PNF TECHNIQUES

• PNF IS A TYPE OF MOVEMENT THERAPY AND DERIVES ITS THEORITICAL BASIS FROM SHERRINGTONS STATEMENT

• INPUTS FROM PERIPHERAL NERVES AND RECEPTORS AFFECTS EXCITABILITY OF ALPHA MOTOR NEURONS & AMN ARE UNDER DIRECT INFLUENCE OF CEREBRAL CORTEX

• THEORTICALLY IT IS POSSIBLE TO MODIFY THE EXCITABILITY OF AMN THROUGH PERIPHERAL INPUTS IN A WAY THAT THE INFLUENCE OF CENTRAL MECHANISMS ARE REDUCED OR INCREASED

• PNF TECHNIQUE ORIGINATED BY HERMAN KABAT & CONTINUED BY MARGARET KNOTT & VOSS

• NEUROPHYSIOLOGICAL PRINCIPLES– ALL HUMAN BEINGS HAVE POTENTIALS

THAT IS NOT FULLY DEVELOPED– MOTOR DEVELOPMENT TAKES PLACE IN

CERVICAL CAUDAL DIRECTION OR PROXIMODISTAL DIRECTION

– EARLY MOTOR BEHAVIOUR IS DOMINATED BY REFLEX ACTIVITY & THE MOVEMENTS OSCILLATE BETWEEN FLEXION AND EXTENSION

• DEVELOPMENT OF MOTOR SEQUENCE OCCURS IN AN ORDERLY SEQUENCE– PROXIMAL STABILITY – SKILLED

MOVEMENTS OF DISTAL

• IMPROVEMENT IN MOTOR ABILITY IS DEPENDENT ON MOTOR LEARNING– VISUAL/AUDITORY/VERBAL & TACTILE

• FREQUENCY OF STIMULATION & REPETITIVE ACTIVITY ARE USED TO PROMOTE MOTOR LEARNNG & DEVELOPMENT OF STRENGTH AND ENDURANCE

• PRINCIPLES OF TECHNICAL APPLICATION

• APPROPRIATE POSTIONING• FREE MOVEMENTS

• MANUAL CONTACT• FACILITATE & GUIDE MOVEMENT• LUMBRICAL GRIP• EXTEROCEPTION/STRETCH/RESISTANCE/

TRACTION & APPROXIMATION

• STRETCH• FACILITATE & INCREASE THE POWER OF

WEAK MUSCLE

• PATTERNS (FOUR BASIC PATTERNS)• D1 FLEXION – FLEXION ADDUCTION• D2 FLEXION – FLEXION ABDUCTION• D1 EXTENSION – EXTENSION ABDUCTION• D2 EXTENSION – EXTENSION ADDUCTION

– COMBINATION OF UPPER LIMB• FLEXION OF SHOULDER WITH EXTERNAL

ROTATION• EXTENSION OF SHOULDER WITH INTERNAL

ROTATION• ABDUCTION WITH WRIST EXTENSION• ADDUCTION WITH WRIST FLEXION

• COMBINATION OF LOWER LIMB– FLEXION OF HIP WITH DORSIFLEXION– EXTENSION WITH PLANTAR FLEXION– ABDUCTION WITH INTERNAL ROTATION– ADDUCTION WITH EXTERNAL ROTATION

• TIMINGS

• OVERFLOW OR IRRADIATION

• MAXIMAL RESISTANCE

• AUDITORY CUES

• VISUAL CUES

STRENGTHENING TECHNIQUESI. REPEATED CONTRACTION

• NORMAL TIMINGS – GENERALISED WEAKNESS – STROKE– REPETITION OF PATTERN WITH FULL RANGE AGAINST

MAXIMUM RESISTANCE

• TIMING FOR EMPHASIS– PATCHY WEAKNESS– SPECIFIC COMPONENT IN A PATTERN IS WEAK– LMN CONDITIONS– PIVOT, HANDLE & STABILISING PART

• COMBINATION OF ISOMETRIC & ISOTONIC– MUSCLES ARE WEAK DUE TO RELATIVE LENGTHENING– EXTENSOR LAG – DUE TO RELATIVE LENGTHENING OF

