Running head: LITERATURE REVIEW 1

Posture for Manual Wheelchair Bound Persons

Brianna L. Stemmler

Sacred Heart University

LITERATURE REVIEW 2

Introduction

Individuals who rely on wheelchairs for mobility and to aid in the completion of activities

of daily living (ADL) typically face adverse effects as a result of prolonged sitting (Goda, Hatta,

Kishigami, Suzuki, & Ikeda, 2015). Wheelchairs are intended to enable mobility and promote

independence, but often result in preventable complications such as musculoskeletal deformities,

poor skin integrity, swallowing and respiratory complications, pain or discomfort, and restricted

mobility (Gavin-Dreschnack, 2004). Occupational therapists (OTs) suggest the use of seat

cushions and techniques to improve posture in order to promote optimal occupational

performance and decrease potential complications (Kim & Chang, 2013).

Literature Review

Wheelchair as a Form of Mobility

Frequently, individuals encounter difficulties attending to their occupations as a result of

impaired mobility. Wheelchairs serve as a way for individuals to be independent, despite their

condition or disease. Walker et al. (2010) suggests that 6.8 million individuals in the United

States use assistive devices to assist with mobility on a daily basis. Assistive devices include

wheelchairs, scooters, canes, crutches and walkers (Walker et al., 2010). Kaye, Kang, & LaPlante

(2000) suggest that wheelchairs and scooters are most commonly used by individuals who report

the inability to engage in one or more major life activities. Evidence suggests that mobility

devices, including wheelchairs, have a positive effect on participation in daily life (Kaye et al.,

2000). When wheelchairs are properly adjusted, they can provide spinal stabilization and

substitute for weak trunk musculature during static sitting and some functional activities

(Hastings, Fanucchi, & Burns, 2003, p.530). Additionally, individuals that are properly trained

on wheelchair usage are more likely to overcome physical barriers in their environment,
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experience feelings of independence, and an overall better quality of life (QoL) (Kilkens,

Dallmeijer, De Witte, Van Der Woude, & Post, 2004).

Implications of Incorrect Wheelchair Usage

Individuals who use wheelchairs for mobility often remain seated for prolonged periods

of time, which could have negative implications for the individual. If the wheelchair is used

incorrectly it could result in restricted mobility, musculoskeletal deformities, pain or discomfort,

poor skin integrity, decreased QoL, and a need for assistance during occupations (Trefler,

Fitzgerald, Hobson, Bursick, & Joseph, 2004). The variables mentioned above need to be taken

into consideration when wheelchair bound individuals are prescribed wheelchairs to better

improve overall interaction amongst the user and the wheelchair.

Postural deformities in the spine are often a result of poor seated posture (Requejo,

Furumasu, & Mulroy, 2015). Two common spinal deformities that impact spinal alignment are

kyphosis and scoliosis. These deformities cause pain in the lumbar region of the spine, which

makes it difficult for wheelchair users to breathe properly, engage in feeding and eating, and

participate in ADLs (Allam & Schwabe, 2013). Also, they can cause the arms to become uneven

and self-propulsion of the wheelchair becomes difficult (Allam & Schwabe, 2013). Adversely,

wheelchair bound individuals may require the assistance of others to engage in their occupations.

In addition to spinal deformities, poor seated posture can also cause in poor skin integrity.

Poor skin integrity often results in pressure ulcers, especially in the elderly population. Pressure

ulcers form when pressure or force is placed on the tissues of the body in varying magnitudes

and durations for prolonged periods of time (Sonenblu & Springle 2011). When seated, nearly

half of the body weight is supported by only 8 percent of the seated areas at or near the ischial

tuberosities (Collins, 1999, p. 50), making that area most susceptible to pressure ulcers. Requejo
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et al. (2015) suggests pelvic tilt and poor seated posture has an influence on the development of

pressure ulcers in wheelchair bound persons. Specifically, Requejo et al. (2015) states that a

slouched posture in a wheelchair causes a pelvic tilt, limits mobility, decreases upper extremity

range of motion needed for repositioning, and results in shearing pressure ulcers. Adversely,

individuals experience difficulties attending to ADLS such as positioning and transferring and

maintenance of hygiene, thereby affecting quality of life (Requejo et al., 2015, p. 4).

