Positioning and Moving of Hemiplegic Pt.

Bed Mobility Exercises

Positioning of UE, head and torso

Arm and head
Position in bed: pt. lying on his back
To prevent shoulder retraction:
place outstretched arm alongside the body on a pillow
somewhat higher than the trunk. Place outstretched hand on
pillow or, better if possible, supinated against the outside of the
pillow
Important:
place the head laterally to the unaffected side, and the
affected shoulder on the pillow as far forward as possible

Pelvis and leg

Position in bed:
Lying on back. A pillow or sandbag is placed under the
pelvis on the affected side in order to lift the pelvis. The pillow
must be long enough to give support to the lateral side of the
thigh. This prevents ER of the leg, but it must not, go beyond the
middle position. If too much extension or supination of the ankle
results, a board may be placed against the foot to give
dorsiflexion and pronation.

Patients who develop extensor spasticity early on

Position in bed:
the pt. should not always be on his back, but should learn to
lie on the sound and, also, the affected side. Support the pelvis
and lift it forward with a sandbag and pillow. In order to avoid
excessive extensor spasticity, the pt. needs support under the
knee by means of a small foam rubber cushion, with the knee
slightly bent. No board should be placed against the foot, as he
will push against it with his toes.

Bed mobility exercises

Turning of Pt. over his unaffected and affected side
Remember:
Turning should begin with the upper part of the body and, in
order to do this, the pt. must first learn to lift the affected arm
with the good arm, and to clasp his hands (i.e. with fingers
interlocked). He should then lift his clasped hands, with elbows
extended, to the horizontal and if possible, above his head. From
there, the pt. should move his arms first to one side and then to
the other.

Bed mobility exercises

Turning of Pt. over his unaffected or sound side

Turning over to the sound side should be started with his arms
and trunk, his hands clasped.
The therapist can give minimal help by turning the pt. pelvis
and move the affected leg to the sound side
When he is lying on the sound side, the shoulder of the
affected side should be brought well forward, the are
supported on a pillow and extended at the elbow.
The pillow can thus be embraced by both arms.
NOTE:
Movement started with shoulder forward; knee kept in slight
flexion with small pillow.

Bed mobility exercises

Turning of Pt. over his affected side

Turning over to the affected side should be started with his

arms and trunk, his hands clasped.
The pt. can use his sound arm and leg for turning it over.
When lying on the affected side, his involved shoulder should
be brought well forward and the arm is then in external
rotation and extended at the elbows.

Bed mobility exercises

Using the bedpan

Bend the affected leg and place his foot flat on the bed.
The pt. will then bend the sound leg and place that foot
parallel with and close to the affected foot.
The therapist must fix both feet with one hand and ask the
patient to lift his pelvis.
The therapist will then place the bedpan under the pelvis. The
patient should keep his legs bent.

The patient pushes himself up in the bed if he has

slipped down
POSITION: (the same when using bedpan)
Fix the pt. affected foot with one hand and help him up from
the shoulder with your other hand.
Place your arm under the pt. arm-pit, at the same time lifting
the shoulder upwards and forwards or the pt. may lift his
pelvis and help him in this way to push himself forwards.

TURNING OVER TO SIT

UP ON THE SIDE OF THE
BED AND SITTING AND
STANDING ACTIVITIES
FROM THE BED

TURNING OVER TO SIT UP ON THE SIDE

OF THE BED
TURNING TO THE SOUND SIDE TO SIT UP

Pt. starts with clasped hands and supports himself on the

sound forearm while pt. brings the sound leg over the
edge into half-kneeling.
If the pt. needs some assistance

The nurse/caregiver may help the pt. to sit up by moving

his head towards the affected side and at the same time,
she moves the affected leg over the edge of the bed with
the other hand .
Note: pt. should keep his/her hands clasped together.
If the pt. does not need help to lower the affected leg on the edge of
the bed for sitting up or if they have been trained to move both legs
flexed on one side or the other

Pt.s hands are clasped, she/he will start to turn the trunk
and then the pelvis. Feet are on the bed and both knees
are kept together when turning over.

TURNING OVER TO SIT UP ON THE SIDE

OF THE BED
TURNING TO THE AFFECTED SIDE TO SIT UP

Pt. starts with clasped hands

When the pt. is lying on the affected side, the PT
supports the pts head on the affected side and helps
the pt to move it towards the unaffected side and up
while the pt. supports himself on the affected
forearm.
The PT will help the pt. to move the affected leg over
the edge of the bed.
While the pt. moves his sound leg over the edge of
the bed, the PT pushes his head further up to the
sound side and so to sitting up.

