(form according to EEC Directive 93/112/EC)NAME : LITHIUM, THIONYL CHLORIDE (Li-SOCl2)1 - IDENTIFICATION (of the product and the supplier)LS 14250, LS 14250 C, LS 14500, LS 14500 C, LS 17500, LS 26500, LS 26500 C, LS 33600, LS 33600 C, LSH 26180, LSH 14, LSH 20Solution of lithium tetrachloroaluminate** Lithium tetrachloroaluminate is a combination of lithium chloride (LiCl) and aluminum chlo
Uaty21(1).book(uaty_a_394748.fm)Assistive Technology, 21:13–22, 2009
Copyright 2009 RESNA
ISSN: 1040-0435 print
log , Vol. 21, No. 1, Apr 2009: pp. 0–0 Brad E. Dicianno, MD,1,2,3,4
Juliana Arva, MS, ATP,5
This document, approved by the Rehabilitation Engineering & Jenny M. Lieberman, MS, OTR/L,
Assistive Technology Society of North America (RESNA) Board of Directors ATP,6 Mark R. Schmeler, PhD,
OTR/L, ATP,2,3,4 Ana Souza, MS,
on April 23, 2008, describes typical clinical applications and provides evidence PT,2,3,4 Kevin Phillips, CRTS,7
from the literature supporting the application of tilt, recline, and elevating Michelle Lange, OTR, ABDA, ATP,8
Rosemarie Cooper, MPT, ATP,2,3,4
Kim Davis, MS, PT, ATP,9 and
Kendra L. Betz, MSPT, ATP10
legrests, power features, recline, rehabilitation, tilt, wheelchair 1Department of Physical Medicine and Rehabiliation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Center for Assistive Technology, INTRODUCTION
University of Pittsburgh, Pittsburgh, Pennsylvania3 The purpose of this article is to share typical clinical applications as well as provide evidence from the literature supporting the application of these assistive technology interventions to assist practitioners in decision making and justification. It is not intended to replace clinical judgment related to Pennsylvania5Permobil, the Netherlands6Department of Rehabilitation, Mount Sinai Hospital, New York, BACKGROUND
New York7Ability Center, San Diego, California Wheelchair technology has evolved considerably in the past 15 years.
8Access to Independence, Inc., Arvada, Colorado Several power and manual features can be added to a power wheelchair to address a constellation of medical conditions. Previous position papers have addressed the medical benefits of seat elevation and standing. Tilt, recline, and elevating legrests are additional options that can be operated manually or that come as power options. This position paper addresses the common medicalreasons for which these features are prescribed and the scientific and clinicalevidence for such prescriptions.
A wheelchair users’ survey study (Trail, Nelson, Van, Appel, & Lai, 2001) examined the utility of various wheelchairs and their features and found that tilt, recline, and elevating legrests were the most desirable features on a power wheelchair. Manual- and power-operated features of power wheelchairs allow Department of Physical Medicine and Rehabilitation, Kaufmann Medical for changes in body and leg position and are features that have gained clinical acceptance for people with disabilities who have limited ability to reposition Pittsburgh, PA 15213. E-mail: email@example.com or reorient their bodies independently.
Changes in body position are necessary to address manual features so that a caregiver can assist with posi- issues related to postural alignment, function, physiol- tioning and care of the wheelchair user. These manual ogy, transfers and biomechanical issues, contractures features are beneficial if the individual needs reposi- or orthopedic deformities, edema, spasticity, pressure tioning many times throughout the day. However, management, comfort, or dynamic movement. Many if the wheelchair user can operate power features payer sources and reviewers often believe that tilt and independently, then those are most appropriate and recline are interchangeable. While they may comple- ment each other, they are not interchangeable and servevery unique medical purposes.
Tilt and recline provide a means for gravity-assisted positioning. Some manufacturers allow for a fixed • Tilt systems change seat angle orientation in relation recline angle to be crafted into the wheelchair frame to the ground while maintaining the seat to back (Lange, 2000b; Sommerfreund & Masse, 1995). This is and seat to legrest angles. Traditional tilt operates in useful when the individual needs a degree of recline to the sagittal plane, while lateral and rotational tilt accommodate trunk positioning, and this feature can systems operate in the coronal or oblique planes, be combined with a tilt system. However, the majority of individuals generally need recline angles that can be • Recline systems provide a change in seat to back changed, especially if they spend most of their time in angle orientation while maintaining a constant seat the wheelchair. Clinicians recommend that users with poor trunk or head control alter their center of gravity • Elevating legrests allow individuals to change the by altering tilt and recline angles to gain balance and angle of orientation of the legs and/or footrests relative stability (Kreutz, 1997; Lange, 2006). Postural align- to the seat, extending the knee. Some legrests are ment is especially important for children or adults articulating, which means they lengthen while also with progressive or static scoliosis (Lange, 2000b).
According to many clinicians, tilt is useful for those with contoured seat backs since it maintains theappropriate angles for clients to remain in contact MANUAL OR POWER FUNCTIONS?
with the shape of the backrest (Kreutz, 1997). Because Tilt, recline, and elevating legrests are available as some recline systems cause shear forces against the either manual- or power-operated features. They serve a individual’s back, the problem of shear can be further variety of medical purposes, which are described below.
compounded with a contoured backrest. The interface Clinicians prescribe power features if an individual’s between the client and seat back can then be suboptimal.
medical condition is such that he or she would benefit However, recline systems reported in the clinical liter- from one of these features but is not able to operate the ature (Kreutz, 1997; Pfaff, 1993) are available that manual feature independently due to a constellation of allow the molded back to track along with clients as cognitive, motor, or sensory impairments. These power they recline, maintaining the seat interface. The clini- features are generally medically necessary as long as the cian should ensure that the client stays in position individual can operate the power version and has medi- when using any recline system with a molded back cal reasons for their use. Age should not be used as a and should consider using tilt in combination with determinant for whether or not an individual is capable of operating power features; the elderly and young alike One benefit of proper alignment is enhancement of are often able to use power features adequately. Rather, function (Nwaobi, 1987). For example, tilting anteriorly clinicians must evaluate each client’s medical and social may be clinically beneficial to assist with functional situation on a case-by-case basis (Kreutz, 1997; Lange, reaching. Use of legrests and footrests has been shown to improve balance, completion of activities of daily If an individual is unable to operate power or manual living (ADLs), and maintenance of safe positioning features independently, it may be necessary to prescribe during braking (R. A. Cooper, Dvorznak, O’Connor, B. E. Dicianno et al.
