Alternative seating system for wheelchair users

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Alternative seating system for wheelchair users

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Research question: What are the benefits of a secondary or alternative seating system for a wheelchair user with tilt, recline and standing features in their primary mobility device?

Date: 19/01/2022 Requestor: Brigid [[[s47F - personal privacy](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/) Endorsed by (EL1 or above): Sandi s47F - personal privacy Researcher: Aaron s47F - personal privacy Cleared by: Illya s47F - personal privac

1. Contents

Alternative seating system for wheelchair users ……………………………………………………………… 1

1. Contents ……………………………………………………………………………………………………….. 1

2. Summary ………………………………………………………………………………………………………. 2

3. Alternative seating systems ……………………………………………………………………………… 2

4. Pressure care …………………………………………………………………………………………………. 3

5. Postural support ……………………………………………………………………………………………… 5

6. References ……………………………………………………………………………………………………. 6

7. Version control ……………………………………………………………………………………………….. 7

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2. Summary

NDIA receives requests for secondary or alternative seating systems for participants who use wheelchairs as their primary form of mobility and seating. Alternative seating systems might be requested to meet the pressure care needs of the participant, to meet their postural needs or to provide a comfortable and supportive seating option.

There is disagreement about whether alternative seating systems are generally reasonable and necessary and what kind of evidence is required to demonstrate compliance with section 34 of the NDIS Act.

There does not appear to be any good quality peer-reviewed evidence demonstrating the need for an alternative seating system for wheelchair users. There is an evidence base that can inform clinical judgement. Based on this evidence, we should not assume that multiple seating systems are required. For some participants a single seating system may meet their postural and pressure care needs. There may be some cases where an alternative seating system is reasonable and necessary but it will depend on the individual needs and resources of the participant.

This paper is a supplement to other TAB research papers relating to postural supports. It refers to:

 RES 204 – 24 hour Postural Management Programmes  RES 214 – Rotating Beds  RES 215 – The Benefits of Power Wheelchair Tilt, Recline and Leg Rests, Power

Wheelchair Standing Systems, and Standing Frames for Power Wheelchair Users

3. Alternative seating systems

I have not found any reliable, high quality, current research directly focussing on the need for both a primary and secondary seating system. A search of PubMed database for the phrases “secondary seating system”, “secondary seating” and “second seating system” yielded no results. A search of Google Scholar for the phrase “secondary seating system” yielded no results and while the phrases “second seating system” and “secondary seating” were used, none of the results were relevant to this question. I obtained similar results searching multiple databases with the phrases “alternative seating system”, “alternate seating system”, “alternate seating” and “alternative seating”.

A 2002 clinical review referred to the possibility of secondary seating, saying that some people “have a need for both armchair and wheelchair seating and often have to resort to using the wheelchair as an armchair, as it will normally meet their postural needs” (Collins, 2002, p.16). The author is here differentiating between postural needs and pressure care needs (p.17).

Some seating system manufacturers or retailers market their products as good secondary seating (Beanseat; Inspired by Drive P Pod; Smith, 5 Expert Tips). Steve Fischer of Bergeron

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Health Care argues that both primary and secondary seating is necessary. He says “[y]ou don’t sit in the same chair all day then all night. Your body needs different textures and points of contact to prevent skin shearing & breakdown and maintain healthy blood flow” (Smith, 5 Expert Tips). This assumes that a primary seating system is not able to provide the variability in textures and points of contact that are required to maintain the user’s health. This claim is made in the context of marketing material and is not explicitly backed up by evidence.

Previous TAB advice varies on this issue. Advice from 2020 states a rule that it “is considered reasonable and necessary to fund one mobility aid and one alternative seating option for participants” (ADV 2020 0457-9). Advice from 2019 also acknowledges that a mobility aid such as a wheelchair and postural support aid could be funded separately (ADV 2019 6517). Other advice from 2019 argues that where a participant’s mobility aid is “configurable and customised” and can meet the participant’s “mobility, seating, safe positioning, occupational, social and pressure care needs”, then an alternative seating system may not be necessary (ADV 2019 3872).

In an informal survey, TAB advisors have reported that another common justification for secondary seating system requests relates to the need for wheelchair users to be able to adopt a relaxed posture at times. This justification assumes there is a difference between a more rigid primary seating system and a more comfortable or relaxed secondary system. It also assumes, as above, that a primary seating system is not able to provide the opportunity for a relaxed posture.

4. Pressure care

A pressure injury (also pressure sore or pressure ulcer) is an area of localised tissue damage caused by unrelieved pressure, friction or shearing on any part of the body. Pressure injuries often occur in areas where there is minimal tissue covering the bone (Gillespie et al, 2020, p.1; Australian Commission on Safety and Quality in Health Care (ACSQHC), 2018, p.1). People are at risk of pressure injuries if they have limited mobility, limited activity and a high potential for friction and shear (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (EPUAP), 2019, p.14).

