NOTTINGHAM
OCCUPATIONAL THERAPY
STROKE CLINICAL FORUM
PROCEDURES
1. Moving in bed
a) Moving across the bed
b) Rolling towards the affected side
c) Rolling towards the unaffected side
d) Moving from lying to sitting on the edge of the bed
e) Moving from sitting on the edge of the bed to lying in bed
2. Positioning in bed
a) Lying on the unaffected side
b) Lying on the affected side
c) Lying in supine
d) Sitting up in bed
3. Positioning in a chair
4. Repositioning in a chair
a) Move bottom forwards
b) Move bottom backwards
5. Transferring
a) Sitting to standing
b) Stroke transfer
c) Functional transfer
d) Sliding / banana board transfer
e) Rotunda transfer
6. Assisting getting in and out of a car
a) Getting into a car
b) Getting out of a car
7. Supervising getting up from the floor
INTRODUCTION
The procedures in this guidance have been based on those produced by Nottingham City Hospital NHS Trust and Queens Medical Centre NHS Trust but should be used in conjunction with the manual handling policy of the organisation in which the person works and following risk assessment.
Correct manual handling of stroke patients is important for the following reasons:
a) to facilitate a 24 hour approach, giving continuity for the patient
b) to facilitate neuroplasticity by correct positioning
c) to facilitate patient independence through normal movement.
It is important to remember that stroke patients may present with various problems that may affect their ability to cooperate in manual handling, such as:
a) Motor problems - changes in tone
- limited active movement
- abnormal reactions on effort
- inability to comprehend activities
b) Sensory problems - impaired sensation
- perceptual difficulties
- problems with midline awareness
- asymmetry due to poor feedback.
The Association of Chartered Physiotherapist Interested in Neurology (ACPIN) adapted the Manual Handling Operations Regulations (1992) flow chart to apply to a therapy environment as shown in figure 1.
All staff should make their own risk assessment of each situation prior to the manual handling of any patient, in respect of their experience, training and patient’s abilities. A task analysis should be carried out for all manual handling procedures, considering the following aspects:
T ask
I ndividual capacity of the person completing the task
L oad being moved, i.e. the patient
E nvironment
Basic manual handling principles should be adhered to in all situations. These include:
1. AVOID moving the patient unless absolutely necessary
2. ASSESS the patients’ needs fully
3. EXPLAIN the procedure to the patient to aid compliance
4. Use appropriate EQUIPMENT e.g. hoist if necessary
5. PREPARE the area and avoid hazards
6. KNOW you and your partners ABILITY and identify a LEADER
7. Consider your POSITION, particularly your feet as a base
8. Use a COMFORTABLE handhold
9. Keep the patient CLOSE
10. DO NOT BEND OR TWIST.
It should be noted that two members of staff might be needed in order to carry out some of these manoeuvres. Equipment may be available in some areas to assist with these manoeuvres where appropriate.
Pillows or similar will be required when positioning patients.
