DefinitionDefinition

• Coordination refers to using the right Coordination refers to using the right muscles at the right time with correct muscles at the right time with correct intensity, extensive organization within intensity, extensive organization within the central nervous system is necessary the central nervous system is necessary to guide motor patterns, coordination is to guide motor patterns, coordination is the basis of smooth and efficient the basis of smooth and efficient movement, which often occurs movement, which often occurs automatically. automatically.

• Coordination and gross or fine motor Coordination and gross or fine motor skills are a highly complex aspect of skills are a highly complex aspect of normal motor function normal motor function

Factors affecting on Factors affecting on coordinationcoordination::

• Anatomical FactorsAnatomical Factors

– Deformity Deformity – Asymmetry Asymmetry – Mal posture Mal posture

Environmental factorsEnvironmental factors : :

– Temperature Temperature

– Pollution Pollution

– Mental and psychological Mental and psychological stress stress

• Pain Pain

• Occupation Occupation

• Life style Life style

• Fullness of bladder Fullness of bladder

• Any medication Any medication

• Repeated pregnancy Repeated pregnancy

• Overweight Overweight

• Age Age

• Type of muscle toneType of muscle tone

Consideration before evaluationConsideration before evaluation

• The presence of parking.The presence of parking.

• Rail way of stair up & down. Rail way of stair up & down.

• Light at entrance. Light at entrance.

• Ramp for wheel chair.Ramp for wheel chair.

• If there is lifter or not If there is lifter or not

A- Outside the clinic

B- Inside the ClinicB- Inside the Clinic • Clearness of room. Clearness of room. • Silence and privacy.Silence and privacy.• Suitable temperature and light. Suitable temperature and light. • Comfortable and relaxed position for the Comfortable and relaxed position for the

patient. patient. • Adjustable and wide bed. Adjustable and wide bed. • Explain procedure to patient. Explain procedure to patient. • Patient pared skin or with light clothes. Patient pared skin or with light clothes. • Avoid air draft but maintain good ventilation. Avoid air draft but maintain good ventilation. • All equipment near the therapist to avoid All equipment near the therapist to avoid

interruption. interruption. • Evaluation sheet should be present. Evaluation sheet should be present.

Consideration during evaluationConsideration during evaluation

• Pain Pain

• Sweating Sweating

• Abnormal heart rate. Abnormal heart rate.

• Abnormal B.P. Abnormal B.P.

• Fever Fever

• Fainting. Fainting.

• HypermobilityHypermobility

• InfectionInfection

• Recent wound and injuryRecent wound and injury

• Avoid position that may exaggerated Avoid position that may exaggerated muscle tone or muscle tone or patient complication. patient complication.

• Mental stress. Mental stress.

• All tests done with tolerance of patient All tests done with tolerance of patient and according the stage of the disease. and according the stage of the disease.

• All tests are done within the limit of All tests are done within the limit of pain. pain.

• All tests from zero starting position. All tests from zero starting position.

Decision Decision MakingMaking

• Diagnostic interview.Diagnostic interview.

• Screening examination Screening examination

• Comprehensive examination. Comprehensive examination.

• Special tests. Special tests.

• Long term goals. Long term goals.

• Short term goals. Short term goals.

• Out come Out come

DIAGNOSTIC DIAGNOSTIC INTERVIEWINTERVIEWPersonal History:Personal History:

•Name:Name: To be familiar with the patientTo be familiar with the patient

•Age:Age: occurs in people aged 40-50 years occurs in people aged 40-50 years (cerbrovascular stroke)(cerbrovascular stroke)•Sex:Sex: affects men and women equallyaffects men and women equally

•Marital status:Marital status: Married or singleMarried or single

•Style of life:Style of life: his habits, activities and if his habits, activities and if he living a sedentary life. It assist in he living a sedentary life. It assist in providing the therapist with hint about providing the therapist with hint about causes and the expected prognosis.causes and the expected prognosis.

