What are some common disorders that can be caused or aggravated by poor wheelchair positioning?

Dr. Gavin-Dreschnack: Inadequate or inappropriate wheelchair positioning can contribute to pressure ulcers, skin tears, bruising, skeletal deformities, dysphagia, impaired respiration and digestion, contractures, discomfort, agitation, inability to self-propel, visual impairment, incontinence, social isolation, unsafe transfers, falls, and injuries to both residents and caregiving staff.

Would you discuss how someone might be perceived as dysfunctional because of poor wheelchair positioning or kyphosis?

Dr. Gavin-Dreschnack: Elderly wheelchair users who are not properly positioned often can be perceived as more dysfunctional than they are. For example, a person who cannot maintain upright trunk alignment may lean heavily to one side without adequate pelvic and/or lateral support. This can contribute to poor head and neck posture, inability to communicate and swallow, exhaustion, discomfort, and even drooling.

Let's consider Mrs. X, an elderly woman, five-feet tall, with severe kyphosis, who has been admitted to a nursing facility after having a stroke. She is initially placed in a standard, 18"-wide wheelchair with a sling seat and back, fixed-height armrests, swing-away footrests, and a 21" seat-to-floor height. As a result of the stroke, Mrs. X is limited to use of her left side only. She cannot reach the wheelchair wheel, since the armrest is as high as her shoulder, and she is too short to reach the floor with her feet. This situation renders Mrs. X totally dependent on staff for mobility, as she must be pushed in her wheelchair. Furthermore, her kyphosis causes her head to remain flexed forward, and swallowing is difficult. Her eyes are directed toward the floor, so it appears that she is unable or unwilling to interact meaningfully with others. Mrs. X appears to have many functional limitations, and she appears to require a great deal of assistance overall.

After a seating evaluation is conducted, Mrs. X is provided with a narrow, hemi [17" seat-to-floor height] frame wheelchair, a pressure-relieving cushion with a stable base, adjustable height armrests, and a contoured, padded backrest that is angled backward and recessed to accommodate her kyphotic spine. Now Mrs. X has armrests that accommodate her shortened arm height, thus enabling her to easily reach the wheel with her left hand. The lower height of the chair allows her to simultaneously use her left foot for propulsion. The new backrest facilitates upright posture, and Mrs. X can now assume a level gaze and keep her head and neck upright without strain. Her swallowing is immediately improved, and she is more comfortable. The improved seating allows Mrs. X to become independent in her wheelchair mobility and promotes social interaction. The way that Mrs. X is perceived by others is dramatically different. While this is just an example, it is not an uncommon scenario in many nursing homes today.

What are some common problems caused by gerichairs, and how might they be remedied?

Dr. Gavin-Dreschnack: Gerichairs are used frequently for residents who cannot maintain upright posture. These chairs often are too wide for residents and generally do not offer lateral stability. Most gerichairs are used in the semireclined position, which can pose a serious threat to people with swallowing difficulty. Extended use of the reclining position also directs the user's gaze upward and can promote sensory deprivation and social isolation. If the footrest section of the gerichair does not have independent movement from the frame, the user may be subjected to discomfort, strain of the hamstring muscles, and risk of contractures. A better solution is using a "tilt-in-space" chair that offers both tilt and/or recline and allows independent positioning of the footrest and legrests. These frames are usually very adaptable and, when appropriately fitted, can accommodate a wide range of positioning challenges.