Redefining What's Possible

Why Supported Lying Matters with Ed Milner | Ep 10 | Redefining What’s Possible

• Independent Living Specialists • Season 1 • Episode 10

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 42:53

The way we lie is the way we sit, stand, move and function. In Episode 10 of Redefining What's Possible, occupational therapist and clinical educator Ed Milner from Medifab makes the case for why supported lying deserves a place in every 24-hour postural care plan. Ed unpacks why lying down is far from a passive, low-risk position for people with movement difficulties, and how the forces at play through the night can quietly contribute to body shape distortion over time.

In this episode:

  • Why supported lying and positioning matters across the full 24 hours
  • How body shape distortion develops during sleep and rest
  • The link between posture in lying and respiratory health, comfort and participation
  • Practical, strength-based ways to introduce supported lying gently, starting where each person is

Thanks for tuning in to the Redefining What’s Possible Podcast! If you enjoyed this episode, don’t forget to subscribe, rate, and review on your favorite podcast platform—it really helps us reach more listeners like you.

🎧 Listen & Subscribe on all of our platforms:

📲 Stay Connected with us:

Got a topic you’d love to hear about? Leave a comment on the episode, let us know on social media or email us at digital@ilsau.com.au!

Welcome to Redefining What's Possible, your guide to assistive technology in Australia. Join us as we explore practical applications of AT, featuring expert interviews and the latest industry insights to enhance your professional development and to improve client outcomes. Welcome to this episode of the Redefining What's Possible Podcast. I'm your host, Sarah Uncle. I'm the head of clinical education at ILS and I trained as an occupational therapist. And today I'm joined by Ed Milner. Ed is also an occupational therapist and he's a clinical educator with Medifab. So Ed, a big warm welcome to the podcast today. Thanks for having me, Sarah. I'm absolutely delighted to be here with you today. Yeah, we're going to have a really great conversation. So we're going to have a chat today around supported lying and the why we should be looking at supported lying for our clients with movement difficulties. So Ed, to kick us off, I'd like to have a chat to you around what actually happens to our body when we lie down and why is that a concern for people with movement difficulties? That is such a great question, Sarah, and it's obviously thinking about the implications of gravity when we're in a lying down orientation is something that we might not think about. And I do feel that the background to not thinking about the lying presentation for our clients with movement difficulties Is around the fact that when we're on a lying support surface, we have this belief that we're getting support all along the body. And also it's this position where a lot of people can find rest and find comfort in this lying position. But what we are starting to learn over time, and this is, I guess, evidence that's sort of been coming out for the last sort of 20 to 30 years and also tracking clients you know, co- doing cohort studies over the years is we're finding that clients with movement disabilities or movement impairments if they're unable to move and change their position in a lying orientation, then they're going to be exposed to gravitational forces, which can be quite harmful, particularly if they have postural tendencies. So when I'm talking about postural tendencies here, I'm talking about the inability to have a postural ability where we can align our body segments. So for example, when I'm in the seating position now, my body, I don't know this, my body's working quite hard to maintain an upright posture. So my head is facing forward, my spine is over my pelvis, I've got grounding through feet, and my thighs are supported. And what this is enabling me to do is to have this discussion with you, to be aware of my environment to be aware of what's going on around myself and to use my upper limbs, for example. Now, if I have a a motor impairment or I have some issues moving my body, what may happen is I could have some issues in terms of my musculatular, so my musculoskeletal system. So that could be that I might have weakness, I might have variances in tone, I might have some orthopedic complications which reduce my ability to stabilize my body segments. So just as I'm stabilizing my body segments here, I can also do that in standing that enables me to be upright and to engage with the world. In lying, it's the same thing. It's this inability to stabilize my body segments, which exposes me to the potential of gravitational force causing distortion. So this is the misconception that happens. People think lying, that individual won't be exposed to forces that could cause postal asymmetry. And what we're learning is it actually can cause postal asymmetry, particularly for these individuals with motor impairments. Yeah, that's a great, great explanation. And I find like talking to therapists, I think a lot of therapists are really well versed in supporting posture in sitting and they understand seating systems and supporting the posture when someone's in a wheelchair, but maybe they kind of overlook supporting posture in lying. So is that because it's a newer concept, do you think, and we're still learning about it? Or is there any other reason