How Nighttime Posititioning Affects Clients and (Caregivers) the rest of the Day

Positioning 24/7

Clinical conditions and co-morbidities. Diagnoses and prognoses. Height, weight and the possibilities of fluctuations. Lifestyle elements, such as nutrition, overall activity levels and medications taken. Accessibility issues at home, in the car, in everyday environments. And of course, funding, funding, funding.

These multiple factors must be considered when a rehab team assesses a client for seating & mobility equipment — i.e., a wheelchair and seating system. After all, the client will spend significant time in the wheelchair to perform mobility-related activities of daily living, to work or study, to travel, to socialize and play, to undergo therapy.

The ideal seating & mobility system maximizes a client’s functioning and independence, while also ensuring that medical needs are met. The ideal system also considers the needs of other family members or caregivers.
But what happens when the client leaves that wheelchair and gets into bed to rest or sleep? What happens to their positioning needs then?

Sleep as a Waking Concern
Judging from the proliferation of TV commercials for Ambien and Lunesta, not to mention new jargon such as “sleep debt” and “sleep driving,” we are a sleep-deprived society.

The possible silver lining is that this nationwide problem has become a nationwide topic in mainstream media.
Elisha Bury is the editor of Respiratory Management, MM’s sister publication that covers respiratory HME, including equipment used to treat sleep disorders.

“Fortunately, sleep has become a popular topic in mainstream media, and that is causing people to seek out information about sleep disorders, especially obstructive sleep apnea (OSA),” Bury says. “There are many organizations, such as the National Sleep Foundation, that are working to educate people about the importance of sleep hygiene and the basics of various sleep disorders.”

Bury suggests that kind of education is urgently needed, as consumers have been generally slow to understand how harmful sleep disorders can be.
“For example,

Sleep has a huge impact on overall health, says Sue McCabe, senior occupational therapist, The Centre for Cerebral Palsy, Perth Australia.
“Good sleep is essential for growth, development, physical health, mental health, well-being and function,” McCabe says. “Research has shown that poor sleep is linked with health issues such as reduced immune function, reduced ability to recover from illness and surgery, and with heart disease and obesity. Sleep is linked with the management of seizures and of pain; it is linked with mental health, including depression and anxiety; it is linked with social and behavioral difficulties; and it is linked with function and performance, affecting motor performance, stamina, attention, memory and learning ability.”

“Getting a good night’s rest does a lot more for the body than just keep you refreshed the next day,” says Mike Sedlak, group product manager of beds & therapeutic support surfaces for Invacare Corp. “It helps it recover from the day before, and your muscles are also a key part of that. If somebody’s able to recover more quickly and be less fatigued during the day, there’s a physical benefit that they’ll have from a good night’s rest.”

But a good — and safe — night’s sleep can be very difficult to attain for some people with mobility-related types of disabilities. And the effects of exhaustion can be particularly trying for those with underlying medical conditions.

“In general, you could say that the adverse effect of inadequate sleep amplifies the everyday challenges of disability,” McCabe says. “We see in our clients that poor sleep affects physical stamina, attention, perseverance — so this affects participation at all tasks. This can apply to everyday tasks — as basic as sitting up straight, holding their head up, chewing and swallowing, paying attention in class, making the effort to interact with others, persevering with learning to drive their wheelchair or to accurately use the switches for their computer or communication device. We know that physical, mental and emotional performance is challenged for all of us when we have inadequate sleep. Further to this, people with disabilities may demonstrate daytime sleepiness — simply falling asleep in their wheelchair. People with epilepsy are likely to have increased severity and frequency of seizures if they have inadequate sleep. We notice that clients’ uncontrolled movements may be more severe when they are tired.”

Why People with Mobility Disabilities Can Be at Higher Risk
According to numerous sources, including the American Academy of Family Physicians, 80 to 90 percent of people who have sleep apnea are currently undiagnosed and therefore may not realize that they are more susceptible to other related medical conditions.
Imagine then the additional sleep challenges faced by people with mobility-related disabilities. If you’ve ever tried to sleep while sick with the flu – and had trouble because of fever, body aches, sinus or chest congestion, etc. — you’ve had a taste of how difficult it can be to get a healing night’s sleep while feeling physically miserable.

