Positioning 24/7

How Assistive Technology & DME Can Also Help Clients at Night

Whether it’s because of too much caffeine, having too much to think about or hearing too often from a new baby in the house, getting a good night’s sleep can be a real challenge.

How much more challenging, then, is it to experience high-quality sleep – the type that physicians say enables our bodies to rebuild and restore, and our minds to truly refresh – if sleep is accompanied by constant pain caused by spasticity? If you can’t reposition – turning, nestling, rolling – as often as needed to stay comfortable? If lying down makes breathing more difficult?

Those are some of the physical challenges (see Update sidebar for more) experienced by people with mobility impairments every night when they get into bed – and more often than that, if they nap or spend daylight hours in bed, also.

Sleep: More Complex Than It Looks

Sleep as a science is a relatively new idea. Only recently have we come to understand the critical role that sleep plays in maintaining overall health.

The National Sleep Foundation (sleepfoundation.org), for example, says there are links between not getting enough sleep and everything from diabetes and obesity to relationship difficulties and automobile accidents. (The National Sleep Foundation [NSF] also says about three in four adults in a 2002 poll said they have trouble sleeping at least a few days a week.)

Although we may look as if we’re just lying around when we’re sleeping, NSF says our bodies are spending that time regaining energy, releasing hormones for growth and development, and consolidating our daytime memories, among other tasks.

But that kind of high-quality, restorative sleep is dependent on our being able to fall asleep and stay asleep long enough to go through the various stages of sleep.

That can be a challenge for many reasons – even more reasons when we’re discussing sleep for clients who use seating & mobility equipment.

Pressure Relief During Sleep: Group 1 Support Surfaces

For many clients with mobility impairments, pressure management is one of the biggest sleep-related concerns.

For good reason, says Marilyn Malone, product manager of therapeutic support surfaces, Invacare Corp.

“We should talk about 24-hour pressure relief, and that includes being in bed at night,” Malone says. “So many (patients) will be on a normal innerspring or a normal mattress, (but) they’re correctly positioned during the day. The nighttime will come, and they’re left to their own devices to shift their weight as best they can.”

Another challenge for people with mobility impairments: Unless a client is completely immobile, current Medicare coverage criteria don’t consider a support surface to be medically necessary until after the client has had skin breakdown. The coverage criteria for a Group 1 support surface for clients with limited mobility require clients to also have a pressure ulcer of any stage, plus impaired nutritional status; fecal or urinary incontinence; altered sensory perception; or compromised circulatory status.

That means clients with some independent mobility, but without current pressure sores, don’t qualify for a support surface under Medicare policy. And that leaves a high number of seating & mobility clients with a compromised ability to reposition themselves – such as those with spinal cord injury (SCI), cerebral palsy, multiple sclerosis or muscular dystrophy – to do their best on mattresses that don’t specialize in pressure relief, heat dissipation, etc.

Combine Medicare’s current coverage criteria with sobering pressure ulcer statistics – for instance, Science Daily reported in 2006 that 10 to 30 percent of SCI patients develop pressure sores within their first postinjury year – and it’s easy to wonder if those criteria should be re-examined in the name of preventive medicine.

“The medical policy on support surfaces needs to be revamped in a logical, reasonable manner,” says Jim Acker, VP of sales and marketing, Blue Chip Medical Products. Acker was among committee members working on new recommendations for the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC), but says that effort was halted when the Centers for Medicare & Medicaid Services (CMS) disbanded SADMERC and created the new Pricing, Data Analysis& Coding (PDAC).

Malone says the National Pressure Ulcer Advisory Panel “is coming up with some guidelines that they’re going to recommend to CMS. And one of those things that they’re planning to recommend, at least according to the most recent update I saw, was that innersprings not be used on home-care bedding.”

Regardless of current CMS medical policy, Acker and Malone both agreed that any client who uses a wheelchair for much or all of their mobility needs to at least be assessed for nighttime positioning needs.

“If (the client has) a cushion to go in their wheelchair and a hospital bed, then someone taking their call at the intake level should walk through the flow chart,” Malone suggests. “Do they have a pressure ulcer? Can they move, are they incontinent, are they eating properly? What’s their circulation like, can they feel when it’s time to move? (Then) they can direct them to whether or not they actually qualify for a Group 1 or 2 (support surface).”

Pressure Relief During Sleep: Group 2 Support Surfaces

“The ultimate goal of a Group 1,” Acker says simply, “is to prevent the need to move up to a Group 2.”

The more complex – and expensive – Group 2 support surfaces are allowed under several specific Medicare scenarios:

  • The patient has multiple Stage 2 pressure ulcers on the trunk or pelvis, has used a Group 1 support surface along with a comprehensive treatment plan for at least a month, and the ulcers have not improved or have worsened.
  • The patient has large or multiple Stage 3 or Stage 4 ulcers on the trunk or pelvis.
  • The patient has had flap surgery or a skin graft on the trunk or pelvis in the last 60 days and was on a Group 2 support surface prior to discharge from a hospital or skilled nursing facility.

