Breaking It Down with Yoga Exercises: Bed Mobility + Sit-to-Stand = Toileting

Breaking It Down with Yoga Exercises: 

Bed Mobility + Sit-to-Stand = Toileting 

By  Tina Bittmann, PTA; Karen Thornton, PT; Sally Shriner, PT; Dr. Kim Byrd-Rider, PT

Chapter 1 

Breaking It Down: 

Bed Mobility + Sit-to-Stand = Toileting 

By  Tina Bittmann, PTA; Karen Thornton, PT; Sally Shriner, PT; Kim Byrd-Rider, PT 

Throughout one’s lifespan, rolling over to sit up in bed and then standing up begins the day. Loss of these transitional activities due to age, disease, trauma and/or associated secondary weakness reduces independence in daily activities including the most basic; toileting. Depending on the use of a bedside (one word) or a bathroom commode, the muscular demands of ambulation may or may not be required for toileting. Although the following yoga home exercise programs can also apply to improving ambulation abilities, ambulation is not directly addressed in this paper. 

This paper outlines bed mobility and sit-to-stand (STS) strength and mobility needs. It defines and groups the specific muscles needed for those functions and then provides a logical yoga exercise program with exercise tips to accomplish those needs. The paper summarizes  yoga accomplishments with exercise analysis charts and conclusions drawn from those charts. Finally, an example of a goal setting plan with reference to the yoga exercises supporting parameters for insurance reimbursement and patient outcomes, plus documentation requirements  are presented. 

The following yoga exercises progress as the patient can tolerate. The bed mobility program requires less strength than the STS program but provides an opportunity to prepare for the more demanding STS program. First, supine bed-oriented strengthening/stretching exercises are applied. Then, the program moves to sitting at the edge of the bed incorporating balance and strengthening/stretching exercises. Next STS strategies are supported with yoga exercises. Toward the end of the program, standing balance and strengthening/stretching exercises are added. All of these progressive yoga exercises prepare the patient for successful toileting skills.  

Advancements in the sequences occur when the patient accomplishes prior and/or less difficult tasks. Modifications to ensure success apply for issues of joint pain, limited range of motion or other impairments inhibiting progress. For patients with recent trauma, exacerbation of disease process and/or sedentary life style, the following programs are  evidence-based regardless of age. Yoga exercises are a vehicle for engaging patients in self-care that could last long after the therapist is needed and help ensure continued independence and health. 

Chapter 2 

Bed Mobility 

Although log rolling is not recommended for trauma patients who may have a spinal cord injury (Conrad, Del Rossi, Horodyski, Prasarn, Alemi, & Rechtine, 2012), bed mobility usually requires the actions of supine-to-side log rolling and then edge of bed (EOB) sitting in the following sequence: 

1. Arm, horizontal adduction to reach for the EOB; 

Figure 1: (Johansson, & Chinworth, 2012) 

1. Minimal-moderate knee/hip flexion ROM with minimal foot push off strength 

  Figure 2: (Johansson, & Chinworth, 2012) 

1. Minimal-moderate spinal rotation; 

  Figure 3: (Johansson, & Chinworth, 2012) 

1. Bilateral arm pushing up from the bed and gravity assisted leg swing to sitting at the EOB 

  Figure 4: (Johansson, & Chinworth, 2012) 

The muscle groups needing concentric, eccentric and isometric strengthening for this bed mobility performance include: 

1. Upper Extremity (UE): Reaching across the body is an open-chain movement that requires minimal strength in the gravity assisted position of supine. The pushing up to EOB portion uses bilateral closed-chain, moderate-maximal strength with partial weight bearing (PWB). Although all of the UE muscles participate in pressing up, the elbow joint muscles perform the primary concentric/eccentric action. Special attention needs to be paid to strengthening the elbow joint muscles concentrically/eccentrically to a moderate-maximal level. The patient’s overall body weight and abdominal/back strength play a role in the amount of UE strength needed to push up to EOB seated. 

The UE muscles include: 

1. Shoulder Girdle Muscles: sternocleidomastoid, serratus anterior, pectoralis minor, rhomboids, trapezius, levator scapulae (Teach PE, 2019). 

1. Shoulder Joint Muscles: teres major, pectoralis major, deltoid, subscapularis, supraspinatus, infraspinatus, latissimus dorsi, teres minor (Teach PE, 2019). 

1. Elbow Joint Muscles: biceps brachii, triceps brachii, pronator quadratus, pronator teres, supinator, anconeus, brachialis, brachioradialis (Teach PE, 2019). 

1. Wrist/Hand Muscle: flexor polices longus, extensor carpi radialis longus, extensor pollicis longus, extensor carpi radialis brevis, flexor digitorum superficialis, flexor carpi ulnaris, extensor digitorum communis, flexor carpi radialis, extensor carpi ulnaris (Teach PE, 2019). 

1. Abdominals/Back Muscles: Rolling and pushing up to seated requires abdominal and back muscle strength to stabilize the upper body. 

1. The abdominal muscles include: external obliques, internal obliques, transversus abdominus, rectus abdominus (Teach PE, 2019). 

1. The back muscles include: quadratus lumborum, splenius, multifidus, erector spinae (Teach PE, 2019). 

1. Hip Flexors: One hip flexes as the knee bends before the log roll but they flex together bilaterally at the end of the sequence to bring the legs off or back onto the bed. The single leg maneuver is gravity assisted and does not require as much strength as the bilateral against gravity maneuvers off and back onto the bed. 

The hip flexor muscles include: psoas major, iliacus, rectus femoris (one of the quadriceps group), sartorius, tensor fasciae latae, pectineus, adductor longus, adductor brevis, gracilis (Mess, 2018). 

