It’s been a while since our last blog. Between courses and mentorships and returning to clinical practice, it’s been a busy few months. I even managed to get away for a holiday - and now am feeling refreshed and ready to get back to sharing my passion with you all!
Something I’ve really loved experiencing over the last year has been working with clinicians as part of our clinical mentorship programme. I have been in awe of how some of these clinicians have opened themselves up once a safe space was provided - they share their fears, successes, hesitations and triumphs. Many of us have felt what might be called imposter syndrome, but not all of us have had a chance to talk about it, or better yet, to be reassured and to address it.
One of the reasons this mentorship is so important to me is because 24 hour postural care is somewhat of a puzzle.
We need to make sure we have all the pieces and know where they go in order to put them together. Gathering the information is like conducting a hands-on assessment, whereas putting the pieces together - visualising the final outcome - is more like translating the findings from the assessment, to give those findings meaning. Just like in clinical practice, the pieces of the puzzle are useless without being able to put them together.
What makes this puzzle unique is that the pieces fit together to create many different pictures, and it’s up to us (the client centred team) to decide which picture best represents what is best for each individual we work with. We often talk about these different pictures as Option A, B, & C.
Throughout these mentorships and on line live question and answer sessions, several clinicians have shared that they feel more confident in their assessment skills (after putting in a LOT of work developing their hands-on skills), but can often lack the confidence in how to translate their assessment findings into meaningful and sustainable solutions. In other words, they feel like they finally have all the pieces to the puzzle, but may have no real concept of how they fit together.
In all fairness, there is a lot to consider here!
In previous blogs, we’ve discussed assessing the life box, the sitting footprint, and the importance of the hands-on supine assessment. Once we have our clinical findings, the next step is to understand how that information will be translated into an optimal sitting position with respect to an individual’s body shape and structure, pressure care, function and participation needs (rather than following a set of arbitrary rules!)
The goal of this step is to identify key features or parameters of the seating system (such as the seat cushion and back support) that are necessary for allowing a person to sit with their body respected - the goal is not to identify specific products at first.
Let’s take a look at what this means:
Let’s say we have a client with a custom moulded seating system who presents in sitting with a pelvic rotation and obliquity and appears to have scoliotic curvature of his spine. We conduct a full 24-hour postural care assessment. Clinical findings include:
50 degrees true hip flexion on this person’s right side (130 degree pelvic-thigh angle)
70 degrees true hip flexion on his left side (110 degree pelvic-thigh angle)
After we reach both of these hip flexion angles with one hand behind the sacrum, we palpate migration of the pelvis and observe the tendency for the pelvic/rib relationship to change (Learn more about The life Box here).
Obviously we would have other pieces of the puzzle to work with - there would be many other findings based on our comprehensive hands-on assessment (check out our assessment forms here). But lets focus on these findings for now to keep this example simple and to translate them to sitting alignment options. As always, we have choices when it comes to this - these puzzle pieces fit together to create five potential pictures that we must chose from.
When we consider how these two key findings translate to clinical features, we come up with the following:
Option A: Respect the body structure limitations by opening up the Seat to Back angle through the back support primarily to accommodate the human angles and therefore maintain an open relationship between the lower ribs and pelvis.
Pros: May facilitate digestion and respiratory function as best as possible.
Cons: Function and accessibility due to the visual field alignment and equipment dimensions (we would need an open seat to back angle PLUS tilt in space along with the seating to accommodate the difference in bilateral ranges plus match the human shape)
Option B: Maintain as upright an alignment as possible for function while still respecting the human angles. Therefore, we would accommodate the hip angles through the customised seat as much as is possible. The Ischial tuberosities would be supported level (we know this is possible as it was evident during our assessment that the presenting pelvic obliquity, pelvic rotation and compensating scoliosis were symptoms caused by the asymmetrical hip limitations) The hip angles would be respected through the customised seat/ posterior thigh and foot supports (imagine sitting on a saddle with shaping of the seat all the way to the back of the knees while the hips are in their respected angles relative to the pelvis) as well as ensuring the posterior pelvis/lumbar/thoracic areas are optimally supported. The lower rib/pelvis alignment (the life box) is open - more rectangular.
