Lab Concepts 1: Assist level, bed mobility, transfers, weightbearing

Levels of Assist are in relation to

what the patient can do versus what the PT does for the patient

• Total Assistance • Max Assistance • Moderate Assistance • Minimal Assistance • CGA/SBA/Supervision • Modified Independent • Independent

total assist

Patient performs less than 25% of the activity

• Requires Hoyer/other lift to reposition in bed

• Requires Hoyer/other lift to transfer to a chair

• Non-ambulatory (*typially)

• Requires multiple people to assist with daily cares (*to stand, pivot)

max assist

Patient performs 25-49% of the activity

• Patient may require 2 people to assist with bed mobility, transfers, gait especially for safety purposes

• Requires cueing/assistance at multiple body parts to complete mobility tasks

• Ambulation distance is limited (5-10 feet)

moderate assist

Patient performs 50-74% of the activity (*can do at least half the work)

• Patient typically only requires one person’s assistance, especially if a rehab professional

• Significant assistance at one area of the body, or minimal assistance at multiple areas

• Ambulation distance can vary, but unlikely >20-30 feet

minimal assist

Patient performs 75%-99% of the activity

*not 100%; includes contact guard + standby assist

• Only requires assistance of one person

• Usually some assistance at one body part (ie at the trunk or at the leg for getting out of bed, or assistance weight-shifting at the pelvis with gait, etc)

• Ambulation distance can vary greatly

CGA/SBA/Supervision

under mid-assist; the 1-2%

-CGA (Contact Guard Assist): PT feels that they need to place their hand(s) on the patient to help maintain balance if it were to be lost, but no assistance provided

-SBA (Stand By Assist): Examples – PT feels they need to be closely guarding/near the patient, but does not put any hands/contact points on the patient

-Supervision: PT is there for verbal cueing/reminders, but no physical assistance provided

modified independent/indepdent

-Mod Independent= Patient uses assistive/adaptive equipment to complete activity, or requires increased time, but completes task without another human’s help

• Mod I includes the use of a walker, cane, etc. to ambulate. Can also include the use of a leg lifter, bedrails to assist getting out of bed.

*if use any assistive device OR need more time; don’t need us to assist or supervise

-Independent= Patient can perform task in normal timeframe without help

• The level of assist is based on what percentage of

• A PT/OT classification of assist level will not necessarily match/correlate with

a specific task the patient can complete

-In theory, a mod assist patient could walk 100 feet, but a contact guard assist patient could only walk 50 feet due to poor endurance

a nursing determination of assist

-Remember: YOU are the rehab professional trained in how to get the patient moving! • A patient whose PT determines they are mod assist may equal a RN determination of max assist of 2 → keep this in mind in acute care!

*dont use how far they can walk! allow pt to do it! see how much they can do

bed mobility: generel

• The act of getting into/out of bed

• Three techniques

-Sequential Roll

-Log Roll

-Long Sit

• Sequential and Log Rolls are broken up into 2 parts

• Supine <-> Sidelying

• Sidelying <-> Sitting

sequential roll

• Used with general medical diagnosis without precautions

-CVA, PD, COPD, UTI, etc

• “Easiest” way for most people to get out of bed

• Patient in supine, knees bent

• Initiate roll to side at trunk OR legs (then follow with the other)

• From sidelying, bring legs forwards off edge of bed, push up with arms and come into sitting position

log roll

• Used with diagnosis that have lumbar/spinal precautions OR when you want to avoid twisting of trunk/abdomen

-Lumbar fusion, CABG, abdominal incision, etc.

• Patient in supine, knees bent

• Initiates roll to side at trunk and legs simultaneously, keeping trunk straight

• From sidelying, brings legs off edge and pushes up from arms simultaneously, keep trunk straight

long sit

• Used with lower extremity orthopedic diagnosis

-TKA, THA, LE fractures/ORIFs, amputations

• Patient begins in supine, knees straight, angled closed to edge of bed

• Patient first pushes up onto elbows, brings legs over the edge of the bend and bends knee(s) as able.

