Published by Clinician’s ViewAlbuquerque, NM

505-880-0058 (Phone) 505-880-0059 (Fax)www.clinicians-view.com

TM

Handling SkillsUsed in the

Management ofAdult Hemiplegia:

A Lab Manual2nd Edition

Isabelle M. Bohman, M.S., P.T.,NDT Coordinator Instructor

Copyright 2003

TABLE OF CONTENTS

Introduction 1Mobilization (General Stretching Skills) 2Trunk Mobilization 4

Lumbar Spine (Anteriorly) 5Lumbar Spine (Posteriorly) 6Lumbar Lateral Shift 7Thoracic Extension 9

Pectoral Stretch 11Scapula Mobilization 12

Abduction 13Adduction 14Alternative Adduction 16Elevation 17Depression 18

Upper Extremity Stretching 21Hand Inhibition 22Placing Hand on a Surface 26Metacarpal Stretch 28Carpal Stretch 30Foremarm Stretch into Pronation 32

Facilitation 34Activities in Sitting 36

Anterior Pelvic Tilt (Therapist at the Side) 37Thoracic Extension & Abdominals 38Alternative Hand Position for Abdominals 39Alternative Hand Position for Thoracic Extension 39Scooting Forward with Alternate Hips 40Alternate Ways to Scoot Hips Forward 43Trunk Flexion and Lift-Off 44Scoot Back 45Ways to Facilitate Leg in Scoot Back 47

Facilitating Weight Bearing of the Arm 48Facilitate Arm in Weight Bearing with Weight Shift 49Reaching 50Scooting 51Lift Off 52More Challenging Weight Bearing Activities 54Activities with Arms Behind Hips 55UE Weight Bearing through Forearm & Humerus 59Weight Bearing with Arm Slightly Elevated 61

Anterior Pelvic Tilt & Thoracic Extension 62Alternative Hand Positions for Therapist 63Lateral Shift 64Scoot Forward with Alternate Hips 64

Lift-Off 65Control of Patient’s Leg(s) 66Scoot Back with Leg Cues 67

Facilitation of Trunk from the Shoulder Girdles 69Anterior Tilt & Extension (incl. Abdominals) 69Lateral Shift 69

Facilitation of Better Weight Bearing on the Involved Leg 70Facilitating Sit to Stand 72Therapist at Side 73Therapist in Front 74

Facilitating Standing 76Bilateral Knee Flexion (Therapist at Side) 76Facilitating Trunk and UE in Standing 77Facilitating Trunk Rotation in Standing 78Stepping Up On a Raised Surface 79

Facilitating a Step Sequence (Therapist at Side) 83Facilitating Standing from the Front 87

Alternative Position 89Facilitating of Trunk Rotation in Standing 90Facilitating the Trunk in Standing 91Facilitation of the Trunk from the Front 91

Stride Weight Shift 93Release of the "Trailing" Leg 94Assisting Involved Leg Forward 94

Facilitating Transfers 95From Bench to Chair – 1 Man 95Foot Positions for Transfer to Right 97Two-Man Transfer 98

Facilitating Gait Activities 99Walking Forward (Therapist at Side) 100Walking Backward (Therapist Sitting in Front) 101Facilitating Involved Leg during Gait 103Pivot Toward Affected Side 106Pivot Away From Affected Side 107

Bending Down to Reach for an Object 108Feet Even and Facilitating Trunk & Hip 108Feet Even and Facilitating Arm 109Feet in Stride and Facilitating Arm 110

Preparation for Stair Climbing 111

Facilitating Step-Up 112Step-Up with the Involved Leg (Therapist Behind) 112Step-Up with the Involved Leg (Therapist in Front) 114Stepping Down Leading with the Better Leg 115

Positioning and Early Bed Mobility 117Supine 118Elevated in Bed 120Half Bridging 122Placing 123Bridging 124Alternate Ways to Facilitate Bridging 125Scooting Upper Body 127

Moving in Bed 130Rolling to Sidelying on Affected Side 131Positioning in Sidelying on Affected Side 134Rolling Affected Side to Supine 135Rolling to Sidelying with the Less Affected Side 137Rolling Less Affected Side to Supine 139Lying to Sitting at Edge of Bed 141Alternative Method for Sidelying to Sitting 144Sitting to Lying on Affected Side 146Alternative Method for Sitting to Lying 148

4

TRUNK MOBILIZATION

If the patient needs mobilization in the low trunk area, the ranges should be checkedin the order in which they are listed. Then, if mobilization is necessary, it should bedone in this same order. Remember only mobilize in those areas required. If thepatient only needs “thoracic extension” or “pectoral stretch,” he/she still needs atleast a neutral low trunk before doing any stretching to the upper trunk. Also, thebetter extended the thoracic area is, the better the mobility and alignment one willachieve in the scapulae. It is always necessary to think about how the alignment of onearea relates to and effects another part.

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UPPER EXTREMITY STRETCHING

Mobilization of the trunk and scapula usually helps to reduce the tone in the UE sothat these should precede any UE stretching. The inhibition of the hand will help youdetermine if mobilization of the metacarpals, carpals and forearm are necessary. If thehand is extremely tight and you cannot get a hold of the first metacarpal to inhibit thehand, then mobilize the metacarpals first. Metacarpal mobilization should always pre-cede carpal and forearm mobilization.

