Positioning of the stroke patient: a review of the literature E. K. CARR, Ph.D., B.Nurs., R.G.N.,

N.D.N. Cert., R.H.V.* Lecrurer, Department of Nursing Studies, King’s College London, Cornwol[ House Annex, Waterloo Road, London SEI 8TX. U.K.

F. D. KENNEY, M.Sc., M.C.S.P.,

Dip. T.P.

Lecrurer. Deparltnent of Physiotherapy, Normanbv College. h’ing’s College London. Bessemer Rood. London SE5 4AN. U.K.

Abstract-Stroke is a common and disabling illness, adversely affecting the quality of life of hundreds of people each year. While there are many therapeutic approaches to stroke patient rehabilitation, encouraging patients to adopt “reflex-inhibiting” patterns of posture is a widely advocated strategy for helping patients to avoid complications of hemiplegia such as spasticity and contractures. However, while the central role of nurses in thus helping patients is recognized, the influence of posture on recovery from stroke has never been evaluated. Prior to undertaking such an evaluative study, texts on stroke patient care were reviewed to clarify the received view about the recommended positioning for patients with hemiplegia. Consensus on some issues was evident (such as positioning the patient with the affected shoulder protracted, spine straight, fingers extended and avoiding external rotation of the affected hip). However, opinion was divided on others and a number of potentially important aspects were ill-covered. This paper integrates a summary of the findings of this review with the physiological rationale for the recommendations. The main areas of agreement are highlighted and issues as yet unanswered are raised for further consideration. *Author

to whom correspondence

should be addressed.

355

356

E. K. C.-IRR .d.VD F. D. h-E’.“.‘El

Introduction

Stroke is common, devastating and is a major cause of disability (Kannel and Wolf, 1983; Kotila ef al., 1984). Although there is thought to have been a gradual decline in the incidence of stroke over recent decades (Grimley Evans, 1986) this may now be at an end (Broderick et al., 1989). Thus stroke continues to be a serious problem with, in some countries, an annual incidence rate of up to 2.5 strokes per 1000 of the population (Aho et al., 1980). In an average British Health District with a population of 200,000-250,000 people there will be about 400 to 500 new cases of stroke each year (Wade ef al., 1985). Although many people die after a stroke [indeed it is currently the third most common cause of death in western countries (Wolf et al., 1986)) there are many who survive with subsequent major disability. It has been suggested that stroke constitutes the most common disabling neurological disease of adult life (Dyken ef al., 1981) and studies in the U.S.A. have indicated that up to 50% of all patients after stroke are severely disabled, with about IO-15% requiring institutional care (Sahs ef al., 1979; Kannel and Wolf, 1983). In Britain, 130,000 impaired stroke victims living at home were identified in a survey for the Office of Populations, Censuses and Surveys. Of these, 93,000 (71.5070) were reported to have severe or serious disability (Harris et a/., 1971). About two-thirds of all survivors of stroke under the care of a General Practitioner will be disabled (Wade and Hewer, 1987a). The consequences of stroke vary depending on the location and extent of the brain damage and there is an almost infinite range of possible permutations of loss of function (Wade ef al., 1985). These include motor, sensory and cognitive impairments which have the potential to affect all aspects of the person’s physical, psychological and social life. There are many costs associated with stroke. These range from the personal costs of physical and emotional suffering in the individual and family (Wade et al., 1986) which cannot be measured financially, to those of providing the services to care for these patients, either at home or in hospital. The latter are difficult to gauge, but it has been estimated that in England and Wales the annual cost to the National Health Service alone is currently over 500 million pounds (Dale, 1988). It is, therefore, important that ways of enhancing the recovery of people who have had a stroke are actively explored.

Hemiplegia:

course and management

One of the most common physical problems following stroke is muscular weakness or paralysis. Typically, when there is damage to some portion of the motor cortex or to the fibres in the descending cortico-spinal pathways, there is motor impairment of the muscles on the contralateral side resulting in a condition known as hemiparesis or hemiplegia (Gresham and Granger, 1987). Studies reviewed by Wade er al. (1985) identified motor weakness in 50-80% of patients after stroke. Such weakness is often persistent, if not permanent. One study identified that 45% of people alive 6 months after their stroke still had weakness in their arm and 43% still had weakness in their leg (Wade and Hewer, 1987b). It is generally recognized that such paralysis after a stroke results in an initial period of muscle flaccidity followed by a gradual or sudden reflex increase in muscle tone (Batehup, 1982). This is believed to be due to the release of reflex patterns of muscle movement which, though present since birth, are normally modified by the activity of the mature nervous system. Where there is cortical damage and resulting interruption of neural transmission such as after a stroke, the primitive reflexes seen in infancy (Table 1) can once again

POSlTlO,V~,VG OF THE STROKE

P.-l TIE‘ST:

.4 LITER.4 TL’RE RE C’IE U.

