24 hour posture management for children with disabilities BY: CAROLINE ADRIAANSE WISHESLANDER SENIOR PHYSIOTHERAPIST/OCCUPATIONAL THERAPIST CERTIFIED PAEDIATRIC MASSAGE THERAPIST (US) EMMETT THERAPY PRACTITIONER & AQUATIC REHAB THERAPIST introduction Children with movement limitations are at risk for body distortions (contractures). The more severe the limitations the higher the risk. We often assume that body shape distortions are inevitable for children with disabilities, but it should not be the case….. PROBLEM SOLVING MOST PEOPLE WITH MOTOR DISABILITIES ARE BORN SYMMETRICAL WHY DO THEY BECOME ASYMMETRICAL? CAN WE HELP THEM STAY SYMMETRICAL? CAN WE IMPROVE HEALTH AND FUNCTION WITH AN SYMMETRICAL BODY? Defining postural care Postural care is very gentle; it is not about doing exercises and stretching to change your child’s shape but instead using equipment to protect the shape they have from birth. Postural care is a program of controlled posture which manages a child’s shape using different pieces of equipment ( it can also be achieved using rolled up towels, soft toys and pillows). It needs to occur throughout the day and night, wherever your child is. It enables your child to be comfortable in sitting, lying standing or when moving position. “ Posture management is a planned approach encompassing all activities and interventions which impact on an individual posture and function ” POSTURAL CARE IS ABOUT USING THE RIGHT EQUIPMENT AND POSITIONING TECHNIQUES CURRENT SITUATION Some of us have not really thought (or heard)about importance Provision of postural care advice/services is still emerging in Sarawak. Wishesland therapists aim to develop this further..and create awareness. Some children have their body shape protected when sitting in their wheelchair but not in other positions/situations… “ “Many people like us, are unaware of how important posture is for those we are caring for. We are allowing problems to arise through ignorance” ” PARENT OF CP TEENAGER (KUCHING) WHY IS POSTURAL CARE IMPORTANT? Failure to protect body shape can result in lots of health complications: • Contractures • Pressure sores • Scoliosis • Difficulty breathing • Poor digestion • Constipation • Pressure on internal organs Promotes health and well being, prevention of disabling positions BENEFITS OF POSTURAL CARE Will help to make eating, drinking, playing and communicating easier for the child Makes it easier for the parents to care for their child Reduces need for invasive and expensive interventions, including surgical procedures. It is time for some postural exercises! Exercise 1: slump in your chair, another person resist your lifted arms….now compare with sitting straight…………….what do you notice? Exercise 1: notice your breathing depth….. Exercise 3: dangle your legs and imagine your have poor sitting balance, what do you notice? Exercise 2: sit sideways , what do you notice about your neck ? Your back? Imagine lying in your bed whole night in same position…….. The link between lying and sitting Lying/sleeping position There are 8,760 hours in a year: on average a child will spend approximately 1,140 hours at school 7,620 hours at home, of which 3,600 of those hours are spent in bed. Night time positioning can be an extremely effective way of protecting body shape. BE AWARE THAT GOOD POSITIONING AT DAYTIME CAN BE UNDONE AT NIGHT….. Lying/sleeping position o This is a poor position because: Head and body o Make sure the head is in the middle and comfortable o Body (spine) must be straight – support on the side if needed with a rolled up towel to keep the body straight o Head pushing back and turned to one side o Hips turning in causing legs to cross (scissor) o o Feet are pointing down, which means the feet cannot get flat if the child is standing Bend the hips – this helps to release tension in lower back o Place support under knees to keep hips bent – help to relax stiffness in legs o Keep legs open and uncrossed o Feet should be as close to a standing position as possible o Shoulders and arms: Should be forward and supported – ca helps to relax upper back and allows hands to open more easily. o Hands and arms away from body o Hands fisted and closed Side lying Head and body: o Head supported on a pillow so the chin is level(in the middle, with head and spine in a straight line) Legs and feet: o Keeps bottom leg straight o Support top leg bent at knee with pillows or blankets so knee is level with hip – this is important to help prevent injury to hip (dislocation) o Bending one leg and keeping the other straight helps to relax the stiffness in their legs Shoulders and arms: o Lower shoulder and arm must be brought forward so they are not trapped underneath o Keep both arm forward to bring hands together – encourage the child to use their hands by playing a game or putting a toy for them to touch or reach Prone lying o Body is not even, because head is turned Head and body: o Difficult for the child to breathe o In a straight line o Legs may be crossed (scissoring) o o Hands are in a fist Encourage the child to lift his head and look something on the floor Legs and feet: o Straight – push down on his bottom from side to side in a rocking motion to help to straighten the hips Shoulders and arms: o Arm should be in line with or slightly in front of shoulders o Encourage