Advances in Physiotherapy 2002; 4:136–144

Case StudyEffects of Staff Training in Natural Mobility:A Long-term Follow-upKRISTINA KINDBLOM-RISING1, ROLF WAHLSTROM2 and CHRISTINA H. STENSTROM3

1Gnesta Primary Health Care Center, Gnesta, Sweden, 2IHCAR Department of Public HealthSciences, Karolinska Institutet, Sweden, 3Division of Physiotherapy, Neurotec Department,Karolinska Institutet, Huddinge, Sweden

in working habits were few, but re-dressed the number of transfer methodsAbstracttained, and comments indicated that thethe staff used, whether they changedtreatment of the patients had changed.The aim of this study was to evaluate their use of methods, how the strain of

work was affected, and how satis�edthe effects of a half-day course in Natu- Natural Mobility training appears to bea useful complement to the patient-ral Mobility, which is an interactive in- they were with their way of assistingtransfer methods used today, by involv-struction method in patient-transfer. A patient-transfer . The results showeding physiotherapist’s tacit knowledge inthat sixty-eight percent had changedphysiotherapist communicates her tacit

knowledge to caregivers, who learn their use of methods and the change the training of health care staff.remained one year after the course. Thehow to understand and improve verbal

KEY WORDS: Attitude – instruction –strain experienced was signi�cantly re-and non-verbal communication to getinteraction – patient-transfer – peda-patients move themselves. Two hundred duced 4–5 months after the course and

this reduction was retained one year gogy – physiotherapy – role-play –and twelve caregivers responded tothree questionnaires before the course staff education – tacit knowledge.later. Work satisfaction showed a sig-

ni�cant increase; which was retainedand 4–5 months and one year after thecourse respectively. The questions ad- one year after the course. The changes

INTRODUCTIONLifting-related injuries are a problem in health andmedical care, and they often occur in the patient-transfer process (1–8). Patient-transfer refers to aworking method for caregivers, when helping dis-abled patients in and out of bed, from wheelchair tobed, from bed to wheelchair, from sitting to standingand standing to sitting. To reduce the strain onthemselves when moving patients, the staff need tolearn proper working postures and techniques (howto stand, how to hold the patient, and how to movethe center of gravity in the body). Several technicaland manual methods are being used in health care(1,4,9–13). The most frequently used method fortransferring a patient is the manual lifting technique,whereby two persons lift a patient under the arms,although this is not recommended and it also de-mands more physical effort than other methods (4).

Giving instructions to the patient is another pa-tient-transfer method, which also reduces physicalstrain on the staff. Physiotherapists use verbal and

non-verbal communication in contact with patientsduring a transfer. Non-verbal communication isde�ned here as the body communication betweentwo persons. The manner of assisting (14) and thetacit knowledge (15) that physiotherapists use areabout interaction with the patient to strengthen his:her trust in the body (14,16). Body trust here meanstrusting the body’s ability and �nding body securitywhen moving. Receiving and transferring bodyknowledge is central in the physiotherapy profession.Part of this knowledge is tacit because it lies in theperiphery of focus in the situations where it is used(17). The tacit knowledge in this study refers to howthe physiotherapist receives and transfers bodyawareness, trust in body ability, and body security inthe transfer act as well as transferring inspiration tothe patient. Part of this tacit knowledge can bearticulated (15,17). Depending on the quality of in-teraction the patient actively participates in the trans-fer to different extents (18). This knowledge has notreceived much attention in the training of health care

© 2002 TAYLOR & FRANCIS ISSN 1403-8196136

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.

Advances in Physiotherapy 4 (2002) EFFECTS OF STAFF TRAINING – LONG-TERM FOLLOW-UP

staff. Physiotherapist’s verbal and non-verbal com-munication as a method in patient-transfer have beenneglected in favor of working postures and tech-niques, and have not been well represented in theliterature.

Many studies have been carried out to developworking methods that are more ergonomically cor-rect for the staff (1,2,4,19). Some studies have com-pared different transfer methods to �nd those thatcause the least strain, while others have reduced thenumbers of moves and yet others have focused onhow workplace accidents can be reduced throughnew attitudes (3–5,20). One study emphasized thatthe staff must learn not to move patients whenpatients can move themselves in a better way (6).

