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BPT Viva Questions & Answers

Obstetrics, Gynaecology & Paediatric Physiotherapy

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PART A — OBSTETRICS & GYNAECOLOGY PHYSIOTHERAPY

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🔹 TOPIC 1: Treatment of Incontinence & Pelvic Floor Dysfunction

• Stress incontinence – leakage with physical exertion (weak sphincter/pelvic floor)
• Urge incontinence – sudden, strong urge to void followed by leakage (detrusor overactivity)
• Mixed incontinence – combination of both

• Patient contracts pelvic floor as if stopping urine flow
• Hold for 5–10 seconds, then relax
• Perform 10–15 repetitions, 3 sets/day
• Both fast (quick flicks) and slow sustained contractions are included

1. Endopelvic fascia – deepest supportive layer
2. Levator ani muscle group – pubococcygeus, iliococcygeus, puborectalis
3. Coccygeus muscle
4. Perineal membrane (urogenital diaphragm)
5. Superficial perineal muscles – ischiocavernosus, bulbospongiosus, superficial transverse perinei

• Kegel / PFMT (Pelvic Floor Muscle Training)
• Biofeedback
• Electrical stimulation (NMES / TENS)
• Bladder retraining
• Vaginal cones
• Behavioural modification and fluid management

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🔹 TOPIC 2: Postnatal Physiotherapy Management

• Bladder incontinence
• Bowel incontinence / constipation
• Pelvic floor muscle weakness
• Postpartum depression
• Low back pain
• Diastasis recti
• Perineal pain / episiotomy healing
• Deep vein thrombosis prevention

• Pelvic floor exercises begin within 24 hours of delivery (vaginal or caesarean)
• Gentle walking and breathing exercises start from day 1
• Core strengthening (transversus abdominis) can begin after 6–8 weeks post-delivery
• Full exercise resumption after 12 weeks, depending on healing

• Managed by transversus abdominis activation
• Avoid sit-ups, crunches, and heavy lifting initially
• Abdominal splinting, gentle progressive core strengthening

• Aerobic exercise increases serotonin and endorphins
• Group-based exercises improve social support
• Yoga and relaxation techniques reduce cortisol
• Breathing exercises reduce anxiety

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🔹 TOPIC 3: Electrotherapy Modalities for Pelvic Floor

• Frequency: 35–50 Hz for stress incontinence (muscle strengthening)
• Frequency: 5–10 Hz for urge incontinence (detrusor inhibition)
• Applied via intravaginal/intrarectal probe or surface electrodes
• Improves muscle tone and sphincter activity

• Detrusor muscle inhibition
• Pelvic pain relief
• Improved blood circulation in perineal region

• Pregnancy
• Cardiac pacemaker
• Active infection or UTI
• Malignancy in the region
• Prolapse (Grade III/IV)
• Sensory impairment in the area

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🔹 TOPIC 4: Therapeutic Electrical Stimulation & Biofeedback

• Types: EMG biofeedback (muscle electrical activity) and manometric biofeedback (pressure)
• Helps patients identify correct muscles, improve coordination, and increase strength
• Especially useful when voluntary contraction is poor

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🔹 TOPIC 5: Osteoporosis — Prevention & Physiotherapy

• WHO criterion: T-score ≤ −2.5 on DEXA scan
• Osteopenia: T-score between −1.0 and −2.5

• Prevent further bone loss through weight-bearing exercise
• Improve muscle strength (especially back extensors, hip abductors)
• Improve balance and reduce fall risk
• Correct posture (reduce thoracic kyphosis)
• Pain management
• Patient education

• Weight-bearing aerobic – walking, low-impact aerobics, dancing
• Resistance training – progressive strengthening of back extensors and hips
• Balance training – Tai Chi, single-leg stance
• Postural exercises – thoracic extension, chin tucks
• AVOID – high-impact, spinal flexion exercises (forward bending), twisting

• Avoid spinal flexion (increases vertebral fracture risk)
• No high-impact activities
• Monitor fall risk (use fall prevention protocols)
• Ensure adequate footwear and environment modification
• Work in conjunction with medical management (calcium, vitamin D, bisphosphonates)

