PT Fundamentals Week 8 - Transfer Training (Notes)

Transfer Types & Devices

• Maximize safety: Transfers (moving from one surface to another) involve risk of injury for both the patient and therapist.
• Utilize safety measures:
  • Patient safety: Use proper techniques and equipment.
  • Therapist safety: Maintain core stability, good posture, and proper body mechanics.

Transfer Types

• Lateral (moving sideways):
  • Manual: Squat pivot, partial stand pivot, stand pivot.
  • Mechanical: Hoyer lift and wall lift.
• Vertical (moving up or down):
  • Floor to chair
  • Chair to floor
  • Chair to plinth (examination table)

Transfer Devices

• Transfer board: Acts as a bridge for lateral transfers between surfaces.
• Trapeze: Helps patients reposition and move within and to the edge of the bed.
• Walker: Provides stability and support during stand-pivot transfers, especially for patients with balance issues, restricted weight-bearing on one leg, or pain with weight-bearing.
• Pivot disc: Facilitates pivoting for manual transfers.
• Pivot pole: Offers stability during the pivot phase of a transfer.

Hoyer Lift (Mechanical Lift)

• Positioning:
  • Use a sling, orienting it correctly with the top facing the patient's head.
  • Position the Hoyer lift crossbar above the patient's sternum.
  • Attach the sling evenly to the lift hooks.
• Transfer process:
  • Ask the patient to cross their arms and tuck their chin for safety.
  • Slowly lift the patient, keeping them high enough to avoid shearing.
  • Rotate the patient towards the destination surface.
  • Slowly lower the patient and remove the sling.

Wall Lift

• Positioning:
  • Use a sling with the top facing the patient's head.
  • Position the wall lift crossbar above the patient's sternum.
  • Attach the sling evenly to the lift hooks, crossing the bottom loops contralaterally.
• Transfer process:
  • Ask the patient to cross their arms and tuck their chin.
  • Slowly lift the patient, maintaining a safe height.
  • Rotate the patient towards the destination surface.
  • Slowly lower and detach the sling, raising the lift to avoid interference.

Dependent Transfers

• Purpose: Used when a patient needs significant assistance with movement.
• Examples:
  • Dependent sidelying to sit (two-person transfer)
  • Dependent wheelchair to bed (two-person transfer)
  • Dependent wheelchair to bed (one-person transfer)
  • Dependent chair to floor
  • Dependent floor to chair

Dependent Sidelying to Sit Transfer

• Two-person transfer:
  • Therapist 1 in front lowers the patient's legs and acts as a barrier.
  • Therapist 2 behind creates a force couple to assist in moving the patient upright.

Dependent Wheelchair to Bed Transfer

• Two-person transfer:
  • Bed lowered as much as possible.
  • Clinician behind the patient, "locking" their arms.
  • Lift and pivot the patient to the bed.

Dependent Wheelchair to Bed (One-Person Transfer)

• Ready position: Patient scooted forward with legs under, arms crossed, hips flexed.
• Clinician: Leans over and reaches under the patient's hips, using good body mechanics.
• Lifting and pivoting: Clinician lifts the patient's hips, pivots the patient, and lowers them to the bed.

Dependent Chair to Floor Transfer

• Preparation: Chair locked with leg rests and armrest removed.
• Positioning: One therapist in front, supporting legs; another therapist behind, straddling the wheels with hips/knee bent and arms around the patient's upper body.
• Transfer: Therapists "lock" the patient's forearms, lift in unison, and lower to the mat.

Dependent Floor to Chair Transfer

• Preparation: Chair locked with leg rests and armrest removed.
• Positioning: Therapists in deep squat; one in front supporting legs, another behind reaching around the patient's upper body.
• Transfer: Therapists stand up, lift the patient, and lower them into the chair.

Seated Transfers

• Types:
  • Lateral seated with transfer board
  • Lateral seated without transfer board
  • Squat pivot/partial stand pivot
  • Stand pivot

Seated Transfer Setup (Acute Care)

• Equipment:
  • Remove wheelchair leg rests
  • Place wheelchair/chair close to the patient, brakes locked
  • Ensure transfer surface is stable

Therapist Placement During Transfers

• Center of mass: Keep your center of mass close to the patient.
• Lower center of mass: Bend knees and bring your trunk upright.

