The Prone Restraint –
Still a Bad Idea

AUTHORS: Unidentified.

This paper is from the "POLICY REVIEW" Newsletter
Published by the International Association of Chiefs of Police
National Law Enforcement Policy Center

Volume 10, Number 1; Spring, 1998.

To date, all I could obtain was a very poor photocopy of this IACP "POLICY REVIEW" Newsletter paper. But, I so strongly wanted to include it in my Library, that I decided to TYPE IT OUT! Although I have restructured this paper (using a single-column layout with a blank line between paragraphs, rather than its dual-column layout with indented paragraphs), and I have changed the text fonts of headings and reference numbers, I have not "edited" the content of this paper in ANY manner. When you see things like dots (...) or dashes (–), or brackets ([ ]), they were IN this paper.

[Charly's "QUICKIE Review" follows the paper.
To "skip" to the review, CLICK HERE.]

The Prone Restraint – Still a Bad Idea

For over a decade, experts have been warning law enforcement officers about the danger of employing the four-point restraint, commonly referred to as the "hog-tie" restraint. Now, some are revisiting this policy and suggesting that the fundamental premise upon which it was based is flawed. It is important therefore to reexamine the evidence that supports prohibition of this restraint and the basis of recent discussions that suggests scrapping this policy position.


Over the years, many deaths have occurred among suspects who, while in the custody of the police, have been restrained in the "hog-tie" restraint: prone with the hands and ankles manacled together from behind. Such deaths inevitably bring criticism of the police and frequently are the basis for lawsuits against the officers and departments involved. Any death involving a person who is in police custody at the time is the subject of scrutiny by the public, the press, and the courts, as well as by the relatives of the deceased. But deaths resulting from this restraint practice are particularly vulnerable to this sort of attention. In part, this is due to the fact that manacling a person's hands and feet to each other and placing the individual in a prone position, particularly a face-down position, often gives the impression of brutality to the public – and to judges and jurors. Over the years, the burden of proof concerning the cause of sudden in-custody deaths has typically fallen upon the arresting and transporting officers. Prior to intensive study of this phenomena, the reputations and even the careers of many officers were sullied or destroyed by a lack of information to adequately explain these tragic events. In addition, large civil damage awards have been paid to persons who have filed lawsuits against arresting officers and their employers.

Research Findings

The causes of prone restraint deaths have been closely examined. A study of these in-custody death incidents was conducted several years ago by Dr. Donald Reay, the chief medical examiner for King County around Seattle, Washington. The Reay Study indicated that when a suspect is placed in this position, particularly when the suspect is face down on his or her stomach, his or her respiration is impaired, and the result may be "positional asphyxia" – in effect, the suspect dies of suffocation.(1)

When published, these findings aroused some skepticism, because many found it difficult to believe that the mere placement of a person in a prone position could cause asphyxia. However, it appears that it is not merely the position that is a fault; several factors are involved, the combination of which can make the prone restraint position deadly. These factors may include both the physical build of the prisoner, the degree of exertion occurring during efforts to gain control of the subject and apply restraints, and the presence of drugs and / or alcohol in the prisoner's system. The Concepts and Issues paper that accompanies the Model Policy on Transportation of Prisoners states

Drug and/or alcohol intoxication may play a part in asphyxia by suppressing the central nervous system that controls respiratory muscle activity. ... When a person in the above condition – particularly one who is overweight with a large stomach – is placed prone in a hog-tie position ... respiration is restricted. In most cases of positional asphyxia, the victim was physically subdued by the arresting and/or transporting officers after exerting substantial energy in violent struggle. When hog-tied and placed face down in the rear seat of the transport vehicle, such individuals are generally oxygen deprived and energy spent. Case studies reveal that such victims typically become quiet during transit and die during transit or shortly after arriving at the booking station or hospital.(2)

