A necessary part of a patient's gait training can be learning to manage a wheelchair. These activities are a part of both gait and daily living training. Use all the basic procedures to help the patient gain skill in these activities. Repetition combined with resistance enables the patient to master the activities in the shortest possible time.
Managing the Wheelchair
The general activities are:
— Wheeling the chair
- Forward (O Fig. 12.7 a, b) and backward (O Fig. 12.7 c, d) with resistance to the arms
- Forward with resistance to the leg (O Fig. 12.7 e, f)
— Locking and unlocking the brakes (O Fig. 12.8)
— Removing and replacing the arm rests (O Fig. 12.9 a, b)
It is necessary for the patient to be able to sit upright and move in a chair. Stretch and resistance at the pelvis can guide the patient into the proper erect posture with ischial weight bearing. Approximation and resistance at the scapula and head teaches and strengthens trunk stability. Use stretch reflex and resistance to the appropriate pelvic motions to teach the patient to move forward and backward in the chair. While working on these activities, evaluate the patient's strength and mobility. Treat any problems that limit function and reevaluate in a sitting position after treatment.
Fig. 12.10a,b. Managing the pedals
Fig. 12.10a,b. Managing the pedals
Example: You cannot get the patient's pelvis positioned for proper ischial weight bearing. Your evaluation shows that there is a limitation in the range of pelvic motion.
— Put the patient on mats and assess pelvic mobility using pelvic patterns.
— Treat the limitations in range and strength with exercises of pelvic and scapular patterns or a combination of the exercises with joint and soft tissue mobilization.
— After treatment, put the patient back into the wheelchair and reevaluate the pelvic position in sitting.
Getting into the Upright Sitting Position
— Use Combination of Isotonics with resistance at the head and shoulders to get the upper trunk into an erect position (O Fig. 12.11 ).
— Use Rhythmic Initiation and stretch at the pelvis to achieve an anterior tilt.
Stabilizing in the Upright Position
Use Stabilizing Reversals (O Fig. 12.12 a, b)
— At the shoulders
— A combination of all of these b a
Moving in the Chair
Use Repeated Stretch, Rhythmic Initiation, and Isotonic Reversals (Slow Reversals)
— Pelvic anterior elevation for moving forward (O Fig. 12.13)
— Pelvic posterior elevation for moving backward (O Fig. 12.14, chair arm removed to show pelvic movement)
Fig. 12.13a,b. Moving forward in the chair b a
Fig. 12.13a,b. Moving forward in the chair
12.6.2 Standing Up and Sitting Down
The following sections are an artificial grouping of activities. A treatment usually proceeds smoothly through all activities in a functional progression. The patient moves forward in the chair, stands up, gets his or her balance, and walks. You break down the activities as needed and work on those which are not yet functional or smooth.
Standing up is both a functional activity and a first stage in walking. The timed "stand up and go" test is a perfect test to evaluate the patient's progression (Podsiadlo, 1991). The person should be able to stand up and sit down on surfaces of different heights. Although everyone varies in the way he or she gets from sitting to standing, the general motions can be summarized as follows (Nuzik et al. 1986):
— The first part of the activity (O Fig. 12.15 a-c):
- The head, neck, and trunk move into flexion.
- The pelvis moves into a relative anterior tilt.
- The knees begin to extend and move forward over the base of support.
- The head, neck, and trunk extend back toward a vertical position.
- The pelvis goes from an anterior to a posterior tilt.
- The knees continue extending and move backward as the trunk comes over the base of support.
Until studies bring other information, we assume that sitting down involves the reverse of these motions. Control comes from eccentric contraction of the muscles used for standing up.
To increase the patient's ability to stand up, place your hands on the patient's iliac crests (O Fig. 12.16 a), rock or stretch the pelvis into a posterior tilt, and resist or assist as it moves into an anterior tilt. Rhythmic Initiation works well with this activity. Three repetitions of the motion are usually enough. On the third repetition give the command to stand up. Guide the pelvis up and into an anterior tilt as the patient moves toward standing. Assist the motion if that is needed, but resist when the patient can accomplish the act without help. As soon as the patient is upright guide the pelvis into the proper amount of posterior tilt. Approximate through the pelvis to promote weight bearing.
Getting to Standing
— Moving forward in chair: The same as practice in sitting.
— Placing hands: Use Rhythmic Initiation to teach patients where to put their hands. Use stabilizing contractions and Combination of Isotonics to teach them how to assist with their arms.
- Using the parallel bars
- Using the chair arms
— Rocking the pelvis: use Rhythmic Initiation and stretch to get the pelvis tilted forward (O Fig. 12.16 a).
— Coming to standing: guide and resist at the pelvis (O Fig. 12.16, 12.17). Guide and resist at the shoulders if the patient cannot keep the upper trunk in proper alignment.
— Placing hands to assist: Use the same techniques as in standing up to teach patients where to put their hands.
— Sitting down: Use resistance at the pelvis or pelvis and shoulders for eccentric control. When the patient is able, use Combination of Isotonics by having the patient stop part way down and then stand again.
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