1. Foundations: planes and axes of motion, posture, center of mass, base of support, muscle contraction types
2. Bed mobility: rolling, bridging, supine-to-sit, sit-to-supine
3. Transfers: sit-to-stand, bed-chair, toilet, and car transfers
4. Mobility: walking, stairs, turning, reaching, carrying objects
5. Upper-body ADLs: feeding, grooming, bathing, dressing, toileting
6. Joint and muscle analysis: movements and prime movers at the shoulder, elbow, wrist, trunk, hip, knee, ankle, and hand
7. Clinical application: compensatory strategies and adaptations in weakness, pain, neurological disorders, or joint limitations

Kinesiology of Activities of Daily Living (ADLs)

1. Meaning and scope

1. Starting position and alignment
2. Base of support (BOS)
3. Center of mass (CoM) and balance demands
4. Joint movements and planes of movement
5. Muscle activity
6. Type of muscle contraction
7. Hand function and object demands
8. Sensory, perceptual, and cognitive requirements
9. Environmental influences
10. Compensations, safety, and energy conservation

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2. Classification of daily activities

A. Basic ADLs or personal ADLs

B. Instrumental ADLs

C. Advanced ADLs

• Employment
• Parenting
• Sports and exercise
• Hobbies
• Religious and community activities
• Social participation
• Driving
• Travel

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3. Fundamental biomechanical concepts

A. Planes and axes

B. Types of muscle contraction

C. Center of mass, base of support, and balance

• Widening the BOS
• Lowering the CoM
• Keeping the CoM near the middle of the BOS
• Moving slowly
• Using hand support
• Increasing friction between footwear and floor

D. Posture and alignment

Stable sitting

• Feet supported on floor
• Hips and knees near 90 degrees when possible
• Pelvis neutral or slightly anteriorly tilted
• Trunk upright
• Head centered over trunk
• Shoulders relaxed

Stable standing

• Weight distributed symmetrically between both feet
• Knees not locked
• Pelvis and trunk aligned
• Head held over trunk
• CoM controlled within the BOS

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4. General task-analysis framework

Person factors

Musculoskeletal

• Strength
• Range of motion
• Joint stability
• Muscle tone
• Endurance
• Grip and pinch strength
• Pain
• Deformity or contracture

Neurological

• Motor planning
• Coordination
• Balance
• Sensation
• Proprioception
• Vision
• Vestibular function
• Cognition
• Attention and memory

Cardiopulmonary

• Exercise tolerance
• Shortness of breath
• Heart rate response
• Fatigue
• Orthostatic symptoms

Task factors

• Required precision
• Amount of force
• Speed
• Bilateral versus unilateral hand use
• Need for reaching, bending, carrying, or twisting
• Need for continuous standing
• Need for problem solving and sequencing

Environmental factors

• Chair height
• Bed height
• Toilet height
• Lighting
• Clutter
• Floor surface
• Grab-bar position
• Shower design
• Clothing type
• Assistive devices available

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5. Bed mobility

A. Rolling

Movement sequence

1. Flex one or both hips and knees.
2. Turn head and trunk toward the desired side.
3. Reach the upper arm across the body.
4. Rotate pelvis and lower limbs.
5. Shift body weight onto the side.

Joint movements

• Cervical spine: rotation
• Thoracic and lumbar spine: rotation
• Shoulder: flexion, horizontal adduction, protraction
• Hip and knee: flexion
• Pelvis: rotation

Major muscles

• Abdominals and obliques: trunk rotation and stabilization
• Hip flexors: flex hip and knee
• Gluteal muscles: pelvic control
• Serratus anterior and pectoralis major: reaching across body
• Neck flexors and rotators: head movement

Common compensations

• Pulling on bed rails
• Using the unaffected arm to move the involved limb
• Excessive trunk extension
• Sliding rather than controlled rotation
• Hooking one foot under the other leg to move it

Clinical relevance

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B. Bridging

Starting position

Movement

Joint movements

• Hip: extension
• Knee: maintained flexion
• Lumbar spine: controlled stabilization, sometimes slight extension

Major muscles

• Gluteus maximus: hip extension
• Hamstrings: assist hip extension
• Quadriceps: stabilize lower limb
• Abdominals: stabilize pelvis and trunk
• Erector spinae: assist trunk control

Key biomechanical point

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C. Supine-to-sit transfer

Typical sequence

1. Roll onto one side.
2. Bring legs over the edge of the bed.
3. Push through the upper limbs.
4. Lift trunk into sitting.
5. Regain sitting balance before standing.

