Positioning

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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. 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 of the movement as they can themselves.

Table.1 Purpose of Positioning

Purpose	Indications
Comfort or Rest	Pain Management
	Energy Conservation
Limb Management/Protection	Injury Prevention
	Prevent further damage to an affected limb Function, Sensory, Neglect
Postural Alignment for Optimal Function	Contracture Management
	Eating, Feeding and Swallowing
	Vocalisation
	Personal Hygiene
	ADL's
	Positional Tolerance
Improve Sensory Input	Increase Arousal
	Orientation to Upright
	Orientation for Reference Point for Movement
Offloading	Pressure Ulcers
	Wounds
Improve Circulation	Edema Management
	Prevention / Healing of Pressure Ulcers
Improve Respiration	Postural Drainage
	Positions of Ease
	Positioning for COPD, Cardiac Conditions, Spinal Cord Injury etc.
Improrove Psychological Well-being	Self-esteem
Maintain Patient Dignity and Privacy	In surgery or during physical assessment Minimise exposure of the patient
Allow Maximum Visibility and Access	In surgery or during physical assessment adequate exposure of part of body to be examined

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;

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 Positioning
   • 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)
3. Reverse Trendelenburg Positioning
   • Contraindication
     • Hypotension
     • Vasoactive Medication

Clinical Considerations

• Baseline Posture
  • 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.  This principle should be applied during any positioning.
  • A postural assessment is necessary when evaluating a patient for a therapeutic positioning.  Common abnormal postures to be considered when planning therapeutic positioning interventions include: 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,
• Orthopaedic Considerations
  • Weightbearing Status
    • for lower or upper extremity: this is important for patients who assist in their repositioning to limit or avoid WB through the involved extremity.
  • 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
  • Transtibial/Below Knee Amputation
    • Avoid shortening of hip and knee flexors
  • Transfemoral/Above Knee Amputation
    • Avoid shortening of hip flexors, 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
    • Following Spinal Surgery - Avoid forward flexion, maintain shoulders and hip alignment with no rotation. 
    • Following Cervical Surgery - Avoid pillow under head or neck to prevent forward flexion of cervical spine.
    • Spinal Bracing - If required, be aware of amount of bed elevation allowed before the brace must be applied - ensure regular pressure checks as brace can act as a source of pressure.
  • External Fixation
    • Bulky and Heavy - Impact Independent Positioning
    • Oedema Management - Require Elevation
• Neurological Considerations
  • Tone
    • Spasticity - Can limit positions available for therapeutic interventions secondary reduced ROM or tonal fluctuations
    • Flaccidity - Increased subluxation risk with improper positioning and require assistance with repositioning
    • Splints - Support tone management or extremity protection with proper alignment but can be source of pressure
  • Cognition
    • Can the patient understand the purpose behind the therapeutic positioning? 
    • Do they know when to call for assistance? 
    • Are they safe to be left in a specific position?
  • Sensation
    • Has the patient got impaired sensation? If so may not be able to feel the effects of prolonged immobilisation
• 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
  • Odema Management
    • Depending on the level of edema present, edematous limbs will require elevation – ideally above the level of the heart.  This needs to be taken into consideration when prioritizing other therapeutic positioning interventions.
• Mobility
  • Can the patient assist in their positioning, or will one or more staff members be required to assist? 
  • Will the patient be able to perform adequate pressure relief independently? 
  • Can they reach the call bell to call for assistance?

Assistive Devices for Positioning

An assistive device is an object or piece of equipment designed to help a patient with activities of daily living, such as a walker, cane, gait belt, or mechanical lift. Assistive devices also allow the the healthcare worker to position and move patients in a way that reduces risk for injury to themselves and patients. Table 2 lists some of the assistive devices found in the hospital and community settings that can be used to help with patient positioning.

