TOUGH Rbprinted with the kind permission of the APTA: Education Department TOPICS IN NEUROLOGY: Lesson 1 Management of the Trunk in Adult Hemiplegia: The Bobath Concept Joan D Woh, PT INTRODUCTION he purpose of this lesson is to intro- dace the assessment and treatiaent of postural control in the adult, hemiparetic patient, with an eraphasis om the tran and its component parts. The speeitic goals are thw following: 1) to provide the neader with An increased awareness of the importance ‘ofthe trunk in postural eontrol;2) to review the sites of mitiation of normal trunk 1no¥ ‘ments; 9) to understand the diseociation of movernert within the trunk iiself ane 4) to apply this inform and treatment of the patient with adult hemiparesis One treatinent approach used in the rehabilitation of the stroke patient is the Boat Newro-Developmertal Treataent (NDT) approach! This approach focuses fon developing ruore nomual patierns of pos ture and mexement thronghout the bedy ‘The NDP approach emphasizes assessment lof movement as the startiry point in treat ment. Other authors who employ tec niques similar to those of the NDT proach? have inchaded information. and techniques that involve the trunk, but have provided 10 specie delineation or analysis ‘of movernents within the trunk itself Spe cific analysis of the trunk is of major impor tance in enhancing the elfectiveness of treatment of the adult stroke patient, Vie ‘ually all functional movements of the head and upper and fower extremities involve shift in the body’ center of gravity: Whether ‘Ue movernent elicits an observable coun: terbolancing in the trunk or a lest discerns {ble postural adjustment, normal movement patterns require u response on the part of the teunk. Althongh the tran represents over halt fof ihe body mass ard plays a major role in ‘he body's overall postural control it ha ‘been largely ignored! in clinical assessraent and rosoarch compared ta the comticerable Information on human limb movements, Many clinieal tots that are appropriate for assessing the extremities (lor example, joint range of motion and proprioeoptive testing) ane inuppropriate viben apped to the trunk. Also it is easier Lo assexs distal parts of the body because Uie patterns of rnwernent are ciearor Neglect of the Lrank nay result in a misinterpretation of che ‘eavse of proolems seen in the extremities, however, because the unk serves a5 the 3s Mohr isan Instructor, consular, ard pave practitioner 2 Coxcont Street, Cressi, New Te Topics vn Newrolomy ccurse erection is Susan 3 Herd Pub. Poe more informetion on this ‘ad other enrses mn the In Touch series, cemtact the APTA Eeiacation Department 1 Now Pairtve Steet, Alexandra, VA 22704 © Copyright 1900 bythe American Physical They Ans, Al sights reserved Lesson Topics rciogy center of control for distal noveruents, ‘This lesson will emphasize the impor- ance of the crunk In movenent in rma subjects. as well as in patients with hem paresis. The frst section discusses trunk algnment and movement, and the second Liscusses selfamovement analysis, In Uhe third, this information is appliog to the as- sesartent and treatment of the adh eati= paretic patient IMPORTANCE OF TRUNK CONTROL All normal functional activities depend ‘on trunk control as their basis of movement. ‘The upper extremity ig attached to the trunk by a bony connection at the stemo clavieular joint and by musele and other soft ussue: The posture of the entire trunk, Including the pelvis, therefore affeots the scapula and clavicle, whieh in turn has dl rect muscular and biomechanical effscts on all muvetvents of the upper extreraly. This means thal upper extremity movernent = highly dependent oa trunk contro and pes- ture. In the hemiparetie patient, even Thought there may be motor return and normal sensation In the upper extremity, ‘ere will not he noma movernent unless the trunk ie sble to perform ite necessary eunutrol tunetions, ‘This samo concept applies to th head and neck. The Inability to held tne head tn midline is often considered to be a major probletn in hemiparotie pauients, ara thus i is important to recognize that the trunk & ‘utcantetval to head contro). In adation, sfvines the hemsiparetie patient maintains his scap- lula and clavicle in an elevated position, ‘many of the