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tr Handling Skills
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r Used in the
rf Management of
rr Adult Herniplegia:
rf Lab Manual
rJ. 2nd Edition
J.
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rt:
t1 Isabelle M. Bohman, M.S., p.T.,
NDT Coordinator Instructor
f:
ra Schoot of ppcungtionat Therapy
Texas Womdn's tjniversltv
6700 Fannin St.
Houston, -fX?OSO_ZASI

t: (713) 794_2128

a Published by Clinician's WewM

a Albuquerque, NM
505-880-005t (phone) S0S_BB0_0059 (Fax)
. www. c lin ic ian s_v iew. c om

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Copyright 2003
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 Handling Skills
Used in the
?
f Managernent of
fr Adult Herniplegia:
rt: A Lab Manual
t:
r: 2nd Edition
r:
C
- Isabelle
e M. Bohman, M.S., p.T.,
NDT Coordinator Instrucbr
C
C t"n?!llJ p,9cLrp_g
C t

u#B't*i,HBIu"uv
i on a I rh e ra py

C nouigul6l1;;iuzesz
C published by
C Clinician,s WewM
Albaquerque, NM
C s0s_Bg0_00st pninel -
c soi_gss_lls9 (Fax)

tr www. c lin ic isn s-view.

com

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Copyright 2003
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 TABLE OF CONTENTS
Introduction
I
Mobilization (General Stretching Skills)
2
Trunk Mobilization
4
Lumbar Spine (Anteriorly)
5
Lumbar Spine (Posteriorly)
6
LumbarLateral Shift
7
Thoracic Extension
9
Pectoral Stretch
t1
Scapula Mobiiization
t2
Abduction
13
Adduction
I4
AlternativeAdduction
t6
Elevation
I7
Depression
18
Upper Extremity Stretching
2l
Hand Inhibition
22
Placing Hand on a Surface
26
Metacarpal Stretch
28
Carpal Stretch
30
Foremarm Stretch into pronation
)z
Facilitation
34
Activities in Sitting
36
Anterior Pelvic Tilt (Therapist at the Side)
37
Thoracic Extension & Abdominals
38
Alternative Hand position for Abdominals
39
Alternative Hand position for Thoracic Extension
39
Scooting Forward with Alternate Hips
40
Alternate Ways to Scoot Hips Forward
43
Trunk Flexion and Lift-Off
44
Scoot Back
45
Ways to Facilitate Leg in Scoot Back
47
Facilitating Weight Bearing of the Arm
48
Facilitate Arm in Weight Bearing with Weight Shift
49
Reaching
50
Scooting
51
Lift off 52
More Challenging Weight B earing Activities
54
Activities with Arms Behind Hips
55
IIE Weight Bearing through Forearm & Humerus 59
Weight Bearing with Arm Slightly Elevated
61
 I
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Anterior Peivic Tilt & Thoracic Extension 62 ;
Alternative Hand Positions for Therapist 63 rt
Lateral Shift 64 ;
Scoot Forward with Alternate Hips 64 n
Lift-off 65 .tf
Control of Patient's Leg(s) 66
Scoot Back with Leg Cues 67 "
Facilitation of Trunk from the Shoulder Girdles 69
.t!
i
Anterior Tilt & Extension (incl. Abdominals) 69 '1
Lateral Shift 69
1
Facilitation of Better Weight Bearing on the Involved Leg 70 .r1

Facilitating Sit to Stand 72 al

Therapist at Side 73
1
.,!tl
Therapist in Front -74
ta .l
Facilitating Standing 76 1
Bilateral Knee Flexion (Therapist at Side) 76 1
Facilitating Trunk and IIE in Standing 77 1
Facilitating Trunk Rotation in Standing 78
Stepping Up On a Raised Surface 1
79
Facilitating a Step Sequence (Therapist at Side) 83 1
Facilitating Standing from the Front 87 1
Alternative Position 89 1
Facilitating of Trunk Rotation in Standing 90 1
Facilitating the Trunk in Standing 9l
Facilitation of the Trunk from the Front 1
91
Stride Weight Shift :1
93
Release of the "Trailing" Leg 94 1
Assisting Involved Leg Forward 94 l
Facilitating Transfers 95
From Bench to Chair - 1 Man 95
Foot Positions for Transfer to Risht 97 -
Two-Man Transfer 98
Facilitating Gait Activities 99 -
Walking Forward (Therapist at Side) 100
Walking Backward (Therapist Sitting in Front)
Facilitating Involved Leg druing Gait
Pivot Toward Affected Side
101
103 i
106 :
PivotAway From Affected Side
Bending Down to Reach for an Object
107
108
I
1
Feet Even and Facilitating Trunk & Hip 108
1
Feet Even and FacilitatingArm 109
Feet in Stride and FacilitatingArm 110 I
Preparation for Stair Climbing 111 :l
:I
I
fr
ff Facilitating Step-Up tr2
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Step-Up with the Involved Leg (Therapist Behind)
Step-Up with the Involved Leg (Therapist in Front)
tr2
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Stepping Down Leading with the Better Leg
Positioning and Early Bed Mobility
Supine
115
It7
118
r: Elevated in Bed 120
t:
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Half Bridging
Placing
r22
t23
t.
rt1
Bridging
Altemate Ways to Facilitate Bridging
Scooting Upper Body
124
125
r27
Moving in Bed
t:
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Rolling to Sidelying onAffected Side
Positioning in Sidelying onAffected Side
130
131
134
t:
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RollingAffected Side to Supine
Rolling to Sidelying with the Less Affected Side
135
137

t:
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Rolling Less Affected Side to Supine
Lying to Sitting at Edge of Bed
Alternative Method for Sidelying to Sitting
139
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Sitting to Lying on Affected Side
Alternative Method for Sitting to Lying
144
146
148
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 I

II\TRODUCTION !

;
This lab manual was developed to assist participants n
in the NDT/Bobath Three
week course on the Treatment of the aoutt ;
Hemiplegia. It shows possible hand
placements and describes inputs
that can be used to facilitate better responses tl
clients' They are suggested hand placements from
but with each client modifications may ;
be needed both in the hand placement
and also in the input in order to achieve
response' It is also important to realize the best
that these are just suggestions to give :
participants possible ways to get started, course
but they must learn to experiment with
through variation to direction and amount them
of input, use of different combinations of
hand placements, and other modifications
to be ableto achieve the best response
the client' Also, recognize that sometimes from
the best input is little or no input. There-
fore, it is the responsibility of the therapist ;
to constantly evaluate the client,s func_
tional abilities and movement patterns in
the following situations:
:
:
1.
-Before -giving input:Assess what the client can do and what
interfering with tuncrion and thus derermine may be
whar i;;";;iriil.
"r;",. i
2. (while eiving) input: Assess whether
?urine any positive or negative
i
changes are occurring in the crient's
movement and thus be able to rriooi4,
that input as necessary.

3. After giving input: Determine if the input

has improved the client,s
movement patterns and/or ability to
function or respond without input.

41

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rr MOBILIZATION
( GENERAL STRETCHING SKILLS)

rr The mobilization shown in this manual covers generalized stretching of the low trunk

ra (lumbar and pelvic movements) and upper trunk (thoracic extension, pectoral stretch
and scapular movements). Also included are ways to inhibit the hand, free up the
metacarpals and carpals and stretch the interosseos fascia in the forearm to allow
a pronation and thus better weight bearing on an open hand.

a The indication for any stretching is decreased range of motion due to soft tissue
- limitations and/or changes in muscle tone that prevent the patient from assuming
- certain positions.
-
- PURPOSE: Increase range of motion to improve structural alignment so that the
- patient can select a more normal movement strategy when performing functional
- tasks.
-
- ASSESSMENT: Always done prior to any mobilization.
- 1. Observe how the patient moves.
a 2. Attempt to facilitate the patient in the desired direction of movement.
3. Determine if there is resistance to movement in that direction.
-
4. Always re-assess during and after any mobilization.
-
-
INTERVENTION:
- 1. Before mobilizing any part, the patient should have a stable base of support
-
t: so that he/she can feel secure and be able to cooperate with the therapist.

-
a 2. Stretching should only be done in the ranges of a movement which are limited and
never to excess. If the patient can move with you into the direction of the tightness,
- you will probably gain range faster and the patient will also be strengthening those
- muscles which will help maintain the range gained.
.
a 3. When stretching any area, enough pressure (force) must be generated to
a overcome the resistance of the part. This pressure must never be abrupl but should
a be graded both when applied and also when released. The therapist must always
t: be aware of what is happening under his/her hands so that damage does not occur.

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4. stretching should always be done in the direction {
of the normal movement. For
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example, mobilization into lumbar extension with

anterior tilt of the pelvis is
done in a forward and up direction, not just a forward
direction.
Thus, with a
better understanding of normal movement the therapist
can be more effective
with any mobilization.

5. Any mobilization should

rrog4atetv ue roiloweo uv (i.e. within the same ffeat-
ment session):

a' teaching the patient how to use the muscles that will maintain
that newly
gained range, and

b' utilizing
the movement in a function so the patient will learn
to use the
increased range in function. The nervous system
does not automatically
use newly gained range in function. It needs to be .,re_programmed,,
through practice and repetition to use newly gained
range and control.

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rr TRIII\K MOBILIZATION

rr If the patient needs mobilization in the low trunk area, the ranges should be checked
in the order in which they are listed. Then, if mobilization is nicessary, it

rr
should be
done in this same order. Remember only mobilize in those areas required.
If the
patient only needs "thoracic extension" or "pectoral stretch, " he/she
still needs at

rr least a neutral low trunk before doing any stretching to the upper trunk.
better extended the thoracic area is, the better the mobility and alignment
Also, the
one will

rr achieve in the scapulae.

area relates to and effec$ another part.