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🔹 TOPIC 6: Breast Cancer Rehabilitation & Lymphedema after Mastectomy

• Stage 0 (Latent) – No visible swelling, subclinical damage
• Stage I (Reversible) – Pitting edema, reduces with elevation
• Stage II (Irreversible) – Non-pitting edema, fibrosis begins
• Stage III (Elephantiasis) – Severe, skin changes, fibrosis

1. Manual Lymphatic Drainage (MLD) – gentle massage to redirect lymph to functioning vessels
2. Compression bandaging – multi-layer short-stretch bandages
3. Therapeutic exercises – active movement with compression
4. Skin & nail care – hygiene to prevent infection

• Prevent shoulder contracture and frozen shoulder
• Restore shoulder range of motion (pendulum, pulley, wall-climbing exercises)
• Reduce lymphedema risk
• Improve upper limb function and strength
• Psychosocial benefit — improves quality of life and reduces fatigue

• Avoid blood pressure measurements on the affected arm
• No venepuncture or IV lines on affected side
• Avoid tight clothing or jewellery on affected arm
• Protect from cuts/infections (risk of cellulitis)
• Avoid heavy lifting initially

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🔹 TOPIC 7: Physiotherapy after Gynaecological Surgeries

• Hysterectomy (abdominal/vaginal/laparoscopic)
• Prolapse repair (anterior/posterior colporrhaphy)
• Incontinence procedures (TVT, TOT slings)
• Myomectomy
• Pelvic floor repair surgeries

• Day 1–2: Breathing exercises (ACBT), ankle pumps, bed mobility, early ambulation
• Week 1–4: Pelvic floor exercises, gentle walking, posture correction
• Week 4–6: Progressive core strengthening (transversus abdominis)
• After 6–8 weeks: Gradual return to full activity
• Avoid: Heavy lifting, high-impact activity for 3 months

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PART B — PAEDIATRIC PHYSIOTHERAPY

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🔹 TOPIC 8: Developmental Milestones

• Primitive reflexes – Present at birth, disappear by 4–6 months. Persistence = CNS pathology.
  • Moro reflex (disappears ~4 months)
  • Rooting reflex (~4 months)
  • Palmar grasp (~6 months)
  • ATNR – Asymmetric Tonic Neck Reflex (~6 months)
  • STNR – Symmetric Tonic Neck Reflex (~8–10 months)
  • Stepping reflex (~2 months)
• Postural/righting reflexes – Emerge as primitive reflexes disappear (head righting, parachute reaction — appears ~8–9 months)

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🔹 TOPIC 9: Cerebral Palsy (CP)

• Spastic CP (most common, ~75%) – Upper motor neuron lesion, hypertonicity, clasp-knife rigidity
  • Hemiplegia, Diplegia, Quadriplegia/Tetraplegia
• Dyskinetic/Athetoid CP – Basal ganglia lesion, involuntary movements
• Ataxic CP – Cerebellar lesion, incoordination, balance problems
• Mixed type

• Inhibition of abnormal tonal patterns and primitive reflexes
• Facilitation of normal postural reactions and movement patterns
• Handling techniques to promote quality of movement
• Used primarily in CP, stroke, and developmental disorders

• Stimulates the CNS to produce coordinated movement patterns
• Used in infants at risk (preterm, birth asphyxia) and children with CP
• Works by activating the spinal cord locomotor centres

• Encourages cortical reorganization (neuroplasticity)
• Constraint worn for 6+ hours/day
• Intensive task-specific training of the affected limb
• Evidence shows improved hand function in hemiplegic CP

• Used in children with autism, developmental coordination disorder, sensory processing disorder
• Activities include swings, balance boards, textured surfaces, deep pressure

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🔹 TOPIC 10: Down Syndrome

• Hypotonia (low muscle tone) — primary physiotherapy concern
• Joint hypermobility and ligament laxity
• Atlantoaxial instability (C1–C2) — must be screened before exercise
• Delayed motor milestones
• Feeding difficulties
• Obesity risk
• Congenital heart disease (in ~40%)

• Strengthening and tone-building exercises
• Postural control and balance training
• Developmental milestone facilitation (NDT approach)
• Hydrotherapy
• Sensory integration
• Oral motor therapy for feeding
• Orthotics if needed (flat feet, genu valgum)

