Wheelchair Seating and Positioning

High Yield Overview

Wheelchair Seating and Positioning

Comprehensive exam-focused review of wheelchair seating and positioning principles including pelvic positioning, pressure management, postural supports, and interface with orthopaedic surgery for patients with neurological conditions

25-35% require wheelchair for primary mobilityCerebral palsy

60-90% prevalenceHip subluxation in non-ambulatory CP

25-66% lifetime incidencePressure injuries in SCI

90-100 degreesOptimal seat-to-back angle

90-110 degrees typically optimalHip flexion angle

Seating Components

Systems

PatternLinear vs Contoured

TreatmentPostural Support

Cushions

PatternFoam / Gel / Air / Hybrid

TreatmentPressure Relief

Critical Must-Knows

Neutral pelvic positioning is fundamental to proximal stability
Posterior pelvic tilt leads to sacral sitting and kyphosis
Pressure mapping guides cushion selection and positioning
Hip surveillance protocols essential in non-ambulatory CP
Spinal fusion timing considers seating and sitting balance

Examiner's Pearls

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ASIS alignment determines pelvic position assessment
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Windswept deformity: combined hip abduction and contralateral adduction
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Obliquity creates asymmetric weight distribution
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Interface pressure target: less than 32 mmHg capillary closure pressure
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Multidisciplinary team essential: OT, PT, orthotist, surgeon

High Yield Exam Points

Pelvic Position Critical

The pelvis is the foundation of seating. ASIS landmarks determine neutral versus posterior tilt. Posterior pelvic tilt causes sacral sitting, thoracic kyphosis, cervical hyperextension, and increased pressure on the sacrum and coccyx. Always assess pelvic position first.

Pressure Injury Prevention

Interface pressure must remain below capillary closure pressure of 32 mmHg to prevent tissue ischaemia. Pressure mapping technology quantifies distribution. High-risk areas include ischial tuberosities, sacrum, coccyx, greater trochanters, and scapulae. Regular weight shifts essential.

Hip Surveillance Link

Non-ambulatory children with CP have 60-90% risk of hip displacement. Seating systems cannot prevent hip subluxation but can accommodate existing deformity. Orthopaedic surveillance every 6-12 months essential. Surgery decisions affect seating requirements.

Spinal Fusion Considerations

Neuromuscular scoliosis progresses in non-ambulatory patients. Spinal fusion typically extends to pelvis (L5/S1 or ilium). Post-fusion, sitting balance changes significantly. Seating reassessment mandatory after spinal surgery. Fusion timing considers skeletal maturity.

At a Glance

Wheelchair seating and positioning is a critical component of care for patients with neurological conditions who are non-ambulatory or have limited mobility. The primary goals include maintaining optimal posture, preventing pressure injuries, maximising function, and promoting comfort. The pelvis serves as the foundation of the seating system, and neutral pelvic positioning is essential for proximal stability and distal function. Proper seating reduces the risk of secondary complications including pressure ulcers, scoliosis progression, hip subluxation, and respiratory compromise. A multidisciplinary approach involving occupational therapists, physiotherapists, orthotists, and orthopaedic surgeons is essential for optimal outcomes.

Mnemonic

PPFCGoals of Seating

P - Posture: maintain alignment and prevent deformity

P - Pressure: distribute load and prevent injury

F - Function: optimise upper limb use and mobility

C - Comfort: ensure tolerance and quality of life

Memory Hook:Think PPFC like Performance, Protection, Function, Comfort for the seated patient

Mnemonic

ASIS CheckPelvic Position Assessment

A - Anterior Superior Iliac Spine location

S - Symmetry between left and right ASIS

I - Inclination determines tilt (anterior/posterior)

S - Stability through support and positioning

Memory Hook:Always Start Inspecting the ASIS to determine pelvic position

Mnemonic

SIT TIGHTPressure Injury Risk Areas

S - Sacrum and coccyx

I - Ischial tuberosities

T - Trochanters (greater)

T - Thoracic spine (kyphotic patients)

