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Bed-time postural management systems may provide pressure relief and reduce the risk of body shape distortion amongst immobile patients as part of a 24-hour postural management plan. Robust evidence investigating their use is not available. This study explored the potential effectiveness of a postural management system considering peak contact pressure and user perceptions. Healthy participants (n=15) were screened using a modified Red Flags Screening tool. Conformat system was used to analyse contact pressure under the shoulder and buttocks and was recorded for ten minutes with/without the postural management system in supine and side lying. Participants were asked questions relating to their comfort/restrictiveness (Numerical Rating Scales). In side lying, peak contact pressure at the greater trochanter was significantly lower with the intervention compared to the control condition. In supine lying, the intervention reported significantly lower peak contact pressures at the shoulder. At the ischial tuberosity peak contact pressure was significantly higher with the intervention compared to the control condition. Perceived comfort did not significantly change between test conditions. Participants reported that they felt significantly more restricted with the intervention. Findings suggest potential benefits of reduced pressure at the shoulders in supine-lying and at the greater trochanter in side lying with a PMS, reducing the risk of pressure injury formation. A postural management system that maintains body shape and reduces risk of pressure injuries could reduce the economic burdens of health implications associated with poor positioning, enhance patient care and reduce risks to carers associated with manual handling techniques used during repositioning.
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24
PRM+ (2019) Volume 2 Issue 2 24-28
ISSN 2489-8457
Postural management system for bedbound patients
Lauren A Haworth
1
, Simon C Sumner
1
, Elia Mercado-Palomino
1,3
, Alex M Mbuli
1,2
, Rachel C Stockley
4
, Ambreen Chohan
1
Abstract
Objectives
To explore the potential effectiveness of postural management
system considering peak contact pressure and user perceptions.
Methods
Fifteen healthy participants were screened using a modified Red
Flags Screening tool. Conformat® system was used to analyze
contact pressure under the shoulder and buttocks and was
recorded for 10 minutes in supine and side-lying positions with
and without a postural management system. Participants were
asked about their comfort and restrictiveness using a numerical
rating scale.
Results
In side-lying position, the peak contact pressure at greater
trochanter was significantly lower when a postural management
system was applied. In supine position, the peak contact pressure
at shoulders was respectively lower. In turn, the peak contact
pressure at ischial tuberosity was significantly higher lower
when a postural management system was applied. The postural
management system did not affect the level of perceived comfort.
Participants reported that they felt more restricted with the
intervention.
Conclusions
A postural management system reduced pressure at the
shoulders in supine-lying position and at the greater trochanter
in side-lying position lowering the risk of pressure injury
formation. A postural management system may reduce the
economic burden of health problems associated with poor
positioning, enhance patient care, and reduce the risks
associated with manual handling techniques when repositioning.
Keywords:
postural management; contracture; spasticity; sleep system
INTRODUCTION
Individuals with disability due to neurologic
conditions, such as stroke, cerebral palsy (CP), motor
neuron disease (MND), spinal cord injuries (SCI), or
catastrophic brain injuries (CBI) often present with limited
mobility and impaired sensory perception. Those with the
most severe sequelae may be unable to mobilize and could
need help in all activities of daily living (1–3) with even
simple postural adjustments to redistribute pressure and
relieve discomfort being impossible to perform without
assistance (2). When in bed, subcutaneous ischemia occurs
within regions that are in contact with the sleep surface (4).
Around bony prominences, the skin becomes compressed
between the sleep surface and the bone due to reduced
amounts of soft tissue (5). In a healthy individual, the
presence of tissue ischemia provides a sensory stimulus
which triggers the individual to alter their position to
relieve pressure within ischemic tissues. An inability to
make postural adjustments independently can lead to many
negative health implications if not remedied with
assistance or intervention (6). These include pressure
injuries and body shape deformity.
