Positioning

Original Editor - Naomi O'Reilly and Stacy Schiurring

Top Contributors - Naomi O'Reilly, Stacy Schiurring and Jess Bell

Introduction

Moving and positioning exist in the broader context of manual handling and are key aspects of rehabilitation patient care. Optimum positioning is a foundation to maximise the benefit of other interventions, such as bed and breathing exercises. It can also assist in rest and mobility and, thus, facilitate recovery, enhance function and prevent secondary complications. Patient positioning must not be seen in isolation but rather as one aspect of patient management where the overall goal is optimising independence.

In medical terms, ‘position’ relates to body position or posture. Positioning involves placing the patient into specific static alignments. Positioning can involve the patient's entire body or a single limb. This skill involves patient handling, transporting or supporting a load (i.e., lifting, lowering, pushing, pulling, carrying or moving) using hands, bodily force and/or mechanical devices. Positioning can be achieved actively by the patient or passively with assistance from one or more other persons.

Positioning has the potential to redistribute pressure and shear forces and subsequently prevent internal tissue deformation, tissue ischaemia, and irreversible tissue damage leading to pressure injury. A major challenge to positioning is placing a dynamic body into a prolonged static position. The human body is made for movement and does not tolerate prolonged periods of immobilisation. Therefore, positioning must be comfortable and allow the patient to reposition as needed, but it must maintain the purpose behind the positioning intervention. It is essential to frequently reassess the therapeutic effect of a positioning intervention to ensure it is achieving the desired result or goal. The positioning procedure should be clinically effective and, ideally, evidence-based.

Indications

The indications and purpose behind therapeutic positioning vary depending on the patient population being treated. However, it is typically indicated for patients who have difficulty moving or require periods of rest when normal function is impaired. Patients should always be encouraged to move independently, but when assistance is required, patients should complete as much of the movement as possible.

1. Comfort:
   • Various studies have investigated the effect of different positioning strategies on patient comfort and pain:
     • Individuals at high risk of pressure ulcers "should use higher-specification foam mattresses rather than standard hospital foam mattresses."
     • Changing from supine to a semi-seated position after trans-femoral coronary angiography helps reduce groin and back pain without increasing vascular complications.
     • After percutaneous coronary intervention, individuals positioned in Fowler's position, with the head of bed elevated to 45–60°, have decreased back pain without an increase in vascular complications.
2. Postural Alignment for Optimal Function:
   • Positioning plays a crucial role in contracture management and postural alignment by maintaining or improving joint range of motion, preventing further contracture development, and promoting / enhancing functional independence.
   • Positioning also plays a crucial role in improving activities of daily living (ADLs) such as swallowing, vocalisation and speech production, and personal hygiene.
     • Swallowing function is "directly and indirectly" impacted by head and neck positioning and altered anterior cervical muscle tone.
     • Upright or slightly reclined positions have been shown to facilitate safe swallowing and reduce the risk of aspiration pneumonia.
3. Reduce Pressure:
   • Routine repositioning reduces the likelihood of hospital-acquired pressure injuries by 14%.
   • Utilising a repositioning device as an alternative to staff-assisted repositioning is associated with a statistically significant reduction in hospital-acquired pressure injuries in intensive care.
   • Positioning devices, including cushions and pressure-relieving mattresses, are associated with improved offloading and reduced pressure injury incidence.
   • Wheelchair cushions are seen as the primary-pressure relieving device for wheelchair users. Backrest shape and incline angle may also have a role in maintaining low buttock pressure and perfusion.
4. Improve Circulation:
   • Positioning is an essential intervention to improve circulation, reduce oedema, and prevent the development of skin breakdown and pressure injury.
   • Positioning strategies aim to elevate and support the limbs to promote adequate blood flow and prevent fluid accumulation.
     • Leg elevation in sitting for patients with venous leg ulcers enhances venous return and minimises oedema and pain. Elevating the leg above heart level showed the greatest benefit, with elevation for one-hour per day significantly associated with venous ulcer recurrence prevention.
     • Hand elevation in acute spinal cord injury assists venous return and reduces arterial hydrostatic pressure to minimise oedema.
5. Improve Respiration:
   • For patients on mechanical ventilation, both semi-recumbent with the head of bed elevated 30-45 degrees and prone positioning improve oxygenation, reduce the incidence of hypoxaemia, increase lung volume and reduce the incidence of ventilator-acquired pneumonia.
   • Evidence suggests that lateral positioning of haemodynamically stable mechanically ventilated patients may increase comfort and remove abdominal pressure from pregnancy or obesity.
   • Postural drainage is a positioning technique to improve respiration by mobilising bronchial secretions with gravity-assisted mobilisation to facilitate drainage of broncho-pulmonary secretions from the tracheobronchial tree.
6. Improve Sensory Input:
   • Adequate arousal and alertness are essential for optimal engagement, participation, and performance in daily activities. Proper positioning can optimise sensory input, increase arousal and enhance engagement in daily activities.
   • Adaptive seating can significantly improve postural control and stability, leading to enhanced sensory processing. Research suggests proper head/trunk alignment with an upright posture can promote increased alertness.
7. Improve Mental Health:
   • Positioning strategies play a crucial role in promoting mental health and psychological well-being.
   • Positioning assistive devices like standers can improve psychological well-being by promoting autonomy and self-esteem.
     • Research suggests assistive device users experience increased independence and a sense of control over their environment, leading to enhanced self-esteem and overall psychological well-being.
     • Evidence supports that upright positioning improves psychological well-being by enhancing alertness, attention and mood. This has been seen in individuals with progressive Multiple Sclerosis and children.
   • Positioning devices that promote an upright posture also promote social engagement, reduce feelings of isolation, and enhance overall mental health and well-being by allowing for increased participation in meaningful activities.
8. Maintain Dignity and Respect:
   • Respecting the dignity of patients is a fundamental principle in healthcare.
   • Patients who are immobilised may feel vulnerable and dependent. Proper positioning techniques that promote patient involvement can help alleviate negative emotions and enhance their sense of dignity and self-worth.

