1

ERGONOMIC SEATING
A TRUE CHALLENGE

Seating and Mobility for the Physically Challenged

Risks & Possibilities
When Using Wheelchairs

BENGT ENGSTRÖM

Some pages from the book

2 / ERGONOMIC SEATING - A True Challenge

"We are all individuals, searching for individual solutions.

When used long-term a wheelchair should, be looked upon as
a body orthosis on wheels."

I dedicate this book to each and every man and woman, boy and girl
who goes through life sitting in a wheelchair

ERGONOMIC SEATING
A True Challenge - When Using Wheelchairs

ISBN 91-972379-3-0

Book Design and Illustrations: B. Engström

Cover Design and Cover Photo: B. Engström and A. Engström

The title of the first edition was

Ergonomics, Seating and Positioning
Published in Sweden, 1993.

© Copyright 2002 Posturalis Books

All Rights Reserved.

This book is protected by copyright. No part of the book may be reproduced in
any form or by any means, including photocopying, or utilized in any information
storage and retrieval system without written permission from the copyright owners.

Printed by Medio Druck & Logistik GmbH, Germany

The production of this book is generously sponsored by

 3

Contents
Foreword ........................................................................................... 5

1 Humans are physically intelligent ............................................. ... 9

How should one sit? .................................................................. 10
Influenced by the senses ............................................................. 12
Factors that cause fatigue .......................................................... 13
The sensitive human body ........................................................ 14
The skeleton - fundamental principles ...................................... 15
Normal sitting behavior ............................................................ 23

2 Fundamental seating principles .................................................. 37

Tendency and reaction .............................................................. 38
Firm or soft seating units .......................................................... 38
Backrest recline ......................................................................... 40
Tilt-in-space .............................................................................. 41
The trunk, forwards ................................................................... 43
From seat, to pelvis, to trunk ..................................................... 44
Seat contours ............................................................................. 47
Pressure and shear ..................................................................... 49
Seat angle and contour .............................................................. 52
Experience seating .................................................................... 54
Posture and reactions ................................................................ 55
Head- on- trunk sensitivity ........................................................ 57
Correcting the trunk .................................................................. 58
Interpret and understand ........................................................... 68

3 Physical intelligence and physical disability ............................. 71

Fatigue and defence .................................................................. 72
Stressed by pressure ................................................................. 73
Equilibrium and stability ........................................................... 74
Contractures .............................................................................. 76
Posture and inner organs ........................................................... 79
Posture and stimulation ............................................................. 82
Pathological patterns ................................................................. 83
Responsibility and financial aspects ......................................... 88

4 Wheelchair Design & Adjustments ............................................ 91

Design and adjustments ............................................................ 92
Seat cushions ............................................................................. 94
Adjusting seat slope .................................................................. 98
The chair’s back - a body orthosis ........................................... 100
Stability for activity .................................................................. 110
Adjusting step-by-step .............................................................. 111
Positioning the feet ................................................................... 116
Armrests and tray-table ............................................................ 118
4 / ERGONOMIC SEATING - A True Challenge

5 Wheelchair Mechanics .................................................................. 121

Improving mobility .................................................................... 122
Rolling resistance ....................................................................... 123
Balancing the centre of gravity .................................................. 126
Rotatory vestibular stimulation .................................................. 130
Wheelbase .................................................................................. 131
Wheels - camber & caster angle ................................................ 133

6 Wheelchair Mobility ...................................................................... 139

Arm propulsion principles ......................................................... 140
The pushrim - grip ..................................................................... 146
Risking hand injuries ................................................................. 148
Foot propulsion .......................................................................... 150
Foot propulsion principles ......................................................... 151
Compensation and adjustment ................................................... 156

7 Wheeling Skills ............................................................................... 163

Basic propulsion ........................................................................ 164
Prevent and correct falls ............................................................ 166
Balancing on drive-wheels ........................................................ 167
Climbing curbs and other obstacles ........................................... 168
Slopes and hills .......................................................................... 170

8 Seating & Mobility Needs ............................................................ 173

General aspects .......................................................................... 174
Paraplegia .................................................................................. 180
Quadriplegia / Tetraplegia ......................................................... 184
Hemiplegia ................................................................................. 188
Traumatic head injuries ............................................................. 192
Cerebral palsy ............................................................................ 196
Arm patterns .............................................................................. 198
Leg patterns ............................................................................... 200
Hip contractures ......................................................................... 202
Knee contractures ...................................................................... 203
Amputated legs .......................................................................... 204
Elderly - women and men ......................................................... 206
Thoracic kyphosis ...................................................................... 208

9 General Comments

Wheelchair Features / Guidelines .............................................. 213-231

Adjustments and Influence / Guidelines .................................. 233-239

Standard wheelchair adaptation ................................................. 240

Literature / Internet Links ............................................................. 242

Index .................................................................................................... 243


Humans Ar
Aree Physically Intelligent
Regardless of what one sits on, an armchair, a
stool, an office chair, a car seat or a wheelchair
the body is always mechanically affected. How
seating is designed always has an impact.
This chapter deals with how the seating unit
may affect the body, in general, and more in
detail. General influence means how the body
reacts when general features like seat and back
angles, and/or softness change. Broken down into
more detail the way the body reacts may be
influenced by an area of a seat, the position of a
footplate or the contour of a backrest etc..
When you understand how a body may be
influenced into reacting by a specific backrest
contour, seat angle or seat contour it is easier to
decide if a seating unit will suit a person’s needs.
To achieve successful and reasonable results,
practical solutions and choices should be based
on how the seating unit affects the body, in the
short, as well as the long term. Long term in this
book means many hours daily, for many years.
When wheelchairs are set up, the goal varies
from one user to another, since every user is
unique, physically and psychologically. The
environments users live in can be very different,
as can the requirements as to how a wheelchair
should function. Each combination of user and
wheelchair is new and, thus, always a challenge.
9
The result is always better when the person
who is responsible for choosing and setting up
wheelchairs is open-minded and very receptive
to what the user wants and needs.
Adapying wheelchairs is sometimes a compli-
cated puzzle. A user who has had a poor position
for several years is not easily convinced that a
“proper” and more upright position is better. The
time the user needs to complete a transition is
often much longer than you expect.
This chapter is about important principles for
use when setting up seating units, and to a lesser
extent for propulsion.
A person’s position is mainly dictated by how
the seat and backrest are designed, or adjusted,
to suit the user. This also includes the armrests
and footplates.
The “pitfall” can be when other people dictate
too much how the user should sit, based on what
they know about seating. It is always worth while
to remember that very few of us can be seated in
an active way for more than a very short while.
If a user doesn´t accept a position, take it
seriously and make the necessary changes.
Experiment, don’t be afraid of making
“mistakes,” they help us to learn. Just make
sure corrections are made in time
10
How should one sit?
How should one sit to be ergonomically seated?
It is not easy to answer such a question.
A list of what many people see as important
factors towards “how one should sit” can be
similar to the list below.
This points out some of the main factors that
are important for a decent sitting situation –
allowing a natural balance between functional
stability and healthy activity.
Feeling safe is a crucial factor to enable anyone
to relax when seated. During long-term sitting,
safety is more important than we realize. When
a person has difficulties in changing positions, a
sense of safety and security is of paramount
importance.
Feeling safe includes: comfortable pressure,
reasonable stability with a possibility to move,
and, last but not least, being able to decide when,
and how, to move.

