SEATING vs BED REST FOR POSTURE & PRESSURE CARE

By Martina Tierney, OT

Bed rest has been prescribed to patients for hundreds of years for those suffering from illness or injury or following an invasive surgical procedure.

In the mid-1940s the beliefs around bedrest and its value began to shift. It was found that soldiers in the Second World War who were forced to get up and about quickly due to a lack of available bed space, recovered much more quickly from their injuries and infections than would have been expected.¹ 

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Why are patients spending long periods of time on bed rest?

“Bedrest’s appropriate objectives are 3- fold: to provide rest for the exhausted, to decrease oxygen consumption, and to reduce pain or discomfort.

Immobility due to Illness or Injury

Following on from an injury or when suffering from a critical illness, a patient may need bed rest in order to recover. 

It can take around four weeks to recover from atrophy caused by immobility – a slower process than recovery from direct muscle trauma (Halar, 1994). Disuse weakness is reversed at a rate of only 6% per week with exercise.5

Patients at risk of falls

We find that patients who are at risk of falls and who need constant repositioning, can be challenging to seat and can sometimes be kept in bed as it is thought that it is the only way to keep them safe.

Manual Handling Risk

Patients who need constant repositioning or with a bariatric condition might be put on bed rest to help limit the manual handling risk to the patient and to the caregiver.

Lack of Resources to Facilitate Effective Repositioning

Repositioning to avoid pressure injuries is required throughout the day and sometimes two caregivers are essential to complete this per patient. In some cases this may be too much of a strain on resources of the facility and solutions such as air alternating mattresses might seem like the only reasonable option to ensuring the pressure is redistributed throughout the body reducing pressure risk.

Lack of Knowledge/Education on Seating and Solutions Available

One of the most common barriers to getting people out of bed and into a proper chair, is the fundamental lack of knowledge of the seating options available and of the impact seating has on a patient’s health and quality of life.

Fixed Contractures/Deviated Posture

If a patient presents a fixed scoliosis or kyphotic posture they might be resigned to bed rest as a perceived only option. However provision of a correct seating assessment, accessories and adaptations can accommodate and address deviated postures through seating.  

Pressure Injuries/Skin Breakdown

Typically through the years the focus when thinking about providing pressure management and relieving pressure injuries and has been on surfaces: i.e. beds, mattresses, and cushions.  It’s often been the case that a patients pressure care needs are managed on a pressure management surface for much of the day, and then they are often moved into a standard wheelchair or unsuitable chair with a pressure cushion, which provides inadequate postural or pressure support effectively eliminating the benefits accrued by the mattress/surface. In laying, the oxygen flow is reduced which contributes to further skin breakdown.

Bed Rest V Seating

Prolonged bed rest can have extensive negative physiological & psychological effects on the patient. Getting patients out of bed and into a proper chair will not only aid their recovery time it will expedite hospital discharge. 

Psychological Impact of Prolonged Bed Rest

  • Learned Helplessness

Prolonged bed rest can lead to learned helplessness, through a sustained loss of control over daily activities and regimes.  

  • Depression and Fatigue

Disuse of muscles and immobility create joint or bone stiffness, which leads to symptoms of profound fatigue, depression, lack of motivation and contributes to a vicious cycle of immobility and decline. 2

Physiological and Physical Impact of Prolonged Bed Rest

  • Respiration

Many studies have shown that prolonged bedrest dramatically increases the risk of respiratory tract infections. Laying in supine position as opposed to sitting up impacts on a person’s ability to breathe properly possibly contributing to recurring lung infections. Additionally, people cannot cough as easily or as well, which allows pooled mucus to stagnate and reduces the clearance of potentially pathogenic material and irritants.1

  • Swallowing / Digestion / Elimination

Dysphagia and choking is a risk since swallowing in the supine position is much more challenging than when sitting. The gastrointestinal tract slows, and food takes 40% longer to be digested and eliminated when a person is supine. 2  The decreased mobility and fluid intake may lead to bowel impaction, constipation and ineffective digestion. This has a knock-on effect to the patients appetite and they may want to eat less and less, and eventually might stop eating.  Dehydration can occur and urination can become less effective, as the bladder tends to retain fluid instead of emptying it. This can cause urinary tract infections and increase the risk for bladder and kidney stones.3

  • Muscle Atrophy & Weakness

A loss of muscle strength at a rate of around 12% a week.  After 3-5 weeks of bed rest, almost 50% of muscle strength is gone. 4

Social Impact of Prolonged Bed Rest

  • Inclusion

In bed rest the patient is restricted from spending time in communal areas of a home or care facility. When they can be transferred to a suitable chair that meets their postural and pressure care needs, they can join others in the living room, day room or even at the dinner table, as a chair is much more mobile than a bed.

