wk 5 - Activity Based Assessment

Activity Based Assessment

Aims

  • Cover practical skills assessment for:
    • Bed mobility
    • Transfers
    • Sitting balance
    • Standing balance
  • Reminder of key points of manual handling.
  • Consideration for documentation.
  • Core elements of objective assessment (ICF framework):
    • Active range
    • Strength
    • Passive range
    • Tone
    • Somatosensation
    • Coordination
    • Vision

Functional/Activity Assessment Elements

  • Bed mobility assessment
  • Transfers:
    • Lie to sit to lie
    • Bed to chair to bed
    • Sit to stand to sit
  • Sitting balance
  • Standing balance

Bed Mobility Assessment

  • Movements up and down the bed.
    • Patients often slide down.
    • Assess and teach how to move back up.
    • Bridging: lifting bottom with knees bent.
      • Important for hip extensor strength.
      • For tasks like using a bedpan.
  • Side to side assessment.
    • Hospital beds are narrow.
    • Patients may not roll without moving to the side.
    • Requires bridging and hip/pelvis shift.
  • Rolling.
    • Repositioning.
    • Rolling out of bed.
    • Assess both left and right sides.
  • Assessment in different settings:
    • More mobile patients may not need all components.
    • Bridging is common for hip extension.
    • Rolling for getting on/off plinths.
  • Assessment Method:
    • Ask patient to complete activity without cues.
    • Note patient's attempts.
    • Consider safety with standby or verbal prompts.

Equipment

  • Slide sheets
  • Triangle (generally discouraged due to shoulder injuries, and may not be available at home)
  • Bedsticks and cot sides (consider home environment)

Video: Assessing Bed Mobility

  • Components:
    • Up and down the bed
    • Side to side
    • Bridge
    • Rolling left and right
  • Safety First:
    • Brakes on the bed (visual check and nudge)
    • Introduce yourself and gain informed consent
  • Full assessment:
    • Is it required? If the patient is very mobile, maybe not.
    • Consider patient goals or deficits.
    • Bridging might still be assessed.
  • Observe First:
    • See what the person can do for themselves.
    • How do they attempt the movement?
    • Ensure safety verbally or physically
  • Normal Movement Example:
    • Demonstrate normal movement to analyze patient's differences.
  • Assistance:
    • Verbal cues first
    • Physical assistance (one or two people or equipment if required)
    • Up and Down the Bed.
      • Patient bends legs and shimmies trunk.
      • May grab the end of the bed or cot sides (allow if safe)
      • Avoid triangles (shoulder injuries)
      • Flatten the bed, take out the pillow, or slope the bed.
  • If Patient Struggles:
    • Verbal guidance: bend knees, stabilize feet, wriggle and push.

Side to Side Movement

  • Patient may bend one leg and reach across.
  • Typically, bend both legs and lift hips across.
  • Facilitation:
    • Stabilize feet.
    • Instruct to lift hips to the left and right.
  • If patient can't do that:
    • Stabilize one leg and help lift the hip.
    • Coordinate with patient on "three" to lift and move hips.
    • Bring the feet across as well.
  • Alternative methods:
    • Slide sheets
    • Lifter or gantry
    • Two people: one stabilizes feet, the other works with the pelvis

Bridging

  • Observe what the person can do themselves.
  • Assess hip strength functionally.
  • Facilitation:
    • Stabilize feet
    • Coordinate lift on "three"
    • Prompt and guide bottom to lift.

Rolling

  • Observe what the person does naturally.
  • Normal movement: bend outer leg, reach across with the same arm, push with the leg to turn.
  • Verbal prompting may be enough.
  • Might need physical assistance.
    • Rolling towards stronger side is easier.
    • Risk of rolling onto the injured shoulder, protect it.
  • Assistance for rolling using the weaker side:
    • Bend up the leg, reach arm across.
    • Key points: outside of the knee and pelvis.
    • Coordinate roll on "three."
  • Safety:
    • Ensure space and prevent falls off the bed.
    • Have someone on the side the person is rolling towards.
  • Second person: on the same side or pushing the trunk into side lying from the opposite side.

Transfer: Lie to Sit

  • Two Methods:
    • Rolling to one side and tipping up sideways
      • Easier to roll to the affected side, but the shoulder might be at risk of injury and it can be difficult to get a good push up with the arms.
      • Assess rolling to both affected and unaffected sides.
    • Swivel method: turn + sit up, feet off the side
      • Requires abdominal strength, can raise tone
      • Not for spinal surgery, trauma, abdominal surgery
      • Risk of sliding off the bed
  • Ask the patient to demo getting into sitting.
  • Stop the patient if unsafe.

