Everybody performs numerous tasks every day and for each task the body is positioned and adjusted for ease of task performance. Eating is one of the tasks that we perform several times a day and able-bodied people unconsciously adjust the position of their body to prepare for eating, and make ongoing adjustments throughout the meal for optimal positioning for eating. Not only do we move our bodies forward and back for each bite of food but we also change the position of our feet many times during each meal to stabilize our trunk. These movements fine-tune our body posture for us to eat comfortably and safely. For many individuals who are unable to feed themselves, adjusting their position for eating is either very difficult or impossible, and they must depend upon their caregiver to position them.
The correct seating and positioning of the body during eating is very important because it improves both the safety and the enjoyment of the meal and facilitates better digestion. A good position for eating requires the trunk to be very stable. To enable the trunk to be stable, the feet must have a firm footing so that they can bear weight as the person eating, moves throughout the meal. Additionally, the thighs and buttocks should bear weight. When the feet, thighs and buttocks bear weight, the body becomes more stable and the shoulders, arms, and head are able to maintain a more constant, steady position. This will promote better control of not just the head and neck, but all of the muscles in the jaw, tongue and mouth. The overall result is that the person will eat more safely and gain better control over eating.
Even people who sit on a standard chair with no type of restraint at mealtimes, should have their stability evaluated. It is also important that their feet can rest firmly on the floor or a foot support. Unsupported feet will lead to instability in positioning during a meal (which is a common occurrence with children in booster seats). For some people it is easier to stabilize themselves if they stagger their feet, rather than having them side-by-side on the floor in front of them. One foot can be moved backwards under their thigh. This will cause a slight toe flex. A staggered foot position helps increase the weight bearing on their thighs and buttocks and, in turn, allows the trunk and upper body to be better controlled. If a person is sitting on a normal upright chair, their knees should be under the table far enough that their hands and forearms can rest on the table if they would like to do so. This, in turn, provides greater stability. If eating at a table, the individual should lean forward towards the table and round their shoulders slightly. This position encourages them to hold their head in a chin-tuck position, which promotes safe chewing and swallowing. (See Promoting a Chin Tuck for Safer Eating in the June 2009 Newsletter for additional information about this topic.)
Many people with disabilities sit in wheelchairs to eat and are unable to freely position themselves. Many of these individuals remain in the same position while conducting all tasks. Commonly, this position is specifically designed for safely transporting the individual, not for task performance. If you are sitting in a wheelchair during a meal, the wheelchair should be as up-right as possible. Foot positioning is normally dictated by the wheelchair foot-rests, and, therefore, it is important to make sure that the footrests support the feet adequately and allow the thighs to bear weight. If the individual has shoulder straps that restrain their upper body, slightly loosening the shoulder straps should be considered to allow a small forward movement of the shoulders. First try loosening one shoulder strap to see if this freedom of movement is enough to encourage the head to move forward and down. Placing a small wedge or rolled-up hand towel behind the individual’s shoulders can encourage this position.
If the person has poor muscle tone and is pulled forward by gravity when they lean forward past the upright, 90 degree, position, producing a chin tuck can be more difficult. However, a chin tuck can be produced while the person is sitting in a slightly reclined position (to avoid the impact of gravity) by supporting the shoulders in a forward, or rolled, position and also supporting the head. A neck pillow can provide support for the head and placing rolled hand towels or small pillows under the shoulders can help shoulder positioning. In this way the pull of gravity is overcome and yet a chin tuck is produced. (This is similar to the position that you would be in if you wanted to watch television while lying in bed.)
It should be noted that while achieving a shoulder roll (i.e., pulling the shoulder forward and down slightly) you do not want the individual to collapse their trunk because it will put pressure on the stomach and increase the occurrence of reflux during and after eating. You must locate the position that allows a chin tuck but does not cause the trunk to collapse.
A laptray on a wheelchair is often a benefit for individuals who have difficulty maintaining their trunk stability. Their forearms can rest on the laptray while eating and can bear the weight of the shoulders. This position will bring the individuals shoulders forward and produce a chin tuck. If the individual leans too far forward on the laptray, pressure will be put on their stomach, either from the laptray physically pushing on their stomach, or because their ribcage is resting on their stomach because they have collapsed their trunk; both are unhealthy for eating and digestion.
Finally, here is a tip for those who feed someone. You too need to be in a specific sitting position to meet the feeding needs of your dining partner. If you stand up while feeding someone, their head will automatically tilt upward to accommodate the position of your arm. This head position puts them at an unnecessary risk of aspiration because their airway protective mechanisms are less effective with their head raised. It is better, when feeding someone, to sit directly in front of them, facing them, and to present the food to them at the level of their lower lip when their head has an adequate chin tuck. Sitting to the side of the individual, tends to induce the person to turn their head towards the utensil and they are no longer in an ideal position to receive food into their mouths.
