Progressive Exercise Therapy in Rehabilitation Physical Education

PROGRESSIVE
EXERCISE THERAPY
IN REHABILITATION AND PHYSICAL
EDUCATION
BY
John H. C. Colson FCSP FSRG DipTRG DipCOT

Remedial Therapy Representative, NHS Health Advisory Service. Formerly Director of
Rehabilitation and Principal, School of Remedial Gymnastics and Recreational Therapy,
Pinderfields General Hospital
and
Frank W. Collison MSRG
Head Remedial Gymnast and Clinical Supervisor, Rehabilitation Department,
Pinderfields General Hospital. Formerly Head Remedial Gymnast, Orseu Hospital
FOURTH EDITION
WRIGHT -PSG
BRISTOL . LONDON . BOSTON
1983
© J. H. C. Colson, 18 The Russets, Sandal, Wakefield, West Yorks, WF26JF, and
F. W. Collison, 10 Castle Crescent, Sandal, Wakefield, West Yorks, WF27HX.
1983
All Rights Reserved. No part of this publication may be reproduced, stored in a

retrieval system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise, without the prior permission of the Copyright
owners.
II
i!
i I
Published by: John Wright & Sons Ltd, 823-825 Bath Road, Bristol BS45NU,
England
John Wright PSG Inc., 545 Great Road, Littleton,
Massachusetts 01460, USA.
First edition 1958

Japanese edition 1966
Second edition 1969
Spanish edition 1974
Third edition 1975
Dutch edition 1981
Fourth edition 1983
British Library Cataloguing in Publicatilm Data
Colson, John H. C.
Progressive exercise therapy in rehabilitation
and physical education.
1. Exercise therapy
I. Title II. Collison, Frank W.
61S.8'24 RM72S
ISBN o7236066SX
Library of Congress Catalog Card Number: 82-S0781
,.,.." .. Gr.- Brimin by

............ s.:.. {Printing) Ltd, at The Stonebridge Press, Bristol BS4 SNU
and
1,
7HX.
I in a
mical,
yright
The Wise,jor Cure, on Exercise depend. DRYDEN.
w
PREFACE
The first edition of this book appeared in 1958. Its main aim was to emphasize
the importance of progression in exercise therapy and to provide a compre
hensive collection of free exercises for all parts of the body, graded and
progressed (as the original preface had it) in strength and mobility from the
simplest to the most strenuous movement.
Since that time two other editions have appeared and the book has been
translated into Japanese, Spanish and Dutch. From comments received from
students and therapists it is clear that the practical slant of the book has been
appreciated. Indeed, it has been heartening to receive so many letters from
different countries offering criticism, encouragement and suggestions for
future editions.
This new edition of Progressive Exercise Therapy, written in collaboration
with my friend and former colleague, Frank Collison, has not only been
completely revised, but expanded to include new sections on assisted and
resisted exercises, functional movement, progressive circuit training and
exercises to music. In addition, the section devoted to the exercise therapy of
various clinical conditions (which illustrates the way in which the exercise
vocabulary may be used when planning treatment programmes) has been
rewritten to bring it into line with modem practice. Running the risk of
criticism we have included a chapter on the re-educational measures which
may be used in the treatment of total hip replacement when the low friction
Charnley prosthesis is employed.
Unfortunately, the addition of so much new material has meant the
deletion of the sections on recreational therapy in the treatment of the
mentally handicapped and the mentally ill, which appeared in the previous
edition. Limitation of space has also meant that it has not been possible to
include any reference to the important role played by neurophysiological
techniques in modern exercise therapy.
We owe much to the late John M. P. Clark, Emeritus Professor of
Orthopaedic Surgery, University of Leeds, not only for his constant en
couragement and advice but for his truly superb teaching at ward rounds and
clinics. For 'Pasco' exercise therapy was the straight and narrow path to
recovery after injury or disease, and progression the keynote of success.
vii
viii PREFACE
Our sincere thanks are due to the surgeons who have given us so much
practical help. Mr J. F. Patrick FRCS, Mr A. E. Rainey FRCS, and Mr
C. Robertson FRCS, of the Orthopaedic Department, Pinderfields General
Hospital, Wakefield, Yorkshire, were always willing to guide us on technical
matters during the preparation of the chapters on orthopaedic procedures.
Mr C. Denley Clark FRCS and Mr G. Bird FRCS gave us generous support
when we were involved in the revision of the section on the use of exercise
therapy after abdominal surgery.
It is also a great pleasure to acknowledge the help given by the nursing staff
of the orthopaedic and general surgical wards at Pinderfields General
IIII
Hospital. Their appreciation of the value of early movement, and their
'Iii
detailed understanding of modern surgical techniques and equipment, have
IIII made for the closest cooperation during practical sessions of exercise therapy. PART 1
Our grateful thanks are due also to Mr John V. Gough MCSP DipTP, for 1. IntroductOi
'II
his advice and help when investigating the use of the myometer in recording 2. Free Exerd
muscle strength. It is also a great pleasure to acknowledge the outstanding
3. Assisted Ell
help given by Mr Robbie Blake MCSP DipTP during the many months of
preparing the revised text of this book. He has listened, commented and
4. Resisted fu
criticized in a most useful and constructive way.
The staff of the Wakefield and District Postgraduate Medical Centre gave PART
us valuable help with the checking of references and the compiling of the 5. Movemenll
bibliography; they also made available the resources of their information 6. Moving fro
service. We are grateful to the team concerned and in particular to Mrs Cecily
A. Miller, BA DipLib ALA, head of information services.
Finally, we must thank our Editor, Dr Sue Passmore, for her interest in the PARl
book and her enthusiasm for the subject matter. Our thanks must also be 7. Head and}
extended to our publishers, John Wright & Sons, for their support and 8. Trunk Exel
cooperation over many years. 9. Breathing I
John Colson 10. Pelvic 11001
Frank Collison 11. Shoulder g
12. Combined,
Exercises
13. Elbow Exel
14. Forearm, "
15. Hip Exercil
16. Knee Exere
17. Ankle and ]
PART ..
18. Constructic:
Specific]
19. Exercise TI
20. Interverteb
have given us so much
Rainey PRCS, and Mr
:at, Pinderfields General
to guide us on technical
Irtbopaedic procedures.
we us generous support
11 OIl the use of exercise
i¥en by the nursing staff

II:Pinderfields General
r movement, and their CONTENTS
IS and equipment, have
iDos of exercise therapy . PART 1 SPECIFIC EXERCISE THERAPY
• MCSP DipTP, for 1. Introductory 3
: myometer in recording 2. Free Exercises 7
IWIedge the outstanding
3. Assisted Exercises 13
iDa the many months of
1Ialed, commented and
4. Resisted Exercises 21
III:Medical Centre gave PART 2 FUNCTIONAL MOVEMENTS

Id the compiling of the 5. Movements on the Bed or Floor 45
:cs of their information 6. Moving from Sitting and Standing 54
particular to Mrs Cecily
mces. PART 3 PROGRESSIVE EXERCISES
R, for her interest in the
lor thanks must also be 7. Head and Neck Exercises 61
• for their support and 8. Trunk Exercises 69
9. Breathing Exercises 109
John Colson 10. Pelvic floor Exercises 115
Frank Collison 11. Shoulder girdle Exercises 118
12. Combined Shoulder joint and Shoulder girdle
Exercises 120
13. Elbow Exercises 139
14. Forearm, Wrist and Hand Exercises 143
15. Hip Exercises 154
16. Knee Exercises 164
17. Ankle and Foot Exercises 171
PART 4 APPLIED EXERCISE THERAPY

18. Construction and Use of Tables of 181
Specific Exercises
19. Exercise Therapy after Abdominal Surgery 184
20. Intervertebral Disc Lesions of Lumbar Spine 212
ix
x CONTENTS
21. Total Hip Replacement

22. Meniscectomy
221
232
PART 1
PART 5 GENERAL EXERCISE THERAPY
23. Progressive Circuit Training 247
24. Exercises to Music 256
APPENDICES
1. Starting Positions 261
, ,I' 2. Gymnastic Terminology 273
SPECIF
,II: THERA
Bibliography 277
I.
Index 279
..
221
232
PART 1
::::ISE THERAPY
247
256
261
273
SPECIFIC EXERCISE
THERAPY
277
279
1. Introductory
Specific or local exercises consist of active movements that are designed to

restore function. General exercises, on the other hand, are those that
provide movement for the body as a whole.
Specific exercises are used to strengthen particular muscle groups,
mobilize certain joints or re-educate neuromuscular coordination, and are of
great value in the treatment of injuries and disorders of the locomotor system
where certain muscle groups and joints are affected and the rest are
comparatively normal, e.g. in fractures and other bone and joint injuries,
orthopaedic conditions, thoracic diseases and postoperative abdominal
conditions.
Specific exercises are not sufficient in themselves to bring about perfect
functional recovery, however, for muscles and joints were never intended by
nature to act as individualists. For the best results specific exercises must be
combined with general exercises, so as to coordinate the movements of the
affected part with the rest of the locomotor system. It is also often necessary
to combine treatment by exercises with passive therapy, occupational therapy
and various recreational activities-games, swimming, walking and cycling.
TYPES OF SPECIFIC EXERCISES

Specific exercises consist of free movements, assisted movements and resisted
movements. The movements, and the various techniques used to achieve
progression, are considered in detail in the next three chapters.
BASIC PRINCIPLES OF SPECIFIC EXERCISES

All types of specific exercises must conform to certain basic principles:
1. They must be performed in a smooth and rhythmical manner, so that
they do not subject muscles and joints to sudden unexpected stresses and
strains.
2. They must be based on sound starting positions.
3. They must provide smooth progression from the stage of extreme
weakness to the stage of full use against the stresses of normal working
conditions.
3
4 PROGRESSIVE EXERCISE THERAPY
In addition, all exercises that aim to strengthen weak muscles should standing, sitting steadier til
provide as wide a range of movement as possible. than sitting. The nearer tb
steadier is the position.
In some instances additio
to be enlarged in the directic
Principle of Rhythm standing is a steadier positic:
arms are moved in the sagi
Muscular contraction must be followed by relaxation, and the relaxation
cause the centre of gravity CI
period must be complete and long enough to allow normal circulatory
backwards. This is partia
conditions to be restored. This principle applies particularly to exercises
movements are performed.
which are used to redevelop weak muscles after trauma or disuse. It is based
I II i~iI upwards. In stride standing
on the fact that the efficiency of a muscle depends largely on the condition of
IIPi' not only by essential small I
its local circulation. If this is good, the breakdown products of contraction are
unnecessary movements ill
IIIII!: quickly carried away; if it is poor, the products tend to accumulate and
moving forwards and back1
,111'1
produce early fatigue.
To conform to the principle of rhythm in practice the therapist must give
as much emphasis to the relaxation period at the end of an exercise as to the
actual muscle work itself. Thus, in using an exercise like Fixed prone lying; Developing Coordination
Trunk bending backwards with Arm turning outwards (Fig. la, p. 8), to In developing neuromUSCU
strengthen the extensor muscles of the thoracolumbar spine, the following chosen so as gradually to iI
type of coaching might be used. e.g. toe standing and stand
'Bend back the head-tum out the arms so that the palms face forward
lift the chest from the floor as far as you can ... A little more ... Now "hold"
the position for a moment ... Lower the trunk down carefully; let the arms
tum in ... Now tum the head and flop out completely. Let everything go ... .' Principle of progr cs ; .
After a few seconds' pause the exercise is repeated. The method of progressioo
It is worth comparing this technique with that often used for the same type to redevelop strength, Ie
of exercise. 'Lift-! Hold the position! Lower ... Rest ... Lift-!' The ordination. One method aI
instructions for relaxation and the restarting of the exercise almost merge into • csercises: progression in til:
one another and completely negate the principle of rhythm. periods of time.
Sound Starting Position Wide Range Movemad

The starting position from which each exercise is performed should facilitate Except in the early phase
the work of the muscles, and be suitable for the particular phase of recovery csercises which aim at sue
reached by the patient. of movement as possible; ~
this way it is more likely t
movement will be exercise
from the action of certain I
Strengthening and Mobilizing raponsible for particular
To strengthen weak muscles or to mobilize stiff joints the starting positions of muscle in part of its range
the exercises should be as steady as possible, so as to give the working muscles fibres will be brought inti
a firm origin from which to work. The larger the base of support the steadier The classic example of 1
<CXIIltract particularly duri
will be the position of the body. For example, stride standing is steadier than
tAPY INTRODUCTORY 5
:hen weak muscles should standing, sitting steadier than stride standing and lying a steadier position
than sitting. The nearer the centre of gravity to the base of support, the
steadier is the position.
In some instances additional stability is achieved by arranging for the base
to be enlarged in the direction of the movement. For example, walk-forwards
standing is a steadier position than stride standing for exercises in which the
Dtion, and the relaxation arms are moved in the sagittal plane, because the movements of the arms
allow normal circulatory cause the centre of gravity of the body to be constantly shifted forwards and
s particularly to exercises backwards. This is particularly evident when vigorous wide range arm
mona or disuse. It is based movements are performed, such as Arm swinging forwards and forwards
largely on the condition of upwards. In stride standing the compensatory balancing required is achieved
products of contraction are not only by essential small movements of the ankle joints but very often by
s tend to accumulate and unnecessary movements in the lumbar spine, with the head and pelvis
moving forwards and backwards alternately.
ia: the therapist must give
_ of an exercise as to the
lise like Fixed prone lying; Developing Coordination
. .ds (Fig. la, p. 8), to
In developing neuromuscular coordination the starting position should be
IIIJbar spine, the following
chosen so as gradually to increase the difficulty of maintaining the balance,
e.g. toe standing and standing with one knee raised forwards.
t the palms face forward
little more ... Now "hold"
own carefully; let the arms
Idy. Let everything go... .' Principle of Progression
d.
The method of progression used depends on whether an exercise is designed
ften used for the same type to redevelop strength, restore mobility or redevelop neuromuscular co
• . Rest . . . Lift-!' The
ordination. One method of progression, however, is common to all types of
~cxercise almost merge into
exercises: progression in time. That is, performing the exercise for increasing
of rhythm.
periods of time.
Wide Range Movements

performed should facilitate
Except in the early phase of recovery when the muscles are very weak, all
articular phase of recovery
exercises which aim at strengthening muscles should provide as wide a range
of movement as possible, and each movement should be taken to its limit. In
this way it is more likely that all the fibres of the muscle responsible for the
movement will be exercised normally. This is important, because it appears
from the action of certain muscles that individual groups of muscle fibres are
responsible for particular ranges of movement. In other words, exercising a
DIS the starting positions of muscle in part of its range of movement does not necessarily mean that all its
o give the working muscles fibres will be brought into action.
ase of support the steadier The classic example of this is the vastus medialis muscle. The lower fibres
Ie standing is steadier than 'contract particularly during the terminal phase of extension of the knee joint
IlERAPY
FREE EXERCISES 9
b
Fig. 3. Progression in strength: eliminating the help given to the abdominal
muscles by the accessory flexor muscles of the thoracolumbar spine.
abdominals. They work strongly in inner range, and the first two muscle
groups produce extension of the shoulder joint in addition to spinal flexion.
Extension is associated, after some 15°, with shoulder girdle movement.
In general, the most difficult starting position for this exercise is lying with
the arms stretched sideways in yard position. This is because the position of
the arms makes it difficult for the performer to pivot at the thoracocervical
junction, and he has to use his abdominal muscles strongly in an attempt to
bring about additional flexion of the thoracolumbar spine.
3. By increasing the range of movement. For example, spanning performed
from angle-hanging (Fig. 4b) is harder work than when it is performed from
IIgtb of the weight arm of the the high reach grasp crook lying position (Fig. 4a). The exercise is made more
difficult still when it is performed from stretch grasp back support long sitting
(Fig.4c).
4. By the addition of subsidiary movements to an exercise, so as to increase
the work of the main muscle group. For example, Prone lying; Trunk bending
rthoracic spine. The combined

JIC!SSion on the single-leg lever
:n forms a strong progression
a'cise, Knee swinging from side

is basicalJy a mobility exercise
Ie mover muscles by accessory

ro touch the floor overhead with
Ics when the arms are in reach
~ by the sides (Fig. 3a). In the
Ie thoracolumbar spine (latis
Fig. 4. Progression in strength: increasing
come into action to assist the the range of movement in spanning.
backwards with Arm turning outwards and single Leg raising backwards (Fig. 5) 3. By introducing prolonged
is harder work for the extensors of the thoracolumbar spine than the same ing the range of flexion of a stiI
exercise without leg movements. Raising both legs backwards at the same the knee and hip joints of the all
time (instead of one leg in turn) makes the exercise more difficult still. producing pain. He artempa
completely, so as to allow the
knee. He then contracts the b
flexed to the limit of pain, 'boll
allows the hamstrings to relax s1
before the knee joint is extend
Fig. 5. Progression in strength: subsidiary movements are added to the exercise

llililim
to increase the work of the main muscle group.
illllill
'illl'l:
:!llilll 3. PROGRESSION IN CO
5. By using first static and then dynamic muscle work. For example, (a)
!ll lIi Half lying; single Quadriceps contractions, and (b) Half lying (thighs supported The main methods of prop
by folded pillow or shaped wooden block, with knees flexed to about 30°); single applicable to all parts of the bo
'I: Knee stretching. lower limbs and trunk.
6. By altering the rhythm of the movement. Slow, controlled movements
require more effort from the muscles than the same movements performed at
a quicker rate. General Methods of Prop"
7. By altering the effect of gravity on the moving part, i.e. arranging for the 1. Giving movements of II
movement to be performed with gravity stresses eliminated, and later against smaller joints later, e.g. shoull
the resistance of gravity. Thus, in strengthening the rotators of the thoracic finger movementS.
spine: (a) Stride sitting; Trunk turning, and (b) Stride lying; Trunk turning with 2. Increasing the precisio
single Arm carrying across the chest (Fig. 129, p. 101). performed.
3. Combining movements 4
Arm raising sideways. An extJ:
performing asymmetrical JI101
and forwards.
2. PROGRESSION IN RANGE
From the viewpoint of function, range of movement is undoubtedly second
ary in importance to muscle strength. In the restoration of stiff joints after Methods Applicable to l.oI
trauma, however, very little headway would be made without employing 1. Diminishing the size of
specific mobility exercises. maintenance of balance becon
ally this is done by (a) bringiJ
the heels from the floor (toe rn
Standing; single Knee raising;.
Methods of Progression such as a balance bench rib 0
There are three main methods of progressing the range of free mobility 2. Increasing the difficulti
exercises: position by (a) placing the am
1. By altering the rhythm of the movement. For example, rhythmical the centre of gravity of the hoc
swingings are used in place of slow movements. the balance, e.g. Balance hal)
2. By adding a series of small rhythmical pressing movements to the end of raising sideways-upwards; and
the main movement, e.g. Stride standing; Trunk bending from side to side with which (because of psychologi,
rhythmical pressing to three counts in position. ably (Fig. 6).
IlERAPY
FREE EXERCISES 9
b
Fig. 3. Progression in strength: eliminating the help given to the abdominal
muscles by the accessory flexor muscles of the thoracolumbar spine.
abdominals. They work strongly in inner range, and the first two muscle
groups produce extension of the shoulder joint in addition to spinal flexion.
Extension is associated, after some 15°, with shoulder girdle movement.
In general, the most difficult starting position for this exercise is lying with
the arms stretched sideways in yard position. This is because the position of
the arms makes it difficult for the performer to pivot at the thoracocervical
junction, and he has to use his abdominal muscles strongly in an attempt to
bring about additional flexion of the thoracolumbar spine.
3. By increasing the range of movement. For example, spanning performed
from angle-hanging (Fig. 4b) is harder work than when it is performed from
IIgtb of the weight arm of the the high reach grasp crook lying position (Fig. 4a). The exercise is made more
difficult still when it is performed from stretch grasp back support long sitting
(Fig.4c).
4. By the addition of subsidiary movements to an exercise, so as to increase
the work of the main muscle group. For example, Prone lying; Trunk bending
rthoracic spine. The combined

JIC!SSion on the single-leg lever
:n forms a strong progression
a'cise, Knee swinging from side

is basicalJy a mobility exercise
Ie mover muscles by accessory

ro touch the floor overhead with
Ics when the arms are in reach
~ by the sides (Fig. 3a). In the
Ie thoracolumbar spine (latis
Fig. 4. Progression in strength: increasing
come into action to assist the the range of movement in spanning.
backwards with Arm turning outwards and single Leg raising backwards (Fig. 5) 3. By introducing prolonged
is harder work for the extensors of the thoracolumbar spine than the same ing the range of flexion of a stiI
exercise without leg movements. Raising both legs backwards at the same the knee and hip joints of the all
time (instead of one leg in turn) makes the exercise more difficult still. producing pain. He artempa
completely, so as to allow the
knee. He then contracts the b
flexed to the limit of pain, 'boll
allows the hamstrings to relax s1
before the knee joint is extend
Fig. 5. Progression in strength: subsidiary movements are added to the exercise

llililim
to increase the work of the main muscle group.
illllill
'illl'l:
:!llilll 3. PROGRESSION IN CO
5. By using first static and then dynamic muscle work. For example, (a)
!ll lIi Half lying; single Quadriceps contractions, and (b) Half lying (thighs supported The main methods of prop
by folded pillow or shaped wooden block, with knees flexed to about 30°); single applicable to all parts of the bo
'I: Knee stretching. lower limbs and trunk.
6. By altering the rhythm of the movement. Slow, controlled movements
require more effort from the muscles than the same movements performed at
a quicker rate. General Methods of Prop"
7. By altering the effect of gravity on the moving part, i.e. arranging for the 1. Giving movements of II
movement to be performed with gravity stresses eliminated, and later against smaller joints later, e.g. shoull
the resistance of gravity. Thus, in strengthening the rotators of the thoracic finger movementS.
spine: (a) Stride sitting; Trunk turning, and (b) Stride lying; Trunk turning with 2. Increasing the precisio
single Arm carrying across the chest (Fig. 129, p. 101). performed.
3. Combining movements 4
Arm raising sideways. An extJ:
performing asymmetrical JI101
and forwards.
2. PROGRESSION IN RANGE
From the viewpoint of function, range of movement is undoubtedly second
ary in importance to muscle strength. In the restoration of stiff joints after Methods Applicable to l.oI
trauma, however, very little headway would be made without employing 1. Diminishing the size of
specific mobility exercises. maintenance of balance becon
ally this is done by (a) bringiJ
the heels from the floor (toe rn
Standing; single Knee raising;.
Methods of Progression such as a balance bench rib 0
There are three main methods of progressing the range of free mobility 2. Increasing the difficulti
exercises: position by (a) placing the am
1. By altering the rhythm of the movement. For example, rhythmical the centre of gravity of the hoc
swingings are used in place of slow movements. the balance, e.g. Balance hal)
2. By adding a series of small rhythmical pressing movements to the end of raising sideways-upwards; and
the main movement, e.g. Stride standing; Trunk bending from side to side with which (because of psychologi,
rhythmical pressing to three counts in position. ably (Fig. 6).
ASSISTED EXERCISES 15
2. AUTO·ASSISTED ACTIVE (TENSION) EXERCISES
Auto-assisted active (tension) exercises are used to restore the mobility of
some of the larger joints-in particular, the knee and shoulder-where
stiffness is due to thickenings and adhesions within the joints and their
capsules. They are only employed in the intermediate and late phases of
recovery and are reserved for joints which are free from effusion. They are
contraindicated in the treatment of elbow injuries.
The exercises resemble assisted active movements carried out with a cord
I and pulley circuit, but include a stressing or tension element which is
I
I controlled entirely by the patient. They are extremely valuable, but need
I careful teaching and supervision.
I
f
I
I
I
+ w
ley circuit: elevation of arm
puIIey circuit: abduction of
.JJer joint with weight-and
rr level with the top of the

K Shoulder joint (Fig. 12).
Fig. 13. Auto-assisted'active (tension) exercise: flexion ofthe knee joint. The cir
cuit may be used to restore the range of flexion from 0 to 130°. In practice it has
been found best to use the combined circuits shown in Fig. 14 to restore the first
40-60° offlexion. Note the simple device used to raise the head end of the plinth
and prevent it moving forwards when the patient is exercising, and the series of
hooks arranged on a wall-mounted upright: they allow easy adjustment of the
circuit's angle of pull. The foot and ankle straps shown are made from soft
leather. Each set consists of a circular foot cuff and adjustable ankle strap. The
cuff and strap are connected by a leather 'cord' which carries a free-moving
galvanized ring. The ends of the circuit cord are looped through these rings.
Fig. 13 shows an auto-assisted active (tension) circuit arranged to assist

flexion of the knee. Fig. 14 demonstrates the use of combined weight-and
iDL. (Illustration reproduced pulley and cord and pulley circuits in the restoration of knee flexion. The
67, 258-262, by kind per simple cord and pulley circuit shown in Fig. 10 can be used to bring about
lie Editor of the Journal.) auto-assisted active (tension) movements of the shoulder joint.
~ of assistance provided Exercise Technique

In performing an auto-assisted active (tension) exercise the patient should
3. Assisted exercises
,.
:IiBicuIty of maintaining the 1. ASSISTED ACTIVE EXERCISES
IbIS used. Assisted active exercises are those performed by the patient with the
assistance of the therapist or some outside force, such as a cord and pulley or
weight-and-pulley circuit. They are used when the muscles acting on one of
the body levers are too weak to bring about movement or to control it
adequately. They are also used in the restoration of mobility.
hich demand considerable
The assistance or external force employed is applied in the direction of the
dination. For example: (a)
ifarN.uts (Fig. 7); (b) Running muscle action. It should be sufficient to give adequate help to the working
muscles, but must not be allowed to exceed this level or a passive movement
will result.
Whatever type of assistance is used the underlying objective must be to
secure the best possible working conditions for the weak muscles and to
eliminate any muscle work other than that which is necessary to achieve the
desired movement. Thus the moving part must be supported fully through
out the movement, and the body stabilized by a sound starting position.
Four examples of different types of assisted active movements are given
-.1 d here:
ith alternate Toe placing
(a) Lying; flexion of the Hip and Knee with therapist's assistance (Fig. 9).
IIIIition on one leg at a given

Jt1fling forwards, backwards,
, Skipping: lwpping with a
L in coordination:
: with a rebound Fig. 9. Assisted active exercise: flexion ofhip and knee with therapist'S assistance.
littetching.
(b) Sitting (chair); elevation of the Arm through abduction with cord and
pulley ct"rcuit (Fig. 10).
13
1. AUTO-ASSISTED A
~ active (n:nsiI
_ of the larger joinb
,.aM 55 is due to tbicb:a
~.. In They are only a
f AN»iCi) and are reserved I
~. ,ai..dio:ated in the treaII
.
t
t
to,
,
•
I
L__ ...II
paIk:y circuit, but iu
/ J
.-
l J
I
i-.6:d corirely by the
}.... -",.,,~
I
I
l-al tracbing and supcn
........... ", I
I
I
I
.. Iw
!il~:
Fig. 10. Assisted active exercise with cord and pulley circuit: elevation of arm
through abduction.
Fig. 11. Assisted active exercise with weight-and-pulley circuit: abduction of
shoulder joint.
(c) Stride standing; assisted abduction of the Shoulder joint with weight-and
pulley circuit (Fig. II).
(d) Sitting on stool or bench in pool (the water level with the top of the
shoulders),' buoyancy-assisted abduction of the Shoulder joint (Fig. 12).
n sIIows an autIH
. . die tnce.. FC- I·
Fig. 12. Buoyancy-assisted abduction of shoulder joint. (Illustration reproduced .... cord. aDd puDc
from 'Basic hydrotherapy', Physiotherapy (1981), 67, 258-262, by kind per ad IDI paIk:y c:iJ
mission of the author, Anne Golland MCSP, and the Editor of the Journal.) II' - d .m.: (n:mic:
Progression
As the strength of the muscles improves the degree of assistance provided
-..,
must be gradually diminished. 2· ... ~
2. AUTO·ASSISTED ACTIVE (TENSION) EXERCISES
Auto-assisted active (tension) exercises are used to restore the mobility of
some of the larger joints-in particular, the knee and shoulder-where
stiffness is due to thickenings and adhesions within the joints and their
capsules. They are only employed in the intermediate and late phases of
recovery and are reserved for joints which are free from effusion. They are
contraindicated in the treatment of elbow injuries.
The exercises resemble assisted active movements carried out with a cord
I and pulley circuit, but include a stressing or tension element which is
I
I controlled entirely by the patient. They are extremely valuable, but need
I careful teaching and supervision.
I
f
I
I
I
+ w
ley circuit: elevation of arm
puIIey circuit: abduction of
.JJer joint with weight-and
rr level with the top of the

K Shoulder joint (Fig. 12).
Fig. 13. Auto-assisted'active (tension) exercise: flexion ofthe knee joint. The cir
cuit may be used to restore the range of flexion from 0 to 130°. In practice it has
been found best to use the combined circuits shown in Fig. 14 to restore the first
40-60° offlexion. Note the simple device used to raise the head end of the plinth
and prevent it moving forwards when the patient is exercising, and the series of
hooks arranged on a wall-mounted upright: they allow easy adjustment of the
circuit's angle of pull. The foot and ankle straps shown are made from soft
leather. Each set consists of a circular foot cuff and adjustable ankle strap. The
cuff and strap are connected by a leather 'cord' which carries a free-moving
galvanized ring. The ends of the circuit cord are looped through these rings.
Fig. 13 shows an auto-assisted active (tension) circuit arranged to assist

flexion of the knee. Fig. 14 demonstrates the use of combined weight-and
iDL. (Illustration reproduced pulley and cord and pulley circuits in the restoration of knee flexion. The
67, 258-262, by kind per simple cord and pulley circuit shown in Fig. 10 can be used to bring about
lie Editor of the Journal.) auto-assisted active (tension) movements of the shoulder joint.
~ of assistance provided Exercise Technique

In performing an auto-assisted active (tension) exercise the patient should
16 PROGRESSIVE EXERCISE THERAPY ASSIST
little or no pain; and (c) a range of 5

is complete loss of movement.
In performing auto-assisted activ
work in the inner part of the first nil
is usually small. He should avoid I
lCICtions. Indeed, exercising in 1
aretching. Evidence of over-tIa
iacreasing pain, and in stationary c
1. SUSPENSION AND SUPPCl

Suspension and supported exercil
!il~
,lll
L
Fig. 14. Auto-assisted active flexion of the knee joint: combined cord and pulley
.er
w:Iopment of weak muscles and tIM
indirect assistance to the wodl
:md gravity stresses.
and weight-and-pulley circuits. The combined circuits offer a smooth and
effective means of restoring the first 60° of flexion. The resistance weight used
should be sufficient to counterbalance the lower leg. From the starting position
demonstrated the patient flexes the stiff knee joint (R), simultaneously extend
&.spension Exercises
ing the sound knee joint (L). The movements must be synchronized so that the III suspension exercises the parts 0
cord and pulley circuit is kept under even tension throughout. When the stiff .., canvas slings attached by adjUSll
joint reaches the point when assistance is required the patient reinforces the points, so that a certain degree of ell:
prime mover muscles by a small movement of extension of the sound joint
which exerts increased tension on the cord and pulley circuit. Mter 'holding' the 1IIis way the body is relieved of I
final position for a moment the patient allows the resistance weight to extend the ~ement is attempted on a horizll
stiff knee joint, and slackens off the extensor muscles of the sound knee so that it plinth. Metal or wooden runners fill
returns to its original starting position. die suspension unit.
adjust the length of the circuit cord, so that it is reasonably taut and therefore
responsive to movement. He then moves the affected limb in the required ~Fixation
direction, simultaneously moving the other limb in the opposite direction so Tbt: overhead attachment point ofl
as to keep the cord taut. IIIe joint to be exercised. When IDI
When the affected limb enters the stiff painless zone of movement (see -...: horizontal plane, the prime IIlO'II
below) and reaches the point when assistance is required, the patient JIIIIt is gravity-free and therefore \111
endeavours to take the movement still further with the prime mover muscles, for varying the type of activity usc:cl
and at the same time reinforces them by further tension on the cord with the 10 assist mobility and promote the
sound limb. On reaching the painful limit he 'holds' the position for a slow controlled movements to inc
moment, and then returns the limbs to their starting position by a reversal of method of arranging axial fixatio
the previous movements. Throughout, the exercise should be performed :movements of the hip.
smoothly and fairly slowly.
Co-axial Fixation
Zones of Movement Axial fixation can be modified tc
With regard to the tension aspect of the exercises it is worth noting that there assistance for individual muscle gr
are three ranges or zones of movement in a stiff joint: (a) a range of free and cords is then moved to one side 0
painless movement, which is generally the largest; (b) a range of stiffness with muscles of the hip are to be resil
r
little or no pain; and (c) a range of stiffness and pain. Beyond this range there
is complete loss of movement.
In performing auto-assisted active (tension) movements the patient should
work in the inner part of the first range, and through the second range, which
is usually small. He should avoid the third range, for it is this that sets up
reactions. Indeed, exercising in this zone is the equivalent of forcible
stretching. Evidence of over-treatment will be found in swelling and
increasing pain, and in stationary or diminishing movement.
3. SUSPENSION AND SUPPORTED EXERCISES

Suspension and supported exercises are widely used in the early rede
velopment of weak muscles and the restoration of mobility. In general, they
offer indirect assistance to the working muscles by freeing them of frictional
IIIIbincd cord and pulley and gravity stresses.
iIs offer a smooth and
~ raistance weight used
_ the staning position
simultaneously extend Suspension Exercises
I!JIICbronized so that the In suspension exercises the parts of the body to be exercised are supported
1IIghout. When the stiff by canvas slings attached by adjustable-length cords to an overhead point or
c .-bent reinforces the
points, so that a certain degree of elevation is achieved (see Figs. 15 and 16). In
.. al the sound joint
alit.. After 'bolding' the this way the body is relieved of the frictional stresses encountered when
KIe weight to extend the movement is attempted on a horizontal supporting surface, such as a bed or
lie: sound knee so that it plinth. Metal or ~ooden runners fitted to the cords ensure easy adjustment of
the suspension unit.
oably taut and therefore

:d limb in the required Axial Fixation
lie opposite directipn so The overhead attachment point of the cords is positioned immediately above
,
the joint to be exercised. When movement is initiated it occurs throughout
lODe of movement (see the horizontal plane, the prime mover muscles being indirectly assisted as the
required, the patient part is gravity-free and therefore weightless. This allows considerable scope
c prime mover muscles, for varying the type of activity used-from rhythmical swinging movements,
OIl on the cord with the to assist mobility and promote the circulation in the region of the joint, to
Ids' the position for a slow controlled movements to increase muscle strength. Fig. 15 shows the
lJOSition by a reversal of method of arranging axial fixation to promote abduction and adduction
~ should be performed movements of the hip.
Co-axial Fixation
Axial fixation can be modified to produce some degree of resistance or
MJdb noting that there assistance for individual muscle groups. The overhead fixation point of the
:(II) a range of free and cords is then moved to one side of the joint. For example, if the abductor
I DOge of stiffness with muscles of the hip are to be resisted, the fixation point is sited over the
M
it~~~j
i~l:
Fig. 15. Suspension exercise: axial fixation used to promote abduction and
JIiir- 16. Suspension e:urcisc:; •
61: 1IIJPC!l" arm, while axial SIB
adduction movements of the hip joint. The overhead attachment point of the ovabead anacbmeDt poiII
suspension cords is positioned immediately above the joint. III: jaioL I_t: radial aspect aI
adductors of the joint; automatically, this causes the lower limb to assume an . . . tissues from pressure m'
adducted position when at rest. When the abductors are activated the lower
limb rises slightly into abduction (in the form of a pendular movement) with
gravity offering resistance.
Gravity will also return the limb to the adducted position passively if the
abductors are relaxed completely; this can be used as an early form of assisted
movement for the adductors. Conversely, if the return movement is con
trolled actively the abductors will work excentrically against gravity.
Vertical Fixation
The overhead fixation point of the cord and sling unit is positioned directly
over the centre of gravity of the part to be supported, Le. over the junction of
the upper and middle one-thirds. On occasions, too, tbI:
Vertical suspension has a stabilizing effect on the part supported; move • bed-head, serves as
ment is restricted to small-range pendular movements. Because of this, !lllpmtions have the disadva
vertical fixation is used to give support rather than to encourage movement
(Fig. 16). It is sometimes employed as a means of achieving either local or comprehensive account j
general relaxation; short tension springs are incorporated into the overhead lladmiques for the trunk, is
aspect of the cord and sling unit or units to provide 'buoyancy'.
Fig. 16. Suspension exercise: vertical fixation used to provide finn support for
- - abduction and the upper ann, while axial suspension promotes movement of the elbow joint.
~ point of the
The overhead attachment point of the axial suspension unit is sited directly over
the joint. Inset: radial aspect of hand and wrist, showing felt cuff used to protect
.-Iimb to assume an soft tissues from pressure of self-locking sling.
i..m.ted the l~er
"'movement) ~ith Suspension Equipment
I \ In the physiotherapy department overhead fixation points for suspension
.... pasively if'the work are usually provided by a rectangular-shaped grill of strong 5 cm metal
~fOnn of assisted mesh, which is sited over a plinth and roughly approximates to its surface
,r
I~t is con area. The grill is securely fastened to the ceiling joists, with a 1·5 m clearance
aravity between plinth top and mesh.
.
Where ceiling fixation is not possible a free-standing tubular steel suspen
sion frame (originated by the late Mrs O. F. Guthrie-Smith) can be used in
r conjunction with a plinth to provide the necessary suspension points.
~directly In the ward situation the adjustable overhead cross-bars of the orthopaedic
~ the junction of framework of a modem variable-height bed are often used to provide fixation
points. On occasions, too, the hook end of a 'monkey pole', securely fastened
to the bed-head, serves as a useful fixation point. Unfortunately, both
adaptations have the disadvantage of reducing the length of the suspension
cords, which restricts the range of movement achieved by the patient.
A comprehensive account of all forms of suspension movement, including
techniques for the trunk, is included in Hollis's Practical Exercise Therapy
(1981).
Progression 4. Resis
When axial fixation is used to strengthen weak muscles a natural progression
consists of introducing a simple weight-and-pulley circuit to provide the
working muscles with graduated resistance. Free exercises of the appropriate
grade can be used to supplement this training. They can also be used to
provide progression in mobility.
Supported Exercises
Supported exercises take place in the horizontal plane and are -similar to
axial suspension movements. The affected part of ilie body is supported by
the buoyancy of water, a highly polished re-education board or ball-bearing
skates. The prime mover muscles are indirectly assisted by the counter
balancing of all gravity stresses.
When a polished board is used movement can take place in an oblique
'~I: plane by tilting the board to the required angle. In this way it is possible to
I! use gravity to give assistance or resistance to the prime movers.
"
Progression
By free exercises of the appropriate grade.
II should diminish
......,.....r, so as to coa.i
REFERENCE of exerting thf:ir I
Hollis M. (1981) Practical Exercise Therapy, 2nd ed. Oxford, Blackwell Scientific shorten their foo
Publications. brief period of COlI
....uica1Iy, weight-aD
. . main muscle p
~. it is usually liD:
it is more usecl
liM lillg muscles is obta

IItUI'al progression
4. Resisted exercises
lit to provide the
of the appropriate
D also be used to
md are -similar to
ly is supported by Resisted exercises are those in which the prime mover muscles work against
!I'd or ball-bearing the resistance of some outside force. Resistance may be provided by
I by the counter- (a) Apparatus: weight-and-pulley circuits, weights, springs and elastic
substances; (b) Malleable materials; (c) Water; (d) the Therapist; and
lace in an oblique (e) the Patient.
'aJ it is possible to In applying resistance to muscles four rules must be observed:
lOVers. 1. It must be given smoothly from the beginriing to the end of the
movement.
2. Whenever possible it should be applied to the moving part so that it
exerts pressure on the surface of the skin facing the direction of the
movement. In this way the exteroceptors are stimulated and movement is
facilitated.
3. It should diminish gradually from the beginning to the end of the
movement, so as to conform to the physiological principle that muscles are
capable of exerting their greatest force when they are fully extended, and that
Blackwell Scientific as they shorten their force diminishes.
4. A brief period of complete relaxation should follow each muscular effort.
1. WEIGIIT-AND-PULLEY RESISTANCE
Theoretically, weight-and-pulley resistance is capable of being applied to any
of the main muscle groups, including those of the trunk. In practice,
however, it is usually limited to the muscles of the upper and lower limbs: on
average, it is more used for the knee extensors than for any other muscle
group.
With a weight-and-pulley circuit the leverage of resistance decreases as the
line of application of the force approaches the fulcrum. In other words, the
maximum effect of a given resistance on muscles is obtained when it is
arranged at right angles to the long axis of the moving limb; the nearer the
force is applied in line with the long axis the less is the resistance offered to
the muscles.
Figs. 17 and 18 indicate the principle of diminishing resistance as applied to
the extensor muscles of the knee. Figs. 18 and 19 show how relaxation for the
working muscles is obtained in the starting and finishing positions by the use
21
22 PROGRESSIVE EXERCISE THERAPY RESJS1
F' POWIII.R.
---:rI1L,J Fig. 17. To illustrate the principle
•, ofdecreasing resistance as applied
to the quadriceps femoris muscle.
A: A = the distance of the force, or
line of application of the resis
tance, from the fulcrum F. The
~
leverage of resistance decreases as
the line of app lication of the
a force approaches the fulcrum.
:RIIi1""
ill~lil
~I!:ii
':all II
'~!:il
~
, "'-'
'
lit! b
c \', -~--;
, <:~~'~i... :.' _,_
"
of a relaxation stop (RS). The stop consists of one of the wooden runners of .;-~-=;;;;:;:;;
the lower pulley circuit. Resisted exercise: e:.r:IaII

Sometimes a rectangular-shaped piece of wood provided with three holes ,,- 0+. -shaped weight-and-puJIq
for the cord is employed as a relaxation stop. See inset, Fig. 22, p. 25. When ..... ~ slighdy backwards, as II
used with very heavy weights, however, this type of stop tends to shift along . , or foam rubber, is ge:neraIIJ
the cord when it strikes the pulley sheave at the end of a movement.
RS
component of the quad!
the last 10 to 20 per cal
~~jnes knee stability, but
knee movement (Williams
lilt....ification consists of atIlIII:
llaposition that it lies immediab
as shown in Fig. 21. Th
' _••w.ically increases the resiI
b
Fig. 18. Diagrammatic representation of a simple method of applying weight
and-pulley resistance to the quadriceps femoris muscle. RS represents the
relaxation stop which frees the muscle from resistance 'pull' in the resting
position.
RESISTED EXERCISES 23
illustrate the principle

g resistance as applied
riceps femoris muscle.
IlUlce of the force, or
IJication of the resi s
L the fulcrum F. The
resistance decreases as
r application of the
aches the fulcrum.
lie wooden runners of

Fig. 19. Resisted exercise: extension of the knee joint using a simple
ided with three holes triangular-shaped weight-and-pulley circuit. The surface of the fixation bench
F~.22,p. 25.VVhen should slope slightly backwards, as shown; in addition a wooden wedge, covered
p tends to shift along with felt orfoam rubber, is generally used under the thigh. Note the relaxation
stop RS.
r. movement.
The triangular-shaped weight-and-pulley circuit for the extensors of the
bee needs a high ceiling (at least 4·2m) for the overhead pulley; otherwise
me patient's shoulder obstructs the main connecting cord. An alternative
type of circuit which can be used when the ceiling height is limited is shown
ill Fig. 20. It has the disadvantage of needing a third pulley, which increases
frictional resistance.
Both circuits can be modified to give specific resistance to the vastus
medialis component of the quadriceps femoris muscle, which is active
throughout the last 10 to 20 per cent of knee extension. Vastus medialis not
cnIy determines knee stability, but is particularly responsible for the inner
range of knee movement (VVilliams and VVarwick, 1980).
The modification consists of attaching an additional pulley to the floor in
such a position that it lies immediately beneath the ankle when the knee joint
is extended, as shown in Fig. 21. The altered direction of pull achieved in this
way automatically increases the resistance offered to the quadriceps action in
full knee extension.
The disadvantage of the modified circuit is that resistance is offered only
Lof applying weight throughout the last 30" of knee extension, and the important middle range of
:. RS represents the
«pull' in the resting
movement is neglected. To overcome this difficulty a special piece of
_ apparatus (known as the 'Constant-resistance-through-range Apparatus' or
24 PROGRESSIVE EXERCISE THERAPY RESISTED
that if the disc were replaced b

resistance could be increased ta.
the vastus medialis more, or to i1
as dictated by needs' (Butler_
circuits are 3D
groups of the elbow and sb
to give resistance to the abd
be used to provide resistance fOl'
Ihe elevators of the shoulder gin:
-j.11
l~
Fig. 20. An alternative type of weight-and-pulley circuit for the quadriceps

femoris muscle. It is used when ceiling height is limited and the triangular
circuit cannot be employed.
J;ir. 22. A weight-and-pulley circuit 81:

8DSCles of the shoulder joint. The cin:l
... the muscles of the elbow and the c
Weight-and-pulley resistance can

suspension in providing early
Fig. 21. Schematic representation of a simple method ofmodifying a weight-and groups of the hip joint, in part
pulley circuit to give specific resistance to the vastus medialis component of the systems can also be used iI:
quadriceps femoris muscle.
'CRTRA') has been designed to give constant resistance throughout the

entire range of knee flexion and extension with very low friction.
This piece of apparatus formed part of a comparative study of three types
of apparatus used for strengthening the quadriceps femoris muscle dynami
cally (Butler and Kepson, 1980). The apparatus (consisting of a bench which
incorporates a lever system linked by a large wooden disc to the weight load)
was found to be effective both for exercise and testing purposes. Trials have
shown that if the disc were replaced by another shape, for example elliptical,
'the resistance could be increased towards the end of range of quadriceps to
work the vastus medialis more, or to increase the resistance at any part of the
range as dictated by needs' (Butler and Kepson, 1980).
Weight-and-pulley circuits are an effective means of redeveloping the
muscle groups of the elbow and shoulder joints. Fig. 22 shows a circuit
arranged to give resistance to the abductors of the shoulder. The circuit can
also be used to provide resistance for the flexors and extensors of the elbow,
and the elevators of the shoulder girdle.
ir cin::uiI Cor the quadriceps ;

;. 1iIaiIal and the triangular /
, I
Fig. 22. A weight-and-pulley circuit arranged to give resistance to the abductor

muscles of the shoulder ;pint. The circuit can also be used to provide resistance
for the muscles of the elbow and the elevators of the shoulder girdle.
~of_'
Weight-and-pulley resistance can be combined most successfully with
axial suspension in providing early strengthening exercises for the main
weigh'-""' muscle groups of the hip joint, in particular the abductors and extensors. The
~ component of the combined systems can also be used in much the same way with the shoulder
! muscles.
i
~~oe throughout the
•w:ry low friction.
Equipment·
....ati:ve study of three types
Weight-and-pulley circuits can be constructed without much difficulty or
bq. femoris muscle dynami
expense, as indicated by the examples illustrated here. They can be rigged up
I (omsisting of a bench which
in the gymnasium or, preferably, in a special pulley room.
IOdc:n disc to the weight load)
In designing or arranging a weight-and-pulley circuit it is important to
lISting purposes. Trials have
remember that the patient must not only be able to observe the moving
26 PROGRESSIVE EXERCISE THERAPY RESISl
-yw,"
weight throughout the exercise but reach it without difficulty, so that he is
capable of adjusting the amount of resistance used and feels fully involved in
his treatment programme. Both these factors are of considerable psycho
logical value.
Shaped canvas sandbags with metal eyelets or rings for the weight hook
make convenient weights. Bags graded in weight between 125 g and 5 kg are
necessary (p. 28). Sometimes metal weights are used instead; they are placed
in an open-topped canvas bag equipped with strong metal rings for the """""'w
weight hook. a
Using separate lengths of cord over individual pulley sheaves, as shown in Fig. 23. Schematic representation cl
Figs. 19 and 22, instead of utilizing one long length of cord for the entire Ruioris muscle in sitting. The resisa
of the knee extension movement becI
circuit, is economical. When they show signs of fraying and wear, which add Iioe of pull of the weight and the III
to frictional resistance, these short lengths of cord can be replaced quickly by
disconnecting the runners. lying position, it decreases from
Specialized pieces of weight-and-pulley equipment which provide a variety are made within an arc of 91
·~illl of resisted movements for different muscle groups are available from a la'Pendicu1ar distance between till:
number of manufacturers of physiotherapy equipment. Most are highly decreases, e.g. straight leg rail
'I~ priced. to the foot, and .fJ.exiou
The 'Quadriceps Bench' manufactured by the Nottingham Medical ~ elbow and a dumb-beD I
Equipment Company has been designed to give resistance to the knee
extensors through a leverage system rather than by the employment of a
weight-and-pulley circuit. The resistance force is applied to the lower leg by
means of a padded cross bar which is attached to a swinging arm fitted with
removable weights. The cross bar can be positioned along the arm at any
point between ankle and knee. This form of adjustment enables the apparatus
to be used after injuries where the stability of the lower third of the tibia does
not allow a resistance force to be applied to the ankle region, as is usual.
2. RESISTANCE BY WEIGHTS
Resistance by weights is a simple and effective method of strengthening
muscles. It is capable of being applied to any of the main muscle groups, but
in practice (as with weight-and-pulley resistance) is used chiefly for the
muscles of the limbs.
The equipment required ranges from metal discs of a known weight, which
are employed with weight boots, dumb-bells and barbells, to bags of sand or
shot. The weight marked on each bag should represent the combined weight
of contents and cover.
Weight resistance has the disadvantage that, when it is applied to the
muscle groups of the limbs in the standing and sitting positions, it incr:eases
from the beginning to the end of all movements made within an arc of 90°
from the vertical plane; this is because the perpendicular distance between wrights are used to provir
the line of pull of the weight and the moving joint increases (Fig. 23). On the • loaded weight rod is held i
other hand, when weight resistance is applied to the muscles of the limbs in
py
lit difficulty, so that he is t ,F ,w
IIIld feels fully involved in I ,!
of considerable psycho i
!F POWER ;
iap for the weight hook

----r--..t··~w
1
i ..
I i '
I:lWI:liI:D 125 g and 5 kg are : w ; 1
.~ they are placed ~
I
!
,
, '
. . . mr:ral rings for the I :
a b c
~ sheaves, as shown in Fig. 23. Schematic representation of weight resistance applied to the quadriceps
femoris muscle in sitting. The resistance increases from the beginning to the end
l1li f'I cord for the entire of the knee extension movement because the perpendicular distance between the
,... . wear, which add line of pull of the weight and the moving joint increases.
_ be Iq)laced quickly by
the lying position, it decreases from the beginning to the end of all movements
_which provide a variety which are made within an arc of 90° from the horizontal plane, because the
. . Be available from a perpendicular distance between the line of pull of the weight and the moving
. . . . . Most are highly joint decreases, e.g. straight leg raising through 50° with a loaded weight boot
attached to the foot, and flexion of the shoulder joint through 90° with
lie N«tingham Medical extended elbow and a dumb-bell held in the hand.
~ n:sisDmce to the knee In applying weight resistance to the muscles of the trunk the saml;' factors
lit' the employment of a hold good. Compare Trunk raising forwards (barbell held at chest level) from
!I6:d to the low"er.l~g by fixed lying, and Trunk lowering forwards (barbell held behind neck) from stride
~ arm fitted \Vith.. standing. In the first example the resistance decreases and in the second it
iId . . . . the arm at any increases .
••ReD.bles the apparatus
alhird of the tibia does
Ik n:gioo. as is usual. Equipment
When the muscles of the lower limb are exercised a light alloy weight boot
(e.g. Variweight boot) is worn on the foot with a short rod positioned in the
slots provided in the sole plate; the metal discs are held securely in place on
the rod by two collars with adjustable screws. Fig. 24 shows a loaded weight
~ of strengthening boot in position for the start of resisted knee extension. The weight rod is
~ muscle groups, but positioned directly under the ankle.
I is used chiefly for the In calculating the weight to be used for resistance it is essential to know
both the weight of the boot and straps, and the rod. The Variweight boot and
~ weight, which straps weigh 500 g, and the rod and collars 454 g.
to bags of sand or Although metal rods are obtainable as standard equipment it is cheaper to
• the combined weight use short lengths of gas piping. These improvised rods provide extremely
strong and lightweight forms of support for the weight discs.
lien it is applied to the The straps and buckles (or Velcro fastenings) securing the weight boot to
. . positions, it incr,eases the foot must be inspected regularly. After considerable use the straps and
. . within an arc of 90° Velcro grips often fail to hold the boot firmly in place, and must be renewed.
Iiadar distance between When weights are used to provide resistance for the muscles of the upper
~ (Fig. 23). On the limb a loaded weight rod is held in the hand; alternatively, a dumb-bell is
:lIIIIScles of the limbs in used.
28 PROGRESSIVE EXERCISE THERAPY RESISTEI
Resisted trunk movements necessitate either the use of a barbell or a canvas

bag (containing sandbag or metal weights) which is positioned on the chest or Ia progressing exercises where wei!
back and held in place by long straps. ...::d the therapist has to bear in min
liiKreasing muscle strength and byp
and atrophied muscles and ttau
comparatively low repetitions US!
Jllr:irtraining programmes, although i
~es, have frequently to be modd
1IIm:aful. On the other hand, if the ,..
repetitions at a comparative!]
idlievi.ng muscle hypertrophy; the n
endurance rather than the develoJ
h is difficult, if not impossible, to I
all conditions and all phases oj
techniques that have been fc
·i!li
'II
to exercise weak muscles.

Fig. 24. The starting position for resisted knee extension when a weight boot is createst weight which they CIIl
used. Some form of support should be employed to relieve the knee ligaments of ..-uDed rate without marked diso
strain in the resting position: here a wall-bar stool has been used for this as the '10 Repetition M.ui
purpose. Ideally the surface of the fixation bench should have a slight backward as the 'Minimum Exercise 1
slope, and a wedge-shaped pad should be used under the thigh or thighs.
the fuSt,day of treatment
exerci~eweight for a peri
Canvas-covered sandbags are available in different sizes and shapes; they ba1f-way through the session.
can also be made up fairly easily. In general, the bags need to be capable of 1f2minutes, rests until his musdel
being strapped in position without difficulty. The saddle type of bag, which for another 2 minutes.
consists of a firm strip of canvas with slots at either end for weights, is
particularly useful. When used for leg exercises from lying (e.g. straight leg
raising) it is often modified by the addition of a canvas loop attached to the
front edge. In positioning the bag the saddle area is placed over the anterior
aspect of the ankle and the loop slipped over the foot. This provides a sound
anchorage during movement.
Flat, rectangular-shaped PVC-covered sandbags can also be strapped in
position without difficulty. In general, the shaped canvas sandbag, with a
metal ring or eyelet incorporated into the upper end, is limited to use in
activities where it can be suspended easily.
Whatever type of bag is used a fairly wide range of weights is necessary, in direct proportion to Ii
e.g. 125 g, 250 g, 0·5 kg, 1 kg, 2 kg, 3 kg and 5 kg. wa:k.ly to ascertain if it may
'Portabell' weighted bands are sometimes used in place of weight bags, and ....asion in time is brought
have the advantage of being extremely easy to apply. The bands incorporate each day until the patienl
pockets filled with lead shot, and are held in place round a limb with Velcro ... 15 minutes before the
fastenings. Two weights of band are available: It lb and 2t lb. «the rest pause naturally 4
fa barbell or a canvas STRENGTH PROGRESSION TECHNIQUES

iooed on the chest or
In progressing£X~rcises where weight or weight-and-pulley resistance is
used the therapist has to bear in mind the fact that although he is aiming at
increasing muscle strength and hypertrophy he is dealing in general with
weak and atrophied muscles and traumatized joints. The very heavy weights
and comparatively low repetitions used by bodybuilders and weight-lifters in
their training programmes, although ideal for boosting the strength of normal
muscles, have frequently to be modified considerably or they may well prove
harmful. On the other hand, if the weights used are kept to a very low figure,
with repetitions at a comparatively high level, there is little chance of
achieving muscle hypertrophy; the technique will promote the development
of endurance rather than the development of strength.
It is difficult, if not impossible, to give a foolproof technique of progression
for all conditions and all phases of recovery. It is possible, however, to
describe techniques that have been found valuable over a considerable period
of time.
Early Technique
It is safe to exercise weak muscles against an initial resistance of 25 per cent of
.... weight boot is the greatest weight which they can lift ten times in succession at a normal
~1Ioec ligaments of controlled rate without marked discomfort or fatigue. This ten-times weight
IIa:o used for this is known as the '10 Repetition Maximum' or 'lORM'. The smaller weight is
~. slight backward
known as the 'Minimum Exercise Weight'.
liP O£ thighs.
On the first day of treatment the muscles are exercised against the
minimum exercise weight for a period of 4 minutes, a brief rest pause being
a and shapes; they taken half-way through the session. Thus the patient exercises continuously
IICd to be capable of for 2 minutes, rests until his muscles feel capable of exercising again, and then
~~ of bag, which exercises for another 2 minutes.
~ for weights, is Progression in strength is achieved very gradually by increasing the mini
~ (e.g. straight leg mum exercise weight by 125 or 250 g, when the patient finds that he has
~ attached to the grown accustomed to the weight he has been lifting, and the effort no longer
d over the anterior tires the muscles to any appreciable extent. Some measure of fatigue is, of
is provides a sound course, unavoidable if the weight used is of the degree necessary to achieve
muscle hypertrophy.
IIso be strapped in The weight increase is continued in this way until the resistance employed
• sandbag, with a is found to be approximately 50 per cent of the 10 Repetition Maximum
I limited to use in (which will also have increased). The minimum exercise weight is then kept
at this level until treatment is discontinued, the actual weight used being
,:iglns is necessary, increased in direct proportion to the 10 RM. This weight must be checked
twice weekly to ascertain if it may be increased.
ofweight bags, and Progression in time is brought about by increasing the exercise time by
: bands incorporate 1 minute each day until the patient is exercising with the minimum exercise
a limb with Velcro weight for 15 minutes before the rest pause, and 15 minutes after it. The
Ztlb. length of the rest pause naturally depends on the degree of muscle fatigue.
30 PROGRESSIVE EXERCISE THERAPY 101
On occasions it is extremely helpful if two exercise periods are organized

daily, provided that they are adequately spaced to avoid undue fatigue. A
morning and afternoon session is ideal, although often difficult to achieve.
It is important that the patient should be encouraged to participate fully in
his training programme. Whenever possible (and this will obviously depend
on his intelligence and attitude towards recovery) he should not only be
responsible for increasing resistance levels, but keep his own check on the
weights used and the number of minutes for which he exercises each day. All
this prevents the exercise regime from becoming tedious and automatic.
A realistic way of persuading patients to maintain records of their own
progress is to install a wall-mounted blackboard in the gymnasium or pulley
room for this purpose.
e!!lnl More Advanced Technique

~III When the muscles have reached a satisfactory state of redevelopment a more
advanced exercise technique, which combines both power and endurance
'ill
~! training, may be used; it can also be used in cases where a more strenuous
l initial exercise programme can be tolerated. This form of training has the
advantage of preparing the muscles for normal working conditions: short
periods of activity against maximum stresses and prolonged periods of work
against minimum stresses.
The technique is much the same as that previously described, with the
exception that two sets of lifts with the 10 RM are incorporated into the
training schedule. Thus
10 lifts with 10RM
Training period with minimum
exercise weight, with half-time
rest pause.
10 lifts with 10 RM
It is important to note that although the patient may not be able to perform
the full number of repetitions during the second set of lifts with the 10 RM he
must be prepared to attempt as many lifts as possible. Unless this is done
maximum hypertrophy will not result. Expert supervision and care are most
important in this type of training. An enthusiastic patient may attempt too
much and bring about muscular strain or joint effusion.
• sing the IORM of aD

iii arying out too many di8
EXERCISE TECHNIQUE muscles will becoInI:::
impossible to make
All movements must be performed in a smooth controlled manner so that the method of determi
muscles work concentrically, statically and then excentrically. Thus, in
strengthening the quadriceps femoris muscle from a sitting position ~ a
fixation bench, the patient extends the knee to its full extent, 'holds' it in this
...... are organized position for a moment, and then allows it to return to the starting position.
~ 1IIIdue fatigue. A After a momentary pause the movement is repeated. (See Figs. 19 and 24,
diIicuIt to achieve. pp. 23 and 28.)
.-niciPate fully in In exercising the muscles of the limbs it is usual to limit resistance to the
abriously depend affected limb only. When the limbs are equal in strength, however, the sound
IIIauId not only be limb may be exercised against resistance also. In practice this is seldom
QIIIl cbeck on the
necessary, because the sound limb will be exercised adequately when other
laa.eseach day. All aspects of the patient's rehabilitation programme are carried out--during
.... automatic. sessions devoted to specific and general exercises and in recreational
"'mldI of their own activities.
, ,_ _um or pulley
ASSESSING MUSCLE STRENGTII

In redeveloping weak muscles it is important to test periodically the 10
repetition maximum weight of the corresponding sound muscle group, so
that the relative weakness of the affected muscle group may be ascertained,
and a standard set for the patient to aim at. The result is expressed as a
fraction: Left/Right = 9kg/4kg, in the case of a weak right quadriceps
femoris muscle. In dealing with the trunk muscles, where this type of
comparison is not possible, a known standard is determined by testing out a
number of normal subjects.
ibed, with the The 10 RM weight of the affected and corresponding sound muscle groups
lllllillPDrlIted into the should be recorded twice weekly and plotted as a graph. These tests not only
form a reliable guide to progress but are extremely instructive. In addition,
the incontrovertible evidence that muscles are becoming stronger is a great
encouragement to both patient and therapist, especially in cases where
progress is slow.
Each time the tests are made the same weight apparatus or weight-and
pulley circuit should be used. This is particularly important when using
lot be able to perform pulley circuits, because the frictional resistance offered by individual pulley
hwiththe 10RMhe sheaves varies considerably. The same precautions apply when weights and
; Unless this is done weight-and-pulley circuits are used for exercise purposes.
1m. and care are most
ian may attempt too
L
MAKING A TEST
In assessing the 10 RM of a muscle group it is important for the patient to
avoid trying out too many different poundages before arriving at the correct
one. The muscles will become so fatigued by this preliminary work that it will
be almost impossible to make an accurate test.
Idmanner so that the A useful method of determining the weight is for the therapist to select a
amically. Thus, in weight which he considers to be a reasonable resistance for the purposes of
lining position on a the test, and then ask the patient to make a small movement against its
11m, <holds' it in this
resistance. In this way the patient can try the effect of the weight on his
32 PROGRESSIVE EXERCISE THERAPY RESIS'
muscles without using them sufficiently to produce fatigue. If he finds the The myometer head, which Cl
weight is too much, or too little (bearing in mind a series of ten repetitions), .-r:asuring element of a standard PI
the poundage is adjusted accordingly and the test repeated. -=amrmg consists of the de8CC1i
When the patient thinks that the correct weight has been found, he tries the the wiper of a conductive II
ten full movements against it. If the patient and the therapist are satisfied 100000000 operations.
after this that the weight is the right one, no further tests are made. If they are To some degree the range of usc
not satisfied with the result, the muscles are allowed to rest until they are ~ of the examiner in resisriD
ready for exercise again and a further test is made. needs to assume an extremely:
For assessment purposes a test with a One Repetition Maximum (the when testing large mu
greatest weight which can be lifted once only by the muscle group) is illllllliriceps femoris.
sometimes used when muscle development has reached a satisfactory level Methods of measuring muscle I
and there is no danger of irritating a traumatized joint. :..ometer and strain gauge, were
evaluation of voluntary-m1l
'~ometer was also the subjcc
Myometer
Recently a hand-held myometer (Fig. 25), which monitors muscle strength,
has been developed for clinical use. * Basically, the instrument is a device to Myometer
.~
measure the peak force applied by the examiner in resisting, and overcoming, simple myometer designed spell
the maximum contraction of a muscle group. The force is expressed in femoris muscle during the '
kilograms and the instrument has a recording range of 0·1-30,0 kg, which by Mr J. V. Gough,
may be seen on the digital readout display.
~IHospitaL
The myometer has the advanIlIl
a rigid frame which is positiOIE
F-wable applicator, which makes,
to the measuring deviCe. 1
a pressure gauge. Compressi
operates the gauge.
TIle resistance training methods I

... those originally formulated by
_ pan of a pioneer scheme of ma
Reset Button - f - - -"'-
UK (Nicoll, 1941, 1943).
Later, other methods of resista
~iques used by bodybuilder.
lime to time. Three main system
..-e in use today: DeLorme ane
Osford technique (1951); and M
Myometer Head with Spreader Applicator

Fig. 25. A hand-held myometer for monitoring muscle strength.
The heavy resistance systems a
* Penny and Giles Transducers Ltd., Christchurch, Dorset. although they may be used equa
. . . . . .1:.. If he finds the The myometer head, which carries a spreader applicator, utilizes the
measuring element of a standard Penny and Giles transducer. The method of
m~asUring consists of the deflection of a diaphragm in air; the deflection
moves the wiper of a conductive plastic potentiometer with a life expectancy
of 100000000 operations.
To some degree the range of usefulness of the instrument is limited by the
strength of the examiner in resisting the contractions ofthe patient's muscles.
He needs to assume an extremely stable position when using the myometer,
Maximum (the especially when testing large muscle groups such as the hamstrings and
. . muscle group) is quadriceps femoris .
a satisfactory level Methods of measuring muscle strength and fatigue, including the use of
myometer and strain gauge, were described by Edwards and Hyde (1977).
The evaluation of voluntary-muscle function by means of a hand-held
dynamometer was also the subject of a paper by Edwards and McDonnell
(1974).
muscle strength,
...ranent is a device to Fixed Myometer
A simple myometer designed specifically to test the strength of the quadri
ceps femoris muscle during the final degrees of knee extension has been
designed by Mr J. V. Gough, Director of Rehabilitation, Pinderfields
General Hospital.
",_Unlt The myometer has the advantage of being firmly stabilized during testing
by a rigid frame which is positioned over the patient's lower leg. A padded
movable applicator, which makes contact with the upper third of the tibia, is
linked to the measuring deviee. This consists of a simple, oil-filled bellows
and a pressure gauge. Compression of the bellows during extension of the
knee operates the gauge.
OTHER METHODS OF RESISTANCE TRAINING