A stable supporting surface is necessary to
“anchor” the parts of the body that are active,
and/or in motion.
When seated, the stability required is for the
pelvis, thighs and feet. With good, but not
exaggerated, stability provided for the correct
appropriate parts of the body, people can be very
active physically when seated. Seat stability is
often interpreted as meaning that the seat should
be firm. This interpretation is discussed below.
Besides providing the stability required, a seat
that gives such stability must not cause
uncomfortable pressure. Pressure is what creates
stability but is more efficient if distributed over
a larger surface. If pressure is concentrated on a
small surface of the body it decreases stability.
Discomfort, due to pressure, results in muscular
fatigue when the user tries to stabilize the
instability of the trunk.
Pressure distribution over a big, soft area gives
more comfort, but, if the area is too soft, stability
decreases.
One crucial detail in sitting is the capability of
being active forwards. It is obvious that forward
activities are hindered if it is difficult to lean
one’s trunk forwards.
When an office chair is adjusted with the seat
sloping slightly forwards, forward activities are
easier to perform.
In such a situation one can easily lean forwards,
but if the trunk’s tendency of falling forwards is
too strong (due to the forward slope) the back
muscles become fatigued.
It should be as easy to lean back and relax as it
should be to lean forwards.
11
When both possibilities exist, position can be
comfortably changed and dynamics are improved.
Poor dynamics increases the static portion of
seating, which causes stress and problems.
How much support the back needs when seated
depends on what type of activity one wants to do.
Where should support be given?
Again this depends on the desired activity,
static rest or dynamic movement.
One thing is clear though, the way the back is
supported dictates the stability of the upper body.
Sometimes too much support, especially when
wrongly placed, makes seating more tiresome
than less support.
Another thing we very often overlook is the
necessity to move our legs when seated. Moving
the legs is one of the important ways of making
seating dynamic. We use our legs and feet as
instruments to influence the upper body when
seated. A more specific analysis of this is given
shortly.
As I mentioned earlier, it is important to feel
safely and securely seated.
A feeling of being safe can increase comfort,
and thereby, the time that can be spent seated.
You become calmer, physically and mentally.
This makes the seating situation more comfortable
- and functional.
12
Influenced by the senses
Our body is very sensitive to positions. There
are many kinds of sense organs registering
changes in the body. All of them are, of course,
important, but in this book the focus is on the
ones that register the position of the body.
We cannot “shut off” our sense organs, they go
on registering continuously.
If no external support is used, the body of a
person who is standing is continuously in motion,
a balancing motion, known as postural sway. We
cannot “see” these movements of the body, but
they are present all the time.
Feet are designed for standing, walking and
running. The sole, the foot joints and foot muscles
as well as the leg joints and muscles register
pressure and pressure-directions when the foot is
in contact with a surface of support.
The pressure on the sole influences the joints
differently, depending on the magnitude and
direction of the pressure.
To maintain balance pressure variations lead
directly to muscular reactions throughout the
body.
When the muscles balance, and stabilize the
body, or its parts, in this way, we are seldom
conscious that it is happening. The muscles are
automatically activated by the senses on a
subconscious level. The reactions and corrections
are very precise and continuous.
Being seated on a chair makes the feet and legs
change in relation to the trunk, radically and
instantaneously.
When standing, the centre of mass of the entire
body is located over the feet, which are the
supporting area. When seated, the centre of mass
of the trunk is only over the pelvis, with the
ischial bones as the supporting area.
This means that the smooth, balancing and
correcting motion, which takes place when we
stand on our feet is not present when we are
seated.
I am not saying that interaction between the
legs and the upper body disappears. But, when
the feet are not loaded under the pelvis their
function of being sensitive “organs” for
maintaining the balance of the body is eliminated.
Instead of relying on the feet for balance, we sit
on two tiny ischial bones. These two bones are
the support surface for the pelvis and, since the
trunk is on top of the pelvis, the entire upper body
balances on the ischial bones.
Balanced seating requires a well-positioned
pelvis. When the pelvis does not have a functional
and stable position the upper body cannot be kept
in an upright position for more than a few, short
moments.
The leg’s connection with the pelvis is through
ligaments, joint capsules and muscles. Because
of this connection, the position of the feet and
legs, as well as their muscle activity, influence
the position of the pelvis directly or indirectly.
In most seated positions the tendency of the
pelvis is to tilt backwards. This tendency can be
blocked or forced by the legs, something we do
continuously. It is a natural part of sitting.
Sit straight! Sit properly! Sit still!
Most of us have said these to our children,
especially when they sit and eat.
- But what is “proper” seating?
If we tell a four-year-old to sit properly he will
probably become confused.
If we do not know what it means to be seated
properly, how can we expect a child to know?
To be seated “properly” is possibly a posture
that feels good - for the moment.
Whenever our posture-sensing organs register
something negative in a position we re-position
the body, over and over again.

Factors that cause fatigue
I am sure you have experienced how awfully
tiresome it can be to sit, especially when you
don’t want to sit.
Imagine sitting and listening to a lecture which
is not at all stimulating. It has been going on for
nearly two hours. You are sitting in the middle
part of the lecture room, which is crowded with
people, so you can’t “sneak out”...and it’s thirty
minutes to the next break!
Sitting makes the body’s physical stability
increase. If you also lean against a backrest you
become highly stabilized. This is like putting the
body in a state of physical “rest”.
You can easily fall asleep when stability
increases and few things happen to keep you
awake – things like a lively, positive lecturer!
Have you ever thought of the fact that an active
and inspiring lecturer makes us decrease our
physical stability. We forget the backrest and sit
more upright, maybe we even lean forwards
towards the speaker - the person who is so
interesting. Physical activity is strongly linked to
mental activity and vice versa.
Imagine you are sitting in a car and you are the
driver. You and your friend have been travelling
for many hours and the last hour you have both
been silent whilst you are driving on a highway.
The engine is humming and the wind whispering.
The weather is grey and it´s raining lightly.
Your eyelids begin to feel heavy. When you
feel you can hardly keep your eyes open, you pull
over, park the car and take a short walk - to “wake
up the brain”.
Physical inactivity and mental under-
stimulation, or monotony, when seated leads to
fatigue and decreasing alertness. The brain “shuts
the systems down “.
Another situation can be when you are sitting
on a chair designed for more active seating, such
as a chair in a restaurant.
It can be frustrating to be “forced” to stay at the
13
table after a heavy meal. If the company you are
in bores you, and you don’t have anything in
common with them, I’m sure you would rather be
somewhere else.
After a while it becomes torturous to sit upright
on “that hard chair”.
You begin to plan... What would be the best
way to get some rest... slide under the table or
just gently fold forwards and rest on the remains
of the dessert...
Other problems occur for those who travel on
long flights in economy class. It may be a ten-
hour flight, which is a very long time to be seated.
You may have the middle seat, making it much
more difficult to change position.
If you are even more unfortunate, you may
have been allocated a middle seat between two
passengers with no interest in talking to you.
This psychologically under-stimulating and
physically locked-in position may come close to
what some people using wheelchairs experience
every single day.
Below are some of the factors that may cause
fatigue when seated;
too much physical stability
too much physical freedom
uncomfortable pressure
monotony / boring environment
wrong chair for the activity
sitting for too long!
22

How do we actually sit? Participants experiment vigorously but come

I always ask seminar participants this question.
They are asked to spend a few minutes to find
five different ways to sit, using the chair they are
sitting on for the moment. The most common
results are presented here and form the basis for
analysis and discussion.
up with more or less the same positions every
time. The different seating positions are given
below.
These different positions can be divided into a
few categories - the whole body, the legs, the
arms and the chair.

WHOLE
BODY

THE LEGS

THE ARMS

THE CHAIR
 23

Normal sitting behavior

MECHANICAL TENDENCY
On the left you find definitions of two Mechanical tendency is when
expressions that are often used in the text, they the whole body, or a part of it, begins
are - balance and tendency. to move when muscles relax.
These definitions make it easier for you to
analyse the following exercises that you can do MECHANICAL BALANCE
to experience seating more in depth. is achieved when the centre of mass of
the body (or body-part) has a tendency
The “90-90-90” position to move away from its present position
but you do not sense it.
To sit in a 90-90-90 position means to sit
upright with ninety degree angles of the hips,
knees and ankles. This is accepted as a correct
ergonomic position in the workplaces seen in
offices and schools.
But, a 90-90-90 position is more a theoretically
good position than a practical and functioning
position. In fact, most seated people use such a
position only for very short moments. This tells
us that there is a gap between ergonomic
recommendations and what is used in practice in
real-life situations.
What is the tendency of the pelvis and trunk in
a 90-90-90 position?
Sitting without support for the back you notice Experience it!
this tendency clearly. By relaxing the muscles Sit upright, 90-90-90.
that keep the trunk erect, the tendency is for the Relax - sit upright again - relax - sit up
upper body to collapes. It begins with flexion of again - relax...
the thoracic spine, which makes the pelvis tilt By doing this you can feel that your trunk
backwards and the spine begins to collapse. has a tendency to flex when extending
When this tendency is present and you want to muscles relax.
stabilize the trunk, or adjust it to a more upright
position, many muscles need to be activated.
Do this exercise slowly:
Sit upright (90-90-90). Relax so your trunk
collapses. Adjust to upright again. You will very
soon notice how easily you collapse when you
relax your muscles, and that you really need to
work to get back to, or maintain, an upright
sitting position.

