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Section 16

Appropriate seating and positioning creating normal alignment between the head, neck, trunk, and pelvis lays the foundation for quality motor control.
Upright posture facilitates alertness, decreases tone and aids in maintaining vital functions such as respiration, cardiac output, etc. It also assists in maintaining skin integrity, muscle tone, self-care skills and social interaction. Refer to the handout to outline specific benefits and goals.

  1. Poor postural alignment due to orthopedic deficits.

  2. Increased/decreased tone causing poor anatomical alignment.

  3. Compromised skin integrity.

  4. Poor postural alignment due to dementia.

  5. Poor postural alignment due to neurological deficits.


  1. Medically unstable.


  1. Specialized seating needed to manage decubiti.

  2. Postural spasms that may cause tightening of positioning devices thereby decreasing blood flow, motor control, etc.

  3. Need for graded endurance programming with new seating devices.

  4. Specific precautions for each powered device as outlined by the manufacturer.

  5. Cognitive impairments that may limit judgment when using high tech seating devices.

  6. Sensory loss and edema.


  1. Tape measure.

  2. Special seating forms.

  3. Various cushions, lateral supports, etc. to try for evaluation.

  4. Standard wheelchairs that can be adapted for specialized seating.

Seating and Positioning (cont.)


  1. Wheelchair evaluations - refer to wheelchair prescription program.

  2. Specialty seating systems available from various manufacturer.

  3. Note resource page for further information.


  1. All seating and positioning evaluations are under a physician’s prescription.

  2. Complete a total OT and/or PT evaluation to note all limitations and areas that positioning would be important to increase or maintain function.

  3. Develop a treatment plan that would encompass the obtaining of appropriate seating devices, analysis of funding for these, and programs of endurance for tolerating the devices.

  4. Once seating/positioning device has been completed further analysis from the optimum postural position needs to take place relating to functional tasks.

  5. The total seating/positioning device must be outlined for the staff/family with reasons for and explanations of how to achieve and maintain alignment.

Refer to handout on how to document for positioning/seating interventions.
Refer to resource outline and tot he Assistive technology program.




9 Body is aligned and balanced right and left of midline.

9 Trunk is aligned according to normal cervical, thoracic and lumbar curves.


9 Equal weight bearing on bilateral ischial tuberosities.

9 Hips in neutral rotation and level to the horizontal plane.

9 Buttocks centered on the seat.

9 Pelvis/hips placed as far back as possible on the seat.

9 Pelvis/hips positioned in a 90 angle.

9 Pelvis maintains slight anterior tilt to promote normal lumbar lordosis.

9 Seatbelt fastened across the hips at 45 - 90 angle.

Knees and Ankles

9 Knees at 90 angles.

9 Knees pointed straight ahead.

9 Knees level with the hips or slightly higher.

9 Ankles at 90 angles.

 Feet supported on firm surface (footrest or floor if resident is not being moved).

 Toes pointed straight ahead.

 Approximately 25% of body weight transmitted to the floor (or footrest).


 Body is aligned vertically.

 Trunk does not demonstrate lateral curvature.

 Body does not lean too far forward or back.

 Slight lumbar lordosis.

Arm and Shoulder Position

 Elbows rest comfortably on the armrests or lap tray.

 Shoulders relaxed and level.

Head Position

 Head in midline between shoulders, slightly forward.

 Neck slightly extended to allow full visualization of the immediate environment.

 Chin tucked (neutral).



  1. LEVEL OF AROUSAL. Upright posture facilitates alertness through visual-vestibular and proprioceptive sensory feedback mechanisms.


    1. Mechanism of Respiration:

1. Enlargement of chest cavity causes negative pressure resulting in inspiration.

        1. Ribs expand upward and outward, enlarging chest capacity.

        2. Diaphragm descends, enlarging chest capacity, abdomen moves outward as a result.

        3. Neck accessory muscles may be used to supplement elevation of rib cage.

        4. Relatively negative pressure causes air to move into check, expanding lungs.

  1. Passive recoil of chest and diaphragm result in passive expiration.

  2. Negative pressure generated from efficient respiration assists in drawing blood back toward the chest as pressure becomes negative during inspiration.

