The team recommended a manual wheelchair with an adjustable angle back to provide a fixed recline and a tilt in space to address the neck and trunk flexion (which was due to a fixed kyphosis) and reduce pelvic forward sliding.
It also recommended a cushion to better position the pelvis and lower extremities, as well as a pelvic positioning belt to keep the pelvis in a neutral position on the cushion. In it, Marilyn was positioned significantly better. She was better able to visually regard her environment, was much more alert and comfortable and even showed improved swallowing during meals.
But there was a problem. Marilyn lives in a long-term care facility that did not allow the tilt or the pelvic positioning belt, as these were viewed as restraints.
Restraints are a red hot topic right now. Once seen solely as an issue in long-term care facilities, this issue is creeping into a variety of settings, including some schools. In the past, certain "seating" components often were used in institutional settings to intentionally restrain limit or control behavior or as a consequence to poor behavior. Over time, policies have been developed to protect clients from undue restraint and to reduce or eliminate improper use of restraints.
Unfortunately, in the wake of this, many clients are unable to receive the postural support they need, particularly in certain settings. The Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) is currently developing a position paper on this topic through its Seating and Wheeled Mobility Special Interest Group. Once complete, the paper will be available on RESNA's website for reference. The purpose of this paper is to clarify the correct usage of seating components for positioning and even address when positional restraint is clinically indicated.
The paper should be available by the end of the year and is being authored by seating specialists in a variety of settings. Although restraints can be used in a variety of positional systems, this paper will primarily address this issue in the context of wheelchairs.
In the meantime, I wanted to review some common seating components and the clinical indicators of each for positioning.
Seating systems are comprised of primary support surfaces and secondary support seating components. Primary support surfaces are the back and seat/cushion. This may be all the support a client requires. Secondary support seating components are indicated when additional postural support or stability is required. Let's review some of them from the feet upward:
• Ankle/foot straps (i.e. ankle huggers, shoe holders with straps). Clinically, restraining the feet can increase stability for many clients, particularly those with increased muscle tone. It may prevent an extensor thrust which can lead to loss of pelvic position which leads to loss of function and exertion of a great deal of energy. Keeping the feet on the footplates can prevent injury to the feet.
But these supports are considered restraints because the client can rarely remove them independently, and movement of the feet is limited. Any such stabilization of the feet must be paired with postural restraint at the pelvis so that a client cannot slip down in the chair while "attached" at the feet, leading to injury.
• Anterior calf straps. Sometimes, one can achieve the same goals by using an anterior calf strap, which is less restrictive. But the client may not be able to release this independently and cannot get up from the wheelchair while the strap is in place.
• Knee blocks. Knee blocks are placed just anteriorly to the knees to limit forward movement of the pelvis into a posterior tilt. These are most commonly used in people with increased muscle tone. Knee blocks may be used instead of or in addition to a pelvic positioning belt. These can limit hip adduction, as well. Again, a client typically cannot remove knee blocks independently and get out of the wheelchair, so they are considered restraints.
• Medial knee blocks. Also known as a pommel, the primary positioning goal of a medial knee block is to limit hip adduction. Hip adduction and extension tend to go hand-in-hand, so limiting hip adduction often reduces extension as well. Pommels are often misused to keep the pelvis from sliding forward into a posterior tilt.
Remember-the groin is not a weight-bearing surface! Medial knee blocks should be used in conjunction with pelvic positioning belts to prevent clients from sliding forward into the pommel.
• Anterior pelvic support. Anterior pelvic supports include pelvic positioning belts (sometimes referred to as hip belts or seat belts), subASIS bars and leg harnesses. This is probably the most common secondary support seating component targeted by restraint policies.
When the pelvis is strapped down, the client certainly is restrained in the wheelchair. However, the pelvis is also positioned and sustained in a neutral posture, without tilt. An anterior pelvic tilt results in a lordosis and moves the center of gravity forward. A posterior pelvic tilt results in kyphosis of the trunk and often hyperextension of the neck.
An oblique pelvis can cause lateral scoliosis (or a C curve) that often results in a double curvature (or S curve) as the client attempts to right the head.
Finally, a rotated pelvis results in a rotated spine, and often a double rotation, as the client attempts to face forward.
A posterior tilt and obliquity are most likely to lead to pressure sore development, as pressure is not well distributed.
• Anterior trunk supports. Clinically, anterior trunk supports often are used to keep people from falling forward or to support the chest in upright and promote upper-trunk extension and sometimes scapular retraction.
An upright trunk improves head control. Supports include vests, shoulder straps, shoulder retractors and chest straps. These are sometimes seen as restraints, as clients cannot typically remove the supports independently and cannot assume standing with them. Some clients can remove chest straps on their own. Anterior trunk supports should always be used with appropriate pelvic positioning belts, otherwise the client could slide forward on the seat and strangle on the support.
• Arm strapping. Yes, the arms sure look restrained. This is not as socially acceptable as other secondary supports. At times, however, arm straps can provide the stability required to be functional (e.g., using a switch mounted at the head). Some clients have spasms that pull the arms off arm rests or out of arm troughs, which could lead to injury. Some clients prefer the arms to be strapped to prevent this.
• Forehead strapping. In conjunction with a headrest, a strap across the forehead is also not very socially acceptable and may be viewed as a restraint. Sometimes this aggressive head support is required for a client with no head control who wishes to be in an upright position-for example a client with a very high-level spinal cord injury or a client with advanced spinal muscular atrophy.
• Trays or Upper Extremity Support Surfaces (UESS). A tray can be used as a work surface and also to support the upper extremities. Trays are sometimes regarded as restraints if the client cannot remove the trays independently and, as a result, cannot get up from the wheelchair.
If you are working with a client who can benefit from any of these seating technologies to meet positioning goals, be sure to stress the clinical indicators in your justifications. If the client is in a setting where restraint policies are in effect, find out what the requirements are. Sometimes a physician letter is required, which places an "order" in the chart necessitating these components.
Is using seating technologies explicitly as restraints ever indicated? Yes, but fortunately not very often. In these situations, the entire team-including all caregivers and the client-must be on the same page with the same goal: protecting the client from injury, not imposing restraint as a behavioral consequence.
If you are struggling with this issue, or making headway with it, I would love to hear from you as we continue to develop the position paper.
Michelle Lange, OTR, ABDA, ATP, is owner of Access to Independence in Arvada, CO. She has 20 years' experience working with assistive technology. She is past secretary of RESNA and a frequent author and presenter. She can be reached at MichelleLange@msn.com or visit her website at www.atilange.com.