What to do about posterior pelvic tilt…?

Happy Wednesday Everyone!

Wishing everyone a Happy Occupational Therapy Month this October! This week Access Community Therapists is hosting a workshop on Friday and Saturday on Wheelchair seating and positioning in the community. Pictures to come! Lindsay Alford, OT and I will be presenting this year. So excited to be a part of this workshop once again. Today, I thought I would share with you some strategies for managing a flexible posterior pelvic tilt. Over the past few months I have actually had 4 clients with similar issues. They are as follows:

  1. A flexible posterior pelvic tilt.
  2. Limited/restricted hip flexion (meaning they were not able to achieve at least 90 degrees of hip flexion before causing the pelvis to move into posterior tilt).
  3. AND a fixed or only mildly improveable thoracic kyphosis.

Although these 3 issues don’t seem overly challenging on their own, together, they make seating and positioning incredibly difficult. For example, if you just accommodate for the kyphosis and limited hip flexion by opening the seat to back angle of the seat or allowing for thoracic relief through a modifyable backrest,  the client may fall into more posterior tilt and start sliding out of their wheelchair. Oh no!

Since I’ve had so many clients with the same 3 issues, I thought I would write about a few of the strategies I’ve used so that you can try them with your clients. Keep in mind, you must do a thorough mat assessment before implementing these strategies so that you know exactly what issue you are trying to address!

1. To address posterior pelvic tilt: Use a pre-ischial shelf or IT block to stop the ITs from moving forwards on the seat:

Above are two examples of pre-ishial shelfs on cushions. the image on the left is a custom built seat made with carved foam. The second is a commercial cushion (which is more on the mild contour end-but there are more aggressively contoured cushions available). Keep in mind that the more angular and high the build up is, the more control you will have.

2.  To address the kyphosis with limited hip flexion: Open the seat to back angle or have or cut down the front of the cushion to allow for a more open hip angle. I don’t have an image for this, this is a very specific and calculated strategy. Based on the client’s hip range, you open the seat to back angle to accommodate for a comfortable/functional hip range. You must do a mat assessment and sitting assessment to find out what this angle is! If a client has less hip range on one side compared to the other, make an assymmetrical front end where you allow one leg to rest lower than the other. This is extremely effective as it prevents you from positioning the client with too much open hip angle, which could result in the loss of control for the pelvis and hence….dum dum daaaa…..sliding!! *gasp!*

3. To control the pelvis and accommodate for a kyphosis: Use a backrest to (1) block the pelvis at the back and (2) provide enough thoracic relief for the kyphosis. 

The backrest above is the comfort company Acta-Relief backrest. I just prescribed this backrest for a client who needed a lumbar-sacral push and upper thoracic relief for his kyphosis. The adjustable straps are well placed and provide a good degree of support where you need it and can be loosened off to allow for more accommodation for the kyphotic part of a client’s back. You can also get laterals for this back to provide some good midline control or guidance. Other products like the Future Mobility Prism Truefitt backrest and the Dynamic Health Care’s Armadillo backrest could also be other options for milder cases. Armadillo backrest has been reported by my colleagues to be a bit narrow, but I haven’t tried this myself. Bi-angular backrests (which have a hinge in the back) can also work here.

The photos above here are of a custom backrest fabricated by Jeff Ducklow at Ability Health Care. This is a hybrid technique using carved foam backrest and foam in place. This client had very stiff pelvic mobility. In lying, her pelvis rested in anterior tilt, but as soon as her hips were flexed, she would fall into posterior tilt. In addition to this, she also presented with a lot of extensor tone. The flexibility in her spine (anterior/posteriorly) was also at a very specific point in her back. Therefore, we built up that part of her backrest to provide a push at her upper lumbar spine to try to prevent her pelvis from falling further into posterior tilt as well as to prevent her from collapsing forwards at her trunk. Once we achieved a good position with the carved foam, we then used foam in place (poured foam) to fill in the rest of the space to ensure good accommodation of her upper back kyphosis. Neat eh?

4. To prevent the pelvis from falling into posterior tilt: Use a supportive anterior pelvic support or belt:

The above two belts are custom belts however, even a four point lap belt can work here as well (although a 4-point belt won’t really help to control for rotation of the pelvis is that is an issue FYI). The placement of the belt is so important here. In these cases, the belt should be positioned under the ASIS to hold the pelvis back and down onto the seat. If it is positioned properly it will keep the pelvis back into the system and down onto the ischial well. When a good anterior support is used with a backrest and a pre-ischial shelf, they all work to prevent the pelvis from falling into posterior pelvic tilt. Ta da!

Keep in mind that if you are dealing with all three of these seating issues in one system, you will probably need to implement most, if not all of these strategies. I hope you liked these tips! Until next time:

Seating is Super!

Cheryl

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