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Teaching independence:

a TherapeuTic approach

To STrokerehabiliTaTion

s e c o n d e d i T i o n

ByJanDavis,MS,OTR/L

VideoRegistrationNo.___________________________________

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Tableof conTenTs

How to Use this Learning Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Program Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Improving Function & Awareness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15IntroductiontoImprovingFunction&Awareness. . . . . . . . . . . . . . . . . . . . . . . . . . . .15

TheFiveBasicTreatmentPrinciples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16EncourageWeightshiftovertheHemiplegicSide . . . . . . . . . . . . . . . . . . . . . . . . . . .16EncourageTrunkRotation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16PutMusclesonLength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16EncourageForwardFlexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17EncourageScapularProtraction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

ImprovingAwarenessDuringBedrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18PositionofthePatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18EnvironmentalFactors:PositionofthePatientintheRoom. . . . . . . . . . . . . . . . . . . . . .19

ImprovingUpperExtremityFunction&Awareness. . . . . . . . . . . . . . . . . . . . . . . . . . . . .20ThreeWaystoIncludeaNonfunctionalUpperExtremityintoaTask. . . . . . . . . . . . . . . . . .20

1.Weightbearing/Stabilizer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .202.GuidedMovement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203.Bilateral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

FunctionalTreatmentIdeas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22ExamplesofGuiding,Weightbearing,andBilateralUseDuringFunction. . . . . . . . . . . . . . .22Summary of Benets of Weight bearing, Guiding, and Bilateral. . . . . . . . . . . . . . . . . . . .23FunctionalTreatmentIdeasinStanding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23StandingwithFearfulPatientsDuringFunction . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

HomeExerciseProgram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25StretchingForwardwithScapularProtraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25ScapularProtractionwithWeightbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25ShoulderFlexioninSitting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25ShoulderFlexioninSupine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25ForearmSupinationandPronation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

WristFlexionandExtension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26FingerExtension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

HomeExerciseProgram,GroupTreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Preventing Shoulder Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29IntroductiontoPreventingShoulderPain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Therapeutic Benets of Preventing Shoulder Pain. . . . . . . . . . . . . . . . . . . . . . . . . . .29

ProperHandlingoftheHemiplegicShoulder:Evaluation&Observation. . . . . . . . . . . . . . . . . .30PreparingtheShoulderforMovement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

ScapularMobilization:Elevation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31ScapularMobilization:Protraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32ScapularMobilization:UpwardRotation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33ScapularMobilizationinSupine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35TherapeuticMethodforTreatingSoft-TissueTightness . . . . . . . . . . . . . . . . . . . . . . . . . .36

FacilitatingMusclesActingontheScapula. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37ProtectingtheHemiplegicShoulder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Properbedpositioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Properpositioninginthewheelchair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Properpositioningofarmonalaptray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Properrepositioninginthewheelchair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Propertransfers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Propersittostand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

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Subluxation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40PossibleCausesofShoulderPaininHemiplegia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Wheelchair Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43IntroductiontoTherapeuticTransfers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43Therapeutic Benets of Transfers Toward the Weak Side. . . . . . . . . . . . . . . . . . . . . . .43

TransferstoSimilarHeightSurfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

AnalyzingNormalMovementDuringTransfers. . . . . . . . . . . . . . . . . . . . . . . . . . . . .44WheelchairTransferwithMaximumAssistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46TransferwithMaximumAssistanceofTwoPersons. . . . . . . . . . . . . . . . . . . . . . . . . . . .48TransferswithModerateAssistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49TransferringOnandOffaHighSurface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Transfer:AnalysisofNormalMovement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51High-SurfaceTransfer:ModerateAssistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

TransferringOffofaHighSurface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52RepositioningintheWheelchair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

AnalyzingNormalMovementinRepositioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54RepositioningintheWheelchairwithModerateAssistance. . . . . . . . . . . . . . . . . . . . . . . . .55RepositioningintheWheelchairwithMaximumAssistance . . . . . . . . . . . . . . . . . . . . . . . .57ScootingForwardandBackwardintheChair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Standing Safely. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

IntroductiontoStandingSafely. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61Therapeutic Benets of Standing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

SittoStand:NormalMovement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62SittoStandwithModerateAssistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64SittoStandwithMaximumAssistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67HowtoFacilitateStandingSafely. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69ShiftingWeightTowardtheHemiplegicSideinStanding. . . . . . . . . . . . . . . . . . . . . . . . . .70StandingSafelyiftheKneeBuckles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72StandtoSit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74StandtoSitwithModerateAssistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

Bed Positioning & Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77IntroductiontoBedPositioning&Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77Therapeutic Benets of Proper Bed Positioning & Mobility. . . . . . . . . . . . . . . . . . . . . . .77

BedPositioninginSidelyingontheInvolvedSide . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78BedPositioninginSidelyingontheNon-involvedSide. . . . . . . . . . . . . . . . . . . . . . . . . . .80BedPositioninginSupine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81ScootingUpinBed:NormalMovement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82ScootingUpinBed:TherapeuticMethod. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83ScootingSidetoSide:NormalMovement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84ScootingSidetoSide:TherapeuticMethod. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85SidelyingtoSittingfromtheInvolvedSide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87SittingtoSidelyingOvertheInvolvedSide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89RollingfromSupinetoSidelying:NormalMovement. . . . . . . . . . . . . . . . . . . . . . . . . . . .91

