Patients a tremendous advantage: that patient has greater skin protection below the age of 50 years were much more successful in and more possibility of independent transfers. Independent transfers contribute to independence in Chronologic age is, by itself, not a negative prognostic factor bowel care, showering, and dressing. Studies of motor recovery in functional recovery; however, cardiopulmonary status is an have produced mathematic models and curves to predict out- important determinant.
The energy expenditure necessary for come. It has been tinue for at least 3 months' postinjury and progresses at a reported ]6 that 3 to 9 times more energy is required for ambu- slower rate thereafter for a year. Motor incomplete injuries of lation in individuals with paraplegia; ambulation is associated the cervical cord recover faster and achieve more recovery, with the neurologic level and completeness of injury, type of compared with complete injuries.
Other associated factors that ues, skills in transfers change and offer greater functional can negatively impact ambulation include spasticity, contrac- variety. Adapting functional capabilities as motor impairments tures, and pain. An in- With shortening lengths of rehabilitation stay, ambulation is tensive setting provides options for daily therapy to provide often not addressed during acute inpatient stay, and more proprioceptive neuromuscular facilitation, biofeedback, and rigorous outpatient therapy is required.
Rehabilitation for am- various electric stimulation techniques to enhance upper ex- bulation training should involve strengthening of the lower and tremity recovery.
Regular exercise can promote motor recovery upper extremities along with trunk and postural control. Me- and reduce spasticity. The exercise promotes lower-extremity weight bearing and recip- rocal movement, potentially triggering gait coordinated by a central pattern generator in the spinal cord.
This technique uses enormous resources on the part of therapists and may not be appropriate during the initial rehabilitation stay. The foci of interventions by members of an interdisciplinary rehabilitation team are guided by many influences. The primary formulation of the problem list and linked short- and long-term goals must be guided by interactions with the patient in the practice of person- and patient-centered care.
This approach requires a comprehensive knowledge of the patient that in- cludes current life roles as well as aspirations. Generalized outcomes expected for various levels of SCI were recently published as clinical practice guidelines for outcomes after traumatic SCI. Despite concerted efforts by the interdisciplinary team and the patient, predictions of functional outcome are only correct in about two thirds of cases.
The case for sustained inpatient com- prehensive rehabilitation can be made by presenting the motor Fig 1. Reprinted with permission. Improved upper-extremity func- tion could lead to tenodesis, to skill in intermittent catheteriza- ously on the anterior chest or abdominal wall. The definitive wheelchair tilator-dependent individuals will be atrophied and must be prescription for daily use could be a manual ultralight chair reconditioned to improve strength and endurance 3 Addition- with friction rims rather than a power wheelchair.
As dressing ally, when individuals are initially switched to the pacing skills reach independence, the need for an attendant may be system, an "acidosis" may develop secondary to the rise of avoided. Gradual adjustment of the ventilator to allow PCO 2 to rise to normal levels should be initiated before 3.
The conditioning phase and transition to primary care to a patient with SCI calls and wants an eucapnia may require 6 to 8 weeks. The basic hardware for update on functional neuromuscular stimulation FNS. Compare and contrast various FNS treatment options Because electric stimulation for bladder and bowel function depends on the ability to activate intact motoneurons from the with regard to functional benefits, surgical risk, cost, and sacral segments of the cord, it is, at this time, limited to persons outcomes.
Describe selection of appropriate candidates. Anterior sacral to develop an action potential. Stimu- "wear" the electric stimulation device or neuroprosthesis to lation by means of the implanted system may also be used to achieve function. Stimulation may be transcutaneous or sub- induce continent defecation and to produce erection.
Subcutaneous electrodes are implanted; an external Continence has been greatly improved by concurrent rhizo- device may be used to activate the electrodes. Advantages Phrenic pacing, the oldest form of implanted FNS, was of the posterior rhizotomy include increasing bladder capacity introduced over 20 years ago. The C upper ulation if these are present. After factoring in the costs of motoneurons ie, the phrenic nerve must be intact for stimu- medications, supplies, medical procedures, drug evaluation lation.