1. Hip Extensors: The hip extensors are used as the foot pushes off against the bed to assist in the log roll. If the abdominal/back muscles are weak, the patient will rely more on the hip extensors to assist the rolling action. 

The hip extensor muscles include: biceps femoris, semitendinosus, semimembranosus (hamstrings) and the gluteus maximus along with the hamstring portion of the adductor magnus (Mess, 2018). 

1. Knee Flexors: a minimal to moderate amount of knee flexion strength is needed for bed mobility to place the foot on the bed during log roll initiation and to sit at EOB (ROM 20°-90°).  

The knee flexor muscles include: hamstrings (biceps femoris, semitendinosus, semimembranosus), gracilis, sartorius, gastrocnemius, popliteus and plantaris. 

1. Spinal Rotators: The spinal rotators muscles engage during the log rolling action and the press up action. Rotation is a complex action as seen by the following amount of muscle recruitment plus it occurs at all three levels of the spine: cervical, thoracic and lumbar. 

The spine rotator muscles include: 

1. Cervical rotation: splenius capitis, splenius cervicis, sternocleidomastoid, semispinalis capitis, semispinalis cervicis, scalenus anterior, scalenus medius, scalenus posterior, longissimus capitis, rectus capitis posterior major, rectus capitis posterior minor, obliquus capitis inferior, obliquus capitis superior, longus colli, upper trapezius, levator scapulae (Alex, 2015). 

1. Thoracic rotation: internal obliques, external obliques,levatores costarum brevis, levatores costarum longus, multifidus, semispinalis thoracis, rotatores brevis, rotatores longus (Alex, 2015). 

1. Lumbar rotation: levatores costarum brevis, internal obliques, external obliques, levatores costarum longus, multifidus, semispinalis thoracis, rotatores brevis, rotatores longus (Alex, 2015). 

Range of Motion (ROM) needed to perform bed mobility are as follows: 

1. Spinal rotation (minimal-moderate) used with the log roll. 

1. Spinal side-bending (minimal-moderate) performed during press up to seated. 

1. Upper Spine flexion (minimal) used at the beginning of the log roll. 

1. Horizontal adduction (maximal) reaching across to the EOB. 

1. Knee flexion (0°-90°) range for bending the knee to push off and for sitting. 

1. Hip flexion (0°-70°) range for helping foot push against the bed with a bent knee and for sitting. 

Chapter 3 

Yoga Exercise Sequence: Bed Mobility 

The various yoga exercises in this list show an activation of specific muscles quantified by electromyograms. (Rathor, Trivedi, Abrahm, & Sinha, 2017).The following sequence gradually increases in range of motion and strength. Each yoga exercise is a warm up for the next yoga exercise. 

1. Kapalabhati Breathing: is a forced exhale breathing technique performed via the mouth or nose for abdominal, diaphragm, pelvic floor, multifidus and intercostal muscle strengthening/stretching (Deshmukh, & Bedekar, 2017). Patients may sit or lie in supine but should not stand (due to decreased back support) during this breathing exercise. When exhaling, the transverse abdominis contracts maximally and the waistline becomes smaller from posterior to anterior as a result. An added benefit is the strengthening of the multifidi and the pelvic floor as they are automatically triggered to contract with the transverse abdominis by the brain (Ferla, Darski, Paiva, Sbruzzi, & Vieira, 2016; Yang, Lin, Chen, & Wang, 2016).  

This exercise also trains an optimal exhale breathing pattern in conjunction with the transverse abdominis contraction, maintaining optimal intra-abdominal pressure during activities of daily living. Intra-abdominal pressure regulation is imperative in hernia, bladder prolapse and uterus prolapse prevention (Qandeel, & O’Dwyer, 2016; Shek, & Dietz, 2016). Improved cardiovascular parameters and pulmonary parameters are benefits of this exercise (Jain, 2016). It is also one of the few abdominal exercises that can be performed in sitting. 

Figure 5: Kapalabhati breathing 

1. Bridge with Fist Push: targets the quadriceps, hamstrings, gluteals, and triceps for strengthening but includes strengthening for the abdominals, adductors, extrinsic, intrinsic foot muscles: arch and toe muscles, AH, FHB, AH, ADM, FDM, ODM, L, QP, FDB, DI, PI, posterior tibialis, anterior tibialis, pronators, soleus, tibialis anterior, spinal multifidi, spinal extensors, and the transverse abdominis(Byrd-Rider, 2018). Important stretches include the iliacus, psoas, rectus abdominus, rectus femoris (Byrd-Rider, 2018).The Bridge exercise can be performed with multiple modifications to accommodate debilitation including lifting the heels for additional foot and ankle muscle strengthening, minimal hip lift or pulsing up/down. The fist press adds shoulder girdle, shoulder joint, elbow joint and even hand muscle strengthening with a high intensity triceps contraction to assist with EOB pressing up. This yoga exercise also facilitates abdominal strengthening and promotes pelvis squaring abilities for standing balance. 