AnalysisofNormalMovement:RollingfromSupinetoSidelying. . . . . . . . . . . . . . . . . . . .91RollingfromSupinetoSidelying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

Self-Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93IntroductiontoSelf-Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

FundamentalTherapeuticPrinciples. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94ActivitiesofDailyLiving(ADL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Therapeutic Benets of Self-Care Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94TherapyTipsforSelf-CareActivities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94

Dressing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96DonningShirt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97DonningShoesandSocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97

One-HandedShoeTying. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98

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Undressing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99UndressingwithAssistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

Dofng Shirt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99Dofng Pants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100Dofng Shoes and Socks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100

CorrectingProblemsinSelf-Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101TipsforGrooming. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102

WashingattheSink. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102Shaving. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102BrushingTeeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102DentureCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102BrushingHair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103BathingTips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103

AdaptiveEquipmentTipsforGroomingandHygiene. . . . . . . . . . . . . . . . . . . . . . . . .103

CEU Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105Certicate of Completion Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107Verication of Time Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109Verication of Time Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Verication of Time Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111CompetencyEvaluationAnswerSheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112

CompetencyEvaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113CompetencyEvaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114CompetencyEvaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115CompetencyEvaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116CompetencyEvaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117CompetencyEvaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118Evaluation&FeedbackForm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

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CEUsYourlearningmodulewillbecompletewhenyouhavewatchedallof

the video segments, nished all of the practice labs, and successfully

takenthecompetencyexam.

InthelastchapterofthisWorkbook,CEURequirements,youwill

nd the information and forms necessary to earn continuing educationcredit.Readtherequirementscarefully,completealloftheformsand

follow the instructions to earn your certicate of completion.

howTo useThis learning Module

Thislearningmoduleismadeupofsixindividualprograms,eachwithvideosandstep-by-stepwritten

instructions.Thesixprogramsare:

ImprovingFunction&Awareness

PreventingShoulderPain

WheelchairTransfers

StandingSafely

BedPositioning&Mobility

Self-Care

Thelearningmoduleisdesignedtobeinteractive.Watchthevideoforeachprogramandfollowalonginthis

text.Asyouwatch,youllalsobeparticipating.

Eachvideoisapproximately30minutesinlength.Althoughyoumayviewthevideosinanyorder,werecommendthatyouwatchthemintheordertheyappearwithintheseries.Whileviewingeachvideo,refer

to the corresponding section in this Workbook for additional written information specically developed for thatparticularprogram.

Pause and Practice: Practical Lab SessionsTheir are 41 individual practice labs illustrated and identied throughout this learning module. Each isextremelyimportant.

Whileviewingthevideo,thesymbolwillappearinthelowerleft-handcornerofyourscreen.Atthispoint,

pausetheprogramandrefertothecorrespondingpageintheWorkbook,notingthePause and Practice

boxes.FollowthedirectionsstatedintheWorkbooktopracticethetherapeuticmethodillustrated.

Duringeachpracticelab,writedownyourobservationsinthespaceprovided.Itishelpfultopracticeeachtherapeuticmethodwithapartnerandtryitmorethanonce.Asyoupractice,youwillfeelmorecomfortable

witheachmethod.Afteryouvepracticed,observed,andanalyzed,continuewiththevideoportionofthe

learningmodule.

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8 TeachingIndependence:ATherapeuticApproachtoStrokeRehabilitation

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Handling Methods

Thetreatmentmethodschosenforthislearningmodulewerecarefullyselectedinordertoprovide

successwiththemajorityofyourpatientswithhemiplegia.

In treatment, your handling should be rm but never forceful. Nothing in this series should ever hurt or

be painful. If you or your patient nds any method uncomfortable, stop. If at any time you do not feelsafe,stopandgetassistance.

Whenpracticingwithapartner,giveeachotherfeedback.Yourhandlingwillimproveasyouandyour

partnershareinformation.

Why We Analyze Normal Movement

Beforewebegin,rememberthatalltherapeuticmethodsarebaseduponnormalpatternsofmovement.To

fully understand the therapeutic value of each treatment idea, you may want to observe your own specic

movementpatternsduringtheactivityyouchooseforyourpatient.

Noticethesequenceandpatternsofyourmovement.

Noticetheamountoftrunkrotation,weightshift,andproximalcontrolrequiredfordistalfunction.

Noticetheplacementofyourhandsandwristsduringactivities.

Thebetteryouareatobservingandanalyzing,thebetteryouwillidentifyandtreatyourpatientskeyproblem

areas.

Agreatvarietyofmovementsandpatternsofmovementsarepossibleduringactivitiesortaskstakenfrom

normaldailyroutines.Ratherthansaynormal,perhapsitisbettertosaytypicalmovementpatternsor

commonpatternsofmovement.Avariationonnormaldoesnotnecessarilymeanabnormal.Themore

observationswemakeofpeoplewithoutcentralnervoussystemdysfunctiondoingfunctionaltasks,theeasier

itwillbetoidentifyabnormalpatternsofmovementtypicalofpatientswithhemiplegia.

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The Five Basic Treatment PrinciplesIn order to maximize the therapeutic benets of this treatment approach, incorporate as many of the followingbasictreatmentprinciplesaspossibleintoeachofyourtreatmentsessions.

Encourage Weight shift over the Hemiplegic Side

Weightbearingoverthehemiplegicsideisthemosteffectiveway

ofregulatingtone.Italsoprovidessensoryinputtotheinvolved

sidethroughproprioception.Asthepatientsawarenessofthe

involvedsideimproves,fearandneglectwilldecrease.

