EVALUATION
Clinicians’ practice philosophies and goals can affect client evaluation and recommendations. It is essential that clinicians examine their own practice philosophies and the ways in which these philosophies affect client service delivery, especially with regard to seating assessments. Occupational and physical Clinician goals The primary goal of the clinician involved in the seating assessment is to determine whether the client’s current seating system, if any, is meeting his or her needs and, if not, to recommend appropriate equipment. The recommended seating system must interface with an existing or new mobility base. This course will address only wheelchair seating; a separate course addresses mobility. A number of general seating principles are commonly accepted and followed in this area of practice: ● Correct the flexible, accommodate the fixed: No single seating posture is deemed as “correct.” Rather, if the asymmetry is flexible or reducible, it should be brought to an anatomically correct posture within the client’s available range of motion and tolerance of this position. For example, if a client tends to lean to the side in a lateral scoliosis of 20°, but the posture is flexible – meaning reducible – then lateral supports are added at the trunk to correct the alignment, with the optimal goal of maintaining a midline posture. Gradual adjustments may be required to achieve maximum alignment. If that same posture is fixed – meaning it is non-reducible short of surgery – then this situation must be accommodated. In the case of a fixed lateral scoliosis, it is important to make sure the head is balanced over the trunk and pressure is distributed along the posterior and lateral trunk as well as the buttocks. ● Skeletal alignment/symmetry: Again, no single seating posture is deemed as “correct.” There is no consensus on what constitutes skeletal alignment in a seated position. The goal is to achieve midline symmetry, if possible, in the frontal and sagittal planes. The key to positioning the spine is to start with the pelvis. Two key angles that affect the position of the pelvis are the client’s available hip and knee flexion. ● Improve postural control: The seating system should optimize trunk and head control particularly. Positioning the pelvis will facilitate trunk and head control, as these are balanced over the pelvis. ● Normalize muscle tone: Although muscle tone cannot truly be “normalized,” certain positions do tend to inhibit significant increases in muscle tone. Completely “breaking up” muscle tone can actually lead to decreased trunk and head control in clients who use their tone to maintain upright sitting. The goal is to maintain a balance of just enough tone for postural control but not so little as to impair function. Clinician philosophies Occupational and physical therapy interventions are greatly influenced by individual philosophies of treatment. In the case of seating interventions, there are three major philosophical approaches: ● Therapeutic: In this philosophy, the goal of the seating system is to promote therapy goals, particularly to increase trunk and head control. Clients who sit for long periods of time do tend to lose range of motion, particularly in hip and knee extension, and clients who use extensive postural supports often lose some trunk control. However, those same postural supports may facilitate function. Clients should not expend all their energy maintaining a seated position. Proper seating can enable clients to enjoy and complete functional daily tasks. Seating assessment Assessment begins with intake. At this time, goals are discussed. The clinician’s and client’s goals are not the only goals to be considered as part of the assessment; the family’s or caregiver’s
therapy practitioners are trained in performing general assessments. Seating assessments, however, include some very specific components, including the mat examination, dimensional measurements, and simulation of seating interventions. These components will be discussed in detail. ● Inhibit abnormal or primitive reflexes: Clients with diagnoses such as cerebral palsy often demonstrate reflexes that affect posture and function. The seating system should not elicit these reflexes (e.g., a posterior tilt of a seating system within a mobility base may trigger tonic neck reflexes). A position that minimizes reflexive activity must be identified during the assessment. ● Proximal stability for distal control: Stabilizing the body allows dissociation of the extremities and isolation of motor control. For example, when sitting at a desk typing, a person’s feet are tucked under him or her, pulling the pelvis into a slight anterior tilt and stabilizing this area. This proximal stability allows better distal control of the arms and fingers during typing. Now imagine a person sitting on a large therapy ball with the toes barely reaching the ground. Typing is now much more difficult because there is a lack of the core stability required to truly free up the arms and hands for this task. Many clients lack intrinsic stability due to paralysis, weakness, or abnormal muscle tone. The seating system provides extrinsic stability to improve function and to allow the client to relax without struggling to remain upright. ● Pressure relief and comfort: One of the reasons a person changes his or her position when sitting through a long movie is pressure relief. When sitting for a long period of time in one position, the tissues are compressed between the pelvis and the skin, and blood flow is reduced (Brienza, 2018). The body sends signals of discomfort – pain, numbness, or tingling. This prompts movement, which restores blood flow to the area. The client may remain within the seating system for many hours at a time. Paralysis, weakness, or lack of motor control leaves many clients unable to independently and/or adequately shift their weight to restore blood flow to compressed tissues. The seating system must provide pressure distribution and a means for pressure relief if the client is unable to independently perform a weight shift. If the client is not comfortable or develops a pressure injury, he or she will be unable to tolerate remaining in the seating system for a reasonable amount of time. (Minkel, 2018) ● Anatomical: In this philosophy, the goal of the seating system is to provide as symmetrical a position as possible, with all joints in correct anatomical alignment. As mentioned previously, there is no consensus on a single correct seated posture. Focusing only on alignment may lead to excessive corrective forces or decreased function. ● Functional: In this philosophy, the goal of the seating system is to promote function. This philosophy may compromise range of motion, trunk control, and symmetry, but it will also promote function and independence. If the client looks great in his or her seating system, but cannot do anything, have the clinician’s and client’s goals really been achieved? (Belle et al., 2016)
goals must also be considered. Although no standardized protocol for wheelchair seating evaluations exists (Plummer, Ito, & Ludwig, 2013), the following sections systematically address
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Book Code: PTNC1023
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