ABC’s of OT: ways to address POSITIONING in the SNF

Seating and positioning is crucial when attempting to maximize functional performance. When posture is poor, functional performance will be poor. We need appropriate posture for successful toileting, safe self-feeding, independence with wheelchair mobility, and general active participation in the environment. Since many tasks among our long-term residents are performed from a seated position, we often receive referrals for patients who need an improved seating system. This means we deal with positioning a lot in the SNF setting.

Posture is all about pelvic alignment.

If the pelvis is poorly rotated, then the rest of the spine will follow suit, as illustrated in the image below.


We cannot improve seating and positioning until we determine the position of the patient’s pelvis. The best way to do this is the get the patient on the plinth. Why? Because the plinth is a solid, level, firm surface that allows for the pelvic position to reveal itself naturally. Surfaces like a mattress, wheelchair cushion, lazy chair, or even a dining chair tend to have too many variables by way of texture, tilt, depth, and height. So the plinth is your best bet.

If the patient is able to maintain a seated position, ask him/her to sit upright on the edge of the plinth. You will quickly see the patient’s automatic pelvic alignment reveal itself naturally. Next (or if the patient is unable to safely sit at the edge of the plinth), assist with a transition to supine on the plinth, and palpate for the anterior superior iliac spine on both sides of the pelvis. Again, this will allow you to understand the patient’s natural pelvic alignment when no external supports are provided.

So once we identify the problem, what do we do about it?

Well, we have two options: 1) we provide the patient with a more appropriate seating system, and/or 2) we implement a therapeutic exercise program to strengthen the hip, back, and abdominal muscles to internally improve posture.

We’ll talk more about wheelchairs next week (spoiler alert!), but for now, here’s what we want to remember. The seating system you choose for your patient should correct the pelvic alignment. So, if the patient exhibits an anterior tilt, the seating system should force the pelvis into a posterior tilt just enough to achieve neutral positioning, and vice versa.

The same basic rule applies for secondary positioning issues such as a greater than or less than 90 degree bend in the hips, knees, or ankles, a pelvic obliquity, or a hip rotation. The simple addition of a sit-straight, wedge, or even a thin towel roll can result in the correction of a seemingly complex issue.

By the time we are done with our patients, their heads should be upright, their backs should be flush to the backs of the wheelchairs, their pelvis should be all the way to the back of the seat, and the hips/knees/ankles should be at roughly 90 degrees, just like our guy pictured below.


In the end, the positioning assessment as a whole will likely be somewhat time-consuming. But I promise it will be worth it, because through it you will help to increase comfort, increase joint protection, increase skin integrity, increase function, and increase quality of life.

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