1. Building a stable posture in lying and sitting Pat Postill, Physiotherapist David Long, Clinical Scientist April 2009

2. Aims of session §To provide the principles of building stable postures in lying and sitting with practical suggestions for everyday clinical practice §To appreciate the importance of 24 hour postural management, and the need for this to fit in with the person’s lifestyle and functional abilities §To appreciate that appropriate postural management can only be achieved following a comprehensive assessment including consideration of physical data, functional aspects and lifestyle considerations

3. Overview Explore what is meant by posture Biomechanics related to stability Demonstration & theory of building a stable posture in lying Demonstration & theory of building a stable posture in sitting

4. Posture is what? §The constant struggle to remain erect against the forces of gravity §A series of positions that we use from which to function

5. Posture - ‘a constant struggle against the force of gravity’

6. In pairs……... Identify the three elements of ‘good’ posture

7. “That body attitude which facilitates maximum performance for minimum energy consumption and without causing damage to the body system.” (Pope, 2007)

8. So what are the ……... Three elements of ‘bad’ posture

9. “That which results in less accuracy, is carried out with increased effort and leads to damage to the body.” (Pope, 2007)

10. Biomechanics

11. Basic concepts Body structure is inherently unstable Without usual stabilising mechanisms it will collapse If posture sustained for long periods the tissues can adapt Multi-segmental and highly flexible wide variety of postures vulnerable to damage

12. Regions vulnerable to deviation The spine: s coliosis, kyphosis, lordosis, cervical flexion/extension The hips/pelvis The feet

13. Characteristics? l wide base l low centre of mass l centre of gravity within base Stability

14. Where forces act about a pivot / fulcrum and produce a rotational effect Moment = force x distance Moments (levers) F f d D

15. §Everyday applications l Opening a door l Lever taps §Clinical applications l Head falling forwards in sitting l Legs falling to side in supine lying §Moments can be helpful or unhelpful Moments

16. § What is pressure? Pressure = Force Area Pressure (stress) § What else is important? l Duration of applied pressure

17. Building a stable posture in lying & sitting

18. Support in lying §Lack of access to high-tech, formal lying supports is not a reason not to address support in lying §It will be shown that it is often possible to support a person in a stable posture using inexpensive, low-tech equipment

19. Aims of postural support in lying and sitting wAlign and stabilise body segments relative to each other and to the supporting surface, and wMinimise the likelihood of causing damage to the body. Thus: Facilitate function Facilitate comfort Reduce energy expenditure

20. Overall The challenge lies in providing the necessary support without compromising functional activity or restricting development

21. The principles The pelvis is the keystone of the structure. It determines the attitude of the body above and below Gravity is used to secure a position, rather than attempting to secure the position against gravity

22. Applying the principles wOrganise inherently stable configurations of posture wEnsure that the support is appropriate to the configuration

23. Applying the principles wEnsure that the contours between the body and the support are compatible w Not too flat w Not too contoured

24. Applying the principles wPromote & maintain symmetry wherever possible, but wAccommodate fixed asymmetry wDistribute the load as equally as possible

25. In summary wAnalyse. Identify what can and what cannot be corrected (from your assessment) wAlign, control and support the body throughout wSupport/off load the regions vulnerable to deviation

26. Lying, the theory Start with legs or pelvis, depending on presentation §Legs supported - why? §Pelvis neutral in 3 planes §Lumbar spine - ensure that strain is taken off the lumbar spine §Thoracic spine - ensure that any kyphosis is accommodated

27. Lying, the theory §Lateral curve – support the trunk and counteract where possible §Feet - which way will the feet tend to fall §Shoulders - what must be considered? §Arms - support to relieve any drag on the shoulder girdle

28. T- rollLog roll

29. Sitting, the theory Start with base (pelvis) and proceed down then up §Pelvis neutral in 3 planes §Thighs horizontal and slightly abducted §Lumbar spine - form and support the lumbar lordosis §Thoracic spine - extend over the lumber curve Secure the pelvis in position

30. Sitting, the theory §Knees - position at around 90° (or slightly extended) but what, vitally, must you consider? §Feet in neutral (plantigrade), with full support along the sole §Arms - support to relieve the drag on the shoulder girdle – why? §Head - balance over the shoulder girdle and trunk, aiming for a forward gaze

31. Support and control of the feet §The inverted foot resting on the support is compounding the problem

32. When there is a lack of postural competence to sit upright Build the posture in the same way, as far as is possible, then: Interface the organised sitting posture to a tilt-in-space chair What will be the effects of tilt-in-space?

33. Issues to consider wIs the piece of equipment needed? wIs it wanted? wDoes the client, do the carers, know how to use it? wCan the client and/or the carers manage it? wDoes it fit in with their lifestyle/needs/decor?

34. Health warning! §Equipment can create more problems through inappropriate recommendation due to lack of thorough assessment

35. Aims of session - revisited §To provide the principles of building stable postures in lying and sitting with practical suggestions for everyday clinical practice §To appreciate the importance of 24 hour postural management, and the need for this to fit in with the person’s lifestyle and functional abilities §To appreciate that appropriate postural management can only be achieved following a comprehensive assessment including consideration of physical data, functional aspects and lifestyle considerations

36. References / Resources §Pope PM 2007 Severe and Complex Neurological Disability Elsevier §Details of further courses available: l pat.postill@noc.nhs.uk pat.postill@noc.nhs.uk l dave.long@noc.nhs.uk dave.long@noc.nhs.uk §www.posture24.com §CEP sleep systems buyers guide. http://pasa.nhs.uk/PASAWeb/NHSprocurement/C EP