Fundamental Seating Principles
A principle is like a rule that stays the same.
The seating principles in this book are also like
basic rules that do not change.
A very simple example:
A man sits on a chair. On the chair's seat is a
paper, shaped like a little ball. The paper is under
one of the man's buttocks.
At first he does not pay attention to the fact
that he is sitting on the paper, but after a while
he begins to feel it, it becomes uncomfortable.
- What do you think the man will do?
Take the paper away of course! But what if it
is not possible to take it away? It does not have
to be a paper, it can be something in the design
of chair seat.
Now we can look at a principle, the principle
of pressure. Should pressure against tissue (here
a buttock) become uncomfortable, the pressure
needs to be changed to decrease discomfort or
to improve comfort.
The principle of pressure is very powerful!
I do not think anybody with normal tissue
sensitivity ignores uncomfortable pressure. The
reaction to go away from pressure that stresses
is deeply integrated in biological life, it is a sub-
conscious reaction. This principle is directly
related to the principle of pain.
We do not want pain, of course not. If the man
in the example above does not move away from
the uncomfortable paper-pressure, his buttock
will, sooner or later, develop pain. Pressure leads
to pain when there is too much pressure-time and
the pressure is long-term. This fact is simple to
understand. Most people do understand the
37
necessity in changing their sitting position
frequently to vary the pressure on the body.
The Principles of Pressure and Pain are
important since they guide us when we adapt
seating systems for long-term sitting.
The second set of principles is the principle of
stability and the principle of balance, closely
related to the pressure-principle.
Pressure is necessary for stability. No pressure
means no contact, which means no stability.
Functional stability on a seat means that it is
possible to reach/lean sideways without falling.
The seat surface is supportive, stabilizing the
buttocks, hips and thighs. Should the seat surface
not be supportive, sideways stability is lost.
Adapting wheelchairs is always a compromise
between comfort and function. Comfort means
pressure-friendliness and safety, but also positive
activity (an activity comfortable to perform).
Function is what activities you can perform,
based on your body's present position.
Well understood and used, the principles of
pressure, stability and balance lead to situations
that are comfortable and functional.
The most important principle of all is the
principle of time. Time is what often changes
comfort and function to become the opposite.
The principles mentioned are logical and can,
to some extent, tolerate modification. There are
also principles of softness, angles, contours...
What we cannot modify so easily, is the person
we are adapting for, the user. Humans have, in
principle, limitations on how much change that
can be tolerated, and it is always time-related.
 39

Tendency Tendency
FIRM / 90-degree angle SOFT / 90 degree angle

FIRM SURFACES SOFT SURFACES

The Pelvis -> Stable The Pelvis -> Backward Tilt

The Trunk Falls Forwards The Trunk Collapses Forwards

Stabilizing the trunk Stabilizing the spine

Ex.: An arm put behind backrest Ex.: Arms crossed on chest

Ex.: Crossed thighs Ex.: Crossed lower legs

Muscular Fatigue Muscular Fatigue

Falling Forwards Sliding Forwards Collapsing

TRUNK FALLS FORWARDS TRUNK COLLAPSES

Compensation: Slouching Compensation: Slouching
44
From seat to pelvis, to trunk
A seat’s quality and features directly affect the
pelvis. The features are angle, softness and
contours.
When you sit on a horizontal, planar seat with
your feet on the floor just in front of the seat, the
pelvis has a tendency to tilt backwards. It is easy
to feel the muscles extending the spine when one
relaxes.
By changing the seat’s angle, backwards or
forwards, this tendency increases or decreases.
Simultaneously, the trunk - the spine - is
influenced to flex or extend.
This co-operation between the seat, pelvis and
spine is easy to observe and feel.
FORWARD SLOPING
Place someone on an ordinary chair, such as a
kitchen chair. The person sits upright
approximately five centimetres from the backrest,
with her feet on the floor under her knees. Tell the
person to maintain an upright and well-balanced
sitting position.
Now tilt the chair forwards a little.
When this is done, the seat slopes forwards, so
the pelvis is moved up and forwards. The person’s
reaction is to extend the trunk to prevent herself
from falling forwards.
Rock the chair slowly. The seat surface changes
between horizontal and sloping forwards. It is
easy to see the trunk’s movement, extension
when rocking forwards and flexion when rocking
back again.
As long as the person’s feet are on the floor the
trunk extension is well controlled.
Try this when the person’s feet are placed
under the seat and her soles face upwards.
The legs´ stabilizing effect on the pelvic girdle
is lost. Pelvic stability (blocking it from rotating
forwards) is greatly needed to prevent the trunk
from falling forwards when the seat is rocked
forwards.
It is mainly the buttock muscles, the glutei that
prevent the pelvis from tilting forwards. They
keep the pelvis in position when the feet press
against the floor.
By having both feet under the seat, the
possibility to press is gone and the response is
different.
The extension of the spine is larger and moves
higher. The reason is that the pelvis, “anchors”
the trunk-extending muscles. The position isn’t
stable, which leads to compensation. To prevent
a fall forwards one moves weight to a higher
level in the trunk.
The forward-tilted seat increases the trunk’s
tendency to fall forwards and stimulates trunk
extension, so it is very important where the feet
are positioned.
To give you a direct and unquestionable
experience of how correct this statement is, try
the following:
Sit upright on the front part of a chair’s seat.
Lean your trunk forwards without letting your
arms have support against your legs. Stay in this
position for a few seconds.
Now, slowly lift up both feet. Can you do it
without falling forwards? No!
To avoid fatigue when sitting on a forward-
sloping seat (planar surface) requires normal
muscle functions and endurance in the trunk and
legs. Even with functional, fully functioning
muscles it can be very tiresome to sit on a seat
that is sloped forward.
When it becomes tiring, a normal compensation
is to slide forwards for stability.
I do not mean that sitting on a forward- sloping
seat is unhealthy. What I mean is that it can be, if
the contours are incorrect.
It is always better if forward sloping is combined
with anatomical contouring since this improves
stability. The key is pelvic stability. If the seat
stabilizes the pelvis, it decreases its tendency to
rotate forwards. This allows the pelvis to be the
trunk’s “anchor” and extension will be more
normal.
 45

The reason I analyse forward-sloping seats in

this book is their fantastic influence on users.
Using this type of seat I have often had the
opportunity to stimulate natural trunk extension
(even for severely impaired persons) in a much
better way.
Many more persons than we believe benefit
from sitting on a seat that is slightly sloped
forwards, and which is well contoured.

BACKWARD SLOPING
Let the person stay on the same kitchen chair.
Tell her to try to maintain her trunk in an upright
position when you tilt the chair backwards.

Tilt the chair back in space, slowly. A forward-sloped seat tilts

the pelvis forwards , making
This time the seat tilts the pelvis backwards.
the spine extend.
For the trunk to stay upright, the pelvis needs to
keep its position, which requires many muscles
to work.
As soon as the person relaxes her trunk-
extending muscles, her thoracic spine flexes.
This forces the pelvis to tilt backwards.
A backward-sloped seat stabilizes the pelvis in
a backward-rotated position, which makes natural
trunk extension more difficult.
Backward sloping stimulates trunk flexion,
while forward sloping stimulates extension.
The leg response (opposite to forward sloping)
is that when leaning forwards the legs extend
easily, making the feet come off the floor (or
footplates).
This isn’t at all strange. When a person wants
to tilt the pelvis forwards, from a backward
position, the hip flexors and knee extensors are
activated to assist the pelvis as it is tilted forwards,
and the legs lift.
A backward-sloped seat also makes the trunk A backward-sloped seat tilts
more stable backwards. the pelvis backwards, which
For the pelvis to have a functional, more upright makes the spine collapse.
position on this seat, the backrest needs to support
the pelvis efficiently.
 47

SEAT CONTOURS
Contours should be looked upon as many
“angles” which, together, form a shape.
What is true for angles is true for contours, the
final result is important since it decides the
position of the legs and pelvis. A seat is more
functional and comfortable when it is
anatomically contoured.