The IACP also published a training document on this subject in 1992 based on a comprehensive research study of sudden in-custody death performed through the San Diego, California, Police Department. The study and its findings – which included a national survey of similar experiences of law enforcement agencies around the United States – was subjected to the scrutiny of a multidisciplinary team of professionals, to include those from the medical and legal fields. Based on that study and related research, the training document stated that

Positional asphyxia is the result of interference with the muscular or mechanical component of respiration. In all such cases, there are one or more contributing factors that inhibit the victim from correcting the problem that causes the respiratory deficiency, whether that be intoxication from alcohol or drugs, head injury, entrapment, restraint or some other form of physical disability. Both the application of the hog-tie restraint and the positioning of the victim in a confined space were found [in the Reay Study] to constitute critical and deadly factors in [the] cited cases.(3)

The relationship between prior exertion and positional asphyxia is also noted, both in the Reay Study and in the IACP training document. The latter states

Another factor that Dr. Reay points to as contributing to respiratory distress and eventual death is the level of energy expended and the resultant fatigue of the subjects who were engaged in violent confrontations prior to being subdued. During these confrontations, substantial amounts of muscular energy [are] expended which robs energy from contracting muscles used in respiration. The typical violent confrontation with subjects who later succumb to positional asphyxia after being subdued is not coincidental. Dr. Reay notes that the victims in the case studies were rendered more vulnerable to respiratory muscle failure through deficits of energy created by violent muscle activity before they were placed in their final restrained positions.

The training document summarizes two of the cases from the Reay Study that are typical of those studied in San Diego.

The first case involved a 28-year-old man who assaulted and threatened to kill his wife and assaulted his mother-in-law. Two officers responded to a call for assistance. A struggle ensued during which one officer was choked, and the subject was struck with a baton. The subject then ran away and was finally cornered in the yard where he became trapped between dense brush and the patrol vehicle. He was overpowered by the officers, placed face down on the ground, and handcuffed with hands and feet behind his back. He continued to resist but relaxed when loaded into the rear seat of a patrol sedan for transport. Because of the lacerations sustained from the night stick blows and contact with the bramble bushes, the subject was taken to a nearby hospital, which took between five and seven minutes. During this time, the subject was not monitored, but did not exhibit any noticeable activity. When the subject was removed from the police vehicle at the hospital, nurses initially detected a faint pulse and respiration, but within a minute the attending physician reported no respiration and no blood pressure. The subject went into cardiac arrest; he was resuscitated but remained unresponsive and died five hours later. An autopsy showed the presence of lithium, lidocaine, and caffeine, but no other drugs. The death was attributed to positional asphyxia.

In the second case, the victim was a 28-year-old male who engaged in a verbal confrontation with his brother outside a residence. Officers responded and attempted to calm the brothers. A records check revealed that the subject had outstanding traffic warrants against him. The subject then attempted to run, but was caught and became involved in a struggle with the officers. Several backup officers assisted in "hog-tying" the subject. Witnesses stated that during this process the subject said, "Gimme some air; gimme some air." Still resisting and complaining, the subject was placed in a prone position in the back of a patrol car on a narrow, molded plastic, one-piece seat. During transport, the subject slipped down and became wedged between the front and back seats. Officers later recalled that during the four-minute trip to jail, the subject's breathing became "raspy and then gurgly." The subject was unresponsive when removed from the patrol car at the jail, and efforts by paramedics to revive him were unsuccessful. An autopsy revealed scalp wounds and contusions to the body and extremities. Toxicology tests revealed a blood alcohol level of 0.12 and the presence of LSD and THC. Death was attributed to positional asphyxia.

Referring to these two sample cases, the training document observes that

The first victim was particularly affected by his obesity and large stomach which interfered with his respiration when placed in the prone position in a confined space. In the second case, the convex contour of the vehicle's floor created a similar effect in restricting the individual's breathing.