1. MOVING IN BED
1. Adjust the bed to the correct working height for the following procedures.
2. Encourage the patient to position themselves with assistance from a member of staff.
(a) Moving across the bed
| ACTION |
RATIONALE |
| 1. Bend the patient’s knees so that their feet are flat on the bed |
To facilitate the move |
| 2. Hold the patient’s affected foot on the bed and support their affected knee in upright position |
To facilitate the move |
| 3. Ask the patient to lift their bottom up and across, away from the edge of the bed, giving help as needed |
To facilitate the move |
| 4. Ask the patient to move their feet and shoulders into line, giving help as needed |
To facilitate the move |
| 5. Repeat 3-4 until correctly positioned |
To complete the move |
(b) Rolling towards the affected side
| ACTION |
RATIONALE |
| 1. Move the patient across the bed towards their unaffected side as in 1(a) |
To facilitate the move |
| 2. Stand to the patient’s affected side |
To facilitate the move |
| 3. Place the patient’s affected arm carefully across their chest and encourage them to hold on to it with their other hand at the elbow |
To facilitate the move |
| 4. Bend the patient’s knee(s) so that their feet are flat on the bed |
To facilitate the move |
| 5. Encourage the patient to turn their head towards you |
To facilitate the move |
| 6. Place your hands on the patient’s unaffected hip and shoulder blade and roll the patient towards you |
To facilitate the move |
| 7. Place a pillow behind the patient’s back |
To reduce the risk of the patient falling back into supine |
| 8. Slide your hand under the patient’s affected shoulder, onto the shoulder blade and ease their arm forward |
To position the patient’s affected shoulder correctly. If done incorrectly this can damage the affected shoulder |
| 9. Place a pillow under the patient’s top leg, keeping the affected leg flexed |
For comfort, support and prevention of pressure sores |
| 10. Position the patient’s unaffected leg in a semi-flexed position |
For comfort |
(c) Rolling towards the unaffected side
| ACTION |
RATIONALE |
| 1. Move the patient across the bed towards their affected side as in 1(a) |
To facilitate the move |
| 2. Stand to the patient’s unaffected side |
To facilitate the move |
| 3. Place the patient’s affected arm carefully across their chest and encourage them to hold onto it with their other hand at the elbow |
To facilitate the move |
| 4. Bend the patient’s knee(s) so that their feet are flat on the bed |
To facilitate the move |
| 5. Encourage the patient to turn their head towards you |
To facilitate the move |
| 6. Place your hands on the patient’s affected hip and shoulder blade and roll the patient towards you |
To facilitate the move |
| 7. Place a pillow behind the patient’s back |
To reduce the risk of the patient falling back into supine |
| 8. Place a pillow under the patient’s affected arm, now on top |
For comfort and support |
| 9. Position the patient’s affected leg in a flexed position, in front of the other leg and support it on pillows |
To complete the repositioning move |
| 10. Position the patient’s unaffected leg in a semi-flexed position |
For comfort |
(d) Moving from lying to sitting on the edge of the bed
| ACTION |
RATIONALE |
| 1. Roll the patient onto their side near the edge of the bed (see rolling procedures 1(b) and 1(c) |
To facilitate the move |
| 2. Keep the patient’s knees bent (as for rolling) and gently slide the knees and feet over the edge of the bed |
To facilitate the move |
| 3. Stand at the head end of the bed, facing the patient with your feet apart. Place one hand under the patient’s shoulder blade and the other hand on the patient’s hip |
To facilitate the move |
| 4. Bring the patient into a sitting position by pressing down on the patient’s hip and helping the patient’s shoulder up |
To facilitate the move |
| 5. Encourage the patient to assist pushing up into sitting using their unaffected hand / elbow |
To complete the move |
(e) Moving from sitting on the edge of the bed to lying in bed
| ACTION |
RATIONALE |
| 1. Stand at the head end of the bed, facing the patient with your feet apart |
To facilitate the move |
| 2. Place your hands on the patient’s shoulder blades and assist the patient down onto their side |
To facilitate the move |
| 3. Lift the patient’s legs (still bent at the knees) onto the bed, one leg at a time |
To facilitate the move |
| 4. Roll the patient onto their back into the centre of the bed |
To facilitate the move |
| 5. Move the patient across the bed as in 1(a) if necessary |
To facilitate the move |
| 6. Position the patient as in 2(a) and 2(b) |
For comfort and support |
2. POSITIONING IN BED
1. Adjust the bed to the correct working height for the following procedures.
2. Encourage the patient to position them self with assistance from a staff member.
3. The preferred positions are (a) and (b).
Contraindicated positions:
