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24 hour Postural Management Programmes
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Please note:
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assist our advisors with their reasonable and necessary decision-making.
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Research question: What are the recommended features of a best practice 24 hour postural management programme for a person with a physical or neurological disability?
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- Contents
24 hour Postural Management Programmes ………………………………………………………………….. 1
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Contents ……………………………………………………………………………………………………….. 2
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Summary ………………………………………………………………………………………………………. 2
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24 hour postural management ………………………………………………………………………….. 2
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Evidence for best practice ………………………………………………………………………………… 3
4.1 An example: Children with Cerebral Palsy ……………………………………………………….. 4
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Measuring benefits of 24 hour postural management …………………………………………… 5
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Reasonable and Necessary ……………………………………………………………………………… 5
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Literature Review ……………………………………………………………………………………………. 7
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References ………………………………………………………………………………………………….. 17
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Version control ……………………………………………………………………………………………… 19
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Summary
24 hour postural management (24PM) programmes are complex and multi-faceted interventions to address a variety of health and functional outcomes. Some interventions such as seating or sleep systems are frequently requested for inclusion in a participant’s NDIS plan. Delegates and TAB advisors have a dilemma when determining whether these requests meet the reasonable and necessary criteria. That is, while there is very little good quality evidence to substantiate their benefits (refer to 6. Literature Review), 24PM programmes and interventions continue to be scripted and recommended by allied health professional and professional organisations. There are arguments suggesting the quality of evidence is an artefact of the complexity and individuality of 24PM programmes and therefore is not something that can be fixed by further research (refer to 4. Evidence for best practice). Regardless, it is very difficult to generalise about the benefits or risks of 24PM separate from anecdotal evidence about individual interventions or small studies relating to specific interventions for specific cohorts.
- 24 hour postural management
Postural management is “the use of any technique to minimize postural abnormality and enhance function” [5]. A postural management programme is “a planned approach encompassing all activities and interventions which impact on an individual’s posture and function.” [7]. 24 hour postural management (24PM), also called 24 hour postural care or 24 hour body positioning, is a treatment or prevention strategy that attempts to maximise a person’s function, comfort, and participation in activities over the whole day [2,4,23]. The 24 hour approach emphasises that postural support may be required for both night and day and for all activities a person engages in. This approach can be useful for anyone who is not able
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to reposition themselves [5]. It needs to be implemented everywhere the person spends time. For example, supports can be implemented at home, school, workplace or care facility.
24PM programmes are individualised [7]. They can include:
provision of assistive technology such as orthotics, adaptive seating, sleep systems
or standing frames development of specific handling techniques individual therapy sessions active exercise education and training for all carers including staff, family and allied health [2,4,7].
Postural management can also involve surgery though the 24PM approach is often considered a less invasive alternative to surgery [17].
Poor body position and posture can affect bodily functions such as digestion, breathing and sleep. It can also influence capacity to complete daily activities such as eating, showering, toileting, and mobility. Correcting body position can greatly affect overall health and comfort [2,4,5]. 24PM is perceived to have a positive effect on quality of life [4].
Designing and implementing a 24PM programme is likely to be time consuming and expensive [1,4,9]. There is no research explicitly focussing on its cost effectiveness. Castle et al found that although approximately 50% of members of multi-disciplinary teams made referrals for 24PM, most of them did not know the purpose of postural management programmes [2].
- Evidence for best practice
It is generally recognised that the quality of the evidence for the effectiveness of 24PM tends to be low and there are significant gaps in the research [1,13,17,18,20].
An early systematic review found a robust link between abnormalities of posture and physiological function including blood flow and lung capacity. The same study found evidence that physical therapy and equipment improves body position and performance, but the quality of this evidence was low to moderate [5]. Besides this 2003 systematic review, I could not find any other papers that focus on the benefits of 24PM in general. Rather, the focus is on specific interventions for specific cohorts.
Research into 24PM is difficult for a few reasons. 24PM programmes are individualised and complex, equipment / supports are interdependent and planning makes use of multiple disciplines. Implementation of the programme depends on allied health and medical professionals, the individual, their family, carers, equipment providers and funding bodies. [13,18,22]. For these reasons, randomised control trials are difficult to design and execute [8].
