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Positioning a neurological patient with tonal problems in a chair

Pre‐procedural considerations

Equipment

When people with shoulder subluxation and weak trunk muscles sit, gravity can exacerbate the subluxation and challenge the weak trunk muscles. It is therefore important to support the trunk and shoulders to optimize the patient's position and reduce the risk of joint damage (Ada et al. [3]).

Seating

Appropriate seating is advocated as an adjunct to management for effective postural support (Crawford and Stinson [22], Preston and Edmans, [102]). Occupational therapists and physiotherapists will consider this for the management of patients with complex needs and provide appropriate seating if required.
Initially, patients may require chairs with plenty of support that can tilted backwards to reduce the challenges gravity presents. As they gain more control, they may be able to sit in a standard chair or wheelchair (see Table 7.7).
Table 7.7  Types of wheelchair
Type of chairPurpose and advantages
Attendant‐propelled wheelchair image
  • Used for patients with good sitting balance but who are unable to propel themselves, whether due to arm weakness, fatigue or cognitive impairment.
Self‐propelled wheelchair image
  • Used for patients with good sitting balance who can use their upper limbs to propel themselves.
  • Promotes independence.
Tilt‐in‐space wheelchair image
  • Used for patients who have limited postural control or sitting endurance.
  • These chairs usually have two modes of adjustment: the backrest can tilt back, or the whole chair can tilt backwards on its axis.
  • These are available in attendant‐ and self‐propelling options.
Powered wheelchair image
  • Options are available with varying levels of support depending on a patient's postural control.
  • Allows independent movement for those patients who are unable to self‐propel.
  • Patients must not have any cognitive impairment that would affect their safety when driving a powered chair.
Table 7.8  Prevention and resolution (Procedure guidelines 7.10 and 7.11)
ProblemCausePreventionAction
Abnormally high tone or spasms, leading to difficulty positioning the patient's arms or legs in bed or in a chair
  • Inadequate pain control
  • Inadequate anti‐spasticity medication
  • Poor postural alignment
  • Bladder and bowel dysfunction
  • Noxious stimuli such as ill‐fitting splint, ingrowing toenail or infection (UCLH [124])
  • Ensure pain control
  • Ensure bowel management
  • Ensure effective catheter drainage
  • Ensure adequate anti‐spasticity medication (UCLH [124])
  • Assess for painful stimuli, infection, constipation and catheter drainage, which may increase tone in patients with CNS disease
  • Use leg flexion position on electric bed controls and/or position a small folded pillow or rolled towel under the patient's knees
  • Avoid contact of the patient's feet against the end of the bed as this can stimulate increased tone in legs
  • Liaise with physiotherapist
  • Consider a medical review
Pain
  • High tone
  • Injury
  • Neuropathic pain
  • Ill‐fitting splint
  • Pressure area
  • Sustained or poorly aligned posture
  • Ensure adequate pain relief
  • Ensure correct management of tone (as above)
  • Ensure good alignment and regular position changes (ACPIN [2])
  • Check fit of splint
  • Liaise with physiotherapist
  • Consider a medical review
Unable to fit splint
  • Swelling
  • Increased tone (ACPIN [2])
  • Encourage ankle circle exercises
  • Manage tonal changes (as above)
  • Refer to therapists for consideration of compression garments
Splint marking the skin or causing pain
  • Splint not fitting properly
  • Splint not applied correctly
  • Splint left in place for too long (ACPIN [2])
  • Follow therapist's instructions regarding fitting, positioning and length of time the splint remains in situ (ACPIN [2])
  • Remove splint and discontinue use until reviewed
  • Liaise with treating therapist
Inattention or neglect: patient may be unaware of the affected side of their body or environment
  • Sensory/motor inattention
  • Neglect
  • Draw patient's awareness to their neglected side
  • Ensure affected limbs are supported by pillows, or folded or rolled towel, as required
  • Liaise with OT, who will recommend strategies to draw attention to the neglected side
Reduced conscious level: changes in the patient's consciousness affecting their ability to participate in positioning and/or sitting
  • Symptom of neurological condition
  • Side‐effect of certain medications
  • Changes in neurological status
  • Consider timing of sedating medications as far as possible
  • Increase arousal levels with activity
  • Liaise with medical team
Cognitive impairment impacting on the ability of the patient to sit in a chair safely
  • Symptom of neurological condition or pre‐existing cognitive disorder
  • Acute illness
  • Side‐effect of treatment or medication
  • Determine any reversible causes
  • Liaise with OT to discuss management strategies to allow safe seating
  • Consider one‐to‐one support
Communication difficulties
  • Language barrier
  • Dysphasia
  • Dysarthria
  • Use interpreter services or family to overcome language barrier
  • Liaise with a speech and language therapist to establish communication strategies for dysphasia and dysarthria
Fatigue
  • Symptom of neurological condition
  • Acute illness
  • Side‐effect of treatment or medication ( Abd‐Elfattah et al. [1])
  • Limit time sitting in bed or chair
  • Allow rest periods
  • Ensure adequate nutrition and hydration
  • Liaise with OT for fatigue‐management strategies
CNS, central nervous system; OT, occupational therapist.

Post‐procedural considerations

For patients requiring the use of an external splint to maintain joint position and range, skin condition must be closely monitored at regular intervals for marking to avoid pressure areas. If there are any concerns about the fit, the use of the splint should be discontinued and the issue should be reported to the providing therapist as soon as possible.
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