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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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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.
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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
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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.
4 Pause and Practice with a Partner
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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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78 TeachingIndependence:ATherapeuticApproachtoStrokeRehabilitation
BedPositioning&Mobility Copyright2000-2009InternationalClinicalEducators,Inc.
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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.
v