DOCUMENT 22 Research paper
OFFICIAL For Internal Use Only24-hour Postural Management Programs
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- Contents
24-hour Postural Management Programs ………………………………………………………………………. 1
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Contents ………………………………………………………………………………………………………….. 1
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Summary …………………………………………………………………………………………………………. 2
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2025 Research Review ……………………………………………………………………………………… 2
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24-hour postural management ……………………………………………………………………………. 7
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Evidence for best practice ………………………………………………………………………………….. 7
5.1 An example: Children with Cerebral Palsy ............................................................... 8-
Measuring benefits of 24-hour postural management …………………………………………….. 9
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Literature summary table ………………………………………………………………………………….. 11
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References ………………………………………………………………………………………………….. 27
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OFFICIAL For Internal Use Only2. Summary
Research for this paper was originally completed in September 2021. An update was added in August 2025.
24-hour postural management (24PM) programmes are complex and multi-faceted interventions to address a variety of health and functional outcomes. Some good quality evidence exists for certain interventions included in 24PM programmes, though recent research on postural management continues to be rated as low quality and non-generalisable due to small participant numbers, the heterogenous nature of the cohorts under study and other methodological factors. However, the sentiment that randomised, blinded and/or controlled studies may not be suitable for research in this area continues to be expressed by researchers. 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). Study results do suggest postural management for lying, standing and sitting may provide benefits for some individuals, and there is little evidence that it can cause harm. Research tends to emphasise that postural management systems should be prescribed individually, developed in collaboration with the patient and/or carer and reassessed frequently. There is widespread clinical consensus that 24PM is best practice for the management of postural care needs.
- 2025 Research Review
Wood and Brown (2022) conducted an exploratory study on the effects of the Symmetrisleep sleep system on sleep quality, pain and carer goals for non-ambulant children and young people with cerebral palsy. 4 children participated in the study over 6 months. Data were collected via the Chailey Sleep Questionnaire, a Sleep Profile, Neutral Zero joint range assessment, the Paediatric Pain profile (PPP), nightly sleep diaries completed by carers and Goal Attainment Scale (GAS) light verbal goals which were agreed upon with carers. Several participants had gaps in data collection due to illness or inability to attend. All participants completed the Chailey Sleep Questionnaire and Sleep Profile while only two fully completed the sleep diaries. Results showed that during the study 3 out of the 4 children reported a decreased number of night time wakings and 2 out of the 4 became less restless and required less turning by their carer. There was no change in pain score on the PPP. GAS goals included maintaining and improving comfort, promoting and supporting good posture and maintaining symmetry and alignment, and all goals showed improvement over the course of the study.
Paleg et al. (2022) provide an overview of studies on postural management for hip health, for individuals with non-ambulant cerebral palsy. Interventions included sleep, standing and seating postural management systems. Results were often found to be inconclusive but there was evidence that postural support may assist in preventing contracture, deformity, pain and asymmetry. The need for postural management systems to be individually prescribed,
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OFFICIAL For Internal Use Onlydeveloped with the patient and caregiver input and regularly reassessed was also emphasised.
In 2023, McLean et al. conducted a scoping review of supported-standing interventions for children and young adults (25 years old or younger) with non-ambulant cerebral palsy based on over 50 systematic reviews, primary studies and clinical guidelines. High quality evidence showed that interventions impact upon bone mineral density and contracture prevention (range of motion). Low-quality evidence (quasi-experimental designs, case studies etc) indicated an impact on hip migration percentage, bowel function, and participation and activity. Evidence for reduced spasticity was contradictory. The authors conclude that individualised assessment and prescription are essential in order to account for personal and environmental needs, and that standing programmes should be incorporated into age-appropriate and meaningful activities to enhance function, participation and overall health.
A scoping review of the evidence for 24PM was conducted by Osborne et al. in 2023. They found that evidence for 24PM was often of low quality but this was attributed to the complications of carrying out robust research in this area. They found that 24PM may have positive effects in lying, sitting and standing.
In 2024, Kittelson et al. published a longitudinal, quasi-experimental study pilot study on posture care management that was conducted over 2.5 years with 55 participants who had disability-related mobility impairment. The posture care management intervention included positioning support for use when lying down, a personalised training workshop for caregiver teams, and in-home initial and follow-up assessments. Participants’ body symmetry was measured using the Goldsmith Indices of Body Symmetry (GIoBS) and pain was measured using the Paediatric Pain Profile (PPP) with measures being taken for pain on a ‘good day’ and pain on a ‘bad day’. Sleep was described using the Pittsburgh Sleep Quality Index (PSQI) or the Children’s Sleep Habits Questionnaire (CSHQ) (age-dependent). Results showed that among participants with comparable responses from baseline to follow-up, 55% reported an improvement in ‘good day’ pain levels, 51% reported an improvement in ‘bad day’ pain levels, and 69% reported improvement in overall sleep quality. All participants saw improvement on at least one health outcome (body symmetry, pain and sleep) and a majority showed improved body symmetry of which none showed worsening of pain or sleep.