The resistance training methods described in the previous section are based
on those originally formulated by Nicoll and Colson over the period 1940-43
as part of a pioneer scheme of medical rehabilitation for injured miners in the
UK (Nicoll, 1941, 1943).
Later, other methods of resistance training (based on the heavy resistance
techniques used by bodybuilders and weight-lifters) were developed from
time to time. Three main systems, known by the names of their originators,
are in use today: DeLorme and Watkins technique (1951); Zinovieff or
Oxford technique (1951); and McQueen technique (1954).
~ Applicator
~ strength. Heavy Resistance Systems
The heavy resistance systems are mainly intended for use with weights,
although they may be used equally well with weight-and-pulley circuits.
34 PROGRESSIVE EXERCISE THERAPY RESI
Common to the three techniques is the 10 Repetition Maximum (10 RM),

the maximum weight which can be lifted by the weak muscle group for ten of the number of indi
repetitions only. For example, in assessing the 10 RM of a weak quadriceps (all with different weigl
femoris muscle, the patient assumes a sound starting position on a fixation syKem irritating. The CODSt
bench, with a weight boot strapped to his foot, and observes the following
schedule. Starting with the weight of the boot and its loading bar, and
increasing by small amounts (e.g. 0,5-2,5 kg), he lifts each weight ten times at
a normal controlled rate. The weight which requires the maximum muscular
effort to perform the ten repetition series of lifts is taken as the 10 RM. IORM resistance is maimaI
ass of lifts.
Thus
1st sec 1
DeLorme and Watkins'Fractional' Technique 2nd sec
3td sec.
The 10 RM resistance is increased gradually over 3 sets of repetitions.
4th sec I
Thus
4~~1; 1st set: 10 lifts with half 10 RM

2nd set: 10 lifts with three-quarters 10 RM
3rd set: 10 lifts with 10 RM
'Iii
Thirty lifts are carried out daily, four times a week. Each week the 10RM
is progressed.
COMMENT
The system has the advantage of being extremely straightforward and simple
to follow. Considerable care is needed in assessing the initial 10 RM or the
patient may be disheartened by finding it almost impossible to achieve the
final full set of lifts.
ZinoviefJ (Oxford) Technique

The 10 RM resistance is decreased gradually over ten sets of repetitions.
Thus
1st set: 10 lifts with lORM
2nd set: 10 lifts with 10RM subtracting 0'5kg
3rd set: 10 lifts with 10 RM subtracting 1 kg
4th set: 10 lifts with 10 RM subtracting I· 5 kg
5th set: 10 lifts with 10RM subtracting 2kg
6th set: 10 Jifts with 10 RM subtracting 2'5 kg
7th set: 10 lifts with 10 RM subtracting 3 kg
8th set: 10 lifts with 10RM subtracting 3'5kg
9th set: 10 lifts with 10 RM subtracting 4 kg ,,- •• u:dmiques I
10th set: 10 lifts with 10RM subtracting 4·5 kg .....,.. In geueral. tbc
.....lCDJ'ft'!l'Yafter iDju
A hundred lifts are carried out daily, five times weekly. At each exercise pIIascs considen
session an attempt is made to progress the 10 RM, linin mel joint II
""'Maimum (lORM), COMMENT

iIIIl* DBISde group for ten Because of the number of individual sets of repetitions which must be
~ of. weak. quadriceps followed (all with different weights) many patients and their therapists find
~ position on a fixation the system irritating. The constant changing of weights is also extremely
,.. • .ebes the following time-consuming.
, - ' - loading bar, and
ca:It ..agbt ten times at
_lDDimum muscular McQueen Technique
IIIiD:D .. the 10 RM. The 10 RM resistance is maintained, without addition or subtraction, over
four sets of lifts. Thus
1st set: 10 lifts with 10 RM
2nd set: 10 lifts with 10 RM
3 leIS of repetitions. 3rd set: 10 lifts with 10 RM
4th set: 10 lifts with 10 RM
Forty lifts are carried out three times a week. Progression is achieved by
attempting to increase the 10 RM every one to two weeks.
Ea:h week the 10 RM COMMENT

The system is straightforward but the overall work load is heavy; the patient
needs considerable determination to follow it satisfactorily. As with the
DeLorme and Watkins technique care is needed in assessing the initial
10 RM, or overloading of the muscles may result and the patient will
experience difficulty in completing the final set of lifts .
......,. .bIe to achieve the

Other Heavy Resistance Systems
A number of other heavy resistance systems have been developed by
therapists and physical educationists with specialized experience of weight
training. In these systems the RM varies between 1 and 10, with a 6 or 8 RM
being common. The number of repetitions and sets of lifts varies also, e.g. 6,
8 or 10. For maximum muscle development six repetitions, in six sets of lifts,
is advocated (total of 36 lifts).
-...H.o-s.
Many experts in the field of weight training consider that the widely
accepted figure of 10 lifts per set could well be replaced by a lower number,
and suggest 6 as a useful compromise. They emphasize that the patient's
1-5. concentration and maximum effort wanes over long lifting sessions .
3.
H.
1r4.
Limitation of Heavy Resistance Systems
Heavy resistance techniques need to be used with considerable care in
ilrHq exercise therapy. In general, they are more applicable to the intermediate and
,~. At each exercise late phases of recovery after injury and disease than to any other stage. Ifused
in the earlier phases considerable modification is frequently necessary to
avoid muscle strain and joint reaction.
lU!
In general, standard spiral S(l

3. RESISTANCE BY SPRINGS are available in four main weig
Springs, rubber elastic strands and various compressible materials, such as and 40 lb (1S·1 kg). The weight
Dunlopillo and Sorbo rubber, all possess the property of elasticity and are n:s1stance or poundage offered .
used to provide different forms of therapeutic resistance. ape inside the spring becomes
and checks overstretching and
When a specific weight of S(l
Long Spiral Springs
1he weight required) can be 1
Long spiral (or long tension) springs, being readily extensible, offer re Kquired resistance (Fig. 274:
sistance to the working muscle group as they are stretched, and assistance to arranged in parallel are equal!
the return movement as they recoil. Alternatively, the recoil movement may
be controlled by excentric action of the working muscles (Fig. 26).
'I~
\
a
Conversely, arranging tw(
(Fig. 27b), can be used to
Fig. 26. Method of arranging a cord and spring unit to provide resistance for the provided the springs are eXD
extensor muscles of the hip in lying. The angle of pull is critical. So also is the its full limit. In practice, the:
weight resistance of the spring used; it must be capable of supporting the lower
limb in addition to providing resistance for the hip extensors.
of linkage can be cumlJen(]
Resistance given by these springs can be extremely useful, but it has two Arranging Spring Resis
disadvantages. It is not physiologically sound: resistance from springs is
In arranging spring resista
always weakest at the beginning of the movement, when the muscles are
1. A stable and cornforUI
extended, and strongest at the end of the movement when the muscles are the resisted movements to
shortened; and it cannot be accurately assessed. 2. The spring must be (J
The weight resistance of a tension spring depends on the type of material
some exercises it must also
and thickness of wire from which it is constructed and the average diameter of
part (see Fig. 26).
the coils.
r
In general, standard spiral springs are still (1982) graded in pounds. They
are available in four main weights: 10 lb (4'5 kg), 20lb (9 kg), 30lb (13'6 kg)
It a.b:rials, such as and 40 lb (18'1 kg). The weight marked on each spring represents the weight
elasticity and are re~tance or poundage offered when it is stretched to its full length. A safety
tape inside the spring becomes taut when the predetermined point is reached
and checks overstretching and damage to the coils.
~ When a specific weight of spring is not available two springs (each of half
~::Dsible, offer re the weight required) can be used in parallel combination to provide the
.... aod assistance to required resistance (Fig. 27a). For example, two 30lb (13'6 kg) springs
~ movement may arranged in parallel are equal to a 60lb (27'2 kg) spring.
~(Fig. 26).
i
Fig. 27. Springs arranged in parallel

a b and springs linked in series.
Conversely, arranging two springs of equal 'weight' end-to-end, or in series

RSisunce for the
(Fig. 27b), can be used to produce a spring of half the weight resistance,
.... So also is the provided the springs are extended through the range required to extend one to
paning the lower its full limit. In practice, the double length of spring produced by this method
I. of linkage can be cumbersome.
lid, but it has two

~ from springs is Arranging Spring Resistance
lme muscles are In arranging spring resistance a number of points must be observed:
• me muscles are 1. A stable and comfortable starting position must be used which enables
the resisted movements to be isolated correctly.
~ type of material 2. The spring must be of the correct weight resistance for the muscles; in
aage diameter of some exercises it must also be capable of supporting the weight of the moving
part (see Fig. 26).
3. The positioning of the spring in relation to the moving part requires possible. A very approximab
considerable care. The arrangement used must not only ensure that the l1li: "weight' of the spring «
spring is slightly stretched at the start of the movement, but offers effective (+5tg) spring by a 20lb (91
resistance throughout the required range of movement. . . . .ed in parallel.
4. The connecting links that attach the spring to the fixed point and the
moving part must be sufficiently strong to withstand considerable stresses.
For many movements, particularly those of a wide range nature, it is
necessary to increase the distance between the fixed point and the spring; the
link then consists of a suspension cord with a single runner for adjustment JIaalding putty, day, PIaSI
purposes. ~ both resistance for 1
The link between the spring and the moving part consists of a spring for the joints.
loaded hook with swivel and some form of sling; the self-locking 3-ring sling This type of resistance is I
shown in Fig. 26 is widely used. (See also Fig. 16, p. 19.) For some arm more realistic functional
movements a handle attached to the spring is used in place of a sling. ~p, e.g. stool searinl
and woodwork (J
~t, such as planes •
Other Types of Springs work.
Short Tension Springs .Rrmedial games which e
~al Short tension springs of a high resistance level offer minimum extensibility, Competitive blow K
and are not used in resistance training. They are sometimes employed in of a syringe to blow oti
suspension therapy to provide buoyancy when a heavy part ofthe body, such ~ly useful and popuI
as the pelvis or trunk, has to be supported in sling suspension for a fairly long the 'players' can b
period of time. The springs are then arranged to form a link between the are described and iI
overhead support and the suspension cords. 3rd ed.
Small Compressible Springs

These springs form the resistance element in the familiar hand grip unit
which is used to improve the coarse gripping action of the hand. Another degree of resistance of!
similar device for improving grip consists of a Z-shaped spring made from moved and the rate (
flat steel. !aically necessitates the di
increase in resistance.
an associated iD
Elastic Strands and Sorbo Rubber ~ce associat$d with
Rubber elastic strands of various widths are sometimes u;ed in place of long in the direction 0
spiral springs; they are especially useful for providing light resistance.
Rubber elastic has the disadvantage of not being particularly durable.
Sorbo rubber, being both compressible and extensible, is extremely useful
in providing light resistance for improving the gripping action of the hand.
Rubber balls and sponges of different shapes and sizes provide useful
variations. i.mieved by the patient usi
the limb through tb
holding a paddle or
Progression of Spring Resistance ..wement. This not only il
With spring resistance an accurate and precise progression in strength is not .. the surface area of the ;
Ie IIIIO'ring pan requires possible. A very approximate degree of progression is achieved by increasing
" euIy ensure that the the 'weight' of the spring or springs employed, e.g. by replacing a 10lb
.... but offers effective (4·5 kg) spring by a 20lb (9 kg) spring, or increasing the number of springs
*III
IIIL
tied point and the
mnsiderable stresses.
arranged in parallel.
,....ad
jIIr: mage nature, it is
the spring; the
~......::c for adjustment
4. RESISTANCE BY MALLEABLE MATERIALS
Moulding putty, clay, Plasticine or wet sand into various simple shapes
provides both resistance for the hand muscles and some degree of mobilizing
~
amsists of a spring activity for the joints.
'-locking 3-ring sling This type of resistance is limited and often employed as an introductory to
.. 19.} For some arn~ the more realistic functional activities provided by an occupational therapy
ia)llllce ofa sling.
I
workshop, e.g. stool seating, which provides both narrow and wide grips,
printing and woodwork (padded handles being used for some of the
equipment, such as planes and sanding blocks), model making and wrought
iron work.
Remedial games which encourage grip complement these workshop ac
lIlioimum extensibility, tivities. Competitive blow football (necessitating the squeezing of the rubber
om.etimes employed in bulb of a syringe to blowout air to propel a ping-pong ball along a table) is
nan of the body, such extremely useful and popular. So also is bar football: the handles used to
pension for a fairly long activate the 'players' can be adapted to offer various types of grip. These
IrDl a link between the games are described and illustrated in Wynn Parry's Rehabilitation oj the
Hand, 3rd ed.
iani1iar hand grip unit 5. RESISTANCE BY WATER

I of the hand. Another The degree of resistance offered by water depends on the surface area of the
iped spring made from part moved and the rate of movement. Increasing the surface area auto
matically necessitates the displacement of a larger volume of water and leads
to an increase in resistance. Similarly, an increase in the speed of movement
produces an associated increase of resistance. This is largely due to the
turbulence associat~d with a-more rapid movement, positive pressure being
:s uied in place of long created in the direction of the movement and a negative, or drag force,
iding light resistance. behind it.
Iicularly durable. In pool therapy, when the body is floating horizontally in the water with
b1e, is extremely useful buoyancy providing support, it is comparatively easy to enlarge the surface
jug action of the hand. area of a limb by the use of a small float, such as a swim ring or cork or
I sizes provide useful polystyrene block. When. the arm is exercised a simple progression can be
achieved by the patient using the flat of his hand (rather than the edge) as he
moves the limb through the water. A more advanced progression consists of
his holding a paddle or bat, or similar flat object, in the hand during
movement. This not only increases the lengrh of the lever but adds effectively
Ilion in strengrh is not to the surface area of the arm.
When movements are made in a downward direction from a floating .mg floats which the patieII
horizontal position the upthrust of buoyancy provides resistance. 'The *-:r the shape and density a
maximum upthrust is experienced when the limb is at right angles to the aacises can be devised in t
buoyant force. The effect is reduced the nearer the moving part gets to the *rapist may well be woIkil
vertical. If the range of movement goes beyond 90°, buoyancy will no longer It should be noted that dm
be providing resistance and the movement beyond the vertical becomes ~cy minimizes or cane:
buoyancy assisted. Flexion of the hip is an example (Fig. 28a). The starting
position is prone lying at the edge of a stretcher or over the exercise bars so
that the hip is free. The patient brings the leg downwards and forwards into
flexion. Only the first part of the movement (outer-to-middle range for the
hip flexors) is resisted by buoyancy. The rest of the movement (middle-to lill::sistance by the therapist is
inner range) is assisted. or where suitable n:
'Similarly, when doing knee extension, the full effect of the resistance will ~lled pressure should b
be felt when the lower leg is horizontal, at right angles to the buoyant force whenever possible, the
(inner range for the quadriceps) (Fig. 28b). -.rement. This is especiaD]
'The muscle work can be increased in the usual ways, by increasing speed, .Pm; the body weight and
duration, length of lever and resistance. Extra resistance can be provided by advantage.
Manual resistance of tim
1GI -.ed accurately. It is also
amount of resistance D
..,...nred for heavy occupatM
a In self-resistance the patia
example, in high sit:tiDI
can be resisted by the
r~ movements of the .
i..ated successfully by the
Self-resistance is obviou
t-.:ogth is not possible an
~ P. and Kepson G. (19E

due types of apparatus fix
ally. PhysiotJrerapy 66, 82~
~~~~~~
Dd.onne T. L. (1945) RestOG
BtaeJoint Surg. Z7, 646-66'
Fig. 28. a, Upthrust of buoyancy used as a resistance for the hip flexors from a Dd.onne T. L. and Watkins A
prone lying position at the edge of a stretcher or over the exercise bars. Only the Arch. Phys. Med. Z9, 263-Z:
first part of the movement (outer to middle range for hip flexors) is resisted by Dd.onne T. L. and Watkins J
buoyancy. The rest of the movement is assisted. b, Buoyancy used as resistance ~ Medirol Applicatio1l. Nc
for the knee extensors: same starting position as described in Fig. 28a. The full DidtF. W. (1968) A review of
effect of the resistance is felt when the lower leg is horizontal, at right angles to 4,35-41.
the buoyant force (inner range for quadriceps). (Illustrations reproduced from
'Basic hydrotherapy', Physiotherapy (1981),67,258-262, by kind permission of
the author and the Editor of the JournaL)
1m from a floating using floats which the patient has to push down into the water. These floats
5 taistance. 'The alterthe shape and density of the moving part. Very powerful strengthening
right angles to the exercises can be devised in this way, but instability is the problem, and the
~ part gets to the /therapist may well be working as hard as the patient, to hold him down.'*
/ImCY will no longer It should be noted that during upward return movements to the horizontal
e ~ becomes buoyancy minimizes or cancels out much of the resistance .
. 2&). The starting
die exercise bars so
laud forwards into
IiiddIe range for the 6. MANUAL RESISTANCE
IaDent (rniddle-to Resistance by the therapist is useful in cases where the muscles are extremely
weak or where suitable resistance apparatus is not available. Smooth
r. resistance will controlled pressure should be applied by the hand throughout the movement
it. buoyant force and, whenever possible, the therapist's stance should be in the line of the
movement. This is especially important when moderate or strong resistance
!J increasing speed, is given; the body weight and the thrusting action of the legs can then be used
em be provided by to advantage.
Manual resistance of this type has the disadvantage that it cannot be
assessed accurately. It is also not possible for the therapist to give or maintain
the amount of resistance necessary to strengthen muscles to the degree
required for heavy occupations.
In self-resistance the patient resists his own movements with a sound limb.
For example, in high sitting, with the ankles crossed, the extensors of one
knee can be resisted by the weight and pressure of the other leg. Similarly,
various movements of the wrist, elbow and shoulder of one limb can be
resisted successfully by the hand of the opposite limb.
Self-resistance is obviously extremely limited. Accurate assessment of
strength is not possible and only a relatively few muscle groups can be
treated.
REFERENCES
Butler P. and Kepson G. (1980) Quadriceps strengthening: a comparative study of
three types of apparatus for strengthening the quadriceps femoris muscle ,dynami
cally, Physiotherapy 66, 82-85.
DeLorme T. L (1945) Restoration of muscle power by heavy resistance exercises. J.
Bone Joint Surg. 27, 646--667.
lap flexors from a DeLorme T, L and Watkins A. L. (1945) Technics of progressive resistance exercises.
:De bars. Only the Arch. Phys. Med. 29, 263-273.
.-s) is resisted by DeLorme T. L and Watkins A. L (1951) Progressive Resistance Exercises: Technique
- t as resistance and Medical Application. New York, Appleton-Century-Crofts.
Fir. 2&. The full Dick F. W. (1968) A review of recent studies pertaining to strength. Br.J, Sports Med.
• right angles to 4,35--41.
n:produced from
iad permission of * This description and the accompanying illustrations are taken from 'Basic hydro
therapy' (Physiotherapy, Sept., 1981) by Anne Golland, MCSP.
Edwards R. H. T. and Hyde S. (1977) Method of measuring muscle strength and

fatigue. Physiotherapy, 63, 51-55.
2
Edwards R. H. T. and McDonnell M. (1974) Handheld dynamometer for evaluating
voluntary muscle function. Lancet 2, 757.
Nicoll E. A. (1941) Rehabilitation of the injured. Br. Med. J. 1,501-506.
Nicoll E. A. (1943) Principles of exercise therapy. Br. Med. J. 1,747-750.
McQueen I. (1954) Recent advances in the technique of progressive resistance
exercises. Br. Med. J. 2, 1193--1198.
Websters B. M. (1982) Factors influencing strength testing and exercise prescription.
Physiotherapy 68, 42--44.
Williams P. L. and Warwick R. (1980) Gray's Anatomy, 36th ed. Edinburgh,
Churchill Livingstone.
Wynn Parry C. B. (1973) Rehabilitation of the Hand, 3rd ed. London, Butterworths.
Zinovieff A. (1951) Heavy resistance exercises: the Oxford technique. Br. J. Phys.
Med. Ind. Hyg. 14, 129.
section describes a nUll

the early stages of mol
positioning and movioa
designed to COl
and directions. For
1111
and from standing
'~
ring muscle strength and
2
iIIImOmeter for evaluating
,. I. 501-506.
1'. 1.141-150.
~ progressive resistance
ad exercise prescription.
,. 36th ed. Edinburgh,
Loodon, Butterworths.
a:dmique. Br. ]. Phys.
FUNCTIONAL MOVEMENTS
This section describes a number of basic functional movements which are

used in the early stages of mobilization and re-education. They are concerned
with positioning and moving in bed and on the floor. They also include
manreuvres designed to enable patients to move safely through various
/ positions and directions. For example, from lying to sitting, from sitting to
standing, and from standing to floor level.
43
5. Movements on the bed or
floor
MOVING ON THE BED FROM SUPINE LYING

Moving Towards the Head of the Bed I......
i I
I
The mana:uvre 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. The body is then moved horizontally towards the head of the bed by a
strong thrusting movement from the soles of the feet. This action is often
associated with extension of the neck.
In clinical practice, when it is not possible to use both legs, the mana:uvre
is modified by changing the starting position. The patient flexes the hip and
0
knee of the sound leg until the knee is bent to about 90 with the sole of the
foot resting flat on the bed; at the same time he flexes the elbows to a right
angle (Fig. 29a). He then raises the pelvis off the supporting surface to the low
Bridge position by a strong movement of extension of the flexed hip and spine
combined with down-pressure from the arms and shoulder girdle (Fig. 29b).
Strong pressure on the sole of the foot of the bent leg then helps to propel the
body horizontally towards the bed head, as previously described .
.......J /'.... L nu ... nm~n

a b
Fig. 29.
Moving Down the Bed I, ..... J I

The patient assumes the crook lying position with the elbows flexed to about
90 c (Fig. 30a). As a preliminary movement he arches the spine strongly
with the pelvis remaining on the bed. He then presses down firmly with
elbows and head and raises the pelvis slightly clear of the supporting surface
(Fig. 30b).
He eases the pelvis downwards towards the heels in a relatively small range
movement. The active muscles are then relaxed smoothly and the pelvis
lowered on to the bed. This sequence of movements is repeated.
45
MOVEMENl
IIIInds facing downwards. This a

...... ~ ......................~ ...
5Drting position (Fig. 3Ia).
a b The pelvis is then raised clear
Fig.30.
.. the hips and thoracolumbar '
In practice, if it is not possible for the patient to flex both legs in the position (Fig. 3Ib).
starting position, the manreuvre can be carried out successfully using one leg
only. ..... ~.
a
Moving Across the Bed I+-I

The position is widely used J
The patient takes up the crook lying position with the anns slightly away lIal-pan and attention to press1l
from the sides and the palms of the hands resting on the bed. He raises the widely used as a preliminary
pelvis off the supporting surface (low Bridge position: Fig. 30b) and eases it JIl1:Viously described.
sideways in the required direction. He then lowers the pelvis on to the bed, In certain clinical conditions
allows the legs to straighten out, and adjusts the alignment of the upper trunk 11K: crook position the bridgil
and head. crooked. The starting position i
It is possible to carry out this manreuvre with one leg in a crook position. daring movement manual supp
When moving to the side of the straight leg it is advisable to place this limb llattocks. Another method ofP
111~ into an abducted position, so as to avoid adduction stresses at the hip during
"111 the sideways movement. This is particularly important in the postoperative
care of a total hip replacement.
Rolling on to the Left Side IL~ I To roll to the left from supim
die left; he then brings the k
The patient flexes the hip and knee of the right leg until the knee is bent to ..u:es contact with the outer si
about 90°, with the sole of the foot resting flat on the bed; the left leg is 1D 90° with the ~1&ow extendec
straight and the left hand grasps the side of the bed with the arm slightly swung vigorously across the '
abducted. A simultaneous movement of strong head turning to the left, right lDIDed strongly to the left ant
arm stretching across the chest-with a finn thrust from the right foot-helps At the end of this manreuvr
to rotate the whole of the trunk and pelvis to the left. die left thigh and the right 2
In this position the flexed right leg lies over the straight left leg. To pient then arches the spine ~
stabilize the body the left leg is then flexed to the same degree as the right. ..,sition.
The patient is then in a modified crook side lying position. If the patient finds it difficul
In this posture considerable pressure is exerted on the left shoulder, and _ indicated here, a series of s
some patients, particularly the elderly, may experience considerable discom em be made with the arm
fort. To avoid this the right hand can be used to press down on the bed and IDOvement which carries the
help to manreuvre the arm and shoulder into a comfortable position. Another method of rolling
die left head post of the be<
IDOvements with a strong pU:
Assuming Bridge Position ~ In the initial stages of ro
1herapist stands at the side 0
The patient flexes the knees to 90 0 with the soles of the feet resting on the bed;
N.B. It is important to no
the legs are slightly astride with the inner borders of the feet about a foot
patient must be positioned s
breadth apart. The anns are slightly away from the sides with the palms ofthe
MOVEMENTS ON THE BED OR FLOOR 47
~----
hands facing downwards. This arrangement oflegs and arms ensures a stable
starting position (Fig. 31a).
The pelvis is then raised clear of the supporting surface by strong extension
of the hips and thoracolumbar spine with associated knee extension: Bridge
II::K both legs in the position (Fig. 31b).
IIfulIy using one leg
.....~ ................. ~ ....
a b
Fig. 31.
IDDS slightly away The position is widely used for various nursing procedures, e.g. giving of
bed-pan and attention to pressure areas. In a modified form (low Bridge) it is
=bed. He raises the
widely used as a preliminary to a number of functional movements, as
ir·3(6) and eases it
previously described.
dYis on to the bed,
In certain clinical conditions when it is not possible to utilize both legs in
tof'the upper trunk
the crook position the bridging manreuvre can be achieved with one leg
crooked. The starting position is then somewhat unstable. To count~ract this
ill a crook position.
during movement manual support can be provided under the lumbar spine or
e to place this Jimb
buttocks. Another method of providing stability is to support the straight leg
!II at the hip a.~ring
• the postoperative with a firm pillow .
Rolling froIn Supine to Prone Lying ffS]

To roll to the left from supine lying the patient crosses the right ankle over
the left; he then brings the left arm close to the left side so that the palm
the knee is bent to
makes contact with the outer side of the thigh. The right shoulder is abducted
bed; the left leg is
to 90" with the elbow extended and the palm facing upward. The arm is then
:h the arm slightly
swung vigorously across the chest to the left. Simultaneously, the head is
IIg to the left, right
turned strongly to the left and the trunk follows the movement.
II! right foot-helps
At the end of this manreuvre the patient lies prone with the left arm under
the left thigh and the right arm, with elbow flexed, under the chest. The
lIight left leg. To
patient then arches the spine slightly and brings the arms into a comfortable
Icgree as the right.
position.
Do
If the patient finds it difficult to achieve prone lying in one main movement,
left shoulder, and
as indicated here, a series of small range rocking movements towards the left
lliderable discom
can be made with the arm and trunk. They culminate in one definite
III on the bed and
movement which carries the patient over into prone lying.
Ie position.
Another method of rolling over to the left consists of the patient grasping
the left head post of the bed with the right hand, and assisting the trunk
movements with a strong pulling action.
In the initial stages of rolling, manual assistance is often helpful. The
rating on the bed; therapist stands at the side of the bed to which the movement is made.
feet about a foot N.B. It is important to note that at the start of the rolling procedure the
:h the palms of the patient must be positioned so that when he assumes the prone position his
48 PROGRESSIVE EXERCISE THERAPY MOVEMEN'l
body is fully supported by the bed and there is no likelihood of his falling over X.B. Seat lifting is widely use
the edge. lime in wheelchairs and an
The lifting is done iI
to accomplish the moveDJI
MANffiUVRES ON THE FLOOR OR BED
~
IliraYeUing': a simple methl
Seat Lifting (to relieve the buttocks of body pressure)
The patient assumes the long sitting position with the trunk inclined slightly ,,,,.,.uung' Forwards ...... -+
backwards and the palms of the hands resting on the supporting surface with patient assumes a modif'icl
the fingers pointing outwards. He then lowers the trunk backwards a few _-breadth apart, the trunk iII
degrees and raises the seat clear of the floor or bed by strong extension of the flat on the supporting S1l
hips, the hands and heels carrying the total body weight (Fig. 32). The seat is He then lifts the seat ck::
then returned to its original position by a reversal of the previous movements. ~eously carrying it fora
knees (Fig. 34b). He then I
_~_L""
a
•••••• ~._
b
... _.
"position the seat is situated
well flexed, and the trunk i
--~
1l1li Fig. 32.
"I Seat lifting can also be carried out from the standard long sitting position ..... -.-.--
with the trunk vertical and the arms by the sides. In this case it is easier if the a
hands are clenched and the weight is taken chiefly on the proximal phalanges.
When seat lifting is carried out on a bed or soft mat (where the supporting
surface will yield to hand pressure) it is advisable to use a pair of hand grips To progress along the floor
mounted on rectangular wooden bases (Fig. 33). distance. He then moVe3
the original starting posit
of movements is repeaD
"TN!lJelling' Backwards .:!=...:
is achieved in much til

!-we:ment starts by the patic
rliKkward direction. He thera
-.,yes it back towards the at!
1Ial. Finally, the feet are m
-nng position is assumed.
"Travelling' Sideways \. .]
The patient assumes a modi!

die trunk inclined backwards
Fig. 33. Seat lifting is facilitated by the use of a pair of platform mounted hand die hands rest on the suppoI1
grips. To move, for example, to t
DOd of his falling over N.B. Seat lifting is widely used by patients who have to spend long periods
of time in wheelchairs and armchairs to relieve the buttocks of constant
pressure. The lifting is done intermittently, the hands grasping the chair
arms to accomplish the movement.
.-n:>.i
I1IDk inclined slightly
'Travelling': a simple method of moving the body over a support
ing surface
<Travelling' Forwards -+ -+
ppotting surface with
The patient assumes a modified crook sitting position with the feet about a
. . backwards a few
foot-breadth apart, the trunk inclined backwards and the palms of the hands
IftlDg extension of the
resting flat on the supporting surface with the fingers pointing outwards (Fig.
~(FW. 32). The seat is
34a). He then lifts the seat clear of the bed or floor by extending the hips,
pn:v:ious movements.
simultaneously carrying it forwards towards the heels by flexion of the hips
and knees (Fig. 34b). He then lowers the seat to the supporting surface. (In
this position the seat is situated some distance in front of the hands, the knees
~.- ..... are well flexed, and the trunk is inclined further back.) (Fig. 34c.)
llong sitting position

I cae it is easier if the
..~... _.. _ . h1____ . _.lvL..
a b c
~proximal phalanges.
Fig. 34.
~ the supporting
r a pair of hand grips To progress along the floor or bed the patient places each foot forwards a
short distance. He then moves the trunk and arms in the same direction, so
that the original starting position is assumed. To cover a wider distance the
series of movements is repeated.
<Travelling' Backwards 4- <Iff-

This is achieved in much the same fashion as 'travelling' forwards. The
movement starts by the patient moving the arms, and then the trunk, in a
backward direction. He then lifts the seat off the supporting surface and
moves it back towards the arms. Next, he lowers the seat on to the floor or
bed. Finally, the feet are moved backwards in turn, so that the original
starting position is assumed.
'Travelling' Sideways 1. . . 1
The patient assumes a modified long sitting position with the feet together,
the trunk inclined backwards with the arms away from the sides; the palms of
Ifixm mounted hand the hands rest on the supporting surface with the fingers pointing outwards.
To move, for example, to the left, the patient leans back slightly and raises
50 MOV!
PROGRESSIVE EXERCISE THERAPY
the seat clear of the floor or bed, so that the body weight rests entirely on the The body is then raised
heels and hands. Simultaneously, he moves the pelvis over to the left. He then legs and arms, the toes oft
lowers the seat to the supporting surface, and moves first the hands with the to the movement. In the p
trunk, and then each foot separately, to the left. over the chair seat, with d
To cover a wider distance this series of movements is repeated. leg fully extended. The rei
N.B. To avoid pressure on the heels 'travelling' sideways can be carried out (Fig. 36c).
from a modified crook sitting position. See 'Travelling' forwards.
MOVEMENTS AT FLOOR LEVEL

.bj:::L..
a
Moving from Sitting on Floor to Sitting on Low Stool ~
The rear leg is now am
The patient assumes a long sitting position (p. 267) with the spine in contact The trunk is then raised t1
with the front edge of a stool, 20-25 cm high, positioned behind him. He
moves the arms backwards and places the palms of the hands on either side of
the stool top, close to the front edge, so that the elbows are well flexed and the
shoulder joints fully extended. Fig. 35a-b. MOVEMENTS IN PR()
1111 Although many individual
mobility, find prone lyiIq
-.~~ ~ ~
«
length of time, it is undoub
a stable starting position, fj
....... ... ..
trauma. Similarly, it allow.
a b c
with the lower legs maina
Fig. 35.
reducing oedema.
He then parts the legs slightly and flexes the hips and knees as far as In addition, prone lyi
possible with the soles of the feet resting on the flo~r, each leg being moved in movemen~s to be carried
tum. Then, with a strong movement of extension of the arms, reinforced by assuming.:prone kneeling. 1
extension of knees and hips, he lifts the body upwards and backwards so as to forwards in a series of 'WI
bring the buttocks on to the front edge of the stool (low grasp inclined long
sitting position) (Fig. 35c). From this position he flexes each knee in tum to Arching
about 90°, inclines the trunk slightly forwards, and eases the seat back on the
Arching movements of til
stool to a better sitting position (by extension of knees and downward
forearm support position (
pressure through the straight arms). The hands, in tum, are then moved
downward at shoulder Ie
backwards to a more comfortable position on the stool.
degree of elbow extension
the movements (Fig. 37a)
A wider range of spinl
Assuming Standing from Prone Kneeling with Use of Chair ~ achieved by placing the
mid-chest level. The eU)01
From prone kneeling (p. 268) with a chair positioned so that the front edge of (Fig. 37b).
the seat is close to the head (Fig. 36a), the patient first places the palm of each
hand on the chair seat. He extends the elbows fully so that the trunk is raised
backwards to an oblique position. He then moves one leg forward so that .---~--------
the hip and knee are well flexed and the sole of the foot rests on the floor
(Fig. 36b).
Itt rests entirely on the The body is then raised upwards by a strong thrusting movement of both
ftr to the left. He then legs and arms, the toes of the rear foot being dorsiflexed to give added thrust
irst the hands with the to the movement. In the position reached in this way the arms are vertically
over the chair seat, with the trunk more or less horizontal, and the forward
~ is repeated. leg fully extended. The rear leg, slightly flexed at the knee, rests on the toes
IIlIJS can be carried out (Fig. 36c).
~ forwards.
a 6 c
rStoolJ. Fig. 36.

The rear leg is now carried forwards and placed alongside the other one.
.. the spine in contact
The trunk is then raised to the vertical.
...m behind him. He
IIIIads on either side of
~ well flexed and the
MOVEMENTS IN PRONE LYING ON BED OR MAT
Although many individuals, particularly the elderly and those with limited
mobility, find prone lying an uncomfortable position to maintain for any
.=
length of time, it is undoubtedly extremely useful in clinical practice. It forms
a stable starting position, for example, for encouraging knee flexion following
trauma. Similarly, it allows ankle and foot movements to be performed freely
with the lower legs maintained in the verticaL This is particularly useful in
reducing oedema.
I lI1ld knees as far as In addition, prone lying not only allows a range of spinal arching
dJ. leg being moved in movements to be carried out, but forms a natural introductory step to
Ie arms, reinforced by assuming prone kneeling. From prone lying the body can also be manreuvred
ad backwards so as to forwards in a series of 'wriggling' movements.
.. grasp inclined long
s each knee in turn to Arching
IS the seat back on the
Arching movements of the spine can be facilitated by placing the arms in
IDees and downward
forearm support position (arms to sides, elbows fully flexed and palms facing
wrn. are then moved
downward at shoulder level). The movements are associated with a small
L
degree of elbow extension, the forearms and palms providing a firm base for
the movements (Fig. 37a).
A wider range of spinal arching, combined with hip extension, can be
JseofCbair J. achieved by placing the palms of the hands by the sides of the trunk at
mid-chest level. The elbows are then extended fully during the trunk arching
ullat the front edge of
(Fig. 376).
!laces the palm of each
.-.-~ ~ ~.-
hat the trunk is raised
Ie leg forward so that
.. - .. -.- ... -.---.- .... ..
bot rests on the floor a 6 c
Fig. 37.
52 MOV1!Ml
The palms may also be moved forwards until they are in line with the head. support position (see ArchiD
Full elbow extension is then associated only with spinal extension (Fig. 37c). plantar surfaces of the toe
Arching is useful in the treatment of postural kyphosis and round populsive action is acbie'¥'
shoulders. It is also valuable in the early mobilization of young adults who pressure from the toes), folIO!
have spent considerable periods of time in bed following various onhopll!dic
procedures, e.g. fractured shaft of femur treated conservatively with
Thomas's splint and traction.
..
,.
Assuming Prone Kneeling

)iI~ With the arms in forearm support position (see Arching) the trunk is moved
#i~
backwards mainly by strong pressure from the arms (full elbow extension
~ with shoulder flexion) combined with flexion of the hips and knees. To bring
the arms into the vertical position the hands are 'walked' backwards to the
required degree (Fig. 38a-c).

C
-~_. ____ LL. ___ .~ __
•
f.I
a b
Fig. 38.
Leopard Crawl ('Creeping')

This is a somewhat complex and strenuous method of propelling the body in
a forward direction along the bed or mat, using a contralateral pattern of
movement. It is carried out from a modified forearm support position with
the upper arms venical and the forearms resting on the supporting surface;
the hands may be clenched, which is preferable, or the palms may face
downward.
The movement starts by the right arm being moved forwards a short
distance while the head and trunk are turned to the left. At the same time the
left knee is drawn up through 90°, with the inner aspect making contact
with the supporting surface. The body is then propelled forwards by a
strong levering movement of the right arm (which acts as a prop for the trunk)
combined with a thrusting movement from the flexed left leg. To continue
the forward progression the same pattern of movement is repeated with the
other arm and leg.
This method of progression in prone lying is often beyond the physical
capabilities of many elderly and disabled individuals. A similar but less
strenuous method of progession consists of a 'wriggling' type of manreuvre.
'Wriggling'
This consists of propelling the body in a forward direction along the bed or
mat. The patient moves in a wriggling motion with the arms in forearm
De with the head. support position (see Arching) and the ankles fully dorsiflexed, so that the
l!IISion (Fig. 37,). plantar surfaces of the toes rest on the supporting surface. The main
IOSis and round propulsive action is achieved by alternate hip updrawing (with strong
oung adults who pressure from the toes), followed by alternate elevation of the shoulder girdle.
nous orthopredic
servatively with
c trunk is moved
dhow extension
Iknees. To bring
.awards to the
~.-
:mng the body in

lateral pattern of
on: position with
pporting surface;
palms may face
fOrwards a short
he same time the
: making contact
If forwards by a
rap for the trunk)
leg. To continue
q>eated with the
IJIld the physical

similar but less
pc of manreuvre.
along the bed or

IIlDSin forearm
MOVING FROIil
6. Moving from sitting and From this position the patient I

1D the right knee. The body is m
standing lland to assume a right side sinD
RSting on the chair seat. This bII
me left lower leg.
c-fl_=
___/\_D._--..
MOVING FROM SITTING TO FLOOR LEVEL .-t a
b
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 From side sitting a variety of (I
of the stool (low grasp inclined long sitting) (Fig. 39a). Taking the weight on 8ting, crook sitting, crook side
his hands he eases the pelvis slightly forwards and lowers it on to the floor N.B. The back of a chair can a
with the trunk held erect (Fig. 39b). During this mana:uvre the knees and .........;na (see belO'W). It is less sul
hips are well flexed, and the main muscle work is confined to the extensors of the patient to keep 11
the elbows .
• 1
<tfl
_L___~
a b
_ __ Grasping Chair Bad
patient grasps the back of I
body positioned as shown in
me weight of the rear leg [1
Fig. 39
_ di _ _ _ _
From the position shown in Fig. 39b the legs are then straightened out and
the palms of the hands placed on the floor (long sitting).
N.B. The use of a stool or chair higher than that recommended prohibits
the use of this mana:uvre because of the demands made on the working
muscles and the stresses imposed on the shoulder joints and shoulder girdle.
J
a b
MOVING FROM STANDING TO FLOOR LEVEL .-t Taking most of the body weigi
modified half-kneeling positill
Hands Supported on Chair Seat !llllckwards until he is in the mo
The patient faces the front of a chair seat with his feet about a foot-length back. The pelvis is then •
away from the front edge. He places the palms of the hands flat on the seat heels (Fig. 41c).
so that the trunk assumes a horizontal position. He then carries one The right hand is taken oft' 1
leg backwards and places the foot on the floor with the ankle dorsiflexed to the right knee. The bo
(Fig.40a). to assume a right-side sin
The body is lowered downwards until the patient is in a modified half the chair back to provid
kneeling position (Fig. 40b). The forward leg is then carried back until it lies die floor by the side of the I
alongside the other; this brings the patient into the kneeling position with the From side sitting many other
palms of the hands resting on the chair seat (Fig. 40c).
54
MOVING FROM SITTING AND STANDING 55
g and
From this position the patient places the right hand on the floor, just lateral
II)the right knee. The body is then lowered sideways in the direction of the
iand to assume a right side sitting position (p. 267), with the left hand still
RSting on the chair seat. This hand is then placed on the floor by the side of
die left lower leg.
ELJ..
_ AB _____ ~_ _ _1H
a b
Fig. 40.
c
lie legs stretched out in

Ie bands grasp the sides From side sitting a variety of other positions may be readily assumed: long
I. Taking the weight on sitting, crook sitting, crook side-lying, prone kneeling and prone lying.
IIWeI'S it on to the floor N.B. The back of a chair can also be used to give support during the body
lIO:UVre the knees and lowering (see below). It is less stable than the chair seat but has the advantage
Bed to the extensors of of allowing the patient to keep the spine erect during the initial stages of the
movement.
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. 41a. The arms are shoulder-width apart
and the weight of the rear leg rests on the toes.
I. straightened out and

1&>.
commended prohibits
III8de on the working
I and shoulder girdle. _ _cd____ dSL-----rU_
a b c
Fig. 41.
Taking most of the body weight on the hands the patient lowers the body to
a modified half-kneeling position (Fig. 41b). He then moves the forward leg
backwards until he is in the kneeling position with the hands still holding the
II about a foot-length chair back. The pelvis is then lowered backwards until the buttocks rest on
baods flat on the seat the heels (Fig. 41c).
fIe then carries one The right hand is taken off the chair back and placed on the floor, just
Ihe ankle dorsiflexed lateral to the right knee. The body is lowered sideways in the direction of the
hand to assume a right-side sitting position (p. 267), with the left hand still
is in a modified half holding the chair back to provide a steadying effect. This hand is then placed
Iricd back until it lies on the floor by the side of the left lower leg.
ling position with the From side sitting many other positions may be assumed, as outlined in the
previous section.
56 PROGRESSIVE EXERCISE THERAPY MOVINGFR
MOVING FROM SITTING TO STANDING ~

Use of Chair
The rising movements can be
Sitting in Chair with Arms
bead of the bed, as shown in E
From the sitting position the patient places the hands well forward on the presses down strongly on the :
chair arms and draws the heels slightly back to bring them underneath the am nearest to him with the 01
front edge ofthe chair. The hands then grip the chair arms and the trunk is
inclined slightly forwards (Fig. 42a). 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 (Fig. 42b).
~-----~--
a b
N.B. With the patient SlaD
n:quires the minimum of effor1
.\
'fli
Fig. 42.
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.
so that he comes to stand witb
(During this re-positioning be
* other.) The patient can n01ll
assist in the lowering process.
N.B. For the elderly and the disabled chairs with arms are essential. They
can then help themselves to stand by using their hands and arms, as
previously described. The base of the chair should be as wide and stable as
possible to prevent tipping when the patient endeavours to stand.
Sitting in Chair without Arms

~
The patient stands on the fl(XJ
Moving from sitting to standing is achieved in much the same manner as llmister rail; the toes are close
previously described, but the patient starts by having the palms of the hands To ascend the stairs the sou
resting over the lower thighs. In rising he exerts downward pressure on the 1Idl forwards on the first trc
thighs. .,vement weight is taken on
For the elderly and the disabled getting up from a chair without arms can provides additional support.) I
be a somewhat precarious manreuvre. Much depends on the physical ability ixwards, the weight being tali;
of the individual concerned. Ibe hand on the banister conti
The sound limb is then strai
position. At the same time tb
Sitting over Side of Bed mee) and the foot placed on tb
To achieve standing from this position the height ofthe bed must allow the The same stair-climbing tc
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 • Preparatory Method. The siD
IISed when the weakness of one leg
mattress or are placed over the lower third of the thighs. Handgrips mounted ammal manner. The same basic I
on rectangular-shaped boards (see Fig. 33, p. 48) may be used to prevent the ~ full weight-bearing on the WC!
hands sinking into the mattress as downward pressure is exerted. ill stair work are outside the scop
MOVING FROM SITTING AND STANDING 57
Use of Chair
The rising movements can be aided by positioning a chair with arms at the
head of the bed, as shown in Fig. 43. In getting up from the bed the patient
lid! forward on the presses down strongly on the mattress with one hand, and grasps the chair
IIan underneath the arm nearest to him with the other, so as to gain additional support.
lIDS and the trunk is
rcdalded and at the
~iDdined position of
.ads take the weight
Fig. 43.
N.B. With the patient standing with one hand holding the chair arm it
requires the minimum of effort to manreuvre the feet and body through 90°,
so that he comes to stand with his back towards the front edge of the chair.
(During this re-positioning he has to transfer his grasp on one chair arm to
tinuous extension of
the other.) The patient can now assume a sitting position, using both hands to
.. and the arms are
assist in the lowering process.
l in standing.
I are essential. They
IIIDds and arms, as
I wide and stable as
NEGOTIATING STAIR8-PREPARATORY METHOD*
I to stand.
Ascending Stairs i
The patient stands on the floor facing the stairs with one hand holding the
!be same manner as banister rail; the toes are close to the riser of the first step.
~ palms ofthe hands To ascend the stairs the sound leg is raised and the sole of the foot placed
.-d pressure on the 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
Dr without arms can provides additional support.) (Fig. 44a.) The body is then inclined slightly
l the physical ability 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 (flexed slightly at hip and
knee) and the foot placed on the first tread alongside the other foot (Fig. 44b).
~ bed must allow the The same stair-climbing technique is used to negotiate the rest of the
I, the feet resting flat stairs.
the previous section

I either rest on the * Preparatory Method. The simple method of negotiating stairs described here is
used when the weakness of one leg prevents the patient moving up and down stairs in a
Handgrips mounted normal manner. The same basic pattern is followed when sticks or crutches are used
~used to prevent the and full weight-bearing on the weak leg is not allowed. The methods of using these aids
is exerted. in stair work are outside the scope of this section and have not been described.
-~----
a
Fig. 44.
b
Ideally, to achieve maximum support-although this is often not a

practicable proposition-the banister should be on the side of the affected leg.
PROGRESSIV
Descending Stairs .-t
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 IntroductiOl
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 The free exercises listed here 81
movement (Fig. 45). and mobility, as described in (
... all parts of the body.
In arranging the neck and tr1
las to be covered, each section I
into Static or Isometric ExercU
with a brief analysis of the IDII
Grading. All the exercises Ii
&Tly, Intermediate and Adv(l1I
icasible, into two or more graI
Fig. 45.
Numbers prefixing the eXI
The body is then lowered downwards, by controlled flexion of the hip and ftrious grades. Where more d
pade, the number is folloM
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 Intermediate Exercises for Sp
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.
PART 3
often not a
: affected leg.
PROGRESSIVE EXERCISES
I the edge; he
IUlld leg, and

)Se to the top
Introduction
\ during this The free exercises listed here are arranged progressively in terms of strength
and mobility, as described in Chapter 2 (pp. 7-12), and include movements
for all parts of the body.
In arranging the neck and trunk exercises, where a wide range of exercises
has to be covered, each section devoted to a particular muscle group is divided
into Static or Isometric Exercises and Dynamic or Isotonic Exercises, together
with a brief analysis of the main type of movement.
Grading. All the exercises listed are grouped under three main headings:
Early, Intermediate and Advanced. In turn, each group is divided, whenever
feasible, into two or more grades.
Numbers prefixing the exercises indicate progression throughout the
rthe hip and various grades. Where more than one exercise of the same type is listed in a
the first stair grade, the number is followed by a, b or c to indicate this. See p. 82,
nee. (During Intermediate Exercises for Spinal Extensors.
a few degrees
hand on the
md the foot
of the stairs.
59
7. Head and neck exercises
Head and neck exercises provide work for the muscles which activate the
atlanto-occipital joints and the joints of the cervical spine. The exercises
given here have been classified in relation to the individual muscle groups.
Starting Positions
Many types of starting positions are used for head and neck exercises, but
those most useful for remedial work are sitting, low grasp sitting (Fig. 46)
and reach grasp sitting (Fig. 47). Crook sitting and cross sitting (Figs. 48 and
49) are often used in the treatment ofsmall children. The low grasp and reach
grasp sitting positions are valuable when head side bending and head turning
exercises are performed, because the shoulders are fixed.
Fig. 46. Fig. 47. Fig. 48. Fig. 49.
In this chapter the sitting position has been used when describing exercises
which may be performed from it or any of its suitable modifications.
FLEXORS OF HEAD AND NECK

Types of Dynamic Exercises
Head on Trunk
Three main groups of exercises are classified here.
1. Flexion of the head and neck from lying and crook lying.
Example: Yard (palms on floor) lying; Head bending forwards (Fig. 50).
2. Part-range (from and to midline) extension and flexion of the head and
neck from sitting.
61
62 PROGRESSIVE EXERCISE THERAPY B
Example: Sitting; Head bending backwards.

3. Full-range flexion and extension. of the head and neck from the high
lying position with the head unsupported.
Example: High lying (plinth: head unsupported); Head bending forwards and
backwards, and return to starting position (Fig. 51).
~~·"~l
,," \,.....
,\(if:ryO·· ,
~ '\... ,...I
J
Fig. 50. Fig. 51.
~ening Exerc:isl
Strengthening Exercises ilr-mtary: No.1, p. 62;
Elementary
-
at
GRADE
GRADE
1
1. Sitting; Head bending backwards.
2
1. ~o progression.
2. Yard (palms on floor) lying; Head bending forwards. (See Fig. 50.)
of Dynamic ED:
from sitting or exta

F.x.am.ple: (i) Sitting; B
(ii) Forehead I
Intermediate
6. Full-range flexion I
GRADE 1
1. No progression. Example: Prone knee~
2. High lying (plinth: head unsupported); Head bending forwards and to starling pt.J
backwards, and return to starting position. (See Fig: 51.)
EXTENSORS OF HEAD AND NECK
Types of Static Exercises
1. Attempted Movement
Attempted movement of the head and neck from lying and crook lying
~ Fig. 53.
without movement of the joints.
Example: Lying; Head pressing backwards.
2. Trunk on Head
This group includes d
2. Fixation of Head and Neck exercises; they are perf(
Stabilization of the head and neck in the Body raising type of exercise from a lying, and stride crook ~
suitable lying position. Examples: (i) Lying; j
Example: Stride lying (head supported by partner); 'Log raising' by partner (ii) Arm C1'e
(Fig. 52). Wrestle!
HEAD AND NECK EXERCISES 63
... oedt from the high
.-i~~fonwardsand
I(FW·51).
b
Fig. 52.
'Y.51.
Strengthening Exercises
Elementary: No. I, p. 62; Advanced: No.2, above.

1. Head on Trunk
Two main groups of exercises are classified here:
a. Part-range (from and to midline) flexion and extension of the head and
wards. (See Fig. 50.) neck from sitting or extension of the head and neck from prone lying.
Example: (i) Sitting; Head bending fonwards.
(ii) Forehead rest prone lying; Head bending backwards.
b. Full-range flexion and extension of the head and neck from prone
kneeling.
Example: Prone kneeling; Head bending fonwards and backwards, and return
I bending forwards and to starting position (Fig. 53) .
... 51.)
Fig. 53. Fig. 54. Fig. 55.

l lying and crook lying
2. Trunk on Head
This group includes the Chest ralsmg and Wrestler's Bridge types of
exercises; they are performed from such starting positions as lying, crook
I type of exercise from a lying, and stride crook lying.
Examples: (i) Lying; Chest raising (Fig. 54).
t "LDg raisi~ by partner (ii) Arm cross stride crook lying (head on mat); press up to high
Wrestler's Bridge (Fig. 55).
m
Strengthening Exercises GRADE 2

1. Prone kneeling; Head
Elementary rhythmical pressing to a gi'V
GRADE 1 la. Prone kneeling; Hea(
1. Sitting; Head bending forwards. 2. Prone kneeling; Head
3. Forehead rest prone I
GRADE 2
1. Prone kneeling; Head bending forwards and backwards, and return to
starting position. (See Fig. 53, p. 63.)
2. Forehead rest prone lying; Head bending backwards.
3. Lying; Chest raising. (See Fig. 54, p. 63.)
Intermediate Types of Dynamic Exer

GRADE 1
1 and 2. No progressions.
Three main groups of exel
3. Crook lying; Chest raising. I. Full-range flexion 3114
lying.
GRADE 2
Example: Crook side-Ij
return to starll
tllM
3. Neck rest crook lying; Chest raising. 2. Part-range (from and
the: head and neck from si
t Advanced
Example: Sitting; Head
chest, foll~
GRADE 1
position.
3. Straightening of the I
3. Arm cross stride crook lying (head on mat); press up to high Wrestler's occipital joints, followed Il
Bridge. (See Fig. 55, p. 63.) occipital joints (Chin inill
usually taken from sitting
GRADE 2
Strengthening Exercls
3. Arm cross stride lying (head on mat); press up to low Wrestler's Bridge
(Fig. 56). Elementary
GRADE 1
:;:;?';:.-3--·~"-·
-S ~
1. Crook side-lying; H
iI""~
...... "
•• '
starting position.
Fig. 56.
GRADE 2
1. No progression.
Mobilizing Exercises 2. Sitting; Head bend
Elementary chest, and Head stretchl
3. Sitting; Head bene:
GRADE 1
chest, followed by Head
L Sitting; Head dropping forwards and stretching upwards.
4. Sitting; Chin indn
2. Sitting; Head nodding forwards (1-2), followed by stretching upwards
position.
(3-4).
GRADE 2
1. Prone kneeling; Head bending forwards, and bending backwards with
rhythmical pressing to a given count, followed by return to starting position.
1a. Prone kneeling; Head bending forwards and backwards continuously.
2. Prone kneeling; Head dropping forwards and bending backwards.
3. Forehead rest prone lying; Head bending backwards with rhythmical
pressing to a given count.
awards, and return to
IJr.Irds.
FLEXORS AND EXTENSORS OF HEAD AND NECK

Types of DynaDlic Exercises
Head on Trunk
Three main groups of exercises are classified here.
1. Full-range flexion and extension of the head and neck from crook side
lying.
Example: Crook side-lying; Head bending forwards and backwards, and
return to starting position.
2. Part-range (from and to midline) or full-range flexion and extension of
the head and neck from sitting.
Example: Sitting; Head bending forwards to press the chin gently against the
chest, followed by Head bending backwards, and return to starting
position.
3. Straightening of the cervical concavity with slight flexion of the atlanto
IS up to high Wrestler's occipital joints, followed by flexion of the neck with extension of the atlanto
occipital joints (Chin indrawing and poking forwards). The movements are
usually taken from sitting.
D low Wrestler's Bridge
Elementary
GRADE 1
1. Crook side-lying; Head bending forwards and backwards, and return to
starting position.
GRADE 2
1. No progression.
2. Sitting; Head bending forwards to press the chin gently against the
chest, and Head stretching upwards.
3. Sitting; Head bending forwards to press the chin gently against the
gupwards. chest, followed by Head bending backwards, and return to starting position.
I by stretching upwards 4. Sitting; Chin indrawing and poking forwards, and return to starting
position.
66 HI
Mobilizing Exercises Mobilizing Exercises

Elementary Elementary
GRADE 1
GRADE 1
1. Crook lying; Head be
1. Crook side-lying; Head bending forwards and backwards continuously.
GRADE 2
GRADE 2
1. No progression. 1. Sitting; Head bendinl
2. Sitting; Head bendin
count.
LATERAL FLEXORS OF HEAD AND NECK

Head on Trunk ROTATORS OF HEAl
Lateral flexion of the head and neck from lying, crook side-lying and sitting. Types of Dynamic Ese!
Examples: (i) Crook lying; Head bending sideways.
Head on Trunk
(ii) Crook side-lying (head resting on pillow); Head bending
Rotation of the head and I
sideways (Fig. 57).
Examples: (i) Crook lyil.
(iii) Sitting; Head bending from side to side.
(ii) Sitting; Jj
III.
Strengthening Exerclsl
f Elementary
Elementary
GRADE 1
GRADE 1
1. Crook lying; Head bending sideways.
1. Crook lying; Head 11
1a. Sitting; Head turni:
~~
((.-
~~
.j,1.' '
Mobilizing Exercises
,,~~ Elementary
GRADE 1
Fig. 57. Fig. 58. 1. Crook lying; Head t
1a. Sitting; Head tumi
GRADE 2
1. Sitting; Head bending sideways.
GRADE 2
1a. Sitting; Head turD
Intermediate
GRADE 1
1. Crook side-lying (head resting on pillow); Head bending sideways. (See
Fig. 57.) CIRCUMDUCTORS.
Types of Dynamic Elll
GRADE 2
1. Crook side-lying (head touching supporting surface); Head bending Head on Trunk
sideways (Fig. 58). Circumduction of the h(
Elementary
GRADE 1
Ckwards continuously. 1. Crook lying; Head bending from side to side.
GRADE 2
1. Sitting; Head bending from side to side.
2. Sitting; Head bending sideways with rhythmical pressing to a given
count.
ROTATORS OF HEAD AND NECK

side-lying and sitting. Types of Dynamic Exercises
....,); Head bending Head on Trunk

Rotation of the head and neck from lying, crook lying, and sitting.
Examples: (i) Crook tying; Head turning.
(ii) Sitting; Head turning from side to side.
Elementary
GRADE 1
1. Crook lying; Head turning.
1a. Sitting; Head turning.
Elementary
GRADE 1
r- 58. 1. Crook lying; Head turning from side to side.
1a. Sitting; Head turning from side to side.
GRADE 2
1a. Sitting; Head turning with rhythmical pressing to a given count.
ending sideways. (See

CIRCUMDUCTORS OF HEAD AND NECK
rface); Head bending Head on Trunk
Circumduction of the head and neck from sitting and prone kneeling.
68 PROGRESSIvE EXERCISE THERAPY
Elementary 8. TrunJ
GRADE 1
1. Sitting; Head rolling.
GRADE2
L Prone kneeling; Head rolling.
Trunk exercises provid

thoracolumbar spine ar
muscles of the hips, eel"!
The exercises given b
muscle groups of the th
FLEXORS OF THE
Types of Static men:
,
1. Abdominal Retractimt
t Retraction of the abdon
lying, prone lying, sinill
Example: Crook lying,
2. Leg or Legs on T~
In this group of exercisl
given range of moveme
the pelvis from being til
the moving leg or legs. ~
the resting leg act static
Four main types of eJ
starting positions as lyiJ
a. Flexion of the hip
Example: Lying,- singl
b. Flexion of one or b
Example: Lying,- singl
c, Flexion of one hip
Example: Lying,' sing.
* In the average subject

final degrees of movement
Flexion of the hip should t
of the abdominal muscles
8. Trunk exercises
Trunk exercises provide work for the spinal muscles which act on the
thoracolumbar spine and pelvis; many of the exercises also activate the
muscles of the hips, cervical spine and atlanto-occipital joints.
The exercises given here have been classified in relation to the individual
muscle groups of the thoracolumbar spine.
FLEXORS OF THE SPINE

1. Abdominal Retraction
Retraction of the abdominal muscles from such starting positions as crook
lying, prone lying, sitting and standing.
Example: Crook lying; Abdominal contractions.
2. Leg or Legs on Trunk

In this group of exercises the hips are flexed in turn, or together, through a
given range of movement. The abdominal muscles act statically to prevent
the pelvis from being tilted forwards by the contraction of the hip flexors of
the moving leg or legs. When the legs are moved in turn the hip extensors of
the resting leg act statically with the abdomin~l muscles to fix the pelvis.
Four main types of exercises are classified here. They are taken from such
starting positions as lying, standing and hanging.
a. Flexion of the hip and knee of one leg almost to the full extent. *
Example: Lying; single high Knee raising (Fig. 59).
b. Flexion of one or both hips up to 90° with flexion of the knee or knees.
Example: Lying; single Knee raising.
c. Flexion of one hip through 45°, with the knee extended.
Example: Lying; single Leg raising through 45°.
* In the average subject flexion of one hip (with the knee well flexed) through the
final degrees of movement is associated with small range backward tilting of the pelvis.
Flexion of the hip should therefore not be taken to its full extent if a pure static action
of the abdominal muscles is required.
69
,
d. Flexion of the hips to 45° with the knees extended.
Example: Stretch grasp back towards standing (wall bars); Leg raising to 45°.
.,
~~(t)
,
/t\-
:: ...
----
___
I \:::----
~
~ll:::::--"""
3. Trunk (Spine Straight) on Legs . oJ. ~~
~
a. Trunk lowering backwards and raising from fixed inclined long sitting
with the spine held straight. The hips are alternately extended and flexed Fig. 61.
through a range of 35-65°.
Example: Wing fixed inclined long sitting (wall bar stool); Trunk lowering
backwards through 450 (Fig. 60). Strengthening Exercises
Elementary
GRADE 1
1. Crook lying; Abdominal
.
2. Lying; single Knee raiD
3. Lying; single high Knee
/ .0-' -"
4. Lying; single Leg raisin;
I '
\' /, ,.m__ j
5. Lying; single high Kno
/
slow lowering.
Fig. 59. Fig. 60. 6. Crook lying; Head bene!
7. Lying; Head bending f(
During the raising and lowering movements the abdominal muscles act 8. Low grasp fixed incline«
statically to maintain the straight position of the spine.
t b. Trunk raising and lowering from fixed lying or fixed crook lying with the
bar stool); Trunk lowering b
1 spine held straight. The hIps are alternately flexed and extended through a
GRADE 2
range of about 90°.
1. Prone lying; AbdoJDina
Example: Wing fixed crook lying; Trunk raising (Fig. 61).
2. Lying; Knee raising (F
During the raising and lowering movements the abdominal muscles act
3. Lying; cycling.
statically to maintain the straight position of the trunk.
4. Lying; alternate Leg I'll
4a. Lying; single Leg rais
4. Head on Trunk 7. Yard (palms on floor)
Head bending forwards from lying and crook lying. The abdominal muscles raising through 45° .
act statically to fix the origin of the scalene muscles and the sternomastoid 8. Wing fixed inclined 1011
muscles. lowering backwards througJ
Example: Crook lying; Head bending forwards. 9. Inclined prone falling
Head bending forwards is often combined with hip flexion movements to
increase the static action of the abdominal muscles.
Example: Lying; Head bending forwards with single high Knee raising.
Intermediate
GRADE 1
5. Arm Bending from Prone Falling Position and its Modifications 1. No progression.
During the exercise the abdominal muscles act statically to prevent gravity 2. Stretch grasp back to'
from tilting the pelvis forwards and exaggerating the lumbar concavity. 3. No progression.
Example: Inclined prone falling (hands on beam); Arm bending (Fig. 62). 4. Lying; Leg raising tb
TRUNK EXERCISES 71
I:Id...
lin); Leg raising to 45°.
I
I
4
II iodined long sitting
r cstalded and flexed
Fig. 61. Fig. 62.
rtIJo/); Trunk lowering
Elementary
GRADE 1
1. Crook lying; Abdominal contractions.
2. Lying; single Knee raising.
3. Lying; single high Knee raising. (See Fig. 59, p. 70.)
4. Lying; single Leg raising to 45°.
5. Lying; single high Knee raising, Leg stretching forwards to 45°, and
slow lowering.
1Iiir·60· 6. Crook lying; Head bending forwards.
7. Lying; Head bending forwards with single high Knee raising.
lJdominal muscles act
8. Low grasp fixed inclined long sitting (hands grasping front edge of wall
bar stool); Trunk lowering backwards through 35°.
dcrook lying with the
II extended through a
GRADE 2
. 61).
1. Prone lying; Abdominal contractions .
Idominal muscles act
2. Lying; Knee raising (Fig. 63).
3. Lying; cycling.
4. Lying; alternate Leg raising through 45 c •
4a. Lying; single Leg raising to 45°, followed by Leg raising to 15°.
7. Yard (palms on floor) lying; Head bending forwards with single Leg
-= abdominal muscles
raising through 45°.
lid the sternomastoid
8. Wing fixed inclined long sitting (wall bar stool or balance bench); Trunk
lowering backwards through 35°.
9. Inclined prone falling (hands on beam); Arm bending (Fig. 62).
bon movements to
lijrlt Knee raising.

Intermediate
GRADE 1
wli/ications 1. No progression.
If to prevent gravity 2. Stretch grasp back towards standing (wall bars); Knee raising.
DDba.r concavity. 3. No progression.
Ibending (Fig. 62). 4. Lying; Leg raising through 45°.
TRUNK EXERCISES 79
Advanced
GRADE 1
1. No progression.
iog backwards. 2. Stretch stride standing; Trunk lowering forwards.
$« Fig. 74, p. 77.) 2a. Neck rest fixed high thigh support across prone lying (balance
II); Arm bending. (See benches, 2 high); Trunk lowering forwards. (See Fig. 75, p. 77.)
3. Over grasp horizontal fall hanging (beam and balance benches, 2 high);
Arm bending with single Leg raising.
4. Fist bend standing; fallout forwards, left Foot forwards, right Foot
forwards, with Arm stretching forwards.
ICight); Arm bending. GRADE 2

1-4. No progressions.

1. Pelvis and Lumbar Spine on Upper Trunk and Legs
F-
III (balance benches, 2
Pelvis tilting forwards, the extensors of the
height); Arm bending
Is. right Foot forwards.
mIs.
living support); Arm
~ forwards, right Foot

TRUNK EXERCISES 73

bar stool); Trunk
1. Spine on Pelvis
I. (See Fig. 62, p.

Flexion of the spine without movements of the pelvis or legs.
Example: Lying; upper Trunk bending forwards (Fig. 67).

bar stool); Trunk Pelvis tilting backwards, the abdominal muscles acting with the hip
extensors .
.) Example: Crook lying; Pelvis tilting backwards (Fig. 68).
Fig. 67. Fig. 68.
3. Legs on Pelvis: Pelvis and Lumbar Spine on Upper Trunk

Full flexion of the hips and knees, or flexion of the hips with the knees
extended, combined with flexion of the thoracolumbar spine.
Examples: (i) Lying; high Knee raising (Fig. 69).
(ii) Lying; high Leg raising to touch the floor behind the head with
the toes (Fig. 70).
Trunk lowering
Fig. 69. Fig. 70.

A modification of this type of exercise consists of circling on rings or ropes.
The extensors of the thoracolumbar spine work to a small extent, but the
main emphasis of the exercise is on the abdominal and heaving muscles.
Example: Stretch grasp standing (rings); circling and return circling with
straight legs (Fig. 71).
4. Spine on Pelvis: Pelvis on Legs

Flexion of the spine and hips, the legs being fixed by apparatus or living
support.
Example: Wing fixed crook lying; Trunk bending forwards (Fig. 72).
s to the floor. 5. Combined Movements of Trunk and Leg or Legs

Flexion of the spine combined with knee-raising movements; the legs are
moved either together or one at a time.
2a. Reach grasp sitting (wall bars); Pelvis tilting forwards. 2. No progression.
2b. Reach grasp standing (wall bars); Pelvis tilting forwards. 3. Head rest fixed prone I
3. Fixed prone lying; Trunk bending backwards with Arm turning 3a. Prone lying; Trunk II
outwards (Fig. 88). and Leg raising backwards.
~=-&?~
~
~qJ
I
I
~~,
{. ~
.!
;
Fig. 88. ,,,4
,
3a. Prone lying; Trunk bending backwards with Arm turning outwards. :
(See Fig. 85, p. 81.) ...
4. Lax stoop back lean stride standing (heels 30--40 cm in front of wall or Fig. 89.
upright); Trunk stretching 'vertebra by vertebra'. (See Fig. 82, p. 80.)
4a. Lax stoop kneel sitting (hands clasped behind back); Trunk stretching 3b. Stride prone lying; 'I
with unclasping of hands and Arm turning outwards. turning outwards, Knee ben
5. As above, but Trunk is stretched forwards to stoop position. the heels together (Fig. 90).
6. Crook lying; Pelvis raising. (See Fig. 150, p. 116.) 3c. Prone kneeling; single
Leg stretching and raising b
Intermediate
GRADE 1
--rl.
1. Neck rest crook lying; Chest raising.
la. High reach grasp lying (wall bars: hands grasping 5th or 6th bar from
floor); spanning. (See Fig. 81, p. 80.)
2. No progression.
3. Neck rest fixed prone lying; Trunk bending backwards. (See Fig. 84, a
p.80.)
3a. Neck rest prone lying; Trunk bending backwards.
4. No progression.
3b. Prone lying; Trunk bending backwards with Arm turning outwards
4a. Fist bend lax stoop ]
and single Leg raising backwards. (See Fig. 87, p. 81.)
stretching to arch position (
4. As Exercise 4 above, but arms in neck rest.
4a. Neck rest lax stoop kneel sitting; Trunk stretching 'vertebra by
vertebra'.
5. Fist bend lax stoop kneel sitting; Trunk stretching forwards to stoop
position with Arm stretching sideways. (See Fig. 83, p. 80.)
6. No progression.
~
a
GRADE 2
1. No progression.
la. High reach grasp crook lying (wall bars: hands grasping 5th or 6th bar
from floor); spanning. (See Fig. 4a, p. 9.) 5. Lax stoop stride standi
lb. Stretch grasp back support kneel sitting (wall bars); spanning (Fig. Trunk stretching forwards
89). 6. No progression.
TRUNK EXERCISES 83
rwards. 2. No progression.
fOrwards. 3. Head rest fixed prone lying; Trunk bending backwards.
I with Arm turning 3a. Prone lying; Trunk bending backwards with Arm turning outwards
and Leg raising backwards.
~llJ:/:~' I.
.. .~O_~\
f.,!
[JJl turning outwards.
.: :
:
I.
I
~
.:~~"'-'
Fig. 90.
::m in front of wall or

Fig. 89.
r Fig. 82, p. 80.)
ck); Trunk stretching
3b. Stride prone lying; Trunk bending backwards combined with Arm
turning outwards, Knee bending and Leg raising backwards, so as to bring
~ position. the heels together (Fig. 90).
)
3c. Prone kneeling; single Arm raising forwards-upwards with opposite
Leg stretching and raising backwards (Fig. 91) .
.....
II 5th or 6th bar from
lwar"ds. (See Fig. 84, a b

Fig. 91.
Is.
[Ill turning outwards

4. No progression.
4a. Fist bend lax stoop leg backward stretch half kneel sitting; Trunk
stretching to arch position (Fig. 92).
:rching 'vertebra by
• forwards to stoop
.80.)
a b
Fig. 92.
liSping 5th or 6th bar
5. Lax stoop stride standing (hands clasped behind neck, elbows forwards);
IUS); spanning (Fig. Trunk stretching forwards with Elbow parting to neck rest position.
6. No progression.
GRADE 3
1-2c. No progressions.
3. Yard (palms on floor) lying; high Leg raising to touch the floor behind
the head with the toes.
4. Inward grasp hanging (rings); circling and return circling with straight
legs.*
5. Hanging (wall bars); high Leg raising.
EXTENSORS OF THE SPINE

1. Leg on Trunk
Raising each leg backwards, in turn, from prone lying, so that the hip joint is
extended about 15°. The extensors of the thoracolumbar spine and the hip
flexors of the stationary leg act statically to )revent the pelvis from being
tilted backwards by the contraction of the hip extensors of the moving leg. I
Example: Forehead rest prone lying; single slight Leg raising backwards.
When hip extension is taken beyond 15° the pelvis tilts forwards, because
of the tension exerted on the ilio-femoral ligament. The extensors of the
thoracolumbar spine then act dynamically.
I
~ 2. Trunk (Spine Straight) on Legs
Trunk lowering and raising from such starting positions as sitting, stride
standing, and fixed high thigh support across prone lying. The trunk is kept
straight while the hips are alternately flexed and extended. The extensors of
the thoracolumbar spine act statically throughout the lowering and raising
movements
.
TRUNK EXERCISES 77
This type of movement is usually introduced by a 'holding' exercise.

Example: Wing fixed high thigh support across prone lying (balance benches, 2
:JUCb the floor behind high); position holding.
circling with straight
....,-,..
,',
, \ ..
.' :;.-_-_....,.;....;:!10.4.
#,... ... _-,
I :
r---_/ L
Fig. 74. Fig. 75.
10 that the hip joint is
... spine and the hip
he pelvis from being
3. Arm Bending from Fall Hanging Position or its Modifications
IS of the moving leg.
raising backwards. During the exercise the extensors of the thoracolumbar spine act statically
lis forwards, because to maintain a straight position of the trunk and to prevent gravity from
('he extensors of the flexing it.
Example: Over grasp fall hanging (beam at shoulder height); Arm bending
(Fig. 76).
DDS as sitting, stride 4. Fallout Forward Ex('-cises

lag.The trunk is kept The exercises are performed with or without arm movements. The extensors
led. The extensors of of the thoracolumbar spine act statically to counteract gravity and to maintain
lowering and raising a straight position of the spine. Unless the exercises are performed with
perfect control the extensors will be used dynamically.
Dt starting positions, Example: Wing standing; fallout forwards, left Foot forwards, right Foot
forwards (Fig. 77).
:wement is limited by
abdomen.
S (Fig. 74).
IIJ movement is taken
m.
e position is usually
»ofthe other. Trunk
with the floor.
.. (balance benches, 2
.n extent, but the main

ilepressors of the arms. Fig. 76. Fig. 77.
Elementary
GRADE 1
1. Forehead rest prone lying; single slight Leg raising backwards.
2. Wing stride sitting; Trunk lowering forwards. (See Fig. 74, p. 77.)
3. Over grasp fall hanging (beam at shoulder height); Arm bending. (See
Fig. 76.)
GRADE 2
1. No progression.
2. Wing stride standing; Trunk lowering forwards.
3. Over grasp fall hanging (beam below shoulder height); Arm bending.
Intermediate
GRADE I
1. No progression.
2. Fist bend stride standing; Trunk lowering
I
TRUNK EXERCISES 79
Advanced
GRADE 1
1. No progression.
iog backwards. 2. Stretch stride standing; Trunk lowering forwards.
$« Fig. 74, p. 77.) 2a. Neck rest fixed high thigh support across prone lying (balance
II); Arm bending. (See benches, 2 high); Trunk lowering forwards. (See Fig. 75, p. 77.)
3. Over grasp horizontal fall hanging (beam and balance benches, 2 high);
Arm bending with single Leg raising.
4. Fist bend standing; fallout forwards, left Foot forwards, right Foot
forwards, with Arm stretching forwards.
ICight); Arm bending. GRADE 2


F-
Pelvis tilting forwards, the extensors of the
height); Arm bending
Is. right Foot forwards.
mIs.
~ forwards, right Foot

(iii) Fixed toward standing (wall bars); Trunk bending forwards GRADE 2
to grasp the ankle of the raised leg-aver-stressing of Trunk 1. Prone kneeling; si
bending-and slow stretching upwards (Fig. 104). followed by Leg strel
All the rhythmical pressing and over-stressing trunk flexion exercises have backwards, and return
been deliberately omitted from the list of mobility exercises in this section,
because they are considered by orthopaedic surgeons to be wholly pernicious.
The exercises seldom do any good, and they are calculated to do the utmost harm Intermediate
to the spine, even when the hamstrings do not seriously limit hip flexion. GRADE 1
A large number of people have congenital shortening of the hamstrings, 1. No progression.
and under no circumstances can these muscles be stretched. The force of 2. Under grasp waD
attempting to stretch the muscles by spinal flexion exercises will be expended forwards-upwards and,
either upon the intervertebral discs, or upon the epiphyseal plates of the p.87, which shows the
vertebral bodies. In the adolescent, damage to the epiphysial plates will be
radiographically observed as osteochondritis, and the defective growth of the GRADE 2
epiphysial plates may cause wedging of the vertebral bodies and permanent 1. No progression.
damage. In adults the force exerted on the fronts of the lower lumbar discs 2. Under grasp waI
may be sufficient to rupture the annulus fibrosus of one of the discs and forwards-upwards and I
produce a frank prolapse of the nucleus pulposus. p.87.)
b. Wide range strengthening exercises for the flexors and extensors of the 3. Low grasp fixed i
spine and hips, which are taken from fixed inclined long sitting (see Fig. 105). forwards to lax stoop
The trunk is flexed to the lax stoop position, fully extended, and then returned lowering and bending t
to the erect position. to starting position. (~
Example: Wing fixed inclined long silting (balance bench); Trunk bending position.)
forwards to lax stoop position, followed by Trunk stretching
upwards, lowering, and bending backwards to touch the floor with
the head, and return to starting position (Fig. 105). Advanced
GRADE 1
1. No progression.
2. Stretch under gr.
\
\ # ~ -"'=...
;,:"."; " . " "
downwards-forwards 'U
,",
\\ ;1
easier starting position
:\1-·····-." ..
!:
'.i,"
3. Wing fixed incli
forwards to lax stoop
\'. ,;., '
\ I ....~
:!... )
\~
'..,;:
t \ ~
-')\1'.
t \1+
J
..\..........
'- .. ;
.~~.;'~
-~~
. lowering and bending 1
to starting position. (oS
Fig. 103. Fig. 104. Fig. 105. GRADE 2

1. No progression.
2. Under grasp I
downwards-forwards ~
Strengthening Exercises easier starting positiOll
3. As Exercise 3, G
Elementary
GRADE 1
No exercises.
* For introductory em
r TRUNK EXERCISES 81
DO on lying; it places the
6. Combined Movements of Legs or Leg on Pelvis with Extension of Spine
!heir ability to raise the
In these exercises the extensors of the thoracolumbar spine are used with the
extensors of the hips. There are two main groups of exercises:
a. Spanning exercises and similar movements.
Examples: (i) Angle hanging (wall bars); spanning (Fig. 86).
(li) Arm cross stride crook lying (head on mat); press up to high
Wrestler's Bridge. (See Fig. 55, p. 63.)
b. Extension of the thoracolumbar spine from prone lying combined with
extension of the lower limbs; the limbs are moved either in tum or together.
Examples: (i) Prone lying; Trunk bending backwards with Arm turning
outwards and single Leg raising backwards (Fig. 87).
(ii) Neck rest prone lying; Trunk bending backwards with Leg
.
raising backwards.
Fig. 82.
.
;'f ~'-".
" ' .. A~ ___ .... __ o
.,~
'If' -.:-----"
.. ,
:oIumbar spine are used •

~ types of exercises: Fig. 85.
bide sitting or standing,
10k [0 the erect position.
JO-.4Ocm in front of wall
, wrtebra' (Fig. 82).
:is uncurled to the stoop
YU:lri.ng forwards to stoop Fig. 87 Fig. 86.

ir- 83)_
, from prone lying with
• backwards (Fig. 84). Elementary
GRADE 1
1. Lying; Chest raising. (See Fig. 80, p. 79.)
2. Crook lying; Pelvis tilting forwards. (See Fig. 79, p. 79.)
2a. Crook side-lying (under hand grasping front edge of mattress, other
hand pressing down on mattress in front of chest); Pelvis tilting forwards.
3. Forehead rest prone lying; single Leg raising backwards.
4. Lax stoop stride sitting (hands on thighs, and lower part of sacrum in
contact with wall or upright); Trunk stretching 'vertebra by vertebra' with
assistance from arms.
5. Lax stoop kneel sitting (palms on floor with elbows bent); Trunk
. . The extensors of the stretching forwards to stoop position with Elbow stretching.
IeIlSOrs ,?f the hips act
GRADE 2
ir Arm turning outwards 1. Crook lying; Chest raising.
2. Reach grasp kneel sitting (wall bars); Pelvis tilting forwards.
2a. Reach grasp sitting (wall bars); Pelvis tilting forwards. 2. No progression.
2b. Reach grasp standing (wall bars); Pelvis tilting forwards. 3. Head rest fixed prone I
3. Fixed prone lying; Trunk bending backwards with Arm turning 3a. Prone lying; Trunk II
outwards (Fig. 88). and Leg raising backwards.
~=-&?~
~
~qJ
I
I
~~,
{. ~
.!
;
Fig. 88. ,,,4
,
3a. Prone lying; Trunk bending backwards with Arm turning outwards. :
(See Fig. 85, p. 81.) ...
4. Lax stoop back lean stride standing (heels 30--40 cm in front of wall or Fig. 89.
upright); Trunk stretching 'vertebra by vertebra'. (See Fig. 82, p. 80.)
4a. Lax stoop kneel sitting (hands clasped behind back); Trunk stretching 3b. Stride prone lying; 'I
with unclasping of hands and Arm turning outwards. turning outwards, Knee ben
5. As above, but Trunk is stretched forwards to stoop position. the heels together (Fig. 90).
6. Crook lying; Pelvis raising. (See Fig. 150, p. 116.) 3c. Prone kneeling; single
Leg stretching and raising b
Intermediate
GRADE 1
--rl.
1. Neck rest crook lying; Chest raising.
la. High reach grasp lying (wall bars: hands grasping 5th or 6th bar from
2. No progression.
3. Neck rest fixed prone lying; Trunk bending backwards. (See Fig. 84, a
p.80.)
3a. Neck rest prone lying; Trunk bending backwards.
4. No progression.
3b. Prone lying; Trunk bending backwards with Arm turning outwards
4a. Fist bend lax stoop ]
and single Leg raising backwards. (See Fig. 87, p. 81.)
stretching to arch position (
4. As Exercise 4 above, but arms in neck rest.
4a. Neck rest lax stoop kneel sitting; Trunk stretching 'vertebra by
vertebra'.
5. Fist bend lax stoop kneel sitting; Trunk stretching forwards to stoop
position with Arm stretching sideways. (See Fig. 83, p. 80.)
6. No progression.
~
a
GRADE 2
1. No progression.
la. High reach grasp crook lying (wall bars: hands grasping 5th or 6th bar
from floor); spanning. (See Fig. 4a, p. 9.) 5. Lax stoop stride standi
lb. Stretch grasp back support kneel sitting (wall bars); spanning (Fig. Trunk stretching forwards
89). 6. No progression.
TRUNK EXERCISES 83
rwards. 2. No progression.
fOrwards. 3. Head rest fixed prone lying; Trunk bending backwards.
I with Arm turning 3a. Prone lying; Trunk bending backwards with Arm turning outwards
and Leg raising backwards.
~llJ:/:~' I.
.. .~O_~\
f.,!
[JJl turning outwards.
.: :
:
I.
I
~
.:~~"'-'
Fig. 90.
::m in front of wall or

Fig. 89.
r Fig. 82, p. 80.)
ck); Trunk stretching
3b. Stride prone lying; Trunk bending backwards combined with Arm
turning outwards, Knee bending and Leg raising backwards, so as to bring
~ position. the heels together (Fig. 90).
)
3c. Prone kneeling; single Arm raising forwards-upwards with opposite
Leg stretching and raising backwards (Fig. 91) .
.....
II 5th or 6th bar from
lwar"ds. (See Fig. 84, a b

Fig. 91.
Is.
[Ill turning outwards

4. No progression.
4a. Fist bend lax stoop leg backward stretch half kneel sitting; Trunk
stretching to arch position (Fig. 92).
:rching 'vertebra by
• forwards to stoop
.80.)
a b
Fig. 92.
liSping 5th or 6th bar
5. Lax stoop stride standing (hands clasped behind neck, elbows forwards);
IUS); spanning (Fig. Trunk stretching forwards with Elbow parting to neck rest position.
6. No progression.
Advanced 6. Arm cross stride lyina

GRADE 1 (See Fig. 56, p. 64.)
1. No progression.
6a. Stride crook lying (p
1a. Angle hanging (waH bars); spanning. (See Fig. 86, p. 81.)
press up to the Crab (Fig.
Ib-2. No progressions.
7. No progression.
3. Stretch fixed prone lying; Trunk bending backwards.
3a. Neck rest prone lying; Trunk bending backwards with Leg raising
'j;
backwards. /'
I'
3b-4. No progressions.
4a. As Exercise 4a Intermediate, Grade 2, but arms in neck rest position.
,
/
,'''f1f'
,'- .. - . ..,
I
I
(See Fig. 92.)
5. Lax stoop stride standing; Trunk stretching forwards with Arm stretch .r---.: L.
Fig. 95.
ing forwards-upwards to stretch position.
6. Arm cross stride crook lying (head on mat); press up to high Wrestler's
Bridge. (See Fig. 55, p. 63.) FLEXORS AND EX1'E
7. Drag grasp lax stoop walk forwards standing (wall bars); assuming Types of Static Exen::ia
reverse hanging position (Fig. 93).
Trunk (Spine Straight) 011
Combined movements ofll
GRADE 2 76) are taken from fixed D
1. No progression.
The spinal flexors and extc
lao Stretch grasp back support long sitting (wall bars); spanning (Fig. 94).
the hips are alternately ex
1b-2. No progressions.
The backward lowering
the forward lowering moVl
muscles. During trunk 1011
---.. ~-.-.- used statically; the spinal
~, . forwards and raised.
----- Example: Wing fixed ill
•-
~
backwards tht
- - ~
to starting pm
-
~ /.
~ c
I:
I,
~ :"" ....
(.
a b
Fig. 93. Fig. 94.
3. Neck rest lax stoop fixed high thigh suppon across prone lying (balance
benches, 2 high); Trunk stretching to arch position (Fig. 95).
3a. Stretch prone lying; Trunk bending backwards with Leg raising
backwards.
3b-4. No progressions. Strengthening Exercll
4a. As Exercise 4a, Intermediate, Grade 2, but arms in stretch position. Trunk lowering forwan
(See Fig. 92.) backwards exercises whi
5. No progression. (pp. 71-72). See exampt.
TRUNK EXERCISES 85
6. Arm cross stride lying (head on mat); press up to low Wrestler's Bridge.
(See Fig. 56, p. 64.)
6a. Stride crook lying (palins on floor behind shoulders, elbows forwards);
86, p. 81.) press up to the Crab (Fig. 96).
7. No progression.
rards.
IU'ds with Leg raising
9
J'
I'
f-'
,~.
'fO
II '.)
5 in neck rest position.
uds with Arm stretch- .r--.':

,
,
,... . -.~'
L
I
B\.}
Fig. 95. Fig. 96.
I up to high Wrestler's
FLEXORS AND EXTENSORS OF THE SPINE
(wall bars); assuming
Trunk (Spine Straight) on Legs
Combined movements of trunk lowering backwards and forwards (pp. 70 and
76) are taken from fixed inclined long sitting with the knees slightly flexed.
The spinal flexors and extensors act statically to keep the spine straight, while
:os); spanning (Fig. 94).
the hips are alternately extended and flexed.
The backward lowering movements are taken through a range of 35-65°;
the forward lowering movements are limited by the tension of the hamstring
muscles. During trunk lowering backwards and raising, the spinal flexors are
used statically; the spinal extensors act statically as the trunk is lowered
forwards and raised.
Example: Wing fixed inclined long sitting (wall bar stool); Trunk lowering
backwards through 65°, raising and lowering forwards, and return
to starting position (Fig. 97).
Fig. 94.
s prone lying (balance

";g. 95).
Us with Leg raising Fig. 97.
as in stretch position. Trunk lowering forwards movements are added to the trunk lowering
backwards exercises which are performed from fixed inclined long sitting
(pp. 71-72). See example above.
~
Pelvis tilting forwards and backwards from such starting positions as crook
lying, prone kneeling and reach grasp sitting. The extensors and flexors of the
thoracolumbar spine act with the hip flexors and extensors.
C
Example: Crook lying; Pelvis tilting forwards and backwards. (See Figs. 79
and 68, pp. 79 and 73.)
2. Combined Movements of Trunk and Leg or Legs

a. Simultaneous movement of trunk and each leg in turn. The spine is flexed a
and extended in prone kneeling, the movements being accompanied by
flexion and extension of each leg. iv. Circling exercises at t
Example: Prone kneeling; single high Knee raising with Head bending Example: Under grasp waIJ
forwards, followed by Leg stretching and raising backwards with forwards-upwat
Head bending backwards, and return to starting position (Fig. 98). (Fig. 102) .
···· .... ,
~
' ........ -~
fl "
......... ".
/"",
a
. ".....
.......
Fig. 98.
,..j;' L
b
b. Simultaneous movement of trunk and both legs. This group of exercises b

includes:
i. Flexion and extension of the spine, hips, and knees in side-lying. a
Example: Side-lying; Trunk bending forwards with high Knee raising,
followed by Trunk stretching backwards with Leg stretching and
carrying backwards (Fig. 99).
ii. Jumping the feet rhythmically backwards and forwards between crouch 3. Spine on Pelvis: Pelvis
sitting and prone falling (Fig. 100).
Two main groups of exm
a. Flexion and extensio
~
rhythmical pressing or
exercises are often consi
1? ~~ c
thoracolumbar spine and

starting positions for the
fixed towards standing at
Examples: (i) Stride l
rhyth"a
Trunkl
a b Fig. 100.
Fig. 99. (ii) Fist be.
stretchi
Nest Hang exercises in rings.
lll.
presses.
Example: Hanging from hands and feet (rings),' Nest Hang (Fig. 101).
TRUNK EXERCISES 87
ws
Irting positions as crook
b::nsors and flexors of the
ttensors.
6tu:kwards. (See Figs. 79 b c d
The spine is flexed

1IlTIt. a
Fig. 101.
being accompanied by
iv. Circling exercises at the beam.
i.Ircwith Head bending Example: Under grasp walk forwards standing (beam at head height); circling
r raising backwards with forwards-upwards and downwards-forwards with straight legs
'lining position (Fig. 98). (Fig. 102).
This group of exercises b c d

e
tIeeS in side-lYIng. a
,;u, high Knee raising, Fig. 102.
fI1ilh Leg stretching and
nvards between crouch

Two main groups of exercises are classified here:
a. Flexion and extension exercises of the spine and hips which incorporate
rhythmical pressing or over-stressing movements in full flexion. The
exercises are often considered to be of use in increasing flexion of the
thoracolumbar spine and in 'stretching' the hamstring muscles. The usual
starting positions for the movements are stride standing, long sitting, and
fixed towards standing at the wall bars. (See Fig. 104, p. 88.)
Examples: (i) Stride standing; Trunk bending forwards-downwards with
rhythmical pressing to beat the floor (1-3), followed by slow
Fig. 100. Trunk stretching upwards (4-6) (Fig. 103).
(ii) Fist bend long sitting; Trunk bending forwards with Arm
stretching forwards to reach the toes, or beyond them, with 3
r Hang (Fig. lOJ). presses.
(iii) Fixed toward standing (wall bars); Trunk bending forwards GRADE 2
to grasp the ankle of the raised leg-aver-stressing of Trunk 1. Prone kneeling; si
bending-and slow stretching upwards (Fig. 104). followed by Leg strel
All the rhythmical pressing and over-stressing trunk flexion exercises have backwards, and return
been deliberately omitted from the list of mobility exercises in this section,
because they are considered by orthopaedic surgeons to be wholly pernicious.
The exercises seldom do any good, and they are calculated to do the utmost harm Intermediate
to the spine, even when the hamstrings do not seriously limit hip flexion. GRADE 1
A large number of people have congenital shortening of the hamstrings, 1. No progression.
and under no circumstances can these muscles be stretched. The force of 2. Under grasp waD
attempting to stretch the muscles by spinal flexion exercises will be expended forwards-upwards and,
either upon the intervertebral discs, or upon the epiphyseal plates of the p.87, which shows the
vertebral bodies. In the adolescent, damage to the epiphysial plates will be
radiographically observed as osteochondritis, and the defective growth of the GRADE 2
epiphysial plates may cause wedging of the vertebral bodies and permanent 1. No progression.
damage. In adults the force exerted on the fronts of the lower lumbar discs 2. Under grasp waI
may be sufficient to rupture the annulus fibrosus of one of the discs and forwards-upwards and I
produce a frank prolapse of the nucleus pulposus. p.87.)
b. Wide range strengthening exercises for the flexors and extensors of the 3. Low grasp fixed i
spine and hips, which are taken from fixed inclined long sitting (see Fig. 105). forwards to lax stoop
The trunk is flexed to the lax stoop position, fully extended, and then returned lowering and bending t
to the erect position. to starting position. (~
Example: Wing fixed inclined long silting (balance bench); Trunk bending position.)
forwards to lax stoop position, followed by Trunk stretching
upwards, lowering, and bending backwards to touch the floor with
the head, and return to starting position (Fig. 105). Advanced
GRADE 1
1. No progression.
2. Stretch under gr.
\
\ # ~ -"'=...
;,:"."; " . " "
downwards-forwards 'U
,",
\\ ;1
easier starting position
:\1-·····-." ..
!:
'.i,"
3. Wing fixed incli
forwards to lax stoop
\'. ,;., '
\ I ....~
:!... )
\~
'..,;:
t \ ~
-')\1'.
t \1+
J
..\..........
'- .. ;
.~~.;'~
-~~
. lowering and bending 1
to starting position. (oS
Fig. 103. Fig. 104. Fig. 105. GRADE 2

1. No progression.
2. Under grasp I
downwards-forwards ~
Strengthening Exercises easier starting positiOll
3. As Exercise 3, G
Elementary
GRADE 1
No exercises.
* For introductory em
TRUNK EXERCISES 89
Tnmk bending forwards GRADE 2

.quer-stressing of Trunk 1. Prone kneeling; single high Knee raising with Head bending forwards,
Is (Fig. 104). followed by Leg stretching and raising backwards with Head bending
k flexion exercises have backwards, and return to starting position. (See Fig. 98, p. 86.)
IeI'Cises in this section,
D be wholly pernicious.
ed to do the utmost harm Intermediate
limit hip flexion. GRADE 1
ring of the hamstrings, 1. No progression.
Itt'etched. The force of 2. Under grasp walk forwards standing (beam at head height); circling
:rcises will be expended forwards-upwards and downwards-forwards with bent knees. *' (See Fig. 102,
piphyseal plates of the p.87, which shows the exercise performed with straight knees.)
piphysial plates will be
defective growth of the GRADE 2
l bodies and permanent 1. No progression.
the lower lumbar discs 2. Under grasp walk-forwards standing (beam at head height); circling
Jf one of the discs and forwards-upwards and downwards-forwards with straight legs. (See Fig. 102,
p.87.)
n and extensors of the 3. Low grasp fixed inclined long sitting (balance bench); Trunk bending
qsitting (see Fig. lOS). forwards to lax stoop position, followed by Trunk stretching upwards,
Jded, and then returned lowering and bending backwards to touch the floor with the head, and return
to starting position. (See Fig. lOS, p. 88, which shows a different starting
bench); Trunk bending position.)
rl by Trunk stretching
!s to touch the floor with
Fig. lOS).
Advanced
GRADE 1
1. No progression.
2. Stretch under grasp standing (beam); circling forwards-upwards and
downwards-forwards with straight legs. (See Fig. 102, p. 87, which shows an
easier starting position.)
3. Wing fixed inclined long sitting (balance bench); Trunk bending
forwards to lax stoop position, followed by Trunk stretching upwards,
lowering and bending backwards to touch the floor with the head, and return
to starting position. (See Fig. lOS, p. 88.)
Fig. 105. GRADE 2

1. No progression.
2. Under grasp hanging (beam); circling forwards-upwards and
3. As Exercise 3, Grade 1, but with arms in neck rest position.
* For introductory circling exercises at the beam, see Technical Points, p. 91.
Mobilizing Exercises 2-2a. No progressiOi

Elementary 3. Hanging from haD
GRADE 1 p.87.)
1. Crook lying; Pelvis tilting forwards and backwards. (See Figs. 79 and 68, 4. Crouch sitting; all
pp. 79 and 73.) jumping the Feet rhyth
lao Crook side lying (under hand grasping front edge of mattress, other p.86.)
hand pressing down on mattress in front of chest); Pelvis tilting forwards and
backwards. GRADE 2
2. Side lying; Trunk bending forwards with high Knee raising, followed 1-2a. No progressiOi
by Trunk bending backwards with Leg stretching and carrying backwards. 3. Hanging from haD
(See Fig. 99, p. 86.) backwards (Fig. 108).
2a. As the previous exercise, but during each trunk arching movement
l
only one leg is carried back to the full extent.
GRADE 2
1. Prone kneeling; Pelvis tilting forwards and backwards with Head
bending backwards and forwards (Fig. 106).
a
~~~ a b c

