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SITTING COMFORTABLY?

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1. 1 3 About transferring to the wheelchair with the use of assistive devices If you are using transfer devices you should avoid pulling your bottom across the seat in case you have ended up not quite sitting in the place where you would like to sit If your assistants decide to pull the back or the sides of your trousers in an effort to move you such a situation could cause tissue damages If there is a need to adjust your seating position this must be done using the sling whilst you are still in it i e whilst you are completely off the seat surface Using a different sling or changing the procedure slightly in accordance with the principles pertaining to 1 stability and 2 pressure distribution might improve the transfer Your end position in the wheelchair following a trans fer must be right from the outset This means that even if the transfer has gone just slightly wrong it has to be repeated immediately For the same reason it is also important to adjust your clothes whilst you are still hanging in the sling in order to avoid pulling your bottom and your buttock bones just that little bit for ward which might cause your pelvis to tilt backwards drawing 3 If this happens the possibility of stabilis ing your pelvis in a neutral position by means of the three support points a b amp d drawing 1 is no longer provided meaning that you need to start the process all over again sitting down About lifting If you do
2. A user manual for wheelchair users By Helle Dreier PURPOSE The purpose of this user manual is to improve your knowledge and options with regards to being able to sit in a wheelchair without having to run the risk of serious damages The aim is to focus on prevention First and foremost the manual aims at preventing pressure sores and deep tissue damages however the intention is also to prevent long term impacts of sit ting in an inappropriately adjusted wheelchair In fact you can prevent both tissue damages and long term impacts by following the same basic principles The goal is to avoid you getting into a situation where you feel forced to lie passively in your bed in order to relieve your bottom instead of actively living your life The idea is to provide you with sufficient knowl edge to allow you to change your situation if ever you might want or need to do so The idea is not for you to reduce your level of ac tivity On the contrary you want to gain sufficient knowledge to ensure that you do not sustain damage by being active In this way hopefully you can still participate in all those activities that you enjoy in your everyday life Nothing indicates that being active is a problem in its own right On the contrary However being active does require your seating position to be just right and thus non harmful to you Hopefully you and your assistants will also be able to transfer this new knowledge to other risky s
3. You can use the tilt in space function in everyday life when changing your position drawing 12 This function tilts both the seat back armrests and footrests at the same time The angle between seat and back i e your hip angle is maintained during the entire movement Tilting the wheelchair back wards as far as possible is a really good function In this way you are able to adjust the effect of the force of gravity onto your bottom feet arms and back with out having to change the basic and necessary level of stability Under no circumstances however should you use the possibility of tilting the wheelchair forward should this function be available If you do so you put yourself at risk of sliding forwards in your seat which might lead to serious tissue damages as a result of shear draw ing 3 The function of tilting the wheelchair forward must only be used when you want to get up FROM the wheelchair NEVER use this function to help you sit down in the wheelchair If the function is available and you might activate it unintentionally you might want to have it blocked in order to avoid exceeding the horizontal position unintentionally In exchange you will be able to tilt your wheelchair slightly further towards the back You need to consider however whether certain everyday situations in your life require you to sit on a slightly forward tilted wheelchair seat Perhaps you utilise this function if you are unable t
4. 84 528 34 Hobson DA 1992 Comparative effects of posture on press and shear at the body seat interface J Rehabil Res Dev 29 21 31 Linder Garz E Shabshin N Itzchak Y Yizhar Z Siev Ner Gefen A 2008 Strains and stresses in sub dermal tissues of the buttocks are greater in paraplegics than in healthy during sitting Journal of Biomechanics 41 567 580 Schubart JR Hilgart M Lyder C 2008 Pressure Ulcer Prevention and Management in Spinal Cord Injured Adults Analysis of Educational Needs Advances in Skin amp wound Care 21 322 329 Shields RK Cook TM 1988 Effect of Seat Angle and Lumbar Support on Seated Buttock Pressure Physical Therapy 68 11 1682 1686 Townsend EA Polatajko HJ 2008 Menneskelig aktivitet II En ergoterapeutisk vision om sundhed trivsel og retf rdighed muliggjort gennem betydningsfulde aktiviteter Munksgaard Danmark Enabling Occupation Il Advancing an occupational therapy vision for health well being amp justice through occupation 2007 Canadian Association of Occupational Therapaists Olsson GR 2005 En unders gelse af faktorer der h mmer og fremmer brugen af hospitalssenge i forebyggelsen af tryks r Masterthesis An analysis of factors hindering and facilitating the use of hospital beds within pressure sore prevention efforts Van Geffen P Reenalda J Veltink PH Koopman BFJM 2008 Effects of sagittal postural adjustments on seat reaction load Journal of
5. Biomechanics 41 2237 2245 e Please also refer to the list of references available at www tryksaar dk SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier GLOSSARY 032 Armrests On the wheelchair can be used to distribute up to 10 of the body weight Must support the arms when the arms are not in use must not be in the way of you moving your arms and shoulders freely if you are driving your wheelchair by means of grip rings drawing 11 Body Your body must function as a resource of pressure distribution When the wheelchair seat and back are perfectly fitted to your body the total amount of pressure on the exposed areas on your buttocks and your tailbone will be reduced You will want to take advantage of this fact drawings 5 amp 8 Buttock bones The two rocker shaped bones located under the buttocks Those are the bones that you sit on and which along with the 3rd support point located on the connection between the spine and the sacral spine are supposed to make the stable seating posi tion drawings 1 amp 4 Clothing Heavy seams on the clothing might add pressure to particularly exposed areas You might want to remove the back pockets from your trousers or buy clothing designed especially for wheelchair users The size and thickness of your outdoor clothing must not influence your choice of wheelchair width You might want to look for outdoor c
6. risk of deep tissue damages In addition you attempt ing to keep your head in an upright position in order to see what is going on around you might lead to pain and soreness around your back neck and shoulders It is important to remove the lifting slings after use and slings that are designed for people to permanently sit on them should not be used They increase the risk of sliding forward thus increasing the risk of tissue damages caused by shear Lifting sling materials are inflexible and they are equipped with some very heavy seams which might lead to pressure injuries Avoid having to dismantle foot and leg rests prior to carrying out a transfer Having to put them back on following the transfer usually disturbs the seating position stability which the transfer is supposed to create Avoid having to lift or stretch your legs forward during and after the transfer Prevent your feet from getting stuck on calf plates heal straps or other technical items found on the wheelchair or on the lifting equipment 7 Take your time during the transfer to ensure that the process is under control OTHER PLACES TO SIT Consider whether your seating position is suf ficiently stable and pressure relieving when you are sitting in a car seat sofa or armchair Does the seat surface provide sufficient space for your buttock bones a amp b and is your entire backside being supported Are your three support points a b amp d
7. seat base and the cushion match If the seat base is to be tightened or is made up of a fixed plate which cannot be shaped to fit you the cushion needs to be thick enough to allow your buttock bones a amp b to sink into the cushion material at a level similar to those addi tional 3 cm reached by the buttock bones If on the other hand you are able to utilise the fact that the seat base below the cushion can be shaped according to the depth reached by your pelvis bones you need to select a cushion that fits the shape of the seat as well as the shape of your bottom and the ad ditional 3 cm needed by your buttock bones drawing 10 The advantage of this type of pressure distribu tion system is that the cushion does not have to be quite as thick and that it allows you to obtain a high level of stability through the combination seat base cushion The pelvis bones must not be able to reach through the cushion material to hit the seat base If this is the case the pressure distribution is insufficient It is recommendable to seek professional and impar tial advice concerning the choice of cushion in order to ensure good interaction between buttock bones bottom seat base and the cushion 7 10 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier Armrests The armrests are intended for body weight distri bution and support of resting arms Therefore it is important to adjust them to the r
