Restoring Confidence

The reason for the hierarchy is to ensure the clients are safe and have the ability to regain their confidence in being mobile. The first, or the bottom of the hierarchy, is bed mobility. It is the most important because if you cannot move in the bed because if you cannot move in the bed, it is going to be very difficult to transfer from a bed to be able to toilet and and get into a wheelchair. Once bed mobility has been sufficiently mastered, you can begin to start working on transfers to a mat. Following mat transfers are wheelchair transfers, bed transfers, functional movement or ambulation for ADLs, toilet and tub transfers, car transfers, functional community mobility and then mobility in the community and driving.

The hierarchy makes sense the way it flows, but honestly I did not originally think about it being this in depth. The reasoning for the hierarchy is so the client can build upon already mastered skills. This makes the client feel comfortable and confident when transitioning to a new skill. Starting a client off automatically trying to be able to move around within their community is not an easy task; therefor, you begin at the bottom and work your way up to a skill that requires several things going on at once. I did see this when I was observing occupational therapists before I began school. I worked a lot in a nursing home, and for some clients we went to their rooms because at that time they were not able to transfer to a wheelchair. So, we worked on them being able to move around in the bed and cultivated activities they could do in bed until they have mastered that and were able to get into a wheelchair and go to the gym.

I definitely agree with this approach to transfers. It is like the old saying, "you have to learn to walk before you can run." It is important that clients are confident in themselves after a health incident where they have been set back some. For me personally, I broke my femur and it took me a little bit to be comfortable and confident in my body's ability after that. So this hierarchy of starting with the less difficult tasks and building upon those makes sense to me. The labs and SIMS labs really drove home the feeling and honestly made it more applicable to what we will be dealing with once we start to practice.

Assistive Devices

Assistive devices beneficial and extremely important in our field. It is important to make sure these devices, such as walkers, canes and crutches properly fit our clients. It is important to have them properly fit because:

1. When the devices are properly fit to the individual client, it promotes better body mechanics and better mobility while using the device.

2. It prevents further injuries, stress or trauma to the client's body.

A client that is using a device that is not properly fitted to them could possibly lead to a fall which would lead to more problems and issues for the client.


Fitting a client for assistive devices is easy and does not take much time. In order to fit a client for a cane or walker, the OT is going to identify some specific landmarks on the client's body. The handgrips should be at the ulnar styloid, wrist crease or greater trochanter. It is also important to note that the clients elbows and shoulders should be relaxed. For a platform walker, the client is positioned where the elbow is bent 90 degrees while standing upright. To avoid any nerve compression, the proximal ulna should be between 1-2 inches off the platform. The handle of the platform should also be fixed slightly medial to allow for grip.

For crutches, the landmarks that should be used to fit the device are the same for the cane and walker. However, for axillary crutches, the arm rest should be about 5cm below the axilla with the client's shoulders relaxed. For forearm crutches, the arm band should be positioned approximately 2/3 of the way up the forearm with the handgrips facing forward.