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:
Arm, horizontal adduction to reach for the EOB;
Figure 1: (Johansson, & Chinworth, 2012)
Minimal-moderate knee/hip flexion ROM with minimal foot push off strength
Figure 2: (Johansson, & Chinworth, 2012)
Minimal-moderate spinal rotation;
Figure 3: (Johansson, & Chinworth, 2012)
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:
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:
Shoulder Girdle Muscles: sternocleidomastoid, serratus anterior, pectoralis minor, rhomboids, trapezius, levator scapulae (Teach PE, 2019).
Shoulder Joint Muscles: teres major, pectoralis major, deltoid, subscapularis, supraspinatus, infraspinatus, latissimus dorsi, teres minor (Teach PE, 2019).
Elbow Joint Muscles: biceps brachii, triceps brachii, pronator quadratus, pronator teres, supinator, anconeus, brachialis, brachioradialis (Teach PE, 2019).
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).
Abdominals/Back Muscles: Rolling and pushing up to seated requires abdominal and back muscle strength to stabilize the upper body.
The abdominal muscles include: external obliques, internal obliques, transversus abdominus, rectus abdominus (Teach PE, 2019).
The back muscles include: quadratus lumborum, splenius, multifidus, erector spinae (Teach PE, 2019).
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).
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).
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.
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:
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).
Thoracic rotation: internal obliques, external obliques,levatores costarum brevis, levatores costarum longus, multifidus, semispinalis thoracis, rotatores brevis, rotatores longus (Alex, 2015).
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:
Spinal rotation (minimal-moderate) used with the log roll.
Spinal side-bending (minimal-moderate) performed during press up to seated.
Upper Spine flexion (minimal) used at the beginning of the log roll.
Horizontal adduction (maximal) reaching across to the EOB.
Knee flexion (0°-90°) range for bending the knee to push off and for sitting.
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.
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
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.
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.
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.
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.
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.
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
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Yoga Bed Mobility Exercise Program
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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 |
|
|
|
|
|
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Prep for STS Muscle Groups |
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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
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Yoga Bed Mobility Exercise Program
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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 |
|
|
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|
Spinal Rotators |
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|
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|
|
|
|
|
|
|
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Preparatory for STS Muscle Groups |
|
|
| |||||
Abdominals/ Back Muscles |
|
| x | x |
|
|
| x |
Hip Extensors |
|
| x |
|
|
|
|
|
Hip Flexors |
|
|
| x | x |
| x | x |
Knee Extensors |
|
| x |
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|
| x Hold |
Knee Flexors |
|
|