Clinical evidence and clinical efficacy are both important factors when choosing seating solutions. Sheila Buck talks about Seating Solution selection and the equally important consideration of comfort, to prevent patient complications and achieve better outcomes…
Sheila Buck B.Sc.(OT)Reg.(Ont), ATP Occupational Therapist – Seating and Mobility Consultant, Therapy NOW! Inc.
What is comfort? In able-bodied persons, sitting discomfort has been identified in terms of bodily symptoms that may include the following: heavy legs, uneven pressure, stiffness, restlessness, fatigue, and pain. Comfort on the other hand is often identified in subjective terms such as: relaxation, refreshed feelings, spaciousness feeling of a chair, and liking the chair (Helander & Zhang, 1997). Wheelchair users were found to identify discomfort as: having pain, feeling the need to move, feeling unstable, feeling physically tired, feeling a burning sensation, sliding out of the wheelchair, feeling stiff and several other components. Alternately, the feeling of comfort included: feeling good, feeling supported in the right places, feeling little pressure under the buttocks, feeling stable, and feeling satisfied. (Monette, Weiss-Lambrou, & Dansereau, 1999). Able-bodied individuals are able to get relief from discomfort while sitting by making small, unconscious body movements of postural adjustments that maintain tolerable levels of discomfort (Hobson & Crane, 2001). Persons with decreased neuromuscular function or orthopedic changes are often unable to adjust their body position to redistribute forces, leading to intolerable periods of discomfort. Populations most affect by seating discomfort issues are those with primarily motor impairments with little or no sensory involvement, often indicated by the aging population.
With respect to seating and mobility technology, discomfort and lack of independent mobility can also limit sensory stimulation, accessibility to interactions, opportunities for meaningful communication and opportunities to maximize function. Inappropriate or lack of supportive seating can create pain through poor posture, inflexible joint ranges, and peak pressure points due to an inability to shift or alter pressures. Pain can therefore become a primary focus in the aging population and further create impaired mobility, decreased participation in pleasurable activities, increased dependence in Activities of Daily Living, increased resistance to care and confused or aggressive behaviors. The negative effect of seat discomfort on function has been identified among individuals in skilled nursing facilities (Herzberg, 1993). Comfort problems can and do lead to individuals retreating to bed for much of the day. This can lead to obvious impaired function, poor quality of life, and medical problems such as pneumonia, bed induced ischemic ulcer, and overall withdrawal from life’s activities (Hobson & Crane, 2001).
Appropriate seating must be addressed in order to prevent physical and cognitive deterioration, but also to decrease pain factors in clients as they age. Current cushion technology has been designed mainly for pressure relief of sensory impaired individuals, and therefore does not meet the needs of the elderly, sensory intact population. Comfort must be addressed clinically from the outset, even if the client is not identified as being at risk for pressure ulcer formation. Often funding agencies will not consider subjective pain or dis/comfort as a legitimate medical necessity for funding. Therefore, physiological or functional goals must be identified which are affected by lack of sitting tolerance induced by pain or discomfort.
Goals of seating the elderly may include:
- ↓pain and fatigue
- ↑comfort
- ↑support and security with decreased risk of falls
- ↑mobility
- ↑body image
- ↑stimulation with increased alertness
- ↑interactions
- Maintained autonomy and interaction with the physical and social environment
- Maintained overall function, dignity and self esteem
Clients in institutions often fall or slide out of systems when attempting to find positions of comfort. We need to determine what are the needs of our clients, and how much pain influences a clients’ activity level. Fragile bones from osteoporosis complicate the mobility of stiff joints. The challenge then is to respect the client’s need for comfort while at the same time supporting them against gravity for function and interactions with others within their environment and cognitive functional capacity, without restraints.
“The most important outcome for the client, is the increased comfort and feeling of well being and safety that our elderly gain from utilizing the assistive technology that has been carefully prescribed for them.”
It is also imperative that the seating system not be used as a therapeutic tool for stretching or in hopes of increasing neuromotor postural control. Constant work effort of the muscles will induce fatigue in clients where body strength has already diminished due to the aging process. This increased fatigue can enhance the likelihood of pain at the stretched or over worked muscle creating the increased likelihood of further sliding due to the lack of ability to reposition, or verbal/behavioral gestures indicating the need to remove oneself from the system. Overall functioning is then again at risk of being depleted. Therefore, therapeutic interventions must be considered as a separate entity from one’s comfort sitting posture, or indeed directed through a system that is dynamic to allow for changes in positioning when determining the need for therapy and/or comfort sitting.