357

predominate and affect normal movement (Dardier, 1980). Although the strength of the reactions elicited by the release of these reflexes varies between individuals and does not always result in observable movement, definite increases in resistance to passive flexion/extension are indicative of changes in tone (Bobath, 1971). It is thought that such changes can lead to spasticity, the possibility of contractures and the common clinical picture depicting flexion in the affected arm and extension in the affected leg (Brandstater, 1987). Thus, stroke patients present typically with the abnormal posture described in Table 2. I.

Table

Primitive

reflexes

normally

under cortical

control

Reflex: Stimulus: Effect:

Symmetrical tonic neck Stretching muscles and joints of neck in tlexion/extension (i.e. nodding movement) Neck extended: increase in extensor tone in upper limbs: increase in flexor tone in lower limbs Neck flexed: increase in flexor tone in upper limbs; increase in estensor tone in lower limbs

Reflex: Stimulus: Effect:

Asymmetrical tonic neck Rotation of neck “Face” side: increase in extensor tone “Occiput” side: increase in flexor tone

Reflex: Stimulus: Effect:

Labyrinthine Change in the position of the head in space Supine: increase in extensor tone through body Prone: increase in flexor tone through body

Reflex: Stimulus: Effect:

Grasp Tactile stimulus in palm of hand Finrers flex and adduct -,

Reflex: Stimulus: Effect:

Positive supporting Pressure on skin of toe pads and ball of foot Increase in extensor tone throughout the limb; simultaneous

Rcllex: Stimulus: Effect:

Crossed extensor Leg llexion Increase in extensor

From Bobath

(IY71.

1990).

tone of opposite

Dardicr

Table 2. Typical

(1980)

and Davies (lY85).

Part of body

Scapula (affected side) Shoulder (affected side) Elbow (affected side) Forearm (affected side) Wrist (affected side) Fingers (affected side) Trunk Pelvis Hip (affected side) Knee (affected side) Ankle (affected side) Sub-[alar joint Forefoot Toes (affected side)

of nexor groups

leg

posture of a patient with an untreated a stroke

Head

co-contraction

hemipiegia

following

Position Side flexed to affected side Rotated away from affected side Depressed; retracted Adducted; internally rotated Flexed Pronated Flexed Flexed Side nexed to affected side Retracted on affected side Extended, adducted and internally Extended Plantar flexed Inverted Supinated Dorsinexed

From Gee and Passerella (1985)

(using U.K.

terminology).

rotated

358

E. h’. CA RR A.VD F. D. A’E.\.b’El’

A major aim of the early management of stroke patients is to prevent the onset of such muscular spasm which, it is thought, will impair the patient’s potential to regain the use of the affected parts of his body (Johnstone, 1982). A range of therapeutic approaches to facilitate stroke patients’ physical recovery have been advocated by protagonists such as Bobath and Bobath (1950), Rood (1954) and Brunnstrom (1970). However, though differing in their emphasis, their common recognition of the importance of reducing spasticity, the influence of reflex activity on early motor behaviour and the potential to use these reflexes during treatment to facilitate or inhibit voluntary movement after a stroke has been identified (Flanagan, 1967; Cotton and Kinsman, 1983). A long-recommended strategy to discourage the development of post-stroke spasticity, contractures and other undesirable sequelae of stroke is to encourage patients to maintain “reflex-inhibiting” patterns of posture (Bobath, 1978, 1990). This strategy has gained popular support (Atkinson, 1986), as evidenced by the plethora of texts following Bobath’s ideas. Such texts frequently emphasize the importance of nurses helping stroke patients to maintain the postures regarded as therapeutic (Johnstone, 1982; Myco, 1983; Gee and Passerella, 1985; Bobath, 1990). Studies have demonstrated that stroke patients in hospital, including those in rehabilitation units, spend between 30 and 50% of the most active part of their daytime in passive pursuits such as sitting unoccupied, lying or watching television (Keith and Cowell, 1987; Lincoln ef al.. 1989; Tinson, 1989); thus attendance to posture may be a means of ensuring that physical recovery is promoted 24 hours a day so that the onset of potentially preventable complications of stroke is averted. However, though clinical experience suggests that careful handling of paralysed limbs is essential to facilitate a good recovery (Wade ef al., 1985) the impact on the recovery process of this widely acclaimed therapeutic strategy has not been evaluated (Wilson-Barnett and Batehup, 1988). Furthermore, fundamental questions about its implementation by nurses in the long periods between the patient’s sessions of formal physiotherapy have never been answered. As the first stage in a study of the positioning of patients after a stroke, a review of commonly used texts was undertaken to establish the received view about recommended postures and their rationale in terms of the underlying physiological activity. Thirteen sources were studied in relation to five positions: lying on the unaffected side, lying on the affected side, lying supine, sitting up in bed and sitting in a chair. For each position information about nine “key points of control” were sought: the head and neck, shoulder, elbow, wrist, fingers, trunk, hip, knee and ankle/foot. The positioning of these key points is thought to influence muscle tone throughout the affected parts of the body (Bobath, 1990). Recommendations were either taken from the text or inferred from any accompanying diagrams or photographs. This paper summarizes the findings of the review in conjunction with a consideration of the effects of the related reflexes. The material is grouped according to the recommendations for the posture of individual parts of the body. Summaries of the main points as they relate to the patient’s overall starting position are given in Tables 3 to 7. Position

of the head and neck

It can be seen from Table I that three of the reflexes identified as contributory to the abnormal posture of untreated stroke patients are elicited by movements of the head and neck. Surprisingly, however, few authors mentioned head position specifically and in many of the accompanying illustrations it was not clear. This applied particularly to the side-