Advanced
GRADE 1
1-2a. No progressio
3. Hanging from 1:Jal
Fig. 106.
~~
la. Reach grasp kneel sitting (wall bars); Pelvis tilting forwards and
backwards.
1 b. Reach grasp sitting (wall bars); Pelvis tilting forwards and backwards.
Ie. Reach grasp standing (wall bars); Pelvis tilting forwards and
backwards. ,
2-2a. No progressions.
a b
Intermediate
GRADE 1
1. Wide lax stretch (palms downwards) lax stoop kneel sitting; Pluto TECHNICAL pom
sniffing (Fig. 107).
Introductory Exerci
1. Beam arranged at 1
~
a
~~ ~

b c
The subject takes up a
so that the chest is pre
practises throwing dl
attempts to straightel
Fig. 107. position on the other
TRUNK EXERCISES 91
3. Hanging from hands and feet (rings or ropes); Nest H~ng. (See Fig. 101,
p.87.)
is. (See Figs. 79 and 68, 4. Crouch sitting; alternating between prone falling and crouch sitting by
jumping the Feet rhythmically backwards and forwards (1-6). (See Fig. 100,
dge of mattress, other p.86.)
ris tilting forwards and
GRADE 2
Knee raising, followed 1-2a. No progressions.
d carrying backwards. 3. Hanging from hands and feet (rings); Nest Hang with single Leg raising
backwards (Fig. 108).
uk arching movement
:.c:kwards with Head
a b c
Fig. 108.
Advanced
GRADE 1
c
3. Hanging from hands and feet (rings); half Nest Hang (Fig. 109).
tilting forwards and
wards and backwards.

biting forwards and
a b c d e
Fig. 109.
) kneel sitting; Pluto

TECHNICAL POINTS
Introductory Exercises to Circling on the Beam
1. Beam arranged at Hip Level
The subject takes up an under grasp full squat position, with knees forward,
so that the chest is pressed against the beam and the feet are under it. He then
practises throwing the legs up to the beam with bent knees. Later, he
c
attempts to straighten the knees and pull over the beam to the standing
position on the other side.
2. Beam a little under Hip Height lower side act staticall:

The subject stands close to the beam, and grasps it with the fingers behind sagging.
Example: Side fall".
and the thumbs in front, so that the hands touch the thighs. He then leans
over the beam as far as possible, simultaneously bringing the chin on to the
chest and looking at the knees; he then bends the knees and brings the heels <-
-':"'::", ...
up to the seat, which allows the weight of the upper part of the body to carry "
the legs over the beam. The body should be kept in this curled-up position \,. ...,
until the feet touch the floor. #
#/\~' "
,,# " I
3. Using Two Beams: Lower Beam placed at Chest Level, and Upper Beam -(
about 60 cm above ~'t
' - ''':'..:-1111____l o L
'''"
The subject takes up the under grasp walk forwards standing position at the
Fig. 110.
lower beam. He throws the legs up and gets the heels behind the upper beam;
he then presses with the heels and bends the arms and circles up on the lower
beam to the balance hanging position (Fig. 243, p. 271), In circling forwards 3. Fallout Outward EJ
downwards he bends the hip and knee joints as much as possible,
The exercises are pert
flexors of the thoracoh
Use of S~pporters spine straight and to p
leg. Unless the exeras.
Until the subject has acquired a good circling technique two supporters
will be used dynamia
should stand on either side of him to give him confidence. Support is most
Example: Wing Stall
often required when the subject changes his grasp before extending the body,
and the assistants' hands should be placed under the shoulders and legs. It is
also a wise precaution to put an agility mattress or mat under the beam in case Strengthening ExCi
·1 the subject should accidentally lose his grasp. Elememary
GRADE 1
1. Side toward stan
LATERAL FLEXORS OF THE SPINE the hand on the stool
Types of Static Exercises 2, Inclined side 6
1. Trunk (Spine Straight) on Leg sideways.
Trunk lowering and raising sideways from standing or thigh support side
GRADE 2
towards standing by abducting and adducting the hip joint of one leg, the
1. Half stretch sid
other leg being raised and lowered sideways with the trunk. Throughout the
exercise the lateral flexors of the spine on the upper side act statically to keep sideways to place the
the spine straight and to prevent gravity from side flexing it. 2. Side falling; sin;
Example: Side toward standing (wall bar stool),' Trunk lowering sideways to
place the hand on the stool with single Leg raising sideways
(Fig. 110). Intermediate
GRADE 1
1. Wing thigh su
2. Lateral Movemems of the Arm and/or Leg from Side Falling Position or sideways with single
its Modifications 2. Half fist bend s
During the exercises the lateral flexors of the thoracolumbar spine on the stretching sidewaYS-I
TRUNK EXERCISES 93
lower side act statically to keep the trunk straight and to prevent it from
ith the fingers behind sagging.
thighs. He then leans Example: Side falling; single Leg raising sideways (Fig. III).
~ the chin on to the
s and brings the heels
rt of the body to carry
lis curled-up position
rei, and Upper Beam
mding position at the

:bind the upper beam; Fig. 110. Fig. Ill. Fig. 112.
:in:les up on the lower
. In circling forwards
3. Fallout Outward Exercises
as possible.
The exercises are performed with or without arm movements. The lateral
flexors of the thoracolumbar spine of the upper side act statically to keep the
spine straight and to prevent it from bending towards the side of the forward
lique two supporters leg. Unless the exercises are performed with perfect control the lateral flexors
:ace. Support is most will be used dynamically.
e extending the body, Example: Wing standing; fallout outwards, left and right (Fig. 112).
oulders and legs. It is
IIlder the beam in case Strengthening Exercises
Elementary
GRADE 1
1. Side toward standing (wall bar stool); Trunk lowering sideways to place
the hand on the stool with single Leg raising sideways. (See Fig. llO.)
2. Inclined side falling (hand on wall bar stool); single Leg raising
sideways .
.. thigh support side
joint of one leg, the GRADE 2
1IIlk. Throughout the 1. Half stretch side toward standing (wall bar stool); Trunk lowering
: act statically to keep sideways to place the free hand on the stool with single Leg raising sideways.
jog it. 2. Side faIling; single Leg raising sideways (Fig. 111).
~ lowering sideways to
Leg raising sideways
Intermediate
GRADE 1
1. Wing thigh support side toward standing (beam); Trunk lowering
Falling Position or sideways with single Leg raising sideways (Fig. 113).
2. Half fist bend side falling; single Leg raising sideways with single Arm
lumbar spine on the stretching sideways-upwards.
3. Wing standing; fallout outwards, left and right. (See Fig. 112, p. 93.) Types of Dynamic EI
4. Stretch grasp high toward toe standing (wall bars); assuming Star 1. Spine on Pelvis
position (Fig. 114).
Lateral flexion of the sJl
4 ..- - ....
such as ride sitting, stricl
" Fixation of Pelvis, p. 9fi
\
,\·l)·~~
"' Examples: (i) Stride
'-¥ I
(ii) Riden
jromJ
iI (iii) Half ~
. .____
r-. I
Trunk
.
,
t
/ \
•
....
\
presm.
i~-~~ ....~:
~:
a b
Fig. 113. Fig. 114.
GRADE 2
1. Half stretch half wing thigh support side towards standing (beam);
Trunk lowering sideways with single Leg raising sideways.
2. Horizontal side falling; single Leg raising sideways (Fig. 115).
Fig. !16.
~
.,.~
,. ~
.!,
2. Spine on Pelvis: Pelt.

Lateral flexion of the 1
Fig. 115. pelvic tilting to occur,
lying. The lateral flez
3. Fist bend standing; fallout outwards, left and right, with Arm stretching abductors and adductOl
upwards. Examples: (i) Stnd
4. No progression. (ii) StritJ
(iii) Fixe;
bendl
Advanced
GRADE 1
1. Stretch side toward standing (wall bars); Trunk lowering sideways to
3. Legs on Pelvis: Pew
grasp the bars with single Leg raising sideways.
2. Half fist bend horizontal side falling; single Leg raising sideways with Leg raising sideways c
single Arm stretching sideways-upwards. group of exercises incll
3-4. No progressions. lateral flexors of the t
adductors.
Examples: (i) HaFQ
GRADE 2 (ii) ()'I)eT
No progressions. swiFQ
py
TRUNK EXERCISES 95
n. (See Fig. 112, p. 93.) Types of Dynamic Exercises
1111 bars); assuming Star
1. Spine on Pelvis
Lateral flexion of the spine from a starting position which fixes the pelvis,
,,---- such as ride sitting, stride sitting, and foot support side toward standing (see
\, .. Fixation of Pelvis, p. 99).
\~'--I~------1 Examples: (i) Stride sitting; Trunk bending sideways.
.
I
(ii) Ridesitting (chair: thighs gripping chair back),- Trunk bending
from side to side (Fig. 116).
,.
r-.
I
..
- __ I (iii) Half neck rest foot support side toward standing (wall bars);
Trunk bending sideways towards the bars with rhythmical
,./' \. pressing to 3 counts (Fig. 117).
~ "-.- .. "
-~:
:
Fig. 114.
~ds standing (beam);

ieways.
layS (Fig. 115).
Fig. 116. Fig. 117. Fig. 118.

Lateral flexion of the trunk from a starting position which allows lateral
pelvic tilting to occur, such as stride standing, stride lying, and fixed side
lying. The lateral flexors of the thoracolumbar spine act with the hip
In, with Arm stretching
abductors and adductors.
Examples: (i) Stride standing; Trunk bending from side to side.
(ii) Stride lying; Trunk bending sideways.
(iii) Fixed side-lying (one leg slightly in front of other); Trunk
bending sideways (Fig. 118).
t lowering sideways to
3. Legs on Pelvis: Pelvis and Lumbar Spine on Upper Trunk
: raising sideways with Leg raising sideways or leg swinging from side to side from hanging; this
group of exercises includes leg lowering sideways from reverse hanging. The
lateral flexors of the thoracolumbar spine act with the hip abductors and
adductors.
Examples: (i) Hanging (wall bars); Leg raising sideways (Fig. 119).
(ii) Over grasp hanging (beam); Arm walking sideways with Leg
swinging from side to side (Fig. 120).
4. Pelvis and Lumbar Spine on Upper Trunk Strengthening Eser

Hip updrawing from such starting positions as heave grasp lying and reach Elementary
grasp standing. The pelvis is tilted sideways by the combined action of the GRADE 1
lateral flexors of the thoracolumbar spine ofthe side of the raised hip, and the 1. Stride lying; Tl1l
hip abductors of the opposite side. 2. Heave grasp lym,
Example: Reach grasp standing (wall bars); Hip updrawing (Fig. 121). Hip updrawing. (Su.l
This group of exercises includes lateral pelvic tilting from side to side; the 3. Stride sitting; TI
usual starting positions for these movements are reach grasp kneel sitting and
reach grasp standing. GRADE 2
Example: Reach grasp kneel sitting (wall bars); Pelvis tilting from side to side. 1. Lying; Trunk be
side.
1a. Lying; Trunk b
2. Reach grasp Stall
3. Neck rest stride
4. Neck rest stride
~
.-.---
~;:::>. Intermediate
~
,,
~w:~l .<:~:.\l GRADE 1
1 and 1a. No prog!
2. Reach grasp W.
Fig. 119. Fig. 120. Fig. 121. Fig. 122. updrawing, and lowe!
3. Stretch ride sitti
sideways.
4. Stretch stride 51
5. Simultaneous Movement of Trunk and One Leg
Lateral flexion of the spine combined with either Hip updrawing or single Leg
GRADE 2
carrying sideways of the side to which the trunk is moved. The movements are 1-4. No progressi(
performed in lying. 5. Side falling (one
Examples: (i) Lying; Trunk bending sideways with Hip updrawing of the supporting surface, n
same side. (See Fig. 122, p. 96.)
(ii) Lying; Trunk bending sideways with single Leg carrying to the
same side.
Advanced
GRADE 1
1-5. No progressil
6. Pelvis Lowering and Raising from Side Falling Position
6. Fixed side-lyin
Pelvis lowering and raising from side falling by combined movements of sideways. (See Fig. J
lateral flexion of the thoracolumbar spine and hip abduction and adduction. 7. Reverse hangiD
The lateral flexors of the thoracolumbar spine on the underneath side of the
trunk act with the hip abductors of the underneath leg and the hip adductors
of the uppermost leg. ." Leg lowering side1i1
Example: Side falling (one leg slightly in front of other); Pelvis lowering to leg raising sideways fu
touch supporting surface, raising as high as possible, and return to one for the average P
starting position (Fig. 122). hanging is often used .
TRUNK EXERCISES 97
grasp lying and reach Elementary
IJI11bined action of the GRADE 1
me raised hip, and the 1. Stride lying; Trunk bending sideways.
2. Heave grasp lying (mattress) or lying (hands grasping sides of mattress);
rflfDing (Fig. 121). Hip updrawing. (See Fig. 121.)
:from side to side; the 3. Stride sitting; Trunk bending sideways.
Jr.lSp kneel sitting and
GRADE 2
filting from side to side. 1. Lying; Trunk bending sideways with single Leg carrying to the same
side.
la. Lying; Trunk bending sideways with Hip updrawing of the same side.
2. Reach grasp standing (wall bars); Hip updrawing. (See Fig. 121.)
3. Neck rest stride sitting; Trunk bending sideways.
4. Neck rest stride standing; Trunk bending sideways.
Intermediate
GRADE I
I and la. No progressions.
2. Reach grasp high half standing (wall bars and stool); Hip sinking,
Fig. 122.
updrawing, and lowering to starting position.
3. Stretch ride sitting (chair: thighs gripping chair back); Trunk bending
sideways.
4. Stretch stride standing; Trunk bending sideways.
rNirawing or single Leg
l The movements are GRADE 2.
flip updrawing of the 5. Side falling (one leg slightly in front of other); Pelvis lowering to touch
supponing surface, raising as high as possible, and return to staning position.
rtle Leg carrying to the (See Fig. 122, p. 96.)
Advanced
GRADE 1
rm 1-5. No progressions.
6. Fixed side-lying (one leg slightly in front of other); Trunk bending
bined movements of
sideways. (See Fig. 118, p. 95.)
mon and adduction.
7. Reverse hanging (wall bars); Leg lowering sideways (Fig. 123, p. 99.)*
lldemeath side of the
ad the hip adductors
r); Pelvis lowering to

* Leg lowering sideways from reverse hanging is easier for the working muscles than
leg raising sideways from hanging. The reverse hanging position, however, is a difficult
JOSSible, and return to one for the average patient to maintain; for this reason leg raising sideways from
hanging is often used before the other exercise.
GRADE 2
5. Wing fixed side u
towards the bars with '
6. Half neck rest fixed side lying (one leg slightly in front of other); Trunk from the bars to 3 slow,
bending sideways. position.)
7. Hanging (wall bars); Leg raising sideways. (See Fig. 119, p. 96.)* 6. No progression.
7. Over grasp hangim
from side to side. (See,
Elementary
Advanced
GRADE 1
1. Stride lying; Trunk bending from side to side. GRADE 1
1. Lax stretch stride
GRADE 2 la-4. No progressiOl
1. Stride standing; Trunk bending from side to side. 5. As Exercise 5, Inll
2. Ride sitting (chair: thighs gripping chair back); Trunk bending from 6. No progression.
side to side, (See Fig. 116, p. 95.)
:!:--..
3. Reach grasp kneel sitting (wall bars); Pelvis tilting from side to side.
:-
Intermediate
GRADE 1 =t=I7f'
1. Neck rest stride standing; Trunk bending from side to side.
la. Stride standing; Trunk bending from side to side with rhythmical ~.
pressing to 3 counts in position.
=0===
2. Neck rest ride sitting (chair: thighs gripping chair back); Trunk Fig. 123.
bending from side to side.
'~I'
2a. Ride sitting (chair: thighs gripping chair back); Trunk bending from
1
side to side with rhythmical pressing to 3 counts in position. Fixation of Pelvis d
3. No progression. The pelvis is securely
4. Stride standing; Trunk bending sideways with single Arm (of opposite 1. Ride sitting on a I
side) swinging forwards-downwards-sideways-upwards, the Trunk being chair back, or the legs
bent to the side during the sideways-upwards swing of the arm. 126.)
5. Half neck rest foot support side toward standing (wall bars); Trunk 2. High ride sitting,
bending sideways towards the bars with rhythmical pressing to a given count. The pelvis is also fu
(See Fig. 117, p. 95.) the hips fully abduCtl
6. Half neck rest leg sideways stretch half kneeling; Trunk bending toward standing, and II.
sideways with rhythmical pressing to a given count (Fig. 124). Fig. 124.) The pelvis
GRADE 2
1. Head rest stride standing; Trunk bending from side to side.
la-4. No progressions.
ROTATORS OF 1:
Types of Dynamic:
* Leg lowering sideways from reverse hanging is easier for the working muscles than 1. Spine on Pelvis
leg raising sideways from hanging. The reverse hanging position, however, is a difficult
one for the average patient to maintain; for this reason leg raising sideways from Rotation of the spine
hanging is often used before the other exercise. ride sitting and proIl1
TRUNK EXERCISES 99
5. Wing fixed side toward standing (wall bars); Trunk bending sideways
towards the bars with rhythmical pressing to 3 counts, and bending away
t front of other); Trunk from the bars to 3 slow counts. (See Fig. 125, which shows arms in neck rest
position.)
'Fig. 119, p. 96.)* 6. No progression.
7. Over grasp hanging (beam); Arm walking sideways with Leg swinging
from side to side. (See Fig. 120, p. 96.)
Advanced
GRADE 1
1. Lax stretch stride standing; Trunk bending from side to side.
la-4. No progressions.
:Ie.
5. As Exercise 5, Intermediate, Grade 2, but arms in neck rest (Fig. 125).
i Trunk bending from
6. No progression.
Dg from side to side.
side to side.
side with rhythmical
: chair back); Trunk Fig. 123. Fig. 124. Fig. 125.
i Trunk bending from

osition. Fixation of Pelvis during Lateral Flexion of Spine
The pelvis is securely fixed in the following positions:
ogle Arm (of opposite 1. Ride sitting on a chair, or a balance bench, with the thighs gripping the
ds, the Trunk being chair back, or the legs gripping the bench sides. (See Fig. 116, p. 95 and Fig.
tfthe arm. 126.)
Ig (wall bars); Trunk
2. High ride sitting, with the legs gripping the high plinth.
ssing to a given count. The pelvis is also firmly fixed in positions where one leg is supported, with
the hips fully abducted; such positions include foot support (or fixed) side
ling; Trunk bending toward standing, and leg sideways stretch half kneeling. (See Fig. 117, p. 95 and
1'ig. 124). Fig. 124.) The pelvis is less securely fixed in stride sitting.
!ide to side.
ROTATORS OF THE SPINE
lie working muscles than
Ill, however,is a difficult
1. Spine on Pelvis
I nising sideways from Rotation of the spine from a starting position which fixes the pelvis, such as
ride sitting and prone kneeling (see Fixation of Pelvis, p. 103).
2. Wing stride-sitt.iol
Examples: (i) Wing ride sitting (balance bench: legs gripping bench sides);
3. Stride-standing; '1
Trunk turning (Fig. 126).
4. Reach grasp close
(ii) Prone kneeling; Trunk turning with single Arm swinging
sideways and rhythmical pressing to 3 counts (Fig. 127).
GRADE 2
1 and 2. No progresl
~ Jt~
3. Stride lying; Trw

(Fig. 129).
Fig. 126. a b
Fig. 127.
2. Legs, Pelvis, and Lumbar Spine on Upper Trunk 4. Heave grasp lyiDj
Rotation of the trunk by moving the pelvis and legs together, the upper trunk 4a. Crook lying; Pel
being the fixed point. 5. Prone kneeling; I
Example: Yard (palms on floor) crook lying; Knee swinging from side to (See Fig. 127, p. 100,
side (Fig. 128). exercise.)
Intermediate
GRADE 1
1-4a. No progressi
5. Turn prone kne
a b turning with single A.!
Fig. 128.
the movement perfor
1ti
.~ 3. Spine on Pelvis: Pelvis on Legs
GRADE 2
Rotation ofthe trunk from a starting position which allows hip rotation, such 1-5. No progressi4
as stride standing, standing, and stride lying. 6. Yard (palms 0
Example: Stride standing; Trunk turning from side to side with Arm swing lowering sideways (I
ing loosely at the sides.

Pelvic rotation from a starting position which allows hip rotation and fixes the j~~
~~-
upper trunk and legs.
Example: Reach grasp close standing (wall bars); Pelvis turning.
a
Pi
Elementary Advanced
GRADE 1
GRADE 1
1. Wing ride sitting (balance bench: thighs gripping bench sides); Trunk 1-5. No progre
turning (Fig. 126).
TRUNK EXERCISES 101
i gripping bench sides); 2. Wing stride-sitting; Trunk turning.

3. Stride-standing; Trunk turning.
I single Arm swinging 4. Reach grasp close standing (wall bars); Pelvis turning.
.anmts (Fig. 127).
GRADE 2
3. Stride lying; Trunk turning with single Arm carrying across the chest
(Fig. 129).
Fig. 129
Mer, the upper trunk 4. Heave grasp lying (wall bars); Pelvis turning.
4a. Crook lying; Pelvis raising, turning, and lowering.
StDinging from side to 5. Prone kneeling; slow Trunk turning with single Arm raising sideways.
(See Fig. 127, p. 100, which shows the movement performed as a mobility
exercise.)
Intermediate
GRADE 1
5. Turn prone kneeling (one arm bent loosely across chest); slow Trunk
turning with single Arm raising sideways. (See Fig. 127, p. 100, which shows
the movement performed as a mobility exercise.)
I'WS hip rotation, such GRADE 2

side with Arm swing- 6. Yard (palms on floor) half crook half vertical leg lift lying; Leg
lowering sideways (Fig. 130).
~
rotation and fixes the
is turning.
a b Fig. 131.
Fig. 130.
Advanced
bench sides); Trunk GRADE 1
6. Yard (palms on floor) vertical leg lift lying; slow Leg swinging from GRADE 2
side to side (Fig. 131). 1-5. No progressiOil
6. Over grasp fixed!
Trunk turning with siJ
Mobilizing Exercises 134, which shows a JDI
Elementary
GRADE 1
Advanced
1. Arm cross ride sitting (chair: thighs gripping chair back); Trunk
GRADE 1
turning from side to side.
1-3. No progressiOil
2. Stride standing; Trunk turning from side to side with Arm swinging
4. Lax reach stoop a
loosely at the sides.
alternate Arm swinginj
GRADE 2
1. Across bend ride sitting (chair: thighs gripping chair back); Trunk
turning from side to side with alternate Arm flinging.
~
2. Half lumbar rest stride standing; single Arm swinging forwards, and
sideways with Trunk turning.
3. Yard (palms on floor) crook lying; Knee swinging from side to side.
(See Fig. 128, p. 100.)
4. Prone kneeling; Trunk turning with single Arm swinging sideways.
(See Fig. 127, p.l00, which shows a rhythmical pressing exercise.)
Fig. 13
Intermediate
GRADE 1
5. No progression.
1. Arm cross ride slttmg (chair: thighs gripping chair back); Trunk
6. Over grasp hom
turning from side to side with rhythmical pressing to 3 counts in position.
such a height that bar:
2. Stride standing; Trunk turning from side to side with Arm swinging
Trunk turning with s
loosely at the sides and rhythmical pressing to 3 counts in position.
3. No progression.
4. Turn prone kneeling (one arm bent loosely across chest); Trunk turning GRADE 2
No progressions.
with single Arm swinging sideways and rhythmical pressing to 3 counts (Fig.
132).
Fixation of Pelvis
Asf
The pelvis is secure.:

1. Ride sitting on a
chair back, or the legs
and 100.)
a b 2. High ride sitti~
Fig. 132. The pelvis is also'
sitting and kneel sittm
5. Reach half kneeling; Trunk turning with single Arm swinging sideways these positions diftk
and rhythmical pressing to a given count. crook sitting provide
TRUNK EXERCISES 103
IV Leg swinging from GRADE 2

6. Over grasp fixed stride fall hanging (beam: feet fixed by living support);
Trunk turning with single Arm swinging sideways to touch floor. (See Fig.
134, which shows a more advanced exercise.)
: chair back); Trunk Advanced

GRADE 1
e with Arm swinging 1-3. No progressions.
4. Lax reach stoop stride standing; Trunk turning from side to side with
alternate Arm swinging sideways and across the chest (Fig. 133).
, chair back); Trunk
inging forwards, and
ElK from side to side.
I swinging sideways.
og exercise.)
Fig. 133. Fig. 134.
chair back); Trunk 5. No progression.

J counts in position. 6. Over grasp horizontal fall hanging (beam and living support: beam at
~ with Arm swinging such a height that hand cannot touch floor if grasp of one hand is released);
" in position. Trunk turning with single Arm swinging sideways (Fig. 134).
best); Trunk turning GRADE 2
sing to 3 counts (Fig. No progressions.
Fixation of Pelvis during Spinal Rotation
The pelvis is securely fixed in the following positions:
1. Ride siuing on a chair, or a balance bench, with the thighs gripping the
chair back, or the legs gripping the bench sides. (See Figs. 116 and 126, pp. 95
and 100.)
2. High ride siuing, with the legs gripping the high plinth.
The pelvis is also well fixed in prone kneeling (see Fig. 127, p. 100). Cross
sitting and kneel sitting give good fixation of the pelvis, but adults usually find
n swinging sideways these positions difficult to maintain. Siuing, stride siuing, long siELing and
crook sitting provide some fixation of the pelvis.
COMBINED EXERCISES FOR THE ROTATORS, FLEXORS,

AND EXTENSORS
Only the main types of combined exercises have been classified here. All the
:. _,.tc - - ~ .. ..,
exercises are based on the following sequence of movement-Spine on Pelvis:

r-.-.. . '1
v '-< , ~
Pelvis on Legs.
lJ i1;~~:::6?:~\ I!J
1. Working Flexors and Rotators of Spine with Hip Rotators
~]
Flexion and rotation of the trunk, without flexion of the hips, from lying and Fig. 137.
stride lying.
Example: Stride lying; upper Trunk bending forwards with turning and single
Arm carrying across the chest (Fig. 135). Strengthening Exerclsel
Elementary
GRADE 1
2. Working Flexors and Rotators of Spine and Hips 1. Stride lying; Trunk t
Flexion and rotation of the spine and hips from fixed lying and fixed crook Arm carrying across the ell
lying.
Example: Neck rest fixed crook lying; Trunk bending forwards with turning GRADE 2
(Fig. 136). 1. Stride lying; upper "I
Arm carrying across the ell
~ ([
V-i~
(~ ~f~~~~ Intermediate
~~.
GRADE1
L No progression.
2. Fixed lying; Trunk 1
Fig. 135. Fig. 136.
from arms.
GRADE 2
3. Working Extensors and Rotators of Spine with Hip Extensors L No progression.
Extension and rotation of the spine, with extension of the hips, from a lax 2. Fixed slight crook l]
stoop position which prevents pelvic rotation. (See Fixation of Pelvis, p. 103.) single Arm carrying acrosl
Example: Fist bend lax stoop kneel sitting; Trunk stretching 'vertebra by
vertebra' with turning (Fig. 137).
Advanced
GRADE 1
4. Working Extensors and Rotators of Spine and Hips 1. No progression.
Extension and rotation of the spine and hips from such positions as fixed 2. Wing fixed crook lyiI1
prone lying and lax stoop stride standing. 136, p. 104.)
Examples: (i) Neck rest fixed prone lying; Trunk bending backwards with
turning (Fig. 138). GRADE 2
(ii) Lax stoop back lean stride standing (heels 30-40cm infront of 1. No progression.
upright); Trunk stretching 'vertebra by vertebra' in different 2. Neck rest fixed crook
planes (Fig. 139). 136, p. 104.)
'Y
TRUNK EXERCISES 105
mRS, FLEXORS, M
D classified here. All the

C'lD.ellt-Spine on Pelvis:
l'Dtators
!be hips, from lying and
Fig. 137. Fig. 138. Fig. 139.
Is with turning and single

Strengthening Exercises (Flexors and Rotators)
Elementary
GRADE 1
1. Stride lying; Trunk turning with Head bending forwards and single
d lying and fixed crook
Arm carrying across the chest.
I' forwards with turning
GRADE 2
1. Stride lying; upper Trunk bending forwards with turning and single
Arm carrying across the chest. (See Fig. 135, p. 104.)
'-;~
~::.:::::.. "
I •
Intermediate
\
. ".
.
GRADE 1
1. No progression.
W·136. 2. Fixed lying; Trunk bending forwards with turning, with assistance
from arms.
Extensors GRADE 2
1. No progression.
£Jf the hips, from a lax
2. Fixed slight crook lying; Trunk bending forwards with turning and
arion of Pelvis, p. lO3.)
single Arm carrying across the chest.
stretching 'vertebra by
Advanced
GRADE 1
1. No progression.
uch positions as fixed 2. Wing fixed crook lying; Trunk bending forwards with turning. (See Fig.
136, p. lO4.)
mding backwards with
GRADE 2
els 30-40cm injront oj 1. No progression.
, vertebra' in different 2. Neck rest fixed crook lying; Trunk bending forwards with turning. (Fig.
136, p. lO4.)
Strengthening Exercises (Extensors and Rotators) 3. Head rest fixed pm

(See Fig. 138, p. 105.)
Elementary
4. As Exercise 4, Adv.
GRADE 1
1. Fist bend lax stoop kneel slttmg; Trunk stretching 'vertebra by
vertebra' with turning. (See Fig. 137, p. 105.)
GRADE 2 CIRCUMDUCTORS 1
1. As Exercise 1 above, but arms in neck rest. Types of Dynamic Elr.l

2. Lax stoop back lean stride standing (heels 30-40 cm in front of upright); The exercises are based ,
Trunk stretching 'vertebra by vertebra' in different planes (See Fig. 139, Pelvis: Pelvis on Legs.
p. lOS.)
1. Working CircumductDI
Intermediate
Circumduction of the sp
GRADE 1
from such starting positi
1. Across bend lax stoop kneel sitting; Trunk stretching 'vertebra by
Example: Wing ride siJ
vertebra' with turning and single Arm stretching and raising midway
rolling (Fig.
upwards.
2. As Exercise 2, Elementary, Grade 2, but arms in neck rest.
2. Working CircumauctIJ
GRADE 2
Circumduction of the :
standing and lax fall hal

3. Fixed prone lying; Trunk bending backwards with turning.
Advanced
GRADE 1
3. Wing fixed prone lying; Trunk bending backwards with turning.

~!
GRADE 2
3. Neck rest fixed prone lying; Trunk bending backwards with turning.
(See Fig. 138, p. 105.) Fig. 141.
4. Wing lax stoop fixed high thigh support across prone lying (balance
benches, 2 high); Trunk stretching with turning to arch tum position (Fig. Examples: (i) Wing
140). (ii) Lax J
/~>!
L-··.J· L :g: .J~
Mobilizing Exercise
Elementary
GRADE 1
Fig. 140.
1. Wing ride sittina!
GRADE 3
rolling (Fig. 141).
2. Wing stride stan.
TRUNK EXERCISES 107
lators) 3. Head rest fixed prone lying; Trunk bending backwards with turning.
(See Fig. 138, p. 105.)
4. As Exercise 4, Advanced, Grade 2, but arms in neck rest position.
It stretching 'vertebra by
CIRCUMDUCTORS OF THE SPINE

-40cm in front of upright);
rent planes (See Fig. 139, The exercises are based on the following sequence of movement-Spine on
Pelvis: Pelvis on Legs.
1. Working Circumductors of Spine with Hip Flexors and Extensors

Circumduction of the spine combined with flexion and extension of the hips
k stretching 'vertebra by from such starting positions as ride sitting and high ride sitting.
iog and raising midway Example: Wing ride sitting (balance bench: legs gripping bench sides); Trunk
rolling (Fig. 141) .
.. in neck rest.
2. Working Circumductors of Spine with Hip Muscles
Circumduction of the spine combined with hip movements from stride
Is with turning. standing and lax fall hanging (rings).
.~-.~-",
, ,
M.... /'
,/~,.# ;i"~
-- ~
f #" ....
;wards with turning. \::';'"

"'-' ... "
: backwards with turning.

