LIVE ONLINE TEACHING

Subject: EXERCISE THERAPY

Topic : FUNCTIONAL RE-EDUCATION
Year : II YEAR BPT

Faculty Name : BIJISH KUMAR B

Designation : VICE PRINCIPAL (PESCOP)
Department : PHYSIOTHERAPY

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LEARNING OBJECTIVES

At the end of the lesson, students will be able to:

1. Demonstrate and prescribe functional re-

education for patients with disabilities.
2. List out the various activities on floor level and
mat activities in lying.
3. Demonstrate Activities in sitting.
4. Demonstrate various activities from sitting to
standing.
5. Teach patients to negotiate ambulation in stairs.
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Functional re-education

• Re-education means educating something which

is already known by individual.
• In functional re-education training, the sequence
of progressions of position is like the
developmental milestones of a child from lying to
sitting.
• The sequence is planned according to the goals
of rehabilitation.
• Restoration of function is important in
achieving the patient's rehabilitation.

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Objectives
Improves
• Co-ordination and balance
• Strength and endurance
• Pelvic instability
• Dynamic and static stability
• Proprioceptive function
• Postural stability
• Ambulatory skills

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Re-education can be done

1) on re-education board
2) on mat
3) using parallel bar
4) using suspension therapy
5) using hydrotherapy

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FUNCTIONAL RE-EDUCATION ON MAT
A normal individual independently perform
activities such as rolling, getting up from
lying position, sitting, standing etc. But a
person who is physically impaired finds it
difficult to do so.
Therapist teaches methods and techniques
to carry out such activities independently
usually on mat as it provides large BOS
and low COG, hence known as mat
activities.

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Functional re-education
Sequential
• Supine to Rolling
o Supine to side lying
o Supine to prone lying
o Supine-Bridging
• Supine to sitting
o Supine to side lying
o Supine to bedside sitting
• Prone to rolling
o Prone to side lying
o Prone to supine
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Functional re-education

• Prone to kneeling
o Prone to creeping
o Prone to crawling (Quadriped position)
o Prone to kneeling
• Side lying-forearm supported side lying
• Kneeling
o Kneeling from standing
o Kneeling from sitting
o Kneeling from side sitting
o Kneeling from prone lying

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Functional re-education

• Transfers
o Bed to chair: chair to bed
o Bed to floor
o Chair to floor
o Chair to toilet seat
• Standing
• Standing from sitting
• Standing from floor

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 Bed Mobility

Changing patient’s position in the bed is very

important factor in patient care.
› It prevents pressure sores.
› It is effective for hygiene : making it easy to
clean body parts, change clothes, etc.

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Moving Towards the Head of the Bed
The maneuver is usually carried out from crook lying.
The patient raises the pelvis off the supporting surface to
the low Bridge position by extension of the hips and
spine combined with down-pressure from the arms and
shoulder girdle.
Moving Down the Bed

The patient assumes the crook lying position with the

elbows flexed to about 90˚ . He then presses down firmly
with elbows and head and raises the pelvis slightly clear
of the supporting surface. He eases the pelvis downwards
towards the heels in a relatively small range.
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Moving Across the Bed

The patient takes up the crook lying position with

the arms slightly away from the sides and the
palms of the hands resting on the bed. He raises
the pelvis off the supporting surface and eases it
sideways in the required direction.

When moving to the side of the straight leg it is

advisable to place this limb into an abducted
position, so as to avoid adduction stresses at the
hip during the sideways movement. This is
particularly important in the postoperative care of
a total hip replacement.
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Mat activities
• Rolling • Side sitting
• Supine to side lying • Sitting
• Side lying to prone lying • Kneeling
• Prone to side lying • Kneel sitting
• Side lying to supine • Half kneeling
• Supine-Bridging • Standing
• Elbow prone lying • Walking
• Hand prone lying
• Quadriped position
• Elbow side lying
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 ROLLING
Techniques to facilitate rolling are:

 Flexion of the head and neck with rotation : It is

used to assist movement from supine to prone
position.
 Extension of head and neck with rotation: It is
used to assist the movement from prone to
supine position.
 Both the hands are clasped, elbow fully extended
and shoulder flexed to 100-110˚.
 Cross the leg over the other, with the upper leg
towards the side of rolling.