In 2025, the Rehabilitation Engineering and Assistive Technology Association of North America (RESNA), and the Clinician Task Force (CTF) published a position paper on standing devices both attached to and separate from wheelchairs (Masselink et al., 2025). Using a scoping review methodology, the authors identified 42 studies on supported frames. Overall, they found evidence to support engaging consistently in supported standing from nine months of age (or as soon possible after onset of ambulatory disability) in order to maximise benefits. Supported frames may also improve hip and ankle range motion and change the related muscle length, balance and stability outside of the standing device, and can lead to acquisition of mobility skills. It may help to reduce pain and effort with bowel evacuation and lead to a decrease in pressure injuries. However, the paper did not systematically analyse bias in the
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OFFICIAL For Internal Use Onlystudies it reviewed and some claims made by the authors are not supported by the publications they cite.
More recently, in 2025, Kimizu et al. published a case study on one child who was born with spinal muscular atrophy. Physical therapy was conducted twice a week using careful postural management including a seating system and a supine stander to promote motor development in the patient. He was also restricted to sitting without support for 30 mins a day. At age 6, the patient is able to stand with support for several minutes, scoliosis and hip subluxation has not been observed, and neither has progression of spinal deformity. The lumbar hyperlordosis has improved and the Cobb angle has also been maintained.
In 2024, an umbrella systematic review was published by Toohey et al. on the effectiveness of postural interventions in cerebral palsy. The review identified several interventions that were effective for improving movement and preventing deformity. The ranking of each intervention assessed can be found in Tables 1-3 below. Overall, the most effective intervention according to the authors was hip surveillance.
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OFFICIAL For Internal Use OnlyTable 1 Postural control interventions (Source: Toohey et al., 2024, pp. 260/272-273)
| Intervention | Lack of effect | Weak/lacking evidence | Some evidence, probably works | Good evidence |
|---|---|---|---|---|
| Postural control interventions | NeuroDevelopmental therapy (Bobath) | Cuevas Medek exercises (CME) Dynamic movement intervention (DMI) Vojta |
Balance training Functional hand splints (e.g. neoprene thumb spica) Hippotherapy via a mechanical horse Sit-to-stand training Taping Transcranial direct current stimulation (tDCS) Virtual reality (VR) Whole body vibration (WBV) |
Hippotherapy |
Table 2 Interventions for movement improvement and deformity preventions (Source: Toohey et al., 2024, pp. 273-274)
| Intervention | Some evidence | Treatments that might work | Treatments that work |
|---|---|---|---|
| Tone management to improve movement and prevent deformity | Baclofen (Oral), Benzodiazepines, gabapentin | Trihexyphenidyl, clonidine and levodopa Deep brain stimulation (DBS) |
Botulinumtoxin (BOTOX) for the lower/upper limb Intrathecal baclofen Selective dorsal rhizotomy (SDR) |
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OFFICIAL For Internal Use OnlyTable 3 Interventions for posture and deformity prevention (Source: Toohey et al., 2024, p. 274)
| Intervention | Might be helpful but consider the risks | What might work | What works |
|---|---|---|---|
| Postural management interventions to support upright posture for function | N/A | Adaptive seating systems Ankle foot orthoses (AFOs) |
N/A |
| Postural management interventions to prevent deformity | Sleep positioning systems Stretching |
Non-Functional night hand splints (e.g. resting hand splints) Orthopaedic Surgery (temporary medial hemi-epiphysiodesis of the proximal femur) Orthopaedic surgery (single event multilevel surgery) Orthopaedic surgery (hip or knee joint reconstruction) Orthopaedic surgery (upper limb) Passive range of motion (PROM) Serial casting Spinal orthoses (back brace or spinal brace) Standing frames |
Hip surveillance Orthopaedic surgery (scoliosis correction) |
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OFFICIAL For Internal Use Only4. 24-hour postural management
Postural management is “the use of any technique to minimize postural abnormality and enhance function” (Farley et al., 2003). A postural management programme is “a planned approach encompassing all activities and interventions which impact on an individual’s posture and function.” (Gericke, 2006). 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 (Castle et al., 2014; Crawford & Stinson, 2015; Stinson et al., 2020). 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 to reposition themselves (Farley et al., 2003). 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 (Gericke, 2006). 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 (Castle et
al., 2014; Crawford & Stinson, 2015; Gericke, 2006).Postural management can also involve surgery though the 24PM approach is often considered a less invasive alternative to surgery (Poutney et al., 2009).
