Wheelchair Skills Training - Transfers

Original Editor - Lee Kirby as part of the Wheelchair Service Provision Content Development Project

Top Contributors - Naomi O'Reilly and Amrita Patro  

Performs Level Transfers

Description and Rationale

The wheelchair user transfers from the wheelchair to another surface that is about the same height as the wheelchair seat and back again. A level transfer is a commonly used skill to move between the wheelchair and a chair, bed, tub, toilet, car or other surface. The average wheelchair user spends about 10 hours per day in the wheelchair and performs about 8 transfers a day but the range is high.A higher number of transfers per day increases the likelihood of overuse injuryto the upper limbs. Proper technique is advisable as a means of reducing overuse and minimizingpain during transfers.The level wheelchair transfer should only be considered a representative transfer. More difficulty may be experienced when transferring to and from other surfaces or heights.

General Training Tips

There are a number of transfer techniques and surfaces to which a wheelchair user may wish to transfer. The sideways transfer described here is representative for people who propel their wheelchairs with two hands. Standing pivot and crouch transfers will not be covered here but can be found in the Wheelchair Skills Program Manual. [1]

  • The sideways transfer is sometimes called a “sliding” transfer but actual sliding is not recommended (to avoid shear forces or injury to the buttocks).
  • Care should be taken to avoid catching the wheelchair user’s intravenous line, urinary catheter or other collection devices when transferring.
  • The height of the starting and target surfaces should be adjusted, to the extent possible, such that the target surface is slightly lower. 
  • The wheelchair should be positioned as close as possible to the targetsurface, with the casters trailingin a way that enhances stability in the direction of transfer.
  • If possible, the learner should position the wheelchair so that the casters are trailing in the direction of the transfer to reduce the likelihood of the wheelchair tipping in that direction. To achieve this position, the learner should finish the wheelchair positioning with a slight movement away from the direction of the transfer. For wheelchairs that are equipped with them, caster swivel locks can be used to help maintain caster orientation.
  • The path between the starting and finish surfaces should be cleared of any obstacles. 
  • The wheelchair user should move the armrest (if any) out of the way on the bench side.
  • The footrests should be cleared away (if possible). The feet should be stably supported on the floor if the footrests can be easily moved out of the way. If the footrests cannot be moved, it is acceptable to leave one or both feet on the footrests as long as forward tipping does not occur during the transfer. In addition to an actual tip, when the rear wheels become unloaded the wheel locks become ineffective and the rear wheels may move sideways due to caster swivel. In considering where to place the feet, the wheelchair user should try to avoid situations in which the feet are not free to swivel when the buttocks are moved to the new surface – this could lead to a torsion injury of the lower leg.
  • The wheel locks (if any) should be appliedand the wheel-lock extension (if any) on the bench side should be removed.
  • The comments below generally apply to the transfer out of or into the wheelchair, but will be described as though the transfer is out of the wheelchair. Transfer into the wheelchair is generally the same except that, once the wheelchair user is back in the wheelchair, he/she should restore the footrests fully and put the feet back on them. The wheelchair user should also make sure that any removed or repositioned wheelchair parts (e.g. armrests, footrests, cushion, seat belt) are in the same position that they were before he/she left the wheelchair.
  • People using sideways transfers tend to lead with the weaker or more painful arm. However, if the arms are fairly symmetrical, alternating the leading and trailing arms allows them to share the stresses. 
  • A forward tip is less likely to cause a problem in wheelchairs that have the footrests behind the casters and will not happen if caster swivel locks (if any) are applied with the caster trailing in the appropriate direction. 
  • The wheelchair user should move forward on the seat, to avoid such obstacles to sideways movement as the rear wheels.
  • To get the transfer board (if using one) under the buttock, the wheelchair user should lean away from it.
  • The wheelchair user should push down on the transfer board and wheelchair to unload the buttocks. 
  • The wheelchair user should avoid fully extending the fingers and wrists, allowing the fingers to wrap around the edge of the target sitting surface. This avoids overstretching the joints and tendons, which may be of importance for people with tetraplegia who use a tenodesis grip (whereby active wrist extension causes passive finger flexion if the tendons are of appropriate length). Keeping the wrists in a neutral position also functionally lengthens the arms, making it easier to get the buttocks off the sitting surface.
  • The wheelchair user should keep the leading hand just far enough away from the body to allow room for the buttocks to land on the target surface, but no farther. The trailing hand should be close to the body.
  • The wheelchair user may shift sideways toward the target surface in a single large movement or several smaller ones. 
  • If possible, the wheelchair user should lean well forward (“nose over toes”). During the actual transfer from this position, the hips and the head move in opposite directions. For instance, if the wheelchair user wishes to move the buttocks up and to the left, the head should move down and to the right. This technique reduces the forces needed from the arms.
  • Once the buttocks are fully supported by the target surface, the wheelchair user should remove the transfer board. The wheelchair user should lean away from it to do so.

