Hierarchy of Mobility

The hierarchy of mobility begins with bed mobility. Improving a client’s overall bed mobility is extremely important to ensure that the client is not in one position for too long resulting in pressure wounds over their boney prominences. Next, is bed to mat transfers. Followed by wheelchair transfers, to bed transfers, to functional ambulation for ADL’s, to the toilet, to the tub, eventually working up to car transfers, and then beginning working on functional ambulation for community mobility, and then lastly driving. As you restore confidence in mobility and move up the client has more and more of a sense of independence.

 Speaking firsthand, from someone who suffered a traumatic accident and has spent 2 months in a wheelchair secondary to a non-weight bearing orders. The hierachy gave me something to look forward to. Something minor like getting out of the bed and moving to a mat is not minor at all for someone who otherwise would have no choice. It gradually works to give the client their independence back, but ensures the client is safe and ready to take these small steps toward regaining their strength and independence. I am sure for someone who has been independent and active their entire life that they this process could seem frustrating. However, in my opinion, it ensures the safety of the client, as well as the safety of the therapist. In order to treat holistically you may have to constantly reassess, modify, and adapt to the hierarchy but I think in general following the hierarchy is a good way to ensure safety of the client and therapist, that the client is healthy enough to be moved around, and the motivation of the client. If the client is elderly then decreased cognition may play a role and may prevent them from working on something like their driving skills, then your primary goal may be working with them on improving their overall mobility in order to prevent pressure sores secondary to prolonged positioning. With increased activity level, you can safely work on transfers and overall mobility so that they can safely perform their regular ADL’s to the best of their ability.  You may have to work with their family on caregiver education to ensure that your client can transfer safely and effectively in and out of a car. One thing to keep in mind is that it’s essentially what matters most to the client as well as realistic goal setting between the client and the therapist, so always keep that in mind when working on the hierarchy of mobility.