Provisionally Licensed Bobath Therapist Discusses Active Lying, Turning, and Rising Movements for Posture Adjustment and Improved Efficiency in Standing and Upper Limb Operations with Anti-Gravity Activities in Sitting Position

To achieve what is mentioned in this title, there are four steps in the process:

First, while lying on your back, keep the leg joints in a neutral position and place the legs straight in relation to the trunk. If there’s low muscle tone in the trunk, it’s hard to place the legs straight, and they often rotate outward. We remove the soft tissue (non-neurogenic?) restrictions to create a situation where the trunk muscles must work, increasing postural muscle tension and activating the muscles around the hip joints from the lower trunk.

Second, create a stable crook lying position with firm weight on the soles of the feet. To achieve this limb position, stability in the trunk is needed to hold the legs in space, and the output of the hip extension muscles is also necessary.

Third, emphasize active rising from the crook lying position. To positively influence standing and upright movements, avoid pressing the shoulder girdle-chest against the bed surface while emphasizing the extension of the non-turning side hip joint, segmental rotation of the spine, and trunk flexion during the rise.

Lastly, achieve pelvic anterior tilt with forward-leaning of the lower legs in a sitting position at the edge. Once sitting is achieved, the goal is to stand up and gain activities in standing and walking. However, if the pelvis remains in a posterior tilt, the efficiency of the rising movement is poor because the lower legs won’t lean forward. We aim to acquire a sitting position that facilitates an easy transition to standing and upper limb operations.

These steps are designed to improve posture and the efficiency of movements from sitting to standing and in operating the upper limbs.

The first step is to maintain the leg joints in a neutral position while lying on your back, ensuring the legs are aligned straight with the trunk. This begins with an intervention at the hip joints and thighs. The neutral position is defined as the state where muscle tension in the thighs is equalized. As a result, the starting limb position often involves directions where there is increased tension or shortening. When I performed self-maintenance on my legs, the neutral position for both hips was a slight flexion, abduction, and external rotation. However, it is common for the tensor fasciae latae and iliotibial band on the outside of the thigh to be tight. Guiding the hip joints to a neutral position also involves correcting the muscle alignment. In the supine position, the quadriceps face upwards, and the hamstrings face downwards towards the bed surface, ensuring that the back of the thigh becomes a functional supporting base. In my case, there was a sense that the adductor muscles and medial hamstrings were slack towards their origin, so I pulled the tensor fasciae latae and iliotibial band forward, elongating the medial hamstrings and adductors towards their insertion. Furthermore, I guided the skin and soft tissues of the entire thigh in an inward rotation. When realignment is done to the point where the back of the thigh becomes the supporting base in the supine position, I noticed that both lower legs were deviated outward at the knee joint and were in an internal rotation of about 20° to 25°. The feet also showed a strong inversion, particularly adduction. The center of gravity on the back of the thigh was slightly outward, giving the impression that the entire lower limb was inclined to rotate outward.

The next step is the intervention to the knee joint and lower leg, which is typically done after addressing the hip joint and thigh. The neutral position for the lower leg is also identified from the start. When I did self-maintenance on my legs, both lower legs were deviated outward at the knee joint relative to the thigh and were in an internal rotation of about 20° to 25°. There was also an impression that the inside of the lower leg was shortened, causing the tibia to bend. Here, the intervention aims to make the proximal part of the gastrocnemius muscle, which faces directly down in the supine position, become a functional supporting base. First, I grasped the gastrocnemius muscle, separating the medial and lateral heads, stretching the medial head and slightly gathering the muscle belly of the lateral head, and then guiding the entire muscle belly in an outward rotation. Additionally, I realigned the skin and soft tissues of the entire lower leg in an outward rotation, stretching the inside of the lower leg. From the alignment, I suspected shortening of the popliteal muscle, and although direct palpation is difficult, I particularly focused on elongating the tissue length at that site. After the intervention, the shortening of the inside of the lower leg remained, but the force that seemed to cause the entire lower limb to fall outward after the thigh realignment disappeared, possibly because the gastrocnemius muscle was functioning as a supporting base. Furthermore, I felt an increased sense of stretch from both sides of the lower chest to around the pelvis and a relatively lower activity on the right side of the lower trunk compared to the left. I also reconfirmed the inversion of both feet, especially the strong adduction.