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CLINICAL IMPLICATIONS FOR MOBILIZATION OF THE FI

I

LTIN,IBAR SPINE ANTERIORLY

I
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a
Lack of lumbar extension and the inability to achieve a neutral or slight anterior pelvic
tilt limits the ability to extend the thoracic spine while keeping the shoulders over the
a
hips. It also limits lateral mobility of the lumbar spine. Both of these factors interfere
with efficient use of the trunk and arms (see thoracic extension page 9) and espe- €
cially with trunk adjustments for balance and function in sitting.

MOBILTZATTON OF THE LUMBAR SPINE ANTERIORLY

;*
Posterior View - The hand of the therapist
is pointing down with the palm over the
erector spinae muscles in the lumbar area.
Wrist is straight and elbow should remain
slightly bent with the thigh against the fore-
arm. The patient is facilitated with a for-
ward and up pressure thru the available range
and then the therapist's thigh grades on more
pressure to move the lumbar spine ante-
rior. The elbow should remain bent to main-
tain an upward pressure.

:F

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Anterior View - The therapists fore-

arm is placed across the upper chest
(below the clavicles) in contact with
the upper sternum more than the
shoulders.This arm stabilizes the up-
per trunk to keep the shoulders over
the pelvis as the lumbar spine moves
toward extension.
I

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CLINICAL IMPLICATIONS FOR MOBILIZATTON OF
LI.N,IBAR SPINE POSTERIORLY

Few patients need this as most compensate with thoracic flexion to make up for the
lost lumbar range, but occasionally this mobilization is necessary to enable the
patient to reach his feet to don shoes and socks, particularly if the patient has
limited hip mobility.

;
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MOBILIZATTON OF LUMBAR SPINE POSTERIORLY

Therapist's position - The therapist kneels behind the patient and places her head in
; the lower thoracic area to stabilize the upper trunk. Her knees should not be too close
to the patient. The hands are placed with the thenar eminence over the iliac crest and
the fingers pointing down and forward.The elbows are bent and in line with the hands
t and shoulders. The therapist facilitates the posterior tilt with the fingers over the
abdominals and then rolls the iliac crest back and downward with her arms. The
- therapist must not shift her body back. More force can be obtained by "hanging" her
f
upper body weight on her arms.
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;
CLIMCAL IMPLICATIONS FOR MOBILTZATION OF i
LTI\,IBAR LATERAL SHIFT

Lack of lateral mobility in the lumbar spine is common and is often

assymmetrical.
Patients compensate by leaning with the upper trunk which
compromises balance
reactions and postural adjustments for function in sitting. By increasing
range and
control the patient wilt have ability to scoot forward with alternate
hips unJ huu.
increased reaching range plus have overall better trunk control. patients
who have
weakness on one side of the trunk may get tight on the opposite
side over time which
in turn limits their ability to weight shift with control toward the
better side. Assess-
ing both sides of the trunk is essential.

MOBILIZATION OF LTII\4BAR LATERAL SHIFT

Anterior View - The therapist stands fac_

ing the patient's sitting surface with out-
side leg parallel to the patient,s side. The -€'
near foot is pointing toward the patient. d
The therapist's near hand is placed on the I
far side of the trunk (arm diagonally across
upper chest but not in contact). Fingers
?t--"
I

are pointing downward with the little fin_ I

ger over the abdominals, thenar eminence 4

horizontal over the lateral ribs and the rest 4
14
of the fingers over the posterolateral sur- I

face of the low thoracic area. This hand

position provides for the ability to facili_
tate lumbar extension, abdominals and
prevent the ribs from moving laterally.

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.
e MOBILTZATTON OF LTN,IBAR LATERAL SHIFT
e
e Posterior View - Finger pads kept to-
e gether and pointing down towards the
e opposite hip are placed along the lateral

r
. aspect of the paravertebral muscles and
between the pelvis and ribs. The thumb

rC
is horizontal over the low scapula area
- and the forearm is resting against the
therapist's thigh. The therapist facilitates

rr lateral weight shift with a medial and up

pressure and the thigh grades on more

rr pressure to add stretch. This is then fol-

lowed by a slight lateral weight shift of

rr both therapist and patient to get a little

more stretch.

a
re
-
Posterior View (alternate method)-Therapist must flex her body more in order to
place the ulnar border of the hand along the lateral aspect of the paravertebral muscles
C between the pelvis and ribs. The elbow is level with the hand so the thigh is against
C the posterior aspect of the humerus. Lateralweight shift is facilitated first and then
C the thigh grades on pressure to get a stretch. A weight shift of therapist and patient
cC can also be added for more stretch.

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 CLIMCAL IMPLICATIOI\S FOR MOBILIZATION
OF THE THORACIC AREA

Thoracic Extension - Thoracic kyphosis is very common in older adults and this can
compromise respiration and arm function. (With the upper trunk flexed the scapulae
are positioned in a more elevated and abducted position which results in more difficult
proximal stabilization and thus less efficient arm function and more limited arm
elevation.) Any increase in thoracic extension range can be very beneficial to the
patient's vital function, but it must be done with extreme care as many patients over
40 years old tend to have some degree of osteoporosis.

MOBILIZATION OF THE THORACIC AREA

Posterior View - 1. Therapist's hand

is placed over the paravertebral muscles
at the lower end of the stiffness of the
thoracic curve. Cup the hand so that
the contact is on the muscles with the
thenar and hypothenar eminences and
the spinous processes are located be-
tween those two surfaces but not being
contacted. Fingers and arm are point-
ing straight down so the therapist may
need to kneel on something to get her-
self high enough. Lumbar extension is
facilitated with the finger pads.
t
a
tr MOBILTZATION OF THE THORACIC AREA

tr 2. Once the lumbar spine is extended to

rt neutral, a straight downward pressure is

applied with the arm to extend the thoracic
spine. Following that a forward and up pres-
. sure is applied with the front hand. (See
e anterior view). Therapist's hand always stays

e below the apex of the thoracic curve. The

C therapist's thigh does not push forward but
just stabilizes the arm so it does not slip
C down.
C
C
C
C
tC
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tC
re Anterior View - The front hand which
is spread is placed below the ribs and
-

.
r then slid up to make contact on the infe-
rior edge of the costal cartilages with the
thumb and little finger. (No contact on
the xiphoid process.) As the lumbar spine
.
e achieves neutral the abdominals are acti-
vated with the three middle fingers to
e
a prevent lumber hyper-extension. Then the

r ribs are moved forward and up (as in tak-

ing a deep breath) as the thoracic spine is

re
. extended.

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 I

1
CLINCAL IMPLICATIONS FOR PECTORAL STRETCH I

Pectoral Stretch - Sometimes the pectoral muscles are very tight which pulls the
shoulders forward and the scapula into abduction. This frequently accompanies tho-
1
4
I

racic kyphosis but may occur separately so one must assess which needs to be done
i
I

or both. With less pectoral muscle tightness the patient can position the scapulae in
t-r
I

a more stable position for better arm function. The patient will need to learn how to
stabilize in the new position for this to become efficient. Also, with better trunk 4
I

extension and scapulae position, the head can align itself better over the spine instead
of being in a more forward position. This allows for better respiration and oral-motor
1
function.
a
4
PECTORAL STRETCH
Therapist kneels behind the patient with her knees outside the patient's pelvis. Place
a rolled sheet or towel in the patient's lower thoracic area so that as the therapist
extends her hips the patient is facilitated into extension. The therapist must bring the
patient into neutral extension only. The therapist's hands are open with the first two
fingers along the clavicles, thumb over the shoulder and ring and middle finger over
the upper ribs to be able to facilitate abdominals as necessary. Therapists elbows are
directed anteriorly (i.e. medial rotation of shoulders) as much as possible. After the
low trunk is extended, the therapist facilitates the abdominals and then abducts her
affns, keeping her elbows forward, to spread the clavicles, thus stretching the pectoral
muscles and extending the thoracic area. The therapist must not lean forward as the
patient's head must be allowed to come back as the thoracic area extends.

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SCAPULA MOBILIZATION

Assessment of the position and alignment of both scapulae in relation to the spine is

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-

-
very important.The scapulae work very closely with the trunk, therefore, the thlrapist
must know appropriate alignment and how the scapulae move as the trunk moves in
a various directions. This assessment is essential to determining the direction(s) that

r
need to be mobilize, and the degree of stiffness present. Occasionally the scapula
.
needs to be mobilized in all directions, however only two directions are usually
required. The therapist determines the tightness by first assessing the position of the
. scapula on the trunk, and then by moving the scapula. One should mobilize onlv when
- the scapula does not move easily. Once some mobility is gained in any direction,
- additional range can be gained by combining the passive stretch with appropriate
- trunk movement (flexion, extension, lateral weight shift or rotation) which the pitient
- does actively while the therapist "holds" or moves the scapula.

r
-

.
Once mobility has been gained, the therapist must work on achieving scapular stabil-
ity through a great deal of upper extremity weight bearing activity, with the arm in
different positions around the body. All patients with proximal upper extremity weak-
-
ness tend to elevate the scapula during arm function. This will soon become a habit
-
and thus must be stopped if the therapist wishes to help the patient achieve the best
-
a possible arm and hand function.

