Effective Seating Assessments Amy Barber @Yorkshire_Care #YORTRAINGOLD2017 www.yorkshirecareequipment.com
Effective Seating Assessments A M Y B A R B E R O C C U PAT I O N A L T H E R A P I S T Y O RT R A I N G O L D O C TO B E R 3 RD 2017
Learning Outcomes Goals of good seating Basic biomechanics of seating How to complete an assessment How to achieve better seating instantly How to get staff and carers involved 24 hour postural management Using manual handling techniques effectively to promote good posture.
Goals of seating Postural stability and control Quality of life Providing appropriate pressure relief Respiratory function Safe oral intake Mobility
Initial considerations
90-90-90 Normal Behaviour in Sitting
Biomechanics of Sitting Even distribution = large base of support provides stability, requiring less active muscle tone to maintain posture against gravity Symmetrical pelvis = trunk alignment which promotes trunk extension, enhancing functional activity, allowing movement of the arms and increasing functional reach. Lumbar support = trunk extension, reduces posterior tilt which can result in sliding down and sheer forces
Posterior Pelvic Tilt This is a common seating position which can occur when muscles of the trunk are unable to hold the spine upright against gravity. It can be the result of abnormal tone, tight hamstrings and limited hip flexion. It can occur when sitting for long periods and therefore can increase the risk of pressure ulcers at the sacrum, heel and spine.
Posterior tilt Anterior tilt
Pressure Ulcers What are they? a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Ref: European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel
At what cost? Cost to the NHS 1.4 billion 2.1 billion each year (4% of the total NHS expenditure) 1 This is based on treatment of individual cases ranging between 1,064 (Grade 1) to 10,551 (Grade 4) 1 BUT, this was in 2004, new figures from 2013 suggests averages ranging between 1214 (category 1) to 14 108 (category 4) 2 The prevalence in a NHS hospital is between 18-20% 3 Let s get up and move!
How to assess for seating The skeletal - the scaffolding The muscle - provides stability and allows movement The nervous system - controls movement, interprets the body s position in space Assessment incorporates all body systems Needs to part of a 24 hour postural plan
The basics of your assessment The setting can determine many factors - home, nursing home, hospital Gain information - Talk with client, carers, family, staff UNITED GOAL Physical Assessment of the client Utilise resources - Arrange to meet with key worker, M&H team leader, other therapists Current positioning posture, use of chair
Assess the current seating Shape, size and weight of client and chair Seat depth; The seat should be deep enough to support the full length of the thighs comfortably without having to lean back to provide support for the shoulders. Seat height: foot placement, ease of egress to promote mobility Arm rest height: provide trunk stability, needed for egress, comfort Cushion: depth, consistency, immersion Functions: riser/recliner, tilt-in-space Head and neck position: Active movement or is support required Foot rest: oedema, reducing mobility Don t look at clothing!
Improvise Look for alternatives Feet foot block / flat cushion aim for feet flat on the floor. Trunk stability use towels, blankets, cushions Arm rests applying foam and tape to increase height Create a wedge Head rest a regular cushion is unlikely to assist.
Types of seating Standard high back Tilt in Space/Care Chairs Riser-recliner Lento Care Chair Cura Legacy Kirton Duo
Tilt in space seating Provides flexibility Pressure relief shifts weight from coccyx, ischial tuberosities and thighs, to the greater surface area of the back and sacrum. NB Be aware of neck position full-body tilt to approximately 25 reduces the surface shear force to near zero. In contrast, a backrest only recline of 20 causes a 25% increase in the surface shear force 3 Ref : Hobson 1992
Visual aids
24 hour postural management It doesn t stop at seating! Ensure that the profiling bed is being used to its best performance. Use of anti-trendelenburg, knee break and headrest
24 hour postural management It doesn t stop at seating! Ensure that the profiling bed is being used to its best performance. Use of anti-trendelenburg, knee break and headrest Side lying to encourage pressure relief and stretching Wheelchair seating lack of support Toilet/commode Dining chair
Implementing good positioning Educate and offer training/support Knowledge is power the reasons why And the reasons why not The goal is not yours, it s a united goal Written care plan/goal Accountability Photographs Markers on equipment
Points to remember in positioning Equipment is only as good as the person using it! The chair even an expensive chair is ineffective if used incorrectly. Initial positioning is key Ensure the correct mode of transfer is used. Correct sling and loops will ensure a good, upright position. Level pelvis with hands Bottom to the back of the chair Position in the middle Do not be afraid of re-positioning
George Patrick Positioning advice given out by OT. To keep in personal file, not by bedside.