TURNING OVER TO SIT UP ON THE SIDE

OF THE BED
LYING DOWN FROM SITTING

The PT holds the affected hand of the pt. The

pts arm is externally rotated and extended
diagonally forward at shoulder height.
While the pt. slowly lies down, using his sound
arm for support.
Then the pt. lifts the sound leg on to the bed.
If at all possible, the pt. should then bend the
affected leg at the knee and move it onto the
bed, the PT gives a little help by lifting from
under the knee

SITTING AND STANDING ACTIVITIES

FROM THE BED
SITTING UP TO STAND

While the pt is sitting on the bed, the PT stands in

front of the pt.
The pt. places his sound arm around the PTs
waist.
PT takes the affected arm and with one hand
under the pt. armpit, lift his shoulder, rotate the
arm outwards and extend the elbow.
Before the pt. stands up, the PT will help the pt.
to move forward from the hips.
The PT will place one of her hands under the pts
shoulder and holding on it while drawing the pt.
lightly towards the affected side.

SITTING AND STANDING ACTIVITIES

FROM THE BED
GETTING UP FROM THE CHAIR

PT stands in front of the pt., taking both

arms of the pt. forward
The knees of the pt. should be together in
mid-line and the feet parallel at right
angles to the knees
The affected foot should not be in front of
the sound one.
PT will press her knees against the pts
knees and help him rise in the same way
as she helped him rise from the bed

First (Mainly Flaccid) Stage

1.To counteract retraction of scapula
2.Preparing the patient for sitting up and
standing
3. Leg extension exercise for preparation
for weight bearing exercise

Turning over from Supine to Side-Lying

Rolling over to sound side

Shoulder and arm should be placed forward

Elbow extended and legs in semi-flexion

Rolling over to affected side

Shoulder and arm should be placed forward

Elbow extended and in Supination

Turning over from Supine to Side-Lying

Preparation for Rolling

Patient in Supine, clasps his hands, the thumb of

the affected hand being above that of the sound
one
Patient practices lifting clasped hands above his
head and down with extended elbows. With both
hands having equal degree of supination.
Patient then practices bending his elbows and
placing his hands on his chest.
Elbow of arm the affected must be well forward to
allow for extension of wrist.
Patient then moves his arm up again and forward.

Turning over from Supine to Side-Lying

Rolling with clasped hands

Patient brings both arms, with clasped hands,

over first to one side and then to another.
PT can assist if necessary to move his leg and
pelvis over to side-lying.

Flexion and extension of arm without Retraction of

shoulder

When lying on the affected side, should be placed

forward. arm in external rotation, forearm
pronated and elbow extended

Controlled Extension Without

Extensor Spasticity

The therapist bends the patient's leg, but

avoids it falling into abduction.
The foot is held in dorsiflexion and
pronation.
The therapist waits until resistance has
subsided and then slowly, extends the
leg, asking the patient not to let the leg
fall or push against her hand.
If during the movement the PT feels the
full weight of the leg or even a slight
push against her hand, she must stop

Active Dorsiflexion of the

ankle

Therapist supports the sole of the foot

Therapist dorsiflexes the foot by giving
some pressure backwards and
downwards against the ankle, while, with
her other hand, she lifts the front of the
foot, with the toes dorsiflexed.
Maintain pronation by raising the lateral
border more than the medial one.
Dorsiflexion with eversion of the ankle
can be reinforced by dorsiflexion of the
toes. Sensory stimulation with quick

Extension in preparation for

weight bearing

Therapist places the patients dorsiflexed and

pronated foot against himself
Therapist holds it in position and asks the
patient to perform small isolated movements
of alternate flexion and extensions of the knee.
If the patient can control his leg during
extensor phase, the PT can bend the leg and
move the foot down over the side of the bed
so that he extends the hip with the knees in
flexion.
Patient then lifts his leg up again and place his
foot on the support

Treatment for standing up and standing

position

Standing training using a high chair

Starting position: sitting c pt. hands clasped in
front
Instruct pt. to stand up
As the pt. is standing up, PT applies pressure on
knee
Train sit stand
Progression

Getting down from plinth using affected side

Staring position: pt. in short sitting
Instruct pt. to touch the ground using affected side
PT puts pt.s affected foot in ankle dorsiflexion,
forearm supination and elbow extension
Ask pt. to extend knee
Progression

Standing training leaning on the plinth

Starting position: pt. in short sitting
Instruct pt. to stand up with both feet parallel on
the floor
Practice weight transfer
Progression

Standing away from plinth

Starting position: pt. standing c both feet parallel
on the floor
Instruct pt. to lift the heel of the sound side
Progress by asking pt. to make small steps
forward and backward c sound foot

Extensor spasticity on affected leg during

stepping forward
To prevent, use toe spreader
PT place hand under ball of pt.s foot and lifts his
toes and dorsiflexes the ankle while standing on
heel until there is no pressure felt

Treatment for walking

Moving pelvis forward over affected leg

Starting position: pt. standing
Instruct pt. to take small step forward and
backward with sound foot

Trunk balance in sitting

Intial treatment of flaccid Stage

-Pt tends to fall on the affected side.