I will briefly describe what may happen on a

seat surface that is planar.
A horizontal seat surface often makes the thighs
lower near the knees, due to a compression of soft
tissue. A mechanical pivotal point is created at
the front edge of the seat (top figure on this page). Horizontal, planar seat surfaces often
The part of the leg in front of the seat move increase pressure against the front of
downwards and the upper part of the leg move the thighs and on the ischials.
upwards. This lifts up the pelvis, which is then When there is a backrest this
tilted back by the weight of the trunk, often stimulates sliding on the seat
making the pelvis slide forwards.
This result is decreased, or eliminated, by a
backward sloping seat surface.
A horizontal, anatomically contoured seat is
thicker under the thighs, preventing them from
being lowered. This makes them have a more
horizontal position, which improves the stability
of the pelvis.
To distribute the body’s pressure against the
seat surface evenly, the contact should be as
congruent as possible. For many people, a planar
seat surface is uncomfortable to sit on long-term
due to high, local pressure on the ischial bones
and other bony parts.
On the other hand - for most people (but not all)
- an anatomically contoured surface is much
more comfortable for the long-term.
A planar, firm seat is said to improve upright Soft, planar seat surfaces easily make
sitting. This is perfectly correct. the pelvis tilt sideways, which
The reason a firm, planar and horizontal seat develops scoliosis in the long term.
stimulates trunk extension better than an Stable surfaces can prevent this, if the
equivalent but soft surface is the position of the pressure does not cause discomfort.
pelvis in space.
48
An anatomically contoured seat is adapted
to the skeleton. The shape distributes pressure
efficiently against thighs and pelvis.
The “Ischial Support” stabilizes the pelvis,
which is beneficial for the entire spine.
Contouring distributes pressure and improves
stability. The supporting surface under the
ischial bones should be horizontal (line) to
avoid pelvic obliqueness..
Supporting surfaces against the thighs from
each side also stabilizes the pelvis.
A soft seat allows the ischial bones and sacrum
to “sink in” more than a firm seat, which makes
the pelvis tilt more.
It must be added that the degree of pelvic tilt
depends on the interaction between the seat and
the backrest.
A firm seat surface makes it easier to achieve
upright sitting. Why is this so? How long does it
last? Is there a time limit?
“Sling” seats are not very healthy to sit on in the
long-term. They often make you sit
asymmetrically. A planar and firm seat is better
but, after a while, may be too hard.
A soft seat is comfortable in the beginning, but
poor stability makes the trunk collapse, which
causes fatigue in the long term. What is a “correct”
and proper seat?
The pelvis and legs need stability and an even
distribution of pressure on the seat.
An anatomically contoured seat is efficient. It
provides pressure distribution as well as stability.
Should it be necessary to decrease pressure, the
contour can be changed, or the seat made softer,
or both.
When experimenting with seat softness and
contours, the pressure experienced by soft tissue
and the stability experienced by the skeleton and
muscles are altered.
Setting up a seat is a balance between pressure
distribution and fair stability.
Even if a planar seat can be uncomfortable
(long term) some persons need such a seat.
People having a pronounced/severe lordosis
and a forward-tilted pelvis often shift weight to
the thighs if the part under the pelvis is too low.
For them, an anatomically contoured, horizontal
seat, or a planar, backward-sloped seat can cause
stress. If, on the other hand, the seat is contoured
and slightly forward-sloped it often functions
better. Such a seat can be very appropriate for
people with Polio, Rheumatism or Spina Bifida.
 49

PRESSURE and SHEAR

Pressure per unit area is lowered when
distributed over a larger contact surface. Thus,
the goal is to create a large contact surface
between the body and the seat.
For low pressure on the seat, body contours
dictate seat contours.
The pressure we normally talk about is
perpendicular to the seat surface. This pressure
compresses soft tissue.
Besides the perpendicular pressure there are
forces that deform tissue from the side. These are
known as shear forces and are difficult to measure.
Shear forces “push” parallel, soft tissue layers
away from one another, which tears and stretches
different connections and blood vessels,
penetrating many layers.
It is uncomfortable to stand if the pressure When standing, shear on the feet from
against the soles is static. We want pressure to the floor develops when the person leans
change, in other words, we want pressure to be against the wall.
dynamic.
When you lean gently against a wall it is more
difficult to change the pressure on the feet,
pressure is more static.
The pressure on the wall increases when your
feet move away from the wall, and the shear
forces on your soles increase.
The same thing happens on your pelvis when
you sit. When your trunk leans against a backrest
(the “wall”), pressure from the backrest pushes
your body forwards. Due to seat friction, the soft
tissue stays in place whilst the skeleton, in this
case the pelvis, moves - slides - forwards within
the soft tissue.. This pelvic sliding of the ischial
bones deforms the soft tissue between the seat
and the ischial bones.

Seat cushions may protect soft tissue from

perpendicular pressure. A decrease of seat shear
is achieved by contouring the backrest. Trunk
balance and extension decrease pressure against
the low and middle part of the backrest. This
decreases seat shear.
Seat shear develops when the pressure
on the backrest increases.
The shear distorts the soft tissue layers
when the person slides forwards.
68
Interpret and understand
There are several goals in sitting. So we sit very
differently. An important condition when
analysing and interpreting other people’s sitting
behaviour starts with discovering these goals.
Of course, most of us can “see” that people sit
differently but the ability to see what a position
reveals, physically and psychologically, is
something you learn.
It cannot be emphasized too often that the most
effective way to learn how seating “works” is to
use your own body as an “experimental
workshop” and to thoroughly observe people
sitting in many different environments.
Every human who sits is an individual with his
or her own conditions and desires. Major demands
are placed on anyone who sets up and
individualizes a seating unit for somebody else.
If you want to become a skilled “wheelchair-
fitter” you have many reasons to observe and
practise seating.
Sometimes you encounter complicated
problems to solve to enable the user to sit with
fair-to-good functionability. From time to time
you may feel that the problems you are responsible
for solving are “unsolvable”, especially if you do
not know where to begin.
For the many sitting positions in which the goal
is some sort of activity it is important that
functional conditions are created for the upper
trunk, head and hands.
It isn’t easy to create a functional position if the
person who is seated doesn’t have the capability
of sitting the way “I want to”. Most of us have an
“inner picture” of how people “should” sit, a
picture “guiding” us when we want to make good
positions for others.
If you meet a person who, due to long-term
poor seating, has physical difficulties such as
stiff joints or tensed muscles, it is good to realize
that the change you want to create for this sitting
person requires some time. It may be a long-term
process!
By looking at how a person is sitting you
receive many invaluable clues as to — why?
A sitting position can tell you what a person is
trying to achieve or create with the help of his
trunk, head, legs or arms.
Users sitting with their knees pressed together
do so for several reasons. If you change the
position of a user’s legs and feet to a more
“correct” one you may influence the user’s trunk
in a negative way. It may seriously influence this
user’s ability to work with his hands.
If, instead, you divide a sitting position into
functional body segments — feet, legs, pelvis,
lower trunk, upper trunk, head arms, and hands
— you may very soon discover how the legs
influence other parts of the body. Starting by
adjusting for some other part first, usually the
trunk, the user’s legs may correct themselves.
Interpreting a sitting position is like putting a
“puzzle” together. Sooner or later you learn,
understanding what the pieces mean and how to
place them in relation to each other. Practice and
experience develop your skill in putting the pieces
“correctly” together, using less and less time.
Every person you meet is a new “puzzle” but
sometimes this new person does not match your
experience. This is a challenge, and opportunity,
to learn more!
A sitting position is a position of the body that
functions well, for the moment... This moment
can last for a few seconds or many hours. How
long it lasts depends on if the person who is
seated is capable of changing position or not.
Those of us who work directly with setting up
and designing chairs, with or without wheels,
must realize that no matter what we do — people
still sit the way they need in order to achieve
comfort and functionability.
I maintain that this is true even when the
seating unit doesn’t function well, the person is
sitting very poorly and the sitting-time is
extensive.
The big difference between persons who can
change position and those who can do it only