8. seat and back without changing the hip and knee angles drawing 12 You may use this function as often as you like because it does not alter the sta bility of your seating position but only the effect of the force of gravity on your body SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier Tissue injuries 048 Although tissue injuries is the same as pressure sores this might be a more precise description of what pressure sores actually are In principle muscle tissue is more sensitive to the combination of pres sure and shear than skin The tissue is much more influenced by pressure and shear when you are sit ting than when you are lying down If the seating position is unstable and if the pressure distribution is also not optimal shear will work from the inside and lead to in depth impacts on the tissue located close to particularly exposed bones This explains under lying tissue injuries which suddenly appear on the skin surface after having developed unnoticed over a long period of time Transfer Is another word for moving Whenever you transfer yourself to your wheelchair and intend to sit there for more than 15 minutes you need to be careful The transfer needs to take place in a controlled manner with or without assistive devices and you must end up sitting on your bottom without having to pull the tissue across the seat surface A transfer well done is a big step towards ensuring
9. see it is your very own skeleton deliver ing stability within your seating position however you also need to assist your skeleton in doing so by having the wheelchair fit your body curves perfectly in both the seat and the back So you need the three support points a b amp d draw ing 1 to cooperate with the wheelchair in order to keep your pelvis in a neutral position drawing 6 thereby preventing it from tilting backwards If your pelvis is tilted backwards you will automatically end up sitting on your tailbone c which is not desir able drawing 7 If the tailbone is your 3rd support point If for some reason it is not possible to stabilise your pelvis in a neutral position by means of the three support points a b amp d in exceptional cases you might need to use your tailbone c as one of the three support points If this happens your pelvis will tilt backwards drawings 2 amp 7 at the same time unfor tunately causing you to lose the possibility of utilising the innate ability of the spine to function as a self supporting construction This means extra muscle work in order to keep your head in an upright position and usually this will also lead to reduced freedom of movement for your arms and upper body SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier At the same time such a position might lead to an increased risk of shear in connection with the buttock bones a amp b an
10. ABLY A user manual for wheelchair users By Helle Dreier The 3rd support point In reality the 3rd support point is more like the area d than an actual point It is located at the lower back where the hip bone and the spine meet drawings 5 amp 6 More precisely the area is defined as the connec tion between the spine and the sacral spine drawing 4 i e it is located higher up on the back than where the tailbone c is located Take a good look at the drawings and try to localise those points on your own body when looking in the mirror You might ask an assistant to localise the points on your body for you It is particularly important that the 3rd support point includes the sacral spine but it is also helpful if it reaches out to the large hip bones which you can locate by the sides of your waist and follow all the way to your back drawing 4 The support point must be fixed and precise because it is needed to support and stabilise your pelvis in a neutral upright position on top of the buttock bones a amp b drawing 1 In this way you also gain support for the natural curve of your spine which then functions as a self supporting construction This makes your head balance without you having to spend unnecessary energy keeping your head upright At the same time it creates stabil ity for the entire body and you avoid malpositions and sore shoulders or a sore chest neck and throat drawing 6 5 6 09 As you can
11. If your sensibility is reduced or completely missing or if you suffer from reduced muscle strength you are at risk of sustaining physical damages caused by sitting Sitting might cause at least two types of serious dam age Damage to the musculoskeletal system i e skel eton muscles and joints This might lead to malpositions and pain which in the long run might reduce your activity level and increase the risk of pressure occurring in particularly exposed areas Damages on or under the skin This refers to pressure sores or deep tissue injuries e g close to the bones that stick out in your buttocks buttock bones a amp b or tailbone c drawing 1 Such damages might lead to life threatening situa tions They require quick reactions from both you and your assistants as well as acute assistance from people specialising in sores and seating positions Luckily both types of damages are preventable and you can do a lot to prevent them Your wheelchair must fit your body perfectly as if it were tailor made for you Many wheelchairs are adjustable in order to fit your body and activities perfectly however exploring these adjustment options to the fullest requires expe rience and knowledge If you sit in your wheelchair for more than 15 minutes at a time and if your sensibility is reduced or lacking completely a wheelchair which cannot be adjusted to fit your body is not suitable for you 1 2 t Da agb
12. SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier TABLE OF CONTENTS PREFACE PURPOSE PHYSICAL DAMAGES Damage to the musculoskeletal system i e skeleton muscles and joints Damages on or under the skin Superficial skin damages Deep tissue injuries beneath the skin BODY SIGNALS EXTRAORDINARY INCIDENTS CENTRAL SEATING POSITION FACTORS 1 Stability Buttock bones The 3rd support point If the tailbone is your 3rd support point 2 Pressure distribution The wheelchair back The wheelchair seat Cushion Armrests Foot rests 3 Everyday activities About sitting About sitting down About transferring to the wheelchair About transferring to the wheelchair without the use of aids About transferring to the wheelchair with the use of aids About lifting About lifting harnesses OTHER PLACES TO SIT CLOTHING 04 05 06 07 07 08 08 010 014 017 018 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier YOUR PERSONAL RESPONSIBILITY THE ROLE OF THE ASSISTENT THE WHEELCHAIR AN AID THAT FACILITATES ACTIVITY The manual wheelchair When you sit dow When you are sitting When you change your position When you are driving Wheelchairs allowing for seating position adjustment When you sit dow When you are sitting When you change your position Whe
13. This movement is so subtle that you might not even notice it It might however be suf ficient to make you end up sitting on tissue subject to shear drawing 3 Therefore the recline function should only be used in the initial adjustment of the wheelchair to fit you and your body Afterwards it is often a good idea to remove or deactivate this function If you believe that there are certain everyday situ ations which you cannot possible handle without the use of the recline function you need to look for alternative solutions to these issues If you are still convinced that those procedures cannot be altered you have to minimise the number of reclines that you do At the same time you should avoid using the recline function to return yourself to a sitting position 025 Amongst other things this means having to have an assistant manually and very carefully helping you to get up and return to a sitting position without using the recline function Once you are sitting upright in the correct position without leaning against the wheelchair back the recline function may be electri cally or manually activated in order to return the back to an upright position Then you can lean back again Another way of using the recline function without suf fering any damages from doing so might be to use it in connection with the tilting function This involves returning the recline function from the lying down to the sitting position whilst t
14. a healthy seating position Transfer devices There are many types of assistive devices that facili tate a transfer well done If you need to use assistive devices to transfer your self you need to find the best way to avoid pulling the tissue on your bottom across the seat surface Wheelchairs allowing for seating position adjust ment This category includes comfort wheelchairs and electric wheelchairs that allow mechanical or electric seating position adjustments Usually they offer tilting or recline functions as well drawings 11 12 amp 13
15. actice and the signals might also change over time Your senses might even play tricks on you as a result of your disease SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier THE ROLE OF THE ASSISTENT If you receive support from care assistants visiting you you need to make sure that they are also aware of the principles of stability and pressure distribution and that they use the wheelchair appropriately when they assist you in sitting down and when you are al ready sitting in the wheelchair Even though it is not always the same assistant ensur ing a good seating position for you it is still important that you are able to provide those assistants with good guidelines to the largest extent possible You might want to have your assistants read through this user manual and you might want to talk to them about the contents of the manual afterwards In this way you and your assistants might be able to plan new procedures if necessary You must remember that you are the only person who is always involved in those situations THE WHEELCHAIR AN ASSISTIVE DEVICE THAT ENABLES ACTIVITY Your wheelchair is typically required to fulfil a whole range of purposes e g being your means of transpor tation as well as your base for participating in every day activities Fulfilling all needs at the same time can be a complicated matter when selecting a wheelchair Often you have to prioritise various factors In
