Seating and positioning interventions can have a significant impact on falls and quality outcome measures in your building.
[Part III of a Series of IV]
Many patients in a sling seat wheelchair will present with IR and Add of their hips. They are often in sacral sitting and sliding and at high risk for falls. As a result, many become “frequent flyers” in therapy for falls or positioning. No one wants to be on this painful ride: the patients are fearful of it, and the clinicians are frustrated by it.
To mitigate fall risk, observe how your patient presents on their wheelchair. A patient who presents with IR, Add of the hips, and a posterior pelvic tilt is likely sitting on a sling seat wheelchair that is hammocked. Once the patient’s pelvis is in a posterior pelvic tilt, the patient will end up with decreased lumbar lordosis and increased thoracic kyphosis. There will be bilateral rounding of the shoulders and forward head posture. The impact on ADLs is a topic for another day. The impact on falls is clear- the patient is destined to slide out, almost like a slip and slide- and the patient’s quality of life is glaring to any clinician. As a result, the correct intervention has an immense impact on the patient, and the “quick” fix is almost never the correct answer for the patient!
Common “quick” fixes to sacral sitting and sliding include elevating the leg rests. This can be painful for a patient who may not have the hamstring length to allow for this elevation. Rather than elevating the leg rests, the clinician should start by determining the etiology of the sacral sitting and sliding and provide an intervention to address this. If hamstring length is a concern then an intervention should be put in place to lengthen the hamstrings.
Another common quick “fix” for sacral sitting and sliding is to add a lap belt, tray, Dycem, or pommel cushion. Lap belts and trays are often uncomfortable and can increase the risk of falls, decrease the ability to perform functional tasks, and be considered a restraint. Dycem placed over a cushion can negatively impact pressure management and skin protection, and will likely not prevent sliding – in fact shearing could be an unintended consequence for fragile skin. Pommel cushions can cause pain by “holding” a patient in their chair by their genitalia, which is an extremely sensitive area for a point of high pressure. This type of intervention can impact skin, pain and may increase risk of UTIs.
Yet another common quick fix for sacral sitting and sliding is to “dump” the wheelchair by elevating the front of the chair and decreasing the height in the back. While “dumping” can decrease sliding, it will also create excessive amounts of pressure over the ischial turberosities. If the patient is unable to perform independent pressure relief, then the patient may be in pain due to poor circulation under the areas of high pressure. As such, consider picking a cushion that has an anterior rise with a pelvic well that will create this “wedge” effect without the high pressure over the ITs. “Dumping” back and forth can also put a patient at risk for shear, alter a patient’s line of vision, and interfere with their ability to perform ADLs which unintentionally diminishes their quality of life.
If a patient is not cognitively intact or verbal, clinicians need to be vigilant of behavior that leads to falls. For example, patients often try to stand up secondary to pain from a wound or a pelvic obliquity; some will stand because they are sitting on a cushion that doesn’t provide enough support and the patient is bottomed out; some will stand in an attempt to self-mobilize, or will stand in an attempt to get to a bathroom.
Providing an intervention to address the biomechanical etiology of sacral sitting and sliding, rather than treating the symptoms, is the key to preventing falls from the wheelchair. Common reasons for sacral sitting and sliding can be due to wounds, extensor/flaccid tone, and pain that is exacerbated by the use of a hammocked sling seat. Getting a patient back to pelvic neutral is the key to stability and safety.
Some products that can support patients getting back to a pelvic neutral position to prevent sacral sitting/sliding and falls include Engage APOD cushions, Position Pro Insert used in conjunction with the Silver Care Basic or Matrix medium profile cushion, and the Space Saver Back Support.
Seating and positioning is half science and half art. As always, please contact The PostureWorks if we can help support improved clinical outcomes through seating and positioning.
