Preface

Mobility lies at the heart of rehabilitation. Whether it is a person’s ability to move from one place to another or the blood’s ability to travel freely through the vascular system, effective and purposeful movement is a fundamental marker of health and independence. For most students in the rehabilitation professions, patient care skills serve as their entry into clinical training. And rightly so. As students master basic patient safety and mobility skills, they lay the groundwork for more complex interventions. Even in this entry-level work, mobility interventions can make powerful differences in patients’ lives—improving the immediate situation, restoring independence, and contributing to the patient’s future well-being.

Traditionally taught as a procedural or “techniques” course, we believe that patient care skills offer an opportunity for the acquisition of more than mere performance skills. Practiced within a larger context, these skills can promote a culture of patient-centered care, instill fundamental principles of rehabilitation, and develop students’ clinical reasoning abilities. From its inception, Mobility in Context has sought to do just that.

By examining the principles underlying mobility decisions, articulating clinical reasoning processes, and applying current evidence and topics of clinical debate, we seek to equip practitioners to succeed in an evolving world of healthcare that will demand the highest levels of critical thinking and professional judgment.

The organizational structure of the book parallels the progression of patient intervention. The first chapters set the stage for the patient encounter, addressing the clinician’s mindset, effective body mechanics, and the creation of a safe environment. In subsequent chapters, interventions progress from care in which the patient is less active, such as patient positioning and assessment of vital signs, to interventions in which the patient is more independent, mobile, and upright, such as independent wheelchair propulsion and gait training.

Other rehabilitation continua are also embedded in the book. Some are implicit in the structuring and ordering of content. Simplicity precedes complexity, for example, and stability precedes mobility. Other progressions are explicitly communicated through written content, thematic features, and representative icons. Complications of postsurgical movement precautions, for example, are added once basic bed mobility tasks are mastered. Assistive gait devices are presented in order from the most stable to the most mobile, with tips for recognizing when a patient needs to progress from one device to another. A new episode of the progressing “Thelma” case, with content-relevant questions, closes each chapter.

This third edition of Mobility in Context came into being during a time of extraordinary cultural and societal shifts. We hope that our continuing efforts to bring to light the social determinants of healthcare inequity will speak to students and educators and empower them to see all patients as individuals to be honored and valued.

Since the textbook’s first printing, we have worked to represent diversity among patients and clinicians. In this newest edition, we continue to include images of people of color and people of different genders, ages, and body habitus. We expanded the information on the assessment of patients with darker skin, particularly with regard to pressure injury risk and pulse oximetry interpretation. We removed all gendered pronouns not specific to a particular person and introduced the gender-neutral pronoun “they” in some patient cases.

This edition also brings a stronger neurological perspective. We provide more information about neurological conditions such as Parkinson’s disease, dementia, and spinal cord injury and how they relate to mobility concepts. Transfer techniques explicitly reference the “head–hips” relationship, and we include a new chair-to-floor transfer technique often used by patients with spinal cord injury.

In our commitment to providing an evidence-based and clinically reasoned approach to mobility skills, we have enhanced the coverage of motor learning concepts, integrating motor control theories and applying the concepts to the facilitation of functional mobility.

The use of a wheelchair as a primary means of locomotion is gaining new recognition in clinical research. Accordingly, we have included evidence-based wheelchair-propulsion techniques and existing normative data on wheelchair-propulsion speeds and distances. We also enhanced the approach to wheelchair fitting with more detailed information about pelvic positioning and pressure mapping.

Among the other additions to the third edition of Mobility in Context are levels of assistance as defined by the Comprehensive Assessment Reporting Evaluation (CARE) tool, edema assessment methods, and expanded application of biomechanics principles to body mechanics for patients and clinicians.

