Be systematic: Identifying postural issues
Postural information obtained from assessment includes:
1. Medical diagnosis
The level of injury indicates the style of sitting and the postural support the client may require (see Module 5 for more information). Insufficient postural support for function and balance will result in a compensatory posture. For clients with good joint flexibility it is generally possible to use a range of postural support equipment to maintain a good sitting posture, however this sometimes effects functional capability or comfort and an appropriate compromise must be determined.
Clients with an incomplete spinal cord injury may present with significant postural asymmetry.
An incomplete SCI may lead to asymmetrical movement or function, e.g. leaning over one side during manual wheelchair propulsion.
An incomplete SCI may present with uneven muscle bulk that influences sitting posture, e.g. uneven gluteal muscles may raise one side of pelvis (pelvic obliquity).
The therapist needs to understand the client’s co-morbidities, medical conditions and their effect on functional abilities and posture, e.g. rotator cuff injury, acquired brain injury, arthritis.
2. Surgical history
It is not uncommon for spinal clients to have undergone surgery which has affected their sitting posture. Take note of any surgical or orthopaedic interventions that may influence skeletal alignment, joint flexibility and body symmetry.
3. Pressure injuries: history and management
Discuss which skin areas and bony prominences were previously or are currently involved. Pay attention to orthopaedic and plastics procedures which may change the shape of the pelvis or the length of the lower limbs as these will have an effect on posture and may increase a client’s risk of pressure injury if not addressed.
Extensive bed rest for pressure injury management may reduce a client’s joint flexibility and increase postural asymmetry.
Provision of suitable postural and positioning equipment on commencement of graduated return to seating may avoid a reoccurrence of pressure injuries.
Consultations with or referrals to a Spinal Seating Service are indicated for those clients who have non-healing ‘sitting-acquired’ or related pressure injuries, or have a history of recurrent pressure injuries
When a spasm occurs, ensure that the client is safe in the seating and wheeled mobility system. If there is a history of falls due to spasm, consider also a referral to the Spinal Outpatient Clinic for medical management.
Assess if there is a specific spasm pattern that interferes with the client’s sitting posture.
- Hip extension pattern may cause the pelvis to slide forward
- Knee extension may cause feet to slide off the footplates, or
- Knee flexion pattern or hamstring activity will cause heels to move rearward into contact with the front castors, or pull the pelvis forwards, inducing posterior pelvic tilt
Assess if the client can independently restore their posture after a spasm. If not, sufficient postural interventions should be provided to maintain the client’s optimal sitting position in the wheelchair.
In consultation with the client, medical practitioner or physiotherapist, try to establish if the current posture is the cause of musculoskeletal pain. In the case of neuropathic pain, seating intervention may not reduce the severity of the pain.
Adopt a team approach to decide on the cause of the pain and an intervention strategy for common causes of musculoskeletal pain:
- Bone, joint and muscular inflammation – consider reduction of activities, load and strain in the affected area. Also consider interim power mobility or revised postural support to allow rest.
- Skeletal mechanical instability – change postural support to improve stability. Alternatively consider orthotic or surgical intervention.
- Muscle spasm – refer to previous heading ‘Spasm’.
- Upper limb overuse syndromes – customise the seating and wheelchair configuration to maximise postural stability, or ergonomics of manual propulsion. Power mobility may be an option.
The client should be made aware that postural intervention alters the sitting position. Other muscle groups may now be involved to maintain posture and balance. It may take some time for the client to become accustomed to improved posture.
A client typically leaning to one side initially may feel “crooked” when repositioned to an upright posture).
Postural change may lead to a change in pain pattern. Incremental postural intervention may be required when the desired outcome is a significant postural change.
Consider referral to a physiotherapist, doctor or pain clinic for the management of chronic pain.
6. Weight gain or loss
Weight gain or loss may require an assessment to resize or make adjustments to postural support. A review of the body measurements against the seating and wheelchair dimensions will be required.
- If the client has gained weight, they may rotate trunk or hips to fit into the existing thoracic support and seat width.
- Clients who have lost body bulk may not be adequately supported by the existing postural system to maintain optimal skeletal alignment and balance.
A client’s head and neck posture is often dictated by the need to optimise vision for safe mobility and interaction with the environment. If the body leans to one side, the neck flexes laterally in the opposite direction to hold the head level, in order to maintain visual spatial perception.
When postural intervention goals are established in MAT, the head position should be taken into account.
