The Trouble With Sitting

How a Good Seating and Positioning System Is Key to Independence and Quality of Life

Seating the pelvisRemember that song from elementary school about your skeleton? You know, “the thigh bone’s connected to the hip bone”? If so, you already understand the basics of your wheelchair seating system.

Because your bones are connected to each other, when one of them isn’t in the right position, the whole body begins to do things it shouldn’t. Misalignment can cause a host of problems for someone who is seated all day aside from general discomfort, including deformities such as scoliosis, improper breathing and even poor digestion. Improper alignment is also responsible for those dreaded pressure sores.

Seating the Pelvis

If your clinician had to pick one bone structure to give the most scrutiny, it would be the pelvis.

“Think of the pelvis as the foundation of posture just like the foundation underneath your house and walls,” says Susan Cwiertnia, PT, MS, clinical specialist at Varilite, a manufacturer of wheelchair seating and positioning products. “If the foundation isn’t level everything that sits on top of it will also be misaligned.”

In fact, if the pelvis isn’t seating correctly, your trunk, head and shoulders could tilt or rotate, she says. Your hips and legs will also be affected.

So, that’s why if your leg isn’t resting properly on the legrest, the clinician inexplicably starts adjusting your pelvis.

Is Your Seating System Working?

Wondering if you’ve got a good seating system? Ask yourself two important questions: Are you comfortable? Do you want to use your equipment?

“Proper seating and positioning is the key to being functional and doing the things that you want to do,” Cwiertnia explains. “Sitting in a chair all day is not an easy task, and when a person is correctly positioned, they are supported by their equipment to assist them with their daily activities. Proper positioning will provide comfort, which means being able to use the wheelchair for longer periods of time and engaging in more activities. This support means that it requires less effort to sit up, resulting in less fatigue.”

You might notice improved breathing, swallowing and digestion as well, Cwiertnia says. Proper positioning also enables you to look someone in the eye when talking.

When the trunk is balanced, you can reach without losing your balance and propel your wheelchair efficiently.

Cwiertnia says it’s important to remember that the ideal seated position is different for everyone. So, even if your clinician thinks she has you properly positioned, if you don’t feel comfortable, speak up.

Getting Into the Right Seat

If your seating system isn’t working, you might experience a few of the following, Cwiertnia says:

  • Back, neck and shoulder pain — usually caused by the back support not being at the right angle
  • Leg falling off the footrest — The footrest could need adjusting, or additional supports might be needed.
  • Constant sliding forward in the wheelchair and frequent repositioning — multiple causes.

“When positioned properly, you should be able to easily reach the pushrim on the wheel of a manual chair or the joystick controller on a power chair for driving,” Cwiertnia says.

One thing to keep in mind, however, is that more support equipment isn’t always better. In fact, equipment could hinder your ability to perform some activities, Cwiertnia says.

“If you are experiencing difficulties and believe that your seating and positioning needs to be re-evaluated, you should begin by seeing your physician,” advises Cwiertnia. “The physician needs to write a referral so that you can schedule a seating evaluation with a clinician that specializes in wheelchair seating.”

Learn more about the wheelchair process, including the seating evaluation process, at Users First. First fill out the checklist to give to clinicians and equipment providers. Then visit the Mobility Map, a step-by-step guide to the process of getting your wheelchair.

If you’ve recently had a change in your health, such as surgery or disease progression, that affects your level of function, you should seek a re-evaluation, she says. Also, if you purchased your equipment a long time ago, chances are you’re due for a re-evaluation.

Part of the evaluation will include a “mat eval”—clinician speak for a process that enables clinicians to “determine how much joint range of motion is available to comfortably position the ankles, hips and knees while keeping the spine and pelvis aligned,” Cwiertnia explains.

The clinician will also assess trunk balance and strength. From that information, the clinician can determine the amount of support needed and the ideal resting posture for that person.

During the evaluation, take an active role and be as open as possible about your lifestyle. Describe your typical day and activities and the types of equipment you have tried. Tell your team what has worked for you in the past and what hasn’t, and don’t forget to mention your goals, Cwiertnia advises.

“Be open to suggestions, but if something is uncomfortable or too restrictive, speak up,” she says. ”Also ask about maintenance of the equipment to find out when and what should be done to keep it in working order and supporting the way it should.”

Common Postural Issues in Wheelchair Users

Kyphotic or C-shaped posture – According to Susan Cwiertnia, PT, MS, clinical specialist at Varilite, a kyphotic posture, the most common in adaptive seating, occurs in people of all ages and conditions, including able-bodied people. You’ll recognize this posture as one that is slouched forward; the head will be forward, the shoulders will be rounded and the back will be shaped like the letter C, Cwiertnia says. This posture limits range of motion in the head, arms and trunk, and interferes with looking up, reaching, breathing and digestion. Skin breakdown is also common in the sacrum or tailbone.

Scoliosis – This posture involves a lateral or sideways tilt of the spine with one side of the pelvis higher than the other. Skin breakdown will occur at the sit bones if not corrected, Cwiertnia says. Often scoliosis occurs because of muscle imbalance, irregular tone or hip problems.

Rotoscoliosis – Like scoliosis, rotoscoliosis involves sideways bending but a rotation of the trunk is also present, which can result in a rib hump. “A rotation of the pelvis will cause one side to move more forward than the other, and the trunk may rotate with it,” Cwiertnia says. “When the pelvis is rotated, one leg may appear longer than the other, or it can cause problems with being able to make full contact with the back support.”

About the Author

Elisha Bury is the editor of The Mobility Project. She can be reached at