Humans convey their perceptions of others andthemselves through attitudes and mostly via non-ver-bal communication (21–25). Insecure caregivers con-vey insecurity to their patients without using words.When feeling secure, security is conveyed.

Several studies have identi�ed details of caregivers’natural movement patterns with patients as well aswith healthy individuals. These movement patternsare used by physiotherapists as standards to whichthey compare the movement pattern of a patient.Many have investigated how we stand up with refer-ence to the different movement sequences, musclework, body weight shift, and force distribution onthe joints (26–35). Studies have also been under-taken on how we turn when we are lying down, andon how we sit on the edge of the bed (36–38).

The aims of several of these studies were to de-velop models to aid in teaching patients about howto transfer. Most of the studies emphasized thatmaintaining patients’ daily functions is importantbecause they are vital to independence and self-re-liance. One task of a physiotherapist is to inspirepatients’ con�dence for maintaining daily activities(14). Engels et al. (2) report that health care staffhave problems with using the patients’ capabilities.The verbal and non-verbal communication betweenpatient and caregiver can be decisive in determiningwhether patients can use and dare to use their ownability. It is probable that staff move patients pas-sively more than is necessary if they do not receivetraining in how to inspire patients to use theircapabilities.

Natural Mobility is an interactive instructionmethod (39) that is used in the transfer of disabledpatients. The basis is human spontaneous movingbehavior and the communication of knowledge bycaregivers to patients about moving oneself. Duringthe course the physiotherapist’s tacit knowledge istransferred to the caregivers through verbal and bodyexperiences. The caregivers experience throughmovements and role-play what their body signals tellthem in different situations. By comparing what feelscomfortable, uncomfortable, secure, insecure, andfrightening (40,41) caregivers receive answers fromtheir body. This helps them to increase their abilityand trust in their own body as well as for thepatients. The aim of the method is to reduce thephysical burden on the staff and help patients main-tain daily activities. It is a method of communicationand pedagogy to facilitate learning and understand-ing by training staff (39).

The purpose of this study was to investigatewhether working habits changed and were retainedafter one year, how the strain of staff work wasaffected, and whether satisfaction with patient-trans-fer was affected after a half-day Natural Mobility-training course.

MATERIALS AND METHODSSubjectsTwo hundred and twelve persons from different mu-nicipalities and county councils in Sweden partici-pated in Natural Mobility-training courses. Aphysiotherapist (K.K.-R.) was the course leader. Thedistribution of professional categories was 1%nurses, 23% licensed practical nurses (LPN), 17%nurse’s assistants, 24% home-help service staff, 17%physiotherapists, 13% occupational therapists, and8% other staff (including personal assistants, physio-therapy assistants, and occupational therapy assis-tants). The average age was 41 years (range 19–62),96% were women and the average time of work inhealth and medical care was 13 years (range 1–35).

Natural Mobility courseHow we move spontaneously as healthy individualsis the basis of this course. The knowledge is trans-ferred through experience-based learning, whichmeans that caregivers learn and understand by doing

137

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.

K. KINDBLOM-RISING ET AL. Advances in Physiotherapy 4 (2002)

various moving tasks spontaneously like standing up,sitting down, turning over in bed, moving higher upin bed, moving in a supine position to the edge of thebed, sitting up on the edge of the bed, lying down inbed, moving from bed to wheelchair and fromwheelchair to bed. Participants practise these move-ments several times and with a certain speed to keepthe spontaneity and con�rm the consciousness of themovement. They also assume the roles of patientsand staff (24) and experience through their bodieshow spontaneous movements change when we arefrightened or tired. The ‘‘staff’’ verbally and non-ver-bally instruct the ‘‘patients’’ to do the same movingtasks as above. They also experience through theirbody how patients stand up when caregivers offertheir hands to assist, in comparison with patientsusing their own hands.

