Postural Assessment for Seating and Wheeled Mobility

Postural Assessment for Seating and Wheeled Mobility
Addressing the cause….
Eric Grieb OTR/ATP/ CRTS
Director of ATP Development
OBJECTIVES — Participants will be able to identify at least two key joints where R.O.M. impacts seated posture.
— Participants will be able to identify how inappropriate seating dimensions may negatively impact posture.
— Participants will identify a minimum of 2 key angles on the wheelchair base which directly affect client posture.
— Participants will be able to translate findings from the Postural Mat Assessment into prescriptive angles of the wheelchair seating system.
— Qualified Participants will express confidence in their ability to appropriately conduct a Postural Mat Assessment.
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WHERE DO WE START?
— The pelvis serves as or primary base of support in the seated position.
— Boney landmarks of the pelvis serve as a frame of reference for pelvic position which impacts overall seated posture.
— When seated, the center of mass of the trunk is primarily over the pelvis with the Ischia Tuberosities acting as the primary area of support and force distribution…..a distance of only about 4.5”
— The interconnecting tendons, joints and muscles of the pelvis have a profound impact on what type of seated posture can be achieved….This is where we begin.
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SEATED DISTRIBUTION OF PRESSURE
— We must give consideration to the individual’s seated pressure distribution in the context of force over area.
— The” Loading Areas” of the pelvis and lower extremities in the seated position include: Ischium, Femurs, Trochanters, Feet and potentially the Sacrum.
— R.O.M. deficits anywhere in the LE’s must be accommodated in order optimize both posture and pressure distribution.
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THE ASSESSMENT
Assessment begins with:  Client / caregiver interview including: likes and dislikes with regard to current seating, perceived problems with current system, functional status, skin integrity issues, environmental access / transportation needs etc.
 Visual assessment in current equipment all planes (frontal or coronal, sagittal and transverse.)  Observe for obvious issues with fit.
 Visual assessment of current equipment features, size and condition
 Brief physical assessment (palpate pelvic and spinal position in current chair.)
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ASSESSMENT Assessment progresses to:
 Assessment of the client out of their existing equipment.
Completion of a mat evaluation on a firm surface in both supine and in sitting gives us the keys to understanding the symptoms vs. the cause of postural difficulties.
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POSTURAL MAT ASSESSMENT
The mat assessment informs us of the following:
 Sitting posture and postural tendencies.
 Range of motion in relation to sitting
 Muscle strength
 Tone
 Skin integrity
 Balance
 Endurance
 Support required for function
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WHAT ARE WE LOOKING FOR?
During the Mat Evaluation we are assessing the client for the presence or absence of the following abnormal postures or postural tendencies.
— Posterior pelvic tilt
— Anterior pelvic tilt
— Pelvic obliquity
— Pelvic rotation
— Kyphosis
— Lordosis
— Scoliosis
We must learn if these postures are fixed, flexible, or partially reducible and we must determine any interrelation between deformities if we are to develop appropriate intervention strategies.
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Client Assessment
Anterior Pelvic Tilt: Often accompanies lordosis.
Increases interface pressure on Ischial Tuberosities. Can impact bladder function, endurance etc.
Can be a component necessary for balance with some disease processes.
Client Assessment
Posterior Pelvic Tilt: Often Accompanied by Lumbo‐thoracic Kyphosis and Cervical Hyper‐extension. Serves to increase interface pressure and shear on the sacrum and coccyx and increases point specific pressure on the Spinous Processes .
Client Assessment
Pelvic Obliquity with Scoliosis
Client Assessment
Windswept Deformity:
Often associated with pelvic rotation and or rotational scoliosis.
MAT EVALUATION IN SUPINE
Client must be positioned on a firm surface and positioned “squared” in relation to top edge of Mat Table.
