Unit 3 - Dynamic Sitting and Transfers

Use in Function: Dynamic sitting

• Weight Shifting

• Turning

• Reaching for an object

• Completing ADLs

• Sitting on an Unstable Surface or Unstable BOS

• Lifting or Carrying

Use in Function: Sitting transfers

• Asymmetrical Scooting

• Symmetrical Scooting

• Pivot from Bed to Chair or W/C

• Pivot from W/C to Toilet

• Pivot from W/C to Car

Body Structure and Function Impairments

• Aerobic capacity/endurance

• Arousal, attention, and cognition

• Cranial and peripheral nerve integrity

• Joint mobility § Motor function

• Pain

• Range of motion

• Reflex integrity

• Sensory integrity

Part to Whole Task

Dynamic sitting

• Occurs when sitting and moving the limbs or when changing posture

• Requires anticipatory postural adjustments

• Initially requires attention, later becomes automatic

Impairment management: Strength Dynamic sitting and transfers

• Initially, the patient's attention is directed toward the critical tasks that require efficient movement and postural adjustments.

• With more repetition, posture modifications will become automatic

• Proper alignment must be accomplished first before starting with dynamic sitting balance exercises

• The cervical, thoracic, lumbar and pelvis must be in neutral position

Sitting Muscles

1. Erector Spinae Muscles

2. Abdominals muscles

3. Hip flexors muscles

4. Gluteal muscles

5. Trunk rotators

6. Arm and shoulder muscles

Sitting Balance: Starting Point

• Patient is seated on a rigid platform with hip-width between LEs and 90º angles at the knee and hip.

• Start with easier tasks that slightly challenge the pt then progress to more challenging tasks

• Patients initially require more concentration to perform tasks

Sitting balance: Interventions

• Sitting-weight shifting with upper extremity support

• Active Weight Shifts Against Resistance

• Voluntary Movements and Task-Oriented Practice

• Resisted Limb Movements

Dynamic Sitting Interventions

• Seated Leg Lifts

• Seated Marching

• Seated Twists

• Reaching activities

• Balancing on a Stability Ball

• Resistance Band Rows

• Ball Pass

• Pulleys

Scooting

• a seated movement where the body shifts forward or backward

• Requires shifting weight to the stable side and lifting the dynamic side to move the pelvis

• Upper extremities are not used for pushing or assisting

• prepares for independent bed mobility and sit-to-stand transfers

Scooting: Interventions

• Scooting in the Short-Sitting Position

• Scooting in the Long-Sitting Position

• Scooting Off a High Table Into Supported Unilateral Standing

• Rocker Board or Inflated Disc

• Computerized Platform/Feedback Training

• Ball Activities

• Dynamic Ball Activities

Seated Integrative Medicine Exercises

Seated Tai Chi

• An ancient Chinese martial art involving slow, deliberate movements emphasizing body awareness, flexibility, strength, and balance.

• Studies highlight improvements in balance, functional mobility, and walking endurance

Seated Integrative Medicine Exercises

Seated Yoga

originated in India to integrate the physical, mental, and spiritual aspects of the body. It includes various styles, typically combining physical postures (asanas) and controlled breathing (pranayama)

Dynamic Sitting with Increased Tone

Common presentation

• Flexor synergy UE (elbow flexion, shoulder adduction)

• LE extension synergy (hip/knee extension, PF)

Impairment Management: Tone (UE/LE) Dynamic Sitting and Transfers

Dynamic Sitting with Increased Tone: Common Presentation

• Flexor synergy UE (elbow flexion, shoulder adduction)

• LE extension synergy (hip/knee extension, PF)

Impairment Management: Tone (UE/LE) Dynamic Sitting and Transfers

Dynamic Sitting with Decreased Tone: Common Presentation

• UE and LE flaccidity

• Poor postural control

• Head forward, trunk slumped

Impairment Management: Tone (UE/LE) Dynamic Sitting and Transfers

UE Positioning – Increased Tone

• Elbow, wrist, finger flexion

• Shoulder adduction/internal rotation

• Management:

