Fundamental and Derived Positions for Starting exercises

Introduction
Movement can be initiated from a wide variety of starting positions or static positions. These positions are maintained by static contraction of the muscles which stabilize the joints and by support of apparatus. These are five basic or fundamental positions; standing, sitting, kneeling, lying, and hanging positions. All other positions that are used are modified from these five basic positions and are known as derived positions.

Fundamental Positions
Standing, kneeling, sitting, lying and hanging are the fundamental positions. Selection of the suitable position is made according to the purpose for which they are required. This may be to: 1. Utilize support essential for relaxation 2. Train balance 3. Achieve adequate fixation, when movement is to be localized to a specific joint. 4. Modify the effect of an exercise to improve ROM or strength. 5. Maintain or improve posture.

Derived Positions:
The position of the arms, legs or trunk may be altered in each of the fundamental positions to modify the effects of the position or that of the exercise. The purpose for modifications may be to: 1. Increase or decrease the size and stability of the base of support of the body. 2. Raise or lower the center of gravity (COG)
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3. Ensure maximum local or general relaxation. 4. Provide a control or fixation for a particular part of the body to localize movements to a specific area. 5. Increase or decrease the muscle work required to maintain the position. 6. Avoid muscle shortening and contractures. 7. Avoid joint stiffness and intraarticular adhesions. 8. Avoid respiratory and circulatory complications as pneumonia, pressure ulcers, DVT. 9. Increase or decrease the leverage. Types of derived positions: 1) From lying position: Crook lying, half lying (30), prone lying, half prone lying, side lying, or modified side lying (45). 2) From sitting position: stride sitting, long sitting, cross sitting (tailor), crook sitting, side sitting, sitting on the edge of the table with side arm support, sitting in a chair, sitting on a chair, sitting on chair with back support, half sitting. 3) From kneeling position: half kneeling, kneel sitting, prone kneeling. 4) From standing position: wing standing, yard standing (wand standing), stride standing, walk standing, half standing, step standing, toe standing. 5) From hanging position: half hanging (hanging with one hand). Common pressure points From supine lying From side lying

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Positions for starting exercises

There are fundamental positions which are usually described along with their derivatives as the starting positions from which exercises start. Selection of the starting position When selecting a starting position for an exercise, the following points should be considered 1- The ability of the patient to assume the position. 2- The need to stabilize one segment of the body to permit safe and efficient movement. 3- The use of gravity for assistance or resistance. 4- The presence of pain or discomfort (the position should be pain free to assure relaxation of the patient). 5- The use of a short lever arm versus a long lever arm. 6- Modification of the effect of the exercise. 1) Lying Position Characteristics It is the easiest of the whole fundamental positions. The body is completely supported with a large base of support and low center of gravity. It is considered the most stable position. Description: The patient lies on his back fully supported either on a plinth or on the floor and the body is erect (Figure 1) with: Head and neck erect in neutral position.
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 Eyes look up, ears at the same line Shoulders at the same level. Trunk is relaxed on bed in neutral position. Arms by the side of the body supported on bed. Palms in contact with table. Pelvis at the same level. Lower limbs (hips and knees) straight together. The feet free from the bed or in neutral position.

Figure (1): Lying (supine or back lying).

Effects and uses As the trunk is relaxed by its own weight, it is a suitable position for many arm and leg exercises. As the alignment is the same as in standing position, static postural training can be carried out in this position once adequate control of the pelvis tilt is established. The spine is relieved from transmitting the weight of the head and shoulders when it is in a horizontal position. Therefore, it tends to elongate and straighten, and this is an advantage in the treatment of spinal deformities.

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Breathing is impeded slightly by pressure on the posterior aspect of the thorax and by increased pressure of the abdominal viscera on the undersurface of the diaphragm, often making the position unsuitable for those suffering from respiratory or heart diseases. Lying position hinders the return of blood from the head and so may be unsuitable for the elderly, or those who suffer from high blood pressure. Positions derived from lying Prone lying (Face lying) (Figure 2) The body is face down rested on the forehead with chin tucked in. also the head may be turned to one side for ease of respiration. Shoulders at the same level. Trunk is relaxed on bed. Arms by the side of the body palms facing up. Pelvis at the same level. Lower limbs (hips and knees) straight. The feet free from the bed or in planter flexion.

Figure (2): Prone lying position.

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Side lying (Figure 3) The body is lying on the side with the arms by the side and the legs straight. This position is difficult to assume as the base of support is small and rounded, some modification is made to make this position suitable for exercises performance. The under arm is bent forward or placed under the head. The upper arm is for balance and to prevent trunk rotation. The under leg is bent forward (flexed 45 degrees at hip and knee) for balance and increase base of support. The upper leg is extended.

Figure (3): Side lying position. Hook lying (Crook lying) (Fig. 4) It is as supine lying position but hips and knees are flexed with the feet rested on the table.

