The Evidence on Tilt, Recline and Elevating Leg Supports

Canadian Clinical Blog by Sheilagh Sherman, BA, BHScOT, MHM, OT Reg. (Ont.) - Sunrise Medical

Past Clinical Corner articles have addressed Dynamic Tilt and Pressure Distribution and Weight Shifting and Pressure Management. The article, Dynamic Tilt and Pressure Redistribution from October 2012, addressed clinical indications for tilt-in-space wheelchairs and the research related to dynamic tilt and pressure redistribution. The article, Weight Shifting and Pressure Management 2.0 from February 2016, addressed recommendations on duration and frequency of repositioning for pressure ulcer prevention based on clinical practice guidelines.

It is noteworthy that the terminology regarding pressure ulcers has changed since the Clinical Corner article was written last February. In April 2016, the National Pressure Ulcer Advisory Panel (NPUAP) announced the change in terminology from “pressure ulcer” to “pressure injury” as pressure injury more accurately reflects all stages of injured skin, including intact skin and open ulcers.1

This month, let’s continue our look at the evidence relating to tilt, in addition to recline and elevating leg supports.

As per the Rehabilitation and Assistive Technology Society of North America (RESNA) Position on the Application of Tilt, Recline and Elevating Legrests for Wheelchairs: 2015 Current State of the Literature, the positioning features of tilt, recline and elevating legrests “enable certain individuals to:

  • Realign posture and enhance function
  • Enhance visual orientation, speech, alertness and arousal
  • Improve physiological processes such as orthostatic hypotension, respiration, and bowel and bladder function
  • Improve transfer biomechanics
  • Regulate spasticity
  • Accommodate and prevent contractures and orthopedic deformities
  • Manage edema
  • Redistribute and relieve pressure
  • Increase seating tolerance and comfort
  • Independently change position to allow dynamic movement.2 (p. 3)

This month, let’s focus on how tilt, recline and elevating legrests work together to bring about desired results with respect to managing edema and redistributing and relieving pressure. For example, for lower extremity edema, we know that the legs must be above the level of the heart by 30 cm, achieved through a combination of tilt and elevating legrests. Elevating legrests alone cannot achieve this effect. The 2015 RESNA position paper cites research that found that a combination of elevating legrests, tilting more than 30 degrees, and using full recline improves blood flow.2 It was noted that the research was conducted on individuals without disabilities, so further research is needed with individuals with disabilities. The picture below illustrates positioning to have the legs above the level of the heart through the application of tilt and elevating leg supports:

Image-1.jpg

Photo is copyright Sunrise Medical Inc.

With respect to redistributing and relieving pressure, the 2015 RESNA position paper summarized research findings and stated:

  • “Tilt and recline affect pressure and perfusion at the skin and muscle tissue at the ischial tuberosities, and to a minimum extent, at the sacrum.
  • Tilt, when used alone, must be greater than about 25° to achieve pressure relief and/or tissue perfusion at the ischial tuberosities.
  • Recline, when used alone, can increase shear but may provide reduction in pressure at the ischial tuberosities at angles greater than 90-100°.
  • The greatest reductions in pressure are seen when tilt and recline are used together, either at tilt of 35° with recline 100° or tilt of 15-25° with recline of 120°.
  • Greater angles of tilt and recline generally provide better pressure relief.
  • 3 minutes duration of 35° tilt with recline of 120° is more effective than 1 minute.
  • Lateral weight shifting may sufficiently offload the ischial tuberosities on one side, but also simultaneously increase pressure on the other.”2 (p. 8-9).

The pictures below illustrate pressure relief positions (fully reclined on the left and 35° tilt with 120° of recline with the leg supports at 145°, on the right):

Image-2.jpg
Image-3.jpg

Photos are copyright Sunrise Medical, Inc.

As indicated above, recline can increase shear; however, anti-shear mechanisms are available in power wheelchairs to reduce shear forces. Without an anti-shear mechanism, the pivot point of the individual’s body does not align with the pivot point of the recline in a back support, causing shearing forces along the trunk as the position of the trunk shifts in the back support with the movement of recline. In addition, without an anti-shear mechanism the head may be positioned well on the head support while the wheelchair is in an upright position, but the head support would be too high relative to the head in a more reclined position. With an anti-shear mechanism, the movement of the back support is adjusted as the wheelchair goes into recline to allow the individual’s trunk and head remain optimally positioned on the back and head supports in all degrees of recline, minimizing shearing forces. The picture below represents the effect of an anti-shearing mechanism.

Image-4.jpg

Photo is copyright Sunrise Medical Inc.

This month, we have looked at the clinical benefits of tilt, recline and elevating leg supports, and the inclusion of anti-shear mechanisms for power recline. Research has shown which angles of tilt and/or recline are required to achieve pressure relief and that greater angles of tilt and recline generally will offer greater pressure relief. A combination of tilt, recline and elevating leg supports to position the legs above the level of the heart will assist with edema management.