POSITfO~VI.L% OF TtiE STROKE P.-i TIENT:

Table

3. Authors’ recommendations

Part of body Head and neck

for positionin_e patient

Consensus of opinion about position (author code: see key) Neutral,

symmetrical

359

A LITER.4 TURE REL’IECC

on unaffected

side: summary

Opinion divided/points (author code: see key)

of main issues

to clarify

position

(2. 5. 6, 7. 8) Affected upper limb

Elbow extended? (3, 7. 9-l’) Elbow flexed?

Shoulder protracted (I-13) Arm forward on pillow (I-13) Wrist in neutral position

(I.

2, 4. 6. 13)

(2. 4, 5. 7. 8, II. Fingers extended (2, 4, 5, 7, 8, Il. Thumb abducted (2, 5, 7. II, 13)

13)

Trunk

Straight

13)

Affected lower limb

Hip forward, flexed and supported (l-11. 13) Knee forward, flexed supported (l-11. 13)

Position of foot? (little detail given)

Unaffacted lower limb

Behind affected

Hip extended/neutral (2, 3. 7. 8. Hip flexed? (2. 5, 6. 9)

(l-9,

13)

II,

limb (l-9,

Support under wrist/mid-trunk? (I. 6. 8. II) Support to maintain position? (I, 2, 9, IO, 13) No support? (3, 5) 90” to bed? (3, 5, 7, 9) >90” to bed? (I. 6, 13)

I I)

1I)

Key to Refs used: (I) Todd (1974); (2) Dardier (1980); (3) Johnstone (1982): (4) Carr and Shepherd (1982); (5) Batehup (1982); (6) Myco (1983); (7) Davies (1985); (8) Gee and Passerella (1985); (9) Turnbull and Bell (1985); (IO) Holmquist

and Wrethagen

(1986);

(11) Swaffield

(1990);

(12) Bobath

(1990);

(13) Bronstein

et al. (1991).

lying positions in which the degree (if any) of side-flexion afforded by the supporting pillows was not obvious and the ideal was not made explicit. The variety of terminology used to describe how the head should be moved, such as “turn” (Dardier, 1980). “tilt” (Gee and Passerella, 1985). “bend” (Swaffield, 1990) and “place laterally” (Bobath, 1990) could be confusing to readers unfamiliar with the separate movements of flexion and rotation. However, the information available seemed to indicate that, when lying on the unaffected side, the head should be supported in a neutral, symmetrical position. This suggestion was largely supported by the illustrations provided by Dardier (1980), Batehup (1982), Myco (1983), Davies (1985) and Gee and Passerella (1985). For lying on the affected side the diagrams were less clear. However, in the latter position, Davies (1985) suggested that the head should be “flexed” (though did not say whether forward or to one side) and Todd (1974) and Myco (1983) indicated that the head should be “forward”. Swaffield (1990) emphasized that the neck should be “straight”. Clarification of these comments may be important as, via the symmetrical tonic neck reflex, forward fle?cion of the neck can promote the undesirable pattern of increased flexor tone in the upper limbs and extensor tone in the lower limbs (TabIes 1 and 2). Slight flexion of the head and neck was specifically advocated for supine-lying (Dardier, 1980) to modify the effect of the tonic labyrinthine reflex. Many authors such as Todd (1974), Johnstone (1982) and Davies (1985) warned that supine-lying should be used as

360

E. K. CAR R AiVD F. D. KE.V,VE k Table 4. Authors’ recommendations Part of body

Consensus

for positioning patient on affected side: summary of main issues Opinion

divided/points

(author

code: see key)

of opinion

about position

(author

code: see key)

Head and neck

Neutral, (though

symmetrical position many illustrations unclear)

Head Head

Affected upper limb

Shoulder protracted (to 90’ to body if possible) (l-3. 5-13) Arm forward

to clarify

“flexed” (7) (I) “forward”

Arm on pillow? (2, 9. 13) Arm not on pillow (I.

7. JO. II)

(l-3. 5-9, I I-13) Elbow extended (I, 3. 5-13) Forearm, hand supinated (1. 3, 5-9, II. Wrist neutral

13)

(2, 3. 5, 8, I I. 13) Fingers extended (3, 5. II) Thumb abducted (3, 5, 8. 11)

-

Unaffected upper limb

On/behind (I.

the body?

3, 7. 13)

In front of the body? (5. 8. 9, II) Trunk

Straight (l-3, s-9,

Affected lower limb

Pillows for support? II.

13)

I I)

Hip extended/neutral?

Knee flexed (l-3, 5. 7-11.

13) -

Unaffected lower limb

(I. 7. 8, 13) No support? (2. 5, 9.

