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As Occupational Therapists, we are always trying to identify activities that a client might connect with. Gardening is an accessible, adaptable pastime, that many clients have experienced and which an intervention can be built around. However, barriers exist with many mental health conditions, such as volition and fatigue, that need to be overcome in order to engage. Take this short course to explore these themes further. Questions and self-reflection will follow content, to help test your knowledge and provide evidence of learning.

Introduction As Occupational Therapists, we are always trying to identify activities that a patient or client might connect with. Gardening is an accessible, adaptable pastime, that many clients have experienced and which an intervention can be built around. However, for many mental health conditions, there are barriers such as volition and fatigue, that need to be overcome in order to engage. These can be minimised by using techniques to encourage engagement, predominantly appropriate for Occupational Therapists, but also Social and Therapeutic Horticulturists. A brief overview of depression Depression (also known as major depression, major depressive disorder, or clinical depression) is a debilitating mood disorder and mental health condition. It can affect people of all ages, races, ethnicities and genders, often presenting itself with low mood and cognitive distortion (Gonzalez et al, 2009). Characteristics often impact the ability to engage with others and in daily life activities, such as sleeping, eating, or working. Although men, women and people of all genders can feel depressed, how they express symptoms - and the behaviours used to cope with them - may differ. An individual with depression is likely to experience some (but not all) of the following signs and symptoms, most of the day, nearly every day: Persistent sad, anxious, or 'empty' mood Feelings of guilt, worthlessness or helplessness Feelings of irritability, frustration or restlessness Decreased energy, fatigue or feeling slowed down Difficulty concentrating, remembering, or making decisions Difficulty sleeping, waking early in the morning, or oversleeping Becoming withdrawn and detached; isolating from family and friends Loss of interest or pleasure in hobbies and activities Problems with sexual desire and performance Changes in appetite or unplanned weight changes Physical aches or pains, headaches, cramps, or digestive problems (no clear physical cause) Thoughts of death or suicide, or suicide attempts [National Institute of Mental Health, 2023] Depression interferes with day-to-day functioning and causes significant distress for the person experiencing it. Statistically, 4-10% of people in England (for example) will have depression at some time (NICE, 2011), with 7.8% being diagnosed alongside anxiety (HSCIC, 2009). The World Health Organisation (WHO, 2008) predicted that depressive conditions would be the second major cause of disability in the world by 2020. As symptom severity is highly variable, any effective intervention should be appropriate to the degree of depression. Evidence that gardening is beneficial for depression Soga, Gaston and Yamaura (2016) carried out a statistical quantitative research review of the health benefits of gardening and concluded it can provide a reduction in depression. This supports many of the qualitative experiences of the benefits of gardening with depression. "Gardening is a constant boost to my consciously nurtured optimism, as I am surrounded by the natural world, which pursues life with eager enthusiasm." (Mind, 2017) Gonzalez et al (2009) evaluated the impact of therapeutic horticulture on clinical depression, by measuring changes in the severity of the depression and the participants' perceived capacity for attention. They found a correlation between the extent to which attention was captured and the reduction in depression. They deduce that this was a result of the disruption to the participant’s rumination and the effortless attention involved in engaging in gardening. Berg and Custers (2011) demonstrated that gardening increased positive mood, reducing cortisol levels and enabled participants to handle acute stress better (Kings Fund, 2016). Rostami et al (2014) noted that visitors of gardens felt that the experience reduced their depression by 94%. Providing access to a garden environment - even visiting public areas - can have positive effects on well-being, evoking a sense of identity, meaning and reducing stress. The MIND charity and University of Essex (UK) have developed an eco-therapy project - including gardening and food growing - to support mental health conditions, including depression. They found 69% of people experienced significant increases in wellbeing by the time they left the Ecominds project. Their survey of GPs stated that the eco-therapy was a valid and suitable treatment for anxiety (52%) and depression (51%) (University of Essex, 2013). Thrive (2017) suggest that gardening is an activity that enables a person to often connect with their past, while developing personally through their growing horticultural knowledge. It provides essential physical exercise, social connectedness and environmental connectedness (Sempik et al, 2005).

Explore themes further - then review all the references that contributed to this course's content.

Multiple and single-choice questions are followed by a self-reflection section. Collectively, these will help to test your knowledge and provide evidence of your learning.