Conclusion: The overall objective of good positioning for eating is to provide the body enough stability that the muscles involved in eating can perform at their best. With a stable body, people are able to better control their muscles and therefore they are able to chew more productively, manipulate the food in their mouth with greater ease and swallow safely. Eating in the right position over an extended time can result in improved muscle tone and thus better overall oral motor control.
A MtP Tip: Put a non-stick material (such as Dycem), on a foot stool to help stabilize feet. Also, it can be used on a seat to help stabilize the buttocks and thighs.
In last months Newsletter, the safety and health issues that relate to the benefits of independent eating were discussed. This month we will expand upon the topic to include the social aspects of independent eating and the impact of independence at mealtimes on people.
Socialization: Mealtimes are generally a social time with family or friends together sharing food and talking. However, if you are being fed, you are unlikely to fully participate in the ongoing conversation because you must always anticipate receiving a bite of food. If you open your mouth to speak, your feeding partner could easily (unintentionally) put a bite of food in your mouth when you are not ready, not knowing that you are about to talk. The result of this situation is that those being fed are usually not able to fully participate in the social interactions surrounding a meal. They are more likely to be passive participants listening to the conversation rather than fully participating. When feeding yourself you choose when to talk and when to eat.
For residents of institutions mealtime conversations are unlikely. While they are being fed, usually quickly (because staff have several people to feed at each meal), staff will talk to one another but typically interact only briefly with the person they are feeding. The interactions are mostly related to eating. In this situation the person being fed is deprived of the normal mealtime social experience. (It should be noted, however, that people who have swallowing difficulties should refrain from talking and eating at the same time. A speech language pathologist should advise them about the best practices to follow at mealtimes. The training should always be adhered to until the swallowing problems abate.)
When empowered to feed themselves using assistive technology (AT), verbal interactions have been observed to change. For children, who have never experienced mealtime independence, the change is gradual. As they realize that they can choose when to speak and when to eat, they are more likely to join in the conversation. For those regaining independence through the use of AT, conversation returns to a normal pattern almost immediately.
Independence. Food selection for those being fed is a difficult issue for a feeding partner. Either they must choose what food is fed for each bite or they must ask the person being fed what they want for every bite. Most commonly the person providing food makes all of the decisions about what will be offered and the pace at which it is provided. Even the very best feeding partners have difficulty matching how they provide each bite of food with what the person they are feeding might like. A good example of this is a wife who fed her husband and carefully provided him each bite with a mixture of food on the utensil (e.g., potatoes and meat, or green beans and tomato). When her husband was able to eat independently by using an assistive dining device, he ate all of his potatoes, next all of his green beans, and finally the meat. His wife was astonished and felt that he was still having difficulty with feeding himself. When the couple discussed this, the husband explained that he was so appreciative of her care that he could not possibly impose upon her further to change how she selected the food that she was feeding him, but that he really preferred that his food not be mixed.
Many children who have never experienced independence at mealtimes, eat whatever is offered to them showing little regard for the flavor. Either they do not realize that they have a choice, or they simply accept that some food doesn’t taste as good as other food, but they believe that they should eat it, regardless. (No clinical explanation of this behavior has been established.) What has been observed is that if independence is gained, food selection and the pace of eating often changes dramatically. On many occasions, it has been observed that a child who has always eaten all of his or her vegetables, for example, when using a Mealtime Partner Dining Device (and can therefore make his/her own food selection), suddenly rejects (i.e., never selects) a specific vegetable, even though all of the family members and caregivers were adamant that the child liked that particular food item. Additionally, the pace at which people eat will change when they are able to control the pace through the use of AT. People diagnosed with gastroesophageal reflux disease have been observed to dramatically slow their pace of eating, in some cases doubling the time spent eating. It should also be noted that they experienced less discomfort after their meal when they ate at a slower pace.
Conclusion. Eisemann Shimizu1, et. al., concluded that for people who are totally dependent on a caregiver to feed them, “the joys of eating and being able to eat by oneself are taken away from him/her. This can lead to feelings of shame, discomfort, loss of appetite, decreased self-esteem and panic or fear”. For those living in a supportive family environment, these findings may not be applicable. Nevertheless, for those who lack the ability to feed themselves, the goal should be to have them participate as fully as possible in eating, not only for reasons defined by Shimizu, but for the many other reasons discussed in this and previous Newsletters.
Being assisted by a Mealtime Partner Dining System when eating affords all of the very important benefits discussed above. The user now has control over his or her meal and gains all of the psychological benefits associated with greater independence, such as improved dignity and self-esteem. In addition, being in control of the pace at which they eat enables normal socializing during the meal.
NOTE: More detailed information about a chin tuck can be found in the June 2009 Newsletter.
1. Eisemann Shimizu, M., Otsuka, A., Kania, S., Oki, S. The Therapeutic Effects of Independent Eating for the Severely Physically Disabled. Journal of Phys. Ther. Sci. 16: 73-79, 2004.
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