“The only time that someone might end up going directly to a Group 2,” Malone says, “is, for instance, someone like Christopher Reeve, who had a spinal cord injury and couldn’t move. They might have put him directly into a lateral rotation mattress that turned him from side to side pretty regularly so he wasn’t lying in one position where he could develop pneumonia. Or someone who’s got cardiac issues or circulation issues and can’t move themselves at all. They could go directly to a Group 2 and be on a lateral rotation mattress.”

Otherwise and more commonly, a patient is upgraded to a Group 2 support surface only if he hasn’t improved on the Group 1 mattress. Once the pressure ulcer heals, under current CMS policy, patients can be “downgraded” from Group 2 to Group 1, and from Group 1 to a standard retail mattress.

And that can lead to some grim and recurring scenarios.

“I think the average time (spent on a Group 2 mattress) is six to eight months,” Malone says. “But then (the patients) will heal, and they will go off of it, and get skin breakdown again. And then they go on a Group 1 for 30 days, and then they go on to Group 2 (if there’s no improvement), until it heals, and then the whole cycle starts over again.”

The situation is similar, she says, with Group 1 support surfaces and patients who experience recurring pressure ulcers: “They might be on it for three months, if they have a Stage 1 or Stage 2 pressure ulcer. And once it heals, currently CMS will not pay for it (the Group 1 support surface). Then (patients) have to go back to their regular innerspring mattress, which they developed their pressure ulcer on anyway, so they can experience skin breakdown again, and then they go back onto a Group 1.

“That’s currently the way the regulations are written,” Malone says.

Support Surface Education

So given the current Medicare coverage criteria, what can providers do to help their clients break the high-risk pressure cycles and get safer, better sleep?

Acker believes education at every level – clinician, consumer, referral sources and payors – could be helpful. To that end, Blue Chip Medical recently debuted two new CEU classes (contact your Blue Chip rep if you’d like “The Importance of Choosing a Proper Support Surface” and/or “The Importance of Choosing a Proper Seating Surface” presented to your rehab staff or referral sources).

Consumers are tougher to educate, Acker says, because of their lack of familiarity with the clinical side of support surfaces and pressure management.

“I think a lot of people watch what they see on TV and believe it,” he says about commercials for retail beds and mattresses. “They assume that it works — the geriatric crowd in particular. They think that if it’s on TV, it must be true, that it can keep people their age comfortable and happy.

“What they don’t understand is that there are a lot more factors that need to be taken into consideration. And that’s where we come into play and the provider comes into play, to educate them on what makes a proper support surface versus a retail surface. A retail surface is similar, but very different than a medically oriented support surface.We’re not just looking at comfort; we’re looking at heat and moisture control, lowshear covers, incontinence-proof covers, longevity of the product.”

Among the reasons that the new Blue Chip classes focus on providers and referral sources, Acker says, is “Essentially, when it comes to the consumer, you can only educate them so much. Ultimately, it’s the provider that needs to understand it, so they can explain it to the referral sources. The referral sources need to be educated. And ultimately, what they all need to realize is that the consumer is only going to promote what they see on TV, not what the best surface is. That’s up to the referral source, the provider and the manufacturer to be able to determine that.”

Malone thinks that Medicare’s 2007 decision to no longer pay to treat pressure sores that worsen while patients are hospitalized may ultimately raise interest in pressure ulcer prevention in this industry.

“With Medicare changing their regulations so that they don’t pay for Stage 3 and 4 pressure ulcers that occur in hospitals…that kind of flows down through all of the other (places) where pressure ulcers might occur,” she says. “(That policy) is already in place in long-term care, but I’m sure it’s going to start showing up and making people more aware in home care, that you can really prevent pressure ulcers from occurring in the first place.”


More Nighttime Support:
Positioning Beyond Mattresses

Mention “nighttime positioning” in the United States, and most of the ensuing discussion will focus on therapeutic support surfaces and hospital beds that can adjust at the head and foot.

But what about clients who need additional positioning help, perhaps due to postural asymmetries or fixed deformities, or in an effort to improve respiratory function, reduce reflux or prevent pain?

Several DME manufacturers offer cushions in different shapes and sizes – such as rolls and wedges – that can offer more consistent support than, say, using a rolled-up towel or blanket. And these products, which are often made of dense foam and designed to bear considerable weight over long periods of time, can also offer greater positioning durability than throw pillows or bedding bought at a department store. In addition, many of these cushions are marketed for use during physical therapy or rehabilitation sessions, so their surfaces are made to resist moisture and are easily wiped or rinsed clean.

For more comprehensive systems, we also searched outside North America. Nighttime positioning seems to be a more popular topic outside the United States; we located a pair of manufacturers with such products in Britain, along with several ongoing research studies in Britain and Australia and, we heard from another source, New Zealand.

Contact the manufacturers or check their Web sites for more specific product information. – Ed.

Achievement Products for Children

Products offered: Positioning wedges, rolls, etc. – possibly intended more for physical therapy than sleeping.