1.  Knee Press: requires a minimal amount of spinal rotation which prepares the spine for the increased spine rotational mobility work in the next two yoga exercises. Upper spine flexion and hand pressing increases rectus abdominus, transverse abdominus (along with multifidi and pelvic floor) and oblique muscle recruitment in a gravity resistive position, enabling the intensity to increase or decrease according to the patient’s needs. An electromyogram study shows that activation of the external oblique muscles peak when the contra lateral arm and leg lift off of the supporting surface together, as they do here (Rathore, et al., 2017). This yoga exercise strengthens hip flexors in a gravity lessened position, enabling intensity to match the patient’s ability. By increasing the hand press intensity, the hip flexor strengthening and UE strengthening increases according to the patient’s ability. This exercise also produces closed chain UE strengthening needed to push up to EOB seated and involves horizontal adduction strengtheningneeded for reaching to the EOB. Both the Bridge and the Knee Press are presented first in this sequence to build heat within the body, helping to increase the mobility potential for the following rotational exercises (Petrofsky, Laymon, & Lee, 2013). The spine flexion in this exercise is a preparation for the sit-to-stand Phase 1 in the next section. 
   

1. Windshield Wipers: The knees rock side to side in a hook lying position, increasing spinal rotation ROM  with minimal-moderate abdominal strengthening (primarily the obliques and transverse abdominis) plus minimal hip flexor strengthening. All motions of this exercise prepare the patient for the intensity and range of motion needed for the Baby Roll exercise and for improved log rolling performance. By adding bilateral heel lifts, the plantar flexors (gastroc/soleus, plantaris, flexor hallucis longus, flexor digitorum longus, peroneus longus, peroneus brevis and tibialis posterior) strengthen concentrically/eccentrically/isometrically for improving sit-to stand ability Phases 2-4. 

1. Modified Baby Roll: The knees bend in this paper’s version of Baby Roll to decrease the intensity of this functional exercise.   The knee bending modification assist de-conditioned patients while still facilitating abdominal strengthening (obliques, rectus abdominis and transverse abdominis along with the multifidi and pelvic floor). The increased spinal rotation motion and non-weight bearing shoulder horizontal adduction of the exercise are used in successful log rolling. When the patient is ready to progress, a more advanced version of Baby Roll can be performed with the legs extended out long in a neutral hip position with ankles crossed..Once the patient is side-lying at the end of this exercise he/she can drop both legs off of the EOB and press up to seated at the EOB. 

Figure 7: From side-lying to sitting with assist if the patient is too weak to press up alone. 

1. Seated Side Plank with and without Rotation: targets biceps and triceps strengthening but also strengthens a (rectus abdominus, obliques, transverse abdominis) multifidi, pelvic floor, quadratus lumborum, cervical spine muscles, hip flexors, infraspinatus, teres minor, serratus anterior , trapezius , deltoids , intrinsic hand muscles (thenar, hypothenar, interossei, lumbricals),extrinsic, subscapularis, supraspinatus and pronators (Byrd-Rider, 2018). Important muscles that are stretched due to the side bend are the quadratus lumborum, multifidi and spinal extensors (Byrd-Rider, 2018). Strengthening intensity and stretching increase with a deepening side bend. Included in this yoga exercise are perturbed righting sitting balance strategies. The surface hand needs to be placed at the EOB or mid-thigh to avoid anterior humoral head translation during the yoga exercise.  
   

1. Swimming Dolphin Tail: In seated, the patient extends and flexes the knees together as if swimming with a tail. This exercise may also be performed in supine with a large bolster under the knees if the patient cannot reach the EOB or cannot sustain the abdominal and back strength needed for bilateral knee extension in seated. The knees should be moved in a simultaneous bilateral manner to replicate the simultaneous bilateral movement of STS Phases 2-4. Importantly, plantar flexion needs to be coupled with the knee extension as it is coupled when one stands up and dorsiflexion needs to be coupled with knee flexion as it is coupled when one sits down. Neurologically coupling the correct motions together is beneficial to muscle memory and brain strategies for STS (Hommel, Brown, & Nattkemper, 2016). The ankle movements are the same as an ankle pump exercise commonly used in hospitals to help decrease the occurrence of deep vein thromboses (DVTs) (Toya, Sasano, Takasoh, Nishimoto, Fujimoto, Kusumoto, Yoshimatsu,Kusaka,… Takahashi, 2016). The knee extensors are concentrically/eccentrically strengthened against gravity but without weight bearing. If the patient holds the knee extension position, then isometric knee extensor strengthening is added. The therapist may apply manual resistance thus increasing the exercise’s strengthening potential. This exercise is a preparation for the weight bearing concentric/eccentric/isometric knee extensor and plantar flexor strength needed to perform STS Phases 2-4.  

Tips for Bed Mobility 

Rest and three-part breathing should be inserted between exercises to minimize fatigue and discomfort. In addition, allow rest breaks to support the patient’s ability for exercise program completion. To help with relaxed and continual breathing in supine, three cues given in the following order promote full diaphragmatic breaths: “inhale air into the pelvis and belly, breathe wide into the ribs, and then allow the collar bones to rise.” The patient exhales slowly and naturally. 

In all exercises, cue the neutral spine position as often as possible to encourage optimal postural function. Also cue the “Ha” sound exhale during the exercise to intensify the specific activation of the transverse abdominus, pelvic floor, intercostals and diaphragm muscles. Intensifying the activation of these muscles is a priority for everyone but especially for de-conditioned people in bed.  

For additional information on each of these exercises please read “The Therapy Bible On Yoga” by Dr. Kim Byrd-Rider, PT available on Amazon.com  

Summary 

Muscles do not work, strengthen nor stretch in isolation and they rarely perform a single type of muscle contraction like concentric, eccentric or isometric (Cormie, McGuigan, & Newton, 2011). When the joint angle and the muscle length do not change the muscle contractions are called isometric. Muscle contractions that occur as the muscle is shortening are called concentric and muscle contractions that occur as the muscle is lengthening are called eccentric. Although the following charts are divided into types of muscle contractions, human movement typically consists of all three together. If needed, the specific muscles of each group listed below can be found within the text of this section’s introduction. 

