An Introduction to Postural Management at Night

What is Postural Management?

Postural management is a carefully planned approach to handling, treatment and positioning of children in order to encourage ability whilst maintaining body shape. It involves positioning children appropriately during all their activities, every day, and at night. It will enable them to participate in daily activities whilst gaining the benefits of careful handling and positioning in specialized equipment.

Generally these are children with a diagnosis of cerebral palsy, but other children with developmental delay may be similarly affected

Children who are unable to sit, stand or walk by themselves and who have difficulty moving are at risk of getting stuck in certain positions. If their posture is not managed well for them, they can become uncomfortable, due to structural changes in the hips and spine, breathing and digestive difficulties may occur, and they may in the end need surgery to make life easier.

Why is it important at night?

Positioning children well at night gives a chance to gently align their posture while they are resting, rather than spending all night in the same tight position, which become habitual and potentially harmful over time. If they are well positioned they may well feel more secure, and develop a better sleeping pattern, giving the whole family a better nights’ sleep.

What are its benefits?

The greatest benefits are for children who fall into the same position to sleep, and are not able to change this during the night in the way that we normally do. Using support correctly should maintain a better position every night, and this helps to slow down body shape changes that can occur when moving is difficult. Some children might not be able to stay in a good position because they have jerky movements that disturb them, and they also need support to give them the stability to feel they can relax and be still, and enjoy a better nights’ sleep.

Guidance from experts (link to find Consensus Statement) suggests that children with cerebral palsy should begin to use positioning equipment any time after they are 4 months old, if they have postural difficulties which might lead to hip or spine problems later.

Starting to support children at night before any changes to their posture are visible, means that they have the benefit of better positioning every night as they are growing, which should ensure that better positioning during the day becomes easier for them to achieve, so they can join in with everyone else

There may well be other benefits for the child and the rest of the family, which arise out of good positioning at night. You need to find the best solution for you all as a family, so ask your therapist or health visitor lots of questions about sleep behaviour and sleep positioning so that you can decide what is best for you.

What are the risks?

There are known postural risks for children with cerebral palsy who have difficulty moving. Doctors and therapists are well aware of this and will explain what can happen over time if children are not able to sit or stand on their own. Your therapist will be able to explain how hip joints develop, and how the pelvic and trunk position affect the shape and development of the spine. Because of these risks we try to ensure that families know what to do, and have equipment that they can use effectively.

Some children who have seizures at night may need to sleep on their side to be safe, and again they will need very good support to stay there because balance is more difficult in this position, and requires greater care.

How do we know if postural management is working?

If your child needs to use postural support at night then your therapist will be observing and recording any changes as your child grows and develops. X-rays are the most reliable way of knowing how well aligned joints and bony structures are (Scrutton 2000) From these you will be able to see how the hips and spine are developing, and that careful positioning is having a beneficial effect.

You should be able to see that your child is in a more aligned position and looks comfortable and relaxed in a well supported position, and you can also take photographs with them in and out of their supported position to keep a record for yourself.

When your child is placed and supported in a better alignment their head should be able to rest in midline, their shoulders and arms should feel more relaxed, their pelvis should be level and their legs should also rest in midline.

The equipment should provide them with plenty of surface shape to rest on, we call this better loadbearing, and this helps them feel more stable and relaxed.

They should be able to move a little within the support, so that they can wriggle their legs up and down a little if the can, and move their hands up to their face if they want to. The equipment should just give them the support they need to maintain the position, not fix them rigidly.

What are the cost implications of providing postural management at night?

Night time positioning equipment costs from £400 to £3000 depending on the type of equipment your child needs. The best may not always be the most expensive, but your therapist will advise you on the most effective equipment for your child, and the latest independent buyers guide is found in the NHS/PASA Buyers Guide.

You can always talk to our physiotherapist who has plenty of experience working alongside families who use postural management. Just give us a call and we will put you in touch.

Or you can look on the web at the sites below which have a variety of information that might be helpful.

http://www.sleepscotland.org
The Sleep solution team at the Centre for Cerebral Palsy, Western Australia;

www.tccp.com.au.tccp.com.au

There is also the opportunity to take part in research based a Chailey Heritage Clinical Services in West Sussex. They are researching to investigate the effects of sleep systems on sleep quality and pain in young people with cerebral palsy. For more information just contact Jessica Underhill or Terry Pountney at Chailey Heritage Clinical Services.
Tel: 01825 722112

Jo Jex, mcsp, Active Design Ltd