How can depressive people be supported to engage? MIND (2017) describes the effects of depression, which may impede effective engagement; these include a lack of stamina, low interest and motivation, low confidence, reduced concentration and social withdrawal. Glowacki et al (2017) carried out a review of the barriers to engagement in physical activity for depressed people. They state that emotional factors are an important aspect of behaviour change, but have been under-considered; for example, negative emotions, deprecating self-assessment and outcome expectations. They recommended further research on interventions focused on emotional behaviour change and the techniques used to facilitate participation. Chen et al similarly state that current traditional theories of behavioural change do not suggest how emotional impact can be managed through interventions. 'Emotional factors are an important aspect of behaviour change, but have been under-considered' (Glowacki, 2017) Ways to facilitate engagement Behaviour activation is an approach for reducing emotional barriers (such as social withdrawal and avoidance) for physical activity with depressed people. This is implemented by scheduling positive activities of daily living (ADLs), rather than emphasising cognitive changes. Rebar and Taylor (2017) highlight that, when experiencing mental health difficulties, engagement in physical activity needs to be tailored to the individual to be effective, to reflect their willingness, commitment and contextual opportunities. This suggests a person-centred approach is relevant. A person-centred approach Adopting a ‘person-centred’ approach for the person with depression (Rogers,1961) may support the identification of areas of interest in gardening and their specific barriers to engaging. Evidence supports this, with Jarrott and Gigliotti (2010) recommending that effective horticultural activities should be person-centred, as this increases the quality of life that the participant considers as important to them. Fieldhouse and Sempik (2014) state that, by taking a ‘humanistic’ approach, the person may be able to more fully express their true nature through gardening. A person-centred approach involves establishing a therapeutic relationship with the client, involving trust, empathy and acceptance. The sharing of knowledge and enthusiasm for gardening by the practitioner utilises the ‘therapeutic use of self’ (Kielhofner, 2009). This can facilitate improved support and communication in the intervention. Further reading on the Hub: Social inclusion Depression can result in social isolation, as the symptoms can discourage personal interaction. Therapeutic horticulture can improve social functioning and reduce depressive symptoms (Harris, 2017). Harris identified that a primary facilitatory driver for occupational engagement was social involvement. Whately et al (2015) highlight how community gardening enables occupational engagement and reduces social isolation through an environment that flexibly supports participation, encouraging learning and community cohesion. They conclude that this is a suitable area for occupational therapists to lead on. Restorative attention Fatigue is often associated with depression, especially through applying directed attention to tasks. Gardening can reduce this symptom; Kaplan (1995) states that nature has an abundance of factors that support the restorative process from stress, requiring a less concentrated and tiring attention. Harris (2017) notes that depressive participants were more engaged by the less 'threatening' gardening environment, finding that nature evoked a calming effect. Occupational Therapy uses a range of techniques for making occupations like gardening easier to partake in. The support of a conducive environment encourages engagement, as part of a Person-Environment-Occupational Performance (PEOP) consideration. Occupation-based activity analysis (Thomas, 2012) enables the breaking down of gardening tasks, to tailor them for better uptake by the depressive person, countering a lack of volition. This can be achieved through: Chunking activities into manageable sub-tasks, to counter negative self-esteem and provide the satisfaction of completion Pacing gardening activities, to counter fatigue and a lack of motivation often present in depression Grading activities, so they are appropriate and manageable for the individual to maintain interest and motivation, with increasing challenges Empowerment of people who are depressed can counter their feelings of helplessness and low self-esteem. By providing responsibility in developing and planning the activity structure, they may regain control. The acts of nurturing and taking responsibility for plants may counter the self-focus often evident in depression. Finally, choice allows a person with depression to take ownership in remediating their symptoms through gardening (and choosing tasks) when they feel it might be beneficial, within a safe, flexible and structured environment. Harris (2017) states that this flexibility regarding what to do and when, empowers people experiencing depression.

References Below are listed - in alphabetical order - the resources used to compile content for this OT CPD Course: Abson, D. (2022) Therapeutic Use of Self. In Therapy Articles, The Occupational Therapy Hub. Available from: https://www.theothub.com/article/therapeutic-use-of-self [Accessed 19 November 2023]. Bragg, R. and Atkins, G. (2016) A review of nature-based interventions for mental health care. Natural England Commissioned Report 204. London: Natural England. Available from: http://publications.naturalengland.org.uk/publication/4513819616346112 [Accessed 24 April 2016]. Clatworthy, J., Hinds, J.M. and Camic, P. (2013) Gardening as a mental health intervention: a review. Mental Health Review Journal. 18 (4), pp 214-25. Fieldhouse, J. and Sempik, J. (2014) Green Care and Occupational Therapy. In: Creek’s Occupational Therapy and Mental Health. China: Elsevier. Harris, H. (2017) The social dimensions of therapeutic horticulture. Health and Social Care in the community. 25 (4), pp 1328-1336. Kaplan, S. (1995) The restorative benefits of nature: Toward an integrative framework. Journal of environmental psychology. 15 (3), pp 169-183. Kielhofner, G. et al (2009) Therapeutic Use of Self: A Nationwide Survey of Practitioners’ Attitudes and Experiences. American Journal of Occupational Therapy. 63, pp 198-207. King’s Fund (2016) Gardens and Health. Available from: https://www.kingsfund.org.uk/publications/gardens-and-health [Accessed 18 November 2023]. Mind (2023) What are symptoms of Depression. Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/depression/symptoms/#.WlnnvyOcZt8 [Accessed 18 November 2023]. National Institute for Health and Care Excellence (NICE) (2011) Common mental health disorders: Guidance and guidelines (NICE) [online]. Available from: http://www.nice.org.uk/guidance/cg123 [Accessed 25 Aug 2015]. National Institute of Mental Health (NIMH) (2023) Mental Health Information: Depression. Available from: https://www.nimh.nih.gov/health/topics/depression [Accessed 19 November 2023]. Rogers, C. (1961) A therapist’s view of psychotherapy On Becoming a Person. Constable: London. Rostami, R., et al. (2014) The Role of Historical Persian Gardens on the health status of contemporary urban residents. Ecohealth. 11(3), pp 308-321. Sempik, J., Aldridge, J. and Becker, S. (2008) Health, Well-being and social inclusion Therapeutic horticulture in the UK. Soga, M., Gaston, K. and Yamaura, Y. (2016) Gardening is beneficial for health: A meta-analysis. Preventive medicine reports. Elsevier. Thrive (2017) Using gardens to change lives. Available from: https://www.thrive.org.uk [Accessed: 10 January 2018]. Turpin, M. and Iwama, M.K. (2011) Using occupational therapy models in practice: a field guide. University of Essex/MIND (2013) Ecominds: Effects on Mental Wellbeing. Available from: https://www.mind.org.uk/media/354166/Ecominds-effects-on-mental-wellbeing-evaluation-report.pdf Whatley, E. et al (2015) Enabling occupational participation and social inclusion for people recovering from mental ill-health through community gardening. Australian Occupational Health Journal. 62 (6), pp 428-437.