Looking for the available pelvic/spine/lower extremity joint ranges/flexibility as related to the seated position ‐ hips and knees flexed. • Pelvis‐Spine relationship
 Anterior / posterior
 Lateral side flexion
 Rotation
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MAT EVALUATION‐ SUPINE
With pelvis in optimal position and knees flexed, assess hip‐pelvis relationship:
 Flexion
 Abduction / Adduction
 Rotation
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MAT EVALUATION‐ SUPINE
With pelvis and hip in optimal alignment in relation to seated position assess:
 Knee extension‐ palpating hamstring range.
 Ankle plantar / dorsiflexion/Inversion/Eversion (observing foot deformities that may interfere with support)
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MAT EVALUATION‐ SUPINE
Additional observations in Supine should include:
 Trunk contact with the Mat Table surface…look for rotation, reduction of lordosis, cervical / head position, evidence of primitive reflex activity etc.
 Skin Integrity‐ Presence of red spots or open wounds; size location shape.
 Return of Postural Tendencies‐ collapse, rotation etc.
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MAT EVALUATION‐ SITTING
The seated portion of the Mat Evaluation is conducted on a firm surface with pelvis aligned and feet properly supported. (We must provide “mock” accommodation for any orthopedic deformities identified in supine.)
 Observe Posture and balance‐ independent‐ hands free, hands supported, fully supported. (Insure client safety 2 person assessment.)
 Look at functional reach in relation to posture and balance.
 Determine optimal position for balance and comfort (supporting posterior pelvis.)
 Determine level of support needed (posterior, lateral, anterior)
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MAT EVALUATION‐ SITTING
 Are there unique or abnormal curves or shapes that must be accommodated or passively corrected?
 Consider the need for gravity reduced / enhanced positioning. How does gravity impact posture. Orientation of seating system; lateral or anterior posterior tilt are all considerations.
 Observe the impact of trunk position on head control. Cervical position in relation to swallowing etc.
 Anatomical measurements should be taken in best achievable posture with accommodation for identified deficits.
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DOCUMENTATION
What should we document?
Specific R.O.M measurements hips, knees, ankles.
Description of identified pelvic / spinal deformity note the amount of effort required to reduce or correct.
(Consider utilizing descriptive terms outlined below for clarity in goal setting.)
— Key: FA = Full Active Correction PA = Partial Active Correction
— NA = No Active Correction FP = Full Passive Correction
— PP = Partial Passive Correction NP = No Passive Correction
— WNL = Within Normal Limits
— Use Key to Describe “Correctable
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DOCUMENTATION
— Balance and anticipated needed support needs.
— Note any tonal influence, spasticity, ataxia or tremor with active/passive range.
— Transfers
— Ability to weight shift
— Skin Integrity‐ all issues should be noted for location size appearance.
— Current Equipment‐ type, dimensions, appearance / condition
— Client / Caregiver / Team Goals — Identify and document physical and functional priorities 20
TRANSLATION TO EQUIPMENT PARAMETERS
In order to translate the results of the postural assessment into appropriate equipment parameters we must first recognize that we are dealing with a biomechanical chain reaction.
— The net result of any intervention strategy employed without consideration of identified factors influencing the “chain” will be failure.
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POSTERIOR PELVIC TILT
Possible Physical Causes Include:
 Decreased or absent strength of trunk musculature.
 Hamstring Tightness.
 Boney or soft tissue limitation of hip, pelvis/spine.
 Abnormal tone of trunk or lower extremities.
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POSTERIOR PELVIC TILT
Possible Mechanical Causes Include:
 Seat Depth Too Long
 Lacks Appropriate Posterior Pelvic Support
 Excessive Seat or Back Sling
 Foot Support Too High or Too Low
 Angle of hanger fails to accommodate for tight hamstrings
 Seat to Floor Height Too High for LE Propulsion  Inappropriate Back Height or Angle
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Possible physical causes Include:
 Asymmetrical muscle tone.
 Asymmetrical R.O.M. deficit at hip.
 Boney deformity or abnormality of hip joint.
 Scoliosis.
 Pain.
