Sleep positioning systems

Specialist occupational therapists and physiotherapists can help people and families to choose a sleep positioning system.

Cerebral Palsy Alliance offers a service where our occupational therapists and physiotherapists work with individuals and families to determine whether a sleep positioning system is the right choice.

Fees may apply for therapists to provide assessment, sleep positioning system prescription and adjustment and ongoing support, and will depend on the provider and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, writing reports or funding applications, and therapist travel.

Most sleep positioning systems are commercially available and expensive to buy. A hospital-style, height adjustable bed will probably be required. Funding for the equipment may be available and this involves completing an application for funding assistance.

Ask the therapists if you are eligible for funding to assist with fees and equipment costs. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

Time needs to be committed to trying out different sleep positioning systems, and selecting one that meets the user’s needs, is comfortable, safe and will not have a negative impact on sleep. Sleep positioning systems should be trialled for several consecutive nights and the impact it has on sleep¹, breathing and comfort evaluated.

This thorough approach to trialling, selecting and evaluating the sleep positioning system will minimise the risk of abandonment of these expensive systems.

Sleep disturbances can have a huge impact on the wellbeing of a person with cerebral palsy and their family. A supported sleep position may reduce night time pain and the risk of postural deformity, including hip displacement, and muscle and joint contractures. They can be used to provide a safe sleep position for people who have breathing difficulties, or are at risk of aspiration. Sleep positioning systems may also be used to increase length and quality of sleep for both the individual and their caregivers.

Sleep disturbances have many causes including breathing difficulties, gastroesophageal reflux, pain and constipation. Advice from a respiratory specialist and sleep clinic will help to identify the issues contributing to sleep problems. They can suggest different strategies - which may include a sleep positioning system – to assist an individual and family to improve their sleep and rest.

A speech pathologist may become involved to advise about the best sleep positions for a person with cerebral palsy who is at risk of aspiration, has reflux or requires overnight gastrostomy feeding.

Other factors to consider

Sleep positioning systems may need to be used with other equipment, including:

• A height-adjustable, hospital-style bed
• Pressure care mattresses
• Hoists and slings used for transferring people in and out bed
• Respiratory devices

They may also need to be transportable between beds if people sleep in other homes and environments.

Things to note

• Consider safety issues when choosing a system - avoiding any that could potentially trap a part of the individual’s body in the bed, the system itself or the bed rails
• Family and carers will need support to learn how to set up, adjust and maintain the sleep positioning system⁵.
• Safe lifting techniques are important, to avoid back injury when positioning people in the sleep positioning system.
• Sleep positioning systems require regular review to ensure the person continues to be comfortable and well supported. Devices will need to be adjusted or replaced to accommodate growth and altered postures of the body and limbs⁵.
• Sleep positioning systems are also referred to as night time positioning devices, night time postural management equipment and supported lying systems

Specialist occupational therapists and/or physiotherapists will consider the child or adult’s unique needs, including their preferred sleep position, rate of growth, susceptibility to pressure sores and physical ability. Other important factors to take into account include their muscle tone, postural deformity or presence of contracture, any pain experienced, respiration and aspiration status, and their ability to regulate body temperature. Therapists can then help to identify goals for a sleep positioning system and whether referral to other health professionals such as a sleep clinic is required. This assessment will identify the most appropriate sleep positioning system to be trialed and evaluated.

The second type of assessment is used to measure whether a sleep positioning system is effective for meeting the needs and goals of both the user and family. The specialist occupational therapist or physiotherapist will help the user and family decide on an outcome measure to determine if the intervention is meeting their needs.

Three commonly used outcome measures for sleep positioning systems are:

• Sleep diary – the family documenting the person’s sleep patterns and issues in a diary can help the specialist identify the best sleep positioning system
• Individually Prioritised Problem Assessment (IPPA) – this measures whether devices are solving the problems a person is experiencing
• Goal Attainment Scaling (GAS goals) – this measures the extent to which a person’s goals are achieved.

Regular reviews with therapists will ensure the sleep positioning system continues to meet the individual needs of the client, family and carers.

We searched the allied health and medical literature to find research evaluating the outcomes of sleep positioning systems for children and adults with cerebral palsy.

We were looking for the best available evidence on whether these systems make a difference for sleep, pain, risk of contracture, ease of care, postural alignment and respiratory function. Orthoses, splints or casts are sometimes used to provide night time stretch to muscles, however, research regarding these types of devices was not included.

The search found no studies evaluating sleep positioning systems for adults with cerebral palsy. Two articles provided the best available evidence about sleep positioning systems for children with cerebral palsy. These were a Cochrane systematic review⁵ and a low level study³ (Level 4).

The Cochrane systematic review⁵ appraised randomised controlled trials (RCTs) of commercially available sleep positioning systems used with children with cerebral palsy. The authors were interested in their effect on hip stability, pain, sleep, physical function and quality of life. Only two RCTs were eligible for inclusion in this review. Both studies were small, including a total of 21 children, aged 5 – 16 years, at GMFCS Levels III to V. Children, who already used a sleep positioning system, were measured during time sleeping in their system (1 or 4 nights) and time not sleeping in their system. Neither study addressed hip stability, quality of life or physical function. These studies reported no differences in sleep or pain when the children were sleeping in sleep positioning system compared with not sleeping in a sleep positioning system. The review concluded that there was insufficient good quality research about whether or not sleep positioning systems were effective.

The second study³ we identified evaluated a commercially available sleep positioning system with 11 children, aged four years old to 14 years old with significant, bilateral cerebral palsy. Outcomes, such as the amount of sleep and number of night wakings, parent reports of ease of caring and three measures of hip stability, were measured after 12 months using the sleep positioning system. Four of the 11 children could not tolerate the sleep positioning system. The amount of sleep and night waking did not alter for the remaining seven children who did tolerate using the sleep positioning system. Parents reported small improvements in ease of caregiving. Measures of hip stability did not change during the 12 months, except that, on average, hip migration slightly improved in the right hips of the children using the sleep positioning systems. The number of children in the study was too small for this finding to be meaningful on its own.

The existing research gives insufficient information about the effectiveness of sleep positioning systems.

Completing research into sleep positioning systems is difficult. There are many different sleep positioning systems available and each potential user has unique abilities and needs. People with cerebral palsy are individuals who differ by type and severity of cerebral palsy and whether they have other impairments (for example pain, contractures and sleeping difficulties). As there are so many factors in customising systems for users, it is difficult to define a uniform intervention to evaluate. In addition, the numbers of users are small, the costs and time involved in setting up sleep positioning systems can be high and the need to follow-up users for a long period of time to evaluate their sleep positioning systems makes it difficult to conduct this research.

Sleep positioning systems may work for some people with cerebral palsy but will not be right for everyone. More good quality research is needed to help us decide which people with cerebral palsy can benefit from sleep positioning systems. People with cerebral palsy who are considering using a sleep positioning system, and their families, are encouraged to partner with a specialist therapist to thoroughly trial and evaluate this intervention.