Explore core themes and related research.

This is a helpful short course if you wish to learn more about trauma - and how early adversity impacts one's development and mental health needs. Questions will follow content, to help test your knowledge and provide evidence of learning.

Challenging definitions The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) definition of trauma requires 'actual or threatened death, serious injury, or sexual violence' [10] (p. 271). Stressful events not involving an immediate threat to life or physical injury, such as psychosocial stressors [4] (e.g., divorce or job loss), are not considered trauma in this definition. However, this definition can be challenged, based on the understanding that a trauma is defined by the individual's experience of the stressful event. If one has enough protective factors, resilience and social support they are likely to be less impacted by a stressful event. Physiology and origins When our body experiences repeated trauma and chronic stress, our cortisol levels increase, in order to enable us to respond to the perceived threat (Levine, 2015). The body remains in a highly anxious state for sustained periods; only basic functions are carried out involving the nervous system survival response (eg. fight, freeze and flight) (Selye, 1976). As a result, other body systems such as the digestive system struggle to function properly (Maté, 2011). This explains the number of physical health difficulties experienced by those who have experienced early adversity. The Adverse Childhood Experiences (ACEs) study found that children who grow up in dysfunctional family environments - including those negatively impacted by alcohol, abuse, domestic violence or poverty - are at a greater risk of psychological distress in later life (Felitti et al., 2019). The original study found that almost two thirds of participants experienced one or more ACE and more than one in five experienced three or more ACEs. This is important to notice, given that the higher the number of ACEs, the more likely someone would experience health issues in later life. This study was the first to indicate the worldwide impact of trauma on the developing child, highlighting the need for affirmative action to offer support for trauma survivors. Watch: 'Why I am rude' "This poem aims to help adults and children to understand the 'why' behind behaviours which may be seen or described as rude, when actually, it is often a defence mechanism. There may be trauma, attachment or adverse childhood events which have impacted on the child's view of themselves and those around them. These children are not rude, they are communicating their pain." [Author: Sarah Dillon / Credit: National Association for Therapeutic Parents] What might trauma look like? Symptoms can take many forms; trauma may display itself through one or a combination of the following: Unexplained anger or fear Passivity or over compliance Hyper-vigilance/hyper-arousal Dissociation/disconnection Avoidance of certain emotions and/or situations Suspicion and hostility Difficulties to manage feelings Disengagement Frequent use of health services

Information on trauma and the link between early adversity may suggest that our health is pre-determined and not in our control to change. However, there is ongoing debate between how far both nature and nurture impact on one's development. In fact, there is some research suggesting that - even in older adults - cognitive functioning can be enhanced when both music and physical exercise are combined (Ball et al., 2002; Satoh et al., 2014). Neuroplasticity The latest research in neuroscience suggests that our brain has the ability to adapt to life circumstances. Neuroplasticity refers to the ability of neurons and neural networks to alter and adapt behaviour as a consequence of new information, such as sensory messages, damage or dysfunction (Britannica Academic, 2022). This can take place throughout the human lifespan, but is particularly prominent at key developmental milestones, such as early childhood or puberty (Erikson, 1982). Throughout the lifespan, synapses strengthen or weaken neural connections and we are able to update our knowledge and adapt our behaviour in context to the environment. There are many different theories of development, including the nature vs nurture debate (Bundy et al., 2020). However, recent literature suggests that gene expression is based upon the specific environment within which one lives, which ultimately influences brain function and behaviour (Nelson et al, 2006). Research suggests that we maintain the neuronal connections and pathways that are most useful to us - and lose those that are less helpful. If someone experiences early adversity, their cortisol levels increase and act as a way to self-protect. Instinctive ways of behaving, such as fight or flight reactions, are formed in the amygdala and hypothalamus (Gerhardt, 2011). This results in the strengthening of neuronal pathways and synapse connections in these areas. Consequently, young children who live in an environment with angry or aggressive people will keep pathways that help them become alert to anger and danger (Gerhardt, 2011). This function also serves to impede the development in other areas of the brain, that relate to social, emotional, sensory and cognitive connections (Ward, 2017). Even when the threat has reduced, a child can maintain higher levels of stress and cortisol into later years, which impacts the parasympathetic system and immune functioning (e.g. rest and digest). It can also impede social and emotional learning, as the brain is preoccupied with managing stress. Neural pathways are formed as a result of environmental factors and situational experiences (Barker et al., 2018). The brain develops in response to social experiences and learned behaviour, a good example being emotional control. It is the primary caregiver who provides initial experiences of emotions being managed, before the baby can learn to self-soothe and manage his/her own feelings well (Gerhardt, 2014).