QUADS DUE TO IMMOBILISATION OF KNEE IN FLEXION

• ISOTONIC CONTRACTION OF LENGTHENED MUSCLE (AGONIST)

↓• UP TO WEAK POINT OF MUSCLE

↓• ISOMETRIC CONTRACTION

↓• ISOTONIC CONTRACTON

↓• FACILITATES MUSCLE IN SHORTENED RANGE

& LENTHENS ANTAGONIST MUSCLE BY RECIPROCAL INHIBTION

II. SLOW REVERSAL• SHERRINTON PRINCIPLE OF SUCCESIVE

INDUCTION• STRONG ANTAGONIST IS USED TO

FACILITATE WEAK AGONIST PATTERNS• GROUP OF MUSCLE ARE WEAK

↓• ITS ANTAGONIST ARE MADE FOR MAXIMAL

CONTRACTION

↓• REVERSAL OF GRIP FOR WEAK AGONIST

CONTRACTION

• LENGTHENING TECHNIQUES– RELAXATION TECHNIQUES

• TIGHTNESS/HYPERTONICITY

PRINCIPLESI. WORKING ON HYPERTONIC MUSCLE

– PRINCIPLE OF MAXIMUM CONTRACTION FOLLOWED BY MAXIMUM RELAXATION

II. WORKING ON THE MUSCLE ANTAGONIST TO

HYPERTONIC MUSCLE– PRINCIPLE OF RECIPROCAL INHIBITION

• 1) CONTRACT RELAX (I ST PRINCIPLE)– PRINCIPLE IS THE CONTRACTION OF ANTAGONIST

MUSCLE IS BY ISOTONIC

• 2) HOLD RELAX (I ST PRINCIPLE)– CONTRACTION OF ANTAGONIST IS BY ISOMETRIC– PAINFUL CONDITIONS

• 3. RHYTHMIC INITIATION– RIGIDITY (PARKINSONISM)

– SPASTICITY (TRUNK)

• 4. SLOW REVERSAL – HOLD RELAX TECHNIQUE (II ND PRINCIPLE)– PRINCIPLE OF RECIPROCAL INHIBITION

– ANTAGONISTIC ISOMETRIC CONTRACTION → AGONIST ISOTONIC CONTRACTION

• MISCELLANEOUS TECHNIQUES– RHYTHMIC STABILIZATION

• RELAXATION AND STRENGTHENING

• CEREBELLAR LESIONS

BRUNNSTROM APPROACH

• MOVEMENT THERAPY DEVELOPED BY BRUNNSTROM (PHYSICAL THERAPIST)

