Become a Physical Therapy Aide: Lesson 8 (printer-friendly version) Your Instructor: Holly Trimble INSTRUCTIONS:

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Chapter 1 Introduction In our last lesson, we discussed ways you can protect your patients and yourself from the spread of infection. In this lesson, we'll talk about two other very important safety issues body mechanics and patient transfers. Your safety, and the safety of your patients, depends on how well you understand these aspects of patient care. When I use the term body mechanics, I mean the posture of your body and how you move it. You must practice good body mechanics whenever you lift, pull, or push a patient or equipment. You should also practice good body mechanics when standing or sitting for any length of time. To understand proper body mechanics, you must understand the anatomy of the spine. It's usually the spine that's injured when health care workers don't follow the principles of proper body mechanics. So we'll spend some time discussing the anatomy of the spine in Chapter 2. You'll learn about the different parts of the spinal column and how they work together. In Chapter 2, we'll also go over the normal curves of the spine and proper posture. We'll then move on and talk about proper body mechanics in Chapter 3. You'll learn about the importance of your center of gravity and base of support, as well as basic principles of lifting and moving objects safely. We'll also talk about preparing patients for moving from one place to another. In Chapter 4, I'll give you specific instructions for four types of transfers that PT aides might commonly use. We'll discuss sliding board transfers from bed to wheelchair, standing pivot transfers, transfers from wheelchair to treatment table, and helping a patient get from a wheelchair to standing in parallel bars.

Fortunately, health care professionals can now use lifting machines to transfer patients instead of doing the lifting themselves! Research has shown that using these machines really cuts down on the number of injuries among nurses, aides, and orderlies. We'll discuss those machines in Chapter 5. Please pay extra attention to the content of this lesson. Work-related musculoskeletal disorders (WMSD) are very common among health care workers. Aides and orderlies usually bear the most risk because they're the ones who move and transfer patients and equipment most often. Research also shows that new employees suffer the highest rate of injury. That makes sense since they lack the experience to easily evaluate when a situation might pose a danger to them. Adequate training, however, lowers the risk of injury. I hope that this lesson lowers that risk for you!

Chapter 2 Anatomy of the Spine If you understand the anatomy of the spine, you'll understand how to protect it from injury. Also, many patients who seek physical therapy treatment suffer back or neck pain. So, knowing how the spine is put together will also help you understand the treatment of some of the patients seen in your PT facility. Take your fingers and run them down the middle of your back. You should feel the back of your spinal column, an amazing structure that allows your trunk to bend in all directions and also allows for a limited amount of rotation. Keeping one hand on your spine, bend forward and backward slightly, then bend side to side, and finally rotate from left to right. You can feel the bones of your spinal column move under your hand. It's truly an amazing feat of engineering! Your spinal column consists of a number of structures that include the following: Spinal cord: This long, thin bundle of nerves allows the brain and the rest of the body to communicate with each other. Vertebrae: These are the bones that surround the spinal cord. They consist of a heavy body, a vertebral foramen (hole) that allows the spinal cord to pass through, processes (bony projections) for attachments of muscles, and surfaces called facets. You have seven cervical vertebrae, 12 thoracic vertebrae, and five lumbar vertebrae.

Sacrum: This is a bony triangular structure just below the lumbar vertebrae. Five vertebrae develop separately, but gradually fuse together between the ages of 18 and 30. Coccyx: This is also called the tailbone. It's at the very bottom of the spinal column. Four vertebrae develop separately, but fuse by age 25. Intervertebral discs: These discs of cartilage separate the bodies of the vertebrae and keep them from rubbing against each other. Sometimes they rupture or protrude, which can cause considerable pain if the disc material pushes against nerves. Ligaments: A number of ligaments connect the vertebrae to each other and with the ribs. These ligaments can tear or get inflamed in an injury. Facet joints: These are the joints between the vertebrae. They can become inflamed and quite painful due to injury or age-related changes. Costovertebral joints: These are the joints between the vertebrae and the ribs. They aren't as likely to become painful as facet joints, but it's certainly possible to injure them. Spinal nerves: Nerves enter and leave the spinal cord through spaces between the vertebrae called intervertebral foramen. Spinal muscles: More than 30 muscles, in multiple layers, move the spine and help keep it stable. Like any muscles, they can get injured. Nerves and blood vessels: The structures of the spinal column have their own nerves and blood supply. Here are three graphics that illustrate the complexity of the spinal column. The first graphic shows the structure of a single typical vertebra, and the second shows two adjacent vertebrae and the ligaments that keep them stable. The third one shows the multiple layers of muscles that run between the vertebrae.

