Clinically Speaking

24-Hour Posture Management: Challenges to Implementation

In our August issue, Lee Ann Hoffman, OT, MSc, defined the concept of 24-hour posture management, which “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.”

In the seating & wheeled mobility realm, clients and their rehab teams typically focus on seated posture. But lying-down posture is often neglected, which can cause problems. “Gravity will negatively influence the position of the unsupported body,” Hoffman said. “The chest itself is particularly susceptible to distortion as a result of the forces of gravity in unsupported lying.” The eventual results of unsupported posture while lying down can include asymmetries that impact a client’s posture the rest of the day.

In part II of this series, Hoffman explores the challenges currently confronting 24-hour postural management, and offers resources for seating teams. — Ed.

What’s the Greatest Challenge to 24-Hour Posture Management Implementation?

24-Hour Posture ManagementMy best guess is, lack of knowledge and awareness.

I used to focus on the seating system as the primary means of intervention for posture management. I became aware of the 24-hour posture management approach — and admit that initially I, too, may have been a bit skeptical.

Once you make that paradigm shift, and understand that postures firstly do not occur in isolation of each other, that gravity does not magically disappear in lying, and that there is a significant link between the lying and sitting posture, you can only have the a-ha moment.

Cue beam of light and angelic music! No more silo-thinking.

Why would I even want to think about providing a supportive seating system, good-quality therapeutic intervention and a dedicated standing program — without the provision of positioning in lying? It is equivalent to building a house with no foundation or base structure for support. As a therapist, I am certainly going to make every effort to ensure that gravity is not going to undo all the good work that has been achieved throughout the individual’s day — but I’m also going to provide intervention to lying postures.

I have generally found once you take the time to explain to someone the impact of unsupported body postures over the 24-hour period, the penny drops, and it starts to become pretty clear that 24-hour posture management has an instrumental part to play in the protection of body shape. It directly impacts the development of:

  • Contractures and deformities
  • Tissue damage and pressure
  • Compromised respiration
  • Swallowing and digestive complications
  • Pain and discomfort
  • Raised levels of fatigue
  • Reduced quality of life

Perhaps there is also a misconception that positioning in lying is restrictive, hard and torturous. Positioning in lying is a gentle intervention that focuses on postural care by providing controlled postural interventions to manage a child’s shape using different pieces of equipment (it can also be achieved using rolled-up towels, soft toys and pillows).

From my international experience, and working in multiple settings, funding can also create challenges on the path to acquiring the correct equipment for 24-hour posture management.

Useful guidelines that may assist in providing clinical justification for funding posture management equipment for children include the Gross Motor Function Classification System (GMFCS). The GMFCS provides a helpful guide for groups IV-V, advocating that they should start with 24-hour postural management programs in lying as soon as appropriate after birth, in sitting from 6 months, and in standing from 12 months. Of further interest, GMFCS level IV at 69 percent and V at 90 percent respectively are the most susceptible, and have the highest incidence of hip displacement.

Further guidance is also provided for children with a motor disorder at GMFCS level III, who require postural management programs that emphasize postural activity from an early age (Gericke 2006).

Here are some examples of the equipment commonly used, which may serve to help promote and achieve good postural care over a 24-hour period:

  • Standing frames (if the individual has this postural orientation available to them) with ranges to stand
  • Wheelchairs (to promote changes in orientation)
  • Special seating
  • Sleep systems and positioning supports in the lying position
  • Wedges and other ways of positioning for play
  • Classroom positioning systems, e.g., equipment to allow a lying posture as an alternative/counter posture to sitting

No one mode of intervention in isolation will be effective. This 24-hour posture management needs to encompass all postural orientations available to the individual.

It is vital to include the family in the 24-hour posture management approach. The success of the 24-hour posture management intervention is heavily reliant on the influential role that the individual’s support network has.

24-Hour Posture Management Resources

There is actually a wealth of free and available knowledge-share happening out there.

The Internet has become such a collaborative tool and fantastic resource for information on 24-hour posture management.

Just a quick search of the World Wide Web, and you are set. There are a variety of ways to skill yourself up, from informal learning and awareness all the way through to more formalized degree courses.

There is a plethora of available literature and research. Some articles are locked and may require a fee to download, and others are free to download.

I too, am always interested in assisting with solutioning an individual’s 24-hour postural management needs. This is my absolute passion. I would definitely welcome any queries or questions.

Web Site Resources

Posture and Mobility Group, United Kingdom (PMG-UK)
PMG Research
PMG Volume 27:1, 2010

Posture 24/7
What is 24 hour postural care?

Postural Care
PDF Downloads

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

Rolling Dynamics, Rolling Resistance &  Optimizing Wheeled Prosthetics