muscles attaching around the anterior neck area lose their point of y= namie stability (dynamic stability ie the ability ofa partof the body to remain stabie bout active in order to allow other parts of the body to move). These muscles are solely responsible for stabilization of the hyoid bone (a bone that is suspended from the kul via ligaments), which ic important in ‘movernents ofthe tongue and in swallowing. ‘Therefore, trunk control is the basis for the movements necessary for speech as well as ‘most other Funetional movements NORMAL TRUNK CONTROL Important requirements for normal moxement inchide normal “tone,” reeipeo- cal Innervation, normal sensation, normal ‘muscle length on both sides of the Joint, ‘normal joint range, and righting and equi librium reactions. ‘These same requisites apply to the trunk: In addition, the fellowing, our important principles of normal motor control development should be applied 10 the assessment and treatment of the hemi paretic trunk: 1) Normal control in any body part de- ‘mands the ability to dissociate (seperate) different parts of the body, 2) An individual must experience move- ‘ment and control at higher developmental levels against gravity prior to achievirg full balance control at a lower developmental level; 3) Midtine control is not complete with out same ability to retste; and 4) Proper postural control of te trunk Includes the need for normal range, d= nani stability, and pois of control ach ofthese principles willbe discussed separately ‘Normal control in any body part de- mands the ability to dissociate (sepa- rate) different parts of the body (ie, hhead from body, one side of body fiom the other, upper trunk from lower trurlk, etc). During development, dissociation does not begin until there is control of rotation around the body axis. This Teads to further dissociation in the extremities and oral area. Movements of the trunk are usually defined according to movements oceurrins, within the spine: extension, Alexion, lateral exion, and rotation, Although it is important to understand ‘the movements of the trank as a unit, is TABLE 4. Norinal Ranges of Trunk Motion Fieion Extension _—_Latoral Flexion Rotation Cervical 409 750 35.450 45.500 Thoracic 105" 60° 20 35 Lumbar 20 5 Entire spine 145 140 75:85 90 staeesurerment 1s for thoraco-umber spine as also important to understand the ability of the tmink to dstociate movements in the upper and lower trunk. For the purposes of this lesson, we will define the upper trunie from T7 up and the lower trunk from 78, own Inthe trun, dissociation means tht the upper trank can be moving differently (in a different direction or a different plane) from the lower trunk. For example, while the upper trunk is rotaiing, the lower trurk and pelvis may be laterally flexing. The point at which there is dynamic stability for this dissociation is 'T7-8. I is the ability to Aissociate that allows the upper extremities and head to function independently of the lower trunk and pelvis (or vice versa). Por instance, when one is siting and reaching a short distance to the side, the lower trun and pelvis may maintain a midline position ‘while the upper trunk rotates. The opposite ction s often seen in such sports as skiing, in which the upper trunk ie performing a ‘ype of holding action while the rotation oc- cours in the lower trunk and pelvis. A more ccomanon example of this principle of disso- ciation is the counter-rotation of the trunk uring walking; the upper and lower snark rotate in opposite directions. This impor tant concept will be discussed In greater depth in the self-movernent analysis section of this lesson. An individual must experience movement and control of movement against gravity at higher developmen- tal levels prior to ackleving full bal- ance control at a lower developmental level. During nocmal development, as the child comes up against gravity he doesn't develop balance reactions at one level un- Jess he is putin situations in which balance reactions at higher levels against gravity are ceded. For instanee, even thought he has sitting balance at 6 months of age, 2 childs full sitting balance isnot achieved until 8 or Topies in Neurlogy 2 whole 40 tots wh tive he seer yp on all fours oF pling to stand. He dossn® get his