why you think it gets overlooked? Oh, it's let me reflect a little bit on my practice. So I've been in OT for a while now and I have, I started off my career really working in wheelchair seating. So working very much from a biomechanical, musculoskeletal sort of background, trying to help my clients be more functional in their wheelchairs and working with them to get postural alignment. So my focus when I saw my clients was purely looking at them in the seating orientation during the day. So what, what would happen over time, more experienced I got, the more I began to understand posture and the impact of not having support in different orientations. So here I'm talking about lying, sitting, standing and moving because we, we deal with clients that can do all those things. And if you're dealing in this complex area, it might be that client can maybe achieve, you know, lying and sitting. Became very narrow focused. I learned more about the area and then I realised, hey, if they're getting lots of support during the day with their wheelchair seating and I'm unable to get them into a really nice position, what are these other areas that I'm neglecting during this sort of 24 hour period? And obviously being in this area working in assistive technology, working with some absolutely amazing therapists, clinical therapists that deal with complex postural asymmetries and supporting these clients to find comfort you know, during the day and at night, my eyes sort of were open to where else in that 24 hour period I need to consider. So it came to this point where if we look at people people without disability, so people that are able to, to move, to stand to engage in these tasks each day, they're spending one third of their life in bed. Okay? It's a lot of time. So we're spending one third of our life in bed. Now, we both know the impact that not being able to find rest in that period of time in bed can have on your daytime function. Obviously, if I see a client in the morning and they haven't had a good sleep, and it could be for various reasons, it could be, you know, they might have been in pain or discomfort during the night. It could be that they've been they, they have a carer coming in and turning them every three to four hours so they're waking them up before they go into these deep sort of REM cycles of sleep. It's various things that could cause them an inability to get rest. That was reflected in how they'd turn up in their daytime activity and function. So we would see clients in the morning, if they had a good sleep, they would present quite differently to when they didn't have a good sleep. And that also goes for other periods of the day. So they would have a different presentation in the morning to the afternoon because obviously we have this impact of gravity constantly pressing on our body. So at some point, our sitting endurance is going to get maxed out and then we're going to rely on adopting postures to to be able to do something functional because asymmetry can be functional. So just going back to the why it's not often considered, I think it comes down to maybe education and training awareness around 24 hour posture care, around the fact that people are still at risk of postural distortion in lying and also the sensitivity around the bedroom. So it's, it is a, a private space. So, you know, if you have a community occupational physiotherapist, you know, a lot of conversation happens in the living room. It happens, you know, obviously in other areas of the house, but when it comes to the bed, we try and as a professional, we're looking at ways to safely get people on and off the bed. We're looking at ways to manage their pressure care whilst they're in bed. And then we could consider risk. For example, if they've got issues with swallowing or breathing, we're going to be looking at how we can use the bed functions to position them better. Then there's the pressure care coming in again. So if we need to offload bony prominences, then we might use supports in bed for that reason. But posture care is not, not something that's sort of considered in that area too. It's generally around pressure presure care and transfers and doing a functional task. So I think if we look at nighttime positioning or support of lying and positioning, there's quite a few things in play that that can lead to, I guess, being, it being a bit of a blind spot for those therapists that haven't worked in this area for a while. Yeah. And I find as well that a lot of family and caregivers, when they have a loved one that's in, you know, seating during the day that has a lot of supports around the body, they kind of have the philosophy, just give them a break. When it's time to sleep, let them have a break from all of that and just be free without the understanding of the impact that the gravity is actually having on their body in that posture. Yeah, totally, totally right. It's the bed, because they've got that large support surface and there's this sense of security when people are lying down, it's where they can be free. I guess then it comes down to acknowledgement of the disconnection between our lying posture and our sitting posture and our standing posture. So, you know the way we lie is the way we sit, the way we stand, the way we move, the way that we function each day. If we are unable to achieve a lying posture that is beneficial to, you know, not only our physiological functioning, but also our musculoskeletal system and our ability to find comfort and rest, then that's