• PRINCIPLES– ASSUMPTIONS

• IN NORMAL MOTOR DEVELOPMENT– BRAIN STEM & SPINAL CORD REFLEXES– INFLUENCED BY HIGHER CENTRES– PURPOSEFUL MOVEMENT

– STROKE – DEVELOPMENT IN REVERESE – USE OF PRIMITIVE REFLEXES– FACILITATES RECOVERY OF VOLUNTARY

MOVEMENT POSTSTROKE

– PROPRIOCEPTIVE/EXTEROCEPTIVE STIMULI ARE USED TO EVOKE DESIRED TONAL CHANGES

– RECOVERY OF VOULUNTARY MOVEMENT• MASS STEROTYPED FLEXOR/EXTENSOR

MOVEMENT PATTERNS

↓• MOVEMENTS WITH COMBINED PATTERNS

↓• DISCRETE MOVEMENT OF INDIVIDUAL JOINTS

↓• PRACTICE IN FUNCTIONAL

↓ • ENHANCES LEARNING PROCESS

• PRINCIPLES OF MOVEMENT THERAPY• TREATMENT PROGRESS FROM REFLEX TO

VOLUNTARY TO FUNCTIONAL• FLACCID → MOVEMENTS ARE FACILITATED

BY REFLEXES

↓• ASSOCIATED REACTIONS & USE OF

PROPRIOCEPTIVE & EXTEROCEPTIVE FACILITATION

↓• DEVELOPS MUSCLE TENSION IN

PREPARATION OF VOLUNTARY MOVEMENT• PROPRIOCEPTIVE – RESISTANCE• EXTEROCEPTIVE – TACTILE STIMULATION

• AS VOLUNTARY MOVEMENT IS GAINED – PATIENT IS ASKED FOR ISOMETIC CONTRACTION

↓

• ECCENTRIC CONTRACTION

↓

• CONCENTRIC CONTRACTION

• AS VOULUNTARY CONTROL IS GAINED FACILITATION IS REDUCED/STOPPED

• PRIMITIVE REFLEXES ARE DROPPED FIRST• EXTEROCEPTIVE ARE DROPPED AS LAST• NO PRIMITIVE REFLEXES ARE USED BEYOND

STAGE – 3

• EVALUATION• NO FACILITATION IS USED DURING

EVALUATION• EACH MOVEMENTS ARE PERFORMED IN

NORMAL LIMB & THEN IN AFFECTED LIMB• INSTRUCTIONS SHOULD BE GIVEN IN

FUNCTIONAL TERMS

– FLEXOR SYNERGY• TOUCH BEHIND EAR

– EXTENSOR SYNERGY• REACH OUT TO TOUCH YOUR OPPOSITE KNEE

– PATIENT ABILITY IS RECORDED ACCORDING TO PERCENTAGE OF ROM THAT HE HAS COMPLETED

– PATIENT IS REPORTED TO BE IN THE STAGE AT WHICH HE IS ABLE TO ACCOMPLISH ALL MOTIONS SPECIFIED FOR THAT STAGE

– IF MOVEMENT IS IN TRANSITION BETWEEN STAGES RECORDED AS “2 GOING ON 3”

• BRUNNSTROM RECOVERY STAGES OF UPPER EXTREMITY (6 STAGES)– STAGE – 1

• FLACCIDITY – NO VOLUNTARY MOVEMENT

– STAGE – II• SYNERGIES DEVELOPING FLEXION

DEVELOPS BEFORE EXTENSION (SPASTICITY DEVELOPING)

