Right in the Middle

I Theoretical Antecedents.- 1 The Normal Trunk — Evolutionary and Anatomical Considerations.- 1.1 The Vertebral Column.- 1.1.1 Movements of the Vertebral Column.- 1.1.2 Movements of the Rib Cage.- 1.2 Conclusion.- 2 Aspects of Trunk Control.- 2.1 The Bridge.- 2.2 The Tentacle.- 2.3 The Bridge-Tentacle.- 2.3.1 Muscular Control of the Trunk.- 2.3.2 Anatomical Considerations.- 2.3.2.1 Extension.- 2.3.2.2 Shoulder Girdle.- 2.3.2.3 Abdominal Muscles.- 2.3.2.4 Respiration.- 2.4 Types of Muscle Action.- 2.5 Conclusion.- 3 Problems Associated with the Loss of Selective Trunk Activity in Hemiplegia.- 3.1 Possible Reasons for the Bilateral Loss of Abdominal Muscle Activity and Tone.- 3.2 Loss of Selective Activity.- 3.2.1 Muscles of the Trunk.- 3.2.2 Muscles of the Trunk and Limbs Acting Simultaneously.- 3.3 Inability to Move in Normal Patterns.- 3.4 The Most Commonly Observed Problems Seen in Relation to Normal Motor Development.- 3.4.1 Difficulties with Breathing and Speaking.- 3.4.1.1 Distorted Configuration of the Rib Cage.- 3.4.2 Difficulties Observed in Lying.- 3.4.3 Difficulties in Moving Between Lying and Sitting.- 3.4.4 Difficulties in Sitting.- 3.4.5 Difficulties in Standing Up from Sitting.- 3.4.6 Difficulties in Standing.- 3.4.7 Some Difficulties Observed in Walking.- 3.4.7.1 The Stance Phase.- 3.4.7.2 The Swing Phase.- 3.4.7.3 Slow and Effortful Walking with the Stride Width Increased.- 3.4.7.4 Associated Reactions in the Arm.- 3.4.8 Difficulties in Moving the Arm.- 3.5 Conclusion.- II Therapeutic Activities.- 4 Activities in Lying.- 4.1 Facilitating Breathing.- 4.1.1 Moving the Chest Passively.- 4.1.2 Assisting Expiration.- 4.1.3 Facilitating Diaphragmatic Breathing.- 4.2 Flexion/Rotation of the Upper Trunk.- 4.2.1 Assisting Passive Movement.- 4.2.2 Facilitating Active Movement.- 4.3 Retraining Active Protraction of the Scapula with Activation of the Oblique Abdominal Muscles.- 4.3.1 Lifting the Elbows into the Air.- 4.4 Rolling to Prone.- 4.4.1 Rolling Towards the Hemiplegic Side.- 4.4.2 Rolling Towards the Sound Side.- 4.5 Flexion/Rotation of the Lower Trunk.- 4.6 Activating the Oblique Abdominal Muscles in Crook Lying.- 4.7 Position of the Arms.- 4.8 Bridging, a Useful Activity for Regaining Selective Extension of the Hip Together with Abdominal Muscle Activity.- 4.9 Actively Controlling the Hemiplegic Leg Through Its Range of Movement.- 4.10 Conclusion.- 5 Moving Between Lying and Sitting.- 5.1 Sitting Up over the Side of the Bed.- 5.1.1 Fully Supported.- 5.1.2 Less Assistance.- 5.1.3 No Support.- 5.2 Lying Down from Sitting.- 5.3 Rocking in Crook Sitting.- 5.4 Moving the Trunk in Long Sitting.- 5.4.1 Long Sitting with Isolated Knee Extension.- 5.4.2 Moving Towards Supine Lying.- 5.4.3 Lying Down with the Trunk Rotated.- 5.5 Conclusion.- 6 Activities in Sitting.- 6.1 Sitting with Both Legs over the Side of the Plinth.- 6.1.2 Selective Flexion and Extension of the Lower Trunk.- 6.1.3 Trunk Rotation with Flexion.- 6.2 Rotation of the Trunk with Both Arms Supported on the Same Side.- 6.2.1 Rotating Towards the Sound Side.- 6.2.2 Rotating Towards the Hemiplegic Side.- 6.3 Active Movements of the Hemiplegie Arm Following the Inhibition of Spasticity.- 6.4 Weight Transference Sideways.- 6.4.1 Moving Towards the Hemiplegie Side.- 6.4.1.1 A Progressive Sequence to Teach the Correct Movement.- 6.4.2 Moving Towards the Sound Side.- 6.4.2.1 A Progressive Sequence to Teach the Correct Movement.- 6.5 Selective Side Flexion of the Lower Trunk.- 6.6 Active Side Flexion of the Trunk Against Gravity.- 6.7 Moving Forwards and Backwards.- 6.8 Conclusion.- 7 Standing Up from Sitting.- 7.1 Therapeutic and Functional Activities.- 7.1.1 Bringing the Extended Trunk Forwards.- 7.1.2 Standing Up from Sitting.- 7.1.2.1 Supported by the Therapist.- 7.1.2.2 Hands Supported on a Stool.- 7.1.2.3 Weight Bearing on the Hemiplegic Leg Alone.- 7.1.3 Alternating Between Selective Extensor and Flexor Activity of the Trunk and Hips.