Trauma-Informed Practice Grounded in an awareness and responsiveness to the impact of a trauma. It requires understanding of maladaptive behaviour (e.g. substance misuse or self-harm), as related to trauma. This approach focuses on developing physical, psychological and emotional safety. Trauma-informed practice looks different in every service, but must facilitate changes in behaviour, through strengthening empathy, resilience and protective factors (Oral et al., 2016). A lot of people do not develop difficulties, despite having experienced ACEs. There are things that we can do to increase the chances of staying well, in both childhood and even adulthood: Increasing our ways of regulating the emotional systems Reducing or responding to the stress response Adapting environments and creating less toxic stress Exploring opportunities for new ‘connections' and neurodevelopment In childhood, regular physical activity and participation in sports can support health and well-being. Research also suggests that, as long as someone has at least one trusted, stable and supportive relationship with an adult, their risk of ill health is remarkably reduced. These relationships can provide opportunities for skills development and resiliency. There are opportunities for neurodevelopment - even in adulthood. We can explore spirituality, mobilise faith, hope and cultural connections. We should continue to engage in opportunities to build self-regulatory and adaptive skills, in relation to adversities and challenges. Trauma-informed care is all about creating environments where a person who has experienced trauma feels safe and can develop trust, to buffer against adversity (Kings, 2019). Supported services (police, social services, mental health and financial support, etc) can help individuals develop a sense of resiliency, through promoting the following five principles: SAFETY CHOICE COLLABORATION EMPOWERMENT TRUST A Safe Environment Physical Using welcoming language on all signage Keeping noise levels in waiting rooms and clinic rooms low Keeping parking lots, common areas, bathrooms, entrances and exits well-lit Ensuring that people are not allowed to smoke, loiter, or congregate outside entrances Making sure individuals have clear access to the door in clinic rooms and can easily exit. Social Keeping consistent schedules and procedures Maintaining consistent, open, respectful communication Welcoming people and ensuring that they feel respected Ensuring the maintenance of healthy interpersonal boundaries Offering sufficient notice and preparation when changes are necessary Being aware of how an individual’s culture affects how they perceive safety and privacy Sending medical forms that require individuals to provide sensitive information ahead of time (Shulner and Menschner, 2018) What we can all do? Community engagement - build support networks Hold in mind that a person’s behaviour or reactions might be related to childhood adversity In order to make sense of a person’s current difficulties, consider "What happened to you?" instead of "What’s wrong with you?" Continue to raise awareness of trauma-informed care and the impact of early adversity Think about the five principles in our own roles and lives

The information on trauma and the link between early adversity may suggest that our heath is pre-determined and not in our control to change. However, there is ongoing debate between how far both nature and nurture impact on one's development. In fact, there is some research suggesting that even in older adults cognitive functioning can be enhanced when both music and physical exercise are combined (Ball et al., 2002; Satoh et al., 2014). Neuroplasticity The latest research in neuroscience suggests that our brain has the ability to adapt to life circumstances. Neuroplasticity refers to the ability of neurons and neural networks to alter and adapt behaviour as a consequence of new information, such as sensory messages, damage or dysfunction (Britannica Academic, 2022). This can take place throughout the human lifespan, but is particularly prominent at key developmental milestones, such as early childhood or puberty (Erikson, 1982). Throughout the lifespan, synapses strengthen or weaken neural connections and we are able to update our knowledge and adapt our behaviour in context to the environment. There are many different theories of development, including the nature vs nurture debate (Bundy et al., 2020). However, recent literature suggests that gene expression is based upon the specific environment within which one lives, which ultimately influences brain function and behaviour (Nelson et al, 2006). Research suggests that we maintain the neuronal connections and pathways that are most useful to us - and lose those that are less helpful. If someone experiences early adversity, their cortisol levels increase and act as a way to self-protect. Instinctive ways of behaving, such as fight or flight reactions, are formed in the amygdala and hypothalamus (Gerhardt, 2011). This results in the strengthening of neuronal pathways and synapse connections in these areas. Consequently, young children who live in an environment with angry or aggressive people will keep pathways that help them become alert to anger and danger (Gerhardt, 2011). This function also serves to impede the development in other areas of the brain, that relate to social, emotional, sensory and cognitive connections (Ward, 2017). Even when the threat has reduced, a child can maintain higher levels of stress/cortisol into later years, which impacts the parasympathetic system and immune functioning (e.g. rest and digest). It can also impede social and emotional learning, as the brain is preoccupied with managing stress. Neural pathways are formed as a result of environmental factors and situational experiences (Barker et al., 2018). The brain develops in response to social experiences and learned behaviour, a good example being emotional control. It is the primary caregiver who provides initial experiences of emotions being managed, before the baby can learn to self-soothe and manage her own feelings well (Gerhardt, 2014).