16. activities 1 Stability If your sensibility is reduced or lacking completely you are at risk of developing pressure sores or deep tissue injuries In this case when selecting a seating position it is important for you to highly prioritise the stability of the entire body Stability will prevent you from sliding forward in the seat however you should NEVER attempt to prevent sliding by sitting on an anti slip material This would only hide the visible problem whilst increasing the development of shear that causes deep tissue injuries Thus the risk of sore development would increase Buttock bones In order to create stability for the entire body within the seating position you primarily need to consider the 2 buttock bones a amp b which you are sitting on and which you can feel underneath each buttock drawings 1 amp 4 These bones are however not shaped to stabilise your body on their own They are 08 1 2 d R Ca f On A A a amp b a amp b more or less shaped like the rockers on a rocking chair drawings 1 amp 2 and if they are not supported by a 3rd support point they will tilt backwards Many people think that the tailbone c drawings 2 amp 4 needs to take on the role as the 3rd support point however this is rarely appropriate Actually the tail bone should only then be used as the 3rd support point if that is the only way to obtain an appropriate seating position SITTING COMFORT
17. als must be flexible and free from back pockets and heavy seams If necessary re move the back pockets from your trousers Think about this when shopping for clothes Several companies offer good and nice clothes for wheel chair users Give their products and yourself a chance e You might be tempted by selecting a wheelchair that will accommodate your winter wardrobe as well by being slightly wider than you are It is however important that your wheelchair fits you perfectly in the summer as well as in the winter Therefore you should look for alternative pieces of winter clothing which do not require additional wheelchair seat width Several companies produce this type of alternative winter clothing e The cushion cover must be sufficiently large flex ible and moisture transporting When you are sitting on your cushion the best thing is for you to be sitting on the original cover Avoid placing protective materials sheepskin rugs or disposable materials on top of the cover This reduces the pressure distributing effect of the cushion thus doing more harm than good The same applies if you are sitting in or lying down in your bed The more layers you are sitting on and the stiffer those layers are the less pressure relieving effect the cushion will have e Always use the standard cover and avoid using pillow covers or other inflexible pieces of material as a substitute Whenever there is a danger of de vel
18. also not sufficient just to tell somebody how you usually do things You really need to try things out at home using the assis tive devices that have been provided to you in your home You might need a sparring partner to assist you in analysing those situations in a thorough manner In this way you can come up with specific and realistic solutions to fit your individual and unique everyday life If you want to assume responsibility for preventing physical damages it is absolutely essential that you gain an insight into the ways in which you can actually carry out your everyday activities You need to ana lyse all risky movement patterns with regards to inap propriate procedures in order to obtain the optimal stability and pressure distribution levels within your seating position Consider this a detective s task and keep looking for further suspects Your everyday activities might be packed with risk factors This might include the way you sit down in your wheelchair or the way you sit in it It might also include daily procedures related to toilet visits showering or resting in your chair It could also include kitchen ac tivities related to cooking or eating or activities that you carry out whilst lying in bed Most activities may be carried out in various ways You need to identify those ways that carry the smallest risk of compromis ing your stability and pressure distribution levels About sitting Sitting is an everyday a
19. alternative transfer devices for a while until you have regained the strength in your arms An extraordinary incident might also include holiday visiting friends and family or being admitted to hos pital You might have had to sit for a very long period of time without being able to adjust your seating posi tion or you might have been sitting uncomfortably in a plane seat a bus seat a car seat or in an inappropri ately adjusted wheelchair that was not your own If you are facing an extraordinary situation e g when going on holiday or being admitted to hospital it is always recommended that you obtain information ahead of time and that you communicate your spe SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier cial needs with regards to transfers bed adjustment functions mattress quality issues as well as toilet and shower facilities In this way you will be better pre pared to prevent undesirable impacts on your body If possible bring your own wheelchair and if necessary have a therapist adjust it to your current state and the situation in question CENTRAL SEATING POSITION FACTORS In order for you to contribute to the prevention of tis sue damages and other physical damages caused by sitting you need to understand the meaning of three central factors that affect your ability to obtain a non harmful seating position 1 Stability 2 Pressure distribution 3 Carrying out everyday
20. and is still intact is there fore not a sufficie to the wheelchair and the cushion through your 2 buttock bones a amp b drawings 1 amp 4 Therefore the surrounding tissue is exposed to a particularly high level of pressure If at the same time you are sliding slightly forward in the seat because you are not sitting in a completely stable position your buttock bones will simply tilt backwards This causes the tissue to be compressed and deformed and shear starts to develop drawing 3 2 3 5SN NNS a amp b BODY SIGNALS lt is very important that you think about your body s signals and react to any kind of pain and discomfort that might be connected to your seating position Using an inappropriate seating position which strains your body can cause general discomfort Potentially such discomfort might be a sign of deep tissue injuries that have yet to surface If you suspect that something is wrong you need to seek medical advice as soon as possible At the same time you need to obtain assistance from a therapist specialising in seating positions In cooperation with the therapist you can explore the possibilities of im proving your situation If you have sustained tissue injuries to your bottom around the buttock bones or the tailbone those inju ries have most probably occurred because you have been sitting for more than 15 minutes in an insuffi ciently adjusted wheelchair armchair sofa or bed or in an inapp
21. ax 06 Superficial skin damages Pressure sores might occur in many different places on your body typically where your bones stick out This includes heels calluses the spine shoulder blades and elbows Often these are friction dam ages occurring in connection with the use of inflexible bedding and clothing material folds nappies lifting harnesses or inappropriate transfers involving barking the skin or hitting something hard whilst moving Such damages are immediately visible on the skin Deep tissue injuries beneath the skin Many tissues injuries occurring in connection with sitting might develop beneath the skin over a longer period of time and unnoticed This might happen deep inside the tissue which is stuck between bones fatty tissue and skin when you are sitting This type of tissue injuries does not always lead to skin reddening but it might suddenly turn up on the skin surface in the form of a small spot pimple or boil after having developed unnoticed over along period of time Such cases typically involve significant underlying damages to the tissue located closest to the bones These dam ages are called Deep Tissue Injuries DTI and they develop from within the deep tissue located closest to the bones and then move outwards towards the skin SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier Just keeping an eye on the skin on your bottom to en sure that it is not turning red
22. ble in order to avoid having to move your body and change your seating position once you have been placed in the wheelchair Spine Your spine must function as a resource with regards to your seating position You need to use this part of your body to balance your head and your upper body The natural curve of the spine is supported by means of the shape of the wheelchair In this way the spine becomes a self supporting construction with the ability to prevent gravity from making your upper body collapse You save energy at the same time obtaining a high level of stability and pressure distribution drawings 5 amp 6 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier 046 Stability Along with pressure distribution and everyday activ ities stability is one of the key words within this user manual We obtain a stable seating position when we utilise the innate ability of the spine to support itself at the same time balancing the head and the upper body by supporting the natural curve of the spine in the correct way drawing 5 Tailbone ls located at the lowest part of the spine and is particularly sensitive towards pressure drawing 2 Therefore it is a good idea not to sit on it In order to avoid this you will want to utilise the 3rd support point located at the lower part of the back as the last leg of the stable base needed when sitting drawing 6 The 3rd su
23. ce have also participated in developing a method of performing seating assessments which has led to very good results with regards to prevention and heal ing of pressure sores and tissue damages connected to sitting If you would like to know more about my professional competences please visit my homepage www tryksaar dk In addition the bibliography which is provided as a download alongside this manual con tains a list of literature forming the basis of my practi cal experience and of this manual would like to thank TrygFonden for supporting me financially thereby allowing me to compile this manual in the midst of a turbulent and busy life also want to thank those wheelchair us ers who have assisted me throughout the process by reading and providing feedback on the material want to thank my colleagues professional peers and other experts for their inspiration feedback and sup port wish to thank those users with pressure sores who have been in my care and thoughts and last but not least want to thank my unusually helpful librar ian my patient and talented daughter and graphic designer Marie L Dreier as well as all my other under standing family members and friends Helle Dreier 2010 Copyright Helle Dreier The text fs meant for personal free download and can be reproduced with properly statement of the source Though it is not allowed to use the text commercially SITTING COMFORTABLY