• Occupation:Occupation: Know the patients interests Know the patients interests and hopesand hopes

• Habits: Habits: Smokers, non smokers, Smokers, non smokers, alcohol drinkers, coffee or tea drinker.alcohol drinkers, coffee or tea drinker.

• Weight:Weight: obesity increase the difficulty in obesity increase the difficulty in performing activities.performing activities.

• Environmental assessment:Environmental assessment:

A) Outside doorA) Outside door

• -- Surrounding home.Surrounding home.

• -- Stairs (height – width) – (sharp, Stairs (height – width) – (sharp, smooth) .smooth) .

• -- Entrance .Entrance .

• -- Noisy – pollution. Noisy – pollution.

• -- Light at entrance .Light at entrance .

• - - rails of stairs – height of pavement . rails of stairs – height of pavement .

B)B) Inside doorInside door

• -- EntranceEntrance

• -- Carpets Carpets

• - - Type of floor Type of floor

• - - Furniture Furniture

• -- Arrangement Arrangement

• - - Devices and accessories Devices and accessories

Work Work assessment:assessment:

• Desks. Desks. • Height of table and chair. Height of table and chair. • Width and height of weed chair .Width and height of weed chair .• How communicate with people.How communicate with people.

B- B- HistoryHistory

• To know precautions. To know precautions.

• To know Contra-indications. To know Contra-indications.

• To decide the plane of care/treatment.To decide the plane of care/treatment.

The importance of History taking:

•Onset & duration of the disease. Onset & duration of the disease.

•Site and extent of the lesion: Site and extent of the lesion: (It affect level of (It affect level of consciousness and prognosis as the site either Rt consciousness and prognosis as the site either Rt of Lt determine aphasia and speech affection)of Lt determine aphasia and speech affection)

•Etiology of the disease. Etiology of the disease.

•Mechanism of the lesion.Mechanism of the lesion.•Distribution of paralysisDistribution of paralysis

•Past history: any disease (diabetes- Past history: any disease (diabetes- hypertension- congenital heart disease), any hypertension- congenital heart disease), any previous operation, any previous trauma. previous operation, any previous trauma.

•History of functional A.D.L:History of functional A.D.L:

Functional A.D.L is divided intoFunctional A.D.L is divided into::

• Transfer activities.Transfer activities.• Hygiene. Hygiene. • Feeding. Feeding. • Dressing & undressing. Dressing & undressing. • Gait & ambulation.Gait & ambulation. Grades (He can do –He can do with minimal Grades (He can do –He can do with minimal

assessment – He can do with maximum assessment – He can do with maximum assistant- He can't do) assistant- He can't do)

Family Family historyhistory: :

• Any hereditary disease Any hereditary disease

• Heart diseases Heart diseases

• diabetes diabetes

• Neuromuscular diseases due Neuromuscular diseases due congenital or genetic factors congenital or genetic factors

• Psychological history: IQ. Level, Cognitive Psychological history: IQ. Level, Cognitive level, Education level, Affection (emotions – level, Education level, Affection (emotions – nervous - fairs), memory, judgment, nervous - fairs), memory, judgment, depression, how to solve problems.depression, how to solve problems.

• Social History: Relationship between patient Social History: Relationship between patient and his family members and if they accept or and his family members and if they accept or reject the patient.reject the patient.

Pain HistoryPain History::

• (time of pain – location of pain– If (time of pain – location of pain– If movement increase or decrease the movement increase or decrease the pain –– severity of pain – distribution pain –– severity of pain – distribution of pain).of pain).

Chief Chief complaincomplain• Difficulties in performing ADL Difficulties in performing ADL

• Difficulty using arms to dress, feed Difficulty using arms to dress, feed self, or perform other tasks self, or perform other tasks

• Urinary incontinence Urinary incontinence

• Problems with balanceProblems with balance

• Decreased sensation, numbness, or Decreased sensation, numbness, or tingling on affected side of the body tingling on affected side of the body

• Difficulty speaking and/or or Difficulty speaking and/or or understanding wordsunderstanding words

• Difficulty walking Difficulty walking

• DepressionDepression

Problem listProblem list

• Spasticity .Spasticity .