going to have implications on us during the day. But yeah. Yeah. And let's talk about what some of those implications are. So if someone's lying unsupported and they're developing what you talked about before, like body shape distortion, like what are some of the consequences of what can happen to the body and to their physiological function? Yeah, so I guess postural distortion it doesn't happen overnight. It happens over a period of time. So we talk often about this pathway to distortion and and how unsupported lying can lead to small changes that don't get noticed over a period of time. And then suddenly we have someone that is in a position in lying where they're unable to bring their knees their legs to straighten out in bed. They're unable to have their shoulders resting, you know, on the support surface and their head in an alignment which is comfortable for them and it allows them to breathe and, and swallow and secrete saliva. So I think if we're going to talk about this pathway, the postural distortion, and some of the implications, I think it's probably important to talk about the effect of gravity on the body and then we'll, we'll move to those areas. So if we're thinking about when we're in lying so say if we're lying in a symmetrical position on the bed. Now that is, is that I've got my back in contact with the bed, my head is in a neutral alignment. I have my legs flat and my knees up to the ceiling my arms to the side. Now there's forces that the body's exposed to even in that position. So you have compression forces. So we talk about this concept of you know, gravity working on the body at all times. We have the support surface which the individual is lying on, and we have this force of gravity. So we have this force, sorry, of compression pushing on the chest. So straight away, if we have gravitational force coming down and pressing on the chest, then what we have is we have a movable structure. So our chest is designed to be able to, to move. It, you know, the cartilage is soft. We have muscles in the chest that allow movement. It's going to compress, which is going to change the the volume of our chest cavity. So the first thing that you might see with people, even if they're able to lie on their back let's say if they're stuck in that position, you know, eight to 12 hours a night is you might see this force happening on the chest, which is going to push on the sternum, which is going to make your chest space narrower. Okay? Which is going to impact obviously your internal organs and your respiratory function. So if we start at the chest in a symmetrical alignment, lying on our back, we might have reduced volume in our chest, which is going to mean it's going to be difficult to breathe and we might start to get digestive complications. Now, say for example, that individual when they're lying on their back, they're unable to straighten their knees. Now, if you're unable to straighten your knees and I might actually bring a friend into this a little bit of help and hopefully you can see my friend. Yes, I can see Your friend. Is your friend's name Hammy? Is that- This is Hammy. . Yeah. Yep. Yep, this is Hammy. He has done more travel than any little doll probably in the world. He has been all over the world. But Hammy is a really good educational tool really good educational tool. So Hammy's lying on his back. We have compression happening in the chest. Okay? So this is happening here. Now, if we're unable to straighten our legs, so say if we have a contracture in the knees in this position, contraction in the knees. Which is so common. It's really common to see that. Yeah. And it's, and it's common across any age and disability as well. So a knee contracture with gravitational forces pushing on the knees, what's going to happen is you're going, your knee's got to go somewhere. So they're either going to go to the side into a pos- a presentation like this, which is once we have hip distortion, or they're going to rotate into external rotation. So if we look at, for example, this posture when our legs go to the side, our legs are quite heavy. And what will happen is they will actually pull the trunk. So they will force the trunk to rotate. So your trunk's going to start rotating. So now if we go to the chest with gravitational forces on the chest, now we are hitting the chest on a diagonal plane, which means you're going to get chest distortion, okay? Which again, is going to cause complication to respiratory functioning, swallowing, digestion, and circulation. Now with our wind sweeping in this position, if we're unable to straighten our legs and we have gravitational forces pulling our legs to the side, and this is happening day in this is happening each night or during the day if we're in line for long periods of time, our muscles are going to adapt. The tissues around our muscles are going to adapt and we're going to lose joint range. So it starts with a knee contracture with having reduced joint range, and that's going to be compounded into other areas of the body, for example, the hips. So you might start to develop shortening of range in the hips and knees, which means if you go to a sitting position, you're now going to a sitting position where you have reduced range in your knees and hips, which is obviously going to impact your wheelchair seating. So we have the development of contractures, which are going to impact our joint range and our ability to have quality movement. If we have restriction in our movement, then it's even going to cause