I

1
:1
Front View :r
Raising the surface on which the pa-
1
:1
tient sits will increase the challenge to
1
the involved leg. Then after facilitating
1
the trunk and slight weight shift the
patient can pick up the better leg and 1
place it on a raised surface. The patient 1
could also repeat the previous activity 1
(raising the leg, abducting it, and then 1
adducting it) as that makes the patient 1
sustain the weight bearing into the in- 1
volved leg longer. 1
1
1
1
:1
1
1
1
Front View 1
The height of the surface on which the 1
Tt

foot is placed can also be raised, but 1

be careful not to ask for too much hip 1
flexion as that may encourage the pa- 1
tient to go into a posterior tilt of the 1
pelvis which will then remove the 1
weight bearing on the involved leg. 1
1
Note: The height of the surface on 4
which the patient sits can be raised un- 1
til he is almost standing to gradually
increase difficulty, but then the patient
1
:1
must be brought to standing and the
:l
sequence continues there.
:r
:r
:l
1
:r
1
1
_1
l-
r
J-
J1
CLIMCAL IMPLICATIONS FOR FACILITATNG SIT TO STAND

r:
rf Sit to Stand - Where the therapist positions him/herself will
be determined by what
part(s) of the patient's body need to be monitored and/or

rr activities that have been done previously. The patient may need
and using the most efficient timing and sequence of
assisted, as well as the
help staying in midline

rr
movement, to u..o*plish this
activity smoothly. An active co-contracted trunk increases the
activity in the legs so
if kept in midline the patient begins to use the involved leg in the
activity. otherwise

rc the patient will go up and down using only the less involved
in sitting are preparatory to sit to stand by achieving a
leg. The activities done
-or. active trunk and by
learning to stay more midline with lift-off activities. Additional
lower extremity
t: weight bearing activities may also be necessary while sitting
on different heigtrt
r: surfaces to prepare for better weight bearing in sit to stand
standing with weight on the involved lower eitremity also prepares
and standing activities.
for better function
-
r: in sit to stand.

a
re FACILITATION OF SIT TO STAND FROM THE SIDE
cC
C This activity begins the same as Scoot_
ing Back (see posterior view descrip-
C tions; page 45 & 46.)
C
- Antero-lateral View - After the patient
- lifts off he continues up toward stand-
l- ing and the therapist maintains a light
c
I-
contact with the front leg as the patient
IF
t^ extends. The therapist assists this move_
C ment with her hand on the patient,s
C back. The front hand must maintain a
G light "down and back" cue for the
C
7-
abdominals.

t^
7-
t-
l-
r
t-
r:
r:
C
G
 FACILITATII{G SIT TO STAND FROM THE SIDE

1
1
1
1
Posterior View - once the hips are off the surface the therapist a
uses her forearm and
elbow to assist the patient's hip extension with a forward motion,
followed by a ,,hip
a
tucking" pressure near the end of hip extension. Both hands 1
active trunk and cueing the upward direction.
are also maintaining an
1
1
1
1
1
1
1
Anterior View (Patient standing)- After 1
the hips extend, the therapist can assist knee 1
extension (if necessary) using her forward 1
leg in a back and downward pressure to 1
facilitate weight bearing. Contact should be
1
on the anterio-lateral aspect, just below the
:l
patient's patella.
1
1
1
1
1
na
IJ
,t'
ff FACILITATING SIT TO STAI\D FROM THE FRONT

r
rr
rr 1. The therapist is positioned so her legs

rr are ready to control both legs of the pa_

tient if necessary. Her hands are on both

rt- sides of the trunk as previously described.

The therapist facilitates a co_contracted
erect trunk, and while maintaining the
f patient's abdominals, has the patient bend

f
rr forward at the hips.

rr
-
-
-
-
-
-
-

rr
-
2. As the patient bends forward. the
therapist slumps and leans back to al_
- low the patient's knees to advance
- slightly. The parient brings his shoul_

rr
- ders over the distal thighs and lifts off.
The therapist maintains the patient's

r
legs aligned and the patient in midline
with cues on the legs of the patient.
r'-
r
[-
C
r:
c
C
C
7
I
 I
1
FACILITATING SIT TO STAND FROM THE FROI{T :r
1
1
1
*l
3. Once the hips are off the surface the 1
therapist reaches one hand onto the back 1
of the patient's pelvis (which hand depends 1
on the patient's response). This hand as- 1
sists hip extension and tucking of the pel- 1
vis. The other hand continues the upward 1
cue while the therapist's legs prevent the 1
patient's knee from buckling or going out 1
of alignment.
1
I
I
-1
I*1
4
*l
4
1
4. After the hips are extended the thera-
pist can assist knee extension, if neces-
Sory, by lifting her heels (plantar flexing).
Care should be taken to prevent over ex-
tension of the hips or the knees by acti-
vating the abdominals to keep the pelvis
neutral and keeping the shoulders over
the hips.
,f
fr CLIMCAL IMPLICATIOI\S FOR FACIUTATII\G

f
rr
STANDNG ACTIVITIES
Standing activities - During standing activities the best possible
alignment of the body
should be maintained while the patient learns to stay in
the middle and then to control

rr
JI weight bearing on the involved side. using the involved
encourages weight bearing on the more involved leg
uE in weight bearing also
as the body automatically tends to

rtI center itself over the base of support. It is easiei to

maintain an erect trunk white
standing so sometimes standing activities can be preparatory
to better function in sitting.
Also, standing with weight shifting to weighr beir on the involved

rr alignment can improve sit to stand and transfer activities. By

the uninvolved leg" the patient gains confidence in
initiating
leg with good
..stepping
with

rr the involved leg as wen as develop-

ing a befter sensory awareness of that leg through continual
a demand must be placed on the involved leg
weight-bearing. Frequently

rft
to make the muscles begin to work again,
but this is most effective if relativety gooo alignment is
maintafid throughout the
whole body' often weight bearing on the involved leg
must be encouraged by even

cfa more challenging activities thanjust a step forward and

Stepping up on a stair or stool of varying heights,
involved leg all while standing on the invotveJ leg with
back with the less involved leg.
moving an object with the less
relatively good alignment,
C encourages a more sustained contraction and also
works on stability in the hip and trunk.
The therapist must develop continual challenges to enable
the patient to develop more
t:
-

t:
sustained control in the trunk and hip on the involved
side. Note: The therapist remains
seated if necessary to assist with control and facilitation
of the patient,s involved les.
C
C STAI{DING WITH BILATERAL KNEE FLEXION
C
C Anterio-Iateral view - The therapist moves her
C hands to be able to maintain co-activation of the
C trunk and the weight in midline, so her left hand is
C now directly over the abdominals. The right hand
C remains the same, as will be seen in the n.itphoto.
C If the trunk is co-activated, the patient should be
C able to release both knees into flexion. The
C
l-
therapist's left leg allows a small controlled release
of the involved leg. The goal is to ailow the knees
l1
to release and then extend simurtaneously while the
G
lF patient has equal weight on both legs.
la
r-
Ir
-[-
C
-[-+ t6
r;
r
 STANDING WITH BILATERAL KNEE FLEXIOI{
Posterior View - The therapists's right
arm maintains thoracic extension and the
elbow is placed behind the left side of the
patient's pelvis to keep it aligned and
shoulders over hips. The elbow could be
moved more laterally to facilitate the ab-
ductors if necessary. The therapist's right
leg is positioned to prevent hyper-exten-
sion, but it can also assist in knee release
if necessary. Do not squeezelhe patient's
leg between your legs.

