this handout is for reference only. non- essential images have … · 2019. 11. 5. · common...

� If you are viewing this course as a recorded course after the live webinar, you can use the scroll bar at the bottom of the player window to pause and navigate the course.

� This handout is for reference only. Non-essential images have been removed for your convenience. Any links included in the handout are current at the time of the live webinar, but are subject to change and may not be current at a later date.

No part of the materials available through the continued.com site may be copied, photocopied, reproduced, translated or reduced to any electronic medium or machine-readable form, in whole or in part, without prior written consent of continued.com, LLC. Any other reproduction in any form without such written permission is prohibited. All materials contained on this site are protected by United States copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior written permission of continued.com, LLC. Users must not access or use for any commercial purposes any part of the site or any services or materials available through the site.

Technical issues with the Recording? � Clear browser cache using these instructions � Switch to another browser � Use a hardwired Internet connection � Restart your computer/device

Still having issues? � Call 866-782-9924 (M-F, 8 AM-8 PM ET) � Email [email protected]

https://www.continued.com/browser-instructions

mailto:[email protected]

01/11/2019

1

Challenges to Seating and

Positioning in Long Term Care:

Common seating misconceptions that get in the way

Ana Endsjo. MOTR/L, CLT

Moderated by:

Fawn Carson, OTD, OTR/L, ATP, Managing Editor, OccupationalTherapy.com

1

Permobil | Clinical Education2

Faculty Disclosure

Ana Endsjo– MOTR/L, CLT

National Education Manager, Permobil

2

01/11/2019

2


Learning Outcomes

1

2

3

Name three common misconceptions that lead to poor posture in a wheelchair.

Name three reasons why a K0004 manual wheelchair is a better option than a

K0001, K0002 or K0003 manual wheelchair in the long term care setting.

Describe three negative consequences to the wheelchair user when using

elevating leg rests on a manual wheelchair.

3


Optimal Seating System - It’s a Simple Equation

Together they allow for maximum contact

with the seat and back surface to:

• attain postural alignment

appropriate style cushion

correct model wheelchair+

optimal seating system=

• allow for pressure redistribution

• achieve postural stability+ appropriate back support

4

01/11/2019

3


Common Seating & Positioning Misconceptions in the LTC Setting

90/90/90

New Cushion

K0001 & K0002

Elevating legrests(ELRs)

90/90/90 is what to aim for with every resident

K0001 & K0002 standard wheelchairs are the economical choice in LTC

A new cushion is all you need to fix a positioning issue

Elevating Legrests (ELRs) are the better option when purchasing a chair

5


Misconception #1

90/90/90 is what we aim for with every resident

6

01/11/2019

4


A train of thought started in the 1880s by a Prussian orthopedic surgeon (5)

Where did 90/90/90 come from?

No scientific proof behind this posture (5)

Based off militaristic culture of stiff, erect posture (5)

Old school optimal posture: 90º angles at knees, hips, ankles, elbows

Some individuals cannot achieve this posture; most cannot maintain it

7


Changes in the elderly body, impossible to achieve 90/90/90

These residents have structural stress and strain that cause:

Age: 20 40 60 80

• Tight muscles

• Decreased flexibility often with flexion or extension

contractures of hips, knees and ankles

• Abnormal curvature of cervical, thoracic, lumbar spine

• Pain

• Decreased mobility

• Decreased strength / endurance To stop unwanted postures, pressure and pain, leading to wounds, contractures and falls, focus on what the resident can tolerate.

8

01/11/2019

5


Why not 90/90/90?

Studies suggest that optimal seat-to-back

angle is NOT 90º

Cornell University Ergonomics website puts the ideal seat-to-back angle in a healthy working individual at 100-110 degrees. (4)

A study performed on college students showed that the preferred seat-to-back angle for comfort is 105 degrees. (4)

A study with video display operators (VDT) showed that the

VDT operators preferred 105 degrees backward incline. (4)

9


What happens in sitting?

Why not 90/90/90?

