The Tribulations of Transferring

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April 2002

By Sarah Gorner, PT

Training, equipment, and adapting to changing needs are integral to safe and efficient client transfers.

I take the armrest off and lean over the side of my chair and then I fall into bed." "I get down on the floor and scoot into the bathroom and then get up on the toilet. The door is too narrow for my wheelchair." "My bed is pretty high, so on nights when my shoulders are hurting too bad, I just sleep in my wheelchair. I figure it saves on the life of my mattress."

People tell all sorts of stories about how they get in and out of their wheelchairs. Some tell these stories with pride in their ingenuity and humor at the obstacles they face, but others relate resignation and frustration with their situation. Often the transfer works but is unsafe and potentially dangerous. Rehab professionals who specialize in transfers can teach better, simpler, and safer methods.

Primary Goal is Safety
One of the main goals in physical therapy at Craig Hospital, Englewood, Colo, is safe transfers. First and foremost is the prevention of falls, which may result in any number of complications, including orthopedic injuries and head trauma. Getting in and out of a wheelchair usually puts a person at risk for both shoulder and skin injuries as well.

For clients who are unable to use their legs but have good upper body strength, shoulder problems can be the result of poor body mechanics or simply years of overuse. Shoulder injuries also result when a caregiver is lifting under the armpits or pulling on a weak or unstable upper extremity during transfers. The patient population at Craig is composed of individuals with spinal cord and traumatic brain injuries, but the methods used to achieve maximal safety and independence in transfers apply to the general rehabilitation population as well.

Skin problems are common with both independent and assisted transfers. They can be caused by shearing across surfaces or bumping into the wheelchair or other objects. The coccyx is particularly vulnerable, along with the feet and any body part with diminished or absent sensation or movement.

The safety and well-being of the caregiver are also at stake. In many cases, the caregiver is a spouse or relative and the only available help. Even if home health care is available, it pays to keep attendants injury-free.

Transfer Goals and Training
At Craig, the patient is assessed as a unique individual with specific assets as well as limitations. Limitations will, for the majority, be physical but might also include decreased cognition or environmental barriers (poorly accessible home or workplace), while assets can include a good attitude and family support. A comprehensive understanding of these qualities results in transfer goals that are meaningful and functional for each individual.

Effective transfer training not only addresses how to get in and out of bed, but how to access the bathroom, a vehicle, or even an airline seat. It covers getting down on the floor and, more important, getting up. And it takes into account the equipment and assistance needed. Transfers are an integral part of the rehab program at Craig and the entire team works together to address the issues specific to each patient, follow through on the training, and prepare the patient for discharge to the most independent and safe living situation possible. Evaluation of and training with the appropriate equipment are started early in the patient's program.

Low-Tech Equipment
For some, transfer equipment needs can be met fairly easily. Ambulators may require only a walker, cane, grab bars, or bed side rails to assist with their transfers. Those with a lower level cervical spinal cord injury can be independent with a sliding board, while a good number of paraplegics do not use any added equipment beyond their wheelchair, toilet seat, and bath bench.

If clients need minimal to moderate assistance due to either physical or cognitive deficits, they are often able to transfer safely with a trained caregiver, doing a squat or stand pivot. This is not recommended when the patient is dependent or unable to adequately assist with the transfer. Low-tech/low-cost options include a sliding board or a flat plastic transfer board.

The sliding board requires the patient to lean forward in a sitting position and slide over on the board, with caregiver assistance as needed. Difficulties arise with this method when the patient is large and hard to slide, gets agitated, has spasticity that interferes, or has difficulty getting up to and down from a sitting position in bed. The obvious advantage of the sliding board is that it is extremely portable, but it is not useful for transfers with significant height differences, like getting up into a sports utility vehicle from a wheelchair. It is also difficult, although not impossible, to use for bathroom transfers, where a towel must be placed between skin and board to prevent shearing injury to the skin.

A flat plastic board, about the length of the patient, can be used to slide a supine patient from a bed to a reclined wheelchair or commode chair. This tends to be a slow, cumbersome process, not well suited for a single caregiver. It is most often used in the acute phase after injury to minimize hypotension and works best with three to four staff members performing the transfer.

High-Tech Equipment
A lift is usually the preferred method for transferring a person with a spinal cord injury or traumatic brain injury who is very dependent. Depending on the patient's size, level of agitation, and amount of spasticity, this transfer can often be performed by one person. With most lifts, an electric option is available that allows one caregiver to lower the patient while simultaneously positioning her, for example, in the wheelchair or bed. One of the best features of any type of lift is that it provides a way for the caregiver to singlehandedly get the patient up off the floor by herself.

A caregiver may comment, "The sling just takes too long to put on. I can transfer him twice by the time I get the sling on." While it is true that the sling does take some setup time, caregivers are at a much lower risk for injury than if they are doing a dependent pivot-type transfer. Training the patient and caregiver from the beginning in this method and getting them into good habits decrease the likelihood that they will switch to quicker, but much less safe, transfers down the road.

Several portable patient lifts are available, but probably the most widely used come with a u-shaped base that will fit around the wheelchair and also roll under a bed. The accompanying sling has back support and head support if needed, while the buttock area is suspended and not covered by the sling, which enables easy application and removal. Variations include straps (rather than a sling) that lift the patient from under the upper thighs with different methods of upper body support as well as lifts that break down for transport in a vehicle.

Permanent lifts are installed with ceiling track systems within the patient's home. This is a very good option for the patient with small living quarters and no space to maneuver a freestanding lift. A ceiling track might go from bedroom to bathroom and is also an option for individuals with a jacuzzi or pool.

Changing Needs
It is important to remember that, with any patient, what works today may not be appropriate 5 years or even 5 months from now. Some regain motor function, become more competent with their existing muscle strength, or improve cognitively. These individuals may simply need different equipment, like grab bars. But they may also need help in retraining their attendant care. Caregivers will often give a patient more help than they need, increasing their own chances of getting hurt while preventing the patient from becoming proficient in new skills.

Unfortunately, some patients will become less independent and find that they need more equipment or assistance, perhaps due to medical issues, a loss in available caregiver assistance, or simply aging.

Because changes-both good and bad-are inevitable, Craig Hospital recommends regular reevaluations. As with newly injured patients, the rehab team must work together with returning patients to determine their specific needs, keeping in mind that the perfect solution might not always be conventional as illustrated by one client's solution: "I don't need attendant care anymore. My service dog helps me get my legs up into bed, helps me turn in bed....we've figured out just about everything...and he's a lot better company."

Sarah Gorner, PT, is a physical therapist at Craig Hospital in Englewood, Colo.

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April 2002