Hierarchy of Mobility Skills

The hierarchy of mobility skills states the order in which mobility skills should be addressed. 

The hierarchy starts with bed mobility, then mat transfer, wheelchair transfer, bed transfer, functional ambulation for ADLs, toilet/tub transfer, car transfer, functional ambulation for community mobility, and lastly community mobility and driving. 

I think the reason this hierarchy is set up this way is so the client can increase their confidence, and then progress to more difficult or strenuous tasks. Bed mobility has a large base of support and is in preparation for transferring. Bed mobility provides a base of skills that a client would need in order to provide pressure relief, get into a comfortable position, and engage in ADLs. It is beneficial for transfers to be done when the client is anterior sitting, which requires a smaller base of support. As the base of support gets smaller when moving up the hierarchy, the risk of instability increases. A bed has a bigger base, so a person can be more stable, but a toilet, for example, has a smaller base and creates more room for instability. As we move up the hierarchy, the tasks have a smaller base of support, become more specialized, and also are in more confined spaces, like a wheelchair or vehicle. 

After my knowledge from the biomechanics course, I am able to make sense of the reasoning behind this hierarchy. When I first looked at the hierarchy, I felt like it was what I expected. In biomechanics lab and the simulation lab, I was able to practice bed mobility and transfers. It makes sense to accomplish the bed mobility task first, before transferring out of the bed, and then to more come confined spaces. Transferring out of the bed requires energy and could lead to dizziness. 

During observation hours, I had the opportunity to shadow in an acute care setting. This experience allowed me to see evaluations of clients. Majority of the time, a patient started in the bed and showed if they could roll over, reposition the covers, sit up or sit down, etc. After that, the therapist would prompt them to get out of bed, and assist as needed. After the client moved out of the bed, the therapist asked questions regarding their ADLs. This approach matches the hierarchy of mobility skills. It starts with movement in the bed, then transferring out of the bed, and then onto functional ADLs. I didn’t know it at the time, but looking back on my shadowing experience, I can see the hierarchy being used.

I agree with this approach. I think it is important to be comfortable and safe when performing bed mobility skills before transferring into a wheelchair, tub, or car. I agree with the next step being transferring into the wheelchair or out of the bed. ADLs and bathing are so important and I agree with those steps following transfers. Car and mobility are also important, but do require more specialized skills.