Postural Care and Management

Postural care takes into consideration your child’s positioning throughout the day and night, taking into account the activities that they engage in throughout the day and their usual routines. Equipment, exercises and changes of position are used to promote posture, health and well-being across a 24 hour period.

Mencap Postural Care Booklet

As part of your 24hour postural management programme, your child may require equipment to support position changes and participation throughout the day. This can include:

• Standing frames
• Postural seating
• Sleep systems
• Walking frames
• Orthotics
• Lycra
• Wheelchairs

Some Equipment is provided by the NHS, however other equipment is sourced from external companies or may require private or charity funding.

In a child with movement disorders or neurological conditions there are a number of things that can cause body changes to occur, this can include:

Gravity

Gravity plays a big part in body shape changes. Gravity is a downward force that acts at all times on the body, as we change position the effect of gravity changes be this is lying, sitting or standing. If one position is maintain for extended period of time gravity can have more permanent or long lasting effects. It is therefore important that for children that have movement difficulties, they are not left in positions that promote asymmetry or in the same position for long periods.

Muscle tone

Your child may have low muscle tone (sometimes described as hypotonia), this is where muscles appear floppy, and this makes it difficult for your child to move. Often the effects of gravity are greater for children with low muscle tone. Children find it harder to sit, stand and even maintain head control without adequate support.

Your child may have high muscle tome (sometimes described as hypertonia), this is where muscles will appear stiff. Children with high muscle tone tend to hold their body in fixed positions. This then often leads to shortening of muscles and stiff joints, which can lead to pain.

Inactivity and the inability to move

Muscle tone (as described above), reduced muscle strength or impaired neurology can make movement difficult for children. This can result in children being in one position and increases the likelihood of body changes due to a lack of movement. This is where they rely on adults and carers to implement a postural care programme.

Body shape changes to a child can have many effects to their Physical, social, and psychological status. Even small changes can have a large impact on the body.

Physical 

Musculoskeletal changes:

Spinal Changes – you may hear the term scoliosis or kyphosis, poor positioning and abnormal muscle tone can contribute to these spinal changes which can in turn effect internal organs and functional ability.

Hip Dislocation – poor posture increases the chance of hips not forming correctly or the hips dislocating.

Joint contractures are a permanent shortening of muscles which result in joints becoming fixed, this directly impacts a child’s functional abilities, movement and often causes pain, as well as unwanted aesthetic appearance.

Often these musculoskeletal changes are irreversible without orthopaedic intervention therefore prevention is key.

Skin Integrity: If in one position for long periods of time the skin can begin to break down and can lead to pressure sores.

Digestion: Poor posture can lead to feeding difficulties as well as the ability for internal organs to work efficiently. Lack of movement can also contribute to constipation which can cause pain and discomfort.

Heart and Lung: This is often linked to spinal changes where increased pressure is placed on the internal organs, making it harder to breathe.

Pain: Poor posture often leads to the above points which can cause an increase in acute or chronic pain.

Sleep: Poor posture can make it difficult to get into comfortable positions which can impact on the quality and amount of sleep. This can then have a knock-on effect to the child’s day to day life as it can increase fatigue and decrease energy levels.

Social and Psychological

Reduction in participation of functional activities: activities that children enjoy may become inaccessible due to the position the child is in.

Isolation: inaccessibility as mentioned above and increased need for health interventions can lead to reduction in time spent within their community.

Impacts on family members: Body changes can lead to an increased need for care support from family members, including siblings, which impacts on their free time and their own social activities (see links below regarding further support for young carers). Often housing adaptations are required and multiple pieces of equipment are needed to support their child’s posture, this can increase stress in the home as well as an increased financial burden.

• Support for Young Carers
• Family Voice
• Disability Living Allowance

Communication: Some children may require additional support to communicate, if not positioned well they may not be able to access their communication aids.

Self Esteem: Often children become self-conscious as their bodies and appearance changes, as well as noticing the difference to their peers. This can result in children withdrawing and can affect behaviour and mental health.

The good news is that with a good postural care plan in place we can help reduce or avoid negative body shape changes. The key is understanding the importance of this and trying to implement a good postural care plan as soon as possible. Prevention is key!

X-rays

What is an x-ray:

X-rays are a type of electromagnetic radiation used produce images of tissues and structures in the body. This enables medical professionals to analyse these body structures and diagnoses pathology.

When may and x-ray be required for your child:

• Unexplained pain or discomfort.
• If your child is significantly delayed with their walking.
• If your child has a diagnosis that increases their risk of hip complications.

Who requests an x-ray:

X-rays will be requested by your child’s Paediatrician or GP. They are reported on by a radiographer and you will be given feedback by the professional who requested your x-ray.

CPIP pathway:

Children with a diagnosis of cerebral palsy will have routine screening x-rays as part of the cerebral palsy integrated pathway (CPIP). Depending on the classification of your child’s cerebral plasy will depend on the frequency of x-rays they have.

Joint Range Measurements

What are joint range measurements and why do we take them:

Measurements are taken at various joints on the body. Therapists are looking at the maximum angle a joint will move to passively. These results are compared to the average/normal joint ranges against the population and results outside of these ranges can indicate an underlying issue. It helps your therapist prescribe your child with appropriate exercises, stretches and equipment to optimise your child's function.

