Modular seating and a moulded wheelchair
Night-time positioning equipment (‘sleep system’)—supine position
The aim is to correct, maintain or compensate for a destructive body posture , by providing adaptive equipment and advice to facilitate alignment, comfort, function and participation over the 24-hour period. The assistive devices and advice should consider the views of the client, carers and the environmental context of the individual, e.g. whether the individual attends day care or school; thus ensuring that the intervention can be implemented across all settings.
Candidates for the Intervention
Candidates for the 24-hour-body positioning include children and adults who lack or have inadequate postural control and are at risk of postural deformity (Vekerdy 2007; Hill and Goldsmith 2010). This will include, but not exclusively, those with cerebral palsy , intellectual disabilities, dementia , muscular dystrophy, multiple sclerosis (MS) , stroke , spinal cord injury , brain injury and Huntington’s chorea. Most individuals who lack the ability to change their position would benefit from this intervention. It is important to emphasise the need for early intervention (Gericke 2006).
There are no epidemiological studies to suggest the proportion of individuals who would benefit from this intervention. However, the application of 24-hour-body positioning will depend on several factors. Firstly, the prevalence of individuals with neuromuscular conditions and secondly, the availability of assistive devices and access to services which will vary from country to country and may depend on the socioeconomic climate of that country or region. It has been estimated that the number of individuals with complex physical needs will increase (Cobb and Giraud-Saunders 2010). One such example is in England, where adults with profound and multiple learning disabilities (PMLD) will increase by 1.8 % annually from 2009 to 2026 (Emerson 2009). This client group frequently utilises 24-hour positioning, and thus the application of this intervention will increase in concurrence.
Twenty-four-hour-body-positioning can be implemented in hospital, school, day care, home, nursing, respite or residential care. It should be implemented across all settings that the individual accesses. Once it has been identified that the individual is at risk of postural deformity by a carer or health professional, a referral should be made to occupational therapy to assess and manage 24-hour positioning.
The Role of the Occupational Therapist
According to Wynn and Wickham (2009), a number of distinct roles are related to the occupational therapy intervention of 24-hour positioning including: (a) comprehensive assessments (see below), (b) provision of assistive devices, (c) communicating individualised postural care programmes, (d) training of staff and carers, (e) reassessment of the individual and (f) orthotics.
Traditionally, occupational therapists have focused on posture and positioning for seating and wheelchairs. However, individuals may spend up to half their time in bed (Hill et al. 2009), and therefore considering posture over the 24-hour period is essential; particularly as sleep position will impact on sitting position (Hill and Goldsmith 2010). Correction and/or maintenance of posture is of immense importance as it is recognised that it can influence respiratory function, oral intake, motor skills , digestion and level of pain, etc . (Pope 2007; Hill et al. 2009; Hill and Goldsmith 2010); and thus greatly impacts on the general health of individuals. This comprehensive intervention will assist with reducing postural-related complications, such as chest and urinary tract infections, pressure and shear injuries, joint contractures , deformity, pain and aspiration (Hill and Goldsmith 2010). It is also important for carers as it can lessen care burden by reducing tone in order to facilitate access for personal care and toileting (Wynn and Wickham 2009) as well as facilitating a safe and upright posture for assisted feeding (Redstone and West 2004; Vekerdy 2007).
Comprehensive assessment is an important part of the intervention (Isaacson 2013; Pountney et al. 2004). It includes: (a) documenting the position of pelvis, spine, head, trunk, hips, knees, ankles, feet and upper limbs in their current assistive devices as well as recording any problems with existing devices (Zollars 2010); (b) chest symmetry measurements taken in the supine posture on a plinth, which comprise measuring vertically and diagonally from the coracoid processes to the anterior–superior iliac spines (ASISs; Pope 2007) and from the xiphoid process to a firm surface on the left and right; (c) measurement of key joint range of motion (Ryf and Weymann 1999) tested in supine or a side-lying posture , including hip flexion/extension, hip abduction/adduction, hip internal/external rotation, hamstring range and cervical flexion/extension; (d) assessing the spine for scoliosis, kyphosis and lordosis; (e) a neurological assessment, including testing muscle power, tone and associated reactions is required (Pope 2007); (f) simulation of optimal sitting and lying postures ; the therapist determines where necessary forces/supports need to be applied in order to correct or maintain positioning (Pope 2007); (g) pressure mapping if indicated (see chapter 16); (h) risk assessment which should consider risks associated with seizures, reflux/dysphagia, body temperature regulation, pressure ulcers and positioning belts; (i) manual handling assessment, e.g. what type of sling is required to assist with positioning; (j) environmental and transportation assessment; this involves ensuring that the equipment is compatible with home environment and the vehicle used for transport (Zollars 2010); (k) pulse oximetry (SpO2 levels)—oxygen saturations in both lying and sitting postures are recorded and (l) gathering and recording important information on the client, including, the level of independence, swallowing issues, ongoing medical problems, pain management, communication , perceptual and cognitive status, sensory , proprioceptive and vestibular deficits, presence of dyspraxia and visual disturbance (Pountney et al. 2004; Pope 2007; Zollars 2010).