All participants move themselves while imaginingthat they have various disabilities, always asking,‘‘How do I do this?’’ and ‘‘How does it feel?’’Participants learn by practising, feeling the responsesthrough body awareness (40) and watching othersmove themselves. To enable patients with severedisabilities to manage to move themselves the staffneed to know how the move should be done andwhat strength is needed when patients change thecenter of gravity in their bodies. With a higher degreeof disability, a greater level of precision is needed inperforming the transfer action (26,27,29–31,34).

Patients who at �rst cannot manage to move bythemselves get support, which enables them to doone action segment at a time. This support is in theform of hand pressures in the direction of movement(39). Course participants increase their body aware-ness through training (42,43) to achieve safety intheir body, as well as helping themselves and thenthe patient to make positive visualizations abouttrusting their body ability (14,16). These differentaspects are part of the physiotherapist’s tacit knowl-edge of communication (15).

Staff trainingThe course was given 13 times during a period fromSeptember 1995 to October 1996. The content, orga-nization, and format of the classes were the same.Each participant was given one course, and each

course lasted for half a day. There were between 10and 24 participants each time. Follow-ups, i.e. re-freshers of the course method, were to take place atthe respective workplaces and were usually led by thephysiotherapist:occupational therapist in charge whohad also participated in the course. The content andextent of the follow-ups were arranged individuallyat each workplace.

QuestionnairesAll 212 (100%) persons participated in the courseand were given three questionnaires, before, 4–5months after, and one year after the course. Thedropout for the third questionnaire was 78 persons,30 of whom were taking parental leave, were inother training, were on vacation, had changed work-places, or had retired. The rest (48 persons) of thedropout do not differ in demographics compared tothe study subjects. The interpretation of the dropoutwill be discussed later.

All three questionnaires contained the same ninebaseline questions about the participant’s gender,age, profession, experience, how many different pa-tient-transfer courses the participants had attended,and which patient transfer methods they used. Addi-tional questions were asked on how they felt aboutthe perceived workload in patient-transfer, to whatextent the same patient-transfer method was used,and how satis�ed they were in general with patient-transfer tasks. The two last questionnaires containedthree and six more questions respectively. The addi-tional questions in the second questionnaire asked if:

The staff had received help with follow-up afterthe courseStaff members had changed anything in theirworking habitsThe changes in working habits had beenmaintained.

In the third questionnaire the following open-ended questions were asked:

What changes had been madePositive experiences of the Natural MobilitymethodNegative experiences of the Natural Mobilitymethod

138

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.

Advances in Physiotherapy 4 (2002) EFFECTS OF STAFF TRAINING – LONG-TERM FOLLOW-UP

TABLE I: Reported distribution of transfer method choices before, 4–5 months after, and one year after theNatural Mobility training course

Before 4–5 months 1 year

n¾212 n¾167 n¾134

n (%) n (%) n (%)

4 (2) 56 (33)Natural Mobility (as single method) 41(30)4 (2) 74 (44) 68 (51)Natural Mobility (combined with others)8 (4) 130 (78)Natural Mobility (single and combined) 109 (81)

Other methods (single and combined) 171 (81) 30 (18) 18 (13)Durewall (as single method) 13 (6) 1 (0.60) 1 (0.70)

8 (4) 1 (0.60)Bobath (as single method) 07 (3) 0 0The Stockholm training concept (as single method)5 (2) 0Roxendal:Wahlberg (as single method) 0

Own method (as single method) 26 (12) 11 (6) 9 (7)Another method (as single method) 74 (35) 10 (6) 5 (4)

33 (15) 7 (4)No response 7 (5)

The questions were valid with respect to the con-tents of the course, the experience of the courseleader, and the literature. Before use they were testedon a different group of 20 health care staff, and onequestion was rephrased. Three questions were openended and the others were answered on verbal ratingscales and on Visual Analog Scales (VAS 0-10). Allthree questionnaires were con�dential. The �rst wasdistributed, answered, and returned to the courseleader immediately before the training took place.The local organizer of the course distributed, col-lected, and mailed the second and third question-naires to the course leader.

Statistical analysisOrdinary descriptive statistics was used to presentthe distribution of outcome variables. The WilcoxonMatched-Pairs Signed-Ranks test was used for evalu-ation of the Visual Analog Scale (VAS) to analyze thedifferences between the responses at the differentstages of time.