There are several strategies to reduce the risk of pressure injury for people who sit for prolonged periods. For example, ensuring skin is clean and dry, maintaining good posture and position, repositioning and weight shifting, scripting cushions and other pressure reliving devices, and ensuring proper nutrition and hydration (EPUAP, 2019; Shi et al, 2021; Gillespie et al, 2020; McInnes et al, 2015; Langer, Fink 2014).

RES 214 – Rotating Beds discusses how regular repositioning can reduce the risk of pressure injury during prolonged periods in bed. Standard practice has involved relieving pressure over key areas (sacrum, ischial tuberosities) for 5 minutes every 2 hours or 10 seconds every 10 minutes for periods of prolonged sitting (Kruger et al, 2013, p.574). More recent clinical guidelines do not recommend a particular repositioning protocol but instead suggest that

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clinicians assess the person’s level of mobility and capacity to reposition themselves to determine an appropriate frequency (EPUAP, 2019; Gillespie et al, 2020, p.23). There is reason to believe that repositioning is effective in maintaining blood flow to affected areas. However, evidence is inconclusive regarding a particular optimum positioning protocol.

When a wheelchair user is not able to independently reposition or perform weight shifts, wheelchair positioning functions can reduce risk of pressure injuries. RES 215 – The Benefits of Power Wheelchair Tilt, Recline and Leg Rests, Power Wheelchair Standing Systems, and Standing Frames for Power Wheelchair Users (RES 215) discusses the impact on development of pressure sores of wheelchair functions including tilt, recline and standing. There is reason to believe that using tilt, recline and standing wheelchair functions reduces risk of pressure sores by redistributing the user’s weight in their chair. This is especially evident for wheelchair users with Spinal Cord Injury (refer to sections 3.1, 3.2 and 4.1 of RES 215). One study referred to in RES 215 notes that while there are reductions in pressure with the use of tilt and recline functions, the angle achieved can increase shear force. However, achieving an optimum angle of tilt (in this case 25°) can reduce shear to 0 (Springle, Maurer, Sorenblum, 2009, p.59-60). The same study refers to an early 1997 investigation on tilt and recline function which finds that some people may not be able to use a recline system for pressure relief because of increased spasticity during recline and because the recline may affect placement of postural supports (p.59).

There is some evidence that higher specification foam surfaces are more effective at preventing pressure injury that standard hospital mattresses (McInnes et al, 2015, p.19) and that reactive air surfaces are more effective at preventing pressure injury than foam surfaces (Gillespie et al, 2020, p.28). However, these results are mostly drawn from research on mattresses and mattress overlays. There is some evidence that certain types of seat surfaces are effective in reducing the risk of pressure injuries. However, according to McInnes et al, the research is inconsistent and there is insufficient clarity to draw a conclusion about the relative effectiveness of different seat cushions in preventing pressure sores (2015, p.17).

Of note, the Clinical Guideline on the Prevention and Treatment of Pressure Ulcers/Injuries jointly developed by European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance does not mention the use of a secondary or alternative seating system in any of their recommendations (EPUAP, 2019).

I was not able to locate any study that directly investigated the effect of sitting on multiple different surfaces or devices. Nor was there any available research focussing on utilising an alternative or secondary seating system on incidence or severity of pressure injury. Given the above research, we may assume that using an alternative seating device could have some benefit due to transferring out of the primary seating system and therefore relieving or redistributing pressure for the length of the transfer. However, I have not located any research to suggest that this would be more or less beneficial than having a properly scripted seating system with repositioning functions (tilt, recline, standing) or maintaining a repositioning protocol recommended by clinical specialists.

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There may be circumstances in which a participant’s wheelchair seating system no longer meets their pressure care needs as their only seating system. In this case, a clinician might investigate whether using the wheelchair for a maximum duration and an alternative seating system for the remainder of time would be more cost effective than rescripting the wheelchair seating system.

5. Postural support

Postural control is “the ability to control the body’s position in space to obtain stability and orientation” (Chung, 2008, p.303; Babinec et al, 2013, p.2). This involves preventing some forms of movement which contribute to bad posture or increase risk of pressure injury while allowing or promoting functional movement (Babinec et al, 2013, p.8.).

Alternative seating systems aim to provide a seating position that is both comfortable and supportive (Specialised paediatric equipment; Adaptive Mall; Smith, 5 Expert Tips). One element of comfort may be the ability to relax. Without a clinical definition of a ‘relaxed posture’, we can take this to describe a situation in which a person is able to allow a chair to take their weight and relieve the strain on their muscles required to maintain a good posture. Collins points out that it can be difficult to sit for long periods of time or independently maintain good posture due to “constant static muscle work in the trunk and spine in order to continually counteract the forces of gravity” (Collins, 2008, p.39). While seated, support is predominantly provided by the buttocks, thighs and feet. This means a smaller surface area is providing support compared to lying (Collins, 2002, p.15; Collins, 2008, p.40). When a smaller surface area is supporting the body, compensatory work is done by the muscles to maintain good posture (Collins, 2008, p.39). If it is possible to relieve the muscles and allow the chair to take some of the force, this can be more comfortable, less tiring, more relaxing.