Boninger, & Jones, 1998; Janssen-Potten, Seelen, Visual Orientation, Speech,
Drukker, Spaans, & Drost, 2002). Tilt or elevating leg- Alertness, Arousal, Respiration,
rests can enable ground clearance for those with low and Eating
seat heights who encounter obstacles or can improveaccess to load the chair into a vehicle. Those who Some individuals may also need tilt and recline for maintain the legs in an elevated position may need visual orientation, speech, alertness, and arousal. It has power features to change the position of the legrests been documented clinically that tilt and recline regularly throughout the day in order to negotiate systems can be used to orient the trunk and head obstacles for clearance. Tilt can be used to promote position (Kreutz, 1997; Lange, 2000a), stimulate the stability in the chair when an individual tends to slide vestibular system (Lange, 2000a), improve line of sight out of the chair due to extensor tone of the back or (Kreutz, 1997), and allow for better communication contractures. Individuals also sometimes use tilt for (Kreutz, 1997). Providing a slightly tilted or reclined stability when driving downhill or when carrying position with headrest support can prevent neck hyperextension if neck flexors are weak. On the other Power features are especially important for pediatric hand, individuals whose neck and trunk are too flexed users to allow them better access to their environment.
when sitting upright may need further tilt or recline More accessible environments may allow for early to encourage extension. Clinicians use customized stimulation, which is important for achieving develop- positioning to maximize breathing and speaking ability mental milestones, especially among children with by maintaining vital organ capacity and to reduce risk disabilities (Garcia-Navarro et al., 2000).
for aspiration (D. Cooper, 2004; Hardwick, 2002;Lange, 2006). Therapists also sometimes use positioningfor stimulation of digestion after meals (D. Cooper, PHYSIOLOGICAL IMPLICATIONS
Proper postural alignment may also aid in main- taining vital organ capacity and has several physio- Bowel and Bladder Management
logical implications (Lacoste, Weiss-Lambrou, Allard, &Dansereau, 2003; Nwaobi, 1987), as documented Some bowel and bladder management techniques such as changing protective undergarments or inter-mittent self-catheterization require supine positioning(Wyndaele, 2002). Some individuals cannot comply Orthostatic Hypotension
with their recommended programs because they cannot The prevalence of orthostatic hypotension is high position themselves appropriately and may require in the general population (Bradley & Davis, 2003), but additional assistance (Wyndaele, 2002). Noncompli- it especially affects individuals with such conditions ance with bladder programs may result in increased as cardiac disease, spinal cord injury (SCI), diabetes, urinary tract infections and, ultimately, increased mor- neuropathy, multiple sclerosis, and Parkinsonism.
bidity, including renal complications (Salomon et al., Part of the management of acute symptoms such as 2006). Individuals with indwelling catheters may expe- dizziness includes assuming a recumbent or semire- rience backflow of urine when using a tilt system.
cumbent position (Claydon, Steeves, & Krassioukov, However, using features such as recline may allow 2006). Clinicians suggest that using a combination of individuals to perform their care independently and tilt, recline, and power legrests can help to achieve reduce the need for caregiver assistance.
such a position (Kreutz, 1997). One cross-sectionalstudy that evaluated several interventions for orthos- TRANSFERS AND BIOMECHANICAL
tasis (Kreutz, 1997; Ten Harkel, Van Lieshout, & Wieling, 1992) showed that sleeping in bed with thehead elevated at 10° to 20° improves symptoms. More Positioning may also be necessary in order to research is needed to determine if positioning during improve transfer biomechanics of both the wheelchair the day, such as in power wheelchairs, might be of user and the caregiver. When an individual is indepen- additional benefit for long-term management.
dently transferring from an upright position, the Tilt, Recline, and Elevating Legrests for Wheelchairs
shoulder can experience forces as high as two and a or orthopedic deformities (Levy, Berner, Sandhu, half times mean arterial pressure (Bayley, Cochran, & Sledge, 1987). People can use tilt and recline to stabilize Therapists also use elevating legrests to provide their trunk in order to position themselves properly passive movement to the knee joints (Lange, 2006).
for a transfer. Reducing load by adjusting the center When contractures are present, the legrests should be of gravity during an independent or assisted transfer adjusted to the appropriate accommodative angle to may reduce the risk for upper limb pain and injury prevent undue tension in the hamstrings and hip (Herberts, Kadefors, Hogfors, & Sigholm, 1984).
joints. It is recommended that elevating legrests be Recline may be used in combination with elevating used in combination with recline when passive exten- legrests to enhance sliding transfers with a person in sion of the knee is limited due to hamstring tightness, supine position. Anterior recline (“precline”) can add as recline allows extension of the hip. Additional foot- momentum to the trunk for transfers. Anterior tilt can plate extensions or angle changes might be necessary.
be used with a seat elevator to improve transfers from Extending the knee near end range, however, can and to elevated positions or to reduce shoulder load often elicit reflex spasticity in those with central when activities would otherwise need to be performed nervous system disorders. Tilt systems with adjustable with arms overhead. Reducing this load is vitally seat and back angles are also useful for positional important for preservation of upper limb function changes in those with limited hip range of motion.
