There are many reasons why positioning needs should be considered for those with brain injury who have physical impairments or altered sensation. These may include safety, health and physical reasons and quality of life considerations.
Safety should be the first priority when considering positioning needs. There are a variety of difficulties which may affect the person’s safety. For example:
- Restlessness and agitation. The person who is constantly moving around may wriggle out of or to the edge of a chair or bed.
- Spasticity. The person who experiences spasticity and associated involuntary spasms may struggle to maintain a safe position in a standard chair as they may slide forward and potentially be at risk of a fall.
- Cognitive impairments may affect safety if the person tries to get out of the chair or bed and walk yet is unable to do so safely.
Comfort
Comfort is important as discomfort may cause increased tone and spasms. The person’s position should be changed regularly to maintain comfort. None of us sit in the same position for any length of time, as it’s not comfortable. Comfort helps the person to maintain a good and safe position.
Skin Care/Pressure
The person with physical impairment is at risk of developing pressure ulcers due to restricted mobility, reduced sensation, incontinence, compromised nutrition etc. It is therefore essential to be aware of the patient’s skin condition and monitor potential pressure areas. A good position will minimise pressure and shearing forces, through maximising the base of support and increasing stability. Equipment should be chosen carefully to meet individual needs. Regularly altering the person’s position, even if only by a small amount, can help to reduce the risk of pressure ulcers. For example, using wheelchairs with a variable tilt mechanism, allows small changes to be made alleviating pressure points.
Muscle Tone
It is important to minimise abnormal tone (e.g. spasticity, hypotonus) through good positioning. Both high and low tone can affect postural control and necessitate postural support. With abnormal tone the overall aim is to provide support whilst inhibiting the development of spasticity. Tone may be affected by discomfort and can influence safe positioning. A variety of positions with good joint alignment may help to prevent secondary contractures. For example, changing the position of upper limbs (e.g. using a pillow and table to support the arm) will help to maintain range of movement at the joint and prevent muscle shortening related to changes in muscle tone.
Joint Protection
Abnormal tone may make the person’s joints more susceptible to trauma. Shoulders are the most common joints to be traumatised and/or painful and therefore must be adequately supported at all times. Care should be taken to avoid stretching of the tissues of the joint which can be caused by an unsupported, heavy arm (i.e. paralysed arm). This can be achieved by ensuring adequate support at the elbow.
Perception
Lack of consideration of a person’s positioning may impact on existing visual and perceptual impairments . For instance, if a person has a body scheme disorder (i.e. inability to recognise parts of their body, or identify left and right parts of their body) use of pillows to support an arm could hide parts of the person’s body, further compounding the perceptual problem. If, however, a clear perspex tray was used for support this would allow a better view of the whole body. The person’s position in relation to their environment should also be considered with those with inattention or hemianopia , for example, if the person has a left sided hemianopia, their bed should be placed so that their right side faces the door; the person can then see who enters their room.
Functional Ability
A good position which increases postural stability can help when participating in functional activities. If the person is well supported they may be less reliant on their upper limbs to prop themselves up, thereby allowing their arms to be free to attempt other tasks.
Communication/Social Interaction
A good position, particularly one which allows an upright head position, maximises opportunities for eye contact and social interaction. Poor head control limits the person’s ability to make and maintain eye contact thus affecting their ability to interact. Good positioning is essential for those people who are dependent on an Augmentative and Alternative Communication system.
Breathing and Swallowing
Good positioning is essential in order to support respiration and a person’s ability to swallow safely if they have dysphagia as a consequence of brain injury. Good positioning:
- Makes it easier to eat and drink.
- Facilitates chewing and oral control of food and liquid.
- May reduce the risk of aspiration of food or fluids and risk of developing chest infections.
- Facilitates maintenance of good nutrition and hydration.