We caught up with commode seating and positioning advocate Jacqueline Abel, who’s an Occupational Therapist at Specialist Rehab Services (SRS). Jacqui shared her thoughts about why it’s so important to get a person’s positioning in a shower commode right, as well as some of the challenges OT’s like her are up against.

What are some of the key challenges OT’s face in achieving the correct positioning in a shower commode or wheelchair?

Change: One of the key challenges is client’s that have lived with a disability for a long time and are reluctant to change to new equipment. Quite often clients have sat a certain way for a long time using compensatory, destructive postures to remain stable whilst seated on the commode. This is mostly due to shower commodes being very simply constructed with little to no positioning support. As a result, clients would hook arms around push handles, sink into the very large apertures in the seat instead of using lateral supports to remain stable in the shower commode.

Postural asymmetries: Client’s with significant postural asymmetries are very difficult to seat on a traditionally flat commode seat. When seated in their wheelchairs they have the option of using a contoured cushion which can accommodate for postural asymmetries such as pelvic obliquities, pelvic rotation, discrepancies in hip range of motion. Commode seats cannot be significantly contoured as an aperture is needed for bowel cares and therapists must look towards providing stability in sitting using external supports such as laterals, hip and thigh guides along the seat of the commode.

Decrease muscle strength and range of movement issues: Another challenge that therapist face is a decrease in strength and fatigue in the trunk, pelvis and lower limb muscles causing the person to slide forward when sitting in the shower commode. When setting up a wheelchair, a therapist can use seat rake (front seat to floor higher than the rear seat to floor measurement) to provide proximal stability when seated in the wheelchair. This option is not readily available in shower commodes therefore many clients seated on a shower commode often say they feel as if they are going to fall forward and out of the shower commode. Back angle adjustment enables the OT to accommodate for the loss of hip range of movement.

Body proportions, size, and shape: As we all know people come in different sizes and shapes therefore one size does not fit all. If the OT fails to take measurements of the client’s seat width and depth, depending on the client’s size they may not be fully supported on the commode seat, either their size and tissues that overhang on the sides of the commode causing skin marking from the armrests or the client is not fully supported under the femurs.

What issues/injuries have you come across that have been a result of an incorrectly fitted shower commode?

• Skin breakdown: The most common issue that can be caused by an ill-fitting shower commode chair is skin breakdown
• Postural deformities: Many clients can spend hours on a shower commode each day whilst completing their bowel cares. If they are not fully supported in the commode, this could result in curvatures of the spine (scoliosis- from movement to the side and kyphosis – from sliding forward in the shower commode), fixed posterior pelvic tilt from sliding forward on the commode and hyperextension at the neck from trying to maintain their eye gaze straight ahead as the person tries to stabilise themselves on the commode
• Falls: Patients have fallen out of their commodes because of poor positioning and decreased sitting balance. If the centre of gravity is not set correctly on the commode the client can potentially fall out of the commode if they are self-propelling

What has made it easier over time to get an individual positioned correctly within a shower commode? What is it about the RAZ that helps?

• Making sure that I have completed thorough postural assessments and taken measurements as I would for wheelchair and seating needs
• Having a fully adjustable shower commode chair with options such as a variety of seat width and depth, the ability to quickly change backrest heights and angles and to change footplate height and add accessories such as lateral supports and thigh guides, gutter armrest, makes setting up a client on a trial commode so much easy nowadays
• The RAZ commode meets many of these needs, therefore, it is often quick and simple to set up a trial for a client

Are there some key tips you would recommend when fitting a shower commode?

• One size does not necessarily fit all, therefore, completing a postural assessment and taking measurements when you first assess the client will likely ensure that the shower commode will fit well. Also, make notes on postural asymmetries and potential accessories you will need to accommodate these
• Make sure you know how good the user’s postural control is. Look at their seating in their wheelchair if relevant, as this will help you determine what accessories are required to offer postural stability and to accommodate and prevent further progression of postural deformities
• Make note on what size of commode the client is likely to need, paediatric, standard adult or a bariatric commode
• One of the key measurements to take is the width between the ischial tuberosities so that you can determine the correct seat aperture size. If you choose incorrectly a slimmer client’s bottom sinks into the aperture and there is the possibility of shear with potential pressure injury.  With a larger client, there is marked pressure taken over the ITs as the seat aperture is too small. With either scenario, the client is at risk of pressure injury
• Determine if the client is likely to need a self-propelling commode or an attendant propelled commode based on their upper limb strength, caregiver availability, etc
• Check if the client requires tilt in space for medical conditions such as postural hypotension, some clients need a slight degree of tilt when completing bowel cares, tilt can help caregivers to position client properly in the shower commode chair. Lastly tilt is useful for pressure relief if the client spends a considerable time seated on the commode each day to complete personal cares
• How the client transfers onto the commode also has implications on the seat height of the commode and accessories the assessor decides upon
• Look up the specification of the shower commode chairs prior to selecting a trial to ensure that it is adjustable, customisable if needed. Most important is to ensure that you check that the commode seat chosen matches the needs of the user, pressure relieving needs, machine-made seams or handmade seams, aperture size, location of the opening, etc.