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April 2003


Losing Friction

By Richard W. Bohannon, PT, EdD, NCS, FAHA

Health care workers are often called upon to assist patients or instruct others in how to assist patients with transfers. There is a high degree of musculoskeletal stress and risk of injury associated with the performance of such transfers.1,2 Garg and coworkers reported that 51% of nursing assistants visited a health care provider in the preceding 3 years because of low-back pain that they attributed to their work.1 The physical burden of these transfers and the risk of injury to those who perform them can be reduced through the use of optimal body mechanics, the recruitment of help, or the use of equipment. Unfortunately, each of these strategies has limitations. Circumstances will not always allow workers to employ ideal body mechanics. Adequate help is often unavailable or used ineffectively. Equipment such as a mechanical lift, though advantageous, is not always available or usable in the situation confronted. Moreover, equipment frequently involves the provision of full assistance to a patient rather than patient participation in a manner that is likely to result in a progression toward independence.

Friction-reducing devices offer a compelling option for lessening the burden on workers who are assisting patients with transfers. Although use of such equipment in health care settings in the United States is rare, friction-reducing devices are readily available commercially and used quite regularly in Europe. A Web search employing the term “patient handling” will provide alternative sources for an assortment of friction-reducing devices. The purpose of this article is to offer generic information on two particular classes of devices: low-friction fabrics and pivot devices.

LOW-FRICTION FABRIC


Figure 1. Low-friction fabric tube (roller) with a quilted inner section.
A variety of low-friction fabric devices are available. They consist primarily of fabric sheets (sometimes referred to as slide sheets) and fabric tubes (often called rollers) that “roll” on themselves. Some of the devices have handles or straps attached. The material of some of the devices is padded or quilted (Figure 1). The cushioning provided by such material may be preferable for patients whose skin is at risk or already compromised. Low-friction fabric devices can be used to ease the burden of moving recumbent or seated individuals. Researchers have shown that the push or pull forces required to transfer passive individuals are significantly less when a low-friction fabric device is placed underneath them. One study reported that the forces required to laterally move supine subjects were about 35% less when they were moved on top of a fabric tube than when they were moved using a draw sheet.3 A subsequent study showed that use of a fabric tube reduced the push forces required to slide seated subjects and that the forces required when using a fabric tube and sliding board were 30% less than when using a sliding board alone.4 Owen and Hasler-Hanson found that use of a low-friction fabric device resulted in a significant reduction in nursing students’ judgments of their exertion when sliding patients up in bed.5 Specifically, the students’ perceived exertion for their whole body was reduced 40.3% relative to its level when using a draw sheet.

Reductions in perceived exertion were also reported for their shoulders (27.9%), upper backs (36.9%), and lower backs (42.0%). More than 50% of the caregivers who were provided with low-friction fabric devices (sheets and rollers) by Pain and associates,6 judged the devices to reduce the effort required to transfer patients. The caregivers rated rollers as superior to sheets for reducing effort and considered rollers more useful overall than sheets. I have personally used fabric tubes to independently move dependent patients between a bed and a tilt-table, a bed and a stretcher, and a bed and a wheelchair. In each case the transfers, which were conducted rather easily alone, would have been difficult or risky without the use of the fabric tubes.

PIVOT DEVICES


Figure 2. Fabric pivot disk.
Pivot devices, which are typically articulating disks of plastic or fabric (Figure 2, page 26), can be used to make pivoting easier for patients who are standing or sitting. In addition to portable devices, pivot mechanisms have been incorporated recently into other equipment (eg, a tub transfer bench). Though little research has been conducted on pivot devices, I have found them indispensable with several patients. One patient’s weakness and impaired motor control precluded her taking a step with either lower extremity. However, she was able to attain and maintain standing with minimum assistance. By placing the pivot disk under her feet before standing, I was able to transfer her independently between bed and wheelchair or mat and wheelchair. I performed hundreds of such transfers with her while she was under my care. Another patient, because of an unstable fracture, was required to transfer without weight-bearing on her right lower extremity. By having her wear a shoe only on the left foot and stand with that foot on a pivot disk, I was able by myself to easily transfer her between her bed and chair and between her wheelchair and car.

CONCLUSIONS

These friction-reducing devices are lightweight and portable. Thus, there is no burden or stress associated with their transport. They can be washed, or in some cases autoclaved. Low-friction fabric devices can also be used to reduce the shear accompanying movement of the body over surfaces. Furthermore, friction-reducing devices can be used by patients themselves, particularly when they are otherwise dependent or marginally independent in horizontal transfers.

Although I would certainly advocate broader use of friction-reducing products and consider them to be well worth the money, they are not without problems or alternatives. Getting them out from under a patient can be a problem. This can be an issue for a patient who has transferred to a wheelchair from bed or from a wheelchair to a commode. When there are gaps to be traversed, fabric devices are best used in conjunction with a sliding board. Cheaper items are available that can be used to reduce friction. A simple plastic bag, for example, can sometimes ease the burden of horizontal transfers and pivots in a manner not unlike commercially available friction-reducing devices.

Richard W. Bohannon, PT, EdD, NCS, FAHA, is a professor, University of Connecticut, Storrs; senior scientist, Institute of Outcomes Research, Hartford Hospital, Hartford; and a consultant, West Hartford, Conn.

REFERENCES
  1. Garg A, Owen BD, Carlson B. An ergonomic evaluation of nursing assistants’ job in a nursing home. Ergonomics. 1992; 35:979-995.
  2. Marras WS, Davis KG, Kirking BC, Bertsche PK. A comprehensive analysis of low-back disorder risk and spinal loading during the transferring and repositioning of patients using different techniques. Ergonomics. 1999;42:904-926.
  3. Bohannon RW. Horizontal transfers between adjacent surfaces: forces required using different methods. Arch Phys Med Rehabil. 1999;80:851-853.
  4. Grevelding P, Bohannon RW. Reduced push forces accompany device use during sliding transfers of seated subjects. J Rehab Research Dev. 2001;38:135-139.
  5. Owen BD, Hasler-Hanson CR. A study comparing three methods for repositioning patients up in bed. Journal of Healthcare Safety, Compliance, and Infection Control. 1999;3:362-367.
  6. Pain H, Jackson S, McLellan DL, Gore S. User evaluation of handling equipment for moving dependent people in bed. Technology and Disability. 1999;11:13-19.

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