Dealing with many people with mobility problems, one of the most nerve-wracking issues is poor postural care. I like this analogy, so I'll use it again: Postural care is like brushing your teeth. Missing it one evening won't do much harm, but repeatedly skipping it leads to more severe problems. There's no excuse for not expecting a care plan from your physiotherapist, doctor, or care staff, and there should be no excuse for not following it. Why, you ask? That's why.
Postural care is often missed in day-to-day care, and from my observation, due to preventative measures, it should be prioritized for bed-bound, non-ambulating people regardless of their age and condition. The lack of appropriate posture often causes headaches for us physiotherapists. Many forget the importance of postural care in healthcare, which cannot be overstated.
But let's dive into the definitions. Postural care is an intervention aimed at preserving the body's natural shape. It's particularly important for individuals with mobility impairments due to conditions like cerebral palsy, muscular dystrophy, or significant injuries, including head injuries or various surgeries. Common interventions include advice for family and care staff, active movement if possible, therapeutic positioning, and specialized equipment. All of these must complement each other as fully as possible. Relying on only one intervention is often not enough. I learned this from the painful experiences of myself, patients, and families facing many complications associated with omitted postural care. There are many problems that occur when we stop moving freely, but let me touch on windswept deformity today, a common yet often overlooked condition.
Windswept Deformity - A Typical Case Study
Let's look at my most recent patient who presented with a windswept position. A typical case of windswept deformity involves an individual whose legs have been forced to one side due to prolonged incorrect positioning. Reasons for these positions can vary - some are beyond our control, while others result from overlooked care, lack of understanding of its importance, insufficient training, improper use or non-use of available equipment, or uncontrolled spasticity forcing the person into a certain position. This can lead to significant discomfort, mobility issues, and further health complications. Early intervention through postural care is essential in preventing and managing windswept deformity.
The Spectrum of Postural Care:
Postural care isn't just for those with severe disabilities. It's relevant to everyone. For example, a sedentary office worker might develop back issues due to immobility or prolonged time spent in poor posture. An elderly individual could face mobility restrictions from incorrect sitting or time spent in immobile or sleeping positions. Postural care involves understanding these risks and implementing strategies to mitigate them. As I've heard before and fully agree with - there are no bad positions to sit or lie in; it's the excessive duration in these positions that's problematic.
24-Hour Postural Care:
Remember, postural care is essential for a reason. Our bodies aren't designed to be stuck in one position, as they are meant for movement. Effective postural care encompasses both day and night. Night-time positioning is often neglected but is crucial in a comprehensive postural care strategy. It involves using specific positioning techniques and strategies over time, and potentially using equipment to maintain a therapeutic posture throughout the night.
Real-Life Stories and Outcomes based on my real-life patients:
1. Filip's Story - FIRE PROTECTION
Filip was a healthy-born child who developed FIRES syndrome, which caused substantial brain damage. I provided rehabilitation for him as well as educated his parents about the importance of daily mobility exercises, stretches, and positioning. We managed to obtain a symmetry kit sleeping system as a preventative measure to reduce the risk of him developing scoliosis, used a standing frame to monitor his bone density and appropriate loading regime, and provided active assistive exercises as well as the most appropriate wheelchair to fulfill his needs. Despite all efforts, as Filip grew, there were unavoidable postural distortions - however, his family, equipped with knowledge, were able to fight off more serious problems, allowing Filip to live without major postural issues.
2. Kate's Story - FIRE FIGHTING
Kate's story is slightly different. In 2020, she had a craniotomy for intracerebral hemorrhage in her left temporal lobe and developed PAID syndrome in her 40s. She lost mobility and verbal communication and became severely disabled. Between my first assessment in 2022 and the start of treatment, it took over a year due to unforeseen circumstances. Initially, I observed increased tensions in both her lower and upper limbs, along with potential contractures. Her position in bed indicated the presence of scoliosis. On the initial assessment, a T-roll to maintain Kate's neutral position was in place. One year later, Kate developed substantial body shape changes, changes in tone, and increased sensitivity in her extremities. My role, as well as the in-house physiotherapists who just started working with Kate, is to find an optimized way to reduce the negative impact of the deterioration. This includes more physical hands-on interventions, taking into account existing contractures, passive range of movement, and pain.
It is time to implement a regimen of therapeutic positioning and gentle exercises to help improve her condition and prevent further deterioration.
3. Mar's Story - RESTARTING THE ENGINE
Mar is one of my current MS patients. Around 40, he is a super nice guy who was gradually losing his mobility over 10 years. He decided to undergo HSCT (hematopoietic stem cell transplantation), which aims to "reset" the immune system by wiping it out and then regrowing it using the patient's stem cells. Part of the deal, alongside other side effects, is an increased long-term risk of developing infections. In Mar's case, this involved prolonged immobility to prevent this risk. It ended up reducing his mobility and increasing muscle tone. I was approached to help restart his mobility and address the immobility. After an assessment, we agreed that without help from the spasticity clinic, we would not be able to effectively address the increasing problems with muscle tone, followed by changes in sitting posture (increasing scoliosis due to imbalanced tone) as well as balance problems. To provide effective therapy and reduce the risk of further deterioration, I had to build trust, add time to explain where the problems were, and explain the importance of daily activities and ongoing therapeutic interventions. We managed to get Mar back to the spasticity clinic for periodic Botox injections, got him appropriate orthotics, and finally established a standing frame regime. Maintaining body shape and freedom of movement is crucial for participating effectively in even the simplest daily tasks as well as for pain reduction - all contributing to maintaining quality of life.
Our Role - Healthcare Professionals
We cannot win this battle alone. Nurses and therapists play a crucial role in identifying at-risk individuals and implementing postural care plans. I must mention spasticity specialists and the successful access to these services to supplement our input with potential muscle relaxants, analgesics, or Botox injections as appropriate. KNOW-HOW must be shared across patients, families, and care staff. No Excuses. Regular assessments and collaboration with a multidisciplinary team are essential. I'll say this again - it's just like brushing your teeth.
References:
1. NHS Education for Scotland. (2017). Postural Care Learning Byte.
2. Goldsmith, S. (2000). The Mansfield Project: postural care at night within a community setting. Physiotherapy, 86(10), 528–534.
3. Houghton, M. (2010). A step by step guide for GP practices: annual health checks for people with a learning disability. Royal College of General Practitioners, London.