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🔹 TOPIC 11: Autism Spectrum Disorder (ASD)

• Improve motor coordination and praxis
• Sensory integration therapy (tactile, vestibular, proprioceptive input)
• Reduce stereotyped motor behaviors
• Improve social participation through play-based therapy
• Aquatic therapy for sensory modulation
• CIMT if motor asymmetry present

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🔹 TOPIC 12: Spina Bifida

• Spina bifida occulta – Bony defect only, cord intact, usually asymptomatic
• Meningocele – Meninges protrude, cord intact, mild neurological deficit
• Myelomeningocele – Most severe; cord and meninges protrude, significant neurological deficit (paralysis, incontinence)

• Prevent deformity (hip dislocation, clubfoot, scoliosis)
• Strengthen remaining functional muscles
• Mobility aids (orthotics, wheelchairs, crutches)
• Bladder/bowel program (in coordination with team)
• Pressure ulcer prevention
• Family and caregiver education

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🔹 TOPIC 13: Hydrocephalus

• Motor delays, spasticity, visual problems
• Often co-exists with myelomeningocele
• Managed medically with VP shunt (ventriculoperitoneal shunt)
• Physiotherapy: developmental facilitation, postural control, caution regarding shunt function

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🔹 TOPIC 14: Early Intervention

• Rationale: Brain plasticity is greatest in early years; early stimulation maximizes functional outcomes
• Includes physiotherapy, occupational therapy, speech therapy, and family education
• Programs target motor, cognitive, communication, and social development

• Denver Developmental Screening Test (DDST II) — ages 0–6 years, screens gross motor, fine motor, language, social
• Bayley Scales of Infant Development (BSID III) — comprehensive assessment
• Gross Motor Function Classification System (GMFCS) — classifies CP severity (I–V)
• Hammersmith Infant Neurological Examination (HINE) — for infants
• Peabody Developmental Motor Scales (PDMS-2) — motor skills 0–5 years

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🔹 TOPIC 15: Neurophysiological Approaches Summary

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🔹 QUICK-FIRE VIVA QUESTIONS

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🧒 PAEDIATRIC PHYSIOTHERAPY — IN-DEPTH VIVA Q&A

BPT Examination Preparation (All Syllabus Topics Covered)

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SECTION 1: PAEDIATRIC NEUROLOGY & DEVELOPMENTAL MILESTONES

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• Assessment of neuromotor function
• Identification of abnormal tone, reflexes, and movement patterns
• Facilitating normal developmental progression
• Managing conditions like CP, spina bifida, Down syndrome, hydrocephalus

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• Help identify developmental delay early
• Guide goal setting in rehabilitation
• Assist in monitoring treatment progress
• Form the basis of developmental facilitation programs

• Gross motor
• Fine motor / adaptive
• Language / communication
• Personal-social

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• Stimulus: Turning the head to one side
• Response: Limbs on the face side extend, limbs on the skull side flex
• Normal disappearance: 5–6 months

• Persistence beyond 6 months → sign of cerebral palsy
• Interferes with midline hand use (bimanual tasks), feeding, and hand-to-mouth activity
• Child cannot look at what they are holding
• Affects rolling and early locomotion

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• Response: Arms abduct and extend (Phase 1), then adduct and flex as if embracing (Phase 2)
• Normal disappearance: 4–5 months
• Absent Moro at birth → bilateral brachial plexus injury, severe hypotonia, or birth asphyxia
• Asymmetric Moro → unilateral brachial plexus injury (Erb's palsy) or hemiplegia
• Persistent Moro beyond 5 months → cerebral palsy

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• Stimulus: Neck flexion or extension
• Neck flexion → arms flex, legs extend
• Neck extension → arms extend, legs flex

• Normally integrates by 8–10 months
• Persistence prevents reciprocal crawling on hands and knees
• Children may "bunny hop" or W-sit instead
• A sign of abnormal neurological development

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• Mediated by the labyrinth (otolith organs)
• Supine position → extensor tone increases (opisthotonus-like)
• Prone position → flexor tone increases
• Normal disappearance: ~6 months
• Persistence → child cannot lift head in prone, cannot come to sitting, increased extensor spasticity in supine (common in spastic CP)

