An introduction to 24 hour posture management – theory and practice in Peru!

Eleanore’s Project is another non-profit organization working internationally to promote 24 hour posture care and responsible wheelchair provision, primarily in Peru. In April 2017 Tamara gave a talk as part of the Global Public Health Minor Lecture Series at the University of Montana. Missoula Community Access Television recorded it so here it is – follow the link!

http://162.219.73.99/Cablecast/public-site/index.html#/show/6956?channel=1

Lena’s Story

Lena is a beautiful 8 year old Montana girl. She is also a very lucky girl because her grandmother chose to learn about 24 hour postural care and has been implementing it since July 2015. Her efforts on Lena’s behalf have paid off in a big way! Lena is now sitting straighter even out of her wheelchair, focusing better in her therapies and best of all – she is no longer expected to need surgery on her spine for scoliosis. Lena and her family did this themselves – what a success story! We are happy to be able to celebrate with them.

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24-hour posture management – it’s a piece of cake!

Have you ever ordered a slice of your favorite cake and then only eaten the icing? And then just left the rest?  Seems crazy, right?

Well – 24-hour posture management is very similar to the scenario above.

By only addressing the postural orientations of sitting and standing, and not postures in lying, a crucial part of posture management is being completely ignored.

Again to the cake analogy:  just try to imagine baking your favorite cake without a key ingredient. Each and every part of any cake recipe is important — as are all three of the major postural orientations in postural management.

Here is how it works:  Posture management aims to maintain and protect body shape by providing support over the whole 24-hour period where three predominant postural orientations are present: Lying, Sitting and Standing.

When appraising a day in the life of a person with complex rehabilitation needs, I am always intrigued and humbled to see the dedication and commitment from therapy teams, support networks, families, and the individual themselves. Numerous therapy sessions per week, time spent in standers, seating systems and various positioning assistive devices. All the focus and emphasis is usually placed on corrective positioning in sitting and standing postures.

However, it saddens me that often this hard work can so easily be undone, usually due to lack of positioning support in lying. Out of the estimated 8760 annual hours, it can be roughly calculated that approximately 3600 hours are spent in lying. Therefore, potentially 3600 hours of unsupported lying.

Enter Gravity into the equation: The distortion of the body in unsupported lying is further influenced by the effect of gravity on the body structures such as the hips, pelvis and the chest wall. Studies on newborns lying in asymmetrical postures have been well-documented noting the negative effect which gravity has on the immobile growing child.

So what does Lying have to do with sitting? There is mounting evidence highlighting the link between habitual postures assumed in lying and their influence, along with a ‘dash’ of gravity, on seated postures. Changes in body shape occur in lying, when the person no longer has the ability to self-correct, or is placed in unsupported postures. Damage occurs to the individual’s body as a result of prolonged and sustained lying postures. It is clearly evident that asymmetrical postures result in unequal tissue loading. If this is left unchecked, the individual is likely to develop postural changes, such as asymmetry, through contractures and deformity, which often makes positioning the individual in any standard equipment challenging and sometimes impossible.

Further evidence highlights the correlation between asymmetrical lying postures and postural deformity, when exploring chest wall deformities, windswept lower limbs, and joint dislocation. Sadly, the net effect of poor unsupported positioning in lying, has a far reaching impact resulting in serious health problems related to pain, breathing, swallowing, digestion and an increased risk of pressure areas. The consequences of failure to prevent the distortion of the individual’s body shape are both serious and potentially life-threatening.

Good supportive positioning in Lying is absolutely essential.

Sometimes it is the smallest changes that can have the biggest impact.

Where to start? I would encourage you to start small. Implement small changes in lying to the night-time positioning of an individual with posture management needs. Gradual changes and a gentle start are so important — as good quality sleep is essential.  Respecting the individual, their comfort and their sleep – as well as those of the family and the support network, is an effective way to begin this process. Remember – the poor posture did not occur in one week, so it won’t be remedied in one week…but changes will literally happen ‘overnight’.