FACILITATING TRTINK AND

UEINSTANDING

Alternate Position - Side View

Often the patient needs more support so a
table is placed in front and the therapist is
sitting on the patient's involved side. It is
preferable to have only the involved hand
on the table throughout these activities un-
less the patient is terribly fearful.The thera-
pist facilitates the bilateral knee bends as
described above.
I

rr
-
FACILITATING TRT.INK ROTATION N STANDNG
-
- Side View
.
rr The patient can also rotate her body around the involved hip and arm while the
therapist keeps her weight bearing on the involved leg so she begins to develop some
rotation control in the hips and shoulder. Rotation away from theinvolved side works
.
rr on external rotation of shoulder and hip. The therapist may need to assist with the
pelvic rotation and also prevent the elbow from coming away from the body. To
challenge the weight bearing control even more the patient could turn the better i.g
o,.
a
rr
step up onto different height surfaces with the better leg while maintaining
control of
the involved arm and leg in weight bearing as she rotated around.

r
.
rr
ra
.
rr
rr
(

rr
rrr
rr
rr
rr
r:
rC
r
 I
1
NCREASING WEIGHT BEARNG ONIN/OLVED ARM AND 1
LEGNSTANDNG 1
CLINTCAL IMPLICATIONS 1
1
It is important to continue to challenge the involved leg in standing and to achieve a
1
more stable hip and knee, which in turn will improve the patient's gait and stability
when on his/her feet. Using the involved arm in weight bearing to assist will also 1
encourage the muscles of the arm to become more active in support as the involved 1
1
leg is challenged.

STEPPING UP ON RAISED SURFACE

I1
Side View 1
1
The therapist is sitting on the patient's involved side with the involved hand on a table
in front. The therapist's front hand is facilitating the patient's abdominals while the 1
arm is over the patient's hand lightly to give a weight bearing input. The therapist's 1
back hand is spread across the low thoracic area with the forearm in light contact 1
with the involved side of the postero-lateral pelvis to cue hip extensors or lateral hip 1
muscles. The patient steps up on a low surface with the better leg while the therapist 1
facilitates the trunk and maintains the alignment of the trunk over the involved leg. 1
There is a slight shift forward of the body over the foot as the patient steps up. 1
1
1
1
1
1
1
1
1
1
1
1
1
t-'l
I,
r
-

rr
- Side View
When the patient begins to step down the
body weight should shift back slightly until
-
rr #. the weight is centered over the involved foot.
The therapistcontinues to maintainthe align-

rr ,',
uu... '
ment but as the better foot is unweighted
the facilitation is increased to help the pa-
tient maintain stability as the better leg steps
down.
-
-
r
-
r
-
rr
-

-
r
-
rr
-
-
ra
a
a
r Side View
As the patient gains bettercontrol the height
-
rr of the surface the patient steps up onto is
increased. If the surface is at the patient's
side there is not an advancement forward

rC
C of the patient's body weight so sometimes
this is an easier place to start. The thera-
pist continues to help with the alignment

fr and facilitation as the patient steps up and

r: down.

t:
r:"
C
r
Antero-lateral View
While the patient's foot is on the surface
at the side, it is important to have the pa-
tient rotate the body around the involved
leg and arm. The weight should be pri-
marily on the involved leg while the better
leg rotates as the body turns. The thera-
pist can help with the whole body rota-
tion to the opposite side and then back to
the center by activating the hip extension
and external rotation and then the
abdominals and hip flexors respectively.
The therapist's front leg prevents the knee
from buckling. This activity also works
on external rotation of the shoulder as the
bodv rotates on the arm.

Side View
To challenge the patientevenmore she canbe asked
to step up onto a small ball. That places greater
demand on the involved arm and leg since the ball
is unstable. Someone may need to hold the ball
until the patient has her foot on it.
2
'
--1

Side Views
;
Once the patient has control with her foot on the ball she can be asked to roll the ball
; forward and back while controlling stance on the involved leg.

; Note: As the patient continues to improve he/she can step up onto achay, turn while
her foot is on the chair or even push the chair forward and back. This latter activity
; can also be done with a low platform or stool first to make it easier. pushing or
pulling an object makes the patient stabilize more strongly as he/she applies enough
; force to move the obiect with the better les.

l^

,6
 I
-1
CLINICAL IMPLICATIONS FOR FACILITATING 1
A STEP SEQUENCE 1
The step sequence worla on each aspect of taking a step, fromheel strike to weight transfer 1
over the foot, to release of the *trailing" leg to stepping. The therapist must assess each 1
aspect and determine whether there is aproblem. If so, she works onthose that are difficult 1
for the patient, keepng in mind that ttre body should stay aligned vertically in all ttnee planes 1
and move as a unit from one foot to the next. The patient usually has great difficulty 1
progressing forward over each foot so weight shift in stride is frequently one activity that 1
needs practice. Initially the emphasis should be on maintaining weight bearing on the 1
involved leg while the less involved leg is moved slowly in various directions. Confol in
1
weightbearing leads to abetter swing phase, although frequenfly the release of the "trailing'
1
involved leg needs to be practiced before stepping with ttrat leg. The therapist can work on
the parts that are difficult for the patient in isolation, but then must put them all together into
1
walking at a functional speed (probably with manual and/or verbal cuing at first) if he or she
1
expects the patient to carry it over between treafinent sessions. Also, use assistive devices
a
that encourage the patient to stay more in midline (i.e. front wheeled walkers) rather than 1
a cane. Note: For all activities, a weight bearing surface in front or on the involved side, 1
could be used for one or both arms. Alignment should be maintained and over-use :1
of the less involved side should be prevented. Initially using only the less involved 1
arm for weight bearing should be avoided, as this contributes to decreased weisht 1
bearing over the involved leg. 1
1
FACILITATING A STEP SEQUENCE FROM THE SIDE 1
1
l.Therapist stays seated at side if it is neces- 1
sary to help control involved leg. Left leg is in 1
light contact below the patient's knee on the a
anterio-lateral aspect. Left hand is positioned :1
to activate abdominals and maintain shoulders 1
over pelvis with a neutral pelvis. 1
a
1
1
1
:1
:1
:1
:1
:l
I
ff
rr 2.
FACILITATII\G A STEP SEQUEI\CE FROM THE SIDE
The therapist's right leg is extended
ff behind the patient's involved leg to pre-

rf vent hyper-extension (but notholding leg.)

Right hand is positioned ro be able to
keep the patient's trunk extended and his

J.
rr shoulders over his pelvis and the pelvis
aligned over the feet. The therapist's el-

rr
bow is not in contact unless necessary,
but is ready to assist with pelvic align-
ment or hip extension.

rt:
r:
rr:
t1

-
r
-
t1
t: 3. With the therapist's hands maintain_
C ing an active aligned trunk, the patient

r
- shifts his whole body slightly roward rhe
therapist to unweight the right leg and

r
-

-
then take a step. The therapist's right
leg allows the patient's left leg to move
forward slightly over the left foot to as_
t:
rC sist inweight shift forward with the step.
This should nor be a big step.

rr:
C
C
C
C
C
C
C
r
 I
*1
FACILITATING A STEP SEQI-IENCE FROM THE SIDE 1
.*1
*1
4. The therapist maintains an active 1
aligned trunk while assisting the pa-
tient to move forward over his right foot
1
*1
to the mid-stance position. Therapist
can help with the left knee release us-
1
*1
ing her hand to cue the pelvis down-
ward slightly. The therapist can assist
1
advancing the leg by bringing her left
1
foot under the lateral aspect of the 1
patient's foot and sliding it forward. 1
*1
*1
1
1
*1
1
*l
1
1
*1
1
5. - 1
Anterior View The therapist's
1
left foot is under the lateral aspect of the
patient's foot and assists with the step 1
forward being very careful to remove 1
her foot at the end. There should be no 1
pelvic elevation or rotation with this step. 1
1
1
1
1
1
1
 FACILITATING A STEP SEQUENCE
FROM THE SIDE

6. Posterior View - Ifthe patient is

stable enough, the therapist should
be
on a rolling stool to allow the taking
of
smoother and easier steps, otherwise,
the therapist must move her sitting
sur_
face after each step of the patient
and
only when the patient has both feet on

rr
, the ground. Note: It is imporfant
to keep
the patient's pelvis facing straight for_

rr ward during steps to achieve better

weight bearing over the support leg and

rr a beffer release of the ..trailing,, leg,

especially when it is the involved leq.