  1. Cardiac Output:

      1. Cardiac Output equals Stroke Volume X Heart Rate (CO=SVxHR)

      2. Stroke volume may be directly influenced by the sitting posture of the patient as it impacts upon respiration and pressure forces on the heart.

  1. Cardiopulmonary benefits of an upright posture.

      1. Allows accessory muscles and rib cage to assist with respiration more efficiently.

      2. Decreases effects of gravity on chest expansion.

      3. Mobilizes pulmonary secretions.

      4. Facilitates circulation of blood back from the extremities, promoting blood flow into the heart which improves stroke volume.

      5. Discourages pooling of blood volume in the abdomen.

      6. Decreases compression of chest and thus facilitates refilling of the heart chambers for increased stroke volume.

III SKIN INTEGRITY. Proper positioning allows for distribution of weight bearing

over larger surface areas and away from bony prominences. When sitting

properly, weight is distributed primarily along the buttocks, thighs, and plantar

surfaces of the feet.
IV VISION. Visual regard of the environment is facilitated through upright

V PERCEPTION is enhanced through reception of normal proprioceptive input

through the feet, back, legs, and buttocks. Midline orientation is enhanced,

as well as upright posture of the head and neck which enhances visual and

auditory perception.
VI MUSCLE TONE is normalized through the appropriate weight-bearing that is

realized through good sitting position. For example, extensor muscle tone of

the back is enhanced through upright posture.
VII MUSCULOSKELETAL INTEGRITY is maintained through appropriate align-

ment of joints and muscles. Joints that are more functional in lengthened,

shortened, or mid-range positions are maintained.
VIII SELF CARE, WORK AND LEISURE activities are enhanced through abilities

to assume and maintain proper sitting position. Proper sitting posture allows

for movement of the extremities and interaction with the environment that may

not be possible in abnormal sitting postures.

by sitting posture. Upright trunk and head posture facilitates interaction with

others and lessens the negative aesthetic and psychological effects of using

a wheelchair. Respiratory support to speaking functions and positioning the

extremities to use alternative communication devices are other areas of

function that can be positively impacted.
X ROLE PERFORMANCE. Proper positioning can maximize independent

functioning in certain skills and decrease the need for assistance. Quality of

life, then, can be greatly enhanced through the ability to maintain a proper

sitting position.



NOTE: Refer to catalogs of seating equipment for illustrations and more detailed descriptions of products: Alimed, Jay Medical, OTTO-Bock, Pin-Dot and ROHO are some of the more frequently used commercial vendors. Addresses are in the section on “Additional Resources”.


  1. Sling Upholstery - Standard wheelchairs are usually supplies with “sling” naugahyde upholstery. These will usually stretch out, some sooner or later depending upon the quality. They can be reinforced early on (i.e., doubling the upholstery) to prolong stretch from occurring. Once stretched out the only solution is to replace.

  2. Solid Seat/Back

      1. Wood is used often to reinforce seats. It can be placed on the metal uprights over the top of the existing sling seat, or can be mounted to the wheelchair frame (the seat height can be lowered to accommodate). The metal hooks used to attach the wood to wheelchair frame are the most expensive in adding this option to seats. Several options exist for solid inserts, including some that are made of high density plastic which offer better protection against mold/mildew and spread of infection. Note that compliance may be difficult to get for placing a cushion over the solid insert and this may preclude using this option. A permanent installation of a combination solid seat and cushion is the best option in this instance.

      2. Seats can be altered to accommodate or correct postural problems by changing the shape of the foam or angle of the metal hooks used to attach the solid seat.

      3. Wedging or inclining the seat is a common correction used to prevent some patients from sliding forward out of the chair. Patients who have increased extensor tone may benefit from this adaptation. Caution: Patients who have wedged seats require ability to tolerate more than 90 degree hip flexion. Wedge seats can also increase posterior pelvic tilt, and probably should NOT be used as a first alternative for patients who slide forward in the chair.