P.O. Box 6013
Carol Stream, IL 60197-6013
(800) 373-4699


Products offered: Positioning wedges, abduction wedges, elevating wedges, bolsters and positioning rolls for various parts of the body. Some products, such as the wedges, are available with antimicrobial protection. The body positioning wedge is described as helpful for “side-lying support and trunk stabilization to maintain positioning schedules and help prevent pressure sores” and is available in sizes to fit larger and smaller clients. Ali-Med sells some Tumble Forms products.

297 High St.
Dedham, MA 02026
(800) 225-2610

CFI Medical Solutions

Products offered: Bolsters, wedges and blocks for positioning and support.

14241 Fenton Rd.
Fenton, MI 48430
(810) 750-5300

Consumer Care Products LLC

Products offered: Wedges, blocks and positioning cushions.

W222 N5739 Miller Way
Sussex, WI 53089
(262) 820-2300

Contour LivingContour Living

Products offered: Cushions that raise or support various parts of the body, such as the head, neck, back and legs. Some products are composed of several different cushions. Generally speaking, Contour Living’s products are aimed at retail consumers rather than complex rehab clients. But individual cushions, wedges, etc., could be useful for nighttime positioning – for instance, the BackMax system’s wedges can be unzipped and used individually. Says Contour Living’s Sue Sarko, “I’m sure that some of our products could be helpful to people who have these conditions for positioning to eat sitting upright in bed, for example.”

4740-A Dwight Evans Rd.
Charlotte, NC 28217
(800) 950-0230


Products offered: The Matchett support system comprises a wide range of cushions, wedges, etc., to elevate and/or support the upper abdomen, feet or legs, or to provide adduction or abduction. Other products support supine, prone or side-lying. Send an e-mail by visiting the Cuneiform Web site.

11 Weasenham Road
Great Massingham
King’s Lynn
PE32 2EY
United Kingdom


Products offered: The Dreama system supports kids and adolescents in supine, prone or sidelying positions (special sizes can be made to order). The modular system includes cushions that can be individually removed, repositioned and cleaned (each piece has a cover that can be machine washed and dried). Glide-Lock supports are pushed into place and locked down to keep each component in the proper position. Dreama can be used on standard or adjustable (powered) beds. Dreama is not currently distributed by a U.S.-based manufacturer, but Vanda Priestly, Jenx’s export account manager, says, “We now sell direct to dealers. We keep Dreama in stock in Atlanta, so we can offer a one-week delivery on this item. We can supply any dealer in the U.S.” Jenx will be exhibiting at the Section on Pediatrics Annual Conference (SoPAC) in Orlando in January; you can send an e-mail to Jenx by visiting its Web site.

Wardsend Road
S6 1RQ
United Kingdom
Phone: 44 (0) 114 285 6108

Sammons Preston / Patterson MedicalSammons Preston/Patterson Medical

Products offered: The Leckey Early Activity System (pictured) is designed as a comprehensive, modular positioning system for kids, but can also be used during sleep. Sammons Preston also offers a large range of Tumble Forms positioning products, along with an extensive selection of positioning wedges, rolls, etc.

1000 Remington Blvd., Suite 210
Bolingbrook, IL 60440-5117
(800) 343-9742


Products offered: Positioning wedges, blocks and cushions.

29 Wells Ave.
Yonkers, NY 10701
(800) 431-2972


Products offered: Wedges, positioners, cushions, etc.

70 Commerce Center
Greenville, SC 29615
(800) 888-6752

CP & Sleep Update:
Actiwatch Being Used in CP Sleep Study

In the October 2008 issue of Mobility Management, Sue McCabe, a senior occupational therapist with The Centre for Cerebral Palsy in Perth, Australia, discussed the many medical issues that can prevent patients with cerebral palsy (CP) from getting a good night’s sleep. McCabe cited studies that showed more than 80 percent of people with CP had sleep difficulties, including:

  • 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, swallow, saliva control, 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 control 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.

A year later, McCabe and her colleague, Caris Jalla, are nearing completion of their study called “Use of the Actiwatch for Assessing Sleep in Children with Cerebral Palsy.”

The Actiwatch – sold in the United States by Philips Respironics – is worn on a patient’s wrist and records motion and light.

McCabe says in her study description, “It can give information about the wearer’s general activity, sleep schedule, naps, wake episodes, as well as information about their sleep quantity and quality. There is little information and resources about the use of Actiwatches in sleep in children with CP. This project aims to find out how the Actiwatches work with our own clients and how therapists can use it to enhance assessment and treatment of clients with sleep problems.”

Among the study’s intended outcomes: “To prepare guidelines for families on how to use the Actiwatches for assessing sleep… (and) to inform clinicians about the usefulness and application of actigraphy (the measurement of activity levels using the Actiwatch) as an objective measure of sleep for people with CP.”

To follow McCabe and Jalla’s Actiwatch study, visit The Centre for Cerebral Palsy’s Web site: tccp.com.au.

This article originally appeared in the November 2009 issue of Mobility Management.

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