After a stroke, the part of daily life that is most affected and most prone to accidents is often not how far the patient can walk but "how to move alone from bed to wheelchair and from wheelchair to toilet". If a transfer is not done safely, it becomes a major source of falls after discharge. If it is mastered well, it is the first step in regaining independence in daily life. From the patient's own side, this article explains how to use the abilities the patient has to move safely between bed, wheelchair and toilet.
Before reading on, please be clear about how the following three areas are divided, so that the points are not confused.
As for training the trunk control ability itself, see the overview of trunk control after stroke. This page concentrates on how that ability is applied to the movement of transfers.
The base of independent transfers: sit-to-stand
(Premise: the patient can already sit steadily at the edge of the bed with both feet flat on the floor. If the patient still cannot get from lying to sitting, first see bed mobility trainingto practise rolling and lying to sitting. The content of this page all starts from "already sitting steadily at the edge of the bed".)
Almost every transfer movement, whether getting in and out of bed, moving to a wheelchair or using a toilet, depends on the same basic movement: sit-to-stand (STS). Whether the patient can stand up from sitting safely and under control is the first threshold in judging whether the patient can transfer independently. Fortunately, STS is an ability that can be mastered through training.
For stroke patients who cannot stand up independently, research shows that two extra weeks of intensive sit-to-stand training on top of usual rehabilitation effectively improves sit-to-stand ability and lower limb strength (de Sousa et al., 2019). A higher-level Cochrane pooled analysis also found that repetitive task training has a positive effect on lower limb function and brings a statistically significant improvement in sit-to-stand (effect size about 0.35), although no equal benefit was seen for the upper limb (French et al., 2010). This shows that treating transfers and sit-to-stand as task-specific goals that can be practised on their own is the right direction for rehabilitation.
Remember the order of practice:before sit-to-stand (STS) is up to standard, do not rush to practise the complete transfer between bed, wheelchair and toilet. The patient must first make "standing up safely from a sturdy, high seat and then sitting down under control" thoroughly reliable, so that transfers have a safe foundation.
Key points of sit-to-stand
The basic method: transferring towards the unaffected side
Once STS is up to standard, the next important principle is direction. The default strategy for independent transfer is to transfer towards the unaffected side. The wheelchair, chair or target seat is placed on the unaffected side, so that the unaffected arm and leg lead the movement, the transfer path is shortest and the safety margin is highest.
- Place the wheelchair or target seat on the unaffected side at about 30–45 degrees to the edge of the bed or the original seat, and as close as possible
- Lock the brakes on both sides of the wheelchair, move or fold away the footrests, and clear clutter and rugs from the floor
- Sit steadily at the edge of the bed or the seat with both feet flat on the floor and drawn back, lean the body forward and complete the sit-to-stand movement
- Once standing steadily, use the unaffected leg as the pivot and take small steps to turn until the back is towards the target seat
- Press both hands steadily on the armrests of the target seat, bend the knees slowly and sit down under control, never dropping down heavily
- Pulling on the affected arm or armpit when standing up, or trying to do all the movements in one go to save time
- Starting the transfer before the brakes are locked or the footrests are moved aside
Safety principles that must be kept: lock the brakes, move the footrests aside, clear clutter, never pull on the affected arm or armpit, and never hurry. Before every transfer the patient must first sit steadily and keep balance before standing up. These points are the basic requirements for lowering the fall risk and protecting the affected shoulder joint.
Two kinds of pivot transfer: stand-pivot and squat-pivot
The "turning" movement in the transfer is technically called a pivot transfer. Which method to use depends on whether the patient can stand briefly.
- Suits people who can stand briefly and steadily
- After standing fully upright, turn on the good leg as the pivot and sit down on the target seat
- Higher centre of gravity and a simple path, but needs enough standing balance
- Goal for progression: a smoother movement needing less support
- Suits people who cannot stand fully upright
- Stay in a half squat with the buttocks off the seat, keep the centre of gravity low and shift position in small steps
- More stable with a lower fall risk, as a transitional stage
- Once ability improves, progress gradually to the stand-pivot
The safety principles common to both are exactly the same: keep the centre of gravity low, move in small steps, slow the movement down and make good use of handrails. Which type to use and in how many steps to turn should be demonstrated and adjusted by the physiotherapist according to the patient's lower limb weight bearing and balance.
Training symmetrical weight bearing on the affected side
The most common hidden danger in independent transfers is the patient relying on the unaffected side to compensate over the long term, so that the unaffected arm and leg do all the movement and carry all the weight while the affected side hardly works at all. This approach seems safe in the short term, but in the long run it makes the muscles of the affected side waste and weaken further and balance worsen, and the transfer posture becomes more and more asymmetrical.