With the adoption of a prolonged position, the skin and
underlying tissues are under continued stress, which over
time reduces blood flow, restricts oxygen and nutrient
1
Allied Health Research Unit, UCLan, Preston, Lancashire, PR12HE;
2
Sport, Exercise & Health Sciences, Edinburgh Napier University, UK;
3
Department of Physical Education and Sports, University of Granada, Spain;
4
Stroke Research Team, UCLan, Preston, Lancashire, PR12HE
Conflicts of interest: The intervention (Hugga) used within the study was provided, free of charge, by the company (PostureCare Ltd)
Corresponding author: Lauren Haworth, University of Central Lancashire, Allied Health Research Unit, Preston, Lancashire, PR12HE
delivery to the tissue, ultimately leading to cell and tissue
degradation (7,8). This produces a pressure injury, which
are the most commonly discussed medical complication for
bed-bound individuals. Pressure injuries are areas of
localized tissue damage caused by pressure, friction or
shear, often developing in areas of bony prominence (8,9).
The formation of a pressure injury is now commonly
viewed as patient neglect if they are considered to have
been preventable with an appropriate level of care (10). As
such there is accountability within the NHS for the
development of a preventable pressure injury, so staff are
required to regularly reposition patients as part of the
Pressure Ulcer Prevention Strategy (11). However,
clinicians must consider the consequences of postural
asymmetry, instability and dysfunction when planning a
pressure injury prevention strategy (12).
Much like pressure injuries, body shape distortion is a
secondary complication that can develop amongst
individuals who are unable to independently change
position (7). It has previously been reported that regardless
of an individual’s diagnosis, if they have movement
difficulties and are unable to maintain a therapeutic
posture, there is a significant risk of developing body shape
distortion and associated negative implications (7). These
JOURNAL OF Quantitative research
in rehabilitation medicine
PRM+
Haworth / Postural management system / PRM+ (2019) Volume 2 Issue 2
25
include the worsening of muscle imbalances associated
with postural asymmetries, contractures and body
deformities, all of which can result in reduced respiratory
and digestive function, compression of internal organs and
reduced personal hygiene (7,13). A 24-hour postural
management plan should be implemented by healthcare
professionals to enable patients to adopt a therapeutic
position (14), protect from body shape deformity,
formation of contractures and provide adequate pressure
relief (14–16). In addition to preventing pressure injuries,
a 24-hour postural care plan should ensure that appropriate
levels of support are provided to modulate muscle tone,
maximize muscle function and assist with the maintenance
of soft tissue length (7,17–20).
Symmetrical supine lying has been shown to achieve
best clinical outcomes through symmetrical and level
positioning of the shoulders and pelvic girdle, and gravity
assisted knee straightening (7,21). Although there is
agreement upon how frequently repositioning should occur
(every 2-4 hours), there is no formal guidance relating to
the processes of positioning, turning or re-positioning
(2,22). Consequently, there are inconsistences amongst
health-care professionals as to what is considered best
practice (2,3,11,18,20,23). Previous research highlights the
need for the development of formal clinical guidance to
inform best practice and standardized patient positioning
methods, as current nursing and care programs do not
provide this (6,16).
Positioning aids, primarily whole-body systems, as a
bed-time positioning intervention may provide a solution
and effectively reduce the risk or severity of body shape
distortion amongst immobile patients (7). The majority of
evidence to support the use of bed-positioning equipment
has been amongst a pediatric population (15) and as a
result, postural support at night is now recommended by
the National Institute for Health and Care Excellence for
children and young people with non-progressive brain
disorders (24). More recently the importance of 24-hour
postural support in sitting, standing and lying for both
children and adults with complex postural needs has been
recognized (3). Furthermore, it has been recommended that
Clinical Commissioning Groups should consider
implementing postural management interventions where
necessary to improve patients’ quality of life (13). A recent
scoping review reinforced the urgent need for further
research into bed-time postural equipment (25). The most
common type of whole-body positioning systems used in
the postural management of a patient incorporate multi-
component parts held in position by a base layer sheet,
although sadly patient access to this equipment varies
(3,26). At present, there is a lack of robust evidence to
support the use of postural management systems (3). The
aim of this research study is to explore the potential
effectiveness of a postural management system (PMS)
through analysis of peak contact pressure and user
perceptions amongst a healthy population.