Knee flexed? (l-3, 5, 6, 13) Supporting pillow (l-3, s-7, II, 13)

(1. 2. 7, II) Hip flexed?

(5. 8.

9. IO. 13) Position of foot? (little detail given) In front of affected (l-3, 6, II) Behind affected

limb?

limb?

(7. 9. 13)

Key to Refs used: (I) Todd (1974); (2) Dardier (1980); (3) Johnstone (1982); (4) Carr and Shepherd (1982); (5) Batehup (1982); (6) Myco (1983); (7) Davies (1985); (8) Gee and Passerella (1985); (9) Turnbull and Bell (1985); (IO) Holmquist and Wrethagen (1986); (I I) Swaffield (1990); (12) Bobath (1990);

(13) Bronstein

er 01. (1991).

little as possible, as in this position the abnormal reflex activity is at its highest due to the influence of the tonic neck and labyrinthine reflexes (Dardier, 1980; Davies, 1985). In providing the requisite flexion of the head and neck, authors recognized that care must be taken to avoid the “half-lying” position in which the degree of flexion in the head and trunk reinforces unwanted flexor tone in the trunk and extensor tone in the lower limbs (Davies, 1985). The rationale for this was not given but may be related to the release of the symmetrical tonic neck reflex. Overall, more attention to the head position in supinelying was paid by authors than for the side-lying positions. All those who addressed this issue advocated supporting the head and neck on a pillow, though again, the number and height of the pillows varied, thus affecting the degree of neck flexion. However, there were

POSlT~O~VI.VG OF THE STROKE Table 5. Authors’ recommendations

PA TIE.NT: .A LITER.4 TURE REVIEW.

for positioning

patient

Opinion (author

summary

divided/points code: see key)

of main issues to clarify

Part of body

Consensus of opinion about (author code: see key)

Head and neck

Support on pillow in “slight” (l-3, 5. 7, 9-13)

Affected upper limb

Shoulder protracted and arm supported on pillow (l-3. 5, 7-12) Wrist in neutral (I. 2, 5. 8. 9, II. 13) Fingers extended (I. 2. 5, 8, 9. 11-13) Thumb abducted (l-3, 5. 8, 9, 11, 13)

Shoulder elevation? (1, 7. 12) Shoulder abduction and external rotation? (l-3, 5, 8, 10, 11) Little/no shoulder abduction and external rotation? (9, 12) Elbow flexed? (1, 5, 13) Elbow extended? (2, 3, IO. II) Hand pronated? (I, 5. 13) Hand supinated? (2, 3. 10. 11)

Trunk

Straight (I-3, 5. 7-9.

Pillow under trunk? (1. 5) No pillow under trunk? (2, 3, 7-9. 11-13)

Affected lower limb

11-13)

Hip forward on pillow (l-3, 5, 7-12) Nothing against soles of feet (l-3, 5. 7, 9, II, (I?), 13)

position

in supine-lying:

flexion

361

Number and height of pillows? In midline? (5. 9. 10. 13) Head turned’ to affected side? (1.7) Lateral flexion to unaffected side? (1, 8, Il. 12)

Knee flexed? (2, 3, 10, 11) Knee extended? (I, 7. 9. 12, 13) Support from buttock to knee? (I. 5. 8. 11-13) No support against thigh? (2, 3. 7, 9) Position of foot? (little detail given)

Key to Kefs used: (1) Todd (1974); (2) Dardier (1980); (3) Johnstone (1982); (4) Carr and Shepherd (1982); (5) Batehup (1982); (6) Myco (1983); (7) Davies (1985); (8) Gee and Passerella (1985); (9) Turnbull and Bell (1985); (IO) Holmquist and Wrethagen (1986); (1 I) Swaffield (1990); (12) Bobath (1990); (13) Bronstein er 01. (1991).

differing ideas as to whether the head should be in midline or “normal” position (Batehup, 1982; Turnbull and Bell, 1985; Holmquist and Wrethagen, 1986; Bronstein et al., 1991) or turned to the affected side (Todd, 1974; Davies, 1985). Since one of the strongest effects of the asymmetrical tonic neck reflex is seen in the supine position (Bobath, 1990) rotation of the head to the affected side may indeed be helpful in promoting extension in the affected upper limb. Todd (1974). Gee and Passerella (1985). Swaffield (1990) and Bobath (1990) suggested that the head should be flexed to the unaffected side, the rationale being to avoid increasing the tone in the muscles of the neck (Gee and Passerella, 1985). Certainly this would seem logical in helping to counteract the abnormal pattern of neck flexion described in Table 2. Dardier (1980) suggested specifically that the neck should be “flexed”, but whether forward or to one side was not made explicit. For sitting positions, either in bed or in a chair, there was agreement that the head should be in the midline, the exception being Gee and Passerella (1985) whose picture showed the patient’s head rotated towards the affected shoulder when sitting in a chair. Though

362

E. K. CA RR AiVD F. D. KEz%‘~L% Y Table 6. Authors’ recommendations Part of body

Consensus (author

Head and neck

Affected upper limb

for positioning patient sitting-up in bed: summary of main issues

of opinion

about position

code: see key)

Opinion (author

divided/points

to clarify

code: see key)

Midline position (1, 2, 4-9, II)

Avoid

Shoulder protracted and arm forward (I, 3, 5-9, II, 13) Elbow flexed (I, 4, 5, 7) Hand pronated (1. 4, 5, 8, 9) Wrist neutral

Shoulder (I. 4-6) Little/no

using pillows for support?

