PROGRAM: TRANSFER TRAINING/FUNCTIONAL MOBILITY DESCRIPTION/PURPOSE: Transfer training refers to the teaching techniques involved in moving a resident from one position to another i.e., supine to sitting, or from one surface to another, i.e., bed to chair, bet mobility, step mobility, and walker sequencing.
Increase functional mobility.
Decrease risk of fall.
Decrease the risk for injury to the staff.
Residents requiring instruction and/or assistance with transfers.
Decreased strength in upper and lower extremities.
Prolonged bed rest.
Pre and post-operative surgical orthopaedic residents.
Residents with lower extremity amputations.
Residents who require technique for pressure relief.
Medical instability - i.e., respiratory distress, angina
Residents with weight bearing restrictions.
Residents with cardiac, respiratory or metabolic (diabetes) disease.
Residents with compromised safety awareness.
Decreased sitting and standing balance.
Extremely sensory processing.
Extremely obese residents (Adequate staff assist to ensure safety of resident and staff).
Transfer Training (cont.)
Wheelchair with removable arm and leg rests.
Raised toilet seat.
Appropriate assistive device.
ROM - Upper and lower extremity
Lower extremity strength
Cognitive status - able to understand and follow directions; able to sequence
The therapist should be aware of the resident’s strengths and limitations, especially for physical and cognitive abilities and how this would influence transfers.
Stabilize or lock all surfaces including wheelchairs and beds.
If indicated, use a transfer belt securely fastened around the resident’s waist.
Equalize heights of surfaces as much as possible.
Transfer Training (cont.)
Remove wheelchair foot rests and leg rests, and when possible and appropriate, arm rests.
Always explain the transfer procedure to the resident so that both the resident and therapist are working toward the same goal.
Avoid grasping the resident’s arm during transfers.
The resident should be properly dressed, draped and wearing appropriate footwear.
Watch for friction between the skin and bed surface, especially in residents at high risk for, or with, skin wounds.
Employ correct moving and lifting techniques.
Maintain broad base of support by standing with feet apart (Shoulder’s length).
Maintain center of gravity by supporting or lifting others as close to the body as possible.
Lift with the legs, not the back.
Avoid spine rotation; move the feet in turn.
Know personal limitations; do not lift alone if in doubt.
It is important to remember that each resident, therapist, and situation is different. Each transfer technique must be adapted for the resident and his or her needs.
Types of Transfers
Standing pivot transfers: Requires that the resident is able to come to standing with assistance if needed, and pivot on one or both feet. It is most commonly used with residents who have hemiplegia, hemiparesis, or general loss of strength or balance.
Seated - sliding transfers: Best suited for residents who can bear weight on the lower extremities or who are too unstable for a transfer. The transfer requires the ability to use both upper extremities and is most often used by residents with lower extremity amputations, paraplegia, or quadriplegia. During initial instruction, a sliding board is used, but the resident becomes stronger and more stable and confident in his or her transfer abilities, the board may no longer be necessary.
Wheelchair bed and return
Position the wheelchair at about a 60 angle next to the bed, preferably toward the resident’s stronger side.
Lock the wheelchair brakes and make sure the bed is stable. Remove the foot rests or swing them out of the way. If wheelchair has anti-tippers, make sure they are down in the correct position.
Transfer Training (cont.)
Position the resident’s feet securely on the floor, 6-10 inches apart directly below and slightly behind the knees.
The therapist should make sure the resident understands the transfer procedure.
The resident moves forward to sit on the edge of the wheelchair.
The therapist is positioned in front of resident, on the affected side. If necessary, the therapist can block the resident’s knees with his/her own.
The resident’s leans forward so the shoulders are above the knees.
Once standing, the resident can either take small steps or pivot until his back is toward the bed. Transfer disc may be used.
The resident reaches for the bed prior to sitting down.
