You Asked for It
February 2002

"Several of our employees drive quite a bit as they work within the community. One question that had been asked is 'what is the correct way to get in and out of a vehicle?' Do you have any suggestions?"
Jackie
Alberta Human Resources & Employment

Passenger Vehicles (i.e. sedan type car)

The most common means of entering a passenger vehicle is to balance on one foot, possibly holding onto a nice unstable object, like a door, with the left hand. While sliding the right foot and leg in between the seat and the steering wheel, the right hip swings to the right. The left knee and hip flex to lower the body, while tilting the upper body to the left. The head usually tilts to the left, with the angle depending on the height of the person. At some point the right hand reaches out to grab the steering wheel, if it is not holding onto a cup of coffee, purse or shopping bag. With some slight modifications, the process is reversed to exit.

When put into words, this series of actions sounds absolutely preposterous. In fact, it is surprising that more people don't fall or otherwise hurt themselves getting in and out of vehicles. If that left foot - which is often the only point of contact - is even remotely unstable, the whole system loses it's stability. Over-exertion injuries frequently occur in an attempt to regain balance.

It is truly interesting to watch a person with an injury entering a vehicle. This person will put the parcels or anything else she/ he is carrying on the passenger seat or in the back first. Once the driver's door is fully open, an injured person will stand with their back to the opening. With both feet firmly planted on the ground, the right hand holding the top of the door (or an inner handle) and the left hand braced against the posterior frame of the door, the buttocks are lowered into the seat. Then the right hand is transferred to the steering wheel (left hand to door handle) and it assists the body to turn to face the front while one or both legs are flexed at the hip and knee to bring the feet into the vehicle. With a back injury, the person will likely have to use the arms to lift the legs in individually. Before starting the vehicle, he/she will carefully position their back for maximum support from the backrest.

The person with an injury is attempting to minimize strain and balance muscle use. In terms of injury prevention, it is also a prudent course of action. Let's break down the safest way to get into a vehicle:

• Clear the hands - the only thing in your hands by the time you enter the vehicle should be the car keys. Take the time to put all items on other seats (even if it means walking around the vehicle) or in the trunk.
• Get good footing - Make sure your feet are firmly planted on the ground. Be aware if the ground is icy or wet. Being prepared for your feet sliding out from underneath you is one of the best ways of ensuring it doesn't happen.
• Get a grip - Hand contact will stabilize the upper body. The more points of contact, the less likely you are to have to suddenly contract postural muscles to protect against sudden movements.
• Lower the buttocks first - Once the buttocks are firmly in place, the bulk of the body has already been moved. Then it is safe to start turning and twisting.
• Swing around - Bring the legs in, using the steering wheel for leverage.
• Position the back - Firmly push your buttocks into the angle of the seat and backrest. Wiggle a bit if you have to. Make sure the lumbar support encourages the natural curve of the lumbar spine. If your backrest does not provide adequate support, look into using a backrest such as an Obus High Back Forme. I recommend the high back model so that there is no increase in the distance to the headrest. Yes, back supports can be irritating because they shift as you enter and exit. Consider how irritating it would be to have a chronic back injury instead.
• Position the seat - Make sure you can reach the foot pedals. This part can be tricky. Transport Canada requires that your chest/sternum be 10" (25 cm) from the steering wheel. If you can't reach the pedals, the tendency is to reach forward with the foot, twisting the pelvis and lower back. I met a woman recently who told me she only experienced back pain driving to and from work, but she was fine when in the passenger seat. Her car was well equipped and had good back support. Even though she was 5'2" tall, her torso was long and her legs were short! She couldn't comfortably reach the pedals. When this happens, you have two choices: 1) find an automotive place that can install pedal extensions (yes, they do exist) or 2) arrange for an on/off switch for the air bag. For considerably more information about the appropriateness of the latter action, please consult the Transport Canada web site on the topic: http://www.tc.gc.ca/securiteroutiere/air_bag_deact/english/eindex.htm.

Raised Vehicles (Vans, SUVs, trucks, etc.)

While the issues around raised vehicles vary slightly from passenger vehicles, the principles remain the same - Stability and Balance. The problem is that you can't do a buttocks first entry when the seat is elevated. Try this:

• 3 Point Contact - The key issue when entering a raised vehicle is to ensure that you have 3 points of contact at all times. Seeing as you can't have both feet in contact when one of them is in mid air / between steps, that means that both hands should have a firm grip. One should be holding the door and the other the steering wheel (or other handle, depending on the height of the vehicle).
• Watch your footing - Running boards and steps can get icy or have gravel on them. Make sure that the surface is clear of obstructions, ice, etc. so that you don't slip or trip on the way in or out.

