Tilt in Space versus Recline: New Trends in an Old Debate

by Michelle L. Lange, OTR, ABDA, ATP

Tilt versus recline is an old debate that has reemerged as new products, theory, and clinicians have entered the field of positioning. In general, a trend toward more tilt-in-space system recommendations versus recline system recommendations is evident. More specifically, many facilities recommend almost solely tilt or solely recline systems. Are we in a rut? Is this because of a lack of knowledge of the options? Do valid reasons exist for such exclusivity? The difference appears to be because of the patient population and primarily involves conditions, age, and living situation.

This article will discuss why certain facilities tend to lean toward one option or the other. The article will present indications and contraindications for each system, including typical conditions and age ranges for each. Finally, the article will clarify when and why to consider each option for a client. This cannot be a "cookbook" approach; a qualified seating specialist must weigh many factors.

Most of us change our positions throughout the day. We sit up tall and tuck our feet under our chairs for awhile and then we slouch and stretch our legs out. Not doing so leaves you feeling like you just sat through a double feature at the theatre. Tilt systems (which change a person's orientation in space while maintaining fixed hip, knee, and ankle angles) and recline systems (which change a person's seat-to-back angle) have traditionally been for clients requiring pressure relief. Today, these systems are useful for many more reasons.

Tilt Systems

A tilt system provides a change of orientation and thus redistributes pressure from one area (e.g., the buttocks and posterior thighs) to another area (e.g., the posterior trunk and head) and maintains physical angles at the hips, knees, and ankles.

Indications

• To distribute pressure to reduce risk of pressure sores, increase comfort, and increase sitting tolerance.
• To elicit extensor tone. Maintaining the physical angles can inhibit muscle tone, and increasing the seat-to-back angle often elicits extensor tone.
• To maintain posture. Changing the physical angles can lead to a loss of posture that one cannot regain by reducing a recline mechanism, and sometimes the client must be removed and repositioned after reclining.
• To prevent sheer. No matter what the brochure says, all recline systems have some sheer that causes friction or dragging of the tissues, particularly on the posterior trunk. This is particularly important in an intimate seating system such as a molded seat. The components may move out of position during recline. Have you ever sat in the dentist chair while reclining, and your head fell off the headpad? Your body was no longer in alignment with the components of the dentist chair.
• To maintain proper position of related devices such as a communication device, computer, and access switches. This can include the powered wheelchair access method as well.
• To maintain a fixed seat-to-back angle. Some seating systems are one-piece systems (e.g., the sitting support orthosis) and cannot accommodate a change in seat-to-back angle.
• When range-of-motion limitations prohibit a recline system, such as hip flexors, hamstrings, or even heterotopic ossification.

Contraindications

• If the client spends much of the day at a workstation. If a client moves up close to a table, then he or she must move away from the table to tilt or the footrests may contact the table, possibly even tip it over, or at least hurt the client's feet. Most tilt systems do not include a stop switch if the client contacts an obstacle.
• If the client is at high risk for pressure sores. Tilt systems generally tilt to 450, although some tilt as far as 55g. This is not as much pressure relief as 180 degrees of recline. The pressure distribution pattern is different for tilt systems and recline systems.
• If the client is having bladder-emptying problems or wears a leg bag. Remaining in a fixed position (i.e., hips at 90g) can constrict the bladder, and tilting with a leg bag can lead to leakage.
• If the client leaves items on the tray. Any items left on the tray during a tilt will slip and fall.
• If the seat-to-floor height is too high with a tilt system. Many tilt systems raise the seat-to-floor height, which affects transfers and the ability get under tables.

Conditions

Tilt systems are often for persons with

• cerebral palsy;
• muscle diseases, particularly with an intimate seating system;
• head injuries, particularly if extensor tone is elicited when opening the seat-to-back angle; and
• spinal cord injuries, particularly in the pediatric population.

Pediatric patients with a spinal cord injury often have more extensor tone than adults, although adults can be susceptible to extensor spasms when the seat-to-back angle is open (increased beyond 90 degrees). Pediatric patients are more susceptible to scoliosis than adults because they are still growing and thus require more aggressive seating, which is contraindicated with a recline system.

Age

A client of any age who meets the indications above would benefit from a tilt system. However, most clients who receive tilt systems are children. Most pediatric mobility bases (dependent mobility bases, manual and powered wheelchairs) offer a tilt system. Some dependent mobility bases (strollers) include a recline system. As a result, because of product availability alone, most pediatric patients are in a tilt system versus a recline system. Children are more likely to need a tilt system if they have abnormal muscle tone. Abnormal muscle tone in a growing body often leads to orthopedic consequences such as scoliosis, which generally requires a more aggressive seating system. Again, the sheer of a recline system is contraindicated with this type of seating.

