Lower Trunk Activities

hooklying (crooklying)
general characteristics
 the base of support (BOS) in hooklying is large
 the center of mass (COM) is low
 this posture is very stable
 hoooklying primarily involves lower trunk, hip, and knee control:
o activation of the lower trunk rotators and hip abductors/adductors allows
the patient to actively move the knees from side to side away from midline.
o activation of the hamstrings allows the patient to keep the knees flexed in
tje hooklying position

treadment strategies and considerations

 hooklying activities are important lead-up activities for controlled bridging,
kneeling, and bipedal gait.
 abnormal reflex activity may interfere with assumption or maintenance of the
possture.
o in supine, the symmetrical tonic labyrinthine reflex (STRL) may cause the
lower extremities (LEs) to extend.
o a positive support reaction (applying pressure to the ball of the food) may
also cause the LE to extend; a heel-down position minimizing contact of
the ball of the food may need to be adopted.
 active movements of the knees from side involve crossing teh midline and can
be an important treadment activity for patients with unilateral neglect (for
example, the patient with left hemiplegia).
 patients with gluteus medius weakness (for example, the patient with a
Trendelenburg gait pattern) may benefit from hooklying activities to activate
the abductors in a less stressful, non-weight-bearing position.
 lower trunk rotation (LTR) should occur without accompanying upper trunk
rotation (UTR) or log rolling.
o the upper extremities (UEs) can be posiitionedin extension on abduction
on the mat.
 o a prayer position (hands clasped together with both elbows extended and
shoulders flexed yo 90 degrees) may be used with the patient recovering
from stroke who demonstrates excess flexor tone in the UE.

Hooklying: Therapeutic activities and techniques

position/activity: hooklying, lower trunk rotation
the patient is in hooklying position
techniques
rhythmic rotation
rhythmic rotation (RRo) is passive technique designed to promote relaxation in the
patient with LE hypertonicity. rhythmic rotation is repeated until relaxation occurs,
generally for several minutes.
the patient is in hooklying position with both feet placed flat on the mat or on the
therapist’s knees. the therapistis in heel-sitting position at the base of the patient’s
feet. the therapist’s instructs the patient to relax end let the therapist move the legs.
the therapist places both hands on top of the patient’s knees and slowly rocks the
knees side to side. range of motion in lower trunk of rotation (LTR) is gradually
increased as tone decreases.
an alternate approach involves positioning the patient’s legs on a Swiss ball (hip and
knees are flexed to approximately 90 degrees). the therapist is half-kneeling, holding
onto the patient’s legs. the therapist slowly rocks the ball from side to side (fig. 9-1).
this thechnique eliminates tactile input to the bottom of the feed, thereby reducing
the possible negative effects of a hiperactive positive support reflex. the ball also
allows the patient to move from side to side easily and may be a more effective
intervention for patient with high levels of spasticity (for example, the patient with
multiple sclerosis and strong LE extensor tone).

Rhythmic initiation
in rhythmic initiation (RI) the lower trunk is rotated as the knees are moved slowly
from side to side. as the patient relaxes, range is gradually increased until the knees
move laterally down to the mat on each side. the movements are first passive (as in .
resistance. progression to next phase is dependent upon the patient’s ability to relax
and participate in the active and resistive phases.
the patient is positioned in hooklying. the therapist is at the patient’s side in a half-
kneeling position. manual contacts are fixed on top of the knees during the first two
phases. during the final (resistive) phase the tharepist’s hands slide to the side (the
medial side of one knee and the lateral side of the opposite knee) to resist both
knees as they pull away and then slide to the opposite side of the knees to resist the
return movement. the therapist;s hands pivot in orser to resist the complete return of
the knees down to the mat (fig. 9-2A and B).

motor control goals (RRo and RI). mobility.

indication. impaired function due to hypertonia (LE extensor spasticity, rigidity) and
decreased LTR.

functional outcomes. the patient performs independent bed-mat mobility.

hold-relax active motion side

in hold-relax active motion (HRAM), the patient’s knee are moved toward one side
(away from the therapist) one-quarter range. the patient is asked to hold this
position, slowly building up the isometric contraction. the patient is then asked to
actively relax. the therapist then moves the knees quickly in the oppsite direction
past midline and asks the patient to actively contract through the range back to the
original position (fig 9 – 3).
the sequence is an isometric hold followed by active relaxation, then passive
movement into the lengthened range followed by a resisted isotonic contraction back
into the short-ened range. the active ralaxation is important; return movement should
not be initiated until the isometric contraction is completly released.
the patient is positioned in hooklying. the therapist is half-kneeling at the patient’s
side. the therapist’s hands are positioned on top of the patient’s knees. the therapist
applies greater resistance to the weaker LE, which typically has weak hip abductor
on one side. the isometric contaction is built up slowly; resistance of the isotonic
movement is light (tracking). verbal commands are dynamic and should reflect the
buildup of effort. a quick stretch can be applied in the lengthened range to facilitate
the return movement.
HRAM emphasizes movement in one direction only. midrange control is achieved
first; progression is to full-range control.

motor control goals (HRAM). mobility.

indication. weak, hypotonic muscles (lower trunk roaotrs, hip abductor).

functional outcomes. the patient performs independent bed-mat mobility.

position/activity: hooklying, holding

in hooklying, the patient actively holds both knees stable and apart, in midline
position. active holding (maintaining the hooklying position with feet in contact with
mat surface) is a useful activity for the patient recovering from stroke. the ability to
hold the foot flat while in hooklying position on the mat is an out-of-synergy
combination that avoids the influence of the mass movement synergies. in synergy,
the patient wiil flex the hip and the knee off the mat with accompanying hip abduction
and external rotation. with the LE in this out-of-synergy combination, the patient is
asked to actively hold the foot flat.
as control increases, the position of the food can be varied, progressing to various
degrees of knee extention. this promotes the development of selective knee control.
progression cam also bo achieved by altering the activity from bilateral to unilateral.
theraband tubing can be placed around the patient’s thighs to increase the
proprioceptive loading ofthe hip abductors.

techniques
alternating isometrics
the patient is asked to hold the hooklying position while the therapist applies
resistance to the knees. side-to-side resistance is applied with one hand on the
medial side of the knee and the opposite han to the lateral side of the other knee. the
hand placements are then reversed to resist holding in the other direction (fig. 9 – 4).
the resistance is built up gradually from very light resistance to the patient’s
maximum. the isometric contraction is maintained for several counts. the therapist
must give a transitional command (“now don’t let me pull you the other way”) before
sliding the hands to resist the opposite muscles; this allows the patient the
opportunity to make apropriate preparatory postural adjutsments.
in alternating isometrics (AI) resistance can be applied side to side, or diagonally. the
position of the therapist will very according to the line of force that needs to be
applied. resistance applied to both hip abductor may be used to gain overflow from
strong to weak muscles (for example, in the patient recovering from stroke). in this
situation, resistance to abductors is tipically maximized while resistance to adductors
in minimal. resistance can also be applied to the ankles.

motor control goals. stability

indication. weakness and instability of the lower trunk (for example, in the patient
with low back disfunction); weakness and instability of the hip muscles. these
activities are important lead-up skills for lower trunk/pelvic stabilization during bipedal
gait.
functional outcomes. the patient is able to stabilize the lower trunk/pelvis during bed-
mat activities.

hooklying, lower trunk rotation

teknik slow reversal
the knees are moved passively from side to side for a few repetition to ensure that
the patient knows the movements expected. the movements are then resisted. the
therapist alternates hand placement, first one one side resist the knees pulling away
from midline, then on the other side to resist the return movement (fig. 9 – 5)