RESULTSAll 212 (100%) persons responded to the �rst ques-tionnaire. The second questionnaire was answered by167:212 persons (79%). The response rate for thethird questionnaire was 134:212 persons (63%).Eight percent of the 212 participants had never had

training in patient transfer before the course, 17percent had received training on one occasion, 22percent on two, 14 percent on three, 37 percent onmore than three occasions and two percent did notanswer this question.

A variety of patient-transfer methods, includingNatural Mobility, were used before the course (TableI). Changes in working habits took place after theself-perceived acquisition of knowledge in NaturalMobility 4–5 months after the course (Table II) and

TABLE II: Answers to the question ‘Did you changeyour working habit after the course?’ given 4–5months and one year after the Natural Mobilitytraining course

1 year4–5 months

n¾134n¾167

n (%) n (%)

98 (71)113 (68)Change29 (24)No change 48 (29)

6 (3) 7 (5)No response

167 (100)Subtotal 134 (100)

45 (21) 78 (37)Dropouts

212212Total

139

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.

K. KINDBLOM-RISING ET AL. Advances in Physiotherapy 4 (2002)

TABLE III: Answers to the question ‘If youchanged your working habit after the course, didyou maintain the changes?’ given 4–5 months andone year after the Natural Mobility training course

4–5 months 1 year

n¾167 n¾134

n (%) n (%)

40 (24) 30 (23)Maintained all71 (42) 62 (45)Maintained some3 (2)Not maintained 4 (3)53 (32)No response 38 (29)

167 (100) 134 (100)Subtotal

Dropout 45 (21) 78 (37)

212Total 212

not receive any help with follow-up after 4–5months, after a year the �gure was 57 percent. Theinternal no response rate was 14 percent both 4–5months and a year after the course.

Seventy-two persons (54%) of 134 commented onwhat they had changed in their working habit.Twenty-two persons gave patients more opportuni-ties to move themselves. Instructions were used morefrequently by ten persons, they communicated exten-sively and more explicitly with the patient. Tworespondents had changed the way they gave patientssupport for turning in bed, four had changed theprocess for moving from lying down to sitting on theedge of the bed, and four the process of transfer fromwheelchair to bed. Seventeen reported that they hadbecome more knowledgeable about the body.

Physiotherapists and occupational therapists madecomments on the questionnaires that included:

I have applied more natural moving patterns andmore instructions in training staff.The instructions have become clearer thanpreviously.I have become more pedagogical in myinstructions.Staff members can try more themselves.Patients can help more than they did before.I think more about how we actually move in anatural way.I have learned to think in a healthier way.My own consciousness has been affected.

Ninety-six (72%) of 134 persons from all profes-sional categories made comments on what theythought was positive about Natural Mobility forexample:

were retained after one year (Table III). The per-ceived workload in patient transfer was signi�cantlyreduced 4–5 months and one year after the course.Also general satisfaction with patient-transfer workshowed a signi�cant increase and this was retainedone year later (Table IV).

Seventeen percent of the 167 participants reportedafter 4–5 months that they had received help from aphysiotherapist with follow-up. After one year 21percent of the 134 participants had received thishelp. Five percent received help from an occupationaltherapist after 4–5 months and after one year sevenpercent had received this help. Four percent receivedhelp from both a physiotherapist and an occupa-tional therapist after 4–5 months and after one yeartwo percent had received this help. Sixty percent did

TABLE IV: Answers to questions about experienced workload and degree of satisfaction in patient-transferwork before, 4–5 months after, and one year after the Natural Mobility training course

IIIII Statistica l signi�canceI

1 year I vs II I vs IIIBefore 4–5 months

n¾212 md (range) PPn¾134 md (range)n¾167 md (range)

B0.013.50 (0.50–9.60)3.30 (0.00–9.70) B0.014.45 (0.00–10.00)Work loadSatisfaction 4.60 (0.00–10.00) 5.20 (0.00–10.00) 5.00 (0.50–9.60) B0.05 B0.05

140

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.

