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or to resist unopposed action of spastic muscle (Edwards and Charlton 1996). They may help gain alignment for proximal and truncal activity (Raine et al. 2009) and enable more balanced and efficient walking (Hesse 2003). As with all therapeutic interventions, they should only be used after detailed assessment and based on sound clinical reasoning.

Seating

Appropriate seating is also advocated as an adjunct to management for effective postural support (Kirkwood and Bardslay 2001, Pope 1996, 2002, Raine et al. 2009).

Occupational therapists and physiotherapists will consider this for management of patients with complex needs.

Environment and positioning

Problems of perception* are considered to be one of the main factors limiting functional motor recovery following stroke (Baer and Durward 2004). These can affect patients with disease or illness affecting their CNS. Here, the patient fails to respond appropriately to stimuli presented on their hemiplegic side, the contralateral side to the brain lesion (Baer and Durward 2004, Lindsay et al. 2004). Environmental factors such as correct positioning are essential for ensuring optimal level of function for each individual (Edwards 2002a). Clinical management strategies include:

addressing the patient from the affected side

deliberate placement of items such as drinks on that side

advice to carers to position themselves on the patient’s affected side whilst talking to them in order to orientate them to their affected side

positioning the patient on their affected side, enabling function with their sound side.

Limited evidence exists to suggest the benefit of these approaches (Baer and Durward 2004). However, it is recognized as a useful treatment adjunct for these patients, through promotion of sensory awareness/appreciation, including perception and body image and enabling function (Bobath 1990, Davies 1985, Edwards and Carter 2002, Grieve and Gnanasekaran 2008, Lynch and Grisogono 1991, Raine et al. 2009).

Rehabilitation opportunity

Patients with neurological illness or disease present with an assortment of clinical symptoms. Positioning can assist in their holistic management and allow future opportunity for rehabilitation where their illness or disease allows.

Procedure guideline 7.10 Positioning the neurological patient with tonal problems

Essential equipment

Pillows or towels (as guidance or basic positioning)

Optional equipment

Hand/foot resting splint if required

Resting splint if required

Medicinal products

Analgesia as required

Antispasmodics as required

Preprocedure

Action Rationale

1 Explain the procedure to the patient. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008, C).

2 Wash hands thoroughly or use an alcohol-based handrub. To reduce the risk of contamination and cross-infection (Fraise and Bradley 2009, E).

3 Ensure that the bed is at the optimum height for handlers. If two handlers are required try to match handlers’ heights as far as possible. To minimize the risk of injury to the practitioner (Smith 2005, C).

Procedure

4 Follow basic advice for positioning the patient in supine, side-lying and sitting in bed as described in the above procedure guidelines for positioning patients. To promote alignment of body segments for patients with high or low tone due to abnormal influences of primitive developmental reflexes resulting in asymmetrical posture (Bobath 1990, E; Davies 1985, E; Edwards and Carter 2002, E; Lynch and Grisogono 1991, R4).

To ensure patient comfort. E

5a Consider and apply possible modifications as specified below for the supine (see Action Figure 5a1(a).

Place pillow under hemiplegic hip for alignment.

Place additional pillows or wedge under knees and/or head.

Place pillow to support feet in neutral/plantargrade position:

Apply foot resting splint (ankle foot orthosis (AFO) (see Action Figure 5a2) to weak foot and ankle if recommended. NB: Ensure the splint is fitted correctly

Place pillow under weak arm.

Apply resting splint for hand/forearm if required.

To control