• 40-90% more stress on the back compared to standing

• 75% of our weight goes through our pelvis, leaving it susceptible to a pressure injury if not positioned correctly

• It is difficult and tiring to maintain an upright erect sitting posture against gravity

Posterior

Pelvic Tilt

Pelvic

Obliquity

Pelvic

Rotation

Anterior

Pelvic Tilt

Windswept

Deformity

Most individuals slide into abnormal postures that are easier to maintain

Seating specialists are working hard to change this train of thought and want to increase understanding of angles

10

01/11/2019

6


Finding the CORRECT angle is important because is the key to decreased risk of falls

and wound development

Increased the risk of a fall from the chair

Without opening the seat-to-back angle enough:

• Less contact is made with the back and seat surface

• Unable to stabilize the pelvis, spine, or extremities

Increased the risk of fall and wound development

If we open the seat-to-back angle too much:

(recline back chairs for example)

• We promote sliding, slouching, and leaning in the chair

• Peak pressures develop at bony prominences

Consequences of using “ “ angles

instead of the right angles

Increased the risk of wound/pressure injury development

If we don’t consider the ROM limitations of the resident:

• It’s impossible to match wheelchair angles to the resident’s joints

• Residents slide into abnormal postures

• Peak pressures develop at bony prominences

11


Look at what the resident’s body is doing and consider that seat angles depend on the individual’s ROM, muscle integrity, and joint integrity

What should we aim for?

• Open or close the seat-to-back angle to accommodate for your resident’s degree of hip ROM. – allows the pelvis to reside in the intended area of the cushion

• Change seat-to-back angle to allow for more contact with the back support and seat surface.

– pressure redistribution off the bony prominences

• Change out a sling back and use a back support that allows you to conform to a resident’s curvature. – stabilization at the pelvis and spine

Fixed 90ºPelvis Pushed Forward

Peak Pressure at the Apex

Open STBAMatch Resident ROM

Increase Surface Contact

Open STBA + ContourOptimal Pressure

Redistribution

12

01/11/2019

7


Misconception #2

K0001 & K0002 standard wheelchairs are the economical choice in LTC

13


Looking for Maximum Adjustability

Image Credit: Volvo

14

01/11/2019

8


Identifying the Common Wheelchair Models Seen in the LTC Setting

StandardK0001

Standard HemiK0002

LightweightK0003

High Strength Lightweight

K0004

Standard

K0001

15


Description of K0001/K0002/K0003 wheelchairs (straight from the wheelchair dealers)

K0001/K0002 Getting warmer* with the K0003 OTHERWISE…

• bare necessities with no

outstanding features

• no frame adjustment or modifications

*K0003 has ability for slight adjustment

• made using different materials

making it 5-6lbs lighter

• ability to lower STFH by 2 inches

compared to a K0002 chair

The skeletons of these 3 wheelchair

models are EXACTLY THE SAME!

16

01/11/2019

9


Criteria for K0001/K0002/K0003 users

The appropriate individual for this equipment:

K0003 only:

• Sits with good postural control

• Has minimal or no postural deformities

• Sits in standard-sized chairs without compromise

• Has no discomfort or pain with prolonged sitting

• Uses this chair for short periods for short distances

• Can functionally propel the weight of the standard

wheelchair to complete all required daily activities

Has a physical condition that compromises ability to propel the weight of a standard chair, i.e. cardiac or pulmonary dysfunction

17


Why does the LTC Resident need so much more than a basic wheelchair?

A minimum of a K0004 wheelchair frame

should be used for anyone:

ü Using the WC all or most of the day

ü Presenting with limited mobility or non-ambulatory ü With poor postural controlü Presenting with postural deformities

ü Needing a non-standard size chair to decrease sliding, slouching, and leaning

ü With discomfort or pain during prolonged sitting

ü Who can not functionally propel the weight of the standard wheelchair to complete all required daily activities

18

01/11/2019

10


1 - STFH (Seat to Floor Height) beyond just the hemi height setting

Adjustability is key when choosing a model wheelchair

Achievable adjustability in a chair:

2 - Armrest Height

3 - Seat-to-Back Angle

Look for a chair with maximum adjustability to be able

to quickly transfer from one body type to another!

4 - Back Height

5 - Ability to create a fixed tilt, “dump” in the seat 5

2

4

3

1

19


Standard Manual Wheelchair Comparison Chart

20

01/11/2019

11


HIT A HOME RUN!!!

Look for a wheelchair that can be molded

to various body types instead of trying to

mold various body types to one chair!

21


Misconception #3

A new cushion is all that is needed to fix a positioning issue

22

01/11/2019

12


New cushions solve all seating issues

A seating referral comes across the desk due to:

• Pain in sitting

• A pressure injury

• A fall from the wheelchair

It MUST be the cushion’s fault, right?

WRONG!

