Using the Developmental Sequence to Progress Your Osteoporotic Patient

When thinking of the Developmental Sequence (Supine, Side-lying, Prone, Quadruped, Tall Kneeling, Half-kneeling, Standing, and Walking), I used to think of either pediatrics or people with strokes. However, the developmental sequence can be very useful from an orthopedic standpoint specifically with osteoporosis patients.

We know that sitting is the most compressive position for our spines, yet repeatedly, I see physical therapists start exercise programs in sitting. There are several reasons I’d like you to consider starting patients in supine.

1. Sitting increases intradiscal pressure. (1)
2. Supine is a restful position, allowing tense muscles to relax, and can be a great way to reduce anxiety and cortisol running through the body. Ensure that the patient is propped with knees flexed or pillows under the knees, and forearms supported if there is tightness in the biceps.
3. Patients can now concentrate on their breath, become aware of any “holding patterns” of tension throughout their body, and free up the mind to focus on learning new skills.
4. When we are in higher levels of positioning-sitting, standing, or walking, our brain is focused on survival such as “not falling”. We have many more muscles and joints to control - ankles, knees, hips, etc. This reduces our ability to focus on learning new skills such as engaging the core muscles, relaxing the neck, stop clenching the fingers, etc.
5. Preparation is key. We must help our patients gain mastery at one level and then move to the next. Once a patient can understand and find a neutral spine in prone, they are ready to move to side-lying.
6. Side-lying can be very beneficial in teaching neutral spine because side-lying is “discombobulating.” We get lost in space and default to the fetal position - a flexed, contra-indicated posture for people with osteoporosis. Use a dowel rod or broom handle to provide feedback from the occiput to the mid-thoracic spine to the sacrum. Have your patient straighten their knees and hips so that, “If you were lying with your back against an imaginary wall, the back of your head, upper back, sacrum, and heels would touch the wall.”
7. Prone: Not every osteoporosis patient you see will be able to ultimately transition to prone, but a high majority can and should. Again, propping is critical to allow any anatomical limitations such as shoulder tightness. Use a pillow longitudinally rather than transversely across the abdomen to elevate the shoulders so they can flex to allow the forehead on the hands. If not, keep arms by their side and provide a towel roll under the forehead. This position requires several “stages” of advancement over time and education to engage transversus abdominus, especially for those with spinal stenosis and/or tight hip flexors. The feet should be off the edge of the bed to allow for tightness in plantarflexion.

Working with patients in these three basic positions, while focusing on intercostal breathing, muscle relaxation of the neck, fingers, and other compensatory patterns as we move up the chain, builds a foundation to prepare for functional activities of sit-to-stand, static standing, and movement. These are not stepping stones to be skipped in order to jump into the higher-level functional activities. You would not build a house without a firm foundation. Make sure your patient has the building blocks necessary for the best possible outcomes.

Please join Frank Ciuba and me for our upcoming remote course: Osteoporosis Management: An Introductory Course for Healthcare Professionals on Saturday, Nov 2, 2024. We will discuss osteoporosis-safe exercises, balance and gait activities, and additional ways to help your patients build a strong foundation for movement competence!

Reference:

1. Comparison of In Vivo Intradiscal Pressure between Sitting and Standing in Human Lumbar Spine: A Systematic Review and Meta-Analysis. Journal ListLife (Basel) PMC8950176 Jia-Qi Li,¹ Wai-Hang Kwong,^1,* Yuk-Lam Chan,¹ and Masato Kawabata²

AUTHOR BIO:
Deb Gulbrandson, PT, DPT

Deb Gulbrandson, DPT has been a physical therapist for over 49 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. She owned a private practice for 27 years in the Chicago area specializing in orthopedics and Pilates. 5 years ago, Deb and her husband “semi-retired” to Evergreen, Colorado where she works part-time for a hospice and home-care agency, sees private patients as well as Pilates clients in her home studio and teaches Osteoporosis courses for Herman & Wallace. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country- currently 46 out of 63 and counting.

Deb is a graduate of Indiana University and a former NCAA athlete where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to combine her skills as a PT and Pilates instructor. She has been certified through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist through the Meeks Method since 2008, and a Certified Exercise Expert for the Aging Adult through the Geriatric Section of the APTA.