The lack of high quality research and the complexity of 24PM programmes means it is difficult to make judgements about best practice [11,18,24]. The contrast between the level of
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evidence and the continued practice of scripting 24PM programmes has led to some push back from researchers. For example, Kittelson-Aldred and Hoffman [13] argue:
Professionally, the use of evidence-based practice is emphasized strongly, yet there is a paucity of high-level research directly supporting the effectiveness of therapeutic positioning over 24 hours in a day, especially at night. In such situations, however, an evidence-informed approach is useful. …[E]vidence-informed practice incorporates the best available research evidence with theory, client values and choices, and practitioner clinical judgement, into the decision-making process when planning interventions.
Reivonen, Sim, and Bulley [2021] also argue that 24PM is not amenable to the particular standard of evidence defined by evidence-based practice guidelines. They suggest Realist review as an alternative that might be better suited to the complexities of 24PM [18,19].
4.1 An example: Children with Cerebral Palsy
One complexity is the need for research targeted at interventions for specific cohorts. For example, several studies have been conducted investigating the effect of 24PM for children with cerebral palsy. Drawing conclusions even about this specific cohort proves difficult.
In 2006, a group of 23 medical and allied health professionals developed a consensus statement on postural management for children with Cerebral Palsy. They recommend the use of postural management programs from soon after birth [7].
A 2009 study into the use of Chailey postural management equipment lends some weight to this consensus, finding children that use the equipment have a greater chance of less than 33% hip migration by the age of 5. The authors also found a reduction in need for surgery [17]. The research quality is affected by use of a historical control group and inability to control for variables such as changes in surgical practice.
Problematising the consensus is a 2015 Cochrane review into the effect of postural management on hip migration. The authors found no randomised control trials investigating the benefit of sleep positioning systems on hip migration. They found two studies examining the benefits of sleep positioning systems for children with Cerebral Palsy. One study found sleep systems do not affect pain levels. Both studies found sleep systems do not affect sleep quality. However, the quality of both studies was very low on the GRADE scale [1].
A 2010 systematic review into the use of standing frames by children with cerebral palsy concludes that there is some limited evidence to support the benefit of standing frame use on bone mineral density, short term changes in muscle tone and improving hip joint development. Though there is little evidence to support physiological or psychosocial benefits [Bush et al. 2010]. A 2013 systematic review endorses the beneficial effect of standing programmes for bone mineral density but notes that this may not have a follow on effect for activity or participation [15].
Goodwin et al [8] note there is reason to think that standing frames improve bone structure, function, activity and participation. However they also note that there is little strong evidence
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for the benefits and little evidence that the benefits outweigh the reported and predicted disadvantages such as pain and discomfort, cost and investment of time for family and carers.
Gough looks at the use of 24PM programmes in the prevention of deformity in children with CP and notes that there is little evidence for the use of specific seating systems and that in general there is little evidence to suggest specialised seating systems improve the child’s posture. He argues that the evidence for benefit of 24PM is ambiguous and concludes:
A continuous physical postural management program aimed at preventing deformity may not be needed for some children with CP and may not be effective in others. We need to define the subgroup of children with CP who may benefit [9].
- Measuring benefits of 24 hour postural management
In the context of seating interventions, Field and Livingstone argue that an assessment of the overall benefit of 24PM interventions should account for all components of the International Classification of Functioning, Disability and Health (ICF) [6]. These components include:
Body Functions and Structures Activities and Participation Environmental Factors Personal factors [12]
Field and Livingstone assessed 19 measurement scales for seating ability using COSMIN checklist and the McMaster rating system. They report poor ratings for most of the scales and note that none of the scales in use address all the components of the ICF [6].
There is an evidence base for several general tools for assessing posture. Reliability and validity have been demonstrated for The Chailey Levels of Ability [16]. The Posture and Postural Ability Scale (PPAS) is based on the Chailey scale, revised and expanded to separate the quality (body shape and alignment) and quantity (ability) of posture. PPAS is a reliable and valid measure of posture in both children and adults [21]. Inter- and intra-rater reliability has been demonstrated for Goldsmith indices of body symmetry [10].
