Seating Positioning With Kyphosis
Seating positioning with kyphosis starts with stabilizing the pelvis. Individuals with kyphosis need reassessed for proper positioning on a regular basis as this disease is progressive in nature.
Looking at the peak of the curvature you may need to look for pressure ulcer development. Make sure the backrest is properly fit for the individual whether it is a mold or one adjusted properly for them from off the shelf. By ensuring a proper fit you are spreading the surface area out over the entire back and relieving the pressure spots.
Keep in mind that your goal with seating positioning with kyphosis is to try to put the individual in the most supportive system available. Determining how well they can manage throughout the day, whether it is in the seating system or side lying in bed to take the weight off the spine as much as possible. Slowing down the progression is what you should focus on.
How Technology Can Help
The overall goal is to prevent further spinal deformity, prevent swallowing and digestion difficulties, provide neutral alignment of the trunk over the pelvis, increase head control without the individual having to work to hold their head up, provide even pressure distribution and improve their visual field.
When measuring and trialing different back supports for upper-thoracic (back) support try to have the back height fall just below the inferior angle of the scapula (below the shoulder blade). This allows upper-thoracic (back) extension and promotes proper movement of the scapula through the shoulder.
Shoulder height support ends at this point for clients who may use tilt in space wheelchairs, however use caution to avoid any increase in shoulder protraction (rolling upward and forward), which can increase kyphosis.
Good posture begins with pelvic stabilization. Two terms commonly used with management of kyphosis are “correct” a flexible curvature or “accommodate” a fixed posture.
Flexible Posture Challenges
Seating position with kyphosis involves several factors that need to be considered with correcting a flexible posture. Determine the location and amount of support needed to gain a balanced head/shoulder posture. Try to be as least restrictive as possible by creating postural stability through the seating system before adding other positioning components.
Evaluate positioning out of the wheelchair to determine range of motion limitations at the hips, knees and spinal alignment. Assess their passive range of motion and flexibility in their pelvis and spine. Look for the apex (peak) of the curve, recalling that the center of gravity of the upper torso is T9.
Move pressure away from the apex (peak point), considering depth of contour and surface materials that are used to allow immersion and wrap around their body.
When establishing seating positioning with kyphosis you want to work to create three contact points . A firm backrest, anterior (front) shoulder or chest support (only as a last resort) and stabilize the pelvis.
Other considerations may include a soft or hard thoracic-lumbar-spinal orthosis (TLSO) which the seating system would be designed to fit. Sometimes an additional external support such as an abdominal binder is used to assist with weak trunk muscles.
Try to accommodate positioning by using the seating system first before considering other supports.
Fixed Posture Challenges
Seating positioning with kyphosis means you are looking at the head over shoulders in functional midline position. Doing so helps to determine where the pelvis must sit to accommodate this posture. If the thoracic kyphosis is severe with associated posterior (backwards) pelvic tilt and you tried to place the hips at 90 degrees, you would cause the person to fall forward in the seating system and cause this individual to be in a non-functional position looking at the floor.
Your goal is to establish a consistent posture, comfort, and enhance functional ability to improve arm reach. Try using a contoured or curved back with different depth contours and tilt/recline angles first. Use an adjustable drop base, modular back with angle adjustment hardware. Provide a tilt-in seat/frame and opening the back angle changes orientation of the visual field.
This in turns provides sacral (tailbone) support, adjusts thoracic (chest) extension, shoulder retraction (pulling backwards) and head positioning. A tilt or recline system provides “gravity assisted” positioning and needs adjusted until the head is able to maintain an upright position without effort.
Comfort and Function
Seating positioning with kyphosis needs to be functional for your client. It also needs to be functional. Even if we can “straighten them out” it may not be the most comfortable position and they will not stay in the position you have set them up in.
Sometimes they will agree in the beginning and once the brace and chair is purchased they decide it is not what they want and are then non-compliant with wearing a hard shelled brace such as a TLSO.
Figure out how much modification is needed – mild, moderate or maximum and what is tolerable for your client. The more force you need the more challenging it will be, and this increases the risk of pressure sores on those contact points.
In the end ask yourself: Is this position one where they can function easier? Can consistency be maintained with multiple caregivers? Will it work with transfer slings and lifts? Will they wear it or use it once they actually get it?
Your work is not complete for seating positioning with kyphosis. This population needs reassessed frequently due to their ever changing posture. And last but not least just because they look good, if they can’t function it doesn’t matter.
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