fall standing balance unt he has been viking. A each lew he needs to be work {ng on someshirg higher in balance io gain full balance control at the lower level gaint gravity ‘In order to have control ofthe trunk én maintaining midline, there must be lateral and rotational control of the funk, The most clea exanype of ths prt ipl is sen in normal development. As the Infant is guning midline control in the er tie trunk, he kas already start his eontrol in lateral ane rotational movernents. When an infant sits and uses his hands in midline a& seven months, he is using, comporents ‘ined earlier when pivot in prone with Intra flexion andl roling with rotation Proper postural control of the trunk includes the need for normal range, dynamic stability, and points of contret. Normal ranges of motion within the spine have been studied by several re- searchers. A eorapilation by Kapendji® of some of these findings for the entire spine and each region are included in Table 1. The ‘Agures represent a maximum range for a particularly supple individual. Rango of ‘votion 11 all movements of the spine de- creases with age, and this must be taken into consideration during assessment.” Be ‘eavse the spine is made up of mary joints, each contributing to the total rarge of mo" tion, ary limitation in range requires further analysis at the region involved. Although thore are standard clinical tools for ortho- pedically measuring range of motion of the spine,” the hemiparetic pstiant’ spine ie more difficult to messure objectively be- cemise of changes in tone In the thoracic spine, Nexion/axtension Increases in a cephalocadiad dicection, and Lesson 1although the Sntersegenental motion in lat feral flexion fs slighi, the total capacity of the thoracie spine for lateral exon is suby ‘fantial*In she lumbar spine, flextorvexten sion is the major activity with little axial rotation, Rotation within the thoraeie spine is four times greator than in the lumbar spine! Recause the trunk is the central part of uve buts, dynamite seabittay is iis esses tial contribution to fianctional mevernents, of the bady. When a persen is sitting and reaches forward for an object with is right hand) the movement initiates at the hand and the heal and upper trunk. As he reaches forward, dhe center of gravity shifts and the trank neds to eoonierhalance the overeat t prevent faling, Reaching on the right is controled, therefore, hy lateral Alexion and extension an the lft side. I this did nos kappen, the person would fallin the ditection toward which ke reached (lhe right side) This is offen seen in the hemi- paretic patient, As he reaches with his non- Jesson i hhomiparetic side, He falls forward and to that side due to lack of control or dynamic stability on the heniparetc side Pree fune: UUon in the upper and lower extremities thus dopends on this dynaruie stability within the crunk, ‘To gain an appreciation for the concerts fof watlous potris of dniedatton aul ter ef Feeis on motemnent and points of eontrol Within the trunk, the bow section eon Iains an exercise in mogerrent.analvsis to ‘be performed by the reader In each section movements of the trunk are explained and illustrated. The rrader is encouraged to perform these movernents as they are de scribed in order to get the feeling of where and how the mewement occurs. When discussing these movertent pat- tems, a distinction must le made besween control related to movements into or against gravity, For example, although tank Axion may oceur as you move down and forward with your head, this does not nee esuly mean that anost contrat has oc ‘opies in Neurcogs FQUAE Fntiting reaching forward wh the ippor an els Spal Ne tae da tet eal re pals svn etesion Oe fourred in uhe trunk Mexors, Following the Initial Mesion evowement, the trunks exter sons fire hn order to aatte a into Mexion'° Inevesyelay if the anatomical site of in tiation of rrovement is deperient on the functional tesk. Most functional tasks of the upper extremities involve Initiation of overnent i he hand, often with the upper trunk initiating the weight shit. For most functional 1asks Involving gross molor mavernents, initiation of weight shit oceans In the lower trunk and pelvis. We will ane alyze the three mavernents of the entire ‘unk with examples of