      4. Drop seats can be used to lower the seat height to enable shorter residents to reach the floor.

      1. Seat Backs may also need to be altered for some patients who have increased extensor muscle tone through the trunk. Wedging the trunk with the thickest part of wedge at shoulder level assists in bringing the shoulders forward over the hips to decrease upper body extensor muscle tone. High trunk extensor muscle tone usually requires use of seat belt to keep pelvis positioned. Seat backs may also provide lumbo-sacral and/or lateral support.

  1. CUSHIONS - All wheelchair seats should be equipped with cushions when using for more than transport purposes. Cushions that are combined with a solid-seat insert are generally best. Some basic types include:


      1. Foam for cushions exist in a wide range of thicknesses, density, and buoyancy. Consult your vendor for more details on the properties of specific foams. In general, high density foam is best for prolonged sitting.

    1. Gel-based or air-based cushions - are more expensive that may offer better pressure relieving systems for patients with special needs or recurrent skin breakdown. Note that these cushions tend to require a higher degree of maintenance and may present with greater complexity for fitting properly.

Note: Cushions do not offer a firm base to sit on unless combined with a

solid insert. Solid seat and cushion combinations are usually the best



  1. Refers to the leg attachments that elevate and support the lower leg.

  2. Even when lowered completely, most leg rests require the patient to be able to achieve less than 90 degrees of knee flexion and require sufficient hamstring length to allow pelvis to be in anterior tilt.

  3. An optional calf pad can be raised or lowered to support the lower leg, and can be purchased in extra-large sizes.

  4. “Swing-away” option is particularly helpful in transfers.

  5. A soft strap wrapped around and secured behind the calves can limit excessive knee flexion, prevent foot drag, and promote stable positioning of the lower leg against the calf pad. The patient must be able to remove the strap if it is not to be considered a restraint.

  6. Note that calf pads may not be needed for all patients. Calf pads can potentially increase flexor muscle tone of the lower extremities, and can be associated with skin breakdown with patients who tend to push against the calf pad due to flexor spasticity.


  1. Refers to the non-elevating supports for the feet.

  1. Proper use of the footrest requires 90 degrees or more flexion at the knee.

  1. Adjusting the entire leg attachment tot he correct height is essential to assist the pelvis into a stable position.

  1. The foot rest should support the foot at a height where the thigh is parallel to the seat bottom.

  1. Comes with option for folding or extra large plates to accommodate large feet, or when increase extensor muscle tone is problematic, and are also available with adjustable angles.

  1. Additional soft (i.e., Velfoam) straps properly placed can assist with keeping foo/feet on the footrests. The patient must be able to remove the strap if it is not considered a restraint.


    1. Commercially available options include desk-style arms, and adjustable-height, removable, or swivel up-down features.

    2. In nursing home settings, many are standard length, non-removable and non-adjustable. This requires that the patients be able to stand in order to transfer.

    3. In some cases creative padding is needed to protect patients with fragile skin.


  1. Seat belts are generally attached to the rear screw of seat bottom for the best stability and angle.

  2. Seat belts should be positioned at a 45 degree angle just above or below the hip joint.

  3. The patient should be able to remove the seat belt if it is not to be considered to be a restraint.


    1. Often used to support hypotonic or hypertonic upper extremities. Can assist in trunk alignment, prevent muscle shortening or scoliosis from developing.

    2. Are available in a variety of styles and materials, including:

      1. Acrylic/clear

      2. Lip or Rim edges

      3. Half-lap trays

      4. Fold-up styles

      5. Economy styles that attach with velcro

      6. Styles with wells for cups.


  1. Lateral supports need to be positioned high enough to provide support but low enough to avoid impingement upon axilla or create excessive pressure areas.

  2. A general rule of thumb is that if you use a lateral support on one side, provide a support on the opposite side even if initially you think it’s not required. More than one point of contact is usually required for supportive correction.