  • WB, positioning aids, splints, slow stretching, modalities

Impairment Management: Tone (UE/LE) Dynamic Sitting and Transfers

UE Positioning – Decreased Tone

• Arm drop, shoulder subluxation

• Poor scapular stability

• Management:

  • Arm troughs, taping, facilitation of proximal control, modalities

Impairment Management: Tone (UE/LE) Dynamic Sitting and Transfers

LE Positioning – Increased Tone

• Hip adduction, knee extension, PF

• Difficulty with WB and foot placement

• Management:

  • WB, wedges, slow transitions

Impairment Management: Tone (UE/LE) Dynamic Sitting and Transfers

LE Positioning – Decreased Tone

• LE abduction, hip/knee buckling

• Foot instability

• Management:

  • Ankle-foot orthoses (AFOs), supported WB, compression

Transfer Challenges with Increased Tone

• Extensor thrust

• Scissoring of legs

• UE flexor patterns blocking push-off

• Postural Tone

Transfer Challenges with Decreased Tone

• Trunk collapse

• Inability to engage UE/LE for support

• High risk of slipping or falling

Pre-Transfer Tone Management

• Normalize tone before task:

  • ROM/stretching

  • WB activities

  • Environmental control (light, noise, cold)

Abnormal Tone-transfers

Transfer Strategies for Increased Tone

• Slow, rhythmical movements

• Break down task into steps

• Facilitation techniques: tapping, guided movement

• Equipment: sliding boards, grab bars

Abnormal Tone-transfers

Transfer Strategies for Decreased Tone

• Maximize stability: block knees, support trunk

• Engage trunk with facilitation

• Use of transfer belts, AFOs, and surface height optimization

Common Positioning Aids

• Lap trays

• Arm troughs

• Foot blocks

• Cushions and wedges

• Dynamic splints

UE Intervention Techniques

• WB through UE

• Rhythmic stabilization

• Bilateral movement tasks

• Use of therapy balls, mirror therapy

LE Intervention Techniques

• Sit-to-stand training

• Supported standing

• Weight shifts and reach in seated

• Supported hip/knee control work

Ataxia: Impairments Overview

• Impaired timing of movements

• Impaired coordination

• Impaired posture at rest and with movements

• Intention tremor impacting movements

• Dysmetria impacting accuracy of movements

• Impaired overall control of movements

• Impaired hand-eye and/or eye-foot coordination

Ataxia

Interventions: General Approach

• Safety and fall prevention

• Improve postural control at rest and during activities

• Compensation and adaptation strategies

• Start with simple tasks and then progress to more complex tasks

• Modulate speed: start with self-selected speeds to fast movements while maintain accuracy

• External cues: visual and tactile

• Environmental modifications to facilitate completion of functional tasks

Ataxia

Interventions: Dynamic Sitting

• Start with sitting with full support and then progress to less support and then no support

• Static sitting on stable surface > static sitting on unstable surface

• Functional weight shift and reaching in various directions: stable surface > unstable surface

• Functional training while sitting: grooming and feeding

• These exercises can help with ADLS

Ataxia

Interventions: Dynamic Sitting Progression

• Eyes open > Eyes Closed

• Sitting on hard surface > sitting on foam pad > sitting on a physio ball

• Perform dual-task activities: cognitive and mechanical

• Perturbations in sitting: static at first, progress to dynamic sitting activities

• Dynamic sitting activities while sitting on an unstable surface: physio ball

Ataxia

Interventions: Transfers

• Postural alignment before performing transfers

• External cues to improve movement timing and coordination

• Break down to the task to be performed: scooting forward, forward trunk lean (nose over toes), trunk extension to come to standing

• Manual cues to guide the movements

• Start with full support: chair with back rest, feet on floor

Ataxia

Interventions: Transfers Progression

• High intensity with repetitions

• Focus on proper biomechanics

• Performance of sit to stand transfers during functional tasks: stand by kitchen sink to wash face, shave etc

• Use surface of various heights: sit to stand from a higher surface > sit to stand from a lower surface

