
movements.6
Muscle Strength: Evaluation of muscle strength assesses functional potential with, and the need for,
appropriate postural supports. The need for adequate support for sitting balance and pressure distribution
versus adequate freedom of movement must be balanced. Overseating can discourage functional potential. For
example, a high back on a person with functional low-level tetraplegia would eliminate his or her ability to
balance the upper body or to hook the arm over the push handle of a lower back in order to increase forward
reach with the opposite arm. Evaluating muscle strength helps determine whether posturing is compensatory
for muscle paralysis, weakness, or imbalance. Clients with Duchenne muscular dystrophy have proximal
muscle weakness and are able to increase their upper extremity reach by leaning forward and to the side.
Restricting trunk motion limits their ability to compensate for proximal weakness in order to reach with and
use the distal strength in their hands.
Evaluation of Protective Sensation: Evaluation of protective sensation and assessing for red areas or
potential pressure areas helps to determine the appropriate seating surface. History of scar tissue or previous
pressure sore intervention can predict areas of high risk. Aging affects the elasticity of the skin and increases
risk of damage from shearing, pressure, heat, and moisture.

Functional assessment
Everything the person presently can accomplish from the seating system should be addressed in the functional
component of the evaluation. This includes all areas of mobility-related activities of daily living: self-
mobility, ability to stand and ambulate, transfer, manage the bladder, and drive a vehicle. New seating and
mobility systems should not interfere with any previously independent abilities. For example, some persons
with tetraplegia need to open the seat to back angle by reclining the back of the wheelchair in order to empty
their bladder. Replacing the power back recline with a tilt-in-space system may affect bladder function by not
allowing the person to empty the bladder as previously accomplished. Swingaway trunk supports allow trunk
movement but lock in for stability when needed. Environmental accessibility, including school or work sites,
and the person’s recreational activities must be explored.
 Transportation: Issues related to safe transportation of the person as a driver or passenger include
tiedown (securing the wheelchair in a vehicle while the person is seated in it), wheelchair seat height,
breakdown of the wheelchair for loading into a car, or overall length of the mobility base on van lifts.
Cognitive Status/Behavioral Assessment: Cognitive status/behavioral assessment includes memory
skills, problem-solving abilities, ability to comprehend, concrete versus abstract reasoning, destructive
behavior, motivation, and safety judgment. For example, clients who are agitated or have destructive
tendencies require seating that is protective and durable so that body parts are not accidentally injured against
hardware.
Visual/Perceptual Ability: Individuals who cannot separate head movement from eye movement can
compensate for visual field cuts by head posturing or trunk movement. Compromises in seating supports are
necessary to compensate for visual impairments. The position of the head and upper body in space affects
visual field.
Other considerations include cosmesis, financial constraints, caregiver management, and changes that
may occur due to physical, cognitive, or medical reasons.
The outcome of evaluation of a person’s seating needs focuses on one of three areas in a framework for
seating and positioning decision making categorized by Cook and Hussey 9: technologies for postural control
(typically for the child or client with cerebral palsy), technologies for pressure control, for those at high risk
(e.g., population with SCI), or technologies for comfort (for the elderly or patient with amyotrophic lateral
sclerosis).

Seating alignment

Ideal sitting alignment is different for an able-bodied person than for a disabled person, and depends on the
individual’s abilities. Sitting is dynamic; it is a continuous process of postural changes whether the position is
task oriented or one of rest. For the able-bodied person, a sitting posture with an anterior pelvic tilt and
decreased lumbar flexion is the most favorable posture. 17,18,40 Generally three postures of sitting alignment
are assumed (Fig. 44-2). Ideally, an upright, symmetrically balanced trunk over a stable pelvis allows better
upper extremity reach, head control, and visual field. However, in the sitting position, the pelvis tends to roll
back into a posterior tilt because the hips are flexed and the hamstrings pull the pelvis back; the tilt is
accentuated when the knees are extended. 50 The line of gravity is posterior to the ischial tuberosities. This
posture is adopted as a position of rest by an able-bodied person and as a position of stability by a wheelchair
user with tetraplegia. The second sitting position is achieved by activating the back extensors to tilt the pelvis
anteriorly into lumbar lordosis. As the pelvis rolls anteriorly, the line of gravity falls directly through the
ischial tuberosities.15 This posture usually is assumed by a person with muscular disease as it is functionally
advantageous because of weakness that is greater proximally than distally. 16 The third seated posture is a
forward sitting posture that has been described by Kangas 25 and Adrian and Cooper1 as a functional task
position or position of readiness. In this position, the trunk is forward and the line of gravity shifts toward the
direction of activity. The trunk flexes forward in a position of anticipation. The arms and trunk are naturally
brought forward into the visual field, and the feet are shifted backward behind the knees and bear more
weight.