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 (Castle et al., 2014; Crawford & Stinson, 2015; Farley et al., 2003). 24PM is perceived to have a positive effect on quality of life (Crawford & Stinson, 2015).
Designing and implementing a 24PM programme is likely to be time consuming and expensive (Blake et al., 2015; Crawford & Stinson, 2015; Gough, 2009). 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 (Castle et al., 2014).
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Evidence for best practice
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OFFICIAL For Internal Use OnlyIt 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 (Blake et al., 2015; Kittelson-Aldred & Hoffman, 2017; Pountney et al., 2009; Quintans et al., 2020; Robertson et al., 2016).
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 (Farley et al., 2003). Besides this 2003 systematic review, we did 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. (Kittelson-Aldred & Hoffman, 2017; Quintans et al., 2020; Stephens et al., 2021). For these reasons, randomised control trials are difficult to design and execute (Goodwin et al., 2018).
The lack of high-quality research and the complexity of 24PM programmes means it is difficult to make judgements about best practice (Humphreys, 2019; Quintans et al., 2020; Tinker et al., 2015). The contrast between the level of evidence and the continued practice of scripting 24PM programmes has led to some push back from researchers. For example, Kittelson- Aldred and Hoffman (2017) 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 et al. (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 (Quintans et al., 2020; Reivonen et al., 2021).
5.1 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 (Gericke, 2006).
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OFFICIAL For Internal Use OnlyA 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 (Poutney et al., 2009). 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 (Blake et al., 2015.
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 (Paleg et al., 2013).
Goodwin et al. (2018) 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 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 (Gough, 2009).6. 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) (Field & Livingstone, 2013). These components include:
body functions and structures
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activities and participation
environmental factors
personal factors (World Health Organisation, 2025).Field and Livingstone (2013) 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.
There is an evidence base for several general tools for assessing posture. Reliability and validity have been demonstrated for The Chailey Levels of Ability (Pountney et al., 1999). 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 (Rodby-Bousquet et al., 2016). Inter- and intra-rater reliability has been demonstrated for Goldsmith indices of body symmetry (Holmes et al., 2021).
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OFFICIAL For Internal Use Only7. Literature summary table
| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Masselink, Detterbeck, LaBerge, Paleg 2025 | RESNA and CTF position on the application of supported standing devices: Current state of the literature | Assistive Technology The Official Journal of RESNA | To provide an updated position statement on wheelchair standing devices. | A scoping review methodology was used to identify 42 studies in order to establish an updated, unbiased and comprehensive position. Inclusion criteria were articles published in a peer reviewed journal between January 2000 and November 2020, in the English language. | A recommendation to consistently engage in supported standing from nine months of age, or as soon possible after onset of ambulatory disability in order to maximise benefits. Clinical reasoning is required to apply the information in this document to unique individual cases. | LOW. The position paper is based on research studies but did not systematically analyse study bias. |
| Kimizu, Yokawa, Horibe, Oki, Nakajima, Tominaga, Mogami, Tamura, Yanagihara, 2025 | A case of spinal muscular atrophy type 0 treated with nusinersen without progression of early-onset scoliosis – possibility of preventing scoliosis with a rehabilitation program focusing on postural management | Brain and Development | To describe a case of SMA type 0 in a patient with 2 copies of SMN2 that was treated with nusinersen, in which the patient’s motor function improved and no progression of spinal deformity was observed. | A case study on one patient. Physical therapy was conducted twice a week using careful postural management using a seating system and a supine stander to promote motor development. The patient was restricted to sitting without support for 30 mins a day | The patient can stand with support for several minutes and scoliosis has been prevented. No hip subluxation or progression of spinal deformity has been observed. The lumbar hyperlordosis had improved The Cobb angle was also maintained. | LOW. A case study on 1 patient so results are not generalisable. |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Toohey, Blatch-Williams, Budini, Ferreira, Griffin, Hines, Jackman, Lind, Massey, Mc Namara, Mitchell, Morgan, Norfolk, Paton, Polyblank, Reedman, Novak, 2024 | Effectiveness of postural interventions in cerebral palsy: umbrella systematic review | Symposium: Cerebral Palsy | To summarise and evaluate the evidence supporting postural interventions for cerebral palsy published after Gough’s review in 2009. Additionally, it aims to provide clinical bottom lines according to Gross Motor Function Classification System or Manual Ability Classification System levels. | Found systematic reviews or population register studies evaluating postural management interventions in people with cerebral palsy using an umbrella systematic review design. Assessed the quality of evidence for each intervention and made recommendations using GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) and the Evidence Alert Traffic Light approaches. 