1. THE PHYSICAL MANAGEMENT OF STUDENTS WITH DISABILITIES
POSITIONING STRATEGIES

2. 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.

3. HAZARDS OF IMMOBILITY MUSCULOSKELETAL DIGESTIVE RESPIRATORY
CARDIOVASCULAR
URINARY
SKIN
PSYCHOLOGICAL

4. MUSCULOSKELETAL Skeletal Deformities Muscle Tone Muscle Strength
Integration of Reflexes
Osteoporosis

5. DIGESTIVE Ability to safely swallow GERD Shift in internal organs
Constipation

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

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

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

9. SKIN
Skin Breakdown
Skin Irritation

10. Psychological
Changes in Perception of and Responses to the Environment

11. 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.

12. ELEVATED SUPINE

13. 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.

14. SUPINE

15. CUSTOM ELEVATED SUPINE

16. SIDELYING ELEVATED SIDELYING

17. 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

18. 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

19. ELEVATED SIDELYING

20. CUSTOM ELEVATED SIDELYING

21. PRONE ON FOREARMS (POF)

22. 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

23. 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

24. PRONE ON FOREARMS (POF)

25. POF (CONT.)

26. QUADRUPED ON FOREARMS

27. 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

28. 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

29. QUADRUPED ON FOREARMS (QOF)

30. QOF (CONT.)

31. CUSTOM QOF

32. CUSTOM QOF (CONT.)

33. STANDING

34. 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

35. 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

36. 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.

37. SUPINE STANDER

38. SUPINE STANDER (CONT.)

39. PRONE STANDER

40. STANDER-OTHER

41. KNEELING

42. 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

43. TALL KNEELER

44. SITTING

45. 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

46. PROPER SITTING POSTURE

47. PROPER SITTING POSTURE (CONT.)

48. 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

49. 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

50. ADAPTIVE SEATING-CHAIRS

51. ADAPTIVE SEATING-WHEELCHAIR

52. QUESTIONS