Manual Lateral Transfers: Seated & Pivot

Question 1

When getting ready to transfer someone you should plan for:

Answer 1

• WBing Restrictions
• Equipment needs (footwear, assistive devices)
• Room setup (move furniture as needed)
• Assistance anticipated (recruit help)
• Movement of tubes and lines
• Secure surfaces (bed, chair, w/c)
• Communicate with all involved
• Arrange activity to promote good body mechanics

This helps in decreasing the risk of injury for clinican and patient

Question 2

Gait Belts

Answer 2

• Check with facility policy regarding gait belts
• Correct use can reduce risk of injury to clinician and patient
  – Does not always prevent a fall
• Used primarily to control movement of an unstable patient
  – Not to lift a patient

Helps clinician keep patient centrally; not to lift but to create create motion and direct.

Question 3

Gait Belt Placement Considerations

Answer 3

• Variety in how they are secured
• Generally placed at the narrow part of thewaist near pelvis
  – If larger abdomen (except for pregnancy), generally placed justunderneath abdomen
• If any of the following, place above the vulnerable site:
  – Pregnant (Under the underarms; Don’t want to hurt fetus)
  – Recent back or abdominal surgical incisions (Risk of dislodging it)
  – Ostomies
  – Feeding tubes

Question 4

Applying Gait Belt

Answer 4

• Let the patient know you will be using gait belt and why
• Place with buckle in front and slightly to one side
• Always place over clothing, not directly against bare skin
• Pull the belt snug, but not uncomfortably tight (you should be able to slide 2 fingers between the belt and patient’s clothing)
• Tuck excess length of belt into the belt

May need to say accoording to the

Question 5

Gripping and Removing Gait Belt

Answer 5

• Should ALWAYS be held with a supinated, or underhand, grip
• Remove when patient is seated (rather than supine)
• Be careful not to cause friction on removal
• Clean belt appropriately
• Various materials
• May use same belt / same patient

Question 6

Preliminary Screening for Transfers

Answer 6

• Knowledge of any medical restrictions and movement precautions
• What footwear will be used
• Assessment for pain; adequate strength; ROM… for the planned transfer
• Ability to control balance when seated and/or standing (static tolerance, weight shifts)
• Tolerance for exertion
• Biomechanical Considerations (surfaces,mechanics, head-hips principle, devices)
• Cognition (Able to understand), Communication, Perception
• Gather equipment, supplies, helper(s)
• Safety for the entire transition (space, room tomove, placement, IV lines,etc.)

Question 7

When giving cues you should…

Answer 7

Give specific details of what you cued for

Question 8

Dionne Egress Test

Answer 8

• Techniques intended to improve safety while manually assisting larger (bariatric) patients
• Elements of test provide preparatory assessment before transfer is attempted
• Can be used for transfers and gait

Question 9

Egress Test: Progression Steps

Answer 9

• From seated on edge of bed, patient first clears hips 1-2 inches from bed and returns to seated position. If successful:patient can try transferrinf
• Patient performs two reps of sit to stand. If successful: (likely can transfer laterally if successful)
• Patient stands and marches in place 3 repetitions. If successful: (Typically have a walker in front in case)
• Patient steps forward and back with one leg then the other. If successful: (likely able to move away from bed and begin walking)

Question 10

Egress Test Instructions

Answer 10

• A gait device may be used during test
• The test is stopped at any point where the patient cannot perform the task safely.
• The patient is always directly in front of the bedside so returning to seated position is possible.
• Passing the Egress test does not mean that the patient is independent, only that safe means to egress from the bed have been determined.
  – Considered safe to ambulate away from bedside with close monitoring and w/c follow

Typically better to do in the morning if possible; Likely not as fatigued.

