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THE PHYSICAL MANAGEMENT OF STUDENTS WITH DISABILITIESPOSITIONING STRATEGIES1POSITIONING Positioning refers to the use of appropriate body positions to insure that the child is in the optimal position for learning and participating in classroom activities.

The best practice is a transdisciplinary approach that bring together therapists and other service providers that fully integrates services within the educational environment.HAZARDS OF IMMOBILITYMUSCULOSKELETALDIGESTIVERESPIRATORYCARDIOVASCULARURINARYSKINPSYCHOLOGICALMUSCULOSKELETALSkeletal DeformitiesMuscle ToneMuscle StrengthIntegration of ReflexesOsteoporosisDIGESTIVEAbility to safely swallowGERDShift in internal organsConstipationRESPIRATORYPosition of the jaw and other oral structuresCoordination of breathing and swallowingPooling of secretions (congestion)Quality and effectiveness of breathingCARDIOVASCULARWeak HeartHeart RateBlood ReturnIncrease Work Load on the HeartBlood Pressure ChangesPooling in the VeinsURINARYUrinary PoolingPotential for Kidney StonesPotential for InfectionLoss or Lack of Bladder ControlSKINSkin BreakdownSkin IrritationPsychologicalChanges in Perception of and Responses to the EnvironmentTHERAPEUTIC POSITIONING PRINCIPLESProvide Firm Base of Support The resting surface of the body in any position should distribute the persons body weight across the broadest area possible.

Facilitate Optimal Positioning AlignmentThe head and trunk need to be as symmetrical as possible so that the front of the head, trunk, and legs are facing in the same direction. The shoulders should be squared over his hips. Start at the pelvis and work up and down.

ELEVATED SUPINE

ELEVATED SUPINEPURPOSE:Good for resting and sleeping. ADVANTAGES:Low energy position except when manual or visual work is expectedBreathing is easierUseful for students with poor neck and trunk controlPOTENTIAL PROBLEMS:Poor position for cognition and awarenessEncourages skeletal deformities especially in the legsPoor positioning of the jaw and oral structuresPooling of secretions in the back of the mouth increases risk of aspirationMucous build-up in the lungs and difficulty with coughing to clear secretions increase the risk for pneumonia.More difficult for the kidneys to drain in this position.If the student is active, they may roll off the edge or release straps.

13SUPINE

CUSTOM ELEVATED SUPINE

SIDELYINGELEVATED SIDELYING

SIDELYINGPURPOSE:Can be used as a resting position or as a work position where the pull of gravity is balanced between muscle groupsADVANTAGES:Allows the body to relax and , therefore, allows more flexibility in the jointsDecreases the influence of immature reflexesPromotes a midline head positionPromotes a more symmetrical body alignmentBrings both hands to midline Allows gravity to affect deformities in the legsBetter alignment of oral structuresPostural drainageIncreased ease of productive coughElevated right sidelying promotes gastric emptyingDifferent visual orientationSIDELYING (CONT.)POTENTIAL PROBLEMS:There is a risk for increased pressure on bony parts of the bodyModifications may need to be made for musculoskeletal deformitiesMonitor the color and temperature on weightbearing extremities especially if there are documented circulation problemsELEVATED SIDELYING

CUSTOM ELEVATED SIDELYING

PRONE ON FOREARMS (POF)

PRONE ON FOREARMS (POF)PURPOSE:Provides an alternative to sitting Can be used for rest or workADVANTAGES:Helps improve flexibility of shoulders, elbows, hips, knees, and spineHelps improve muscle strength of the neck and trunk extensorsImproved weightbearing through the shoulder jointsHelps trunk alignment for improved breathing and digestionHelps clear congestion for those with trachs, URI, and chronic congestionBrings the jaw forwardAids kidney and bladder drainageInhibits/integrates abnormal reflexes/movement patternsPressure relief on the skin

POF (CONT.)POTENTIAL PROBLEMSMuscle tightness at the shoulders or hips may not allow proper positioningSafety risk for students that are able to moveFrequent repositioning may be requiredPRONE ON FOREARMS (POF)

POF (CONT.)

QUADRUPED ON FOREARMS

QUADRUPED ON FOREARMS (QOF)PURPOSE:Same as other prone positioning with additional benefits

ADVANTAGES:Prone position available for those with severe hip flexion contracturesHelps improve flexibility in shoulders, elbows, hips, knees, and trunkImproves muscle strength of neck and trunk extensorsIncreased weightbearing through the shoulders and hipBrings the jaw forwardAids kidney and bladder drainagePressure relief on the skinInhibit/integrate primitive reflexesQOF (CONT.)POTENTIAL PROBLEMS:Modifications may need to be made for those with shoulder and hip tightnessSafety risk for those students that are able to moveFrequent repositioning may be requiredQUADRUPED ON FOREARMS (QOF)

QOF (CONT.)

CUSTOM QOF

CUSTOM QOF (CONT.)

STANDING

STANDINGPURPOSE:To allow students to bear weight through their extremities while in an upright postureADVANTAGE: SUPINEProvides full length support which is better for those with limited head controlPromotes weight bearing through the heelsAllows students with limited head and trunk control to be in a more vertical position with their peersPromotes improved physiological function

STANDING (CONT.)ADVANTAGES: PRONE:Promotes strengthening of the neck and trunk muscles to facilitate a more upright postureProvides support while allowing arms and hands to be free to engage in an activityProvides for weight bearing through the arms and legsProvides maintained passive stretch to hip and knee flexors and calf musclesPressure relief for the skinAllows students to be in a more vertical position with their peers

STANDING (CONT.)POTENTIAL PROBLEMS:Elevation should be gradual if the student is not used to upright. Can be done in times increments during a session.Students may experience circulatory changes if they are not used to being upright. Watch for changes in color and temperatureStudents may experience hypotension if they are not used to being upright. Watch for pallor, sweating, changes in breathing.SUPINE STANDER

SUPINE STANDER (CONT.)

PRONE STANDER

STANDER-OTHER

KNEELING

TALL KNEELERPURPOSE:To provide an alternative upright posture when limitations prevent a standing positionADVANTAGES:Same as for standing but with a shortened lever armPOTENTIAL PROBLEMS:Availability is limited as this is a custom piece of equipment. Not available commercially.Hip flexor tightness may not be able to be accommodated if moderately severe.May not be recommended for students with little to no head and trunk control

TALL KNEELER

SITTING

PROPER SITTING POSTUREPelvis is neutral or slightly forwardWeight is evenly distributed on both buttocksHips and knees are bent to 90 degreesFeet are supportedShoulders are squared over the hips and evenHead is midlinePROPER SITTING POSTURE

PROPER SITTING POSTURE (CONT.)

ADAPTIVE SEATINGPURPOSE:To provide needed support to allow the student to be in a seated position for workADVANTAGES:Allows students to sit at a work surface with their peersProvides head and/or trunk support for visual orientations, trunk control, and balance while concentrating on tasksAllows arms to be available for functionBreaks up undesired patterns and positionsAllows adjustments as the student changesBetter positioning for feedingVisual orientation for tracking and eye hand coordinationADAPTIVE SEATING (CONT.)POTENTIAL PROBLEMS:Provides too much support Skin breakdownCirculatory impairmentsRange of motion or presence of contractures may not allow positioning in adaptive seatingPositioning in seated positions for too long may encourage formation or worsening of contracturesWork surface heights may need to be adjustedADAPTIVE SEATING-CHAIRS

ADAPTIVE SEATING-WHEELCHAIR

QUESTIONS