The next step involves intervention at the ankle and foot. I noticed a strong inversion in my feet, which seems to be not uncommon. The goal is to have the heel function as a supportive base, allowing the foot and toes to achieve at least 0° of dorsiflexion through assisted movement. Initially, exercises are performed to increase the flexibility of the foot from the neutral position. In my case, the neutral position of my foot was characterized by a strong adduction in an inverted ankle position. The exercise begins by emphasizing the inversion of the ankle further, then returning to the neutral position, repeating this to enhance the flexibility towards eversion of the ankle, particularly the flexibility of the insertion of the anterior tibial muscle. To increase the perception of the anterior tibial muscle, fingers are inserted at the boundary of the anterior lateral surface of the tibia while repeating inversion and eversion movements. Sensation is inputted to the long toe flexor at the boundary with the posterior surface of the tibia and to the long big toe flexor at the boundary with the posterior surface of the fibula, similar to the approach to the anterior tibial muscle and the anterior lateral surface of the tibia. Although some adduction of the foot remained, the heel became a supporting base, and the minimum necessary dorsiflexion angle, that is, more than 0° of dorsiflexion, was secured. From there, sensory input is also provided to the outer side of the foot sole and the transverse arch, intervening to improve perception and support on the foot sole. The skin on the outer side of the foot sole is spread outward, preparing a state where the outer side of the foot sole can make broad contact with the floor. Additionally, movement between the metatarsal bones is facilitated to ensure proper support and perception from the floor through the foot sole.

This concludes the content of the first step, maintaining a neutral position of the leg joints while lying on your back and aligning the legs straight with the trunk.

The second step is to establish a crook lying position with firm plantar weight-bearing, which is essential for facilitating active movements in turning, rising, and sitting. This intervention is performed after you can maintain the leg joints in a neutral position while lying on your back, with the legs straight in relation to the trunk. With assistance, you guide the hip joints into flexion within a neutral range of adduction, abduction, internal and external rotation, while maintaining the ankle in a slight dorsiflexion and eversion, and the toes in slight dorsiflexion. The aim is to reach at least 90° of hip flexion through assisted movement. If achieving 110° of hip flexion is possible, that is sufficient. If there is high muscle tension in the adduction, abduction, internal or external rotation of the hip joint, you move towards the side with higher tension and then return to release it, repeating this to adjust the muscle tension. While maintaining the hip joint in a 90-110° flexed position through assisted movement, you repeat the maximum possible range of knee flexion-extension within that limb position. Once the knee flexion angle reaches approximately 130°-140°, you lower the heel to the bed surface to weight it and induce hip extension. It is ideal if you can extend the hip joint without pressing the shoulder girdle or thorax against the bed surface. Ultimately, since the goal is to lead to standing and walking, you want to avoid reinforcing motor learning with the shoulder girdle and thorax as the supporting base and the lower limbs as the operating parts. If these interventions do not allow for the maintenance of the leg position in crook lying, the therapist will hold the entire lower limb and directly assist the muscle while promoting concentric contraction of the proximal part of the hamstrings and eccentric activity of the internal and external oblique muscles.
This concludes the content of creating a well-weighted crook lying position as the second step.

The third step is the active rising from the crook lying position. This involves shortening the lever arm of the lower limbs to reduce the difficulty of trunk function during lower limb manipulation and to positively influence the standing and upright movements. This is achieved by emphasizing the extension of the non-turning side hip joint, segmental rotation of the spine, and trunk flexion during the rise. First, you tilt the turning side’s lower limb outward. The side to turn towards is chosen by comparing the strength of both halves of the body and opting for the relatively stronger side. For bone and joint diseases, turn towards the healthy side; for cerebrovascular diseases, turn towards the non-paralyzed side; for others, decide based on the level of muscle tension, muscle activity, or pain. Next, tilt the opposite lower limb towards the turning side, ensuring that the fallen knee does not overlap with the knee on the turning side. Overlapping knees would mean inducing flexion in the relatively weaker hip joint, so you keep the hip joint extended while tilting the lower limb. Then, bring the non-turning side upper limb in front of the body and assume an ‘on elbow’ position in front of the face. This position prepares the length of the back and induces segmental rotational movements of the neck, trunk, and pelvis. Next, place the body’s weight on the upper limb that is in the ‘on elbow’ position in front of the face, making sure not to use the turning side’s upper limb as much as possible. Using the turning side’s upper limb to pull on the rails or push against the bed surface would weaken the trunk function needed for rising, so this procedure eliminates that element. Finally, rise using the trunk flexion from that position. The lying down movement is performed by reversing the current procedure.

