In my early career as a hospital-based physio, I recall walking into the room of a frail elderly woman lying in a small wad inside the ‘V’ of her inclined bed and thinking “Holy cow, that looks terrible. Why don’t you move?”
Alas — she couldn’t. She was stuck there, at the mercy of scheduled treatments and chance passers-by. There is even a name for it – patient migration – or the amount of movement toward the foot of the bed when the bed is elevated.
The truth is, bed mobility is no simple task. Gravity partners with friction; maliciously, they conspire in concert with bedding to make it a fait accompli that patients in hospital beds end up in an undignified lump.
And while it is tempting to think the answer is to simply practice “moving about in bed” more, this doesn’t work. When a patient is unable to rise even with a struggle, trying to get her to repeat a movement she can’t do will just frustrate both of you.
Have you ever thought about the steps you follow every time you get out of bed? Do you roll over first? Prop yourself up with your arm? Do you slide your legs off the bed before rising? Just one or both? It’s an intricate dance. But, if you break apart the act of bed mobility into its component parts, it becomes possible to work on individual elements, testing for the ‘limiting factor’ and practicing those elements until they no longer impede mobility.
In other words, if you can figure out which steps needs improvement, you can use a part-task training approach to concentrate on those areas first.
Breaking the Whole into Its Parts
By beginning with a simple breakdown of the act of bed mobility, you can divide bed mobility into discrete steps which allows improvement in overall ability and rise time in older adults. It is even possible to increase the intensity by modifying the bed position, adding in linen or pillows, or adding multiple movements to one repetition.
Here are some tips from a well-known bed-rise study for ways to break down the act of a supine-to-sit transfer from bed into its different steps.
Arm reach and trunk lift. This drill helps teach the act of lifting and turning of the trunk for the initial moment of rising from the bed. The patient’s starting position is supine, in bed. Cue the patient to reach forward and across midline to the opposite side of the bed (towards the “exit” side of the bed). Provide a physical target by placing a hand 2’ above the umbilicus and slowly move it towards the exit side.
Lateral leg movement, single leg. This drill is designed to teach the ability to laterally shift the lower extremities towards the exit side of the pool. Cue the patient to move one leg and then the other towards the side of the bed necessary to get out of bed.
Unilateral heel raise. This drill teaches the patient to elevate the legs as will be necessary to move them across the bed surface without encountering friction. Instruct the patient to place one leg in hooklying (knee flexed and foot on bed) then to elevate the opposite leg into a straight leg raise, rising 4-6 inches from the bed. Repeat on other side.
Roll to side lying. One of the limiting factors in bed mobility is the inability to roll the pelvis. With the patient in the same position as above (1 leg in hooklying), cue rolling of the pelvis by encouraging bearing down on the foot.
Bridging. This task can help patients understand the simultaneous use of arms and legs for lifting the buttock and trunk off the bed. Cue the patient to place both legs up into hooklying (flexed hips and knees). Instruct the patient to place hands by hips and to use both upper and lower extremity muscles to lift the buttock off the bed. Work towards a 3 second hold.
Trunk elevation by upper extremity extension. The purpose of this drill is to teach the patient to use the triceps and other upper extremity muscles to push the trunk up into a sitting position. After rolling the pelvis towards the exit side of the bed, the patient should be cued to place the hand in contact with the bed and to extend the elbow in order to lift the trunk off the bed. Alternative drill: Instruct the patient to lie side-lying in a foetal position (hips and knees flexed), facing towards the exit side of the bed, with feet near edge of bed. Cue the patient to push down with the elbow and hand which are contacting the bed until rising to a seated position with the legs dangling over the bed’s edge.
Weight on hip and hold. Once sitting on the edge of the bed, it is important for patients to be able to retain their balance even while their weight is shifted from side to side. Place the patient in sitting on edge of bed and arms folded across the chest (to prevent the substitution of upper extremity work for core work). From this seated position, cue the patient to shift weight as far as possible onto one hip, lifting the opposite hip and balancing. Repeat on other hip. Work towards a goal of a sustained 3 second hold in this “off-balance” position.
Supine to sit. Now that this task has been broken down and practiced in its parts, it is possible to attempt the entire task as a whole. Cue the patient to use the previously practiced elements to rise from supine to sitting, using the edge of the bed or railing if available.
Who Will Benefit?
Even the most frail patients can benefit from simple in-bed interventions. With the risk of developing weakness while in the ICU, finding safe methods of active rehabilitation such as bed- and chair-rises is crucial. In patients with femoral access veno-venous extracorporeal membrane oxygenation (VV ECMO), a traditionally high-risk population for rehab, both bed and chair mobility were possible.
As always, advancing technology continues to improve our understanding of patient care. A new sensor system was proposed recently to monitor mobility on a bed. Although you might picture other inconvenient sleep testing apparatus such as the CPAP machine, this sensor system is completely non-invasive. Piezoelectric sensors are placed underneath the bed to harvest information while the patient moves unencumbered. While this system is primarily designed to look at how much movement occurs, it could potentially be used to determine exactly how patients move during transfers and bed mobility.
Technology is not limited to assessing bed mobility. It is not possible to determine how much movement is occurring in patient’s rooms, even in highly-trafficked settings like the ICU. It is now possible to classify the mobility level achieved by any patient using an 11-point mobility scale using a system which monitors whether the patient moves in bed, out of bed, walks or does none of the these.
- Alexander, NB, Galecki, AT, Grenier, ML, Nyquist, LV, Hofmeyer, MR, Grunawalt, JC, Meddell, JL & Fry-Welch, D 2001, ‘Task‐Specific Resistance Training to Improve the Ability of Activities of Daily Living–Impaired Older Adults to Rise from a Bed and from a Chair’, Journal of the American Geriatrics Society, vol. 49, no. 11, pp. 1418-27.
- Cho, SH & Cho, S 2015, ‘A Noninvasive Sensor System for Discriminating Mobility Pattern on a Bed’, In Information Science and Applications, Springer, Berlin Heidelberg, pp. 35-42.
- Davis, KG, Kotowski, SE & Coombs, MT 2017, Stopping the Slide: How Hospital Bed Design Can Minimize Active and Passive Patient Migration’, Journal of Nursing Care Quality, vol. 32, no. 1, pp. E11-E19.
- Ma, AJ, Rawat, N, Reiter, A, Shrock, C, Zhan, A, Stone, A, Rabiee, A, Griffin, S, Needham, DM & Saria, S 2017, ‘Measuring Patient Mobility in the ICU Using a Novel Noninvasive Sensor’, Critical care medicine, vol. 45, no. 4, pp. 630-6.
- Morris, K & Osman, L 2017, ‘Physiotherapy on ECMO: Mobility and beyond’, Qatar Medical Journal, 58.