Video: Lying to Sitting and Sitting to Lying

  • Two typical methods:
    • Roll and tip up
    • Swivel and sit up
  • Normal movement demo:
    • Roll and tip up
    • Swivel to bring legs off the side and push trunk with arms.
  • Observe First:
    • Ask the person to try and get out of bed themselves.
    • Ensure safety.
  • Verbal facilitation:
    • Focus on the roll to tip method.
    • Guide through bending leg, reaching across, pushing with the leg.
  • Physical assistance:
    • One or two people.
    • Two people: one at legs, one at the trunk.
      • The person in front is always responsible to make sure the person's not going to slide off.
    • If assisting with One Person:
      • Stabilize leg.
      • Key point at the knee and pelvis
      • Coordinate on three to roll onto the side.
      • Then, tuck legs off the side and push up with elbow and hand.
  • Return to lying:
    • Elbow down, shoulder down, lift feet up, and roll.
  • If the patient has reduced ability:
    • Get a second person.
    • The person in back assists on three coordinate
    • If the person is doing the swivel option guide the trunk.

Hierarchy of Transfers (Most to Least Assistance)

  • Mechanical gantries or sling lifters
  • Mechanical stand lifters
  • Manual stand lifters
  • Slide board transfers
  • Pivot transfers (low or high)
  • Stand transfers (pivot in standing or stepping/walking)

Gantry or Ceiling Hoist & Sling Lifter

  • For most dependent patients.
  • Key Indicator: the patient doesn't have independent sitting balance and enough leg strength.
  • Also consider:
    • Fatigue
    • Unreliability
    • Cognition and behavior
  • 24-hour picture:
    • Consider patient capabilities at all times of the day, not just during therapy.
    • May recommend mixed transfers (different types at different times).
  • Device specifics: Learn the specifics of the devices on-site.
  • Two people are needed for these transfer techniques.
  • Sling usage: Cross the leg straps in between the patient's legs, colored tabs matching shoulder straps indicates lying or sitting position preference.
  • Gantries: Ensure charging and battery maintenance.
  • Sling sizes: Consider appropriate sling size.
  • Sling hygiene: Follow workplace policies on cleaning and sharing.

Video: Sling Lifter (Wheelchair to Bed)

  • Communication is key
  • Describe the movement to the client and get consent.
  • Check the environment: ensure enough room for the hoist.
  • Adjust the height of the wheelchair and bed to be similar.
  • Two-person assistance: maintain strong communication.
  • Application of Sling:
    • Lean the client forward.
    • Apply sling behind them.
    • Wrap straps around legs and loop.
  • Moving the hoist: the person in charge of the hoist communicates, another person to make sure the patient doesn't hit anything, the hoist needs to be mobile.
  • Raise slowly:
    • Reassure the client.
    • Check for enough bed clearance.
  • Lower into bed: don't apply brakes to the mobile hoist.
  • Removing the sling: roll Simon to the side.

Stand Lifters

  • Used if patient has some sitting ability, but somewhat limited, and some leg strength but limited.
  • Two slings:
    • waist belt.
    • full sling has straps that go between the legs
  • Once set up, the person can complete sit to stand with one person, but to move the person from chair to chair, and the initial set up, 2 people are needed.

Non Mechanical Stand Lifter

  • Moderately dependent patients:
    • 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 device 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.

Video: Non-Mechanical Sara Steady Lifter

  • Non mechanical sit to stand assistant transfer.
  • The patient needs to have some trunk control and leg ability (3+/4).
  • Completed with two people, assisting with sit to stand and moving.
  • Use:
    • Bed to chair
    • Chair to chair type transfer
    • Sit to stand and sit to stand practice.
  • Patient setup: feet on the gray platform, bottom forward in chair, knees onto support.
  • Therapist assists with sit to stand and transfers from knee and under hip.
  • Once standing, bring paddles in behind for patient to sit back on.
  • Transfer: with two people, take brakes off and turn the device towards the bed.
  • Then, ask the person to stand up to sit on the bed.

