Guidance

Postural care and people with learning disabilities: guidance

Published 8 May 2018

Introduction

This guidance is to help health and social care professionals and family carers and supporters learn more about how to support the postural care needs of people with learning disabilities who are at risk of body distortion.

We searched for policy, guidelines and research that relate to postural care for people with learning disabilities. A summary of this information is the following sections. We put a request out through a range of networks for people interested in services and care for people with learning disabilities. We asked people to send us information about what they have done to support people with learning disabilities who have postural care needs.

This guidance sets out what we found and describes the online resources we used and where you can access them. This is accompanied by a selection of case studies about how postural care services have been developed and how individuals have been supported to get good postural care.

We would like to thank everyone who shared expertise, resources and contributed examples from practice to this guidance.

What is postural care?

Postural care refers to an approach that aims to preserve and restore body shape and muscle tone for people with movement difficulties. People with profound and multiple learning disabilities often sit and lie in limited positions, leading to a high risk of body shape distortion. This is not inevitable. The right equipment and positioning techniques can help to protect body shape in people with movement difficulties ^{[footnote 1]}.

Postural care addresses all body positions that an individual adopts over the day and it usually involves a personalised 24 hour programme that includes ^{[footnote 2]}.

• provision of adaptive seating
• positioning equipment to support the person in lying, including at night time
• moving and handling techniques
• advice and training for family carers and professionals across all settings

A recent systematic literature review did not find any studies looking at the numbers of people with learning disabilities likely to need postural care ^{[footnote 3]}. This would be useful information for those commissioning services for this group. However, the number of people with profound and multiple learning disabilities can be used as an approximation. In 2009, this was estimated to be just over 16,000 adults and this figure is expected to rise until 2026. There is more recent data available relating to children and in 2014 to 2015 and it was estimated that there were over 10,000 children with profound and multiple learning disabilities in England.

National guidance and reports

Two national reports have highlighted the gap in services to protect body shape for people with profound and multiple learning disabilities ^{[footnote 4]}, ^{[footnote 5]}. It was noted that early intervention can prevent the need for surgery and it was recommended that NHS bodies should provide a service that recognises postural care issues and addresses them effectively.

In 2012, NICE recognised the clinical efficacy of body shape protection in their guidance about managing spasticity in children and young people ^{[footnote 6]}. They stated the need for a 24-hour postural care management programme that includes assessment of the postural needs of a child or young person when they are asleep or resting. The guidance also recognised the importance of training and support of family members or carers as part of effective postural care.

The Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD) established the link between a failure to protect body shape and resultant premature death ^{[footnote 7]}. It recommended that clinical commissioning groups (CCGs) should ensure they commission expert, preventative services including proactive postural care support.

Why is this an important issue?

There are physical, psychological and emotional effects of body shape distortion, and poor postural care can have severe and life-threatening consequences. In someone with movement difficulties, failure to provide postural care will lead to the person regularly adopting their preferred sitting and sleeping positions. Over time, due to a lack of movement and the effects of gravity, highly predictable body shape changes develop which eventually mean they cannot move out of their preferred position ^{[footnote 8]}. Their body shape will continue to deteriorate, resulting in health problems, pain, increased equipment needs and greater dependence.

Respiratory problems are the main reason people with profound and multiple learning disabilities need primary or secondary medical care; pneumonia is the most common cause of death in this group ^{[footnote 7]}. Some of the risk factors for respiratory problems that can be reduced by good postural management are:

• airway clearance dysfunction
• saliva management difficulties
• immobility
• reflux
• sleep disordered breathing
• thoracic deformity

Other physical health problems associated with body shape distortion include ^{[footnote 8]}:

• problems with the musculoskeletal system, such as hip dislocation, contractures, curvature of the spine and reduced movement
• difficulties in swallowing and risk of choking
• constipation
• pressure on internal organs
• recurrent pressure sores

Such complications will cause discomfort and possibly severe pain. They will certainly have a negative impact on someone’s quality of life and can lead to emotional and psychological problems including:

• fatigue
• depression
• isolation
• feelings of helplessness

The Mencap booklet Postural care: protecting and restoring body shape and the accompanying videos (check Resources for more links) share family stories about the range of problems faced by people with body distortion.

What are the benefits of postural care?

