Are back pain and shoulder pain an inevitable consequence of using a wheelchair for people with spinal cord injuries? Jennifer Hastings doesn't think so, and she's on a crusade to change the way patients, providers and manufacturers think about wheelchair seating.
Hastings is a Physical Therapist who specialized in SCI Rehabilitation for 13 years. She established the wheelchair seating clinics at both the VA and Harborview medical centers. She has lectured and published widely on the subject and is recognized as a national expert.
The reason pain is so common among wheelchair users with SCI, Hastings believes, is that "we've forgotten the skeleton and deal with all the neurological patients—stroke, SCI, Parkinson's—as if they are only a nervous system." She thinks close attention to the skeleton and proper postural alignment can alleviate or avoid many of the typical muskuloskeletal pain problems in this population.
The obvious purpose of a wheelchair for people with SCI is to provide mobility, but a less recognized need is to provide stabilization of and substitution for weak or absent trunk muscles during sitting and Functional activities. "If you don't have use of your trunk muscles (abdominals and back extensors), as in a Cervical injury", Hasting said, `you don't have an anchor to your wheelchair." To feel more stable, people slump back and slide the buttocks forward in the seat. "That's very stable," said Hastings, "but you can't sit that way all day without eventually developing posture-related pain problems." The traditional 90/90 wheelchair (seat parallel to the floor; high seatback at a 90 degree angle to the seat) sets people up for this kind of posture problem from day one, Hastings claimed. "Some facilities are still prescribing these for people with SCI, and it should not be allowed."
One way to increase stability in a wheelchair is to recline the backrest or tilt the chair in space. While this allows the lower back to stay against the seat, it also thrusts the neck forward, which quickly becomes fatiguing and painful for the neck muscles.
Whether standing or sitting, proper postural alignment places the ears over the shoulders over the hips while maintaining normal spinal curves. This alignment is optimal because "it takes the least muscular work to maintain," Hastings explained. Less muscular work means less fatigue and pain and more functionality.
Frequently the lowered backrest height meets with resistance from other clinicians. "I've had many arguments with doctors who say, "You can't have a backrest that low—they're jelly above that!" Hastings recounted. "But it's jelly that I want to align this way to allow the person to use the strength they have." In case after case she has found that maintaining a normal Thoracic curve and providing Lumbar support do provide stability without compromising alignment.
She has the same goals for newly injured patients trying out their first wheelchair while still in the hospital. "I start with the backrest a little higher and more reclined than I would go (with a long-time injured person)," Hastings said. "But by discharge the backrest height should be lowered and the angle more acute."
The concept is the same for power wheelchair users. While you need to use a higher backrest for a power wheelchair due to the need for power recline and often driving from a chair "you can still set it up to allow the normal thoracic curve," she said. The key is to support the lumbar spine and have the backrest fall (rearward) at the thoracic area to allow for the normal spinal curves.
Hastings and many of her patients have noticed that improving posture results in better overall appearance. In one case, a woman went home after Hastings adjusted her power wheelchair to a more normal upright alignment, and her family immediately noticed the difference. "Her kids said she looked taller, and her husband thought she looked thinner," Hastings recalled. "Posture is also about vanity."
Hastings also cautions patients against forming bad postural habits that occur while performing routine activities. Computer users, for example, position the keyboard too far away; as a result, they have to slump down to avoid pitching forward. "The keyboard should be positioned close to you so that you aren't reaching out," Hastings said. "If you're an all-day keyboard user, I recommend using a strap to give you a little support." Crossing the legs while typing twists the torso and cuts off the blood circulation if maintained for too long. "You should adjust your posture to different tasks throughout the day," Hastings continued. "It's good to shift your position around frequently."
A seat cushion that's too long is a common mistake in wheelchair configuration. Recently the standard length of the seat cushion was increased to 18 inches (too long for all but the tallest people) because a longer seat was thought to distribute seat pressure over a larger area and reduce the risk of skin problems. The longer seat can also make transfers easier. But Hastings believes that a seat that is too long makes good upright posture impossible. "Unless you're really tall, it makes you sit with your buttocks forward and your pelvis tilted posteriorly." The seat should not be any longer than the distance between the small of the back and the bend in the