rr
rr
rr
rr
rr 7. The patient then shifts his body as
unit forward over the involved leg (pre_
a

rr: r venting knee hyper-extension), while

therapist maintains alignment and trunk
contraction. The weight needs to come
forward to mid-stance (slight dorsi_flex_
the
co_

ion) to get good weight beaiing on the

C leg before stepping with the right leg.
left
C
C
C
C
C
C
C
C
r:
 1
FACILITATNG STANDING FROM TIIE FRONT a
1
Standing - As soon as the patient is stable, 1
a weight bearing surface is provided to al- a
low the patient to weight bear on the in- a
volved arm. The height depends on pain and/ a
or tightness of the patient's wrist or elbow.
a
The therapist is then in a position to facilitate
1
the abdominals with her left hand and main-
1
tain alignment of the shoulders over the hips
1
with her right hand as well as facilitate weight
bearing on the upper extremity (thru input a
on the arm) and encourage better weightbear- a
ing on the involved leg thru input on the leg. 1
1
1
1
a
1
1
1
FACIUTATNG TIIE TRTIINK IN STANDING a
a
1. Alternate hand position: Anterior View a
- The therapist's right hand is over the 1
patient's shoulder with the thumb activating I
the abdominals and the fingers approximat- 1
ing the scapula against the rib cage. The little I
finger can sometimes be used to give a weight 1
bearing input into the humerus to facilitate a
"1
the arm in weight bearing. The therapist's
left hand is still over the lateral pelvis, the -1
thumb cues the abdominals and the fingers 1
"tuck" the pelvis to keep it in neutral. Some- 1
times this hand position enables the therapist
1
to maintain the trunk alignment more easily
by giving a slight diagonal pressure toward
1
the middle and between both hands. :r
:r
1
tt'
rf FACIUTATNG TIM TRI.INK IN STANDNG

fr 2. Posterior view - The therapist's left

rf finger pads give a downward pressure to

the back of the pelvis to keep it neutral (i.e.

rr out of an anterior tilt.) The right hand on

the shoulder keeps the shoulders over the

rf pelvis in good alignment.

rr
fr
f
-
r
-
rr
a
rr
- 3. If the patient needs more assistance with
the trunk alignment the hand on the upper
-
trunk can be placed behind the thoracic area
-
with the fingers pointing upward. It can
r
.

.
then cue the shoulders forward while fa_
cilitating thoracic extension. also, with pres_
sure of the thumb or little finger, it can
e control rotation or lateral flexion. The
e therapist's other hand is usually placed over
e
rr the abdominals to facilitate them and keep
the pelvis neutral with ribs down.

rr
rr
t:
C 88

r"
7
I
L
 I
1
FACILITATION OF THE TRTII{K AND I.IPPER EXTREMITY :r
IN STANDING :r
:r
Alternative Arm Position
:1
:
:1
The therapist can use her right arm lightly over the patient's left hand to keep it in
:1
weight bearing while spreading her hand posterior-laterally to cue the pelvis and
:1
upper trunk. The left hand is facilitating the abdominals and maintaing pelvic align- :1
:1
ment.
:r
:1
1
1
1
:1
1
1
1
*l
1
1
*1
1
*1
1
*1
1
a
1
1
1
1
1
1
1
1
:1
1
1
1
1
,i
rr FACILITATION OF TRTNK ROTATION AWAY FROM TIIE

rr Side View
IN/OLVED SIDE

rr Therapist sitting in front with her left foot between the patient's feet and left knee
outside patient's involved leg to provide support if necessary. The therapist's left
arm is over the patient's involved hand on the table with her fingers behind the

r
patient's humerus to give a weight bearing cue down and forward into the patient,s
- hand. The therapist's right hand is over the patient's left lower trunk to facilitate the

r
abdominals and maintain a neutral pelvis.Keep the patient in weight bearing on the
- right as she rotates her body to the left and reaches behind with her left hand. The
therapist may need to help rotate the pelvis initially and be awarethat the knee may
- buckle as the pelvis rotates toward the left. Also be careful to prevent the arm from
-
rr going into too much medial rotation.

rr TRTINKROTATIONTOWARD
-
rr THE IN/OLVED SIDE

-
-

r
-

rr
-

r
-
rr
rr Side View
As the patient turns and reaches toward the

rC right the therapist continues to facilitate the

abdominals and keeps the patient's weight
on the right while preventing too much rota-
t'

r: tion to the right. It is important for the pa-

C tient to be able to rotate his/her body around

t: the involved hip and ankle without losing

control as well as being able to maintain the
r" involved arm in weight bearing.
t:
 CLINICAL IMPLICATIONS FOR FACILITATION OF
THE TRUNK WITH THERAPIST STAI\DING
When the therapist no longer needs to assist a lot with the involved leg, and/or needs
to increase the speed of gait, she needs to stand to allow her to move faster with the
patient. Recognize that the therapist cannot walk very fast when she is moving back-
wards, but sometimes it is helpful to be there, as the patient may be less fearful of
coming forward. No matter where the therapist places her body or hands, the result
must be that the trunk stays aligned in all planes and moves as a unit over the patient's
base of support.

FACILITATION OF TRTNK WITH HANDS ON SHOULDER

& OPPOSITE HIP
Antero-lateral View - 1. The therapist may be in front with one hand on the lateral
pelvis activating the abdominals with the thumb, and tucking the pelvis with her
finger pads. The little finger can also facilitate the hip abductors. The other hand is
on the opposite shoulder to approximate the scapula and facilitate extension with the
finger pads and to assist abdominal activation with the thumb. Additional pressures
can be given, as necessary, to keep the shoulders and pelvis aligned over the feet in
standing,or each foot as in walking.
rf
!

rr FACILITATIOI..{ OF TR{.II\K WITH HAND'

& OPPOSITE HIP
oN
'H'ULDER
rr Posterio-Iateral View - 2. Therapist can be

rr behind the patient with one hand on the lateral

low trunk so that the index and middle finsers

rr facilitate the abdominals, the ring fingeifa_

cilitates the hip abductors and the little finger

rr cues the pelvic tuck. The thumb extends

the thoracic areato keep the rib cage forward
up

rr if necessary. The other hand is on the oppo_

site shoulder to cue the abdominals with ihe
finger pads below the clavicle and to approxi_
mate the scapula with the thumb. pressures
- may also need to be applied between the two
- hands to keep the shoulders over the hips
in
- good alignment.
a
rr
r
-
rr HANDS OI\{ MIDDLE OF TRUi\K FROM THE
BACK

rr Alternative Hand position _ 3. Both hands

can be spread so the thumbs are extended
the posterio-lateral rib cage to keep
up
the upper
( trunk aligned over the pelvis. The inderind
C
rr
middle fingers are over the abdominals, just
under the rib cage, to apply a slight back
pressure to activate the abdominals. The
ring
l: and little finger are over the posterio_lateral

rr pelvis to active the hip abductors and tuck

pelvis. Note: Patient,s arms are raised for
the

r
t:
purposes of this photograph only, to
for a view of the therapist's hand.
allow

rr
r:
r:
r:
r:
t:
rI
 n

FACILITATII\G STRIDE WEIGHT SHIFT FORWARD AND STEP

WITH INiOLVED LEG FROM THE FROI{T 1
1
Side View - 1. The therapist has her hands placed as in the previous example on page 1
89, to keep the trunk aligned and extensors and abdominals active. Afteithe puti.nt 1
takes a step with the less involved leg, the therapist keeps the trunk stable and guides a
the body as a unit to shift forward over the forward foot. 1
1
1
1
1
a
1
1
a
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
:l
1
rr
I

rr FACILITATING STRIDE WEIGHT SHIFT FORWARD AND

WITH THE INVOLVED LEG
STEP

rr Posterio-lateral View - 2. Once the

rr weight is on the forward right leg , the pa_

tient releases the back left leg. The thera_

rr pist can assist by giving a slight downward

cue on the pelvis.

rr Note: The therapist is maintaining the

patient's less involved leg so that it will not

rr bend when the patient bendsireleases the

involved leg.