This section explores factors that improve the chance of staying well, despite an individual experiencing adverse childhood experiences (ACEs).

This is a helpful course if you wish to learn more about trauma and how early adversity impacts one's development and mental health needs. Questions will follow content, to help test your knowledge and provide evidence of learning.

The information on trauma and the link between early adversity may suggest that our heath is pre-determined and not in our control to change. However, there is ongoing debate between how far both nature and nurture impact on one's development...

The relationship between posture and pressure Body posture and positioning have a direct influence on the pressure going through specific body sites (Sprigle and Sonenblum, 2011). The body can only withstand high interface pressures for a very short period of time; when the pressure is not regularly relieved, pressure injuries can develop (Waterlow, 2007). For example... A 32-year-old gentleman with cerebral palsy who presents with hypertonicity, kyphoscoliosis, windsweeping and pelvic obliquity*. If his seating needs aren’t met - and without appropriate upper limb and foot support - his posture will result in 96% of his body weight just going through one point of his pelvis. It is therefore no wonder pressure injuries can develop in those who have difficulty managing their posture. * Definitions Pressure injuries and their impact Also termed a 'pressure sore', a pressure injury is any area of damage to the skin due to: Intrinsic factors ('internal') – age, diagnosis, medication, continence, nutrition, cognition, mobility Extrinsic factors ('external') – pressure, shear, friction, moisture 'Localised damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure, or pressure in combination with shear.' (NPUAP, 2016) Everyone is potentially at risk of developing a pressure injury (NICE, 2014). How does a pressure injury occur? The skin and underlying tissues are compressed for a period of time Blood cannot circulate, causing lack of oxygen and nutrients The lymphatic system cannot drain waste products Cells die and the area of resulting dead tissue is called a pressure injury The level of pressure injury that an individual might sustain depends on a range of factors. Injuries are classified from Grade 1 to Grade 4: N.B. There are 'unstageable' stages and other forms of pressure injury. The impact of a pressure injury on a person is significant, with them being affected physically, psychologically, socially, emotionally, spiritually and financially. (Langemo, 2005) Pressure injuries in older people are associated with a fivefold increase in mortality (Grey and Harding, 2006). Pressure injuries can result in longer lengths of stay in hospitals; in one study, adult patients who developed pressure injuries had an extended stay of over four days (Graves et al., 2005), which can have a major impact on their health outcomes. Pressure injuries are often painful and debilitating (Moore et al., 2015). Quality of life is understandably reduced in those suffering from pressure injuries. No person’s ability to enjoy normal life should be impacted by a mostly preventable cause. (NHS Improvement, 2018) The Health and Social Care Information Centre stated in their NHS Safety Thermometer (2015) report that, on average, 2000 pressure injuries are newly acquired each month within the NHS in England. The cost to the NHS of treating these pressure injuries and related conditions was up to £4 billion a year (Royal College of Nursing and NHS England, 2013); in the most severe cases, it can cost between £11,000 and £40,000 per person. Considering the burden on the economy - and combining this with the unnecessary human suffering - there is an increasing need to raise awareness of the importance of postural management within pressure care; ultimately affirming the vital provision of postural management equipment. Postural management is a key part of pressure injury prevention. Prevention can not only improve an individual’s outcomes, but it can also reduce the costs to the service and benefit the wider community: Core take-aways Appropriate postural management and equal weight distribution - with adequate pressure relief and a regular change of position - can help reduce a person’s risk of developing a pressure injury. Health and social care professionals should: Know the needs of individuals, communities and population - and the services available Be aware of activities which can prevent pressure injury, protect existing injuries and promote recovery Provide holistic health assessments for people at risk of developing pressure injuries Ensure people with an existing pressure injury, or identified at risk of developing one, have access to pressure redistribution devices Recognise the important role individuals, families and carers have in preventing and managing pressure injuries (Public Health England, 2015)

Learn about how the human body is designed to be aligned - and what can happen when it isn't.

Content references, a test of your knowledge and a chance to reflect on learning.