– STAGE – III• BEGINNING VOLUNTARY MOVEMENT IN

SYNERGY, INCREASED SPASTICITY WHICH IS MORE MARKED

• STAGE – IV• SOME MOVEMENTS DEVIATING FROM SYNERGY

– 1. HAND BEHIND BODY– 2. ARM TO FORWARD HORIZONTAL POSITION– 3. PRONATION – SUPINATION WITH ELBOW FLEXED TO

90 DEGREES, SPASTICITY DECREASING

• STAGE – V• INDEPENDENCE FROM BASIC SYNERGIES

– 1. ARM TO SIDE HORIZONTAL POSITION– 2. ARM FORWARD AND OVERHEAD– 3. PRONATION – SUPINATION WITH ELBOW FULLY

EXTENDED, SPASTICITY WANING

• STAGE – VI• ISOLATED JOINT MOVEMENTS FREELY

PERFORMED WITH NEAR NORMAL COORDINATION, SPASTICITY MINIMAL

HEMIPLEGIA – CLASSIFICATION AND PROGRESS RECORD

DATE STAGE

1

2

3 – SYNERGIES INITIATED VOLUNTARILY, SPASTICITY MARKED

PERCENTAGE ACTIVE JOINT RANE

FLEXOR SYNERGY

SCAPULAR ELEVATION

SCAPULAR RETRACTION

SHOULDER ABDUCTION

SHOULDER EXTERNAL ROTATION

ELBOW FLEXION

FOREARM SUPINATION

EXTENOR SYNERGY

4 – MOVEMENTS DEVIATING FROM SYNERGIES

PERCENTAGE ACTIVE JOINT RANE

A. HAND BEHIND BACK

• TONIC REFLEXES• STNR & ATNR• TONIC LABYRINTHINE REFLEX• TONIC LUMBAR REFLEX

• ASSOCIATED RECATIONS– FLEXOR SYNERGY

• RESISTANCE TO SHOULDER ELEVATION/ELBOW FLEXION

– EXTENSOR SYNERGY• RESISTANCE TO HORIZONTAL ADDUCTION

• RAIMISTES PHENOMENON

• FLEXOR SYNERGY– STRONG COMPONENT – ELBOW FLEXION

& FIRST TO BE FACILITATED– WEAK – SHOULDER ABDUCTION &

EXTERNAL ROTATION

• EXTENSOR SYNERGY– STRONG – PECTORALIS MAJOR– SHOULDER ADDUCTION & INTERNAL

ROTATION IS THE FIRST TO BE FACILITATED

– SECOND STRONG – PRONATION– WEAK – ELBOW EXTENSION

– TYPICAL POSTURE OF HEMIPLEGIA – STRONG COMPONENTOF FLEXION & EXTENSOR SYNERGIES

• FLEXOR SYNERGY OF LL – STRONG – HIP FLEXION – WEAK – HIP ABDUCTION & EXT ROTATION

• EXTENSOR SYNERGY OF LL– STRONG – HIP ADDUCTION, KNEE

EXTENSION, PLANTAR FLEXION & INVERSION

– WEAK – HIP EXTENSION, INTERNAL ROTATION & PLANTAR FLEXION

• TREATMENT– STAGES 1 TO 3

– FLEXOR SYNERGY IS FIRST TO DEVELOP– ELBOW FLEXION IS THE FIRST MOTION TO BE

ELICTED– RESISTANCE TO LATERAL FLEXION OF NECK

TOWARD AFFECTED SIDE → SCAPULAR ELEVATION

– PERCUSSION/STROKING OVER TRAPEZIUS– ISOMETRIC – DON’T LET ME PUSH YOUR

SHOULDER DOWN– ECCENTRIC LET THE SHOULDER MOVE DOWN

SLOWLY– CONCENTRIC – NOW PULL YOUR SHOULDER UP

TOWARD YOUR EAR– ACTIVE SHOULDER EVOKES OTHER FLEXOR

COMPONENTS & INHIBIT PEC MAJOR

– SHOULDER ELEVATION EVOKES SHOULDER ABDUCTION

– EXTERNAL ROTATION & FOREARM SUPINATION

• EXTENSOR SYNERGY– ASSOCIATED REACTION TO HORIZONTAL

ADDUCTION COMMAND – DON’T ALLOW ME TO PULL YOUR ARM APART

– DUE TO WEAK EXTENSORS & STRONG FLEXORS FOLLOWING METHODS ARE ADOPTED