24. ce you are in the seat Lifts Various lifts are available to suit any type of purpose and wish however a ceiling lift is usually the most appropriate type of lift in cases involving pressure sores resulting from sitting Manual wheelchairs The type of wheelchair which is driven by means of grip rings on the wheels Usually it is most appropri ate for such a wheelchair to be fitted with a strap back a strap seat foot rests and arm rests drawing 10 A light chair is also most appropriate because this typically makes it easier for you to move the wheel chair forward without you sliding forward in the seat Pressure distribution Along with stability and everyday activities pressure distribution is one of the key words within this user manual By distributing the body pressure across the largest area possible we are able to reduce the amount of pressure on those areas which are usu ally exposed to a high level of pressure e g buttock bones and the tailbone The contact surface be tween the wheelchair seat back and the back of your body must be as large as possible Amongst other things this might be achieved by supporting the natural curve of the spine and by shaping the seat and back padding of the wheelchair crosswise to fit the body drawings 5 8 amp 10 Pressure sores The traditional term for damages resulting from pressure usually within particularly exposed areas This user manua
25. com modate the anatomical shape of your pelvis drawing 6 So it needs to allow your buttock bones a amp b to sink an additional 3 cm into the cushion material in the back without hitting the seat base drawings 8 amp 11 When you sit down During lifting you might find it useful to utilise the tilting function drawing 12 to tilt the wheelchair backwards If the wheelchair is fitted with a neck sup port it is a good idea to remove that during lifting It is a good idea to leave the leg supports on the wheel chair during the transfer however you must make sure that your feet do not get stuck on calf plates heel straps calf straps or any other items during the trans fer process It is also important to ensure that your knees are not stretched during the transfer 5 8 A aab 022 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier When you are sitting If you have an electric wheelchair the control system must be adjusted to fit you allowing a seating position that relaxes your head neck arms hands and upper body You obviously need to be able to control your direction of sight in a relaxed manner If you are using a joystick the armrest must provide a stable base for your hand and lower arm allowing you to steer your wheelchair properly whilst resting your arm In addi tion the armrest must function as a pressure distribu tion area It is often possible to fit a vari
26. ctivity We are not supposed to think about the fact that we are sitting when we are When we are doing some thing else sitting is not supposed to be an issue When your wheelchair has been adjusted correctly to fit your body the most important point in time will be the moment when you sit down About sitting down So it is the process of sitting down in the correct manner which is important for your stability and pres sure distribution in everyday life At the same time you being aware of how you sit down is also your way of preventing the development of shear drawing 3 3 k About transferring to the wheelchair Transfers TO a wheelchair car seat or other types of sitting furniture are the most important ones Such transfers must form the base of ensuring a stable and non harmful seating position when sitting for a long period of time A transfer well done is a big step to wards ensuring a healthy seating position How your transfers FROM the wheelchair take place is not im portant for your seating position SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier About transferring to the wheelchair without the use of assistive devices If you do the transfers on your own it is important that you finish your transfer by lifting yourself completely from the surface that you are sitting on Perhaps you need to sort out your clothing following the transfer or perhaps you pull yourself across the s
27. d or prevent your arms from moving freely This might be a problem if you are supposed to move the wheelchair manually by means of grip rings The wheelchair seat Anatomically your skeleton is constructed in such a way that when you are sitting the two buttock bones a amp b on your pelvis reach some 3 cm deeper into the base than your femur bones do drawing 6 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier In order to distribute the pressure in the best way possible this means that the shape of the seat surface must fit the shape of this part of your body perfectly Therefore the wheelchair seat shape must be approx 3 cm deeper at the back in the spot where your but tock bones are located when you are sitting drawings 8 amp 10 You have to imagine that what you are sitting on needs to be a kind of a cast of you If the base or the cushion is inflexible this might mean insufficient space for your two buttock bones a amp b As a result your muscles will get stuck and be ex posed to a significantly higher risk of pressure than if the seat base and the cushion fit your bottom perfect ly At the same time it will be difficult to stabilise your pelvis in a neutral position i e on top of the rockers of the buttock bones drawing 6 which would also make it difficult to prevent the tissue from being ex posed to shear drawing 7 Cushion When you select a cushion make sure that the
28. d the tailbone c drawing 3 Therefore if your pelvis is tilted backwards and you are using the tailbone c as the 3rd support point these issues will call for extra attention when selecting a suitable cush ion If your tailbone c makes up the 3rd support point you will usually need to select a cushion product which is able to join the body in that forward sliding movement which will inevitably happen throughout the day Selecting the right cushion requires the help of an expert who is has an in depth product inde pendent and impartial knowledge of relevant cushions available on the market In addition utilising the ability of the wheelchair to change its position must be con sidered when using tilting drawing 12 2 Pressure distribution Pressure on particularly exposed areas e g on the buttock bones a amp b or the tailbone c can be mini mised by increasing the size of the total area on which the body touches the wheelchair This is either done by shaping the wheelchair seat and back to fit your body perfectly or by distributing some of the pressure to your forearms and the soles of your feet 2 3 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier It is common to imagine that pressure distribution is amatter of distributing the pressure between the wheelchair seat and the cushion but one should also explore the possibility of moving some of the pressure to the contact area between
29. e Selecting and adjusting a wheelchair is like tailor making a suit or producing a pair of handmade shoes In those latter cases am sure that nobody would question the need for a tailor or a cobbler Not only must your wheelchair be able to trans port you from A to B it also needs to fit your body measures perfectly and be suitable to your everyday activities That is what makes the choice so difficult Small issues in your everyday life or slight variations between two wheelchair models might turn out to determine the most suitable product for you It is vital to carry out an analysis of your individual needs in your own home You should be able to obtain advice from therapists working in the municipality or at the hospital treating you You can also find therapists on the internet You might want to carry out a search using words such as seating assessment seating position specialist pres 04 sure sores or pressure sore prevention In this way you might be able to locate a therapist close to your home The most important task of such a therapist is to facilitate activity and if you need certain aids in order to be able to carry out your daily activities the therapist is required to make his or her knowledge on wheelchairs cushions and transfer devices available to you My basis for compiling this user manual is my professional background as an occupational therapist Next to more than twenty years of practical experi en
30. e cooking leisure time activi ties personal hygiene or work Think about how you carry out your everyday activi ties Perhaps you are able to identify other less risky ways of carrying out those activities Foot rests Used to distribute up to 10 of the body weight Foot rests allowing the knees to remain at a 90 degree angle provide a better pressure distribution than other types such as elevatable foot rests drawing 9 Length of the lower leg The length from the hollow of the knee to the sole of the foot it is used to determine whether or not the thighs are utilised appropriately as a pressure distributing area If the distance is too short the knees will be elevated from the seat surface anda high amount of pressure will build up underneath the buttock bones If the distance is too long there is a risk of clamping blood vessels and nerves within the hollow of the knee SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier 044 Lifting A process requiring you as well as your assistants to be very careful Your level of stability and pres sure distribution in relation to your seating position depends on the quality of the lifting procedure You and your assistants might want to practise the lifting procedures together in order to identify the best ones If for some reason the lifting procedure fails it is better to try again than to adjust the seating po sition on