Case Study

The following case study highlights some of the issues related to a tilt system. Pete has cerebral palsy, is in his teens, and has had orthopedic surgery on his hips and several tendon releases of the hamstrings and hip adductors. He attends high school, where he must sit in his wheelchair from the time he gets on the bus in the morning until he arrives home at night. He is rarely out of his wheelchair during the day and, as a result, often does not have a diaper change until he is home. His sitting tolerance was only 2 hr, at which point he would indicate that he wanted to get out of the wheelchair.

We recommended a powered tilt system that could be retrofitted to his current powered wheelchair. Pete's sitting tolerance eventually increased to a full day. He operates his tilt independently with a lever switch by his right forearm. He tends to make 5 to 10 degree changes at least every 15 minutes. Two to three times daily, he will tilt a full 45 degrees for 10 to 15 min.

Pete needed changes in position to shift his weight to extend comfort and sitting tolerance. Typically, tilt systems are to prevent pressure sores. He has never developed a pressure sore and has sensation (unlike most clients who are at risk for breakdown). However, he has reason to be uncomfortable: Pete is quite thin; has obvious bony prominences; experiences pain and numbness in his hips, back, and posterior thighs; and is seated so aggressively that he cannot move his hips. So why does he not experience skin breakdown? His extensor tone does provide changes in his pressure distribution, even if his bottom does not appear to be moving around.

A recline system was inappropriate because Pete did not have sufficient hip extension to recline far. Pete is not a candidate for elevating leg rests (which are often recommended in conjunction with a recline system) because his hamstrings are tight. Increasing knee extension would have caused his pelvis to slide forward into a posterior tilt and cause discomfort. Pete uses a communication device. By mounting this above the tilt mechanism of the wheelchair, the device was located appropriately regardless of Pete's position in space. With a recline system, Pete would have moved away from the communication device as he reclined. This change in distance would have affected his visual regard of the device and his access, which was directly touching the screen.

Commonalties Between Tilt and Recline Systems

Before we explore recline systems, let us examine the similarities between the two systems to prevent redundancy. Both tilt and recline systems can provide pressure relief, increased blood flow, increased head and trunk control, increased positioning for function and access, easier transfers, improved sleep and rest, and increased vestibular stimulation; minimize fluctuations in muscle tone; improve feeding, respiratory function, and visual field; and regulate blood pressure.

Neither a tilt system nor recline system is appropriate if the client displays abnormal reflexes in a more supine posture (i.e., tonic labyrinthine) because this can be elicited regardless of hip position. If the client drives a powered wheelchair with an access method behind the head (e.g., ASL Electronic Head Array, Adaptive Switch Laboratories, Spicewood, TX), then this must be disengaged before tilting or reclining back so that the client can truly rest the head. Disengage this feature by switching modes through the wheelchair electronics or by fuming off the power to the access method without turning off the power to a powered tilt or recline system. If the client has a vent tray, then the tilt or recline system must not "run into" the vent during the weight shift cycle. If the vent must remain upright at all times, then a special pendulum type mount is necessary and generally attaches to the back of the wheelchair.

Tilt and recline systems are available in manual and powered versions but not on all wheelchairs. Combination tilt and recline systems are available as well. These systems do not always offer a full 1809 recline and are more expensive than a single system. If a fixed recline is necessary to accommodate hip flexor contractures or a kyphosis, then adjust the back canes rather than ordering a combination tilt and recline system.

Recline Systems

Recline systems provide a change in orientation by opening the seat-to-back angle and, in combination with elevating legrests, open the knee angle as well. Recline systems may include a reduced sheer back that moves down as the seat-to-back angle opens. Sometimes the armrests slide back as the seat-to-back angle opens to help prevent the arms from slipping.

Indications

• To distribute pressure to reduce the risk of pressure sores, increase comfort, or increase sitting tolerance.
• To provide passive range of motion at the hips and knees.
• When a contoured seat is not necessary.
• When a client uses a tray for eating or work and needs to shift position regularly without disturbing the setup.
• To ease transfers. Sometimes a fully reclined position can help with transfers.
• To assist bowel and bladder function. Intermittent catheterization is easier in a reclined position.
• To alleviate orthostatic hypotension.
• For aesthetic reasons. Many adults prefer the recline system, which they may view as less intrusive in a social or work setting.
• Elevating legrests may assist with edema control and increased circulation in the lower extremities.