METHODS
Participant Recruitment
All volunteers were screened using a modified Red Flags
screening tool (27) to assess eligibility. Eligible volunteers
were aged between 18 to 50 years and had no history of
musculoskeletal disorders, including back pain, within the
six months before participation. Volunteers were excluded
if they had any musculoskeletal or neurological disorders
of the spine, pelvis, or shoulder. Anyone with a history of
postural corrective or spinal surgery was also excluded. All
data collection conformed to the Declaration of Helsinki
(28) and general data protection regulations. Volunteers
gave written informed consent before participation. Full
ethical approval was granted by the University of Central
Lancashire’s Ethics Committee (STEMH).
Procedure
The study was set in a movement analysis laboratory. This
was a repeated-measures crossover study. Throughout the
study there were two conditions; the PMS intervention
(Hugga®, PostureCare®, UK), and the control condition
(without PMS). For each condition there were two test
positions; side lying and supine (Figure 1).
Participants were asked to wear comfortable unrestrictive
clothing throughout testing. A standard hospital bed frame
and foam mattress was used for testing. Two pressure
sensor mats (Conformat®, Tekscan®, USA) were
positioned on top of the mattress to collect body-mattress
interface contact pressure data from the top of the shoulder
to the inferior angle of scapula, and from the posterior
superior iliac spines (PSIS) to the gluteal fold. The PMS’s
associated bed sheet was placed over the top of the mattress
and pressure sensor mats.
Body-mattress interface contact pressures were recorded
for thirty seconds after 10 minutes of each test condition
(Figure 2). The order of the test conditions was randomized
using an online generator (www.randomization.com). For
the PMS conditions, the components were installed around
each participant in accordance with manufacture’s
guidelines and training. Following each of the test
conditions participants completed Numerical Rating Scales
(NRS) relating to perceived comfort and restrictiveness.
Statistical Analysis
Peak contact pressure at the shoulder, greater trochanter (in
side lying) and ischial tuberosity (in supine lying) were
exported from Conformat® Clinical 7.60 (Tekscan®,
USA) into Microsoft Excel® 2016 (Microsoft Corp. USA).
NRS scores for perceived comfort and restrictiveness were
input into Microsoft Excel® 2016 (Microsoft corp. USA).
Statistical analysis was performed in SPSS 24 (SPSS®,
Inc., Chicago, USA). Repeated measures ANOVA tests
with post-hoc pairwise comparisons were used for
statistical analysis of mean and peak contact pressures. For
non-parametric data, a Friedman test was performed.
Significance was set at p≤0.05.
Table 1: Peak Contact pressure recorded at the shoulder and hip with
and without Postural Management System (PMS).
Position
Condition
Shoulder (kPa)
Hip (kPa)
Side Lying
Control
1.56 (0.6)
1.71 (0.5)
1.61
(0.5)
1.55
a
(0.4)
Supine Lying
Control
1.23 (0.4)
1.24 (0.4)
1.18
a
(0.4)
1.32
a
(0.5)
a
Significant difference (p<0.05)
Haworth / Postural management system / PRM+ (2019) Volume 2 Issue 2
26
RESULTS
Of the fifteen healthy participants, 10 were women and 5
were men. Their mean age was 29.1 (8.7) years, height 1.71
(0.6) m, and weight 78.2 (17.9) kg.
Side lying
In side lying, peak contact pressure at the greater trochanter
was significantly lower with the PMS compared to the
control condition (p=0.001, 9.3%) (Figure 3, Table 1).
There was no significant difference in peak pressure at the
shoulder with the PMS compared to the control condition
in side lying.
Supine lying
In supine lying, the PMS reported significantly lower peak
contact pressures at the shoulder (p=0.007, 4%), but at the
ischial tuberosity peak contact pressure was significantly
higher with the PMS compared to the control condition
(p=0.034, 6%) (Figure 3).