Chapter 4 

Charts for Bed Mobility Muscle Actions 

Concentric/Eccentric Muscle Strengthening for Bed Mobility
Yoga Bed Mobility Exercise Program
Primary Bed Mobility  Muscle Groups		Kapala-bhati Breath-ing	Bridge	Knee Press	Wind-shield Wiper	Baby Roll	Seated Side Plank	Swim-ming Dolphin Tail
UE			x	x		x	x
Abdominals/  Back Muscles		x		x	x	x	x
Hip Flexors				x	x
Hip Extensors			x			x
Spinal Rotators				x	x	x	x  w/ rotation
Prep for STS  Muscle Groups
Abdominals/ Back Muscles		x		x	x	x	x
Hip Extensors			x
Hip Flexors				x	x	x	x
Knee Extensors			x					x
Knee Flexors			x	x	x	x		x
Plantar Flexors					x  w/heel lift			x
Dorsiflexors								x

Isometric Muscle Strengthening for Bed Mobility
Yoga Bed Mobility Exercise Program
Primary Bed Mobility  Muscle Groups		Kapala-bhati Breath-  ing	Bridge	Knee Press	Wind-shield Wiper	Baby Roll	Seated Side Plank	Swim-ming Dolphin Tail
UE							x
Abdominals/ Back Muscles			x	x				x
Hip Flexors				x	x		x	x
Hip Extensors			x
Spinal Rotators
Preparatory for STS  Muscle Groups
Abdominals/ Back Muscles			x	x				x
Hip Extensors			x
Hip Flexors				x	x		x	x
Knee Extensors			x					x  Hold
Knee Flexors			x	x	x	x
Plantar Flexors			x	x  Point toes	x  Heels lifted			x  Hold
Dorsiflexors			x					x  Hold

Figure 10: Isometric Muscle Strengthening for Bed Mobility 

Important Range of Motion for Bed Mobility
Yoga Bed Mobility Exercise Program
Primary Bed Mobility  Muscle Groups		Kapala-bhati Breath-ing	Bridge	Knee Press	Wind-shield Wipers	Baby Roll	Seated Side Plank	Swimming Dolphin Tail
Spinal Rotation (minimal-moderate)				x	x	x	x  w/ rotation
Spinal Side Bending (minimal to get to EOB)							x
Horizontal  Adduction				x		x
Hip Flexion (0°-90°)			x	x	x	x	x	x
Upper Spinal Flexion (minimal)				x		x
Knee Flexion (0°-90°)			x	x	x	x	x	x

Chapter 5 

Sit-to-Stand 

Sit-to-stand (STS) requires three to four Phases: 1. Forward lean, 2. Momentum transfer, 3. Hip and knee extension  4. The action of obtaining immediate standing balance, some diagrams and research include this action in Phase 3 (Caruthers, Thompson, Chaudhari, Schmitt, Best, Saul, & Siston, 2016). Below is a sequential chart for STS phases as charted in only 3 Phases: 

Figure 12: STS phases (Taati, & Mihailidis,2014) 

During the STS transfer, the mass center of the body (MCB) moves forward mainly by means of upper thoracic flexion and hip flexion (Taati, & Mihailidis, 2014).The main contribution to the upward displacement of MCB is from extension of the hips and knees during the standing motion. (Roebroek,Doorenbosch, Harlaar, Jacobs, & Lankhorst, 1994). 

Prior to start, sitting at the EOB utilizes both abdominal and spinal extensor isometric strength plus ankle dorsiflexion to tuck the feet back or under the sitting surface slightly for standing preparation (Caruthers, Thompson, Chaudhari, Schmitt, Best, Saul, & Siston, 2016). Hip flexors contract concentrically with trunk lean during Phase 2 and then switch to eccentric as hip extensor muscles contract concentrically for upward motion during the 3-4 Phases. For immediate upright balance in standing, the previous muscles recruit isometrically as stabilizers with an emphasis on sustaining balance, which may take less strength than the transition to reach standing (Roebroek, & et al, 1994). Below is another 3 Phase chart symbolizing the previous information and again, the 4th Phase can be standing balance. 

Figure 13: Maximal hip flexion and maximal dorsiflexion during phase 2 in STS (Caruthers, Thompson, Chaudhari, Schmitt, Best, Saul, & Siston, 2016) 

The muscle groups which need concentric, eccentric and isometric strengthening for STS performance include: 

1. Abdominals/Back Muscles: These muscles are primarily used isometrically as trunk stabilizers throughout the STS activity, Phases 1-4. 

1. The abdominal muscles include: external obliques, internal obliques, transversus abdominus, rectus abdominus (Teach PE, 2019). 

1. The back muscles include: muscles include: quadratus lumborum, splenius, multifidus, erector spinae (Teach PE, 2019). 

1. Hip Extensors: Because the hips may flex to almost end range of hip flexion in Phases1-2, it is the concentric contractions of the extensors pulling the hips back to a neutral position during the upward motion to standing in Phases 2-3 and isometrically involved in Phase 4. The hip extensors also contract eccentrically to help decelerate sitting back down. 

The hip extensor muscles include: biceps femoris, semitendinosus, semimembranosus (hamstrings), and the gluteus maximus along with the hamstring portion of the adductor magnus (Mess, 2018). 

1. Hip Flexors: The hip flexors initially concentrically contract with the forward lean of Phases1-2 and then eccentrically give way to the concentric action of the hip extensors to stand in Phases 2-3. They are isometrically involved in Phase 4. Reversely, they concentrically begin the decent of sitting down from standing.  