This concludes the content of the active rising from the crook lying position, which is the third step.

The fourth and final step involves acquiring an anterior pelvic tilt with forward-leaning of the lower legs in the edge sitting position. This is a crucial element for a seated posture that facilitates an easy transition to standing and upper limb movements. First, an assessment of the ischial tuberosities is conducted. If the ischial tuberosities are deviated forward or inward, it typically indicates that the pelvis is in a posterior tilt. To correct this, you work on elongating the proximal parts of the hamstrings and adductor magnus to shift the position of the ischial tuberosities more posteriorly and slightly laterally. Then, you encourage weight-bearing on the ischium through lateral pelvic tilting. If this proves difficult, you can use the opposite upper limb to de-weight the trunk laterally or guide the movement by returning from a lateral tilt to the opposite side. Once the position of both ischial tuberosities is adjusted, you promote anterior pelvic tilting. To facilitate this, you first achieve the maximum posterior tilt of the pelvis, and from that position, you tilt the pelvis forward. The posterior tilt in the edge sitting position begins with the downward movement of the ribs through the activity of the abdominal muscles, followed by the pelvic tilt. The transition from maximum posterior pelvic tilt to anterior tilt is guided by using the multifidus muscle to sequentially extend the spine from the bottom upwards. The multifidus muscle, which attaches along the entire spine, is most accessible on the inside of the upper posterior iliac spine. To initiate movement in the multifidus muscle, you hold that area and guide it outward and downward during posterior pelvic tilt, and inward and upward during anterior pelvic tilt. When in a posterior pelvic tilt in the edge sitting position, the hip joint tends to flex to maintain balance, and this, along with increased activity in the gastrocnemius muscle, causes the lower leg to tilt backward, making it difficult to perform upper limb operations, including standing and reaching. To facilitate smooth upper limb operations and transitions to standing and walking, you guide the pelvis into anterior tilt while in the edge sitting position.

This concludes the content on acquiring anterior pelvic tilt with forward-leaning of the lower legs in the edge sitting position, which is the fourth step.

To summarize, there are four key points for active lying, turning, and rising movements to adjust posture against gravity and improve the efficiency of standing and upper limb operations while seated:

The first point is to maintain the leg joints in a neutral position while lying on your back, ensuring the legs are placed straight in relation to the trunk. If there is low tone in the trunk, it can prevent the legs from being placed straight, typically resulting in the entire lower limbs rotating outward. By removing soft tissue (non-neurogenic?) restrictions, you create a situation where the trunk muscles must activate, increasing postural muscle tension to activate the muscles around the hip joint from the lower trunk.

The second point is to create a crook lying position with firm plantar weight-bearing. To achieve this limb position, stability of the trunk is required to maintain the lower limbs in space, as well as the output of the hip extension muscles.

The third point is active rising from the crook lying position. To positively influence standing and upright movements, you emphasize rising through the extension of the non-turning side hip joint, segmental rotation of the spine, and trunk flexion, all while avoiding pressing the shoulder girdle and thorax against the bed surface.

The fourth point is to acquire an anterior pelvic tilt accompanied by forward-leaning of the lower legs in the edge sitting position. Once seated, the goal is to progress to standing and walking activities. However, if the pelvis remains in a posterior tilt, the lower legs will not lean forward, making the rising movement inefficient. Therefore, you aim to achieve a seated posture that facilitates an easy transition to standing and upper limb operations.

This concludes the summary.