McCabe adds that studies have shown more than 80 percent of clients with cerebral palsy (CP) have sleep difficulties, for a great range of reasons. Among them:
• Pain and discomfort due to muscle spasms and muscle tone pulling their body or limbs into uncomfortable positions.
• Pain and discomfort due to inability to change positions.
• Pain and discomfort due to uncontrolled movements that can startle the person awake.
• Breathing difficulties related to impaired cough, swallowing, saliva control or reflux.
• Pain and discomfort due to reflux.
• Gastro-intestinal problems, such as constipation or abdominal pain; many children with conditions such as CP have difficulty with oral intake.
• Discomfort due to incontinence.
• Discomfort due to temperature regulation difficulties related to impaired autonomic function, or effects of high activity/movement levels, or effects of being unable to remove or add bedding as required to maintain a comfortable temperature.
• Circadian rhythm disturbance (affecting their internal “body clock”) caused by the neurological impairment.
• Effects of seizures — sleepy during the day due to seizures or medication, and then unable to sleep at night.
• Effects of seizures on sleep architecture, affecting the stages of sleep and the ability to sustain deep sleep.
• Effects of other interventions (such as splinting, serial casting, surgery).
• Effects of anxiety or depression.

In addition to breathing concerns, pressure relief is a major nighttime issue for clients unable to feel the type of pressure-related discomfort that would ideally cue them to roll over or otherwise reposition. Spinal cord injury clients, for example, may not be able to discern when pressure is building up on one portion of the body or may be unable to independently perform a weight shift to alleviate the situation.

“The pressure that is put on certain body parts can cut off the blood flow, and that can lead to a variety of complications, including and ultimately pressure ulcers building up,” says Sedlak. “It can go from general redness and a sore spot on somebody’s heel, for example, all the way up to open wounds, where they get exposed down to the bone and can be quite complicated to resolve.”

And pressure sores, Sedlak adds, can raise a client’s risk for a lifetime.
“There’s a little bit of a misnomer out there that pressure ulcers are ‘healed,’” he says. “The reality is they’re never really healed. Pressure ulcers are areas of dead skin, essentially, and while that may heal over, it is still a little bit more suspect to injury. It’s going to occur a little bit more quickly in that area.”

The Role of Positioning in Sleep
While traditional sorts of sleep-related HME — such as Continuous Positive Airway Pressure (CPAP) machines — work well for many able-bodied clients, they may be less effective for people with mobility-related disabilities such as CP.
“People with CP can have particular challenges with the management of their breathing during sleep,” McCabe says. “They are more likely than the general population to have breathing difficulties, and yet less likely to be assisted by interventions such as CPAP or oral devices. This can be because they have reduced tolerance to the masks — due to behavioral difficulties or difficulties managing oral secretions, or atypical facial structure.”
Those sorts of challenges, coupled with some clients’ lack of sensation and/or inability to easily or independently reposition themselves, escalate the need for proper positioning around the clock.

“Nighttime positioning is an important aspect of 24-hour postural care,” McCabe says. Referring to her clinical colleagues in Australia, McCabe notes, “Our knowledge of the importance of 24-hour postural care has developed over the past 10-plus years thanks to information provided by a number of clinicians, such as Liz and John Goldsmith, Pauline Pope and Terry Pountney — all based in the United Kingdom — who have all provided valuable information about the importance of 24-hour postural care for function, comfort and management of postural deformity.

“The notion of 24-hour postural care is more than positioning,” McCabe adds. “It is to do with all the activities and interventions that will impact on a person’s postural management. Having said that, nighttime positioning is an important part of the whole picture: Most people spend over one-third of their time in bed. If this time is spent unsupported, people with CP are likely to assume habitual postures, which over time become difficult to correct, leading to postural deformities, which of course then impacts on comfort, health and function. Time in lying — not just for sleep, but also when resting — is an important and valuable time to make sure that posture is supported in a position that is comfortable and as symmetrical as possible.”

