Guest blog from Dr Lee Ann Hoffman, OTD, ATP, OTP, SMS 
Lee Ann Hoffman’s doctoral thesis discusses the importance of sleep and the influence of culture on sleep as an occupation. It also reminds us that sleep is not limited to ‘night-time’, and we need to be inclusive in our approaches, mindset, and language when addressing postures associated with sleep and rest. In the extract from her thesis, Hoffman highlighted that occupational therapy’s traditional role focused on addressing lying posture in infants, especially in the NICU. The author notes that a change in U.S. public health in the 90s impacted infant positioning, with the “back to sleep” campaign where infants were recommended to sleep on their backs to reduce the risk of Sudden Infant Death Syndrome (SIDS). Following the implementation of the U.S. public health policy, a reduction in SIDS numbers were reported. However, evidence showed a sharp increase in the prevalence of positional plagiocephaly and motor developmental delay, due to the changes implemented for infant positioning. In contrast, Fulford and Brown’s foundational work dates back to the 70s and noted that positional asymmetrical distortions, including plagiocephaly, were already evident in the pediatric population with a health condition. This thought-provoking article highlights that postural care management is often readily accepted in typically developing populations and reinforces the continued need to advocate for positioning for individuals with complex disabilities.
It is evident from my time here in the U.S. that a lot more work needs to be undertaken to share the benefits and gains of addressing lying postures. The potential number of hours an individual may spend in unsupported lying positions for occupations related to rest and sleep has long been unaddressed and dare I add- a forgotten posture.
I would like to share an extract from my doctorate (Hoffman, 2022):
Occupation of Rest and Sleep. Occupational science has outlined the importance of sleep as the foundation of all waking occupations. Sleep is vital in the achievement of occupational balance and well-being with a direct relational impact between sleep and performance skills. Sleep as an occupation, beyond the physiological benefit, is multifaceted and linked to occupational identity, occupational engagement, belonging, routines and rituals, and co-occupation. Sleep is influenced by the values of a community and culture. Many non-western cultures participate in occupations of rest and sleep throughout the day, whereas Western cultures reserve these occupations for the nighttime. Although sleep has been identified as an area of occupational need, it remains underrecognized by many practitioners.
My takeaway: Sleep is not just limited to “nighttime”. We need to be inclusive in our language and mindful of all cultures and contexts.
Occupational Therapy and Sleep Positioning. Occupational therapy’s role in addressing posture in lying has traditionally been focused on the infant population relating to the neonatal intensive care unit (NICU) and the correction of positional plagiocephaly (PP). Since the 1970s changes in infant positioning have been the focus of the neonatal occupational therapist’s interventions. The need to provide better postural orientation for neurotypical preterm infants in the NICU was originally focused on prone versus supine positioning. The benefits of both postural orientations have been associated with improved sleep and observed as changeable throughout various developmental stages. During early development, the preterm infant’s postures were associated with the flexed prone position, which was determined to promote self-soothing and regulation, in addition to being an easier position for the infant to adopt against gravity. During this developmental period, the supine position results in a lack of stabilization and leaves the body shape of the infant at risk of adopting extension postures against gravity. The focus of interventions in the NICU is to provide safe sleep practices through the implementation of supportive positioning. The benefits of positioning through strategies such as swaddling promote neuromuscular development and improve sleep. The use of blankets and positioning rolls can be used to create body boundaries, encourage midline positioning, and improve motor performance, and postural development.
A change in U.S. public health impacted the positioning of infants. In 1988, it was deemed standard practice to position infants in a prone position. With the steady rise of Sudden Infant Death Syndrome (SIDS), a health initiative was implemented in 1994 known as the “back to sleep” campaign, recommending supine positioning for all infants during sleep. In the following year, a 40% reduction in deaths was reported. However, in 1995 positional and developmental changes associated with the supine position were reported. It became evident that the supine sleep position was the same as the awake position with little to no time spent in the prone.