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 Rolling progression :

1. Rolling from supine to side lying.

Purpose and use of the roll

 Patient has the freedom to make
the decision as to when he shall roll over to get a different
view of his surroundings, ease the pressure on his back or
stiffness of his legs. Patient can also reach and use a
more comfortable sleeping posture.
 This roll is the first part of an integrated series of
movements which leads directly to a sitting position and to
getting out of bed.

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2. Rolling from supine lying through side lying to prone

Purpose and use of the roll

The most important aspect of this activity and of the

prone position is that it helps to combat and counteract
the effects of long-term recumbency in bed, sitting up in
bed or reclining in a lounge chair.

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 BRIDGING

The patient is in hook lying position and elevates his pelvis off the
mat surface.
Progression of the activities takes place in the following sequences:
1. Assume and maintain the position with or without assistance.
2. Maintain the position independently
3. Elevation of the pelvis off the mat then again depressing it on the
mat, it is perform several times.
4. Resistance can be applied
on the ASIS.
5. Decrease the angle of hip
and knee flexion.

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Purpose and use of bridging

Improves pelvic mobility

Strengthens low back and hip extensors

For the bed-bound patients, bridging makes

bedpan routines easier.

By lifting the lower back from the bed, sensitive

pressure areas are relieved of the body weight.
Thus preventing pressure sores.

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 Forearm support side lying

This position is usually reached by rolling to one side and

then pushing with the elbow to support the upper trunk with
the whole forearm. Both the shoulders should lie on the
same plane; stability of the pelvis is ensured by bending
one leg.

Purpose and uses

The position is used en route from

lying to sitting.
Some find it convenient for reaching across to a bedside
table with out sitting up.
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 Prone lying with forearm support

This position may be reached from side lying with forearm

support, the free elbow being moved to a position shoulder
width so that both shoulders are supported. The upper arms
must be vertical to ensure balance in the position with
minimum effort.

Purpose and uses

Extensibility of the hip joints and
lumbar spine is maintained. Creeping movements which
propel the body along the floor using the arms can be
initiated from this position.

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Prone on hand position ( Cobra position)

This position is a transition from prone lying with forearm

support. Palms should be pressed down on the mat and
upper body along with the head should be raised up
towards the ceiling. Assure that the pelvis is rested on the
mat. In yoga the position is called as “Bhujangasana”.

Purpose and uses

It strengthens the upper limb muscles.
It stretches the anterior trunk muscles.
It strengthens back extensor muscles.

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 Prone kneeling ( Quadruped position)
Prone kneeling or the ‘four foot position’ may be reached
from prone on hand position by bending the head forward to
put the chin on the chest, then by walking the hands
backwards as the hips and knees bend.
Progression of the activities takes place in the
following manner:
1. Weight shifts in forward, backward and
side to side direction can be incorporated.
2. Raising of one of the upper limb and
bearing weight on rest of the 3 limbs.
3. Raising of one of upper limb and contra lateral lower limb.
Increase the time gradually for 2 and 3.
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Purpose and uses

When balance and stability have been achieved in

quadruped, crawling may be started. This activity
facilitates the co-ordination of the whole body including
reciprocal movement of the arms and legs as require in
walking.
This is the starting position for ‘crawling’ which gives the
patient mobility at door level in any direction he wishes. It
may prove very useful for patients with vertigo and others
who cannot bear weight on the feet for time being.
Functional activities such as cleaning floor, gardening
(planting seeds and weeding) can be used to teach static
and dynamic stability of quadruped position.

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 Crawling

When balance and stability have been established in prone

kneeling patients can begin to practice lifting a hand or a
knee from the floor to balance ‘on three legs’.
Purposes and uses of crawling
Crawling activities build up co-ordination of the whole body
including reciprocal movement of the arms and legs as
required in walking. The direction of the crawl, i.e. forwards,
backwards; sideways determines the distribution and
emphasis of the neuromuscular
activity employed.