mavennetus of the separate parts of the trunk, The demands for coutrol in the trunk duriag diferent aTOUGH FIGURE 2. Initiating a backward-reach ing movement with the upper unk re- sulls an spinal extension (A), while Bei ating from the lower trunk ond pobvis results in spina flevion (B). ‘movernents vary depending on the part ot the trun initiating the movement. Extension Flexion. Two different mave- ment strategies can be used when you reach forward when in a seated position’ 1) when you reach forward the hand, aur, tid ‘upper trunk initiste the mevernent. and the pine flexes ifyou are reaching dow oF 2) You can initiate 2 forward movement. with the lower trunk ard pelvis and the spine will extend. To demonstrate this, try the folowing activity: + While seated, reach for an chjecton the {oor in font of you ‘The raovement is iiti= ated at the hand, and therefore the unper trunk follows (Figure 1), Your entire trunk ‘will flex to allow the upper extremity to reach the object, you initave the forward movernent at the lower trunk and pelvis, ‘your trunk will extend, ‘The opposite trunk movements occur if you reach upward and back, asin Figure 2 lye initiation may occur at the upper trunk {again following the hand and arm) and the spine wil extend of if you shut your weight, Yack with your lower trunk and pelvis, the spine wil ex. ‘When a normal person wants to reach Aorward and upward for an object, he int tes with his hand, and his head aid upper teunk more forward first and ule spine flexes. As he continues to reach, to shift the eight more forward, the lover trunk and pelvis become mare active and finally the spine extends. A hemiparetic patient attempting the same functional task may exhibit a diferent movement pattern. As he attempts the movement, his trunk Mexes. If te does not ave lower trank and pelvie cantro, he esn- not perform the active weight shin the lower trunk and pelvis and therefore the "Topes in Neurogy trunk stays in flexion. Ihe grasps a stable surface, he may continue to move forward by pulling himself with his non-heaniparetic arm, This is a compensatory movernents the ‘upper extremities are taking over the job of performing the necessary weight shi that normally is accomplished by the lower tmunk and pelvis. Often the affected side ‘will compensate with upper trunk extension, and bring the upper extremity into scapular adduction, elovation, hameral extension, in ternal rotation, elbow flexion, and foreurm pronation. Lateral Flexion. Two different movesvent strategies may occur when you reach down to the cide: 1) the inition may cceur in the upper trank and the ipslateral spine Inuerally chortons, or 2) the movement can be initiated with your lower’ trunk and belie, oculting in ipstatezal elongation. To demonstrate this, try the following move- monte, using Figure 9 a a guide, + Reach down to your right side from an “upright sitting position With this movernent, lessen 1Initiation oceues at the upper trae with lat ‘eral leon to Ue right, Now reach down to the right, but initiate the movernent at the lover tmnk and pelvis by stifting your ‘weight onto the right butteck. Latoral Mes: Ton tothe left occurs, When you initiate with your upper tru: ‘Curing taetal Nexion to the right, the mayor control of the movernsnt is elongation om the left. Studies of electromyograpnie (BMG) analysis of trunk moments dem ‘onstrate that laoral Fesion is anosely re slr of eccentric contraction of usc on te oppose side when it is nislted at the Dead and upper inank 2” But when you shit Your weight to your right by initiating wth your lower Lrunkand pelvis, youare actively shortening on the let sie. In patients with bemiparesis, changes in tone will affect the movestert. As they at: tempt to reach directly down ta their nes: Temiparetic side Gnitatiny with Uke uppee ‘trunk if their tone fs high on the hemi- paretic side there may be only a small amount of lateral flexion to the reaching side, I they have Tow tone, hey ray have excessive moxement and will usually rot Lesson 1 reach due fo fear of falling, the hennipare= {Ue patient atlempts Lo initiate in the lower trunk and pelvis, ho may laterally Mex sins rainy low trunk extensors with increased tono. The heminaretiepetiont will often ses- ist weight shutting with the