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SECTION 2: ASSESSMENT IN PAEDIATRIC PHYSIOTHERAPY

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1. History – Birth history, APGAR, gestational age, prenatal/perinatal insults, developmental history, family history
2. Observation – Posture, spontaneous movement, symmetry, head control, play
3. Palpation – Muscle tone, muscle bulk, joint range
4. Milestone examination – Gross motor, fine motor, speech, social
5. Developmental reflex examination – Primitive and postural reflexes
6. Higher mental functions – Cognition, attention, behavior
7. Cranial nerve examination – Facial symmetry, eye movements, swallowing
8. Motor & Sensory examination – Tone, power, coordination, sensation
9. Reflex testing – Tendon reflexes (hyporeflexia / hyperreflexia), Babinski
10. Differential diagnosis – Based on findings
11. Balance & Coordination examination – Romberg, tandem walking
12. Gait analysis – Scissor gait, toe walking, Trendelenburg
13. Functional analysis – ADL performance, transfers, mobility

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• Scissor gait – Hip adduction + internal rotation (spastic diplegia in CP)
• Toe walking (equinus gait) – Plantarflexion, no heel strike (spastic CP, idiopathic toe walking)
• Trendelenburg gait – Pelvis drops on unaffected side (hip abductor weakness — MMC, CDH)
• Crouch gait – Excessive knee and hip flexion (CP)
• Steppage gait – High stepping due to foot drop (peripheral nerve problem)
• Hemiplegic gait – Circumduction of affected leg (CP hemiplegia)

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SECTION 3: CEREBRAL PALSY (CP)

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1. Disorder of movement and posture (onset before 1–2 years of age)
2. Evidence of disturbance in the fetal or infant brain
3. Non-progressive (no evidence of worsening)
4. Significant functional limitation
5. Expected to persist throughout life

Although non-progressive, CP should be viewed as a dynamic disorder — its clinical expression evolves with growth and development. — Bradley and Daroff's Neurology in Clinical Practice

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• Periventricular leukomalacia (PVL) in preterm infants
• Congenital brain malformations
• Intrauterine infections (TORCH)
• Genetic/chromosomal disorders
• Maternal vascular disease

• Hypoxic-ischaemic encephalopathy (HIE) — birth asphyxia
• Neonatal stroke
• Prematurity, very low birth weight

• Meningitis/encephalitis
• Traumatic brain injury (shaken baby)
• Prolonged seizures / status epilepticus

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• Intellectual disability – 50–60%
• Epilepsy – 25–45%
• Speech and language disorders – 38–60%
• Visual impairment – strabismus, nystagmus, cortical visual impairment
• Hearing impairment – especially in athetoid CP (kernicterus)
• Feeding difficulties/dysphagia – 43–99%
• Behavioural problems – ADHD, autism features
• Sleep disturbance
• Drooling (sialorrhoea)
• Pain (often under-recognized)

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• Reduce spasticity and abnormal tone
• Inhibit persistent primitive reflexes
• Facilitate head control, rolling, sitting
• Improve joint range of motion
• Prevent contractures and deformities
• Improve functional mobility and transfers

• Maximize independent ambulation
• Maintain musculoskeletal integrity (prevent scoliosis, hip dislocation)
• Achieve age-appropriate ADL function
• Improve quality of life and social participation
• Educate caregivers in handling techniques

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SECTION 4: NDT, VOJTA & NEUROPHYSIOLOGICAL TECHNIQUES

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• The brain has plasticity — it can learn and reorganize
• Abnormal movement patterns are learned and can be changed
• Inhibit abnormal tonal patterns and primitive reflexes
• Facilitate normal postural reactions and movement patterns
• Use specific handling techniques at key points of control (head, shoulder girdle, pelvis)

• Proximal: head, trunk, shoulder girdle, pelvic girdle
• Distal: hands, feet

• Inhibition – Reflex Inhibiting Postures/Patterns (RIP) to reduce spasticity
• Facilitation – Guide patient through normal movement sequences
• Weight bearing and weight shifting – Promote postural reactions
• Sensory stimulation – Normalize sensory input

