Stroke: Positioning

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Introduction

The aim of positioning the patient is to try to promote optimal recovery by modulating muscle tone, providing appropriate sensory information, increasing spatial awareness and prevention of complications such as pressure sores, contracture, pain, respiratory problems and assist safer eating.

Correct positioning can help to reduce the risk of;
• Aspiration
• Contracture
• Pressure Areas
• Shoulder Pain
• Swelling of the Extremities

Aims of Positioning

• Patient Comfort
• Provide Support to Weak and Unstable Body Segments
• Increased Stimulation to Affected Side
• Increased Spatial Awareness
• Improved Ability to Interact with the Environment

Who is Responsible

Who is Responsible?
• All members of the MDT
• Nursing Staff play key role in ensuring 24 Hour Adherence

Types of Positioning

The most appropriate position in which to place a patient following a stroke remains unclear. There is no RCT evidence to support the recommendation of any one position over another but five main positions have been recommened, a survey of physiotherapists’ current positioning practices found the most commonly recommended positions to be: sitting in an armchair as recommended by 98% of respondents; side lying on the unaffected side then side lying on the affected side. Sitting in a wheelchair (78%, 95% CI 74 to 82%) and supine lying were less commonly recommended. 

Sitting in a Chair or Sitting in a Wheelchair 

(98% CI 97 to 100%) or (78%, 95% CI 74 to 82%)

It is vital that as soon as the person is capable of sitting out that they are facilitated to do so. Sitting out is essential to build up tolerance; provide maximum stimulation; give a sense of normality.
• Head over Pelvis
• Hips at 90 degrees
• Knees at 90 degrees
• Slight extension of lumber region
• Feet in neutral position and supported
• Weight evenly distributed between both buttocks
• Arm should be protracted forward and supported

Side Lying on the Unaffected Side

(97%, 95% CI 95 to 98%)

One or two pillows for head.
Affected arm forward and supported on pillow
Affected leg backwards on one or two pillows
Place pillow behind.

Side Lying on the Affected Side

(92%, 95% CI 89 to 95%)

One or two pillows for head
Affected shoulder positioned comfortably
Place unaffected leg forward on one or two pillows
Place pillows in front or behind to give support

Lying Supine

(67%, 95% CI 63 to 72%)

Place three pillows in a ‘triangle’, supporting shoulders and head
Place affected arm on pillow
Ensure feet in a neutral position

Sitting up in Bed

• Sitting in bed is desirable for short periods only
• Must be upright and well supported with pillows
• Consider extra support using pillows under arms or knees

Sitting v Lying....

What are the differences?
• When seated, nearly half of the body weight is supported on 8% of the sitting areas at or near the ischial tuberosities (Crow,1988)
• Therefore, interface pressures are much higher in sitting than lying.

Distribution of Weight when Seated Normally

Buttocks & Thighs 75%
Feet flat on floor 19%
Back 4%
Arms 2%
Total 100%

Pressure Relief

• A person who has had a stroke may be susceptible to developing pressure sores
• Assess the person and decide on an appropriate cushiono use in order to:
  Prevent further skin breakdown,
  To assist with healing
  To facilitate the patient to sit out as much as possible

References

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