Evidence for 24-hour posture management: A scoping review

Introduction:

People with complex physical disabilities unable to change their position independently are at risk of developing postural deformities and secondary complications. 24-hour posture management is needed to protect body structure. With inconsistencies in current service provision, this research aimed to scope the evidence for a 24-hour posture management approach.

Method:

A scoping review was conducted using four health and social science databases. Inclusion and exclusion criteria were applied; further papers were included through citation chaining.

Results:

The evidence for 24-hour posture management was often low quality due to the complications of completing robust research studies in this complex specialty. However, many professionals in the field agree that a 24-hour approach to postural care is essential.

Conclusion:

There is a need for clear national policy and guidance relating to postural care and scope for development of dedicated posture management services. Current NHS service provision is variable and inconsistent. Lack of postural care is a safeguarding and human rights issue. Specialist training and research in postural care within the Occupational Therapy profession is required to raise awareness of the role Occupational Therapists can play in preventing postural deformities and other secondary complications through providing good postural care.

Educating rehabilitation professionals on clinical skills for postural care services: A scoping review

Background: This scoping review aims to identify evidence-based practices for educating rehabilitation professionals who provide assistive technology interventions, specifically night-time postural care, to children with cerebral palsy.

Methods: A review of both peer-reviewed and grey literature published between 2000 and 2021 was undertaken in June 2021. The articles were analyzed using a process outlined by Arksey and O’Malley in 2005: scanning abstracts, completing initial and critical reviews, collating and summarizing data into themes.

Results: The search resulted in 15 articles, predominantly from the United Kingdom and the United States: 10 primary research, two reviews, two conceptual/theoretical, and one gray-literature source. Four themes emerged (1) Successful service delivery required competence, (2) Benefits of incorporating practice, collaboration, and feedback, (3) Effective online education through multifactorial approaches, (4) Considering different learning requirements among team members.

Conclusions: There’s beginning evidence that rehabilitation professionals’ competence with night-time postural care might be achieved via active, interactive, multi-factorial online training.

Educating caregivers of persons with cerebral palsy in night-time postural care: A randomized trial comparing two online training programs

OBJECTIVE

Compare effectiveness of two differently formatted training programs in educating night-time postural care implementers.

DESIGN

Mixed-methods parallel-group double-blind design with random assignment.

SETTING

United States academic institution.

PARTICIPANTS

Thirty-eight adult caregivers/providers of children with cerebral palsy.

INTERVENTIONS

Both 2-hour online programs included content on night-time postural care evidence, risk-factor monitoring, sleep-system types, positioning methods, and assessments. Group A used interactive videos, Group B summary information with web-links.

MAIN MEASURES

We measured self-perceived competence via questionnaires (baseline, post-training, post-simulation) containing 4-point rating-scales of knowledge, ability, and confidence and measured positioning ability via a simulation observation instrument comprising 16 positioning-task ratings with space for describing performance. We recorded participant actions/statements using fieldnotes.

RESULTS

Thirty-eight completed training (19 per group). Group A (vs B) showed significantly greater self-perceived competence changes post-training (0.46 points (SE 0.17), P = 0.008). Thirty-seven positioned a standardized "client," with groups not differing significantly on total tasks completed correctly (F(1, 92.32) = 1.91, P = 0.17) averaging 11.85 (SE 0.83) and 12.60 (SE 0.84) of 16 tasks correct. Group A's post-positioning/simulation self-ratings were significantly associated with actual ability (r = 0.53, P = 0.019). In both groups ⩾47% of caregivers incorrectly completed the tasks of placing head and neck in neutral and snugging up all [positioning] parts.

CONCLUSION

The sleep care positioning training program (interactive video-based format) is effective in building caregivers' self-perceived competence for night-time postural care. While the lesson was well-received by caregivers and considered a "match [to their] learning style," the lesson did not lead to greater improvement in actual ability to position the "client" compared to control training.

Current clinical practice in 24-hour postural management and the impact on carers and service users with severe neurodisability

Introduction

The clinical benefits of 24-hour postural management are widely recognised by occupational therapists, but little is known about its impact on service users and carers or whether clinical practice is consistent across regions. The aim of this research was to investigate the use of 24-hour postural management by occupational therapists and to explore its impact on service users with neurodisability and their carers.