-In sitting and standing, balancing s arm support
when weightbearing on one side makes the normal
person move his head laterally towards the
opposite side. However,normal side of hemiplegic
pt is unable to counteract the pull of fall to the
affected side.It may be due to the pull of spastic
mm towards the affected side and also to sensory
loss, depriving the sound side of info about what
happens on the affected side.

-Pt gets trunk control c righting of his head towards

the normal side.
-Pt needs elongation of the side flexors of the trunk
and neck and raising of his shoulder on the affected
side.

TREAMENT
-pt sits on the bed c therapist on his affected side.
-Pt raises his shouldergirdle supporting it from the
under the axilla, holding his arm abducted in lateral
rotation,extended at the elbow, hand extended at
the wrist c fingers extended if possible c the normal
hand on knee.
-Then pt leans torwards therapist, and straighten
himself up again to mid posn. He should start this
by side flexing his head lateral to the normal side
and not just turn his head

.-When moving to the affected side, pt should not

lean backwards.
-The shoulder should be kept in raised by the
therapist. Next, pts hand is placed on the support
some distance away from the body, therapist
holding hand firmly down while lifting his shoudler
up c the other hand.
-Pt is then ask to move his trunk towards the therapist
so that he takes full weight on the affected hip.

-Pt is then helped to take weight on FA, his hands

clasped, or his hand being held flat down on the
support either c his sound hand or by the therapist.
-If he feels very insecure and tends to collapse on his
arm, his shoulder can be kept raised by the
therapist or alternatively, if possible, she should
just keep his head lateral flexed towards the normal
side to stop his pulling down or falling to the
affected side .

-It is always difficult for pt to lean forward at hips

when sitting s being afraid of falling forward.
-It is important to practice this balance as well as
standing up. -Therapist stands in front of the pt,
fixing his affected extended arm against her waist c
her elbow, and letting him hold on to her c his
normal side.
- Then ask and help to lean lean well forward at the
hips .

-Care should be taken see that he extends his back

and does not bend his head and look down.
-From this position he is then helped to stand up.

Preparing for walking

without circumduction
Rameer Zerwin S. De Vera
Coleen C. Dequito

Control of adduction and abduction

of the hip
Pt. Position:
o Supine, both legs flexed and feet flat for support
o Both feet should be parallel or near to each other

Procedure:
o The pt. hold and keep the unaffected knee in midposition
o The pt. should not move the unaffected when the affected
limb perform small movement of adduction and abduction
alternately
o At first, he may have difficulty in reversing the movement
especially if the leg fall outwards into abduction
o When he can control the movement, the affected leg will
be keep to midline while moving the unaffected into
adduction and abduction

Control of adduction and abduction

of the hip
o The independent holding of the affected leg when
moving the sound one is very important for later
walking
o As otherwise there will be no control and fixation of the
affected leg at the hip when making a step with the
sound leg
o Same maneuver can be practiced later on with the
pelvis raised off the support
o If this is possible and done well, the patient can next
lift one foot off the bed or plinth and support himself
only on the other, but when he lifts the sound leg
o His pelvis should be level and not allowed to drop on
the affected side

Preparing for walking without

circumduction
Pt. Position:
o Supine, affected limb hip extended, knee
flexed, foot DF and pronation
Procedure:
o The pt. can use the foot to push the pelvis forward
towards the unaffected side
o Then, move the affected leg across the unaffected
with the medial border of the foot touching a wall
o Then perform selective flexion and extension of
the knee while moving the foot up and down

Trunk Balance in Sitting

Side Leaning on the

affected side
Pt. Position
o Sitting, arm abducted in lateral rotation,
extended elbow, hand extended, wrist
and fingers are extended if possible

Physical Therapist
o Standing on the affected side of the pt.
o PT will raise the pt. shoulder girdle
supporting it under the axilla

Side Leaning on the

affected side
Procedure
o Flex the head laterally to the unaffected
side lean towards the therapist and
straighten up to mid-position
o Lean towards the therapist and
straighten up to mid-position
o Dont let the pt. lean backwards when
moving to the affected side
o Shoulder girdle should be kept raised by
the PT

Side Leaning on the

affected side
Pt. Position
o Sitting, pt.s hand placed on the support
some distance away from the body

Physical therapist
o Holding the hand firmly while the other
hand lifting the shoulder girdle up