The response is to deliberately train symmetrical weight bearing on the affected side. Research shows that adding immediate visual feedback to sit-to-stand training (for example using bathroom scales or a sensor device to measure the distribution of weight between the feet and the symmetry of weight bearing) improves lower limb strength, balance and gait more effectively than conventional STS training (Hyun et al., 2021). The simplest way to practise at home is to deliberately put part of the body weight on the affected footwhen standing up, and even to use two bathroom scales to see whether the readings on the left and right are close, so that "symmetrical weight bearing" becomes a measurable, correctable goal.
Three home environment limits common in small flats in Hong Kong
Traditional textbooks often assume the patient is in a spacious room fitted with a full set of handrails. In Hong Kong, however, small flats, narrow bathrooms and older buildings or rented flats with no handrails are the real environment patients face. The following gives practical layout principles, which are general advice, for three common home situations. The aim is to keep to the safety red lines of "lock the brakes, hold on to something steady, keep the centre of gravity low and slow down" even in less than ideal spaces. The specific adjustments to the environment should still be assessed and guided on site by a physiotherapist according to the patient's real ability.
Situation 1: the bathroom is too narrow, so the patient can only turn towards the affected side
Toilet transfers are the most frequent situation in daily life and also the one with the highest fall risk. The ideal is of course to turn towards the unaffected side, but a small bathroom in Hong Kong often leaves the patient no choice. Because of the relative positions of the door, basin and toilet, the patient may only be able to turn towards the affected side. In practical training, both directions, unaffected and affected, must be practised, and the patient should never practise only the easier side.
| Direction of entry | Before entering the bathroom, think clearly about which hand can hold a support once inside. As far as possible arrange for the unaffected hand to be next to the handrail on the wall beside the toilet. If the position of the door means the affected side ends up against the wall, work out beforehand what can be pressed for support, such as the edge of a sturdy basin or a solid wall. |
| Path to sitting | After standing steadily, use the leg that can support as the pivot and turn in small steps until the back faces the toilet. When the back of the lower legs touches the edge of the toilet, confirm the position is right before bending the knees, and sit down slowly and under control while holding the handrail. Never sit down at random before the position is confirmed. |
| Making up for the space | If space is limited and the patient can only turn towards the affected side, the centre of gravity must be kept lower (using the squat-pivot method more), the steps must be smaller and the speed slower, and at least one hand must hold a reliable support surface all the way through. |
| Floor and height | Remove rugs from the floor and wipe up water to avoid slipping. A raised toilet seat can also be used to reduce the depth of the squat and the difference in height for sit-to-stand, so that getting up and down in a narrow space takes less effort and is easier to control. |
Situation 2: not enough room beside the bed to place the wheelchair at 45 degrees
Standard transfer teaching suggests placing the wheelchair at 30–45 degrees to the edge of the bed and close to the unaffected side. In Hong Kong bedrooms, however, one side of the bed is often close to the wall and the foot of the bed faces the wardrobe, so there is no room to place it at 45 degrees. In this case, the following can be considered.
Workarounds for positioning
- First make sure there is enough room for the wheelchair on the unaffected side. It is better to move the bedside cabinet or clear clutter for the time being to leave space on the unaffected side as the direction of transfer
- If the space is really too narrow and the wheelchair can only be placed flat against the bed (at 90 degrees), reduce the angle of each turn, take more small steps and complete the turn in several goes, and never force it in one step
- A mattress that is too soft or a bed that is too low makes sit-to-stand harder. The patient can first move to a firmer position at the edge of the bed, or put a firm pad on the mattress, to give a steady point of support when getting up
- Before the transfer, the brakes on both sides of the wheelchair must be locked and the footrests folded or moved aside. However narrow the space, this step can never be left out
Common mistakes
- Forcing a turn towards the affected side to fit the position of the wheelchair, with no handrail to support, which most easily leads to losing balance and falling towards the affected side
- A clear difference in height between the bed surface and the wheelchair seat but still forcing the transfer across. The right way is to adjust the two to about the same height first, or to complete the transfer in stages
- Not moving the wheelchair footrests aside, so that the patient trips or misses a step when turning
- Wanting to do it all in one go to save time, turning in a hurry before standing fully steady
Situation 3: no handrails at home
Many older buildings and rented flats cannot have fixed handrails fitted. In this kind of setting, the key to safe transfers is to "scan" by eye before moving for a route that has things to support, confirming which sturdy surfaces that will not move and can take body weight are available to press on along the way. This is a temporary measure that fits the limits of the environment and cannot replace proper safety handrails.
