Activity Based Assessment Notes

Activity Based Assessment

Aims of Lecture

• Cover practical skills assessment components:
  • Bed mobility
  • Transfers
  • Sitting balance
  • Standing balance
• Reminder of key points of manual handling
• Consideration for documentation

Core Elements of Objective Assessment (Previously Covered)

• Impairments within the ICF framework, such as:
  • Active range
  • Strength
  • Passive range
  • Tone
  • Somatosensation
  • Coordination
  • Vision

Functional or Activity Assessment Elements

• Assessment of bed mobility
• Transfers (lie to sit to lie, bed to chair to bed, sit to stand to sit)
• Sitting balance
• Standing balance

Assessment of Bed Mobility

• Movements of up and down the bed.
  • Up is important as patients in hospital end up too far down the foot end of the bed.
  • Teach how to get themselves back up the bed.
  • Includes bridging: lifting the bottom up with knees bent in crook lying.
    • Important to look at for hip extensor strength functionally.
    • For completion of tasks such as lifting the bottom to go onto a bedpan.
• Side to side assessment
  • Hospital beds are narrow, and patients often cannot roll without first moving to one side.
  • Movement requires patients to bridge and then shift the hips and pelvis to the left or right.
  • Usually completed after or as part of assessing bridging.
• Rolling
  • Important for patients to reposition.
  • To be able to roll to get out of bed.
  • Assess to both the left and right sides.
• For more mobile patients/those in ambulatory outpatient or private practice type settings:
  • May not need to assess all or any of these components specifically.
  • Bridging is commonly assessed because of its value in looking at hip extension.
  • Rolling is common as part of getting patients on and off plinths.
  • Ask the patient to complete the activity, if safe.
  • "Can you get yourself up the bed?"
    • See what and how the patient attempts to do this without any further cues, prompts, or assistance in the first place.
    • Patients may need two or more people to help them.
    • One person for safety, a standby, or verbal prompts and cueing may be enough.

Equipment

• Slide sheets
• Triangle (generally discouraged as patients can injure their shoulders, and they cannot generally have a triangle at home).
• Bedsticks and cot studs may also be an option, but the question needs to be whether patients can use these in their home environment.

Assessing Bed Mobility (Video Demonstration)

• Look at:
  • Up and down the bed
  • Side to side
  • Bridge
  • Rolling left and right
• Safety: Ensure brakes are on the bed.
• Presume introduction and informed consent has been gained.
• Consider if a full bed assessment is required for mobile patients.
• For all movements, want to see what the person can do for themselves first.
  • How do they go about trying to do it?
  • Ensure the person is safe, and stop them if needed.
  • Also going to do normal movement example of these so you can see what a person that's able-bodied would normally do before being able to analyze with your patients about what they're doing differently with that as well.
• If assistance is needed, try verbal cues first.
• Up and Down the Bed:
  • Observe what the patient does when asked to get up the bed.
  • Patients may grab for the end of the bed or cot sides (allow if safe).
  • Flatten the bed, take the pillow out, or slope the bed to assist the patient.
  • If struggling, talk the patient through it.
  • Stabilize the person's feet if needed.
• Side to Side:
  • Observe how the patient attempts to move from side to side.
  • Patients may bend one leg and reach across to pull themselves across.
  • If assisting, bend both legs up and instruct the patient to lift their hips.
  • Stabilize the feet if needed.
  • One person can stabilize a leg and help lift the hip.
  • Options: Slide sheets, lifter, or gantry.
• Bridging:
  • Observe what the person can do themselves.
  • Assess hip strength functionally.
  • If a person is having trouble, stabilize their feet and assist with lifting.
  • Prompt and guide the bottom to lift.
• Rolling:
  • Observe how the person rolls.
  • Normal: Bend the outer leg up, reach across with the same arm, and push with the leg to turn onto their side.
  • Patients may need verbal prompting or physical assistance.
  • Rolling away from the affected side may be easier.
  • Risk of rolling onto the injured shoulder (protect the shoulder).
  • Key points are the outside of the knee and the pelvis.
  • Ensure the patient is safe and will not fall off the side of the bed.
  • Have someone on the side of the bed or plinth that the person is rolling towards.
  • If a second person is needed, they might be on the other side, pushing the trunk into side lying.