Table.2 Assistive Technology Devices to Support Positioning

Device	Purpose
Towels	Towels are easy to obtain, easily washed to maintain good hygiene and can be folded for many purposes. May be used to provide support for a range of body parts to minimise strain on limbs.
Pillows	Pillows provide support, elevate body parts and splint incision areas, and reduce postoperative pain during activity, coughing, or deep breathing. They should be of the appropriate size for the body to be positioned.
Cushions	Cushions provide comfort, pressure relief and offloading, provide postural support to assist patient with optimal positioning and compensate for any deformations. There are a range of classification systems developed to describe cushions that provide useful information in relation to construction materials, different functions of the cushions and their ability to prevent pressure injuries.
Wedges	Positioning wedges provides essential support to keep patients safe and comfortable in bed. They can provide back and side support, help to alleviate pressure and prevent slipping down the bed. In paediatrics wedges are frequently used to support prone positioning to help promote cervical extension and use their arms for play.
Trochanter Roll	Trochanter roll refers to a cylindrical prop such as a rolled-up towel, foam roll, cylindrical cushionpillow, or rolled-up blanket, which is used to prevent external rotation of the hips when a patient is in a supine position.
Hand Rolls	Hand rolls maintain the fingers in a slightly flexed and functional position and keep the thumb slightly adducted in opposition to the fingers to minimise the risk of flexion contractures and reduce skin breakdown. Hand rolls made from face cloths can be easily washed to maintain good hygiene.
Splints	A splint is a rigid support made from metal, plaster, or plastic. It's used to protect , support, or immobilize an injured or inflamed part of the body. A splint can be a generic model or cutom fit to support a specific limb to maintain is optimal alignment
Side Rails	Side rails are bars along the sides of the length of the bed. They ensure patient safety and are useful for increased bed mobility. They can assist with rolling from side to side or sitting in bed.
Trapeze	A trapeze positioned above the patient near the head of the bed allows the patient to grasp and reposition themselves or to help with re-positioning. These can be fixed to the bed or free standing. They are contraindicated in some situations including new spinal cord injury, post abdominal surgery, and shoulder conditions.
Slide Sheets	Nylon sheets used under the patient to help reduce friction during patient repositioning.
Abdominal Binder	Abdominal binders are elasticated binders typically used when reintroducing patients to the vertical position and are associated with a significant reduction of orthostatic hypotension. Commonly used during tilt tabling the binder works by reducing splanchnic venous pooling under orthostatic stress.
Specialised Beds	There are a wide range of specialised beds which can support patient positioning including profiling beds that allow the patient to be positioned in a wide range of position. The roto rest bed provides continuous, slow, side-to-side turning of the patient by rotating the bed frame. Keeping the patient in maximal rotation assists with prevention of skin breakdown and provides the most effective therapy for pulmonary indications.
Sleep Systems	Sleep systems are prescribed postural support systems used in lying that contain components, held in place using a base or sheet, forming part of a 24h posture management programmes, for children and adults with severe motor disorders and neurological conditions. Improved posture reduces the likelihood of secondary complications such as contractures, pain and poor sleep quality, thus improving quality of life.
Tilt Tables	Tilt tables are commonly used in intensive care and rehabilitation settings as a technique to minimise the adverse effects of prolonged immobilisation such as orthostatic hypotension, reduced oxygen consumption, venous pooling, reduced lung volumes, impaired gas exchange, muscle atrophy, joint contractures, peripheral nerve injuries, and pressure areas and to reintroduce patients to the vertical position. Benefits of tilting include increased ventilation, increased arousal, improved weight bearing of the lower limbs, and facilitation of antigravity exercise of the limbs.
Adaptive Seating	Specialist seating is a tool which offers continuous posture management and enables a patient to receive a maximum quality of life. A commonly used intervention to enhance head and trunk stability for optimal positioning. The use of adaptive seating can help develop motor skills, facilitate arm and hand mobility, self-feeding, visual scanning and tracking and reduce the need for assistance from caregivers. Studies have shown that individuals using adaptive seating often have positive experiences, including increased performance of activities of daily living and social interaction.
Wheelchair	A wheelchair provides both wheeled mobility and seating support for a person with difficulty in walking or moving about. The aim of wheelchair design is to provide appropriate seating and postural support without compromising strength, durability and safety. Design features must be matched to the user`s functional ability and posture support needs, and also to the environmental and durability requirements.

Principles of Positioning

A patient should never be placed in a static position, which can cause them harm or pain. 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. Regular reassessment is necessary to allow for modification of plans to reflect changes in status.

Determine Purpose for the Positioning:

• Why is this positioning being used with this patient? 
  • For accurate examination performance? e.g. measuring muscle strength or length
  • To achieve a specific therapeutic effect? e.g. improving upright tolerance or postural drainage.  
  • As a preventive measure? e.g. contracture prevention
• Prioritise positioning to focus on areas of greatest concern.

Assessment for Positioning:

• To 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.
• To determine level of assistance required: How much support does your patient need 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
• To determine type of assistive devices required
  • Use of positioning aids can help maintain the desired position while providing comfort for the patient. 
  • Positioning aids can include pillows, rolled up towels, splints, cushions, sliding sheets, hoist, and slings or speciality equipment that can facilitate the ease of changing positions.
• Reassessment after each positioning intervention
  • Did the positioning achieve the desired result?
  • Were there any negative outcomes? e.g. development of pressure areas

Document: Any correct or incorrect position 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.

Educate; Rehabilitation professionals are experts on body alignment and mobility, share that knowledge with the patient, their family/representatives, and other members of the multidisciplinary team on why the positioning is being used. Other members of the MDT may find that their treatments are more effective when performed while the patient is in the therapeutic position. For example, a patient could produce improved vocalization and have an increased level of arousal and focus with speech therapy when in a seated upright position as compared to supine in bed. 

Communication; Explain to the client why their position is being changed and how it will be done. Rapport with the patient will make them more likely to maintain the new position.

Encourage Patient Assistance; Promote patient assistance during positioning as able. This will help increase patients independence and self-esteem.

Body Mechanics: Observe good body mechanics for your and your patient’s safety. Avoid twisting your back, neck, and pelvis by keeping them aligned, flex your knees and keep a wide stance and use your arms and legs and not just your back. The person with the heaviest load should coordinate and initiate the positioning.

Conclusion

Positioning is a useful therapeutic tool that can 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.

References