a reduced likelihood of being able to move out of that position in lying. So you're going to have limited ability to move out of that position as well. So you've got this circle happening. So I mentioned contractures. I mentioned with chest distortion, how that can cause physiological issues for breathing, digestion, circulation. Obviously if our head position is not in a neutral alignment and say if we've got lateral trunk flexion or we have rotation happening and our head is falling to the side, that also is going to impact breathing and swallowing. So we have a common cause that leads to periods of, of very poor health, hospitalization, and even death is aspiration pneumonia. And this is one of the most common causes, unfortunately, that's quite life-limiting for people with disability impacting their motor function. So if we have aspiration pneumonia, that can be linked actually to our posture and the position of our head and neck. So musculoskeletal complications with contractures, reduce joint range. Obviously, if we're unable to get contact with the bed in a symmetrical alignment, that's going to mean that we're going to have parts of the body that is going to, there's going to be peak pressure, which means it's going to lead to pressure care issues. So even in lying even on the best mattress, if the individual doesn't get appropriate development immersion and contact with that mattress is going to expose them to risk of pressure injuries. So providing postural care actually helps with pressure care distribution. And then obviously if an individual has all these things going on with them, it's going to cause pain and discomfort, which is going to impact the quality of their sleep. Also the, the restorative function of sleep. So if we look at REM cycles, if they're in pain and discomfort, they're not going to enter into those lovely cycles throughout the night, which is going to be for restoration, repair of muscle tissue help with the brain, recover from the day. So they're not going to experience that, unfor tunately. It's going that that's going to be an impact that they have. So you've got sleep disturbance, pain, which is going to reduce quality of life during the day because it's going to impact your daytime functioning. So it's going to impact your ability to do the things that are meaningful to you due to the fact that you haven't had that restorative sleep you haven't and you're not able to get your body ready for daytime function. So there's quite a lot to unpack there in terms of those complications that arise from you know, individuals that are unsupported in the lying orientation and how very slowly over time these patterns of distortion can sneak up on you. And then, you know, over the years, you'll have a presentation and it will become remarkably hard to manage that postural presentation for that individual to do the things that I love doing each day. Yeah. Have you got any stories of any clients you've worked with, those stories you've heard where all this sort of stuff that you're talking about, these consequences actually happened? Yes, I do. I, I do have I do have stories and it's some of them. I'll start with a story that's quite dear to me. And there was actually a good outcome with it. Okay. So I had a, I had a client that had Huntington's disease. So there's also, I guess, this belief that supporter lying and positioning is only for neurodevelopmental populations, so for cerebral palsy particularly. And you know, it is very important in that population, but also supported lying can be used across other diagnoses because we're thinking about people that that have motor impairments and, and whatnot in that affects them in lying in their lying posture. So this client he started to adopt presentations in a lying position where he had knee and hip contractures. He also had ankle contractures and he was he was assuming a more of a fetal position. Then obviously with the Huntington's disease we had involuntary dystonic movements of the head and the shoulders. Now this client was remarkably tall. So his long legs were actually the, the fact that he was going into a wind swept tip distortion were actually causing distortions also in the trunk. So he was unable to find rest. So this, this happens quite frequently in these neurological disabilities where individuals that have these movements and when they're not supported, so they're not actually getting sensory feedback. So they feel unsupported, they're not getting the support from the support surfaces around them. So they assume these positions, which can be flexion positions of flexion to actually feel where their body is in space. And it might give them a sense of security of knowing where they are. So they're getting this tactile integration of where their body is. I've seen that. Yeah. In dementia, I've seen that quite a bit. Yeah, so Dementia Is another one, peritonia. So this particular client we were unable to seat him in a wheelchair. So the reason why I got involved was due to the fact that due to his height and his presentation he was unable to assume a posture in a whelchair. Because when you think about a wheelchair, whelchair's a box with wheels. And if you don't fit that box with wheels realistically, then you need to start moving things around. But when your body shape, when your dimensions, when your presentation can't fit that box, then it leads to safety concerns. And it also leads to like exposure of risks such, such as pressure injuries, you know, or putting that person in a