- Before transferring, confirm for each step a sturdy surface where the hand can press steadily, for example a solid wall, a sturdy window sill, or the edge of heavy furniture fixed to the wall with screws
- Choose the shortest route needing the fewest turns, so that there is something to hold on to at every moment during the movement
- Keep the floor clear, dry and non-slip, and make sure there is enough light, to reduce the chances of losing balance and having to rely on the hands alone to save the situation
- Treating a chair with wheels, an unsteady bedside cabinet, a towel rail or a wall-mounted shower hose as a handrail and pressing on it for leverage
- Pressing on furniture that is not fixed and can easily move or tip over to stand up
- Forcing a transfer alone in a space with no sturdy support at all
Temporary support cannot replace proper handrails. Using a wall or the edge of furniture for leverage is only a transitional measure. The positions for fixed safety handrails and home accessibility modification work must be assessed by a professional, and that is the way to lower the fall risk in the long term. For information on choosing rehabilitation equipment such as handrails and raised toilet seats, see home rehabilitation equipment for stroke. Bathroom and toilet modification, and the analysis of movements in activities of daily living (ADL), are in the field of occupational therapy; for details see occupational therapy after stroke and retraining activities of daily living (ADL) after stroke. In addition, the effect of cognitive impairment or unilateral spatial neglect on transfer safety should be assessed and handled by the occupational therapist.
The step-down ladder: from "maximum assistance" gradually to "independence"
Independent transfer is not a yes-or-no matter of "can or cannot" but a step-down process in which the level of help is reduced, from needing the maximum help at first to being done entirely by the patient. Clinically, a patient's transfer ability is often described by "how much help is needed". It is set out below as a practical path of progression (this is general advice and not a fixed timetable). A patient does not move up simply by accumulating enough practice time but must meet the ability criteria for that stage and have it confirmed by the therapist before help is withdrawn and the next stage begins.
- 1Level 1 · Maximum assistanceMost of the sit-to-stand and turning movement depends on someone holding the patient, and the patient puts in little effort alone. The focus at this stage is to feel the right direction of movement with someone's help, and to lay the foundation of sit-to-stand and sitting balance first (see above). At this stage it is not yet suitable for the patient to try the complete transfer alone.
- 2Level 2 · Moderate assistanceThe patient can do the forward lean and standing movements of sit-to-stand alone, but still needs someone to steady the pelvis or guide the direction while turning and sitting down. At this stage the patient should begin deliberately practising symmetrical weight bearing on the affected side, so as to rely less on the unaffected side to support the whole body.
- 3Level 3 · Minimal assistance / light touchThe whole transfer towards the unaffected side can basically be done by the patient alone. Another person only needs to give a light touch as a cue, or stand by ready to protect, mainly to stop the patient losing balance rather than to support directly. At this stage, training in transfers towards the affected side and in narrow spaces can begin.
- 4Level 4 · Supervision (no contact)Another person only needs to watch from beside the patient without physical contact, and the patient can safely complete a stand-pivot or squat-pivot transfer towards both the unaffected and the affected side, and can carry out safety steps such as locking the brakes, moving the footrests and holding the armrests alone. This is the key stage before fully letting the patient do it independently.
- 5Level 5 · IndependenceIn a familiar environment that has been set up properly (brakes locked, handrails or a reliable support surface in place, the floor clear of clutter and dry), the patient can reliably and safely complete the whole transfer between bed, wheelchair and toilet alone, and can also cope with the narrow bathroom and limited space beside the bed at home.
The criteria for progression (rather than counting weeks) broadly include: being able to complete sit-to-stand steadily, being able to bear weight safely on both feet, the affected side being able to share the body weight, being able to manage transfers in both the unaffected and affected directions with ease, and being able to carry out safety steps such as locking the brakes and moving the footrests unprompted. Incidentally, "how much time is needed to reach independence" really varies from person to person. The subacute stroke study mentioned earlier showed that, grouped by starting ability, the time to reach independent transfer ranged from about 4.6 weeks to 13.3 weeks (Kitamura et al., 2024). Because each person starts from a different point, the course of rehabilitation naturally differs, so real ability and not calendar time should be the measure.
The therapist must decide when help is reduced.Whether help can be reduced at each stage should never be guessed by the patient or family. Only after the physiotherapist has professionally assessed the patient's weight bearing, balance and quality of movement in transfers should help be withdrawn step by step. Readers can refer to the matching rehabilitation programme by severity for the lower limb according to the patient's ability: lower limb physiotherapy after a moderate stroke, lower limb physiotherapy after a severe stroke. For the part where the carer provides help throughout (the holding techniques of levels 1 to 3), see the guide for stroke carers.
Summary of transfer techniques and fall prevention measures
Finally, one core idea needs to be made clear: failed transfers are the main source of falls after the patient is discharged. Stroke survivors living in the community have a high risk of falling after discharge. About 14% had a fall in the first month after discharge, and the chance of a fall in any single month was about 11%, with the bathroom and toilet the places where accidents happen most often (Wagner et al., 2009). In other words, safe independent transfer technique together with proper arrangements in the environment is the key to lowering the risk of falls in these settings.
This page mainly covers falls situations and movement techniques that are directly related to stroke hemiplegia. For fuller balance training and fall prevention strategies, see the overview of balance and fall prevention after stroke. For general fall prevention information for older people (not stroke patients), see balance and fall prevention exercise.