Slide Board Transfers

  • The patient has some trunk control, isn't as limited as a hoist, but can't complete more advanced pivots.
  • Reasoning behind doing before a lifter:
    • Patient may gain independence.
    • Less dependent on equipment.
    • More active component.
  • Assess:
    • Can a patient complete a lateral shift up and down in sitting?
  • Wheelchair position is important
    • Angle to the stronger side, and go towards this side.
  • The goal is for patients to learn all steps independently.
  • Ensure fingers are safe the whole time, do not curl under

Video: Slide Board Transfers

  • Patient:
    • Some level of trunk control in sitting (may still need support)
    • Unable to stand
    • Haven't managed a pivot transfer yet.
  • Transfer is done to stronger side
  • Wheelchair positioning: slight angle
  • Height matters: flat or slightly downhill.
  • Preparing the Wheelchair.
    • Circle effect with chair
    • Taking the side arm out of the way
    • Either completely removing the foot plates or at least swinging them out of the way.
  • Assessment
    • Trunk control
      • Bunny hopping up and down the side of the bed
  • Therapist
    • Stay on the weaker side and block that knee
    • Reach around to grab trousers or a belt.
  • Instruct patient to lean their trunk forward, lift their bottom, and take it to the right.
  • Second Therapist can move around if needs assistance, stabilizing trunk
  • Wheelchair positioning: bit of angle, move from the front and onto the wheel, with the feet forward
  • Board position: under the bottom, with stability, and also onto the wheelchair.
  • Have a slide board in place in case the patient needs to sit in between.
  • Ensure safety, brakes do not fall off.
  • Instruct the patient + verbal and physical communication assist
  • Reaching hand on the chair is stable
  • Ensure the leading foot if pushing the other foot

Pivot Transfers

  • Require reasonable sitting balance and trunk control.
  • Patient is completing slide board well.
  • Assess low pivot first always, that is before a higher pivot
  • Goal: to get bottom from bed/plinth to chair (one movement)
  • High Pivot:
    • Uses semi stand.
    • Patient is nearly capable of standing but uses upper limb contact at times
    • Goal to get the bottom transfer (one movement), no slide board should be used
  • Pivots are completed to the stronger side, or for practice on the other, as well as what needed for functionality.
  • Wheelchair Set Up
    • Include slide board if low
    • Foot Split, and the leading leg is put forward during assessment
    • Can be on 1-2 person Assist, until they're independent.
  • Could be a Long Term Transfer for an Amputee Patient

Video: Pivot Transfers

  • Low Pivot:
    • The board is in place.
    • The goal is transfer to the chair, if they sit the board will be there to catch them
    • Setup is very similarly - the wheelchair is at a slant
  • High Pivot
    • The patient stands a little, and uses the wheelchair
    • Setup - the feet are setup to pivot with one leading
    • Hands should be used to reach

Sit to Stand Assessment

  • Already have assessed: sitting balance, trunk control, and leg strength.
  • For more dependent patients, using manual stand, 2 person assistance + plinth/rail is required.
  • Trunk Control Patients, used 1 Assist with cognitive + behavioural support.
  • Patient Setup: Setup + what you will spontaneously do with their movement
    • Bottom forward in one of three ways
      • Rock side to side + Each hip forward
      • Lean Back + Slide Themselves Forward
      • Bunny Hop Bottom Forward (Good if there's a lift, good balance)
    • Move feet back, otherwise can cue them to move or move for them.
  • Therapist Position
    • One or Two Person Block
    • Verbal Cues
  • Assessment for Trunk Movement
    • Flexion-> Extension through Hip + Knees, leg flexion through sit
    • Evenness Of Weight Bearing
    • Also through the activity want the Range and Soft Touch for the patient, if it inhibits
  • Assess
    • High and Low Seat
    • Hands on the Rail

Video: Assessing Sit to Stand to Sit

  • Normal movement
    • Bottom forward
    • Feet backwards
    • Forward trunk lean
  • Placement of patient
    • Dependent on arm usage
    • Plinth = less grip, more reference
  • 3 Component Lean
    • The Side Lean
    • Assisted hip movement
    • Verbal Cues
  • Bunny Lift
    • Used by more supported cases
    • Knee Stability is used with Legs
  • Techniques - depending on the ability or ability of the patient there are options that allow support verbally, with the arm, with the hip on the side, as well as what feels stable for the patient

Transfers: Stand, Pivot, Step Transfer

  • Ability to stand, and level to trunk control + support + equipment.
  • Patients may start to come to their strongside, but may need to pivot due to other movements.
  • Assistance + Walking, + Aids if needed.
  • Consider swapping patient at a rail, moving other chair behind them to move position, + if you're not aiming to move person there