How are measurements taken:

Your child will be positioned on the floor or plinth (depending on what is most appropriate on the day) and their therapist will move their limbs to specific positions and will hold these for a short period whilst another therapist or therapy assistant measures the range. The ranges are measured using a goniometer (see picture below).

Does it hurt?:

Joint range measurements should not be painful. Joints will be stretched to their end range position but will not be pushed to a point that will cause your child pain.

How can I prepare for a joint range measurement assessment:

• Where possible it is helpful if your child attends an appointment in shorts or clothing that does not restrict the movement of their limbs. If your child is not suitably dressed then they may be asked to undress so that accurate measurements can be taken.
• If your child struggles to settle or does not like this assessment, it is helpful if you bring their favourite toy/distraction to support the appointment.

There is a range of different equipment that may be put in place for your child, it is important to remember that each child is different and therefore so are their postural needs. This means that the equipment provided will vary for each child.

Please note different areas/trusts will fund for different equipment, if a piece of equipment is provided, only one will be given, you will not be able to have multiple for different settings i.e home and school.

Any equipment provided by your Physiotherapist will be reviewed every 6 months by a member of their team. However here is a link for what to look for if you think there are problems with your equipment: Need link

Please contact the Physiotherapy team for any of the following reasons:

• Pain when using equipment
• Equipment visible broken
• Marking or rubbing from equipment
• Obvious miss-sizing
• Poor posture when using equipment

Standing Frames

A standing frame is a specialist piece of equipment that holds/supports a child in standing position, it enables a child to access standing for longer periods of time without the need of hands-on intervention.

Benefits of standing

• Improved digestion, bowel function and bladder drainage.
• Improved respiratory functioning and voice control.
• Promotes good hip development and formation in early development.
• Maintains and increases bone density and reduces the risk of fractures.
• Enhances circulation and blood pressure.
• Stretches muscles helping to prevent the onset of contractures.
• Allows children to interact eye to eye with their peers and participate in standing activities.
• Improves skin integrity by relieving pressure from sitting.
• Improves level of alertness and sleep patterns.

For more details on each of these topics, please see the useful links below

• Posture and Importance of Standing Leaflet
• Why Stand? Poster

Types of standing frames

Prone Standers:

    

Prone standing frames support the child from the front. These frames have the ability to tilt forward to mimic a child being in forward facing position.

Supine Standers:

Supine standing frames support children from the back. It requires a child to be lifted or hoisted onto the frame, where they are then strapped into the frame before safely standing up.

Standing Activities for Home Leaflet

Mobility Equipment

There are a variety of different mobility aids that your child may need to support them with their walking. These vary in the level of physical support they provide, and your child will be assessed for the most suitable option.

Photos of the following:

Minimal Support

• Sticks
• Tri/Quad sticks

Moderate Support

• Rollator frame

• Kaye walker (posterior walker)

         

Maximum Support

• Rifton Pacer/Grillo

 

 

Sleep Systems

A sleep system is a postural support system that is made up of a number of different parts, these can include pillows, brackets and rolls. These are designed to be used in your child’s bed to support best possible posture overnight. The aim of this is to protect your child’s body shape and can be adjusted to support position changes i.e. side lying or lying on your back.

There are 8760 hours in a year (with 24 hours in a day over 365 days of the year). Assuming your child gets 8 hours of sleep a night (and it is often more), then your child spends 2920 hours a year lying down. This equates to 1/3 of their time. It is therefore vitally important that good sleeping posture is maintained.

Usefu Links:

• A Rough Guide to Lying Straight Poster

Specialist Postural Equipment (excluding wheelchairs):

Please note, not all products seen on the below websites will be funded or provided for by the NHS. Please ask your therapist about the local provision Peterborough as it may be different from other counties. Your therapist will be happy to support you with signposting to other methods of funding if appropriate for your child I.e. charity applications.

Schuchmann - Walkers and Standers

Leckey - Walkers and Standers

Jiraffe - Walkers, Standers and Sleep Systems

R82 - Walkers and Standers

RMS - Walkers

Symmetrikit - Sleep Systems

Simple Stuff works - Sleep Systems

AAT - Sleep Systems

Above are a variations of different mobility equipment, these will vary on what is available and what your therapist deems is most suitable to your child’s clinical needs. Not all equipment is funded by the NHS and there may be times when self- funding or charity funding is required.

Wheelchairs

Wheelchairs within the Peterborough area are provided by AJM healthcare, wheelchair services. A referral by a health care professional is required before accessing this external service. AJM healthcare have an eligibility criterion and not all referrals are accepted. If your referral is not accepted, then you will be given further support/advice by their team on ways to access a wheelchair via charity funding. Please see their leaflet for further information:  Wheelchair non eligible Leaflet.pdf [pdf] 2MB

Contacts for AJM healthcare:

Website - Wheelchair services - AJM Healthcare

Phone no. – 0808 169 9633

Email – cambridgeandpeterborough@ajmhealthcare.org

Equipment Servicing

All standing frames and mobility equipment is sourced through NRS healthcare. They will deliver newly assigned equipment and collect unused/no longer needed equipment. They are contracted to service and maintain your child’s equipment.

Please use the below contact information if you required:

Website: https://www.nrshealthcare.com/

Main no. : 0345 121 3456

Email: enquiries@cambspeter.nrs/uk.net