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ERGONOMIC SEATING
A TRUE CHALLENGE

Seating and Mobility for the Physically Challenged


Risks & Possibilities
When Using Wheelchairs

BENGT ENGSTRÖM

Some pages from the book


2 / ERGONOMIC SEATING - A True Challenge

"We are all individuals, searching for individual solutions.


When used long-term a wheelchair should, be looked upon as
a body orthosis on wheels."

I dedicate this book to each and every man and woman, boy and girl
who goes through life sitting in a wheelchair

ERGONOMIC SEATING
A True Challenge - When Using Wheelchairs

ISBN 91-972379-3-0

Book Design and Illustrations: B. Engström


Cover Design and Cover Photo: B. Engström and A. Engström

The title of the first edition was


Ergonomics, Seating and Positioning
Published in Sweden, 1993.

© Copyright 2002 Posturalis Books

All Rights Reserved.


This book is protected by copyright. No part of the book may be reproduced in
any form or by any means, including photocopying, or utilized in any information
storage and retrieval system without written permission from the copyright owners.

Printed by Medio Druck & Logistik GmbH, Germany

The production of this book is generously sponsored by


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Contents
Foreword ........................................................................................... 5

1 Humans are physically intelligent ............................................. ... 9


How should one sit? .................................................................. 10
Influenced by the senses ............................................................. 12
Factors that cause fatigue .......................................................... 13
The sensitive human body ........................................................ 14
The skeleton - fundamental principles ...................................... 15
Normal sitting behavior ............................................................ 23

2 Fundamental seating principles .................................................. 37


Tendency and reaction .............................................................. 38
Firm or soft seating units .......................................................... 38
Backrest recline ......................................................................... 40
Tilt-in-space .............................................................................. 41
The trunk, forwards ................................................................... 43
From seat, to pelvis, to trunk ..................................................... 44
Seat contours ............................................................................. 47
Pressure and shear ..................................................................... 49
Seat angle and contour .............................................................. 52
Experience seating .................................................................... 54
Posture and reactions ................................................................ 55
Head- on- trunk sensitivity ........................................................ 57
Correcting the trunk .................................................................. 58
Interpret and understand ........................................................... 68

3 Physical intelligence and physical disability ............................. 71


Fatigue and defence .................................................................. 72
Stressed by pressure ................................................................. 73
Equilibrium and stability ........................................................... 74
Contractures .............................................................................. 76
Posture and inner organs ........................................................... 79
Posture and stimulation ............................................................. 82
Pathological patterns ................................................................. 83
Responsibility and financial aspects ......................................... 88

4 Wheelchair Design & Adjustments ............................................ 91


Design and adjustments ............................................................ 92
Seat cushions ............................................................................. 94
Adjusting seat slope .................................................................. 98
The chair’s back - a body orthosis ........................................... 100
Stability for activity .................................................................. 110
Adjusting step-by-step .............................................................. 111
Positioning the feet ................................................................... 116
Armrests and tray-table ............................................................ 118
4 / ERGONOMIC SEATING - A True Challenge

5 Wheelchair Mechanics .................................................................. 121


Improving mobility .................................................................... 122
Rolling resistance ....................................................................... 123
Balancing the centre of gravity .................................................. 126
Rotatory vestibular stimulation .................................................. 130
Wheelbase .................................................................................. 131
Wheels - camber & caster angle ................................................ 133

6 Wheelchair Mobility ...................................................................... 139


Arm propulsion principles ......................................................... 140
The pushrim - grip ..................................................................... 146
Risking hand injuries ................................................................. 148
Foot propulsion .......................................................................... 150
Foot propulsion principles ......................................................... 151
Compensation and adjustment ................................................... 156

7 Wheeling Skills ............................................................................... 163


Basic propulsion ........................................................................ 164
Prevent and correct falls ............................................................ 166
Balancing on drive-wheels ........................................................ 167
Climbing curbs and other obstacles ........................................... 168
Slopes and hills .......................................................................... 170

8 Seating & Mobility Needs ............................................................ 173


General aspects .......................................................................... 174
Paraplegia .................................................................................. 180
Quadriplegia / Tetraplegia ......................................................... 184
Hemiplegia ................................................................................. 188
Traumatic head injuries ............................................................. 192
Cerebral palsy ............................................................................ 196
Arm patterns .............................................................................. 198
Leg patterns ............................................................................... 200
Hip contractures ......................................................................... 202
Knee contractures ...................................................................... 203
Amputated legs .......................................................................... 204
Elderly - women and men ......................................................... 206
Thoracic kyphosis ...................................................................... 208

9 General Comments

Wheelchair Features / Guidelines .............................................. 213-231

Adjustments and Influence / Guidelines .................................. 233-239


Standard wheelchair adaptation ................................................. 240

Literature / Internet Links ............................................................. 242

Index .................................................................................................... 243


9

Humans Ar
Aree Physically Intelligent

Regardless of what one sits on, an armchair, a The result is always better when the person
stool, an office chair, a car seat or a wheelchair who is responsible for choosing and setting up
the body is always mechanically affected. How wheelchairs is open-minded and very receptive
seating is designed always has an impact. to what the user wants and needs.
This chapter deals with how the seating unit Adapying wheelchairs is sometimes a compli-
may affect the body, in general, and more in cated puzzle. A user who has had a poor position
detail. General influence means how the body for several years is not easily convinced that a
reacts when general features like seat and back “proper” and more upright position is better. The
angles, and/or softness change. Broken down into time the user needs to complete a transition is
more detail the way the body reacts may be often much longer than you expect.
influenced by an area of a seat, the position of a This chapter is about important principles for
footplate or the contour of a backrest etc.. use when setting up seating units, and to a lesser
When you understand how a body may be extent for propulsion.
influenced into reacting by a specific backrest A person’s position is mainly dictated by how
contour, seat angle or seat contour it is easier to the seat and backrest are designed, or adjusted,
decide if a seating unit will suit a person’s needs. to suit the user. This also includes the armrests
To achieve successful and reasonable results, and footplates.
practical solutions and choices should be based The “pitfall” can be when other people dictate
on how the seating unit affects the body, in the too much how the user should sit, based on what
short, as well as the long term. Long term in this they know about seating. It is always worth while
book means many hours daily, for many years. to remember that very few of us can be seated in
When wheelchairs are set up, the goal varies an active way for more than a very short while.
from one user to another, since every user is If a user doesn´t accept a position, take it
unique, physically and psychologically. The seriously and make the necessary changes.
environments users live in can be very different, Experiment, don’t be afraid of making
as can the requirements as to how a wheelchair “mistakes,” they help us to learn. Just make
should function. Each combination of user and sure corrections are made in time
wheelchair is new and, thus, always a challenge.
10

How should one sit? Feeling safe is a crucial factor to enable anyone
to relax when seated. During long-term sitting,
How should one sit to be ergonomically seated? safety is more important than we realize. When
It is not easy to answer such a question. a person has difficulties in changing positions, a
A list of what many people see as important sense of safety and security is of paramount
factors towards “how one should sit” can be importance.
similar to the list below. Feeling safe includes: comfortable pressure,
This points out some of the main factors that reasonable stability with a possibility to move,
are important for a decent sitting situation – and, last but not least, being able to decide when,
allowing a natural balance between functional and how, to move.
stability and healthy activity.
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A stable supporting surface is necessary to When both possibilities exist, position can be
“anchor” the parts of the body that are active, comfortably changed and dynamics are improved.
and/or in motion. Poor dynamics increases the static portion of
When seated, the stability required is for the seating, which causes stress and problems.
pelvis, thighs and feet. With good, but not How much support the back needs when seated
exaggerated, stability provided for the correct depends on what type of activity one wants to do.
appropriate parts of the body, people can be very Where should support be given?
active physically when seated. Seat stability is Again this depends on the desired activity,
often interpreted as meaning that the seat should static rest or dynamic movement.
be firm. This interpretation is discussed below.