So I remind you, that by only addressing the individual’s postures in standing and sitting and not those in lying, it is truly like eating only the icing on the cake — and consequently missing out on the whole cake.

With 24-hour Posture Management, you can now have your cake and eat it too!

 Lee Ann Hoffman, MSc. Rehabilitation: Posture Management

Talking about posture and disability

Posture means many things to different people. The words “good posture” often conjure memories of being told to “sit up straight” as a kid or images of ramrod stiff military posture – but that is not what we are talking about here!

At Posture 24/7 we focus on how habitual postures (used persistently and frequently as a habit) can have a huge impact on the lives of people with motor disabilities – and not necessarily for the best! While most of us take for granted that we can choose the postures we assume, this is not the case for many people with impaired movement. When we have the intrinsic ability to control our bodies against gravity we can choose to move in all manner of ways, to assume and maintain all kinds of positions. We may choose whether to slouch as we relax or sit erect with good core stability as we work, but what if we did not have that choice?

When a person has limited ability to move the whole game changes. This is true not only for those who can move very little or not at all, but also for individuals who move only in limited ways. This can be related to irregularities in muscle tone, paralysis, sensory impairment, poor coordination, joint contractures and many other factors. We can describe this as having a limited movement repertoire. When one cannot easily, independently and frequently move into a variety of different postures during the day and night, gravity and time can become the foe.

When the body is positioned unequally between its two sides we call it postural asymmetry. This is not a bad thing for short periods of time, when it is counteracted by movements or postures in the opposite direction so that the body is in balance. 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 the ability or assistance to move out of it and into better balance.

When that happens a person’s body shape can slowly and inexorably change from symmetry to distortion. It can be so gradual that the progression toward scoliosis, dislocated hips and a flattened chest is not noticed and addressed until it is so obvious that it cannot be ignored.  By then the person’s health has already been compromised and surgery is considered to be the only alternative. Over 30+ years of living and working as an occupational therapist in my community, I have seen what happens over time to children born with impairments and beautiful, symmetrical little bodies.

24 hour postural care augments traditional therapies and treatments to provide the foundation that every person with a disability needs in order to develop and/or rehabilitate to their own personal best functional level – a symmetrical, balanced body shape.

Tamara Kittelson-Aldred, MS, OTR/L, ATP/SMS

 

Finding Pieces of the Puzzle

For many years now I have spent my work days with people who have motor impairments, and need wheeled mobility and seating systems. Most of them are children and adolescents, but some are adults who have developmental disabilities. Since kids grow up, living and working in the same community for 32 years has given me the opportunity to see many of them mature into adulthood. I have grown and learned along with them, and have watched children born with beautiful, symmetrical bodies become adolescents and adults with distorted body shapes.

These kinds of secondary complications – scoliosis, hip dislocations and so on – only get worse as time goes on. Last year a young man I knew from 3 months of age to adulthood died at age 30 – his breathing and digestion compromised by his complex body shape. During his growing up years I thought we were doing all we could by providing the best wheelchair seating systems available. I learned too late (for him) about a crucial missing piece that could have improved the quality of his life immensely and perhaps even changed its course – 24 hour postural care.

What if there were a gentle, non-invasive, inexpensive way to:

  • Preserve and improve quality of life and muscle tone
  • Reduce pain
  • Ease physical care
  • Prevent/limit distorted body shapes in people with motor disabilities?

What if this gentle, non-invasive approach for people with motor impairments could:

  • Improve sitting posture and tolerance?
  • Increase successful use of seating systems?
  • Help complex seating systems last longer?
  • Help people sleep better?

There is such an approach – 24 hour postural care – which when well implemented can often provide these benefits and more. It may be a fairly new idea on the North American side of the Atlantic, but in other places it has been around for years now. Perhaps the time has come to raise awareness in the United States?

Tamara Kittelson-Aldred, MS, OTR/L, ATP/SMS