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Post-Polio Health (ISSN 1066-5331)

Vol. 14, No. 4, Fall 1998

Read selected articles from this issue ...

Scoliosis and Seating
Carrie W. Clawson, OTR/L, ATP, National Rehabilitation Hospital, Washington, DC

Post-Polio Motor Neurons and Units: What We Know for Sure
Neil R. Cashman, MD, University of Toronto, Toronto, Canada

Five Ways to Find Peace with One's Self and the World
Robert J. Ronald, SJ, Operation De-Handicap, Taiwan

Sleep-Disordered Breathing and Nocturia
Mary Umlauf, RN, PhD, Associate Professor, University of Alabama School of Nursing, Birmingham, Alabama

Research Focuses on Barriers to Participation

Health Information

More about Crutches: Ergonomics, Inc., Walk Easy; Edward L. Openshaw

Have You Heard About ...

Readers Write

Post-Polio Bibliography


Scoliosis and Seating

Carrie W. Clawson, OTR/L, ATP, National Rehabilitation Hospital, Washington, DC

Carrie W. Clawson, OTR/L, ATP, a Senior Occupational Therapist at National Rehabilitation Hospital (NRH) in Washington, DC, specializes in wheelchair seating, mobility and other assistive technologies. She has also been involved in the Post-Polio Clinic at NRH as the occupational therapist team member. She received a Bachelor of Science in Occupational Therapy from Virginia Commonwealth University/Medical College of Virginia in 1991. She is currently an Adjunct Clinical Assistant Professor at Shenandoah University School of Occupational Therapy in Winchester, Virginia.Carrie W. Clawson, OTR/L, ATP, a Senior Occupational Therapist at National Rehabilitation Hospital (NRH) in Washington, DC, specializes in wheelchair seating, mobility and other assistive technologies. She has also been involved in the Post-Polio Clinic at NRH as the occupational therapist team member. She received a Bachelor of Science in Occupational Therapy from Virginia Commonwealth University/Medical College of Virginia in 1991. She is currently an Adjunct Clinical Assistant Professor at Shenandoah University School of Occupational Therapy in Winchester, Virginia.

Scoliosis, or curvature of the spine, is well-known to many polio survivors. It occurs in a large percentage of individuals due to muscle imbalance as a result of paralysis or weakness.

Changes in appearance as well as changes in the way the body functions can result from scoliosis; fortunately, these issues can be alleviated or ameliorated with proper treatment.

Complications

Problems associated with scoliosis include pain, decreased pulmonary function, decreased digestion and reduced use of the arms.

In general, pain in thoracic (upper spine) curves is not a frequent complaint, but is much more common in lumbar (lower spine) scoliosis.1 Pulmonary function may be compromised when a more severe curve limits the lungs' ability to expand, presenting particular danger for polio survivors who are often at risk for respiratory complications from other factors as well.2 Severe scoliosis that affects the position of the head can cause individuals to aspirate food and liquid into the lungs. Pressure from the ribs and spine on the intestines and stomach affect their ability to function properly.

The ability to use the arms depends upon solid support from the trunk. As scoliosis affects trunk balance and positioning, arm use declines and is less efficient. Polio survivors know that energy conservation is key to living with the late effects of polio and addressing scoliosis to optimize function of the arms is no exception. This is especially true for manual wheelchair users, who use their arms for mobility in addition to their daily activities. Because of the musculoskeletal alignment changes that occur with scoliosis, long-term wheelchair users with scoliosis are at high risk for orthopedic injuries and pain in the spine and shoulder areas.

Treatment of Scoliosis

One treatment of scoliosis is proper trunk support. (Other options often used include braces, corsets and jackets, as well as internal structures such as rods in the vertebral column.) For wheelchair users, the wheelchair back and cushion can be modified for proper support. Addressing scoliosis through the wheelchair seating system begins with an assessment of the individual's sitting posture and ability to function. The position of the pelvis is always evaluated first, as changes in the pelvis affect the positioning of the trunk, head, and extremities (arms and legs).