Those with limited hip flexion can use tilt and/or Better biomechanical position not only reduces the recline systems when the seat to back angle is appropri- need for assistance with ADLs and transfers but also ately configured. In some cases, therapists must set a reduces the risk of injury to caregivers (Edlich, limit to prevent closing of seat to back angle beyond the Heather, & Galumbeck, 2003; Fragala & Bailey, 2003).
available hip range of motion so that excess force is not Furthermore, by prolonging sitting tolerance with use placed on the hips and the user is not pushed out of the of power features, the number of times a person may seat (Kreutz, 1997). However, some people need to bring need to be transferred can be reduced.
their trunk more upright for limited periods of time toengage in ADLs such as reaching. The impact of seat toback angle on function must always be considered.
Offering a client the ability to change joint angles can allow independent management of tone. Becausetilt systems maintain static joint angles and thus muscle Clinicians also use power elevating legrests to man- fiber length, clinicians use these features in those with age edema (Kreutz, 1997; Levy et al., 1999). The lower spasticity to offer positional changes without eliciting limbs of wheelchair users may act as a reservoir for increases in tone (Kreutz, 1997). Clinically, recline fluid accumulation (Kinzer & Convertino, 1989).
systems should be considered on a case-by-case basis for Elevation of the legs above the level of the left atrium management of spasticity since it has been noted that by about 30 cm is generally recommended as part of in some individuals recline can increase tone, especially the management of edema in conjunction with, rather in the spine extensors (Kreutz, 1997; Lange, 2006).
than in lieu of, other measures such as support gar-ments (Abu-Own, Scurr, & Coleridge Smith, 1994;Douglas & Simpson, 1995; O’Brien, Chennubhotla, & CONTRACTURES AND ORTHOPEDIC
Chennubhotla, 2005). This allows for reduction in DEFORMITIES
venous pressure and increases arterio-venous pressureand capillary flow. Elevating legrests, therefore, are Clinicians argue that static seating systems can most effective when used in combination with tilt to sometimes lead to contractures, especially in the ham- allow elevation of the legs above heart level. Some tilt strings (Lange, 2006). Power elevating legrests are systems, when combined with elevating legrests, still often medically necessary when an individual cannot do not allow for adequate leg elevation above the independently operate manual legrests but needs to heart, and in these cases elevating legrests must be elevate the lower limbs to manage contractures combined with tilt and recline systems.
B. E. Dicianno et al.
even the best pressure relief cushions are inadequateto prevent pressure ulcers if the individual sits on Studies comparing seating pressure among subjects them too long without adequate position changes with SCI, spina bifida (SB), and control subjects (Lacoste et al., 2003). Therefore, current accepted (Aissaoui, Kauffmann, Dansereau, & de Guise, 2001; practice is to provide a combination of cushion tech- Hobson, 1992; Vaisbuch, Meyer, & Weiss, 2000) have nology and means for position changes in order to shown that individuals with disabilities experience prevent and treat pressure ulcers (Henderson, Price, seating pressures that are significantly higher or focused over smaller surface areas than those experienced byindividuals without disabilities. A tissue’s tolerance forpressure depends on the disability type as well as a Wheelchair Push-Ups
number of additional factors, including age, nutrition, Clinicians often prescribe power features when an temperature, anatomical location, moisture, presence individual cannot transfer into and out of the chair of incontinence, and tissue metabolism (Edlich et al., independently. This is based on the assumption that prolonged sitting increases risk for skin breakdown and A key component in preventing and managing pres- limitations in ability to transfer preclude adequate sure ulcers involves the use of various support surfaces weight shifting capability. There is, in fact, a wealth of and position changes to reduce forces. There are two scientific evidence to support this notion, but transfer different types of forces that act on tissues (Sprigle, ability is not the only factor that should be considered.
2000). “Normal” force acts perpendicularly to the skin Many wheelchair users perform wheelchair “push-ups” surface. “Shear” force acts tangentially to the skin as a way to alleviate pressure. Most individuals perform surface and/or deeper tissues. Both can occlude blood such maneuvers for approximately 15–30 seconds and lymph vessels. Friction is a type of shear force that (Coggrave & Rose, 2003), but frequency is variable, acts at the interface between the skin and supporting with recommendations ranging from one shift every tissues. When shear occurs, the magnitude of the load minute to one per hour (Boninger & Stripling, 2007; needed to cause ischemia is reduced to half (Bennett, Paralyzed Veterans of America, 2000; Vaisbuch et al., 2000). In one retrospective review article (Coggrave & Valid and reliable outcome measures for seating Rose, 2003), transcutaneous oxygen tension of 46 sub- pressure have not always governed clinical practice.
jects performing wheelchair push-ups was measured. It Conventionally, manufacturers of pressure-relief prod- was reported that each lift needed to last nearly 2 min- ucts have felt that any load that exceeds 32 mmHg is utes, regardless of frequency, in order to return tissues harmful. This value came from a historical article in to unloaded levels. This is clearly impossible, imprac- 1930 (Landis, 1930) that calculated the capillary pressure tical, and undesirable for any wheelchair user, even of the fingernail bed to be approximately 32 mmHg, users with healthy upper limbs and joints. In fact, the as well as from microscopic studies (Kosiak, 1959, load on the shoulder and arms during these maneu- 1961) in which 32 to 40 mmHg was considered a safe vers increases substantially and may predispose people threshold. However, to date, no research has produced to repetitive strain injuries (Bayley et al., 1987; Reyes, a cutoff value for load that is known to be causative Gronley, Newsam, Mulroy, & Perry, 1995). Thus, for ulcer formation. In fact, one reliability study on many clients who cannot transfer independently, and pressure testing (Sprigle, Dunlop, & Press, 2003) even some of those who can, need power seat func- showed that peak pressure is not a reliable outcome measure and suggested that the use of other, more reli-able measures, including average pressure, may be Forward and Side Leaning
more appropriate. One retrospective review of tissueoxygen measurement techniques (Coggrave & Rose, Several of the studies done in SCI and SB on seating 2003) used transcutaneous oxygen tension as a reliable pressures (Coggrave & Rose, 2003; Henderson et al., means of determining load on the tissue.
