Non-Invasive Treatment: 24-Hour Posture Management's Potential Impact on Spasticity
- By Lee Ann Hoffman
- Feb 01, 2018
The primary aim of 24-hour posture management is to prevent or reduce secondary complications resulting from poor posture, improve function, improve comfort and ultimately improve quality of life. We know that gravity combined with immobility will result in secondary complications, such as muscle and bony distortions caused by the adverse effects of spasticity, such as muscle spasms, fatigue, pain, decreased function, muscle and joint distortions. Body shape distortions result in asymmetrical postures, which increase the likelihood of peak pressure due to unequal loading of the body over the support surface.
The focus of intervention is to decrease spasticity, which can, in turn, improve mobility and function and help reduce the development of contractures. Bower (2009) stated that “despite the best physical therapy, orthotics and medications, spasticity combined with skeletal growth can result in the formation of joint contractures and or dislocation.” The muscles of the hips are among the strongest and largest in a child and therefore the most commonly seen results of hip spasticity are hip dislocation and a shortening of tendons, which then lead to contractures and pain. Spasticity is also often observed in the displacement of bones of the hands and feet. Distortion of the spine (scoliosis) is a commonly observed phenomenon in the population with cerebral palsy.
Therapy and orthoses are not administered to reduce spasticity, but rather to control the effects resulting from the neurological symptom with the aim of maintaining function and body alignment by working towards reducing the secondary consequences of spasticity.
A Holistic Management
It is essential that the focus is on the holistic management of spasticity to prevent musculoskeletal distortion. The 24-hour posture management approach provides a foundation for building a stable foundation for posture and takes into account the individual’s tone and how to facilitate movement to maximize activity and participation (Mendoza et al 2015) in line with the domains of the World Health Organization’s (WHO) International Classification of Function, Disability and Health (ICF) Framework (WHO 2001).
The individual’s positioning needs must be considered over the 24-hour period — i.e., sleep and resting positions, sitting and standing — in addition to any other movement opportunities the individual has available to them, such as leisure time. Body postures form an essential component of the individual with spasticity’s physical management. No amount of hands-on therapy can compensate for this core element in preventing or relieving the secondary complications that can arise from spasticity and ineffective postural management.
By providing services to individuals with complex rehabilitation needs, which are geared towards early intervention and prevention, rather than surgical procedures to correct hip dislocations and scoliosis, in addition to the associated rehabilitation needs — it is evident that cost savings can be achieved by implementing 24-hour posture management plans, equipment and protocol.
Treatment is planned on a case-by-case basis with the aims of reducing the physical challenges for caregivers, i.e., those of taking care of the individual’s personal hygiene, dressing and feeding.
Sitting and Standing Postural Orientations
There are many types of wheelchairs, seating systems, standing frames and other pieces of adaptive equipment, which are available to assist individuals with motor impairment to maintain symmetrical, stable postures during the daytime to promote function, and also to reduce or prevent secondary complications that often result from poor posture.
Lange (2009), noted that the concept of therapeutic positioning during the daytime is widely accepted. We just need to take a look around at most equipment providers’ Web sites, conferences and exhibition booths to note the plethora of equipment available to address both seating and standing postural needs. Everything is linked; for instance, Mendoza et al (2015) noted that the child with CP’s ability to “acquire postural control in sitting will influence the development of gross motor functions, such as standing and walking.”
It is also worth noting that, albeit challenging to manage in the seated orientation at times, spasticity is not all bad!
Usually, upper motor neuron lesion (UMNL) signs are viewed as a negative occurrence, resulting in spasms, spasticity and pain. This is not always the case, as many individuals make use of spasticity to recruit for movement such as transfers, standing and walking. Orthotic devices may be employed to assist in harnessing the correct joint and limb alignment while making the most use of this UMNL phenomenon.
Lying Postural Orientations
It is vital to consider that many of the individuals who make use of therapeutic positioning during the daytime often spend in the region of eight to 12 hours a day in bed, lying in unsupported, asymmetrical, destructive postures, which negate the gains and benefits of good positioning during the daytime (Lange 2009).
Night-time therapeutic positioning during rest and sleep hours is an effective intervention that continues to promote the daytime positioning and postural gains achieved. Night-time positioning supports are gentle and provide stability in the lying position with the aim of protecting body shape. The use of both informal and formal supports thus have application and benefit in providing gentle positioning and a stable postural base.
Pope (2007b) undertook work with individuals with multiple sclerosis (MS) who presented with largely reduced or minimal ability to independently move or change their position. Health professionals with extensive experience in the field, such as Pope (2007b), share their clinical experience in providing effective night-time positioning and postural supports for people with MS. Supports such as a T-roll can assist in providing stability and postural control. It is essential that the correct size and application of the postural support equipment is provided to ensure that it assists in controlling the spasms/spasticity in the lower limbs without restricting movement available to the individual. With the introduction of postural support equipment, the movement following the spasticity-sequenced movement pattern will enable the individual to settle back into a more ‘relaxed,’ yet corrected position due to the postural support offered by the device (Pope 2007a and b).
Equipment and supports used over the 24-hour period aim to provide the individual with support to help control movement and positioning/position changes (Porter et al 2007, 2010), the regulation of temperature and thermoregulation — all the while providing positioning to protect body shape (Clayton et al 2017) and promote hip health (Pountney et al 2002, Picciolini et al 2009) and prevent lateral spine curvature (Pope 2007a, Clayton 2017).
Noninvasive and Invasive Treatment: Polypharmacy & Surgery
Posture management is part of the treatment intervention that is used in conjunction with tone-reducing medication. Medication alone is rarely able to address and improve outcomes.
Oral medication used in the treatment of spasticity includes Baclofen, Benzodiazepines, Dantrolene sodium, Imidazolines and Gabapentin.
Injectables, such as Botulinum toxin type A, are used for the treatment of focal spasticity.
Intrathecal interventions: Baclofen/Phenol pumps are treatment modalities considered when oral medication is deemed to not have the desired impact on the management of spasticity.
Surgery has an important role in the management of chronic spasticity. Selective dorsal rhizotomy and/or orthopaedic surgery are surgical interventions undertaken. Orthopaedic surgery is a treatment pathway undertaken to repair the negative effects resulting from spasticity, such as hip dislocation. Orthopaedic interventions may be required to release tendons, fuse joints or cut bones — however, this does not address the underlying neurological phenomenon. It is important to note that post-surgery postural management is required to assist with recovery and maintaining the surgical corrections achieved over the long term.
Food for Thought
Gough (2009) stated, “Children with disability become adults with disability; we need to develop a paradigm of postural management that will enhance their environment and participation as children [and] will continue to be effective as they become adults, [so they aren’t] facing potential isolation and a loss of support.” Equally — we are faced with a large aging population with co-morbidities who are living longer due to advances in medical interventions and treatment.
If we know that spasticity is a major contributing factor to problematic biomechanical changes and how it interferes with the function and care of the individual, then surely we need to consider all interventions, especially preventative measures, in our resource-limited climate that we currently find ourselves in?
Isn’t it time you considered a 24-hour posture management approach for the individuals you serve?
This article originally appeared in the February 2018 issue of Mobility Management.