While so much of seating focuses on wheeled mobility, much of life happens out of the wheelchair. That’s especially true for children, whose daily environments can include home, school, cars and caregivers’ homes, where activities such as sleeping, eating, bathing, learning and playing still require functional, safe support.
This summer, Mobility Management hosted three clinical experts for our Pediatric Positioning: Beyond the Wheelchair webinar. Lee Ann Hoffman, Caitlin Miller, and Cathy Ripmaster discussed, respectively, lying posture care management, standing and gait training, and sitting outside the wheelchair.
Understanding all that 24-hour positioning support can achieve is a work in progress. But our clinical experts supplied plenty of motivation to continue educating all stakeholders.
Use the QR code in this story to register for free and access the full webinar on demand.
Lee Ann Hoffman on Lying Posture Care Management
“Lying posture care management (LPCM) is a therapeutic process that helps those with limited movement lie in supported symmetrical positions,” said Lee Ann Hoffman, OTD, EdD, MSc, OTR, ATP/SMS, CAPS, the assistant program director and assistant professor of occupational therapy programs at the University of St. Augustine for Health Sciences in Dallas. Hoffman has also served as co-vice chair for the RESNA 24/7 posture care management special interest group.
“This is part of something that we call 24-hour posture care management,” she explained. “This includes standing and sitting over the 24-hour period. The idea itself is actually very simple. However, it’s powerful.”
Hoffman pointed out that people with mobility impairments might spend eight or 12 hours a day lying down. “If those hours are spent in an unsupported posture, the results can be damaging,” she said. “So think about the presentations we often see: scoliosis, hip dislocation or contractures. But if we intervene early and consistently — that’s key — then we can address those postures and provide support of lying positions. We can actually aim to and have the outcomes of protecting body shape, improving comfort and even supporting functions such as respiration, sleep and pain management.”
Hoffman emphasized that LPCM is about more than just nighttime sleep. “It applies to napping that some of us do during the day, at times at rest, and then also any other time spent lying down. So think about rest and therapeutic positioning when you think about lying posture care management.”
High-quality sleep is so foundational that when it’s disrupted, “the impact the next day can be so powerful,” Hoffman added. Consider how you feel after a poor night’s sleep: “Maybe you have found that you’re quicker to snap at somebody and you think, ‘Oh, this is not really typical for me.’
“Now let’s think: How is my person who’s nonverbal going to communicate this discomfort they’re in, this pain, this fatigue they’re experiencing because of that poor-quality sleep? I want us to really think back to not just the individual themselves who is requiring sleep positioning, but what impact does that also have on the family and the care support who are around this individual? They are most likely also having sleep disruption.”
Cathy Ripmaster on standing and gait training
Cathy Ripmaster, MSPT, has worked as a physical therapist at Lincoln Developmental Center in Kent County, Michigan, for the past 25 years. Her school has approximately 100 students, ages 5 to 26, who qualify for the school with the label of severe multiple impairments.
Ripmaster has worked with the MOVE program — Movement Opportunities Via Education/Experiences — since 2002 and is a MOVE international trainer.
“When I think of kids that need 24-hour postural care, these are individuals who are not able to move unless other people help reposition them,” she said. “Think about what happens to our bodies if we are on prolonged bed rest. Now imagine that this is these kids’ lives, and what can happen to them if they’re not up and moving.”
Therefore, Ripmaster said, getting children upright to stand or use a gait trainer is “not only supporting bone and joint health, but we’re able to help them participate in their lives.”
That participation brings with it increased autonomy. “They’re able to become an active participant in the things going on around them,” Ripmaster said. “Being able to be upright and moving not also helps them make choices with their body — they’re also in a less dependent position. They have options to move towards things that are preferred. It’s easier for them to be at eye level with their peers, and people are more likely to interact with them and encourage communication.”
The Lincoln Developmental Center uses the MOVE program, whose principles “are very much how we direct our day and interact with our students,” Ripmaster added. “It’s more than just getting kids up in equipment. It’s a six-step program, so we’re looking at the highest level of skills that a person needs to be independent in sitting, standing and walking, and transitioning, and they’re all linked to very functional activities — for example, walking 10 feet to get from the hallway to their bed because their wheelchair doesn’t fit through the doorway.”