Joint actions

• Trunk: flexion and lateral flexion
• Shoulder and elbow: extension during push-up
• Hips: flexion as legs move off bed
• Cervical spine: extension to orient vision

Main muscles

• Obliques and rectus abdominis: trunk movement
• Shoulder depressors and elbow extensors: pushing from bed
• Hip flexors: bring legs forward
• Scapular stabilizers: support upper-limb pushing

Safety

• Pause after sitting up to check for dizziness or orthostatic hypotension.
• Feet should be supported before attempting a standing transfer.
• Avoid twisting after surgery if precautions apply.

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6. Sitting and sit-to-stand

A. Controlled sitting down

Phases

1. Turn and back up until legs touch the chair.
2. Reach back for armrests if used.
3. Flex hips and knees.
4. Shift pelvis backward.
5. Lower body in a controlled manner.

Muscle action

• Quadriceps eccentrically control knee flexion.
• Gluteus maximus and hamstrings help control hip flexion.
• Ankle dorsiflexors and plantarflexors stabilize the tibia and ankle.
• Trunk extensors and abdominals stabilize the torso.

Common errors

• Dropping suddenly into chair
• Reaching too early for chair
• Sitting without fully turning
• Poor eccentric quadriceps control
• Knees collapsing inward
• Unequal weight bearing

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B. Sit-to-stand

Four practical phases

1. Preparation

• Feet placed beneath or slightly behind knees
• Trunk upright
• Hands may rest on armrests or thighs

2. Forward trunk lean

• Trunk flexes forward
• Pelvis moves toward front of chair
• CoM shifts forward toward the feet

3. Lift-off

• Buttocks leave the chair
• Hips and knees begin extending
• Balance demand rises because the CoM is moving forward and upward

4. Stabilization in standing

• Hips and knees fully extend
• Trunk becomes upright
• CoM is controlled over the feet

Main joint movements

Major muscles

Important biomechanical factors

• A low chair requires greater hip and knee flexion and more lower-limb force.
• A higher chair reduces demand and is useful for weak or painful individuals.
• Armrests decrease lower-limb demand but increase upper-limb demand.
• Inadequate forward trunk lean prevents the CoM from moving over the feet and makes standing difficult.
• Feet placed too far forward make standing more difficult because the knees cannot translate forward adequately.

Common compensations

• Pushing heavily through armrests
• Rocking forward repeatedly
• Excessive trunk flexion
• Weight bearing mainly through the stronger leg
• Locking knees into hyperextension once upright
• Pulling on a walker, which is unsafe unless specifically trained and the device is stable

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7. Transfers

A. Bed-to-chair transfer

Requirements

• Sitting balance
• Lower-limb strength
• Trunk control
• Ability to pivot or step
• Adequate cognition and safety awareness
• Sufficient transfer surface height

Types

• Stand-pivot transfer
• Squat-pivot transfer
• Sliding-board transfer
• Mechanical lift transfer

Stand-pivot transfer sequence

1. Position wheelchair close to transfer surface.
2. Lock wheelchair brakes.
3. Move footrests away.
4. Scoot toward chair edge.
5. Place feet firmly on floor.
6. Lean forward and stand.
7. Pivot in small steps toward destination.
8. Back up until legs touch surface.
9. Reach back and lower slowly.

Kinesiology

• Requires symmetrical weight shift where possible.
• The person turns with the feet rather than twisting excessively through the knee.
• Hip and knee extensors generate lift.
• Trunk and pelvic control maintain alignment.
• The arms may push from a surface but should not pull on unstable objects.

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B. Toilet transfer

Special demands

• Toilet may be low, increasing hip and knee flexion demand.
• Small bathroom space restricts turning.
• Clothing management requires balance and hand function.
• Urgency may lead to rushed and unsafe movement.

