Positioning

Welcome to Understanding Basic Rehabilitation Techniques Content Development Project. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!! If you would like to get involved in this project and earn accreditation for your contributions, please get in touch!

Original Editors - Naomi O'Reilly and Stacey Schiurring

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

Introduction

Moving and positioning lie within the broader context of manual handling and is a key aspect of patient care. Optimum positioning is a good starting point to maximise the benefit of other interventions, such as bed exercises and breathing exercises; it can also assist rest and mobility, thereby facilitating recovery, enhancing function and preventing secondary complications. However, although it is important, it must not be seen in isolation and is just one aspect of patient management where the overall goal is to optimise independence.

In medical terms, ‘position’ relates to body position or posture, thus positioning involves placing the patient into a specific static alignment, which can involve their entire body, or just a single body part or limb, which involves patient handling, transporting or supporting a load (i.e., lifting, lowering, pushing, pulling, carrying or moving) by using hands, bodily force and/or mechanical devices. Positioning can be achieved either;

• actively by the patient, meaning they are able to move under their own volition, or
• passively, where the patient is placed into a specific position with assistance of one or more other persons. 

A major challenge to positioning is trying to place a dynamic body into a prolonged static position. The human body was made for movement, it does not tolerate prolonged periods of immobilisation well. This means the positioning must be comfortable and allow the patient to reposition as needed, while maintaining the purpose behind the positioning. It is essential to frequently evaluate the effect that positioning is having on the individual to ensure that the intervention is helping to achieve the desired result or goal. Consider whether the positioning procedure is being clinically effective and, where possible, is evidence based.

Purpose

The purpose and indications for therapeutic positioning vary depending on the patient population being treated, but 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 themselves where possible, but where assistance is required they should to do as much of the movement as they can themselves.

Comfort and Rest

Several studies have investigated the effect of different positioning strategies on patient comfort and rest. Lateral positioning with a pillow between the legs was more comfortable than semi-fowler positioning with a pillow under the knees in postoperative patients (Lemos et al. (2015)), with use of pressure-relieving surfaces, such as low-air-loss mattresses and alternating pressure mattresses, associated with improved comfort and rest. (Martins et al. (2016) found that the Positioning is also considered an essential component of pain management, which can help alleviate the intensity and severity of pain. Prone position was found to be more effective in reducing pain and disability caused by low back pain than the supine position , while positioning as part of a multi modal pain management program showed reduced usage of opioid medication. Use of appropriate positioning devices, such as orthopedic cushions or pressure-relieving supports, can alleviate discomfort, enhance relaxation, and positively influence psychological states. Finally, patient-specific factors should also be considered when choosing a positioning strategy with tailored protocols, based on individual patient needs, patient preferences, underlying condition and severity of pain as identified by resulting in a significant improvement in both comfort, rest and pain, which highlights the importance of individualised positioning plans. Boschetti and colleagues (2018)

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 functional independence. Regular repositioning, combined with adequate support, can help manage postural alignment and minimise the progression of contractures. Studies have shown that dynamic positioning interventions, such as tilt-in-space wheelchairs or adjustable beds, can effectively reduce the severity of contractures. Collaborative goal setting and regular re-evaluation of the positioning plan are essential for effective contracture management. Communication and coordination among team members are critical for optimal positioning and contracture management outcomes.

Positioning also plays a crucial role in improving activities of daily living (ADLs), such as feeding, vocalization, and personal hygiene and can enhance functional independence. Supporting an upright or slightly reclined position can facilitate safe swallowing and reduce the risk of aspiration pneumonia and optimise respiratory support and airflow, enhancing vocal quality and volume. Adaptive equipment can enhance postural stability, reduce fatigue, and promote efficient feeding, facilitate speech production and can enhance safety and facilitate accessible personal hygiene routines.

Offloading

Turan and colleagues (2013) compared the effect of supine positioning with a foam wedge under the knees to semi-fowler positioning with a foam wedge under the hips in critically ill patients. They found that the semi-fowler position was more effective for offloading and reduced the incidence of pressure injuries. Martins et al. (2016) examined the effect of different surfaces on pressure injury incidence found that the use of pressure-relieving surfaces, such as low-air-loss mattresses and alternating pressure mattresses, was associated with improved offloading and reduced pressure injury incidence.