- 7.1.3.1 Incorporating Active Plantar Flexion of the Foot.- 7.1.3.2 Legs Crossed.- 7.1.3.3 Performing an Additional Task.- 7.1.4 Standing Up from a High Plinth or Bed.- 7.1.4.1 Transferring the Patient onto a High Bed.- 7.1.5 Standing Up and Returning to Sitting from a High Plinth or Bed.- 7.1.5.1 Weight Taken on the Hemiplegic Leg.- 7.1.5.2 Weight Taken on the Sound Leg.- 7.2 Conclusion.- 8 Activities in Standing.- 8.1 Important Considerations Before Standing Activities Are Begun.- 8.2 Activities to Train Selective Trunk and Leg Movement.- 8.2.1 Tilting the Pelvis Forwards and Backwards.- 8.2.2 Weight Bearing on the Hemiplegie Leg with Abduction and Adduction of the Contra-lateral Hip.- 8.2.3 Bending the Trunk Forwards and Bringing It to the Vertical Again.- 8.2.4 Bending the Trunk Forwards and Returning to an Upright Position While Standing on a Sloping Surface.- 8.2.5 Weight Bearing on the Hemiplegie Leg While Placing the Sound Foot on a Step.- 8.2.6 Weight Bearing on the Hemiplegie Leg with the Sound Leg Abducting.- 8.2.7 Hip Extension with Abduction and Outward Rotation.- 8.2.8 Active Plantar Flexion of the Ankles with Flexed Knees.- 8.2.9 Controlling the Hemiplegie Leg Actively Against Gravity.- 8.2.10 Active Control of the Hemiplegie Leg when the Hip Is Extended.- 8.2.11 Moving the Arms Actively While Standing.- 8.2.11.1 Holding a Pole in Both Hands.- 8.2.11.2 Hitting a Ball with a Pole.- 8.2.11.3 Hitting a Balloon Away with the Hemiplegie Hand.- 8.3 Conclusion.- 9 Ball Activities.- 9.1 Ball Activities in Supine Lying.- 9.1.1 Lifting the Ball off the Bed with Both Legs.- 9.1.2 Abducting and Adducting One Leg with the Other Leg Supported on the Ball.- 9.2 Ball Activities in Prone Lying.- 9.2.1 Lying Prone on the Ball with Weight Supported Through Both Arms.- 9.2.2 Lower Trunk and Hip Flexion with Both Knees Supported on the Ball.- 9.2.3 Rotating the Trunk Until Only One Trochanter Is Supported on the Ball.- 9.3 Ball Activities in Sitting.- 9.3.1 Flexing and Extending the Lumbar Spine.- 9.3.2 Lateral Flexion of the Lumbar Spine.- 9.3.3 Bouncing on the Ball.- 9.3.4 Walking Both Feet Forwards Until Only the Shoulders Are Supported on the Ball.- 9.4 Ball Activities in Standing.- 9.4.1 Standing on One Leg with the Other Foot on a Moving Ball.- 9.5 Conclusion.- 10 Walking.- 10.1 Observing, Analysing, and Facilitating Walking — Theoretical Considerations.- 10.1.1 Rhythm and Cadence.- 10.1.2 Step Length.- 10.1.3 Position of the Feet on the Floor.- 10.1.4 The Knee.- 10.1.5 The Pelvis.- 10.1.6 The Trunk.- 10.1.7 The Arms.- 10.1.8 The Head.- 10.1.9 Maintaining Balance.- 10.2 Facilitating Walking — Practical Considerations.- 10.2.1 Footwear.- 10.2.2 Assisting Hip Extension.- 10.3 Facilitating Walking Backwards.- 10.3.1 Tipped Backwards Without Taking a Step.- 10.3.2 Taking Steps Backwards.- 10.4 Facilitating Walking Sideways.- 10.4.1 Towards the Sound Side.- 10.4.2 Towards the Hemiplegic Side.- 10.5 Facilitating Walking Forwards.- 10.5.1 Stabilising the Thorax and Moving the Trunk Forwards.- 10.5.2 Facilitation to Prevent Side Flexion of the Trunk and Associated Reactions in the Arm.- 10.5.2.1 Supporting the Hemiplegic Arm.- 10.5.2.2 Holding a Ball.- 10.5.2.3 Holding a Pole in Both Hands.- 10.5.2.4 Applying Pressure to the Patient’s Chest.- 10.5.3 Facilitation Using Stimulating and Inhibitory Tapping.- 10.5.3.1 Stimulating Tapping over the Hip Extensors.- 10.5.3.2 Stimulating Tapping for the Lower Abdominal Muscles.- 10.5.3.3 Inhibitory Tapping.- 10.5.4 Facilitation to Narrow the Stride Width.- 10.5.4.1 Walking Along a Line.- 10.5.4.2 Walking Along a Plank.- 10.5.5 Facilitation to Re-establish Rhythm.- 10.5.5.1 Using a Tambourine.- 10.5.5.2 Bouncing a Ball with the Sound Hand.- 10.5.5.3 Bouncing a Large Ball with Both Hands.- 10.5.5.4 Imitating the Therapist’s Steps.- 10.5.6 Facilitating Walking on the Toes.- 10.5.7 Walking with the Head Moving Freely.- 10.5.7.1 Throwing and Catching a Ball.- 10.5.7.2 Beating a Tambourine.- 10.6 Conclusion.- References.