This stage is characterized by progressive weakness and deterioration of mobility and endurance. The patient uses a wheelchair when out of bed, and arm muscles may exhibit moderate or severe weakness. Transferring the patient to and from a wheelchair becomes a major effort, and a lift may be necessary. Patients become unable to move themselves in bed; thus, frequent repositioning and skin care by the caregiver are necessary. Pain may become a major problem in immobilized joints and needs to be addressed in the overall treatrnent plan. Pain is addressed according to the pathophysiology of the problem causing the pain.