(1, 7) abduction? shoulder abduction?

(9)

(1, 3, 4, 5, 8, 9, ll) Fingers extended (I. 3, 4. 5. 8, 9, Jl) Thumb abducted (1. 3, 4, 5. 9, II) Straight (I, 5-9.

Trunk

Affected lower limb

and supported II)

Legs straight out in front (1, 5-7.

-

by pillows

9)

Support under hip and thigh? (3. 5, 8. II) Support along hip and thigh? (I. 6, 9) Position of foot? (little detail given)

Key to Refs used: (I) Todd (1974); (2) Dardier (1980); (3) Johnstone (1982); (4) Carr and Shepherd (1982); (5) Batehup (1982); (6) Myco (1983); (7) Davies (1985); (8) Gee and Passerella (1985); (9) Turnbull and Bell (1985); (IO) Holmquist and Wrethagen (1986); (I I) Swaffield (1990): (12) Bobath (1990); (13) Bronstein er 01. (1991). Table 7. Authors’ recommendations Part of body

Consensus (author

Head and neck

Affected upper limb

Trunk Lower

for positioning patient sitting in a chair: summary of main issues

of opinion

about position

code: see key)

Midline position (l-7, 9-l I) Shoulder protracted and arm forward (I, 3, 5-9, II, 12) Hand pronated (I, 3. 5. 8. 9. ll) Wrist neutral (I. 3, 5, 8, 9, ll) Fingers extended (1. 3. 5, 8, 9, 11, 12) Thumb abducted (I, 3, 5, 8. 9. 11) Straight and supported (1, 3. 5-9. II)

limbs

Hips flexed at 90” to trunk (I, 3. 5-9, II) Knees flexed at 90” to hips (I. 3. 5-9. II) Equal weight through both hips (I, 3. 6, 8-10) Feet flat on floor (I, 3. 5-11)

Opinion

divided/points

(author

code: see key)

to clarify

Turned

towards the affected

side?

(8) Shoulder

straight

forward?

(7. 9) Shoulder abducted and externally rotated? (I, 5, 6, 8, I I) Elbow extended? (9, 11, 12) Elbow flexed? (2. 3, 5, 7. 8)

Feet slightly apart? (3. 5, 7-9. II) Feet together? (I. IO) Support from buttock to hip? (1, 5. 12) No support along thigh? (7-9, II)

Key to Refs used: (I) Todd (1974); (2) Dardier (I 980); (3) Johnstone (I 982); (4) Carr and Shepherd (1982); (5) Batehup (1982); (6) Myco (1983); (7) Davies (1985); (8) Gee and Passerella (1985); (9) Turnbull and Bell (1985); (IO) Holmquist and Wrethagen (1986); (I I) Swaffield (1990); (12) Bobath (1990); (13) Bronstein er a/. (1991).

POSITl0Xl.W

OF THE STROKE

PATIENT:

A LITER.4 TL’RE REVIEW.

363

no rationale was given for this, turning the head thus may facilitate extension in the upper limb through the asymmetrical tonic neck reflex. Opinions differed as to whether pillows should be used for support in sitting (Dardier, 1980; Carr and Shepherd, 1982; Batehup, 1982; Turnbull and Bell, 1985; Gee and Passerella, 1985; Swaffield, 1990) or whether the head should be unsupported which was recommended by Davies (1985) and shown by Todd (1974). Davies’ reason for this was to encourage the patient to learn to support himself. However, since sitting up with the head thrown backwards is another of the positions in which the asymmetrical tonic neck reflex is seen most strongly (Bobath, 1971), presumably great care should be taken if supporting pillows are not provided. Overall, however, though there was some difference of opinion, the consensus was that the head and neck should be in the midline or turned to the affected side. This has the added advantage of encouraging the patient to attend to the environment on the affected side which some may tend to neglect (Dardier, 1980). No authors suggested turning the head to the unaffected side. If side-flexed, this should be away from the affected side.