  • Social Interaction/Communication

When on bed rest it is more difficult to interact with others as opposed to when sitting upright. Sitting upright enables eye contact to be made more easily with others and makes communication easier for the patient as well as the caregivers and friends and family. In turn this increases the patients motivation to get involved with activities around them, or conversation.

  • Involvement in ADLs

A sitting rather than laying position enables more functionality, possibly enabling a patient to take part in activities of daily living such as reading, writing, self-feeding and personal care, more independently than before.

  • Quality of Life

Overall – health, wellbeing and quality of life can be significantly improved when sitting up can be achieved and bed rest is reduced.

 Some of the Key Benefits of Sitting Up

  • Quicker discharge from hospital or rehab which also means a quicker recovery from injury or illness.
  • Increased function, more independence.
  • Better overall pressure management – reduces risk of pressure injuries.
  • Overall health and wellbeing is positively impacted.
  • Families and caregivers happier to see their loved one/patient out of bed and sitting comfortably.
  • Improved social interaction, inclusion, communication, and increased motivation.

Bed Rest & Seating = 24 hour Approach to Care

Best results are achieved when proper therapeutic chairs are used in conjunction with pressure relieving beds and mattresses to manage pressure care and postural needs over a 24 hour period.

Overall health and well-being improves when sitting opposed to laying – digestion, elimination, respiration, as well as cognitive health and well-being and motivation for activities such as feeding, socialising, communicating and personal care are all positively impacted. 

For patients in palliative care who are at the end stage of their life, being able to get these patients out of bed and sitting comfortably in a chair means a great deal to them and their families. The families often think “They are having a better day today – it’s great to see them out of bed.”

We often link being in bed to being ‘sick.’

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Prescribing Therapeutic Seating

A seating assessment should be carried out by an Occupational Therapist, Physiotherapist or qualified Seating Specialist, to determine the extent of the postural and pressure management needs of the patient. The impact of specialist, individualised seating solution positively affects the patients’ health and quality of life in many ways from supporting posture, reducing the risk of pressure injuries, and most importantly, providing comfort. When proper seating with real clinical evidence is used to apply the Four Principles of Pressure Management, optimum results can be expected. This goes far beyond the typical idea that a pressure cushion is enough. Thorough seating assessments & adjustable chairs can keep patients safe and secure, reducing need for time spent in bed and overall aiding a quicker recovery and a better quality of care and patient outcomes.

REFERENCES

  1. http://www.nursingtimes.net/clinical-archive/cardiology/effects-of-bedrest-1-cardiovascular-respiratory-and-haematological-systems/5002005.fullarticle
  2. DeLaune SC, Ladner PK. Fundamentals of Nursing, Standards & Practice. 2nd ed. Clifton Park, NY: Delmar; 2002. – See more at: http://www.pharmacytimes.com/publications/issue/2011/january2011/featurebedrest-0111#sthash.uRJFEdun.dpuf
  3. https://www.hypervibe.com/au/blog/prolonged-bed-rest-and-its-physiological-effects/
  4. Jiricka, MK. (2008) Activity tolerance and fatigue pathophysiology: concepts of altered health states. Essentials of Pathophysiology: Concepts of Altered Health States.  Philadelphia:  Lippincott Williams & Wilkins
  5. Halar, E.M. (1994) Disuse syndrome. In: Ross, M. et al (eds) Recognition and Prevention in Chronic Disease and Disability: a Contemporary Rehabilitation. New York, NY: Demos Medical Publishing. – cited in http://www.nursingtimes.net/effects-of-bedrest-3-musculoskeletal-and-immune-systems-skin-and-self-perception/5003298.fullarticle 

** Note – the purpose of this blog is to give an overview of the product with some tips to consider on its use. This is not intended to be a substitute for professional or medical advice, diagnosis, prescription or treatment and does not constitute medical or other professional advice. For advice with your personal health or that of someone in your care, consult your doctor or appropriate medical professional.

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