lower trunk and pelvis to tho hemiparciie side. Rotation. wo diferent movement steate les may occur when rotating the total trunk: D initiation may occur a the upper (Crunk, or 2) the movement may be initiated at the lower trunk ard polis, If retaion o2- ‘curs diggoraily forward when initiated with the upper trunk, the spine rotates and moves Into & position more toward Mesion And rotation. IP rotation ceeurs disgorsaly forward wiih lnkiaton at the lower trunk nd pelvis, the spine moves toward exten sion and roxain, ‘The follawing movemorts, Mastruted in Figure 4, desnonstrate this + Prom a sitting position, reach forward sand toward your left with Doth hands at ahout shoulder hejght. Tho initiation is at the upper trun and the movement of the tink one of flexion and rotations IF you Tupiesin Newrotgy FIGURE 3. ff person roaches donor to- dl the side tnd initiaies the move iment with the upper trunk, the result 5 spinal leteral shartening ipsitaterally (A). Initiating the seme movement wit. the lowor trunk and pelvis rovults tw lenatheniny the ipsitaterat side (B) initiate the movernent by moving your lower trunk and the let side of your pelvis for: ward and to the left the result is extonsion ‘nd rotation. ‘The same principle holds true for mave- ments in the opposite directin as shown in Figure 5. IF you shuft your weight back to sour right diagonally (asi reaching up and clo, initiating with your upper tmnk, the teunk will extend and rotate, If you shift your weyaht back to your right diagonally, Inisoting with your lower trunk and pelvis by shifting your weight onto sour night bat tock, the whole trunic wel lex ancl rotate ‘ward the lt When the upper trunk lultlates the ‘weigit shift, the loser trunk and polvis set to counterbalance, This is extretuely Anpor-IN TOUCH FIGURE 4. fuitiating a diagonally for- ward movement with the upper trunk ‘yosuilts in spinal flexion and rotation (A), white inisiating i with thu: lower Prank and pelvis results in spinel exten- ‘iam and rotation (B) tant in order to allow the upper extreruities tn be free to funetion. A major role of the lower trunk and pelvis isto act asa dynamic stabilizer to alow this to happen. When the lower trunk and pelvis initiate enough of a ‘woight shift that the center of gravity is ‘moved out of the base of suppert and more control is needed, the upper irark and possibly the upper extremities act to ‘counterbalance. During many functional activities, the ‘above movements of the trunk are often ‘combined. For example, if you reach for- ward and toward your left with both hands ‘at about shoulder height, the initial move- ‘ment of the trunks one of exion and rota tion. As you continue the movement and 6 You need snore length in your reach, you Shift your weight with your lower trunk and pelvis to the left, causing the trunk Lo go into a position of extension and rovation, During the movement, there is a transi tional stage in which you may have exten- sion in the lower trunk and flexion in the upper "The stroke patient will very rarely rotate ‘because normal rotalion reamires extensors ‘and flexors to be active simultansously on ‘opposite sides ofthe trunk. Often the her: paretic pationt will maintain his uppor ‘trunk “pulled baek” on his hemparetie side. “This increased extension on the hertipare Lc side gives the appearance of more active range in rotation toward the hemiparetic side, The hemiparetic patient with more Fesxion in his trunk on the hemiparetic side may give the appearance of being able to actively rotate more toward his non-hemi- paretie sie. Counter-rotation. Luring functional 2c tivities, the trunk most often performs "Ties in Neurology smoverncnts tat involve separation ef the ‘upper and lower trunk in combinations of movements in differert planes and diree- tions. One ofthe many possibilities of move- ‘nent combinations is ester rotation. Dur ‘ng counterotation, the lower trunk and. pelvis rotate in one direction and the upper ‘rank counterbalances by rotating in the ‘opposite direction. The following move ‘ments, Mlustrated in Figure 6, demonstrate this * While walking, begin by initiating the weight shift through your lower trunk and pelvis forward on your right side. As you Walk, notice that upon heel strike on the "ight, the right lower