1994; Hobson, 1992; Vaisbuch et al., 2000) have Duration of the load is also a factor in ulcer forma- shown that forward and side-to-side leaning can be tion (Sprigle, 2000). Many clinicians maintain that effective methods for relieving pressure over the Tilt, Recline, and Elevating Legrests for Wheelchairs
ischial tuberosities. However, not all individuals who recline can increase normal forces at the ischial tuber- use wheelchairs have the arm strength or trunk control osities (Gilsdorf, Patterson, Fisher, & Appel, 1990), so required to perform these maneuvers independently clinicians often recommend using tilt before return to (Lacoste et al., 2003) or may not be able to do so due upright to minimize shear. Elevating legrests may also to autonomic dysreflexia or neurogenic bladder (Vais- help in alleviating ischial and foot support pressure buch et al., 2000). Moreover, these maneuvers may (Aissaoui, Heydar, Dansereau, & Lacoste, 2000) and not be effective when used with some cushions (Koo, can help reduce shear along the entire seating surface Mak, & Lee, 1996). For those individuals who cannot (Carlson, Payette, & Vervena, 1995). The aforemen- perform adequate weight shifting, current clinical tioned “shear-reducing” recline systems (Pfaff, 1993) practice is to promote pressure relief by providing are thought to reduce shear forces, but at the time of power features that the user can operate indepen- this writing the only supporting evidence was anec- dently (Lacoste et al., 2003; Vaisbuch et al., 2000).
dotal. Yet, their utility is especially important clini-cally when they allow the user to remain in contactwith the seat back for positioning purposes.
Power Features for Pressure Relief
Simply providing these power features when they Tilt and recline features provide the most pressure are medically necessary may not be adequate; training relief when used in combination. One study (Vaisbuch and follow-up are important. One survey study et al., 2000) found significantly lower maximum pres- (Lacoste et al., 2003) showed that although 97.5% of sure in the combined position of 25° of tilt with 110° individuals who had tilt and recline used these of recline in subjects with SB. A study in subjects with- features every day, less than 35% used these features out impairments (Aissaoui, Lacoste, & Dansereau, primarily for pressure relief but, rather, also to reduce 2001) showed that 45° of tilt with 120° of recline pro- pain and promote comfort. The majority of individu- vided a 40% load reduction. A study on two subjects als used angles that were inadequate for pressure relief.
with tetraplegia (Pellow, 1999) showed a trend toward There is also insufficient research that documents the interface pressure reduction with a combination of 45° appropriate duration and frequency of use of these features, but clinicians sometimes estimate a duration Tilt alone may also confer some advantage for pres- of 30 seconds with a frequency of 15–30 minutes or sure relief. Significant ischial pressure relief has been 60 seconds every 60 minutes to be a conservative shown at 65° of tilt (Henderson et al., 1994) and lower estimate given the research on wheelchair push-ups shear forces noted even at 25° (Hobson, 1992). How- and clinical practice guidelines published for SCI ever, one study showed that 15° or less provides no (Coggrave & Rose, 2003; Paralyzed Veterans of America, advantage in terms of pressure reduction (Aissaoui, 2000; Vaisbuch et al., 2000). This evidence substantiates Lacoste, & Dansereau, 2001) but may have benefits for the need for follow-up visits with clients for extended postural stability. Power lateral and rotational tilt can be beneficial in adding more degrees of freedom tothe maneuvers available.
PAIN, FATIGUE, AND SITTING
When effects of elevating legrests on posture were TOLERANCE
studied in subjects without impairments (Stinson,Porter-Armstrong, & Eakin, 2003), it was found that Although clinicians may configure seating systems 120° of recline in combination with elevation of legs according to body dimensions, the types of seating can significantly reduce seating interface pressure.
systems people find comfortable may be quite differ- When used alone, recline tends to reduce normal ent from what their anthropometry may predict force but increase shear (Hobson, 1992), especially (Kolich, 2003). Ergonomic literature on drivers sug- when individuals recline to 110° and 120° (Aissaoui, gests that seating systems should not be configured Lacoste, & Dansereau, 2001). Care must be taken with solely based on static postures. Instead, sitting tolerance is sole prescription of recline because when used in isola- a dynamic phenomenon that requires a dynamic tion it may put a client at risk for skin breakdown, assessment (Porter, Gyi, & Tait, 2003). Clinicians face especially if the client does not know how to use it time constraints when doing seating evaluations. The properly. Additionally, return to upright position after most experienced clinicians doing thorough evaluations B. E. Dicianno et al.
are still not always able to assess all of the sitting for individuals who use office furniture and worksta- postures the client will undoubtedly need to assume in tions (Kroemar, 1994) and should undoubtedly be daily life in a routine evaluation. In fact, many individ- applied to wheelchairs as well, since many wheelchair uals’ postures are so variable that more than 2 hours are users may not have the same level of dynamic move- needed to observe the critical seating postures an indi- ment as able-bodied office workers. Power tilt, recline, vidual assumes to remain comfortable (Gyi & Porter, and elevating legrests can provide individuals who use 1999). This suggests that power features, when used to wheelchairs with a means of providing and assisting promote dynamic sitting tolerance, may be useful to assume many postures beyond those seen in a clinical Dynamic movement is healthy for the spine. Chair assessment. If power features are not available, and designs that allow passive motion during seating may high interface pressures are present, individuals may actually help to prevent back pain (Reinecke, Hazard, & seek alternative postures that may prolong sitting Coleman, 1994). The loading and unloading of inter- tolerance but are poor for overall postural alignment, vertebral discs that occur during dynamic repositioning skeletal development, or function or may hasten the of the spine may increase nutrient supply to the discs (Andersson, 1981; Kolditz, Kramer, & Gowin, 1985).