I - Inferior scapular angles

G - Greater pressure with immobility

H - Heels in supine

T - Time is critical factor

Memory Hook:Where you SIT TIGHT is where pressure injuries develop

Wheelchair Cushion Types

Cushion Type	Description	Advantages	Disadvantages	Best For
Foam	Polyurethane or viscoelastic foam layers	Lightweight, low cost, good stability	Limited pressure relief, degrades over time, heat retention	Low risk patients, backup cushions
Gel	Viscous gel in flexible container	Excellent pressure distribution, good stability, durable	Heavy, may leak, temperature sensitive	Moderate risk, stable posture
Air	Interconnected air cells (e.g., ROHO)	Best pressure envelopment, adjustable, lightweight	Requires maintenance, unstable base, puncture risk	High risk SCI, bony prominences
Hybrid	Combination of foam, gel, and/or air	Balances pressure relief and stability	More complex, higher cost	Mixed needs, moderate-high risk
Custom Contoured	Moulded to patient anatomy	Optimal positioning, maximum control	Expensive, difficult to adjust, accommodates growth poorly	Complex deformity, fixed postures

Principles of Wheelchair Seating

Fundamental Concepts

The Pelvic Foundation

The pelvis serves as the foundation of the seating system and the key to proximal stability. Proper pelvic positioning enables optimal trunk alignment, head control, and upper limb function. The pelvis should be positioned in neutral alignment, with the ASIS landmarks level and the pelvis neither excessively tilted anteriorly nor posteriorly. [1]

Neutral pelvic position characteristics:

ASIS and pubic symphysis in vertical plane
Weight distributed evenly on ischial tuberosities
Lumbar lordosis preserved
Thighs parallel to seat surface

Posterior pelvic tilt consequences:

Sacral sitting with increased sacral pressure
Loss of lumbar lordosis
Thoracic kyphosis compensation
Cervical hyperextension for visual field
Increased risk of pressure injuries
Compromised respiratory function

Biomechanical Principles

The seated posture involves a kinetic chain from the pelvis through the spine to the head. Optimal positioning requires understanding of force distribution, pressure management, and postural alignment. [2]

Key biomechanical considerations:

Seat depth affects thigh support and popliteal pressure
Seat width affects lateral trunk support availability
Seat-to-back angle affects posture and pressure distribution
Footrest height affects thigh loading and pelvic position
Armrest height affects shoulder positioning and transfers

Goals of Seating Intervention

1. Posture and Alignment:

Maintain neutral pelvic position
Preserve or improve spinal alignment
Support head position for function
Prevent or accommodate deformity

2. Pressure Management:

Distribute forces over maximal area
Reduce peak pressures at bony prominences
Enable regular pressure relief activities
Prevent tissue breakdown

3. Function Optimisation:

Facilitate upper limb reach and manipulation
Enable safe swallowing and breathing
Support communication and vision
Allow mobility and environmental access

4. Comfort and Tolerance:

Maximise sitting duration
Reduce pain and fatigue
Improve quality of life
Promote participation in activities

Pelvic Positioning

Pelvic Alignment and Control

Assessment of Pelvic Position

Clinical assessment of pelvic position requires palpation of bony landmarks with the patient seated. The ASIS landmarks are the primary reference points for determining pelvic tilt and obliquity. [3]

Assessment technique:

Patient seated on firm surface
Palpate bilateral ASIS landmarks
Determine relative position to assess tilt
Compare ASIS heights to assess obliquity
Assess rotation by comparing ASIS to PSIS planes
Determine if deformity is fixed or flexible

Pelvic Tilt

Neutral pelvic tilt:

ASIS and pubic symphysis in same vertical plane
Optimal for pressure distribution
Preserves lumbar lordosis
Goal for most seating interventions

Posterior pelvic tilt:

ASIS posterior to pubic symphysis
Common in hypotonic patients
Causes sacral sitting
Increases sacral and coccygeal pressure
May be fixed or flexible

Anterior pelvic tilt:

ASIS anterior to pubic symphysis
Less common in wheelchair users
May occur with hip flexion contracture
Can cause increased lumbar lordosis

Pelvic Obliquity

Pelvic obliquity refers to asymmetric height of the ASIS landmarks in the coronal plane. One side of the pelvis is higher than the other. [4]