33 unique studies met the inclusion criteria. | Several postural control interventions are effective for improving movement, and several postural management interventions may prevent deformity, with hip surveillance having the best evidence. Many interventions show positive effects on postural outcomes including range of motion, spasticity, pain, hip migration, gross motor function, hand function, gait parameters, muscle strength, balance, and ease of caregiving. The quality of evidence for these interventions and outcomes is mostly low to very low, meaning conclusions and | HIGH. |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Kittelson, Kittelson-Aldred, Justad, Hoffman, Coombs 2024 | The Montana Postural Care Project: A pilot study implementing posture care management in a rural, low-resource region | Heliyon | To determine the feasibility of introducing posture care management to a rural-based, medically complex patient population, evaluate response of body symmetry, and examine its impact on pain and sleep quality. | A longitudinal, quasi-experimental study pilot study over 2.5 years with 55 participants completing the study. The posture care management intervention included positioning support for use when lying down, a personalised training workshop for caregiver teams, and in-home initial and follow-up assessments. The Goldsmith Indices of Body Symmetry (GIoBS) was used to measure body symmetry. Pain was measured using the Paediatric Pain Profile (PPP) with two measures: pain on a ‘good day’ and pain on a ‘bad day’. | All participants saw improvement on at least one health outcome. A majority of participants improved body symmetry. | LOW. There was no control group. Data were collected via self-reporting. There were potential issues with consistency of intervention administration. |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Osborne, Gowran, Jackie, 2023 | Evidence for 24-hour posture management: A scoping review | British Journal of Occupational Therapy | To scope the evidence for a 24-hour posture management approach. | A scoping review was conducted with 44 papers meeting the inclusion criteria including grey literature, scientific studies, and various other literature published between 2003 and 2019 and in English. | There were no random controlled trials and only one quasi-experimental design amongst the included papers. The evidence for 24-hour posture management is often low quality due to the complications of completing research in this area. Nevertheless, benefits of posture management in lying, sitting and standing were identified. | LOW. Limited information about the included studies’ quality and no indication of possible biases. |
| Paleg, Livingstone. 2022 | Evidence-informed clinical perspectives on postural management for hip health in children and adults with | Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach | To provide an overview of the evidence supporting use of postural management to positively influence hip health in individuals | An overview of relevant systematic reviews and experimental research studies. | High-quality experimental research is difficult to carry out in this area and systematic reviews tend to | LOW. The reviews and research studies included in this overview were generally low-level or low-quality. |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| produce inconclusive results. More single-subject studies are required. There is limited evidence of harm being caused by postural management devices/programs. Positioning supports enable participation and function and ease caregiving. | ||||||
| McLean, Paleg, Livingstone, 2023 | Supported-standing interventions for children and adults with non-ambulant cerebral palsy: A scoping review | Dev Med Child Neurol. | To describe the evidence, outcomes, and lived experience of supported standing for children and young adults with cerebral palsy aged 25 years or younger, classified in Gross Motor Function Classification System levels IV and V. | Scoping review methodology including papers from up to 21st February 2022. No limits were placed on design methodology, age range, language, or publication status to ensure that the search was as comprehensive as possible. Studies, reviews, and guidelines were all considered for inclusion | Systematic reviews were rated as low-confidence quality or critically low, while bias ranged from low to high. The primary studies’ quality ratings and risk of bias ratings ranged from low to high. Evidence from most experimental studies supported the maintenance of bone mineral density and contracture | HIGH. |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| prevention outcomes. Evidence supporting other outcomes was primarily quasi-experimental or descriptive. Evidence suggests that individualised assessment and prescription are essential to match personal and environmental needs. | ||||||
| Wood, Brown, 2022 | An exploratory study: The effects of sleep systems on sleep quality, pain and carer goals for non-ambulant children and young people with cerebral palsy | Journal of Rehabilitation Assistive Technologies Engineering | To investigate the effect of sleep systems on sleep quantity, pain for young people with Cerebral Palsy and outcomes for carers. | Exploratory study conducted over 6 months. 4 children were given the sleep System (Symmetrisleep) to use. Data on sleep quality and quantity, and pain levels were gathered using the Chailey Sleep Questionnaire, a Sleep Profile, sleep diaries the Paediatric Pain Profile and GAS | Pain levels remained static. Improvements in sleep quality and quantity were found and GAS goals achieved. 