When Seating Isn't Enough

In many care settings, “positioning” has become closely associated with seating. A referral leads to a mat assessment, followed by the prescription, fitting, funding and review of a seating system. This is careful, skilled work, but it addresses only the portion of the day a person spends seated.

A complete assessment should also consider the hours spent outside the wheelchair, particularly the hours spent in bed. Of a person's 24 hours, how many are spent seated? How many are spent lying?

These hours should not be considered neutral. The body remains under load throughout them.

Body shape changes such as windswept hips, pelvic obliquity, scoliosis, and chest flattening or rotation can follow predictable biomechanical patterns. When a person lies in a sustained asymmetrical posture, gravity applies low-level deforming forces to the skeleton and soft tissue for extended periods. The direction of the habitual posture can influence the direction of the resulting distortion. Because these patterns are predictable, appropriate postural support may help reduce or slow their progression. [2]

The effects of unmanaged lying posture may extend beyond body shape. Sustained asymmetry in lying is associated with contracture progression, hip migration and dislocation, compromised respiration and digestion, pressure injury risk over dependent bony prominences, pain, and disturbed sleep. [1][2] Poor sleep may also affect daytime function, participation and behaviour, making daytime goals more difficult to maintain.

In February 2025, RESNA — the Rehabilitation Engineering and Assistive Technology Society of North America — approved a formal position paper on assistive technology for lying posture care management (LPCM). RESNA identifies lying posture care as a foundational component of 24-hour postural care and recommends it as standard practice for people who cannot independently move into and out of a stable midline position. [1]

RESNA also acknowledges that the evidence base is still developing. Studies are generally small, study quality is mixed, and standardized protocols are still emerging. The position paper therefore calls on care teams to measure and report outcomes as lying-posture programs are introduced. [1] This supports careful implementation, outcome monitoring and reassessment as the evidence continues to develop.

Postures in lying and sitting can influence one another. The asymmetry present during sleep may be the same asymmetry a seating system must accommodate the following day. If support is provided only in the wheelchair, it may be more difficult to maintain seating goals throughout the full 24 hours. [3]

Residents with advanced dementia, stroke, Parkinson's disease, multiple sclerosis or late-stage frailty may be unable to reposition themselves and may spend 12 or more hours each day in bed. In-bed positioning, however, is sometimes defined primarily by a repositioning schedule rather than by a postural plan that describes how the resident will be supported between position changes.

Canadian and international guidance emphasizes both the timing and the quality of positioning. Wounds Canada's 2025 best practice recommendations describe individualized repositioning and recommend a 30-degree lateral tilt rather than 90-degree side-lying, which places load over the greater trochanter. They also recommend fully floating the heels with purpose-designed supports rather than standard pillows. [8]

The International Guideline similarly suggests individualized 30-degree lateral positioning so that the sacrum and greater trochanter are offloaded. It also makes clear that repositioning remains necessary regardless of the support surface in use because no foam or powered surface entirely replaces it. [9] RNAO's positioning education for long-term care teams likewise emphasizes body alignment and support between position changes, rather than focusing only on the repositioning interval. [10]

A 24-hour postural care program can help Directors of Care integrate pressure redistribution, contracture management, comfort, sleep quality and the preservation of body shape within one plan. It also clarifies how day and night teams contribute to shared clinical goals.

In community practice, a seating clinic may be the only setting in which posture is formally assessed. The assessment can end when the client transfers out of the chair, leaving lying posture unexamined.

RESNA recommends incorporating a lying assessment into the mat evaluation. Can the client be positioned in a neutral, midline supine position? Can they move into and out of that position independently? If not, lying posture care management should be considered. [1]

The RESNA position paper may also support clinical documentation and funding rationale for lying posture equipment. Clinicians have historically found this category difficult to fund because it lacked a comparable consensus document. [1]

Potential candidates extend beyond a traditional neurological caseload. RESNA identifies people with multiple sclerosis, ALS, spinal cord injury, acquired brain injury, stroke, intellectual disability and advanced dementia. It also discusses clients without motor impairment whose daytime spinal pain may relate to sustained end-range postures during sleep. [1][11]

Children with limited mobility spend long periods in habitual lying postures while they are growing. Over time, these postures may be reflected in patterns of body shape distortion. [2] Among children with cerebral palsy at GMFCS levels IV–V, hip displacement and scoliosis are sufficiently common that formal surveillance programs have been established. Up to 75% of children with cerebral palsy are affected by neuromuscular scoliosis, and nearly all children with spinal cord injury develop it. [12][13]

The 24-hour approach developed in part from the recognition that a child may be well supported for six hours in a seating system and then spend twelve hours in bed without comparable postural support. [3]

When night positioning begins before distortion becomes established, the focus is on prevention. When it begins later, the focus shifts toward accommodation, comfort and preserving available range. [2] For Canadian pediatric teams, lying posture care should be considered alongside formal hip surveillance. In British Columbia, the Child Health BC Hip Surveillance Program for Children with Cerebral Palsy was Canada's first province-wide program. [14] Lying posture care complements, but does not replace, hip surveillance or orthopaedic management. It should be assessed together with seating, standing and growth.

Although sleep systems first entered practice largely through pediatric cerebral palsy care, 24-hour positioning is not limited to pediatrics. Foundational adult work took place in a residential neurodisability setting, where clinicians identified unsupported lying as a contributor to secondary complications in adults. [3]

RESNA's 2025 position applies across the lifespan, including congenital conditions, acquired injury and advanced dementia. Its case evidence includes adults whose pain, sleep and postural ability changed after lying support was introduced. [1]

For an adult with a progressive condition, the clinical goal is to preserve body shape and available range for as long as possible, using the least invasive appropriate interventions.

The 2026 guideline supports the individualized use of positioning devices. [7] RESNA's implementation guidance identifies several practical considerations for teams evaluating a positioning support. [1]

Positioning devices complement, but do not replace, the support surface, individualized repositioning, skin assessment or wound care. [7][9] The mattress manages the bed interface, while positioning supports extend the individualized plan across lying, seated and transitional positions. Both are components of a 24-hour approach.

Seating assessment is essential, but it addresses only the hours a person spends seated. A complete positioning plan also considers lying, standing and transitions across the full day.

At the next assessment, consider where the person spends the rest of the day and night, which positions they can change independently, and what support they need when they cannot reposition themselves. For Directors of Care, community OTs, and clinicians working with children or adults, these questions are the starting point for 24-hour positioning.