Participant Reported Outcome Measures
Perceived comfort was not significantly different between
the test conditions (p=0.558, range 7.67–8.33) (Table 2).
There was a significant difference between conditions in
perceived level of restrictiveness NRS (p=0.001).
Participants reported that they felt significantly more
restricted with the PMS in both supine (p=0.002, mean
3.47) and side lying (p=0.007, mean 3.13) compared to the
control conditions (mean 0.53 and 0.60 respectively).
DISCUSSION
Although many healthcare professionals position
patients as part of a 24-hour postural management plan, it
has been recognized that there is a lack of evidence-based
guidance to inform standardized and effective therapeutic
positioning (2,3,11,18,20,23). The findings from this study
present interesting information relating to perceived
comfort and restrictiveness of a whole-body PMS; the
presence of the PMS did not alter perceptions of comfort
compared to the control condition, although it was
perceived to be significantly more restrictive. When using
these systems with people who have severe neurological
impairments, it may not be possible to gather this
information as they are likely to have severe sensory,
cognitive and motor impairments making communication
difficult (3).
The results provide a proof of concept that postural
management systems have the ability to reduce peak
pressure in healthy participants. The findings suggest that
use of this system can reduce the risk of pressure injury
formation at the greater trochanter when adopting a side-
lying position and at the shoulder when adopting a supine
lying position. Given that the greater trochanter is the
region of most concentrated pressure and most susceptible
to pressure injuries when in a side lying position (5), the
ability to reduce this risk through use of the PMS provides
potential clinical benefit for the end user, the caregiver and
the NHS in terms of reducing the cost of treating secondary
complications.
The shoulder region, most specifically the scapulae is
another region that is at risk of developing pressure injuries
when placed under prolonged stress (5). In this study,
through use of the PMS peak pressure at the shoulder was
reduced compared to the control test condition in supine
lying, providing further potential clinical benefit in PMS
use as a whole-body system to manage body-mattress
interface pressure. In the supine test condition, pressure at
the ischial tuberosities were greater in the PMS condition
compared to the control condition. When positioned in the
PMS, the knees and hips are slightly flexed which may in
turn transfer pressure towards the buttocks. However, a
peak pressure value of 1.32 KPa, as recorded at the ischial
tuberosities with the PMS in supine is not considered large
enough to cause ischemia within the compressed tissues,
with an acceptable threshold for pressure when sleeping
Table 2: Perceived comfort and restrictiveness (NRS 1-10)
Position
Condition
Comfort
Restrictiveness
Side Lying
Control
7.67 (1.72)
0.60 (1.3)
PMS 7.93 (1.49) 3.13
a
(2.26)
Supine Lying
Control
8.33 (1.11)
0.53 (1.36)
PMS 8.07 (1.53) 3.47
a
(2.10)
a
Significant difference (p<0.05)
Figure 1. Top left: supine lying control without Postural Management System (PMS). Top right: supine lying control with PMS (Top right). Bottom left:
side lying position without PMS. Bottom right: side lying position with PMS. The PMS system bed sheet is placed over the pressure sensors to enable
the proper attachment of PMS
Haworth / Postural management system / PRM+ (2019) Volume 2 Issue 2
27
previously estimated to be between 3.9 and 5.3 KPa (4). A
pressure of 9.3 kPa applied for 2 hours could cause dermal
damage and pressure exceeding 10.7 kPa could cause
necrosis (29). Through implementation of a PMS alongside
adhering the guideline of 2 hour turning by alternating
between supine and side-lying, there is the potential to
offload two key bony prominence areas of high risk for
pressure injury development, and by doing so, reduce the
risk of pressure injury development.
PMS were developed with therapeutic aims of making
end users as comfortable as possible, preserving body
shape, and improving sleep quality (3). Whilst posture or
body position was not an outcome measure tested within
this study, it is suggested that the significant level of
perceived restrictiveness may be associated with a
restriction of unwanted peripheral or trunk movement
which often occurs when an individual with neurological
impairment is left unsupported in an unstable position.