Side Leaning on the

affected side
Procedure
o Ask the patient to move his trunk towards
the therapist
o Help the patient to take weight on his
affected side with his forearm, hands
clasped, or being flat down by his
unaffected hand or the therapists hand
o If he feels insecure, keep raising the
shoulder girdle or keeping the head
laterally flexed to the unaffected side

WORKING FOR EXTENDED

ARM SUPPORT IN SITTING

WORKING FOR EXTENDED ARM

SUPPORT IN SITTING
The practice of support and weightbearing on
extended arm is important for two reasons:
> Extension, with outward rotation, abduction
and supination counteracts flexor spasticity
which is associated with inward rotation,
pronation and retraction of the shoulder.
Weightbearing on the extended arm activates
the extensor muscles in a much needed
functional pattern.
>Weightbearing on the extended arm is part of
the process of gaining balance and makes the

Weightbearing can
be pratice in the ff.
ways:
position of pt.: SITTING with AFFECTED limb on the
side. (important reminder: to avoid IR of the arm, pt's
hand should be sideward or even diagonal backwards
with fingers extended)
TRAINING A: pt hand is placed on the support, some
distance away from his body
> pt SH girdle is lifted & supported under the PT's
axilla
> pt moves his trunk over his supporting arm
(*transferring most of his weight on affected hip)
when pt can maintain elbow extension without help,
PT can put a downward pressure on the shoulder to
extension activity & stability.

TRAINING B: If flexor
spasticity is very strong
and pt cant keep his arm
extended by his side
PT stands behind the
patient > move the pts
arm backward in
extension & full ER >
move the arm backward,
lift them off the support
while the pt slowly moves
his hips forward > PT will
gently push & pull the
arm to stimulate pt's
active extension.

Initial Flaccid stage:

Controlling the arm at the shoulder

Presented by :
Arnaiz, Pauline
Villas, Karl

Initial flaccid stage:

Controlling the arm at the shoulder
MOBILIZING THE SHOULDER GIRDLE
It is easier for the patient to get control of his shoulder
girdle and arm in supine than in sitting, because when the
hips are flexed, the tendency to flexor spasticity is increased.
Mobility of the scapula is important not only to obtain
movements of the arm at the shoulder, but also to prevent
shoulder pain.
Spasticity of the Rhomboids, Trapezius and Latissimus
prevents the inferior angle of the scapula from turning
outwards and upwards when the arm is raised.
Mobilizing the shoulder girdle can be done best in supine,
but can also be done in side-lying on the sound side. The
aim is to make the painless elevation of the arm possible.

A. INHIBITION OF THE HYPERACTIVE SHOULDER

Inhibition of the hyperactive shoulder flexor and
depressors prepared the patient to attempt
independent movement of the shoulder girdle such
as shrugging.
B. Mobilizing the shoulder girdle in sidelying
and supine position:
-The patient's arm is supported by the therapist with
his elbow extended and in external rotation.
-She uses both hands to move his shoulder girdle
upwards, forward and downward, but avoids moving
it backwards as this reinforces retraction of the
scapula.
-The patient's head should be laterally flexed
towards the sound side. If shoulder retraction is very
strong, the procedure can be done in side-lying on

Fig. 6 17a Patient in sidelying:

mobilizing shouldergirdle.
Note: Shoulder and scapula
are
moved upwards and forwards.

Fig. 6. 17b This is done with

the arm in external rotation.

Fig. 6. 17c Patient in supine:

mobilizing shoulder girdle
forward and upwards with arm
in extension and supination.

Fig. 6.17d This is followed by

elevating arm and placing
palm of hand against wall.
Note: Abduction of thumb.

C. Elongation of the affected side:

-Another way of mobilizing the shoulder girdle is to
extend the patient's arm above his head, with his hand
held firmly in this position, the arm in external rotation.
He is then asked to turn over into side- and prone-lying.
-Moving the trunk against the limb is reducing
spasticity more effectively than pulling the arm against
the trunk. The whole of the affected side becomes
maximally elongated. In this way, using rotation, the
patient counteracts his flexor spasticity actively (Figs.
6.l8a, b, c, d).
-When resistance to moving the shoulder girdle is no
longer present, the therapist gradually raises the
extended arm in supine, using some traction and
keeping the shoulder well forward.

Fig. 6. 18a Shoulder

retraction makes
patient start movement from
the pelvis.

Fig. 6.18b Therapist now helps

patient
by mobilizing shoulder girdle and
trunk

Fig. 6.18c Note: Elongation of

the.
whole of the affected side as
the
turning movement goes on.

Fig. 6. 18d Movement almost

completed.
Note: Elongation of affected side
maintained throughout.

