How to transfer people with SCI to

respect their intimate regions

Booklet for Caregivers

Acknowledgments

This booklet was created under the supervision of Dr. med. Hans Georg Koch at the Swiss

Paraplegics Association in Nottwil, Switzerland. Included information is based on the

knowledge and experience of physiotherapists, occupational therapists and nurses from the

Swiss Paraplegic Centre and people with a spinal cord injury (SCI).

This booklet should give an idea on how to help people in a wheelchair with transfers, no

matter whether those people suffer from a SCI or whether they need to use a wheelchair

due to other conditions. Apart from examples of wheelchair transfers, the first pages

provide some advice and recommendations which is good to read and follow to ensure

dignity and safety during any type of transfer. Furthermore, this booklet lists general rules

that are important to be aware of and to be followed during transfers.

There are many ways of wheelchair transfers which you can choose from and it depends

only on your preferences. Do not forget, however, that these transfer techniques need

practice as anything else which is done for the first time, so do not stress yourself in case

you cannot do it perfectly right from the beginning. Communication with people that need

to be transferred, trust and adhering the principles of correct transfer techniques are

altogether the key to successful wheelchair transfers.

I hope that this booklet will provide you with some good information, advice and ideas on

how wheelchair transfers can be performed. Besides, I hope that you will be able to use this

knowledge actively whenever it is needed.

Katerina Salficka

Public versus Private Regions of the Body

In courses of Kinesthetics, it is often taught that the human body can be divided into two main

groups, private body regions and public body regions.

The “private regions” are the ones which you don’t want to be touched by other people,

especially by those you don’t know. Usually only partners or very close family members are

allowed to approach such regions. Contrarily, “public regions” are those regions which might

get touched sometimes by other (foreign) people’s public regions without even noticing it. This

can happen for example on the bus, tram or in other busy places such as festivals etc.

The concept says, that as long as two strangers both touch with their public regions (e.g. my

back touches your back), or, one person touches the other person’s public region with his/her

private region or vice versa (e.g. my back touches your chest), uncomfortable feelings are less

likely to be experienced.

However, if unknown people both touch with their private regions only (e.g. when my chest

touches your chest or my hand touches your abdomen), it provokes unpleasant feelings such as

shame and a feeling of low self-esteem.

I have tried to illustrate those zones in a picture below, but it is essential to experience

yourselves how it makes you feel when you touch another person with both, private and public

regions of your body. This is to make you realize what body regions might be more sensitive

than others. However, sometimes there are situations when it is not possible to avoid some of

those regions. In this case, you ALWAYS need to communicate to the person what, why and

where you need to touch him. A dignified attitude together with communication are essential

factors.

Public versus Private regions of the body. The red color stands for "private regions", the green color stands for "public regions".

Table of Contents

A) GENERAL RULES .................................................................................................................. 1

What is important to know before transferring the person with a SCI ................................ 1

What to consider before performing wheelchair transfers .................................................. 1

Approaching the person with a SCI ....................................................................................... 1

What to do to protect your back! ......................................................................................... 2

Preparation for wheelchair transfers .................................................................................... 3

Instructions on how to use a sliding board ........................................................................... 3

B) TRANSFERRING IN ACTIVITIES OF DAILY LIVING (ADL) ..................................................... 4

1. Transferring from wheelchair to bed ............................................................................ 4

2. Transferring from floor back to wheelchair .................................................................. 9

3. Transferring from wheelchair to bath bench ............................................................. 11

4. Transferring from wheelchair to shower chair ........................................................... 13

5. Transferring from wheelchair to toilet ....................................................................... 15

6. Transferring from wheelchair to car ........................................................................... 16

C) UNIVERSAL TRANSFER METHOD ..................................................................................... 20

D) HOW TO ADJUST TROUSERS IN THE END OF TRANSFERS? ............................................. 21

E) TRANSFERRING IN SPORTS .............................................................................................. 22

F) TRANSFERRING AT THE AIRPORT .................................................................................... 23

G) FREQUENTLY ASKED QUESTIONS..................................................................................... 24

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A) GENERAL RULES

What is important to know before transferring the person with a SCI?