Fig. 141. Fig. 142.
toSS prone lying (balance
I) arch turn position (Fig.
Examples: (i) Wing stride standing; Trunk rolling.
(ii) Lax fall hanging (rings); rolling (Fig. 142).
Elementary
GRADE I
1. Wing ride sitting (balance bench: legs gripping bench sides); Trunk
rolling (Fig. 141).
2. Wing stride standing; Trunk rolling.
GRADE 2 9. Breal
1. Neck rest ride sitting (balance bench: legs gripping bench sides); Trunk
rolling.
2. Neck rest stride standing; Trunk rolling.
Intermediate
GRADE 1
No progressions.
GRADE 2 Breathing exercises rna

1 and 2. No progressions. unilateral exercises whi
3. Lax fall hanging (rings); rolling. (See Fig. 142, p. 107.) exercises combined wit
breathing.
Bilateral localized e:JI
breathing, and General
See Trunk rolling exercises in previous section. The movements are per
exercises are crook hi
formed more slowly than when used as mobility exercises.
respiratory movemenb
by the use of a webbiJI
Examples: (i) Crook
CosUIJ
~
Fig. 143. La
(ii) Cr/)j
breIJ
dun
(iii) Crt)
endl
prel
Bilateral breathin
thorax when the rail
py
ping bench sides); Trunk

9. Breathing exercises
Breathing exercises may be divided into three main groups: (1) Bilateral or
unilateral exercises which are localized to the respiratory muscles; (2) Arm
• p. 107.) exercises combined with breathing; and (3) Trunk exercises combined with
breathing.
Bilateral localized exercises consist of Apical, Costal, and Diaphragmatic
breathing, and General deep breathing. The best starting positions for these
lie movements are per exercises are crook half-lying, crook lying and half-lying (p. 269). The
rcises. respiratory movements are localized by the therapist's or patient's hands or
by the use of a webbing strap or belt.
Examples: (i) Crook half-lying (hands on sides of lower ribs); lower lateral
Costal breathing with light pressure from hands (Fig. 143).
Fig. 143. Lower lateral Costal breathing from crook half-lying.
(ii) Crook half-lying (hand on upper abdomen); Diaphragmatic

breathing, with emphasis on contraction of abdominal wall
during expiration (Fig. 144).
(iii) Crook half-lying (webbing strap round lower chest, with free
ends held by hands); lower lateral Costal breathing with light
pressure from strap (Fig. 145).
Bilateral breathing exercises are used: (a) to increase the mobility of the
thorax when the range of expiration or inspiration is reduced; (b) to ventilate
109
~
.-~
!1'\"
.11:""
PI
function. For example

breathing the ribs are til
the serratus anterior III
dragging action of the I
increase the range of iI
BILATERAL LOCi!
Exercises to InCreBIi
In these exercises eIDIl
must be as easy and sl
1. Crook half-lying
with emphasis on coni
Fig. 145. Using a strap to localize lower lateral Costal breathing. 144, p. 110.)
2. Crook half-lying
breathing with pressu
the lungs and prevent stagnation of mucous secretions; and (c) to teach
p. 109.)
correct breathing habits.
3. Crook half-lying
Unilateral localized exercises are used in the treatment of certain chest
breathing with pressu
conditions. For example, Crook half-lying (hand on side of left lower chest); left
4. Crook half-tying
lower lateral Costal breathing with hand pressure (Fig. 146), may be used in the
clavicles); Apical breli
treatment of empyema.
In Exercises 1-3 a 1'.1
2. Arm exercises with breathing, e.g. Stride sitting; Arm raising sideways
(See Fig. 145, p. llO.
upwards with breathing.
5. Slight stoop sin
3. Trunk exercises with breathing, e.g. Stride sitting; Trunk bending sideways
resting on a table iI
with breathing.
pressure by therapisl
Physiotherapists tend to concentrate on the first group of exercises,
may use a strap to 10
because in the remainder the associated arm and trunk movements neutralize
6. Crook half-Iyinj
the action of the respiratory muscles; hence there is no net gain in respiratory
BREATHING EXERCISES 111
Fig. 146. Unilateral Costal breathing.
function, For example, in the exercise Arm raising sideways-upwards with

breathing the ribs are fixed by the intercostal muscles, to stabilize the origin of
the serratus anterior muscle; the fixation of the ribs neutralizes the upward
dragging action of the pectoral muscles on the thorax, which would otherwise
increase the range of inspiratory chest movement.
BILATERAL LOCALIZED BREATHING EXERCISES

Exercises to Increase the Expiratory Range
In these exercises emphasis is laid on prolonged, full expiration. Inspiration
must be as easy and shallow as possible,
1. Crook half-lying (hand on upper abdomen); Diaphragmatic breathing
with emphasis on contraction of abdominal waH during expiration. (See Fig.
ostaI breathing, 144, p, 110,)
2. Crook half-lying (hands on sides of lower chest); lower lateral Costal
ions; and (c) to teach breathing with pressure by hands on ribs during expiration, (See Fig. 143,
p, 109.)
IDlent of certain chest 3. Crook half-lying (hands on sides of upper chest); upper lateral Costal
rof left lower chest); left breathing with pressure by hands on ribs during expiration,
16), may be used in the 4, Crook half-lying (forearms crossed and fingers resting on chest below
clavicles); Apical breathing with pressure by fingers during expiration,
Arm raising sideways- In Exercises 1-3 a webbing strap may be used to localize the chest movements,
(See Fig. 145, p, 110,)
Trunk bending sideways 5, Slight stoop sitting (patient's forehead and arms supported on pillows
resting on a table in front of his stool); posterior Basal breathing with
[ group of exercises, pressure by therapist's hands during expiration, Alternatively, the patient
movements neutralize may use a strap to localize the rib movements,
net gain in respiratory 6, Crook half-lying; general deep breathing with emphasis on expiration,
7. Stride sitting; Trunk dropping loosely forwards-downwards to lax

stoop position, with expiration, and Trunk stretching 'vertebra by vertebra'
with shallow inspiration.
8. Stride sitting; Trunk turning with Arm swinging loosely at the sides:
expiration during the backward turning movements, and shallow inspiration
during the forward turning movements.
Exercises to Increase the Inspiratory Range
In these exercises emphasis is laid on deep inspiration, followed by 'normal'
expiration.
1. Crook half-lying (hand on upper abdomen); Diaphragmatic breathing

with emphasis on the relaxation of the abdominal wall during inspiration.
(See Fig. 144, p. 110.)
2. Crook half-lying (hands on sides of lower chest); lower lateral Costal
breathing with light pressure from hands. (See Fig. 143, p. 109.) I
3. Crook half-lying (hands on sides of upper chest); upper lateral Costal
breathing with light pressure from hands. full-width Velcro fasteni
4. Crook half-lying (forearms crossed and fingers resting on chest below it provides the chest wal
clavicles); Apical breathing with light pressure from fingers. Supporting the sides 4
In Exercises 1-3 a webbing strap may be used to localize the chest movements has the effect of enhaD
and to give light resistance. (See Fig. 145, p. 110.) diaphragm and thoracic:
5. Crook half-lying; general deep breathing. expended in a lateral dO
6. Skipping and rhythmical hopping exercises, running and swimming, to
make the patient breathe deeply.
TECHNICAL POINT
Practical Techniques
When the breathing eXeJ
EXERCISES TO VENTILATE THE LUNGS AND PREVENT hands to localize the m
STAGNATION OF MUCOUS SECRETIONS
understands the breathil
The bilateral localized breathing exercises given in the previous lists are used,
(about 1·5 m long and '
a full respiratory excursion being encouraged. Unilateral localized exercises
143-146, pp. 109 and 11
are also used.
the strap when the exet'1
Postural drainage and some form of percussion, especially shakings and When the therapist is
coarse vibrations, are frequently employed in association with the breathing supervising his breathiJ
exercises. The patient is also trained to cough effectively in order to assist the enables him both to fet
expectoration of the loosened secretions. difficulty. The patient'5
The coughing action is greatly improved if the therapist or the patient particularly during expi
supports the sides of the lower chest firmly with the hands. Alternatively, hygiene, but reduces the
support can be given by the use of a broad webbing strap, which is positioned infected secretions.
as shown in Fig. 145, p. 110. The patient tightens the ends of the strap held
in his hands to produce the necessary tension.
A Hawksley Cough-Lok (Fig. 147) is sometimes used in place of a webbing Starting Positions
strap; it has the advantage of being about 10 em wide and of being fitted with Ideally, localized breath
BREATHING EXERCISES 113
Is-downwards to lax
'vertebra by vertebra'
,.~,: ..
J loosely at the sides:
Hi shallow inspiration ..';
'.,,"<:~ .
....
followed by 'normal'
~gmatic breathing
o during inspiration.
; lower lateral Costal

:3, p. 109.) Fig. 147. A Hawksley Cough-Lok.
; upper lateral Costal
full-width Velcro fastenings. When adjusted in position round the lower ribs
~g on chest below it provides the chest wall with an extremely firm and stable support.
ngers. Supporting the sides of the lower thorax in this manner during coughing
re the chest movements has the effect of enhancing the upward pressure of the abdomen on the
diaphragm and thoracic contents by preventing some of the pressure being
expended in a lateral direction.
:og and swimming, to
TECHNICAL POINTS
Practical Techniques
When the breathing exercises are first taught the therapist generally uses his
o PREVENT hands to localize the movements for the patient. Later, when the patient
understands the breathing techniques, he uses his hands or a webbing strap
ll"eVious lists are used, (about 1·5 m long and 7 em wide) to localize the chest movements (Figs.
raJ localized exercises 143-146, pp. 109 and 111). Light resistance may be given with the hands or
the strap when the exercises are used to increase the range of inspiration.
[JCcia1ly shakings and When the therapist is localizing breathing movements for the patient, or
:Ill with the breathing supervising his breathing techniques, he should adopt a position which
, in order to assist the enables him both to feel and observe the respiratory movements without
difficulty. The patient's head should be turned away from the therapist,
:rapist or the patient particularly during expiration. This is not only in the interests of normal
bands. Alternatively, hygiene, but reduces the possibility of the therapist coming into contact with
p, which is positioned infected secretions.
:ods of the strap held
in place of a webbing Starting Positions

d of being fitted with Ideally, localized breathing exercises are carried out from a starting position
which gives the body maximum support, relaxes the abdominal muscles, and 10. Pe]
does not require any unnecessary muscle work, e.g. crook half-lying (Fig.
143, p. 109), crook lying (Fig. 148) and half-lying. The head is generally
supported by a pillow; in the crook and crook half-lying positions pillow
support for the thighs is also very helpful in ensuring relaxation.
Exercises to strengtbel
(1) Minor degrees of
Stress incontinence CIl
by laxity ofthe mud
may be produced by i
Pelvic floor exercise
Fig. 148. Crook lying as a starting position for localized breathing; the thigh and
head pillows ensure relaxation. TYPES OF PELVI(
Other starting positions are used to achieve specific purposes. For example, The muscles of the pc
a modified half-lying position (with the patient lying on one side) is useful in 1. By contracting t
localizing movement to the ribs of the 'free' side. A modified stoop sitting maximus. This produ
position is also used for posterior basal breathing (p. 111). sphincters of tbe blad
The hip adductor'S
together from such S1:II
Physical Education muscles are also exen:
From the standpoint of physical education sitting and standing may be used Examples: (i) CrooJ
(ii) Crool
as starting positions for localized breathing exercises in addition to the
positions previously described. Pelvi
2. By activating 'til
pelvic floor whereby
Breathing Exercises in Physical Education abdominal wall in 01
Correct breathing habits are of considerable importance to the normal abdominal pressure'. i
individual. For example, correct diaphragmatic breathing helps to prevent The abdominal wa
the development of lax abdominal muscles, and so indirectly assists in the gluteus maximus and
maintenance of good posture. In the older age groups full diaphragmatic crook lying and 'crool
excursion is essential in order to ventilate the base of each lung adequately. Examples: (i) Croo,
Full ventilation prevents the accumulation of stagnant mucous secretions in ing '/)
the base of the lung, which are prone to become infected. Infected secretions expir,
may contribute to the formation of such conditions as bronchiectasis and lung (ii) Croo,
abscess. ing r.r.
contT
*Yates-Bell J. G. aru
(Congress number: Sep
Iiominal muscles, and
rook half-lying (Fig.
10. Pelvic floor exercises
be head is generally
ring positions pillow
relaxation.
Exercises to strengthen the pelvic floor muscles are used in the treatment of
(1) Minor degrees of prolaps; of the vaginal wall after childbirth, and (2)
Stress incontinence caused by injury to the bladder sphincters, or, in women,
by laxity of the muscles of the pelvic floor. Injury to the bladder sphincters
may be produced by instrumentation or by prostatic resection.
Pelvic floor exercises are also used in ante- and post-natal training.
ilhing: the thigh and

TYPES OF PELVIC FLOOR EXERCISES
lIpOses. For example, The muscles of the pelvic floor are exercised indirectly in three ways.
one side) is useful in 1. By contracting the hip adductors and the lower fibres of the gluteus
lDdified stoop sitting maximus. This produces an associated contraction of the levator ani and the
11). sphincters of the bladder.*
The hip adductors and extensors are exercised as separate groups or
together from such starting positions as crook lying, lying, and standing. The
muscles are also exercised in association with the sphincter ani.
landing may be used Examples: (i) Crook lying (soft pillow between knees); Knee closing.
I in addition to the (ii) Crook lying (soft pillow between knees); Knee closing with
Pelvis raising and contraction of Sphincter ani.
2. By activating 'the postural reflex between the abdominal wall and the
pelvic floor whereby the pelvic floor contracts at the same time as the
abdominal wall in order to withstand the strain of the increased intra
IDee to the normal abdominal pressure'. *
ing helps to prevent The abdominal wall is exercised either alone or in association with the
Iirectly assists in the gluteus maximus and external sphincter ani from such starting positions as
I fun diaphragmatic crook lying and crook side lying.
IICh lung adequately. Examples: (i) Crook lying (hand on upper abdomen); Diaphragmatic breath
DUCOUS secretions in ing with strong contraction of the Abdominal wall during
LInfected secretions expiration. (See Figs. 144 and 148, pp. 110 and 114.)
lDCbiectasis and lung (ii) Crook lying (hand on upper abdomen); Diaphragmatic breath
ing with strong contraction of the Abdominal wall, plus Anal
contraction, during expiration.
*Yates-Bell J. G. and Cooksey F. S. (1937) J. Chart. Soc. Massage Med. Gymn.
(Congress number: Sept.), pp. 28, 31, and 32.
115
(iii) Crook lying; Pelvis tilting forwards and backwards, with 4. Crook lying (baJ
emphasis on the backward tilting movement. (See Fig. 149, strong contraction 01
which shows a different starting position.) expiration.
3. By contracting the external sphincter ani. It is possible that a con 5-5b. No progress
traction of this muscle is associated with a contraction of the pelvic floor
muscles.
Intermediate
The external sphincter ani may be exercised independently or in asso
GRADE 1
ciation with the gluteal, abdominal, and hip adductor muscles. Specific
1-3a. No progressi
exercises for the sphincter are performed from such starting positions as
lying, crook lying, and standing. 3b. Standing (legl
Example: Crook lying; Anal contractions (attempting to draw anus up into contraction.
pelvis). 4-5b. No progresSi
6. Walking while II
7. Standing; practi
~~_. r~-
_b ~r-----
;e
8. Standing; practi
Gluteal and Anal COIl
a
Fig. 149. Fig. ISO.
Pelvic floor Exercises

Elementary
GRADE 1
1. Crook lying; Anal contractions (attempting to draw anus up into pelvis).
1a. As above, but with legs crossed. Fig. 149 shows the starting position.
2. Lying; Leg turning outwards with Anal contractions.
3. Crook lying (soft pillow between knees); Knee closing.
4. Crook lying (hand on upper abdomen); Diaphragmatic breathing with
strong contraction of the abdominal wall during expiration. (See Figs. 144
and 148, pp. 110 and 114.)
5. Crook lying; Pelvis tilting forwards and backwards, with emphasis on
the backward tilting movement. (See Fig. 149, which shows a different
starting position.)
Sa. As Exercise 5, but taken from crook side lying.
5b. As Exercise 5, but taken from lying, with legs crossed (Fig. 149).
GRADE 2
3. Crook lying (soft pillow between knees); Knee closing with Pelvis
raising and Anal contractions (Fig. 150).
3a. Slight leg lift lying (legs crossed: heels supported on stool); Pelvis
raising with Hip adduction.
3b. Inclined long sitting (ankles crossed); pressing Knees together with
Gluteal and Anal contractions.
PELVIC FLOOR EXERCISES 117
and backwards, with 4. Crook lying (hand on upper abdomen); Diaphragmatic breathing with
rlDJUmt. (See Fig. 149, strong contraction of the abdominal wall, plus Anal contraction, during
tion.)
expiration.
I possible that a con
S-Sb. No progressions.
DO of the pelvic floor
Intermediate
pendently or in asso
:tor muscles. Specific GRADE I
I starting positions as
3b. Standing (legs crossed); Heel raising with Gluteal and Anal
r to draw anus up into contraction.
4-Sb. No progressions.
6. Walking while maintaining contraction of Gluteus maximus.
----, 7. Standing; practising combined sustained Gluteal and Anal contraction.
A.!-.,.- 8. Standing; practising coughing while maintaining combined sustained
~i ----,.
Gluteal and Anal contraction.
Fig. 150.
.. anus up into pelvis).
I the starting position.
tions.
losing.
pnaric breathing with
irarion. (See Figs. 144
rds, with emphasis on
ich shows a different
crossed (Fig. 149).
e closing with Pelvis
n:ed on stool); Pelvis
Knees together with

11. Shoulder girdle exercises
RETRACTORS
Strengthening
1. Sitting; Shoulder
2. Lying; Shoulder 1
PROTRACTORS AI
Strengthening
1. Sitting; Shoulder:
These exercises provide work for the muscles which activate the sternoclavi
2. Crook lying; exen
cular and acromioclavicular joints without causing movements of the shoulder
joint. Examples of some dynamic exercises are given here.
Mobilizing
Sitting; Shoulder r01lD
ELEVATORS
Strengthening
Sitting; Shoulder raising. ELEVATORS, PRa
Mobilizing
Mobilizing 1. Sitting; Shoulder
1. Sitting; continuous Shoulder raising and lowering. 2. As above, but wi1
2. Sitting; alternate Shoulder shrugging.
DEPRESSORS
Strengthening
1. Sitting; Shoulder depression.
2. Lying; Shoulder depression.
ELEVATORS AND DEPRESSORS

Strengthening
1. Lying; Shoulder raising and depression, and return to starting position.
2. Sitting; Shoulder raising, lowering, depression, and return to starting
position.
PROTRACTORS
Strengthening
1. Sitting; Shoulder rounding
2. Lying; Shoulder rounding.
l1S
SHOULDER GIRDLE EXERCISES 119
exerCIses RETRACTORS
Strengthening
L Sitting; Shoulder bracing.
2. Lying; Shoulder bracing.
PROTRACTORS AND RETRACTORS

Strengthening
1. Sitting; Shoulder rounding and bracing, and return to starting position.
I activate the sternocIavi
2. Crook lying; exercise as above.
IOvements of the shoulder .r;
:II here.
Mobilizing
Sitting; Shoulder rounding and bracing.
ELEVATORS, PROTRACTORS AND RETRACTORS

Mobilizing
L Sitting; Shoulder girdle rolling with emphasis on retraction.
:.ring. 2. As above, but with emphasis on protraction.
:rum to starting position.

II, and return to starting
SHOll
2. Bend sitting (stil

12. Combined shoulder joint and forwards-upwards. *
shoulder girdle exercises 3. Grasp walk-foIWlll
bending, stretching fOI1
4. Reach grasp stOOl
Arm raising forwards-u
Advanced
In the majority of the exercises given here the shoulder- girdle moves with the
GRADE 1
shoulder joint; in certain of the exercises, however, shoulder girdle move 1. No progression.
ment is negligible, e.g. in rotation of the shoulder joint from the neutral 2. First bend walk-fCl
position. forwards-upwards.
3--4. No progressiODll
5. Grasp walk-foIWlll
1. SHOULDER FLEXORS AND FORWARD ELEVATORS forwards-upwards, and
OF ARM forearm to 3 counts.
Strengthening Exercises 5a. As above, but bot
Elementary 6. Grasp walk-foIWlll
forwards-upwards, and
GRADE 1
forearm to 3 counts.
1. Bend lying; single or double Elbow raising forwards.
6a. As above, but bot
GRADE 2
GRADE 2
1. Bend sitting; single or double Elbow raising forwards or forwards
1-4. No progressiODll
upwards.
5-6a. Grasp walk-fa
2. Bend sitting; single or double Arm stretching forwards-upwards.
forwards-upwards, and
forearms to 2 counts, ani:
GRADE 3
2 counts. (See Fig. 151.:
1. Sitting; single or double Arm raising forwards or forwards-upwards.
2. No progression.
Intermediate Mobilizing Exercises

GRADE 1 Elementary
No progressions. GRADE 1
1. Bend crook lying; ;
GRADE 2
1. Grasp walk-forwards standing (stick crosswise in front of body); Arm GRADE 2
raising forwards or forwards-upwards. * 1. Bend sitting; alten
* Stick Exercises: The types of sticks used for these exercises are broomsticks and ash
sticks. In general, broomsticks are more suitable for remedial work than ash sticks,
because they are lighter. * See footnote, p. l20.
120
SHOULDER JOINT AND GIRDLE EXERCISES 121
2. Bend sitting (stick crosswise in front of chest); Arm stretching

fer
.lses joint and forwards-upwards. *
3. Grasp walk-forwards standing (stick crosswise in front of body); Arm
bending, stretching forwards-upwards, and lowering to starting position.*
4. Reach grasp stoop stride standing (stick crosswise in front of body);
Arm raising forwards-upwards. *
Advanced
:del" girdle moves with the GRADE 1
:1'", shoulder girdle move 1. No progression.
er joint from the neutral 2. First bend walk-forwards standing; single Arm punching forwards or
forwards-upwards.
5. Grasp walk-forwards standing (Indian clubs); single Arm swinging
I ELEVATORS forwards-upwards, and club circling backwards or forwards behind the
Sa. As above, but both arms are moved together (Fig. 151).
forwards-upwards, and club circling backwards or forwards in front of the
ixwards. 6a. As above, but both arms are moved together.
GRADE 2
III forwards or forwards- 1-4. No progressions.
5-6a. Grasp walk-forwards standing (Indian clubs); Arm swinging
B forwards-upwards. forwards-upwards, and club circling (a) backwards or forwards behind the
forearms to 2 counts, and (b) backwards or forwards in front of the forearms to
2 counts. (See Fig. 151.)
ds or forwards-upwards.
Elementary
GRADE 1
1. Bend crook lying; alternate Elbow raising forwards.
ise in front of body); Arm GRADE 2

1. Bend sitting; alternate Elbow raising forwards.
n:ises are broomsticks and ash
:medial work than ash sticks,
... See footnote, p. 120.
122 PROGRESSIVE EXERCISE THERAPY SHO
GRADE 3 Strengthening Exel'

1. Crook lying; alternate Arm raising forwards. Elementary
2. Toward standing (wall); single (affected) Arm 'crawling up the wall'
GRADE 1
(Fig. IS2).
1. Bend sitting; sin.!
,,
.. i'd
:','~.~:" ~",
:J GRADE 2
...p, ...,' :
'): i #0, '<' I.... .' 1. Sitting; single or
,::.~.
I
:;,;::;-",:'£
I .....
i
Intermediate
'.. . ... GRADE 1
........ _....,
1. Prone lying; sing

2. Reach stoop stricl
GRADE 2
1. No progression.
2. Reach grasp stoo
Fig. 151. Fig. 152. Fig. 153. Fig. 154. raising backwards (F~
Intermediate
GRADE 1 3. SHOULDER FI..I
1. Crook lying; alternate Arm swinging forwards. ARM WORKING W
2. No progression. Many of the movemen
3. Walk-forwards standing; alternate Arm swinging forwards-upwards. the starting positions
4. Walk-forwards standing; Arm swinging forwards-upwards, with in exercises of the should
creasing range to reach stretch position on the 4th count. examples are given bel
S. Walk-forwards standing; Arm swinging forwards and forwards 1. Walk-forwards 51
upwards. and downwards-bam
2. Half crook side
GRADE 2
downwards-backward!!
',1 3. Reach stoop strid

3. Walk-forwards standing; alternate Arm swinging forwards-upwards
~ and raising backwards
with rhythmical pressing to 3 counts.
4. Grasp walk-forwards standing (stick crosswise in front of body); Arm
swinging forwards-upwards with or without rhythmical pressing. *
S. Grasp walk-forwards standing (stick crosswise in front of body); Arm
4. SHOULDER AD)
swinging forwards and forwards-upwards.* OF ARM
Strengthening Exerl
Elementary
2. SHOULDER EXTENSORS GRADE 1
In these exercises movement of the shoulder girdle occurs after the shoulder 1. Sitting (affected \
joint has been extended fully. See also Exercises for the Depressors of the about 90°, and elbow l
Arm, p. 127.
* See footnote, p. 120. * See footnote, p. 120.
Elementary
Iwling up the wall'
GRADE 1
1. Bend sitting; single or double Elbow raising backwards.
GRADE 2
1. Sitting; single or double Arm raising backwards.
Intermediate
GRADE 1
1. Prone lying; single or double Arm raising backwards.
2. Reach stoop stride standing; Arm raising backwards (Fig. 153).
GRADE 2
1. No progression.
2. Reach grasp stoop stride standing (stick crosswise behind legs); Arm
:r;r. 154. raising backwards (Fig. 154).*
3. SHOULDER FLEXORS AND FORWARD ELEVATORS OF

ARM WORKING WITH SHOULDER EXTENSORS
Many of the movements given in the previous sections may be combined (or
[)[Wards-upwards. the starting positions modified) to give wide range flexion and extension
-upwards, with in exercises of the shoulder joint, with movement of the shoulder girdle. Some
[. examples are given below.
:ds and forwards 1. Walk-forwards standing; alternate Arm swinging forwards-upwards
and downwards-backwards.
2. Half crook side-lying; single Arm swinging forwards-upwards and
downwards-backwards.
3. Reach stoop stride-standing; Arm raising forwards-upwards, lowering,
forwards-upwards
and raising backwards as far as possible, and return to starting position.
ront of body); Arm
pressing.*
ront of body); Arm 4. SHOULDER ABDUCTORS AND SIDEWAYS ELEVATORS
OF ARM
Elementary
GRADE 1
s after the shoulder 1. Sitting (affected upper limb resting on table, with shoulder abducted to
: Depressors of the about 90°, and elbow flexed); single Deltoid contractions.
* See footnote, p. 120.

124 PROGRESSIVE EXERCISE THERAPY SHOULDER
GRADE 2 5. Grasp stride standing (l

1. No progression. upwards, and club circling I
2. Bend half-lying; single or double Elbow raising sideways. 3 counts.
3. Half crook side-lying; single Elbow raising sideways. Sa. As No.5, but both am
6. Grasp stride standing (1
GRADE 3 upwards, and club circling ba
1. No progression. 3 counts.
2. Bend sitting; single or double Elbow raising sideways. 6a. As No.6, but both arDI
3. Half crook side-lying; single Arm raising sideways (Fig. 155).
GRADE 2
5-6a. Grasp stride standil
upwards, and club circling (a)
(b) backwards in front of the J
Elementary
Fig. 155.
GRADE 1
1. Bend half-lying; altematJ
GRADE 4
GRADE 2
1. No progression.
1. Bend sitting; alternate EI
2. Half-lying or sitting; single or double Arm raising sideways-upwards.
2. Side toward standing (1
3. No progression.
wall'. (See Fig. 152, p. 122.11
4. Bend sitting; single or double Arm stretching sideways-upwards.
GRADE 3
Intermediate 1. Sitting; alternate Arm ra
2. No progression.
GRADE 1
No progressions.
Intermediate
l1 GRADE 2
!~ GRADE 1
1-3. No progressions. 1. Stride standing; Arm sw
4. Bend grasp stride standing (stick crosswise in front of chest); Arm 2. No progression.
stretching sideways-upwards. * 3. Stride standing; AJ;m sw.
the same time and direction. (
Advanced 4. Low arm cross stride sta
5. Stride standing; Arm s
GRADE 1
range to reach stretch positic:m
4. Fist bend stride standing; single Arm punching sideways or sideways GRADE 2
upwards. 1. Stride standing; Arm S'll
* See foomote, p. 120. * This exercise provides some 11

5. Grasp stride standing (Indian clubs); single Arm swinging sideways

upwards, and club circling backwards or forwards behind the forearm to
: sideways. 3 counts.
:ways. Sa. As No.5, but both arms are moved together.
6. Grasp stride standing (Indian clubs); single Arm swinging sideways
upwards, and club circling backwards or forwards in front of the forearm to
3 counts.
ieways. 6a. As No.6, but both arms are moved together.
(Fig. 155).
'Ilys
GRADE 2
5-00. Grasp stride standing (Indian clubs); Arm swinging sideways
upwards, and club circling (a) backwards behind the forearms to 2 counts, and
(b) backwards in front of the forearms to 2 counts.
Elementary
GRADE 1
1. Bend half-lying; alternate Elbow raising sideways.
GRADE 2
1. Bend sitting; alternate Elbow raising sideways.
ing sideways-upwards.
2. Side toward standing (wall); single (affected) Arm 'crawling up the
wall'. (See Fig. 152, p. 122, which shows the toward standing position.)
ideways-upwards.
GRADE 3
1. Sitting; alternate Arm raising sideways-upwards.
2. No progression.
Intermediate
GRADE 1
1. Stride standing; Arm swinging sideways-upwards.
1 front of chest); Arm 2. No progression.
3. Stride standing; Arm swinging to right and left, both arms moving in
the same time and direction. (See Fig. 156, p. 126.)*
4. Low arm cross stride standing; Arm swinging sideways-upwards. *
5. Stride standing; Arm swinging sideways-upwards with increasing
range to reach stretch position on the 4th count.
: sideways or sideways- GRADE 2

1. Stride standing; Arm swinging sideways-upwards to beat the fists
* This exercise provides some work for the shoulder adductors.

126 PROGRESSIVE EXERCISE THERAPY SHot
together (1-2), and swinging downwards-sideways to beat the sides of the GRADE 3
thighs (3-4).* 1 and la. No progre
2. No progression. 2. Sitting (elbows fI
3. Wide grasp stride standing (stick crosswise in front of body); Arm Shoulder adduction, to
swinging to right and left (Fig. 156).t
GRADE 4
·•
I
I
1 and la. No progre
2. Stride standing; si
~,
"'ti\
R across the chest.
1 ,
: '\
.~ .
r----
·
!
: R 6. SHOULDER ADD
'1\'
OF ARM WORKING
See Exercises marked wi
movements given in Se
abduction and adductiCl
shoulder girdle.
Fig. 156.
S. SHOULDER ADDUCTORS 7. DEPRESSORS OJ

In these exercises movement of the shoulder girdle accompanies movement Strengthening Exerc
of the shoulder joint. (See also Exercises for the Depressors of the Arm, Elementary
p. 129.)
See Introductory Exer1
rings or ropes, and Rot
Elementary Intermediate
GRADE 1
GRADE 1
1. Sitting (hands clasped in front of body with elbows flexed to about 90°);
1. Under grasp stan
pressing palms together strongly to produce static contractions of pectoralis
with take-off from floo
major.
la. Sitting (hands and forearms resting on thighs); single or double Arm
GRADE 2
pressing inwards against the trunk to produce static contractions of pectoralis
1. Under grasp ~
major.
2. Inward grasp haD
3. Heave grasp staru
GRADE 2
bent knees, touching d
1 and la. No progressions.
movement. (See Fig. I(
2. Bend sitting; single Shoulder adduction, to move Elbow across the
exercise with straight I
chest.
4. Under grasp waf
* This exercise provides some work for the shoulder adductors. forwards-upwards and
t See footnote, p. 120. p. 87, which shows the
, beat the sides of the GRADE 3

I and lao No progressions.
2. Sitting (elbows flexed to 90° and forearms in front of chest); single
front of body); Arm Shoulder adduction, to move Arm across the chest.
GRADE 4
I and 1a. No progressions.
2. Stride standing; single or double Shoulder adduction, to move Arm(s)
across the chest.
6. SHOULDER ABDUCTORS AND SIDEWAYS ELEVATORS

OF ARM WORKING WITH SHOULDER ADDUCTORS
See Exercises marked with an asterisk in Section 4, pp. 123-126. Certain ofthe
movements given in Sections 4 and 5 may be combined to give wide-range
abduction and adduction exercises ofthe shoulder joint, with movement ofthe
shoulder girdle.
7. DEPRESSORS OF ARM AND SHOULDER EXTENSORS

:companies movement Strengthening Exercises
~i'essors of the Arm,
Elementary
See Introductory Exercises to Arm bending from hanging, circling on the
rings or ropes, and Rope climbing, pp. 129-130'.
Intermediate
IrSflexed to about 90°); GRADB 1

lttactions of pectoralis 1. Under grasp standing (beam slightly above head level); Arm bending
with take-off from floor.
single or double Arm
GRADE 2
IltIactions of pectoralis
1. Under grasp hanging (beam); Arm bending (Fig. 157).
2. Inward grasp hanging (beam); Arm bending (Fig. 158).
3. Heave grasp standing (rings or ropes); circling and return circling with
bent knees, touching the floor with the feet at the end of the forward circling
movement. (See Fig. lOla, p. 87, for starting position, and Fig. 71, p. 74, for
[We Elbow across the
exercise with straight legs.)
4. Under grasp walk-forwards standing (beam at head height); circling
aors. forwards-upwards and downwards-forwards with bent knees. (See Fig. 102,
p. 87, which shows the exercise performed with straight legs.)
128 PROGRESSIVE EXERCISE THERAPY sa
8. DEPRESSORS
Strengthening ED
Elementary
See below IntroductOl
1. Stretch grasp hi
Fig. 158.
Fig. 157.
Advanced
GRADE 1
3. Heave grasp standing (rings or ropes); circling and return circling with
F.
straight legs, touching the floor with the feet at the end ofthe forward circling
movement. (See Fig. lOla, p. 87, for starting position, and Fig. 71, p. 74, for
movement.) Intermediate
4. Under grasp walk-forwards standing (beam at head height); circling
forwards-upwards and downwards-forwards with straight legs. (See Fig. 102, GRADE 1
p.87.) 1. Angle hanging
5. Rope climbing: left or right Hand leading with Leg grasp. 2. Over grasp SbI
with take-()ff from tl
GRADE 2
1-2. No progressions. GRADE 2
1. No progressiOi
3. Stretch grasp standing (rings or ropes); circling and return circling with
2. Over grasp ba:I
straight legs. (See Fig. 71, p. 74.)
3. Over grasp ba:I
4. Stretch under grasp standing (beam); circling forwards-upwards and
from side to side. (~
5. Rope climbing: Hand over Hand with Leg grasp.
Introductory Exel
GRADE 3 Arm Bending from J
1-2. No progressions. Subject Working fl1it
3. Inward grasp hanging (rings); circling and return circling with straight weight during the aJ
legs. (See Fig. 71, p. 74, for movement.) waist.
4. Under grasp hanging (beam); circling forwards-upwards and Exercise Performed
downwards-forwards with straight legs. (See Fig. 102, p. 87, for movement.) standing, with the b
5. Rope climbing: Hand over Hand without Leg grasp. rest his arms after I
8. DEPRESSORS OF ARM AND SHOULDER ADDUCTORS

Elementary
See below Introductory Exercises to Arm bending from hanging.
1. Stretch grasp high stoop standing (wall bars); Arm bending (Fig. 159).
FW·158.
-.
-.
\ Fig. 159.
-.
::::::::::: .
--:--:
ling and return circling with Fig. 160.

Ie end of the forward circling
Iition, and Fig. 71, p. 74, for
Intermediate
m at head height); circling
luttaight legs. (See Fig. 102, GRADE 1
1. Angle hanging (wall bars and living support); Arm bending (Fig. 160).
with Leg grasp. 2. Over grasp standing (beam slightly above head level); Arm bending
with take-off from floor.
GRADE 2
ling and return circling with 1. No progression.
2. Over grasp hanging (beam); Arm bending.
ling forwards-upwards and 3. Over grasp hanging (beam); Arm walking sideways with Leg swinging
_102, p. 87, which shows an from side to side. (See Fig. 120, p. 96.)
: grasp.
Introductory Exercises
Arm Bending from Hanging
Subject Working with Partner. The partner takes some ofthe subject's body
return circling with straight weight during the arm bending. He stands behind him, and grasps him at the
waist.
I forwards-upwards and Exercise Performed from Standing. The arm bending is performed from
.102, p. 87, for movement.) standing, with the beam arranged at stretch height. This allows the subject to
L.cg grasp. rest his arms after each arm-bending movement.
130 PROGRESSIVE EXERCISE THERAPY SHl
Circling on Rings or Ropes Strengthening Exc!

The subject attempts the circling in stages, first trying out a quarter turn, Elementary
then a half circle, and finally a full circle. He need not attempt the return GRADE 1
circle at first, but may let go of the rings or ropes and stand up when his feet 1. Neck rest lying;
touch the floor at the end of the forward circling.
Until the subject has acquired a good circling technique two supporters GRADE 2
should stand on either side of him to give him confidence and, if necessary, to 1. No progression.
support him. It is also a wise precaution to put a mattress under the rings or
ropes in case the subject accidentally loses his grasp. GRADE 3
1. Yard (palms fOl
161).
Circling on the Beam
See p. 91.
,, "
Rope Climbing ,,
Leg Grip. The subject practises taking and maintaining the leg grip, first with .........
'"
one foot behind the rope and then with the other. In the initial stages he sits
on a stool which has been placed close to the rope. He grasps the rope as high
as he can with both hands, and tries the leg grip without throwing any weight
on to the arms. He must be taught to carry the feet well forward when he has
gripped the rope, to prevent it from being held between the thighs instead of
11/ 1
the knees; this would result in a weak grip.
The subject tests the grip by lifting his buttocks from the stool and Intermediate
swinging on the rope, or using his legs as in climbing. Thus he bends the
arms and stretches the legs without losing his grip with the knees and feet, GRADE 1
and then sits down on the stool again by allowing the arms to straighten out 1. No progression
and the knees to bend. 2. Inclined prone
Ascending and Descending the Rope. When the leg grip has been mastered height); Arm benditJ
the subject practises ascending and descending the rope from standing,
without raising the hands much higher than stretch height. He then GRADE 2
progresses to the full climb. 1. No progressior
2. Inclined prone
bending. (See Fig. 6
Advanced
9. SHOULDER PROTRACTORS
GRADE 1
Protraction of the shoulder joint 'is a movement in which the fully abducted 1. No progressiOl
arm is brought towards the fully flexed position'.* The movement is 2. Prone falling;.
associated with protraction of the shoulder girdle.
GRADE 2
1. No progressia
.. ApPLETON A. B. (1946) Surface and Radiological Anatomy, 2nd ed., p. 46.
Cambridge: Helfer. 2. Horizontal pn
lout a quarter turn, Elementary
II attempt the return GRADE 1
rand up when his feet 1. Neck rest lying; single or dOUble Arm protraction.
aique two supporters GRADE 2

e and, if necessary, to 1. No progression.
:lIS under the rings or
GRADE 3
1. Yard (palms forwards) lying; single or double Arm protraction (Fig.
161).
,_-0,
/ "
t :;~"'''
',
i
be leg grip, first with

.
'" I
"I \
II/~~
~ initial stages he sits

asps the rope as high
throwing any weight
rorward when he has
the thighs instead of Fig. 161. Fig. 162.
from the stool and

Intermediate
, Thus he bends the
I the knees and feet, GRADE 1
ms to straighten out 1. No progression.
2. Inclined prone falling (wall bars: hands between shoulder and hip
p has been mastered height); Arm bending (Fig. 162).
:ope from standing,
h height. He then GRADE 2
1. No progression.
2. Inclined prone falling (beam below hip height: hands supported); Arm
bending. (See Fig. 62, p. 71.)
Advanced
GRADE 1
b the fully abducted 1. No progression.
The movement is 2. Prone falling; Arm bending. (See Fig. 65, p. 72.)
GRADE 2
~, 2nd ed., p. 46. 1. No progression.
2. Horizontal prone falling; Arm bending. (See Fig. 66, p. 72.)
Strengthening :I
10. SHOULDER RETRACTORS
Elementary
Retraction of the shoulder joint is a movement in which the fully flexed arm is
GRADE 1
moved backwards through the horizontal plane to the fully abducted 1. Neck rest (e1
position. The movement is associated with retraction of the shoulder girdle.
GRADE 2
Strengthening Exercises 1. Reach si~
Elementary
GRADE 3
GRADE 1
1. Yard (palms
1. Neck rest (elbows forward) stoop stride standing; single or double together strongly.
Elbow parting.
return to starting
GRADE 2
1. No progression. Intermediate
GRADE 3 GRADE 1
1. Reach stoop stride standing; single or double Arm parting. 1. Reach gras)l
stick carrying ba
repetition of mml
Intermediate 2. Reach gra5II
GRADE 1 Arm bending in :
1. No progression.
2. Reach grasp stoop stride standing (stick crosswise in front of body); GRADE 2
Arm bending to bring stick to chest (Fig. 163).* No progressions.

Fig. 76, p. 77.)
Advanced
GRADE 2 GRADE 1
1-2. No progressions. 1-2. No prog1
3. Over grasp fall hanging (beam below shoulder height); Arm bending. 3. Fist bend
the chest (Fig. 1
GRADE 3
3. Over grasp horizontal fall hanging (beam and living support); Arm
11. SHOULDER PROTRACTORS AND RETRACTORS

For definition of protraction and retraction of the shoulder joint see previous
sections.
* See footnote.
Elementary
h the fully flexed arm is
GRADE 1
II) the fully abducted
1. Neck rest (elbows forwards) sitting; single or double Elbow parting.
of the shoulder girdle.
GRADE 2
1. Reach sitting; single or double Arm parting.
GRADE 3
1. Yard (palms forwards) sitting; Arm carrying forwards to press the palms
iIing; 'single or double
together strongly, followed by Arm carrying backwards to the full extent, and
return to starting position.
Intermediate
GRADE 1
1m parting. 1. Reach grasp walk-forwards standing (stick crosswise in front of chest);
stick carrying backwards to the right, and return to starting position, and
repetition of movement to the left. *
2. Reach grasp walk-forwards standing (stick crosswise in front of chest);
Arm bending in horizontal plane to bring stick to chest. *
rise in front of body); GRADE 2
No progressions.
Il); Arm bending. (See
Advanced
GRADE 1
!eight); Arm bending. 3. Fist bend stride standing; single Arm punching horizontally across
the chest (Fig. 164).
"'CTORS
Ilder joint see previous
Fig. 163. Fig. 164.

134 PROGRESSIVE EXERCISE THERAPY SHot
Intermediate
.---~,
GRADE 1
1. Reach grasp walk forwards standing (stick crosswise in front of chest);
~'
stick swinging backwards and forwards in the horizontal plane.*
2. Across bend walk forwards standing; Elbow pressing backwards with
Arm flinging on the 3rd count.
3. Standing (arms crossed firmly over chest); Cabman's warm-up swing.
..:;::::
Fig. 165.
12. LATERAL ROTATORS OF SHOULDER JOINT
See Exercises in which the arms are raised sideways-upwards, p. 123. In these
exercises the lateral rotators of the shoulder joint act with the shoulder 13. MEDIAL ROTA
abductors and the elevators of the arm. Strengthening Exer
Elementary
Elementary GRADE 1
1. Forearm reach si
GRADE 1
2. Sitting; Arm nm
1. Forearm reach sitting; single or double Arm turning outwards
(Fig. 165).
GRADE 2
2. Sitting; single or double Arm turning outwards. 1. Heave lying; sin:
(Fig. 168).
GRADE 2 2. No progression.
1. Forward heave lying; single or double Arm turning inwards through 90°
(Fig. 166).
2. No progression.
GRADE 3
1. Half crook side-lying (elbow of uppermost arm flexed to 90°, and
forearm in contact with chest); single Arm turning outwards.
2. Sitting; single or double Hand placing on back of neck or slight distance
behind neck.
1 GRADE 3
Intermediate 1. No progression
2. Sitting; single
GRADE 1 distance behind it.
1. No progression.
2. As Exercise 2, in previous grade, but performed in prone lying.
3. Heave grasp sitting (stick crosswise); Arm turning inwards to bring Intermediate
stick against chest. Fig. 167 shows the exercise taken from walk-forwards GRADE 1
standing.* 1. Heave grasp ly
* See footnote, p. 120. 2. As Exercise 2,
I
rise in front of chest);
Ial pIane.*
ISing backwards with
ill'S warm-up swing.
!NT Fig. 165. Fig. 166. Fig. 167.
'8l'ds, p. 123. In these

:t with the shoulder 13. MEDIAL ROTATORS OF SHOULDER JOINT
Elememary
GRADE 1
1. Forearm reach sitting; single or double Arm turning inwards.
ning outwards 2. Sitting; Arm turning inwards.
GRADE 2
1. Heave lying; single or double Arm turning inwards through 90°
(Fig. 168).
inwards through 90° 2. No progression.
. flexed to 90°, and

IraI'ds.
edt or slight distance
Fig. 168.
GRADE 3
1. No progression.
2. Sitting; single or double Hand placing on lumbar spine or slight
distance behind it.
I prone lying.
Ig inwards to bring
Imermediate
!'rom walk-forwards
GRADE I
l. Heave grasp lying (stick crosswise); Arm turning inwards through 90°.
2. As Exercise 2, in previous grade, but performed in prone lying.
s
14. LATERAL AND MEDIAL ROTATORS OF
SHOULDER JOINT
Many of the movements given in the two previous sections may be combined
to give wide-range rotation exercises of the shoulder joint. Two examples of / ..............
mobilizing exercises are given here.

1.. Forearm reach sitting; Arm turning outwards and inwards continuously
to a given count. I
2. Sitting; alternate Hand placing behind the neck and the lumbar spine. t
\
15. SHOULDER CIRCUMDUCTORS AND ELEVATORS

OF ARM
Mobllizing Exercises
Fig. Ifill
Elementary
GRADE 1 2a. As Exercise :
1. Bend sitting; single or double Elbow circling forwards or backwards. direction.
2. Bend sitting; alternate Elbow circling forwards or backwards.
GRADE 2
GRADE 2
1. Wide grasp WI
No progressions.
Arm circling fol"Wlll
stretching forwards
GRADE 3 forwards to startin8
1. Sitting or walk-forwards standing; single or double Arm circling la-2. No progres
forwards or backwards. 2a. Wide grasp s
la. Sitting or walk-forwards standing; alternate Arm circling forwards or swinging in a circle,
backwards. left.*
2. Stride standing; single Arm circling in the frontal plane, the circling
starting in an outwards or inwards direction. Advanced
2a. As Exercise 2, but both arms are moved together and in the same
direction. GRADE 1
1. Grasp walk-f(l
swinging in a foIWII
la, b. No progm
1 Intermediate
2. Grasp stride 5
I GRADE 1 the frontal pillne, d
1. Walk-forwards standing; single or double Arm swinging in a circle: 2a. As Exercise
forwards or backwards. direction (Fig. 170)
la. Walk-forwards standing; alternate Arm swinging in a circle: forwards
or backwards. GRADE 2
lb. Fallout forwards standing (hand on thigh); single Arm swinging in a 1. Grasp walk-fo
circle: forwards or backwards (Fig. 169). forwards circle, pill
2. Stride standing; single Arm swinging in a circle in the frontal plane, the backwards behind tl
circling starting in an outwards or inwards direction.
* See foomote, p. I
OF
- ..)....
......
/
Isections may be combined "
da joint. Two examples of \
/'~'-........
\
sand inwards continuously
'\ ..I
I \ R,' "
I
xdt and the lumbar spine. J
\ }
\ /
--
./
ELEVATORS
Fig. 169. Fig. 170.
2a. As Exercise 2, but the arms are moved together and in the same
g forwards or backwards. direction.
rds or backwards.
\
GRADE 2
1. Wide grasp walk-forwards standing (stick crosswise in front of body);
Arm circling forwards-upwards (Arm bending to bring stick close to chest,
stretching forwards-upwards to stretch position, and lowering downwards
forwards to starting position)."
or double Arm circling 1a-2. No progressions.
2a. Wide grasp stride standing (stick crosswise in front of body); Arm
~ Arm circling forwards or swinging in a circle in the frontal plane, the circling starting to the right or
left ..,
frontal plane, the circling
Advanced
together and in the same
GRADE 1
1. Grasp walk-forwards standing (Indian clubs); single or double Arm
swinging in a forwards or backwards circle.
la, b. No progressions.
2. Grasp stride standing (Indian clubs); single Arm swinging in a circle in
the frontal plane, the circling starting in an outwards or inwards direction.
bIn swinging in a circle: 2a. As Exercise 2, but the arms are moved together and in the same
direction (Fig. 170).
tIging in a circle: forwards
GRADE 2
single Arm swinging in a 1. Grasp walk-forwards standing (Indian clubs); single Arm swinging in a
forwards circle, pausing in the half high reach position to swing the club
:k in the frontal plane, the backwards behind the forearm to I count.
on.
" See footnote, p. 120.
la, b. No progressions.
Ie. As Exercise 1, but the arms are moved together.
13. Elb«
2. Grasp stride standing (Indian clubs); single Arm swinging in a circle in
the frontal plane, pausing in the half high yard position to circle the club
backwards behind the forearm to 1 count.
2a. As Exercise 2, but the arms are moved together.
See Exercises in previous section. The movements are performed more
slowly than when used as mobility exercises. FLEXORS
Strengthening Exerc:l
Elementary
GRADE 1
1. Sitting (forearms i
forearms supinated); siI
GRADE 2
1. No progression.
2. Lying; single or d
GRADE 3
1. No progression.
2. Sitting; single or .
Intermediate
GRADE 1
1. No progression.
2. Grasp standing (l
3. Reach grasp stOC
Arm bending to bring
GRADE 2
• 1-3. No progressiOl
4. Grasp stride sou
chest, bending (allowi
circling backwards I
downwards.
4a. As previous exc
5. Stretch grasp hi
159, p. 129.)
* Srick Exercises:
sticks. Because they are
r. 13. Elbow exerCIses
I swinging in a circle in
lion to circle the club
f.
are performed more

FLEXORS
Elementary
GRADE 1
1. Sitting (forearms and hands resting on table, with elbows flexed and
forearms supinated); single Biceps contractions.
GRADE 2
1. No progression.
2. Lying; single or double Elbow bending through 90°.
GRADE 3
1. No progression.
2. Sitting; single or double Elbow bending.
Intermediate
GRADE 1
1. No progression.
2. Grasp standing (stick crosswise in front of body); Arm bending.*
3. Reach grasp stoop stride standing (stick crosswise in front of body);
Arm bending to bring stick to chest. (See Fig. 163, p. 133.)*
GRADE 2
4. Grasp stride standing (Indian clubs); single Arm swinging across the
chest, bending (allowing the upper arm to return to side of trunk), and club
circling backwards behind the forearm to 3 counts, and stretching
downwards.
4a. As previous exercise, but both arms are moved together.
5. Stretch grasp high stoop standing (wall bars); Arm bending. (See Fig.
159, p. 129.)
" Stick Exercises: The types of sticks used for these exercises are broomsticks and ash
sticks. Because they are lighter, broomsticks are more useful for early remedial work.
139
2. Bend sittil:
Fig. 76, p. 77.)
Intermediate
Advanced GRADE I
l-la. No prCl
GRADE 1
2. Bend gra
upwards.*
5. Angle hanging (wall bars and living support); Arm bending. (See Fig.
160, p. 129.)
GRADE 2
6. Over grasp fall hanging (beam below shoulder height); Arm bending.
1-2. No PfOi
7. Under grasp or over grasp hanging (beam slightly above head height);
3. Graspsm
Arm bending with take-off from floor. (See Fig. 157, p. 128, and Fig. 171, of
the frontal plan
Arm bending without take-off.)
pa using in the I
brought behind
GRADE 2
to 3 counts.
4. Inclined I
6. Over grasp horizontal fall hanging (beam and living support); Arm
height); Arm b
7. Under grasp or over grasp hanging (beam); Arm bending. Fig. 171
shows Arm bending from over grasp hanging. (See also Fig. 157, p. 128.) Advanced
GRADE 1
1-3. No prCl
4. Inclined I
bending. (See
GRADE 2
1-3. No p~
4. Horizon.
"
Fig. 171.
EXTENSORS
FLEXORSJ
Strengtheni
Ii
Elementary
GRADE 1 Elementa,ry
1. Sitting; single Triceps contractions. GRADE 1
1a. Lying; single Arm pressing downwards. 1. Lying;!
GRADE 2
GRADE 2
l-1a. No progressions.
1. Bend si
2. Bend lying; single or double Arm stretching forwards. la. Bend 1
GRADE 3
* See foom!
l-la. No progressions.
ELBOW EXERCISES 141
eight); Arm bending. (See 2. Bend sitting; single or double Arm stretching sideways-upwards.
Intermediate
GRADE I
I-Ia. No progressions.
2. Bend grasp sitting (stick crosswise); Arm stretching sideways
); Arm bending. (See Fig. upwards.*
~ height); Arm bending. GRADE 2

lr;InIy above head height); I-2. No progressions.
7, p. 128, and Fzg. 171, of 3. Grasp stride standing (Indian clubs); single Arm swinging in a circle in
the frontal plane (the circling starting in an outwards or inwards direction),
pausing in the half stretch position to (a) bend the arm, so that the hand is
brought behind the head, and (b) circle the club backwards behind the forearm I'
to 3 counts.
ad living support); Arm 4. Inclined prone faIling (wall bars: hands between shoulder and hip
height); Arm bending. (See Fig. 162, p. 131.)
~ Arm bending. Fig. 171
'e also Fig. 157, p. 128.) Advanced
GRADE 1
4. Inclined prone falling (beam below hip height: hands supported); Arm
GRADE 2
4. Horizontal prone falling; Arm bending. (See Fig. 66, p. 72.)
FLEXORS AND EXTENSORS

Elementary
GRADE I
I. Lying; single or double Elbow bending.
GRADE 2
I. Bend sitting; single or double Arm stretching forwards.
o.:wards. la. Bend sitting; Arm stretching forwards and sideways.
- - - - - - - - - - - - - - - - - - - - _ _-_ _ - .. ..

Intermediate
No progressions.
14. Fore=
.
exercises
Advanced
GRADE I
1. Fist bend walk-forwards standing; single Arm punching forwards, and
strong return movement.
la. Fist bend stride standing; single Arm punching sideways, and strong
return movement.
The weight of the moving
impracticable to give lisn
Mobilizing Exercises Specimen exercises for tb
Elementary
GRADE 2
1. Sitting or walk-forwards standing; alternate Elbow bending and stretch 1. FOREARM EXERG
ing, the extremes of both movements being emphasized. PRONATORS
2. As above, but elbow flexion is combined with supination of forearm, Strengthening Exercis
and elbow extension is combined with pronation of forearm.
Elementary
1. Sitting (elbows fleD
forwards-downwards); siJ
Intermediate
GRADE I Intermediate
1. Walk-forwards standing; single Elbow bending and stretching, with 2. Half forearm read
gentle rhythmical pressing to 3 counts on reaching the extremes of pointing downwards: hal
movement. single Forearm turning ill
2. No progression. end pointing outwards. Jl
3. Wide grasp stride standing (stick crosswise in front of body); Arm standing.*
circling forwards-upwards (Arm bending to bring stick to chest, stretching
forwards-upwards to stretch position, and lowering downwards-forwards to
starting position). *
~
:,
----_ _- ..
* Stick Exercises: The typ

sticks. Because they are ligl
14. Forearm, wrist and hand
exerCIses
D punching forwards, and
bing sideways, and strong
The weight of the moving part in these exercises is relatively small; hence it is
impracticable to give lists of progressive exercises as in previous chapters.
Specimen exercises for the individual muscle groups are listed.
!bow bending and stretch 1. FOREARM EXERCISES

1Sized.
PRONATORS
Ih supination of forearm,
iforearm. Strengthening Exercises

\
Elementary
1. Sitting (elbows flexed to 90°, with palms together and fingers pointing
forwards-downwards); single or double Forearm pronation.
Intermediate
ing and stretching, with 2. Half forearm reach grasp standing (stick vertical with distal end
IChing the extremes of pointing downwards: hand grasps shaft some distance from proximal end);
single Forearm turning inwards until stick is in horizontal position with distal
end pointing outwards. Fig. 172 shows the exercise taken from walk forwards
in front of body); Arm standing. *
stick to chest, stretching
downwards-forwards to
Fig. 172.
" Stick Exercises: The types of sticks used for these exercises are broomsticks and ash
sticks. Because they are lighter, broomsticks are more useful for early remedial work.
143
FORI
3. Starting position as above, but distal end of stick points upwards; single Advanced
Forearm turning outwards until stick is in horizontal position with distal end 3. Stick exercises as
pointing outwards." proximal end."
Advanced PRONATORS AND

4. Stick exercises as above, but hand grasps the stick close to the proximal Strengthening Exerc:
end."
Elementary
1. Forearm reach sill
SUPINATORS Fig. 165, p. 135, shoWl!
Elementary Intermediate
1. Forearm reach sitting (palms downwards, lax wrists and fingers); single 2. 'Screwing' inward
or double Forearm supination, so that the fingers point upwards. Fig. 165, resistance (Fig. 174).*
p. 135, shows Forearm reach position. 3. Half forearm reac
zontal, with distal end
from proximal end); l
Intermediate horizontal position will
2. Half forearm reach grasp standing (stick vertical with distal end
pointing downwards: hand grasps shaft some distance from proximal end);
~
single Forearm turning outwards until stick is in horizontal position with
distal end pointing inwards. Fig. 173 shows the exercise taken from walk
~ r·
forwards standing."
Fig. 174.
.
3a. Starting positio
turning inwards ,until
11'
inwards.*
~
~ Fig. 173
1 Advanced
2a. Starting position as above, but distal end of stick points upwards; 4. Stick exercises
single Forearm turning inwards until stick is in horizontal position with distal resistance is increased
end pointing inwards." the stick close to the I
* See foomote, p. 143. * See footnote, p. 143

FOREARM, WRIST AND HAND EXERCISES 145
toints upwards; single Advanced

JSition with distal end 3. Stick exercises as above, but the hand grasps the stick close to the
proximal end.*
PRONATORS AND SUPINATORS

close to the proximal
Elementary
1. Forearm reach sitting (lax fingers); single or double Forearm turning.
Fig. 165, p. 135, shows Forearm reach position.
Intermediate
as and fingers); single 2. 'Screwing' inwards and outwards movements with a stick against self
n upwards. Fig. 165, resistance (Fig. 174).*
3. Half forearm reach grasp standing (palm downwards, and stick hori
zontal, with distal end pointing outwards: hand grasps shaft some distance
from proximal end); single Forearm turning outwards until stick is in
horizontal position with distal end pointing inwards (Fig. 175).*
ica1 with distal end
from proximal end);
izontal position with
,,r'.\ .
ise taken from walk
., \
! '\
I
- - - --=--1'if---_ I
.
Fig. 174. Fig. 175. Fig. 176.
3a. Starting position as above, but palm faces upwards; single Forearm
turning inwards until stick is in horizontal position with distal end pointing
inwards.*
Advanced
ick points upwards;
4. Stick exercises as above. In the 'screwing' movements the self
11 position with distal
resistance is increased, and in the Forearm turning exercises the hand grasps
the stick close to the proximal end.

146 PROGRESSIVE EXERCISE THERAPY FORE
5. Grasp stride standing (Indian clubs); single Elbow bending to 90", and WRIST FLEXORS
club swinging in a circle in an outwards or inwards direction. Fig. 176 shows a Strengthening Exerci
swinging which starts in an outwards direction.
Elementary
5a. As Exercise 5, but both arms are used at the same time.
1. Forearm reach sitt
forwards-upwards, and club circling (a) backwards behind the forearm to 2 Wrist flexion (Fig. 177).
2. As above, but with
counts, and (b) backwards in front of the forearm to 2 counts.
6a. As Exercise 6, but both arms are moved at the same time.
Intermediate
3. Half grasp standinl
with distal end resting
Mobilizing Exercises proximal end); single W
Elementary
1. Forearm reach sitting (lax fingers); single, double, or alternate Forearm
J
turning inwards and outwards.
Intermediate
2. Forearm reach sitting (lax fingers); single or double Forearm turning
tff
inwards and outwards with rhythmical pressing to a given count.
3. Forearm reach sitting (lax wrists and fingers); alternate Forearm
turning inwards and outwards with a shaking motion.
4. Sitting or walk-forwards standing; alternate Elbow bending (with
Fig. 1
Forearm supination) and stretching (with Forearm pronation).
5. Half Forearm reach grasp standing (stick in vertical position, and
grasped at centre of shaft); single Forearm turning inwards and outwards 4. Forearm reach gra
with a swinging motion. flexion. Fig. 165, p. 13~
6. 'Screwing' inwards and outwards movements with a stick. (See Fig. 174,
p. 145.)
Advanced
5. As Exercise 3, but
Advanced
See Club Exercises in previous section.
WRIST EXTENSOR
Strengthening Exere
:1 Elementary
;t
2. WRIST EXERCISES 1. Forearm reach sitl
or double Wrist extern
The muscles of the wrist are exercised synergically when the fingers are used, 2. As Exercise 1, bu
e.g. in gripping, the wrist extensors act synergically. Exercises and simple
occupations for the fingers should always be used in association with specific
wrist exercises. * See footnote, p. 143.
I' FOREARM, WRIST AND HAND EXERCISES 147
lx>w bending to 90 and

0
, WRIST FLEXORS
rection. Fig. 176 shows a Strengthening Exercises
Elementary
same time.
I; single Arm swinging 1. Forearm reach sitting (palms upwards, lax fingers); single or double
behind the forearm to 2 Wrist flexion (Fig. 177).
2 counts. 2. As above, but with Finger flexion.
Ie same time.
Intermediate
3. Half grasp standing (palm forwards, and stick held obliquely forwards
with distal end resting on floor: hand grasps shaft some distance from
proximal end); single Wrist bending (Fig. 178).*
Ie, or alternate Forearm
iJuble Forearm turning

given count.
~); alternate Forearm
L
Elbow bending (with
...,
ronation). Fig. 177. Fig. 178.
vertical position, and
inwards and outwards
4. Forearm reach grasp standing (palms upwards: stick crosswise); Wrist
flexion. Fig. 165, p. 135, shows Forearm reach position.*
:hastick.(SeeFig.174,
Advanced
5. As Exercise 3, but the hand grasps the stick close to the proximal end.*
WRIST EXTENSORS
Elementary
1. Forearm reach sitting (palms downwards, lax fingers and wrists); single
or double Wrist extension. Fig. 165, p. 135, shows Forearm reach position.
en the fingers are used,
2. As Exercise 1, but with Finger extension.
Exercises and simple
ISOciation with specific
FO
Intermediate Intermediate
3. Half grasp standing (palm backwards, and stick held obliquely forward 2. Forearm reach si
with distal end resting on floor: hand grasps shaft some distance from with gentle rhythmica
proximal end); single Wrist extension (Fig. 179).* movement.
3. Forearm reach s
wrists); alternate Wl
(Fig. 180).
Fig. 179.
4. Forearm reach grasp standing (palms downwards: stick crosswise);

Wrist extension. Fig. 165, p. 135, shows Forearm reach position.*
4. Standing or sitri
sides); alternate Wrisl
Advanced
5. As Exercise 3, but the hand grasps the stick dose to the proximal end. *
WRIST ABDUcn
Strengthening EUl
WRIST FLEXORS AND EXTENSORS
Elementary
1. Sitting (hands a
Elementary and fingers lax); sing:
2. As above, but'll
1. Sitting (forearms and hands supported on table, palms facing inwards
and fingers lax); single or double Wrist flexion and extension, and return to
starting position. Intermediate
2. As above, but perfotmed from Forearm reach sitting.
IlII 3. Half gras" stan
with distal end rest
11 proximal end); singh:
,1: Mobilizing Exercises
~I
Elementary
1. Forearm reach sitting (lax fingers); alternate Wrist flexion and extension. Advanced
(See Fig. 180, which shows a modified position of forearms. 4. As Exercise 3, t
'" See footnote, p. 143. " See footnote, p. 14:

Intermediate
tk held obliquely forward
2. Forearm reach sitting (lax fingers); single Wrist flexion and extension,
batt some distance from
with gentle rhythmical pressing to a given count on reaching the extremes of
movement.
3. Forearm reach sitting or standing (palms downwards, lax fingers and
wrists); alternate Wrist flexion and extension with a shaking motion
(Fig. 180).
Fig. 180.
~ds: stick crosswise);
reach position. *
4. Standing or sitting (fingers interlocked, with elbows flexed and arms to
sides); alternate Wrist flexion and extension.
JSe to the proximal end. *
WRIST ABDUCTORS
Elementary
1. Sitting (hands and forearms supported on table, palms facing inwards
and fingers lax); single or double Wrist abduction.
k, palms facing inwards 2. As above, but with fingers straight.
extension, and return to
Intermediate
I sitting.
3. Half grasp standing (palm inwards, and stick held obliquely forward
with distal end resting on floor: hand grasps shaft some distance from
proximal end); single Wrist abduction. (See Fig. 179, p. 148.)*
istflexion and extension. Advanced

Orearms. 4. As Exercise 3, but the hand grasps the stick close to the proximal end.*
"See footnote, p. 143.

F(
WRIST ADDUCTORS 3. HAND EXERCI.

Strengthening Exercises Simple occupations a
Elementary used in association wi
1. Sitting (forearms and hands resting on table, palms facing inwards,
fingers lax); single or double Wrist adduction.
2. As above, but the fingers are kept straight. EXERCISES TO !
Elementary
1. Forearm reach S1
WRIST ABDUCTORS AND ADDUCTORS and slow recoil: each
shows Forearm reach
Mobilizing Exercises 2. Sitting; squeeziI
Elementary 3. Sitting (comer c
I. Sitting (forearms and hands resting on table, palms downwards and into a tight ball in the
fingers lax); alternate Wrist abduction and adduction. 4. Sitting (end OfUl
2. As Exercise 1, but the fingers are kept straight. into a ball in the pabI
Intermediate Intermediate
3. As previous exercises, but with gentle rhythmical pressing to a given 5. Standing; stick 1
count on reaching the extremes of movement. places alternately (F,
6. As Exercise 5.
loosened and tighteD
7. Standing; stick '
WRIST CIRCUMDUCTORS
Elementary
1. Forearm reach sitting (lax fingers); single or double Wrist circling.
Fig. 165, p. 135, shows Forearm reach position.
1~,
Advanced
2. Grasp stride standing (Indian clubs); single Elbow bending to 90°, and
club swinging in a circle in an outwards or inwards direction. (See Fig. 176,
p. 145.)
Za. As above, but both arms are used together.
r
Fig. is!.
forwards, and club circling (a) backwards behind the forearm to Z counts, and 8. Reach grasp Sll
(b) backwards in front of the forearm to 2 counts. the arms to catch it ;
3a. As above, but both arms are moved together. 9. Bend grasp sa
". catching.*
10. Reach standiJ:
Arm lowering and 51
Advanced
See Club Exercises, above. * See footnote, p. 14:
APY FOREARM, WRIST AND HAND EXERCISES 151
3. HAND EXERCISES
Simple occupations and everyday activities for the hand should always be
used in association with specific exercises for the fingers and thumb.
lie, palms facing inwards,
EXERCISES TO STRENGTHEN THE GRIP

Elementary
1. Forearm reach sitting (lax fingers); strong Finger and Thumb bending,
and slow recoil: each hand in turn or both hands together. Fig. 165, p. 135,
shows Forearm reach position.
2. Sitting; squeezing a sorbo-rubber balL
3. Sitting (corner of sheet of newspaper held in hand); rolling up paper
Ie, palms downwards and into a tight ball in the palm of the hand without assistance from the free hand.
:ion. 4. Sitting (end of unrolled crepe bandage held in hand); rolling up bandage
:ht. into a ball in the palm of the hand without assistance from the free hand.
Intermediate
lIJlieal pressing to a given 5. Standing; stick travelling upwards and downwards, the hands changing
places alternately (Fig. 181).*
6. As Exercise 5, but the stick is held in one hand, and the grasp is
loosened and tightened alternately during the 'travelling'. *
7. Standing; stick throwing from hand to hand (Fig. 182).*
Dr double Wrist circling.