trank and pelvis rotate forward and the right upper tran rotates back. Initiation of the weight shift with the up per trunk is not as cornmonty seen as initia ton with the lower trunk and pelvis, al ‘though it does occur in more subtle coun- torbalancing in the trunk during fanetional ‘movements of the upper extremities and. ‘more obviously in such sports activities askayaking. Control in countersrotation, or the ahibity to separate upper and lower teon, is the highestlevel of trunk contnoland there- fore is not often seen in the hemiparetic patient. ‘The proceding examples demonstrate that different responses are seen im he tank dopeneirg on where the inition of movement oecirs, When the initistion of ‘he weight shift is through the lower trunks ard pelvis, the major eontrel of Lie move- ment is the same as the spinal position (Ut is, a Lackwant weight shi results in trunk flexion and the flexors are the mar Soule of control) When initiation oecurs it the uppor trunk, the majer control of the suoveunent is the oppesie ofthe spanal pos sion (that is, baekewurd weight shift resulta Jn tmink extension and the flexors are the major source of eontroD. The motions deseribed in this section are often seon within normal patterns of mncee- ‘ment. It is important to realize, howevee, that normal individuals can consciously ‘make variations of these, but. that such vari- Lesson | ations are no} the common antomatie re sporse. It must also be stated that the ex amples given donot represent all the pass ble movements of the trunk. However, a Understanding of the normal ranges and movements of the trunk ard the impor ‘ance of identifying the poinis 0” initiation ‘of muwemenis within the trunk il help the ‘therapist make a more accurate and thor- ‘ough assessment of his or hee patients ancl their neees, It is extremely important for therapists to realize that many functional _avoss motor mente require initiation a the Tower trunk and pelvis ard most upper extremity functional movements are Inti ‘ted in the upper trunk, and that differeat "musele groups are resporsible for he ean trol in each case, The application of this Information to assessment of the heminare- tie patient is discussed in the following section. ASSESSMENT A protocal fur assessinent of the Nerul pparelic ationt has been suggested by the ‘Tipiesin Newelosy FIGURE 5. sing He upper trunk to int ate a backward diagonal mocement re snlis #2 Spinal extension and rotation (A), while initiating with the lower imank and pelvis rests tn spinal fer tom and roéation (B), otaths.1 Recanco a diseusion of ench as pect of a comprehensive assessment Is be- ‘Yond the seopeof this losson, alist of neces Sury assessouent items Js presented as a uide (Table 2). Some of these stems are discussed us Uhey relale specifically t0 the trank In addition, sere cannon pitfalls to be avoided, as well as a meted for assess ing tank range of motion in various parts of the trunk, are preserted, General Considerations Assessment of the hemiparctie patient begins with observation of his highest fune- LUoral level, noting the patient abilities anct Inabiities and always posing the quostions "Pow" and “why” for each, Dunn the as- sessment process, iis important to remert 7INTOUCH TABLE 2. Assessment tom List ‘Obeorvation and Assessment of: Highest functional level withaut assistance and with assistance (Overall tone cistrbution, uoper vs lower trunk Consistent abnormal pattesns of movement (eg, lack of dissociation) FIGURE 6. During walking there is courier rotation af the spine with di annie stability at 77-8, ber that the non-herniparetie side as well as the heraiparetic side is affected anc there- fore sould not be ignored. The therapist should carefully watch the patient’ head ‘and trunk — but, most importantly, the lrunk. Movement of the trunk will deser- mine the aligarnent of the head, The thers- bist should note how the patient performs the activity and from where tho patiort ini tates the movement. Observation should be made not only of the trunk asa whole, but also of the separave parts of the upper and lower trunk, noting whether those pattorne are consisvent Uaroughout various positions and transitions. As mentioned in the pre- vious seclion, two different responses are “often seen in these two parts ofthe trunk, When assessing tone in the trunk, the ‘therapist fist should look at the trunk to tally and then stould separate the upper 5 Alignment, ranges of motion, and asymmet 1 2 3 4. Information irom what tho thorapist foots under his or her hands 5 6 Balance reactions 7. Sensaton and perception Analysis of: 1. Asymmetry of function 2. immobility 3. Consistenty aonermal patiemns of movement. 