Sedlak agrees that the rehab team needs to be concerned about the various surfaces a client is on throughout the day. “It’s not just at nighttime,” he says. “It’s anytime they’re out of that chair. Oftentimes, somebody could come out of a chair and spend the daytime hours in a bed. So it’s not just sleeping; it’s anytime they’re out of that chair, you have to be aware of what type of surface they’re on.”

What Nighttime Positioning Can Accomplish
Proper positioning at night, McCabe says, can help manage many factors that prevent a good night’s sleep, including pain and muscle discomfort; exaggerated or uncontrolled movements that can result in a client becoming entrapped or hitting arms and legs against bedrails or walls; reflux; sleep apnea; temperature regulation; and pressure relief.

Pressure relief, Sedlak says, is the top priority of support surfaces and beds.
“A lot of focus for mobility products is put on proper positioning and seating of the patient while they’re in that chair,” he points out. “And many (clients) do spend their entire waking hours in their chairs. Where the focus gets lost a little bit is once they come out of the chair and you lay them on a standard mattress that isn’t offering much relief of pressure ulcers. And if it’s somebody that’s not able to reposition themselves, they’re going to be lying in the same position all night. If you don’t have the proper surface underneath them, it could lead to that skin breakdown.”

And by the way, competitive bidding aside — both beds and support surfaces were among the product categories bid in the now-postponed Medicare program — Sedlak says the funding picture for these items is relatively good.
“Prior to competitive bidding, (reimbursement) was very stable,” he says. “There’s a broad range of codes that encompass beds and support surfaces. There’s a variety of not only codes for the products themselves, but codes for the reimbursement of them, such as (whether) they were a purchased item or if they were a rental item.

“The ones for the mattresses – E0184 – that one offers relatively good reimbursement for the product. If we consider the floor and the ceiling, it ranges from $21 to $24 a month on a rental basis and $165 to $195 from a purchase standpoint. So the funding is definitely there to be adequate to cover the investment that somebody might have to make on these products. Likewise for the powered surface: Floor to ceiling on those range from $650 to $700.”

Sedlak says the powered support surfaces that can physically reposition a client in bed is usually treated as a rental item “because they are intended to be treatment; you qualify for those surfaces when you have a condition that needs to be treated. Once that condition is treated, you revert back to what’s called a

Group 1 (pressure-reducing) type of surface. So you’ll go back to a static surface.”
Purchasing a powered support surface may be called for, Sedlak says, “if it’s not as much a treatment as it is a need for a lifestyle. If you have somebody who cannot reposition themselves regardless – it’s not rehabbing an injury or a pressure ulcer or anything like that, they cannot reposition themselves on their own – they would be the right candidates for a purchase of one of these systems.

“Somebody who is not able to turn on their own would most likely benefit from a lateral turning mattress. If they are constantly lying prone and aren’t able to position themselves, they run the risk of fluid building up in their lungs and having some pulmonary distress from that. The lateral turning mattresses provide that motion to keep the fluids moving through your chest, through your lungs. And that’s something that somebody would consider the purchase of.”

Assessing client risk and therefore determining the type of support surface needed, Sedlak says, is often conducted by a team including a clinician, the supplier and perhaps a home health nurse or similar team member using the Norton or Braden scale as an evaluation tool (see sidebar) after a physician writes a prescription.

As for those increasingly popular, name-brand, high-end consumer beds designed to provide an ultra-comfortable, “custom” fit, Sedlak says, “There is a school of thought out there that for viscoelastic (foam) to work properly, it uses the body’s heat to soften up the foam. Consequently, it traps the heat a little bit. It softens the mattress; you fold into it. That’s nice and comfortable, but for somebody that might be running a fever or is prone to perspiring profusely, you don’t want them laying in a surface that is raising their body heat. That will lead to perspiring, excess moisture and if they have a little bit of pressure on the back of the calves (for instance), now all of sudden, their skin starts to macerate. That could lead to the first signs of skin breakdown.”