-
r
-
a
r
-
-
rr 3' After the weight is forward over the right leg and the "trailing,,
left leg has
- released, the therapist can assist the leg to advanie by hooking
her toes under the
-

-
r lateral aspect of the patient's foot and sliding it forward. once
therapist may need to again facilitate weigtrt bearing by guiding
over the forward foot while preventing knee hyper-extension.
the leg is forward the
the patient,s body

-
a
r
-
rC
C
r:
C
C
C
C _1,
C
C 94

C
r
 CLINICAL IMPLICATIOI{S FOR FACILITATING TRANSFERS

Transfers - Squat transfers can be accomplished quite early in the patient's recovery
process with adequate preparation of the trunk and legs, primarily in sitting. Keeping
the patient low during the transfer is safer as he can use the arm(s) more effectively
and needs only to lift the body high enough to clear the surfaces he is leaving or
approaching. The patient also needs to learn to transfer to both sides eventually in
order to be totally safe and functional. He needs to learn to adjust his base of support
so that he can keep his center of mass over it as he moves. The use of a second person
in the transfer is to add facilitation of hip and leg extension and give the patient a
"feel" of the appropriate movement. That person should not lift the patient at the hips
but is there for safety reasons.

TRANSFER FROM BENCH TO CHAIR

1. The therapist positions herself

to be able to facilitate trunk exten-
sion, control the involved leg and
if possible incorporate the in-
volved arm in weight bearing at the
side. Before facilitating lift off, the
patient's feet should be turned
slightly to assist the turn. The
therapist can then facilitate a lift
off and then cue a lateral shift with
the leg. Note: If shifting toward
the involved side, the involved leg
should be allowed to advance for-
ward over the foot slightly to en-
able the body to turn.
rr
I
ff TRAI\SFER FROM BEI{CH TO CHAIR

rr 2' & 3' If the arm cannot be controlled in weight

placed more medially on the patient's
bearing at the side, it should be

rr
thigh. Th;therapist facilitates the trunk, leans
back so the patient can bend forward ano
iift off, and then shifts the patient to the side
with her leg' If the therapist slumps as the patient

rr
bends forward, this allows the knees
to advance so the patient can get his weigit
over his f'eet.)

rr
rr
r
-

rr
-

-
rr
-
r
r,
rr
G
cr Note: The therapist does not lift with her arms
but merely leans back so that her
shoulders are behind her hips. This helps guide the patient
forward over his feet. To
C assist the patient in turning, the therapisti
left leg cues the patient,s right leg back
C slightly' and her right leg moves away to allow
rF $:rfTJjtt:ltv'
the patient's left leg to advance over
This is accomplishedby trre trrerapisr rotaring
herp.ruir; norpulling

r.
l:,
r:
t:
l:
F,
F, 96
r,
r
 TRANSFER FROM BEI{CH TO CHAIR

4. & 5. This process is repeated making sure to adjust the patient's feet prior to each
lift off and turn. When the therapist is ready to have the patient scoot back, she
remains leaning back after lift - off and lifts her heels (by plantar flexing her feet)
which applies a back pressure against the patient's legs and moves the hips backward.
Once the hips are down on the surface the therapist comes forward which allows the
patient's shoulders to realign over the hips (i.e. sit up).

FOOT POSITION FOR TRANSFERS

When the patient is being transferred, it
is helpful to offset the feet slightly, with
the forward foot being the one in the
direction toward which the patient is
going. Thus, in this picture the patient is
turning toward the right so the right foot
is slightly ahead of the left. Both heels
must still be slightly behind the knees.
Also, if the foot is turned slightly, it is
easier to turn the patient.
I
t:
r:
rr TWO.MAN TRANSFER
Position and Function of the Back person:

r:
rr: The therapist in front does exactly what she would do in a one-man transfer
on pages 95- 97 . The person behind positions herself with a wide base
as shown
of support and

rrr slightly in the direction toward which the parient will be moving. (Note: She
be kneeling with one leg on the surface toward which the patient ii going,
as demonstrated in this photo.) The hands are placed over the greater
could
or standing,
trochanters of

rr
the patient with the fingers spread and pointing toward the paiient's knees.
As the
patient bends forward the therapist approximates the trochanters into
the hips and with
her thumbs gives a pressure forward toward the knees and into the feet

rf push of the patient's legs. The therapist then moves with the pelvis
therapist cues the turn with her legs.
to facilitate the
as the front

rr
-
-
-
-

rr
-

rC
C
C
C
cr:
r: Note: The therapist must
not go under the buttocks
C and lift the hips as the
C patient will then let the
C therapist lift him.
C
C
C
C
C
C
C 98

G
N-
 *1I
CLIMCAL IMPLICATIONS FOR FACILITATNG 1
GAIT ACTTWTIES 1
1
1
Gait Activities - Walking slowly enables the therapist to work on control of specific
:1
components, however, the speed must be increased to make it functional. This must
:1
:1
happen at the end of every session to get carry-over so the therapist must position her/
1
himself either beside or behind the patient to be able to increase the speed and keep
it smooth while giving cues if necessary. The therapist must make his/her own
1
1
walking smooth and step with the same foot as the patient to help with the rhythm. If
walking behind the patient, the therapist should also step directly behind the patient's 1
feet, otherwise there is too much lateral movement. During walking the therapist 1
should be facilitating and encouraging more equal step length and timing as well as 1
progression of the body forward over each foot to increase efficiency. 1
1
Functional walking incorporates many aspects some of which have been included in 1
*l
this section , such as walking backwards, turning or pivoting, stepping up and/or
down, bending down to pick something up, etc. These are just the beginning and the 1
therapist must listen to his/her patient as he describes what is difficult and then work 1
on those specific problems. Moving the body over the base of support in many 1
different ways and positions, while one performs tasks with the anns, is what function 1
is all about. Usually the patient has a limited variety of movements which severely 1
interferes with his ability to function safely, independently and efficiently. The more 1
creative the therapist can be in his/her choice of activities to present to the patient, the
1
more the patient will improve, if the quality of movements is maintained relatively
1
well. Remember your choice of activity often will be crucial to your success.
1
1
Each activity should be:
1
1. Performed at the appropriate level of challange to the patient. 1
2. Meaningful to the patient. 1
3. Of interest to the patient. 1
4. Successful within a reasonable time frame. 1
5. Lead to other challanging activities. 1
6. Performed in actual functional situations if at all possible. 1
1
*l
,t'
ff FACIUTATNG TTM TRUI{KWHILE WALKNG

rf FROM THE SIDE

rf Note: In all trunk facilitation the therapist must

trunk and rower trunk at ail times to keep the
be able to influence both the upper

r
trunk alisned.

rr
r:
rr Anterio-lateral View - l. The therapist,s
right hand is over the abdominals cueins

rr the upper abdominals to bring the rib

cag!
down and/or the lower abdominals to keep

rr
the pelvis neutral.