• Muscle weakness Muscle weakness

• Loss of balance Loss of balance

• Loss of coordinationLoss of coordination

• Inability to do functional activities .Inability to do functional activities .

• Shoulder pain.Shoulder pain.

• Poor hand function.Poor hand function.

• Respiratory and circulatory problems.Respiratory and circulatory problems.

Medical recordMedical record – Medications Medications – Associated handicapped (Vision, Hearing, Associated handicapped (Vision, Hearing,

Speech)Speech)– Associated reaction. Associated reaction. – Any epileptic fits. Any epileptic fits. – Incontinence. Incontinence. – Bed sores. Bed sores. – Vital signs (B.P.- Heat rate - Temperature) Vital signs (B.P.- Heat rate - Temperature) – X-ray - C.T Scan – M.R.IX-ray - C.T Scan – M.R.IRespiratory and circulatory disorders.Respiratory and circulatory disorders.– Orofacial dysfunction.Orofacial dysfunction.

Screening Screening examinationexamination

• Any abnormalities. Any abnormalities.

• Asymmetry. Asymmetry.

• Distribution & Pattern of paralysis. Distribution & Pattern of paralysis.

• Position of head in relation to spasticity.Position of head in relation to spasticity.

• Position of head in relation to spasticity.Position of head in relation to spasticity.

• Associated reactionsAssociated reactions

• Imbalance Imbalance

General observation:

• General heath (out look of face). General heath (out look of face).

• Gait & ambulation. Gait & ambulation.

• Assistive device. Assistive device.

• Way of taking off clothes, way of getting Way of taking off clothes, way of getting up & down bed. up & down bed.

• Handling of the patient with his family. Handling of the patient with his family.

• If the family reject or accept the patient.If the family reject or accept the patient.

Specific observation: with the patient pared Specific observation: with the patient pared skin. Postural assessment from three views skin. Postural assessment from three views (lateral – anterior - posterior). (lateral – anterior - posterior).

Dermatological system (Scar – operation Dermatological system (Scar – operation – skin disease).– skin disease).

Skeletal system (size of bone – mal Skeletal system (size of bone – mal alignment of bone).alignment of bone).

Muscular system (atrophy – asymmetry – Muscular system (atrophy – asymmetry – hyper trophy).hyper trophy).

Join system (edema – swelling).Join system (edema – swelling). Breathing pattern.Breathing pattern.

PalpationPalpation

Tender point Tender point Muscle tone Muscle tone Soft tissue Mobility Soft tissue Mobility Trigger point Trigger point Fascial restriction.Fascial restriction. Skin texture& temperature.Skin texture& temperature.

Comprehensive examinationComprehensive examination

Vision Vision Hearing – speech Hearing – speech Way of solving Way of solving

problem problem Judgment Judgment Excitement. Excitement. Interest. Interest.

A- Communication abilities

By Pantomine. Communication board

B- Mental StatusB- Mental Status

IQ level IQ level Cognitive level Cognitive level Education level Education level

C- Arousal status: see the response of the patient to any movement and see if the arousal status is low or high.