Caregiver needs to respect the physical abilities and

limitations of the people with a SCI as well as their

behavior, perception and thinking. It is also important that

the caregiver is aware of his/her own physical abilities and

limitations.

Caregiver needs to be able to communicate clear,

sequential instructions to the person.

The use of correct transfer techniques.

Wheelchair transfers need practice like anything else so don’t blame yourself if you are not a

star right from the beginning .

What to consider before performing wheelchair transfers:

Can I do it on my own or do I need help from a second person?

What assistive aids would be helpful to use?

a sliding board

a low-friction fabric (sliding) sheets

a block (to even the surfaces out in case

adjusting transfer surface is not possible)

Do I have enough time or am I in hurry?

Does the person understand what is going to happen? Doesn’t he/she look

confused or concerned?

Approaching the person with a SCI:

1) Never grab the person’s wheelchair from the back without asking!

2) Approach and talk to the people from the front.

3) In case of falling out, ask whether she/he needs help even though you are convinced

she/he does. Also, do not be disappointed if the person declines.

4) Ask first whether she/he has preferences regarding transfer techniques. Don’t forget

that spinal cord injury differs from person to person, thus affected people know best

their condition and how they want to be transferred.

5) Encourage the person with a SCI to cooperate with you as much as possible.

6) If possible, ask the person to lean forward and stabilize his legs in the area of the knees

during the transfer – this makes it easier to transfer him.

7) Always explain every step of what you are doing, e.g. “Now, I am going to touch you

here so that I can do this”

- 2 -

8) Always provide the person enough time to do what you ask for, e.g. “Slide to the edge

of the chair, please.”

How to prepare yourself before wheelchair transfers:

Protect your back! It’s all about body mechanics!

Stand with your feet shoulder-width apart either with one foot in front of

the other foot or set astride, whichever makes it easier for you to move the

person’s weight!

Keep your back and neck straight!

Do not transfer while flexing, extending, or rotating your spine!

Bend your hips and knees before transferring and use your leg muscles to

take any weight (think of yourself as a professional weightlifter)!

Keep your feet flat on the floor and always wear shoes!

Do not transfer with your back muscles, always consciously activate your

abdominal muscles!

Exhale while taking more weight!

Keep the weight of the person as close as possible to your body!

Listen to your body. If anything starts to hurt or you get tired, make a

break!

Make use of assistive devices!

Especially if you help someone in a wheelchair on every day basis, you must be careful and

beware of any kind of pain which occurs. It’s important to not underestimate the pain as it can

result in injuring yourself and subsequently losing the ability to be a caregiver.

- 3 -

Preparation for wheelchair transfers:

1. Make sure that you and the transferee wear non-skid shoes

2. Position the wheelchair in a correct position – as close as possible to the transfer

surface (ca 30° in between)

3. In case it is not possible to adjust the heights of the surfaces, use blocks

4. Lock the brakes of the wheelchair and pay close attention in which

direction the front caster wheels are turned – position the large

part of the small front wheels to face forward! (Since those

wheels have the ability to move in all directions, in case they are

not positioned as mentioned above, there is a risk of tipping)

5. Ask or help the person to get to the edge of her/his e.g. wheelchair

and then always ask: “Are you enough on the edge? Is it ok?”

6. The feet of the person in the wheelchair have to be on the floor (not on the

footrest)

7. Make sure there is no obstacle in the way (footrests, armrests)

8. Stand in front of the person to make sure she/he can’t fall over.

9. After the transfer, make sure that the person is sitting in the middle of his

wheelchair and that he doesn’t sit on the wrinkles of his clothes – a pressure ulcer

(decubitus) can be formed immediately!

Instructions on how to use a sliding board

First, take a sliding board, lean the person over the side a little bit (pull his trousers up to

prevent formation of cloth wrinkles) and slide it under the person’s buttock. This must be

performed in the way which doesn’t hurt the person’s skin or anyhow cause discomfort in

his/her intimate region.