Advances in Physiotherapy 4 (2002) EFFECTS OF STAFF TRAINING – LONG-TERM FOLLOW-UP

It’s kinder to the body.There’s less strain on the back.One learns not to lift unnecessarily.It’s an aid to self-help.Heavy lifts are avoided by having patients helpthemselves.Patients can do more than you think.Patients gain self-respect when they realize theycan help.There has been an increase in staff:patient co-operation.The patient is more activated.

Thirty-one participants (23%) of 134 made com-ments on what they felt was negative in NaturalMobility. The most frequent comments were that themethod did not work for everyone, that it wasdif�cult to use with demented patients, that it tooklonger, and that it was dif�cult to get the patient toco-operate.

DISCUSSIONThe study showed that the caregivers, who hadchanged their working habits after the half-daycourse, also retained the changes wholly or partiallyone year later. Different caregivers changed differentactions and also made different numbers of changes.In this patient-transfer course as in other trainingactivities there seems to be a limit to the number ofchanges that persons can make.

There is often a dif�culty in presenting the resultof long-term studies because of the large number ofnon-respondents. If the dropouts are included thereis a risk that this may be understood as if thenon-respondents did not change their workinghabits. In this study the choice was made not toinclude the dropouts in the result but present them inTables II and III. This decision was guided by theaim of the study, to investigate whether changes inworking habits could be retained or not. In Table IIIthe no response rate is very high because those thatdid not change their working habits did not answerthis question.

Natural Mobility was used as a single method orcombined with others by 109 persons (81%) oneyear after the course, but 98 persons (71%) experi-enced having changed their working habits. When

changes are small they may have been ignored. Thecomments in response to the open questions indi-cated that attitudes towards and treatment of thepatients had changed.

The reason for not using work-related injuries forevaluation is related to previous studies (7,8). Once alower back symptom develops, it may not be cured,even by the introduction of a new, well-developedwork technique. Work-related injuries are in�uencedby many different factors in life and it is thereforenot advisable to conclude that such injuries are theresult of a training intervention.

In most of the studies referred to, as in this one,there is unfortunately no information on how manydetails:actions each participant had changed. In re-sponse to the question, ‘‘What did you change?’’most persons mentioned 1–3 actions. It would havebeen interesting to know how many actions staffmembers managed to change after one trainingcourse, and what they would accept:reject in train-ing, and why. The way patient-transfer is usuallyevaluated might give a false picture of what healthcare staff really change.

The participants who answered the second andthird questionnaires had the same place of workduring the evaluation period. However, they did notseem to have attended any patient-transfer coursesduring the year of the questionnaire evaluation. Mosthad not received help at their workplace in practicalfollow-up of the course. The refresher courses didnot seem to relate to those who noted an improve-ment. There is no information about the quality ofthe follow-up, how it was carried out and why somany did not receive this help. If several participantshad received follow-up, it is possible that even morestaff would have dared to change their workinghabits. In the future, follow-up at the workplace willbe a part of the Natural Mobility training course. Itwould also have been advantageous if a controlgroup had been used. Another limitation of the studywas that the question ‘‘to what extent the samepatient-transfer method was used’’ was not clearlyformulated, and thus could be answered in differentways. Therefore it was excluded from the evaluation.It has been taken into consideration that the partici-pants may want to please, by answering more posi-tively than they actually think, which would also givethe result less validity.

141

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.

K. KINDBLOM-RISING ET AL. Advances in Physiotherapy 4 (2002)

The focus of the previously mentioned studies wasmore a comparison between different patient-transfermethods to �nd the best one (20), while later studiesseem to focus more on other matters like reducingback strain among nursing personnel (5), making achecklist where patient’s capabilities in patient-trans-fer are taken into consideration (2,6) as well asdeveloping new attitudes when on-the-job accidentsoccur (3).

There is only one previous study (39) that investi-gated how verbal and non-verbal instructions in pa-tient-transfer in�uence the staff’s working habits andtheir perceived workload and there is little writteninformation at all about verbal and non-verbal com-munications in patient-transfer. There is a need formore studies on how the physiotherapist’s tacitknowledge of communication can be used in theserespects to improve the training of health care staff.

