Pelvic Diagonals

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O Fig. 6.10. Patient with right hemiplegia. a Combination of scapula (posterior depression) with arm motion. b Combination of scapula (anterior elevation) with arm motion

6.5.1 Specific Pelvic Patterns

The pelvis is part of the trunk, so the range of motion in the pelvic patterns depends on the amount of motion in the lower spine. We treat pelvic patterns as isolated from the trunk if no great increased lumbar flexion or extension occurs. Bio-mechanically, it is impossible to move the pelvis without motion in the spine because it is connected with the spine. Pelvic patterns can be done with the patient lying, sitting, quadruped, or standing. The side that is moving must not be weightbearing. Side lying (illustrated) allows free motion of the pelvis and easy reinforcement of trunk and lower extremity activities.

The movements and muscle components mainly involved are as follows (Kendall and McCready 1993):

□ Table 6.2. Pelvic movements

Movement

Muscles: principal components

Anterior elevation

Internal and external oblique abdominal muscles

Posterior depression

Contralateral Internal and external oblique abdominal muscles

Posterior elevation

Ipsilateral quadratus lumborum, ipsilateral latissimus dorsi, iliocostalis lumborum, and longissimus thoracis

Anterior depression

Contralateral quadratus lumborum, iliocostalis lumborum, and longissimus thoracis

Anterior Elevation and Posterior Depression (O Fig. 6.11 a-e)

The therapist stands behind the patient facing up toward the patient's lower (right) shoulder.

Anterior Elevation (O Fig. 6.11 b, d; O Fig. 6.12) Grip. The fingers of one hand grip around the crest of the ilium, on and just anterior to the midline. Your other hand overlaps the first.

Ilium Posterior Nerve Leg Pean1st Pelvic Grip

O Fig. 6.11. Pelvic patterns in function: d pelvic pattern in anterior elevation, e pelvic pattern in posterior depression d__^_ e

O Fig. 6.11. Pelvic patterns in function: d pelvic pattern in anterior elevation, e pelvic pattern in posterior depression a

Fig. 6.12a,b. Resistance to pelvic anterior elevation

Fig. 6.12a,b. Resistance to pelvic anterior elevation

Elongated Position (O Fig. 6.12 a). Pull the crest of the pelvis back and down in the direction of posterior depression. The pelvis moves in a dorsal convex arc backward and down (O Fig. 6.11). See and feel that the tissues stretching from the crest of the ilium to the opposite rib cage are taut. Continued pressure should not cause the patient to roll backward or rotate the spine around one segment.

Command. "Shrug your pelvis up." "Pull."

Movement. The pelvis moves up and forward with a small posterior tilt to follow the arc movement.

There is an anterior shortening of the trunk on that side (lateral flexion).

Body Mechanics. Start with your elbows flexed to pull the iliac crest down as well as back. As the movement progresses your elbows extend and your weight shifts from your back to your front foot.

Resistance. The line of resistance curves following the patient's body. Start by pulling the pelvis back toward you and down toward the table. As the pelvis moves to the mid-position the line of the resistance is almost straight back. At the end of the motion the resistance is up toward the ceiling.

End Position (O Fig. 6.12 b). The pelvis is up (elevated) and forward (anterior) toward the lower shoulder with a small increase in posterior tilt. The upper side (left) of the trunk is shortened and laterally flexed with no change in lumbar lordosis.

Functional Activities. This movement is seen in parts of the swing phase in gait and in rolling forward.

Fig. 6.13a,b. Resistance to pelvic posterior depression

Fig. 6.13a,b. Resistance to pelvic posterior depression

Posterior Depression (O Fig. 6.11 c, e; O Fig. 6.13)

Grip. Place the heel of one hand on the ischial tuberosity. Overlap and reinforce the hold with your other hand. The fingers of both hands point diagonally forward.

Elongated Position (O Fig. 6.13 a). Push the ischial tuberosity up and forward to bring the iliac crest down closer to the opposite rib cage (anterior elevation). Continued pressure should not cause the patient to roll forward or rotate the spine around one segment.

Command. "Sit into my hand." "Push."

Movement. The pelvis moves in an arc down and posteriorly. There is an elongation of the trunk on that side without a change in the lumbar lordosis.

Resistance. The resistance is always upward on the ischial tuberosity while pushing diagonally forward (anterior and cranial).

End Position (O Fig. 6.13 b). The pelvis is down and back (posterior) with a small increase in the anterior tilt. The upper side (left) of the trunk is elongated with no change in the lumbar lordosis.

Functional Activities. We see this movement in terminal stance activities, in jumping, walking stairs, making high steps.

Body Mechanics. Your elbows flex as the patient's pelvis moves downward and you shift your weight from your front to your back foot.

Anterior Depression and Posterior Elevation (O Fig. 6.15 a-c)

The therapist stands behind the patient, facing toward a line representing about 25° of flexion of the patient's bottom (right) leg.

Anterior Depression (O Fig. 6.14 b, e; O Fig. 6.15 a-c)

Grip. Place the fingers of one hand on the greater trochanter of the femur. The other hand may reinforce the first hand (O Fig. 6.15 a) or you may grip below the anterior inferior iliac spine.

Alternate Grip. The fingers of the posterior hand grip the ischial tuberosity. The anterior hand grips below the anterior inferior iliac spine.

For a grip using the leg, place your right hand on the patient's anterior-inferior iliac spine and your left hand on the patient's left knee (O Fig. 6.15 b, c) You must move the patient's leg until the femur is in the line of the pattern (about 20° of hip flexion) (O Fig. 6.15 b).