References

  1. National Pressure Ulcer Advisory Panel. (April 2016). National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. Retrieved from http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/
  2. Dicianno, B.E., Lieberman, J., Schmeler, M.R., Schuler P. Souza, A.E., Cooper, R., Lange, M., Liu, H., & Jan, Y.K. (2015). RESNA position on the application of tilt, recline, and elevating legrests for wheelchairs literature update. Retrieved from http://www.resna.org/sites/default/files/legacy/resources/position-papers/RESNA%20PP%20on%20Tilt%20Recline_2015.pdf

As always, please provide your comments, questions, and suggestions regarding Clinical Corner. Please email me at Sheilagh.Sherman@sunmed.com. I look forward to hearing from you!


Sheilagh Sherman BA, BHScOT, MHM, OT Reg. (Ont.) - Clinical Education Manager, Canada

Sheilagh Sherman, BA, BHScOT, MHM, OT Reg. (Ont.)

Sheilagh Sherman joined Sunrise Medical Canada in 2010 as a Clinical Educator. Prior to joining Sunrise, Sheilagh gained extensive clinical experience working in a variety of settings, including neurological rehabilitation, complex continuing care, and community rehabilitation. As the Clinical Education Manager, Sheilagh is a clinical resource for therapists across Canada involved in seating and mobility. She leads workshops, seminars, and webinars on the clinical aspects of seating and mobility. In addition, Sheilagh has presented at national and international conferences on seating and mobility.

Sheilagh also has an educational background that makes her well suited to the role of Clinical Education Manager. Sheilagh earned a Bachelor of Arts degree in Political Science from the University of Toronto in 1988, which enables her to understand healthcare policy and policy changes. Sheilagh graduated with a Bachelor of Health Sciences (Occupational Therapy) degree from McMaster University in 1994. In 2012, Sheilagh earned a Certificate in Adult Education/Staff Training from Seneca College. She applies adult learning principles to the workshops she leads. Finally, she also has a Master of Health Management (MHM) degree from McMaster University after graduating in 2015. Courses that Sheilagh completed during the MHM degree, such as Knowledge Translation, Evaluating Sources of Evidence, and Quality & Safety in Healthcare, assist Sheilagh in using an evidence-based approach in her work.

In her free time, Sheilagh enjoys running, in addition to practicing yoga.


Date: 2017-01-24


DISCLAIMER: FOR PROFESSIONAL USE ONLY. THIS WEBSITE (AND THE DOCUMENTS REFERENCED HEREIN) DO NOT PROVIDE MEDICAL ADVICE. Sunrise Medical (CA) LLC (“Sunrise”) does not provide clinician services. The information contained on this website (and the documents referenced herein), including, but not limited to, the text, graphics, images, and descriptions, are for informational purposes only and should be utilized as a general resource for clinicians and suppliers to then use clinical reasoning skills to determine optimal seating and mobility solutions for individual patients. No material on this website (or any document referenced herein) is intended to be used as (or a substitute for) professional medical advice, diagnosis or treatment. Never disregard your professional medical training when providing medical advice or treatment because of something you have read on this website (or any document referenced herein). Clinicians should review this (and any other materials) carefully and confirm information contained herein with other sources. Reliance on this website (and the information contained herein) is solely at your own risk.


Categories

AdaptedStrollers AdaptiveDriveControls AdjustableSeating Anniversary assessment BackRest BackSupport Bariatric Batteries BestPractice BodyShape Camber CasterHousingPosition CentreOfGravity ChangeInFunction ClinicalEducator COG Comfort ControlModule Cushion CushionCover CushionDesign CushionMaterial Customization CustomSeating Design dissipation DriveWheel DynamicTilt EarlyInterventionDevices Edema Education ElectricScooters ElectricWheelchair Electronics Encoders Falls FallsPrevention FemoralLoading Growth Handcycling Hardware HeadRest HeadSupport Heat ISO7176-19 KnowledgeTranslation LateralPosition Maneuverability Manual ManualWheelchair ModularFrame ModularSeating Moisture Motors OccupantRestraint OccupationalTherapy OTA/PTA OutcomeMeasures Outcomes Parasport PelvicObliquity PelvicRotation positioning PosteriorPelvicTilt Postural PowerAssist PowerMobility PowerWheelchair Pressure PressureInjury PressureManagement PressureRedistribution PressureUlcer PreventionOfSliding Programming protection PushrimActivatedPowerAssistWheelchair RearWheel Recline RehabAssistant ReviewArticle Rigid rigidity RigidWheelchair RollingResistance scooter Scooters SeatElevation Seating SeatingAndMobility SeatingGoals SeatingProductParameters skin SkinProtection Sliding SpecialtyControls Sports StaffTraining StandardizedTerms StandardWheelchair SteerCorrection supports technology TherapistAssistant Tilt Tilt-in-Space TiltMechanism transit VibrationDampening WC18 WC19 WC20 Wear Weight WeightShift WeightShifting Wheelchair wheelchairbasketball WheelchairConfiguration WheelchairCushion WheelchairProvision WheelchairProvisionSteps WheelchairTennis WheelchairTiedowns

OUR FAMILY OF BRANDS