Provision of 24-hour postural care reduces health risks and improves quality of life for individuals. It can also benefit those caring for the person. Evaluation after the first year of an occupational therapy postural management service showed a positive impact for both patients and carers ^{[footnote 2]}. For people receiving the postural care these included:

• improvement in quality of life
• improved daily functioning and participation
• increased comfort
• reduced agitation and less disruptive behaviour
• reduced muscle tone
• improved overall positioning

The benefits reported by family carers and paid support staff were:

• greater understanding of postural issues and positioning
• reduced stress
• easier to assist with basic activities of daily living
• more consistent approach for staff

Person centred outcomes such as reduction in pain, increased dignity and better sleep are important. However, body symmetry measurements are fundamental to assessing the outcomes of postural care interventions. The Goldsmith Indices of Body Symmetry ^{[footnote 9]} can be used to measure:

• degree of rotation of chest
• chest depth width ratio
• wind sweeping index of hips
• right and left hip abduction/external rotation

The Goldsmith Indices of Body Symmetry provide a systematic, objective approach that give clarity as to what is actually happening in terms of the body shape. The measurements are taken when the person is lying down, meaning they are not affected by someone being poorly positioned in a chair or seating system.

It is generally expected that children with postural problems will deteriorate over time. Interventions may only slow this deterioration down, rather than stop or reverse it. Therefore, maintenance of body symmetry should be viewed as a positive outcome.

Other objective outcomes that can be used to assess the impact of postural care interventions include the number of hip dislocations.

Although postural care can be an expensive service it does reduce the need for invasive and costly interventions including ^{[footnote 8]}:

• surgical procedures
• complex equipment for mobility
• adaptation to the home
• enteral feeding
• pain management
• increased need for medications such as Botox or Baclofen

So, in addition to the tangible benefits for individuals and their carers, a postural care service could also be cost effective in the long term.

What are the barriers to good postural care?

Lack of awareness

Research has shown that health and social care practitioners, teachers and short-break/respite carers are often unaware of both the consequences of body shape distortion and the fact that it is avoidable ^{[footnote 3]}. Physiotherapists have an essential role in the implementation of a postural care programme for an individual, but they are reliant on referrals from other professionals. There is a need for greater awareness of postural care needs in members of multidisciplinary teams and better knowledge about why and when they should refer someone for 24-hour postural care ^{[footnote 10]}.

Dysphagia and constipation are some of the health problems that can be caused by or made worse by body shape distortion, yet this link is not always made. Therefore, if someone has constipation/dysphagia and also movement difficulties, carers should adopt a more holistic approach and a consideration of postural needs, or an appropriate referral for this. Too often the acute needs are addressed rather than the underlying issue of body shape distortion.

A study exploring postural care knowledge in nursing students concluded that the information the students are given is too complex and recommended a broader introduction to postural care needs. The authors proposed that this would help students transfer their university learning to practice in a range of settings ^{[footnote 11]}.

Family members caring for someone with profound and multiple learning disabilities will usually have multiple other health needs to address. They may not always recognise postural care as an important issue ^{[footnote 12]}. There is a need to raise awareness of the significance of postural care, especially in view of the fact that body distortion is likely to be contributing to other health problems.

Lack of resources

Even if the problem is recognised, postural care services do not exist in all areas. People with more severe body shape distortion are liable to need specialist services which may not be available locally ^{[footnote 13]}.

Where services do exist, there may still be difficulties in funding the equipment that is needed. Specialist equipment such as wheelchairs, seats and postural support systems is an important aspect of protecting the health of disabled children and the people caring for them ^{[footnote 14]}. Evaluation of an occupational therapy postural management service found that most of the reasons for dissatisfaction related to waiting times for equipment ^{[footnote 2]}. Lack of funding is one of the most common reasons given for lack of night time postural management equipment ^{[footnote 3]}.

Challenges in implementing postural care programmes

A survey of physiotherapists reported that family carers often rejected night time positioning systems. Studies have identified a number of reasons why family carers and teaching staff may not participate in postural care management programmes. These include ^{[footnote 3]}, ^{[footnote 12]}, ^{[footnote 15]}:

• negative perceptions about the appearance of specialist seating and standing supports
• lack of understanding of the benefits of postural care
• lack of knowledge and confidence in carrying out the programme
• lack of time and competing priorities
• parents feeling unsupported in the implementation of programmes
• difficulties with practical aspects of using equipment
• lack of relevant ongoing training

There is evidence that when families manage to use night time positioning for a consistent period of time they see benefits such as their children lying straighter, sleeping better and showing less pain. However, parents may need a lot of support when beginning to use night time positioning as a number of difficulties in adopting these have been observed ^{[footnote 16]}:

• equipment can be difficult to use and transport
• difficulty in sleeping
• increased repositioning at night
• concerns about discomfort and temperature regulation

Hospital admissions

Many people with profound and multiple learning disabilities have regular, and sometimes lengthy, stays in hospital. The problems this can cause in terms of body distortion are only anecdotally reported (see case studies).