??bt
I
i
~i
Dbow bending to 90° , and
s direction. (See Fig. 176,
lIS); single Arm swinging Fig. 181. Fig. 182. Fig. 183.
e forearm to 2 counts, and 8. Reach grasp standing (stick crosswise); releasing stick and 'dropping'
the arms to catch it in the hands again. *
r. 9. Bend grasp standing (stick crosswise); stick throwing upwards and
catching. *
lO. Reach standing (palms downwards: stick rests crosswise on arms);
Arm lowering and stick catching (Fig. 183).*

152 PROGRESSIVE EXERCISE THERAPY FOI
11. Inward grasp fall hanging (2 ropes); Arm bending. (See Fig. 76, p. 77, 2. Starting positiOil
where a beam is shown in place of ropes.) relaxation: each hand I
12. Stretch grasp standing (lor 2 ropes); Arm bending with Ankle 3. Sitting (palms of
stretching to take weight off feet. upwards and thumbs
together with flexion 0
joints being kept extel
Advanced
13. Inward grasp horizontal fall hanging (2 ropes and living support); Arm
bending. (See Fig. 78, p. 78, where a beam is shown in place of ropes.) EXERCISES TO S
14. Over or under grasp hanging (beam); Arm bending. (See Figs. 157 and HYPOTHENAR J\II
171, pp. 128 and 140.)
15. Heave grasp walk-forwards standing (rings or ropes); circling and See Exercises to Stn:
return circling with bent knees, touching the floor with the feet at the end of localized exercises of I
the forwards circling movement. (See Fig. 71, p. 74, which shows a 1. Forearm reach Ii
progression on the exercise.) each finger in tum wi
16. Rope climbing with Leg grasp. hands together. Fig. 1,
2. Forearm reach s
(opposition of Thumt
together.
EXERCISES TO STRENGTHEN THE FINGER AND
3. Forearm reach si
THUMB EXTENSORS
4. Forearm reach:
Elementary abduction and adducti
1. Sitting (forearms and hands resting on table, palms downwards); Finger
and Thumb extension: each hand in turn, or both hands together.
2. Forearm reach sitting (lax fingers); exercise as above.
EXERCISES TO INCREASE THE RANGE OF FINGER

FLEXION OR EXTENSION
See Exercises given in two previous groups. Other exercises consist of:
(a) Finger flexion or extension with rhythmical pressing to a given count, and
(b) Wide range flexion and extension of the fingers and thumb.
Examples: (i) Half forearm reach (lax fingers)j Finger flexion with rhyth
mical pressing to 3 counts. Fig. 165, p. 135, shows Forearm
reach position.
Oi) Forearm reach sittingj Finger and Thumb bending and
stretching: each hand in turn, or both hands together.
EXERCISES TO STRENGTHEN THE INTRINSIC MUSCLES

Elementary
1. Sitting (forearms and hands resting on table, palms downwards); single
or double Hand shonening (flexion of the metacarpophalangeal joints with
the interphalangeal joints kept extended).
I
og. (See Fig. 76, p. 77, 2. Starting position as above; Finger or Thumb parting, closing and
relaxation: each hand in turn, or both hands together.
bending with Ankle 3. Sitting (palms of hands together in front of chest, with fingers pointing
upwards and thumbs extended); Hand shortening (pressing finger tips
together with flexion of the metacarpophalangeal joints-the interphalangeal
joints being kept extended-and opposition of carpo-metacarpal joints).
d living support); Arm

in place of ropes.) EXERCISES TO STRENGTHEN TIlE TIlENAR AND
jog. ~See Figs. 157 and HYPOTIlENARMUSCLES
£ ropes); circling and See Exercises to Strengthen the Grip, pp. 151-152. Examples of some
h the feet at the end of localized exercises of an elementary grade are given below.
. 74, which shows a 1. Forearm reach sitting (lax fingers); 'making O's' (touching the tip of
each finger in turn with the tip of the thumb): each hand in turn, or both
hands together. Fig. 165, p. 135, shows Forearm reach position.
2. Forearm reach sitting (palms upwards, lax fingers); Palm hollowing
(opposition of Thumb and 5th Finger): each hand in turn, or both hands
together.
RAND
3. Forearm reach sitting; single or double Thumb circling slowly.
4. Forearm reach sitting (palms upwards); single or double Thumb
abduction and adduction.
lIS downwards); Finger
Dds together.
rove.
F FINGER
~ exercises consist of:

g to a given count, and
Id thumb.
fler flexion with rhyth
•. 135, shows Forearm
, Thumb bending and

hands together.
!liSIC MUSCLES
os downwards); single
phalangeal joints with
15. Hip exercises
Certain hip exercises in which the lower limbs are moved on the trunk are
associated with movements of the pelvis and lumbar spine. These associated
hip and trunk movements are described in the chapter on trunk exercises 2. Low grasp back
(pp. 69-108). 2a. As above, but l
When leg exercises are used to activate the hip muscles the lower limbs
ought not to be moved together as, for example, in Leg raising from lying.
'Double leg' exercises have a greater specific effect on the spinal muscles.
Mobilizing Exerds
Elementary
1. Lying; alternate
2. Lying; alternate
HIP FLEXORS
(See also Exercises for the Flexors of the Spine, pp. 69-76.) Intermediate
1. No progression.
2. Lying; cycling.
Elementary
GRADE 1
1. Lying; single Knee raising. (See p. 69.)
GRADE 2
HIP EXTENSORS
1. Lying; single high Knee raising. (See Fig. 59, p. 70.) Strengthening Ese
(See also Exercises f(
Skipping ExerciseS 0
Intermediate
GRADE 1
1. Low grasp back towards standing (wall bars); single high Knee raising Elementary
(Fig. 184). GRADE 1
2. Lying; single Leg raising to 45°.
1. Lying or prone
2a. Lying; single Leg raising.
2. Lying; single L
lowering. GRADE 2
1-2. No progressi
GRADE 2 3. Reach grasp 51
1. No progression. backwards.
154
HIP EXERCISES 155
lOVed on the trunk are Fig. 184.

pine. These associated
tel' on trunk exercises 2. Low grasp back towards standing (wall bars); single Leg raising to 45°.
2a. As above, but single Leg raising.
uscles the lower limbs
Leg raising from lying.
11 the spinal muscles.
Elementary
1. Lying; alternate Knee raising.
2. Lying; alternate high Knee raising.
1)9-76.) Intermediate
1. No progression.
2. Lying; cycling.
HIP EXTENSORS
.70.) Strengthening Exercises
(See also Exercises for the Extensors of the Spine, pp. 76-85. Hopping and
Skipping Exercises may also be included.)
lIgle high Knee raising Elementary

GRADE 1
1. Lying or prone lying; single or double Gluteal contractions.
2. Lying; single Leg down pressing.
~ forwards to 45°, and
GRADE 2
3. Reach grasp standing (wall bars or chair back); single Leg raising
backwards.
Intermediate 5. Toward standing (b

affected Leg leading (1-2
GRADE 1 leading (3-4).
1-2. No progressions. 6. No progression.
3. Forehead rest prone lying; single Leg raising backwards. 7. Half wing half low y:
4. Low reach grasp standing (wall bars); Heel raising and Knee bending. stool); single Heel raising
(See Fig. 194, p. 165.)
arms, and Fig. 188 for mo
5. Low reach grasp high standing (wall bars and balance bench); stepping 8. Half wing half low J
down backwards, sound Leg leading (1-2), and stepping up forwards, sound Knee full bending.
Leg leading (3-4). (See Fig. 195, p. 165.) 9. Low reach grasp higt
6. Climbing the wall bars, 1-2 bars at a step. full bending (Fig. 186).
GRADE 2
GRADE 2
1-2. No progressions. 1-3. No progressions.
3. Prone kneeling; single Leg stretching and raising backwards. (See leg 4. Neck rest standing; I
movement of Fig. 98b, p. 86.) 5. Back toward standina!
4. Half wing half low yard grasp standing (wall bars); Heel raising and affected Leg leading (1-2),
Knee bending (Fig. 185). (3-4) (Fig. 187).
·It rr
~
Fig. 185.
5. Reach grasp standing (wall bars and balance bench); stepping up

Fig. 186.
forwards, affected Leg leading (1-2), and stepping down backwards, affected
Leg leading (3-4).
6. Climbing the wall bars, 2-3 bars at a step. 6. No progression.
7. Low reach grasp instep support standing (wall bars and stool); single 7. Wing instep suppor1
Heel raising and Knee bending. (See Fig. 188, p. 157), which shows a bending (Fig. 188).
progression on the exercise.) 8. Wing standing; Heel
8. Low reach grasp standing (wall bars); Heel raising and Knee full 9. Half low yard grasp
bending. Knee full bending.
GRADE 3
Advanced 1-3. No progressions.
GRADE 1 4. Stretch standing; He
1-3. No progressions. 5-6. No progressions.
4. Wing standing; Heel raising and Knee bending. 7. Stretch instep suppcl
~y HIP EXERCISES 157
5. Toward standing (balance bench or stool); stepping up forwards,

affected Leg leading (1-2), and stepping down backwards, affected Leg
leading (3-4).
6. ~o progression.
: backwards.
7. Half wing half low yard grasp instep support standing (wall bars and
Using and Knee bending.
stool); single Heel raising and Knee bending. (See Fig. 185 for position of
arms, and Fig. 188 for movement.)
. balance bench); stepping
8. Half wing half low yard grasp standing (wall bars); Heel raising and
pping up forwards, sound
Knee full bending.

9. Low reach grasp high half standing (wall bars and plinth); single Knee
full bending (Fig. 186).
GRADE 2
1-3. ~o progressions.
ising backwards. (See leg
4. ~eck rest standing; Heel raising and Knee bending.
5. Back toward standing (balance bench or stool); stepping up backwards,
I bars); Heel raising and
affected Leg leading (1-2), and stepping down forwards, affected Leg leading
(3-4) (Fig. 187).
,,,,'
Ii
II
ICe bench); stepping up

Iown backwards, affected Fig. 186. Fig. 187. Fig. 188.
6. ~o progression.
III bars and stool); single 7. Wing instep support standing (stool); single Heel raising and Knee
p. 157), which shows a bending (Fig. 188).
8. Wing standing; Heel raising and Knee full bending.
I raising and Knee full 9. Half low yard grasp high half standing (wall bars and plinth); single
Knee full bending.
GRADE 3
4. Stretch standing; Heel raising and Knee bending
18· 7. Stretch instep support (stool); single Heel raising and Knee bending.
8. Neck rest standing; Heel raising and Knee full bending. Mobilizing Exerd
9. Lax reach high half standing (plinth or high bench); single Knee full Elementary
bending. (See Fig. 200, p. 167.) 1. Half crook side
forwards and backwl
2. As above, but t
Intermediate
GRADE 1
1. Forehead rest prone lying; single Leg raising backwards with rhyth
mical pressing to 3 counts.
2. Bend grasp high standing (wall bars); Knee full bending and stretching
with Hand travelling down and up the bars. (See Fig. 206, p. 169.)
GRADE 2
1. Prone kneeling; single Leg stretching and ralsmg backwards, with
Intermediate
rhythmical pressing to 3 counts. (See leg movement of Fig. 9gb, p. 86.)
2. No progression. 1. No progression
2. Reach grasp hq
forwards and backwl
HIP ABDUCTOR:
IDP FLEXORS AND EXTENSORS
Strengthening ED
(See also Exercises fi
(See also Exercises for the Flexors and Extensors of the Spine, pp. 85-91.)
Elementary
Elementary
GRADE 1
GRADE 1 1. Reach grasp sn
1. Half crook side-lying; single slight Leg raising sideways, and carrying 2. Reach grasp stl
forwards and backwards, and return to starting position. hip abductors of staJ
3. Hanging (wall .
GRADE 2
1. Lying; single high Knee raising, and return to starting position, GRADE 2
followed by Leg downpressing. 1. Standing;' sing)
2. Standing; sing)
3. Half crook side
Intermediate
GRADE 1
1. Reach grasp standing (wall bars); single high Knee ralsmg, Leg IDPADDUCTOR
stretching and raising backwards, and return to starting position.
Strengthening &
2. Prone kneeling; single high Knee raising, Leg stretching and I"dising
backwards, and return to starting position. (See also Exercises f
HIP EXERCISES 159
bending. Mobilizing Exercises

~ch); single Knee full Elementary
1. Half crook side-lying; single slight Leg raising sideways, and carrying
forwards and backwards to a given count (Fig. 189).
2. As above, but the Leg is swung forwards and backwards.
JlllCkwards with rhyth-
tJending and stretching

'. 206, p. 169.)
1
,
Fig. 189.
ising backwards, with

Intermediate
Jf Fig. 98b, p. 86.)
1. No progression.
2. Reach grasp
the Spine, pp. 85-91.)
lideways, and carrying

ion.
to starting position,
b Knee raising, Leg

ng position.
5lretching and raising
ANKLE AND FOOT EXERCISES 175
ore); single Foot turning Mobilizing Exercises

Elementary
I
prudinal arches. 1. Half lying or long SIttIng with trunk inclined backwards and hand
support (heels free); alternate Foot turning inwards and outwards con
tinuously to a given count.
2. High sitting (plinth); as above.
3. Sitting (one ankle crossed over opposite knee); single Foot turning
inwards and outwards continuously to a given count.
rig; in,ner Border raIsmg.
4. Short stride sitting; inner and outer Border raising continuously to a
•accentuate mediallongi given count.
CIRCUMDUCTORS
Elementary
1. Half lying or long SittIng with trunk inclined backwards and hand
support (heels free); single or double Foot circling.
3. Sitting (one ankle crossed over opposite knee); single Foot circling.
N.B. Emphasis may be placed on a particular part of the circling, e.g.
cd backwards and hand
Circling with emphasis on inversion.
outwards.
IIDing outwards.
The movements given in the previous section may also be used as strengthen
I:IC); single Foot turning

ing exercises; they are then performed more slowly.
rder raising.
INTRINSIC MUSCLES
Elementary
I. Sitting; single or double Foot shortening (flexion of the metatarso
II:' standing; outer Border phalangeal joints, with extension of the interphalangeal joints) (Fig. 211).
la. Half lying (feet supported by footboard, with ankles dorsiflexed);
single or double Foot shortening. See above. (Fig. 212.)
::Yious sections may be

Dtlrds and outwards, and
2. Halflying or long sitting (trunk inclined backwards with hand support); TOE FLEXORS A
Toe parting and closing. The strengthening ell
la. Sitting (feet resting on floor or in tray of sand); Toe parting and strong flexion and e:I
closing. starting position.
Example: Half lyi
support),
both tog.
The mobilizing e
which are performecl
Example: Long sit
bendiJrg
together.
~~
. 'to. ~~-
~
~-~~C
--~
---~.....;,...~
- j
Fig. 212. Foot shortening adapted for bed use: the feet are supported by a
footboard.
~~l"'l
::--:;:~~~
~-
.;~-,
J!
Fig. 213. Another exercise for the intrinsic muscles.
3. Sitting (toes resting on book); Toe flexion at the metatarsophalangeal

joints, with extension of the interphalangeal joints: each foot in turn, or both
together (Fig. 213).
4. Sitting (feet resting on book, with all the toes free); Toe flexion at the
metatarsophalangeal joints, with extension of the interphalangeal joints: each
foot in turn, or both together.
Intermediate
1. Standing; single or double Foot shortening. (See Exercise 1, Elemen
tary grade).
2. No progression.
3. Standing; practising correct 'push off' movement from toes in walking
(interphalangeal joints of toes must be kept extended).
swards with hand support); TOE FLEXORS AND EXTENSORS

The strengthening exercises for the flexors and extensors of the toes consist of
of sand); Toe parting and strong flexion and extension movements, followed by a slow return to the
starting position.
Example: Half lying or long sitting (trunk inclined backwards with hand
support); strong Toe bending, and slow recoil.' each foot in turn, or
both together.
The mobilizing exercises consist of flexion and extension movements
which are performed in a continuous manner.
Example: Long sitting (trunk inclined backwards with hand support); Toe
bending and stretching continuously to a given count.' both feet
together.
be feet are supported by a

il:
_muscles.
at the metatarsophalangeal
I: each foot in turn, or both
IICS free); Toe flexion at the

interphalangeal joints: each
• (See Exercise 1, Elemen
:meat from toes in walking

1Ided).
HIP EXERCISES 163
As strengthening exercises, above, but the movements are performed in a
continuous manner, e.g. Stride lying; single Leg turning inwards and outwards
continuously to a given count. (See also Exercises for the Rotators of the Spine,
pp. 99-103.)
CIRCUMDUCTORS OF HIP
ards, so that lower leg Elementary
1. Reach grasp high half standing (beam and block); single Leg circling or
swinging in a circle.
IWing Thighs to turn
2. Lying; single Leg circling.
3. Half crook side-lying; single Leg circling.
See Exercises in previous section. The movements are performed more
slowly than when used as mobility exercises. See also Exercises for the
Circumductors of the Spine, pp. 107-108.)
99-103.)
: turning inwards and
lis and outwards, and
turning inwards and

lion.
raising to cross other

16. Knee exercises
KNEE FLEXORS
(See also single Leg raising backwards exercises, pp. 155-156.)
Elementary
GRADE 1
1. Crook lying or sitting; single or double Hamstring contractions.
GRADE 2
1. No progression.
2. Forehead rest prone lying; single or double Knee bending to 90°.
GRADE 3
1. No progression.
2. High sitting (table or bench); single or double Knee bending.
3. Reach grasp standing (wall bars); single Knee bending backwards.
KNEE EXTENSORS
(Hopping and Skipping Exercises
KNEE EXERCISES 165
2. Lying; single Leg raising with Knee firmly braced.
2a. As above, but with Ankle bending.
3. High sitting (plinth); single or double Knee stretching.
3a. As above, but with Ankle bending.
Intermediate
GRADE I
slow lowering.
la-2a. No progressions.
3. Low reach grasp standing (wall bars); Heel raising and Knee bending
(Fig. 194).
'. 155-156.)
, ...
• I
- :' I
~
,_ I
ring contractions. I
..
, 1
.,I
(.
~s
,
lIee bending to 90°.
".
Fig. 194. Fig. 195. Fig. 196.
Knee bending.
4. Low reach grasp high standing (wall bars and balance bench); stepping
bending backwards.
down backwards, sound Leg leading (1-2), and stepping up forwards, sound
Leg leading (3-4) (Fig. 195).
5. Climbing the wall bars, 1-2 bars at a step.
GRADE 2
led.) 1-2a. No progressions.
3. Half wing half low yard grasp standing (wall bars); Heel raising and
Knee bending.
4. Reach grasp standing (wall bars and balance bench); stepping up
forwards, affected Leg leading (1-2), and stepping down backwards, affected
land support) or half Leg leading (3-4).
5. Climbing the wall bars, 2-3 bars at a time.
I:..g. single Quadriceps 6. Low reach grasp standing (wall bars); Heel raising and Knee full
bending.
7. Low reach grasp stride standing (wall bars); Heel raising and single
Knee bending (Fig. 196).
y braced. 8. Low reach grasp instep support standing (wall bars and stool); single
Heel raising and Knee bending.
:APY TABLES OF SPECIFIC EXERCISES 183
same type of exercises are is confined to bed--capable of being performed with the minimum distur
nore strenuous exercises, bance of the bedclothes. For example, Quadriceps contractions and single
straight Leg raising in small range are the 'key' exercises prescribed for a
specific exercises is given patient resting in bed after meniscectomy.
LISTS OF SPECIFIC EXERCISES

To aid the therapist in planning exercise tables for certain clinical conditions
p:oups: those of primary
some lists of progressive exercises are given in the following chapters.
The' exercises which are
Introductory notes in each chapter describe the conditions for which the
two groups: Primary and
exercises are suitable and give details of the SUrgical procedures used.
m in compiling the lists of
included in the following
ICb exercise period. The

lIlY exercises, e.g. two or
1'0 secondary exercises. In
1: being subjected to too
~ consists of one group of
IpS should not be given

Exercises which use the
es, to produce different
oger of over-fatigue. For
,
I exercises which use the ,t

at be given consecutively,
uscles are used as flexors,
)1e. Short rest periods are
I
:rcise therapy the patient

sereises from the exercise
Ifortunately, this aspect of
imple, and-if the patient

T
after
J
EXERCISE THERAPY AFTER ABDOMINAL SURGERY
respiratory passages of secretions. After general anaesthesia, with or without

postoperative analgesic drugs, the reflex is very often diminished for as long
185
! as twenty-four hours; in addition, the patient is disinclined to cough because

.t
of the associated pain in his wound.
Interaction oj these Factors

Both the decreased respiratory movement and the increased amount of
secretions lead to pulmonary congestion and the danger of blockage of a main
bronchus, or to multiple patchy collapse by blockage of many small
~erCJse therapy which bronchioles. The latter complication is specially likely to proceed to
ctmny, cholecystectomy, bronchial pneumonia, if inadequately dealt with. Bronchopneumonia, how
ilical herniae. For con ever, may arise independently of collapse, due to infected material (often
Jicb are used to prevent inhaled from the mouth) gaining a foothold on predisposed ground.
ions have been grouped
and techniques to be
IICS Alteration of Posture
~therapist explains very After major operations, such as gastrectomy and cholecystectomy, the patient
way alarming the patient is often encouraged to lie flat on his back, and on the left and right side (Fig.
214) during the 1st and 2nd postoperative days. He remains in each position
for about 1-2 hours at a time.
This routine alteration of posture assists in the drainage of the lungs and is
of great importance in the prevention of pulmonary complications, such as
atelectasis. It also helps to 'break' any flatulence which may be present. While
;tIications, such as bron in the various positions the patient is encouraged to carry out localized
} Decreased respiratory breathing exercises at frequent intervals.
die excursion, and (2) Ballinger and Drapanas (1972) emphasize the value of skilled physio
.ory passages as a result therapy after surgery. 'In the experience of Bendixen and colleagues, chest
(for a variable period) of f physiotherapy before and after operation reduces the incidence of atelectasis
or pneumonia from 42 to 12 per cent.'
Postural Drainage
md not expanding fully, Should a collapse of a particular area of the lung develop in spite of all
oduce this state are pain precautions, the patient's posture must be modified to secure adequate
drainage of the affected part. For example, if the lateral area of the left lower
especially limited after lobe is affected the patient is placed in the right crook side-lying position (Fig.
lOSt evident on the 1st 214), and the foot of the bed is raised 30-60 cm. Routine alteration of posture,
I low as 20-25 per cent of as previously described, must still be continued, but the patient spends more
lIduaIly over the next six time in the specific drainage position.
Postural drainage of this type will be reinforced by the use of shakings and
coarse vibrations, encouragement of coughing and expectoration of secretions
in lying and crook side-lying (the wound area being supported by the
patient's hands or a Cough-Lok), and unilateral breathing exercises, e.g.
successfully empties his Crook side-lying (therapist's hand on side oj lower chest); lower lateral Costal
186 PROGRESSIVE EXERCISE THERAPY EXERCISE THERAPY
3. Crook lying (hands on sid!

breathing.
4. Crook lying (forearms eros
clavicles); Apical breathing.
5. Crook lying; general deep hi
CIRCULATORY COMPLICA
'Various factors have been record!
ofthrombosis and embolism. ThR
the possible causes: (a) Increased 1
the intima of the vein at operation,
The last is probably the most imp!
postoperative day and is present t
Fig. 214. Alteration of posture after major abdominal surgery. The patient is 'Several competent authorities
encouraged to lie on his back, and on the left and right side, for about 1-2 hours which occurs in the veins of the 1m
at a time during the first and second postoperative days. This routine alteration
of posture is of great importance in the prevention of pulmonary complications, interference with the action of the ,
such as atelectasis. fulfilling a respiratory function,
movement of the blood through t
action of the diaphragm [by prom.
breathing, and Crook side-lying (therapist's hand on posterior aspect of lower the chest]. As the movements of
chest); posterior Basal breathing. abdominal surgery, the pumping ~
slowing of the venous circulation 1
Postoperative Breathing Exercises

Bilateral breathing exercises are used in the early postoperative days follow
ing all forms of abdominal surgery. They are particularly important in the Postoperative Leg Exercises
period before the patient is allowed out of bed for the major part of the day. Simple foot, ankle and leg exerc:iSl
In addition to being part of regular treatment sessions supervised by the days to accelerate the venous circu
therapist, some of the more important exercises should be carried out by They are especially important in til
the patient throughout the day on 'little and often' lines. In addition to forming part of II
The starting positions used for the exercises will obviously depend on the therapist, some of the more impoI1
patient's condition and the individual preference of the therapist. To avoid patient throughout the day on <J
repetition crook lying and crook side-lying are used for the exercises given important in the period before rq
here. Useful exercises, taken in'lyi7l1f
1. Crook lying and crook side-lying (hand on upper abdomen); Diaphrag 1. Lying; alternate Ankle bend
matic breathing.* (See Fig. 144, p. 110.) 2. Lying; alternate Foor tu1'1liII
2. Crook lying (hands on sides of lower chest); lower lateral Costal 3. Lying; single Foot circling.
breathing. (See Fig. 143, p. 109.) 4. Lying; Toe bending and st1'
5. Lying; single slight Knee ra
* After gastrectomy and cholecystectomy, where the incisions used involve the upper down pressing.
abdomen (pp. 188-201), diaphragmatic breathing is generally extremely shallow on the 6. Lying; single and double QJ
1st postoperative day and may be almost impossible to obtain. 7. Lying; combined Quadricep
9. Fallout forwards standing (hands on forward knee); small range bend

ing and stretching of forward knee. (See Fig. 203, p. 169.)
17. An:
10. As Exercise 10, previous section.
11. Bend grasp high standing (wall bars); Knee bending and stretching with
Hand travelling down and up the bars. Fig. 206 shows Hand travelling over
two bars only.
12. Lax stoop half kneeling (hands on floor); small range bending and
stretching of forward knee (Fig. 207).
1. ANKLE EXERCj
DORSIFLEXORS
Strengthening Exa
(Balance Exercises IDlI
Elementary
Fig. 207. a b GRADE 1
Fig. 208
1. Half lying or k
13. Forearm reach grasp kneeling (wall bars); attempting to assume kneel support (heels free); si
sitting (Fig. 208). 2. As above, but w
GRADE 2
1. High sitting (pli
2. No progression.
3. Sitting; single 0
Intermediate
GRADE 1
1. No progression.
2. Reach grasp stl!
3. No progression.
PLANTAR-FLEX( .
Strengthening Ext
(See also Exercises fo
and Balance Exercise
Elementary
GRADE 1
1. Long sitting (1
lying; single or dout
188 PROGRESSIVE EXERCISE THERAPY EXERCISE TID
,
General Progressions
8. Sitting over edge of bed; alternate Ankle bending and stretching.
9. Sitting over edge of bed; alternate lower Leg swinging with Ankle 1
bending and stretching.
10. Sitting over edge of bed; single Knee stretching.
II. S itting (chair); alternate Forefoot raising (1-4), followed by alternate
Heel raising (5-8).
I,
12. Sitting (chair); single high Knee raising, lowering and downpressing of
Foot on to floor.
•
.
1. GASTRECTOMY*
.
Partial gastrectomy may be performed in the treatment of peptic ulcer
(gastric or duodenal ulcer), and carcinoma of the stomach. Total gastrectomy
may be performed for: (1) Carcinoma of the stomach; (2) High gastric ulcer;
,
and (3) Ulcer of the lower end of the oesophagus. .I
if
Kocherls s~~~~i~~ J II
.,•
TYPES OF INCISION
A right upper paramedian incision is commonly used (Fig. 215). Sometimes a
, Gridiron (M~~~~i~r:~
+ __
Battle's pararectal _ _
incision
, ....
i
left upper paramedian incision is used, e.g. in certain cases of gastric ulcer
and in carcinoma when wide removal of the stomach is necessary. J
The incision is vertical in direction and is situated 1·2-2'5 cm from the !
midline; it extends approximately from the costal margin to a point one side t
Fi.!
of the umbilicus (Fig. 215).
f
Stages of Incision
I. Incision of skin and subcutaneous tissues, down to the anterior sheath of
•·•
•
••
4. Incision of the posten
skin incision.
the rectus muscle.

2. Incision of the anterior sheath of the rectus muscle in the line of the skin •" EXERCISE AND THE ~
incision. t
The aponeurosis of the obi
,·
~
3. Retraction of the rectus muscle laterally, so that no large nerves or
~ anterior and posterior shea!
vessels are damaged.
therefore tend to pun more
* a. A gastro-enterostomy (to short-circuit the pyloric part of the stomach and

duodenum) is performed by some surgeons for inoperable cases of carcinoma of the
••
~
trunk exercise. When tnm1
be of the slow controlled tl
Although it is quite post
pylorus and for pyloric stenosis. A right upper paramedian incision is used. After "
treatment by exercise therapy is the same as described for gastrectomy. t simple abdominal exercises
b. Vagotomy, together with gastro-enterostomy or pyloroplasty, is sometimes it has been found more co
performed for cases of duodenal ulcer. A left upper paramedian incision is used; the the 3rd day. Breathing ell
exercise therapy is as described for gastrectomy. essential during the first
c. Highly selective vagotomy (also known as 'proximal gastric denervation') is now
widely used in the treatment of duodenal ulceration. time for abdominal exercil
,
GRADE 2
1. Prone lying (plinth: feet free); as previous exercise.
GRADE 3
1. Sitting; single or double Heel raising.
Intermediate
GRADE I
1. Reach grasp standing (wall bars); Heel raising.
GRADE 2
1. Half yard grasp standing (wall bars); Heel raising.
2. Reach grl'Sp instep support standing (wall bars and stool); single Heel
raising. (See Fig. 209,
DORSIFLEXORS AND PLANTAR-FLEXORS

n::ise. Strengthening Exercises
(Balance Exercises may also be included.)
Many of the movements given in the two previous sections may be
combined, e.g. High sitting (plinth); Ankle bending, stretching, and return to
starting position.
Elementary
1. Half lying or long sitting with trunk inclined backwards and hand
suppon (heels free); alternate Ankle bending and stretching.
iDg. 2. High sitting (plinth); as above.
I and stool); single Heel 3. Sitting (one ankle crossed over opposite knee); single Ankle bending
l this exercise.) and stretching continuously to a given count.
4. Sitting; alternate Forefoot and Heel raising (Fig. 210).
Orwards and forwards-
bars and stool); single
1 Fig. 210.
:d raising (Fig. 209). 2. FOOT EXERCISES

INVERTORS
(Balance exercises may also be included.)
Elementary
GRADE 1
1. Half lying or long sitting with trunk inclined backwards and hand
support (heels free); single or double Foot turning inwards.
lao As Exercise 1, with Toe flexion.
GRADE 2
1. High sitting (plinth); single or double Foot turning inwards.
lao As Exercise 1, with Toe flexion.
174 PROGRESSIVE EXERCISE THERAPY ANI
2. Sitting (one ankle crossed over opposite knee); single Foot turning Mobilizing Exercises
inwards. Elementary
3. Sitting; single or double inner Border raising. 1. Half lying or long Iii
4. Sitting; attempting to accentuate medial longitudinal arches. support (heels free); alten
Intermediate 2. High sitting (plinth);
3. Sitting (one ankle c:I'
GRADE 1
inwards and outwards conI
1-2. No progressions. 4. Short stride sitting; il
3. Reach grasp standing (wall bars) or standing; inner Border ralsmg.
given count.
4. Starting position as Exercise 3; attempting to accentuate mediallongi
tudinal arches.
CIRCUMDUCTORS
EVERTORS Mobilizing Exercises
Strengthening Exercises Elementary

(Balance exercises may also be included.) 1. Half lying or long s
support (heels free); single
2. High sitting (plinth);
Elementary 3. Sitting (one ankle en:
GRADE 1 N.B. Emphasis may be
1. Half lying or long sitting with trunk inclined backwards and hand Circling with emphasis on
support (heels free); single or double Foot turning outwards.
GRADE 2 Strengthening ExerciM

1. High sitting (plinth); single or double Foot turning outwards. The movements given in tl
2. Sitting (one ankle crossed over opposite knee); single Foot turning ing exercises; they are the
outwards.
3. Short stride sitting; single or double outer Border raising.
INTRINSIC MUSCLE.l
Intermediate Strengthening Exerdsl
GRADE I Elementary
1-2. No progressions. 1. Sitting; single or <It
3. Reach grasp short stride standing (walls bars) or standing; outer Border phalangeal joints, with ell
raising. lao Half lying (f~et 51
single or double Foot she:
INVERTORS AND EVERTORS

~
(Balance Exercises may also be included.)
Certain of the movements given in the two previous sections may be I "
"J/
combined, e.g. High sitting (plinth); Foot turning inwards and outwards, and .... ~,-~
return to starting position. Fig. 211. Foot sI:

ore); single Foot turning Mobilizing Exercises

Elementary
I
prudinal arches. 1. Half lying or long SIttIng with trunk inclined backwards and hand
support (heels free); alternate Foot turning inwards and outwards con
3. Sitting (one ankle crossed over opposite knee); single Foot turning
inwards and outwards continuously to a given count.
rig; in,ner Border raIsmg.
4. Short stride sitting; inner and outer Border raising continuously to a
•accentuate mediallongi given count.
CIRCUMDUCTORS
Elementary
1. Half lying or long SittIng with trunk inclined backwards and hand
support (heels free); single or double Foot circling.
3. Sitting (one ankle crossed over opposite knee); single Foot circling.
N.B. Emphasis may be placed on a particular part of the circling, e.g.
cd backwards and hand
Circling with emphasis on inversion.
outwards.
IIDing outwards.
The movements given in the previous section may also be used as strengthen
I:IC); single Foot turning

ing exercises; they are then performed more slowly.
rder raising.
INTRINSIC MUSCLES
Elementary
I. Sitting; single or double Foot shortening (flexion of the metatarso
II:' standing; outer Border phalangeal joints, with extension of the interphalangeal joints) (Fig. 211).
la. Half lying (feet supported by footboard, with ankles dorsiflexed);
single or double Foot shortening. See above. (Fig. 212.)
::Yious sections may be

Dtlrds and outwards, and
2. Halflying or long sitting (trunk inclined backwards with hand support); TOE FLEXORS A
Toe parting and closing. The strengthening ell
la. Sitting (feet resting on floor or in tray of sand); Toe parting and strong flexion and e:I
closing. starting position.
Example: Half lyi
support),
both tog.
The mobilizing e
which are performecl
Example: Long sit
bendiJrg
together.
~~
. 'to. ~~-
~
~-~~C
--~
---~.....;,...~
- j
Fig. 212. Foot shortening adapted for bed use: the feet are supported by a
footboard.
~~l"'l
::--:;:~~~
~-
.;~-,
J!
Fig. 213. Another exercise for the intrinsic muscles.
3. Sitting (toes resting on book); Toe flexion at the metatarsophalangeal

joints, with extension of the interphalangeal joints: each foot in turn, or both
together (Fig. 213).
4. Sitting (feet resting on book, with all the toes free); Toe flexion at the
metatarsophalangeal joints, with extension of the interphalangeal joints: each
foot in turn, or both together.
Intermediate
1. Standing; single or double Foot shortening. (See Exercise 1, Elemen
tary grade).
2. No progression.
3. Standing; practising correct 'push off' movement from toes in walking
(interphalangeal joints of toes must be kept extended).
swards with hand support); TOE FLEXORS AND EXTENSORS

The strengthening exercises for the flexors and extensors of the toes consist of
of sand); Toe parting and strong flexion and extension movements, followed by a slow return to the
starting position.
Example: Half lying or long sitting (trunk inclined backwards with hand
support); strong Toe bending, and slow recoil.' each foot in turn, or
both together.
The mobilizing exercises consist of flexion and extension movements
which are performed in a continuous manner.
Example: Long sitting (trunk inclined backwards with hand support); Toe
bending and stretching continuously to a given count.' both feet
together.
be feet are supported by a

il:
_muscles.
at the metatarsophalangeal
I: each foot in turn, or both
IICS free); Toe flexion at the

interphalangeal joints: each
• (See Exercise 1, Elemen
:meat from toes in walking

1Ided).
PART 4
APPLIED EXERCISE
THERAPY
179
18. Construction and use of
tables of specific exercises
The tables consist of lists of movements which provide exercise for a

particular part of the body; they are used in the treatment of localized lesions,
such as fractures, chest diseases and postoperative abdominal conditions. A
series of graded tables is required to provide smooth, progressive exercise
from the early to the late phase of recovery. If a patient's condition remains
stationary for a considerable time the exercises are changed or modified to
maintain interest.
The patients are treated individually or by group or class methods. In "II'
many hospitals and rehabilitation centres men and women are exercised
together in the same groups or classes.
Group and Class Work

The difference between group and class methods of instruction is not always
understood. In group work a small number of patients (6 at the most), with
the same or similar types of disability, are treated together. The therapist
indicates the exercise to be performed and the patients practise it individu
ally. The therapist goes from patient to patient and gives individual coaching
as required.
In class work a number of patients (10-12 at the most), with the same or
similar types of disability, exercise in unison under the guidance of the
therapist.
General Exercises
In rehabilitation centres general exercises and games are used in addition to
specific exercises. In hospital rehabilitation departments the limited amount
of time available for treatment makes it difficult to organize full-scale general
exercise classes. The difficulty can be overcome to some extent by arranging
short sessions of general 'warming-up' exercises to music before the specific
exercise periods (p. 256).
THE EXERCISE TABLE

The exercises are selected with regard to the aims of treatment and the phase
181
of recovery reached by the patient. In general, the same type of exercises are is confined to bed...-a
used for both men and women. Some of the more strenuous exercises, bance of the bedclodJ
however, are not suitable for women. straight Leg raising ill
One method of compiling and using a table of specific exercises is given patient resting in bed :
here. ~.
I
Compiling the Exercise Table
t LISTS OF SPECIF:
To aid the therapist in
The aims of treatment are divided into two groups: those of primary some lists of progres
importance and those of secondary importance. The exercises which are
I
Introductory notes in
chosen to achieve the aims are also divided into two groups: Primary and exercises are suitable I
Secondary Exercises. This method has been followed in compiling the lists of
progressive exercises for the clinical conditions included in the following
chapters.
Ii
Using the Exercise Tables
Primary and secondary exercises are used at each exercise period. The
secondary exercises are spaced between the primary exercises, e.g. two or
three primary exercises are followed by one or two secondary exercises. In
this way there is no danger of the affected part being subjected to too
concentrated a period of activity. When the table consists of one group of
i,
exercises only this suggestion cannot be followed.
Avoiding Fatigue
Exercises which activate the same muscle groups should not be given
consecutively, because this may produce fatigue. Exercises which use the
same muscles in association with other muscles, to produce different
movements, may follow each other with little danger of over-fatigue. For
example, in strengthening the trunk muscles two exercises which use the
abdominal muscles as flexors of the spine should not be given consecutively,
but a series of exercises in which the abdominal muscles are used as flexors,
rotators and lateral flexors of the spine is permissible. Short rest periods are I
given whenever they are thought to be necessary.
I ~
•
'LITTLE-AND-OFTEN' SELF-PRACTICE I
~
To obtain the maximum benefit from specific exercise therapy the patient I
should practise two or three of the more important exercises from the exercise £
table on a 'little-and-often' basis during the day. Unfortunately, this aspect of I
physical treatment is often overlooked.
The exercises selected for self-practice must be simple, and-if the patient
-----
:APY TABLES OF SPECIFIC EXERCISES 183
same type of exercises are is confined to bed--capable of being performed with the minimum distur
nore strenuous exercises, bance of the bedclothes. For example, Quadriceps contractions and single
straight Leg raising in small range are the 'key' exercises prescribed for a
specific exercises is given patient resting in bed after meniscectomy.
LISTS OF SPECIFIC EXERCISES

To aid the therapist in planning exercise tables for certain clinical conditions
p:oups: those of primary
some lists of progressive exercises are given in the following chapters.
The' exercises which are
Introductory notes in each chapter describe the conditions for which the
two groups: Primary and
exercises are suitable and give details of the SUrgical procedures used.
m in compiling the lists of
included in the following
ICb exercise period. The

lIlY exercises, e.g. two or
1'0 secondary exercises. In
1: being subjected to too
~ consists of one group of
IpS should not be given

Exercises which use the
es, to produce different
oger of over-fatigue. For
,
I exercises which use the ,t

at be given consecutively,
uscles are used as flexors,
)1e. Short rest periods are
I
:rcise therapy the patient

sereises from the exercise
Ifortunately, this aspect of
imple, and-if the patient

EXERCISE
19. Exercise therapy after respiratory passages of !II

postoperative analgesic c
abdominal surgery as twenty-four hours; in
of the associated pain iD
Interaction of these Facn

Both the decreased res
secretions lead to pulmol
bronchus, or to multiJ
This chapter describes the various forms of exercise therapy which bronchioles. The lattel
may be used in the postoperative treatment of gastrectomy, cholecystectomy, bronchial pneumonia, if
appendicectomy and inguinal, femoral and umbilical herniae. For con ever, may arise indepell
venience of description the exercise procedures which are used to prevent inhaled from the mouth
postoperative respiratory and circulatory complications have been grouped
together as an introductory section.
Preoperative training of the patient in the exercises and techniques to be Alteration of Posture
used is essential. It is also most important that the therapist explains very After major operations, !
simply the reasons for the exercises, without in any way alarming the patient is often encouraged to iii
or increasing his apprehension of surgery. 214) during the 1st and:
for about 1-2 hours at a
This routine alterati~
of great importance in t
RESPIRATORY COMPLICATIONS
atelectasis. It also helps I
The main causes of postoperative respiratory complications, such as bron in the various positiOOl
chitis, bronchopneumonia and atelectasis, are: (1) Decreased respiratory breathing exercises at fr
movement, particularly limitation of diaphragmatic excursion, and (2) Ballinger and DrapIQ
Increased amount of mucous secretions in the respiratory passages as a result therapy after surgery. <)
of some anaesthetic agent irritation, and inhibition (for a variable period) of physiotherapy before an
the normal ciliary action. or pneumonia from 42 I
Decreased Respiratory Movement Postural Drainage

This means that parts of the lungs are out of action and not expanding fully, Should a collapse of a
especially at the bases. The principal factors that produce this state are pain precautions, the patien
and associated reflex spasm of the diaphragm. drainage ofthe affected .
The respiratory excursion of the diaphragm is especially limited after lobe is affected the patiel
operations on the upper abdomen, and this is most evident on the 1st 214), and the foot of the
postoperative day. The fall of vital capacity may be as low as 20-25 per cent of as previously described,
normal on the 1st postoperative day. It improves gradually over the next six time in the specific drai
to ten days. Postural drainage of tl
coarse vibrations, enCOll
in lying and crook sid
Increased Amount of Mucous Secretions • patient's hands or a Q
Normally the cough reflex ensures that the patient successfully empties his Crook side-lying (therap
184 ,
#
~
T
after
J
EXERCISE THERAPY AFTER ABDOMINAL SURGERY
respiratory passages of secretions. After general anaesthesia, with or without

postoperative analgesic drugs, the reflex is very often diminished for as long
185
! as twenty-four hours; in addition, the patient is disinclined to cough because

.t
of the associated pain in his wound.
Interaction oj these Factors

Both the decreased respiratory movement and the increased amount of
secretions lead to pulmonary congestion and the danger of blockage of a main
bronchus, or to multiple patchy collapse by blockage of many small
~erCJse therapy which bronchioles. The latter complication is specially likely to proceed to
ctmny, cholecystectomy, bronchial pneumonia, if inadequately dealt with. Bronchopneumonia, how
ilical herniae. For con ever, may arise independently of collapse, due to infected material (often
Jicb are used to prevent inhaled from the mouth) gaining a foothold on predisposed ground.
ions have been grouped
and techniques to be
IICS Alteration of Posture
~therapist explains very After major operations, such as gastrectomy and cholecystectomy, the patient
way alarming the patient is often encouraged to lie flat on his back, and on the left and right side (Fig.
214) during the 1st and 2nd postoperative days. He remains in each position
for about 1-2 hours at a time.
This routine alteration of posture assists in the drainage of the lungs and is
of great importance in the prevention of pulmonary complications, such as
atelectasis. It also helps to 'break' any flatulence which may be present. While
;tIications, such as bron in the various positions the patient is encouraged to carry out localized
} Decreased respiratory breathing exercises at frequent intervals.
die excursion, and (2) Ballinger and Drapanas (1972) emphasize the value of skilled physio
.ory passages as a result therapy after surgery. 'In the experience of Bendixen and colleagues, chest
(for a variable period) of f physiotherapy before and after operation reduces the incidence of atelectasis
or pneumonia from 42 to 12 per cent.'
Postural Drainage
md not expanding fully, Should a collapse of a particular area of the lung develop in spite of all
oduce this state are pain precautions, the patient's posture must be modified to secure adequate
drainage of the affected part. For example, if the lateral area of the left lower
especially limited after lobe is affected the patient is placed in the right crook side-lying position (Fig.
lOSt evident on the 1st 214), and the foot of the bed is raised 30-60 cm. Routine alteration of posture,
I low as 20-25 per cent of as previously described, must still be continued, but the patient spends more
lIduaIly over the next six time in the specific drainage position.
Postural drainage of this type will be reinforced by the use of shakings and
coarse vibrations, encouragement of coughing and expectoration of secretions
in lying and crook side-lying (the wound area being supported by the
patient's hands or a Cough-Lok), and unilateral breathing exercises, e.g.
successfully empties his Crook side-lying (therapist's hand on side oj lower chest); lower lateral Costal
186 PROGRESSIVE EXERCISE THERAPY EXERCISE THERAPY
3. Crook lying (hands on sid!

breathing.
4. Crook lying (forearms eros
5. Crook lying; general deep hi
CIRCULATORY COMPLICA
'Various factors have been record!
ofthrombosis and embolism. ThR
the possible causes: (a) Increased 1
the intima of the vein at operation,
The last is probably the most imp!
postoperative day and is present t
Fig. 214. Alteration of posture after major abdominal surgery. The patient is 'Several competent authorities
encouraged to lie on his back, and on the left and right side, for about 1-2 hours which occurs in the veins of the 1m
at a time during the first and second postoperative days. This routine alteration
of posture is of great importance in the prevention of pulmonary complications, interference with the action of the ,
such as atelectasis. fulfilling a respiratory function,
movement of the blood through t
action of the diaphragm [by prom.
breathing, and Crook side-lying (therapist's hand on posterior aspect of lower the chest]. As the movements of
chest); posterior Basal breathing. abdominal surgery, the pumping ~
slowing of the venous circulation 1
Postoperative Breathing Exercises

Bilateral breathing exercises are used in the early postoperative days follow
ing all forms of abdominal surgery. They are particularly important in the Postoperative Leg Exercises
period before the patient is allowed out of bed for the major part of the day. Simple foot, ankle and leg exerc:iSl
In addition to being part of regular treatment sessions supervised by the days to accelerate the venous circu
therapist, some of the more important exercises should be carried out by They are especially important in til
the patient throughout the day on 'little and often' lines. In addition to forming part of II
The starting positions used for the exercises will obviously depend on the therapist, some of the more impoI1
patient's condition and the individual preference of the therapist. To avoid patient throughout the day on <J
repetition crook lying and crook side-lying are used for the exercises given important in the period before rq
here. Useful exercises, taken in'lyi7l1f
1. Crook lying and crook side-lying (hand on upper abdomen); Diaphrag 1. Lying; alternate Ankle bend
matic breathing.* (See Fig. 144, p. 110.) 2. Lying; alternate Foor tu1'1liII
2. Crook lying (hands on sides of lower chest); lower lateral Costal 3. Lying; single Foot circling.
breathing. (See Fig. 143, p. 109.) 4. Lying; Toe bending and st1'
5. Lying; single slight Knee ra
* After gastrectomy and cholecystectomy, where the incisions used involve the upper down pressing.
abdomen (pp. 188-201), diaphragmatic breathing is generally extremely shallow on the 6. Lying; single and double QJ
1st postoperative day and may be almost impossible to obtain. 7. Lying; combined Quadricep
! THERAPY EXERCISE THERAPY AFTER ABDOMINAL SURGERY 187
3. Crook lying (hands on sides of upper chest); upper lateral Costal

breathing.
4. Crook lying (forearms crossed and fingers resting on chest below
S. Crook lying; general deep breathing.
CJRCULATORY COMPUCATIONS
'Various factors have been recorded as being responsible for the production
ofthrombosis and embolism. Three main factors are now recognized as being
the possible causes: (a) Increased tendency for the blood to clot, (b) Injury to
the intima of the vein at operation, and (c) Slowing ofthe venous circulation.
The last is probably the most important ... The slowing starts in the second
postoperative day and is present until the patient becomes ambulant . . .
Ibdominal surgery. The patient is 'Several competent authorities think that the slowing of the circulation
.wright side, for about 1-2 hours which occurs in the veins of the lower limbs after abdominal surgery is due to
rative days. This routine alteration
interference with the action of the diaphragm. The diaphragm, in addition to
Iu::ioo of pulmonary complications,
fulfilling a respiratory function, also accounts in large measure for the
movement of the blood through the veins to the right heart-the pumping
action of the diaphragm [by production of intermittent negative pressure in
Iumd on posterior aspect of lower the chest]. As the movements of the diaphragm are much depressed after
abdominal surgery, the pumping action is interfered with and consequently
slowing of the venous circulation takes place' (Gunn Roberts, 1946).
I: early postoperative days follow

are particularly important in the Postoperative Leg Exercises
bed for the major part of the day. Simple foot, ankle and leg exercises are used during the early postoperative
lbIlent sessions supervised by the days to accelerate the venous circulation through the lower limbs and pelvis.
:ercises should be carried out by They are especially important in the period before regular walking is allowed.
lid often' lines. In addition to forming part of regular treatment sessions organized by the
:ises will obviously depend on the therapist, some of the more important exercises should be carried out by the
li::rence of the therapist. To avoid patient throughout the day on 'little and often' lines. This is especially
are used for the exercises given important in the period before regular walking is allowed.
Useful exercises, taken in lying or half-lying, include:
lid on upper abdomen); Diaphrag 1. Lying; alternate Ankle bending and stretching.
10.) 2. Lying; alternate Foot turning inwards and outwards.
wee chest); lower lateral Costal 3. Lying; single Foot circling.
4. Lying; Toe bending and stretching rhythmically: both feet.
S. Lying; single slight Knee raising and lowering, followed by firm Leg
Ie the incisions used involve the upper
downpressing.
g is generally extremely shallow on the 6. Lying; single and double Quadriceps contractions.
sible to obtain. 7. Lying; combined Quadriceps and Gluteal contractions: alternate legs.
188 PROGRESSIVE EXERCISE THERAPY EXERCISE TID
,
General Progressions
8. Sitting over edge of bed; alternate Ankle bending and stretching.
9. Sitting over edge of bed; alternate lower Leg swinging with Ankle 1
bending and stretching.
10. Sitting over edge of bed; single Knee stretching.
II. S itting (chair); alternate Forefoot raising (1-4), followed by alternate
Heel raising (5-8).
I,
12. Sitting (chair); single high Knee raising, lowering and downpressing of
Foot on to floor.
•
.
1. GASTRECTOMY*
.
Partial gastrectomy may be performed in the treatment of peptic ulcer
(gastric or duodenal ulcer), and carcinoma of the stomach. Total gastrectomy
may be performed for: (1) Carcinoma of the stomach; (2) High gastric ulcer;
,
and (3) Ulcer of the lower end of the oesophagus. .I
if
Kocherls s~~~~i~~ J II
.,•
TYPES OF INCISION
A right upper paramedian incision is commonly used (Fig. 215). Sometimes a
, Gridiron (M~~~~i~r:~
+ __
Battle's pararectal _ _
incision
, ....
i
left upper paramedian incision is used, e.g. in certain cases of gastric ulcer
and in carcinoma when wide removal of the stomach is necessary. J
The incision is vertical in direction and is situated 1·2-2'5 cm from the !
midline; it extends approximately from the costal margin to a point one side t
Fi.!
of the umbilicus (Fig. 215).
f
Stages of Incision
I. Incision of skin and subcutaneous tissues, down to the anterior sheath of
•·•
•
••
4. Incision of the posten
skin incision.
the rectus muscle.

2. Incision of the anterior sheath of the rectus muscle in the line of the skin •" EXERCISE AND THE ~
incision. t
The aponeurosis of the obi
,·
~
3. Retraction of the rectus muscle laterally, so that no large nerves or
~ anterior and posterior shea!
vessels are damaged.
therefore tend to pun more
* a. A gastro-enterostomy (to short-circuit the pyloric part of the stomach and

duodenum) is performed by some surgeons for inoperable cases of carcinoma of the
••
~
trunk exercise. When tnm1
be of the slow controlled tl
Although it is quite post
pylorus and for pyloric stenosis. A right upper paramedian incision is used. After "
treatment by exercise therapy is the same as described for gastrectomy. t simple abdominal exercises
b. Vagotomy, together with gastro-enterostomy or pyloroplasty, is sometimes it has been found more co
performed for cases of duodenal ulcer. A left upper paramedian incision is used; the the 3rd day. Breathing ell
exercise therapy is as described for gastrectomy. essential during the first
c. Highly selective vagotomy (also known as 'proximal gastric denervation') is now
widely used in the treatment of duodenal ulceration. time for abdominal exercil
,
EXERCISE THERAPY AFTER ABDOMINAL SURGERY 189
Kocher', .ubco'tal _ _-+~~!i-:;/

incision
Battle', pararectal
incision
ed (Fig. 215). Sometimes a

nain cases of gastric ulcer Incision for inguinal
ach is necessary. ~->!i~~- hernia
lilted 1·2-2·5 cm from the

margin to a point one side
, Fig. 215. Abdominal incisions.
j
4. Incision of the posterior rectus sheath and peritoneum in the line of the
• skin incision,
m to the anterior sheath of
,
uscle in the line of the skin EXERCISE AND THE SUTURE UNE
) that no large nerves or The aponeurosis of the oblique and transverse abdominal muscles form the
anterior and posterior sheaths of the rectus muscle, Active trunk rotation will
therefore tend to pull more strongly on the suture line than any other form of
trunk exercise. When trunk rotation movements are performed they should
ric part of the stomach and
be of the slow controlled type, and quick jerky movements must be avoided,
tJIe cases of carcinoma of the
dian incision is used. After Although it is quite possible, and safe, for the average patient to perform
Dc gastrectomy. simple abdominal exercises of all types on the 1st and 2nd postoperative days,
pyloroplasty, is sometimes it has been found more convenient in practice to leave these exercises until
mtedian incision is used; the the 3rd day, Breathing exercises and movements for the lower limbs are
I gastric denervation') is now essential during the first 2 postoperative days, and usually there is little
time for abdominal exercises.
i EXERCISE 1
EXERCISE THERAPY Remedial Aims

The lists of progressive exercises given here are intended to be a guide to the PRIMARY
after-treatment of partial and total gastrectomy. 1. To prevent postopel
2. To maintain the al
transverse groups.
FIRST 2 POSTOPERATIVE DAYS SECONDARY
Usually, intravenous therapy is used on the lst day, and one of the patient's 1. To maintain the otb
arms or legs is immobilized for this purpose. A Ryle's tube may be in position 2. To maintain the mu
for intermittent aspiration of the stomach remnant. the feet.
To help prevent pulmonary complications the patient should spend a
considerable amount of his time lying flat on his back and on the left and right Exercise Period
sides; he stays in each position for about 1-2 hours at a time (p. 185). Should a 20 minutes, twice daily_
collapse of a particular area of the lung develop in spite of all precautions,
exercises on 'little and 01

postural drainage will be instituted as outlined on p. 185.
Primary Exercises
Sitting out of Bed Breathing, Ankle/Foot an
Provided that there are no respiratory complications, sitting out in a chair for Trunk Exercises
about 10-20 minutes is generally allowed on the 1st postoperative day. 1. Crook lying (hand (
Supervised walking round the bed is usually allowed on the 2nd day. 2. Stride lying; Trunk
See Fig. 129, p. 10]
3. Lying; Head bendiJ:
Remedial Aims 50 and Fig. 59, p. C
To prevent postoperative respiratory and circulatory complications.
Exercise Period
15-20 minutes, two or three times daily. In addition to these treatment
sessions the patient will practise some of the exercises on 'little and often'
It
Secondary Exercises '
Trunk Exercises
1. Lying; slight Chest
t raising.)
lines.
t,
2. Crook lying; Pelvis
Primary Exercises
L Leg Exercises
Breathing, Ankle/Foot and Leg Exercises (see previous section, pp. 186-188)
,t 1. Half lying; single 0

2. Half lying; si~g]e
It should be noted that diaphragmatic breathing is extremely shallow on the
1st postoperative day and may be almost impossible to obtain (p. 184).
• 0
i
5th TO 10th POSTOf
3rd and 4th POSTOPERATIVE DAYS
Usually the stitches are I
The patient rests in bed between intervals of sitting out in a chair; provided the patient's condition
there are no respiratory complications he takes up an ordinary half-lying sutures are sometimes us
position. Short periods of walking in the ward are encouraged. 8itting in a chair. The a
THERAPY EXERCISE THERAPY AFTER ABDOMINAL SURGERY 191
Remedial Aims
intended to be a guide to the
Ire PRIMARY
ny. 1. To prevent postoperative respiratory and circulatory complications.
2. To maintain the abdominal muscles, particularly the oblique and
transverse groups.
SECONDARY
1st day, and one of the patient's 1. To maintain the other trunk muscles.
!\ Ryk's tube may be in position 2. To maintain the muscles that support the medial longitudinal arches of
mnant. the feet.
tIS the patient should spend a
lis back and on the left and right Exercise Period
IOW'S at a time (p. 185). Should a
20 minutes, twice daily. In addition, the patient will practise some of the
dol> in spite of all precautions, exercises on 'little and often' lines throughout the day.
II:d on p. 185.
Primary Exercises
Breathing, Ankle/Foot and Leg Exercises (see previous section, pp. 186-188
Cations, sitting out in a chair for Trunk Exercises
co. the 1st postoperative day. 1. Crook lying (hand on abdomen); Abdominal contractions.
, allowed on the 2nd day. 2. Stride lying; Trunk turning with single Arm carrying across the chest.
See Fig. 129, p. 101.
3. Lying; Head bending forwards with single high Knee raising. See Fig.
50 and Fig. 59, p. 62 and 70.
DJlatory complications.
Secondary Exercises
Trunk Exercises
in addition to these treatment 1. Lying; slight Chest raising. (See Fig. 80, p. 79, which shows full Chest
r:: exercises on 'little and often' raising.)
2. Crook lying; Pelvis raising. (See Fig. 150, p. 116.)
Leg Exercises
previous section, pp. 186-188)
1. Half lying; single or double Ankle bending.
iiog is extremely shallow on the 2. Half lying; single or double Foot turning inwards.
~ble to obtain (p. 184).
5th TO 10th POSTOPERATIVE DAY

Usually the stitches are removed on the 10th postoperative day, depending on
sitting out in a chair; provided the patient's condition and the surgeon's opinion. (Absorbable cutaneous
Ikes up an ordinary half-lying sutures are sometimes used.) The patient spends an increasing amount of time
:d are encouraged. sitting in a chair. The amount of walking is also increased.
192
Remedial Aims
,
i
IF EXEIlC
As for the 3rd and 4th postoperative days. An additional (Primary) aim is to
improve posture.
Exercise Period
20-30 minutes, once or twice daily.
1. PATIENT LYING ON BED

Primary Exercises assume a modified b
Breathing, Ankle/Fool and Leg Exercises without producing di:
(Fig. 217).
See pp. 186-188. Because of the patient's increasing mobility the number of
exercises used from this section can now be limited to, say, diaphragmatic and
lower lateral costal breathing and a general leg movement.
3. PATIENT STAJ
Trunk Exercises Primary Exercises
1. Stride lying; Trunk turning with Head bending forwards and single Posture and Walking
Arm carrying across the chest. (See Fig. 129, p. 101.) 1. General correcti
2. Lying; single high Knee raising, Leg stretching forwards to 45° and 2. Walking practio
slow lowering.
3. Lying (hands grasping edges of mattress); upper Trunk bending
forwards with assistance from arms.
4. Heave grasp lying (head posts of bed); Hip updrawing. (See Fig. 121,
p. 96, which shows exercise performed in standing.) 10th TO 14th PO~
The patient is often d
Secondary Exercises
Trunk Exercise
Remedial Aims
Lying; Chest raising. (See Fig. 80, p. 79.)
PRIMARY
To redevelop the abel
2. PATIENT SITTING IN CHAIR groups.
Primary Exercises
SECONDARY
Trunk Exercises 1. To redevelop tIi
1. Stride sitting; Trunk turning with Arm moving loosely sideways in 2. To redevelop tb
the direction of the hands to grasp the chair back (Fig. 216). the feet.
2. Stride sitting; Trunk bending sideways. 3. To re-educate Il
Secondary Exercises
Trunk Exercise
Stride sitting (hands on thighs); Trunk bending forwards-downwards to
I1 Exercise Period
30 minutes, once or
I
..I.
T.
I•
IRAPY
I•
lditional (Primary) aim is to j
i
t
,•
Fig. 216. Fig. 217.
assume a modified lax stoop position (movement taken as far as possible

without producing discomfort in wound area), followed by Trunk stretching.
(Fig. 217).
ling mobility the number of
d to. say, diaphragmatic and
lDOVement.
3. PATIENT STANDING
Primary Exercises
~ forwards and single Posture and Walking

ft, p. 101.) I. General correction of posture in standing and walking.
Idling forwards to 45° and 2. Walking practice.
IS>; upper Trunk bending
, updrawing. (See Fig. 121,

I113Dding.) 10th TO 14th POSTOPERATIVE DAY
The patient is often discharged from the ward between the 10th and 14th day.
Remedial Aims
PRIMARY
To redevelop the abdominal muscles, particularly the oblique and transverse
groups.
SECONDARY
1. To redevelop the other trunk muscles.
rring loosely sideways in 2. To redevelop the muscles that support the medial longitudinal arches of
ir back (Fig. 216).
the feet.
3. To re-educate neuromuscular coordination.
Exercise Period
og forwards-downwards to 30 minutes, once or twice daily.
194 PROGRESSIVE EXERCISE THERAPY EXERClSI
Primary Exercises &£rcise Period

Trunk Exercises 30 minutes, once or tw
1. Fixed stride lying; upper Trunk bending forwards with turning and
single Arm carrying across the chest. (Fig. 218).

Primary Exercises
2. Crook lying; Pelvis raising and turning. Trunk Exercises
1. Fixed stride lyiDt

single Arm carryi

4. Low reach grasp standing (chair back); Hip updrawing. (See Fig. 121,
p. 96.) which shows a different starting position.)
5. Stride standing; Trunk bending sideways.
6. Lying; high Knee raising, followed by over-pressure with the hands,
and upper Trunk bending forwards. (See Fig. 73, p. 74.)
7. Lying; upper Trunk bending forwards with single high Knee raising.
(See Figs. 59 and 67, pp. 70 and 73.)
Secondary Exercises
Trunk Exercises HI!
1. Lax stoop stride sitting; Trunk stretching 'vertebra by vertebra' in
different planes. (See Fig. 139, p. 105.)