3 out of 4 children reported decreased number of night time wakings, 2 out of 4 children became less restless and required less turning. | VERY LOW. Small sample size. Gaps in data collection due to participants being ill or unable to attend follow-ups. No randomisation or blinding. Limited information given on several measures including the Sleep Profile and Neutral Zero joint range assessment. |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Castle, Stubbs, Clayton, Soundy, April 2014 | A 24-hour postural care service: Views, understanding and training needs of referring multidisciplinary staff | International Journal of Therapy and Rehabilitation VOL. 21, NO. 3 | To consider the views, understanding and training needs of members of a multidisciplinary team (MDT) around 24-hour postural care. These MDT members refer individuals with profound and multiple learning disabilities (PMLD) and postural care needs to a 24-hour postural care service. | Two phase mixed method sequential explanatory design. Phase 1: online survey of 57 multi-disciplinary team members views experiences and understanding of 24 postural support. Phase 2: 14 semi-structured interviews and 3 profession specific focus groups. | Members of multi-disciplinary team generally lacked understanding of 24hr postural management but nevertheless continued to make referrals. | LOW. Small and probably non-representative sample size and the presence of possible bias in selecting study participants. |
| Gericke, 2006 | Postural management for children with cerebral palsy: consensus statement | Developmental Medicine & Child Neurology 2006, 48: 244–244 | To provide a consensus statement of the best practice interventions to support posture of children with cerebral palsy including recommendations for further research | NIL | An 8 point consensus statement in which contributors agree to, on the one hand, the benefit of 24 hour postural care for children with CP and on the other hand, the need for more research and greater consensus on standards for assessing postural management programmes. | LOW. While undoubtedly evidenced based and clinical experience of 23 professionals, this is a policy statement rather than a clinical study. |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Stinson, Crawford, Madden, June 2021 | Current clinical practice in 24-hour postural management and the impact on carers and service users with severe neurodisability | The British Journal of Occupational Therapy; London Vol. 84, Iss. 6, | To investigate the use of 24-hour postural management by occupational therapists and to explore its impact on service users with neurodisability and their carers. | Two phase data gathering: 1. Online survey of 96 Occupational Therapists to get responses relating to understanding and experience of 24hr postural management; 2. Two focus groups of 4 or 5 people comprising people with a neuro-disability and carers of people with a neuro-disability to elicit discussion of understanding and experience of 24hr postural management. Phase 1 data were analysed for correlation between responses. Phase 2 data were coded, themes extrapolated and conclusions drawn. | Occupational therapists’ skills in 24-hour postural management improve with frequency of use. Reliance on postural management equipment leads to service user and caregiver frustrations that need to be addressed | LOW. Phase 1 results based on adequate sample size for a population of UK OTs, but may not generalise to AUST or other regions. Phase 2 qualitative results based on small sample and themes may not generalise for other regions. |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
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| Crawford, Stinson 2015 | Management of 24 hr-Body Positioning | International Handbook of Occupational Therapy Interventions (Ed. Söderback) | To introduce 24 hr body positioning, its benefits, target patients and evidence base. | Contains sample lit review of 7 items found via database search. Larger narrative review describing the procedure, best practice interventions, additional considerations etc. | 24hour positioning is essential to the care of people unable to reposition themselves. Further research is required to determine the long term benefits of the intervention. | LOW. Effectively a narrative review used as a tool to introduce OT students to the subject area. |
| Field, Livingstone Nov 2013 | Clinical tools that measure sitting posture, seated postural control or functional abilities in children with motor impairments: a systematic review | Clinical Rehabilitation; London Vol. 27, Iss. 11 | “To identify and critically appraise clinical measurement tools used to assess sitting posture, seated postural control or functional abilities for children with motor impairment who are candidates for seating interventions.” | Systematic review | “Evidence supporting reliability and validity varied, with small sample sizes influencing quality ratings. Evidence of the tools’ reliability was more prevalent than evidence of the tools’ validity. Only four tools reported on responsiveness, an important consideration for evaluating change. Little information on clinical utility was provided. Although a number of tools are available, evidence supporting their use for seating | HIGH |
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OFFICIAL For Internal Use Only| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
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| interventions is limited, as is the evidence supporting the strength of their measurement properties. Few tools address participation, environmental factors and the child’s and family’s perspective.” | ||||||
| Robertson et al 2016 | Postural care for people with intellectual disabilities and severely impaired motor function: A scoping review | Journal of Applied Research in Intellectual Disability | To map and summarize existing evidence regarding postural care for people with intellectual disabilities and severely impaired motor function | Systematic review. Studies were identified via electronic database searches covering January 1990 to March 2016, and email requests to researcher networks. Results were collated via descriptive numerical of studies and thematic analysis. | “The evidence base relating to postural care for people with intellectual disabilities and severely impaired motor function is small and lacking in studies that employ robust methodological designs.” | HIGH |