Generally in hospitals, there is no recorded information about positioning and, therefore, it is not addressed. Hospital passports should include details about how a person needs to be positioned at different times; for example, for eating and drinking or at night-time, and all staff need to be aware of these needs.

It can be difficult for people to take their own equipment, such as night positioning systems, into hospital due to problems with space and laundry. The special sheets that some people use are not able to cope with high temperature washes and may not be returned to the correct person. If someone with a postural care programme is admitted to hospital and likely to stay for more than a few days then ideally their physiotherapist should write some temporary guidelines for their stay which may include advice on recreating a positioning system using available materials such as pillows.

This case (provided by a senior physiotherapist) illustrates some of the problems that can occur when an individual with postural care needs is admitted to hospital:

When Simon was admitted to hospital, his family took his positioning system in. They were told by hospital staff that it could not be used as it was an infection control risk. However, it later transpired that this information was incorrect. When equipment belongs to one person there should not be any issues around infection control.

Simon’s hospital passport flagged his positioning needs but it was not read and he was not being positioned correctly during his admission and spent the majority of his time lying on a flat mattress. Simon ended up in hospital for over 3 months and in this time his posture deteriorated to the extent that he no longer fitted properly in his moulded wheelchair. It also meant it became more difficult to wash and dress him. He had to start taking painkillers due to the muscle pain and a referral had to be made to the special seating service for adjustments to be made to his moulded wheelchair.

Thus, hospital staff need better education regarding positioning. Hospital risk assessments should also address issues of positioning and equipment. If necessary, an individual should be referred to the physiotherapy department. If a hospital has a learning disability liaison nurse they could play a role in consideration of positioning for people with postural care needs and ensuring that hospital passports are read and followed.

If hospitals are going to provide positioning systems then they need to consider issues such as:

• versatility
• noise
• cross infection risks
• impact on temperature regulation of the person using it

There can also be issues for people coming in for out-patient appointments. There is a need for simple, adaptable seating to accommodate body-shape changes in X-ray rooms. If someone is wrongly positioned during an X-ray, this means further discussions will be based on images that do not accurately reflect usual posture. There should be a selection of seat inserts in the X-ray room that radiologists can put into place to support someone correctly during the X-ray.

Lack of consideration of postural care as a safeguarding issue

Despite the fact that a failure to support body shape can lead to serious consequences and even be life-threatening, it is not always viewed as a safeguarding issue. Families have reported respite and short-break settings not using recommended night time positioning systems, and some family carers and supporters view positioning and the use of night time positioning as restrictive. There is a need for more education around the concept of positioning as a method for keeping people safe and comfortable, rather than as something restricting them. Failure to implement someone’s positioning routine should be considered a safeguarding issue rather than a treat.

Clayton (2013) makes a series of recommendations about postural care in relation to safeguarding ^{[footnote 13]}. These include:

• empowerment - protection of body shape must be viewed as part of a holistic approach to supporting individuals to live fulfilled, pain free lives within their local community close to the people that love them
• prevention - protecting body shape reduces the need for complex care provision enabling people to be supported closer to home

Lack of research

A systematic review of the relevant research literature identified a number of gaps in the evidence base ^{[footnote 3]}. There is an urgent need for evidence about the effectiveness of 24-hour postural care programmes and night-time positioning equipment. This could support the calls for improved specialist services and better funding for equipment, such as night time positioning systems. The existing research does not provide the evidence required by commissioners.

It would be useful to have studies looking at the potential cost effectiveness of postural care services. This type of specialist service could be cost effective in the long-term but there is no research into this ^{[footnote 2]}. A report by Centre for Economics and Business. Research proposed that if better provision of equipment resulted in even a modest reduction in the need for surgery and other interventions such as Botox, the costs of the equipment could be recuperated ^{[footnote 14]}.

