Tight hamstrings are a common culprit in sabotaging wheelchair positioning for the elderly.

In a perfect world, a person could sit in a chair with knees flexed at 90◦ and their pelvis in a neutral or anterior tilt, assisting with upright trunk posture. However, in our world of long term care, many of our patients sit with their knees in extension, feet anterior to the body, which automatically moves them into a posterior pelvic tilt. This tilt leads to precarious sacral sitting, dangerous sliding, and possible skin breakdown.

When positioning a frail elder in a wheelchair it is very important to have hamstring length evaluated, primarily because it is a two joint muscle. It is also important to note that the role of wheelchair positioning management is to accommodate tight hamstrings, not to lengthen them.

A resident’s hamstring length should be assessed as it relates to the position of the pelvis while sitting so that you can determine proper foot support. Most elderly have tight hamstrings and therefore sacral sit due to posterior pelvic tilt. Use of elevating leg rests or leg rests that are too long can further increase posterior tilt and tendency to sacral slide.

A solution for residents with tight hamstrings may be as simple as changing to standard swingaway footrests that are adjusted to the correct length. This will often increase knee flexion, help maintain hip flexion, assist the pelvis to neutral, and increase safety and stability.

References

J.,D. “Real Solutions.” Wheelchairnet.org. 18 Jul. 2009.

http://www.wheelchairnet,org/WCN_ProdServ/Docs/TeamRehab/
RR_95/9505art1.PDF

Portoghese, Caroline. “Seated Impact.” Rehabpub.com. Jun. 2005.

18 Jul. 2009. http://www.rehabpub.com/features/62005/5.asp

The science of humor has been studied more closely in the last few decades.  Much discussion has been documented in the attempt to define humor, and it seems no universal conclusions have been made.  Philosophers, psychologists, sociologists, poets, comedians and educators have all attempted to explain and define it, but have not been able to come to a consensus.  W.F. Fry was able to identify the three basic elements in the science of laughter or Gelotology:

1) The stimulus- humor/comedy

2) The emotional response- mirth

3) The accompanying behavior- laughter/smiling

Research has shown that laughter involves extensive physical activity and is comparable to that of physical exercise.  The respiratory rate, heart rate, oxygen exchange and muscle activity all increase.  This is turn is followed by a relaxation state where the  respiratory rate, heart rate, and muscle tension return to below normal levels.  Studies have also shown that the immune system is stimulated with humor. 

In the healthcare setting, humor serves 3 major functions:

1) A communication function to deliver important messages

2) A social function to promote social relations

3) A psychological function to manage the “delicate” situation which may occur in this setting

In times of illness, strangers are thrown together into very intimate contacts without time to build a relationship.  We must interact without much knowledge of each other.  Our patients must trust us and accept our competency and we expect cooperation almost without question.  What are some examples of how we use humor in our daily work life?

Humor to communicate
You are working with a woman who fell at home and is very anxious about falling.  Your attempts to reassure her are not very successful.  Then her therapist says “Don’t worry Mrs. Smith, we will not let you fall- it is too much paperwork!”  Then she laughs and is more at ease.

Humor to socialize
You are working with a male who had a myocardial infarction.  He says in an attempt to connect with his nurse “It’s you who makes my heart race and raises my blood pressure!” You respond “Relax, I’m really your mother in law in Disguise!”

Humor as a psychological function
The recent H1N1 or “swine flu” outbreak is a good example of our coping mechanisms.  An online greeting card site has a popular card that reads “I think it is best if I work from home today rather than risk infecting people with my paralyzing fear of swine flu”.

 The key is to use humor while being sensitive to whose needs are being met.  Planned well, the use of humor can be as healing and therapeutic as the spontaneous situational humor which occurs in our daily work.  “Humor can restore the human touch , the caring, to the highly technical , potentially dehumanizing world of healthcare.”

 Dr. Debra Molsick, MBA, PT 

References:
Benson, Herbert:  The Relaxation Response
Cousins, Norman: Anatomy of an Illness, NY , Bantam, 1979
Johnson, “Non- pharmacologic pain management in RA” Nursing Clinics of North America, 1984 Dec, 19(4)583-91
Moody, Raymond: Life after Laughter, Headwaters Press, 1978
Robinson, Vera: The Therapeutic use of Humor in Healthcare, NJ, Slack Inc, 1991
Ziv, A:  Personality and Sense of Humor, NY, Springer, 1984
Marcus and Godlasky, “Jokes break out over swine flu”  USA Today , May 11,2009

Nursing home care has improved dramatically over the last decade - I am proud of our advances.  Many facilities are now restraint free, and decubitus ulcers have decreased considerably. 

Lately I have recognized a new challenge in our field.  There is growing commitment to preventative measures.  We all believe in it.  We have never stopped documenting it; but are we directly looking to aid that patient who is silently suffering, just waiting to become our next incident report?

Challenges
State Surveys, insurance reimbursements and accreditations demand a tremendous amount of time from all heath care providers.  Yet as long term care professionals, our responsibilities include ensuring that each and every patient who is dependent on us receives appropriate care.  We have learned to screen, plan and implement with great success.  When one of our seniors begins to deteriorate we move in to action.  If skin integrity is the issue, departments formulate their interventions, pressure relieving treatments are begun, the patient is observed closely and new equipment may be ordered.  Likewise, when a patient falls we quickly intervene:  fall prevention teams gather, close supervision is mandated, physical therapy evaluates and alternate seating options are explored.

The Other Patient
Who is The Other Patient?  She is the woman whose skin is still intact, thou she may be on the verge of breakdown. He is the man who sacral slides in the chair but, has never fallen out.  They are the patients who don’t complain about their sore bottoms or aching backs.  These are the patients who often don’t fully experience our expertise and compassion until after an occurrence.

As a registered nurse working  with the geriatric population for over twenty five years  I have come to realize that with all our proficiency in planning, treating, fixing  and documenting each problem that arises, it is easy to become blinded to a growing majority of patients.

Jennifer Skula, RN
Healthcare Consultant