FUNctional Exercises for the Non-Weight Bearing Patient Presented by: Michelle Green, PT Rehab Summit 2012 Session 306
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FUNctional Exercises
for the
Non-Weight Bearing Patient
Presented by:
Michelle Green, PT
Rehab Summit 2012
Session 306
Any opinions, findings, recommendations or conclusions expressed by the author(s)or
speaker(s) do not necessarily reflect the views of Rehab Summit or Cross Country
Education, LLC. This publication is designed to provide accurate and authoritative
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the publisher is not engaged in rendering legal, accounting or other professional service.
If legal advise or other expert assistance is required, the services of a competent
professional person should be sought. Copyright 2012 Michelle Green & Cross Country
Education, LLC. No part of this presentation may be reproduced in any manner without
the expressed written consent of Michelle Green & Cross Country Education, LLC.
From a Declaration of Principles jointly adopted by a Committee of the American Bar
Association and a committee of Publishers.
FUNctional Training for the
Non-weight Bearing Patient Michelle Green, MS, PT
Cross Country Education
Leading the Way in Continuing Education and Professional Development. www.CrossCountryEducation.com
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• I declare that I or my family do not have any financial relationship in any amount, occurring in
the last 12 months with a commercial interest whose products or services are discussed in my
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•Requirements for successful completion are completing this webinar and passing the test at
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Learning Objectives
Identify proximal control requirements needed for functional tasks
Utilize a problem solving strategy to identify needed preparatory
exercises for the single or multi-joint weight bearing restricted patient
Outline individualized therapeutic exercises and progress the exercises
to work toward identified functional limitations
North Carolina
I live here
CAPE FEAR HEALTH SYSTEM
500 BED ACUTE CARE
70 BED IN-PATIENT REHAB FACILITY
DO YOU FIND THIS
CHALLENGING?
WHAT WE WILL NOT DO
Review surgical procedures and common
post-surgical limitations
Review time-lines of return to
weightbearing
Review medical and neuro conditions that
may be co-morbidities
Let “how we’ve always done it” block our
patient’s potential for better recovery
WHAT WE WILL DO…
Identify the unique role of the therapist
with this challenging patient
Create a strategy to plan en effective
treatment plan for patients who are non-
weight bearing
Generate LOTS of ideas for treatment and
how to progress for function now and later
2 THINGS NEED TO HAPPEN
1. They need to be FUNCTIONAL
while NWB
CONSIDER TASKS THEY NEED TO DO
WHILE NWB’ing….
-Bed Mobility…. Get call bell, pull up covers, roll over, supine to sit….
-Transfers…… sliding board…… boost…… squat pivot….sit- stand
-ADL’s…..modified due to NWB status….lots of seated ADL’s….
-Step Management……. Assistive device….. Boost on bottom….
-Getting Around…. Ambulation……wheelchair propulsion….
2 THINGS NEED TO HAPPEN
1. They need to be FUNCTIONAL
while NWB
2. They need to MAINTAIN mm. activation and length and core for function when they return to normal weightbearing
2 THINGS NEED TO HAPPEN
1. They need to be FUNCTIONAL
while NWB
2. They need to MAINTAIN mm. activation and length and core for function when they return to normal weightbearing
2 THINGS…..EASY RIGHT????
STEP 1:
FUNCTIONAL WHILE NWB
TASK ANALYSIS!!!!!
Understand how the task needs to be performed with the muscles
THEY DO HAVE!!!!
STRENGTHEN
THE PATTERN not the
SPECIFIC MUSCLES!!!!
STEP 1:
FUNCTIONAL WHILE NWB
TASK ANALYSIS
Where does task initiate from? (proximal stabilization)
Which muscles/joint motion?
What are the joint movements needed at
limbs? (distal movement)
Schenkman 2006
EXAMPLE:
BED MOBILITY
CHECK IT OUT…
ALIGNMENT
Do they have the best alignment for muscle activation for the task?
IF NOT…….. DON’T DO THE TASK!!!!