Contraindications and Precautions

There are no general contraindications for positioning. However, some positions are contraindicated for specific conditions or situations, most typically conditions seen within hospital settings, particularly in intensive care units or on post-surgical wards.

Prone	Trendelenburg	Reverse Trendelenburg
Absolute Contraindication: Unstable spinal fracture or spinal instability Acute bleeding (eg, haemorrhagic shock, massive haemoptysis) Raised intracranial pressure (ICP) >30 mmHg or cerebral perfusion pressure <60 mmHg Tracheal surgery or sternotomy within two weeks	Contraindications: Intracranial pressure > 20 mm Hg Patients where increased intracranial pressure is to be avoided (eg, neurosurgery, aneurysms, eye surgery) Uncontrolled hypertension Distended abdomen Oesophageal surgery Recent gross haemoptysis related to recent lung carcinoma treated surgically or with radiation therapy Uncontrolled airway at risk for aspiration (tube feeding or recent meal)	Contraindication: Hypotension Vasoactive medication
Relative Contraindication: Raised intracranial pressure >30 mmHg or cerebral perfusion pressure <60 mmHg Haemodynamic instability Unstable pelvic or long bone fractures Open abdominal wounds

Clinical Considerations

1. Baseline Posture. Clinical considerations in patient positioning are crucial for various medical procedures, diagnostic tests, and therapeutic interventions. The baseline posture of a patient can significantly impact these considerations.
   • Posture can be simply defined as the position of the body in space where the body can maintain balance during dynamic and static movements. This position should provide maximum stability with minimal energy consumption and stress on the body, which is fundamental to any positioning strategy. 
   • A postural assessment is necessary before therapeutic positioning. It should consider abnormal postures, such as forward head posture, kyphosis, lordosis, scoliosis, and pelvic malalignments, such as windswept hips.
2. Sources of Pressure. Pressure injuries develop in localised areas when soft tissues are compressed between a bony prominence and an external surface for a prolonged amount of time. Immobility is a major risk factor for the development of pressure injuries. Prevention is the best intervention, particularly in patients who have difficulty repositioning themselves. Prioritise positioning to focus on the areas of greatest concern.
3. Orthopaedic Considerations. Orthopaedic considerations for patient positioning play a significant role in achieving successful surgical outcomes and minimising complications.
   • Weight-bearing Status. The weight-bearing status of a patient can significantly impact the positioning considerations. Patients who are non-weight bearing or restricted from bearing weight on a specific limb may require additional support and stabilisation during positioning. Proper positioning should aim to distribute the patient's weight evenly to maintain stability and prevent excessive strain on unaffected areas.
   • Total Knee Arthroplasty. A pillow or roll should not be placed under the surgical knee when patients are in supine. Evidence does suggest that use of inactive continuous passive motion (CPM) with hip and knee flexion of 30° may mitigate knee swelling and minimise blood loss, leading to early rehabilitation and improved post-operative range of motion. Weight bearing through the surgical knee, such as in kneeling, should be avoided until the incision line is well healed and pain controlled.
   • Hip Arthroplasty. Associated movement precautions based on the method of surgical replacement. Traditionally, these precautions stay in place for 6 weeks following the joint replacement. However, current evidence does not routinely support the use of these hip precautions in patients post-total hip arthroplasty for primary hip osteoarthritis to prevent dislocation.
     • Anterior Approach - Avoid hip external rotation, active abduction and flexion beyond 90°
     • Posterior Approach - Avoid hip internal rotation, adduction across midline, and flexion beyond 90°
     • Lateral Approach - Avoid hip external rotation, active abduction, and extension