While there is some disagreement in the literature Indeed, this has also been shown in animal (Holm & about what reduces sitting tolerance, higher pressure Nachemson, 1983) and cadaveric (Adams & Hutton, has been found to be a significant factor (de Looze, 1983) models. Prolonged static sitting without appro- Kuijt-Evers, & van Dieen, 2003; Goossens, Teeuw, & priate back support can increase risk for herniated Snijders, 2005). Interestingly, in the aforementioned discs (Adams, Green, & Dolan, 1994; Kelsey, 1975) survey study (Lacoste et al., 2003), power wheelchair because, when an individual slumps, his or her spine users stated that they primarily used their features to is flexed, and the anterior annulus experiences a com- promote comfort and reduce back and joint pain.
pressive force about 50% higher than when the spine Indeed, the ergonomic literature on automobile driving is naturally erect (Adams & Hutton, 1985). Reduction suggests back pain is one of the most common symptoms in the lumbar curvature during slumping may shift the of sitting, especially when seating is not adjustable load to ligaments, which can then deform the spine (Porter & Gyi, 2002). Distance traveled while driving (Kumar, 2004). In addition, while the apophyseal and the number of hours spent sitting are significantly joints can resist intervertebral shear force when the spine related to low back pain (Gyi & Porter, 1998; Porter & is flexed, they are less able to resist compressive force than when in the erect position (Adams & Hutton,1985).
Even when the pelvis is stabilized on the seat, if the DYNAMIC MOVEMENT
backrest is supported at less than 110° of recline, the When allowed to move freely, people are usually in pelvis can still rotate posteriorly, resulting in flattening constant motion (Branton, 1969). It is difficult for of the lumbar spine (Bendix & Biering-Sorensen, 1983; most individuals to tolerate unsupported and static Nachemson, 1981), just as in unsupported sitting.
seated positions for more than a short while (Reinecke, Thus, the pelvis must be supported and the thigh to Bevins, Weisman, Krag, & Pope, 1985). People generally torso angle must be a minimum of 110° to keep change postures up to 30 times per hour while sitting the natural curve of the lumbar spine (Andersson, (Graf, Guggenbuhl, & Kreuger, 1991). Static seating Murphy, Ortengren, & Nachemson, 1979; Keegan, systems can restrict an individual from assuming the vari- 1953; Lueder, 2005; Nachemson, 1981). However, ety of postures that are natural for the body (Bendix & individuals in the reclined position also must reach Biering-Sorensen, 1983) and may cause the body to farther to perform ADLs, increasing the load on shoul- move into postures that are harmful (Bhatnager, Drury, & ders and arms (Lueder, 2005) as well as the cervical Schiro, 1985). The only effective way to endure a spine (Grandjean, Hunting, & Pidermann, 1983). Also, seated posture for an extended period of time and to be tilting a seat with a static back angle has been shown to productive and functional in that posture is to change cause increased thoracic flexion instead of extension positions constantly (Lueder, 2005). The concept of (Engstrom, 1993). Therefore, in order to perform a “dynamic sitting” is endorsed in the ergonomic field variety of functional tasks comfortably and safely, Tilt, Recline, and Elevating Legrests for Wheelchairs
most users will need varying degrees of recline. For a legrests. Tilt was used in conjunction with recline for wheelchair user who is not able to independently cycle pressure relief. Tilt and elevating legrests were used through a range of positions using a manually adjustable together to manage edema more effectively. After recline system but who needs to perform a host of func- 6 months of use, she noted marked improvement in tional tasks from the wheelchair, the solution is to use edema, and her wound closure remained intact. She power-operated recline. Obviously, a clinician must con- also now is able to catheterize herself while in her sider how shear forces may act in these cases and reserve chair, which she finds very useful when she is at work.
recline systems for those who can operate them safely Louis is an 85-year-old man with a history of an and consider tilt in combination with recline.
ischemic stroke and left hemiparesis. He developedspasticity of the left hemibody that has been unre-sponsive to treatment with botulism toxin. His tone fluctuates, but he notes less spasticity and clonus Tilt, recline, and elevating legrests may be useful when his legs are elevated. He can no longer ambulate and medically necessary to address issues related to but is able to stand pivot transfer independently. He postural alignment, function, physiology, transfers lacks dexterity in his left hand to operate manual leg- and biomechanical issues, contractures or orthopedic rests or hand propel his current manual wheelchair deformities, edema, spasticity, pressure management, and can no longer use foot propulsion for mobility.
comfort, or dynamic movement. However, they are not He was prescribed a power wheelchair with recline and required for or desired by everyone; therefore clinical power elevating legrests to manage tone and accom- judgment is required in prescription. RESNA therefore modate knee flexion contractures. With frequent repo- recommends power tilt, recline, and elevating legrests sitioning of his limbs, Louis has noted an improvement when such features are needed to treat or prevent the medical issues described above and when the user can- Yolanda is a 46-year-old woman with spastic athetoid not operate the manual versions of these features.