Causes of pelvic obliquity:

Leg length discrepancy
Hip contracture (adduction/abduction asymmetry)
Scoliosis (pelvic obliquity secondary to spinal curve)
Muscle imbalance (asymmetric tone)
Fixed bony deformity

Management of obliquity:

Determine if flexible or fixed
Flexible obliquity can be corrected with seating
Fixed obliquity must be accommodated
Unilateral seat elevation or contouring
Consider orthopaedic intervention for severe fixed cases

Pelvic Rotation

Pelvic rotation occurs when one ASIS is anterior relative to the contralateral side in the transverse plane. This is often associated with windswept hip deformity.

Windswept deformity:

Combined hip abduction on one side and adduction on the other
Creates apparent limb length discrepancy when supine
Associated with pelvic rotation and obliquity
Common in non-ambulatory cerebral palsy
Difficult to accommodate in seating systems

Pressure Management

Pressure Injury Prevention

Pathophysiology of Pressure Injuries

Pressure injuries develop when sustained external pressure exceeds capillary closure pressure (approximately 32 mmHg), leading to tissue ischaemia and necrosis. Additional contributing factors include shear forces, friction, moisture, and nutritional status. [5]

Risk factors for pressure injuries:

Impaired sensation (SCI, neuropathy)
Impaired mobility
Incontinence
Malnutrition
Cognitive impairment
Previous pressure injury
Bony prominences
Muscle atrophy

High-risk seated pressure areas:

Ischial tuberosities (highest risk when seated)
Sacrum and coccyx (especially with posterior pelvic tilt)
Greater trochanters (lateral positioning)
Spinous processes (kyphotic patients)
Scapulae (thin patients with high backrests)

Pressure Mapping Technology

Interface pressure mapping provides objective measurement of pressure distribution between the patient and seating surface. This technology uses sensor arrays to quantify pressure at multiple points and display results as colour-coded maps. [6]

Clinical applications of pressure mapping:

Cushion selection and comparison
Positioning adjustment optimisation
Identification of high-pressure areas
Documentation for funding justification
Patient and caregiver education
Outcome measurement

Pressure mapping parameters:

Peak pressure (maximum value at single point)
Average pressure across contact area
Pressure gradient (rate of change)
Contact area (distribution of load)
Pressure time integral (duration factor)

Cushion Selection Principles

Cushion selection depends on pressure injury risk level, positioning needs, transfer ability, lifestyle factors, and budget constraints. [7]

Selection considerations:

Risk level (low, moderate, high, very high)
Postural stability requirements
Transfer method and frequency
Weight and build of patient
Continence status
Maintenance capacity
Environmental factors (temperature, moisture)

Postural Support Systems

Trunk and Extremity Positioning

Seating System Types

Linear (Planar) Systems:

Flat surfaces at various angles
Adjustable and versatile
Suitable for flexible postures
Lower cost
Examples: solid seat insert, flat back support

Contoured (Custom-Moulded) Systems:

Shaped to patient anatomy
Maximum contact and support
Optimal for fixed deformities
Higher cost and complexity
Examples: custom-moulded back, seating simulator cast

Trunk Support Components

Lateral trunk supports:

Provide coronal plane stability
Prevent or accommodate scoliosis
Position varies with curve pattern
May be fixed or swing-away
Must not impede respiration

Back support systems:

Solid insert replaces sling upholstery
Provides consistent postural support
May be flat, contoured, or custom-moulded
Height affects head control and comfort
Angle affects pelvic position

Pelvic Positioning Devices

Pelvic guides/laterals:

Position pelvis in midline
Prevent lateral migration
May accommodate or correct obliquity

Anterior pelvic supports:

Seat belt positioning (45-degree angle optimal)
Subasis bar (padded bar below ASIS)
Positioning belt systems
Prevent forward sliding

Hip positioning aids:

Pommel or medial thigh support
Prevents adduction
Abductor wedges for hip positioning
Thigh guides for rotation control

Head Support Systems

Indications for headrest:

Poor active head control
Fatigue with prolonged sitting
Transportation safety
Posterior head positioning