Alternatively, intercostal nerve grafting of the phrenic matrix, and attendant care, the hardware cost is approximately nerve has been performed with some success. The VOCARE system appears to offer greater nerve electrodes and connecting wires from the electrodes to independent functional control of bowel and bladder evacua- the radio-frequency receiver, which is implanted subcutane- tion for the individual with a complete spinal cord lesion.
Electric stimulation of the peripheral nervous system has through lumbosacral stimulation to decrease total colonic tran- been used to provide function control of the upper extremities sit time.
A classification scheme of the upper extremities in SCI has been developed by hand surgeons. Stimulation can Adaptation to sexuality after SCI involves not only the be delivered through external and implanted devices.
Surface physical interaction between partners but also the emotional stimulation techniques are noninvasive, easily used, and of low and social aspects of the individual's expression of maleness or cost but are associated with painful repeatable activation and femaleness.
Implanted systems overcome these obsta- expectancies, managing their own care, and maintaining health cles but at a high initial cost in terms of invasive surgery and and an expectation of improved QOL, including sexuality. The 2 available surface stimulation units Rehabilitation professionals have a responsibility to offer ed- are the Handmaster g and the Tetron Glove.
Problems and goals related to Food and Drug Administration FDA and provides 2 grasp sexuality after SCI include self-esteem, body image, libido, patterns: the key grip and release. The rehabilitation over a lifetime. Tendon transfers in tetraplegics can restore elbow extension Masters and Johnson 39 have reported that the human sexual and hand grasp.
Elbow extension enables one to reach out or response cycle consists of 4 phases: excitement, plateau, or- overhead, or to stabilize the body when sitting.
This ability can gasm, and resolution. These phases should be reviewed with be achieved by using the posterior third of the deltoid muscle patients and partners. The male sexual response is a result of and elongating it with free tendon grafts into the triceps. Tenodesis grasp can also be enhanced with tendon transfers, Physiology of male erectile furiction includes cavernosal tre- usually from brachioradialis to flexor pollicis longus and ex- becular and arterial smooth muscle relaxation, venous sinusoi- tensor carpi radialis longus to the finger flexors.
Postopera- dal relaxation, increased arterial blood flow, and increased tively, the shoulder and elbow are typically immobilized up to venous resistance. The innervation of the penis includes con- 6 weeks, and relative immobilization of the wrist and hand is tributions from the sympathetic via hypogastric nerve, T 1 0 - needed for 3 to 4 weeks. Erectile function is stimulation of the expiratory muscles to promote effective controlled mainly by the parasympathetic nervous system and cough, 35 as well as functional magnetic stimulation of the colon ejaculation function by the sympathetic.
Contraceptives vas deferens are deposited in the posterior urethra. During the containing low doses of progestin alone are associated with a ejaculatory phase, parasympathetic and somatic nerves pro- lower risk of venous thrombosis. Penile venous outflow pro- uterine sensation or limited hand dexterity.
At present, the moted by sympathetically mediated sinusoidal contraction con- barrier method of male contraception appears to be the safest stitutes the resolution phase. In general, erection and ejacula- option with the added benefit of protection against sexually tion function has been shown to be better preserved in transmitted diseases.
Should the patient not have a urinary tract infections, pressure ulcers, deep vein thrombosis, partner, education regarding options is appropriate. The mode of delivery in SCI women of options, including oral and intraurethral medications, intra- is primarily determined by standard obstetric indications; how- cavernosal injections, vacuum devices, and penile prosthesis. Intraurethral instillation of alprostadil has shown 38 limited sat- isfaction with erectile rigidity.
Penile vacuum devices consist 3. Intracavernosal injections of alprostadil, would like to return home to the care of family. Penile implants rigid, malleable, of secondary complications, family education, elimination of inflatable, hydraulic were popular before more recent ad- pain, and identification of appropriate equipment and assistive vances and are less commonly used because of possibility of devices.
