Pediatrics Clinically Speaking

24-Hour Posture Management: An Introduction

Clock: Managing Posture around the clockThe 24-hour posture management approach considers all the relevant postures an individual has the ability to adopt over the 24-hour period of any given day. The three core postural orientations are lying, sitting and standing.

Consider for a moment that we are healthy individuals able to adopt these three core postures, freely moving in and out of them.

Now consider the reduced ability of an individual who has complex rehab needs. At times, many are functionally compromised, and their functional ability has been significantly reduced. Perhaps they are limited to only standing in a stander/standing frame for one hour a day. This effectively means that the remaining 23 hours are spent either lying or sitting.

Some of our complex rehab individuals may be in a seated orientation for any length of time ranging from a couple of hours right through to 16 hours a day, depending on their situation. I would like to invite you to consider the wide range and variety of seating systems available to address the seating & positioning needs of our complex rehab group.

There are so many, right?

The point is that great care and effort is taken to provide the correct seating system to meet the postural needs of the individual. Good supportive seating provides an individual with a stable posture in sitting, creating a good foundation for function and serves to promote active participation in daily living.

Excellent! At this point the individual’s standing and seated postures have been supported, and have been provided to meet the individual’s postural needs.

Two supportive postural orientations. Check.

In addition for good measure, I am going to add occupational and physical therapy sessions into the mix. All efforts are aimed towards addressing the postural management needs of the individual.

Unfortunately, this is also the point where most posture management intervention ends.

When Support Is Absent

But what happens to the body in unsupported postures in the lying orientation? What about the effects of gravity?

Reflect on this fact for a moment: There are 8,760 hours in a year, of which roughly 3,600 of those hours are spent in bed (Goldsmiths 2000).

Gravity will negatively influence the position of the unsupported body.

How, you ask?

The sternocostal bridge is a vulnerable site. The chest itself is particularly susceptible to distortion as a result of the forces of gravity in unsupported lying (Goldsmiths 2000, Poutney et al 2002, Pope 2007, Porter et al 2008, Rodby-Bousquet et al 2013). Rotation of the chest will occur in unsupported lying. Chest distortion can have devastating implications, including a reduction in the internal capacity of the thorax and abdomen. This in turn affects digestive and cardio-respiratory function, which can lead to pain, suffering and premature death.

Also, hips are always a hot topic.

A study undertaken in 2000 — The Mansfield Project: Postural care at night within a community setting (Goldsmiths) — provides evidence of effective hip management intervention through the implementation of a 24-hour postural management program. Basically, to promote hip health during the stages of early development, hips are encouraged to be placed into some degree of flexion and abducted (Goldsmiths, McLean et al, Poutney, Pope). Interestingly, the head of the femur is most secure in the acetabulum in the supine lying position (Goldsmiths).

Where to begin?

How Asymmetry Begins

Let’s go back to the start. Healthy babies are usually born with a symmetrical body shape (e.g., no curvature of the spine). However, children with reduced mobility, who are born with or acquire a disability, are significantly more predisposed to asymmetries as their bodies alter and deform, due to the effects of gravity, and influences such as muscle tone (Goldsmiths 2000).

These asymmetrical lying postures become further established through a habitual sleeping position. The net effect is that these destructive, asymmetrical postures may become obligatory as they age, and as their bodies change shape.

A downward spiral is created as postural asymmetries occur, creating further challenges to the individual trying to move into an alternative lying posture. Postural asymmetries increase the risk of tissue adaptation, and are associated with scoliosis, hip dislocations, hip-knee contractures, and an inability to change position (Rodby-Bousquet et al 2013). These postures become known as “preferred postures.”

Preferred lying postures have an impact on the direction of the deformity — hip dislocation, windsweeping, spinal curve — (Porter et al 2008). Therefore, early intervention needs to focus on maintaining symmetry, and assisting those who are unable to change their posture.

The introduction and implementation of safe and gentle positioning in the lying posture may serve to protect against the development of these asymmetries by protecting body shape.

Next month, we’ll look into the biggest challenges in implementing 24-hour postural management.

This article originally appeared in the August 2016 issue of Mobility Management.

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