| Farley et al Oct 2003 | What is the evidence for the effectiveness of postural management? | International Journal of Therapy and Rehabilitation. 10/10 | To provide an overview of evidence base for the link between postural management and positive health outcomes. | Systematic review organising literature into 8 themes including: physiological function, neonates and children under | Scientific quality of evidence varies according to Sackett’s levels. Evidence of link physiological outcomes was | MODERATE. Methodology is reasonably strong but age of the paper means the conclusions may not be reliable, |
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OFFICIAL Page 529 of 595| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Blake et al 2015 | Sleep positioning systems for children with cerebral palsy | Cochrane Database of Systematic Reviews | “To determine whether commercially-available sleep systems, compared with usual care, reduce or prevent hip migration in children with cerebral palsy. Any negative effect of sleep positioning systems on hip migration will be considered within this objective. Secondary objectives were to determine the effect of sleep positioning systems on: (1) number or frequency of hip problems; (2) sleep patterns and quality; (3) quality of life of the child and family; (4) pain; and (5) physical functioning. We also sought to identify any adverse effects from using sleep positioning systems.” | Systematic review of “all randomised controlled trials (RCTs) evaluating whole body sleep positioning systems for children and adolescents (up to18 years of age) with cerebral palsy”. | “No randomised controlled trials were found that evaluated the effectiveness of sleep positioning systems to reduce or prevent hip migration.” Researchers found two RCTs related to sleep quality of children with CP while using sleep positioning systems. However the “quality of the current evidence regarding the effectiveness of sleep positioning systems for children with cerebral palsy is very low and more robust research is needed to help families and professionals make informed decisions about whether to use this intervention.” | HIGH |
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| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Humphreys et al. 2019 | Sleep positioning systems for children and adults with a neurodisability: A systematic review | British Journal of Occupational Therapy, VOL 82/1 | To identify and summarise studies of people with neurodisability using sleep positioning systems | Systematic review of academic and non-academic literature on sleep positioning use by people with neurodisability. Search results current at Feb 2018. | The review “found some evidence that there are potential benefits in hip stability, improved sleep quality and an improved quality of life for users that can tolerate using a sleep positioning system but the quality of the evidence is very poor. No statistically or clinically significant differences were found in respiratory function in or out of a sleep positioning system.” | HIGH |
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| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Stephens, Bartley, Priestly 2018 | Evaluation of night time therapeutic positioning system for adults with complex postural problems | University of Salford, monograph | To evaluate the Simple Stuff Works sleep positioning system for effectiveness based on pain, physiological observations, oxygen saturation, nutrition and fluid intake, weight, Waterlow risk score, sleep score, skin integrity, comfort and quality of life. | Sleep system showed beneficial effects on pain, sleep, weight, choke risk, Waterlow score, food/fluid intake, depression score, medication, and analgesia. | LOW. Small sample size and difficult to generalise for the effectiveness of sleep systems as a whole. So far unpublished. | |
| Gough 2009 | Continuous postural management and the prevention of deformity in children with cerebral palsy: an appraisal | Developmental Medicine and Child Neurology, 51 | To assess the evidence for effectiveness of postural management for the prevention of deformity in children with Cerebral Palsy. | Narrative review | Postural management programs require further research. We need to determine which cohorts of children with CP will benefit from postural management and which will not. We need to redirect focus from body shape to function to promote the activity and independence of children with CP. | LOW. Narrative review without stated method or stated criteria for assessing the evidence. |
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| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Goodwin et al. 2018 | Standing frames for children with cerebral palsy: a mixed-methods feasibility study | Health Technol Assess. 22(50):1–232 | To determine the likelihood of a possible trial of standing equipment for children with cerebral palsy. | Survey of 551 clinicians and parents, focus groups, in depth interviews. | It is not feasible to progress to a full randomised controlled trial to test the effectiveness of standing frame intervention. | MODERATE. While conclusions depend on qualitative data, the phenomenon they were investigating was apt for that style of investigation. Conclusions are modest. |
| Holmes, Fredrickson, Brock, Morgan. 2021 | The intra- and inter-rater reliability of the Goldsmith indices of body symmetry in non-ambulant adults with cerebral palsy. | Disabil Rehabil. 43(18):2640–6. | To establish intra- and inter-rater reliability of the Goldsmith Indices of Body Symmetry in nonambulant adults with CP. | 17 males with CP and 48 young people without CP were tested using the Goldsmith Indices multiple times by a single clinician and multiple times by multiple different clinicians. | Good inter and intra-rater reliability for measuring thoracic shape and symmetry, pelvic orientation and hip range. | MODERATE. Presence of controls but small sample size. |