– ROWING– RESISTANCE TO NORMAL FOREARM &

ASSISTANCE TO AFFECTED FOREARM

• AFTER INITIATION BILATERAL RESISTANCE TO ELBOW EXTENSION

• HOLD AFTER POSTIONING• BILATERAL WEIGHT BEARING WITH ELBOW

EXTENSION STROKING ON TRICEPS• WEIGHT SHIFTING

– AS SYNERGIES COMES UNDER VOLUNTARY CONTROL – FUNCTIONAL ACTIVITIES

• EXTENSOR SYNERGIES– PUSH ARM IN TO SLEEVES– SMOOTH OUT SHEET ON BED

• FLEXOR SYNERGIES– PUTTING ON GLASSES

• BOTH SYNERGIES– IRONING, POLISHING

• STAGES 4 TO 6• PROMOTE VOLUNTARY MOVEMENTS THAT

COMBINES COMPONENTS OF BOTH SYNERGIES LEADING TO DEVAITE FROM SYNERGY PATTERNS

• DISSOCIATION OF TRICEPS & PECTORALIS MAJOR

• DROP OUT ASSOCIATED REACTIONS• PROPRIOCETIVE & EXTEROCPTIVE CAN BE STILL

USED FOR TRAINING

– FIRST OUT OF SYNERGY– 1. HAND BEHIND BODY – SHOULDER

ABDUCTION, ELBOW EXTENSION & FOREARM PRONATION

• STROKING THE DORSUM OF HAND TO SACRUM

• ASSISTED BY THERAPIST• BECOMES VOLUNATRY WITH PRACTICE• PRACTICE WITH FUNCTIONAL TASK

– TUCKING SHIRTS– PUTTING BELT

– 2. SHOULDER FLEXION – HORIZONTAL POSITION WITH ELBOW EXTENSION

• FACILITATION OVER ANTR DELTOID & TRICEPS & ASSISTED PASSIVELY TO POSITION → ACTIVE MOVEMENT

• FUNCTIONAL TASK – PAINTING

– 3. PRONATION & SUPINATION WITH ELBOW FLEXED WITH 90 DEGREES

• RESISTANCE TO PRONATION IN ELBOW EXTENSION → ELBOW FLEXION → FT – TURNING OBJECTS

• STAGE 4 TO 5– ACTIVE MOTIONS OF PATIENT TO MOVE

IN PATTERNS AWAY FROM SYNERGY– EXCESS EFFORT SHOULD BE AVOIDED

• I - ARM RAISED TO SIDE HORIZONTAL - SH ABD WITH ELBOW EXTENSION

– PRACTICE WITH FUNCTIONAL TASK

• II – ARM OVERHEAD– PASSIVE SCAPULAR MOBILIZATION– ACTIVE SCAPULAR PROTRACTION– FUNCTIONAL TASK – PAINTING

• III – SUPINATION & PRONATION IN ELBOW EXTENSION

– SWISS BALL ROTATION IN ELBOW EXTENSION

STROKE REHABILITATION

POSTIONING STRATEGIES

• TO MAXIMIZE PATIENT AWARENESS ON HP SIDE

• OUT OF UNDESIRABLE POSTURES

• AVOID PROLONGED STATIC POSTIONING

• EARLY UPRIGHT POSTIONING– PELVIC TRUNK ALIGNMENT– SCAPULAR ALIGNMENT– GLENOHUMERAL ALIGNMENT

– UE MALALIGNMENT– LE MALALIGNMENT

• LYING IN SUPINE POSTIONING– SCAPULA PROTRACTION– UE – EXT ROTATION & ABDUCTION– LE – PELVIS PROTRACTION, NEUTRAL

ROTATION

• LYING ON THE UNAFFECTED SIDE– PILLOW UNDER TRUNK TO MAINTAIN

ELONGATION OF HP SIDE– SH PROTRACTION, THUMB ABDUCTION &

HIP PROTRACTION

• LYING ON THE AFFECTED SIDE• SITTING ON WHEELCHAIR/BED

– SYMMETICAL WT BEARING ON BUTTOCKS

• RANGE OF MOTION/PREVENTION OF LIMB TRAUMA– ROM EXERCISES– SPLINTING – PROLONGED STRETCHING– SCAPULAR MOBILIZATION– SELF ROM TECHNIQUES– SH ROM TO 90 DEGRESS– TABLE TOP POLISHING