Each of these two cases involved the three elements most often cited as operative in positional asphyxia cases: a struggle before and / or during restraint, the presence of drugs and / or alcohol in the subject's system, and placement of the subject in an unnatural face-down position following rear restraint of hands and feet. Further, in the first case the positional problem was aggravated by the subject's obesity, and in the second case by the subject's becoming wedged between the seats of the patrol car on the irregularly shaped floor of the vehicle. The combination of factors proved lethal. In many cases, application of restraints to a violently resisting subject requires that officers apply their weight on the back of the subject in order to gain control of the hands so that handcuffs can be applied. This action typically compresses the subject's chest cavity and further adds to oxygen depletion and difficulty in breathing.

So many deaths have occurred under these or similar circumstances that positional asphyxia has received a great deal of public and professional attention. Because of the Reay Study, the San Diego investigation, and similar conclusions reached by other experts, during the past decade police departments have been repeatedly warned not to permit the restraint of prisoners in the prone position.

For example, the IACP training document quoted above concludes that

Because of the increased risk of sudden death, it is recommended that arrestees not be transported in the hog-tie position. While this is a highly secure position, evidence demonstrates that there is a significantly higher risk to prisoners because of the possibility of positional asphyxia.(4)

Taking an even stronger stance, the Model Policy on Transportation of Prisoners states that

Officers are prohibited from transporting prisoners who are restrained in a prone position."(5) The policy's discussion paper notes that "the Model Policy not only prohibits use of the hog-tie position but also recommends that transporting officers continuously monitor the well-being of all prisoners. Indications of lethargy or unresponsiveness on the part of prisoners, particularly those at risk as described here [i.e., overweight intoxicated persons who have engaged in physical exertion prior to or during restraint], should be addressed immediately by responsible officers.(?6)

This is good advice, and it ought to be a part of every department's policy. Positional asphyxia is a real possibility, with tragic results for all concerned. Therefore, use of the prone restraint technique should not be employed, particularly where the prisoner exhibits traits that make him/her at greater risk of positional asphyxia. If there are no other reasonable alternatives to the prone restraint when dealing with a highly combative subject, officers should continuously monitor the prisoner's vital signs and take immediate steps to aid the prisoner should his/her respiration become hampered. Monitoring in this manner will usually require at least two officers during transport of the prisoner. Furthermore, agencies should explore enlistment of available techniques that provide for safer means of transporting highly combative persons.

Emerging Controversy

Recently, there has been some controversy regarding the positional asphyxia problem. This controversy is unfortunate, because it may induce some police personnel and their agencies to overlook established practice based on prior research and threat presented by use of the four-point restraint. The most recent example of this controversy occurred in a case tried in a federal district court in southern California and decided in January, 1998. In that case, Ann Price v. County of San Diego, a federal judge, relying upon a recent study at the University of California at San Diego, concluded that "the hog-tie restraint in and of itself does not constitute excessive force." Unfortunately, this decision is being hailed by some as a blanket judicial approval of this restraint procedure.

This far-reaching interpretation of the case does not seem to be justified. In the first place, the decision was very limited in its scope, and was expressly stated by the court to apply only to the Price case. Secondly, it is not clear that the academic study upon which the court apparently based its conclusion is applicable under the real-world conditions encountered by police on the street. The University of San Diego study, as described in an article in the Los Angeles Daily Journal, involved 15 healthy young volunteers who were hog-tied after several minutes of exercise on stationary bicycles. As reported by the Los Angeles Daily Journal, "no one died, and the volunteers' ability to breathe did not change."(?7)

CHAS NOTE: I don't have a "Los Angeles Daily Journal" article about the Price case. But, I DO have the January 14, 1998 San Diego Union-Tribune newspaper article in this Library. I'll put its link at the end of this paper.