  3. Proper support provided through the seat may eliminate the need for lateral supports.


    1. Used to maintain the pelvis in a neutral position (side to side).

    2. Often used bilaterally to take up extra width in wheelchairs to stabilize the pelvis.

    3. Usually extend along the thigh to approximately 2-3 inches before knee.

    4. Can assist with excess abduction and can prevent some “windsweeping”.

    5. Often the easiest and most economical type are towels firmly folded or rolled and duct-taped to prevent unraveling.

IMPORTANT: When applying seat belts, lap trays, trunk supports and/or hip guides/blocks, NEVER “Wedge” the patient into the chair. The patient should be able to weight shift to relieve pressure as needed while in the chair.

  1. Intended to encourage knee separation and femur alignment with hip/pelvis. They are not intended to prevent patients from sliding forward.

  2. Must be used sparingly and cautiously. They should be as small as possible and placed as distal as possible.

  3. Be careful to monitor skin for pressure areas.

  4. Can often be replaced by a supportive firm seat surface and/or small towel roll under center front of cushion.


    1. Evaluating the thoracic area is critical when making adjustments to cervical area.

  1. Finding appropriate contact point for pressure on head and neck and achieving satisfactory alignment that continues over time is extremely difficult and requires skill.

  2. Frequent monitoring and trial and error are usually necessary.

  3. Some prefabricated headrests are available. May require a solid back insert for attaching to the wheelchair. Some “temporary” headrest systems attach to the armrests of the wheelchair and do not require a solid back.

  4. May be able to eliminate need for head supports with good trunk and pelvis positioning. Allows patient to “balance” instead of “lift” head.


    1. A variety of different handrims are available depending on patient hand and arm function. Some variations include rubber coating for extra-traction, and spokes or knobs for easier grasping.

    2. Clinicians can also purchase kits or foam to increase the width of the grip.


  1. Brake extensions may be required by patients with limited UE movement, visual deficits or hemipareses.

  2. Brakes can also be located in the rear of the wheelchair to increase safety of disoriented patients. Note that rear-mounted brakes could be considered a restraint if the resident can not physically reach back to release them.


    1. One arm drive–2 handrims on non-hemi side; very difficult to coordinate propulsion when cognitive and/or perceptual deficits are present.

    2. Ratchet or pump handle–requires only one arm to propel and steer. This wheelchair works well for many patients with hemipareses, however, it is expensive.

    3. Other options include Electric Chairs or Scooters–Hand Control, Sip’n Puff, Head Control. These options are very expensive . Obtaining reimbursement may be very difficult.


  1. Some patients may require smaller diameter wheels to bring them lower to the ground for better propulsion. Vendor input is needed to ensure integrity of chair is not compromised.

  2. Wheels can be moved forward to shift the center of gravity of chair forward for patient with double LE amputees who do not wear prostheses.


    1. Chairs can be constructed to shift the center of gravity backward or forward. This is especially helpful for patients whose center of gravity is shifted forward or backward significantly. Patients in lower-extremity casts, with LE amputations, and those who tend to tip themselves forward or backward are examples.


The following sections will present positioning problems that are primarily stemming from the patient or from the chair.

  1. Problems with the PATIENT: (adapted from Hallenborg, S. “Wheelchair Needs of the Disabled Adult.” In O. Jackson-Klykken, Ed. Therapeutic Considerations for the Elderly. New York: Churchill Livingstone, 19887.).


Possible Solutions

Pelvic Posterior Tilt-flexible

- Firm seat and back with belt placed at 45 degree angle to

sitting surface

- Lumbar roll or lumbar corset

Pelvic Posterior Tilt-fixed

- Accommodate with semi-reclining backrest

Pelvic Obliquity-flexible

- Firm seat and back with belt placed at 45 degree angle to

sitting surface

- Pelvic block pads to maintain midline position

Pelvic Obliquity-fixed

- Accommodate by building up seat or cushion under high


Hip Adduction

- Proper pelvic position

- Knee Spreader placed at most distal point seat midline

(easily removable)