Helpful modifications

• Raised toilet seat
• Grab bars
• Toilet safety frame
• Adequate lighting
• Non-slip flooring
• Clothing with simple fasteners

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C. Car transfer

Sequence

1. Back up until legs touch the seat.
2. Reach for stable support.
3. Sit first.
4. Pivot the pelvis and bring legs into the vehicle.
5. Reverse the sequence to exit.

Main movements

• Hip flexion and rotation
• Trunk rotation
• Knee flexion
• Ankle dorsiflexion
• Upper-limb support through the door frame or seat

Difficulty increases with

• Low car seat
• Hip pain or stiffness
• Limited trunk rotation
• Poor single-leg balance
• Weak quadriceps
• Need for assistive devices

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8. Functional walking

A. Gait cycle

B. Major muscle actions during gait

C. ADL-related gait tasks

• Starting and stopping
• Walking while carrying objects
• Turning
• Walking in narrow spaces
• Crossing obstacles
• Walking on uneven ground
• Dual-task walking, such as talking while walking
• Walking to a toilet at night
• Carrying groceries
• Using stairs

D. Turning

Key requirements

• Weight shift
• Trunk and pelvis rotation
• Foot repositioning
• Vision and vestibular integration
• Motor planning

Safer strategy

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9. Stair climbing

A. Ascending stairs

Kinesiology

• Hip and knee flexion lift the foot to the next step.
• Hip and knee extension raise the body.
• Ankle plantarflexors help with push-off.
• Gluteus medius stabilizes the pelvis.

Main muscles

• Quadriceps
• Gluteus maximus
• Hamstrings
• Calf muscles
• Hip flexors
• Trunk stabilizers

Common instruction with unilateral weakness

B. Descending stairs

Main demands

• Quadriceps eccentrically control knee flexion.
• Hip extensors control forward trunk movement.
• Ankle muscles regulate forward tibial progression.
• Visual monitoring and dynamic balance are important.

Common instruction with unilateral weakness

Safety

• Use handrails.
• Ensure adequate lighting.
• Avoid carrying bulky items that block vision.
• Use a step-to pattern if needed.

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10. Reaching, grasping, and carrying

A. Reaching

Forward reach

• Shoulder flexion
• Scapular upward rotation and protraction
• Elbow extension
• Wrist stabilization
• Trunk control
• Anterior weight shift

Overhead reach

• Shoulder flexion or abduction
• Scapular upward rotation, posterior tilt, and external rotation
• Thoracic extension
• Cervical control
• Stronger balance demands

Lateral reach

• Shoulder abduction
• Trunk lateral flexion or weight shift
• Pelvic stability
• Increased risk of moving CoM beyond BOS

Safe reaching principles

• Stand close to the object.
• Keep frequently used items between waist and shoulder height.
• Step toward objects rather than overreaching.
• Avoid twisting while holding heavy objects.
• Use both hands for heavier or awkward loads.

B. Grasp patterns

C. Carrying

Muscles involved

• Finger flexors: grip
• Wrist extensors: stabilize wrist
• Biceps and shoulder muscles: support object
• Rotator cuff and scapular muscles: shoulder stability
• Trunk muscles: counterbalance and prevent lateral sway
• Hip abductors: pelvic stabilization during walking

Principles

• Hold loads close to the body.
• Divide load between both sides when possible.
• Avoid carrying and turning rapidly.
• Use a cart, walker basket, backpack, or trolley if appropriate.

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11. Feeding and drinking

A. Components of feeding

1. Sitting balance and postural alignment
2. Reaching for utensil
3. Grasping utensil
4. Scooping, cutting, or spearing food
5. Bringing food to mouth
6. Releasing utensil safely
7. Chewing and swallowing coordination

B. Upper-limb kinesiological sequence

C. Major muscles

• Deltoid: shoulder elevation
• Rotator cuff: glenohumeral stability
• Serratus anterior and trapezius: scapular control
• Biceps: elbow flexion, forearm supination
• Triceps: controlled extension to reach table
• Wrist extensors: stabilize hand
• Finger flexors and intrinsic hand muscles: utensil control

D. Common compensations

• Excessive shoulder elevation
• Leaning trunk toward spoon rather than moving arm
• Using whole-arm movement because of poor wrist/hand control
• Bringing head down to food because of shoulder limitation
• Using a non-dominant hand to stabilize plate