31. eat into the final seating position In any case you need to elevate yourself for a moment in order to allow the tissue to fall back into place so that you do not end up sitting on tissue being exposed to shear If you have been bedbound for a longer period of time you might have lost some of the strength in your arms meaning that you are no longer able to lift your self the way you used to In that case you will need to identify other ways of transferring yourself for a cer tain period of time A temporary alternative e g assis tive devices might prevent your bedrest from causing serious tissue injuries You might want to ask the local authority therapist to assist you in finding a suitable solution to cover the period of time needed for you to regain the strength in your arms and be able to do the transfers the way you used to If you need a person to assist you in transferring your self e g from your bed to your wheelchair it is recom mendable to use assistive devices instead An ap propriate transfer requires more than just a person to assist you in order to obtain the needed stability and pressure distribution within the seating position en suring that all three support points a b amp d drawing 1 on your pelvis are in contact with your wheelchair to the extent needed A large selection of assistive devices and transfer methods are available and you might be able to use those as an alternative method for the time being
32. ent space or does it hit the back tubes or the back padding prevent ing you from utilising the entire seat depth or making you end up sitting on the peak of your buttock bones drawings 1 amp 8 e Is your upper body as well as your spine rest ing within the wheelchair back in a stable manner when looking at it from the side drawings 6 amp 11 Remember that your wheelchair is supposed to function as a substitute for your reduced muscle strength If your wheelchair does not provide sufficient support your upper body will typically collapse spontaneously causing you to slide for ward in the seat and dropping your head so that you are required to spend a lot of energy making yourself look forward and up drawing 7 e Is the 3rd support point at the connection be tween your spine and your sacral spine secured and sufficiently stable for you to maintain yourself on top of the two buttock bones below the but tock a amp b drawings 6 amp 11 Is your head balanced at the end of the natural curve of your spine so that you do not need to spend energy keeping it in an upright position against the force of gravity drawing 6 e Are you able to look in the direction that you want to and turn your head the way that you want to in a completely relaxed manner e Is the seat angle between your back and your thighs approximately 90 degrees drawing 8 e Is the knee angle between your thighs and your lower legs as
33. ety of foot and leg sup ports onto an electric wheelchair Usually an electric wheelchair is fitted with electric leg supports that might be elevated to a horizontal position However such extras jeopardise the maintenance of a stable and pressure relieving seating position Instead you might want to use footrests that allow your knees to 9 be at a 90 degree angle when you are sitting drawing 9 You can select divided standard leg supports or a central leg support Depending on your physical and functional needs and perhaps also on your physical surroundings you need to select whatever type best meets your needs Remember that a wheelchair is an advanced assistive device which is able to transport you from A to B and which must allow you to maintain a comfortable seating position Do not expect your wheelchair to also take on the role as a bed or a piece of gymnastics equipment O24 When you change your position Comfort wheelchairs and electric wheelchairs are usu ally equipped with mechanical or electrical adjustment features allowing you or your assistants to change your seating position within the wheelchair Changing your position regularly is a good idea as it shifts the physical effects of the force of gravity Most comfort wheelchairs and electric wheelchairs offer two differ ent adjustment options a tilting function drawing 12 and a recline function drawing 13 The wheelchair tilt in space function
34. he wheelchair is still tilted backwards having the wheelchair tilt you the rest of the way until you are back in a sitting position How ever if at all possible avoid using this function in eve ryday life When you drive If you are supposed to drive your comfort wheelchair yourself by means of the drive wheels these must be placed appropriately in proportion to your arms and shoulders If they are not you will feel worn and sore after each drive You need to make sure that your sit ting position is stable and that you do not pull yourself forward in seat during the drive e g in order to main tain your balance As a rule a comfort wheelchair is not particularly well suited for you to drive it yourself by means of drive wheels It might be a good idea to utilise the wheelchair tilting function and allow the seat to be tilted slightly towards the back during the drive This also applies when driving an electric wheel chair In this way you make sure that you do not slide forward in the seat as a result of bumps and shaking caused by the road conditions drawing 3 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier LOOK AT YOUR BODY In order to gain an insight into your personal seating position you want to look at yourself from top to toe in a mirror This is a useful tool in your attempts to control your sitting options and your seating position at the same time ensuring that sitting does not cau
35. ight height You can distribute approximately 10 of your body weight to the armrests making them quite important Foot rests Foot rests are used to increase the pressure dis tribution area This requires the sole of the foot to be able to support the foot and the weight to be able to distribute itself vertically drawing 9 If the feet are malpositioned certain special sup port measures are required You need profes sional help to solve this issue The distance between the hollow of your knee and the soles of your feet i e the length of your lower leg must equal the distance from the up per edge of the seat to the footplates You have to make sure that the entire back of your thighs are supported This is important for the purpose of pressure distribution If the distance is too short your knees will be elevated too much caus ing your body weight to rest too heavily on your buttock bones only If the distance is too long the front of the seat will apply pressure to the back of your thighs thereby hindering blood circulation and nerve supply Try to find out whether your body and the seat surface fit each other well by sliding your hands under your thighs If you are unable to do so ask your assistant to do it for you A good fit also ensures proper pressure distribu tion If you sometimes wear different shoes with a dif ferent height remember to adjust the distance from the upper edge of the seat and the foo
36. ility and reducing pressure distribution when returning to a sitting position If you need to treat or prevent swollen legs it is much better to do so in bed 3 9 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier 3 Everyday activities Luckily you can do a lot to contribute to the preven tion of physical damages as long as you are familiar with the basic prevention principles described in this user manual in the sections 1 Stability and 2 Pressure distribution It is impossible to predict and describe all possible risky situations that might occur in your eve ryday life however if you and your assistants under stand these principles you are well prepared to come up with your own solutions to various everyday issues If you find it too difficult you may always seek advice and guidance from a therapist specialising in body assistive devices and activities Whereas an outsider s eyes might see things differently your own common sense is definitely also an important tool You particularly need to explore your everyday sur roundings to identify potential risk factors Take a critical look at your daily personal procedures with regards to the use of your wheelchair your cushion and your transfer devices You need to include every little detail also the ones that you consider to be only trivial matters Simply imagining what you are going to do once you are back home is not sufficient It is
37. ituations that might occur in your life and in your everyday life in connection with sitting Such situations might include being transported by car being admitted to hospital or dealing with seating positions in other seats in cars on planes in beds or in other chairs Your body is unique and your everyday life is full of your personal activities and ways of carrying these out Therefore many individual factors must be taken into consideration This manual cannot possibly de scribe all situations in full Instead the aim is to shed light on the most important principles and point out certain typical risk factors in order for you to be able to improve your personal situation and seating posi 05 tion within your personal everyday life The starting point of this manual is that you are the expert in your own life in your own everyday life and on your own body however you do need impartial and product independent advice in order to make informed choices If you use a wheelchair on a daily basis and sit in it for more than 15 minutes at a time and if you have partly or completely lost sensibility you ought to obtain professional advice from a thera pist specialising in wheelchairs seating positions and prevention of pressure sores Because this means that you are at risk of sustaining serious physical damages caused by sitting SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier PHYSICAL DAMAGES
38. l only covers damages related to sitting SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier 0435 Seating assessment A method of analysing the combination of body assistive devices and activities in order to make this combination as stable pressure relieving non harm ful and meaningful to you as possible This method requires a specific analysis of your everyday activi ties within your home using your current assistive devices based on your specific functional abilities Shear Displacement forces which might lead to defor mation and damage of the tissue located around protruding bones such as buttock bones and the tailbone drawings 3 amp 7 Skeleton Your skeleton is the most important resource within your body when it comes to your seating position You need to utilise your skeleton to stabilise your upper body and it contains the three support points the two buttock bones as well as the 3rd support point which make up the base of your seating posi tion drawings 4 amp 6 Slings The fabric which is supposed to carry the person who is being lifted Many types of slings are avail able and you should test various types at home before making a choice Usually you would need to select a sling which is able to create a position that resembles your final seating position At the same time the sling must be as small as possible and it must be easily remova