The difference between the conditions of this experiment and the conditions under which such restraint occurs in the field are readily apparent. Further, the earlier Reay Study related the positional asphyxia deaths not merely to the method of restraint or the degree of exertion occurring before or during the restraint, but also to the physical condition of the prisoners (overweight, large stomachs), and the presence of drug or alcohol intoxication. So far as is known, the volunteers in the University of San Diego study were young, healthy, and not intoxicated. Why the court in Price v. San Diego rejected Dr. Reay's findings and accepted the University of San Diego study as conclusive evidence is not known.

Another question regarding the dangers of the prone restraint was raised in an article, "Positional Asphyxia Revisited," which appeared in the January 1998 Police Chief magazine. This article made an analogy of the concern over the four-point restraint and positional asphyxia to the medieval practice of wearing garlic to ward off vampires. As the author states, "It must have worked; no person who was wearing garlic was ever attacked by a vampire." The basis of this comparison is apparently the author's conclusion that positional asphyxia is not the threat that it is commonly believed to be. In view of the considerable body of evidence regarding the dangers of positional asphyxia, one may question whether this position is warranted.

Nevertheless, the article makes a good point: Whether or not restraint in the prone position actually increases the risk of positional asphyxia, the current general belief is that it does. As a result, when litigation arises following the death of a prisoner who has been restrained in the prone position, the outcome is likely to be a verdict for the plaintiff, simply because it is accepted by many medical experts (and many courts) that restraint in the prone position can and does lead to positional asphyxia. Therefore, the article suggests, prone restraint of prisoners should be avoided simply because it is widely believed to lead to positional asphyxia, and, right or wrong, this belief in turn leads to liability for the police department being sued.

This view is very practical from a legal standpoint. The conclusion that a department may reduce the risk of legal liability by avoiding the use of hog-tying is certainly valid. However, this does not address the issue that should be the primary concern of every police executive: the possibility that, despite the questions being raised about the degree of danger involved, restraint in the prone position may in fact cause the death of the person being restrained. Notwithstanding claims to the contrary, there is considerable evidence, both in terms of expert opinion and actual field experience, that indicates that the practice of prone restraint does in fact lead to deaths among suspects in the custody of the police. Therefore, until such time as this threat is proven non-existent, a prohibition against unqualified use of this restraint procedure for prisoners should be included in all law enforcement agency policy.

Oh, JEEZE!!!

At this point in time (November 13, 2003), the copy I have of this paper ENDS THERE – at the end of the first column on page 3 of the paper! I don't have the "second" column of page 3 ... nor do I have a page 4 (if one exists) ... NOR do I have the references list! Until such time as I obtain the remaining text of this paper – something I'm working on! – this is all I can post.

I'm also working on obtaining copies of:

IACP Contact Information:
International Association of Chiefs of Police
515 N. Washington St., Alexandria, VA 22314 USA
800-843-4227 703-836-4543 (fax)

About the IACP's Policy Review Newsletter [Text from their website]:

The policy center also publishes a quarterly newsletter, Policy Review, that highlights recent court decisions and trends in the field that have direct bearing on policy development and revision. Policy Review is available only to policy center subscribers for $12 annually or $16 for nonsubscribers.

For more information, contact Courtney King at IACP headquarters at 1-800-THE IACP.
[1-800-843-4227, ext. 319] Or, Email Courtney King at:

Here is a link to the miserably inaccurate & misleading
January 14, 1998 San Diego Union-Tribune newspaper article:
"Police Hogtie Restraint Doesn't Kill, Evidence Now Shows"*

Those who read this IACP Newsletter may also be interested
in reading the following:

Hog-Tied Revisited
Dr. Donald T. Reay (Seattle, Washington, King County Chief Medical Examiner)
responds to the FALSE accusations that he "Retracted" the value and conclusions
of his prior research, during the testimony he provided for the Price case!

Dangerous Misinformation Published
Charly's opinion paper about the Price case San Diego Union-Tribune article.

An Example of what Dangerous Misinformation Can Do!*
An extremely dangerous San Diego County "News Release"
spawned by the misinformation-laden Price case San Diego Union Tribune article.