E. Adaptive equipment

• Built-up utensil handles
• Angled spoon
• Rocker knife
• Plate guard
• Non-slip mat
• Two-handled cup
• Straw or lidded cup, when clinically appropriate

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12. Grooming

A. Brushing teeth

Movements

• Shoulder flexion
• Elbow flexion
• Forearm pronation/supination
• Wrist stabilization
• Fine finger movements

Requirements

• Visual guidance
• Bilateral hand use, often one hand holds brush and the other stabilizes toothpaste or cup
• Standing or seated balance at sink

B. Combing hair

Important joint demands

• Shoulder flexion and abduction
• External rotation of shoulder
• Elbow flexion
• Wrist extension
• Repetitive hand gripping

C. Washing face

• Shoulder flexion
• Elbow flexion
• Forearm rotation
• Hand cupping
• Trunk flexion if leaning over sink

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13. Dressing

A. Upper-body dressing

Shirt or blouse

1. Identify front/back and correct orientation.
2. Insert one arm into sleeve.
3. Pull garment over shoulders.
4. Insert the second arm.
5. Adjust garment and fasten buttons or zipper.

Joint movements

• Shoulder flexion, abduction, external rotation
• Elbow flexion/extension
• Forearm pronation/supination
• Wrist and finger movements
• Trunk flexion, rotation, and lateral flexion

Main muscles

• Deltoid
• Rotator cuff
• Scapular stabilizers
• Biceps and triceps
• Finger flexors/extensors
• Intrinsic hand muscles
• Trunk stabilizers

Hemiplegia strategy

• Dress the affected arm first
• Undress the unaffected arm first

B. Lower-body dressing

Tasks

• Putting on underwear, trousers, socks, shoes
• Fastening zippers, buttons, belts, laces

Main movements

• Hip flexion
• Hip external rotation
• Knee flexion
• Trunk flexion
• Single-leg balance in standing tasks
• Finger pinch and bilateral coordination

Main muscles

• Hip flexors
• Quadriceps
• Hamstrings
• Abdominals
• Hip abductors for pelvic stability
• Ankle muscles for standing balance
• Hand muscles for fasteners

Difficulties

• Limited hip flexion
• Restricted trunk flexion
• Poor balance
• Pain after hip, knee, or back surgery
• Reduced hand dexterity
• Visual impairment
• Cognitive impairment

Adaptive equipment

• Reacher
• Sock aid
• Long-handled shoehorn
• Elastic shoelaces
• Velcro fasteners
• Dressing stick
• Button hook

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14. Bathing and showering

A. Major movement demands

• Standing or sitting balance
• Stepping into shower
• Reaching to feet, back, hair, and lower legs
• Grasping soap, sponge, showerhead, and towel
• Turning in a wet environment
• Drying body while maintaining stability

B. Kinesiology

• Shoulder flexion and abduction for washing hair and upper body
• Shoulder extension and internal rotation for washing back
• Hip flexion and trunk flexion for lower legs and feet
• Knee flexion and ankle control for stepping
• Grip and wrist stabilization for holding equipment
• Trunk and hip strategy for balance

C. Safety modifications

• Shower chair or bath bench
• Handheld showerhead
• Grab bars
• Non-slip mat
• Long-handled sponge
• Liquid soap dispenser rather than bar soap
• Towel and clothing within easy reach
• Good lighting

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15. Toileting

1. Walking to toilet
2. Turning and positioning
3. Lowering onto toilet
4. Managing clothing
5. Maintaining sitting balance
6. Performing hygiene
7. Standing again
8. Readjusting clothing
9. Washing hands

A. Kinesiological demands

Lowering and rising

• Hip and knee flexion/extension
• Forward trunk lean
• Quadriceps eccentric and concentric activity
• Gluteus maximus activity
• Ankle balance reactions

Clothing management

• Bilateral hand use
• Fine motor control
• Standing balance, often with one or both hands occupied
• Trunk rotation and hip motion

Hygiene

• Shoulder extension, internal rotation, and adduction
• Elbow and wrist control
• Trunk rotation or lateral flexion
• Sufficient sitting balance

