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Evidence‐based approaches

The general principles of moving and positioning patients mentioned earlier in this chapter are all relevant to this section and can be applied when assisting those with complex neurological impairment. Patients with neurological impairment may be able to participate in the usual transfer techniques but the risk assessment will consider several additional factors. This section identifies considerations for staff in their decision making. Where there is any doubt when moving patients with complex needs, guidance should be sought from a physiotherapist or occupational therapist.
For those with acute and long‐standing neurological issues, the principles of moving and positioning can be applied at any time along the patient's treatment trajectory from rehabilitation to deteriorating function to palliative management.

Consequences of incorrect positioning and handling

There are various potential consequences of incorrect positioning and handling (Lundy‐Ekman [67]):
  • Shoulder joint subluxation (Figure 7.22) in patients with low tone if their shoulder joint is not correctly supported.
  • Traumatic shoulder injury if there is inappropriate handling of a patient during transfers, especially in low‐tone patients.
  • Pain from being in sustained postures and positions.
  • Exacerbation of spasticity due to pain.
  • Muscle shortening from sustained positioning. This most commonly occurs in the ankles where the feet fall or pull into plantarflexion (pointed toes) and stay in that position for extended periods, especially when a patient is not standing and stretching the posterior ankle muscles. This can become permanent if it is prolonged and is known as contracture. Contracture is most evident in people with high tone, because it is difficult to stretch their muscles in the normal way.
Patients with neurological deficits may vary in their presentation on a daily basis. The additional considerations for positioning and moving patients with neurological impairment are listed in Box 7.5.
Box 7.5
Considerations for moving patients with neurological impairment
  • Variations in tone, for example flaccidity or spasm
  • Cognitive problems including attention deficit
  • Behavioural problems
  • Communication problems
  • Variable patient ability, for example ‘on/off’ periods for patients with Parkinson's disease and patients with changing presentations, for example multiple sclerosis and degenerative conditions
  • Sensory and proprioceptive problems, including reduced midline awareness
  • Pain and/or altered sensitivity
  • Decreased balance and co‐ordination
  • Visual disturbance
  • Varying ability over 24 hours, for example fatigue at the end of the day or at night
  • Effects of medication
  • Varying capability of the patient according to the experience and/or skill mix of handler(s)
  • Post‐surgery: presence of tracheotomy, chest and other drains
  • Traumatic and non‐traumatic spinal injury: risk of spinal instability
  • Importance of maintaining privacy and dignity
Source: Adapted from CSP ([24]) with permission of The Chartered Society of Physiotherapy.
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