Therapeutic positioning is the placement of body parts in posture to achieve the following goals:

1. To maintain normalized muscle tone
   
2. To maintain alignment of body parts
   
3. To maintain stabilization of body parts
   
4. To promote active participation in meaningful activity

Although the first three goals are critical, they are not ends in themselves; rather, they are means to achieve the ultimate goal of preparing a person to perform functional activities. Proper positioning is an essential prerequisite for effective instruction of students with multiple disabilities.

Positioning can be either static or dynamic. Dynamic positioning is achieved and maintained entirely through therapeutic handling; static positioning is maintained through use of adapted equipment. Static positioning is considered a supplement to, rather than a substitute for, dynamic positioning. Prior to positioning a child in an adapted chair, for example, therapeutic handling techniques are applied to place the child in a sitting position with tone normalized and the body properly aligned. Without performing this dynamic positioning first, it becomes difficult to achieve any of the four goals listed above through static positioning. There are advantages, however, to providing static positioning with adapted equipment. These include 1) making the student more mobile, 2) freeing the student from a one-to-one relationship with parents or educational staff, 3) freeing staff from positioning to provide instruction and to facilitate other types of student performance, and 4) enabling students with disabilities to participate in activities with peers without disabilities without constant adult presence.

In addition to the therapeutic benefits of positioning, researchers have identified several functional benefits for providing children with physical disabilities with adapted equipment for positioning. Benefits include the following:

1. Children at school maintained upright postures longer, attended to and participated in more instruction, and learned to perform academic and self-care tasks more quickly and more independently (Trefler, Nickey, & Hobson, 1983).
   
   
2. Children at home spent less time lying in their bedrooms, spent more time sitting and less time lying down, maintain better alignment in upright postures, improved their abilities to eat and drink, increased their abilities to grasp objects and feed themselves, and spent more time interacting with others (Hulme, Poor, Schulein, & Prezzino, 1983; Hulme, Shaver, Acher, Mullette, & Eggert, 1987).

When positioning equipment also provided a means of mobility (e.g., wheelchair), the following additional benefits were demonstrated:

1. Children went more places outside of their homes (Hulme et al., 1983).
   
   
2. Children (and their families) engaged in more social activities, had more contact with peers outside of school, increased their participation in activities in school, and had greater independence in all environments (Kohn, Enders, Preston, & Motloch, 1983).
   
   
3. Children engaged in more positive social interactions, became more curious about the environment, and became interested in other activities involving movements (e.g., playing baseball, going hiking) (Butler, 1986; Butler, Okamoto, & McKay, 1983).

Determining the Need for Positioning Adaptations

When positioning children with physical impairments, the dangers of providing too much or too little control must be considered. The obvious danger of providing too much or too little control must be considered. The obvious danger of providing too little control is that proper positioning is not maintained, and therefore fails to offer experience in aligned and upright postures, allows deformity, and hampers participation in instructional activities. In fact, research conducted with preschoolers showed that poor positioning lowered performances on IQ tests, both for children with cerebral palsy (Miedaner & Finuf, 1993) and for children who had no motor impairments (Sents & Marks, 1989). Providing too much support is also potentially dangerous, however, because some children will rely on whatever support they are given, using their own motor skills as little as possible and eventually losing rather than gaining abilities. Maintaining too much external control also limits opportunities to improve motor skills and to develop internal control. Maintaining adaptations and monitoring their use is a time-consuming responsibility that should be eliminated if the adaptations are not necessary. Furthermore, chair adaptations increase the time and difficulty of seating the child for work or transportation and removing the child for repositioning or emergencies. Finally, the presence of numerous adaptations on a chair may elicit undesirable reactions, such as pity or apprehension, that should be minimized. Although unnecessary adaptations can be completely eliminated from chairs, even essential controls or supports might be removed at certain times of the day. For example, a student might need a headrest during transportation but not when listening to a story. During eating, the static positioning offered by the headrest might be less beneficial than dynamic positioning, in which the teacher puts one hand on the student’s head only when stabilization is needed.