Hip Extension-flexible

- Proper pelvic position

- Increase flexion past 90 degrees with inclinable seat or

wedge cushion

Hip Extension - fixed

- Accommodate with reclining back wheelchair

Thigh Length Discrepancy

- Proper pelvic position

- Asymmetrical seat depth

Knee Flexion Contracture

- Accommodate with shorter seat depth and footplates

which extend posteriorly

- Proper pelvic position

Knee Extension Contracture

- Accommodate with elevating leg rests

Fixed Deformities of Feet

- Support with foot cradle

Poor Trunk Control-No Asymmetries

- Proper pelvic position

- Lateral supports mounted on high back

- Reclined back, inclined seat (maintain 90 degree seat to

back angle)

Fair Trunk Control

- Lateral support used part-time especially in transit


Possible Solutions


- Proper pelvic position

- Three-point pressure system


- Proper pelvic position

- Three-point pressure system for support

- Total contact system may be indicated for skin protection


- Proper pelvic position

- Lumbar roll

- Clavicular pads

- Reclined back, inclined seat (maintain 90 degree seat to

back angle)


- Accommodate with concave backrest or heavy padding

Shoulder Protraction-Excessive

- Firm back

- Clavicular pads

Shoulder Retraction - excessive

- Concave backrest

- Laptray

- Humeral wings on tray

Poor Head Control

- Reclined back, inclined seat

- Postero-lateral head rest

- Anterior restraint for car transport

- Cervical orthosis may be indicated

Fair Head Control

- Removable head rest–used especially for travel


(chin and head jutting forward)

- Proper alignment of pelvis and spine




  1. Documentation should contain specific rationale for wheelchair positioning, including:

    1. Wheelchair positioning evaluation. Document key results on the EPOT. Keep a copy of that evaluation worksheet in the “soft” file.

    2. Factors indicating need for wheelchair positioning evaluation at that time.

    3. Prior level of function.

    4. Rehabilitation potential related to wheelchair positioning goals; including positive prognostic indicators.

    5. Specific functional outcomes.

  2. Incorporate documentation of skilled intervention and terminology.

  3. Patient-specific examples of treatment goals include:

    1. “Through improved postural control, the patient will sit upright in wheelchair for 30 minutes, to feed self independently for one meal a day.”

    2. “Through improved wheelchair positioning, the patient will safely and effectively mobilize his wheelchair with minimal assistance to complete grooming tasks.”

    3. “Following caregiver training, patient will set upright with stand by assistance for 20 minutes to complete grooming activity with moderate assistance.”

    4. Through improved positioning and maintenance of appropriate posture in bed, patient will have no areas of skin breakdown in the sacral area.

    5. Through improved position in wheelchair, patient will be able to be transported safely by staff.

    6. Following caregiver training, patient will transfer from bed to chair with moderate assist to be positioned appropriately for participation in activities.

    7. Follow caregiver training and improved trunk stability, patient will be able to maintain sitting for _____sec./min. To allow caregiver time to prepare for transfer bed to chair.

    8. Through improved trunk mobility and strength, patient will safely perform transfer with supervision.

    9. With properly fitted wheelchair, patient will be able to mobilize self throughout facility with supervision using both Les for propulsion.

    10. Through improved positioning, patient will have decreased flexor muscle tone in right LE allowing appropriate weight-bearing for stand-pivot transfer with minimal assistance.

  4. Document specific training to caregivers.

    1. In weekly summary, document that training was provided and identify the caregivers trained.

    2. Provide written communication for follow through by caregivers.

  5. Diagnosis Coding Examples for Rehab/Treatment Diagnoses may include:

    1. Malaise & Fatigue, 780.7

    2. Abnormal Posture 781.9

    3. Abnormal Involuntary Movements, 781.0

    4. Muscular Incoordination, 781.3

    5. Disorder of Muscle, Ligament, and Fascia, 728.9

    6. Low Back Pain, 724.2

    7. Vertigo, equilibrium disturbance, 780.4

    8. Contracture of joint, 718.4 *

* must add fifth digit to identify area of body


  1. Compare baseline status to current status. Consider discharge if:

    1. Patient has reached maximum potential with goals at this time; AND

    2. Training has been completed; AND

    3. Discharge status has been documented and communicated to staff and family.

  1. Determine follow-up/screen date

  1. Discharge order obtained from physician.

  1. Complete discharge documentation, include written instructions given to patient and/or caregivers, the date the equipment was given, type of device provided, how the resident responded to use of the equipment, and how the equipment contributed to achieving the resident’s rehabilitation goals.