Performs Wheelchair Ground Transfers

Description and Rationale

The wheelchair user gets from the wheelchair to the ground and back.Getting onto the ground is useful for an activity (e.g. gardening or playing with a child). Getting from the ground back into the wheelchair can also be helpful when recovering from a fall.

General Training Tips

  • There are a number of techniques that wheelchair users can use to get safely from their wheelchairs to the ground and back, the variations reflecting differences in the nature of the wheelchair user’s impairments and wheelchair characteristics. Only a few of the more commonly used techniques will be described. 
  • Getting from the wheelchair to the ground:
  • If there is a removable seat cushion and the learner can remove it (either while seated in the wheelchair or after transferring to another surface), the cushion may be placed on the ground in the position that the buttocks will land. This provides a surface that will protect the buttocks from excessive pressure. Additionally, doing so lowers the effective seat height and raises the effective floor height. 
  • The technique is similar to that for a level transfer, the major exception being that the hand of the reaching arm should be positioned on the ground before any significant weight is transferred to it. The learner should not use a controlled fall due to the potential for injury to the hand or wrist. The non-reaching hand is on the seat. 

Getting from the Ground to the Wheelchair:

  • As noted above, the wheelchair user can use the seat cushion to increase the starting height above the floor and to lower the height of the wheelchair seat.
  • The casters of the wheelchair should be oriented so that they are trailing forward, the wheel locks and caster locks (if any) should be applied and, unless they will be used as an intermediate sitting surface, the footrests should be moved out of the way if possible. 
  • A commonly used technique is with the wheelchair user in the sitting position on top of the seat cushion facing sideways in front of the wheelchair as close to the seat as possible, with the hips and knees flexed as much as possible. The wheelchair user can lift the buttocks with one arm on the seat and one on the ground. This approach is similar to a sideways level transfer (discussed earlier). Moving the head in the direction opposite to the direction to the hips is useful (i.e. move the head down when moving the hips up). 
  • After getting up onto the wheelchair seat, the cushion can be placed back under the buttocks by rolling to a transfer surface that is the same height as the wheelchair seat and transferring out of the wheelchair. When replacing the cushion, the learner should ensure that the well area (if any) is at the back of seat and the cushion is oriented evenly between the seat rails. Although it is possible for some wheelchair users to replace the cushion without getting out of the wheelchair, the methods for doing so vary widely.

Variations:

  • The technique described above can also be performed with the wheel locks off. As the wheelchair user lifts the buttocks off the floor, he/she can use the hand on the wheelchair to simultaneously pull the wheelchair under the buttocks.
  • The wheelchair user with his/her back facing the front of the wheelchair can lift the buttocks with both arms on the seat or front rigging. The footrests can be used as an intermediate level between the ground and the wheelchair seat, if they are wide enough and if sitting on them does not tip the wheelchair forward. Even if the footrests are not wide enough for both buttocks, by turning slightly to one side, if may be possible to support one buttock.
  • The wheelchair user can move progressively from the floor to a foot stool, a bench and finally to the wheelchair seat. The number of steps can be gradually reduced.
  • Some wheelchair users may find it easier to face the wheelchair, getting up onto the knees (which may be on top of the seat cushion) before moving up to the seat level and twisting into the forward-facing position. If one leg has adequate knee-extension strength, the wheelchair user can kneel on the knee of the weaker leg with the foot of the stronger leg on the ground. 
  • If the wheelchair user has the use of both of his/her legs, he/she can use the wheelchair to help get up onto his/her feet, then pivot and sit down.
  • If there is another stable object nearby (e.g. a chair or low table), the wheelchair user can put one hand on the object and the other hand on the wheelchair seat.
  • Some wheelchair users are able to right themselves while remaining in the wheelchair. To train someone to perform this technique, the wheelchair user can start on a surface partway between seat height and the ground, with the wheelchair on its back on an elevated mat. The wheelchair user should first pull on the rear wheels to get the buttocks firmly against the wheelchair seat. The wheelchair user may let the knees bend over the front of the seat. The wheel lock should be applied on the side of the stronger arm. The wheelchair user turns the trunk to the other side and uses the forward (stronger) hand to grab the hand-rim of the rear wheel on the unlocked side, with the hand as far forward as possible. The wheelchair user then reaches with the other hand to the surface on which the backrest of the wheelchair rests. The wheelchair user simultaneously and vigorously pushes with the floor hand and pulls with the hand-rim hand. This step is repeated as necessary, moving the floor hand progressively forward on the surface until the wheelchair is upright.

References

  1. Kirby RL, Rushton PW, Smith C, Routhier F, Best KL, Cowan R, Giesbrecht E, Koontz A, MacKenzie D, Mortenson B, Parker K, Smith E, Sonenblum S, Tawashy A, Toro M, Worobey, L.Wheelchair Skills Program Manual. Available at: https://wheelchairskillsprogram.ca/en/skills-manual-forms/.