Therapist Foot Placement During Transfers

• Mimic patient: Place your feet so that you mirror the patient's foot position for better control and stability.

Therapist Trunk Position During Transfers

• Slight forward lean: Lean slightly forward, but avoid leaning too much.
• Core stabilization: Actively stabilize your core before lifting the patient.

Lateral Seated Transfer with Transfer Board

• Procedure: Patient scoots to edge of surface, transfer board is placed at an angle. Patient lifts trunk and hip to slide across the board.

Lateral Seated Transfer Without Transfer Board

• Procedure: Patient scoots to the edge of the wheelchair, uses one arm on the support surface and the other pushing on the wheelchair to lift the bottom.

Squat Pivot Transfer

• Preparation:

  • Patient weight shifts forward (up-and-forward lift).
  • Patient slides hips forward.
  • Patient adjusts foot position.
  • Therapist places a gait belt around the patient.
  • Therapist has a staggered foot stance.

• Transfer:

  • Knee blocking: If the patient has weak legs, block one or both knees.
  • Rising: Therapist assists patient to stand.
  • Pivoting: Patient pivots on the ball of their foot.
  • Sitting: Patient sits down, therapist assists for stability.

Squat Pivot Transfers

• Also known as partial stand transfers
• Require the patient to partially stand before moving to the desired position

Both Lower Extremities Weak - Both Guarded Transfers

• Indications: Both legs are weak and the patient is unable to fully stand
• Setup:
  • Remove both leg rests
  • Place a wheelchair or chair on either side of the patient
  • Remove the appropriate armrest
  • Place the wheelchair or chair as close to the patient as possible with brakes locked
  • Place a gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so both feet are underneath them and flat on the ground
  • Have the patient lean forward and push up from the surface/chair on the clinician's cue
  • Have the patient reach for the chair as able as the transfer is taking place
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding both legs in case of instability during the transfer

Both Lower Extremities Weak - Right Leg Guarded Transfer Right

• Indications: Both legs are weak and the patient is unable to fully stand
• Setup:
  • Remove both leg rests
  • Place a wheelchair or chair on the right side of the patient
  • Remove the appropriate armrest
  • Place the wheelchair or chair as close to the patient as possible with brakes locked
  • Place a gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so both feet are underneath them and flat on the ground
  • Have the patient lean forward and push up from the surface/chair on the clinician's cue
  • Have the patient reach for the chair as able as the transfer is taking place
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding the right leg in case of instability during the transfer

Both Lower Extremities Weak - Left Leg Guarded Transfer Left

• Indications: Both legs are weak and the patient is unable to fully stand
• Setup:
  • Remove both leg rests
  • Place a wheelchair or chair on the left side of the patient
  • Remove the appropriate armrest
  • Place the wheelchair or chair as close to the patient as possible with brakes locked
  • Place a gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so both feet are underneath them and flat on the ground
  • Have the patient lean forward and push up from the surface/chair on the clinician's cue
  • Have the patient reach for the chair as able as the transfer is taking place
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding the left leg in case of instability during the transfer

Right Leg Weak - Transfer Right

• Indications: Right leg is weak and the patient is unable to fully stand
• Setup:
  • Remove both leg rests
  • Remove the appropriate armrest
  • Place a wheelchair or chair on the right side of the patient
  • Place the wheelchair or chair as close to the patient as possible with brakes locked
  • Place a gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so both feet are underneath them and flat on the ground
  • Have the patient lean forward and push up from the surface/chair on the clinician's cue
  • Have the patient reach for the chair as able as the transfer is taking place
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding the right leg in case of instability during the transfer

Right Leg Weak - Transfer Left

• Indications: The right leg is weak and the patient is unable to fully stand
• Setup:
  • Remove both leg rests
  • Remove the appropriate armrest
  • Place a wheelchair or chair on the left side of the patient
  • Place the wheelchair or chair as close to the patient as possible with brakes locked
  • Place a gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so both feet are underneath them and flat on the ground
  • Have the patient lean forward and push up from the surface/chair on the clinician's cue
  • Have the patient reach for the chair as able as the transfer is taking place
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding the right leg in case of instability during the transfer

