In complex rehab’s world of responsive electronics, CAD drawings and space-age materials, it’s easy to see how the lowly transfer gets overlooked. When done correctly, transitions from bed to wheelchair to shower bench to car seat can be mere afterthoughts in a wheelchair user’s day. But when transfers are difficult or unsafe, they open the door to a range of problems, from heightened risk of falls and skin breakdown to reducing participation in activities when wheelchair users and caregivers decide the hassle of a transfer just isn’t worth it. The sheer number of people who use wheelchairs, and the family members, friends and professional caregivers who support them, indicate that mastering the transfer is vital to the overall mobility equation.
Goals of the Transfer
To that point, Julie Piriano, PT, ATP/SMS, director of rehab industry affairs for Quantum Rehab, pointed out, “With an estimated 3.3 million wheelchair users in the United States, 1.825 million of whom are greater than 65 years of age, there is a minimum of 6.6 million wheelchair transfers completed every day.”
So what is a successful transfer? “Many may say that the number one goal of a successful transfer is for the wheelchair user to perform the task independently,” Piriano said, “so that he or she can use the chair. However, this really is a subset of the real goal of a successful transfer, which is to prevent falls and avoid injury to the wheelchair user and/or the caregiver.”
Ginger Walls, PT, MS, NCS, ATP/SMS, clinical education specialist for Permobil, says of transfer activity, “For a transfer to be successful, it has to be safe and it has to be functional. Why did the person need to transfer? They’re going to get out of their chair for a reason, and that reason is usually attached to an activities of daily living goal, to do something functional: to use the toilet, to bathe, to go to bed or get up in the morning, to do dressing. Or it could be a participation goal, like to get in the car to go to work or get into a sports chair or kayak or their sled for sled hockey.”
Regardless of why the wheelchair user is transferring, Walls added, “The goal is to be safe wherever you’re transferring to, and the goal is once you get to where you’re going, to be able to do whatever that functional activity is.”
Clinical Considerations of the Transfer
Veteran wheelchair users can perform transfers so quickly that their motions — left hand here, right hand there, lift, twist, stick the landing — are a blur. But there’s a lot going on in any transfer, and even more to consider for a safe transfer.
“We want to make sure that we’re protecting the skin,” Walls said, “so that the person doing the transfer is either not shearing their skin, dragging their [body] across an unfriendly surface, or that the person is not plopping down hard, whether it’s getting back into their chair, or plopping down hard onto another surface. That can cause significant tissue deformation. You can think of it almost like a deep bruising that can happen. You can hurt yourself that way, too.”
Piriano said, “Studies have shown that transferring to/from the wheelchair puts higher stress on the arms than any other activity. Hence, incorrect transfer skills may predispose wheelchair users to developing upper limb pain and overuse-related injuries, such as rotator cuff tears, elbow pain and carpal tunnel syndrome, which can increase transfer-related falls significantly.”
Upper-extremity pain and injury are often discussed in regard to
propelling an ultralightweight wheelchair, but does the topic come up as much with transfers, when the wheelchair user is lifting his/her own body weight and moving it?
“We want to protect the upper extremities during transfers, particularly with clients who might be tetraplegic or otherwise have weakened upper extremities,” Walls said. “Without those upper extremities functioning, that person’s really stuck.”
Sustainability of the Transfer
Perhaps the most difficult challenge of developing good transfer techniques is also creating sustainability. At minimum, a wheelchair user transfers from bed into his/her wheelchair, then back into bed — two transfers per day. But transfers add up quickly if the wheelchair user transfers to the toilet, a bath/shower bench, the seat of an automotive vehicle, into a standing frame, onto another chair or surface for sports or recreational activities, or even onto the sofa to watch TV.
Transfers, therefore, have to be more than just safe. The wheelchair user must also be able to replicate it throughout the day, all week, for years — and must still be functional after making the transition.
Said Walls, “The type of transfer the person is going to do every day to get in and out of their bed, and in and out of their wheelchair needs to be a safe and effective and efficient one. If it requires maximal effort and the person is exhausted, then that’s not realistic. It’s not functional to have to struggle. And if someone has a progressive condition like multiple sclerosis or ALS, in addition to simply aging with a disability, then efficiency and energy conservation come even more into play, because we have to think about that person not burning up all their energy in the beginning of the day just to get in and out of bed, and just to get dressed. We also have to think about at the end of the day, when that person is tired. Are they still going to be able to complete their transfers safely?”
Types of Transfers
With transfer goals now set, what can the seating & mobility team, wheelchair users and caregivers do to put successful transfers into play?
A first step, Piriano said, is to identify which type of transfer would be most suitable for the client.