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1. Reflex Creeping (Reflex Kriechen) – From the prone position
2. Reflex Rolling (Reflex Umdrehen) – From supine and lateral positions

• These movement patterns are genetically encoded in the CNS
• In children with neurological impairment, normal locomotor patterns are blocked
• Pressure on specific body zones unlocks these patterns
• With repeated activation, the CNS reorganizes and voluntary movement improves

• Medial epicondyle of humerus
• Lateral third of clavicle
• Heel
• Inside of knee

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• Constraint worn for 6+ hours/day on the unaffected limb
• Intensive task-specific training of affected limb simultaneously (2–6 hours/day)
• Duration: typically 2–3 weeks intensive program

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1. Tactile – Touch discrimination
2. Vestibular – Balance and spatial orientation (inner ear)
3. Proprioceptive – Body position and movement (muscles, joints)

• Swings (linear and rotary) — vestibular input
• Textured surfaces, vibration — tactile input
• Heavy work (pushing, pulling, carrying) — proprioceptive input
• Balance boards, trampolines
• Brushing protocol (Wilbarger protocol) — deep pressure/tactile

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SECTION 5: DEVELOPMENTAL DELAY & EARLY INTERVENTION

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• Developmental Delay – Performance significantly below average (>2 SD) in one or more developmental domains for age
• Specific Developmental Delay – Delay in only ONE domain (e.g., only motor, only language)
• Global Developmental Delay (GDD) – Significant delay in TWO or more developmental domains; used in children <5 years (after 5 years termed Intellectual Disability)

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• Neuroplasticity is at its peak during this period — the brain forms ~1 million new neural connections per second in early infancy
• Myelination progresses rapidly in the first 2 years
• Abnormal sensorimotor experiences entrench abnormal patterns; early correction prevents this
• Early intervention is dramatically more effective than later treatment for outcomes in CP, Down syndrome, autism, and preterm infants

• Physiotherapy (motor development, tone management)
• Occupational therapy (fine motor, feeding, ADL)
• Speech and language therapy
• Special education and family training
• Psychological support

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• Assessment first — Identify which milestones are delayed and by how much
• SMART goal setting — Short and long-term goals aligned with GMFCS level
• Postural management — Appropriate seating, sleeping positioning
• Developmental milestone facilitation — Progress through head control → sitting → standing → walking
• Handling and movement facilitation (NDT-based)
• Tone management — Stretching, positioning, splinting
• Sensory stimulation — Vestibular, proprioceptive, tactile input
• Family and caregiver training — Home exercise program (HEP)
• Multidisciplinary team approach — Paediatrician, OT, speech therapist, psychologist

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SECTION 6: CONDITIONS — DETAILED

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• Hypotonia — Primary concern; affects all muscles from birth
• Joint hypermobility — Ligamentous laxity
• Atlantoaxial instability — Excess laxity at C1–C2; present in ~15% → must SCREEN before any vigorous exercise (risk of spinal cord injury)
• Delayed motor milestones (walk avg. ~24 months vs. 12 months)
• Flat feet (pes planus), genu valgum
• Congenital heart disease (~40–50%)
• Intellectual disability
• Obesity risk

• Strengthening exercises to combat hypotonia
• Balance and postural control training
• Gait training and orthotics (AFO for flat feet)
• Developmental milestone facilitation (NDT approach)
• Hydrotherapy — excellent for tone, strength, confidence
• Oral motor therapy for feeding difficulties
• Pre-sport screen for atlantoaxial instability
• Family education and home program

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• Impaired social communication and interaction
• Restricted, repetitive behaviours and interests
• Sensory processing differences

• Sensory integration therapy — Most significant PT contribution; addresses tactile hypersensitivity, vestibular dysfunction, proprioceptive seeking
• Motor coordination training — Children with ASD often have DCD (Developmental Coordination Disorder)
• Aquatic therapy — Calming, excellent for proprioceptive and vestibular input
• CIMT if motor asymmetry is present
• Social play-based therapy — Structured physical play to improve interaction
• Core strengthening — Many children with ASD have core hypotonia
• Manage stereotyped motor behaviors (hand flapping, rocking) with sensory substitution