Clinical reasoning underlies every section of this textbook. In addition to updating research findings in every chapter, we developed a new decision-making algorithm to guide the clinician’s choice of mechanical and manual transfer methods (see Fig. 8-2). In the instructor’s online materials, we have provided new clinical reasoning scenarios, guides for using concept maps to facilitate clinical reasoning, and ready-to-use standardized patient 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 will necessitate adaptations in other areas of the process. For example, an alteration in a person’s mental status, a restriction in trunk rotation during the task of sitting up, or the addition of multiple lines and tubes in the treatment environment will affect a patient’s ability to move about. An awareness of PTE can also facilitate problem-solving. When an obstacle in one area prevents the accomplishment of a mobility goal, modifications in either of the other areas may be used to create a solution. For example, if a patient is too weak (person) to use crutches to ascend (task) a set of stairs (environment), success may still be achieved: The person may develop more stability through practice, the environment may be altered by creating a ramp or relocating upstairs items to ground level, or the task may be altered through the use of a wheelchair or even by having the patient go up and down the stairs in a seated position.

As Much as Possible, as Normally as Possible (AMAP/ANAP)

Fundamental to rehabilitation is the encouragement of patient independence and the incorporation 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. When rolling in the bed with total assistance, for example, the patient can still be encouraged to turn the head and look in the direction of movements. The ANAP reminder to choose normal movement patterns guides students in designing movement tasks. For example, patients in facilities often pull on the bed rail to move from supine into a sidelying position. Initiating rolling through elbow flexion and scapular retraction, however, is not representative of a 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 must always be made within the larger context of the patient’s needs and abilities. In particular, the clinician must choose whether to focus on the recovery of mobility or the development of compensatory techniques. Interventions aimed at recovery directly address the body structures and functions that are causing limitations in activity and assume that the patient has the potential to regain lost function. Recovery of “normal” body structures and functions may not be possible or advisable for some patients, however. For these patients, interventions are more wisely focused on effective and meaningful compensatory mobility techniques. Pulling on the bed rail may be the best choice if the patient is using a hospital bed at home and if pulling on the bed rail is the difference between dependence and independence.

Control Centrally, Direct Distally (CCDD)

One of the challenges that students face as they engage in patient care tasks is how to both facilitate desired movements and prevent undesired movements. The principle of controlling movements with more proximal contact is expressed as CC, controlling centrally. To prevent 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 patient for bedpan placement, for example, contacting the patient 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 movement of the patient’s most distal parts (DD). To encourage a patient to lean forward in sitting before 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.”

Stability and Mobility

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 must be able to stabilize themselves in a position before they can be expected to superimpose controlled mobility tasks. Furthermore, patients are typically able to maintain (stability) a position before they are able to attain (mobility) it. For example, a patient who is unable to maintain sitting balance independently cannot be expected to perform upper-body grooming tasks while sitting unsupported on the edge of the bed, nor is this patient likely to be able to move from supine into a sitting position without considerable assistance.

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, a lightweight wheelchair that allows for speed and agility will do so at the cost of postural and structural support.

Biomechanics

Applying the fundamental aspects of biomechanics allows clinicians to facilitate patient mobility while minimizing their risk of injury. Teaching patients and care partners how to apply these same principles can be essential to patient recovery and to injury prevention. Chapter 2 describes important biomechanical principles and how they can be applied to patient mobility tasks. The biomechanics icon continues to highlight the role of biomechanics in clinical decision-making throughout the remaining chapters.

Boxed Features

In addition to the icons representing fundamental principles of patient care, themed, stand-alone boxes—Try This, Thinking It Through, Health Condition, Clinical Reality Check, and Intervention—provide added learning enhancements throughout the text. Still other design features highlight important elements of the text. Students are alerted to important safety reminders in the Watch Out! feature, with added red and yellow flags (, ) to help identify risk levels. 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.

In revising Mobility in Context, our commitment to grounding 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 third edition of Mobility in Context, like the first, is intended to be a textbook that goes beyond “textbook” situations. By presenting foundational skills within the contexts of current evidence, clinical reasoning, and patient-centered care, we strive to empower emerging clinicians to provide excellent care, adapting skillfully to a future none of us can yet know.

This 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 book’s core focus. We are excited by the updates and enhancements in this edition and hope that it will serve you well.