Transfer of Lie to Sit

• Two typical methods:
  • Rolling to one side and tipping up sideways into sitting.
    • Generally easier to roll to their affected side, but this means rolling onto their affected shoulder, which might put the shoulder at risk of injury.
    • Assess both sides.
  • Swivel method: patient turns and angles themselves more across the bed so their feet come off to the side and then they use their abdominals to do a more of a sit up essentially, to sit themselves forward or up.
    • Requires significant abdominal strength.
    • Not suitable in cases of spinal surgery, spinal trauma, or abdominal surgery.
    • Not great for the spine in general.
    • Patients are often at more risk of sliding forward off the edge of the bed.
    • May increase a patient's tone and associated reactions.
• Ask patients to show you how they go about getting into sitting onto the side of the bed.
• Stop someone partway through if it is becoming unsafe.

Lying to Sitting and Sitting Back to Lying (Video Demonstration)

• Two typical ways a patient may look to do this naturally:
  • Roll themselves and tip up to sitting
  • Swivel and sit up
• Observe what normal movement looks like.
• Ask the person to have a go at getting out of bed.
  • See what that person would do for themselves.
  • Ensure safety.
• Verbal facilitation first.
  • Focus on the roll to tip as the more recommended method.
• Physical assistance if needed (one or two people).
• If two people assisting:
  • Someone at the legs and someone at the trunk.
  • Someone front and back.
  • The back person is responsible for the trunk, and the other person is responsible for the legs.
  • The person in front is always responsible to make sure the person's not going to slide off, and be mindful of your own manual handling.
• If assisting with one person, use key points at the knee and pelvis.
• If the person can look after their legs, they'll bring them across.

Bed to Chair/Chair to Chair Transfers

• Hierarchy (most assistance to least):
  • Mechanical gantries or sling lifters, as well as mechanical stand lifters
  • Manual stand lifters
  • Slide board transfers
  • Pivot type transfers (low pivot or high/semi standing pivot)
  • Stand transfers (pivot in standing or stepping and walking between)

Gantry or Ceiling Hoist & Sling Lifter

• Mechanical device that uses a sling to lift a patient
• Used with the most dependent patients.
• Key indicator: patient does not have independent sitting balance control and does not have enough leg strength at the same time.
• Considerations:
  • Patients with significant fatigue may be able to sit or even stand but for short durations only, or may be too fatigued at the end of the day or overnight to complete a different type of transfer.
  • Patient is unreliable and so highly unsafe with other options (behavior, cognition, impulsivity, disorientation).
  • Consider the 24-hour picture, as therapists often see patients at their most optimal time.
  • Recommendations might be mixed (different transfer types for day vs. morning/evening/overnight).
• Each gantry, sling lifter, and sling is slightly different.
  • Learn the specifics of the devices that you have on-site and in your future workplace.
  • Have a clinical educator or supervisor or trained staff member with you when trying one of these devices and transfer starts out for the first time.
  • Completed with two people in any case.
• Typically, cross the leg straps in between the patient’s legs and attach to the opposite side of the lifter arm piece.
• For a more sitting position, use shorter shoulder straps and longer leg straps. For lying, typically have equal for both.
• There will be manual release options for safety reasons, but this is not what we want to do for picking patients up without power.
• Cleaning slings and sharing slings policies. So you need to be sure you check this out on placement at and at future workplaces.

Sling Lifter (Video demonstration) from Wheelchair to Bed Using a Toileting Sling

• Describe the movement to the client and get consent.
• Check the environment:
  • Enough room for the hoist to fit around the wheelchair to be able to maneuver that over to the bed.
  • Get the height of the wheelchair and bed to be a similar height.
• Maintain strong communication between workers.

Steps

1. Lean Patient Forward
2. Apply the Sling
3. Bring in the Hoist
4. Attach Sling to Clippers
5. Raise the patient and move them across to the Bed

• Maintain reassurance for the client.
• Rolling Simon to the side to pull it out or you could, lean him forward to collapse.

Stand Lifters

Mechanical Stand Lifter (Arjo Sara Plus)

• Used with moderately to severely dependent patients.
• Key indicators:
  • Patient has some sitting ability, but it is limited.
  • Patient has some, but limited, leg strength to complete their sit to stand.
• Two slings available: waist belt & full sling.
• The setup is also best completed with two people.
• Once set up, the person completes the action of sit to stand with one person, but to be able to move the person from chair to chair or bed to chair, there needs to be two.

Non-Mechanical Stand Lifter (ArjoCeraSteady)

• Used with moderately dependent patients.
• Those with more independent sitting balance and trunk control.
• Can generally sit to stand by pulling up at a rail with or without some extra assistance.
• No slings and no mechanical help.
• The person may be able to complete the sit-to-stand element with one person, but if actually moving the patient while they're in the device from bed to chair, two people are needed.