Question 11

Manual Lateral Transfers - Biomechanics

Answer 11

• Require good sitting balance
• Require patient ability to assist in lift / shift / lower
• Head-hips relationship during lateral transfers
  – Advantageous to engage hips in direction of movement and head in opposite direction of movement
• Nose over Toes during vertical transfers

Lift, Shift, Lower Aspect to EVERY Transfer

Question 12

Initiation of the beginning of transfer of nose over toes - If someone is scared

Answer 12

Get them reaching out over a bosu ball to get use to initiation and gain confidence

Question 13

Head Hips Principle

Answer 13

“Throw hips this way and hips that way”

Question 14

Which direction for a transfer?

Answer 14

• Grab bar placement
• Environment
  – Setup
  – Available space
• Biomechanical direction of least resistance:
• Toward “stronger” side of body when able

At times, the space and grab bar placement may not allow for transfer toward the patient’s stronger side, so valuable to practice going both directions

Question 15

slide

Answer 15

• Need to have UE ability to lift
• Allows patient to perform a transfer without having to bear weight through LE(s)
• Board lengths, shapes, and materials vary
• Works best when used between even height surfaces or moving from higher to lower surface
• The patient must have good trunk control to complete independently (to participate in this actively)

Question 16

Independent Slide Board Transfer to Left: Bed-to-Wheelchair - Setup

Answer 16

1. Adjust bed height to same level of w/c (as able).
2. Angle right side of wheelchair 45 degrees and close to surface (arm rest removed and leg restsswung away or removed).
3. Secure surfaces. (Lock wheelchair)

Question 17

Independent Slide Board Transfer to Left: Bed-to-Wheelchair

Answer 17

• Lean
  – Lean trunk to right; place one end of board underleft ischialtuberosityand other end over wheelchair seat (in front ofdrive wheel).
• Place
  – Place left hand out on board and press down with both handsas you lift, shift, and lower hips.
  – Having the patient lean slightly forward and using head-hips principlewill make this process easier
• Remove
  – Remove board and replace w/c arm rest and leg rests.

don’t let them grab the outside of the board use the handle.

Often used for SCI

Question 18

When doing a SB transfer you should be aware of:

Answer 18

Do not allow the patient to grasp the end of the board or place fingers through the handle during the lateral shift.

Question 19

Clinician Assisted: Slide Board Transfer

Answer 19

• Typically guard from front.
• Hips and knees flexed and wide BoS
• Assist with hip movement (control centrally, direct distally [CCDD]) as needed.
• May need to make several small moves to complete transfer. (Want to maximize patient ability)
• Assist with hip movement by gripping lateral aspects of gait belt.
• While guarding, be prepared to block the patient’s knees to prevent the patient from sliding forward off the board.

Question 20

When transferring someone on the commode, what could you put in place?

Answer 20

A pillowcase, towel on top of board.

Question 21

Pivot Transfer: Rise, Pivot, Sit

They can get up.

Answer 21

• Primary action occurs at the feet
• Requires weight-bearing (WB) on at least one LE
  – Squat-pivot transfers (Get up into a squat position; SCI, posture decifiences, Amputee)
  – Standing-pivot transfers
• Benefits (over slide board transfers):
  – Decreased shearing forces
  – Decreased energy expenditure
  – Easier to transition between multiple surfaces

Question 22

In the presence of weak quadriceps muscles or reluctance to flex trunk, patients often compensate by:

Sit-to-Stand Compensatory Techniques

Answer 22

• Relying heavily on UE strength to push up (on armrests or on knees)
• Rocking to gain momentum (adduction; use valgus force to push them up)
• Bracing lower legs against chair to create leverage (force coupling)
• Pressing knees together to create leverage

Can overcome these compensations

Sit-to-Stand Compensatory Techniques

Question 23

Stand Pivot

Answer 23

Patient stands erect, turns, and sits

If no gait device then you need to be very close to the patient for stability

Question 24

Squat Pivot

Answer 24

Patient achieves a partially erect posture, turns, and sits

Question 25

Assisted Pivot Transfer Set Up

Answer 25

• Ensure appropriate footwear.
• Gather assistive devices as needed.
• Place surfaces close to one another.
• Equalize surface heights as able.
• Swing away or remove obstacles, including w/cleg rest and armrest if possible.
• Secure both surfaces.
• Use a gait belt for assisted transfers.