When a person's pelvis sits higher on one side than the other, it is called a pelvic obliquity. If the obliquity is flexible, the scoliosis may be partially or completely corrected once the pelvis is level. This is accomplished by adding a pelvic build-up, or small pad, under the wheelchair cushion on the side where the pelvis is lower. Leveling the pelvis equalizes the pressure. For a fixed obliquity, a build-up is added under the higher side of the pelvis to accommodate the deformity and better distribute pressure.3

For someone who does not sit in a wheelchair, a folded towel on a chair seat can be used to support or correct a pelvic obliquity. The towel should be placed so that it is under the lower side of the pelvis if the pelvis is flexible, and under the higher side if the pelvic obliquity is fixed. It can be difficult to make this determination; sometimes the towel is placed under first one side and then the other, using the more comfortable arrangement.

The next concern is the curvature and rotation of the spine and the position and mobility of the scapulae (shoulder blades). Lateral supports attached to the back of the wheelchair can be used to correct or support curvatures.

A three-point system should be used to provide a balance between maximum force and pressure relief.

If a "c" shaped curve causes an individual to lean to one side, the first support should be positioned at the top of the curve, allowing at least two finger widths at the armpit. The second support should be placed on the other side at the apex of the curve or slightly below it. The third support will be at the pelvis to prevent shifting. This is often accomplished by the contour of the cushion, hip guides, or the wheelchair armrest.

If an individual has an "s" shaped curve rather than a "c," lateral supports should be positioned at the apex of each curve. Unfortunately, it is difficult to provide this type of lateral support to a non-wheelchair user. For some, a brace or corset can provide this effect.

For individuals with severe curvatures of the spine, a standard wheelchair back does not conform as needed for pressure relief and comfort. In these cases, a wheelchair back that is custom contoured to the individual offers the best solution.

Often gravity causes a flexible scoliosis to worsen when a person sits upright in a wheelchair. Tilting or reclining the wheelchair back a few degrees counteracts this and allows the lateral supports to be more effective. A wheelchair tilt occurs when both the back and seat of the wheelchair move; a recline occurs when only the back moves and the seat is stationary (as with most car seats).

Each has its advantages and disadvantages. A reclining back allows the hip flexors to be stretched and can provide a comfortable resting position, especially with the legs elevated. Tilting allows a person who uses a more complex seating system to sit in the same position at the hips and can prevent shifting or loss of proper position.

For a person using a custom contoured back, a tilt is preferred over a recline, because reclining would change the position of the contoured back relative to the person.

A polio survivor with scoliosis investigating a mobility aid such as a scooter, must consider their seating needs. Many scooters and some wheelchairs cannot be modified to address scoliosis. An occupational therapist or physical therapist who specializes in seating can evaluate both positioning and mobility needs to recommend the appropriate choice of equipment.

References

Parthasarathy, S.R., & Clawson, C.W. (April 1998). Taming the Curve: Scoliosis in Wheelchair Users. Advance for Directors in Rehabilitation, 7-4, 13-14, 76.

Halstead, L.S. (1998). Managing Post-Polio: A Guide to Living Well with Post-Polio Syndrome. Washington, DC: NRH Press.

Bergen, A.F., Presperin, J., & Tallman, T. (1990). Positioning for function: Wheelchairs and other assistive technologies. Valhalla, NY: Valhalla Rehabilitation Publications Ltd.

Other Scoliosis Resources (updated 2007)

National Scoliosis Foundation, publishers of The Spinal Connection, 5 Cabot Place, Stoughton, MA 02072, 781-341-6333, 781-341-8333 fax, 800-NSF-MYBACK (673-6922), or nsf@scoliosis.org, www.scoliosis.org

Scoliosis Research Society, 555 E Wells St Ste 1100, Milwaukee, WI 53202-3823, 414-289-9107, 414-276-3349 fax, info@srs.org, www.srs.org