Hierarchy of Mobility Skills

The hierarchy of mobility skills begins with bed mobility, to mat transfers, to wheelchair transfers, to bed transfers, to functional ambulation for activities of daily living, to toilet and tub transfers, to car transfers, to functional ambulation for community mobility and finally to community mobility and driving. This hierarchy is intended to restore a client’s confidence and increase their activity demands. I believe that this hierarchy is in this particular sequence because as the client advances their base of support is getting smaller which allows for easier mobility, however as a result the client becomes less stable. This is why they need to work up to each stage to help ensure the client can safely manage less stable environments. In addition to this, I believe that this hierarchy takes other factors that makes transferring more challenging into account, like confined or awkward spaces to transfer in and variables like wet, slippery surfaces in the bathroom. For instance, a car transfer often has a large gap between the wheelchair and the car seat due to the setup and there is cramped space once inside the car, too. This could be why car transfers are near the top of the hierarchy. 

In my time observing occupational therapists in skilled nursing facilities, this hierarchy was roughly followed. If the resident was very weak, the therapist would first have the resident shift around in bed to help relieve any pressure points, then if they had made progress they would have the resident sit up in bed to get them comfortable with the feeling. If this was accomplished, the therapist would then work with the client on wheelchair transfers, so they could then bring them to the therapy gym where treatment could be continued. When observing in the hospital setting, this hierarchy was followed less in my opinion. From what I observed it was typical for the patient to work on wheelchair or toilet transfers closer to the beginning of therapy services. I think this could be because both the therapist’s and the client’s goals change when in the hospital setting. For instance, most of the therapists I observed did not take any patients to a therapy gym, but instead worked on functional skills in the patient’s room. This could be why the mat transfer was skipped in this situation. In addition to this, many therapists in the hospital have the primary goal of getting the patient prepared and safe to go home, which should include getting in the car and being able to go to the bathroom on their own, or as independently as possible. 

When learning this hierarchy in class, it went along relatively close with what expected, however there were some parts that did not; specifically, how far up the toilet transfer is. While I understand that it is a challenging transfer, it is also a vital skill to have especially for someone who is accustomed to having the ability to go on their own. It would be important to keep this in mind when working with a client in this situation to help maintain their dignity as best as possible. Even facilitating a transfer to a bedside commode might be more important to someone than moving to a wheelchair. This situation demonstrates how a client’s preference might come into play and things things that the occupational therapist may want to reflect on when creating a holistic treatment plan!
Considering the opportunity we had and materials we covered in lab and simulation experiences, the mobility skill hierarchy makes sense because it definitely proved to be much easier to assist someone with bed mobility versus a transfer. This all furthered my understanding of why the hierarchy is set up the way it is. 

Appropriately Fitting Assistive Devices

There are many reasons why an assistive device should be individually adjusted to each client that an occupational therapist sees. One reason to appropriately fit clients for their assistive devices is to prevent injury from the use of the devices. For instance, if someone’s crutches are too tall for them, this could place significant pressure on their axilla – which could damage, or compress, nerves and blood vessels. Another reason why fitting assistive devices is so important is to provide the client with the appropriate amount of stability and mobility considering their given condition and prescribed assistive device.

To appropriately fit a client for a cane the therapist should adjust the height to the client’s greater trochanter with them standing with shoes on(or ulnar styloid process, or wrist with the elbow flexed around 20 degrees and to the side). The therapist should also ensure that the client is using the cane on the uninvolved side. In addition to this, they should ensure that the cane’s wider feet (if more than one – like a quad cane) are angled out away from the client’s center.

For axillary crutches therapists need to adjust the height and the hand grips in the appropriate place. For the height of the crutches, the arm pads of the crutches should be approximately five centimeters below the client’s axilla. Once that is done, the therapist should adjust the crutches’ handgrips to the height of the client’s greater trochanter with their shoes on and standing (or the ulnar styloid process, or wrist crease with the elbow bent at 20 degrees and arms to the side).

Lofstrand crutches, or forearm crutches, should be adjusted so that the height of the grip is at the same place for axillary crutches hand grip placement – which is to the height of the client’s greater trochanter with shoes on and standing (or their ulnar styloid process, or wrist crease with the elbow bent at 20 degrees and arms to the side). The arm band of the Lofstrand crutches should be placed two-thirds up the forearm of the client. The therapist should also ensure that the client has the grips of the crutches facing forward when in use.

To appropriately fit a client for platform walker the therapist should  first adjust the height of the walker’s hand grips, especially if only one platform is attached. For this, the therapist should fit the walker so that the hand grips are at the same height as the client’s greater trochanter with shoes on and standing (or their ulnar styloid process, or wrist crease with the elbow bent at 20 degrees and arms to the side). To appropriately fit the handle of the platform, the therapist should have it positioned to allow weight-bearing through the forearm(s) when the client’s elbow is flexed at 90 degrees, is standing tall and has their shoulders relaxed. The therapist should adjust if needed and/or inform the client that their proximal ulna, or forearm, should be one to two inches off of the platform surface to avoid nerve compression. Finally, the handle of the platform should be adjusted slightly medially in order to allow the client to have a comfortable grip.

For a rolling walker the height of the walker should be positioned so that the handgrips are at the client’s greater trochanter with shoes on standing straight ahead with their arms relaxed (or their ulnar styloid process, or wrist crease with the elbow bent at 20 degrees and arms to the side). The therapist should ensure that the adjustment buttons are clicked back into place for the rolling walker and all of the other assistive device adjustments listed above.

Following these steps and considering other factors – like a client’s strength, balance, motor coordination and endurance should ensure that they are getting the most appropriate assistive device and that it’s fitted correctly to them.