'The gold standard' The optimum 90-90-90 sitting position is well-known: 90° angle at the hips 90° angle at the knees 90° angle at the ankles However, this isn’t always achievable in day-to-day life, often depending on the physical environment that surrounds us and the furniture we have available to use. Even if we are able to achieve this 'gold standard' position, our weight distribution is as follows: Through buttocks & thighs = 75% Through the feet = 19% Through the arm rests = 2% Through the back = 4% (Collins, 2001) Why is good sitting posture so important? Comfort Well-being is paramount! Ensuring comfort - which includes pain management and energy conservation - can ultimately improve quality of life. Proper positioning can promote comfort, increase tolerance of a desired position and decrease fatigue. Therapeutic seating can be effective in both inhibiting spasticity and in accommodating its sequelae, which can have a significant impact on pain levels. A 2017 study by Bartley and Stephens suggested that, regardless of the clinical benefits, therapeutic seating should not be used if the user is not comfortable. Function A proper sitting posture, especially one that promotes good postural alignment and stability, is a critical requirement for movement. Use of the upper limbs is vital to successful performance of tasks and participation in activities of daily living (ADLs). Freedom of movement in the upper limbs is achieved through effective stabilisation of the pelvis and trunk. Therapeutic seating - and the way in which it is set-up - can also reduce the influence of abnormal tone and reflexes, consequently encouraging normal movement. Physiological function A major goal in postural management is to enhance autonomic nervous system function; the autonomic nervous system comprises a sympathetic and parasympathetic division, as per the graphic below. The inability to sit upright may result in decline in health overall, primarily reflecting altered physiological function. Trunk asymmetry and poor head position can impair:  Swallow  Respiration  Digestion  Cardiac efficiency Through the use of therapeutic seating, an upright sitting position can facilitate a normal swallowing pattern. Proper seating can also provide an optimum position for respiratory and circulatory function. Social interaction, engagement and development It is believed that the introduction of postural management interventions at an appropriate age can facilitate psychosocial and cognitive development. Individuals with learning disabilities benefit from postural interventions; benefits include enhanced cognitive function and communication skills, all precursors to improved learning and participation. An upright sitting position can offer a better line of vision for interaction and provide an increased ability to achieve cognitive tasks; improved head control is essential for orientation and socialisation. A stable posture can help an individual participate more fully in social activities at home, school or work and as part of the community. Each outcome, whether viewed collectively or individually, has the potential to significantly influence quality of life. What are the consequences of poor posture? Beyond pressure injuries themselves, secondary complications include: Pain and discomfort Contractures and deformities Poor physiological function General deterioration in health Reduced function and independence Social isolation and limited opportunity for participation Reduced quality of life In worst cases, death A priority for you and those you support should be to achieve the best position for comfort, freedom of movement, independence and interaction. Ultimately, this is to enable a happy and healthy life.

Answer the following questions, to review your learning and complete this course.

Whether you work from home or in an office, it is important to have a chair that does not pose any risks to your physical health. Workplace ergonomics is a wide subject, but the importance of finding the right working chair cannot be ignored. Below are a few key aspects to consider, for yourself as a working clinician and for those you support: 1) Chair versus lower back How does your chair support posture? A working chair has a significant influence on the alignment of the vertebrae of your spine, especially at lower thoracic and lumbar regions. Ensure that your back is firmly resting on the chair whilst working Avoid slouching forward, by sitting up tall and looking straight ahead at your monitor; doing the opposite will lead to lower back pain and spinal complications The individual in the graphic below has adopted a suitable alignment at knees and ankles. However, their hips are posteriorly tilted. This contributes to a slouched back (akin to kyphosis) and likely increased pressure under elbows and wrists. The desk chair being used does not offer optimum sitting posture for working. 2) Chair versus leg height The height of a chair has to fully support the legs and body weight evenly distributed on your thighs. While seated, your legs have to be positioned in a way that the feet are flat on the floor. Having a chair too high, for example, will destabilise your trunk and could cause swelling in the legs and ankles. 3) Chair versus hand position While seated, it is important to ensure you can get close to your desk, with full support of chair armrests. Lower arms and hands should be positioned at a 90° angle from the upper arms. A perfect ergonomic setup is when armrests support this 90° alignment of the hands with the keyboard. If lower arms, wrists and hands are not in the position illustrated below, muscles can become fatigued over time. Other more severe complications could also occur, such as carpal tunnel syndrome. This is 'a common neurological disorder that occurs when the median nerve (which runs from your forearm into the palm of the hand) becomes pressed or squeezed at the wrist' (National Institute of Neurological Disorders and Stroke, 2023). Symptoms include numbness, weakness and pain in the hand and wrist. Fingers may become swollen - and therefore less dextrous and functional. It is important for all employers to provide ergonomic chairs that offer proper back support - to prevent strain, tiredness and eventual injuries to their employees. (From a business perspective, this can also optimise productivity, safety compliance and culture, with lower associated costs from potential injuries). How to set up your desk: An ergonomics expert explains. To wrap up this course and provide a few additional considerations, watch this short video: 'Our desks weren't made for us. They were made for everyone.' 'Simple fixes, like adjusting your chair to match your height and adjusting your monitor to an arm's distance can make a huge impact. What are some other adjustments to optimise your workspace? Ergonomics expert Jon Cinkay, from the Hospital for Special Surgery, is here to show you how to make your desk and office chair adapt to you - and not the other way around.' (Wall Street Journal, 2019)

How should our bodies be positioned during regular self-care, productivity and leisure occupations?

During daily occupations, the importance of good posture and body positioning stretches (pardon the pun) far beyond comfort and avoidance of joint pain. Optimal positioning benefits us all, from digestion to respiration and beyond. Take this short course to learn about these themes and explore their core principles. Questions will follow content, to help test your knowledge and provide evidence of learning.

