Night-time postural support for people with multiple sclerosis
Pauline Pope, consultant physiotherapist
Way Ahead 2007;11(4):6-8
Introduction
For people who have lost or have little ability to move or change position by themselves, body posture forms an essential component of their physical management. No amount of hands-on therapy can compensate for this core element in preventing or relieving the secondary complications that can arise from ineffective postural management.
Evidence to support the effectiveness of posture management for people with multiple sclerosis (pwMS) is largely anecdotal, but is endorsed by health professionals' wide experience in the field. Though the plight of those who have not been managed in this way is well recognised and graphically portrayed in the literature 1-3, there remains a great need for further well-conducted investigation in the field. Funding is currently being sought to investigate the effects of night-time postural control for pwMS by a team at Exeter University.
General points about posture
Before exploring the significance of postural support during the night, the following general points are pertinent:
- efficient functional activity is dependent upon a stable posture. However, a stable posture is not synonymous with a symmetrical posture. Different activities require different postures to maximise efficacy. The person with a posture or movement deficit adopts a limited number of postural attitudes that are sustained for long periods of time;
- a sustained posture that is consistently adopted leads to adaptation of the tissues corresponding to the particular body attitude. Some tissues will stretch while others adapt to their shortened position, leading to contracture and eventual structural deformity;
- asymmetrical postures lead to unequal tissue loading, thus creating localised areas of high pressure which, if sustained, can lead to tissue damage;
- respiratory function may be compromised. A slumped posture compresses the lungs impeding lung excursion (movement). Swallowing may be compromised by incorrect position of the head to neck, predisposing the person to choking and aspiration;
- neurological signs such as spasms, spasticity, tremor or ataxia are influenced to a greater or lesser degree by postural attitude and instability.
What is postural management?
Postural alignment is a concern for many people, not only those who are considered to have a disability. Zacharkov4 and others attest to the diverse benefits experienced by practitioners of the Alexander Technique and Yoga. However, the management of posture for pwMS can have a number of prescribed outcomes depending on the needs of the individual. Achieving these outcomes means controlling alignment of body segments relative to each other and to the supporting surface in order to:
- minimise tissue adaptation;
- maximise the area of support in order to reduce pressure and tissue trauma;
- control positive neurological phenomena such as spasms.
The ideal management is control of the individual's posture and position throughout the day and night. In practice such an ideal is rarely achieved as postural support may interfere with function or care activities - function should always take precedence over postural alignment. Realistically, the aim is to provide the appropriate support for as much of the time as is feasible.
The need for postural support throughout the day has been recognised for many years. Postural support in lying and at night-time is a relatively recent phenomenon and the cause of much discussion.
Why is night-time postural support necessary?
Most people, with or without disability, spend a considerable amount of time in bed. In people with advanced MS the time spent in bed may exceed that not in bed, and it may be they are in bed for most of a 24-hour period. The same posture consistently adopted in bed can predispose to the secondary complications already mentioned. Active intervention is necessary if these complications are to be minimised. Whilst postural support during the day may compromise function, appropriate support in bed may ameliorate the worst effects of the seated posture.
Who needs postural support in bed?
Postural support should be considered for anyone unable to move or change position independently when in bed. However, this alone should not trigger prescription without careful consideration of other factors that will influence feasibility:
- provision of support is necessarily restrictive; thus any support may compromise function. For example, support may impede ability to reach a switch or roll over;
- positioning the appropriate support may be too difficult for the client or carer to manage. Many people living on their own, or a caring relative, have neither the time nor energy to carry out an additional procedure;
- where multiple carers are involved it can be difficult to train, monitor and communicate with everyone involved with a given person5. It is often impossible to ensure consistent and correct application of support. Inappropriately applied support will not be effective and may even cause damage;
- the use of support when couples share a bed may be unwelcome and should not be used unless both partners agree;
- no support should be used if the individual is not willing.
The points noted are not necessarily a contraindication for use. Each signals the need for careful consideration prior to prescription.
What equipment is appropriate?
There are an increasing number of specially designed sleep systems currently on the market, ranging from simple rolls and bead bags to the more sophisticated systems such as Symmetrisleep, Jenx Dreamer and Leckey Sleepform.
Many devices are abandoned for various reasons, most commonly those already noted. Abandonment signifies a waste of scarce resources6. This may be avoided by ensuring a full/comprehensive assessment is carried out before making any recommendations and by simulating the support. The following guidelines may also help:
- in general it is preferable to try simple, less restrictive (and less expensive) means before the more sophisticated and expensive systems;
- less restrictive systems may be more acceptable to people who retain some active movement or those with involuntary/uncontrolled movements, but there are those for whom the greater support provided by a restrictive system is comforting;
- those with significant deformity may be more effectively accommodated with a system that can be customised to their shape;
- if a simple means of night-time support is not acceptable to the pwMS it is unlikely that a more sophisticated one will be.
However simple the equipment used, training in use (as opposed to a demonstration) is critical to effectiveness, with on-going monitoring of progress and encouragement.
It has been observed that one of the most effective and least restrictive postural supports is a foam positioning roll. Not only are they proven to be more acceptable to pwMS, they also provide a simple but effective means of controlling postural alignment, increasing the area of support and controlling spasms. Ensuring that the roll is customized to the needs of the individual is an important consideration. For instance, the foam used must be firm enough to support a leg but must retain some conformity and the size of the roll should also be appropriate to the individual. A small roll can be used where a larger one is indicated, by placing it on a pillow. The diameter of the roll should not cause discomfort when placed between the thighs. The foam stretch covering can also be made water impermeable where continence is a problem.
