People with 'low incidence' disabilities are those with less common and normally more severe disabilities.  These would include disabilities such as severe orthopedic impairments and physical disability as well as vision and hearing disabilities.
Due to the very nature of their physical disabilities, individuals with 'low incidence' disabilities are often those who have the most difficulty with effective positioning for work.

Seating and positioning is an ongoing, dynamic process, with constant evaluation and modifications where needed especially with changing body and changing needs.  No one system is perfect - there are no recipes.  Each positioning system for each individual is often unique.  Constant problem solving and critical evaluation can result in the most appropriate system at the time.

Some important concepts:

 We cannot underestimate the effect of positioning on:
  • socialization 
  • interaction 
  • motivation 
  • confidence 
  • participation 
  • comfort 
  • safety 
  • function
  • Positioning is not static - it's DYNAMIC.  Frequent changes in posture and positioning for varied activities and times of day are important.  A wide range of positions and movement between positions is essential for assisting neurological, muscular and autonomic functions. 
    (breathing, cardiac function, bladder clearing, joint compression, joint pressure, pressure relief, alternate weight bearing, digestions, eating/swallowing etc.)  

  • The best position for function might not always be the most conventional, or the 'best looking' system.  Positioning and seating is not ONE method.  It involves different positions depending on the individuals activity or need

  • Try to maintain a balance between 
      1.  Support / stabilization / strapping and
      2.  Movement / mobility.  
    The balance between these two will have a significant effect on fatigue, endurance, motivation, energy, function, participation.

  • Structured and planned seating and mobility can not be started too early.  Power mobility needs to happen as soon as possible.  Early Mobility article.
    Pediatric Powered Mobility - a GREAT resource project from Rancho Los Amigos on the relationship between power mobility and a positive effect on development.

  • Symmetry is not always essential, although we've been told for many years to get the body into a 90-90-90 position with knees at the same height.  
    Asymmetry, if it assists with function and does not lead to contractures/pain/deformity, may be necessary.   Good seated positions for work should maximize function while minimizing pathology.

  • Abnormal tone and reflex patterns - a 'b-a-l-a-n-c-e'     It is not always necessary to inhibit 'abnormal' movement patterns or positions - some people need these for function.  Some physically disabled people learn and develop motor patterns, movements and skills that their parents, therapists, family and friends may have never thought possible for that individual.  Movements based on abnormal movements and abnormal tone patterns are not always negative, unless there is potential to develop muscle contractures, pain or skeletal deformity.  Inhibition of abnormal postures and positions is best but not always necessary especially if the individual needs to use those movements for function.  Maximize function while minimizing pathology.

  • Temporary loose or tight strapping can help with specific movement control or learning specific movement.

  • Remember - ergonomic principles are important for people with disabilities too - what better place to start than when a student is still in school?  This is especially the case with a student who is performing repetitive switch presses or key presses for communication or computer access.  See this article on ergonomics and disability.

  • Aesthetics is important - positioning systems should be as low profile as possible, and make use of common components that are used by peers in the classroom or in the workplace if possible. 

Joint and body stabilization:  Positioning of each individual joint is essential.  While determining most optimal positions, we need to look at individual joint and skeletal / neuromuscular positions.

  • Stabilizing proximal joints often results in improved quality and accuracy of distal joints

  • Shoulder - large multiaxis joint, allows large range of motion of full arm. For students with poor control, full range of motion of the arm often results in little productivity or accurate activity with full arm and hand.

  • Elbow, wrist and finger joints - if the shoulder is stabilized, many students can control movements more efficiently at distal joints.

Strapping:  Strapping can be LOOSE or TIGHT and is often effective in reducing unwanted, random, poorly controlled movement and providing the stability required to improve desired movement patterns.  Loose strapping can allow for enough movement to activate a communication device or other equipment, while still being effective in maintaining the hand / arm in close proximity to the switch or device to be activated.  In some cases, strapping for stabilization of a proximal joint (e.g. elbow or shoulder) increases functional skills of distal joints (e.g. hand or fingers) for access.   Strapping can also provide kinesthetic, sensory input for improving awareness of movement and arm placement for activities.  

Two blocks on either side of the forearm, with strap across top, allows movement but limits large, uncontrolled movements, and hold the hand in close proximity to the keyboard or adaptive input device.


HIERARCHY for POSITIONING
 

Legs and arms last  (equally as important)

'Best' positions are not always the most structured, stabilized or immobile positions.

Don't start with positioning the activity.
Hips and Pelvis:  What is optimal?
  - 90 degrees is NOT always best
 - Weight bearing and stabilization
- 'Optimal' and 'best' positions can be very different for different individuals
- Opening seat to back angle is often effective for improving lumbar curvature and improving upright posture of trunk and body, resulting in overall better control
- During assessment trials and while positioning of the pelvis at varying angles in terms of seat and back angle, evaluate the students' control of upper body movement 'with' and 'without' upper body strapping (e.g. butterfly harness).  Some students show remarkable improvement of upper body control with altered hip and pelvic angles.  Click here for more detail about seating angles. 

START with the student, get the student positioned as well as possible, THEN position activity according to student

Examples of equipment positioned according to student's position:  
- raised height and adjustable monitor angles and heights
- Intellikeys keyboards or communication devices on floor mounts for students in floor seats or prone creepers.
Trunk positioning
  The trunk can often be positioned with collateral movements and support of the upper limbs.  Providing a height adjustable tray or table, with angled work surface or raised computer monitor are all aspects that encourage upright head position, eye contact at a raised height compared to the normal 'work-on-desk' position.  The arms and hands resting on a raised work surface often provide significant stabilization and help with trunk control.
What do we need to consider when looking for optimal positions?
 
- Students' movement patterns

- Natural postures of comfort

- Joint and soft tissue integrity / damage
Head and Neck
  Positioning of the head for effective interpersonal interactions, communication, visual contact with educational activities and the teacher and overall contact with the environment remains one of the most challenging, elusive tasks in the quest to position students with severe physical disabilities.

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