Posture, Proper Wheelchair Fit and Seating

Each individual has his/her own specific needs for wheelchair and seat cushion
specifications depending on the level of injury, amount of mobility, and skin
sensitivity/tolerance. Proper posture, seating and wheelchair fit allow each person to
maximize the ease of transfers, mobility and skin protection.

Why is proper posture, wheelchair fit and seating important for

individuals after a spinal cord injury?

Protection of skin integrity

Even distribution of pressure
Prevention of muscle imbalances and contracture development that may
develop from prolonged poor posture
Prevention of excess and/or abnormal shear forces or pressure on the skin
during sitting, mobility or transfers

Posture:

When sitting in a chair or wheelchair, the skin overlying the ischial

tuberosities (the sitting bones) and the tailbone are especially at risk for skin
breakdown.
Proper Posture in a Wheelchair:
o Knees and hips positioned at right angles
o Buttocks back in the seat
o Buttocks centered on the seat
o Pelvis slightly tilted forward (anterior pelvic tilt)
o Pelvis horizontal (not leaning to one side or the other)
o Trunk upright and following the natural curvature of the spine
o Shoulders relaxed, elbows at right angles on the arm rests and/or free to
move
o Head upright and in midline, chin slightly tucked
The above two photographs are examples of an individual sitting with ideal upright
posture. Below are examples of an individual sitting with poor upright posture that will
cause him to be susceptible to pressure ulcers, pain and soreness, muscle imbalances
and contractures.
Proper Wheelchair Fit:

To determine if your wheelchair is an ideal fit, the user should sit in the
wheelchair with ideal upright posture (see above for examples of proper and
improper sitting posture), sitting on the cushion he/she will be using and wearing
shoes.

o Seat Width - Slightly wider than the users widest point (usually the hips or
the thighs)
o Seat Depth The wheelchair seat should end 1-2 inches before the back of
the users knees. The front of the wheelchair seat should never rub the back
of the knees.
o Seat Height When the footplates are adjusted appropriately for the user to
sit with proper sitting posture, there should still be a few inches from the
footplates to the floor. NOTE: If the user will be propelling the wheelchair with
his/her feet, the seat height should be such that the users feet rest flat on the
floor.
o Backrest Height Should be higher if the user has trouble sitting upright on
his/her own to provide maximum support. A backrest should not rub the
users arms when he/she is propelling the wheelchair.
o Backrest Width Slightly wider than the users torso
o Armrest Height The users forearms should rest comfortably on the arm
rests the elbows bent to 90 degrees and arms at his/her side.

Wheelchair Cushions:

The most important factor in selection of a seating system and/or wheelchair

cushion is to minimize excess pressure and/or shear forces on the skin.
There are many different types of wheelchair cushions available, all of which
have advantages and disadvantages. Each individual is different in his/her
body build, functional mobility and skin tolerance to pressure. Selecting the
proper wheelchair cushion can help individuals with spinal cord injuries
maximize these individual needs.
Commonly used wheelchair cushions:
Foam
Made of viscoelastic foam, vary in thickness and density
based on the individuals needs
Advantages: light, generally do not inhibit a persons function
(i.e. transfers), are relatively inexpensive and easily modified
Disadvantages: usually cant be washed, increased skin
temperature at the sitting surface, must be replaced more
frequently than other cushions (approx every 6 months)
 Air-Filled
Made of multiple small air-filled cushions, users buttocks
immerses into the cushion as far as possible without
bottoming out on the seat
Advantages: better weight distribution when compared to
foam, lowest interface pressures if inflated properly
Disadvantages: a heavier cushion when compared to foam,
air-filled cushions are easily punctured, stability in sitting is
decreased, transfers are more difficult, ineffective at reducing
skin pressure if the cushions are under or over-inflated
Gel or Fluid
Usually made of inflated pouches with gel inside on top of a
foam base
Advantages: better weight distribution when compared to
foam, minimal heat buildup on the skin, excellent for
minimizing shear forces during mobility and/or transfers and is
therefore a good choice for the active individual
Disadvantages: heavy cushion, can promote increased skin
temperature and moisture build-up at the sitting surface,
stability in sitting is decreased, difficulty of transfers is
increased
Flexible matrix
Made of thermoplastic urethane that is formed into open cells,
honeycomb
Minimal research in the literature

Resources for Patients and Families:

