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For many therapists, it is incredibly frustrating when, after providing a productive therapy session, we set up a child with non-typical development in "optimal" seated posture only to find shortly after that the child looks nothing like how they were first positioned. We slowly notice that the pelvis begins to posterior tilt, the child slides forward in their seat, the trunk starts to round out (causing thoracic kyphosis), the cervical spine is hyperextended, and the chin pokes forward. Eventually, the child's caregiver or teacher brings the child back to therapy and asks us, the therapists, to "fix" the seating system.
We reassess and realize that although all the measurements and angles are accurate, we have been unable to control the pelvis – the culprit of this poor positioning. As we presented in our blog, The Role of the Pelvis in a Postural Management Plan, the pelvis is the foundation of good positioning. We know that the head and the trunk will also come out of alignment when it is not in a neutral position. Therefore, it is crucial to maintain the neutral position of the pelvis.
What are some solutions for maintaining a neutral pelvis?
Ensure that all measurements are accurate
If a seat depth is too long or too short, it can cause the pelvis to move posteriorly. If the seat width is too narrow, we may see that the pelvis starts to rotate to fit in. If the seat width is too wide, the pelvis may have too much room and begin to skew to find a stable point, leading to an obliquity.
Provide adequate support to the pelvis on all sides
Posterior, lateral, anterior, and distal. It is vital to have a level seating surface that is firm, yet allows the pelvis to be enveloped into the seat. It is also essential to have a firm posterior surface to prevent the pelvis from tilting posteriorly. Lateral hip supports can help to keep the pelvis in midline and thus prevent it from skewing to one side, creating an obliquity, and an anterior pelvic support can prevent the pelvis from rotating.
Provide postural support devices
Using a trunk support or pelvic support will help maintain the pelvis's desired position. These supports should be secure enough that they do not allow movement. However, it must be noted that periodic breaks from the position and repositioning are required for comfort and monitoring.
Ensure that all secondary postural supports are being used correctly
When a secondary support does not have the correct direction of pull or is not tight enough, it can exacerbate the position that is being corrected. Common errors include a pelvic support that is placed too high, supports that are too loose, and belts that are placed upside down or at the wrong angle.
Provide a good base of support for the lower extremities and feet
When the feet are grounded, the pelvis can be maintained in better alignment. Use of a secondary support (sandals, ankle huggers, foot straps) can assist in maintaining lower extremity placement. If the lower extremities go into hip and knee extension, the pelvis is likely to posterior tilt and thus cause sliding.
Accommodate the pelvis if it cannot achieve neutrality
Asymmetries need to be reduced as much as possible, but the angles of the seating system should align with the non-reducible contractures. If a non-reducible asymmetry is not accommodated, then the child will look to find comfort at another body angle and will inevitably compensate to achieve that.
Some recommendations from our experts in the field include:
- Make sure the position of the pelvis is the first thing and last thing you check during an assessment.
- The transfer into the seat (either hoisted, sliding, or standing transfer) is the best opportunity to get pelvis positioning optimized.
- Educating the educational and care staff about not just how to position the supports, but why they are there, will reap the rewards in the long-term.
- Use tilt when possible to get the pelvis into a neutral position and back into the seating system.
- Utilize a "Seating Passport" to provide clear instructions on how and why the child needs to be positioned according to plan.
As with all postural plans, it is important to perform an extensive mat assessment before recommending a position for the child. This will help determine the plan's goals, alternative positions, frequency of positioning, and expected outcome.