Functional Training Strategies

    To perform accessory skills and transfers, the patient must have or acquire the necessary physical and skill prerequisites, such as strength in muscles and range of motion in the joints used during the skill and transfer. After the patient has learned to tolerate an upright Sitting position, the following techniques will help the patient develop the prerequisites to accomplish a functional goal, such as transfers.

1. Unsupported Sitting Balance - To maintain an unsupported sitting balance, the patient first learns to sit and then:
   • Finds his/her position of balance, with the therapist supporting the patient at the shoulders until the therapist no longer feels the patient's trunk pushing forward, backward, or to the side
   • Maintains the position of balance, by moving the hands in the air and the head in the direction opposite to the direction the trunk starts to fall, with the therapist continuing to support the patient at the shoulders
   • Improves unsupported sitting balance by the therapist reducing and then eliminating shoulder support, and then disturbing the balance, by having the patient catch or throw things, for example
   • Practices alone while long-sitting on a mat or short-sitting between mats
2. Elbow Extension with Muscle Substitution - While still confined to bed, the patient stabilizes one of the hands with the help of the therapist and pushes. Many patients automatically make the muscle substitution needed to do this. For those who do not, the therapist can tell or show the patient the anterior deltoid muscle. The patient can practice elbow extension in many different positions.
3. Upright Trunk from a Forward Leaning Position - The patient lowers the trunk while in a sitting position, allows the elbows to flex a few degrees, and then pushes the trunk upright again, while maintaining full control of the motion. This can be done in a wheelchair, or, practiced while short-sitting between two mats.
4. Elbow Lock - The patient:
   • Externally rotates the shoulder, extends the elbows and wrists, supinates the forearms, and, when in this position with the help of the therapist, bears weight on the palms, holding the elbows in extension with the anterior deltoids and shoulder external rotators
   • Holds the "locked" position, while the therapist applies resistance, and pushes the elbow toward flexion
   • Practices elbow locking while in a wheelchair by stabilizing the palms on the seat or nearby mat.
5. Arm Placement behind Wheelchair Push Handle - After learning to sit, the patient crosses an arm over the torso and then throws it back and up, with enough force to provide the momentum needed to carry the arm to a position behind the push handle. The therapist can assist with the throw at first and/or have the patient practice with a small wrist weight, which will add to the arm's momentum. The patient practices in a wheelchair and improves by performing the motion in a tilted position.
6. Trunk Stabilization in Wheelchair - With one arm hooked behind the push handle (achieved independently or dependently), the patient holds the body stable and improves stability by:
   • Moving the free arm to various positions
   • Adding weight to or forcefully throwing the free arm
   • Leaning the trunk in various directions and increasing angles of lean. To lean, the patient must also learn to relax the arm on the wheelchair and fully control the motion.
7. Trunk Movement in Wheelchair - After learning to pull upright from a leaning position, the patient:
   • Pulls on the armrests or push handles to lean forward or return to upright. Momentum from head motions can increase the ability to pull, in a patient with insufficient strength
   • Throws the head and an arm forcefully in the direction he/she wants to move, with the other arm behind the push handle for stability. To achieve the necessary momentum, the movements must be abrupt, powerful, and exaggerated, and/or a wrist weight can be used.
8. Armrest Manipulation - After learning to stabilize the trunk, the patient with intact upper extremities can be shown how the armrests work. The patient without active finger flexors can reposition the armrest by pushing or pulling it with the forearm or with the back of the hand and the wrist extended.
9. Buttocks Movement in Wheelchair - After learning to move and stabilize the torso, the patient can learn to Move the Buttocks in a Wheelchair. The therapist can help by pulling the patient's buttocks, at first, and then diminishing the pull as the patient's efforts improve.
10. Forward Prop on Extended Arms - After learning to sit, extend the elbows, and hold them in extension against resistance (with the triceps or muscle substitution), the patient:
    • Places the palms lateral to the thighs and anterior to the hips and leans forward to support the trunk on the arms (with or without assistance from the therapist)
    • Holds the elbows straight with support from the therapist, which should decrease as the patient's ability improves
    • Improves this activity by:
      • Learning to support the truck independently
      • Bending and extending the elbows and lowering and raising the trunk
      • Performing these activities as the therapist applies resistance to the shoulders in various directions, during long-sitting on a mat or short-sitting between two mats.
11. While propped forward on extended arms, the patient learns to:
    • Prop Forward on One Extended Arm - by shifting the trunk laterally. The therapist places a hand on the lateral surface of the patient's shoulder, and the patient pushes against the hand. As the arcs of motion increase, the patient learns to lean far enough to support the trunk on one arm. The patient improves this activity by changing arms, balancing with the supporting arm in different positions, and reaching the free arm in difference directions.
    • Unweight Buttocks - by leaning forward and tucking in the chin. The therapist can assist by placing the hands on the anterior surface of the patient's shoulder and having the patient push against them.
    • Move Buttocks Laterally - by twisting the head and upper trunk away from where the buttocks are to move. At first, the therapist either needs to verbally encourage the patient to increase the force and excursion of the twist to the point where the buttocks move and/or assist by applying force to the patient's shoulders and lateral force to the buttocks. Since transfers frequently require more than one twist, the patient then moves the head and torso, without force, back to the original position between twists. Quadruped is an excellent position for working on this skill, once the patient has achieved stability in this position. Patients with functioning triceps can practice the head-hips relationship to assume the quadruped position. Patients who cannot assume this position may be able to practice this activity while positioned on elbows and knees.
12. Buttocks Lift - While propped forward on extended arms against resistance, the patient:
    • Lifts the buttocks by leaning well forward over the extended arms, tucking in the head, protracting the scapulae as much as possible, and finding the balance point of this position to accept the full weight of the body on the arms
    • Lifts the buttocks and maintains the lift.
    At first, the therapist should assist with the scapulae protraction in the initial position and the actual lift. Further strengthening and/or practice locking the elbow may be needed in patients with nonfunctional triceps. This skill requires considerable practice.
    