39. located in accordance with drawing 8 Avoid sitting in your bed As a rule a bed is for lying down If for some reason you need to sit in your bed instead of lying down make sure that you do so for the shortest amount of time possible If your wheelchair has been adjusted correctly it is much safer to stabilise your seating position in a wheel chair than in a bed In such cases you should con sider using your wheelchair instead If you decide to sit in bed after all it is important to make sure that your seating position is stable If you slide down on the mattresses towards the end of the bed and need to be pulled upwards one or several times a day your seating position in bed is unac ceptable and presents a danger to your bottom The bases of some nursing beds are split into four parts By means of an electric function the base 8 A aab SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier automatically adjusts itself to a seating position by including a so called knee break If you need to sit in your bed such a function might be able to pro tect your bottom But remember as a rule a bed is for lying down e Make sure that neither your bottom nor your bones are able to reach through the mattress to touch the bed base Have your assistant check this by sliding his or her hand in between your body and the bed whilst you are lying down and or sitting in bed CLOTHING e Trouser materi
40. lothing that is not bulky on the sides or on the back Shoe soles might have different heights which might influence the extent to which the wheelchair foot rests fit the length of your lower leg You might want to buy shoes with the same sole height if not you will have to adjust the length of the foot rest whenever you change into shoes with a different sole height SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier 044 Cushion An assistive device which most people associ ate with pressure sore prevention Unfortunately the cushion on its own does not create sufficient pressure relief if the seating position is unstable Therefore cushions only make up a small part of the efforts needed to secure pressure sore prevention The Danish market offers more than 100 different cushions and your choice of cushion must be based on an analysis of your particular wheelchair your body as well as your everyday activities Everyday activities Along with stability and pressure distribution every day activities is one of the key words within this user manual Everyday life is full of activities that make good sense to you Most of these activities can be car ried out in a variety of ways but some of these ways might be risky in terms of developing pressure sores or tissue injuries One such everyday activity is the transfer from one assistive device to another Other activities might includ
41. n you adjust your position e Tilting function Recline function When you are driving LOOK AT YOUR BODY e From the front From the side From above REFERENCES 018 019 019 026 030 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier PREFACE This user manual has been compiled for wheelchair users who would like to know more about wheel chairs seating positions and pressure sore preven tion The idea is for this manual to supplement your personal knowledge and improve your ability to assess your own need for professional impartial and product independent advice hope that this manual can contribute to preventing serious physical psychological and social consequenc es of pressure sores stemming from inappropriate seating positions and wheelchairs expect the manual to provide you with more ways of identifying your personal everyday risk situations in order for you to handle such situations as quickly as possible and be fore it is too late sincerely hope that this user manual will provide you the wheelchair user with sufficient knowledge and options to ensure that you are able to live your life the way you want to without having to suffer unnecessary deprivation No matter whether you are selecting a wheelchair or a washing machine you should be able to make informed choices Selecting a wheelchair is just a much more complex matter than selecting a washing machin
42. not have the power to lift yourself up com pletely from the seat surface once you have sat down the most optimal way of doing so is by using a ceil ing lift A ceiling lift provides the best possibilities of ending up in the optimal seating position i e on top of the buttock bones a amp b stabilised by means of the 3rd support point d located on your lower back drawing 6 You want to adjust your seating position once you have sat down because if you fail to do so you might be jeopardising the healthy base position needed in order for you to be able to sit in a stable pressure relieving and risk free manner for hours upon hours SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier About lifting slings Lifting and transfer methods involve various types of needs procedures and assistive devices Depending on the extent of your disability a suitable method will be chosen for you e Often selecting the right sling can really make a difference and improve the transfer Slings should be shaped in a way that makes the seating posi tion within the sling resemble the final wheelchair seating position as much as possible Therefore it is important to prevent the sling from turning your body into a banana shape Instead the sling must enhance and support the natural curve of your spine drawing 6 Small low slings are usu ally the best way to ensure the natural postural sway however the slings must be te
43. o get close SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier enough to your dining table at home Perhaps you are unable to fit your knees under the steering shaft of your car unless you tilt the wheelchair seat forward If this is a regular everyday issue you ought to talk to a therapist in order to look for alternative solutions by altering the surroundings or the wheelchair If this is only an extraordinary problem e g when visiting peo ple going to restaurants or doing something unusual and special you need to look for alternative solutions to such situations which do not involve the risk of you sliding forward in your seat drawing 3 The wheelchair recline function On the contrary it is recommended to not use the recline function in everyday life drawing 13 The recline function offers the possibility of reclining the wheelchair back separately By doing so the hip angle is widened This function should NOT be applied in everyday situations particularly not if you are suffer ing from a reduced or completely missing sensibility Look for other solutions This function carries a sig nificant risk of developing deep tissue damages when you want to return to a sitting position after having used the recline function to make yourself lie down The recline function will push you slightly forward on the seat surface
44. opment of tissue damages the cushion should come with a spare cover Many cushions come with a special cover that has certain special fea tures which fit the cushion perfectly Therefore it is not a good idea to experiment with alternatives If there is a need to protect the cushion against incontinence it is often possible to buy special cushions with built in protection measures Make sure that the material is sufficiently large and flex ible in order to ensure that you are not sitting ona hammock of tight covers YOUR PERSONAL RESPONSIBILITY Every time you sit down in your wheelchair it is im portant that you attempt to visualise and register whether or not you are sitting in a way that provides your body with stability and pressure distribution For this purpose you might want to get hold of a mirror in order to be able to look at yourself in your seating position from top to toe This is a good way of check ing selected areas of your body each time you get comfortable in your wheelchair This procedure might assist you in creating a mental picture of the way that you are supposed to be sitting in your wheelchair Elevating your arms in order to verify whether you are as stable with your arms lifted as with your arms rest ing on the armrests is also a procedure which acts as a guideline as to whether or not you have obtained stability and pressure distribution Learning to read your body signals might require a bit of pr
45. per body balance when sitting down then your wheelchair has not been appropriately ad justed to fit your body The seat surface below you might have been tightened too much at the back You must have this issue attended to immediately espe cially if you are lacking your sensibility It might also be that the back padding is restricting the natural curve of your spine because it is too tight either around your lower back or around your upper body Make sure that both the seat and the back allow plenty of space for your bottom drawing 8 The wheelchair back must fit the sides of your chest perfectly in order for it to support your upper body crosswise drawing 5 and at the same time it needs to follow the curve of your spine from the bottom to the top which you will be able to verify when looking at yourself from the side drawing 8 You also need to make sure that the one back strap which is supposed to fixate your 3rd 020 support point d has been pulled tight drawing 5 This area is supposed to provide sufficient stability to your spine in order for it to keep its natural curve and function as a self supporting construction Find out whether you have obtained the largest possible sup port surface on both the seat and the back You might want to look at yourself in the mirror from the front and the sides then compare yourself to draw ings 5 8 and 10 5 8 SITTING COMFORTABLY A user manual for wheelchair user