SCI Info Pages: Skin & Pressure Sore Care, Treatment, and Prevention After Spinal
Cord Injury:
http://www.sci-info-pages.com/skin_pres2.html
Rosen L. Fit to Function: Four areas where function can be improved by selecting
the proper fit of the manual wheelchair. Rehab Management: The Interdisciplinary
Journal of Rehabilitation [serial online]. November 2010;23(10):14-15.
Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment
Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care
Professionals. Washington, DC: Paralyzed Veterans of America, 2000.
Christopher and Dana Reeve Foundation Paralysis Resource Center Website:
Wheelchairs, Seating, Positioning
http://www.christopherreeve.org/site/c.mtKZKgMWKwG/b.4453477/k.3D3E/Whe
elchairs_Seating_Positioning.htm
 Posture, Proper Wheelchair Fit and Seating

Proper Wheelchair Fit:

Observe the patient sitting in the wheelchair with proper, upright

posture, shoes on

o Seat Width
< 1 inches wider than the WC users width at greater trochanters or
widest portion of the thighs
o Seat Depth
1-2 inches less than distance between posterior buttocks and popliteal
fossa
o Seat Height
Measure with wheelchair cushion that the patient will be using in place
There should be at least 2 inches of clearance between the floor and
footplates when the footplates are at their lowest position (allows for
ramp/curb clearance)
If patient will be propelling WC with legs: feet should rest flat on the floor
o Backrest Height
Measure with the wheelchair cushion that the patient will be using in
place
Depends on the users ability to stabilize his/her trunk too high will
impede shoulder motion, too low will provide inadequate postural support
and lead to postural deformities
Observe the user propel his/her wheelchair and check for any impedence
of shoulder motion/propulsion ability by the backrest. If shoulder motion is
hindered, the backrest height may need to be lower
o Backrest Width
inch wider than torso width at the level of the top of the backrest
o Footrest to Seat Distance
Measure with wheelchair cushion that the patient will be using in place
and the patients shoes on
At least 2 inches of clearance between the floor and footplates
 o Armrest Height
Measure with wheelchair cushion that the patient will be using in place.
Measure with user in upright sitting posture with arms at sides and elbows
flexed to 90 degrees, forearms should rest comfortably on armrests

Additional Research/Resources:

o Somers, Martha Freeman. Spinal Cord Injury: Functional Rehabilitation. 3rd ed.
Upper Saddle River, NJ: Pearson Education, Inc; 2010.
o Nawoczenski D. Pressure sores: Prevention and management. In: Buchanen J,
Nawoczenski D, eds. Spinal Cord Injury: Concepts and Management Approaches.
Baltimore: Williams and Wilkins, 1987: 99-121.
o Mayall J, Desharnais G. Positioning in a Wheelchair: A Guide for Professional
Caregivers of the Disabled Adult. 2nd ed. Thorofare, NJ: Slack, 1995.
o Yuen H, Garrett D. Comparison of three wheelchair cushions for effectiveness of
pressure relief. American Journal of Occupational Therapy [serial online]. July
2001;55(4):470-475.
o Akins J, Karg P, Brienza D. Interface shear and pressure characteristics of
wheelchair seat cushions. Journal of Rehabilitation Research & Development [serial
online]. May 2011;48(3):225-234.
o Ferrarin M, Andreoni G, Pedotti A. Comparative biomechanical evaluation of different
wheelchair seat cushions. Journal of Rehabilitation Research & Development [serial
online]. May 2000;37(3):315-324
o Sprigle S, Wootten M, Sawacha Z, Thielman G. Relationships among cushion type,
backrest height, seated posture, and reach of wheelchair users with spinal cord
injury [corrected] [published erratum appears in J SPINAL CORD MED
2004;27(3):262]. Journal of Spinal Cord Medicine [serial online]. September
2003;26(3):236-243.
o Reenalda J, Van Geffen P, Nederhand M, Jannink M, IJzerman M, Rietman H.
Analysis of healthy sitting behavior: interface pressure distribution and subcutaneous
tissue oxygenation. Journal of Rehabilitation Research & Development [serial
online]. May 2009;46(5):577-586.
o Rosen L. Fit to Function: Four areas where function can be improved by selecting
the proper fit of the manual wheelchair. Rehab Management: The Interdisciplinary
Journal of Rehabilitation [serial online]. November 2010;23(10):14-15.

Updated December 2013