13. Buttocks Lift and Lateral Move - While lifting the buttocks and pivoting forward on extended arms, the patient throws the head and torso to the side, quickly and forcefully, moving the buttocks laterally. This can be learned by lifting and twisting as two separate steps at first. To achieve the two steps as one activity, the patient must be sure to keep the head low during the lift and keep the elbows locked in extension.
14. Buttocks Lift from Floor- After learning to lift the buttocks, move laterally while pivoting on extended arms, and lift the body by pushing down with both arms, starting with the hands close to the shoulders, the patient learns to lift the buttocks from the floor using one or more techniques.
    • Side Approach - The patient:
      • Sits in front of the higher transfer surface and faces it at a 30- to 45-degree angle, flexes the knees and points them upward, and places one hand on the higher surface and the other hand on the floor, slightly lateral and anterior to the hip
      • Pushes on both arms and throws the head way down and away from the higher surface, in a forceful and exaggerated way, to lift the buttocks
      • Practices this activity by starting with a transfer to a low surface, transferring up and down between the floor and the surface, and then gradually increasing the height of the transfer surface, such as a progressively higher stack of folded mats.
      • Protracts the scapulae more forcefully as the height of the transfer surface increases
      • Is ready to transfer to a wheelchair when able to achieve the wheelchair's height
    • Front or Back Approach - From a starting position of either kneeling in front of and facing the wheelchair with the hands on the armrests, or, sitting on the floor facing outward with the hands on the front of the wheelchair seat, the patient:
      • Lifts the body by leaning toward the chair and pushing straight downward until buttocks have been lifted as high as possible
      • Tucks the head and protracts the scapulae to lift the buttocks higher
15. Body Turn and Drop to Wheelchair Seat - After the patient can lift the body to above the wheelchair seat from a kneeling position, the patient lets go of an armrest and throws the arm and head away from the armrest, causing the body to turn and drop into the seat. The lower the lead, the more protracted the scapulae, and the more forceful the twist, the better the outcome.