12. Transfers

Objectives

• Identify preparation steps for safe bed mobility and transfers

• Integrate PT evaluative findings into transfer decisions

• Discuss how specific weight-bearing (WB) restrictions influence choice of transfer technique

• Review standardized levels of assistance and their descriptors

• Describe & demonstrate proper patient handling for common bed-mobility / transfer methods

• Review universal safety considerations for all transfers

• Explain the concept of Safe Patient Handling (SPH) and its effects on PTs & other health professionals

Preparation for Safe Bed Mobility & Transfers

• Thorough chart / medical-record review

  • Recent PT eval, MD orders, WB status, hip precautions, vitals, lab values, imaging red flags, lines & tubes

• Patient examination / screening

  • Current vital signs, pain, cognition, ROM, strength, balance, tone, communication, vision, coordination

  • Identify patient abilities, limitations, precautions

• Environmental & equipment set-up

  • Obtain gait belt (unless contraindicated), ADs, slides boards, walkers, trapeze, drawsheet, pillows

  • Address draping, modesty, proper dress & non-slip footwear

  • Assemble necessary staff → plan for 1-, 2-person, or mechanical assist

  • Clear the area; keep frequently used items in reach (call bell, water, handset)

• Plan for lines, tubes, monitors

  • Arrange IV poles, drains, catheters to travel on the safer side; secure slack

• Communication

  • Explain procedure to patient & team; confirm understanding

  • Use countdown ("1-2-3") or key word to initiate

• Body-mechanics reminders for clinician

  • Neutral spine, wide BOS, bend knees, shift weight rather than lift

• Timing

  • Initiate only when both PT & patient are ready; pause if unsure vs. commit if mid-transfer ("No-Man’s-Land")

• Post-transfer security

  • Reposition, add seatbelts / bedrails, attach footrests, supply call light, tray, etc. → transfer not complete until patient safe

PT Examination Findings Affecting Transfers

• ROM limitations (e.g., spinal precautions, 90^\circ shoulder flex restriction)

• Strength deficits → determine need for assistive device or additional personnel

• Postural control & balance (sitting / standing)

• Tone & spasticity (e.g., extensor thrust → need for knee block)

• Motor control / coordination (ataxia, dysmetria)

• Cognition & communication (impacts instruction follow-through)

• Vital signs / cardiopulmonary endurance (orthostatic hypotension, \mathrm{SpO_2} drop)

• Sensory / vision deficits → spatial awareness

• Social & environmental factors

  • Home layout, available caregiver, equipment, motivation, previous activity level

• WB status & hip precautions (critically dictate transfer selection)

Weight-Bearing Status (Standard Definitions)

• Full Weight Bearing (FWB) – unrestricted

• Weight Bearing As Tolerated (WBAT) – limited only by patient’s pain

• Partial Weight Bearing (PWB) – MD specifies % of body weight (default 50\% if unspecified)

• Toe-Touch / Touch-Down WB (TTWB) – toes may contact floor for balance; 0\% load through limb

• Non-Weight Bearing (NWB) – foot must not contact floor
  Significance:

• NWB / TTWB → sliding board, squat-pivot, or mechanical lift; avoid stand-pivot on affected limb

• PWB → may allow stand-pivot with unloading via UE support or therapist assist

Hip Precautions

Posterior approach

• No hip flexion > 90^\circ

• No adduction past midline (use abduction pillow at rest)

• Avoid hip internal rotation
  Anterior approach

• No hip extension beyond neutral (no prone or bridging)

• Avoid external rotation

• Emphasize step-to gait pattern, avoid long stride on involved side
  Clinical relevance:

• Choose higher seats, raised commodes; enforce pillow under thigh during transfers

Levels of Assistance (Class Terminology)

• Independent – no verbal or physical help in safe, timely manner

• Modified Independent (Mod I) – independent but requires assistive device or extra time

• Stand-by Assist (SBA) / Supervision

  • Verbal cues only; no contact

  • Steve’s subclassification: SBA = within arm’s length; Supervision = across room

• Contact Guard Assist (CGA)

  • Hands on gait belt for protection; provides no lifting unless loss of balance

• Minimal Assist (Min A) – patient performs > 75\%; PT < 25\% effort

• Moderate Assist (Mod A) – patient 50–75\%; PT 25–50\%

• Maximal Assist (Max A) – patient 25–50\%; PT 50–75\%

• Dependent / Total Assist – patient < 25\%; PT, ≥2 staff or mechanical device provides > 75\%

Progression of Assistance (Typical Rehab Goals)

\text{Total} \;\rightarrow \text{Max} \;\rightarrow \text{Mod} \;\rightarrow \text{Min} \;\rightarrow \text{CGA} \;\rightarrow \text{SBA} \;\rightarrow \text{Supervision} \;\rightarrow \text{Mod I} \;\rightarrow \text{Independent}
Purpose: provides measurable milestones toward functional independence

Documentation Clarity – Steve’s Pet Peeve #1

• Ambiguous: “max assist ×2”

