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Whilst bones provide the structural framework for protecting vital organs and providing stability, skeletal muscles maintain body alignment and help movement (Tortora and Derrickson 2009). In order for skeletal muscles to provide this function, they often cross at least one joint and attach to the articulating bones that help form the joint so that when a muscle contracts, movement of a joint can occur in one direction. Muscles tend to work in synergy with each other (rather than in isolation) not just to create but also to control the movement. The ability of a muscle to either contract or to extend assists their function (Figure 7.1). However, muscles will waste if not used and can also become shortened if not stretched regularly.

Figure 7.1 Relationship of skeletal muscles to bones: origin and insertion of skeletal muscle.

Reproduced from Tortora and Derrickson (2009).

Joints are supported not just by the muscles but also by ligaments which are strong connective tissue structures attached either side of the joint, for example the knee (Figure 7.2). Ligaments can also become shortened if they are maintained in one position repeatedly or over a long period of time, which can prevent full joint movement.

Figure 7.2 Anterior view of the right knee (tibiofemoral) joint.

Reproduced from Tortora and Derrickson (2009).

Evidence-based approaches

Rationale

Moving and positioning are important aspects of patient care because together they can affect the patient physically, physiologically and psychologically. They can have a major influence on the patient’s recuperation and well-being, addressing impairments in order to optimize their function and participation in society.

Positioning is often a good starting point to maximize the benefit of other interventions such as bed exercises, breathing exercises, optimizing rest and mobilizing in order to facilitate recovery and maximize function. However, although it is important, it must not be seen in isolation and is just one aspect of patient management within the context of preventative, rehabilitative, supportive and palliative rehabilitation models (Dietz 1981) where the overall goal is to assist independence.

It is important to frequently evaluate the effect that moving and positioning have on the individual with different pathologies to ensure that the intervention is helping to achieve the desired result or goal. This relates to considering whether the moving and positioning procedure is being clinically effective and, where possible, is evidence based.

There are several points to consider with regard to the clinical effectiveness of moving and positioning.

Is the timing right for moving the patient? For example, is the pain relief adequate?

Is it being carried out in the correct way? This relates to manual handling with regard to preventing trauma to both the patient and the practitioner. It is well known that nurses have a high incidence of work-related musculoskeletal injuries (Nelson et al. 2006) so that approved patient handling techniques are essential for safe practice.

Is the required position taking into account all the pertinent needs of the patient? This emphasizes the need to consider the patient in a holistic manner and take into account any co-morbidities as well as the primary focus that is being addressed.

Is it achieving the desired or a detrimental result?

Indications

Assistance in moving and positioning is indicated for patients who have difficulty moving or require periods of rest when normal function is impaired.

Contraindications

There are no general contraindications for moving and positioning. The severity of an illness may leave no choice except bed rest, but the rest itself is rarely beneficial.

Patients who are unstable may also need medical attention prior to any moving or change in position.

Principles of care

The principles of positioning are based on patterns of posture which maximize function with the minimal