Preface

For most, if not all, students in the rehabilitation professions, patient-care skills serve as their entry into clinical training. And rightly so. Not only must students master basic skills of patient safety and mobility before attempting more complex interventions, but also mobility—whether blood moving effectively through vessels or bodies locomoting between desired locations—lies at the heart of the rehabilitation process.

Traditionally taught as a procedural or “techniques” course, we believe that patient-care skills can serve as the foundation for far more than mere motor skills. When presented within a larger context, the subject matter provides an ideal opportunity to ground students in fundamental rehabilitation principles, establish a culture of patient-centered care, and foster habits of clinical problem-solving and critical thinking.

Linking patient-care skills to basic principles of patient interaction and mobility, examining the evidence related to the skills, and navigating the decision-making process leading to patient-care choices will equip practitioners to excel in their ability to care for patients today while also positioning them for ongoing success in an evolving world of healthcare that will demand the highest levels of critical thinking and professional judgment.

From the outset, Mobility in Context has sought to do just that. The organizational structure of the book parallels the progression of patient intervention, starting with what needs to happen before the patient encounter begins, addressing the clinicians’ mental and social mind-sets, emphasizing awareness of how to move themselves, and demonstrating creation of a safe environment in which to care for patients. From there, the content progresses from care in which the patient is minimally mobile and a more passive participant to mobility tasks in which the patient is more active, upright, and mobile, such as independent stair climbing with an assistive device. Patient application of each chapter’s content is embodied in the ongoing “Thelma” case at the end of each chapter.

Several continua are embedded in the rehabilitation process: progression from dependence to independence, from passive to active movements, from stability to mobility, and from simplicity to complexity. These progressions are woven throughout the text, some implicitly as in the structuring and ordering of content material, and some explicitly through written content, thematic features, and representative icons. Complications of postsurgical movement precautions are added once basic bed mobility tasks are mastered. Assistive gait devices are presented in order of increasing mobility and decreasing stability with tips for recognizing when a patient needs to progress from one device to another.

This second edition reflects several ongoing changes in healthcare practices and terminologies with updated content and references. Chapter 1, Establishing the Therapeutic Alliance, expands the discussion of healthcare bias to include immigrant bias and provides suggestions for providing culturally competent care for transgender patients. The revised chapter also addresses issues of inappropriate patient sexual behavior and compassion fatigue.

In response to the large and growing body of evidence regarding the effectiveness of early mobility in intensive care, we expanded the coverage of this area in Chapter 3, Special Environments. A sample mobility rating scale and team protocol for patients in intensive care and specific guidelines for approaching the complexity of the environment in a systematic way are among the chapter additions.

In Chapter 4, Keeping It Clean, improved diagrams and illustrations serve to clarify donning and doffing procedures for personal protective equipment and enteric precautions, frequently being used in healthcare facilities, in the coverage of transmission-based precautions.

Terminology has been updated where indicated in the new edition. For example, in April 2016, the National Pressure Ulcer Advisory Panel changed the term pressure ulcer to pressure injury and made several changes to the staging system for pressure injuries, which are now reflected in Chapter 7, Positioning Your Patient for Mobility.

Chapter 8, which previously addressed dependent transfers through manual and mechanical means, has been revised to more closely match the classroom reality. Although both of these transfer techniques represent similar levels of patient participation, teaching manual dependent transfers in conjunction with maximum-, moderate-, and minimal-assistance transfers is more efficient and follows a natural motor learning progression. The manual dependent transfer portion of Chapter 8, therefore, was moved to Chapter 11.

In an effort to make lengthy Chapter 14 less cumbersome, and to emphasize both the basic principles of assisted ambulation and the decision-making process of selecting, using, and progressing gait assistive devices, we divided its content. Chapter 14, Navigating the Challenges of Ambulating, now covers the fundamentals of gait, an introduction to assistive devices, principles of guarding during ambulation, and functional tasks such as walking over uneven surfaces and opening doors. The new Chapter 15, Implementing Device-Specific Gait, addresses the selection, fitting, and therapeutic use of each device, along with instruction on other aspects such as guarding, turning, and recognizing when patients are in need of a more stable device or are ready to progress to a more mobile one.

Other, more global enhancements throughout this edition include new and revised photographic illustrations of principles and techniques and the broadening of tasks and language to be more inclusive of patient-care skills provided by occupational therapists and occupational therapy assistants. Clinical decision-making has been further emphasized through the addition of review questions at the end of each chapter applying new concepts to clinical scenarios.

A unique feature of Mobility in Context is the repeated use of icons to reinforce important principles of patient-care skills throughout the progression of care.