  1. Patient should be monitored informally as needed. Do not keep the patient on caseload for monitoring, as it is a non-skilled service.

  1. Follow-up screenings are to be documented.

  1. Patients should be re-screened for further positioning intervention within 3 months.

  1. Restorative Aides or other nursing personnel should be instructed to notify appropriate rehab staff member if patient’s status changes.



A. To receive payment from insurance companies, the following requirements are usually necessary:

    1. The client’s condition must be a result of an illness or accident.

    2. The equipment must be prescribed by a physician and certified as a medical necessity.

    3. For an insurance company to consider payment:

      1. The equipment must be a covered charge.

      2. The equipment must be medically necessary.

      3. The client must be covered by the medical insurance on date of service. Some policies may require insurance coverage on date of prescription.

      4. Benefits have not been exhausted.

    4. The equipment must be a therapeutic and/or prosthetic device which replaces a limb, organ or non-functioning body part, must be curative or improve the condition and/or function of the client.

    5. Equipment must be able to be used repeatedly (durable) and is non-expendable (wheelchair, hospital bed, communication prostheses, etc.)

    6. The client must be able to use the equipment, although training may be required. Training requirements must be documented in the physician’s note when equipment is prescribed.

  1. When dealing with insurance companies, always:

    1. Obtain complete client insurance information prior to contacting them.

      1. Client’s name

      2. Client’s address

      3. Client’s phone number

      4. Insurer’s name

      5. Insurer’s address

      6. Insurer’s phone number

      7. Insurer’s employer

      8. Policy Number

      9. Group Number

      10. I.D. Number

    2. Obtain other funding information.

      1. Secondary insurance - same information as #1. (Important as coordination of benefits clause may be included. Do not take coordination of benefits for granted because it is not always a part of the policy benefits.)

      2. Medicaid, Medicare, Children’s Medical Programs, etc.

    3. Verify current information every time a claim is filed.

    4. Client or authorized person must sign the release of medical information and the payment authorization on the claim form.

    5. Be specific when giving the client’s name, identification, diagnosis, service date, services performed and costs.

    6. Sign, date, give your provider number, and your federal tax identification number on all claim forms, as indicated.

    7. Complete all blanks on any form as accurately as possible, indicating n/a in sections that do not apply.

    8. Claim forms are submitted for actual services provided only. It is illegal as well as unethical to submit claim until services have been provided.

    9. A tickler or follow-up files should be maintained on claims for quick reference and follow-up.

    10. Keep well informed by reading booklets and information on insurance, Medicaid, Medicare, Campus bulletins, etc.

    11. Attend workshops offered in your area since changes occur regularly.


  1. Medicare

    1. Definition of Durable Medical Equipment (DME): “Durable medical equipment” is equipment which (1) can withstand repeated use, (2) is primarily and customarily used to serve a medical purpose, (3) is generally not useful to a person in the absence of illness or injury, and (4) is appropriate for use in the home. Most wheelchairs and positioning devices are considered to meet the Medicare definition of DME.

    2. Reimbursement under Part A

      1. The reasonable cost of DME can be recouped by a facility with Medicare certification during the cost settlement process. This process can occur annually, semi-annually or more frequently. Reimbursement at cost settlement means that the facility must budget for the purchase of the DME needs of its residents. Direct reimbursement to the facility through Part A is not available. The nursing facility recoups its costs in the form of adjustments to the per diem rate structure.

Reimbursement under Part B

      1. In general, Part B denies specific coverage for DME for nursing facility residents who are not in a part of the facility that meets the definition of home, are not going to use the DME in a home, and/or who do not occupy a Medicare-certified bed.

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