with great effort is that the person with difficulties
uses fewer positions during the same amount of
time. These persons’ “right now” positions just
last longer.
What is it that makes us continuously change
position when we sit?
Life! Standing as well as seated...
Physical forces always influence your body.
How your body is influenced is, to a great extent,
dictated by how your body is built and what you
do when you sit.
The chair you use has the greatest influence on
your body. This means that the interpretation of
how a person places her body in the chair tells us
about this particular seating unit, its seat and
backrest and, perhaps, also armrests.
A wheelchair’s seating unit may also be
equipped with footplates, leg rests, calf supports,
trunk supports and a headrest.
Seats and backrests have features such as being
soft or hard, horizontal or angled and planar or
contoured.
The human body is a live mechanical system
made of pieces of bone and muscles. Joint
positions and muscle tension are registered and
controlled by the nervous system every moment.
Every change, like altered pressure on a body-
part or an altered position of the entire body or
body-part is registered by sense organs, directly
reporting to the brain which acts and influences
nerves, if necessary.
We, the observers and interpreters, need to see
and understand how each seating unit influences
and creates reactions in the body of the user who
sits in it.
A person who is capable of continuously shifting
position avoids the risk of harmful, static seating.
Persons with physical dysfunctions may not be
able to defend themselves against the dangerous
influences of poor seating units.
Their sitting positions and behaviour are what
we need to interpret and understand, based on
individual functions and how the seating unit’s
features influence the user in several ways.
69
- Why does the person slide on the seat?
- Why does the person always lean towards the
right side - why not the left?
- Why does this man slide off the seat of his
wheelchair even though he has a belt around his
chest? And always at lunch-time!
- Why does this woman place her left foot on the
seat so often?
- Why does this girl keep crossing her legs all
the time?
- What is the cause of this woman not being
able to keep her head up?
- Why does this boy always extend his legs and
rotate them inwards?
- Why is it more difficult for him to keep his
trunk up when his legs are corrected?
We can keep on asking many, many questions
as to why people using wheelchairs sit the way
they do. We can also keep on forever trying to
answer all the questions if we do not steer away
from focusing on symptoms (what we see) and,
instead, start searching for what is the cause of
what we see.
When we begin to know what actually creates
the positions we see in people using wheelchairs
we can begin to change things more appropriately.
Knowing how to interpret sitting positions
increases our knowledge of how seating units
influence their users.
When we begin to grasp “what influences what”
we will better understand how to design and
adapt wheelchairs, not just simply for sitting but
for much more functional sitting!

Physiological Sensitivity In
Physically Challenged Humans
The wheelchair, an assistive device, always
influences the user in some way.
It can create seating of reasonable comfort,
which functions well, or lead to additional
problems. Physical treatment influences the body
being treated. Effects can be positive, neutral or
negative.
Wheelchairs influence. For a user who uses
one every day, with few opportunities to stand
and walk, a wheelchair is a physical treatment.
The goal of this treatment is to improve, develop
or maintain functions and to prevent further
deterioration and/or injury.
We must never overlook poor sitting postures
in wheelchairs, postures that may lead to serious
impairments and injuries.
If a user is sitting poorly you will always find
the cause when you examine the wheelchair.
Faulty seating is not the fault of the user! Users
sit the way they are influenced to sit - by the
wheelchair.
What then, is a poor sitting posture?
Any posture, which is, or may become, static
and long-term may develop into a harmful sitting
posture.
Some people assume that when a wheelchair
user sits poorly it is because the user has impaired
functions, is handicapped, and “this is the reason
he/she cannot sit properly”.
71
Being deeply involved with seating and
wheelchairs you soon learn not to blame poor
positions on a user’s impaired function. If that is
the case you should change your profession! It is
usually possible to achieve sitting positions that
prevent serious sitting problems.
We have only two choices – to do things well
or not to do them so well. There are NO short-
cuts to creating good seating.
Common problems that develop because of
poor seating are pressure injuries, joint and muscle
contractures (shortness-stiffness), muscle
weakness, high or low muscle tension and
negative effects on inner organs.
Other common and very negative functional
problems are difficulties in staying awake,
decreased appetite and impairment of vital daily
activities (primary ADL) such as eating and
dressing.
When reasoning about problems it is also natural
to wonder how much seating problems “cost”
society. Pressure sores are concrete and the cost
to heal a sore can be “calculated”. It is, however,
not so easy to put a price-tag on a stiff hip, a
scoliotic spine, decreased lung capacity,
obstipation, swollen legs or neck pain. Poor
seating is probably extremely costly! If we want
to know how costly, more research is needed.
72
Fatigue and defence
What happens if the chair you sit on is not
sufficiently comfortable?
It creates discomfort and makes you tired.
The many different “techniques” we use (like
crossing our legs or arms) can be effective ways
to temporarily increase comfort.
There can, however, be a big difference between
a person with optimal functions and a person
with impaired functions when comparing how
arms and legs are utilised.
The non-disabled person does not sit still,
frequently changes position. When sitting
becomes tiring, it is natural to stand up and do
something else.
A wheelchair user may have no other alternative
than to sit in the wheelchair the entire day. Some
users are able to change their sitting positions,
others are unable to do so.
If a user’s trunk has a strong tendency to
collapse, crossing his/her thighs, or his/her arms
on the chest, prevents this from happening.
But, if this is not possible, there are other
functional alternatives to help the trunk. Active
When trunk-extending muscles fatigue, you collapse.
- How do you protect your body from collapsing?
extension of the spine or sliding forwards on the
seat are two other ways of helping.
Crossing arms and/or legs and extension of the
spine are activities which may cause muscles to
fatigue after some time.
The alternative - sliding forwards on the seat -
is convenient and the most common way people
stabilize their trunks, to avoid excessive load on
muscles. This is not a problem as long as it is
short term. It will, however, become harmful if
maintained long-term, leading to muscular
inactivity and back problems.
Every person compensates a poor posture and
so does a wheelchair user. We do what we need
to do to avoid discomfort, to prevent the body
from being harmed.
All human beings are very intelligent
mechanically and physiologically. If we are sitting
unpleasantly our bodies’ senses send information
requesting protection against physical stress. We
are “defensive” because we do not want to lose
comfort and functions and try to stay away from
situations that cause pain!
A wheelchair user’s protection against physical
stress, a perfectly natural reaction, often causes
other types of serious problems.

Stressed by pressure
The first thing one experiences when sitting
down is how hard, or soft the seat, backrest and
armrests are. It may feel fine at first, but after a
few hours a chair, which was comfortable,
becomes uncomfortable. This is the normal case
in real life!
Time is always the deciding factor when
“comfortable” changes to “not comfortable”.
We all have a tolerance level that decides when
pressure is becoming uncomfortable. Some
people are thin and others fat, some are young
and others old, some people have big, well-built
muscles whilst other´s muscles have never done
hard work.
Soft tissue can adapt to, and thus tolerate, a
seating unit’s long-term pressure. But even if this
is so, pressure against the body will, sooner or
later, become a source of stress for a person who
sits for a long time.
- How much is a chair pressing against you and
what can be dangerous pressure?
Do the following exercise:
Sit on a chair and make sure your pelvis and
back have good contact with the backrest. Put
your feet flat on the floor.
Feel how the seat presses against your thighs
and ischial tuberosities (sit-bones).
Now, lift your heels up (let your toes stay
down). This increases the pressure against your
ischial tuberosities. This is the situation when
wheelchair users have their footplates too high.
Move both feet forwards on the floor. This
instantly increases the pressure on your thighs
and decreases the pressure on your sit-bones!
This is a common and effective way of decreasing
unpleasant pressure on ischial tuberosities.
But another thing is also happening.
Press your thighs a little harder against the
front of the chair seat. The ischial tuberosities
pressure decreases more and the upper part of
your trunk presses against the backrest (the mid
to top part).
73
The pressure on the backrest and seat-front of
the chair makes your pelvis lift. When you stop
pressing with your legs you may slide forwards
a bit. If you relax you can feel that the pressure on
your upper (thoracic) spine has increased.
If this is uncomfortable and you want to change
the pressure by changing position it can only be
done if you move your trunk away from the
backrest. Feel where, and how, the backrest
presses against your back, and the seat against
your pelvis and legs.
Now re-position yourself. Sit on one buttock,
with your pelvis in an oblique position. This
makes pressure move from your ischial
tuberosities and sacrum to your buttock’s soft
tissue.
How does the backrest press?
Your trunk rotates when you sit obliquely and
presses against your rib-cage on the same side as
the buttock you are sitting on. After a while this
can cause discomfort.
Slide forwards a bit more and the pressure
changes. Every time you slide, pressure against
the backrest increases. Should you choose to
deviate by leaning your trunk sideways, the
armrest-plate may stop you and press against
your ribs (it hurts!).
Pressure against the body often develops as
described here. So, it is not surprising that
wheelchair users may risk sliding off their seats
and ending up on the floor. When that happens,
it is not unusual to stabilize the user in the chair
by using specific stabilizing devices. Different
types of belts, vests or even tables can prevent the
user from sliding off the seat.
People sit the way they are influenced to sit!
Uncomfortable pressure - from the seat, backrest,
headrest, armrests, leg rests and footplates creates
seating problems. The cause why many users sit
poorly is to be find in the seating unit. Stress is
compensated - it is physiologically intelligent!
Poor seating should never be blamed on the user.
74