Person/task/environment (PTE): Keying into dynamic systems theory, the PTE icon alerts students to the dynamic and interactive nature of their efforts with patients. On the one hand, a change in any one area—an alteration in a person’s mental status, a restriction in permitted trunk rotation during the task of sitting up, or the addition of multiple lines and tubes in the treatment environment—will necessitate adaptations in other areas of the process. An awareness of PTE can also facilitate problem-solving; when an obstacle in one area prevents accomplishment of a mobility goal, modifications in either of the other areas may be used to create a solution. For example, if a patient using crutches is too unstable to climb (task) a set of stairs (environment) because of repeated episodes of dizziness (person), the environment may be altered by creating a ramp or by relocating the upstairs items to ground level or the task may be altered through use of a wheelchair or by having the patient go up and down the stairs in a seated position.

AMAP/ANAP

Fundamental to rehabilitation is the encouragement of patient independence and the use of functional movement that most closely approximates normal movement patterns. The AMAP portion of the icon, frequently highlighted in descriptions of mobility procedures, reminds the student to invite maximum patient participation even at the most dependent levels. Rolling in the bed with maximum assistance, for example, the patient can still be encouraged to turn the head or even just the eyes to participate in the activity. The ANAP reminder to choose normal movement patterns guides students in designing movement tasks. For example, patients in the hospital or skilled nursing facilities often pull on the bed rail to move from supine into a sidelying position. Initiating rolling through scapular retraction and elbow flexion, however, is not representative of typical rolling movement. Instead, lowering the bed rail and encouraging the patient to reach across and out with the uppermost arm facilitates scapular protraction followed by trunk rotation. The ANAP choice is always made within the larger context of the patient’s needs, however. Pulling on the bed rail may be the best choice if the patient is using a hospital bed at home, for example, and pulling on the bed rail makes the difference between dependence (AMAP) and independence.

One of the challenges that students face as they engage in patient-care tasks is how to facilitate desired movements on the one hand and prevent undesired movements on the other. The principle of controlling movements with more proximal contact is expressed as CC, control centrally. To limit unwanted movement, such as a fall during ambulation, the clinician guards centrally at the shoulders and hips. The same principle applies when attempting to create a controlled movement. When rolling a dependent patient to his or her side for bedpan placement, for example, contact at the hips and behind the scapula will give the clinician the greatest ability to control the movement.

Attempting to elicit movement from the patient using central control, however, is rarely effective and almost never a satisfying experience for either the patient or the clinician. Patient-initiated movements are best elicited by directing the patient’s most distal parts (DD). To encourage a patient to lean forward in sitting prior to standing up, for example, the clinician does not push the trunk forward, an action that, paradoxically, will often result in trunk extension. Instead, the patient is directed to bring the head forward to touch the clinician’s hand or to bring the “nose over toes.”

The relationship between stability and mobility affects many areas of decision-making and intervention in patient care. The icon reminds students that patient stability typically precedes mobility. When engaging patients in mobility tasks, it is important for students to understand that patients are typically able to maintain (S) a position before they are able to attain (M) it. Furthermore, patients must be able to stabilize themselves in a position before they can be expected to superimpose mobility tasks. For example, a patient who is unable to maintain sitting balance independently on the edge of the bed is not likely to be able to move from supine into sitting without considerable assistance, and the patient cannot be expected to perform upper-body grooming tasks (M) before mastering stable sitting (S). The icon also represents the inverse relationship between stability and mobility: gains in one typically come with losses in the other. When selecting assistive devices for ambulation, for example, the more stability a device provides, the less mobile the patient is likely to be when using it. Similarly, when choosing the most appropriate wheelchair for a patient, the trade-off between stability and mobility must always be considered.

Other important elements are highlighted within design features of the text. Students are alerted to important safety reminders in the Watch Out! feature. Keeping Current draws attention to recent research or ongoing clinical debates that may affect their decision-making, and Clinical Tips offer students pointers for increasing effectiveness and efficiency in the clinic.

Themed, stand-alone boxes—Try This, Clinical Reality Check, Thinking It Through, and Pathophysiology—throughout the text provide additional learning enhancements.

In revising Mobility in Context, our commitment to rooting patient-care skills in the underlying principles of rehabilitation and developing them within the context of the best available evidence has, if anything, only deepened.

This second edition of Mobility in Context, like the first, is intended to be a textbook that goes beyond “textbook” situations to facilitate the thinking and doing skills essential to quality care and to the advancement of healthcare professions. The commitment to promoting care and mobility skills that are shaped by sound principles, evolve with our expanding knowledge, and reflect ultimate respect and compassion for the patient remains the central focus.

We are excited by the updates and enhancements in this edition and hope that it will serve you well.