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 Sitting
Sitting is the position which requires and facilitates trunk
control and balance. It also allows some amount of the
weight to be born by upper extremity. There are 2 forms of
sitting need to be practiced.

1. Long sitting

2. Short sitting

Long sitting – patient sits with knees fully extended; hips

flexed hands may or may not support the upper part of the
body weight (hands may be position laterally, posteriorly or
anteriorly with relation to pelvis).
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Short Sitting - Patient sits on high surface (bed, chair etc)
with knees at the edge making hip and knees 90 degree
flexed and feet flat on the floor surface. BOS is smaller
than long sitting.

Progression of the both positions may take place in

following sequence – (patient usually progress from long
sitting to short sitting).
1. Initially patient assumes and maintains position with
support.
2. Patient raise one hand placing the weigh on other one.
He repeats the movement with other hand.
3. Patient sits independently without any external or hand
support.
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4. Patient performs activities such as ball throwing (light to
heavy weight), clapping overhead etc.
5. Push ups in both type of sittings should be performed
with or without push up blocks. Increase the number of
repetitions gradually.
Hitching and Hiking
The ability to take the weight on the arms, lift and move
the pelvis is essential for transfers for wheelchair patients,
e.g. from bed to chair. Blocks, sandbags or short crutches
help to make these easier for the patient to practice.
Hitching- Hiking-

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 Side Sitting

Unlike the push up to sitting on the side of the bed, the

push up to side sitting on the floor includes little or no
rotation as the trunk is pivoted to sit upright. The legs are
bent and remain resting on the floor.

Purpose and uses:

This is an elegant way to sit either on the floor or out of
doors for those who find it possible and comfortable. It can
be practiced safely and it is easy to return to a resting
position.

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• Floor level house hold activities
• Great stability
• Usually preliminary to standing
• Prevent from falling
• For dressing and toilet activities

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 Kneeling

Patient can assume kneeling position from quadruped by

moving the hand back until the body weight is equally
distributed on knees and feet.
The kneeling surface should be sufficiently comfortable for
the patient to tolerate pressure on the knees.
There should be sufficient range of knee
flexion, a minimum of about 100°.
Any other disability which affects the
patient has been taken into account,
e.g. restriction of ankle joint movement,
painful toes.

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 Half Kneeling
To reach this position from kneeling the body weight is
supported on one knee while the other leg is lifted and
brought forwards to put the foot on the floor. From standing
the half kneeling position can be assured either by stepping
forwards to kneel or by stepping backwards to kneel on one
knee. Good balance or some support is essential for
stability.
This position improve pelvic control, hip extension, ankle
and knee movement.
Progression takes places in the following manner :
1. Weight shift from one limb to other and even anterior and
posterior.
2. Upper limb activities such as ball throwing light to heavy
weight) peg lifting and clapping etc.
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PES Institute of Medical Sciences & Research
MOVEMENTS AT FLOOR LEVEL FOR
STABILITY:
Seat Lifting (to relieve the buttocks of body pressure.
'Travelling': a simple method of moving the body over a
supporting surface travelling forwards.
‘Travelling' backwards.
'Travelling' sideways.
Moving from sitting on floor to sitting on low stool

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Assuming standing from prone kneeling with use of chair

Movements in prone lying on bed or mat

o Arching

Assuming prone kneeling

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MOVING FROM SITTING TO FLOOR LEVEL

The patient sits on a low stool, 20-25 cm high, with the legs
stretched out in front of him and with the heels resting on the
floor; the hands grasp the sides of the stool (low grasp
inclined long sitting). Taking the weight on his hands he eases
the pelvis slightly forwards and lowers it on to the floor with
the trunk held erect. During this maneuver the knees and hips
are well flexed, and the main muscle work is confined to the
extensors of the elbows .