Female sexual excitation phase can most common cause of metastatic cord compression. Life expectancy in patients with neo- pathetic efferent stimulation via the pelvic nerve. During the plastic SCC ranges from 2 to 16 months after treatment. Psychogenic lubrication is medi- strategies. Vertebral and bone pain from compression fractures ated by the thoracolumbar sympathetic nervous system.
During or lyric lesions may respond well to bracing in addition to orgasm, uterine and vaginal contractions occur, followed either pharmacologic interventions. The orthosis should be modified by return to plateau or progression to resolution. Women with for maximal patient comfort. Absolute stabilization may not be cervical and upper thoracic complete upper motoneuron inju- the priority; rather a happy medium between flexibility and ries can have reflex vaginal lubrication, whereas those with pain relief should be the goal.
Pharmacologic intervention with incomplete injuries may also have psychogenic vaginal lubri- SCC must address neural-mediated dysesthetic pain as well cation. Anticonvulsants gabapentin, oxcarbamazepine, port experiencing o r g a s m s. Opiates are used as with any cancer patient, with activity, desire, and satisfaction after SCI. Although many women have a delay which often transfers , upper- and lower-extremity dressing, and tub and lasts for m0 postinjury in the resumption of normal men- toilet transfers.
Follow-up survey there is no change in female fertility. Effective, convenient at 3 months' postdischarge indicated that the majority of pa- birth control presents some challenges. Post-traumatic acute an- tients with terminal cancer were satisfied with rehabilitation in terior spinal cord syndrome. Paraplegia ; In A reappraisal of fact, Yoshioka's whole study was predicated on patients being acute traumatic central cord syndrome. J Bone Joint Surg Br enrolled in hospice.
All patients should be given the opportunity to discuss and Age effect on prognosis make advanced directives consistent with their cultural and for functional recovery in acute, traumatic central cord syn- religious beliefs.
This includes explicit discussions of the com- drome. Arch Phys Med Rehabil ; Energy cost of am- ponents of do-not-resuscitate orders with their family and phy- bulation in traumatic paraplegia. Am J PhysMed Rehabil ; sician, with physician documentation of the plan in the orders Clear objectives and time lines must be Hybrid paraplegic locomotion with the established in order to meet realistic goals early and to avoid ParaWalker using intramuscular stimulation: a single subject "rehabbing people to death.
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The patient then reverses direction and brings the dynamic limb back down to the start position. The dynamic LE is non-weightbearing at all times. Functional skills achieved: The patient gains postural control and dynamic stability of the trunk in quadruped position and is able to perform DE reaching and LE movements.
Indications Impairments in static-dynamic control in quadruped are indications. These activities are important lead-up skills for function within the posture i. Position and Activity: Quadruped, Creeping. The sequence is repeated for continued progre sion.
A two-point pattern allows for a more continuou. Some patients may adopt an ip ilateral pattern in which the hand and the knee on the ame ide move together. A stretch can be used to facilitate the initiation of pelvic and LE movements.
During the application of resisted progression, the patient is in quadruped position, with the head in midposition and the trunk in neutral alignment. The therapist moves with the patient and is positioned standing, with knees slightly flexed partial squat position , behind the patient.
Alternatively, the therapist may be positioned in half-kneeling behind the patient and slide forward as the patient progresses. Bilateral manual contacts are over the iliac crests Fig. It requires trunk counterrotation and contralateral limb movements, important prerequisites for locomotion. Creeping can also be used to improve strength resisted progression , promote dynamic balance reactions, and improve coordination and timing. Movement within the quadruped posture is also an important precursor to assuming a standing position from the floor e.
To initiate creeping, the patient is in quadruped position, with the head in mid position and the trunk in neutral alignment. The patient moves forward or backward using the upper and lower limbs hands and knees for locomotion. Either a four- or two-point -equen e i used. Bilateral manual cor"o'S 0'6 over the iliac crests to provide resistance during 'ceo'.