D. If pain occurs during upward movement of

the affected limb:
-At the first indication of shoulder pain, the upward
movement must be stopped and the arm slightly
lowered again. Shoulder pain occurs when the patient
pulls the scapula back and downwards.
-The arm is then slowly moved up again until full
elevation has been obtained without pain. The whole
pattern of the flexor synergy has to be counteracted
by elongating the side of the trunk, by movement of
the shoulder forward and upward, by external rotation
of the arm, and by keeping the elbow and wrist
extended, with the fingers also extended, if possible
(Fig. 6.l9a).

-As soon as there is no resistance to the arm in full

elevation, the patient is encouraged to extend his
elbow actively, while his hand is still supported in
extension. He is asked to push upwards against
the therapist's hand. Alternate small movements
of flexion and extension at the elbow are practised
to obtain selective movements of the elbow (Fig.
6.19b).
-When the patient is able to do this, the therapist
releases his hand and the patient tries to keep the
arm up unaided and then to move it a little at the
shoulder without letting it fall sideways or forward
and down.

Fig. 6.19a Elevation of arm.

This is
done with extension and
external
rotation.

Fig. 6 19b The patient pushes

intermittently
upwards against the
therapist's hand with alternating
slight
and isolated flexion and extension of

Stage of Spasticity
Flaccid Stage

 Most treatment during this stage is

done in supine, but will have to be
continued and progress towards sitting
and standing.
It is the stage wherein most patients
with hemiplegia come for out-patient
treatment.
Spasticity usually develops in the flexor
muscles of the UE, and the extensor
muscles of the LE
As spasticity develops, there is

Most affected muscles groups

in
UE

Depressors of shoulder girdle and

arm
Fixators and retractors of the scapula
Side-flexors of the trunk
Adductors and internal rotators of the
arm
Flexors and pronators of the elbow
and wrist
Flexors and adductors of the fingers

Affected muscle groups in

LE
Extensors of the hip, knee and ankle
Supinators of the feet

(+) SUBLUXATION

 Wearing of sling is supposed to push the humerus

upwards mechanically and so prevent
subluxation.
As the arm is in flexion, adducted, pronated and
internally rotated in the sling, flexor spasticity is
reinforced.

a. Teaching a pt. to use the

Bobath sling
In the early stages, before the patient can use
active extension--lifting and holding the arm up
against gravity-- a temporary support may be
given to the shoulder girdle to prevent long
lasting stretch of the superior part of the capsule
and supraspinatus
the pt. will need this support when he is upright
until such time as he can use the supraspinatus
and deltoid to hold the humeral head in the
glenoid fossa.
Support should consist of a cuff applied to the
upper arm and held by a figure-of-eight bandage.
Small and soft foam rubber cushion is placed
under the axilla to abduct the arm slightly.

 Pt. in upright position, support of the

upper arm keeps it mobile and leaves
the elbow free to extend.
For flaccid pt. it is necessary to
prevent the arm from hanging down,
pt. could be made to put his hand
into the pocket by his side.

To obtain extension of wrist and fingers:

a foam rubber finger-spreader can be usedabducts fingers and thumb
Clasping the hands has the same effect as fingerspreader- it reduces flexor spasticity and gives
extension through abduction of fingers and
thumb, and has the added advantage of keeping
the forearm in supination.

 When pt. does not need to use the sound limb for
any task, he should sit with his fingers clasped.
The pt. then sees both his arms and hands in
front of him and get the feeling of bilaterality.
The affected arm then looks, and perhaps feels,
more like the sound one and, therefore, becomes
more acceptable as part of his body percept
again.
If possible, pt. should sit at a table or in
wheelchair, with tray in front of him. So that his
upper arm is supported and raised forward.

WEIGHT SHIFTING
EXERCISE USING 3 CHAIRS

When standing up:

The affected foot is in front of the
sound one and all the weight is taken
on the sound leg.
Pt. pushes himself up with the sound
arm
He may hold the affected leg in
extension and external rotation
Swing the leg forward by lifting and
pulling the pelvis up on the affected

 Have pt sit on the middle chair

Affected foot should not be in front
of the sound one
Equal weight should be distributed
on both hips or more weight on the
affected one
Have pt learn how to shift himself
from one chair to another
Find the center of a chair with his
hips

CONTROL OF ADDUCTION
AND ABDUCTION IN
SITTING

a. Leg crossing exercise, (+)

Difficulty in adduction and
abduction

When sitting, the patient carries more

weight on the unaffected hip than on the
affected one.
The affected arm is flexed
If knee is flexed, the leg is more widely
abducted than the unaffected one.
If there is strong extensor spasticity, the
knee is in some degree of extension and
the leg is adducted.
There is side flexion of the trunk
The shoulder on the affected side is held
lower than that on the unaffected side