| Paleg, Smith, Glickman. 2013 | Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. | Pediatr Phys Ther. 25(3):232–47 | To produce evidence based recommendations for dosing of paediatric supported standing programs. | Systematic review. | “Standing programs 5 days per week positively affect bone density (60 to 90 min/d); hip stability (60 min/d in 30◦ to 60◦ of total bilateral hip abduction); range of motion of hip, knee, and ankle (45 to 60 min/d); and spasticity (30 to 45 min/d).” | HIGH. |
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| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Pountney et al. 1999. | Content and criterion validation of the Chailey levels of ability. | Physiotherapy 85(8):410–6 | To validate the Chailey levels of ability scale. | Content validity established by appeal to data set of 38 infants and 85 children with CP. Criterion validity testing was performed by correlating the Chailey scale with Alberta Infant Motor Scale and Gross Motor Function Measure. | The study established content and criterion validity for Chailey scale. | MODERATE. Some discrepancy in establishing criterion validity. |
| Pountney et al. 2009 | Hip subluxation and dislocation in cerebral palsy - a prospective study on the effectiveness of postural management programmes. | Physiother Res Int. 14(2):116–27 | To investigate the effectiveness of early postural management programmes on hip subluxation and dislocation in children with CP. | Group of 39 children with CP commenced using postural supports. Xrays of children’s hips and 30 and 60 months. Compared with rates of hip problems in control group. | Early use of postural management programmes can assist in reducing number of hip problems and need for treatment in children under 5 years old. | MODERATE. Historical control present but could not control for missing data and changes in surgical practice. |
| Rodby- Bousquet, Persson-Bunke, Czuba. | Psychometric evaluation of the Posture and Postural Ability | Clin Rehabil. 2016;30(7):697–704 | “To evaluate construct validity, internal consistency and inter-rater reliability of the Posture and Postural | 29 children with CP were tested by 3 different clinicians using the Posture | “The Posture and Postural Ability Scale shows high psychometric properties for | LOW. Reasonable sample of test subjects but very small number of |
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| Author / Date | Title | Source | Aim / Objective | Methods | Results | Quality of Research |
|---|---|---|---|---|---|---|
| Scale for children with cerebral palsy. | Ability Scale for children with cerebral palsy”. | and Postural Ability Scale. | children with cerebral palsy, as previously seen when evaluated for adults. It enables detection of postural asymmetries indicating potential need for support and where it needs to be applied” | clinicians testing the measure. |
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8. References
Blake, S. F., Logan, S., Humphreys, G., Matthews, J., Rogers, M., Thompson-Coon, J., Wyatt, K., & Morris, C. (2015). Sleep positioning systems for children with cerebral palsy. Cochrane Database of Systematic Reviews, 2015(11), Article CD009257. https://doi.org/10.1002/14651858.CD009257.pub2
Castle, D., Stubbs, B., Clayton, S., & Soundy, A. (2014). A 24-hour postural care service: Views, understanding and training needs of referring multidisciplinary staff. International Journal of Therapy and Rehabilitation, 21(3), 132–139. https://doi.org/10.12968/ijtr.2014.21.3.132
Crawford, S., & Stinson, M. (2015). Management of 24hr-Body Positioning. In: I. Söderback (Ed.). International Handbook of Occupational Therapy Interventions (pp. 189 – 204). Springer. https://doi.org/10.1007/978-3-319-08141-0
Farley, R., Clark, J., Davidson, C., Evans, G., MacLennan, K., Michael, S., Morrow, M., & Thorpe, S. (2003). What is the evidence for the effectiveness of postural management? International Journal of Therapy and Rehabilitation, 10(10), 449–455. https://doi.org/10.12968/bjtr.2003.10.10.13476
Field, D., & Livingstone, R. (2013). Clinical tools that measure sitting posture, seated postural control or functional abilities in children with motor impairments: a systematic review. Clinical Rehabilitation, 27(11), 994–1004. https://doi.org/10.1177/0269215513488122
Gericke, T. (2006). Postural management for children with cerebral palsy: consensus statement. Developmental Medicine and Child Neurology, 48(4), 244–244. https://doi.org/10.1017/S0012162206000685
Goodwin, J., Lecouturier, J., Basu, A., Colver, A., Crombie, S., Smith, J., Howel, D., McColl, E., Parr, J. R., Kolehmainen, N., Roberts, A., Miller, K., & Cadwgan, J. (2018). Standing frames for children with cerebral palsy: a mixed-methods feasibility study. Health Technology Assessment (Winchester, England), 22(50), 1–232. https://doi.org/10.3310/hta22500
Gough, M. (2009). Continuous postural management and the prevention of deformity in children with cerebral palsy: an appraisal. Developmental Medicine and Child Neurology, 51(2), 105–110. https://doi.org/10.1111/j.1469-8749.2008.03160.x
Holmes, C., Fredrickson, E., Brock, K., & Morgan, P. (2021). The intra- and inter-rater reliability of the Goldsmith indices of body symmetry in non-ambulant adults with cerebral palsy. Disability and Rehabilitation, 43(18), 2640–2646. https://doi.org/10.1080/09638288.2019.1708979
Humphreys, G., King, T., Jex, J., Rogers, M., Blake, S., Thompson-Coon, J., & Morris, C. (2019). Sleep positioning systems for children and adults with a neurodisability: A
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systematic review. The British Journal of Occupational Therapy, 82(1), 5–14.
