Sarah Clayton, BSc (Hons) PGCE, is CEO
of Simple Stuff Works, a manufacturer
in the United Kingdom focusing on
nighttime/sleep positioning. Clayton
is a therapeutic nighttime positioning
specialist, and a passionate believer
in the importance of positioning at all
times, not just when someone is in a
wheelchair.

“We need to have an understanding
of how the lying and seated postures
are related,” Clayton said. “The way
you lie is the way you sit, and so rather than thinking of a kyphotic
posture as a stand-alone phenomenon that has an impact in
sitting and lying, we need to look at how different postures
develop over time.”

She said a kyphotic posture “is usually associated with a
habitual side-lying sleeping position with hips and knees flexed.
It can be very difficult for an individual with a kyphotic posture to
adopt a less destructive, supported supine position. They often
need very deep support, and difficulties can arise if their head is
not supported well in terms of swallowing. As kyphotic postures
are often associated with tight hamstrings, support for the legs
can also be an issue. As always, prevention is far better than cure,
and ideally the earlier a person can be supported to move toward
supported supine lying, the better.”

Why is it so important for the seating and mobility team to also
pay attention to a client’s lying-down posture?

“If we analyze where an individual may spend their time, it
becomes obvious why the need to address lying makes such
sense,” Clayton answered. “If we consider children, for example:
They will be in bed on average three times longer than they are
in school. Combine this with the fact that children release growth
hormone and grow when they are asleep: We start to see how
important it is to ensure that this time is as beneficial as possible.

“Sadly, many adults have not had access to supported lying.
It is important that we look not only to prevent distortion, but
also to consider restoration of body shape. Ultimately, if we don’t
address the thousands of hours spent in bed at night, our seating
solutions will always be limited.”

A Consideration for All Wheelchair Users

Clayton believes all wheelchair users should be assessed for
nighttime/lying postural needs.

“It is vital that we recognize that people exist 24 hours a day,”
she said. “Their disability affects them 24 hours a day, and gravity
is a force that is with them 24 hours a day. That we don’t routinely
consider seating and lying together seems illogical — without
supporting people to understand the impact of their sleeping
posture, seating services will forever be playing catch-up.”

People with postural problems while lying down can also experience
poor-quality sleep.

“When we think of our beds, we tend
to think of a place of comfort, rest and
relaxation,” Clayton said. “But for those
who are unable to move independently,
[beds] can often become a place of
discomfort, pain and restlessness.
Changes in body shape take place slowly
night after night — Rachel Wright at www.bornattherighttime.com describes a
lack of postural care in bed as the carbon
monoxide of disability. Any person who
finds it difficult to change position independently,
if at all, should be assessed with consideration to all of
the places and positions in which they may find themselves.”

The seating and mobility team can start out by asking how
a client sleeps at night, Clayton said: “The problem, once you
establish that they are not in supported supine, is how do you
support them to make that transition? Changing your sleeping
posture is not simple, particularly if you have established changes
in body shape. When we support people to make any changes,
we have a comprehensive safety checklist to consider the physical
implications of any changes. But then we also need to consider
the emotional support that is needed. In the same way that
people need help to make lifestyle changes around diet and
exercise, they also need support when making lifestyle changes at
nighttime. Here we need to explore an alternative, co-productive
way of working. We can make recommendations, but unless a
person understands the impact of their lying posture, they will not
be motivated to change it.”

And Clayton confirmed that working on seated posture and
lying posture concurrently is the optimal approach.

“To work in seating and lying in tandem is essential if you are
to establish a long-term seating solution that will continue to
meet an individual’s needs,” she said. “If you are prescribing a
seating solution, it is important to understand the goals of the
nighttime positioning plan. If restoration of body shape is the
goal (and unless there are specific safety reasons, it should be), it
is important that the seating solution is suitable.

“For example, if you are supporting someone who is able to
adopt a therapeutic night position (one in which restorative forces
can be safely applied), a custom contoured solution may not be
appropriate, as you know that within weeks/months the person’s
shape will change, and the seat will no longer be suitable.”

And the approach that has the best chance of working is one
that includes plenty of communication between the postural team
and the wheelchair user.

“The other thing to mention here is the level of collaboration
needed between therapist and individual,” Clayton said. “Delving
into nighttime is a highly personal and emotive aspect of a
person’s life, and as such great care should be taken!”

Visit Simple Stuff Works Associates at www.simplestuffworks.co.uk.