CHANGING POSITIONS AND GIVING EXERCISES FOR BEDRIDDEN PATIENTS

1. CHANGING POSITIONS
AND GIVING EXERCISES
FOR BEDRIDDEN
PATIENTS
By – R.M.A.U. Ranasinghe (BSc. Hons in Physiotherapy)
Physiotherapist
Teaching hospital- Anuradhapura

2. Who are “bedridden patients” ?
•A bedridden patient is
a patient that, for some
reason, has to stay in bed
for a long period of time.

3. Reasons for being bedridden
• Orthopaedic conditions
Eg- multiple trauma
fractures of the spine, pelvis
and lower limbs
• Neurological conditions
Eg- Stroke
Spinal cord injuries
• Chronic progressive diseases
Eg- GBS
Multiple sclerosis
• Musculoskeletal conditions
Eg- Muscular dystrophies
Myopathies
• Advanced age
Eg- Alzheimer's disease
Dementia
Parkinson’s disease
• Surgeries
• Coma

4. Common Complications of bedridden patients
Musculoskeletal
complications
• Muscle weakness
• Muscle atrophy
• Muscle shortness
• Joint stiffness
• Bone demineralization
Circulatory
complications
• Thrombosis
Eg- DVT
• Embolism
Eg- MI
Pulmonary
embolism
Stroke
• Pressure ulcers
Respiratory
complications
• Breathing difficulties
• Lung infections
Eg- Pneumonia
Brochiectasis
• Exacerbation of asthma
COPD
Psychosocial
complications
• Stress
• Depression
• Ceiling syndrome

5. Musculoskeletal complications
• Muscle weakness/atrophy
Wasting or thinning of muscle mass caused by disuse of muscles or
neurogenic conditions. This can be identified with decrease in muscle
mass, one limb smaller than the other, numbness and weakness and
tingling in the limb.
• Muscle shortness
Remaining of the patient in the same position (lying or sitting)
can cause the muscles to stay in a short position; a position in which
those muscles are relaxed. Since the muscles quickly adapt their length
to the position in which they remain causing the muscle to become
shorter.

6. • Joint stiffness
As you age, joint movement becomes stiffer and less
flexible because the amount of lubricating fluid inside your joints
decreases and the cartilage becomes thinner. Ligaments also
tend to shorten and lose some flexibility, making joints feel stiff.
• Bone demineralization
Also called bone mineral density loss or disuse osteoporosis.
Bones become weaker (it looses too much minerals which make
the bone strong) when the bones are not simulated enough.
Bones are “stimulated” when constraints are applied on them
(for example, when walking, constraints –the body weight- are
applied on the bones. Those constraints help the bone to remain
strong.). When a patients stays in bed, there are less constraints
applied on the bones; this results in bone demineralization.

9. Circulatory complications
• Thrombosis
Blood clots (a callus or a thrombus) will form faster when the blood
circulation decreases (the speed of the blood circulating in the vessels
decreases) in some part of the body. This callus will decrease and eventually
stop the blood circulation (the callus forms an obstacle to the blood) creating
thrombosis (a stop of blood circulation).
• Embolism
The callus will get loose in the blood circulation releasing an embolus.
This embolus will then reach smaller blood vessels, get stuck and stop the
blood circulation there causing embolism.
• Pressure ulcers/sores
Appearing of wounds on parts of the body where there is pressure on
the skin close to a bone prominence. Constant pressure at a specific point on
the skin stops blood supply from reaching the skin on that particular area
causing the skin to die and form an ulcer.

12. Respiratory complications
• Breathing difficulties
• Lung infections
The lower flux of air in the respiratory tracts resulting in a less efficient
expectoration system which avoids the pulmonary secretions to “climb
up” the respiratory tracts and to get out of the lungs leading to
accumulation of secretions in the lungs, which can easily get infected
resulting lung infections.
• Exacerbation of asthma/COPD

14. Psychosocial complications
• Stress
• Depression
• Ceiling syndrome

15. Positioning of BEDRIDDEN
• Any position, after a period of time becomes uncomfortable and then
painful.
• The independent person has the ability to assume a great variety of
positions, the dependent person may be limited.
• The resident who is unable to move limbs freely to change positions or
who is partially or totally dependent because of injury or disease must
be moved at regular intervals.
WHY ?

16. • Changing the dependent’s position at least every 2 hours
accomplishes four things:
a) Contributes to the comfort of the patient
b) Relieves pressure on affected areas
c) Helps prevent formation of contractures or deformities
d) Improves circulation.

17. •KEY PRINCIPLES OF POSITIONING
1. Patient must be positioned in correct body alignment at all times.
2. The patient’s body should be supported with positioning aids to maintain
good alignment.
3. The position of the patient in bed must be changed at least every 2 hours.

18. PRINCIPLE # 1
Resident must be positioned in correct body alignment at all times.
GOAL - to position the patient so that the movable segments of the
body are aligned in such a way that there is no undue stress placed on
the muscles or skeleton. Good body alignment should be maintained
from side to side (laterally) as well as front to back (anterior-posterior).

19. IMPORTANT - amount of support required for positioning depends on the
individual patient. When creating a care plan and positioning schedule for a
patient we must look at the individual needs of that patient. understanding
the concept of correct body alignment and correct positioning helps us to
think “outside the box”, be creative and utilize resources that are readily
available.
PRINCIPLE #2
The resident’s body should be supported with positioning aids to maintain good
alignment.

