It has been reported that complications post-stroke can impede rehabilitation, increase hospital length of stay and the direct cost of patient care, as well as negatively affect functional outcomes [2]. As such, strategies to reduce the occurrence of complications post-stroke should be readily implemented. There are a number of potential complications that can arise from limbs being immobilised in poor alignment for prolonged periods of time as well as positions being sustained that may affect physiological parameters. These potential complications described in the literature are listed in Table 9.2 [26–39]. As pressure care will be discussed later in this chapter, this section will focus on the musculoskeletal and physiological complications arising from incorrect positioning.

One of the consequences of immobility imposed by the different impairments post-stroke is that the resting positions of different body regions can place muscles in shortened positions [26]. For example, the upper limb resting on the patient’s thigh in sitting upright results in shoulder adduction and internal rotation, elbow flexion, forearm pronation, and wrist and finger flexion and places these muscle groups in shortened positions compared to their antagonist muscles. Muscles adapt to this enforced immobilisation through loss of sarcomeres [27], resulting in muscle shortening, as well as changes in the viscoelastic properties of the surrounding connective tissues, including an increase in the ratio of collagen to muscle fibre [28]. These adaptive changes result in less compliance when passively stretched and manifest clinically as increased resistance on passive ranging. These adaptive changes have been demonstrated to occur within days of immobilisation [27] and could lead to more permanent soft tissue shortening, known as a contracture, if not effectively managed. Contractures are a common complication post-stroke, occurring in up to 60 % of patients within the first year post-stroke [2]. As upper limb function is more likely to be comprised with greater restrictions in joint range [11], strategies to prevent or slow down the development of contractures should be implemented. Whilst most studies have demonstrated that currently used positioning strategies have limited effect on contracture development [15], positioning patients early post-stroke may slow down the development of contractures [11].

In addition, positions or postures that do not provide adequate support to weak and hypotonic body regions may contribute to the development of other musculoskeletal abnormalities and pain. The shoulder joint is particularly vulnerable to these complications as it derives most of its stability from muscular support, which is often reduced or lost post-stroke [29]. If the upper limb is unsupported against gravity, the shoulder joint capsule and surrounding ligaments can stretch over time, which can result in inferior glenohumeral joint subluxation [29, 30]. Whilst subluxation itself may not be painful, it is strongly associated with hemiplegic shoulder pain [31], which can be a significant clinical problem resulting in poor recovery of arm movement and upper limb function. In addition, external and uncontrolled forces applied to the weak and hypotonic upper limb can lead to sub-acromial impingement, rotator cuff injury, and bicipital tendonitis [30]. Subluxation, soft tissue damage, and pain may be minimised if the upper limb is well handled and supported in different positions [29–31].

There are a number of respiratory and cardiovascular physiological changes that can arise in different positions, which may have clinical implications if patients maintain these positions for prolonged periods of time. Oxygenation may be lower in the supine and flat side lying positions compared to sitting upright at least 45° post-stroke [32, 33]. However, there may be no difference in oxygenation between side lying with the head of bed elevated at 45° compared to sitting upright in bed at 70° [34]. Blood pressure changes have been noted between supine and sitting upright positions, though results have been mixed [35–37]. Studies have also investigated the effects of positioning on cerebral blood flow and perfusion [37–39], which may have important consequences in ensuring that penumbral tissue post-stroke is sufficiently perfused. Again, results have been mixed due to small sample sizes, but more authors suggested that the supine position may result in improved cerebral blood flow and perfusion compared to sitting upright positions [37, 39]. Due to the inconclusive results from these studies, it is important that the patient is monitored closely for physiological changes arising from changes in positioning. It also supports the notion that patients require regular position changes due to the benefits of adopting different positions.

Immediately following a stroke, patients can demonstrate a range of impairments that will limit their ability to engage in rehabilitation [40]. Muscle weakness and flaccidity, due to decreased descending inputs on spinal motor neurons, as well as somatosensory impairments, can make it difficult for patients to move their limbs and adjust their position. Cognitive impairments, such as reduced attention, as well as decreased nutritional intake arising from dysphagia, can make it difficult for patients to participate in rehabilitative activities for sustained periods of time. As such, patients may spend a considerable amount of time in bed in the initial period post-stroke. Therefore, correct positioning of stroke patients in bed is important to prevent complications arising from poor positioning, which may influence the rehabilitation process and affect functional outcome [2].

Positioning of stroke patients in bed is not just confined to the initial period post-stroke. All patients will spend time in bed for sleeping, and patients who are able to sit out will need to return to bed at some point in order to rest and relax. As well, the initial period post-stroke may be followed by the emergence of abnormal posturing of the different body regions, due to muscle imbalance, soft tissue shortening, and increased tone [1, 40]. Common abnormal postures described in the literature [1] are listed in Table 9.3. The suggested positioning strategies for supine, side lying, and sitting upright in bed described in the literature and reported in this section are designed to counteract the effect of this abnormal posturing, which may result in secondary musculoskeletal complications if not prevented. Whilst these abnormal postures and suggested positioning strategies to counteract these postures have been well described in the literature [1], the actual presence of these postures in patients post-stroke has been inferred mostly from observations of clinical practice rather than through direct scientific evaluation. In addition, the suggested positioning strategies to counteract anticipated abnormal postures arising from stroke are based on the assumption that all patients experience these postures. However, there is no direct evidence to confirm this assumption. As such, these suggested positioning strategies should not supersede the findings from an individualised patient assessment. Instead, the strategies should provide guidance to assist clinicians in the optimal positioning of patients.

As positioning is considered to be most effective when applied consistently over a 24-h period [1], the use of diagrams or photographs taken with patient consent can be used in the clinical setting to demonstrate individual positioning strategies and use of equipment to convey to all members of the multi-disciplinary team how to optimally position patients (Fig. 9.1a–d).

For the following positions and unless otherwise stated, the reported joints refer to the joints on the affected side of the body, i.e. the side of the body presenting with the most impairments as a direct result of the stroke.

Why is seating important? Following damage to the central nervous system by a stroke, a patient’s ability to sit independently and unsupported can be affected [40]. Some stroke patients will demonstrate difficulty sitting unsupported in the short term or the acute phase of stroke recovery, whereas other patients will present with more significant impairments and require more long-term and complex postural management support. Being able to sit independently is integral to most, if not all, functional daily life tasks [40]. Therefore, ensuring that patients are positioned correctly in the seated position is seen as an essential part of the rehabilitation process to regain sitting balance and is pivotal to a patient’s recovery. Due to the limited evidence available to guide clinicians regarding correct seating post-stroke, providing appropriate seating for patients after stroke can be challenging and requires a multi-disciplinary approach involving nursing, physiotherapy, and occupational therapy. As such, it may be worthwhile to review the typical sitting postures adopted by stroke patients, and subsequently discuss the optimal seating positions in stroke rehabilitation.