Equilibrium and stability

As a factor causing discomfort, pressure is
rather well understood. Two other factors, which
are greatly underestimated as causes of harm in
sitting, are poor equilibrium and lack of stability.
Most people can feel that poor equilibrium and
Collapse of the thoracic stability in standing makes it difficult to being
spine makes the head drop functional when standing and walking.
forwards. Over time this
A person who has consumed alcohol, impairing
makes the neck region stiff
his balance, often needs a wider surface of support.
and painful.
One way to create more stability is to move the
feet apart.
If you are sitting with poor equilibrium and
have a tendency to fall (in any direction) you will
improve stability, sooner or later, by decreasing
the “fall-tendency”. At the risk of saying this too
To be able to look
straight ahead a many times, I repeat - the most natural thing to do
person with a is to slide forwards on the seat, to a greater or
strongly kyphotic lesser extent. This is, in fact, the most common
spine, leans the head position in a wheelchair. Being in this situation is
to one side in not the problem, it is staying in such a position,
combination with long-term.
neck rotation.
Long-term, this When the spine collapses the head falls forwards
leads to neck
- or backwards.
contractures
A user slides forwards on a horizontal seat. The
.
unit’s backrest is upright. This make the head fall
forwards and downwards.
If the seating unit is tilted back, when the
thoracic spine flexes the head has a tendency to
If the thoracic spine flexes fall backwards, so a correctly adjusted headrest
in a backward-tilted is needed.
position, the head falls Many users who are positioned like this, and
backwards causing over- who drop their heads backwards or forwards, are
extension of the neck. elderly, or have had traumatic brain injuries.
The spine must be prevented from collapsing.
Improving natural, spinal alignment allows a
more functional and balanced position of the
head. This is achieved by adjusting the seat and
backrest correctly.
84

Time and compensations

It is to some extent possible to "classify" sitting
patterns based on physical impairment and quality
and features of seating units. Many positions we
see in long-term sitting are logical and, thus
possible to explain.
Time and influence may lead to...? Here are some explanations, based on changes
made to a seating unit and the user's response.
The bottom-line is to change how physical forces
are influencing a user.

SLIDE FORWARD AND RELAX

The most common compensation among
wheelchair users, and every other human being,
Sliding forwards is to slide forward on the seat.
on the seat is short The backrest is too upright or high, "pushing"
term positively stable.
on the trunk from behind. This causes muscle
fatigue and trunk instability. The smart thing to
do for more trunk stability is to move forward on
the seat and relax. This makes the spine flex --
downwards, forwards and sometimes sideways
-- and you risk the development of a major
thoracic kyphosis and, sometimes, a scoliosis.
The measure to take is to improve the trunk's
stability and upright posture against the backrest.
If it is easy (low muscle activity) to have the
trunk against the backrest the need to slide
decreases.
But...sliding and
slouching also PRESSURE - FOR STABILITY
create inactivity A way to "assist" the trunk to stay upright
and fatigue, (prevent flexion) is pressing the feet against the
sometimes pain. foot plates and the hands against the armrests
This is a very direct and effective way to
stabilize the trunk, preventing it from falling
forward. If though, "pressing" becomes a habit it
may result in a user "trapped" in an extensor
pattern. This may create serious functional
problems such as difficulties to lean the trunk
forward for - eating - standing up - transfering -
walking, etc..
If this "pattern" has been used for a long time
(several years) it could be difficult to solve, but
 85

it can also change rapidly to the better. The

measure is to use (once again) to adjust the
backrest, making the trunk stable and balanced
against the backrest. These users are often very
sensitive to where the trunk is placed in space.
Leaning too much backward or forward may
trigger the extension. Be gentle and patient!

LEG AND TRUNK EXTENSION

Users who have physical impairments from
birth like in Cerebral Palsy often have seating
units that make their sitting tilted back in space in
relation to gravity.
The trunk is moved to behind the position it
should have had if it was upright. Suppose that
this person wants to move the trunk forward to sit
more upright.
To make this mechanically possible the Centre
of Gravity (CoG) of the trunk needs to move
By pressing against one
forwards. To be sitting upright the CoG needs to
or both armrests and/or
have a position over the hips.
one or both footplates the
trunk is assisted - or
Step 1 The chest moves forwards / trunk flexion pushed - to an extended
position.
Step 2 The pelvis rotates forwards

Step 3 The trunk extends

After step 3 the trunk should be upright...

The beginning of the movement, step 1 is a
normal "sit-up" activity. The problem is that it is
done "uphill" - the seat is backward-sloped.
Doing a sit-up uphill requires more muscle force.
An attempt will trigger the legs to extend and, if
the person tries to sit up as "a habit", the extension
of the legs is an important part of this habit.
If this person's abdominal muscles are weak
and he/she tries to lean forwards from a tilted
position and the legs are triggered to extend, the
A pattern often seen in children
response is trunk extension. Extended legs help
with Cerebral Palsy. The pattern
the pelvis to pivot forwards. If the abdominal is so common that it is looked
muscles cannot keep the ribcage's position the upon as a "CP-pattern".
forward rotation of the pelvis, and the thighs'
pressure against the seat, extends the spine.
86
Changing position now and then, being
dynamic, is a good way to influence for
changing undesirable, negative sitting
patterns to become more natural.
An often encounered arm and leg pattern
(sitting as well as in bed) among brain
injured adult persons after head trauma.
The extension of the spine presses the trunk
against the backrest. This blocks the trunk's
movement forward and the movement becomes
more blocked when the thighs press against the
seat front.
The solution is to make it easier for the person
to move the trunk forward (if this is what he/she
wants!). A fast way to test a person's response is
to place a small pillow behind the pelvis, put on
a hip belt and place wooden plates under the
drive-wheels -- tilts the seating unit forward. Let
it stay like this five-ten minutes.
Sometimes it is surprising to see how fast a
person's arms and legs relax and are lowered in a
more upright sitting position.
Success when doing a permanent set up in
accordance with these guidelines is to give the
legs and lower trunk functional stability and the
upper trunk a possibility to move. It is a delicate
balance, demanding observation and follow up.
One thing that needs to be observed is when the
person has a mild or moderate scoliosis. A more
upright posture makes the scoliosis increase, if
the backrest does not have functional side
supports. Remember, if the seating system is
dynamicit is an advantage to alternate the person's
trunk position during the day.
ARMS AND LEGS FLEX
A brain-injured person often has a wheelchair
with a high back and a headrest and is seated
tilted back in space.
A brain-injured person who has been a
functional walker used to use normal
compensations like crossed legs and crossed
arms. If the tendency of the trunk is to collapse
and/or fall forward it is normal to stabilize the
trunk by using the legs and arms in this way.
If coordination of arms and legs is a problem,
crossing them can be difficult to do.
If the sense organs register and "tell" the brain
that the trunk is losing its position it may trigger
specific muscles to begin bending the arms
towards the chest and bending and pulling up one
 87

leg. These movements may be an attempt to

cross the arms and legs. It is not done consciously
but subconsciously because this functioned before
the injury.
We can also see this as primitive reflexes! But
if the flexed arms relax when the seating situation Forward pelvic tilt
is improved and the hands stay on the legs, one extends the spine.
important cause was the poor position. It mechanically creates
Create balance and stability. Make sure that the functional stability
when trunk muscles are
upper part of the spine, the shoulders and the
weak. When it works it
head can move smoothly. is also used by some of
the strong users.
PELVIS FORWARDS
Tilting the pelvis forward is an effective way to
create an extended and stable spine. The spine
becomes stable in all directions and can be used
to compensate impaired trunk muscle function
and balance.
Some users are highly dependent on such
compensation, to be able to sit upright.