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Figure (4): Crook lying position. 2) Sitting Position Characteristics It is comfortable, natural and very stable position. The center of gravity is low but near to the edge of the base of support which is the area between both the legs of the seat and the feet. Description: The position is taken with the body is resting on a chair (with back support) or stool (without back support). The height and width of which allow the thighs to be fully supported and hips and knees to be flexed in a right angle. Head in neutral position. Eyes look forward, Ears at the same line Shoulders at the same level. Back is straight. The back is supported in case of sitting on chair with back support. While when sitting on stool the

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back is unsupported making the position less stable and need effort of the subject to maintain back straight. Arms by the side of the body. Pelvis at the same level. Thighs fully supported and together on the chair. Hips, knees, and ankles at right angle flexion. Knees are apart sufficiently to allow the femora to be parallel. The feet rested on the floor with the heels vertically below the knees. In case of sitting on stool, according to the height of the stool the feet may be rested or not on the floor. Effects and uses Sitting Position is a comfortable, natural and very stable position which is much used. It is particularly suitable for those who lack the necessary strength and control to maintain a more difficult position. Lateral and rotatory mobility of the pelvis is eliminated by the weight of the body and the positions of the legs so that lateral movements can be localized to the spine. As none of the body weight is transmitted to the legs, many non weight-bearing exercises for knees and feet can be performed in this position. It is also suitable for training correct alignment of the upper part of the body in the habitual sitting position, which is used by the majority more than any other position in everyday life.
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Positions derived from sitting Long Sitting (Figure 5) As in supine position but the body is bent at the hips and the trunk is raised from lying to an angle of 90 degree. Head in neutral position. Eyes look forward, Ears at the same line. Shoulders at the same level. Back is straight. Arms by the side Knees are extended Ankles are relaxed.

Figure (5): Long sitting position. Forward Lean Sitting (Figure 6) Trunk is inclined forwards in sitting position and the head is supported on pillows on a table at the front.

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Figure (6): Forward Lean Sitting Position.

3) Standing Position (Position of attention) Characteristics Standing position is the most difficult of the fundamental positions to maintain, as the whole body must be balanced and stabilized in correct alignment on a small base of support by the coordinated work of many muscle groups. The interaction of the muscles concerned is controlled by a complex series of reflexes known collectively as Postural reflexes. The base of support is very small and the center of gravity is high. Description: The body is erect with: Head and neck are erect in neutral position. Eyes look straight forward. Ears are leveled at the same line. Shoulders are drawn down and back. Shoulders at the same level. Arms hang loosely by the side of the body Palms facing inwards towards the thigh.
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 The back is straight and stretched to its maximum length. Pelvis is balanced on the femoral heads with both ASIS at the same level. Hips are in midline and slightly lateral rotated. Knees are together and extended. The heels are together at the same level. The toes are slightly apart and turned out with the angle between the feet does not exceed 45. It is usually preferable to modify the position of the legs with the heels are slightly apart and the inner borders of the feet are parallel, as this is the natural functional position of the feet when it is used as a lever to propel the body forewards. Effects and uses As the base of support is relatively small and the COG is high, the state of equilibrium of the body is relatively less stable than in other fundamental positions. Therefore, the standing position is only suitable as a starting position for exercises for those who can maintain it correctly. The muscle work is minimal when perfect balance is achieved. Therefore, practice in attaining and holding a satisfactory pattern of standing posture reduces fatigue and also conditions the postural reflexes. The erect position of the whole body is the position of alertness, in which the thorax is free and the abdominal viscera are well supported.

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Positions derived from standing a) Stride Standing It is the most commonly used position assumed by the physical therapists during treatment of patients. It is the same as standing, but the feet are sideways apart and the base of support is therefore wide side to side giving good lateral stability. b) Walk Standing It is the same as standing, but the feet are a forward pace apart and the base of support is therefore wide from front to back giving good anteroposterior stability. 4) Kneeling position Characteristics The position is unstable and difficult to maintain as the center of gravity is high and the line of gravity falls close to the edge of the base which the area of the legs only. Description: In this little used position, the body is supported upright on the knees which are held at right angle. Head in neutral position. Eyes look forward, Ears at the same line. Shoulders at the same level. Arms by the side of the body
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 Palms facing inward. The back is straight. Pelvis at the same level. Hips in midline and straight Knees flexed right angle. Knees and legs are together or slightly apart and supported on the floor. The feet are planter flexed. Or, if a plinth is used, the feet may be in the mid-position over the edge of the bed. Effects and uses Although the COG of the body is relatively lower than in standing, kneeling position is only slightly more stable and is uncomfortable for most people. It is therefore, seldom used except as a starting position for backward movements in a sagittal plane, during which the feet are pressed to the floor by the extensors of the knees and dorsiflexors, so that the lower leg acts as a bracket. As there is tendency to hollow the back, this position may be of value for the patient with flat back.

Positions derived from kneeling a) Kneel Sitting The position is stable. From kneeling position, the subject sits back on the heels.

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b) Prone Kneeling (cat position) (Figure 7) Kneeling position supported by the four limbs. The arms should be straight and the hands in line below the shoulders. Right angle should be maintained at the hips and knees. The ankles are planter flexed.

Figure (7): Prone Kneeling Position. 5) Hanging Position Description The body is suspended by grasping over a horizontal bar or wall bars, which is arranged on such that the patients feet are just off the floor: The forearms being pronated Hands overgrasp and not less than shoulder width apart. The arms straight, directed upwards and at least shoulder width apart. The head is held high and in neutral position. The scapulae are drawn down and together. The neck appears as long as possible.
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 The trunk and legs are straight in neutral position. Heels together. Ankles plantar flexed. The body is slightly lifted between the arms without any bending of the elbow.

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