 Have pts feet flat on the floor

Ask pt to perform adduction and abduction of the
affected leg
Pt should hold and keep sound knee stable and
in mid position (no movement during movements
of the affected leg)

b. Leg Lifting exercise in sitting position (+

pressure downwards) while performing hip
abd and add

the effort used in lifting the stiffly extended leg

in walking increases the flexor spasticity of the
arm.
pt. uses his affected leg as a rigid prop (cocontraction) to take his weight in standing and
walking, for without extensor spasticity and cocontraction his leg will collapse
difficulty in lifting leg is due to extensor
spasticity which results to feeling of heaviness of
the leg and downward pressure on the ball of the
foot upon lifting passively

 passively flex the leg into full flexion and slowly

lower it asking the pt to hold and control it until
foot touches the ground without pressure

c. Knee bending while moving

the foot backward
in order to bend his knee, he has first to lift his
leg with the knee extended until there is enough
hip flexion to make flexion of the knee possible
the pt. cannot keep his foot on the support when
bending his leg and he should learn to do this
from the beginning.
the lack of control over extension has a
detrimental effect on walking, as the pt. will drop
his leg, or push it down when making a step.
the leg, and especially the ankle, is then stiff, the
ball of the foot touches the ground first and
presses against it.
dorsiflexion of the ankle is lacking, making
weight transfer over the standing leg difficult or

 pt. in short sitting position

ask the pt. to dorsiflex the affected foot
PT then passively move the foot backward under
the chair with the heel remaining on the ground

Stance Phase

Standing in Front of a Plinth

Patient is made to stand in front of a plinth with feet
close together
PT is standing at affected side of patient, with hands
supporting patient on the axilla to keep shoulder
girdle raised, and with other hand supporting patient
with wrist and elbow extended
Patient is then asked to move hips towards affected
side, transferring his whole weight towards affected
side
When patient feels safe, he is asked to make very
small steps forward and backward well behind the
affected one
Patient should not bend his trunk forward and flex his
hip, but keep it well extended, as this counteracts
hyperextension of knee

Stance Phase Training with Knees in

Flexed and Extended Position
When patient is in step position, patient is asked to
maintain his full weight and to balance on the affected
leg with the sound foot in front
Patient should then transfer his weight forward to the
sound one, leaving the affected leg behind with the heel
on the ground
Patients greatest balance problems occur when he has
to have his full weight on the affected leg while the
sound one remains in front: patient tends to fall
backwards if he flexes his hip on his weight bearing leg
Small isolated movements of the knee alternating
flexion with extension should be practiced to ensure
mobility of weight bearing leg

Swing Phase

Knees in flexed and extended in

prone position
Patient lying on prone with leg
lowered over the edge of the plinth,
the hip fully extended an knee made
to bed
PT bends patients knee until there is
no resistance in flexion
He is then asked to hold it flexed and
to maintain it in various degrees of
flexion when the leg is gradually
extended by the PT

Hip abduction and Adduction in Standing

Position for Stepping Forward Without
Circumduction
The patient is asked to stand with his full weight on the sound
leg, the affected one is slightly behind it then he is asked to
relax and bend his affected knee, adduct his thigh and his foot
should remain on the ground in pronation.
Ask patient to make a step forward, however, there may still
be some pressure of the toes against the ground which may
produce a supination of the ankle and stiffening of the knee,
the patient is forced to make a step with a stiff knee and
plantiflexed foot, in order to not scrape the ground with his
toes, he has to pull his pelvis upwards and circumduct his leg.
Therefore, the PT will lift the patients foot of the ground and
check for resistance to this movement then the patient is
asked to lift his foot without pulling his pelvis upwards while
the PT is controlling the foot to prevent supination

Hip abduction and Adduction in Standing Position

for Stepping Forward Without Circumduction

The patient should practice doing

small alternating moment of flexion
and extension of the knee, while
keeping the toes on the ground.
If the patient can do this without
stiffening of the knee, he is now
asked to step forward while the PT
guides the foot by controlling the
dorsiflexed foot

Trunk Twisting Exercises to Improve

the Patients Gait
Trunk twisting exercises is a good way to
improve the gait of patients
The patient is asked to stand on a small
base of support and the feet parallel and
rotate his pelvis or twist his trunk against
his limbs for a few seconds then he is
asked to take a step forward.
When the walking pattern deteriorate the
pelvis rotation is repeated before taking
the next step

Walking Sideways
It is usually easier for a patient to walk
sideways on a line if PT wants him to move his
knee, than to walk forwards or backwards,
especially if he walks sideways towards the
sound side
The advantage when walking sideways towards
the affected side is that he has to take full
weight on to that leg
However, PT should make sure that the patient
does not place the affected foot in front of the
line

STAGE OF RELATIVE RECOVERY

I. STEPPING POSITION

A. HEEL STEPPING TRAINING

-. To train dorsiflexion of affected limb
-. Position: Step-positon c sound foot forward