-
-
-
-
-
-

r
-

rr
-

e Posterio-Iateral View - Z. Thetherapist, s

G left hand uses the thumb to cue the rib
rt- cage forward and the fingers cue the back
C of the pelvis down into a *fuck". There
C should be no contact over the low back
C as the patient is usually already over_ex_
C tended there, due to frequent leaning of
the upper trunk back or tilting the pelvis
C
forward.
t:
C
C
C 100

F,
r
 I
:l
SEQUENCE FOR WALKNG BACKWARD :r
:1
:1
1. While maintaining the patient's trunk erect and active, the therapist facilitates :1
weight bearing over the involved left leg and the patient takes a small step back with
the right foot. The hand position selected by the therapist is always determined by
:1
what input the patient needs for alignment or facilitation. In this example the therapist's
:1
hands are controlling the trunk alignment and facilitating the abdominals.
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
:1
1
n
:1
:1
:1
:1
:r
:r
:r
:r
:r
:r
101 1
'1
1
rr
I

rr SEQUENCE FOR WALKNG BACKWARDS

rr 2. After the patient shifts back over the back, less involved foot, the therapist can
assist the release of the involved left leg with a slight downward cue on the pelvis.
fr Once the knee is released, the therapist can place her toes on the distal shin just above

rr the patient's ankle. She then lifts the foot up and back while maintaining trunk
alignment so the movement comes primarily from the knee. The patient then extends

rr the leg as his weight is shifted back onto it and the sequence is repeated.

rr
rf
rr
rt.
ft.
f
rr
fr
r:
rr
rr
f
rr
rr
rr
C
r
 FACILITATNG THE IN/OLVED LEG DURNG GAIT
(Therapist standirg)

1. The therapist is sinrated behind and slightly toward the involved side. She could be
sitting on a rolling stool or crouched (as pictured) but needs to be able to move
smoothly with the patient as he walks. The therapist's right arm is around the patient
so she can facilitate the abdominal muscles.
,r
rr FACILITATNG THE IN/OLVED LEG DTIRIT{G GAIT

rr 2' & '

(Therapist standing)
The therapist spreads her left hand so thar the thumb is pointing

rr
3
up and the
little finger down and both are placed on the posterio-lateral
aspect of the thigh. The
other three finger pads are along the lateral ispect of the

rr
thigh. Note: If the hand is
close to the hip the therapist controls the pelvii and hip
she controls the knee hyper-extension more.) The
-or.; if closer to the knee,
thumb pressure is down to help

rf,
*tuck"
the hip in stance, the little flnger blocks the knee
hyper-extension and while the
leg is in stance there is a pressure into the floor applied
thiough the therapist,s whole

rr arm to facilitate weight bearing so the patient ian tate

(Note: The therapist must step with the same leg.)
u ,i.p with the better leg.
Then as the weight is transferred

rr over the less involved leg, the therapist can faciliiate the
the thumb, and knee flexion with the little fineer.
timing of thJpetvic drop with

rr
rr
rr
rr
rr -*ry$
rr ,r*
rr ,;}
i.

rr r w<
i'-l

tr
rC *lo'.q,

rC
C
C
C
C 104

r,
7
 I

:1
FACILITATING TIIE INVOLVED LEG DTIRNG GAIT :1
(Therapist standing) :r
:1
4. :1
As the body moves over the less involved leg, swing of the involved leg can be
assisted with a cue forward with the little finser. a
:1
a
:1
:1
:1
:1
:1
:1
:1
:1
:r
:1
:'t
:1
:1
:1
:1
:l
:l
:1
:1
:1
5. Once the leg has reached "heel strike" the therapist is again positioned to prevent :1
hyper-extension, while guiding the body forward, facilitating the pelvic "tuck" and :1
weight bearing into the floor to assist loading the leg in stance. :l
:1
:1
:1
:1
:l
:l
:1
:r
:l
:l
t^
ff SEQTIENCE OF PTVOTING (TURNNG) TOWARD
THE AFFECTED SIDE
ff 1. While maintaining the patient,s trunk

ff aligned and active, the therapist facilitates

weight shift to the affected left side, and

rr the patienr sreps slightly forward with the

right foot, turning in, so the toes of both
feet are closer together.
fr
rf
f
ff
f
fr
rr
f
a
-

rr
-

rt: 2. Patient weight shifts onto the right leg,

releases the left leg and turns the heel in.

-
rr
rr 3. The therapist can place her foot on the
outside of the patient's heel to assist furn_
ing in of the heel. The sequence is then
fr
rC repeated. At no time should the affected
foot come totally off the floor. Also, re_
member to move the weight bearing sur_
C face for the arm with each step to keep the
C arm in good alignment.
C
C 106

t:
L
 PWOTNG AWAY FROM TI{E AFFECTED SIDE

1. Patient shifts onto the affected left side and then steps back with the right leg so
the heels come close toqether.

2.Patient then shifts onto the right leg, releases the left leg and the therapist helps
move the heel out. Do not pick up the foot.

Note: The weight bearing surface for the arm must be moved with each step in order
to keep the arm aligned and in weight bearing.

.l
rJ.
I

rr FACILITATING BENDNG DOWN TO REACH FOR AN OBJECT

(Feet even)

rf
rr: 1. The therapist places herself behind and
slightly toward the involved side in a stride

rt1 position with the forward leg behind the

patient's involved leg. Her right arm is

rr
around the trunk with the hand over the
abdominals to facilitate them. The
therapist's left hand is spread over the

rr involved side of the pelvis and lateral hip

to facilitate the abdominal and hip abduc-
tor muscles. The therapist's leg is in light

rr
t1 contact with the patient's leg without
supporting him as he starts to bend.

rr
ra

rr
rr
rr
rr
rr
rr 2. As the patient continues to bend and
reach with the less involved arm, the

rr therapist maintains the patient in mid-

line and bends with him without sup-

rr porting him. She continues to facilitate

abdominals and hip muscles to help the
patient maintain control. The therapist
C needs to move smoothly with the patient

C to be able to facilitate and not interfere

with the patient's movements.
C
C
C 108

C
(
 FACILITATING BENDING TO REACH AN OBIECT
BILATERALLY, WITH THE FEET EVEN

1. The therapist's body is positioned as be-

fore but the hand of the left arm is on the
patient's involved arm to facilitate and guide
it. The thumb is poinring up behind the
humerus to facilitate shoulder approxima-
tion with an upward pressure (if necessary)
and forward flexion while controlling rota-
tion; the index flnger can assist lateral rota-
tion and supination and the middle and ring
finger can stabil2e the forearm during reach.
As the patient bends the therapist assists by
facilitating the abdominals, keeping her leg
in light contact with the patient's leg and
facilitating the begiruring of reach with her
left arm.

2. As the patient continues to bend and

reach, the therapist continues to facilitate
the trunk and arm as she moves with the
patient and keeps him in midline.

-t
l-
ft: FACILITATNG BENDING AND REACHING BILATERALLY
f FROM STRIDE POSITIOI\
ft:
rf 1. The therapist is positioned as previ-
ously described but the patient's feet are
in stride position with the more involved
r: foot forward.
t:
r:
r:
rr r
rf
rf
f
rC
rri
t1

rr
-
a
rft 2.
rr The therapist bends with the parient
and keeps him over the forward involved
leg and as he bends and reaches he should

r: also shift more forward over that leg to

assist in the reach. The therapist can as-
r: sist this by shifting her weight forward as
C the patient reaches with both arms. The
C therapist assists with the involved ann as
C previously described.
C
C
C
C 110

C
(
 I

1
PREPARATIOI\ FOR STAIR CLIMBING 1
CLU\ICAL IMPLICATIONS
1
It is useful to work on the components of stair climbing as many patients can learn to a
go up and down step over step with a little preparation. 1
1
Ascending the stairs: To make the lift easier for the foot on the step the back ankle
plantar flexes to help the front leg with the lift. The body moves forward over the 1
front foot to get the weight over it so the back leg can then step up. This means the 1
ankles need to have both dorsi flexion and plantar flexion range and power in the 1
plantar flexors. 1
1
Descending the stairs: When coming down the stairs forward the stepping foot
1
plantar flexes to contact the step below. This assists the back leg because it shortens 1
the distance that the weight bearing leg has to lower the whole weight of the body
1
down and forward onto the next step. Coming down the stairs forward is more
1
difficult so in the beginning it is helpful to practice going down backward.
1
FACILITATNG ANKLE PLANTAR FLDilON 1
1
1
1
a
Side View
1
1
The therapist is facilitating the trunk and a
maintaining the alignment while assist-
ing the patient's involved ankle to plan-
1
1
tar flex by cueing under the heel to help
1
raise it.to raise the heel. The better leg
1
is on the step but most of the body weight
is on the involved leg. This activity 1
could be preceded by bilateral plantar 1
flexion with both feet on the same sur- 1
face. Be sure to keep the weight equal 1
on both legs during that activity. 1
1
1
1
1
1
:1
1
111 1
1
, 1
-.a
-a FACILITATNG A STEP UP WITH TIIE IN/OLVED LEG
?<a
.2 FROM BEHII\D
2
; 1. The therapist is positioned on her knees
F.l behind and on the involved side of the
; patient with her right shoulder under the
patient's involved ischial tuberosity. Her
-2 hands are placed on either side of the
patient's distal thigh to control the align-
ment and to give a weight bearing input
into the foot. (Note: The patient should
have at least one hand on a weight bearing
surface which is high enough to allow sup-
port throughout the entire step- up.