1. Lying on the affected side if the patient has a painful shoulder.
2. The following positions are not encouraged when following the normal movement approach.
· Supine
· Sitting up in bed
(a) Lying on the unaffected side
| ACTION |
RATIONALE |
| 1. Move the patient across the bed towards their affected side, as in 1(a) |
To facilitate the position |
| 2. Roll the patient into full side lying, as in 1(c) |
To facilitate the position |
| 3. Place a pillow behind the patient’s back |
To reduce the risk of the patient falling back into supine |
| 4. Position the patient’s head in midline, with the trunk straight |
To facilitate the position |
| 5. Position the unaffected shoulder so that the patient rests on the shoulder blade rather than the point of the shoulder. |
For comfort |
| 6. Carefully bring the patient’s affected shoulder and arm forward onto a pillow, facilitating from the shoulder blade. |
To facilitate the position |
| 7. Position the patient’s affected leg in front on pillows, hip and knee flexed and ankle supported. The unaffected leg should be in a semi-flexed position |
The position of the leg and pelvis mimics the gait pattern |
| 8. DO NOT place anything in the patient’s affected hand or under the sole of the affected foot |
To reduce the risk of abnormal reactions |
(b) Lying on the affected side
| ACTION |
RATIONALE |
| 1. Move the patient across the bed towards their unaffected side, as in 1(a) |
To facilitate the position |
| 2. Roll the patient into full side lying, as in 1(b) |
To facilitate the position |
| 3. Place a pillow behind the patient’s back |
To facilitate the position |
| 4. Position the patient’s head in midline, with the trunk straight |
To facilitate the position |
| 5. Carefully bring the patient’s affected shoulder and arm forward. |
To facilitate the position |
| 6. Position the affected shoulder so that the patient rests on the shoulder blade rather than the point of the shoulder. |
For comfort |
| 7. Extend the patient’s affected leg at the hip and slightly flex the leg at the knee. Flex the unaffected leg at the hip and knee and place it on a pillow in front of the affected leg. |
To facilitate the position |
| 8. DO NOT place anything in the patient’s affected hand or under the sole of the affected foot |
To reduce the risk of abnormal reactions |
(c) Lying in supine
| ACTION |
RATIONALE |
| 1. Place the patient’s head in a comfortable, neutral position |
To facilitate the position |
| 2. Elongate the patent’s trunk on the affected side |
To facilitate the position |
| 3. Bring the patient’s affected shoulder forwards raised on a pillow, with the arm by their side |
To facilitate the position |
| 4. Place a pillow under the patient’s affected hip and leg |
To prevent retraction of the pelvis and lateral rotation of the leg |
(d) Sitting up in bed (i.e. propped up on pillows with back rest up)
Disadvantages:
This position should be avoided whenever possible as it may encourage abnormal muscle tone and poor posture.
| ACTION |
RATIONALE |
| 1. Position the patient as upright as possible, with the head and trunk in line and weight evenly distributed on both buttocks |
To facilitate the position |
| 2. Bring the patient’s affected shoulder forwards on a pillow with the arm slightly elevated or straight by their side |
To facilitate the position |
| 3. Place a pillow under the patient’s affected hip and leg |
To prevent retraction of the pelvis and lateral rotation of the leg |
3. POSITIONING IN A CHAIR
| ACTION |
RATIONALE |
| 1. The patient should sit with their feet flat on the floor |
To facilitate the position |
| 2. The patient should have their hips and knees flexed at 90o |
To facilitate the position |
| 3. The patient should have their bottom at the back of the chair |
To facilitate the position |
| 4. The patient’s head should be positioned in neutral |
To facilitate the position |
| 5. Use pillows to maintain symmetry e.g. for flaccid arm or when the patient lacks sitting balance |
To complete the positioning |
4. REPOSITIONING IN A CHAIR
(a) Move bottom forwards
| ACTION |
RATIONALE |
| 1. Lean the patient to one side |
To move the patient’s weight |
| 2. Facilitate the patient to slide their opposite hip forwards |
To facilitate the move |
| 3. Lean the patient to the other side |
To move the patient’s weight |
| 4. Facilitate the patient to slide their opposite hip forwards |
To facilitate the move |
| 5. Repeat 1-4 until the patient is in the correct position |
To complete the repositioning |
(b) Move bottom backwards
This procedure might not be possible with some patients, in which case the task should be reviewed and the use of equipment considered.
| ACTION |
RATIONALE |
| 1. Lean the patient to one side |
To move the patient’s weight |
| 2. Facilitate the patient to slide their opposite hip backwards |
To facilitate the move |
| 3. Lean the patient to the other side |
To move the patient’s weight |
| 4. Facilitate the patient to slide their opposite hip backwards |
To facilitate the move |
| 5. Repeat 1-4 until the patient is in the correct position |
To complete the repositioning |
5. TRANSFERRING
The following techniques can be used to transfer a stroke patient according to the patient’s abilities. It should be noted that two members of staff might be needed in order to carry out some of these manoeuvres. Equipment may be available in some areas to assist with these manoeuvres.