One thing is clear though, the way the back is


Besides providing the stability required, a seat supported dictates the stability of the upper body.
that gives such stability must not cause Sometimes too much support, especially when
uncomfortable pressure. Pressure is what creates wrongly placed, makes seating more tiresome
stability but is more efficient if distributed over than less support.
a larger surface. If pressure is concentrated on a
small surface of the body it decreases stability.
Discomfort, due to pressure, results in muscular
fatigue when the user tries to stabilize the Another thing we very often overlook is the
instability of the trunk. necessity to move our legs when seated. Moving
Pressure distribution over a big, soft area gives the legs is one of the important ways of making
more comfort, but, if the area is too soft, stability seating dynamic. We use our legs and feet as
decreases. instruments to influence the upper body when
seated. A more specific analysis of this is given
shortly.

One crucial detail in sitting is the capability of


being active forwards. It is obvious that forward
activities are hindered if it is difficult to lean As I mentioned earlier, it is important to feel
one’s trunk forwards. safely and securely seated.
When an office chair is adjusted with the seat A feeling of being safe can increase comfort,
sloping slightly forwards, forward activities are and thereby, the time that can be spent seated.
easier to perform. You become calmer, physically and mentally.
In such a situation one can easily lean forwards, This makes the seating situation more comfortable
but if the trunk’s tendency of falling forwards is - and functional.
too strong (due to the forward slope) the back
muscles become fatigued.
It should be as easy to lean back and relax as it
should be to lean forwards.
12

Influenced by the senses


Our body is very sensitive to positions. There stand on our feet is not present when we are
are many kinds of sense organs registering seated.
changes in the body. All of them are, of course, I am not saying that interaction between the
important, but in this book the focus is on the legs and the upper body disappears. But, when
ones that register the position of the body. the feet are not loaded under the pelvis their
We cannot “shut off” our sense organs, they go function of being sensitive “organs” for
on registering continuously. maintaining the balance of the body is eliminated.
If no external support is used, the body of a Instead of relying on the feet for balance, we sit
person who is standing is continuously in motion, on two tiny ischial bones. These two bones are
a balancing motion, known as postural sway. We the support surface for the pelvis and, since the
cannot “see” these movements of the body, but trunk is on top of the pelvis, the entire upper body
they are present all the time. balances on the ischial bones.
Feet are designed for standing, walking and Balanced seating requires a well-positioned
running. The sole, the foot joints and foot muscles pelvis. When the pelvis does not have a functional
as well as the leg joints and muscles register and stable position the upper body cannot be kept
pressure and pressure-directions when the foot is in an upright position for more than a few, short
in contact with a surface of support. moments.
The pressure on the sole influences the joints The leg’s connection with the pelvis is through
differently, depending on the magnitude and ligaments, joint capsules and muscles. Because
direction of the pressure. of this connection, the position of the feet and
To maintain balance pressure variations lead legs, as well as their muscle activity, influence
directly to muscular reactions throughout the the position of the pelvis directly or indirectly.
body. In most seated positions the tendency of the
When the muscles balance, and stabilize the pelvis is to tilt backwards. This tendency can be
body, or its parts, in this way, we are seldom blocked or forced by the legs, something we do
conscious that it is happening. The muscles are continuously. It is a natural part of sitting.
automatically activated by the senses on a Sit straight! Sit properly! Sit still!
subconscious level. The reactions and corrections Most of us have said these to our children,
are very precise and continuous. especially when they sit and eat.
Being seated on a chair makes the feet and legs - But what is “proper” seating?
change in relation to the trunk, radically and If we tell a four-year-old to sit properly he will
instantaneously. probably become confused.
When standing, the centre of mass of the entire If we do not know what it means to be seated
body is located over the feet, which are the properly, how can we expect a child to know?
supporting area. When seated, the centre of mass To be seated “properly” is possibly a posture
of the trunk is only over the pelvis, with the that feels good - for the moment.
ischial bones as the supporting area. Whenever our posture-sensing organs register
This means that the smooth, balancing and something negative in a position we re-position
correcting motion, which takes place when we the body, over and over again.
13

Factors that cause fatigue table after a heavy meal. If the company you are
in bores you, and you don’t have anything in
I am sure you have experienced how awfully common with them, I’m sure you would rather be
tiresome it can be to sit, especially when you somewhere else.
don’t want to sit. After a while it becomes torturous to sit upright
Imagine sitting and listening to a lecture which on “that hard chair”.
is not at all stimulating. It has been going on for You begin to plan... What would be the best
nearly two hours. You are sitting in the middle way to get some rest... slide under the table or
part of the lecture room, which is crowded with just gently fold forwards and rest on the remains
people, so you can’t “sneak out”...and it’s thirty of the dessert...
minutes to the next break!
Sitting makes the body’s physical stability Other problems occur for those who travel on
increase. If you also lean against a backrest you long flights in economy class. It may be a ten-
become highly stabilized. This is like putting the hour flight, which is a very long time to be seated.
body in a state of physical “rest”. You may have the middle seat, making it much
You can easily fall asleep when stability more difficult to change position.
increases and few things happen to keep you If you are even more unfortunate, you may
awake – things like a lively, positive lecturer! have been allocated a middle seat between two
Have you ever thought of the fact that an active passengers with no interest in talking to you.
and inspiring lecturer makes us decrease our This psychologically under-stimulating and
physical stability. We forget the backrest and sit physically locked-in position may come close to
more upright, maybe we even lean forwards what some people using wheelchairs experience
towards the speaker - the person who is so every single day.
interesting. Physical activity is strongly linked to
mental activity and vice versa. Below are some of the factors that may cause
Imagine you are sitting in a car and you are the fatigue when seated;
driver. You and your friend have been travelling
for many hours and the last hour you have both too much physical stability
been silent whilst you are driving on a highway. too much physical freedom
The engine is humming and the wind whispering. uncomfortable pressure
The weather is grey and it´s raining lightly. monotony / boring environment
Your eyelids begin to feel heavy. When you wrong chair for the activity
feel you can hardly keep your eyes open, you pull sitting for too long!
over, park the car and take a short walk - to “wake
up the brain”.
Physical inactivity and mental under-
stimulation, or monotony, when seated leads to
fatigue and decreasing alertness. The brain “shuts
the systems down “.
Another situation can be when you are sitting
on a chair designed for more active seating, such
as a chair in a restaurant.
It can be frustrating to be “forced” to stay at the
22

How do we actually sit? Participants experiment vigorously but come


up with more or less the same positions every
I always ask seminar participants this question. time. The different seating positions are given
They are asked to spend a few minutes to find below.
five different ways to sit, using the chair they are These different positions can be divided into a
sitting on for the moment. The most common few categories - the whole body, the legs, the
results are presented here and form the basis for arms and the chair.
analysis and discussion.

WHOLE
BODY

THE LEGS

THE ARMS

THE CHAIR
23

Normal sitting behavior


MECHANICAL TENDENCY
On the left you find definitions of two Mechanical tendency is when
expressions that are often used in the text, they the whole body, or a part of it, begins
are - balance and tendency. to move when muscles relax.
These definitions make it easier for you to
analyse the following exercises that you can do MECHANICAL BALANCE
to experience seating more in depth. is achieved when the centre of mass of
the body (or body-part) has a tendency
The “90-90-90” position to move away from its present position
but you do not sense it.
To sit in a 90-90-90 position means to sit
upright with ninety degree angles of the hips,
knees and ankles. This is accepted as a correct
ergonomic position in the workplaces seen in
offices and schools.
But, a 90-90-90 position is more a theoretically
good position than a practical and functioning
position. In fact, most seated people use such a
position only for very short moments. This tells
us that there is a gap between ergonomic
recommendations and what is used in practice in
real-life situations.
What is the tendency of the pelvis and trunk in
a 90-90-90 position?
Sitting without support for the back you notice Experience it!
this tendency clearly. By relaxing the muscles Sit upright, 90-90-90.
that keep the trunk erect, the tendency is for the Relax - sit upright again - relax - sit up
upper body to collapes. It begins with flexion of again - relax...
the thoracic spine, which makes the pelvis tilt By doing this you can feel that your trunk
backwards and the spine begins to collapse. has a tendency to flex when extending
When this tendency is present and you want to muscles relax.
stabilize the trunk, or adjust it to a more upright
position, many muscles need to be activated.
Do this exercise slowly:
Sit upright (90-90-90). Relax so your trunk
collapses. Adjust to upright again. You will very
soon notice how easily you collapse when you
relax your muscles, and that you really need to
work to get back to, or maintain, an upright
sitting position.
37