46. pport point ls an area located on your lower back It is located where your spine and your sacral spine meet drawing s Locate this area by following the highest point of your hip from your waist towards your back Along with the two buttock bones inside the buttocks this area is supposed to make up the stable base of your seating position drawing 4 Within this area support from the wheelchair is supposed to allow your spine to function as a self supporting construction From this position the up per body and the head are maintained in a balanced position drawing 6 The neutral pelvic position Involves you sitting on the peak of your rocker shaped buttock bones drawing 6 You can only remain in this position as long as your body is supported by the 3rd support point Think of this position as being similar to a 3 legged milking stool You can only keep your pelvis in a neutral position by utilising the 3rd support point on your back lo cated where your spine and your sacral spine meet drawing 5 If you end up sitting on your tailbone instead the pelvis is no longer able to stay in a neutral position Therefore it will also not be possible to obtain sta bility in a seating position utilising the tailbone as the 3rd support point drawing 7 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier The wheelchair back The part of the wheelchair which is supposed to suppo
47. ropriate car or plane seat If you wish to keep sitting you need to have a thor O7 ough analysis of your seating position and your transfer devices carried out In this way you will find out which factors related to your wheelchair and your everyday life might have caused your pressure sores to develop It might be necessary to change some of your daily routines in the wheelchair or adjust certain factors related to the sitting furniture that you use in your everyday life including your bed You might also need to avoid certain risky procedures for a while e g related to transfers however such issues would need to be thoroughly analysed EXTRAORDINARY INCIDENTS You might be carrying out certain everyday proce dures in one way at home but in a different way when you are in hospital or on holiday Deep tissue damages might have developed during extraordinary incidents As an example if your general physical state has de teriorated significantly following a prolonged bedrest you being discharged and attempting to handle your everyday life as usual will often lead to extraordinary and critical situations You need to consider such a discharge an extraordinary incident and prepare your self for it by evaluating and testing risky activities and procedures at home in cooperation with experienced therapists In this way you will be able to find out whether you need to look for temporary alternative procedures e g by using
48. rrounding Progression of Pressure Ulcers in Com munity Residing Adults With Spinal Cord Injury The American Journal of Occupational Therapy 63 3 301 309 Engstr m B 2002 Ergonomi Sittande og rullstolar Posturalis Books Sweden Garber SL Rintala D H Rossi C D Hart K A Fuhrer M J 1996 Reported pressure ulcer prevention and management techniques by persons with spinal cord injury Archives of Physical Medicine and Rehabilitation 74 1172 1177 Gawlitta D Oomens CWJ Bader DL Baaijens FPT Bouten CVC 2007 Temporal differences in the influence of ischemic factors and deformation on the metabolism of engineered skeletal muscle J Appl Physiol 103 464 473 Gefen A Gefen N Linder Ganz E 2005 In Vivo Muscle Stiffening Under Bone Compression Promotes Deep Pressure Sores Journal of Biomechanical Engineering 127 512 524 Gefen A van Nierop B Bader DL Oomens CW 2008 Strain time cell death threshold for skeletal muscle in a tissue engi neered model system for deep tissue injury Journal of Biomechanics 41 2003 2012 e Gilsdorf P Patterson R Fisher S 1991 Thirty minute continuous sitting force measurements with different support surfaces in the spinal cord injured and able bodied Journal of Rehabilitation Research and Development 28 4 33 38 e Hastings JD Fanucchi ER Burns SP 2003 Wheelchair configuration and postural alignment in persons with spinal cord in jury Arch Phys Med Rehabil
49. rt the natural curve of the spine in order to create a stable seating position and maintain a bal anced head It must be adjustable by means of straps or it must otherwise be possible to extend it by means of a pelvic support in the area of the 3rd support point drawing 10 The wheelchair back can be used to distribute body pressure and remove it from the seat surface drawing 8 O57 The wheelchair recline function A function available on many comfort wheelchairs and electric wheelchairs The function releases the wheelchair back allowing the back to recline and the hip angle to be changed drawing 13 Usually this function should only be used in connection with the initial adjustment of the wheelchair Afterwards you might want to have this function dismantled so that you do not activate it unintentionally The wheelchair seat The part of the wheelchair which is supposed to match and support the shape of your bottom at the same time providing sufficient space for the 3 cm of additional depth of your buttock bones compared to the rest of your seat surface drawings 8 amp 10 If you are using a manual wheelchair it must be equipped with adjustable straps on the wheelchair seat in order to create the largest possible support surface for your bottom The wheelchair tilt in space function A function available on many comfort wheelchairs and electric wheelchairs This function releases the wheelchair
50. s By Helle Dreier 1 3 5 When you are sitting You need to be able to handle the wheelchair without moving around in the seat Therefore the seat base and or cushion must fit the shape width and depth of your seat surface perfectly The snug fit of the back padding onto your chest will contribute to a good and stable seating position drawing 5 The weight of the wheelchair also determines whether or not you are able to remain seated when manoeuvring When you change your position It is very important that you are able to lift yourself up completely from the seat surface whenever you want to change your seating position You can either use your arms or if necessary a harness It is very impor tant that you take a realistic look at your ability to el evate yourself from the seat surface and not just carry on with a lifting procedure that you were able to han dle when you were younger stronger and healthier You also need to consider your current physical abili ties in order to avoid the development of pressure sores and deep tissue damages When you drive You need to be able to drive your wheelchair using as little strength as possible and the wheels must be placed in a way that allows you to drive the wheelchair with your arms and shoulders in a natural and neutral position Your shoulder blades must be clear of the back padding in order to allow free arm movements If your wheelchair is too wide or too hea
51. se you any harm From the front Concentrate on relaxing yourself as much as possible and then look at yourself from the front Do your eyes seem to be in a horizontal position when you are sitting drawing 4 e Are you able to maintain your head and sight in a straight forward position without any problems when you are sitting Do your shoulders seem to be in a horizontal and symmetrical position drawing 4 Do you have sufficient support for your lower arms from the elbows to the wrists Do your hips seem to be in a horizontal position drawing 4 e Are your thighs parallel or do they seem to fall open to the sides drawing 4 e Are both your knees located at the same height drawing 4 e Are your feet fully supported feet flat down Does the wheelchair support your chest on the sides allowing you to sit in a symmetrical and bal anced position without any problems even if you are unable to lean on your arms drawing 5 You might want to try elevating your arms in order to find out whether you might be tilting towards one side or forward whilst doing so From the side Concentrate on relaxing yourself as much as possible and then look at yourself from the side e Is your bottom placed as far towards the wheel chair back as possible drawings 10 amp 11 026 10 11 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier e Is your bottom allowed suffici
52. sted on each individual person prior to selecting one During the sling transfer and when you are just about to be sat down it might be a good idea to use some type of hip bone support from the front drawing 4 This is a means of ensuring that your pelvis is going to end up being placed symmetrically on top of your buttock bones a amp b drawings 1 amp 4 Pushing your hip bones from the front rather than pushing your knees ensures a much better work position for your assistants as well as a better seat ing position for you e The lifting sling must be easy to put on and par ticularly easy to remove This ensures that the stability of your seating position and your pelvis 1 2 da S Voa X T aap e AD aa is not shifted When the leg straps are to be re moved and the trouser legs are to be pulled into place it is important to do so very carefully and without lifting the knees Even tiny buttock bone movements might shift the starting point for the 3rd support point d thereby jeopardising the seat ing position stability needed If this happens your bottom will slowly slide for ward and you will end up sitting on your tailbone c drawing 2 Then your upper body will slowly SITTINGCOMFORTABLY v A user manual for wheelchair users By Helle Dreier but surely collapse and be weighed down by your head drawing 7 Such a situation implies a great risk of shear within the tissue and an increased
53. such 5 10 a situation it is important to be able to prioritise cor rectly The Danish market offers a large selection of wheel chairs This user manual deals with two types of wheelchairs manual wheelchairs and wheelchairs al lowing for seating position adjustment Most wheelchairs offer a range of individual adjust ment options Utilising these options is of vital impor tance You have to imagine that your body is to be supported by means of the largest possible wheelchair contact area All wheelchair parts which come into contact with your body i e your bottom back lower arms and feet must be adjusted individually in order to fit your body Only then will you be able to achieve the largest possible level of stability and area of pres sure distribution Only paying attention to the fea tures of the cushion is NOT sufficient Manual wheelchairs A manual wheelchair is either foldable or fitted with a fixed frame Normally it is moved manually by means of grip rings drawing 10 With this type of wheel chair you would usually not be able to change your seating position by means of the wheelchair functions If you need to do so you are better off selecting a comfort wheelchair or an electric wheelchair Usually the back padding as well as the seat is adjustable in manual wheelchairs Utilise these options in order to make the wheelchair fit you and your individual shapes and resources perfectly In this way