Headrest types:

Flat posterior support
Contoured occipital support
Circumferential support (complex needs)
Dynamic headrests (allow movement)

Seating Considerations in Cerebral Palsy

Cerebral palsy represents the most common cause of childhood physical disability, with 25-35% of affected individuals requiring a wheelchair for primary mobility. Seating needs vary significantly based on motor type (spastic, dyskinetic, ataxic, mixed) and functional level (GMFCS I-V). [8]

GMFCS-specific considerations:

Level III:

May walk with assistive devices
Wheelchair for longer distances
Usually maintains sitting balance
Linear seating often sufficient
Focus on positioning for function

Level IV:

Limited self-mobility
Requires wheelchair for community
May have some sitting balance
May need moderate postural support
Progressive scoliosis risk

Level V:

Dependent for all mobility
Limited head and trunk control
Maximum postural support required
High risk for hip displacement
Complex contoured seating often needed

Hip displacement in CP:

Prevalence in non-ambulatory: 60-90%
Migration percentage monitoring essential
Seating cannot prevent displacement
Seating accommodates existing deformity
Surgical intervention may be required

Scoliosis in CP:

Progressive in non-ambulatory patients
Affects sitting balance and function
Seating can support but not correct
Spinal fusion may be indicated
Post-fusion seating reassessment needed

Seating intervention in CP requires ongoing review due to growth, changing tone, and progressive deformity.

Interface with Orthopaedic Surgery

Surgical Considerations

Hip Surveillance and Management

Non-ambulatory children with cerebral palsy are at high risk for hip displacement, with prevalence of 60-90% in GMFCS levels IV and V. Hip surveillance protocols recommend regular clinical and radiographic monitoring. [11]

Hip surveillance parameters:

Clinical hip examination every 6 months
Anteroposterior pelvis radiograph annually (minimum)
Migration percentage calculation
Acetabular index measurement
Assessment of hip pain and function

Migration percentage thresholds:

Less than 30%: observation, continue surveillance
30-50%: increased surveillance, consider soft tissue surgery
More than 50%: high risk for dislocation, consider reconstruction
Dislocated: salvage procedures may be needed

Seating implications of hip surgery:

Soft tissue releases may improve positioning
Bony procedures require healing before seating
Post-operative seating assessment needed
Accommodating versus corrective approaches

Spinal Surgery Considerations

Neuromuscular scoliosis is progressive in non-ambulatory patients and frequently requires surgical intervention. Spinal fusion significantly impacts seated posture and function. [12]

Indications for spinal fusion:

Progressive curve despite bracing
Curve magnitude affecting function
Pelvic obliquity causing sitting imbalance
Respiratory compromise from curve
Pain related to deformity

Fusion extent considerations:

Upper level depends on curve pattern
Lower level typically to pelvis in neuromuscular
L5/S1 or iliac fixation common
Preserves versus sacrifices lumbar motion
Sitting balance goals influence levels

Post-fusion seating changes:

Loss of compensatory spinal motion
Fixed spine requires seat angle matching
Improved pelvic alignment often achieved
May need new seating system
Function may improve or decline

Limb Procedures and Seating

Orthopaedic procedures on the limbs affect positioning requirements and seating prescription.

Lower limb considerations:

Hip flexion contracture release may improve sitting angle
Knee flexion contracture affects footrest positioning
Foot deformity correction improves footplate placement
Limb length discrepancy affects pelvic position

Upper limb considerations:

Elbow and wrist positioning for function
Hand support needs at armrest level
Splinting integration with seating

Multidisciplinary Team

Team Approach

Core Team Members

Occupational Therapist:

Seating and positioning assessment
Functional upper limb evaluation
Equipment prescription
Home and school environment assessment
Activities of daily living training

Physiotherapist:

Physical assessment and mobility
Postural management programmes
Respiratory physiotherapy
Strengthening and stretching
Gait training when applicable

Orthotist:

Fabrication of custom seating components
Orthotic devices for positioning
Technical expertise in materials
Fitting and adjustments
Maintenance and repairs

Rehabilitation Engineer:

