To Tilt or Not to Tilt: The Prescriber’s Guide to Tilt-In-Space

As an occupational therapist or physiotherapist, prescribing the most suitable equipment for your clients is crucial. When it comes to seating for individuals with postural or mobility concerns, optimising seating that supports their needs can be life-changing. Choosing the wrong chair can lead to significant posture issues and increased risk of pressure injuries.

Many recliner chairs come with a host of features designed for a broad spectrum of users, from those with no mobility or posture concerns, to those with more specialised needs. Most recliner chair features are produced for mass market consumption and offer no posture or pressure care support. Navigating this ever-growing range of features can be overwhelming, but understanding the critical clinical features will improve your prescription accuracy.

In this blog, we will explore the importance of one key feature: tilt-in-space. What is tilt-in-space, why is it important, and who can benefit from it? We will also help you to improve prescription accuracy by identifying the difference between tilt-in-space and simply putting the backrest into a reclining position. 

What is Tilt-in-Space?


Tilt-in-space refers to a seating mechanism that maintains a constant backrest-to-seat angle while the entire seat unit tilts backward. It can also be referred to as zero gravity, zero G, or no-shear backrest recline. This feature ensures that the user's hip, knee, and ankle angles remain unchanged during the tilt. The primary purpose of tilt-in-space is to redistribute pressure from the buttocks and thighs to the back, promoting better posture and pressure care.

Correct tilt-in-space positioning

Tilt-in-space can exist on a range of product types, including:

  • Recliner chairs

  • Wheelchairs

  • Commodes

  • Beds

Who Can Benefit from Tilt-in-Space?

Tilt-in-space seating systems provide a change in position for clients who cannot maintain pelvic, thoracic, or head position and balance against gravity for prolonged periods. While sitting in the upright position, gravity pushes down on the body. Suppose muscle strength or overall endurance is compromised. In that case, clients will be unable to maintain a proper upright posture, leading to postural deviations such as a posterior pelvic tilt, thoracic kyphosis, and/or lateral lean. Clients with pressure concerns can also benefit from tilt-in-space positioning.

Importance of Tilt-in-Space Functionality

Tilt-in-space is essential in seating solutions for clients with limited ability to reposition themselves. This includes individuals with physical disabilities, neuromuscular conditions, or those who spend prolonged periods in a seated position. The key benefits include:

Pressure Redistribution: By shifting the user's weight from the buttocks and thighs to the back, tilt in space reduces the risk of pressure ulcers.

Postural Support: Maintaining a constant angle between the seat and backrest helps promote better posture and prevent deformities.

Improved Comfort: Regular tilting can alleviate discomfort and pain associated with prolonged sitting.

Respiratory and Digestive Benefits: Adjusting the seating position can enhance respiratory function and aid digestion, particularly in individuals with compromised systems.


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The Difference Between Tilt-in-Space and Backrest Recline

When it comes to seating solutions for individuals with mild to complex postural needs, the choice between tilt-in-space or backrest recline is crucial. Both features offer distinct benefits and address specific clinical needs, making it essential for occupational therapists, physiotherapists, and seating prescribers to understand their differences and appropriate applications.

Back Rest Recline

A chair's backrest may be adjustable using recline, this can be beneficial for a change in position for the individual. However, an inappropriate seat-to-back angle may result in excessive pressures, specifically shear forces at the interface of the buttocks as a result of the person sliding forward.


Some wheelchairs and specialist armchairs allow the user to tilt the seat back to maintain a constant backrest-to-seat angle. This assists a person in maintaining good posture and reduces the risk of pressure damage to the buttocks and feet.

Backrest Recline vs Tilt-in-Space

How Much Tilt is Needed for Effective Posture and Pressure Care?

The degree of tilt required for effective posture and pressure care can vary depending on individual needs. Research suggests that a minimum of 25 degrees of tilt is generally effective in redistributing pressure and reducing the risk of pressure injuries. For clients who have complex posture issues a further degree of tilt is required. With strong clinical evidence demonstrating the benefits of tilt-in-space, many equipment suppliers are rushing to add a tilt chair to their stores. However, not all tilt-in-space chairs are considered equal. Chairs that offer any degree of tilt, can be marketed as a tilt-in-space chair. But as the research suggests, any chair with below 25 degrees of tilt will not have the required pressure care and posture support as the chairs with tilt of 25 degrees and above. Understanding the tilt capabilities of a chair is crucial for an accurate prescription.

According to RESNA 2017, utilising tilt-in-space with recline can also be an optimal way to reduce the risk of pressure injuries. The greatest reductions in pressure were seen when combinations of tilt and recline were used together, with studies using 25-45° of tilt with 110-150° of recline.

If you want to learn more about recliner chairs with the optimal amount of tilt, check out this blog.

Problems Arising from Inadequate Tilt in Space Support

For clients who need tilt in space but do not receive it, or who are not achieving the required amount of tilt, there are several issues can arise:

Increased Risk of Pressure Injuries: Without proper pressure redistribution, clients are more likely to develop painful and potentially severe pressure injuries.

Postural Deformities: Lack of appropriate postural support can lead to long-term deformities, worsening the individual's condition and overall health.

Discomfort and Pain: Prolonged sitting in an inadequate position can cause significant discomfort, reducing quality of life.

Compromised Respiratory and Digestive Function: Improper seating can affect breathing and digestion, particularly in clients with severe physical disabilities.

If a client cannot maintain an upright posture and falls into postural collapse, their respiratory system can become compromised. With less room for the diaphragm to drop as it contracts, the lungs do not fully expand, increasing the risk of pneumonia. Breathing becomes shallower and faster, making it more challenging to take a deep breath. Tilt-in-space can often be used to promote thoracic extension and reduce the risk of respiratory complications.

Tilt-in-space provides a change in position while minimising the risk of extensor spasticity. A slight opening of the hip angle at the beginning of a weight shift can sometimes cause an extensor spasm. Tilt maintains the optimal hip angle throughout the weight shift. This means there is no forward sliding of the pelvis on the seat, and no shear forces are generated. This is important because shear forces are a major cause of pressure injuries and can also contribute to discomfort and pain for the client.

There are many reasons why prescribing a chair with tilt-in-space may be the right option for your client. To significantly reduce the risk of pressure injuries and worsening posture complications, prescribing a chair with tilt in space is recommended. Remember to always determine the degree of tilt of a chair to ensure the client experience the benefits.


Jan YK, Crane BA, Liao F, Woods JA, Ennis WJ (2013) Comparison of muscle and skin perfusion over the ischial tuberosities in response to wheelchair tilt-in-space and recline angles in people with spinal cord injuryArchives of Physical Medicine and Rehabilitation.

RESNA (2017). RESNA Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs Literature Update: A Review of the Evidence.


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