Methods

Quantitative and qualitative methods were employed in two phases: (a) online survey with 96 occupational therapists across one UK region, with data analysed by descriptive statistics and correlations; (b) focus groups with service users and/or carers ( n = 9), with data analysed by thematic analysis.

Results

Findings showed moderate positive correlation between frequency of use and (a) all key intervention skills and (b) knowledge of night-time positioning ( p < 0.001). Moderate positive correlations were found between level of training and (a) assessment skills and (b) knowledge of night-time positioning ( p < 0.001). The overarching theme from focus groups was ‘reliance on individualised equipment’, with overwhelming frustration from lack of support, loss of identity, equipment cost, insufficient focus on preventative strategies and accessibility issues.

Conclusion

A clinical practice guideline, including training, is crucial to direct practice. Providers must engage with service users and carers to address their frustrations.

Sleep positioning systems for children and adults with a neurodisability: A systematic review

Introduction

Sleep positioning systems are often prescribed as part of a 24-hour postural management programme for children and adults with neurodisabilities. In a search for evidence of effectiveness for children with cerebral palsy a recent Cochrane review found two randomised controlled trials. This review aims to appraise a broader set of studies including any neurological diagnosis and users of all ages to inform therapists about the quality of the evidence underlying practice.

Method

A comprehensive search for all peer-reviewed studies that evaluated the use of sleep positioning systems was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library databases, BNI, HMIC, PEDro, OTSeeker and clinical trials registries. Disability organisations, manufacturers and colleagues worldwide were also contacted. Titles were screened for relevance by two reviewers. Data were extracted into bespoke quantitative or qualitative forms by one reviewer and checked by a second. Findings were analysed into simple themes.

Results

A total of 14 studies were eligible for inclusion; all were small and most were of low quality. Inferences of benefits cannot be made from the literature but also no harm was found.

Conclusions

The body of evidence supporting practice remains small and mostly of low quality. Therapists should remain cautious when presenting the benefits to families.

Sleep positioning systems for children with cerebral palsy

BACKGROUND

Sleep positioning systems can be prescribed for children with cerebral palsy to help reduce or prevent hip migration, provide comfort to ease pain and/or improve sleep. As sleep disturbance is common in children with developmental disabilities, with impact on their carers' sleep, and as sleep positioning systems can be expensive, guidance is needed to support decisions as to their use.

OBJECTIVES

To determine whether commercially-available sleep positioning systems, compared with usual care, reduce or prevent hip migration in children with cerebral palsy. Any negative effect of sleep positioning systems on hip migration will be considered within this objective.Secondary objectives were to determine the effect of sleep positioning systems on: (1) number or frequency of hip problems; (2) sleep patterns and quality; (3) quality of life of the child and family; (4) pain; and (5) physical functioning. We also sought to identify any adverse effects from using sleep positioning systems.

SEARCH METHODS

In December 2014, we searched CENTRAL, Ovid MEDLINE, Embase, and 13 other databases. We also searched two trials registers. We applied no restrictions on date of publication, language, publication status or study design. We checked references and contacted manufacturers and authors for potentially relevant literature, and searched the internet using Google.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) evaluating whole body sleep positioning systems for children and adolescents (up to 18 years of age) with cerebral palsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened reports retrieved from the search against pre-determined inclusion criteria and assessed the quality of eligible studies.Members of the public (parent carers of children with neurodisability) contributed to this review by suggesting the topic, refining the research objectives, interpreting the findings, and reviewing the plain language summary.

MAIN RESULTS

We did not identify any randomised controlled trials that evaluated the effectiveness of sleep positioning systems on hip migration.We did find two randomised cross-over trials that met the inclusion criteria in respect of secondary objectives relating to sleep quality and pain. Neither study reported any important difference between sleeping in sleep positioning systems and not for sleep patterns or sleep quality (two studies, 21 children, very low quality evidence) and pain (one study, 11 children, very low quality evidence). These were small studies with established users of sleep positioning systems and were judged to have high risk of bias.We found no eligible trials that explored the other secondary objectives (number or frequency of hip problems, quality of life of the child and family, physical functioning, and adverse effects).