When positioning children with multiple disabilities in adapted chairs or other equipment, it is necessary to view each child as an individual. An adaptation that is necessary or effective for one child may be neither for another child. Many minute adjustments may be necessary before a chair adaptation has the desired effect. Once the desired effect is attained, change in the child’s size or condition may necessitate more modifications. These warnings are not meant to be discouraging; they emphasize that positioning equipment is not a quick cure but a tool to be used skillfully. In the same way, chair positioning has many advantages for children with multiple disabilities, but it cannot meet all the positioning needs of any child. Therefore, a variety of positioning options should be considered for each child. Selecting the proper pieces of equipment requires knowledge of what equipment is available or technologically feasible and how that matches therapeutic, functional, and social needs and goals of the individual child and family (Taylor, 1987). Exceptional parent magazine regularly provides resource guides to commercially available adapted equipment. To ensure access to the full range of positioning apparatus, rehabilitation equipment specialists as consultants are now essential members of teams for children with multiple disabilities (Hedman, 1990).

Alternative Positions

In selecting a variety of positions for a student with physical disabilities, the educational team addresses each of the following questions:

• What postures should be reinforced?
• What postures should be avoided?
• What functions must be performed?
• What are the social contexts?
• What positioning alternatives are possible in the course of the day?

The postures to be reinforced may be nay in which the child is currently developing greater control. The postures to be avoided are those that reinforce primitive reflexes, deformities, abnormal pastures, or abnormal movement patterns. An analysis of the functioned to be performed requires an evaluation of the postural and movement demands of the tasks involved. A good frame of reference for this analysis is to consider how people without disabilities perform the task. To perform the task of face washing, discussed previously in this chapter, a student must be able to see the task area and reach the materials (e.g., water, soap). Although a basin of water might be placed on a table or tray where the student sits, it is awkward to put both hands in a basin at chest height, and it may be difficult to see to perform the task. Removing the child from the sink also eliminates the possibility of performing important steps in the task, such as turning the water on and off. Children with physical disabilities may be unable to use the “normal” position of standing unsupported at the sink for face washing. Many children can perform the task while standing in a prone stander or parapodium stander, either of which gives postural support, frees the hands sufficiently to perform the task, provides a clear view and good access to the necessary materials, and approximates the normal position for the activity. These positions accommodate the performance demands of the activities and simultaneously facilitate normal postures and movements. Of equal importance, the child’s daily routine provides natural opportunities to use a variety of therapeutic positions.

Finally, the education team must consider the various positions available to the students over the course of the day. Medical professional have long recognized that immobility had adverse effects on motor, cardiovascular, respiratory, gastrointestinal, urinary, and metabolic functions (Olson, 1967). Prolonged sitting invites hip and knee flexion contractures and other deformities, particularly for children who cannot independently assume other positions (Fulford & Brown, 1976). Some muscles will develop contractures unless they are in a lengthened position for a minimum of 5 hours per day (Tarideu, Lespargot, Tabary, & Bret, 1988). Once deformities develop, the best positioning does not reverse contractures of muscles and tendons (Kunkel et al., 1993; Lespargot, Renaudin, Khouri, & Robert, 1994). Sitting motionless creates circulatory problems underneath the hipbones, with noticeable changes occurring after just 30 minutes and pressure sores developing in as little as 1-2 hours (Garber, 1985). Intense pressure, friction on the skin, or irritation from urine all increase the possibility of skin breakdown over bony areas when children with severe physical disabilities remain in the same position for long periods. Immobility and lack of weight bearing on the legs contribute severely to osteoporosis (Kaplan, 1983), which is irreversible (Kunkel et al., 1993). Immobility and poor positioning interfere with pulmonary function and are directly related to shortened life expectancy for people with profound disabilities (Eyman, Grossman, Chaney, & Call, 1990; Nwaobi & Smith, 1986). For these reasons, it is important that children experience a variety of positions. A good rule of thumb is for students to have at least two different positions between which they can alternate, and for these positions to be changed at least once an hour, preferably every 30 minutes. Table 3.3 [not available] presents a list of positions, equipment that might be used to achieve positions, and activities that typically would be performed in those positions. It is useful to develop a positioning plan to ensure that each student’s positioning matches daily activities while alternating between positions in which 1) the head and trunk are upright, then reclined: 2) the hips and knees are flexed, then extended; and 3) weight bearing is on the hips and thighs, then on other body parts (preferably of the feet). The relative importance of each consideration depends on the student’s risk for the health and therapeutic concerns identified previously.


References

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Eyman, R., Grossman, H., Chaney, R., & Call, T. (1990). The life expectancy of profoundly handicapped people with mental retardation. New England Journal of Medicine, 323(9), 584–589.

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