   • Post-Amputation. When positioning a person after amputation, there are several considerations depending on the level and type of amputation, the individual's overall health, and recommendations from healthcare professionals.
     • The residual limb should be aligned in a way that minimises pressure on the incision site, promotes healing and helps manage oedema.
     • To minimise the risk of contractures:
       • Trans-tibial/Below Knee Amputation avoid shortening of the hip and knee flexors
       • Trans-femoral/Above Knee Amputation avoid shortening hip abductors and external rotators
   • Sternal Precautions. Following open heart surgery: Avoid shoulder flexion above 90 degrees, shoulder external rotation beyond neutral, and shoulder abduction past 90 degrees. If the patient can reposition themselves, avoid excessive pulling or pushing with their upper limbs and one-sided upper limb activity.
   • Spinal Precautions. Spinal precautions are guidelines or restrictions put in place to protect the spine and reduce the risk of further injury after spinal surgery, spinal trauma, or suspected spinal instability.
     • Restrictions in forward flexion following spinal surgery limit the patient's ability to assume certain positions comfortably and may require modifications in their positioning to avoid excessive bending, twisting, or flexion of the spine. Clear communication and understanding of the specific precautions and their impact on positioning are vital to ensure patient safety and optimal outcomes.
   • External Fixation. An external fixation device is a bulky and heavy medical device used to stabilise and immobilise bone fractures or other orthopaedic conditions. Depending on the location and purpose of the device, certain movements, positions and weight bearing may be restricted or limited, which may limit the patient's ability to move or perform certain activities. Appropriate cushioning, padding, or specialised positioning supports may be necessary to relieve pressure, improve comfort, and prevent skin breakdown.
4. Neurological Considerations.
   • Tone
     • Spasticity can limit positioning due to reduced range of motion or tonal fluctuations
     • Flaccid tone can increase the risk of subluxation risk with improper positioning
     • Splints can support tone management or protection of the extremity, but it is important to monitor pressure
   • Cognition. Attention, comprehension, and memory play a crucial role in a patient's ability to understand and follow positioning instructions. Consider whether the patient can understand the positioning, know when to call for assistance and is safe for a specific position.
   • Sensation. Directly affects a patient's ability to sense and communicate discomfort or pain. With impaired sensation, the patient may not be able to provide accurate feedback on their comfort level.
5. Cardiorespiratory Considerations.
   • Aspiration Risk. Aspiration is when food, liquid, or some other foreign material enters the airway and lungs. Patients with a known aspiration risk should have the head of the bed elevated to at least 30-45 degrees for up to an hour after eating. Read more about the relationship between posture and swallowing here.
   • Pacemaker Precautions. These precautions are the same as sternal precautions with the additional precaution of limiting reaching behind the back (e.g. movements like fastening a bra strap). Read more about precautions after insertion of cardiac implantable electronic devices here.
6. Circulation Considerations.
   • Oedema Management. Typically oedematous limbs will require elevation, ideally above the level of the heart. This should be considered when prioritising other therapeutic positioning interventions. Read more about oedema management here.
7. Mobility Considerations. Mobility plays a significant role in positioning, as it influences a person's ability to independently change positions, move, and maintain stability. It is important to assess an individual's mobility level and consider their specific mobility challenges to develop a comprehensive positioning plan that promotes mobility, safety, and overall functional independence.