As our focus with the elderly moves from optimum mobility, to comfort, and the minimization of pain and fatigue, our recommendation of technology must adjust to meet these new needs. Often the sense of comfort comes from a feeling of being “held or that of a security blanket”. Do we need to look at these subjective factors to enhance comfort which will enhance sitting tolerance and possible overall functioning? Comfort for one person may have a whole different meaning than that for the next
A full assessment is critical with each evaluation. Multiple conditions and dysfunction within the body will increase the speed in which changes occur and likelihood that discomfort will be present. Special consideration needs to be taken for observation of at-risk skin areas over frail skin, bony protrusions, tone and contractural changes from lack of movement and long-term hemiparesis. As well, potential for change, past hip fractures or bony changes, ability to identify and communicate pain, comfort or discomfort, and stimuli that promote relaxation or agitation including all therapeutic interventions must be assessed.
Once an assessment has been completed to determine the client’s problems and potential for functioning, goals must be set and objectives stated for selecting assistive technology for each area. These goals must be appropriate to the client’s age and current as well as perceived level of functioning. Current pain levels may be so great that functioning has decreased or been lost. With appropriate comfort and support, the client may be able to complete components of a task at hand. Areas of goal determination may include function, mobility, prevention of discomfort, pressure sores/shearing, postural deformity and injury (to client and caregiver), accommodation to changes in weight, posture, environment, and aging factors.
Common bodily changes that occur with aging and the effect these have on comfort may include:
- Skeletal changes: calcium loss with increased fractures and non-union healing, posterior pelvic tilt, kyphosis/scoliosis due to weak abdominal/back musculature, stiff and painful joints due to lack of movement or arthritic changes. Consider: increased shock absorption and, pressure relieving seating
- Kidney and bladder: decreased size, less blood filtration, enlarged prostrates. Consider: materials on covers, size of abductor pommels
- Endocrine and glandular changes: hormonal changes resulting in fragile bones. Consider: shock absorbing bases, pressure relieving cushions, comfort positioning versus correction.
- Nervous system: decreased sensation to touch and temperature, slower movements due to decreased nerve activity to muscles, decreased balance and reaction timing. Consider: support surface temperatures, high pressure relieving surfaces, maximum contours on support surfaces to maintain stability
- Sensory changes: poor vision for far, near, and colors, poor hearing, decreased taste and smell (decreased food intake with weight loss and poor skin conditions) Consider: pressure relieving surfaces, material textures, material softness, adjustable systems to accommodate weight changes.
Product parameters must be set based on the assessment of the client and the goals/objectives that have been set realistically based on the client’s age and goals for overall sitting/function. Parameters may need to include pressure considerations of continuity between surfaces, maximized surface contact, decreased peak pressures, and material considerations of softness (plushness), firmness, thermal regulation, breathable, friction/texture. Postural support and pelvic stability can be gained through posterior pelvic support, posterior lateral support.
The most important outcome for the client, is the increased comfort and feeling of well being and safety that our elderly gain from utilizing the assistive technology that has been carefully prescribed for them. Involvement in daily life activities and decision-making returns to the elderly the respect which they deserve and desire.
References;
- Hobson, D., Crane, B. (2001). State of the Science White Paper on Wheelchair Seating Comfort, University of Pittsburgh. Paper presented at the State of the Science Workshop
- Helander, M.G., & Zhang, L. (1997). Field studies of comfort and discomfort in sitting. Ergonomics, 40(9), 895 – 915.
- Herzberg, S. (1993). Positioning the nursing home resident: an issue of quality of life. American Journal of Occupational Therapy, 47(1), 75 – 77.
- Monette, M., Weiss-Lambrou, R., & Dansereau, J. (1999). In search of a better understanding of wheelchair sitting comfort and discomfort. Paper presented at the RESNA Annual conference.
Sheila Buck is an Occupational Therapist from Ontario, Canada and has been actively working in the field of seating and mobility for over 30 years. Sheila provides consultation, assessment and treatment in the area of seating & mobility, accessibility, and ergonomics, through her company Therapy NOW ! Inc, in Southern Ontario, CANADA
Sheila has spoken extensively and presented workshops at National, International and European seating symposiums on seating and mobility issues including basic and advanced positioning with emphasis on pressure management, cognitive functioning and maintaining independent living skills and restraint reduction. Sheila’s clinical skills have been developed from experience as a RTS / ATP as well as current involvement as a clinician in long term care facilities. Sheila has published a book titled “More than 4 Wheels: Applying clinical practice to seating, mobility and assistive technology”. Details about her book can viewed and ordered at www.sheilabuck.ca