Fundamental Seating Principles


A principle is like a rule that stays the same. necessity in changing their sitting position
The seating principles in this book are also like frequently to vary the pressure on the body.
basic rules that do not change. The Principles of Pressure and Pain are
A very simple example: important since they guide us when we adapt
A man sits on a chair. On the chair's seat is a seating systems for long-term sitting.
paper, shaped like a little ball. The paper is under The second set of principles is the principle of
one of the man's buttocks. stability and the principle of balance, closely
At first he does not pay attention to the fact related to the pressure-principle.
that he is sitting on the paper, but after a while Pressure is necessary for stability. No pressure
he begins to feel it, it becomes uncomfortable. means no contact, which means no stability.
- What do you think the man will do? Functional stability on a seat means that it is
Take the paper away of course! But what if it possible to reach/lean sideways without falling.
is not possible to take it away? It does not have The seat surface is supportive, stabilizing the
to be a paper, it can be something in the design buttocks, hips and thighs. Should the seat surface
of chair seat. not be supportive, sideways stability is lost.
Now we can look at a principle, the principle Adapting wheelchairs is always a compromise
of pressure. Should pressure against tissue (here between comfort and function. Comfort means
a buttock) become uncomfortable, the pressure pressure-friendliness and safety, but also positive
needs to be changed to decrease discomfort or activity (an activity comfortable to perform).
to improve comfort. Function is what activities you can perform,
The principle of pressure is very powerful! based on your body's present position.
I do not think anybody with normal tissue Well understood and used, the principles of
sensitivity ignores uncomfortable pressure. The pressure, stability and balance lead to situations
reaction to go away from pressure that stresses that are comfortable and functional.
is deeply integrated in biological life, it is a sub- The most important principle of all is the
conscious reaction. This principle is directly principle of time. Time is what often changes
related to the principle of pain. comfort and function to become the opposite.
We do not want pain, of course not. If the man The principles mentioned are logical and can,
in the example above does not move away from to some extent, tolerate modification. There are
the uncomfortable paper-pressure, his buttock also principles of softness, angles, contours...
will, sooner or later, develop pain. Pressure leads What we cannot modify so easily, is the person
to pain when there is too much pressure-time and we are adapting for, the user. Humans have, in
the pressure is long-term. This fact is simple to principle, limitations on how much change that
understand. Most people do understand the can be tolerated, and it is always time-related.
39

Tendency Tendency
FIRM / 90-degree angle SOFT / 90 degree angle

FIRM SURFACES SOFT SURFACES

The Pelvis -> Stable The Pelvis -> Backward Tilt

The Trunk Falls Forwards The Trunk Collapses Forwards

Stabilizing the trunk Stabilizing the spine

Ex.: An arm put behind backrest Ex.: Arms crossed on chest

Ex.: Crossed thighs Ex.: Crossed lower legs

Muscular Fatigue Muscular Fatigue

Falling Forwards Sliding Forwards Collapsing

TRUNK FALLS FORWARDS TRUNK COLLAPSES


Compensation: Slouching Compensation: Slouching
44

From seat to pelvis, to trunk It is mainly the buttock muscles, the glutei that
prevent the pelvis from tilting forwards. They
A seat’s quality and features directly affect the keep the pelvis in position when the feet press
pelvis. The features are angle, softness and against the floor.
contours. By having both feet under the seat, the
When you sit on a horizontal, planar seat with possibility to press is gone and the response is
your feet on the floor just in front of the seat, the different.
pelvis has a tendency to tilt backwards. It is easy The extension of the spine is larger and moves
to feel the muscles extending the spine when one higher. The reason is that the pelvis, “anchors”
relaxes. the trunk-extending muscles. The position isn’t
By changing the seat’s angle, backwards or stable, which leads to compensation. To prevent
forwards, this tendency increases or decreases. a fall forwards one moves weight to a higher
Simultaneously, the trunk - the spine - is level in the trunk.
influenced to flex or extend. The forward-tilted seat increases the trunk’s
This co-operation between the seat, pelvis and tendency to fall forwards and stimulates trunk
spine is easy to observe and feel. extension, so it is very important where the feet
are positioned.
To give you a direct and unquestionable
FORWARD SLOPING experience of how correct this statement is, try
Place someone on an ordinary chair, such as a the following:
kitchen chair. The person sits upright Sit upright on the front part of a chair’s seat.
approximately five centimetres from the backrest, Lean your trunk forwards without letting your
with her feet on the floor under her knees. Tell the arms have support against your legs. Stay in this
person to maintain an upright and well-balanced position for a few seconds.
sitting position. Now, slowly lift up both feet. Can you do it
Now tilt the chair forwards a little. without falling forwards? No!
When this is done, the seat slopes forwards, so To avoid fatigue when sitting on a forward-
the pelvis is moved up and forwards. The person’s sloping seat (planar surface) requires normal
reaction is to extend the trunk to prevent herself muscle functions and endurance in the trunk and
from falling forwards. legs. Even with functional, fully functioning
Rock the chair slowly. The seat surface changes muscles it can be very tiresome to sit on a seat
between horizontal and sloping forwards. It is that is sloped forward.
easy to see the trunk’s movement, extension When it becomes tiring, a normal compensation
when rocking forwards and flexion when rocking is to slide forwards for stability.
back again. I do not mean that sitting on a forward- sloping
As long as the person’s feet are on the floor the seat is unhealthy. What I mean is that it can be, if
trunk extension is well controlled. the contours are incorrect.
Try this when the person’s feet are placed It is always better if forward sloping is combined
under the seat and her soles face upwards. with anatomical contouring since this improves
The legs´ stabilizing effect on the pelvic girdle stability. The key is pelvic stability. If the seat
is lost. Pelvic stability (blocking it from rotating stabilizes the pelvis, it decreases its tendency to
forwards) is greatly needed to prevent the trunk rotate forwards. This allows the pelvis to be the
from falling forwards when the seat is rocked trunk’s “anchor” and extension will be more
forwards. normal.
45

The reason I analyse forward-sloping seats in


this book is their fantastic influence on users.
Using this type of seat I have often had the
opportunity to stimulate natural trunk extension
(even for severely impaired persons) in a much
better way.
Many more persons than we believe benefit
from sitting on a seat that is slightly sloped
forwards, and which is well contoured.

BACKWARD SLOPING
Let the person stay on the same kitchen chair.
Tell her to try to maintain her trunk in an upright
position when you tilt the chair backwards.

Tilt the chair back in space, slowly. A forward-sloped seat tilts


the pelvis forwards , making
This time the seat tilts the pelvis backwards.
the spine extend.
For the trunk to stay upright, the pelvis needs to
keep its position, which requires many muscles
to work.
As soon as the person relaxes her trunk-
extending muscles, her thoracic spine flexes.
This forces the pelvis to tilt backwards.
A backward-sloped seat stabilizes the pelvis in
a backward-rotated position, which makes natural
trunk extension more difficult.
Backward sloping stimulates trunk flexion,
while forward sloping stimulates extension.
The leg response (opposite to forward sloping)
is that when leaning forwards the legs extend
easily, making the feet come off the floor (or
footplates).
This isn’t at all strange. When a person wants
to tilt the pelvis forwards, from a backward
position, the hip flexors and knee extensors are
activated to assist the pelvis as it is tilted forwards,
and the legs lift.
A backward-sloped seat also makes the trunk A backward-sloped seat tilts
more stable backwards. the pelvis backwards, which
For the pelvis to have a functional, more upright makes the spine collapse.
position on this seat, the backrest needs to support
the pelvis efficiently.
47

SEAT CONTOURS
Contours should be looked upon as many
“angles” which, together, form a shape.
What is true for angles is true for contours, the
final result is important since it decides the
position of the legs and pelvis. A seat is more
functional and comfortable when it is
anatomically contoured.