Thepositiveeffectsofweightbearingcanbeobservedinnearly

everystageofrecovery.Correctweightbearingcanbeassimple

aspositioningthepatientinsidelyingontheweaksideinbedor

as difcult as the facilitation of stance phase during gait training.Whenweightbearingisintroducedtothepatientearlyinthe

program, the benets can be seen throughout the rehabilitationprocess.Evenwhenyouworkwithpatientswhoarelongerterm

post-stroke,theintroductionofweightbearingintodailytaskscanstill be extremely benecial.

Encourage Trunk Rotation

Trunkrotation,ordissociationoftheupperandlowertrunk,

isanotherveryeffectivewayofpromotingnormalmovement

throughouttheupperandlowerextremities.Hemiplegicpatients

oftenmoveinablocklikepattern,withlittleseparationofpelvic

girdleandshouldergirdle.Tofacilitatenormalmovement,the

therapistshouldsetupactivitiestostimulateorfacilitatetrunk

rotation.Astrunkmusculaturebecomesactivated,patientswill

becomemorestableandhavebetterpotentialforupperextremity

function.

Settingupthetaskatdifferentheightsandoneachsideofthepatientincorporatesnotonlytherotational

components of movement but mobilizes the shoulder girdle and pelvic girdle as well. Additional benets from

activitiesfacilitatingtrunkrotationinclude:increasedsensoryinputtotheinvolvedside,improvedawarenessof

the involved side, and better compensation for visual-eld decits.

Put Muscles on Length

Itiscommonforhemiplegicpatientstobecomeshortenedon

theinvolvedsideasmuscletoneincreases.Acommonposture

forsomepatientsisscapularretractionwithdownwardrotation

whilethepelvisisinretraction.Thisposturecaneventuallylead

tosoft-tissuetightness.

Duringtherapeuticactivities,encourageyourpatienttogently

putmusclesonlengthinordertopreventtightness.Thiscanbe

accomplishedbyselectingataskorbyplacingtheactivityinsuch

awayastorequiregentlestretchingofthetrunkandextremities.

Do not position the patient or the activity in such a way as to

cause the patient to lose their balance.

v

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Encourage Forward Flexion

Stroke survivors often have difculty exing forward. This is due in

largeparttohipextension(astrongcomponentoflower-extremity

extension synergy), posterior pelvic tilt and fear. Difculty in

exing forward can limit functional abilities such as sit to stand,surface-to-surfacetransfers,andlowerextremitydressing.

Patients who have learned to come forward during the rst fewweeksofrecoveryareoftenlessfearful.Inaddition,encouraging

forward exion with your patients helps to break up extensortoneofthehip,resultinginbetterselectivecontrolofthelower

extremity.Italsodiscouragesposteriorpelvictilts,allowingfor

morenormalpatternsofmovementaswellasbetteralignmentofthetrunkandshouldergirdle.Insitting,you

mightaskyourpatientstoreachtowardtheirfeet.Or,forfearfulorlower-levelpatients,youcanmodifythe

amount of forward exion by using a sturdy table and having them slide their arms forward, using the table asasupport.

Encourage Scapular Protraction

Themusculaturearoundthescapulaplaysanimportantroleintheoverallrecoveryoftheupperextremity.Proximalstabilityis

necessaryfordistalfunctionandthestabilityofthescapulais

criticalforhandfunction.However,forfullactivevoluntarycontrol

oftheupperextremity,thescapulaneedstohavefullexcursionas

well.

Bringingthescapulaforwardintoprotractionhelpstomaintain

thenormalexcursionofthescapulaandalsohelpstoregulate

abnormal exor tone of the upper extremity. Protraction of thescapulacanbeincorporatedduringbedrest(whileinsidelyingon

the involved side), during dressing activities (exing forward at the hips in order to place the hand in the shirtsleeve),orwhilesitting(wipingoffthetable)orstanding(washingthecar).

For more specic information on mobilizing the scapula, please see Preventing Shoulder Pain.

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Home Exercise ProgramPatientsshouldbeinstructedinahomeexerciseprogrambeforeleavingyourfacility.Instructyourpatientsto

dothisprogramatleastonceaday.Sinceitiseasiesttodoatatable,yourpatientscouldroutinelydothis

programastheywaitforameal.Theprogramtakesonly10or15minutes.

The exercises are done in sitting, but some can be modied to be done in supine.

Start with a good base of support, feet at on the oor and trunk forward (out of a posterior pelvic tilt)witharmsrestingonthetable.

Work proximal to distal, beginning with the trunk and shoulders before working with the wrist and ngers.

Dotheexercisesinthesamesequence,10repetitionseach.Thismakesiteasierforpatientsto

remember.

Thefollowingexercisesshouldneverbepainful.Apatientshouldstopifanydiscomfortisnoted.Inrarecases

painmaysignifyamalalignmentofstructuresandimpingementcouldoccur.

Stretching Forward with Scapular Protraction

Haveyourpatientclasptheirhandstogetherandslidethemforwardonthetablesurface.Thisencouragesthepatienttocome

forwardoutofaposteriorpelvictiltandalsoencouragesscapular

protraction.Repeat10times.

Scapular Protraction with Weight bearing

Withtheshoulderinfullprotraction,havethepatientrolloveronto

theshoulder.Thisencouragesweightbearingovertheinvolvedside,facilitationofdynamictrunkcontrol,andtrunkelongation.

Repeat10times.

