ADL Building Blocks: Posture and Balance
What comes to mind when you are asked, “What are ADLs?”
Some ADLs that are most likely to cross your mind at first are bathing, dressing, and toileting.
Can you recall all of the others?
Bathing, dressing, grooming, toileting, eating, feeding, sexual activity, ADL-related functional mobility, and personal device care are the activities that the occupational therapy profession classifies as activities of daily living (or ADLs).
ADLs are an occupation that come up for all occupational therapists, no matter which population you work with and what setting you work in.
In my experience, it is almost guaranteed that a client or family member will name at least one ADL (or related ADL task) when we ask, “What are your goals?” during an OT evaluation.
The bulk of my experience has been with the young to older adult populations on an inpatient rehabilitation unit and outpatient acquired brain injury clinic. During my school and career experiences, I have learned how to break down basic activities of daily living (BADLs) to subtasks and the body functions needed to complete them.
However, it was not until I was hands-on with clients with a variety of abilities at different stages in recovery that I realized how vital body posture is for optimal participation in ADLs. Posture is a foundation that helps build other body functions to carry out the complete activity.
In other words, static and dynamic sitting and standing balance are building blocks needed to safely and independently complete BADLs.
Therefore, the next time you get ready for a true ADL session with a client who is freshly bathed and dressed, remember to be flexible. Know that there are other interventions and activities that allow the targeting of ADL activity demands without completing a true ADL session.
Let’s discuss the importance of interventions that can address posture and influence all ADLs.
The Pyramid of Posture
The pyramid of posture I utilize in my practice is:
Static sitting balance > Dynamic sitting balance > Static standing balance > Dynamic standing balance
Have you ever had a client go to thread their lower extremities through their pants and lose postural control while sitting (leaning posteriorly, laterally, etc.)? I know I have!
I have had clients unable to complete ADLs such and lower body dressing and grooming even if they have the functional range of motion throughout their extremities. The reason they struggle is due to poor trunk control and posture.
Even if your client can reach their feet, it’s a problem if they cannot maintain safe and appropriate posture while doing so.
What can you do to help?
When I come across this in my practice, I think of the pyramid I mentioned above. Where is my client within this pyramid? Where do they have difficulty and strengths?
Once I determine where my client is on this pyramid, I then decide how to provide intervention at this level that most appropriately progresses them in the pyramid and to overall increased ADL participation.
Keeping Things Client-Centered
It is important to note here, that we should remain client-centered. ADLs should be taken into consideration depending on what barriers the client is facing and how they prefer to complete.
Will it be safer for the client to complete ADLs from their bed or from sitting in a chair? Does the client prefer to complete grooming standing at the sink versus sitting at the sink?
What is the safest and most appropriate method of reaching goals long-term? Do they want to be able to complete all ADLs as independently as possible and are open to any technique we provide? Do they want to complete ADLs close to they were able to prior to recent events?
As OTs, we must be ready to adapt the occupation and sub-tasks to meet the client where they are, with what potential progress we expect to be made, and with the environmental modifications and setups that are realistic for the client.
Therefore, we must not forget the client-centered approach when thinking about the clients’ goals on this pyramid related to ADL participation.
Let’s talk about each place on the pyramid and how to intervene:
Static Sitting Balance
Edge of mat (EOM) is my preferred place to work on such a skill with clients. It is possible to work on this skill from a wheelchair to grade down and edge of bed (EOB) to grade up.
I find EOM sessions to be highly beneficial because you can begin incorporating the next level (dynamic sitting balance) right there to see if your client is ready. Also, you are able to obtain functional transfer training in the session getting to/from the mat. Before transferring to the mat, I usually demonstrate what we will be doing EOM and why.
My favorite way to work EOM is with a tall mirror in front of the client to provide biofeedback for posture. Depending on the client’s abilities, sometimes I am behind the client providing support and tactile input at the hips to facilitate anterior pelvic tilt and enable self-corrections for returning to midline. While providing tactile input, I commonly provide verbal cues to “find midline” while prompting the client to look in the mirror for biofeedback.
