24-Hour Posture Management: Challenges to Implementation
- By Lee Ann Hoffman
- Sep 01, 2016
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
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
My 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
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
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
- 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
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
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
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.
This article originally appeared in the September 2016 issue of Mobility Management.