Shoulder Flexion in Sitting

Withclaspedhands,haveyourpatientbringtheirarmsup

overhead.Instructthemtogoonlytothepointofdiscomfortorto

thepointtheyfeelresistance,andnofurther.Iftheyfollowthese

guidelines,thisexercisewillbesafe.Never force range or movebeyond the point of pain.Repeat10times.

Shoulder Flexion in Supine

If your patient has a heavy arm, has difculty bringing it overhead,orhaspoorscapulargliding,havethemdothisexerciseinsupine.

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Home Exercise Program, Group TreatmentIliketoteachthehomeexerciseprograminagroup,ratherthantaketimefrommyindividualtreatment

sessions.Yourgroupcouldmeetonadailybasisorseveraltimesaweek,dependingonyourworksetting.

Sitaroundatablelargeenoughthatyourpatientscanreally

reachandstretch.SometimesIneedtoputtwotables

together.

Beginthehomeexerciseprogram(onpreviouspage).

Ithelpswhenthegroupmembersinteractwitheachother.

Givingeachotheramorninggreetingcanencouragethem

toturntheirheadstowardtheweakside,whichisgreatfor

thosepatientswhohaveneglect.

Beavailabletogoaroundandhelp.Ineverjustsitinmy

chairtoleadthegroup.

Ioftenaskthepatientstotaketurnsleadingtheprogram.

ThatwayIknowthattheyhaverememberedeachexerciseinthecorrectorder.

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Proper Handling of the Hemiplegic Shoulder:Evaluation & ObservationThe more specic and in-depth your observations are, the better

yourevaluationwillbe.Goodobservationsprovidethefoundation

foragoodassessment.

Position your patient in sitting with their feet at on the oor.Properalignmentofthetrunkandshouldercomplexisdependent

ontheproperpositionofthepelvis.Checkthepositionofthe

pelvis.Makesurethatyourpatientisnotinaposteriorpelvictilt.

Next,observeyourpatientfromthefrontandtheback.Your

observationswillbemoreaccurateifyoucanseethepatients

skinandshoulderstructures.Doyounoticeanything

asymmetrical?Forexample,measurethedistancefrommidline(vertebralcolumn)tothemedialborderofboth

scapulae.Comparethedistanceoftheinvolvedsidewiththenon-involvedside.Howdoesthescapulareston

thethorasicwall?Noteanyasymmetry.Noteanyretractionordownwardrotation.

Beforeattemptingtomoveyourpatientsarm,givethempermissiontocomplainofanypainordiscomfort.I

usuallysay,Ifanythinghurtsorisuncomfortable,letmeknow.Explaintoyourpatientthatasharppainmay

indicateaproblemofalignmentorimpingement,anditisimportantforthemtotellyou.Itiscriticaltomaintain

propershoulderrangeofmotion.Remember:Protectingtheshoulderdoesnotmeanimmobilizingit!

Thecombinationofmuscleweaknessandincreasedtonecausesimbalanceandpooralignmentofthe

shoulderstructures,puttingthematriskforinjury.OurhandlingmethodscombineROMtechniqueswiththose

techniques used to decrease abnormally high tone. Your hands should be rm but never forceful. The following

techniquesshouldneverbepainfulforyourpatient.

Preparing the Shoulder for Movement

Thescapulahasthreeplanesofmotion.Mostfunctionalmovementsareacombinationofthefollowingthreeplanesofmotion:

elevationanddepression

protractionandretraction

upwardrotationanddownwardrotation

Beginningwithscapularelevationisrecommendedbecauseitissafe,doesnotcauseimpingement,andgives

informationabouttheamountofscapularexcursion.Besuretocheck:Isthereanyresistance?Ashoulder

thathasbeenimmobilizedmayfeeltightand,ifthereisanincreaseintone,youmayfeelresistanceagainst

movement. In contrast, a accid or low tone arm will feel heavy, but the scapula will glide easily.

Oncethescapulaisglidinginelevation,bringthescapulaforwardintoprotraction.Onlywhenyouareableto

getscapularexcursioninelevationandprotractionwillyoubeginupwardrotationofthescapula.Thefollowing

guidelinesprovideastep-by-stepapproachtoscapularmobilization.

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Scapular Mobilization: Elevation

Starting Position

Before beginning scapular mobilization, position the patient with feet at on the oor and pelvis in a neutralposition,outofaposteriorpelvictilt.

Handling

1. Cupyourhandandplaceitovertheheadofthehumerus.

Dontapplypressureontheheadofthehumerusapply

pressurewiththeheelofyourhandonthepectoralis,

medialtothehumeralhead.

2. Placetheotherhandalongthemedialandinferiorborder

ofthescapula.Usetheheelofyourhand,notyour

thumb,tocradletheinferiorborderofthescapula.

3. Bringyourelbowsdowntoyourside.Youllhavemore

strengthandbetteralignmentofyourwristsinaneutralposition.

4. Applypressurethroughtheheelsofyourhandsand

bringtheentireshouldergirdleintoelevation.Youllbe

surprisedathowmucheffortittakestobringtheentire

shoulderintoscapularelevation.

5. Elevatethescapulatoendrange.Holdforafewseconds

andallowittoreturntoarestingposition.It may feel

heavy or somewhat tight. With repetition, this

movement will get easier.

VariationsForpatientswithpoortrunkcontrolorpoorsittingbalance,youcanmobilizethescapulawhilethepatientis

insupineorinsidelyingonthenon-involvedside.Thesidelyingpositioncanalsobehelpfulforapatientwho

hasaveryheavyarmorpoortrunkcontrol.(SeeScapular Mobilization in Supine.)

