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Chapter 4
Posture Diversion Protocol
- Interjecting
a Bias for Improvement or Change
-
The Posture Diversion Protocol (PDP) is the formulated theory
that while we may not be able to correct a physical deformity, we
can at minimum, eliminate the bias towards progression and even
introduce a bias for reduction and/or redirection. The PDP also
includes a number of guiding precepts and parameters while asking
the question: Should we ever be content to simply maintain the status
quo?
Posture Diversion Principles
- The best seated posture imposes the least structural stress
- Time, distance and force dictate degrees of proactive intervention
- Consider the structural integration of the entire body relative
to posture and pain
- At no time should realignment or diversion reach the limits
of ROM of the targeted structures
- Positioning and alignment outside the wheelchair should reflect
the goals established for seated posture
- The redirect of postural alignment requires the inclusion
of open space or channels into which redirection or distraction
can occur
For the sitting dependant person, the success for diversionary
alignment depends significantly upon the application of gravity
pressure in the direction of positive realignment; over prolonged
periods of time. This theory is applicable to various forms of:
kyphosis, scoliosis, Z-axis pelvic rotation, and posterior pelvic
tilt.
In orthopedic management and deformity prevention, the protocol
includes guidelines for positive outcomes, such as: minimum time
requirements, distance parameters, degrees of force, and the identification
of suitable anatomical structures. There are also critical precautions
for over-correction and the requirement that gravity influenced
postural improvements can only be achieved through engagement of
the collective protocol.
The following are additional components of the protocol:
Structural Stress
The vertical stress applied to the seated body is both constant
and structurally destabilizing. The natural curves that are necessary
for standing and ambulation seem to be counterproductive to long-term
seated posture. Since both the spine and pelvis have multiple pivot-points,
the potential for derangement, under the stress of gravity, is very
high. As the demand for sitting duration increases so does the stress
from an imbalance in weight distribution. Add to these structures
an intrinsic mechanical or neurologic anomaly and the propensity
for progression of stress, pain and deformity become magnified.
So long as a negative flexion bias exists so does the tendency for
instability and deformation.
Total Body Integration
Unless the whole of the body is considered, no corrective or preventative
measure will be adequately effective. In the presence of either
scoliosis or kyphosis there exist two abnormal flexion biases: at
the lumbosacral region and again at the region surrounding the apex
of the superior curve (which translates into additional skeletal
distortions and mal-alignment issues). Unless these biases are managed
collectively or alleviated all together, the likelihood of progression
and the rate of progression increase with time.
Time, distance and force
The degree of success in preventing deformity or deterring its progression
is directly influenced by the amount of time a person spends, not
just sitting in and effectively using the posture support system,
but also the time spent in repose on other surfaces. The concept
of effective posture diversion requires that at least a portion
of time spent outside the seating system include time spent in a
posture which reflects similar relative angles and structural alignments
established by the seating system. Recognizing that these principles
may conflict with ROM therapies, the protocol recommends a rational
balance of objectives.
The most extreme implementation of posture diversion is the concept
of 24-hour positioning. How this concept is integrated into a client's
lifestyle and living arrangements can have considerable impact on
medical care and routine maintenance. Cautionary insight for caregivers
should be included within the protocol.
Over-correction
Interpreting maximum correctable ROM as the ideal alignment can
prove highly counterproductive to the needs of long-term sitting
posture. While this altered position may appear improved and not
initially pain producing, it is very likely that a client will reposition
away from any tension producing alignment. Within this category
falls the misguided perception that posterior pelvic tilt should
be minimized to correctly align head and shoulder positions. However,
if an independent and highly experienced client's stability or function
is predicated on pelvic alignment, then altering an established
behavior can produce highly negative results. Other over-corrections
outcomes include:
- The client who displays behavioral actions that align their
body (or segment) into a position of their own choosing; no matter
what postural altering forces are applied. The head righting reflex
may be a good example.
- Fixed head and neck distortion that requires excessive force
to improve alignment. The force should be simulated during the
casting process to determine how the rest of the body must be
aligned and supported. That force should then be diminished or
removed altogether to determine postural response.
Principles of Six Points of Alignment Channeling (6-PAC)
6-PAC represents the application of an advanced interpretation of
Three-Point-Pressure (TPP), where, in addition to three spots of
localized pressure, three additional channels of open space are
included in a molded seating system. The three channels of open
space provide an area of deflection into which realignment or distraction
can occur. This distinction is made because the lack of open space
is a common omission in molded systems that include principles of
TPP.
In recline, distraction is allowed with an emphasis towards midline
channeling of all body structures. In passive upright sitting, postural
alignment is directed rearwardly and to midline. Where significant
spine or rib deformity exists, the use of 6-PAC is directed towards
de-rotation and lateral stability by means of establishing channels
into which the point of postural equilibrium can be established.
_______________________
What I present here is just one point of observation of a still
evolving approach to the management of sitting dependant, postural
anomalies. As the concepts of 24-hour positioning advance, the Posture
Diversion Protocol becomes a vitally important addition to the governances
and teachings of the industry. A collective guideline must be established
to encompass the widely diverse populations that could be affected
by such aggressive interventions. It will become the responsibility
of this industry to determine how such approaches and precautions
are wholly fashioned.
_______________________
Additional Observations:
- Relative to planar seating and a lateralized hip: when too
much leg length discrepancy is built into the seat, the opportunity
for pelvic de-rotation is completely lost. This conflict becomes
most apparent in the position of tilt-in-space.
- Total contact at the rear of the anteriorly rotated pelvis
will also prevent de-rotation. Both observations are particularly
true with low-tone sitting posture.
- Rotating the upper backrest to reduce a lateral flexion bias
is a quick postural fix but does not correct the structural deficiencies
inherent in the backrest. Furthermore, the allocation of support
pressure will remain inappropriately dispersed and imbalanced.
Richard Xavier Cushmaster
©
Copyright December, 2007 - CUSHMAKER.com
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