Left Leg Weak - Transfer Right

• Indications: The left leg is weak and the patient is unable to fully stand
• Setup:
  • Remove both leg rests
  • Remove the appropriate armrest
  • Place a wheelchair or chair on the right side of the patient
  • Place the wheelchair or chair as close to the patient as possible with brakes locked
  • Place a gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so both feet are underneath them and flat on the ground
  • Have the patient lean forward and push up from the surface/chair on the clinician's cue
  • Have the patient reach for the chair as able as the transfer is taking place
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding the left leg in case of instability during the transfer

Left Leg Weak - Transfer Left

• Indications: The left leg is weak and the patient is unable to fully stand
• Setup:
  • Remove both leg rests
  • Remove the appropriate armrest
  • Place a chair or wheelchair on the left side of the patient
  • Place the chair or wheelchair as close to the patient as possible with brakes locked
  • Place a gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so both feet are underneath them and flat on the ground
  • Have the patient lean forward and push up from the surface/chair on the clinician's cue
  • Have the patient reach for the chair as able as the transfer is taking place
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding the left leg in case of instability during the transfer

Stand Pivot Transfer

• The patient is fully standing up when pivoting
• The goal is to stand first, then pivot once stable

Lower Extremity Non-Weight Bearing: Right Side

• Indications: Right leg non-weight bearing, patient able to fully stand on the left leg
• Setup:
  • Remove both leg rests
  • Place a chair or wheelchair on the left side of the patient
  • Place the chair or wheelchair as close to the patient as possible with brakes locked
  • Place a gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so their left foot is flat on the ground
  • Have the patient lean forward and come to a full stand
  • Once standing, have the patient reach for the chair and pivot on their left foot to sit
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding the left leg in case of instability during the transfer

Lower Extremity Non-Weight Bearing: Left Side

• Indications: Left leg non-weight bearing, patient able to fully stand on the right leg
• Setup:
  • Remove both leg rests
  • Place a chair or wheelchair on the right side of the patient
  • Place the chair or wheelchair as close to the patient as possible with brakes locked
  • Place the gait belt on the patient to assist with the transfer
• Patient Position and Cues:
  • Have the patient scoot forward so that their right foot is flat on the ground
  • Have the patient lean forward and come to a full stand
  • Once standing, have the patient reach for the chair and pivot on the right foot to sit
• Clinician Position and Guarding:
  • Stand in front of the patient and assist as needed with positioning and transfer
  • Be prepared to assist by guarding the right leg in case of instability during the transfer

Elements of Patient’s Squat-Pivot and Stand-Pivot Transfers

• Movement Component:
  • Patient position:
    • Squat Pivot: Hips scooted forward
    • Standing Pivot: Hips scooted forward
  • Patient's foot position:
    • Squat Pivot: Underneath the patient, inner foot forward
    • Standing Pivot: Underneath the patient, inner foot forward
  • Patient's hand placement:
    • Squat Pivot: Both hands on armrests initially, reaching to the far armrest if possible
    • Standing Pivot: Both hands on armrests (if needed) positioned posterior to the glenohumeral joint
  • Rise:
    • Squat Pivot: Partial Standing
    • Standing Pivot: Full Standing
  • Mode of weight shift:
    • Squat Pivot: Up, lateral, and down in one continuous movement
    • Standing Pivot: Up, pivot, and down, may pause between aspects
  • Controlled descent:
    • Squat Pivot: Control descent with hands and legs, sit with the chair hips fully back in the chair
    • Standing Pivot: Reach back with both hands, lower the body with hips positioned at the back of the seating surface

Standing Transfers

• Sit to Stand Transfers: Scoot forward
• Position the feet posteriorly, extending the non-weight bearing lower extremity if appropriate
• Place the hands on the armrests of the chair
• Flex the hips to lean the trunk forward
• Push down through the arms and legs to extend the trunk and lower extremities
• Establish a stable upright stance

Stand to Sit Transfers: Back Up

• Back up until the back of the legs contact the chair
• Adjust assistive devices as needed
• Reach back for the arms of the chair
• Extend the non-weight bearing lower extremity if appropriate
• Flex hips to lean the trunk forward and bend the knees
• Lower the hips to the seat in a controlled manner