Commissioning considerations

In order for people to have good postural care there is a requirement for people to have access to services, equipment and training to support the long term management of their body shape ^{[footnote 17]}. CIPOLD recommended that commissioners acknowledge the need for expert and proactive postural care support ^{[footnote 7]}. CCGs should consider investing in postural care interventions to improve quality of life and save money.

There are lots of barriers around the provision of good postural care services, including:

• strict eligibility criteria for wheelchair services, excluding people who need these services
• delays in the provision of equipment meaning that sometimes people are measured for a moulded wheelchair but by time it arrives they have grown or their body shape has changed and it is no longer suitable and may not even be safe
• the range of equipment an individual needs are likely to be provided by different departments or statutory bodies, who may have different commissioning and assessment arrangements
• lack of integration between services and organisations
• lack of knowledge around the demand for services and equipment
• funding not matching demand
• lack of evidence of the outcomes of a good postural care service
• overall lack of accountability for protection of body shape and an acceptance that body shape distortion is inevitable for people with complex disability

What do we know about what works?

There are some published studies about what works in postural care services. A systematic review described the evidence around interventions and reported ^{[footnote 3]}:

• research around surgical interventions showed mixed results, as there can be complications from surgery
• case studies into behavioural approaches suggest that using a reward stimulus for holding a posture can lead to people maintaining a therapeutic posture for longer
• appropriate and personalised equipment can result in positive outcomes, for example people show physical and functional benefits from moulded seat inserts in wheelchairs
• positioning can have an impact on communication and oxygen saturation

Night-time positioning

There is some research around the benefits of night-time positioning and the use of sleep-systems. This was reviewed in the NHS Buyer’s Guide to Night-time postural management equipment for children produced by the Centre for evidence-based purchasing ^{[footnote 18]}. The guidance concluded that there is a need for more robust and long-term research evidence about 24-hour postural management programmes but cites several studies that are indicative of improvements such as better sleep, reduced pain and benefits for hips. As discussed above, it can be difficult to introduce changes to night-time positioning but with a high level of support and gradual changes it can be done successfully ^{[footnote 16]}.

Training

There is some evidence of the importance, and effectiveness, of training. Evaluation of a postural training programme across 7 Primary Care Trusts for health professionals and family members showed positive feedback with participants reporting increased confidence in their skills in relation to postural care ^{[footnote 19]}.

Another study evaluated a training programme developed for parents and school staff ^{[footnote 15]}. This used a questionnaire to assess knowledge and understanding, concerns and confidence in providing postural care before and after the training as well as focus groups and interviews. One of the positive outcomes of this was parents reporting a greater understanding of the importance of postural care for their child. Additionally, school staff reported improved knowledge and understanding about the impact of posture on learning and the child’s learning.

There are examples of how training can be effective in the case studies.

Commissioning

Commissioning postural care services should be a key part of the local strategy to meet the health needs of people with profound and multiple learning disabilities, but as noted above there are challenges. CECOPS CIC is the independent standards and certification body for all assistive technology services. They have produced a code of practice for disability equipment, wheelchair and seating services. This covers the commissioning, provision, and clinical and technical aspects of services. It consists of 47 measurable outcomes and some of the benefits of using it are:

• it provides a benchmark for all related services
• it provides a template for commissioners and providers and a tool for managing contracts
• it addresses problems, such as rigid eligibility criteria
• it promotes integration of services and shows how this can be done
• it promotes a holistic and person-centred approach

This code of practice is a tool that can support commissioners to ensure that people using services get positive outcomes. Commissioners can include requirements in a contract stipulating that suppliers must be accredited to CECOPS or a similar organisation.

Partnership working

Many people will have a role to play in ensuring good postural care for an individual; this could be the escort on the bus, the teaching assistant at school, family carers and supporters as well as health and social care professionals. Partnership between working professionals and those who provide hands on care and support is vital ^{[footnote 12]}, ^{[footnote 13]}. Case studies that illustrate this can be found in ‘Examples of reasonable adjustments and case studies’.