The hip flexor muscles include: psoas major, iliacus, rectus femoris (one of the quadriceps group), sartorius, tensor fasciae latae, pectineus, adductor longus, adductor brevis, gracilis (Mess, 2018). 

1. Hip Abductors: In the standing balance of Phase 4 and the rising balance of Phases 2-3, the hip abductors contract isometrically to keep the hips and pelvis in a neutral position squared on the sagittal and frontal planes (Wang, et al., 2013). 

The hip abductors include: the gluteus medius, the gluteus minimus and the tensor fascia latae muscles. 

1. Knee Extensors: The knee extensors are concentrically involved in standing up and eccentrically involved in sitting down, Phases 2-3, and isometrically involve in Phase 4. 

The knee extension muscles include: rectus femoris, vastus lateralis, vastus medialis, vastus intermedius, (Quadriceps),and aticularis genus (Quara, 2018). 

1. Knee Flexors: The knee flexors concentrically contract when the feet are tucked back in Phases 1-2 and then eccentrically contract for added stabilization with the upward motion Phases 2-3 and finally isometrically contract in standing for Phase 4 (Caruthers, Thompson, Chaudhari, Schmitt, Best, Saul, & Siston, 2016). 

The knee flexor muscles include: hamstrings (biceps femoris, semitendinosus, semimembranosus), gracilis, sartorius, gastrocnemius, popliteus and plantaris. 

1. Plantar Flexors: The plantar flexors not only isometrically stabilize the ankle but concentrically act to decrease the amount of dorsiflexion from 20°to 0° for standing, Phases 2-3. They behave eccentrically for sitting down from standing (0°-20° dorsiflexion) and are isometrically involved in Phase 4. 

The plantar flexor muscles include: gastrocnemius, soleus, plantaris, flexor hallucis longus, flexor digitorum longus, tibialis posterior, peroneus longus, peroneus brevis (Morrison, 2017). 

1. Dorsiflexors: The dorsiflexors act concentrically as the feet move back in Phase 1, eccentrically in Phases 2-3 and isometrically as stabilizers in Phase 4. Although the plantar flexors are performing the heavy concentric and eccentric load, the dorsiflexors must co-contract with them (Taati, & Mihailidis, 2014). 

The dorsiflexor muscles include: tibialis anterior, extensor hallucis longus, extensor digitorum longus and peroneus tertius. 

Range of Motion (ROM) and Stabilization needed to perform STS are: 

1. Dorsiflexion: All of the available dorsiflexion of the ankle is utilized for Phases 1-2 to reach end-range dorsiflexion. Normal end-range mobility is approximately 20°. 

1. Knee ROM (0°-110°): Approximately 110° of knee flexion (90° sitting + 20° added by moving the feet to 20° of dorsiflexion) is used during Phases 1-2. Then the knees move through the ranges to completely straight by Phase 4 (0°). 

1. Hip Flexion: Only 90° of hip flexion is needed in sitting but as the patient leans forward to prepare for surface lift off, the hip flexion ROM increases to greater than 90° during Phases 2-3. 

1. Upper Spine Flexion: This is used in Phase1 with the initial lean forward. The amount of upper spine flexion ROM is minimal as the hips flex for most of the forward lean ROM. 

1. Simultaneous Ankle, Knee & Hip Stability: Non-weight bearing (NWB) stability is used in Phases 1-2, partial weight bearing (PWB) stability is used for Phase 2 and full weight bearing (FWB) stabilization is used for Phases 3-4. 

Chapter 6 

Yoga Exercise Sequence: Sit-to-Stand 

Sitting Exercises: mild-moderate strengthen/stretching for preparation of STS Phases 2-4  

According to a Journal of Clinical Biomechanics’ article which researched biomechanics and muscular activity during STS transfers with an EMG, nine muscles were named for their significance in the STS activity: gluteus maximus, biceps femoris, semitendinosus, rectus femoris, vastus lateralis, vastus medializes, gastrocnemius, soleus and tibialis anterior (Roebroeck, Doorenbosch, Harlaar, Jacobs, & Lankhorst, 1994).The following seated yoga exercises where chosen to address these STS needs and the cues pointed out here increases the muscle recruitment of those muscles. 

The tucked feet on the ground actively press downward through the heel, increasing end-range dorsiflexion range of motion stretching for Phases 2-3 standing preparation. The quadriceps, adductors and anterior tibialis also isometrically contract as stabilizers, as a result of pressing through the heels. The 4 Phase chart below outlines when and where the vertical forces distribute to the feet during STS emphasizing the importance of this cue.  

Figure 14: Vertical forces under feet and thighs (Boukadida, Piotte, Dehail, & Nadeau, 2015) 

1. Serve the Platter: is performed in a seated position with a neutrally aligned trunk lean back from the hip joints. The elbows come in towards the ribs with the lean back and alternate to each side with elbow extension and rotation when returning to upright as if serving a platter. This exercise facilitates transverse abdominus, multifidi, pelvic floor, and oblique strengthening while using the rectus abdominus as a stabilizer in neutral spine. Minimal-moderate concentric/eccentric UE strengthening using gravity as resistance occurs along with moderate hip flexor concentric/eccentric strengthening. 

1. Seated Tree: One leg is placed in external hip rotation with its foot dorsiflexed and pressing on the front of the other legs shin, increasing its hip and ankle range of motion. Because the leg is being held off the floor, externally rotated and pressing into the shin, the gluteals, quadriceps, adductors, gastroc, hamstrings and anterior tibialis are minimally-moderately strengthening. Neutral spine is maintained with the arms in any position that facilitates or exacerbates sitting balance for core strengthening, depending on the patient’s challenge needs. 