Improve Circulation

Positioning can be an essential aspect of patient care to improve circulation, reduce edema, and prevent the development of skin breakdown and pressure injury. Proper positioning strategies aim to elevate and support the limbs to promote blood flow and prevent the accumulation of fluid. Elevating the heels using offloading devices was the most effective approach to improve circulation and reduce edema in the lower limbs, while elevation therapy had statistically significantly greater reductions in edema at 4, 8, and 12 weeks than standard care in patients with venous leg ulcers. Furthermore, proper positioning can be an essential aspect of preventing and managing lymphedema with evidence that positioning the limbs in a dependent position resulted in greater reductions in limb volume than elevation therapy in patients with breast cancer-related lymphedema.

Improve Respiration

Several studies have investigated the effect of different positioning strategies on respiratory function. Li et al found that lateral positioning with 45-degree elevation of the upper body and a 30-degree elevation of the leg was more effective in improving venous oxygen saturation and reducing incidence of hypoxemia than supine positioning in critically ill patients. Similarly semi-recumbent positioning improved oxygenation, reduced the incidence of hypoxemia, and increased lung volume when compared to supine positioning in patients undergoing mechanical ventilation. In addition to the specific position, the timing of position changes has also been shown to impact respiratory function with frequent changes in position shown to be more effective in improving oxygenation and reducing the incidence of hypoxemia than static positioning in critically ill patients.Again patient-specific factors should also be considered with significant improvements in oxygenation and respiratory mechanics shown with individualised positioning based on the severity and location of lung injury in patients with acute respiratory distress syndrome (ARDS). Postural drainage is a positioning technique to mobilise bronchial secretions involving the positioning of a patient with an involved lung segment such that gravity has a maximal effect of facilitating the drainage of broncho-pulmonary secretions from the tracheo-bronchial tree, based on the concept of gravity-assisted mobilisation of secretions to improve respiration.

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 has been shown to significantly improve postural control and stability, leading to enhanced sensory processing.Research suggests that maintaining an upright posture, with appropriate head and trunk alignment, can promote increased alertness.

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 that individuals who use assistive devices experience increased independence and a sense of control over their environment, leading to enhanced self-esteem and overall psychological well-being. These devices also promote social engagement, reduce feelings of isolation, and enhance overall mental health and well-being. Evidence also shows that being in an upright position can enhance alertness, attention, and mood, leading to improved psychological well-being.

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 involving the patient and promoting patient involvement can help alleviate these negative emotions and enhance the patient's sense of dignity and self-worth.

Contraindications

There are no general contraindications for positioning; however, some positions are contraindicated for specific conditions or situations, most typically 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, Hemorrhagic Shock, Massive Haemoptysis) Raised intracranial pressure >30 mmHg or cerebral perfusion pressure <60 mmHg Tracheal Surgery or Sternotomy within two weeks	Contraindications Intracranial Pressure (ICP) > 20 mm Hg Patients in whom 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		3rd column 3rd row

Clinical Considerations

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 is able to maintain balance during dynamic and static movements, which should provide maximum stability with minimal energy consumption and stress on the body, which is fundamental to any positioning strategy. .Postural assessment is necessary prior to therapeutic positioning taking into consideration abnormal postures including: forward head, kyphosis, lordosis, scoliosis, and pelvic malalignments such as windswept hips.

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 development of pressure injuries thus prevention is the best intervention, particularly in patients who have difficulty repositioning themselves. Prioritise positioning to focus on areas of greatest concern.

Orthopaedic Considerations

Orthopaedic considerations for patient positioning play a significant role in achieving successful surgical outcomes and minimising complications.

Weightbearing Status; The weightbearing status of a patient can significantly impact the positioning considerations. Patients who are non-weightbearing 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 Arthroplasy; In supine, a pillow or roll should not be placed under the surgical knee. Evidence does suggest use of inactive 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. Weightbearing through the surgical knee, such as in kneeling, should be avoided until the incision line is well healed and pain controlled.