Pain and discomfort is a major concern for wheelchair users due to their dependence on

the upper extremities for activities of daily life such as wheelchair propulsion, personal care,

dressing, and transfers (Will et al., 2015, p. 1). Research suggests poor seated posture is a

predictor of pain in the upper extremity and back (Hastings et al., 2003). Forward head posture

(FHP) is one of the primary positions seen in wheelchair bound individuals with upper extremity

musculoskeletal disorders. FHP is characterized by seated posture with a protracted neck and

head making it difficult to engage in ADLs and increases the risk of aspiration during eating

(Goda et al., 2015). To decrease the pain caused by FHP and other incorrect postures, wheelchair

users attempt to reposition themselves. Repositioning becomes difficult because once incorrect

posture develops it becomes difficult to maintain a functional, erect position (Goda et al., 2015).

Guidelines for Correct Wheelchair Posture

Proper posture is a state of musculoskeletal balance that involves a minimal amount of

stress and strain on the body (Yip, Chiu, & Poon, 2008, p. 149). Hastings et al. (2003) states

that sitting is not a normative position for locomotion, therefore, it is difficult to determine an

ideal sitting posture. Sitting is typically considered a transitional period or a position of rest, not

a position of movement and interaction with the environment. Recent research concludes that a

sitting posture with an anterior pelvic tilt and decreased lumbar flexion is the more favorable
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position (Hastings et al., 2003, p. 532). Current guidelines for correct seated posture involve the

ischial tuberosities of the pelvis evenly supporting the weight of the upper body. The pelvis

should be slightly anteriorly tilted to relieve pressure off the body prominences on the pelvis and

allow the hip, knee and ankle joints to rest in 90 of flexion. Feet should lie flat on the floor so

they can adequately support 19% of the body weight (Collins, 1999). Lin et al. (2006) suggest

that upright seated positioning in wheelchairs has a positive effect on respiration, feeding and

eating, pressure ulcer development, comfort level, and overall QoL.

Although it is important to obtain correct seated posture, it is imperative that individuals

who are wheelchair bound are frequently repositioned to reduce the risk of pressure ulcers. If

they are unable to reposition themselves, care givers should reposition them at least once every

two hours (Reddy, Gill, & Rochon, 2006). In addition to repositioning, the use of therapeutic

positioning has proven to decrease or limit the progression pressure ulcers (Nixon et al., 2006).

Therapeutic positioning involves the use of therapeutic surfaces that lower the interface pressure

between the body and the wheelchair, which is the supporting surface. The most common

therapeutic surfaces are foam, air, or gel cushions (Thorne, Sauve, Yacoub, & Guitard, 2009).

Wheelchair Biomechanics and Propulsion

Once correct seated posture is achieved, an important component of utilizing the

wheelchair is using correct biomechanics to propel the wheelchair. Wheelchair propulsion

requires a person to impart a force to the wheelchair push rim to move forward. As a result, the

joints of the upper limb are loaded repeatedly as the manual wheelchair user engages in their

occupations (Collinger et al., 2008 p. 667). Clinicians working with wheelchair bound

individuals must educate them on the importance of proper biomechanics during propulsion.
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Wheelchair propulsion is separated into two phases, the push phase and the recovery

phase. The push phase occurs when the hands come in contact with the rims and produce a force

to propel the wheelchair. The recovery phase is the nonpropulsive phase where the hands are

preparing to restart the push phase (Vanlandewijck, Theisen, & Daly, 2001). To ensure that

wheelchair propulsion is complete and effective, it is important to note the individuals position

relative to the axle and seated posture. Research suggests that seat height has an impact on

mechanical efficiency, energy consumption, hand, arm and trunk range of motion and push phase

duration (Kotajarvi, Sabick, An, & Zhao, 2004). Kotajarvi et al. (2004) summarizes that

improvements in wheelchair biomechanics can be achieved when there is a shorter vertical

distance between the shoulder joint and wheelchair axel. To maximize benefits, wheelchair users

could be provided with an adjustable axel position to further improve propulsion biomechanics

and reduce the risk of musculoskeletal complications (Kotajarvi et al., 2004). In conclusion,

research suggests that wheelchair bound individuals who are able to manually proper their

wheelchair are more likely to participate in their occupations and have an overall better QoL

(Walker et al., 2010).

Conclusion

An increasing percentage of individuals require the use of a wheelchair for functional

mobility (Walker et al., 2010). Wheelchair bound individuals are at risk of facing a variety of

preventable complications as a result of prolonged sitting (Goda et al., 2015). Correct seated

posture is believed to have a positive effect on the overall health, well-being and QoL for

individuals who are wheelchair bound (Lin et al., 2006). Occupational therapy aims to promote

independence and engagement in occupations for wheelchair bound individuals through

provision of correct seated positioning for those individuals (Walker et al., 2010).
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