Elongated Position (O Fig. 6.15 a, b). Gently move the pelvis up (cranial) and back (dorsal) toward the lower thoracic spine (posterior elevation). Be careful not to rotate or compress spinal joints.

Command. "Pull down and forward." ("Push your knee into my hand.")

Movement. The pelvis moves down and anteriorly. There is an elongation of the trunk on that side without a change in the lumbar lordosis.

Body Mechanics. Start with your elbows flexed to keep your forearms parallel to the patients back. Shift your weight to your front foot during the motion and allow your elbows to extend.

Resistance. At the beginning of the movement the resistance is toward the patient's lower thoracic spine. As the motion continues, the line of the resistance follows the curve of the body. At the end of the pattern the resistance is diagonally back toward you and up toward the ceiling.

End Position (O Fig. 6.15 c). The pelvis is down and forward. The trunk is elongated with no change in the lumbar lordosis.

Functional Activities. In daily activities we see this activity in an eccentric way (going down stairs, terminal swing, loading response). To facilitate these activities we place our hands as when facilitating posterior elevation of the pelvis and give resistance to an eccentric contraction.

Fig. 6.14a-e. Pelvic diagonal. a Neutral position; b Anterior depression; c Posterior elevation
Push Diagonals
Fig. 6.14d, e. Pelvic patterns in function: d pelvic pattern posterior elevation, e pelvic pattern anterior depression
Legs Sex Position Both Partners

O Fig. 6.15a-c. Resistance to pelvic anterior depression. The grip on the trochanter is shown in a d e b c

Posterior Elevation (O Fig. 6.14 c, d; O Fig. 6.16) Grip. Put the heel of one hand on the crest of the ilium, on and just posterior to the midline. Your other hand overlaps the first. There is no finger contact.

Elongated Position (O Fig. 6.16 a). Gently push the pelvis down and forward until you feel and see that the posterior lateral tissues on that side are taut (anterior depression). Continued pressure should not cause the patient to roll forward or rotate the spine around one segment. The pelvis is positioned in a direction of anterior depression.

Command. "Push your pelvis up and back - gently."

Movement. The pelvis moves up (cranial) and back (dorsal) into posterior elevation. There is a posterior shortening of the trunk on that side (lateral flexion).

Body Mechanics. As the pelvis moves up and back shift your weight to your back foot. At the same time flex and drop your elbows so that they point down toward the table.

Resistance. The resistance begins by lifting the posterior iliac crest around toward the front of the table. At the end of the motion the resistance has made an arc around the body and is now lifting the ilia crest up toward the ceiling.

End Position (O Fig. 6.16 b). The pelvis is up and back. The upper side (left) of the trunk is shortened and laterally flexed with no increase in lumbar lordosis.

Functional Activities. Walking backward, preparing to kick a ball.

O Figure 6.17 a, b shows a pelvic diagonal used when treating a patient with hemiplegia.

Points to Remember

Pure pelvic patterns do not change the amount of pelvic tilt. The pelvic motion comes from activity of the trunk muscles. Do not allow the leg to push the pelvis up.

The muscles involved in pelvic depression are the contralateral pelvic elevating muscles.

Fig. 6.16a,b. Resistance to pelvic posterior elevation
Contralateral Trunk Tilt And Pitching

6.5.2 Specific Uses for Pelvic Patterns

The pelvis and lower extremities facilitate and reinforce each other. Pelvic depression patterns work with and facilitate weight-bearing motions of the legs. Pelvic elevation patterns work with and facilitate stepping or leg lifting motions.

— Exercise the pelvis for motion and stability. (O Fig. 6.17 a, b)

— Facilitate trunk motion and stability by using timing for emphasis and resistance for facilitation.

- Resist the pelvic patterns to exercise lower trunk flexor, extensor, and lateral flexor muscles The pelvis should not move further into an anterior or posterior tilt during these exercise.

1) Use Repeated Stretch from beginning of range or through range to strengthen these trunk muscles.

2) Use Reversal of Antagonist techniques to train coordination and prevent or reduce fatigue of the working muscles.

- Use Stabilizing Reversals or Rhythmic Stabilization to facilitate lower trunk and pelvic stability.

— Exercise functional trunk activities.

- Use a stabilizing contraction to lock in the pelvis, then give a functional command such as "roll" and resist the activity using the stabilized pelvis as the handle (7 Sect. 11.3.1).

- Use Repeated Contractions to strengthen and reinforce learning of the functional activity.

- Use the technique Combination of Isotonics to teach control of the trunk motions. Have the patient control trunk motion with concentric and eccentric contractions while maintaining the pelvic stabilization.

- Use reversal techniques to prevent or relieve muscular fatigue.

— The pelvis and lower extremities facilitate and reinforce each other.

- Pelvic depression patterns work with and facilitate weight-bearing motions of the legs. Lock in pelvic posterior depression then exercise extension motions of the ipsi-lateral lower extremity.

- Pelvic elevation patterns work with and facilitate stepping or leg lifting motions. Lock in pelvic anterior elevation then exercise flexion motions of the ipsilateral lower extremity.

— Treat the upper trunk and cervical areas indirectly through irradiation. Give sustained maximal resistance to stabilizing or isometric pelvic patterns until you see and feel contraction of the desired upper trunk and cervical muscles.

6.6 • Symmetrical, Reciprocal and Asymmetrical Exercises

Points to Remember

Pelvic motions work with and facilitate the leg motions, pelvic patterns do not correspond exactly with lower extremity patterns.

When using pelvic patterns for rolling, the pelvis is the handle and the rolling is exercised.

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