A client with a fixed thoracic kyphosis may develop a cervical hyperextension of the neck position to improve vision. In this situation the use of seat tilt and/or backrest recline can facilitate head positioning for better vision.
It is important to recognise that some changes in postural realignment may alter the client’s visual spatial perception and judgement. Discuss this with the client and adopt staged interventions to allow relearning and adjustment.
Visual impairment such as cataract and hemianopia may adversely affect the client’s wheelchair skills or posture. Health professionals should work as a team to identify alternatives or compensatory strategies.
8. Range of motion, joint flexibility and influence of gravity
Significant losses in muscle length and joint range of motion can have marked effects on posture, pressure and function. Refer to Module 3 for MAT assessment.
Muscle length and reduced joint flexibility can:
- Restrict the posture or positioning that the client can assume in seating, and
- Restrict functional capacity such as arm reach to control a joystick or propel a manual wheelchair.
A client’s posture should be assessed throughout the full range of chair tilt and recline to determine any situations of inadequate postural support. One of the key external factors affecting posture is gravity, which constantly acts upon the body. As the angle of seating changes in recline and tilt the effect of gravity on body parts will change and may help or hinder achievement of the postural goals. Ensure that the body, especially the head and shoulders, are appropriately supported in all angles of tilt and recline that are to be used.
9. Functional skills and dynamic sitting
Improving a client’s posture will typically lead to improved stability and control in wheeled mobility. Posture also plays an important role in a range of daily functional tasks. It is necessary to assess the client’s static and dynamic posture in four situations:
- During manual wheelchair propulsion or driving a power wheelchair
Check if the correction to posture may interfere with primary mobility or functional capacity.
A client with asymmetric upper limb strength or range of motion may lean to one side and/or rotate his pelvis in order to propel his manual wheelchair. Correcting the posture may reduce push efficiency. In this case, education in postural self-correction after propulsion, regular stretching exercise and skin checks may prevent development of fixed deformity and pressure injuries.
- Transferring and positioning
Determine if seating equipment aids or impedes transferring into and out of the chair, and initial positioning in the chair.
A fixed lateral thoracic support may impede a client’s ability to perform a slide board transfer. A swing-away lateral may be explored as a viable alternative.
- Adjustment of the body position in the chair
Check if the client is able to transfer and reposition independently, or requires assistance.
Activities throughout the day, such as driving over rough terrain, may result in the client slouching or sliding forwards on the seat. If the client has no capacity for readjusting their seating posture, postural belts or harnesses may be considered.
- Alternative postures used to engage in other functional tasks
Some other functional tasks that may require specific postures include: self-catheterisation, computer work at a desk, meal preparation and cooking, and fitting other assistive devices.
A client habitually hooks an elbow around the back post to prevent their trunk from falling forwards. This posture encourages the client to lean to one side. Over time a thoracic scoliosis and pelvic obliquity may develop unless the client is able to independently correct the posture to a neutral alignment. The introduction of a tilt-in-space system, lateral and posterior back supports for correcting this posture would require the client’s commitment to training and adjustment.
10. Seating system limitations
The presence of well scripted postural support components is not a guarantee that seating will be effective. Check that any fitted postural support components are being used correctly and are set up correctly for the client (note that they may have been altered since initial setup).
To be effective a postural support system must be:
- Properly adjusted and fitted to the client’s body size, shape and functional needs
- Properly fitted to the wheelchair, and
- Not compromised by wear or breakage.
Following postural intervention the client must retain the ability to access their environment and function as independently as possible.
- A client needs to sit in a slumped position and slide the pelvis forward to lower their overall sitting height in order to fit into a motor vehicle
- A client who leans to the side in order to operate a computer or use kitchen appliances may find the thoracic lateral support restricts their reach, or
- The client’s current hoist does not have sufficient clearance and reach to position the client’s pelvis correctly in the wheelchair.
12. Psychosocial and care issues
The client’s self-image, aesthetics and cosmetic preferences influence acceptance or rejection of postural supports.
When developing a postural support system, the client’s ability to follow instructions to achieve good posture and adjust the postural support system is critical to a good outcome. Where clients rely upon carers to assist with transfers and adjusting seating position, the expertise of the carers and adequacy of care hours will often influence the effectiveness of seating equipment. The intervention needs to be realistic and practical, and appropriately tailored to the individual and their care setting.
Providing easy to follow written equipment instructions, photos or videos to client, carers and case managers is a good way to ensure all the relevant people are clear on the correct procedures.