Complex seating solutions
Power mobility systems
Electronic access devices
Environmental controls
Technical problem-solving

Orthopaedic Surgeon:

Hip surveillance and surgery
Spinal deformity management
Contracture correction
Bone health management
Coordination with seating team

Rehabilitation Physician:

Medical oversight of rehabilitation
Spasticity management
Pain management
Coordination of care
Prescription authority

Assessment Process

Initial assessment components:

Medical history and diagnosis
Physical examination (range of motion, tone, posture)
Current equipment evaluation
Functional assessment
Goals identification with patient/family
Environmental considerations

Seating simulation:

Trial of positioning options
Angle adjustments
Cushion comparisons
Component testing
Pressure mapping
Photography documentation

Evidence Base

Hip Displacement in Non-Ambulatory Cerebral Palsy

Observational Study

Soo B, Howard JJ, et al. • Developmental Medicine and Child Neurology (2006)

Key Findings:

90% prevalence of hip displacement in GMFCS V
Correlation between functional level and hip risk
Foundation for surveillance recommendations
Early detection enables preventive intervention

Clinical Implication: This evidence guides current practice.

Pressure Injury Prevention in Spinal Cord Injury

Clinical Guideline

Consortium for Spinal Cord Medicine • Clinical Practice Guidelines (2014)

Key Findings:

25-66% lifetime pressure injury prevalence in SCI
Weight shifts every 15-30 minutes recommended
Pressure mapping aids cushion selection
Education critical for self-management

Clinical Implication: This evidence guides current practice.

Interface Pressure Mapping in Wheelchair Seating

Systematic Review

Crawford SA, Stinson MD, et al. • Archives of Physical Medicine and Rehabilitation (2005)

Key Findings:

Pressure mapping provides objective cushion comparison
Target interface pressure below 32 mmHg
Useful for positioning adjustment
Documentation value for funding

Clinical Implication: This evidence guides current practice.

Spinal Fusion in Neuromuscular Scoliosis

Retrospective Cohort

Tsirikos AI, Lipton G, et al. • Journal of Bone and Joint Surgery (2008)

Key Findings:

Curve correction improves sitting balance
Pelvic obliquity can be addressed surgically
Post-operative seating changes required
High complication rate in this population

Clinical Implication: This evidence guides current practice.

Postural Management in Cerebral Palsy

Expert Review

Gericke T • Developmental Medicine and Child Neurology (2006)

Key Findings:

24-hour postural management concept
Seating is one component of positioning programme
Early intervention may slow deformity progression
Multidisciplinary approach essential

Clinical Implication: This evidence guides current practice.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Cerebral Palsy Seating Assessment

EXAMINER

"A 10-year-old child with spastic quadriplegic cerebral palsy (GMFCS level V) is referred for wheelchair seating assessment. The parents report increasing difficulty with positioning and skin redness over the sacrum. On examination, there is a posterior pelvic tilt when seated, thoracolumbar scoliosis, and bilateral hip flexion contractures of 30 degrees. How would you approach this patient?"

EXCEPTIONAL ANSWER

This child with GMFCS level V cerebral palsy requires comprehensive seating assessment within a multidisciplinary team. The presenting concerns of positioning difficulty and sacral skin changes suggest suboptimal pelvic positioning with posterior tilt leading to sacral sitting and increased sacral pressure. The key priorities are correcting or accommodating the posterior pelvic tilt, managing pressure to prevent skin breakdown, and addressing the scoliosis and hip contractures within the seating system. Assessment should include palpation of ASIS landmarks to confirm pelvic tilt, hip range of motion documentation, spinal examination for curve flexibility, and sitting balance assessment. The hip flexion contractures of 30 degrees mean the seat-to-back angle should be opened beyond 90 degrees to approximately 100-110 degrees to accommodate the contracture without forcing posterior pelvic tilt. A solid seat insert with moderate contouring would provide better pelvic control than sling upholstery. For pressure management, an interface pressure map should guide cushion selection, likely a gel or hybrid cushion given the moderate-high risk level. Lateral trunk supports are needed to accommodate the scoliosis, and hip surveillance radiographs should be reviewed to assess hip migration percentage. The sacral redness requires immediate intervention with improved cushion selection and positioning before tissue breakdown progresses. This patient would benefit from a tilt-in-space wheelchair frame to allow passive pressure redistribution. Regular review is essential given the progressive nature of postural issues in non-ambulatory CP.