20. • NOTE - If the resident’s position is not changed at least every two hours,
the individual will be at risk for pain from muscle discomfort, pressure
ulcers, contractures and damage to superficial nerves and blood vessels.
• Pressure ulcers may develop in a period of a few hours in an elderly,
undernourished and/or dehydrated resident.
PRINCIPLE #3
The position of the resident in bed must be changed at least every two hours.

21. Basic body positions and variations
SUPINE
Varies from flat
to 60 degrees
SITTING
Feet flat and a
90º/90º/90º
position
LATERAL
A 30 degree turn
to either side
• Supine (0-15 degrees)
• Supine (with pillows)
• Semi fowler’s position
(15-30 degrees)
• Fowler’s position (30-60
degrees)
• Lateral
• Sims's position
• Sitting on a chair
• Sitting on wheelchair

22. Supine
• For short period of time
• Head end may be elevated 15 degrees to add
comfort.
• Hyperextension of the neck is prevented and
alignment is maintained.
• A pillow under the thigh will decrease knee and
hip extension and relaxes lower back.
• Heels are resting on the bed.
Supine with pillows
• Older adults with kyphosis or limited neck
extension are supported and alignment
maintained.
• Pillows placed lengthwise starting at the ankles
and continuing to the bottom of the buttocks.
• Heels are off the bed floated by using pillows.
• Arms are rested parallel to the body and
supported in good alignment.

23. Semi fowler’s position
• Head end of the bed elevated 15-30 degrees.
• Often used for sleeping. (elevated 15 degrees)
• Foot of the bed can be raised slightly as to maintain a
slight flexion of the knees to provide more comfort by
reducing strain on abdominal muscles and lower back.
• Placed in this position for 30-60 minutes following
feeding as it aids in digestion when elevated for 30
degrees.
Fowler’s position
• Head end of the bed raised to 60-90 degrees.
• Position of choice for those who have breathing
difficulties or experiencing heart problems; gravity pulls
the diaphragm downward allowing greater chest
expansion.
• Not suitable for patients at risk of developing pressure
ulcers.
• Slightly flexed knees prevents from sliding down the bed
and causing shearing.
• A foot board can be used to maintain alignment of the
foot and prevent foot drop.

24. Lateral position
• A side lying position.
• Can lie on one side or the other.
• Can be positioned with upper trunk rotated forward or
backward.
• A 30 degree turn to either side is recommended.
• Relieves pressure on the sacrum and heels.
• Good position for resting and sleeping.
Sims’s position
• Variation of the lateral position.
• Usually used for administration of enemas and other
procedures.
• Can be used for resting if the patient finds it
comfortable.

25. Sitting position
• Promotes good positioning.
• Foot support is essential for maintaining a
stable base of support.
• Knees (at a 90 degrees angle with the hips)
are slightly separated to provide relaxation
and promote further alignment.
• Hips positioned at midline of the chair seat
with the pelvis stable.
• Back is supported to meet the hips at 90
degrees angle.
• Arms are flexed and supported by the arms
on the chair.
• Head is positioned in midline of the body and
is supported by the back of the chair.
• Reposition hourly if in a chair or wheel chair.

26. Exercises for BEDRIDDEN
• Bedridden patients are usually kept in bed for long periods, slowly
evidencing several problems caused by immobility.
• Prolonged bed rest is the leading risk factor for the development of
disuse syndrome, which causes significant systemic and organic
pathological changes.
• The disuse syndrome, in the long term, increases the risk for the
development of several conditions at a metabolic and systemic level.
• Some clinical entities to monitor and treat are joint contractures,
pressure sores, respiratory complications, and bone demineralization,
which significantly decrease patients’ quality of life and delay the
recovery process.
• Many studies have shown that these complications are associated with
increased morbidity and mortality.
WHY ?

27. • Goals of physical therapy for bedridden
• To remain as independent as possible/maximize independence and
daily function.
• To optimize and maintain quality of life (QoL) – determined by
physical functioning and psychological symptoms.
• Reduction/control of the consequences of the illness.
• Coping mechanisms and self-management – to be in more control of
their lives.
• To avoid secondary complications associated with life-limiting illnesses.
• Psychological support.

28. Types of Exercises for bedridden
• Breathing exercises
• Lung clearance techniques
• Range of motion exercises
• Stretching exercises
• Strengthening exercises
• Relaxation techniques

29. • Breathing exercises
I. Deep breathing
II. Localized breathing
III. Pursed lip breathing
IV. Diaphragmatic breathing
V. Resisted breathing
VI. Incentive spirometry
VII.Postural drainage

31. • Lung clearance techniques
I. Cough
- assisted cough
- supported cough
I. Forced expiratory technique
II. Active cycle of breathing
technique (ACBT)

33. • Range of motion exercises
I. Passive exercises
II. Active assisted exercises
III. Active exercises

34. • Stretching exercises
I. Upper limb stretching
II. Lower limb stretching

35. • Strengthening exercises
I. Strengthening with body weight
II. Strengthening with small weights dumbbells etc
III. Back and core strengthening

36. • Relaxation techniques
I. Meditation
II. Progressive muscular relaxation