Position

of the upper limb

In all positions there was agreement that the shoulder should be protracted with the arm brought forward [ideally to 90” to the body when lying on the affected side (Gee and Passerella, 1985; Davies, 1985)\ to counteract the tendency for retraction of the scapula. In supine-lying this may be particularly important where the release of the tonic labyrinthine reflex has resulted in resistance to shoulder protraction (Davies, 1985). However, the number and height of the pillows (or table for sitting positions) recommended to support the shoulder and arm in this forward position was varied. This may be important as the degree of shoulder flexion and protraction of the scapula are thereby affected. For example, for lying on the affected side some authors recommended that the affected arm should rest on a pillow (Dardier, 1980; Turnbull and Bell, 1985; Bronstein ef al., 1991) while others did not (Todd, 1974; Davies, 1985; Holmquist and Wrethagen, 1986; Swaffield, 1990). Gee and Passerella (1985) suggested it should not, unless the elbow is flexed and needs support. In supinelying Bobath (1990) suggested that the arm should be positioned higher than the trunk and two authors identified an alternative position with the upper limb flexed at the shoulder and elevated above the head (Todd, 1974; Davies, 1985). A second area of controversy concerned the strategy for counteracting the tendency for the affected shoulder to adduct and rotate internally. In supine-lying, Johnstone (1982) Gee and Passerella (1985) and Holmquist and Wrethagen (1986) stated that the shoulder should be positioned in external rotation and the illustrations of Todd (1974), Dardier (1980) Batehup (1982) and Swaffield (1990) indicated a degree of shoulder abduction. In contrast, those of Turnbull and Bell (1985) and Bobath (1991) showed little, if any. Similarly there was conflict among the recommendations for this aspect of the sitting positions. For sitting in bed, while little mention was made of shoulder abduction in the texts, the illustrations of Todd (1974) Batehup (1982), Carr and Shepherd (1982) and Myco (1983) indicated varying degrees of abduction. In the illustration provided by Turnbull and Bell (1985) no abduction was evident. For chair sitting, the illustrations differed as to whether the arm should be brought straight forward (Davies, 1985; Turnbull and Bell, 1985) or whether it should be slightly abducted/externally rotated (Todd, 1974; Batehup, 1982; Myco, 1983; Gee and Passerella, 1985; Swaffield, 1990). Dardier (1980) suggested that both positions

364

E. K. CARR

A.VD F. D. KE.\.\El

have advantages: a position of slight abduction and external rotation at the shoulder the trunk and can help to hold the forearm in the preferred position of supination; bringing the arm straight forward onto a table keeps the arm in the patient’s visual field and promotes bilateral integration of the hands. There was general agreement that the wrist should always be in a neutral position with the fingers extended and the thumb abducted. However, opinions again were varied about the elbow and forearm. Extension of the elbow and supination of the forearm, which might be the expected recommendations to counteract the reflex tendency of the elbow to flex and the forearm to pronate after a stroke (Table 2) and which were advocated almost unanimously for lying on the affected side were not always the suggestions made for other positions. For lying on the unaffected side opinion was divided as to whether the elbow should be extended (Johnstone, 1982; Davies, 1985; Turnbull and Bell, 1985; Holmquist and Wrethagen, 1986; Bobath, 1990; Swaffield, 1990) or partially flexed (Todd, 1974; Dardier, 1980; Carr and Shepherd, 1982; Myco, 1983; Bronstein et al., 1991). Indeed, Gee and Passerella (1985) advocated “arm extension” in the text but showed elbow flexion in the accompanying photograph. Siqlarly for supine-lying, opinion was divided: elbow flexion with hand pronation was recommended by several authors (Todd, 1974; Batehup, 1982; Bronstein et al., 1991) while extension with the hand supinated was indicated by others (Dardier, 1980; Johnstone, 1982; Holmquist and Wrethagen, 1986; Swaffield, 1990). Gee and Passerella noted that the latter option was preferable but that the former would suffice if the preferred position was unattainable. For sitting in bed, while not specifically mentioned, most illustrations showed the elbow to be slightly flexed, including that by Swaffield (1990) who wrote that the elbow should be straight. In that of Turnbull and Bell (1985) it was shown as extended. However, for sitting in a chair there were again two schools of thought: either full extension of the elbow (Turnbull and Bell, 1985; Swaffield, 1990; Bobath, 1990) or slight flexion (Dardier, 1980; Batehup, 1982; Johnstone, 1982; Davies, 1985; Gee and Passerella, 1985). For both of the sitting positions and for lying on the unaffected side most agreed that the hand should be pronated. Finally, the position of the unaffected arm was considered. In most positions the authors’ recommendations were similar, disagreement being evident only for lying on the affected side in which some authors recommended that the unaffected arm rest on or behind the body (Todd, 1974; Davies, 1985; Johnstone, 1982; Bronstein ef al., 1991). Others clearly favoured forward placement (Batehup, 1982; Turnbull and Bell, 1985; Gee and Passerella, 1985; Swaffield, 1990). Overall, therefore, it was clearly recognized that the affected shoulder should be protracted, the arm brought forward and the fingers extended. The degree of shoulder flexion, abduction and external rotation recommended tended to vary. Perhaps the important point is the implication that extension, adduction and internal rotation of the shoulder should be avoided. While extension of the elbow and supination of the forearm when lying on the affected side were clearly deemed to be important by all, may there be more scope for flexibility in these aspects of positioning in other postures? Whether or not the position of the unaffected upper limb is of any therapeutic importance may be worthy of reflection. SUPPOSES

Position of the trunk The consensus for all positions was that the trunk should be straight and in the midline.