“There are several different types of transfers that can be performed, dependent upon the individual’s muscle strength, tone and reflex activity, range of motion in the upper and lower extremities, sitting and standing balance, and overall endurance to perform or participate in the task,” she said. “Each transfer type has its own rewards and risks over the lifespan and may need to change with the changing needs and capabilities of the wheelchair user.”
Examples, Piriano added, include sit-pivot or stand-pivot transfers for clients who cannot walk between surfaces, but can bear weight on their lower extremities.
Sliding boards can be used if a client can’t safely perform a pivot transfer. “To complete the transfer the person must be able to shift their weight onto the opposite hip, and place 1/3rd of the sliding board under their upper thigh/bottom,” Piriano explained. “With the trunk leaning forward, the person’s head must move in the opposite direction of their hips (the head-hip relationship), and their arms are used to lift and push their bottom across the board. The wheelchair user must then be able to shift their weight onto the other hip to remove the board once the transfer is complete. Every effort should be made to lift the body slightly during the transfer to avoid dragging the skin across the board to reduce skin tears and decubitus ulcers. In addition, clothing should be worn to reduce friction and shear while sliding on the board.”
Piriano noted that setting up the environment beforehand is critical, regardless of the type of transfer. That means making sure, in a pivot transfer, that the floor is free of obstacles, and that the two surfaces are adjacent and either level or that the surface being transferred to is lower than the surface being transferred from. Transfers using sliding boards should also use a “downhill” trajectory.
“It is recommended that the wheelchair user alternate the direction of their transfer to reduce repetitive strain injury and keep the leading/trailing arm muscles balanced,” Piriano added.
Technology & the Transfer
While sliding boards have long been used in transfers, higher-tech components and powered positioning options can also help to make transfers more efficient and successful.
Todd Hargroder, founder of Accessible Designs Inc. (see sidebar) and a wheelchair user for nearly 30 years, pointed out it is critical for the wheelchair to stay put as its user transfers: “My wheelchair disc brakes are a huge benefit in helping me transfer. With regular wheel locks, it all depends on tire pressure, tire wear and tire condition, as well as brake adjustment for them to truly hold. For the type of transfer that I do — more of a push-scoot — I have to have my chair locked down tight. Before I designed the disc brake system for wheelchairs, I had over-center wheel locks, and my hands still have scars from wearing my hands and wrists out when locking them and unlocking them. With the mechanical advantages of the disc brakes, it’s less than a pound to lock and unlock the brakes. I recommend any type of true wheel lock over the over-center brakes. [Mechanical locks] just give you the ability to lock your chair in place so you have that true core stability.”
Hargroder also has billet push handles on his chair, “but I don’t use them for people to push me as much as I use them for positioning, to be able to hook and push and pull and slide myself around.”
On the power positioning side, Piriano said seat elevation can help. “A power height-adjustable seat allows the individual to elevate the position of their wheelchair seat along the vertical continuum so that it can be level with, or higher than the surface being transferred to, in order to perform a pivot or sliding board transfer at the highest level of independence and lowest level of risk for secondary complications possible. An added advantage of the iLevel system from Quantum Rehab is its stability lock-out system that engages as the seat is elevated off the platform. This allows the wheelchair user to keep his/her feet on the footplate and use the surface to provide a stable base of support during the transfer without risk of the chair tipping in the process.”
Walls said anterior tilt — a hot positioning topic these days — can help facilitate transfers: “That anterior tilt function can really help with forward reach and access while at the same time giving the end user a safe platform to do it from, with enough postural support and skin protection. Certainly in combination with the seat elevator, you’re able to reach higher places. With the [Permobil] F3 you get 12″ of seat elevation; with the F5, you get 14″. When you add anterior tilt, [it] is going to bring you forward and you can actually reach further forward. Then you can get to the center of that second shelf in the refrigerator, or up and over your sink. Or if you need to do a transfer that’s downhill, you can use elevation and anterior tilt. You wouldn’t have to go to the top range of the device, but you’d go up high enough so that you could position your transfer board or just position the chair so you can have that downhill position.”
When to Make a Change
Over time, transfer techniques often need to evolve to keep pace with client needs. “Transferring in and out of the wheelchair,” Piriano added, “has been found to be one of the most strenuous activities wheelchair users perform on a daily basis.”
Walls said, “If there’s pain [during a transfer], that’s a sign that something needs to change. Certainly if a skin problem develops, that could be sign that maybe you’re not lifting your [body] up as much as you used to, and you’re shearing. Or maybe you’ve plopped down a little harder, and you’ve caused deformation, and now you’re trying to heal from a skin breakdown. If you’re just noticing the transfer is more difficult, and you just can’t do it as effectively and efficiently, or the caregiver is saying the same thing: This is really hard, I’m nervous, I’m scared.”
Because of that, both wheelchair users and caregivers need to stay vigilant about signs that their transfer needs are changing. As Walls said, “Their bodies are speaking to them, and they should listen.”