– SITTING, CLASPED HANDS – REACHING FLOOR

– HUMERAL CUFF SLING – SH SUBLUXATION– PLANTAR FLEXOR SPASTICITY – AFO, TILT

TABLE WITH TOE WEDGES, MODIFIED PLANTIGRADE POSITION

• SENSORY TRAINING STREATEGIES– STRETCH, STROKING, PRESSURE, WT

BEARING WITH APPROXIMATION

• STRATEGIES FOR TONE REDUCTION– SPASTICITY

• ELONGATION OF SPASTIC MUSCLES

– RHYTHMIC INITIATION– WT BEARING POSTURE – SH EXTENSION,

ABDUCTION & EXT ROTATION & EXTENSION OF ELBOW, WRIST & FINGERS

– PNF TECHNIQUES– INHIBITION TECHNIQUES

• STRATEGIES TO INPROVE POSTURAL CONTROL & FUNCTIONAL MOBILITY– FUNCTIONAL TRAINING ACTIVITIES

• ACTIVITIES IN LYING– ARM

• ELONGATION OF TRUNK• MOBILISATION OF SCAPULA• ELEVATION OF ARM

– FLEXION WITH WRIST EXTENSION– ABDUCTION WITH WRIST EXTENSION

• SELF ASSISTED ARM MOVEMENTS

• LEG• HIP EXTENSION WITH KNEE FLEXION OVER SIDE

WITH ANKLE DORSIFLEXION• KNEE FLEXION & EXTENSION WITH FOOT

DORSIFLEXION• HIP ABDUCTION & ADDUCTION IN HOOK LYING

• ISOLATED KNEE EXTENSION• BRIDGING WITH ROTATION OF PELVIS• BRIDGING ON AFFECTED LEG & STRAIGHTENING

OF SOUND LEG• ROLLING TOWARDS AFFECTED & UNAFFECTED

SIDE

• ACTIVITIES IN SITTING• WT TRANSFERENCE FROM SIDE TO SIDE WITH

FEET UNSUPPORTED• MOVING IN SITTING WITHOUT HANDS• WT TRANSFERENCE THROUGH ARMS BEHIND • WT TRANSFERENCE THROUGH ARMS SIDEWAYS• RAISING THE HIP IN SITTING WITH LEGS

CROSSED

• STANDING FROM HIGH BED TO GROUND WITH FOOT IN DORSIFLEXION

• PRACTICE ISOLATED KNEE EXTENSION WITH FOOT IN DF

• STANDING FROM CHAIR• MOVING IN SITTING WITH FOOT ON FLOOR• TRUNK CONTROL – CLASP HANDS & REACHING

FORWARDS/SIDES & TO FEET

• ACTIVITIES IN STANDING• WEIGHT BEARING ON AFFECTED LEG• PLACING THE SOUND LEG ON STEP• STEPPING OUT TO SIDE WITH SOUND LEG• MAKING A FIGURE OF 8 WITH SOUND LEG• WT BEARING ON AFFECTED LEG & PLACE SOUND

LEG AT RIGHT ANGLE TO AFFECTED LEG IN FORWARD/BACKWARD

• CONTROL OF HIP ABDUCTORS & EXTENSORS

• STEPPING UP WITH AFFECTED LEG ON STEP

• PUTTING SOUND LEG FURTHER BACK

• WITH AFFECTED LEG ON STEP, STEP UP & OVER WITH SOUND LEG

• RELEASING KNEE IN HEMIPLEGIC LEG IN STANDING

• RELEASING KNEE WITH HEMIPLEGIC LEG BEHIND & PELVIS FORWARD

– STAIRS• ASCENDING STAIRS – ASSISTING AFFECTED LEG

UP

• ASCENDING STAIRS – SUPPORTING THE AFFECTED KNEE TO STEP UP BY SOUND LEG

• DESCENDING STAIRS – HAND SUPPORT ON AFFECTED KNEE

• ACTIVITIES IN TILT BOARD• GAIT TRAINING

• ACTIVITIES FOR ARM– IN LYING

• SMALL CIRCLES ON AIR WITH ELBOW EXTENSION

• TOUCHING HEAD & UP AGAIN• FLEXION & EXTENSION OF ELBOW WITH

HAND IN DORSIFLEXION• HOLDING A POLE IN HAND RAISING &

LOWERING IT

– IN SITTING• HOLDING A TOWEL IN AFFECTED HAND

• IN STANDING• MODIFIED PLANTIGRADE POSITION• WEIGHT BERAING IN AFFECTED HAND &

TRUNK ROTATION• HANDS FLAT ON WALL

PT MANAGEMENT OF PARKINSONS DISEASE

RELAXATION EXERCISES

• GENTLE ROCKING & ROTATIONAL EXERCISES• SLOW REPETETIVE VESTIBULAR STIMULATION• EXERCISE IN FULLY SUPPORTED POSITION• SUPINE – SLOW SIDE TO SIDE HEAD ROTATIONS• HOOK LYING – LOWER TRUNK ROTATIONS• SIDELYING – UPPER & LOWER TRUNK

ROTATIONS• RHYTHMIC INITIATION• DBE – B/L PNF D2 F (INSPIRATION) & D2 E

(EXPIRATION)