them to open the hands and push down on them Sitting on a chair, or on a couch Head and body: o o o o o Head is pushing back, and the child tends to slide out of the chair Hips are too straight and stiff Shoulders are not supported, and are either pulling back, or pushed too far forward Body leans sideways and is not stable Leg problems can develop from twisting of leg bones o Sit upright with back straight and head upright o Buttocks are all the way to the back o If there is a lap strap, make sure it is tightened firmly enough to stop them from sliding down the chair Legs and feet: o Legs and feet must be supported Shoulders and arms: o Should be supported slightly forward and in front of the body Principle of HoSoPoA Head over Shoulders over Pelvis over Ankle Proper seating for function Tilt in space wheelchair A wheelchair with a tilt-in-space feature allows the whole chair to tilt up to 30 or 60 degrees, depending on the model, while maintaining the hip and knee angles at 90 degrees. Traditionally been used by special need persons who require pressure relief. However, they are beneficial in many other ways as well. Here are some physiological benefits of a tilt-in-space wheelchair: reduce pressure, shear, improves stability and balance, improves endurance (child less tired), stimulate vestibular function, improves independence and promotes participation. Reclining wheelchair Like a reclining easy chair, the seat back of a reclining wheelchair tilts back. The reclining feature allows to change position in the chair without having to get up. ... The reclining feature and leg lift feature on some chair models means that a person can lie completely flat in the chair (easy for sleeping and transfers) Seating = Extension of therapeutic treatment Tilt and recline affect pressure and perfusion at the skin and muscle tissue at the ischial tuberosities, and to a minimum extent, at the sacrum. Tilt, when used alone, must be greater than about 25° to achieve pressure relief and/or tissue perfusion at the ischial tuberosities (4) Recline, when used alone, can increase shear but may provide reduction in pressure at the ischial tuberosities at angles greater than 95-100°(4) The greatest reductions in pressure are seen when tilt and recline are used together, either at tilt of 35° with recline 100° or tilt of 15-25° with recline of 120°(4) STAND UP! When to start a standing program? Children at risk of hip subluxation/dislocation should begin a standing program between 8 -12 months of age. There is no “cut off” age for implementing a standing program and it is just as important for a teenager/adult to stand daily as a child. Children with a GMFCS of IV or V are most at risk of hip subluxation/dislocation with a prevalence of between 68 – 90% of this population Types of standers: posterior and anterior and combination of both Standing in abduction Most published clinical research is based on standing with legs in 30º to 45º abduction and for levels IV and V on GMFCS Standing in abduction increases the opportunity for the head of the femur to locate into the acetabulum groove TOMMY’S STORY https:youtu.be/fbmNt4uNeGw Tommy’s story….. Use Gross Motor Function Classification system as a clinical guide Earlier is better but it is never too late….. For GMFCS type IV and V use: Good sleeping posture as soon as appropriate after birth Sitting from 6 months Standing from 12 months It is vital to include family, paediatrician, therapists, teachers SUMMARY 1 Promote awareness of 24 hour posture management 2 Introduce the basic 3-S postures Sitting Standing Sleeping 3 Introduce the basic #-S strategies Support Stable Symmetrical Thanks for attending BRING HOME MESSAGE: EFFECTIVE POSTURAL CARE-----IT IS NEVER TOO LATE REFERENCES 1. Fulford, G.E. and Brown, J.K. (1976) “Position as a cause of deformity in cerebral palsy”. Developmental Medicine and Child Neurology, Vol. 18, pages 305-14. 2. Hill [Clayton] S., Goldsmith J. (2010) “Biomechanics and Prevention of Body Shape Distortion”. Tizard Learning Disability Review, Vol. 15, No. 2, pages 15-29 3. Pope, P. (2014) “Conception, Birth and Development of Management of the Physical Condition in People with Significant Posture/Motor Deficit”. 4. RESNAPPonTiltRecline_2015.pdf 5. https:www.physio-pedia.com/Module_3:Positioning_Your_Child Some Malaysian companies Sleep positioning systems are suggested to address a range of issues. In the absence of research evidence, it is important that families do not feel pressured to use sleep positioning systems, especially if it disrupts their lives. Equally, it is important to support families in persevering, if it is something they wish to pursue. As sleep positioning systems are expensive and frequently abandoned, occupational therapists and physiotherapists need further, specific clinical guidance about how to assess who might be appropriate and which system to recommend over another, if at all. As the children typically prescribed sleep positioning systems (GMFCS Level IV or V) are often unable to express feelings of discomfort or pain (Gough 2009), careful consideration should be given to how to assess the effects for individual children. Routine audit of provision of sleep positioning systems may help identify which children benefit from, and why children and families abandon using this equipment.