I will briefly describe what may happen on a


seat surface that is planar.
A horizontal seat surface often makes the thighs
lower near the knees, due to a compression of soft
tissue. A mechanical pivotal point is created at
the front edge of the seat (top figure on this page). Horizontal, planar seat surfaces often
The part of the leg in front of the seat move increase pressure against the front of
downwards and the upper part of the leg move the thighs and on the ischials.
upwards. This lifts up the pelvis, which is then When there is a backrest this
tilted back by the weight of the trunk, often stimulates sliding on the seat
making the pelvis slide forwards.
This result is decreased, or eliminated, by a
backward sloping seat surface.
A horizontal, anatomically contoured seat is
thicker under the thighs, preventing them from
being lowered. This makes them have a more
horizontal position, which improves the stability
of the pelvis.
To distribute the body’s pressure against the
seat surface evenly, the contact should be as
congruent as possible. For many people, a planar
seat surface is uncomfortable to sit on long-term
due to high, local pressure on the ischial bones
and other bony parts.
On the other hand - for most people (but not all)
- an anatomically contoured surface is much
more comfortable for the long-term.
A planar, firm seat is said to improve upright Soft, planar seat surfaces easily make
sitting. This is perfectly correct. the pelvis tilt sideways, which
The reason a firm, planar and horizontal seat develops scoliosis in the long term.
stimulates trunk extension better than an Stable surfaces can prevent this, if the
equivalent but soft surface is the position of the pressure does not cause discomfort.
pelvis in space.
48

A soft seat allows the ischial bones and sacrum


to “sink in” more than a firm seat, which makes
the pelvis tilt more.
It must be added that the degree of pelvic tilt
depends on the interaction between the seat and
the backrest.
A firm seat surface makes it easier to achieve
upright sitting. Why is this so? How long does it
An anatomically contoured seat is adapted last? Is there a time limit?
to the skeleton. The shape distributes pressure “Sling” seats are not very healthy to sit on in the
efficiently against thighs and pelvis. long-term. They often make you sit
The “Ischial Support” stabilizes the pelvis, asymmetrically. A planar and firm seat is better
which is beneficial for the entire spine. but, after a while, may be too hard.
A soft seat is comfortable in the beginning, but
poor stability makes the trunk collapse, which
causes fatigue in the long term. What is a “correct”
and proper seat?
The pelvis and legs need stability and an even
distribution of pressure on the seat.
An anatomically contoured seat is efficient. It
provides pressure distribution as well as stability.
Should it be necessary to decrease pressure, the
contour can be changed, or the seat made softer,
or both.
When experimenting with seat softness and
Contouring distributes pressure and improves
contours, the pressure experienced by soft tissue
stability. The supporting surface under the
ischial bones should be horizontal (line) to and the stability experienced by the skeleton and
avoid pelvic obliqueness.. muscles are altered.
Setting up a seat is a balance between pressure
distribution and fair stability.
Even if a planar seat can be uncomfortable
(long term) some persons need such a seat.
People having a pronounced/severe lordosis
and a forward-tilted pelvis often shift weight to
the thighs if the part under the pelvis is too low.
For them, an anatomically contoured, horizontal
seat, or a planar, backward-sloped seat can cause
stress. If, on the other hand, the seat is contoured
and slightly forward-sloped it often functions
better. Such a seat can be very appropriate for
people with Polio, Rheumatism or Spina Bifida.
Supporting surfaces against the thighs from
each side also stabilizes the pelvis.
49

PRESSURE and SHEAR


Pressure per unit area is lowered when
distributed over a larger contact surface. Thus,
the goal is to create a large contact surface
between the body and the seat.
For low pressure on the seat, body contours
dictate seat contours.
The pressure we normally talk about is
perpendicular to the seat surface. This pressure
compresses soft tissue.
Besides the perpendicular pressure there are
forces that deform tissue from the side. These are
known as shear forces and are difficult to measure.
Shear forces “push” parallel, soft tissue layers
away from one another, which tears and stretches
different connections and blood vessels,
penetrating many layers.
It is uncomfortable to stand if the pressure When standing, shear on the feet from
against the soles is static. We want pressure to the floor develops when the person leans
change, in other words, we want pressure to be against the wall.
dynamic.
When you lean gently against a wall it is more
difficult to change the pressure on the feet,
pressure is more static.
The pressure on the wall increases when your
feet move away from the wall, and the shear
forces on your soles increase.
The same thing happens on your pelvis when
you sit. When your trunk leans against a backrest
(the “wall”), pressure from the backrest pushes
your body forwards. Due to seat friction, the soft
tissue stays in place whilst the skeleton, in this
case the pelvis, moves - slides - forwards within
the soft tissue.. This pelvic sliding of the ischial
bones deforms the soft tissue between the seat
and the ischial bones.

Seat cushions may protect soft tissue from


perpendicular pressure. A decrease of seat shear Seat shear develops when the pressure
is achieved by contouring the backrest. Trunk on the backrest increases.
balance and extension decrease pressure against The shear distorts the soft tissue layers
the low and middle part of the backrest. This when the person slides forwards.
decreases seat shear.
68

Interpret and understand By looking at how a person is sitting you


receive many invaluable clues as to — why?
There are several goals in sitting. So we sit very A sitting position can tell you what a person is
differently. An important condition when trying to achieve or create with the help of his
analysing and interpreting other people’s sitting trunk, head, legs or arms.
behaviour starts with discovering these goals. Users sitting with their knees pressed together
Of course, most of us can “see” that people sit do so for several reasons. If you change the
differently but the ability to see what a position position of a user’s legs and feet to a more
reveals, physically and psychologically, is “correct” one you may influence the user’s trunk
something you learn. in a negative way. It may seriously influence this
It cannot be emphasized too often that the most user’s ability to work with his hands.
effective way to learn how seating “works” is to If, instead, you divide a sitting position into
use your own body as an “experimental functional body segments — feet, legs, pelvis,
workshop” and to thoroughly observe people lower trunk, upper trunk, head arms, and hands
sitting in many different environments. — you may very soon discover how the legs
Every human who sits is an individual with his influence other parts of the body. Starting by
or her own conditions and desires. Major demands adjusting for some other part first, usually the
are placed on anyone who sets up and trunk, the user’s legs may correct themselves.
individualizes a seating unit for somebody else. Interpreting a sitting position is like putting a
If you want to become a skilled “wheelchair- “puzzle” together. Sooner or later you learn,
fitter” you have many reasons to observe and understanding what the pieces mean and how to
practise seating. place them in relation to each other. Practice and
Sometimes you encounter complicated experience develop your skill in putting the pieces
problems to solve to enable the user to sit with “correctly” together, using less and less time.
fair-to-good functionability. From time to time Every person you meet is a new “puzzle” but
you may feel that the problems you are responsible sometimes this new person does not match your
for solving are “unsolvable”, especially if you do experience. This is a challenge, and opportunity,
not know where to begin. to learn more!
For the many sitting positions in which the goal A sitting position is a position of the body that
is some sort of activity it is important that functions well, for the moment... This moment
functional conditions are created for the upper can last for a few seconds or many hours. How
trunk, head and hands. long it lasts depends on if the person who is
It isn’t easy to create a functional position if the seated is capable of changing position or not.
person who is seated doesn’t have the capability Those of us who work directly with setting up
of sitting the way “I want to”. Most of us have an and designing chairs, with or without wheels,
“inner picture” of how people “should” sit, a must realize that no matter what we do — people
picture “guiding” us when we want to make good still sit the way they need in order to achieve
positions for others. comfort and functionability.
If you meet a person who, due to long-term I maintain that this is true even when the
poor seating, has physical difficulties such as seating unit doesn’t function well, the person is
stiff joints or tensed muscles, it is good to realize sitting very poorly and the sitting-time is
that the change you want to create for this sitting extensive.
person requires some time. It may be a long-term The big difference between persons who can
process! change position and those who can do it only
69