Fig. 44-2 Three dynamic postures of sitting: upright with slight anterior pelvis, posterior pelvis, and forward trunk or
position of readiness.

Outcome studies of seating and positioning for function

A number of studies reported on how seating affects functional activities, upper extremity function, head
control, and visual field.24,33,36 The components of a seating system can provide support to align the body,
normalize tone, prevent deformities, and clearly influence upper extremity movement. In one study, the sitting
surface was explored to better determine the capacity to maintain balance and posture as a prerequisite for
activities of daily living. The center of pressure of reaching was determined to be significantly greater on a
generically contoured sitting surface than on a flat foam surface or a 3-inch Roho seat cushion. 2 The effect of
different backrest heights and types of cushions were investigated in the SCI population to determine the
relationship between posture and upper extremity reaching. The posture adopted by the user and the American
Spinal Injury Association (ASIA) score were significant, and no evidence indicated that the type of cushion or
back height affected reach.48
Improvements in autonomic functioning, including respiratory, oral intake and digestion in children
with cerebral palsy was found following adjustments in seating systems with improvement of the trunk, neck
and head alignment.7 Hulme23 found positive perceived changes in social interaction, positioning, tracking,
grasping, and self-feeding skills. Nwaobi 37 found that the vital capacity in children with cerebral palsy
improved with positioning in a seating system versus a sling type wheelchair. Improvements in speech
intelligibility were documented in children with cerebral palsy using adapted seating versus without. 34
Reports on the effects of seating on upper extremity function are conflicting. In a 1986 study of children
with cerebral palsy, different amounts of hip flexion were found to affect upper extremity function. 36 Another
study found that children with cerebral palsy were able to activate and release a switch the fastest when they
were in an anterior 15-degree tilt or in the position of readiness versus 0, 15, or 30 degrees of tilt
back.35 However, McPherson et al.31 found no significant differences in the quality of upper extremity
movement in subjects with cerebral palsy in four different positions. Seeger et al. 45 also did not find any
improvement (Fig. 44-3).

Fig. 44-3 Outcomes of studies of seating and positioning.

Seating assessment

Hands-on evaluation should be performed with the person either sitting or supine on the mat. Critical
assessment of whether deformities are dynamic or fixed is more accurate when the patient is supine.
Depending on the person’s disability, a mat assessment is not always mandatory. The three main
determinations of the hands-on evaluation are as follows:
1. Person’s ability to sit
2. Pattern of deformity while the patient is in the sitting position
3. Deformity is fixed or flexible

Classifications and description of sitting ability

The ability to sit independently is one factor that determines the type or amount of seating support needed.
Hoffer21 classified a person’s ability to sit according to the amount of trunk control present. His
classifications were modified by Tredwell and Roxborough in 1991 to include generalizations regarding the
type of seating needed (Fig 44-4):

Fig. 44-4 Classification of sitting ability grouped according to the amount of trunk control present and the amount of
support needed in a seating system.

Hands-Free Sitting Ability: Maintains independent sitting for long periods without using hands for
support. Demonstrates good trunk balance and the ability to weight shift. In general, a person needs a simple
seating system designed primarily for pelvic stability, comfort, and mobility (e.g., person with paraplegia).
Hand-Dependent Sitting Ability: Requires either one or both hands for support. Trunk control and
balance are generally poor. Trunk supports are needed to allow use of hands for functional activities.
Providing a more stable base of pelvic support may change a hand-dependent sitter to a hand-free sitter.
Propped Sitting Ability: Because of severe physical involvement or structural deformity, the person is
unable to sit without total body support. Trunk and head control are very limited. Total support of the trunk,
head, and extremities is needed, as for a person who demonstrates total body involvement with cerebral palsy,
has a severe muscle disease, or has a high-level tetraplegia.