• Preferred: “Two-person assist required; patient performed < 50\% of effort (max assist) for bed⇄WC transfer” OR “Total assist of two people…”

• Rule: state both # of helpers and level of assistance clearly

Fundamental Mobility: Scooting in Chair / WC

Patient-controlled scoot

• Lean trunk against backrest → slide pelvis forward → bring trunk erect at new edge position
  Assisted scoot

• Therapist blocks knees, tilts chair slightly if needed, rocks patient to shift weight & advance pelvis

Basic Transfer Techniques

1. Stand-Pivot Transfer

   • Ideal for WBAT / PWB with adequate standing balance

   • Steps: apply gait belt → PT blocks knees → cue “nose over toes” weight shift → patient stands, pivots toward target, sits

2. Tuck (Squat) Pivot

   • Patient stays flexed; faster & efficient; good for hemiplegia or low endurance

3. Sliding-Board Transfer

   • Board under proximal thigh; fingers flat (avoid pinch) → multiple short scoots OK

   • PT blocks knees; lean forward to unload board (reduce friction)

4. Walker-Assisted Transfer

   • Patient stands to walker then pivots; PT guards from side with belt; used for mod / max assist if PT strong & knee control adequate

Dependent & Advanced Transfer Options

Mechanical & assistive devices

• Trapeze (self repositioning, NOT for bed→chair)

• Drawsheet surface-to-surface transfer (bed⇄gurney); level surfaces; lock beds

• Full-body transfer boards, roller boards, inflatable mats to minimize friction

• 2-person lifts (front-back or bilateral sides) – avoid when possible; not practiced in lab

• Hydraulic / electric mechanical lift ("Hoyer")

  • Check sling size, weight limit, base-leg clearance; ensure brakes off during lift, locked when positioning

• Quad lift – manual dependent lift offering trunk support when device infeasible

• Dependent sliding board / dependent pivot – therapist performs most effort while maintaining knee block & hand placement control

Dependent Pivot Best Practices

• Patient’s hands: lap or far arm over therapist shoulder (avoid around neck)

• PT blocks both knees (Steve’s Pet Peeve #2 – “You HAVE to block the knees!”)

• Feet placement: patient feet staggered or on floor plate; PT foot/knee outside to facilitate pivot arc

Wheelchair ↔ Floor Transfers

Forward WC→Floor

• Scoot forward, feet under → controlled “fall” onto extended UEs → lower to sitting
  Floor→WC (hemiplegic example)

• Side-sitting → tall kneel → half-kneel on strong leg → stand → pivot into chair
  Turn-Around Transfer (backward approach)

• Useful in narrow spaces; ensure brakes & anti-tippers engaged

Universal Safety Checklist (“Things to Always Remember”)

1. Establish control of patient (gait belt, knee block)

2. Plan ahead (equipment, path, staff)

3. Level & stabilize surfaces when possible

4. Clear pathways (remove clutter, rugs, IV lines)

5. Communicate continuously (pre-brief, countdown, feedback)

6. Optimal patient positioning (alignment, comfort, precautions)

7. Utilize momentum judiciously; avoid pure lifting when sliding / rocking suffices

Safe Patient Handling (SPH)

• Ergonomic paradigm prioritizing mechanical lifts & low-friction transfer aids

• Goal: minimize musculoskeletal injuries among health-care workers

• Now considered standard of care in nursing & allied professions

• PT Perspective: balance between fostering patient mobility/strength and protecting staff; choose “minimal-manual” when patient cannot actively participate

Ethical & Practical Implications

• Patient autonomy vs. safety: always solicit patient effort up to safe limit

• Documentation accuracy impacts inter-professional communication & reimbursement

• Over-reliance on devices (e.g., trapeze) can foster learned dependency; clinicians must encourage progress toward independence

Numerical / Statistical References & Formulae

• Hip flexion restriction: \le 90^\circ posterior approach

• Percentage assistance thresholds: \text{Min A} > 75\% patient effort, \text{Mod A} = 50–75\%, \text{Max A} = 25–50\%, \text{Total A} < 25\%

• PWB default when unspecified: 50\% body weight

Key Reminders & Mnemonics

• “Nose over toes” – cue for standing up

• “Block the knees, hold the belt, count to three” – core transfer mantra

• Progress assistance ladder (Total→Independent) as goal setting framework

Example Scenario Connections

• Post-op THA (posterior) NWB → likely sliding board with hip precaution adherence

• Stroke with hemiplegia, Mod A → squat pivot toward strong side; walker adjunct once standing control improves

• High BMI, low trunk control → mechanical lift indicated under SPH standards

Potential Exam Questions to Practice

• Describe how WB status alters transfer choice (provide 3 examples)

• List & explain three hip precautions for anterior approach THA

• Differentiate SBA vs. CGA with clinical example

• Outline steps of a dependent pivot including knee block rationale

Concluding Thought

Safe, efficient transfers hinge on meticulous preparation, clear communication, evidence-based technique selection, and unwavering respect for both patient capacity and clinician ergonomics. Mastery of these principles safeguards everyone while promoting functional independence.