Using vehicles for business

People who drive in the course of their work may spend considerably more time in the vehicle than the seat was designed for. This results in deterioration of the foams and other support components. As most of your body weight is on the seat pan, this is where you will notice damage first. The seat starts to "dish" out. Heat from the body, plus continuous pressure causes the foam to disintegrate over time. Soon you can feel springs pushing up (if there are any) or if you hit a big pothole, you "bottom out" or hit the base. Vibration is not absorbed as well, increasing load to your disks. To counteract this, try adding a firm cushion to the seat. Personally, I like the Obus Buttock Rest because it has a hard plastic frame to level the seat and a firm layer of foam to absorb vibration. Some organizations have found it cost effective to either re-upholster an over-used seat or to simply replace the seat. When this happens, look for industrial grade upholstery materials so that you get more out of the vehicle and the worker will stay comfortable (and less distracted on the road) for longer.

Feedback

My dad writes a weekly column for his local newspaper. A few weeks ago he quoted last month's article on safe practices for entering and exiting vehicles in the context of learning from those we consider disadvantaged. The following comments came in from his readers:

"...how can a woman with an impaired right leg - due to a badly scarred adductor muscle in the right thigh - can get into the driver's seat of a car using her technique. If my wife, Helen, follows Sharon's instructions, she cannot get her right leg into the car except by lifting it with both hands."

John

There are always exceptions to the general principles I outlined in my article, and a person who has had a specific injury or disease process often falls into the exception category. Of course, there is absolutely nothing wrong with lifting her right leg with both hands. She may find that the rear entry method is preferable to use in winter when footing is less stable, but then resume a side entry stance when the ground is dry and ice free.

The key issue with both stances is stability. If a person has a good grip on the frame of the car and the steering wheel, then even as they are stepping into the car they still have 3 points of contact. It is often the strong muscular contractions from the reflex to slipping and falling that cause musculoskeletal injury. The more contact, the less likely the postural muscles are to react to changes in stability.

"Your column of March 6 included a description of "how to get into a car with the least risk of accident" which made so much sense I decided to adopt that practice. Now I can tell you why most people don't use this method to get into their cars. Put quite simply, it's fabric upholstery. Following the instructions, I turned and sat in the car, then turned my body to face forward. Unfortunately, my winter coat did not turn with me as it would not slide on the upholstery fabric. This left me uncomfortably twisted inside the coat. In attempting to straighten my coat and make myself more comfortable, I wrenched my back. Fortunately the injury was not serious but it did result in my spending one night bolt upright in a very firm chair. Needless to say, I have gone back to entering my car the "wrong" way. I guess it just goes to show us that there's a reason for everything, even if it looks wrong from some points of view."

D. Lamb

I take very seriously the feedback I get. So I put on my two biggest long winter coats (one with a smooth finish and one with a rough woolen finish) and proceeded to try to get into my Honda Civic. As I expected, the coat with the smooth finish moved with me and the one with the rough finish caught on the upholstery of the car. The wool coat had to be re-adjusted more so that it did not pull on the right side of my body. To do this I had to lift my hips while pushing my back against the backrest and use both hands to straighten out my coat. My neighbours probably thought I was a little crazy, getting in and out of the car and switching coats.

The interesting thing was that if I moved the seat back when I got out of the vehicle, it was much easier to make the garment adjustments when I got back in and less adjustment was needed. Even more interesting was that if I used the side entry stance while wearing either of the long coats, I still had to re-adjust the coat so that it didn't pull on the right side. So part of the problem may be the method used to re-adjust the garments.

The moral of the story: While the rear / buttock entry position is definitely safer from a balance and muscle use perspective, it may take a while to figure out how to make it work for you. You may find that it is easier to teach yourself to use this method in the dry season, when coats are not as much of an issue. If standing on ice and gravel (or other unstable surfaces) is not an issue in your area, the side entry stance may be adequate for your needs. But keep in mind though, that the side entry stance is an inherently unstable posture and (just like your re-adjustment muscle reaction) strong muscle contractions to attempt to stabilize the body, for whatever reason, are often a source of back injury.

Ms. Lamb responded:

"Thanks for your input regarding my comments about entering a car. I appreciate your advice and will keep trying. Ironically, I used the method you recommend successfully for several weeks following a serious ankle injury a few months ago. I have to admit, though, that it was not winter and I didn't need a long coat. Also, as I was unable to drive with the injury, I was entering from the passenger side only and still get into the car on that side using this method. My husband and I are both tall and the car seats are already back as far as they will go. Once I am in the driver's seat there is no room for moving to adjust a coat. The coat in question is made of a smooth synthetic fabric which is one of the reasons I thought this method of entering my car would work for me. I can tell that I am much older, taller, and less agile than you are and you know what they say: 'It's hard to teach and old dog new tricks.' I will keep trying and hopefully find a way that works for me."

Thanks again,
D. Lamb

....Hmmm, another issue might be the height / position of the steering wheel....

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