Chair to Plinth Transfer

• The wheelchair needs to be locked and placed close to the plinth
• While guarding from the front, one hand should be placed on the patient's upper shoulder, and the other hand on the gait belt in the front
• The client steps upward with the strongest leg with a hand on the plinth
• The weaker leg is then lifted to the stool
• The therapist should remain close to the client because they are guarding them in an unstable position

Alternate Transfers

• Alternative Transfer Scenarios:
  • Toilet
  • Bathtub bench
  • Car

Toilet Transfers

• Similar to a squat pivot or stand pivot transfer
• Significant difference is that clothing must be taken into consideration
  • Squat pivot: Remove pants and underwear prior to the transfer
  • Stand pivot: Remove pants and underwear in standing after the transfer, before sitting
• Consider maintaining balance while adjusting clothing
• A raised toilet seat makes transfers easier to perform; should be approximately the same height as the wheelchair seat

Car Transfer

• Fall risks are high during transfers in and out of a car
• Injurious falls are more frequent when exiting a vehicle than entering a vehicle
• Use the same principles of a squat pivot and stand pivot transfer or use of a transfer board

Cues

• A car simulator can be used to evaluate and discharge for inpatient populations
• This simulation allows the patient and clinician the ability to practice indoors in a safe and efficient manner and can be included in family training sessions. The car stimulator should allow height adjustment, ability to scoot seats forward or backward, open and close doors, and to fasten seatbelts.

Transfer Training Special Considerations

• Special Considerations:
  • Hemiparesis
  • Total hip arthroplasty
  • Spinal cord injury (limited lower extremity use)

Hemiparesis - Pivot Transfer

• It is typically easier to transfer toward the stronger side
• A stand-pivot transfer of a patient with a very weak lower extremity on one side should resemble a unilateral weight-bearing pivot; a series of small pivots or “hops” on the strong leg
• A flaccid arm is extremely weak with reduced muscle tone
  • Should not be allowed to hang by the patient's side
  • Distraction forces on the shoulder joint, stressing the muscles, ligaments, and tendons
  • May also have decreased awareness of the involved side
  • To prevent injury, the patient's hand must not be allowed to be pinched, or to get caught in the wheel of the chair

Total Hip Arthroplasty (THA) Supine to Sit

• Posterior surgical approach has the greatest restrictions; up to 2-4 months
• Dislocation is the leading cause of hip replacement failure
• A posterolateral THA typically results in the following movement restrictions of the involved hip:
  • 70-90 degrees hip flexion
  • 0 degrees hip internal rotation
  • 0 degrees hip abduction

Total Hip Arthroplasty - Pivot Transfer

• Due to movement restrictions, transfers must be adjusted and cued to limit trunk flexion for each component of the transfer
  • Leaning the trunk toward the hip has the same effect on the hip joint as flexing the hip
• Utilize support of a walker
• Can choose a different method of moving, e.g. forward to the edge of the chair - alternate weight shift technique
• Provide cueing, e.g. standing pivot - small steps rather than an actual pivot
• Monitor internal rotation of the hip
• Standing LE is stationary and rotate the truck

Spinal Cord Injury (SCI) or Limited use of LEs

• Sitting Pivot Transfer
  • Individuals with SCIs (lower extremity paralysis) at level C7 and lower typically have sufficient remaining motor control to gain independent transfers
  • On average, perform 14-18 of these transfers every day
• During the pivot, most of the downward force is exerted through the arms
• Feet on the floor provide additional stability but minimal weight through the lower extremities
• Movement is powered predominantly by the upper extremities and momentum from the head and upper trunk, and the upper extremities.
• The therapist guards for anterior loss of balance due to trunk instability from the SCI injury
• Monitor skin integrity during lateral transfers; patients with SCI may not be able to “feel” and sense tissue damage

Chair and Floor Transfers

• Consider Long Sitting or Turnaround into Quadruped if the patient has limited LE ROM
• Consider quadruped facing the chair if the patient has limited UE ROM
• Consider Long Sitting with a step stool if the patient has limited UE strength
• A variety of techniques may work for this patient if they have adequate LE ROM, UE ROM, and UE strength.

Test your knowledge on proper patient transfer techniques and equipment usage. This quiz covers important safety measures, methods, and considerations to ensure effective and safe patient handling. Improve your skills in using transfer boards, Pivot Poles, and other essential tools.