FUNCTIONAL REHABILITATION: TRANSFERS:
To perform accessory skills and transfers, the patient
must have or acquire the necessary physical and skill prerequisites, such
as strength in muscles and range of motion in the joints used during the
skill and transfer. After the patient has learned to tolerate an upright
Sitting position, the following techniques
will help the patient develop the prerequisites to accomplish a functional
goal, such as transfers.
Unsupported Sitting Balance - To maintain an unsupported sitting balance,
the patient first learns to sit and then:
Finds his/her position of balance, with the therapist supporting the patient
at the shoulders until the therapist no longer feels the patient's trunk
pushing forward, backward, or to the side
Maintains the position of balance, by moving the hands in the air and the
head in the direction opposite to the direction the trunk starts to fall,
with the therapist continuing to support the patient at the shoulders
Improves unsupported sitting balance by the therapist reducing and then
eliminating shoulder support, and then disturbing the balance, by having
the patient catch or throw things, for example
Practices alone while long-sitting on a mat or short-sitting between mats
Elbow Extension with Muscle Substitution - While still confined to
bed, the patient stabilizes one of the hands with the help of the therapist
and pushes. Many patients automatically make the muscle substitution needed
to do this. For those who do not, the therapist can tell or show the patient
the anterior deltoid muscle. The patient can practice elbow extension in
many different positions.
Upright Trunk from a Forward Leaning Position - The patient lowers
the trunk while in a sitting position, allows the elbows to flex a few degrees,
and then pushes the trunk upright again, while maintaining full control of
the motion. This can be done in a wheelchair, or, practiced while short-sitting
between two mats.
Elbow Lock - The patient:
Externally rotates the shoulder, extends the elbows and wrists, supinates
the forearms, and, when in this position with the help of the therapist,
bears weight on the palms, holding the elbows in extension with the anterior
deltoids and shoulder external rotators
Holds the "locked" position, while the therapist applies resistance, and
pushes the elbow toward flexion
Practices elbow locking while in a wheelchair by stabilizing the palms on
the seat or nearby mat.
Arm Placement behind Wheelchair Push Handle - After learning to sit,
the patient crosses an arm over the torso and then throws it back and up,
with enough force to provide the momentum needed to carry the arm to a position
behind the push handle. The therapist can assist with the throw at first
and/or have the patient practice with a small wrist weight, which will add
to the arm's momentum. The patient practices in a wheelchair and improves
by performing the motion in a tilted position.
Trunk Stabilization in Wheelchair - With one arm hooked behind the
push handle (achieved independently or dependently), the patient holds the
body stable and improves stability by:
Moving the free arm to various positions
Adding weight to or forcefully throwing the free arm
Leaning the trunk in various directions and increasing angles of lean. To
lean, the patient must also learn to relax the arm on the wheelchair and
fully control the motion.
Trunk Movement in Wheelchair - After learning to pull upright from
a leaning position, the patient:
Pulls on the armrests or push handles to lean forward or return to upright.
Momentum from head motions can increase the ability to pull, in a patient
with insufficient strength
Throws the head and an arm forcefully in the direction he/she wants to move,
with the other arm behind the push handle for stability. To achieve the necessary
momentum, the movements must be abrupt, powerful, and exaggerated, and/or
a wrist weight can be used.
Armrest Manipulation - After learning to stabilize the trunk, the
patient with intact upper extremities can be shown how the armrests work.
The patient without active finger flexors can reposition the armrest by pushing
or pulling it with the forearm or with the back of the hand and the wrist
Buttocks Movement in Wheelchair - After learning to move and stabilize
the torso, the patient can learn to Move the Buttocks
in a Wheelchair. The therapist can help by pulling the patient's
buttocks, at first, and then diminishing the pull as the patient's efforts
Forward Prop on Extended Arms - After learning to sit, extend the
elbows, and hold them in extension against resistance (with the triceps or
muscle substitution), the patient:
Places the palms lateral to the thighs and anterior to the hips and leans
forward to support the trunk on the arms (with or without assistance from
Holds the elbows straight with support from the therapist, which should decrease
as the patient's ability improves
Improves this activity by:
Learning to support the truck independently
Bending and extending the elbows and lowering and raising the trunk
Performing these activities as the therapist applies resistance to the shoulders
in various directions, during long-sitting on a mat or short-sitting between
While propped forward on extended arms, the patient learns to:
Prop Forward on One Extended Arm - by shifting the trunk laterally.
