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A Beginner’s Guide toPostural ManagementSue HallHead of PhysiotherapyKaren MarshallWheelchair & Seating DepartmentManager
Aims of this PresentationWelcomeThis afternoon we are aiming to give you anoverview of postural management - what it is,the underlying principles, and to outline ourapproach to managing posture in the clientwith severe and complex Neurodisability.A Beginner's Guide to Postural Management
Postural Management - what is it?Postural Management (PM) is a multi disciplinary approach that hasthe potential to assist in enhancing and maximising an individual’sabilities in a wide variety of ways including: CommunicationTaking part in activities including self care activitiesEnabling choiceIt is a 24 hour approach involving the assessment and managementof all positions that an individual uses i.e. lying in bed, sitting andstanding, and is part of the rehabilitation process or disabilitymanagement programmeTan WS et al (2009) Mortenson WB et al ( 2007) Ham R et al (1998) Levy l et al (2003)A Beginner's Guide to PosturalManagement
When would a Postural Managementprogramme be needed?If, after injury or because of disease, the individual finds it difficult to: Attain or sustain a good posture allowing him/her to move freelyand take part in daily activitiesTo sit without supportTo sit or lay comfortablyIs at risk of changes to joints or tissueHe / she will need the PM approach.A Beginner's Guide to PosturalManagement
What might have gone wrong?Severe disability and the associated postural problems arise frombrain injury and damage to the central nervous system and may leadto development of compensation strategies and postural changes.The body becomes unable to effectively control posture andmovement.The injury or disease may also lead to movement deficits, weaknessand subsequent impairment of balanceThe whole picture is also often complicated by sensory deficitsA Beginner's Guide to PosturalManagement
So how does Postural Management fitin with disability?We need to manage the individual’s posture in order to: Improve and optimise the user’s possibilities of taking part indaily life - physically, mentally and socially Stop the situation from getting worse, and losing skills, andminimise the chances of injury e.g. development of pressuresores Improve life qualityA Beginner's Guide to PosturalManagement
What other reasons are there formanaging posture?We also want to make sure that the individual is in thebest position to: Be comfortable and as pain free as possibleMove as freely as possible, with as much independentmobility as can be achievedCommunicate, breathe easily and be able to eat drink andsleep without too many problemsIf we do not help our individuals with complex disability itcan all go horribly wrong !A Beginner's Guide to PosturalManagement
What postures might you see? Most are associated with the position of the pelvis which is thekeystone to the alignment of the body in sitting, influencing thetrunk, head, leg and arm positionIn the absence of muscle control, the pelvis is free to rockforwards or backwards altering the posture and stabilityA Beginner's Guide to PosturalManagement
The PelvisThis is the text book position for thepelvis – but few of us use this for anylength of time!A Beginner's Guide to PosturalManagement
What are the underlying reasons for thealtered postures?The human body is made up of several different systems that worktogether to allow us to get on with our lives - we do not usually haveto think about how we move about and undertake our daily tasks, orthe position that we adopt to do anything.As we grow our brains develop a pattern of learning and interactionwith information being sent from many directions, enablingmovements and responses to be automatic.Disruption or damage to any of these systems can lead to changes inposture and the ability to do things.A Beginner's Guide to PosturalManagement
The Body SystemsThere are 3 main systems: The skeletal system forms the scaffolding The muscle system holds it all together and allowsmovement The nervous system measures what is going on withthe body’s position and controls its movement.A Beginner's Guide to Postural Management
The Skeletal SystemBones, joints and ligaments - without muscles theskeleton will collapse on the floor!A Beginner's Guide to Postural Management
The Nervous SystemComplicated system of nerveswired together including thebrain itselfIn addition to recognisingposition and controllingmovement it also analyses thesensory information coming infrom touch, sight, smell, hearingand tasteA Beginner's Guide to PosturalManagement
Postural Control – Movement and BalanceVisionVolition, feedforward IntegrationProprioceptionSkin - touchInfoOctober 2012BiomechanicsexternalconstraintsMovements
The BrainDamage to any part of the braincan result in changes to movementcontrol and therefore postureKey parts influencing this are Cortex Brain stem Basal ganglia CerebellumA Beginner's Guide to PosturalManagement
The Muscle SystemEach muscle is made up of fibres that will shorten (or lengthen) whenthey are stimulated by the nerves within the muscles, allowingmovement - controlled by the brainA Beginner's Guide to PosturalManagement