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CLINCAL IMPLICATIOI\S FOR i.
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SCAPULAR MO BILTZ ATION IN ABDUC TION
?
Scapular Abduction - Usually it is the patients who are several years post insult ;-
who
have tight scapular adductors and this is often due to high tone. These patients
may
?
need mobilization into abduction to gain the necessary mobility for
active abduction ?,
and upward rotation for reach. ?
?
?
SCAPULA MOBILIZATIONS

Therapist sits at the side of the patient with her leg curved around the patient,s a
back so she can facilitate extension and lateral weight shift toward her. Before
low
a
mobilization the trunk should be brought into neutral extension.
each
1
a
a
-
MOBILIZING THE SCAPULA IN ABDUCTIOI\ a
a
a
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Anterior View - The hand is placed
:r
with the thenar eminence in the pos-
:r
terior concave surface of the clavicle
:r
and the pads of the fingers on the up-
per sternum or close to it. Stay off the :r
Pectoral muscles. This hand stabilizes :l
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the rib cage while the back hand moves
the scapula. :t
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MOBILIZATTON OF THE SCAPTILA IN ABDUCTION

Posterior View - The hand is horizontal with the fingers spread. Contact is made
1 primarily by the PIP joints over the dorsal aspect of the vertebral border. A slight
- pressure into the rib cage (to approximate the scapula) is made and then the scapula
is slowly moved in a lateral direction. A slight pelvic lift on the opposite side ( in this
case the right side) at the end of the lateral movement, will gain more abduction.
1 il.
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C LII{I C AL IMPLIC ATIONS FOR S C APULAR MO BTLIZ ATION

IN ADDUCTION
Scapular Adduction - Most patients tend to have a scapula that is already in abduc-
tion (often at end of range) because of the upper trunk flexion posture and also the
weight of the arm pulling on the shoulder girdle. Therapists may also teach the patient
to bring the arm across the body to protect it which tends to pull the scapula forward
into abduction. Thus, patients may become tight anteriorly and may need mobilization
into adduction. Thoracic kyphosis can also contribute to this tightness. A scapula that
f^, cannot adduct will limit arm movement into extension and reaching behind the body
I
with trunk rotation. It also compromises the ability of the scapula to stabilize proxi-
I
f-r mally which can interfere with all arm function.
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 MOBILTZATTON OF THE SCAPULA IN ADDUCTION

Anterio-lateral View - The front hand is

placed around the opposite upper humerus
with thumb lightly over the shoulder.The
arm is across the upper sternum to stabilize
the rib cage and be able to keep the
abdominals facilitated with a slight down_
ward pressure. A slight counter rotation
pressure may be required to keep the shoul_
ders aligned over the pelvis.

Posterior View - Thumb and thenar eminence are placed lateral

to the axillary border
of the scapula so that the fingers point diagonally across the scapula.
An inward 5
pressure is applied over the vertebral border to make the
axillary border more acces- A
sible' Then the thumb and thenar eminence move the scapula back and medially
J
around the ribs toward the spine.

a
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6
I

I
 AN ALTERNATIVE S CAPULAR ADDUC TION

Front View
The back hand is placed as seen in the previously described posterior
View. The front
hand is placed under the clavicle on the involved side with the
heel of the hand over
the anterior shoulder to stabilizethehead of the humerus. The
scapula is adducted as
much as possible by the therapist and then the patient is asked
to turn her head, neck
and trunk toward the opposite side and to bring the better arm
behind her back.
Meanwhile the therapist maintains the scapula adduction, which is
very difficult to
do. This will give a very good stretch to the Pectoral muscles on
the involved side.
If the patient's elbow comes away from the body, the therapist can use
the elbow of
her front arm to control that. This could cause pain if the patilnt
is tight so the rotation
should be graded to stay within the patient's pain tolerance.

;" r
:,:';

CLIMCAL IMPLICATIONS FOR

SC APULAR MOBTLTZATION N ELEVATION
Scapular Elevation - A patient may become tight in the scapular
depressors if he/
she is habitually collapsed to that side. The therapist must
assess carefully to deter-
mine if there is real tightness as this is much less common. Tightness
in the down-
ward rotators (latissimus dorsi & lower trapezius mostly) could also
contribute to this
tiehurcss.

t6

7
 a
a
SCAPULAR MO BTLIZ ATION IN ELEVATION a
a
a
:1
a
a
Antero-lateral View - The pads of the
a
fingers are placed over the upper ster-
a
num to stabilize the upper trunk. The
J
thenar eminence is in the posterior con-
a
cave surface of the clavicle. The thenar
J
eminence can assist the elevation of the
clavicle as the scapula is elevated with J
the back hand. All pressures on the an- J
terior surface of the trunk should be light. J
J
J
J
J
J
J
J
J
J
J
.1
Posterior View - Hand is cupped .1
so the the inferior angle of the
,1
scapula sits in the palm of hand ,1
and there is light contact with the ":1
fingers. A slight pressure inward .:1
is applied (to approximate the ,:l
scapula) and then the scapula is ,1
elevated by an upward pressure :l
below and around the inferior 1
ansle. :l
1
:l
:l
t7
1
:l
J
I
r
r CLINCAL IMPLICATIONS FOR
r SCAPULAR MOBTLIZ ATIOI\ IN DEPRESSION
r
r
r Scapular Depression - Scapular elevation is the active motion that many patients
r can perform early and it tends to be used when attempting any arm movements or just

r generally becoming tense in the upper trunk and neck. Therefore the patient more

r commonly becomes tight in the scapular elevators and needs to be stretched into

r depression.

r
r Scapular elevation tends to become a habit so the therapist must constantly cue the
patient to stabilize (not elevate) when doing any arm or hand movement once the
r range and stabilizing strength have been achieved. Otherwise arm and hand fuction
r- frequently deteriorates over time. Scapular elevation also compromises proximal
stability and limits arm elevation.
r
rC SCAPULAR MOBILTZ ATION IN DEPRESSION
C
rC
rr
rr Anterio-lateral View - The hand is

rC placed with the middle finger under

the anterior convex edge of the clavicle

rr with the index finger right above it.

As the scapula is depressed with the
back hand, the clavicle can be rotated
. on its long axis by a slight upward
. pressure with the middle finger.
.
i
ra
a
t"^
I,
rt-
C. 18

-
r
 I

1
SC APULAR MOBILIZ ATION IN DEPRE SS ION :1
1
a
:1
Ws" :1
b.s€I
- @t: :1
:1
uN
a
:1
:1
a
a
a
1
1
1
1
-1
-1
1
1
'1
Posterior View - Place two or three finger pads above the root of the spine of the
1
scapula and rest the remainder of the hand over the scapula. Apply a slight inward
pressure with the hand to approximate the scapula and then move the scapula down- -l
ward with the pads of the fingers. This should be a straight downward pressure with -l
no lateral trunk flexion. 1
1
Note: The patient can assist by moving the head and neck in a diagonal direction 1
(flexion, lateral flexion and rotation) away from the scapula while the therapist holds 1
the scapula down. 1
1
1
1
1
1
1
1
I

e
.
a Alternative Movement -Front View
- Additional stretch of the neck muscles can be achieved by having the patient
diago-
. nally flex the neck with head rotation toward the opposite side *ttitr
the therapist
. maintains the scapular depression previously achieved.
-
-
-
.
a
ra
.

.
a
-
r
C
.
rt-
rC Alternative movement - Front View
Sometimes adding movement of the head and neck into lateral
flexion away from the
involved side while the therapist maintains the depression, helps to get
a release of the
tight neck muscles which prevent furl range of depression.
C
re
e
c
e
rr
r
rr
r:
r:
f:
C
r:
20
r.
F
r
 I

1
UPPER EXTREMITY STRETCHING 1
Mobilization of the trunk and scapula usually helps to reduce the tone in the UE so
1
that these should precede any UE stretching. The inhibition of the hand will help you
:1
:1
determine if mobilization of the metacarpals, carpals and forearm are necessary. If the
a
hand is extremely tight and you cannot get a hold of the first metacarpal to inhibit the
a
hand, then mobilize the metacarpals first. Metacarpal mobilization should always pre-
cede carpal and forearm mobilization. 1
a
Once you can get the hand in weight bearing (on a flat or curved surface) maintain it :1
there with the arm in as much lateral rotation as possible; then have the patient move :1
the trunk over the arm. Use small movements at first and gradually the tone will :1
decrease. The patient should be encouraged to actively weight bear on the hand, but :1
this will probably need to be facilitated. (See section on facilitation of the arm in :r
weight bearing page 48.) :1
:1
:r
:1
:r
:1
:1
:1
:1
:1
:r
:1
:1
:1
:'l
:1
:l
:l
:1
:1
:r
:r
:r
:r
:l
rr
I

rr CLIMCAL IMPLICATIOI{S FOR INHIBITION OF THE HAND

rr Inhibition of the Hand - This handling skill is performed to enable the patient's
hand to be open on a surface in weight bearing. Once this is achieved it should
be

rC maintained throughout the session. The patient should also be taught to inhibit his own
hand and place it on a surface. If the hand is in a weight bearing position appropriate

-
r for the function on which the patient is working, then he might use it automatically.
So the hand position should always be considered for whatever function the patient
preparing to perform. It is very normal for one hand to be in weight bearing while
is
the
r: other is involved in the task more directly.

t:
ra
a INHIBITION OF THE HAND
C
e The patient should be sitting in midline and in as good a posture as possible during
C this process. Usually this sequence is preceeded by increasing trunk and shoulder
C girdle mobility when necessary.
C
C
C
C
C 1.
C The therapist sits in line with
the patient's elbow and hand.
C The patient's arm should be
C away from the body with
C much lateral rotation as is com-
as

