Immobile patients are at constant risk for developing decubitus ulcers. This is particularly true for patients with geriatric disorders. The exact incidence and prevalence is unknown, but it is estimated that 400,000 people in Germany suffer from a decubitus that is in need of treatment. The prevalence in German hospitals has been estimated to be about 10% in geriatric clinics, 30% in retirement homes and 20% for patients cared for in a home environment [1]. In stationary health care, patients with the highest risk are those with a higher age, longer duration of the stay, treatment at the intensive care unit and transfer from a stationary care facility [2]. Mean estimated costs for therapy of a decubitus ulcer are 50,000 € [3]. In Germany, treatment costs, prolonged stays at the hospital and inability to work due to the condition are estimated to produce an economic damage of about 1 to 2 billion € per year. Severens et al. estimate that in 2010, the costs correspond to 1% of the entire health budget of the Netherlands [4]. Thus, besides the pain and long duration of the healing process of such an injury for each individual patient, decubitus ulcers also play a large economic role [5].
A main reason for developing pressure sores, besides immobility and malnutrition, is believed to be sustained pressure on the skin as well as pressure combined with shearing force [1, 6]. The pressure leads to a compression of the blood vessels, reduction of oxygen perfusion with local ischemia and, as a consequence, the formation of necrosis [7, 8]. To avoid sustained pressure, patients at risk have to regularly be put into different positions. In case that this is insufficient, the patient is positioned on antidecubitus soft foam or alternating pressure mattresses, which reduce the total pressure [9]. The disadvantage of these mattresses, however, is that they compromise patients’ perception of the body. Moreover, they hinder patients’ activities and impede nursing care [3]. In a European prevalence study, it was shown that only 10% of patients at risk for developing decubitus ulcers receive adequate preventive treatment [10].
Positioning is performed by turning patients into different positions such as supine, 30° side lying, 90° side lying or prone lying. Conventionally, during positioning nurses focus on placing support materials at specific parts of the body (e.g., at the back, under the leg). Due to gravity the body adapts to the mattress, and the effect this has on the alignment of the body parts is accepted. Hollow spaces can occur. Support material is intended to be used quite sparingly (Fig. 1).
A possible alternative solution is Positioning in Neutral (Lagerung in Neutralstellung, LiN), a positioning concept developed a few years ago. Initially, this method was developed for patients with central nervous system damage; nowadays it is increasingly being used for immobile patients with other symptoms and disorders.
Attention to the alignment of body parts is the basic principle of the LiN approach. The joints are positioned as neutrally as possible. A joint is in neutral when it is not flexed, extended, abducted, adducted or rotated. The purpose is to avoid overstretching and shortening of muscles. For example, in supine-, prone- and 30° side lying the posture looks like a person standing upright as long as the patient does not have contractures. Turned 90° to the side one or both legs are flexed but abduction, adduction and rotation are avoided. All parts of the body are supported against the influence of gravity. Paretic body segments, regardless of high or low tone, are stabilized with special techniques to normalize tone. Hollow spaces should be avoided and therefore filled. A sufficient number of blankets and pillows is needed to follow these principles. As a result, the material offers a much broader base of support than CON. The weight of the body is distributed equally. Areas of high risk to develop decubitus ulcers such as heels, ischium and sacrum are exposed to less pressure compared to CON. Each conventionally used position can be converted from CON to LiN.
In a multicentre randomized controlled trial, it was shown that LiN lead to improved passive mobility of patients’ hips and shoulders compared to conventional positioning (CON). Furthermore, LiN was perceived as substantially more comfortable than CON [11]. Neither LiN nor CON changed patients’ pulse, blood pressure or respiratory rate [12]. In LiN, all body parts are brought, as much as possible, into a neutral zero-position and are stabilized using special techniques, so that they do not malalign due to gravity. For this purpose, more positioning material is needed compared to CON. Body parts are evenly supported without allowing empty spaces. In LiN, there is a larger total surface area on which the patient’s weight is distributed compared to CON (Fig. 1). The aim of this pilot study was to investigate whether LiN, compared to CON, leads to a lower total support pressure and in particular to smaller areas of high pressure (Fig. 2).