Step back- spend time on ROM, length, activation to get alignment…. Before
ACTIVATION
Set up treatment to get muscles to be active in SAME WAY they need to work for the task!!!!!
We wouldn’t do this….
We wouldn’t do this….
To learn to do
this….
We wouldn’t do this….
We wouldn’t do this….
To learn to do
this….
We wouldn’t do this….
We wouldn’t do this….
To learn to do
this….
SOOOO……
WHAT IS THIS GOOD FOR?
WHAT IS THIS GOOD FOR?
?
WHAT IS THIS GOOD FOR?
? Certainly not……
Toileting tasks
WHAT IS THIS GOOD FOR?
WHAT IS THIS GOOD FOR?
?
WHAT IS THIS GOOD FOR?
?
Certainly not……
HOW IS THE MUSCLE
ASKED TO WORK?
OPEN CHAINED
VS.
CLOSED CHAIN OPEN CHAIN: Put simply, your hand or foot is free to move during an open
chain exercise (like a chest press). These types of movements tend to isolate a
single muscle group and a single joint
CLOSED CHAIN: During these movements, your hands or feet are in a
constant, fixed position (usually on the ground) during the exercise (such as
pushups). Closed chain movements usually involve multiple joints and multiple
muscle groups at once
SHORT OF IT…..
UNDERSTAND THE TASK!!!!! How is it going to be performed for THIS patient with THESE limitations?
(NO RULES HERE!!!!! YOU HAVE TO FIGURE IT OUT!!!!)
DO PARTS OF THE TASK….. Be sure you have the needed alignment and muscle activation FIRST!!!! If not, create alignment, get muscles active, THEN PRACTICE TASK as it needs to be performed WHILE NWB!!!!
(Will be different for every patient…. Considering their limitations, pre-morbid function and debility from current event)
SEATED ADL’S
PUTTING ON PANTS
WIPING FROM REAR
GETTING ON BUTTON UP SHIRT
WASHING THE BACK
GROUP ACTIVITY
Identify:
Point of initiation/Proximal Stabilization
Muscle Activation and Joint Motion/Distal Mobility
“Rehabilitation should match the demands of the task” Kuhn 2009
SEATED ADL’S
WEIGHTSHIFT TO LEFT
POST. PELVIC TILT
Left Lower Trunk initiated lateral
weight shift with upper trunk
rotation, shoulder extension and
IR with push through right heel for
right hip hike….
SEATED ADL’S Key considerations
PELVIC DISASSOCIATION
TRUNK ROTATION (ESP. POSTERIOR)
LATERAL WEIGHT SHIFTS (LOWER TRUNK
INITIATED)
PELVIC TILTS
SCAP STABILIZATION
SEATED CLOSED CHAIN HIP HIKE
BODY ON UE CLOSED CHAIN
LE NWB AMBULATION
What is the point of initiation/ stabilization
requirement for this task?
What joint motions/muscle activation
patterns make this task successful?
SO….. IF THIS TASK IS NOT ACCOMPLISHED….
What is your treatment?
Bachschmidt, 1997
WHEELCHAIR PROPULSION
WHAT IS THE NEEDED PROXIMAL
CONTROL?
WHAT IS THE NEEDED ALIGNMENT?
WHAT MUSCLES NEED TO BE ACTIVE? (IN WHAT JOINT POSITION, OPEN CHAIN OR CLOOSED CHAIN, WHAT TYPE
OF MUSCLE ACTIVATION?)
“Rehabilitation exercises should simulate normal neuromotor patterns”
Kuhn 2009
Always remember…….
WHEELCHAIR PROPULSION
Shld. over axis of rotation Shld.
extension
Trunk upright
Does your set-up lead to
success????