Return transfer - the procedure is essentially the same, except when resident is positioned on the edge of the bed, the surface is less stable when the resident is positioned on the edge of the bed, than in a wheelchair and there is no firm surface or arm rests for the resident to push from to come to a standing position.
Seated Sliding Transfer
The locked wheelchair is positioned next to the bed at a 90 degree angle or parallel to bed.
The arm rest on the wheelchair nearest the bed is removed.
The resident slips the transfer board under the buttocks and bridges the board across to the bed.
Assist the resident as necessary to scoot across the surface of the sliding board. Utilize a sitting pushup to lift the buttocks for proper clearance to prevent shearing force and move toward the bed in a series of consecutive lifts.
When securely on the bed surface, remove the sliding board.
Transfer Training (cont.)
To return, the procedure is reversed.
An alternative technique is to place the locked wheelchair facing and touching the edge of the bed. The resident sits on the bed with his back towards the wheelchair. The resident places a hand on each arm rest. The resident pushes his body up and over into the seat of the wheelchair.
May use talcum powder to lessen friction and sheering force.
Wheelchair to chair and return - This transfer is very similar to the wheelchair to bed transfer and can be accomplished using steps 1-6 in bed to wheelchair transfer except for the following exceptions.
Prior to sitting down, it is generally better to have the resident reach for the seat of the chair instead of the arm rest if there is a risk of tipping the chair.
Standing from a chair is often more difficult if the chair is low or the seat cushions are soft. Select a chair with height equal to the wheelchair and add firm cushions to raise the seat height.
Seated sliding transfer
This transfer is best accomplished when a resident can transfer
without using a sliding board since a chair allows less room for
Wheelchair to toilet and return - This difficult transfer is further compounded by the confined space in most bathrooms, the slick and small surface area of a toilet seat and the additional task of managing clothing. There are advantages and disadvantages to removing clothing before transfer or after being seated on the toilet. A safe and efficient method is developed between the resident and the therapist. The techniques for the standing pivot and seated sliding transfers are essentially the same as the wheelchair to be with the following exceptions:
It may be necessary to position the wheelchair at an angle greater than 60 degrees, often even facing the toilet.
The therapist and resident should be aware of the instability of the hinged toilet seat.
Transfer Training (cont.)
Because of the confined space, it may not be possible to transfer the resident toward the stronger side.
Adaptive equipment such as grab bars and raised toilet seat may increase independence and safety in transfers. Also, there are commodes with drop arms.
Wheelchair to tub and return - Whether the resident is using a standing or sliding transfer technique, the technique is similar to a wheelchair to chair transfer. It is not recommended that a resident transfer directly from the wheelchair to the floor of the bathtub, but instead to a commercially produced tub chair or bench. If a standing pivot transfer is employed, the locked wheelchair is placed at a 60 degree angle to the bathtub, if possible.
The resident should stand, pivot, sit on the bathtub chair (with his/her
back toward the tub) then turn and place the lower extremities into the
bathtub. If a seated transfer is used, the wheelchair is placed next to the
bathtub with the arm rest removed. The resident should then slide to the
tubchair (with or without sliding board).
In general, the resident exits by first placing his/her feet outside the tub
on a non-skid floor surface and then performing a standing or seated
transfer back to the wheelchair.
Wheelchair to car -
Open the car door.
Position the wheelchair as close to seat at a slight angle with leg rests removed if possible, locking the brakes.
Assist the resident to a standing position, and then pivoting, have them turn their back to the seat.
Watching that the resident does not hit his/her head on the car rim, have them sit down in the seat.
Assist the resident in fastening the seat belt and closing the door, if needed.
Spinal Cord Injury, Bilateral L.E. Amputees, or non-weight bearing residents: a sliding board transfer will be needed. The procedure is the same as the sliding board transfer.
THR: may need to transfer into back seat and across to maintain less than 90 degree angle hip flex.
Transfer Training (cont.)
