A common conundrum for licensed therapy professionals who specialize in treatment of the long term care patient residing in a nursing home is how to best address seating and postural deficits. Determining the type of seating device is one hurdle, but an even bigger obstacle can be devising goals that are patient related, functional and reasonable for a set time frame. Orthotic fitting and training for the fragile elderly patient is an art form and requires the unique skills of an experienced geriatric therapist.
Often times we review records that contain broad assessments with an overall analysis versus a detailed account of joint limitations, pain and functional barriers. For example, one case reviewed reported on the patient’s posture in a generalized manner. Abnormal posture was stated as leaning to one side related to impairment in range of motion. The recommendation was simply noted as a need for positioning devices. This type of documentation leaves the reader/reviewer without an in-depth analysis of the joints involved, the muscles affected and specific regions with pain. In this case we recommend that the evaluating therapist consider an augmentative evaluation to identify patient-specific barriers hindering optimal positioning.
We would also recommend that therapists consider using a formalized seating and positioning assessment including an unsupported seated mat assessment to identify patient barriers. By transferring patients from the seating system and placing them in a supine position, therapists are able to assess overall joint alignment, pain, and positional abnormalities. Through an assessment in an unsupported seated position, such as at the edge of the therapy mat, therapists will be able to examine specific body alignments that contribute to abnormal posture, assess ability to weight shift, as well as identify any self-correcting abilities. Once the evaluation is completed, therapists can identify specific impairments and barriers that hinder optimal alignment.
By completing an assessment outside of the current seating system, the evaluating therapist has the opportunity to really drill down to the root cause of the postural instability causing a decline in the patient’s upright seating. This assessment may result in a completely different treatment plan when looking at potential areas of muscle weakness involving the trunk and extremities. This full body assessment may result in a treatment plan focused on restoration versus adaptation, or at times a combination of both.
With the patient out of the chair, review and assess all of the current positioning equipment to ensure it is being utilized correctly and does not require a replacement. Also, during an assessment, speak with direct care staff to identify if any changes in medication have occurred due to an increase in pain or behaviors. If the patient is uncomfortable in the seating system, the resulting posture may have been an attempt to alleviate pressure or pain from the current chair.
Other areas to consider assessing include:
- Pharmaceutical effects: Drowsiness, vestibular disturbance, etc.
- History/dates of falls: Is it the seating system or the behavior causing the fall?
- Skin/Braden scale.
- Continence assessment.
- Current wheelchair seating system: Include specifics of type, devices used, etc.
- Self propelling and wheelchair management.
- Safety issues.
- Self feeding abilities.
Therapy goals should reflect the findings of the seating assessment and address the core barriers impacting optimal alignment. Harmony (HHI) recommends therapists treat the patient first, then modify the wheelchair second. Examples of goal focus areas include, but are not limited to:
- What can be restored, such as ROM, strength, tone, trunk control, etc?
- Utilize modalities as needed, such as E-stim, short wave diathermy, ultrasound, and hot packs.
- Utilize splinting.
- Incorporate therapeutic bed positioning.
- Identify functional tasks of interest to increase upright initiation.
- COMPENSATE and ADAPT:
- Patient training on adaptive equipment.
- Identifying cognitive leveling and dementia program development.
- Caregiver and patient education on pressure relief and skin integrity.
- Environmental changes.
- Adaptive equipment and wheelchair prescription.
When completing modifications to a patient’s seating system, even if it is just to issue a different cushion, Harmony (HHI) recommends follow-up visits at different times of the day to determine if the adjustments are a clinical benefit to the patient. A patient may look great in a chair when it was first issued, but as time progresses throughout the day, the therapist should be re-evaluating the effectiveness of the seating system to ensure that it continues to meet the needs of the patient. In the follow-up treatment sessions, the therapist should be evaluating not only the positioning of the patient, but also the ability of the staff to utilize the new positioning device. This will allow the therapist the opportunity to provide any caregiver education that may be required to ensure continued success with the use of the device and to optimize the patient’s clinical benefit from the modification.