B. USING A TROLLEY (FORWARD, SIDEWAYS

AND BACKWARDS)
- To practice swing phase of affected limb
- Position: Standing c affected foot on small trolley
fitted c castors

C. MODIFICATION USING WEIGHING SCALES USING

AFFECTED LEG

- To check and control pressure

given on affected leg
- Position: Standing c affected
foot on flat scale

D. 2 SCALES TIPPING MOVEMENTS

- To see and control how much weight puts on each
leg
- Position: Standing c both feet on 2 scales

TREATMENT IN PRONE-LYING AND KNEELING

It is important that all patients be taught how to
get up from the floor in case they fall at anytime.
Tx in Four-foot kneeling ,Balancing on the
affected knee, Kneel standing training and Half
kneeling will help in practicing the to stand up
from the floor and will make patients less afraid of
falling.

Four-foot kneeling
1. From prone-lying, pt. will first bend the affected
the leg then the sound leg.
2. Pt. will extend the affected elbow and hand
placed flat on the ground with the fingers
extended and thumb abducted then the sound
arm.

Balancing on the affected knee

1. pt. get down on his hands and knees by first bending
the affected leg and immediately putting weight on it.
2. Support the affected arms, elbow in extension, hand
placed flat on the ground with the fingers extended
and thumb abducted.
3. weight on the body should be well over the affected
arm and leg.
4. Pt then made to rock forward and backward and from
side to side, in order to obtain mobility and balance
reactions.
5. The normal leg or arm is lift to support his weight on
the affected side.

Kneel standing training

Starting position: four-foot kneeling
1. Raise the head and trunk so that pt. stands on
their knees only.
If pt. is having difficulty in extending the hips
especially the affected side:
2. Pts arms are elevated in external rotation
3. Hands are placed on the PT shoulders as she stands
in front of the PT.
4. Pts stands by using affected side and move
affected down to the side held in extension at the
elbow. PT support the hand and wrist in full
extension.

Half-kneeling
1. Pt. stands by the side of a chair or stool with the
affected knee resting on the seat.
2. pt. is asked to make small steps forward and
backward with the sound leg.
Note: prevent flexor spasticity of the arm by
controlling elbow and wrist extension at the side or
above the head

Working for Independent Controlled

Movement of the Elbow
Johnson N. See
Art Joseph Valencia

A. In sideways, diagonal and

forward position, lastly placing
Procedure:
1. To begin with, the therapist holds the patient's hand with
wrist and fingers extended, the thumb abducted.
2. The patient extends his elbow, pushing against the
therapist's hand.
3. The therapist should be able to use some intermittent
pressure to stimulate active extension.
4. Patient can now hold his elbow in full extension, therapist
moves patients hand slowly sideways and down, but only as
long as the patient is able to keep his elbow extended.

5. Patient is then asked to move his arm up again.

6. Gradually, the whole range of movement
sideways for full horizontal abduction is performed.
7. The movement is then done diagonally forward,
as long as external rotation can be maintained.
8. As a progression, the therapist holds the patient's
fingers, but only lightly, to prevent the occurrence
of flexion until eventually the therapist is able to
take his hand away at various points of the
downward movement, and the patient is able to
control his arm at each stage.

B. Stimulating the flaccid arm

If the patient's arm is more flaccid than spastic,
contraction of the deltoid for holding the arm up in
horizontal abduction can be facilitated by :
Procedure:
1. Suddenly and without warning dropping the arm, but
letting it fall only a little way down
2. Move it up again. (Letting it fall may produce a
protective holding reaction through sudden stretch in
the inner range of the Deltoid and supraspinatus)
The patient can then use this contraction immediately,
i.e. before its effect has subsided, for lifting his arm up
again.

C. Pull-push training
Another way of stimulating active extension of the flaccid arm is
a technique called 'pull push'.
This inhibits flexor spasticity
Procedure:
1. Place patient's hand in wrist and fingers extension
2. Patients arm is also raised sideways to the horizontal, or
above
3. A quick pull followed by a push against his extended arm is
given through his hand.
4. This should be done with the patient's arms in any direction,
sideways, forward and diagonally, and also gradually downwards.
5.When sufficient activation has been obtained at shoulder and
elbow, the therapist lets go of the patient's hand and should hold
his arm up unaided.


D. Functional movements of the elbow
joint by touching various body parts in
different direction

Position:
In supine, or sitting

Procedure:
1. Patient is asked to bend his elbow to touch the top of his
head with his palm.
2. Followed by moving his hand to the opposite shoulder, then
back again to his head.
3. He can also be instructed to touch the opposite ear and
then move his hand to the shoulder and down the arm, as if
washing himself.
4. Whenever the patient moves his hand downwards, he
should be able to raise it again.