Question 26

The first thing before standing to look for:

Answer 26

Look for the hips to be up on the edge of the chair

Question 27

Ways to get patients to the edge of the chair:

Answer 27

Scooting hips forwardon the seating surface
– Lift, forward shift, and lower
— Pushing down through arms and legs
– Alternate weight shifts
— Lateral trunk lean and multiple movements
– Forward hip slide
— Posterior trunk lean into backrest, using trunk extension to shift hips forward on seat

Question 28

Ready position before an assisted pivot transfer

Answer 28

• Feet back, inner foot slightly forward if no WBing restrictions
  – If WBing is restricted, extend restricted LE before standing
• Trunk flexed (“nose over toes”)
• Hands placed on armrests at position posterior to flexed trunk
  – May need other devices

Question 29

If someone cannot use arms to get up you should:

Answer 29

Encourage them to use the one arm they can use to try to get up.

Question 30

We pivot better if we have:

Answer 30

a split squat stance. The side you move too should be slightly forward as a patient. Clinician mimicks patient.

Question 31

When using an assistive device to transfer where should the clinican stand?

Answer 31

The side away from the bed. In this case on the left side.

Question 32

Clinican position on transfer and grip on gait belt:

Answer 32

Clinician position:
In front of patient
Hips and knees flexed, wide staggered stance
Inner foot slightly posterior

Grip on gait belt:
For central controland assisting in descent if necessary
NOT to pull the patient into position or lift the patient

Question 33

Rising - How to cue/perform

Answer 33

• Count of “3”
• Rocking for momentum
• Patient maintains trunk flexion while pushingdown through their hands and feet
• Clinician leans posteriorly to help patient rise

Question 34

Pivot - movement

Answer 34

• Patient and clinician pivot their feet together
• Generally, pivoting toward the stronger side is easier for the patient
• Equipment: Pivot disc, ortho shoe (rounded in the front - helps with transfers; do have grip)

Question 35

Blocking the knees

Answer 35

• In cases where the patient has impaired strength and/or motor control
• Creates extension moment to counteract the flexion moment at the patient’s hips and knees
• Contact at the patient’s proximal tibia
  – Clinician : Patient
  – 1:1, 2:1, or 2:2

Outside of foot and inside knee

Ex:
- CVA
- Pt. who haven’t stood in a while
- Using a pivot disc

Question 36

Before Sitting Pt. should:

Answer 36

• Patient backs up all the way to the surface (with assistive device) until they feel the surface on the back of their legs
• If WBing is restricted, extend restricted LE before sitting
• Patient reaches hands to surface / armrests (one hand at a time)
• Patient flexes trunk.
• Controlled descent
  – To minimize need for re-positioning
  – To decrease risk of injury to PT and patient

Question 37

If a patient needs to get back farther in a seat:

Answer 37

• Patient uses upper extremities (UEs) and lower extremities (LEs) to lift hips up and back (requires forward trunk lean – unless restricted).
• Clinician assists from front with knee block and /or at gait belt to facilitate weight shift andprevent slipping off front of surface.

Question 38

No patient is complete until:

Answer 38

• the patient is safely and comfortably positioned
  – Replace arm rests and leg rests
  – Place patient feet on leg rests / footplates
  – Bed or chair alarms are set (as needed)
• Has a way to call for assistance

Question 39

What is this called?

Answer 39

Sit to Stand With Walker

Question 40

Sit-to-Stand With Axillary Crutches

Answer 40

• Move forward in chair / position feet
• Hold both crutches to one side (holding on inside)
• Push down through crutch grips and contralateral armrest
• Stand and balance before a crutch
• Transfer a crutch under each arm

How to teach: Push down arm rest of the uninvolved side to get up.