The changes in working habits that were madewere few but important and wholly or partly re-tained one year after the course. The commentsindicated that attitudes towards and treatment of thepatients had changed. Natural Mobility courses canbe a complement to the patient-transfer methodsused today by involving the physiotherapist’s tacitknowledge in the training of health care staff.

ACKNOWLEDGEMENTSThe Research and Development unit in Sormland,Sweden supported this study. Special thanks to HansEriksson for help with the statistics, and to all partic-ipants for taking their time to answer thequestionnaires.

REFERENCES1. Best M. An evaluation of manutention trainingin preventing back strain and resultant injuries innurses. Safety Science 1997;25:207–22.

2. Engels J, Bransma B, van der Gulden J. Evalua-tion of the effects of anergonomic-educational pro-gramme. Int Arch Occup Environ Health1997;69:475–81.

3. Engkvist I. Events and factors involved in acci-dents leading to over-exertion back injuries amongnursing personnel. Work & Health 1997;30:1–28.

4. Garg A, Owen B, Beller D, Banaag J. A biome-chanical and ergonomic evaluation of patient trans-ferring tasks: Bed to wheelchair and wheelchair tobed. Ergonomics 1991;34:289–312.

5. Garg A, Owen B. Reducing back stress to nurs-ing personnel: An ergonomic intervention in anursing home. Ergonomics 1992;35:1353–75.

6. Hellsing A-L, Linton S, Andershed B, BergmanC, Liew M. Ergonomic education for nursing stu-dents. Int J Nurs Stud 1993;30:499–519.

7. Kemmlert K, OÈ relius-Dallner M, Kilbom AÊ ,Gamberale F. A three-year follow up of 195 re-ported occupational overexertion injuries. Scand JRehabil Med 1993;25:16–24.

8. Lagerstrom M, Hagberg M. Evaluation of a 3year education and training program. AAOHN J1997;45:83–92.

9. Dotte P. La Manutention des malades et dehandicapes. Paris: Maloine; 1986.

10. Durewall K. Durewall-Systemet. Studentcom-pendium in help and liftingtechniques for medicalservice (in Swedish). Goteborg: DS-tryckeri; 1993.

11. Durewall K. Durewall-Systemet. Principalcom-pendium (in Swedish). Goteborg: Typogra�a AB;1995.

12. Lagerstrom M, Johnsson C, Carlsson R, et al.Workshop in patient transfer techniques. In: Hof-mann F, Michaelis M, Stossel U, Symington I, edi-tors. Pro Health Care-3rd International Congresson Occupational Health for Health Care Workers.Edinburgh: Ecomed; 1999, 174–177.

13. Roxendahl G, Wahlberg C. Everyday healthcare – where hands meet. Lund: Studentlitteratur;1992.

14. Schon-Olsson C. Professional paradigm inphysiotherapy (in Swedish). Sjukgymnasten-Veten-skapligt supplement 1994; 2:4–10.

15. Polanyi M. The tacit dimension. London: Rout-ledge & Kegan Paul; 1967.

16. Hedlund L, Gard G. Trust your own body (inSwedish). Nordisk Fysioterapi 2000;4:75–81.

142

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.

K. KINDBLOM-RISING ET AL. Advances in Physiotherapy 4 (2002)

17. Kalman H. The structure of knowing can makeprofessional skills visible (in Swedish). Nordisk Fys-ioterapi 1999;3:99–103.

18. Lundvik-Gyllensten A, Gard G, Salford E, Ek-dahl C. Interaction between patient and physiother-apist: a qualitative study re�ecting thephysiotherapist perspective. Physiother Res Int1999;4:89–109.

19. Landewe M, Schroer H, van der Heide M.Only a hospital itself can make transfer trainingeffective. In: Hagberg M, Hofmann F, Stossel U,Westlander G, editors. Pro Health Care-2nd Inter-national Conference on Occupational Health forHealth Care Workers. Stockholm: Ecomed; 1995,346–349.

20. Nordin M, Andersson G, Grimby G. A calmerworking tempo using the lifting technique accord-ing to the Durewall-system (in Swedish). Sjukgym-nasten 1984;8:14–7.