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• L1–L2: Hip flexors intact, no knee extension → needs KAFO, limited ambulation
• L3–L4: Knee extension intact → KAFO or AFO, community ambulation
• L4–L5: Dorsiflexion intact → AFO, functional ambulation
• S1–S2: Near-normal ambulation; mild bladder/bowel issues

• Prevent deformity — Hip dislocation, knee contractures, clubfoot (serial casting), scoliosis
• Strengthen available muscles — Progressive resistive exercises within neurological capacity
• Mobility — Orthotic prescription (KAFO, AFO), crutches, wheelchair as needed
• Pressure ulcer prevention — Sensation absent below level; regular skin inspection, pressure relief
• Bladder/bowel program — In collaboration with nursing/urology team
• Hydrotherapy — Supports body weight, facilitates movement
• Family education — Handling, positioning, skin care

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• Enlarged head circumference (macrocephaly)
• Sunset sign (eyes deviated downward)
• Prominent scalp veins
• Irritability, vomiting, bulging fontanelle

• Aqueductal stenosis (most common congenital cause)
• Post-meningitis
• Intraventricular haemorrhage (in preterm)
• Associated with myelomeningocele (Arnold-Chiari malformation)

• Delayed motor milestones → developmental facilitation
• Spasticity of lower limbs (spastic diplegia pattern)
• Visual problems — therapist uses large, high-contrast materials
• VP shunt precautions — No neck compression, no contact sports, report any signs of shunt malfunction (vomiting, irritability, headache) immediately
• Positioning to avoid pressure on shunt site

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• Sydenham's chorea (post-streptococcal, rheumatic fever) — most common in children
• Huntington's disease (juvenile form)
• Kernicterus
• Metabolic disorders

• Stability training — Proximal stabilization exercises
• Coordination and balance training
• Weight and resistance — Proprioceptive input helps dampen involuntary movements
• Adaptive strategies — Weighted utensils, clothing adaptations
• Functional task training — Writing, feeding, dressing
• Speech and swallowing therapy (oropharyngeal chorea)

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• Cape-like dissociated sensory loss (pain/temperature lost, touch preserved) — "cape distribution"
• UMN signs below lesion
• LMN signs at lesion level (weakness, wasting)
• Autonomic dysfunction

• Joint protection — Avoid positions that cause shunt expansion
• Strengthening — Available muscles, avoiding Valsalva manoeuvre
• Hydrotherapy — Low-resistance environment
• Splinting and orthotics — Prevent deformity
• Sensory compensation strategies — Visual monitoring of insensate limbs
• Post-surgical rehabilitation (after syrinx drainage)

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SECTION 7: MINIMUM BRAIN DAMAGE & RISK BABIES

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• Mild motor incoordination (clumsiness)
• Learning disabilities (reading, writing, arithmetic)
• Attention deficit (ADHD features)
• Soft neurological signs (mild hyperreflexia, mild tremor, dysdiadochokinesia)
• Normal intelligence

• Coordination and balance training
• Fine and gross motor skill development
• Sensory integration therapy
• School-based physiotherapy for handwriting, physical education participation

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• Preterm birth (<32 weeks gestation)
• Very low birth weight (<1500g)
• Birth asphyxia / HIE
• Neonatal seizures
• Intraventricular haemorrhage (IVH)
• Congenital infections
• Hyperbilirubinemia (kernicterus risk)

1. Vojta therapy — Activates innate locomotion patterns; started from first weeks of life
2. NDT/Bobath handling — Correct positioning, facilitate normal postures
3. NIDCAP (Newborn Individualized Developmental Care and Assessment Program) — Minimize stimulation in NICU, positional support
4. Kangaroo mother care — Skin-to-skin; improves neurodevelopmental outcomes
5. Developmental follow-up programs — Regular milestone monitoring, early detection of CP

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SECTION 8: QUICK-FIRE VIVA (HIGH-YIELD)

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Sit to Stand Using NDT (Bobath) Principles

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📸 Clinical Demonstration — Actual NDT Session

Image A → Seated position with trunk support at pelvis/hips, hands on ball for upper limb loading Image B → Transition/mid-phase — therapist facilitates at hips & trunk, child pushing through arms Image C → Full standing — therapist shifts hands to lower trunk/thighs to maintain pelvic stability

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What is Sit to Stand (STS) in NDT?