B. Common causes of difficulty

• Low toilet height
• Painful knees or hips
• Limited shoulder internal rotation
• Poor standing balance
• Urgency
• Weak grip
• Cognitive impairment
• Obesity
• Restricted trunk rotation

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16. Housework and kitchen activities

A. Sweeping and mopping

Movements

• Alternating shoulder flexion/extension
• Scapular protraction/retraction
• Trunk rotation
• Weight shifting
• Step movements
• Sustained grip

Muscles

• Deltoid
• Triceps
• Scapular stabilizers
• Obliques
• Hip abductors
• Calf muscles
• Hand and forearm muscles

Safer technique

• Move feet with the object rather than twist through the spine.
• Use long-handled equipment.
• Keep the object close.
• Avoid repeated bending and twisting.

B. Cooking

Physical demands

• Standing endurance
• Reaching into cupboards
• Lifting pans
• Chopping and stirring
• Carrying plates
• Walking between workstations

Cognitive demands

• Attention
• Sequencing
• Time management
• Hazard recognition
• Heat and knife safety

Work simplification

• Sit for preparation tasks.
• Store often-used items between waist and shoulder height.
• Slide heavy items on a counter instead of lifting.
• Use lightweight cookware.
• Prepare ingredients before turning on heat.
• Avoid carrying hot liquids long distances.

C. Laundry

Movement requirements

• Reaching
• Bending
• Lifting
• Carrying
• Pushing/pulling
• Sorting and folding
• Standing tolerance

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17. Hand function in ADLs

A. Functional positions

Wrist

Thumb

Intrinsic hand muscles

• Finger abduction/adduction
• Fine control
• Precision pinch
• Adjusting grip around objects

B. Examples of hand requirements

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18. Balance strategies used in ADLs

A. Ankle strategy

• Body moves as a relatively straight unit around the ankle.
• Calf and shin muscles correct small forward or backward sway.

B. Hip strategy

• Hips flex or extend to reposition CoM.
• Useful when standing on a narrow or unstable surface.

C. Stepping strategy

• A step creates a new, larger BOS.
• Essential for preventing falls during loss of balance.

D. Protective extension

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19. Common compensatory movements

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20. Energy conservation and joint protection

Energy-conservation principles

• Plan tasks before beginning.
• Alternate heavy and light activities.
• Pace activity and take planned rests.
• Sit rather than stand when possible.
• Keep frequently used items within easy reach.
• Avoid unnecessary trips and repeated movements.
• Use wheeled carts or assistive devices.
• Use good breathing patterns and avoid breath holding.

Joint-protection principles

• Use larger joints rather than small finger joints for heavy tasks.
• Hold objects close to the body.
• Avoid sustained tight gripping.
• Avoid twisting under load.
• Use two hands for heavier objects.
• Respect pain, swelling, and prolonged fatigue.
• Use adaptive equipment when it reduces joint stress.

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21. Functional assessment tools

A. Katz Index of Independence in ADL

• Bathing
• Dressing
• Toileting
• Transferring
• Continence
• Feeding

B. Lawton Instrumental ADL Scale

• Telephone use
• Shopping
• Food preparation
• Housekeeping
• Laundry
• Transportation
• Medication management
• Finances

C. Barthel Index

D. Functional Independence Measure

E. Timed Up and Go

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22. Clinical interpretation of ADL difficulty

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23. Key practical points

• ADL performance depends on more than muscle strength. It also requires balance, coordination, sensation, vision, cognition, endurance, and a safe environment.
• Basic ADL loss usually indicates greater functional dependence than isolated IADL loss.
• IADL difficulty may appear earlier than basic ADL difficulty in cognitive decline or early physical frailty.
• A task should be analyzed in the person’s real environment because chair height, bathroom design, lighting, and available supports can substantially change performance.
• Independence does not necessarily mean doing a task without equipment. Safe and effective use of a device can represent functional independence.
• The best intervention may be restorative, compensatory, environmental, or a combination:
  • Restorative: strengthen muscles, improve range of motion, train balance.
  • Compensatory: change technique or use an unaffected limb.
  • Adaptive: introduce equipment.
  • Environmental: modify the home setup.
  • Caregiver-based: provide supervision or physical assistance when needed.