The Impact of Transfers on Posture

The term “transfers” refers to the method by which a person moves from one surface to another, this may be in and out of bed, on and off their wheelchair or armchair, in and out of a car. As therapists, we regularly assess and review transfer methods as part of the rehabilitation process; this may include prescribing a piece of equipment to assist with the manoeuvre or providing advice on technique and practice to build strength and independence. People may be able to move independently between different surfaces, require a grabrail to stabilise or need additional support from other people and equipment. This process can be stable or changing as part of rehabilitation and gaining strength or decreasing due to degenerative conditions and loss of function.

For those who are unable to move their body independently and require a full body hoist and support from family or carers, they really rely on those people being competent at using the transfer equipment and placing their body in its optimum position to ensure they are as functional as possible and to safeguard their body from postural changes due to the effects of gravity.

When we are assessing posture and considering supportive seating, lying supports or wheelchairs, an important consideration is how will the person using the device get into and out of it? We have previously explored how the effects of gravity can impact posture for those who are unable to move their body independently and cause secondary complications such as muscle contractures and deformities, tissue damage, osteoporosis, respiratory and urinary infections, constipation, pain and discomfort.[1] If someone relies on others to position their body, they are more susceptible to these risks, particularly if they have multiple carers involved and are unable to communicate their needs.

Poor positioning due to inadequate transfer technique can result in:

  • Sliding out of the seating.
  • Postural deviations, e.g. posterior pelvic tilt, leading to kyphosis.
  • Tissue damage through pressure and shearing.
  • Increased need for re-positioning and additional support.
  • Increased need for use of postural restraints.
  • Pain and discomfort.
  • Reduced ability to function due to postural instability.

Proper positioning can not only ensure that someone is more functional, more comfortable and better able to use their postural seating, it can also reduce the use of restraints[2], which may otherwise not be required. If someone is transferred into seating and doesn’t have the optimal position, then they are already more likely to experience complications or impacts from poor positioning.

This is particularly important for people who use custom-moulded seating systems or positioning aids and supports as the supporting surfaces may not be in the right place if the body is not correctly positioned. Often, caregivers can mistakenly think that the postural seating or wheelchair is not providing the necessary support, when in fact, a positioning error causes the postural supports to be incorrectly placed.

[1] Pope, P. (2007) Severe and complex neurological disability: management of the physical condition. Edinburgh: Butterworth-Heinemann/Elsevier.
[2] Rappl, L. and Jones, D.A. (2000) ‘Seating Evaluation: Special Problems and Interventions for Older Adults’, Topics in geriatric rehabilitation, 16(2), pp. 63–72.

Methods of transfer can pose challenges as they depend on several different factors:

  • Individual strength and coordination.
  • Cognitive function to understand and execute the task.
  • Sensorimotor skills – proprioception and vestibular ability.
  • Size and shape of the person being moved and their caregivers.
  • Adequate space in the environment for moving around and using transfer aids if required.
  • Appropriate flooring, lighting and footwear to minimise falls risk.
  • Training and support for families and carers in how to use transfer aids, including regular refresher updates.

Another important aspect that influences transfer method is the individual’s personal preferences. Some people find it difficult to accept using equipment to help them move and they prefer to persevere with transferring without aids if they are able.

This can sometimes pose challenges for us as clinicians if we can see that a transfer method is resulting in poor positioning and use of an aid would be safer for the individual and/or their caregivers or would achieve a better position once the person has landed in their destination.

For example, you may work with someone who has a degenerative condition such as multiple sclerosis and they may be able to stand and pivot with support, but when they sit down, they don’t have the required strength to shuffle their bottom into the best position or to the back of the seat. Consequently, they sit in posterior pelvic tilt, which then encourages their spine into kyphosis, and they experience neck pain due to the weight of their head being dragged forwards by gravity. As a clinician, you may feel that if the person were hoisted, their pelvis could be positioned in a more upright and neutral position, assisting to encourage trunk extension and therefore meaning they are able to hold their head up more easily.

Subsequently, they are less likely to slide forwards in their seat, and their arms are more freely able to move because the trunk is more stable, their skin and joints are protected, plus manual handling risks are reduced[3]. However, the person may not wish to use a hoist, may have had a previous bad experience, or doesn’t have space for one in their home. These situations need to be handled sensitively and with appropriate risk assessment considerations. It is always recommended to have a full manual handling plan tailored to the individual and their specific equipment to ensure that the transfer method used is the most appropriate and compatible with the situation faced.

It may also be necessary to involve different members of the multi-disciplinary team in creation of that plan to ensure a cohesive approach across care and therapy goals. In addition to specialist seating, CareFlex also offer a range of manual handling products which could assist with safer transfers: Moving and Handling Products.

If you would like to complete a joint assessment for someone you’re working with or find out more about the seating assessors at CareFlex, take a look at this previous blog: Dedicated Seating Assessors.

More about the ways in which CareFlex can support specialist postural professionals can also be found here: Supporting Seating Professionals.

[1] Pope, P. (2007) Severe and complex neurological disability: management of the physical condition. Edinburgh: Butterworth-Heinemann/Elsevier.
[2] Rappl, L. and Jones, D.A. (2000) ‘Seating Evaluation: Special Problems and Interventions for Older Adults’, Topics in geriatric rehabilitation, 16(2), pp. 63–72.
[3] Rappl, L. and Jones, D.A. (2000) ‘Seating Evaluation: Special Problems and Interventions for Older Adults’, Topics in geriatric rehabilitation, 16(2), pp. 63–72.