Sara Steady Lifter (Video demonstration:) a Non-Mechanical Sit-to-Stand Assistant Transfer

• People generally need to have some ability, some level of trunk control, some level of ability in their legs
• Completed with two people: talk through where the second person would be and how they would be helping.
• Can be used for a bed to chair, chair to chair type transfer. It can also be used for sit to stand and sit to stand practice as well.

Steps

1. Bring it in and get Kim to pop her feet on, and we're gonna make sure we pop our brakes on.
2. Can you get your bottom forward in the chair at all?
3. Use Leg and Trunk Control to Stand
4. Bring Paddles In
5. Sit Back.

Slide Board Transfers

• Key indicators:
  • Some level of sitting balance and trunk control
  • Do not rely completely on their arms to maintain this.
  • Unable to complete sit to stand or safely stand for a transfer.
  • Unable to complete any of the more advanced pivot options.
• Assess a slide board option before trying the pivot.
• Patient may be able to achieve more independence.
• Less dependent on equipment.
• More active component to complete -> encourages good functional practice.
• Assess if they can complete a lateral shift up and down the edge of the plinth or bed in sitting.
• Position of wheelchair or shower chair:
  • Slight angle, and always go towards the stronger side of the patient.
  • Most boards will have cut out for the wheel.
• Patients need to keep their fingers safe and not curl them under the edge of the board.

Slide Board Transfers (Video demonstration)

• These might be done for someone that has some level of trunk control in sitting, although they still might need some support to be able to do this transfer and that's okay, but not a person that needs really heavy assistance with their trunk in sitting.
• Always do our slide board transfers to someone's stronger side.
• Position the wheelchair on a very slight angle.
• So you can see the chair is just on a slight angle.
• So we talked a little bit there about the trunk control, but the other thing we can do as both a preparation and also as sort of a strengthening activity for this is look at what we call them bunny hopping up and down the side of the bed and seeing how they go with that in preparation for, or as a training way therapy to improve this live or transfers.
• If someone needed more assistance, we could have a second person in behind.

Transferring Action Steps

1. Position the board with the aid of assistance.
2. Keep Fingers Safe
3. Make sure breaks are on.
4. Move with assistant towards the chair with care.
5. Make sure they fit in front wheel to stop fingers from squashing.

• Take side arm off the wheelchair.
• To practice back to the bed, I'm just gonna move your Kim around to the other side so we can have a practice going back to the bed.
• There is set up and foot position is important.

Pivot Transfers

• Key indicators:
  • Reasonable to good sitting balance and trunk control.
  • Completing a slide board option well or easily, but not yet standing well enough to stand completely or step transfer.
• Assess a low pivot first (with slide board) before a higher pivot.
• Goal: the bottom from the bed or plinth to the chair or vice versa in one movement only.
• High pivot: uses a semi-stand position - can be completed if the patient is managing the low pivot well and reliably and that they are nearly capable of standing but perhaps with upper limb contact at times.
  • Person almost stands and compared to the low pivot is definitely up on their legs, but usually remains holding on in a semi crouched position.
• Pivot is always completed to the stronger side.
  • There is a need to move the wheelchair in the circle if the patient is completing getting in and out of bed.
• Wheelchair setup and patient starting position (feet) is important.
• Either a low or high pivot could be completed with one or two person assist until the patient is independent.
• A pivot transfer may be someone's long term transfer option, and this is often the case with our amputee patients as well.

Pivot Transfers (Video demonstration)

• The difference is a low pivot. The board is still in place, as we saw with slide board transfers, but the goal is that the person actually makes the transfer in one go all the way to the wheelchair. The board is there just to cover the gap and in case they do sit in the middle until they're reliable.
• Our setup is very much the same. The wheelchair's on a slight angle.
• They tend to get divided as a low pivot or a high pivot, transfer.

The Higher Pivot Steps

1. Remove board from the transfer.
2. Use semi stand to swivel to turn.
3. Get you to land on the chair in a good position.

General Considerations

• It's a lot easier for me to turn on my feet than necessarily to rely on the chair as the person's getting a little bit more able.
• One or two people may need to assist.
• It is important that second person is coming in from behind assist to help turn.

Assessing Sit to Stand to Sit

• Assess sitting balance,trunk control and leg strength.
• For more dependent patients, assess sit to stand with stand lifter or two people with rail or plinth.
• Patients with good trunk control in sitting may be assessed with one person only.