• Transfers to/from different surfaces

Ataxia

Interventions: Home Exercises

• Safety education

• Patient and caregiver education

• Involve caregivers in providing assistance with activities

• Evaluate the need for assistive devices to promote independence with daily living activities

• Perform HEP to maintain improvements with therapy

Somatosensation in Dynamic Sitting and Transfers

• Somatosensation includes proprioception, kinesthesia, and vibration

• These are key to maintaining posture, alignment, and adaptive movement

• Deficits affect trunk stability, orientation, and reactive balance

Somatosensation

Ex; Key Clinical Findings

• Impaired static and dynamic sitting balance

• Delayed protective and reactive responses

• Relies on visual input

• Impaired proprioception in the left upper and lower extremities

• Requires verbal/tactile cueing

• High fall risk

Somatosensation

Treatment Considerations

• Prioritize safety and modify the environment

• Simplify tasks and enhance multisensory feedback

• Emphasize task-specific, repetitive training

• Improve weight bearing through the left upper and lower extremities

• Stimulate proprioception with touch, pressure, and visual inputs

Somatosensation

Ex: Compensatory Interventions

• Use mirror for midline orientation and visual feedback

• Provide tactile/verbal cues to promote weight shift to the left side

• Incorporate bright-colored floor tape to guide reaching and foot placement

Somatosensation

Ex: Restorative Interventions

• Use joint compression and rhythmic stabilization

• Incorporate textured mats and vibration for re-education

• Task specific training

Vision in Dynamic Sitting and Transfers

• Visual Input for Postural Control and Balance

• Spatial Orientation and Navigation

• Compensatory Transfer Strategies Due to Visual Deficits

• Increased Fall Risk and Safety Concerns

Vision

Ex: Key Clinical Findings

• Visual Deficit: Left homonymous hemianopia (visual cut in the left field of vision in both eyes)

• Motor Deficits: Mild left-sided trunk weakness and delayed trunk righting reactions

• Functional Impact:

  • Misses objects on her left side

  • Slightly loses balance when reaching to the left

  • Requires contact guard assistance with pivot transfers due to poor spatial awareness and delayed protective reactions

Vision

Ex: Treatment Considerations

• Improve safety and independence during transfers through visual compensation and retraining

• Promote dynamic sitting balance through graded, task- oriented interventions

• Increase spatial awareness of the left visual field

Vision

Ex: Compensatory Strategy — Environmental Setup

• Arrangement

  • bed and toilet angled slightly to the right

  • high-contrast tape

  • decluttered path

• Lighting

  • ensured even and adequate

• Consistent Setup

  • predictable positions

  • mirror feedback

Vision

Ex: Compensatory Interventions

• Transfer rehearsals with cuing

• use of landmarks and visual anchors

Vision

Ex: Restorative Interventions

• Visual Scanning Training During Transfers

• Reaching and Scooting Tasks with Leftward Bias

• Graded Transfer Practice

Evaluation Considerations — Seated position requires:

• Upright trunk posture

• Support surface through ischial tuberosities and posterior thighs

• Various combinations of head, trunk, UE and LE motions

Evaluation Considerations — Transfers requires:

• Dynamic trunk postural control

• Ability to control the center of mass over the base of support

• Various combinations of head, trunk, UE and LE motions

Evaluation Considerations — Consider impairments that are contributing to poor balance contro

• Standardized tests specific to sitting include:

  • Reach Test

  • Sit-and-reach Test

  • Sitting Arm Raise Test

  • Trunk Impairment Scale

  • Trunk Control test

  • Scale for Contraversive Pushing

  • Lateropulsion Scale

Goals of Balance intervention

• Safety and fall prevention education

• To improve balance

• To teach compensation strategies when needed

• To return the patient to previous activity levels

Safety (balance)

• Determine the amount of assistance needed

• Proper guarding technique to prevent falls

• Gait belt and/harness

• Non-slip shoes

• Wide base of support

• Proper lighting

• Remove environmental hazards/obstacles

Balance

Interventions: General approach

• Do not leave the patient unsupported

• Plan ahead for necessary equipment needed

• Gait belt to protect against falls

• Never “pull” on a weak or impaired upper extremity

• Therapist positioning for required tasks

• Consider position of the patient’s UE to avoid injury

• Consider patient’s goals, current sitting ability, prognosis

• Determine if focus is

  • Compensation (orthotics, use of upper extremities, chair back/arm rests)