When thinking of the Developmental Sequence (Supine, Side-lying, Prone, Quadruped, Tall Kneeling, Half-kneeling, Standing, and Walking), I used to think of either pediatrics or people with strokes. However, the developmental sequence can be very useful from an orthopedic standpoint specifically with osteoporosis patients.

We know that sitting is the most compressive position for our spines, yet repeatedly, I see physical therapists start exercise programs in sitting. There are several reasons I’d like you to consider starting patients in supine.

1. Sitting increases intradiscal pressure. (1)
2. It is a restful position, allowing tense muscles to relax, and can be a great way to reduce anxiety and cortisol running through the body. Ensure that the patient is propped with knees flexed or pillows under the knees, and forearms supported if there is tightness in the biceps.
3. Patients can now concentrate on their breath, become aware of any “holding patterns” of tension throughout their body, and free up the mind to focus on learning new skills.
4. When we are in higher levels of positioning-sitting, standing, or walking, our brain is focused on survival such as “not falling”. We have many more muscles and joints to control - ankles, knees, hips, etc. This reduces our ability to focus on learning new skills such as engaging the core muscles, relaxing the neck, stop clenching the fingers, etc.
5. Preparation is key. We must help our patients gain mastery at one level and then move to the next. Once a patient can understand and find a neutral spine in prone, they are ready to move to side-lying.
6. Side-lying can be very beneficial in teaching neutral spine because side-lying is “discombobulating.” We get lost in space and default to the fetal position - a flexed, contra-indicated posture for people with osteoporosis. Use a dowel rod or broom handle to provide feedback from the occiput to the mid-thoracic spine to the sacrum. Have your patient straighten their knees and hips so that, “If you were lying with your back against an imaginary wall, the back of your head, upper back, sacrum, and heels would touch the wall.”
7. Prone: Not every osteoporosis patient you see will be able to ultimately transition to prone, but a high majority can and should. Again, propping is critical to allow any anatomical limitations such as shoulder tightness. Use a pillow longitudinally rather than transversely across the abdomen to elevate the shoulders so they can flex to allow the forehead on the hands. If not, keep arms by their side and provide a towel roll under the forehead. This position requires several “stages” of advancement over time and education to engage transversus abdominus, especially for those with spinal stenosis and/or tight hip flexors. The feet should be off the edge of the bed to allow for tightness in plantarflexion.

Working with patients in these three basic positions, while focusing on intercostal breathing, muscle relaxation of the neck, fingers, and other compensatory patterns as we move up the chain, builds a foundation to prepare for functional activities of sit-to-stand, static standing, and movement. These are not stepping stones to be skipped in order to jump into the higher-level functional activities. You would not build a house without a firm foundation. Make sure your patient has the building blocks necessary for the best possible outcomes.

Please join Frank Ciuba and me for our upcoming remote course: Osteoporosis Management: An Introductory Course for Healthcare Professionals on Saturday, Nov 2, 2024. We will discuss osteoporosis-safe exercises, balance and gait activities, and additional ways to help your patients build a strong foundation for movement competence!

Reference:

1. Comparison of In Vivo Intradiscal Pressure between Sitting and Standing in Human Lumbar Spine: A Systematic Review and Meta-Analysis. Journal ListLife (Basel) PMC8950176 Jia-Qi Li,¹ Wai-Hang Kwong,^1,* Yuk-Lam Chan,¹ and Masato Kawabata²

AUTHOR BIO:
Deb Gulbrandson, PT, DPT

Deb Gulbrandson, DPT has been a physical therapist for over 49 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. She owned a private practice for 27 years in the Chicago area specializing in orthopedics and Pilates. 5 years ago, Deb and her husband “semi-retired” to Evergreen, Colorado where she works part-time for a hospice and home-care agency, sees private patients as well as Pilates clients in her home studio and teaches Osteoporosis courses for Herman & Wallace. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country- currently 46 out of 63 and counting.

Deb is a graduate of Indiana University and a former NCAA athlete where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to combine her skills as a PT and Pilates instructor. She has been certified through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist through the Meeks Method since 2008, and a Certified Exercise Expert for the Aging Adult through the Geriatric Section of the APTA.