Clinically Speaking

Case Study: 20 Years of Lying in Bed

Picture this: England 2013. The telephone rings. I am asked to assess and provide seating for an individual who just happens to have been in bed for the last 20 years.

Is something like this even possible? Yes — it is!

Let me set the scene. Twenty years of lying in bed translates to approximately 175,200 hours spent solely in the postural orientation of lying. This situation was complicated by unsupported lying against the natural forces of gravity. There had previously been a myriad of diagnoses that resulted in extremely limited mobility and consequently, an inability to move out of harmful postures.

Lying in Bed Case Study

PHOTOS COURTESY THE AUTHOR, ALAN TOMBS, JULIA BROWN & SEATING/MOBILITY TEAM

Despite being in bed with no sleep system for 20 years, in less than five months, Alan progressed to trying a sleep system.

Would this assessment reveal the “human sandwich” effect identified by Hare in 1987? Prolonged immobility often leads to shortening of muscles, leading to contractures compounded by the forces of gravity and the reactive force of the supporting surface. Would I see an established “preferred posture” as described by Pope 1991, where the body returns to its habitual position, after correction? Yes — to all of the above!

Getting Started: The Assessment

Pope identified a strong correlation between the postural presentations found in lying — due to physiological tissue adaptation — and the postural presentations found in sitting and standing. Therefore, to establish seating needs, a comprehensive and thorough assessment in lying would be absolutely necessary.

For my assessment tool, I used the Oxford Centre for Enablement (OCE) Management of Physical Disability 24-7 (MPD 24-7) because this assessment form is closely linked to the core values of the International Classification of Functioning, Disability, and Health (ICF) (WHO 2001). The MPD is the assessment tool that highlights the need for 24-hour posture management. This tool was extensively used to identify the critical joint ranges which, in turn, would heavily influence postural options in lying and sitting.

Twenty-four-hour posture management (PM) focuses on the three main postures available during a 24-hour period: lying, sitting and standing. The fundamentals of PM are promoting comfort, function and seeking to reduce secondary complications associated with poor posture, such as pressure areas, contracture, deformity, pain, difficulties with breathing and respiration.

This requires a holistic team approach, so using rehabilitation engineers, physical therapists (PTs), occupational therapists (OTs) and specialist rehabilitation nurses, we set to work.

Lying in Bed Case Study

PHOTOS COURTESY THE AUTHOR, ALAN TOMBS, JULIA BROWN & SEATING/MOBILITY TEAM

The cast process: Note open hip angle to accommodate loss of hip flexion ranges on the left. By “dropping” left lower limb to accommodate hip range, and allowing the right to assume a comfortable range of flexion, a stable base was created for sitting. A Chunc mobility base was the “cast chair.”

Making Progress: Slow & Steady

Axiomatically, Alan and his nuclear family members were at the center of the team and formed an essential support mechanism. Where to start? Having established Alan’s critical joint ranges and also where accommodation would be required due to a number of established postural deformities, the first step was positioning in lying. After the trial and implementation of a sleep system, with the aim of providing a stable posture in lying, a better position for feeding, pressure care, promoting general health and enabling nursing needs had to be addressed. We had taken the first step down a very long road of rehabilitation.

The aim of creating and providing Alan with a custom sleep system was to prevent further postural deterioration, and to promote postural orientations that are aimed toward symmetry. In Alan’s case, it was also to prepare him for another critical part of the 24-hour PM intervention, namely sitting.

The next very important consideration was related to sensory systems, such as the vestibular system. Careful and graded raising of the head of the bed to simulate a more “vertical” than horizontal plane, with continuous observation for factors such as postural hypotension, was undertaken. Alan’s tactile system also had to be addressed, as he had not worn clothing in 20 years of lying down.

This was a significant milestone for all concerned!

By achieving an orientation other than horizontal, the Reticular Activating System (RAS), the brain’s “generator,” could now be fired up. There are numerous studies providing evidence that when a person is upright, a natural increase in awareness occurs. Being in an upright posture serves to stimulate the RAS in the brainstem, and allows for more alert and engaged interactions. The RAS is affected by many types of stimuli, especially the vestibular and proprioceptive changes that occur during more “upright” or “vertical” postures when compared to those in a horizontal plane.

This new postural gain presented an excellent opportunity to the neuro-OT for her expert assessment. The Sensory Modality Assessment and Rehabilitation Technique (SMART) was selected as the most effective clinical tool. This tool was pioneered at the Royal Hospital for Neuro-disability (RHN), United Kingdom, in 1988 and is used for the assessment and rehabilitation of people with disorders of consciousness following severe brain injury.

Lying in Bed Case Study

PHOTOS COURTESY THE AUTHOR, ALAN TOMBS, JULIA BROWN & SEATING/MOBILITY TEAM

Custom carved-foam system: separate seat and back. Ventilation holes aid heat dissipation. Custom covers (left) drape over the side of the seating.

Next up was a customized seating system. Even without assessment findings, it was clear that Alan’s seating options would be in a totally different galaxy from “normal,” modular, off-the-shelf products. The only solution was custom-molded seating. You can never have too many hands during any custom mold capture exercise, and this case was no exception. Careful consideration was given to the choice of materials. I have included a guide for material choice selection by Aburto and Holbrook (2009) in References.

With absolute comfort in mind, foam was selected as the material for the seating system. Of maximal benefit was that the foam material could meet the specific curves and shapes where accommodation was required, and that it would be “kinder” to such a delicate and fragile individual as Alan.

A separate seat and back were created to allow greater postural variation of positioning as needs changed with time. The initial seat cast allowed for a very open hip angle. A well-documented, negative quality of foam is that it is a heat insulator. Therefore, holes were made in the back support to allow some ventilation, in addition to a heat dispersion fabric integrated into the seat cover.

Pressure mapping assessments and ongoing reviews were also undertaken to determine the effectiveness of the custom shape and the material choice with regard to pressure care. Padding was added to the individual foot plates of the wheelchair to protect Alan’s vulnerable feet, which were fixed in contracture in the plantar-flexed position.

Lying in Bed Case Study

PHOTOS COURTESY THE AUTHOR, ALAN TOMBS, JULIA BROWN & SEATING/MOBILITY TEAM

Custom seating system on a manual mobility base: custom upper limb wraps, bilateral. Custom foot padding on footplates. Hoist sling seen in photo.

I included a picture of the finished custom seating system, with covers draped over the system, on a manual wheelchair mobility base. The mobility base offered a large degree of posterior tilt and accommodated the back support in a reclined orientation without affecting the stability of the system.

Soft custom wrap supports were added to encourage better upper-arm placement. The thought was that we would make gravity our friend to assist in addressing upper-limb positioning.

As part of 24-hour PM, all postural orientations available to a specific individual need to be addressed. As only lying and sitting were available to Alan, both orientations had now been addressed.

See how it all turned out — including how bathing issues were tackled — in the August issue of Mobility Management.

Thanks to Alan Tombs and his sister, Julia Brown; Phil Swan and Zeeshan Shafi from Contour 886; Bridget Churchill from Life4Living; Janet Radcliff from Symmetrikit; and the QA Unit Rehabilitation staff, United Kingdom.

References

This article originally appeared in the July 2016 issue of Mobility Management.

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