Maintaining manual contacts, the therac S' Ided 0 as not to disrupt the patient's momentum. Resistance can also be provided using wrist and ankle cuff weights. Clinical Note: Some patients may be resistant to creeping as a treatment activity, feeling it is too childish. These feelings must be respected and explored; such feelings may indicate the patient is not fully aware of the rationale for the activity.
The therapist should stress the clinical relevance of creeping to other functional activities. For this activity. Hoo lying General Characteristics In Iz.!. The po,ture primarily involves lower trunk, hip, and knee control. DE lifts using active movements and cone stacking Quadruped, creeping, resisted progression manual Quadruped, creeping. Members of the group will assume different roles described below and will rotate roles each time the group progresses to a new item on the outline.
One person assumes the role of therapist for demonstrations and participates in discussion. The remaining members participate in discussion and provide supportive feedback during demonstrations. One member of this group should be designated as a "fact checker" to return to the text content to confirm elements of the discussion if needed or if agreement cannot be reached. As each item in the section outline i- - n:idered. An initial discussion of the activity, including patient and therapist positionin!!..
An initial discussion of the technique, including its description, indication s for use. Discussion dUling the demon tr: should be continuous the demonstration shoul the sole re ponsibiJity of the designated therapi. All group members should prO' I recommendations. Particularly imponarduring the demonstrations is discussion of strate!!
If any member of the group feels he or she require practice with the activity and technique, time should be allocated to accommodate the request. All group members providing input recommendations, suggestions, and supportive feedback should also accompany this practice. Abnormal reflex activity may interfere with assumption or maintenance of the posture. In supine. Active movements of the knees from side to side lower trunk rotation involve crossing the midline and can be an important treatment activity for patient with unilateral neglect e.
UE positions can also be haneel. The patient then moves independently. If needed. Progression to each phase of movement is dependent on the patient's ability to relax and participate in the movements. For the application of rhythmic initiation in hooklying to promote lower trunk rotation, the patient is in the hooklying position with both feet placed flat on the mat.
The therapist is in the half-kneeling or heel-sitting position at the base of the patient's feet. To assist with movement, manual contacts for the passive and active-assistive components are on top of the patient's knees Fig. The patient is instructed to relax as the therapist slowly - - - the knees from side to side and the lower trunk is ro. The movements to and from midline are first. Dunng the resistive phase of rhythmic initiation, manual - change.
The therapist remains in the half-kneeling ,.. Therapist hand placements are on the tops of the knees. The knees are moved from side to side and the lower trunk is rotated. This sequence is repeated with the gradual introduction of appropriate levels of resistance typically beginning with light resistance.
Manual contacts then move to the opposite sides of the knees to resist movement toward the therapist. Functional skills achieYed: The patient learns the movement requirements of lower trunk rotation and strategies for initiating movement and relaxation. Indications Indications include impaired function due to hypertonia spasticity.
YCs should be soothing, slow, rhythmic. The patient is passively moved to the end of the desired motion or available range and asked to hold against resistance isometric contraction. The patient then relaxes and is moved passively through a small range in the opposite direction: the patient then actively returns concentric contraction to the initial end range position.
For apo c::r C 0' resistance. For the application of reph ation to promote lower trunk rotation in hooklying. Manual contact, for passive movements are on the tops of the patient"', knee,,: for resistive hold components, manual contacts are on the medial side of one knee and the lateral side of the oppo"ite knee Fig.
This is the initial start position. The patient then actively relaxes. The patient then actively contracts concentric 'ontraction and moves through the range back to the initial tart position. Movement is through increments of range; midrange control is achieved first. With successive replication of movement, the range is gradually increased until full range is accomplished. Don't let me move you, hold, hold, hold. Now relax completely, and let me move your knees back toward lIIe.
Now pull all the way back to the starting position. The patient is moved back through the range once relaxation is achieved. Outcomes Motor control goal: Initiation of movement mobility.
