Presentation by Wendy Hendrie

1. Posture matters:
how simple changes in position
can improve the lives of people
with advanced MS
Wendy Hendrie
Specialist physiotherapist in MS
Norfolk Community Health & Care

2. My aim:
• to make you a Posture Warrior!
NO!

3. By telling you…
• why posture is important
• how to do a basic assessment
• how easy it is to make a difference

4. 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

5. Not usually something we have to think
about…

6. 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

7. 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

8. Many systems contribute to posture
POSTURE
SENSORY
VESTIBULAR CEREBELLAR
VISUALMOTOR
muscle flexibility, tone
range of movement

9. In people with MS…
• things go wrong when automatic and
voluntary postural control is lost
• compensatory strategies are used to maximise balance,
stability and function
• secondary complications inevitably arise

10. 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)

11. 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

12. Good posture?

13. ‘Good’ Posture
Sitting Standing

14. 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

15. ‘Bad’ or ‘Normal’
Posture?!
Sitting Standing

16. Posture is normally
asymmetrical(Ferreira et al 2011)

17. Symmetry takes energy

18. Why manage
posture?• to improve function
• to minimise or avoid secondary complications
• to increase quality of life for person and family/carers

19. Posture changes
early

20. Early intervention is
desirable
• stretch hip flexors
• work hip extensors
• upright standing e.g. frames
• Address tone issues

21. Management v Treatment
Management
Management + Treatment
Treatment
21

22. Stretching hip flexors

24. 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
24

25. Assessment
• use your eyes – ‘deviations’ may be obvious
• subjective/objective assessment may reveal problems
• remember - not all postural problems are problems!
• 24 hour approach

26. 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)

27. 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

28. Would you drive a car with its
brakes on, or a runaway train?
28

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

30. 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)

31. Preferred posture

32. Assessing sitting posture
If the person is sitting asymmetrically:
•look at the preferred posture on the bed

33. Fixed postures?
•may be contracture at hip flexors/
extensors/knee flexors
•consider Botox, anti-spasticity medication
change, stretching regime

34. 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

35. Start in the middle – the
pelvis

36. Assessing the pelvis
• put your fingers on the ASIS
• look at the position of the pelvis in relation to neutral

37. Pelvis position – the key
stone
Posterior pelvic tilt
Pelvic rotation
– right ASIS
forward
Pelvic obliquity – higher
on left

38. Can measure between the
coracoid process and the
ASIS

39. Look at the rest of the
body
• leg position
• trunk, shoulders and head position
• ability to balance and function?
• does posture relate to problems?

40. Goals
• emphasis on function
• aim for dynamic or static success
• person/family/carer led and agreed

41. 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

51. Good posture =
function!

53. £5 of foam!

54. Correcting pelvic obliquity

60. Postures for function

61. Normal eating
posture

62. Using the toilet/commode

64. Ataxia

66. Hoisting

68. 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

69. Matchett support - Leanne

73. ‘Windswept’ posture in
bed

77. Head support

78. Headmaster
collar

79. 24/7 management
• meeting of experts
• Care Plans that describe the correct positions
• photos/drawings
• family /carer awareness and training

80. Don’t forget….
• sleep systems
• positioning devices (chair and bed)
• bed turning devices
• URIAS air splints (hands and elbows)

82. 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

83. 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

85. Thanks for listening!

86. 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