A typical vertebra

Adjacent vertebrae

Spinal muscles

Along with protecting the spinal cord and allowing the trunk to move, the vertebral column supports the head, neck, trunk, and lower back. It also provides attachments for the ribs and muscles of the trunk. Ideally, the heavy part of the vertebrae, the vertebral body, bears the weight of the column and the structures that it supports. The spinal column has four normal curves. These are the cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis. From the back, the cervical and lumbar curves are concave (bow inward), and the thoracic and sacral curves are convex (bow outward).

Normal curves of the spinal column

When the vertebrae are properly aligned, these curves allow the bones, discs, ligaments, and muscles to support the weight of the spinal column, trunk, and head with the least amount of strain. When you stand, sit, and move with proper posture, you help keep these curves in the best possible position. So, let's talk about good posture next. Proper Posture When you sit and stand correctly, you reduce the strain on your muscles, joints, and ligaments because your vertebrae are properly lined up. Proper posture will also help decrease your risk of injury. Proper posture even helps your organs function their best. I've already told you that maintaining the curves of your spine helps maintain proper posture. When you're standing, these curves keep the top of your head right over your feet. When you stand just right, from the side it looks like an imaginary vertical line runs right through your ear, shoulder, hip, knee, and ankle.

Side view of normal posture

Compare the proper way to stand with these two examples of poor posturea slouched posture and a military posture. When you stand with a slouched posture, your head is forward, your upper back is rounded too much (kyphosis), and your lower back has too much arch to it (lordosis). When you stand with a military posture, your head is pulled too far back, your chest juts out, your scapula are winged, your low back has an excessive lordotic curve, and your knees are locked.

Slouched and military postures

You should also keep your spine and head vertically straight so they aren't curved more to one side than the other. This also helps reduce strain on the structures of your spine. From the front and back, you can imagine a line running right down the middle of the body, ending equal distances from each foot. You don't want one hip to be higher than the other, and you want your shoulders to be level.

Front and back views of correct posture

Pay attention to your posture when you're sitting, too. Keep your spine and head erect, and again maintain the natural curves in your spine. Don't slouch or jut your head forward. That will really increase the strain in your back and neck. Your computer monitor should be at eye level so that you're not looking up or down, and you should have a document holder attached to the monitor so you don't have to look down when typing a document. Plant your feet firmly on the floor and keep your knees level or slightly higher than your hips.

Good sitting posture

Proper posture requires strong and flexible muscles. You need adequate strength and flexibility in the muscles of your neck, back, abdomen, hips, and legs to maintain your spine's natural curves. We'll talk more about strengthening and flexibility later in the course. I'm also including a Web site that has some great exercises in the Supplementary Material. It's called Strengthen Your Core.

Chapter 3 Center of Gravity Now that you know the basics of proper posture, let's move on to principles of lifting and movement. First, you must understand what I mean when I say center of gravity and base of support. Gravity is always pulling the molecules of our body toward the earth. The center of gravity is the theoretical point in the body where all the body's weight is concentrated. It's the part of the body that the force of gravity pulls on. In humans, this shifts depending on your body's position. The center of gravity can also lie outside your body. Look at the graphic below that shows how the center of gravity shifts depending on the position of Carol's body. She's most stable when standing with her hands by her side. She's least stable when her center of gravity is outside her body.

Center of gravity

Normally, when an individual is standing in the anatomical position, the center of gravity is located in the upper third of the sacrum. It's a little lower in women because we have more weight concentrated in the pelvis and thighs than men. In standing, the area underneath and between your feet provides your base of support, the area that supports most of your weight. This base of support keeps you balanced and allows whatever is touching the ground (your feet if standing) to keep you upright.

Base of support

Proper Body Mechanics Body mechanics refers to both your posture and how you move. Here's a list of principles for using proper body mechanics:

Let your strongest and largest muscles do most of the work when you're moving something heavy. This means you should lift with your stronger leg muscles instead of your weaker back muscles. Keep your center of gravity close to the center of your base of support and just above it. Generally, you'll have more stability with a low center of gravity.

