I will never forget a woman, let’s call her Margery, who I worked with in the home health setting. Margery had suffered through a stroke and was now receiving physiotherapy and nursing. But no matter what time of day I arrived on her doorstep, she would be in her nightgown, in bed. 10 a.m.? In bed. 2:00 p.m.? In bed. I finally pulled her husband aside to discuss my concerns over Margery’s mood, trying to feel my way towards whether she was falling into depression. He laughed and laughed and quickly filled me in.
Every day, immediately after I called to give the warning that I was in my car and on my way, Marg would struggle to walk back into her bedroom, pull on her gown, and lie in bed. She was ‘playing possum’, hoping I would go away. I was astonished she was going to that much trouble to avoid doing work!
If Marg thought that I had nothing vigorous to offer a woman in bed, she was mistaken. It was that day that my bed-based physiotherapy treatment was born.
The Bed as Rehab Equipment
In my opinion, therapists and nurses rarely think of a bed as a piece of rehab equipment, but bed-based exercises are nothing but functional and can be a fantastic workout. Even patients who are too weak to be seen out of bed can be gently guided through some of the easier drills with good results. Both nursing and therapy should be actively involved in generating quality episodes of mobility during the patient’s admission time, whether in hospital, a nursing or rehab unit, or the home setting.
I have listed some of the simplest bed-based drills and named them in order to help nurses and physios remember them. All drills should be performed with the necessary amount of supervision or assistance for the client. Remember that falls can happen from bed just as easily as from a chair or standing position!
Before beginning, the nurse or physio should ensure that all lines and catheters are clear (and will not get tangled or occluded) and that there are no contraindication to any of the movements (sitting, rolling, or transferring) involved. Pain should be noted and respected. Certainly, if the physician has determined that only the physio team should work with the patient on bed mobility and transfers, then nursing should stand-down. But there are many patients who are routinely transferred (often mechanically) from bed to a chair as part of the nursing team’s responsibilities. These are the perfect moments to add bed-based physiotherapy.
The first drills offered below are based off the basic bed transfer and can be performed as a part of nursing cares or (in a more elaborate fashion) as a skilled therapy session. Safety is always the first concern. The bed should be positioned so that patients can rest their feet firmly on the floor and, as in any transfer situation, they should be guarded against sliding off the bed. The advanced exercises should be performed by qualified therapy staff.
Sneak a (Buttock) Cheek
(Activities performed: Sitting balance, side leans, equilibrium drill.)
Instruct the patient to sit on the edge of the bed, feet resting on the floor, midway between the headboard and footboard. From this start position, have them lean until their weight is resting on their left elbow, then sit back up. Can they return to a sitting position without help? Can they do so without pushing off with their arm (in other words, by using their trunk muscles only)?
Progress this drill by placing their elbow further away from them with each attempt until they are almost side-lying on the bed. Repeat on the right side.
(Activities performed: Partial negative sit-up.)
Instruct the patient to sit half-way down the bed. Place two or three pillows behind their back. Without collapsing, cue them to begin to shift their weight backward as if they plan to lie on the pillows. Before their weight is transferred to the pillows, have them reverse direction and sit back up. Repeat.
Time for Bed
(Activities performed: Sit-to-supine transfer, equilibrium drill.)
Instruct the patient to sit on the edge of the bed, feet resting on the floor, midway between the headboard and footboard. From this sitting position, they should lie back in the bed so that their head is near or on the pillow. Can they do so in one fluid movement? Can they place their head so it is positioned straight on the pillow? Can they lift her legs into the bed without help? With only moderate resistance? With only minimum assistance? Did they need help repositioning in bed?
Now, reverse directions. It’s time to sit back up. Can they ‘walk’ their feet to the edge of the bed while still lying down? Can they drop their feet over the edge themselves? Can they rise to a sitting position by rolling onto an elbow then rising? Can they sit up without rolling first?
Classic rehab research shows that it is possible to find out exactly which element is the limiting factor preventing people from getting out of bed. How? By breaking up the transfer exactly as I have just described. In order for patients to improve their performance on bed mobility tasks, and specifically on the transfer from supine to sitting, our mobility training must shift beyond strengthening the trunk. There needs to be training designed around upper limb movements and positioning of the legs on the bed, these two factors are often the weak link in a successful bed transfer.
The following drills require weight shift, sidestepping, and balance recovery and should be performed by physiotherapy staff.
(Activities performed: Sitting balance, upper extremity open chain exercises and tracking)
Remove the pillows from behind the patient. Instruct the patient to sit on the edge of the bed. Standing in front of them with a pillow placed across your chest, instruct them to ‘box’ using both right and left arms alternating or performing movements on command. Move the target by stepping side to side. Cue the patient to exert force, pushing the pillow back away from the bed. When the patient hits the pillow, cue them to make a guttural sound to rid the lungs of functional reserve volume (stale air). Repeat.
(Activities performed: Sit-to-stand transfers, overhead reach, forceful exhale, sidestep)
Instruct the patient to sit on the edge of the bed, near the headboard. From this sitting position, have them stand up and raise their arms over their head while making a guttural sound. Then have them side-step towards the footboard, lower their arms and sit back down. Repeat.
There is nothing more pivotal to an individual’s quality of life than the ability to get into, move around in, and get out of bed. It is foundational to independence and should be practiced repeatedly every day. Thankfully, there is no need for weights, bands or specialized equipment to perform this bed-based physiotherapy.
The Margery’s of the world can stay in bed, therapy is coming to them!Document this CPD