Patterns of deformity
The position of the pelvis influences the alignment of the trunk and therefore of the shoulders, upper
extremities, and head. The three common patterns of postural malalignment are as follows 28:
Symmetrically Slouched: This position begins with a posterior pelvic tilt. The trunk collapses into a C
curve, and the shoulders are protracted with the head forward. The most common cause of a posterior pelvic
tilt in persons with cerebral palsy is hamstring hypertonicity. For persons with tetraplegia, the symmetrically
slouched position can be a position of stability in which they are able to raise their arms for balance and
functional activities28.
Lordotic Posture: This posture begins with an anterior pelvic tilt. The pelvic tilt locks the lumbar facets
into extension, mechanically providing spinal stability. Hyperlordosis typically is observed in patients with
Duchenne muscular dystrophy prior to spine fusion because of proximal weakness and an imbalance in
strength between the abdominals and back extensors.
Asymmetrical or Windswept Posture: This posture is one of the most difficult deformities to control and
to treat. The windswept deformity is described as being windswept to the left if the left thigh is abducted and
the right thigh is adducted. It is associated with a triad of deformities: dislocated or subluxed hip usually on
the adducted side, pelvic obliquity, and scoliosis. A dislocated hip may be painful, severe scoliosis may
compromise cardiopulmonary function, and the increase in pelvic obliquity increases the risk for pressure
sores.12,41 The person may try to offload the painful hip, which worsens the position and pressure
distribution.
The relationship among windswept hips, pelvic obliquity/hip dislocation, and scoliosis was first
described by Letts in 1984 in children with cerebral palsy. “Acquired and preventable Special Seating
will NOT prevent a contracted hip from dislocating.” However, Letts did advocate abduction of the lower
extremities to 25 degrees and not just neutral to decrease abnormal muscle activity. 27 Increased abduction
also results in good approximation of the head of the femur into the acetabulum, which promotes bony joint
development in children. Therefore, flexion and abduction of the hip are recommended to prevent extensor
and adductor posturing in children with cerebral palsy who are at risk for development of the windblown
syndrome. Without adequate fixation of the pelvis, however, this position may be difficult to obtain.
High complication rates have been documented in patients with severe neuromuscular scoliosis: 81% by
Loinstein30 in 1984 and 48% by Boachi8 in 1989. They believed that the high risk of surgery outweighs the
benefits, so comfortable seating is the treatment of choice. Table 44-1 lists possible causes and equipment
solutions for postural alignment problems.
Table 44-1 Causes and equipment for patterns of deformities

Problem Cause Equipment Solutions

Slouched posture
   

Posterior pelvic tilt Sling upholstery Three-point control: solid seat, firm
back, and pelvic/hip seat belt
    Rigid anterior pelvic support: subasis
bar, knee blocks

  Inappropriate seat Measure from PSIS to popliteal,

depth include fixed kyphosis

Hip/knee extension Extensor tone (hip and Antithrust seat

knee)

    Increase hip angle >90 degrees

    Increase knee angle >90 degrees (foot

placement behind knee)

  Hip extension Accommodate seat cushion to

contracture unilateral contracture

Thoracic kyphosis Trunk Unilateral split seat or leg trough, to

weakness/paralysis maintain trunk upright

  Fixed deformity Recline back, tilt back in spine

    Lower back height, accommodate in

back cushion
Shoulder protraction Spasticity/weakness Firm back with lumbar/thoracic
extension

  Back height too high Appropriate back height

    Accommodate with molded back

    Shoulder straps pulling up and back

Forward head Weakness Occipital support with capital

posture extension

  Spasticity Head band (stationary or dynamic)

attached to head rest

  Reflex posturing if too Recline back or tilt back to seat angle

reclined

Rotational/oblique
posture
   

Pelvic Sling seat Firm seat

obliquity/pelvic
rotation
  Scoliosis Lateral hip guides

  Hip dislocation Flexible: build up under low side for

even pressure

  Asymmetrical hip Fixed: build up under high side,

ROM relieve pressure under low side

    Custom-molded seat

    Off-set cut-out in cushion

    Accommodate seat depth for leg

length discrepancy

    Anterior pelvic belt

    Two-piece sub-ASIS bar

Hip problems Sling seat Firm seat with medial thigh support

Hip adducted— Adductor tone Medical thigh support

internal rotation
Hip abduction— Hypotonia Lateral thigh/knee stabilizers
external rotation

  Fixed deformity Accommodate

Windswept hips Pelvic rotation Three-point control: hip guides,

medial, and lateral thigh support

Adducted thigh with Dislocated hip Build up for lack of thigh support
abducted thigh

  Scoliosis Custom-molded seat

Thoracic scoliosis Pelvic obliquity and Three-point control: pelvic/trunk

rotation supports

Flexible Weakness Deep contoured back or trunk

supports

  Spasticity Rotational deformity: curved supports

Fixed Asymmetric Custom-molded back or adjustable-

tone/muscle strength tension back upholstery to
accommodate to rib hump deformity
Asymmetric head Scoliosis Appropriate support of pelvis, trunk,
posture and shoulder girdle

  Fluctuating tone  

  Reflex posturing Head and neck support. Support of

occiput to mastoid process or over the
ear to the temple for lateral control

  Weakness  

  Visual compensation Stationary or dynamic headband

Lordotic posture
   

Anterior pelvic tilt Muscle imbalance Placement of belt across ASIS

Hip flexion Abdominal weakness Wedge seat/cushion to accommodate

if fixed

Thoracic lordosis Contractures Tilt in space manual or power frame,

adjustable seat angle

    Anterior chest support: molded chest

 plate, wide Velcro strap

Retracted shoulders Spasticity Appropriate pelvic/trunk positioning

with chest support

  Posturing for trunk Shoulder wedges

weakness

Extended head Spasticity Neck ring

posture

  Weakness Occipital support