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Any disagreement was largely about the use of pillows for support and helping to maintain alignment. While for sitting positions such support was advocated in bed and (via a backboard) in a wheelchair (Davies, 1985; Bobath, 1990). The recommendations were not so clear for lying positions. For example, for lying on the unaffected side the diagrams provided by Batehup (1982) and Johnstone (1982) showed no. supporting pillows; Todd (1974). Gee and Passerella (1982). Myco (1983) and Swaffield (1990) all suggested a pillow or folded towel under the waist or in the mid-trunk region to stretch the affected side/keep the spine straight; and Todd (1974) Dardier (1980), Turnbull and Bell (1985), Holmquist and Wrethagen (1986) and Bronstein et al. (1991) suggested using pillows to support the back, helping to maintain the patient’s position. In discussing trunk alignment when lying on the affected side, Todd (1974), Davies (1985), Gee and Passerella (1985) and Bronstein et al. (1991) advocated placing a pillow behind the back to keep the affected side forward. In contrast, Dardier (1980), Batehup (1982), Turnbull and Bell (1985) and Swaffield (1990) omitted or advised against a pillow. This was rationalized by Swaffield who suggested that the patient would push back against it. In the supine position only two authors clearly showed pillows under the trunk (Todd, 1974; Batehup, 1982). Todd implied that such a pillow would facilitate “elongation” of the affected side. It was also interesting that for lying on the unaffected side there was a lack of consensus as to what constituted “side-lying”. Authors whose text or illustrations suggested that the patient’s back should be at 90” to the bed included Batehup (1982) Johnstone (1982) Davies (1985) and Turnbull and Bell (1985). Other authors suggested that the body should be rotated through more than 90” (Myco, 1983; Gee and Passerella, 1985; Bronstein ef al., 1991) in “full side-lying” (Todd, 1974). In summary, therefore, there was agreement that the spine should be straight and that flexion of the trunk should be avoided. The benefits of supporting pillows when lying would seem to be debatable.

Position

of the lower limb

For sitting positions and lying supine there was some recognition that the hip should be prevented from external rotation/abduction with support from buttock to knee. For those who advocated such support, either with the edge of a pillow (when supine) or with a rolled towel/sandbag when sitting in a chair (Swaffield, 1990; Bobath. 1990) the imperative was that the support should be placed alongside the limb. For sitting in bed, while some authors also thought that support should go alongside the buttock and thigh (Todd, 1974; Myco, 1983; Turnbull and Bell. 1985). others advocated placing such support underneath them (Batehup, 1982; Johnstone, 1982; Gee and Passerella, 1985; Swaffield, 1990). For lying supine and on the unaffected side there was largely agreement that the affected hip should be lifted forward with the limb on a supporting pillow, although in the illustrations of supine lying provided by Davies (1985) and Bronstein ef al. (1991) this was not clear. Such forward placement is clearly congruent with the aim of minimizing the tendency of the affected hip to retract (Table 2). Flexion of the affected hip was advocated by nearly all when lying on the unaffected side but only by some (Batehup, 1982; Gee and Passerella, 1985; Turnbull and Bell, 1985; Holmquist and Wrethagen. 1986; Bronstein ef al., 1991) for lying on the affected side. In the latter position Todd (1974) Dardier (1980) Davies (1985) and Swaffield (1990) indicated that it should be extended or in a neutral position. Johnstone (1982) suggested a “comfortable” position but the accompanying

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diagram was unclear. Given the anticipated increase in extensor tone of the hemiplegic hip, clarification of these recommendations may be important. There was agreement that the affected knee should be flexed in the side-lying positions and be forward, with support from a pillow when lying on the unaffected side. In supine lying several authors also recommended slight flexion with a little support (Dardier, 1980; Johnstone, 1982; Swaffield, 1990). Holmquist and Wrethagen (1980) recommended using a folded towel to avoid flexion of the calf and hyperextension of the knee. However, others suggested knee extension with no supporting pillow for supine lying. These included Todd (1974). Davies (1985), Turnbull and Bell (1985), Bronstein et al. (1991) and, under certain circumstances, Bobath (1990). For sitting in bed, authors agreed that the patient’s legs should be straight out in front. Overall, the position of the affected ankle and foot received little comment or clear illustration. For lying on the affected side no specific details were mentioned in the texts. For lying on the unaffected side, while some specifically indicated that the foot should be supported and not hanging over the edge of the pillow (Dardier, 1980; Davies, 1985), the diagrams of Todd (1974) and Myco (1983) showed the foot unsupported. Dardier (1974) recommended that the ankle should be in dorsiflexion and the foot slightly everted but this was not clear in the accompanying diagram. This position would oppose the tendency of the affected foot to plantarflex and invert (Table 2). Footboards were not advocated except by Bobath (1990), again under certain specified circumstances. It is thought that pressure against the sole of the foot may trigger the positive supporting reflex which would increase undesirable extensor tone and spasticity in the affected limb (Dardier, 1980). The position of the unaffected limb in side-lying was also a cause of debate. For lying on the unaffected side, while agreeing that the unaffected hip should be behind the affected one to stop the patient rolling back, authors differed in their opinions as to whether the unaffected hip should be in a neutral/extended position (Johnstone, 1982; Davies, 1985; Gee and Passerella, 1985; Swaffield, 1990) or slightly flexed (Batehup, 1982; Myco, 1983; Turnbull and Bell, 1985). Dardier (1980) suggested that either is acceptable. For lying on the affected side most authors Iwith the exception of Davies (1985); Turnbull and Bell (1985); and Bronstein ef a/. (1991)l agreed that the unaffected limb should be in front of the affected one, with the knee flexed. Most also recommended placing a small pillow under the unaffected leg although Turnbull and Bell (1986) did not. Davies suggested that such a pillow helps to maintain the position of the hemiplegic leg in addition to supporting the unaffected leg. Overall, the extent to which the position of the unaffected limb is of importance was not clear. No authors discussed the possible influence of the crossed extensor reflex whereby flexion of the unaffected limb may increase extensor tone in the affected limb (Table 1). When sitting in a chair, Davies (1985) hypothesized that the effects of the tonic labyrinthine reflex result in an increase in the extensor tone of the muscles of the lower limb. This encourages the patient to slide forward in the chair with the affected knee extended and the foot pushed forward, such that either he falls off, or slips into the undesirable “half-lying” position described earlier. The consensus was, however, that the hip and knees should be flexed, both at right angles (Turnbull and Bell, 1985; Gee and Passerella, 1985) with equal weight being borne through both hips. Hip abduction should be prevented as described earlier by Swaffield (1990) and Bobath (1990). Feet should be flat on the floor or on the step of the wheelchair with most authors suggesting that they should be slightly apart [Turnbull and Bell (1985) suggested 6 to 8 inches] although

