Hierarchy of Mobility

The hierarchy for restoring confidence in mobility is as follows: bed mobility, mat transfer, wheelchair transfer, bed transfer, functional ambulation for ADL’s, toilet and tub transfer, car transfer, functional ambulation for community mobility, and community mobility and driving. As you move up the heirarchy, the size of the base of support gets smaller and the level of stability decreases, but the level of mobility increases. 

To be totally honest, before this course, I had not given much thought as to what order mobility skills would be addressed in. After my experiences in this course, the hierarchy of mobility makes perfect sense. I believe the hierarchy is in this particular order because it builds from one step to the next. This order ensures that a client has mastered one set of activity demands and prepares them to move forward to the next set.

For example, the hierarchy begins with bed mobility. Bed mobility is the ability to move the body in bed to perform activities in various positions. These are basic functional skills that provide the basis to allow the client to participate in ADL’s. Bed mobility is also the basic skill in preparation for transfers. So, it makes sense that bed mobility would come before any type of transfer.

During my observations, I was able to spend time in an assisted living facility. The therapist I observed would ensure that a client displayed appropriate bed mobility before moving on to another task, such as a transfer. At the time, I was unsure as to why the therapist did this, but after taking this course, I now realize that the therapist was using the hierarchy of mobility.

I agree with this approach because I believe it gives your client the best chance in reaching their individual level of independence, while ensuring the safety of theclient. Each level builds off of the next, making sure that the client is never unprepared for the next set of activity demands.

The Perfect Fit.

Assistive devices, put simply, are things that help people do things that they may not be able to do otherwise. Some of the commonly used assistive devices include a cane, axillary crutches, lofland crutches, a platform walker and a rolling walker. These devices can be instrumental in helping a client regain independance. Fitting your client’s assistive device appropriately is extremely important. If an assistive device is ill-fitting, it can negatively affect a client’s gait, cause instability, and even cause pain.

To properly fit a cane, the hand grip should be at the level of the greater trochanter, the ulnar styloid process, or the wrist crease. The elbow should be relaxed and flexed between 20-30 degrees. The shoulders should also be relaxed and not elevated. For crutches, the hand grip should be at the level of the greater trochanter, the elbows should be relaxed and flexed between 20-30 degrees, and the shoulders shoulb be relaxed and not eleveate. The axillary rest should be 5 centimeters below the axilla with the shoulders relaxed. For Lofstrand crutches, the arm band should be placed about 2/3 up the forearm.

In addition to crutches, it is important to properly fit walkers as well. When fitting a platform walker, the platform surface should be placed so that weightbearing is allowed through the forearm when the elbow is bent to 90 degrees. The client should be standing with the scapula relaxed. The proximal ulna should be placed 1-2 inches off the platform surface and the handle should be place towards the middle to allow for a comfortable grip. For a rolling walker, the height should be adjusted to that of the client and the hand grips should be inline with the greater trochanter or wrist crease when the hands are at the clients sides. The client’s elbows should be flexed between 20-30 degrees.

Regardless of the type assistive devices being used, to maximize the benefit of the device and minimize further damage or pain, it is of the utmost importance that they be properly fit for patient usage, comfort, and mobility.