Total 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, although current evidence does not support the routine use of these hip precautions for patients status 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, 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, helps manage oedema. To minimise the risk of contractures in Transtibial/Below Knee Amputation avoid shortening of hip and knee flexors, while with Transfemoral/Above Knee Amputation you also need to avoid shortening hip abductors, and external rotation

Sternal Precautions; Following open heart surgery: Avoid shoulder flexion above 90 degrees, shoulder external rotation beyond neutral, and shoulder abduction past 90 degrees.  If patient able to 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 risk of further injury after spinal surgery, spinal trauma, or suspected spinal instability. Restrictions in forward flexion following spinal surgery limit 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 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 and 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.

Neurological Considerations

Tone; Spasticity can limit positions secondary to reduced range of motion or tonal fluctuations, while flaccid tone can increase risk of subluxation risk with improper positioning. Splints can support tone management or extremity protection but monitor pressure.

Cognition; Attention, comprehension, and memory, play a crucial role in patient's ability to understand and follow positioning instructions. Consider whether the patient can ,understand the positioning, know when to call for assistance and are safe for a specific position.

Sensation; Directly affects a patient's ability to sense and communicate discomfort or pain. With impaired sensation, may not be able to provide accurate feedback on their comfort level.

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.

Pacemaker Precautions; To protect the newly implanted device, which has leads interacting with cardiac tissue are the same for sternal precautions with the additional precaution of limiting reaching behind the patient’s back such as a movement like fastening a bra strap.

Circulation Considerations

Oedema Management; Typically oedematous limbs will require elevation, ideally above the level of the heart, which should be considered when prioritising other therapeutic positioning interventions.

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's important to assess an individual's mobility level, consider their specific mobility challenges, to develop a comprehensive positioning plan that promotes mobility, safety, and overall functional independence.

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 the healthcare worker to position and move patients in a way that reduces 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. You can read more detail about the wide range of assistive devices available to support patient positioning here.

Overview of Patient Positions

{| width="800" border="1" cellpadding="1" cellspacing="1"

|-

! scope="col" | 1st Column Heading

! scope="col" | 2nd Column Heading

! scope="col" | 3rd Column Heading

! scope="col" | 4th Column Heading

|-

| 1st column 2nd row

| 2nd column 2nd row

| 3rd column 2nd row  

| 4th column 2nd row

|-

| 1st column 3rd row

| 2nd column 3rd row

| 3rd column 3rd row  

| 4th column 3rd row

|-

| 1st column 4th row

| 2nd column 4th row

| 3rd column 4th row  

| 4th column 4th row

|-

|}

Principles of Positioning

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

Individualised Assessment: Each patient has unique needs and preferences. Conducting an individualised assessment, considering patient's medical condition, mobility limitations, and comfort preferences, is essential for providing dignified and respectful positioning care.

• Define the patient’s functional impairments and abilities as related to positioning.
  • Does the patient have appropriate muscle length to comfortably maintain the desired position? 
  • Does the patient have the cognitive ability to safety remain in the position? 
  • Can the patient tolerate the position due to cardiopulmonary needs?

• Identify Risk Factors from 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 outcomes? e.g. development of pressure areas

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.

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? 

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's understanding, cooperation and tolerance of positioning.

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.

Body Mechanics: Observe good body mechanics and follow moving and handling principles for your and your patient’s safety.

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 structures on why the positioning is being used

Document: All positions can be detrimental to the patient if maintained for a long period of time. Document level of assistance required, assistive devices used, any safety precautions taken, especially if the patient is left in a position after your treatment session, for example: patient’s call bell was left in reach, hand-off communication with next treating rehabilitation professional including timeframe for when repositioning is due.

Conclusion

Positioning is a useful multidisciplinary therapeutic tool that can be individualised to a patient’s unique needs and limitations. In summary, evidence-based findings suggest that positioning can significantly impact a patient's comfort and rest. The choice of position should be individualised to the patient's needs and preferences, and the timing and frequency of position changes may be important considerations. Use of pressure-relieving surfaces may further enhance their 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.

References