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Holmquist and Wrethagen (1986) suggested that the feet should be together, as does the diagram provided by Todd (1974). Overall, therefore, the consensus was that external rotation and abduction of the hip should be prevented through support such as pillows or rolled towels. The affected hip should be brought forward but the emphasis on maintaining flexion of the hemiplegic hip which might be expected to counteract increased extensor tone (Table 2) seemed to vary with the starting position of the patient. Similar variation was evident with the knee: flexion was largely advocated but opinions were divided on this issue for supine lying. Although no authors recommended the use of footboards there was an overall lack of detail about the positioning of the ankle and foot despite acknowledgement that if untreated, a hemiplegic foot is likely to develop postural abnormalities (Table 2). Given the importance of the position of the foot for walking and achieving a normal gait this may be a noteworthy omission. As with the upper limb, opinions were divided about the best position for the unaffected side. Discussion This literature review has identified a consensus among authors’ recommendations for some aspects of the positioning of hemiplegic stroke patients but disagreement on others. Issues on which there was broad agreement included protraction of the shoulder, alignment of the spine, extension of the fingers, avoidance of external rotation of the hip and avoidance of pressure against the soles of the feet. Examples of aspects of posture for which recommendations conflicted included, elbow flexion/extension and the position of the unaffected limbs. Several potentially important aspects of posture were ill-covered and, not infrequently, the desired information was both missing from the texts and difficult to interpret from illustrations. For example, little detailed consideration was given to the discussion of the best position for the head and neck, ankles and feet. Not all of the texts included information on all of the parts of the body and not all were illustrated. Terminology tended, at times, to be confusing and few included the underlying rationale. The use of pillows or folded towels for support afforded some confusion and aIso begged questions: while Davies (1985) pointed out that pillows come in different sizes, textures and thicknesses, there was little, if any, recognition by other authors that the degree of flexion or elevation achieved through the use of pillows will vary accordingly. On the whole it was difficult to gather from the illustrations how pillows should be used and the issue of comfort was rarely mentioned. Whether “neutral” postures should be adopted as far as possible, or whether it is thought to be helpful to use posture to evoke patterns of muscle activity directly opposite to any abnormalities was also unclear. The question remains, of course, as to whether the positioning (either in isolation or in combination) of any or all of the parts of the body subjected to such close scrutiny in this paper has an effect on the extent of the patient’s overall recovery from hemiplegia after stroke. However, current understanding seems to suggest that attendance to posture is likely to be an important element in maximizing patients’ functional gains and quality of life. There is already some consensus on how this can be achieved. Clearly further research is needed, both to evaluate the importance of assisting patients to maintain those postures agreed to be therapeutic and to explore the areas where there are yet discrepancies. Nurses’ and (with the increasing emphasis on community care) relatives’ potential to assist recovery

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from stroke through careful attention to posture is enormous, but can be maximized only through the judicious development of knowledge. Henderson (1980, p. 245) suggested that nurses are “rehabilitators par excellence”. This can be achieved through teaching patients and their carers as well as through giving direct care. There is yet, however, much more exploration needed to facilitate the ideal and to maximize the contribution of nursing care to the enhancement of quality of life in those unfortunate enough to suffer a stroke.

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1992)

Positioning of the stroke patient: a review of the literature.

Stroke is a common and disabling illness, adversely affecting the quality of life of hundreds of people each year. While there are many therapeutic ap...
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