So while those types of beds can be very comfortable for able-bodied consumers without mobility-related conditions, “It’s not really the intent of that to treat pressure ulcers,” Sedlak says.

Advocating for 24/7 Solutions

Both McCabe and Sedlak agree that treating positioning with a 24-hours-a-day, seven-days-a-week attitude can be very beneficial to clients with mobility-related disabilities.

“In terms of postural care, it makes obvious sense to consider nighttime positioning,” McCabe says. “Why put so much skill and resources into providing good positioning in seating, when clients may be spending even more of their time in lying, possibly in a position that is damaging and likely to contribute to the development of deformity? As you know, good positioning in seating is not just about postural care, it is about function. And this is the case too with positioning in lying: Function is still an issue — this function may be to do with breathing, swallowing, sleeping.”

Asked if, generally speaking, a client who used a skin-protection wheelchair cushion could benefit from being assessed for support surface needs, Sedlak says, “I would agree with that thinking. If somebody is in some type of specialty seating, it’s for a reason. Either they’re a little contracted in their body positioning, they’re not able to move, they could have thin skin or some of the other conditions we talked about. So yes, what you put them on in the nighttime hours is just as important. Certainly, it should be taken into account what some of those factors are.”

Sedlak adds that providing proper positioning at all times, including at night, might improve the conditions of the entire household.
“The caregiver is almost the forgotten one in this whole mix of problems we’re trying to resolve,” he says. “The caregiver, just by their nature, is focused on the patient that’s in the bed and oftentimes, they’ll wake up in the middle of the night just to check on the patient. If they realize they are on a good surface and a reliable surface, and they have a lot of confidence that it’s not going to shut off in the middle of the night and will provide the proper relief that the patient is looking for, they’re going to be able to sleep more soundly through the night and then the next day provide a higher level of care for that patient.”

“As previously mentioned, studies have shown that over 80 percent of people with disabilities such as CP may have sleep disturbance, and yet clients or their families/caregivers rarely ask for help in this area,” McCabe says. Therefore, the task of raising the question of sleep and nighttime positioning may lie with the rehab team. McCabe says her clinic takes a “multidisciplinary approach” that includes not only herself as the OT and physiotherapist Linda Mercer, but also “we work in close partnership with the referring teams, which may comprise OT, physio, speech therapist, social worker, nurse — and we refer our clients to other clinicians when indicated, such as dietician, clinical psychologist or pediatrician, neurologist or respiratory physician.”

Understanding sleep difficulties and the drastic impact they can have on clients’ lives is a relatively new and growing field — says Respiratory Management’s Elisha Bury, “Because sleep is a relatively new health field, there are many, many primary care physicians who do not understand sleep. As a result, they do not ask questions about how patients are sleeping at night, nor do they necessarily know how to prescreen for sleep apnea.”

That means rehab technology suppliers may be in a more feasible position to ask the questions that can change clients and caregivers for the better.
“Even when we address nighttime positioning (in terms of postural care), families often do not report sleep difficulties unless we actually ask how they are sleeping,” McCabe says. “Nor do they report safety issues — entrapment, vomiting during sleep, breathing difficulties during sleep, banging arms or legs against walls and siderails — unless we actually ask.”

Assessing for Pressure Sore Risk & Support Surfaces

The venerable Norton Scale and newer Braden scale offer criteria to help clinicians, home health agencies, DME suppliers and other members of the health-care team assess for pressure sore risk in conjunction with choosing the most appropriate support surface. For instance, the Braden Scale asks the assessor to rate the client on ability to clearly and specifically express pain or discomfort, their skin moisture levels and frequency, and level of independent mobility and activity.

To read the Braden Scale for Predicting Pressure Sore Risk, go to
To read the Norton Scale, go to

This article originally appeared in the October 2008 issue of Mobility Management.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at

In Support of Upper-Extremity Positioning