2. Prone kneeling;:
2. Crook lying; Chest raising. (See Fig. 80, p. 79.) (Fig. 219.)
3. Forehead rest prone lying (pillow under abdomen); single slight Leg
3. Stride standing;
raising backwards.
4. Neck rest stride sitting; Trunk lowering forwards.
Leg Exercises
5. Low reach grasp standing (chair back); inner Border raising.
,
~
•
4. Fixed crook lyin;
(See Fig. 72, p.'
5. Fist bend fixed
backwards tllrml
Secondary Exerclsl
,. Trunk Exercises
Balance Exercises
6. Back towards standing (wall bars or wall); single Knee raising. . 1. Lax stoop back )
front of wall baI
7. Half yard finger support side toward standing (wall bars or wall);
different planes.
balance walking forwards with Knee raising.
2. Neck rest crook

3. Forehead rest p
may have to be II
FROM 14th POSTOPERATIVE DAY abdominal muse
4. Prone kneeling:
The exercises suggested here are of a moderately strenuous type. They are
bending backwa
used for one to two weeks if exercise therapy is prescribed for the patient after
5. Fist bend stride
he is discharged from the ward.
Remedial Aims Foot Exercise

As for the 10th-14th postoperative day. 6. Standing; inner
Bxercise Period
30 minutes, once or twice daily.
:wards with turning and
S). Primary Exercises
IWinging forwards, and Trunk Bxercises
1. Fixed stride lying; upper Trunk bending forwards with turning and
pdrawing. (See Fig. 121,
00.) •
•• single Arm carrying across the chest (Fig. 218).
•
ressure with the hands,
73, p. 74.)
iDgIe high Knee raising.
Fig. 219.
Fig. 218.
Patebra by vertebra' in
2. Prone kneeling; slow Trunk turning with single Arm raising sideways.
I.) (Fig. 219.)
1IDeIl); single slight Leg 3. Stride standing; Trunk bending sideways.
4. Fixed crook lying; Trunk bending forwards with assistance from arms.
lids. (See Fig. 72, p. 74, which shows a different starting position.)
5. Fist bend fixed inclined long sitting (wall bar stool); Trunk lowering
backwards through 45°. (See Fig. 60, p. 70.)
lJorder raising.
Secondary Exercises
Trunk Bxercises
~ Knee raising. 1. Lax stoop back lean stride standing (heels about a footlength or more in
Dg (wall bars or wall); front of wall bar upright); Trunk stretching 'vertebra by vertebra' in
different planes. (See Fig. 139, p. 105.)
2. Neck rest crook lying; Chest raising. (See Fig. 80, p. 79.)
3. Forehead rest prone lying; single Leg raising backwards. The exercise
may have to be modified, so that the spinal extension does not stretch the
abdominal muscles unduly or cause pain.
renuous type. They are 4. Prone kneeling; Pelvis tilting forwards and backwards with Head
ibed for the patient after bending backwards and forwards. (See Fig. 106, p. 90.)
5. Fist bend stride sitting; Trunk lowering forwards.
Foot Bxercise
6. Standing; inner Border raising.
EXERCISE .
Balance Exercises EXERCISE THERAP

7. Balance walking forwards with opposite Knee and Arm raising.
8. Balance halfstanding (balance bench rib); balance walking fowards and
,
As suggested for gastrCI
be noted, as indicated he
backwards. 1. Usually intravenow
•i,. 2. 'Getting Up.' Aftel
2. CHOLECYSTECTOMY
•
••
hours, sitting in a chair
postoperative day. WaJkiI
t After cholecystectomy, ..
The gallbladder is removed in cases of chronic cholecystitis, with or without f drainage into bag), the 'I
the presence of gallstones. Disease of the gallbladder is more common in Ii ttle slower.
women than in men. 3. Discharge from ,.
patient is usually allO'tl
t
postoperative day. Wba
generally discharged froll
TYPES OF INCISION t
day.
The most common incision used today is the right upper paramedian incision
(Fig. 215, p. 189). In certain cases (obese subjects, for example, where good
t
---
I
--~-- ...
exposure is required), Kocher's subcostal incision is used (Fig. 215,

p. 189). This incision was employed more often in the past, before the Appendicectomy is per.
introduction of muscle relaxing drugs in anaesthesia. chronic inflammation of
J
It appendicitis the operati
appendix occurs, or afta
Right Upper Paramedian Incision. (See p. 188.) will complicate the origi
is removed between attlll
Kocher's Subcostal Incision (Fig. 215, p. 189)

The incision begins just below the xiphoid process and extends downwards TYPES OF INCISIO
and outwards to the tip of the 9th costal cartilage, 2·5 cm below and parallel
The most common inm
with the costal margin. All the abdominal muscles, including the lateral half
or muscle-splitting incil
of the rectus and its sheath, are divided in the same line. The 9th intercostal
and the right lower pan
nerve is severed. Thus this incision produces a flaccid paralysis of certain of
the fibres of the abdominal muscles, which predisposes to herniae.
I
Gridiron Incision (F~
The incision is an obliQ1
Drainage in the line of the fibres
In a straightforward cholecystectomy some form of drainage is employed for length, with its centre at
48-72 hours. Bile secretions are drained into a Redivac vacuum bottle or a drawn from the umbilic
Porto-vac suction unit.
When the common bile-duct is incised and explored (for the presence of an
Stages of Incision
obstructing stone), aT-tube is used to drain the common bile-duct. The tube
drains into a bag attached to the patient's thigh and is usually retained for 1. Incision of skin an
about 10 days. muscle.
i
!
ERAPY EXERCISE THERAPY AFTER ABDOMINAL SURGERY 197
EXERCISE THERAPY
Dee and Arm raising. As suggested for gastrectomy (pp. 190-196). Certain modifications must
ba1ance walking fowards and be noted, as indicated here:
1. Usually intravenous therapy is not given.
2. 'Getting Up.' After cholecystectomy, when a drain is used for 48-72
hours, sitting in a chair for 10-20 minutes is usually allowed on the 1st
MY .
';
postoperative day. Walking is encouraged when the drainage is discontinued.
After cholecystectomy, with exploration of the common bile-duct (T-tube
:holecystitis, with or without , drainage into bag), the 'getting up' regime is much the same but may be a
iJladder is more common in • little slower .
3. Discharge from ward. After straightforward cholecystectomy the
patient is usually allowed to return home between the 7th and 10th
postoperative day. When the common bile-duct is explored the patient is
generally discharged from the ward between the 10th and 12th postoperative
day.
It upper paramedian incision
::ts, for example, where good
Icision is used (Fig. 215, 3. APPENDICECTOMY
~ in the past, before the
Appendicectomy is performed in the treatment of acute, subacute, and
hcsia.
chronic inflammation of the vermiform appendix. During an acute attack of
appendicitis the operation may be carried out before perforation of the
appendix occurs, or after perforation has occurred (when a general peritonitis
188.) will complicate the original condition). In chronic appendicitis the appendix
is removed between attacks-'interval appendicectomy'.
It)
~ and extends downwards TYPES OF INCISION
I!:;2·5 em below and parallel
IS, induding the lateral half The most common incision used in this country is the gridiron (McBurney)
me line. The 9th intercostal or muscle-splitting incision. Other incisions are Battle's pararectal incision
t.ccid paralysis of certain of and the right lower paramedian incision. (See p. 189.)
Iisposes to herniae.
Gridiron Incision (Fig. 215, p. 189)
The incision is an oblique one and runs in a downward and inward direction
in the line of the fibres of the external oblique muscle. It is about 5 cm in
of drainage is employed for length, with its centre at the junction of the middle and lateral thirds of a line
lledivac vacuum bottle or a drawn from the umbilicus to the right anterior superior iliac spine.
Iored (for the presence of an

lBIlDlon bile-duct. The tube Stages of Incision
and is usually retained for 1. Incision of skin and subcutaneous tissues, down to the external oblique
muscle.
t
I'
198 PROGRESSIVE EXERCISE THERAPY EXERCU
2. Incision of the external oblique in the line of its fibres. Retraction of the When the pararectal
external oblique to expose the internal oblique muscle. based on that suggeste
3. Separation of the internal oblique and transversalis muscles in the line should be more rapid.
of their fibres.
4. Incision of the peritrneum.
The abdomen is closed in five stages.
1st POSTOPERAn
Battle's Pararectal Incision (Fig. 215, p. 189)
The patient is usua1ly ,
This incision is considered to give better views, but is said to be somewhat
the morning or afterno
more liable to hernia. The incision is a vertical one, sub-umbilical in position
in bed he is encouraged
and about 5 em in length.
left and right sides. (FQ
hour at a time. This alt
and helps to 'break' at
Right Lower Paramedian Incision (Fig. 215, p. 189)
The incision is used when the diagnosis is uncertain, or when exploration of
the lower abdomen (usually in the case of a female) is desired. See p. 188 for
Remedial Aims
details of right upper paramedian incision.
PRIMARY
1. To prevent postCl
2. To prevent posUl
3. To maintain the
EXERCISE AND lHE SUTURE LINE
transverse group!
Gridiron Incision
Because the muscles have been split in the direction of their fibres abdominal
SECONDARY
exercises will not tend to separate the sutured muscle edges. Nevertheless,
To maintain the othel
reasonable care should be shown in the choice and performance of trunk
exercises throughout the postoperative phase of treatment.
Exercise Period
20 minutes. In additi
Battle's Incision and Right Lower Paramedian Incision
some of the exercises

Both types of incision entail cutting of the anterior and posterior sheaths of
the rectus muscle, which are formed by the aponeuroses of the oblique and
transverse abdominal muscles. Active trunk rotation movements will there

Primary Exercises
,
fore tend to pull more strongly on the suture line than any other form of trunk
exercise. The suggestions made on p. 189 regarding choice and performance

Breathing, Ankle! FOOl
of trunk exercises in the after-treatment of gastrectomy should be followed.
Trunk Exercises •
1. Stride lying; T
chest (See Fig. I
2. Heave grasp lyiJ
EXERCISE lHERAPY p. 96, which sh4
The lists of progressive exercises given here are intended to be a guide to the
t1
after-treatment of (1) Interval Appendicectomy, and (2) Appendicectomy .. This aim is not so iJ
II
,
performed for acute appendicitis before perforation has occurred. It is involves the upper abdc
assumed that a gridiron incision is used. the diaphragm is far les
'Y EXERCISE THERAPY AFTER ABDOMINAL SURGERY 199
5 fibres. Retraction of the When the pararectal or the paramedian incision is used exercise therapy is
: muscle. based on that suggested for gastrectomy (pp. 190-196). Progress, however,
rsalis muscles in the line should be more rapid.
1st POSTOPERATIVE DAY

The patient is usually allowed to sit out in a chair for 30-45 minutes during
I is sa,id to be somewhat the morning or afternoon and to walk in the ward for a short distance. While
;ub-umbilical in position in bed he is encouraged to spend much of his time lying on his back and on the
left and right sides. (Fig. 214, p. 186); he remains in each position for about an
hour at a time. This alteration of posture assists in the ventilation of the lungs
and helps to 'break' any flatulence which may be present.
. 189)
\0 or when exploration of
is desired. See p. 188 for Remedial Aims
PRIMARY
1. To prevent postoperative respiratory complications.*
2. To prevent postoperative circulatory complications.
transverse groups.
Dftbeir fibres abdominal SECONDARY
de edges. Nevertheless, To maintain the other trunk muscles.
Ii performance of trunk
IbD.eDt.
Exercise Period
• Incision 20 minutes. In addition to this treatment session the patient will practise
some of the exercises on 'little and often' lines during the day.
md posterior sheaths of
roses of the oblique and
I movements will there
Primary Exercises
Lany other form of trunk
choice and performance Breathing, AnklejFoot and Leg Exercises (See previous section, pp. 186-188.)
my should be followed. Trunk Exercises
1. Stride lying; Trunk turning with single Arm carrying across the
chest (See Fig. 129, p. 101.)
2. Heave grasp lying (head posts of bed); Hip updrawing. (See Fig. 121,
p. 96, which shows a different starting position.)
Ided to be a guide to the
ad (2) Appendicectomy
*This aim is not so important as in the treatment of conditions where the incision
DI1 has occurred. It is involves the upper abdomen (e.g. gastrectomy), because the respiratory excursion of
the diaphragm is far less limited.
200 PROGRESSIVE EXERCISE THERAPY EXERCISI
Secondary Exercises Remedial Aims

Trunk Exercises PRIMARY
1. Lying: slight Chest raising. (See Fig. 80, p. 79, which shows full-range ! To redevelop the abdoll
Chest raising.) groups.
2. Crook lying; Pelvis raising. (See Fig. 150, p. 116.) •
SECONDARY
1. To redevelop the I
2. To re-educate nell
2nd-5th POSTOPERATIVE DAY ...
The patient spends an increasing amount of time sitting out in a chair and in Exercise Period
walking in the ward. • 30 minutes daily.
•
Remedial Aims
t Exercises
PRIMARY As after operations fOl'
1. To prevent postoperative respiratory and circulatory complications.*

•
transverse groups.
3. To maintain normal posture and reinstitute walking. FROM 7th POSTOP

I
The exercises suggestcc:
SECONDARY .. be used for 1-2 weeks it
To maintain the other trunk muscles. has been discharged m
Exercise Period Remedial Aims

20-30 minutes daily.
As previous section.•
activity.
Exercises
As after operations for inguinal hernia. (See pp. 205-206.)

Exercise Period
30 minutes daily.
6th-7th POSTOPERATIVE DAY Exercises
As after operations fOl'

The stitches are removed on the 7th day. Provided that the patient's
condition is satisfactory he is discharged home on the same day.
4. OPEl!
* These aims are achieved by the patient sitting out of bed and walking about in the
ward. Breathing exercises and movements to accelerate the venous circulation through DEFENCE MECHA
the lower limbs are therefore not necessary in the average case after the first
postoperative day. In this connection it must be borne in mil.::l that the bulk of the
The inguinal canal COl
appendicectomy cases fall into the younger age group, in which postoperative temporary increase in i
pulmonary and circulatory complications are less to be feared. in coughing and defaet:
l
Remedial Aims
PRIMARY
lich shows full-range To redevelop the abdominal muscles, particularly the oblique and transverse
groups.
•
SECONDARY
:out in a chair and in Exercise Period

30 minutes daily.
Exercises
As after operations for inguinal hernia. (See pp. 206-207.)
KY complications. * •
ty the oblique and
lC· FROM 7th POSTOPERATIVE DAY

The exercises suggested here are of a moderately strenuous nature. They may
be used for 1-2 weeks if exercise therapy is prescribed for the patient after he
has been discharged from the ward.
Remedial Aims
As previous section. In addition (Secondary): To promote generalized
activity.
)6.) Exercise Period

30 minutes daily.
Exercises
I that the patient's As after operations for inguinal hernia. (See pp. 208-209.)
arne day.
- ..- - --;:--=-=-==-~:-=-::-:-::--=:-:-::-::c:-::.--:~-:-::-:-:-:-==-:;::-::------
4. OPERATIONS FOR INGUINAL HE.:..:R.:..:N..:::.IA-=--_..._ _
Id walking about in the
IJUS circulation through DEFENCE MECHANISM OF INGUINAL CANAL
~ case after the first
.::1 that the bulk of the The inguinal canal constitutes a weak area in the abdominal wall. During a
I which postoperative temporary increase in intra-abdominal pressure, such as occurs, for example,
in coughing and defaecation, there is a tendency for the abdominal viscera to
202 PROGRESSIVE EXERCISE THERAPY ED!
be forced into the canal. The canal possesses an efficient defence mechanism
against this occurrence:
i contents to be ext
opposite the subCll
does not traverse til
hernia" , (Beesly aJ
Shutter Action Oblique inguinal
The muscles of the inguinal region 'react to strain in the following manner: appears first in infaJ
(1) Contraction of the external oblique narrows the gap in the external ring. in females' (Aird, I
(2) Associated tightening of the rectus sheath and the underlying muscle
forms a firm foundation for the remaining actions. (3) Straightening of the
arched conjoint tendon diminishes the interval between it and the inguinal
OBLIQUE INGU
ligament, but a weakened triangular area persists with its base in the region of
the emerging cord at the external ring, due to the tendinous segment of In general, two mai
conjoint tendon. Recurrent herniae are common at this site and care should may be recognized
be taken at operation to repair this portion adequately. (4) Lateral and This is the method
upward movement of the U-shaped internal ring tightens the fascia trans the hernia is genen
versalis. (5) Finally, there is blockage of the inguinal canal by the bulk of the canal still revisable
cremaster muscle which is pulled upwards on contraction' (Macfarlane and inguinal canal. Thi
Thomas, 1977). abdominal muscuJ:
hernias.
Valvular Mechanism
The obliquity of the canal (which to some extent constitutes a valvular Simple Hernioto
mechanism) is an additional safeguard. Increased intra-abdominal pressure An incision is madt
apposes firmly the posterior and anterior walls of the canal. Opposite the area two-thirds of the i
of greatest weakness in the posterior wall (the deep inguinal ring) is placed the external oblique ml
strongest part of the abdominal wall: the internal oblique fibres and the inguinal ring is de
aponeurosis of the external oblique. external oblique is'
inguinal canal. n
identified. The sac
is closed in three 5
INGUINAL HERNIA
An inguinal hernia results when the mechanism of the inguinal canal fails and
the abdominal viscera escape through the deep inguinal ring, the inguinal Excision of Sac ,
canal, and the superficial inguinal ring, to reach sometimes the scrotum or After excision of d
labium majus. The escaped viscera are contained in a sac which is composed the inguinal canal.
of peritoneum and extraperitoneal tissue.
The hernial sac descends within the coverings of the spermatic cord in the
male; its contents may include omentum, bowel, fluid, or loose bodies (from Bassini Procedure
omentum). The most common contents are omentum and small intestine. The operation ail:
Failure of the inguinal mechanism may be the result of irregularities in the posterior wall of d
development of the contents of the canal (congenital hernia). It may also be and the conjoint te
due to loss of the shutter action from the hypotonus of age or debility This method has b
(acquired hernia). 'In the most frequent type, the hernia passes down the be used 'only if th
inguinal canal. For this reason it is referred to as "oblique inguinal hernia". and parallel, so tI
Weakness of the abdominal musculature may, however, allow the abdominal brought together u
It defence mechanism contents to be extruded at the other weak area of the inguinal region
opposite the subcutaneous (superficial) inguinal ring. This variety, which
does not traverse the full length of the canal, is referred to as "direct inguinal
hernia'" (Beesly and Johnson, 1939).
Oblique inguinal hernia may develop at any age, but 'it most commonly
be following manner: appears first in infancy, youth or early adult life. It is commoner in males than
, in the external ring. in females' (Aird, 1957a).
Ie underlying muscle
Straightening of the
:0 it and the inguinal
OBLIQUE INGUINAL HERNIA: OPERATIVE PROCEDURES
s base in the region of
endinous segment of In general, two main types of operative treatment for oblique inguinal hernia
l site and care should may be recognized. (1) Simple herniotomy, or complete removal of the sac.
rely. (4) Lateral and This is the method of choice in infants, children and young fit adults, where
lenS the fascia trans the hernia is generally congenital and the secondary changes in the inguinal
nal by the bulk of the canal still revisable. (2) Excision of the hernial sac, followed by repair of the
ion' (Macfarlane and inguinal canal. This is usually indicated in the older age group (where the
abdominal musculature is of poor quality) and in the case of recurrent
hernias.
mstitutes a valvular Simple Herniotomy

Hlbdominal pressure An incision is made about a finger's breadth above and parallel to the medial
1I8l. Opposite the area two-thirds of the inguinal ligament, so as to expose the aponeurosis of the
ioal ring) is placed the external oblique muscle. (See Fig. 215, p. 189.) The margin of the superficial
mque fibres and the inguinal ring is defined and the cord is isolated. The aponeurosis of the
external oblique is divided from the subcutaneous ring along the line of the
inguinal canal. The coverings of the cord are then divided and the sac
identified. The sac is transfixed at its neck, ligated and removed. The wound
is closed in three stages.
IgUinal canal fails and

Ial ring, the inguinal Excision of Sac with Repair of Canal
times the scrotum or After excision of the hernial sac a variety of methods may be used to repair
Ie which is composed the inguinal canal. The Bassini operation is summarized here.
spermatic cord in the

tJI" loose bodies (from Bassini Procedure
md small intestine. The operation aims at strengthening the whole of the potentially weak
If irregularities in the posterior wall of the inguinal canal by suturing the internal oblique muscle
:mia). It may also be and the conjoint tendon to the inguinal ligament, behind the spermatic cord.
IS of age or debility This method has been much criticized, and Aird (1957b) states that it should
Dia passes down the be used 'only if the conjoint tendon and inguinal ligament lie close together
rue inguinal hernia". and parallel, so that they may be apposed without tension'. If they are
,allow the abdominal brought together under tehsion, the conjoint tendon may tear, thus losing the
204 PROGRESSIVE EXERCISE THERAPY EXERCI
desired effect. A further criticism levelled at the Bassmi operation is that it is

• FIRST 3 POSTOPI
said to interfere with the shutter mechanism of the canal.
It On the 1st postoperat

for about 30---45 mim
•
,•
sitting and walking is
When resting in bet
ABDOMINAL EXERCISES FOLLOWING OPERATIONS FOR
\#I his back and on the let
INGUINAL HERNIA
each position for aboll
The scope of abdominal exercises depends on the type of operative procedure
the ventilation of the :
which has been performed.
l present.
1
After Silnple HerniotolnY
Abdominal exercises assist in the functional recovery of the inguinal mechan
,
~
~ Remedial Aims
ism (p. 202), and so help to prevent a recurrence of the hernia.

I
PRIMARY
1. To prevent post
l 2. To maintain til
transverse groUJ;
Exercise and the SUlure Line 3. To maintain the

Because the aponeurosis of the external oblique muscle is divided in the
line of its fibres, abdominal exercises will not tend to separate the sutured
edges. Reasonable care should be taken, however, in the choice and per
•;• SECONDARY
To maintain the othc:

formance of trunk exercises throughout the postoperative phase of treatment.
After Excision of Hernial Sac, with Repair by Bassini Operation I

Exercise Period
20-30 minutes daily.
Abdominal exercises help to restore the strength of the abdominal muscles,
and so assist in the recovery of the valvular aspect of the inguinal mechanism
(p. 202). It is debatable if the exercises can assist in the functional recovery of
the shutter mechanism of the canal; theoretically, this has been obliterated by
the repair process. In practice, however, it may be doubted if such function
II

practise some of the'
has been completely replaced. Prilnary Exercise!

Breaching, Ankie/FOI
TRUNK EXERCISES
Exercise and the Suture Line
1. Stride lying; Tl
Much the same attitude towards trunk exercises may be taken as previously
(See Fig. l29, I
suggested. From experience it would appear that the repair procedures do not
2. Crook lying (hi
necessitate a more conservative approach to exercise therapy.
tI 3. Lying; Head b
4. Lying (hands g
1 p. 96, which sl:
EXERCISE THERAPY I! HIP EXERCISES
The lists of progressive exercises given here are intended to be a guide to the 5. Lying; single ~
after treatment of (a) Simple herniotomy, and (b) Excision of hernial sac, of movement.
with repair of inguinal canal by Bassini operation. 6. Lying; single I
I
.l
oi operation is that it is FIRST 3 POSTOPERATIVE DAYS

mal.
On the 1st postoperative day the patient is generally allowed to sit in a chair
for about 30-45 minutes and to walk a little in the ward. The amount of
sitting and walking is gradually increased over the 3 days.
When resting in bed the patient should spend some of his time lying flat on
!RATIONS FOR
his back and on the left and right sides (Fig. 214, p. 186); he should remain in
each position for about an hour at a time. This alteration of posture assists in
of operative procedure the ventilation of the lungs and helps to 'break' any flatulence which may be
present.
Remedial Aims
If the inguinal mechan PRIMARY
!be hernia. 1. To prevent postoperative respiratory and circulatory complications.
transverse groups.
3. To maintain the mobility of the hip joint of the affected side.
~e is divided in the
o separate the sutured SECONDARY
D the choice and per

To maintain the other trunk muscles.
m phase of treatment.
Exercise Period
IIassini Operation
20-30 minutes daily. In addition to this treatment session the patient will
be abdominal muscles,
practise some of the exercises on 'little and often' lines throughout the day.
be inguinal mechanism
~ functional recovery of
bas been obliterated by
ubted if such function
Primary Exercises
Breathing, Ankle/Foot and Leg Exercises (see previous section, pp. 186-188)
TRUNK EXERCISES
be taken as previously 1. Stride lying; Trunk turning with single Arm carrying across the chest.
pair procedures do not (See Fig. 129, p. 101.)
lherapy. 2. Crook lying (hand on abdomen); Abdominal contractions.
3. Lying; Head bending forwards with single slight Knee raising.
4. Lying (hands grasping sides of mattress); Hip updrawing. (See Fig. 121,
p. 96, which shows a different starting position.)
HIP EXERCISES
led to be a guide to the 5. Lying; single Knee raising (of affected side), gradually increasing range
scision of hernial sac, of movement.
6. Lying; single Leg carrying sideways.
E
Secondary Exercises 4. Lying; Heal

5. Lying (hant
TRUNK EXERCISES wards with.
7. Lying; slight Chest raising. (See Fig. 80, p. 79, which shows full-range 6. Crook lying
Chest raising.) being restn
8. Crook lying; Pelvis raising. (See Fig. 150, p. 116.)
4th-7th POSTOPERATIVE DAY Secondary Exe

The patient spends an increasing amount of time sitting in a chair and Trunk Exercises
walking about in the ward. The stitches are removed on the 7th postoperative 1. Crook lying
day. (Absorbable cutaneous sutures are sometimes used.) The patient is range Chest
warned not to attempt to lift any heavy object. Before being discharged home
he should be given some elementary instruction in the correct techniques of
lifting and carrying.
2. PATIENT S
Remedial Aims Primary Exerc
PRIMARY Trunk Exercises
1. To prevent postoperative respiratory and circulatory complications. '" 1. Stride sittiD
2. To maintain the abdominal muscles, particularly the oblique and direction of
transverse groups. 2. Stride sittin
3. To maintain normal posture and reinstate good walking habits.
SECONDARY
Secondary Exe
To maintain the other trunk muscles.
1. Stride sittin
assume am
Exercise Period without pri
stretching •
30 minutes daily.
1. PATIENT LYING ON BED 3. PATIENT ~

Primary Exercises Primary Exel'l
Trunk Exercises Check on PostUT~
1. Stride lying; Trunk turning with Head bending forwards and single 1. General COl
Arm carrying across the chest. (See Fig. 129, p. 101.) 2. Walkiitg pI
1. Crook lying (hands grasping sides of mattress); slow Knee swinging
from side to side. (See Fig. 128, p. 100.)
3. Lying (hands grasping sides of mattress); Hip updrawing. (See Fig. 121,
p. 96, which shows the exercise in standing.)
FROM 7th P(J
* These aims are achieved by the patient sitting out of bed and walking about in the The exercises Sl
ward. Breathing exercises and movements to accelerate the venous circulation through be used for 1-2 .
the lower limbs are therefore not necessary in the average case after the 3rd
has been discha
postoperative day.
4. Lying; Head bending forwards with single Knee raising.

5. Lying (hands grasping sides of mattress); upper Trunk bending for
wards with assistance from arms.
which shows full-range 6. Crook lying; Pelvis tilting forwards and backwards (range of forward tilt
being restricted). (See Figs. 68 and 79, pp. 73 and 79.)
.16.)
Secondary Exercises
, Slthng in a chair and Trunk Exercises
OIl tht 7th postoperative 1. Crook lying; slight Chest raising. (See Fig. 80, p. 79, which shows full
, used.) The patient is range Chest raising.)
: being discharged home
lie correct techniques of
2. PATIENT SITTING IN CHAIR

Primary Exercises
Trunk Exercises
atory complications. * 1. Stride sitting; Trunk turning with Arm moving loosely sideways in the
IiJarly the oblique and direction of the turning to grasp the chair back. (See Fig. 216, p. 193.)
2. Stride sitting; Trunk bending sideways.
I wallting habits.
Secondary Exercises
1. Stride sitting (hands on thighs); Trunk bending forwards-downwards to
assume a modified lax stoop position (movement taken as far as possible
without producing discomfort in wound area), followed by Trunk
stretching 'vertebra by vertebra'. (See Fig. 217, p. 193.)
3. PATIENT STANDING
Primary Exercises
Check on Posture and Walking
og forwards and single
l. General correction of posture in standing and walking.
t. 101.)
2. Walking practice.
:); slow Knee swinging
Idrawing. (See Fig. 121,
FROM 7th POSTOPERATIVE DAY

d and walking about in the The exercises suggested here are of a moderately strenuous type. They may
ftDOUS circulation through
be used for 1-2 weeks if exercise therapy is prescribed for the patient after he
aage case after the 3rd
has been discharged from the ward.
208
Remedial Aims
PRIMARY
,,
• ED
1. To redevelop the abdominal muscles, particularly the oblique and

transverse groups.
2. To educate the patient in the correct technique of lifting and carrying
heavy objects.
SECONDARY
Fig. 220. a, Inca

Exercise Period straight back, posi
30 minutes daily. object lifted. c, Co
vision unobst:ruCU
Primary Exercises
Balance Exercises
Trunk Exercises 3. Balance walkil
1. Fixed stride lying; upper Trunk bending forwards with turning and 4. Balance walkil
single Arm carrying across the chest. (See Fig. 218, p. 195.)
2. Prone kneeling; slow Trunk turning with single Arm raising sideways.
4. Low reach grasp standing (chair back); Hip updrawing. (See Fig. 121,
p.96.) FEMORAL HER
5. Lying; Trunk bending sideways with single Leg carrying sideways to A femoral hernia c
the same side. the femoral canal"
6. Stride standing; Trunk bending sideways. contains omentum.
7. Lying; high Knee raising, followed by over-pressure with the hands, Femoral hernia i
and upper Trunk bending forwards. (See Fig. 73, p. 74.) because the ingum
8. Lying; upper Trunk bending forwards with single high Knee raising. female, and pregna
(See Figs. 59 and 67, pp. 70 and 73.) Men who suffer j
bakers, stokers and
Education in Lifting
9. Practice in correct technique of lifting and carrying heavy objects. Surgical Treatm
(Fig. 220). An operation' is pc
The sac is ligated a
are employed, the
Secondary Exercises
Trunk Exercises
1. Lax stoop back lean stride standing (heels about a foot-length in front of High Operation
wall bar upright); Trunk stretching 'vertebra by vertebra' in different An incision is maw
planes. (See Fig. 139, p. 105.) (p. 203), above and
2. Crook lying; Chest raising. (See Fig. 80, p. 79.) The external oblic
DAPY EXERCISE THERAPY AFTER ABDOMINAL SURGERY 209
lIIIrticu1arly the oblique and
IOique of lifting and carrying

x
t
D.
a b c
Fig. 220. a, Incorrect lifting technique. b, Correct lifting technique. Note
straight back, position of legs and feet (giving stable base), and finn hold on
object lifted. c, Correct carrying posture: object held securely and close to body,
vision unobstructed.
Balance Exercises
3. Balance walking forwards and backwards with Knee raising.
~ forwards with turning and 4. Balance walking fowards with opposite Knee and Arm raising.
~Fig.218, p.195.)
single Ann raising sideways.
!bID swinging forwards, and
5. FEMORAL AND UMBILICAL HERNIAE
iip updrawing. (See Fig. 121,
FEMORAL HERNIA
~ Leg carrying sideways to A femoral hernia consists of a downward extension of peritoneum through
the femoral canal. Usually the hernia is not very large; as a rule the sac
contains omentum.
rer-pressure with the hands,
Femoral hernia is commoner in women than in men. This is said to be
Fig. 73, p. 74.)
because the inguinal ligament makes a wider angle with the pubis in the
iIh single high Knee raising.
female, and pregnancies increase intra-abdominal pressure.
Men who suffer from this condition usually follow 'stooping' occupations:
bakers, stokers and gardeners.
md carrying heavy objects. Surgical Treatment
An operation is performed unless there is some definite contra-indication.
The sac is ligated and the femoral canal closed. Two main types of procedure
are employed, the high operation and the low operation.
Ibout a foot-length in front of High Operation

:bra by vertebra' in different An incision is made, similar to that described for simple inguinal herniotomy
(p. 203), above and parallel to the medial two-thirds of the inguinal ligament.
!t. 79.) The external oblique aponeurosis is divided and the posterior wall of the
210 PROGRESSIVE EXERCISE THERAPY EXERCISI
inguinal canal exposed; the protuberance of peritoneum which forms the After Repair of a Large
hernia can then be drawn out of the femoral canal from above. The patient remains in 1
sit in a chair on the lSi
time of sitting out an(
Low Operation generally removed on d
A vertical incision, 5-7·5 cm in length, is made over the hernial protuberance. Great care must be tlII
The sac is exposed and dealt with from below. tissues are of poor qualit
In both operations the hernial sac is cleared of its coverings, opened, and cause reherniation.
explored, and the contents (if any) returned to the general peritoneal cavity. described for simple il
The pectineal fascia is sutured to the under-surface of the inguinal ligament. suggested for starting tb
This closes the femoral canal. addition, some of the 51
• early stages of treatmeol
An abdominal belt or 4
Postoperative Exercise Therapy
As for operations for inguinal hernia (pp. 205-209). Exercises for the hip of • She must wear it when sI
the affected side are important during the first few postoperative days.
•
,
t
• REFERENCES
UMBILICAL HERNIA i Aird 1. (1957a) A ComJHl1l
p.527.
An umbilical hernia consists of a protrusion of the abdominal contents Aird 1. (1957b) Ibid. p. 64!
Ballinger W. F. and DrlI)
through the umbilicus. If the protrusion occurs close to the umbilicus the
pp.166-7.
condition is known as a 'para-umbilical hernia'. Beesly L. and Johnson T_
Adult umbilical hernia occurs almost exclusively in obese women at the Oxford University Press
end of the child-bearing period. The hernia is probably the effect of increased Bendixen H. H. (1965) RIll
intra-abdominal pressure (pregnancies, omental adiposity, bronchitis) on the Macfarlane D. A. and Tho
Churchill Livingstone, I
umbilical cicatrix or the linea alba. The hernia sometimes reaches a huge size.
It contains usually omentum and sometimes transverse colon and small
intestine as well.
Surgical Treatment
The hernia is treated by operation. Before operation an attempt is often made
to reduce the patient's weight by dietetic means.
A transverse elliptical incision is made which outlines the hernial protru
sion; it is deepened through the fat until the stretched linea alba is exposed.
t
r
The sac is defined and opened. Protruding bowel is returned to the general
peritoneal cavity; omentum may be widely excised to reduce the volume of
the abdominal contents; the sac is then ligated at the neck and excised.
The stretched linea alba is sutured transversely with two rows of stitches, so
that the flaps overlap; the subcutaneous tissues and the skin are then sutured.
Exercise Therapy
After Repair of a Small Umbilical Hernia
As after operations for inguinal hernia (pp. 205-209.)
om which forms the After Repair of a Large Umbilical Hernia

above.
III The patient remains in the ward for about 10 days. Usually she is allowed to
sit in a chair on the 1st or 2nd postoperative day for 15-20 minutes. The
time of sitting out and walking is gradually increased. The stitches are
generally removed on the 10th day.
~alprotuberance. Great care must be taken in exercising the abdominal muscles, because the
tissues are of poor quality and any excessive strain may break down the repair
IS coverings, opened, and cause reherniation. The same types of abdominal exercises are used as
cral peritoneal cavity. described for simple inguinal herniotomy (pp. 205-209), but the time
the in.guinalligament. suggested for starting the exercises in sitting and standing must be delayed. In
addition, some of the stronger abdominal exercises must be omitted in the
early stages of treatment.
An abdominal belt or corset is worn when the patient is allowed out of bed.
She must wear it when she first sits out, as well as when standing and walking.
a:rcises for the hip of
stoperative days.
REFERENCES
Aird 1. (1957a) A Companion in Surgical Studies, 2nd ed. Edinburgh, Livingstone,
p.527.
: abdominal contents Aird 1. (l957b) Ibid. p. 646.
Ballinger W. F. and Drapanas T. (1972) Practice of Surgery. St Louis, Mosby,
, to the umbilicus the pp. 166-7.
Beesly L. and Johnson T. B. (1939) Manual of Surgical Anatomy, 5th ed. London,
I obese women at the Oxford University Press, p. 340.
the effect of increased Bendixen H. H. (1965) Respiratory Care. St Louis, Mosby.
ity) bronchitis) on the Macfarlane D. A. and Thomas L. P. (1977) Textbook of Surgery> 4th ed. Edinburgh,
Churchill Livingstone, pp. 240-1.
ICS reaches a huge size.
erse colon and small
attempt is often made
ICS the hernial protru

linea alba is exposed.
:wrned to the general
:n:duce the volume of
meek and excised.
wo rows of stitches, so
skin are then sutured.
Jl
EXERCISE THEF
20. Intervertebral disc lesions of IS USED
the lumbar spine The exercise program
when bed rest, with
modified for use wheo
support by plaster-o
treatment is then on s
extensors.
When the annulus fibrosus of the intervertebral disc remains intact, but
bulges posteriorly, the patient may complain of low back pain. When, PROGRAMME 1: 1
however, the annulus ruptures and a prolapse of the nucleus pulposus occurs, TRACTION, IS US
the prolapse may impinge on a lumbar nerve root and cause sciatica.
Conservative treatment will be sufficient for most disc lesions. Surgical Remedial Aims
treatment will be required for a small percentage of patients in whom the PRIMARY
prolapse cannot be warded off the nerve root. 1. To maintain the
the lower limbs 1
the method of D
2. To maintain til
CONSERVATIVE TREATMENT shoulder joints I
Conservative treatment consists of: 3. To prevent pos
1. Bed rest in the supine position on a rigid mattress for one to three weeks. the period of inJ
Traction may be applied to the lower limbs (skin extension) or to the pelvis
by means of a well-padded pelvic band. If traction is used the foot end of the
bed is elevated. Exercise Period
2. Intermittent spinal traction. This is generally carried out in the physio Initially, 10-15 ~
therapy department. The method of application will depend on the patient's placed as soon as poll
condition and the clinical judgement of the therapist.
3. Manipulation. On some occasions this will be carried out by the
Examples of Pt'iJn
orthopaedic surgeon, with or without a general anaesthetic. On other
occasions manipulation will be performed by a physiotherapist skilled in Leg Exercises
passive mobilization techniques. 1. Lying; single;
4. Spinal support: plaster-of-Paris jacket, surgical brace or belt. All these 2. Lying; single;
supports are individually made and fitted. 3. Lying; single;
Exercise therapy is often used in association with these conservative 4. Lying; (a) sin
measures. It should be noted that some surgeons do not allow trunk exercises double Foot n
when bed rest is prescribed (see Programme 1, p. 213). 5. Lying; single]
6. Lying; single
supporting su
'comfortable' I
SURGICAL TREATMENT
Surgical treatment consists of the removal of the prolapsed portion of the
intervertebral disc. Exercise therapy is used in the postoperative phase of Shoulder and Should;
recovery, as described on pp. 215-220. 7. Heave lying; iI
212
DISC LESIONS OF THE LUMBAR SPINE 213
EXERCISE THERAPY WHEN CONSERVATIVE TREATMENT

:lise lesions of IS USED
The exercise programmes outlined in this section have been arranged for use
when bed rest, with or without traction, is used, Programme 2 may be
modified for use when other conservative measures are employed, e.g. spinal
support by plaster-of-Paris jacket or surgical brace. The emphasis of
treatment is then on strengthening the muscles of the spine, particularly the
extensors .
...;u disc remains intact, but

in of low back pain. When,
PROGRAMME 1: WHEN BED REST, WITH OR WITHOUT
lthe nucleus pulposus occurs,
TRACTION, IS USED
root and cause sciatica.
.. most disc lesions. Surgical Remedial Aims
age of patients in whom the PRIMARY
1. To maintain the strength ofthe muscles and the mobility of the joints of
the lower limbs within the limits imposed by the patient's condition and
the method of immobilization used.
2. To maintain the strength of the muscles and the mobility of the
shoulder joints and joints of the shoulder girdle.
3. To prevent possible respiratory and circulatory complications during
.nress for one to three weeks. the period of immobilization .
kin extension) or to the pelvis
lion is used the foot end of the
Exercise Period
Illy carried out in the physio Initially, 10-15 minutes, twice daily. Supervised exercise periods are re
n will depend on the patient's placed as soon as possible by self-care practice on 'little and often' lines.
aapist.
will be carried out by the
Examples of Primary Exercises
:neral anaesthetic. On other
r a physiotherapist skilled in Leg Exercises
1. Lying; single and double Quadriceps contractions.
1I'gica1 brace or belt. All these 2. Lying; single and double Gluteal contractions.
3. Lying; single and double Ankle bending.
Iioo with these conservative 4. Lying; (a) single and double Foot turning inwards, (b) single and
15 do not allow trunk exercises double Foot turning outwards.
~ p. 213). 5. Lying; single Foot circling.
6. Lying; single small range Knee ralsmg with heel in contact with
supporting surface (Le. flexion of each hip and knee through a
'comfortable' range, not exceeding 15° of hip flexion).
'the prolapsed portion of the

in the postoperative phase of Shoulder and Shoulder girdle Exercises
7. Heave lying; inward and outward rotation of shoulder joints.
214 PROGRESSIVE EXERCISE THERAPY Dl
8. Lying; Shoulder rounding and bracing. Postural Training

9. Lying; Shoulder shrugging. The patient must be D
posture, especially wbc
Breathing Exercises value in this respect. "I
I
(and in some instanc
10. Lying (hands on sides of lower chest); lower lateral Costal breathing.
emphasized.
11. Lying (hand on upper abdomen); Diaphragmatic breathing.
~ Technique of Uftina
I
PROGRAMME 2: WHEN SYMPTOMS HAVE SUBSIDED AND I t is essential to give il
TRACTION, IF USED, IS DISCONTINUED with particular referelJj
The patient rests in bed for a day or so and then progresses to short periods of
sitting, standing and walking; it is important that a chair of suitable height
and design is used. The emphasis of exercise treatment is on (a) strengthen
ing the main trunk muscles, particularly the extensors; and (b) promoting the EXERCISE THE
mobility of the thoracolumbar spine and knee joints. If spinal flexion is IS USED
allowed by the surgeon it is best carried out in side-lying.
The patient is retume.
Side-lying is maintain
Examples of Primary Exercises
from right to left, and ,
Back Exercises positioned between the
1. Lying; Chest raising. (See Fig. 80, p. 79.) A well-padded adlH
2. Prone lying; Shoulder bracing. venous therapy is sou:
3. Forearm support prone lying; Trunk bending backwards with Redivac wound drain i
assistance from arms. (See Fig. 37a, p. 51.) About the 2nd posIl
4. Prone lying (arms behind back, fingers clasped); Trunk bending back-lying position, pI1
backwards with Arm raising backwards. From then on the pall
5. Lying; opposite Arm and Leg downpressing. side-lying.
During this initial P'
freely in bed and to '
Abdominal Exercise
respiratory and circula
6. Lying; Head bending forwards.
Sitting out of Bed

Rotation Exercises
The patient is allowed
7. Stride lying; small range Trunk turning (i.e. raising one shoulder well
periods between the ,2
off the bed).
chair of correct height
8. Lying (hands grasping sides of bed); Pelvis turning from side to side.
Lateral Flexion Exercise Spinal Flexion

9. Stride lying; Trunk bending sideways. Opinion varies amoll,
movements ofthe thor
in side-lying about the
Knee Exercise sutures have been rem
10. Prone lying; alternate Knee bending. specific flexion moven
r
IERAPY DISC LESIONS OF THE LUMBAR SPINE 215
I Postural Training
The patient must be made aware of the importance of maintaining a sound
posture, especially when standing and sitting. A full-length mirror is of great
value in this respect. The need to guard against flexion stresses of the spine
(and in some instances to prevent flexion taking place) must also be
l'Wer lateral Costal breathing.

emphasized.
u:agmatic breathing.
Technique of Lifting and Back Care
f.t\VE SUBSIDED AND It is essential to give instruction in correct lifting and carrying techniques,
ED with particular reference to the patient's occupation. (See Fig. 220, p. 209.)
progresses to short periods of

bat a chair of suitable height
'C3tIDent is on (a) strengthen
ensors; and (b) promoting the EXERCISE THERAPY WHEN SURGICAL TREATMENT
:e joints. If spinal flexion is IS USED
I side-lying.
The patient is returned from the operating theatre in a side-lying position.
Side-lying is maintained for at least 24 hours, the position being changed
from right to left, and vice versa, at regular 2-hour intervals. A firm pillow is
positioned between the knees.
A well-padded adhesive dressing is used over the incision area. Intra
venous therapy is sometimes used for a day or so. In certain instances a
k. bending backwards with Redivac wound drain is employed for up to 48 hours.
51.) About the 2nd postoperative day the patient is encouraged to take up a
[5 clasped); Trunk bending back-lying position, provided that it does not give rise to pain and discomfort.
From then on the patient's resting posture varies between back-lying and
sing. side-lying.
During this initial postoperative period the patient is encouraged to move
freely in bed and to carry out simple exercises to prevent postoperative
respiratory and circulatory complications.
Sitting out of Bed

The patient is allowed to sit out in a suitable chair (at the bedside) for short
:i.e. raising one shoulder well
periods between the 2nd and 5th postoperative day. It is important that a
chair of correct height and design is used.
Iris turning from side to side.
Spinal Flexion
Opinion varies among orthopaedic surgeons as to when simple flexion
movements of the thoracolumbar spine should be started. Some allow flexion
in side-lying about the 6th postoperative day, while others delay this until the
sutures have been removed (10th or 12th postoperative day). Others prohibit
specific flexion movements.
After Sutures have been Removed 4. Forearm sUJII

The patient is discharged home when the sutures have been removed; he with assistan
attends the hospital for exercise therapy for 4-6 weeks, depending on his 5. Prone lying;
occupation. 6. Prone lying
backwards w
PROGRAMME 1: FIRST 2 POSTOPERATIVE DAYS

Abdominal (Static)
Remedial Aims
7. Lying; Head
PRIMARY
1. To prevent postoperative respiratory complications. (See pp. 184-185.)
2. To accelerate the circulation through the veins of the lower limbs and
pelvis. (See p. 187.) Breathing and Lee J
8. Breathing, fCl
9. Lying; single
Exercise Period 10. Lying; single
10 minutes, two or three times daily. 11. Prone lying;
N.B. (1) From
encouraged to C3I'Il
Primary Exercises For example: (a) b
Breathing exercises, particularly unilateral Apical and lower lateral Costal stride standing, (b)
breathing; foot and ankle exercises, with emphasis on dorsiflexion move position. In additio
ments; and small range flexion and extension of hip and knee (in side-lying the quadriceps an
this is confined to the uppermost limb). extension movemea:
(2) In the early 51
patient's height) c
confidence.
PROGRAMME 2: 3rd TO 10th OR 12th POSTOPERATIVE
DAY WHEN SUTURES ARE REMOVED
Remedial Aims
PRIMARY
As in previous section. In addition: To strengthen the muscles of the PROGRAMME]
thoracolumbar spine, particularly the extensors. FORA PERIOD
Remedial Aims
PRIMARY
Exercise Period
1. To strengthen
15-20 minutes, twice daily.
extensors.
2. To increase d
Primary Exercises 3. To teach soUl
Back Exercises
1. Lying; slight Chest raising. (See Fig. 80, p. 79, which shows a full
range movement.) Exercise Period
2. Lying; opposite Arm and Leg downpressing. 30 minutes, once l
3. Prone lying; Shoulder bracing with Arm raising backwards. used.

:APY DISC LESIONS OF THE LUMBAR SPINE 217
4. Forearm support prone lying; small range Trunk bending backwards

es have been removed; he with assistance from arms. (See Fig. 37a, p. 51.)
i weeks, depending on his 5. Prone lying; small range single Leg raising backwards.
6. Prone lying (arms behind back, fingers clasped); Trunk bending
backwards with Arm raising backwards.
rIVE DAYS
Abdominal (Static) Exercise
7. Lying; Head bending forwards.
ications. (See pp. 184-185.)

:ins of the lower limbs and
Breathing and Leg Exercises
8. Breathing, foot, ankle, and static Quadriceps exercises.
9. Lying; single Hip and Knee flexion.
10. Lying; single and double Gluteal contractions.
II. Prone lying; alternate Knee bending.
N.B. (1) From about the 5th postoperative day the patient wi11 be
encouraged to carry out some simple trunk movements in the erect position.
For example: (a) lateral flexion movements of the thoracolumbar spine in
II and lower lateral Costal stride standing, (b) gentle small range trunk rotation in the same starting
ISis on dorsiflexion move position. In addition, in standing, the patient will be encouraged to exercise
llip and knee (in side-lying the quadriceps and gluteal muscle groups by small range flexion and
extension movements of hips and knees.
(2) In the early stages of standing and walking a Rollator (adjusted to the
patient's height) can be used effectively to provide both stability and
confidence.
II()STOPERATIVE
gthen the muscles of the PROGRAMME 3: FROM 10th OR 12th POSTOPERATIVE DAY
FOR A PERIOD OF 2 WEEKS
Remedial Aims
PRIMARY
1. To strengthen the muscles of the thoracolumbar spine, particularly the
extensors.
2. To increase the mobility of the joints of the thoracolumbar spine.
3. To teach sound postural habits and provide instruction in back care.
p. 79, which shows a full

Exercise Period
11&. 30 minutes, once daily_ Extra time should be allowed if pool therapy is
ming backwards. used.
Primary Exercises
Back Exercises
I PROGRAMME 4
RECOVERY
1. Lying; Chest raising. (See Fig. 80, p. 79.) Remedial Aims
2. Stride lying or lying; Pelvis raising (bridging). (See Fig. 31b, p. 47.) As in previous secti
3. Prone lying; Trunk bending backwards with Arm turning outwards.
(See Fig. 85, p. 81.)
4. Prone lying; single Leg raising backwards. Exercise Period
30 minutes, once d
Abdominal Exercise used.
N.B. Progressive·
*5. Lying; upper Trunk bending forwards with assistance from arms.
suggested here. In a
designed to simuJatl
Combined Flexion and Extension Exercises tional therapy, in tb
*6. Side lying; slow high Knee raising with or without Trunk bending used.
forwards, followed by Trunk bending backwards with Leg stretching
and carrying backwards. (See Fig. 99, p. 86.) Primary Exercise
*7. Prone kneeling; Pelvis tilting forwards and backwards with Head
Back Exercises
bending backwards and forwards. (See Fig. 106, p. 90.)
1. High reach gJ
floor); spanniJ
Rotation Exercises 2. Prone lying; .
8. Stride lying; Trunk turning with single Arm carrying across the chest. and single Lc
(See Fig. 129, p. 101.) 3. Fist bend fixe
9. Yard (palms on floor) crook lying; Knee lowering from side to side. 4. Fist bend fixe
(See Fig. 128, p. 100, which shows the movement performed as a (See Fig. 138,
swinging action.)
Abdominal Exercisel
Lateral Flexion Exercises *5. Fixed crook ~
10. Stride lying; Trunk bending from side to side. resting on mat.
11. Lying (hands grasping sides of mat); Hip updrawing. (See Fig. 121, *6. Crook lying;
p. 96, which shows the exercise performed in standing.)
Combined Flexion al
Postural Training *7. Prone kneem
The patient should be made aware of the importance of maintaining a sound followed by I
posture at all times, particularly when at work. The need to guard against backwards, 31
flexion stresses of the spine must be emphasized.
Rotation Exercises
Back Care
8. Tum prone'
It is important to give adequate instruction in correct lifting and carrying single Arm 11
techniques, with particular reference to the patient'S occupation. exercise peri
* Used if spinal flexion is allowed. * Used if spinal fiell
'BERAPY DISC LESIONS 0(1 THE LUMBAR SPINE 219
PROGRAMME 4: FROM 4th TO 6th WEEK OF

RECOVERY
19.)
Remedial Aims
ridging). (See Fig. 31b, p. 47.)
As in previous section.
is with Arm turning outwards.
Exercise Period
30 minutes, once daily. Extra time should be allowed if pool therapy is
used.
N.B. Progressive circuit training forms a useful alternative to the exercises
•with assistance from arms.
suggested here. In addition, in the later stages of recovery, a pre-work circuit
designed to simulate normal working stresses (p. 251) can be used. Recrea
tional therapy, in the form of modified volley ball and basket ball, can also be
ith or without Trunk bending used.
tlackwards with L~g stretching
p.86.) Primary Exercises
is and backwards with Head
Back Exercises
Fig. 106, p. 90.)
1. High reach grasp lying (wall bars: hands grasping 5th or 6th bar from
2. Prone lying; Trunk bending backwards with Arm turning outwards
:Arm carrying across the chest. and single Leg raising backwards. (See Fig. 5, p. 10.)
3. Fist bend fixed prone lying; Trunk bending backwards.
r:e lowering from side to side. 4. Fist bend fixed prone lying; Trunk bending backwards with turning.
be movement performed as a (See Fig. 138, p. 105, which shows a stronger version of the exercise.)
Abdominal Exercises
*5. Fixed crook lying; upper Trunk bending forwards with palms of hands
: to side.
resting on mat.
flip updrawing. (See Fig. 121,
*6. Crook lying; small range Knee raising.
med in standing.)
Combined Flexion and Extension Exercise

*7. Prone kneeling; single high Knee raising with Head bending forwards,
onance of maintaining a sound
followed by Leg stretching and raising backwards with Head bending
m.. The need to guard against
backwards, and return to starting position. (See Fig. 98, p. 86.)
red.
Rotation Exercises
8. Turn prone kneeling (one arm bent across chest); Trunk turning with
in correct lifting and carrying
single Arm raising sideways. (See Fig. 132, p. 102, which shows the
ment's occupation.
exercise performed as a mobility exercise.)
* Used if spinal flexion is allowed.
9. Yard (palms on floor) half crook half vertical leg lift lying; Leg 21. To
lowering sideways. (See Fig. 130, p. 101.)
Lateral Flexion Exercise

10. Wing fixed side towards standing (wall bars); Trunk bending sideways
towards the bars, and bending away from the bars. (See Fig. 125,
p. 99, which shows an advanced mobilizing form of the exercise.)
Total hip replacemeDl

REFERENCES conditions as osteo- 3J
Adams J. C. (1980) Standard Orthopaedic Operations, 2nd ed. Edinburgh, Churchill and discomfort but 11
Livingstone, pp. 108-114. function. The procedl
Edmonson A. S. and Crenshaw A. H. (ed.) (1980) Campbell's Operative Orthopaedics,
Vol. 2, 6th ed. St Louis, Mosby, pp. 2107-2114. associated with specif
In recent years 80m
successfully to restore
in obliteration of the i
acute suppurative art
ment is often emploY'
For example, after pi
In general, total hi
group. When used fOl
to the hip or a cri!
Longton (1982) state
fails with stress and
feasible, and hip PI'Ol!
the elderly, frail, or c
are used in young, hi
· vertical leg lift lying; Leg
t.)
21. Total hip replacement
us); Trunk bending sideways

rom the bars. (See Fig. 125,
ring form of the exercise.)
Total hip replacement is widely used today in the surgical treatment of such
conditions as osteo- and rheumatoid arthritis, associated not only with pain
IS, 2nd ed. Edinburgh, Churchill
and discomfort but with severe restriction of joint movement and loss of
..pbell's Operacive Orchopaedics, function. The procedure is also used following severe trauma of the hip joint
associated with specific damage to the acetabulum.
In recent years some orthopaedic surgeons have used total hip replacement
successfully to restore movement in old joint conditions which have resulted
in obliteration of the joint surfaces, e.g. bony ankylosis of the joint following
acute suppurative arthritis or tuberculosis in childhood. Total hip replace
ment is often employed when previous hip surgery has proved unsuccessful.
For example, after partial or hemi-arthroplasty.
In general, total hip replacement is confined to patients in the older age
group. When used for younger patients it is usually because of severe trauma
to the hip or a crippling rheumatoid condition. Commenting on this,
Longton (1982) states: 'The strength of a man-made prosthesis necessarily
fails with stress and use. Prostheses of at least reasonable durability are
feasible, and hip prostheses have given service for 20 years or so--usually in
the elderly, frail, or crippled. The story may prove different if the appliances
are used in young, heavy, active individuals.'
Fig. 221. Total replacement of the hip joint with a

low friction type of prosthesis: high density poly
ethylene cup and stainless steel femoral component.
Fixation is by methacrylate cement. (Illustration
reproduced from Texcbook of Surgery, 4th ed., by
kind permission of the editors, David A. Madarlane
FRCS and Lewis P. Thomas FRCS, and the pub
lishers, Churchill Livingstone.)
221
The low friction Charnley hip prosthesis (Fig. 221) is the most widely used patient is admitted to tl
of the many different types of prostheses designed for total hip replacement. discharged home. Smol
It employs a femoral component of either stainless steel or cobalt-chrome many patients resent th
alloy and a high-density polyethylene acetabulum. The femoral head is small, firmness by both nursil
22·25 mm in diameter. Both the femoral stem and acetabular component are discouraged; often th.i3
cemented in position by a polymerizing plastic cement, such as methyl expected; patients com
methacrylate. function. •
The artificial weight-bearing surfaces between metal and polyethylene The breathing exercil
provide low friction areas eapable of withstanding immense forces of many with postoperative resJ]
times the body-weight. A strain gauge inserted in a hip prosthesis has of hip mobility the baH
revealed that 'forces of at least four times the total body-weight may pass Although the bilatera
through such a joint in taking a single walking step' (Longton, 1973). must also be taught uni
For patients who are heavier than normal (over 80kg in weight) a heavy important in the early
duty prosthesis, with a thicker stem, is employed. patient's arms will be 1]
Rehearsing Positiqn of 1
PREOPERATIVE ASSESSMENT It is necessary to expJ=
Normally the patient is admitted to hospital a few days before the operation is which the patient will
to be pe~formed. This ensures that there is adequate time for the various Salient points include:
preoperative tests and procedures to be carried out, e.g. cross-matching of surgeons prefer bilaten
blood and X-ray examination. The period also gives the therapist an ofthe affected hip. 'Big
opportunity of making a careful assessment of the patient's function, this connection.
establishing a good rapport, and gauging his future physical potential with
regard to age and general condition. In this respect an understanding of the
patient's past medical history is essential. Bridging
In making an assessment the therapist will concentrate on: (a) range of A modified bridging m
movement of the joints ofthe lower limbs of both the affected and sound sides procedures) is taught'
with particular reference to possible joint deformities and inequality between affected limb well supp
the lengths of the limbs; (b) effectiveness of the muscles controlling these a correctly adjusted 'JD(
joints; (c) range of movement of the lumbar spine; and (d) ability of the upper in stabilizing the body
limbs to handle and control walking aids. The special problems of the elderly Bridging, as describe
with regard to impairment of sight, hearing and general co-ordination must This will help to minD
also be borne in mind. when a bed-pan is usee
PREOPERATIVE EXERCISE THERAPY PREOPERATIVE E

Respiratory Function A simple programme
As most patients for hip arthroplasty are in the older age group, and the admission. It aims at (l
operation itself is a major and lengthy procedure, it is vital that every effort is strength of the quadri
made to improve respiratory function. Many patients are totally unaware of venous circulation thn
their poor respiratory levels, particularly those who have been habitual improving the mobiI1t
smokers. should also include sui
Correct breathing techniques are taught as soon as possible after the limbs and shoulder g:iJ:
nD!RAPy TOTAL HlP REPLACEMENT 223
Fig. 221) is the most widely used patient is admitted to the ward and continued on a regular basis until he is
igoed for total hip replacement. discharged home. Smoking is not allowed for 48 hours before the operation;
ltllinIess steel or cobalt-chrome many patients resent this bitterly, and have to be handled with considerable
116m. The femoral head is small, firmness by both nursing and therapy staff. After the operation smoking is
and acetabular component are
II. discouraged; often this presents fewer difficulties than would have been
ilastic cement, such as methyl expected; patients come to realize the value of their improved respiratory
function.
sween metal and polyethylene The breathing exercises used are those recommended in the section dealing
IDding immense forces of many with postoperative respiratory exercises, pp. 186-187. Because of the lack
IICrted in a hip prosthesis has of hip mobility the half lying position is used in place of crook lying.
he total body-weight may pass Although the bilateral approach to costal breathing is employed the patient
og step' (Longton, 1973). must also be taught unilateral breathing techniques. Unilateral exercises are
(over SOkg in weight) a heavy important in the early postoperative phase of treatment when one of the
Ioyed. patient's arms will be used for intravenous therapy.
Rehearsing Position of Immobilization

It is necessary to explain and demonstrate the position of immobilization
few days before the operation is which the patient will be required to maintain immediately after surgery.
>adequate time for the various Salient points include: (a) Abduction of the affected hip joint to 20° (some
jed out, e.g. cross-matching of surgeons prefer bilateral hip abduction); and (b) Avoidance oflateral rotation
II also gives the therapist an ofthe affected hip. 'Big toe pointing towards the ceiling ... ' is a useful hint in
:m: of the patient's function, this connection.
I future physical potential with
tapeCt an understanding of the
Bridging
ill concentrate on: (a) range of A modified bridging manreuvre (used for toilet purposes and other nursing
orb the affected and sound sides procedures) is taught with the sound leg flexed at hip and knee and the
xmities and inequality between affected limb well supported by the therapist or nurse (see p. 47). The use of
r the muscles controlling these a correctly adjusted 'monkey' chain or strap can be of considerable assistance
line; and (d) ability of the upper in stabilizing the body during the bridging movement.
: special problems of the elderly Bridging, as described here, needs to be practised carefully by the patient.
md general co-ordination must This wilJ help to minimize the risk of possible dislocation of the prosthesis
when a bed-pan is used in the early phase of postoperative care.
ETIlERAPY
PREOPERATlVE EXERCISE PROGRAMME
A simple programme of exercises is started as soon as possible after
I.the older age group, and the admission. It aims at (a) improving respiratory function, (b) maintaining the
He, it is vital that every effort is strength of the quadriceps and gluteal muscle groups, (c) accelerating the
patients are totally unaware of venous circulation through the veins of the lower limbs and pelvis, and (d)
!lose who have been habitual improving the mobility of the joints of the lower limbs. The programme
should also include suitable exercises to strengthen the muscles of the upper
as soon as possible after the limbs and shoulder girdle in preparation for the use of walking aids.
When possible, it is advisable to measure the patient for the appropriate

walking aid-generally elbow crutches, but sometimes a walking frame-and Individual surge
to give instruction in their correct use. The patient should then be en habilitative treall
couraged to walk freely in the ward with the help of his specific aid. is only necessary
importance of usi
From practiatl
Examples of Preoperative Exercises
much to commel
1. Half lying; breathing exercises (both unilateral and bilateral). (See only based on tbi
pp. 109-110.)
the low friction (
2. Half lying; single and double Quadriceps contractions.
3. Half lying; single and double Gluteal contractions.
4. Half lying; single and double Ankle bending.
5. Half lying; alternate Ankle bending and stretching. 1. IMMEDIA"fl
6. Lying; single Knee raising with heel in contact with supporting When the patien!
surface, followed by Leg downpressing: sound limb only. him to carry out
7. Lying; same exercise as above, but confined to affected limb. Therapist taught; he will all
encourages the widest range of movement possible. In practical terms designed to accel
only a few degrees of true hip flexion may be possible. Ward nursing!
8. Lying; single and double Hip abduction. At the affected hip movement time to time they
may be limited to a few degrees. exercises in the '
9. Bend (fists on chest) stride lying; Elbow circling backwards. nurse and themp
10. Stride lying; single Arm raising forwards-upwards and rhythmical
pressing in final position.
11. Standing; correction of faulty posture as far as possible. The use of a 2. 1st AND 2nd
posture mirror is an advantage in giving this form of instruction. It The therapist ell
increases the patient's awareness of his faulty stance. correct position (
ensure that the I
rotation. It shoul
POSTOPERATIVE TREATMENT move his trunk i
When the patient is returned to the ward from the recovery room he is placed trunk position m
on the bed in a modified lying position (trunk raised slightly) with either the
affected leg, or both legs, abducted to 20 c • The abducted position is used to
ensure the stability of the prosthesis in the new acetabulum. Exercises
A variety of methods of fixation and support is used to maintain the Quadriceps drill
abducted position of the hips. For example: (a) Triangular foam wedge with confined to the !
wide base positioned between ankles; (b) Individual foam gutter trough or limb are started
troughs; (c) Individual thigh slings attached to the sides of the bed; (d) Ankle (generally after 2
'gaiters' attached to a horizontal strut; (e) Pillow 'mound' positioned between in a fairly slow
the knees; and if) Hamilton-Russell traction arranged to provide positive essential.
abduction for the affected limb. With the surge
Intravenous therapy will be used for a day or so: the dorsum of one of the and knee are als
hands is generally used for this purpose. A vacuum drain (Porto Vac or maximum supp<
Redivac) is used for approximately 24 hours to drain the wound area. A bed brief period oft;
cradle is in position to protect the affected limb from the weight of the and knee should
bedclothes. patient needs en
ERAPY TOTAL HIP REPLACEMENT 225
r: patient for the appropriate ...... _ _ ~OSTOPERATIVE EXERCISE THERAPY _ _ _ __

etimes a walking frame-and Individual surgeons have established their own particular regimes of re
patient should then be en habilitative treatment following total hip replacement. Some consider that it
:IPof his specific aid. is only necessary to give practice in standing and walking; others stress the
importance of using simple bed exercises as a preliminary to walking training.
From practical experience the authors consider that the latter regime has
much to commend it. The postoperative training plan outlined here is not
:bIateral and bilateral). (See
only based on this premise, but has been arranged specifically for use when
the low friction Charnley prosthesis is employed.
I contractions.
Inactions.
6ng.
IIlretching.
1. IMMEDIATE POSTOPERATIVE CARE
in contact with supporting
When the patient's level of awareness permits, the therapist will encourage
round limb only.
him to carry out the simple breathing exercises which have been previously
II to affected limb. Therapist
taught; he will also encourage him to practise the foot and ankle movements
t possible. In practical terms
designed to accelerate the venous return through the lower limbs.
y be possible.
Ward nursing staff have an important part to play in this form of care; from
U the affected hip movement
time to time they should remind the patient of the necessity of practising his
\
exercises in the correct manner. This calls for close cooperation between
circling backwards. nurse and therapist.
lIs-upwards and rhythmical
far as possible. The use of a 2. 1st AND 2nd POSTOPERATIVE DAYS

this form of instruction. It
The therapist checks the position of the affected limb to ensure that the
IIllty stance.
correct position of hip abduction has been maintained. It is also important to
ensure that the hip is in a neutral position and has not fallen into lateral
rotation. It should be noted that there is a marked tendency for the patient to
move his trunk in line with the abducted limb. If this occurs the patient's
Ie recovery room he is placed trunk position must be adjusted so that he lies centrally in bed.
ised slightly) with either the
abducted position is used to
acetabulum. Exercises
.n: is used to maintain the Quadriceps drill is started on the I st postoperative day; usually this is
rriangular foam wedge with confined to the sound limb. Contractions of the quadriceps of the affected
idual foam gutter trough or limb are started when the vacuum drain is removed from the wound area
Ie sides of the bed; (d) Ankle (generally after 24 hours). It is important that the contractions are performed
'mound' positioned between in a fairly slow and positive manner. Adequate periods of relaxation are
rranged to provide positive essential.
With the surgeon's permission gentle flexion movements of the affected hip
so: the dorsum of one of the and knee are also started on the 1st postoperative day, the therapist giving
ICUum drain (Porto Vac or maximum support. Assisted movement of this type should occupy only a
!rain the wound area. A bed brief period of time; in all, only about five careful flexion movements of hip
Ilb from the weight of the and knee should be attempted. During this period of early hip movement the
patient needs encouragement and reassurance.
In addition to this specific work, exercises to assist respiratory and The return movement ot
circulatory function will be emphasized. (See Preoperative Exercise Pro encourage assisted activt
gramme, p. 223.) It is helpful if the parie
Ideally, the therapist should arrange to visit the patient in the morning and position. This not only
afternoon for individual exercise sessions of about 10 minutes each. degree relieves the butU
'Getting Up': The IDiI