Use it or lose it?If a movement e.g. straightening a knee - is notcarried out regularly it may become stiff, and over along period of disuse adapts by reducing the numberof muscle units within each muscle resulting in acontracture – the presence of contractures will affectour ability to position the client effectively andcomfortablyA Beginner's Guide to Postural Management
What effect does gravity have? –The Human SandwichForces of gravity act asthe top layer pushingdown on the bodyThe person acts as the filling beingsquashed between the two forcesThe supporting surface acts asthe base of the sandwich withforces pushing up against thebodyA Beginner's Guide to PosturalManagement
The Importance of the SurfaceThe surface on which the body is resting hasan effect on comfort and position - if it iscontoured to the shape of the body it will bemore comfortable than a flat surface and willdistribute the weight more evenlyA Beginner's Guide to Postural Management
Normal Sitting PostureA Beginner's Guide to PosturalManagement
Factors Contributing toFunctional SittingThe factors that make it possible for individuals touse their skills in the sitting position are: Stable support surfacePressure distributionAbility to lean forwardsSupport of the backFreedom of the feetSecurity / safetyA Beginner's Guide to PosturalManagement
Do you need stability? - Yes!A Beginner's Guide to PosturalManagement
What could happen if postureis not managed?If the effect of the injury isso severe contracturesdevelop positioning andmanagement of the posturebecomes much moredifficult to deal with as theflexibility of the jointmovement is lostA Beginner's Guide to PosturalManagement
Simplistically – The issues to consider when planning aPostural Management angeReduced SocialFactorsEnvironmentPositioning for FunctionFatigueGjelsvik BEB (2008) PopeP (2002)
WheelchairsThree main types of wheelchair used at the RHN: Standard manual uprightTilt-in-space manualPoweredA Beginner's Guide to Postural Management
Standard Upright Wheelchair SimpleLightweightCheap Little postural supportA Beginner's Guide to Postural Management
Tilt-in-space Wheelchair Alternative positions– upright and tilted More posturallysupportive More comfortableA Beginner's Guide to Postural Management
CushionsMany different types available: FoamA Beginner's Guide to Postural Management
CushionsMany different types available: FoamGelA Beginner's Guide to Postural Management
CushionsMany different types available: FoamGelAirA Beginner's Guide to Postural Management
CushionsMany different types available: FoamGelAirContouredA Beginner's Guide to Postural Management
Other Adaptations Headrests Trunk supports Arm supportsA Beginner's Guide to Postural Management
Custom SeatingA Beginner's Guide to Postural Management
Custom SeatingA Beginner's Guide to Postural Management
The Assessment ProcessAdmission / ReferralAssessmentEquipment TrialsPMC ReviewPrescriptionA Beginner's Guide to Postural Management
Making the Right ChoicesA Beginner's Guide to Postural Management
Other Factors for ConsiderationSecondaryDiagnosesMedicationA Beginner's Guide to Postural ManagementWeight loss & gain
Other Factors for ConsiderationVision & HearingRespiratory StatusCognition &CommunicationFeeding & SwallowA Beginner's Guide to Postural ManagementTransfer MethodSkin Integrity
Spinal Curves – Support RequiredAdvancedMildLateral forces: placed to counteractGravitational forces Efficient Effective
Scoliosis – Support RequiredSevere scoliosis ( 30º) exaggeratescomplexities: Rotational forces more evident Lateral forces inefficient Longitudinal forces more efficientSevere
Choosing the Level of SupportIncreased function on the Right side disturbs equilibrium causing thepatient to fall to the side of the movement in a manner similar tocutting a guy rope holding a mast(Pope 2007)
Choosing the Level of SupportMinimal functionalmovement e.g.switch accessIncreased movementaway from base e.g.computer keyboardaccessGross armmovements e.g.self-propellingNo proximal lateralsupport needed,shoulder girdlesupportedMinimal proximallateral supportMaximum proximallateral support
Challenges to Wheelchair ProvisionA wheelchair is an assistive mobility device Every user is unique, with their own set of needs andwishes, physical functions and environment.The sitting position must allow the natural balancebetween functional stability and healthy activityachieving the most suitable user position in space.A Beginner's Guide to Postural Management
Core Aims of PositioningTake home messages - postural management helps: Encourage normal movement patterns, by re-establishing thememory of normal movement, and allowing freedom ofmovement Enable the individual to take part in everyday activities , makesure remaining abilities are used to the full, and enable thepatient to make choices about activities. Help the internal organs work as well as possible Reduce discomfort or pain and fatigue Reduce the possibility of further changes to joints and spine, andhelp manage the spasmsEngstrom B et al (2002) , Ford P (2004) Cooper RA (1998) Ham R et al 1998,A Beginner's Guide to Postural Management
Core Aims of Positioning Take home messages - postural management helps: Encourage normal movement patterns, by re- establishing the memory of normal movement, and allowing freedom of movement Enable the individual to take part in everyday activities , make sure