4. How tone influences the above three factors ‘Summary of: 1, How the above fincings relate to the quality of function 2. Treatment plan 10 achieve goals related 0 functional and and lover trunk Por example, in the same person the lower trunk may have low tone at rest and the upper teunk say have high tone at rest. If the patient has been as- sessed as having simply higher tone in the trunk and the therapist is working on gain- ing range in the shortened side ofthe trun, the “gains” mast commoniy will oceurin the low tone lower trunk, which probably has ‘normal or more-thar-normal range. Over strotching the lower trunk ray make con- tral even more cificuit to obtain. ‘Associated Reactions, ‘Phe tank is sometimes the unsuspected ‘cause of abnormal movement patterns in the extremities as the patient compensaues ‘to perform a functional activity. When lower trun control is lacking and the patient ‘wants 1o reach down, the upper trunk eom- ppencates for lack of control in the lower {cunk with increased extension of the neck ‘and upper trunk. For example, if the lower ‘trunk and peivis on the hemiparetic side Gove not have normal extensor control, ‘when the stroke patient reaches dowm with his nonhemiparetie side to put on his shoe or sock, an associated reaction in the hem paretic uppor tank and extremity sill oc ‘Gar Most commonly (early on in recxyery) ‘this willbe in a pattern of trunk extension, Scapular adduction, slight humeral exten- sion, and internal rotation (may have 2b- ‘duction or adduction of the humeras) with ‘Toles in Newrobey ‘ebow flexion, proneion, wrist exon, and finger flexin. The extent of wach depends fo the degree of hyper- andlor typotonal involvement The astorated rostion ofthe upper extremity is seen beers tere s Tack of contri te oor trunk Biomechanical Alignmont “Another common but litte recomized problem is that of biomechanical rail ‘ment tat produces pattern a ook ike stasticity but in fet snot die to incroaoed tone. For exemple, Is not uncarnmon te tha pater of shoulder slevation and humeral action arty in patents re cewery The more the patient utoe tha pot tern, the more he also feces inthe Upper trank when trying to rove, casing an in crease In sespala elevation an abduction fn the thoraie wall This in turn tte the head ofthe umes into more iveral 9- tation. AS the seapnla comes forward, the hammers predisjosel biomechanical 1 tstension and internal rotation due to in araiomical postion inte glenod fossa, As this happens, the elhw tars to fax, the forearm to pronate, and the wnst and tne ers to flex. (Try thison yoanslf using ony Your shoulder ekeazors and scapular aby ‘uetors) This postion lok exactly ike a stasti pattem. If you biomecharicaly re- align the entre opper tru, scapula an chivicle, however, no ressiance or tone i Toand ‘The effects of biomoshanisal ali bessonsent on the observed pattems need to be assessed and separated! from those seen as fdiroct result of tone When assessing the impact of bio- mechanical alignment on obsorved postural ahgranent, 138 umportant to take no con- sideration the posbare ané lfesivle of the patient prior to the steoke. A O-vear-old tetired Army officer may have very diferent trunk pasture (extremely rig extended) than an 80-year-old grandmother who hasnit been physically accive and has a i= phoxis, A kyphosis prosent prior to the stroke, with 1s already abdubod seapubse, will further predispose a heriparetic pa ‘lent to some of the elects of bomechan- Jove ‘Sin 0A 22 10 Thertensan A. O4dsonL Carn Acca stselustarytrine erent a eanag. ete ys ‘Sond wane ADDITIONAL READINGS 1 Nasour Lesh M, Nok Met A duced Sunt itt scgnentl ands fe ners ut peologcal Maan alt J Btomacrantes Tsoi 12 12 Oly §, Nonga Cota P Mocha enero alg of ceoke pate tr Pp td a 18 Caran H, Nsom {. Thortension A al Motor ‘anal Soe S128, Hea 15 fersons Lie: ural onto ao meses Lesson 1