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.[1][2][3]

Correct positioning can help to reduce the risk of;

  • Aspiration
  • Contracture [2][1]
  • Pressure Areas
  • Shoulder Pain [1]
  • Swelling of the Extremities

Aims of Positioning

  • Normalise Tone or Decrease Abnormal influence on the Body
  • Maintain Skeletal Alignment
  • Prevent, Accommodate or Correct Skeletal Deformity
  • Provide Stable Base of Support 
  • Promote Increased Tolerance of Desired Position
  • Increased Stimulation to Affected Side 
  • Increased Spatial Awareness 
  • Promote Patient Comfort 
  • Facilitate Normal Movement Patterns
  • Control Abnormal Movement Patterns
  • Manage Pressure
  • Decrease Fatigue
  • Enhance Autonomic Nervous System Function (Cardiac, Digestive and Respiratory Runction)
  • Facilitate Maximum Function
  • Improved Ability to Interact with the Environment [4][5]

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. [5][3]

Sitting in a Chair or Sitting in a Wheelchair 

(98% CI 97 to 100%) or (78%, 95% CI 74 to 82%)[5]

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%)[5]

  • The stroke arm should be well forward, keeping the elbow straight and supported on a pillow.
  • The stroke leg should be brought far enough in front of the body to prevent the patient rolling on to the back, the knee bent and leg supported on a pillow.
  • A small pillow can then be placed under the patient's waist to maintain the the line of the spine.
  • When lying on the side position, the patient should have two pillows only under the head.    

Side Lying on the Affected Side

(92%, 95% CI 89 to 95%)[5]

  • This should always be encouraged with the stroke shoulder well forward so that the body weight is supported on the flat of the shoulder blade and not on the point of the shoulder.
  • One or two pillows for head
  • Place the stroke leg with the thigh so that it is in line with the trunk, and bend the knee slightly.
  • The unaffected leg should be brought forward and placed with the knee bent on a pillow in front of the affected leg for comfort. This prevents the patient rolling onto his back.
  • Lastly, bend the head forward a little.    

Lying Supine

(67%, 95% CI 63 to 72%)[5]

  • This is the position most likely to encourage spasticity, but some patients do like to lie on their back for a while and it will be required for some treatments.
  • Place two pillows under the patient's head and help him/her bend their head slightly towards their unaffected shoulder and gently turn their head towards their stroke side but do not uses force.
  • A small pillow is placed under the buttock of the stroke side and should extend just to the knee, this will relax the leg and prevent it turning out at the hip.
  • A pillow is placed under the stroke arm which is kept straight at the elbow and if possible, the palms of the hand facing upwards.
  • The bed must be the correct height to promote independence and safety for the patient, family and health care workers.    

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 cushion use in order to

  • Prevent further skin breakdown,
  • To assist with healing
  • To facilitate the patient to sit out as much as possible

References

  1. 1.0 1.1 1.2 Ada L., Goddard E., McCully J., & Bampton J. (2005). Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 86(2): 230-34.
  2. 2.0 2.1 De Jong L.D., Nieuwboer A., & Aufdemkampe, G. (2006). Contracture preventive positioning of the hemiplegic arm in subacute stroke patients: a pilot randomized controlled trial. Clinical Rehabilitation, 20: 656-667.
  3. 3.0 3.1 Mee L.Y., & Bee W.H. (2007). A comparison study on nurses’ and therapists’ perception on the positioning of stroke patients in Singapore General Hospital. International Journal of Nursing Practice, 13(4): 209-21.
  4. Jones M & Gray S (2005) Assistive technology: positioning and mobility. In SK Effgen (Ed) Meeting the Physical Therapy Needs of Children. Philadelphia: FA Davis Company.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Chatterton H.J., Pomeroy V.M., & Gratton, J. (2001). Positioning for stroke patients: a survey of physiotherapists aims and practices. Disability and Rehabilitation, 23(10), 413-421.