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What does training functional movements follow?
- - a thorough assessment of mm length, strength, spasticity
- - obs determine what is over active and what is underactive and functional task analysis allows us to determine the missing compnents of the task
- - these comp are retrained concurrently withany specific mm or jt treatments
What are common adaptive behaviours for rolling?
- - wriggling instead of turning
- - pulling with intact arm
What are the components to activate and retrain for the shoulder and arm to reach across the body?
- - protraction, horizontal adduction of shoulder and arm to reach across body
- - active practice in supine or sidelying
- - for added awareness, activation and control use vision to attend to affected body parts, handle more firmly, counter- pressure at shoulder
- - an air- splint may be used for awareness and support during early practice of activities
- - if neglect is severe may need to remind pt and teach pt to lift arm across body if motor return is poor
What are the components to activate and retrain lower limb?
- 1) bend ur leg using hip and knee flexors- active practice of hipflex, using vision
- 2) place foot on bed and push through foot to extend hip and roll pelvis forward- practice hip ext (sidelying), pushing into the therapist thigh, use compression, mirror for added awareness
- 3) other techniques for activation, awareness and control include- sweep tapping/ finger stretch gluteals
- - tactile/ stretch stimlation abs for stabilisation (supine lying)
- 4) flex and add leg across body using momentum to finally roll with whole body
What are the componenets to activate and retrain with bridging?
- 1) practice hip ext as above
- 2) bend up both legs using hip and knee flexors (assist affected side if necessary)
- - may need to support feet on bed for stable base and compression from knee towards heel for soleus activation (bridging)
- 3) push down through both feet, extend hips and lift bottom off bed
- 4) bridge and move sideways across bed
What are the common adaptive behaviours for sit up over edge of bed?
- - rotation and flexion of neck forward
- - excessive pushing up on intact arm
- - hooking intact leg under affected leg
- - falls backwards
What are the components of lateral neck flexion you can retrain for sit up over edge of bed?
- - manually lift head and then eccentric lowering of head
- - practice active lateral flexion
- (progress to forward flexion and rot from supine)
What are the components you can retrain for sidelying to sit over edge of bed?
- - lift head, shoulders (lateral flexors), and lean up on unaffected elbow, lower to bed
- - repeat and push through hand
- - position flexed legs close to edge before starting, then guide and lower legs over edge of bed
- - actively flex and lower legs over edge during sitting up
- - actively assist with affected arm or position limb and assist pt to through arm (elbow extensors, scapular and G/H stability required)
What are common adaptive behaviours of sitting?
- - shifting onto the unaffected/ less affected buttock in sitting
- - wide BOS ie both hips externally rotated or feet/ knees too far apart in sitting
- - voluntary restriction of movement ie pt holds himself stiffly and holds breath
- - pt leans forward or backwards when the task requires the body weight should be shifted sideways
- - use of arms ie grabbing for support, holding arms out of sideways or forward, on minimal shift in COG
- - avoiding threat to balance ie reducing movement, speed, minimising distance reached
What practices can you use to help pt with alignment and holding for sitting?
- - handling for safety/ correction of posture/ place feet on stool
- - practice active holding of correct posture
- - positioning for arm (pillow, extended arm etc)
- - weight bearing through forearm, or hand (scap, GH and elbow stabilisers progressively activated) to maintain length of mm ( may apply air splint at elbow if required)
- - eliciting mm activity: ext for upright posture, abs for stabilization, lower limb stabiliser (load affected leg)
- - for added activation of abs practice bracing, add hip/ knee flexion, then bracing plus bridging (supine lying)
- Use mirror for active correction
- - if pushing pt use a more structured envt
What postural adjustemnts and reactions can you use to help train a pt in sitting?
- Internal perturbations:- turn head, body
- - reaching forward and up (hip flexion, trunk ext)
- - reaching forward and down (controlled flexion- eccentric activity)
- - reaching laterally (lengthen and shorten sides)
- - reaching backwards (rot and ext)
- - practve functional tasks in sitting
- - reach with two hands for objects on stool or floor
- External perturbations:- for writing, placing and equilibrium responses
- - manual displacement
- - use of equipment for surface instability
What are common adaptive behavious for standing and sitting down?
- Pre-extension phase:- weight bearing particularly through intact side- due to loss of strength, dexterity of trunk and leg mm of affected side as well as intact foot nback, affected foot forward because of weak hamstrings on affected side
- - Wide BOS- at knees and/or feet due to poor balance
- Extension phase:- falls backwards- due to shoulders not moved far enough forward and or moved forward slowly as well as knees not mved forward
- - pushes through arms- to compensate for weak leg mm and loss of momentum
- - weight bearing through intact side- due to loss of stenght/ dexterity of hip/ knes, ankle mm of affected side, as well as intact footback, affected foot forward because of weak hamstrings on affeted side
- - final alignment flexed- due to hips and knees not extended around 0 degrees when standing
How can we improve hip ext, abduction and trunk stabilisation for standing up and sitting down?
- - sidelying and brige over edge of bed for more selective activation of gluteals, pushing through foot on stool to practice inner range control
- - bridgingg with rhythmical stabilisation
- - theraball work
- - remove hand in sidelying, for added abduction control
- - add compression, knee to foot for awareness
- - sweep tap, finger stretches etc along verbal cuing for added activation
How can we improve knee ext for standing up and sitting down?
- - elicit active contraction in quads in supine or sitting
- - eccentric/ concentric contraction of quads with compression through heel (mimicking stance phase of gait) in half lying and sitting
- - add sweep tapping, FES to activate and enhance feedback in extension
What do you need when preparing to stand from sitting?
- - approproate sitting position and control of sitng balance
- - practise foot placement
- - practise forward lean (flexion at hip) with eret trunk
- should try mental and verbal rehearsal of task
What can you use when practising sit to stand?
- Practise part stand
- - stand fom higher chair (progress to lower)
- - even weight distribution (limb load monitor, scales)
- - add compression for awareness
What are some common adaptive behaviours in balance standing?
- - wide BOS- feet to far apart or one or both hips externally rot
- - voluntary restriction of movement ie pt holds himself stiffly and holds breath
- = pt shuffles feet instead of making adjustments with appropriate body segments
- - pt takes a step prematurally ie as soon as COG moves
- - pt flexes at hips instead of DF at ankles in reaching forward and moves trunk instead of hips and feet when reaching sideways
- - pt lean forwards or backwards when the task requires the body weight should be shifted sideways
- - use of arms ie grabbing for support, holding arms out to sideways or forward, on minimal shift in COG
- - shifting on the unaffected leg
- - avoiding threat to balance eg reduced movement speed, minimising distance reached
How can you help a pt with alignment and postural holding in balanced standing?
- - correct alignment, practice holds
- - practice weight shift, lateral pelvic shift and even weight bearing (hip abductors)
- - practice inner range holds hip ext (may use splint on knee)
- - practice inner range holds knee ext without locking knee
- - practice small knee bends/ ext for inner range control
- - progress to stpe standing, narrow base
- - use table,rail etc as required to minimse pushing
- - use vdeo feedback for increase awarenes of problems
Internal/ external perturbation used in standing (balance)
- - use verbal cues, then more automatic responses
- - turn head, trunk
- - reach in all directions, including overhead and to floor as more stable
- - facilitate ankle strategy form wall, then open space
- - facilitate hip strategy
- - facilitate stepping reactions in all directions