North Carolina Physical Therapy Ebook Continuing Education

Some individuals with motor impairment also have significant health problems, causing them to require frequent attention during the night to keep them safe. For some individuals, basic physiological mechanisms such as breathing and swallowing are influenced by body posture and movement as well as body position with respect to gravitational forces. Some individuals are even at risk of becoming entangled in bedcovers or pillows because of uncontrolled movement patterns, leading to possible asphyxia (Ágústsson & Jónsdóttir, 2018). Additionally, many individuals with neuromuscular problems are at risk of developing pressure injuries, loss of joint range of motion, and orthopedic distortions such as scoliosis and hip dislocation that may lead to costly surgical interventions. Many of these people spend much of their days and nights in destructive, asymmetrical postures that actually facilitate the development of orthopedic distortions and associated health complications. For example, Mark is a young man with cerebral palsy who is developing a lateral scoliosis. When positioned in his wheelchair seating system, his scoliosis is about 20°. When first placed in bed, his curvature is about the same. After a short period of time, however, as Mark’s muscle tone is triggered, his scoliosis is pulled into 45° – where his spine remains for the next 10 hours. The concept of therapeutic positioning during the daytime is widely accepted. Many types of wheelchairs, seating systems, and other pieces of adaptive equipment are used in order to help individuals with motor impairment maintain symmetrical, stable postures during the day, both to help them function but Figure 17: Brad’s Pre-Intervention Sleeping Posture

also to help prevent orthopedic complications. However, these same individuals may be spending 8 to 12 hours a day in bed, lying in asymmetrical, destructive postures that can negate the benefits of good positioning during the daytime. Therapeutic positioning during sleep can be especially effective because the person is not performing tasks that may increase muscle tone and abnormal movement patterns. Sleep positioning can therefore be a vital component in the overall 24-hour postural management and care of individuals with severe motor impairment. Postural care has even been demonstrated to reverse established orthopedic and range-of-motion limitations. Case study Brad is 16 years old and has cerebral palsy. His spinal curvatures and rib cage distortions have worsened significantly over the past 9 months due to a growth spurt. He has a custom-molded seating system, but his positions in bed (both for daytime care and nighttime sleeping) are very destructive (Figure 17). The most commonly recommended sleep position is in supine, sometimes with the head elevated if reflux or other aspiration concerns are present. Breathing issues in supine and side lying leave Brad able to tolerate sleeping only on his stomach. A combination of positional supports was placed at nighttime (Figure 18) to achieve and maintain as symmetrical a position as possible. Brad reportedly had never slept more than 2 hours at a time since birth. With the sleep positioning system in place, he is now averaging 6 hours of sleep at a time. His spine curvature, which had progressed to 40°, was actually reduced to 20° after several months of nighttime positioning.

Figure 18: Brad’s Nighttime Positioning System

COMMON POSITIONING CHALLENGES AND STRATEGIES

The following sections will systematically look at common seating challenges by area of the body. Although, in actuality, these issues cannot be addressed in isolation, they will be presented separately here for the purposes of instruction. When identifying specific challenges, it is critical to determine what is causing the problem because this will determine the best intervention. The goals of the intervention are important to keep in mind as well. These goals can be used as justifications for funding approval of any recommended equipment. Pelvis The pelvis is known as the cornerstone of positioning. The position of the pelvis directly influences the position of the trunk, making up the core and providing stability for the extremities and head. Common seating challenges of the pelvis include posterior and anterior tilt, rotation, and obliquity.

Interventions can utilize various materials, such as off-the-shelf cushions and backs or other linear or molded seating systems. The principles presented here may apply to various products. Seating challenges may be reducible (meaning they can be corrected by reasonable forces); non-reducible (meaning they cannot be corrected without surgical intervention); or partially reducible. Non-reducible limitations may not improve without surgery but can worsen. Posterior pelvic tilt In a posterior pelvic tilt, the top of the pelvis is tipped rearward. This is a rotational movement of the pelvis and results in a flexed or kyphotic trunk. Activity idea: Sit on your hands and feel for two bony prominences called the ITs (Figure 19). Move your pelvis into a posterior pelvic tilt. The ITs move forward off of your hands.

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Book Code: PTNC1023

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