  • Recovery: Level of motor control-mobility, stability, controlled mobility, skill

• Surface considerations

• Strategies to move from supine to short sit or long sit

Balance

Interventions: Dynamic Sitting Balance

• Static sitting balance on stable surface

• Static sitting balance on unstable surface

• Dynamic sitting balance

• Functional weight shift and reaching:

  • Seated on a stable surface

  • Seated on an unstable surface

Balance

Interventions: Dynamic Sitting Balance —> Short Sitting

• Rolling chair, reach for desk or books on bookshelves

• Edge of bed, donning socks and shoes

Balance

Interventions: Dynamic Sitting Balance —> Long Sitting

• Sitting in bed, pulling slacks on hips

• Sitting on floor, watching TV

Balance

Interventions: Progression to transfers —> Mobility

• Symmetrical weight bearing

• Perform lateral pelvic tilts

• Scooting in all directions

Balance

Interventions: Progression to transfers —> Stability

• Maintain sitting against Perturbations

• Alter surfaces and functional tasks

• Dynamic reaching and weight transfers

Balance

Interventions: Progression to transfers —> Controlled Mobility

• Upright positioning during weight shifts, reaching and scooting

• Dissociate upper & lower trunk movement

• Combined trunk and extremity movements with functional tasks

• Alter environment, speed, manipulation of objects and coordination tasks

Balance

Interventions: Progression to transfers —> Improve Skills

• Upright positioning during weight shifts, reaching and scooting

• Transfer to different surfaces

• Move from sit to stand

Balance

Interventions: Home Exercises

• Safe practice at home and with social roles

  • Dressing and bathing

  • Transfers: dining room chair, toilet seat, car seat

  • Lower caregiver assistance over a period of time

• Patient and family education/ Home exercises

  • Practice transfers from and to various surfaces

  • Home adaptations: elevated seated surface, grab bars

  • Incorporate exercises with daily living tasks

Perception in Dynamic Sitting & Transfers

• Deficits: Difficulty interpreting sensory input to guide safe and appropriate actions

• Misjudging distance during reaching, scooting, or transferring

• Missing or misjudging support surfaces

• Delayed or unsafe postural adjustments

Cognition in Dynamic Sitting & Transfers

• Deficits: Impaired attention, memory, organization, and executive function

• Distractibility during motor tasks

• Difficulty following multi-step directions

• Unsafe decisions during complex movements

Communication in Dynamic Sitting & Transfers

• Deficits: Impairments in speaking, understanding, reading, or writing

• Misunderstanding safety instructions

• Inability to express needs or concerns

• Delayed or inappropriate task performance

Perception/Cognition/Communication

Ex: Key Clinical Findings

• Mild left-sided neglect

• Visuospatial deficits

• Mild somatosensory deficits

• Mild cognitive impairment

• Attention impairments

• Functional impact?

Perception/Cognition/Communication

Ex: Treatment Considerations

• Enhance left-sided awareness

• Support cognitive function

• Improve alignment and weight shifting

• Manage attention deficits

• Use clear, step-by-step verbal cues

• Gradually increase complexity

Perception/Cognition/Communication

Ex: Compensatory Interventions

• Visual scanning strategies

• Environmental setup

• Use of tactile, verbal and visual markers

• Simplified task environment

• Written or pictorial cue cards

Perception/Cognition/Communication

Ex: Restorative Interventions

• Visual scanning training: structured to the left

• Dynamic sitting balance training

• Object recognition exercises

• Task specific training

• Dual-task activities

• Attention training

• Progressive complexity

Movement Disorder (BG)

Ex: Direct impairments

• Rigidity

• Bradykinesia

• Slowed postural reflexes

• Decreased initiation of movement

• Resting Tremor

• Decreased motor control

Movement Disorder (BG)

