Have people stand up & palpate their bony landmarks. You can feel how you sit on your sitting bones in a hard chair or a bike. If you are sitting on Lordosis rare with our population In a w/c it is virtually impossible to maintain contact with your sitting bones.
Because the thoracic and sacral curvatures are maintained.
The surfaces of the vertebral body become more concave and mores convex.
You can see in children with CP that TLS is deregulated. Put a baby on its stomach and see what is does. On their back.
Many more of our patients suffer form the forward TLR positioning refles. Need to support extension. For Backwards TLR- Need to support flexion (you might have knees slightly higher than hip but with good cushion)
I am always asking Geary or Dan for help with w/c positioning. With Complex patients scott and I had to change a chair 3x in one stay. Melissa asked for help with parkinsons patient…
Dan will go over what is the right fit and use of equipment.
With klyphosis, remember to line up the convex curvature of the thoracic spine and sacrum. If the sacrum is in a posterior tilt the kyphosis will worsen. SSI is most under used of all our WC accessories.
Dan goes over stages and cushions.
Seating & positioning v2
Laura Staton, OTR/L, RYT
Staten Island University Hospital
The pelvis links the vertebral column with the LE’s
and defines the base of the trunk.
Pelvic bowl formed by 2 pelvic bones (ilium, ischium,
pubis) and sacrum.
Important bony landmarks are ASIS, PSIS and
ischial tuberosity (sitting bone).
The 2 pelvis bones attach to the sacrum at the
sacroiliac joints with strong ligaments. The SI joints
so firmly bind the pelvis to the sacrum that each tilt,
rotation and postural shift affects the spine.
A posterior tilt flattens/rounds the lower spine, the
anterior tilt increases lordosis.
It’s not the just the pelvis that has to be back in the
chair, it’s the sitting bones, which insure proper
positioning of the pelvic bowl, sacrum & spine.
The spine has 4 curvatures: 2 concave (cervical &
lumbar) and two convex (thoracic & sacral).
Cervical & lumbar are lordotic curvatures.
Thoracic & sacral are kyphotic curvatures.
In fetus, the entire spine is kyphotic and
curvatures develop as we crawl, sit & walk
(specifically the cervical and lumbar curvatures).
All four curvatures act together as a flexible
springboard to maintain our upright posture and
When seated, the curvatures are more difficult to
maintain (especially with tight hip flexors).
Intervertebral discs are comprised of a gelatinous
inner core called the nucleus pulposus (approx 15% of
total mass) and confined by the fibrous ring of the
As the spine ages (20-70) the disc dehydrates and
vertebral bone loss occurs. The annulus fibrosus takes
more weight with compressive forces.
Forward flexion of the spine posteriorly herniates the
Posterolateral herniations are the most common and
typically the cause of nerve pain due to the proximity
of the nerve root.
Approximately 95% of posterolateral lumbar
herniations are at the L4-L5 or L5-S1 vertebral level.
Spinal extension is good for posterolateral herniated
discs, flexion is not.
TONIC LABYRINTHINE REFLEXES
TLR is an infant reflex which helps baby to
master head and neck control, increase tone in
trunk and self correct posture & head alignment.
Forward/prone: As head curls in to flexion
entire body, UE/LE’s and trunk curl into flexion.
Backwards/extension: As head extends the
entire body, UE/LE’s and trunk curl unfold in to
Tone can effect w/c positioning
Forward TLR - pull your knees up towards your
chest and notice what happens to your lower
back and trunk: Hip Fx, Kyphosis, Parkinson's,
Spinal Stenosis, MS, CVA, SCI.
Backwards TLR- Sit on edge of chair and extend
head and legs out straight and notice what
happens to your body: CVA, SCI, Neurological
WHAT CAN WE DO TO HELP?
Prioritize w/c positioning as a part of your scope
of practice and treatment time.
Do not be afraid to problem solve with patient
(client centered care) and make changes.
Ask for help if you can’t figure out what to do.
Educate yourself and the patient.
Change if it does not work.
QUESTIONS TO ASK YOURSELF
Do they LOOK comfortable in chair?
What are patients here for?
Where do they have pain?
What is their static sitting posture/balance?
Are the hip flexors excessively tight?
Are they w/c bound at home?
Do they complain of pain after sitting in chair?
Are they excessively stiff when they get up?
WHAT IMPROVES W/C
The right fit of w/c.
Good usage of equipment (SSI, lumbar support,
cushions, back support, lateral support, arm tray,
calf panels, knee spreader).
The spine and pelvis (as much!) in alignment as
Neutral pelvis with IT bones touching back of
Back support to reduce pain & increase thoracic
spinal /neck extension.
Lateral leaning supported.
Feet and limbs supported.
BASIC GUIDELINES TO FOLLOW
With a THR ALWAYS have a SSI.
With a Hip FX, Stenosis, Low Back Pain, Spinal
Surgery, kyphosis - SSI may be highly appropriate.
With kyphosis and back/neck pain lumbar support
should be considered.
Any skin breakdown or history of skin breakdown use
a specialized cushion.
With excessive lateral leaning consider a specialized
cushion to prevent skin breakdown on one side.
Consider a knee spreader to assists with organizing
With a CVA check to see if they need lateral support?
If very tight hip flexors use extra cushion to elevate
pelvis and stretch front of thighs.
TEACH & EDUCATE PATIENT ON
IMPORTANCE OF PRESSURE RELIEF EVERY
20 MINUTES FOR TWO MINUTES (seated &
Provide inspection mirror/take picture/educate pt. &
family. on importance of compliance with pressure
relief from day 1!
Prioritize daily self inspection of bony prominences.
Make sure w/c fit is a good match and cushion is
matched to stage of ulcer.
Limit time spend seated if IT skin breakdown (meals
Does pt. require a turning/OOB schedule? If so,
schedule should be posted above bed and nursing
should be educated on importance of strict 24-hour
PRESSURE RELIEF TECHNIQUES
EVERY 20 MINUTES FOR TWO
Seated: lean forward over bed or table, chair
push ups, lateral weight shifting, semi-bridge,
reclining backwards in tilt in space.
Supine: rolling, bridging, ½ bridging, ½ twist
turning schedule, OOB schedule.
Moore and Dalley (2006). Clinically Oriented
Anatomy, 5th edition, Lippincott Williams &
Wilkins, Baltimore, MD.
Lasater, Judith (2009). Yogabody: Anatomy,
Kinesiology, and Asana. Rodmell Press, Berkeley,
H. D. Coulter (2001). Anatomy of Hatha Yoga,
Published by Body & Breath, Inc. Albany CA.
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