1. Seated Crescent: Because Crescent is a seated backbend, it provides mild-moderate concentric/eccentric spinal extensor strengthening to get into the crescent shape and then isometric strengthening at the end-range. This exercise strengthens the back and abdominal muscles for stabilizing in Phase 2-3 and standing in neutral, Phase 4. The UEs concentrically/eccentrically strengthen against gravitational resistance as the shoulders flex to 160° (or to end-range) and then isometrically strengthen at end range. End-range ankle dorsiflexion range of motion plus minimal hip flexion strengthening derived from a slight forward lean at the hips are achieved, as well. 

Standing Up Exercises: moderate-maximal strengthening/stretching for STS Phases 2-4  

Figure 15: Motions of STS (Chen, Zhong, Zhao, Ma, Guan, Li,... & Liao, 2017) 

The following exercises simultaneously target three functionally important muscle groups for the transfer from sitting to standing, Phases 2-4; the hip extensors/flexors, the knee extensors/flexors and the ankle plantar/dorsiflexors. Isometric hip abduction strengthening is also needed yet not mentioned in the above chart (Figure 15) because it is not utilized as an action but as a stabilizer. The abductors will be addressed by the following charts of this paper because Wang and colleagues’ 2013 study, concerning yoga’s biomechanical demands, chose four yoga exercises that generate the greatest hip abductor neutral stabilizing strength used in standing balance: Chair, Intense Side Stretch and One-Legged Balances (specifically Standing Tree). These exercises also achieve the additionally needed knee/hip/ankle strengthening so they are included in the following exercise program. 

The similar Stork exercise was chosen instead of the Tree exercise because it strengthens similar muscle groups but on the sagittal plane (Stork) which is the plane used in STS as opposed to the frontal plane (Tree). The study also mentions Chair and One-Legged Balance exercises generate the greater support movements over other exercises. Strengthening these muscles prevents poor relocation of the MCB during the standing process, thus improving standing performance (Wang, et al., 2013). 

The standing yoga exercises here are in a specific order to alternate hip flexion and hip extension strengthening exercises, thus avoiding fatigue. The standing balance yoga exercises also facilitate stabilization/isometric strengthening of the ankle joints. Righting reactions and balance are challenged throughout the following yoga exercise sequence due to the varied balance position challenges. Exercise #5 is STS phase 2 in practice and exercises #6-8 strengthen and stretch muscles to improve STS phases 2, 3 and 4 performance. 

1. Seated Chair: represents STS Phases 2-4 in practice. The exercise minimally-moderately strengthens back and abdominal muscles isometrically as spine and trunk stabilizers in a neutral spine alignment. Mild-Moderate UE concentric/eccentric strengthening happens as shoulders flex to 160° (or to end-range) against gravitational resistance during UE elevation and lowering. UE isometric strengthening occurs while holding the arms overhead. 

Strengthening abdominals, multifidi, pelvic floor, adductors, extrinsic foot muscles (TA, EDL,EHL, PL, PB, M S, G,, TP, FHL, FR), intrinsic foot muscles, arch and toe muscles (AH, FHB, AH, ADM, FDM, ODM, L, QP, FDB, DI, PI), quadriceps, hamstrings, soleus, gastroc, spinal extensors, , tibialis anterior, flexor , flexor halluces longus, gluteus maximus, gluteus , gluteus  and psoas muscles occurs (Byrd-Rider, 2018). Important lower extremity stretches resulting are the tibialis posterior and soleus muscles (Byrd-Rider, 2018). End-range ankle dorsiflexion stretching plus increased hip flexion range of motion result too. 

1. Intense Side Stretch (Pyramid): In a pyramid shape, one foot is about a foot and a half in front of the other. The back-leg externally rotates to end-range of approximately 10°-20°while the ASISs face almost forward. The back leg’s ASIS should be slightly posterior from neutral, mimicking back leg ambulation stance. Back hip external rotation accommodates end-range dorsi-flexion of 20° as opposed to a hyper-dorsiflexed or a pronated foot needed for a non-externally rotated hip. The foot points in the direction of the knee to avoid knee rotation.  

This yoga exercise recruits both iliopsoas muscles concentrically/eccentrically/isometrically to bring the trunk forward as well as strengthening all the lower extremity muscle in isometric co-contractions for balanced stabilization. Specifically, strengthening includes the , quadriceps, gluteus , gluteus , intrinsic foot muscles, arch and toe muscles (AH, FHB, AH, ADM, FDM, ODM, L, QP, FDB, DI, PI), extrinsic) and cervical spine muscles when retracting and resisting gravity. Important muscles stretched include peroneals, hamstrings, gluteus maximus, gastrocnemius, soleus, spinal extensors, flexor , flexor halluces longus, posterior tibialis, iliotibial band, plantar fascia and cervical spine muscles if the head relaxes and hangs down (Byrd-Rider, 2018). Muscles that are slackened and released include psoas major and rectus femoris only in the deepest part of the exercise (Byrd-Rider, 2018). 

1. Stork Pose: Focus is on concentric/eccentric/isometric strengthening of the psoas/iliacus and other hip flexors(rectus femoris, sartorius, adductors, pectineus, gracilis, tensor fascia e) as the leg lifts/holds and strengthening the psoas, gluteus medius, hip muscles and lower extremity (LE) muscles isometrically as joint stabilizers on the standing leg to improve standing balance and righting abilities. 