C fortable for the patient. Keeping

C one's hands off the flexor sur-
C faces of the arm and hand,, cor-
C rect the wrist deviation but keep
C it slightly flexed.
C
C
C
C
r:
r:
r:
t; 22

r-
r
 I

a
INHIBITION OF THE HAND a
a
a
"1
a
a
a
a
a
a
a
a
a
a
a
2. The therapist, using her right hand on the patient's left hand (or vice versa), places a
her finger pads on the shaft and head of the first metacarpal and the heel of her hand a
on the dorsum of the patient's hand. The thumb can be placed on the lateral aspect a
of the distal phalanx if it is accessible, but very little pressure should be applied at that a
point as it is possible to sublux the MP joint. The therapist's other hand is contacting
a
the palmar surface of the head of the 5th metacarpal to apply a lateral pressure to
a
spread the metacarpals. Note: Keep the wrist in neutral deviation with slieht flexion.
a
a
a
3.Maintain the above position a
and spread the metacarpals; a
radially abduct the patient's a
lst metacarpal and thumb by a
applying a lateral pressure on
a
the shaft of the metacarpal and
rolling the thumb out (thereby
a
increasing the distance be-
:1
tween the heads of the 1st and
:l
5th metacarpals).This is done :1
by the therapist extending her :1
MP joints with a slight :l
counter pressure on the heel :r
of her hand. :l
:l
:l
t

a
rr INHIBITION OF THE HAND

ra
rr
r
rr
-

rr
-
t-
:ffimrr.=
a
r
rr
.
4. While maintaining the metacarpal spread, the therapist pivots her left hand on the
head of the 5th metacarpal so that her index finger lies under the heads of all the

r metacarpals (2 - 5) and the rest of her fingers are inside the patient's fingers. This is
most easily done if the wrist and MP joints are kept flexed.
.
rr
rr 5. Maintaining the wrist

rr and MP flexion and the

metacarpal spread, the

r therapist uses her thumb

and fingers to extend the

r
- PIP and DIP joints of the
patient's fingers. She

rr
. spreads her fingers while
applying a counter pressure
with her thumb on the dor-
a sum of the fingers. This
a may need to be done one or

a two finsers at a time.

a
rr
rC 24

C
r
 I

:1
TNHIBITION OF THE HAND a
a
a
a
a
a
a
a
a
a
-
a
a
fl
1
-1
6. Once the fingers are extended the therapist maintains a "shelf" with her fingers
to maintain them, while the wrist and MP joints stay flexed.
1
1
Fl
Fl
7. Keeping the wristbent
1
and the PIP's and DIP's
extended, the therapist
1
maintains her index fin- 1
ger under the patient's
MP joints and slowly a
extends those joints with 1
her fingers raising the 1
patient's fingers on the
palm. The therapist
keeps her index finger
^cl
under the heads of the
..
metacarpals to prevent
J
hyper-extension.
J
J
J
J
25
J
J
 INHIBITION OF THE HAND

8. While maintaining the previous position, therapist applies an upward pressure on

each head of the patient's metacarpals while stabilizing the wrist with the ulnar
border of her other hand. Do not push down on the wrist. Note: The therapist may
get beffer releases by alternating back and forth between #5, #6, #7 ,, and #8.Itis very
important for the therapist to "feel" what movement(s) help release the hand most.

9. Once the hand is open the therapist maintains this position and finds an appropri-
ate surface on which to place the hand for weight bearing - ie. flat preferably but it
may need to be curved if the hand cannot be fully opened. The therapist places the
hand down contacting the ulnar border first and then rolling the palm and thumb
down. The therapist slides her hand distally out from under the patient's fingers and
lastly takes her hand off the thumb which is maintained in radial abduction.
26
 II\HIBITION OF THE HAND

10. If contact is necessary to maintain the hand on the surface the therapist uses two
fingers to maintain weight bearing over the wrist with a distal pressure into the sur-
face (not too heavy). The rest of her hand can rest lightly over the patient's hand to
monitor the finger position and also to maintain thumb abduction.
 CLIMCAL IMPLICATIONS
FOR MOBILIZING THE METACARPALS

Metacarpals - If a hand is constantly fisted, the tissue between the metacarpals

becomes tight and then it is difficult to get the hand open on a surface for weight
bearing. To achieve better hand inhibition the thumb should be radially abducted
and the metacarpals spread, which is what normally occurs when the hand is in
weight bearing.
MOBILIZATION OF THE METACARPALS
Dorsal View - The therapist places her thenar eminences over the dorsal aspect of
t the patient's 4th & 5th and 2nd & 3rd metacarpals with the thumbs resting lightly
over the wrist.

t
)

*,

.)

28

t
 'r*t
MOBILIZATTON OF TIIE METACARPALS

Palmar View - The pads of the therapist's left fingers are on the shaft and head of
the lst metacarpal and the right finger pads are on the shaft and head of the 5th
metacarpal. The metacarpals are spread and the wrist is kept slightly bent; then a
down and away pressure on the 4th & 5th metacarpals is applied with the right
thenar eminence while and up and away pressure on the thumb is applied with the left
finger pads. These pressures are then reversed to slowly stretch the tissues between
all the metacarpals while always maintaining the metacarpal spread.

1
I

-1 I

1
I

1
I

1
'*4

4
I

1 I

1 I

a
a
a
a
,a

a
a
:1
,a

-,
29 ,J

:l
;
,i4
CLINICAL IMPLICATIONS FOR MOBILIZING THE CARPALS
;

; Carpals - A hand that has been fisted with the wrist flexed frequently has become
,d tight between the carpals. Also they do not move appropriately in relation to one
; another with the various wrist movements. This usually cannot be determined until
the metacarpals have been spread and the hand has been inhibited. Without free
; movement of the carpals it is impossible to get good wrist extension and it will tend
to be painful.

;
MOBILIZATTON OF THE CARPALS
;
Palmar View - The same hand position used in the metacarpal mobilization is used
; for the carpal stretch except that the pads of the index fingers of the therapist are
placed on the distal row of carpals. The left index finger pad is placed on the proxi-
; mal edge of the tubercle of the trapezium and the pad of the right index finger is
placed on the proximal edge of the hook of the hamate.
;

tF
I
la

I
l-
I
la
I

I
I1
7
Ja

30
-
r
I

r
I
 a
MOBILIZATION OF TTIE CARPALS a
1
a
a
a
a
a
a
a
a
a
a
a
a
a
,:1
3
1

Dorsal View - The wrist is kept flexed by the counter pressure of the therapist's thenar
eminences (not thumbs) while a pressure is applied distally (toward the fingers) with
the index fingers on these two prominences. The rest of the therapist's fingers main-
tain the metacarpal spread.
rr
I

rr CLINICAL IMPLICATIONS FOR MOBILIZING THE FOREARM

INTO PRONATION
Forearm into Pronation - This stretch is only necessary if the first metacarpal
t--
cannot be maintained on the surface following the other UE mobilizations. If you
- cannot keep the thenar eminence down then it is more difficult to maintain the hand
- in weight bearing to help control the tone and allow for UE weight bearins.
t--

-
- FOREARM MOBILIZ ATION INTO PRONATION
-

rr- 1. The distal phalanges of the therapist's index fingers are placed under the distal
radius and ulna on the volar surface. (This keeps the fingers off the flexor tendons and
muscles of the forearm.)

-
rr
ra
ra
a
-
rr
a
rr
a
r
r
a
rr
rr Z.The thenar eminences of the therapist are placed over the dorsal surface of the distal
C radius and ulna. The right hand stabilizes the patient's ulna while the left hand rotates
r- the distal radius into more pronation by applying a down and medial pressure with the

r. thenar eminence.

r:
r: 32

r:
r
 FOREARM MOBILIZ ATION II\TO PRONATION

3. With the patient's hand on a firm surface, the therapist places the pads of 2 fingers
of the right hand on the proximal end of the radius and the thenar eminence of the left
hand over the distal radius. Applying a distal pressure (in the direction of the radius)
at the proximal end of the radius with the right hand, and a down and medial pressure
with the left hand the therapist can stretch the proximal forearm tissues into more
pronation.

aa
JJ

1
I
t:
rr: FACILITATION

rr In contrast to mobilization, facilitation is always light. you are influencing

receptors of the patient through contact and building tension (isometric
the skin
muscle con-
r:
rr traction of the therapist) usually over the muscles you are trying to activate.
muscles activate' the therapist guides the movement in the direction
would move the part. (See specific activities.)
As the
that these muscles

-
a The descriptions of the facilitation for each of the various activities
are examples of:
a. different positions the therapist might be in relation to the patient.
-
a b. a sampling of activities that can be done.
c' a variety of hand and arm positions that can be used to accomplish an activity.
-
a The therapist must make choices according to the needs of the patient
a of the body need to be controlled and/or facilitated to accomplish the
and what parts

a activity.

a Some of the earlier activities are parts of more complicated

activities or functions so

r
-

-
the therapist needs to understand the normal components of the
task so that heishe can
facilitate whatever the patient is unable to do himself. For example,
be able to sit up independently but when he attempts to reach forward
the patient may
across the table
a to get an object, the trunk collapses which limits the patient's reach, decreases
a efficiency and may make the patient unsuccessful. Patients need to not
only be able
a to achieve an alignment, but they need to be able to sustain that alignmenr
or posfure
a as they then move over the base of support and into a function.

ra
C AIMS:
1. To achieve
2.
the best alignment of the trunk and limbs for the task.
To inhibit abnormal tone through weight bearing in good alignment.
a 3' To incorporate both sides of the body and thus u.tti.u. more riormal sensorimotor
r: experience.
C 4. To facilitate active participation of the patient.
C 5' To enable the patient to incorporate more normal movement components
into

rt:
C everyday function, through repetition and practice of the specific components
necessary to accomplish the function.