Depending on the client’s ability to comprehend cues affects the complexity of such cues and how often I would provide cuing. The goal here is to assist the client with strengthening and relearning midline in the sitting posture.
We will practice maintaining midline and measure with seconds/minutes. When the client begins to shift, I cue them “You are leaning to the left, can you get to center?” or “Look in the mirror, can you return to center?” This might be the first time a client is sitting unsupported for a couple months since their recent health event. Providing breaks for client to recline on a bolster or supporting them with an exercise are also important.
Once a client has shown progress over a couple of sessions, I will start to incorporate dynamic sitting activities EOM to see if we are ready to push to the next level.
Dynamic Sitting Balance
This is also preferred to be completed EOM, as it will increase the demand on trunk control and allow for increased reaching outside of midline. I will usually transition sessions towards dynamic sitting balance when I see the client is at contact-guard assist (CGA) or standby assist (SBA) level for static sitting balance.
With the client sitting EOM, get creative and use the client’s interests to motivate them. For example, have the client reach for balls in functional diagonals outside of their midline to obtain them, and have them toss the balls into a basket.
Another example is completing some ADLs like donning socks and shoes from EOM. When working from a wheelchair, the client can load a dishwasher. The important thing is to make sure you are using activities that create a demand on trunk control, while remaining client-centered.
Static Standing Balance
When you are working on static standing balance with a client, remember to incorporate safe use and positioning/placement of your client’s durable medical equipment (DME – rolling walker, straight cane, etc.) during the activity.
For example, have the client stand with a rolling walker at the counter or table to put together a peanut butter and jelly sandwich with supplies already within reach. Observe if the client is keeping the walker in front or if they are pushing it to the side out of reach.
I enjoy completing an activity the client enjoys, simply standing at an elevated table or countertop to do so in order to target static standing balance. As with static sitting balance, this could be the first time your client has stood in a therapy session. Allow rest breaks while also ensuring quality effort towards achieving goals.
Safety is very important when deciding when to push to the next level in the pyramid: dynamic standing balance. Do not be shy to ask for a therapy aide or other team member to standby in the session while you approach such activities the first time with a client. I would consider implementing dynamic standing activities once your client is completing static standing activities with SBA.
Dynamic Standing Balance
Again, get creative and have fun! Some of my favorites include grooming at the sink while standing, toileting (adjusting garments to/from waist while standing), loading/unloading a dishwasher, picking up items from floor level, completing more subtasks of shower in standing (when safe), and more.
Documentation and Goal Writing
When using such interventions mentioned above, I highly recommend noting that you are addressing one of those pyramid levels in order to increase a client’s safety and independence in ADLs.
Document the amount of time a client can tolerate static/dynamic sitting/standing and the assist needed at the level of the pyramid they are on in order to create a history of their progress in posture and activity tolerance related to ADLs. For more assistance with thorough balance documentation, this balance guide is very handy to print out and keep with you.
Examples of goals I have used in the past:
Client will tolerate sitting EOM during dynamic sitting activity w/SBA for 15 min to increase activity tolerance needed for BADLs within 2 weeks.
Client will complete simple meal preparation activity w/SPV while demonstrating good kitchen and DME safety awareness and dynamic standing tolerance.
Looking for more goal writing tips? Check out OT Goal Writing Tips for Adults & Older Adults.
We hope this ADL Building Blocks: Posture and Balance article helps give you some helpful ideas on incorporating posture during your ADL training.
For more information on ADLs and balance interventions, also be sure to check out our balance intervention article, Occupation-Based Balance Interventions For Your OT Practice.
For even more intervention ideas, we recommend the Note Ninjas’ ADL Treatment Guide and Balance Treatment Guide to further equip you with a toolbox of functional treatment ideas with included documentation tips. You can get 25% off these using our promo code MYOTSPOT.
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