- Reasonable and Necessary
Current research into the effectiveness of 24PM raises concerns with support requests meeting the s34(1) reasonable and necessary criteria [14].
In particular, if there is research indicating that a 24PM programme has little or no benefit to people with physical or neurological disabilities, this makes it unlikely to meet s34(1)d. If the delegate cannot be confident that the support meets s34(1)d then they may not be able to determine if the supports meets s34(1)a-c.
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While there is good evidence that posture/body position effects health and functional outcomes, the quality of the evidence for the general effectiveness of 24PM programmes on quality of life and related measures is low. This is significantly due to small sample sizes of current studies, the lack of randomised control trials and gaps in evidence for specific populations. It is worth reiterating however that while the evidence is generally of low quality, there is evidence for benefits of certain aspects of a 24PM programme. It is also worth noting that allied health and medical professionals continue to script postural programmes and refer patients to physiotherapists or occupational therapists for the development of postural programmes. Professional bodies also continue to recommend provision of these supports.
In order to determine whether a request for postural management equipment, training, exercises etc. meet s34(1)a-d, the delegate should rely on specific recommendations of treating professionals. The recommendations should include trials of equipment where possible to ascertain whether a benefit is achieved for the individual participant. Where trials are not possible (as in the case of heavily customised equipment), delegates should expect the assessor/treating professional should demonstrate how the participant’s circumstances are sufficiently similar to others in which there has been a demonstrated benefit to 24PM.
In order to determine whether the support will be effective and beneficial, delegates should look for evidence of risk. For example, if there is evidence that a sleep positioning system reduces a participant’s discomfort or improves their mood during the day, but reduces their quality and length of sleep, then these risks and benefits will have to be weighed by the participant and their support network.
Purported benefits of 24PM programmes include health outcomes such as alleviating breathing difficulties, assisting with sleep quality, aiding digestion and reducing risk of choking. Components of a 24PM programme can include surgery, medication, and time limited therapies. This raises the question of whether and to what extent the supports meet s34(1)f. Is the request a disability related health support? Is it more appropriately funded by state health services? Answers to these questions may depend on the primary motivation for the intervention. Is it intended more to address functional or health outcomes?
If a support is scripted and requested as part of a 24PM programme, details of the programme should be included with other evidence so that the delegate can make an R&N decision in the context of the full programme and so that the TAB advisor is able to judge the support request against R&N criteria.
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- References
[1] Blake SF, Logan S, Humphreys G, Matthews J, Rogers M, Thompson-Coon J, et al. Sleep positioning systems for children with cerebral palsy. Cochrane Database Syst Rev. 2015;(11):CD009257
[2] Castle D, Stubbs B, Clayton S, Soundy A. A 24-hour postural care service: Views, understanding and training needs of referring multidisciplinary staff. International Journal of Therapy and Rehabilitation. 2014;21(3):132-139.
[3] Crawford S, Curran A. 24 hour postural management for community dwelling adults with learning disabilities. Posture and Mobility. 2014;31:15-19
[4] Crawford S, Stinson M. Management of 24hr-Body Positioning. In: Söderback I, ed. by. International Handbook of Occupational Therapy Interventions. 2nd ed. Dordrecht: Springer; 2015. p. 189 - 204.
[5] Farley R, Clark J, Davidson C, Evans G, Maclennan K, Michael S et al. What is the evidence for the effectiveness of postural management?. British Journal of Therapy and Rehabilitation. 2003;10(10):449-455.
[6] Field D, Livingstone R. Clinical tools that measure sitting posture, seated postural control or functional abilities in children with motor impairments: a systematic review. Clinical Rehabilitation. 2013;27(11):994-1004.
[7] Gericke T. Postural management for children with cerebral palsy: consensus statement. Developmental Medicine & Child Neurology. 2006;48(4):244-244.
