A Q & A on Wheelchair Assessment and Seating
One of the hallmarks of Dr. Pandya's teaching style is her willingness to speak plainly, drawing on decades of real clinical experience to bring abstract principles to life.
Throughout her June webinar on Wheelchair Assessment and Positioning, she posed questions to her audience of PTs, PTAs, OTs, and OTAs, then followed up with the kind of insights and stories that made this one of our most engaging sessions of the year.
For those who could not attend, here is what Dr. Pandya had to say, in her own words.
Question 1
Have you come across patients who try to step on the footrest while mounting or dismounting from the wheelchair?
I've seen so many patients tend to do that, and they are a lot quicker than my ninja moves of flipping the footrest up. They're just so quick at doing that!
Something to advise prior — go behind the wheelchair and say, 'Hey, I'm going to unlock your brakes, but do not move until I've done this.' Because if you flip up the footrest prematurely, then they will try to stand up on their own as well. So it's in a way kind of restraining them there for their safety until you're upfront.
Question 2
What would you look for when assessing a patient's posture in a wheelchair?
I've split this up into upper and lower body. We're looking at pelvis and midline. Shoulders should also be level, and arms should be free to move. If the wheelchair is wide, what they're going to do is tuck the arms by their side — and I've seen this a lot happening in the skilled nursing facility. If the wheelchair is too narrow, then the arms are hanging off the side.
Lower body — we want 90, 90, 90. That's your ankle, knees, and hips. And when we are looking at our patients and we do regular observation — anterior view, posterior view, lateral reviews — make sure that you're doing similar observations with patients in all three views with the wheelchair as well.
104603 Lumbar Spine Pathologies
This live, interactive course offers an in-depth exploration of lumbar spine pathologies, including their classification, hallmark clinical features, and evidence-based assessment strategies. It addresses mechanical, inflammatory, degenerative, acute, chronic, recurrent, central, and peripheral pain sources to support a clear understanding of diverse clinical presentations.
A strong focus is placed on differential diagnosis and physiotherapy decision-making, including thorough red-flag screening. Core...
Question 3
Why do we need the legs to be in slight abduction in the wheelchair?
What would happen if the legs had to be constricted like that, sticking to each other — if the two knees were touching each other? There would be skin breakdown. There'd be pressure sores. And there will be abductor contractures as well, absolutely. So, we need to look at abductor issues, as well as we need to look at what's happening at the medial femoral condyles.
Because if the knees are touching, the chances are the ankles will be touching, and if the ankles are touching, again, the medial malleoli are going to rub. So, heels should be directly below the knees, and feet flat on the floor or on the footrests.
Question 4
Have you seen wheelchairs with hammock or sling-style seats? What problems, if any, have you noticed with them?
Those of you who work in skilled nursing facilities — we see, with all the good intentions, the nursing staff transfers the patient from bed to the chair. Sometimes they keep them ready for therapy at 9 o'clock in the morning when the therapy is probably going to be at 11 o'clock. In those two hours, your patient has slouched, drooped, lolled onto one side, rolled off the center of the wheelchair, and perhaps their buttocks has slid. And at this point, all the good intentions are kind of lost, isn't it? Because they've done more bad than good.
Nurse education, CNA education, PCA education, caregiver education — just putting them out in the wheelchair is not going to do them any good. Because if they're flexed like that, what is their chest expansion going to look like?
Question 5
Should a patient hold themselves up without support, or are we weakening their postural muscles by providing too much external support?
I don't think it's possible for anybody to hold themselves up for even 45 minutes to an hour. I mean, try sitting in a chair for 45 minutes without having to slouch. And I go to the gym regularly, and I think I've got a pretty strong back — but there's always a level of postural muscle fatigue.
Yes, provide back support. Again, depends on how long a person sits in that chair. Are they propelling the wheelchair? Because if they're propelling the wheelchair, then they'll more or less need to sit up. So the functionality matters as well.
If you're providing them back support, provide it for partial awareness — such that if they've got a pillow or a backrest behind them, you can remove those for 10 minutes, see if we can hold that posture up. So you can use it as a cue for postural retraining as well.
104628 The Clinician's Guide to Supporting Individuals With Chronic Pain & Co-Occurring Conditions
Chronic pain affects millions of people across the lifespan and can have a profound impact on physical health, emotional well-being, daily functioning, and overall quality of life. This webinar provides an overview of chronic pain, including current perspectives on the nature and derivation of pain, factors that contribute to its development and persistence, and the complex ways it affects individuals....
Question 6
Poor seating posture affects more than just comfort. What else is at stake?
The position of the hip is going to determine the shape of the rest of your spine above — which is going to determine if it's going to end up being a forward head posture or protracted shoulders — and those protracted shoulders are going to determine what's going to happen to your lung capacity. So it basically starts it all starts from the hip.
If somebody's squashed in, they are doing a lot of apical breathing. They're not doing diaphragmatic breathing overall. They just end up having constipation. It's all connected. If you're not getting enough breathing, you're not going to get enough movement in the gut. And then they take all kinds of laxatives and fibers for constipation. The idea is — you're making things move when the body is not moving.
Question 7
What is your advice on customizing wheelchair seating when budgets and insurance coverage are limiting factors?
When I graduated 26 years ago, what we were doing is we were getting really creative with makeshift supports. We were using foam pads to create a block in between the knees. Those were the days where you could get creative and customize the wheelchair as much as possible. Even in the last 10 years, sometimes you put a towel roll under their knees if the back of the knee is rubbing against the seat.
We do customize it, we do tend to make it as personal as possible — because sometimes cost factor is a big issue. You can get a high-end wheelchair, but sometimes insurance doesn't cover it. In the end, continually contouring the wheelchair to your patient — that is absolutely a skill. A clinical skill in itself. ◼
Want to make the most of everything Impact CE has to offer?
The Ignite Membership unlocks unlimited live webinars, hundreds of self-paced courses, a growing library of recorded content, and free e-library access — all in one place, for one low annual price. Learn more about Ignite today.
Opinions and viewpoints expressed in this article are the author's, and do not necessarily reflect those of CE Learning Systems.
