24-hour positioning; why addressing the wheelchair and seating in isolation is not enough
As therapists, we are constantly supporting our participants to replace and review their wheelchair and seating devices and within this context, we talk a lot about posture. There are now so many options and products available on the market that are specifically designed to support effective wheelchair positioning. However, if we are only addressing positioning in the wheelchair, we are failing to consider an important piece of the puzzle and that’s looking at the entire 24-hours of positioning in a person’s day
Across a full day and night, we all spend time in various positions and on different surfaces. This looks different for every person; two hours in the car getting to work, eight hours sitting in an office chair, three hours in an armchair, and eight hours in bed overnight, interspersed with periods of walking or exercise. These positions that we move in and out of during the day and night, are all considered when looking at a person’s 24-hour positioning. A wheelchair user might have a slightly different breakdown of their 24-hour period, for example; nine hours in bed, twelve hours in their wheelchair, and three hours in their supportive lounge chair at home, all of which they often require support to transition between. Within this time we can develop habitual postures which impact our day to day.
Habitual postures – the real cost over time
Habitual postures can lead to deformities that will later impact participation and independence. Poor habitual postures can lead to postural deformities that can cause pain, discomfort and ill health. When left unsupported a person’s habitual postures can progress over time and become asymmetrical, particularly with someone in a wheelchair who is not able to change in and out of different postures independently. Depending on the extent of the asymmetrical deformity the impact on someone’s life can be significant and is often associated with reduced health and wellbeing.
Extensive time, effort, support and funding are utilised when assisting participants to replace their wheelchairs and seating and therefore there is the motivation for them to last as long as possible, rather than requiring replacement because of the shape of a person’s body has changed. This is where addressing the person’s full 24-hours can help. 24-hour positioning does not only support a wheelchair user to reduce the likelihood of their posture deteriorating, it can also support someone’s posture to become more symmetrical over time through the addition of appropriate postural care throughout the day and night – not just in their wheelchair. In turn, this can have a significant effect on other factors within their life including improved sleep and reduced pain.
Why does it have such an impact?
The most considerable impact on our posture and its symmetry throughout the day and night is gravity. That’s because “posture” is the result of a body which is constantly working against the force of gravity.
Fulford and Brown (1976) published findings on motor development and body symmetry in children with cerebral palsy. They tied together gravity, immobility and time as a trio that often leads to these asymmetrical postures. While studying two groups of babies – typically developing and with cerebral palsy – they noticed that both groups showed some similar postural asymmetries early on when their movement was limited. The big change came as able-bodied children learned to roll, sit up, crawl and so on because at that point the similarities diverged. The babies with cerebral palsy developed worsening postures whereas the asymmetries largely disappeared in the typically developing babies. This is where reviewing 24-hour positioning is so essential.
24-hour positioning is simply considering an individual’s needs over an entire 24-hour period, providing the equipment and supports necessary to maximise function. It is important to recognise that 24-hour positioning is not simply a sleep system and that it consists of looking at all tasks someone completes in a day, not only sleeping. Everyone feels comfortable in different positions. The aim when providing positioning support is always to achieve a neutral or symmetrical posture.
Some options for providing participants with a range of positions during their 24-hours are:
- Make use of the recline and tilt in space functions on wheelchairs
- Regular re-positioning – make sure to re-position someone even when they “look comfortable”
- If they can offer the opportunity to stand or walk
- For those who do not stand or walk, can they be supported in a standing machine
- Encourage participation in exercises, stretching or other movements
Sleep systems No one mode of intervention in isolation will be effective. This 24-hour posture management needs to encompass all postural orientations available to the individual.
Evidence tells us we can see the following measurable benefits through addressing 24-hour positioning:
- Improved range of motion
- Reduction in tone
- Reduced pain
- Improved sleep hygiene
- Improved positioning in seated positions (wheelchairs)
- Prolonging the need for orthopaedic intervention
- Reduction in the risk of developing pressure injuries
- Reduction in the risk of respiratory infections through the protection of body shape
What about the functional impact?
When we have a reduction in pain and tone and an increase in range of motion, the occupational performance of a functional task can also improve by supporting someone to meet their goals.
For full-time wheelchair users, as mentioned above, it can have a considerable impact on their seating system becoming less complex and costly. Generally, a person with complex postural asymmetries requires more custom and complex support in their wheelchair, which inevitably becomes more expensive.
An improvement in positioning during the day can also result in a reduced need for care support. For example, if a person is easier to position in their commode and their tone has reduced, then showering, toileting and dressing activities may only need the assistance of one rather than two carers, significantly reducing the cost of care. Transfers can also become easier if the tone is reduced as slings can be easier to fit, resulting in a decrease in time required for the transfer and the possible reduction of care staff required.
It is time to consider not just the wheelchair and seating but the full 24-hours of positioning.
Fulford, G.E., Brown, J.K. (1976). Position as a cause of deformity in cerebral palsy. Developmental Medicine and Child Neurology, 18, 305-14.
Wynn N, & Wickham J. (2009) Night-time positioning for children with postural needs: what is the evidence to inform best practice? British Journal of Occupational Therapy;72(12):543–50.
Hill S., Goldsmith J. (2010) Biomechanics and Prevention of Body Shape Distortion. Tizard Learning Disability Review, 15 (2), 15-29.
GTK 24 Hour Positioning – A Review of the Evidence https://blog.gtk.com.au/24-hour-positioning-a-review-of-the-evidence. Accessed May 2022
About the author
Briar Reid is a Team Leader and Clinical Lead at KEO. Briar has over 10 years of experience working as an OT in NZ, Australia and the UK, and specialises in assistive technology including complex wheelchair and seating.
Briar provides a very hands-on approach to mentoring and supporting the KEO team and is passionate about sharing her knowledge to upskill and develop the KEO team to achieve great outcomes for the participants they support.