Common Mistakes

Themostcommonmistaketherapistsmakeinscapularelevationisthattheydontmovethescapulatoend

range. They are afraid theyll hurt the patient. But for the patient to benet, you really need to take the scapulato end range. Practice on your partner rst to see just how much scapular excursion is normal.

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3 Pause and Practice with a PartnerItwillbehelpfultowearatanktoporbathingsuittoreallyseethe

structuresoftheshoulderduringpractice.

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Scapular Mobilization: Protraction

Starting Position

The patient should be in a good sitting position with feet at on the oor and pelvis in a neutral position, (not inaposteriorpelvictilt).Evaluatescapularexcursioninelevationbeforeproceedingwithprotractionofthe

scapula.

Handling

1. Standinfrontofyourpatient.

2. Gentlytaketheinvolvedarmandbringitintoforward

exion of no more than 90.

3. Supportthearmattheelbowandtuckitalongyourside.

Thishelpstokeepitinneutralanddoesntallowittofall

intointernalrotation.

4. With your other hand, reach along the scapula and ndthe medial border. With a at open hand press along

themedialborderandglidethescapulaforwardinto

protraction. (Dont hook your ngers around the scapula.)

5. Maintainthispositionforasecondortwoandthenreturntothestartingposition.

6. Asthescapulareturnstoitsrestingposition,allowittofollowthenaturalcurvatureoftheribcage.

7. Withrepetition,thescapulawillbegintoglideforward.Onceyouveachievedprotraction,youmay

beginupwardrotation.

Common Mistakes

Dont curl your ngers around the medial border of the scapula. This can stimulate the rhomboids andincreasescapularretraction.

Thehandsupportingundertheelbowshouldnotpullthearmforward.Itonlycradlesandsupportsthe

weightofthearm.Thehandonthescapuladoesallofthework.

Dontbringthearmintoabductionwhileattemptingtoseethescapula.Getusedtofeelingfortheborder

andnotdependingonvisualcues.

Althoughitisnormalforthetrunktocomeslightlyforwardasthearmisbroughtforwardintoprotraction,

sometimes the patient substitutes trunk exion for the scapular protraction. When this happens, the

armcomesforwardonlybecausethetrunkiscomingforwardandthescapulaisnotglidingatall(or

minimally).Ifthisisthecase,youcantrycueingthepatienttomaintainamoreerectposture,oryou

mighttryhavingthepatientworkinsupineorsidelyinginstead.

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Protecting the Hemiplegic ShoulderThefollowingexamplesillustratehowtoprotectthehemiplegicshoulderinordertopreventshoulderpain:

Proper bed positioning

Duringbedrest,themosttherapeuticpositionissidelyingon

thehemiplegicside.Makesurethatyourpatientislyingonthe

scapula,andnotontheheadofthehumerus.Youllknowthe

scapulaisfullyprotractedifyoufeelalongthethoracicwall.If

it feels smooth, its ne. If it is winged and you feel the medialborderofthescapula,itisnotfarenoughforward.Formore

information,seethechapteronBed Positioning & Mobility.

Proper positioning in the wheelchair

Goodseatingallowsforbetteralignmentoftheentireshoulder

girdleandreducesthepossibilityofimpingement.Giveyour

patientagoodbaseofsupportwithawheelchairseatinsert.

Trytohaveyourpatientsitstraightinthechair,usingequipment

onlyasneeded.Patientswhoareseatedinaposteriorpelvictiltorleaningagainstthearmofthewheelchairaremoreatriskfor

impingement.

Proper positioning of arm on a lap tray

Notallpatientsneedtohavetheirarmsupportedwhileinthe

wheelchair.However,problemsofedemaorneglectmayrequire

theupperextremitytobesupported.Ipreferalaptrayrather

thananarmtroughtosupporttheinvolvedarm.Alaptrayallows

the arm and hand to remain in the visual eld where the patientismorelikelytoincorporateitintoactivities.Impingementatthe

shoulderisalsolesslikelywiththeuseofalaptrayratherthanan

armtrough.

Proper repositioning in the wheelchair

Whenpatientsslideoutoftheirwheelchairandneedtobe

repositioned,helpthemtoleanforwardandassistthroughthe

scapula,trunk,andknees.Donotpullorliftunderthearms.For

moreinformation,seethechapteronWheelchair Transfers.

Proper transfers

Transfersaredoneinasimilarway,whethermaximumassistance

ormoderateassistanceisneeded.Ineverpullonthearm.More

patientsdevelopshoulderpainduringimpropertransfermethods

thanatanyothertime.Formoreinformation,seethechapteronWheelchair Transfers.

Proper sit to stand

Whenpatientsaretaughttostandbyleaningforward,notonlyis

theirshoulderprotectedbuttheyarealsolearningmorenormal

patternsofmovementatthesametime.Formoreinformation,

seeStanding Safely.

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What to Avoid

Allmembersoftheteam,includingfamilymembersandcaregivers,shouldavoidthefollowing:

Never pull on the hemiplegic armtohelpthepatientchangeposition,transfer,orstandup.

Avoid placing your hands under the patients arms when repositioning in the wheelchair.

Avoid using slingstosupportapain-freeupperextremity.Itnotonlyimmobilizesthembutputsthe

shoulderinapositionofinternalrotationandadduction,apositionthatshouldbeavoided.