23


New cushions solve all seating issues

Keep in mind: Whole Body Seating Component Design It’s a Seating SYSTEM

The pelvis does not work

alone. Overall alignment

from the head all the way

to the ankle and foot is

impacted by the seating

system.

The best cushion can be

ineffective if not used in

combination with the

correct model wheelchair

and appropriate back

support.

A back support is just as

critical as the cushion in

an ideal seating system

24

01/11/2019

13


Back supports assist in maximizing optimal posture as they:

Role of the Back Support

• Allow for pressure redistribution to alleviate peak pressures on the spinous processes

• Immerse and envelop the spine for optimal contact

• Capture the curvature, whether normal or abnormal, for optimal upright, midline posture

• Allow for the addition of lateral trunk and head supports

• Replace the existing overstretched, hammocking sling back that has lost its shape and

can no longer stabilize the trunk as needed

Fixed 90ºPeak Pressure

on the Spine

Open STBAMore Surface Contact

Redistributes Pressure


Redistribution

Fixed 90ºPeak Pressure

at the Apex

Open STBAMore Surface Contact

Match Resident ROM


Redistribution

25


Back Supports Help to Complete the Seating System

The cushion and back

support and wheelchair go

hand-in-hand to stabilize

the pelvis and spine for

optimal alignment

26

01/11/2019

14


Misconception #4

Elevating leg rests (ELRs) are the better option when purchasing a wheelchair

27


ELRs are the better option

Why do clinicians/suppliers use ELRs?

• “Keep the hips back in the wheelchair”

• “Help reduce edema”

• “Decrease pressure on the pelvis”

• “Assist with LE alignment.”

So ELRs are the best option, right?

WRONG!

28

01/11/2019

15


ELRs Keep Hips Back in the Wheelchair, Right? WRONG!

• Elevating the legs pulls on already

tightened hamstrings

• ITs are pulled forward causing a

posterior pelvic tilt and sacral sitting

• Individual begins to slide forward out

of the wheelchair

The result is the exact opposite of

keeping the hips back in the seat!

ELRs do just the opposite if the hamstrings are tight!• ELRs do just the opposite!

• When we elevate the legs, we pull on already tightened hamstrings.

• The shortened hamstrings cause a greater pull on the pelvis, bringing the pelvis into a posterior pelvic tilt.

• The posterior pelvic tilt makes the pelvis slide forward, resulting in sacral sitting.

• The resident begins to slide forward out of the chair, the exact opposite of keeping the hips back in the chair!

29


ELRs Reduce Edema, Right? WRONG!

Why is this wrong?

ELRs used on manual WCs (typically seen in

medical facilities) CANNOT reduce edema

ELRs on a manual WC can decrease

optimal circulation by cutting off blood flow

at the groin and inhibiting flow to the LEs

To decrease edema, the legs must be 30 cm ABOVE heart level. The

only way to achieve this with ELRs

is with a tilt-in-space wheelchair

Periodic elevation of the LEs with ELRs might help prevent edema

from developing, but it cannot reduce edema that is already there

30

01/11/2019

16


Talk to the IDT and consider other solutions for edema control

Make a schedule for your resident to balance time

spent sitting in chair vs. lying down with legs elevated

above heart level for maximum edema control.

Provide compression stockings to compress the

edema and stimulate circulation.

Reduce sodium intake as sodium increases fluid

retention.

Increase resident’s water intake as water flushes

excess sodium from the body.

Decrease resident’s caffeine intake as caffeinated drinks

contain a high level of sodium.

Develop a walking schedule or an exercise schedule for

your resident to increase circulation and fluid movement

by pumping fluid from the edematous lower extremity

back to the heart.

Encourage the nursing staff to review any medications

that may increase fluid retention such as hormone

replacement drugs, calcium channel blockers, anti-

depressants, and steroids known to increase edema.

Consider substitutions without this side effect.

31


ELRs Decrease Pressure on the Pelvis, Right? WRONG!

• Increased pressure on bony prominences

of the ITs, sacrum, and coccyx

• Increased risk of wounds in those areas.

ELRs position pelvis in a posterior pelvic tilt

• Decreased femoral contact shifts pressure

back to the ITs and sacrum/coccyx

Elevating the legrest promotes knee flexion

• ELRs actually position the pelvis in a posterior pelvic tilt.

• The forced posterior pelvic tilt increases pressure on the bony prominences of the ITs, sacrum, and coccyx.