• RELAXATION AUDIOTAPES

• GENTLE POSTIONS OF YOGA

• STRESS MX TECHNIQUES

• LIFE STYLE MODIFICATIONS & TIME MX TECHNIQUES

• FLEXIBILITY EXERCISES• AROM & PROM EXS

• STRENGTHENING – WEAK & ELONGATED EXTENSOR MS

• RANGING – SHORTENED TIGHT FLEXOR MS

• D2 F PNF – B/L PATTERNS IN SITTING – TO IMPROVE EXTENSION

• D1 E PNF – COUNTERACT LL FLEXION & ADDUCTION

• HOLD RELAX & CONTRACT RELAX• TRADITIONAL STRETCHING – KNEE

FLEXORS/ELBOW FLEXORS & PF• JOINT MOBILISATION TECHNIQUES• STRETCH – 15 TO 30 SECONDS• AVOID BALLISTIC/AGGRESSIVE/VIGROUS &

EXCESSIVE STRETCHING• PASSIVE POSTIONING• AVOID PHANTOM PILLOW POSTIONING• MECHANICAL STRETCHING

– WEIGHTS/TILT TABLE

• MOBILITY EXERCISES• MVTS SHOULD OCCUR WITH TRUNK ROTATIONS• AIM – TO IMPROVE SEGMENTAL MOBILITY OF

HEAD, TRUNK, HIP & SHOULDERS• PRONE – EXTENSION ACTIVITIES• STANDING – WALL PUSH UPS• BED MOBILITY ACTIVITIES• SIDE LYING ON ELBOW – TRUNK ROTATIONS

WITH LATERAL FLEXION• PELVIC MOBILITY EXS (PELVIC TILTS)• SWISS BALL• UE WT BEARING IN SITTING → WT SHIFTING →

REACHING ACTIVITIES• PNF D2F & D2 E OF UE

• ROCKING FORWARD & BACKWARD IN STANDING• ROCKING CHAIR• RAISED SEAT – SIT TO STAND ACTIVITIES• MODIFIED PLANTIGRADE POSTION• SUPPORTED TO UNSUPPORTED STANDING –

RECIPROCAL ARM SWINGS• WT SHIFTING IN STANDING• STEPPING – SIDE, FORWARD, LATERAL STEP

UPS• FALL – BACK TO STANDING• FACIAL MOBILISATION FOR FACIAL MS

– MASSAGE/STRETCH/VERBAL COMMANDS/MANUAL CONTACTS

– MVTS OF TONGUE, SWALLOWING, SMILING, FROWNING, OPENING & CLOSING MOUTH

• BALANCE ACTIVITIES• WT SHIFTING IN SITTING & STANDING

→REACHING TASKS• MOVEMENT TRANSTIONS

– SIT TO STAND– HALF KNEELING TO STANDING

• SITTING TASK ON GYMNASTIC BALLS• EXTERNALLY INDUCED PERTUBRATIONS• KITCHEN SINK EXERCISES

– HEEL RISE, TOE OFF, PARTIAL WALL SQUATS, CHAIR RISE

– SINGLE LIMB STANCE - SIDE KICKS, BACK KICKS– MARCHING IN PLACE

• GAIT TRAINING• MARCHING IN PLACE • WT TRANSFERENCE IN STANDING• SIDE STEPPING, CROSS WALKING• BRAIDING• STOP, START & TURN 180 DEGREES• TWO WAND STICKS• SHUFFLING GAIT

– SMALL BLOCKS– COLOURED TRANSVERSE LINES

• FREEZING– USE OF TRAINED ASISSTED DOGS

• AUDITORY TAPES

• FUNCTIONAL ADAPTATIONS• ELECTRONIC BEDS – SUPINE TO SIT• KNOTTED ROPES• FIRM MATRESS• CAPTAINS CHAIR• CHAIRS WITH SPRING LOADED SEATS• SHUFFLING GAIT – HARD COMPOSTION

SOLES• FESTINANT GAIT – WEDGES HEEL/TOE

– PROPULSIVE – TOE WEDGE– RETROPROPULSIVE – HEEL RAISE

• CANE/WALKER• SPECIALLY ADAPTED UTENSILS

• RESPIRATORY EXERCISES• BREATHING EXS• AIR SHIF MANOEVUER

• AEROBIC CONDITIONING• WALKING/SWIMMING

• GROUP HOME EXERCISES