We have already discussed above the benefits for skin integrity of being able to adopt a variety of postures throughout the day, including reclining. RES 204 – 24 hour Postural Management Programmes (RES 204) notes that poor body position and posture can also affect bodily functions such as digestion, breathing and sleep (refer to section 3.1). If a person’s wheelchair has a recline function then the need to adopt a reclining posture throughout the day can be met with their primary seating system.

RES 204 also notes that postural supports should aim to balance postural control and comfort. Some users are not able to tolerate recommended postural supports due to discomfort. RES 215 describes a study in which wheelchair users whose device has tilt and recline functions rate the chair more comfortable compared to those without the additional functions.

In circumstances where a person is not able to tolerate their seating system for the length of time they are in their chair, then the seating system may have to be re-examined to determine if adjustments can be made to improve comfort and sitting tolerance. If no adjustments can be made to the primary seating system, then it may be reasonable to investigate a secondary

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seating system in which the balance of postural support and comfort leans more towards comfort.

Participants who can manage independent weight shifting or postural correction may fatigue more easily during long term chair use. This could form the basis of a clinical justification for an alternative seating system for participants with postural and pressure care needs. However, without direct evidence establishing the benefit of alternative seating systems, this remains speculative.

6. References

Australian Commission on Safety and Quality in Health Care. (2018) Pressure Injury Fact Sheet. Sydney: ACSHQC; 2018. Available at: https://www.safetyandquality.gov.au/sites/default/files/migrated/Healthcare-associated- infection-detailed-fact-sheet.pdf (Accessed January 14, 2022).

Babinec, et al. (2013) Position on the Application of Wheelchairs, Seating Systems and Secondary Supports for Positioning vs. Restraint. Arlington: Rehabilitation Engineering & Assistive Technology Society of North America. Available at: https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNARestraintPositionPape rFinal02022017.pdf (Accessed: January 14, 2022).

Beanseat (2020) Specialised Paediatric Equipment. Available at: https://at4kids.com.au/product/beanseat/ (Accessed: January 14, 2022).

Chung, J. et al. (2008) “Effectiveness of adaptive seating on sitting posture and postural control in children with cerebral palsy,” Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association, 20(4), pp. 303–317. doi: 10.1097/PEP.0b013e31818b7bdd

Collins, F. (2002) “Use of pressure reducing seats and cushions in a community setting,” British journal of community nursing, 7(1), pp. 15–22. doi: 10.12968/bjcn.2002.7.1.9439.

Collins, F. (2008) “An essential guide to managing seated patients in the community,” British journal of community nursing, 13(3), pp. S39-40, S42-3, S45-6. doi: 10.12968/bjcn.2008.13.sup1.28686

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. (2019) Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA. Available at: https://internationalguideline.com/static/pdfs/Quick_Reference_Guide-10Mar2019.pdf (Accessed January 14, 2022)

Gillespie, B. M. et al. (2020) “Repositioning for pressure injury prevention in adults,” Cochrane database of systematic reviews, 6(6), CD009958. doi: 10.1002/14651858.CD009958.pub3

Inspired by Drive P pod (no date) Adaptivemall.com. Available at: https://www.adaptivemall.com/inspiredbydriveppod.html (Accessed: January 14, 2022).

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Kruger, E et al (2013) “Comprehensive management of pressure ulcers in spinal cord injury: Current concepts and future trends”, The Journal of Spinal Cord Medicine, 36(6), 572-585, doi: 10.1179/2045772313Y.0000000093

Langer, G. and Fink, A. (2014) “Nutritional interventions for preventing and treating pressure ulcers,” Cochrane database of systematic reviews, (6), CD003216. doi: 10.1002/14651858.CD003216.pub2

McInnes, E et al. (2015) “Support surfaces for pressure ulcer prevention,” Cochrane database of systematic reviews, (9). CD001735. DOI: 10.1002/14651858.CD001735.pub5.

Shi, C. et al. (2021) “Reactive air surfaces for preventing pressure ulcers,” Cochrane database of systematic reviews, 5(8), p. CD013622. doi: 10.1002/14651858.CD013622.pub2.

Smith, H. (no date) 5 expert tips to help you choose the best special needs seating, Rehabmart. Available at: https://www.rehabmart.com/post/5-expert-tips-to-help-you-choose- the-best-special-needs-seating (Accessed: January 14, 2022).

Sprigle, S., Maurer, C. and Soneblum, S. E. (2010) “Load redistribution in variable position wheelchairs in people with spinal cord injury,” The journal of spinal cord medicine, 33(1), pp. 58–64. doi: 10.1080/10790268.2010.11689674.

7. Version control

Version Amended Brief Description of Change Status Date by

1.0 AHR908 Alternative seating systems for wheelchair Approved 21/01/2022 users

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