WHEELCHAIR PROPULSION KEY CONSIDERATIONS
THORACIC EXTENSION WITH SCAP
RETRACTION
SHOULDER EXTENSION/ IR
GRIP
OPEN CHAIN SHOULDER FLEXION
AGAINST RESISTANCE FROM
EXTENDED POSITION
ANT PELVIC TILT (PELVIS ON FEMUR)
TRANSFERS/BOOSTS
SCAP DEPRESSION/STABILIZATION
PELVIC DISASSOCIATION ON FEMUR
LATERAL LOWER TRUNK WEIGHT
SHIFTS
ANT PELVIC TILTS
CLOSED CHAIN
TRICEPS
TRANSFERS/BOOSTS
SCAP DEPRESSION/STABILIZATION
PELVIC DISASSOCIATION ON FEMUR
LATERAL LOWER TRUNK WEIGHT SHIFTS
ANT PELVIC TILTS
CLOSED CHAIN TRICEPS
STEP 2: READY FOR FUTURE Maintain muscle ACTIVATION, LENGTH and Core
Muscles which are left inactive by NWB
restrictions must be activated and “kept alive”
during NWB phase. (within pt. specific restrictions)
Muscles must remain LONG ENOUGH for best
recruitment potential…. Contractures will get in
the way of return to function
Core…. Keep it active in all planes of movement
MUSCLES MOST IMPACTED BY
IMMOBILIZATION “Loss of strength of as much as 40% has been reported
within the first week of immobilization, and the antigravity muscles of the calf and back needed for standing up , appear to atrophy at a faster rate that
non-antigravity muscles. “ Bernhardt, 2008
Loss of TYPE I – MUSCLE ENDURANCE FIBERS FASTER
than TYPE II – POWER/STRENGTH FIBERS. Loss of Type I noticeable at 11 days of withdraw of activity,
Type II can be preserved up to 6 weeks!
WHAT DOES THAT MEAN FOR SETTING UP TREATMENT?
ACTIVATE: Get These Active!
Hip and trunk extensors
Hip Abductors
Gastroc (2 joint muscle!)
Shoulder extensors
Trunk rotators – posterior
Any muscle immobilized and limited in
WB’ing!!!
ACTIVATE…. consider
E-stim
Isometrics – sustained holds
AAROM/AROM
Resisted
Progression….
Supported – unsupported
Gravity assisted – G. minimizes – Against G.
Short level length – long lever length
Single plane- multi-planar movement
One joint – multi- joint – functional movements
Type I mm fibers(endurance) – Type II (speed, power,strength)
LENGTH: Get These LONG!
Hip Flexors
Hip Adductors
Plantar flexors
Pecs
Upper Traps
Small Hip Rotators
LENGTH: Get These LONG!
Hip Flexors: PRONE!!!!!!!
Hip Adductors
Plantar flexors
Pecs
Upper Traps
Small Hip Rotators
LENGTH: Get These LONG!
Hip Flexors: PRONE!!!!!!!
Hip Adductors: REVERSED SITTING
Plantar flexors
Pecs
Upper Traps
Small Hip Rotators
LENGTH: Get These LONG!
Hip Flexors: PRONE!!!!!!!
Hip Adductors: REVERSED SITTING
Plantar flexors: WEIGHTBEARING!!!
MANUAL!!
Pecs
Upper Traps
Small Hip Rotators
LENGTH: Get These LONG!
Hip Flexors: PRONE!!!!!!!
Hip Adductors: REVERSED SITTING
Plantar flexors: WEIGHTBEARING!!!
MANUAL!!
Pecs: MANUAL WORK. FOAM ROLLERS
Upper Traps
Small Hip Rotators
LENGTH: Get These LONG!
Hip Flexors: PRONE!!!!!!!
Hip Adductors: REVERSED SITTING
Plantar flexors: WEIGHTBEARING!!!
MANUAL!!
Pecs: MANUAL WORK. FOAM ROLLERS
Upper Traps: MANUAL. THERABAND
Small Hip Rotators
LENGTH: Get These LONG!
Hip Flexors: PRONE!!!!!!!
Hip Adductors: REVERSED SITTING
Plantar flexors: WEIGHTBEARING!!!