The T roll
Figure 1 illustrates a typical postural attitude found in many people with advanced MS or occasionally in the earlier stages of the condition. The tissues will adapt to the postural attitude if left unmanaged. The T roll is used in the supine position to align and stabilise the lower part of the body with the upper part
Procedure for use
A T roll is placed under the knees and rolled forwards securing abduction and external rotation thus avoiding undue pressure on venous return at the back of the knee. It is essential that the vertical segment be placed between the thighs rather than between the knees. A small soft cushion is placed under the lower legs to lift the heels and relieve pressure. Where plantaflexion of the feet causes concern, night resting splints may be advised, but it is important that these are comfortable.
If lateral flexion of the trunk persists on realignment of pelvis with thorax, use of a pillow tucked under a sheet on each side of the trunk will assist in control of this problem (see Fig 3). Pillows used in this way also provide support for the arms. Where pillows are used to control trunk position it is advisable to place a sheet, folded lengthways, across the bed before the pwMS goes to bed.
Where reflux is a problem, the bed head is raised, but should be kept as low as is consistent with reflux prevention, in order to reduce sliding down the bed. The T roll will help to reduce sliding but use of a profiling bed, where available, provides additional support under the knees. Apart from maintaining body segmental alignment the T roll support in supine tilts the pelvis posteriorly thereby increasing the weight bearing area and transferring the load from pelvis to thorax7.
The T roll is particularly effective where extensor spasticity or spasms feature in the clinical picture. The roll does not constrain the spasm but encourages the limbs to return to the desired position of abduction and external rotation after the spasm passes. Healthcare professionals have found that consistent use of the T roll results in 'looser limbs' and easier care management. Where movement threatens to dislodge the roll a padded strap attached from the centre roll across the thighs and velcroed to each end of the horizontal roll may prevent displacement.
Contraindications
There are few definite contraindications to use of the T roll in supine, some of which are not exclusive to T roll use. The most commonly encountered contraindications are:
- vomiting;
- aspiration;
- opisthotonus ie severe total body extension (rarely seen in MS);
knee flexion contractures greater than 90 degrees (measured with the hip in flexion). Severe hamstring shortening prevents the back of the knee from resting on the roll, reducing control of alignment. In addition contact of the calf muscle with the roll predisposes to pressure damage especially if flexor spasms are present.
The presence of a sacral or coccygeal pressure ulcer is not necessarily a contraindication to use of the T roll in supine. Relief of pressure in the damaged area is achieved by increasing posterior tilt of the pelvis with a pillow placed under the T roll.
The log roll
The log roll is used for support in side lying as an alternative to the T roll where the supine position is contraindicated, or where side lying is the preferred position for sleeping. The log roll is a straight cylinder of firm foam that aligns and stabilises the lower half of the body with the upper part.
Procedure for use
A lengthways folded sheet is placed crossways on the bed and the pwMS is positioned as follows:
- on his/her side with hips and knees flexed to 90 degrees;
- a firm but malleable pillow is placed along the back of the trunk under the cross sheet. The pillow is secured by tucking the sheet around and under the pillow. The pwMS is then leant against the pillow off the shoulder and hip joints;
- the knees are separated and the log roll is placed between the thighs with the posterior end resting on the bed to prevent rotation of the pelvis;
- both lower legs are positioned in front of the roll not under and on top of it;
- a small pillow is placed between the feet to prevent undue pressure;
- another pillow may be placed under the arms for added comfort.
Where flexor spasms are dominant and likely to dislodge the roll, leg position is secured by wrapping the legs in a bath towel folded lengthways around both ankles. There is no need to tie it. This is sufficient to prevent the spasm dislodging the roll. On relaxation the desired position is regained. Constraint used in this way is acceptable, as it is of benefit to the pwMS.
In most situations it is advisable to simulate the support described either in supine or side lying using a firm pillow rolled up in a bath towel. Where a T roll is indicated, a similar makeshift roll can be positioned between the knees. Pillows used in this way make an effective substitute for a roll and can be used to test benefit, comfort, compliance and practical application before recommending the specially designed rolls. Pillows not rolled up lack firmness and do not make an effective substitute for a roll.
References
- Thomson AP, Lowe CR, McKeowen T. The care of the ageing and chronic sick. London: E & S Livingston: 1951.
- Pope PM, Bowes CE, Tudor M, et al. Surgery combined with continuing post-operative stretching and management for release of knee flexion contractures in cases of multiple sclerosis. Clin Rehabil 1991; 5: 15-23.
- Pope PM. Posture management and special seating. In: Edwards S, editor. Neurological physiotherapy. 2nd ed. London: Churchill Livingstone; 2001. p189-218.
- Zacharkov DJ. Posture sitting and standing: chair design and exercise. Springfield Illinois: Charles C Thomas; 1988.
- Pope PM. Management of the physical condition in people with chronic and severe neurological disabilities living in the community. Physiotherapy 1997; 83(3): 116-22.
- Verza R, Messmer Uccelli M. A team approach to evaluating the need for assistive technology reduces equipment abandonment. Way Ahead 2007; 11 (2): 4-5.
- Pope PM. Severe and complex disability: management of the physical condition. Edinburgh: Butterworth-Heinneman; 2006.
Acknowledgements
Gary Inwood for the illustrations and Catherine Scott for permission to use the illustrations that feature in the night positioning paper available from C&S Seating (Telephone: 01424 853331).
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Way Ahead articles are reproduced as published. They are not updated to take account of subsequent developments. Use appropriate caution in acting on the information in any article.