• Once knee(s) are bent, patient then pushes up onto hands, and continues pivoting until seated at the edge of the bed

weightbeariing statuses: generel

-Weightbearing: The amount of weight placed through an extremity (upper or lower) by a patient.

-Weightbearing Status: Medical designation of the amount of weight permitted to be placed through a patient’s affected extremity

• Determined, modified and updated by the physician

• Based on the safety of the structures in that extremity to bear weight

• Found in physician’s notes or orders for physical therapy

-Common diagnosis with weightbearing designations: THA/TKA, ORIF, Amputations, LE/UE fractures, tendon/muscle repairs

weightbearing terminology

-FWB/Full Weight Bearing *no restrictions

-WBAT/Weightbearing as tolerated *up to pt

• Patient can place as much weight as tolerated (by pain, weakness, etc) through the extremity. It is orthopedically stable, will not damage the affected extremity.

• Common Diagnosis: TKA, THA

-PWB/Partial Weightbearing *wide variety

• Patient can place a specific percentage or force (i.e. weight) through the extremity. Going above that amount could cause damage to the affected extremity.

• Common diagnosis: ORIF

*education and maintence trickest, teach them how to offload in other areas

-TTWB/Toe touch weightbearing

• Patient can place the extremity lightly on the ground to facilitate balance/proprioception, however NO force may go through the affected extremity.

• Common diagnosis: ORIF

-NWB/Non-weightbearing

• Patient cannot place the affected extremity on the ground at all, no force may go through it.

• Common diagnosis: ORIF, bunionectomy, rotator cuff repair

posterior hip precautions

-No affected hip flexion past 90 degrees

-No affected hip adduction past midline

-No affected hip internal rotation past neutral

• “Don’t bend forwards past 90 degrees, don’t twist over your surgical hip, and don’t cross over your legs.”

• “These precautions are designed to protect the integrity of your surgery, and will be lifted at the discretion of your surgeon.”

lumbar/spinal preautions

• No twisting, side bending, or flexion/extension at the lumbar spine

• “These precautions are designed to protect the integrity of your surgery, and will be lifted at the discretion of your surgeon.”

thoracic/abdominal preautions

-Varies on diagnosis, but highly recommended to follow vs. an absolute requirement, might not be in PT order

• Lumbar Fusion: Risk of impacting surgical integrity if not following precautions

• CABG: Painful for patient to rotate through chest, risk aggravating incision

-Done to facilitate patient comfort with mobility

-No twisting/rotation through spine

knee blocking

• Use of therapist’s lower extremities during a transfer or gait to provide additional external support to one or both of patient’s knees to prevent buckling.

• Cannot be done on a leg that recently had surgery, nor on an amputated LE

• Requires different positioning for therapist based on PT and patient heights.

*1 block: use inside so tibial tuberosity in between

*2 block: same but both knees inbetween

squat pivot

• No device utilized • Requires single or double knee block • Patient is facilitated to stand up straight, weight bear through LE’s as tolerated/permitted • Used with all types of diagnoses

slideboard

• Uses slide board underneath buttocks • Requires gentle double knee block to prevent forwards sliding on board • Non -weightbearing transfer through LE’s • Used with amputees, patient with significant difficulty weightbearing through LE’s

mechanical lifts

• Used when patients need higher levels of assist and it is not safe for the patient and/or the caregiver to physically transfer the patient

• Use of mechanical lifts could be due to weakness, severe deconditioning, line management, time, patient’s cognitive presentation, etc

• The use of a mechanical lift is NOT based on the patient’s weight!

Types

-Hoyer: sling/hammock, from sit or laying, past shoulders and crosses under each leg

-Sara steady and EZ stand: sit → stand higher level (not for total assist), good for nursing staff, pivot though