Michelle L. Lange, OTR/L, ATP/SMS
In our last two blogs, we met Alex, a young woman who has very forceful and large movements as well as increased muscle tone. Alex uses a Seating Dynamics Dynamic Rocker Back interface (DRBi) and required new elastomers secondary to wear and tear as a result of her large, repetitive, and forceful movements.
Alex’s team had also recommended Dynamic Footrests in the past. Unfortunately, these were never placed on the manual wheelchair and parts are now missing. She requires Dynamic Footrests as she has large, repetitive, and forceful movements in her lower extremities. Alex will often sit with her legs crossed over each other or only one leg crossed over the other. She appears to assume these postures to find stability, as well as variety of position.
Legs crossed over one another
One leg crossed over the other
These postures are acceptable for short time periods, though have drawbacks. First, these positions can lead to loss of range. When both legs are crossed, her hips are in significant external rotation and the knees are quite flexed. Pressure is also occurring between the lower legs. When one leg is crossed over the other, the top leg is in external rotation and there is pressure between the back of one knee and the top of the other. Due to these issues, these postures are referred to as ‘destructive postures.’ In wheelchair seating, pressure is distributed between the buttocks, posterior thigh, and the bottom of the feet. As her feet are rarely in contact with the footrests, pressure distribution is compromised.
When Alex is not in one of these destructive postures, she is often moving her legs in large and forceful patterns. She does sometimes collide with parts of the wheelchair frame which can lead to bruising.
An alternative means of providing stability would be to secure her feet to the current footplates. Alex wears AFOs and shoes when in her wheelchair. She does have strapping over her feet that keeps her feet on the footplates, however there is quite a bit of movement between her feet and the footplate. More concerning is that her frequent and forceful movements have led to the connection of the footrest hanger to the footplates becoming quite loose due to significant frame wear and tear. Between the movement of her feet on the footplates and the movement of the footplates in relation to the footrest hanger, Alex is not getting the stability that she requires. She obviously requires movement of her lower extremities that a Dynamic Footrest would provide.
With her feet strapped in static footrest hangers, Alex demonstrates movement of her lower extremities and obvious wear and tear, particularly between the footplate and the footrest hanger.
With her left foot unstrapped, Alex demonstrates lower extremity large and forceful movements.
With both feet unstrapped, Alex quickly extends both knees with sustained force.
We recommended Seating Dynamics Dynamic Footrests with a more secure means of maintaining Alex’s feet on the footplates with less movement (Sunrise Medical Flexi-feet). Movement of the feet on the footplates means that less of that force leads to movement of the Dynamic Footrest which is what provides movement and variety of knee position. Keeping the feet well positioned will also increase stability - something that Alex seeks out.
Alex needs to move. And she is already doing so when her feet are not strapped to the footplates. However, this movement is leading to a lack of stability, decreased pressure distribution, destructive postures, and even injury. Dynamic Footrests will provide movement in a controlled pattern of movement while securing her feet for stability and absorbing force. We hope to follow-up with Alex soon once she receives her new equipment!