THE PHYSICAL MANAGEMENT OF STUDENTS WITH DISABILITIES POSITIONING STRATEGIES

POSITIONING “Positioning refers to the use of appropriate body positions to insure that the child is in the optimal position for learning and participating in classroom activities.” The best practice is a transdisciplinary approach that bring together therapists and other service providers that fully integrates services within the educational environment.

HAZARDS OF IMMOBILITY MUSCULOSKELETAL DIGESTIVE RESPIRATORY CARDIOVASCULAR URINARY SKIN PSYCHOLOGICAL

MUSCULOSKELETAL Skeletal Deformities Muscle Tone Muscle Strength Integration of Reflexes Osteoporosis

DIGESTIVE Ability to safely swallow GERD Shift in internal organs Constipation

RESPIRATORY Position of the jaw and other oral structures Coordination of breathing and swallowing Pooling of secretions (congestion) Quality and effectiveness of breathing

CARDIOVASCULAR Weak Heart Heart Rate Blood Return Increase Work Load on the Heart Blood Pressure Changes Pooling in the Veins

URINARY Urinary Pooling Potential for Kidney Stones Potential for Infection Loss or Lack of Bladder Control

SKIN Skin Breakdown Skin Irritation

Psychological Changes in Perception of and Responses to the Environment

THERAPEUTIC POSITIONING PRINCIPLES Provide Firm Base of Support The resting surface of the body in any position should distribute the person’s body weight across the broadest area possible. Facilitate Optimal Positioning Alignment The head and trunk need to be as symmetrical as possible so that the front of the head, trunk, and legs are facing in the same direction. The shoulders should be squared over his hips. Start at the pelvis and work up and down.

ELEVATED SUPINE

ELEVATED SUPINE PURPOSE: ADVANTAGES: POTENTIAL PROBLEMS: Good for resting and sleeping. ADVANTAGES: Low energy position except when manual or visual work is expected Breathing is easier Useful for students with poor neck and trunk control POTENTIAL PROBLEMS: Poor position for cognition and awareness Encourages skeletal deformities especially in the legs Poor positioning of the jaw and oral structures Pooling of secretions in the back of the mouth increases risk of aspiration Mucous build-up in the lungs and difficulty with coughing to clear secretions increase the risk for pneumonia. More difficult for the kidneys to drain in this position. If the student is active, they may roll off the edge or release straps.

SUPINE

CUSTOM ELEVATED SUPINE

SIDELYING ELEVATED SIDELYING

SIDELYING PURPOSE: ADVANTAGES: Can be used as a resting position or as a “work” position where the pull of gravity is balanced between muscle groups ADVANTAGES: Allows the body to relax and , therefore, allows more flexibility in the joints Decreases the influence of immature reflexes Promotes a midline head position Promotes a more symmetrical body alignment Brings both hands to midline Allows gravity to affect deformities in the legs Better alignment of oral structures Postural drainage Increased ease of productive cough Elevated right sidelying promotes gastric emptying Different visual orientation

SIDELYING (CONT.) POTENTIAL PROBLEMS: There is a risk for increased pressure on bony parts of the body Modifications may need to be made for musculoskeletal deformities Monitor the color and temperature on weightbearing extremities especially if there are documented circulation problems

ELEVATED SIDELYING

CUSTOM ELEVATED SIDELYING

PRONE ON FOREARMS (POF)

PRONE ON FOREARMS (POF) PURPOSE: Provides an alternative to sitting Can be used for rest or work ADVANTAGES: Helps improve flexibility of shoulders, elbows, hips, knees, and spine Helps improve muscle strength of the neck and trunk extensors Improved weightbearing through the shoulder joints Helps trunk alignment for improved breathing and digestion Helps clear congestion for those with trachs, URI, and chronic congestion Brings the jaw forward Aids kidney and bladder drainage Inhibits/integrates abnormal reflexes/movement patterns Pressure relief on the skin

POF (CONT.) POTENTIAL PROBLEMS Muscle tightness at the shoulders or hips may not allow proper positioning Safety risk for students that are able to move Frequent repositioning may be required

PRONE ON FOREARMS (POF)

POF (CONT.)