(a) Sitting to standing - To be carried out before procedures (b) or (e)
(c) Functional transfer - For patients who have chosen a more functional unilateral
approach in order to gain greater independence or patients progressing to full
weight-bearing in standing
(d) Sliding / banana board transfer - For patients following a functional approach
who require greater assistance or patients progressing to full weight-bearing
in standing
(e) Rotunda transfer For patients who need to pull themselves up into a standing
position or patients progressing to full weight-bearing in standing
(a) Sitting to standing
|
ACTION |
RATIONALE |
|
1. Assist the patient to move their bottom forwards as in 4(a), so that both their feet are flat on the floor directly under their knees |
To facilitate the move |
|
2. If the patient is unable to push up with both hands, ask / assist the patient to leave both arms free |
To encourage bilateral activity |
|
3. Stand at the side of the patient, facing the patient at a slight angle |
To facilitate the move |
|
4. Place your hands on the middle of the patient’s back and chest (central key point) or use a long low hold around the patient’s back, with your other hand at the front of the patient’s shoulder |
To facilitate the move |
|
5. Assist the patient to lean forwards until their shoulders are directly over their feet |
To facilitate the move |
|
6. Encourage the patient to stand, with facilitation when required and ensure the patient’s affected foot doesn’t slide forwards. Care should be taken to avoid rotation and/or flexion of the staff member’s back. |
To complete the move |
(b) Stroke transfer
|
ACTION |
RATIONALE |
|
1. Assist the patient into standing as in 5(a) |
To facilitate the move |
|
2. Verbally encourage and assist the patient to move their body weight from one foot to another as they step round. Assistance may be required at the patient’s hip / knee. |
To facilitate the move |
|
3. Encourage the patient to sit back in the chair, as in 4(b) whilst bending your hips and knees |
To complete the move |
|
4. Ensure that the patient is correctly positioned as in 3 |
To maintain correct posture |
(c) Functional transfer
This procedure could be used for patients who are unable to stand fully erect but are able to carry out this manoeuvre with minimal assistance. The functional transfer is usually to the patient’s unaffected side.
|
ACTION |
RATIONALE |
|
1. Position the chair the patient is transferring to (the receiving chair) at 900 on the unaffected side |
To facilitate the move |
|
2. Assist / encourage the patient to move their bottom forwards as in 4(a), so that both their feet are flat on the floor directly under their knees |
To facilitate the move |
|
3. Encourage the patient to reach with their unaffected arm to the furthest arm of the receiving chair |
To facilitate the move |
|
4. Stand on the patient’s affected side, facing the patient and maintain the position of the patient’s affected foot if required |
To facilitate the move |
|
5. Encourage the patient to move round to the chair on the unaffected side, guiding themselves with their unaffected hand without coming up into the full standing position |
To complete the move |
|
6. Ensure that the patient is correctly positioned as in 3 |
To maintain correct posture |
(d) Sliding / banana board transfer
Best practice recommends that this is an independent transfer, but in the early stages of teaching this manoeuvre, minimal assistance may be given. In this situation, there should be one member of staff behind the patient and one in front, to increase the patient’s confidence and to give minimal assistance only.
