Restoring Confidence in Mobility

September 2013. My grandfather was showing some impressive bed mobility while recovering from a stroke and I was heading to my senior homecoming dance!

       Mobility is defined as controlled instability. Occupational therapists play a large role in  promoting mobility in individual's that have faced setbacks or weakness. A body is more mobile when the center of gravity is moving, the base of support is smaller, and inappropriate joint motion is controlled.  The Hierarchy of Mobility Skills outlines the order in which you should direct a client to master movement. With each level, the demands of the activity increase and the base of support gets smaller.
          The first phase of mobility is bed mobility. This includes moving up and down the bed, rolling, or sitting up. It is important for the therapist to practice good body mechanics and move the bed to waist level in helping a client in this step. The client will not move independently from the bed until they are able to move within the bed. The client will then continue to transfer to the mat, wheelchair and bed. These become increasingly more difficult because a mat is harder material that provides more stability. A wheelchair has arm rests to and a back rest push off from. A bed is less stable and does not have a hard back. The next step after, bed transfer, is functional ambulation for ADL. This requires the client to be out of bed and on their feet. Their base of support has becomes dramatically smaller in this step. After a client can safely ambulate, they can begin transferring to the tub and toilet. This step requires control of several joints and visual perception. The final three steps support a patient becoming safe in the community. A car transfer might involve transferring from different levels and using a sliding board. Ambulation in the community will present new hazards and control. The final step in the hierarchy of mobility is community driving and mobility. A client that is able to dwell among the community can regain a sense of safety and independence.
        The order of these steps were initially surprising but after spending time in the simulation lab, the steps became more practical to me. These steps not only involve mobility but strength, coordination, and planning. Following these steps to promote mobility can help a client to regain confidence. I believe that fear of transfers to different surfaces ambulation can hinder a patient's recovery. That fear can be diminished by encouraging and teaching clients to move safely. The simulation lab gave me a new perspective to these steps of mobility. I am just a student that has not experienced an injury or weakness and I still felt a sense of uneasiness in the steps when first beginning this lesson. I can now better imagine how it would feel to conquer these steps for an individual that has had had a stroke, a surgery, or spent many days in the hospital. I am grateful for the opportunity to spend time in the simulation center to gain a  hands-on experience in such a valuable lesson.

Fittiing Assistive Devices

Appropriately fitting an individual for an assistive device requires careful attention, consideration, and knowing the needs and abilities of each person. It is important to ensure the most practical fit for individuals because a device is an extension of the person. Choosing an poor fit could lead to a lack of stability and increase the risk for fall or injury. It is also important to choose appropriate devices by considering a client's capabilities, environment, and roles. Based on the client's abilities, you want to offer the support needed without hindering the client from doing what they are capable of doing.

When fitting a person that is going to use a cane, it is important to begin with the client standing straight, looking ahead, with arms relaxed by their side. You should palpate the ulnar styloid, wrist crease, or greater trochanter to determine the placement of the hand grip. The elbow should be slightly flexed. It is important to explain to the client that the cane should be used on the unaffected side. A standard cane allows the most freedom to move and a quad cane has four points, providing more stability.

Axillary crutches are a better choice for an individual with restricted lower extremity weight bearing and the ability to bear weight through hands and wrists. The length can be determined be having the client stand tall and placing the arm pad 5 finger width beneath the axillary floor. Again, the hand grips should be in line with the ulnar styloid, greater trochanter or wrist crease.

Lofstrand crutches reduce the strain in the arms and allows the client to use hands without dropping crutches. The lofstrand or forearm crutches should be sized in the same way that I described axillary crutches to be fitted. In addition, the the arm band of the forearm crutches hsould be positions 2/3 of the way up the forearm.

A platform walker is device that is appropriate for those that cannot bear weight through hands or wrists. It is a good alternative for patients that do not have the trunk support to control a rolling walker. The platform surface should be positions below forearm when the patient is standing tall with the elbow bent to 90 degrees. The ulna should be 1-2 inches off of the surface of the platform. The hand grip should stand upright and be placed slightly medially.

A rolling walker allows for a normal gait pattern and could be an appropriate option for client's with low endurance. The client should stand tall looking ahead and the handgrips should be in line with the wrist crease, ulnar styloid, or greater trochanter while the arms are resting at the client's side. When gripping the hand grips, the client's elbows should be slightly flexed.