Same sequemce for sit to stand with forearm crutches

Question 41

Sit to stand with hemiwalker

Answer 41

For sit-to-stand, the hemi walker is place on the patient’s stronger side at about a 45° angle to the chair.
There is a lower crossbar on the hemi walker which may be used followinginitial push from the arm rest into standing, with the patient’s hand moved to the hand grip when the patient nears an upright position.
-may need to consider supportive sling for other arm

Question 42

Sit to Stand with Cane

Answer 42

• Move into ready position.
• If using single point cane:
  – Grasp cane and arm rest together on one side. (Use wrist strap if available
  – Push to standing using both arm rests and place cane upright upon standing.
• If the cane can stand on its own:
  – Place cane next to chair.
  – Push to standing on both armrests.
  – Grasp cane upon standing.

Question 43

How would you cue the patient for Toe-Touch Weight Bearing?

Answer 43

• “for balance only”
• “imagine you have an egg under your forefoot that you do not want to crush”

Question 44

How would you measure and cue the patient for Partial Weight Bearing?

Answer 44

• Scale / Limb load monitor (will look at in gait training unit)
• “you may place some of your weight on your extremity”

Question 45

Unilateral Limited WBing Considerations

Answer 45

• Moving to edge of surface prior to standing is very important
• Slide affected LE forward before rising.
  – Provides a visual cue to the patient to restrict WBing
• Keep NWBing limb slightly off the ground throughout sit to/from stand transition andpivot transfer
• Pivot on uninvolved LE through series of small hops or pivots.
• Extend knee of involved LE before sitting.

Question 46

Unilateral Limited WBing - Side of crutches

Answer 46

• Some clinicians instruct patients to place the crutches on the involved side and others recommend placement on the uninvolved side.
  Placement on the uninvolved side (per picture) will tend to result in increased lateral sway toward the involved side during the standing process.

To manage the NWBing limb, PT may need to manually assist, be ready to assist, and/or potentially have another person / helper present to assist (if help is also needed with the physical transition)

Question 47

Hemiplegia or Hemiparesis Considerations

Answer 47

• Following CVA
• Easier to transfer toward the stronger side
• May need to rely on stronger side only for unilateral pivot
• Involved UE should be supported manually or in a sling (not hanging dependently)
  – Do not pull on the patient’s involved arm.
• May need to use blocking for affected LE

Question 48

THA Posterior Approach

Answer 48

• Scoot forward in chair without trunk flexion beyond 60° to 90°.
• Extend knee of involved LE before standing and rest heel on the floor
• This places involved hip at decreased risk of unwanted flexion when transitioning to standing position
• Pushing to standing without trunk flexion is very difficult.
• Avoid IR of involved hip during pivot. (Trunk and walker move together)
• Avoid forward trunk flexion beyond 60° to 90° during sitting. (NO NOSE OVER TOES)
• Ensure to lift involved leg before sitting down.

Question 49

SCI Considerations

Answer 49

• SCI at level C7 and lower typically has potential to perform transfers independently.
• Sitting-pivot transfer
  – Feet contact the floor for stability, but force to power transfer comes from UEs and trunk momentum.
  – Very quick movement
  – Head-hips principle should be applied
  – Note removal of arm rest on side toward sitting-pivot
  – When considering direction for transfer, because more force is applied under the hand of the trailing arm than under the leading arm in this type of transfer, it is usually recommended that the trailing arm be the stronger or less painful one.

Question 50

Car Transfer: Wheelchair to car

Answer 50

Procedure:
- seat back and recline the backrest.
-Remove w/c armrest and leg rest on car side.
- Position wheelchair in door opening and apply brakes.
- Scoot to front edge of chair, position feet.
- Grasp secure item in car. (NOT INNER DOOR FRAME)
- Flex neck/upper trunk.
- Pull with the arm and pivot hips onto car seat.
- Bring LEs into car.
- Adjust seat position as needed.