This study was an exploratory trial to further understand
the potential use of a PMS. The study is not without its
limitations; it was a small study (n=15) and participants
included were of a healthy status; it would be unethical to
conduct an initial study investigating the use of a PMS
intervention on a patient population without first
understanding what effects it has amongst a healthy
sample. A second limitation of the study is that each test
condition was only maintained for 10 minutes when, in
practice, much longer periods would be spent in one
position.
However, the findings from this study suggest that the
PMS does not negatively influence perceived comfort, yet
does provide significant restriction, which may assist in the
prevention of body shape deformity or spasticity amongst
a patient group requiring postural support. The peak
pressure reductions identified at the greater trochanter in
side lying and at the shoulder in supine lying also further
support its potential evaluation amongst a physically
impaired patient group when used over longer durations.
Further research is now required to investigate the efficacy
and effectiveness of the PMS amongst people with
significant mobility restrictions. Gathering the views and
opinions from the caregivers may also provide an insight
into whether the PMS would likely be accepted and
integrated into clinical practice.
CONCLUSIONS
A postural management system reduced pressure at the
shoulders in supine-lying position and at the greater
trochanter in side-lying position lowering the risk of
pressure injury formation. A postural management system
may reduce the economic burden of health problems
associated with poor positioning, enhance patient care, and
reduce the risks associated with manual handling
techniques when repositioning.
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Background: Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. This is an update of an existing review. Objectives: To assess the effects of pressure-relieving support surfaces in the treatment of pressure ulcers. Search methods: In September 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any participant group or setting. Data collection and analysis: Data extraction, assessment of 'Risk of bias' and GRADE assessments were performed independently by two review authors. Trials with similar participants, comparisons and outcomes were considered for meta-analysis. Where meta-analysis was inappropriate, we reported the results of the trials narratively. Where possible, we planned to report data as either risk ratio or mean difference as appropriate. Main results: For this update we identified one new trial of support surfaces for pressure ulcer treatment, bringing the total to 19 trials involving 3241 participants. Most trials were small, with sample sizes ranging from 20 to 1971, and were generally at high or unclear risk of bias. Primary outcome: healing of existing pressure ulcersLow-tech constant pressure support surfacesIt is uncertain whether profiling beds increase the proportion of pressure ulcer which heal compared with standard hospital beds as the evidence is of very low certainty: (RR 3.96, 95% CI 1.28 to 12.24), downgraded for serious risk of bias, serious imprecision and indirectness (1 study; 70 participants).There is currently no clear difference in ulcer healing between water-filled support surfaces and foam replacement mattresses: (RR 0.93, 95% CI 0.63 to 1.37); low-certainty evidence downgraded for serious risk of bias and serious imprecision (1 study; 120 participants).Further analysis could not be performed for polyester overlays versus gel overlays (1 study; 72 participants), non-powered mattresses versus low-air-loss mattresses (1 study; 20 participants) or standard hospital mattresses with sheepskin overlays versus standard hospital mattresses (1 study; 36 participants).High-tech pressure support surfacesIt is currently unclear whether high-tech pressure support surfaces (such as low-air-loss beds, air suspension beds, and alternating pressure surfaces) improve the healing of pressure ulcers (14 studies; 2923 participants) or which intervention may be more effective. The certainty of the evidence is generally low, downgraded mostly for risk of bias, indirectness and imprecision.Secondary outcomesNo analyses were undertaken with respect to secondary outcomes including participant comfort and surface reliability and acceptability as reporting of these within the included trials was very limited.Overall, the evidence is of low to very low certainty and was primarily downgraded due to risk of bias and imprecision with some indirectness. Authors' conclusions: Based on the current evidence, it is unclear whether any particular type of low- or high-tech support surface is more effective at healing pressure ulcers than standard support surfaces.