position of pain to sit them in that wheelchair. So essentially, we looked at him in the supported in the lying presentation. And first thing we did is we did a physical assessment to work out what kind of range of motion we had. And there was restrictions there, obviously. And then we tried to provide him with support to support him in the positions that we couldn't move and try to find some correction in the positions that we could. For example, we could bring his pelvis to a neutral position if we accommodated his windswept hip distortion. Okay? So we're starting to give him sensory integration. And before we provided these supports during the trial this client had movement happening in the shoulders, head moving side to side and was groaning because he was uncomfortable. And then the more support we provided to this client we started to see relaxation. So we, what we actually saw is that muscle tone started to relax, which meant meant that we could get a little bit more range, tiny bit more on his hip and knee. And then we could start to work in through his trunk to provide some support there to try and get a better shape. And this is all about trying to restore body shape. So providing deep sensory contact to this client actually helped him work out. So his amount of sensory cortex in his brain, knowing where he is from this tactile integration, and then him able to be able to switch off his muscle tone to find comfort. And he actually started to fall asleep during the trial. So we noticed the movement starting to, to reduce. Groaning started to reduce. And because this client was nonverbal his primary carer was there and was extremely impressed with the fact that we were able to find comfort for this client because the goalposts change for people and you have to meet people where they're at. And this particular client was very much end stage of Huntington's disease and it was all about trying to just restore what we could, provide comfort and to distribute pressure. And we were able to do that from providing support. And I think if a client that is moving, that is grimacing and showing pain settles and finds comfort and starts to nod off. Yeah, that's a Very good outcome. It's a good outcome. So I Guess That really showed showed the importance of it to me. Again, it really did clarify this importance of providing these solutions to people across a lifespan. So not just from a young age to people that, you know, are middle-aged or even elderly people, no matter what their diagnosis is, as long as we mitigate risk and we're aware of those risks, then we can provide some solutions to work on improving those areas for them in the lying posture. So in terms of using lying, supported lying as a preventative tool to these sort of body shape distortions you're talking about, like when should a therapist or a caregiver start to be considering about implementing this type of equipment? Yeah. So I think that's a really good question. So it comes down to of, okay, so you're going to get a referral. So your therapist is getting a referral to see a client. And that referral, it could be, let's say we're a community therapist, it could be regarding AT. So review the AT or to do a functional capacity evaluation just to see where they're at. Now, firstly, eligibility for supported lying and positioning interventions effectively as mentioned across the lifespan across disabilities. Any disability that impacts your ability to maintain body alignment to stabilize body, body segments. And is there exposure to things like postural tendencies, pain discomfort, heightened pressure care risks? It could be that they're worried about head positioning due to their client maybe having a stroke and experiencing dysphasia, so we're having swallowing difficulties. There is a checklist that you can go through and it's all around eligibility. But for me, if I'm working from a holistic lens, I'm going to ask about that individual's, what their 24 hours look like. So I want to understand on a deep level what they're doing during the day, what they're doing at night, where they feel that they have the support to be able to engage in those meaningful activities and where there might be some spots where they're unsupported. Now, we have a a postural graph, which is essentially a 24 hour clock, and it enables clinicians to work with the client, but also with their support network to identify where they're spending their time in that 24 hours a day. And what we're seeing is that, and this is something that we were talking about at the start of the session, people are going to have equipment that helps them during the day if they are unable to independently mobilize themselves. So they're going to have, you know, a wheelchair. You know, if they're able to walk and they need some support with walking, they may have a mobility device there. So the AT will happen during the day. And what may happen is that this period in lying, we might identify that they're spending a period of time unsupported and lying. So then we start having conversations about, let's talk about, you know your lying position. Let's talk about your rest. Let's talk about your sleep routine. If they're, if they have carers, they might be getting woken up during the night. We want to understand how they're being managed in their bed if they're unable to. .. To relieve their own pressure. So from the start, the initial assessment, I want to gather information about their 24 hours. If I'm going into postural sort of reviews for that