Elizabeth Cole, MSPT, ATP

Director of Clinical Rehab Services, US Rehab

Each week in your role as seating and mobility equipment providers many of you encounter individuals with a wide variety of postural and seating problems.  And you work with the clinicians to provide potential solutions to these problems in order to allow the individual to be mobile, functional and safe.  The selection of the most appropriate product and components should be a thoughtful exercise in analyzing the results of the clinical evaluation and matching product parameters to the person’s needs, limitations and capabilities.  However, there is a very crucial step in this process that I believe is often short-changed or even omitted altogether.  And that is the step in which we identify the specific cause of the problem

Postural abnormalities or deformities are caused by two basic types of causes; equipment (technical) causes and physical (clinical) causes.  Equipment causes might include things like poor base of support for the pelvis, lower extremities or back; inappropriate size, shape and/or angle in the base or the components; poor, inappropriate or incorrect adjustment or configuration of the frame or a component or; an inappropriate option or accessory.  Physical causes are related to a limitation of the individual him/herself and might include decreased muscle strength; decreased ROM and joint contractures; abnormal muscle tone; decreased endurance; or some kind of anatomical asymmetry.

For each postural abnormality we may have a list of potential solutions that might work for that issue.  However, we cannot just identify the postural problem and then start selecting from that list.  We must first identify the specific underlying cause or causes in this particular case.  Why is the individual sitting like that and how can we eliminate that cause?  If it is a simple equipment cause, then choosing a solution based on the individual’s physical limitations or condition will not solve the issue.  It will just put a bandaid on the problem or, in the worst case, will cause further harm.

For example, if someone is sitting in a posterior pelvic tilt with increased spinal kyphosis, it is critical to determine why. Is it because the seat depth is too long, or the footrests are too low or the seat to floor height is too high or the back height is too high or the armrests are too low?  Or is it because the individual has poor core muscle strength or tight hamstrings or hip, pelvic or trunk contractures or extensor spasticity or obesity?  If it is a physical problem, is the primary issue in the trunk or the pelvis or the hips?  The solution may be as simple as adjusting the footrest height or it could be as complex as adding an open seat to back angle and a fixed tilt in the frame or adding deep contour and shape to the seat and back support.  But it will depend on the primary cause or causes.

In addition, each postural abnormality is fixed or reducible (flexible) or partially reducible.  So we not only need to identify the cause, but we need to know whether the goal is to correct the deformity or to accommodate it.  We may choose a very different solution depending on this goal. In all cases, however our goal should always be to prevent further deformity and we cannot do that without knowing the cause.

So why do I think that this step is often overlooked?  .  As I review documentation from therapists and ATPs for seating and mobility products, I do not see evidence that the cause of the postural issue was identified and that the solution was chosen based on that specific cause or causes.   The cause is rarely documented and I see justifications for the solutions that are often unrelated or inappropriate for the individual’s specific issues.  In some cases, even the problem itself was never mentioned in the exam results, while in other cases, the justification does not match the exam results and the apparent cause.  For example, a skin protection cushion is recommended to redistribute and decrease pressure.  This is definitely a valid reason to provide a skin protection cushion in many cases.  But in this case, the physical exam results provide no data regarding current/past skin breakdown, sensory deficits or inability to weight shift.   Or a tilt is justified as “helping to manage tone” but even if there is a mention of abnormal tone in the exam results, it is not explained how the tilt will do help this particular individual manage his/her tone.  Some of these justifications are very generic and written in “cookie-cutter” language without any specific reference to the individual.   It appears as if the justifications were chose from a drop-down list or cut and pasted from another document without any individualization and no explanation as to how these solutions will rectify the problem.  In some cases, the choices are actually on the assessment form as boxes to be checked off with no additional comments. 

It is not appropriate (or best practice) if the solution is chosen just because it seems logical or has worked in the past or the justification is pulled from a list. The cause(s) must be identified and should be documented in the evaluation results.  Then a solution should be chosen that will specifically address that cause and how and why it will do this should be in the justification.  In other words, what is the problem, what is the cause, what will address that cause and how or why will it do this?  The justifications should be specific for the specific problems and causes related to that individual and should be documented as such.  That does not mean a drop-down list, cutting and pasting and/or check boxes are taboo.  As long as the evidence is in the exam results and the justifications are individualized or comments are added that are specific to that individual, then these are certainly helpful time-savings tools.  But the analysis and thought process must come first.

Don’t just put a bandaid on the postural problems of your clients.  Know why you are choosing the solution and make sure the documentation contains clear evidence of the problem, why it occurred and how the solution will address it.