Clinical Perspectives on Postural Management for Hip Health

Introduction

Children with non-ambulant cerebral palsy (CP) at GMFCS levels IV and V have limited opportunity to be independently mobile; this predisposes them to effects of immobility and progressive secondary deformities such as postural asymmetries. Research supports postural management at the amber or “probably do it” level, which means that evidence is low quality, and a good outcome measure is needed to assess intervention effectiveness.

A recent paper by Paleg and colleagues, titled Evidence-informed clinical perspectives on postural management for hip health in children and adults with non-ambulant cerebral palsy, provides insight into current postural management guidelines for lying, supported sitting, and standing, as well as supported stepping and orthotics.¹ The article examines the available evidence to synthesize recommendations across the lifespan, based on the ICF model and “F-words” framework: Fitness (body structure and function), Function (activity), Friends (participation), Family (environmental factors), Fun (personal factors) and Future.² Emphasizing the F-words taxonomy allows clinicians and caregivers to focus more on the environment, family needs, and participation of the patient rather than the specific body structures and functions while developing goals.

Considerations for Lying and Night Time Positioning Support

Regarding postural supports while lying and sleeping, the paper discussed the effects of supported sleeping towards decreasing the incidence of pain, reducing the risk of windswept deformities and hip dislocations, and improving comfort and sleep quality. The authors point out that patients who are unable to change their sleeping position are more likely to present with postural asymmetries especially if static positioning persists for over eight hours. This may be particularly poignant for individuals classified in GMFCS levels IV and V where tolerance for multiple sleeping positions is low. The existing body of evidence, although minimal, points to the overall benefits of nighttime postural management in children with CP, while acknowledging that sleep disturbance and discomfort make adherence to the protocols challenging in some cases. So, in consideration of postural support for the prevention of musculoskeletal asymmetries, the considerations for quality of sleep and reduction of pain in these positions are of equal importance. Children with non-ambulant cerebral palsy thus require comprehensive and regular postural assessment, incorporating familial input to determine appropriate positioning systems and lying positions to achieve the best outcomes.

Considerations for Adaptive Seating

Adaptive seating is supported widely through clinical practice consensus, with no evidence of harm found in the intervention. The authors summarize the available research indicating that upright positioning in an adaptive chair can potentially increase levels of activity and participation, upper extremity function, pulmonary function and reduce pressure. Particularly, molded seats or lateral and pelvic supports that increase hip abduction may decrease windswept positions and increase tolerance to sitting. Additionally, the authors note that although there is limited evidence for supported seating and its effect on hip stability, the positioning intervention is still thought to slow the progression of hip deformity. And regardless of the continued discrepancy in the literature, clinical practice suggests that ten to 15 degrees of hip abduction is well tolerated in sitting and is said to reduce the negative effects of spasticity, further underscoring the importance of adaptive seating as part of a comprehensive postural management plan.

Considerations for Supported Standing and Weight Bearing

It is generally recognized that supported weight bearing in standing for children with motor impairments increases bone mineral density, improves range of motion and hip stability, but there remains a lack of high-quality evidence supporting these recommendations. The authors point to studies recommending standing in ten to 15 degrees of hip abduction, as this appears to be more tolerable for children with spasticity. Dosage recommendation to stall hip migration percentage is thought to be at least one hour for five times per week, with the intervention continued over years to maintain optimal hip stability. Moreover, positioning in standing allows individuals to participate more during ADLs and activities with peers.

Supported stepping with a gait trainer increases physical activity and improves walking abilities. There are to date no studies that show the impact of supported stepping on hip stability, but bone mineral density and joint development are thought to improve with gait training.

Clinical Recommendations

The review article concluded by making seven clinical recommendations regarding how to apply the evidence surrounding positioning and postural management for children functioning at the GMFCS levels IV or V.

1. Comfortable and non-harmful lying and sitting positions are to be promoted, and if possible the ability to attain one or more sleeping positions is also beneficial. Medial thigh support in lying and the use of molded seating or an abductor should be used to prevent hip adduction and wind sweeping in children with increased tone. Frog leg (excessive bilateral hip abduction, flexion and external rotation) positions can be avoided using full-length pelvic and thigh lateral support in children with decreased tone.
2. Supported standing for at least one hour daily in ten to 15 degrees of hip abduction bilaterally is to be encouraged.
3. All positioning and equipment or support devices are to promote functioning and increased participation in activities.
4. Movement and active weight bearing using a supported stepping device reduces sedentary behavior as well as other possibilities such as cycling and swimming.
5. Unsupported supine lying, especially during the daytime, should be avoided by increasing the time in various upright positions. No single position should be maintained for more than eight hours.
6. Postural management is important during all parts of the daily routine and should be considered during transfers, eating, toileting, dressing, and bathing. Figure 1 below outlines the appropriate age for the introduction of these interventions.
7. A valid and reliable postural assessment should be used to identify issues and intervene early on.

Conclusion

Overall, it is most important that when implementing these postural recommendations, a client-centered and team approach is taken so that the individuals’ preferences and goals are considered. The ICF and F words frameworks provide helpful guidelines to ensure that the chosen interventions improve a patient’s participation and activity as well maximize independence to ease caregiving.