with great effort is that the person with difficulties


uses fewer positions during the same amount of - Why does the person slide on the seat?
time. These persons’ “right now” positions just
last longer. - Why does the person always lean towards the
What is it that makes us continuously change right side - why not the left?
position when we sit?
Life! Standing as well as seated... - Why does this man slide off the seat of his
Physical forces always influence your body. wheelchair even though he has a belt around his
How your body is influenced is, to a great extent, chest? And always at lunch-time!
dictated by how your body is built and what you
do when you sit. - Why does this woman place her left foot on the
The chair you use has the greatest influence on seat so often?
your body. This means that the interpretation of
how a person places her body in the chair tells us - Why does this girl keep crossing her legs all
about this particular seating unit, its seat and the time?
backrest and, perhaps, also armrests.
A wheelchair’s seating unit may also be - What is the cause of this woman not being
equipped with footplates, leg rests, calf supports, able to keep her head up?
trunk supports and a headrest.
Seats and backrests have features such as being - Why does this boy always extend his legs and
soft or hard, horizontal or angled and planar or rotate them inwards?
contoured.
The human body is a live mechanical system - Why is it more difficult for him to keep his
made of pieces of bone and muscles. Joint trunk up when his legs are corrected?
positions and muscle tension are registered and
controlled by the nervous system every moment. We can keep on asking many, many questions
Every change, like altered pressure on a body- as to why people using wheelchairs sit the way
part or an altered position of the entire body or they do. We can also keep on forever trying to
body-part is registered by sense organs, directly answer all the questions if we do not steer away
reporting to the brain which acts and influences from focusing on symptoms (what we see) and,
nerves, if necessary. instead, start searching for what is the cause of
We, the observers and interpreters, need to see what we see.
and understand how each seating unit influences When we begin to know what actually creates
and creates reactions in the body of the user who the positions we see in people using wheelchairs
sits in it. we can begin to change things more appropriately.
A person who is capable of continuously shifting Knowing how to interpret sitting positions
position avoids the risk of harmful, static seating. increases our knowledge of how seating units
Persons with physical dysfunctions may not be influence their users.
able to defend themselves against the dangerous When we begin to grasp “what influences what”
influences of poor seating units. we will better understand how to design and
Their sitting positions and behaviour are what adapt wheelchairs, not just simply for sitting but
we need to interpret and understand, based on for much more functional sitting!
individual functions and how the seating unit’s
features influence the user in several ways.
71

Physiological Sensitivity In
Physically Challenged Humans

The wheelchair, an assistive device, always Being deeply involved with seating and
influences the user in some way. wheelchairs you soon learn not to blame poor
It can create seating of reasonable comfort, positions on a user’s impaired function. If that is
which functions well, or lead to additional the case you should change your profession! It is
problems. Physical treatment influences the body usually possible to achieve sitting positions that
being treated. Effects can be positive, neutral or prevent serious sitting problems.
negative. We have only two choices – to do things well
Wheelchairs influence. For a user who uses or not to do them so well. There are NO short-
one every day, with few opportunities to stand cuts to creating good seating.
and walk, a wheelchair is a physical treatment. Common problems that develop because of
The goal of this treatment is to improve, develop poor seating are pressure injuries, joint and muscle
or maintain functions and to prevent further contractures (shortness-stiffness), muscle
deterioration and/or injury. weakness, high or low muscle tension and
We must never overlook poor sitting postures negative effects on inner organs.
in wheelchairs, postures that may lead to serious Other common and very negative functional
impairments and injuries. problems are difficulties in staying awake,
If a user is sitting poorly you will always find decreased appetite and impairment of vital daily
the cause when you examine the wheelchair. activities (primary ADL) such as eating and
Faulty seating is not the fault of the user! Users dressing.
sit the way they are influenced to sit - by the When reasoning about problems it is also natural
wheelchair. to wonder how much seating problems “cost”
What then, is a poor sitting posture? society. Pressure sores are concrete and the cost
Any posture, which is, or may become, static to heal a sore can be “calculated”. It is, however,
and long-term may develop into a harmful sitting not so easy to put a price-tag on a stiff hip, a
posture. scoliotic spine, decreased lung capacity,
Some people assume that when a wheelchair obstipation, swollen legs or neck pain. Poor
user sits poorly it is because the user has impaired seating is probably extremely costly! If we want
functions, is handicapped, and “this is the reason to know how costly, more research is needed.
he/she cannot sit properly”.
72

Fatigue and defence extension of the spine or sliding forwards on the


seat are two other ways of helping.
What happens if the chair you sit on is not Crossing arms and/or legs and extension of the
sufficiently comfortable? spine are activities which may cause muscles to
It creates discomfort and makes you tired. fatigue after some time.
The many different “techniques” we use (like The alternative - sliding forwards on the seat -
crossing our legs or arms) can be effective ways is convenient and the most common way people
to temporarily increase comfort. stabilize their trunks, to avoid excessive load on
There can, however, be a big difference between muscles. This is not a problem as long as it is
a person with optimal functions and a person short term. It will, however, become harmful if
with impaired functions when comparing how maintained long-term, leading to muscular
arms and legs are utilised. inactivity and back problems.
The non-disabled person does not sit still, Every person compensates a poor posture and
frequently changes position. When sitting so does a wheelchair user. We do what we need
becomes tiring, it is natural to stand up and do to do to avoid discomfort, to prevent the body
something else. from being harmed.
A wheelchair user may have no other alternative All human beings are very intelligent
than to sit in the wheelchair the entire day. Some mechanically and physiologically. If we are sitting
users are able to change their sitting positions, unpleasantly our bodies’ senses send information
others are unable to do so. requesting protection against physical stress. We
If a user’s trunk has a strong tendency to are “defensive” because we do not want to lose
collapse, crossing his/her thighs, or his/her arms comfort and functions and try to stay away from
on the chest, prevents this from happening. situations that cause pain!
But, if this is not possible, there are other A wheelchair user’s protection against physical
functional alternatives to help the trunk. Active stress, a perfectly natural reaction, often causes
other types of serious problems.

When trunk-extending muscles fatigue, you collapse.


- How do you protect your body from collapsing?
73

Stressed by pressure The pressure on the backrest and seat-front of


the chair makes your pelvis lift. When you stop
The first thing one experiences when sitting pressing with your legs you may slide forwards
down is how hard, or soft the seat, backrest and a bit. If you relax you can feel that the pressure on
armrests are. It may feel fine at first, but after a your upper (thoracic) spine has increased.
few hours a chair, which was comfortable, If this is uncomfortable and you want to change
becomes uncomfortable. This is the normal case the pressure by changing position it can only be
in real life! done if you move your trunk away from the
Time is always the deciding factor when backrest. Feel where, and how, the backrest
“comfortable” changes to “not comfortable”. presses against your back, and the seat against
We all have a tolerance level that decides when your pelvis and legs.
pressure is becoming uncomfortable. Some Now re-position yourself. Sit on one buttock,
people are thin and others fat, some are young with your pelvis in an oblique position. This
and others old, some people have big, well-built makes pressure move from your ischial
muscles whilst other´s muscles have never done tuberosities and sacrum to your buttock’s soft
hard work. tissue.
Soft tissue can adapt to, and thus tolerate, a How does the backrest press?
seating unit’s long-term pressure. But even if this Your trunk rotates when you sit obliquely and
is so, pressure against the body will, sooner or presses against your rib-cage on the same side as
later, become a source of stress for a person who the buttock you are sitting on. After a while this
sits for a long time. can cause discomfort.
- How much is a chair pressing against you and Slide forwards a bit more and the pressure
what can be dangerous pressure? changes. Every time you slide, pressure against
Do the following exercise: the backrest increases. Should you choose to
Sit on a chair and make sure your pelvis and deviate by leaning your trunk sideways, the
back have good contact with the backrest. Put armrest-plate may stop you and press against
your feet flat on the floor. your ribs (it hurts!).
Feel how the seat presses against your thighs Pressure against the body often develops as
and ischial tuberosities (sit-bones). described here. So, it is not surprising that
Now, lift your heels up (let your toes stay wheelchair users may risk sliding off their seats
down). This increases the pressure against your and ending up on the floor. When that happens,
ischial tuberosities. This is the situation when it is not unusual to stabilize the user in the chair
wheelchair users have their footplates too high. by using specific stabilizing devices. Different
Move both feet forwards on the floor. This types of belts, vests or even tables can prevent the
instantly increases the pressure on your thighs user from sliding off the seat.
and decreases the pressure on your sit-bones!
This is a common and effective way of decreasing People sit the way they are influenced to sit!
unpleasant pressure on ischial tuberosities. Uncomfortable pressure - from the seat, backrest,
But another thing is also happening. headrest, armrests, leg rests and footplates creates
Press your thighs a little harder against the seating problems. The cause why many users sit
front of the chair seat. The ischial tuberosities poorly is to be find in the seating unit. Stress is
pressure decreases more and the upper part of compensated - it is physiologically intelligent!
your trunk presses against the backrest (the mid Poor seating should never be blamed on the user.
to top part).
74