DOCUMENTATION: Documentation must reflect the need for skilled therapy, support the skilled nature of the Transfer Training program, present objective and measurable progresses and the resident’s improvement as related to functional abilities. Also include the resident’s response and tolerance to the treatment procedure; to activity/training provided to family/staff, and post therapy recommendations.
RESOURCES: Pedretti, L.W., and Zolton, B. (1990) Occupational Therapy Practice Skills for Physical Dysfunction 3rd. St. Louis, MO: C.V. Mosby Co.
The role of the caregiver in therapy is one of extreme importance. After all, you assist the impaired person throughout the day and have the greatest influence on recovery. That is why the occupational or physical therapist has educated you on steps to follow while positioning and moving the individual with a physical impairment.
Each sequence has a specific purpose; sequences will change as the individual progresses in physical ability. Practice these sequences with the therapist before trying them with the impaired person. If you have difficulty understanding or completing any of the prescribed sequences, consult the attending therapist.
Good bed positioning will assist in maintaining joint range of motion and in decreasing abnormal muscle tone. Prescribed positions will change as the individual progresses. You will need to note these changes on the instruction sheet. Bed positions are not meant to be permanent. The individual will move out of the positions naturally. Although rest times may not appear to be therapeutic, they can be with proper positioning.
Some important concepts repeated throughout the bed positioning sequences are:
* Comfort: All positions should be comfortable tot he person, but as close to the recommended illustration as possible. The therapist may adapt the position to meet the needs of the individual. Sometimes a preferred position can actually increase the physical problem of the impaired person. Positions should avoid
extreme range of motion or locking of the joints. When rolls or padding are used, they should be of minimal thickness and support the entire area described. Never pull or tug on the affected limb. Move the person slowly and ask for his/her assistance when possible.
* Normalize muscle tone: Due to the nature of the impairment of the individual you are working with, he/she may have had a change in muscle tone and sensation, affecting the ability to move in a smooth and coordinated way. The positions the therapist has chosen will help to achieve normal muscle tone and sensation for the impaired person. This is often achieved through weight bearing or by lengthening or rotating specific muscles or body parts.
Bed positioning includes sidelying on the affected side, sidelying on the less-affected side, and lying supine (on the back).
Early initiation of bed mobility sequences can help the person develop good habits of movement, increase body awareness, and achieve a sense of self-control. Assistance
should be given for each step and gradually removed as the impaired person gains independence.
INSERT ADULT POSITIONS, TRANSITIONS, AND TRANSFERS SHEETS HERE! (24 SHEETS)
PROGRAM: UPPER EXTREMITY FUNCTIONAL RESTORATION INTRODUCTION Upper extremity functional restoration includes a variety of assessment and interventions to encourage functional performance vis-a-vis upper extremities involved in the disease injury/disuse process. The overall purposes of upper extremity functional restoration are:
to normalize tone
to reacquire skilled voluntary movement
to increase coordination and dexterity
to increase active range of motion
to increase passive range of motion (elongate soft tissue)
to increase strength
to increase muscular endurance
to decrease edema
to retain sensory awareness of discrimination
Activities directed to these ends should be within an individual’s capabilities, meaningful, and appropriate to an individual’s developmental and environmental context. The underlying assumption of this program is that functional tasks help to organize motor behavior.
RANGE OF MOTION RECORD - UPPER EXTREMITY
Fill in all blanks.
Note the date evaluation was performed.
Use a goniometer to determine measurements.
Normal full range of motion (ROM) measurements are listed in the second column for reference. Note that “normal” varies in persons of different ages, sex, and occupations. If one extremity is uninvolved, compare results of the involved extremity with results of the uninvolved extremity to determine what is “normal” for that patient. Complete the evaluation and sign and date the document.
Note that there are diagrams on the back of the form to provide visual aid in recalling planes of motion and arcs of movement.
Refer to physical therapy assessment for lower extremity ROM results.