Afterward, seat the person down on the sliding board while its other ending is safely on the bed

(or other transfer surface). In the end, always ask: “Does it fit well?”

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B) TRANSFERRING IN ACTIVITIES OF DAILY LIVING (ADL)

These transfer techniques explain transfers in one direction only (e.g. from wheelchair to bed)

as the same transfer technique can be used for the way back, just the other way around.

Note: Before you start transferring the person, let him count to three and then perform the

transfer (that way you assure that the person is ready).

1. TRANSFERRING FROM WHEELCHAIR TO BED

a) Transfers with 1 caregiver – First option:

① ②

④ ③

Always start by pulling the

person’s legs to get to the

edge of his wheelchair.

- 5 -

Second option: The same technique is also possible to perform with flexed knees. Here is an

example of such a transfer from bed to wheelchair. In case of 2 caregivers, the second one can

help from the back (viz. “Transfers with 2 caregivers”).

① ②

③

- 6 -

Third option:

① ②

③ ④

Start by putting the

person‘s legs over

your legs.

- 7 -

⑤ ⑥

⑦

- 8 -

b) Transfers with 2 caregivers:

In case of 2 caregivers, communication is very important to assure that movements are

synchronized during the transfer.

Another variation of this transfer would be that the caregiver on the right side has flexed

knees. (viz. “Transfers with 1 caregiver” – “Second option”)

① ②

③ ④

In the end, support

the person with your

hands if needed.

- 9 -

2. TRANSFERRING FROM FLOOR BACK TO WHEELCHAIR (helpful in case of falling out)

This transfer is helpful especially in case the person falls out of his wheelchair. In case this

happens, check for injuries. A person with SCI possibly does not feel pain, even when his

leg is broken. Call ambulance or admit the person to the emergency department if

necessary.

① ②

③ ④

- 10 -

In case you need to transfer the person to the floor, first, turn his feet to the right if you are

helping from the person’s left side. Turn them to the left, if you want to perform the transfer

from the person’s right side.

⑤

- 11 -

3. TRANSFERRING FROM WHEELCHAIR TO BATH BENCH

Depending on anatomy and stability of the body, you can choose whether you want to put

both legs to the bath tub → transfer OR only one leg → transfer → second leg OR transfer →

both legs to the tub. All the variations are possible so try out yourself what fits you best.

① ②

③ ④

- 12 -

On the way back, first help the person to get her legs out of the bath tub:

③

① ②

- 13 -

4. TRANSFERRING FROM WHEELCHAIR TO SHOWER CHAIR

① ②

③ ④

- 14 -

⑥

Shower

curtain can

also be used as

a protection

for a

wheelchair.

⑤

- 15 -

5. TRANSFERRING FROM WHEELCHAIR TO TOILET

Positioning your elbows on your knees

helps you to transfer the person.

③

① ②

④

- 16 -

6. TRANSFERRING FROM WHEELCHAIR TO CAR

For this kind of transfer, it is recommended to use a banana sliding board. This board has a

shape of the angle between a wheelchair and a car and is longer than other types of sliding

boards. This helps you to bridge a longer gap.

First option:

① ②

Put the sliding board under

the person’s bottom.

- 17 -

Slide the person with your

hands or with his belt (only

if necessary!). Mind to

always adjust his/her

trousers once you’re done!

⑤ ⑥

③ ④

- 18 -

Second option: A caregiver transfers from the side (e.g. if there is not enough space in the

front, or if the person in the wheelchair or the caregiver is taller than the other person).

③

② ①

④

- 19 -

⑤ ⑥

- 20 -

C) UNIVERSAL TRANSFER METHOD

This is a universal transfer method performed by 2 caregivers. It is an easy method which is

possible to use in every situation.

However, it is a passive technique which means that the people in a wheelchair cannot help

anyhow even if they were able to! This can make them feel less valued, less comfortable and

safe (due to having no control over the transfer).