Position
Lying on the affected side.
Procedure:
1. Pts. arm is extended and in full external rotation.
2. Shoulder should be placed well forward.
3. Ask patient to bend his elbow to bring his hand to
his mouth, and then back to extend it again.
4. This movement of the elbow should be slow and
controlled at every stage
5. The same movements can be practiced in supine
6. Pts. arm lying in horizontal abduction, or lower
down by his side.
7. Ask pt. to touch his shoulder with his supinated
hand.

Position:
Sitting (Forearm resting on a table)
Procedure:
1. Flexion of the elbow with supination
brings his hand to his mouth and to
the opposite shoulder or ear.

Balance Reaction Training

On Affected Side
To improve balance reactions on the affected leg,
the therapist transfers the patient's weight well
over to that leg.
Therapist stands by this side and holds his hand
with his arm abducted and extended.
Pt.'s shoulder girdle should be prevented from
pulling downward.

On Affected Side
Pt. should be encouraged to flex his head laterally
towards the sound side and his arm and leg on
that side should lift and abduct.
When pt can do this well, he should be asked to
perform small alternate movements of flexion and
extension of the knee of the affected leg.

Crossed Standing
When pt is standing with his legs crossed, they
should be externally rotated so that the toes of his
feet point towards each other.
When the affected leg is in front, his hip is
extended and brought well forward.
Small movements of his hips from side to side, or
with rotation, can be done when he is safe enough
to stand still and balance.

Crossed Standing
Pt. is then asked to bring the sound foot forward
and across the affected one.
Pt. should do this slowly so that he carries his full
weight for as long as possible on the affected leg.
The therapist must guard against hyperxtension of
the knee at the back, which can be done by
bending it a little to touch the back of the sound
knee.

Crossed Standing
The pt. should then bring the affected leg forward
again and across the sound one, but he should not
abduct it more than absolutely necessary.
This movement is very useful, as the pt. has to
bend his knee to get the affected leg in front of the
sound one without circumducting the hip.

Walking Backwards and

Forwards
Walking backwards and forwards should be

practised alternately by making, for instance, a

few steps backwards and then one or two steps
forward.
When making a step backwards, the patient has to
bend his knee and then he need not pull his pelvis
upward.
As soon as the toes touch the ground at the back,
he should gradually put his heel down before he
puts weight on the leg.

Walking Backwards and

Forwards
He should keep his hip well forward in extension;

this prevents hyperextension of the knee and gives

full dorsiflexion of the ankle.
Weight transfer forward and backward is practised
in between making steps.

Walking Backwards and

Forwards
When walking, the therapist is at the patient's

affected side.
His arm is held in external rotation and extended
by his side, slightly diagonally backwards.
His wrist and fingers should be extended and his
thumb abducted.
Walking can also be practised with the therapist
behind the patient, holding both arms backward as
described when sitting on a stool.

Walking Backwards and

Forwards
The patient then walks and moves his hip well

forward over his foot before he makes a step with

the sound leg.
When his weight is on the sound leg, he should
stop for a moment before making a step with the
affected one, so that he has time to release his
knee, drop his pelvis on the affected side, and stop
himself from pushing his foot down to the ground.
He can then take a step forward.

TRUNK ROTATION
TRAINING
Reyes, Jessie Marie D.

 Rotation of the pelvis and shoulder girdle is

necessary practice to improve coordination in
walking.
Rotation of the shoulder girdle can first be
practiced by the patient in standing.
He swings his arms from side to side rotating his
trunk and touching the opposite thigh with one
hand.
To practice the same movement when walking, the
therapist stands in front of the patient and holds
him by both hands while she walks backwards.

 As the patient steps forward with, say, the right

leg, she swings both his arms diagonally towards
the right, the left arm well forward and across his
body so that he touches his right thigh.
As the patient transfers his weight over the right
leg and makes a step with the left foot, the
therapist reverses the movement of his arms.
The rhythmical swinging of the arms and the
rotation of his trunk helps to develop a more
normal walking pattern.

 The movement of his arms have to be well timed

to coincide with the patient's steps.
The patient then continues this procedure
unaided.

 Another, and even better, way of introducing

rotation into the patient's walking pattern can be
done by the therapist standing behind him and
rotating his hips or shoulder girdle.
If she wants to influence the movement of his
legs, it is better to rotate his pelvis; if she wants.
to work for more arm swinging, she rotates the
shoulder girdle.
The therapist should avoid bringing one side
forward as a whole against the other.

 The patient should then perform rotation of the

pelvis when standing without the help of the
therapist and continue the movement when
walking.
However, if he reverts to his former pattern of
walking, i.e. moving one whole side against the
other, he should stand still again, twisting his
pelvis a few times before walking again.