When a patient performs functional tasks from a wheelchair, the environment in which they are seated needs to promote function.  The right seating and positioning interventions can have a significant positive impact on ADLs.

Part IV of a Series of IV]

Over the past 3 months we have discussed wheelchair seating and positioning and its impact on Quality Measures of wounds, falls & restraints, and pain. This month we are focusing on function, which is often overlooked when thinking about seating and positioning.

When a patient has a change in ADL status, therapists typically look at strength, range of motion and balance in relation to the patient’s ability to perform functional tasks like ADLs. A less obvious but equally important area that needs to be assessed and addressed is seating and positioning.  For patients performing their ADLs from a wheelchair, proper positioning promotes function and allows therapy to work on goals that they may not have been able to address otherwise.

There are many obvious detriments to ADLs that can arise from poor seating and positioning; the patient’s position in relation to their environment is a great place to start.  For example, when a patient pulls up to a table to eat, notice where their body is in relation to the table.  Are they able to sit with their legs under the table or are the wheelchair/geri-chair leg rests preventing proximity to the table?  Notice the height of the patient in the super-hemi wheelchair – are their utensils and plate now just inches from their face?  We have all seen patients placed in this position – it is difficult to eat, and undignified.

Another obvious example is taking a patient out of sacral sitting and sliding.  Getting the patient into pelvic neutral decreases forward head posture, rounded shoulders and kyphotic thoracic spine positioning which enables them to swallow without fear of aspiration.

Less obvious examples would be a seat that is too deep and makes it difficult to scoot forward in their wheelchair, or arm rests that are too high/low which promotes pain (impacting ADLs), and causes abnormal posture like elevated shoulders.

If your patient is laterally leaning, then self-feeding/grooming becomes incredibly difficult, often resulting in food/toothpaste all over the floor and a frustrated individual.   Upset families inevitably request a CNA to help their loved one with their ADLs.  This is not the best clinical outcome:  patient independence and function is lost, and nursing cost is increased.

Proactive, routine seating & positioning clinics are integral to improving and preserving our patient’s ADLs, versus the typical screen and referral after an issue is identified.  This assessment includes not only standard positioning, but also a proactive approach to improve function and include ADLs in their plan of care. For example, if a patient is on a modified diet, this may be an opportunity for a diet upgrade via corrective positioning.

R&D and theory regarding wheelchair positioning is advancing as our population ages; the importance to quality of care – and quality of life – are widely recognized.  For example, the 90/90/90 approach to seating and positioning is no longer taught because it is unnatural and uncomfortable for anyone to sit in this position all day.  Current practice places emphasis on function and the patient’s specific needs rather than making patients fit into a cookie cutter idea of proper positioning.  Seating and positioning interventions and utilization are not only a common metric to track for internal clinical outcomes, but also feed into other external measurements such as 5 Star Ratings.

Ultimately, what drives most therapists is the ability to help a patient achieve their highest level of function. If the patient is performing their functional tasks from a seated position, then the environment in which they are seated needs to promote function.  If you are assessing a patient for ADL change then you should be assessing seating and positioning. Likewise, if you are assessing seating and positioning you should be assessing the patient for changes in ADLs.

Please contact The PostureWorks if we can help support improved clinical outcomes through seating and positioning.