What interventions can be implemented to prevent a patient with cerebral palsy (CP) from becoming stuck in a leaning position to the right in their wheelchair?

Preventing Fixed Lateral Lean in Wheelchair Users with Cerebral Palsy

Immediately implement proper wheelchair positioning with adaptive equipment including a seat belt, trunk support belt, lateral trunk supports, and an abduction pommel to maintain midline alignment and prevent the patient from becoming fixed in a right-leaning posture. 1

Immediate Positioning Interventions

The priority is correcting the abnormal posture before it becomes fixed. Start by:

• Seating the patient well back in the wheelchair with weight evenly distributed between both hips, as pelvic sliding is a common precursor to lateral trunk deviation 1
• Installing a seat belt to prevent forward pelvic migration that contributes to asymmetric positioning 1
• Adding lateral trunk supports or a trunk belt positioned to counteract the rightward lean and maintain midline spinal alignment 1
• Using an abduction pommel if hip adduction is contributing to the asymmetric posture 1

Equipment Selection and Customization

Proper cushioning and support surfaces are essential to maintain corrected positioning:

• Select a seat cushion that provides firm support and helps maintain even weight distribution across both ischial tuberosities 1, 2
• Adjust footrest height as low as possible to create a levering action that lifts the pelvis and reduces pressure asymmetry 2
• Ensure the backrest angle is optimized, as returning from recline increases both normal and shear forces that can promote sliding and asymmetric positioning 2

Positioning Strategy for Athetoid Cerebral Palsy

For patients with athetoid movements specifically:

• Focus on maintaining optimal postural alignment at rest and during function, using a 24-hour management approach 3
• Encourage even distribution of weight in sitting to normalize movement patterns and muscle activity 3
• Avoid postures that promote prolonged positioning of joints at end range, such as full hip or knee flexion while sitting 3
• Implement strategies that reduce muscle overactivity, including supporting the affected side when at rest using pillows or lateral supports to take the weight off overactive muscles 3

Dynamic Positioning and Movement

Static positioning alone is insufficient—incorporate movement strategies:

• Encourage the patient to lean forward momentarily after any recline to reduce undesired shear forces that promote asymmetric positioning 2
• Facilitate regular position changes throughout the day, as wheelchair users typically change seating positions every 53.6 minutes on average 4
• Consider powered seating functions (tilt-in-space, recline) if available, as users spend 39.3% of their day in varied positions to manage pressure and posture 4

Critical Pitfalls to Avoid

Do not use splinting or rigid immobilization as the primary strategy, as this can:

• Increase attention and focus to the area, exacerbating symptoms 3
• Lead to muscle deconditioning and learnt non-use 3
• Increase pain and potentially worsen the fixed posture 3

Avoid excessive padding that is too tight or restrictive, as this can compress tissues and worsen positioning problems 3

Do not delay intervention—asymmetric positioning that becomes habitual is much harder to correct than early intervention 1

Ongoing Assessment Requirements

• Conduct thorough ongoing reviews of both the patient and equipment use to prevent deformities from developing 1
• Involve the patient and caregivers in the selection and decision-making process, as participation leads to better compliance and successful outcomes 1
• Reassess the patient's prognosis and environment regularly to prevent harmful and disappointing results from poorly fitted equipment 1

The goal is to increase the patient's function and ability to move around, which directly affects attitude toward daily living and quality of life 1. Early, aggressive positioning intervention with appropriate adaptive equipment prevents the development of fixed deformities that would require more invasive interventions later.