During a recent interview with Seating Matters, I was asked what my advice would be for a clinician seeking seating solutions, and what makes the supine assessment so important.
It’s no secret that I am a strong advocate for the hands-on supine assessment.
Truly, I do not feel like I can do my job without completing that component. My advice and opinions on this topic have been sought out numerous times over the years, and each time I discuss this topic I feel even more strongly about the importance of the supine assessment as a key step in the overall seating assessment.
There is an overwhelming tendency in the world to go straight to technology to address a perceived problem. For example, we might see an individual sliding out of their seat frequently and therefore needing frequent repositioning. Common ‘Solutions’ or in my terms, ‘band-aids’, may be the addition of any of the following: pelvic positioning straps, a seat slope where the front overall seat to floor height is higher than the rear overall seat to floor height, a rearward tilt mechanism, a seat cushion with a deeper pelvic loading area in the rear, medial thigh supports/pommels, trays, or non slip fabric to name a few.
I believe we should not even think about solutions until we evaluate the individual and understand the cause of the symptom which in this example is ‘sliding’. For me, sliding is always a symptom of something else. We need to get to the bottom of the “why” - why is this person sliding?
A thorough wheelchair/seating assessment must consider a person’s body structures and functions with the end goal aimed towards improving the individuals ability to perform activities and increase or maintain levels of participation.
Once we know the why - the solution options in terms of body alignment strategies become very visible. The only way I can be sure I get all the answers to the WHY is by doing a full hands on assessment in supine and sitting.
If I only have 5 minutes in supine, I will focus on comparing the person’s life box between sitting and supine and the impact of hip mobility and hamstrings on the pelvis/trunk relationship.
It is my experience that this is almost impossible to assess if we were to look at the individual in sitting only.
When looking at body structures and functions related to the seated posture, the pelvis is our base of support and also the link between the upper and lower parts of the kinetic chain. Limitations in body structure of the trunk and lower extremities often have a direct consequence on the pelvic position in sitting, and the relationship between the pelvis and lower extremities can have a direct impact all the way up to the head and upper extremities.
While teaching and training with clinicians around the globe, many are honest in sharing that they do not always include a hands-on supine assessment in their clinical decision making process regarding seating interventions.
Some of the common reasons for not completing the hands-on supine assessment that have been shared with me include:
Varying experience levels
Many clinicians who are newer to the world of seating or who did not receive previous training on the hands-on assessment may lack confidence with finding anatomical landmarks, accurately documenting measurements, or communicating the purpose of each step in the process.
Fear of increased paperwork
While we all know that documentation is important, sometimes it can become overwhelming. Some clinicians have shared that they do not have the time or capacity to complete more documentation than they already have. Additionally, the lack of standardised assessment forms and processes can lead to uncertainty about what we should be documenting as well as how to interpret our findings accurately in our documentation.
Limited time for an assessment
There seems to be less and less time available during the day in clinical practice, and often we feel rushed on time. This leads to the need for clinicians to prioritize assessment procedures that will yield the greatest amount of meaningful information in the quickest amount of time. As many clinicians have not been trained in how to conduct the supine assessment, or how to interpret the findings, they may not see the value in spending time on performing it.
Lack of understanding of complex rehab technology
Working with individuals who have complex seating configurations and significant body shape distortion can be intimidating and challenging. Some clinicians may do what they can to align the shoulders, head and legs without fully understanding or appreciating the impact of body structure limitations, and without the knowledge of different seating systems that are available to meet a variety of needs.
Limited training provided in University OT and PT programs and consequential fear of failure
We made a blog post about the rules many of us learned in university (click here to read about why we should ditch the rules!). Education in universities and many continuing education courses are out of date and often do not provide the hours of skilled training necessary for clinicians to feel confident in the entire assessment process. When we don’t feel confident doing something, chances are we are not going to do it, especially when working with new clients.
No place to do the supine assessment especially when assessments are being conducted in the community
Set-up is important for accurate measurements, and often times lack of equipment or space is an issue. Bringing a plinth/mat table from house to house may be an option, however we all know that many do not have adequate space in their home to set one up, especially if the person will require a hoist or needs a hi-low table to effectively transfer. And if you’ve ever tried this with an individual on the floor or on their bed, you probably know how difficult it can be to palpate what we need to feel and measure what needs to be measured to make it a valuable use of everyone’s time.
The idea that a seating assessment should be done in seating
When we are sitting, the surfaces we are sitting on are acting as external forces against our body. When we combine the external forces of the seating system with the force of gravity, any structural limitations in our body will cause compensatory postural deviations and we will have an incredibly difficulty time assessing which part of the kinetic chain is the cause, and which are the presenting symptoms. The supine position allows us to see and palpate the body without the external forces acting on it, and with gravity acting more in our favor.
From my years of analysing the posture of those who function from a seated position, I believe that every person who needs postural support and skin protection in sitting has the right to a full hands-on assessment which includes analysis in sitting and in supine. Clinicians need to do a supine and a sitting assessment if we are to truly understand the causes behind the presenting symptoms in the persons existing seating system.
In the absence of doing this we are very likely to miss some potentially critical information and won’t have what we need to determine the key features of a seat cushion or back support needed by that individual.
This will likely result in the selection of ‘band-aids’ for the presenting symptoms in place of ‘solutions’ for the true causes. Sustainable outcomes can only happen when we put the work into the assessment.
This chart highlights the key areas of our seating assessment. You will note that step 4 is all about the supine assessment. I always try to do this on a firm flat surface and where this is not available perhaps in a community setting, I bring my own portable massage table. Where there is a will there is a way! This could be done with the person in supine on their bed, however it can be challenging due to the squishiness of the mattress which is why I prefer a firm flat surface.
An overview of our seating assessment
Take a look at our hands-on postural assessment forms to see how we structure the hands-on part of the seating assessment!
We would love to hear about your experience with doing wheelchair and seating assessments - Do you perform a supine assessment? Do you find it to be a beneficial part of your overall assessment? Is there any information you feel you cannot gather from only looking at the person in sitting? What assessment forms or documentations tools do you use?
Leave a comment below!