The object you're moving will also have a center of gravity. Keep the combined center of gravity of the object you're moving close to your own center of gravity. This means you should hold objects close to you. Keep your base of support the appropriate size and shape. A wider base of support, up to a point, provides for more stability. Generally, it's best if you keep your base of support about as wide as the distance between your shoulders. Always wear supportive shoes with low heels whenever you move patients, supplies, or equipment, or when you'll be standing or walking for any length of time.

Let's now move a box of supplies from the floor to a shelf in another room to illustrate these principles. 1. Decide if you can safely move the box by yourself. Assess its weight and awkwardness. If you decide you can safely carry it, make sure nothing is in your way that could cause you to trip or stumble. 2. Place your feet about shoulder width apart. Put one foot beside the box, and the other foot slightly behind it. 3. Bend at the knees and keep your back straight (squat). Don't bend over. If you do, your center of gravity will fall outside your base of support. 4. Grip the box with the palms of your hands and your fingers. Tuck in your chin to make sure your back is straight before you start to lift. 5. Lift by pushing up with your legs, keeping your arms and elbows close to your body. Keep the box as close to your body as possible. 6. Since you're moving while carrying the box, you're moving your center of gravity away from the center of your base of support. This could possibly cause you to lose your balance. To prevent this, increase the size of your base of support by slightly widening the distance between your feet. Avoid crossing your legs, because that will decrease the size of your base of support. 7. Don't twist your spine while carrying the box. If you need to change direction, move your feet and turn your whole body. Most spinal injuries are caused by twisting the spine while moving something that's heavy. 8. When you lower the box, bend the knees. Again, don't bend over! Place the box on the edge of the shelf, and push it into position.

Picking up a box safely

Now, here's the most important rule of all. If you think an object is too heavy or awkward for you to lift safely, get help! Don't risk an injury. For those of you who are really fit, don't overestimate your abilities. Even fit, strong people can injure their spines if they lift something that causes too much strain or they lift incorrectly. You'll find moving patients is more challenging than moving equipment. The first step is patient preparation. Patient Preparation Unless you work with babies or small children, you'll seldom, if ever, carry a patient. Instead, you might help a patient move from one piece of equipment to another, such as from a hospital bed to a wheelchair. Moving a patient safely starts with proper patient preparation. If you work at a hospital and you're responsible for transporting patients to the PT department, make sure the nursing staff knows when to expect you. That way, they can have the patient ready and dressed appropriately. You don't want to arrive in your patient's room only to discover that the nursing staff is giving him a bath! Please respect patients' modesty during transportation. Hospital gowns may not provide the necessary coverage when a patient is traveling through the hospital in a wheelchair. An additional hospital gown or robe will help, and you can also cover the patient with a sheet

if needed. One of the worst aspects of illness or injury is the loss of control. Your patients will really appreciate your efforts to help them keep their dignity.

Protecting patient modesty

If your patient is using any kind of medical equipment, you'll need to exercise care not to disrupt it. For example, your patient may have an IV, a chest tube, or a catheter. If that's the case, and you're not sure how best to handle this equipment, ask for help from the nursing staff. You'll become more comfortable with medical equipment as you gain more experience. Once you're ready to transfer a patient, your patient must have a clear idea of what he needs to do to make the transfer safely. You should give clear, simple verbal commands that are very specific. For example, don't say, "Stand on my count of three." That's confusing. The patient may not know if he should stand when you say three or right afterward. Instead, say, "I'm going to say, '1 2 3 Stand.' When I say 'Stand', stand up." Check that your patient understands the instructions the first couple of times you do a task. Don't ask, "Do you understand the instructions?" because you can't be sure that he does. Instead, ask the patient to repeat the instructions to you. That way, the patient rehearses what he's supposed to do, and you can make sure he accurately understands the instructions. In the next chapter, we'll talk about some specific transfers.