Video: Stand Pivot or Step Transfers

  • This case uses
    • One or Two People depending on the Person
    • Emphasis on the QuadStick due to Hemiperetic Side
  • Ensure stand BEFORE using QuadStick for support.
  • Maintain knees in front of Kim, ensure stability for knees in rotation

Transfers 180 Pivot Transfer

  • Not used, due to set up, should be last
  • Three Chairs
  • Gantry Set Up, Harnessed
  • Two SlideBoards for both patients standing/supporting each other

Assessing Sitting Balance

  • Static Position vs Dynamic Position
    • Static:
    • Hold up against Gravity:1-2 people/ Propping yourself.
    • Static -> Maintain Posture -> Mid-Line -> Endurance.
    • Re-Inforce what support will be like for the chair, or chair in their environment, otherwise use a space chair.
    • Pertubations:
    • Gently push out of Mid-Line to asses what reactions are, in case it's more reactive in nature.
    • Surfaces:
    • Asses the Surfaces as the contact.

Video: Assessment of Sitting Balance

  • Key component: Orientation to midline, and there is also a test available to see how and what challenges come
  • Goal : Test for Safety, and also trunk control with the therapist to assist
    Static Test
  • Can they maintain the posture? Can they use Arm? Check Posture.
  • Can find Middle (Do they FEEL like they're sitting in the middle?)
    Dynamic Test
  • Can they use visual support?
    Perturbations - Check them opening eye and resisting and what side they resist/prefer.
  • Dynamic - Reach over to touch and see the reach that is sustainable with the person
    • With the support of 2 people, or dynamic reach can be reached through any type of dynamic or challenge

Assessing Standing Balance

  • Same rules for Static vs Dynamic + Vision

  • Static

    • Ultimately - Without supports, but what is needed support
    • Maintain Knees = Hip-> Trunk Control is the Key
    • Assess - Midline Posture with Stance + Feet placement- Also

  • Dynamic - Start with Weight-shift. With Hip/Knee Trunk. -> reach

    • Support - Is the key measure for patient side (measure their side vs unaffected side.)
    • Challenges
    • Base Support (Feet, wide, stance etc.)
    • Dynamic- March vs Tapping.
    • Surfaces - Foam etc/Grass challenge.
    • Visual challenges.
    • Obstacles

Video: Assessment Standing Balance

  • Key- Points from less to abled body points + key Challenges to Balance
    Standing Ability
  • Chair and hand on chair for reaching.
  • Can test with touch with shoulder for resistance and challenge, compared to what stability is given
    Pertubations and what type can be challenged.
    Reaching Testing.
  • Foam Mat - Feet together.

Manual Handling

  • Occurs when a person is lifted, lowered, pushed, pulled, carried, moved, held, or restrained.
  • Repetitive and sustained forces/movements and awkward postures.
  • Aim to protect ourselves and the person we are assisting from injuries.
  • Principles:
    • Complete a risk assessment and plan prior to attempting the task.
    • Assess the safety of the task to be completed, considering postures, movement and forces required, duration and frequency of the task, and environmental factors.
    • Complete risk assessment every time and for each task.
    • Consider equipment needed and the use of aids/additional people.
    • Plan the activity before and get equipment or help
    • Consider positioning or adjusting equipment, and where you and others need to position yourselves
    • Maintain neutral spine at all times and use body postures that maximize effort and minimize strain.
    • Flex at the hip and not the waist to maintain spinal alignment.
    • Stick your bottom out and bend your knees more like a squat, but use your legs and not your spine or arms
    • Use a lunge position for moving things sideways.
    • Keep the load close to the body
    • Push rather than pull to use your body weight, when needed.
    • Encourage patients to do as much as possible themselves rather than jumping in to assist them.
    • Encourage and teach patients normal movement patterns and options that allow them to move with more independence and movement control

Documentation

  • Objective assessment
  • Ward recommendations or advice to family or carers may be different to what we can do.
  • Structure objective component:
    • Bed mobility
    • Transfers
    • Sitting balance
    • Standing balance
  • Comment on level of ability
    • Independent
    • Standby
    • One times light assist
    • Two times light assist
  • Document equipment required and any particular directions.
  • Include any cues or tips (e.g., stabilize feet with your hands).