Functional skill achieved: The patient performs independent initiation of lower trunk rotation. Indications Indications are to promote the initiation of lower trunk rotation in the presence of muscle weakness e. The patient should be instructed in the end result outcome of the movement. For the application of holding in hooklying, the therapist guards from a heel-sitting or halfkneeling position to one side of the patient's LEs.
Manual contacts are used to assist if initial holding of the posture is difficult. The patient actively holds the hooklying position. Both of the patient's knees are stable knees are not touching , feet are in contact with the mat sUli'ace, and biomechanical alignment and symmetrical midline weight distribution are maintained. As control increases, the position of the feet can be moved more distally, decreasing the amount of hip and knee flexion.
Holding is imposed at each successive repositioning of the feet as hip and knee flexion is gradually decreased. This promotes development of selective knee control at different points in the range.
Verbal Cues for Active Holding in Hooklying '"Hold the position, keep your knees stable and apart, feet lar all rhe mat, and your weight evenly distributed. Hold, hold. The example illustrates the 'e ;3 metric component. Following passive movemer- c' --;3 tient's knees through partial range to one side e';3. Indications Decreased strength, diminished lower trunk stability, and inability to stabilize hips and knees in flexion with feet supported are indications. Clinical Note: Trunk core and hip stability control holding is among the most critical elements for successful functional task execution Initiated in dependent postures.
Trunk stability provides the foundation and support for extremity function as well as the individual's ability to interact with the environment. Functional kills achieved: The patient gains independent , 3. There is no relaxation with directional changes. For the application of stabilizing reversals in hooklying, the therapist is positioned in half-kneeling to one side of the patient's LEs. The patient is asked to hold the hooklying position while the therapist applies resistance to the knees Fig.
Resistance is applied in a side-to-side direction; the therapist's manual contacts alternate between the medial side of one knee and the lateral side of the opposite knee.
The hand placements are then reversed to resist holding in the other direction. Resistance is applied until the patient's maximum is reached and then reversed. This sequence is repeated with gradual introduction of appropriate levels of resistance, typically beginning with light resistance. For example, diagonal resistance at the knees can be applied with manual contacts alternating between the distal anterior medial side of one knee and the distal anterior lateral side of the opposite knee.
The hand placements are then reversed to the proximal superior medial side of one knee and the proximal superior lateral side of the other knee to resist holding in the opposite direction. Distal resistance can be used to further promote trunk stability. In addition, this variation shifts the focus more distally and can be used to recruit more activity of the knee muscles, especially the hamstrings. The technique involves continuous resisted movement in opposing directions. For the application of dynamic reversals in hooklying, the patient mOle, both knees together in side-to-side movements i.
The therapist is positioned in half-kneeling slightly to one side of the patient's LEs. Resistance is applied as the knees move in a side-to-side direction, with the therapist's manual contacts alternating between the medial side of one knee and the lateral side of the opposite knee.
The hand placements are then reversed to resist movement in the other direction. For example, as the knees move toward the therapist, hand placements are on the lateral side of the knee closest to the therapist and the medial side of the knee farthest from the therapist Fig. The hands then move to the opposite sides of the knees to resist movement away from the therapist.
Manual contacts should allow sillooth transitions between opposing directions of movement. An isometric hold may be added in the shortened range or at any point of weakness within the range.
The hold is a momentary pause the patient is instructed to "Hold" : the antagonist movement pattern is then facilitated. The hold can be added in one direction only or in both directions. Dynamic reversals may be combined with repeated stretch if weakness exists.
The purpose of repeated stretch manual stretch or tapping over muscle is to elicit the stretch reflex to suppOl1 active movement. The repeated stretch is performed in the lengthened range and carefully timed to coincide with the patient's volunta.
Rep J'e " e ,h m also be superimposed on an existing contr..! I'OlIlt of weakness within range. Postural adjustments are required during each and every limb movement. Movements can be performed individually or in combination bilateral symmetrical or alternating from one limb to the other. The therapist can provide a target "Reach out and touch my hand" , or a functional task like cone stacking can be used Fig.
