The “Other” Benefits of Proper Positioning

Why Achieving Functional Posture Can Impact a Client’s Entire Life

Are you sitting down?

If yes, you’re actually doing much more than just sitting. Depending on your posture at the moment, you could be affecting a number of other bodily functions, including breathing and digestion. Your posture might be affecting what you’re able to see; it could be impacting how you’re holding your head, and therefore what your field of vision is. And if your posture is causing you to be slumped over so you’re staring downward…then your posture could be affecting your ability or desire to socialize, as well.

When clients are assessed for seating & mobility technology, so much attention is paid to their clinical needs – postural asymmetries, fixed deformities, high or low tone, pressure relief – and rightfully so. But any positioning system or change of position can also have a huge impact on the rest of the body, as well as the client’s social, emotional and cognitive growth and well-being.

“An individual’s seating system and how they are positioned can have a tremendous effect on the circulatory, respiratory and digestive systems for the good or ill of the individual,” says Elizabeth Stevens-Persing, MS, OTR/L, ATP, with The Comfort Company.

With that in mind we wanted to investigate the “other” benefits of proper positioning…and how they can influence providers’ decisions when creating optimal positioning systems and regimens.

The Impact on Respiration

Among the bodily functions affected by positioning is respiration – clinically known as inspiration and expiration, aka, breathing in and out.

“During inspiration with neutral posture,” says VARILITE’s Susan Cwiertnia, PT, MS, “the diaphragm contracts, and it moves downward, while the lower part of the rib cage moves upward and outward. This motion of the ribs is commonly referred to as the ‘bucket handle motion,’ which creates a lower pressure in the thorax and lungs, causing air to enter. The upper ribs also move with the assistance of accessory muscles as part of inspiration.”

Expiration, meanwhile, “is normally a passive process,” Cwiertnia says, “except in active breathing, when the abdominal muscles assist.”

When a person’s posture is affected, however, those functions can be thrown off. “With abnormal postures such as scoliosis or posterior pelvic tilt with thoracic kyphosis,” Cwiertnia notes, “respiration becomes less efficient due to altered mechanics. Lung volume and capacity can decrease, and it may take more energy to breathe.”

Cwiertnia explains that the different posture physically changes the way respiration can take place. “When the trunk is flexed forward or to the side, the available motion for the ribs to move is limited and less air is taken into the lungs, requiring shorter, more frequent breaths. The diaphragm, one of the major muscles for respiration, attaches to the lower ribs, sternum and vertebrae. The efficiency of the diaphragm to contract may also decrease with abnormal posture, affecting respiration.”

The Impact on Digestion

“The provision of appropriate trunk support and head positioning is also vital in matters of feeding to reduce the risk of aspiration,” says Stevens-Persing, who notes that difficulties with postural control, muscle tone or fixed orthopedic deformities can also increase the risk for choking.

“Seated posture can affect digestion and swallowing,” Cwiertnia says. “Proper positioning can facilitate more effective swallowing and prevent food from entering the airway. Food is also assisted by gravity to flow through our digestive system. Positioning can help to elongate the trunk and abdomen to maximize the effects of gravity for improved digestion.”

Andy Hicks, ATP, eastern regional sales manager for Altimate Medical, is authoring an educational seminar about the benefits of positional changes and movement for wheelchair users. Hicks is especially interested in how changing positions can help ward off metabolic syndrome.

“Metabolic syndrome is the medical consequences of obesity, such as high blood pressure, dyslipidemia (high cholesterol/high levels of triglycerides), type 2 diabetes, stroke, heart disease and several other serious health conditions,” Hicks explains. He adds that people who have mobility disabilities may be at increased risk for the syndrome.

“This is the main reason the disabled community has poorer general health than the general public,” he notes. “Many people with a disability have what they call ‘normal-weight’ obesity, which means their fat cells outnumber their muscle cells, so although they are not large in weight, they have the problems resulting from metabolic syndrome.”

Hicks says good nutrition and exercise can combat metabolic syndrome, but that type of mobility can be difficult for people with disabilities to achieve.

“Most people that are confined to a wheelchair do not have the opportunity to exercise, to increase their cardiovascular output,” Hicks says. “Even pushing a wheelchair does not burn calories as much as walking. So, equipment like handcycles, FES cycling, and active standing will work large muscle groups to produce higher cardiac exercise and burn more calories.”

Thanks to improvements in technology, Hicks adds, exercising options are greater than ever. “If a person is unable to exercise aggressively, then standing while playing Wii or other active games can also be a good form of exercise,” he points out. In fact, this form of changing positions – playing a game while standing instead of sitting – can make a sizable difference in calories burned. According to the Lance Armstrong Foundation’s Livestrong.com Web site, the average 145-lb. person who stands while watching television for an hour instead of sitting burns 104 calories vs. 66.

The Impacts on Social, Emotional & Cognitive Growth

There’s a very simple reason that achieving proper position can facilitate a person’s communication with others, says John Phillips, ATP, CFo, clinical education manager, Otto Bock Health Care.

“Proper posture and position for a wheelchair user can significantly improve socialization because, quite simply, they’re able to participate in conversations and social events,” he says. “It’s really tough to socialize if you’re sitting in a wheelchair that’s very uncomfortable and ill fitted.”

“Position change can open up tremendous opportunities for cognitive and developmental improvement,” Hicks agrees. “Head control and improved upper-extremity motor skills are the key to this improvement. Many disabled individuals have visual impairments, so it is important for them to bring their head into a controlled alignment to what they want to see.”

