Pediatrics Clinically Speaking
24-Hour Posture Management: An Introduction
- By Lee Ann Hoffman
- Aug 01, 2016
The 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
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
Gravity will negatively influence the position of the unsupported
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.