2. As the patient begins the step- up, the

therapist extends her hips and brings the
patient's hips up and forward while giving
a weightbearing input into the foot. These
inputs must be graded to keep from throw-
ing the patient off balance. The object of
this activity is to get the hips over the foot
before the knee fully extends. The posi-
tion of the therapist allows her to give a
) great deal ofassistance ifnecessary. It is
t>
also helpful to have the patient rt.i down
/> backwards with the less involved leg to
/> work on a lengthening contraction of the
D same muscles used to step-up.
)
D.

t)

t)
t12

r-
a-
L
 I
a
:1
a
Side Views a
a
As the patient requires less assistance the therapist can stand behind the patient and a
assist the involved leg by giving a weight bearing input to the distal thigh as the knee a
moves forward over the foot. This will help the involved leg extend and lift the body. a
If you have the patient leave the better leg off the step, you can practice lifting up and a
then down with the more involved leg. The therapist would continue to maintain the
a
alignment and facilitate the trunk if necessary. The patient's hand would be on the
a
table as pictured or on the stair railing.
a
1
a
a
:1
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
:l
:1
:1
:r
r13 :l
1
l.
rr
rr FACILITATING A STEP- UP WITH THERAPIST IN FRONT

rr Note: The step must be high enough so that the patient cannot do the entire step up
by plantar flexing the back leg. The patient should also have arm supporr.

C
r. 1. The therapist is positioned in front with
her hand over the distal thigh of the in-
r-
rr volved leg so she can give a weight bear-
ing input into the patient's foot and keep

r the knee forward. The other hand is posi-

tioned so she can control the trunk and
-
rr facilitate the abdominals and hip exten-
sion.

rr
rr
rr
rr
rr
rr
rr
rr
rr 2. As the patient steps up the therapist
maintains the weight bearing input into
the foot and keeps the patient from lean-
r: ing to far forward while the patient ex-

rC
r" tends the hip.

rr
rr
 I
1
FACILITATING STEPPING DOWN LEADING WITH 1
THE LESS IN/OLVED LEG FROM THE FRONT :r
:l
:r
l. The therapist's hands are in the same :r
position as previously described. As the 1
patient steps off with the better leg, the :r
therapist gives a weight bearing input into :r
the involved foot while keeping the :r
patient's trunk erect and active. :l
:r
:1
:l
1
:r
:1
:1
:l
:1
1
:1
:1
a
:r
:1
:1
:1
2. The weight bearing input is maintained :1
until the patient's forward foot has reached :1
the step. a
a
a
a
a
:1
J
:1
J:1
a
J
I
fr
rr FACILITATII{G STEPPING DOWN LEADING WITH
THE LESS II{VOLVED LEG FROM THE FRONT

rf 3. Then the therapist guides the body for-

rf ward over the forward foot as the heel goes

down and also controls the alignment of the

rr involved leg.

rf
rr
-
-

-
r
-
-
-

r
-

r
-

r
C
-
4. If necessary the therapist can assist
the step down of the involved leg by com-
- ing under the lateral border of the foot and
- everting the foot while also bendins the
c
rC knee slightly to clear the step.

C
c
G
C
G
G 116

G
 I
:r
POSITIONING AND EARLY BED MOBILITY :r
GENERAL ATMS :r
:r
1. To provide support. :r
2. To discourage movement strategies that ericit abnormal tone. :r
3. To promote symmetry in alignment, weight bearing and orientation. :r
4. To provide more normal sensory feedback. :r
5.
6.
To encourage awareness of the affected side. :r
7.
To relieve pain and provide comfort.
:r
To develop and reinforce basic strategies of movement for function in bed.
:r
:r
:r
CLINICAL IMPLTCATIONS FOR POSTTIONING AND
:r
EARLY BED MOBILITY
J
J
Proper early positioning of the patient is extremely important to the prevention of tight-
ness and to maintain sensory awareness of the body parts through weight bearing. J
:|
Teaching the patient how to move in bed is also extremely important. However, trying to 1,
move the body around while horizontal is extremely difficult because of the influence of -t
gravity on the body parts. Therefore, these bed activities should be preceeded by some 1
firm
preparatory activities in sitting on the edge of the bed with feet flat on floor or on a :l
support surface. Activating the muscles of the trunk in sitting and/or standing is much :l
the
easier because of the decreased influence of gravity, as well as, the decrease in size of
:l
base of support which creates an increased demand on the muscles. Thus, many activities :l
described earlier under "sitting activities" might be used as a preparation for the bed :l
mobility activities. :l
It is also important to recogn tze thatthese activities are encouraging the patient's active
participation, so it is very important to wait for the patient's response following facilita-7
tory input. Otherwise, the therapist is doing the "work" which teaches the patient very -l
;
little. It is much better to do fewer activities, but insure that the patient is actively involved
)
in everything that is being attempted.This does not imply that the patient is doing "every-
)
thing" for himself, rather that the therapist helps only as much as is necessary to help the .I
patient achieve the activity, As the patient becomes more active, the therapist withdraws .
t
her input to allow the patient to achieve more in a shorter period of time. :l
1
Note: In the following photographs, the "patient's" involved side is indicated by the sash J
tied around the model's arm. 1
:l
:l
Lt7 :l
.l
a
I
fr
POSITIONING IN SUPINE
fr
fr HEAD: Position head in midline with slighr flexion.
A rolled towel placed under the pillow will prevent side flexion

fr if necessary.

rf TRUNK: The trunk should be symmetrical - i.e equal length on both

sides.
The pelvis should be even - if affected side is rotated back, place
folded sheet under that side to bring it even. Equal weight bearing
a

ff should be maintained.

rr ARM: The shoulder should be in slight abduction.

rr External rotation is critical. Elbow crease facing upward.

Forearm can be pronated and resting on pillo* ioislight erbow
flexion.

rr Avoid elbow hyper-extension.

Wrist in neutral or slight extension.
Fingers relaxed and open.

r
-
-

rr
-

rr
rr
':

rr
ra
rr
rr E

ii
r:
r-
rr
r: r 18

r
7
 I
1
POSITIONINIG IN SUPII{E :r
:r
LEGS: Placing pillows on edge under the knees will maintain knee flexion, give
1
support and allow patient to relax while keeping the heels in weight bearing.
:r
Do not use a foot board.
:r
For longer periods or ifpatient is staying in supine with legs extended, place
a folded sheet under distal thigh to flex the knee slightly. If necessary ro 1
relieve pressure under heel, place a small towel under the Achilles tendon or :r
use sheepskin booties. 1
:r
SCAPULA: Mobilizations in the supine position prior to positionng to inhibit tone, :r
may be necessan)i if the scapula is immobile. :1
Mobilizations may be bilateral. :r
Place a small folded towel under the affected scapula to maintain scaoula :r
against thorax , but don't unweight it. :r
Shoulders should be even in all planes. 1
1
1
1
1
1
1
1
1
1
1
1
'iii,r
1
1
itli
1

:::i:t

ffi ,;tiw#
t
rr
2
POSITIONIING IN BED - HEAD OF BED
ELEVATED
r:
rr with the patient sitting in bed, the hips must
be placed at the bend in the bed.

