Mobility Hierarchy

The hierarchy for mobility skills begins activities that have a larger base of support and progress to activities that are completely independent. The bottom or base of the pyramid begins with bed mobility. Bed mobility something most of us take for granted every night. However, for client's with disabilities, bed mobility requires assistance. Bed mobility is the first step to a client gaining independence and for transfers. The next is mat transfer followed by a wheelchair transfer. As we move up the pyramid the activity demands increase and the transfer surfaces change. The pyramid continues to bed transfer, functional ambulation for ADL's, toilet and tub transfer, car transfer, functional ambulation for community mobility, and community mobility/ driving. 

At first look this pyramid did not make much sense to me. However, having the knowledge I do now it makes complete sense. The goal is to see what the client is capable of and provide assistance as needed. That may be giving them extra time, a cue, or adaptive equipment. The pyramid starts off with bed mobility. In a bed, the client is completely supported and there is lower risk of injury when moving. Bed mobility can be therapist assisted by bridging, log rolling or a segmented roll. Ultimately, the client has to trust the therapist guiding them. As they gain more skills to meet changing activity demands, the client can progress up the hierarchy to gain more independence. As a client progresses, their self efficacy increases. They can work towards their goal on the pyramid, like walking or community mobility. The hierarchy progresses from the basic bed mobility because it is an important skill needed as a base, in order to do transfers. The pyramid makes perfect sense in how it builds on basic mobility skills all the way up to very complex activities like driving. I agree with using this approach because it builds skills, client confidence and trust. 

In the past, I have observed this hierarchy even though I was unaware of the pyramid at the time. In a nursing home, the OT would assist the client out of bed and into the wheel chair using a stand pivot. Once in the wheelchair, the client was able to go where she pleased, including meeting her family for lunch in the cafeteria. In SIM labs, I have learned how to properly assist my clients when transferring, assess their level of competence, and safely transfer a client. I learned the importance of properly placing bed height and where to place the wheelchair. Simple things I have seen in observation like maneuvering heels towards the transfer surface and a stand pivot now make complete sense as I continue to learn the sound reasoning behind the techniques. Finally, I learned the key safety topics to always do with a client: gait belt, locking the brakes of wheelchair and bed, and moving castor wheels of the chair backwards. The SIM labs were a very valuable learning experience that I am so grateful to complete. 

Assistive Devices

Assistive devices make an enormous impact in establishing or maintaining independence for people with a permanent or temporary disability. In order to properly assist our clients with their devices, we must make sure they are fitted to our client. Properly fitting a client ensures the client has proper body mechanics and posture when using a device like a cane or wheelchair. Properly fitting also decreases compensatory movements that can strain the body over time. Properly fitting a device also decreases the risk of injury or fall. Safety while using a device is top priority.

Another consideration is fitting a client to a device that is most appropriate to meet their needs. These needs include personal and environmental. A client may benefit from a power wheelchair over a standard. Considering their diagnosis, choose their assistive device based on their condition for the next five years, not just their abilities at the present moment. Insurance will only pay for a wheelchair once every five years so as a clinician, it is our responsibility to advocate for the most beneficial device.

When fitting a client to a cane, axillary crutches, Lofstrand crutches, platform walker, or a rolling walker, certain body landmarks are to be used for reliability and comfort. 

For a cane, the handle should be in line with the wrist crease, ulnar styloid or greater trochanter. The cane's height is easily adjustable and can be secured by tightening the locking mechanism. The cane should be held with the elbow slightly flexed. Quad cane's wider legs should be pointing away from the body to avoid a tripping hazard.

Axillary crutches should rest 5 cm below to axilla to avoid compressing nerves in the brachial plexus. The hand grips should be in line with the wrist crease, ulnar styloid and greater trochanter. Lofstrand crutches arm band should be positioned 2/3 of the way up the forearm.

For walkers, the hand grip should be in line with he wrist crease, ulnar styloid and greater trochanter. For a platform walker, the platform surface should be positioned to allow weight bearing through the forearm. The ulna should be 1-2 inches from the platform surface. The handle should be positioned towards the midline for comfort.