Pros: May optimise respiratory and digestive functions as well as head alignment, upper extremity alignment and visual field
Cons: Overall height from the floor at which this person is now sitting, which would be approximately 4 inches (10.2 cms) higher under the ITs than at the posterior distal thigh due to the 50 degree available hip flexion on the right. This in turn likely makes this option a no-go due to the compromise to transfers and transportation and maybe even the individuals lack of desire to sit with their knees and feet at different levels. Remember also that very few manufacturers /seating specialists can make a custom seat as described.
Option C: A combination of both opening the back angle by 20 degrees (Left hip is now happy as it has 70 degrees of true flexion) and managing the remainder of the limitation 20 degrees (right hip can only flex to 50 degrees) though the seat support by maintaining a level pelvis and dropping the right leg from the trochanter forward to achieve a happy right hip.
The Pros for this option are the same as above as the life box will be optimised.
Cons: This setup will also require some tilt to overcome the open seat to back angle, so visual field and function may be still compromised even if a better option for this individual
Option D: No change to the current seating system set up. This means that the life box will remain compromised as he will continue to sit with a pelvic obliquity and rotation. Maybe modifications such as straps or padding are added to address sliding, lateral collapse or pressure areas.
Pros: The client is familiar with navigating the world in this setup
Cons: Physiological compromise and risk of further deterioration.
Option E: Medical/surgical review to explore the possibilities for an increase in hip mobility which is essential for successful sustainable sitting. This may or may not be a desire for the individual or their care team for various reasons.
In all of these options: the facts remain that the human angles are NOT enough for effective and safe sitting so in all likelihood compromises have to be made.
It may well be that Function and Participation trumps all.
The individual and their care team may opt to be OK with a seating system in the wheelchair that actually gives them a pelvic obliquity, scoliosis and posterior pelvic tilt with a triangular life box alignment, if this is how they function best day to day. This would/should be documented in exactly this way as these are the facts.
My recommendation in this case would be to facilitate optimal function with one seating system and to prescribe an alternative seat for times when transportation and ‘upright’ functional sitting is not the top priority. In this alternative seated alignment the goal would be to respect the hip limitations and preserve respiratory, skin, and GI functions - because in my opinion, those are necessary functions for LIFE.
If this person can be transferred from their wheelchair on a regular basis or for an extended period of time (as they will be in all likelihood at school or at home), it would be critical in my clinical opinion to ensure that wherever they are, they will be positioned to preserve physiological functions as well as body shape protection.
Often times we are quick to dismiss the options that may compromise certain aspects of function - and that’s okay if the client and the multidisciplinary team understand the physiological implications and it is an informed decision.
What tends to happen, however, is that the assessment findings related to body structure and function are not translated into potential seating options as given in the example here - Rather, transportation and mobility functions are automatically prioritised at the cost of body shape deformation and physiological function.
Translating the findings requires that we have all of the pieces of the puzzle related to body structure an function, activities, and participation, as well as personal factors and environmental factors (think ICF model), and we put those pieces together with the client and their team to determine which option is optimal for the person sitting in front of us.
Therefore I believe we need to be documenting this for every person we evaluate. With this, often comes the recommendation for both an alternative seat as well as supported supine/lying down positioning.
Approximately 90% of all the individuals I have had the pleasure of doing hands on assessments with around the globe do not have the range of motion around their hips and knees to sit in the systems they are in without physiological and body shape compromise. They will often have molded /custom seating and at every opportunity are removed from it by loved ones or carers who worry about their comfort. These are the very individuals who truly need their bodies respected everywhere they sit, lie and stand (as applicable). And the only way we can do that is through translating the findings of our comprehensive assessment.