Unit 6D - Coordination, ROM & Balance Deficit

I. Coordination Deficits

A. Upper-Extremity (UE) Coordination ↓

• Goal: ↑ coordination of the UE.

• Interventions / Examples

  • Regular PNF UE diagonal patterns (D1 & D2, flex/ext).

  • Symmetrical & asymmetrical bilateral PNF.

  • Functional reaching (multi-planar, varied height/distance).

  • Touching specific body parts (nose, ear, opposite knee, etc.).

  • Frenkel’s exercises adapted to UE (see Table 13-5).

  • Occupational-therapy fine-motor coordination tasks (pegboards, buttons, utensil use).

  • Functional exercises in Morris & Knach (M&K).

  • Any rapid, timed, alternating motions (RAM) → document time & accuracy.

• Patient Position: Supine or supported sitting selected according to individual sitting balance; decreases postural demand so focus remains on coordination.

B. Lower-Extremity (LE) Coordination ↓

• Goal: ↑ coordination of the LE.

• Interventions / Examples

  • Regular LE PNF patterns in supine (D1 & D2).

  • Frenkel’s LE exercises in supine progressing to standing.

  • Standing Frenkel’s inside parallel bars → progress outside bars with forearm support or hand-held assist (HHA).

  • Specific foot-placement drills (targets, taped footprints); progress out of bars → minimal assist (min A) or close CGA.

  • Rapid alternating plantar-/dorsiflexion, heel-toe tapping, etc.

  • Any rapid repetitive LE motion with timing component.

C. Frenkel Exercise Scheme (Table 13-5 Highlights)

• Purpose: Improve coordination through visual feedback & controlled, repetitive motions.

• Supine Series

  1. Heel slide flex/ext down mid-line.

  2. Hip abd/add with knee flexed (heel contact).

  3. Hip abd/add with knee ext (straight leg slide).

  4. Flex/ext hip & knee with heel off table (no friction cue).

  5. Heel on opposite knee → slide down shin & return.

  6. Bilateral leg flex/ext together.

  7. Alt. reciprocal – one leg flexes while other extends.

  8. Complex: one leg flex/ext while other abd/add.

• Sitting Series

  1. Place foot in therapist’s moving hand (variable target).

  2. Lift leg to hit traced footprint on floor.

  3. “Sit steady” endurance hold.

• Key Teaching Points: Eyes open for visual cue; slow → smooth → speed; count cadence; record repetitions; encourage symmetrical trunk.

II. Range-of-Motion (ROM) Deficits

A. UE ROM ↓

• Goal: ↑ ROM; preventt pain & capsular stiffness, especially shoulder/scapula.

• Interventions

  • Gentle PROM with scapular mobilization (avoid impingement).

  • Passive or active-assistive (AA) PNF patterns.

  • Scapular specific PNF patterns (anterior elevation/posterior depression, etc.).

  • Self ROM sheets/exercises if OT unavailable.

  • Caregiver training for PROM, bed positioning, & wheelchair (w/c) support.

  • OT consult for w/c accessories; PT for AFO decisions.

B. Subluxed Shoulder (post-stroke)

• Goal: ↓ humeral subluxation; promote glenoid seating.

• Interventions

  • Stability activities (weight bearing on extended arm, closed-chain).

  • Humeral cuff orthosis.

  • UE trough, lapboard, or sling for passive protection.

  • Support UE when sitting/standing (pillows, table).

  • Traditional sling only while ambulating (“up”).

  • Neuromuscular/FES stimulation to supraspinatus & posterior deltoid; devices such as Twin Stim IV, Bioness, estim units.

C. LE ROM ↓

• Goal: ↑ hip/knee/ankle ROM; preserve pelvic & trunk mobility.

• Interventions

  • Passive & AA LE PNF patterns.

  • Passive/AA pelvic PNF (anterior elevation, posterior depression).

  • Self-stretching (hamstrings, gastroc, hip flexors).

  • Caregiver PROM & bed/w/c positioning education.

  • Trunk mobility stretches (see Intervention 6-9, chest wall stretches from SCI & MD units).

• Clinical Pearl: Never overlook trunk rotation & lateral flexion; these directly influence gait mechanics.

III. Balance & Postural Control Deficits

A. Functional Balance Grading (O’Sullivan & Schmitz)

• Normal – Maintains steady balance without support; accepts max challenge, full weight shift.

• Good – Maintains balance independently; accepts moderate challenge (object off floor).

• Fair – Maintains balance with handheld support; minimal challenge (turn head/trunk).

• Poor – Needs support + mod→max Assist to maintain balance; cannot accept challenge.

• Absent/Zero – Cannot maintain balance.

B. Static Sitting Balance ↓

• Goal: ↑ midline sitting with neutral pelvis (anterior tilt).

• Key Concepts

  • Neutral pelvis is prerequisite for distal control; may use sheet wrap.

  • Progression variables: arm support → no arm support; eyes open/closed; surface compliance.

• Activities

  • Static sitting with/without UE support; hold ↑ duration.

  • Rhythmic Stabilization (RS) or Alternating Isometrics (AI) applied at shoulders/trunk.

  • Timed endurance targets (e.g., $30$ s → $2$ min).

C. Dynamic Sitting Balance ↓

• Goal: ↑ controlled trunk & limb movement over stable BOS.

• Biomechanics

  • Weight shift → trunk elongation on WB side, shortening on opposite; head remains upright.