Chapter 4 Patient Transfers PT aides who work in hospitals will often transport patients from their hospital rooms to the PT department. This may involve transferring the patient from a hospital bed to a wheelchair and then back to bed. PT aides will also often help patients transfer from the wheelchair to a treatment table, and from a wheelchair to parallel bars. The instructions I'm giving are for patients who are able to assist you. Generally, you shouldn't attempt to transfer patients who are unable to assist you without equipment. Health care facilities are using equipment more and more to assist in transferring these patients. (We'll talk about that equipment in the next chapter.) Here's an example of a transfer with a patient who can help you. This is the procedure for moving a patient from a bed to a wheelchair using a sliding board. A sliding board allows a patient to scoot from one surface to another, reducing friction to the skin as much as possible. Patients with reasonably strong arms and backs, but with paralyzed or weak legs, are most likely to use sliding board transfers. 1. The patient should sit on the edge of the bed with his feet flat on the floor. 2. Adjust the bed so it's the same height as the wheelchair. 3. Place the wheelchair as close to the bed as possible. Lock the wheels and remove the armrests and footrests on the side closer to the bed. 4. Place one edge of the sliding board under the patient's hip. Place the other edge on the wheelchair seat. 5. Encourage the patient to push up from the bed, lift his buttocks so he's sitting on the board, and move across the board to the wheelchair. 6. Remove the sliding board. 7. Replace the armrests and footrests on the wheelchair.

Sliding board transfer from bed to wheelchair

Some patients may be able to transfer to the wheelchair without using a sliding board. A healthy patient with a broken leg and no other injuries should be able to do this. Here's the procedure for that type of transfer. 1. Prepare the wheelchair as above. 2. Have the patient sit on the bed and lean forward with his good leg closer to the wheelchair. 3. The patient should push down with his arms while he straightens his good leg, coming into a standing position. 4. Once he stands, he should reach for support to the far armrest of the wheelchair. 5. He should next pivot so that his back is to the chair. 6. The patient should bend forward, and slowly lower himself to sit in the chair, supporting his hands on the armrest. 7. Replace the armrests and footrests on the wheelchair. Your PT may want you to use a transfer belt on a patient doing this or other types of transfer. (A transfer belt is also called a gait belt, and it's placed around a patient's waist.) These belts have handles you can grasp so you can more easily control the patient.

Transfer belt

If you use one for this type of transfer, stand in front of the patient with a wide base of support. Bend your knees and grasp one loop of the belt while placing your other hand on his shoulder. Stand up with the patient, but don't attempt to lift him. If he can't stand on his own, get assistance or use a mechanical lift.

Standing transfer from bed to wheelchair

Once the patient gets to the PT department, he may need to transfer from the wheelchair to a treatment table. Follow these steps:

1. Assess the situation. If the person is too unsteady to provide assistance with the transfer, get help. 2. Put a transfer belt on the patient if there's any chance the patient could lose his balance. 3. If you can adjust the height of the treatment table, make it level with the seat of the wheelchair and use the sliding board method as described above, or use a standing pivot transfer. 4. If you can't adjust the height of the treatment table, it will likely be higher than the wheelchair. In this case, place a stool alongside the treatment table. The stool should have four legs with rubber tips. It should also have a nonslip surface. 5. Lock the wheelchair and remove the footrests and armrests. 6. Widen your base of support, stand in front of your patient, grasp the transfer belt, and instruct your patient to stand. 7. If his legs are weak, use your knees to block his legs, and tell him to step onto the stool with his stronger leg. 8. The patient should then turn his back toward the treatment table and lower himself into a sitting position. You should make sure his buttocks will rest securely on the table. 9. If the patient is too unstable to step on a stool safely and turn, and you can't use a sliding board or standing pivot transfer, get assistance.

Transfer from wheelchair to treatment table

When helping a patient get back into his wheelchair or back into bed, you'll essentially reverse the above procedures. Sometimes patients use parallel bars to practice walking. Parallel bars allow patients to use their arms for balance and support. Here is the procedure for assisting a patient to get from the wheelchair to standing in the parallel bars.

1. 2. 3. 4. 5. 6.

Position the wheelchair between the parallel bars. Lock the wheelchair's brakes. Swing the wheelchair's footrests out to the side. Put a transfer belt on your patient. Have your patient place his feet flat on the ground and his hands on the bars. Standing in front of your patient, bend your own hips and knees, bringing yourself down to his level. 7. Place your arms around him, and hold on to the transfer belt. 8. Block your patient's knees for added stability. 9. Instruct your patient to stand while giving him minimal assistance. Don't attempt to lift his weight. He should be pushing up with his arms. 10. If your patient is unsteady and at risk for falling, get assistance.