r:
r
The head of the bed is slightly elevated
patient from sliding toward the foot
and the knees may be flexed slightly
to keep the

rr IJse a lumbar pad to facilitate back

of the bed.

rf
extension. The pad is placed above the
below the T11 vertebra and only thick enough iliac crest and
to encourage lumbar extension to neutral.

rr There may be a need to place a pillow

with the pelvis.
behind the head and shoulders to keep
them aligned

rr Pillows may be placed under the affected

forearm to promote weight bearing

rr prevent trunk collapse to the affected and to

side. The upper arm should be in slight
abduction and lateral rotation. flexion,

rr
-

-
r
-
rr
rC
a
;
F
; i"
) ;i; {tk

;
n
a
a
-l-' 120
l-
t-
 I
1
EARLY BED MOBILITY :1
:1
:1
ROM CERVICAL SPINE: :1
:1
Use a pillow to do ROM of head and neck. :1
Move slowly. a
Work on rotation, side bend, diagonals. :r
Gradually work toward flexion. :1
Note: It is often easier for the patient to become actively involved if
:1
the head of the
:1
bed is raised 30-40 desrees.
1
:r
:1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
,r_
fr HALF.BRIDGNG
f Half bridging helps facilitate co-contraction around the hip
and better placing responses

f in the leg with increased weight bearing into the foot.

rf Place the heel of the affected leg nearly under

rr
the knee; less involved leg remains straight.
Facilitate by:
Cueing with one hand on the distal 113 offemur and one
hand at the lateral pelvis.
The pressure is down and forward into the foot from
f the distal f'emur to promote
weight bearing. wAIT until the hip muscles are activated
f femur forward over the foot and slightly inward to keep it in
and then guide the

f as it rolls' The hand at the pelvis guides the pelvis

line with the pelvis
down and forward on a
f diagonal. These movements are best accomplished by
the therapist shifting her
f body weight in a diagonal direction. If the patient requires
more input, a draw
f sheet can be placed under the patient and pulled
snug over the lateral pelvis. The
f same input is then given to the femur and as the femur
is drawn forward and in,
f the pelvis is drawn down and forward. This is also
best done by the therapisi
f shifting her body in a diagonal direction.

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PLACNG 1
1
While the patient is in supine with the affected leg bent and the less involved leg straight,
1
work on controlled knee and hip extension (i.e. eccentric contraction of the flexors). Use
1
distal key point to control tone by keeping the lateral four toes in extension and maintain
1
ankle in slight dorsiflexion/eversion. Give input into the hip from the proximal tibia to
1
facilitate hip flexion. Heel stays in slight weight bearing while hip and knee extend with
control. 1
1
1
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,r1
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r BRIDGING

rr Teach the patient to use his unaffected foot over his affected
foot to assist in hip and knee

rr
flexion to get heels under knees.

Pelvic lift can be facilitared by:

rr Pressure into the feet from the distal end of the femurs to activate
the hip
muscles. Then guide the femurs forward over the feet while maintaining

rr weight bearing pressures. Note: This pressure can be applied in a variety

the
of
ways.In the bottom photograph, the cue for hip lift is given by the fingers

rr along the lateral border of the femur.

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ALTERNATTVE WAYS TO FACILITATE BRIDGNG 1
1
1. The therapist places her hand and forearm across the patient's distal thighs, and her 1
opposite forearm over her hand to reinforce weight bearing. The therapist facilitates 1
weight bearing into the patient's feet by pulling her arms toward her. She then 1
facilitates abdominals and asks patient to lift as she shifts back slightly to assist lift. I1
2. Use the same hand and forearm position as above except the free hand is on the lateral
pelvis instead of the abdominals. The therapist facilitates weight bearing into the feet
1
by pulling her arms toward her and then assists hip lift on affected side while shiftine :1
:1
back slightly.
1
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125
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F
rr BRIDGING (cont.)

ff If the patient needs more help, use a draw sheet under the pelvis at hip
level. The

rf therapist's forearms are on the patient's femurs. Hold sheet taut. Give pressure
feet with your forearms; then by leaning back slightly with your
into the
body guide the patient,s

rr r femurs forward over the feet while simultaneously cueing the pelvic
sheet. Always give a verbal directive at the appropriate time.
lift with the draw

rr Ys{

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 scoorlNc PELVIS To SIDE (Bridging with rotation)
Pressure is applied into the feet from the distal femurs to activate the hip muscles. Then
cue for bridging.

While maintaining the bridging cues, add a lateral pressure on the patient's left femur and
a forward pressure on the right femur, and the hips will shift slightly to the right in bed.

Cues must be applied slowly and released slowly.

Reverse the cues to shift hips in opposite direction.

This can also be done with the draw sheet. Once the patient has bridged, then give a
lateral cue with the sheet on the left, and a forward cue with the forearm on the risht
femur, to move the hips to the right.
,i
rr SCOOTING PELVIS TO THE SIDE STANDING BESIDE BED

r (Bridging with rotation)

(
rr The therapist stands at the side of bed next to patient's hips. She places her
on the patient's distal thigh of his near leg and her upper arm across distal
upper rib cage
thigh of his far

rr leg. Placing her hands on the lateral pelvis, the therapist shifts backward against
patient's distal thigh to apply pressure into the patient's feet and then assists hip
or scoot as needed.
the
lift and/

fr
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SCOOTING TPPER BODY :1
:1
The therapist's body is positioned near the patient's hips. Feet are in a stride position with :1
outside leg forward. The therapist's hands are over the patient's shoulders so thumbs are :1
in front and fingers are spread on patient's scapula. :1
:1
Roll the shoulders forward and diagonally across to opposite hips. Slight pressure with
the thumbs under the clavicle facilitates the head lift. Shift your body weight back to bring
:1
the patient's shoulders closer to hips. Must clear scapula to move trunk easily. To
:1
facilitate lateral translation of upper trunk to the left: apply a lateral pressure on axillary
:1
border of the right scapula and maintain elongation of the left side of trunk while shiftine
:1
the upper trunk to the left. :1
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rf
I

MOVING UP IN BED
f
rr The head of the bed is flat and the pillow is away from the patient's shoulders.
Bend the knees so the heels are nearly under the knees. Trap the foot.

rr Facilitate and maintain bridge while giving pressure under the lateral aspects of femurs,

rr or the pelvis toward the shoulders. This moves the patient's bottom closer to his shoulders
by hyper-extending the low back.

rr To adjust upper body, facilitate head and upper trunk lift from shoulders and bring

rr patient's thorax off the bed by a backward weight shift of the therapist. This lengthens the
back and as the head and shoulders are guided back down they land closer to the head of

rr the bed. Move the patient up in an inchworm fashion.

rr i

rr
rr
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ROLLING TO SIDELYING ON AFFECTED SIDE :r
Lying on the affected side is the position of choice because of the weight bearing input :r
through the affected side. Head and scapula position are critical to lying on the affected :r
side without pain. :1
:1
With the patient supine, facilitate scoot to other side of the bed. Keep both knees bent. :r
Prior to rolling, abduct the affected scapula. The patient can assist with this by placing :1
his less involved hand over his scapula and abducting.The hand then slides down the arm :1
to place it in slight abduction to avoid lying on it. Patient may then place his less involved :1
hand on outside of involved thigh to help control leg (i.e. prevent it from flopping) as he :1
rolls. The therapist should be on the side of the bed toward which the patient is rolling, :1
as a safety precaution.
:1
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The therapist stands along side the patient's affected side. patient starts to
turn head.
Facilitate head lift through pressure down on less affected shoulder, toward
the pelvis. As
upper body rolls, allow legs to follow in a controlled way. The therapist

rr patient control affected leg.

may need to help

rr once on the affected side, patient rolls upper body back slightly and using the
affected hand, abducts the more affected scapula further. A pillow may
less
be placed under

rr the forearm to facilitate eye-hand and hand-hand contact.

rr
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ROLLING TO SIDELYING ON AFFECTED SIDE :1
One additional adjustment will help the patient's comfort. Place less affected hand on the
:r
mattress (level with patient's waist) and less affected foot near patient's affected knee. :1
The patient pushes into the mattress with the less involved hand while the therapist helps :1
patient push his less involved foot into the mattress while assisting the underside of the :1
pelvis to rotate backwards slightly. !
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rr
'r.' POSITIONING IN SIDELYING ON AFFECTED
SIDE
r*
rr
Use two pillows under the head so it is
tilted away from the affected side.
No pillows for the legs' Affected leg is in
slight lexlon at the hip and more flexion
at the

rr
knee for a wider base' Patient is encouraged
to move the other leg. If there is a problem
of perspiration, use a sheet or bath blanket
between the legs. The involved arm can
placed on a pillow as shown, or be

rr
with the elbow bent and resting on a pillow placed
the bed rail' or bent and laterally rotated against
and supported on a pillow near the head.