(Note always described on low side.)
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 Significant Seat Sling.
 Chair Too Wide.
 Inadequate Height or Type of UE Support.
 Inadequate Immersion or Envelopment of Support Surface (no trochanteric support.)
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— Posterior Subluxation of Hip
— Leg Length Discrepancy
— Tonal Disturbance
— Asymmetrical Abduction or Adduction of Hip
— Unilateral Foot Propulsion
— Asymmetrical Hip R.O.M. Without Accommodation
— Unilateral Neglect
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PELVIC ROTATION‐ MECHANICAL CAUSES
— Seat Depth Does Not Account for Discrepancy in Leg Length.
— Inadequate Support for Posterior Pelvis.
— Seat Height Inappropriate for LE Propulsion.
— Inadequate Trunk Support 27
— Tight Hip Flexors
— Tight Spinal Extensors and Weak Abdominals
— Obesity Can Contribute.
— Can be a function of balance.
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ANTERIOR TILT‐ MECHANICAL CAUSES
— Too Aggressive with Posterior Pelvic Support / Lumbar Curve
— Back Angle too closed
— Anterior slope of mobility base or support surface.
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KYPHOSIS
Determining the type and or possible causes can help to shape the intervention strategy.
o Postural Kyphosis Generally correctable, actively or passively. Related to postural weakness and related tendencies; reinforced by inadequate support. The hump in postural kyphosis is generally round and smooth. o Structural Kyphosis Structural kyphosis involves a problem with a part of the spine, such as a deformity in the vertebrae. The hump caused by structural kyphosis is much more angular than a hump caused by postural kyphosis. A particularly sharp, angular curve is called a Gibbous Deformity. 30
KYPHOSIS‐ MECHANICAL CAUSES
— Inadequate posterior pelvic support
— Inadequate back height or angle
— Unaccommodated lower extremity R.O.M deficit
— Feet not supported — Seat Depth too great
— Back Sling
— Inadequate UE Support
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SCOLIOSIS
— Congenital scoliosis. Caused by a bone abnormality present at birth.
— Neuromuscular scoliosis. A result of abnormal muscles or nerves. Frequently seen in people with spina bifida or cerebral palsy or in those with various conditions that are accompanied by, or result in, paralysis.
— Degenerative scoliosis. This may result from traumatic (from an injury or illness) bone collapse, previous major back surgery, or osteoporosis (thinning of the bones).
— Idiopathic scoliosis. The most common type of scoliosis, idiopathic scoliosis, has no specific identifiable cause. There are many theories, but none have been found to be conclusive. There is, however, strong evidence that idiopathic scoliosis is inherited.
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SCOLIOSIS ‐ MECHANICAL CAUSES
— Seat / Back Width too great. — Inadequate or inappropriate placement of Lateral Trunk Support.
— Seat or back sling.
— Inadequate UE support
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SUPPORTING A SCOLIOSIS
Minimum 3 points of control
1. Apex: Find the corresponding rib and follow it to determine placement on lateral trunk.
2. As high as possible on concave side (watch impeding Brachial Nerve Complex.)
3. Lateral Pelvis Concave Side
4. Consider fourth point to “lock “ pelvis into place
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CONTACT INFORMATION
For more information please visit our website at: www.numotion.com
Eric Grieb, OTR/L, ATP, CRTS: Cell: 719.351.5720
Colorado Springs, CO Numotion
Clinical Education
800‐500‐9150
Course transcripts and additional copies of certificates of completion are available
upon written request: 5501 Wilshire Blvd NE Ste C ABQ, NM 87113
1.800.500.9150.
REFERENCES
— Cook, Albert and Miller‐Polgar, Jan; (2008) Cook and Hussey’s Assistive Technologies: Principles and Practice, Third Edition — Stark, Freddy; ( 1991). Start Exploring: Gray’s Anatomy: A Fact‐Filled Coloring Book
— Takahashi, Takeo; (1994). Atlas of the Human Body
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