cerebral palsy. She is not able to self-propel a manual While some of the recommendations for use of tilt, wheelchair and is not independent with power mobility.
recline, or elevating legrests are based on clinical Her caregivers are propelling her in a depot-style manual observations, the use of these features is also substanti- wheelchair. They note that she slides out of the chair ated by a wealth of scientific literature that stems from due to extensor tone and coughs and gags when eating research on sitting postures, interface pressures, ergo- because of her slumped position. She is prescribed an nomics, and user surveys. Provision of one or all of attendant-propelled manual wheelchair with a manual these features may improve an individual’s sitting tilt-in-space feature that helps keep her from sliding tolerance and overall quality of life by increasing out of her chair. Yolanda does not have as much diffi- function and reducing pain, as well as reducing or culty eating when her position can be changed so that delaying secondary complications from long-term Hank is a 32-year-old man with a C6 ASIA A SCI.
He uses a power wheelchair with tilt, recline, andpower elevating legrests to control edema and spasticity CASE EXAMPLES
and to provide pressure relief. He is being evaluated Julie is a 24-year-old woman with SB. She recently for a new power chair because of electrical problems.
developed chronic pressure ulcers on the bilateral He has noted a progression in his scoliosis since his ischial tuberosities requiring flap surgery. She presents last visit, and a significant trunk lean interferes with for a new power wheelchair because hers is now in functional use of his arms. He is prescribed a new disrepair. She has been using a power wheelchair with power chair with the same features, but this time, pressure relief cushion and manually elevating legrests power lateral tilt is added. He typically uses slight to control edema but has no power features. She now lateral tilt at all times to improve trunk position, but cannot operate the manual legrests because of carpal also often independently adjusts the tilt to aid in pres- tunnel syndrome. She transfers out of the chair to sure relief and stability. He has noted an improvement catheterize herself. She was prescribed a new power in reaching, comfort, and use of his computer access wheelchair with tilt, recline, and power elevating B. E. Dicianno et al.
Edlich, R. F., Heather, C. L., & Galumbeck, M. H. (2003). Revolutionary advances in adaptive seating systems for the elderly and persons Abu-Own, A., Scurr, J. H., & Coleridge Smith, P. D. (1994). Effect of leg with disabilities that assist sit-to-stand transfers. Journal of the Long elevation on the skin microcirculation in chronic venous insufficiency.
Term Effects of Medical Implants, 13, 31–39.
Journal of Vascular Surgery, 20, 705–710.
Edlich, R. F., Winters, K. L., Woodard, C. R., Buschbacher, R. M., Long, Adams, M., & Hutton, W. (1983). The effect of posture on the fluid W. B., Gebhart, J. H., et al. (2004). Pressure ulcer prevention. Journal content of lumbar intervertebral discs. Spine, 8, 665–671.
of the Long Term Effects of Medical Implants, 14, 285–304.
Adams, M., & Hutton, W. (1985). The effect of posture on the lumbar Engstrom, B. (1993). Fundamental seating principles, correcting the spine. Journal of Bone & Joint Surgery, British Volume, 67, 625–629.
trunk. Retrieved from http://www.posturalis.se/eng/EngView.pdf Adams, M. A., Green, T. P., & Dolan, P. (1994). The strength in anterior Fragala, G., & Bailey, L. P. (2003). Addressing occupational strains and sprains: bending of lumbar intervertebral discs. Spine, 19, 2197–2203.
Musculoskeletal injuries in hospitals. AAOHN Journal: Official Journal of Aissaoui, R., Heydar, S., Dansereau, J., & Lacoste, M. (2000).
the American Association of Occupational Health Nurses, 51, 252–259.
Biomechanical analysis of legrest support of occupied wheelchairs: Garcia-Navarro, M. E., Tacoronte, M., Sarduy, I., Abdo, A., Galvizu, R., Comparison between a conventional and a compensatory legrest.
Torres, A., et al. (2000). Influence of early stimulation in cerebral IEEE Transactions on Rehabilitation Engineering, 8, 140–148.
palsy. Revista de Neurologia, 31, 716–719.
Aissaoui, R., Kauffmann, C., Dansereau, J., & de Guise, J. A. (2001).
Gilsdorf, P., Patterson, R., Fisher, S., & Appel, N. (1990). Sitting forces Analysis of pressure distribution at the body-seat interface in able- and wheelchair mechanics. Journal of Rehabilitation Research and bodied and paraplegic subjects using a deformable active contour Development, 27, 239–246.
algorithm. Medical Engineering and Physics, 23, 359–367.
Goossens, R. H., Teeuw, R., & Snijders, C. J. (2005). Sensitivity for pres- Aissaoui, R., Lacoste, M., & Dansereau, J. (2001). Analysis of sliding and sure difference on the ischial tuberosity. Ergonomics, 48, 895–902.
pressure distribution during a repositioning of persons in a simulator Graf, M., Guggenbuhl, H., & Kreuger, H. (1991). Movement dynamics of chair. IEEE Transactions on Neural Systems and Rehabilitation Engi- sitting behaviour during different activities. In Y. Queinnec & neering, 9, 215–224.
F. Daniellou (Eds.), Designing for everyone: Proceedings of the 11th Andersson, G. B. (1981). Epidemiologic aspects on low-back pain in Congress of the International Ergonomics Association (pp. 15–17).
industry. Spine, 6, 53–60.
Andersson, G. B., Murphy, R. W., Ortengren, R., & Nachemson, A. L.
Grandjean, E., Hunting, W., & Pidermann, M. (1983). VDT workstation (1979). The influence of backrest inclination and lumbar support on design: Preferred settings and their effects. Human Factors, 25, 161–175.
lumbar lordosis. Spine, 4, 52–58.