Patient setup

• Bottom forward in the chair:
  • Rock side to side and shuffle each hip forward
  • Lean back and slide themselves forward
  • Bunny hop their bottom forward
• Move feet back under them.
• Prompt or cue them and physically assist them if required -> Patients commonly need to be educated or re educated about how to set themselves up to be ready to stand as they don't remember how they used to do it spontaneously.

Therapist Considerations

• Options: two assist, one assist; standby, or just verbal cues and prompting.
• Patient completes the action:
  • Assess trunk movement and control from flexion to extension.
  • Note evenness of weight bearing
  • See why they complete it the way they do
  • Assess Range of movement and Strength.
  • Consider fear concerns about bringing the trunk forward and initiation.
• Ability to sit to stand from a higher seat will be easier than a lower seat.
• The help can be on the rail in front of them; this helps them bring their trunk forward, and also make sure they feel secure while they bring their trunk forward with their hands on something, and it also can help with balance, as well as give the legs some assistance if required.
• Pushing up with the hands from the chair as assisting arm movement.
• Assess if someone can complete sit to stand without using their arms at all (Berg Balance Scale requires more leg strength and balance).

Assisting Sit to Stand From Video

• Get bottom in the right position.
• Move feet back
• Lean truck forward to get balance.
• There are certain ways a person will have to lean, so assess those situations.
• Important to be ready to help if needed to make sure the person does not fall.
• It is important to maintain knee contact and transfer belt. If needed, assist the hip. Make leg goes slow.

Stand Type Transfer

• Stand and then either pivot or step or actually walk
• Completed with a patient that can stand and has some level of trunk controlling standing plus or minus using support of either one or two people and or equipment.
• Patients might stand but still pivot where they cannot step
• Patients that can stand and step which would still initially be completed towards the stronger side.
• Assess and documented as either standby or independent.
• Ability to complete sit to stand while facing and holding a rail.

180 degree pivot transfer

• This is not ideal for transfers into single toilets.
• Assess three chairs or use ganary support or waling harness.
• It is important to setup with feet apart so they do not twist over.

The Static Position With Balance

• Static is the patient's ability to hold themselves up right. Also, again, observing posture as they do this.
• Able to determine with support what supports do you need.
• Whether not they can recognize and orientate themselves to midline and for how long they can maintain this is what we will also assess.
• Take knee, hip andtrunk for key points in control to maintaining standing is what you're taking notice of.
• Dynamic control (may start is as simple as assessing weight shift) that is, the patient's ability to move their weight to where they have there control.
• Dynamic control : how far you can work away from the base of support and can be be compared and assessmented on their normal, unaffected side.
• Change vision by completing eyes open or closed.
• Moving objects to maintain stability.

Assessment of Sitting Balance (Video Demonstration)

• Key components:
  • Static balance and orientation to midline
  • Response to perturbations
  • Dynamic balance (reaching out of base of support)
• Therapist in front of the patient; second person may be from the side or behind.
• Look at:
  • Control
  • Posture
  • Endurance
• Maintain midline balance with:
  • Arms open
  • Eyes Open
  • Eyes Closed
• Reaching maximum capacity for assessment to to maintain full extension.

Assessment steps:

1. Orientation to midline and can the person maintain that?
2. What maximum capacity to reach out

Assessing of Standing Balance (Video)

• Less able use plinth and rail to help maintain stability.
• Able to assist getting upto standing. So Kin making sure's you bottom's forwarding in chair and then I'm gonna block knee and you can push from you can have a hand up here and we'll come standing on three.

Key Points

• Knee controls.
• Side preference if it's their affect side.
• Resistance can be added by gently pushing and making sure to what extend to what side can they maintain stable.
• Challenges:
  • Closing their eyes.
  • Standing arm up for a minute.

Manual Handling

• Occurs when a person is lifted, lowered, pushed, pulled, carried, moved, held, or restrained.
• Repetitive and sustained forces and movements and awkward postures are also important.
• Aim to protect ourselves and the person from injuries.
• Principles:
  • Complete a risk assessment and plan prior to attempting the task.
  • Posture Maintenance.
  • Keep weight closed and if needed pushed and used patients to help weight support.
• Documentation:
  • Objective assessment.
  • Remember ward recommendations or advice to family or carers may be different to what we can do or over that twenty four hour picture.
  • Document what we are capable of doing
• Structure our objective component with the following components of:
  • Bed mobility
  • Transfers
  • Sitting balance
  • Standing balance
• Comment on the level of ability:
  • Independent.
  • Standby.
  • One times light assist.
  • Two times light assist.