Progression is to increased range and speed of movements and increased time on task. The patient holds the Ra. The patient lifts both UEs up while leaning forward as shown , The arms are moved to one side or the other, combining movements of upper trunk rotation with flexion, This is a good early sitting ac Ivi because the therapist provides support for the patient and he position of the therapist reduces fear of falling.
The patient practices crossing and uncrossing the left leg over the right. This activity requires a weight shift toward the static side and away from the side of the dynamic limb, The UEs are held steady in front. Sitting, Weight Shifts, Dynamic Reversals The patient moves from side to side medial-lateral shifts or forward and backward against graded resistance.
The therapist alternates hand placement, first on one side of the upper trunk to resist the upper body pulling away and then on the other side to resist the return movement. Manual contacts alternate between the anterior and posterior surfaces of the upper trunk to resist forward-backward movement.
The therapi. A quick stretch I" initiate the reverse movement. Progression i froIT' r.. Shifts may also be re I 'ed '1 agonal and in diagonal with rotation directions. A hold may be added in one or both direc lOn, " , e patient demonstratcs difficulty moving to one ,ide ;. The patient is in.
Red Flag: UE PNF D2 patterns are contraindicated for patients recovering from stroke who are in early to mid recovery and firmly locked into abnormal synergy patterns.
The limbs move down and across the body with head and trunk rotation and flexion Fig. In the reverse chop pattern, the lead limb is positioned in D IF Fig. In order to resist this pattern, the therapist is positioned slightly in front and to the side of the patient wide, dynamic BOS in the direction of the chop.
The limbs move up and out with head and trunk rotation and extension Fig. In the reverse lift pattern, the lead limb begins in D2E Fig. To resist this pattern, the therapist is positioned slightly behind and to the side of the patient in the direction of the lift.
One is not a progression from the other, and there is no need to use both in order to improve sitting control. PNF patterns. Smooth reversal of antagonists is facilitated by well-timed Yes. The patient is instructed to open the hand, turn, and lift the hand up and out while following the movement with the eyes Fig. Clinical Note: The therapist selects either a chop or lift pattern. B The patient is then instructed to open the hand. The therapist resists the movement. B The patient is instructed to close the hand, turn, and pull both UEs up and across the face.
The DEs move together up and across the face. This is a protective pattern for the face and promotes actions of shoulder tlexion and elbow extension with scapular protraction. In withdrawal or reverse thrust, the hands close, the forearms supinate with elbow tlexion, and the shoulders extend. Holding in the withdrawal pattern is a useful activity to promote symmetJical scapular adduction. The pattern begins with the UEs in extension. As the DEs move up and out, promoted Fig.
The therapist is ,. A hold may be performed in the D2F -' ;-;her emphasize trunk extension. This helps to enhance reso '::' en sc olle Imlted with restrictive lung conditions. The patient is then asked to actively move with the therapist through the range active-assistive movements. Progression to the next phase is dependent on the patient's ability to relax and participate in the active and resistive phases.
This is an ideal technique to use with the patient who has difficulty with initiation of movement e. Outcomes Motor control goal: Improved controlled mobility dynamic control. Functional skills achieved: The patient demonstrates appropriate functional balance in sitting, allowing independence in reaching and ADL e.
The t'le'GC 5- ';;;: s-s -'le movement and must weight shift bac, ,. Balance control is achieved through the actions of a number of different body systems working together.
Reactive balance control refers to the ability to maintain or recover balance when subjected to an unexpected challenge and is based on feedback-driven adjustments. These include manual perturbations disturbances in the COM and changes in the support sUIt'ace disturbances in the BOS , such as force platform perturbations. Interventions selected are based on a careful examination of the systems contributing to balance control and the functional outcomes of impairments e.
For most patients, balance training is a multifaceted program. It frequently begins in the sitting posture and is progressed through other upright postures that serve to increase the challenge by raising the COM and decreasing the BaS e. More severely involved patients e. For other patients who are less involved, it may represent only a brief part of the balance training program, with greater emphasis placed on standing balance training. The following section offers suggested training activities.