• Inhibit abnormal tone and spasticity
• Facilitate normal weight shift and postural reactions
• Promote symmetrical lower limb loading
• Build antigravity muscle activation (quads, glutes, trunk extensors)
• Develop standing postural control and equilibrium reactions

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NDT Principles Applied to Sit to Stand

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Step-by-Step: Sit to Stand Using NDT

🟡 PHASE 0 — Preparation (Before Movement Begins)

• Sitting at the edge of a plinth or stool
• Hips at 90° flexion, feet flat on the floor, hip-width apart
• Trunk erect, head in midline

• Assess tone — if high extensor tone or ATNR pattern, inhibit first
• For spastic child: perform slow rotational trunk movements (trunk rotation RIP) to reduce spasticity before initiating STS
• Ensure symmetrical pelvis — no posterior pelvic tilt or lateral lean
• Position feet BEHIND the knees (ankles dorsiflexed) to prepare for weight acceptance

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🟡 PHASE 1 — Anterior Weight Shift ("Nose Over Toes")

• Trunk inclines forward (hip flexion) — "nose over toes"
• Body weight moves from ischial tuberosities → onto feet
• Ankle dorsiflexion occurs
• Eccentric quad activity prepares for push-off

• Therapist kneels/sits in front of or behind child
• Both hands on the anterior superior iliac spine (ASIS) or lateral pelvis
• Facilitate anterior pelvic tilt + forward trunk lean
• Prevent posterior pelvic tilt (which causes the child to fall back)

• Hands on shoulder girdle
• Guide trunk forward and slightly down (inhibiting scapular retraction in spastic child)

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🟡 PHASE 2 — Momentum Phase (Initiation of Rise)

• Continued forward trunk lean generates momentum
• Hip and knee extensors (gluteus maximus, quadriceps) begin concentric contraction
• The child rises from the seat — hips and knees extend simultaneously
• Arms may assist by pushing off thighs or a surface

• Therapist facilitates upward and forward direction of movement at the pelvis
• Prevent the child's hips from shooting backward (common in extensor spasticity)
• If scissoring (hip adduction) occurs — guide hips apart with thumbs on medial thighs
• For a child with poor initiation — use tapping (quick stretch) on quads just before rise to activate muscle spindles

• Child places hands on a Swiss ball placed in front
• Ball provides proprioceptive input through upper limbs
• Prevents forward fall and gives confidence
• Therapist handles at trunk/pelvis from behind

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🟡 PHASE 3 — Full Extension & Standing

• Hips, knees, and ankles fully extend
• Trunk aligns over lower limbs
• Postural tone activates in trunk extensors, hip abductors, and ankles

• Therapist's hands move to lower trunk / greater trochanter area to support upright pelvis
• Check for:
  • Hip hyperextension (common in hypotonic child) — facilitate slight hip flexion, engage glutes
  • Knee hyperextension (back-knee) — press gently behind knee to encourage slight flexion/co-contraction
  • Equinus (toe standing) — guide heel contact with floor, provide firm input through calcaneus
  • Lateral lean — facilitate midline through pelvic handling

• Once standing is achieved, introduce gentle weight shifts side-to-side and forward-backward to stimulate standing equilibrium and righting reactions
• This is a core NDT principle — postural reactions must be facilitated, not just achieved

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🟡 PHASE 4 — Consolidation in Standing

• Progress from maximum assistance → minimum assistance → hands-off
• Use graded withdrawal of therapist support (reduce handling gradually)
• Introduce reaching tasks while standing (activates anticipatory postural adjustments)
• Use mirrors for visual biofeedback of upright posture

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Common Problems & NDT Solutions

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NDT Handling Images — Trunk & Pelvis Facilitation

Panel A — Therapist facilitates at pelvis and lower trunk from behind (seated) Panel B — Swiss ball used to challenge dynamic core stability Panel C — Quadruped facilitation for trunk co-contraction and weight bearing

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Grading the Activity (Progression Levels)

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Summary — NDT Sit to Stand Checklist

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