Equilibrium and stability


As a factor causing discomfort, pressure is
rather well understood. Two other factors, which
are greatly underestimated as causes of harm in
sitting, are poor equilibrium and lack of stability.
Most people can feel that poor equilibrium and
Collapse of the thoracic stability in standing makes it difficult to being
spine makes the head drop functional when standing and walking.
forwards. Over time this
A person who has consumed alcohol, impairing
makes the neck region stiff
his balance, often needs a wider surface of support.
and painful.
One way to create more stability is to move the
feet apart.
If you are sitting with poor equilibrium and
have a tendency to fall (in any direction) you will
improve stability, sooner or later, by decreasing
the “fall-tendency”. At the risk of saying this too
To be able to look
straight ahead a many times, I repeat - the most natural thing to do
person with a is to slide forwards on the seat, to a greater or
strongly kyphotic lesser extent. This is, in fact, the most common
spine, leans the head position in a wheelchair. Being in this situation is
to one side in not the problem, it is staying in such a position,
combination with long-term.
neck rotation.
Long-term, this When the spine collapses the head falls forwards
leads to neck
- or backwards.
contractures
A user slides forwards on a horizontal seat. The
.
unit’s backrest is upright. This make the head fall
forwards and downwards.
If the seating unit is tilted back, when the
thoracic spine flexes the head has a tendency to
If the thoracic spine flexes fall backwards, so a correctly adjusted headrest
in a backward-tilted is needed.
position, the head falls Many users who are positioned like this, and
backwards causing over- who drop their heads backwards or forwards, are
extension of the neck. elderly, or have had traumatic brain injuries.
The spine must be prevented from collapsing.
Improving natural, spinal alignment allows a
more functional and balanced position of the
head. This is achieved by adjusting the seat and
backrest correctly.
84

Time and compensations


It is to some extent possible to "classify" sitting
patterns based on physical impairment and quality
and features of seating units. Many positions we
see in long-term sitting are logical and, thus
possible to explain.
Time and influence may lead to...? Here are some explanations, based on changes
made to a seating unit and the user's response.
The bottom-line is to change how physical forces
are influencing a user.

SLIDE FORWARD AND RELAX


The most common compensation among
wheelchair users, and every other human being,
Sliding forwards is to slide forward on the seat.
on the seat is short The backrest is too upright or high, "pushing"
term positively stable.
on the trunk from behind. This causes muscle
fatigue and trunk instability. The smart thing to
do for more trunk stability is to move forward on
the seat and relax. This makes the spine flex --
downwards, forwards and sometimes sideways
-- and you risk the development of a major
thoracic kyphosis and, sometimes, a scoliosis.
The measure to take is to improve the trunk's
stability and upright posture against the backrest.
If it is easy (low muscle activity) to have the
trunk against the backrest the need to slide
decreases.
But...sliding and
slouching also PRESSURE - FOR STABILITY
create inactivity A way to "assist" the trunk to stay upright
and fatigue, (prevent flexion) is pressing the feet against the
sometimes pain. foot plates and the hands against the armrests
This is a very direct and effective way to
stabilize the trunk, preventing it from falling
forward. If though, "pressing" becomes a habit it
may result in a user "trapped" in an extensor
pattern. This may create serious functional
problems such as difficulties to lean the trunk
forward for - eating - standing up - transfering -
walking, etc..
If this "pattern" has been used for a long time
(several years) it could be difficult to solve, but
85

it can also change rapidly to the better. The


measure is to use (once again) to adjust the
backrest, making the trunk stable and balanced
against the backrest. These users are often very
sensitive to where the trunk is placed in space.
Leaning too much backward or forward may
trigger the extension. Be gentle and patient!

LEG AND TRUNK EXTENSION


Users who have physical impairments from
birth like in Cerebral Palsy often have seating
units that make their sitting tilted back in space in
relation to gravity.
The trunk is moved to behind the position it
should have had if it was upright. Suppose that
this person wants to move the trunk forward to sit
more upright.
To make this mechanically possible the Centre
of Gravity (CoG) of the trunk needs to move
By pressing against one
forwards. To be sitting upright the CoG needs to
or both armrests and/or
have a position over the hips.
one or both footplates the
trunk is assisted - or
Step 1 The chest moves forwards / trunk flexion pushed - to an extended
position.
Step 2 The pelvis rotates forwards

Step 3 The trunk extends

After step 3 the trunk should be upright...


The beginning of the movement, step 1 is a
normal "sit-up" activity. The problem is that it is
done "uphill" - the seat is backward-sloped.
Doing a sit-up uphill requires more muscle force.
An attempt will trigger the legs to extend and, if
the person tries to sit up as "a habit", the extension
of the legs is an important part of this habit.
If this person's abdominal muscles are weak
and he/she tries to lean forwards from a tilted
position and the legs are triggered to extend, the
A pattern often seen in children
response is trunk extension. Extended legs help
with Cerebral Palsy. The pattern
the pelvis to pivot forwards. If the abdominal is so common that it is looked
muscles cannot keep the ribcage's position the upon as a "CP-pattern".
forward rotation of the pelvis, and the thighs'
pressure against the seat, extends the spine.
86

The extension of the spine presses the trunk


against the backrest. This blocks the trunk's
movement forward and the movement becomes
more blocked when the thighs press against the
seat front.
The solution is to make it easier for the person
to move the trunk forward (if this is what he/she
wants!). A fast way to test a person's response is
to place a small pillow behind the pelvis, put on
a hip belt and place wooden plates under the
drive-wheels -- tilts the seating unit forward. Let
it stay like this five-ten minutes.
Sometimes it is surprising to see how fast a
person's arms and legs relax and are lowered in a
more upright sitting position.
Success when doing a permanent set up in
accordance with these guidelines is to give the
Changing position now and then, being
dynamic, is a good way to influence for legs and lower trunk functional stability and the
changing undesirable, negative sitting upper trunk a possibility to move. It is a delicate
patterns to become more natural. balance, demanding observation and follow up.
One thing that needs to be observed is when the
person has a mild or moderate scoliosis. A more
upright posture makes the scoliosis increase, if
the backrest does not have functional side
supports. Remember, if the seating system is
dynamicit is an advantage to alternate the person's
trunk position during the day.

ARMS AND LEGS FLEX


A brain-injured person often has a wheelchair
with a high back and a headrest and is seated
tilted back in space.
A brain-injured person who has been a
functional walker used to use normal
compensations like crossed legs and crossed
arms. If the tendency of the trunk is to collapse
and/or fall forward it is normal to stabilize the
trunk by using the legs and arms in this way.
If coordination of arms and legs is a problem,
crossing them can be difficult to do.
An often encounered arm and leg pattern If the sense organs register and "tell" the brain
(sitting as well as in bed) among brain that the trunk is losing its position it may trigger
injured adult persons after head trauma. specific muscles to begin bending the arms
towards the chest and bending and pulling up one
87

leg. These movements may be an attempt to


cross the arms and legs. It is not done consciously
but subconsciously because this functioned before
the injury.
We can also see this as primitive reflexes! But
if the flexed arms relax when the seating situation Forward pelvic tilt
is improved and the hands stay on the legs, one extends the spine.
important cause was the poor position. It mechanically creates
Create balance and stability. Make sure that the functional stability
when trunk muscles are
upper part of the spine, the shoulders and the
weak. When it works it
head can move smoothly. is also used by some of
the strong users.
PELVIS FORWARDS
Tilting the pelvis forward is an effective way to
create an extended and stable spine. The spine
becomes stable in all directions and can be used
to compensate impaired trunk muscle function
and balance.
Some users are highly dependent on such
compensation, to be able to sit upright.