On the single standing leg, LE isometric strengthening occurs which improves postural standing balance, righting abilities and even ambulation (Guner, & Inanici,2015). These muscles include the adductors, extrinsic), intrinsic foot muscles, arch and toe muscles (AH, FHB, AH, ADM, FDM, ODM, L, QP, FDB, DI, PI), gastrocnemius/soleus,posterior, anterior tibialis, peroneals,quadriceps, hamstrings, gluteus maximus, gluteus , gluteus , anddeep external hip rotator (gemelli, obturator externus, obturator internus, piriformis, quadratus femorus) in addition to the abdominals with the multifidi and pelvic floor (Byrd-Rider, 2018). 

1. Warrior III: builds further on the Stork exercise by adding a forward lean (standing leg hip flexion) and opposing hip extension to the one footed balance. Using the ability to lean forward with balance is a common occurrence in activities of daily living and is useful for STS. This exercise focuses on concentrically/eccentrically strengthening the hip extensors on the lift and lowering (gluteus maximus,hamstrings—long head,biceps femoris, semimembranosus, semitendinosus, adductor magnus, gluteus medius) and isometrically on the hold. The spinal extensors, abdominals with the multifidi and pelvic floor, other back muscles and standing leg muscles work isometrically as joint stabilizers. Due to the forward MCB displacement and the back-leg lift, gravity adds the resistance needed for this moderate to maximal strengthening yoga exercise.  

Figure 16: Warrior III 

Tips for Sit-to-Stand 

Touching a countertop or a chair-back in standing may assist with balance. The hands should be flat on the counter or use fingertips only to avoid gripping with the fingers. Gripping decreases balance demands and builds dependent habits for assistive devices during exercise and balance challenges. Cueing retraction of the head in all of the seated and standing yoga exercises strengthens the muscle which keep the head retracted during ideal posture. This in turn, improves standing balance (Haruyama, Kawakami, & Otsuka, 2017). 

The spine should be kept in a neutral position as often as possible to encourage ideal postural function. Head retraction and breathing into the anterior, posterior and side rib areas should be cued throughout. Deep diaphragmatic breathing with a transverse abdominis expansion or relaxation is not suggested in any standing exercise. If the transverse abdominis relaxes to expand, the lumbar has less muscular support (Larivière, Boucher, Mecheri, & Ludvig, 2019). If a patient breathes deeply into the diaphragm and the transverse abdominis stays contracted, as the transverse should in standing, the intra-abdominal pressure will increase. 

For additional information on each of these exercises please read “The Therapy Bible On Yoga” by Dr. Kim Byrd-Rider, PT available on Amazon.com  

Summary 

Muscles do not work, strengthen nor stretch in isolation and they rarely perform only one type of muscle contraction of concentric, eccentric or isometric (Cormie, McGuigan, & Newton, 2011). As stated in the bed mobility section, concentric contractions occur as the muscle shortens, eccentric contractions occur as the muscle lengthens and in isometric contractions the joint angle and muscle length do not change during the exercise. Although the following chart muscles are divided into types of muscle contraction, human movement consists of all three, together. The concentric/eccentric muscle recruitment used to enter and exit the standing exercises of Intense Side Stretch, Stork and Warrior III is not documented in the following charts unless noted under the x. The specific muscles of each muscle group listed below can be found within the text of this section’s introduction. 

Chapter 7 

Charts for Sit to Stand Muscle Action 

Concentric/Eccentric Muscle Strengthening for Sit-to Stand (STS)
	Yoga Sit-to-Stand Exercise Program
Primary STS  Muscle Groups		Serve the Platter	Seated Tree	Cres-cent	Chair to Stand	Intense Side Stretch	Stork	War-rior III
Abdominals/ Back Muscles		x		x  begin/end
Hip Extensors					x	x  w/ lower of torso		x  w/leg lift
Hip Flexors		x			x	x  w/ lower of torso	x  w/leg lift
Hip Abductors
Knee Extensors					x
Knee Flexors					x  w/ sit
Plantar Flexors					x			x  initial
Dorsiflexors					x

Figure 17: Concentric/Eccentric Muscle Strengthening for Sit-to Stand (STS) 

Isometric Muscle Strengthening for Sit-to Stand (STS)
Yoga Sit-to-Stand Exercise Program
Primary STS  Muscle Groups		Serve the Platter	Seated Tree	Cres-cent	Chair to Stand	Intense Side Stretch	Stork	War-rior  III
Abdominals/ Back Muscles		x	x		x	x	x	x
Hip Extensors						x	x	x
Hip Flexors		x	x	x		x	x	x
Hip Abductors					x	x	x	x
Knee Extensors			x	x		x	x	x
Knee Flexors		x  w/ tuck	x  w/ tuck	x  w/ tuck		x	x	x
Plantar Flexors						x	x	x
Dorsiflexors		x  w/ tuck	x  w/ tuck	x  w/ tuck		x	x	x

Figure 18: Isometric Muscle Strengthening for Sit-to Stand (STS) 

ImportantRange of Motion&Stabilization  for Sit-to Stand (STS)
Yoga Sit-to-Stand ExerciseProgram
Primary STS  Motions		Serve the Platter	Seat-ed Tree	Cres-cent	Chair to Stand	Intense Side Stretch	Stork	War-rior III
Dorsi-  flexion (end range-20°)		x	x	x	x	x	x
Hip Flexion  (greater than 90°)					x	x	x
Knee range (0°-110°)		x  110°	x   110°	x  110°	x  110°-0°	x  0°	x  0°	x  0°
Upper Spine Flexion  (minimal)		x			x
Simultaneous Ankle, Knee & Hip Stability: NWB-PWB		x  w/heel press	x  w/ heel press	x  w/ heel press
Simultaneous Ankle, Knee & Hip Stability: FWB					x	x	x	x

Figure 19: Important Range of Motion & Stabilization for Sit-to Stand (STS) 

Chapter 8 

Conclusion 

Observational statements can be concluded from the summary charts of bed mobility and STS. In the bed mobility charts, concentric/eccentric and isometric exercises are equally balanced and training for the primary muscular demands of bed mobility are met. NWB-PWB preparation for the more demanding PWB-FWB of the STS exercises is thoroughly covered in the bed mobility program. Range of motion  and stabilization training needs are met in both programs. 