Across the country there are examples of innovative services and practice and some evidence suggesting benefits, although there is a need for more robust evaluation. These include:

• a postural care pathway in Wakefield (see case study section for further details) – children in this area have equipment provided if needed and their postural symmetry is measured objectively. Since the development of this service there is evidence of a reduced need for surgical interventions, such as hip surgery ^{[footnote 20]}
• training for supported living staff which led to an increase in referral rates ^{[footnote 21]}
• a 24-hour postural care service led by occupational therapists – evaluation after the first year reported very positive feedback from professionals and family carers as well as maintenance or improvement in objective body measurements ^{[footnote 2]}

Resources

The 2 lists below contain all the information and resources we have found in relation to supporting the postural care needs of people with learning disabilities.

List 1 lists websites and resources that may be of use to professionals/family members and carers who want more information and resources.

List 2 lists the easy-read resources and films we have found. This is where you can find information to use with people with learning disabilities.

Some resources may be available from more than one site, but we have only given one link. We have only included resources that are free to download, although some of the websites may also include resources you can buy.

List 1: Resources about postural care for professionals/family members and carers

1. Postural care: protecting and restoring body shape, Postural care action group and Mencap. A booklet about what postural care is and why it is important.

2. Postural care -protection of body shape, NHS Education for Scotland and Simple Stuff Works This ‘Learning Byte’ provides a brief guide to postural care. It includes stories to illustrate the points and also activities to aid learning.

3. Postural care: A guide to 24 hour postural management for family carers, PAMIS and NHS Lanarkshire. Information with case studies about the importance of postural care. It describes how Lanarkshire provides 24 hour postural management plans for those who need this.

4. It’s My Life! Postural care pathway, Simple Stuff Works. This care pathway has been developed to put families and personal assistants in control to self-manage effective postural support for people with impaired movement. The pathway is divided into 5 steps.

5. The economic benefits of better provision of equipment for disabled and terminally ill children, British Healthcare Trades Association and Centre for Economics and Business Research.
   A report on the potential benefits of an improvement in the availability of equipment for disabled and terminally ill children.

6. An A to Z of postural care, Canterbury Christ Church University. A guide for Teaching Assistants, Educationalists, Children, Young People, Parents and Everyone. This A to Z booklet aims to give basic information and may act as a starting point for discussions with the therapy team, the child’s family and others in the school.

7. Postural Care factsheet, Learning Disabilities Mortality Review (LeDeR) programme. A brief factsheet about the principles of postural care and why it is important.

8. Got my back!, Changing Our Lives. A booklet that accompanied a conference about postural care called ‘Got my back!’. This provides background information as well as desired outcomes from the day.

9. Top tips for supporting and meeting the needs of people with profound and multiple learning disabilities, NHS Midlands and East. This includes 10 top tips for supporting the postural and mobility needs of people with profound and multiple learning disabilities.

10. Postural Care Profile, Care Management Group. This is a template for a 2 page postural care profile. It is designed to provide a pictorial overview of postural care recommendations for an individual.

List 2: Videos and easy-read information about postural care

1. What is postural care?, PCSP (UK) Ltd. A short easy-read leaflet about postural care.

2. Sensory stories, Simple Stuff Works and The Sensory Story Project. Sensory stories designed to support the delivery of good postural care. As you move through the story there are cues for your postural care night-time routine. There is advice on how to gather or create the sensory stimuli required for the stories.

3. Connor’s story, Simple Stuff Works.

A 4 minute film about good postural care.

1. Postural care family stories, Simple Stuff Works.

A 14 minute film where families share their experiences of postural care.

1. Postural Care Training Video for Parents & Carers, Lincolnshire Community Health Services NHS Trust.

An 11 minute film (aimed at parents and carers) explaining the need for postural care.

1. Sarah Clayton talks about postural care, University of Derby.

A 13 minute film about the need for postural care, the importance of a personalised approach and the need for objective outcomes.

1. Myth Buster Animation, Simple Stuff Works.

A 4 minute film addressing some of the myths about postural care.

1. A simple story: therapy for children with complex needs, Simple Stuff Works.

A 3 minute film about the need for night-time positioning.

1. Never too old, Simple Stuff Works.

A 4 minute film about how postural care issues can be addressed for older adults.

1. Postural Care, Mencap.

A series of 6 short films including case studies.

1. Postural Care, PAMIS Scotland.

Series of 7 film segments.

1. Got My Back!, Changing Our Lives.

A series of 4 short films.

1. Tommy’s Story - 24-hour postural care

A 5 minute film from Disability Services Commission Western Australia about Tommy’s experiences of body distortion and the difference his postural care plan has made.