Avoid arm troughs.Aweakarmstrappedtoanarmtroughisatriskforimpingementandtraction

injury.Also,ifyourpatientweretoslidedowninthewheelchairwhilethearmwaspositionedonthearm

trough,animpingementcouldoccurthroughmalalignmentattheshoulder.

Dont force painful ROM. Rangeonlytothepointofdiscomfortorresistance.

Dont raise the arm in exion or abduction without external rotation of the humerus.Without

externalrotationofthehumerus,thegreatertuberositywillnotbeabletocleartheacromion.

Do not raise the arm in exion or abduction (past 90) without the scapula gliding.The

scapulohumeralrhythmisapproximatelya2:1ratio.Thatmeansthatforevery2partsthehumerus

moves,thescapulamoves1part,or1/3thedistance.Ifthescapuladoesnotglide,whilethehumerusis

moved over 90 of shoulder exion or abduction, impingement can occur.

Never use reciprocal overhead pulleys with stroke patients. Thereisnowaytomonitortheglidingactionofthescapula,resultinginpainandtraumatotheshoulder.

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wheelchair Transfers

Learning Objectives

Listfourcomponentsofmovementnormallyrequiredtotransferfromonesurfacetoanother.

Identify ve therapeutic principles required to safely transfer a stroke survivor using maximum

assistance.

Recognizecomponentsofmovementnecessarytotransferapatientontoahighsurface.

Identifytwomethodsforcorrectlyrepositioningastrokesurvivorintheirwheelchair.

Introduction to Therapeutic Transfers

Therearemanywaystotrainastrokesurvivortogetinandoutofawheelchair.Someofusweretaughtto

dostand-pivottransfers.Othersweretaughtlow-bottomtransfers,andmanyofusweretaughttoalways

transfertothestrongside.

Thetruthis,notonetransferwillworkwitheverypatientineverysituation.Duringthisprogram,Iwillprovide

theinformationnecessaryforsafeandfunctionaltransfers.Iwillshowyouexamplesofpatientsduring

differentstagesofrecoveryandjusthowtomodifyyourhandling.

The following two transfers are the ones that I use most often. They best reect those components of normalmovementobservedduringmovementfromonesurfacetoanother.

Remember, safety is our number one goal. Thetransfermustbesafeforboththepatientandtheperson

transferring the patient. The following guidelines may need to be modied if your patient has additional medicalororthopedicconditions.If, at any time, you feel unsure of your ability to transfer a patient, always stop

and ask for help.

Therapeutic Benets of Transfers Toward the Weak SideWhenteachingstrokepatientstotransfertowardtheweaksideutilizingthefollowingmethods,weare

preparingthepatienttoachieveahigherleveloffunction.Patientswhoaretaughttomovetowardtheirweak

side,putweightontotheirweakleg,andcomeforwardwithout pulling uporpushing off,arepotentiallyless

fearful,needlessequipment,andeventuallydevelopmorenormalpatternsofmovement.

Inordertofunctioninallsettings(forexamplegettinginandoutofthebed,thecar,andthebathtub)patients

needtobeabletotransfertowardtheweaksideaswellasthestrongside.Wewillemphasizeweaksided

transfers in order to increase the patients awareness of and condence in using their weak side. If a patient istaughttotransferonlytowardthestrongside,thepatientseventuallevelofindependencewillbediminished.

Mosttherapistsandnursesaretrainedtodostand-and-pivottransfers.Therearetimeswhensuchatransfer

willbeused.However,Iliketoencouragelow-bottomtransfersaswell.Theyarebasedonnormalandthey

aresafe,astheyhelptokeepthepatientscenterofgravitylow.

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Transfers to Similar Height Surfaces

Analyzing Normal Movement During Transfers

Beforewebegin,rememberthatourtherapeuticmethodsarebaseduponnormalpatternsofmovement.To

fullyunderstandthetherapeuticvalueofeachtechnique,wewillobserveandanalyzethenormalcomponents

ofmovementnecessarytotransferfromonesurfacetoanotherandrepositioninthechair.Thebetteryou

areatobservationandtheanalysisofyourobservations(ofbothnormalandabnormalmovement),thebetter

youwillbeatidentifyingandtreatingyourpatientskeyproblemareas.Ratherthansaynormal,perhapsitis

bettertosaytypicalmovementpatternsorcommonpatternsofmovement,sincethereisagreatvarietyof

normalmovementcomponentsinthegeneralpopulation.Avariationonnormaldoesnotnecessarilymean

abnormal. In the following section, the underlying factors which can inuence normal movement patterns arediscussed.

Ihavetaughtthistransfermethodliterallyhundredsoftimesoverthepasttwentyyears.BeforeIteachthe

therapeuticmethod,Ihavetheclassobservethenormalmovementcomponentsnecessaryforthetask,just

asIdowhenIteachanyfacilitationmethod.Icanasksomeonetoroll,scoot,orstandup,buttheword

transferisntinourusualvocabulary.Sowhenobservingnormalmovement,insteadofaskingsomeoneto

transfer,Isimplyputtwochairsnexttoeachotherandaskthemtomovefromonechairtothenext.Ihaveobservedover100peopledothisanditrarelyvaries.

Thepersonpreparesforthetransfer(movingfromonechairtotheother)bypositioningthefootslightly

towardtheemptychair.

Next,thepersonoftenreachestowardtheemptychair,lightlyrestingtheirhandonthechair.

Thepersoncomesforward,shiftingtheirweightfromtheirhipstotheirfeet,keepingtheircenterof

gravitylow.