AUTHORS' CONCLUSIONS

We found no randomised trials that evaluated the effectiveness of sleep positioning systems to reduce or prevent hip migration in children with cerebral palsy. Nor did we find any randomised trials that evaluated the effect of sleep positioning systems on the number or frequency of hip problems, quality of life of the child and family or on physical functioning.Limited data from two randomised trials, which evaluated the effectiveness of sleep positioning systems on sleep quality and pain for children with cerebral palsy, showed no significant differences in these aspects of health when children were using and not using a sleep positioning system.In order to inform clinical decision-making and the prescription of sleep positioning systems, more rigorous research is needed to determine effectiveness, cost-effectiveness, and the likelihood of adverse effects.

A systematic review of interventions for children with cerebral palsy: state of the evidence

AIM

The aim of this study was to describe systematically the best available intervention evidence for children with cerebral palsy (CP).

METHOD

This study was a systematic review of systematic reviews. The following databases were searched: CINAHL, Cochrane Library, DARE, EMBASE, Google Scholar MEDLINE, OTSeeker, PEDro, PsycBITE, PsycINFO, and speechBITE. Two independent reviewers determined whether studies met the inclusion criteria. These were that (1) the study was a systematic review or the next best available; (2) it was a medical/allied health intervention; and (3) that more than 25% of participants were children with CP. Interventions were coded using the Oxford Levels of Evidence; GRADE; Evidence Alert Traffic Light; and the International Classification of Function, Disability and Health.

RESULTS

Overall, 166 articles met the inclusion criteria (74% systematic reviews) across 64 discrete interventions seeking 131 outcomes. Of the outcomes assessed, 16% (21 out of 131) were graded 'do it' (green go); 58% (76 out of 131) 'probably do it' (yellow measure); 20% (26 out of 131) 'probably do not do it' (yellow measure); and 6% (8 out of 131) 'do not do it' (red stop). Green interventions included anticonvulsants, bimanual training, botulinum toxin, bisphosphonates, casting, constraint-induced movement therapy, context-focused therapy, diazepam, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care, and selective dorsal rhizotomy. Most (70%) evidence for intervention was lower level (yellow) while 6% was ineffective (red).

INTERPRETATION

Evidence supports 15 green light interventions. All yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions should be discontinued since alternatives exist.

Ventilatory function in children with severe motor disorders using night-time postural equipment

AIM

Night-time postural equipment (NTPE) can prevent hip subluxation in children with severe motor disorders (SMDs). However, it is unclear how it affects ventilatory function. The aims of the study were to determine how NTPE use affects ventilatory function and to compare night-to-night variability of ventilatory function in children with SMDs and typically developing healthy children.

METHOD

Fifteen NTPE users (six males, nine females), aged 1 to 19 years (mean age 8y 7mo) alternated sleep condition between NTPE and sleeping unsupported for 14 nights. In all but two participants, gross motor function was classified as Gross Motor Function Classification System (GMFCS) level V; in the other two it was level IV. Oxyhaemoglobin saturation (SpO2 ) was monitored each night and transcutaneous CO2 (PtcCO2 ) for one night in each sleep condition. In 17 healthy children of similar age, home SpO2 only was monitored for seven nights.

RESULTS

In 13 of 15 NTPE users and 12 of the 17 typically developing children, SpO2 monitoring was satisfactorily completed. Of the children with SMDs, two had mean SpO2 levels below the treatment threshold for supplemental oxygen, which was uniquely associated with use of NTPE in only one participant, and three had nocturnal hypoventilation, which was uniquely associated with NTPE use in only one case. Night-to-night SpO2 variability was higher in children with SMDs than in typically developing children.

INTERPRETATION

NTPE may impair or enhance ventilatory function in a minority of children. Owing to night-to-night variability in SpO2 , at least three nights of monitoring are recommended to determine optimal positioning for effective ventilation before and after NTPE introduction.