TRUNK DEVIATION AND ROTATION


Side-deviation and rotation of the trunk is
normal when we sit. It is also very common in
hemiplegia.
This user moves the pelvis asymmetri-cally
forward on the seat. The pelvic position makes
the spine flex forwards and sideways and it also
rotates. This makes the trunk tend to fall sideways.
The cause can be impaired trunk muscle
function in combination with poor body
awareness. The cause can also be the user's foot
trying to reach the floor or the hand trying to
reach the pushrim.
The most common cause, however, is when
wheelchairs are not set up correctly for
comfortable sitting and effective mobility.

A user who has had a stroke often slides


and deviates the trunk to one side which
can be the only effective way to stay
mobile.
96

A home-made seat solution


BASIC SEAT CONTOUR
In many countries the possibility to have a
functional seat cushion is very limited. This can
be because there are no such cushions available
1 2
or society will not pay for it. After all, high-tech
good cushions cost a lot of money. However, the
3 money spent on a cushion is worth every cent if
it prevents pressure sores and posture problems.
Of course! But real life may be that the money (or
1 Slightly lower under the pelvis.
the will to pay) may not be there!
2 In front of the pelvis 3 The seat needs to Even, if you do not have a functional
it should be slightly be a little higher manufactured seat cushion it is still possible to
"uphill" to prevent under the thighs for make the seat surface function rather well if you
forward sliding. effective leg support.
follow some basic principles shown in the illus-
When factors 1, 2 and 3 are functional they trations on the following pages.
create; For better pressure distribution, the surface
should smoothly follow the body contour -- the
Pressure Relief contour of the skeleton. In the example here on
Pressure Distribution (also on surfaces) how to build a functional seat surface it is assumed
Pelvic Stability / Slide Prevention that a backrest is used.
Leg Support and Trunk Stability

Such a seat surface also makes the legs, the


1 The seat surface under the pelvis should be
pelvis and the trunk more stable. a little lower (approx. 2-3 cm) than under the
legs, to make the pressure against the ischial
tubesosities and nearby soft tissue decrease.

2 An important reason for making the surface


1 2 3 change from low under the pelvis to higher under
the legs is that the area connecting low and high
creates an anti-thrust function. It makes the pel-
12345678901234567890123456789012123456789012345
12345678901234567890123456789012123456789012345 vis more stable by preventing it from sliding
forwards. It is very important that this area is
If you have a planar foam cushion you smoothly rounded, to avoid high pressure locally.
can make it function much better by
changing its shape a little. 3 The slightly higher surface under the legs
Add a pelvic stabiliser (opposite page), improves leg support and make the legs more
or a foam-layer with higher density stable sideways. This also, makes it easier for the
than the seat cushion, under the cushion trunk to stay against the backrest, which is the
where the legs are (dark grey). Make important reason for doing this. Functional thigh-
sure that it is placed just in front of the against-seat pressure improves trunk-against-
the ischial tuberosities (sit bones).
backrest pressure. The result is less muscle force
The function of this more anatomically
contoured cushion improves seating. being needed to maintain the upper body against
the backrest.
97

Many wheelchairs have sling seat upholstery.


The problem with this, especially when the sling
is hanging down a lot, is that the seat cushion
follows the sling (see below, A) making the legs
move closer to the to midline of the seat. One
solution to this problem is to put a wooden board
on the seat to improve leg position. But a pressure
problem may develop if the firm board under the
cushion begins to create local pressure.
Instead of a board it is possible to better utilize
the sling shaped seat by placing a cone-shaped
wedge on the seat front in midline under the
cushion (inside the cushion cover) (see B). The
wedge should be 2-3 cm high forwards and,
closer to the pelvis, it should be very thin. 3 3
Such a piece used on sling upholstery makes
the front of the seat contoured to the legs and the
2
area under the buttocks stays rounded (C).
1
Seat cushion information
There are plenty of cushions to choose from
and the only way to really know or have a chance
to know is to try them out, not only on users. We Pelvic Stabilizer (VICAIR) function areas.
who prescribe them need to try them out
thoroughly.
Many seat cushions are said to be specifically
designed for long-term sitting. Some are clinically
tested and some are not. Be critical, read the A
Legs before
product information and ask questions.
Our main responsibility is to protect the user
from developing a pressure injury and other
types of seating problems. It is not uncommon
that people who adapt wheelchairs compromise B
between protection against high pressure and
protection against physical deformaties (long- Legs with wedge.
term poor posture) and choose pressure protection
before postural function.
It is fully possible to fulfill both objectives -
pressure and posture protection if we know what
(product) influences what. It is important to learn C
Rear
how the different products you see and try really
influence the user. Seat cushion representatives A cone-shaped wedge under the front of the
inform us but it is our responibility to evaluate cushion improves the sling seat by making it
the user-benefit of every product we prescribe. more anatomically contoured (see text).
100

The backrest is a personal differences, many wheelchair users can be


orthosis for the trunk comfortable on standard seat cushions.
The backrest on the other hand needs to be
Numerous reports have been written about strictly individualized since every person needs
factors leading to the development of pressure to be individually balanced and positioned in
injuries during prolonged sitting. In order to relation to gravity.
prevent serious harm from pressure, many types When standing upright we balance our body
of pressure-decreasing seat cushions are in use using our feet as support. When sitting upright
today. we need to balance the trunk with the pelvis
Some manufacturers have developed adjustable (ischial tuberosities) as support.
seating systems for wheelchairs. Such systems It is much more difficult to maintain upper-
include both seats and backs. Some manufacturers body balance when sitting. So, the backrest needs
sometimes integrate contourability as a standard to be adjusted optimally for each individual. The
feature. goal is to assist the upper body to achieve its
A seat needs to be individually contoured for optimal position, a position that makes it possible
user protection and trunk stability. The seat works to change between balanced activity and stable
as the base for the trunk, but, for the seat to be relaxation. The backrest's function is to stimulate
fully functional, it needs to be in harmony with natural upper-body function.
the backrest. For any user who is in long-term contact with
The seat's role is to distribute pressure and a backrest, and who may not easily change
create necessary stability. The backrest assists position, the backrest should be considered an
the trunk to reach fair stability and the balance individual trunk orthosis.
required for various types of activities. Not even for the many, many people who do
Let's suppose that a seating unit's seat and not have any physical impairment and who can
footplates are well adjusted. This gives us an shift and change, a functionally contoured
effective basis, and about half the unit is set up. backrest may not function well (car seat, office
The footplates and seat surface create a stable chair, airplane seat) if it is insufficiently contoured
platform, focusing on the pelvis and legs. This by design. Salvation in such situations is the
gives half the body a good start. possibility of standing up and doing something
Now, the other half of the seating unit is adjusted else...
for the rest of the body, the trunk. This includes
setting up the backrest and, in most of cases, the For many physically challenged people who
armrests. are sitting in wheelchairs this may not be an
When considering the contouring of the seat it option. Their real life situation may be to sit in
is relatively simple to find a shape and softness their wheelchair or to be in bed. Because of this,
that suits many people. the wheelchair's backrest is one of the factors that
Individual factors influencing a person's totally dictates the seating unit's influence on the
possibility to sit on a seat surface are soft tissue upper body, and thus, the whole body.
quality, blood circulation and, for some users, Spinal Cord Injury, Hemiplegia, Rheumatoid
impaired skin sensibility and- of course - duration. Arthritis, MS and Cerebral Palsy are all different
There are different needs, but many humans have diagnoses and conditions requiring different
a relatively "standardized" shape against a seat backrest solutions.
surface, based on the shape of the skeleton.
This "standard" means that, despite minor
101

