Therapeutic Scenario 4

Case Study 4
Transfer using Banana Board

Introduce yourself and assistant to the patient. Inform the patient of what will be occurring that you will be transferring them from the wheelchair to the plinth using a banana board as a result of a sore shoulder. The board acts as a bridge between the wheelchair and plinth and has a smooth surface on one side to make for a smooth transfer ant a rougher side to give friction between the two surfaces. Reassure the patient that they will be perfectly safe, that yourself and assistant will be close by and we will carry out a demonstration 1st(beware of infection control) Inform patient that you are aware of sore shoulder, transfer from right side using philislides as well as the board. All work will be carried out by the assistant and physio. Patient will b sliding over the board and they will end up sitting on the side of the bed when transfer is completed, that the assistant will be kneeling behind them to secure them incase they may fall forward or back. Once patient is on bed you are going to position them so a hot pack can be placed on shoulder and finally you are going to analyse the movement in shoulder during removal of jumper. Confirm with patient if they are happy to go ahead with it all.

Firstly you want the wheelchair to be secure, so position chair alongside plinth approx mid way between the head and bottom of bed facing the end of the bed and then put breaks on the chair, then you will want to remove the foot plates only if the patient will be able to have their feet on the ground and then the side of chair to be removed on the side you will be transferring which is the right side. Ensure to remove jumper or t-shirt before transfer, easier for treatment. Patient will remove arm plate if they are able. Ensure that the bed is at the same height as the chair or just slightly lower. Get a handling belt and put it on patient around waist. Then check if patient needs to be forward in chair to clear wheel if so, they can assist themselves moving right hip with good arm but physio will assist moving left hip forward. Then with patient doing as much as they can, get them to lift their right with assistance of right hand under knee cross it over left. Then place banana board with philislide on top of it under thigh and buttocks. There will be another philislide on the bed, this could be placed under end of banana board on bed. The physio will then kneel on the bed and secure board. The reason for this is so they are in the plane the patient will be moving as they will be using handling belt to move patient. Physio will be doing most of the effort while the assistant will just be guiding from the front. Patient then place right hand on the board but not to far away from body. Ready steady slide. Done in three phases to give physio time to reposition themselves and assistant reposition themselves and patients legs as the have no control or feeling in the lower limbs. Small movements and take their time. Patient will hopefully end up on the philislide on bed, remove top philslide by rolling to side and then other side, then use philislide in position to move patient back so in centre of bed, ask assistant to hold legs up if moving back in bed and to reduce the friction between patient and bed as the have no feeling when turning legs to place on bed. Again patient may need to be pulled up bed to be in a comfortable sitting position, done using handling belt, then back rest is then elevated. But pulling up the bed can be avoided if positioned correctly on bed in the first place.



Heat Pack
Inform patient what you are going to do now, is apply heat pack to the sore shoulder, benefits of this are relieves pain, sedative effect, speeds up tissue healing and finally reduces muscle spasm but there are many things that can change the effect of heat, such as area size, intensity and duration of heat. Important to check that the patient has no contraindications to heat pack such as poor skin sensation, wounds, Deep vein thrombosis, varicose veins, defective arterial blood supply and skin condition and allergy rash. Important for patient to understand procedure and for physio to obtain consent for treatment.

Once consent is obtained, position patient with a pillow under arm for extra support and it will raise arm up slightly. Gather equipment for application such as dry towel, hot pack cover and thermometer. Expose the area that shall be treated, drape appropriately and protect other clothing. Carry out a sensation test using something sharp and blunt, test area and also using hot and cold test tube test area for sensation. It is vital that the patient can notice the difference in the heat test as if they cant they may get severely burnt from the heat pack. Observe the area for any contraindications also. Check the heat of heat pack should be 75-80 degrees. Then remove heat pack and place in cover and then towel heat pack until there is 6-8layers. Then inform patient when you are applying heat pack, ask if they are comfortable. Remind them of heat sensations and to be aware and to ensure to stay awake. Set timer so heat pack is only applied for max of 20mins. Then every 5mins check area, ask patient how it feels. If area blotchy more layers may be required but if patient can’t really feel the heat, layers may need to be removed. Once time is up, remove the heat pack dry off the area and inspect for any reactions. Remove any towelling and help patient to dress. Ask patient how they feel and how the treated area feels.


Functional Analysis
Shoulder joint during removal of jumper

Again vital to know everyone is going to be different with removal of jumper. But you can give your model a hint on how you want them to remove their top. Things you need to be aware of are shoulder movement, the planes these movements occur in and the muscles that are involved in these mvts. Start and finish position is arm beside your side.

Ask patient to remove their jumper 3-4 times and observe them from different angles.

Phase 1: Flexion at the glenohumeral joint (GH jt), occurs in the saggital plane, frontal coronal axis. Concentric contraction. Muscles involved are bicep brachii, anterior deltoid, coracobrachialis

Phase 2: Arms starts in flexion and then reach across to opposite side of jumper.Adduction and internal rotation at the GH jt. Adduction occurs in the frontal/coronal plane, saggital axis. Muscles of adduction are latissimus dorsi and pectoralis major. Internal rotation is in the transverse plane. Muscles are pectoralis major, latissimus dorsi, teres major and supraspinatis. All these contractions are concentric

Phase 3: Holding end of jumper. Further Flexion at the GH jt to approx 160degrees, occurs in the saggital plane, frontal coronal axis. Concentric contraction. Muscles involved are bicep brachii, anterior deltoid, coracobrachialis


Phase 4: At this point the jumper is over your head.There could be then reduction in flexion, either against resistance of jumper which means muscles working concentrically ~triceps or the flexors could be working eccentrically to lower the arm. Elbows freed from jumper

Phase 5: Is over head but elbows freed. External rotation and abduction of the GH jt External rotation occurs in the transverse plane. Muscles are teres minor and infraspinatus. Adduction but it is the abductors working eccentrically and eventually arms lower to side. Muscles working eccentrically are middle deltoids. Finish position,arms by side

Flexion off the GH jt is working against gravity
Having to work against inertia
Friction occurs between jumper and human body
NB to observe bodies posture and check if it changes so COG changes