MANUAL!!
Pecs: MANUAL WORK. FOAM ROLLERS
Upper Traps: MANUAL. THERABAND
Small Hip Rotators: WEDGED SITTING.
TILTS.
LENGTH: Get These LONG!
HOW?
Static stretch
Active antagonistic muscle for
prolonged HOLD!
Manual/Soft Tissue Work
INTACT, OPTIMIZED ANATOMY WILL
ULTIMATELY FUNCTION BEST!!!!
CORE STABILITY The ability to control the position and motion
of the trunk over the pelvis and leg to allow
optimum production, transfer, and control of
force and motion to the terminal segment in
integrated kinetic chain activities
Kibler, et al Sports Medicine 2006
PROXIMAL CONTROL BEFORE DISTAL MOBILITY.
CORE STABILITY
LATISSIMUS ENGAGEMENT THROUGH
SCAPULAR DEPRESSION
The largest spinal stabilizer. It attaches
via the thoracolumbar fascia to the lumbar
vertebrae, sacrum and pelvis, and runs upward to the
humerus.
LINK TO THE KINETIC CHAIN!!!!
PRODUCES STABILITY
PROXIMALLY FOR EFFECTIVE DISTAL
MOVEMENT
CORE STABILITY Progression
Stability in Neutral – stable position
Add limb movements on stable neutral
Stability in Neutral – less stable position
Add limb movements on less stable position
Stability in Neutral – weightbearing
Add limb movements in weightbearing
Vary weightbearing positions quadruped, plank, side plank
Articulated movement of spine – all planes Same progression as above… think pelvic tilts, rolling up and down, lateral weight shifts, rotation
SUMMARY:
Create interventions which make the patient as functional as possible WHILE NWB’ing!!!!! – Task Analysis model – Improve coordinated movement/neural adaptation for the performance of task (versus building
muscle)
Provide interventions aimed at optimizing anatomy for best function when able to WB – Activate muscles susceptible to atrophy due to disuse
– Maintain length of muscles susceptible to shortening
– Maintain core activation in all planes of movement as solid base for proximal control when distal movement is re-introduced.
References
Loria Carol, Relationship of Proximal and Distal Function in Motor Development. PHYSICAL THERAPY, February 1980
60:167-172.
Wiles, J, Colemena DA, Swaine IL. The Effects of Performing Isometric Training at Two Exercise Intensities in Healthy
Young Male. EUROPEAN JOURNAL OF APPLIED PHYSIOLOGY. 2010. 108:3, 419-428.
Tsao Henry and Paul W Hodges. Immediate ghanges in feedforward postural adjustments following voluntary motor training.
EXPERIMENTAL BRAIN RESEARCH. 2007.181;4, 537-546.
Tsao Henry , Galea Mary P and Hodges Paul W. How fast are feedforward postural adjustments of the abdominal muscles?
BEHAVIORAL NEUROSCIENCE 123:3, Jun 2009 687-693.
Marshall, Paul W. Electromyographical analysis of upper body, lower body and abdominal muscles during advanced swiss
ball exercises. Journal of Strength & Conditioning Research. June 2010. 24;6, 1537-1545.
Luttgens, Kathryn and Nancy Hamilton. Kinesiology: Scientific Basis of Human Motion. McGraw & Hill Humanties. 2011.
Andrade R, Araújo R C, Tucci H T, Martins J, Oliveira A S. Coactivation of the shoulder and arm muscles during closed
kinetic chain exercises on an unstable surface. Singapore Med J 2011; 52(1): 35
Schoenfeld, Brad MSc, CSCS; Contreras, Bret MA, CSCS Do Single-Joint Exercises Enhance Functional Fitness? Strength
& Conditioning Journal:2012 34 (1): 63-65
Rankin JW, Richter MW and Neptune RR. Individual muscle contributions to push and recovery subtasks during wheelchair
propulsion. Journal of Biomechanics. 2011; 44 (7): 1246-1252.
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