Once you can get the hand in weight bearing (on a flat or curved surface) maintain itthere with the arm in as much lateral rotation as possible; then have the patient movethe trunk over the arm. Use small movements at first and gradually the tone willdecrease. The patient should be encouraged to actively weight bear on the hand, butthis will probably need to be facilitated. (See section on facilitation of the arm inweight bearing page 48.)

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MORE CHALLENGING WEIGHT BEARING ACTIVITIES

Patient’s involved arm is placed out to theside in external rotation. The therapist is atthe side with her foot on the patient’s involvedfoot and thigh over the patient’s hand. Thetherapist facilitates the trunk and arm withher left hand. The patient rotates the uppertrunk and reaches with the left arm across thebody toward the more involved side takingweight on the involved arm and letting it bendslightly. The patient then returns to midline,extending the involved arm while the thera-pist facilitates the trunk extension and scapulaapproximation. To activate the involved armmore resistance can be applied to the trunk asit returns to the middle. The more the rotationand reach the harder the activity so it must begraded carefully.

To increase the demand on the involvedside, the patient can bend forward andreach with the better arm as he/she main-tains weight on the involved side, keepsthe trunk active and lifts the hips off thesurface. The therapist maintains thedominals with the right finger pads andapproximates the scapula with her rightthumb while the patient pushes into bothfeet (heels) And the involved arm to leftoff the surface. The therapist’s back handcan assist with the lift off as previouslydescribed (see page 51).

REACHING FORWARD WITH “LIFT OFF”Anterior View

ROTATION AND REACHINGAnterior View

100

FACILITATING THE TRUNK WHILE WALKINGFROM THE SIDE

Note: In all trunk facilitation the therapist must be able to influence both the uppertrunk and lower trunk at all times to keep the trunk aligned.

Anterio-lateral View - 1. The therapist’sright hand is over the abdominals cueingthe upper abdominals to bring the rib cagedown and/or the lower abdominals to keepthe pelvis neutral.

Posterio-lateral View - 2. The therapist’sleft hand uses the thumb to cue the ribcage forward and the fingers cue the backof the pelvis down into a “tuck”. Thereshould be no contact over the low backas the patient is usually already over-ex-tended there, due to frequent leaning ofthe upper trunk back or tilting the pelvisforward.

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POSITIONING AND EARLY BED MOBILITY GENERAL AIMS

1. To provide support.2. To discourage movement strategies that elicit abnormal tone.3. To promote symmetry in alignment, weight bearing and orientation.4. To provide more normal sensory feedback.5. To encourage awareness of the affected side.6. To relieve pain and provide comfort.7. To develop and reinforce basic strategies of movement for function in bed.

CLINICAL IMPLICATIONS FOR POSITIONING AND EARLY BED MOBILITY

Proper early positioning of the patient is extremely important to the prevention of tight-ness and to maintain sensory awareness of the body parts through weight bearing.

Teaching the patient how to move in bed is also extremely important. However, trying tomove the body around while horizontal is extremely difficult because of the influence ofgravity on the body parts. Therefore, these bed activities should be preceeded by somepreparatory activities in sitting on the edge of the bed with feet flat on floor or on a firmsupport surface. Activating the muscles of the trunk in sitting and/or standing is mucheasier because of the decreased influence of gravity, as well as, the decrease in size of thebase of support which creates an increased demand on the muscles. Thus, many activitiesdescribed earlier under “sitting activities” might be used as a preparation for the bedmobility activities.

It is also important to recognize that these activities are encouraging the patient’s activeparticipation, so it is very important to wait for the patient’s response following facilita-tory input. Otherwise, the therapist is doing the “work” which teaches the patient verylittle. It is much better to do fewer activities, but insure that the patient is actively involvedin everything that is being attempted.This does not imply that the patient is doing “every-thing” for himself, rather that the therapist helps only as much as is necessary to help thepatient achieve the activity, As the patient becomes more active, the therapist withdrawsher input to allow the patient to achieve more in a shorter period of time.

Note: In the following photographs, the “patient’s” involved side is indicated by the sashtied around the model’s arm.

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As the patient turns his head, the therapist facilitates head lift. As upper body turns, legsfollow. If patient’s involved knee is bent and affected foot is trapped, therapist canfacilitate weight bearing into the affected foot to encourage pushing with the leg.

Affected arm is positioned on pillows to avoid too much adduction and external rota-tion. Pillows should not block patient’s view.

The bottom leg is straight and the top leg is flexed slightly at the hip and knee andpositioned on 1 or 2 pillows placed in front of the bottom leg. This helps avoid too muchadduction at the hip and should keep the entire leg and foot in alignment.

The spine should be fairly straight. If necessary, a folded sheet placed under the patient’sless affected side prior to rolling, should prevent shortening on the affected side. Thewidth of the folded sheet is such that it lies between the patient’s iliac crest and inferiorangle of scapula.

Note: Patient will usuallymake his own comfort ad-justments when lying on theless involved side.

ROLLING TO SIDELYING ON THE LESS AFFECTED SIDE