For impro. The patient sits on a stationary surface platform mat with feet flat on the floor. Manual contacts should be on the trunk, not on the shoulders.
It is important to ensure appropriate postural responses. For example, with backward displacements, trunk and neck flexors are active. With forward displacements, trunk and neck extensors are active.
DE protective extension reactions can be initiated if the displacements move the COM near or past the LOS, and are more easily activated with sideward displacements. If patient responses are inappropriate or lack countermovements, the therapist may need to guide the initial attempts either verbally or manually.
The patient can then progress to active movements. The therapist can vary the BaS to increase or derease difficulty during the pel1urbations. It is equally important to PART" Intenentions to ImproH Function adjust responses, increasing the level of difficulty appropriate to the patient's improving capabilities. Sitting on a Moveable Surface Activities on a moveable surface wobble or rocker board. Wobble boards are constructed to allow varying motion.
The type and amount of motion are determined by the design of the board. A curved-bottom bidirectional board allows motion in two directions; a dome-bottom board allows motion in all directions.
The degree of curve or size of the dome determines the amount of motion in any direction; motion is increased in boards with large curves or high domes. The type of board used is dependent on the patient's capabilities and the type and range of movements permitted. An inflated disc is a dome-shaped cushion that is positioned under the patient while sitting. It allows limited motion in all directions Fig.
Challenge can be varied by the level of inflation a firm disc provides a greater challenge than a soft disc or by varying the BOS Fig. During sitting on the wobble board or disc, the patient's feet should be flat on the floor. A step or stool may be needed for some patients.
Initial activities include having the patient maintain a balanced, centered, or aligned sitting position. The patient can then progress to active weight shifts, tilting the board or moving on the disc in varying directions.
These patient-initiated challenges stimulate balance using both anticipatory and reactive balance mechanisms. The therapist can also manually tilt a wobble board to stimulate reactive balance responses.
Various names have been used to describe the balls used for therapeutic interventions, including therapy ball, balance ball, stability ball, and Swiss ball. Sitting on the ball facilitates postural mechanisms through intrinsic feedback mechanisms visual, proprioceptive, and vestibular inputs and challenges CNS adaptive postural control.
The use of the ball also adds novelty to rehabilitation programs and can be easily adapted to group classes. Patients may feel initially insecure and should be carefully guarded. The therapist may sit directly behind the patient, shadowing the patient's body with his or her own Fig.
If the patient is very insecure, the ball can initially be positioned on a floor ring that prevents the ball from moving in any direction. A ball that is slightly underinflated and positioned on a soft floor mat will roll less easily than a hard fully inflated ball positioned on a tile floor.
Initially the therapist can provide manual and VCs or manual assistance to guide the patient in the correct movements. As control develops, active movement control is expected a hands-off approach. When the patient sit on the ball, the hips and knees should be flexed to 90 degrees the rule with knees aligned over the feet. Feet should be flat on the floor and positioned hip width apan. The patient sits on an inflated disc with both feet flat on a small step, A The hands are clasped together in a forward position elbows extended, shoulders flexed.
The therapist instructs the patient to maintain a steady posture, B The patient then is instructed to maintain balance while crossing the right leg over the left, a movement that reduces the patient's BOS and increases the challenge to balance. ImproH "ilting and Sitting Balance Skills and hold. Initially the hands can rest on the knees a position of maximum stability.
As control develops, the patient is instructed to hold the UE in a forward position with the elbows extended and the hands clasped together hands-clasped position. Alternatively, the patient can hold the arms out to the sides. The patient should also be instructed to focus on a visual target. Sitting on the Ball, Dynamic Activities Dynamic activities should be attempted only after static control is achieved.
Initially, as the patient sits on a therapy ball, the therapist can shadow and support the patient from behind by sitting on a mat for maximum security or on another ball, The therapist maintains both hands near the patient's hips but does not hold onto the patient.