QUADRUPED ON FOREARMS

QUADRUPED ON FOREARMS (QOF) PURPOSE: Same as other prone positioning with additional benefits ADVANTAGES: Prone position available for those with severe hip flexion contractures Helps improve flexibility in shoulders, elbows, hips, knees, and trunk Improves muscle strength of neck and trunk extensors Increased weightbearing through the shoulders and hip Brings the jaw forward Aids kidney and bladder drainage Pressure relief on the skin Inhibit/integrate primitive reflexes

QOF (CONT.) POTENTIAL PROBLEMS: Modifications may need to be made for those with shoulder and hip tightness Safety risk for those students that are able to move Frequent repositioning may be required

QUADRUPED ON FOREARMS (QOF)

QOF (CONT.)

CUSTOM QOF

CUSTOM QOF (CONT.)

STANDING

STANDING PURPOSE: ADVANTAGE: SUPINE To allow students to bear weight through their extremities while in an upright posture ADVANTAGE: SUPINE Provides full length support which is better for those with limited head control Promotes weight bearing through the heels Allows students with limited head and trunk control to be in a more vertical position with their peers Promotes improved physiological function

STANDING (CONT.) ADVANTAGES: PRONE: Promotes strengthening of the neck and trunk muscles to facilitate a more upright posture Provides support while allowing arms and hands to be free to engage in an activity Provides for weight bearing through the arms and legs Provides maintained passive stretch to hip and knee flexors and calf muscles Pressure relief for the skin Allows students to be in a more vertical position with their peers

STANDING (CONT.) POTENTIAL PROBLEMS: Elevation should be gradual if the student is not used to upright. Can be done in times increments during a session. Students may experience circulatory changes if they are not used to being upright. Watch for changes in color and temperature Students may experience hypotension if they are not used to being upright. Watch for pallor, sweating, changes in breathing.

SUPINE STANDER

SUPINE STANDER (CONT.)

PRONE STANDER

STANDER-OTHER

KNEELING

TALL KNEELER PURPOSE: ADVANTAGES: POTENTIAL PROBLEMS: To provide an alternative upright posture when limitations prevent a standing position ADVANTAGES: Same as for standing but with a shortened lever arm POTENTIAL PROBLEMS: Availability is limited as this is a custom piece of equipment. Not available commercially. Hip flexor tightness may not be able to be accommodated if moderately severe. May not be recommended for students with little to no head and trunk control

TALL KNEELER

SITTING

PROPER SITTING POSTURE Pelvis is neutral or slightly forward Weight is evenly distributed on both buttocks Hips and knees are bent to 90 degrees Feet are supported Shoulders are squared over the hips and even Head is midline

PROPER SITTING POSTURE

PROPER SITTING POSTURE (CONT.)

ADAPTIVE SEATING PURPOSE: ADVANTAGES: To provide needed support to allow the student to be in a seated position for work ADVANTAGES: Allows students to sit at a work surface with their peers Provides head and/or trunk support for visual orientations, trunk control, and balance while concentrating on tasks Allows arms to be available for function Breaks up undesired patterns and positions Allows adjustments as the student changes Better positioning for feeding Visual orientation for tracking and eye hand coordination

ADAPTIVE SEATING (CONT.) POTENTIAL PROBLEMS: Provides too much support Skin breakdown Circulatory impairments Range of motion or presence of contractures may not allow positioning in adaptive seating Positioning in seated positions for too long may encourage formation or worsening of contractures Work surface heights may need to be adjusted

ADAPTIVE SEATING-CHAIRS

ADAPTIVE SEATING-WHEELCHAIR

QUESTIONS