D- Motor control stagesD- Motor control stages::

Muscle test : Muscle test : Group muscle test Group muscle test (voluntary muscle test because of (voluntary muscle test because of spasticity or in pattern of movement) spasticity or in pattern of movement) (gross movement) (gross movement)

Functional ROM test : as Functional ROM test : as feeding – feeding – dressing – undressing – hygiene dressing – undressing – hygiene

a- Mobility stage

Flexibility test (Flexibility test (Sound, Affected, and Sound, Affected, and associated areas associated areas

Examples: Examples: long sitting test long sitting test Straight leg raising test Straight leg raising test Cross sitting test Cross sitting test Standing with forward bending test Standing with forward bending test Supine and hand stretched overhead Supine and hand stretched overhead

b- Stability b- Stability stagestage

Elbow prone test:Elbow prone test:

importanceimportance

Sitting position on a tableSitting position on a table Sitting position on an armchair. Then sitting Sitting position on an armchair. Then sitting

on a stool: Test patient ability to maintain on a stool: Test patient ability to maintain position against gravityposition against gravity

Standing positionStanding position

For head controlFor head control

– raise head and sustain position for 30 raise head and sustain position for 30 sec sec

– If collapse quickly If collapse quickly poor poor

– If can't take or sustain in the position If can't take or sustain in the position zero zero

– If maintain it for 30 sec If maintain it for 30 sec normal normal

Sitting on the edge of the bed or Sitting on the edge of the bed or table, test the patient ability to table, test the patient ability to maintain position against gravity . maintain position against gravity .

Sitting on arm chair then on a stool Sitting on arm chair then on a stool to test the patient ability to maintain to test the patient ability to maintain position against gravityposition against gravity

Maintain postural alignment Maintain postural alignment

Sitting position

Standing positionStanding position

Test the patient ability to Test the patient ability to maintain position against gravity. maintain position against gravity.

C- Control mobility stageC- Control mobility stage

Change position with maintaining postural controlChange position with maintaining postural control1) Rocking (body shift): 1) Rocking (body shift): Bushing from different Bushing from different

directions, and from different positions or by lying directions, and from different positions or by lying on rocking plate . on rocking plate .

Done from different positions (Elbow Prone, Done from different positions (Elbow Prone, quadruped, sitting, kneeling , standing) quadruped, sitting, kneeling , standing)

Rocking plate from supine - prone and raise from Rocking plate from supine - prone and raise from different direction all testes done 2-3 times before different direction all testes done 2-3 times before giving grade.giving grade.

2)2) Quadruped position Quadruped position raise one hand, then the raise one hand, then the other hand, raise one hand with opposite leg, raise other hand, raise one hand with opposite leg, raise one leg then another one leg then another

d- High Skilled activity d- High Skilled activity stagestage

Swallowing test. Swallowing test. Speech test. Speech test. chewing testchewing test Cranial nerve assessment. Cranial nerve assessment. Hand function test: a- Volk's man Hand function test: a- Volk's man

angle test & b- Metacarpal stability test angle test & b- Metacarpal stability test Hand Hand

Gait and ambulation test: also test Gait and ambulation test: also test patient ability to get up & down stairs. patient ability to get up & down stairs.

E- Voluntary E- Voluntary movementmovement

Observe pattern and sequence of movement from Observe pattern and sequence of movement from different position different position

*Supine: do flexion –extension – abduction – *Supine: do flexion –extension – abduction – rotation- abdominal exercises rotation- abdominal exercises

*Sitting: the same movements +trunk rotation + *Sitting: the same movements +trunk rotation + trunk bending.trunk bending.

*From supine to standing: observe the sequence *From supine to standing: observe the sequence of movement: some patients make side bending + of movement: some patients make side bending + rotation of trunk then stand while others take the rotation of trunk then stand while others take the kneeling position then stand. kneeling position then stand.

F- Functional A.D.L test:F- Functional A.D.L test:

Physical Physical Affection (emotion - Affection (emotion -

psychological)psychological) Mental (IQ level – Mental (IQ level –

Cognitive level - Cognitive level - education)education)

Social. Social.