Charly's QUICKIE Review:

OH, SurpriZe.
I could "nitpick" and whine about several incidents of medical information inaccuracy
contained within this law enforcement Newsletter.
BUT! I think that this Newsletter deserves FAR more "CREDIT" than it does "CRITICISM!"

I have only two "major complaints" about this Newletter's content.
After I discuss these two complaints, I'll identify the KUDOS this paper strongly deserves!

1) Although it actually does touch upon the importance of a UNIVERSAL prohibition of forceful-prone-restraint application, this paper's content could easily be misinterpreted as suggesting a prohibition of forceful-prone-restraint ONLY during the "transportation" of subjects (suspects, prisoners – whatever). Such a limited prohibition is WAY WRONG!
Yes, the two cases referred to in this paper involved individuals who were alive when put into the police vehicle. But, I've read multiple restraint asphyxia case studies, and have personally examined multiple restraint asphyxia incidents, when the individuals did not SURVIVE forceful-prone-restraint long enough to be PUT IN a police vehicle! In other words, the subjects died due to forceful-prone-restraint application long before they were able to be "transported" by law enforcement or EMS personnel.
When a prohibition of forceful-prone-restraint is limited to the "transportation" of restrained individuals, the prohibition suggests that police officers (and others) MAY USE forceful-prone-restraint up until the time of "transport." Thus, such a limited prohibition puts police officers (and others) at risk for suffering the consequences of causing a forcefully-prone-restrained individual's "wrongful death" prior to transportation.
ANY use of forceful-prone-restraint must be prohibited – PERIOD.

2) "If there are no other reasonable alternatives to the prone restraint when dealing with a highly combative subject, officers should continuously monitor the prisoner's vital signs..."
That statement is ALSO WRONG – for at least three reasons!:

  1. There are plenty of "reasonable alternatives to the prone restraint": When an individual is handcuffed and hobbled (not "hog-tied," but "hobbled") forceful application of LATERAL (side) restraint or SUPINE (on the back) restraint is entirely "reasonable," entirely effective, and entirely SAFE for all concerned.
    However, the phrase "If there are no other reasonable alternatives to the prone restraint when dealing with a highly combative subject," SUGGESTS that officers are ALLOWED to SOMETIMES employ forceful-prone-restraint.

  2. Unless ALL officers are TRAINED, CERTIFIED, and EQUIPPED to accurately and effectively "monitor the prisoner's vital signs," mandating that they do so is incredibly inappropriate, and entirely unfair to the officers.

  3. MOST IMPORTANTLY: ANYONE exhibiting AN ALTERED LEVEL OF CONSCIOUSNESS – especially an altered LOC that makes them act in a bizarre and excessively-physically-exertive manner – REQUIRES MEDICAL ASSESSMENT AND CARE.
Rather than inappropriately suggesting that forceful-prone-restraint may occasionally be a "reasonable" form of restraint; rather than inappropriately mandating that untrained and unequipped individuals should be responsible for monitoring the vital signs of someone suffering an altered level of consciousness;
the IACP SHOULD MANDATE the following:


In 2003, when I finally learned of this IACP Newsletter and read it, I was immediately impressed by the fact that the IACP had so clearly recognized the January 1998 Price v. San Diego case decision – and the November 1997 Chan et al Annals article's study findings, upon which the Price decision had been based – as being a blatant example of restraint misinformation, generated by individuals with "personal agendas."

But, what enormously impressed me, is the fact that the IACP ACTED upon their recognition of this blatant restraint misinformation, by publishing this Newsletter only a month or two after the January 1998 Price case decision!

Consequently, the International Association of Chiefs of Police is one of the few United States POLICE entities that has acted to protect police officers from suffering the consequences of causing restraint asphyxia death, in a TIMELY and relatively EFFECTIVE manner.


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COUNTER started in November, 2003