George Patrick
George Patrick
Conclusion Individualised seating Experiment with the resources available Impart knowledge Risk of pressure damage is everyone s responsibility
References European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC. National Pressure Ulcer Advisory Panel: 2009: Prevention and Treatment of Pressure Ulcers: Quick Reference Guide (pdf) 1. Bennett Get al (2004) The cost of pressure ulcers in the UK Age and Ageing, Volume 33, Issue 3, 1 May 2004, Pages 230 235 2. Dealey C et al (2013) The cost of pressure ulcers in the United Kingdom. Journal of Wound Care Volume 21, Issue 6 3. Hobson D (1992) Comparative effects of posture on pressure and shear at the body-seat interface. Journal of Rehabilitation Research and Development Vol. 29 No. 4, Pages 21-31 Michael S, Porter D, Pountney T (2007) Tilted seat position for non-ambulant individuals with neurological and neuromuscular impairment: a systematic review. Clinical Rehabilitation 2007; 21: 1063 1074 Yih-Kuen Jan, PT, PhD,a Barbara A. Crane, PT, PhD, ATP/SMS,b Fuyuan Liao, PhD,a Jeffrey A. Woods, PhD,a William J. Ennis, DO, MBA. (2013) Comparison of Muscle and Skin Perfusion Over the Ischial Tuberosities in Response to Wheelchair Tilt-in-Space and Recline Angles in People With Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation 2013;94:1990-6 Turner C (2001) Posture and Seating for Wheelchair Users: An Introduction British Journal of Therapy and Rehabilitation 8 (1) 24-28 Chan D, Laporte D, Sveistrup H (1999). Rising from Sitting in Elderly People, Part 1: Implications of Biomechanics and Physiology British Journal of Occupational Therapy, February 62(2) Chan D, Laporte D, Sveistrup H (1999). Rising from. Sitting in Elderly People, Strategies to Facilitate Rising Part 2 British Journal of Occupational Therapy, February 62(2)
References Thirugnanachandran, T; Bateson, A (2012) Seating for improving function in older people European Geriatric Medicine, 02/2012, Volume 3, Issue 1 Ukita A, Nishimura S, Kishigami H, Hatta T (2015) Backrest Shape Affects Head Neck Alignment and Seated Pressure Journal of Healthcare Engineering Vol.6 No.2, Page 179 192 Turner C (2001) Considerations when prescribing manual wheelchairs British Journal of Therapy and Rehabilitation 8 3 109-115 Christenson MA (1990) Chair Design and Selection for Older Adults. Phys Occup ther Geriatr. 67-85. Nitz JC (2000) The seating dilemma in aged care. Australian Journal of Physiotherapy.46: 53-58. Alexander NB, Koester DJ & Grunawalt JA (1996) Chair design affects how older adults rise from a chair. JAGS. 44 (4):356-362. Gillen G & Burkhardt A (1998) Stroke Rehabilitation A Function-Based Approach. Mosby, Gebhardt K & Bliss, M R. (1994) Preventing pressure sores in orthopaedic patients is prolonged chair nursing detrimental? Journal of Tissue Viability. 4(2):51-54. Rader J, Jones D, Miller, L (1999) Individualized Wheelchair Seating: Reducing restraints and Improving Comfort and Function. Topics in Geriatric Rehabilitation 1999:15(2);34-47