Causes of disability of ADL:

ADL are assessed by: *Questionnaire or Self questionnaire*Multi dimensional function: it include physical examination to detect if patient can do ADL or not.

factors affecting muscle factors affecting muscle tonetone

AnxietyAnxiety TemperatureTemperature TensionTension Drugs Drugs FearFear Fullness of bladderFullness of bladder Position of the headPosition of the head Environmental conditionEnvironmental condition Vision and hearingVision and hearing PainPain

G- Assessment of Muscle ToneG- Assessment of Muscle TonePassive MovementPassive MovementAshworth Scale :Ashworth Scale : To perform this test, the part is moved To perform this test, the part is moved

through the joint range-of-motion (ROM).through the joint range-of-motion (ROM). Ashworth Score CriteriaAshworth Score Criteria:: 0 0 No increase in toneNo increase in tone 11 Slight increase in tone, giving a “catch” Slight increase in tone, giving a “catch”

when the limb is moved in flexion or when the limb is moved in flexion or extensionextension

22 More marked increase in tone, but limb More marked increase in tone, but limb easily flexedeasily flexed

3 3 Considerable increase in tone; passive Considerable increase in tone; passive movement difficultmovement difficult

4 4 Limb rigid in flexion or extensionLimb rigid in flexion or extension

H- Reflex assessment: H- Reflex assessment: Assess Assess superficial and deep reflexes (tendon superficial and deep reflexes (tendon reflex,, and babiniski sign). reflex,, and babiniski sign).

I- Postural assessment testes:I- Postural assessment testes:

Shobber test Shobber test Adam's test Adam's test Forward bending test. Forward bending test.

J- Sensation & perception J- Sensation & perception teststests::

Superficial sensation: Superficial sensation: assessment of assessment of pain, touch, and temperature. Sensation pain, touch, and temperature. Sensation test is done by pin pricking or test tube. test is done by pin pricking or test tube.

Deep sensation (Proprioception):Deep sensation (Proprioception): Dynamic sense (sense of movement) Dynamic sense (sense of movement) Static sense (sense of position)Static sense (sense of position) Vibration senseVibration sense

Joint Joint sense:sense:

Rate of motion Rate of motion Velocity of motion Velocity of motion Direction of motion Direction of motion

Combined sensationCombined sensation::

stereognosis, two point discrimination, stereognosis, two point discrimination, tactile localization, vibration, tactile localization, vibration, paragnosis, and texture of different paragnosis, and texture of different materials.materials.

Perception Perception can be evaluated by observation: can be evaluated by observation: patients with perceptual defect have the following patients with perceptual defect have the following criteria: criteria:

Can't follow instruction. Can't follow instruction. Suffer from confusion Suffer from confusion Difficulty in performing A.D.L.Difficulty in performing A.D.L. Repeated mistakes Repeated mistakes Can't repeated movement Can't repeated movement Can't discriminate between body Can't discriminate between body

image and body parts (Summate). image and body parts (Summate). Can't do purposeful movement Can't do purposeful movement

(Apraxia). (Apraxia). Can't do any construction form.Can't do any construction form.

IV- Special testIV- Special test

Righting reactionRighting reaction Equilibrium testEquilibrium test Upright position Upright position

testtest

A- Manual Test

Special tests for Special tests for coordinationcoordination

Finger to nose: The shoulder is abducted to 90o with Finger to nose: The shoulder is abducted to 90o with the elbow extended, the patient is asked to bring tip the elbow extended, the patient is asked to bring tip of the index finger to the tip of nose. of the index finger to the tip of nose.

Finger to therapist finger: the patient and the Finger to therapist finger: the patient and the therapist site opposite to each other, the therapist therapist site opposite to each other, the therapist index finger is held in front of the patient, the index finger is held in front of the patient, the patient is asked to touch the tip of the index finger patient is asked to touch the tip of the index finger to the therapist index finger.to the therapist index finger.

Non-equilibrium coordination

Finger to finger: Both shoulders are abducted to Finger to finger: Both shoulders are abducted to bring both the elbow extended, the patient is asked bring both the elbow extended, the patient is asked to bring both the hand toward the midline and to bring both the hand toward the midline and approximate the index finger from opposing hand .approximate the index finger from opposing hand .

alternate nose to finger: the patient alternately touch alternate nose to finger: the patient alternately touch the tip of the nose and the tip of the therapist's finger the tip of the nose and the tip of the therapist's finger with the index finger.with the index finger.

