Wheelchair Positioning for the Classroom
Optimal seating and positioning is essential for student access and learning while in the classroom. At The Avalon Academy, we make it a priority to check our students’ positioning at the start of class, as well as when students prepare for community outings.
It is important for us as therapists, teachers, parents, and caregivers to understand what key elements to look for and also why we need to assess these areas of positioning so we may provide the best foundation for our students success. Below, we will go over a head-to-toe review of seating:
Many of our students have an option for their wheelchair to tilt-in-space. The option to tilt-in-space is useful when a student may not have the head and upper body control and/or strength to maintain their head and trunk upright for long durations. Tilting backwards to a reclined position gives the student the availability to rest from the demands of gravity. In addition to endurance, modifying the tilt can also help with trunk alignment, breathing, speaking, and eating.
When we think about the classroom, it is an active setting where our students access their assistive augmented communication devices through individualized body switch access points to share and make choices. Additionally, all are encouraged to participate and explore in multi-sensory materials (e.g. feeling objects, smelling or tasting related items). Students are also asked to visually attend to supporting icons, and media materials. Participation in class requires physical interaction, thus it is necessary to set up our students in the best position for each student to be an active learner.
The ideal position for a student with limited postural control with a tilt-in-space option is one against gravity that allows the student’s head to be supported from behind on their headrest, with their shoulders in favor of the direction of the seat back. It is a fine line to position the chair so that the student is encouraged to actively position their head to engage with the class materials, but not too demanding where the physical demand of bringing and maintaining their head up becomes the focus and interrupts learning. The degree of tilt is all individual, but generally, we want to see that the student is not slouched forward from the shoulders and can independently bring their head up and attend to material without fatigue for the duration of a class period. However, it should not be too tilted where they are resting and cannot engage in material. It is worthy to note that the greater the tilt, the harder it is for arm access to reach and engage with educational material.
HEAD & NECK
As a physical therapist, optimal sitting is with a head in “anatomic neutral” where the head is directly stacked over the neck and spine. With our students, we have a different set of rules when this cannot be achieved. Often we need to modify the position of a headrest to support the head in a slightly forward, or slightly back position. When a student’s position of comfort is with upper cervical extension (e.g. head hinges backwards at the base of the head and top of the neck) we want the headrest to be positioned slightly forward of the shoulders to meet the position of their head when it is upright.
We look for shoulders to be supported against the seat back, often with the help of chest straps that go over the front of the chest. The chest straps should be snug against the body. If a student is using a butterfly or “H” style harness, we take care to keep the front neck area clear and airway open by ensuring that the straps are pulled snug and there is a fist width gap from the top of the sternum (base of the neck) and the harness. The seat back should be as high or higher than shoulder height to work in conjunction with the front chest strap to guide the shoulders to rest on the seat back.
Generally, all of our students use a tray during class. Often, the tray provides a platform for switch access and AAC use. In addition, students can sometimes use the support of the tray against their forearms to help stabilize and prop their body upright. When using a tray, we look to see that the elbows are resting and supported on the tray. If the tray it too high, the shoulders will shrug up to the ears and can encourage a slouched forward position.
Although this list takes us from top to bottom, the hips are the keystone to alignment and is starting point for seating. It is essential to ensure that the hips are positioned completely back against the back of the seat with equal weight over each hip. This position allows the trunk to rest against the seat back, which then allows for better and easier head control. If the hips are not secured back, students often slide forward in their seat due to gravity or extensor hip thrust, The result is the student in a slouched position, which essentially “turns off” the student’s postural muscles and results in difficulty with head and arm control, reducing active participation in the classroom.
Notice: (left) Student in preferred slouched position with hips forward, resulting in rounded back, altered head position, and reduced reaching range. (right) Student with hips aligned with trunk resulting in better alignment in the head and shoulders
The feet can be thought of as the point of stability and grounding for students. The feet should be secured by ankle and foot straps as necessary to maintain contact with the foot plates and align the knees at 90 degrees. Securing the feet so that the knees are bent at 90 degrees will also help keep the hips from sliding forward for students who tend to extend and straighten their legs.
We hope this general guideline for positioning is a helpful tool for the classroom and beyond. For more complex seating needs, please start a conversation with your student’s physical therapist to discuss additional and alternative accessories and custom modifications to help achieve optimal seating. Let’s remember: a good foundation in positioning is key to active learning!