Therefore, this technique should be used only when the person agrees. It is commonly used e.g.

in situations with limited amount of time, or if the caregivers lack of a proper training and

experience. “Emergency” situations are also one of the indication for this transfer as the

transfer must be carried out as fast as possible (e.g. falling out of a wheelchair on the crossing).

NOTE: Since this method needs 2 caregivers, communication is of significant importance.

During transfers, the

caregiver holding the

knees “stretches out” the

person a bit which helps

to reduce the load on the

second caregiver.

③

② ①

People in a

wheelchair

should keep

their shoulders

down if possible

- 21 -

D) HOW TO ADJUST TROUSERS IN THE END OF TRANSFERS?

After every performed transfer, it is important to adjust the trousers of the person in the

wheelchair. This prevents wrinkled clothing from rubbing over the skin and therefore, it is

prevention of pressure ulcers (decubitus).

Caregiver gently pulls the trousers to the sides and towards herself.

Other 2 options:

1) The same method is also possible to do while the person in the wheelchair has her

head on the caregiver’s shoulder. This helps the person to lift up her buttocks a bit

which makes it easier to adjust her trousers.

2) The person can also lean her head against e.g. a wall while the caregiver adjusts her

trousers from the back.

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E) TRANSFERRING IN SPORTS

The transfer techniques mentioned above can be also used in transfers during sport activities.

The majority of people with a SCI are able to transfer themselves, but in the beginning it is

important to know couple of rules as the wheelchairs in sports differ from one sport to another.

In basketball, the wheels of the wheelchair are skewed to assure better stability, plus in the

back, there is one small additional wheel which enables the people to turn around.

It is important to know that this wheelchair does not have any brakes (it is against the rules of

basketball) and therefore, the wheelchair has to be placed in front of a wall to avoid an injury.

Afterward, the transfer can be performed in the same way as described above. The person in

the wheelchair is bending over and a caregiver helps him from the front to transfer to the

basketball wheelchair. The same technique is used in transfers to rugby wheelchairs too.

For swimming, the transfer is realized on the raised edge of the pool. Then, the transfer is the

same – a wheelchair is as close as possible to the edge of the pool and a caregiver helps from

the front as mentioned in this booklet. Especially here, it is important to wear non-skid shoes

as the floors in the swimming area are often wet and therefore it might be slippery. Besides, it

is of a paramount importance to protect the nude skin by a little mat or a towel.

Monoski-bob is unstable and therefore it needs to lean against a wall or a car. Again, a lot of

people are able to do this transfer on their own as they get experience, but beginners might

need help. In this case, it is better to have two caregivers as the “shell” of the monoski-bob is

very hard and tight and therefore can hurt the skin when manipulated inappropriately (this can

lead to skin damage or to the formation of a pressure ulcer – decubitus).

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F) TRANSFERRING AT THE AIRPORT

Wheelchair transfers at the airport are performed by a specialized company. For instance, at

the airport in Zürich, Switzerland, this company is called “Careport”.

These companies are a part of every airport all over the world and they ensure that people who

need assistance, will be guided safely and comfortably to their planes. The support personnel

assist people from check-in at the airport through their departure. They are also all well trained

in wheelchair transfers.

After luggage check-in and security checkpoints (including the screening process), there are two

to three wheelchair transfers which will need to be conducted. First, people with high

tetraplegia need to transfer to the airport chair as their electric wheelchair has to be checked-in

just like their luggage. Second, the person will need to transfer to the aisle chair shown below.

These chairs are designed rather narrow in order to fit in the aisle of the plane, but are also

equipped with safety belts and other safety equipment. Finally, the last transfer is carried out

on board the plane, from the aisle chair to the seat of the plane.

Note: ALWAYS take the cushion from the wheelchair on board as well as everything else

which is not permanently attached to the wheelchair! If the person in the wheelchair wants to

sit on the cushion, make sure that his feet are not hanging. In case they are, put e.g. a swim ring

under his feet as a support. The cushion as well as other medical equipment does not count as

one of the carry-on luggage.

Those who use an air cushion should also check the pressure during and after the flight.

Increased pressure makes the cushion harder which might cause a pressure ulcer.