21. Ajzen I. Attitudes, Personality and Behaviour.Milton Keynes: open University Press; 1988.

22. Benjamin L. Structural analysis of social be-haviour. Psychol Bull 1974;81:392–425.

23. Fast J. Body Language. New York: MIF; 1985.

24. Holm U. Empathy in the doctor-patient rela-tionship a theoretical and empirical analysis. Upp-sala studies in education, 1985; No 24.

25. Molcho S. Body Language ( in Swedish).VaÊ steraÊ s Ica-bokforlag; 1987.

26. Alexander N, Schultz A, Warwick D. Risingfrom a chair: Effects of age and functional abilityon performance biomechanics. J Gerontol1991;46:91–8.

27. Burdett R, Habasevich R, Pisciotta J, Simon S.Biomechanical comparison of rising from two typesof chairs. Phys Ther 1985;65:1177–83.

28. Hanke T, Pai Y-C, Rogers M. Reliability ofmeasurements of body center-of-mass momentumduring sit-to-stand in healthy adults. Phys Ther1995;75:105–13.

29. Ikeda E, Schenkman M, Riley P, Hodge A.In�uence of age on dynamics of rising from achair. Phys Ther 1991;71:473–81.

30. Millington P, Myklebust M, Shambes M.Biomechanical analysis of the sit-to-stand motion inelderly persons. Arch Phys Med Rehabil1992;73:609–17.

31. Nuzik S, Lamb R, VanSant A, Hirt S. Sit-to-stand movement pattern: A kinematic study. PhysTher 1986;66:1708–13.

32. Rodosky M, Andriachi P, Andersson G. Thein�uence of chair height on lower limb mechanicsduring rising. J Orthop Res 1989;7:266–71.

33. Schenkman M, Berger R, Riley P, Mann R,Hodge A. Whole-body movements during rising tostanding from sitting. Phys Ther 1990;70:638–48.

34. Wheeler J, Woodward C, Ucovich R, Perry J,Walker J. Rising from a chair: In�uence of age andchair design. Phys Ther 1985;65:22–6.

35. Wretenberg P, Arborelius U. Power and workproduced in different leg muscle groups when ris-ing from a chair. Eur J Appl Physiol 1994;68:413–7.

36. O’Neil, McCoy J, VanSant A. Movement pat-terns of adolescents rising from a bed. Phys Ther1993; 73:182–193.

37. Shumway-Cook A, Woollacott M. Motor Con-trol Theory and Practical Applications. Baltimore:Williams & Wilkins, 1995; 11: 257–267.

38. VanSant A. Rising from a supine position toerect stance. Description of adult movement anddevelopmental hypothesis. Phys Ther 1988;68:185–92.

39. Kindblom-Rising K. Natural Mobility evalua-tion of staff training in patient transfer (inSwedish). Sjukgymnasten-Vetenskapligt supplement1996;1:28–33.

40. Valaeyen J, Kole-Snijders A, Rotteveel A,Ruesink R, Heuts P. The role of fear of movement(Re) injury in pain disability. J Occup Rehabil1995;4:235–52.

143

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.

K. KINDBLOM-RISING ET AL. Advances in Physiotherapy 4 (2002)

41. Menzies I. The functioning of social systemsas defence against anxiety. The Tavistock Instituteof Human Relations. London: Tavistock Center1970.

42. Dropsy J. Live in ones body (in Swedish).Stockholm: Natur & kultur; 1987.

43. Mattsson M. Body awareness, applications inphysiotherapy. UmeaÊ University, Medical disserta-tions 1998; 1–106.

ADDRESS FOR CORRESPONDENCE:

Kristina Kindblom-Rising, RPT, MScGnesta Primary Health Care CenterNygatan 29SE-646 35 Gnesta SwedenTel.: »46-158-52443Fax: »46-158-52450E-mail: kristinakindblom@hotmail.com

Submitted 8 November 2001;accepted for publication 23 April 2002

144

Adv

Phy

siot

her

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Cen

tral

Mic

higa

n U

nive

rsity

on

11/0

4/14

For

pers

onal

use

onl

y.