Overview of Patient Positions

Each of the patient positions listed below has unique advantages and considerations, and the specific position used will depend on the activity or intervention being performed, patient factors, and the rehabilitation professional's preferences. Additionally, patient positioning should always prioritise patient safety, help prevent pressure injuries, maintain proper alignment and ensure adequate circulation and breathing.

Assistive Devices for Positioning

Assistive devices for positioning are tools or equipment designed to assist individuals in achieving optimal body positioning and support for enhanced comfort, function, and independence. These devices are particularly beneficial for individuals with mobility limitations, physical disabilities, or medical conditions that affect their ability to maintain proper posture and positioning. Assistive devices also allow the healthcare worker to position and move patients in a way that reduces the risk for injury to themselves and their patients.

Assistive devices that can be utilised for positioning include slide sheets, towels, pillows, cushions, splints, sleep systems, adaptive seating, tilt tables and standing frames.

Read more detail about the wide range of assistive devices available to support patient positioning here.

Table.2 Common Patient Positions

Position	Description	Purpose and Populations	Assistive Devices
Supine (Dorsal Recumbent)	Lie on back in anatomical position. Head and shoulders can be slightly elevated with pillow for comfort, unless contraindicated. Figure.1 Supine Position	Most commonly used position Supports patient assessment Recovery and rest position	Pillows for comfort and offloading - under head, lumbar spine or extremities. Wedge to elevate limbs for oedema management Splints for limb alignment and to maintain muscle length Heel protectors or float heels over towel roll to reduce risk of pressure injury
Trendelenburg Position	Lower head of bed and elevate the foot of bed or tilt table with arms by side. Figure. 2 Trendelenburg Position	Promotes venous return Postural drainage - Good position for chest physiotherapy	Monitor vital signs (HR, BP and SpO2) Tilt table to allow gradual and slow change in position Abdominal binder to assist with venous return
Reverse Trendelenburg Position	Elevate head of bed and lower foot of bed or tilt table with arms by side. Figure 3. Reverse Trendelenburg Position	Minimises gastroesophageal reflux Reacclimates to upright position after prolonged bed rest
Lateral or Side Lying Position	Lie on one side with the top leg in front of the bottom leg with hip and knee flexed. Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base of support and greater stability. An increase in flexion of the top hip and knee provides greater stability and balance. Figure.4 Lateral or Side Lying Position	Reduces lordosis and promotes good back alignment Pressure relief for sacrum, ischial tuberosity and heels Improves body weight distribution Lowers sympathetic tone - Right Side Lie Right Side Lie is optimal for heart failure and post-infarction without bradycardia Decreases severity of sleep apnoea	Pillows and wedges for comfort, alignment and stability under the head, upper arm and lower limb. Can also be placed behind back to reduce rotation over into supine.
Sim's or Semi-prone Position	Lie halfway between side lying and prone with lower arm behind and upper arm flexed at the shoulder and elbow. The upper leg is more acutely flexed at the hip and the knee than the lower leg. Figure.5 Sim's Position	Prevents aspiration Pressure relief for sacrum, greater trochanter, ischial tuberosity and heels Position of ease / comfort for sleep when pregnant	Pillow for comfort underneath the head Pillow under the upper arm to minimise internal rotation
Prone Position	Lie on abdomen with head turned to one side and hips not flexed. Figure.6 Prone Position	Helps prevent and manage hip and knee flexion contractures Improves blood oxygenation Offloads and manages pressure injury Drainage of secretions	Pillow for comfort under the head and abdomen. Face cut out on treatment surface / plinth. Rotaprone bed
Fowler’s Positions (Semi-sitting or Semi-recumbant)	High Fowler's; Head of bed almost vertical	Fowler's and High Fowler's facilitate swallowing and reduce aspiration Promotes lung expansion Reduces venous return Improves tolerance of upright position Reduces intracranial pressure Reduces intraocular pressure Reduces gastroesophageal reflux Optimal for patients with a nasogastric tube Useful for cardiac, respiratory, or neurological impairments to improve upright tolerance after prolonged bedrest	Profiling bed or wedge to elevate upper body Pillows to offload extremities Foot board to minimise prolonged plantarflexion and minimise sliding down
	Fowler's; Head of bed elevated to 45° to 60° Figure.7 Fowler's Position
	Semi-Fowler’s; Head of bed elevated to 30° to 45 ° Figure.8 Semi Fowler's Position
	Low Fowler’s; Head of bed elevated to 15° to 30°
Standing	Body held in erect position. Shoulders, hips and feet aligned with weight supported by the feet.	Improve tolerance of upright position Increase lower limb weight bearing Promote increased bone density	Tilt table Standers Orthotics Body weight support systems

