Conventional versus neutral positioning in central neurological disease: a multicenter randomized controlled trial

Abstract

Background: Severe immobility due to lesions of the brain necessitates therapeutic positioning over the long term. There is little scientific evidence concerning the efficacy of different positioning methods. This clinical trial compares the effects of conventional positioning (CON) with those of positioning in neutral (LiN).

Methods: A prospective, multicenter, investigator-blinded, randomized, controlled trial was performed on a total of 218 non-ambulatory patients (underlying disease: stroke, 141 patients; hypoxic brain damage, 28; traumatic brain injury, 20; other, 29). The subjects were randomly assigned to either LiN (105 patients) or CON (113 patients) and stratified within each of these two positioning concepts to five different positions. They remained in the assigned positions for two hours. The primary endpoint was change in the passive range of motion (PROM) of the hip joints. Secondary endpoints were change in the PROM of the shoulder joints and patient comfort.

Results: Patients in the LiN group had a significantly better PROM of the hips after positioning than those in the CON group (difference, 12.84°; p<0.001; 95% confidence interval [CI], 5.72°-19.96°). The same was true for PROM of shoulder flexion (11.85°; p<0.001; 95% CI, 4.50°-19.19°) and external rotation (7.08°; p<0.001; 95% CI: 2.70°-11.47°). 81% of patients in the LiN group reported their comfort level as good, compared to only 38% in the CON group (p<0.001).

Conclusion: Positioning severely immobilized patients in LiN for two hours improved passive hip and shoulder mobility and patient comfort compared to conventional positioning. Further studies are needed to determine whether prolonged LiN positioning might improve rehabilitation and quality of life, prevent pressure sores, or ease nursing care.

Figure 1

Example of conventional positioning (CON) and positioning in neutral (LiN) for a patient lying on the right side The figure shows a typical 90° side lying position (a: CON; b: LiN). In both approaches the patient is lying entirely on one side, the upper leg is flexed, the lower leg may be flexed or extended. a) In CON, the stabilizing materials are placed at certain defined sites (e.g., at the back, under the leg). The body adapts to the mattress, and the effect this has on the alignment of the body parts is not taken into account. Hollow spaces can occur or are required (22). Support material is intended to be used quite sparingly. Positioning a patient conventionally is simple. In the position shown, a rolled duvet and a rolled towel are placed behind the trunk. A small pillow supports the abdomen. The cervical spine is unsupported and the head is slightly raised. The torso is laterally flexed. The shoulder girdle malaligns to the elevation and is compressed towards the trunk. The upper leg is adducted. Points of pressure occur at the ears, the lower shoulder, the ribs, and the greater trochanter. These areas are at risk of pressure ulcers. b) In the LiN approach, the focus is on the alignment of the body segments. Overstretching and shortening of muscles are avoided. The joints are positioned as neutrally as possible. All parts of the body are supported against the influence of gravity. Paretic body segments are stabilized using special techniques. Every hollow space should be filled. A sufficient number of blankets and pillows is needed to follow these principles. This makes LiN slightly more demanding than CON. Applying these principles in the position shown requires a folded duvet to be placed under the trunk while using its ends to stabilize the trunk behind and in front. The position of the body segments relative to each other is considered while in particular the upper leg, the cervical spine, and the head are completely supported. The pressure of the body is distributed over the whole bed, so the risk of pressure ulcers is low.

Figure 2

Enrollment and randomization of patients (CONSORT [22]). LiN: positioning in neutral; CON, conventional positioning

Figure 3

Primary endpoint: change in passive range of motion (PROM) of hip joints, in degrees LiN: positioning in neutral; CON: conventional positioning

Figure 4

Secondary endpoint: Patient comfort in LiN and CON (χ²-test shows a significant difference [p<0.001]). LiN: positioning in neutral; CON: conventional positioning