Managing Posture 24 Hours per Day: Why Is It Important?
In our industry we spend a great deal of time training clinicians, suppliers, end users, and caregivers on the importance of proper positioning when clients are seated in their wheelchairs. While proper seating is vital, it's important that we consider what happens when clients are not seated in their customized seating systems. Longtime friend of Sunrise Medical and Occupational Therapist Tamara Kittelson-Aldred provides fantastic insight on 24-hour postural care.
Most of us have a vast array of postural choices throughout the day — and night. We have the ability to control our bodies against gravity and can choose to assume and maintain all kinds of positions. We choose whether to slouch as we relax or sit erect as we work, but not all people have a full array of choices when it comes to posture. In the seating and mobility world we spend much time, energy, creativity, and money on developing seating and mobility systems for folks who have postural challenges and need support. But if we are not considering the hours spent outside of the wheelchair as well as in it, we are missing a big piece of the postural puzzle.
The inability to move into a variety of positions easily, frequently, and with stability is a game changer when gravity takes over. This is true not only for those who can move little or not at all, but also for individuals who move in limited ways because of muscle tone irregularities, sensory impairments, poor coordination, joint contractures, and other factors. We can describe this as having a limited movement repertoire. When one cannot easily and frequently move into a variety of different postures during the day and night, then gravity and time become the foe. Persistent postures that become habitual will have a huge impact on the lives of people with motor disabilities — and not for the best. Believe it or not, a person's sleeping posture at night may be undermining the good done by that great seating system in the daytime.
When body posture is unequal between sides we call it postural asymmetry. This is not a bad thing when counteracted by movements or postures in the opposite direction. It is even important for function — we all use one side of the body differently than the other for certain activities. The problem arises when a person spends many hours over weeks, months, or years in the same or similar posture without ability or assistance to move into better symmetry. The result for many people, slowly but surely, will be a change from symmetry to skeletal distortion. An easy example is seen in babies whose heads become flattened from sleeping on their backs without enough "tummy time". The same forces continue throughout life but this is often overlooked, leaving people with limited motor control at risk for developing distortions that go far beyond head shape.
Changes can be so gradual that the progression toward scoliosis, pelvic rotation and obliquity, dislocated hips, and rib distortions are not addressed until they are so obvious they cannot be ignored. By then the person's health may be compromised and seating needs become vastly more complex. Over 34 years of work as an occupational therapist in my community, I have seen how children born with beautiful, symmetrical little bodies change over time to become adolescents and adults with distorted, painful bodies that impact their health and daily activities. For most of them this happened with ample opportunities for therapies, daytime equipment and other interventions. I used to wonder where we had gone wrong.
Providing good positioning and mobility options throughout the day fosters health and an active lifestyle for people with disabilities, but what about nighttime? Studies have shown that children with cerebral palsy move less than their typically developing peers, with prolonged periods of immobilized posture while they sleep. This is true of many people with motor impairments, no matter their age or diagnosis. If we ignore what is happening to a person's body when they are lying in bed, then we are missing a crucial piece of the puzzle. The time spent sleeping and relaxing outside of typical positioning/mobility equipment far exceeds school and therapy hours. Why not make good use of this time and harness the forces of gravity in a positive way during sleep, when muscle tone relaxes?
I no longer ask the question "What did we miss?" The Montana Posture Care Project is providing a systematic approach to 24-hour postural management for individuals throughout our large rural state, thanks to support from the Montana Council on Developmental Disabilities. Initial results are highly encouraging, with clear improvements in body symmetry, sleep, and reduction in pain seen in a majority of participants within 5-6 months of beginning therapeutic night positioning. These children, adults, and their families and caregivers have embarked on a path toward better health and function going forward. They are doing it through learning about and choosing to practice 24-hour postural care.
In the United States we have long focused on posture and positioning in two of the three primary postural orientations — sitting and standing. Many of us have watched as our clients' posture declined and bodies distorted. Isn't it time we began paying attention to the orientation in which we spend roughly a third of our time — lying?
- Tamara Kittelson-Aldred, MS, OTR/L, ATP/SMS
Tamara is an occupational therapist, RESNA-certified as an Assistive Technology Professional/Seating and Mobility Specialist. After years working with 24-hour postural care in her practice, she earned certificates in advanced postural care through the Open College Network West Midlands in England in 2012. Tamara has written and presented on the topics of seating, positioning, and 24-hour postural care in the United States, Jordan, and Peru. She is Project Director for the Montana Postural Care Project, funded by the Montana Council on Developmental Disabilities, and Director of Eleanore's Project, promoting postural care and responsible wheelchair provision in Peru. Tamara has worked with children, youth, and adults who have complex neurodisabilities in western Montana since 1983. She believes that her best teacher was her youngest daughter Eleanore, who was born with cerebral palsy and profound deafness.
For resources on 24-hour postural care please visit www.posture24-7.org or contact Tamara directly at firstname.lastname@example.org.
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Posted by: Date: 2/14/2017 10:49:41 AM
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