The patient is instructed to maintain a steady position on the ball. Both UEs are held out to the sides in a low guard position with hips and knees flexed to 90 degrees and feet apart. Sitting on the Ball, Static Activities Initially the patient is instructed to mam The patient sits on a ball, holding both hands clasped together in a forward position elbows extended and shoulders flexed.
The head. The therapist instructs the patient to roll the ball forward and backward, moving the ball by using pelvic movements backward or posterior pelvic tilts and forward or anterior pelvic tilts.
Clinical Note: It is important for the patient to actively stabilize the upper body, preventing any attempts to move by tilting the upper trunk. This can be promoted by having the patient maintain the UEs steady e. The patient is instructed to "Hold your upper trunk steady. Don't lean forward, backward, or side to side. The patient rolls the ball from side to side Fig.
The patient rotates the ball by using hip actions around in a full circle, first clockwise and then counterclockwise. The patient raises one DE to the forward horizontal position or overhead, holds for three counts, and then returns to neutral position. This activity can progress to the opposite UE or to bilateral movements e. The patient holds both UEs out to the sides and rotates first forward clockwise and then backward counterclockwise.
The patient lifts one knee up into hip flexion, holds for three counts, and then returns to neutral position; this activity is repeated with the other limb. The patient marches rhythmically in place, first slowly and then with increasing speed. The patient raises the right UE and the left knee. The patient straighten the knee and holds the foot out in front for three counts and then returns to neutral position Fig. This activity can progress to alternate knee extension,. The therapist instructs the patient to roll the ball from side to side, moving the ball to the side using pelvis movements lateral tilts.
The patient practices marching alternate hip and knee flexion movements while maintaining stable sitting on the ball. These movements are combined with reciprocal UE movements shoulder flexion and extension. This is a four-limb movement pattern that requires considerable dynamic stability while sitting on the ball. The patient practices lifting one foot up and extending the knee while maintaining stable sitting on the ball.
The UEs are held out to the sides in a guard position. The activity can be progressed by having the patient trace letters or numbers with the dynamic foot circles.
The patient lifts both heel rh keeping the toes in contact. The patient raise, both LE claps the hands. The pu' e tices passing. The patient practices stepping out to the side, moving one LE into hip abduction with knee extension while maintaining stable Sitting on the ball. The UEs are held with both hands clasped together in a forward position elbows extended and shoulders flexed. The pa :es head and trunk rotation to the left while holdnd maintaining sitting stability.
The patient -. The ball can be inflated or weighted Fig. Kicking a ball. A small ball is rolled toward the patient. Red Flag: Patients with vestibular insufficiency may experience increased dizziness, nausea, or anxiety during activities on the therapy ball.
This should be carefully monitored and the level of challenge decreased to tolerable levels. For some severely involved patients. Clinical Note: During episodes of instability, ball activities should be modified to ensure patient safety e. The therapist should be attentive and utilize appropriate guarding techniques.
For some patients e. Adaptive Sitting Balance Activities Adaptive balance control can be enhanced by modifying or changing task or environmental demands. Examples include the following: o o Change the support surface. Change from an inflatable disc to a ball with a floor ring holder to a ball with no ring holder; change from a hard floor to dense foam. Modify the BOS. Change from feet wide apart to feet together to one leg crossed: change from hands on thighs to hands folded across the chest.
Ime a position is held. The ball is thrown at or near he LO or toward the side of an instabi Iity. The patient performs two tasks simulataneously e. Change from feet on a sticky mat yoga mat to a tile floor to a soft mat to a foam cushion to an inflatable disc. Progress from a closed environment quiet room to an open environment busy treatment area.
Outcomes Motor control goal: Improved sitting balance control. Functional skills achieved: The patient demonstrates appropriate functional balance ski lis in sitting for independence in ADL. Activities to Improve Mobility in Sitting Scooting is the ability to move the hips forward or backward while sitting. It requires a weight shift onto one hip in order to partially unweight the other hip for movement.
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