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. Positioning 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.  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 of Positioning

The purpose and indications for therapeutic positioning vary depending on the patient population being treated. Positioning is 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 as the movement they can themselves..

Needless to say, there are many justifiable reasons to use positioning as part of a rehabilitation plan of care. 

1. Positioning for Comfort or Rest
   • Pain Management;
   • Energy Conservation
2. Limb Management/Protection
   • Injury Prevention
   • Prevent further damage to an affected limb
     • Function, Sensory, Neglect
3. Improve or Normalise Postural Alignment for Optimal Function
   • Contracture Management
   • Modify Muscle Tone
   • Eating, Feeding and Swallowing
   • Vocalisation
   • Personal Hygiene
   • ADL's
   • Positional Tolerance
4. Improve Sensory Input, Awareness and/or Arousal
   1. Orientation to Upright
   2. Orientation for Reference Point for Movement
5. Offloading
   • Wounds
6. Improve Circulation
   1. Edema Management
   2. Prevention / Healing of Pressure Ulcers
7. Improve Respiration
   1. Postural Drainage
   2. Positioning for COPD, Cardiac Conditions, Spinal Cord Injury etc.
8. Improve/Protect Self esteem and Psychological Well-being
9. Maintain Patient Dignity and Privacy
   • In surgery or during physical assessment minimise exposure of the patient
10. Allow Maximum Visibility and Access
    1. In surgery or during physical assessment surgical access

Contraindications

There are no general contraindications for positioning; however, some specific positions are contraindicated for specific conditions, most typically seen within hospital settings, particularly in Intensive Care or post surgical wards ;

1. Prone Positioning;
   • 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
   • Relative Contraindication
     • Raised Intracranial Pressure >30 mmHg or Cerebral Perfusion Pressure <60 mmHg
     • Haemodynamic Instability
     • Unstable Pelvic or Long Bone Fractures
     • Open Abdominal Wounds
2. Trendelenburg Position;
   • 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)

1. Reverse Trendelenburg Position;

• • Hypotension
  • Vasoactive Medication

Clinical Considerations

1. Baseline Posture
2. Sources of Pressure
3. Orthopaedic Considerations
4. Neurological Considerations
5. Cardiorespiratory Considerations
6. Circulation Considerations
7. Mobility

Principles of Positioning

When approaching any therapeutic intervention, it is important to fully assess your patient before proceeding with therapeutic positioning. A patient should never be placed in a static position which will cause them harm or pain. The main principles underpinning all interventions involving patient positioning should focus on their short‐ and long‐term goals of rehabilitation and management for each specific patient. It is imperative that a thorough assessment is carried out prior to any intervention in order to plan appropriate goals of treatment. Wherever possible, goal setting should be a joint patient and healthcare professional discussion. It may be necessary to compromise on one principle, depending on the overall goal.

Regular reassessment is necessary to allow for modification of plans to reflect changes in status. Communication and involvement of the multidisciplinary team will assist rehabilitation interventions as treatment can be incorporated during positional changes. This potentially allows an opportunity for multip-rofessional working and allows many individuals to act with a common purpose and with co‐ordinated activity.

Common Positions

Conclusion

Positioning is a useful therapeutic tool that c an be individualised to a patient’s unique needs and limitations.  It is a natural continuation of the assessment skills you have reviewed in previous courses.  While positioning can appear simple and straightforward at the surface, I hope this course has provided some insight into the skill and mindfulness that goes into effective and safe positioning.

Resources

References