Specialised assistive devices are necessary to support positioning and function (Pountney et al. 2004), for example sleep systems, moulded wheelchairs or static seating (Figs. 14.1 and 14.2), bespoke shower chairs and specially designed hoist slings. Some individuals may require all of these assistive devices depending on their functional needs. The occupational therapist assesses with these devices and then prescribes to meet the client’s positioning needs, e.g. a moulded wheelchair might be prescribed for positioning during the day, and an ‘in chair sling’ may also be recommended to facilitate ease of positioning for use with the moulded wheelchair. Furthermore, a sleep system will facilitate optimal positioning at night, and finally a tilt-in-space shower chair with lateral supports might be issued to maintain a safe position during showering. The assistive devices aim to ensure that the most functional body position is maintained over the 24-hour period .
Communicating the Information
The assistive devices and the optimal positioning of the individual within each device are photographed by the occupational therapist. Photographs are a useful method of documenting intervention and can be used to record progress (Pope 2007). Written instructions are devised to accompany the photographs, providing step-by-step instructions on how to achieve and maintain each position. For example, instructions for the wheelchair might read: (a) ensure the wheelchair is in full tilt to assist with hoisting in, (b) remove the wheelchair headrest, (c) ensure the client is hoisted into the wheelchair with hips positioned at the back of the chair, (d) fasten the positioning belt and ensure it snuggly fits below the ASISs, (e) take off the tilt and (f) reattach the headrest. The same process is followed for all assistive devices that are prescribed. This information is collated into the 24-hour-positioning programme booklet which is shared across all settings, e.g. home, day care and school. The importance of 24-hour-positioning booklets to educate carers and staff has been highlighted by several researchers (Maher et al. 2011; Hutton and Coxon 2011) to ensure adherence to the recommendations and advice provided by the occupational therapist.
All staff and carers involved with the individual are educated by the occupational therapist on the importance of 24-hour-body-positioning for functioning and for preventing deformities, pressure ulcers , chest infections, etc. They are trained on the use of the assistive devices prescribed, using the individual’s 24-hour-body-positioning booklet. Carers practice using the equipment and achieving the positions shown in the 24-hour-positioning booklet until they are competent, under the guidance and supervision of the occupational therapist. This type of education and support has been found to be an essential component of 24-hour positioning (Maher et al. 2011; Hutton and Coxon 2011), and therefore the occupational therapist must make education a priority when providing 24-hour-body-positioning intervention.
Gibbs (2005) recommended that each client who receives 24-hour positioning should be reviewed annually. This is to ensure that the adaptive devices continue to support functioning and to record any changes in physical and social abilities. An outcome measure that allows comparisons of functional ability from one assessment to another should be an integral part of the 24-hour positioning. The outcome measure(s) selected will largely depend on the type of clients that attend your clinic.
Some individuals will require input from other professionals to optimise their positioning over the 24-hour period. For example, a review of the medication from a physician may be required to assist with the management of spasticity, a dysphagia assessment may be requested from a speech and language therapist or a spinal brace may be requested from an orthotist. The occupational therapist should ensure that all referrals to other professionals are made in a timely manner.
There is a growing evidence base in support of 24-hour-body-positioning with a number of authors finding this intervention enhanced comfort, musculoskeletal alignment, participation and functioning (Farley et al. 2003; Chia 2005; Gibbs 2005). Researchers also highlighted the need to implement this intervention to support physiological functioning such as respiration (Farley et al. 2003). Only one study did not support this intervention and reported that there was inadequate evidence that 24-hour positioning prevented deformities in children with cerebral palsy (Gough 2009). However, this author did highlight the importance of shifting the focus of 24-h positioning towards occupations and daily life and away from body structures. This is a reasonable recommendation as optimal positioning will enhance comfort and stability, thus freeing up body parts to engage in meaningful activities. A number of studies found that education and co-operation of carers was deemed an essential component of successful 24-hour-body-positioning (Humpherys and Pountney 2006; Hutton and Coxon 2011; Mahler et al. 2011). Table 14.1 shows a summary of the literature reviewed.