Postural care is all about protecting the body shape – and lying, sitting or standing in asymmetrical positions can cause serious problems over time.
Pain, pressure injuries, joint contractures, muscle shortening, and even hip dislocations can occur if someone is in the wrong position, severely limiting their ongoing functional ability. Distorted posture can also contribute to difficulty breathing, poor digestion and pressure on internal organs.
Positioning aids are a proven way to reduce your client’s pain, improve their quality of sleep, comfort and mood, and reduce the workload of carers who don’t have to reposition them as often.
“Sleep is so important for us,” says Deb Wilson from Seating To Go. “A lot of people with disabilities experience pain and fatigue during the day so having a good night’s sleep can make an enormous difference to them, their carers and their family.
“People are able to be more easily positioned into their wheelchairs during the day if they’ve been positioned well at night.”
Deb is an occupational therapist who has specialised in wheeled mobility and postural management for the past 35 years.
She co-founded Seating to Go in 1997 and her team now offer specialised wheelchair and seating assessments plus technician services throughout the Waikato, Lakes and Bay of Plenty regions. The business is also contracted by the Ministry of Health to deliver nationwide training workshops to OTs and physios who are following the wheeled mobility and postural management competency pathway.
“I enjoy seeing the functional benefits for people in terms of being able to participate in everyday life,” Deb says. “I also love the fact that technology keeps changing and what’s possible for people is different today than it was even five years ago.”
Traditionally, wheelchairs and other seats have been the primary focus when it comes to correct posture. “But when you think about how long people spend sleeping and out of their wheelchairs, you realise it’s important to consider all the other positions as well.”
Deb says a 24-hour approach to postural management includes looking at all the positions the client is in day and night (which may include beds, wheelchairs, commodes and standing frames), to identify which positions are potentially damaging and where more support may be required.
Start by physically assessing their range of movement and looking for any red areas on their skin. Asking their carer to keep a sleep diary for seven nights is also a great tool – how long did they take to fall asleep? How often did they wake? How often did the carer need to attend to them, and for what reason? Were they stiff or easy to move the next morning? Were they irritable or happy? All of this information will help you to build a picture and pinpoint what to focus on.
Look not only at what people sleep on, but how people sleep and what positions they naturally adopt. Can they move in and out of those positions independently? Deb says the quality of the sleeping position is very important as some can be more damaging than others.
“As a therapist, you need to decide if the position the person is adopting is damaging to their body. People who are at highest risk are frail, aged adults and those who adopt positions of asymmetry and are unable to move in and out of them such as wind sweeping where both legs head in one direction. This twists the spine and increases loading on bony prominences which can cause pressure injuries. The top hip is also at risk of dislocation in children with cerebral palsy.”
Other undesirable positions include having the knees together (adducted). This can cause pressure on the inside of the knees and make it difficult to manage personal cares long term. Having the knees fall apart while lying in bed (abducted) isn’t good either as muscle shortening along the outside of the thighs can make it more difficult to be seated.
There are a wide range of positioning aids of all shapes and sizes that will support your client to lie, sit or stand comfortably and safely.
What products should you use?
“The thing I’ve learned over the years is don’t do too much all at once, particularly when people have habitual positions they go to sleep in. It can be hard to introduce a change of position,” Deb advises.
Modular lying supports are the best approach because you can introduce items one at a time and gradually increase the level of support as your client tolerates it.
Deb recommends looking to mix and match products to suit individual needs (which may come from different brands or suppliers). “What you’re aiming for is a position that is as symmetrical as the person can tolerate. The easiest position to achieve that in is supine but some people have medical reasons why this isn’t possible, or it goes against the client’s own preferences.”
What to watch out for
Adding postural supports can increase the temperature around your client. So using bed linen with four-way stretch or cooling technology can help with thermo-regulation.
“Also consider the infection control properties of products and how easy they are to clean. If they’re likely to be re-issued or shared between multiple people, choose anti-bacterial material.”
Clear, visual instructions should be made available to remind carers or family members how to use each positioning aid correctly. Remember, not everyone has had training in postural management.
If your client is a young child, place the positioning aid underneath their sheet rather than on top so it doesn’t become a suffocation risk.
Other challenges might include clients who suffer from seizures (and therefore move around a lot) or who have learning difficulties and do not understand what you’re trying to achieve. “They may not be able to communicate and could be anxious about having a positioning aid in the bed with them, so be mindful of that.”
Deb suggests reviewing the effectiveness of the supports you’ve chosen over time. “Re-do your physical assessment and make sure the positioning aids still fit them and are suitable for their needs.”
For positioning aids to be successful, they do not have to be used all night. Deb says you’re still able to create positive change for your client even by introducing products for part of the night or periods of supported lying during the day.
“Another misconception is that people need to be turned or moved every two hours. If you’re in a supported lying position, the need to change position can be reduced so it’s important to use other things like pressure mapping and skin checks to decide how often your client needs to be turned. In some cases, they can be left to sleep all night.”
Deb’s final piece of advice is to start small and focus on whatever the single biggest issue is for your client when it comes to positioning. “When people have significant or multiple postural asymmetry, it can be difficult to know where to start. But even a small change could make a big difference to their lives.”