KEY POINTS TO SCORE

GMFCS V indicates high support needs and hip displacement risk

Posterior pelvic tilt causes sacral sitting and pressure problems

Hip contractures require accommodation with opened seat-to-back angle

Pressure mapping guides cushion selection

Multidisciplinary approach essential

COMMON TRAPS

✗Focusing only on wheelchair without comprehensive posture assessment

✗Ignoring hip surveillance requirements in this population

✗Not addressing skin changes as urgent pressure injury prevention

✗Prescribing 90-degree angles when contractures require accommodation

LIKELY FOLLOW-UPS

"What hip surveillance protocol would you recommend?"

"When would you consider referral for spinal fusion?"

"How do you differentiate fixed from flexible pelvic obliquity?"

VIVA SCENARIOStandard

Scenario 2: Spinal Cord Injury Pressure Prevention

EXAMINER

"A 25-year-old male with T6 complete spinal cord injury from a motorcycle accident 6 months ago is transitioning from rehabilitation to community living. He has had no pressure injuries during rehabilitation but you are asked to optimise his seating for community use. What are the key considerations and how would you prescribe an appropriate cushion?"

EXCEPTIONAL ANSWER

This young man with T6 complete paraplegia is at high risk for pressure injuries due to absent sensation below the injury level and impaired mobility. The priorities for community seating are aggressive pressure injury prevention, enabling functional independence, and supporting an active lifestyle. For pressure management, the absence of sensation means he cannot detect early tissue damage, so prevention is critical. Interface pressure mapping should be performed to assess his current sitting posture and identify high-pressure areas over the ischial tuberosities and sacrum. Given his high risk level, an air-flotation cushion (such as ROHO) or high-performance gel or hybrid cushion would be appropriate. Air cushions provide excellent pressure envelopment but require regular inflation checks, while gel cushions offer stability for active transfers. The choice depends on his transfer technique and lifestyle preferences. For a manual wheelchair user with good upper limb function, cushion stability during transfers is important, so a hybrid or gel option may be preferred. Education is crucial, and he must understand the importance of weight shifts every 15-30 minutes, skin inspection protocols using mirrors, understanding of pressure injury risk factors, and recognition of early warning signs. The wheelchair should have appropriate seat dimensions, and seat width should allow one finger gap on each side, seat depth should be two to three finger widths from popliteal fossa, and seat height should enable efficient propulsion. Regular follow-up with pressure mapping at 6-monthly intervals in the first few years helps identify problems early.

KEY POINTS TO SCORE

T6 complete SCI: absent sensation creates high pressure injury risk

Air or hybrid cushions preferred for high-risk patients

Regular weight shifts every 15-30 minutes essential

Skin inspection protocols must be taught

Pressure mapping guides initial and ongoing assessment

COMMON TRAPS

✗Assuming rehabilitation success predicts community success

✗Not emphasising education for self-management

✗Choosing cushion without considering transfer technique

✗Forgetting about environmental factors in community

LIKELY FOLLOW-UPS

"What is the target interface pressure and why?"

"How would management differ for a cervical SCI patient?"

"What are the warning signs of early pressure injury?"

VIVA SCENARIOStandard

Scenario 3: Neuromuscular Scoliosis and Seating

EXAMINER

"A 14-year-old boy with Duchenne muscular dystrophy has progressive scoliosis now measuring 55 degrees. He has been wheelchair-dependent for 2 years. His respiratory function is declining with FVC of 60% predicted. The spinal surgeon is considering posterior spinal fusion. How does seating assessment inform surgical planning, and what changes do you anticipate post-operatively?"