Ex: Indirect impairments

• Postural impairments

• Strength deficits

• Decrease ROM

• Festinating gait pattern

Movement Disorder (BG)

Ex: Composite impairments

• Decreased coordination

• Impaired balance

Movement Disorder (BG)

Ex: Functional Performance

• Activity limitations:

  • Impaired bed mobility

  • Impaired transfers

  • Impaired locomotion

  • Difficulty with dressing

  • Difficulty with feeding

  • Increased fall risk

• Participation restrictions:

  • Cannot help around house

  • Cannot drive car

Movement Disorder (BG)

Ex: PT Interventions — General Approach

• Exercise with bracing/adaptive equipment

• Auditory and visual cues

• Proprioceptive neuromuscular facilitation techniques

• Mirror therapy

• Constraint Induced Movement Therapy (CIMT)

• Transcutaneous Electrical Nerve Stimulation (TENS)

• Active range of motion, motor control

• Fall prevention

• Home exercise program

Movement Disorder (BG)

Ex: Interventions — Dynamic Sitting

• Improve sitting posture: heat application, myofascial release, stretching, contract relax and joint mobilizations

  • Improve alignment in sitting

• Improve endurance by working on improving breathing control

  • Improve chest expansion

• Improve dynamic sitting: provide external cues – visual and auditory

  • Improve attention and motor learning

• Improve active ROM of UE and LE: active weight shifts, reaching for objects at various heights

  • Improve ability to perform dynamic activities

Movement Disorder (BG)

Ex: Interventions — Transfers

• Preparation for activity: provide external cues: visual, auditory (including instructions – nose over toes, extend your back as you stand)

  • Improve attention and motor learning

• Improve scooting: work on side to side scooting and scooting front and back

  • Improve dynamic movements, prepare for transfers

• Improve UE and LE motor control: weight shifts while sitting a foam surface, leaning forward with hands on a physio ball, sit to stand from a high surface height

  • Practicing a part of sit of stand task before attempting the task

• Improve transition from sit to stand: provide external cues – auditory and visual, progress from easy to more difficult task

  • Improve performance across all stages of a sit to stand transfer

Movement Disorder (BG)

Ex: Home Activities

• Encourage Ed to implement the exercise to daily living tasks such as dressing himself and when eating

• Teach Ed to safely perform activities around the house

• Educate on fall prevention strategies

• Focus on improving ADLs and IADLs

Extrinsic Feedback Strategies

Dynamic Sitting

• Involves maintaining postural control in sitting while moving and shifting one’s weight.

• Requires controlling a moving center of gravity over one’s base of support.

• Becomes more challenging when:

  • Feet and/or hands are not bearing weight

  • Points of assistance/support are moved lower on the trunk

  • Activities are performed farther away from midline

  • Movement speed increases

Extrinsic Feedback Strategies

Common Functional Tasks in Dynamic Sitting

Extrinsic Feedback Strategies

Task Analysis — Stage of Learning: Initial (Cognitive)

• Provide lots of visual FB

• Demonstrate task

• Emphasize desired outcome & critical task elements

• Provide KR to reinforce successful movement outcomes

• Provide KP when errors are consistent

• Allow for trial-&-error learning

• NOTE: Although constant FB improves performance in early learning, it is important to start incorporating variable FB to improve retention

Extrinsic Feedback Strategies

Task Analysis — Stage of Learning: Intermediate (Associative)

• Less dependent on visual FB

• Encourage pt. to self-assess motor performance & focus on the "feel of the movement"

• Provide variable FB to improve retention: summary, faded, bandwidth

• Reduce hands-on assistance

• Continue to provide KR with successful movement outcomes

• Continue to provide KP with consistent errors

• Stress relevance of functional outcomes

Extrinsic Feedback Strategies

Task Analysis — Stage of Learning: Advanced (Autonomous)

• Only occasional FB required

• Focus on key errors

Extrinsic Feedback Strategies

Ex: Transfers

• The functional task of transitioning between body positions body positions & surfaces

  • Bed <-> wheelchair

  • Floor < - > stand

  • Wheelchair < - > therapy mat / toilet / tub bench