Insomewhatofasquatposition,thepersonmovesfromonechairtotheotherbyswingingtheirhips

fromoneseattothenext.

Afterchangingchairs,thefeetareslightlyrepositionedundertheknees.

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8 Pause and Practice

Self Experience

Itmightbeinterestingforyoutopauseandobserveyourownpersonal

patternsofmovement,aswellasothers.Thereareseveralfactorswhich

inuence just how each of us moves, whether weve had a stroke or not:

heightandbuild

joint exibility

strength

previousinjuriesororthopediclimitations

environmentalfactors(suchastheheightofthechair,thedistancebetween

thetwochairs,andwhetherornotthechairhasarmrests)

Notice

Yourownfootplacement,whatfeelscomfortable.

Howfarforwardyouleanasyourhipsclearthechair.

Try

Placingyourfeetaninchortwoforwardfromyournormalfootplacement.

Whatdoyounotice?

Placingthechairsafootormoreapart.

Howdoesthisaffectyourtransfer?

Observe and AnalyzeOthers

Notevariationsinmovementsandsequencesofmovements.

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Sit to Stand with Maximum AssistanceThefollowingguidlineshelpdetermineifyourpatientwillneedmaximumassistancetostandup.

Howalertisthepatient?

Isthereanyactivetrunkcontrol?

Isthepatientfearful? Are there any conditions that make leaning forward difcult?

Dotheyhavetroubleextendingtheirtrunkorbearingweightonlowerextremity?

The following guidelines may need to be modied if your patient has already developed tightness or

contractures or if medical conditions interfere.

Starting Position

Thepatientissittinginawheelchair,inaregularchair,onabed,oronamattable.

Handling

1. Standontheweakside,nexttoandfacingthepatient.

2. Position the patients feet at on the oor, parallel and about shoulder width apart.

3. Scoot the patient forward in the chair, if necessary, in order for the feet to reach the oor or for thedistal1/3ofthefemurtobeunsupported.

4. Positionthefeetbehindtheknees,rememberingthatthetallerthepatient,thefurtherbackthefeet

needtobepositioned.

5. Askthepatienttoplacetheirhandseitherontheirthighor,

forpatientswithneglect,askthepatienttoclasptheirhands

togetherifpossible.

6. Usingthreepointsofcontrol,youwillbeabletobringa

maximumassistpatientfromsittostand.Do not lift.Instead,shifttheirweightfromtheirhipstotheirfeetbydoingthe

followingsteps.

7. Positionyourlegsoitwillbeinfrontofthepatientsknee.This

will be your rst point of control in helping with knee extension.

8. Placeyouropenhandontheirsternum,beingcarefulnotto

slide up their neck. Gently bring the patient into trunk exion,maintainingsupportthroughthesternum.Thiswillbeyour

secondpointofcontrol.

9. Placeyourotherhandaroundthepatientundertheirstronghip.

Thiswillcuethemtocomeforward,andyoullalsobeableto

tellwhenthepatientleavesthechairwithoutneedingtolookback.Thisisyourthirdpointofcontrol.

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10. Nowcuethepatient(fromthesternum,theknee,andunderthe

oppositehip)torock forwardandshifttheirweightfromtheir

hipstotheirfeet.Youcandothisbyshiftingyourweightfrom

yourbackfoottoyourfrontfoot(theonethatiscontrollingthe

weakknee).

11. Itisveryimportantnottolift.Asthepatientshipsclearthechair,

bringthepatientintofullstanding,usingyourthreepointsofcontrol. Press the sternum, hips, and knees gently but rmly,

andthepatientwillcomeintoextension.

Tips & Variations

Asyoubringthepatientforward,watchthestrongleg.Thepatientoftenbringsitbackbehindtheknee

(furtherthanitwasoriginallyplaced)tothecorrectposition.Ifthishappens,stopandrepositionthe

involvedfoot,parallelwiththestrongfoot.

Fearisoneofthemostcommonproblemsforourstrokepatients.Forfearfulpatients,modifytheenvironmentbyplacingthemnexttoorbehindasolidsurface(suchasaheavytable).

Common Problems

When the patient has difculty standing up,theproblemisoftenfootplacement.Checkthepositionofboth

feet.Remember,thetallerthepatient,thefurtherthefeetarebehindtheknees.Asyoubringthepatient

forward,watchtheirnon-involvedfoot.Ifyourpatientchangestheirpositionandbringstheirfootfurtherback,

thenthatsacuetocorrectandrepositiontheinvolvedfootaswell.

When the patient has difculty leaning forward, rst determine why they are having trouble. Some patientsneedpreparationtocomeforwardbeforestandingup.Whileinsitting,haveyourpatientleanforwardand

reachtowardtheirshoes.Arethereanyorthopedicorneurologicalconditionsthatmakeleaningforward

difcult? If so, some adaptive equipment may be necessary.

When the patients feet are staggered,withtheweakerfootinfront,therearethreecommonreasonswhy

strokepatientsdothis:

1. Limited ankle dorsiexion due to shortening of the Achillestendon.

2. Ifthepatientwearsalower extremity orthopedic device,

which limits ankle dorsiexion, it wont allow for proper foot

placement. An AFO xed at 90 is rigid and makes ankledorsiexion impossible. An AFO with a joint that allows

dorsiexion is best, as we see here. If that isnt possible, unstrapthetopoftheAFOandallowthekneetocomeforwardduring

sittostand.Re-straptheVelcrooncethepatientisinstanding.