[8] Goodwin J, Lecouturier J, Basu A, Colver A, Crombie S, Smith J, et al. Standing frames for children with cerebral palsy: a mixed-methods feasibility study. Health Technol Assess. 2018;22(50):1–232
[9] Gough M. Continuous postural management and the prevention of deformity in children with cerebral palsy: an appraisal. Dev Med Child Neurol. 2009;51(2):105–10.
[10] Holmes C, Fredrickson E, Brock K, Morgan P. The intra- and inter-rater reliability of the Goldsmith indices of body symmetry in non-ambulant adults with cerebral palsy. Disabil Rehabil. 2021;43(18):2640–6.
[11] Humphreys G, King T, Jex J, Rogers M, Blake S, Thompson-Coon J et al. Sleep positioning systems for children and adults with a neurodisability: A systematic review. British Journal of Occupational Therapy. 2018;82(1):5-14.
[12] International Classification of Functioning, Disability and Health [Internet]. World Health Organisation. [cited 2021 Sep 13]. Available from: https://apps.who.int/classifications/icfbrowser/
[13] Kittelson-Aldred T, Hoffman L. 24-hour Posture Care Management: supporting people night and day. Rehab Management Online [Internet]. 2017 [cited 3 September 2021]. Available
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[14] National Disability Insurance Scheme Act 2013. s 34.
[15] Paleg GS, Smith BA, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther. 2013 Autumn;25(3):232–47
[16] Pountney TE, Cheek L, Green E, Mulcahy C, Nelham R. Content and criterion validation of the Chailey levels of ability. Physiotherapy. 1999;85(8):410–6.
[17] Pountney TE, Mandy A, Green E, Gard PR. Hip subluxation and dislocation in cerebral palsy - a prospective study on the effectiveness of postural management programmes. Physiother Res Int. 2009;14(2):116–27.
[18] Quintans JR, Yonekura T, Trapé CA, Soares CB. Realist evaluation for programs and services in the health area: an integrative review of the theoretical and methodological literature. Rev Lat Am Enfermagem. 2020;28:e3255
[19] Reivonen S, Sim F, Bulley C. Learning from biology, philosophy, and sourdough bread - challenging the evidence-based practice paradigm for community physiotherapy. In: Nicholls D A, Groven K S, Kinsella E A, Anjum R L ed. by. Mobilizing Knowledge in Physiotherapy. New York: Routledge; 2021. p. 83 - 96.
[20] Robertson J, Baines S, Emerson E, Hatton C. Postural care for people with intellectual disabilities and severely impaired motor function: A scoping review. Journal of Applied Research in Intellectual Disabilities. 2016;31(S1):11-28.
[21] Rodby-Bousquet E, Persson-Bunke M, Czuba T. Psychometric evaluation of the Posture and Postural Ability Scale for children with cerebral palsy. Clin Rehabil. 2016;30(7):697–704
[22] Stephens M, Bartley C, Priestley C. Evaluation of night time therapeutic positioning system for adults with complex postural problems. Mancester: University of Salford; 2018 [cited 3 September 2021]. Available from: http://usir.salford.ac.uk/id/eprint/48470/1/Simple%20Stuff%20Works%20Final%20Report%20S ept%202018%20amended%20version%20for%20SSW%20%28002%29.pdf
[23] Stinson M, Crawford S, Madden E. Current clinical practice in 24-hour postural management and the impact on carers and service users with severe neurodisability. British Journal of Occupational Therapy. 2020;84(6):355-365.
[24] Tinker J, Bettany-Saltikov J, Gressman M. The 24 hour Management and Protection of Body Shape for Adults with a Profound Intellectual and Multiple Disability (PIMD) and body shape distortion: A Delphi consensus study exploring physiotherapists’ perceptions of practice. Poster presented at Physiotherapy UK. 2015 Oct 16-17. Liverpool:UK
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ResearchFOI 24/25-0889paper
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Version Amended Brief Description of Change Status Date by
0.1 AHR908 Draft research paper focussing on DRAFT 2021-09-13 effectiveness of 24 hour postural care programmes.
0.2 SLL928 Cleared DRAFT 2021-09-24
1.0 AHR908 Position paper and literature review on APPROVED 2021-09-24 the effectiveness of 24 hour postural management programmes
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