1. Birmingham’s 24 Hour Postural Care Pathway,

A 13 minute film about Birmingham Community Healthcare NHS Trust’s 24 hour Postural Care Pathway. Their approach is family centred, with input from physiotherapists, sleep system providers and parent carers.

References

1. UK Parliament (2010) Equality Act 2010 (accessed 13 December 2017) ↩

2. Crawford S and Curran A. (2014) 24 hour postural management for community dwelling adults with learning disabilities. Posture and Mobility: The Journal of the Posture and Mobility Group; 31: 15 to 19 ↩ ↩² ↩³ ↩⁴ ↩⁵

3. Robertson J, Baines S, Emerson E and Hatton C. (2016) Postural care for people with intellectual disabilities and severely impaired motor function: a scoping review. Journal of Applied Research in Intellectual Disabilities: 1 to 18 doi: 10.1111/jar.12325 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

4. Michael J (2008) Healthcare for All: Report of the Independent Inquiry into Access to Healthcare for People with Learning Disabilities. London: Department of Health (accessed 13 December 2017) ↩

5. Mansell J (2010) Raising Our Sights: services for adults with profound intellectual and multiple disabilities. Department of Health, London (accessed 13 December 2017) ↩

6. National Institute for Health & Care Excellence (2012) Spasticity in under 19s: management (clinical guideline 145) (accessed 13 December 2017) ↩

7. Heslop P, Blair P, Fleming P, Hoghton M, Marriott A and Russ L. (2013) Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD): Final report. Bristol: Norah Fry Research Centre, University of Bristol (accessed13 December 2017) ↩ ↩² ↩³

8. Hill S and Goldsmith J. (2010) Biomechanics and prevention of body shape distortion. Tizard Learning Disability Review; 15: 15 to 32 ↩ ↩² ↩³

9. Goldsmith E, Golding RM, Garstang RA and MacRae AW. (1992) A technique to measure windswept deformity. Physiotherapy; 78: 235–242 ↩

10. Castle D, Stubbs B, Clayton S, Soundy A and Williams G. (2014) A 24-hour postural care service: Views, understanding and training needs of referring multidisciplinary staff. International Journal of Therapy and Rehabilitation; 21: 132 to 139 ↩

11. Page A and Clayton S (2016) Knowledge on postural care amongst nursing students at Birmingham City University. Postural and Mobility Group Journal (accessed13 December 2017) ↩

12. Morrison, M, Frew L, Boslem C, Jordan K and Sloan D. (2016) Working together to improve 24 hour postural care within NHS Lanarkshire. PMLD Link; 28(3): 10 to 14 ↩ ↩² ↩³

13. Clayton S (2013) Living Local Postural Care Project Evaluation. Simple Stuff Works (accessed13 December 2017) ↩ ↩² ↩³

14. Centre for Economics and Business Research (2014) The economic benefits of better provision of equipment for disabled and terminally ill children. Report for the British Healthcare Trades Association (accessed13 December 2017) ↩ ↩²

15. Hotham S, Hamilton-West KE, Hutton E, King A and Abbott N. (2017) A study into the effectiveness of a postural care training programme aimed at improving knowledge, understanding and confidence in parents and school staff. Child: care, health and development; 43(5): 743 to 751 ↩ ↩²

16. Bush, S Nocturnal postural management systems - what evidence is available? (accessed on 13 December 2017) ↩ ↩²

17. Improving Health and Lives, Royal College of GPs and Royal College of Psychiatrists (2012) Improving the Health and Wellbeing of People with Learning Disabilities: An Evidence-Based Commissioning Guide for clinical commissioning groups (CCGs) (accessed on 13 December 2017) ↩

18. Polak F,Clift M and Clift L. (2009) Buyer’s Guide: Night-time postural management equipment for children. Report for the Centre for Evidence-based purchasing (accessed on 13 December 2017) ↩

19. Hill S. (2011) A One Year Postural Care Training Programme for the Workforce Supporting the Needs of those with Complex and Continuing Healthcare Needs: Project Evaluation. Postural Care CIC & Skills for Health (accessed on 13 December 2017) ↩

20. Clayton S, Goldsmith L and Ellis T. (2016) 24-hour postural care: The journey so far in the UK. Simple Stuff Works (accessed on 13 December 2017) ↩

21. Mooney, H. (2014). Pole position. Frontline Magazine: Chartered Society of Physiotherapy, 20, 34 to 36. ↩