Ripmaster added that MOVE focuses “on what is needed for that child to be participating in their home, what is physically challenging for that student, and what breaks the backs of their families. Then we’re looking at what kinds of activities the families would like them to do based on their level of function.”
Caitlin Miller on non-wheelchair seating
Caitlin Miller, OTD, OTR/L, received her doctorate in occupational therapy from Belmont University in Nashville, Tenn., and went on to work at Vanderbilt Children’s Hospital in its outpatient setting and within its specialized seating and positioning clinic. At Numotion, Miller now serves as director of sales.
“It is very all encompassing,” Miller said in considering seated positioning outside the wheelchair. “There are so many other alternative positioning places that a child could be, so I like to provide framework around that, as a clinician and now as someone who works on the vendor side. The framework allows us to look very holistically at the child.”
Miller said she considers “areas of occupation” that include sleep, playing, social participation, activities of daily living. She also referenced what Hoffman and Ripmaster said earlier about lying posture and standing.
“If a child needs positioning support in one of those areas of occupation, typically they’re going to need positioning support in the other ones,” Miller noted. “And so in looking at that holistic approach, I like to organize it in my brain that way. Not only does this give us framework, but it actually leads us to our goals of the piece of equipment.”
This approach, Miller added, can provide a starting point.
“I locally guest lecture at some universities and new clinics, where clinicians don’t have experience with equipment,” she said. “You walk in and they’re looking at you wide eyed and terrified, because they have no idea where to start. So I like to bring them back to baseline and say, ‘This evaluation for equipment is going to be no different than any other evaluation, right? We’re going to leave with a goal.”
For example, an activity chair: “It has a tray, it has positioning components like laterals and a chest harness, because we know as clinicians that posture promotes function. If we don’t give them that proximal stability, we are not getting that distal mobility to be able to self feed. We can accomplish that through a piece of equipment.
“Same thing with grooming: If we have a child that wants to complete grooming at the sink, activity chairs can have an anterior tilt feature, which allows them to really have good weight bearing through their lower extremities. That can help promote that reach that Cathy was talking about.”
Advocating for consistent posture management
How do these clinicians promote the need for 24/7 posture care management to parents, school aides, clinical peers?
“Caitlin’s using my favorite OT term: It depends,” Hoffman said. “It depends on who I’m speaking with. If I’m speaking with a medical professional, I can maybe cut to the chase. If I’m dealing with folks who are not in the medical realm — families, friends, caregivers, teachers — I like to use an individualized approach. ‘Have you ever slept in a hotel for the first night of your vacation, and it’s not your pillow, the room temperature is not right, all the things just don’t align?’ And then bringing that back to the client in front of us: ‘These could be things that are impacting their function.’”
The discussions, Hoffman added, “are not a monologue or a soliloquy. It is about having that real interaction about ‘What have you noticed?’”
“I was in an evaluation with a parent who had just had a baby welcomed home out of the NICU,” Miller said. “And I love equipment because I know what a gift it can be to families. But I had no knowledge of where mom was in her phase of acceptance of all of this; it can be very overwhelming. So I think gaging where your families are in their journey, meeting them where they are with lots of empathy and lots of explanation.”
Ripmaster added, “I also feel like it’s everyone’s role, right? I think it is not only educating that family and talking with them, but it’s also looking at all the people who are on the team and making sure that everyone understands the importance of these items, starting now.”
Another important message: Optimal positioning beyond the wheelchair can make a positive difference even if it that support doesn’t start in early childhood. “I work with students up to age 26, and I can still see a difference when we’re really intentional with our programming and positioning when we start in their 20s,” Ripmaster said. “So we can all start now and not feel bad that we haven’t started before. Because we didn’t know. But move forward. We can make a difference every day in what we do.”
Editor’s Note: This story was originally published in the digital edition of Mobility Management’s Seating & Positioning Handbook.