Equilibrium coordination testsEquilibrium coordination tests::

Standing in a normal comfortable posture.Standing in a normal comfortable posture. Standing with feet together (narrow base of Standing with feet together (narrow base of

support) support) Standing with one foot exactly in front of Standing with one foot exactly in front of

the other in tendon (toe of one foot the other in tendon (toe of one foot touching heed of opposite foot).touching heed of opposite foot).

Standing on one foot.Standing on one foot.

Arm position may be altered in each of the above Arm position may be altered in each of the above postures (that is arm at sides, over head, hands on postures (that is arm at sides, over head, hands on waist) . waist) .

Displace balance unexpectedly (with carefully Displace balance unexpectedly (with carefully guarding patient).guarding patient).

Standing and then alternate between forward trunk Standing and then alternate between forward trunk flexion and return to neutral.flexion and return to neutral.

Standing with trunk laterally flexed to each side .Standing with trunk laterally flexed to each side . Standing to test the ability to maintain an upright Standing to test the ability to maintain an upright

posture without visual feedback.posture without visual feedback. Standing in tandem position from eyes open to Standing in tandem position from eyes open to

eyes closed.eyes closed.

B- Mechanical B- Mechanical testtest

Instrumentation used to assess Instrumentation used to assess coordinationcoordination

Pivot turning mat Side turning matFrenkle's mat

II- Rehabilitation II- Rehabilitation programprogram..

A- Rehabilitation team A- Rehabilitation team Physician – Nurse – Therapist – Social Physician – Nurse – Therapist – Social

worker –vocational counselor worker –vocational counselor occupational therapist – psychiatrist occupational therapist – psychiatrist – Dietician – relatives of patients.– Dietician – relatives of patients.

B- GoalsB- Goals

Return subject to be independent or Return subject to be independent or partial independent in ADL and to be partial independent in ADL and to be productive member in his society. productive member in his society.

1- Long term goals1- Long term goals

2- Short term goals2- Short term goals

Enhance functional activities Enhance functional activities Improve range of motion Improve range of motion Restore symmetry of both sides Restore symmetry of both sides Improve sensory awareness Improve sensory awareness Normalization of muscle tone Normalization of muscle tone Improve balanceImprove balance Improve co ordinationImprove co ordination Improve gait pattern Improve gait pattern Strengthening weakened muscle.Strengthening weakened muscle.

Consideration during rehabilitationConsideration during rehabilitation: :

Avoid exhaustion for the patientsAvoid exhaustion for the patients Avoid the bad habits and poor positioning .Avoid the bad habits and poor positioning . Avoid position that may exaggerated Avoid position that may exaggerated

muscle tone or muscle tone or patient complication. patient complication. Mental stress. Mental stress. Check for precautions and contraindication Check for precautions and contraindication Rest in between the exercise Rest in between the exercise There should be goad fixation and There should be goad fixation and

stabilization stabilization Rehabilitation should proceed according to Rehabilitation should proceed according to

stages of motor learning. stages of motor learning.

Physical problems of motor control Physical problems of motor control stagestage::

Defect in postural tone.Defect in postural tone. Defect in postural balance.Defect in postural balance. Defect in functional pattern.Defect in functional pattern.

C- Program of treatmentC- Program of treatment

– Avoid any thing or position that increase Avoid any thing or position that increase spasticity (excitement, fatigue, pollution, air spasticity (excitement, fatigue, pollution, air drafts)drafts)

– Suitable clothes not tight or restricting, it Suitable clothes not tight or restricting, it should be made of cotton. should be made of cotton.