Transfer from wheelchair to parallel bars

You will sometimes see directions for assisted transfers that require the aide to actually lift a patient using a transfer belt. This is quite dangerous because the aide has to lift the patient's full body weight. In most cases, this puts the aide at too much risk of injury. Instead, you should use equipment, such as a lifting machine, to transfer a patient who's unable to assist in his transfer. We'll talk about lifting machines in the last chapter of this lesson.

Chapter 5 Lifting Machines

I mentioned that health care workers now commonly use equipment to transfer patients. In fact, some states have enacted legislation that requires hospitals to use safe handling policies, including patient lifts. This type of legislation also typically states that health care workers may refuse to transfer patients if they feel they or the patient will be at risk for injury. What exactly are patient lifts? These are mechanical devices used to transfer patients. You might see three basic typesmobile lifts, overhead lifts, and sit-to-stand lifts. You can move mobile lifts from room to room, while overhead lifts are installed over patient beds. Sit-to-stand lifts are typically mobile and help patients move from a sitting to a standing position. Lifts incorporate a sling, usually made of some type of fabric. Lifts may be powered by electricity or be manually operated. Slings will vary, depending on the type of transfer. A health care worker transferring a patient to an operating table will use a different sling than a worker transferring a patient from a bed to a wheelchair. Mechanical lifts make transfers easier on health care workers and, when used correctly, they protect patients from falls and accidental skin damage. They're especially helpful when you have to transfer obese patients or patients with frail or damaged skin. Really, though, you should use them for any patient who must be lifted. Unfortunately, sometimes health care workers think it's too time consuming to use them, so they risk injury instead by lifting patients themselves. Don't be one of them!

Mobile lift

Overhead lift

Sit-to-stand lift

I've included a Web site in the Supplementary Material section that has a video of a health care worker moving a patient using a patient lift. If you use equipment like this, make sure you thoroughly understand how to use it. Never operate equipment unsupervised until you know you can do so safely.

Conclusion I hope you've enjoyed this second lesson on safety for physical therapy aides. Thankfully, training, common sense, and proper equipment go a long way toward preventing injuries. When you understand the anatomy of the spine, principles of body mechanics, and safe transfer techniques, you'll be much less likely to suffer a work-related injury. In this lesson, we spent quite a bit of time on the anatomy of the spine. You can see how important it is to be smart about moving equipment and people. Have the same attitude about this that you should have about infection control. If you have any doubt about the safety of a situation, ask for help. Your PT doesn't want to have to treat her aides for injuries! Remember that you have the right to refuse to put yourself in danger. If you think it's unsafe for you to transfer a patient safely by yourself, speak up! Use good judgment, and don't take unnecessary risks. Yes, it might take a little more time to get a lifting machine set up to move a patient, but it's worth it if it keeps you from getting hurt. In our next lesson, you'll learn about just how complicated one everyday activity really is walking! You'll learn about exactly what goes on in your body whenever you take a few steps, and how you can help patients with this very important activity. You'll also learn about walking assistive devices, and how to help patients navigate situations such as stairs and curbs.

Supplementary Material Using Good Body Mechanics to Help Keep Your Spine Safe http://www.spineuniverse.com/displayarticle.php/article895.html This article has fantastic pictures showing the anatomy of the spine. Body Mechanics 101 http://www.spineuniverse.com/displayarticle.php/article836.html When you visit this site, you'll see links to several different topics related to preventing work-related injuries. Moving a Patient Using a Hoyer Lift http://video.search.yahoo.com/video/play?p=using+a+lift&ei=UTF-8&fr=slv8sbc&fr2=tab-web&tnr=21&vid=0001540645857 Watch a video showing an aide moving a patient using a Hoyer lift. Safe Patient Handling http://www2.umdnj.edu/eohssweb/publications/SafePatientHandlingBrochure.pdf Read this pamphlet for a quick overview about handling patients safely.

Wheelchair Transfers After Spinal Cord Injury http://www.drugs.com/cg/wheelchair-transfers-after-spinal-cord-injury.html This site has a wealth of information for any patient (and his or her caregivers) who uses a wheelchair. Strengthen your core http://exercise.about.com/cs/abs/a/coreandposture.htm This site includes some great exercises to strengthen the muscles responsible for good posture and a strong core. Please check with a physician, though, if you have any back, neck, or shoulder problems before doing these exercises. LIFTEM Patient Lift http://www.youtube.com/watch?v=e7mL9793_9c Watch a video demonstrating the use of an electric powered lift.