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ROLLING AFFECTED SIDE TO SUPINE
Flex the patient's knees up towards chest. Trap the foot by placing the less affected foot 1
over affected foot. Patient places affected arm across his chest, close to body. Then the 1
patient places his less involved hand under his affected thigh, and keeps it there as he rolls 1
back leading with the shoulders. Therapist assists the legs by maintaining a hand on 1
patient's hand. 1
1
1
1
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rr ROLLING AFFECTED SIDE TO SUPII{E

rr scooting the hips will be necessary once the patient is in supine.

rr
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ROLLING TO SIDELYING ON THE LESS AFFECTED SIDE -l
1
With the patient in supine, facilitate scooting to the other side of the bed. Remove exrra 1
pillow. This will avoid shortening on the affected side of neck once the patient is in 1
sidelying. Using his less affected hand, the patient brings his affected arm across his body
so his hand is near his hip. Then he slides his less affected hand up to the scapula to
1
*1
abduct the scapula.
1
1
1
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- ROLLING TO SIDELYII\G ON THE LESS AFFECTED SIDE
As the patient turns his head, the therapist facilitates head lift. As upper body turns, legs

rr
- follow. If patient's involved knee is bent and affected foot is trapped, therapist can
facilitate weight bearing into the affected foot to encourage pushing with the leg.

- Affected arm is positioned on pillows to avoid too much adduction and external rota-
- tion. Pillows should not block patient's view.
-
The bottom leg is straight and the top leg is flexed slightly at rhe hip and knee and
-
positioned on 1 or 2 pillows placed in front of the bottom leg. This helps avoid too much
- adduction at the hip and should keep the entire leg and foot in alignment.
-
- The spine should be fairly straight. If necessary, afolded sheet placed under the patient's
- less affected side prior to rolling, should prevent shortening on the affected side. The
. width of the folded sheet is such that it lies between the patient's iliac crest and inferior
- angle of scapula.
-

r
-

- Note: Patient will usually

-
1 make his own comfort ad-
justments when lying on the
a less involved side.
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1
ROLLII\G LESS AFFECTED SIDE TO SUPINE 1
*1
Patient bends his less affected leg pushing pillows out from under the affected leg and
1
brings both knees toward chest. Then he traps his affected foot with his less involved foot.
1
1
The patient grasps his affected arm at the wrist and supports it while he rolls onto his
back. The roll is initiated with the hips and the upper body follows. The therapist may 1
need to assist with the less. 1
a
1
a
1
1
1
1
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rr ROLLING LESS AFFECTED SIDE TO SUPINE

rr
rr once in supine, hips will need to be scooted to
correct the alignment.

rr
rr
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rr
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 I
1
LYING TO SITTING AT EDGE OF BED -1
-1
This is easier initially if the head of the bed is elevated, but eventually the patient must be
able to do it from a horizontal position. ta
Remove the pillows, under the arm and leg, if they are present. Flex hips and knees as a
much as possible and trap the involved foot. a
a
Therapist is on the patient's affected side. a
:1
Patient's affected arm is abducted while his hand is on the therapist's thigh, pelvis or
a
bed, to allow weight bearing. Therapist's hands are over the patient's shoulders to
a
facilitate trunk flexion on a diagonal toward the affected side.
a
:1
Ask patient to turn head toward you and cue for head lift.
a
a
a
a
-
a
a
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,r-
f
rf LYING TO SITTING AT EDGE OF BED

rr As the head and shoulders lift off, the therapist's hand on the affected side slides
the rib cage to assist in trunk elongation and to free up the other hand to assist
off the surface.
down
the less

ff
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1
LYING TO SITTING AT EDGE OF BED a
a
Then as the shoulders get over the hips , cue for trunk shortening on the affected side and 1
trunk extension. This helps get the less affected hip down on the bed and the trunk erect 1
with shoulders over hips. a
a
Note: The hips should be close enough to edge of bed before you start so that the knees a
are just off the edge when the patient is sitting up. It also helps to have a surface to place a
the feet on once sitting to give the patient more stability. Knees should be same height as
a
hips when sitting on the edge of the bed.
a
a
a
a
a
a
a
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a
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Ir
rl* ALTERNATIVE METHOD: SIDELYING To SITTING

rr With the patient lying on his affected side, have him place his less aff'ected hand
bed under his affected arm, which is flexed at the shoulder.
on the

rr The affected hand weight bears on the therapist's thigh or pelvis,

the affected arm and maintain protraction of scapula.
or therapist may cradle

rr
l* Flex knees up toward chest so feet are nearly off the bed.

rr Ask the patient to lift his head off the pillow. The therapist may facilitate
pressing less affected shoulder toward the less affected hip.
head lift by

rr
rr
fr |ii
s

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:1
ALTERNATIVE METHOD: SIDELYING TO SITTNG :1
Patient pushes with less involved arm while the therapist slides one hand down to the
:1
:1
lateral rib cage on the patient's affected side, to elongate that side and assist with trunk
1
support while patient adjusts less affected hand to continue to push himself up.
1
1
If feet do not slide off automatically, therapist 1
assists by lowering the legs off the bed. Keep
1
hips flexed.
1
1
1
1
1
:1
1
a
1
4
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1
n
n
a
1
1
1
Therapist then facilitates
1
1
trunk extension and lateral n
flexion on the affected side a
to get the opposite side of
1
the pelvis down on the bed
1
and shoulders over hips.
1
1
:1
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145 1
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1
l-
rr
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SITTING TO LYING ON AFFECTED SIDE

rr Cross less affected leg over affected leg, at the ankle, to control extension
and to assist

-
r in lifting the leg into bed.

Affected hand is placed on therapist's thigh or hip to encourage weight bearing. Thera-
pist maintains hand there by maintaining her thigh at anangle and with
input Uetrind ttre
- humerous from the hand on the patient's affected side of trunk.
-
rr: Ask the patient to bring sound hand across body (in front) and to slide that hand

r
toward
the pillow. Therapist must help by facilitating trunk flexors.

-
-
r:
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1
1
SITTING TO LYING ON AFFECTED SIDE
1
*rl
As the patient lowers himself down, the therapist assists at the lateral rib cage on the
affected side to maintain trunk elongation and assist weight bearing through the affected 4
*l
arm. Patient must be instructed to keep head up and away from pillow.
*1
As the trunk is half way down, therapist then assists patient to place lower legs and feet
on the bed while maintaining hip and knee flexion.
4
*l
1
Patient initially is in sidelying and then rolls onto his back as described earlier. 4
4
1
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1
1
1
1
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141 1
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a
I

rr ALTERNATIVE METHOD FOR SITTING TO LYING

-
rr Place feet on stool or chair so knees
and hips are the same height. The thera-

rr pist assists patient down to a lying po-

sition as previously described, but leaves

rr the involved foot on the chair. (The pa-

tient will probably automatically bring
the less involved leg up.)
r:
r:
r:
r:
r:
r:
rr
r3

f Once the patient is down, the therapist

ri can assist the patient in bringing the in-
rT volved leg up using the same facilitation
e as described with placing the leg. (see
rT page 123)
rv
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