A lot of patients in post-acute rehab cannot stand without holding onto something - walkers, tables, grab bars, THERAPISTS, etc. Many of these patients have just endured a major life change (CVA, TBI, surgery, etc.) and are notably hesitant. That being said, returning home to "normal" life requires relearning how to stand again without hand support. Most ADLs are typically performed in standing while using both hands for the activity (not holding on): washing dishes, preparing a meal, showering, cleaning house, etc. As such, learning to stand without hand support needs to be a focal point in rehab. Below are 5 progressive steps to teaching patients to standing again without hand support:
STEP ONE: 2-Hands Horizontal. Patient is standing and holding onto horizontal support (parallel bars, balance trainer, etc.) with both hands. Horizontal supports allow patient to bear weight and support themselves through their arms and hands. As the therapist, I sit on a stool or chair in front of the patient and use my hands to facilitate upright and balanced posture. I like to place my hands on the lateral aspects of the patient's hips. This lets me support the patient and use tactile cues to direct needed weight shifts (to help patient stay balanced). The goal is to help the patient learn to stand upright and balanced. The patient is learning to feel equal weight distribution in side-to-side (not too heavy on left or right foot) and forward-back directions (not too heavy through heels or toes). I instruct patients that they will know they are "balanced" when they can let go of the supports and won't tip over.
STEP TWO: 2-Hands Vertical. Patient is standing and holding onto vertical supports with both hands. Vertical supports provide balance help and a sense of security, but eliminate weight bearing through the arms and hands. This helps the patient assume a more upright standing posture. Vertical supports are somewhat hard to find in many rehab gyms; I like to use the ones on the ADL Balance Trainer. Similar to STEP ONE, sit on a stool or chair in front of patient and use your manual skills to help them learn to stand upright and balanced.
STEP THREE: 2-Hands Unstable Surface. Patient position is standing with hands resting on balls (as shown in picture), sticks, or other unstable objects. Because the items will shift and move about, the patient is forced to rely on their trunk and legs more for balance. In this set up, the patient's hands can still provide some sensory feedback and support, but will be less effective because of the unstable surfaces on which they are holding. Similar to STEP ONE, sit on a stool or chair in front of patient and use your manual skills to help them learn to stand upright and balanced.
STEP FOUR: 1 Handed. In this step the patient is standing and using only one hand for support. They can progress through the same sequence of horizontal, vertical, and unstable supports as noted in STEPS 1-3; however, now it is with only one hand. Similar to previous steps, sit on a stool or chair in front of patient and use your manual skills to help them learn to stand upright and balanced. Additionally, have patient alternate holding on with either hand, trying to work each side equally. A great way to do this is to add reaching/placing tasks with the patient use one hand for support and the other for reaching and placing objects (see ADL Balance Games for more information on reaching/placing tasks).
STEP FIVE: No Hands. Patient is now ready to stand without hand support. Typically, patient is still standing in the same spot as STEPS 1-4 (support nearby in case they need to grab hold). However, now they just turn loose and enjoy standing without hand support. As the therapist, you will continue to sit on a stool or chair in front of the patient. However, as the patient learns to stand without assistance, only use intermittent tactile cues as needed to redirect patient. The emphasis shifts to verbal cues for facilitating upright and balanced posture. With the parallel bars or balance trainer on each side of patient, and you in front of them, they will feel more comfortable standing without hand support. As their steadiness and confidence improves, continue to progress and challenge patients by adding balance challenges (see blog 4 Ways to Overload Balance Training for more information).
NOTE: Shane Haas, PT, MSIE, CPE will be in Dallas, TX on February 24th 2018 teaching Balance Training by ADL. For more information on course, please visit www.ADLbalance.com.