For assisted transfers, the support personnel usually use the universal transfer method (viz.

Universal transfer method). The person in the wheelchair should always notify the staff of any

sensitive areas if he is not asked first. (An experience with transfers at the airport of a girl with paraplegia

can be found here (in EN): http://www.newmobility.com/2014/04/air-travel-manual-wheelers/)

- 24 -

G) FREQUENTLY ASKED QUESTIONS

1) When do I use a sliding board?

When people in a wheelchair or caregivers do not feel secure in transferring, or when the

distance between the two transfer surfaces is too large.

2) Can I grip the person’s trousers to help myself?

YES and NO. It is better not to but if you can’t find any other way, you can do it. However,

you mustn’t forget to adjust the trousers in the end of the transfer. Clothes wrinkles

between the buttocks and the seat can immediately cause a pressure ulcer (decubitus)! It is

important to keep in mind that such a pressure ulcer requires a return of the person to the

hospital for more than 6 weeks! This means a significant loss of many hours of hard work

and achieved progress to the person with a SCI.

3) How many people are needed for transfer?

Number of caregivers needed for transfers depends on (1) experiences and confidence of

the caregiver and (2) on the level of injury and the achieved activity of the person in the

wheelchair. In the beginning, it is better to carry out the transfers with two caregivers to

gain experience.

4) How can I prevent a pressure ulcer during transfers?

To prevent a formation of pressure ulcers, it is important to avoid injuring the person’s skin.

This can occur for instance as a consequence of incorrect application of a sliding board,

incorrect transferring e.g. when a sliding board rubs over the person’s nude skin or when

the skin scrapes against the armrest of the wheelchair etc. Pressure ulcers are a big issue in

healthcare and therefore it is recommended to read more information about it, for instance

on this governmental website (EN): http://www.msktc.org/sci/factsheets/skincare.

!!!For people in a wheelchair, it is also very important to lift themselves up or change their

position regularly by bending over for a while, leaning back, sitting on one side etc. This

should be done at least once every hour!!!

5) What is the biggest mistake which caregivers make during transfers?

The biggest mistake is when caregivers think that they know how to do the transfers and

carry out the transfers automatically and confidently. This is to say that caregivers should

always be careful no matter whether they have previously transferred someone a 100 times

or only once. It’s important to remain careful and keep in mind the general rules and the

individual steps of the particular transfer.

Special thanks to these people:

Hans Georg Koch

Franziska Reding

Nicole Andres

Ines Bersch

Monika Schachschneider

Jessica Decker

Christa Schwager

Angelika Lusser-Gantzert

Tim Shelton

Erwin Zemp

Beat Bösch

Martina Meyer

Martin Senn

Catherine Debrunner

Physiotherapy Department at SPZ, Nottwil

Occupational Therapy Department at SPZ, Nottwil

Walter Eggenberger

Fabian Aggeler

Photos: Nicole, Martin, Katerina, Franziska, Catherine, Martina

Taken by: Fabian, Katerina

Places: Occupational Therapy Department and Fotostudio at SPZ in Nottwil, Switzerland and

Sörenberg, Switzerland.

Information in this Booklet was also inspired by these sources:

National Caregivers Library

Promoting Independence Following a SCI

Pedretti’s Occupational Therapy

http://www.wikihow.com/Transfer-Someone-Out-of-a-Wheelchair

https://osha.europa.eu/en/publications/e-facts/efact28

www.paraforum.ch

www.spv.ch

Internal documents of the Swiss Paraplegic Centre

Sources of Pictures:

http://www.wheelchairnet.org/WCN_ProdServ/Docs/MWTG/Sec3/sec3.html

http://www.funelf.net/cant-you-do-anything-right/

http://www.clipartpanda.com/categories/tramp-clipart

http://www.yogadirect.com/foam-yoga-block-3-inch-x-6-inch-x-9-inch.html

http://www.themusculoskeletalelf.net/risk-factors-for-the-onset-of-nonspecific-low-back-pain-

in-office-workers-a-systematic-review/