References Below are listed - in alphabetical order - the resources used to compile content for this OT CPD Course: Bartley, C. and Stephens, M. (2017) Evaluating the impact of WaterCell® Technology on pressure redistribution and comfort/discomfort of adults with limited mobility. Journal of Tissue Viability 26 (2): 144-149. Bergen, A., Presperin, J. and Tallman, T. (1990) Positioning for Function: The Wheelchair and Other Assistive Technologies. New York: Valhalla Rehabilitation Publications Ltd. Collins, F. (2001) Selecting cushions and armchairs: how to make an informed choice. Journal of Wound Care / Therapy Weekly Supplement. 13 (5). Cook, A.M. and Hussey, S.M. (2002) Assistive Technologies Principles and Practice. St Louis: Mosby. Cutter, N.C. and Blake, D.J. (1997) Wheelchairs and seating systems: clinical applications. Physical Medicine and Rehabilitation. 11 (1): 107-32. Farley, R., Clark, J., Davidson, C., Evans, G., MacLennan, K., Michael, S., Morrow, M. and Thorpe, S. (2003) What is the evidence for the effectiveness of postural management? International Journal of Therapy and Rehabilitation. 10 (10): 449-455. Gilinsky, G. and Smith, C. (2006) New wheelchair or new solutions? Rehab Management (serial online). Available from: http://www.rehabpub.com/features/1022006/3.asp. Graves, N., Birrell, F. and Whitby, M. (2005) Effect of pressure ulcers on length of hospital stay. Infection Control and Hospital Epidemiology. 26 (3): 293-7. Green, E.M. and Nelham, R.L. (1991) Development of sitting ability, assessment of children with a motor handicap and prescription of appropriate seating systems. Prosthetics and Orthotics International. 15: 203-216. Grey, J.E. and Harding, K.G. (2006) Pressure ulcers. British Medical Journal. 332 (7539): 472–475. Ham, R., Aldersea, P. and Porter, D. (1998) Wheelchair Users and Postural Seating: A Clinical Approach. London: Churchill Livingstone. Health and Social Care Information Centre (2015) NHS Safety Thermometer: Patient Harms and Harm Free Care England April 2014-April 2015, official statistics. Available from: http://digital.nhs.uk/catalogue/PUB17488. Healy, A., Ramsey, C. and Sexsmith, E. (1997) Postural support systems: their fabrication and functional use. Developmental Medicine and Children Neurology. 39: 706-710. Herman, J.H. and Lange, M.L. (1999) Seating and positioning to manage spasticity after brain injury. Neurorehabilitation. 12 (2): 105-117. Jones, M. and Gray, S. (2005) Assistive technology: positioning and mobility. In Effgen, S.K. (Ed) Meeting the Physical Therapy Needs of Children. Philadelphia: FA. Langemo D.K. (2005) Quality of Life and Pressure Ulcers: What is the Impact? Wounds. 17 (1). Langemo, D.K., Melland, H., Hanson, D., Olson, B. and Hunter, S. (2000) The lived experience of having a pressure ulcer: a qualitative analysis. Advances in Skin and Wound Care. 13 (5): 225-35. McClenaghan, B.A., Thombs, L. and Milner, M. (1992) Effects of seat-surface inclination on postural stability and function of the upper extremities of children with cerebral palsy. Developmental Medicine and Child Neurology. 34: 40-48. McClinton, D.H. (2007) Seating and positioning systems provide pediatric patients with clinical, environmental benefits. Care Management. 13 (2): 23-7. Moore, Z.E., Webster, J. and Samuriwo, R. (2015) Wound-care teams for preventing and treating pressure ulcers Cochrane Database of Systematic Reviews. 16 (9). National Institute for Health and Care Excellence (NICE) (2014) [CG179] Pressure ulcers: prevention and management. Available from: www.nice.org.uk/guidance/cg179. National Institute of Neurological Disorders and Stroke (2023) Carpal Tunnel Syndrome. Available from: https://www.ninds.nih.gov/health-information/disorders/carpal-tunnel-syndrome. National Pressure Ulcer Advisory Panel (NPUAP) (2016) NPUAP Pressure Injury Stages. Available from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. NHS Improvement (2018) Stop the Pressure. Available from: https://www.nationalwoundcarestrategy.net/. Nwaobi, O.M., Brubaker, C.E., Cusick, B. and Sussman, M.D. (1983) Electromyographic investigation of extensor activity in cerebral-palsied children in different seating positions. Developmental Medicine and Child Neurology. 25: 175-183. Pain, H., McLellan, L. and Gore, S. (2003) Choosing Assistive Devices: A Guide for Users and Professionals. London and Philadelphia: Jessica Kingsley Publishers. Pope, P.M. (2002) Posture management and special seating. In Edwards, S. (Ed) Neurological Physiotherapy. London: Churchill Livingstone. Pope, P.M. (2007) Severe and Complex Neurological Disabilities: Management of the Physical Condition. London: Butterworth-Heinmann. Postural Care Action Group (2011) Postural care: protecting and restoring body shape. Available from: www.preparingforadulthood.org.uk/media/293084/postural_care_booklet.pdf. Pountney, T.E., Mulcahy, C.M., Clarke, S.M. and Green, E.M. (2000) The Chailey Approach to Postural Management. Birmingham: Active Design Ltd. Public Health England (2015) Guidance Pressure ulcers: applying All Our Health. Available from: https://www.gov.uk/government/publications/pressure-ulcers-applying-all-our-health/pressure-ulcers-applying-all-our-health. Royal College of Nursing, NHS England (2013) Pressure ulcers A guide to eliminating all avoidable grade 2, 3, and 4 pressure ulcers. Available from: http://nhs.stopthepressure.co.uk/docs/Pressure_ulcer_care_best_practice.pdf. Simply Psychology (2023) Autonomic Nervous System (ANS) Division and Functions. Available from: https://www.simplypsychology.org/autonomic-nervous-system.html. Sprigle, S. and Sonenblum, S. (2011) Assessing evidence supporting redistribution of pressure for pressure ulcer prevention: A review. 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Introduction The human body is made up of different systems that work together, with the aim to achieve optimum posture. As we grow and develop, we learn from and respond to information that is sent from a breadth of sources, including: visual stimuli vestibular function (sense of balance) proprioceptive input (movement sensations from muscles and tendons); awareness of our body within space Damage to any of these systems can occur through injury, illness, disease and/or the ageing process. This can affect our ability to interact with sensory information and, in turn, our ability to maintain good posture. It is important to note that maintaining good posture at all times can be difficult for anyone, with or without system damage! So what exactly is posture? To reduce a very complex structure into manageable proportions we need to consider it as a system of segments. Posture is the way we hold ourselves or position our body segments in relation to one another and their orientation in space. This might be intentional or unintentional. Posture can be influenced by many factors, including our body shape and size, the task at hand and even the supporting surface on which we are sitting, standing or lying. Posture has two main purposes: Antigravity – to provide the rigidity necessary to maintain an erect frame against gravity Interface with the outside world – to orientate body segments to interact with the environment What makes good posture? Energy efficiency Effective functional performance Reduced harm to the body systems What is not good posture?  A few visual examples: The body structure is complex. It is inherently unstable, multi-segmental and highly flexible, which allows for a wide variety of postures, but also makes it vulnerable to damage. What is postural management? If an individual is at risk of postural challenges, potentially due to injury or disease, then a postural management programme should be considered. Postural management is the use of any technique to minimise postural abnormality and enhance function. It is a multi-disciplinary approach, that encompasses a person’s daily routine across 24-hours - respecting all activities and interventions that impact on posture and function. It must be considered on an individual basis following a comprehensive assessment. Failure to protect an individual’s body shape can result in many secondary complications. You will learn more about these in a later section... Why 24-hour postural management? Sitting ability and lying ability are closely linked. Imagine an elderly lady diagnosed with dementia, who instinctively curls up into a foetal position when she gets in to bed, but lacks the cognitive function to change position throughout the night. Or a young man with cerebral palsy who, due to gravity and neurological involvement, remains restricted in a windswept position, but lacks the physical ability to change position. Prolonged periods of abnormal postures increases the risk of postural deterioration and the associated secondary complications. It is unlikely that either individual will be able to achieve a comfortable sitting position during the day, after a full night fixed in one asymmetrical position. It is important to consider the management of posture throughout the full 24-hours, otherwise it will be difficult, if not impossible, to sit out. This will impact on other aspects of daily living and, ultimately, quality of life.