Gyi, D. E., & Porter, J. M. (1998). Musculoskeletal problems and driving Bayley, J. C., Cochran, T. P., & Sledge, C. B. (1987). The weight-bearing in police officers. Occupational Medicine, 48, 153–160.
shoulder: The impingement syndrome in paraplegics. Journal of Gyi, D. E., & Porter, J. M. (1999). Interface pressure and the prediction of Bone and Joint Surgery, American Volume, 69, 676–678.
car seat discomfort. Applied Ergonomics, 30, 99–107.
Bendix, T., & Biering-Sorensen, F. (1983). Posture of the trunk when Hardwick, K. (2002). Insightful options. Rehab Management. Retrieved sitting on forward inclining seats. Scandinavian Journal of Rehabilation from http://www.rehabpub.com/features/102002/4.asp Medicine, 15, 197–203.
Henderson, J. L., Price, S. H., Brandstater, M. E., & Mandac, B. R. (1994).
Bennett, L., Kavner, D., Lee, B. K., & Trainor, F. A. (1979). Shear vs Efficacy of three measures to relieve pressure in seated persons with pressure as causative factors in skin blood flow occlusion. Archives of spinal cord injury. Archives of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation, 60, 309–314.
Bhatnager, V., Drury, C. G., & Schiro, S. G. (1985). Posture, postural Herberts, P., Kadefors, R., Hogfors, C., & Sigholm, G. (1984). Shoulder discomfort, and performance. Human Factors, 27, 189–199.
pain and heavy manual labor. Clinical Orthopaedics and Related Boninger, M., & Stripling, T. (2007). Preserving upper-limb function in Research, 191, 166–178.
spinal cord injury. Archives of Physical Medicine and Rehabilitation, Hobson, D. A. (1992). Comparative effects of posture on pressure and shear at the body-seat interface. Journal of Rehabilitation Research Bradley, J. G., & Davis, K. A. (2003). Orthostatic hypotension. American and Development, 29(4), 21–31.
Family Physician, 68, 2393–2398.
Holm, S., & Nachemson, A. (1983). Variations in the nutrition of the Branton, P. (1969). Sitting posture. In E. Grandjean (Ed.), Proceedings of canine intervertebral disc induced by motion. Spine, 8, 866–874.
a symposium held in September 1958 at the Swiss Federal Institute Janssen-Potten, Y. J., Seelen, H. A., Drukker, J., Spaans, F., & Drost, M. R.
of Technology (pp. 202–213). London: Taylor & Francis.
(2002). The effect of footrests on sitting balance in paraplegic sub- Carlson, J. M., Payette, M. J., & Vervena, L. (1995). Seating orthosis jects. Archives of Physical Medicine and Rehabilitation, 83, 642–648.
design for prevention of decubitus ulcers. Journal of Prosthetics and Keegan, J. (1953). Alterations of the lumbar curve related to posture and Orthotics, 7(2), 51–60.
seating. Journal of Bone and Joint Surgery, 35, 589.
Claydon, V. E., Steeves, J. D., & Krassioukov, A. (2006). Orthostatic Kelsey, J. L. (1975). An epidemiological study of the relationship hypotension following spinal cord injury: Understanding clinical between occupations and acute herniated lumbar intervertebral pathophysiology. Spinal Cord, 44, 341–351.
discs. International Journal of Epidemiology, 4, 197–205.
Coggrave, M. J., & Rose, L. S. (2003). A specialist seating assess- Kinzer, S. M., & Convertino, V. A. (1989). Role of leg vasculature in ment clinic: Changing pressure relief practice. Spinal Cord, 41, the cardiovascular response to arm work in wheelchair-dependent populations. Clinical Physiology, 9, 525–533.
Cooper, D. (2004). A retrospective of three years of lateral tilt-in-space.
Kolditz, D., Kramer, J., & Gowin, R. (1985). Water and electrolyte con- Proceedings of the International Seating Symposium, 20, 205–209.
tent of human intervertebral disks under varying load. Zeitschrift für Cooper, R. A., Dvorznak, M. J., O’Connor, T. J., Boninger, M. L., & Orthopädie und ihre Grenzgebiete, 123, 235–238.
Jones, D. K. (1998). Braking electric-powered wheelchairs: Effect of Kolich, M. (2003). Automobile seat comfort: Occupant preferences vs.
braking method, seatbelt, and legrests. Archives of Physical Medicine anthropometric accommodation. Applied Ergonomics, 34, 177–184.
and Rehabilitation, 79, 1244–1249.
Koo, T. K., Mak, A. F., & Lee, Y. L. (1996). Posture effect on seating de Looze, M. P., Kuijt-Evers, L. F., & van Dieen, J. (2003). Sitting comfort interface biomechanics: Comparison between two seating cushions.
and discomfort and the relationships with objective measures.
Archives of Physical Medicine and Rehabilitation, 77, 40–47.
Ergonomics, 46, 985–997.
Kosiak, M. (1959). Etiology and pathology of ischemic ulcers. Archives of Douglas, W. S., & Simpson, N. B. (1995). Guidelines for the manage- Physical Medicine and Rehabilitation, 40, 62–69.
ment of chronic venous leg ulceration: Report of a multidisciplinary Kosiak, M. (1961). Etiology of decubitus ulcers. Archives of Physical workshop. British Journal of Dermatology, 132, 446–452.
Medicine and Rehabilitation, 42, 19–29.
Tilt, Recline, and Elevating Legrests for Wheelchairs
Kreutz, D. (1997, March). Power tilt, recline or both. Team Rehab Reinecke, S., Bevins, T., Weisman, J., Krag, M., & Pope, M. (1985, June).