C
t:
C
C
F
 FACILITATION

The activities shown demonstrate very basic movements and how to facilitate them in
a variety of ways. These movement components may be preparatory to or part of a
variety of more complicated activities or functions. They are examples of trunk
-
facilitation in different postures and ways to facilitate UE and/or LE weight bearing
in preparation for function.The activities are grouped according to activities in sitting,
different transitional movements, standing activities and gait, with the therapist posi-
tioned first at the side and then in front. A variety of positions are shown for gait. This
order is not necessarily the order in which these activities are taught during a course.
They are presented in a sequence with the therapist in one position to provide a natural
flow of movement activities. Each activity builds on the previous one, but in a therapy
1
session one needs to work on only those specific parts with which the patient has
difficulty. The table of contents will help you find the specific activity that you need.
1
'€1 1

The descriptions and photos are guides as to approximate hand and body placements I

and movement directions. The therapist must adjust the hand placement, input and
1
I

his/her own body position according to the needs and responses of the patient. The
therapist's own body structure and mobility may also influence where he/she places 1
his/her body. These are examples of a variety of handling skills but they are far from 1
1
I

being all-inclusive.
€'1

1
I

The success of any mobilization andior facilitation is dependent upon:

1. An accurate assessment of the patient and his/her problems which interfere with '--1 I

1
I

function. This assessment must be done prior to the application of the handling
_l
skill, as well as during and after its application. >t
_t
2. Achieving and maintaining appropriate biomechanical alignment during the appli- '.n
-l
cation of the handling skill. a<
3. Continual re-assessment of the responses of the patient which guides the therapist :1
I

in modifying the input to achieve the best possible results. I

a
A great deal of emphasis has been placed on the trunk and proximal areas because they
a
provide the foundation for all head, neck and timb movements. Without appropriate
mobility and then stability while moving over a base all limb function is compromised a
and becomes more difficult. If the therapist can help provide and maintain the best a
possible alignment for the patient, while that patient is recovering function, the thera- a
pist has a much better opportunity to bring out the greatest potential of the patient.If a
the therapist does not assist the patient in using both sides of the body most efficiently, a
then the therapist will be contributing to the patient's learning non-use. It is not a
enough to tell the neurologically involved patient what to do. One must help him a
through manual facilitation and verbal feedback, to reach the most potential possible. :1
J
35
:r
I
T
r
rr FACILITATION

rr The acdvities are presented

in a sequential flow from simple
The therapist needs to determint to more complicated.

rr and work on those components

whut movement components
to improu. th... Then
are missing or weak
the therapist can continue

rr
movemenh making sure ro with
#:::#tlicated r*intut. trr. wiut.r components
as

rr ff::T.1fi'I}'ul|:1il?;ffi; t chauenge patienrs so they conrinue ro improve.

toimprove.ont,orof specin";jj:il;i,".5fJffiJl:;l#ilHifl?"?il.j*ti
done with the parienr on t
- i, f..ifi . standing unl *ufnngl.
a does little to
improve a padent's function
be challenged at the revel
Wo*ing in horizonral
in ,itiinglstanding or gait.
The patient must
- u, *rri.tr he is n nrti3ning,
control body alignment over or beyond, while helping to
G the base of supporr. t*oqporating
a activities frequently brings
and enables the patient to
in uutoruti. upp.. extremity
trtp riirt rri, own alignment and
arm support into these
weight bearing responses
G control.
G
C
C
C CLINICAL IMPUCATIOI\S
FOR FACILITATI]\G
C ACTTITIES IN SITTII\\IG
t:
;, Activities in Sitting - when
r. sitting, normal individuars
ments as they function' use a variety of trunk
Many of thise u.. ro* t urrk move-
f: lateral flexion and rotatiott -ou.-"n,, oT.*tension, flexion,
uno-the correrponffi movements
E and lateral pelvic tilts or of anterior, posterior
a combinatil;;*"f
E without
impossible to achieve an
tt"tipor*re with thoracic extension, lumbar extension it is
r mises arm function' Also, which in turn compro-
tut'J flexion in the lumbar spine requires
h sion and a neutral or slighi neutrar exten-
un*rio. tilt of tte pervis. Each
h a specific trunk movement lab activity is directed at
or combination oi *ou..ents
f complicated functions' The which are parts of more
b,

rt help the patient gain controt

therapistshoulo t".t on the necessary component(s)
to
orthe movement and strengthen
Il| components should be put the muscres. Then those
into functions whicr.rrr. pu,i.nt
(
t
basic tunctions (i.e. scooting,
rift-oh,;;r;;r#;io needs ti*.n. some very
( the therapist
uE weight bearing) have been
I
il?ilil;but -"utt uoo to these uv o.*r*ining the specific
needs of hisi
t

36
 I

1
FACILITATING ACTryITIES N SITTING 1
1
FACILITATION OF ANTERIOR TILT 1
'-1
Postero-lateral View - The open and relaxed hand is placed over the lumbar erector
spinae muscles and both therapist and patient are slumped. Therapist tenses her hand 1
to activate the extensor muscles of the patient and lumbar extension is guided with a 1
forward and up pressure. As this occurs both patient and therapist sit up (i.e. extend). 1
1
INITIAL 1
1
1
1
1
1
1
*1
*l
1
1
1
1
1
1
1
FINAL
1
1
1
1
1
1
1
1
1
t-
.
- FACILITATING ACTWITIES N SITTING
rr
.

Anterior View - 1. The pads of the thumb and index finger of the front hand are
placed on the lower edge of the clavicles. (Note: Therapist's web space should not be
-
fully spread.) If more thoracic extension is needed as the patient becomes more erect,
C
a the therapist spreads the clavicles with her thumb and index finger at the end of the

r movement.

.
r
.
rr
.
.
.
rr
.
rr
rr r
rr
rrr
rr 2.To facilitate the abdominals with this hand placement, apply a slight down and back

rrr pressure (into the pelvis) with thumb and index finger pads. The rest of the hand is
relaxed and the elbow should be down.

r:
rr
 I
*1
FACILITATING ACTIVITIES IN SITTING 1
1
FACILITATION oF ABDOMINALS (atternate hand position) 1
a
a
a
a
The hand is relaxed and placed directly over
a
the abdominal muscles with the thumb just
below the xiphoid process and the pads of
a
the ring and little finger near the pubic :1
symphasis. The hand is tensed with slight a
opposition and MP flexion. The fingers stay :1
extended. The pressure is very light. a
:1
:1
:1
:1
:1
a
:1
a
FACILITATION oF THORACIC EXTENSION (alternate method) :1
a
:1
:-r
Posterior View - The hand is 6l
horizontal over the lumbar back -l
muscles to facilitate lumbar exten-
sion as done previously. To get
a
I

additional thoracic extension at the

a
end of the movement, bring the
a
thumb and index finger up over
a
the thoracic extensors (while keep-
ing the ulnar border of the hand in a
contact with the lumbar area to a
maintain lumbar extension). Then a
apply a downward pressure with a
thumb and index finger pads to a
get the thoracic extension. a
a
a
:1
I
r:
rf: FACILITATION OF ACTTVITIES IN SITTNG
FACILITATION FOR SCOOTNG FORWARD WITH
-
- RIGHT HIP FROM THE SIDE
e
r
-
1. Facilitate weight shift to left (toward
therapist) - Therapist facilitates an erect
trunk and gets co-contraction to maintain
- a neutral pelvis. Therapist's hand is angled
- so that the pads of the fingers are over the
- lateral aspect of the right paravertebral
e muscles just above the iliac crest. The
e thenar eminence is over the bulk of the
e paravertebral muscles on the left.The
e therapist activates the right quadratus and

t: lumbar extensors with a medial and up-

e ward pressure. As the hip begins to lift

e the therapist weight shifts to her left with

e the patient and facilitates more extension

of the left paravertebral muscles, with her
C thenar eminence. Note: Therapist and pa-
C
cC tient must shift weight together as the
patient's hip lifts.Therapist's front hand
keeps the patients shoulders over his hips,
C not allowing patient to lead with the shoul-
c ders.

-
ct: 2. Facilitation of right hip forward
cr: Once the right hip is elevated and the
patient is weight bearing on the left hip,
the therapist moves her right thumb
C down to where the fingers were to
C maintain the elevation. The pads of the
C fingers move down to the back of the
C right pelvis to facilitate the pelvis for-
C ward. The patient advances the hip
C by weight bearing on his right foot and
C pulling with the hamstrings or calf
C muscles.

C
C
C 40

C
e
 a
*1
FACILITATNG ACTIVITTES N SITTNG
-1
-l
1
,-1
3. Facilitation of left hip elevation *1
(weight shift away from therapist) -
-1
The pads of two or three fingers are placed
over the left paravertebral muscles just I
above the iliac crest and the thumb is placed -l
*l
over the low thoracic extensors and lower
scapula to help maintain extension. The 1
therapist facilitates left hip lift with a cue 1
in a medial and upward direction (toward 1
opposite shoulder). As the hip lifts, the 1
therapist and patient weight shift slightly 1
toward right. 1
1
1
1
FACILITATING LEFT HIP LIFT (Alternate Front Hand Position) 1
1
1
-l
1
The hand on the patient's back is facili-
1
tating the left lateral paravertebrals and
1
quadratus muscles to lift up, while the
1
thumb maintains thoracic extension and
1
scapular approximation. The therapists's
front hand could be placed over the 1
patient's near shoulder with the finger "1
pads below the clavicle, facilitating the
abdominals while the thumb maintains
1
thoracic extension and scapular
approximation. The therapist's whole hand
keeps the shoulders from initiating the
movement.