3. Thethirdreasonthatapatientmaystaggertheirfeetistoputweightontheirstrongsideandavoid

shifting weight onto their weak side.Fear,weakness,andsensorylosscanallcontributetothis

problem.Initiallyitcanbefrighteningforpatientstostandup.Standingupinfrontofastrong,stable

supportcanbeveryreassuringtothepatient.

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bed posiTioning & MobiliTy

Learning Objectives

Identify four therapeutic benets of proper bed positioning for stroke survivors.

Listthreecomponentsofmovementnecessarytoassistinrollingfromsupinetosidelying.

Identifythemosttherapeuticpositionforbedrestandexplainwhy.

Listfourcomponentsofmovementnecessarytoscootfromsidetosideinbed.

Introduction to Bed Positioning & Mobility

Therehabilitationprocessbeginsbeforethepatientgetsoutofthehospitalbed.Usetheproceduresoutlined

inthisprogramandgiveyourpatientaheadstartintherehabilitationprocess.

Theultimategoalofbedpositioningistohelpthepatientrestmorecomfortably.Inaddition,weneedto

preventpressuresores.Itisnotrealistictoexpectfamilymemberstogetupeverytwohoursduringthenight,

nightafternight,afterthepatienthasreturnedhome.Therefore,itisnecessarythatwedontimmobilizeour

patientsbuthelpthemtolearnhowtomoveinbed.

Notonlyisitimportanttoencourageproperbedpositioning,butthepositionofthebedintheroomcanalso

betherapeutic.Ifpossible,donthavethepatientpositionedwiththeirweaksidetowardthewallbecause

allofthestimulationwillbetowardthesoundside.Instead,havethepatientpositionedsotheweaksideis

facingthedoorandothernecessities(suchasthenightstand,telephone,television,andwaterpitcher).This

willencourageawarenessoftheweaksideasitallowsthosecomingintotheroom(nurses,therapists,and

visitors)tomoreeasilyapproachthatside,increasingvisual,auditory,andtactilestimulation.

Encouragingthepatienttolookandmovetowardtheweaksidecanalsohelppatientswhoarefearfulor

have problems with neglect or visual-eld decits. One exception, just make sure the call-light for the nurse is

placedontheirstrongsidewheretheycaneasilyseeitandreachit,inordertogettheassistancetheyneedassoonaspossible.

Therapeutic Benets of Proper Bed Positioning & Mobility

Encourageyourpatientstorelearnnormalpatternsofmovementbeforebadhabitsbegin.Forexample

puttingweightintotheinvolvedfootduringbridgingwillhelpprepareyourpatientforstandingandwillhelp

toregulatelowerextremitytoneatthesametime.Wecanachievenumeroustherapeuticgoalsduringbed

positioningandbedmobilitybyfollowingfourbasictreatmentprinciples.

1. Encourageweightbearingovertheinvolvedsidetohelpdecreasefearandincreaseawareness.

2. Encouragetrunkrotationfordissociationofpelvisandshouldergirdlesandtofacilitatemorenormal

movement.

3. Encourageelongationofthetrunkandgentlyputmusclesonlengthinordertopreventtightness.

4. Encourage scapular protraction to prevent shoulder pain and inhibit exor tone of the upperextremity. If you are working with patients who are longer-term post stroke, they can still benet fromtheseguidelines.However,iforthopediclimitationshavealreadybegun,youmayneedtomake

modications. Work from proximal to distal when making modications.

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Bed Positioning in Sidelying on the Involved SideForthemosttherapeuticvalue,positionthepatientontheirweakside.

Weightbearingontheweaksidewillhelpthepatientbecomemoreawareofthatside.

Weightbearingalsohelpstonormalizeorregulateabnormalmuscletone.

Whenpositionedcorrectlyontheweaksideduringtheacutestageofrecovery,abnormalposturestypicallyseeninhemiplegicpatientscanbecontrolledorinhibited.

The following guidelines may need to be modied if your patient has already developed tightness or

contractures, or if medical conditions interfere.

Starting Position

Patientispositionedinsideylingontheinvolvedside.

Handling

1. Positionthepatientsidelyingontheweaksidewiththeback

parallel with the edge of the bed (reducing trunk exion). Apillowcanbeplacedbehindthepatienttokeepthemfrom

rollingsupine.

2. Theheadshouldbewellsupportedonapillowlargeenoughto

taketheweightoffoftheinvolvedshoulder.

3. Bringtheshoulderintofullprotraction.Becarefultohavethe

patientlieonthescapulaanddonotallowthepatienttolie

onthehumeralhead.Youwillknowwhentheshoulderisfully

protractedifyoufeelthemedialborderofthescapulalying

smoothlyalongthethoracicwall.Ifyoufeelthemedialborderof

thescapula,correctitbycarefullyslidingyourhandunderthe

scapulaandbringingtheshoulderforward.Donotpullonthe

armtobringitforward.

4. The shoulder should be in at least 90 of exion in order toinhibit exion synergy patterns.

5. Theforearmissupinatedandtheelbowcaneitherbein

extension or exion. (Patients with long arms will need to ex attheelbowiftheirhandscometooclosetothebedrailsofthehospitalbed.)

6. The weak leg is slightly exed at the knee.

7. Thesoundlegisplacedonapillow,forwardoftheweakleg.Forpatientswithwidehips,twopillows

maybeneededtosupporttheleginordertolessenthestressatthehip.

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