The information on trauma and the link between early adversity may suggest that our heath is pre-determined and not in our control to change. However, there is ongoing debate between how far both nature and nurture impact on one's development. In fact, there is some research suggesting that even in older adults cognitive functioning can be enhanced when both music and physical exercise are combined (Ball et al., 2002; Satoh et al., 2014). Neuroplasticity The latest research in neuroscience suggests that our brain has the ability to adapt to life circumstances. Neuroplasticity refers to the ability of neurons and neural networks to alter and adapt behaviour as a consequence of new information, such as sensory messages, damage or dysfunction (Britannica Academic, 2022). This can take place throughout the human lifespan, but is particularly prominent at key developmental milestones, such as early childhood or puberty (Erikson, 1982). Throughout the lifespan, synapses strengthen or weaken neural connections and we are able to update our knowledge and adapt our behaviour in context to the environment. There are many different theories of development, including the nature vs nurture debate (Bundy et al., 2020). However, recent literature suggests that gene expression is based upon the specific environment within which one lives, which ultimately influences brain function and behaviour (Nelson et al, 2006). Research suggests that we maintain the neuronal connections and pathways that are most useful to us - and lose those that are less helpful. If someone experiences early adversity, their cortisol levels increase and act as a way to self-protect. Instinctive ways of behaving, such as fight or flight reactions, are formed in the amygdala and hypothalamus (Gerhardt, 2011). This results in the strengthening of neuronal pathways and synapse connections in these areas. Consequently, young children who live in an environment with angry or aggressive people will keep pathways that help them become alert to anger and danger (Gerhardt, 2011). This function also serves to impede the development in other areas of the brain, that relate to social, emotional, sensory and cognitive connections (Ward, 2017). Even when the threat has reduced, a child can maintain higher levels of stress/cortisol into later years, which impacts the parasympathetic system and immune functioning (e.g. rest and digest). It can also impede social and emotional learning, as the brain is preoccupied with managing stress. Neural pathways are formed as a result of environmental factors and situational experiences (Barker et al., 2018). The brain develops in response to social experiences and learned behaviour, a good example being emotional control. It is the primary caregiver who provides initial experiences of emotions being managed, before the baby can learn to self-soothe and manage her own feelings well (Gerhardt, 2014).