• Wound development risk is increased in those areas.

• Elevating the legrest promotes knee flexion, leading to decreased femoral contact, shifting the pressure back onto the ITs and sacrum/coccyx.

32

01/11/2019

17


ELRs assist with LE Alignment, Right? WRONG!

• Since less femoral contact with the seat

surface, it is easier for the leg to

internally/externally rotate or abduct/adduct.

• Legs then fall off legrests more easily.

• Windswept deformity is more prevalent.

• ELRs promote flexion of knees, hips, and

ankles increasing risk of contractures at

those joints.

ELRs prevent full femoral contact with the seat surface.

Elevating Leg Rests Standard Leg Rests

• ELRs prevent full femoral contact with the seat surface.

• Since less of the leg is making contact with the seat surface, it is easier for the leg to internally/externally rotate or abduct/adduct.

• Legs then fall off legrests more easily.

• Windswept deformity is more prevalent.

• ELRs promote flexion of knees, hips, and ankles increasing risk of contractures at those joints.

33


Knowledge is Power!

Understand basic principles of seating

and positioning

Identify abnormal postures that place your

residents at high risk

Familiarize yourself with the misconceptions to

avoid them

Knowledge arms you with the tools to prescribe the best equipment to prevent and heal existing pressure injuries!

+ + =

34

01/11/2019

18


AfterBefore

Knowledge arms you with the tools to prescribe the best equipment to prevent and heal existing pressure injuries!

35

References

1. NearSay. (2015, May 10). Adult wheelchairs categorized and explained - Northwest Pompano. Retrieved from

http://nearsay.com/c/44448/33117/adultwheelchairs-categorized-and-explained

2. Karman Healthcare. (2014). LT-K5 – 28 Lbs 18 Inch Seat Ultra Light Adjustable Wheelchair K0004. Retrieved from

http://www.karmanhealthcare.com/product/lightweight-wheelchairs/lt-k5/

3. Mounic, Gerard. (2014). Evaluation and seating strategies with regulatory guidelines, wheelchair seating and positioning improving

functional mobility and patient ADLs. Summit Professional Education Continuing Education Course. North Carolina, Asheville.

Lecture.

4. Cornell University. (2016). DEA 3250/6510 Class Notes: Sitting and Chair Design. Retrieved from

http://ergo.human.cornell.edu/DEA3250Flipbook/DEA3250notes/sitting.html

5. MacLeod, Dan. (2016). Favorite low cost success stories. Retrieved from http://www.danmacleod.com/Articles/rightangles.htm

6. Dicianno, B. E., Arva, J., Lieberman, M., Schmeler, M. R., Souza, A., Phillips, K, Betz, K. L. (2009). RESNA Position on the

application of tilt, recline, and elevating legrests for wheelchairs. Assistive Technology, 21(1),13-22. Available from

http://www.resna.org/sites/default/files/legacy/resources/position-papers/RESNA%20PP%20on%20Tilt%20Recline_2015.pdf

36

http://nearsay.com/c/44448/33117/adultwheelchairs-

http://www.karmanhealthcare.com/product/lightweight-wheelchairs/lt-k5/

http://ergo.human.cornell.edu/DEA3250Flipbook/DEA3250notes/sitting.html

http://www.danmacleod.com/Articles/rightangles.htm

http://www.resna.org/sites/default/files/legacy/

01/11/2019

19

References

7. Cole, Elizabeth. (2016). Causes and prevention of skin breakdown. US Rehab Seating and Mobility Master Program. Lecture.

8. Lange, Michelle L., and Jean Minkel. (2018). Seating and Wheeled Mobility: a Clinical Resource Guide. Thorofare, NJ: Slack

Incorporated.

9. Borisoff, J., & Mitchell, S. (2015) Dynamic wheeled mobility: Next chapter in the ultralight evolution. 31st International Seating

Symposium, Pittsburg, PA.

10. Jones, D., Radar, J. (2015.) Seating and mobility for older adults living in nursing homes: What has changed clinically in the past

20 years? Topics of Geriatric Rehabilitation, 31, 10-18.

37

Thank youThank you

Ana Endsjo MOTR/L, CLTNational Education Manager, Permobil

[email protected]

/permobilpower

/permobilseatingandpositioning

Follow and like us

/permobilmanual

38

this handout is for reference only. non- essential images have … · 2019. 11. 5. · common...

Documents