Postural Management

Introduction

When prescribing a riser recliner chair or a specialist seating system, the aim is to achieve a well-supported upright position, so the user can sit in a chair comfortably and function. This can be greatly affected by the size of a chair. Just by having the correct seat height, depth and width, we can often accommodate a user’s posture and enable them to maintain a good position in the chair. Due to various medical conditions it may not be possible for the user to maintain an upright position and there may be several postural limitations which require additional support. Without adequate support, the user’s ability is limited to maintain an optimum postural position. This impacts on function, respiration, digestion and pressure distribution, and can lead to further postural deformities.

When assessing a user who presents with poor posture, we need to understand the cause of the user’s position in their chair. Is their poor posture as a result of:

  • Unaccommodated and unsupported postural deformities
  • Poor transfer method
  • Pain and discomfort
  • Incorrect size chair
  • Personal choice
  • Other

A full assessment is required:

  • Baseline assessment of current seating and issues with this
  • Functional needs of the user (what do they need to do when sitting in the chair)
  • Transfer methods
  • Physical assessment (position of body segments and range of movement) and postural limitations – what is fixed and what is correctable (i.e. what needs to be accommodated and what needs to be supported)
  • Sensory and pressure requirements
  • Cognitive impairment

Baseline assessment

It is important to know what seating is currently being used and what the issues are with this i.e. why are you considering changing this? It is important to know what the user likes about this chair and what works well for them. These features will be important to include with new seating.

Most often comfort or being uncomfortable can be indicated here. This can be very subjective and so it is important to gauge pain and discomfort with the seating in context, over a 24 hour period. Are the pain and discomfort only present in the chair, or is there also an issue perhaps with the bed, a shower chair or wheelchair etc? Does the pain or discomfort subside when they have got out of the chair? It is important to also understand any underlying conditions and health needs which should be considered in context with seating.

Functional needs of the user

It is important to understand what the user wants to use the chair for. What functional tasks and activities do they want to complete when sitting in the chair. If your intervention results in a perfect posture, but the user cannot carry out the activities they want to when sitting in the chair, they are unlikely to use it; the optimum postural position has therefore not been achieved. Being comfortable can be considered as a function.

How a person transfers in the chair is key to how they will end up being positioned in it. The type of equipment used and how this needs to be used is important to understand. The range of Configura chairs has been designed to work with different types of transfer aids including stand aid, mobile hoists and ceiling track hoists, for example.

Whichever method the user adopts for transfers, it needs to result in them being positioned with their buttocks to the back of the chair and centrally within the seat of the chair. If this cannot be achieved with the current size of chair or transfer methods, further assessment of these is required. If the person sits too far forward in the seat, they will not be adequately supported. It will increase the risk of uneven loading, with increased pressure on the ischial tuberosities and possibly sacrum. The risk of sliding down in the chair and shear is increased and the person will likely require to be repositioned frequently.

 

It is important to understand how the body segments (legs in relation to pelvis, pelvis, spine, shoulders and head) are stacked in relation to each other when seated and in lying. This is to establish what asymmetry is being caused by the seating and what is fixed. Asymmetrical alignment of body segments can lead to uneven loading, postural deformity and increased risk of pain, discomfort and pressure damage.

The pelvis is often described as the keystone when considering posture. The pelvis gives a sound base for the other body segments to be stacked onto. If the pelvis is not level or symmetrical, the remaining body segments are unlikely to be either.

The range of movement of the lower limbs in relation to the pelvis is important to determine. For example, if it is not possible for the user to flex their hips to 90° in relation to their pelvis, they will not be able to sit in a chair which is set up with the back rest at 90° to the seat. If the hips only flex to 70° and the person has to sit in a chair set up for 90°, then they are going to have to move their posture in the chair to accommodate for the lack of hip flexion – this may be sitting with their buttocks forward on the seat.

 

If someone has reduced sensation, they are more at risk of developing pressure ulcers, as they do not have the feedback to initiate movement to relieve the pressure. A user may also have additional sensory needs. This may mean they need close fitting support to help them feel secure in the chair, or it may mean the opposite. It is important to understand how the seating used will be accepted from a sensory perspective by the user.

See also section on pressure ulcer prevention and management.

It is important to understand the level of capacity the user has in terms of their ability to understand the issues relating to their seating and the rationale behind changes to the seating. This is key to the acceptance and correct usage of the seating products. Changing the chair may lead to several other changes to the user’s routine, such as transfer processes and methods, the environment the chair is to be positioned in and number of carers needed to assist them.

The Configura Lite 2, Comfort and Bariatric chairs have a tilt in space (TIS) mechanism and the Configura Care, Porter and Advance chairs have a true tilt in space mechanism. Tilt in space is a feature which can enable a user to sit in a more upright position against gravity. If they tend to slide down in the chair, slump to one side or fall forwards, it may be because they lack the muscle activity in their core to enable them to sit up against gravitational forces. By tilting in space, the effects of gravity are offloaded to enable the user to gain full support from the seat, back and head support in the chair.

 

The Configura range of chairs has different backrest support options, which can mostly be interchanged between all chairs:

The waterfall backrest can accommodate a number of postural needs, such as a kyphosis or scoliosis, by repositioning the cushions or removing or adjusting some of the stuffing within the cushions e.g. the stuffing can be moved to one side to provide additional support, or removed to enable a user to sink deeper into the back of the chair. Additional lateral support can be added using wedges, as required.

The CocoonTM backrest cushion replaces the lower two cushions of the waterfall back. It is split into multiple sections to enable more finite adjustment to support and accommodate the spinal position.

The lateral support backrest gives additional support around the pelvis to provide stability. By providing the pelvis with support and stability, a user may be able to obtain and maintain a more symmetrical  position

The adjustable lateral support backrest works in conjunction with the lateral wedges. The wedges can be used to manage a user’s posture. They can be fitted to provide support where the user requires it most. The flexibility of this adjustable lateral support backrest means the support can be provided exactly where it is required. This in conjunction with the TIS mechanism, can make a significant difference to maintaining a user’s posture.

For a full video on how to assess posture and achieve an optimum postural position, please email info@accora.care or contact us to book a seating assessment.