Contraindications

• Persons with spasticity. Opening the seat-to-back angle can elicit flexor or extensor spasms that may alter the patient's positioning.
• Persons with limited range of motion at the hips or knees. A recline system may go beyond available range and pull the client out of position.
• Persons with a contoured seating system. Newer recline systems greatly decrease sheer; however, only a tilt-in-space system can fully alleviate sheering forces.

Conditions

Recline systems are often for persons with:

• spinal cord injuries (this is the leading population using recline wheelchairs and generally includes persons with quadriplegia who cannot independently perform weight shifts [i.e., wheelchair push-up] and for whom changes in seat-to-back angle do not affect spasticity),
• head injuries, and
• muscle diseases.

Ages

In the past, adult manual and powered wheelchairs often offered a recliner and, less often, a tilt-in-space version. Nowadays, more adult tilt-in-space bases are available, both in manual and powered wheelchairs, than recliners. Adults buy most recliners. Most of the pediatric recliners are temporary, and clients use them on a rental basis (e.g., to accommodate a hip Spica cast after surgery).

Case Study

The following case study highlights some of the issues related to a recline system. Jake has a spinal cord injury at C5 with resultant quadriplegia. He is in his mid-20s and plans to return to school to get a bachelor's degree in business administration and then go to work. His school day will entail sitting for approximately 6 to 7 hr without a transfer. Because of the need for early morning care (e.g., bowel program, grooming, breakfast, and transportation schedules), Jake begins his day in the early morning hours and is in his wheelchair for a total of 10 to 12 hr.

Jake is unable to do his own weight shifts, so we ordered a recline system primarily to maintain his skin integrity. At the time of discharge, Jake was able to tolerate a full day of sitting with good skin integrity. He was doing independent recline weight shifts every 30 to 45 min with a toggle switch.

Another benefit of the recline system is passive range of motion to Jake's hips and knees with each weight shift. The recline position provides Jake comfort and relaxation. Jake does not require transfers from his wheelchair throughout the day because he can fully recline with his legs elevated for short periods of time. Jake has a suprapubic catheter, so no intermittent catheterization is necessary. Jake's spasticity can pull him out of an optimal position at times, so his reclining system includes a flat back that allows for easier repositioning as necessary by caregivers.

Jake uses a tray that is mounted on the base of his powered wheelchair. He uses this to hold his personal computer, and it provides a surface for his meals while he is away from home. With the recline system, he is able to freely change his position, do his weight shifts, and return to his work setup (the tray is static) without having to remove the tray. In a tilt system, the items would have fallen off the

Summary

Clients are using both tilt systems and recline systems more frequently as they discover increasing benefits of their use. Each system has advantages and disadvantages for clients. Tilt systems, in general, work best for those clients who have aggressive seating needs, high tone, or orthopedic limitations. Recline systems, in general, work best for those clients who have sufficient range of motion, can benefit from a passive stretch, require a full weight shift because of high pressure risk, and need to recline away from a work surface rather than risking items on a tray slipping and leg bags leaking. The decision of tilt system versus recline system is more closely related to condition and age than clinician bias. H

Acknowledgments

I thank Colleen M. Knoll, OTR, for her contributions.

Suggested Readings

Kreutz, D. (1997, March). Power tilt, recline or both. TeamRehab Report, 29-32 (This article and all the issues of TeamRehab Report are archived with permission of the publisher on WheelchairNet.)

Kreutz, D., & Taylor, S. J. (1996). Medical and functional considerations of power tilt and recline systems. Presentation from MedTrade, Atlanta, GA.

Leonard, R. B. (1995). To tilt or recline. Topics in Spinal Cord Injury Rehabilitation, 1(1), 17-22.

Pfaff, K. (1993, October). Recline and tilt: Making the right match. TeamRehab Report, , 23-27. (This article and all the issues of TeamRehab Report are archived with permission of the publisher on WheelchairNet.)

Ross, R. (1996, November). To tilt or to recline? That is the question. New Mobility, 34-36.

Michelle L. Lange, OTR, ABDA, ATP, is Clinical Director, the Assistive Technology Clinics of The Children's Hospital of Denver, 1056 East 19th Avenue B410, Denver, CO 80218, and Editor of the Technology Special Interest Section Quarterly.

You can reach Michelle by email at: lange.michelle@tchden.org

Last Updated: 3-2-2006