TRUNK DEVIATION AND ROTATION

Side-deviation and rotation of the trunk is
normal when we sit. It is also very common in
hemiplegia.
This user moves the pelvis asymmetri-cally
forward on the seat. The pelvic position makes
the spine flex forwards and sideways and it also
rotates. This makes the trunk tend to fall sideways.
The cause can be impaired trunk muscle
function in combination with poor body
awareness. The cause can also be the user's foot
trying to reach the floor or the hand trying to
reach the pushrim.
The most common cause, however, is when
wheelchairs are not set up correctly for
comfortable sitting and effective mobility.

A user who has had a stroke often slides

and deviates the trunk to one side which
can be the only effective way to stay
mobile.
96
BASIC SEAT CONTOUR
1 2
3 money spent on a cushion is worth every cent if
1 Slightly lower under the pelvis.
2 In front of the pelvis 3 The seat needs to
it should be slightly be a little higher
"uphill" to prevent under the thighs for
forward sliding. effective leg support.
When factors 1, 2 and 3 are functional they
create;
Pressure Relief
Pressure Distribution (also on surfaces)
Pelvic Stability / Slide Prevention
Leg Support and Trunk Stability
Such a seat surface also makes the legs, the
pelvis and the trunk more stable.
1 2 3 change from low under the pelvis to higher under
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If you have a planar foam cushion you
can make it function much better by
changing its shape a little.
Add a pelvic stabiliser (opposite page),
or a foam-layer with higher density
than the seat cushion, under the cushion
where the legs are (dark grey). Make
sure that it is placed just in front of the
the ischial tuberosities (sit bones).
The function of this more anatomically
contoured cushion improves seating.
A home-made seat solution
In many countries the possibility to have a
functional seat cushion is very limited. This can
be because there are no such cushions available
or society will not pay for it. After all, high-tech
good cushions cost a lot of money. However, the
it prevents pressure sores and posture problems.
Of course! But real life may be that the money (or
the will to pay) may not be there!
Even, if you do not have a functional
manufactured seat cushion it is still possible to
make the seat surface function rather well if you
follow some basic principles shown in the illus-
trations on the following pages.
For better pressure distribution, the surface
should smoothly follow the body contour -- the
contour of the skeleton. In the example here on
how to build a functional seat surface it is assumed
that a backrest is used.
1 The seat surface under the pelvis should be
a little lower (approx. 2-3 cm) than under the
legs, to make the pressure against the ischial
tubesosities and nearby soft tissue decrease.
2 An important reason for making the surface
the legs is that the area connecting low and high
creates an anti-thrust function. It makes the pel-
vis more stable by preventing it from sliding
forwards. It is very important that this area is
smoothly rounded, to avoid high pressure locally.
3 The slightly higher surface under the legs
improves leg support and make the legs more
stable sideways. This also, makes it easier for the
trunk to stay against the backrest, which is the
important reason for doing this. Functional thigh-
against-seat pressure improves trunk-against-
backrest pressure. The result is less muscle force
being needed to maintain the upper body against
the backrest.
 97

Many wheelchairs have sling seat upholstery.

The problem with this, especially when the sling
is hanging down a lot, is that the seat cushion
follows the sling (see below, A) making the legs
move closer to the to midline of the seat. One
solution to this problem is to put a wooden board
on the seat to improve leg position. But a pressure
problem may develop if the firm board under the
cushion begins to create local pressure.
Instead of a board it is possible to better utilize
the sling shaped seat by placing a cone-shaped
wedge on the seat front in midline under the
cushion (inside the cushion cover) (see B). The
wedge should be 2-3 cm high forwards and,
closer to the pelvis, it should be very thin. 3 3
Such a piece used on sling upholstery makes
the front of the seat contoured to the legs and the
2
area under the buttocks stays rounded (C).
1
Seat cushion information
There are plenty of cushions to choose from
and the only way to really know or have a chance
to know is to try them out, not only on users. We Pelvic Stabilizer (VICAIR) function areas.
who prescribe them need to try them out
thoroughly.
Many seat cushions are said to be specifically
designed for long-term sitting. Some are clinically
tested and some are not. Be critical, read the A
Legs before
product information and ask questions.
Our main responsibility is to protect the user
from developing a pressure injury and other
types of seating problems. It is not uncommon
that people who adapt wheelchairs compromise B
between protection against high pressure and
protection against physical deformaties (long- Legs with wedge.
term poor posture) and choose pressure protection
before postural function.
It is fully possible to fulfill both objectives -
pressure and posture protection if we know what
(product) influences what. It is important to learn C
Rear
how the different products you see and try really
influence the user. Seat cushion representatives A cone-shaped wedge under the front of the
inform us but it is our responibility to evaluate cushion improves the sling seat by making it
the user-benefit of every product we prescribe. more anatomically contoured (see text).
100
The backrest is a personal
orthosis for the trunk
Numerous reports have been written about
factors leading to the development of pressure
injuries during prolonged sitting. In order to
prevent serious harm from pressure, many types
of pressure-decreasing seat cushions are in use
today.
Some manufacturers have developed adjustable
seating systems for wheelchairs. Such systems
include both seats and backs. Some manufacturers
sometimes integrate contourability as a standard
feature.
A seat needs to be individually contoured for
user protection and trunk stability. The seat works
as the base for the trunk, but, for the seat to be
fully functional, it needs to be in harmony with
the backrest.
The seat's role is to distribute pressure and
create necessary stability. The backrest assists
the trunk to reach fair stability and the balance
required for various types of activities.
Let's suppose that a seating unit's seat and
footplates are well adjusted. This gives us an
effective basis, and about half the unit is set up.
The footplates and seat surface create a stable
platform, focusing on the pelvis and legs. This
gives half the body a good start.
Now, the other half of the seating unit is adjusted
for the rest of the body, the trunk. This includes
setting up the backrest and, in most of cases, the
armrests.
When considering the contouring of the seat it
is relatively simple to find a shape and softness
that suits many people.
Individual factors influencing a person's
possibility to sit on a seat surface are soft tissue
quality, blood circulation and, for some users,
impaired skin sensibility and- of course - duration.
There are different needs, but many humans have
a relatively "standardized" shape against a seat
surface, based on the shape of the skeleton.
This "standard" means that, despite minor
differences, many wheelchair users can be
comfortable on standard seat cushions.
The backrest on the other hand needs to be
strictly individualized since every person needs
to be individually balanced and positioned in
relation to gravity.
When standing upright we balance our body
using our feet as support. When sitting upright
we need to balance the trunk with the pelvis
(ischial tuberosities) as support.
It is much more difficult to maintain upper-
body balance when sitting. So, the backrest needs
to be adjusted optimally for each individual. The
goal is to assist the upper body to achieve its
optimal position, a position that makes it possible
to change between balanced activity and stable
relaxation. The backrest's function is to stimulate
natural upper-body function.
For any user who is in long-term contact with
a backrest, and who may not easily change
position, the backrest should be considered an
individual trunk orthosis.
Not even for the many, many people who do
not have any physical impairment and who can
shift and change, a functionally contoured
backrest may not function well (car seat, office
chair, airplane seat) if it is insufficiently contoured
by design. Salvation in such situations is the
possibility of standing up and doing something
else...
For many physically challenged people who
are sitting in wheelchairs this may not be an
option. Their real life situation may be to sit in
their wheelchair or to be in bed. Because of this,
the wheelchair's backrest is one of the factors that
totally dictates the seating unit's influence on the
upper body, and thus, the whole body.
Spinal Cord Injury, Hemiplegia, Rheumatoid
Arthritis, MS and Cerebral Palsy are all different
diagnoses and conditions requiring different
backrest solutions.

