When getting into bed requires little or no effort, it’s easy to take lying down comfortably for granted.
But last week, a new position paper from the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) addressed bed as a place of pain and discomfort for too many clients with positioning challenges.
The paper — RESNA Position on Assistive Technology for Lying Posture Care Management (LPCM) — is open for public comments through Feb. 5. It was written by Patricia J. Toole, MAT, MsOT, OTR/L, ATP (group leader), Clear Path Occupational Therapy, Seattle, Washington; Tamara Kittelson, MS, OTR/L, ATP/SMS, executive director, Posture 24/7, and executive director, the Clinician Task Force, St. Paul, Minnesota; Lee Ann Hoffman, OTD, MSc., OTR, ATP/SMS, CAPS, University of Saint Augustine for Health Sciences, Dallas, Texas; Jennifer Hutson, Ph.D., OTR/L, ATP, St. Catherine University, St. Paul, Minnesota; and Kourtni Bopes, OTD, OTR/L, Central Wisconsin Center, Madison, Wisconsin.
The paper advocates for greater consideration for LPCM. “Postural support in the seated and standing orientations have been addressed in previous RESNA position papers,” the LPCM paper said. “This document fills a gap in knowledge by specifically discussing LPCM, both outlining the need for such intervention as well as providing appropriate definitions, current evidence, and best practices in this area.”
Within 24-hour posture care management (PCM), LPCM is a subset “that addresses the time when an individual is in a lying orientation,” the authors said. “LPCM involves providing whole-body support while the person is lying supine, which may include head elevation. This supine position optimizes musculoskeletal alignment not possible with other horizontal orientations, while additionally maximizes pressure distribution.
“This use of the supine orientation for LPCM is strongly encouraged, but supports can also be applied in side-lying or semi-side-lying alignment for individuals who cannot safely assume the supine position. LPCM should be implemented as standard practice as part of the 24-hour PCM.”
Sounds logical. You work so hard to achieve and maintain the best functional position for your clients in wheelchairs. You advocate for standing as well, when indicated. Given that wheelchair riders typically spend much more time in bed than standing, optimizing their position while they’re lying down seems reasonable.
Takeaway #1: Not everyone can lie symmetrically without support
The paper defines LPCM as “ a collaborative therapeutic process by which a person with limited movement ability is enabled to lie in increasingly symmetrical positions through skillful placement of therapeutic supports.
“The purpose of LPCM is to protect healthy posture and maximize the user’s everyday function when customarily, the individual may have spent hours in asymmetrical, unsupported lying postures.”
That was my first takeaway: Not everyone is able to lie symmetrically in bed without support, just as not everyone can sit in a functional position without support.
Anyone with “a limited movement repertoire” is a candidate for LPCM, the paper noted. “These individuals typically cannot independently move in and out of a balanced, symmetrical supine lying position and may present with secondary complications — e.g., hip dislocation, spinal curvature, rib cage compression or rotation — known to arise from being in extended periods of asymmetry.”
So clients who use complex seating and wheeled mobility should likely be assessed for LPCM. “People requiring support for sitting and standing usually require support for lying,” the paper affirmed.
Takeaway #2: Lying posture impacts posture at other times
Poor lying posture can make it difficult for clients to sleep and can have long-term postural effects when they’re awake.
“Without lying postural intervention, individuals continue to lie in asymmetrical positions, develop painful secondary health conditions, and often require expensive and invasive medical procedures (e.g., hip and spine surgery) and/or other interventions,” the paper said.
The good news is that LPCM can also ripple to positively impact a range of functions. Over time, it can relax muscle tone, reduce pressure, reduce daytime pain, produce a stronger cough or reduced risk of choking, support better range of motion, and improve hip integrity.
Takeaway #3: Homemade LPCM devices can work well
The paper describes three “tiers of complexity” for LPCM assistive technology: materials available at-hand; specially applied general-use products; and specialty products.
The first two tiers include household items, from towels, pillows and stuffed animals to non-slip rug backing, spacer mesh crib overlays, and custom-carved foam supine leg positioners. The costs of products in those first two tiers are relatively low.
Products in the third tier — modular/custom sleep positioning systems, supine leg positioners, recumbent orthoses — are typically supplied by durable medical equipment providers or Complex Rehab Technology (CRT) providers, are more costly, and would likely require insurance or other payer involvement.
But it’s still amazing that many LPCM interventions are low cost and therefore readily available. LPCM can be within easy reach for many clients.
Takeaway #4: A good night’s sleep improves so many things
The most impactful part of the paper for me were the case studies — especially the first one about Jim, 54, with “mild intellectual disability, profound deafness, and MS [multiple sclerosis].”
Jim lived in a group home, used a power chair in which he sat with an asymmetrical posture, and reported headaches and chronic shoulder/neck pain “poorly managed with medication.”
He was prone to “pain-related behavior outbursts” — hardly surprising, given his pain and chronic exhaustion.
In wheelchair clinic, Jim was assessed for sleep, pain and postural ability — and his asymmetrical sitting and lying postures “were noted to mirror each other.” Jim had flexibility toward neutral “and could be positioned to rest and sit in greater symmetry than was typical for him.”
Jim and his group home assistants were shown how to support his lying posture using everyday materials, with lateral supports “placed snugly on both sides of his hips and chest, as well as under his legs.”
At a two-month follow-up, Jim and his assistants reported that he was sleeping well and had stopped asking for pain medication at bedtime. His outbursts had stopped, his postural ability had improved, and he could now be placed in a neutrally aligned lying position.
All of that accomplished in a couple of months, using readily available materials.
The paper’s authors noted that the “overall body of evidence about the impact of LPCM is limited,” and that additional research is needed “to further develop service delivery protocols and evidence of LPCM outcomes.”
Advocate for more research and consideration for LPCM — and clients like Jim — by sharing your comments with RESNA by Feb. 5.
Image: Pixabay/emrahozaras