– Ask visitor to seat at affected side to allow Ask visitor to seat at affected side to allow weight bearing and encourage symmetry.weight bearing and encourage symmetry.

– Avoid over weight (diet that give energy Avoid over weight (diet that give energy but reduce carbohydrates intake). but reduce carbohydrates intake).

1- Instruction

– Wide and stable bed Wide and stable bed – Turning every 2 hours to avoid bed sores. Turning every 2 hours to avoid bed sores. – Massage back & buttocks Massage back & buttocks – Rearrangement of furnitureRearrangement of furniture– Head should be deviated to sound side to Head should be deviated to sound side to

ovoid retraction of shoulder also make ovoid retraction of shoulder also make elongation of the neck muscles on the elongation of the neck muscles on the affected side.affected side.

– Encourage symmetry: by engagement of Encourage symmetry: by engagement of the sound and affected upper limbs.the sound and affected upper limbs.

22 - -PositioningPositioning::

Put the patient in anti-spastic Put the patient in anti-spastic position.position.

Head deviated to the sound side. Head deviated to the sound side. Long pillow under pelvis – thigh to Long pillow under pelvis – thigh to

avoid retraction of pelvis, prevent avoid retraction of pelvis, prevent lateral rotation, and assist turning. lateral rotation, and assist turning. Put small pillow under the knee.Put small pillow under the knee.

Pillow under the axilla.Pillow under the axilla. Shoulder in abduction and hand in Shoulder in abduction and hand in

functional position.functional position.

Use board or wall to put the feet at Use board or wall to put the feet at right angle to avoid drop foot.right angle to avoid drop foot.

7- Put pillow on his abdomen or in 7- Put pillow on his abdomen or in front of him and he engage his hands front of him and he engage his hands on it. on it.

8- Abduct the sound LL apart. 8- Abduct the sound LL apart.

33 - -General & Local General & Local relaxationrelaxation

Reassure the patient and encourage Reassure the patient and encourage himhim

Massage Massage Hot back Hot back Bio-feed back Bio-feed back Small pillows Small pillows Towel or small pillow under the knee Towel or small pillow under the knee Suitable & comfortable bed Suitable & comfortable bed Temperature room, music. Temperature room, music.

44 - -Breathing Breathing exerciseexercise

Diaphragmatic Diaphragmatic Costal Costal Ask patient or his family to open windows Ask patient or his family to open windows

to allow good ventilation. to allow good ventilation.

Proprioceptive training for hemiplegic patientProprioceptive training for hemiplegic patient::

a- Bridging exercise & Single leg bridging a- Bridging exercise & Single leg bridging

A- Mobility stage:

b) Placing exercisesb) Placing exercises::

in placing exercises we can use wall as function tool in placing exercises we can use wall as function tool proprioception, placing, inhibition, facilitation) proprioception, placing, inhibition, facilitation)

For example:For example: Raise leg on wall in certain points this position used Raise leg on wall in certain points this position used

in (1) function standing (dorsiflexion -planter in (1) function standing (dorsiflexion -planter flexion- stretching – proprioception – prevent flexion- stretching – proprioception – prevent deviation). Also it is used as a coordination training deviation). Also it is used as a coordination training for leg from supine. for leg from supine.

Supine and place hand on wall by hand contact on Supine and place hand on wall by hand contact on certain markes on the wall this position used in certain markes on the wall this position used in prevention of drop wrist as well as coordination.prevention of drop wrist as well as coordination.

Proprioceptive neuromuscular facilitation (PNF)Proprioceptive neuromuscular facilitation (PNF)

P.NF is a very important exercise to improve P.NF is a very important exercise to improve co ordination between agonistic and co ordination between agonistic and antagonistic muscle groups, and to improve antagonistic muscle groups, and to improve limb co ordination in general, in the Mobility limb co ordination in general, in the Mobility stage we can use it in the form of active free stage we can use it in the form of active free exercise. exercise.