The STS program does provide an exercise for every primary muscle group. While concentric/eccentric muscle contractions are used to enter and exit the standing and sitting exercises of STS, the program is heavy on isometric training in comparison to its delivery of concentric/eccentric training. The benefits of isometric training over concentric/eccentric training are better stabilization capabilities, less pain if movement is painful, less pain for arthritis patients plus may help lower high blood pressure (Laskowski, 2018). Isometric training downfalls include its inability to strengthen the muscles at every joint angle like concentric /eccentric strengthening does but isometric training may be a good precursor to concentric/eccentric training as a patient advances in strength or decreases in pain (Laskowski, 2018). Among the STS program’s exercises, the Chair yoga exercise addresses the largest amount of muscle groups in the concentric/eccentric category. The Chair mimics the actual STS movement making the Chair exercise a “go to” exercise with the most concentric/eccentric punch.  

An important question concerning low load yoga exercises is if they are producing enough stress on the muscle to induce muscle hypertrophy or increased strength. According to a study using 19 men age of approximately 21yrs, muscle myofibrillar (MYO) protein synthesis is already maximally stimulated at 60% of a one repetition maximum (1RM). No further increases at higher load intensities (i.e., 75–90% 1RM) are necessary to increase the amount of muscle hypertrophy produced at 60% of a 1RM (Burd, West, Staples, Atherton, Baker, Moore,. . . Lucia, 2010). Burd and colleagues’ 2010 study concluded that low-load with high volume resistance training is more effective at muscle strengthening than high loads or even work matched resistance with low volume training. This study would confirm that the lower load yoga exercises presented here may produce the desired outcome with higher volume participation in the exercises.  

Although the exercise plan is comprehensive and meets primary strengthening, range and stabilization needs, the therapist’s initial and repeated guidance is critical to achieve all of the needed elements of each yoga exercise. For example, the continued cue of pressing through the heels during Serve the Platter, Seated Tree and/or Crescent is imperative for the patient to accomplish NWB-PWB ankle/knee/hip stabilization strengthening for the preparation of sit-to-stand. The needed cue of lifting heels during Windshield Wipers strengthens plantar flexors for STS. Many patients forget to perform these additional yet critical nuances without therapist cueing. 

For additional information on each of these exercises please read “The Therapy Bible On Yoga” by Dr. Kim Byrd-Rider, PT available on Amazon.com  

Chapter 9 

Targeted Goals 

The following SMART goals (Specific, Measurable, Attainable, Relevant and Time Based) support  the previous yoga exercises as skilled interventions and are billable  in the hospital, clinic or home health settings. The motion needed for the performance and comments about the goal are in parentheses and the exercises used to meet those performance needs are in brackets for reader’s referencing purposes. 

1. The patient will be able to reach for the bedpan on the bedside tray-table and perform bowel-movement bedpan toileting independently [by Bridging] in 5 days.  

(Shoulder horizontal adduction [Bridge, Knee Press, Baby Roll] plus spinal rotation with thoracic spine flexion [Knee Press, Baby Roll] is needed here. If the therapist can only choose three exercises to meet this goal for the patient’s homework, then Bridge, Knee Press and Baby Roll would be the best choices. These exercises would be listed in the documentation and referenced to this goal.) 

1. The patient will be able to perform bed mobility and sit at the EOB independently in order to brush his/her teeth/hair and self-wash with a wash-rag independently in 10 days. 

([All bed mobility yoga exercises] and UE strength for washing = [Bridge, Knee Press, Baby Roll, Seated Side Plank] can be used here. These exercises would be listed in the documentation and referenced to this goal.) 

1. The patient will be able to perform bed mobility independently and STS with moderate assistance   of one during standing balance while his/her sheets are being changed or his/her gown is changed for good hygiene in 10 days. [All yoga exercises in the bed mobility program and Serve the Platter, Seated Tree, Crescent, Chair to Stand from the STS program] are needed here. The Chair to Stand exercise would be priority during therapy treatments because the patient will need skilled STS training for this level of a goal. These exercises would be listed in the documentation and referenced to this goal.) 

1. The patient will be able to toilet at a bedside commode independently  with contact guard of one for sit to stand pivot transfer to toilet in 15 days. [All yoga exercises in the bed mobility program and STS program] can be used here. The [Intense Side Stretch, Stork, and Warrior III] would be the priority yoga exercises during therapy treatments for this goal because the patient will need skilled balance training with supervision. These exercises would be listed in the documentation and referenced to this goal.) 

1. The patient will be able to transfer  from bed to wheelchair with stand by assist (SBA) of one in 17 days in order to attend his/her doctor’s appointments. ([All yoga exercises in the bed mobility program and STS program] can be used here but [Intense Side Stretch, Stork, and Warrior III] would be the priority yoga exercises for skilled balance treatments progressing to non-contact guard by the therapist. [Intense Side Stretch, Stork, and Warrior III] might be added to the home exercise program now but with contact-guard or with countertop/chair-back assistance. These exercises would be listed in the documentation and referenced to this goal.) 

The patient may be ready for discharge after goal 5 is reached or may be reassessed for a different set of non-toileting goals. 

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