41
t-
C
t:
rC FACILITATNG ACTTVITIES N SITTNG

C
cr 4. Anterior view - The therapist's front hand is open with index and thumb pads
under the clavicles to stabilize the upper trunk and facilitate the abdominals as previ-

rr:
C ously described.
OR

r: 5. Front hand could be positioned over the patient's near shoulder with therapist's
finger pads below the clavicles and thumb on the scapula. This hand position may
C enable the therapist to control shoulder movement better and still be able to facilitate

ca
- the abdominal muscles.

ra
C
r
C
C
t:
r
r:
r
r:
r-
C
C
t:
C
C
C
G
C
C
C
C
 *l I

FACILITATING ACTIVITIES IN SITTNG 1

1
FACILITATION FOR SCOOTNG FORWARD 1
WITH THE LEFT HIP 1
1
1.The Therapist's front hand keeps the patient's shoulders over the pelvis and the 1
abdominals active.The thumb of the therapist's right hand moves down to the lateral 1
*l
paravertebral and quadratus muscles to maintain the hip lift. The finger pads move
*l
down onto the back of the pelvis to cue it forward.
*l
ALTERNATE WAY TO SCOOT HIPS FORWARD 1
*l
2. The therapist's right hand stays in position as shown( on page 39, #3), to facilitate
the hip lift. Once the hip is lifted the therapist's left hand moves from the upper trunk 1
or shoulder onto the distal thigh of the patient's involved leg. A downward and I1
forward pressure is given into the patient's heel to assist the patient in pulling the left
side of the pelvis forward with his leg. (Note: This is easier when the patient's heel *l
is under the knee and not behind it.)
-l
-l
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
,f
rr FACILITATING ACTIVITIES IN SITTII\G

rr TRTINK FLEXIOI{ AND LIFT.OFF WITH

rr TRLII\K ERECT

rr
rr 1. The therapist facilitates an erect trunk

rr with her right hand, followed by the

abdominals. Using her left tranO to

rr achieve a co-contraction. Then the pa_

tient bends forward at the hips while

rr
therapist maintains an active trunk (i.e.
thoracic extension and active abdomi_
nal muscles).

r
J1
rr
C
fi
C
C
rt: 2. Lateral View (Intermediate posi-
C tion) - As the patient bends forward
C so
his shoulders come over his distat thighs,
C the therapist slides her back hand up
C over the thoracic area so she can get her
C elbow over the posterior aspect-of the
C pelvis, while maintaining active exten_
C sors and abdominals.
C
C
C
C
C
C
C 44

C
r
 I

1
FACILITATING ACTTVITIES N SITTNG 1
*1
a
1
1
3. As the patient's shoulders move forward
1
over his distal thighs, the therapist gives a
forward and up cue with her arm (in the di-
1
*1
rection of the inclination of the trunk) while
maintaining the patient's abdominals and tho- 1
racic extensor muscles active. The thera- 1
pist also bends forward herself to assist the 1
lift-off. If the toes come up (as seen in this 1
picture), the patient's weight is too far back. 1
This could be resolved by bringing the 1
shoulders more forward or the feet further 1
back. 1
1
1
1
1
SEQUENCE OF SCOOT BACK (from side) 1
1
1
1
Posterior View -1. Therapist sits beside and 1
facing patient with the near leg extended un- 1
der the patient's thighs (to get it out of the 1
way). Therapist facilitates an erect co-con- 1
tracted trunk. 1
1
*l
*l
1
*l
*l
*l
I

-
- FACILITATING ACTTVITTES IN SITTING

rr
-

rr
ra 2. The patient bends forward at the hips and
the therapist slides her hand up and places her
elbow on the patient's pelvis, near the sacrum,
as his trunk inclines forward. When the shoul-
- ders get over the distal thighs, the therapist gives
- a forward and up cue with her arm to help the
- patient lift his hips. Therapist may also need
- to lean laterally (left) to keep from blocking the
- patient's movement.

r
-

r
-

rr:
-

a
a
ra Anterior View - The therapist's far leg
t: is placed so as to contact the patient's
lower leg just below the patella and on
C the antero-lateral aspect. As the patient
C lifts off the therapist allows the leg to
C come forward slightly (so patient can get
C weight over feet). The therapist applies a
C slight back pressure with her leg to help
C patient move the hips back on the sur-
C face. The shoulders should be kept for-
C ward until the hips are down on the sur-
C face.

C
C
C
C
C
C 46

r:
r
 *l
)

FACILITATING ACTTVITIES IN SITTING 1

1
FACILITATE LIFT OFF & SCOOT BACK (leg assisted) 1
1
1
1
1
1. The therapist sits beside the patient and 1
brings her near arm around the patient so 1
that her forearm can facilitate low back
1
extension. Her fingers can facilitate the
1
abdominals (with a light back and up pres-
1
sure). The hand of the other arm is placed
1
over the distal thieh of the affected les.
1
1
*l
*l
1
"l
1
*l
1
1
*l
2.The patient and therapist bend forward
at the hips. As they lift-off, the therapist
1
exerts a down and forward pressure into
the patient's foot to facilitate lift off. The
therapist must move with the patient and
do what the patient needs to do. As soon
as the hips are unweighted the therapist
gives a backward cue on the thigh to as-
sist the hips in moving back. Both thera-
pist and patient stay flexed at the hips thus
keeping the shoulders forward and the
weight over the feet.
,f
cr CLINICAL IMPLICATIONS FOR FACILITATING
WEIGHT BEARING OF THE ARM
C
C It is important to get the arm in weight bearing as soon aspossible in treatment. The
t:
r:
arm and trunk work together normally and doing activities which combine them will

rr
increase muscle activitiy in the trunk, as well as begin getting some activity in the
extensor muscles of the arm. Proprioceptive input from weight bearing and move-
ment helps the patient become aware of the limb. Weight bearing on the arm can be
combined with sitting activities such as lateral weight shift, scooting forward and
C back, lift-off and reaching, as well as standing activities.
C
C
rC In sitting, the placement of the hand in relation to the trunk also determines how much
one tends to push with the arm. When the hands are beside the hips, the arms are
more active than when the hands are placed on the thighs. Where the patient's hands
f: are placed in the beginning may be partially determined by the range and/or the
C presence of pain in the shoulder and/or wrist. One must always stay below the

C threshold of pain.

C It is important that hip movement be initiated in the low trunk without allowing the
C shoulders to lean away. (Leaning the shoulders causes the hand to come out of weight
C bearing and may also cause pain.) Facilitating approximation of the scapula against the
C rib cage also enhances the response. Note: Maintaining an active and erect trunk is
C also critical to achieving a positive response.
C
C FACILITATING WEIGHT BEARING OF THE
C ARM WITH WEIGHT SHIFT
C
C
C Anterior View -1. The therapist sits beside the
C patient with one leg behind the patient and the other
C leg positioned in front to prevent leg abduction and
C maintain the left (involved) hand in weight bearing.
C The therapist's foot can be placed over the patient,s
antero{ateral tarsal bones to maintain the foot in
C weight bearing. The therapist's front hand is placed
C over the patient's near shoulder with the finger pads
C below the clavicle to facilitate abdominals and the
C thumb on the scapula to approximate the scapula
C against the rib cage.
C
C
rz
rz
 *l I

FACILITATING WEIGHT BEARII\G OF THE ARM 1

WITH WEIGHT SHIFT :1
1
,--l
,."1

Posterior View -2. The therapist's right

1
...*1
hand is placed with the pads of the fin-
1
gers in the lumbar region and against the
1
lateral paravertebral muscles just above
1
the iliac crest to facilitate lateral shift
1
using a medial and up pressure.
1
1
1
1
1
1
1
*l
3. The therapist's right thumb pad is on
the back of the humerus to give a down 1
and slightly forward pressure into the 1
heel of the hand to facilitate arm weight
1
bearing to assist the patient's pelvic lift
and lateral shift.
1
*l
1
:r
1
:r
:l
:r
:l
4. Same as above, except that the patient's :l
hand is on a table and is not maintained in
:l
weight bearing by the therapist's leg.
:f
l-
f:
C FACILITATNG WEIGHTBEARING OF TIM ARMWITH
- REACHING
- Posterior view
-
t: The patient is sitting with left (involved) upper extremity in weight bearing and reaches

r up with the opposite arm. The therapist is sitting beside the patient with her foot on
top of the tarsals of the involved foot and the thigh over the involved hand which is on

r
- the surface. The patient is sitting erect and the therapist facilitates lateral weight shift
with the finger pads of her right hand by giving a cue in and up toward the opposite

rt:
- shoulder. The involved UE weight bearing is facilitated by giving a downward
pressure into the humerus with her right thumb pad while maintaining an erect trunk

rri and scapula approximation with her left hand. The weight bearing pressures into both
left extremities are given while the patient is reaching up with the right arm.