3. FROM 2nd OR 3rd POSTOPERATIVE DAY UNTIL SUTURES For the majority of pari
ARE REMOVED BETWEEN 10th AND 14th DAY taking weight on the 'ne
they will need a conside
Standing, Walking and Sitting
all is well. It is most imp«
Individual surgeons differ considerably with regard to the exact time when expected of them, and ~
the patient is first allowed out of bed for standing and walking. Some allow discomfort.
this on the 2nd or 3ed postoperative day, while others postpone standing and Initially, the therapi
walking for several days: this gives time for the patient to increase his range of manreuvring the patient
hip flexion. It should be noted that some surgeons prefer their patients to be positioned at right angle
able to sit comfortably in a chair of suitable height before they attempt to it is essential for the de
stand and walk. for the hips to be maine
In the sitting position the patient must have his hips well abducted. prevent undue hip fleD
Because of limited hip flexion many patients experience considerable dif During the main pivo
ficulty in assuming a normal sitting position. To compensate for this the chair chain to relieve pressun:
seat is 'angled' by the addition of two pillows, so that the patient assumes an from the far side of the
inclined sitting position. To bring the patient t
A stable well-designed armchair with the following features is an essential the bed. When the bun
piece of equipment for an orthopaedic ward specializing in reconstructive hip the legs and at the same
surgery: this way the patient is I
Adjustable legs, to ensure correct seat height; hip flexion.
Firm, non-sagging seat with cloth (rather than vinyl) covering; Throughout this mOll
High raked back, capable of easy adjustment; by the use of the 'mom
Firm elongated arm rests to assist the patient in rising and lowering N.B. Both the thef3J
movements. patient immediately if b
A Tubigrip bandage is often used on the affected leg to prevent oedema change of body positiOl
when the patient is ambulant or sitting in a chair. The bandage should extend
from the webs of the toes to the tibial tubercle, and it is essential that the
correct size of Tubigrip is used. It is also important that the support should Using the Tilt Table
be removed at night. The use of a tilt table (4
process of moving the }:
is recommended.
Exercise Programme Fundamentally, the 1
Routine breathing, quadriceps, foot and ankle exercises are continued. Arm a stable tubular-steel b
and shoulder girdle exercises are progressed in strength. Generally the can be moved from
patient is allowed to take a more normal half lying position. stabilized effectively iJ
Assisted active flexion of the hip and knee of the affected limb is continued inclination can be me
as before, but the therapist encourages the patient to take a more active part. incorporated in the tal
HERAPY TOTAL HIP REPLACEMENT 227
liltS to assist respiratory and The return movement of active extension is also emphasized. Some surgeons
Ie! Preoperative Exercise Pro encourage assisted active abduction of the affected hip.
It is helpful if the patient spends short periods oftime resting in the supine
!lie patient in the morning and position. This not only assists in promoting a better posture but to some
bout 10 minutes each. degree relieves the buttocks of pressure.
'Getting Up': The Initial Approach

i DAY UNTIL SUTURES For the majority of patients getting up for the first time after surgery and
14th DAY taking weight on the 'new' hip is something of a psychological ordeal, and
they will need a considerable amount of reassurance from the therapist that
all is well. It is most important that they should be given a clear idea of what is
II.:g3rd to the exact time when
expected of them, and how they can be got on their feet safely without pain or
ling and walking. Some allow
discomfort.
others postpone standing and
Initially, the therapist will need a competent assistant to help in
patient to increase his range of
manreuvring the patient from the normal lying position to one in which he is
DDS prefer their patients to be
positioned at right angles to the long axis of the bed. During this manreuvre
ICight before they attempt to
it is essential for the affected limb to be fully supported by the therapist, and
for the hips to be maintained in an abducted position. It is also important to
liNe his hips well abducted.
prevent undue hip flexion.
experience considerable dif
During the main pivoting movement the patient will pull on the 'monkey'
,compensate for this the chair
chain to relieve pressure on the buttocks; the assistant will support the trunk
10 that the patient assumes an
from the far side of the bed.
To bring the patient to the standing position he is next eased to the edge of
lowing features is an essential
the bed. When the buttocks are resting on the bed edge the therapist lowers
r:ializing in reconstructive hip
the legs and at the same time the assistant helps to raise the patient's trunk. In
this way the patient is manreuvred into the standing position with minimal
Ii
hip flexion.
III vinyl) covering;
Throughout this movement the patient helps to minimize his body weight
;
by the use of the 'monkey' chain.
ian in rising and lowering
N.B. Both the therapist and his assistant must be prepared to assist the
patient immediately if he shows signs of fainting or distress due to the sudden
li:cted leg to prevent oedema
change of body position.
~. The bandage should extend
e, and it is essential that the
nant that the support should
Using the Tilt Table
The use of a tilt table (either manually or electrically operated) simplifies the
process of moving the patient from the horizontal to the vertical position, and
is recommended.
Fundamentally, the tilt table consists of a padded platform which pivots on
:xacises are continued. Arm a stable tubular-steel base equipped with small braked wheels. The platform
in strength. Generally the can be moved from the horizontal to the vertical position and can be
ing position. stabilized effectively in any position between zero and 90°. The angle of
be affected limb is continued inclination can be measured with the aid of the graduated angular scale
nt to take a more active part. incorporated in the table's design.
One end of the platform is equipped with a strong footrest; fold-away suitable heigl
with his feet!
handles are provided on either side of the platform at about mid-position.
Anchorage points are available for the use of restraining straps. evenly on botl
hip and knee t
Positioning the tilt table. The tilt table is used in conjuction with a variable
by hip exten
height bed. The platform is set in a horizontal position alongside the bed (and
carried out wi
securely braked) on the side of the patient's affected limb; the level of the
the patient's'l
platform and bed surface must be equal. The table is positioned as dose to the
A brief pel
bed edge as possible.
preliminary n
Before transferring the patient from the bed to the tilt table the platform
practised in I
surface should be covered with a sheet or cellular blanket. The covering not
allows him to
only adds to the patient's comfort but provides an easy means of adjusting his
The patien
position when he is resting on the platform. Pillows are wedged longitudinally
affected leg, ;
into the gap which exists between the edge of the platform and the bed.
pattern with
Trans/erring the patient. In transferring the patient from the bed to the tilt
walking traini
table the therapist needs the help of two assistants. The therapist and one
general condi
assistant kneel on the platform, facing the bed; the second assistant stands at
The patien
the far side of the bed.
The patient (who lies in a supine position on the bed with his legs when walkinl
Turning mO"ll
abducted) grasps the 'monkey' strap or chain, which is arranged on the
using a series
overhead fixation point as near to the tilt table as possible so that its angle of
Walking WI
indination assists in the transference process. The patient's legs are well
with two stid
supported by the therapist; his seat and trunk are supported by the assistant
of patients, Il
kneeling alongside the therapist.
been dischaQ
The patient is transferred by stages to the tilt table by the combined efforts
home circum
of the kneeling supporters; their actions are reinforced by the patient using
the 'monkey' strap or chain to take some of his body weight. The second
assistant (who initially helped in the transference while standing by the
4. WHEN S
bedside) now kneels on the bed to provide support and help in the final stage
AND PATI
of the process. During this stage it is necessary for the kneeling supporters to
move backwards into standing. The prognu:
Once securely positioned on the platform of the tilt table, with a pillow covered in '\11
under his head, the patient is eased carefully down the platform until the soles areas and sIt
of his feet make firm contact with the footrest; the hips remain in an abducted curbs will be
position with the toes pointing upwards. The hand grips are positioned so In associa
that when the patient grasps them his elbows will be slightly flexed. therapist she
Tilting the patient. A very careful and gradual adjustment of the platform physical abi:
from the horizontal to the vertical position is then carried out. The actual provided in
time spent in reaching the vertical position can be extended, as thought armchair of
necessary, by giving the patient short rest periods in various inclined Before bei
positions. In this way the patient's circulatory system has time to adjust to the how to cope
overall change of posture. postures wb
Adductio
When restir
Training in Standing and Walking pillow arraI
settees, whi
Initially the patient should stand with the help of a walking frame of a
'Y TOTAL HlP REPLACEMENT 229
tong footrest; fold-away suitable height. He should be trained to stand in a good balanced position
Il at about mid-position. with his feet slightly apart. Once he has sufficient confidence to take weight
iWng straps. evenly on both legs he is encouraged to carry out some simple exercises, e.g.
njuction with a variable hip and knee flexion of the affected leg through a comfortable range, followed
III alongside the bed (and by hip extension and abduction. Simple 'walking' movements are then
:d limb; the level of the carried out within the compass of the frame. This is very useful for boosting
positioned as close to the the patient's morale.
A brief period of walking with the assistance of the frame is used as a
Ie tilt table the platform preliminary to walking with elbow crutches. Walking with crutches is best
mutet. The covering not practised in a relatively small area; this gives the patient confidence and
sy means of adjusting his allows him to concentrate on his gait.
re wedged longitudinally The patient should be tauglit to move both crutches forwards with the
latform and the bed. affected leg, and to take small even steps. Later on, a reciprocal walking
l from the bed to the tilt pattern with the crutches is adopted. Care must be taken not to overdo
. The therapist and one walking training in the early stages, bearing in mind the patient's age and
I:IOOIld assistant stands at general condition.
The patient must be warned against making sudden changes of direction
the bed with his legs when walking; this can produce rotation stresses at the 'new' hip joint.
Iich is arranged on the Turning movements are best carried out by either describing a wide arc or
ISible so that its angle of using a series of small hitching movements of the pelvis (lateral tilting).
: patient's legs are well Walking with sticks. Some patients are able to progress rapidly to walking
pponed by the assistant with two sticks, and are encouraged by their surgeons to do so. The majority
of patients, however, use elbow crutches for a week or two after they have
by the combined efforts been discharged home. Much depends on the patient's general capability and
zd by the patient using home circumstances.
dy weight. The second
while standing by the
xl help in the final stage 4. WHEN SUTURES HAVE BEEN REMOVED (10th-14th DAY)
e kneeling supporters to AND PATIENT REMAINS IN HOSPITAL FOR A DAY OR SO
The programme of ambulation and exercise is progressed. The distance
tih table, with a pillow covered in walking will be gradually increased and should include uneven
~ platform until the soles areas and sloping surfaces. The technique of negotiating steps, stairs and
IS remain in an abducted curbs will be practised.
grips are positioned so In association with the occupational therapist and the social worker the
~ slightly flexed. therapist should check on the patient's home circumstances in relation to his
IIStment of the platform physical ability. It may be necessary for simple aids to daily living to be
carried out. The actual provided in the home, e.g. raised toilet seat, bath board, and suitable
~ extended, as thought armchair of correct seat height.
lis in various inclined Before being discharged from the ward the patient must be given advice on
bas time to adjust to the how to cope safely at home, with special reference to the avoidance of certain
postures which put stress on the 'new' hip.
Adduction of the hips should be avoided, particularly in sitting and lying.
When resting in bed on his sound side the patient should always have a firm
pillow arranged longitudinally between the legs. Sitting on low chairs and
a walking frame of a settees, which emphasizes hip flexion, must also be avoided.
The patient should be instructed to keep his overall body weight within Edmonson A. S. and
reasonable limite, so as to avoid overloading the prosthesis. He should also be VoL 2, 6th ed. St
advised to spend short periods of time (if feasible) in prone lying. Longton E. B. (1973)
59, 116-119.
Pool therapy. Provided the wound area is soundly healed, and the surgeon Longton E. B. (1982
approves, pool therapy can be used with considerable advantage to improve
the function of the lower limbs and body as a whole. It also provides a
pleasant variation of the exercise programme. Patients for pool therapy need
to be selected with considerable care.
Outpatient treatment. It is helpful if the patient attends the hospital
rehabilitation department two or three times a week for about 2-3 weeks after
he has been discharged from the ward. This enables the therapist to check on
his gait and general progress, and determine whether he needs one or two
sticks in place of crutches. At this stage of recovery many patients do not
require any form of walking aid.
OTHER ASPECTS OF TOTAL HIP REPLACEMENT

REVISION ARTHROPLASTY
In conditions where the original prosthesis has to be replaced due to
mechanical failure or infection, the initial period of immobilization is extended
considerably. It may consist of a 3-week period of complete bed rest. The
treatment regime previously described (pp. 225-230) is then modified
according to the surgeon's specific instructions.
ARTHROPLASTY FOLLOWING JOINT DISEASE IN

CHILDHOOD
When total hip replacement is used to restore movement in old joint
conditions which have resulted in obliteration of the joint surfaces (bony
ankylosis following acute suppurative arthritis or tuberculosis in childhood),
both the initial period of immobilization and the treatment regime previously
described are modified considerably, as indicated above.
After restoration of joint movement one of the most difficult problems
facing both surgeon and therapist is the weakness of the controlling hip
muscles. The original joint disease may have severely damaged, or obliterated,
some of the main muscle groups. Considerable instability of the joint may
occur.
REFERENCES
Adams J. C. (1980) Standard Orthopaedic Operations, 2nd ed. Edinburgh, Churchill
Livingstone.
Duthie R. B. and Ferguson A. B. (1973) Mercer's Orthopaedic Surgery, 7th ed.
Edinburgh, Churchill Livingstone.
•
.t.
TOTAL HIP REPLACE,\1ENT 231
ill body weight within Edmonson A, S, and Crenshaw A. H. (ed.) (1980) Campbell's Operative Orthopaedics,
ais. He should also be Vol. 2, 6th ed. St Louis, Mosby, pp. 2319-2324.
prone lying. Longton E, B. (1973) Orthopaedic surgery in arthritic lower-limb joints. Physiotherapy
taled, and the surgeon 59, 116-119.
Longton E. B. (1982) Personal communication.
advantage to improve
lie. It also provides a
for pool therapy need
anends the hospital

·about 2-3 weeks after
e therapist to check on
· he needs one or two
many patients do not
NT
\ be replaced due to
:milization is extended
mplete bed rest, The
0) is then modified
SEIN
'Yement in old joint

joint surfaces (bony
rulosis in childhood),
I:I1t regime previously
e.
1St difficult problems
r the controlling hip
'(
aaged, or obliterated,
lity of the joint may
· Edinburgh, Churchill
FIIdic Surgery, 7th ed.

~
22. Meniscectomy
management employee
regimes that are widdJ
therapy.
1. Non-weight-bearl
•
After the operation the
wool compression baD
rosis. The patient resa
quadriceps control aD
Meniscectomy is performed after an injury to a meniscus when the diagnosis pillow is sometimes USI
of splitting and displacement is beyond doubt, e.g. when the meniscus has and does not extend to
been displaced on more than one occasion. position of the joint.
After about the 3rd 1
short periods of sittinl
TYPES OF INCISION supported in a horizo
gutter trough. Wa1kinl
Excision of Medial Meniscus
elbow crutches.
Two main types of incision are used: the oblique incision and the transverse Non-weight-beariIq
incision. 10th or 12th postopc
The oblique incision, 3'8-5 cm in length, begins close to the inframedial discharged home or n
aspect of the patella and extends downwards and slightly backwards to a point After the stitches ha
about 1·2 cm below the joint line. The structures involved include skin, joint to control oedem
subcutaneous tissues, capsule, and synovial membrane of the knee joint. makes a gradual progl
The infrapatellar branch of the saphenous nerve may be divided. This
causes temporary anaesthesia of the small zone of skin on the anterior aspect
of the knee joint which is supplied by this nerve, and sometimes persistent Exercise Therapy
tenderness of the scar. Smillie (1978a) states: 'The presence of the patellar Exercises to maintaiI
plexus implies that sensory overlap is well developed in this region, and it is started on the 1st po!!
thus unusual for an area of diminished cutaneous sensation to remain quadriceps statically,
permanently.' the reflex inhibition (
The traverse incision, about 3·8 cm in length, is made over the anteromedial Transient pain loe;
aspect of the knee joint, parallel with the articular surface of the tibia, and starting quadriceps i
about 1·2 cm above it. This incision does not damage the infrapatellar nerve produced by the conI
and provides good exposure. If the incision is placed too low the scar may
become adherent to the surface of the tibia.
AFTER REMOVAL OF SlJ
Excision of Lateral Meniscus The main aims COM

The technique of approach is similar to that used for excision of the medial educating walking, =
meniscus. flexion. The reactiOi
observed very carefu
amount of activity a1l
the effusion has sum
ESSENTIALS OF TREATMENT The length of tinH
Orthopaedic surgeons differ with regard to the type of immobilization and depends to a consideJ
232
MENISCECTOMY 233
management employed in the postoperative phase of treatment. Three

regimes that are widely used are outlined here with the appropriate exercise
therapy.
1. Non-weight-bearing Regime
After the operation the knee is immobilized by a firm flannel or domette-and
wool compression bandage; this helps to prevent postoperative haemarth
rosis. The patient rests in bed for about two to three days until he has good
quadriceps control and can perform straight leg raising satisfactorily. A
IiCUS when the diagnosis
pillow is sometimes used to support the limb; it is placed under the lower leg
wben the meniscus has and does not extend to the knee joint. Its purpose is to maintain the straight
position of the joint.
After about the 3rd postoperative day the patient is allowed out of bed for
short periods of sitting and walking. When sitting the affected limb must be
supported in a horizontal position by a stool and pillows or foam rubber
gutter trough. Walking is restricted to a non-weight bearing technique with
ision and the transverse elbow crutches.
Non-weight-bearing is continued until the stitches are removed on the
lose to the inframedial 10th or 12th postoperative day. During this phase the patient may be
dy backwards to a point discharged home or remain in the ward.
involved include skin, After the stitches have been removed a crepe bandage is applied to the knee
lie of the knee joint.
joint to control oedema and provide some degree of support. The patient then
may be divided. This makes a gradual progression from partial to full weight-bearing.
lon the anterior aspect
d sometimes persistent
Exercise Therapy
m:sence of the patellar
in this region, and it is Exercises to maintain the strength of the quadriceps femoris muscle are
s sensation to remain started on the 1st postoperative day. Generally the patient can contract the
quadriceps statically, although in some cases it may be difficult to overcome
c over the anteromedial the reflex inhibition of the muscle.
IIl'face of the tibia, and Transient pain localized to the site of the operation is to be expected on
the infrapatellar nerve starting quadriceps exercises. It results from the drag on the incision
I too low the scar may produced by the contracting muscle.
AFTER REMOVAL OF SUTURES
The main aims consist of redeveloping the quadriceps femoris muscle, re
excision of the medial educating walking, and (if flexion exercises are allowed) restoring knee
flexion. The reaction of the knee to weight-bearing and exercise must be
observed very carefully; any marked increase of effusion indicates that the
amount of activity allowed must be decreased and knee flexion omitted until
the effusion has subsided.
The length of time required to achieve full recovery after a meniscectomy
If immobilization and depends to a considerable extent on the patient's occupation. 'Experience has
shown that whereas a clerk can return to his desk in the 4th week, a degree of adhesive orthopaecl
physical fitness which will withstand the rigours of athletic activities is rarely when the patient i:
possible in less than twelve weeks of organized rehabilitation. This applies in impinging on the
equal degree to those engaged in the manual occupations of heavy industry' surgeons prefer to
(Smillie, 1978b). lizer' .* The splint j
the upper third of
The patient reS
ALLOWING KNEE FLEXION thoroughly and fi
Opinion varies among surgeons as to when knee flexion is to be allowed. raising-to be prac
Some consider that knee flexion exercises should not be used until the later periods of standin!
phases of recovery, because in the earlier stages the movements may irritate crutches) on the 3:
the joint and produce an effusion. They stress that knee flexion usually When the patiell
returns by itself without any difficulty. Surgeons who hold this opinion will, satisfactory he is a
in the absence of marked effusion, generally allow the patient to flex the knee safely.) The plastc
within a pain-free range of movement once or twice daily about two weeks 10th and 12th pos
after the operation. patients' depart:m4
Other surgeons allow gentle knee flexion exercises between the 10th and Acrepeban~
14th postoperative days, provided they are kept within a painless range of degree of support.
movement and there is no significant joint effusion. continued for a rei
The transitiOn fu
must be gradual ..
2. Early Weight-bearing Regime (after 5 days) whether the joint
Immediately after the operation the knee is immobilized in extension by a
firm flannel or domette-and-wool compression bandage; this helps to prevent
postoperative haemarthrosis. A gutter-type back splint is sometimes used in Exercise Therapy
addition. As described pw
The patient rests in bed for approximately 5 days with the affected limb
elevated (foam rubber trough resting either on pillows or on an adjustable
elevation frame). After five days the back splint is discarded and, provided MENISCECTO
that straight leg raising can be performed satisfactorily, the patient is allowed
out of bed for short periods of walking practice (partial weight-bearing with Severe pain and :
elbow crutches). complications wi
The stitches are removed between the 10th and 12th postoperative days, plications indud
and the patient is discharged from the ward. A crepe bandage is applied to the haemarthrosis.
knee joint to control oedema and provide some degree of support. Full weight Of trauma at 4
bearing is allowed. operation is peru
and capsule are
Exercise Therapy membrane expo
As described previously (p. 233). persistent synovi
inadequate corol
3. Early Weight-bearing Regime (with Plaster Cylinder)

* The 'knee iron
metal struts, one e
After the operation a well-padded plaster cylinder is applied to the affected
is constructed frO!
limb; it extends from the upper third of the thigh to just above the malleoli. allows a degree (J
During the application of the cylinder the lower edge is well padded with division of Charie
MENISCECTOMY 235
the 4th week, a degree of adhesive orthopaedic foam. This helps to maintain the position of the cylinder
llh1etic activities is rarely when the patient is in the erect position and prevents the lower edge from
»Iitation. This applies in impinging on the dorsum of the foot. (Instead of a plaster cylinder some
mons of heavy industry' surgeons prefer to use a Raymed wrap-around back splint or 'knee immobi
lizer'. * The splint is applied over the compression bandage and extends from
/ the upper third of the thigh to the ankle.
The patient rests in bed for about 2 days to allow the plaster to dry
thoroughly and for quadriceps exercises-and, if possible, straight leg
llexion is to be allowed. raising-to be practised. In general, the patient is allowed out of bed for short
It be used until the later periods of standing and walking practice (partial weight-bearing with elbow
movements may irritate crutches) on the 3rd postoperative day.
IBt knee flexion usually When the patient's walking and control of the affected limb are considered
10 hold this opinion will, satisfactory he is allowed home. (It is important that he can negotiate stairs
Ie patient to flex the knee safely.) The plaster cylinder and stitches are usually removed between the
I: daily about two weeks 10th and 12th postoperative days, the patient returning to the hospital out
patients' department for these procedures.
:s between the 10th and A crepe bandage is applied to the knee to control oedema and provide some
thin a painless range of degree of support. In general, partial weight-bearing with elbow crutches is
continued for a few days until the patient has regained full control of the knee.
The transition from partial to full weight-bearing without elbow crutches
must be gradual. Much will depend on the individual's reaction to pain and
t whether the joint is free of effusion.
iIized in extension by a
!lei this helps to prevent
int is sometimes used in Exercise Therapy
As described previously (p. 233).
5 with the affected limb
IIWS or on an adjustable
liscarded and, provided
Iy. the patient is allowed MENISCECTOMY WITH COMPLICATIONS
:iaI weight-bearing with Severe pain and reactionary effusion of the knee are associated with certain
complications which may arise during or after the operation. Such com
2th postoperative days, plications include: (1) Trauma during the operation, and (2) Postoperative
I8J1dage is applied to the haemarthrosis.
ofsupport. Full weight- Of trauma at operation Smillie (I 978c) states: ' . . . Cases in which the
operation is performed only with difficulty and in which the medial ligament
and capsule are subjected to prolonged stretching . . . and the synovial
membrane exposed to prolonged pressure . . . frequently suffer from
persistent synovitis ... .' Postoperative haemarthrosis may occur as a result of
inadequate compression of the knee by the bandage or padding of the plaster
Cylinder) * The 'knee immobilizer' consists of a tapered back splint incorporating 4 removable
metal struts, one each on the lateral and medial aspects and 2 on the posterior aspect. It
applied to the affected
is constructed from fabric-backed felt with a Velcro 'fold-back' closure system which
just above the malleoli. allows a degree of adjustability. The 'immobilizer' is obtainable from Raymed (a
Je is well padded with
t division of Charles F. Thackray Ltd.), of Viaduct Road, Leeds, LS42BR.
t
cylinder. The condition gives rise to adhesions, residual synovial thickenings, Primary Exercil
and persistent effusion. Quadriceps ExerciJ
Patients with a marked reaction of the knee will experience increased pain 1. Half lying; S1
when they attempt to exercise the quadriceps femoris muscle. The authors 2. Half lying (af
are of the opinion that patients should not be bullied into exercising the 60"); 'holdini
muscle (as is often done), but allowed to rest the limb until the main reaction 3. As above; sm
of the joint has subsided and a static contraction of the quadriceps can be 4. Half crook s
obtained without difficulty. (This does not mean, however, that the patient is (affected) Kt
allowed to forget his role in attempting to activate the quadriceps muscle.) carrying fon
Straight leg raising will usually be possible about a day later. 5. Half crook 5
(affected) KI
backwards. I
EXERCISE THERA:..:...P-"-V_ _ _ _ _ _ __
Secondary EXeI
The lists of exercises given here are intended to be a guide to the
postoperative treatment of meniscectomy when anyone of the three treat Lower Leg Exera
ment regimes described (pp. 233-235) are used. 1. Half lying; 1
2. Half lying; (c
turning inWl!
3. Half lying; (
4. Half lying;
PROGRAMME A: FOR USE WHEN KNEE IS IMMOBILIZED outwards.
BY COMPRESSION BANDAGE, WITH OR WITIIOUT
A BACK SPLINT (Regimes 1 and 2, pp. 233-234.)
Hip Exercises
TABLE 1
5. Lying; sing!
From 1st postoperative day until straight leg raising can be performed
6. Lying; sing
without assistance: usually by 2nd or 3rd postoperative day.
7. Lying; sing
Remedial Aims TABLE 2

PRIMARY
From 2nd or 3r
To maintain the quadriceps femoris muscle.
removed).
The patient p
bearing reg'ime at
SECONDARY
(non-weight-~
1. To maintain the mobility of the toes, ankle, midtarsal and subtalar joints.
Patients on tb
2. To maintain the muscles of the lower leg and hip joint.
operation. Usua
standing al)d Wi
over the quadric
Exercise Period
10 minutes, twice daily.
N.B. The patient must be instructed to contract the quadriceps femoris Remedial Aims
muscle correctly at least six times every half hour-'Give it six of the best ...'. As in previous:
'(
MENISCECTOMY 237
131 synovial thickenings, Primary Exercises

Quadriceps Exercises
perience increased pain
is muscle. The authors 1. Half lying; single Quadriceps contractions.
lied into exercising the 2. Half lying (affected limb well supported by therapist: hip flexed to about
60"); 'holding' the position for a brief period.
, unti!-the main reaction
, the quadriceps can be 3. As above; single Leg lowering with assistance.
rever, that the patient is 4. Half crook side-lying (firm pillows supporting affected limb); single
be quadriceps muscle.) (affected) Knee bracing, followed by slight Leg raising sideways and
:lay later. carrying forwards. Initially, therapist provides support.
5. Half crook side-lying (firm pillows supporting affected limb); single
(affected) Knee bracing, followed by slight Leg raising and carrying
backwards. Initially, therapist provides support.
D be a guide to the Secondary Exercises

one of the three treat- Lower Leg Exercises
1. Half lying; Toe bending and stretching: both feet.
2. Halflying; (a) alternate Ankle bending and stretching, (b) alternate Foot
3. Half lying; (a) single Ankle bending, (b) single Ankle stretching.
4. Half lying; (a) single Foot turning inwards, (b) single Foot turning
IMMOBILIZED outwards.
rIlIOUT
•
Hip Exercises
iog can be performed 5. Lying; single Gluteal contractions.
ve day. 6. Lying; single and double Gluteal contractions.
7. Lying; single Leg downpressing.
TABLE 2
From 2nd or 3rd postoperative day until the 10th day (when stitches are
removed).
The patient performs the exercises on the bed. Patients on the non-weight
bearing regime are allowed out of bed for short periods of sitting and walking
:sal and subtalar joints. (non-weight-bearing) from about the 3rd postoperative day.
p joint. Patients on the weight-bearing regime remain in bed for about 5 days after
operation. Usually they are allowed out of bed on the 5th day for sitting,
standing and walking (partial weight-bearing), provided they have control
over the quadriceps muscle and can perform straight leg raising satisfactorily.
Ie quadriceps femoris Remedial Aims

e it six of the best. . .'. As in previous section.
Exercise Period N.B. Before the p

15-20 minutes, twice daily. inspect the state of
N.B. The patient must be instructed to contract the quadriceps femoris intact; fine cracks c
muscle correctly at least six times every half hour-' Give it six of the best .. .'.
Remedial Aims
Primary Exercises PRIMARY
Quadriceps Exercises To maintain the qu
1. Half lying; single and double Quadriceps contractions.
2. Half lying; combined (single) Quadriceps and Gluteal contractions. SECONDARY
3. Lying; single Leg downpressing. 1. To maintain t

4. Lying; single Leg raising. When the patient can perform straight leg joints.
raising without any difficulty weight resistance is added, with the 2. To maintain d
surgeon's permission. Usually a weight of 0.5 kg is used at first. It is
progressed gradually. The exercise must not be allowed to cause pain or
Exercise Period
to overfatigue the quadriceps muscle. Throughout the leg lifting and
lowering the knee must be kept firmly braced. 10 minutes, twice c:l
N.B. The patien
muscle correctly at ,
Secondary Exercises
Lower Leg Exercises
1. Halflying; (a) alternate Ankle bending and stretching, (b) alternate Foot Primary ExerciSl
turning inwards and outwards. Quadriceps Exercis4
2. Half lying; single or double Foot circling. 1. Half lying; su
3. Half lying; (a) single and double Ankle bending, (b) single and double 2. Half lying; sU
Ankle stretching, (c) single and double Foot turning inwards. outwards.
3. Lying; single
4. Half lying; su
Hip Exercises and adductiOi
4. Half crook side-lying; single (affected) slight Leg raising sideways, and
carrying forwards and backwards to 6 counts. (See Fig. 189, p. 159.)
5. Half crook side-lying; single (affected) Leg raising sideways. Secondary E:xe~
6. Forehead rest prone lying; single Knee bracing, followed by slight Leg
Lower Leg Exercis.
raising backwards.
1. Half lying; T
2. Halflying; (a
turning inwa
PROGRAMME B: FOR USE WHEN KNEE IS IMMOBILIZED BY 3. Half lying; (!
PLASTER CYLINDER OR RAYMED 'KNEE IMMOBILIZER' 4. Half lying; (
TABLE OF EXERCISES outward),<
For first 2-3 postoperative days.
The patient rests in bed for about 2 days to allow the plaster to dry out.
Hip Exercises
A plastic sheet is usually in position under the affected limb to protect the
bedclothes. A bed cradle allows air circulation and prevents bedclothes from 5. Lying; sing}.
coming into contact with the damp plaster cast. 6. Lying; singl~
EKAPY MENISCECTOMY 239
N.B. Before the patient starts his exercise programme the therapist should
inspect the state of the entire plaster cylinder to ascertain if the plaster is
ttact the quadriceps femoris intact; fine cracks can easily go undetected.
'-'Give it six of the best .. :.
Remedial Aims
/
PRIMARY
To maintain the quadriceps femoris muscle.
oontractions.
IOd Gluteal contractions.

SECONDARY
1. To maintain the mobility of the toes, ankle, midtarsal and subtalar
:nl can perform straight leg
joints.
~ce is added, with the
2. To maintain the muscles of the lower leg and hip joint.
, 0.5 kg is used at first. It is
It be allowed to cause pain or
mughout the leg lifting and

Exercise Period
a:d. 10 minutes, twice daily.
N.B. The patient must be instructed to contract the quadriceps femoris
muscle correctly at least six times every half hour-'Give it six of the best ... '.
lllretcbing, (b) alternate Foot Primary Exercises

1. Half lying; single Quadriceps contractions.
Idiug, (b) single and double
2. Half lying; single Knee bracing, followed by Hip turning inwards and
IIturning inwards.
outwards.
3. Lying; single Leg lifting (assistance from therapist) through 10-15 c •
4. Half lying; single Knee bracing, followed by small range Hip abduction
and adduction.
II: Leg raising sideways, and
lIS.(See Fig. 189, p. 159.)
raising sideways.
:ing, followed by slight Leg Secondary Exercises
Lower Leg Exercises
1. Half lying; Toe bending and stretching; both feet.
2. Half lying; (a) alternate Ankle bending and stretching, (b) alternate Foot
t IS IMMOBILIZED BY
3. Half lying; (a) single Ankle bending, (b) single Ankle stretching.
IE IMMOBll.IZER'
4. Half lying; (a) single Foot turning inwards, (b) single Foot turning
outwards.
[low the plaster to dry out.

ft'ected limb to protect the Hip Exercises
I prevents bedclothes from 5. Lying; single Gluteal contractions.
6. Lying; single Leg downpressing.
Progression of Exercise Programme Primary Exercises

On the 2nd or 3rd postoperative day the patient is allowed out of bed and is Quadriceps Exercises
given instruction in standing and walking techniques. Elbow crutches are 1. Long sitting (rru
used for walking practice, and initially the patient is partial weight-bearing. double QuadriCCl
As a preliminary to walking training the patient practises hip strengthening 2. Halflying orlyin
exercises in the standing position: he can stabilize himself by holding on to 3. Half lying or lyjI
the back of a suitable chair. Later he can carry out the movements while extension of kneI
stabilized by the crutches. Hip updrawing movements (with knee firmly 4. High sitting (plil
braced) are of particular value. supported on sto
The patient is discharged home about the 4th postoperative day. It is most
important that before he leaves the ward he has receIved adequate training in
stair climbing with the help of crutches. Knee Flexion Exercise
N.B. The patient must be aware of the importance of practising his 5. Lying; single K:
exercises at home in the correct manner. surface."
6. Forehead rest pi
Walking
PROGRAMME C: FOR USE AFTER 10th OR 12th
POSTOPERATIVE DAY. THE EXERCISE TABLES HAVE BEEN 7. Re-education in
ARRANGED TO SUIT THE REQUIREMENTS OF ANY OF THE N.B. When the WOJ
THREE TREATMENT REGIMES DESCRIBED (pp. 233-235) exercises in the pool
suggested.
TABLE 3
From 10th or 12th postoperative day, when stitches are removed, for about 2
weeks. Full weight-bearing is allowed. (If a non-weight-bearing regime has TABLE 4
been followed previously, progression from partial to full weight-bearing For use about a moo
must be gradual.) A crepe bandage is worn on the knee to control oedema and could be included as
to provide some support.
Remedial Aims
Remedial Aims PRIMARY
PRIMARY I. To redevelop t
1. To redevelop the quadriceps femoris muscle. 2. To restore the
2. To restore the mobility of the knee joint.
3. To re-educate walking. SECONDARY
1. To redevelop t
SECONDARY 2. To develop nel
I. To redevelop the muscles of the hip joint.
2. To re-educate neuromuscular co-ordination.
Exercise Period..
30 minutes, once d
extension exercise a
Exercise Period
30 minutes, once or twice daily. Additional time is required for the straight * Not to be used in t
leg raising exercise against weight resistance. not permit knee ftexk
IiRAPY MENISCECTOMY 241
Primary Exercises
t is allowed out of bed and is Quadriceps Exercises
miques. Elbow crutches are
1. Long sitting (trunk inclined backwards with hand suppon); single and
:nt is partial weight-bearing.

double Quadriceps contractions.
II: practises hip strengthening

2. Halflying or lying; single straight Leg raising against weight resistance.
ize hiJnself by holding on to
3. Half lying or lying (wedge or pillow under affected knee); shon range
':Y out the movements while

extension of knee, with or without weight resistance.*
lWements (with knee firmly

4. High sitting (plinth: knees flexed comfortably to about 30°, with heels
supponed on stool); single Knee stretching.*
postoperative day. It is most

n:a:Jved adequate training in
Knee Flexion Exercises
DpOnance of practising his
5. Lying; single Knee raising with heel kept in contact with supporting
surface.*
6. Forehead rest prone lying; alternate Knee bending and stretching.*
OR 12th Walking
I! TABLES HAVE BEEN 7. Re-education in walking.
e:NTS OF ANY OF THE N.B. When the wound is fully healed and no effusion of the joint is present
tIDED (pp. 233-235) exercises in the pool may be used as an adjunct to the specific exercises
suggested.
IK:s are removed, for about 2
I-weight-bearing regime has TABLE 4
niaI to full weight-bearing
For use about a month after the operation. Some of the exercises suggested
: knee to control oedema and
could be included as part of a Specific Exercise Circuit (p. 249).
Remedial Aims
PRIMARY
1. To redevelop the quadriceps femoris muscle.
:Ie. 2. To restore the mobility of the knee joint.
SECONDARY
1. To redevelop the extensor muscles of the hip joint.
2. To develop neuromuscular co-ordination.
L
Exercise Period I:
30 minutes, once daily. Additional time is required for the resisted knee
extension exercise and graduated pool therapy.
is required for the straight * Not to be used in the presence of marked effusion of the knee, or if the surgeon does
not permit knee flexion exercises (p. 234).
Primary Exercises • Exercise Period

Quadriceps Exercises As in previous section.
1 Half wing half low yard grasp standing (wall bars); Heel raising and
Knee bending.
Primary Exercises
2. Low reach grasp stride standing (wall bars); Heel raising and single
Knee bending. (See Fig. 196, p. 165.)
1. Wing standing; f
3. Low reach grasp instep support standing (wall bars and stool); single
2. Wing stride StalK

Heel raising and Knee bending.
3. Wing instep SUp!

4. Skipping: (a) Skip jumps with a rebound, (b) High skip jumps.
bending. (See F;"
5. High sitting (bench); single (affected) Knee stretching against weight or
4. Skipping; Hoppa
weight-and-pulley resistance.
Fig. 8, p. 12.)
5. Bend standing; I
Knee Flexion Exercises opposite Arm sm
(with opposite Al
6. Bend grasp high standing (wall bars); Knee bending and stretching with
6. Hopping with a !
Hand travelling down and up the bars. (See Fig. 206, p. 169.)
7. Wing standing; I
7. Lying; cycling.
sideways.
8. High sitting (ben
weight-and-pulk
Secondary Exercises
Balance Exercises
1. Balance half standing (balance bench rib); balance walking fowards and
Knee Flexion Exercise
backwards.
9. Forearm reach I
2. Balance walking with Knee and Arm raising of the same side, and
sitting. (See Fig.
opposite Arm raising backwards.
3. Toe balance walking along a straight line to 3 counts, followed by Knee

Secondary Exercls4
full bending and stretching with the knees forwards to 6 counts.
Balance Exercises
1. Balance half sa
Hip Exercises with Knee and j
4. Primary Exercises 1-4. backwards.
2. Balance half sa
wards to 3 coun
knees forward tl
TABLE 5*
A final exercise programme suitable for use when a high degree of physical
fitness is required.
Hip Exercises
3. Primary Exercil
Remedial Aims
/
As in previous section. REFERENCES
Smillie I. S. (19788)
* Progressive circuit training with weight resistance forms a very useful alternative to Livingstone, p. lSI.
the exercise table. So also does a pre-work circuit designed to simulate normal working Smillie I. S. (197Sb)n
stresses (see p. 251). Smillie L S. (197Sc) Il
! THERAPy MENISCECTOMY 243
Exercise Period
As in previous section.
• (wall bars); Heel raising and
Primary Exercises
II bars); Heel raising and single
/
ling (wall bars and stool); single 1. Wing standing; Heel raising and Knee bending.
2. Wing stride standing; Heel raising and single Knee bending.
1Ild, (b) High skip jumps. 3. Wing instep support standing (stool); single Heel raising and Knee
~ stretching against weight or bending. (See Fig. 188, p. 157.)
4. Skipping: Hopping with a rebound and alternate Knee stretching. (See
Fig. 8, p. 12.)
5. Bend standing; hopping with alternate Toe placing forwards (and
opposite Arm stretching forwards), and alternate Toe placing sideways
:nee bending and stretching with (with opposite Arm stretching sideways). (See Fig. 7, p. 12.)
· (See Fig. 206, p. 169.) 6. Hopping with a rebound and opposite Knee and Arm raising.
7. Wing standing; hopping with a rebound and alternate Leg swinging
sideways.
8. High sitting (bench); single (affected) Knee stretching against weight or
weight-and-pulley resistance.
b); balance walking fowards and Knee Flexion Exercise

9. Forearm reach grasp kneeling (wall bars); attempting to assume kneel
· raising of the same side, and sitting. (See Fig. 208, p. 170.)
Ie to 3 counts, followed by Knee

leeS forwards to 6 counts. Secondary Exercises
Balance Exercises
1. Balance half standing (balance bench rib); balance walking forwards
with Knee and Arm raising of the same side and opposite Arm raising
backwards.
2. Balance half standing (balance bench rib); Toe balance walking for
wards to 3 counts, followed by Knee full bending and stretching with
knees forward to 6 counts.
when a high degree of physical
Hip Exercises
3. Primary Exercises 1-7; Secondary Exercise 2.
REFERENCES
Smillie 1. S. (1978a) Injuries of the Knee Joint, 5th ed. Edinburgh, Churchill
ICe forms a very useful alternative to Livingstone, p. 18l.
csigned to simulate normal working Smillie 1. S. (l978b) Ibid. p. 173.
Smillie L S. (l978c) Ibid. p. 179.
PART 5
GENERAL EXERCISE
THERAPY
In the broad sense general exercise therapy encompasses a wide spectrum of

physical activity, ranging from informal movement and recreational pursuits
to more organized and purposeful forms of exercise.
This section of the book deals with two widely differing aspects of general
exercise in use today: progressive circuit training (representing an intensive
and highly organized form of movement) and exercises to music, which
represent a more informal approach to general e.:'ercise.
245
23. Progressive circuit training
Circuit training was originally evolved by Morgan and Adamson in the early
19508, and was designed as a system of exercise training for maintaining and
increasing physical fitness. It is capable of being adapted for all ability levels
and aims at progressively developing endurance, strength, function and
cardio-respiratory efficiency.
Fundamentally, circuit training consists of a number of performers
carrying out a series of pre-determined exercises, with or without apparatus,
which are arranged in a definite sequence. The floor areas in which the
activities are performed are known as 'exercise' or 'task stations'. The stations
are visited in tum by the performers and the movements indicated for each
individual are performed against a prescribed time allocation.
Three circuit laps are completed with increasing rapidity, each successive
lap taking less time than the previous one. During the final circuit lap the
performers are working at maximum capacity. Several variations of this
theme are possible (p. 254).
It should be noted that a circuit may be the main core of a specific exercise
session, or the culmination of a general fitness programme.
TYPES OF CIRCUIT
There are four distinct types of circuit: (1) General Circuit (Fig. 222a), which
aims at providing an overall fitness programme (p. 248); (2) Specific Circuit
(Fig. 222b), which is used to exercise a particular body region with special
reference to strengthening and mobilizing (p. 249); (3) Function Circuit (Fig.
222c), which utilizes the types of movement encountered in ordinary daily
living as distinct from gymnastic exercises (p. 250); and (4) Pre-work Circuit
(Fig. 222d), which provides a series of realistic work situations with emphasis
on manual skills (p. 251).
PRACTICAL APPLICATION
In a full circuit there are normally 7 or 8 exercise stations. The performer
works at each exercise task for a set period of time, usually 1 minute. He
247
General Fitness Circuits for 7 Exercises

These indicate how a theme may be modified to promote AIMS:To redE
interest, and progress physical output. mobility of I
CIRCUIT 1 CIRCUIT 2 CIRCUIT 3 DESCRIPn
NO APPARATUS EMPHASIS ON
WORKING IN PAIRS RESISTANCE
1rUDE SITTING (BAI.
CONTINUOUS s~UTTLE RUNS 1 RUN UP JDOWN INCLINED BENCH: BUTTOCJ<:
~:~~I~~~"~
i=OLDED TOWEL)'
FORWARD AND
BACKWARD fIDqt
BODY BY Lf(;
~
ECK SUPPORT ~K EXTENSiONS
SPANNING WITH WElG~HT
DIs('
CLA'OPED •
i
. ." TO
CHEST
c.. ........ ~"

~----------------~--- 31 STAt-':DiNG(HAND
---, "":t..::r
FIXED CROOK LYING FIXE'D CROOK LYING GRASPING ONE 1
SIT UPS SIT UPS WITH WEIGHT
Ql= INCLINED pru
BENCH)- SQUAT
/" \ V'lITH FEET CU.
~vn==!. ~ ON FLOOR
1
j
41
41 ~ SQUATTING(HEELS MISED
I
SQUAT
STANDING :I, HALF
WITH SQUATS ON BLOCK)-DUMB-BELLS IN INCLINED PRONE
EACH HAND FALLlNG~ 'WALl<
,~ ~'i".,. ~~' LEGS FORWM.~
51 PRONE LYING-ROCKING UP PRONE LYING ( PARTNER

~t
CLASPING PLINTH WITH 5
AND BACKWARD
AND DOWN USING ARMS FIXING SHOULDERS) TRUNK SUP>DRTED UNDER
~--+------l~
LEG LIFTING BACKWARDS
ROPE TO STAt-.iJ
~<?'
UPRIGHT: cONTlN
~ FLOW
61~~L~~ ~~~~g ~ ~II~~

WITH
6, STEP UP3{ srcx
BAL.ANCE BEN....'1-l
"""""7 I PRRTNER
A5SISTING
WITH
DUMB-BELLS WITH DJM~
: t ON AND
OFF BENCH
flFi=ECTED LEG
LEADING
71 PRESS UPS
SUPP:;-10RTED
PRESS uPS
BENCfl PRESSING
WITH BARIlELL
7
ALTERNATE SEf
~ I ~
AND LEG RA1311
TO ROLL ,MEDIC
BALL ALONG U
Fig. 222a. General Fitness Circuit.

PROGRESSIVE CIRCUIT TRAINING 249
Or 7 Exercises Specific LeSJ Circuit

, modified to promote AIMS:To redevelop quadriceps femoris muscle, to restore
IicaI output. mobility of hip and knee, and to improve general fitness.
/ CIRCUIT 3 DES.CRIPTION TASK SCORING
EMPHASISQN
RESISTANCE
IS RUN UP JDOWN INCLINED

! BENCHES
~
SECURED TO TOTAL EACh LENGTH
./ WALL BARS COMPLETED
'6 ;
: 11'
.... '
r: BI'O<. E)(TENS10fl.'S
MU~"; J
CU\';PED •
COUNT EACH
TO SIT UP
OIEST
, r--:
3 STANDiNG { HANDS
, FIXED CROOK LYlNG
SIT uPS WITH WEIGHT
O~Zj
GRASPING ONE END
OF INCLINED PJlLANCE
BENCH)- SQUATT~ING
VV'TH FEET FLAT
i TOTAh Ep,cH
OOUAT
ON ROaR
SQUATTING(HEEL<3 AAISED 4
C»I Bi..OCK)-DUMB-BELLS IN INCLINED PRONE:
El>CH HAND FALUNG- 'wALkiNG' TOTAL E~CH
~t
LEGS LEG MOVEMENT
AND nM'u,,'M'"
UASPlNG PLINTH WITH

'TRUNK '3UPI'ORTED
5 DUCK~NG UNDER LOW
LEG LIFTING BACKWARDS
ROPE TO STAND COUNT EACI1 DOCK
CONTINUOUS UNDEP. ROPE
ASTRIDE
l\.M!:ING
WlTf\
IllJI.4B-BELiS TOTAL EACH
~AND i STEP UP
OFF BCNC;'!
----t--~ . .-
BEIOCH PRES\';ING
WITH BARBELL 7
ALiERNA,"[ SEAT
J l AND
TO
RA!SING
MEDICINE
a c
cruNT EPCH
SUCCESSFUL ROLL
OF BALL
b~
\ S' BALL ALONG LEGS
n:uit. Fig. 222b. Specific Leg Circuit.

Function Circuit
The circuit is designed to reinforce the functional N.B. It is imI
skills that may be required at home. The activities
are performed at a steady pace. DESCRIPTK
DESCRIPTION TASK SCORING
1~HOYELLING
1. SITTiNG AND RISING
MOVING FRO'll
TO STOOL
t - fF11
u2 u u3 u
rr===i1
COUNT NUMBER OF
STOOL CHANGES
If~1DAREA·B'~
21 PV3HING lOll, ~
FUi
MEDiCINE BALLS IJ,j
AREA A, THEN BAI
!
I [,
2ICRAvvUr\G ON ALL ..m----""----_.-.+-___m_ __

TROLLEY BETWEI
FOUR? OVER TWO POINTS-ttl
OBSTACLE TO STAND ../ : COUNT EACH l.AP TURNiNG
AT WALL BARS .-------.e ~ :.
iF i!;./1,
AND RETURN ,-J""':':::" \...~.b.!. ~
31 STACKiNG MIUC(]
31 ROLU.i'JG
PRONE TO F.F;OM
SUPINE
~ . .. I ('HANGt:SPOSITION
COUNT '
FILLED WITH BlOC
TO CHEST I-jEIGI
FROM 'A' TO '8'
h···· . ,..
LYING , !~. , ~ I THEN 'B' TO 'A'
4~
4rpUSHlNG LOADED CLIMBING UP WE
WJ.lELCrlA.lR OR . ,OTAl OBSTACLES SECURED u:DDE
TROLLEY OVER NEGOTIATED HiT OP AND RETURN
MEASURED DISTANCE ~ DISTANCE TRAVEuED
OR AROUND OBSTACLE, . _ .l J. •
5rs;IR CliMBIN~-;;-t- . "". I
51 LIFTING
LONG LOG
PIT W
~
SEAT WITH BACK TO' I. ~ ! COUNT EACH SINGLE
FLOOR TO 5fPtJLJ
3URMOUNTI/IIG '
STAIRS-AND RETURN ! ' STAIR NEGOTIATED
OBSTACLES-AN> III
1t, SAME POSITION I .
6[PICKING UP BE~---
I
61 ROLLING UNDER 1
HURDLE, CRAWUI
UNDER 2ND, STEP
:~:i~;::D if. TOTAL BEAN BAGS OVER 3M, AND

.},) BUCKET
I CLIMBING ntRO
m"hH_ _ __
71 WALKiNG W!H\ CARE I · · · - - - ..... -----+-A.'J-f)-D-l-A-p.::-O-R--.-..r
71 CARRY LARGE
REINFORCED m;
LINEN FROM '1-\' 1
CNER RUBBER MATS -:;, i c,r TI1 ,t;~~ 'B', LOWER 1'0 Fl
OR UNEVEN SOFT
SURFACES a
-
b
Ii ,r.rl
T';;AV·~"\~,;=n
Cc..~~w
AND DRAG BPC~
FflON'I 'f,' TO 'A'
/J ~I~~~:'EROR
815TEPPi~;G--UP AND
n
81 ROLLI~~ OIL-;
--;J
~ c3TEPS
SINGlf
BARREL,FILLED II'
SAND, UP pUGH'
INCLlNE-THEN !)
AND RETURN
Fig, 222c. Function Circuit.

tAPY PROGRESSIVE CIRCUIT TRAINING 251
Iit Pre-worl< Circuit

:e the functional N.B. It is important to indicate and mark clearly weight
fie. The activities of articles to be lifted.
Iv pace. DESCRIPTION TASK SCORE
SCORING
1 SHOVELLING RUBBER
I!COUNT NUMBER OF
MEDICINE BALLS INTO
AREA A, THEN BACK
COUNT BALLS
SHOVELLED
! STOOL Cf1ANGES INTO AREA '5' -QUICK LY
i
I
2 PLBHING LOW, LOADED b
I
; TROLLEY BETWEEN TOTAL LAPS
, COUNT EACH LAP
TWO POINTS AND
, TURNING
,,
/ : COUNT POSITION
! CHANGES
,
3 STACKING MILK CRATES
FILLED WITf1 BRICKS
TO CHEST HEIGHT
FROM 'A' TO 'B'
THEN 'B' TO 'A'
a
D
- -
§b TOTAL CRATES
STACKED
!
4 COUNT
CLIMBING UP WELL
: TOTAL OBSTACLES SECURED LADDER ASCENDS PND
! NEGOTIATED, HiT OP AND RETURN DESCENDS
" 'DISTANCE TRAVELLED
A.
5 LIFTING PIT PROP OR
LONG LOG FROM TOTAL LAPS OR
, CooNT EACH SINGLE FLOOR TO SIiOULDER DISTAI'-!CE
, STAIR NEGOTIATED SURMOUNTING - - . . TRAVELLED
E
OBSTACLES-AND RETURN n
6 ROLLING UNDER 1ST
,, HURDLE, CRAWLING
UNDER 2ND, STEPPING COUNT HAZARDS
; TOTAL BEAN BAGS
't-'-I i
:, IN BUCKET OVER 3,,0, AND ! COMPLETED
CLIMBING THROUGH
! Xli) LAPS OR 7 ~~~R'f

REINFORCED
LARGE OF
8(:¥3
LINEN FROM 'A' TO - COUNT LIFTS
",=" :::.sTA>'CE '6', LOWER TO FLOOR AND DRAGS
~~g~~ .fo~~WARDS b ~ a b
-,b -:-;::':'VClLED
-~-------
8 ROLLING OIL DRU~-~ - --~oi--'--

a
,
; ::.J'J~~~
EACt-l liME
. : - ;'EET ARE
=:::~
: TOGEThER ,OR SINGLE
BARREL,FILLED WITH
SAND, UP SLIGHT
INCLINE-Tf1EN DOWN a
c=- - b
i TOTc\l
" ,UPS
AND COv\INS
; ",,:CPS AND RETURN __
L Fig, 222d, Pre-work Circuit.

p.
works as quickly as possible and then moves on to another exercise station. In 2. Allocate a set numt
this way he completes all the set work for the full circuit of exercises. time taken to complete tI
At the end ofthe first circuit lap the performer has a short rest. The second up all the times. This pi
and third circuit laps are performed in a similar manner to the first. At the 3. If the performer hi
third and final lap the performer is working at maximum capacity. recorded in (a) time tab
Fixing the Repetition Dose. The repetition level or dose of each exercise in and measured, and (c) D1I
the circuit must be established for each performer. A useful method of fixing 4. When a pair of pe
the dose is to time the maximum number of repetitions achieved by the score totals may be adda
performer at each activity over a period of 1 minute (with only brief rest followed. This method 01
intervals being allowed between the various activities). The scores recorded work together at a circui
in this way are halved and these become the performer's training doses. 5. If a skill element is
The performer's time for three laps at his training doses or levels is from the viewpoint of me
recorded. He aims at attempting to reduce this time before re-testing takes the number of baskets so
place. to score a number of bal
SETTING STANDAII
TASK 6
Circuit activities must b
well within the physical
sometimes overlooked.
Sit up - Chest pass ball to The individual tasks "
and physical effort requ
bounce off wall- the instructor must pert
Catch - Lie down gauge the individual ani
In organizing circuits
(". ( / - - - .. --G-----~
physical ability a simple,
colours, is sometimes
/\ ..,J Circuit (more advanced
e-.('-'\, vities). This colour codD
" I reference to a particular
for easy recognition 01
individual performers.
Circuit training in ~
performer. Before talciJI
completion of a strenuc
Fig. 223. A numbered circuit guide board. The boards are placed alongside the walking or gentle jOggD
activity stations and are used to record the scores for individual circuit tasks.
after effort.
Scoring. The score for individual circuit tasks can be recorded on the /
circuit guide boards (Fig. 223). A number of different methods of scoring is METHOD OF TIMfI'I
used. Some examples are given here.
1. Count the number of repetitions performed at an individual task in a set Accurate timing of a em
time. Then, taking the lap as a whole, total up all the repetitions performed. the instructor. Altemal
This procedure is followed for the three laps. (positioned so that it CI
HERAPY PROGRESSIVE CIRCUIT TRAINING 253
I to another exercise station. In 2. Allocate a set number of repetitions at each exercise station. Check the
. full circuit of exercises. time taken to complete the activity. When the first circuit is completed total
11:1' bas
a short rest. The second up all the times. This procedure is followed for the three laps.
Iar manner to the first. At the 3. If the performer has a task involving moving over a distance it can be
I maximum capacity. recorded in (a) time taken to complete distance, (b) actual distance covered
:veJ or dose of each exercise in and measured, and (c) number of laps completed between the two set points.
nero A useful method of fixing 4. When a pair of performers work at some tasks separately, individual
f repetitions achieved by the score totals may be added together. If sharing one task the same procedure is
minute (with only brief rest followed. This method of scoring can also be used when a team of performers
:rivities). The scores recorded work together at a circuit.
lerf'ormer's training doses. 5. If a skill element is included in the circuit the score can be considered
is training doses or levels is from the viewpoint of movement or time. For example, in basketball shooting
is time before re-testing takes the number of baskets scored in a set tirr.e can be recorded, or the time it takes
to score a number of baskets.
SETTING STANDARDS
6 Circuit activities must be carefully selected and graduated, so that they are
well within the physical capabilities of the performers; unfortunately, this is
sometimes overlooked .
.s ball to The individual tasks vary considerably, depending on the degree of mental
all and physical effort required. In evaluating the performers' repetition levels
the instructor must perform the activities himself, so that he can accurately
DWn gauge the individual and cumulative effort required.
-----~
In organizing circuits for a group of performers with varying standards of
physical ability a simple three-tier grading system, associated with distinctive
colours, is sometimes used, e.g. White Circuit (simple activities), Blue
Circuit (more advanced tasks), and Red Circuit (the most strenuous acti
vities). This colour coding is carried through to the circuit boards, where any
reference to a particular circuit is given in the appropriate colour. This makes
for easy recognition of the various modifications to be undertaken by
individual performers.
Circuit training in any form makes strong physical demands on the
performer. Before taking part it is essential to 'warm up' thoroughly. On
completion of a strenuous circuit a short period should be spent in relaxed
10lUd5 are placed alongside the
walking or gentle jogging on the spot. This provides a suitable 'run down'
s fOl' individual circuit tasks.
after effort.
~ can be recorded on the

ift'erent methods of scoring is METHOD OF TIMING CIRCUIT
d at an individual task in a set Accurate timing of a circuit can be achieved by the use of a stopwatch held by
III the repetitions performed. the instructor. Alternatively, a large-faced clock with second sweep hand
(positioned so that it can be seen easily by the performers) can be used.
Timing is best registered by a battery of three Smith-type lever-operated 2. Allowing the cit
timing clocks, mounted on a wooden base and protected by a metal carrying preference.
handle (Fig. 224). Two of the clocks are second-elapsed timers; they are used 3. Changing the !
individually to time two separate performers. The third clock (a second stituting Press 1
interval timer) is used for overall timing. 4. Varying the app
Press machine.i
5. Allowing the tiD
period to each Cl
6. Arranging for
repetitions wbill
7. Beat the score.
achieved on the·
the task endeavc
8. Splitting the ciJ
groups-work e:
9. Adding a skill III
Fig. 224. Timing is best registered by a battery of three lever-operated timing
clocks. Two of the clocks are second-elapsed timers. The third clock is a second scoring.
interval timer.
It is a useful practice for the instructor to indicate verbally the progress of EQUIPMENT
time at intervals while the circuit is being worked. When the speed of the
activity is relatively slow, repetition counting can be done by the performers. Most conventional gy
If the pace is fast and demanding, however, it is best for a non-performer to
bars, climbing ft'llIIle
and mats. Weight n:
carry out this function.
calf-machines, squat
gym' (which indudt
extremely useful.
INTRODUCING THE CIRCUIT Small equipment 1
When a circuit has been devised and levels of performance set, the performers weights, basketballs.
A wide selection oj
should tryout the exercise tasks in their own time. This, coupled with good
crates, barrels, oil dI
coaching, should develop correct technique of performance--not to be lost
different sizes, ladde
when working under pressure.
A numbered circuit guide board (Fig. 223), painted matt black with simple
diagrams and exercise instructions, is placed alongside each activity station.
The direction taken by the performers round the circuit can be indicated by a CLOTHING
series of large arrows chalked on the floor. The type of clothin
After a session of circuit training it is extremely useful to encourage the employed. StrenuoUl
performers to give their opinion on the effectiveness of the lay-out and range shirts, shorts and gyJ
of activities used. protection for knees
Ideally, pre-work act
the particular occupl
VARIATIONS OF CIRCUIT TRAINING
Some of the most useful practical variations include: REFERENCE
1. Rearranging the circuit tasks in a different order. Morgan R. E. and Ada
rBERAPY
PROGRESSIVE CIRCUIT TRAINING 255
aree Smith-type lever-operated
2. Allowing the circuit tasks to be selected by the performers in order of
I protected by a metal carrying preference.
d-elapsed timers; they are used
3. Changing the starting positions of some of the exercises, e.g. sub
So The third clock (a second-
stituting Press Ups for Bench Pressing.
4. Varying the apparatus while maintaining the same effect, e.g. using Leg
Press machine in place of Squats with Weights.
5. Allowing the timing of the circuit to be one of the tasks: this gives a rest
period to each of the performers.
6. Arranging for the performers to work in pairs. One counts the
repetitions while the other works: the roles are then reversed.
7. Beat the score. On concluding a task the performer chalks the score
achieved on the floor and initials it. The next performer who attempts
the task endeavours to exceed this score, and so on.
S. Splitting the circuit into two sections and the performers into two
groups-work each section separately and then change.
ci I:Iu= lever-operated timing 9. Adding a skill task, such as basketball shooting: points are included for
~ The third clock is a second scoring.
ldicate verbally the progress of EQUIPMENT

orked. When the speed of the
;::an be done by the performers. Most conventional gymnastic equipment can be used for circuit training: wall
. is best for a non-performer to bars, climbing frames, balance benches, paranel bars, stools, climbing ropes
and mats. Weight resistance apparatus is also used: barbells, dumb-bells,
calf-machines, squat stands and leg press machines. The all-purpose 'multi
gym' (which includes a selection of weight training equipment) is also
extremely useful.
Small equipment can be usefully employed: medicine balls of different
crformance set, the performers weights, basketballs, footballs, bean bags, hoops and ash poles.
lime. This, coupled with good A wide selection of equipment for functional circuits is required: wooden
l pcrfonnance--not to be lost crates, barrels, oil drums, scaffolding and planking, wheelbarrows, tyres of
different sizes, ladders, chains, bricks and shovels.
(lllinted matt black with simple
Ikmgside each activity station.
lie circuit can be indicated by a CLOTHING
The type of clothing required will depend on the nature of the circuit
:mely useful to encourage the employed. Strenuous work needs the minimum of clothing: sleeveless T
atess of the lay-out and range shirts, shor~ and gym shoes. Functional activities are best carried out with
protection for knees and elbows, and a light track suit is recommended.
Ideally, pre-work activities need to be performed in the protective clothing of
the particular occupation simulated.
Jdude: REFERENCE
order.
III
Morgan R. E. and Adamson G. T. (1961) Circuit Training, 2nd ed. London, Bell.
STEREO EQUIP
24. Exercises to music
Essential equipmCll
taking long and sin
For normal class'
with the bass vollDll
to hear the leader's
..;:,. It is not easy to s
the various class me
of the movements.
used, ranging from
In many rehabilitation centres and health clubs morning and afternoon
instrumental and VI
treatment sessions start with a 20-30 minute period of 'warming-up'
exercises to music. This provides a lively start to the sessions and presents
general exercises in a stimulating and acceptable form.
In hospital practice there is rarely time to give properly organized periods
of general exercises and this aspect of treatment tends to be neglected. The MUSIC FOR M(]
difficulty can be overcome to some extent by arranging a 5 or 6 minute period
of general 'warming-up' exercises to recorded music before the specific No attempt has b
exercise period. numbers,ofparticu
life and quickly bee
suggest the names
interpretations haVl
Recordings mad!
STARTING POSITIONS
Alpert and his TijUl
In general, standing and sitting are the best starting positions to use fo!" and his Orchestra,
'warming-up' exercises; they allow patients to observe the instructor without Orchestra.
difficulty. The lying position can be used but coaching and change of exercise Certain piano ~
are made more difficult. interpretations by (
In organizing a class of patients with mixed disabilities it is best for the
more able patients to stand and the more disabled to exercise in sitting. The
leader, facing the class, performs the movements in time to the music and the
class follows his lead. Ideally, there should be no break between individual
exercises, and the movements should flow as naturally as possible into each WIDENING INTI
other.
Simple equipment,
To provide an overall balance of activity, and prevent undue fatigue, the
to great advantage il
instructor should not dwell too long on anyone exercise.
which form the em
partner activities pc
facing in walk forwl
moving backwards
SEQUENCE OF EXERCISES bouncing between I
The warming-up programme is arranged in such a way that all parts of the Singing while UK
body are exercised in turn. To achieve variety of movement and avoid fatigue participation in the
of anyone muscle group it is helpful to start with the upper aspect of the body other occasions it is
and progress downwards, and then repeat this sequence with different keep this form of e:
exercises, as indicated in the specimen tables (p. 258). disrupt the class aD
256
EXERCISES TO MUSIC 257
STEREO EQUIPMENT AND MUSIC

Ie
Essential equipment consists of a good, well-sprung record deck capable of

taking long and single play records, plus amplifier and two speaker units.
For normal class work the volume output should be set at a reasonable level
with the bass volume gently obvious. It should be possible for class members
to hear the leader's instructions without difficulty.
It is not easy to select music which is acceptable to the individual taste of
the various class members and which at the same time matches the character
of the movements. To overcome this problem a wide selection of music is
used, ranging from classical to 'pop', and including synthesized music. Both
IS morning and afternoon instrumental and vocal recordings are used.
period of 'warming-up'
I the sessions and presents
form.
properly organized periods
rends to be neglected. The MUSIC FOR MOVEMENT
aing a 5 or 6 minute period
music before the specific No attempt has been made to list individual records, with their serial
numbers, of particular types of music. Popular records have a relatively short
life and quickly become unobtainable. It has been considered more useful to
suggest the names of individual band leaders and groups whose music or
interpretations have been found of value in matching music to movement.
Recordings made by the following artistes are extremely useful: Herb
Alpert and his Tijuana Brass, Bert Kaempfert and his Orchestra, Geoff Love
uting positions to use fo!" and his Orchestra, Kenny Ball and his Jazzmen, and James Last and his
ave the instructor without Orchestra.
bing and change of exercise Certain piano pieces played in strict tempo are also of value, e.g.
interpretations by Charlie Kunz and recordings of Scott Joplin's works.
lisabilities it is best for the
I to exercise in sitting. The
D time to the music and the
, break between individual
orally as possible into each WIDENING INTEREST
Simple equipment, such as sticks, balls, hoops and dumb-bells, can be used
prevent undue fatigue, the to great advantage in widening the interest and scope of some of the activities
exercise. which form the exercise tables. Equipment of this sort also lends itself to
partner activities performed in time to the music. For example, (a) partners
facing in walk forwards standing, and grasping ends of sticks, alternate Arm
moving backwards and forwards (rhythmical 'piston' action), and (b) ball
bouncing between partners facing each other.
Ia way that all parts of the Singing while moving to music is another way of increasing the patients'
oovement and avoid fatigue participation in the exercise programme. This can occur spontaneously; on
be upper aspect of the body other occasions it is initiated by the instructor. At all times it is essential to
s sequence with different keep this form of expression under control. If overdone, singing can easily
258). disrupt the class and undermine the authority of the instructor.
OTHER USES OF MUSIC The patients use cb

sound sitting postun
Certain functional activities, such as crawling, stair climbing, alternate sitting
and standing, can be carried out rhythmically to music with considerable Music: 'Rags and Tam
advantage. In gait training and walking re-education music can also be used, Playing time: 2 min 52
either as a background to the activity or to emphasize certain aspects of the 1. Sitting; Head bend
2. Sitting; Shoulder r.
walking pattern, e.g. heel strike, push off from rear foot, and spacing of stride.
(,flopping').
3. Sitting (hands resti
emphasizing expinl
SPECIMEN TABLES with pressure from
4. Stride sitting; Tl'1II
1. General Warming-up Table in Standing with loose Arm swi
Music: 'Eye Level' (Simon Park)-single disc Suggested 5. Sitting; alternate F
Playing time: 2 min 18 sec. repetitions (marching in sittinj
1. Stride-standing; alternate Shoulder raising and
16
depressing.
2. Stride-standing; alternate Arm punching forwards. 8

3. Stride-standing; Trunk bending loosely from
8 6. Sitting; Head cirdi
side to side.
7. Sitting; Shoulder II
4. Standing; alternate high Knee raising. 8 8. Sitting; rhythmical
5. Standing; Heel raising. 8 with cupped hands
9. Stride sitting; Tru
10. Sitting; Knee streU
6. Stride-standing; Head turning from side to side. 8

7. Stride-standing; Shoulder-girdle circling with
12
emphasis on backward movement.
II. Sitting; Head bend
8. Stride-standing; alternate Arm punching with
8 (emphasis on mow:
Trunk turning from side to side.
12. Bend (fingers restil:
9. Stride-standing; rhythmical Trunk bending from
8 alternate Elbow em
side to side with alternate Arm swinging
13. Sitting; Arm raisiDJ
sideways-upwards over the head.
the fingers overhe8
10. Standing; assuming Squat position 14. Stride sitting; Tl'1II
(90' bend at knees). 8 to lax stoop positia
15. Sitting; rhythmical
position) and renm
II. Stride-standing; Head bending from side to side. 8
12. Bend (fingers resting on chest) stride-standing; 8
wide Elbow circling with emphasis on backward
movement.
13. Fist bend stride-standing; Trunk bending sideways 8
(to left) with Arm stretching, and return to
starting position, and repeat to right. MUSIC AND MO-'
14. Standing; rhythmical lunging forwards: 12 MENTALLY HAN
(al left Leg forwards, (b) right Leg forwards
For some of the me
centres regular ses.si
provide an excellenl
2. General Warming-up Table in Sitting for complete change of a
Chronic Chest Conditions these activities are tI:
The exercises are arranged for use in the treatment of ambulatory patients In general, a fairl!
suffering from such conditions as bronchitis, emphysema and bronchiectasis. music and movemem
: TIlERAPY EXERCISES TO MUSIC
259
The patients use chairs without arms or gymnasium stools which allow a
sound sitting posture.

