Pain Management & Wheelchair Seating

Pain is extremely challenging to treat because its etiology is often difficult to determine.  Often the focus of pain treatments is medications, however therapy can have a huge impact on pain without any medications. Therapy has the tools to assess the underlying etiology of pain and can focus their interventions to mitigate or eliminate the need for medications. Wheelchair seating and positioning can have a significant impact on pain and quality outcome measures in your building, yet are often overlooked.   

While the causes of pain are many, let’s take a look at a few common causes in the SNF / PAC environment.  

Pain can be a result of insufficient lumbar support. During the mat and wheelchair evaluation it may become clear that the patient is in sacral sitting with limited lumbar lordosis. If the patient is unable to sustain pelvic neutral and an upright mid-line trunk position, then you may want to offer the patient a cushion and a lumbar support to treat the positional abnormalities and related pain.

Patients who are bottomed out on a cushion (or who do not have a cushion) can have hip and back pain. When picking a cushion you want ensure that your patient will not bottom out, particularly if seated for a prolonged period of time. Keep in mind that patients will bottom out on many general use cushions within 30 minutes of sitting time. The human body is not intended to sit for prolonged periods of time.  When a patient needs to sit due to pathology, it is important that they are supported or they will likely present with pain.

Wounds can commonly cause patients significant pain. The treating clinician will want to determine the cause of the wound and determine a cushion that treats the underlying etiology of the wound.  See Wheelchair Seating Interventions & Quality Outcome Measures: Part I, Skin Protection for further details.

Pelvic obliquities can be extremely painful for patients. If a patient has a flexible pelvis, then the obliquity can often be corrected from picking the correct cushion. If a patient is unable to verbalize the pain that they are having from sitting on their pelvis with a pelvic obliquity, then you may see the patient have increased “behaviors” as well as attempting to stand to relieve the pain.

Pelvic obliquities can also result in lateral leaning. Lateral leaning can cause pain due to increased pressure on the unilateral ischial tuberosity (skin, blood flow etc.), and due to the fact that muscles and tendons will become tight and immobile on the affected side of the lateral lean. Picking a cushion that corrects lateral leaning can significantly impact pain in your building given that lateral leaning is a common dx in the SNF setting.

Forward head posture, rounded shoulders and excessive thoracic kyphosis can be very painful and fatiguing for a patient.   Many clinicians instinctively want to treat neck and shoulders when they see a patient who is sitting in a wheelchair with forward head posture, rounded shoulders, and excessive thoracic kyphosis.   However, when the patient is wheelchair bound, it is critical to start with the pelvis.  Correcting the pelvic position in the chair will likely have significant impact on the forward head posture, rounded shoulders, and excessive thoracic kyphosis. The patient may require both pelvic correction and support as well as lumbar support. The clinician should then move up the body to address support and positioning.

A common quick intervention to prevent a patient from sacral sitting and sliding is to elevate 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.  

Insufficient foot support can result in a patient sitting with their legs dangling.  This can cause both circulation issues and pain. Ensuring that all patients feet are fully loaded (drop the seat height down or shorten the leg rests) will ensure that your patients will not have pain from insufficient foot support.

There are many causes of pain and a significant number of issues can be impacted by an effective seating and positioning intervention.

Please do not hesitate to contact The PostureWorks if you and your team are addressing pain with your clients.

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