-
r
-

-
r
r:
ri
C
C
C
C
C Anterior View
C The therapist asks the patient to reach up as high as possible while facilitating the UE
C weight bearing and hip lift on the involved side. The therapist's left finger pads apply
C a slight downward pressure under the clavicle to maintain the abdominals through out

C this activity

C
C
C
C
C
C
C
C
C
C
t:
r:
(
 1
FACILITATING \ryEIGHT BEARING OF TIIE ARM }VITH
SCOOTING 1
*1
Anterior view
Facilitation of the lateral shift and hip lift is done as described in the previous 1
sequence. Once the hip is up the therapist can use her left hand on the involved leg 1
(distal thigh) and apply a downward pressure into the foot and a slight forward 1
pressure to assist the patient in pulling that side of the pelvis forward. 1
1
1
1
1
1
1
a
1
1
1
1
1
*1
1
1
Anterior View
The therapist's right hand maintains the erect trunk, facilitates the hip lift and facili- a
tates the weight bearing into the left arm as the involved side of the pelvis moves a
forward. The upper trunk should not rotate as much as is seen here. a
a
a
a
1
:l
:1
:1
:1
:r
:1
:r
C
a II\CORPORATING UPPER EXTREMITY WEIGHT BEARING INTO
r
-
..LIFT OFF"

Anterior View
. The therapist places her foot over the tarsal area of the patient's foot to maintain
- weight bearing and her thigh lightly keeps the involved hand in weight bearing. The
- therapist's right hand facilitates trunk extension and UE weight bearing while the front
r- hand keeps the abdominals working with a downward cue.
.
.
.
.
a
a
a
ra
.

re
-

a
r
G
l-
t1
G Side View
G Trunk co-contraction is maintained as the
l- patient bends forward at the hips and
added weight bearing into the patient's left
G leg and arm is given by the therapist.
G
C
C
C
C
C
C
C
G
C
C
r;,
r
 I

1
1
1
*-l
Side View - Lift Off
As the shoulders get over the distal thighs the patient pushes into her feet and arms 1
and lifts the hips up slightly. The therapist maintains her input while moving with the 1
patient's trunk and assists with the lift off by giving a slight forward and up cue with 1
the back hand. The front hand must maintain the downward cue to keep the abdominals 1
working. If the involved hand comes off the surface, raise the height of the surface 1
that the hand is on as it is important to maintain weight bearing on both arms and legs.
1
a
1
*1
1
1
1
1
1
1
1
1
1
1
1
*1
1
1
*1
1
1
1
1
1
1
1
1
1
I
.
a MORE CHALLENGING WEIGHT BEARING ACTIVITIES
.
. ROTATION AND REACHING
Anterior View
-

r
ilq i.t,W
. Patient's involved arm is placed out to the
side in external rotation. The therapist is at
. the side with her foot on the patient,s involved
- foot and thigh over the patient,s hand. The
. therapist facilitates the trunk and arm with
. her left hand. The patient rotates the upper
. trunk and reaches with the left arm across the
. body toward the more involved side taking
. weight on the involved arm and letting it bend
slightly. The patient then returns to midline,
-
extending the involved arm while the thera-
-

rC
pist facilitates the trunk extension and scapula
- approximation. To activate the involved arm
more resistance can be applied to the trunk as
it returns to the middle. The more the rotation
-
rr and reach the harder the activity so it must be
graded carefully.

- REACHING FORWARD WITH "LIFT OFF''

C
r
-
Anterior View

:T! ffi;, To increase

the demand on the involved
- -i'rq side, the patient can bend forward and
; ,,! reach with the better arm as he/she main_
; e i' tains weight on the involved side, keeps
; @ the trunk active and lifts the hips off the
surface. The therapist maintains the
a dominals with the right finger pads and
a approximates the scapula with her right
thumb while the patient pushes into both
- feet (heels) And the involved arm to left
C off the surface. The therapist's back hand
t- can assist with the lift off as previously
r- described (see page 51).
l-
l*
rn
1-
t-
r:
r
 I

:1
ACTIVITIES WITH ARMS BEHII\D HIPS :1
:1
As the arm and shoulder girdle become stronger and the patient gains range into :1
shoulder external rotation gradually bring the hands behind the hips and slightly out to :1
the side. (Note: This is not a good position for a patient who tends to sublux the :1
shoulder anteriorly.) The therapist must prevent the patient from "locking" the elbow a
while also facilitating the trunk co-contraction, scapula approximation and weight 1
bearing on the involved arm. A variety of activities can be done from this position a
but always emphasizing upper trunk extension, scapular approximation and depres-
a
sion with the elbow sliqhtlv bent.
a
a
ALTERNATE HIP LIFT a
Anterior View a
a
Therapist is positioned to facilitate weight bearing into the involved foot with her foot
a
and pressing the pads of her right fingers in a slightly downward direction to facilitate
a
abdominals. The patient lifts the right side of the pelvis as she pushes into the surface
a
with her right arm.
a
-
a
a
a
a
a
a
a
a
a
1
a
a
a
a
a
1
a
a
a
a
a
1
rr
I

rr Posterior View

rr The therapist facilitates extension and right hip lift with the pads
approximates and depresses the scapula with her thumb She
of her left hand and

rr
also uses her right
thumb to help approximate while cueing the abdominals with her
finger pads. The left
forearm can be used to give a pressure down on the patient's invJveo

rr
humerus to
facilitate weight bearing. prevent elbow hyperextension.

rr
rr
rf
rr
-
r
-
-
-

r
-

r
-

-
i,"r Anterior View
e ln

r liiftiing the opposite

Kepeat tne actlvl
ivity by
hip while maintaining trunk, shoulder
girdle and arm in the appropriate posi-
- tion. Feet should be placed under the

rr
- knees.

C
C
a
rr
c
rC
L
 1
BILATERAL HIP LIFT
:r
Posterior View
:'l
As strength improves the patient's hands can be moved further back behind the hips.
The therapist facilitates upper trunk extension, depression of the scapula and pushing
into the surface with both arms and legs to lift both hips. Note: Sometimes the patient
will need help from someone in the front to help with the hip lift at first.

?
1
1
a
Anterior View 1
1
It is important to facilitate the abdominals at the same time
posterior tilt of the pelvis as the hips lift off the surface.
as normally there is a slight
1
1
a
1
1
a
1
4
?

a
a
1
1
1
a
a
l^
rr
rt: Posterior View

f
rr If the patient hyper-extends the involved arm the therapist can control that by placing
her arm in front of the elbow. To add difficulty the patient can be asked to shift her

r
weight slightly side to side or forward and back while maintaining the hip lift.Difficulty

rr
can be increased further by asking the patient to lift the better foot off the surface
once the hips are up.
Caution: These activities are hard on the wrists so they should be used spar-
ingly.
t1
ra
fr
r:
ra
fi
fr
r:
rt1
fl
rr:
r:
r:
_ _,fu,]
. i
r:
rr
f,
C
rr:
C
C
C
C
C
C
G
C
C 58

C
r
 I

1
FACILITATION OF UPPER EXTREMITY WEIGHT BEARING 1
THROUGH THE FOREARM ANID HTN4EROUS 1
1
1
l. The therapist sits beside and slightly 1
behind the patient so that she can place 1
her left hand on the patient's left arm. The 1
patient's arm is positioned in slight lateral 1
rotation with the hand below the 1
elbow.The therapist's index and middle 1
finger pads form a trough in which the 1
patient's ulna sits. (thumb pad is on the 1
distal humerus). To facilitate weight bear-
1
ing a light pressure downward on the ulna,
1
toward the hand, is applied with the
1
therapist's fingers. The thumb can apply
1
an upward pressure to facilitate shoulder
approximation or a downward pressure 1
to release the shoulder elevators. 1
1
1
1
1
1
1
1
1
1
1
1
2. 1
The patient is maintained in an erect
1
posture with cues from the therapist's right
forearm to extend the trunk while the fin- 1
gers activate the abdominals.
 FACILITATION OF UPPER EXTREMITY WEIGHT BEARING
THROUGH THE FOREARM AND HTN,IEROUS

3. The therapist's right arm and hand facilitate the trunk into extension and the left
hand facilitates slisht arm extension with a cue into the hand.

4. The therapist's right hand maintains the trunk erect and active while having the
patient bend at the hips. The left hand facilitates a decrease of left arm weight bearing
to allow the patient's elbow to bend as the hips bend.
 WEIGHT BEARNG WTTH TIIE ARM SLIGHTLYELEVATED ,
F
Side View A-
As more shoulder girdle stabitity is achieved, it is important to begin working F
on
control with the arm in elevation. A way to begin is to weight bear on
a slanted F
surface. (Note: the lower the incline the less demand on the arm muscles)
The hand ,
is placed up on the slanted surface so the upper arm is away from
the trunk. The €
therapist facilitates weight bearing into the surface with her right hand
by using the €'
thumb on the back of the humerus while controlling rotatio-n with the
index and €
middle fingers. The trunk and shoulder girdle are facilitated with the therapist,s
left -rt-
hand while asking the patient to hold her hand against the surface. placing
the arm
in other positions of flexion and/or abduction.un uury this activity. Atso
the height
of the hand and the degree of inclination can be altered to make the activity
more
?
difficult. If the patient can maintain the hand in the position, then ask her to gradually
release so the hand slides slowlv down the surface. As control is increased
a pup.i
can be placed between the hand and the surface so the patient can
move the arm ?
down, up or to the side. The therapist must still facilitate to help the patient
grade her
pressures as she moves the arm.
Note: These activities are best begun in sitting but can also be done in standing
to
place more demand on the patient because of the added requirement
of controlling 4
the body in standing with good alignment while controlling the moving
arm. The
therapist must also be prepared to facilitate and control wherever necessary I

at first.
(See page 89) I

>a I

a
a
a
-1
a
a
a
-

,)

'aa

'z
I
t
I
rr
a
I

rr FACILITATION OF ANTERIOR TILT AND TRLINK EXTENSION

FROM THE FRONT

rr
rr Posterior View - The therapist sits facing the patient with her legs outside the patient,s
legs (being careful not to adduct them) and far enough back to stay out
the patient's knees.
of contact of

rr
t1 The therapist's hands are open with her little finger pointing down
and in contact with
the patient's abdominal muscles under the lateral rib cagi. The other fingers

rr spread over the postero-lateral aspect of the trunk (thoraco-lumbar area)

thumbs are horizontal over the dorsal thoracic area. The index, middle
are
and the

rr finger activating the abdominals with a backward cue ro ger a co-contraction

pelvis is in neutral position. The thumbs can then give a downward cue
and ring
finger facilitate lumbar extension with a forward and up cue followed by the little
when the
to increase
t1 thoracic extension if necessary. As the patient sits up, the therapist stays flexed
at the

rr
t1 hips but extends her back which enables her to give a better "up cue, " but
also model
what she wants the patient to do. The therapist's arms stay abducted and mediallv

rr rotated to stay out of contact with the patient's arms.

rr
rr
1
rr
rr
rr
rr
rC
C

C
C
C
C 62

C
r
FACILITATION OF AI\TERIOR TILT AND TRTINK EXTENSION
FROM THE FRONT

Alternative Arm Positions:

;

L. If the therapist
cannot reach around the
patient's arms she can go outside the in-
volved arm and underneath the uninvolved
arm. Be careful not to medially rotate the ,
ann.