Frenkle's exercisesFrenkle's exercises::

The main principles of frenkel's The main principles of frenkel's exercises are the following :exercises are the following :

– concentration or attention.concentration or attention.– Precision Precision

- Repetition- Repetition

frenkel's exercises from frenkel's exercises from supinesupine

Flex and extend one leg by the heel sliding Flex and extend one leg by the heel sliding down a straight line on the table.down a straight line on the table.

Abduct and adduct hip smoothly with knee Abduct and adduct hip smoothly with knee bent and heel on the table.bent and heel on the table.

Abduct and adduct leg with knee and hip Abduct and adduct leg with knee and hip extended by sliding the whole leg on the table .extended by sliding the whole leg on the table .

Flex and extend hip and knee with heel off the Flex and extend hip and knee with heel off the table .table .

Flex and extend both legs together with Flex and extend both legs together with the heel sliding on the table.the heel sliding on the table.

Flex one leg while extending the other.Flex one leg while extending the other. Flex and extend one leg while taking the Flex and extend one leg while taking the

other leg into abduction and adduction.other leg into abduction and adduction.

C- Controlled Mobility stageC- Controlled Mobility stage::

1- Quadruped position: t1- Quadruped position: the patient at this stage can he patient at this stage can support weight on the affected limb effectively so he support weight on the affected limb effectively so he can do reciprocal movement between the affected can do reciprocal movement between the affected upper and sound U.L or the affected and soured L.L upper and sound U.L or the affected and soured L.L or between upper and lower limb. This improve or between upper and lower limb. This improve coordination between patient extremities and coordination between patient extremities and improve self-esteem. improve self-esteem.

In the controlled mobility stage we can use be In the controlled mobility stage we can use be PNFPNF in the form of active resisted exercises in the form of active resisted exercises

Frankle's Exercises for the legs in Frankle's Exercises for the legs in sittingsitting: :

One leg is stretched to slide the One leg is stretched to slide the heel to a position indicated by a heel to a position indicated by a mark on the floor.mark on the floor.

The alternate leg is lifted to place The alternate leg is lifted to place the heel on the marked point.the heel on the marked point.

From stride sitting posture patient is From stride sitting posture patient is asked to stand and them site.asked to stand and them site.

Rise and site with knees together. Rise and site with knees together.

Frenkle's Exercises for the legs in Frenkle's Exercises for the legs in standingstanding::

In stride standing weight is transferred In stride standing weight is transferred from one foot to other.from one foot to other.

Place foot forward and backward on Place foot forward and backward on straight line.straight line.

D- Highly skilled activity D- Highly skilled activity stage: stage:

Walks along a widening s teps .Walks along a widening s teps . Walk between two parallel lines.Walk between two parallel lines. Walks sideways by placing feet on Walks sideways by placing feet on

the marked point. the marked point. Walk and turn around.Walk and turn around. Walk and change direction to avoid Walk and change direction to avoid

obstacles.obstacles.

Sideways walkingSideways walking Pivot turningPivot turning From sitting position : we can improve From sitting position : we can improve

coordination (eye – hand coordination) coordination (eye – hand coordination) by using puzzles and big board. by using puzzles and big board.

also we can use roller and move it using also we can use roller and move it using both hands to improve co ordination both hands to improve co ordination between both hands between both hands

Squatter and trolley for the leg and Squatter and trolley for the leg and move the foot forward, backward and move the foot forward, backward and sideward. sideward.

• use roller and move it using use roller and move it using his both hands his both hands

Home program and advicesHome program and advices

1- Regular maintaining antispastic position.1- Regular maintaining antispastic position.

2- Always use affected side together with 2- Always use affected side together with the sound side to decrease the associated the sound side to decrease the associated reactions.reactions.

3- Patient instructed to do movements in 3- Patient instructed to do movements in functional pattern.functional pattern.

4- Patient trained on defensive mechanism.4- Patient trained on defensive mechanism.