The therapist places a hand on the lateral surface of the patient's shoulder,
and the patient pushes against the hand. As the arcs of motion increase,
the patient learns to lean far enough to support the trunk on one arm. The
patient improves this activity by changing arms, balancing with the supporting
arm in different positions, and reaching the free arm in difference directions.
Unweight Buttocks - by leaning forward and tucking in the chin. The
therapist can assist by placing the hands on the anterior surface of the
patient's shoulder and having the patient push against them.
Move Buttocks Laterally - by twisting the head and upper trunk away
from where the buttocks are to move. At first, the therapist either needs
to verbally encourage the patient to increase the force and excursion of
the twist to the point where the buttocks move and/or assist by applying
force to the patient's shoulders and lateral force to the buttocks. Since
transfers frequently require more than one twist, the patient then moves
the head and torso, without force, back to the original position between
twists. Quadruped is an excellent position for working on this skill, once
the patient has achieved stability in this position. Patients with functioning
triceps can practice the head-hips relationship to assume the quadruped position.
Patients who cannot assume this position may be able to practice this activity
while positioned on elbows and knees.
Buttocks Lift - While propped forward on extended arms against resistance,
Lifts the buttocks by leaning well forward over the extended arms, tucking
in the head, protracting the scapulae as much as possible, and finding the
balance point of this position to accept the full weight of the body on the
Lifts the buttocks and maintains the lift.
At first, the therapist should assist with the scapulae protraction in the
initial position and the actual lift. Further strengthening and/or practice
locking the elbow may be needed in patients with nonfunctional triceps. This
skill requires considerable practice.
Buttocks Lift and Lateral Move - While lifting the buttocks and pivoting
forward on extended arms, the patient throws the head and torso to the side,
quickly and forcefully, moving the buttocks laterally. This can be learned
by lifting and twisting as two separate steps at first. To achieve the two
steps as one activity, the patient must be sure to keep the head low during
the lift and keep the elbows locked in extension.
Buttocks Lift from Floor- After learning to lift the buttocks, move
laterally while pivoting on extended arms, and lift the body by pushing down
with both arms, starting with the hands close to the shoulders, the patient
learns to lift the buttocks from the floor using one or more techniques.
Side Approach - The patient:
Sits in front of the higher transfer surface and faces it at a 30- to 45-degree
angle, flexes the knees and points them upward, and places one hand on the
higher surface and the other hand on the floor, slightly lateral and anterior
to the hip
Pushes on both arms and throws the head way down and away from the higher
surface, in a forceful and exaggerated way, to lift the buttocks
Practices this activity by starting with a transfer to a low surface,
transferring up and down between the floor and the surface, and then gradually
increasing the height of the transfer surface, such as a progressively higher
stack of folded mats.
Protracts the scapulae more forcefully as the height of the transfer surface
Is ready to transfer to a wheelchair when able to achieve the wheelchair's
Front or Back Approach - From a starting position of either kneeling
in front of and facing the wheelchair with the hands on the armrests, or,
sitting on the floor facing outward with the hands on the front of the wheelchair
seat, the patient:
Lifts the body by leaning toward the chair and pushing straight downward
until buttocks have been lifted as high as possible
Tucks the head and protracts the scapulae to lift the buttocks higher
Body Turn and Drop to Wheelchair Seat - After the patient can lift
the body to above the wheelchair seat from a kneeling position, the patient
lets go of an armrest and throws the arm and head away from the armrest,
causing the body to turn and drop into the seat. The lower the lead, the
more protracted the scapulae, and the more forceful the twist, the better
The PoinTIS SCI Physical Therapy site
of the SCI Manual for Providers is based on information in Spinal Cord Injury:
Functional Rehabilitation, by M.F. Somers, Norwalk, CT, Appleton & Lange,
1992, and information in "Respiratory Rehabilitation of the Patient with
a Spinal Cord Injury", by J.L. Wetzel, B.R. Lunsford, M.J. Peterson, and
S.E. Alvarez, Chapter 28 in Cardiopulmonary Physical Therapy, S. Irwin and
J.S. Tecklin, eds., St. Louis, Mosby, 1995, unless otherwise