https://doi.org/10.1177/0308022618778254Kittelson-Aldred, T., & Hoffman, L. A. (2017). 24-Hour Posture Care Management: Supporting People Night and Day: The relationship between lying posture and function in sitting and standing, as well as the forces of gravity, are key among this evidence-informed approach to therapeutically limit or avoid body shape distortions. Rehab Management, 30(6), S14. https://rehabpub.com/conditions/neurological/cerebral-palsy/24-hour- posture-care-management-supporting-people-night-day/
National Disability Insurance Scheme Act 2013 (Aus). https://www.austlii.edu.au/cgi- bin/viewdoc/au/legis/cth/consol_act/ndisa2013341/s34.html
Paleg, G. S., Smith, B. A., & Glickman, L. B. (2013). Systematic Review and Evidence-Based Clinical Recommendations for Dosing of Pediatric Supported Standing Programs. Pediatric Physical Therapy, 25(3), 232–247. https://doi.org/10.1097/PEP.0b013e318299d5e7
Pountney, T. E., Cheek, L., Green, E., Mulcahy, C., & Nelham, R. (1999). Content and Criterion Validation of the Chailey Levels of Ability. Physiotherapy, 85(8), 410–416. https://doi.org/10.1016/S0031-9406(05)65499-5
Pountney, T. E., Mandy, A., Green, E., & Gard, P. R. (2009). Hip subluxation and dislocation in cerebral palsy - a prospective study on the effectiveness of postural management programmes. Physiotherapy Research International : The Journal for Researchers and Clinicians in Physical Therapy, 14(2), 116–127. https://doi.org/10.1002/pri.434
Quintans, J. R., Yonekura, T., Trapé, C. A., & Soares, C. B. (2020). Realist evaluation for programs and services in the health area: an integrative review of the theoretical and methodological literature. Revista Latino-Americana de Enfermagem, 28, Article 3255. https://doi.org/10.1590/1518-8345.3933.3255
Reivonen, S., Sim, F., Bulley, C., Kinsella, E. A., Groven, K. S., Anjum, R. L., & Nicholls, D. A. (2021). Learning from biology, philosophy, and sourdough bread – challenging the evidence-based practice paradigm for community physiotherapy. In D. A. Nicholls, K. S. Groven, E. Kinsella & R. Anjum (Eds.). Mobilizing Knowledge in Physiotherapy (pp. 83– 96). Routledge. https://doi.org/10.4324/9780367855338-7
Robertson, J., Baines, S., Emerson, E., & Hatton, C. (2018). Postural care for people with intellectual disabilities and severely impaired motor function: A scoping review. Journal of applied research in intellectual disabilities: JARID, 31 Suppl 1, 11–28. https://doi.org/10.1111/jar.12325
Rodby-Bousquet, E., Persson-Bunke, M., & Czuba, T. (2016). Psychometric evaluation of the Posture and Postural Ability Scale for children with cerebral palsy. Clinical Rehabilitation, 30(7), 697–704. https://doi.org/10.1177/0269215515593612
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Stephens, M., Bartley, C., Priestley, C. (2018). Evaluation of night time therapeutic positioning system for adults with complex postural problems. University of Salford. http://usir.salford.ac.uk/id/eprint/48470/1/Simple%20Stuff%20Works%20Final%20Repor t%20Sept%202018%20amended%20version%20for%20SSW%20%28002%29.pdf
Stinson, M., Crawford, S., & Madden, E. (2021). Current clinical practice in 24-hour postural management and the impact on carers and service users with severe neurodisability. The British Journal of Occupational Therapy, 84(6), Article 0308022620944739. https://doi.org/10.1177/0308022620944739
Tinker, J., Bettany-Saltikov, J., Gressman, M. (2015, October 16-17). 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. Physiotherapy UK 2015 Liverpool, United Kingdom. google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjN- aX96N6OAxV_3jQHHcDKOAwQFnoECBkQAQ&url=https%3A%2F%2Fwww.csp.org.u k%2Fsystem%2Ffiles%2Fdocuments%2F2018- 10%2Fpost_mgmnt_consensus_statement_october_2015.docx&usg=AOvVaw16p323 WNMWPXncLgI5ZNAw&opi=89978449
World Health Organisation. (2025). International Classification of Functioning, Disability and Health. https://apps.who.int/classifications/icfbrowser/
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