The impact can be especially great, Stevens-Persing says, with young children: “In the school system,” she says, “some of the most common benefits we see in students who have access to proper seating and independent mobility early in their life are greater expressive and receptive language skills, decreased learned helplessness and increased self-determination, as well as greater selfconfidence in their abilities and what the future holds for them.

“They seem to take greater responsibility for their behavior, management of school materials and completion of assignments. By providing the individual with positioning that is pleasing to their eyes as well as to the eyes of others, along with self-directed and independent mobility, the world is open to them – and the cognitive, emotional and social gains follow.”

And for all wheelchair users, attaining proper position can be the first step toward achieving a range of other goals.

“There is less energy required to sit upright or propel a wheelchair when positioned properly,” Cwiertnia says. “Proper positioning can also increase comfort. Less fatigue and more comfort with sitting means that the seating system can be used more, offering additional opportunities for self care, socialization with family and friends or other activities of daily living (ADLs).”

“An ideal seating system for a client should take into account the client’s social goals such as work, community, school, home, etc.,” Phillips points out. “Planning accordingly for these goals will almost certain facilitate cognitive goals.”

How Positioning’s “Other Benefits” Can Impact Client Assessments

Given the fact that so many critical daily activities and bodily functions are affected by positioning, what should an “optimal” seating& positioning system look like?

“When our bodies are properly positioned while seated in a wheelchair, vital internal organs – lungs, bladder and bowel – should function without interference,” Phillips says. “One of the priorities when fitting someone for a wheelchair or seating system is good trunk extension. This ensures that vital internal organs are not compressed or blocked from full function.”

Stevens-Persing says, “General seating principles would say to maximize spinal alignment and trunk elongation to prevent the compression of internal organs and allow for normalization of inspiration/expiration, circulation to the extremities and the movement of solids/liquids through the digestive track.… After careful assessment of an individual’s orthopedic and neuromuscular status, we must strive to strike a balance between maximizing an individual’s freedom of functional movement with providing the positioning for unimpeded vital bodily functions.”

 

Do Payors Pay Attention to Positioning’s “Other Benefits”?

In the current financial climate, no complex rehab technology discussion is complete without considering whether payors will reimburse for the equipment and services involved. Because payors increasingly seek evidence-based research as justification for reimbursement, we asked for resources providers can call upon during the documentation process.

“Sadly, funding sources do not pay for exercise equipment, so no mention of exercise should be in the written justification,” says Altimate Medical’s Andy Hicks. “Medicaid and private insurance is focused on the physical, medical benefits of the device, so they will not pay for equipment for cognitive benefits. But school districts will buy standers for this reason if it is written into the student’s IEP (Individualized Education Program), or they purchase the stander using the stimulus money recently allocated.”

VARILITE’s Susan Cwiertnia suggests turning to RESNA’s position papers, “a great place to start because they are written and reviewed by experts in our field and contain summaries of research, and best practice trends for implications on cognitive and social function are discussed in these papers.”

Indeed, RESNA’s “Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs” includes a section called “Visual Orientation, Speech, Alertness, Arousal, Respiration, and Eating” as well as “Bowel & Bladder Management.” It also discusses “Pain, Fatigue & Sitting Tolerance” – certainly related to comfort, but explained in more clinical terms that may be more welcomed by payors looking for justification.

She adds, “An individual’s most functional posture is sometimes not the most symmetrical one.”

As far as action items to consider during seating & mobility evaluations, these experts suggested…

  • Consider standing as a positioning alternative. Says Hicks, “When a person is standing – or the seat has a +15 degree incline – many people can have better head control and rotation of the neck for better visual field.… A standing system should provide multiple position changes for multiple therapy opportunities, but also to provide relief when the individual fatigues, such as providing a slight recline when a child is standing to help when head control becomes difficult.”

  • Test respiration as part of the assessment process. Phillips says, “Some clinicians are using pulse oximeters now to measure oxygen saturation rates before and after a seating evaluation to measure the increased lung capacity that resulted from the improved posture.”

  • Consider seating systems separately from the client’s positioning, Stevens-Persing says: “All the specialized components in the world put on a chair to maximize alignment of the spine, extension of the trunk and proper head positioning will not make up for unsafe transfer and poor positioning techniques carried out by a caregiver.”

  • Strive for an emotional buy-in. Clinically speaking, clients need seating & positioning solutions. But the ideal situation is when this “need” is also turned into a “want.”

“The client and/or their caregiver should always have input into the process when choosing equipment to prevent equipment abandonment,” Cwiertnia says. “Important things can be overlooked that might determine successfully creating a system that is accepted and used by the client. Some situations can be challenging: For example, sometimes with pediatric clients, the parents do not want equipment that looks ‘too medical,’ such as a wheelchair. They may opt for a stroller-style system instead because they feel that is more socially acceptable.”

Phillips notes, “Emotion drives action!” Translating that into proper posture, he suggests, means, “Increased socialization and function facilitate learning, whether in a formal setting or an informal setting. Imagine how important this is to children going to school! Improved socialization and learning improve self-esteem. Improved self-esteem encourages the user to participate even more.”

So when it comes to recommending or building an appropriate positioning system, Phillips suggests, “If emotion drives action, it’s critically important to get emotional buy-in from the client. There’s a lot of great equipment sitting unused in closets because this issue is often overlooked.”

This article originally appeared in the Seating & Positioning Handbook: March 2010 issue of Mobility Management.

In Support of Upper-Extremity Positioning