EXCEPTIONAL ANSWER

This adolescent with DMD presents a complex scenario requiring close coordination between the seating team and spinal surgeon. The 55-degree scoliosis with declining respiratory function in a wheelchair-dependent patient typically indicates surgical intervention is warranted. Seating assessment informs surgical planning in several ways. First, current sitting balance assessment documents how the patient compensates for the scoliosis, whether through trunk lean, upper limb prop, or head positioning. Second, pelvic position evaluation determines whether there is pelvic obliquity secondary to the spinal curve, as fusion extent to the pelvis may be needed if significant obliquity exists. Third, functional assessment documents current upper limb reach, table-top activities, and self-feeding ability, as these may change post-fusion. Fourth, respiratory considerations are important because upright positioning generally improves respiratory mechanics, and the current seating system's tilt-in-space usage should be documented. Pre-operative seating recommendations to the surgeon include desired pelvic orientation (typically neutral), optimal lumbar lordosis for sitting, and how fusion extent affects future seating options. Post-operatively, significant changes are anticipated. The fused spine is rigid, eliminating compensatory motion, so the seat-to-back angle must match the surgical sagittal alignment. Sitting balance often improves with correction of the curve and pelvic obliquity. A new seating system is typically required three to six months post-operatively once the fusion is consolidated. Respiratory function may stabilise or improve with curve correction. Power tilt-in-space becomes more important as the patient cannot actively reposition. The multidisciplinary team should meet with the family before and after surgery to explain expected changes and plan the seating reassessment timeline.

KEY POINTS TO SCORE

Scoliosis greater than 50 degrees with respiratory decline indicates surgery

Pre-operative seating assessment informs fusion planning

Fusion extent to pelvis determined by pelvic obliquity

Post-fusion spine is rigid requiring matched seat angles

New seating system typically needed 3-6 months post-operatively

COMMON TRAPS

✗Not coordinating seating and surgical planning

✗Expecting existing seating to work post-fusion

✗Ignoring respiratory impact of positioning

✗Not discussing expected changes with family preoperatively

LIKELY FOLLOW-UPS

"What are the indications for extending fusion to the pelvis?"

"How does spinal fusion affect respiratory function?"

"What is the optimal timing for spinal fusion in DMD?"

Australian Context

Australian Healthcare System

NDIS Funding for Seating

The National Disability Insurance Scheme (NDIS) provides funding for wheelchair seating and positioning equipment for eligible participants. Seating systems are classified as assistive technology and may be funded as capital supports within a participant's plan. [13]

NDIS funding considerations:

Prescription from qualified clinician required
Quote from registered supplier
Justification of clinical need
Functional goals alignment
Review of alternatives considered
Ongoing maintenance costs

Equipment categories:

Low-cost assistive technology (under $1,500): may not require formal assessment
Mid-cost assistive technology ($1,500-$15,000): assessment report required
High-cost/complex assistive technology (over $15,000): comprehensive assessment and justification

Complex seating typically requires:

Seating therapist assessment
Trial of equipment
Pressure mapping documentation
Supporting medical reports
Supplier quotations
Maintenance schedule

Seating Services in Australia

Specialised seating clinics exist within tertiary paediatric hospitals and rehabilitation centres across Australia. These services provide comprehensive assessment for complex seating needs.

Major paediatric seating services:

Royal Children's Hospital Melbourne: Victorian Paediatric Rehabilitation Service
Children's Hospital at Westmead Sydney: Rehabilitation Department
Queensland Children's Hospital Brisbane: Rehabilitation Medicine
Princess Margaret Hospital Perth: Rehabilitation Services
Women's and Children's Hospital Adelaide: Disability Services

Adult rehabilitation services:

State-based spinal cord injury units
Brain injury rehabilitation services
Neuromuscular disease clinics
Aged care rehabilitation services

Australian Hip Surveillance Guidelines

The Australian Hip Surveillance Guidelines for Children with Cerebral Palsy provide evidence-based recommendations for hip monitoring in this population. These guidelines inform orthopaedic referral and intervention timing.

Key recommendations:

Hip surveillance from diagnosis of motor impairment
Frequency based on GMFCS level and age
Standardised radiographic protocol
Migration percentage as primary measure
Surgical referral thresholds defined

Compliance with hip surveillance integrates with seating assessment to ensure coordinated care.