client, a good way also to start the conversation around the lying orientation is when you're doing a physical assessment and you're looking at their postural presentation and you're looking at their, their range of motion. Because part of that assessment is in lying. So it's actually a very natural conversation to have during that part of the assessment too. So there's a few things to consider the initial assessment, talking about their 24 hours what it looks like for them, and then if we're going down to assessing them for AT, also that physical assessment where it gives you an opportunity to have conversations around the lying orientation. Yeah, I think does that answer your question? Yeah. Yeah, no, it does. It does. Okay. Yeah. I really appreciate all your knowledge. Like you have so much knowledge in this area and something that I think therapists can really benefit from, from your experience and your expertise. So thank you so much for everything that you've shared with us today. Is there anything else around supported lying that you think it would be helpful for therapists to understand if they're new to this area of practice? Definitely. So this area, supported lying and positioning, it's like it's back to roots, occupational therapy and physiotherapy. So it's very holistic. It's very client and family centered. So what that means is that in order to get the outcome and to get the appropriate supports for that individual in lying, then we really need to bring in that client. We really need to bring in that family and their support network into the discussion around supported lying and positioning. So if we want to reduce abandonment and we want to reduce misuse and we want to actually get consistency in using the supports in bed, then from the outset, it's all around resourcing and educating the key stakeholders. Because at the end of the day, when we leave we leave that house and we shut that door, these are the people who are going to be driving this extremely important part of postural care. Now that's number one. Number two is is meeting them where they are. So for example, if you see from a clinical, if your clinical goals are around, for example, muscle skeletal alignment and, and improving things like range of motion or looking at restoring chest shape, if that family or that client is not ready to have supports that it may require steps to put in place. So we're thinking about bringing supports into lying posture. If there's quite a lot of steps that are required then that can actually be a barrier to use. So asking our client and their primary carers and their families about what their nighttime routine looks like, if they need to be, if they need to receive medical care during the night if they're having to be repositioned, we just need to be aware of all the things that are happening during the night because we don't want to add barriers for them to be able to carry out those those steps because we don't want to add extra burden and stress. So that might, might be scaling down your expectations regarding how many supportive lying and positioning products you're actually able to bring to that client and what you're actually trying to achieve clinically. So here it comes about prioritization and weighing what are the important goals for that client? So you know, there could be goals related to, for example, pressure care. It could be around restoring chest shape getting some lengthening happening in the hip and knee. It could be about hip stability and health. There's a range of goals clinically, but obviously we can't do everything at once, so we need to do things slowly, gradually, and meet the client, the family, and support network where they are. And the third thing around supported lying and positioning just as a bit of another key takeaway is just being very strength-based in your focus. So the language that we're using there was a study done by a physiotherapist in New Zealand, her name's Jane Hammer. So please look into her. She's done some amazing work. And she talked around key themes that would happen for sleep systems, so supported lying and positioning systems not being used consistently, potentially being abandoned. And one of these things was around the language that we use regarding these products. So instead of talking about things, for example, you know future protection future proofing, for those clients that have difficult nights, again, meeting them where they are and saying," This is going to help you here and now and this is going to benefit you in these situations over this 24 hour period during the day. So it could be that from doing bringing these supports in, it's going to really help stretch out your muscles, get some elongation in your joints, which it may improve you during the day in your transfers personal care. It's going to help you in your wheelchair seating or in your standing over time. So it's really just bringing it back to the here and now and being very strength-focused in your language and using information that meets them in terms of their health literacy and their understanding of themselves and their requirements and needs. So I guess there's three themes talking to talk to there with supported lying and read up on it. There's some amazing resources around nighttime positioning, people that have been doing this for years that are incredible in their field. You know, we work with amazing manufacturers as well, which have amazing resources. For example, Simple Stuff Works is, is a great resource to go to. They