Backrest Contour
Contouring of the backrest - Levels and Principles
A backrest's contour should be such that the
surfaces in contact with the trunk and spine
follow their contours.
The objectives are pressure distribution,
stability and functional balance.
Begin with the position and stability of the
pelvis, then balance and support the upper body
by contouring for extension of the thoracic spine.
Lastly, the area of the backrest against the lower
back should be in gentle contact with the low
back lordosis.
First the pelvis, then the thoracic spine and
finally the lower back. A functional position of
the head, shoulders and upper trunk is the goal.
101
#1 "ROOM" FOR THE PELVIS
By adjustment of the lowest part of the backrest
the basis is created for making the backrest above
the pelvis optimally contoured and functional.
One very common cause of seating problems is
insufficient contouring of the area of the backrest
that is in contact with the pelvis.
One common mistake in backrest design is that
this pelvis-area is too flat, or sometimes even
forward convex! Such a contour decreases the
room needed by the pelvis for an upright and
functional position.
If, due to a flat surface, the pelvis presses hard
102
against this area it will rotate backwards very
easily if/when the thoracic spine begins to flex
(remember that thoracic flexion makes the pelvis
rotate backwards).
When the pelvis' position is upright or forward-
rotated it is more stable. This influences the
position of the trunk's centre of gravity (CoG). A
more upright pelvis mechanically influences the
thoracic spine to extend and the CoG moves
upwards and backwards. This shortens the CoG's
momentum and decreases the muscle force
required to keep the trunk's CoG-position.
To make the backrest, as a whole, functional
for the trunk its lowest part must allow the pelvis
to have an optimal position.
By "positioning the pelvis" several different
structures are influenced. The pelvis' position in
space dictates factors like the placement of the
sacrum's upper surface (the base of the spine),
hip joints (position) and leg and trunk muscles
(muscle length). All these factors influence the
pelvis and spine differently.
When the pelvis has a "final" position, this
position decides the spine's mechanical
conditions, its balance and its possibility to move.
For most people it is better to make the backrest's
lowest part, which is in contact with soft tissue
and the lowest part of the pelvis, too "roomy"
than too tight. If more contact against the backrest
is needed, or wanted, it can always be created...
You may wonder why I focus on this low-
pelvis-area of the backrest so deeply?
The reason is very simple. If this area of the
backrest is insufficiently addressed, the result is
that seating problems will develop very soon.
Give the pelvis the room it needs to be in a
position that makes it muscularly easy for a user
to keep his/her trunk extended!
#2 PELVIC STABILITY
After the pelvis has been placed, its position
needs to be stabilized by making the backrest
support the pelvis' upper sacral area, from side to
side. It is important that the pressure against the
pelvis is not too great. Should it become
uncomfortable, the user decreases the pressure
by moving the pelvis -- by sliding forwards on
the seat.
For many people, supporting the back means
the same as supporting the lower back. The goal
is primarily to stabilize the pelvis, not to support
the lower back.
When the pelvis and sacrum, which are the
lowest part of the spine, are sufficiently stabilized,
the backrest above the pelvis is easier to adjust,
in order to balance and stabilize the rest of the
spine.
A roomy contour for the pelvis in the backrest's
lower area, creates the conditions for the pelvic
position. With the backrest supporting the pelvis
from behind the condition needed for a stable
position is maintained.
Contouring for room and sacral supporting
complement each other to give the pelvis a
functional and stable position in relation to
gravity.
#3 THORACIC EXTENSION
When the backrest's lowest part, the area in
contact with the pelvis, is well adjusted the next
step is normally not to adjust for the lower back.
For a better, faster and often more accurate
result, instead of focusing on the lower back,
adjust for the thoracic spine first, then for the
lower back.
The reason is simple. When adjusting the
backrest for upright sitting, the goal is to assist
the lower back to maintain its forward convex
curve, its lordosis. The problem is that you very
seldom know what kind of curvature you are
adjusting for. Is it big or small? Perhaps it's stiff!
Can the person you have in front of you sit
upright with a lower back lordosis?
To know for certain, he or she should be seated

stably and relaxed, with the thoracic spine upright,
naturally extended.
After the pelvis has a stable position, the next
step is to contour the backrest's upper area. The
objective is individual and comfortable extension
of the thoracic spine, giving the trunk a functional
balance, and minimizing its flexion tendency
when extensor muscles relax. Now the backrest
should be contoured to be in good contact with
the lower back.
If the thoracic spine's extension is maintained
(with very small or no muscle force) the result is
that the spine stabilizes the pelvis and its backward
rotation is blocked. Thoracic extension restricts
the pelvis' possibility to rotate backwards. As
long the thoracic spine is extended the pelvis is
mechanically hindered from doing so.
Thoracic extension is positive for the trunk and
for pelvic stability. The pelvis and thoracic spine
always interact and influence one another. When
the pelvis rotates backwards, the thoracic spine
flexes and when the pelvis rotates forwards the
thoracic spine extends. If you flex your thoracic
spine it makes your pelvis rotate backwards and
when you extend your trunk your pelvis rotates
forwards.
If you want to block your pelvis or thoracic
spine from moving when the counterpart moves,
you need to use many muscles. Thus, for a
thoracic spine, the backrest contouring should be
for balanced extension.
The backrest's contact area against the ribcage
needs to be large and very comfortable. If it isn't
comfortable it isn't working! Functional support
for the trunk is created by contouring the backrest's
middle-to-upper area. This stabilizes the trunk
sideways and stabilizes one of the spine's "pivot
points", the lumbo-thoracic junction, which
stimulates and makes extending the spine more
effective.
Let the upper part (4-5 cm) of the backrest have
some slack, or be a little softer, to allow extension
when needed, which is very often!
103
#4 THE LOW BACK CONTOUR
Good contact and individual contour on both
sides. Observe that the curve of the lower back,
the lordosis, is created and regulated by
interaction between the pelvis and thoracic spine,
their positions respectively, in relation to one
another.
Avoid excessive lower back contouring. It over-
extends the spine and, if the user finds it
unpleasant, (extension and/or pressure)
stimulates sliding on the seat.
A lower-back support is only seldom func-
tional for maintaining a lumbar lordosis. The key
to keep a lordosis is a functional and stable pelvic
position in interaction with the upright extended
dynamically moving thoracic spine.
#5 NECK AND HEAD BALANCE
The purpose of the design (or adjustment) of
the backrest is (mostly) to make it easy for the
head to have an upright and functional position.
The balance of the neck (cervical spine) and
dynamic position of the head is based on how the
pelvis and thoracic spine cooperate and interact.
The best condition for the head is when the pelvis
has a functional and stable (not fixed) position
and the thoracic spine extends and can change
naturally between extension and flexion.
When a backrest has been set up, the user's head
will show you if it is functional. If the user moves
his/her head to a position other than upright,
relaxed and controlled, you should re-set the
backrest.
110
ACTIVITY
STABILITY
Backward seat slope. A high, reclined
backrest makes the pelvis and most of
the trunk stable. It allows activity in the
upper part of the trunk.
ACTIVITY
STABILITY
Backward seat slope. A low backrest,
angled forwards, makes the pelvis and
lower trunk stable. It allows more
activity above the area of stability, which
means most of the trunk.
Stability for activity
The trunk's pressure against the backrest creates
upper body stability.
How much upper body stability is created and
in what direction(s) depends on where the backrest
is in contact, the magnitude of the pressure and
the contact area. Together, the backrest and seat
angle decide how great the pressure against the
backrest will be.
If the whole seating unit is tilted back in space
the body-backrest pressure changes - the greater
the tilt, the greater the pressure against the
backrest.
On a seating unit with a ninety-degree seat-to-
back angle and a horizontal seat, seat pressure is
maximized. When this unit is tilted back ninety
degrees it maximizes the pressure against the
backrest. Tilting backwards decreases seat
pressure and increases backrest pressure, which
means that trunk stability is increased.
Stability through backrest pressure always
makes it more difficult to move the trunk away
from the backrest. This is the principle to use
when users have impaired upper body muscle
function and stability.
A backward-sloped seat makes the pelvis have
a strong tendency of backwards rotation. A
forward-angled backrest, and more hip flexion
(seat slope) increases stability by making the
pelvis be pressed harder against the backrest. Pay
attention to this pressure for sensitive users!
For users who need a lot of pelvic and trunk
stability, slope the seat backward and use a high,
reclined backrest (the upper figure on this page).
For users who need pelvic and lower trunk
stability for freedom of movement and activity
of the upper trunk, slope the seat backward and
use a shorter, well contoured and forward-angled
backrest (see lower figure on this page.)
Published 2002, hardcover, 250 pages, 4-colour illustrations

Posturalis Books
Jägarvägen 14, SE-139 40 Värmdö, Sweden
Phone/Fax: +46 8 650 51 71 / E-mail: engstrom.posturalis@swipnet.se