L stair climbing, alternate sitting
ally to music with considerable Music: 'Rags and Tatters' (Geoff Love)-section of LP. Suggested
Playing time: 2 min 52 sec. repetitions
ducation music can also be used,
emphasize certain aspects of the 1. Sitting; Head bending fowards and backwards. 8
2. Sitting; Shoulder raising and dropping
8
D rear foot, and spacing of stride.
('flopping').
3. Sitting (hands resting on sides of lower ribs);

8
emphasizing expiratory movements of chest
with pressure from hands,
4. Stride sitting; Trunk turning from side to side

8
diDg with loose Arm swinging.
Suggested 5. Sitting; alternate Foot tapping on floor

16
repetitions (marching in sitting).
ad 16
-ros. 8
8 6, Sitting; Head circling. 8
7. Sitting; Shoulder girdle rounding and bracing. 8
8 8. Sitting; rhythmical self-percussion of chest
16
8 with cupped hands.
9. Stride sitting; Trunk rolling. 8

10. Sitting; Knee stretching and bending. 8
ide. 8
II 12
11. Sitting; Head bending backwards 8
II 8 (emphasis on movement of 'looking up').
12. Bend (fingers resting on chest) sitting; 8
Imm 8 alternate Elbow circling backwards.
13. Sitting; Arm raising sideways-upwards to touch 8
the fingers overhead.
14. Stride sitting; Trunk dropping loosely forwards 8
8 to lax stoop position, and 'uncurling'.
15. Sitting; rhythmical Leg parting (wide astride 12
position) and returning to starting position.
!ilk. 8
g; 8
:ani
Ir:ways 8
MUSIC AND MOVEMENT FOR THE

12
, MENTALLY HANDICAPPED
For some of the mentally handicapped living in hospital or attending day
centres regular sessions of music and movement and game-form activities
provide an excellent method of improving physical fitness and giving a
• for complete change of activity. The three groups that benefit particularly from
these activities are the profoundly, severely and moderately handicapped.
atment of ambulatory patients In general, a fairly high staff/patient ratio is needed. Practical details of
emphysema and bronchiectasis. music and movement programmes for the mentally handicapped, together
with organizational procedures, are given in the 3rd edition of Progressive APPENDIX 1
Exercise Therapy (1975).
Starting pO~
REFERENCE
Colson J. H. C. (1975) Progressive Exercise Therapy in Rehabilitation and Physical
Education, 3rd ed. Bristol, Wright.
Two types of starting po

Positions. The fundamc
lying and hanging. The
from the fundamental p
trunk.
FUNDAMENTAL P(]
Standing (st.) The be

looking forwards. The s
easily by the sides with p
fingers relaxed. The knc
with heels and inner bo
legs (not so functionally
the same line with the to
feet should not exceed 4
There should be no $I
Siuing (silt.) The pal
height, and width of seal
the hips and knees flexed
on the floor, toes facing
standing.
Kneeling (kn.) As stan
which are slightly apan
position is taken on the
plantar flexed; if taken (
edge (a more comfortabl
Lying (iy.) The body j
together, with the toes}:
relaxed. The palms of
exercise therapy the pos
When lying is used as,
palms of the hands usw
generally supported by a
APY
3Td edition of Progressive APPENDIX 1
Starting positions
• Rehabilitation and Physical
Two types of starting positions are used: Fundamental Positions and Derived
Positions. The fundamental positions consist of standing, sitting, kneeling,
lying and hanging. The derived positions are numerous and are obtained
from the fundamental positions by altering the position of the arms, legs or
trunk.
FUNDAMENTAL POSITIONS
Standing (st.) The body is held erect with the chin level and the eyes
looking forwards. The shoulders are down and slightly back; the arms hang
easily by the sides with palms of the hands facing the outer sides of the thighs:
fingers relaxed. The knees are straight and the feet point straight forwards,
with heels and inner borders slightly apart. An alternative position for the
legs (not so functionally sound) consists of having the heels together and on
the same line with the toes pointing slightly outwards. The angle between the
feet should not exceed 45~.
There should be no suggestion of strain or rigidity about the position.
Sitting (silt.) The position is taken on a gymnasium stool or chair. The
height, and width of seat, should allow the thighs to be fully supported, with
the hips and knees flexed to 90 . The knees are slightly apart and the feet rest
on the floor, toes facing forwards. The rest of the body should be held as in
standing.
Kneeling ( kn.) As standing, but the body-weight is supported on the knees,
which are slightly apart (to increase the size of the base) or together. If the
position is taken on the floor the lower legs are supported with the ankles
plantar flexed; if taken on a thick mattress or plinth, with the feet over the
, edge (a more comfortable position), the ankles are in mid-position.
Lying (ly.) The body is fully supported in the supine position. The feet are
together, with the toes pointing upwards, and the arms by the sides: fingers
relaxed. The palms of the hands face the outer sides of the thighs. For
exercise therapy the position is generally taken on a firm surface.
When lying is used as a starting position for various forms of movement the
palms of the hands usually rest on the supporting surface. The head is also
generally supported by a pillow when the position is used in the treatment of
261
\ 262 PROGRESSIVE EXERCISE THERAPY
patients confined to bed. The exception to this is when head and neck and Low arm cross IowA
standing
certain trunk exercises are performed.
Drag drags
Hanging (hg.) The body hangs from a horizontal beam or bar with the feet standing
off the floor. The position ofthe hands varies with the type of hanging, but in
over-grasp hanging (the most common type) they are pronated and at least Reach rch. 51
shoulder-width apart. The body hangs at full length between the arms, which standing
are straight, with the head held erect. The legs hang loosely with the feet
together, ankles plantar flexed.
Low reach lown:
standing
POSITIONS DERIVED FROM STANDING High reach high 11

standing
a. By Altering Position of Arms
Forearm reach FOrelll
Wing wg. st. Hands rest on iliac crests, with fingers standing rch.51
standing pointing forwards and thumbs behind. The Yard yd. st.
shoulders are dropped and the elbows kept standing
in line with the trunk.
Bend bd. st. Finger-tips are placed well back on shoulders, Low yard low yll
standing with elbow joints flexed, shoulder joints standing
rotated laterally, and upper arms vertical and
close to trunk.
High yard high Y'
Fist bend Fist bd. st. A similar position to the previous one, but the standing
standing hands are clenched, the wrists are straight, and Stretch str. 5L
the arms are not kept so closely to the sides. standing
(Fig. 225.)
Across bend acr. bd. st. Arms are held sideways at shoulder level, with
standing elbows fully flexed, wrists and fingers straight,
and palms facing downwards.
---=
Neck rest
standing
N. rst. st. Arms are held sideways in line with trunk,
with shoulder joints laterally rotated and
elbow joints flexed, so that fingers are placed
uTu
behind the neck at junction of head and neck. Fig. 225. Fig. "
Palms face forwards; tips of fingers touch each
other; wrist and fingers are straight.
Head rest H. rst. st. Similar to previous position, but hands are Modification of Hand ,
standing placed on top of the head, with palms facing One or both hands ~
downwards. and upper part of the I
Forehead Frh. rst. st. As neck rest, but hands are placed on forehead the body is lowered 3DI
rest standing with the palms facing forwards.
from side to side, and (6
Lumbar Lmb. rst. st. As neck rest, but shoulder joints are rotated
rest
Knee bending.
medially and hands are placed behind lumbar
standing spine, palms facing backwards. When one arm is c
Heave hv. st. Upper arms are held sideways at shoulder position, e.g. Half ylm
standing level, with elbow joints flexed to 90°; palms position, e.g. Half will!
face inwards. In addition to the p
Arm cross A. X st. Forearms are crossed loosely in front of chest further by (a) Changin
standing at approximately right angles to the upper'
standing; (b) Relaxing
arms. Hands make contact with the upper
arms. See Fig. 56, p. 64. hands, e.g. Stretch c~
lERAPY STARTING POSITIONS 263
• is when head and neck and Low arm cross IowA. X st. The arms hang loosely in from of, and close
standing to, the body with wrists crossed.
Drag drag st. The arms are raised backwards as far as
[Ita)beam or bar with the feet standing possible, with elbow, wrist and fingers
th the type of hanging, but in straight, and palms facing inwards.
iley are pronated and at least Reach reh. S1. The arms are held parallel with each other in
19lh between the arms, which standing from of the body at shoulder level, with palms
:s hang loosely with the feet facing each other. The elbows, wrists and
fingers are straight, and the shoulders kept
down. (Fig. 226.)
Low reach low rch. S1. As previous position, but the arms are held
standing midway between reach position and the
normal position by the sides of Ihe body.
NG High reach high rch. st. As reach position, but the arms are held
standing midway between reach and stretch positions.
0
Forearm reach Forearm The elbow joints are flexed to 90 with palms
,
iJiaI;: crests, with fingers standing reh. st. facing each other. (Fig. 227.)
ids and Ihumbs behind. The Yard yd. st. The arms are held sideways at shoulder level,
rropped and the elbows kept standing with palms facing downwards. The elbows,
, trunk. wrists and fingers are straight. (Fig. 228.)
placed well back on shoulders, Low yard low yd. st. As previous position, but arms are held
115 flexed, shoulder joints standing midway between the yard position and the
r. and upper arms vertical and normal position by the sides of the body.
High yard high yd. st. As yard position, but Ihe arms are held
... to Ihe previous one, but the standing midway between yard and stretch positions.
:bed, Ihe wrists are straight, and Stretch str. st. The arms, shoulder-width apart, are stretched
Il kept so closely to the sides. standing vertically above the head with palms facing
each other. (Fig. 229.)
lideways at shoulder level, with
---',-
sed, wrists and fingers straight,
.~
lIB downwards.
sideways in line with trunk,
joims laterally rotated and
:Rd, so !hat fingers are placed
Fig. 225. Fig. 226. Fig. 227. Fig. 228. Fig. 229.
k III junction of head and neck.
ards; tips of fingers touch each
1I:6ngers are straight.
Pious position, but hands are
Modification of Hand Position
1'11: the head, with palms facing One or both hands may be used to grasp apparatus, so as to fix the shoulders
and upper part of the body, or to give assistance to leg movements in which
_ hands are placed on forehead the body is lowered and raised, e.g. (a) Low grasp sitting (chair); Head bending
facing forwards.
from side to side, and (b) Low reach grasp standing (wall bars); Heel raisirlg and
_ shoulder joints are rotated
Knee bending.
~ are placed behind lumbar
lCiog backwards.
When one arm is employed the prefix 'half' is placed before the arm
c beld sideways at shoulder
position, e.g. Half yard grasp. The free arm is often placed in some suitable
.. joints flexed to 90°; palms
position, e.g. Half wing half yard grasp standing (wall bars); Heel raising .
In addition to the previous modifications arm positions may be modified
rossed loosely in front of chest
further by (a) Changing the position of the palms, e.g. Yard fpalmsforward)
Iy right angles to the upper'
standing; (b) Relaxing the arms, e.g. Lax yard standing, and (c) Joining the
like contact wilh the upper
hands, e.g. Stretch clasp standing.
56, p. 64.
b. By Altering Position of Trunk Knee bend K. bd. st.

standing
Stoop stp. st. The trunk is inclined forwards from the hip
(squat)
standing joints with the spine kept straight. The
movement is generally taken as far as the
length of the hamstring muscles allows. The
hips are inclined backwards by plantar flexion
at ankle joints, so that balance of body is
maintained. Knee full K. full bd.
bend st.
Lax stoop lax stp. st. The spine and hip joints are flexed in a standing
standing completely relaxed manner. The arms hang
(full squat) "
loosely downwards, and the hips are inclined
backwards as in stoop standing. Instep Ins. sup. 51
Lax stoop lax stp. B. As previous position, but with heels about support
back lean lean st. 30-38 cm in front of a wall or wall bar upright, standing
standing and the coccyx region in contact with it. The
position is used for trunk uncurling 'vertebra
by vertebra'. See Fig. 82, p. 82.
Fixed fix. st.
standing
c. By Altering Position of Legs

Half ! st. Standing with the weight of the body on one
standing leg. The other leg is either free or supported
by apparatus, e.g. Foot support side towards
standing (wall bars).
Balance bal. st. Standing on beam or rib of balance bench with
standing one foot behind the other, body facing
lengthwise. (Fig. 230.)
Balance bal. t st. As previous position, but standing on one leg.
half The foot of the free leg hangs down by the
standing side of the beam or rib. (Fig. 231.)
Fig. 230.
Balance bal. acr. st. Standing on beam or rib of balance bench with
across feet close together and at right angles to
standing supporting surface. (Fig. 232.)
j
Close cl. st. Standing with the feet pointing forwards and
standing inner borders touching.
Stride std. st. Standing with feet astride, a distance of 2 foot
standing lengths between heels. The feet point out
wards at an angle, due to the lateral rotation
associated with abduction of the hip joints.
Wide stride wd. std. st. As previous position, but a distance of 3 foot
standing lengths between heels. Fig. 233.
Walk forwards wlk. f. st. One leg is moved directly forwards, so that Fig. 23
standing there is a distance of 2 foot-lengths between
the heels. See Fig. 172, p. 143. Foot F. sup. st.
Toe Toe st. Standing on the toes, with ankle joints plantar support
standing flexed. standing
STARTING POSITIONS 265
Knee bend K. bd. st.

Standing on the toes with ankle joints plantar
standing
flexed and knees flexed to 90 . If feet are
wards from the hip
(squat)
pointed forwards in standing position the
: straight. The
knees are carried straight forwards over toes.
ten as far as the
If heels are together and feet pointed outwards
nuscles allows. The
in starting position the knees are turned
m by plantar flexion outwards over the toes.
lance of body is
Knee full K. full bd. As previous position, but knees are fully
bend st. flexed. (Fig. 233.)
are flexed in a standing
er. The arms hang (full squat)
he hips are inclined
oding. Instep Ins. sup. st. Standing on one leg with dorsal surface of foot
with heels about support of other leg supported on stool, so that the
III or wall bar upright, standing knee joint is flexed to about 90 . The thigh is
OOIlt3ct with it. The usually carried a little behind the body. The
. uncurling 'vertebra position is used for single knee bending
p.82. exercises. (Fig. 234.)
Fixed fix. st. Standing with the body either facing wall bars
standing or sideways on to the bars, with one leg raised
so that the foot is fixed between the bars, with
ankle joint dorsiflexed, so that the foot acts as
a hook. The knee joint of fixed leg is kept
extended (Fig. 235).
t of thebody on one
0'free or supported
wpport side towards
of balance bench with

~. body facing
[ standing on one leg.

IJangs down by the
[Fig. 231.)
Fig. 230. Fig. 231.
of balance bench with
[ right angles to
232.)
riIlting forwards and
I:,a distance of 2 foot

be feet point out
~the lateral rotation
l of the hip joints.
: a distance of 3 foot
Fig. 233.
, forwards, so that Fig. 234. a b
«-lengths between Fig. 235.
,_ 143. Foot F. sup. 8t. As previous position, but foot of raised leg is
b ankle joints plantar support supported on a wall bar or the top of a balance
standing bench.
Thigh Thigh sup, One or both thighs are supported by the beam, High ride big
support st, which is usually placed midway between the sitting sin
standing knee and hip joints. Both thighs are supported Crook crk
if the patient faces the apparatus; one thigh is sitting
supported if he is sideways on to the
apparatus. See Fig. 113, p. 94.
Cross Xl
d. By Altering Position of Trunk and Legs sitting
Fallout fallout f. st. One leg is moved forwards to a distance of ,
forwards about 3 foot-lengths, and the knee is bent to
standing about 90 over the toes. The rear leg is
C
Long ~
straight and the trunk is inclined forwards in sitting
line with it. Foot of straight leg is kept in
contact with floor. See Fig. 77, p. 77.
N.B. The position may be taken with the
thigh and buttock of forward leg supported
Inclined inc
across a gymnasium stool (fallout sitting). The
long siD
toes of the rear foot rest on floor, with ankle
sitting
joint plantar flexed.
Fallout As previous position but the foot of the
Long sitting ~
fallout o. (Trunk inclined (T.
outwards (or (or s.) st. forward leg is either moved obliquely
backwards with w.
sideways) forwards-outwards or directly
Hand support)
standing sideways,
Lunging. When the trunk is kept erect in fallout positions it is usual to Side sitting S.
employ the term 'lunge', e.g. lunge forwards standing. It shOUld be noted
that in some gymnastic textbooks 'lunge' is used instead of 'fallout', which
can be confusing.
POSITIONS DERIVED FROM SITTING

As in standing. c. By Altering P4I
b. By Altering Position of Legs Stoop sql
sitting
Stride std. sitt. The feet and knees are placed apart, so that
sitting there is a distance of about 1 foot-length
Lax stoop l3lII
between the heels. The knees are flexed to 90 ~
sitting sill
and the feet point obliquely outwards in line
with the legs.
I •
Half '2 sm. Sitting on apparatus, such as a plinth or high
sitting bench, with the buttock and thigh of one leg
supported; the other leg is free. The position
is used to allow a patient with a fixed or stiff
hip joint to sit reasonably comfortably. He
takes weight on his sound side and places the
free limb in whatever posture is required to
compensate for the fixed position of the hip. POSITIONS DEI
Ride ride sitt. Sitting astride apparatus, such as a chair or a. By Altering P4
sitting balance bench. The legs grip the apparatus if a
very steady position is required. As in standing.
py STARTING POSITIONS 267
are supported by the beam, High ride high ride

As previous position, but taken on a high
ICed midway between the sitting sitt.
plinth; the thighs are usually strapped down.
· Both thighs are supported Crook crk sitt.
Sitting on the floor with knees flexed to about
the apparatus; one thigh is sitting 90 , and the soles of the feet resting on the
idcways on to the floor. The knees may be together, without
113, p. 94. actually touching, or slightly apart. See Fig. 48,
p.61.
Cross X sitt. Similar to crook sitting, but ankles are crossed
sitting and hips abducted and laterally rotated, so
X'WlII'ds to a distance of that outer aspect of each knee approaches the
s,. and the knee is bent to floor. See Fig. 49, p. 61.
IDeS. The rear leg is Long 19. sitt. Sitting on the floor with the legs straight, fully
. . is inclined forwards in sitting supported, and the same distance apart as in
r straight leg is kept in
standing. The trunk is held erect, with hip
see Fig. 77, p. 77. joints flexed to about 90 0, and ankle joints
ID3Y be taken with the plantar flexed to a comfortable degree.
f forward leg supported
I srool (fallout sitting). The
Inclined incl.lg. The long sitting position is taken on
rest on floor, with ankle long sitt. apparatus, such as a balance bench or stool,
sitting with heels resting on the floor.
l but the foot of the
Long sitting 19. sitt. A widely used position for certain types of leg
· moved obliquely (Trunk inclined (T. incl. b. exercises, e.g. Quadriceps contractions and
.. directly backwards with w. Hnd. sup.) single Leg raising. Seldom described in
Hand support) textbooks of gymnastics, probably because
of the lengthy description. See Fig. 32a, p. 48.
t positions it is usual to Side sitting S. sitt. Sitting on the floor on the left or right side,
1Dding. It should be noted with both legs bent and turned in the opposite
II instead of 'fallout', which direction. The weight of the body rests chiefly
on the hip which is nearer the floor. The arm
of the same side is vertical and supports the
trunk.
c. By Altering Position of Trunk

Stoop stp. sitt. As stoop standing, but the trunk movement is
sitting limited by the apposition of the thighs and
R placed apart, so that abdomen.
·about 1 foot-length
be knees are flexed to 90 Lax stoop lax stp. As lax stoop standing. (Fig. 236 shows lax
sitting sitt. stoop stride sitting.)
ltiquely outwards in line
, such as a plinth or high

iJdr; and thigh of one leg
leg is free. The position
imt with a fixed or stiff
mbly oomfortably. He
tIUIld side and places the
ff1 ~
Fig. 236.
· posture is required to
a:d position of the hip. POSITIONS DERIVED FROM KNEELING
IUS, such as a chair or
:gs grip the apparatus if a
a. By Altering Position of Arm.s
s required. As in standing.
Leg lift L.lifi

b. By Altering Position of Legs
lying
Stride std. kn. The knees and feet are placed about a foot
kneeling length apart.
Kneel kn. sitt. Sitting back on the heels with the trunk held Stride lying std.1y
sitting erect. If a thick mattress or mat is available
the position may be taken on it with the feet Half lying ! ly.
over the edge; this relieves the pressure on the
feet and makes the position more comfortable.
Half tkn. Kneeling on one knee with the other leg in
kneeling front of the body with the foot on the floor.
Hip, knee and ankle joints of forward leg are Crook half edt.!
bent to 90 . lying
Leg stretch L. str. Kneeling on one knee with the other leg Prone lying pr.1y
half Hn. stretched in a named direction. Thus: (a) Leg
kneeling sideways stretch half kneeling. (b) Leg forwards
stretch half kneeling.
c. By Altering Position of Trunk Leg prone L. pro

Prone pro kn. The trunk is horizontal and supported by the lying
kneeling arms and thighs, which are vertical. The hip
and knee joints are flexed to 90 . The correct
position of spine and head is maintained.
(Fig. 237.)
t-L
Fig. 237.
Fixed high
Thigh support
across prone
lying
fix. hi
sup. I
Iy.
POSITIONS DERIVED FROM LYING

As in standing. Side-lying SAy
b. By Altering Position of Legs

Crook lying cr.ly. Lying with the soles of the feet resting on the
floor. The knees are flexed to varying degrees,
but the usual position is about 90 .
Stride crook std. cr. [y. As previous position, but the legs and feet are
lying placed astride, with the heels about 45 em
apart. The feet point obliquely outwards in
line with the legs.
Crook lying cr. ly. W. From crook lying position the pelvis is raised
with Pelvis P. rais. until there is a straight line between the trunk
raised and the thighs.
iRAPY STARTING POSITIONS 269
Leg lift L. lift Iy. Lying with the legs raised; the range of move
lying ment must be indicated, e.g. Vertical lift
eet are placed about a foot lying. The legs are kept together, with
knees extended and the ankles plantar flexed.
!he heels with the trunk held
Stride lying std.ly. Lying with feet astride as in stride standing.
mattress or mat is available
, be taken on it with the feet Half lying ily. Lying on a plinth or bed with the
lis relieves the pressure on the trunk supported by a back rest or pillows in
be position more comfortable. a position midway between lying and sitting
~ knee with the other leg in upright. The legs are straight and fully
r with the foot on the floor. supported.
IIIkle joints of forward leg are Crook half crk.ily. As half lying, but the knees are flexed and the
lying feet rest on the plinth or bed as in crook lying.
knee with the other leg Prone lying pr.ly. Lying face downwards with the body fully
med direction. Thus: (a) Leg supported. This is an unpleasant position for
'IaIf !meeting. (b) Leg forwards the face, and so the head is generally turned to
iIg. one side. Similarly, the arms are often allowed
to rest on the supporting surface with the
palms turned upwards instead of being held to
the sides as in lying.
Leg prone L. pro ly. Lying face down on a high plinth. or plinth, in
izontal and supported by the lying such a manner that only the legs are supported
'Which are vertical. The hip (from the iliac crests downwards), and the
Ie flexed to 90 c. The correct trunk lies unsupported in the horizontal plane.
and bead is maintained. The ankles are strapped down to the plinth.
The chin is kept in and the arms are by the
sides, as in the lying position. A stool is placed
under the trunk, so that the hands can rest on
it and support the trunk during rest periods.
Fixed high fix. high Th. As prone lying, but the thighs rest across
Thigh support sup. acr. pr. apparatus, such as a stool, or two balance
across prone Iy. benches placed one on top of the other. The
lying feet are fixed by the wall bars or living
support. The trunk, head and legs form a
straight line with the chin kept in. The arms
are by the sides, as in lying. (Fig. 238.)
Strong extension exercises for the spine and
hips are given from this position.
Side-lying S.-Iy. Lying on one side. The under arm is either
allowed to rest loosely in front of the body, or
is bent up, so that the hand supports the head.
As the position is unstable, the under leg is
sometimes placed a little in front of the other
lies of the feet resting on the
one. Alternatively, the under leg is flexed at
.-e flexed to varying degrees, the hip and knee joints.
ilion is about 90' .
'.
OIl, but the legs and feet are
:b the heels about 45 cm
int obliquely outwards in
position the pelvis is raised

light line between the trunk
Fi!!. 118.
POSITIONS DERIVED FROM HANGING

By Altering Position of Legs Prone falling
Angle hanging ang. hg. Hanging with the feet resting on the floor. The
hips are flexed, the knees extended and the
ankles plantar flexed. The arms are straight
and shoulder-width apart. (Fig. 239.)
Fall hanging fall hg. Hanging from the beam with the body Inclined inel
obliquely forward, and the feet or heels prone fall.
resting on the floor. The legs and trunk falling
should be in a straight line. Horizontal ho£~
The arms are generally described as being prone fall
'vertical'. In practice, however, when the falling
position is used for arm bending exercises it is Side falling S.1i
better to have the arms at right angles to the
trunk. Over-grasp position for the hands is
used. (Fig. 240.)
Horizontal hor. fall hg. As fall hanging, but the feet rest on apparatus, Inclined ind
faU hanging such as a stool, or the ankles are held by living side falling fall
support. In the latter case the legs are parted, Horizontal bar.
the supporter holding the ankles in the same side fall
way as the handles of a wheelbarrow. falling
Reverse rev. hg. Hanging with the head downwards. The Horizontal bar.
hanging position is generally taken on the wall bars. half
standing
Balance bat
hanging
"
-i:I~~_~- Front rest fr.l
Fig. 239. Fig. 240.
Grasp Positions used in Hanging

Over grasp over gr. Grasping apparatus with hands in pronated
position.
Under grasp undo gr. Grasping apparatus with hands in supinated
position.
Alternate alt. gr. Grasping apparatus with one hand supinated
grasp and the other pronated.
Inward grasp inw. gr. Grasping apparatus with the palms facing
~
inwards.
N.B. When the wall bars are used for hanging positions, it is usual to
omit any reference to the grasp. Hanging (wall bars J indicates that the
position is taken with the back towards the bars. Towards hanging (wall
bars) is used when the body faces the bars. Fig. 241.
ERAPY STARTING POSITIONS 271
OTHER DERIVED POSITIONS

Prone falling pr. fall. The body, which is in a straight line from
be feet resting on the floor. The head to heels (and faces the floor), rests on the
the knees extended and the hands and toes. The arms are vertical and
bed. The arms are straight shoulder-width apart, with elbows extended.
idth apart. (Fig. 239.) Hands are generally turned inwards. (Fig. 241.)
:be beam with the body Inclined incl. pro As previous position, but the hands are
ro, and the feet or heels prone fall. supported on apparatus: beam, wall bars or
100£. The legs and trunk falling stool. (Fig. 242.)
Ill'2ight line. Horizontal hor. pro As prone falling, but the feet are supported on
r::oerally described as being prone fall. the beam or a stool, so that the body is in the
ICtice, however, when the falling horizontal position. See Fig. 66, p. 72.
for arm bending exercises it is Side falling S. fall. The body, kept straight, and with one side
lie arms at right angles to the turned towards the floor, rests on one hand
lip position for the hands is and one foot. The supporting arm is vertical
) with elbow extended. See Fig. Ill, p. 93.
, but the feet rest on apparatus, Inclined incl. S. As previous position, but the supporting hand
or the ankles are held by living side falling fall. rests on the beam or a stool.
latter case the legs are parted,

Horizontal hor. S. As side falling, but the feet are supported on
oIding the ankles in the same

side fall. the beam or a stool, so that the body is in the
Ik:s of a wheelbarrow. horizontal position. See Fig. 115, p. 94.
falling
IiIe head downwards. The Horizontal hor. ! st. Standing on one leg with the body and the
:nlIy taken on the wall bars.

half free leg in the horizontal plane. Free leg is
standing kept straight, in line with the trunk, with ankle
joint plantar flexed. N.B. An arched position
may be assumed.
Balance bal hg. The bod}, f3cing forwards and supported by

hanging hands and thighs, rests across the beam. The
body is arched and held as near to the
horizontal as possible; the legs are pressed
lightly backwards. The arms are straight and
parallel. (Fig. 243.)
Front rest fro rst. A similar position to balance hanging, but the
body is held in a straight line and the forward
~. 240. leaning is restricted to about 15 c. Apparatus
such as the beam, or beam saddle on beam,
may be used. (Fig. 244.)
lIS with bands in pronated
lIS with hands in supinated
as with one hand supinated

-.ed.
B with the palms facing
aging positions, it is usual to

(mall bars) indicates that the
~ bars. Towards hanging (wall
L Fig. 241. Fig. 242. Fig. 243.
Crouch crch. sitt. Thc body is supported by the toes and hands,
sitting which rest on the floor, with hips and knees
flexed as much as possible, and trunk inclined
forwards. The arms are vertical and may be
outside the thighs (clo~e crouch) or between
the thighs (open crouch). (Fig. 245.)
Throughout this booI
gymnastic movements
Ling Physical EdUC21
technical terms used. 1
in this appendix, alODj
writing of exercise pn:
a b Gymnastic terminol
Fig. 244. Fig. 245. cularly suitable for c!
exercise therapy. It is
and complicated. On
systems of recording Il
and difficult to learn. 1
an elaborate system oj
square or frame. Labl
based on a system of l
TERMS DENOTINI
Bending bend
Bracing brae.
Carrying carry.
Circling (on cird.

apparatus)
* Now the Physical Ed...

THERAPY
s supported by the toes and hands,

JIl the floor, with hips and knees
APPENDIX 2
och as possible, and trunk inclined

De anns are vertical and may be
thighs (c1o:;e crouch) or between
open crouch). (Fig. 245.)
Gymnastic terminology
j;P
Throughout this book the terminology used to describe the exercises and
gymnastic movements is based on that standardized some years ago by the
Ling Physical Education Association. * Thc method of description and
technical terms uscd, with some additions and modifications, are given in full
in this appendix, along with the various abbreviations used to facilitate the
L writing of exercise programmes.
b Gymnastic terminology, being largely descriptive in character, is parti
Fig. 245. cularly suitable for describing the specific forms of movement used in
exercise therapy. It is sometimes criticized, however, as being cumbersome
and complicated. On the other hand, it must be emphasized that other
systems of recording movement in use today are infinitely more complicated
and difficult to learn. Benesh Movement Notation, for example, is based on
an elaborate system of signs which are written on a five-line stave within a
square or frame. Laban Notation (widely used in movement studies) is also
based on a system of signs.
TERMS DENOTING MOVEMENT

Bending bend. Flexion of the part indicated. N.B. Extension
of the spine from the neutral position is
referred to as 'bending backwards', e.g. Fixed
prone lying; Trunk bending back-<1Jards with Ann
turning outwards.
Bracing brae. The term indicates either the stabilization of a
joint or the drawing together of two parts. It is
used mainly in connection with hyperextension
of the knee and adduction of the scapulae, e.g.
Ca) Standing; Heel raising and Knee bracing,
,
(b) Sitting; Shoulder bracing.
Carrying carry. The armes) or leges) is moved in a horizontal
direction.
Circling (on circl. Circling over or under apparatus, such as the
apparatus) beam, from which the body is suspended by
the hands.
*Now the Physical Education Association of Gt. Britain and N. Ireland.
273
Circling or eircl. The part of the body indicated is moved TERMSDENO'

rolling or smoothly in a circular direction. N.B. In
rolL rolling in rings the body as a whole is moved, Across aa
the toes acting as the fixed point. Backwards b.
Behind bel
Closing clos. The arm(s) or leges) is moved towards the Downwards d.
midline of the body.
Forwards f.
Flinging fling. A quick elbow extension from the across-bend
Horizontal hoi
position.
Lowering lower. The part of the body indicated is lowered in a

TERMS INDICi ~
straight line from its axis of movement.
Bend bd.
Raising or raise. or The part of the body indicated is raised in a
Close d.
lifting lift. straight line from its axis of movement.
Crook crk.
Rebound reb. A term used in connection with rhythmical
Cross X
jumping and hopping. It indicates that a
Crouch crch.
second, subsidiary jump follows the first main
Grasp gr.
jump.
Hanging hg.
Recoil recoil A controlled slackening off of a muscle group Heave hv.
after a position has been reached, e.g. Forearm
reach (lax fingers) sitting; strong Finger bending N.B. ]
and slow recoil. positio
Tilting tilt. A term used in connection with forward syllabi!
backward movement of the pelvis on the
femoral heads. Lateral tilting of the pelvis is PARTSOFTHI
usually described as 'hip updrawing'.
Abdomen
AbeL
Ankle(s)
Ank..
Arm(s)
A.
Back B.
Chest Ch.
ElbowCs) Elb.
Feet F.
Finger(s) Fing.
Forehead Frh.
TERMS DENOTING TYPE OF MOVEMENT
Single The term is used when one arm (or leg) is TERMSREFEi
moved in turn with the other arm (or leg), or RELATION TO
when one arm Cor leg) is moved several times
in succession before the other arm (or leg) is Fixed Ii
exercised, e.g. Ca) Standing; single Arm raising
forwards, (b) Forearm reach sitting; single High 1:
Forearm turning inwards and outwards
cominuously to a given coum.
Single is also used when one limb only is to be
exercised; the term is then qualified by
additional information, e.g. Reach grasp high
half standing (beam and block); single (affected)
Leg swinging forwards and backwards. Support
Alternate alt. The term is used when one arm (or leg) moves
towards one limit of the movement while the Living
other arm (or leg) moves towards the other support
limit, e.g. Walk forwards standing; alternate
Arm swinging forwards and backwards.
HERAl'Y TERMINOLOGY 275
Ie body indicated is moved TERMS DENOTING DIRECTION OF MOVEMENT

circular direction. N.B. In
the body as a whole is moved, Across acr. Inclined incl. Outwards o.
: as the fixed point. Backwards b. Inwards inw. Right r.
Behind beh. Lateral la1. Sideways s.
leg(s) is moved towards the Downwards d. Left I. Under undo
body. Forwards f. Medial med. Upwards u.
'e:x:tension from the across~bend Horizontal hor. Oblique obI.
e body indicated is lowered in a TERMS INDICATING POSITION OF LIMBS AND TRUNK

IlDl its axis of movement.
Ie body indicated is raised in a

Bend bd. Kneeling kn. Squatting squat.
IlDl its axis of movement.

Close cl. Long 19. Standing st.
Crook crk. Lying ly. Stretch str.
IOJIlIlecUon with rhythmical

Cross X Prone pro Stride std.
oopping. It indicates that a

Crouch crch. Reach rch. Wing wg.
iuy jump follows the first main

Grasp gr. Relaxed lax, Yard yd.
Hanging hg. Rest rst.
Ia:1ening off of a muscle group Heave hv. Sitting sitt.
Ihas been reached, e.g. Forearm

Inl Dlling; slrong Finger bending N.B. In abbreviating terms used to describe movement, rather than
position, which end in -ing (bending, stretching, carrying, etc.) the final
IOJIlIlecUon with forward syllable is omitted. See Terms denoting Movement, p, 273.
rmmt of the pelvis on the
Lateral tilting of the pelvis is PARTS OF THE BODY AND THEIR ABBREVIATIONS
at as 'hip updrawing'.
Abdomen Abd. Hand(s) Hnd. Pelvis P.
Ankle(s) Ank. Head H. Shoulder(s) Sh.
Arm(s) A. Heel(s) HI. Shoulder Sh. bl.
Back B. Hip(s) Hp. blades
Chest Ch. Instep Ins. Side S.
EIbow(s) EIb. Knee(s) K. Thigh(s) Th.
Feet F. Leg(s) L. Tee(s) Toe
Finger(s) Fing. Neck N. Trunk T.
Forehead Frh. Palm(s) Pa. Wrist(s) Wr.
!!NT
011 when one arm (or leg) is TERMS REFERRING TO THE POSITION OF THE BODY IN
Irith the other arm (or leg), or RELATION TO APPARATUS OR LIVING SUPPORT
(01' kg) is moved several times
!:fore the other arm (or leg) is Fixed
fix. One or both feet are fixed in or under
:41) Slanding; single A rm raising apparatus, such as wall bars, or by a partner.
ruum reach silting; single High
high The term is used to indicate that a position is
~ imz:ards and outwards taken on apparatus (e.g. high sitcing); it may
• given count. also be employed in exercises to indicate that a
led when one limb only is to be movement is to be taken as far as possible, e.g.
111m is then qualified by Lying; high Knee raising. The term is also used
mation, e.g. Reach grasp high to modify such positions as yard and reach,
_ and block J; single (affected) e.g. high yard.
~ds and backwards. Support sup. The part of the body named is supported by
d when one arm (or Jeg) moves apparatus.
lit of the movement while the Living (.) A partner provides support, e.g. Over-grasp
II> moves towards the other support horizontal fall hanging (beam and living sup
jm"C:Jards standing; alrernate port J; Arm bending.
rr:lKD'ds and backwards. ( .. ) represents two supporters.
Towards tow. The body faces apparatus. When grasp REFERENCES

positions are used it is not necessary to use Laban R. (1975) Modem Et6
the term. Ling Physical Education A
Back towards B. tow. The back is turned towards the apparatus. Gymnastics. London.
When the hanging position is taken at the wall McGuiness-Scott J. (1980) B
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Side towards S. tow. One side of the body is turned towards the
apparatus. When a grasp position is used it is
not customary to use the term. "
Bibliogra
METHOD OF DESCRIBING EXERCISES IN TERMINOLOGY
1. The name of the starting position is given first; it is followed by a
General Surgery
description of the movement to be performed. A semi-colon is used to
Aird 1. (1957) A CompaniIM
separate the starting position from the movement, e.g. Lying; high Knee Ballinger W. F. and Drapm
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2. The term half is used to prefix the starting position when one limb Macfarlane D. A. and TboaI
only is involved, e.g. Half yard grasp standing (wall bars). Churchill Livingstone.
3. In describing the movement, the part of the body moved is mentioned
first, and then the type and direction of the movement. When more than one
part of the body is involved the following order is usually suggested: Head,
Arms, Trunk, Legs, Feet. This sequence is modified, however, when
Orthopaedic Surgery
Adams ]. C. (1980) StarukD
describing exercises where the movement of one part of the body is more
Livingstone.
important than the other subsidiary movements involved. This part is Charnley J. (1970) Total hi!
mentioned first, e.g. (a) Fixed prone lying; Trunk bending backwards with Arm 72,7.
turning outwards and single Leg raising backwards and (b) Standing; Heel Duthrie R. B. and FeI'gllS
raising and Knee full bending with loose Arm swinging forwards-backwards. Edinburgh, Churchill Lit
Edmonson A. S. and Crensl
It is unnecessary to mention the return movement unless it is intended that Vol. 2, 6th ed. St Louis,.
the return movement shall not be the opposite of the original movement. Longton E. B. (1973) OrthOl
4. In describing movements of the limbs the plural is indicated by Arm 59, 1l6-119.
CA.), Leg (L), Knee (K.) etc. When one limb is to be moved on its own, or in Muller M. E. (1970) Total]
Smillie 1. S. (1978) InjllJ
turn with the other limb, the term single (1) is used. See Terms denoting
Livingstone.
type of Movement, p. 274.
5. When a movement consists of several parts a comma is used to separate
each part, e.g. Prone kneeling; single high Knee raising, Leg stretching and
raising backwards, and return to starting position. Brackets are used to give Physical Education
Knudsen K. A. (1947) Text,
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Laban R. (1975) Modem Et.
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down backwards, affected Leg leading (3-4 J. Ling Physical Education j
6. In abbreviating terminology a full stop is used after each abbreviation Gymnastics. London.
Mace R. and Benn B. (\982
employed, e.g.
Morgan R. E. and AdamSOl
Ca) pro kn.; P. tilt. f. and b. W. H. bend. b. andf. Munrow A. D. (1963) Pure
Cb) st.; HI. rais. W. A. swing. f. and f.-u. Thulin J. G. (1947) GymllQJ
(c) N. rst. fix. pro ly.; T. bend. b. w. turn. Verducci F. M. (1980) M ..~
IRAPY BIBLIOGRAPHY 271
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Ling Physical Education Association (1950) Terminology of Swedish Educational
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1 the tenn 'back towards'.
body is turned towards the
11 agrasp position is used it is
o usc the term.
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beavy resisrance exercises. J.

19ttSsive resistance exercises.
'esisla1lC£ Exercises: Technique

ry-Crofts.
INDEX
) strength. Br. J. Sports Med.
dynamometer for evaluating

Abdominal exercises, 69, 73
Balance exercises, 11, 12, 196,209
See also Applied exercise therapy,

Bassini operation for inguinal hernia,
rpy, 4th ed. London, Bell &

after abdominal surgery
203
Aids to daily living, 229

abdominal exercises after, 204
few York, Paddington Press.

Anal sphincter, exercises using, 115,
Battle's pararectal incision, 189, 197,
Oxford, Blackwell Scientific

ll6 198
Ankle exercises, 171-173

Beam, circling exercises on, 87, 89
r.eIwbiJ.iration, 2nd ed. Phila- Apical breathing, 109, Ill, 112

introductory exercises, 91, 92
Appendicectomy, 197-201
Breathing exercises, 109-114
exercise therapy after, 198-201

after abdominal surgery, 185, 186
I!S of progressive resistance

Applied exercise therapy, 184-243
surgical treatment for intervertebral
'ed.]. 1,501-506. after abdominal surgery, 184
disc lesions of lumbar spine,
appendicectomy, 197
215,216,217
'lid.]. 1,747-750.
cholecystectomy, 196
in physical education, 114
. . and Remedial Exercises.

gastrectomy, 188
practical techniques, 113
repair of inguinal hernia, 204

starting positions for, 113, 114
II.. New Jersey, Prentice-Hall.

cd. Philadelphia, Saunders
femoral hernia, 209
to increase range of expiration, III
umbilical hernia, 210

inspiration, 112
after intervertebral disc lesions of

to prevent stagnation of mucous
III!: and exercise prescription.

lumbar spine, 213, 215
secretions, 112
meniscectomy, 236
when bed rest is used for
:I cd. London, Butterworths.

total hip replacement, 222, 225
intervertebral disc lesions of
iIrd Technique. Br. J. Phys.

Arm depressors, exercises for, 129
elevators, exercises for, 120, 123, 127,

with arm movements, 110, 111
136
trunk movements, 110
exercises, with breathing, 109, 110,

Bronchopneumonia, after abdominal
III
surgery, 184, 185
Loodoo, Oxford University Arthroplasty, of hip, 221-231
following joint disease in childhood,
L Pbiladelphia, Saunders. 230
~ Atlas of Human Anatomy. revision, 230

Cholecystectomy, 196-197
Axial fixation, 17-20

exercise therapy after, 197
6th ed. Edinburgh, Churchill Chronic chest diseases, 'warming up'
exercises for, 258
Circuit training, progressive, 247-255
Back care, after intervertebral disc

clothing for, 255
lesions of lumbar spine, 215,

definition of, 247
218
equipment for, 255
exercises, dynamic, 79
practical application of, 247, 253, 254
static, 76
setting standards, 253
279
280 INDEX
Circuit training (cont.) Exercise(s) (cant.) General exercise then

specimen circuits, 248-251 resisted, 21
exercises, 3, 181
types of circuit, 247 manual,41
Gridiron incision, 189
variations of, 254 spring, 36
Grip, exercises to SIm
Circulatory complications, after water, 39
151
abdominal surgery, 187 weight, 26
Group, difference bet1
minimized by postoperative leg weight-and-pulley, 21
class method!
exercises, 187 See also resisrance by malleable treatment, 181
Class, difference between group and materials for strengthening Gymnastic terms, Z11
class methods, 181 grip, 39
treatment, 181, 256 specific, 3
Co-axial fixation, 17 supported, 20
Co-ordination, progression of, II suspension, 17

Haemarthrosis, POSlDl
Costal breathing, 109-111 rabies, 181
meniscectlXD
unilateral, 110, 111 terminology, 273
Hamstring muscles, a
Cough reflex, diminished after genera) shortening oj
anaesthesia, 185 'stretching', 88
Cough-Lok, Hawksley, 112, 113, 185 Hand, exercises for, 1
functional activities
Fatigue, avoidance of, in specific exercises, 39,
exercise rherapy, 182, 256 resisted exercise by
De Lorme and Watkins 'fractional' in assessing muscle strength, 31, 32 materials, 39
technique of strengthening in strength progression techniques, Head and neck exeni
muscles, 34 29,30 Heavy resistance sysu
Diaphragm, limitation of movement Femoral hernia, 209, 210 stren~
after abdominal surgery, 184, postoperative exercise therapy, 210 techniques of, 34, :3
186 Finger and thumb exercises, 151-153 Hernia: see Femond" :
Diaphragmatic breathing, 109, 110 Foot exercises, 173-175 203; Umbilil:
benefits to normal person, 114 Forearm exercises, 143--146 Hip arthroplasty, sa .
Drainage after cholecystectomy, 196 Free exercises, 7 replacemeut,
total hip replacement, 224 arranged progressively, 59-177 exercises for, 15t
definition of, 7 against spring ra
methods of progression, 7, 10, II using susperWClIII,
See alsa 'warming up' exercises, 256 with manual assiI
Elastic strands, as resistance, 38
Functional manoeuvres on the floor or Hypothenar and tbID
Elbow exercises, 139-142
bed,48-50 exercises fOl',
Embolism, postoperative, 187
movements, in early stages of
Epiphysial plates, damage to, by spinal

mobilization/re-education,
flexion exercises, 88
43--58
Equipment, for assisted active exercises,

at floor level, 50-53 Incisions, for abdomi
13
in prone lying on bed or mat, appendicectomy, I~
auto-assisted active (tension)
51-53 cholecystectomy, I!
exercises, IS, 16
moving on bed from supine lying, gastrectomy, 188
circuit training, 255
45-48 hernia: femoral, 201
exercises to music, 257
free exercises, 7, 61-177 from sitting and standing, 54-57 203; umbi1ic
negotiating stairs, 57-58 used in meniscectu
supported movements, 20
suspension exercises, 17, 18, 19 Indian clubs, in elbo1
weight resisted exercises, 26--28 141
weight-and-pulley resisted exercises, forearm exercises, I
25,26 Games, in combination wirh specific shoulder and shoul
Exercise(s) assisted active, 13 exercise therapy, 3, 181 exercises, 12
auto-assisted active (tension), 15 remedial, to encourage grip, 39 wrist exercises, 15Cl
free, 7 Gastrectomy, 188-196 Inguinal canal, defCD
See also Progressive exercises, 59--177 exercise therapy after, 190 201,202
general, 245 Gastro-enterostomy, 188 hernia, direct, 203
INDEX 281
1:(5) (cont.) General exercise therapy, 245-260

Inguinal canal (com.)
m,21 exercises, 3, 181

oblique, 202
oual,41 Gridiron incision, 189, 197

operative procedures for, 203
iDg,36 Grip, exercises to strengthen, 38, 39,

abdominal exercises following,
115',39 151
scope of, 204
icJn, 26
Group, difference between group and
i&bt-and-pulley, 21
class methods, 181
Inspiratory range, exercises to increase,
60 resistance by malleable treatment, 181

112
materials for strengthening Gymnastic terms, 273-276

Intervertebral disc(s), damage to, by
grip,39 spinal flexion exercises, 88
1ic,3 lesions of the lumbar spine, 212-220
.ud. 20
conservative treatment of, 212
1IIISion, 17
Haemarthrosis, postoperative, in
exercise therapy during, 213-215
181
I, meniscectomy, 235, 236

surgical treatment of, 212
DOIogy,273 Hamstring muscles, congenital

shortening of, 88
Intrinsic muscles of foot, exercises for,
'stretching', 88
175,176
Hand, exercises for, 151-153
functional activities to complement
• avoidance of, in specific exercises, 39, 151
c::u:n:ise therapy, 182, 256

resisted exercise by malleable
Joint, hip, surgery to restore movement,
~ing muscle strength, 31, 32
materials, 39
221,222
IU'aIgth progression techniques,

Head and neck exercises, 61-67
of knee, 15
,29,30
Heavy resistance systems for muscle
using combined circuits, 16
11lcniia, 209, 210

strengthening, 33-35
knee, restoring flexion after
llipeiative exercise therapy, 210

techniques of, 34, 35
meniscectomy, 233, 234, 241,
IDd thumb exercises, 151-153

Hernia: see Femoral, 209; Inguinal, 202,
242,243
cn:ises, 173-175
203; Umbilical, 210
restoring mobility by auto-assisted
• aercises, 143-146
Hip arthroplasty, see Total hip
active (tension) exercises,
~7 replacement, 221
15-17
p:d progressively, 59-177

exercises for, 154-163
of shoulder, 15
Iiaa of. 7
against spring resistance, 36
spine, thoracolumbar, promoting
Ids of progression, 7, 10, II

using suspension apparatus, 17, 18
movement after disc lesions,
... ~ up' exercises, 256

with manual assistance, 13
214, 215, 217-220
... manoeuvres on the floor or

Hypothenar and thenar muscles,
zones of movement of stiff joints, 16,
bat, 48-50
exercises for, 153
17
IIII:IItS, in early stages of
DKIbilization/re-education,
4:3-58
.... level, 5(}--53
Incisions, for abdominal surgery, 189
Knee exercises, 164-170
_ lying on bed or mat,

for extensors, 164-167
appendicectomy, 197, 198
51-53
for flexors, 164
• OIl bed from supine lying, gastrectomy, 188

to restore range of knee flexion,
ti-48 hernia: femoral, 209, 210; inguinal,

168-170
II silting and standing, 54-57

203; umbilical, 210
See also Meniscectomy, 232-243
.mg
, stairs, 57-58
used in meniscectomy, 232
Kocher's subcostal incision, 189, 196
Indian clubs, in elbow exercises, 139,
141
forearm exercises, 146
in combination with specific

shoulder and shoulder girdle
Leg exercises, ankle and foot, 171-177
a-ercise therapy, 3, 181

exercises, 121, 125, 137, 138
after abdominal surgery, 187
IiII. to encourage grip, 39

wrist exercises, 150
surgical treatment, intervertebral
1III1lY, 188-196
Inguinal canal, defence mechanism of,
lie therapy after, 190

201,202
216, 217
:merostomy,I88 hernia, direct, 203

total replacement of hip, 225, 226
282 INDEX
Leg exercises (cont.) Muscle strength, methods of resistance

Plaster-of-Paris cyliD
during conservative treatment,
training, 29-31, 33-35
meniscectoo
intervertebral disc lesions of
assessment of, with myometer, 32,
jacket, in conserval
33; with 10 RM test, 31
disc lesions
Lifting, education in, after repair of

early and advanced techniques, 29,
212
inguinal hernia, 209

30
Pool therapy, 39-41,
Lung(s), ventilation of, exercises for,
heavy resistance systems, 33-35
'Portabell' weighted 1
109, 110, 112
De Lorme and Watkins
resistance, 2
Lunging, 266
'fractional' technique, 34
Postural drainage, 11
Lying positions, in functional training,
McQueen technique, 35
after abdominal su
45-48, 51-53
Zinovieff (Oxford) technique, 34
repair of inguinll
See also Starting positions, 261, 268,
Music, exercise to, 256
training, after disc
269
equipment for, 257
spine, 215, :
exercise sequence, 256
Posture, alteratioo 01
organization of class, 256
major abdol
specimen programmes, 258, 259
185, 186
stereo equipment and suitable

Pre-work circuit, 24'
McQueen technique of resistance
music, 257
Progression of free c
training, 35
use of, 256
ordinatioo.
and functional activities, 258
II; strengdl
Manipulation and passive mobilization,
212
gai t training, 258
principle of, 5
Manual resistance, 41
movement for mentally handicapped,
specific exercises,
Meniscectomy, 232-243
259
supported move:m
complications of, 235
suspension exerci!
essential of treatment, 232-235
resisted exercises"
exercise therapy for, 236-243
39-41
pool therapy after, 241

Progressive circuit 1
Neck exercises, 61-68
exercises, free • .,.,
programmes of treatment, 236-243
Non-weight-bearing regime after
regimes of treatment, 233-235

Prosthesis, low frid
meniscectomy, 233
replacema
Mobility exercises, for ankle, 173
Nursing staff, role in exercise therapy
elbow, 142
Pulmonary congesO
after total hip replacement, 225
185
fingers, 152
foot, 175
forearm, 146
hip, 155, 158, 159, 161, 163
knee, 168-170
Occupational therapy, 3
shoulder girdle, 118, 119

functional activities provided by, 39
Range of movemeD'
shoulder joint and shoulder girdle,
Overhead fixation point(s), in
exercises" .
121, 122, 125, 126, 134, 136,
suspension exercises, 17, 19
progression of,
137, 138
Oxford (Zinovieff) technique of
11
spine, cervical, 64, 65, 66, 67, 68

resistance training, 34
Raymed 'knee imm
thoracolumbar, 90, 91, 98, 99, 102,
after mmi
103, 107, 108
Rehabilitation reot
wrist, 150
to music,
Mobilizing stiff joints, by assisted active
Paramedian incision, 189
general exercises
exercises, 13, 14
in appendicectomy, 198
Repctition dose (J£
auto-assisted active (tension)
training, ,
exercises, 15, 16, 17
gastrectomy, 188, 189
Resistance trainiDI!
free exercises, 10, 11
Pclvic floor exercises, 115-117
progressK
Pelvis, fixation of, during lateral flexion
33-35,38
Movements, functional, 45-58
of thoracolumbar spine, 99
Resisted exercises.
Mucous secretions, causing
during spinal rotation, 103
Respiratory oompl
postoperative complications,
tilting exercises, backwards, 73-75;
abdomina
184, 185
forwards, 79, 81, 82
prevention of, II
prevention of, ll2, 185, 186, 187
forwards and backwards, 86, 90
Revision arthropla
INDEX 283
~ strength, methods of resistance

Plaster-of-Paris cylinder, use of, after
Rhythm, principle of, in specific
~g,29-31, 33-35
meniscectomy, 234, 235
exercises, 4
ar:ssment of, with myometer, 32,

jacket, in conservative treatment of
Rings, circling on, 75, 76, 127, 128, 130
33; with 10 RM test, 31

nest hang in, 86, 87, 91
tty and advanced techniques, 29,

212
Ropes, circling on, 91,127,128,130
30
Pool therapy, 39-41, 219, 230, 241
climbing, 128, 130
IVy resistance systems, 33-35

'Portabell' weighted bands, as weight
De Lorme and Watkins

resistance, 28
'fractional' technique, 34
Postural drainage, 112
McQueen technique, 35
after abdominal surgery, 185, 186
Self-practice, 'little-and-often', 182,
Zinovidf (Oxford) technique, 34

repair of inguinal hernia, 207
183,186,187,190,199,205,
cu:rcise to, 256

training, after disc lesions of lumbar
213
llipmcnt for, 257.

spine, 215, 218
Shoulder girdle, exercises for, 118, 119
:rcise sequence, 256

Posture, alteration of, in bed, after
joint and girdle, exercises for,
IIIOization of class, 256

major abdominal operations,
120-134, 136-138
:cime:n programmes, 258, 259

185, 186
rotators of shoulder joint, exercises
neo equipment and suitable

Pre-work circuit, 247, 251, 255
for, 134-136
music,257 Progression of free exercises, in co

Sitting positions, for head and neck
~of,256 ordination, 11, 12; range, 10,

exercises, 61
imaiooal activities, 258

11; strength, 7-10
Skipping, use of, in promoting co
l1IiDing, 258
principle of,S
ordination, 12
ment for mentally handicapped,

specific exercises, 3, 5
to redevelop quadriceps femoris after
259
supported movements, 20
meniscectomy, 242, 243
suspension exercises, 20
Specific exercises, see Exercise(s)
resisted exercises, 29, 30, 33-35, 38,
Spine, circumductors of, exercises for,
39-41
107,108
acises, 61-68
Progressive circuit training, 247-255
Spring resistance, 36-38
_-bearing regime after

exercises, free, 59-177
progression of, 38, 39
UVTri~omy, 233
Prosthesis, low friction, in total hip

Springs, long spiral, 36
~ suIf, role in exercise therapy
replacement, 221, 222

other types, 38
8ia' toal hip replacement, 225

Pulmonary congestion, postoperative,
Starting positions, importance of, in
185
specific exercises, 3, 4, 5
listed,261-271
Stereo player, use of, in exercises to
music, 257
ionaJ lherapy, 3
Stick exercises, for shoulder and
. . . activities provided by, 39

Range of movement, in specific
shoulder girdle, 120-124, 126,
d fiDtion point(s), in
exercises, 4, 5
132-135, 137

progression of, in free exercises, 10,
for elbow, 139, 141, 142
[Zioovieff) technique of
11
for forearm, wrist and hand, 143-145,
RSistance training, 34
Raymed 'knee immobilizer', use of,
147-149,151
after meniscectomy, 235, 238

Strength, progression in, of free
/
Rehabilitation centres, use of exercises
exercises, 5, 7-10
to music, 256
See also resistance training
!ian incision, 189

general exercises and games in, 181
Stress incontinence, pelvic floor
lBldicectomy, 198
Repetition dose or level, in circuit
exercises in treatment of, 115
:ys(eCtomy, 196
training, 252
Suture line, and exercise, after
ClIlIDy, 188, 189

Resistance training, strength
appendicectomy, 198
:101" exercises, 115-117

progression techniques, 29, 30,
gastrectomy) 189
:arion of, during lateral flexion

33-35,38,39-41
inguinal herniotomy, 204
of tboracolumbar spine, 99
Resisted exercises, 21-41
. . spinal rotation, 103

Respiratory complications, after
cu:rcises, backwards, 73-75;

abdominal surgery, 184
fOrwards, 79, 81, 82

prevention of, 185-187
Ten Repetition Maximum, 29-32, 34,
'IUds and backwards, 86, 90

Revision arthroplasty of hip, 230
35
284 INDEX
Terminology, gymnastic, 273--276

Vaginal wall, prolapse of, pelvic floor
Thenar and hypothenar muscles,

exercises in treatment of, 115
exercises to strengthen, 153

Vagotomy, with gastro-enterostomy,
Thrombosis, postoperative, 187

188
Toe flexors and extensors, exercises for,
177
Total hip replacement, 221-230
assessment, preoperative, 222
exercise therapy, preoperative,

Walking, after meniscectomy, 233, 234,
222-224; postoperative,
235, 240
225-230
surgical treatment of disc lesions of
forces passing through replacement

lumbar spine, 217
joint in walking, 222

total hip replacement, 226, 228, 229,
training in standing and walking,

230
/
228-230
'Warming up' exercises to music, 256
use of tilt table, 227,228

Water, exercises in, 39-41
variation of exercise programme by

See also Pool therapy
use of pool therapy, 230

Weight resistance, 26-28
Trunk exercises, 69-108

Weight-and-pulley resistance, 21-26
after appendicectomy, 199-201

Weight-bearing, after meniscectomy,
gastrectomy, 191, 192, 194, 195

233--235, 237, 240
operations for inguinal hernia,

total hip replacement, 226, 227, 228,
205-208
229,230
with breathing, 110, 112

Wrist exercises, 146-150
Umbilical hernia, 210, 211

Zinovieff technique of resistance, 34, 35

Progressive Exercise Therapy in Rehabilitation Physical Education

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PROGRESSIVE

IN REHABILITATION AND PHYSICAL

John H. C. Colson FCSP FSRG DipTRG DipCOT

Rehabilitation and Principal, School of Remedial Gymnastics and Recreational Therapy,

Pinderfields General Hospital

Pinderfields General Hospital. Formerly Head Remedial Gymnast, Orseu Hospital

All Rights Reserved. No part of this publication may be reproduced, stored in a

First edition 1958

Second edition 1969

Spanish edition 1974

Third edition 1975

Dutch edition 1981

Fourth edition 1983

British Library Cataloguing in Publicatilm Data

Progressive exercise therapy in rehabilitation

and physical education.

Library of Congress Catalog Card Number: 82-S0781

,.,.." .. Gr.- Brimin by

The Wise,jor Cure, on Exercise depend. DRYDEN.

i¥en by the nursing staff

III:Medical Centre gave PART 2 FUNCTIONAL MOVEMENTS

PART 4 APPLIED EXERCISE THERAPY

21. Total Hip Replacement

24. Exercises to Music 256

, ,I' 2. Gymnastic Terminology 273

Specific or local exercises consist of active movements that are designed to

TYPES OF SPECIFIC EXERCISES

BASIC PRINCIPLES OF SPECIFIC EXERCISES

Sound Starting Position Wide Range Movemad

Wide Range Movements

rthoracic spine. The combined

:n forms a strong progression

a'cise, Knee swinging from side

Ie mover muscles by accessory

Fig. 5. Progression in strength: subsidiary movements are added to the exercise

rthoracic spine. The combined

:n forms a strong progression

a'cise, Knee swinging from side

Ie mover muscles by accessory

Fig. 5. Progression in strength: subsidiary movements are added to the exercise

ley circuit: elevation of arm

puIIey circuit: abduction of

.JJer joint with weight-and­

rr level with the top of the

Fig. 13 shows an auto-assisted active (tension) circuit arranged to assist

~ of assistance provided Exercise Technique

IIIIition on one leg at a given

ley circuit: elevation of arm

puIIey circuit: abduction of

.JJer joint with weight-and­

rr level with the top of the

Fig. 13 shows an auto-assisted active (tension) circuit arranged to assist

~ of assistance provided Exercise Technique

little or no pain; and (c) a range of 5

1. SUSPENSION AND SUPPCl

3. SUSPENSION AND SUPPORTED EXERCISES

oably taut and therefore

liM lillg muscles is obta

the lower pulley circuit. Resisted exercise: e:.r:IaII

.JJer joint with weight-and

.JJer joint with weight-and

rStoolJ. Fig. 36.

-~_. __ LL. _ .~ __