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To exercise neck and upper trunk flexion, use prolonged static contraction of the legs and lower trunk muscles. Using the legs and lower trunk in this way works well when the patient's arms are too weak to use for upper trunk exercise. This combination is also useful when the patient has pain in the neck or upper trunk.

Alternative Positions

Use this lower extremity combination on the mats to facilitate rolling from supine to side-lying or in the short sitting position (O Fig. 10.7 c, d).

Points to Remember

The lumbar spine must not be pulled into hyperextension

The legs become the handle; only the pelvis moves to exercise the trunk

10.3.2 Bilateral Lower Extremity Extension, with Knee Extension, for Lower Trunk Extension (Left) (O Fig. 10.8)

Position at Start

Position the patient close to the left side of the table.

Body Mechanics

Stand in a stride position facing the diagonal. Lean forward to stretch the pattern. As the patient's legs move into extension, step back with your forward leg. Use your body weight to resist the motion.

Grip

Distal Hand

Your left hand holds both of the patient's feet with contact on the plantar and lateral surfaces close to the toes. If the feet are too large for your grasp, cross one foot partially over the other to decrease the width.

Proximal Hand

Your right arm is underneath the patient's thighs. Hold the thighs together with this arm.

Elongated Position

The patient's legs are flexed to the right. The right leg is in flexion-abduction-internal rotation with knee flexion, the left leg in flexion-adduction-external rotation with knee flexion. The lower trunk is flexed with rotation and lateral flexion to the right.

Stretch

Use traction with rotation through the thighs to increase the trunk flexion to the right.

Command

"Toes down, kick down to me."

O Fig. 10.8a,b. Bilateral lower extremity extension with knee extension for lower trunk extension

O Fig. 10.8a,b. Bilateral lower extremity extension with knee extension for lower trunk extension a

Movement

As the feet plantar flex the trunk extensor muscles begin to contract. The legs extend together, the left leg into extension-abduction-internal rotation, right leg into extension-adduction-external rotation. When the legs reach the end of their range, the motion continues as lower trunk elongation with rotation and side-bending to the left.

Resistance Distal Hand

Resist trunk and hip rotation with pressure on the feet. Resist the knee extension with this hand as you did with the single leg patterns by pushing the patient's heels back toward the buttock. Resistance with your distal hand to the knee extension at the beginning of the motion will prevent over rotation of the hips and trunk.

If the knees remain straight, give approximation through the line of the tibia.

Proximal Hand

Continue to hold the thighs together with this arm as you resist the hip motions.

End Position

The left leg is in full extension-abduction-internal rotation, the right leg in full extension-adduction-external rotation. The lower trunk is elongated with rotation and lateral flexion to the left.

Normal Timing

The trunk extensor muscles contract as soon as or just before the legs begin their motion. By the time the leg motion is completed the trunk is in full elongation.

! Caution

The end position is trunk elongation, not lumbar spine hyperextension.

Timing for Emphasis

To exercise the neck and upper trunk extension, use prolonged static contraction of the legs and lower trunk muscles. Using the legs and lower trunk in this way works well when the patient's arms are too weak to use for upper trunk exercise. This combination is also useful when the patient has pain in the neck or upper trunk. The pivot of emphasis can be changed to trunk lateral flexion. See 7 Sect. 10.3.3.

Alternative Positions

Use this lower extremity combination on the mats to facilitate rolling from side-lying or prone to supine.

Points to Remember

Resistance with your distal hand to the knee extension controls the trunk activity The desired activity is trunk elongation, not lumbar spine hyperextension

10.3.3 Trunk Lateral Flexion

The lateral flexion pattern can be done with a trunk flexion bias or an extension bias. To exercise the motion, use the bilateral leg flexion or extension patterns with full hip rotation.

Left Lateral Flexion with Flexion Bias

Begin at the shortened range of bilateral lower extremity flexion to the left. You may place the legs here if the patient's condition requires that.

Command

"Swing your feet away from me (to the left)." If you are working with straight leg patterns, a good command is: "Turn your heels away from me."

Resistance

With your proximal hand give traction through the thighs to lock in the hip flexion. Lateral pressure resists the lateral hip motion. With your distal hand lock in the knees and feet and resist the hip rotation.

Movement

The hips and knees are flexed to the left. As the hips rotate left past the groove of the flexion pattern, the lumbar spine side-bends to the left and the pelvis moves up toward the ribs.

Points to Remember

Traction through the femurs locks in the trunk flexor muscles

It is the hip rotation that controls the trunk side bend

Right Lateral Flexion with Extension Bias

We can exercise this motion in the lengthened or the shortened range of the leg patterns.

In the Lengthened Range

Begin with the patient's legs in full flexion to the left (the lengthened range of bilateral lower extremity extension to the right) (O Fig. 10.9 a).

Body Mechanics

Stand in a stride position by the patient's left shoulder. Use your body weight to resist the leg and trunk motion.

Command

"Swing your feet to the right and push your legs away." If you wish, ask for a static rather than a dy a

O Fig. 10.9. Right lateral flexion with extension bias. a, b Lateral flexion in the lengthened range. Resistance to bilateral asymmetrical leg extension: motion of the rotatory component results in the trunk lateral flexion. c Lateral flexion in the shortened range b c

O Fig. 10.9. Right lateral flexion with extension bias. a, b Lateral flexion in the lengthened range. Resistance to bilateral asymmetrical leg extension: motion of the rotatory component results in the trunk lateral flexion. c Lateral flexion in the shortened range a c namic contraction of the hip and knee extension (O Fig. 10.9 b).

Resistance

With your proximal hand resist the hip extension and lateral motion. Your distal hand locks in the knee and foot motion and resists the dynamic hip rotation.

Motion

The hips rotate fully to the right. The lumbar spine extends and side-bends right.

Allow a few degrees of hip and knee extension to the right.

In the Shortened Range

You may begin with the patient's legs in full flexion to the left or preposition the legs in full extension to the right.

Body Mechanics

Stand on the right and use your body as you did for the pattern of trunk extension to the right.

Command

"Kick and turn your heels toward me." "Keep your legs down and turn your heels to me again."

Resistance

Give the same resistance as you did for trunk extension. Allow full hip rotation.

Motion

The patient's legs extend to the right with full hip rotation. The lumbar spine extends and side-bends right (O Fig. 10.9 c).

Points to Remember

In the lengthened range traction through the femurs locks in the trunk extensor muscles

It is the hip rotation that controls the trunk side bend

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