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MOVING FROM STANDING TO FLOOR
LEVEL
Hands supported on chair seat. The patient faces the front
of a chair seat with his feet about a foot-length away from
the front edge. He places the palms of the hands flat on the
seat so that the trunk assumes a horizontal position. He
then carries one leg backwards and places the foot on the
floor with the ankle dorsiflexed. The body is lowered
downwards until the patient is in a modified half kneeling
position. The forward leg is then carried back until it lies
alongside the other; this brings the
patient into the kneeling
position with the palms of
the hands resting on the
chair seat.

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 Hands grasping chair back

The patient grasps the back of a chair (which must have

a stable base) with the body positioned as shown in Fig .
The arms are shoulder-width apart and the weight of the
rear leg rests on the toes.
Taking most of the body weight on the hands the patient
lowers the body to a modified half-kneeling position .He
then moves the forward leg backwards until he is in the
kneeling position with the hands still holding the chair
back. The pelvis
is then lowered
backwards until
the buttocks rest
on the heels.

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Sitting in Chair with Arms

From the sitting position the patient places the hands well
forward on the chair arms and draws the heels slightly back
to bring them underneath the front edge of the chair. The
hands then grip the chair arms and the trunk is inclined
slightly forwards. The elbows are now extended and at the
same time extension of the hips and knees takes place, the
inclined position of the trunk being maintained. During this
movement the hands take the weight of the trunk. When the
body weight is fully over the feet (by continuous extension
of hips and knees) the hands are removed from the chair
and the arms are allowed to hang loosely at the sides. The
patient is then in standing.

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Sitting in Chair without Arms
Moving from sitting to standing is achieved in much the
same manner as previously described, but the patient starts
by having the palms of the hands resting over the lower
thighs. In rising he exerts downward pressure on the thighs.
Sitting over Side of Bed
To achieve standing from this position the height of the bed
must allow the patient to sit comfortably with the thighs fully
supported, the feet resting flat on the floor, and the knees
flexed to a right angle. The actual rising technique is the
same as described in the previous section (Sitting in chair
with arms), but the patient's hands either rest on the
mattress or are placed over the lower third of the thighs.

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NEGOTIATING STAIR - PREPARATORY
METHOD:
Ascending Stairs
The patient stands on the floor facing the stairs with one
hand holding the rail; the toes are close to first step. To
ascend the stairs the sound leg is raised and the sole of
the foot placed well forwards on the first tread by flexion of
hip and knee. (During this movement weight is taken on
the affected leg, and the hand on the banister provides
additional support.) The body is then inclined slightly
forwards, the weight being taken principally by the flexed
sound limb, while the hand on the banister continues to
provide support. The sound limb is then straightened fully
and the trunk raised to the erect position. At the same time
the weak leg is lifted and the foot placed on the first step.

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 Ideally, to achieve maximum support-although this is often
not a practicable proposition-the banister should be on the
side of the affected leg.

Descending Stairs
The patient stands at the head of the stairs with the toes
close to the edge; he holds the banister rail with one hand.
To descend the stairs the weight of the body is taken on the
sound leg, and the weak leg is carried forwards so that the
back of the heel is close to the top of the first riser. The
hand on the banister provides support during this
movement.
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The body is then lowered downwards, by
controlled flexion of the hip and knee of the
sound leg, and the foot of the weak leg is
placed on the first stair tread. The weak leg
is now straight and fully extended at the knee. (During this
stage it is advisable for the patient to incline the body
backwards a few degrees to counteract any tendency to tip
forwards.) Full body weight is then transferred to the weak
leg, with the hand on the banister offering support, and the
trunk is held erect. Next, the flexed sound leg is carried
forwards, extended, and the foot placed alongside the other
foot on the stair tread. The same leg-placing technique is
used to negotiate the rest of the stairs.
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References:

• Kisner, C. & Colby, L.A. (2000). Therapeutic

Exercise: Foundations and Techniques. Info
Access and Distributions Pvt. Ltd.
• Gardiner, M.D. (2001). The Principles of
Exercise Therapy. [Link] Sons Ltd.

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THANK YOU

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