Postural Challenges

I have a personal interest in what should be considered best practice in the field of posture, seating, and mobility. It used to be considered too risky for governing bodies to offer advice in case it was found to be wrong. The result has been too many poor quality products, and badly positioned patients. I am delighted that we have moved on and best practice advice is now available to a certain degree, but it’s not far enough to make the difference that is needed. The Rehabilitation Engineering Society of North America (RESNA) has produced eight position papers over the last ten years.

• The Application of Pediatric Power

• The Application of Seat Elevating Devices

• The Application of Tilt, Recline, and Elevating Leg-rests for Wheelchairs

• The Application of Wheelchair Standing Devices

• Wheelchairs used as Seats in Motor Vehicles

• The Application of Ultralight Manual Wheelchairs

• The Application of Wheelchairs, Seating Systems, and Secondary Supports for Positioning vs Restraint

  • Wheelchair Service Provision Guide

If you wish to read them they can be found at


Best practice is to use items that have been tested to, and meet these standards: not doing so can put
patients at risk. You have to be careful of claims that items have been supposedly “Tested”. They may have been tested, but may not have passed! The correct term for a system that has passed is ‘crashworthy’. Also, be careful of claims that some items such as head supports have been crash-tested, where there is no international standard for this.

Postural support devices – are they safe or not?

ISO 16840-3, published its second edition in early 2014, this covers test methods for static, impact, and repeated load strength of postural support devices (PSD) such as pelvic belts and anterior harnesses. This standard describes a rig in which the PSD is mounted to simulate mounting on a wheelchair. For repetitive load tests, the rig stretches and releases the PSD 1000 times. To pass, the belt needs to have stretched or moved no more than 10 mm.

ISO Clinical Guidelines

For the less technical, many of these standards are very turgid and difficult to understand. As an outcome of this ‘criticism’, a number of ISO technical reports have been produced in a format to help clinicians. An example of the latter is ISO TS 16840-9 covering pressure mapping. There has been resistance by clinicians in some countries to the idea that clinical guidelines should be seen as international standards, since they had assumed that these were only technical documents, but what better starting point for gaining international consensus? And what is the point of publishing technical standards if they are not understood, and therefore not used?

Another valuable document that has been developed is ‘A Clinical Application Guide to Standardized Wheelchair Seating Measures of the Body and Seating Support Surfaces’ which is 340 pages long, and serves as a textbook in its own right. This document was developed as a means to make use of ISO 16840-1, which contained a series of turgid definitions. These guidelines are currently free to download, and will eventually be published as ISO 16840-8. In this document you will find extensive diagrams, methodology of measurement, and the clinical relevance of each measure described.

In My Opinion

There have been improvements in the roll out of guides and terminology, and changes have been made, but there is still a long way to go. These latest guidelines offer standardization encouraging a breadth of common language, and decreasing the chances of miscommunication – all of which contributes to best practice. However, I have seen first hand the difference a correctly placed quality harness, can make to a persons quality of life. This can, not be stressed enough. If we can push governing bodies to take the reins and stop being controlled by fear of reprisal, there would be a lot of lives that improved. 


Lucina Ridgewell

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