54. t plates You might want to consider this issue when shopping for new shoes in order to avoid this po tential source of irritation in everyday life Foot rests facilitating a knee angle of 90 degrees drawing 9 offer the best possibility of distribut ing at least 10 of your body weight in this man ner Such foot rests are usually available as stand ard wheelchair features however sometimes you have to ask for them In terms of developing tissue damages on the bottom the use of elevatable leg rests makes up a disadvantage and a risk factor for several reasons Amongst other things they often disturb the vi tal stability of the seating position by preventing the legs from being placed at a 90 degree angle drawing 9 When lifting up the leg rests towards a horizontal level in order to stretch the legs a bit you also inevitably pull your pelvis a little bit caus ing the buttock bones to tilt backwards drawing 3 This is not a particularly desirable situation given that you actually want to improve the pres sure distribution You might have been told that elevatable leg rests prevent the legs from swelling Unfortunate ly this is rarely an option because it requires the legs to be elevated to above the height of your heart First of all this would require your head and heart to be placed at a lower level than the level of your legs and carrying out such a procedure would involve the risk of shifting your seating stab
55. t be sliding forward In this case you need professional help to solve this issue SITTING COMFORTABLY a A user manual for wheelchair users By Helle Dreier SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier REFERENCES Please refer to the bibliography which may be downloaded along with this user manual or visit www tryksaar dk which contains a more detailed bibliography Finally please refer to the glossary explaining key words contained in the user manual 040 SITTING COMFORTABLY a A user manual for wheelchair users By Helle Dreier BIBLIOGRAPHY e Agam L Gefen A 2007 Pressure ulcers and deep tissue injury a bioengineering perspective Journal of wound Care 16 8 336 342 Breuls RGM Bouten CVC Oomens CWJ Bader DL Baaijens FPT 2003 Compression Induced Cell Damage in Engi neered Muscle Tissue An In Vitro Model to Study Pressure Ulcer Aetiology Annals of Biomedical Engineering 31 1357 1364 Bush TR Hubbard RP 2007 Support Force measures of Midsized Men in Seated Positions Journal of Biomechanical Engi neering 129 58 65 e Clark F Jackson J Scott M Carlson M Atkins M Uhles Tanaka D et al 2006 Data based models of how pressure ul cers develop in daily living contexts of adults with spinal cord injury Archives of Physical Medicine and Rehabilitation 87 1516 1525 Dumn CA Carlson M Jackson JM Clark FA 2009 Response Factors Su
56. that you react to any kind of pain and discomfort that might be connected to your seating position Perhaps you need to seek professional help from a doctor a nurse ora therapist Do you have the impression that your upper body is placed in a symmetrical position within the wheelchair How does it feel Do you feel that your upper body is supported or do you have the feeling that there is still a bit of space on the sides Perhaps you can feel yourself tilting slightly to one side when elevating your arms If this is the case the sides need to be ad justed to fit your body more closely e Find out whether you are able to create a more swayed back than your support mechanisms actu ally allow You want to obtain good contact be tween the wheelchair back and your 3rd support point drawing 5 e Assess whether or not your knees are the same SITTING COMFORTABLY A user manual for wheelchair users 028 By Helle Dreier length If not it might be a good idea to ask a therapist to find out whether the wheelchair could be adjusted to fit you better or whether or not the transfer procedures might be improved e Try checking whether you slide forward in the seat during the day or whether you slide forward when you sit down lt might seem that your thighs turn longer during the day causing them to lose part of the support area of the cushion drawing 7 Examining your thighs can be a good way of checking whether you migh
57. vy you are at risk of sliding forward on the seat during the drive and you might put yourself at risk of tissue damages as well drawing 3 Wheelchairs allowing for seating position adjustment This category includes comfort wheelchair and elec tric wheelchairs Although these models typically do not come with back and seat straps like a manual wheelchair does the seat and the back of a comfort wheelchair or an electric wheelchair still must be able SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier to support your body perfectly The back padding of the wheelchair must support your 3rd support point d at the connection between your spine and the sacral spine drawings 1 amp 4 Ina comfort wheelchair or an electric wheelchair such support might also be created by placing a pelvic sup port in the correct area d drawings 1 amp 11 Unless you are an unusually body conscious person it usually requires professional expertise to identify the exact location of the 3rd support point d drawing 5 within your back and to support it appropriately At the moment comfort wheelchairs and electric wheelchairs do not offer many options when it comes to shaping the seat base to fit your body Therefore you will have to compromise Amongst other things this will influence your selection of cushion to place on top of the seat base A cushion for a comfort wheel chair with a fixed seat base must be able to ac
58. well as the foot angle between your lower legs and your feet approximately 90 de grees drawing 9 e Are your feet fully supported feet flat down Slide your hands under your thighs to find out whether the cushion supports your thighs all the way to your knees within the entire depth of the seat Your bottom must be placed all the way to wards the back and your pelvis must rest against the wheelchair back on the 3rd support point drawings 8 amp 11 You might have to ask your as O27 sistant to check If the seat depth is too long this might prevent you from reaching the back of the seat In this case there will be a space between your bottom and the wheelchair back making it impossible to obtain the correct support for the 3rd support point drawing 5 e Take a look at the drawings drawings 8 10 amp 11 to find out how the seat and the wheelchair back must be shaped in order to fit your body shape when you are sitting Check whether the wheelchair seat is at least hori zontal or even better tilted slightly backwards If your chair is equipped with a forward tilting function you might unintentionally end up sitting on a slide It is important to avoid this From above Put away the mirror and start looking at yourself from the top down inspecting your upper body thighs knees and perhaps feet It is very important that you think about the signals that your body is sending you It is also important
59. you create the best setting for obtaining a seating position which is both stable and pressure relieving even if you need to use your arms to make the wheelchair move forward etc drawings 5 amp 10 SITTING COMFORTABLY A user manual for wheelchair users By Helle Dreier Many manual wheelchairs allow the adjustment of the actual seat base to fit the anatomic shape of the user s buttock bones a amp b drawings 6 amp 10 By utilising this function not only will you be able to create a large pressure distribution area within the seat you will also assist your pelvis in obtaining a stable neutral position as well as maintain a self supporting upper body drawing 10 In a manual wheelchair the support for the 3rd sup port point d is created by means of the back straps of the wheelchair which must be particularly tight at this point d All other straps must allow sufficient space for the upper body and ideally they must take on the shape of the sides of your body drawings 5 amp 10 If the seat base of your wheelchair is already tightened completely either the seat straps have not been ad justed to fit your body or the seat base does not fea ture this adjustment function at all In such cases you would be able to have a strap base fitted onto your wheelchair as an extra When you sit down If as an example you feel the urge to push your bot tom alittle bit forward on the seat surface in order to reach a good up
60. your back and the wheel chair back drawings 5 amp 8 The wheelchair back The wheelchair back must be adjusted in such a way that it encases the sides of the lower part of your back as much as possible and so that is fits to the shape of your back drawing 5 If you are a man it might be a good idea to select a wheelchair with a back that is shaped to fit a person whose shoulders are broader than the hips If you are a woman it might be a good idea to select a wheelchair with a back that is shaped to fit a person whose hips are broader than the shoul ders In addition the wheelchair back must be perfectly adjusted to support the 3rd support point in the area where the spine and the sacral spine are connected drawings 5 amp 8 5 6 When the wheelchair back is correctly adjusted you are able to sit and keep your head balanced at the top of your spine without having to spend energy keeping your head in place In this way you will easily be able to look around without having to strain yourself and without feeling any tension in your upper body shoul ders or neck At the same time the pressure distribut ing area is increased and the risk of sliding forward in the seat is reduced The optimal height of the wheelchair back is usually level with or lower than the lower tip of your shoul der blades If the wheelchair back is higher than that you need to be aware that it might hinder the natural curve of your spine an

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