  • If COG remains over BOS = static; moves within BOS = dynamic; outside BOS but returns = controlled mobility.

• Activities / Progressions

  • Multidirectional weight shifts with manual cue or reaching.

  • Bilateral or unilateral arm/leg raises.

  • UE PNF patterns, chops / lifts.

  • Trunk rotations (eye-head-trunk dissociation).

  • Reaching tasks (clasped hands, weight-bearing on involved UE).

  • Seated Swiss-ball work (very advanced) → demands $90^\circ$ hip/knee/ankle ("$90-90-90$" rule).

  • Dual-task: balance plus fine-motor (buttoning, card sorting).

D. Static Standing Balance ↓

• Goal: ↑ independent upright posture on both LEs.

• Intervention Framework – Use Developmental Sequence to reduce degrees of freedom then challenge:

  • Kneel-stand → Half-kneel → Supported stand (parallel bars).

  • RS / AI at trunk & pelvis.

  • Begin with 2-arm support → 1-arm → no support.

  • Early-stage option: One leg on padded stool inside bars for patients unable to fully extend involved knee (still practice trunk/pelvis stability).

  • Higher-level: Standing at countertop or rail; remove UE support quickly.

  • Gradually ↑ standing time, then introduce weight shifts within BOS (M/L, A/P).

E. Dynamic Standing Balance ↓

• Goal: ↑ mobility over BOS and preparatory skills for gait.

• Posture Keys: Spinal elongation, neutral pelvis, avoid synergistic abnormal patterns (esp. extensor synergy).

1. Developmental Sequence Stations

• Quadruped → Kneel-stand → Half-kneel-stand.

• Activities include:

  • RS/AI, UE reaching, resisted crawling, “walking” on knees.

  • UE PNF, chop/lift, trunk rotations.

  • Catch/throw balloon, beach-ball.

  • Transition practice: half-kneel ↔ stand (strong leg forward first; progress to involved leg forward).

• Swiss-ball half-kneeling for active-assist transitions (see Fig. A-C).

2. Pre-Gait Activities (Modified Plantigrade)

• 2 → 1 → 0 arm support.

• Options:

  • Stand with one knee on stool, weight shift; progress to stepping.

  • Step forward/back with strong LE then involved LE (A/P).

  • PNF LE patterns in standing; UE patterns simultaneously for dual control.

  • UE/LE coordination drills (dissociation).

3. Ambulation Progression Steps

1. Master static stand & weight shifting.

2. Advance uninvolved LE → forces single-limb stance on involved side.

3. Advance involved LE with tactile cue at hip to reduce hip-hike & circumduction.

4. Step back with involved LE (extensor tone release).

5. String multiple steps together, emphasize stance-phase weight shift & swing-phase limb clearance.

4. Advanced Dynamic Balance

• Tilt / Rocker Board – adjustable amplitude & speed; begin hemiplegic foot first.

• Body-Weight Supported (BWS) Treadmill – ↓ load, ↑ repetition; therapist assists pelvic rotation & stepping.

• Environmental & Task Variables (Fig. 15.7):

  • BOS: seated uncrossed → crossed legs; standing wide → tandem → single-leg.

  • Surface: firm → foam, ball.

  • Vision: EO → EC.

  • UE: light fingertip → no touch; arms out → crossed.

  • Movements: UE raise, LE stepping, trunk turns.

  • Destabilizing Functional: sit↔stand, floor transfers, lunges.

  • Gait: fwd/back/sidestepping, crossover.

  • Dual-Task: holding tray, conversing, ball catch/kick.

  • Context: closed clinic → open community.

IV. Practical / Ethical Connections

• Safety First: Many activities require guarding; use CGA → min A guidelines. Therapist must ensure no falls, subluxations, or over-stretch.

• Caregiver Involvement: PROM & positioning essential to prevent contracture & pain; training reduces long-term complications & burden.

• Device Selection: Evidence supports slings only during ambulation to balance protection vs. learned non-use. NMES can reduce time UE is immobilized.

• Motor Learning Principle: High repetition, task specificity, and progression of challenge underpin all interventions; integrate visual, vestibular, and proprioceptive cues.

• Documentation Precision: Use functional balance grades, specify support level, duration, quality of movement (smoothness, timing).

• Outcome Measures: Consider Fugl-Meyer (coordination), Modified Ashworth (tone), Berg or Tinetti (balance), 10-Meter Walk Test (gait) for quantifiable progress.

V. Quick Reference Equations & Numeric Values

• Neutral seated alignment: $90^\circ$ hip, $90^\circ$ knee, $90^\circ$ ankle ("90-90-90").

• Timed balance holds often progress in $5\,\text{s}$ increments (e.g., $5 \rightarrow 60\,\text{s}$).

• Body-Weight Support: typically $40\%$ BWS initial → reduce $10\%$ per stage as control improves.

VI. Summary Check-List for Session Planning

1. Identify primary deficit domain (coordination, ROM, static/dynamic balance).

2. Choose patient position that minimizes extraneous postural demand (supine, supported sitting, quadruped, etc.).

3. Select exercise set (PNF, Frenkel, RS/AI, reaching, plantigrade, tilt board, BWS).

4. Determine starting assistance (2 UE support, CGA, etc.) and measurable target (reps, sec).

5. Progress one variable at a time: speed, range, BOS, vision, surface, dual-task.

6. Educate patient & caregiver; reinforce home program.

7. Document functional balance grade & pain/sub-lux status each visit.