Figure.7 Patient Positions

Figure.8 Patient Positions

Principles of Positioning

The following positioning principles should be considered in relation to the short‐ and long‐term goals of rehabilitation and management for each patient.

1. Individualised Assessment. Each patient has unique needs and preferences. Conducting an individualised assessment and considering a patient's medical condition, mobility limitations, and comfort preferences are essential for dignified and respectful positioning care.
   • Define the patient’s functional impairments and abilities as related to positioning
     • Does the patient have the appropriate muscle length to comfortably maintain the desired position?
     • Does the patient have the cognitive ability to safely remain in the position?
     • Can the patient tolerate the position due to cardiopulmonary needs?
   • Identify risk factors from the proposed positioning
     • Including impaired sensation, sources of pressure or skin tears, risk of falls, increase in pain, or patient safety awareness
   • Determine how much support and level of assistance your patient requires for positioning
     • Independent
       • Patient is able to re-position independently and safely
     • Supervision
       • Patient requires no physical assistance but may require verbal reminders
     • Minimal Assistance
       • Patient is cooperative and reliable but needs some minimal physical assistance with positioning
       • Is able to perform 75% of the required activity on their own
       • Typically requires only one person
     • Moderate Assistance
       • Patient requires moderate physical assistance
       • Is able to perform 50% of the required activity on their own
       • Typically requires two people
       • May require equipment to assist with positioning
     • Maximal Assistance
       • Patient requires full physical assistance for re-positioning
       • Is able to perform 0-25% of the required activity on their own
       • May be unpredictable and uncooperative
       • Requires equipment to assist with positioning
   • Reassessment after each positioning intervention
     • Did the positioning achieve the desired result?
     • Were there any negative / adverse outcomes? e.g. the development of pressure areas
2. Determine Purpose for the Positioning. Why is this positioning being used with this patient? Is it for accurate examination performance, to achieve a specific therapeutic effect or as a preventive measure? 
3. Collaboration and Communication. Engaging patients in the positioning process by seeking their input and involving them in decision-making empowers them and promotes respect. Clear and compassionate communication enhances patient understanding, cooperation and tolerance of positioning.
4. Adequate Support and Equipment. Utilising appropriate support surfaces (e.g., pressure-reducing mattresses, cushions) and assistive devices (e.g., bed rails, pillows) ensures proper alignment, comfort, and safety during positioning manoeuvres.
5. Body Mechanics. Observe good body mechanics and follow moving and handling principles for your and your patient’s safety.
6. Training and Education. Rehabilitation professionals should receive comprehensive training on proper positioning techniques and share their knowledge as experts on body alignment and mobility with other rehabilitation professionals, their patient and support persons on why the positioning is being used.
7. Regular Repositioning. Patients should be repositioned frequently to relieve pressure and promote blood circulation. Implementing a repositioning schedule based on the patient's tolerance and healthcare guidelines helps maintain dignity while preventing complications.
8. Document. All positions can be detrimental to the patient if maintained for a long period of time. Document the level of assistance required, assistive devices used and any safety precautions taken, especially if the patient is left in a position after your treatment session. For example, document that patient’s call bell was left in reach, any hand-off / handover communication with the next treating rehabilitation professional, including the timeframe for when repositioning is due.

Summary

• Positioning is a useful multidisciplinary therapeutic tool that can be individualised to a patient’s unique needs, preferences and limitations.
• Evidence-based findings suggest that positioning can significantly impact a patient's comfort and rest.
• The timing and frequency of position changes may be important considerations.
• The ue of pressure-relieving surfaces may further enhance patient comfort and prevent pressure ulcers.
• Through individualised assessments, regular repositioning, collaborative communication, and adequate support, healthcare settings can foster an environment that upholds the principles of dignity and respect. Regular evaluation of the effectiveness of the positioning strategy is essential to ensure that the desired goals are being achieved.