The relationship between seating postures and low back pain. Paper Kroemar, R. (1994). Sitting at the computer workplace. In R. Leuder & presented at the annual meeting of the Rehabilitation Engineering K. Noro (Eds.), Hard facts about soft machines: The ergonomics of Society of North America, Memphis, TN.
sitting (pp. 181–191). London: Taylor & Francis.
Reinecke, S. M., Hazard, R. G., & Coleman, K. (1994). Continuous Kumar, S. (2004). Ergonomics and biology of spinal rotation. Ergonomics, passive motion in seating: A new strategy against low back pain.
Journal of Spinal Disorders, 7, 29–35.
Lacoste, M., Weiss-Lambrou, R., Allard, M., & Dansereau, J. (2003).
Reyes, M. L., Gronley, J. K., Newsam, C. J., Mulroy, S. J., & Perry, J.
Powered tilt/recline systems: Why and how are they used? Assistive (1995). Electromyographic analysis of shoulder muscles of men with Technology, 15, 58–68.
low-level paraplegia during a weight relief raise. Archives of Physical Landis, E. (1930). Micro-injection studies of capillary blood pressure in Medicine and Rehabilitation, 76, 433–439.
human skin. Heart, 15, 209–228.
Salomon, J., Denys, P., Merle, C., Chartier-Kastler, E., Perronne, C., Lange, M. (2000a, May 8). Tilt and recline systems. OT Practice, pp. 21–22.
Gaillard, J. L., et al. (2006). Prevention of urinary tract infection in Lange, M. (2000b). Tilt in space versus recline: New trends in an old spinal cord-injured patients: Safety and efficacy of a weekly oral debate. Technology Special Interest Section Quarterly, 10(2), 1–3.
cyclic antibiotic (WOCA) programme with a 2 year follow-up—An Lange, M. (2006, March). Positioning: It’s all in the angles. Advance for observational prospective study. Journal of Antimicrobial Chemo- Occupational Therapy Practitioners, pp. 42. therapy, 57, 784–788.
Levy, C., Berner, T. F., Sandhu, P. S., McCarty, B., & Denniston, N. L. (1999).
Sommerfreund, J., & Masse, M. (1995, October). Combining tilt and Mobility challenges and solutions for fibrodysplasia ossificans progressiva.
recline. Team Rehabilitation Report, pp. 18–20.
Archives of Physical Medicine and Rehabilitation, 80, 1349–1353.
Sprigle, S. (2000). Prescribing pressure ulcer treatment. Rehabilitation Lueder, R. (2005). Ergonomics review. Retrieved from http:// Management, 13(5), 72–77.
www.humanics-es.com/ergonomics_movement.htm Sprigle, S., Dunlop, W., & Press, L. (2003). Reliability of bench tests of Nachemson, A. (1981). Disc pressure measurements. Spine, 6, 93–97.
interface pressure. Assistive Technology, 15, 49–57.
Nwaobi, O. M. (1987). Seating orientations and upper extremity function Stinson, M. D., Porter-Armstrong, A., & Eakin, P. (2003). Seat-interface in children with cerebral palsy. Physical Therapy, 67, 1209–1212.
pressure: A pilot study of the relationship to gender, body mass O’Brien, J. G., Chennubhotla, S. A., & Chennubhotla, R. V. (2005).
index, and seating position. Archives of Physical Medicine and Reha- Treatment of edema. American Family Physician, 71, 2111–2117.
bilitation, 84, 405–409.
Paralyzed Veterans of America. (2000). Pressure ulcer prevention and Ten Harkel, A. D., Van Lieshout, J. J., & Wieling, W. (1992). Treatment of treatment following spinal cord injury: A clinical practice guideline orthostatic hypotension with sleeping in the head-up tilt position, for health care professionals. Retrieved from http://www.pva.org/ alone and in combination with fludrocortisone. J Internal Medicine, Pellow, T. R. (1999). A comparison of interface pressure readings to Trail, M., Nelson, N., Van, J. N., Appel, S. H., & Lai, E. C. (2001). Wheel- wheelchair cushions and positioning: A pilot study. Canadian Journal chair use by patients with amyotrophic lateral sclerosis: A survey of of Occupational Therapy, 66, 140–149.
user characteristics and selection preferences. Archives of Physical Pfaff, K. (1993, October). Recline and tilt: Making the right match. Team Medicine and Rehabilitation, 82, 98–102.
Rehabilitation Report, pp. 23–27.
Vaisbuch, N., Meyer, S., & Weiss, P. L. (2000). Effect of seated pos- Porter, J. M., & Gyi, D. E. (2002). The prevalence of musculoskeletal troubles ture on interface pressure in children who are able-bodied and among car drivers. Occupational Medicine (London), 52, 4–12.
who have myelomeningocele. Disability and Rehabilitation, 22, Porter, J. M., Gyi, D. E., & Tait, H. A. (2003). Interface pressure data and the prediction of driver discomfort in road trials. Applied Ergonomics, Wyndaele, J. J. (2002). Intermittent catheterization: Which is the optimal technique? Spinal Cord, 40, 432–437.
B. E. Dicianno et al.
CIALIS WESTERN OPEN PGA TOURNAMENT AND CHICAGOLAND SPEEDWAY NASCAR RACES CHICAGOLAND 300 BUSCH SERIES CHICAGOLAND 400 NEXTEL CUP SERIES JULY 3 THROUGH JULY 9, 2006 In anticipation of a significant number of aircraft traveling to the Chicago, Illinois, area during the Cialis Western Open PGA Tournament and the Chicagoland Speedway NASCAR races, a temporary air traffic cont