Backrest Contour

Contouring of the backrest - Levels and Principles

A backrest's contour should be such that the #1 "ROOM" FOR THE PELVIS
surfaces in contact with the trunk and spine
follow their contours. By adjustment of the lowest part of the backrest
The objectives are pressure distribution, the basis is created for making the backrest above
stability and functional balance. the pelvis optimally contoured and functional.
Begin with the position and stability of the One very common cause of seating problems is
pelvis, then balance and support the upper body insufficient contouring of the area of the backrest
by contouring for extension of the thoracic spine. that is in contact with the pelvis.
Lastly, the area of the backrest against the lower One common mistake in backrest design is that
back should be in gentle contact with the low this pelvis-area is too flat, or sometimes even
back lordosis. forward convex! Such a contour decreases the
First the pelvis, then the thoracic spine and room needed by the pelvis for an upright and
finally the lower back. A functional position of functional position.
the head, shoulders and upper trunk is the goal. If, due to a flat surface, the pelvis presses hard
102

against this area it will rotate backwards very support the pelvis' upper sacral area, from side to
easily if/when the thoracic spine begins to flex side. It is important that the pressure against the
(remember that thoracic flexion makes the pelvis pelvis is not too great. Should it become
rotate backwards). uncomfortable, the user decreases the pressure
When the pelvis' position is upright or forward- by moving the pelvis -- by sliding forwards on
rotated it is more stable. This influences the the seat.
position of the trunk's centre of gravity (CoG). A For many people, supporting the back means
more upright pelvis mechanically influences the the same as supporting the lower back. The goal
thoracic spine to extend and the CoG moves is primarily to stabilize the pelvis, not to support
upwards and backwards. This shortens the CoG's the lower back.
momentum and decreases the muscle force When the pelvis and sacrum, which are the
required to keep the trunk's CoG-position. lowest part of the spine, are sufficiently stabilized,
To make the backrest, as a whole, functional the backrest above the pelvis is easier to adjust,
for the trunk its lowest part must allow the pelvis in order to balance and stabilize the rest of the
to have an optimal position. spine.
By "positioning the pelvis" several different A roomy contour for the pelvis in the backrest's
structures are influenced. The pelvis' position in lower area, creates the conditions for the pelvic
space dictates factors like the placement of the position. With the backrest supporting the pelvis
sacrum's upper surface (the base of the spine), from behind the condition needed for a stable
hip joints (position) and leg and trunk muscles position is maintained.
(muscle length). All these factors influence the Contouring for room and sacral supporting
pelvis and spine differently. complement each other to give the pelvis a
When the pelvis has a "final" position, this functional and stable position in relation to
position decides the spine's mechanical gravity.
conditions, its balance and its possibility to move.
For most people it is better to make the backrest's
lowest part, which is in contact with soft tissue #3 THORACIC EXTENSION
and the lowest part of the pelvis, too "roomy"
than too tight. If more contact against the backrest When the backrest's lowest part, the area in
is needed, or wanted, it can always be created... contact with the pelvis, is well adjusted the next
You may wonder why I focus on this low- step is normally not to adjust for the lower back.
pelvis-area of the backrest so deeply? For a better, faster and often more accurate
The reason is very simple. If this area of the result, instead of focusing on the lower back,
backrest is insufficiently addressed, the result is adjust for the thoracic spine first, then for the
that seating problems will develop very soon. lower back.
Give the pelvis the room it needs to be in a The reason is simple. When adjusting the
position that makes it muscularly easy for a user backrest for upright sitting, the goal is to assist
to keep his/her trunk extended! the lower back to maintain its forward convex
curve, its lordosis. The problem is that you very
seldom know what kind of curvature you are
#2 PELVIC STABILITY adjusting for. Is it big or small? Perhaps it's stiff!
Can the person you have in front of you sit
After the pelvis has been placed, its position upright with a lower back lordosis?
needs to be stabilized by making the backrest To know for certain, he or she should be seated
103

stably and relaxed, with the thoracic spine upright, #4 THE LOW BACK CONTOUR
naturally extended.
After the pelvis has a stable position, the next Good contact and individual contour on both
step is to contour the backrest's upper area. The sides. Observe that the curve of the lower back,
objective is individual and comfortable extension the lordosis, is created and regulated by
of the thoracic spine, giving the trunk a functional interaction between the pelvis and thoracic spine,
balance, and minimizing its flexion tendency their positions respectively, in relation to one
when extensor muscles relax. Now the backrest another.
should be contoured to be in good contact with Avoid excessive lower back contouring. It over-
the lower back. extends the spine and, if the user finds it
If the thoracic spine's extension is maintained unpleasant, (extension and/or pressure)
(with very small or no muscle force) the result is stimulates sliding on the seat.
that the spine stabilizes the pelvis and its backward A lower-back support is only seldom func-
rotation is blocked. Thoracic extension restricts tional for maintaining a lumbar lordosis. The key
the pelvis' possibility to rotate backwards. As to keep a lordosis is a functional and stable pelvic
long the thoracic spine is extended the pelvis is position in interaction with the upright extended
mechanically hindered from doing so. dynamically moving thoracic spine.
Thoracic extension is positive for the trunk and
for pelvic stability. The pelvis and thoracic spine
always interact and influence one another. When #5 NECK AND HEAD BALANCE
the pelvis rotates backwards, the thoracic spine
flexes and when the pelvis rotates forwards the The purpose of the design (or adjustment) of
thoracic spine extends. If you flex your thoracic the backrest is (mostly) to make it easy for the
spine it makes your pelvis rotate backwards and head to have an upright and functional position.
when you extend your trunk your pelvis rotates The balance of the neck (cervical spine) and
forwards. dynamic position of the head is based on how the
If you want to block your pelvis or thoracic pelvis and thoracic spine cooperate and interact.
spine from moving when the counterpart moves, The best condition for the head is when the pelvis
you need to use many muscles. Thus, for a has a functional and stable (not fixed) position
thoracic spine, the backrest contouring should be and the thoracic spine extends and can change
for balanced extension. naturally between extension and flexion.
The backrest's contact area against the ribcage When a backrest has been set up, the user's head
needs to be large and very comfortable. If it isn't will show you if it is functional. If the user moves
comfortable it isn't working! Functional support his/her head to a position other than upright,
for the trunk is created by contouring the backrest's relaxed and controlled, you should re-set the
middle-to-upper area. This stabilizes the trunk backrest.
sideways and stabilizes one of the spine's "pivot
points", the lumbo-thoracic junction, which
stimulates and makes extending the spine more
effective.
Let the upper part (4-5 cm) of the backrest have
some slack, or be a little softer, to allow extension
when needed, which is very often!
110

Stability for activity


The trunk's pressure against the backrest creates
upper body stability.
How much upper body stability is created and
in what direction(s) depends on where the backrest
ACTIVITY is in contact, the magnitude of the pressure and
the contact area. Together, the backrest and seat
STABILITY angle decide how great the pressure against the
backrest will be.
If the whole seating unit is tilted back in space
the body-backrest pressure changes - the greater
the tilt, the greater the pressure against the
backrest.
On a seating unit with a ninety-degree seat-to-
back angle and a horizontal seat, seat pressure is
maximized. When this unit is tilted back ninety
degrees it maximizes the pressure against the
Backward seat slope. A high, reclined
backrest makes the pelvis and most of backrest. Tilting backwards decreases seat
the trunk stable. It allows activity in the pressure and increases backrest pressure, which
upper part of the trunk. means that trunk stability is increased.
Stability through backrest pressure always
makes it more difficult to move the trunk away
from the backrest. This is the principle to use
when users have impaired upper body muscle
function and stability.

ACTIVITY A backward-sloped seat makes the pelvis have


a strong tendency of backwards rotation. A
STABILITY forward-angled backrest, and more hip flexion
(seat slope) increases stability by making the
pelvis be pressed harder against the backrest. Pay
attention to this pressure for sensitive users!

For users who need a lot of pelvic and trunk


stability, slope the seat backward and use a high,
reclined backrest (the upper figure on this page).
Backward seat slope. A low backrest,
angled forwards, makes the pelvis and For users who need pelvic and lower trunk
lower trunk stable. It allows more stability for freedom of movement and activity
activity above the area of stability, which
of the upper trunk, slope the seat backward and
means most of the trunk.
use a shorter, well contoured and forward-angled
backrest (see lower figure on this page.)
Published 2002, hardcover, 250 pages, 4-colour illustrations

Posturalis Books
Jägarvägen 14, SE-139 40 Värmdö, Sweden
Phone/Fax: +46 8 650 51 71 / E-mail: engstrom.posturalis@swipnet.se