|
ACTION |
RATIONALE |
|
1. Position the chair the patient is transferring to (the receiving chair) at 900 on the unaffected side |
To facilitate the move |
|
2. Assist the patient to walk their bottom forwards as in 4(a), so that both their feet are flat on the floor directly under their knees |
To facilitate the move |
|
3. Remove the chair arms on the patient’s unaffected side, both from the chair that the patient is sitting in and the chair that the patient is transferring to |
To place the sliding / banana board in position |
|
4. Stand on the affected side or in front of the patient and maintain the position of the affected foot if required |
To facilitate the move |
|
5. Encourage the patient to lean over to the affected side and place the sliding / banana board under the patient’s unaffected hip |
To enable the board to be place under the patient’s unaffected hip |
|
6. Place the other end of the sliding / banana board on the receiving chair seat to the patient’s unaffected side |
To place the sliding / banana board in position |
|
7. Ask the patient to place their unaffected hand either on the end of the sliding / banana board or to reach for the chair arm (ensure the patient does not put their fingers under the end of the sliding / banana board or pull on the chair arm) |
To facilitate the move |
|
8. Encourage the patient to slide along the board to the receiving chair. Encourage the patient to raise their bottom slightly off the sliding board, taking their weight through their feet, as they move across the board. |
To facilitate the move |
|
9. Assist / encourage the patient to remove the board by leaning to the affected |
To complete the move |
|
10. Ensure that the patient is correctly positioned as in 3 |
To maintain correct posture |
(e) Rotunda transfer
|
ACTION |
RATIONALE |
|
1. Ensure the two surfaces to be transferred between are positioned at 900 to each other with sufficient space to permit the Rotunda to rotate |
To facilitate the move |
|
2. Assist the patient to walk their bottom forwards as in 4(a), so that both their feet are flat on the floor directly under their knees and place the Rotunda in front of the patient |
To facilitate the move and to ensure patient safety |
|
3. Place the patient’s feet centrally on the turning disc in the base of the Rotunda |
To facilitate the move |
|
4. Encourage the patient to reach forward and place their hands either side of the frame. If the patient is unable to use their affected hand, extreme care should be taken regarding its position. |
To facilitate the stand |
|
5. Encourage the patient to pull them self up into standing |
To facilitate the stand |
|
6. Release the catch on the front of the Rotunda and turn the frame until the patient is positioned with the receiving chair directly behind them |
To facilitate the move |
|
7. Release the catch to lock the Rotunda into position and encourage the patient to sit down as in 4(b) |
To complete the move |
|
8. Ensure that the patient is correctly positioned as in 3 |
To maintain correct posture |
6. ASSISTING GETTING IN AND OUT OF A CAR
A careful risk assessment should be undertaken to determine which sort of transport should be used for each patient, i.e. car, wheelchair taxi or ambulance. If a patient needs more than minimal assistance of one person, car transfers should not be attempted.
Banana board, sliding board, sitting turning disc
(a) Getting into a car
| ACTION |
RATIONALE |
| 1. Park the car to avoid the kerb if possible |
To facilitate the move |
| 2. Move the passenger seat back |
To give maximum room to manoeuvre |
| 3. Place the wheelchair at 900 to the open car door, with the brakes on and foot plates and front wheels angled backwards |
To ensure a safe transfer |
| 4. Bring the patient forwards in the wheelchair as in 4(a) |
To facilitate the move |
| 5. Transfer the patient onto the car seat as in 5(b), 5(c), 5(d) or 5(e). Make sure the patient does not bang their head on the doorframe. |
To facilitate the move |
| 6. Assist the patient, if necessary, to lift their legs into the car one at a time |
To complete the move |
(b) Getting out of a car
| ACTION |
RATIONALE |
| 1. Place the wheelchair alongside the car, with the wheelchair brakes on, and footplates and front wheels angled backwards |
To ensure a safe transfer |
| 2. Assist the patient, if necessary, to lift their legs out of the car one at a time |
To facilitate the move |
| 3. Proceed as for transfers, as in 5(b), 5(c), 5(d) or 5(e), making sure the patient does not bang their head on the door frame |
To complete the move |
7. SUPERVISING GETTING UP FROM THE FLOOR
The patient is reasonably able to help them self and to follow instructions.
The patient has been injured in the fall.
The patient is assessed as too difficult to move.
Firm chair / settee nearby or access to the bottom step of the stairs
Pillows nearby (for head support)
| ACTION |
RATIONALE |
| 1. Do not rush to get the patient off the floor. Give the patient a chance to recover before getting them self up |
To ensure safety |
| 2. Ensure that the environment if clear and safe |
To ensure safety |
| 3. Get a pillow and / or blanket to keep the patient as comfortable and warm as possible on the floor |
To ensure safety |
| 4. Encourage the patient to get into a kneeling position with their unaffected leg nearest the chair, settee or bottom step of the stairs |
To facilitate the procedure |
| 5. Encourage the patient to bring one leg through so they are kneeling on one knee |
To facilitate the procedure |
| 6. Encourage the patient to use their unaffected arm and leg to get their bottom on to the chair, settee or bottom step of the stairs |
To complete the procedure |
this document was prepared by:
Julie Napper, OT Department, Health Care Of The Elderly, Highbury Hospital, Highbury Road, Bulwell, Nottingham NG6 9DR
&
Dr Judi Edmans, Stroke Unit, Beeston Ward, City Hospital, Hucknall Road, Nottingham NG5 1PB