have easily accessible educational resources on YouTube. There's then obviously we've got some training coming up too with with Medifab and ILS around supported lying and positioning too. So there's opportunities for therapists to really engage in it because it's an area that it's, it's a gentle way to provide a really positive change to an individual's life. So- That's such a great way of summing it up. Yeah. It really is. Yeah. And everything you share, like the consequences, like it is a little bit scary hearing about, you know, the consequences of not doing anything. So doing something is better than doing nothing. Totally. And starting slow and, and, and gentle, like you said, and just knowing that we can protect and restore body shape through these amazing types of AT. I think it's a wonderful area to practice in, but it does. It can be really daunting, I think, for therapists. So I think the way you just explained that and the way you talked about our language with clients and their caregivers is so important because this stuff is really positive. It's positive. Just, yeah, it's gentle and go slow. Gentle and go slow and always prioritize that individual's comfort and sleep and yeah, and just meet them where they are. It's, it's an amazing thing to offer someone to offer them these things in, in lying. So yeah. I agree. Well, Ed, I'm going to ask you one final question that we ask all our guests who come onto our podcast. And that is, can you describe a moment when assisted technology has significantly changed your client's life and how it inspired you to think differently about your work? Oh, wow. Yeah. So a, a few sort of a few sort of experiences come to mind, but one in particular that I always come back to. And again, it's this polarization of, you know, at the time it might have been really tricky finding an appropriate outcome for this client and but then the positive ramifications of that actually happened a year or two later. So when I was working in the UK I was working in an acute spinal cord injury ward. And there I had a client, it was a young client that got their spinal cord injury from a motorcycle accident. So life-changing event. Obviously seeing them in the acute setting and I, I can't even imagine how difficult that would be turning up for things like rehabilitation, right? You're, you're trying to process this. Anyway, so this particular client had goals around independent mobility. So fortunately this client had really good upper limb function, was able to push themself in the wheelchair. So first step was to find them a wheelchair a form of mobility that they were happy with, that that they felt comfortable and confident in which gave them freedom to go places where, where they wanted to go. So that was stage one. So we had, we did that together, but this, the second most important stage is that this client wanted to be able to just get in the car and drive somewhere. And we worked a lot around car transfers. So, you know, I'm an OT and we were doing car transfers. So I was very lucky to be able to, to work in all these areas in this client's life to try and improve their functional independence. And we worked on this car transfer for weeks using a a slide board. And there was frustrations there, you know he was, again, going through some things and I was, I understood it. Anyway, ended up, we ended up doing the car transfer. He discharged and then I saw him a year and a half later when he came back for an appointment on the ward. And he came up to me and he he's just like, " Mate, I just want to, I just want to thank you for putting up with me one but also just taking your time with me around this area, which was really important to me. And it was something as just as simple as that, that car transfer, because that was a really important thing for him to be able to, to go the places he wanted to go independently. And even though there were highs and lows with working with this client and and this is something that a therapist goes through on a daily basis is because we're dealing with people in difficult situations. There's heart and emotions, you're getting pulled different ways. You've got all these stakeholders asking something from you, but if we come back to the why, why we're working in this area, why we're working with these people we want to improve their lives, want to help them. And that was something that was very small for me where I managed to, to see something a year and a half later and to see this client happy. And that made me smile. So yeah. And so nice that he was so grateful just to know that you made a real difference. That's a wonderful story. It's really good. That's why I got into doing OT. I just want to make a difference and help people. Exactly. It's what it's all about. Exactly. And thank you so much for coming on the podcast today and sharing your wonderful knowledge with us and I think really inspiring people to, to really, you know, go forth and, and learn more about supported lying and positioning and to get more confident with it. You reach out, reach out and, and get more confidence because it's really, really important. And so our next episode, I'm actually going to meet with your colleague, Steph, and we're going to talk through sort of not just the why, but then the how and putting it into practice. So that's the next episode coming up. Amazing. Yeah. So thank you so much for your time today. And thank you so much for joining us on the podcast and hopefully we'll see you in the next one. Bye. Bye.