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Introduction Sleep positioning systems are often prescribed as part of a 24-hour postural management programme for children and adults with neurodisabilities. In a search for evidence of effectiveness for children with cerebral palsy a recent Cochrane review found two randomised controlled trials. This review aims to appraise a broader set of studies including any neurological diagnosis and users of all ages to inform therapists about the quality of the evidence underlying practice. Method A comprehensive search for all peer-reviewed studies that evaluated the use of sleep positioning systems was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library databases, BNI, HMIC, PEDro, OTSeeker and clinical trials registries. Disability organisations, manufacturers and colleagues worldwide were also contacted. Titles were screened for relevance by two reviewers. Data were extracted into bespoke quantitative or qualitative forms by one reviewer and checked by a second. Findings were analysed into simple themes. Results A total of 14 studies were eligible for inclusion; all were small and most were of low quality. Inferences of benefits cannot be made from the literature but also no harm was found. Conclusions The body of evidence supporting practice remains small and mostly of low quality. Therapists should remain cautious when presenting the benefits to families.
Article
Background: Poor postural care can have severe and life-threatening complications. This scoping review aims to map and summarize existing evidence regarding postural care for people with intellectual disabilities and severely impaired motor function. Method: Studies were identified via electronic database searches (MEDLINE, CINAHL, PsycINFO and Web of Science) covering January 1990 to March 2016, and email requests to researcher networks. Results were collated via descriptive numerical summary of studies and thematic analysis. Results: Twenty-three studies were identified and summarized narratively in relation to three themes: characteristics and prevalence, interventions and service related issues. The evidence base is small with significant gaps. Lack of evidence for night-time positioning equipment and 24-hr postural care needs to be addressed urgently. Conclusion: Future research should be clearly directed towards ascertaining how best postural care interventions can be employed to help improve the health and quality of life of people with intellectual disabilities.
Article
The aim of this study was to investigate nursing staff induced repositionings and the patients' spontaneous movements during the day and night among older immobile patients in nursing care. Furthermore, the aim was to identify factors associated with the nursing staff induced repositionings and the patients' spontaneous movement frequency. An observational cross-sectional design was used. Spontaneous movements among patients (n = 52) were registered continuously using the MovinSense monitoring system. The nursing staff documented each time they repositioned the patient. Patients spontaneous movements were compared with nursing staff induced repositionings. There were large variations in the patients' spontaneous repositioning frequency during both days and nights, which shows that, although immobilised, some patients frequently reposition themselves. Analgesics were positively related to the movement frequency and psycholeptics were negatively related. The nursing staff more often repositioned the patients who were assessed as high risk than those assessed as low risk, but the patients' spontaneous movement frequency was not correlated to the risk score. This may be important when planning repositioning schedules. A monitoring system may be useful in decision making with regard to planning repositioning and positions used in the prevention of pressure ulcers among elderly immobile patients. © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
Conference Paper
Pressure ulcer is a prevalent complication for bed-bound patients who are not able to shift their body weights over time. Continuous monitoring of patient's postures in the bed can be helpful for caregivers in order to keep track of patient's movements and quality of their repositioning during a day. This information allows hospitals to plan an effective repositioning schedule for each patient. In this paper, a high speed and robust posture classification algorithm is proposed that can be employed in any pervasive patient's monitoring system. First, a whole-body pressure image is recorded using a commercial pressure mat system. Image enhancement is then applied to the raw pressure images and a binary signature for each different posture is constructed. Finally, using a binary pattern matching technique, a given posture can be classified to one of the known posture classes. Our extensive experiments show that the proposed algorithm is able to predict in-bed postures with more than 97% average accuracy.
Article
The aim of this article is to elevate the standard of ward-based routine care by informing readers about the prevention and management of muscular contractures post-cerebrovascular accident (CVA). Musculoskeletal complications can develop at any time during the acute or latter stages of stroke care and rehabilitation; therefore, it is imperative that all nurses understand the importance of correct limb placement and some of the detrimental complications that can occur. By placing more onus on therapeutic positioning and earlier mobilisation, nurses, working alongside allied health professionals, can significantly improve morbidity-related outcomes.