Figure 37: Lateral Scoliosis
Figure 38: Shape Capture in Molding Bags
Lower extremities The position of the lower extremities is very dependent on the position of the pelvis. It is important that the lower extremities bear weight, if possible, to distribute pressure along the pelvis, posterior thighs, and under the feet, as well as to increase stability for the client. Common positioning challenges seen at the hips include flexion, extension, abduction, and adduction. These postures are only problematic if excessive enough to affect a seated posture. These postures may be reducible, partially reducible, or non-reducible. Hip flexion Some clients actively pull their hips into flexion while others have lost range of motion, with the result that the hip cannot be extended to a reasonable position for sitting. Loss of range may occur due to poor range-of-motion management or long- term poor positioning. Some clients actively flex the hip in an attempt to stabilize or “hang on.” If the hip flexion is reducible or active, strapping is often provided over the feet (Figure 39). If the hip flexion is non-reducible, the seat-to-back angle must be closed to match the thigh-to-trunk angle (Sutherland, 2018). This is often accomplished by placing a wedge under the seat itself. Pulling the thigh downward into extension will only pull the pelvis into an anterior tilt (Minkel, 2018). Goals in a reducible scenario include providing stability, keeping the feet on the footplates to prevent injury, and promoting weight-bearing. Goals in a non-reducible scenario are to prevent anterior pelvic tilt. Figure 39: Ankle Straps
many clients are positioned at a greater than 90° seat-to-back angle, 90° of hip flexion is generally required for a seated position. Some clients who actively extend may be attempting to unweight a painful hip. If the hip extension is active, strategies can be employed to reduce overall extension. This can sometimes be achieved by increasing flexion and abduction throughout. A pelvic positioning belt placed over the lap at 90° may limit pelvic elevation. Another choice is to explore dynamic options at the knees to diffuse force. This alternative will be addressed in a subsequent section. The goals of decreasing active hip extension include energy conservation, shear reduction, maintaining alignment with other positioning components, and providing a consistent position from which the client can access assistive technology or perform other functional tasks. If there is a range limitation, the seat-to-back angle needs to be opened to accommodate the client’s position (Sutherland, 2018). Although the hip may be able to flex, if hip extensors are limited, flexion will only push the pelvis back into a posterior pelvic tilt. If the hamstrings are tight, increasing knee flexion may be helpful. Occasionally a client will have more hip flexion available on one side of the body than the other. In this case, a specialized seat can be used (off the shelf or molded) to allow for the limitation in hip flexion on one side and take advantage of a functional range on the other side (Figure 40). Flexing one side where range is available (generally to 90°) can prevent loss of hip flexion range on this side and better keep the client back in his or her seat. When a client is positioned in hip extension, it is hard to keep the pelvis back in the seat. Goals of addressing hip extension in the seating system include preventing further range-of-motion losses, which could lead to a more reclined and less functional position – affecting vision, feeding, and respiratory function. Figure 40: Asymmetrical Hip-Angle Cushion
Note . From Bodypoint, n.d., retrieved from http://www.bodypoint. com. © Bodypoint. Reprinted with permission. Hip extension Hip extension can be reducible or non-reducible. Some clients actively extend at the hip, often as a part of a total extensor pattern. Other clients may have lost range of motion, making it impossible for the hip to be flexed to a 90° angle. Although
Note . From Invacare Corporation, n.d., retrieved from http://www. invacare.com. © Invacare Corporation. Reprinted with permission. Hip adduction Hip adduction, which causes the legs to come together at midline, is a component of extension and can also be a result of loss of range. Many off-the-shelf cushions include a generic contour to encourage the upper legs to be aligned with the hips (Kreutz, 2018). Contouring of a cushion to facilitate hip external
Page 35
Book Code: PTNC1023
EliteLearning.com/ Physical-Therapy
Powered by FlippingBook