General concerns over motor developmental delay resulted due to supine positioning. It was noted that motor development patterns in infants before 1994 achieved the motor skill of rolling from prone to supine, and after 1994 from supine to prone. Developmental delays observed were attributed to the fact that rolling from supine to prone was more challenging for the infant to achieve as it required greater strength and coordination to flex against gravity to initiate and execute the roll. Furthermore, due to the extended periods that infants were positioned in supine during periods of both of sleep and wake states, the prevalence of PP rose sharply in the period following 1994. An infant’s head is malleable and susceptible to distortion as the skull bones have not fused and are therefore vulnerable to deformation due to the forces of gravity pushing down and the resistance of the firm supporting surface where the head is positioned. The occipital area of the skull flattens due to constant contact with the flat surface of the crib or the supportive upright seating. Furthermore, the deformation of the infant’s head was more likely to occur on the right-hand side, presenting as a flattened area to the right of the occiput and the right ear displaced (anteriorly and lower) when compared to the left side. In addition to this, right-sided torticollis and mandibular asymmetry were also observed. These specific patterns of postural distortions in healthy babies were a result of prolonged supine positioning, in accordance with the public health messaging to reduce SIDS. It was, however, not anticipated that most caregivers (parents and nurses) are right-handed, providing interventions such as bottle feeding and care predominantly from the right-hand side, driving and reinforcing this positional deviation to the right side through daily care practices. Parental and nursing education were identified as crucial to addressing and correcting these post-natal positioning distortions in healthy babies.
Positioning for Individuals with Complex Postures. Discussions surrounding PP in the neurotypical population surged around 1995, however almost 2 decades prior Fulford and Brown (1976) paved the way for discussion surrounding causes of positional asymmetrical distortions (plagiocephaly, unilateral bat ear, both face and upper body asymmetry, pelvic obliquity, and unilateral lower limb contracture) and the subsequent management of these positional changes in the cerebral palsy (CP) population. These positional asymmetrical distortions were identified as resulting from the forces of gravity on the immobile still-developing child and the supporting surface, as was the case with PP. Even as far back as the 1970s, Fulford and Brown (1976) determined that therapeutic interventions could positively influence these postural distortions and that they should be addressed and even prevented. This article has become the hallmark of 24-hour posture care management and postural interventions to address the secondary complications resulting from poor and unsupported positioning against gravity.
(Hoffman, 2022)
My takeaway: Occupational injustice – it became “accepted” that those with a health condition would inevitably develop postural distortions, while there was much concern about seemingly healthy babies developing postural distortions leading to greater action and intervention. We now know and understand that we can influence posture positively – so let’s not waste time. Move ahead with assessments and interventions to make positive changes for the populations we serve.
References
Fulford, G. E., & Brown, J. K. (1976). Position as a cause of deformity. Children Developmental Medicine and Child Neurology, 18(3), 305-314. https://onlinelibrary. wiley. com/doi/abs/10. 1111/j. 1469-8749. 1976. tb03652. x
Hoffman, L. A. (2022). Assistive technology education for occupational therapy students on 24-hour posture care management [Unpublished doctoral dissertation]. University of St. Augustine for Health Sciences.
About the Author
Lee Ann Hoffman, based in Dallas, Texas, is an occupational therapist with more than 20 years of experience. She has worked internationally and in a variety of healthcare settings and systems throughout her career. She is invested in contributing to the field of assistive technology and complex rehabilitation technologies and holds certifications as an assistive technology professional (ATP) and seating and mobility specialist (SMS) through the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). Lee Ann volunteers her time as co-vice chair for the RESNA 24-7 posture care management (PCM) special interest group and is part of the core team for the RESNA position paper for 24-hour PCM. She has presented and published internationally about 24-hour Posture Care Management. Lee Ann teaches entry-level occupational therapy doctoral students assistive technology at a Health Sciences University (USA) and is a lifelong learner having obtained a Bachelor of Occupational Therapy (Republic of South Africa), Master of Science in posture management (United Kingdom), post-professional Doctor of Occupational Therapy (USA) and is currently undertaking a second doctorate degree in education.
This blog is part of our 40 stories for 40 years’ series, celebrating our partnerships over the years. Click here to read more blogs in this series.