2. If thepatient's hands are in weight bear-

ing to the side and there is space between
the arms and the trunk, then the therapist
may place both arms under the patient's
anns.

I
I

-'a I

a
*.1
,
a
,

^-,
rr
I

rr FACILITATNG LA]ERAL WEIGHT SHIF,T

FROM THEFRONT

rr
rr
rr The therapist maintains the patient,s pelvis in
neutral with a co-activated trunk. Then with

rr
2 or 3 fingers, the therapist gives a cue along
the lateral border of the erector spinae muscles
just above the pelvis in a medial and upward

rr direction (toward the opposite shoulder) to

facilitate elevation of the pelvis on that side.

ra As the pelvis lifts, the therapist and patient

shift slightly laterally together. The initiation

r of the movement from the shoulders is pre_

vented by the opposite arm of the therapist.

-
rr
a
a
rr FACILITATING TIIE PELVIS FORWARD AFTER WEIGHT
SHIFT
C
C
C
C
C While the therapist's hand maintains the
G patient's trunk extension and elongation
C on the weight bearing (right) side, the
C therapist moves the fingers of her other
G hand down so they contact the patient's
G pelvis on the left and then gives a cue
G forward on that side.
l-
rl'x
|l1

-| -'"
f
l-^
C
C 64

r\
r
 FACILITATING LIFT- OFF FROM TITE FRONT
WITH NO LEG ASSIST

4
4

1. Therapist is seated in front with her legs outside the patient's legs but having no
contact. The therapist bends at the hips so she can reach around the patient's arms
and contact the patient's trunk with both hands -i.e. little finger pointing down and in
contact with the abdominals, 2nd thru 4th fingers spread and over the postero-lateral
aspect of the thoraco lumbar area and the thumb over the thoracic area). The therapist
facilitates the patient's trunk extensors and then the abdominals to ger an erecr co-
contracted trunk, as previously described.

A
I

1
I

a
I

1
I

-1
2- The therapist maintains the patient's trunk and asks the patient to bend forward at 1
the hips. (A cue forward can be given with the thumbs if necessary.) As the patient 1
bends forward the therapist slumps and leans back to get out of the patient'i *uy, jt

while still maintaining facilitation of the trunk. Patient must be kept in midline at all
times. 1
65 :l
:1
rr
I

rr FACILITATING LIFT.OFF FROM THE FRONT

WITH NO LEG ASSIST
rr
ft.
t.
rt.
t1

t1
rr
t1
3. Making
a::!.{,tia=

sure that
|l

hat the patient's trunk is co-activated by maintaining

thoracic exten_
- ::":,::1:::'.1.,1ll"Tina^ls,
coming
,h.,1l.r1qisr leans back
forward over his feet to lift
;*,, ;'rrir,
-J the parienr,s
ofi. r\
rL urr. A uurnmano
command Io to lllt
lift ls qi
is gtven as the patient,s
-
r: shoulders get over his distal thighs. Be sure
and stay on the floor.
the patient's heels are behind the rhe knees

-
- coNTRoL oF PATIENT'S LEG FROM THE FRoI\rr

rf:
C
1. The therapist sits far enough away from

rC the patient so that her knee just passes the

patient's knee. Therapist's foot is between

ra the patient's feet but not in contact with

either foot or ankle. (Note: The patient,s
feet must stay aligned with the hip joints _

rr
G i.e.4-5 inches apart.) The therapist,s leg is
in contact with the patient,s proximal lower
leg on the antero-lateral aspect (Anterior
Tibialis muscle area). Get as much contact

rr
C as possible without any bony contact on
the
shin bone. The therapist,s foot can be moved
anterior or posterior to achieve the best con_
l-
t '- tact. The therapist should be able to give a
C weight bearing input thru the patient,s leg
C by extending her hip slighrly and pushing
C
rr into the floor. Do not plantar flex as this
will lift the patient,s heels off the floor.

r- 66

r
r.,
 -.-t
:1
CONTROL OF PATIENT'S LEG FROM THE FRONT :1
:1
:1
:1
:1
2. Once the appropriate leg position is :1
achieved the therapist can slip the other leg .:1
between the patient's legs (without abduct- :1
ing them) and place her heel behind the :1
patient's heel to prevent knee flexion if nec-
essary. This leg also helps to prevent leg
:1
adduction. Do not squeezethepatient's leg.
:1
:1
:1
:1
:1
:1
:1
FACILITATNG SCOOT. BACK USII\G LEG CTIES :l
:1
1. Therapist places her feet between the patient's feet. This must be done without :1
separating the patient's feet out of alignment with his hips. (Note: If using two feet
the therapist places 1 foot on top of the other as demonstrated in the photo below.)
:1
The bottom foot belongs to the leg that is facilitating the patient's involved leg as
:1
:1
described in#Z on page 68.) The top foot belongs to the leg facilitaring the betteileg
:r
if necessary. There should be no contact with the patient's feet or ankles by either o6
:r
the therapist's feet. As the patient comes forward for "lift-off, " the therapist allows
the patient's lower legs to come forward slightly by relaxing her legs, slumping and :r
leaning back to get out of the patient's way. :1
:1
:r
:1
:1
:r
:r
:r
:r
:r
:r
:r
67
:r
.l
:1
1
t
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FACILITATNG SCOOT-BACK USNG LEG CUES
t
ff 2' & 3' once the patient has lifted off the surface, the therapist
plantar flexing with eversion to keep her heels together)
lifts her heels (by
which brings her lower legs
ff against the patient's legs. The therapist moves th-e patient's
shifts the patient's hips back on the surface. (Note:
legs ua"ct which in turn
lr tn. therapist does not keep her
ff heels together, she tends to roll the patient's feet
supination.)
onto the lateral border and into

fr
t1
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1
*-]
FACILITATION OF TIIE TRTINK FROM THE SHOULDER
GIRDLES :1
-.1
Anterior tilt & extension - the patient's *..]
arms are in weight bearing with the :1
hands outside the shoulders-i.e. lateral
:1
rotation.The therapist's hands are
:1
placed over the patient's shoulders with
the thumb pads below the clavicles and
a
the finger pads spread and extending :1
below the spine of the scapula if pos- a
sible. The therapist flexes her wrists a
and applies a forward and in pressure :1
with the pads of the fingers to facilitate a
trunk extension. (This usually does not a
work if the patient is totally slumped. a
A cue directly in the lumbar area is a
then necessary.) When the pelvis 1
reaches neutral the therapist applies a 1
down and back pressure with the thumb 1
pads to activate the abdominals.
a
a
1
a
Lateral shift - The therapist maintains a
a
:1
co-activated trunk in the erect posture and
1
then facilitates right lareral weight shift.
This is accomplished by applying a lareral
1
pressure on the axillary border of the left :1
scapula with the ring and little finger (by a
supinating the forearm) to facilitate the :'l
left hip to lift. Do not push down on the a
shoulder girdle. The therapist's left hand :1
prevents the shoulders from moving until :1
the opposite hip lifts. Both patient and :r
therapist should weight shift slightly. (The :l
therapist should be a mirror image of the
:r
patient - i.e lift her right hip.)
:r
:r
:r
:r
1
1
I
ff FACITITATION OF BETTER WEIGHT BEARNG ON TIIE
fr II\IVOLVED LEG

rt: CLINICAL IMPLICATIONS

Even after the patient has improved in the trunk he may still have a very unstable hip.

t:
rt:
It is helpful to demand greater weight bearing on the involved leg by asking the patient
to liftihold up the better leg. The therapist must also decrease the use of the better arm
that will compensate for the leg. The better arm could be placed on the better leg, or

r:
rt:
ultimately on the chest, while the patient raises the leg. This sequence must be graded
and can begin in sitting and then continue after the patient is in standing. The pictures
are demonstrating a graded sequence for the leg, but the better arm is placed in the

rt: most challenging position -i.e. on the chest.

Front View

fr The therapist is seated on the patient's involved side with one leg behind the patient.
The other foot gives weight bearing input into the tarsal area of the patient's involved

r= foot and the therapist thigh helps to maintain the involved hand in weight bearing.
t: The therapist facilitates the patient's trunk, assists with a slight increase in weight

r:
ft
bearing over the involved side and gives added input into the involved foot while the
patient picks up the better leg. The patient must maintain an erect trunk and the

t: therapist should keep the legs parallel and maintain the weight on the involved side.

tr Note: The therapist should be able to see or feel the activity in the patient's involved

r
rr
leg. As the patient gains control, she can lift the leg and keep it up while abducting
the hip and bringing it back to midline before placing it on the floor again.

t:
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