Posture matters: how simple changes in position can improve the lives of people

with advanced MS

Wendy HendrieSpecialist physiotherapist in MS

Norfolk Community Health & Care

My aim:• to make you a Posture Warrior!

NO!

By telling you…• why posture is important

• how to do a basic assessment

• how easy it is to make a difference

Posture• is the shape and position our body adopts and is constantly changing

• provides balance and stability - which is vital for function

• is a learned skill

Not usually something we have to think about…

Posture is about…• adapting to the surface your body is resting on• organising body segments• being able to adjust quickly e.g. to the disturbance of

moving a limb• being able to position the body for movement

Posture is about…• changing position• taking the weight off limbs in order to move them – e.g.

walking• allowing muscles to act by providing a fixed point to act

against• keeping stable/balanced in order to function

Many systems contribute to posture

POSTURE

SENSORY

VESTIBULAR CEREBELLAR

VISUALMOTOR

muscle flexibility, tone

range of movement

In people with MS…• things go wrong when automatic andvoluntary postural control is lost

• compensatory strategies are used to maximise balance, stability and function

• secondary complications inevitably arise

Secondary complications• pain• pressure ulcers• contractures• breathing dysfunction• digestion problems• speech and swallowing difficulties• decreased function• decreased quality of life(Coyle et al, 2000; Pope, 2007)

What is ‘good’ posture?• stable base - supported and balanced

• uses as little energy as possible

• causes the least damage to the body

• a position from which we function effectively

Good posture?

‘Good’ Posture

Sitting Standing

What is ‘bad’ posture?• any position that causes damage to the body

• asymmetrical postures can often cause the most damage

• damage often occurs when bad postures are held for a long time

‘Bad’ or ‘Normal’ Posture?!

Sitting Standing

Posture is normally asymmetrical

(Ferreira et al 2011)

Symmetry takes energy

Why manage posture?• to improve function

• to minimise or avoid secondary complications

• to increase quality of life for person and family/carers

Posture changes early

Early intervention is desirable• stretch hip flexors

• work hip extensors

• upright standing e.g. frames

• Address tone issues

Management v Treatment

Management

Management + Treatment

Treatment

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Stretching hip flexors

Standing Up in MS – SUMS study• RCT in Norfolk/Suffolk/Devon/Cornwall

• N = 140, EDSS 6.5 and above

• Oswestry standing frames at home

• www.plymouth.ac.uk/research/sums

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Assessment• use your eyes – ‘deviations’ may be obvious

• subjective/objective assessment may reveal problems

• remember - not all postural problems are problems!

• 24 hour approach

Assessment – talking• rarely mention posture • pain(MSK)• pressure ulcer/red area• speech or swallowing problems• breathing difficulties• handling or positioning problems• balance problems in chair• spasms/increased tone (incl medication)

Anti-spasticity medication• Gabapentin (Neurontin) - 100/300/600mg, max = 3.6g

• Baclofen (Lioresal) - 10mg, max 100mg

• Tizanidine (Zanaflex) - 2mg/4mg, max 36mg

• Dantrolene (Dantrium) - 25mg, max 400mg

• Diazepam - 2mg/5mg/10mg, max 60mg

Would you drive a car with its brakes on, or a runaway train?

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Assessment - measuring• ROM• tone• functional movements• tissue damage• respiratory infections• pain• preferred posture

The ‘preferred’ posture• the posture which the body customarily adopts when

placed in any position

• on release of passive correction the posture reverts to the original attitude indicating the existence of tissue adaptation

(Pope, 2007)

Preferred posture

Assessing sitting postureIf the person is sitting asymmetrically:

•look at the preferred posture on the bed

Fixed postures?•may be contracture at hip flexors/ extensors/knee flexors

•consider Botox, anti-spasticity medication change, stretching regime

Fixed postures• the aim is get the pelvis as straight as possible then block

trunk / legs so that no further deformity can take place

• consider referral to wheelchair services

• but, if the body is able to lay completely straight, a symmetrical posture can be achieved in sitting

Start in the middle – the pelvis

Assessing the pelvis• put your fingers on the ASIS

• look at the position of the pelvis in relation to neutral

Pelvis position – the key stone

Posterior pelvic tilt

Pelvic rotation – right ASIS forward

Pelvic obliquity – higher on left

Can measure between the coracoid process and the ASIS

Look at the rest of the body• leg position

• trunk, shoulders and head position

• ability to balance and function?

• does posture relate to problems?

Goals• emphasis on function

• aim for dynamic or static success

• person/family/carer led and agreed

If no deformity in lying:• pelvis in neutral or slight posterior tilt

• femurs in line with pelvis (knees apart)

• hips/knees/ankles at 90°

• trunk straight

Good posture = function!

£5 of foam!

Correcting pelvic obliquity

Postures for function

Normal eating posture

Using the toilet/commode

Ataxia

Hoisting

Posture in lying•most damage done in this position• keep body as straight and in-line as possible, hips in line with

knees and shoulders and avoid twisting in the middle• keep knees apart and supported• support arms and move them away from the sides of the body if

possible• use foam/towels/pillows before sleep systems

Matchett support - Leanne

‘Windswept’ posture in bed

Head support

Headmaster collar

24/7 management•meeting of experts

• Care Plans that describe the correct positions

• photos/drawings

• family /carer awareness and training

Don’t forget….• sleep systems

• positioning devices (chair and bed)

• bed turning devices

• URIAS air splints (hands and elbows)

Summary• pelvis is the keystone – correct pelvis first

• static success is a good outcome

• ‘sell’ the concept of good posture and ensure that people know what to do

• try ‘Blue Peter’ devices first

Summary• often a compromise between posture and function • try to make people feel stable and balanced

• change position regularly if possible

•most damage done in lying position

Thanks for listening!

References• Ferreira et al (2011) Quantitative assessment of postural alignment in young adults based on photographs of anterior,

posterior and lateral views. Journal of Manipulative and Physiological Therapeutics 34(6):371-380

• Coyle et al (2000) Secondary conditions and women with physical disabilities: a descriptive study. Archives of Physical Medicine and Rehabilitation 81: 1380-1387

• Rimmer, JH (1999) Health promotion for people with disabilities: the emerging paradign shift from disability prevention to prevention of secondary complications. Physical Therapy 79(5):495-503

• Pope, PM (2007) Severe and complex neurodisability: management of the physical condition. Butterworth Heinemann Elsevier Ltd, London

• Sutherland, G. Anderson, MB (2001) Exercise and multiple sclerosis: physiological, psychological and quality of life issues. Journal of Sports Medicine and Physical Fitness 41:421-432

• Riskind, JH (1984) They stoop to conquer: guiding and self-regulatory functions of physical posture after success and failure. Journal of Personality and Social Psychology 47:479-493

• Bohns, VK (2011) I hurt when I do this (or you do that): posture and pain tolerance. Journal of Experimental Social Psychology 48(1):341-345